93-026541
After Recording Return Copy of Recorded Document to: {p 3
City Recorder - City of Tigard °9 3 0 2 6 5 41
13125 Sl'V Hail Blvd. - Tigard, 0., ,1223 Washington County
f INDIVIDUAL File No.
t3 DEDICATION DEED
FOR ROAD OR STREET PURPOSES
Ernest C. Jensen and R. Virginia Jensen
G do hereby dedicate to the public a perpetual right-of-way for street, road, and utility purposes on, over,
across, under, along, and within the following described real propety in Washington County, Oregon:
Attached Exhibit "A"
To have and to hold the above-described and dedicated rights unto the public forever for uses and
purposes hereinabove stated.
The grantors hereby covenants that they are the owner in fee simple and the property is free of all liens
and encumbrances, they have good and legal right to grant their right above-described, and they will pay
all taxes and assessments due and owing on the property.
The true consideration for this conveyance is $ 0.00 . However, the actual consideration consists of or
includes other property or value given or promised which is the whole consideration.
IN WITNESS W-HEREOF, I hereunto set my hand on this /0 -~4N day of 191
Signature Signature
11330 S.W. Tigard Street
Tax Statement Address Mailing Address
Tigard, OR 97223
STATE OF OREGON )
) ss.
County of Washington ) -
This instrument was acknowledged before me on 3 o j (date)T zVjk6-(A:(f1 J EN~c"N~.
(name of person(s)).
tary s Si ure
My Commission Expires:
Accepted on behalf of the City of Tigard this / Tof of )werLl , 19 93
VIP-
City Engineer
L- E- G- A- L D- E- S- C- R I- P- T- I- 0- N
March 9, 1993
EXHIBIT "A"
PURPOSE: 10 FEET OF ADDITIONAL RIGHT OF WAY DEDICATION TO S.W. TIGARD
STREET (COUNTY ROAD No. 916), BEING A PORTION OF THAT LAND AS
DESCRIBED IN DEED RECORDING No. 89-018294, WASHINGTON COUNTY
DEED RECORDS.
FROM: ERNEST C. JENSEN AND R. VIRGINIA JENSEN.
TO: ACCEPTED BY THE CITY OF TIGARD ON BEHALF OF THE PUBLIC.
THE FOLLOWING DESCRIBED STRIP OF LAND BEING A PORTION OF THAT
LAND AS DESCRIBED IN DEED RECORDING No. 89- 018294 WASHINGTON
COUNTY DEED RECORDS, ALSO BEING A PORTION OF LOT 11 OF THE
DULY RECORDED PLAT OF "CHERRY HILL ACRE TRACTS", SITUATED IN
THE S.E. QUARTER OF SECTION 34, TOWNSHIP 1-SOUTH, RANGE 1-
WEST OF THE WILLAMETTE MERIDIAN, CITY OF TIGARD, WASHINGTON
COUNTY OREGON.
BEGINNING AT A POINT ON THE EAST LINE OF SAID LOT 11, AND THE
SOUTH 20 FOOT RIGHT OF WAY LINE OF S.W. TIGARD STREET, BEING
S 00°01'00 E 20.00 FEET FROM THE N.E. CORNER OF SAID LOT 11,
WHICH IS ON THE CENTERLINE OF S.W. TIGARD STREET; THENCE
CONTINUING S 00°01'00" E 10.00 FEET; THENCE PARALLEL WITH
THE CENTERLINE OF S.W. TIGARD STREET, N 89°45'45" W 36.00
FEET TO THE WEST LINE OF SAID DEED; THENCE N 00°01'00" W
10.00 FEET TO THE SOUTH LINE OF S.W. TIGARD STREET; THENCE
S 89°45'45" E 36.00 FEET TO THE POINT OF BEGINNING.
CONTAINING: 360.00 SQUARE FEET.
COUNTY SURVEY No. 16,261 IS THE BASIS OF BEARING OF THIS
DESCRIPTION.
I
I
I~2
i
0
i 14.30 I v+
N I o 72.90 117.83
W 08900 9000
n I f ~ b
o= _
o s 6 c
o
.°.o' o (C. S. No. 6747) 5
O O f
~e~ eo;•
-18800
N 4
N e9° 41' W 19(
EXHIBIT "A"
No.5301) 600 ySTREET DEDICATION MAP 105.07 0
o
/.05 Ac. = 8700 3 s~ ~ Q
IN THE S.E. 1/4 OF SECTION 34, a
TOWNSHIP 1-SOUTH, RANGE 1-WEST
01
WILLAMETTE MERIDIAN, WASHINGTON 136'
~N COUNTY, CITY OF TIGARD, OREGON. 08600
in
h
SCALE: 1"=100 FEET 136'
o (C.S. No. 674 8500
oCROSS HATCHED AREA IS LAND
" TO BE DEDICATED. I . 50'
120.97 d• b~
° i (C.S. No. 13,079) 7} . o MCo. Rd. No. 91`6
\
04`` K ~72 g9tbOt J a 8!-524381 / \9) 72 ~f T2 S e90 45 3/4 E - 72
3 L 65.08 w6991
46 1B 4800 50 D 4900 00 u R-20S8e°1~fE 2900
)0 D7& 2800 D _ 8400 .21A c. 3000
a . /6Ac. Z 15 ' I6.53Ac.
7 01 36 w m SCHOOL DISTR/CT 23..E
2b N so 91.15 (PTJ FOWLER ✓P. HIGH
1os I °
«
91.15
m Q s 8300 1498e*36WE~
t*E
4901 9
M
m„ o ,2801 00
155.13
~Q I °.13Ac.$
1152 ,z5ec 2802 8200 02Ac. ° 13
0 119.57 1r r
500
W % p J j
U 25 „70 0
5 o m8100 LL,
78 < 12C 5100 a 6 + 12
~ 7100 ~
24 8000 5 4
zo 3O
- 3 O c 26 "46 1
%
5200 7200 c m
0 4400 ° 3 -1 J 110.21 N m
K 5 120 g In= 11 In J 7900, 1
4 _ Q 10 H
118.03 7300 m m
5300 I
4300 Q
6 Q I 10.21
0 22 « 136
7800%
L 7400 n
w
9 118.03 1 5400 a's 5 c~ 4 p 9
3'41-E J 3 in 21 b Q ~4200 J\ _ 0 120 I0o.41 ° 7700 118
~
7 ~ 86
11 j L = 5500 7500 TO 6
I I8 03 $ O I~ / r
Pn 40 20 - 6 00, 0 7600 Ile ss
I A L 4100 = 120 POINITIAL
A 88029'04" W e I o
INITIAL POINT W2D 5600 6 72 72 72
DAWN'S INLET f m
2 6991 pq m 653.20
TR. ° 19 s~ 2 r()
S. . 9+T 60 11999 w 3 T~ r
►IlQ rT
~'qr¢ ~I" Y _ _ \y ,~VIII~~ , i I°~'~l MZ ~IP l t~\A~•(,; WI'c ~yc'J
~ •51Prw~It~las>;x i.-~ri~taa(sasr`•.xi.aa~ ;:1
47-
~'4rr OREGON HEALTH DIVISION
r- at{fiPtA _ ! IfEBYIF!~fi' 1R°~~
CENTER FOR HEALTH STATISTICS
''ENT r-- I 17940 OREGON DEPARTMENT OF HUMAN RESOURCES F
INK
1.0, TAG NO. HEALTH DIVISION
CENTER FOR HEALTH STATISTICS I 136
Local cub NUMt)er CERTIFICATE OF DEATH S1aTp Fllc N-b4l
Nf CFE ENT S Frr., w oV,r tsar 1 SEA J. OATS OF DEATH !Hoorn. Oar, v..rr Y
Ruth E. IJEN'STROM Fenjale Januar 8 1993 I•~~S)
• SOCIAL SECUnIIr NUMII V+'u (Y. AG.L.L1 a H~•IM . u Unnnt 0.' 6 RIRTNP1.ACk lf,•ry antl bau e+ r•qn r OATF OF L111- rwor•m . D.V -'j-
543-26-936 ~r,wr G•.nm.Yr w
9 94 W :F Helena, Montana April 7 1898
b urns UL (:f Uf rrl r.vrll era-_-- - -Y. PLAC( DF of wl rr
U': ANMfO 1 CJIIl,{!'.r ' rCnrca bnry nn.I
1rlVPIt AI I.]IK)
[ I Vwa I xNO ~ Ir,ur . nI i LIUUI, I O 1 11 E ri OI Istw
}D( L1ra .•ry l4rnw l-1Owcnllnnl'c ,Lnn.r I.I I•rr cnyl
eu FwCILIrv NAME fu nor •n.n..... . tl,w erred! antl nu,nn.,) _ _ qr. CITY, TOWN On IOC.AOON OF DF.TN W COUNTY OF DLa1N '.•`~4'~~'R-
Bess Kaiser Medical Center Portland Multnomah
I.. DECEDENT'S U$UAt OCCUPATION to. KIND OF HU$INC$$/INUI/$1 nY MAnOAl STATUS Ma,n,ttl. Ij SPOuSE III Narri.tl, Weowra) i~ ,~t~, 11, rG•+n.L•neo/..o+r don. ow~r•p mace or ~o,a•np rr Nwr Marrntl, W,tlowce !r r'';7
Do nor vat rerrree) 0--d lS-11,J
r n Home Widowed Charles fff0 13a RESIDENCE Si ATC Q., Co.." 13C CITY, TOWN ON LOCATION Q.,, SIHEF I ANO NUMDER
gn -1 on Tieard 11330 SW Ti and St. F
lk INSI(1 [11Y ,)I ZIP COLIC 1a, y+AS DECEDENT OF N15-F,IC ORICINT 1S RACE AmerKan Inn.. n, rG DE GC DEN T"S EDU-,C
LIM175'' 15VwcIrY No o. as IT y ♦ _01 y Cuban, B,.C,. Wnn•, elG ISP ISVrC onry n•pnw Fr q,anw CV,n Pr.rrdr
r1 Puerlo RIC.n, r:c 1 I)(I Nn r] Y.c Elunwm y , conea•Y 10111 CourOe II • or 5 • 1
❑1..iJNb 97223 •"/y White rr5 .
Ir hit N(R .NAME rear mi+k)Ie I'M 1A MOIIILII NAME Hr•I min.Ve maiden IY INf nRMANT NAME anJ .eMUen♦n•V In u.rraaro
Co F.11a R d VA
.r _SLPio Jcnscll-il<IU};ISE•r
,q, ML uVU Or Ul gl'OSn IOIY I IMUUrn•„n, lob PLn(.1 or UI!.POSIIION INanrr nr cnnlnr r. c,rnr.r r. r %fk. I OILAIn P+ (.dr u• ton, t,l-l.
u,r, Pr.r.l wr m ~ ~
kwrLl [ ]crwma.nn L7 nwn,r,•ra Hom s.Ir Ir ~
❑Unnnun 01rwr l::Pec•Irl.._
Crescent Grove Cemetery Ti and Oregon
7'c " Ir ATUT OF FUNFRAL St"VICE CL NS C On - 71b LICENSE NIIMdLR 77 NnM[, nUUIIE $G ArID ZIP OF FACILITY
PE RCON A$ $ 1 IOr l~cnn aw.!
Young's Funeral Home
118 l' PL c Hu Ti ac OR. 97223
D k ILLD (MOnI/,, D. r, Ytar! q• ILL "1N, Ifs 51' AT
J RC I'TQ
AId 13 1993
)IL) I10S-AL HEPPE$ENTATIVE MAe( 11E000ST 'On ANAIOMICnL GIFT COIVSCNTY 76 WAS GIFT AUk' ti (r,
lU OC CUN VI C1CO OY CC nTItYINC• InLYSICIATa UL CTTTU---MVI.C iLD ONLY BY MEDICAL E%wMINEH~
I '.YES ;][No [ Ir,.G.E,,...,.. 1 0 []ww "-'1{
11 TIME III DFAIN $ MFI)~C.nl f w AM1111 II NCII IF IE Or _ ll• IH III 1334 M 1 j- X iN M In bus
•ani r es PlaCl ano.10 DA1L S,G.[U My 1 D.r. IMOnrn. U.,. real COUNTY
93
N N.11E, 111LE, AUUOESS AND ZIP UE CFHIIf -..,MEDICAL fFAMINEII (Tend o, Pr,nH - L ,
Leonora Dantas, M.D.. 5055 N. Greeley, Portlan~,_ Qr~g_g11.__-97217
35 MANE OF ATTENDING PHYSICIAN IF OTHER THAN CFR11FIfO ITru. ar Prrnr) i
•Yr 35 II-fO1AIF CAUSE ICITEA O/ILY UNt CAUSC PCP LINF !On rx, o•.c v .rv' once! .t q0
.r rat: nl. ANO Irll Iron muUr ur nrr•q.. q. G, r Fl--Illy ♦„rcr
I .I Urlro.n
PART lal ~ Y>✓/ ~fi C~~sf"✓YYl< .7 I I x„~ _ f~J
DUE TO. OR AS COr+SEOUENCE OF. - Inle,.,al p,Il~. once! '~•fG1{
n
nl aw
DUE TO. OR AS a CON SEGUE NCE OF nlcrvnl bol,.een o ael
YTM
rc) nb H. Eh
OTI1rR $IGNIFICANI CONDUe••:tI IO~'$ ]Y O,d lubacco vu convlbu:e Jb wUTO~Y >J •u " ~,LI
Ce-l-0 na Cnnlr :1VI•np In but rlbl reaubmb •n llI. urVM,lyrnp a uin g1+on •r, PART I I.
Ind Ona1nT wrr+ L1 cw.waeoe.~ ~V
1 Ilya [ I P,LaWOIy VVV
wt c~L GrvY C! C LUfeti, ;SNO L i un.no n O Yr ❑ Ill J No L r + 5p H
aD MANNER OF DEATH la ()ATF OF INJUNY alb. TIME Oi •lC INJURY j
u eta DFSCO11tL 1IOW FNjunY OCCUIanCE)
•'~((J
r' 1 ral 1"] Pend•np rMbn n Day,Yea,J INlVHY Al WURKT
_ niRgrl !,~~!v~y/'~
Jµ
~]ACCItl.nl r>DOnlne; •n:neU M UYwa [1 Nb Y"N
]SuiclJe x PLACE Or INJURY. pr
Roure numbe•
❑HO m•c.nc ['I ~ ega~en non bu.lunp w c r$++e /y! ' nub,...... u CIO roll, I LOCATION IS—, and Nunuu nr Rural C.,, I.- SO.,,
nFGF nvFD On NFGISTnAn'S USE
I~
ORIGINAL-VITAL STATISTICS COPY .5.7 RaY a.oq
fIItCLnE,AL UIw Mk.'eCna Gvr1 - -
4)g
wY~YY~r1 ~ vv~YYlll , 9
,l ' hp I CERTIFY THAT THIS IS A TRUE, FULL AND CORRECT COPY OF THE ORIGINAL CERTIFICATE ON FILE IN
LL'41
THE VITAL RECORDS UNIT OF THE OREGON STATE HEALTH DIVISION. 1i(iJ
42~ yrlh S _1~ Ty 1 /r~/~t;~~
rig _ ~•.a p j/~
W K •1T~TKF7•
DATE ISSUED EDWARD J. JOHNSON II,
LA• _ STATE REGISTRAR
t
I -
~
~S
~~S:,1U~ -~L~\\ ~ ..a- `s-.._~~',~ Li~~L1gI{F ~ ~•t;11~j;, Jr'•- '"-'_L%,) 1 J."'~ •'z." III'\\1\~~~~:1 ~ ~~f~~
,1....,.. I 1 r...:T. a,,.xl.. -.~..,1t11• ...,lrl,lw9tnS~, .r'`~7.`-E~. ~ I uu. ...:F• .,~,r;• 1,au.<•
t c:+alT~,sfsnrt~r-0".AkTt'•iS115'"iYh~'.+hr~':•.e "eti
amt •rDAM N•. M-01110, WARRANT} Sunl nhi I.dl.id.-+I •r C•, ~
_ 89-18294 i
WARRANTY DEED-SURVIVORSHIP Washington County 1 T
Co RUTH E. WENS') ::OM 1 •
t • KNOW ALL MEN BY THESE PRESENTS, That
RUTH E. WF; 'TROMereinqJfer Rcq-!I d'PheC., rantur,
Lr7 for the consideration hereinafter stated .o the grantor paid by aRd ENS
cIZ
JENSEN and R. VIRGINIA. JENSEN, husband and wife,
• I-•'A p~,~ i hereinafter called grantees, hereby gra.•t,, bargains, sells and convey.. unto the said grantees, not as tenants in com-
mon but with the right of survivorshi t;,rir assigns and the hair, of the surv,t or of said grantees, al) of the follow-
ing described feel property with the n .tr n llereditamrnra and nppurtenanl + thereunto belonging or to any sole
as h>ngton
~ appertaining, situated in the County Dr . State of Oregon, ..-wit:
East 36 feet of the Nccth 100 feet of Lot 11, C erry Hill Acre ,
Tracts in the County cF Washington and State of Oregon, more
* particularly describe' as beginning at the Nor'_ !ast corner of
the said Lot 11, run '';:.ease South along the EaF^. line of Lot 11
100 feet; run thence ' st parallel to the North line of Lot 11, a 't~•
distance of 36 feet; run thence North parallel _.o the East line
r of said Lot 11, a distance of 100 feet to the North line of said
l Lot 11 and the South ine of Tigard Street; run thence East 36
feet to the point of eginning. .;'b.
1 4t
1 J.i y'r1' ~
1 7 III %-CI IriSUl11C11141. CONIINUI DISCRINION ON DEWITT S'Dll `•f k '+'1
TO HAVE AND TO HOLD the above described and granted premises unto the said grantees, their assign.
'4Y1 ; y and the heirs of such survivor, lorever; provided that the grantees herein do not fake the title in common but with
the right of survivorship, that is, that the fee shall vest absolutely in the survivor of the grantees.
And the grantor above named hereby covenants to and with the above named grantees, their heirs arid assigns,
b that grantor is lawfully seised in lee simple of said premises, (flat ,none are Ire, irom all encumbrances
,.r 1
jA
and that ' i
grantor will warrant and forever defend the said premises and r ,ery part and parcel thereof against file lawful claims
a_: and demands of all persons whomso ,,r except those claimin tinder file above described encumb~at~Cr s .
Q Iflfie~l tance '~iY:.'•>'-
.i The true and nctual consider ran paid for this transfer, -rated in tern,, of dollars, is /
r Purgous k
d I mHowever, the actual consideration nstets of or include, ocher property r value given or pro ns which is ±1a,
Phi f i flhw consideration (indicate whir t ~'(Th• .rnr•nc• b. n. •.n rile •rmhn!• "I, it not vpl¢whlr, rhou/d h. d.l.rwd. 5.. ORS 9) 030.) Y4
e" In construing Nlis deed and wl r flip context sn rrquire•, the tingulnf i cludes Ihr plural and nll orammaliea/
Yt 't! changes shall be implied to make the ~rovisiorn hereof apply equally to cory -Tions artd odividunl,. 5, r
+'y^ :(r In Witness Whereof, the Qrnnfr . hn, executed this inorrument this / ay of ~ 9
µl '3 if a corporate grantor, it has cau-ed , name to be signed and seal affixed hl is officers, duly nufhorired thereto by F
order of its board of directors. f.
THIS INSTRUMENT WILL NOT ALLOW USE r1' THE PROPERIY DE
SCRIBED IN THIS INSTRIMENT IN VIOLA110', .lf APPLICARLE LAND RUTH E • ~'1Et" r'f'ROM f
•71" USE LAWS AND REGULATIONS RErORE SC-ING OR ACCErTIht,
f'.~ THIS INSTRUMENT THE PERSON ACUUIRIN FEE TITLE TO THE A - Ax
PROPERTY SHOULD CHECK WITH THE A;'PROPRIATE CITY OR
p,Id t~ COUNTY PLANNING DEPARTMENT TD VERI11 APPROVED USES
"a STATE OF OREGON, ) STATE OF OREGON, Cou,' - of I••• `qK
r co ty ar . Washington 19 x r
Oyu-( t9 8 q) P.--illy Pwuwd ar.r s
g tl ~y who. ls.ln/ duly no,n. » .sr' ~~',1•L
r.ch for hi-it .,,it nor on. lot the other, did my that the fpnr, is tM y, 1
Personally appeared the above named h
! RUTH E. WENSTROM p...id.nr ad that rM I.rlw Is rM
r na y
ewre/wy of • I,
r
. . con por.rlen, 3`'
end .ck-.l.d4,d file L-gon,g imnl" wad fh.r N,• •e.1 If-d • fm.doiy fnurunrnf h IM
m.nf to be ro por.n
tar,,..r. r,..n d fho aid lase-nf .wr •ig d .ref :wl.d In M, +
her rl end d-1, r.l -d wa
tY; •nlunrnrl r
hnl7 of .aid u,rr.or a,ian b. rhoriry or In tNa.rd of d:r.crorr: .n! r.rA of -
fhrm -knu..b•dg.d u,d In,--nf fo be in •olunf.ry w<r .nd d..d.
Dt ♦ D.lur nrJ ~r Ile for. nr. •
(OFFICIAL - rte( / T rt// I (OFFICIAL
SEAL) SF.AL)
.It' rr~ I /lyuray Public for Or•gun Not.ry Public Im Ong-I
: ~ My commhlon w.Dlrrr ) ~ M) commu.ron r.P,r•,, nr ^n...HM» rW 'L -f`
f/ I RUTH E. WENSTROM STATIOF 011Ww"
11340 SW Tigard Street u
Tigard, Oregon 9 7 2 2- '-Ounly a waahWg6*n R
w`^ I " • `
v;- I, Qorsafd W. Mason, Oradw a Aaaseanles &
Ruth E. Wenstrom~
*r . and TaAatlon *n_j oar d Ca1• - -
Ernest 6 R. Virginia: Jensen ayw vn to self tw oer" ow
x 11340 SW Tigard Street xx. w m WV*V recd w
Igi
i Tigard, OR 97223 recoroK 7OI'rr °Oia'1y
y ~ AII.r nrMR.a m.r. h, rn. i!J R ; w..~...' a f
t • Ernest s Virginia nsen ..<nw1,,..u.,X1t E"
11340 S. W. Tigard Street t, 1~.:~:f
f ti I Tigard, OR 97223 L;,•; f `h^:
Y.Ill . d.nq• 1. nWrIN .11 1.. n.-h rbell b. ,.wl I. he hlhrlne di-
Ernest 6 Virginia Jensen
1,1340 S.W. Tigard Street oo : (31)018294
t r
11.00
i,c 14/2 99E7 r9PM
3 Tigard, OR 97223
v I N•MR 4/Z5/t989 U3:r ~3:
. •oo.ue. x1.
f 1
1f 'f
~ t:
STATE OF OREGON
County of Washington SS
I, Jerry R. Hanson Director of Assessment
and Taxation and Ex-bfficio Recorder of Con-
veyances for said county, do hereb certify
that the within instrument of writing was
received and recorded in book of records of
said county.
Jerry R. Harmon, Director of
Assessment and Taxation, Ex.-
Officio County Clerk
Doc : 93026541
Rect : 97658 63.('.
04/08/1993 12:21:45PM
I L
/.'%~yrTNItITrnHtrt n^Tr•YrMV~Vr •ItiV•!V+ 1 t•YrT•mm-t • r-~i-~•.we-w .M. t+•-i-.hw~~rv..~..~r.. r.. rTri n ~ ~ NM'si`~."' ,1~~
1 805 i OR= 'EP ;FTrr1ENT Or UhtAh R;-:SOURCES
Y 1,0. TAG NO HEALTH DIVISION
~ ~ ~•/~1 i CENTER FOR HEALTH STATISTICS
~t CERTIFICATE OF DEATH
Local PII¢ umCer state Five Numpgr r,
I CECEDr_NT-S Frrv +o¢w. t.,,
7 NAME 2. 30 1 D•,TE Of OcAYn ~tt,. Dey. ".er)
Ernest C. JENSLN Male Ma 1
a. DOC-L SECURITY NUMSEA 5a. AGE1..1 tLhe°a•( ;t. Ur•der f Year w. VnJr•r Ory 6. PARTHPISCE (Gryarld Srar•orFar~r 7. DA OF fslPTr ((onto. Jey. /•.rl
501-05-0891 son S _ Dakota October 20, 15 16
aWAs DECfDENY EVER IN '4, PLACE OF DEATH e,>- -k a'n) ,
US_ ARMED FORCE47
Q Y.S Q1a ~arTAL §~Inpatlarl CEHiCtI[pu~t ❑DOA Or1+ER CNurtlno HUnr, 0OeQMnI'a H- QOlhW (SO-l,;
g¢. FAC'II r. Y NAVE Id not wtcnuUOn- piw err..( and name..) 7e. C)TY, TOWN, OR LOCATION OF DEATH St. COUNTY OF DEATH
T St_ Vinceant Hospital P tland washincrt
Z tO•, CECECEN a U&JAL OCGZJoATION tCD. KIND OF HLjrN EJSItNOU'uTRY t1. MARITAL STATUS - a --U( t£ SPrY-E ry/ r.r.r.y, wrd-o ~
(rS.+A.ry roR Oen. d.~MQ.w»I e/ r.ar•4q ate. Aor wreP...t
D.7g1 ii1ii°' State of Oregon ni--d t~ r;
3 Supervisor /a
to REStD01CE - STATE utb CCIUNTY 133 O11Y, TOWN Oq TION TJd. STREET AND NUMBER
4
5 Ty, tNa
DE Z CITY TSr, Z)P GQDE T4 WAS DECEDENT OF NJZvANIC ORIGIN7 ri FaCE A~C p rndfW% t TiR&
F1YX_.A7lOr
[JMIT;r`7 (spay Nov yes • It ye4 yn.~Cly C,t. elxk. whits .EL aa+etry} (4-ify -0y ft'g-sr V,.d. ce .Al.n.d).
6 Me:icx~. uer:¢ Rlar•. +:.:1 No 1CY.a ~n.r"[YryM,,.ynda..y l6tA C¢tt.,Q. (14 a Sal
t'SC ❑N. 97223 sp.°rv:
L- White 12
I,T
Y FATHFR-NAME Est,... - saiOdke - 1 :6. NOTHZR . r:A,sE -r. -4,;4 m W-n 3 irFOGrMwKT - wn•[E; ara.nrlaterdu0 la ar~a.6
F. II{ g-n-se-n-wife
METVOD Oc OGPC*1r.ON 0V - m :re. PEACE Or D*POSmON fNam. ofnJrn.fwc id a,- &tory, ay 20r- LOG ,OM • Cry or To , Sr.i.
r' '~Gaun.r ❑c,etlu[I°n GRirtc,r.l tnarn state vn.r p).a.)
T 0Ql tk¢ 00trwrSa. ) Crescent Grove Cemetery Tigard, Oregon
Zia. a OF RlN9iAL SEA-ICE UCEN :c' 21G LCENSE Nur,ec. 27•. NAAI£ ADDRE ° AND T.P OF F.=TV ,F
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MAY 1, 1 1992
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u Masud Ahmad, t; t} 1510 Division St. Oregon City Oregon 9,7045
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ORIGINAL-VITAL STATISTICS COPY
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THIS IS A TRUE AND EXACT REPROdt;CTION OF THE DOCUMENT OFFICIALLY
°+e REGISTERED AT THE OFFICE OF THE WASHINGTON COUNTY REGISTRAR.
COUNTY RFT1S'7 lAR £ :
j s DATE ISSUED WASHINGTON CAUIaTT. OREGON t~ fem..,: