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' e _ • 1, GcRTiI=iCATE OF DEATH -STATE Flit/vuMaER STATE OF CALIFORNIA LOCAL REGISTRATION dEYRICT AND CERTIFICATE IA.NAME OF OECEOENT-FIRST i IB M,DOLE IC. LAST 2A.DATE OF DEATH pK.!N*H.DAT. r4R I$B.HOUR Phyllis Jo Lane December 14, 1988 2225 3,SM 4. RACE/Ey.-CITY 15, SPAMS11 OF BIRTH 7 AGE a UNDER t r[wR 1"' UNDER 24"0"0"YIDWYNE DAYS HOURS WPOWMG Female White November 14, 1936 52 ,[ARE DECEDENT S.BIRT%PLACE OF OBCOMNT 9. VAMB AND BMTHPLACM OF FATHER 10.DOWN NAW AND MWrMP.ACS D•MOTNER PERSONAL. ([SATE on FOREIOM COUNTRY) DATA Ks. I Albert Coffelt-Ks. Gladys Jones-Ok. 1 IA.CMZMN OF11S. IF DECEASED WAS[VMS-V /2. SOCWL SECURITY 13. MARTIAL STATUE 14.NAME OR SURVIVING SFOUG&SP WIPE.ENTER WHAT COUNTRY N.afT.J"GNE DATES a SERVOC4 BIR'M NAAgI USA 19_= To 19=__ .tarried Bill Lane IF,PRIMARY OCCWATIaY16.NUMBEI OR YEARS 17.EMPLAYMA OF SW-WPLOTED.90 STATE) 18.KID a W stNupose TIBS OCC'JFATYDN Housewife 31 Self-employed Homemaking IRA.USUAL RESIDENCE-STREt7 ADOR[SS ISTREET AND I MB[M UP�OCATIONI i 198. 19C.CITY ONTO-" 23125 South Henry Rd. Riverbank USUAL - RESIDENCE 190 CO'1NTY IgE. STATE -- 20. NAME AND AOOR£SS OF INFORMANN" T-RELATIO -P . .. Stanislaus , California Bill Lane-Husband ...; ..21 A.PLACE OF DEATH ':13. COUNTY- -- - cc PLACE iMedical Center at UCSF San Francisco 23125 South Henry Rd. OF � 21C.STRET!T ADDRESS(STRRRT ANO RUMORS OR LOCATION) '210. CITY OR.TOWN DEATH 505 Parnassus Avenue San Francisco Riverbank, California 22.DEATH WAS CAUSED AT: (ENTER ONLY ONE CAUSE PER LINE FOR A.S. AND C) 24-WAS DEATH REPORTED IMMEDIATE CAUSEAPPROXI- TO CCRONWI (A) Brain Death ----- '4 6 days MATE Yes �. IF ANY.CAUSE DATE TO,OR A!A COIMOUENCE OF INTERVAL 28.WAS EgF/T POWOMMOT OF WHICH GAVE SAN TO __.... BETWeRN CD DEATH THE ROOMMATE CAWS.t(c) (B) Massive Cerebral Infarction 44 6 days oNzaT No _ ETATE•S THE IAWER- DUE TO.OR AS A CONSEQUENCE OF AND WAf AUROFEY FSM• T DEATH D`AL'E LAST. Internal Carotid Artery Thrombosis 4416 days I I No 22,o'rNMe SSASJRCANT COMMTIONS-CONrR/wTING TO DEATH BUT NOT RELATED TO CAUSM GIVENPCraniotomy gIO .WAS OPERATION PERFORMED FOR ANY CONTN IN 976"22 OR N 22A 31 TV"OR Subarachnoid Hemorrhage, ICA An r sm 12-08-88 DAT. SEA.I CEITMY THAT DEATM OCCURRED AT THE 268.PHYSICIAAr 6 AND DEGREE OR TITLE 1 28C.DASD ETA 1280.PNYMIAWS LICENSE NUMBER HOUR DATE AND PLACE STATED FROM TNM C.USES 1104"9111- S•ATW. w: ,1 lAR ACLJj r`• 47 12-15-88! G062844 I..AA /WaV-Y UR.:eMI. 6.'ERT>FIC.A_ MO.DA ,-J 1 E/MYSR MO.DA. YR.) i 28E.TYPE PHY ICIAN'S_NAMr AND ADDRESS Tom' ^112-12-88 12-14-88 Samuel F. Ciricillo M.D. 505 Parnassus Avenue S.F.94143 29.SPECIFY ACCIDENT.SURCIOE.ETC. 30.PLACE OF INJURY 31.INJURY AT WORE i 32A.DATE OR INdURV--•MONTH.DAY.YEAR 1 320L HOUR INJURY INFORMA- 33. LOCATION (STREET AND NUMBER OR LOCATION AND CIT'OR TOWN 34. DESCRIBE HOW INJURY OCCURRED (SYWTS WHICH MZW LT90 IN INJURY) TION CORONER'S USE SEA.1 CLPV THAT DEATH OCCURRED AT TIE HOUR. DAYS AND PLACE STATES)ROOM a CORONER-SNONARR®AN.)JE4AEB OP TITLE 3x.DATE BroNED ...I ONLY TNM CAUSES STATED.AS REQUIRED BY LAW I HAVE HELD AN IINOUt SY-INVtT 3A TORI 1 I I 36. DISPOSITION 37. .^.ATE'-MONTH DAY.YEA AR 38. NAME AND ADDRESS OP CEMETERY OR CREMATORY 39.EMBLMER'S UCSNSS NUMBER AND SIGNATURE r -rial Dec. 20, 1988 1Burwood Cemetery Escalon, Calif. Not Embalmed 40A.NAW OF PUMERAL DIRECTOR(OR PERSON ACTINO AE SUCM1 4CB. UCEN$E NO. 4 GAL REGI TUR! 42. OATS ACCEPTED RY LOCAL RIOIItTRAR Oakdale Memorial Cha el 764 P a ` G101986 STATE REMSTRAR VS1111-851 IBM me THIS IS TO CERTIFY THAT, IF BEARING THE SEAL OF THE SA`i FRANCISCO ^EPARTm-'TT OF PUBLIC HEALTH, THIS IS A TRUE COPY OF THE DOCUMENT FILED IN THIS OFFICE. NO. 88 sDhTED: J :�: ;_ .c', 1'?3u IOL4- :.FMvGAR, ...D. , M.P.H. DIREC-:OR OF K'31.IC HGL TH AND I.(�C:')LL REG I STR?R SAN FRANCISCO, CAC.IrORNIA