STATE OF CALIFORNIA
STATE FILE NUMBER
DECEDENT
PERSONAL
DATA
LOCAL REGISTRATION DISTRICT AND CERTIFICATE NUMBER
1A. NAME OF DECEDENT—FIRST I IB. MIDDLE
HEY
soo
I
LEE
3. SEX
FEMALE
4. RACE/ETHNICITY
KOREAN
8. Birthplace of Decedent (state or
for'-icn co
mimh
11. CITIZEN OF WHAT COUNTRY
U.S.A.
15. primary Occupation
HOMEMAKER
5. Spanish/Hispanic
NO
s
6. DATE OF BIRTH
OCTOBER 20, 1900
9. NAME AND BIRTHPLACE OF FATHER
CHUN MYON KIM, KOREA
12. SOCIAL SECURITY NUMBER
557-20-9906
16. Nt/MDEF. OF YEARS
This Occupation
62
13. MAR'STAL STATUS
WIDOWED
17. Employer (if self-employed, so state)
SELF EMPLOYED
2A. DATE OF DEATH 'KON'.h, day. year) I 2B. hour
ATTflTTST 10 , 1 Qft? I 1 C)A 5
7. AGE
82
NDER 1 YEAR
<S | DAYS
IF UKDER 24 HOURS
HOURS I MINUTES
10. BIRTH NAME AND BIRTHPLACE OF MOTHER
UNKNOWN, UKNOWN
14. NAME OF SURVIVING SPOUSE (IF WIFE. ENTER
BIRTH NAME)
18. Kind of Industry or Business
HOMEMAKING
19A. Usual residence—street address (street and number or location)
il9B.
USUAL
RESIDENCE
661-C W. 164th STREET
19C. City or Town
GARDENA
19D. County
LOS ANGELES
1 19E. STATE
CALIFORNIA
PLACE
OF
DEATH
21A. PLACE OF DEATH
QUEEN OF ANGELES HOSPITAL
1 21B. COUNTY
LOS ANGELES
21C. STREET ADDRESS (STREET AND NUMBER OR LOCATION
2301 BELLEVUE AVENUE
I 21D. CITY OR TOWN
!LOS ANGELES
20. NAME AND ADDRESS OF INFORMANT RELATIONSHIP
EDWIN K. LEE (SON)
8324 AMOND LANE
CANOGA PARK, CA. 91304
22. DEATH WAS CAUSED BY:
IMMEDIATE CAUSE
(ENTER ONLY ONE CAUSE PER LINE FOR A. B. AND C)
CAUSE
OF
DEATH
conditions, if any.
which cave rise to
the immediate cause,
stating the underlying cause last.
DUE TO. OR AS A CONSEQUENCE OF / -
O. OR AG A CONSEQUENCE OF t .
DUE TO, OR AS A CONSEQUENCE OF
< c > /V/^Z/cf *)a*Jt //y/t&Z TvS/V 3 ? O a/
23. OTHER CONDITIONS CONTRIBUTING BUT NOT RELATED TO THE IMMEDIATE CAUSE OF DEATH
'4A
*.
'<*Ai
TO CORONER?
APPROXIMATE
INTERVAL
BETWEEN
ONSET
AND
DEATH
4
24. WAS DEATH REPORTED
Ml
25. Was biopsy performed/
26. was autopsy performed7
a>0
27. WAS OPERATION PERFORMED FOR ANY CONDITION IN ITEMS 22 OR 2 3 !
TYPE OF OPERATION DATE
AJO
1 28C. DATE SIGNED J 28D. PHYSICIANS LICENSE NUMBER
PHYSICIAN'S
CERTIFICATION
2-8A. I certify That death Occurred at the Hour. Date! 28B. physj/Tan
and Place Stated From the Causes stated.
I attended Decedent Since J I Last Saw decedent Alive)
(ENTER.MO. DA. YR.) (ENTER MO. DA
7/f/fi \ s>
a/ii.
| 28E. TYPE PHYSICIANS NAME AND ADDRESS
I WILLIE C. SUHR M.D., 4220 W. 3rd ST., SUITE 204,
LOS ANGELES
CALIFORNIA
29. SPECIFY ACCIDENT, SUICIDE. ETC.
INJURY
INFORMATION
CORONER'S
USE
ONLY
30. PLACE OF INJURY
31. INJURY AT WCRK 32A. DATE OF INJURY MONTH DAY. YEAR I 32B. HOUR
33. LOCATION (STREET AND NUMBER OR LOCATION AND CITY OR TOWN)
34. DESCRIBE HOW INJURY OCCURRED (EVENTS WHICH RESULTED IN INJURY
35A. I CERTIFY THAT DEATH OCURRED AT THE HOUR, DATE AND PLACE STATED FROM I 35B. CCRONER SIGNATURE AND DEGREE OR TITLE
THE CAUSES STATED. AS REOUIRED BY LAW I HAVE HELD AN ( INOU ESTlNVESTIGATION) J
I .
I 35C.
I
I
J
DATE SIGNED
36. DISPOSITION
BURIAL
37. DATE MONTH. DAY. YEAR
AUG. 13, 1983
38. NAME AND ADDRESS OF CEMETERY OR CREMATORY
GREEN HILLS MEMORIAL PARK, 27501 SO.
WESTERN AVE.r SAN PED.Bgg Ci
39. E M B A L)*f RS LICENSE NUMBER AND SIGNATURE
5746
UOA NAME OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH
GREEN HILLS MORTUARY ■
AOB. LICENSE NO.
1175
42. DATE ACCEPTE
. DATE ACCEPTE C/yr LOCAL OEGISTRA
AUG 1«1963
S
STATE
REGISTRAR
C.
F.
d- tf-/* o£3S
VS-1 1 (6-82)
^O/d)
\
;; .r>t»v OF THF RECORD
FILED «N THE COUNTY OF LOS £"^~H|S sEAL |N
OF HEALTH SERVICES IF IT BEARS Tn
PURPLE INK.
AUG 1 2 1983
io ^MS^^
Director of Healrti Sorvices^dj^lL
