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H1 217538 <br />COUNTY of SANTA CLARA <br />PUBLIC HEALTH <br />2220 MOORPARK AVENUE., SAN JOSE, CALIFORNIA 95128 200001628 <br />CERTIFICATE OF DEATH <br />STATE OF CALIFORNIA <br />USE [LACK INK ONLY /NO RASTEOUTS OR ALTERATION/ <br />STATE FILE NUMEiEIE E URES, WHI LOCAL REGISTRATION NURSER <br />ST SS DATE ISSUED <br />COUNTY OF SANTA CLARA By <br />This is a true and exact reproduction of the document officially registered and placed�`� <br />on file in the VITAL RECORDS SECTION, DEPARTMENT OF PUBLIC HEALTH. MARTIN D. FENSTERSHEIB <br />0 c 7 / HEALTH OFFICER AND LOCAL REGISTRAR <br />OF BIRTHS AND DEATHS <br />This copy not valid unless prepared on engraved border displaying seal and signature of Registrar. <br />4 <br />M. MAIZE OF 010110LNM1 -PIROT IOIVLM) 2. MIDOII <br />3. URY IFAMILYI <br />Vivid' Mae <br />Cunningham <br />4. an OF SIRTH M M I G D I C C Y Y <br />E. AO[ YRS, lR 1 <br />Y R OU • f. <br />"1MINY,1. <br />Stt 7. DATE of DEATH M M I D D I c C Y Y <br />8. HOUR <br />DAY. DDS. <br />03/13/1919 <br />80 MDNTN.I <br />F 08/31/1999 <br />2215 <br />QECEDENT <br />f, STATE OF SIRTH ID. <br />SOCIAL SECURITY NO. 11. <br />MILITARY fERVICE <br />12. MARITAL STATUE <br />13. IDUCATI-EAR[ COMPLETED <br />PLl <br />NB <br />549 -26 -1828 <br />x0 <br />Divorced <br />1 <br />12 <br />DATA <br />DATA <br />1., No LINK <br />/ . RACE <br />16. HIS ►ANIC- OPLCIFY <br />IO. YSVAi [MPLAYtR <br />White <br />" "" <br />Self-Employed <br />PEr . ; ND <br />17. G01PA S "� 1 <br />R OOF W 1a. <br />YEARS IN OCCUPATION <br />Homemake <br />Own Hamel - <br />60 <br />20. lIIEIDEII AMd:MMALO OR LOg;AT10 .... -::. <br />Fa <br />b. <br />° <br />22 COUNTY, ' <br />; L4. MS IN COUNTY <br />25. STATE OR FORK COUNTRY <br />� teuntain Vi ` <br />anTa a <br />9404-0 31 <br />California <br />"NAME, RELATIONtMIP <br />27, MAHJNC ADDRESS ISTMR AND NtM- DR RURAL RDUT[ NUMStR, clrY OR tewN, 1Tw,l, ZIP) <br />RiWt y, (Soo <br />5069 Corbin Ave., R Jose, CA 95118 <br />20. <br />" *POW[4. ►TROT _ 2E. <br />MIDOL4! ?O. <br />LAST 4m <br />'ICI" <br />f 11 <br />NA ATM S1 32. <br />MIDOL! <br />T <br />34. 11R,M nATs <br />EsN�r�y <br />�Rt <br />Hays <br />P <br />Mott <br />NY <br />$8. NA GF waliaER� -FIRST 38. <br />MIDDLE 37. <br />WT IMAIOEN� <br />18. OIRTN OTAT[ <br />d <br />„� <br />M, <br />pn'i' II ° �;� Weaver <br />� <br />NY <br />dN(a1 <br />g <br />a <br />6'akwood Memorial P Park Santa`Crut, CA <br />a <br />1II <br />41 T1OM(b <br />4 . wa...LINE OF [NRALMER .:. <br />43. LIGENS! MO. <br />1FYR�ntR4p <br />tot Embalmed <br />- <br />�I <br />44�JUME aIF NERAI., DIRECTOR <br />45. LICENSE N6. pis. SI ATUR[ LO DAL RESISTRA <br />w► <br />47, CIA M M / D D / C C <br />d <br />iatrocrd lMemartal_iar 1 <br />fiD1530 �r� a <br />III <br />09/02/1999 <br />.� <br />i0 gPT�CL s • ...> ... <br />102. IF H�PITAW �IECIFY QNN . <br />�,« <br />FA1IYIJTY R1HU 1�lA.{11ASN :� id. <br />COUNTY <br />nFain'�3ew'EFtk ; e .Ctr. <br />0 "IP E) R C] N <br />R� @ARE OI Santa <br />Clara <br />„ <br />T ADD S-If ATIq P ER OR LOCATION) 'i <br />10µa I <br />l ��II <br />25 <br />CITY <br />S61at" Place <br />View <br />- ' <br />ICt. ,SAIJS , SYI (ENTm,*4LT ONE CAUS! PER LINE FOR.. I O, C. AND. D! <br />108. DEATH REPORTED TO CORONER <br />X <br />© <br />Te <br />• <br />Rl�[RRAL NUN ND <br />s <br />#A) CARDIOPULMONARY ARREST <br />NS. <br />245 -IY5 <br />_ <br />' �./ <br />I VIII <br />10f. WO FEY PERFORMED <br />�I III i <br />nurTO csl ` (;' ,CORONARY ARTERY DISEASE '.. ;g <br />YEARS <br />vu No <br />I Io. AUTO- PERFORMED <br />Yn ®NO <br />CAUSE <br />OF <br />'1 <br />TO <br />DEATH <br />ry����IE.' ,1C1II�I <br />111. USED IN DETERMINING CAUSE <br />�r <br />1n1 <br />s <br />YES O ND <br />1 IA. -OTM T L GB/TSRYTING TO OE CTN SUT NOT Rt1.AiD TO. � GIVEN IN 107 <br />` <br />CONG - = T TAIL*E, S/P 'UCEjdAK!Y: , "ES <br />� <br />„ <br />Its. WA - Y COW DfT10N IN ITEMS S• LIST TYK OR OF[RAT1al1 A" @'ATE. <br />NO <br />114. 1 C[IITST THAT TO THE SENT OF MV KNOWL- 1 <br />Is. SIG ATURE AND TITLE OF CERTIFIER 118. LICENSE NO. <br />117. DATE M M to D/ C C Y <br />`ti PN'FfH <br />!GU DEATH OCCURRED AT THE HOUR, DATE <br />AMO Fl.ACE STATED THE CAU611 STATED. ► <br />C050043 <br />09 /01 / 1999 <br />FROM <br />�N M <br />A. <br />NORRJO DA ICC III /DO /C�CEP YLI- IIa. <br />1 <br />TYPE ATTENDING PHTSICIAN'S NAM MAILING ADDR[EE, 21p CA 94087 <br />noN'' <br />03/25/1999 1 08/09/1999 Gaeta <br />Krishnapriyan, MD 665 Knickerbocker Dr. #5,Sunnyvale <br />1 CERTIFY THAT RE MY ONMIGH DEATH :120. <br />INJURY AT <br />WORK 121, INJURY DAYS M M 111111 C C Y Y <br />ISf. HOUR 123. <br />PLACE OF INJURY <br />OCCYARSD AT THE NOWT. DATE AND PLACE <br />STATED FROM THE CAUSES STATED. <br />❑ <br />YES F1 <br />NO <br />1 <br />M,LNNt" OF DEATH <br />124. <br />a��MATURAL � SWCI @[ � HOMICIDE <br />DESCRISL HOW INJURY OCCURRED (EVENT! WHICH RESULTED IN INJURY) <br />�b'!R@ RtE <br />: PEMD/NO COULD NOT S[ <br />NT INY[lTNiA N� D[l[RMINtD <br />DNLT <br />121; C., 1*1R <br />L TIEET AND NUMSER OR LOCATION AND CITY, ZIP) <br />IaS. 0ININATIAt 60 GORONRR 0R DEPUTY CORONER 127. <br />DATE MMIDD/CCYY Ila. <br />TYPED NAME, TITLE OF CORONER OR DEPUTY CORONER <br />fTATE <br />A <br />a <br />C D <br />a <br />F <br />O H <br />FAX ALITN.IS <br />00626 <br />CEN3 Us TRACT <br />RcwIS,7111LR <br />ERTI IED C <br />PY O <br />VITAL <br />RECD DS <br />ST SS DATE ISSUED <br />COUNTY OF SANTA CLARA By <br />This is a true and exact reproduction of the document officially registered and placed�`� <br />on file in the VITAL RECORDS SECTION, DEPARTMENT OF PUBLIC HEALTH. MARTIN D. FENSTERSHEIB <br />0 c 7 / HEALTH OFFICER AND LOCAL REGISTRAR <br />OF BIRTHS AND DEATHS <br />This copy not valid unless prepared on engraved border displaying seal and signature of Registrar. <br />4 <br />