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, <br />STATE OF CALIFORNIA <br />CERTIFICATION OF VITAL RECORD <br />11; <br />/11 <br />COUNTY OF MARIN 20200010 <br />SAN RAFAEL, CALIFORNIA <br />CERTIFICATE OF DEATH <br />STE U OF D6lWOWM <br />STATE ALE NUMBER <br />WE BLACK NK qAY/H FEMA St EOUfS OR ALTERATIONS <br />3201221001192 <br />LOCAL REGISTRATION NUMBER <br />DECEDENTS PERSONAL DATA <br />1. NAME OF DECEDENT -FIRST (Dean) <br />LUCIEN <br />2. MIDDLE <br />MATHIAS <br />3. LAST (Famgy) <br />PEREZ <br />AKA. ALSO KNOWN AS - IMude IW ARA (FIRST, MIDDLE. LAST) <br />A. DATE OF BIRTH mMOd/ccyy <br />07/12/1926 <br />5 AGE Ara. I IF UNDERDEC YEAR <br />86 Monts , an <br />FUNDER{AIISRS <br />Hmwm """" <br />6 SEX <br />9. BIRTH STATE/FOREIGN COUNTRY <br />FRANCE <br />,0. SOCIAL SECURITY NUMBER <br />530-20-1211 <br />1 I. EVER N U.S. ARMED <br />. YES X <br />FORCES? <br />No fl UM, <br />12.,AARTALSTARRSROP ea Tm 0AMI <br />MARRIED <br />7. DATE OF DEATH mAUNRRyy <br />08/18/2012 <br />8. HOUR DI Reuel <br />1505 <br />IT EDUCATION-HgIWIM.IDgee <br />X"""""" Mpg <br />TARS WAS DECEDENT HISPANICMIWO(NISPNSSH? R rm.. OW....... EDW <br />f YES X IO <br />16. DECEDENTS RACE -UP '03 races ROT b. Nt04 ReeWRNneelan bcq <br />CAUCASIAN <br />17. USUAL OCCUPATION - Type of wort for RHO of U. DO NOT USE RETIRED <br />LANDSCAPER <br />18. KIND OF BUSINESS OR NDUSTRY (e.g.. grocery sign, road construction. employment agency, Mc.) <br />LANDSCAPING <br />19. YEARS IN OCCUPATION <br />40 <br />_, Ski5�T2j <br />2 3 <br />E <br />20. DECEDENTS RESIDENCE (SI M and number. U1 EERIE,) �•. <br />800 TAMARACK DRIVE <br />21. CITY <br />SAN RAFAEL <br />22. COUNTY/PROVINCE23. ZIP CODE <br />I MARIN 194903 <br />24. YEARS IN COUNTY <br />. 40 <br />25. STATE/FOREIGN COUNTRY <br />CA <br />5 I <br />: <br />SAR26. AH PEREZ, SPOUSEIP <br />SARAH PEREZ, <br />800 TAMARACK DRKE, SANRAFAEL <br />CA 94903 an'''t <br />SPOUSE/SRDP ARO <br />PARENT NFORMATYN <br />28. NAME OF SURVIVING SPOUSE/SRDP,-FIRST <br />SARAH <br />29. MIME <br />L. <br />*LAST (SMITH NAME) <br />LEUNG <br />91. NAME OF FATHER/PARENT-FIRST <br />EUPHRASIO <br />32. MIDDLE <br />- <br />31 EAST - <br />PEREZ <br />. <br />34. BIRTH STATE <br />SPAIN <br />35. NAME OF MOTHER/PARENT-FRET <br />BALBINA <br />36. MIDDLE <br />- <br />37. UST (BIRTH NAME) <br />GONI <br />38. BIRTH STATE <br />SPAIN <br />FUNERAL DIRECTOR/ <br />LOCAL REGISTRAR Il <br />39. DISPOSITION DATE rnmkkyNyy <br />08/24/2012 <br />AO. PlACE OF FINAL DISPOSITION MOUNT OLIVET CEMETERY <br />270 LOS RANCHITOS ROAD, SAN RAFAEL, CA 94903 <br />Al. TYPE OF DISPOSITION(S) <br />CR/BU <br />W. SIGNATURE OF EMBALMER <br />► BRIAN HOOD <br />^`"* <br />43. UCENSE NUMBER <br />EMB8471 <br />M. NAME OF FUNERAL ESTABUSHMENT <br />MONTE'S CHAPEL OF THE HILLS <br />A5. LICENSE NUMBER <br />FD602 <br />4. SIGNATURE OF LOCAL REGISTRAR <br />► CRAIG A LINDQUIST, MD, PHD <br />go <br />47. DATE mm/dN¢yy <br />08/22/2012 <br />101. PUCE OF DEATH <br />n, OWN RESIDENCE <br />102. IF HOSPITALL, SPECIFY ONE <br />❑ 1P ❑ mon Q oak <br />103.1F OTHER <br />Q HolpiCY <br />THAN HOSPITAL. SPECIFY ONE <br />❑ M' KTC X D''''''' ❑ 01w <br />gg 106. CeUNTY <br />d MARIN <br />105. FAGUTY ADDRESS OR LOCATION WHERE FOUND (Street andnunbr. RI location) <br />800 TAMARACK DRIVE <br />100. CITY <br />SAN RAFAEL <br />CAUSE OF DEATN <br />z' z= .t=='ill <br />s <br />m41i— E it?. E <br />i 1 HH !IFii Rs '4 <br />p Nm <br />i i 11 p <br />-ila <br />: o m <br />D s <br />m _ m <br />I {g <br />a p R <br />a i <br />1 <br />1 7 „c lit <br />1 <br />A 11 <br />288 <br />1 <br />l EOW*AMem <br />o../....a...■ <br />118 QflR TO <br />YES XX-, NO <br />(AT)weeme.,,we.. <br />SEC. <br />;�n <br />'DAYS <br />59.B0PSYPERFORMED7 <br />❑YES <br />X <br />NIG <br />-: 1L11 <br />20 YRS. <br />110.%AUTOPSY PERFORMED? <br />'}UT <br />�s <br />X <br />NO <br />on <br />MUSED IN OETERMWWGCWSEP <br />■ YTS <br />■ <br />NO <br />It3A F FEMALE R@W6TNWTYTMT <br />•YFs •NO ILNc <br />ea § W,14REOORDOEANOIDMFYTWWTIEEESTOFMT71074 DEiWH00. <br />PIAOSW®ROATIECVWNSD SO <br />Needed sinus Mad. Lae sm.,Iwe <br />115. SIGNATURE AND TITLE OF CERTIFIER <br />F <br />0. JOSEPH ANTOINE HABIS M.D. a <br />1111 LICENSE NUMBER: <br />G73451 <br />IIT. DATE RNIddICRYy <br />08/21/2012 <br />1DeMden <br />(A) mmPoNcyy <br />• J 01/15/2009 <br />(B) mMOyccyy <br />08/03/20127 <br />118. TYPE ATTENDING PHYSICIAN'S NAME, MAILING ADDRESS. ZIP CODE <br />JOSEPH ANTOINE <br />4000 CIVIC CENTER DR STE 200B, SAN RAFAEL, CA <br />HABIS M.D. <br />94903 <br />MANN�OF (MATH a (WNW I 1 ACGORpa� <br />MolNt � Suicide ®� ....°'":1,..... CAUSESCorti MI. Mel i 1---,1 I20. Ni'_. i IJURED AT SA; Q <br />1-i LJ �J <br />121. gLIUP' DATE me✓ddtryY <br />122. HOUR calico* <br />) 123. PLACE OF INJURY Mg. NATO, co sbudlon rte, wooded nee. etc.) <br />g124. DESCRIBE HOW INJURY OCCURRED (Events which resulted In A)urp) <br />N <br />ZW <br />125. LOCATION OF FLOURY (Sheet and mnnlOao or location, end.000113, AM 0(B) <br />126. SIGNATURE OF CORONER / DEPUTY CORONER <br />► <br />127. DATE nONdyccyy <br />128. TYPE NAME. TITLE OF CORONER / DEPUTY CORONER <br />STATE <br />REGISTRAR <br />A <br />B <br />C <br />D <br />E <br />9ry p <br />I,,, IIIII'�'.'.', ',I,�'. 111111111111111111111111111311111111111H <br />'010001002136155' <br />FAX AUTH.9 <br />CENSUS TRACT <br />fili <br />This ia-a true and exact reproduction of the document officially registered and <br />placed on file in the VITAL RECORD SECTION, MARIN COUNTY PUBLIC <br />HEALTH DEPARTMENT. <br />081 22/ 2012 <br />hiLl IIIIHUUII I LI <br />ill <br />)N,IJ <br />NkYf�l` H1�11 m <br />Cr Ig A. Lindquist MD, PhD <br />Marin County, California <br />magagiailigainumicral caurviausi kids iligaailip <br />DATE ISSUED <br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE 1, <br />4L <br />