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CERTIFICATE OF DEATH STATE OF CALIFORNIA 'STATE FILE .NUMBER USE BLACK INK ONLY LOCAL REGIlrR ON DISTRICT ANO ^.E111 NUNEER tA. NAME OF DECEUENT-FIRST 18 MIDDLE IC. LAST (FAMILY) 2A. OAT( OF ORATH-MO. DAY. YR128. .0U.13. SEx TONY iGiv'"' STORM BADANO December 12, 1991 11540 M I 4 RACES. HISPANIC-SI[GIFY 6. DATE OF BIRTH-MO. DAY. YR 7. AGE IN ' IP UNDER 1 YEAR IP UNDER 24 HOURS YEARS IIIONTHS DAY! HOUR! MINUTE! White ❑ YES X NO April 17, 1946 45 DECEDENT 8. STATE OF 9. CITIZEN OF WHAT 10A. FULL NAME OF FATHER IDB, STATE 001 I IA. FULL MAIDEN NAME OF MOTHER I118. STATE OF PERSONAL BIRTH COUNTRY I BIRTH ! BIRTH Albert ano CA U.S.A. AlbB. Bad DATA Iltaly I Gloria A. Diaz ; NM 12. MILITARY SERVICE' 13. SOCIAL SECURITY NO. 14. MARITAL STATUS S. NAME OF SURVIVING SPOUSE IIF wFE. ENTER MAIDEN NAHEI 19 66 TO 1968 ❑ NONE 547-66-8648 Married Margaret Wilson [IIIA- USUAL OCCUPATION 168. USUAL KIND OF BUSINESS 16�1St}IyOWEO%ER 1160. T[Aw3 IN 17. EDUCATION-YEARS COMPLETED OR INDUSTRY CLQ LL�� 11 11 JJ OCCUPATION Truck Driver ,Ready Mix Concrete ; Concrete 2 12 ISA_ RESIDENCE-STPUrT AND NU16ER OR LOCATION ! 188. CITY �18C. ZIP CODE USUAL 25407 Tully Road Acampo I 95220 RESIDENCE 180. COUNTY ISE. NUMBER OF YEAR!r18F. STATE OR FOREIGN COUNTRY 20. NAME, RELT1ONSHIP. MAILING ADDRESS IN THIS COUNTY i AND ZIAP COOS OF INPORMANT San Joaquin 2 California Mrs. Margaret Badano - Wife L 19A. PLACE OF DEATH i 198. IP PITAL_ 19C. COUNTY 25407 25407 Tully Road ONE: IP. ER/OP. DOA PLACE Residence San Joaquin Acamno, California 95220 OF DEATH :90. STREET ADDRESS-STREET AND NUMBER2.OR LOCATION ' 19E. CITY 2WAS DEATH REPORTED TO CORONER? I TIME INTERVAL y � 25407 Tully Road I Acampo BE A.0DEATH F I rESE�R�1N .8[R VO 21. DEATH WAS CAUSED BY: ENTER ONLY ONE CAUSE PER L,NE FOR A. 8, AND CI I 23. WAS EI JPSY PERFORIAED7 ,MMEOIATE IAI {��\✓P (,�7 '.'( / SSI l , ✓(L'/� CAUSE ` ` I ❑ YE! R,NO CAUSE ///�/////A/ 24A. WAS AUTOPSY r�L�P(E/RFORMED? (DEATH EDUE TO (8) / `V� � / { O" r C�� , --------------❑ YES U NO -r 248.WAS IT USED IN OHTERMINING CAUSE OP DHATH7 DUE TO (C) ❑ YES NO 25. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RfiUTED TO CAUSE GIVEN IN 21 26. WA9 OPERA TION PER FOA MED FOR ANY CONDITION IN fTEM 21 OR 25' IF YES.LIST TYPE OF OPERATION AND DATE. No No I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE DEATH 278. SIGN URE ANp0;�OR TITLE OF CERTIFIER 27C.CERnPIER'S uCENSE NUMBER 270. DATE SIGNED PHYSI- OCCURRED AT THE HOUR. DATE AND PUCK STATED FROM THE( CAUSES STATED. ! CIAN'S 27A DECEDENT ATTENDED SINCE'DECEDENT LAST SEEN AUVE CERTIFICA- MCNTH. DAY. YEARMONTH. DAY.YEAR 27E. TYPE ATTENDING PHYSICIAN'S .NAME AND ADDRESS O Cf. 2-5 To Cy' Z. l `"'}' TION Dr. Pak C. Chan M.D. , 18980 E. H 88, Lockeford, CA I CERTIFY THAT IN MY OPINION DEATH OCCURRED AT 28A. SIGNATURE AND TITLE OF CORONER OR DEPUTY CORONER 1 288. DATE SIGNED THE HOUR. DATE AND PLACE STATED FROM THE CAUSES STATED. , I CORONER'S 29. MANNER OF DEATH-SDKIIV ;ne ^.d(Irtil. JCC,Cenf, 30A. PUCE OP INJURY 30 B. INJURY AT WORK 30C. DATE OF INJURY j 31. HOUR USE I smclaw. nomvcw Jenonq IMfSt,RJ(IQn 0, COYI(I .'1of oe Jefe,mined 1 MONTH. DAY. TEAM ONLY ❑ YES [:] NO I 1 32. -OCATION (STREET ANO NUMBER OR LOCATION ANO CITY) 33. OESCRI6E HOW INJURY OCCURRED ;EVENTS WHICH RESULTED 'N NJUR" I 34A. DISPOSITION(S) 34B. LACE OF FINAL DISPOSITION-NAME AND ADDRESS 34C. DATE SIGNAr OF EM6ALM ER 358. LICENSE FUNERAL Lodi ,Memo ial Cemetery M A NUMBER DIRECTOR I Burial 5750 E. Pine, Lodi, CA c Y�,�� t 6794 ANO LOCAL 3.A NAME OF cU NERAL DIRECTION IDR PERSON ACTING AS iUCHI 360. LICENSE NO. 37'Si NATURE F OCAL REGISTRAR 38. REGISTRATION DAT= REGISTRAR Gierhart-Wells & Donahue F.H. F435 i �;'�W" j No1 3 1951 STATE A C. j CENSUS TRACT REGISTRAR I 1 I VS-I I (REV I-901 MAKE NO ERASURES. NHITEOUTS.OR OTHER ALTERATIONS I, Jogi Khanna, M.D. , Local Registrar of Vital Statistics for the County of San Joaquin, do hereby certify that, if bearing the seal of the Public Heard; Services of San Joaquin County, the foregoing is a true and correct copy of the certificate on file in my office_ PA - 0 300074 Date: DECEMBER 16, 1991 By. L Deputy Registrar