ent000602-011

5fAir fill \ "?╟≤ z CERTIFICATE OF DEATH STATE OF CALIFORNIA?╟÷DEPARTMENT OF PUBLIC HEALTH 7097-026828 LOCAL REGISTRATION DISTRICT AND CERTIFICATE NUMBER 2a. DATE OF DEATH?╟÷month, day. year ~J2b. HC*MF* I' ound June 2)i5 1971 1 6:h^ P ?╜ DECEDENT PERSONAL DATA J A? 9 1a. NAME OF DECEASED?╟÷FIRST NAME 11b. MIDDLE NAME [RENE 3. SEX Female 4. COLOR OR RACE Caucasian ' HARR1ETTE 1c. LAST NAME ! PETERSON Illinois 8. NAME AND BIRTHPLACE OF FATHER Jacob Billiet- Belgium 10. CITIZEN OF WHAT COUNTRY USA 14. LAST OCCUPATION Secretary U. SOCIAL SECURITY NUMBER 20 6. DATE OF BIRTH August 17, 1898 7. AGE <LAST BIRTHDA"! (2 YEARS IF UNDER 1 YEAR IF UNDER 24 HOURS 9. MAIDEN NAME AND BIRTHPLACE OF MOTHER Sylvia Bnneman- France 12. MARRIED. NEVER MARRIED, WIDOWED. DIVORCED (SPECIFY) Widowed 16. NAME OF LAST EMPLOYING COMPANY OR FIRM (IF SELF EMPLOYED. SO STATE) Son- Donn Arden 13. NAME OF SURVIVING SPOUSE (if wife, enter maiden name> 17. KIND OF INDUSTRY OR BUSINESS Theatrical Director PLACE OF DEATH USUAL RESIDENCE ii DEATH OCCURRED IN INSTITUTION, ENTER RESIDENCE BFFORE ADMISSION) I8d. CITY OR TOWN Los Angeles 19a. USUAL RESIDENCE?╟÷STREET ADDRESS (street and number or location) lib9 Nicholas Canyon Road 18L9 Nichols Canyon Road 18c. inside city corporate limit I (SPECIFY YES OR NO) Yes 18e. COUNTY 18F. LENGTH OF STAY IN COUNTY OF DEA' Los Angeles I 19b. INSIDE CITY CORPORATE LIMITS (SPECIFY YES OR NO) Yes 19c. CITY OR TOWN Lo,s Angela s_ 19d. COUNTY |19e. STATE LosAngeles 1 Californi 21a. CORONER. ; ?╜2ib. PHYSICIAN: PHYSICIAN'S OR CORONER'S CERTIFICATION AND PLACE STATED ABOVE FROM. THE ED BELOW AND THAi ! HAVE HELD ON 5 OF DECEASED AS REQUIRED BY LAW -.^31 CERTIFY THAT DEATH OCCURRED A E HOUR. DATE, AND PLACE STATED ABOVf E CAUSES STATED BELOW AND THAT I ATTENDED THE DECEASED: FROM DAY. YEAR>| ENTER MONTH.DA INVESTIGATION OR INQUEST! i^i-44 C-m-H dece'. L-A-A 17 YEARS I !8G. LENGTH OF STAY IN CALIFORNIA 17 YF??S 20. NAME AND MAILING ADDRESS OF INFORMANT ..Donn ...Arden - . ^on 2177 Live Oak Drive West Hollywoodj California 21c. PHYSICIAN OR CORONER?╟÷signature and degree or title I 2to. DATE SIGNED *AA. -r- /'U-^U/A /n-A 2l?·AADDRE$S / ?√ß X-W/ LICENSE NUMBER FUNERAL DIRECTOR AND LOCAL REGISTRAR 22a. specify burial, entombment 22b. DATE or cremation I I Burial 6-28-71 25. NAME OF FUNERAL DIRECTOR (OR PERSON iCTING AS SUCH) GU&DALS, CJfeUFOBBUk 23. NAME OF CEMETERY OR CREMATORY vh ftttST UiWH ?╜E*f9RfAL.r?╜Bif MST9 "- ?╜LE??DALE. CALIFORNIA F^MBALMER SlGWm|?·E (IF body EMBALMED) LICENSE NUMBER 0?· IF NOT CERTIFIED BT CORONER WA *~U" TH.S DEATH REPORTED TO CCRCNEf (SFECIFY YES OR NO) WJX4 27. L< j>Mi8Ql sm l %-mi <A 1 CAUSE OF DEATH 29. PART I. DEATH WAS CAUSED BY: IMMEDIATE CAUSE (A) f DUE TO. OR AS A CONSEQUENCE OF CONDITIONS. IF ANY. WHICH GAVE RISE TO THE lMMEDI- j(B) ATE CAUSE (A). STATING NTER ONLY ONE CAUSE PER LINE FOR A. B. /Xz?^^ *^yyf-*A THE UNDERLYING CAUSE , LAST. (C) DUE TO. OR AS A CONSEQUENCE OF 30. PART II: OTHER SIGNIFICANT CONDITIONS?╟÷ contributing to death but not related to the immediate cause given in part u 31. "ny conditio!!iin itei A **"/""*?╟÷ A j j $ AL OPERAT?╜Q?·U3>^.?╜3>|< BIOPSY ^W4 /A 'facte-???√ß>.*-*?╜ , J AAA 33. SPECIFY ACCIDENT, SUICIDE OR HOMICIDE 34. . PLAOt?OF INJURY freeway. highwayRstr^t0RY' 35- INJURY AT WORK 36a. DATE "r AND 32a autopsy ' 32b '' >z' v,-: <->*-*?√ß (specify! ~":-0- side.'.ed in yes or no ) cause of death? ;: 34. placWof injury Freewa' OFFICE BL/!LD\NG ETC.) LA INJURY INFORMATION 37a. PLACE OF INJURY (street and number or location and city or town) 137b DISTANCE FROM PLACE OF INJURY TO USUAL RESIDENCE. ITEM 19. 36a. DATE OF INJURY?╟÷month, day. year j 36b. HOUR I OQ WERE LABORATORY TE! -,;7- DONE FOR ALCOHOL7 (SPECIFY YES OR NO > JO 40. DESCRIBE HOW INJURY OCCURRED (enter sequence of events which resulted in injury, nature of injury should be entered in item 29) STATE REGISTRAR /9 V/ rev. l-t-ee form vs-n THIS IS A TRUE CERTIFIED COPY OF THE RECORD * FILED IN THE LOS ANGELES COUNTY HEALTH DEPART- i MENT IF IT BEARS THE SEAL IMPRINTED IN PURPLE INK. FEE $2.00 G. A. Heidbreder, MP., M.P.H., Health Officer and Registrar