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FILED OCT 20 1145 MAME B. BfAm , Count)' Becorde! ov
Form 5 1. l'ULL DISTR ICT No.~l_Q~9~2 _ ___ ,RtGISTRAR 'S No._7......,2 .. 51._ __ _
NAME___John__lyatll;L.0.l!!Yl...te~~
2. PLACE OF DEATH , ( Al CoUNTY_LoJL.Ange.188 / - q :7 3 . USUAL RESI DE:ICE OF' DECEASED :
( B ) c m OR TOVHI Nati onal Mil 1.t.ary_ HQ.l'Oe~Jll- ( A) STATr.__ ___ -'C,.,_,,,a.l==it..::;o -=rn=-=1::.::ac..._ __ ,;?._ 7 _____ _
( C ) ~ A~~T~~EH~;;,~:zooWRN ,~~':;~ r 'u~~~INC RURAL Ho S_Jl1..,,.. +..a..,1 _ _____ ,11 u, c ouNTY ____ ..,L..,1o= s,_.A'""n=-1i,;i:= e,.,,l ..,e,e;s,<_ _________ _
Veter ans Adaministratio_n Facilitv , c , c1n oRTow11 sen Fernando
I V HOT ltl HOS P'IT>L OM INS TIT UTION• GIVE :a"EU ffUM Ulll (,R LUt ,HION ( - : J) If" OUT$10 t CITY 0111 TOWH LIMllS, Y. llllC RURA L
(0 ) L ENG TH OF STA Y: (SP'EC IFY WHtTHl:R 'fCA RS, MONTIIS OR DA'f S) / ,,_./
'"-----~-----Jl=~( O~)b S~T;,;ngE,;t,:,T~N~'o:;,;, ~P;;;e~~o~. ~B~o~x~.;3~3~2~=============
, N HOSPITAL OR INSTITUTIOll- --'A.,_..,,rl..,IR_,.,.p. " 0
111 TH1s coMMu N1n 6 days IN CALIF0R111.._'""'4=-4.,._~ve=_,,a..,rs= '--li 20. DATE o r DEATH , MoNT" September 23, 1945 D•Y·- ---
( £) I F FORE ICN BORN, HOVI LOUG IN THE U. S. A • YE.\ RS YeAR HouR 8: 35 A, M !l,l1NUT•
3 . ( El I F VETERA N, NA ME OF WAR II 3 , <F> SOCIA L S EC URITY No. 21. MEDIC A L C ERTIFICATE 22. CORONER'S CERTIFICATE
RnAn1 Ah AmAri ,-an II TJnknnwn I HEREBY CERTIFY. THAT I ATTEN DEo
11=::!,!!.a!,!!!,!!~ !!!,!,;;e!!,!!!!!!5,!!!,:!~~ !!,::===;;,===!!c=~,!!!!~~~i====,)fTII E DECEASED I HEREBY CERTIFY, THAT I HELD AN
4 . S EX ,,5. COLOR OR RACE 1,G. ( A ) SINGLE. MARRl ~D. W1 0ow1:o on FRO -September 17 , ,9_45
0 1 ORCED AIJ 'l'OrST. IHQU CS l Oft IH YCSTIGATI ON
sent ember 23,,9--49.
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11 •
6. ( 0 ) NAME OF' H use ND OR W IFE 1,6. ( C) AOE OF HUS0AND THAT I LAST SAW II i m •LIVE FROM SUCH ACTION TIIU DECU U D CAM( TO
OR Wtr E tr ALIVE -----~
"=5=Nli;i'~o~r~a~~O~l~ms§:;t~e§;§a~d~================~==~?=l6~ ==~Y,§EA~R~S~I 011 September 23. 19 45 I -~---- O( UH OH TH[ ••n ••• HOU ft
II; AND T HAT DEATH OCCUR RE D ON TH E DATE ST A'l' CD AIOvt.
AN D HOUR STA TE D A80 VC. DUR AT ION
7 . B l RTHDATE OF D ECEASEQ _ _ _.~::i.81_1.:..,~!.I! -,.!lll'--• e..J:'.._°.Li7•~.JJ1.8u_7..2._ 5 _ _ _ ~1 IMMEDIATE cAuse oF Den..Coron1=1rv beA,..t d iseaA1 TTnk.
- MONTH DAY
If IF LESS THAN ON E DAY OLD
~ B=-~A~G~E~7:alO~==~Y•~·~·:::jo~ =:lM~O~S~.~- ~1~6~ ~D•~v~•~ll==~~~H~•~··======~M~IN~I DU E TO- - --------------f-'J/-=.~=--11-- ---
9. 8 1RTHPLACrc__ ___ ___,W"""'i l!9.21!.1 - New YOrk
10. U SUAL O c c UPATION _ _ ..,,c,..a ... r ... pr:.e,,.,.,n,.,,t'-"e..,r,._.._{ R....,,ec...:te.-=1:.:re'--"'-=d ..... ) ____ 11 Due T0--------- - ---------11----
11. I NDU STRY OR 8 USJtl ESS__c_B.rlle_ ... nLJt..,e""r ...... 1~n~g- --------tl----------------- - ----iJ-----
~{ 12 . N AM E Watson Olms~rl orn ER coND1mmBro n ch ial Asthma, se.1:,..,e,,_,,l'e,._.. __ n_unk ....... =-•-
..... ._ _______ 11 tl HCLUD l l"lt[ Ct,Al~C'f Wlfltll, TH RCt MONTH$ o, DCAT H)
I~ 13. B I RTHPL,ArE JTn.kn,o .... w._n ____________ n---------------- -------n- ---
s ..... ka MAJOR F111u1NGs, PHYstctAN
:!; 14. MA IDEN NAM " era rar OF OPERATION·~-----------------11
:,: TJnkn DATE Of UNDULINl THE
:; 1s. 01 RTHPLAC "E.....- ----'-="'o= w'-'n,.__ _________ __ -1 1 _ _ ______________ 0PeRAn or: _ ___ -1,c•u•• TO wH 1c•
~6. ( A ) I NFO:IMANT Records of Veterans or AUTOPSY_ ..,JJ'.u<n'-.-'e...,.u'-' 1t,.,..n~na...,_v __________ -ll •~T:.:~~~~·
Administration Faci lllL.
( 9 1 ADDRESS •rn1s11cALLT
11. <• > Burial <• > D,.TE sept. 27, 1945 23. IF DEATH WAS DUE TO EXT ERNA L CAU SES , FILL If~ THE FOLLOWIN G:
DtlRIAL, rJIMA_lli_;J,N OR RUI OY A?.. ( A ) ACCIDCNT, SUICIDE, ( B ) DATE OF
<ci P LA"E xe,;erans Administration cemetery OR HOMI CI DE?- -------- INJUR Y ________ _
18. ( A ) EMBALMER 'S ~--orooe ,.. m.. LI CENSE (C) WHER E DID I
,- • A
SIGNATURE L~--e- L' ♦ ::UJJ"l'ler N 0 ,- - - ~·<-=-,...,....,_,..-11 INJURY OCCUR'·------------- - ------
CII Y OR lOWH COUNTY 5 TAll!
( 8 ) FU NERAL D IRECTOR Ee Ke Breazesla ( 0) DIO INJURY OCCUR IN DR ABOUT HON E, 011 FARM , IN INDUSTRIAL PLACE, OR IN
ADDREss Veterans Anmini Atr11tion li'at!i 1 i 1: PUBLIC PLACEl-::,-:c,.:c:Cc-:ff~,-c,"',.,,:c-,o"", -c,,-LA-cC~[- --WHILE AT WORKl----
BY ( [ } M EANS OF' UU URY
9-25-45 H. o. Swartout M D 24 · ~=c~s1GNA-1'tM!•McClellan, Lt.col. ,M.c.
19. ( A) --.-.,-.-,-IL-EO-- CB>----- -,R,-[-. l-. -,.-. -• . -.""s,-,.-.-.,-u-•• - - - - - -11 (H(CIFT WHICH) Clinical Direct.or
BY Marie Lsrenn ADDRES• Yet, Adm FM, L •A, Cs] 1tmm 'jt-25-45
STATE OP CALIFORNIA CERTIFICATE OF DEATH u. s. DEPT. OF COMMERCE
DEPARTMENT OF PUBU C HEALTH BUREAU OP THE CENSUS