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0 N <br />w U 67 <br />as♦ e w S <br />O 8 <br />7 <br />ja D. <br />D v o <br />6 N G <br />m Do <br />�2 <br />� o <br />O <br />10 017 <br />0 v <br />o <br />U U <br />O` <br />sr ` <br />L U <br />�+ vc <br />eCD � <br />s. <br />DI .` <br />�D <br />cd <br />u z -ry <br />!. <br />• LOCAL INIGNI ATION <br />BYM[ 479 <br />MUE CERTIFICATE OF DEATH DBTNICTAND, <br />STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH CLNnFI- ---- - RIK= s R <br />v v <br />11. NAME OF DECEASED -FIRST MANEi14. YIDOLE NAME ,_ SIC. LAST INU[ _ . _..._ _. _. i <br />h <br />, <br />b 1 Alb 1 <br />3. SEX 4. COLOR OR RACE 5. BIRTHPLACE "c `«,'„"s.;; rO"bOx 6. DATE OF BIRTH 7. AGE, "AfxO"' I rw <br />N br sk April 8 1886 73 r <br />nuMBFA <br />S. NAME AMP BIRTHPLACE OF FATHER Y. MAIDEN NAME AND BIRE ACE OF MOTHER 10. CITIZEN OF WHAT C4uNTRr 11. SOCML SECU6m <br />Hatilda Kem, Wisconsin USA None <br />LeTFls Bald peon. °• 15KIND OF INDUSTRY OR BUSINESS <br />« <br />12: UST OCCUPATION 13. I:-« « w 14. NAM[ OF LAST EMPLOY_ P <br />Self Hedicine <br />16. 'r"o+cn on+wA+w oATUwu +r . `w"`c m IB•. NAME Oi PRESENT SPOUSE 18+. PRESENT OR LAST OCCUPATION <br />w• ++[ +. ° +_K 17 Pie <br />Oi SPOU <br />Alice N Bald ib' eTaifer <br />NET ,D[ND <br />NAPE OF HOSPITAL 19F. STREET ADDRESS n -1. DA..Al.=oA [acA <br />19A. PUCE OF' PEAT H. -'c "I«fl ° <br />.[ <br />N0W:: <br />Laka 7050 parkwa Driv <br />F11, <br />IN <br />TUTN CAL =F.STAY <br />19c. CITY OR TOWN - 190. COUNTY 19[ NH OF S <br />10 <br />La Mesa San Diego 10 yEAN, <br />YEARS <br />ADDRESS ,can sms 20R H OTSIX nrr H OUTDO[ ITr c 11 unns 24. NAME OF INFORMANT �IF T.I. o THIN srous[I <br />� <br />20A�� UST USUAL <br />RESIDENCE .1T"111 <br />«46 Altadena ... , ® [" U„ I.,. ❑ u rw" <br />.n •20[. <br />w►/,L'.`, <br />20c. CRY OR TOWN 20o. COUNTY STATE 21+. ADDRESS OF INFORMANT <br />°CAN <br />22A. 'PHYSICIAN. I „c+n•cTa nrr •.•T OC,•NOU°.Awo TTNC NOU +e••c' o�n S) •O 22c. P OR CORONER -51GNA uRE <br />•,R d>x w. <br />[[won[ <br />,rr• „,TO[, „..[ - +..•[ . n cs•ATOn 220. AD DRESS _ <br />SIGNED <br />22AAC RO ER: iROVC r+ w . „e u°en a•.Teo.aow,N°•N.•'.wc .no �- , <br />+[„ S33 �P (1E r. p <br />f c <br />-- <br />2g, 24. GATE 25 [NAME OF CEMETERY OR C EMATORY 26. EMBALMER -SwnAT E.If o0r [ [• <br />1/22,A 960 Rose Lawn Cem.Col us Nab C- <br />27. NAME OF FUNERAL DIRECTOR �",`,°"'c "NO 2B. o nucmm wRroc • 29 LO AL TRA I UJE <br />1960 ► /Ki/.V1V1� <br />D MM Y JAN 20 <br />L :^ " .OF DEATH [Nr[A wu w[ cws[ nA uN . 010i <br />y9am] <br />PPRO I OT{ <br />,YM: tlyj•H WAS CAUSED By. Cardl c dec gnsation _ <br />EDIATE CAUSE IAI - _ -. -�- - - _-_. -__- <br />INTERVAL <br />BETWEEN <br />' / <br />PO9terlOr B<90Cardial Infarction __ _ - <br />onsEr AND <br />/ otAX . DDE TO I+r <br />DEATH <br />CoronaI thrombosis ___ - <br />,,A DDEroICI_ <br />\ To DEATH BUT NOT NELATED TO THE TERMInAL DISEASE CONDITION GIVEN IN PART I IA, <br />I <br />PART (60TMER SIGNIFICANT CONDITIONS CONTRIBUTING <br />w.onrrlAro,"so- <br />31.4eP TION-{HECA O E. 32 DATE OF OPERATION 33 AUTOPSY�HECA ONE. <br />onu.w n,rwwlo wAUgnxw+leeo. w +usso, <br />1O•si,nia <br />❑ ^ � <br />N•w „• <br />1. <br />❑ <br />IT_ <br />O.ASUICIDE ,DESCRIBE <br />` FY ACCT OR HOMICIDE 94a HOW INJURY • ^"❑'°•" «'•' ^' ^ " "' ° " "' " "' "' <br />I <br />-SA. TIME xouA Nwx OATuA <br />OF INJURY <br />35+. .URY OCCURR^ED 3k. PUCE OF INJURY ,.r, «, .,wn «nn "...e.,, <br />350. CITY. TOWN. OR LOCATION couNrr <br />n WMIE I I AvT.MLE <br />. I Je4 Q <br />State of Nebraska <br />County of Mall ; ss <br />Entered on Numerxal Index and filed <br />for record in Office of register of <br />Deeds on the ----- 22nd.-.-- day of <br />- - -- August- - - - - -- 19.6II_ at - -- q - - - -- <br />o'clock an l ___DD.___ minutes -A---M- <br />and recorded in Book -- � °� <br />$ __� of <br />--- 14seel' --- t page.(-,- <br />r�'126 <br />--- - - -egi f -Deeds <br />By _w__ <br />Fees $ - -2--25- hd. <br />M <br />Deputy <br />9 fl �J <br />