STATE FILE NUMBER
CERTIFICATE OF DEATH
STATE OF CALIFORNIA—DEPARTMENT OF PUBLIC HEALTH
LOCAL REGISTRATION DISTRICT AND CERTIFICATE NUMBER
DECEDENT
PERSONAL
DATA
T
!a. NAME OF DECEA
Mfift/A
3. SEX
lei
-ale
D—FIRST NAME j la. MIDDLE NAME
he.
4. COLOR OR RACE
Aorea
8. NAME AND BIRTHPLACE OF FATHER
Hal Ghan£i lee - Korea
10. CITIZEN OF WHAT COUNTRY
Korea
14. LAST OCCUPATION
Komemaker
1. SOCIAL SECURITY NUMBER
15.
70
OtJ
6. DATE OF BIRTH
1877
2a. DATE Oft DEATH—m#nth. day. year j 2b. HOUR
/
HA
UHOAl >f '
(0 a
7. AGE <LSST BIRTHOA
YEARS
IF UNDER 1 YEAR
£Zai
IF UNDER 24 HOURS
9. MAIDEN NAME AND BIRTHPLACE OF MOTHER
Unknown Unknown Korea
12. MARRIED. NEVER MARRIED. WIDOVVEO.
DIVORCED (SPECIFY)
Widow
16. NAME OF LAST EMPLOYING COMPANY OR FIRM
(IF SELF EMPLOYED SO STATE*
Own Hone
13. NAME OF SURVIVING SPOUSE cif wife, enter maiden nam.£>
17. KIND OF INDUSTRY OR BUSINESS
Own Heme
PLACE
OF
DEATH
18a. PLACE OF DEATH—NAME OF HOSPITAL OR OTHER IN-PATIENT FACILITY J 13b. STREET ADDRESS—(STREET and number, or LOCATION)
Hollywood Palms Cmvalscent Hospital j L6l8 Fountain Avenue
18d. CITY OR TOWN
Los Anreles
|18e. COUNTY
1 Los
I8F. LENGTH OF STAY IN COUNTY OF DEATit
! t„„ Angeles
21
18c. INSIDE CITY CORPORATE LIMIT:
(SPECIFY YES OR NO)
Yes
18C LENGTH OF STAY IN CALIFCRI
21
USUAL
RESIDENCE
OF DEATH OCCURRED IN
INSTITUTION. ENTER
RESIDENCE BEFORE
ADMISSION)
19A. USUAL RESIDENCE STREET ADDRESS (STREET AND NUMBER OR LOCATION) Jl9s. INSIDE CITY COHFORATE LIMITS
I (SPECIFY YES OR NO)
°33 Maltnan Avenue j Yes
19c. CITY OR TOWN
Los Angeles
19d. COUNTY
Lo?
|19e. state
California
^IAN OR CORagR--rsi^?i
20. NAME AND MAILING ADDRESS OF INFORMANT
Mr« David Hvun -Son
"933 ^alfcnan "Avbnue
Los Angles t Cal:
PHYSICiAN'S
OR CORONER'S
CERTIFICATION
21a. CORONER: ^^SS*^
^Cl P. OATF-ASO PLACE STATED A30VE FROM THE
CAUSES STATED BELOW AND THAT i HAVt HElO UH
REGAINS OF DECEASED A5 HECU1RED BY LAW
AN:
(INVESTIGATION OR INQUEST»
21b. PHYSICIAN:
Y THAT DEATH OCCURSsD AT
HE HOUR. DATE. AND PLACE STATED A30VE.
FROM THE CAUSES STATED BELOW AN? THAT | ATTENDED THE DECEASED
FROM | TO I AND
ENTER Urv
ES MONTH. DAY JfEAB i: ENTER MONTH DAY. YEAH >J I LAST SAW THE
# #1 I I OECE
t/a*fi9\ /yyty|/V^Ky
—r S-^^yiURE AND DEGREE CS TITLE
2,E'MD§£SS,
DATE SI
- JgfS^NSt NUMEER
Grtsxn
FUNERAL
DIRECTOR
AND
LOCAL
REGISTRAR
22A. SPECIFY BURIAL ENTOMBMENT
OR CREMATION
Burial
22 b. DATE
Dec.2^19^8
25. NAME OF FUNERAL DIRECTOR fOR PERSON ACTING AS SUCH)
Ftreat Ixu KoEywcfc! IVMc Mortuary
23. NAME OF CEMETERY OR CREMATORY
{SPECIFY YES OR NO?
No
27. LOCAJ.-REGISTRAR—SIGNATURE ,
SIGNATURE (IF BODY EMBALMED) LICENSE NUMBER
9
-y
DEC 2 8 198
29. PART I. DEATH WAS CAUSED BY:
IMMEDIATE
(A)
CAUSE
OF
DEATH
CONDITIONS. IF ANY. WHICH
GAVE RISE TO THE IMMEDI- ((B)
ATE CAUSE (A). STATING
DUE TO. OR AS A CO|
ENTER ONLY ONE CAUSE PER LINE FOR A. B. AND C
n-r
'j^JjL*J%$L~
C^^a^^:^%€aa&^,
THE UNDERLYING CAUSE
LAST. I (C)
DUE TO. OR AS A CONSEQUENCE OF
30. PART U: OTHER SIGNIFICANT CONDITIONS—cjntrwutingto death but kot relatfo to the immediate cause given in part u
operation isn/oa aigpsY
/^4^
APPROXIMATE
INTERVAl
BETWEEf
ONSET
AND
DEATH
09 . AUTOPSY I OO- IF YES. WERE FINDINGS t'V-i-
OCA- (3PECJFY j gtB- SICERFD IN CETtftMiNIVJ
"m&' !cM,,t""'
;SEOFOCATH? i SPECIFY YES i>? NO'
33. SPECIFY ACCIDENT. SUICIDE OR HOMICIDE
UT
PLA<~F OF INJURY <SP H0M£ FARM- FACT0HY-
PLACfc. Ul- iNJUHY faEEWA/. HIGHWAY. STREET,
OFFICE BU1LDIHS. ETC.)
35. INJURY AT WORK
(SPECIFY YES OR NO3
INJURY
INFORMATION
p
37a. PLACE OF INJURY (street and number or location and city or town)
137b
DISTANCE FROM PLACE OF
INJURY TO USUAL
RESIDENCE. ITEM 19.
36A. DATE OF INJURY—month day year 3oB. HOUR
(SPECIFY YES OR NO)
40. DESCRIBE HOW INJURY OCCURRED (enter sequence of events which resulted in injury, nature of injury should be entered in item 29)
STATE
REGISTRAR
19 5*9
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