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ent000602-020
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I agree.mm mm APPLICATION FOR CERTIFIED COPY OF DEATH CERTIFICATE COUNTY OF LOS ANGELES HEALTH DEPARTMENT FOR OFFICE USE ONLY FULL NAME OF DECEASED IRENE HARRIETTS PETERSON CITY WHERE DEATH OCCURRED LOS ANGELES )ATE OF DEATH (MONTH-DAY-YEAR) FOUND JUNE 2k 9 1971 NAME AND ADDRESS OF APPLICANT IF CERTIFICATE IS TO BE MAILED* FILL IN BELOW! MA I L TO STREET ADDRESS C ITY, STATE & ZIP CODE- Mr. Donn Arden 2177 Live Oak Drive SKB& West Hollywood, California 90068 H-693 (Rev. 1-6 76A668A- Cdb 6-70 JOURNAL NO. OR RECEIPT NO. CERTIFICATE NO. ^] PICK-UP \~_~] MA 1 L NO. COPIES FEE PAID* 10 $ 20*00 FREE** ^><c VITAL RECORDS - ROOM J00 OLD HALL OF RECORDS 220 NORTH BROADWAY LOS ANGELES, CALIFORNIA 90012 * Fee $2*00 each. ** For purposes specified by law*