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F '` COUNTY OF RIVERSIDE
<br />200809849 _ RIVERSIDE, CALIFORNIA fOSt 2008 -
<br />8 4 7 9
<br />CERTIF� A,0E DEATH 209
<br />.FU
<br />Wf NAn1 Y6l CLTIND@IAemEe.wHTK14TS IXiALTEMTION4 LOCAL REGISTRATION NUNS
<br />ry
<br />H
<br />STATE PILE NUMBER
<br />1. NAME OF DECEDENT - FIRST (GW-)
<br />YS11 4W
<br />2. MIDDLE
<br />3, LAST (Fem11,7
<br />4
<br />Dorothy
<br />Day
<br />Bl I 6. SEX
<br />G
<br />AKA. ALSO KNOWN AS •- IrNWd. IWI AKA (FIRST. MIDDLE, LAST)
<br />4, DATE 01 811 nmJdlraT/
<br />Q A,E Yn. Medw I m Hev.
<br />1 Uk".
<br />C
<br />_
<br />07/12/1917
<br />86
<br />F
<br />COUNTRY
<br />10. SOGAL SECURITY NUMBER
<br />11. EVER IN U.S. ARMED FORCC37
<br />12-
<br />MARITAL STATUS
<br />(a Thm'e1 DUB) 7.0DATE OFD
<br />60922 )
<br />q. BIRTH BTAYF/FOREIGN
<br />569 -32 -2455
<br />�YEB n.- 0- Widowed
<br />007
<br />WI
<br />13 E�O�WT�TKIN HtlrW y;ep�
<br />lBaerNheleonMre'Ys
<br />1V1e. WAS DECfDENr SPM11& NIISPANICIUTIN07 (B,�.e. naNN,.., m, C.eMJ I ,I.OECEDENT7RACE- UPW9rper mey""" dlam^� .
<br />2"0 Caucasian
<br />W
<br />[:]YE.
<br />G1T.
<br />u8UAi, OCCUPATION - Type
<br />d w xA Wr dru.( N.. DO NDT USE RETRED
<br />1e. KWD OF BUBwEB9 DR 6HDU8TRr' (e•9 � g1mT1'tl�� mb �"` DOn• rnPW/nvi ° '' �'1 1B
<br />YEAR IN OCCUPATION
<br />School Teacher
<br />Education
<br />30
<br />N. DECEDENT'S RESIDENCE IS— I or I-Wn)
<br />2230 Lake Park Drive 11171
<br />21. CITY ZL
<br />COUNTYUPROYINCE
<br />2a ZIP CODE 4. MIlaIS IN CO1INTY
<br />26. STATFJFOREKiN COUNTRY
<br />0
<br />San Jacinto
<br />Riverside
<br />92'583 27
<br />CA
<br />N, INFORMANT'S NAME. RELATIONSHIP
<br />57 ,.A IWNfd,.IIe-INGADDR AIM e110 mm1brV nlmue,wmbr,mly dr NYaI .I.I., ZIP)
<br />Lars, Chino CA 91709
<br />Sharon Kaatmann, Daughter
<br />14 9 �Il_�lJ6`ild ,Hills,
<br />N. NAME OF SURVIVING SPOUSE -- FIRST
<br />NDD4g'
<br />lA4T rte)
<br />31. NAME OF FATHER -• FIRST
<br />William
<br />01,
<br />0Wi('. -!
<br />Reeniy'
<br />aa.1/sT
<br />Day
<br />N. BIRTH STATE
<br />MN
<br />W, NAME OF MOTHER -• FIRST
<br />A--,-5R
<br />Elizabeth
<br />Y7. LAST (Maww)
<br />Krueger
<br />$e. BIRYH STATE
<br />MN
<br />N
<br />May
<br />::0�4/ ITION DT
<br />13/2004
<br />w P1 -ACE OF AL D
<br />Pomorr Va�1�y
<br />(ON
<br />Memorial O'he}y 50 Euapklin'Ave PitmeJtpp
<br />,�
<br />e
<br />a' BN3N
<br />LICE NUMBER
<br />TYF DISPOSITION(8)
<br />I.�I
<br />'' T
<br />7010
<br />Elf 44. NAME OF FUNERAL ESTMUMMENT ';
<br />45, IL }Y,
<br />1N + 04/08/2004
<br />DATE mlNdNd�y
<br />McWane Family FuneraHome
<br />F?�19$
<br />101. PLACE OF DEATH n, t
<br />�"
<br />DOA
<br />,, C m E DMER j7MIN HOSPITAL IFY ONE
<br />❑1�7, ❑N r.uq ;C ❑Pceaerdl ❑OMv
<br />Hemet Valle Medical Canter
<br />1M. TY
<br />Riverside
<br />109. FAGLI DRESS OR LOC WHERE Yry�lpl Wl "' 1
<br />AT ^
<br />City NRhW
<br />lrylnr ul "� I,: Hemet „
<br />1117 Devonshire ,
<br />107. CAUSE OF DEATH EnlN erlpminNevrN.; -dl. DYnb.r NM�,aeO, pyrdd -M DO NOT rer �n„e,d.•etlw ! ". TYm YenvJ ,�. DFAIHREPDRTEO
<br />M PMd m ene.A reepV6lYty.rreJ, a .delmA.r I �wi.,o.rinq du MkhgY. tla NOT ABBREVIATE °'d ❑
<br />TrO- CU}bIFAi
<br />YEB NO
<br />IMMEDIATE CAUSE W
<br />(nnM dh.... dr Respiratory ArreSit T,I ;i "u.: I M, its
<br />n,lUdn r.rdllrp III$.
<br />,•,'
<br />BIOPSY PERFORMED?
<br />a) ",ry �` ,II a ;. "1.Days ❑YEB
<br />�x No
<br />swaw.11e6Y, 6M Pneumonitie
<br />Ie'i ing W " (� 41,17 (an 1,0.
<br />LIMA E- p• •. 1 ❑
<br />UNDERLYING
<br />AUTOPSY PERFORMED?
<br />YES M NO
<br />Ory
<br />11b
<br />CAUSE tlm(dWme (DTl 111.
<br />,.
<br />w
<br />WED INDEIETYnM1 GIpE7NO
<br />El
<br />❑YE9
<br />- i.a,Md Ih)
<br />WP N6e.I LAST
<br />112. OTHER SIGNIFICANT CONDITIONS CO"TRIBUTNIG To DEATH HUI NO7 RESULTING IH --'N'S CAUSE GIVEN IN 107
<br />None
<br />113. WAS OPERATION PERFORMED FOR ANY CONDITION IN ITEM 1W OR 1157 CU Yr. I IA IF FEeP(f.
<br />❑YES
<br />PREGNANT W LAST YEAR?
<br />ID NO ❑uaq
<br />No
<br />1H. ICERDFYTIMTMTN9AES�Lw�&�W:y- LrM�%TY. UREAOTTREOFOERTiRETH
<br />DEATH
<br />116. LICENSE MJMBER 117. DATE
<br />mllYW -W
<br />AT THE I461R, DANE, A0 PLACE ED.
<br />745541 04 /O5
<br />/2004
<br />DeeeerN Aa-w SN we
<br />mnvddl ry 9 y
<br />TTEWIw3 RryeK AANB NAPE. NAILING 98, 21P ooDE John W Hunter M.D.
<br />W
<br />10/30/2003 ? 04/02/2004
<br />920 E Morton P1 Hemet, CA 92543
<br />In ICERTIFYTIMTWWORNION DEATH coa RRED AT THE HEAR DATE, AND PL ACE STATED RIDMTIE GAUSES STATED.
<br />120. KIIREGIATWOM
<br />❑TES ON' ❑LINK
<br />15,. INAIRT DATE IrerVdNa%t'
<br />155.Hp1R (24 Heue)
<br />?
<br />MANNEROFDEATH ❑FLb.eI ❑-- ❑HdmWM ❑a- ❑ m ❑darda.�l.d
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<br />12a. PUCE Of INJURY (e.p, Mme, dNRerutlm W., wm,dd eras eke)
<br />124. OESCRIBE HOW IN,NRY OCCURRED(EY.N. W -IM 11 IrI-Y)
<br />bdstlen, ertl CIIy rd ZIP)
<br />1
<br />125. LOCATION OF INJURY IS- eN Iwmbx, r
<br />12e. SIGNATURE OF CORONER I DEPUTY CORONER
<br />IS/.DATE mMdNdyy
<br />,2e. TTPE NAME. TIRE OF CORONER!DERTTY CORONER
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<br />A ® C C E
<br />FAX AIfTT5,6
<br />C[N9N8 TRACT
<br />STATE
<br />RRGISTRAR
<br />GERTI
<br />IED COPY F VITA
<br />146232
<br />P F COUNTY ON RIVERSIL)E ss
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<br />'
<br />unelcq yF °� This is a true and exact reproduction of the document officially registered and placed on file
<br />+I`lullllllll
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<br />in the office of County of Riverside, Department of Health; l-
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<br />Gary FGICman M 0 Local Registrar =1 80023
<br />9 RIVERSIDE COUNTY, CALIFORNIA
<br />� i �
<br />/' SIi +aW
<br />,+
<br />IT DATE ISSUED 04/15/2 004 �>
<br />AMIN
<br />This copy not valid unless prcpar d On engraved border displaying seal an f d signature o Registrar.
<br />2� F O a•� "B"
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