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STATE OF OREGON <br />OREGON STATE HEALTH DIVISION <br />N <br />DEPARTIVIEffl OF.HU�,% 87. 102367 <br />I <br />R ,,PESOURCES <br />Local F.In N <br />El <br />or ORS - 146 <br />In <br />RACE .—%, <br />619. <br />--weNool"L3 <br />. .... ... ........ . <br />aanuary 9, 1981 <br />CITY.T*W".CR LOCATION OF <br />want <br />Portland <br />TATS Of' �1 RTN <br />21 lo. Ax� <br />CPUNTwYJ <br />weep <br />SOCIAL SECURITY NUMBER <br />"' I. - W <br />%E <br />531-09-2746 <br />ITa.ws <br />13 <br />Z-.T-TZ C <br />.7"'O"N" <br />0regon <br />21F <br />FA HER .— F1— m- <br />Fredrick Scts' <br />r % L, e, vAovLA I" MAT.-- . Rmg <br />,A Burial <br />CE I vjrr I <br />STATE OF OREGON <br />OREGON STATE HEALTH DIVISION <br />N <br />DEPARTIVIEffl OF.HU�,% 87. 102367 <br />I <br />R ,,PESOURCES <br />CERTIFICATE OF DEATH <br />El <br />or ORS - 146 <br />State File Number <br />I—T <br />--weNool"L3 <br />HILDE'GARDE A. <br />aanuary 9, 1981 <br />04,NWA. <br />AV 0) <br />I .. a ' wT ATE Of MIRTH Imotorm, a^v- ya-.-mT- <br />"T" <br />NA <br />17- <br />21 lo. Ax� <br />22 S. W C <br />EITIM1W WHAT R Ito <br />.713 Multnomah <br />` . <br />'[, <br />OU IV RGED <br />- "USA <br />"' I. - W <br />%E <br />A, <br />5 <br />I,'w" S K a r � e <br />L <br />i.rnoiTign, ,c rorzianq I'm VVZZ, SW 3'Dtb yes <br />t He"rbener i aines - Karle husband <br />I... sTATz <br />Ri verview Cemetery I Portland Ore <br />ow <br />-Olgg,s Flaxsclp Springer Chapel <br />yerton, Oregon <br />STATE OF OREGOW-4 ORIGINAL - VITAL STATISTICS COPY <br />COUNTY OF'MEIt Tl.po <br />Date JAN 1 5 1981 <br />This ft--1_10 certify that:tht foregoing is',a reproduction of the original record which <br />was Wthe Multhooh.County Department of Human Services. <br />411ner <br />AGISTRA F VITAL STATISTICS <br />ire <br />r. <br />DEATH o;nl, r AS PROMOUNC90 rX <br />VK4ft <br />El <br />9,f 7 <br />:IA in 1981 4:00 El <br />. fl 0- - <br />--weNool"L3 <br />ja <br />C Irl R we <br />.;AL <br />21 lo. Ax� <br />21E LARRY V. LEWMAN, <br />M.D. <br />NER <br />D L <br />DATE $HMWEN rag;*-,W. -e... ;7*.;l <br />21F <br />January 12, 1981 <br />5 1981 <br />IAN 1 <br />L044j <br />PAM L4" <br />jip. k..Ja Tsior <br />N7 T <br />4"', T <br />SPkV,(j� FROM,4MIAL ATION OF CARB011; MOMX16E. <br />PART <br />­7 <br />N <br />O <br />DATEaF INJURY Dun <br />I I -40W INJURY OCCURRED <br />Z4 <br />zb^ Jan. 1. Inhaled auto exhaust <br />PLACE I I <br />INJ. A WORK INJURY AT - A. - .. - I <br />, . — ---- <br />D N <br />NO Auto in garage <br />L <br />9922 S.W. 30th, Portland, <br />Multnomah, Oregon <br />STATE OF OREGOW-4 ORIGINAL - VITAL STATISTICS COPY <br />COUNTY OF'MEIt Tl.po <br />Date JAN 1 5 1981 <br />This ft--1_10 certify that:tht foregoing is',a reproduction of the original record which <br />was Wthe Multhooh.County Department of Human Services. <br />411ner <br />AGISTRA F VITAL STATISTICS <br />ire <br />r. <br />