^ITSTTiLTliOHggR"
CEITSF1CATE OF DEATH
STATE OF CALIFORNIA—DEPARTMENT OF PUBLIC HEALTH
LOCAL REGISTRATION DISTRICT AND CERTIFICATE NUMB
1a. NAME OF DECEASED—FIRST NAME IB. MIDDLE NAME
DECEDENT
PERSONAL
DATA
14. LAST OCCUPATION
Minister
3
oor\
3. SEX
Male
4. COLOR OR RACE
EarQBn
5. BIRTHPLACE £™trv? FO"oaN
8. NAME AND BIRTHPLACE OF FATHER
Chei Chang Hyita - Korea
10. CITIZEN OF WHAT COUNTRY
Korea
11. SOCIAL SECURITY NlWAFA
575-21-9U35A-
15
; ofIi
6. DATE OFlBIRTH
March 21, 1878
2a. DATE OF DEATH—month, day. year J 2b. HOUR
August 115 1968
! ii:10 y.
7. AGE 1 LAST BIRTHDAY)
90
r UNDER t YEAR
IF UNDER 24 I I iRS
"■
9. MASDaN HhMt, AND BIRTHPLACE OF MOTHER
Sei XI11 - Korea
12. HARRIED., NEVER MARRIED. WIDOWED,
m /.CEO (SPECIFY)
Married
16. NAME OF LAST EMPLOYING COMPANY OR FIRM
1 ,t S*.t.F EMPLOYE? SO ITAIf
Methodist Church of Kauai
13. NAME OF SURVIVING SPOUSE -if wife
Maria Lee
17. KIND OF INDUSTRY OR BUSINESS
Religion
PLACE
OF
DEATH
8a. PLACE OF DEATH—NAME OF HOSPITAL OR OTHER IN-PATIENT FACILITY |18». STREET ADDRESS—(street and number, or location*
Bollywood Palms Convalescent HospitaJL I46I8 Fountain Avenue
8d. CITY OR TOWN
Los Angel e 3
18f COUNTY
Los Angeles
ISP. IENCTH OF STAY IN COUNTY OF DE'A1
21
18C. iNSlDfc ITY COF r' • 'T. I ■ *'
.SPECIFY YESJl$ NQi
USUAL
RESIDENCE
(IF DEATH OCCURRED IN
INSTITUTION, ENTER
RESIDENCE BEFORE
ADMISSION)
19a. USUAL RESIDENCE—STREET ADDRESS (street and number or location ' 19b INSIDE CITY CORPORATE LIMITS
! ' SPtClFY YES OR NO)
! Yes
933 Maltman Avenue (Apt. l)
19c. CITY OR TOWN
Los Angeles
9d COUNTY
Los Angeles
PHYSICIAN'S
OR CORONER'S
CERTIFICATION
21a. CORONER: ^Hbiii
*?.: w DTI ANO PLACE STATED AROV
CAiJSL^ -AaTEO BF.LOW AND THAI' I HA
21b. PHYSICIAN.
r»c* THfc ?AHSfS STATFD
'!9f STATE
i California
20 NAME AND MAILING ADDRESS OF INFORMANT
Mr® David Hyun - son
933 Maitman Avenue (kpt^ 2)
Los Angeles , C ilifornia
. I raDRESS
A
^^\.
21o DATE SIGNED
(y&j b-il-^J-\)<^ <-/iiP^P,*i> [ £-n ^[;yf jTJLth.
FUNERAL
DIRECTOR
AND
LOCAL
REGISTRAR
Z2A. SPECIFY BURIAL. ENTOMBMENT
OR CREMATION
Burial
25 NAME OF FUNERAL DIRECTQfi.tOR .PERSON ACTING AS SUCH)
ftroat U*a Hottyimd Hills isrtuarf
23 NAME OF CEMETERY. OR CREMATORY Q
August T5»1948fcbEST LAWN MEMORIAL-PAR
24 EMBALMER—SIGNATURE (IF BOD - Mto. LICENSE NHV
26
m COROHtR VtA
So
tO - <..
LRJ£
27 LOCAjf REGISTRAR—SIGNATURE /
2?£
LU£ 1 5 138.
19. PART !, DEATH WAS CAUSED BY:
ENTER ONLY ONE CAUSE PER LINE FOR A B. AND C
CAUSE
OF
DEATH
CONDITIONS IF ANY. WH
GAVE RISE. TO. THE .IMMEDI
M| AUS
THE UNDERLYING CAUSF
LAST. ,; ' ' '
IMMEDIATE CAUSE /? S /
j DUE TO OR AS A CONSCIENCE OF ^
:"DL ^B> //-'^C^^-'l ^l^*"^^^7 i^^^O*^
O'U 10 '■ ' l ' i rC.JFN I C««
30 PART Sf OTHER *•; , ' !•;-. . ', • ■• , b
;,;/_ //!/"' , ';':^ 4j :'y„y;\,, 'yf&&££j.
h&
32a
¥■
h9
"7 "t , " " " , i... ' fiNM' ", , ' I i'JIM'i .T A ' | '■■•':• LA A ■>:■ iNIIIRi
IURY
'MATION
:( m,.t. .......
., ■ , • -. bl - b OR1 •■ 5 4s-.ri.iyi . us ti. km , n or town*
4u DfV RfPfV,'HOW INJUR f OCCURRED 5 N'fR -,equew«..c
' i
.w *.' '.;'/
39 *,;!
STATE
REGISTRAR
