Shaver, Henry 45997 7-28 2554 --2�
Form 7A 'PLACE OF DEATTo be DDnse tea by Re tra0/ PERMIT FOR REMOVAL AND BURIAL
County of_ LAN DIEGO THIS IS NOT A DEATH CERTIFICATE
A City oof SAN DIEGO, a
CALIFCALIF• hlalifornta Otate licarb of ioraltlt, Bureau of Vital 'tatistirs
U U t d.NAVAL HOSPITAL SA:; l EGO ard)CAL ,+ Local Registered Number
or Rural Regis-
tration District /
'
PI 2FULL NAME HENRY CHARLES SHAVER
E-I PERSONAL AND STATISTICAL PARTICULARS CORONER'S CERTIFICATE OF DEATH
z SEX ;COLOR OR RACE 'SINGLE,MARRIED,WIDOWED, "DATE OF DEATH
.�x11 MALE WHITE OR DIVA,{{}ritg the word) DEC.13.1931
�Y (Month) (Day) 19(Year)
a If married,widowed,or divorced
HUSBAND of
i7 I HEREBY CERTIFY, as to the person above named and
aW' (or) WIFE of SINGLE �E� 1� 1931
J 6 DATE OF BIRTH herein described, That on-DEC, A_ 19
.I DEC.15.1911 I I held
,,''aj}n inquest
��1and the} jury+r,}�rendered a
verdicte on the death.
bD (Month) (Day) (Year) Or, { .,{tlyii yistrlte�tit 11P�tlbS' CL AlIl tt! r AGE If LESS thanto
li tJ jZ ccount of
Ca a Ca I-a U �.9 11 28 laay,____hrs. The CAUSE or DEATH* wa as "3-6—.
years months days or min. 1:MULTIPLE liNIR a :HEMORRH GE-
a1 a s OCCUPATION __ PIT CTU OF—
SKULL
E-i W (a) Trade,profession,or SEAMAN FIRST CLASS
I particular kind of work
14 Q business,or stablishmentral nature of u nrvsl a .S•NAVY s 'r'0C ry-i-_'-* �s
sZi which employed(or employer) 6►,RIDER�i--COLLESON WITHVCY—A-Tr"
a (c) Name of employer U1 S.GOVERNMENT is t.& BEACH STS_.VE__RDIET
H Z 'BIRa a P Aountry ACCIDENT CAUSED BY NEEILI GENCE- DF---
A (Statetowll> GLENNS FALLS NSW YORK DEG ABEJJ �� _/��
.�1 a °NAME OFrr ('�� "�
W FATHER HENRY V.SH�i V LI R State whether attributed to dangerous or _ )
W Insanitary conditions of employment
0 ix-. F 11 BIRTHPLACE OF FATHER (city or town)_ UNKNOWNon.
p.m{ 0 w (State or count-v) i rr AI. r eFire iff_t-r ry "---
HW a ce '2-MAIDEN—NAME-.._ _ (Signed) .tid D : V
z < OF MOTHER UNKNOWN CHEST i PU ,KT dutopsy Surgeon
Approved: (Signed) P
UNKNOWN EC.16.1931 SAN DIEGO,COUNTY Coroner
' BIRTHPLACE OF MOTHER (city or town) -UN-KNO 19____. (Address)
A (State or country) -UNKNOWN r-�M-__-__r_��� ��_���
z i8.LENGTH OF RESIDENCE — 8 'State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES,
MEANS state7
(1) OF INJURY: and (2) whether (probably) ACCIDENTAL, SUI-
At Place of Death years months days CIDAL• or HOMICIDAL. (See reverse side for additional space.)
a44 (Primary registration district) TT C+ �,'VP A' 18b SPECIAL INFORMATION for Hospitals, Institutions, Transients or Recent Residents
(If nonresiderg,ginRo�town land Rtli.y_.�c.A.u.k ia.w.ai.+ Where was disease contracted,
In California Prr S months days if not at place of death? •� �t
64 W How long in U.S.,if of foreign birth? Former or U SS•BARRACUDA
Years months days usual residen e
'4 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1°PLACE 0 I L R REMOVAL DATE OF
(InformanAddr#�t)
-AV o Al '� ll '� GLENNS FALLS ,NEW YOpK DEC.13.1 �31
AY . 1Vt� �1Fily.g � L.N .
lb 2°UNDE I<E EMBALM R'S
j BO NHAM BROTHERS MORTUARY LICENSE No.---
egliFiled/ —I I03-i ' 1770-4th.ST.SAN DIEGO 1740
a Registrar or Deputy ADDRESS
LOCAL REGISTRAR'S PERMIT FOR REMOVAL C .
N.B.—This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District in which the death
occurred after the FILING and acceptance of a COMPLETE AND CORRECT CERTIFICATE OF DEATH LEGIBLY WRITTEN IN DURABLE
BLACK INK,
A CERTIFICATE OF DEATH having been presented to me, and after examination the same appearing to be COMPLETE, CORRECT AND
SATISFACTORY AS REQUIRED BY LAW, I have filed it with the above stated LOCAL REGISTERED NUMBER, and on the basis thereof I
HEREBY GRANT A PERMIT to the above named undertaker for the REMOVAL AND BURIAL OR CREMATION of the body of said deceased
person as stated above. In the case of death from a dangerous or communicable disease, the burial o removal be conducted according to the
rules of the State and local boards of health. '�j y
' /fJi )4,
I'" ' p- K- Loca Registrar
Dated O r 191?/ By--- - a
Clerk
This Permit is sufficient for the removal and burial or cremation of a body at destination as above boated (subject to local cemetery or other
regulations).
Endorsement of Sexton or Person in Charge of Premises on Which Interments or Cremations are Made
,f
-- - E
I (Signature of person in charge of Cemetery,Crematorium,etc.)
,f
Date of interment or cremation -.. + 192-z _
(Strike out word not used) (Name of Cemetery,Ceete•ostrah•ta.)
Person in charge must return this Permit to Local Registrar of his district within ten(10) days from above date. If no person is in charge the
undertaker must sign the above statement, writing across the face of the Permit the words "no person in charge" and FILE PERMIT WITHIN TEN
(10) DAYS with Local Registrar in the district in which the cemetery is located.
.ate`
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