93-026541 & 89-18294 ~ 11330 SW Tigard Street ~ Gallo Avenue After Recording Return Copy of Recorded Document to: '
City Recorder- City of Tigard ' 93026541
13125 SW Hail illvd. -Tigard,Olitme223 Washington County
3
23- INDIVIDUAL File No.
DEDICATION DEED
FOR ROAD OR STREET PURPOSES
/r Ernest C . Jensen and R . Virginia Jensen
l✓ 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.
1-1
IN WITNESS WHEREOF, I hereunto set my hand on this /D ,day of A ,, , 199 3
Signature Signature - 7
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 3/0 3 (date) h t f / /Ve6-(N'r A 31 cN' cN/.
(name of person(s)).
,
M1,5,1/4_,-- 0—_
arys Sig ure
My Commission Expires: /—'
Accepted on behalf of the City of Tigard this /7'64 of /nett% , 19 93 .
City Engineer
1 -7
L - E - G - A - L D - E - S - C - R - I - P - T - I - O - 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.
2
0
°
1/4,30 T 0
In t\__ L<tttTt
• N I �� 72.90 117.83
'o Oa.'8900 9000
. I • .1.7.
= s 6 a
o= = ^ : 5 e c
F)O o (C.S. No. 6747) co in c / -�
IP ode a 0
f
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in- 0:8800 0e,. eo 30•p3
'> ON 4 s CL
- N 99° 4i W 191 0
EXHIBIT "A" _ / w
No.5301) 600 STREET DEDICATION MAP ''. 0 105.07 0 AC
�,Cr
1.05 Ac. _` 8700 3y?
IN THE S.E. 1/4 OF SECTION 34, 6.4.0.
Q
r ( TOWNSHIP 1-SOUTH, RANGE 1-WEST j�° 3 a4`Y ' a"
NN WILLAMETTE MERIDIAN, WASHINGTON di 136' 1i Z
COUNTY, CITY OF TIGARD, OREGON. 0 8600
0; 2
SCALE: 1"=100 FEET jn 136' h E_
o (C.S. No. 674' 8500 >
p ° CROSS HATCHED AREA IS LAND 0 I a
TO BE DEDICATED. �'° 9 w (I),
+.J, g5o
120.97 4
o "'Co. Rd. No. 916
o / (C.S. No. 13,079) •
T-t �p
Cit
..... N L\.�� e1-52438 4 .. 72 td 72 72 n
$6 NI' •• -1 5O Jp 02700 65.08 W 4)••
S869.91 8°16'13"E S e9°I 45 3/4' E I
4800 , 4900 R=20 2900
07140.
)0 2800 _ 8400 �,_ = tz 3000
.2/q c.
/6Ac. L
1 "� 41)
I I = 15 -6.0. 2 I °' /6.53Ac.
7 Rg 6 / 36 W o
eu
° SCHOOL DISTR/CT 23✓
zo N 4190 91.15 ((PT.) FOWLER ../R.R. HIGH
I
ST4 103 ' 26 I&16 01 N 91.IS
55'4('E 4700 " I 4901 s5.69 1 Q 8300 I4s88030 35"E:
M p
m
rA+ '- 9r N i
2 p • ,,, 2801oo 0 15533 •
.4 1 .I3 Ac. _g61-9,5,�
�1 1 111.13 u.52 125 80 , 0 2802 �a 8 200 13 n
.O2Ac.
4600 A 5000 119.57 �-' 1 r
1l I ' 3 m U & 25 •
„70 0 I C/� Pp6. pv • :8100 LI-, • Ti
v) 118.03 578 Q 120 0 °'.1 12 n
9 r 136
4500 a. 5100 "4 " N �'
W
• 4 • � 24 X7100 2 800001 6 5 4
�20 c 11 3 0
\�p 118.03 / • 0 O o �, i°o O
5200 W 7200 ., "
en
M 4400 \ 23 8 n 3 J o no.21 •
N
\ pp, o
= I' S •0 120 0 Q o 9 L11 "s I
u6.o3 5300 �' 7300 j m 0 m 10 N J--, I I
4300 �� 1 CD
N 4 n o t10.21
6 �1� 22 13 j, 7800%, ,
° �
7400 �� �tio n 9
118.0309 5400 r
o ,r o 5 h. ,,• a
3'.1"E ') ; 21 Z d e ,
4200 C.) s° 120 l00.4 l.. .4,7700 118 46
I I -C z 5500 7500 '0 . 8
in
118.4100 03 M 20 --:. - th 6 �' y7600 hie•ss
t.
• 120 POINTL i p 7
I�L 8 A TRACT Ag ' 89°29•04"W 8 1 O I
INITIAL POINT R-?a 5600 .6 . 72 i 72 O 72
DAWN'S INLET r
4.2 69.91 ati m �S `%•,- 653.24
S. %. TR-.4. 1 4j �f (9 b' / r
t a,/L.60 119 99 5800 j 3 T� :..� r
u c r T
R` x_� T` \�� ,'.i .,` �\ I /id) :', ,,h'\.4f7�v//b �\l�; �1�'t"strA) /) .,.. ,0\:Iriq , w, ,, ry . . .,.._;ate,,�wh,
�°' 1 n� ..ra �,� IV . . , "V( Rt .E ,�2�^�li `mss 5 s,:,:,‘a 's�C +i
��yiCL
.� s r TIFICATION OF VITAL RECORD ..1 +
y' w 1 � �� J .•.onto .r,rrTr.rr• ••.onto. n rrr•rr• rr•r.H,r., •rr•rrr Fr •r•Hrrrr. r•••rr••r rrltil l•T.r•• H r••.r•r • HM TH Ha•.•• , 5'
S
(,; bitu �� OREGON HEALTH DIVISION Z1.0'SIr �� ��
CENTER FOR HEALTH STATISTICS • \.(,. '' .rt a1 ':x"1"4;1
N 1,r
+nJKENT I— 11 7940 -1 OREGON DEPARTMENT OF HUMAN RESOURCES
I.G.TAG NO. HEALTH DIVISION ?,
CENTER FOR HEALTH STATISTICS[ 36 �
Local File NumDel CERTIFICATE OF DEATH s,Np File Numb.,
0.
I DECEDENT'S first Minnie teal 7.SEA 3.DATE OF DEATH(Hoorn"Oar,V...rl 1
NAME1
Ruth E. WENSTROM Female January 8, 1993 1
4.SOCIAL SECUnrly NIIMBLR 50 AGE Last BrT0day .n U.ne,1 ear _c.Und.,1 Pay 6 BIRTHPLACE(rnyano State or/woof, 7 BATE OF BIRTH(uon,n.Day.Veen:
' ;Da, hours ;Mons.
Counnyl
543-26-9369 94 M,1a Helena, Montana April 7, 1898
A WAS DECEDENT EVER Ira---'-
U 5 A11111D FOIICF ST --^--- Y4 PLACE OF NEAT II(Check only noel
IN1 .t.03,11 A --
.MI vol I gN° - �(Ir.uxlrenl CI LflfOWP•LOnf 1_100J-61'''n 1.Halon,, Iwo
R- v 1 e 1..1 D.cenmr•Hnn.e(.I Olner fsPeory)
-
00 riACILITY NAME of.101 mat 1pbon,paw ureal 000 n.mnn.l `- Ac CITY TOWN On LOCATION OF DEATH `
w COUNTY Of nE•Ta
- Bess Kaiser Medical Center Portland Multnomah
IOa DECEDENT'S USUAL OCCUPATION 1Bu KIND OF BUSINCSSIINOUSITTY I1.MAIIII Al.STATUS Mefferd 12 SPOUSE(II Married,woof/owed/ 4 owed/ 44
- IC,ee kind of wore done 0wr,.p must of working role Never MHrrred.W,00we0, �,r
on not We reined Oivoroed aoecilin
4iiHomemaker Own Home Widowed Charles F�
135.RESIDENCE.STATE 13b.COUNTY 130.CITY.TOWN OF,LOCATION 13d.519111 AND NUMBER yCF'
_Oreon Washington Tigard 11330 SW Tigard St. F
- 13e INSIDECO,. 131 ZIP CORE IA.WAS DECEDENT OF HISPANIC ORIGIN, 15.RACE American Inman 16.DECEDENT'S EDUCA LHON
LIMITS? (Speclly No or Yes•11 y..,specify Cuban. Black.Wille,etc.(Spelily) (Specify wiry nrpneal vane complef.01
MoSICan,PVer10 PICen,etC.l 1X1 Nn rivet ElpnwMaryIS.CRR*,,Y IB"121 COnepe 11 4 Or S•1
—
D .[No 97223 aserry 1
J Whlte 1 5 a,eo .
II FATHER NAME fuel mngre 15s1 IA MOTH(II NAME forst needle ArOon IP INFORMANT NAME H1d•e a�
11 )1,1L: 1 • ':11a Red VjrP_kp.e Jensgn-(IId1 ,Isrt•r V4Np' 1�
li
7114 ML 111U11 Of DISPO (TION 1 IMArrarnenn, 700 PIACI CO IISPOSITICIN/Name nI cnnrntnry.1,400:011.0r 2(10,1°CAI111N.Cd,0.Town,51.1,
1WN t')/,,,t')/,,,,It')/,,,,I.1UCrernalion❑Rmul
eOv•I from S , mee,Plot e:
0 Dnnn l l 016.,!Specify)_._
Crescent Grove Cemetery _ C)igard, Oregon _
21a NA Uri OF FUNERAL SFHVICE E OR 210 LICENSE NUMBER 77 NAME,ADDRESS AND ZIP OF FACILITY
PERSON •CT AS 5 lrcnnir
, rJ
•
'
Young's Funeral Home
4/7"c� `—'----;> 3312 1 183 1W Pa- ,c.. Hw . Tigar�OR. 97223 4
73 •a if IUD(month.Dry,Veep JAN
r/I `� e� 1993 24 11E(�-j•�I R,J,1R,5 Si AT RE X 1t
Ali E !L�]1(n J•(FOR AR ASGIF MADE Il
1tT�`C....',/
1=1,ltUHOSPITAL REPRESENTATIVE MARE ITEOUCST FOR ANATOMICAL GIFT CONSENT, 76 WAS GIFT MADET / d'• V •:
�` �.;
1`.YES ;IND 1IN/A OYES .1 NO Li NM �,ti'f,
.I
TO BE COMPI ETED BY CCRTIFYINC:PHYSICIAN 10 BE CCOOMPI.LIED ONLY BY MEDICAL EXAMINER �
27 TIME(IF DEATH IJR WAR MF 1T'CA1 FAn MIRTH NOTIFIED, 310 VIM((IF(KATHM 3tio DAD p11RNUUNCCD DEAD IMnnln ney P.•• H
1334 -L1 ,I Iv.. RIND n•,I 101
Y1 Irl,,,,,.1;„, .I rr,,I awl n r , In,Ili,0.CV•rwl al 1,,HTS y IlIaLlI anR �+- J/;n 1 too 1101.6eor, nd..rn YCt VNY0 I
Ila Due 10 Rre Cann,Hl and menet,Meted 1 4 nog lnro *Hu.01400 N 1n I dun Roca 0 told lan0'mS V1rrr r0'a1.0 lu
1► ICr0na10151 ►(S,pnnrfornl and
ua a I rr sl _.. 9
30 DATE SIGNED IMunrn,Der.orad >J.DATE 51GNEV IMo,m.nal.turf COUNTY !',• '
-
3A.NAME.111LE,AUDIICSS AND ZIP OF CEHIII-IFIIIMEDICAL EXAMINER ITP0D 0,Print/ - — ��-
Leonora Dantas, M.D. , 5055 N. Creel.ey• Portland.__Qr.gg.411.__.92717 , ..
35.NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER hypo pr Piing
:..J�
Ill
:16 PWAF RIME CAUSE'ENTER Willy ONE CAUSE PCP LINE FOR 66,In:.AND lcl)Ilw 001 enter rPOW of dying,e.g.Cain,.or Resprralory Arrest, 1.7..m4l Y.Iwoen onset 5
IC
pA nT /) and Otaln :y
'off
I 1111 �C�� '/�/ 1 IiL/r t= .71
.•IC
DUE 10.OR 0 S A CONSEQUENCE OF.
cc, / v •------- ;IC be set
1 Int -____, 0 deathDUE TO.OR ASA CONSEOUENCE OF
IMervel bet.wen Onset
4
�{ III >ro aeHn
..-. PAD
OTHER SIGNIFICANT CONDITIONS• 31 Ord tobacco use eonnibule 38 AUTOPSY 37 or TES were r..o,nes eau
Conal n
on.con,nulurp In Oee: Innenbut not ensullrnp on gm unno•lyncans°Innen on PARI I to Inc 0nalll? r
t"� r-/Y,„ C•(. /.. `'1.., C C-6- '.Z- NO 1.1 Unknown O Yci{[j No CI Yes LI eso U NrA �1
40 MANNER OF DEATH 114 DATE OF INJURY ATE.TIME OF ITE INJURY .10 OFSCRRIE HV0 OINJURY OCCURRED , \
r..latuul ii PenOInp IMOnrn,Oa y,vrar) INJURY Al WUHK, .10
Inyesu0u •
0 ASTIR.,, U UnOOlenninee M U r.a❑No
r ls„,clue M.nner
❑TlOmrc•Oc r'I legal Ate PLACE O;INJURY.At num „n.sl,eellh
,laClo,y.O ,Ce 411 LOCATION(Suet,ARO Number of Rural RouRumme,,G r loon,Shale
:rel Orvenlion buirdmf 014 lSFxcil y/ ny o
RESERVED FOR REGISTRAR S USC
•
ORIGINAL•VITAL STATISTICS COPY
I.
LAM CU 11;AL. UMIN.rd CM*\:TJry '
.Ft
.4
0„
Ilmvvr, , I CERTIFY THAT THIS IS A TRUE,FULL AND CORRECT COPY OF THE ORIGINAL CERTIFICATE ON FILE IN n Yl\!\1A1 $-�G
•y am 1 , THE VITAL RECORDS UNIT OF THE OREGON STATE HEALTH DIVISION. Ail,' �1� t
F �,4 I f( I 1 . . .� ,i L
+ab '� 41
�a �o l)-1i/ J A f.l I) I 9 9 3 � /e v =4,— l'�'�\Y�N(I >r
'iOgR 'cone b.! (/ i) I W t e raiiq a��2 v i
ti �� c: . I A' ?ti's4f�er' I�� ''4P
FTBr," firsa JV)G DATE ISSUED EDWARD J.JOHNSON II, hI r ,�' / ?
1 11�J r STATE REGISTRAR //A T.
1,` 5,,,),,,j,14-5T gif' yl
"-
11-,,,L-,-,....k emra4canLauexwe , 1.;: .. ... .,. ¢_--aa• 4 1 C
�� 1 ANY ALTERATION OR'IERASURE VOIDS THIS CERTI KATE �hlr.,�k�a-"e'.� �zt•t , �s'
� ;I. RFI �I ��
y 1. xr,-.1.,.. 4.,. `,; !t. ',h.\ ,T.e�:k; /•sx .,wk,-,..i...- ./ar,/,if .R:lRT.>•."'.._::..�..,/d: „hb1..'A .1._......./2151 .,i'I.,:c ..c..•. .'..i/.tl?rurI'>w�.._"n?f ir,aiffl..?L�Ii E,..s.0-� -.7.r,
ss_�
A'fi1A rrwr3f aCwaAk,v dry'S>.,,
-11 .ste
JJ �• �{/�pff ' gy�,�y
pi r "'d • FOAM H 650--DEED WARSANTY(Survivorship)IlndlrldsJ or[,P.ro,.I. - _ 89-18294 ,„• e rr
t Washington Count F, x^�
�^ _ .' K WARRANTY DEED—SURVIVORSHIP
''',‘•
`
,smC ' ''tri) -
Q KNOW ALL MEN BY THESE PRESENTS, That RUTH E. WENS):,r)M dd the
y VD 1 RUTH E. WF” 'TROhm efeinafteER!led 4rantor,C.
` I for the consideration hereinafter stated.o the grantor paid by
II. JENSEN and R. VIRGINIA JENSEN, husband and wife,
• , * hereinafter called grantees, hereby gra.+ts,bargains, sells and conveys unto the said grantees, not as tenants in corn- •rel
mon but with the right of survivorshi ti,eir assigns and the heirs of the survivor of said grantees,all of the follow-
1 1 mg described real property with the t,.eTints hereditaments and appurtenanl i thereunto belonging or in any wise 't' -
tN } I' appertaining, situated in the County or ashington ,State of Oregon, ,,-wit:
r �
0 it East 36 feet of the North 100 feet of Lot 11, C eery Hill Acre +,;
II Tracts in the County c. Washington and State of Oregon, more
j. particularly describer' as beginning at the Nor' 'east corner of ,t
CRS 1i
f the said Lot 11, run i .ence South along the Ea.,,,-. line of Lot 11 j. A• —
'.� -' 100 feet; run thence ' est parallel to the North line of Lot 11, a 'j.
`{ distance of 36 feet; run thence North parallel .o the East line ). a
Cc i, of said Lot 11, a distance of 100 feet to the North line of said -'.:.i.
SW ° Lot 11 and the South ine of Tigard Street; run thence East 36 %r-''14 [a
c' ;',,,t. feet to the point of .'eginning. casiw;
Ea
elsr� :
'''' lA. 11 lit VACS n,SUr11CIENT. CONTINUE DESCIIPIION ON 5E51151 SIDEI ''F' •• t .rP
iCh H ill' I TO HAVE AND TO HOLD the above described and granted premises unto the said grantees, their assigns : ty',
OltI and the heirs of such survivor,forever; provided that the grantees herein do not take the title in common but with •
a• the right of survivorship, that is, that the fee shall vest absolutely in the survivor of the grantees.
lAnd the grantor above named hereby covenants to and with the above named grantees, their heirs and assigns,
that grantor is lawfully seised in lee simple of said premises,that same are Ire, from all encumbrancesA.
1;"t 6•.
r y
d 4•
` and that
grantor will warrant and forever defend the said premises and every part and parcel thereof against the lawful claims "t#,
, . v and demands of all persona whomsoa'.r,except those claiming under the above described encumbrances stance
rot' .I The true and actual consider Nan paid for this transfer,stated in terms of dollars,is$ Purposes 'h "
.pF o " 7 I OHowever, the actual consideration c' mists of or includes other property r value given or promixecr which is
the whole l7 m n,r I alse
pare of the consideration (indicate which (The sentence letueen the symb is 1 nor wait-Able,should be deleted.Se•OHS 91.0.)0.
'$' V In construing this deed and wl a the context so rrqurres. the singular I.,ludes the plural and all grammatical g „ #
11' I changes shall be implied to make the mansions hereof apply equally to corpo '(ions andi.q.Inc/ividuals. -
/n Witness Whereof,the grant,.• has executed this instrument this / lay of I Pe( (' .1049 ; r r—
a ! if a corporate grantor,it has caused = name to he signed and seal affixed by ;s officers,duly authorized thereto by tt
order of its board of directors.
.
.,
THIS INSTRUMENT WILL NOT ALLOW 115E fl' THE PROPERTY DE r%"
',. '.'{a� SCRIBED IN THIS INSTRUMENT' IN VIDLATIO:'.?F APPLICABLE LAND RUTH E, WET':•,'PROM y:. .r _•
'n'Y� USE LAWS AND REGULATIONS. BEFORE SI',i'INC OR ACCEPTING
.r.', THIS INSTRUMENT. THE PERSON ACOUIRIN- FEE TITLE TO THE ,5Y^I4
•
" ,
PROPERTY SHOULD CHECK WITH THE 4!'V ROPATD CITY OR ''. >
�
COUNTY PLANNING DEPARTMENT TO VE RI11 APPROVED USES.
a , ) STATE OF OREGON, Cour.' el 1'••
STATE OF OREGON, e �;�
Washington ;•• , 19
; ti I •
Coy(Ery oto A /... � • 8 9 Personally appeared _ _ and
U 19 who, batty duly ssan.
�� each roe himself and not one for the other.did say that the tunmar is the '
yt5 yii. Personally appeared the above named president and that the leer«to the :.
}} RUTH E. WENSTROM
kY rwerafiry of
. a corporation.i I
r.
,,, arid acknmvhdQed the hn'CoinQ in.fru' and rhnr the seal alli,ed to ..e Iore'oinit instrument I. the corper•re real d )-
.
'y 6
� meat to be .. her votsnia, ,rr and deed u1 said cnp,varrun and rhe •id Instrument u.s silted and sealed In be. F -
hall of said u,r poranon b+ nforh r of Its board of director.:and each of ki g;
Dolor
) them ecinoeledged .aid inn•unwnt to be its voluntary act and deedBelo . ti
rI / /�,' l • erre: (OFFICIAL � '.
(OFFICIAL - Ta'! �/ SEAT.) ;
,. a i SEAL) NourF 1`uhllc fur O,eQnn P.
/y r•ry Public for Or Q r ,
•• , "My commblon expire. nE..«are nu •1•••••••••••seer,
y' —
S
r.i // My commission es plea. assesses 1 ,t,#
Ny
R(1TH E WEN ST ROM aMTi Or W1lOON i,
k I 1 u
•
'., 11340 SW Tigard Street
caw,ty a w.wr�a, ,
Tigard, Oregon 9722
i 3/ ` 1' sass oeANloa s NAM.AND AD, ,'s• I,Domed W.$••••%.condos,d Asa•aansarN
Ruth E. Wenstrom and Tmtfon reel i• d Con. Illiiiii—
i '` • Ernest & R. Virginia: Jensen , lot•rlf�,,aq,
11340 SW Tigard Street 1$• --
t-•, ! •2 Tigard, OR 97223A A awe b ol•w•oNMr► oounFr•
} i ( asANr.R'e a•NDA ',. PAca•,.naysD a�7 re l • „ �'
it -- me 4s . W
'" R ' ere lei Fa
AEI.,.remedies M
R'
1 Ernest & Virginia nsen ntCme„I.R•„a, '
,
7.
� 61;'s 11340 S.W. Tigard Street 'lr\
V'
A
I i f.,-S, Tigard, OR 97223
,, ;f I sass ...
' ', ,
NAM[.ADDa U.,i
i''41 a,y 1•I)Url�i •�.
ll•fll a dean•1.reg meted ell les.MemaaN.hell be seal to M•fallowing address. R d f e
r6 r. k ,.nest & Virginia Jensen 'Ior- : 09018294
' ii • 11340 S.W. Tigard Streetv. r •
ei:t f3�F37 11.00
` ti { Tigard, OR 97223 4/2' /h 89 03: 53: 59PM � �
\Y
[it_ :> I�_IaI-..L U . ILL _I — �1'_-i 1'1ctr 1 i ' '_-+ 1I_I : ll t. fell . Li(I F' . U
VX' fr ,t ,�— ^• ly ni% •r -•[U;. , ;C'n .:4'S.,, •p F NA t At:, Nee-
�. - : RTIFICATION OF VITAL RECORD ; ,,.. •. • �', .• `. :, «'
4 r E t _ _ .
d „r y 1, wr, r r - SSSS. ••••••••••.• •... ,..,:. .::, r •••'r•r.. .1.,.w . . .,„•..'"w'..1•,.w. . ••• •« .. may' ,Ayr'.....•_ -N'• '...
IIY� �
4,.., 4y I� li,l;�r`.S 1 18051 7 OREGON DEPARTMENT OF HUMAN RESOURCES
�//fi6t I.o.TAG No. HEALTH DIVISION
/�� CENTER FOR HEALTH STATISTICSI—
, .t',-
* ��~ i� CERTIFICATE OF DEATH 1 136 4",w
p State file Num per Local FILO umpgr
!t I DECEDENTS Fiat m,011e L.,l 2.SEX A.0..TE OF OEA1n(MoOln,Oey veer;
NAME
Ernest C. JENSEN Male may 1 1
I a.,P.00IAL SECURITY NUMBER SA A(OEJ-set PJrthOay '11:.Under I Year $;; V�.le
. r I Def E.01RTT'IPLAGE(Gyaed Sumo,Fay.:_, 7.DATE OF RAPIN(Nor f4.Oey.rhe,)
(F arSJ Mos. ;DAv1 •MowsMins. Gauntry)
501-OS-0891 75 iso", S. Dakota _ October 20, 1916
&WAS DECEDENT EVER IN 9o.PLACE OF DEATH(Ow),ontr one,
U.S.ARMED
Np'PeOKEOSNI0Yes afa - tt kInpatlenl CEWCutoat(ei1 0 DOA OTHER CNuralnE Home 0Oetworm aHome❑Onet(sieya(r) ./
10.FACILITY HALE(I/riot AWttWoe,oim stmt 004',LIMO.") --7e.Cr?'?.TOWN,OR LO ATIOH OF DEATH 4m.COUNTY OF DEATH
1 St_ Vincent hospital
Portland
Washi .Mae DECEDENT'S USUAL OCCUPATIONbb,KIND OF Bu:NESS HDUSTRY It MARITAL STATUS fd / SpyjgE p/1.11,1.1.,WOowsd)2 (L.►tMC•/wore dev eluting moor O/waning"he o4...,MR.rrNQ w(drawmt,Co nor us•ANNwlI State of Oregon ��•�( +n
3
- iso State W aster Marr jg3 Virginia
4 13A R IDE]NCE•STATE 1:4i,COUNTY 130.ON,TOWN OR NUMBER
131.STREET AND NUMB
• - .• - • • •• •a ' •. • . N •. . •
5 ANSI• CLTY 13r,DP CODE14,WAS DECEDENT OF ISFANIC ORIGIN? IA.RACE Am.pay,Irn ran. I..131ECE1394TS Fr>tr.T(ON
LIMJT$? .(sporty NP o.Tee•It yes.e,iac ICY CuErn Black Whit..ata(boedtrt (Sidaclia—nigh*?Teedes eoe/Welert
6 'Mellow%.tome Riwn,•l-.1 1,'S.No❑Yes
Utter 0440 97223 fr'•cnY I B""r�Yp•�°wr(6tA cotwM(1taSa)
•7 lrATMFR-.NWE tf6j,._ .,pddt�__ toot. Il rLlte 12
IE.h40111ER.FAYRE test m•duIa Mallon ;di_INF'OkMAKT•NAME'aAd.A•4atlonan p Us&ceased
. ..
F. %Teasea Mabel S. anrge.Sen , Virginia Je�5e•n-seri'fe
an.MET+OD OF O 000o-TT10N OM.,OAdaim me.RAGE OF OI;PO; ION(Nan ',M
Marna al corm/oder,UIY
Amat0 ,re aAc.COG N.Qty a To..et,Sten.
O15>:OS1TLON XI&oat Dc mnatlm fien
Onwl to**State 0717."DieO.)
•
7 0Ounatlon°Othrinserlyl - Crescent
Grove Cemetery Tigard, Oregon
2107•o A OF FUNERAL SERviCE UCENV 21b.(Cf Uc.E NurBCu 22 MALE ADORES,.AND ZIP OF FACAJTY
N A IN 'Sup
$ (Or Uc•ns.•J
• •
Young's FLneral'.aome 97223
9 r,•••'� G 3 3 1 2 _1 1811 SW Pacific Tigard. OR
EL Q LED(Lo"rh.Oar,rn. 24. . s •- O7GNATU,t1E 1
RFGislBAS MAY 1;1 1992
•
Iv ADE? J
.'S. O 40sPtTAL REPRESENTATIVE LAKE REOUCST FOR ANATOMICAL LIFT CONTAN11 IE.W 4 MADE?
DTES 0ND SIA 410.0 IR**
10 TO BE COMPLLTED BY CERTIFYING PHYSICIAN TO BE COMPLETED ONLY BY MEDICAL ETAMINESi
11 •r.TIME OF DEATH 2&WAS MEDICAL EXAMINER NOTIFIED? ala.11145 OF OEATN 31b.DATE PgpI O 0EA0(Month,Oar.Tem.Hour)
9:.30 4 " ❑Yea. C ., L M
29.To(M aIOT of 1,.dell',marred at the NM*,OAgp.DIK•sod On the beets ot mrunination Mrdtd Inn li orlon.to my OPInIOrl dirtlA omrerep
CFSTIFIFA QA.a to itAe rJ and InanPAp stat.��J//J��� et IM time,date,plum and duo to the eaya(s)and manner stated.
op ISrWtattA+J���1 "/ fSy„arw.l
-
12 30. (Mama.SIGNED(MoDay.
Yeer) OATS SIGNED(Month,Dan Year) COUNTY
s'_ 6 9 Y
• 10- 34,NAME,TITLE.A0ORESS ANO DP OF CERTIFIEW.IEDICAI EXAMINER(Try a bawd
la Masud Ahmad, ti,D. 1510 Division St. Oregon City. Qreg a 27045
JS N..ML 04 ATTENDING PHYSIC IAN IF OTHER THAN CERTIFIER(Type or Piing -
CONOfT10Ng
• •WHICH GAVE -.JS IMMEDIATE CA E(ENTER ONLY ONE C e PER Lin FGR(al( AND ATI 1707 anter mod.of dywy,.9,Cardiae a Re,p6N0-y ams!. [int�er,W Cbetween onset 624.0 :;
✓►CY TO Jr
IMMED ATE `, Pg2T W 1/4 I�,{� //yI' ar,e
c.v.tsz r' •I
STATING THE DOE TO,OR' comsEouarce OR
Intds+d Ow.a..+
r
Int- .0%.4.0 .
and
•
.;.' ., DUE TO;O/ts41 A COKSEWEDot E OF: W_�•rY�_ r onset §
CaLJSE or ,¢L� � E
OECIN ;PART OTHER SIGWR AMT CONDITIONS-
Rlons c00trtbutOq to d.50%but Int t•lat.d to 0.use{slew,In PART i. 37.(7010 m naelo ConultN.[• $AL1TOi$Y 5. a Yes...twee et tower?
155 •°4 -/ •.r.e+.A�e.rr Ma..an
;ki 0Yes0MaFa •oeenty0WO fly..4114, DYni Otro 0mon
• 115a.
a•%•G.MANNER OF DEATH <Sa.DaTE OG AHJURY 41b.TILE OG 4'A.INJURY -41d. INJURY NOW URY OCL1JRRa<£1 C
i f` I�(•{..mi Q Pwata a (Monrn.OaY,Yaan, Ita1U+rY AT WORK? I
IT s,. lri-m Acatton
rOAcri.s.0 Q UnONvmlf+d U Q Y..";414
[(4O�OaI '41._PLACE OF INJURY-At hares/arm 1A
tarm.rtneat fA ,/ctiiu Ill.LOCATION(Street and Sumter It Rota)Route Number,City or To..it Stagy.
.f, 'O Horn47d.' Ift.YiMdlo,t Oulld(rv,mc.(4,4mly)
i
RESE1wE0 FOR R.GLr)TRAR'S U8E
1
• ORIGINAL-VITAL STATISTICS COPY
•
THIS IS A TRUE AND EXACT REPRODUCTION OF THE DOCUMENT OFFIGALLY ' '�^
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'4174-0i1-„,.„4".,-,.4-70 -019-1,,,,� REGISTERED AT THE OFFICE OF THE WASHINGTON COUNTY REGISTRAR- t• ,�
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