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H1 5951 <br />G <br />rp <br />M <br />I <br />COUNTY of SANTA CLARA <br />PUBLIC HEALTH DEPARTMENT 200304055 <br />VITAL RECORDS AND REGISTRATION <br />645 SOUTH BASCOM AVENUE, SAN JOSE, CALIFORNIA 95128 <br />CERTIFICATE''OF DEATH <br />STATE OF CA.-NIA <br />USE BLACK INK ..",NO ERASURES, WHITEOUTS OR ALTERATION. LOCAL REGISTRATION NUMBER <br />..... <br />.._... _...__. ._ .. ...__. <br />1. NAME or DECEIINT -FIRIT (GIVEN, 2. MID L <br />3. LAST IFAwILr) <br />Richard Walter <br />Becker <br />4. GATE OF BIRTH M M I D D I C C Y Y <br />C. w08 Ylif. . 1 v <br />°'" "'E <br />ER 24". OURE 6. <br />SEX <br />M <br />7, E OF DEATH M/ O D/ C C Y <br />6. HOUR <br />pDR. MNNT <br />M <br />10/26/2002 <br />0920 <br />10/14/1938 <br />64 ; <br />; <br />9. STATE OF BIRTH <br />10. SOCIAL fECURITY NO. <br />11. MILITARY SERVICE, <br />12. MARITAL STATUB <br />13. EDUCATION -v EARS COMPLETED <br />DECEDENT <br />PERSONAL <br />-3557 <br />Q ®No ❑ <br />Married <br />18 <br />DATA <br />NE <br />016 -30 <br />y[y, uN. <br />14. RACE 15. <br />HI -NIC- SPECIFY <br />16. USVAL EMPLOYER <br />White <br />Y[t ® No <br />V. M. Labs <br />18. <br />HIND OT 'SU.1HCff <br />19. YEARS IN OCCUPATION <br />17. OCCUPATION <br />40 <br />Research Scientist <br />Computer <br />20. Rlflp[NC!- (1TRE`T; N° ....ER OR LOCATION, ' <br />1133 Robin Wa <br />USUAL <br />22. COVNTY 23, 24087 24. YRS IN COUNTY 25. STATE OR FoR E(ON COUNTRY <br />RESIDENCE <br />21. CITY <br />CA <br />Sunnyvale Santa Clara 94087 28 <br />_ . a -.- ' <br />26. AMC, N RELATIONSHIP <br />INFORMANT <br />Janice Becker Wife 1133 Robin Way,Sunnyvale,CA. -94087 <br />28. NAME OF ISURVI -G fPOU.E -FIRST 29. <br />MIDDLE 30, <br />LAST (MAIDEN NAME) <br />Janice <br />Arlene <br />Kuck <br />SPOUSE <br />31. NAME OF PATNCR -FIRCT 32. <br />MIODL! 33. <br />LAST <br />N <br />34. aI RT ErAr <br />ANO <br />PARENT <br />Walter <br />Henry <br />Becker <br />NEE <br />INFORMATION <br />34. NAME :OF MOTNER- -FIRST 36. <br />MIDDLE 37. <br />LAST IMAIOEN, <br />38. einrl. " T <br />NE <br />Dorothy <br />Bernice <br />Voss <br />39. DATE N M / D D I C C <br />..*-TI.. <br />PAE OF FINAL <br />DISPOSITION(S) <br />10/29/2002 <br />Alta Mesa Memorial Park,695 Arastradero Rd., Palo .Alto,CA,.94306 - <br />-z-17 -Pr OF .,--ON(s) <br />42. SIGNATURE OF EMSALMER <br />43. 1ICIS -9 NO. <br />FUNERAL <br />DIRECTOR <br />Cr /OA� U <br />(• Not Embalmed <br />AND <br />NAME OF UNRAL DIRECTOR 43 SE . UCEN N0. 46. SIG TUB[ OR L E61fTRAR 47. DATE M. M / D o , C C v Y <br />bq, F E <br />LOCAL <br />Mortuaries, Los Altos FD-927 jo. 1PA&A . 0/29/2002 MJS <br />REGISTRAR <br />Spangler <br />101. �PU1LE[ OF OC,1ATTN 1OE. IF HOSPIT- .P[CIfY ONE: 103. FACILITY OTHER THAN .0-1 L: 104. cEI <br />Own Residence CONY. RCS. .Santa Clara <br />O <br />PLACE <br />O IP � EA /OP D DOA HOSP. CwR[ OTN[R ' <br />OF <br />105. fTR6[T ADORIft -(STREET AND NUMBER OR LOCATION) <br />106. CITY <br />DEATH <br />1133 Robin Way. <br />Sunnyvale. <br />107. DEATH WAS CAUSED BY (ENTER ONLY ONE CAUSE PC.' LINE FOR A. B, C, AND D) <br />TIME INTERVAL <br />.DWEFN ONEEl <br />106. DEATH R! OPTED TO 10....R <br />- <br />M.D BEAT. <br />�yryl <br />IT.I V[s No <br />IMMEDIATE <br />13 Mos. <br />�T JO <br />E.�2'� <br />CAUSE (A) Cancer, Oropharynx <br />/O <br />109..^91110PSY PERFORM EO <br />D A <br />DUE TO IS). <br />YES NO <br />110, AUTOPSY PERFORMED <br />CAUSE <br />Q E� <br />OF <br />DUE TO (C) <br />YES No <br />DEATH <br />111. USED IN DETERMINING CAUSE <br />O <br />DUE TO (D) <br />YES NO <br />112. OTHFR fIGNIFICAN CONDITIONS CONTRIBUTIND TO DEATH OUT NOT RELATED TO CAUSE GIVEN IN 107 <br />None <br />113. WAS OPERATION PERFORMED FOR ANY CONDITION IN ITEM 107 OR 1121 IF YES, LIST TYPE OF OPERATION AND DATE. <br />No <br />EDGE DEATH OCCUINI [D AT TNl NO UIt DAT E <br />r'ATU /iE_ ND TITLE OF CIERTIF,IFR � <br />%, <br />1`1A6 LICENSE <br />7 L 1 1 7 . DATE M N I D D I C C Y Y Y <br />V / 10/ L 002 <br />PHYSI <br />AND T I C T 10. <br />N -!/� v "' <br />j _`� �� G <br />. <br />C AN 8 <br />DECEDENT ATTENDEDSINCE DECEDENT LAST <br />V11 <br />AILING ADDRESS, ZIP <br />B. TYPE ATTENDING PHYSICIANS NAME, <br />C ERTIFICA. <br />M DICCYY M M D I C <br />i <br />Camino Real,Palo Alto,CA 94301 <br />TION <br />11/03/1999 ; 10/26/2002 Jaya <br />Virmani, M.D. 795 El <br />I CERTIFY THAT IN MY OPINION DEATH 120. <br />OCCURRED AT THE HOUR. DATE AND PLACE <br />INJURY AT WOK. <br />II21. INJURY DATE M M I O D I C C Y Y <br />1 <br />122. HOUR 123. <br />PLACE .1 INJURY <br />STATED FROM THE CAUSES STATED. <br />❑ yEt ❑ NO <br />119. MANNER OF DEATH 124. <br />DESCRIBE HOW INJURY OCCURRED (EVENTS WHICH RESULTED IN INJURY) <br />NATURAL fU1C1D! HOMICIDE <br />CORONER'S <br />❑ ACC IDENTa MV SITI6ATION❑ DETERMINED C <br />ONLY <br />125. LOCATION (STREET AND NUMBER OR LOCATION AND CITY. ZIP) <br />126. SIGNATURE OF CORONER OR DEPUTY CORONER <br />127, DATE M M I D D I C C 1 1 <br />126. TYPED NAME, TITLE OF CORONER OR DEPUTY CORONER <br />D <br />E <br />F <br />G <br />N <br />F <br />A9 N 4 <br />CENSUS TRACT <br />STATE <br />S <br />C <br />03 <br />r. GISTRAR <br />ors 1 lr)w %,vr T yr vi i s►- mcL unwn nnnn <br />STATE OF CALIFORNIA SS ISS .UE D NOV Q � 2V4L <br />DATE <br />COUNTY OF SANTA CLARA By E,EE <br />This Is a true and exact reproduction of the document officially registered and placedK` <br />on file in the VITAL RECORDS SECTION, DEPARTMENT OF PUBLIC HEALTH. MARTIN D. FENSTERSHEIB <br />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 />_ R Igy1 II <br />y. 4 <br />t <br />