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<br />f`, tERTlFltATE OF DEATH
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<br />Elmer ! E. ± TaKt;e ~ dctobez 12. 1975 i 4:2$ PN
<br /> 3 5£% ~ COLOR OR RACE
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<br /> Male Caucasian Nebraska January 9, 1911 55
<br />rEANS
<br /> DECEDEYT 8 NAME Ate BNRNPLRCE OF FATHER S MAIDEN NAME Aw0 BYSTYPLACE OF lgTRER
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<br />DATA ~Chazlea Tagge -Nebraska , Lena Benefelt - Nebraska
<br /> p, CRIZEN OF WHAT COUNTRT R SOCU1 SECURRT NiJM~R f2 .••ncs. nrnvur NAyrtA •nyOwED 13 NAME OF SiW.ViYRY SPOttSE rM sc enn y>7,N~s
<br /> II.S.A. 508-09-1074 Divorced
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<br />~ 76 MANE of us: u.LOrwb CoyrANV c+r TWN n tcR+o of t»DUSTar OR BIPSNfE55
<br /> Carpenter 35 ~N`~S!"to~ey Ca. Construction
<br /> 78. PLACE OF DEATH-NAME !K HOSPITAL OR OTHER DI-IATeEMT EAtAm X18• STREET ADDRESS--.stsFA Any ANNy0. a [DCATCN• smmE flit TDq,., t~1y
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<br />Dameron Hospital ~ 525 W. Acacia St
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<br /> Stockton ' San Joaquin ' 10 4
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<br /> DSUAAI 19A. USI;AL RESIDENCE-SiFEET ADDRE>5 rzneEEr Aso wryEy ar w[.nd.s 19y W:1DE tm GdVORRTE LARTS 2D !~AyE AtiD YAR.lYCa ADDRESS ~ MFOAI~If
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<br />1504 RoselaTAm Yea - Deanna R. Rays
<br /> asNm+•Ni EATER t9c. CRT OR TOEMN 719y CODNTY ii9E STATE 20327 Blose Ave.
<br /> = Stockton ; San Joaquin ; California Hilmar, Calif. 4532&
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<br />a< 23 NAYS OF CEMETERY Oft CREMATORY 2A. EMBALMER- TvfF In ysR. E••~NTe+ i+CENSf NyINlEJ
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<br /> 29. PART I DEATH WAS CAUSED M: ENTEII OhiT ONE tADSE LINE i011 A D. AND C
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<br /> STATE A_ e. c. D. E. F.
<br /> REGISTRAR
<br />Z, Sack J. FTilliaras, M. D., Local Registrar of Vital Statistics for the County of San Joaquin,
<br />do hereby certify that the foregoing is a true and correct copy of the certificate on file
<br />in my office. f~~n~~ -.
<br />By. Cj~~ +rA~~/
<br />Deputy Registrar
<br />Date:; aCTOffiR 13, 1976
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