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<br />CERTIFICATE OF DEAT H
<br />Use BLACK INK ONL SIT T. OF 1ALF.—A 3199941
<br />ST E FILE NUMB R: %1I.A. WHITIECUT. R ---- I '1!1!,I,,:LOCAL REdISt"ATION NUMBER
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<br />dERTW,1ED COPY OF VITAL REcb bg
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<br />T T OF 6X 1FORNAA,il "DATt'ISSM)
<br />COUNTY OF SA.
<br />This is a true and 1rC!!hct reproclIJ&Pon of th6ldocument officially registered and placed All
<br />on file in the office of the SAN MATEO 60LINTY HEALTH DEPARTMENT.
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<br />IV013MAN II, PRINCE
<br />RIEF
<br />H OFFICER AND REGISTRAR
<br />4. DATE 01 DID C Y I 6. All 1011, 1 I.A. IF U ..to alU a- SEA
<br />urqly�l Health Officer,
<br />DATE 00, DEATH I cc Y
<br />07/07/021 78 i ...... ewr. I ..... I'_ Male
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<br />`C RTIFY THAT IN M, OPINION DEATH 120.
<br />INJURY AT
<br />WORK 121. INJURY DATE M PIP 1 0 0
<br />1 C C Y Y 122. HOUR 123.
<br />PLACE Or INJURY
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<br />D.SCRISE NOW INJURY OCCURRED (EVENTS WHICH RESULT IN INJURY)
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<br />DAYS
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<br />F C A;9 2 2
<br />i7 I U ZS F1
<br />dERTW,1ED COPY OF VITAL REcb bg
<br />S AE
<br />T T OF 6X 1FORNAA,il "DATt'ISSM)
<br />COUNTY OF SA.
<br />This is a true and 1rC!!hct reproclIJ&Pon of th6ldocument officially registered and placed All
<br />on file in the office of the SAN MATEO 60LINTY HEALTH DEPARTMENT.
<br />n off HEAL
<br />1,11111 q!I11!
<br />This copy not valid unJe§s,Iprepoted`,on, engraved border displaying sea[ and signature, oft k .
<br />. ...... .. �J
<br />n W,
<br />SCOI MORROW, M.D.
<br />g
<br />H OFFICER AND REGISTRAR
<br />o -.
<br />urqly�l Health Officer,
<br />
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