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1. 1 23'760
<br />CoI�I IT' OF RIVERSIDE
<br />f�
<br />RIVERSIDE, CALIFORNIIA';°
<br />200809849 inst.l 2008
<br />�- 8.4'79
<br />CERTIFICATE OF DEATH
<br />ATE CALIFORNIA
<br />OF
<br />STATE FILE NUMBER USE BLACK INK ONLV /NO ERASURES, IFLOUYS.OR pLi ERAT'.O ry:S
<br />�+^,
<br />V. I1 'REV IIGOI LICAL 1'i,E618TRAT10N
<br />�`
<br />nwm[
<br />Nu MBER
<br />V
<br />1. or P xr TACT 'eirervl 2. M.PO.L 'J LARYIF M1k1)
<br />11/17/2001
<br />0918
<br />Wayne Harlan Bl'y
<br />9. STATE OF BIRTH 10,
<br />SOCIAL 8 c NO,
<br />4.D E BIRTH MM ✓q D/c'cvv 9. ACEV S wly xouR
<br />�iIOxTH b RST .rvures 6 SEZ �. DATE HOUR
<br />08/22/1915 86 R I
<br />This is a true and exact reproducton of the,document officially registered and ! � ��� gryv
<br />placed on file in the office of County of RivOtside, Department of Health. Gary FeldmAn M'b,
<br />Loral Registrar
<br />RIVERSIDE COUNTY, CALIFORNIA
<br />DATE ISSUED 1 1 / 6 / 20U1
<br />This copy not valid unless prepared on engraved border displaying seal and signature of Registrar.
<br />f
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<br />M
<br />11/17/2001
<br />0918
<br />DECEDENT
<br />9. STATE OF BIRTH 10,
<br />SOCIAL 8 c NO,
<br />1 I. MILTT'Agv E vlc
<br />12.' MARITAL STATU
<br />�''
<br />13. ED CATION -YEARS COMPLETED
<br />PE DATA
<br />NB
<br />555 -14 -9428
<br />-:.
<br />®
<br />DATA
<br />YES ❑RHO DNK
<br />MarY3.ed
<br />12
<br />14. RACE 15, HISPANIC - SPECIFY 18, USUAL EMPLOYER
<br />White ❑ Y¢® Nn Potlatch
<br />I7. OCCUPATION 10. KIND �,YSIM; 1.; TT : 1E. YEARS IN OCCUPATION
<br />_
<br />Lead Supervisor Paper Manufacturar., 30
<br />20, RESIDENCE-( AND NUMBED On „I:OCATIONV
<br />2230 Lake Park Drive #1.71
<br />USUAL
<br />RE91D6NCE
<br />21. clTV
<br />'R2, cou NT'Y:
<br />23. zIP 'conE
<br />24, IRS IN COUNTY
<br />26. STAFF OR FOREIDN co UNTRY
<br />San Jacinto
<br />Riverside ,;
<br />92583
<br />24
<br />CA
<br />29, NAME, RELATIONSHIP " "'
<br />VG ADD RERL FRMq w �q RURAL ROUx xuuq[w, cITT On TO— qT..T., TIP.
<br />INFORMANT
<br />Dorothy l W
<br />y � ifs 2230LI,jjke
<br />Park Earive.#171,San Jacinto, CA 92583
<br />2R. NAME Or SURVIVING efn. SE -FIRST
<br />u
<br />29.' IDDLL ':- ....'.30.
<br />LASTAMA. NwME'W„
<br />Dorothy
<br />L1
<br />Day
<br />31. NAME OF FwTHG. FIptTM •'
<br />SPOUSE
<br />34. Muk,
<br />BBT qFH eiwte
<br />PARENT
<br />Carlton ..
<br />Bl
<br />INFORMATION
<br />n b
<br />, NB
<br />3a. NAME OF MOTHER FIpbT
<br />3R µ,11PalE
<br />a7jj
<br />LANT (MAID N, :
<br />38, n RIH a r<
<br />Della
<br />`;
<br />j attersan �'
<br />NB
<br />39. RATE M ✓ D O� / c c W
<br />41?, PLA ✓ rti
<br />I b.T1 N
<br />DISPOSITION(S)
<br />11/21/2 1.
<br />1 41 OQ
<br />S t©
<br />h tort!
<br />I
<br />I t ', I I
<br />, Shelton Ng, I II
<br />FUNERAL
<br />41. TYPE OF DIYPGBIYl0 N1 R :II
<br />Apl 4 IrIRT „ d L dA'4M i ,, VIII �.
<br />�
<br />'I'
<br />IT
<br />. lE NO.
<br />DIRECTOR
<br />/+t}/Fp� r'
<br />CR R/ By
<br />j II
<br />1� Not
<br />R` �No 7+' � � I
<br />-
<br />(.ANAL
<br />d I I�,IC $pE N 4 DI zL� LO A R�U"Ii'+RI R il"
<br />47. DATE M M / D D
<br />44. NAME OF PUU+NERA DIRECTOR
<br />RE'G19TRAR
<br />��}}'�;
<br />McWane Tamil ✓ ELn Pal L1om
<br />'� 'D198 0- 1t'/
<br />11/21/2001
<br />101, PLACE Or DEATH,
<br />IGA.:':. `R PIFAW SPECWW WNE� 109,;FACILITI OTHER THAN HOSPITAL:
<br />104. COUNTY
<br />PLACE;
<br />OF
<br />Hemet Valley,:Medical Center
<br />J 1, ❑ ER/OP [I DOA' d , ❑ RARE T„ 4!
<br />Riverside
<br />DEATH
<br />105. STREET ADORESS-( #RE T AND NUMIl R OR LocATIONI is
<br />106, CITY:
<br />1117 E. Devonshire Avenue
<br />Hemet
<br />10]. DEATH WAS CAUSED BY: (ENTER ONLY ONE CA'U'SE. PER LINE FORA, B, C. AND D1
<br />TIMC IKT[RYAL
<br />'1 R, DEATH REPORTLb TO CORONER
<br />NOFN AFSET
<br />❑A
<br />KI
<br />minutes
<br />IMMEDIATE i
<br />CAUSE (A) Cardiopultnonary Atre t
<br />C. NO
<br />PAwL xu
<br />•...
<br />109, BIOPSY PBRKaRMED�-
<br />Dux TO (D) Pneumonia
<br />da s
<br />❑ YLf © NO
<br />CAUSE:
<br />--
<br />110. AUTOPSY PE RMEO
<br />RF©
<br />OF
<br />DEATH��IiI
<br />DUE TO (C)
<br />❑ TES" NO
<br />DUE to ID)
<br />TEa
<br />_
<br />THLR SIDN TI ONT
<br />c
<br />112. O CANS [nxblT.O RIDUTING TO DEATH BUT NOY RELATED 'TO CAUSE GIVEN IN 1 '
<br />PT
<br />None
<br />113. WAS OPERATIVN PERFORMED PON ANY CONDITION IN ITEM 107 OR 1127 IF YES, LIST TYPE OF OPERATION w e.
<br />No
<br />1 14.1 CERTIFY THAT TO YH[ BEST OF MY KNOWL-
<br />11 S. g w OF CERTIFIER
<br />116. n
<br />11 O. D D / c c T
<br />PHY$1
<br />CIpN'S
<br />EPGE LACE OCCURRED AT THE HOUR, SATE
<br />ANtl PLAN! STATED DECEDENT CAST STATED.
<br />THE
<br />[c
<br />DECEDENT ATFENPED SINCE I DECEDENT N!T liCN
<br />. `A-Ul Ai Y
<br />♦ _ _ L,
<br />A054049
<br />11/21/2001
<br />C ERTIPICA.
<br />M M / D D / L c Y Y MR / b b / c c TT
<br />11 B. TYPE ATTENDING, PHYSICIAN'S NAME, MAILING ADDRESS, ZIP -
<br />T1ON
<br />05/09/1996 11/17/2001
<br />Stephen McKenzie M.D.41511 E. Florida, 4emet, CA 92544
<br />1 CERTIFY THAT IN MI OPINION DEATH
<br />Oc'COR REn AT THE HOUR, DwTE AHD PLACE
<br />120, INJURY AT WORK
<br />121, INJURY DATE M M v D Of C C Y Y
<br />122. HOUR 129,
<br />PLACE OF INJURY
<br />BTgFEp FRO- TXE Cr- STATED.
<br />Ih�I
<br />❑ I IIJD
<br />119, MANNER OF DEATH.
<br />Y EEE....yyy�YYY
<br />124. B.EgCRjBE NOW NIMRI oC CIJ RED E E, Yd I H RESULTED IN JURY)
<br />❑ ❑
<br />NATURAL SUI 1 E ❑II OMI DE
<br />CORONER'S
<br />USE
<br />U NOT BE
<br />❑ ACCIDENT '' INV S 1 N DL [RM NED
<br />ONLY
<br />125, LOCATION (STREET M U -N R w LOCATION AND CITY T-
<br />I
<br />126 SIGNATURE OF CORONER OR DEPUTY CORONER
<br />121. DATE M M ✓n D✓ v I2W�
<br />T�, ED I�I,IyME, TIT" OF Rgf1ER GP PLPUTY ggq:,oN ER
<br />STATE
<br />REGI9TNAR
<br />A
<br />c C
<br />pRTIFI
<br />ED CO
<br />Y OF
<br />ITAL \tCOR
<br />"75 q59�...
<br />OEN9L.g TRACT
<br />IS
<br />STATE OF CALIFORNIA
<br />ss ,,fi�gg�, '" P "�
<br />COUNTY OF RIVERSIDE
<br />riXt�.['��i,,1. I •III T
<br />This is a true and exact reproducton of the,document officially registered and ! � ��� gryv
<br />placed on file in the office of County of RivOtside, Department of Health. Gary FeldmAn M'b,
<br />Loral Registrar
<br />RIVERSIDE COUNTY, CALIFORNIA
<br />DATE ISSUED 1 1 / 6 / 20U1
<br />This copy not valid unless prepared on engraved border displaying seal and signature of Registrar.
<br />f
<br />"Alt
<br />
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