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Violet Mae Halstead
a H U H a HxwF-4 En Pq C7 P4 w H H H W �z d H W p -I CU FTa U � A w a H V Q� En H C7 fL] co PP4 r�Tr+i H O cn W H x xH H W 0 H 5-+ P4 O vi v WH (n 00 .A H r1 00 En ,l c*1 H �I cn H U H 4 � W PA I w W H W Hvw]AP 44 � W� WdW H z 0 H P w A ) A O wo H C7 A H A Cn P4 U) 0 fil �1 0 A O vWJ 0 CERTIFICATE OF DEATH STATE OF CALIFORNIA USE BLACK INK ONLY/NO ERASURES• WHITEOUTS OR ALTERATIONS LOCAL REGISTRATION NUMBER TE cll C NUMBER R.1I fRFV. I1/RBI 1. NAME OF DECEDENT -FIRST (GIVEN) 2. MIDDLE 3. LAST(FAMILY) Violet Mae Halstead 4. DATE OF BIRTH M M / D D / C C Y Y S. AGE YRS. IF UNOER I YEAR I IF UNDER 24 HOURS 6. SEX 7. DATE OF DEATH M M / D D /CCYV B. HOUR MONTHS ( DAYS HOU RB 1 MINUTES F 02/11/1997 0653 06/08/1913 83 I I 1 9. STATE OF BIRTH 10. SOCIAL SECURITY NO. 11, MILITARY SERVICE 12. MARITAL STATUS 13. EDUCATION -YEARS COMPLETED 11 ❑ R Wid. 12 SD 508-24-6017 YES No 14. RACE 15, HISPANIC -SPECIFY 16. USUAL EMPLOYER ❑ ❑x No Self employed Cauc YES 17. OCCUPATION 18. KIND OF BUSINESS 19. YEARS IN OCCUPATION k 60 Homemaker Own Home 20. AMSIDFNCE--STREET AND NUMBER OR LOCATION 11434 Meadow Creek Rd. 21. CITY 22. COUNTY 23. ZIP CODE 24. YRS IN COUNTY 25. STATE OR FOREIGN COUNTRY El Ca ' on San Diego 92020 8 GA 26. NAME, RELATIONSHIP 27. MAILING ADDRESS (STREET AND NUMBER OR RURAL ROUTE NUMBER, CITU OR TOWN, STATE, 21P) Lana Fauskin, daughter 11434 Meadow Creek Rd., El Ca'on, CA 92020 28, NAME OF SURVIVING SPOUSE -FIRST 29. MIDDLE 30. LAST (MAIDEN NAME) 31. NAME OF FATHER -FIRST 32. MIDDLE .33. LAST 34. BIRTH STATE William - Wentworth CN 35. NAME OF MOTHER -FIRST 36. MIDDLE . 37. LAST (MAIDEN) 36. BIRTH STATE Georgia - Buckingham SD 39. DATE M M/ D D/ C C Y V 40. PLACE OF FINAL DISPOSITION 02/14/1997 1 RES -Lana Fauskin, 11434 Meadow Creek Rd., E1 Cajon, CA 92020 41. TYPE OF DISPOSITION(S) 42. SIGNATURE OF EMBALMER 43. LICENSE NO. CR/RES / not embalmed - 44. NAME OF FUNERAL DIRECTOR 45. LICENSE NO.46. BIGNA E LOCAL RAR 47. DATE M M / D D / C C Y Y Featheringill Mortuary FD1083 • 02 13/1997 iC1. LACE OF DEATH 102. IF HOSPITAL, SPECIFY ONE: 103 FACILITY OTHER THAN HOSPITAL' 104. COUNTY Grossmont Hospital IP ER/OP DOA ® [:1 ❑ ❑ CONY, ❑ RES. ❑ HOS P. CARE OTHER San Diego 105. STREET ADDRESS -STREET AND NUMBER OR LOCATION 106, CITY 5555 Grossmont Center Drive La Mesa 107. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR A. 8, C, AND D) TIME INTERVAL BETWEEN ONSET 108. DEATH REPORTED TO CORONER AND DEATH X ❑ NO 12 Hrs. IMMEDIATE CAUSE (A) Acute Myocardial Infarction YES REFERRAL NUMBER 2-246 109. BIOPSY PERFORMED DUE TO (B) Coronary Heart Disease 5 years ❑ YES ® No 110. AUTOPSY PERFORMED ❑ © DUE TO (C) YES NO 1 1 1. USED IN DETERMINING CAUSE ❑ DUE TO (D) ❑ YES NO 112. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN IN 107 Hypertension 113. WAS OPERATION PERFORMED FOR ANY CONDITION IN ITEM 107 OR 112? IF YES, LIST TYPE OF OPERATION AND DATE. 1 14. 1 CERTIFY THAT TO THE BEST OF MY KNOWL• 1 IS. SIGNATURE AND TITLE OF CERTIFIER 1 18. LICENSE NO. 1 17. DATE M M / D D / C C YY EDGE DEATH OCCURRED AT THE HOUR, DATE THE CAUSES STATED. , C34065 02/13/1997 AND PLACE STATED FROM DECEDENT ATTENDED SINCE I DECEDENT UST SEEN ALIVE 1 18. TYPE ATTENDING PHYSICIAN'S NAME, MAILING ADDRESS, ZIP MM/ O D/ C C Y V 1 MM / D D / C C Y V 08/09/1990 110/08/1996 Henry Samtoy 1625 E. Main St., E1 Cajon, CA 92021 I CERTIFY THAT IN MY OPINION DEATH 120 INJURY AT WORK 121, INJURY DATE M M / D O / C C V Y 122. HOUR 123. PLACE of INJURY OCCURRED AT THE HOUR, DATE AND PLACE STATED FROM THE CAUSES STATED. ❑YES ❑ NO 124. DESCRIBE HOW INJURY OCCURRED (EVENTS WHICH RESULTED IN INJURY) ' 119. MANNER OF DEATH ❑ ❑SUICIDE ❑ HOMICIDE NATURAL COU�D NOT ❑ ACCIDENT[:] NVESITIGATION❑ DETERMINED E 125. LOCATION (STREET AND NUMBER OR LOCATION AND CITY, ZIP) 126. SIGNATURE OF CORONER OR DEPUTY CORONER 127. DATE MM/DD/CCYY 128. TYPED NAME, TITLE OF CORONER OR DEPUTY CORONER B C D E F G H FAX AUTH. 11 CENSUS TRACT 9702533