Page 14 - hb1906_docs

ITATI LOCAL ltl'GIITIIA'TlON •
CERTIFICATE OF DE'ATH DmlUCTAIIO
STATE OF CALIFORNIA-OEP RTIIENT OF PUBLIC HEALTH 3672
OF 0£CEASED---n!ST NAIi[ la. NIOOU: NAIIE I k , I.AST NAIIE 2A. .... ~ ,2, ~
Martha . 1 Elizabet~ l New~omb Febru 1960 I :.de. A
3. so. 4. CO(OR OR RACE 5. BIRTHPLACE ~':,' • 00 • - 6. DA TE ,OF BIRTH
Femal'! White Ohio Janua 1891 69
DECEDENT 8, NAME AHO lllRTKPLACE OF FATHER 9, MAIDEN NAME ANO BIRTHPLACE OF MOTHER 10. CITIZEN or WHAT COUNTRY II. SOCIAL StcURITT H,Ull9Elt
PERSONAL ·Alexander Kech- Germli Anna Krom- Ohio r.s.A. 46-42-21 o A
DATA
12. LAST OCCUPATION 14. NAIi£ or LAST ENl't.OTING cow,AHY OR mu, ;:~~:-""'" 15. KIND OF INDUSTRY OR BUSINESS
Mana er 18 Self Motel
18•. NAME OF PRESENT SPOUSE 18t, PRESENT OR LAST OCCUPATION OF SPOUSE
I
No
19A. PUCE OF DEA~[ or HOSPITAL 191. STREET ADDRESS-,c:,vr nun oa IIOIIAL ADDRU$ oa LOCATION ,oo NOT un ,. o eox NU111ns1
r:1-cm
PLACE lone 21610 • Cleardale Rd. □ ""'°'"" ~ ~'="""
=-'"
OF
DEATH 19c. CITY Of! TOWN 190. COUNTY 19, lEN<i'Tll Of' STAY IN
CAUrORNIA
Newhall Los An eles 66
LAST USUAL 20A. LAST USUAL RESIDENCE-STIIECT AOOl!ESS '""'""'' ., OUTSID( cm (Otl,c)(II.A' t llWllS ·21A, NAME OF INFORMANT '" OTHCII THAN s_,r,
RESIDENCE N ..... ANIOilotlOUnotl IO-'tlMP 0 IOl,,aivtnPti1 ( 111((,1 Olt(
21610 w. Cleardale Hri. Lavender E. Gilliland
•- DIO DlCURD
uvr--. • IIISll'M'IOII 20c. CITY OR TOWN 200. C01JNTY 20r. STATE 211 ADDRESS OF INFORMANT ;:_:;;=.•-...,.°"'.""--
mDIIUIOlla-
DHAUOIITin(
PHYSICIAN'S
OIi tbl :Rillfll i
CERTIFJCA TION 22D. ADDRESS levball
.... HC .... •-or,D<C:CA6CDAl•<ou1o«o ■TLAW 242'.3.7 N. S.:1n F~rnlindo Rd.
25. NAME OF CEMETERY OR CREMATORY
Cremation 2-19-60 Restland Crematory
27. NAME Of" FUNERAL DIRECTOR.':'~"'"- 28 ~~:=~t!"'-
: ilburn's F neral Cha l FEB 1· 9 1960
t/- tNru OfrlLT ON( CAUSt ,u UNt fOlt t,U . c ■ , , AND cc,
,ART L DEATH WAS C.WSCO IY,
INNClltATE CAUSE 1••-------"'==<-=-"-'='-"''--=""-":.e-X-__,,u,~~-~"-- --------- --+ ------1
A t
l
·
i h ff
c.o~o,.,·10Ha. 11,
:.:~;.;.~:;.; ouc To "'------==r'-"'_,,e,.,r"-"'"'o,.,,s=ct.e.~e~r!..o~sit..~s!..._w~!,_,!,t~_..!;~Jl.li!A...J<.:!iil12.~j!.lj4 1t!!i~ .. ..._.......__....,,...M.......,
A8OVI CAI.fee DEATH
CAI ffA'ftMG TMC
UNOUILYINO OU( lO ,c,
CAUN .......
,uT II: OTH[lt SIGNIFICANT CONDITIONS CONTRIIUTING TO DEATH IIIT NOT REUTCO TO TH[ TERMINAL DISEASE CONDITION GIVEN IN PART I IAI

••• •u•

35c. PLACE OF INJURY 350. CITY. TOWN. OR LOCATION COUIITY nut