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DECEDENT
PERSONAL
DATA
1A. NAME OF DECEDENT -FIRST 1 18. MIDDLE 11C. LAST
ANTONIO ROBERT 1 PERCY
2A. DATE OF DEATH (MONTH, DAY. YEAR) 1 2B. HOUR
August 2, 1984 1714
3. SEX
MALE
4. RAGE /ETHNICITY
CAUCASIAN
5. SPANISH /HISPANIC
NO
6. DATE OF BIRTH
JAN. 5, 1
1932
7. AGE
52 YEAR5
IF UNDER
MONTHS
1 YEAR
l DAYS
IF UNDER
HOURS
24 HOURS
I MINUTES
8. BIRTHPLACE OF DECEDENT
(STATE OR FOREIGN COUNTRY)
MICHIGAN
9. NAME AND BIRTHPLACE OF FATHER
LOUIS PERCY, ITA
10. BIRTH NAME AND BIRTHPLACE OF MOTHER
ROSE LORANGER, MICHIGAN
11. CITIZEN OF WHAT COUNTRY
U.S.A.
12. SOCIAL SECURITY NUMBER
379 -30 -1466
13. MARITAL STATUS
MARRIED
14. NAME OF SURVIVING SPOUSE (IF WIFE. ENTER
BIRTH NAME)
THELMA L.STRAHM MICHIGAN
15. PRIMARY OCCUPATION
AVIONICS
MRCRANTC
16. NUMBER OF YEARS
THIS OCCUPATION
28
17. EMPLOYER (IF SELF- EMPLOYED, 50 STATE)
AMERICAN AIR LINES
18. KIND OF INDUSTRY OR BUSINESS
TRANSPORTATION
USUAL
RESIDENCE
19A. USUAL RESIDENCE- STREET ADDRESS (STREET AND NUMBER OR LOCATION) 1 1913.
1
21326 HOWARD AVENUE 1
19C. CITY OR TOWN
TORRANCE
19D. COUNTY 19E. STATE
LOS ANGELES CALIFORNIA
20. NAME AND ADDRESS OF INFORMANT RELATIONSHIP
THELMA L. PERCY(WIFE)
21326 HOWARD AVENUE
TORRANCE CA. 90503
PLACE
OF
DEATH
21A. PLACE OF DEATH
Daniel Freeman Marina Hospital
218. COUNTY
Los Angeles
21D CITY OR TOWN
Marina Del Rey
_J
21C. STREET ADDRESS (STREET AND NUMBER OR LOCATION)
4650 Lincoln Blvd.
CAUSE
OF
DEATH
22. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR A. B, AND C)
IMMEDIATE CAUSE
(A) ACUTE CARDIAC INSUFFICIENCY 1
CONDITIONS. IF ANY.
APPROXI-
MATE
INTERVAL
B ONSET N
AND
DEATH
24. WAS DEATH REPORTED
734 ORON RT
-9
DUE TO, OR AS A CONSEQUENCE OF
WHICH GAVE R15E TO
THE IMMEDIATE CAUSE, (B ATHEROSCLEROTIC CORONARY HEART DISEASE 4
25. WAS BIOPSY PERFORMED?
No
STATING THE UNDER-
DUE TO, OR AS A CONSEQUENCE OF
26. WAS AUTOPSY PERFORMED?
Yes
LYING CAUSE LAST.
(C) 11 011
23. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN
IN 22A
27. WAS OPERATION PERFORMED FOR ANY CONDITION IN ITEMS 22 OR
23? TYPE OF OPERATION DATE
N
PHYSI-
CIAN'S
CERTIFICA-
TION
28A. I CERTIFY THAT DEATH OCCURRED AT THE
HOUR. DATE AND PLACE STATED FROM THE CAUSES
STATED.
I ATTENDED DECEDENT SINCE I 1 LAST SAW DECEDENT ALIVE
(ENTER MO. DA. YR.) I (ENTER MO. DA. YR.)
I
28B. PHYSICIAN SIGNATURE AND DEGREE OR TITLE 128C. DATE SIGNED 1 28D. PHYSICIAN'S LICENSE NUMBER
1 I
I I
1 I
28E. TYPE PHYSICIAN'S NAME AND ADDRESS
INJURY
INFORMA-
?ION
CORONER'S
USE
ONLY
29. SPECIFY ACCIDENT. SUICIDE, ETC.
30. PLACE OF INJURY
31 INJURY AT WORK
32A. DATE OF INJURY MONTH. DAY, YEAR 1 328. HOUR
I
33. LOCATION (STREET AND NUMBER OR LOCATION AND CITY OR TOWN)
34. DESCRIBE HOW INJURY OCCURRED (EVENTS WHICH RESULTED IN INJURY)
35A. I CERTIFY THAT DEATH OCCURRED AT THE HOUR, DATE �AN��j D��--yyP��LACE STATED FROM 1 358. CORONER SIGN R' AND D 1 3 C. DATE SIGNED
THE CAUSES STATED. AS REQUIRED BY LAW I HAVE HELD AN,�u'u T- INVEST GATION) I 1
;Deputy C ro• c 8 -5 -84
I
36. DISPOSITION
BURIAL
37. DATE MONTH, DAY, YEAR
AUG.7, 1984
38. NAME AND ADDRESS OF CEMETERY
GREEN HILLS MEMORIAL
275n1 S_ WFSTFR
OR CREMATORY
PARK
I ;r_
ER' CENSE NUMBER AND SIGNATURE
4
40A. NAME OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH)
GREEN HILLS MORTUARY
408. LICENSE NO.
1175
4 19AT j=5: AL REGISTRAR
AUG w/
STATE
REGISTRAR
A.
B.
STATE FILE NUMBER
THIS IS A TRUE CERTIFIED COPY OF THE RECORD
Rft PO 'IV THE COUNTY OF LOS ANGELES DEPARTMENT
or I4TALTH SERVICES IF IT SEARS THIS SEAL IN
PURPLE INK,
CERTIFICATE OF DEATH
STATE OF CALIFORNIA
11 IC n 7 1484 FEE
PAID
33 (ttr'
•lrsctrr of WWI kakis and Ns&*u
504
84. 1329408
67604 -445 8 -83 400M DUP 0 OSP