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DECEDENT <br />PERSONAL , • <br />DATA <br />IT252 OR <br />PRINi NAND <br />�'`�} L / <br />d L ) <br />IA. NAME OF DECEASED - FIRST NAME <br />Jane 1 <br />10. MIDDLE NAME <br />Burniston <br />IC. LAST NAME <br />Brown <br />2A. DATE OF DEATH - 0011211. BAT. YEAR <br />July 23, 1950 <br />2e mom/ <br />6;15P <br />3. SEX <br />Female <br />4. COLOR OR RACE <br />Yhh <br />5, Ilailtt?b 5 ' 54 " " 10.wm0W00 <br />Married' <br />6. DATE OF BIRTH <br />Feb. 27, 1883 <br />7. AGE I.AST BIRTHDAY) <br />67 YEARS <br />IF UNGER I YEAR <br />IP UNDER 24 HOURS <br />MONTH" OATS <br />NOON. <br />MINOTI. <br />84. U S AL UPA Ripe.' <br />Housewife <br />Be 8o 4IND OF BUSINESS OR INDUSTRY <br />At own home <br />9. MOM OMQR'O" " <br />New York <br />10. CITIZEN OF WHAT COUNTRY? <br />United States <br />I1. NAME AND BIRTHPLACE OF FATHER <br />Abraham Beekman . New• York <br />12. MAIDEN NAME AND BIRTHPLACE OF MOTHER <br />Sarah Van der Veer Unknown <br />13. NAME OF SPOUSE uF WARMED) <br />James B. Brown <br />14. WAS DECEASED EVER IN U. 5, ARMED FORCES? ' <br />15 .SOCIAL SECURITY NUMBER <br />16. INFORMANT Y] <br />James B • }3Y'Own <br />55(015T YES, N0. IIN.NOWN <br />Ili TLS. 01VE. WAR OR DATES OF 520910E <br />• <br />None y <br />® <br />PLACE <br />17A. PLACE OF DEATH - CITY 05 TOWN TP.II°d1&°trailfA7i tiowiif. <br />F'yi.., <br />San Diego <br />5 rs PUCE; <br />170. LENGTH OF STAY u TM <br />3 years <br />17c. COUNTY <br />San Diego, <br />OF <br />DEATH • <br />Q(( // , <br />170. FULL NAME AND /muss OF HOSPITAL OR INSTITUTION - 11F NOT IN HOSPITAL OR INSn10TI0N, GPM STREET ADORERS OR LOGATioN <br />Mercy Hospital. Hillcrest Drive San Diego, Calif. <br />SUy,REyDENCE <br />111 E SED veal <br />K¢iEfFl <br />N� 1l/1II�077J� IIt�SI. <br />OEIICFEI' <br />I8A. STREET ADDRESS 1 F RURAL. GIVE LOCATION;' 118e CITY OR TOWN F4 ° .?FB abSiaC MP ! 18c. COUNTY <br />T - Meta RAn ' niegn <br />7950 El Vap.1,T;an ^JJ�. 3.Yd La LlEiV4 <br />16°. STATE <br />Calif. <br />2 ;1 , <br />/'� / <br />CAUSE <br />OF <br />DEATH <br />IENTER ONLY ONE <br />CAUSE 151 LINE FOR <br />!A). III ANO IC I; <br />DOGS NOT <br />MEAN THE 500E <br />1 93 DISEASE OR CONDITION <br />DIRECTLY LEADING TO DEATH A <br />C35 <br />/ APPROXIMATE <br />S - <br />INTERVAL <br />BETWEEN <br />ONSET AND <br />DEATH <br />sup <br />DYING ch . <br />OF AS HEART FAILURE. <br />ASTHENIA. Era <br />I T N EANSI T <br />/AI <br />ANTECEDENT CAUSES , <br />MORBID CONDITIONS IF ANY. GIVING /N''� <br />DUE TO,0, <br />. <br />055EASE IN <br />0R COMPLICATIONS <br />WHICH CAUSED <br />DEATH. <br />RISE TO PIE ADOVE CAUSE ^� <br />141 STATING <br />• �C <br />7HE O110ERLYING CAUSE LAST. DUE TO ICI ���EY���CCC .. <br />19.2. OTHER SIGNIFICANT CONDITIONS <br />CDN0ITIONS CONTR DOING TO THE 0RATM.0 <br />NOT RLLATI°TOTHC DI 05 CONDITION <br />CAUIINO. ; [A'1 <br />OPERATIONS <br />20A. DATE OF OPERATION <br />200. MAJOR FINDINGS OF OPERATION <br />21. AUTOPSY <br />❑ YES 1 N0 <br />14TH <br />D L <br />EXTERNAL <br />VIOL L NC NCE <br />2 24. ACCIDENT 15522(52 <br />SUICIDE <br />HOMICIDE <br />225 PLACE OF INJURY �� p 0, I Ld17. I ' <br />pm. KAOTDII,..TIIET, 01116 ..D '� <br />22c LOCATION CITY OR TOWN. Cou1Fr7 STATE <br />22o. TIME MIN OAT ;EAR NOUN <br />OF INJURY <br />M <br />22E. INJURY OCCURRED <br />x2 ❑ Nor wxAE <br />AT 112 WORA AT 110811 <br />'125 HOW DID INJURY OCCURS <br />• <br />PHYSICIANS <br />OR CORONER'S <br />CERTIFICATION <br />23A. COROHCR'I■ I IIERE07 WIN" THAT I NAVE NCLO AN❑AUT0•IY.❑ IMOUISI, OR <br />0INVI.TIDATION 0)4 MM.. HAW. 01105 UECA'ASEO AND 5,•0 'NAT TNT 0CCCASCO <br />CAL" TO DEATH NOON AND DATE 0051:0 A YC. <br />..11 <br />238 10701 ■401 11110[.! CENT ter I THAT 1 ATTCNOEG THE OCCCAICO F"OM -.. � /. kS� IPIC.�,O <br />_ ` I OCOUDRTD /NOM THE CA .X....3.- _.110 0111AT 1 YI LAW THE OTC LASED ALIYION- / ✓ i J- 11 /1 <br />M. AND AT TML NOUN AND OATS .TATCD OVC. •1a- <br />AN YC <br />230. ADDRESS - <br />3 21 ' • *.'_irT./[.Qv ■ .. 3� , <br />P URE <br />232. OA E SIGNED <br />./ <br />Z $ // � L <br />23c. SIGN 5001(00 115 NIL <br />� . N <br />bIRECTO <br />. I DURIAL 24R. DATE `2 • METER! ORTREMATORY <br />I,HI,•■ � g_2!t- 0 I e . i • st!g�braska <br />22447 > 1? 0 + <br />SVG OFAMB`,4LMER /.7 /� ENSE MBER <br />?. � \ f 111 (/ .,- 35 :; 2- <br />,41.4.4,1_ <br />AND <br />REGISTRAR <br />L_- __ _._�_. <br />27, DATE REcEiv9 BY L0 REGISrRAR <br />L 2 � <br />. TUflE • L• REGISTRAR <br />�B1iQ <br />�E. u <br />g FU ERA'pECTpg <br />/J 1i rother � a M 1770 -4th <br />� � fn•erOCUT nE 011141 it SAGA' TA <br />n <br />+� (t tfGT.. PI, <br />CERTIFICATION OF VITAL RECORD <br />^tom b a *�•. G.ccr <br />�� �Sg f f� Ot .. x.. • ?,.,1 : ..< �'� ...�.c .. _,. _ ._._ <br />REGISTRATION <br />3 ?O1 . 5.6:2? 02586 <br />COUNTY OF SAN DIEGO <br />ASSESSOR/RECORDER /COUNTY CLERK <br />CERTIFICATE OF DEATH <br />$64.6P's6>'Pi4$QP4 N4PP�eP r4ff44PF4S'kST! . •`P44�i"1'$3?L ye>{'� $ PC "�3`¢�i�69`'v�pe%>+ 4�ff$P'�"�i'++ P4N PC'�i NU4ff9iP74k4 <br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE( <br />OF CALIFORNIA <br />IDNM II IA II <br />December 14, 2012 Ernest J. Dronenburg, Jr. <br />Assessor /Recorder /County Clerk <br />This copy is not valid unless prepared on an engraved border <br />displaying date, seal and signature of the Recorder /County Clerk <br />1 <br />2 01210870 <br />STATE 5O -O54 <br />FILE 50 VV 1/ V Z <br />This is a true and exact reproduction of the document officially registered and placed on file in the office of the <br />San Diego County Recorder /Clerk. <br />1Il1II IIiII( IIIUt 11IIll IlI <br />1 111 1111111111111 1111 <br />111 11 1 ,' ' II <br />�r� c OG f. <br />