ST?ITE CALIF'OBNIA - Wikimediast?ite ([)f' calif'obnia state of california department of public...

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ST?ITE ([)F' CALIF'OBNIA STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH 305201 1005848 CERTI DEATH 3201 1 380001 57 6E BUfr tN( otLY/ &TBNON L(]drcElmNUMffi 3.6T (Feril, DYE E o tF L u lt z 6.9 M WHITE 25 <E de .3 G 718 CHURCH STREET 5 CALIFORNIA = o 2 d D o o ; = G o = 2 BMSAE SSlPPlz o z G - G n4t2al O= HK iH CS 2l o9 6\ ? z E o o This is to certify that this deument is a true copy of the official rcsd filed with Vital Rsords. DATE ISSUED /'^"rP'-'- ao ne H..".: -7 ?:13 JAMES GREENE, MD, MS STATE REGISTRAR OF VITAL RECORDS llr rIilllilillililililltIil This copy seal is not valid unle$ prepared on an engraved border, displaying the and signature of the State Registrar CARROLL 1 . NsE OF D€CEOENT- FIR$ (Otoe) JOHN rfM NE YM isL 4.UGGEmddry 0'ti3'111963 7 8_@F e{l@ 1210 f,*s !^o ! gIMSTffiEIGNffiY 10.s()@s@mwffi 11 EEruu.sM6rcEs? 0111012011 NEVER MARRIED ra MISSISSIPPI E* TE ee6d BACHELOR t- ENTERTAINMENT 14 SAN FRANCISCO SAN FRANCISCO 1a ACTOR 10 JIM DYE, FATHER 29. M]DDIE .4 \1 P.MIru CLYDE JIM LYNN ) l'r{REE DUVAI-L PARK MS 38821 (n\\"c}t" , R.-Ti H, Eff'fl*' SAN FRANCISCO #7 ,-)- Eg -n* 2011{040 UNK [re [m D'? x v f .a: .-''2 | 6EffiMENrcffiMEre5m ll#Mk tMbbh 121 rcfl** a.*ffiffi*" tr 1r9. t@flTUTN M\\BtrE}ft 120. NUEDATWORK? flrc f rc fl** uh112011 JON J SMITH MD, ASST MEDICAL EXAMINER FAAlfrI a E SIATE iEOSTffi date, CACDPH--OII r 00460 1 39 CEf,SIJS TUCT CERTIFICATI OF VITAf- RECORD E -]@ ,, /_,, *_- (A zPc@E larc*riffiEg,|4ffi*d4e) il ilt

Transcript of ST?ITE CALIF'OBNIA - Wikimediast?ite ([)f' calif'obnia state of california department of public...

Page 1: ST?ITE CALIF'OBNIA - Wikimediast?ite ([)f' calif'obnia state of california department of public health 305201 1005848 certi death 3201 1 380001 57 6e bufr tn( otly/ &tbnon l(]drcelmnumffi

ST?ITE ([)F' CALIF'OBNIA

STATE OF CALIFORNIADEPARTMENT OF PUBLIC HEALTH

305201 1005848 CERTI DEATH 3201 1 380001 576E BUfr tN( otLY/ &TBNON L(]drcElmNUMffi

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This is to certify that this deument is a true copy of the official rcsdfiled with Vital Rsords.

DATE ISSUED

/'^"rP'-'- ao ne H..".: -7 ?:13

JAMES GREENE, MD, MSSTATE REGISTRAR OF VITAL RECORDS

llr rIilllilillililililltIilThis copyseal

is not valid unle$ prepared on an engraved border, displaying theand signature of the State Registrar

CARROLL1 . NsE OF D€CEOENT- FIR$ (Otoe)

JOHNrfM NE YM isL4.UGGEmddry

0'ti3'111963 78_@F e{l@1210f,*s !^o !

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FAAlfrIa ESIATEiEOSTffi

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Page 2: ST?ITE CALIF'OBNIA - Wikimediast?ite ([)f' calif'obnia state of california department of public health 305201 1005848 certi death 3201 1 380001 57 6e bufr tn( otly/ &tbnon l(]drcelmnumffi

STATE OF CALIFORNIADEPARTMENT OF PUBLIC HEALTH

PHYSICIAN/CORONER'S AMENDMENT305201 1005848 NO ERASURES, WHITEOUTS, PHOTOCOPIES, 3201 1 380001 57

STAG FILE TUMBER OR ALTERATIONS LOC{ REGISTilNOX NUTBER

1'1 tr BIRTH a DEATH tr FETAL DEATH

TYPE OR PRITIT CLEARLY IN BLACK INK ONLY - THIS AI'ENDMENT BECOTES Ail ACTUAL PART OF THE OFFICIAL RECORD

PART I INFORMATION TO LOCATE RECORD

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This is to certify that this dmument is a true copy of the offcial r$ordfiled with Vital Rmords.

DATE ISSUED

/^"/f'*'' ,t D 'r9 HiR _7JAMES GFIEENE, MD, MSSTATE REGISTRAR OF VITAL RECORDS

This copy is not valid unle$ pEpared on an engmved bords, displaying thedate, seal and signature ol the State Registrar

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