ST?ITE CALIF'OBNIA - Wikimediast?ite ([)f' calif'obnia state of california department of public...
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](https://reader035.fdocuments.us/reader035/viewer/2022070722/5f01ae927e708231d40089eb/html5/thumbnails/1.jpg)
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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DATE ISSUED
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JAMES GREENE, MD, MSSTATE REGISTRAR OF VITAL RECORDS
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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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I HEREBY DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION ITt TRUE AND CORRECT TO THE BEST OFMY KNOWLEDGE.
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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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