Brown, Annie Form 7 1 pLACEJFDEATMoDIST. No. PERMIT REMOVAL AND BURIAL
Original THIS IS NOT A DEATH CERTIFICATE� COUNTY OF Los Angeles LOCAL REGISTERED NO
'_ s �" CITY,TOWN OR V 2 y y
1'a tA/ 1JI RURAL DISTRICT OyyF��yy�,,,��Los Angeles STREET AND NO.�riIgnX 3417E s 69th St
k . FULL NAME Annie_'F3rown IF DEATH OCCURRED IN HOSPITAL OR INSTITUTION,GIVE ITS NAME -
yyy///---���!!! RESIDENCE:No. 7.' 1 East 69th st ST. CITYO OR TOWN,AND'STATE
y - USUAL PLACE OF ABODE
O 3.SEX 4.COLOR OR'ACEI 5.SINGLE, MARRIED,WIDOWED OR Sept 2?1932
C.) DIVORCED? (WRITE THE WORD) 22. DATE OF DEATH
'eMale White I Widowed MONTH DAY YEAR
5A.IF MARRIED, WIDOWED OR DIVORCED,NAME OF HUSBAND OR WIFE 23.MEDICAL CERTIFICATE OF DEATH 24.CORONER'S CERTIFICATE OF DEATH
I
HEREBY
FY,THAT I TOOK
ARGE
z David M Dec-rowrn� p g DECEASED HEREBY
Aug�I THAT TT1932 OF ITHE REMAINS DIESCRIBED ABOVE, HELL
14 6.DATE OF BIRTH D 1862 TO Sept 26C71932 ,``J'
FEZ MONTH DAY YEAR
'l 6C) C� 2 I IF LESS THAN THAT I LAST SAW H or ALIVE AN
�eyl 7.AGE_ 2 YR. 9 M0. 2 DAYS. ONE DAY'} HYyRS, MIN. Sept 6 1INQUEST,AUTOPSY OR INQUIRY
w $ 2
AS SPINNER,SAWYER, BOOKKEEPER,ESSION OR KIND OF ,K ETC.NE., Home AND THAT DEATH OCCURR93 THE
THEREON, AND FROM SUCH ACTION FIN[
`0..1 a 9. INDUSTRY OR BUSINESS IN WHICH WORK WAS ABOVE STATED DATE AT THE HOUR OF THAT SAID DECEASED CAME TO H
DONE, AS SILKMILL, SAWMILL, BANK, ETC. 3. /1 DEATH ON THE DATE STATED ABOVE.
QI - V 10.DATE DECEASED LAST WORKED AT 11.TOTAL YEARS SPENT ' N.
u
W 0 THIS OCCUPATION (MONTH AND YEAR) IN THIS OCCUPATION THE PRINCIPAL CAUSE OF DEATH AND RELATED CAUSES OF IMPORTANCE, IN ORDER OF
ONSET, WERE AS FOLLOWS: DATE OF NS
~ x 12.BIRTHPLACE (CITY OR TowNTink. Cerebral Hemorrhage Sep. o
H U �7
�qy STATE OR COUNTRY Ertel_ It
H B) . 13.NAME Smmmers
x
A��{ LL 14.BIRTHPLACE (CITY OR TOWN) Unk OTHER-CONTRIBUTORY CAUSES OF IMPORTANCE.
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z r-+ STATE OR COUNTRY Unk
nk
F-I
A w 15. MAIDEN NAME Unk
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Z '0- 16. BIRTHPLACE (cITY OR TOWN) Unkn IF OPERATION, DATE OF WAS THERE
1 AN AUTOPSY?
A STATE OR COUNTRY Unk CONDITION FOR WHICH PERFORMED -
NAME LABORATORY TEST
• W B A. CITY, TOWN OR RURAL q 2 CONFIRMING DIAGNOSIS
z uw DISTRICT OF DEATH i YRS. MOS. DAYS F wo 25.IF DEATH WAS DUE TO EXTERNAL CAUSES (VIOLENCE) FILL IN THE FOLLOWING:
L./ �-1w B. IN CALIFORNIA 13 YRS._ MOS. DAYS ACCIDENT,SUICIDE DATE OF
P 'D: OR HOMICIDE? INJURY
ITI �I,- C. IN U.S., IF OF 40
�O FOREIGN BIRTH_ 4' YRS. T} MOS. DAYS INJURED 1 CITY OR TOWN OF _
H 18. INFORMANT (SIGNATURE) Annie R Crouch AT COUNTY AND STATE OF
341th St DID INJURY OCCUR IN HOME,
ADDRESS F+.St 69 INDUSTRY, OR PUBLIC PLACE?
N Removal MANNER OF
• 5; 19. BURIAL iER;ATI0.1 OR REMOVA L? �7 q /t II INJURY
lot PLACE Glens falls jv�Y --WHITE THE
DATF1Of 3/ `�1 INJURNATURY
OF
2013 26.IF DISEASE/INJURY RELATED
LICENSE NO. TO OCCUPATION,SPECIFY
20.EMBALMER �r y� ---
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SIGNATURE ♦Y ,Simpss-on
FUNERAL T� 27.SIGNATURE Mina Pohl
H DIRECTOR Delm-er A Smith 1�l M.D.
I� PHYSICIAN,AUTOPSY SURGEON
ADDRESS 731 Washington ADDRESS 341 W Florence
21. PICl 3 W-""
,J7� (/-// /yf'� 28.WHEN REQUIRED
DATE �`�-/��""V BY LAW
CORONER
L AA`REGI'SF{sIZSIH' COUNTY OF_ .
21;.42./r1. Zit v-7-£
7FPUT'T
LOCAL REGISTRAR'S PERMIT FOR REMOVAL
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 SATIS-
FACTORY AS REQUIRED BY LAW, I HAVE FILED IT WITH THE ABOVE (TATED LOCAL REGISTERED NUMBER, AND ON THE BASIS THEREOF I HEREBY GRANT
A PERMIT TO THE ABOVE NAMED UNDERTAKER FOR THE REMOVAL ArD BURIAL OR CREMATION OF THE BODY OF SAID DECEASED PERSON AS STATED ABOVE.
IN THE CASE TSF- ATH 20 NGEROUS OR COMMUNICABLE DISEA$„ THE BURIAL OR REMOVAL MUST BE CONDUCTED ACCORDING TO THE RULES OF THE STATE
AND LOCAL BOA Rb OF HEAL ; n/ ,,.� /am/t
" REGISTRAR
DATED 19 - BY // a ' -0 "
C LE RK
THIS PERMIT IS SUFFICIENT FOR THE REMOVAL AND BURIAL OR CREMATION OF A BODY AT DESTINATION AS ABOVE INDICATED (SUBJECT LOCAL CEMETERY
OR OTHER REGULATIONS).
Endorsement of Sexton or Person in Charge of Premises on Which Interments or Cremations are Made
(SIGNATURE O P ON IN CHARG OF CEM ET�EMATORIUM, ETC.)
DATE OF INTERMENT OR-oRWANIIIIIIN V'- U-Cr l_t. ,-, 57.,-L( 79,12_ . i..z.. .0 �-Lj?{_��_�L}_� Ze-t,f_., .v7
(STRIKE OUT WORD NOT USED) (NAME OF CEMETERR rCREMATORIUM. ETC.) /
ORIGINAL-TO FOLLOW THE BODY TO ITS DESTINATION-IF BURIAL OR CREMATION TAKES PLACE IN CALIFORNIA, THIS PERMIT MUST BE DELIVERED TO
THE PERSON IN CHARGE OF THE CEMETERY OR CREMATORY BEFORE THE BODY IS BURIED OR CREMATED. THE PERSON IN CHARGE MUST RETURN IT, PROPERLY
FILLED OUT, TO THE LOCAL REGISTRAR OF HIS DISTRICT WITHIN TEN (10) DAYS FROM THE DATE OF INTERMENT OR CREMATION. IF NO PERSON IS IN CHARGE, THE
-UNERAL DIRECTOR MUST SIGN THE ABOVE STATEMENT, WRITING ACROSS THE FACE OF THIS PERMIT THE WORDS "NO PERSON IN CHARGE"AND FILE THE PERMIT
"(THIN TEN (10) DAYS WITH THE LOCAL REGISTRAR OF THE DISTRICT IN WHICH THE CEMETERY IS LOCATED.
STATE OF CALIFORNIA
DEPARTMENT OF PUBLIC HEALTH
A 100M
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