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is Fur “glizabeth. Short : -2= Lace of DEATH: oo. Sau os_+ coo ro8 Los sngetes:= CR OW oe tome atter wart a - pund—en-Nortorx - 40) NAWE OF HOSPITAL OR INSTITUTIO a . . netween orton and Colliseum | ce cirron 108 i? mor is Stat OR INSTITUTION, GIVE STREET HUMBER OR LOCATION ' If OUTSIDE CITY OR TOWN LIMITS, WRITE RURAL (bd) LENGTH OF STAY: (SPECIFY WKETKER YEARS, MONTHS OR DAYS) . oe k . _ . fm Hosprrat, on 1nSTITUTIO! ait cb) Streer No. Hynenown IN THIS CONRURT unknow CALIFORNIA enn Poo, DATE OF DEATH: Mont anuary DAY * xy te rorcicn sone, HOW LONG In THE U.S.A nn SEARS |i ae 5: Ee ee ee 3. (CE) IF VETERAN, NAME OF WAR [3. cr» Social Security No! | 21. MEDICAL CERTIFICATE |, . § 22. CORONER’ Ss CERTIFICATE pale) : i unknown : a” : feneey sere TH Taat 1 | ATTENDED] nesY CERTIFY, THAT r HELD aK 4. SEX 5. COLORORRACE 6. ca» SINGLE, MARRIED, WipoweD on eno 9 ] nnn AUTORSY. INQUEST, i Divorced ma single female | cauc ate Sinele PO on ee bttG USS be 6. cay NAME OF HUSBAND OR WIFE 6.ce) Act of HuspAND FROM SUCK ACTION THAT DECEASED CAME TO cay RN . AGE OF HUST ANE THAT 1 Ast saw Heenan ALIVE, - NEARS i i 2a \ OB. ATH on me att axe noe AND THAT DEATH OCCURRED ON THE PD e||svareo ABOYE. AT EO “ve yn? HOUR STATED ABOVE. : DURATION 7. BIRTHDATE OF DECEASER y 29, 1965" MONTH Bay TEAR ee 2 ag 9. ~ BIRTHPLAG SO 10. Usuai OccuPatio fieitress 41. Inovsray or Business TE S tauren E[42. Nawe_-CLEO Alvin “Short ahs BIRTHPLAC! Virginia : ; £[ 14. Maren Naw Phoebe. M Server eee ks eget ar Y FinvSIcrAN Save ey Te ge oe OTHER CONDITION _ GUNCLUDE FREGMARCY WITHT H aNDERLINE var USE TO wach S38) eers x ee ine. atest 6. cay INFORMANT. Phoebe SAW er- » AppRes , S Headford Task rs ty arene totem eet — Gi) BATE t= n SH Berk = t OR HOMICIDE c) PLA 18. a EMSALNER'S Zed LICENSE is i €) WHERE DID SIGNATURE, P78 zl o. a . ¢e) FUNERAL Director D ... ony Dip tnguRY OCCUR IM O8 ABOUT HOME, ON FARM, IN INDUSTRIAL PLACE, OR IN at , * Pupiic snr econ opgter Hong A at wonnr—2t__ ; , vg BPECIELIYOE OF PLACE, £) MEANS OF InJURY_OA) Aten rept Pryrr’ 4A j 24. ‘Coroner's JAN 2 2 Ba . ~ Farrsiciaes SIGHATUR ra) . i, Carey i \_ Aooress 4-28 LE DEPARTHENT OF PUBLIC HEALTH * os, CERTIFICATE OF DEATH 5 OT Oe Scenes ce carey This Is to certify that this document is a true copy of the official record filed with the Reglatrar-Recorder/County Clerk, SR ke Wate | So, NOV 2 - 1902 oS PAP 4 he {CHARLES WEISSBURD “ , 4 9 0998245 gistrar-Recorder, i, ot ‘| 4 tder/County Clerk . .- , D ; ¥ . Z * 1 As ee This copy not valid untess : Registren Recorded Comny een on engraved border displaying. ‘the Seal and Signature of the , ODES ca Wee S EWR ee pal 423