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CERT'IF'ICATIO OF 1�'IT_AL RECORD <br />K <br />3052014019427 <br />STATE FRE NUMBER <br />1. NAME OF DECEDENT- FIRST (GMn) <br />CAMILLE - ' <br />8. BIRTH awAwefe]RFIONCOUNTOm <br />CALIFORNIA <br />.PIN AXA FIRST. M L STI <br />FRO / VS, MMEO FOR£ES9 :10 t 5TAl61RCP' KN.e1Bal ,e roArn .3'308M • wi I8 ) <br />ENO L31 , M< wIDOwED 01125!2014' 0. 1 200 <br />15. mUCATICN- H2MLL LwWeww 1,15. WAS DECEDENT W&(W'ICADINCIMSPAMSNR Ono Bee 16: DECEDENTS RACE- Up MD: .o noy see nIP1P .'^rwnw"an acp <br />u . . : :w.we w «e L . r� ©ip CAUCASIAN <br />SOME COLLEGE LD <br />17, USUAL OCCUPATION -Type a w055 or mom 0127 .D0 NOT USE RETIRED ' .. 18. KIND OF BUSINESS OR 58405,50117 Oa snowy star, road cnnsencam, employment nom, ,, raw) 19. YEARS IN OCCUPATION <br />ELECTRONICS TECHNICIAN ELECTRONICS 25 <br />75 500544. SECURITY NUII <br />[549 -30 -9120 <br />25 DEL/DENrs 0ESIOENCE (serer and namnw, arlao}9an) <br />tt 10711 THORNTON ROAD, 4212 <br />PUBLIC HEALTH SERVICES <br />STOCKTON, CALIFORNIA <br />2. MWOL <br />BERTHA <br />a+ Thisis'a true and exact reproduction of the document officially registered <br />m, and placed on file with San Joaquin County' Public Heelth Services. <br />201401` 699 <br />3201439000417 <br />LOCAL REG0TRRIONSAlMBE8 <br />6 LAST fenM1 - - . • <br />SMITH . <br />4 LATE OE /OATH mnVd0/50Y 5. AGE Yrs. I F 180550 0858 5057 0 DHOW H1� F <br />09!23/1 88 , M.O. . Der Hews IAN... IAN... <br />CA <br />CERTIFIED COPY OF VITAL Ip <br />STATE OF CALIFORNIA . p q �Qt/ `': �I ��� ����I '+ 11111111111111111111 t <br />COUNTY OF SAN JOAQUIN Sg DATE ISSUED: FEB 0' 4 2'014 * 0 D O 6/0-0 5.:1 * <br />KAREN FURST, MD, MPH <br />Rev <br />LOCAL. REGISTRAR <br />This copy not valid unless prepared on-engraved border displaying date and signature of Registrar. <br />00 <br />8840 1 .. - -. .. `... <br />