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Full text of "San Francisco Death Certificates July 1, 1904 - Dec. 1, 1904"

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1 



WBmmmmm^ 



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\ 



LOCAL I TY OF 



R E CO R D 



SAN F^^T^^^ {SCO 

COUMTY 

S AN FRANCISCO 

» - • 

calLfornia 



T I T L E 



OF 



RECORD 



• •» 



DEATH CERTIFICA 




■"•V 



( 



MICRO F I LMED 



FOR 



T H E G E N E A L G I C A L SO C I E T Y 



OF SALT LAKE 

. ■ ■ .1 

C A L I ^ R N I A 



CITY 



UTAH 



DATE 




APRIL 



^ 



1975 



PHOTOGRAPHER 



MAX JOHNSON 



CAMERA 




NO 



26831 



RED 



1018 



i^ '■ 



\ . 



^ 



\ 




EG IN 




'■(l.o .. *.,^. 



r 



», 





I 



C REUOfiOER 












<i 



«• 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board of Health— F No. 15 



n&PCo 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



^j 



fc- ' 



Registered JVo. 




Date Filed, LLL1.0LL\..3i 1 190 H 

(^yvt^.<> aUavi. Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 



( "CI. S. StanDarO ) ^ 

PLACE OF DEATH: — County of^'/CLT\j VCV>VCi4CoCity oi^)/CL^V aIAO.W/C.U.CC 



(No- 




VjX 



ChiVulabsu 



Dist.; bet* and 



AWAY FROM IJISUAL R E S I DE NC E CI VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



(^ 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



lv.tr:YyUL^.\J3xU^ 



SEX 



DATK OF HIRTH 






COI.OR 



U)Jv.U 



« Month) 



30 

(Day) 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



AOK 



X^ 



}'rtn.s 



MoMt/is 



Da \:\ 



STNCI.R. MARKIKT). 




wa 



WIDOWED OR DIVORTED Q 

(Write ill nocial desijciiatioii) ^ 

- u vvva 

O^KlXjX/Yv(L 



lURTlI PLACE 
(State or Country) 



NAME OF 
FATHER 



BIRTHPLACE 
OF FATHER 
(State or Conntry) 



MAIDEN NAME 
OF MOTHER 



BIRTHPLACK 
OF MOTHER 
(State or Country) 





3,0 

(Day) 



(Ye«r) 



IKREBY CI':RTIFV, That I attended deceased from 

ie 190H to ....N|.jL.vt.vjL...iO. 190H 

that I las! saw h yLArv alive on NkA-iciL ^C 190 H 

1, on the date stated aljove, at i-^O^^ 



ami that death occurret 

M^ The CAUSH DE^DH^^TH was as follows 



intyjXKLL 



DURATION rears . Months Days Hours 



CONTRIBUTORY 



OCCUPATION 



Nfsidfd in San Ft am ism ^ \ Yfars •" .^fonthf 



DURATION /v^ Vciirs 

(SIGNED) vJ... 

.VVU il 190H 




(Address) 



FECIAL INFORMATION only for ll^spitils, JRStitutioRS, Traisieits, 
or Recent Residents, and persons dying away from liome. 



Former or 



Pa V. 



THE ABOVE STATED PERSONAL PARTICT LARS ARE TRl E P) THF) 
BEST OF MY KNOWLEDC.E AND BELIF:F 



(Infomtant 






(AddreRH 




i 



Isual Residence o^>5' iQl "^O^ 



Wlien was disease contracted, 
If Rotatplaceof deatli? 




ow lonq at ^ , ^ 
eof Oeatfc? 314 Days 



PI^ACE OF BIRL\L OR REMOVAL | DATE of BiRiAl. or REMOVAL 

^ 190 ?1 







rNDERTAK^.R W ^^ ^l^LcU^ ^^ 

f Addrew 1 1. 1. 1 AmA^XTl^^ 




N. B. Every ttem off Infopmatlon should be cspeffully supplied. AGB should be stated BXACTLY. PHY8ICIAN8 should 

state CAUSE OF DEATH In plain terms, that it may be properly classiffied. The "Special Information** for psr- 
aons dying away from home should be given In svery instance. 



1 1 




Hoard of Health— f* No. iK 



WRITE PLAINLY WITH UNFADING INR-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



H&FCo 



Date Filed, 




i\ »-( 



-1 



1 190\ 

Deputy Health Officer 



Registered JSTo, 



697 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



Certlftcate of Death 

( TH. S. stanftato ) 



A 



fNa 



PLACT OF DEATHs-County of 0^>v J A<t^vev«xo City of O^'a, Ja^Vwc^cc 

tl 



-1, "f J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



^UV^L^JL Lcu^1wJ[.\.^aia. 



SKX 



J. 



I 



COI.OR ^ 



DATK OF MIK rn 



%v 



^\Al. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



'NfontJi) 



31 

(Day) 



/ ill. 

(Year) 



AC.K 



\ 



I go H 

(Year) 



\\ 



J 'I'ii I 



MoHtkS. 



M. 



Davs 



srNC.I.K, MAKKIKD 
WIDOWKD OR niVORCKD 
(Write in .social (leNiiftiatioii) 



lUKTHPI.AOK 
IStattor Countrj-^ 



N'AMK Ol 
FATIIKR 



niRTHPI,ACB 
OF FATHKR 
(State or Country) 




A % 



OwWU^ 



0; 



jOjy<) \J Xcl Yve v4 CO 



i^Au 3.O.. 

jjo "th) jj (Day) 

I HKREBY ChFtiFY. That I att^ulecrdeceased from 

^^'^'^ ^ 190S to . .|^ ,90 H 

that I last saw h .^'^j alive on \ks^l^ ,^t^ 

and that death occurred, on the <late stated above, at 
^'wvJ^^ CArSlv OF DIvATII was as follows: 



w.L.a^. 



MAIDKN NAMF 
OF MOTIIKR 



niRTHPr.ACK 
OF MOTIIKR 
(State «)r Country) 



OCCUPATION 






D I' RAT I ON Via IS, 

CONTRIIU'TORY L 




A(onifys ^W^ f fours 



t.V\.Ji.. 



DURATION Years 






^^\m/ 0,. 




ll 



i^Tonths 




Days 



(Signed) W)\rm 

iqoH (Address) ^^i^'S 




Hours 
M.D. 



Special information only for Hospitals, institiitifiis, TransifRts, 
or Recent Residents, and persons dying away from lioiiie. 




. ■'^2!!!^£i!!_^"" f'lann.y^o ')!,% )>«,., ^.V.mfhs ?)tnays 



^"bEST o5'*'Jv'u^ll\[*,!^'*,*^'^^'^'' PAKTiriF.ARS ARK TRIK TO THK 
UEbT OF MY K\'0\VMU)C.F;^\NI) RKMEF 

(Informant M., \ji^ 




(ArUl 



ress .. 



1001 Liou^Ji. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



How loiif at 

Place of Death? Days 



PI.ACE OF RIRIAI, OR REMOVAL I DATEof Birial or REMOVAI, 

S^<X^^yyyu I LW^......\ xoo4 




190 



UNDERTAKE 



I 



•:. (I. UV %cvvtv^\ Co 



(Address . 



. Every Item of Infopmatlon should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information*' for per- 
««ns dying away from home should be given in svsry instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of Health— F No. 15 t^^^^ H&P Co 




WtFgR TO BACK Of CgRTIFJCATt FOR INSTRUCTIONS 



WO'i 



Registered JV*o, 



698 



Deputy Heafth Officer 



Date Filed, 

DEPARTMENT (fr PIIBIIC HEALTMly and County of San Francisco 

Cettificate of 2»eatb 

( 'CI. S. Stan&ar5 ) 

ofUXXAV OA/OyVL^U/C^City of CJ/O/rv; J JuX/VUr^t^/C^ 



PLACE OF DEATH:— County 



(Na 





is 

I: 




St; 



Dist; bet ; : -....and 



( " ^^-J^^^i^ri^t^.L-ni^^t ^i';:p^:^i:r:i\ ^t;^i:^^::^^:iv~^F) 



) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



%A 



COI.OR 



DATE OF IJIRTH 



U)l^. 



(Month) 



(Day) 



Ala 

(Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF dp: 




.3.1 

(Day) 



(Year) 



a<;e 



. I HEREBY CERTIFY, Tha^ I attended deceased from 

^UJLm,..x(q 



. y<a 



t s 



Months .rr Pavs 



srxr.l.E. MARRIED. 
WrpOWED OR DIVORCED 
(Write in social <le.si|!:nation) 



BFRTH PLACE 
(State or Country) 



NAME OF 
FATHER 



BIRTHPLACE 
OF FATHER 
(State or Country) 



'€ 



t 

i 
I 



MAIDEN NAME 
OF MOTHER 



BIRTHPLACE 
OF MOTHER 
(State or Country) 






^ . --- I90H 

that I last saw h^^w alive on 



to .. 



.^ j-^^ '90 H.. 

f^- ^C^ 190..H 

and that death occurred, on the date stated above, at H >>^; 

aj.o^^Mi^.vjijjuA^ 



..a 




'^ 



DLR.^TION Years AfoHl/,s 1 Pays Hours 



CONTRIBUTORY 



.(to'v^...cL.: 



? 



\^'LiJy. »:iut.UL/y.v«H.. 




DURATION....^ .^JVajj^ ^Mouths ^ Days Hours 

(Signed) 



'J- J Months 3L 



YV) 



^^ IQOH (AddressV SHIJD - Q ,tL ^t 



M.D. 



.^^^eS?e!5^J.7JSS!!?ftS^^^ fl'llJl*^*"^' •««*-'--• ^--^ 



OCCUPATION 

Resided in San Franriseo " Veais sS .1A> 



nfhs 



Da vs 



THE ABOVE STATED PERSONAL PARTICII \RS \«K TBfir Tr. -rtio 
BEST OF MY KNOWLEDGE AnD IIELIEK ** '^**^' ^**^^ ^^ ^"^ 

(Informant CWjUM. VTUL^Jk^ 



rtnMT w « 1. 
UsMi Rfsidf nee c^^ 

Wlw was disease contracH 
IfMtat^aceff^eatk?. 




Ntw iMf at 
^^Plaretf Deadi? J ^ys 



(A<l<lre.ss 




^•^Tl?^of Burial or REMOVAI, 

1^ IQOH 



.«.. dyl„» .w., fro- h.m. ^IKH-Id ™;i..»"n'U"r;; InsST^c^. ' "•"•'•^'•- ^"^ •«-«'•' ■-««-..l.-" f<nill- 



WRITE PLAINLY WITH UNFADING INK — 



Boanl of HenJth— F No. 15 



B&FCo 



THIS IS A PERMANENT RECORD 

WCFgR TO BACK OP CgRTIFICATC FOR INtTRUCTIONS 



Date Filed, QL,uty.>v^ | 190'\ 




Registered JVo. 



699 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certfffcate of Beatb 

( Ta. S. StanDarD ) 



^ 



PLAp OF DEATH:— County of O^.n^'JA.am/eA^CU^G of O/CXm^aAXXAX/CvA 
(No. ut. 




Z^ 



(ir DC 
IF 



ATH OCCURS A 
DEATH OCCURRED 



DisL; bet a nd 



FROM USUAL RESIDENCE GIVE facts called for under "special INroWl*T.««» \ 
N A HOSPITAL OR .NST.TUT.ON O.VC ITS NAME .NSTEAD " .TRE tl AND N U JbI- ) 

FULL NAME LL......i' L^JLuJL.L 



r=^ 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



DATK OF HIRTII 






(Month) 



..a.. 

(Day) 



AM... 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



AGE 



O t) J>a,5 S 



.yfon(f,.\ 



M 



Davs 



SINC.I.E. MARKIKO. 
WinoWKD OR niVORCKO 
(Write ill socia' clt-siKnation) 



lURTriPI.ACE 
(Stati- or Coiiiitrv) 



NAME OI' 
FATHER 



Wv. 



•Va^JUcL 



V-^JUjl 

thfit I last 




(Month) 



.3.1.. 

(Day) 



190% 
(Year) 



I ^HEREBY CERTIFY. ThaJ^ I attended deceased fronr 
^ 190^ to .. 





'^^ 190 H 

last saw h -i-VYialive on Wiia .. ^ 30 iqq H 

aiid that death occurred, on the date stated above, at H 
il-^M. The CAIJ^ OF DEATH was as follows: 

^^^^-^^^^^^i-^.^.a 

vAAiJkjLa.VA 



V^ 



BIRTHPLACE 
OF FATHER 
(State or Country) 






MAIDEN NAME 
OF MOTHER 




niRTHPI.ACE 
OF MOTHER 
(State or Country) 



OCCUPATION 




DURATION Years 
CONTRIBUTORY 

DURATION ^ Years 

(Signed) 



k.w.a. 



Months Days Hours 



\XVU-CL 




kx_ 



"^^ TQoH (Address^ l0'3> Ajj 



Mouths Days Hours 



Rfsidfd in San Ftunrisro | }',irt. 



.^r,>„f/is 



Dav: 






a 



^*"S,?^^^?1^'^^^;^:5;^;^^---;i;-- TO THE 

(I"f«>nnant M fUV) W f^Wj L^dk^Jtli 



(Address 



Ul 0' J .<xvyllit 



Wfcf II was disease CMtractrt, 
If Mtatplace»f dfatli? 



Pl«fe»f Dfatli? Bays 



PLACE OF BURIAL OR REMOVAL 



UNDERTA 



f^^XKof BiRiAL or REMOVAL 

i I90H 



KER db.i a^uivu V C(J 



(Address... 



IN. B. Every Item of information should be carefully 8unnll«<i ACE ». 1^ w . ■ 

::«'/f?^ OF DEATH l„ p,.,„ ..r^:X\ r. r." t Pro?.H'°cu''..'rf.:r' Thf •S^V; . T"*«C'*N8 .h.„M 
.on. dyint away Jrom homo .hould be 4lv.„ 1„ .v.ry In.tance. ""*•'"*''• The Special Inrormatlon" fer per- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoanl of Utalth— F No. is W 



n&PCo 



Dale Filed, 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



WO'i 



Registered J^o, 



700 



Deputy Health Officer 

DEPARTMENT OF fUBLIC HEALTH-Cfty and County of San Francisco 



Cettiffcate of E>eatb 

( TH. S. Stan&ar& ) 
of Cj,<Xox' JAxX/^vc^ACtCity of *^ 



PLACE OF DEATH: — County of Cj/CXox' JAxX/^vc^ctCity 



(IHo. 



vdu 







t 



^ 



FULL NAME 




.aML\.a: 



PERSONAL AND STATISTICAL PARTICULARS 



SEX 



^\A 



COi,OR 



DATK OF HIRTH 



k). 



-\A. 



tjL 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




190 H 

(Year) 



SINr.I.K. MARRIED. 

wrnowKD OR divorckd 

(Writf ill social (leKivriiation) 



J 



niRTHPLACK 

(Statf or Country) 



NAME OF 
FATHER 



BIRTH Pr.ACE 
OF FATHER 
(State or Countrv) 






t\AXVCW 



1"U^W^"VV 



I^HEREBY CERTIFY, That I attende*! deceased from 

^^ '90 H to .|\a1^ j^^ 

that I last saw h.^:>>v alive on ^mLLul. .^. .:i.C. ,90 H 

and that death occurred, on the date stated above, at CL 31 li 
•-* ^- The CAUSE OF niCATH was as follows- 




Y\jLi-i.<tv\.'v-*^ 



."\-\..<5C. 



MAHIEN NAME 
OF MOTHER 



niRTHPLACE 
OF MOTHER 
(State or Countrv) 



DURATION rears Months Days Hours 

CONTRIBUTORY vL^faL^.wo '0.<AjU>,.^JC^ 

...'Al.'CX^vcjAjw.vxje^ ^h..hjirs.^^{\j±,'^2. 

DURATION ^'ears 



(K^*'"/r\'l\. ^/if^'/Mj Days 



( Signed ) ±..\h. .ob oaJL.. 



"^^ 



OCCUPATION 

Raided in San Fninrisro Xr^ )Vii>s ■" 







Hours 
.D. 



"^^ IQOH (Add 



ress) Utu^ U fe(M^>tfcvL 



.^fintthf 



Dit ys 



^^9'ft'- Information Miy f«r N«s»iuis. iRstitiucis Traa^i^atc 

or Recent Residents, and arsons dying aw«y from hwie. '""'""•«. iraislents, 

5!«TR«lde.ceH0^LLv^^ I 

When was disease contracted, 
If net at Hare of deatk ? 



THE ABOVE STATED PKRSOXAI, PARTlCFf \RS \RFTklK Tr» riii.- 
BEST OF MY KNOWI.EDOE AND juaiEF ^ ^" **' 

(Infonnant LU TW . Vf A.. 




(A<l<lres.H .. 




ot CHLJxvtai. 



PLACE OF BPRIAI, OR REMOVAL 



rXDERTAKER 

(Address 




jVRIAI, OR REMOVAL DATE of BrK.A,. or REMOVAL 

UJL:.mJ: sX^^.i ,^^ 



H^aJLu^ a "^mIx^Vvvi 



3.05^ J>V^ 



-n. d>l„g .w.y fron. home Ilhou.d l^livenfa .v^^J ^.tUT' "'''''''' "^'^ *'"^'-' '"'<>— '»-»' for pT.. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Bojinl of Health— I* No, 15 '9^^83ft>B&P Co 



Bate Filed, 




WCFgW TO BACK OF CgRTIFICATC FOR INSTRUCTIONS 



W0'\ 



Pe p u ty H e a 1 1 h Offi c e r 



Registered J^o, 



701 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( TH. S. Stan&arJ) ) 



PLACE OF DEATH: — County 

(No. H13 VJ CMlt 



of ^<X>-rv^.vJ7UXory.^^v4^C:City ofOOLTV/ O.AxL/TMIa^cc 








SU ^ Dist.; bet. ....J..trvA>VA^ and 

«TM OCCOHS «W«V FROM USUAL R E 8 1 DC NCE Gl VC FACTS CALLCD WOn UNOCR "9PZC\A\. INFONMikTIOM' \ 
Ot*TM OCCURPEO IN A M«.^IT*L OR INSTITUTION GIVE ITS NAME INSTEAD o" STNCc) iJJ NuJilll ) 



^^y^ 



) 



FULL NAME 




UX..TV\..C 




xcuvl 



i 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



u.d^ 



COL 



rv 



kXl 



DATE OF HIRTH 



(Month) 



(Day) 



./..ill... 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



AGE 



7^ 

I v? Yeats 



Mouitis 



Davs 



SINC.I.E. MARRIKI. 

winowKD OR nivoRiKi) 

(Write in social clesiKnatioii) 




BIRTHPLACE 
(State or Country' 



NAME OF 
FATHER 



BIRTHPLACE 
OK FATHER 
(State or Country) 



xcrvvnv 







Month) 




^1 ipo\ 

(Day) (Year) 



vX^rsJkA^ 



MAIDEN NAME 
OF MOTHER 



I 



BIRTHPLACE 
OF MOTHER 
(Slate or Country) 



OCCUPATION 




11 



n 



«« 



I^HEREBY CKRTlFi?, That I attended deceased from 

^•^ I9OH to Ji^^ ,go H 

that I las'tsaw hJ^^rx. alive on ^k^^^^ "2)^) iqo^ 

and that death occurred, on the date stated alx)ve, at ^dsrlr^.. 
%^..M. The CAUSR OF DHATII was as follows: 

AXXh-dA^^...^^ -VCMjti J^h^.\^L 

cdjst 

DURATION 1 rears ^ Mouths Days Hours 

CONTRIBUTORY UtlAj.^.wA^W^^ 



DURATION Yean 




mi 



Months 



r:QLA.dLi,:VVO 

I^ays Hours 



(SIGNED) .WV....J ....U.XX/>^|^^tr>.%. M.D. 

'^^ IQOH (AddressHSi B^uJrtth. Bt 



or Rcce-t ^.^^^l^^V.^'A J^^"^"*'^' '"«^""^' ''^'^^'^^ 



Resided hi Sun /'ra,i,is,'o $ 'X )<'ars ff^.. Afonf/ts T. Davs 



(Informant V-> , J , NAj'<4^\AA,^'0^u 

5^,5 .(fl^.Q^l+. it 



Former w U '\ ». (V 

Usual Rfsidence 1 A ■5> NJ 



i«Me«, Hl5.VIfi^t dt *Zll't^^7 



When was disease contracted. 
If notatplaceofdeatk? 



lays 



(Address 




%^CE OF BfRIAI OR REMOVAI, 




Qi.i..<wV Z 



DAT^:of BiRiAL or REMOVAI, 

I90M 




UNDERTAKER \lX, Sj A/O^Vi 

(AddresM 3.51 ..OjufcLlA, ..dl 



It 



N. B. Every Item o? Information should be 

state CAUSE OF DEATH I 
sons dyinit away from home 



should be carefully supplied. AGE should be stated EXACTLY PHVAiriAMa u .^ 






1^ 



! t 



WRITE PLAINLY WITH UNFADING INK — THIS 18 A PERMANENT RECORD 

Bnnni of M.aith-F No. .. i»^^B&pco WKPCR TO BACK OP CCRTIFICATC FOR INSTRUCTIONS 



Date Filed, 




1 



WO'i 



Registered JVo, 




Deputy Health Officer 



DEPARTMENT OF PUBLIC BEALTH-City and Coonty of San Francisco 



Cettfffcate of H)eatb 

( XX* S. standard ) 

unty of MrUx,^.A./vu City of \1 » UJULvAj^<rtKL L^ 



PLACE OF DEATH: — Co 



(No. 



Su 



Dist.; bet a nd' 



/ ir DCATH OCCURS AWAV PMOM USUAL R E 8 1 DE NCC Ol VC rACT* CALLCO rOfI UNOKM "s»CIAL INroilMATIOM'' \ 
V IF OtATM OCCUNRCO IN A H.SF.TAL OH .N.T.TOT.ON GIVE ITS NAME •N.TCAD o" .^Ccl iN^ NOlTijH ) 



) 



FULL NAME 




LLyvyv m 



x^A,A.A.i.\'. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
DATK OF IJIRTII 



A(;P. 




(Akoiith) 



(Day) 



fill. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




[ V JVrf*> 1 



I HEREBY CERTIFY, That I attemletl deceased from 

r-rto ■■■■- 



Months I Davs 



SINr.I,E. MARRIED. 



WIDOWED OR DIVORCED \ 

(Write ill social (lesiKiiatioii) IN 

W A^(L&AAr 



BIRTHPLACE 

(Stat 



NAME OF 
FATHER 



Oj^tt 



IgO-.TT- 

that I last saw hTr— alive on 



and that death occurred, on the date stated above, at 
^^~~ M^ The CAUSE OF DEATH was as follows: 

^-^-^^aJLs. ..X>,x.c.<w 



..rr90 
190 



I DURATION y^ars 
CONTRIBUTORY 



BIRTHPLACE 
OF FATHER 

(State or Countrj-) 



MAIDEN XAME 
OF MOTHER 




BIRTHPLACE 
OF MOTHER 
(State or Country) 






Months 



Days Hours 



YVfrvvryV- 



OCCUPATION 

Resided in Sati Ftanciseo Years 



DURATION :::^'ears Months Days .Hours 

(SIGNED) U V ll-vv<U>VMr>v M D 




How f«af at 



Months Days 



Fermfr M- 

Usual RfsMfice PU^eTlJitli ? 

When was disease coatractetf, 

If ii«t at H<retf ^atli? 



Ba)r$ 



'^"S.^J??^^ STATKD PERSONAJ. PARTICILARS ARE TRIE TO THK 
BEST OF MY KNOWI.EDOE AND BELIEF ' 

C ^' 



(Infoniiant 




(Address 




L 






BURIAL OR REMOVAL I DATE of Bi'RiAL or REMOVAL 



li. 



UNDERTAKER VlV jU A.<Xu ^^ L 




^S^A 



(Address JSl fd^^^tLu^ £ 



N. «•— ^;;;/ »;•- -^^";<>^^^^^^^ -hould be c.r.,.^^, ,upp„ed. AGE .houid be .tated EXACTLY. 
•t«te CAUSE OF DEATH In plain term., that it may be properly classified. The "Snecl.l 
•on. dyint away from home should be 4lven in every Instance. ^ 



PHYSICIANS should 
Information*' for per- 



•Ml 

m 



i) 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of Ifealth— P No. i^ "S^^^^fc H&P Co 



WCFCR TO BACK Of CCRTIPICATC FOR INSTRUCTIONS 



Dff.fe Filed, 




\ 



.190 \ 



Registered J^o, 




^./vHjL Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and Counf)- of San Francisco 

Certificate o( S»eatb 

( 'CI. S. Stan&arD ) 
PLACE OF DEATH:— County ofCjOmiAtAO/rV/CUXC Gty of O/CUYU -JAOavo^co 



(No. 1131 VI 1 1 



Su 



Dist: bet 





( *' ."Z!!^" OCCURS AWAV rnoM USUAL RESIDENCE Give rACTs'cALLCO roR under '•^tCIAL INroWlM*TIOW \ 
V tr DCATH OCCURRED IN A HOVRITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 



FULL NAME 



>vo\JL ) 



PERSONAL AND STATISTICAL PARTICULARS 




SKX 



OXvw 



clLl 



COI,OR 



DATK OF BIRTH 



klldu. 




rotith) 



(Day) 



rlXX 

(Year) 



MEDICAL CERTIFICATE OF DEATH 




ACK 



■^ \) )V<7>.V 



MoMlhs 



\ 



Davs 



SINcn.R, MARKIRD. 

wrnowED OR nrvoRCKD 

(Write in social desiKnation) 



BIRTH PI, ACK 

(State or Country^ 



\IiuxvujuL 



VAMH OF 
FATHKR 



BIRTHPLACE 
OF FATHER 
(State or Country) 



MAIDEN NAME 
OF MOTHER 



BIRTHPLACE 
OF MOTHER 
(State or Country) 







I HEREBY CERTIFY, That I attended deceased from 

1^^ 190:^ to WJax... .3A ,90 H 

that I last saw h-^^ alive on ^klW^M 190 H 

and that death occurred, on the date stated above, at t? 

U. M. The CAUvSE OF OICATH was as follows: 

jx.. 

^^ Ltx^^:^v^..^a: 

Vc^.'Mx^A^ m^.j^vctli^ 

DURATION X Years Months Days Hours 

CONTRIBUTORY 



E^. 





'itVX.' 



OCCUPATION 



rai s 



I .yfonths \%. 



DURATION ^ Years...— Mouths 

(SIGNED ) M:tSi». 11- A^ 

^^ iQoH (Address) llS" 





..Days 



BEST OF M\ ^Ni>\\ l.hp«;K AND liKLIEF 



•r Rweit ResMents, i§4 perMis 4ylig away from konc. 

Ftrwff or n,^ |,,^ ,, 

Usual ResMeace p,^, •! Oeatli? . 

Whf a was disease coatracted, 

If not at place of death? 



Days 



(Infonnant 






PI,ACK OF BURIAL OR REMOVAL 



^r^'^V 



DAT^uf Bf KiAi. or REMOVAL 
» I90H 



UNDERTAKER 

(Address. 



N. B. Every Item of Information should be 

state 
son 




s dylnft away from home should be ftlven in svsry Instance. "••'"•*'• ■^''« »»»««»•» Information" for psr- 



'■» 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boardofllealth-KNo ,,<i^i^B&PCo RCFER TO BACK OF CgRTIFICATC FOR INSTRUCTIONS 



Date Filed, 

i 



^y\.^.^J^ 




Hegistered JVo. 



1 190 "i 

Deputy Health Officer 

DEPARTMENT OP PUBLIC HEALTH-Cify and County of San Francisco 

Certiffcatc of Death 

( Ta. S. StanDarO ) 



jPLACE OF DEATH: — County of U^LYVj JAXXrruXftXr^CiCity of U/OLmj JaxWvx:.Au1ci^ 



(No. 





St. 



Dist.; bet. : and 



/ ( " ?rtV* ®*=<^""» *^*^ ^"0«« USUAL RESIDENCE GIVE r*CT8 CAlLtO worn \JtiDKm''9t'€CIALmwonmHTiOH--\ 
y V IF DC*TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUM«R ) 



) 



FULL NAME 







SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



DATK OF lURTH 






UJJ\^Aji 



ac;r 



1 onth) 



It 

(Day) 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




M fpoH 

(Day) (Year) 



I HEREBY CERTIFY, That I attended deceased from 



/ b5 I p, * MKKUBY CERTIFY, That I attend 

_jv^:L. ^vvOr-.-.^w. ,9oH to .4^^^ 



O }'i'ars \) 



MoHl/lS 



Pavs 



SIN<;i.E. MARKIEn. 

WrnoWKI) OR DIVORCED Q 

(Write ill s<x:iat tlcsiKiiatioti) mX 

Dx%v 

niRTHPI.ACE 
(State or Conntrv) 



NAME OF 
FATHER 



BIRTHPLACE 
OF FATHER 
(State or Countr.w) 










•-.••i.0. 190H 

that I last saw h Low alive on ^UXJLu, J^ 3»H 1^ \ 

anjJ that death occurred, on the date stated alx)ve, at J CL 2) C 

The CAUSE OF DEATH was as follows: 



NfAIDEN NAME 
OF MOTHER 




t 



AAAf;vvwc::v\A/!t. 

JA<\JLMl^<«,iMjL**^va 

DURATION Years ^ Months ?^ Days 

CONTRIBUTORY 




Hours 



i 




BIRTHPLACE 
OF MOTHER 
(State or Country 



'O^^^Ut^jOu 



0' 



^Ax^yyv 




OCCUPATION JP (] 

Rfsidfd in Sun I'ntm isfo I \ JV«j; < 



OL'^^xL^ 



DURATION^ Years Months Days . Hours 

(Signed ) ..UJr)^vyj vjj <XAv^\x<xt3L>db/vv m.D. 

"^^ T90H (Address) Gl 




;iAL Information only for h^ 

or Receit ResWeits. and persoRs tfyjif away from hooe. 



oVpitals, iRstitittoRs. TraRsints, 



Formfr or 



Months 



Pavs 



rvimcr "f "H 1. I !' Raw Um ^ 

Usual RfsidcRce ^J OJl\XXj\^-\JuysXjb WL Ware of IkaHi ? S H Bays 

Wlifn was disease coRtractH, 

If Rot at Mare of deatk ? 



'^"!:i.:^!?^*^'*^.^7^'^'''' PKRSOXAI. PARTICn.ARS ARE TRl E TO THE 
BEST OF MY KNOWI.EIM-.K AND BELIEF 



(Informant 



(; 



A.l.lresH I 0^1^ ^l AA/ . d<X^^,<X^VYUA\>U 




PLACE OF BURIAL OR REMOVAL DATE of Bpria,. or REMOVAL 

3iQ^i:^^o-^!mjL/>\lo l^^ r'^^ ^-^ iQoH- 



UNDERTAKER 

(AddrMff 



N. B.— Every item of Informatton should be 
State CAUSE OF DEATH I 
sons dylnft away from home 




should be carsfully supplied. AGB should be stated EXACTLY. PHY8ICIAIN8 should 
le should be ftivcn In svsry instance. "^ 







1 



U 

.■i:w 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ikinnl of Health— F No. 15 '^^S^^ b&F Co 



RtPgR TO BACK OF CERTIPiCATE FOR INSTRUCTIONS 



1 190^ 

Deputy Health Oiricer 



Registered J^^o, 



705 



Date Fne(l,A_ 

DEPARTMENT OPPUBUC HEALTH-City and County of San Francisco 



Certificate of 2»eatb 

( in. S. Stan5ar& ) 



PLACE OF DEATH 



^ ^ 



(No. 



: — County of ^'CVWjO AAAVCMACO Gty of ^Jo^IAj JaxV >v C^\^ACi) 



Hm^ LJvk^ntiv St.: "{ Dist^bet 5lo-i and^ od. 




FULL NAME 



_ P ERSONAL AND STAT ISTICAL PARTICULARS 





MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(Month) ^ 



I 

(Day) 



SINT.I.E. MARRIKD. 
WrUOWKI) OK DIVORI'KI) 
(Write in social desitmatiiHi) 



BIRTHPI.ACK 
(State or Country) 



190 \ 

^ <Y«»r) 

I HEREBY CERTIFY. That I attended deceased fronT 

Y^^"^ '90 1 to \Xcva I ,^^ 

that I last saw h i.'Vn alive on V^^U ^i 190 H 

and that death occurred, on the dale stated above, at \ 
tlM The CAUSE OF.DE^XTH was as f<dloms: 






NAMH OF 
FATHER 



RIRTHPI.ArE 
OF FATHER 
(State or Countrj') 



MAn)EN NAME 
OF .MOTHER 



BTRTFIPLACE 
OF MOTHER 
(State or Country) 



i 

OAvcL 



Dr RAT ION 



JVarj- .VoHtks H n^s ' Hemrs 



CONTRIBl TORY ^L\.Vviv<VCc> (^ ^LCvwi^ 




niRATIOX Vfars 

(Signed) v 

a 




Mo Niks Dmrs 

\UXvcCLCf%V 



tV.C\ i ,goH <Addrtss>^X^ VrAi^^MLU At 



mL INI 



ftl.D. 



OCCrPATION (W 5 

Rfsidfd /// Son f'ntniis^n ^ }Viii.< 



lA .«///. 



/'.n 



'"'i.i^^^iii'^^;^::^^^ 



or iffcffl RfsWfits. 4ii4 ptn—s 6ii| ^j^ frM Nar. •»«™«n 



Ftnifr tr 
Usual RrsMf Iff 

Whf« i»a$ tfisrasf CMtractH. 
If Mtatpijrftf^ratk? 



Rm lM|«t 



ii>s 



(IiifiMHiant 



^OA^-CUL 



'■vMrc, foxn -iitlv ^t 



l-I.ACK OF BIRIAI. ..R RKMOVU. I l.ATKof B, .,», 

-U cJLUm> C cxi l_ J-'L^^ 3 



"r KKMOVAI. 
•--•90S 




^J, 






'"■ ^" ^""'y '««"> »» Information should b- cni-afullv ......ilj ,^c i. . T^"^"^"'^'^"^"""""'"^""^'^^""" 

.t.t. CAUSE OP DEATH In pl.ln t;rmr,C » mJl t 1 ■ ^..'!""' '5''*'=TLV. PHYSICIANS .hould 

.on. dWn» aw., from hon.. Should ir«i..nJn,v""J ^^IZ!" ■"""""'• ^'" •»'«' ' '"'•-"•..'on" for p„! 



- [ 

;. i 

. 1 

V I 



I I 



M 



I II 



I .; 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoard of Health— I* N'o. 15 '^^^^^H&PCo 



Dfffe Filed, 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JV'o, 




1 190^ 

Deputy Heatth Officer 

DEPARTMENT OfPUBLIC tIE ALTH-City and Connty of San Francisco 

Cectfficate of ®eatb 

( TH. S. StanDarO ) 

PLACE OF DEATH:— County of na>VO AAAVC^ACf) City of ^'C^'yXJ OX<t>VC/vaCo 

(No. HO^l Ujxtu.>vtk St.; % Dist^bet. 9fUt- and^ OvlLvoL ) 

FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




SKX 



<V\ 



MEDICAL CERTIFICATE OF DEATH 



JX^vuxXit 



COI,OR 



lo.Ltc 



DATE OF DEATH 



DATK OF IJIRTH 



^ 



OA^ 



(Nfoiith) 



H 

(Day) 



vE^a 

(Year) 



AC.K 




(Month) 



a^'^ I zpoH 

1 (Day) (Year) 



y***rs .^ .Vopi/Zis 



XX 



Davs 



SIVr.l,E. MARKIKD. 
WIDOWKD OR DIVORCKr) 



Write ill social deKi}<rnati(>ii) \ \ \ 



BTRTHPI.ACK 
(State or Country) 



NANTK OF 
FATHKR 



BIRTHPLACE 
OF FATHER 
(State or Country) 



dM.1 



I HEREBY CERTIFY, That I attended deceased from" 

[O^ ' H 190 1 to lUv<v...l ,90 H 

that I last saw h Xl<n alive on p^iu 31? ion M 

and that death occurred, on the (hite stated above, at \ 
*^^J-Q The CAUSE ^>P«J^KAT" "^"^ "^ follows: 



<Vvva^ 



MAIDEN NAME 
OF MOTHER 



niRTHPLACE 
OF MOTHER 
(State or Country) 






DURATION ^ Years - Months IH D. 
CONTRIBUTORY 






OCCUPATION (?jy n , 



DURATION Years Jfopiths 

( SIGNED )X.M'^^ 

\ I90H (Address)XX^ 




Hon 



rs 





'Xotsi. 

^ays Hours 



^ M.D. 



«r?i!5?' M*-. "^!r°^'^^''"'ON only for Hospitals, iRstltutlons, Translfiits 
or Recent Resldenls, and persons dying away from home. •""siews. 



Rfsiiird in San /'i am ism ' A )>ars 



y font /is 



Pa v.< 



(Iiifomiam >ir(\<X\^4 UXJiXtu, 

fl T,|\ Q 

<-Mres, "i^XX" JIUX^ ?<it 



Former or 

Usual Residence 

Wlien was disease contracted, 
If not at plar e of deatli ? 



How loRf at 

Ware of Death? o^ys 



N. B. Every Item of Information should hi 






PI,ACE OF BIRIAI, OR REMOVAI, I IMTE ot IlrK..r. or REMOVAI, 

UNDERTAKER Nil xj 
(.\ddress . 




— »..jr ,icm o¥ inTormatlon should bs carefuilv aimnlt.^ »/>«? u •_• .^ ^^^ 

.t.t. CAUSE OF DEATH in pl.l„ ,;rmrth« Hr^^^t. 1 ■ ^c,'\'^'* EXACTLY. PHYSICIANS ,ho«W 

..n. d,l„4 .„., ,^„ h„„. Should b.TvenJn.v";!; ^^T,^ """""'• '^*^ »>-"-' •"»o-"...<on" .or p.r- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of Health— F No. 15 '^^^^^ H&P Co 



1 



WtFCR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JV*o, 




Date Filed,. \__ 

DEPARTMENT OFTUBLIC HEALTH-City and County of San Francisco 



1 190\ 

Deputy Health OITIcer 



Certificate of H)eatb 

( B. S. StaneatO ) 



4 <^ 



M< 



t ,'j 

■ 'V 



PLACE OF DEATH: — County of OarwO AAAVX^UIC^ City of ^JO^^ JVa^C^UK^ 



CNo. 



H oil LJy!UJL^ St. 1 Dist. bet. W .„a% a4n^ ) 

( .r Jr*T^Sc?!pV:^*J.:"°"* "•"*'- RESIDENCE Give rACTS callcd roR under "s-ccal .NroRMATiON- \ ^ 

\ IF OCAT^ OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NOlTsCR J V 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




vjX^>xcJu. 



iD.lwU 



I>ATK OF niRTH 



^ 



I Month) 



ccv 



H 

(Day) 




AC.K 



... JVlT* Jf 



MoHlhs 



311 



(Year) 



Pars 



SINCI.K. M.^RRIKI). 

WMKtWKI) OR DIVOKCKI) 

(""" ■ ■ 



VVriti- ill social de.sivrnation) 1 1 \ 
\XJ KJX.^W;' 



HIRTFIPF..\CK 
(Statf or Country) 



V.AMK OF 
FATHKR 



RTRTMPI.ACE 
OF FATHHR 
(State or Country) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH >» 

>^^-^^qtV.^ I igoH 

(Month) y ^ _ ^ __ (^ay^ <Vear) 

I HRRKBY CERTIFY. That I att7n7ed aecc^d"fi^" 

|CX^ ^H ,90.4 to -U^-l igoi 

that I last saw h /i-rvx alive on iVVArU ?)li' ,^ U 

and that death occurred, on the «late stated al>ove, at \ 
^1'^ '^^^ CArSR OF niUTH was as follows: 



MAIDKN NAME 
OF MOTHER 



niRTHPf.ACE 
OF MOTHER 
(State or Country) 



^ -V^ \X-lcwvdL 

- -OuXo^ 



DURATION ^ Years ' Mouths H 1% 




Hours 



<k 




OCCI'PATION 



N(?iv — ^o^^^^vdw^ 

Rrsidrd in S,jti /'Kin.isro ^ )'rais ^ 



CONTRIBUTORY ^^ 

DURATION ^ars Jfonths 

(SIGNED )....£..,. 1)...M' 

I iQoH (Address) %%^ 






Days 



Hours 



^ M.D. 



«r?i!59'\i*-. ''^f^'^^^'^'ON only for Hospitals, Insmutions, Translfits 
or Recent Residents, and persons dying away from hone. '""wiis. 



.V. »!//// ,. 



n 



'<; v.< 



'A....res, fOLl ~i^ til, est 



Former or 
tsuai Residence 

When was disease coRtracted, 
If Mtatplareofdeatli? 



Now loRf at 
Place of Death? 



Days 



PI,ACE OF BIRIA,. OR RKMOVAI, I DATE of Hikia,. or REMOVAl/ 




rXDERTAKER 

(Addres.s.. 



1)11 



190H 




.«.. d,l„» aw., W™ hon.. Should b7»iv.„i„.v":j i^.tV^cT ' """""'• ^'^ "»-"•• >"W„,...„„.. ,„ p.,. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

» '"rfl of Healtli-FNo. i.^^t^^^B&PCo RCFER TO BACK OP CCRTIflCATC FOR INSTRUCTIONS 



Date Filed, 




1 



190 \ 



Registered JVo. 



^^ Deputy HeafthpfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



{ "CI. S. StanDarD ) 



PLACE OF DEATH:— County of CJ£uLc-yxOL^ City of 





C 0\.xrv^ LolN 



(No. 



(ir DEATH OCCURS AWAY FROM USUAL 
IF DEATH OCCURRED IN A HOSPITAL 



St.; 



Dist*: bet. : and 



RESIDENCE GIVE facts called for UNDER "SRECIAL INFORMATION 
OR INSTITUTION GIVE ITS NA 



LED FOR UNDER "SPECIAL INFORMATION" \ 
ME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 




€uy\/y.\^JLJ\A.\/y\J. 



■Ll' 



sKx n^ 



PERSONAL AND STATISTICAL PARTICULARS 

I COl, 



DATK OF niRTM 






r.oR \ (V 

loJ 



XOU 



■OJ\j 

(Month) 



(Day) 



/ina 

(Year) 



AC.K 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




2S 

(Day) 



jgo \ 

(Year) 



I HEREBY CERTIFY, That I attended deceased from 

— to 



190 



190 



J ■«•</ ; 



MoHlh$ 



Pars 



SINC.I.K. MARKIKD. 

wiDowKD OR nrvoRrnr) 

'Write in s<x"ial (levivrnatiou) 



h 



BIKTHPI.ACK 
(State or Country) 



NAMK OF 
FATHKR 



BIRTH PI.ACK 
OK FATHKR 
(State f»r Country) 



MAIDKN NAME 
OF MOTHER 






that I last saw h •'. '-alive on 190 

and that death occurred, on the date stated alwve, ai-^:^^^^ 
TTrrr- M. The CAUSE OF DEATH was as follows: 

I2.^a.a..x^. %^,vvt 1^ 



A,r4JL<\..4u^. 



niRTMPLACE 
OF MOTHER 
(State or Country) 



OCCrPATlON (J\P 






DURATION Years 

CONTRIBUTORY 



Months 



Days Hours 



CC>V 



dL 



Rfsidfil in Stin hiamisfn ' J )V<j;.c t. ^f,mlhf 



DURATION Years Months Pays Hours 



(Signed) 



iXa^-v^w^ M.D. 



rlV. 



iu.. 



7.0- 



190 



(Ad<lress) 



FECIAL INFORMATION only for HospJt«rs, Institutions, Transifits, 




otujv^ va^. 



or Rrcent Residents, and |»ersons dying away from home. 



Former or 
Usual Residence 



How Joif at 

Place of Deatli? Days 



/)<? V.v 



' "l^^^i*^'*'' ^TATKn PERSONAL PARTICULARS ARE TRIE TO THE 
llEhT OF MY KN0\VI.ED(;E AND HEMEF 



(Inforniant 







When was disease contracted, 
If not at place of death? 



PLACE OF BURIAL OR REMOVAL 




DATE of BlKlAl. or REMOVAL 
I I90H 




(Ad«lress 



^(XxxJ. 



INDERTAKER yuJU^AA^ O- v) frd^i 

3. 5 Au\^&'-v^i<wvv^Jl^A4....vL 



IN. B. Every Item o? information sliould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information** for per- 
sons dyinft away from home should be ftiven in mywy instance. 



f ^ ; 



Si 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



RomhI of Health— F No. 15 



B&PCo 



RCFER TO BACK OP CCRTIPICATE FOR INSTRUCTIONS 




kA; 1 19 o\ 

Deputy Health Officer 



Be^istered J^o. 



7m 



Date Filed, 

DEPARTMENT Of^PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Ta. S. Stan&arD ) 
PLACE OF DEATH: — County of C)<LTVj O/VCL^veui^City of ^^X/V^ OAOy>VCV4/CO 



(N0.C) 




.&.is^kcla.iL' 



St4 



••Dist.; bct» and 



(irlocATH occuns aw4v rnoM USUAL RESIDENCE Give facts called for under "special information" "X 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



LUl^KJL J JWiiiv.. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



OluL 



COI«OR 




DATE OF r::<T»i 



(hi 



cvv 



(Month) 



(Psy) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 




(Day) 



190 n 

(Year) 



ACR 



^ A J 'ra » .V V 



Mnulhs 



Davs 



SIxr.l.K. MARRTKn. 
WIDONVKD OR niVOkv'KD 
(Write in social ilt-siKnatiou) 



niRTHPI.AOH 
(State or Country) 



n>L'>xaLL 



NAMK OF 
FATHKR 



RIRTHPI.ArK 
OK FATHKR 
(State or Country) 



MAIDKN NAMK 
OF MOTIIKR 







^EREBY CERTIFY, That I attended deceased from 

1 190N to .....VJLw....2>Ci 190 .H 

that I last saw h^^vn alive on >j|rvJu^ '^.0 190 H 
and that death occurred, on the date stated above, at 3^ 
ll M. The CAUSE OF DEATH was as follows: 

vAr^.XXX.^V^VV^t3C 



Hours 






d 



BIRTHPr.ACE 
OF MOTHKR 
(State or Country) 



JL\*L 




v^vcV 



DURATION T- Yeai^s ^ "Mouths X Days ' 




CONTRIBUTORY 

DURATION -r Years '^ Months " Days ''Hours 

Ju^cu<LeA;. „ „ 

SS) ^ 1^ 9.^rvttt\^ Ot 



(Signed) 

^ ^^...3 ' 




M.D. 



IQO 



(Address) 



OCCrPATlON 



"(?lo 




J^. 




Resided in San Ftanriseo JL^n )V-<7;.f \ Mintfis v Pays 



THK ABOVE STATKD FRRSONAI. PARTICri.ARS ARK TRIK TO THE 
BEST OF MY KNiMiJ.KDOE AND BELIEF 

(Informant 



.sJ , oW^JL 




(Address 1511 V.bO^WiXVxi d± 



i 



Special information wly f«r Hospitals, iRstitHttoNS, Transients, 
or RecfRt ResMents, aii4 persons ^yins away from home. 



Former or 
Usual Residence 



ni.'l(^^^<L^^«:.Tfci 



Death? Days 



When was disease contracted. 
If not at place of death? 



PIPAGE OF BURIAL OR RKMOVAI. I DATK of BlRlAL or REMOVAL 



NDERTAKER AO . 




I90H 



(Address . 



.(J..'i!>.l....QllL>M.i^ 



tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
TH in plain terms, that it may be properly classified. The "Special Information** for per- 



N. B.-^Bvery Item of in forma 

state CAUSE OF DEATH ^ , , 

sons dyin4 away from home should be (Iven in every Instance 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



:« !> 



11 



■ 



l[ i: 



Ho:in1 of lIctiltli-FNo. K 



»& P Co 



REFER TO BACK OP CERTIPICATE FOR INSTRUCTIONS 




Registered JVo. 



708 



MXV5 



1 190H 

iXv^ Deputy Health pfTlcer 

DEPARTMENT # PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2>eatb 

( "a. S. StanOarO ) 
PLACE OF DEATH: — County of OO/Tu OA<V>vCUl^City of Oa^yj J AXXAvCCA/Oii 

vjj (yv<>\j6 wv-i civ lltL su S Dist4bct.Jbcrvv^>uL and ^crL^trnoi 

CALLCD rOR UNDER "SPECIAL INFORMATION" "X 
NAME INSTEAD OF STREET AND NUMBER. / 



Nail 



(IF DEATH 
IF DEA 



OCCURS AWA 
ATH OCCURRED 




OM USUAL RESIDENCE GIVE FACTS Ci 
A HOSPITAL OR INSTITUTION GIVE ITS 



FULL NAME 




\AXU>\1 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR 



1 



i>\TK or inKTH (q?^ 






iO.lvJti 



(Month) 



AC.F. 



I I )V</;. O 



(Day) 



Months 



r US 

(Year) 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Year) 



Days 



^INi.I.K. MARKIKI) 
WIlHiWKI) Ok DIVnKt'KI) 
< Write ill Mxrial clcHiKiiation) 



RIKTHPI.AOH 
'Slatf or Country) 




NAMH <)l 
FATHKR 



\ctVujt<x 

vXvCVwvccLa' Lo LoJb 



I HEREBY Cr':RTIFY, That I attended deceased from 

.Q(l^<w 1 190H to f^^^ '^^ '90H 

that I last saw h M\) alive on J\^A^ 155 190^ 

and that death occurred, on the date stated above, at ^ 
sJ M. The CAl'SE OF DEATH was a.s follows: 

U/Vvt i\4^^aA,:3 }l<uJ^yy\^^\\.oXui 



BTRTHPI.ACK 
OK FATIIKR 

(State or Country) 



MAIDKN NAME 
OF MOTHKR 




nTRTTIPLACK 
OF MOTHER 
(State or Country* 



OCCrpATlON 



¥ 






Dr RATION I Years'' Months ♦ Days - Hours 
CONTRIBUTORY \\.)\/OJ\M^V\^nuK\>A^ 



DURATION ^_^>fV'''jJi Jfofti^s *^ Days * //ot4rs 

M.D. 

I 190H (. 



( SIGNED ) \].., . to, vij WW r^. ^ ^..•. 

vLtva I looH f Address)S X Oa^^XxX^ U!^ 



^v 




Rrsidnf in San I'uniihro ^<jlO)V^;v •" Mniitfif • 



Pa 1: 



THE ABOVE STATED PFRSONAI. PARTICII.ARS ARE TRIE TO THE 
BEST OF MY K^SmVl.^:Dr.I^yAND BEI.J^EF 



(Informant 



(Address 



J . NL. 6JOvUlX\JL 
\ 1 /^^^Vc^U. UAKt 



:ciAi 



Special information only for Hospitals, Institutloiis, Transknts, 
or ReccRt Residents, and persons dying away from home. 



Former or 
Usual Residence 



How lonq at 

Plate of Death? Days 



When was disease contracted, 
If not at place of death? 



PLAQK O^^ BFRIAI, OR KEMoVAI, I DATEof BiRiAL or REMOVAl, 



rXDHRTA 






(Address 



lil\ OflOA^a.^^^ 




N. B.- 



-^\cry item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for per- 
sons dyinft away from home should be ftiven in 9V9ry instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board of Health— F No. \s 



H&PCo 



REFER TO BACK OP CERTIPICATC FOR INSTRUCTIONS 









a. 



Registered JVo, 



709 



Date Filed, \J<r:^r^AY^^^■ \ 190'\ 

Xm.a^^ Xt^j-ir Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( "CI. S. Stan&arJ> ) 
PLACE OF DEATH: — County ofC)/a^^>\; J AX»^rbCAw^ooCity of G<VrsjA);uXrruiv^e^ 
''No* I^OS OAiX'Vu.vrvck' St; I Dist.;bct 

(IP OCATH 
ir OCA 




and 




OCCUnS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




\jj\j.. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



<^aL 



lUjvdt 



DATK OF BIRTH 



AC.K. 



^^iith> 



11 

(Day) 



rWJ 

(Year) 



1 



) 'I'U > . 



\o 



Months 



IS 



Pa vs 



HINT.I.K. MARKIKD. 
WIDdWKn OR niVORCKO 

(Writf in Mxrial iloiKnation) 



JURTHri.AOK 
(State or Country) 



NAMK OF 
FATHKR 




BIRTHPI.ACR 
OF FATHKR 
(State or Conntry) 



MATDKN NAMK 
OF MOTHKR 



BIRTHPI.ACK 
OF MOTHKR 
(Slate or Country) 



OCCUPATION \l) 



Residftt in San Franc isfn '()>«».< V .\foiillis • I 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 

LAA,Lu Si 



(Mdnth) 




(Day) 



(Year) 



^ I HRRHnY CIvRTIFY, That I attended deceased from 

.^ItJLu JiL igoS to IjlJLul.M 190 M 

that I last saw h 4. >/; alive on %4JUa 3>.l igo H 
and that death occurred, on the date stated above, at 
.^ M. The CAl'SR OK DICATH was as follows: 

L<.M:vinJLA'vdLA.^v.i..'L-a 



DURATION "^ Years 
CONTRIBUTORY 



Months ^ Days ' Hours 



Pars 



THK AKOVH STATKD PKRSONAI. PARTICII-ARS ARK TRIK TO THK 
BEST OF MYJvNONVI.KlX'.K A.NI) BKI.IKF 



VAA/V 



(Informant ^JUmJlXt. "o^^O^^ 

f Address \% S .yA;U.rNAAA.C^...B.fc. 



DURATION ;, years Months 

(SIGNED) OX<i 

iqo 



■i tears J/ot 



Days 



Hours 



.^^vLl^-^.j T9< 

SPECIAL INI 



rkw, M.D. 

(Address) US I ^lVM.m/ . QJ 



_ _ FORMATION o"ly lor Hos^Uls, Institittons, Traisleits, 

or Recent Resklents, and persons dying away Irom home. 



Former or 

Usual Residence • 

When was disease contracted, 
II not at place ol death? 



How loRf at 

Place ol Death? Days 



PI.ACE OF BIRIAI. OR RKMOVAI. 

T" A 4 



INDKRTAKKR 

(Addreif's .. 



O 



DATK of BiRiAL or REMOVAI, 
•X I90H 




fvcLia^^i 

5.0.5. '!!ft\^\lA)vv..Ql..v^. 








N. B. Every Item of Infopmatlon should be carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information** for per- 
sons dying away from home should be given In mvry instance. 






«> 






III 



u 



I! 



ii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hojirilof Health— I- No. is 



Il&PCo 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



..,\ I'JO'i 

Deputy Health Officer 



Registered JVo, 



710 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. StanDarD ) 
PLACE OF DEATH; — County of Oa^ OAXVtlCUICC City ofCJ/CVru 1\^X^\cuicl.o 



! 



^No. ni5 V!J3x^dJL^^ck 



St.; *i 



Dist.:bct VJ.V>vC and MllA.\.A.h' 



(ir oc*TM occuns away rmom USUAL RESIDENCE Give facts called for under ■•fecial information- \ 
IF DEATM nccuRRro IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



ATM occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N( 



FULL NAME 




\-.H.Lu.t. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI, 



QUJ. 



LOR rrs 



DATK OF BIRTH 



AGK 



vA' V n 



(Month) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(Month) 



(Day) 



)■«•</».< 



•^ Von //is 



(Year) 



Davs 



SIsr.l.K. MARKIKD. 
WinnWKI) OR DIVORCKD 

'\Vrit«-iii social (It-siKiiutioii) 



hikthpi.aof: 

(State or Country^ 






VCxVACC 



namf: of 
fathf:r 



1 



{tKl*. A\/aX^\.\j 



If L\A-C1^X4^U 



BIRTHPLACE 
OF FATHKR 
•State or Count rv) 



maii)f:n namk 
oi mothkr 



BIRTH Pl.ACK 
OF MOTHKR 
(State or Country) 



txxo 



nth) jT 



1 



(Day) 



(Year) 



I HEREBY CERTIFY, That I attended deceased from 

LLn^vcl. \. 190H to LL^-v-cv.-i 190 u 

that I last saw h alive on 190 



and that death occtirred, on the «latc stated al>ove, at vJ: ^J^. 

r 
^kM. The CAI'SE DE DlvATII was as follows: 

O^tJd. iD.ft^^ 

LLfccluLcLx.A.A^ 



DURATION Years 

CONTRIBUTORY 



Months 



Days 



Hours 



\X\^^T\.^^\A. 



occrpATiox 

Rfsidfd in Siin I'l am isfit 




\.(X >v 



)■/•<?/ 



\r.inth': 



Ihirf 



thf: above statf:i> phrsonau partumlars arf: trff: to thf 

BEST OF MijpKNOWl.F:i><;K AND BF:Ln:F 
(Informant J.. \i I uJkA^^^xVLc 



r\<l<lress 



ni5 



Mja^kIjavcIi at 



DURATION 



(SIGNED) 



Years 



(l * 0)1' t^Jl 



Months Days Hours 



fr'wwX-LL M.D. 



LUva 1 190' (Address) 1 1 1 ytDvU '3i 



SPECIAL INFORMATION only ^or Hospitals, Institutions, Transients, 
•r Recent Residents, and persons dyinq away from home. 



FoTMer or 
Usual Residence 

When was disease contracted, 
If not at N«fr of death? 



How lonf at 

?^9Kt of Death? ~ tays 



PLACE OF burial OR RF:M0VAL 



DATF;of BcRiAI. or REMOVAL 

.Lm.a^ 3. 190H 

UNDERTAKER vA; vU \' ' tOLAA^^A, "^ 

(Address 2)1.^.. V J -a^^U^ii.^.t 



^ 



P 



? 

c 



J 



N. B. Every Item of Information should be carefully supplied. ACE ahould b« stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special information" for per- 
sons dying away from home should be given in mvnry Instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•f 



[>!' 



u 



t 



ft 



Hoard of lUitlth-F No. is 



nfkv Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ffe Filed, 




I 



loo'x 



Registered JVo. 



711 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



( TH. S. StanDar^ ) 



% 



^ % 



PLACE OF DEATH:— County of 



.a">\» KCuy\Z^^.ZC. City of VJ CL^W ^ XAX.^^Z<^Z.i 



No, ^\ ^ 



,-V.^. 



St.; X Dist*;bet* 




cmj.. 



(P 

and \y ^^AM, 



(ir OC»TM OCCURS *W«V FROM USUAL RE 8 1 OENCE Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



"iJ.X6:\..a.f:- N.llsL,<l.lu... 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



'^\Ju 



U.\Ll 



DATK 1>F BIRTH 



ACR 



iMoiilh>/r 



15- 



} Vi/ / . 



I 

<Day) 



Monlfis 



(Year) 



Ditvs 



SINC-.l.E. MARKIKO. 
UinoWKD OR DIVORCKD 
\N'»itf in Mjcial «U-sijf nation) 



^. 



OJxv^^ccL 



HlkTHIM.AOK 
'State or Cf»untry) 



NAMK OF 
HATMKR 



HIRTHIM.ACK 
Ol I ATHKR 

'Statr or Cfiuntrj-) 



MXIIiHN NAMK 
Ol MOTHKR 



lURTHIM.ACK 
o! MOTHKR 
(State or Country^ 



-^ 



X^V>"wol">vu 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DK 



ll 



(Month) 



A^VwCl 1 iQo ' i 

^\t 



(Day) 



(Year) 



I IirCRrvRY CERTIFY, That I atteinled tleceased from 

— to 1 90^^^- 



190- 



that I last saw h alive on ~ 190" 

and that <leath occurred, on the date stated al)Ove, at -^-^:^- 



rrrrr.yi. The CAI'SH OF DlvATH was as follows: 




JL^\K 



h 



1 




LA.C4XjL-^ 



Di; RAT ION Years 

CONTRIIU'TORY 



Months 



Days Hours 



OCCri'ATION ^^ 




1 



\(X^v>va ' 



„_ AJX^^WX^W 



Resiiled in San Ftanrisfo 



^ 



Dl'RATION ^ Years Months, 



Days 




( ^1 

(SIGNED) Ur\-trvaA;vJ 

LLv^I tqo'a (Address) Ln^\Jl>>^ V |U<:i.>>. 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutlois, TraRslents, 
or Recent Residents, and persons dying away from home. 



> ><T If 



.\f,>,ifhs 



/hjv: 



THK ABOVE STATKO PRRSONAI, rARTUMLARS ARK TRlK TO THE 
BEST OK MY KNOWI.EIX.E AM) BEMEF 



flnfoiniant 



(Add 



A..Bi .0/Cvct<) V<t.^ 



iHc^a 



or -A 
Residence O^ 



Former ^ ^ ^^ ^ 

Usual Residence 0£^V)^^-\^ 



ll 



\i 



X f ll«w l«R9 at I 
vli/rvVd vaV Place of Oeatli? l Days 



When was disease contracted. ^, ^^^^ ^.o^ 
If not at place of death ? CJ O^li^a^^Vt > 



\t«. 



h 




PLACE OK BIRIAI, OR REMOVAI, 



^ 



^CVCt\>v8.-> 



vU ^qX_ 



DATE of BiRIAL or REMOVAI, 

I90H 



.U^v^a.l. 



UNDERTAKER 



Clod v(K^.t!: 



(Address . 



(9 1 X- b ^H Aj cw:\v. 



.v-^ 



N. B.— Bvery Item of Information .houid be carefully supplied. AGE should »>« •i-^^jJ^EXACTLY ^"Y«»CIAN8 should 
•fate CAUSE OF DEATH In plain terms, that It may be properly classified. The Special Information for pr- 



sons dyln^ away from homo should be 4lven In svory Instance. 



I' 



i|!iij| 



II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoard of Healtli~F Xo. i^ "^ 



H&PCo 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Date Filed, 




I lOO'i 

Deputy Health Officer 



Registered J^o, 



71^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



PLACE OF DEATH 

. .0 



: — County ofvJ 



( TH. S. StanDarD ) 



(Xy\) Xv<XAveiAcocity of O/O/ru d.Axt/vvec4,-<i^ 



(No. wL ^U 



iSt, 



^^^M , ^^ WW! vMo, V v,>^>^ vvvivu:>t.; i> iist>; bet* and -^^^^^rrrrrr 

r/^ ir DEATH OCCURS ^AY rROM U^UAL R E S I DE NC E Gl VE FACTS CALLED rOR UNDER "SPECIAL I N TORMATIO N " \ 
ij V IF DEATH OCCUR^D IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




SKX 



^\jx __rU)Lu 



DATK OK niRTII 



*£ 



-CO. 

(Month) 



(Day) 



rllL 



(Year) 



AdK 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




(^ V )'tuits \ 



Motil/is 



n 



Da YS 



SINC.I.K. MARKIKI). 



wrnowKi) OK nivoKiKi) 1) 

(Write in stx-ial (lisiKnation) ~\ 




HIKTHPI.ACK 
(State or Country^ 




} H)^REBY CERTIFY, That I attcmlcd deceased from 

^b 190S to ^k^ ,90 ^ 

that t last s^w h -rtAn alive on WuJLtL J^ XH 190 4 

and that death occurred, on the date stated al>ove, at I V- J 5... 
U^>I. X»it? CAITJSJ? OF DEATH was as follows: 




VU) 



vtIaa/^ 

MAIDHN NAMK • 

OF MOTHKR Ji J\ 



HIRTH PLACE 
OF FATHKR 
(State or Country) 



DURATION ?^ Ve^rs ^.. Months S Days , * Hours 
CONTRIBUTORY ULm^XA:^. ULL^C^X^ 



RIRTHFI.ACK 
OF MOTHKR 
(State or Country) 



(T. 



OCCUPATION /r> I I 

Kfsidfd in Sum Fitnitisro U JVi/; » *^ 



DURATION ^y^/tis ^ AfoNths 

(SIGNED) J . \\, ofcoXt 

oO IQOI (Address) 




Days Hours 

M.D. 



vLl>4t' 



B^^^'ft*- iNfORMATION only for Hospitals, lnstltM(i«ii$, TraBSkiits, 
or Recent Resident^^ and persons dying ^way from home. 



'z^w^^!X^^^t^^jz^^^, 3 



Months 



/hi 1 



THK AHOVK STATKI) FKR ,AI. PARTICII.ARS ARK TKIK TU THK 
IJKST OF MY KNO\VI,KI>i-E AND IJKI.IltF 



Informant L\) OYNJ ^ ' TL • JcCLW^Vtr'V) 



(Address 



N. B.- 



utu "V Co *% (SI \o±A. 



When was disease contracted, 
If not at place of death ? 



Days 



PI.ACK OF BlRjU^I, OR RKMOVAI. 



(W^<OD 



D.l^K of RiKiAf. or REMOVAI, 
3^ I QO H 

rNDKR/AKKRMT\ /(X<A.dL£/>vMriV 

(Address I 111 .iDtC^l^UrW 




\ 'Jl^ 



tt^t^c'Il'se'^OF^TATH^n^^^^^ •' '""•^k"'' supplied. AGB should be stated EXACTLY. PHYSICIANS .houid 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The 'Special Information" for per- 
sons dylnft away from home should be ftiven in every instance. information for per- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Xoanl of lIialt!i-»- No i<; 



n&i'Cc) 



RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




p 



Date Filed f LLi,\.atv<L^ I 






190H 



Registei'cd JVo. 



713 



dL^WA_A -U.V-U, Deputy Heafth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanDar^ ) 

% J? 



PLACE OF DEATH:— County of O.Ct>V OAa > VCv4 CC Gty of '^'0^>'V OXCtTW:.VA^c 
•^ hft f\^. (^ ft 



No. 



l^l 




r-LV 



i 



St.; 



Dist*; bet. 




and O.CluL^\-'... 



(!F OCATH 
ir OCA 



occuns AWAv rm 
ATM occunnco in 



OM USUAL RESIDENCE GIVE FACTS CALLCD FOR UNDER "SPECIAL INFORMATION" \ 
A H08PrT«L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMSER. / 



) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



(kcut 



COI.OR ^ 



DATK OF UIRTII 



.nth) r 



\<.K 



"^C ,v.„. 



It 

(Day) 



1/..W///* 



fl~iH 

'Year) 



/)<M.< 



HINT.I.K. MAKKIKI) 
WIHOWKI) OK niVoKlKH 

WiittJn vK'ial ilf sij^natioij) 



^ 



HIKTHPI.AOK 
(State or Country'* 



NAMF c»|- 
FATin:R 



BIRTHIM.ACH 
OF I ATHKR 

•Statr or Country^ 




1 

10 ^ ! 






NfAIIIKN XAMK 
OI MOTHKR 



BIRTH PI.ACK 
(»F MOTHKR 
(State or Country) 



OCCrPATION 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




M 

(Day) 



(Year) 



I HEREBY CERTIFY, That I attended deceased from 

Vl\.^wlu. XI 190H to .• |>;^H 'i-^ 190"^ 

that I last saw h -J^ )^. alive on ^(vvlci ij^ 190 '^ 

anil that death occurred, on Ihe date stated above, at ^ X 
M, The CAUSE OF DI-ATII was as follows: 

..C.^^A<>vt>w A*^^^L d.axj^.....ilMl(^Jl aA.<vvvr.<ks 

vX\^\^Li.VH- ,;, •- 

nr RATION Vt-ars Mouths 1 ^ Days ^^ Hours 



CONTRIIR'TORY 






Vfsiiinf ill S,nt /'laMrifrn oO )V,iis " .!/-"////> A V An « 



THK A»OVE STATKI) I'HRSONAI, TA K rirtl.AKS AKH TKl K T« • TH H 
HKST OF MY KNnWI.HIX.K AM) HKI.IHK 



(Infotmant 



(^<l<lres8 



a. Jdu. icjj 



vt\j 



DURATION 
(SIGNED) 



}'cyirs : .^fouths Pays Hours 
JJk\X^<x,L^ M.D. 

fi [Ci M (15 ^ . 

'h\ iQoH (Addres s) \X^^KX\> ^BX^q 




Special information only for Hospitals, Institutions, Tfanslents, 
or Recfnt Residents, and persons dying away from home. 

former or How lonf at 

Usual Residence Pl«f* of ^«tt? ^1^ 

When was disease contracted, 

If not at place of death ? 



PI.AC_K OF BliyAI. OK RKMOVAI, 



DATK of HfKiAi- or REMOVAL 
LvwOL I .^ J^QOH 



L-NDKRTAKKR V^^-^-^^^^^ 

(Address^ 305 VjYU^VvttW .11^ 



.CLVV 



L OF DEATH In pl.i. term., th.t it ma, b. properly cl...WI.<i. The Specl.l Inform.tlon tor p.r. 



N. B.— Every Item 

•tate CAU8L 

•on» dying away from home should be ftiven in every instance. 



i 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n 



,,.,,,1 „r H.-altli-K No. l^ 



il&HCo 



RCFCR TO BACK OP CERTIPICATC FOR INSTRUCTIONS 



lh((o Filed y 




-v- 



M 



I W0'\ 

Deputy Health Officer 



Jtegisterad JVo. 



714 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Ta. S. Stan&ar& ) 



Ji ^ 



PLACE OF DEATH: — County of O-Ol/vv OX^^-YVCA-A/CtCity of )<V>v OAO.'-y-.C'-a.c.t, 



:f 




Na 



aaow 



II 



W 



^w\.^m\) 



St. 



Dist.; bet* 




and 




:L<'.->.\-L?:u. 



/ ir Of ATM OCCUR* »WAV rHOM USUAL RESIDENCE Give r*CT» CACLCD ron under "s^tCUL INrORMATIOH" '\ 
V ir OCATH OCCURRCO IN A HOSI>IT*L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



i.X'vtLvAAx 




-W.. 



PERSONAL AND STATISTICAL PARIICULARS 



SKX 



DATK OF HIKTII 



COI.OR \ 

' LU 



iMoiithl^ 



lb 

(Day) 



(Year) 



?i. 




\'.H 



l>ar« 



U 



Mouths 






Davs 



•^INt.l.K. MARKIKI) 

wiixiwKn <»R nivoki-Ki> 

Write ill *<)cial «ltsitfnali<>n) 



HIKTMIM.AOK 
• Stale- or Country^ 



-? 






I 



C)rCt'>V J AXX/VX/C.C^'^^C^ 



N'AMK <»f* 
FATIIKR 



^ 



/CU>v<X) 



i/tLJ 



MEDICAL CERTIFICATE OF DEATH 




.S.l /poH 

(Day) (Year) 

I HRRF.BY Cni^TIFY, That I attended deceased from 

!i\.u-k\X. '^Ci 190 '*. to N|^laJLjl... ..2>.L 190 H 

that I last saw h.^^^- alive on )|rA-^W ^^ 190 • 
and that death occurred, on the <late stated above, at o a 3 
U-M. The CAUSK OF DICATII was as follows 



c)i'w>AxxJL Ay.jCLizvvA^vxxyvX^^^ 



va\. 



cLa 



crvv 



niRTHPl.ACK 
or I ATIIHR 

'St:it«- or Country) 



MAIDKN NAMK 
Ul MOTHER 



HIKTHPI.ACK 
OF MOTHKR 
(Slate or Country) 






OCCUPATION 

Rfsh1f,i i n San FraMrifft^ Vrarx 1 Cj Mottths \S />"' > 

TUl ABOVE STATED I'KRSOXAI. PAKTU ILAKS ARE TRIE To THE 
HEST OH MY KN0\VI.ED<;K AND HEMEF 



Informant \j O^AVCU ciw . ^XA./cJrV<:t^^ C^-O^^^fV 



(Address 



DT RAT ION " Years I Months ?- /^^jf^ 

..A:>\XX/>:VlLX*-Crv:v 



Hours 



CONTRIBUTORY 




Months 



Days Hours 



ylT^JiUfiZxx. M.D. 

s s) iaoxll^^^>^^ ^^ 

only for Hos^tals, instltiitioiis, Transirnts, 
or RKfiit^fVMeuls, and persons dying away from home. 



DURATION .Years 
(SIGNED) VR-.S 

Vvlu ^1 iQoH (Addres 
SPECIAL INFORMATION 



Fomier or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



How Itng at 

Place of Death? Days 



PI.ACE OE BIRIAI, OR REMOVAL 



tOE Bl RIAI, OK Ki 
INDHRTAKER ^^ ^t^vCt/VOAj Jj 



DATliof HiKiAl. or REMOVAL 
9» I90H 




(Address . 



\x^\ Qry\v4(iA.^^.v... Jt 



., J xoin .Kn..lH Im atflted EXACTLY. PHYSICIANS should 



^' B' Every Item of informs 

state CAUSE OF DEATH in p 

sons dyinft away from homo should be ^iven in svsry instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I^,ar.l <.r lUnlth- I- No ,^^ WCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Date Filed, LLw,v/QA^v^ .1. 



r \ 




.V/CUL^ 



190' 



Registered J^o, 



715 



i^vui ItoHa Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County 



Certificate of Death 

( Ta. S. Stan^ar^ ) 



►i 



Na 





MS VLi/t\>V St.; I .Dist.;bct .^5..U\i and lt...U\i. 

/ ir DcItm occurs away rHOM USUAL RESIDENCE Give FACTS called for under "special INroRMATION" \ 
( TfTeATH OC^RRtO 11. A HOSflTAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. J 



FULL NAME 




^Ahjyyx/Xr^yj.. Q(L.ks^::)JsJs>jJM 



PCRSONAL AND STATISTICAL PARTICULARS 



SKX 



DATK OF lilRTH 






COI.OR 



\ 



LL.iWwv 



( Month t 



AOK 



. J» >V<7*< 1 



as 

(Day) 



Mouths 



(Year) 



Pars 



SINT.I.E. MARKIi:i>. 
\VII>0\VKI> OR DIVoRTKn 

•VViitriii s«Mrial •Usii;iiati<»ii) 



HIK THHI.ACK 
(StaUor Country) 



\AMK OF 
FATHKR 



RIRTMIM.ACK 
OF FATHF.R 
(Slate or Country) 





MAIDHN NAMK 
OF MOTHHR 



RIRTHPI.ACK 
OF MOTHKR 
(State or Country) 



OCCrPATION 










C 



_ vW^^VLavk 









Kfsidrti in San rmmisfo \ Vr.its " .l/^w/A-^ L 



/)</ 1 .< 



tiif: abovkstatf:i) phrsonai. par ricn.AKS arf: trtf: to thf: 
nF:sT OF MY isNo\vi.f:i)(;k and hkmkf 



fin forma lit 



(AcMrciw 



•:d/.K and m-AAWV 



13^5 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DEAT 



JATH A I 

H.'lJU. 



(I^onth) J 



(Day) 



(Year) 



1 HEREBY CKkTIFY, That I attended deceased frotu 

that I last saw h^^^v.alive on r^^^ ^^ '' 

an«l that death occurred, on the date stated above, at 10 i 
M. The CAUSE OF DEATH was as follows: 

[^XsJmJ^\XKxjx> 

J,..fr:-:U0uLA:^.xiwOu 



Dr RAT ION Years 

CONTRIBUTORY 



Months 



Days 



Hours 



DURATION ;*^: >V<i''^ ^ Months 



(SIGNED) 

\L\,Lq r..' iQO' 




Pays 



Hours 
M.D. 



( 



Address) 1^1 -^ ^^U^^x- 3t. 



SPECilAL INFORMATION only for Htspitals, liistltitl«is, Traiskits, 
or Rcceit ResMcnts, aiMJ persons dyiifl away from horn*. 



FonKf or 
Usual RfsMfRCf 

WkfR was diseasp contractH, 
If not at pface of dfath ? 



How I0119 at 

Place of Deatli? Days 



PLACE of BURIAU OR REMOYAI. 



I NDKRTAKKR 

(Address I ■ 




ij ;r. AfiF .hould be stated EXACTLY. PHYSICIANS should 

N. B. Every Item of information should be carefully supplied, aud •"" ^^ . -.,^ "Special Information" for per- 

state CAUSE OF DEATH in plain terms, that it may be properly class.tiea. P- 

sons dying away from home should be given in every instance. 



fl 



i 



I 



* 

V 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,r.l .ni':'it»'- 1^^'" n:^f^^H&PCo WEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Date /'V/^'^/,.. LLLVXlAAAfc i 



Registered JVo. 




190^ 

L^m Deputy Health ORlcer 

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 



i i 



^ 



No. 



Certificate of Death 

( 'CI. S. StanOarD ) 
PLACE OF DEATH: — County of ^CL^ ^XXX/WCUlCcCity of ' J a/>^' ^^CX/>A^A^^e.<x. 
X[% i)<Xm St.; It Dist.;bct. IS iJL. and S.C...tL ) 

/ ir DC«TM 0dcU«« *W*Y r»»OM USUAL RESIDENCE GIVt facts called rOR UNDtR "SPECIAL INFORMATION" \ 
( rF"EATHlSc?lRRtO IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

LkcuJLu LI c).av,.eLLu.. 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



•^i:x 



(^^xU 



COM>R 



\})kjU 



DATK «>I- HIR TH 







I 



.\C.H 



Vfrnts 



(Day) 
M.mths 



fVear) 



X% 



Pavs 



siNT.i.K. MARK I HI) 
WmnWKI) OR DIVOKCKI) 
Write in •UM.-ial «U-si}riiati<)ti) 



niRTHPl.AOK 
(State or Country) 



^^ 



ft 



NAMK OF 
FATMKR 



4 



aOtAA^^ 'CC^^VVCl. 




RIRTHPI..\CK 
OF FATIIKR 
'StMt«- or Country^ 



IM 




MA1T>KM NAMH 
OI- .MOTHKR 



niRTMPI.ACK 
OF MOTHKR 
(Slate or Country > 






,U.t T wv 



CX'CrpATlON 

ft es id fit in San /'niMtisri} 



Wars . O 



^ f. 
M,>iifhs ^■■ 



/)(/!> 



TMK AHOVE STATKU I'HRSONAI. PAR TICri.ARS ARF: TRFE TO TIIK 

HKST OF MY knowm:i)()J': and BKUKK 



(Informant 



VlfVvi C\MX; 6/C\.vLUl 



(A<Mres« 



ail l)^^)i 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DK.\TH 




.11. 

(Day) 



(Year) 



I HEREBY CERTIFY, That I atteiKle<l deceased from 

H to,....Wi^ -^A 190 H 

...i'iCi 190 'v 



ivdu %l 

that I last saw hU\i\ alive on 



190 




aiuLthat death occurred, on the date stated above, at 
^^ M. The CAl'SE OV DEATH was as follows: 

Cir"V"UX<'>-CNX-*-«">-'- 



DIRATION ^- years 1 Mofi//is ^ Pays r^ Hours 



CONTRIBUTORY LA.\.ft^:i Ar.^x 



.iCir.lwCt.. 



y'ears 



f 



Afonths 



Days Hours 



DURATION 
(SIGNED) 

VLvV .a 1 TQ 

^mL INFORMATION on'y ^or Hospitals, iBstltotlons, Traiskats 



L \J. ^J)\(r1.\.w >X: M.D. 

Address) HCV A) O^rrJ^^ 



( 



SPEC ^ 
or RecMt RfsMfilts', Vnd persons dying away trom home 



Former or 

Usual Residence 

When was disease contracted, 
If not at place of deatfc ? 



Hew lonf at 

Place of Death? Days 



I'UACK OF niRIAI, OR RKMOVAI 




DATK of BiKlAL or REMOVAI, 

X 190H 



INDERTAKKR 

(Address 







A-4^V\. 



..>?-s..... 



I \r, .pF «hould be .tated EXACTLY. PHYSICIANS should 

, should be carefully supplied. ^^B .hould fc^ .t- ..g ,., Information- for per- 

in plain terms, that it may be properly classitiea. i^ 



N. B. Every Item of Information should be 

state CAUSE OF DEATH in plain te 

sons dyinft away from home should be ftiven in every instance. 



II 






Hon 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

BStP Co RtFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ranflUalth-l-No ^KV^ 




lOO'K 



Date Filed, 

dwM.vA^ JoX^vi Deputy Health OfTlcer 



Registered JVo. 



717 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "Q. S. StanOarC> ) ^ 

^ i 

:itv of ^ ^ 



^ 



lOuYv 0X(X/>xcc4.>eo. 



No, 



I ! ' 



'.|ii 



PLACE OF DEATH : — County of ''' OJTu XO-^ VCoiLCl City 
oil U\.^M St.; It Dist.;bet. IH tL and 15LIv 



) 



FULL NAME 





V-^-UA! 



.Uy^urvNi... 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^X 



COI.OR 




^rvs.L'u 



DATK OF HIRTII 



(Month) V 



15- 

(Day) 



(Year) 



\<.K 



7C 



) V<7 » » 



\| 



MoMlhs 



KS 



Ai V. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Month) 




5.0 

(Day) 



(Year) 



I HEREBY CERTIFY, That I attended (leceased from 

H. xs 190H to |xAiu... aa 190 H 



SfNr.I.R. MARKIKn. 



\vido\vf:i) or nivoRCKD A 

'Write in social clf«.iv;nation) \ iMA 



0JVvu-<L-_ 



lURTMPI.ACR 
(State or CiMintry) 



VAMK 01* 
FATHKR 



RIRTIlPT.ArK 
OI- FATIIKR 
(State or Conntry) 






I 






•< 



maidf:n namk 

nl MOTHKR 



RIRTIIPLACK 
OF MOTHKR 
(State or Country) 



OCCUPATION 



•» 



Rfsidftf in San Ftamhro ?>0 )><»'-« 



VoHffis 



Pa \s 



THK AROVK STA TKD PF.RSONAl, PARTICn.AKS ARK TRlK TO THK 

nF:sT OF MY KN^vi,Kp<;K AND iiki.if:f 



tlia't I lasf saw h.L.:*>^ alive on |vvJU^...'' .X*:^ 
and that death occtirred, on the date stated above, at 
]VI. T|ie CAl'SI*: OI' IHv^TlI was as follows: 

.9.4iiL.>vv>\,.a..^ ^ 



190 V 

11 



1)1' RATION Yeafs 



Months 



Days 



Hours 



CONTRIBUTORY UjxJL^rWL^ 




-L-O^JC 



DURATION 
(SIGNED) 



l. 



Years 




,)foNi/is Days 



Hours 



M.D. 



Vdu *^l TQoH (Address) 1 



k 



swWxSji m 



lAL INFORMATION on'Y 'or Hospitals, Institutions, Transleiits, 



or 



Recent Residents, and person ^y^nQ **'«> ''•'" ''""'*• 



Former or 

Usual Residence 

When was disease contracle*, 
If not at place of death? 



How lon^ at 

Place of Death? Days 



(Informant 






(Address .. 



3>^1 




PI ACH OF BlRIAIv^OR RF:M0VAI 



DATK of BiRiAL or REMOVAI, 

.LIaa^.....I 190H 






UNDERTAKER 3 ivjUt^LcJ^^ <^XXxJk 

....^.5.1 



(■\ddress 



\AAx.*:v\. 




N. B. Every Item of Information should be ca 

state CAUSE OF DEATH In plain term .♦.„^- 

sons dytnft away from home should be 4iven In svery instance. 



::= "--t ."4:Ar.'irr4^"S^.'.. .==r=" 






h 

* 






i i 



I 



I 



u 



,%m 



Bofinlof neaUh-KNo.n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RKFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H&PCo 



> ^- 




Registered JVo, 



Date Filed, Ux^-Owyj 1 190 'i 

i^rvcvsXtAvu Deputy Health Off] 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



cer 



Certificate ot Beatb 

( xa. S. StanDarD ) 



% 



PLACE OF DEATH:— County ofOcL^J AXJ.-n^C^C<yCity ofQaAV O^^XmXlxAtC 



e 



, IcH-KdaBt; 



( '^ r/rc*:T^"oc:te;4" HO^pVt^^^ ?"hS™^"o.VC%S ..AME^^.TC^O or STRC.T *.0 NU-BCR. ^ 



Dist; bet ^nd 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

SKX On> * COLOR 







T t 

[)\TK OF HIRTII 0(7^ |] 

J xl^ 




VW 



.i^ 



(Month) 



^1 

(Day) 



(Year) 



\<-.K 



II 



} Vii » > 



r 



Mntilhs 



Days 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

(Day) 




'i 



igo 

(Year) 



I IIRRKBY CKRTIFV, That I attended deceased from 

IQO-^-:-- 

190 -""^ 



190 



to 



that I last saw h •::"" alive on 

and that ilcath occurred, on the date stated above, at 



>I\r.i,K MARRIKI). 

\viiM»\vKn OR nivi»Ri'Kn 

Write in •iJtcial dt-niif nation) 



IMRTMIM.AOK 
(State or Country < 



NAMK OF 
FATIIKR 




RIRTIIPl.ACK 

OF FATHKR 

• State or Country) 






^^vcVL 




d 



MAIIlKN NAMK 
01 MOTHKR 



niRTiipr.ACK 

OF MOTIIKR 
(State or Country) 






OL^.^^CX.^ui 



--;7 ^I. The CAl'SH UF DUATJLI was as follows: 

^^CJ^ 1^Lvc-^:vvxv.A^.^^^^ 



DIRATION Years 

CONTRIBUTORY 



Months 



Days Hours 



.U*Vtr>\iK; J. ^i} U).XlLol/^.v-(L M.D. 



(SIGNED) 




?^l iQoS (Adilress) 
CIAL (NFORMATIONonly for Hospitals, institattoils, Translfiits, 



or Recfit Residents, and persons dying away from home 



OCCI'PATION 



Rfsiitfd in Situ I'l am !>•/•<> 



W Vrars S^ }r.mlh$ ^iiPays 



TMU ABOVE STATKI) FERSONAI. PARTIcri.ARS AKK TRlK ft) THE 
BEST OF MY KNOWI.KIX.E AND BI^IKh 



(Informant 



(Address 1151 O^LUAWLH^ 



Former w 
Usual Residence 

Wlien was disease contracted, 
If not at place of death? 




How long at t 

Place of Oeatli? > Days 



PLACE OF Br RIAL OR REMOVAI 



DATF:of BfRiAL or REMOVAI, 
..3v 190*4 



UNDERTAKER 



(Address 




Q0^WMi.^..^ry\...3.t. 



N. B. n^/^ry Item of Information should be ca 

•tate CAUSE OF DEATH In plain term ,«.».«« 

aon« dying away from home .hould be given In .very Instance. 



■"""■""""^r^i I^^hould be stated EXACTLY. PHYSICIANS should 
refuliy supplied. AGE •^''"'f JT *"' y^ -Special Information- for per- 
s that It may be properly classified, i ne ope*; 



% 



u 



t 



M 



. 



n«w 



r.l ..f Hcalth-F No. l*> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„&1> Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Registered J^o, 



719 



lUile Filed, LLuuy-^Jtt X 1^0 \ 

lt.wu lov^. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



th 



I 



PLACE OF DEATH:— County 

No. l/OutxlvAi fcch<l)vvial 

r \r Dt»Ti 
\j ir oc 



Certificate of 2)eatb 

( "d. S. StanOar^ ) 
of OOav J.\.Ou-k\x^lA/Oo City of O.CLoro JA^Wvti.ui.e>o.. 



St. 



Dist.; bet. and 



rn occu4* *w*v rnoM 

:*TM OCCOBWtO IN A 



FULL NAME 



• USUAL RESIDENCE GIVE r»CTS C*LtCO for UNDER "SPECIAL I N FORMATION" N 

mos.pVta!: Tr institution give its name instead of street and number. J 



PERSONAL AND STATISTICAL PA RTICULARS 

COI. 



1»\TK OF HIKTIl 



Cn 



^ VU JLu^- 



(Moiitli) 



IS 

(Day I 



visa.. 

(Year) 



\«-.K 



53. 



)><!».* 



s 



M.mlhs 



% 



Hovs 



>^!\'^.I.R. MARVtiKD. 
\Vn>«>\VKI> OR T>IV<»Rt*KI> 

'Writf ill HiKMat dr-^ivrtrntioti) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DK 



1 

(Day) 



(Year) 



.:ath n 

LLu-'Cv 

(Month) K 
FhRRICBY C1':RTIFY, That I attenaed deceased from 

LLla^o. 1 190 H 

^ . ..^ ,: iX^^cv \ 190^ 




^uvxX<jL 



imktiu'I.aof: 

(st.itc or Country) 



WMF <»F 

lA IMKR 



lUKTIIIM.ACK 
ni- lATHKR 
ist.itr or Country) 



MAIinCN NAMK 
<>I MOTIIKR 



ro 



VOL 



'dL*c>L^rvu n JkxJL 



JURTHPI.ACK 
ni MOTIIKR 
(Statf or Country) 



a 



Xk 190 ; to 

that I last saw h ..Ar^^^" alive on 

anilthat death occurred, on the date statett above, at 

.....S.,..M. The CAl'S^v OF Dl^ATH was as follows: 



a^v 




1 



Dl'RATION '^. Years ' Mou^s ^ Days ' Hours 

CONTR IBUTORY ' Ulvfe^.d^ 
ULllvv%vwvv».iUvA.OL loAxU^x^ Vk 

Years Mouths Days Hours 

C,iv(].tti. , 



M.D. 



WYVCC 



OCC! 



'PATION (?p 






/)<; v.« 



TIIK AHOVR STATFD PHRSONAl. rAKTlCT- l.ARS AKK TKlK TO TIIK 
IJFIST OF MY KNO\VI,f:D<.K AND HKMh-F 



(Informant 



3oL^>vQ J^Mrk "^ 



(AddresH 



no 



L Jxxc^^^'Bt 



/OLAX^ 



Dl'RATKJN j^ »<'''^ 
(SIGNED) 

l lu^ % igo"^ (Address) lpC(o — - 

SPEdlAL INFORMATION only for Hospitals, InstltytlORS, Transients, 
or Reffnt Residents, and persons dying away from home. 

How lonq at 
Wareol Deatli? Days 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



7l,ACE..Ot' niRIAUOR RKMOVAI. | DATF of HrR.AL or REMOVAL 



VAAA^MCV 



rSDHRTAKKR 



(Address 




C)/CV 



n.().bL..^i <c4.<i"\lA^. ■•'3± 



|. . ACE .hould bo .tated EXACTLY. PHYSICIANS should 
Led. AGE •''""'«'•'••' -,. -Soeclal Information'* for p.r- 



N. B.— Every Item of Information should be carefully «"PP''«J- Jt^^^^^^ classified. The "Special 
state CAUSE OF DEATH in plain terms, tha It may »« P^^P;'**'' 
sons dylnft away from home should be ftWen In every Instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,. „,-KSo..*^»'^'-Co .EFEB TO BACK Or C.RT.P.OT, FOR .N9TRUCTI0N» 

. iLut:j^ ^ I'JO'^ 



Registered JVo. 



720 



Dale Filed 

'Wcv^'L/vvM Deputy Health OfTJcc 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



p. 

\ 



II: 



: M 



Ccvtificate of Death 

PLACE OF DEATH:-County of 0^^ i^UX.>VC.4cCity of CVcv^ ^.V^CUvvc^CC 
No. Hll ^X^^.^vlK' St.; 



Dist/bct. ot 'OA^u^A^ov and : D >L4a,'tX.'>'vt ) 



^U AN^^v^L^'^t St.: V L>ist.;bct. u ^ 'va^ ^ ^v^*^ . w «ii« CI 



FULL NAME 




R ! 



sr.x 



PERSONAL AND STATISTICAL PARTICULARS^ 



i» vri. ni- HI Kin 




^ 



CC\; 



ACK 



i Month) 



(Day) 



(%'ear) 



MEDICAL CERTIFICATE OPJ^^A^TH 



DATE OF DEATH 




31.., 

(Day) 



(Year) 



r».« 



•l 



M.iMlh^ 



11 



Da V. 



«^I\«.1,K MAKKIKD 
WIDoWKI* <»K IHVoRiKD 
\\ litf in iMicial <Usi»rnatioii) 



U) 



HIKTIITM.At'K 
^^1 itr or C'Minlry) 



\ \ M F OF 

1 ATIIKK 



HikTJiri.xrH 

ni I ATIIKR 
statf or Country) 



NtMDKN NAMK 
• •I MOTMKR 



-^ A 



.1 



lUK rnPLACK 

••I MuTMKR 
fsiatf or Country) 



-I 1\ A 



A 



Ak 



O-^^irvv 




I IinRHRY CKRTIFY, That I attended deceased from 

iUh ^ -to.^ ^ ^ iqo ^ 

that I last saw h -Ch^ilive on ^s^^-^ ^90 '^ 

and that death occurred, on the date stated above, at 
" M. The CAl'SI-: OF DICATII was as follows: 

cU:U.axu^.- A,Jivfr\AJU....a^t^ xUxxU.- . .<Wvv 

DIRATION ^C^ rears Mouths Days Hours 

CONTRIIU'TORY "^ 



I 



^ 

^ 

c 





»t 



Pays 



Hours 



Dl'RATION 

(SIGNED) AJ. O, OUL/WAY^yv 



f Ad<lress) 



SPECIAL INFORMATION only for Hospitals, Institutions. Transients, 
or Rtcent Rfsldfnts, and persons dying av^ay from home. 



.!/,.;////> 



/>.n 



OCCIPATION 

KfsltWJ iv <r^>r rtiuutsfn H J- )>'M < 

Tln•Mm)VKSTATl^Dl•HKS<)^•Al.l^^RTIv•^•|,\KS AKi: IKl K 1«> 



(Informant 



/ 



\-knowij:d<".k and hkukh 



Ho\« lonq at 

Ptafeof Death? Days 



former or 
Usual Residence 

When was disease contracted, 

If not at place of death ? 

7j.ACEOFnrRIALORREMOVAl/| DATl^of H.k.a. or REMCAAI. 

'tk 190^ 



i't 



?>.51 »B. 



INDKRTAKER 

(Address 



(\ddrrss 



_. _^^^^^^^ ^— ^^^^■— ^*^"^^^^ . FVACTLY PHY8ICIAN8 should 

N. B._Bve.. Ite. of InW^.tlon .Hou.d he c«.cf«n. .uppncd ^^«^-^;,;;7;.^^^^^^^^^^^ ..Speci;. .nfor^-tion'' fo. pr- 

state CAUSE OF DEATH In plain term.. »»'"?'' "^"^ instance. 

son. dylnft away from home should he ft.ven .n every Instanc 



t« 



t+ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Moanl of lltiilth— F No. 15 "v^ 



USi V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r FiJetl f 




X l'JO\ 



Registered J^o. 



721 



^^-VA.^^ 



Deputy F' Uh Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "Q. S. Stan^acD ) 



^ 



No. 



PLACE OF DEATH: — County of ^^^CL/T^' ^ Va/wo.><MU» City of Cl/CL/>\; JAa vvxtc^ Ct 

im OXaJu St.; ^1 Dist.;bct. UC^tJu. and 'lu.^./<;U ) 

(ir ocATH occuns awav rpoM USUAL RESIDENCE Give facts called roR under "special information-* N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /. 



FULL NAME UkvLd, C|. UkoxLu 'MrAI..,l(LTvt. ' sD OLtul-i\maxi..ix, 



f 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



<?fi^ 



•V I) 



CUI.oK 



llA.U 



»\ II <>l niKTU 



lie 



\ Month 



n 



\r.K 



i t'U I . 



1 



yf.itifh'. 



/^li 



(Vcar) 



-^a 



MEDICAL CERTIFICATE OF DEATH 



I).\TE OF DKATII 



iL 



(Month) J 



(Day) 



J go \ 

(Year) 



Ai I 



^l\<.I,K MAKKIHD. 

\vri)i»\yi;i) ok DrvnkCKi) 

Writi ill MK-ial dt sii^itatioii) 



A 



niKTifPi.ArK 

state or Cou 



J A Tin: R 




MIKTHI'I.AfK 
01 I ATHKR 
•Hiato or Counlrv* 



n f 'I 1 




I II K RUBY CERTIFY, That I attended deceased from 

LU«m:v I 190S to LAaa^ 1 190 H 

that I last saw h"N-<^u. alive on "^ .^- 190 - 

and that death occurred, on the date state<l al)ove, at > • 
*vy. M. The CAl'SIC UV Dl'ATII was as follows: 

CjX4w<>A yj &*\irw X^-fr^W AJwXi^V'^iwJw^i 

,...A.<X^lLhdS:.\? 



DT RATION Vtuirs 

CONTRIIJl'TORV 



Months 



Davs 



/Fours 



^^X^r^A 



M\n»KN NAMK 
•'1 MOTIIKR 



luk rmM.ACK 

•>l MuTHKR 

• Statf or Couiitrv) 



Qlav^WlL, 



^y]i 



DOCrPATlON 



\^^^uAA) 







)\'ars 



Months 



Days 



Dl'RATIOX 

(Signed) Vj . LL' . v>cx\/.cL 

lluuQ 0. iQoH (Ad.lrcss) 5^0^ HjJcA>va^xUA^ M 



/fours 
M.D. 



SPEcJaL INF 



SPECVAL Information only for Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dying away from home. 



t^f^idfil in Siitt /'t ofii i^ro • )'»•(?;< 



}r,,„lli^ ' /><n 



TMH AHOVKSTATHI) fHRSONAI, I'AKTUII.AK.S ARK TRIK TO THH 
in:ST «)1- MY KNOWl.KDC.K AM) HKI.IHF 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



How lonq at 

Place of Death? Days 



I'l.ACK OF niKiAi. OR rf:movai. 





I>AT_F;of HiRiAh or KF:M0VAI. 
....O ....^ I90H 



INDFRTAKKR VOyVTUtO ob aXytVYX,... J^^Lft 

(AcMrL , .Ha - 5 lJi)iJ}^KCJ. 



N. R.- 



nformatlon .hould b. cnrefully supplied. AGE should be stated EXACTLY PHYSICIANS .hould 
►F DEATH in plnin term., thot it mHy be properly ci««.l«ed. The Special Information for per- 



-Every Item o? I 

•tate CAUSE OF __ ^ 

«on« dying away from homo Hhould be given in •very instance. 



WRITE PLAINLY WITH UNFADING INr^ — THIS IS A PERMANENT RECORD 



H^Minlof lUalth-l* No \% 



H/tl'Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



liegistered J^o, 



Dale riled, LLu.aMJLt 5. 100\ 

-Ltu^A^ cWy>M Deputy Health OfTlr^r 

DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 

Certificate of Beatb 

( 'a. S. StanDac& j 

) (Tvx ' . vo; City of Vi I LLuJtta) voJu 



722 



PLACE OF DEATH: — County of ' ^^"^ ' vex. 



No. 



St.; 



Dist.; bet. 



and 



(ir Oe»TM OCCURS »W«V WnOU USUAL RESIDENCE give facts called rOR under "special INrORMAXION- \ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



IL 




« 



XA.i^\.trv^% 



i.x 



PERSONAL AND STATISTICAL PARTICULARS 



:i\ 11. Ml UlRTH 



(Mouth) 



\" . K 



\0 b )>«r.< 



(I);.v 



y.'N/As 



(Year) 



A; IV 



-IN'.l.K. MAKklKI). 
WinoWKn «»R DIVORCKI) 



A inoWKn «»R DIVORCKI) \ 

\\ritr in MH'iitl (le<«it^n:«tion) j \ 

„ LvvcL 

(11 

iL^vIv 



lUK rifPI.ACK 
Mati or Crmntry^ 



NAMK OF 

» ATHKR 






MEDICAL CERTIFICATE OF DEATH 

DATK OF I>1;aTII 

M 

(Day) 



Jfonth) \ 



(Year) 



I III:RI':BY Ci:RTrFV, That I altcii(lo<l deceased from 

190 to IgO ~~~^ 

that I last saw h ^::— — ^livc on I90 " 



and that dealli occurred, on the date stated above, at 

- M. The CAISI-: OF DI^ATII was as^fqllQws: 



lUkTUIM.ArK 
'•I lATMKR 
'Matt- or Countrv* 



M\I1>i:n NAME 
01 MOTHKR 



1)1' RAT ION }'i'ars 

CONTRinrTORV 



Moui/is 



Days 



Hours 



niRTTIPT.AOK 
<»l- MOTMKR 
(Statv or CouiUrv) 



OCCTPATIOX 

Rfsiifrtf in Sail /'i iiiii isr<t " Yrm >■ 



Months 



Da r. 



THH AHOVR STATKI) PHRSONAI. PARTIOr LARS AKH TRl K TO THK 
BHST OF MY KNOWLHIX.H AM) BKMltF 



(Inf. 



miiant 



(? 



( ^«l(lress 



.VCtVNJt^ 



DURATION Years .Vofif/is Days 

(SIGNED) |.U) |ul^ 

I- UX^ i IQO '■ (Adilress) ^' 





J Jours 
M.D. 

V) 




SPECIAL INFORMATION only for Hospitals, Instilullons, Transients, 
or Recent Residents, and persons dying away from liome. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



How lonq at 
r>lareof Death? 



Days 



PI,AQE OF BURIAI, OR RKM<nAI. 



rXDHRTAKER \ O.^ J 0^ CCiUVC- 



DATK of BiRiAL or RKMOYAI, 

5 190H 




(Address 



3.0 s Ql^"*^<Y-v'^'^^ 



E OF DEATH in plain terms, that it may be properly cia««itiea. 



^' B.— Every Item 

4 State CAUSE Uh Dt A m m p 

sons dylnft away from home should be ftiven in every instance. 



i^ 



li: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



B„.n.1-f I!i'mU1»-I' ^'« i^ ^^: 



»&l»Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 










m 



Dale FiU*(l , 




X 10 0\ 

Deputy Health Officer 



Registered JS(*o, 



723 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccrtiticatc of Bcatb 

( "U. S. StanDarC^ ) 
PLACE OF DEATH: — County ofO.CX^x' '.XCC^wa^C^^City of O/O/vu JAXXa^/C^^ at 



No. 'Ki^'^^^ V! I Vv^c 



C^^-C^x 



St.; t Dist.;bct. 'll ^vtL 



(ir OCaTM OCCURS »W*V r»»OM USUAL RESIDENCE give facts called rOR UNDER SPECIAL INrORMATION" "^ 
\r DtATH OCCURRED IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



and % S A^ 

MA 
MB 








l*'M 



■!•! 






FULL NAME 



UvvLcLctLuj \> ^^ Xoitx) LittA. 



PERSONAL AND STATISTICAL PARTICULARS 
si;\ A ^ i coi.oR v 

- ' m 



W(i 



,MvCL<- 



\'\V\ •.! IIIRTH 



.\t.H 




J '»a t .1 



\ 

(I)ay> 



.!/.»»////* 



U 



(Year) 



/>*»' 



I.I M \kkiKi) 



- • I.I M \kkiKi) (^ 

uilHiWKUnK lilVMRCKn V A 

. ^^Sj a. YvcyLt 



lilK nH'I.ACK 
'State or ^.Nuintrv 



NAMK OF 

»■ > rniR 



HlKTHPl.ArK 
•»l » ATIIHR 
' st.it t or Country 



M \Il»KN NAMK 

"1 m<)Tiii;r 







MEDICAL CERTIFICATE OF DEATH 



DATE or Dl'ATH 



il 



(Monlh)A^ 



.1 

(Day) 



(Year) 



I lII'iKIiHV CMRTIFV, Tliat I atteinled <lecease<l from 
\^'i to tVvvCL .1 190 H 



G.VV.CL ■ "^'^ to tVVi 



that I last saw h'. . alive op LLu^ I 190 4 
and that death occurred, on the date stated above, at A 
' \I. The CAI'SIC or Dl^TII was as follows: 
VJ X"^^ > vcCLcvAJL ' J) AA^Ja^ 







iilRTffPLArK 
01 MOTHKR 
">VMv or Country^ 






<n CITATION 



.<kur 




Lt'iLtet 



hi: amove STATKI) PKRSONAI. rXRriCII.AKS akk tki H in THE 
IJKST OF MY KNOWl.EDC.E AND lUCIJi:!' 



L^Ajl^ 



TX'Mress 



iH 




wm 



it 



\A IrLcivAxA-A^ 



i' 



DIKATHIN' 



% 



) 'iiirs 



( SIGNED ) ^h^yyyjc>js 






Days 



Hours 



A^»"VXX.^i. 



M.D. 



LLt\-o 



.V. 



IC)0 



(Address) RlH J CX^LlAVg-^O- 



i. 



SPECliAL INFORMATION only lor Hospitals, Institutions, TranslfBls, 
or Recent Residents, and persons dyin^ away Irom home. 



Former or 
Isual Residence 

When was disease contracted, 
If not at place of death ? 



How lonq at 
Place ol Death? 



. Days 



PI ACE OH BTRIAI, OK KEM<»VAI. 

INDERTAKER ^ 'm^JyyJ^JJyJ 
(Address 5vl&bk) 



DATE of IHRIAI. or REMOVAL 

1 




N. B. 



'Wmn 



^ ItF Mhould be stated EXACTLY. PHYSICIANS should 
Every item of Information should be carefully supplied, aud s . ^ .„^j xu^ "SDecial Information" for per- 
•tatc CAUSE OF DEATH in plain terms, that it may be properly classified. The »p 
•ws dyinft away from home should be ftiven In every Instance. 



I 



.1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



„,,;,,.1nf Ilralth- »-No. i^ ^Jj^f^i^SiV Co 



R5FER TO BACK OP CERTIFICATC FOR INSTRUCTIONS 



^\ 



^i^ 



! ji 



4 



M 



)i 



!)((/(> Filed, \Jju^^C3\/\\aX X lOO'i 



Beglstered J\^o. 



724 



n 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Deatb 

( X\, S. StanDar^ ) 



^f! 



PLACE OF DEATH: — County 



of ^Aa. 



>x 



No. ^1^ (pyj-vdLx/Y^^CJL OV' ^ ^ 1 \ C I ^ I St.; 



% 



t 



City of 



.<xXXaX \XI 'OuaJkj 



(ir DCATM occuns AWAV rn^M USUAL RESIDENCE Give facts callcd for under "special information- \ 
ir OCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



MX 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.OR 




Dist.;bct. ^ 

rs CAi 
rs NA 



and 



■) 



YWU 



1 



(hiccL 



DATK <•! niKTIl 




• M.Aith) 



I 



lulcU 



\ ' ■ )■; 



\L' \ > ;■„ , . 



0>l 

(I)av> 



.}/.>» t/is 



(Vear) 



Pit \ s 



^ISC.IM. MARKIKD. 
\vn»u\VKl» OK I)[VnRt*KI> 
'Write it; MK'iiil <lt-si)fiiati<>ii) 



BIk THIM.AOK 
(Slate or Country* 






CKA/VwL 



I- A Tin: R 



HIRTHPI.ArK 
^»r lATlIKR 
'^t.tleor Country) 



MAIKKN NAMK 
<»» MOTHF.R 



I 



tURTHPI.ACR 
«>l- MoTHKR 
(Siati (If CcMintry) 



I 



^vlv/vu^vov 



<x\/y^L 



X\/cyv. 



\,'<3L>Cr^nj. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



i. 

>4nt 



1 



(Day) 



(Year) 



I IlKRiaJV CIU^TIFV, That I attrn<U-.l decoasiMl from 

.^ 190 • to IQO """" 

that I last saw h :"^ alive on "— igo-^^"^^- 



and that death occurred, on the date stated above, at 
M. The CAISH OV DlvATII was as follows 






IH' RAT ION )'ears 

CONTKIIU'TORV 



Mouths 



Days 



Hours 




) V(7 > 



yr.'utir 



Pit 



* •OCfPATlON A 

Rfsuird iv Snti r> atn isro ' 

TMK MU)VK STATKD PKRSONM, TAK' ' TKARS AKK TRIH T« > V\\\\ 
HKST OH m- KN'OWI.HDC.K AND UJKMltF 

^Informant \l f\\^ \l K \A J XNOV'^A-^'C'^^- 



fAfl.l 



ress .. 



iSHb 



<kxx\Jfi^/rL ^Cjt 



UCRATION 
(SIGNED) 



Years 



Mouths 



Days 



lA.k.iu.'^H M^ ' 






Hours 
M.D. 



Special information only for Hospitals, Institutions, Transients, 
or Rfcint RfsMfBfs, and persons dying away from home. 

iCrReidencf H"^ ^ "laJum.. .B:^ Place' or^ath ? Days 

When v»as disease contracted. 

If not at place of death ? ^^ 



IM \CH «)l- niRIAl, OR RKMOVAI, 



DATKof niRlAL or REMOVAI, 

H 190H 




IN'Dl- 



(Address 



.Lb..! (YVVvA^A^xr^ dt. 



■""""""■"""""""""""^T VA ^AGE should be stated EXACTLY. PHYSICIANS should 

nformatlon should he carefully -PP'-^' ^^^^^^^Hy classified. The "Special Information" for pT- 
►F DEATH In plain terms, that it may i>e propeny 



^' B.— Every Item of i 

•tate CAUSP OF DEATH in p 

«on» dylna away from home should be ftiven in ^yry instance 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hojinl of Henlth-F Xo. 15 ^^^^ »&f Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



NM I 




I I 




I K 



1 

II 



,^ WO'i 

Deputy Health Officer 



Registered JVo, 



785 



J)((fe Filed,. \J,^AJ)^^Y^ 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Xa. S. StanOar^ ) 
PLACE OF DEATH: — County of v^'/<X/Vu A<XA^euiCCCity of CJ/Oav AxX/wa>L;tt^ < 

No* lo I S J A\Aj\.d^ 

(ir DCATI 
ir oe 



:*TH OCCURS AWAY moM USUAL RES 
tATH OCCURRCO IN A HOSPITAL OR 



-3. ^....UA .J 

SIDENCECIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" ^ 
INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



St.; "' Dist.;bct. U\^VyvyuX/vu and J O^UTrLAJiAxdL) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS' 

COI.OR \ j\ 




VtA^, 



duy^JiX<X) 




f 



DATK OF niRTH 



VirUxA; 



1 Month* 



UJay) 



All 

(Vear) 



\<".H 



II- 

m 






I I )></>.« 5 . 



MoMtflS... 



Pll vs 



^IN«.i,K MARKIKD. 
UIDnWKI) OR I>IV<»R(*KI) 
'\Vrit«'in MK-ial chsiy^nati'm) 



BIRTHI'I.ACK 
'State or Country^ 



NAMK or 
FATHKR 



WfRTHPT.ACK 

<)!• FATMKR 

I State or Country) 



MAIDKN NAMK 
OF MOTHKR 



RtRTHPI.ACH 

OF mothf:r 

(state or Country) 



© 



d^i^^wcilx 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




(Month) T 



.1 

(Day) 



(Year) 




VO. 1.5 igo^ 



to 



I HF'RIUiY CI'RTIFV, That I attendcMl deceased from 

LL^wc<Ql...I 190 H 

that I last saw \\.^J\. alive on j|a.vU^ 3C 190 H 

and that death occurred, on the date stated above, at ^ 
LV M. The CAl'SK OF DlvATM was as follows 




SI? OF DlvAT 



ilTrV^YV OXA^ VULM1(, 



occrpATiox 






DTRATION 1 Year^'X Months i- Days \ Hours 



CONTRIBrT(^RY 




t/CXA-^cL-AA^ii . 



DURATION \ Years ^ Mouths b Days % Hours 



(SIGNED) 



%%. 




M.D. 



Rfsitffil in San /'i iiniisrn 1 I )'ritis. 



.1 A. ;////.« 



Pll 1 > 



THK AMOVE STATED J'HRSONAI. PAKTUri.AKS AR1-: TRIE To 
BEST OF MY KNOWEEDf*.F;^ND BELIEF 



THE 



(Infonnant 



WT\yV^ J-V^n^ 



^vnJaXu 



(fi 



(Afldress ^W *" 3 A^ 




Llcu\. 



\ iqoH (Address) S'S i * ^A-St C't 



X 



SPECIAL INFORMATION only lor Hospitals, InstUutlons, Transieats, 
or Rfcfnt Residents, and persons dying away from home. 



Former or 

Usual Residence 

When was disease contracted, 
If not at place of death? 



How long at 

narr of Death? Days 



I'UACE OF lURIAI, OR REMOVAL 

f"t> 





UNDERTAKER 

(Address 



%.? iJ. 




DATE of m-KiAL or REMOVAL 



lisa Qf^^ 



o» Information .hould b. carefully aupplied, AGE ahould be atated EXACTLY PHYSICIANS ahould 
E OF DEATH in plain terms, that it may be properly claasl«ed. The Special ln?ormat.on for psr- 



N. B.— Every item 

state CAUSE 

«on» dying away from home should be given in ^vcry instance. 



T 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoard of Hciilth-I" No. i^ "ft^K^ H&P Co 



WEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Ddle Filed, \L 



u^/OiUjdL % 100^ 

f\J^r^u^^^ dUL/wu Deputy Health QfTi 



Registered JVo. 



726 



cer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



ti 



Certificate of 5)eatb 



( "a. S. StanDarD ) 

J. 



PLACE OF DEATH: — County of ' '<Xo^ JA^CX^X/CUi/CfCity of '^^OL/^TU dAxX/>\/CA.<i.C C 

y V ir oci 




Oc^4vcta/ 



St.; 



Dist.; bet« and 

NroRMATION" N 
ATM OCQjLiRRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



rH OCCUM AWAY rR(^M USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL 



) 



FULL NAME *)JL« 



PERSONAL AND STATISTICAL PARTICULARS 






DM i: «H IJIKTII 



^'{L^uyxOJs 



I Month) 



10 

(Day) 



,1.11... 

(Year) 



AOK 



O (\ y.uns \ 



MoutJis . 



X\ 



Davs 



«IN<.I,H. MARKIKI). 
WfDoWKD OK DIVOROKD 
Write in uncial (IcsiKnatiun) 



niRTHPI,\CH 
'Statf or Country) 






Ux^VU' U vo a^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

Tpo\ 

(Year) 

HEREBY CERTIFY, That I attended deceased from 

lo 190 S to . J^aJ^ 190 H 

that I last saw h^V>x.alive on /^nJUjl. 31 190 H 

anci^that death occurred, on the date stated above, at * .i.s5. 





(f 



M. T 



The CAISE OP I^'iA'^'I was as follows: 

J /VvAKih>CAALftr14..^^^. 




lUKTHIM.ArK 
<)F' KATUHR 
•State or Country) 



MAIDKN NAMK 
<)!• MOTHKR 



nTRTHPI.ACR 
<»l- MOTIIKR 
(State or Country) 



OCCrPATlON 



'(hi \^ H 

A I 



nrRATION 4 Yearx ^..Monfjis - Days * Hours 

.LLIUA.rCL.'LA.'ft^ 



CONTRIIRTORY 




A' 



t\fsttie,i in Sav Ft am ism o J. )>(?>,< yfnulh^ 



diration 
(Signed) 



EC I 



Years Mojiths 

/rnj . Mll- 

TQoH (Address) 





Ddys Hours 

fr\ M.D. 

. AOM:^pi' 



Special information only for HA^plUls, institutions, Iranslfnts, 
or Recent ResMents, and (lersons dying away from home. 



/X) 



/),/ 1 ,» 



THK AHOVK STATKT) PKRSONAI. "ARTICrrARS ARK TRl E TO TlIK 
IJEST OK MY KN(nvI,KIKiE AM) IJKI,IEK 



(Informant 



UJ ryvvj . M y\. X<xvvrv<j^\-' 



(Afldress 




^ Lc . o\9 CMl|aA.ial 



Former or - « 
Usual Residence ^v 1 

When was disease contracted, 
If not at place of death ? 




How lonq at , ^ 

Place of Death? "O Days 



PUACE OK BURIA^y OR RKMOVAI, | DATE of IUrial or REMOVAI, 



'LACE OK BURIAL OR 




.'DKRTAKER "^J <V)ryA^V>wX>V; \DA.^y^ ^ 

IXCi.^ M^^ 



(Address . 



N. B. Every Item of information should be carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should 

state CAU»E OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dying away from home should be given in every instance. 



t> 



I 



n 



w\ 



•'.-r 



w 



I'i! 




'fl 



J 

* 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoard of IIcnlth-F No. i% '^^^^B&F Co 



RCFER TO BACK OF CERTiFICATg FOR INSTRUCTIONS 



Dfffe Filed, 




% 190'\ 



Registered JS/'o, 



Deputy ' ••. OfTlcer 



DEPARTMENT OF PUBLIC IIEALTH=Cify and County of San Francisco 



Certificate of H»catl) 

( tl. S. StanOar& ) 

aXy of 0/Ouru 0. 



PLACE OF DEATH: — County of ' JCUw.^ ^IXOywDu^City of ^J'Ouw 0/v(X/w>c>(la^>C) 
^No.OM. Lo (ADMi'XA.tal St.:-r-r 



Dist.; bet and 



(ir DEATH OCCUiRS AWAV FROM USUAL R C S I D E NCE Gl V t FACTS CALLED rOR UNDER "SPECIAL I N FOR MATIO N " ^ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME CX^^a: U... mv^kj^fa:^, 



-) 



sKX 



i<\ ri; ni iiiK rii 






PERSONAL AND STATISTICAL PARTICULARS 
(1^ . I COLOR' 

'^ A^\ 





I Month) 



(Uay) 



(Year) 



\«'.F, 



^ I )V«i»* a 



MEDICAL CERTIFICATE OF DEATH 
UATK OF DKATH 



(Month) Q 



I 
(Day) 



7^M 

(Year) 




that I last saw h-v' alive on 



M.tMtks 



V\ 



Jhm 



^IV^.l.K. M.XKKIKIi 
WlDoWKh UK DtVOKrKI) 
•Writtin sociiil lit-Hiirnation) 



^\ 



a^^oL>cL 



niRTIIPl.ACH 
'Matt- or Country) 



NAMK OF 
lATHKR 



inkTiii'i.ArK 

<»» I ATHKR 
^talt tn Country) 



MAIIIKN NAMK 
<»I M«>TIIKR 



e 



HfRTIIlM.ACK 
••H MOTHKR 
(statf or Country) 



(? 

\ 



KklCHV CI'RTIFY, That I attende*! deceased from 

"^^ I90H to ..... LLu^ i iQO H 

V h-v' alive on L^Aa^Ol » 190 1 

antl that death occurred, on the «late stated above, at I 
V. M. The CArSr? OI- DKATII was as follows: 

. O.^OLVCfrjVvv^; crt 'k^^JL \ty\XAJUyiXx^ jIL 

QryV^u<xJLv ,<>i:>^t-lA,A-.^^:vxA 



OCCri'ATlON 






ux 



I)UR.\TrON - Years Mouths Days 



I /ours 



CONTRIIJUTORY 



duration 
(Signed) 

LUv qi % 



Years 



IC)0 



% O' 



Mouths Days 

I) 




Hours 
M.D. 



f A<ldress) 5 I \J CXW^' 



Ma\>u^ti\i)M 



Special information only for Hospitals, Institutions, Translei 
or Recent Residents, and persons dyin^ away from liome. 



ffs. 



Former 

Usual Residence 



esidence ^ 



}r, tilths 



1 1 

*. tht I 



Tin: AnovK statfd pfrsonai. i-ar ricrr.xKs aki: trik to thk 

HHST OF MY KN0\VM:I)(".K AND WVAAV.V 
(Itiformant sJX^A.Cl'^ (k) \JU^\<JLty\f 



( \fl<lr«'S!H 



^. 



XVwXi. '>V>wVA-<,'\j 



When was disease contracted, 
if not at place of death ? 



\ 



How toRf at 



Hare of Death? 



Days 



PI^ACK. OF BIRIAI, OR Rf:moVAJ, I DATK of Hirial or REMOVAI, 

/t) 1/1 

^ I90H 



9) 



-4Xik\A/>:n.A-w>u 



u 




INDKRTAKKR ^ <xXj^XxA. ^*V. Aa..... 



(.Ad drew 



ai*!f5 



N. B. F.very Item of Infopmatlon should bs carefully supplied. AGE should bs stated EXACTLY. PHYSICIANS should 

ntatc CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per- 
sons dying away from home should be ftiven in 9\9Py instance. 




\ V 



4 




» ii 



1"! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M.,an1 of Hcalth-l' No. i% ^^^H&FCo WEFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Registered J[^o, 



728 



Dafe Filed, LU,vA'\-a^ .Qi» 190 H 

oUrw^^ • ixasu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( XX. S. StanOatO ) 
PLACE OF DEATH: — County of OcV>v 'JA.CXy>vt^uicCity of^'<XAA; J>^XL/ru<^c^C>C 
■ No. l^C VfrVyAH^^ oil 'ft\tta.^\t St.; ■? Dist.;bct. i llL and ^lib 

M occu«»JmI*v rnoM VjSUAL RESIDENCE Givt r*CTS called roR undcb "spccial information-' N 

ATM OCCUfi^O IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME ^Ouyu, d^cu^OuJ 



(IF DEATH 
IF OEA 



) 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR 



Q^J. 



LL.>vvaJx 





U) 



4 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII 



a 



I'\ I K of- HIKTII 



C3xlxfc 



'MotitW' 



13 

(Day) 



,U'i 

(Year) 



\f.K 



1 C ,-, 



fats 



10 



M..nlliy 



\% 



Da \s 



•'IM.I.K. MARklKI) 

W IlxiWKI) OK DIVOKCKI) 

Wtitr ill Mtcinl clfviifttiition) 



statt or Ciintrj) „? U ] V 

FAT.ViT" P L (? V i( I 

niKTiii'i.ArK A 

'»! lATHKR r~\ 1 1 

St,«t« or Country) V \ 



X>V>WCXAaM 



(Month) r 



I 



(Day) 



(Year) 



I IIHRI'BY CI'RTIFY, That I attemlcMl deceased from 
IrKoA; iQo4 to 0^,^^\^Cu 



I 



lc)oM 
190 '. 



1904 to 
that I last saw h <!■ >»>■ alive on Lv'L<v<Q i 
and that death fKTCurred, on the date stated al)Ove, at 
-/^Af- '^'li^* CAl'SK OF DFATH was as follows: 

J AAJl>-Ov>tXAJL^X>v \V>jJf<A>J)jf^k^^*^ 



'^ 



MMUKN NAMK 



oJ X/y\/y^^</XK. r . 



Years 



RTRTHI'I.ACK 
•»» MuTHKR 
(Statf <»r Country) 



Ql;JLruT>vojJk 



'KCri'ATlON Q^ 

Rf-iifr,! in San /'i iitti i<-fi> \^ )>(•» 



DL'RATION 3' Years ' 3fonths ^ Days " Hours 

CONTRIllUTORV I R CVxJkx<L U/V^UU^^ 

CCvxX^ L>VV<X/C.V<XlLL«r>\ « 

nr RATION 
(Signed) 

SPECI/A. Information only for Hospitals, iRstitutlons, Translfits, 
or RecfRt Rrsldents, and persons dying away Irom home. 



, ^^r - Afonths Days 
iX...NDLlAV0LLl ..™ 



f fours 
M.D. 



(Address) 



\T.>nth^ 



K 



I'MK ABOVH STATHI) I'KRSONAI. 1' \KTH T r. \ KS AK K TKIH To TH 

HKsT OF MY KNo\vij:n<;K AM) »F:i.n:F 

»"«nt vX/VV/WAwX 0\JLv/VVQ 

(0 



'^ifor 



(A<M 



resH 



bO Ccrv\AH.^JLi ^^"t 



former or How lonq at 

Usual Residence Plare oi Oeath? 

When was disease contracted, 
If not at place of death ? 



Days 



I'l.ACE OF Bl'RIAI, OR KFIMOVAI, I IIATF: of Hi kiai, or RKMoVAI, 
INl>KRrAKKR 0*^. Vjl SJxt«.>v4.t/VV 

3L^i Of>i« OULL^JttA.. 31 



(Address 



N. B. Every Item of Information should be carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH In plain terms, that It may be properly classified. The • Special Information for per- 
sons dyln^ away from home should be i^iven In svsry Instance. 



■ I 




111 

11: 

1 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



licKinl of lli-:ilth~»" No. K 



H& I' Co 



WgFER TO BACK OP CCRTinCATC FOR INSTRUCTIONS 



Jhife Filed, LLv^cjAAAt % 190 "i 

"L^vw^ lo^M^ Deputy HeaMh Officer 



Registered JSTo, *729 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of ®eatb 

( H. S. StanOarO ) 
PLACE OF DEATH: — County of 'CLT^' ' \a>VC>ULCcCity of HOL/YV <^A^Xaa^^Ul.c^ 



No. 



Ul 



JJ^^h^i ., St.; 1 Dist.: bet. d-JLL 



TVMtM and 




'J^/WXC«< ,. 

(ir DCATM ocoiins AWAY rnoM USUAL RESIDENCE Give facts called for under "special information-' \ 
IF DEATH OpCUnHEO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



-l.\ 



5 



PERSONAL AND STATISTICAL PARTICULARS 

U ...L_ 

VAXVQ. 

Monlh) K 



vulaX'CjyllhJLt V. .AjJ\jixJ^ 



I \ ri: nr mirth 




MEDICAL CERTIFICATE OF DEATH 



DATE OK 



•' DKATH A 



5- 

(Day) 



,tl4 

(Year) 



Ar.K 



So ,„„. II 



.\/it»^fy.\ 



\s 



Da IS 



^I\<'.I,K. MARKIKI), 

U IDOUKD «»K DIVORiKD 

'Writr ill MKMiil ilrsitrtiatioti) 



lUKTUfM.Al'K 
'"-^t.'itf or Country) 






NAMK OP 
FATMHK 



inkTMIM.ACK 
<>• I ATIIKR 
'Stalf or Country) 



MAIDKN NAMK 
<»»• MOTIIKR 



niKTMPI.ACK 
<>l MOTHKk 
(Statf or Country) 



OAjJLoL/vui 




(Day) 



(Year) 



q^ I HRRKBY CERTIFY, That I attemlcd deceasecl from 

.J.xlr.....L upi to WL......'it> igo*^ 

that I last saw h-t.'v alive on j|f\^rLu. lb 190 i 

ami that <lcath occurred, on the date stated above, at P vP 
X M. The CAI'SE OI' DIvATH was as follows: 

LK^.'Crru.'C, yj \.^>v^KA.tv/) 



1)1 RATION 



.}fonths .*^ Days 



^»j 




CONTRIHL'TORY X/V ^^-^'-^^-^-^-'^^^ U^O^NxtL 

4 ' 



- Hours 

L 



DURATION years 



(Signed) 



Months 



Days 



ll 



. ■ ^ .. \>-V 



XX")^vdw 



nCCrpATION 

A'^Mtfnf /;/ Sati /'i(rn< isfo I t )V,m > * 







Hours 



M.D. 



M (Address) Sioi^^xtijL^ ^.. 



SPECIAL INFORMATION only for Hospitals, Instifutions, Transknts, 
or Recent RcsMents, and persons dying away from howe. 



Month '^ 



Ihivs 



THK AMOVR STATKD PHRSONAI. I'ARTICC I,AKS ARK TRIK TO THK 
HKST OF MY KN0\VUKD(;K AND IIKI.IHF 



niiffntnant 



(\i\i\ 







Former or 
Usual Residence 

Wlien was disease contracted, 
if not at place of deatN ? 



How Ion) at 

Place of Deatli? Days 



PI,ACE OF Bl'RIAU OR RKMOVAI. I DATK of BiKtAL or REMt^VAI. 
UNDERTAKER UvX^ ^ JO ^Vl\d/Jjih. 



(Addrfss 






mmm 



IN. B.— Every Item of Information should be carefully .uppUccI. AGE should be stated EXACTLY. PHV8ICIAN8 should 
•tate CAUSE OF DEATH in plain terms, that It may be properly classified. The Special Information for per- 
sons dytn^ away from home should be ftiven in 9S9rv Instance. 




-A 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M....r.l of llralth-FNo. IS »g^K)HS:l'Co ^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'f.i 



Hi : 



I 



», 



f 




I 



••i. 



H 



'I' 

n 



/)ft/(' Filed, 




VJO'i 



Registered J\/'o.. 



730 



Deputy flcafth OfTI-cr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "Q. S. Stan^arO ) 



No, 



PLACE OF DEATH: — County 



of ^CLna» ^)\JX/>(\zu^sj^ City of Cj/Olav 0AXX/>ve4.>«U'e>t 



rnoM US< 

\f OCATH OCtUlNll^O IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET Afio 



I 



St.; I Dist.;bct. ^B^^<X_'dAA^.a^.^ and J.'^^ ) 

/ ir DEATH OCCURS 1^^ A V FROM USUAL R C S I DE NC E CI VE FACTS CALLED FOR UNDER "SPECIAL )i N FORM ATIO N 



FORMATION" '\ 
NUMBER. / 



u 



FULL NAME 



\^\ 



\W^<X/y\ni^ 




h.^^. 



■-1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

\Xlu:i Xb /^LX 

tM«>iith) ^ (Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

\U J . , .2,1., 



( 



\n)nth) h 



(Day) 



(Year) 



I 



Yfatt 



II 



M.mih" 



i J 



/>./! 



•-IN<'.l,!v MARKIKII 
WriMiWKI) OK IUVnRiKIl 
t\Vrit«- ill sficiul (lr««iKnalion) 



FUKTHPI.AOK 
^t.it»- or Cuuntryi 



N \MP OF 

t \i mi:k 



HIKTIIIM.At'K 
«>l lATIIKK 
(Slati- Df t'ouiitry^ 



MAIIiKN NAMF 
OF MOTHKR 



(? 






.^^AX: OLn^i:L>C) 



I^ HEREBY CERTIPY, That. I attended deceased from 

f^^ '>>^^ 190 '1 to |y^ '^^^^ ^9°*^ 

tliat I la«;t saw h l-L alive on ^VvUi, ?)L igoM 

and that death occurred, on the date stated above, at I U 

.. CLjr. The CArSH OF DEATH was as follows 

.'J , vJLMA/tArvJU-slA^ ■J,A 




or RAT ION " Years I Moniha ' Days * Hours 
CONTRIBUTORY 



i^crW 






HI RT HI' LACK 
ol- MOTIIKR 
fStatt or Country) 



)l\.av 



YV 



OCCIPATION 

^_^ K folded in San /'i aniisfo \ )V-<r/> 1 I .^F- 'nlhy ' 1 /'■" ' 

TMi: AHOVHSTATHD PKRSoNAI. I'ARTUMI.AR S AR K TRIK TO THK 
»FST OF MY KNOW mux; K AND HHI.I1:F 



DURATION Yt'ars Months Days 



(Signed) 



.A^4.^^VUVW 



Hours 
M.D. 



Special information only for Hospitals, Institutions, Transients, 
or RfCfnt Rrsidrnts, and persons dying away from home. 



Hoca,l TQoS (Address) HH\ 



:iAL INI 



(Informant 



J\K/^^Ol>\j6u^ \jXjJ\^ 



r\fl«lrc«»s 



b ijLA^lyjLAj LAJLIuj 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How lonfi at 

Place of Death? Days 



190H 



PI.ACK OF BIRIAU OR RKMOVAI. I I>AT^: of BlKiAr. or RKMOVAI, 

1 i0 5 




INDERTAKER 

(AcMress 




.(W.. 



N. B._Bvcry Item o? InformHtion .hould b. cnrefully Rupplied. AGE should »>« •»«*«i^E'^.?^CTLY ^"YS'J;*;^:;* •;»»"'*« 
•t-te CAUSE OF DEATH In plain term., that it m»y be properly cla«.iflcd. The Special ln?ormation for pr- 



aons dying away from home should be given in m\9ry instance. 



; 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nor.r.lnf HeHmi-l- No n "t?^ REFER TQ BACK OF CERTIFICATE FOR INaTRUCTIONS 






I' 






*' "ill! ,■! 




1!J0H 



Registered J\,''o. 



731 



/)ii/c /•'///''/, AAvX/OVA,^ X 

ift-cvv^ dU^^i Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Xl, S. StanC>nrC» i 
PLACE OF DEATH: — County of ^'<X>v IXCOVtu/tx^City of ^<Xnrv AXt vvX^l4.CX) 

St.: 3. Dist.: bet. V' "T (dhXlLL and ^ -40.^.1.1 



No. ID^'J^VvvlUj St.; ol Dist.; bet. V '^^u^J\JL^^ and ^J-^uxa.q 

(ir DCATM occuns AWAv rnoM USUAL RESIDENCE give facts callco roR under "special information" \ \ 

ir DEATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / j 

i ff 41 

FULL NAME OX^rA^ m^^.cvC::^-. 



>j;\ 



PERSONAL AND STATISTICAL PARTICULARS 

i COI. 



i» V 1 ' 'I itik I II 



^aU 



l.nti\ ft 



Month* 



X'.i-: 



"^^v r.vj.< 



(I>ay> 



.\/.>nf/n 



fV<-!ir) 



/>./! 





'"IN'.l.Iv MAKKIKI) 

W I|M>\\ KI» OK IHVoktj:i> 

(Write ill •>(M:i(i] ilroifrnatidn) 



4 



Stut. iir t'oMJitr V ' 



V \M1 (II 

I \'rin:K 



'>• I ATHHR 
'*»t.Ui or CiMiiitrvl 



MXtDKN NAMl- 
«»» MUTHKR 



•MkTHPI.ACE 
(Mate or Country^ 










MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII A j 

Wlu sl. 

(Mlmth) \ (Day) 



(Year) 



I m;Ri:BY CHRTIFV, That I attemleil deceased from 

1^^^ >90 to jk^XlJL 3.1 K^H 

tliat I last saw h -L. i ; . alive on V^^ '^ '-^ KjO ' 

ami that (Itath occurred, on the date stated ahove, at ^MTJ^^X 
lil.M. The CAlSIv Ol* DI-ATH^vas as follows: 

U <uUrv^XpA; ^..OUUX>JX Crt tLi. jfc.r:yxvt. 



.JLkjUnJcaaJU- 



Ihy 



J/ours 







La\ 



Viaiir 



^trV4-. 



OCCrPATlON j^ 

A^u'ifrif in S tni Ftntnisfo ^^ Yrai _^_____— ^ 

MK AHOVK STATKI) pyRSOXAI. PAR TICIKARS ARK TRIK TO THH 
HhST OK MY KNOW m: DC, p: AM) BKI.IKF 



nr RATION I )V<7;'5 *" Mouths " /^av? 
( SIGNED ) VD . JV. V'^'^^^tlry 



rVX 



UUvCtl TQoH (Address) 5H d.AA ttc/. 



'ECTALlN 



Hours 
M.D. 

It.. 



SPECfAL Information «n'y fo*^ Hospitals, institutions, Transients, 
or Recent Residents, and persons dying a*ay from home. 



Mont In 



/Vi. 



Onforniaiit 



Uftd 



'W 

llH 




Former or 
Usual Residence 

When was disease contracted, 
if not at place of death ? 



How lonq at 
Place of Death? 



Days 



PI,ACK OH niRIAL OR REMOVAL | DATKof BiRiAi. or RKMOVAI. 



.^-VU^LX^CH^^ 




3L. 



190H 



UNDERTAKKR 

(Address 






lA/VwYV 



vL. 



•tate CAUSE OF DEATH in plain terms, that it may be properly Uassitica. i ne p^ 
«^n« dying aw«y from homo should be given in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noar.l of ii.;.!th » vo i.»^^^H«crro REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'vkM 



\\h\ 










Diilr Filed , \AV\Xl\A^ X 

i ^ 



10 0\ 



Registered J\,''o. 



732 



O^A^Aj) \tA>ii, Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( "a. S. StanC>ar& ) 



VJ 



PLACE OF DEATH: — County of *^ ■<X>V' 1 Va W^^A^C^ City of '""Jct/Tu vJAXV'>vtAA Ci 
<No. ^1 n -D^UOLVxt' St.; 4 Dist.;bct. T t/K) and lUr. 

(ir oCAtV orcuPS AWAV rmom USUAL RESIDENCE give facts called for under "special information- N 
ir Dt)»TM OCCUNNCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



s| \ 



\>\ 



PERSONAL AND STATISTICAL PARTICULARS 
■\\ ^ I COi.oR 



UU>yxIm.U 



^A\y\xJL.<i.t. J . 



• ' c»vcJLt 



Ic.Lt. 



IKlll , 



< Month) 



A'.l 



(oO ),„. 



5.0 

tDayi 



M.tHfkl 



(Vt-ar) 



11 



/)</ » . 



wiiMiwin OK nivoRTKi* 

(Writ' '<• V V-,:,; (Icsiirnnliuii) 



(Slatf ur *N>iintr>* 



XAMl- MI 

I' \ nil k 



I 



lu 



^{X^-uO" 



I] 



X>V'^^ vex . vt 



\ 



RlRTHiM.ArK n . \ 

<>»•' » vriiKR n J 

tSlali or Country) ^ j[i 



MAll»KN NAMF 
OK MOTHKR 



HIKTmM,A('K 

pK mothkr' 

(Statt or Country) 



a 



OxX'Vw.^ola 



MEDICAL CERTIFICATE OF DEATH 

DATK HI I)i:ATn I 

fNfontliM lUay> 

I IIi:Ki;r.V CI-RTII'V. Tliat I attcti<loil lUivasctl frf)iii 

— to 



IQO 
1 Year I 



I9O 



190 



tliat I last saw h alive on 

atnl that iloath occurred, mi tlie «latc stated above, at - 
M. The CAl'SH Ol" DliATII was as follows: 



DIKATION Years 

CONTRIIU'TORV 



Months 



Days 



Hours 







yr.„itii< 



' ] XK/\'\xAXy\M 

^^^\„yV^'^- >^TATKn PHRSi^XAI. 1V\RTIC|- J. \KS ARK TRCK 

"hsroF MY kn<>\vi,ki)<;k and bhi.ii:f 

(Informant Vj . C3/tuy 



n,n 



Tit rnK 



< \<h\ 



rv'i'i 




1)1' RATION Y''JfS Months Pays Hours 

(SIGNED) Lt^'C^^X^; I i^ IX '^-»iXQ^^n.<l. M.D. 

iLul Q :^ TooH (Address) UV^^xi^A UjiuV- 

cJlAL INFORMATION only tor Hospitals, Institutions, Iransicnts, 



or Recent Residents, and persons dving dway from hotiie. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at pla«eof death? 



How lon(| at 
Place of Death? 



Oavs 






(Adtlrt'ss 



\fTUxCLA> 



■«M|i«i 



M -^ FXACTLY. PHYSICIANS should 

• ^ E^ei-y Item o? Information should be cnrefully nupplied. AGE •hould bo • ta e .. .^J information" for p«r- 

•tate CAUSE OF DEATH In plain term., that It may be properly claaslfied. ne pc 
•«n« dylnft away from homo should be ftlven In ovory Instance. 



•i 

} 
1 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nnnrd of Health r No. .. 1^^^ H.".!' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.1 ' 



Date Filed, 




X 190\ 



Registered J^o. 



^ 



I 

I 



AH4 Deputy Health Offleer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( tn. S. StanOate ) 



PLACE OF DEATH: 



— County of 0/CX/vu V<X'>vcx4/CoGty ofCI/CLAv i )\JXj\yj^UiAl.i, 



NoS^t 




CHlkAi 



O-l. 



St,; — Dist.; bet. 



-and 



/ ir dcaiIh occurs *\*av from USUAL RESIDENCE Give facts callcd for under "special information- \ 

V \r MjATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

Xi 



I 



COI.OR 



DATK OF HIRTH 




^xxaMjr ...d.l\.^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(Month) 



(Day) 



(Year) 



Ar.K 



...I V. Yeatf 



.\/n>iihs Dav's 




TQO \ 
(Ytrnr) 



^INi'.I.K. MARRIRn. 

U IIHlWKn OR DIVORIKO 

(Write in Mx-ial (Icsijfiiation) 



kfrthpi.acf: 

(Stati- or Conntry) 



NAMK OI- 
FATin:R 



vJ.at 






^.A^ 



cJk \i nxAjvl vl-v^ 



I HRREBY CERTIFY, That I attended deceased from 

H^^-'vvX i5 190 S to C.U.1UX.4 190 S 

that I last saw h.«^*L^ alive on LLccO I 190 H 

and that death fx:curred, on the date <*tated above, at \ I 
LL M. The CAUSE OF DJ'ATII was as follows: 



frVOL/Xt. 



WIRTHPI.ACK 

OF FATHKR A A 

(State or Con ntry) Vj I 



DURATION Years 

CQNTRIHUTORY 




Mouths Days X Hou 




rs 



MAII)F:n NAMK 
*)F MOTHKR 



nTRTHPr.ACR 
OF MOTIIKR 
(State or Conntry) 






DURATION Years 



Months 



^ rXN A ^''^^ Hours 

4 



OCCUPATION 



Resided in Sa» Fianrisen 



) ></ 1 s 



yfonths '' Da 1 > 



THF: above STATKP PKRSONAI. PAKTIOn.ARS AR1-: TRIK TO THK 

bp:st of mv knowi,k»<;k and hh:mf:f 



(SIGNED) 

i ALv,a i TQoH (Address) 

SPEci'AL INFORMATION only for 
or Recent Residents, and persons dying away from home. 

Former or "^ 

Usual Residence X^.aKA/V>\>6S^ 

When was disease contracted, n 

If not at ^iareof death? ^VVANth^YUAX 



V ^JX'VCUi M.D. 

Hospitals, InstiiytioRs. Traislwifs, 



el R«wlMf4t 
<XLpUfe»f De^tk? 



(Iiifoimant 




I. 




(Ad.lreHS y 7 U/OLajU-CUx IXLoL'"VVNJx1<L Lc 



ri«\CE OF niRIAU OK KF310VAI. 



1 



I :ni)f:rtakkr 

(Address 




4 

QfYuXlut. it.. 



N. B. Every item of informatJon should be carefully nuppiied. AGE »hould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for psr- 
sons dyin^ away from home should be 4iven in every instance. 



ft • 



I 



-• ,! 



.-t. 
%' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hn;.nl..nuMitli--KNo. K^^^^B&I'Co REFER TO BACK OF CERTIFICATE FOR IN3TRgCTION3 




X WO'i 

Deputy Heafth Officer 



Registered JVo, 



734 



Date Filed, 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



fNo. 



Certtflcate of Beatb 

( "CI. S. Stan5ar0 ) 

Jj <^ SI 

PLACE OF DEATH: — County of ^'<X/>v JXOL/TX^^ud/CCity of^M 
S IH ^ CrWuU, St: 1 1 Dist.; bet ll tL and M iL 



^ 



'yOL/>\; ^ >yuOuw.<ixA/t<<x 



(\r DEATH OCCURS AtMAV FROM USUAL R E S I DE NC E Gl VC FACTS CALLED FOR UNDER "SRECIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



ILLL^JLuX/vry. 



PERSONAL AND STATISTICAL PARTICULARS 



DATK OK niRTH 



(Month) 



n 

(Day) 



r It C: . 

(Year) 



AOK 



l^ y,-ats s) MoN/As 1.^ ^. Days 




^ ■ I 

.sJJLuxLUj 



V. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




(ivft>nth) 




(Day) 



(Year) 



SIN<.I.K. MARKIKI). 
WIDOWKD OR DIVORTKr) 
(Write ill social (leKii^natioii) 



OA^voul 



BTRTHPr,AOH 
(State or Country) 



NAME OF 
FATHKR 



a 



niRTun.ACE 

OF l-ATHER 
•State or Country) 



MAIDEN NAME 
OK MOTHER 



niRTHPI.ACR 
OK MOTHER 
(State or Country) 



^ I. I 



I HEREBY CERTIFY, That I attended deceased from 

■'^■'^ 190 H to ^Ka.JU.i..3.1 190 H 

that I last saw h A^»> * alive on Hf\A.iAA_ . .?>0 190 H 

and that <leath occurred, on the date stated above, at 
CV M. The CAUSE OF DEATH was as follows: 



. vXX^vCV>v*-K>vciu frfc- rjtt^rvvo^^ 



.^.. 



DURATION 1 Vears t Afonths ^ Days * f/ours 
CONTRIIIUTORY .>l.y\^CXAyCLA/^»(>:iuu(U5 



1)1' RATION ^■■- Years ^^Motiths ' Days ' Hours 
(SIGNED) ^A). It. JUvoJLjIA^^ M.D. 



h 



^ J jUvvwcl/wu 



OCCUPATION 



%<x^cx/vvdL "^-N^ou.^ JU^aiuA, 



Residfii in Sa J Fra nrisro %X y^"*"' * .y/o„f/is^^_n<lvi 




U iqoH ( 



Address) t I ?> OAjutti/v ol 



SPECiAL INFORMATION only for Hospitals, Institutions, Transients, 
or Rfcrnt Residents, and persons dying away from lionie. 



THE ABOVE STATED PKRSONAI. PARTIOrF.AKS ARE TRIE TO THE 
BEST OK MY KNOWIj:n<iE AND BEMEF 



(Informant 



(Address 




^L^uj)..."a: 



Former vr 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



Now l«Rf at 

Mace if Deatk? Bavs 



PLACE OK BKRIAI. OR REMOVAL 



MtJ 



i 



DATE of BiRiAL or REMOVAL 
•^ I90H 



UNDERTAKER ot • OaJK^J ^M. La 



(Address 



N. B.— Every Item oi information should be carefully supplied. AGE should "^^ •^-^'il^E'^.^CTLY ^"YS'CIANS .hould 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special information for psr- 
•ons dyinft away from home should be ftiven in svery Instance. 



I( 



i!^ 



1 



1 I 



•Hi 
4 



I • 

5 



:l 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i?„:,nl(.rHia1th-FVo if *|^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



V* 



.-ct X. 



190 'i 



Registered JVo. 



735 



Deputy Health QfTlcer 



Date Filed, 

DEPARTMENT OFVUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( X3. S. StanOarD ) 

»unty of ^rOLTsj vLVtXrvaA^A^iCiCity of ''"^'^^^'^^ J A/CX/W/CvA-Ct 
(No* ^f^*C> 'dbAvcLL St.; X Dist.;bct.W 0/a\hxlL and "iJXXX^ll, 

(IF OcAtH OCCUnS away from USUAL RESIDENCE give facts CALLCD for under "special INFORMATION" N K 

IF 9EATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J 



PLACE OF DEATH:— Cot 




FULL NAME 




aJJL^Uu. 



PERSONAL AND STATISTICAL PARTICULARS 
«KX A^ K I COI.OR 



I>ATK o|- ItlKTU 







4- 



MEDICAL CERTIFICATE OF DEATH 



(M^nth) 



(Day) 



, IS 5 .. 

(Vear) 



AC.K 



/I \ Yfats 1 



Months 



X 



Pa vs 



SJNT.I.R. MARKIKD. 
WIDOWKI) OR DIVOkrHI) 
(Writf in s<x-i.Tl (lesijfuation) 



BrRTHPI.ACK 

(State or Country) 



NAMK OF 
FATMKR 







rs 



^^.1 

(Day) 



(Year) 



I HEREBY CERTIFY, That I attended deceased from ' 
— 190 to 



190 



that I last saw h ■■ alive on 190 

an«l that death occurred, on the date stated above, at 



M. The CAISK OF DEATH was as follows: 



CnA^r^A-vc. \Rj^vvsj^^s^ 



RIRTHPI.ACK 
OF FATIIKR 
(State or Country) 



MAIDKN NAMK 
OF MOTHKR 



VLOIOl/YV 

li L ' 

LVW TV YV (H. ij^Tu 



Dr RATION Years 

CONTRIHl'TORY 



Monihs 



Days 



Hours 



niRTH PLACE 
Ol- MOTIIKR 
(State or Country) 



OCCUPATION (^ ~! H^ Jf 

Rfsidfil in San Francisfo J*. C )><;/ 



DURATION Years ^Fouths Days Hours 

( SIGNED ) Lcr\xjvuuv ,1.>Jj.uJ-1jlLcx/>u1 M.D. 

LLu^a^v loo^^ (Address) V<A.lrYU?L'i UXiA.><i:-.. 



A, 



SPECIIaL information only for Hospitals, insmutlons, Transicits, 
or Recent Residents, and persons dying away from home. 



llSVsMence 3lH M l^adA^MrYvUAHtlTaff of Deat*? 



Months 



Dav!' 



THK AHOVE STATKD PKRSONAU PAR TICFI-ARS ARK TRIK To THH 
BEST OF MY KNOWUKDC.K AND HKIJKF 



(Informant. 



(AdflreM .. 



%.% 



/CL/vvQjL/Vw 



gLiHta^HSt 



Usual Residence 

When was disease contracted, 
If not at place of death ? 



Days 



PLACE OF BIRIAI. OR REMOVAL | DATE of lU'RiAL or REMOVAL 

LAavq. 3 




UNDERTAKER NkXA-V^JtOMlV OAJx/W H VX 

(Achlrels llH^^Ld^-t. Ot 



I90H 



o. indorsation .hould be carc.u... supplied. AGB .hould XT'y^^^sl'^.^ .n^o7nfJ.';L«"Vr';:r' 
E OF DEATH In plain term., that It may be properly classified. The Special Information Tor p«r 



IN. B.^— Every item 
state CAU8 
sons dying away from home should be given in every instance. 



4 



i' 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HmmkI ..f lU'filtll — FNo. n •<^ay^]>&i'Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 




Dafe Filed, lOAAXVUurt X 100'\ 

i \ 



Registered JVo. 



736 



Avu Deputy Health Officer 

DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 






rNa 



PLACE OF DEATH: — County 

, 111 J.rtvvd. Uam. 



Certificate of H)eatb 

( TX. S. StanDarD ) 

I DisUhct LcJkx and La,AaX 



St 



., - Dist., ,^ 

/ ir ocATM occuns *w«v rmoH USUAL RESIDENCE give facts callco ron under "special iNroBMATioN \ l\ 

V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. / V 



t^AXLO.) 



FULL NAME 




^ % 



<\ACiCY\4XJ.\ 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATII 



DATK OF IIIRTH 



S 



t Month* 



IS 

(Usiy) 



(Year) 



AC.K 



bl )V,M.v 1 



lAiM///.* 



IX 



Ai I . 



SINr.l.R. MARKIKD. 

\vriM»\vKi) OK iMvoRCKn 

(Writt in s<K'inl dcsitf nation) 



OxlhOuXuXm. l). O.rL 



BIRTH PI.AOK 
'State or Country) 



(Mi 



aaXu 

Lth) I 



n 



(Day) 



(Year) 




I IirCRHBY CIvRTIFV, That I attcudtMl (leceased from 



>XX 11 igoH 



IqO S 
that I last saw hi. > ^ ^ alive on )jfVAwM^ Al up ^ 
ami that death occurred, on the date stated above, at "^ 




M. The CArSK OF DICATH was as follows: 









ty^xxxAj 



BIRTHPLACE 
OF FATHER 
(State or Countrj*) 



MAIDEN NAME 
OF MOTHER 






VOL 




DURATION * }'ears ^^ MoNi/is ' Days ' Hours 



CONTRIBUTORY ■;"• 



DURATION 



Years 



HIRTHPLACE 
OF MOTHER 
(State t)r Country) 



OCCUPATION 

A' 



LLu^tjinXL^>vcio alL 

'rsiiinf in Sau Fiitnnsm H\ )V,j>s .}r.>iif/is 




Months Days 

( Signed ) lt./cu.uixn\ Uj. ' jA./Yyv/wv/e!y>c^ 



I 



1 lOoH (Address) ^^ I 



/lours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying anay from fiome. 



I\t rf 



THE ABOVE STATKO PHRSOXAI. P AKTICn.ARS ARE TRIE TO THE 
BEST OF MY KNDWI.KIKiE AND BKMEF 



(Informant 



SI 




(Address 



\X\^ \k± U^m. 



Former or 

Usual Residence 

When was disease confracW, 
If not at place of death ? 



How loRf at 

Place of Death? Days 



PI. ACE OF BIRIAI, OR REMOVAL 



DATE of BiKiAi. or REMOVAL 




l-NDHRTAKER LhJXUl V^'t.|^^^ ^^U.. 

(Address IHX^ ^^O^l-cU/VV JkxII CLv^. 



» .. It -1 ACF .Hnuld ha Stated EXACTLY. PHYSICIANS should 

N. B.— Every item of Information should be carefully supplied ^^^^^^^J^/.^^^Vf^^^^ Information" for pr- 

state CAUSE OF DEATH In plain terms, that it may be properly classmea. nc p^ 
sons dyinft away from home should be ftiven in every instance. 






111 



l« 



J 



i' '.* 



■>> 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'xvinl of Hoalth— K No. 15 "S^: 



B& I* Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date Filed, 




lOO'i 



Registered J^o. 



Deputy Health OfTicer 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



Certificate of Beatb 

( Xl. S. Stan&arD ) 

of O/tX^yj O.\,a>\Cv4C0 City of ^^ 



PLACE OF DEATH: — County 



01^ 



/tXTV; 0.\,Ct >\Cv4CC City of ^)cuy\} AXX/>x^Ca^ C <. 



iVMUSt. 



Dist; bet. and 



f / ir OC*TH PCCUHS|*W*V FftOM USUAL RESIDENCE GIVE MCTS called row UNDER "SFECIAL INrORMATIOH" "\ 
!] V If DEATH OCCURReO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



^llcjl 



DATK OF III R Til 



(M 






U).Lu 




.^L.Cm.X'.. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 



(Day) 



/S^a 

(Vear) 



ACR 



Si 



J 't'O t s 



Ik 



MoMlhs .<?> M. A/.i.' 



SIN<*.I.K. MARK if: D. 
\Vinn\VF:i) <»R DIVoRCFtn 
• Write in scxMal dtsij^ nation) 




niRTHIM.ACK 
(State or Country) 



VAMK OF 

fathf:r 



RIRTIfPI.ACK 
OF FATHKR 
(Stale or Country) 



maidf:^ namf: 
of mother 



a 



(h 



,^/^^\<x 



,u 



>ViA,n 






' df:ath a ij 
^<uJiu 3.1 /poH 

j|<<onth)/f (Day) (Year) 

I HKRHBY CHRTIF'^V, That I attended deceased from 

MX/CXA; l.0 190H to WW ^^ 190 H 

that I last saw li^>>^ alive on J^^H- *^^ 190 H 

an<l that death occurred, on the <late stated above, at **' \ . 
U.M. The CAl'SI': C)l< DI^ATII was as follows: 

4 



OX/^vc 




Cjju>-cdLx/> 



yjJuJtJr-O; vXcL>ibv/CLdLt 



D r R A T I ( ) N ) 't'ars X Months 3* Days Hon rs 
CONTRIHUTORV 



'•••*#^*«a*»**«i 



ur RATION Years Mouths Days Hours 

U). \>. C^JLol/^v....... M.D. 



(SIGNED) 



RIRTHPI.ACK 

<JF MornF:R 

(State or Country) 






) V'<f » 



Months 



Pax 



OCCUPATION 

Rfsidrd in San Francisfo _^___»_— ^^^— — ^^ 

THF: AROVF: STATKD F'HKSONAL IVXKTIcrLAKS AKK TKIK To TMK 
BKST OF MY S.^0\VI,KI)<.F: AND imuKF . 

(Informant 



(.XddreM 






,V^W>flL.J 



UAVQ ^ iq 

SPEdllAL IN 



qoH (Address) 



^ J FORMATION only (or Hospitals, iRstitutloRS, Traisifits, 

or Recent Residents', and persons dying away from home. 

How loRf at 

Ptarcff Deatk? Days 



Former or 
Usual Residence 

When was disease confracted. 
If not at pl«ice of death ? 



I'J,ACK OF mklAI. t)R RKMnV.AI. I l>ATK<*f IH kiai. or RKMOVAI« 
rNDKRTAKKR AlJ-V^ ^ OVJ <MVtX^ 



(A(MreM 



jiaaa- i°^ -til! i.l 



i9oH 



'•««•«•>• »*»*4«**-»* 



- .. ,, , .pp -hnuld b« •tated EXACTLY. PHY8ICIAN8 should 

N. B. V^.f^ry Item of lnform«tion .hould be carefully |iuppllecl. AGE f ""'^ JT •*""^he •'Spccl.! Information" for per- 

.—/cAIISF OF DEATH In plain term., that It may be properly Jaa.lfled. The »p«cia. p- 



state CAUSE OF DEATH in pi 

aona dying away from home ahould be given In every Instance. 



■ I t 



t 



f 



jk *' 





\' 



I I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoanl of Health— F No. i% 



hSi.y Co 



REFER TO BACK OP CERTIPICATi; FOR INSTRUCTIONS 




.<^WCVO 



J^ lOO'i 

^ Deputy Health Officer 



Registered J^o, 738 



Date Filed, 

1 
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( TH. S. StanDarC> ) 



^ % 



PLACE OF DEATH: — County of HourVj *varu^U/C{City of ^/CL^w \)7UXax/C.a^<ii:,>Cx 



(fio. 



utuV\^i 



M,v-^vlu y^'N^lvv. 




.la I 



St. 



Dist.: bet. 



and 



(ir Dr*TM occun«ir*w*v from'usUAL RESIDENCE Give facts called for undkr "special information" '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



^^X/yy.xXJ^ 



) ChiiLL. 



SKX 



DATK OF BIRTH 



PERSONAL AND STATISTICAL PARTICULARS 

OfYlocL l'"""lDld. 



(Month) 



(Day) 



(Year) 



AGK 



ct 



it 



MEDICAL CERTIFICATE OF DEATH 




3i 

(Day) 



(Year) 



I,HERKBY CICRTIFY, That I atte!i(le«l «leceasetl from 

ab 190H. to n^uJlu.....3 1 190 \ 




b 5" Yi-ats f' ..Months .fr Pays 



SINC.I.K. MAKKIHD. 

\vriM>\vKr> OR orvitRCKn 

(Write ill sfxrial (Jesij^natimi) 



HIRTHPI.ACR 
'State or Country) 



NAMK OF 
FATHKR 



niRTHPI.ACK 
OF FATHKR 
(State or Country) 



MAn>HN NAMK 
OF MOTHKR 




niRTHPLACK 
OF MOTHER 
(State or Country) 



occup.vrioN 



^(?. 







that I last saw h ...^ »>v.alive on ^^Kj^^ ^ I 



^|vaJ^ 'h{ 190 n 

atul that death occurred, on the date stated al)ove, at I 
tL M. The CAl'Sr: OP DHATII was as folJows: 

M VVAJL-fr-^CLN-^iAjLv^ 

..O-l/WA.VsJa^. „ 




DURATION 
CONTRIBUTORY 



Years Months 



Days 



Hours 



V 



Rfsidrti ill Sail /'laiirisYO 



duration 
(Signed) 



«, 



rears 




( 



^ Months Days Hours 

. lvD<XhJL M.D. 

Cdu H U) fO CHi^xt 



Address) VXJu H ' 
\TION only for No^tais, 



^FECIAL INFORMATIO 

or RecMl ResMeiits. and persons dyiiig d*dy from home. 



W y,-ai< 



}r,>,itiis 



Ihn 



THF: above STXTKD PKRSONAI. PARTICrr.ARS ARK TRFK To THK 
BEST OF MY KNOWI.KIX.K AND BKMKF 

(Informant UJ (» V . V A. ^^JXa^aT^^^^ ■' 

(X,Mros« Lct^°^^ JbCMav^lxvi 



Former or 
Usual Rrsidencf 

When was disease contracted. 
If not at place of death ? 



1 1 HI MFlv^-^^-^COx^nyearDeath? S. 



Iistltuttons, Traiisleiits, 
Mow loif at 



Days 



PI.ACK OF HIRIAI, OR RK-MnVAI. I UATK of BlRIAl. or REMOVAL 
r.NDKRTAKKR JU_UU, ^ h 



(Address 






flUYV 



« \ ., „ . .pe .K„„id ha stated EXACTLY. PHYSICIANS should 

of Information should be carefully -UPP''^?- Jt^^J^^Z^.^^^^^^ ♦Spccl.l Information" for pr- 

E OF DEATH In plain terms, that It may be properly ciassmea. nc ^^ 



N. B.-^^Every Item 

state CAUSE _. __ , 

sons dylnft away from homo should be ftlven In svsry Instance. 




4i 



II 






nonnlof Htaltli— K No. n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

WCPgR TO BAC*^ OF CERTIFICATE FOR INSTRUCTIONS 

739 



n&j'Co 



190'\ 



Registered JVo. 



Dale Filed, .iLLVQy'-va^ ^. 

i^rvul^XJvMj Deputy Health Officer 

DEPARTMENT OF PUBLIC flEALTH=City and County of San Francisco 



Certificate of ©eatb 

( "a. S. StanDarD ) 






CUV\j jAcl^^vca^^cc 



PLACE OF DEATH: — County o{Oa>V OyVa 

" r."o;•:T°H"occ^•fc;^.''°to".^rT•^ :"n"?u" °n o.vc .ts name ..stc*o or .t.^ct *no NUM.r«. 



( 



) 



=) 



FULL NAME -tCLtvr>U.T<xcX VWiu?- 




PERSONAL AND STATISTICAL PARTICULARS 

ixt 



DATK OI lURTII 



(Mouth) 



(Day) 



(Vear) 



ac;k 



years 



S V. 



nil lis 



XI 



Pa vs 



SINC.I.K. \fARKlKn. 

\vii>«>\vKn OR nivoKiKO 

(Write ill social <lesiKnatiou) 



niKTMPI.AOK 

(State or Country) 



A 






^ 



NAMR OI' 
KATIIKR 



niRTll PLACE 
OF FATHKR 
(State or Country) 



MAIDKN NAVIK 
OF MOTIIKR 






v<rwi^:itv_^ 



RIRTHPLACK 
OF MOTHHR 
(State or Country) 



OCCUPATION 

Rfsidfd ill San Fni>r< isff "" y^C 



,., 5" Afo„l/i< X ''" 



\s 



THKAHOVESTATKDPKRSONAI.PARTIOl^LARSARK TRIK TO TIIK 
BKSTOK^O^^^Kr^^^ 

(inronnant Vj R . 3. Vl TOxU^^ivoXJO 

i>JUU-rt.(r\JL al 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 




I llURl-nY CIvRTIFY, That I attendca deceased from 

QOXOL^v 1 190S to V 1^^ ^-^ '90 H 

that I last saw h .A^>^% alive on |^^^ ^^ '^0 1 

and that death occurred, on the date stated al)ove, at 1 
CI M The CAl'SH OI' DIvATII was as follows: 

"o -OL^oX^./ft t/>^cA.XA.»Xv/) 



DURATION years 

CONTRIIU'TORY 



Mouths 



I 



Days 



Hours 



DURATION 
(SIGNED) 



Years Mouths He 



(Iaa O 1 TooH (Address) as 00 
zilKi. IN 



Pays Hours 
M.D. 



SPECN\L INFORMATION «nly for Hospitals, listltytlons, TranslfBts, 
or Recent Residents, and persons dying a»>ay from h««e. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 

Place of Death? Hays 



PL.VCKOF BIRIAUOR RKMOVAI, DATKof lU RIAL or REMOVAI. 



a 



(Address 



Uoo 



v% 






rN-I.KRTAKKR ".JUJLUl V "^^^V 



- |j K- t t d EXACTLY PHYSICIANS should 

N. B.— Every ...n. o. .n.o.n...l.n .hou.d b. c«..M.x .upp...-. ;«^;;;"r..w,.V 'tH. "Specl.. .n»orm...o«" to- p.,- 

/-»ii«fr OF DFATH In plain term., that it may ne p i* ^ 



:r-r/.^^r .~™ -: :;«.- .. ..«„ .-.-«. 



i 



m 



Fvk: 



P 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

II ...r.n.f i!r.ith-l*N'o ,.^S^H&i'Co REFER TO BACK OP CERTIFICATt FOR INSTRU CTIONS 



! 

I 



Date Filed, 




190^ 



Registered J^o. 



740 



\ 






Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( "a. S. Stan^ar^ ) 

PLACE OF DEATH: — County of CJ/OL/Vu J.^^w^U^C^City of O.Oav A.<X/>VCvA,Cc 

No. loss lb CH^^OLX^i^-. SU H Dist.;bct. B XL and lolk ) 

^"^ / ,r oc*TH occu., *w.x mo. USUAL RESIDENCE o.vr;*cTs c*tj^co -« "« J, ^'"C..^ --;--;-' ) 

V ir OC*TM OCCUHRCO in a hospital or institution give its name instead or STREET AND NUMBER. y 

m L>crk^ 



FULL NAME 




\xvrvv 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR 



(!>uL 



DATK OF HIRTH 





MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



(Day) 



(Year) 



Ar.R 



vl V )t'ais 



Months 



11 



Pa vs 



STNT.M?. MARRTKn. 

winowKi) OR nivoRTKn 

iWriteiii social designation) 



niRTHPI.ACK 
(State or Country) 



4). 



hv^ 



\^jlA. 



NAMK OF 
FATHKR 



BIRTHPLACE 
OF FATHER 
(State or Conntry) 



MAIOHN NAME 
OF MOTHER 



BIRTHPLACE 
OF MOTHER 
(State or Country) 






i) 



XK/y^"^^^ 



^ 



OCCUPATION (V\/\ P «U 

Resided h, San Francisro ^S Years J^ .^/""fi^ ' 



Pii ) 



THE ABOVE STATED PERSONAL I'ARTK^V LARS ARE TRIE TO THE 
BEST OF MY KNOWLEDGE AND HhLIEH 



(Informant 



(Address . 






105S 



.01. 



(Month) 



1 



(Day) 



(Year) 




I HKRICBY CICRTIFY, That I attendctl deceased from 

Xb 190H to LU-v<v '^ 190 H 

that I last saw h -V > >^alive on \A.W:a I 190 > 
and that death occurred, on the date stated aliove, at o 
LL M. Tlu' CAl'Slv OF DHATH was as follows: 

C>AX/CV-^v^^^-V^^<f"»^ 



DERATION VtW -MoNihs £ays 15 //ours 

lj./Ow^;dLA-\!fcwa V'.V\.^L.ft:>.VAr;.'S. 



CONTRIBUTORY 



years "^ dMonths t Davs T...//ours 

M.D. 



DURATION C /V^ 

(SIGNED) U- O. J^U^fvLi^ 

ClL.... n X loo'-- (Address) lO'^ b<V-wylUui.U 

;IAL INFORMATION only f§r Hospitals, Jistltutieiis, Traisiffts, 



SPEC . . 

or Rfce»t Rcsldfiits, and persons ••>'"<I ••**)' •'•" "•■* 



Formfr or 
Usiial RfsidfRCf 

When was disease contracted, 
If not at Haf f •' <•*«*•» • 



How loM| at 

Plate of Deatli? • Ii)rs 



DATE of HraiAL or REMOVAL 

H 190% 




PLACE OF BURIAL OR REMtAAL 

UNDERTAKER AX^rCU^' cUaXN^ j, .- 

^$-\ VmAAA.v<rvv...3i 



(Address 



, ~ .PE .hould !>• stated EXACTLY. PHYSICIANS should 

,t.on should be carefully supplied. AGB •»»»"'«» ^J* "Special Information" for pr- 



N. B.— Every item of Information should oe carc,«.., •--"— properly classified. The "Specli 
atate CAUSE OF DEATH in plain terms, that it may t>e prop 
;or. dyfng -way from home should be ^iven in .very instance. 



%^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

741 



H&PCo 



Hoard of lle nlth— F No. 15 

Jh(te Filed, \Lk.^jOu\j^ 3 VJO S 



Registered J^o, 

Li-uvvo "Lxvu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

(Tevtificate of Death 

( Ta. S. StanOarO ) 
: — County of^loLA^ A<]L^rL>CyUl^Gty ofVJ/Om, OAXt^VCA^'C^ 



PLACE OF DEATH 



( •' %''^:.^..i'%iii::.v:r^^^^ :r.ii^.';s.'iorir.v.\ name ..»tc*o o. ..n... ..o .u...n. ; 



■) 



FULL NAME 




.O.^^utLcL L(r.ta 



ih;. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



(niju 



lO.Lii. 



DATK OF BIRTH 



iM^lith) 




Ar.R 



) V«i » .» 



1 

(Day) 



Months 



r 1.0 .H 

(Year) 



X H ^«''* 



SINr.I.R. MARKIKI). 

winowKi) <)K nivoRi'Kn 

(Write in social dtsijfnali«>t») 



HIRTIfPLACK 
(State or Coiuitry) 



NAMK OF 
FATHKR 






llli 



UL-vJiVv^^v 



C^AJ 



BIRTH Pl.ACR 

OF KATHKR 

I State or Country) 



• ' 



MAIDKN NAMK 
OF MOTHKR 



BIRTHPI.ACK 
OK MOTHKR 
(State or Country) 



«* 



OCCUPATION 

Rf$uif<f ill Sail /■'iiiinis/'o 



^ JV„,< *^ .1 A >»///> 2, \ 



/)it \s 



HKAnOVESTATKDPHRSONAI rAKTIcriARSARKTRlK TO THK 
BKST OF MY KNO\VIJ:F)<.h AND Ml-MF^ 



(lufortnant 



MY KNO\VIJ;i»«'n .A.>w ...,.,...• 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Venr) 



SI 

(Day) 
titled deceased from 

to .>kW.<UjL.....'^..l 190 H 

W!>L..."^l 100 M 



attc 



I HF:RKBY CFCRTIFY, That 

VaJLjl u 190 *^ 

that I last saw h rir^m alive on J^-*-^ 
and that death (x:curred, on the date stated above, at 
(P. M. The CAUSK OF DRATH was as follows: 



190 



DURATION JVar5 

CONTRIBUTORY 



Months Days 



Hours 



Years 



DURATION 

(SIGNED) 

Si iQoH (Ad.lress) 



Months 



Davs 



Hours 



^.i.^^^Ko^KA^^ MD. 



FECIAL INFORMATION only 'o^ Hospitals, iRstitutions, Transients, 
or'Jecent Rcsl^cnls, and persons dying av»ay from home. 

How loRf at 

Place ol Death? Days 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



PIACKOF BFRIAI. OK RKMnVAI. 



DATK of BiRiAL or REMOVAI, 

IXa^vql H 190H 



'-- -^h::. Ii3"t 



(Address 



(Address . 



.„pHu.. ACB .-- r'4Hf4'=:^.:; .rrr;.'..:'::'.^ 



..... CAUSE OP DEATH In ^'-'" •'^"•;i;J'„'' „ ."^J Lr.nC 
■ons dyin* aw.y •'om l-ome nhould b« »lven in . . y 



H.i;ii 



,1 of Hcalth—F No. 15 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nzrzn to back op cewtificati; for instructions 



H&PCo 






Dale Filed,..{i^a^ 3. 190 i Registered J\ro. 

X«-wu> Iuavu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Ta. S. StanOarO ) . ^^ 

J) m 4 ^ 

DEATH: -County of '"V>^ /va'VAXU^C.Gty of O/a'W O^UX/VVCaA^O 



PLACE OF 



PLAUl ur UCAin: — v.oumy u« — — p • /-» 

.,M m 4 H ^' OLlL^ti-v St. 1 DIst.,bet. B'C^ andVL 



UX^CX ) 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL^PARTI CULARS 

COI.OR 




UJ L&::>xLima. 



^cvL 




DATK OF HIRTll 



u.vut 

(Month) 



AC.K 




^Ib IV<i».v I 



3.^ 

(Day) 



MoM/ftS 



(Year) 



Pa vs 



SINC.I.K. MARKIKH. 



SINC.I.F.. MARKIKIJ. ^ 

\Vn>o\VKI) OR niYORCKO JJ (\ 

(Writf ill sticial tlesijftiation) -A . U 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DE 



'"" (L. 



(Month) 



t 



(Day) 



(Year) 



I HEREBY CERTIFY, That I atten<le(l deceased from 
CbXOcA^. 190 2» to ,^^% ^• 



.190 H 

that I last saw h..V»^ alive on U^l^X^ ' '^^ 190 '^ 

and that death occurred, on the date stated al)Ove, at I ^ t ' 
QL M. The CAUSE OF DEATH was as follows: 






HIRTHPI.AOK 
(State or Country) 



NAMK OF 
FATHKR 



BIRTHPLACE 
OF FATHKR 

(State or Country) 



MAIDEN NAME 
OF MOTHER 






BIRTHPLACE 
OF MOTHER 
(State or Country) 




_a^JJLoL/ 



r\XK - 



OCCUPATION {^Ij^^ 

RfKided i n Satt /inHrisro ^H i^'^" *■ 

THEABOVBSTATK.>PKRSONMPAKTK;r|;AKSAKKTRlE TO THK 
BEST OF MY KNO\VI.HD<.h AND BhI,Ih»" 



(I1 






Days Hours 



Dl'RATION ' Years ^Months 

coNTRmrroRY ^ 

DURATION Years Months Days Hours 

(SIGNED) L-i).W^il.ttL^^-^^^^ M.D. 

(Lc g.X 190 H ^A,i.lr.ss^ X^3> VJ ^v^mXI dt 
^MoTlNI 



SPECI'AL INFORMATION •»ly »or HQSfltals, liistltolioiis. Traiisletts, 
or Rfccnt Residents, and persons dying away from honie. 



Former or 
Usual Residence 

When was disease contracted, 
If iot at place of death? 



Now loRf at 

Place of Death? Days 



PI.4CE OF BVRIAI. OR RKM«)VAI, 



DA'q;:of BrRiAL or REMOVAI. 

H 190H 



UNDERTAKE 










.^irrv.....' 




L 




N. B.— Every item 

state CAUSE Uh un« . " ■" »-:"■" .-""j^^^ ,„ ,v«ry Instance, 
son* dying away from home ehould be 4'ven in e e y 



' 




I' 






1:1 



Una 



anl of llealth—F No. 15 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

WtFgR TO BACK OP CERTIPICATC FOR INSTRUCTIONS 

Registered JSfo, * 3^ 



H&PCo 



l)ateFne<l,l}sJj^a^^\A. 3 1^0^ 

Xcr»„.^A^ Xiv<< , Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( Ta. S. StanDarO ) 
PLACE OF DEATH:-County ofO.C^^ J^u^vwc^ity of 0^^ ^K.C^^^ 
.,Q II ^\ c. 1 r»:.* , k.f/i J^X^At and Ottrcllitr^^ ) 



(No. 



St • I Dist ♦ bet. oUx^'t.fr^AX' and 



FULL NAME (Jxcul-L^.^ 



S' a J 



SKX 



PERSONAL AND STATISTICAL PARTICULAFIS 

COLOR 



cJL 



liij 



\.kXjl 



DATK OF HIRTII 



( Month > 



AOK 



>M Yi'atf 



(Day) 



Months 



r 155.,. 

(Year) 



A; 15 



SIN<-.I.K. NfARKlKn. 
WIDOWKO OR DIVORTKI) 
(Write ill social (lesitr"»tion) 



niRTHPi.ACK 

< State or Country) 



NAMK OF 
FATHKR 



C) 






BIRTHPLACE 
OF FATHHR 
(State or Country) 



MAIDKN NAME 
OF MOTHER 






\ *^' 



BIRTHPLACE 
OF MOTHER 

(State or Country) 



tjx- 

OCCUPATION ^^^^_ VJO^vW- 



1 



Resided in San Fianfiseo 




DATE OF DEATH 



MEDICAL CERTIFICATE OF DEATH 

1 



(4,11th) ^ 



(Day) 



(Vear) 



I HKRHBY CI:RTIFY, That I attemlea ileceased from 

--— ;: .i90 — to 190 ""^ 

that I last saw h r— alive on - -— — 190 " 
aiul that death occurred, on the date stated a1)Ove, at 
M. The CAl'SFi; 'OF DKATII was as follows 

•Hi 







DURATION )Va/'J 

CONTRIBUTORY 



Months 



Days 



Hours 



DURATION^ ^ '*'"'" ff> ^'^'"'''''•^ ^''^' 




( SIGNED ) urumiA' . ^. LU AjJLou>vA. 



Hours 
M.D. 



^AA icy 
;iAL INI 



SPECIAL INFORMATION only for Hospitals, liistlt«tl*iiV, Traiskrts, 
or Recent ResMents, vA persons dying a^ay from home. 



y,ars 



Months 



PlI \s 



THE ABOVE STATED P^RSONAI PART|CrLAR. ARK TRIE TO THE 
BEST OF MY KNUWUEDtE AN;^*^^^*' 



(Informant 



jUlX}\Ai ^ 'CU(>VV^ 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of death ? 



Now foRf at 
Flare of Oeatfe? 



Bays 



PLACE OF BIRIALOR REMOVAL 



i^yLojuL/OL^»^ 



DATE of BiRiAL or REMOVAL 

H 190H 




15 XH Bt>t.kt<r>x ^it 



(Address 



— ^i^^^^^^^"^^"""'^'^'^'^'"^"^^^""'"^"" A %^ t * d EXACTLY PHYSICIANS should 

„, ,„.<.r™...o™ .Ho„.d be ci...-., .upp"e-. ^''^'^^,^^t Vh. 'Spec ..rm.ti.n" .o, p.r- 

E OF DEATH tn pl.ln 1""... th-t -t m.y ^^T^, 



N. B. Every item 

state CAUSE OF Ut/% i n .n »'■— ■'*/■■:,' ;„j„ .^.^y Instance, 
sons dylnft away from home should be 4iven In .very 



l> 



)!<>;( I 



,1 of Health— F No. is 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



K&P Co 




Registered JVo. 






mteFi1e<l,XKK.u,>^ ^ i'^O'i 

Awj^vc^ iuLv-M Deputy He aft h Officer 

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco 



Ccrtitfcate of Death 

( "CI. S. StanOarD ) 



PLACE OF DEATH:-County of 6^^\^aC^VV3^.. ^Si.r^'Xif^y^ 







I 



No. 



Q^ . "Dist • bet* ^^^ 

FU LL NAM E .'l].Ur\HX/>^'^<J ^ -^J Uaa.u^U)-. 



— ) 



SKX 



PERSONAL AND STATISTICA IMPART I CU LARS 

COLOR 



maU 



iXLkdx- 



DATE OF niRTH 



(Month) 



(Day) 



/ SlC: 

(Vear) 



AC.K 



XH yra,s .?^ ''*f"""'' 



Pavs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Day) 



(Year) 



(Month) 
riiRRHBV CHRTIFYrThat I attcMKlcl deceased from 

up 



— T 190 to 

that I last saw h ;^— alive on - 



■190 



SINCI.R. MARKIKI). 

winowKD OR nivoKi'Kn 

iWritf in social «lisJt(:nation) 



HIRTHPI.ACK 
(State or Country) 



VAMK OF 
I ATHKR 



C 



BIRTHPLACE 
or FATHER 
(State «>r Conntry) 



MAIDEN NAME 
OF MOTHER 






cvw^o<v 



an.l that death (Kcurred, on the <late state.l above, at - 
M The C\rSH OF DKATII was as follows: 

(?: 



^SA 



W ^^Ow 



BIRTHPLACE 
OH MOTHER 
(State or Country) 



OCCUPATION 






\/^Z^'0^. 



Residrd in San ritinri.wo 



\r,„ilhs " A"" 



THE ABOVE STATED P«R!;?,^^r;'';;r ,kI IFF 
BEST OF M^Y KN(>WLKn<.E AND BKLIKl- 

(Infor„.ant "l- h X>.^:.oLtXA. 



iLPARTICrLARSARKTRrK TO THE 



DURATION yean 

CONTRIBUTORY 



Months 



Days 



Hours 



Months 



Days 



(SIGNED) i%- IwvUmvJv. 

190H r^ddrc- sst^^'J^Aa V<tl 



Hours 
M.D. 




.1 



QprfelAL INFORMATION wly »or Hospitals, Instltytlws, Traisknts, 



or 



Rcant Rcsldenls, and pffsons dying away from home. 



Pormfr or 

Usual RtsMeBce - 

Wlitn was disease contracted, 
If not at place of death ^ 



How loRf at 

Place •! Deatli? layj 



. „w-o,»f OH RKMOVvL I DATEof Bi RiAi- or REMOVAL 
PLACE OF BI RIAL OR RhM«»^ '•- I / ^ 5 ,^ 

I VX^wA^ O. I90I 



^J^jCA^ 5j.Vv«X>^^S^....V<>. 



fA'Mress 




rS. B.— Every Ue«. of ^-^^--l^JlVrJ'n t:;:: th-t TZy ^ P-PcHy 
state CAUSE OF DEATH In P»"'" **.7'^„"i„ .very instance, 
son. dyint away from home ahould be ft.ven 



^ 'a fvacTLY. PHYSICIANS should 



I; 



V i 



|l 



.■'i; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Honr.l of Health-F Xo. i^ »^^^ B&P Co RCPER TO BACI^ OP CERTIFICATE FOR INSTRUCTIONS 



A>cU: s loo'i 

Deputy Health OfTicer 



Registered J^o, 



.74.5 




Date Filed, \Xjuu(x 

DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "CI. S. Stan&arD ) 



0n 



PLACE OF DEATH: — County ofCj^YU 0\XXOVC.v4yCCCity of ^'/OlAV \JA<V>VtVAC^ 



Na C) ...M U Ob (M.kdo.1 



(IF DCATH 
\W OCA 



St. 



-Dist.; bet. — and- 



OCCUns AWAY PROM USUAL RES 
A OCCUNRO IM A HOSPITAL OR 



FULL NAME 



SIDENCEgivc pacts callcd por undcr "special INPORMATION" \ 

INSTITUTION Give ITS NAME INSTCAO OP STRCCT AND NUMBER. / 

i 



-) 



lAxx^vCA>i 




KJUL 



PERSONAL AND STATISTICAL PARTICULARS 



-i:\ 



(^IcJU 



COI.OR 



_.]lLfM±^, 



DATK OF IJIKTH 



i>A)iith) 



B 



(Vear) 



AOK 



O A »«#.» V 



.lA#w///.« 



, IH 



Davs 



MEDICAL CERTIFICATE OF DEATH 

DA TK OF DKATH 

,0...... 

(Day) 



(Month) 



% 



ipo\ 

(Year) 



•^JN<.I.K. MARK IK I) 
WIIXIWKI) OK DIVdRCKI) 
'Write in social (ii-<>itrnali<>ii) 



^M 



III 



^t.ite or Country) y H ^ i J 



NAMF. OI- 
FATHFR 



HIKTHPI.ACK 
OK FATHKK 

'St.'itr or Conntrv) 



MAIDHN NAMK 
OF MOTIIKR 



AiXcv> 



^ I HKRKBV CKRTIFY, That I attended aeceased from 

?J JUT 'Xl 190 H to LUa^.. ..X 190 H 

that I last saw h iArv alive on Lm«\,<CI^ X igo *i 

and that death occurred, on the date stated above, at ^ 

Ji^ M. The CAUSE OF DHATII was as follows: 

\,OJ\JZA*.nrutr'\^^^>^/0<j W^^ 



DrRATION % Years ' Months ' Days Hours 
CONTRIHUTORY .LLaXJ(\X^vv.!UCX^ 



V 



<L 



J^uxUl 



Vua^-vxjL 



1 



DURATION 



(SIGNED) 



MIKTIIPI.ACE 
01- MOTHHR 
'Slate or Country) 






OCCUPATION 

Kfsidrd in San /•'$ am isfn 



) ></ / s 



\f,>lltflS 



Par 



^ 

vA^vC\^ ^ 190 \ 



Years <i Months*^ Days ■'^- Hours 

M.D. 



Years ^ Mouths Days 



(Address) 



i(?. L% 




6-^^v^l.£L4.. 



SPECIAL INFORMATION only for Hos^lUls, JRstitutioiis. Transleits, 
or RecfRt Residents, and persons dying away from hoae. 



Fomfr or 
Usual Residence 



UxxJkXa/vvxi. W«^ Place of Deatii? S 



O.V\^;5 Diys 



THK ABOVF. STATFD PHKSONAI. PARTIcri-ARS ARF: TKrF: TO TH K 



nF:ST OF MY KN0\VI,KD<.F: AM) HKIjr.F 



'\fl dress 



'L'l b XcydLvOC Ot U «ak.i<3La\. ti 



When was disease contracted, 
If not at place of death? 



PI,ACK OF BIRIAUOR REMOVAL, I DATF: of BrRiAL or REMOYAl, 

Wa ^ Qf>l<V>xv^ 

dre«»s 1 CKi O^vui. V0L^bu3..*a.b) V' 



IXUHRTAKKR 




N. B. Every item of Information should be carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The ''Special Information" for psr- 
sons dying away from home should be l^iven in myi^ry Instance. 






CONTINUED 



t Q C A L I T Y P 



R ECO'R D S 



SAN FRANCISCO 
COUNTY 

S AN FRANCISCO 
CALIFORNIA 



T I TL E 



OF 



RECORD 



DEATH CEi^TIFICATES 



M I CROP I LMED 



FOR 



THE GENEALOGICAL 



SOC I E TY 



OF SALT LAKE 



C LT Y 



UTAH 



-a 



CA LIFORN lA 



DATE 




APRIL 



PH OTOGR AP HER 



1975 

MAX JOHNSON 



CAMERA 




NO 



2683| 



RED 



VOLUME 696 



904 



1018 







ROLL 



t. 




LO)CAL I TY OF 



RECORD S 



SAN FRANCISCO 
COUNTY 

S AN FRANCISCO 
CALIFORNIA r 



TITLE 



RECORD 



DEATH CERTIFICATES 



t. f I 



M I CROP I LMED 



FOR 



TH E GENEALOG ICAL 



OF SALT LAKE 

^^ ft 

CALIFORNIA 



SOC I E TY 



CITY 



UTAH 



DATE 




APRIL 



PH OTOGRAPHER 



1975 

MAX JOHNSON 




CAMERA ■N02683 




RED 



VOLUME 696 



il^-^ 



904 



1018 




i 



WRITE PLAriMLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

r-oMKluf iic.ith !• No n *-^^^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



li| 



Datr Fil(><1 , \jj^o./u^ 5 WO H. 

cLcru^ louvu Deputy Health Officer 



Megistcrecl JVo. 



745 





DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( la. S. StanDarO ) 
PLACE OF DEATH: — County ofClOLTsj OA^XX^TU^UXOCity of ^^'/<X/Vu OA^X/YV^VACC 



(No.^^) U. (lb^^Kdc^l 



St.; 



Dist«;bet» and 



(\T DEATH occJns *WAV moM USUAL RESIDENCE Give r*CTS callcd roR under "special information-* "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



(^ 



FULL NAME 



I 



^ 



A.'CL^YVC.U^ cUr>V<X.K.A.AJL. 



SKX 



• ^l^-i 



II 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



(^icL 



Uj. 



DATK Ol- lUKTH 



• Nlk)nth) 






(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKAT 



Li. 



(Month) K 



a>av) 



(Year) 



Ar.K 



O ^ y,a,> t) 



Mntifh 



> 1' 



Da I . 



SIN<.1.K. MARKIKI>. 

winnxvKi) OR niviiRrKr) \ 

iWrite ill MR-ial )lt*»i);natioii) j 



BIKTHIM.AOK A . W il 

'Statr or r.iinitryi I' U »^ . U 

-^ ' si L 



Nwii: i»i 

» ATHKR 



q^ I^HRREBY CICRTIFV, That I attemUMl .Icccase.l from 

^..JLir ^% i9oh to LIa^vOL. .CL 190 M 

that I last saw h - . > . alive on LvVk\..CI^ X 190 . 

ami that death occurred, 011 the date state<l above, at ^ 

ii^ M. The CAISK Ol- DI-ATII was as follows: 



I'i 



lURTMIT.ACK 
ni I ATMHR 
'St;tt< or CtMititrv 



maii)i:n namk 
oi" mothkr 



oLocL'' 



^'Vs.CLrLVA^L 






Dr RATION rs }'rars ' Mouths 



Days 



Hours 



CONTRIJU'TORV 



C« 



mkTHPr.ArH 

oi- MiiTllKR 
'State or iNmiitrvi 



OCCli-ATloN (Yv^ OTN 

^ I r V(X^^»^ J ' 






^ 



DURATION 

(Signed) 



Years 



^fl>flt/ls 



190 



Days 

(Addn-ss) 9.4. Co . dt 6^4xA.la.'. 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Trinsifiits 
or Rfcrnt Residents, and persons dyin^ away from homf. 



Former or 
Usual Residence 



UAX-rL^a^vdw VO pfareof Deatli? To.Va.^.. Oiys 






f'.i 



rHK AROVE ST^TFI) F'KRSONAI. PARTirn. \RS AKK TRt H To TMK 
HKST OF MY KNOWI.HIX'.K AM) HHMl'F 



(Infonnant \] iV*^ » ^^ -'W-^MTW 



When was disease contracted, 
If not at place of death ? 



PKACE OF BFRIAI. UK kKM<»\ \l, I J»\Ti:.,f !{. kiai. or RF:Xf(»VAI. 



190H 



rNi)F:RTAKj:k 






N. B. Every Item of information ahould be carefully nupplied. AGE •hould be stated EXACTLY. PflYSICIAINS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special information'* for par- 
sons dyinft away from home should be It'ven in mv^ry instance. 




i.' 



. » 



1 



' I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,;,nl nf He:.Uh I No ,. iJ-^g^H&lCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((tc Filed , LU.Ul.vc>^ 3 



7.9(9 4 



Begistered J^o, 



746 




KKJ^^. 



y^^ Deputy Heafth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( H. S. Stan^ar^ ) 



PLACE OF DEATH:— County of '^^'<X-»vOAa>vtv4.cx City ofOa>v JA.(VvvCv<l co 



No. I L CL vLc^nrin* C't 



-t, 



%l 



^ rv^- V u .' >. V tU- I ^ tL St.; ^ Dist; bet. '^^VviL^A^^^ and J^' Crllr^U.. ) 

/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
I IF DEATH OCCURREbWN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




a\. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



(VHcL 



W. 



aXx 



nXTK nj- niRTII 



(Month) 



AC.K 



1 



)'<•</; 



1C» 



(I)av) 



M.iulhy 



/Hex.. 

(Year) 



/)rtl.v 



WIDnWKI) nk DlVuKiKn 
tWiittiii *i<K'i;il fltsi^nation) 



lURTHIM.M'H 

'Slatt or Country^ 



OwvaVt 



KATHKK 




IMKTnn.AiK 
<>l- I ArilKK 
'Stat* or v'oiintry) 



IlIKTni'I.AfK _ A 

Ol- MmTMKR \) U 

fStatr or Country) 




^ 




Aj-V'YU dUvt 



^ 




MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 



(Month) /T 



% igo H 

(Day) (Year) 



I II1':K1:HV C1:RTIFY, Tlmt I attciulo.l iKm case.l from 

|.LcLa^ i 190 H to LLmwCL X 

that I last saw h a. > 1 .alive on Lvca^O^ X 



190 H 

on c^.A-A^QL " X 190 H 

aii<l that <Kath occurred, on the date stated alxn-e, at I v 



LL M. _The CArSr: Ol" I)I<:ATII was as follows 



M^-WyV-vv^Lv 



V'ly^vs 



L£Ia\I/Ol> 




^ 

1/lD 



oceri'ATioN 

h'f'-iiifil in S,nr I'mmixo \ )V</;> 1 t .\foiitliy 



Pin 



vnv. AHovK sr \ rjj) pkk'^onai, paktumi.aks aki: tkik in vwv. 
HKST OI- MV KNUW l.i:i)<. K AM) in':i.iKf-' 



(Infoitnant 






Mouths 



<^cL*VjLVI.>vi. 



1)1 RATION Years Mouths ''^ Days Hours 

DT RATION _>V<ii^ 

-I 
:iAL IN 



Pays 



(SIGNED) 



Hours 
M.D. 



lL>LQ X iqoH (A.Mrtss) -S^^b ^AaJIAAX\>^ CT 



or 



dPEClJ\L INFORMATION only for Hospitals, Institutions, Transients, 
Recent Residents, and persons dying away from home. 



former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



i;^,ACK OF BIKJAI. OK RKMoVAl, I DATK o! H» HiAt. f)r RKMOVAI, 

•NDKKTAKKR \l j'l6^>V<x( Va >V vJ (jC aVO' '^<w Lc 
(Ad.lrtss XhW QfXv^^vOv ^ 



IN. B.— Every Item of information .houlcl bv cnrenilly HuppUecl. AGB «houI«l he «t«te.l EXACTLY. PHYSICIANS should 
•tatc CAUSE OF DEATH in pliiin terms, thnt it may be properly classified. The Special Information for psr- 
sons dyinft away from home should be ftiven in every instance. 



it 



V 



ff 



I 



MomkI "f II«-:iltli I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

..:,,, ^J?5S:^ ns: V Co REFER TO BACK OF CER TIFICATE FOR INSTRUCTIONS 

Re^Lsteved ^''o. 747 



Dnic /-V/f'^/, Uwcvajvc^t "h i'>0 S 

i^^uvv^ Xi^vu Dep>.?tv Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Bcatb 

( "a. S. StanDarD ) 
PLACE OF DEATH: -County of Oo-^V -JxO^^UccCity of C'C^vv J A.O^^,^^a.c 

/ IF OE*TM OoipURS AW 



Na 




■) 



FULL NAME 



W 



.,CC^ 



.oxL. 1 ^^^ • 



iiSM 



m:\ 



PERSONAL AND STATISTICAL PARTICULARS 

COM)R 



^>\<xL 



i»\'n-: oi- luRTJi 



At.K 






lOivf^Lc. 



T / 1 L'i 

(Day) (Year) 






M.ttillis 



'l\ 



An. 



\Vn)t)\VKI> OK I»IVnKlKI> 
t Writf ill social tlf«»i»rnatioti) 



lUKTUJM.vrK 
Statr or Country' 



<1U 



CL'V^A-U^ 



li 



»! 



\ \M1- nl- 

I A III i:k 



IMKTHri.ACK 
<>»• I ATHKK 
iStatr .>r Cotiiitry) 



MAIDKN NAMH 
OI MoTHKR 



MiKTinM.Arv: 

OI M(»TI!KK 
isiatr .ir rounlryt 



(T 







1 



/(XVVcc. 



/k Co, 



-I 



Ou>v 



OCCITA IION 



LiJ 






V 



Rr^iilfii ill <an I'mmi^rn 






lh!\ 



Tin: \HOVKSTATi:i) rKK^«iNAI. rXKTini.AKS AKKTRli: TO THK 

in%sr OI- MY KNo\vij;i)<".K and nKi.ii.i- 



(Itifomant rsU JLa^ 



\^Osj L/Cyo^^w- 



(A'Mnss 



W^K 



A-^'> A^lj-o-^v. ^^ •^'t 



Medical certificate of death 

DATK OI* DKATH 



(Month) A 



(Day) 



I go 

(Year) 



^rTnrRi:HV C1;RTIFY, That I attctulcil «lcccasea from 

190 .r-—-. to •■• xtp-rr— 

that I last saw h ■ alive on '9° ' 

ami that tlcalh occurred, on the «latc stated above, at 
y[^ The CAl'SF. OT DICATII was as follows: 

lLc/O^c:^ ^ ..to.,'. 



I )r RAT ION Vii^ys 

CONTRIIUTORV 



Mouths 



Days 



Hours 



DIRATION 
(SIGNED) 



Years 



KEk.li 



Mouths 



1^ 



Days 



Hours 



Ct^vcL VfeV^^xZ^j M.D. 



lU', 



,. ^ 



iqO 



A.Mrt-ss) C6V(n\x^,^ U^k-. -.... 



SPECIAL INFORMATION on'y ''*r Hospitals, Institutioiis, Traiisifiits, 
or Rfctnt Rfsldfnts, and pfrsons dying a^ay from honif. 



Formfr w 
Usual Residence > 

Whfn was disfasf contracffd, 
If not at piarr of drath ? 



Jl I How loRii at 

Xdl dLrv>v'xx,*v<*- ' Mare of Death? 



.. Pays 



I'l.ACK OI" nrRFAi. OR ki:movai< 

^ 



t^\ 



DAIllof Ml RIAL or REMOVAI, 



u 



^L^vC 



% 



190 '. 






fAcMress 



"■~~— ~^ r^ AGE should be atated EXACTLY. PHYSICIANS ahould 

N. B. Every item of information .hould be carefully auppi.ed. ^uo a ^^^ -Special Information" for par- 

•tate C4U8E OF DEATH in plain terms, that it may be properly Uaaa.nc 
aona dylnft away from home ahould be ftiven in avcry .natance. 






*i 



I 



'^*?' 



f 



!i 



f • -* 
I I 










WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,„„„„.,..„ ..*?S!!*.«... CO BtPER TO BACK OP CERTT.CATE FOR INSTRUCTIONa 

/>././■•//../, lUv-o* ^ I'^OH Megl^tered JVo. ^^^ 



~^)cer 







DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of ©eatb 

( H. S. StanOarC» ) 
CriK ^^? }4^ c.. i Dist • bctX .ctaorv ex and ^CLav^^v^ ) 

FULL NAME O o^^^^^v U 



PLACE OF DEATH : — County of 



No. 





;^.r 



m 



> ]■. \ 



PERSONAL AND STATISTICAL PARTICULARS 

COI/)R 



^Icvt 



UJ.Vujt!. 



n.\Ti: ol- IllKTH 



^^•.K 



Qw> 



Month) 



O i JV,/».v V- 



(I):iv) 



M.nitlis 



(Year) 



XX 



Pa \s 



. \ 



W 



( » 



Jll< 



t > 



<IN«.I,K. MARklKI) 

i\Vrit« in -M-iiil (Ifjiijfnatijin) 



niR rmM.AiM-: 

iSt:it< iir «."<nintrv' 



NAMK OF 
I ATI IKK 



r.lRTHlM.AlK 
«M FAIIIKR 
(StMti' or Country^ 



M \11>KN NAMK 
<)l- MOTIIKR 



lURTMPI.ACK 
<)|- MoTHKR 
StMtt or Country^ 









.OJhJ 



MEDICAL CERTIFICATE OF DEATH 



DAT!-; <>i" i>i:atii 



(Month) ([ 



.1 .. 

(Day) 



I^o 'I 
(Year) 



I HICKl-nV CI:RTIFV, That T attended «lecfaseil from 

fi .'C-t i9o3> to iL^^O.-.-.'^ 190 H 

that I last saw h '• alive on LU^ X. 190 ^ 

and that .loath occurred, on the date stated above, at H- 3 
M. The CAl'SH 0F^)1':AT1I was as follows: 



lA-^-^WCXAXi. 



dl 



t)rcriv\Ti()N ^ I \ I 1 



RVsiifnf III S.rtt fiami-r,) Oo ) '<" < 



* M.'iith- 



/>in. 



TMKAnoVKSTXTKni'KRS.^NAM'ARTirri.AKSARKTRrKTo TllH 
IJKST Ol- MV KNOWI.KD'.K AN D ,M1'.M1.1' 



(InfiiniKint 



<\<h\ 



5 1 C) o.A.v\rLt5^v ^ 



I)r RATION Vi-ars 

CONTIUrd'TORV 



I\/ouths 



Days 



I lours 



nr RAT ION >lv7;'i J/o/z/Zm" Day^ I fours 

(SIGNED) t)tU ^-^'■"^••^-L, , '^:°- 

(Address) HD^ Kxxva^d 

SPECI'AL INFORMATION on'y *9r Hospitals, Instllutitflis, Translfnts, 
or Rwfut Residents, and persons dying away from home. 



vWv-C^ '■ i< 



)0 



Former or 
Usual Residence 

When was disease contrarted, 
If not at place of death ? 



How long at 
Place of Death? 



Days 



I»I ACK OF ni-RIAI, OK KKM«>\ AK 



I ni)Krtaki:r 



'^ 



I>\1J: of IHKiAl- or RKMOVAI, 



%, 



^ ■'*^.vv>-\^ k,i-V- '''*^ 




b 



I90i 



(AcMr.ss %^^^ \n\v<J.^V<r. 



0> 



■n 



1 I h* t ted EXACTLY. PHYSICIANS should 

N. B.— Every item of Information .hould be carefully f»PP»;-?; prl^eHrria««ifled! The -Special Information" for per- 
state CAUSE OF DEATH in plain term,, tha -t ma> ^J^^J. 
son. dying aw.y from home should be ftiven m every instance. 



ft 

I 

t I 

«| 

i. 

% 




I 



I i 



'J 








H,,;n'i "f lUiiUli 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PEflMANENT RECORD 

,,„ ,,^ tfS^„^vc. BEFER T O BACK OF CERTIPICATt FOR INaTRUCTIONa 

749 



/)((/r Filed, 





1^' 



\Aj 3. 



IfJO^ 



Registered J^'^o, 



K'to^u Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( "U. S. Stan^a^^ ) 






PLACE OF DEATH:-County of da'.V Jx^>xCu.C<Gty of 0^^ Ik^^^^^^ 



LLvsji. 



) 



FULL NAME 



a OR INSTITUTION GIVE ITS NAME INSTEAD 

,E V^ 



.X/.\xtax..^ 



^i:x 



PERSONAL AND STATISTICAL PARTICULARS 

I COI. 



^\A^ 



"" lOl.U 



OATH OI- IMKTII 



UA 



(Month) 



(Day) 



A^s 

(Year) 



a<;k 



\" )>./»< 



Months 



/ht\. 



sIxr.i.K. MAKKIl.n. 
\VI1)0\VKI> OR niV«»Ki'KI» 
Wrilf in «.ikm!»1 lU-si^natinii) 



lUKTm'I.AOK 

st;itf or Conntry^ 



NAMK «»1 
KATHKR 



MEDICAL CERTIFICATE OF DEATH 



DATK OJ- ni'ATH | 



(Month 






(Day) 



(Year) 



HIKTMP1,ACK 

or I ATHKR 

• Statf or Conntry* 



MAIOKN NAMK 
OF MOTHKR 



HIKTH.r.ACK 
OF MOTHKK 
'Siatf or Country t 



1 fVOwX'V'^X^ct 



I 1II:K1:BV CI:rTIFY, That I attendca acceasea from 

— 190 to ^90 

that T last saw h--— alive on "^^o "' 

ami that <Uath occurrea, on the aate statea above, at 
M. The CAISF-: OF pICATII was as follows: 

/1X'v'xCl»«...0^.. 



•'^ 



.\jL^vA;^.5.r?vL .d..*^:v;V.>:^^ 



nr RAT ion' yt-ats 

CONTRIIU'TORY 



Afonths 



Days 



Hours 



ni'RATION 



Years 



^fouths 



Pays 



( SIGNED ) ..U*UP^^^J^ ^' ^^ ^ ^^-^^'^ '- 



f fours 
M.D. 



CLv 



1^ (HP 



PFCiAL INFORMATION on'y '«r Hospitals, InslltullOT^, Trauslfnts, 



or Recent Residents, and persons dying away from home. 



oeCIl'ATION 



WVV^' 



'■^ 






P^:-i(tfif in S,7n riitn, ism 



),ai 



Moiith^ 



Ihn 



THK AnoVK STATKI) .•KRSONAI. I'AKTlori.AKS AKIC TKIK TO TIIH 
UHST OF MY KNOWIJCDOK AND MhUn-.F 



-TP 



(Informant 






f Xfldrcss 



Former or u u 

Usual Residence ^ I v> ^ 

When was disease contracted, 
If not at place of death ? 



7y ■ Hi,w ionq at 

(JUC-W-Ol^^ ' Place of Death? 



Days 



PLACE OF RIRIAI. OK RKMOVAI. 
INDHRTAKKR 



^^. 



(Address 






i)A'rF:of nt RIAL or removai, 

.. \LcvQ. -: 

,c1 "-- 



190 



:-% 



' ' in ItE ahould b« stated EXACTLY. PHYSICIANS ahould 

of information .hould be carefully auppHed. J^^^^^J^^.^.i^^d. The "Special Information" for p.r- 
F OF DEATH in plain terms, that it may be properly ci»« 



N. B.-^Every item 

state CAUSE OF DEATH in p , i„.»«„ce 

*or. dyinft away from home should be ftiven in every Instance 



• I 



• 




i J' 



i i\ 



=s-rn 




!' 



WRITE PLAI 



jt.ar.l ..f HeaUh-l'N'"- i 



^ t^i^^H&l'C 



NLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

HEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale W^'^/. iX^v^At. '^ I'^O H 

iL<ru^^ 1u^ Deputy Health Officer 



Registered JVo, 



750 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of l©eatb 

( "a. S. StanDarC^ ) 



PLACE OF DEATH:-Coun.y of Bcv.. lva^.CU.C< City of <^.C^ Oa^. VC^ O-c 



No. V. VU^^vttJLl- oU L^K-^ '^ 



Dist.; bet. "-- 



and 



/ .r oc*TH OCCUR, .viy .ROM ^" ^ U A L' R E S ^ E NC^^^^^ C^-^ ^ ,^^,,,, ^, ,,,„, *hd number. ; 

V IF DEATH OCCURRED IN * HOSPITAL, OR INSTITUTION u 

FULL NAME 



— ) 



Oil 

kkL^\, si ^\jo^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI 



I)\TI-: .>!• HIK I'll 






I Month) 






(Day) 



\<;k 



-55 >v<i#.« ^ 



M,mthf 



\H 



(Year) 



Da \s 



MEDICAL CERTIFICATE OF DEATH 



..a..... 

(Day) 



(Year) 




siNT.i.K. M.\KKli:i) 
\Vri>o\VKI) MR IHV<»KvKI> 
Writf ill siK'ial il«-»ii,'nati<>ii) 



HIRTMPI.AOK 

*Stat« c.r t''>iintry* 



NAMi: nf 

1 AT hi: K 



lURTHIM.ArK 
c)l- lATIIKR 
State 4(r Coiiiitryi 



MAlltl.N NAMK 
<>1 MoTMF.R 



Itik IMIM.AtK 
Ml MoTIIKK 
iStatf i»r CounliN • 






L 



L'rLVw>- 






DATE OF DKATII /^ 

(Month) K 
I HI^RlTnY CJCRTIFV, That I attcii<kMl dcctasea from ^ 
. looS to LWql.X 190H 

V- n " 

that I last saw h^- • • ahvc oti Ua-v^ '^^ t^H 

aiultliat .Kath ncrurrcMl, nn the -late stated alM.vc. at 1 
(j. ^I^ 71h. CAISIC t)l' DI'ATM was as foll«)Ws: 



r 



<v 



t 



^^ff) 



PI* RAT ION 
CONT 




V^W N 



\!,,iith- 



Ihn 



«»CtTl'ATH)N A"V-» a_ 

\ I I \.^^'^xX*^' 
hV'i.i^.f III S. ni Ikiik I--" ' ' "'' 

THKAH<,VKSTXTKI..'KkS<,NAI.I'ART|r,^KARSARKTRrKTu Till 

HKST ni MY KNo\VI.):i>«.K AND lU.I.H.l- 
anf..,mnnt lAJ-CA^Q ^)^>^^^ 

1 iq UL^tM ' 



RATION )V^' ■""""" ^fP'\^ """" 

DIRATION )■'•"" ^ ,)/.'"//« /'<»>* //<"'" 

(SIGNED) \X^ t.^.-^L M.D. 






^ 






c C 



:^ 



SPECIAL INFORMATION only lor Hospitals. iBstilutlons, Traiisleits. 
or Recent RfsMpnts. and pcrsans dying away Irom homf. 



When was disfasf contractrd, "V 



. ^ N*w lomi at _ 

VvXOiAx 4) <X^ PUf e •! Of ath ? A 



Days 



rv'wvis^ 



J\JL4..\^'dLL/\\, 



t-C 



(A'l<lr<'«x 



",., ACKOF m-KIAKOKKKMuVAI. I LATK-f »• h.a,. or RKMcVAI. 



I NDHKTAKKK W^ A/^W 

(Atl<lrr's«i 



t\?\Lt(x>c^ 'U 



i- I' 



% 



__—,^^ i—<U—— ——'——""*' t t I EXACTLY. PHYSICIANS should 

N. B.-F.vcr, ...» of ,«for™....on .Hou.d b. c»r..uH, .upp.i.d *;;;^;;^7;.*'..r„.V 'tH. ••Sp.c... .nfo.-n-.o-" lor p.r- 

....e CAUSE OF DEATH .» -'"'»!""•;;;.„„.«.", W.nC 
.'HI. dyint 8way from homo «hould be ftlven in .v.ry 






WR.TE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,.u.l of Hc:nth-l'No- 1^ 



]J&PCo 




l>al,- h'ilp^l , LA^wcu^.^ a ^-^^"^ 

Xtrvcv^ it^'^ Deputy Health Office 



Registered J^''o. 



751 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ceitificate of 2)catb 

( XX. S. Stan^arD ) 




PLACE OF DEATH:-Coun.y of^O^- ^Va^>V^^ Cty of ^CU- ^K<^.^^ 



1 ( ^^^^^^^^^ :R^?:?f.?.^4ro^v774 ^i^i r.^o o. s.ee. and ....... ) 



FULL NAME 




wv 






PERSONAL AND STATISTICAL PARTICULARS 



^i:x 



ftuL 



COl; 



,OR ^ 



avl.-u 



DATK OF lURTH 



a«;k 



I Month) 



(I)«v) 



Mntilhs 



rX'h.^. 

(Year) 



\n 



MEDICAL CERTIFICATE OF DEATH^ 



DATK OI I)1:aTH , I 



(Month) 




1 



Lt 
(Year) 




lia \s 



sINT.i.K MAKkn-.n (\ 

\vino\vi".i> OR i»iv«»KrHi» V 

iWriuiu smjal iU»it?ii;ition> "^ 

niKTIIlM.M'H 
>t:itf or CiMintry) 



I ATMKR 



HIRTHIM.AOK 
Ul' lATHKR 
<st:»tf or Country) 



MAIT»KN NAM1-; 
«H- MOTIIKR 



mRTIUM.ACK 
<>I- M THKR 
(Statf or Country) 




FlIKKIiBY CHRTII'Y, That I atten.le«l «leroase«l from 

tliat I last saw h V • alive on "^vUxj 'M i^ '^ 

ana that tlcath occurre.l, o„ the .late stated al>ovc, at O .• I.-^- 
UL M. Tho CAlSr- OI- DIvATir was as follows: 



OCCri'ATlON 



c^ 






o1 



/cJIa^vvUvv 



DURATION >Va;^ 

CONTRIIU'TORV 



Months'^ '• Pay'i 



I lout 



s 



Vi'afS 



Hours 
M.D. 

ft 

■^PIECIAL INFORMATION '"ly !•' ""Pl""'. l«5Ht.llMS, Iramiwh. 
o( ««elrt fesMwIs aiU ptrwiis dyinj may ff«™ I""- 



Dl-RATION y''"S ^'^"""" ^"^^ 

(SIGNED) U). ^- U>vU^ 



^VQ ' T<)0 



(A«Mress) 






/>(M. 



THK ABOVE STATKDPKRSOVM.rKKTjrrrXK.AKKTRrK TO .nH 
IJKST OH MY KNO\Vl.KI)«-.h AND "' '•" ' 



n 1) J How lonq at 



Usual RfsMencc WVUWv^ 

When was disease contracted. 
If not at place of deatti? 



Plare«f Dfatk? 



kys 



PLACK OV ni RIAL OR KKMoVAI. 



I»ATi:of Ml KlAi. or RHMOVAI, 

vA^'^'^-A. " 1 90/. 



_^__^i^^— — — — —— , FVACTLY PHYSICIANS should 

.. B._Bve.. i.e. o. lnW.-Uo„ .H..U. He c^.o^^. ^PP.^- ^-^r.." cTV .'Sped.; .n^o.^aHon'^ .0. p-.- 

.talc CAUSE OF DEATH in »»•»•" *V'^^'e„„.v.rt instance, 
-on. dylnft away from home nhouid be ft.ven .n .vry 



I 



f»t? 



f 



tto^ 



lii 



Ill 







, 



[■ffi;! 




II 



WRITE PLAINLY WITH UNrAD.NG .NK-TH.S IS A PERMANENT RECORD 

REFER TO BAC^ OF CERf lMCATE FOR INaTRUCTIONa 

.] . 5_ joQu Registered ^'^o. J^?.."^ 

lutle Filed, LLlcO,v.^X D. ^-^^^ 

i^.wu> -L..M Deputy Hea!thCff.cer ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of S)catb 

1 13. S. StanOatO ) 



PLACE OF DEATH:-County of^ ' a>v OXa-. vCc. Uty ot 



^ 



No 



, ,0 ^ i Qf. 1 Disfbct. 0<XvvA.(r\? and Y\ 

n (^ r ^ ^^ ^ ^*»» "^ L'lSI., DCU ^-.I__ "SPECIAL INFORMATIOU" \ 



^ \ ^ . ■*. 



) 



( 



FULL NAME 



M. IsJL.^/ 



PERSONAL AND STATISTICAL PAR TICULARS 



I 



DM K Ml HIRTII 



\C'.K 




COl.oK 



LOJvd-4. 



H 






J Vi/» 






M.ifiths 



//lb I 
(Vear) 



A;r 



MEDICAL CERTIFICATE OF DEATH 

DATE i)F HKATII ^ 

I La^o -^ /poi - 



sixi-.t.K. MAKKlKn 
WIlMiWl-P OR I)IVoKrKI> 

Wtitt in >.iKial «l««.ii'n;ition) 



RIRTHl'l. Ai'K 
statf or Country^ 



^\ 



OLX^-w^v^ 



THrRl'HV CI-RTIFV, That I atten.UMl aeccascd from 

<i^-' ■ ..^H t„ .CU^.;^.3 .90 H 

' , . u . ' alive on vXA„V.a- O- 190 * 

that I last saw h "■ «nve on ^ 

ana that death cccurrcl, on the date stated above, at M 
CIm. The ^\^^'^'k^^^' DKATIl was as follows: 




N \MK «>l* 

I AT Hi: R 



lUKTiiri.ArK 
III iArni-:R 

si st< «.r Country) 



MAIDKN NAMK 
OF MOTHER 



niRTItPT.ACE 
• '1 MOTHER 
stMtt <)r Country) 



W^c^ 






xnjLC 



I. 



\:, ; 



DIRATION 
CONTRIIHTOKV 

DIRATION 



Yt-ars 




vl. 



MoHt/ts ' Days 



Hours 



(SIGNED 



Years ^ Months Days 



Hours 

M.D. 



^ 1 ' 




,-v-^ve^* 



u^ 



OCCl TATION (TVP 
Iniortiiant O - \1 V- c^—j*-^'^-^'^ 



Cl^ n?^ .ooH (Achlres O Ha I ^I^V-CU. W 

"STrcrkL INFORMATION only tor Hospitals. Iiislltutlow. Translfiits. 
or ReTeS Residents, and persons dying ai^ay from home. 



Former or 
Usual Residence 

When <»as disease contracted, 
If not at place of death ? 



How toil at 
Place of Death? 



Days 



(Address 



7,,CF<>1- mRIAI.OKKKMoVAri HATE of m hi... or REMOVAI, 

- ' -?^ 1^ i JLm:i H 190H 

5^^ a iv^±U^- Bl 



PI \CEor m-RiAi. OK K »•.>.«. V- 

Ami Lt..;..ak,., 



INDERTAKER 

(Address 



^^— ^-^— ' ^ . pYACTLY PHYSICIANS should 

E OF DEATH In pl.in tc-m.. .h. Jt "»> r..r.„«. 



M. B. Every Item 

•tatc CAUSE OF DEA rn -n •'•-"7""::^;„ |„ .^ery Innt.nce 
,«on. dyinft away from home should be ftiven in • 



» 



Vu 



it I 






-"T^- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nrarlnf II. ,11!. I Vn i ^ ^^!^^. WSi V Co RgFER TO BACt^ OP CERTIFICATE FOR INSTRUCTIONS 



i> 




^tf 




/i/i/c Fi/ci/, LLccOa-v^ S 

i ■ V 



KegLstered JVo, 



753 



wo\ 

-vMi Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "CI. S. Stan^ar^ ) 



PLACE OF DEATH: — County of 



City of M LUat 




iU 0\ 



No. 



St. 



Dist.; bet. 



and 



/ ir otATM occons avwAv rnoM USUAL RESIDENCE Give facts called for unocr "special information- \ 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




<xcLcLc?.\. 



si.:\ 



PERSONAL AND STATISTICAL PARTICULARS 



DATi: i)V lURTII 



DATK OF HEATH 



MEDICAL CERTIFICATE OF DEATH 



I Month) 



(Day) 



(Virar) 



AC.K 



'^ )V.i; 



M.nilh!' 



Da\> 



wrnnwKi* UK nivoROKn 



Writt, in stui:!! (U'<«iiJr<iati<>n) \\/\ 



mKTupi.ArK 

(Stat* or l."<nintiv) 



N \Mi: oi 
I AT Mi; K 



(X/^nth) K 



(Day) 



(Year) 



I III'lKI'illV CIvRTIFV, That I atteiukMl deceased from 

' ,... 190 to 



til at I last saw h -^ — alive on 



190—— 
190 — 



and that (loath occurred, on the date stated above, at 
rrr- M. The CAl'SH OI'' DIvATII was as follows: 



>v^r\v 



niKTlllM.AvK 
OI" FAIIIKK 

'"^t.'it? r>r C.Mintrv) 



«»i motiii:r 



HIRTllPUACK 
OI- MOTMKK 
(Stau or Country) 






^u 
I 



^^y\/y^^(^J cL>_vi. 



} 



f\r>nir<f in San /'i nn./^ro )''■■!'- ^f,nlf/l^ 



or RAT ION y'tuirs 

(.'ONTRlHrTORV 



Months 



Days 



Hours 



duration 
(Signed) 



Years 



Mouths 



Pays 



Hours 
M.D. 



iqO 



(A 'ress) 



SPECIAL INFORMATION only f»r Hospitals, InstitutloBs, TraBslfnts, 
or Recent Residents, and persons dying away from home. 



I>iX \ 



TMi: AHOVE STATFD rKRSOXAI. PARTICn.ARS ARK TRTK To TIIK 
IIEST OF MY KNOWI.KIX.F: AM) HHMKF 




Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of death ? 



Now loiiq at 
Place of Death ? 



Days 



DATK of Ht KiAi. or KKMOVAI, 

^' ^, t 190 . 



PLACE OF RFRIAI. OR KFM<»VAI. 

Address 'SS "\ O.VvCXx^ O.t 



rxnERTAKKR 

( 



N. B.— Every iten, of inforn^atlon should be carcfuMy supplied. AGB .hould ^^T'^^'^'^^'llx .n^oraUon^'Vr''::!.- 
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for pr- 
•ons dying awoy from home should be given in every instance. 



I 



i 



"T»n 



I 




IV .a 



;,! ,,f IU:i!lh l> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

N„ ■ ^ »S^*> 1>& 1' ^o WEPen TO BACK OF CERTIFICATE TOR IWSTRUCTIONa 

754 



^ClA-V^ 



t '^ 



190H 



Eeginlered •N'o. 



ludr Filed, ^Lcc 

"Icrcco'ltx-i Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "a. S. Stan^arD j 

PLACE OF DEATH:-County of C)cc>v ^/vCvv^c^'^Gty of 0<Xm; O.^^^v^cA ^ ■ 

,No llOCUvVOUC*.- St.; 'I Dist.,bet.mwlcav and JM^clouJ!:.. ) 

<NO. V;> V V V- '. r ^ VLV-V . .,,,,,.. RESIDENCE GIVE r*CTS CALLED rOR UNOEB "SPECIAL INroRM*TION • ^ 

( '' ':r:;^.^:\iii:::: ::t.o^^^\\ o%":sn?Jv^ -ve .ts name inste*o o. street *ho .umber. ; 



FULL NAME 



cLurvv 




OLK.U-hj. 



if 



^K\ 



PERSONAL AND STATISTICAL PARTICULARS 
. I COI.OR \ f\ 




1>M i: Of- HIRTII ( 



• Month) 



^xl^ 



\ t . K 



1 V JVv#.v O 



w 

(Day) 



Mouths 



(Year) 



1^ 



Pa I v 



^IN'.l.K. MAKklKI* 
WIlKiWKI) «»K I»IVt»Ki"K.I> 




I'.IK lliri.WK 
si:it«' or riiniiti y 



NAM J- OI 
I AT 11 IK 



lUKTMI'I.ACK 
«•!• I \rHFK 

St:it( 1)1 r.)tiiitry 



M \1I)1:n NAM1-: 
Ol- MOTIIKR 



lUKTHlM.ACK 
Ol MoTHKR 
(Stntf or Country) 



• KCri'ATlON 







T 



..i 



f. ' 



Kfidni in S'.fv /'i an, ir<> v "^ « 1" 



/ ' 



Mnllth^ 



/>.n 



Tin: AMOVKSTATKDI'KKSONAI, PA KTU' T I. \K> A K 1. TK 1 K Ti > Till- 
HKST Ol- MY KNOW l,i;i)t'.K AND HMJll- 



(1 






MEDICAL CERTIFICATE OF DEATH 
I)\TR OK DKATIl 

(Day) 



(Month) ^ 



I go '; 

(Year) 



I IinRKHV CI'RTIFV, That I attended tleccased from 



(\a^ ib 190 .^ to 



a, 



OL., 



■\ 



190 H 



that I last saw h-CAw alive on L^^^A^a '.>. up . 

uid that death occurred, on the date stated above, at -^ l-O 



^_ M. The CAl'SK ()!• I)l':.\Tn vwts as follows 






.& \vx<x- .e.i. 



DlkATION '^ IVtfr.y 
CONTKIIU'TORY 



Mouths 



Days 



Hours 



Ur RATION^ >*<'<'''^ 



Months 



Days 



( SIGNED ) .sJ.N^CLAxCC'3 LU C LLv^iX »-c4 



(L.^ ^ -^ .c^'^ (Addrc-ss) 1^^^%CVV 



SPECIAL INFORMATION only for Hospitals 
or Recfnt ResMfnts, and persons dying d»>ay Irom homr. 



i, Institutions, 



Formfr or 
Usual Rfsldcncc 

When was disease contracted, 
If not at place of death ? 



Now lonq at 
Place of Deatk? 



Hours 
M.D. 

Transients, 

.. Days 



IM ACK Ol niKIAI. OK KKMoV Al 



DAII- <>! m KlAI. or RKMOV.AI, 

^..s^CV'V*--^'^'' ^ 190H 






K ►, 






'Addrt-ss 



nil 



OU 



,V^4^v.^vv 



N. B. Every Item olf Information should be carefully supplied. ^ « ^ * classified. The -Special Informalion" for p.r- 

state CAUSE OF DLATH in plain terms, that it may be properl> wlassltfi 
sons dying away from home should be given In every instance. 









WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,a,. l ..f lUaltl.-K No. i. ^^^^ H-'^t' ^'^ 

Dafc Filed, iLwMpr.vutt 3) l'^0\ 

X^^v^vo "Ajuva-^ Deputy Health Offjcer 



Registered JS'^o. 



^55 



• *^ 



DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco 



Ccvtiticate of 2)eatb 

( H. S. StauDarD ) 



No. 



• PLACE OF DEATH:-Co«nty of C^Oa^ J^^V^L^vc^^Gty of> '^'^^ ^A^v^C. 




\ 



^ VKA^vt^ ^Ll'VVV^V^^^^^^SU -"--"^ Dist;bct 



"and 






FULL NAME 



PERSONAL AND S TATIS TICAL PARTICULARS 

I COI.oK \ 



■■~ ^uU 



iJyxxXjl^ 



DATK <>| HIKTII 



A<".K 



1 1> r,ii»> » 



IS" 

( Day) 



y/.>nf/n 



(Vtar^ 



\^ 



Pit \> 



U'ltJnWKU «»K niVoKi KI> 

Write in MK-i:i1 (W-sivnalioii) 



L 



JUK rnpi, Ai'K 

^-ii!. or (.'luiitry^ 



\\MK ni" 
I ATIIKR 



H1KTHI"I,AI*K 
<M 1 ATMKK 
st.itr i)r (.MHintry) 






MEDICAL CERTIFICATE OF DEATH 

DATK t>H DKATH 

I 

(Day) 



Month) A^ 



irM***"*"** •••*•*•"• 



(Y«»r) 



that I last saw h .A-^nr> alive on LU^v Q 



MMI)1:N NAMl- 
ol MOTHKK 






''1^^.- 



h^ 



ItlKTHIM.ACK 
'>|. MOTHKR 
(Statf or Country) 



,va^\x 



A 



^ 



lvi\4,^V 



euvk 



d c^Lv (X > xd 



IHI'KKnV ClvRTIFV, That I attendc-l deceasea from 

CLw/Ct,. \ 190 ^ 

LmwV d: 1 190 

an.l that death occurred, on the date stated above, at I(-30 
(F M. The CAl'SH Ol- I)i-:ATII was as follows: 

Qju-YXA-Lcfcu. 



DIRATION Vc^^rs 3 Monlhs \^ Days Hours 
CONTRIBUTORY 



Years 



DTRATION y^ars nioni/is Days 

(SIGNED) U) As W^JL 

iXvM:\ '>■ too' (Address) UX 



rqo 



Months Days Hours 

cv M.D. 



SPECIAL INFORMATION only 'o^ Hospitals, Institutions, Transients, 
or Rfcent Residents, and persons dying away from home. 



•^ )'rnr^ 



M,,»tli.< 



D.ns 



OCei I'A TION 

Rfsulni til Sail I'l an< <>'' 

THK ABOVE STATHOrKKSONAI. !■ \ Kiur LARS ARH TRlH 1«) 
HKST OF MV KNOW 1.1:1 Hi H AND in.l.H»- 



(Informant 



iA^O^^vl^ U 3^ofv^>-uJ^^ 



f \<l<lres«« 



LUC'>WA^ 



X,<>.v'>->M, 



When was disease contracted, 

If not at place of death ? 



Days 



I'l ACE 01- BrRIAI, OR ri:m"Vai, 



r.NDERTAKKR 

fA<Mrr«5S 



DATE of Itt KIAI- or REMOVAI, 

LLv^^ 3^ _ T90H 

3ii%- ^"^ -ti. :^^ 



i^«^«i^^— ^"^■^^^^■^■""■'^^"^^^"'"^"^""'"^"^ * i FXACTLY PHYSICIANS should 

, ,„.on.atlo. .hould be ..e^uH. «uppned ^;^^^^;,7;,^,^k"i!"^He ••Specl.i lnfon„,«t1o„" .or pr- 
OF DEATH Jn plain terms, that .t ma> bf P^"P 



N. B. Every item o^ 

state CAUSE OF DEATH in p.—. -V" ;: , instance, 

son, dying away from home should be fe.ven m every 



I « 






^F 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

, ,„ ,„„.,.„ ,..r,-^„.,.0., ^ REr.R TO BAC. OP C.RTTICATt TOR .NaT.UCT.ONS 

„., , I V - 4- ^ TJn^ Registered ^''o■ 70D 

Diilc l-ih'd , ■ 



^ lOO'A 

i^^^^\L^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bcatb 

( H. 5. StanOarD ) 



PLACE OF DEATH: -County of -^ CUC'va>^Vt >vU City 



;ity of ^ <^JL/VU.v 



X UA^CaM^LcL 



L\. 



No, 



St.; 



Dist.; bct/ 



md 



-r-) 



/ .r OtATH OCCURS AWAY .ROM USUAL « "^ ^f.^^JV^^^J^, 
t IF DEATH OCCORRtO IN A HOSPITAL OR INSTITUTION 



r FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \ 
GIVE ItI name instead of street and NUMBER. J 



[..UXA/CLu. 



PERSONAL AND STATISTICAL PARTICULARS 

COI.<»K 



I)ATK ni lURTH 



(ilonth) 



Id 

(Day) 



V 



-UjL 



ALX 

(Vear) 



AC.K 



MEDICAL CERTIFICATE OF DEATH 



DATE OF Dl 



IvXTH 1 

LWa 

(Month) /T 



I 
(Day) 



(Year) 



T in'.RinvS^^'^'KTIFV, That T attcndcl deceased from 

190 — ■■ to ' 190 — 

that T last saw h ' alive on ^9° 



•-IXt.I.K MARKIKD. 
XVIIMIWKD OK DIVnRiKD 
Write in Mx-ia! <l<'«»i>?iiati«>n) 



HIKTIIPI.AOK 
(State or Country 



N\MI-. «»1- 
FATIll.R 



mRTHIM.AOK 
(»l I ATHKR 
•Statt "ir Country! 



mmi)i:n namk 

uj MOTMKR 



lUKTHI'I.ACK 
nK MOTHKR 
'State or Country) 



A 






r,,,,, an<l that .Uath .KTcurred, en the date stated above, at - 
— M. The CAI'SP: OF DIvATII was as follows: 



C^U. 




% 



iZ'XXAV 



3,1 



(D ^ 



Oc-a. U^A-A^-!* i-^ -S«^4L<X..QL-.«- 



Dr RAT ION yt-ars 

CONTRIIUTORY 



Months 



Pays 



I /ours 



DURATION 
(SIGNED) 



) 'cars_ 



jrofti/is Days 



Hours 
M.D. 



ars jioHi/is 

SIGNED) vv.l\0M)Wtv.. .... 

T~" . ^».. ••ri/^Ki nnlv fnr Ho^Lttitals. In^titutioiS. Transit 



vc-^a_a<i w_ 



OCCITATION 

Kr sided in Snv rmihisro ^ )'t7i> 



.\f,mfli^ 



/hivs 



IHK AHOVK STXTKD PKRSONAl. I'ARTICrUARS ARK TRlH TO THK 
HKST OF MY KNOWI.HDt.H AND lU.lAl.f 



(Informant 



Jk^C^LiXXA^ 



"" SPECTAL INFORMATION only for Hospitals, InstitufloiS, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at plare of death ? 



How loRQ at 
Place of Death? 



Days 



PLACE OF m-RIAUOK KKMoVAI. 



DATF^of Ht KiAi- or RF:MoV.M, 







(Ad«lress 



(AfMress 



— ^ ^M^M^— ^M^^^— ^ . EXACTLY PHYSICIANS shoula 

N. B.-Bve.. Ue. o. InW.a.on .Hou.d .e ca.e.uH. auppUea -^l^^t.l^.a, %He "SpeCa'. .n.o....W^ for pr- 

•tate CAUSE OF DEATH In "'«'" ^V*"*' '**" J^.rery \n^KnZ^' 
Ron. dyinft away 5rom home «liould be ftWen .n every 



■^ 






WRITE PLAINLY WITH UNFADING INK 

!h,/(' /'V/^^r/, LLv^vcA.t ^ -^^^^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFtC^VTE FOR INSTRUCTIONS 

Registered J\'*o. 



DEPARTMENToIf public HEALTH=City and County of San Francisco 



.i|; 



s H 



■.| 






Certiticate of H)eatb 

( •a. S. StanDarD ) 



\ 



( -a. S. 5tanDarC» ) 
PLACE OF DEATH-.-Countv ofC^C^'^VO^--^- CUy of ^a^ J,Va^..a. 



No. i^^ 



r ?lri^"^" ;:n^^^ :^^-?^" 'S'Sfe r:i:?iJif:i-i^=^r'^ 



aA.n.a ) 



FULL NAME 



„toi 



.a^u jL vJ^ai^trA 



PERSONAL AND STATISTICAL PARTICULARS 



DATK <)! niRTII 



I 



COI.OR 



lo.L-u 



• Mouth) [1 



(Day) 



AHC... 

(Vear) 



A«-.K 



Ip3^,V.,.< 11 ^'"'""^ 5..^ An> 



MEDICAL CERTIFICATE OF DEATH 



DATK OJ- DKATH ~1 , 

LLcNwQAV'VV 

(Month) J 



(Day) 



(Year) 



NlXi-.l.R. MARKli:!). 
Writiiii >-(Hi:il (!«->>tv;nati'>ii) 



UIRTMIM.vrK 



\ \M»' Ml 

1 atiii;k 



niK TMlM.ArK 
OF ! ATHKR 
"^t:it« or Country^ 



MAIUl-.N NAMK. 
<>l MOTMKR 



lURTHI'I.ACK 
<»I MOTHKR 
(Slate or Country) 




vc" 



<X') 



A 



C> vuLcL vvcL 



rilKUIvBV CHRTIFY, That I atten.UMl .kcoasea from 

Llvua ^ 190H to ^^ ^ 190H 

that I last saw h•^^ alive on JwA^ X 190 ^ 

aii.l that .Uath on urrc.l, on the .late stated above, at S 
M. The CAISIC OI' I)i:ATn was as foll.ms: 







? 





(SIGNED) i ^' ^^^ n ^•^' 

VLAA. q .*. TOO \ ( A.Mnss) ^ .^1 

SPECIAL INFORMATION only tor Hos|Mtals. listltutbis, Translfiits. 
or ReTfnt Residents, and persons dying away from home. 




'H CII'ATION 



I i(i\ 



TnKAm.VKSTATKI)PKR.c>NAirART|.rjARSAKKTRrK TO IMK 
HKST OF Xn KNOWM-njjl'- AND Ul.l.Ill 



(Iiifotmant 




/ \<l<lrcss 



IX. b- -^7.*' '»•''•"•• 



VoJA OT- 



Former or 
Usual Residence 

When was disease contracted, 
If not at piaf e of deattt? 



law lomj at 
Place ff Deatk? 



Days 



I'l.ACK or niRIAI. OK KHMOVAI, 



UVMA- 



DA IK of HiKiAi. or RKMoVAI, 

I90S 









(A<Mrc'i«« 






i 



^_^^,^,^^^,^^,mmmmmmmmmmmmmmmmmmm^mmmmmmmm^<mmmm^— FX4CTLY PHY8ICIAN8 should 

state CAUSE Ot- un^ • " »- A'.ven in «very inatunce. 

son. dylnft away from homo should be 4'ven • cry 



4 



Pfvird <»f II 



WRITE PLAINLY WITH UNFADING rNK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



...Ith-K No. I. -i^r^^ lU«tPCo 



Registered JSTo. 



Ihf/c Filed , LLa^^^w^ 'h ^ '^ ^ H 

K^^^^ Ajuxnm Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



rt 



Cevtificate of Beatb 

{ H. S. Stan^ar^ ) 






PLACE OF DEATH : — County of ^ ^ ^ v -' -^ O/^A^Ul (^OUty ot ' 

Pi ^. ^ Dist * bet. MKou^^^r>v andJ.oJUx; 

^'^'^M- . _.-S!-^^cE a.Ve ^CTS C^LCO .or under •special .NrORMAXION- \l 

^,?UT^N G,ve';i NAME INSTEAD OP STREET AND NUMBER. J \] 



No. \\^\ 



) 



( " »■™ec^^•"cV,"r„o".^r.t :i^:s^p^^i< 



FULL NAME Uva.t->xva 



(tAxjOuoo- 



Sl"\ 



PERSONAL AND STATISTICAL PARTICULARS 
D.VTi: ul niKTll -. «v -N 



'lO.Lu 



xr.K 



12l v, U 



M.mlh^ 



11 



Al V: 



MEDICAL CERT IFICATE OF DEATH 

DATK OF I)H.\TH 



LIs^vol. 

{Month) (f 



.;ts.... 



(Day) 



(Year) 



I III'RKHV CI'RTl^Y, That I atteiKk-.l (leceastHl from 
l:^ 190 N to ;::^^-^-^-^ ^ ^90 H 



ds 



\vn>«>\vi:i» «>K i)!v«>Kri:i) 

Wiiti ill x<K-ial <1. sitfiiatioit) 



HIKTHI'I.XOH 
iHtati- or I'oiintt v^ 



lATIlHR 



mKTIlI'l.AOK 
OK I AIJIKR 
ist.iu itr Ce)iiniry) 



MAI1»i:n NAMK 
01 MoTIIKK 



lUK THri.MK 
«»1 MOTIIKK 
(St;i!« •)! CulltltJvi 






JL 



(T 



^cr\KX >v>x*^ 



V^jLaXj^ 



a 



CuU 



V 



that T last saw h •• '^ alive on WWVa^ <^ 190 . 

an.l that iloath ,»ccurre.l, on the date stated above, at 
M. The CAISI*: OF DKATII was as follows: 






,0) 






)V(M 



M'Oith' 



lhi\ 



• HCl I'ATION 

AV ' /V/c(/ in *^it ^ ^ 

Tln^Am^VKSTATKI».•KK^ONA^ rXKTU-ri.AKSAKKTR'HTo Hlh 

BKST OI- MV KNOWI.KIM.K AND Hl.I.ni 



^1 



(Itlfiitliuitlt 



( \(1«lrfss 



K^' >\^ 1, 1 .1' 



DI'RATION rears Months j ./^p 

coNTKinrTOKV lO^tJ^^-^^4'^^^ 



(SIGNED) L0l\JU "OXV^^vHtlt 

duun ^ .00' fA.Mrcss) ioOn LUoaJL 



Hours 



.Q -6 i<)0 
■diAL INF 



w 



/fours 

M.D. 

1. 



^ 



SPEdlAL INFORMATION only for Hospitals, Inslltytions, Translfits, 
or Recent Residents, and |>ersons dyinq a»»ay from liome. 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of death ? 



How lent at 

Mace of Death? Days 



ri.A 



[90H 




\U OK KKMOVAI. I DATKof »« rial or RKMOVAI, 



fA<Mre«*« 






-i^^^.^^w^^^^— ^*— FVACTLY PHYSICIANS nhould 

^ .. %*iieF nF DFATH n p ain termH, that it ma> "c i» 
state CAUSE OP wt« • " ^ Aiven In cvory instance, 

son* dylnft away from home should be ft.ven 



P 



!| 



« 



-fji 



nn;,r.l nf Ml mUIi-H NO. »^ ^'^ 



nSiVCn 



WRITE PLA.NLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

RtFER TO BACK OF CERTIFICATC FO R INSTRUCTIONS 

^ ., ^ Registered A^o. 7oJ 

Ihtfr Fifed, 




t'A^-^^-*-^^^ 



,t *^ l'^0'\ 

UoKw Deputy Health Officer 



DEPARTMENT OF PUBLIC llEALTH=City and County of San Francisco 



Cettlficate of 2»eatb 

( XX, S. StanOarO ) ^ 

9 % -^ 



(^ 



PLACE OF DEATH : — County ol ui- t v v 



) 



FULL NAME 



J^Ko-vuLli. 



s,.:x (^ 



COI.OR 



PERSONAL AND STATISTICAL PARTICULARS 

L 



UATK «>f HIRTH 



lllk^tx 



1 Month > 



15- 

(Day> 



(Year) 



ACR 



^XH Tmm * 



.1 /.»»//// 



n 



.U^.lV.VC'^fc::^ 



DATE OF DKATH 



MEDICAL CERTIFICATE OF DEAT H 



4 

(Month) A 



,.,.X... 
(Day) 



(Year) 



/)<» v.< 



SIN'<;i.E. MARKIKP. 
\VIIU»\VKI> OK I)lVnKiKI> 

Writtin *.«K-ia1 (lisivrnali-'ii* 



^.A^VOVt 



*>t.it< or «,'imntry 



NAM I- <»1 

I A Tin: R 



HIK IMIM.At'K 
Of « AIIIKK 

'St;it< or Country) 



MAIDKN NAMK 
<»l MOTIIKR 



niRTHPKACH 
<)l- MOTHKR 
'Statf or Connlry) 










,C/>^v1^d^ 




" ThHRI-HV CI'RTIFY, That I attended neoeased from 

Llu. ....^-i 190 H to iU-^c^ a. 190H 

tliatllastLh^v -aliveon LUa^. :^ 190^ 

and that death occurred, on the date stated above, at 15^ 
[J_,yi^ The CAl'SH OK DKATII was as follows: 

^ ^, \-,^.-r 1A»;//Av /^<rrv '^^'31 Hours 

DIRATION ^ ^, Monins ^ i^u) 



DIRATION 



Years 



J f on //is 



/)avs 



Hon 



rs 



A 



(SIGNED) i K^^^^ ^^^■. 



k' 



LLaw-Nw^ 



a. 



IQO 



rxddress) ^^i^ C^Xs^tU^^ ^i 



«KC THAT JON r?\ 



yf,.nlli' 



Ptl vs 



(Informant 



C)-A^ A^ V. 1i.^>-^ 



■<5prClAL INFORMATION only lor Hospitals, lustilytlons. Transifnts, 
or RfTflit Residents, and persons dyin!) a^ay from home. 



(7) \ fit How lonq at 

ERe'sldence llHr hx^^k<^^^^ ^ict of Death? 

When was disease contracted, 

If not at pl ace of death ? . 

n.ACK OK nVRIAI. OR RKMOVAI 




Days 




k 



llKsr Ol- MY KNll«l.r.l><-.h AM> HlX^.f 

(II - -^^ 



(\.l.lrc«i EXACTLY PHYSICIANS should 



OATLof BiKiAi. or KKMOVAI« 

LLvv/Ql H T90H 

INDhRrAKKR J C A . 1- 1 ^3 



m ' I 



II 



WR.TE PLA.NLV W.TH UNFADING .NK-TH.S .S A PERMANENT RECORD 

__^ BEFER TO B ACK OP CERTIFICA TE rOR INSTRUCTIONS 

,.f M,-„ui.-i-N-n...i>^^»i''"-'-" — ■' ' — " ^yan 



1 



Deputy Heafth Officer 



Registered JVo. 



DEPARTMENT O^PUBLIC HEALTB-City and County of San Francisco 



Certificate of 2)eatb 

( •a. S. StanSarC ) j. 



lt?'> I 



PLACE OF DEATH: — County of^-tvi^ 



0- 



No. 



,/T^ AAA* ■«.»>-» »»^-- - / 

XduV C^^vv^du ll^^^^ '\^■'-:^«^i„-:^ 



FULL NAME ll'JlU^>-'^ 



) 



SKX 



PERSONAL AND STATISTICAL PARTICULARS^ 

I COI.oR 



DMK ol- lilK I II 



A(-.K 



CnicJU 



lui^t. 



Qi 



M.Hltll» 



(Day) 



m 



LI 



^ 1 iw„. "l^ iroHths X 



/.Xi..iS.^\- ■■ 
(Year) 



Pars 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH ^ ^ 



(Month) A 



(Day) 



I go \ 

(Year) 



Ti1HKI:HV CI-RTIFV, That I atten.lc.l aeccasc<l from 

^. - ^ .-^v^ to .. V Ja^ ..2j L 190 H 



190 






■>»IV«*.I,R. MARKIKI* 
\Vn»M\VHI> OK DlVnKCH.n > 

Wntf in stK-ial <lt-Hivnati'>u) 



1 



tlSat I last saw h ^ax.alive on ^vi^ ' ---^ '« ]^^ 

a„a that .Uath occurred, on the .late stated above, at 1 - 
OL M. The CAl'SH OF I)I':AT1I was as follows: 



IIIKTMIM.ACH 
•^t.itf iir CxiititrV 



I A riir.K 



ItlKTHIM.ACK 
Ol FATHKK 
st.itt or Coiintrv 



MMUHN NAMK 
<U MOTHKK 



UIRTHIM.ArK 
Ml MOTMKR 
(Siatf or Country! 



OCCri'ATloN \ 



I 







xc'^'- 



/ 1 



\)i 







IHRATION Years t Months ' Pays Hours 

CONTRIHITORY 






DIRATION , year^ ^ ''^''"^'" 



Davs 



Rfsnir,1 in Snn /»«»f >/>''> 

^;vo..A a. ^^^^t^ 3-^ 



(SIGNED) 



1^ ■ 



//ours 
,Okyv\j M.D. 

( A'Mrcss) >^^ 



WwX< 



^Xiii \\'^ ^"-a • 



SPECIAL INFORMATION •-•>'.' H«HUh, I.Mit.li..S Ir«sfc.ls. 

Wliffl was dlsfasf cwitrartH, 

If wtat^laretf^atli? — 



AAaA'VlaJtl. 



'^ 



,«-\AAa- 






DATKof Bi KIA? or KKMoVAI, 

LLwci S..™« ^90^ 



USDH 



(Atl<lrt<«s OV l>^ 



!N. B. 



<^'^'^re<^^ A-AA/V^^V^ ^ ^^ Iiriir- .hould 



v.i- 



:^4i 



■ i' 



•i-' 



I 






i,4 



WRITE PLAINLY WITH ONFADI 




NG INK-THIS IS A PERMANENT RECORD 

BBFER TO BACK OF CERT -'"'"r FOR IN8TRUCTI0N8 

761 



ioo\ 



-L^ il^., Deputy H..Hh Officer 



Be^lstered JSI^o, 



DEPARTMENT OF PUBLIC HE ALTH-City and County of San Francisco 

Certificate of ©catb 

( H. 5. Stan^arO ) 



No. 115 1 LUu^^^^ 



St.; I Dist.; bet. 



.\Ax 



i 



.Uk* 



i l^ , ^-N^ St.; ^ ^*^^-^'; ■/oruiW" 'SPCC.AL.NrORMAT.ON-^l 

i L^-> V^^ 'r^ • RESIDENCE GIVE TACTS CALtCO '0« "'^J'^J ^'^.^ AND NUMBER. ) 

( ,r OtATM OCCURS AWAY r^ROM USUAL „ ^^^^,^^^,Q^ ^,vE ITS NAME .NSTEAO O 

V, ir OCATM OCCURRCO IN A MOSPIT i. ^ H (^ 



and >v<X.U^A.<^.. ) 



FULL NAME 



— ^- 



vLX, 




SKX 



«? 



PERSONAL AND STATISTICAL^ARTJCU ILARS^ 

I COI,<iR 



DA IK OF IMR III 



,^^<XAJL 



lo.lvJL. 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



lllttl) 



1 

(nay> 



ASS 

(Year) 



\f*.K 



ul 



(Month^ 



tr 



.1. 
(Day) 



(Year) 



V 



rnrRi:R'vl:';RTIl'V, T1...t I |.tte.i<to.l .leccascl from 

.V-W^ X I90H to aVV^..:j« TOO'. 



LL^-\. 



^ 



11 



) III ts 



M.,t,lhs 



1.1 



Af \s 



fsINi*.!,!?. MAKUIKO 



UIKTMIM.AOH 
(Statt- or CoMHtrv 



N \MI. of 
I 



\WV. ni- / \ 

\thi:k V^ \ 




II ,. V jLA^v. Q \ IQO • 

tliat llastsawh ■.-'Jalivcoll WWVAi^ v- 

a„.l that -Icatl. (K.curre.1, on the .late state.l al-nve, at 
- M TheCAlSKOl- DK.Vril wnsasfomms: 






^\>^LL^- 



HlRTlirUACK 
01 I AlllKR 
iSt:it« or I'linnlry) 



M \ini-N NAM! 
<•! MOTMHR 



lURTIM'I.AOK 
01 MnTnF:R 
(Stale or Country) 






DURATION ^ )<'^'"^ 
CONTRim'TORY 



iLlLcl.lL.cv^-- 



• Hours 



DIRATION 



)V<7r5 



(SIGNED).. ts.l.'l-X'v'^CC^ 



Months 



Pays 



f fours 
M.D. 



I()0 



H ( 



A,l,lress) ^bS ^-C^tU^ ^^ ' 



/)(n5 



lil-STOl- MV KNOWl.KIX-h AM> HKl.lhl- 



(Informant 



"information only t.' "o'lHtaK I«IW.I1«'. I™*"'- 

How lonq at 
Former or piare of Death ? Days 

Usual ResMence 

Wlien was disease contracted, 

If not at ^»t of deat h? — 

-.cKoHBrKU..oKK...«....:r| uvrK "' ...".-•" "-^x--^ 

U-v^vO H T90I 



/ ft ^l^lroKS ^ V 



(Address 




10- "S LH ax I ^_.«_-— — — — — — — — ^^^^ 

^Address '^ ^ ■■ i pHYSICIAIS 8 should 

N. B.— Every Item -» «"J«7?1»S",;*;T;,^„ term" that It m»y He properly cl...lf1ed. Th 
•tate CAUSE OF DEATH In P "»" JY"' :„.„ ,„ .v.ry In.t.tice. 



Vt.te CAUSE OF DEATH In »;'-;;,;-";;;,„",„ .v.ry In.t.nce. 
•on. dying -w.y from homo .hould be ft.ven 



II 



WRITE PLAINLY WITH UNFADING INK 

„ ,, ,., .■,v„,.^^V..>«cPC-„ __ 



THIS IS A PERMANENT RECORD 

„PeR TO P ACK OF CERTIFICA Tr TOR IN3TRUCTI0N3 



7G52 



1 1 



a 



I hill' Filed, Ll^-^^vc4t "^ 

\^ u> IoLavm Deputy Health „ 

DEPARTWENT OF PUBLIC nEALTH=City and County of San Francisco 



Officer 



Cevtificate of Bcatb 

( "a. S. StanDarD ) 



PL ACE OF DEATH: -County of O'COVOV^ r p 



i. 



X and'^K^^ ) 



No. 



V \r DIATM OCCURRtO IN * HOSPIT-l- /> \ f\ (\ 



FULL NAME 



L.^ ^- "^^ 



.Sr.'.CX/.>. • ^ 



Ni:\ 



TThsonal and statistical particulars 

I COI.OR 



i 



nxTK «»! lUKTU 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH ^^ j, .^ 

(Day) 



(Year) 



iM..uth> 



A«-.K 



oiv-t xs >vii»> 



(Dair) 



MoUtll!^ 



(Vcar) 



l\iy 



TnivKluTY^TRTIFY, That T atten.UMl dereased frr>ni 
that Hast saw hr—- alive on 







\viiMi\vi:i) OR nivnRi i-.n 

(Write in sixial ilt«^iriiati«in) 



lUK TMlM.Av'K 
I Slate or Count ry> 



N \MJ" oi- 
1 ATHKR 



niRTIHM.Al'K 
OF I ATHKR 
iStntt or Comitryi 



MAIDKN NAMK 
OF MOTllKR 



HIRTHIM.ACK 

OF mothf:r 

(Statf or Countryt 



V^ 




„,.,, that .Ua.l, .Kcnrrea. on ll.e .laU- stated a.Knc. at 
J, The CAl si; t)l' I>i:ATI1 «as^as foll.-wst 






/\A.<6^^^>'* 



I)r RATION >'«'"''^ 

CONTRIIU'TORV 



.1A>;/M5 



/></i'.? 



J Jours 



ti 



ti 



DIRATION 



-Lec^al information "ly ij'»«'""^. '"^'«»«'«- '"'""'^• 



OCCV rATU)N J( 






nF:sT OF MY KN*)\M«F. I ><•**• AM' 



Hon lonq at 
Ptarf of Dcatl? 



D«ys 



Former or 
Usual RcsMfnce 

Whffl was disease contracted, 
If not at place of deatfi? 



II HOI *l Fi«»«^'" _. ^— ■ t,T,-vi<»vM 



(Iiiforniaiit 






rNDKRTAKKR W^^^^^v^ 



d^.A^^^.^k^^^''* 



T90H 




iHtiv'-^i 



fArUlrcss 6bn O "^^^^^^^ ,, I ^PHYSICIANS ahould 

state CAUSE OF fEATH .n P »»'"** .^,„ ,„ .very instance, 
ann. dylnft away from home ahould be ft 



pi 



r I 
I 



m 



:\n 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,, . , „. „..:. uh-rNn...^^^:M>'^»'Co REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS 

763 



Da/r Filer f, \Xv>L/avvAX .3i .1^0^ 

4' fl 



Registered JVo. 



iLtrv^ v> \!c\j^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccitificate of Death 

( XX. S. StanDarO ) 

SI ^ ■ -^ 



% 



PLACE OF DEATH: -County of^ CU>V Jxa^V^X^CjCity ol^^C^ ^i ^<V>^CvXi C^ 
No SS Ov^jk St.; 1 Dist.!bet. JaivUS and M I UL4. t :. v ) 

iNO. VJ I V .-W-W WT^ ..-.,-, orcsinFNCF Giur FACTS CALLED rOR UnLeR "s PECIAL I N FORMATION" A 

( -^ r."o7AT°H"o^c"u%rcV.;"rHo".^rAt o^'?,;s^'.?J;^"v.;ETTl s^ame ..steaJJof street a.o bomber. ; 



FULL NAME 




"Xyyjj)^^. 



lL>t^ cU^'^ vtik; 



PERSONAL AND STATISTICAL PARTICULARS 



It\ i J", ol- lUKTU 



Ai'.R 



0x1 



iM'.tith* 



^L ll^l- 

(Day) (Year) 



O V Vt'ats I 



M.nilhs 



Pavs 



SINT.I.K, MARUIKO. 
Wn><)\Vi:i> OK DIVOKCKU 

\\ tilt- ill s(K'ial <l<«-i»?nati'tii) 



MrLa^w\,u 



niRTH!T,\rK 

stall (ir Connlry^ 



NAMK OF 
I ATHKR 



niKTHPI.AOK 
<>! lATMKR 
'Statf or Country) 



MAIUKN NAM!-: 
Ml MoTHKR 



lUKTMJM.AOK 

Ml MOTIIKR 

' Stale or V-uiintrv' 



<Hil I'Ai ION 






^)\^.> 









h'CMitfd lit Sil'i r'i,tli.:rn \ '• )'>ii. 



\r,,>fii< 



n.n 



Tin- AH<,VKSTAT»:i)l'KKSnN-ALI'AKTir!I,\KSAKl-:TRrH To TIIK 
1U:>>T Ol- MY KNoWMvIX.K AND MKMl-.H' 



(li 



3S ^XK\X '^^ 



(A.M 



DATK OF DKATH 



MEDICAL CERTIFICATE OF DEATH 



iL 



(Month) 




(Day) 



(Year> 



I HRRHBY CRRTIFY, That I atten<le<l dcccase«l from 

V^ i-^ ^9o'i to V^ ^-^ '^^^ 

tliat I last saw li-.^tA; alive oti /|'A.Ol\^. ^ I90 • 

and that .Uath <)Cinrre<l, on the date stated alK>vo, at \X 

•^ M. The CAl'SH 1)F DIvATII was as follows: 

^J .V^Ct-TLvQ^N^ U ^.sMnl^>,^rys.xiX^M 



I)i:r.\ti(^n 

CoNTKim'TORV 



) 'cars 



Months 



Pavs 



Hours 



Years Months Pays 

Cii) 



or RAT ION 

(SIGNED) L' . d . 3J <^VNr>% J^ 



/fours 
M.D. 



■CIAL IN 



SPECIAL INFORMATION only for Hospitals, iRsUtutions, TransifRts, 
or Recent Residents, and persons dying away Iron home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How I0R9 at 
Piareof Death? 



Days 



PI ACF <H lU KIAI. Ok KKMM\ \l. I l>\|-^of IUkiai. c,r RKM<»VAI. 




(Ad(lit-*s 



Hl'^ "^^o^ldjt...' '^loX^Xl^' 



N. B.- 



""^ TT ,. . *r.E should b« statetl EXACTLY. PHYSICIANS iihould 

of information .hould be cnrefully |.uppl.ed. ^^J' "77*;"^^,'j. The -Speci.l Information" for p.r- 
E OF DEATH in pinin term., that it may be properly claa.iflcd. ne pc 



-Every item 

state CAUSE OF DEATH in p .«..«„« 

Ron< dyinft away from home should be ftiven in .very instance. 



\W 



:i 



i 



IJoai.! "f !U.<Itli- »•■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

V. , , . ^PS!?* >* PC. REFER TO BACK OF CERTIFICAT E FOR INSTRUCTI0N3 



I)(f/r hllod , 

i 



vvn^vxit ^ I'^^O^ 

Xt-LKu Deputy Health Officer 



Re^isteved J\^o, 



764 



DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 



Cevtificatc of Bcatb 

( Ta. S. StanDarD ) 






No. 



PLACE OF DEATH:-Coonty ofOaAW^ --va^v^co City of ^V^^^ dA<VwtvAC^ 



xcarvv St.; 



Dist: bet 



and 



-) 



^ :,. 



ATION 
BCR. 



) 



FULL NAME 



IE J .<x^.\A^-kx^ \v|Ux 



m:x 



PERSONAL AND STATISTICAL PARTICULARS 



lUalU 



It\l J", ul HlkTM 



\«,K 



(MAnth> 



(Day) 



,90H . 

(Year) 



J ■»•<; » .« 



Months 



a3> 



A/ij 



•>1\«.I,K. MARKIKn 

W II>»»\VKI> OK I>IVo«rKI> 

Writf ill social ilf«»iK""tion) 



lUKTm'I.M*!- 
stiitf or Country^ 



I ATM IK 



A • t 



HIKTIHM.ArK 
«)l- I ATHKK 

'.St:it« or i'outiti V 



MAIUKN NAMK 
Ol M«)TnKK 



r.TKTHPT.ACK 
(>I MOTIIKR 
'State or Countrv'* 



• K 







AO^^"vxa.AA^ 



AVwV/f*<.' Ill S,in /'iiin<i''ii 



J V-(f ; < 



yf,,>i'li- 



/'i; 1 



THK XHOVK ST XT! I) l-KKS<.NM. I'AKTICr I.AKS AKK TRIK TO THH 
HKST OI- MV KNoWI.IIXiK AND HKLIKH 



fliifoniinnt 



(AfUlress 



45 JA.li>^vrv c^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



.LLcv-q- 



(Month) 



1 

(Day) 



u 
(Year) 



I III' Ki: BY CI:RTIFY, That r atteinU-a .IccoaHcd from 

kviu. -^ 190H ^"(> r fi"^^ ''^"^ 

that I lalt saw h AVrialivc 011 Y^^"-)^ ^^ '*^ '* 

ami that death occurred, on the <latc stated ahnvo. at 



H 



CI M The CVl'S!': OF DIvATII was as follows 



A^ 



DTK AT ION >V'<7;-^ 

CONTRir.rTORY 



Years 



Months 



% 



Days 



Hours 




Months 



Pays 



J /ours 



(Addrc«;s) 5.5 00 Ja^CUa 



vfr\i. 



M.D. 



Special information ©"ly *«r Hospitals, Institutions, Translfnts, 
or Recent Residents, and persons dying away from home. 



former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 
Place ot Death? 



Days 



1-I.ACK«»F HIRIAI, OK KKMoVAI. | DATK 0} lU riai. or KKMoVAI. 

LVvvOi 3 190*1 

tNDKKTAKKR ^ ^ -^ ' ^^ ^- v) AVVAAV<V - v"^ U 






\jL4-J-. 



(Ad<iross 






wr>A ^t 



V 

? 



i 






<D 






In plain term., that It mi.y he properly cl»M.«cd. The »pec . 



IN. B. Every Item of information 

state CAUSE OF DEATH in p • i„«tance. 

•on. dying away from home should he ftiven in every instance. 



I 



m 



f 



llOMll .^f H 



WRITE PLAINIV WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,„„ , so ,. iCg|^ uScV CO REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed , LvSwVqyuv^bfc \ 



100\ 



BegLstcred JVo, 



Deputy Health Officer 

DEPARTMENT 01^ PUBLIC nEALTH=City and County of San Francisco 



Certificate of IDeatb 




•U. S. 5tan^ar^ ) 



■si % 



PLACE OF DEATH: -County ofC^/CV^v W->XC^^C, Gty of ^/OA^ J^VA^^^C^ 



No. 



ink 



,t>\-'l<i 



St.; X Dist.; bct."^ Cyl<i 



iy\) 



D,at.i 



i and vl'UA.' 



, . ,,e,,., orSIDCNCE GIVE FACTS CALLED rOR UNDER 'SPECIAL INroRMATION" "V 



) 



FULL NAME 



^ ,CVQ-V^\AXC 







.^•v/w. 



■11 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



■If 

DATH MI- HIK III 



\, 



i\.K^^.ji^ 



• Moiithi 



MW. 



\ <K )V'rt».» 



(Day) 



MoMths 



/Hi 

(YeHr> 



1 r 



/></!> 



SI\«*.T.K. MAKKIKIK 



IUKTMri,A»'K 

' Stati <it t '.1111111 \ 



NAMl- Ol 
» ATIIIK 



HIK lUfM.ArH 

Ol I A Tin: K 

'Sl:Ui iir iOiiutry) 



MAIUKN NAMK 
Of. MoTUHR 



HIRTIIIM.ACK 
«H- MnTHKR 
'St.itc or Country* 







JusJO\^. 



occri 



3 /^A tt-fr\j '-^ vhJL 



Kfsitifii in Siin I'l ,i,i. i <■< 



UoXliu '^o. 



JV,;/ 



\r<,iifh- 



fhn 



Tin: AIU>VEST\TKI>»'KK^ONAKl'AKTir( I.AK>^AKKTKrK "* ""'" 
HKST OF MY KNO\VI.i:i><VK AND lU-.I.Il.l- 



(Iiifonnaiit 



% x>. 



iXAihv^^ 






MEDICAL CERTIFICATE OF DEATH 
DATK Ol- I)1:aTII ^ 

LVv^Q ?^ 

(Month) <»>ay' 



(Vtnr) 



I ni:ki:»V CIIRTIPY, That I atten<UMl «!eivascMl from 
lL^^O 1 Kp'i to LLcm3i 3 uro\ 

that I last saw h -.^A alive on lUvC| 3» H MiilUvigo % 
ami that «U>ath (Kxnirred, <»ti the date stated above, at ' 

. :J M . The C A r S E OV I ) I ' A T 1 1 was as fol 1« »ws : 
L aX CLh^ i vcx,L...U/:>:UJLA^.V-Vv^:yv^sx. 



►^^♦•^r*-'^ 



CONTRIIU'TORV 



Hours 



nrUATION 
(SIGNED) 



Years 



Mouths 






Days 



Hi 



nirs 



M.D. 



lL^Q H Too'^ (A.Mrrs.) ^iCq lOxU^U^i, il 



gp-^|^l_ iiMPORMATION onlv to*^ Hospitals, Institutions, TraRsirnts, 
er Rttfiit Rfsidcnts, and persons djing d«»d) Iroro homf. 



f ormfr or 
Usual Residrncr 

Whfn Has disfasr fonfraftfd, 
If not at place of death ? 



Hew iomi at 
Plareof Death? 



Days 



IM.ACH ol IUKIAI. OR KKMoVAi. 




ini)i:rtakkk 



lu-N^'^^>i 



't 



DATI^of HrKiAi. t)r RIvMOVAI, 



■» p -if 1 ' 






I 



1 






^ 




^ 
^ 



3 



' , .. .. . 7^ -soulcl be Mated F.XACTLY. PHYSICIANS should 

N. B._F.very Item of Information .hould b. carefully «uppl.ed. ^^^ '"^ classified. The "Special Information" for per- 
.tate CAUSE OF DEATH In plain term., that .t may be ^J^J^^J^^ 
aon. dying away from home should be given .n every Instance. 



H.ui;<l "f IliJiUh— l" No. !«, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H8:1*CNj 



Registered J^o, 



7G6 



/(' I'iU'tl, U-Vaxvva^ H I'-iO S 

n J \ 

X«rvow Xtv^ Deputy HeaRh Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "Q. S. Stan^ar^ ) 



No, 



PLACE OF DEATH: — County 

I' \ \ ^\ 



o£'.'/CL^>V'^'/ 



/OL r\-' ' >V<X/^ v^v.^ e< City 



< City of '^^ 







Dist.; bet. 






"^nd 



LLEO rOR UNDER "SPECIAL INFORMATION • A 
SIlAD O? STREET AND NUMBC" / 



FULL NAME 



tr<L 




UIX^ 




.■Y.\.\J.... 



si:\ 



PERSONAL AND STATISTICAL PARTIC ULARS 

I COl.OR 



(^luL 



li.k.t 



I»\TK nl 111 kill 



ll^vk.> 



(Month) 



(Day) (Vtar> 



\«;k 



65 Yeat^ 



M.ttiths 



Pars 



SINr.I.K. MAKK5KI). 
\VIIM»\VKI> OR niVoKiKH 

Wriuiti MK-Jal flrsi^nation) 



HIRTMIM.ACH 
(Statf ur (.'ouiilrv) 



WMK Ul 
lATllKR 



HIRTMIM.ACK 

Ol- lATHKR 

I Statf or Country) 



MAIDKN NAMi: 
Ol- MOTMKR 



HIRTHI'LArK 

OF MOTHKR 

I Statf or Cotintry) 



occrrATioN A 






4 



yx/J 



/VOlA- 






Lv'>vK.'> 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATII 

J 

(Day) 



a 



(Month) 




(Year) 



I lIKRI'iBY CI'IRTII'V, Tliat I attcinkMl (lcrcase<l from 

-190 to 190 ""^■ 

that I last saw h ■- alive on — *9° " 



aiul that aoath occiirre.l, on the «late stated above, at 
M. The CAl'Slv Ol* Dl^ATII was as fallows: 



M. The CAl'Slv Ol* DlvATII was as fallows: 



DURATION Vt-ars 

(.ONTRUUTORY 



Months 



Days 



Hours 



PURATK^N )>«?'-? nc\^rl'^'''^ 



(SIG 




L-V. 






- y.;ii< ,*l V..'^///< 



na\: 



THK AHOVE STATKD I'KRSONAl. I'AKTl./ri \RS AKl. TKn- TO THK 
«KST OF MY KNO\Vl,KD<".K AND Ilhl.ni' 

(Informant ^OL^T^^V^ 



( \<hlrfss 



a 



5 11^ rv^a<Lco-a.u "^ 



aa___iqoj_ 

:iAL INFO 



c 



( A.l.lnss) LfrXfrWjA^ 



Days Hours 

XX.Avd. M.D. 

m - 



SPECIAL INFORMATION only *»f Hospitals, Institutions, Transifnts, 
or Rfcent Residents, and persons dying away from home. 



Former or | £ 

Usual Residence > ^-iJOJM ^ >^vcU i 

When was disease contracted. 

If not at place of death ? 



How lon9 at 
\xis^\X Place of Death? 



Days 



I'UACK OI' lURIAI. OR KHM«»VAI. 



I'UACK Ol- 151 



DATKof m-RiAl. or REMOVAL 

ULcA-<L H 1 90 1 



(Ad<lrf»<s 



je- /^ 



A . V 




^ Ta ItF should be atated EXACTLY. PHYSICIANS .tiould 

tion •hould be carefully supplied. AOb »"'*". ^^ ••Special information" for per- 
TH in plain term., that it may be properly classified. The i»pe 



N. B. Every Item of informs 

•tate CAUSE OF DEATH ... ,-..- s„.f«ce 

Ron. dylnft away from home should be ftiven m evry .natance. 



1 t- 



Hoiir.l ..f H talth-t- No i^ 

1 )((!(* Filed , 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

RIFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n&rco 




^1' 



V\./4Ai "^ 



l!)0'i 



Registered JVo. 



ifrvws "l^wv^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)eatb 

( tl. S. Stan^arC* ) 



A 



PLACE OF DEATH:— County of'^CL^x, >Ta.(Vyvcu>.CO Gty of JOAV 



\ 



\,<X^ V>eA,^iy <^-<i 



(^No. 



ti 



In^l 'il^A.0. St.: H Dist; bet. T A>o and "^ ^ 

VO b IVA^^VwV Br«TnrNcr GIVE facts called roR onoek •'•Ptci*L iNroRM*Tio«- 

( J r.-or.T^H^O^C-u'.rcV.^-rHO^.^V.^.t 0%^?:?T^^"4°:^0.;r.TS nam. ...TE-O O. ST.EET *.0 .UM.CR. 



tl 



) 



FULL NAME 



I^Ji^M. -h XXjV\J&X*U>}l\.> 



1 



1 j 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I»\TK OF lUK III n /, 



■Month) 



(Day) 



vr.K 



TCi ,v,-,. 



M.miks. 



(Vcar) 



Da I 



^IVr.l.K. MARKIKD 
WIDOWKI) OK DIVOKVKI) 
Write in •social <le<*ivnatioii) 



HIKTMl'I.AOK 
iStntr or Country^ 



NAMl". 0|- 
lATHKR 






niKTMPI.ACH 
or TATHKR 
(Sti'tc or Country 



MAIDKN NAMK 
OF MOTHKK 







niRTHPLACK 
OF MOTHKR 
(State or Conntry^ 



1 






MEDICAL CERTIFICATE OF DEATH 



..3 

(Day) 



190 H 

(Vcar) 



DATE OF DKATM ^ 

(Month) / 1 
I rn^RlTHYCKRTIFY, That I atteiukMl <lccease<l from 

i 190 \ to . ^Jou^lX, ^ 190H- 

that^I last 4w h ..i\ alive on LUu^. I 190 H 

atia that death .K-ourrea. 01, the .late state.l al)Ove, at • -^ 

•. M The CAl'Si: Ol' DlvATIl nas as follows: 



DIRATION )Va/^*"'"'\lW/// Days Hours 

rovTKlIU TORY t/>CLL^cxi4^ >^^ 



r)rRATION 
(SIGNED) 




Years Months ic /Mj.? Hours 



M.D. 



SPECIAL INFORMATION wly »•' Hos^tals, iBstititltiis, Trapsleils, 
er Rfceit RfsMents, and persons dying away fr«m hame. 






yi,,»tln 



rhi\ 



THF. ABOVKSTATKDPKRSONAI.rAKTU'ri.AKSAKH TKrK To THH 
HF:ST of my KNO\VI.F:n<.E ANT HF.IJF.F 



(Informant 



l)0.'v>vQ^ 



(A»lclrc«*s 







J 




Formff or 
llsiial Residence 

When was disease contracted, 
If not at place of deatli ? 



How loif at 

Place of Oeatli? Biys 



ri.Ai 



•RIAU (»K KKMo\ AI 






'Af1«lre«««« 



DATE of Hi KlAl. or RKMOVAI, 



■"^"""■■■""^■■^■^^^^"^~^^"^""'^^"'^""^^^"'^"'"^^*"^'^^ Id ha t ted EXACTLY PHYSICIANS should 

N. B.— Every Item of information .hould be carefully --^J^''^^' ^^^^Hy^laaaWed! The -Speci.i Information^ for per- 

.tate CAUSE OF DEATH in plain term., th.t .t may ?• f^^^; ^ 

.on. dying .w.y from home should be given .n .very Inst-nce. 







y 
f 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

„„„,, „-,.s.,,..gg^..<..Co ....RTOaA0KOrC.RT,rlC>T.POR.NSTPUCT.ON, 



/)(( 




V 



Deputy HeaUh Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




No. 



Cevtificate of H)eatb 

( Xl. S. StanOarS ) 
PLACE OF DEATH: -County of U^xt^O^ t^^W- City of 

^\ i 1 t ■ 







and — " 



FULL NAME 




^I'.X 



PERSONAL AND STATISTICAL PARTICULARS 

' "■•'■" Vol 




la.! 



L 



^VC 



u 



ItATK Ol- lUK III 



Qli 






(Mfinth) J 



5 

(Dny) 



(Year) 



\<.K 



JVrt» 



X 



M., Mills 



siNT.l.K. MARKIKI). 
\V||>n\Vi:i» OR IHVoKt'KD 



lUKTuri.Ari-: 

'Stiit« or Country^ 



NAMl- O! 
J ATIIKR 



HIRTHIM.Ai-K 
ni- lATIIKR 
'Stair or Coiititrv' 



M MI)I:n NAMK 
»>l MOTIIHR 



lUKTHPI.AOK 
Ol- MOTUHR 
(Slatt- or Country I 




MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DKATH r\ j 

.....\i\.lu ■■^- 

(Month) > <D«y> 



(Year) 



I III'RHnV CI:RTIFV, That I atteiutea (lercawd from 

-^r— 190 to ;:i90 rrrr-:. 

that I last saw h -^r— alive on '^0 ""^"^ 



an<l that death occurrea, on the <latc statcl al)ovc. at 
— r: M. The CAISK OF DIIATII was as follows 



,\wt->v:> 



OCCri'ATION A. 



AajuL 




(X-^v 



,cL 



\JL 



ffrsHtrif in Siin /'kiik ''•■> ^ ^ ' '" 



yr.iiilhy 



/>,!• 



rm: above statkd vkr^onai. i'AKTu;ri,AKs ari; iRrK r.) rm: 

HHST Ol- MY KNoWl.l-IX.K ANI) HhMI-.H 



DIKATION )'c(irs 

CONTKir.rTORY 



A/on/Zis 



Pavs 



Hours 



Mouths Pays 



Hours 

M.D. 



DIKATION )Vj/r^ ^ 

(SIGNED) \ ^ ^ 

LUv<\ H tqoH (A( ^ 

" SPECIAL INFORMATION only lor Hospitals, li.stltytt»«s, Traislf nts, 
or Recfiit Rfsldfuls, and prrsons dying away from ho«e. 



JLyvU^ 



Pormff or 
Usual RrsidfRcr 

When was disease fontracted, 
If not at plafe of death ? 



Now loM 'I 
Ptareof Death? 



Days 



(Itiformnnt 



C3 -XA-A^tV^V>- 






IM XCK OF m-RIAI, (»R KHMoVAI 



rSDHRTAKKR 

fA<Mre'«» 



I)\T1-L;)f Hi KiAi. or RKMOVAI, 

L^-V%-^ H T90H 

t1 .OL^rCL>vjt\, ^iVv^^ 



Onru^^v^nv. ^.' 



■"^■■■■'■'^■'"^~*^^^^*^^^*"'*"'"^^^"'"""'"^ Id h« t ted EXACTLY PHY8ICIAN8 nhould 

E OF DEATH In plain lern... th.t It m«, ,"' P'oP"'* 



N. B.— Every Ite 

•tate CAUSE \3V un/i 1 n «" m""" ; - .^.„v iniitance. 

son. dylnft aw.y from homo should he g.ven In .vry In.tance. 












% 



'4 



,{..;,.,;. 1 Health- K No. i^ 



l)((lr Filed y 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Rk 



I 




lift 1' Co 



\.aX H 



lOO'-K 



Registered .A''o. 



X^vcvA isx^vu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



h 
\ 



Cevtificate of Beatb 

{ XX, S. StanOarO ) 
PLACEOFDEATH:-Countyof'^- .5^cX>v^c^c<Gty ofO^ u vj. 



"(^.IveUvHLvl 



,No. HOC) <"l\vc-Vcy< 

(ir DEATH OCCURS 
ir DEATH OCCU 



b Xr\; 



Sf \o Dist.;bct. ^^ tk' and '^b 

•JU. ^ i^iai., UNDER "SPECIAL INrORMATION- \ 

EAD OF STREET AND NUMBER. / 





) 



-R^^ViiTj^i^^t ^^i:i^::^^^i:^^ -- ^ 



FULL NAME 



IE UkcldLcrl i.L(r^^<x.^ ''' ^ 



.t/VYW 




.^'^XCVOlotl'.. 



^l.\ 



PERSONAL AND STATISTICAL PARTICULARS 
Af.K 



I >«!».* 



.!/,»»////« 



Ai t .' 



«-IN«.I,K. MARUn.n 
Wiiteiu "mcial €|f«.!K":«ti«»n) 



HIKTHPI.ACK 
(Statv or Country^ 



NAMK nl 
» ATHHR 



niRTUn.ACH 

OF FATIIKR 

I State «>r Country) 



MAIDKN NAMK 
OF MOTHKR 



HIRTIlPf.Ai'K 
OF MOTHKR 
(Slatf itr Country* 




MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATJi \ 

LLcvxii 

(Month) Jj 



H 

(Day) 



(Year) 



~ lTlUIUui\' CHKTIKV, Th^it I atteiKkMl aeceased from 

OLlmx H 190S to UwA^ca '^. 

at I last saw h • " alive 



^ 



190 H. 

that I last saw U aiivc on ^9° 

a„.l that death occtirred, on the .late state.l a1)Ove, at 



J <1^ 

J Of 



lv\A^Ltt 



5 



1 



C' OL'YU ^ ' ^\,<x vx/eca c <: 



M. The CAl SH Ol' HI^ATll was as follows 

%^d.\,:0-JL^^vAvOJa.c^ 



DIR.XTION >Vrt/5 

CONTRIIH'TORY 



Months 



Pays 



Hours 



DI-RATION 



Years Mouths Pays 

(SIGNED ) ULa.vJk ^riL«wV> J va. . > 



SPECI 



il 



Hours 

M.D. 

^1 



) UX\ ^)jl^\>x^<vcO.K.t ^t 



-iPtuiMu INFORMATION only for Hospitals. InstitutKms, Translfits. 
or RfCfBt Rfsldfflts, and persons dying anay from hoiw. 



.1 /,.»////< 



/),n. 



OCCrPATION 

Rfshfrd in S,ifi riiinrhf<-> ' Yfois ^ 

THK AHOVK STATKD PKRSONAl. rAKTlCt |.AKS ARK TRlK lO 
HKST ORJMY KNOWI.KIX'.K -VNI) HKMF.h 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How lomi at 
Place of Death? 



Day) 



(lnf.>,n,an, '''jMv<r-V>^<V1 iVo Lft^^C-VCWV 






fA.l.lre 



ss 



HOC) 



rtxAJ-C'sJl 



'I 



DA if: of lii RIAL or RKMOVAI, 



P, ACE OF lURIAL OR RKMoX AI. 



(A(l«lress 



■^^■— ■•■^^^— ^^— ^■■^^■^^^^"^"■■""^^^^^^'""^^^^^^^ t d EXACTLY PHYSICIANS should 

N. B.— Every Item of i„forn,atlon should h. cBrefu..y suppHed ^^^^J^^^l^^^^^^^^^ %he "Sped.. Information" for per- 
•tate CAUSE OF DEATH in plain terms, that .t m..y »« P^^^* '' 
Jo^s dylnft away from home should be ftiven In .vry Instance. 



I 



* 



^^m 



WR,TE PLAINLY WITH UNFAD.NG INK-TH.S IS A PERMANENT RECORD 

..«p^ REFER TO BAC K OF CERTIFI CATE FOR INSTRUCTIONS 



Ec^lstered J\'o, 



I) 



1 



ji ijt-«-' Deputy Health Officer 



DEPARTMENTOF public HEALTIi=City and County of San Francisco 



Certificate of S)eatb 

XX, S. Stan^ar^ j 



, U. S. Stan^ar^ j ^. 

PLACE OF DEATH,-Co„., .r^.c.JU^^C^^Cy.?-- '-^-jp-. 



No. 



FULL NAME 



RESIDENCE G.vr f*cts c*tLCD ;o« 7°JB s^^^^ ^^^ HU«IBE«. ; 

OR INSTITUTION GIVC ITS NAME INSTE.o 



Ur^Q (Is^^-^ St.; U- Di^t.; tet. }y JtU^^ 

V IF ot»TH oc^VRHCd in a hospital 



) 




'.YV 



• i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



^ 1 

It\ 11-: nl- niKTII 



,U1 



Month* 



(Day) 



(Year) 




\r.K 



MEDICAL CERTIFICATE OF DEATH 
"lyXTE OF HKATH H 

Liv\.Q ^\' 

(Month) 1\ <»>«y> 



./90 'i 

(Year) 






M.mlhs 



Davs 



siN..i,K MARRlKn 

W n»»\VKI> OR DIViiRrKO 

•Writrin jtoctal <lr>i»fnati»>n) 




\.^ 



TTTFRliirrcnR'ril'V, That I atteiulea accvascl from 

U.v 190 A to O^ ^ 190H 

U,.t-I last saw h..- alive on Ua^ X Ic^i 

,,„l that .Uath .KTurre.l. on the .lato stated al>ove, at V..0 V3 
Cl.M. The CAISI- OF DIIATII was as folli)WS 



CLct dlv^ ^>Oi ..."ii.^^-^xrva^'^ 




f* 




lUKTHri.AOK 
"^latr or Country 



NAMK ol- 

PATH i:r 



HIRTHIM.ACK 
«H lATHKR 
'State or Country 



MAIDHN NAMK 
Ml- MOTHKR 



niRTHPKACK 
••I M«»THKR 
Statt or Country) 






CONTRIIUTORV 



Years 



,}fon//is 



Pays ' Ilour^ 



"te*"^ 



ov cri'ATION 



%, 





Months 



/)rfv.? Hours 






QprdAL INFORMATION o«!y tor Hospitals, l«sUtutl.«s, Tra«sie«ts, 
or ReTcil ResMcms, aM persons dying d*»ay from home. 



Rfsidrd in S,if> I'unu i:f<> 1 -♦ ) ' " ' -y ^ 

Tin- ABOVE STATKI. PKRsONAl. '•.),'*';! 7,1;.;^.''^ ^''^'' '''^^^' 
HKST OF MY KNOWI.KDC.K AM) Ml l.n.i 



( Informant 




^' 






,h^>"v^ 



^ 



Formfr or 
Isual Rcsidfwce 

When was disease contracted. 

If not at pl ace of death ? ^ 

PL^CKOF ni RIAL OR RKMoVAI. 

>( 



Hot* Itiif it 
Ptareaf Death? 



Day^ 



I»\li:of 111 KIAI- or REMOVAL 



nil \lKv^Vi^^ir>v !a 



^ ^'l'^^^**" ^ 0^^ WVUT>v^ J : FVACTLY PHYSICIANS .hould 

— ,. .Hould b- carefully supplied. AGE «''-'** ^„:i"*'TI^*'Spcci.i Inform.tlon" for pr- 

N. B. Every Uem of lnform«t.on .hould \- ^^J ' , ^ properly clarified, inc p- 

.fte CAUSE OF DEATH In P'-^jr"*:;;*; „ .very In.t.nce. 

•on. dying away from home .hould be ft.ven .n • y ^ 










%\ 



1.1,1 ■lllMTfT-^^'*- 



lUiai' 



,,f lli;ilth ' 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

771. 



; V,, n <»'?^»*K*fc lUtl' Co 



IfJO'i 



Be^isterecl Xo, 



Dale Ff/r(f,\LiJ^piA^^^ ^ 

X^^cvUi^WH DeDuty Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of ®eatb 

( XH. S. Staii6ati> ) , 



<^ 



PLACE OF DEATH:-Coun.y ^^ O^J ^C^^-^^^^^C^ ^r^^ix.C^^^<^^ 



No, 



^0 '^ 



u 



.kd 



CVw' St.; 



Dist; bet 



rand 




tli V VvC^^^OVUi VCh^t'^'^VCVw* St.; ^*^^**,„ro. UNDER '•SPEC.AL INFORMATION- \ 

ixirv CL^ 



-^ 



FULL NAME 



.<Ju.. 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



\)\ n. Ill niK III 






iMotilh) 



.\<*.K 



o1 IVm'a O 



(Day) 
Mouths 



(Yt-ar) 



.Pay> 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



CL 



(Month) 



5 



...1 

(Day) 



I go \ 
(Yenr> 



riTRRKBY CERTIFY, That I atten.lc.l .krc-ascd fnnii 

QTlotcv -^ ^ '9oH to -.^^ ^ ''^ ^ 



,cu.» ..s>-A igo"^- 

that I last saw h .L n. ahvc on U^v<^^ I I90^^ 

a„a that death ocrurrcd, on the date state.l above, at i - 60 



SfVr.l.R. MAKKIi:!) 
Wiitcjn MK-ial <U«-iKiiation) 



niKTHIM.XOK 
Statt <»r Country^ 



NAMK OF 

1 A IllKR 



HlRTUri.AiK 
<»!• I MHKK 
->t;ii< or I'ountry^ 



MAIDKN NAMK 
<>l MOTHKR 



IMR THPI^ACK 
(>l MOTHKR 
(Slatf or Country"* 



oCCri'ATlON 






ItHUJ 







L\ M. The CAISI' C)l' DICATH was as follows 



t\ 






VxA x< 



rY\.6uUu^ 



\\oj 



X\.\ 



1 



i 






Rrsidf<f i>i Stift I'lan.i.'O y^ ^r<ii> 



.}f,.itf/iy 



/'<n. 



IlKST OK MY KNOWI.KDCK AND Hhl.H.t- 



or RAT ION >V«''^ 

CONTRim'TORV 



}'ears 



.Vont/is 



Days 



Hours 



Mouths 

\ 



DURATION 

( SIGNED )..li)A^^. l^^^^^^f^^^ 

X^Q I ^^H (Address) llvCiC) 



I^avs 



Hours 
M.D. 



SPECIAL INFORMATION onlyjorjospltals. Iiistllullois. Transkiits. 



f 



or RcTeS ResMcnts, and persons dying away from home. 

Former or M N1 \ li n <-. v '- 

Usual Residence ^^ ' ' aCv^ - 

When was disease contracted, 
If not at place of death ? 



How I0119 at , . 

f»1afe of Death? "PA Days 



Informant AJO.'Vto V^\ XcV^C^l^^- 



(Address 



^ 



DATKof HiRiAl. or RKMOVAI, 



-OwQ 



PI.ACE OK BIRIAU OR RKM(.\ AU 

..vrtJr V^^ ^^^ ^ 



190 



,,_i_i»— — i-— — -"^ ^ » . I Fl^ACTLY. PHYSICIANS should 

,o„ .Hould be cancfuny .uppHcH ^^^^^^^^^^^^^^^ 'Specl.. Info.n^a.lon'' for pr- 
rH in plain term., that it may be properly ca 



N. B. Every Item of informat 

.tate CAUSE OF DEATH in P '" ■":-•":.';„ i„ .very instance 
aon. dying away from home should be t-ven m • e y 



% 



% • 




Jl 



;^i 



f^: 



ji 



'^•' 



4 



Vi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoanl of Ikaltlv -I No K *^S^ H&I' Co RgFER TO BACK OF CERTIPICATg FOR INSTRUCTIONS 



Dafr Filed, \ 




100\ 



Registered JV^o. 



77 



O 



^X/^-VLx^ 



<^XA>\^ Depute Health ■Offtnf^r 

DEPARTMENT OF PUBLIC HE ALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. Stan^arO ) 



PLACE OF DEATH: — County of Cj/Ol/vu vJA^Xnx^u^cc. City oi^-Ojy\} 0.\.aYV<l^^c<i 



^No 



, H^H hx.J)\.^\M. St.; ^\ DisUhctO^O^QA^y^Oj and^l>A^olv<V^xav) 

/ IF Dt*TM OCCUN* AWAY FROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UfA>ER "SPECIAL INFORMATION" \ 
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAO OF STREET AND NUMBER. / 



FULL NAME 




k .OjL^ucL-aixLu,. 



si;.\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



(iUoJ.. 



OATH or mKTII 



a(;r 



( Month » 



\/t IVrt»> s) 



VUiv^wt. 



(DRy) 



(Year) 



A/oMf/is 



IS 



Davs 



SINC.Mv MAKRIKI) 
WIDnWKn OK DIVORCKO 
(Write ill stR-ial <lt->i dilation) 



HIRTMIM.AOK 
Statf or Country) 



NAMK OF 
I AT I IKK 



^ 



OuowJ-K 



mRTHIM.AlK 
OF FATMKK 

(Stall or Country) 



MAIDKN NAMK 
OF MOTHHR 



iurthi'i.acf: 

o|- MOTHKR 
(Statf or Country) 



CLAvx::L 





MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH ^ 

(Month) if 



1 

(Day) 



IQO " 

(Year) 







I HRRRBY CHRTIF'Y, That J attenrled deceased from 

ol 3i 190H 



'^1 190H to lLa^ol 3i. 

X 



LLl^i 



that I last saw h -v. ^ . . alive on W\Aa^Q, a up . 

f Q 

and that death occurred, on the date stated alnive, at o 

CL M. a:i>e CATSH OF I)i:ATn was as follows: 

it 



1)1 RATION " ^'^<^*'% ' ^^fouths ^ Days S Hours 
CONTRniUT(JRY L^\Jk.O^K-\^Lv,.«.>.L 







OCCIFATION ^ (j 



Kfsidfd ni San FKimisfn ^| )></»> •■ Muiilh< - A/i. 



TUF: AHOVK. STATKI) PHRSONAI. I'ARTICl I.ARS ARK TKIK To THK 
HKST OF MY KNOWI.KDC.K AND HKI.IKF 



(Informant 




K\ 



\<1«lrcs« 







DT RATION - Years ' Mouths S Days 5 Hours 

(SIGNED) ^■\- vyi^UTVCukjA^. 



kvcva 



M.D. 



LVCVQ ?^ i<)oH (Address) "X*^ I I) /oXjU^ 

SPECiAl Information only for Hospitals, lR$titutifR$, Traiisleiits, 
or Recent ResMents, and persons dying a^ay froni home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at ptaceof deatfi? 



New I0R9 at 
Plare of Death ? 



Days 



TQo'i 



PLACK OF lUKIAI. OR RKMoVAI. 

i-ndkrtakkrMh 0<uiliuAvMl\ DAXXIaJL^' UUJUvxi 

nil \^^\^J^J^usJsy^Ah 



DATKof HiKMl- or REMOVAI, 



(A«Iclress 



N. B. Bvcpy item of informntlon should be car«?ully supplied. AGB should be stated 6XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
snns dying away from home should be given in avsry instance. 




I 



I I 

I 



1! 



il 



\ 



V\ 



t 



MM 



p 



4 






IIoiikI of H<:iHlr I" 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

S.„„»^S»„).,Co BEFEH TO BAC.^ O P CERTIFICATC FOR INaTRUCTIONS 



l)a/r Fih-d , iLvcvvoCfc H I'JO^ 

■Uv^ Wh. Deputy Health Officer 



Registered J\^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( H. S. StanDarD ) 

rSn >^, J; 



-J 



PLACE OF DEATH:-County of ^^CC^v XvOA^c^^ccCity of'^'C^v 3 VCv.^vav<L e . 



No. ^Ol 




(rvv 



St.; X Dist.;bct. ^J.cd^Lc'v 

:allci 
NAME 



(1^ f 



and ^1^>^ML 



) 



.,;» >^>rv N ,,eii*l nr«TDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' "\ 

( '^ rF"D7AT°H"o^:uVRr;;N''rHo".^PrAt o"r ?n?t'i?U^T^O°n"o.VE%S NAME INSTEAD OF STREET AND NUMBER. ; 



FULL NAME 



.JJ.JUr' 



')|] 




.ai 




SHX 



PERSONAL AND STATISTICAL PARTICULARS^ 

I COH>R \ , j) 



(nicvL 



DATK t)I- lUKTll 






/lis 

(Year) 



AC.R 



^^ lV.i».v -^ M.mths ..^.X . 



/JavA 



SINf.I.K. MARKlKn 

wino\vKi> OK DivoRfKr) 

(\\ lite in s<KMal dt-sivrnatioii) 



niKTniM.ACK 

(State or Country) 



FATHHK 



RIKTHri,AOK 
OF FATHKR 
(State or Country) 



MAIHKN NAMK 
or MOTHKR 



"? 






A^Ol/^vV' 





<rV>vca. 




lcx\X4va' 



HIRTHPI.ACK 
o»- MOTHKR 
(St;(tv ur Country! 




oCCri'ATION J? 

Kr^i.fftf III S.ni Fiaiuisro (0 >V^?'.< '^ 1A->;///> 



MEDICAL CERTIFICATE OF DEATH 



DATE OF l)K 



'"" a 



(Month) A 



(Day) 



(Year) 



I HRRRBY CKRTIFY, That. I attended tlcccased from 

aJLu, .0^.1 190H to-lL.^ 2> 190M 

that I last saw h *>.>^^. alive on Li^^A.^ Ta 190 ' . 

'j 

and that death occurred, on the <late stated above, at 
•^ M. The CAl'SR OF DICATII was as follows: 

5)aJIoJL^(dl1.v^v cr|%-i^^^ d^v.J.... 

J^ Juirv^v^ >vuHC!w« <:Lv^^ dr\A-^-^.^va Cvfr*- 1 



DIRATK^N 



) 'eats 
CONTRIIUTORY LL>x<4v ^^-«^' 



Mouths ^ Pays 



Hours 



Years 



Months 



d.iij. ^IUvU>v. 

,7^ 



Days 



flours 



nr RATION 
(SIGNED) 

tlwa H TOO S ( Address) ^ ^^ '^ OJ\.K^ 

S^ECIALINFORIVIATIO N on'y fo*^ Hospitals, Institutions, Transifiits, 
or RfCfBt Residents, and persons dying d*»ay from home. 



M.D. 



/),7 1.< 



THK AROVK STATIM) PKRSOVAI, PAKTICr I.AKS AKl-. TKIK TO THK 

liKST OH Mv kno\vm:d(;k and hkmhf 



(Informal 



5 5-H nx<3uvu nt 



( \(1<lrc«is 



Former or 
Usual Residence 

When was disease contracted, 
If net at piareof death? 



Now lon9 at 
Rare of Death? 



Days 



PI \ZV. OF BIRIAI, OK KHMOVAI 



190H 



$0 G'^ ev^..ai. 

•NDKRTAKKR \-AXXA^ "^ iJC^Jw-Vx, 

(AcMrc.s ^\X- bis. \} a>v V\JU,^. dvsi. 



I)ATi;of Hi KiAl, or RKMOYAI, 



N. B.— Every Item oif inWmatlon should ^be carefully supplied. AGE should ^-\-'-^:L^\'^^'^'^y\ , ^.''^JtTot^^lr*'^!.'' 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Spec.al Inform-t.on for psr- 
sons dyinft away from home should be f^lven in svsry instance. 



I 



I ■ 



t 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACH OF CEHTIFICATE FOR INaTRUCTIONS 

774 



HoMHl of II.aUh-1- No. 1^ *'ra^_»«^l^ 



lh(te Filr(L LLaXXo^ "^ ^^^ "^ 

!>..... i..M. Deputy Health Officer 



Ecgistered jVo, 



.^CCV^ cKL'\>M 



DEPARTMENT OF PUBLIC BEALTH=City and County of San Francisco 



dcvtificate of 2)catb 



( Ta. S. StanOarD ) 

on 



PLACE OF DEATH: — County ofHOAW 



J? (^ 

J. 



\/VTL<X^CC. City of OyO^V JXXX/^VC^.^ CO 



e^ 



No. l^Ci^ 



,^ 



„,.^ St.; ^ Dist.;bctAOrt^cLt\A,U< and 

\J^V ^V-.. ,,-,,., RPSIDENCEGIVt r*CTS CALLCD FOR UNDER -SPECIAL INFORMATION- \ 



a K.i\ 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTI CULARS 

CO I. OR 



(!lvU 




kdt 



DATK Ol- UlkTM 



ACK 




(Month* 



(o )V4/».v ?> 






Months 



M'i 



-)0 



(Year* 



/J.f I 



SINT.I.K. MAKK1K1>. 
WIDnWKI) OR I)IV<»Rt*KI> 

(WrJtriti smial <U siv.iiattuii) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH ^ 



(Moiitli) /f 



(Day) 



(Year) 



I HI'iRICBY C1':RTIFV, That I attemUMl «k-ccase«l frmii 
K^Cl, 3 I90H to LLc^^C^ H 190'^ 



lUKTin'I.ACK 
(Stiitf or Coniitry'l 



NAMl i>l 
lAIIIHR 



niRTHPl.AOK 
or lATIlKR 
'Statt or Couulry) 



>fAn>KN NAMK 
Ol* MOTHKR 



mRTHPLAOK 
Ol- MOTHKR 
(Slate or Country^ 



? f 



L/vs^a^o-'\ 



1 ^ 

that I last saw h >»->:» V alive on ^CwCy H igo . 

anil that iloath occurred, on the <latc statcil alK.ve, at ^05 

Ul M. The CATJ^H C^l- DltATII was as follows: 

C 



V^ccv^ci-A^ oi CJXxr\^v<xc^\ 



DTK AT ION ^ Years " Mont /is ' Pays 
CONTK I lU'Ti )R V C>*^ vcLuO^-La^^:^^ 


Hours 




I )r RATION ^ Years ^Months Pays 

( SIGNED ) . LIx^CUJ \D luLCLi ^"c\.^ 
LIcvQ K TooS (Aihlress) \l^\Q ) a^AiU 


Hours 
M.D. 



Special information on'y *»r Hospitals, lnstituti«iis, TraRsleits, 
or Recent Residents, and persons dying away from home. 



X 



occ 






<L 



1 /' 



)VlM 



M.'iitli^ ' .' /'<" 



THV ^ROVFSTATl-nPKRSONAUPARTJrri.ARSAKK TKIK To T)IK 
HKST Ol- MY KN'>^VI.l•:i)^•.K AND IJKMhF 

(Diformant 




(Address 






Hon loRf at 



Former or \\Y^ i "•'* '•*' " 

Usual Residence J ' ^a\c^<l xTvCU --^ ' Ptare of Death? 

When was disease contracted, ^ 

If not at place of death ? 



Days 



PI.ACK 01 ni' RIAL OK KKMmVAI. 



r 



DAT^of UiKiAi. or RKMOVAI, 

5^ 190H 




I NDl-RTAKK.R .V CLV^i^A^AXA- WV - 



r*<l<lrcss 



, .. ^. *rE -hr»ilrf he stated EXACTLY. PHYSICIANS should 

N. B.— Every Item «? information .hould br carefully supplied. AGE "^° 'j* ^* '*"' ^he "^^^^ Information" for pr- 
state CAUSE OF DEATH in plain term*, that it may be properly wlass.f.ed. The Special intorma p« 

dons dylnft away from home Hhould be tiven In every Instance. 



~ I 



II, .1,1.1 .>f Hcnlth- t-N'^ 1^ "*- 

Date Filed, 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO RACK OF CERTIFICATE FOR INSTRUCTIONS 



H&l'Co 




Xtr^^^ 1jLa>^ 



i^ 1DG\ 

Deputy Health Qfificer 



Registered JSTo, 



775 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Ta. S. StanDarD ) 



4 f?R> 



PLACE OF DEATH 



:-County of ^O^ vi;UVAV<luie^ City of '^O.y^' vl^a^v^^c. 






— ) 



FULL NAME 



kcLt^t 



/CXA^^^.^. 



sKx r7j> 



PERSONAL AND STATISTICAL PARTICULARS 

COI.«»R 



DATK OF IJIKTII 



ACE 



JX>>voJui 



vL^^K\itx- 



(Month) (\ _ 



(Day) 



»3 ^ y.uits 



Mouths 



r ILL.... 

(Year) 



Dav. 



MEDICAL CERTIFICATE O^ DEATH 
DATE OF DKATH 



ll 




(Month) 



...a ../^oH 

(Day) (Year) 

FhKREBY Cr^RTIFY, That I atteiKkd .Icccasca from 

LLIol \ 190M to.J^^ 



190H 

«4 



SINJ'.I.H. MARHIKH. 
WinoWKI) OK l>lVoKrKI> 
'Write iti WK-ial <U *ijf nalioii) 



nVojvv^ 



BIRTH PI. ACK 
(Statf or Country) 



NAMK <)! 
FATHKR 






that I last ;;aw h >^^' alive on .LU.<>^C^ ^ '90 

an<l that death (Kcurre.l, «.n the .late stated above, at 
J M. The CAl'SK OF DlIATH was as follows: 

dL^\KCwh^ . . X' 



'OJ\j IrrULA^^ > v^trw^^ix 



.:i 



DIRATION * >Va/.« 
CONTRIHITORY 



Months 



Days 



I /ours 



lUKTiin.ArK 
OF fathf:k 

'St.Mtr or Country) 



MAIDF.N NAMF: 

OF motiif:r 



iukthi'lacf: 

01 MoPHFlR 
(State «jr Country* 



(KCIFAIION 





^^^\a^.jL...v, 



^ VcLoul 



I)r RATION 



Years 



Mouths 



Pays 



Hours 
( SIGNED ) sXvLkcOv J. 4 H J.C^\.Im M.D. 

UL.^a k U..S rA<Mress>4 .1f>laVLV:'^><M 



Address)'^!. I riOLVLy: 'V 

QprriAL INFORMATION «"'> lo^ Hospitals, Ins^itutloiS, Traisk Mts, 



^X 



vcL 




f) ^-vx^M-uJ^^M 



Kf>i,lf,1 ill S,iu /'tiiv,i-<;> 



)Vi" "^ 



M,„>th^ 



/i,n > 



TMK ABOVE STATKI. .-KKSONA,. rXKTUM-I,VK. AKK TKIK TO TIIH 
BF:sT OF ^''^/W'"''^^'V'"'*'Ai(n Bl.Un.V 



(Iiifornuint 



(Af1<lrt-ss 



5 I \ J'^ C^vv^OL^^d. '3t 



or Rccfnt Residents, and persons dyinq away from howe 

5 IH OSDH^MXV^ * 



f.n.".' «,H%, • -'' "••'•""' 



Usual Residence 

Wlien was disease contracted. 
If not at place of death ? 



Place of Deatk? 



Days 



lL'wvo. h 



(Address 



I)ArF:of lirkiAi. or RKMOVAI, 



PI^ATK OF BIKIAI. OK KFIMoVAI, 



N. B.— Every item of inform«tion .hould be c«re?ully •"PP'-«^- J^^*;^ J«..ified. The -Specl.l Information" for p-r- 
state CAUSE OF DEATH In plain term., that It mB> ^^ r^^P^-^'^ 
nnn. dyinft away from home «hould be given .n every mntance. 



i^ 



i\ 



<l 



?. 



# 



H„.nl of nc:.lth-K No. .. I^ggg^ H-'^^' ^''> 



WR.TE PLAINLY WITH UNPAD.NG .NK-TH.S .S A PERMANENT RECORD 

^K np CERTIF.CATt FOR I NSTRUCTIONS 

I ,1 J „ lo/iu Registered Xo. 776 

"Lrvvv* "ilv-M Deputy Health 0?ncer 

DEPARTMENHF PUBLIC HE ALTH-City and County of San Francisco 

dertificate of Beatb 

PLACE OF DEATH:-Co.ntv o, ^ C^ ^ 'V C. -....C Gty of-^<X.. d ,>VC. > vC^-C c 



No 



Dist.; bet. — — :_:.;::::::. ,..^. 



-) 



FULL NAME ^ J:^^.. | iLv^^^^ 



SK.\ 



PERSONAL AND STATISTICAL PARTICULARS 

coi.oR 




^-UcJU 



yJU^v^wX^ 



DATK or HIKTM 



iMotith) 



I Day) 



vii 

(Year) 



AC.K 



OW J'<"» 



Months 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DK 



!:: d 



(Month) 



Ol. 



.3^ 

( Day) 



(Year) 



Ai t .V 



Stvr.T.K MARRIKD. 
WIDOW KI> OK n!VORvKI> 
(Write in wjcial ile-iirnation) 



niK TMJM.AOK 
tSliitf or voiintryt 



N \MI «»l- 
I- A 11 II. R 






ThrFtCBY CKRTIFY, That I atten.lctl .lerca.scil from 

CL. as 190M to jl^cj. 2i 190 H 

that I lastlaw h A ^ ualive on U^^C^ >> ^^ ^ 

and that .leath (M^currecl, on the .h.to statc^l above, at So 
LLm. The CAISH Ol' DI'.XTll was as follows: 



nr RAT ION yc^f'^ 

COST RIBl TORY 



Months 



Pays 



Hours 



RIKTlllM.At'K 
Ol- I AIUKR 
(StMtf or Cotintry^ 



MAIDKN NAMK 
Ol- .MOTIIKR 



lURTHPI.ACK 
Ol* MoTIlKR 
(State or Country) 



OCCIFATION 



Years 



Afofitfis 



Pays 






.% 



Hours 
M.D. 



(• 



A 






yr.oifff 



fhty 



THK A,>.,VK STATK,. '■KK-.NA, rAKrj.MM.AKS AKK TR.H To nU- 
nnsT OF MV KN«nVI.i:D<.H AND Hhl.N.I- 



nr RATION 

(SIGNED) -- , 

i lvVQ^TQoH fAa.lress)^irUv^ 
SPEClA. INFORMATION only tor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying a^ay from tioine. 



Kk/\\X h.bA.i\A.QLL. 



Former or 
Isual Residence 

When was disease contracted. 

If Bo tatplaccofdeatli? 

n.ACK OF m-RIAU OR RHMo\ AI. 



Now I0R9 at 
Place of Death? 



Days 



.X<P»v 



nnsT OF MV KN«nVI.i:D<.H AND HF.I 
(I„f..nnant 1)0 ■ ^l. 'BtvA>V^V' 



vlJ-ii - X*wV-ct. 



DATK of in KiAi. or RKMOVAI. 



(Adtlres*; 






■— ^-^— ^-^— ^^^■^^^^■^■^■^"^^'""""'"'^^^^""""""""""^^^^ Ilk t t I RXACTLY PHYSICIANS •hould 



It 



i 



,1 



:!H: 




» 



WRITE PLAINLY WITH UNFADING INK 

l,..„,,.t,U..m,-l--N0.,.»^^»lUS:l.O, 



THIS IS A PERMANENT RECORD 

REFER TO B» CK OF CERTIFIC ATE FOR IN8TRUCTION» 

777 



Re^iaterecl JSI'o, 






Deputy Health Oflflcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccctfffcate of ®eatb 

{ tl. S. Stan^ar^ ) . 

i~v»» ^ ...J.w mrtM 



vJ . 



rv^^^=-=^^^ 



) 



FULL NAME 







PERSONAL AND STATISTICAL PARTICULARS 

I COI. 



DATK OF lURTII 




Set 

• Monlh* 



■■"" lu J.JU 



(Day) 



,\h'> 

(Year) 



MEDICAL CERTIFICATE OF DEATH 






DATE OP I^''- 



-:ATn 'I 

LL-^o 

(Month) \ 



%. 

(Day) 



(Year) 



nTKRilW Cl'tRTIFY, That I aUcndca aeccasca fr.mi 



AOK 



b^ 



) ■«•<» > 



S 



Mouths 



na\: 



\jXu^ ^.^ 190 H 



to UjwVQl ..^ 190 S I 



m\«.T,l-: MARKIKI). 
\Vn)o\VKl> <»R niVOKCKO 
(Write in s«»ci:il «ieH!tf nation) 



niRTHri.AOK 
(State or Tounti v» 



NAMK 01 
FATllKK 



UlRTHri.AiK 
Of lATHKR 
(State or Country) 



MMDKN NAMK 
OI- MOTHKR 



niKTuri.ArK 

01 MoTHKR 
(State or CoutUry^ 



1 ) 



that I lalsaw h .<V.>."live on CLc^<^. .:.-^ i^ 

a,ta that death occttrred, on the date statcl al»ove. at 
? M. -The CAl'SK or Dl-ATII was as follows: 



M iVvvtr^ <X^,cL^ C^.'' 



.v^i 



r^ 



C). J. Xu^c]vit\^ 



DIRATION ^ y^ars 
CONTRIIU'TORV 



- Mofiths Pays * Hours 






I 



1 



.JU^I-^^^-^^^"^^ 



Ul'RATION ^V--^ ^^^'"'^^ ^ ''''' 



(Signed) v:^ ^ ycvwC^\-uTv 



Hours 
M.D. 



< ( 



« U,,(////' 



Da 



OCCITATION (3^J(^^^ ^^vC^^^tV 

Rf^idrd in S,ni /•'«;>/< /-',> A ^ ' '" ' 
T„K AHOVH ST VrKO "KK-N., r JKT,;_r ...K. AKK TK.K To T„K 
BKST 01 MV KNt>\Vl.KI><.H AND lUUUf- 



" cipriiAL INFORMATION only tor Hospitals, lustit-lifis, Iransknts, 
or RfTenl Rcsldenls, and persons d)inq a»»d> from home. 

Former »r '^s'xa ^1»^^v<t Llx^ Rare •! Oealli ? o Days 

V^licn was disease contracted, 
If not at place of death ? 



"PI,ACK OFJ^ri^lAl. OK RKMOVAUI l.ATKof IM K..,. or RKMoVAl, 



PUACK OF31 KlAl. 01 



T90S 



'^'■a 







N 



WR1 



^fjQ^ Registered ^'o, ^"^ 



i*.r^^^»&j*<^'«' 




ii 



V. , .,a..f H.:>Uh -KNo- ' 

nulc Filed, LUa^^^^^' "^ 

4 A Deputy Health Officer 



DEPARTWIENT OF PUBLIC HEAl^ and County of San Francisco 

Certificate of 2)eatb 

PLACE OF DEATH: -County of a^ ^AA, j 

V^ IF OC*TM OCCUWUCO IN * HOSPITAL ^^ ^ 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTlCOtARS 




\KX.i±: 



MEDICAL CERTIFICATE OF DEATH 



.-lA 



'B 






COl.oR 



vXvVvc 



h\l H ol- lllRTII 



(Month) 



A<.K 



^1 



(Day) 



M.intfis 




DATK OF DKAl'll 



(Monlh) J 



5 

(Day) 



(Year) 



1 in- 



/)<; » -v 



SIN<M.E. MARK1KI> 



\VIlM>\VKI> OR niXORiKO (A^ 

iWrJlf in '^•^•ial .le-iv'nati..M) \Vn > /4 



niRTllVI.AOK 
(Statf or Conntry) 



NAMV: Of 

FA Tin: R 



, nrl^Tli^rrKRTII'Y. That I attcn.UM .lecvascl from 

It ,go'i to AL-Vt^^^ '*''< 

saw h ..^V »r.ve on a.vc^..-3... T.^' 

„„, that ,l«.th .KO«rre.l, on the -late stat..l alH.vo, at I 
'T. M. The CAUSH Ol- DI'ATII was as follnws: 



1)1 RATION 
CONTKIIUTORY 



^ Vtars 






//ours 



"YU-vxjiL 



HIRTIUM.ACK 
OF FATIIKR 

(Slittr or Country) 



/louys 
M.D. 



MAIIlKN NAMK 
OF MOTIIKR 



!URTHI'I,AiF: 

OF motiif:r 

(Statr or Country) 



tM cri'ATIoN 




,«cXytvv'^^^ 



(SIGNED) I '^ ^ \.w%.w 

-QPEC^AL INFORMATION .»l» t.r 11os|»Ws. I.^li.u.i.ns, lt-ns,«ts. 




•4 




Former w 
Isual RfsMfBCf 

When was disease contraclfd, 
If not at plaf e of (Jf alfj ? 



How I0114 at 
Ptareof Dfatli? 



Days 



T„K.HOVKsrvr.nr;KK^.V.,.VJKT,or,.KS.K.TK, K 
HF:sT of my KSONM.F-IX'K AM' 

(Informant J /OwC^-'^-^•'^ \i ' ^ 

(^ \<l(lrf<i'* V. V V 




DA if: of Hi KIAI- or RFtMOYAI, 



•^ 



IM.ACK OF HFRFM. OK KKMoVAl. 



190 . 



.tate CAUSE OF DEATH .n ^J"'" !'7^,„ ,„ .very instance, 
•on. dymft away from home •hould be ft.ve 



I ' 



r-1 



* ^1 





»ri(> 



I I 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,..,„..„.„--■ N....^^^^I-^1-0. REFER TO BACK OF CtRTirlCATt FOR l>.8TRUCTION9 

J)a/r Fifed, lL^<^WI H H^O H Registered ^^o. "^^^ 

■l^wv.i^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "a. S. StanOarD ) . 



PLACE OF DEATH: — County of '^'a^^-O/V.a'TVaiACi City of HO/^V O.'UX'rvCVA.CC 
\ ^r^SK.Ai.^^, c*. ?i r>irt..k»». oA^dL and jiAJrXi 



(No no 1\D /a\.VV(l.6>V St.; 3 Dist.;bet. ^^vd- and H 

-X- 



FULL NAME 



rUr'VMXh.cLu, 



PERSONAL AND STATISTICAL PARTICULARS 

si:n fJC^ Q I COLOR 

u 



'p 



DATK OF HIKTM 



'lOixvU. 



• Month) 



(Day) 



(Year) 



ACR 



.^1 



)><!».' 



MoMlhi. 



Pa \s 



SIN<-.I.K. MAKklKI) 
\VM>«>\Vi:i» ok l»I\oKiKI> 
(Write ill MKMal ilrsijriialion) 



^ 



HIKTHI'I.AOK 
(Statf c»r (."ountrv^ 



\AM1-: o| 
I ATHKK 



HIK THPI.ArK 
o|- I-ATHKR 
(Siat«- or Country) 



MAIUKN NAMK 
Ol- MOTIIHR 



IWK TllTM.ArV. 

nl- m(»thi:k 

'Siati or Country) 



• X CI J'ATION 






Vv>v UJ OcWru 




i 



^^^L^O-^vxd^ 







/\f>idfd in Sun /'inn, iu'o 






) V(; I " 



.\/..,>f/i' 



l},!\ 



Tin-: AHOVK STATI.I) PKKsONAI, I'AK lICC LARS ARl*. TRCK TO TMK 

HKsT OF MY kn<)\vij:i)<".f: AM) iuiji:f 



flnfoinuint . J /OXK-X^C^k J f\^X 



r\-Mrc 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII <--\ 



(Month) K 



3 

(Day) 



(Year) 



^itVA^i 



I IIKRHBY CKRTIFV, That I attciukMl aeoeased from 
90'i to LLa-A^CL 3 iqo H 



a^v 



tliat I last saw \\ J^' alive on V^V^vcu .v>. 190 

ami that death occiirre«l, on the ilati- stated alnn-e, at I \ 
^- M. The CALSK i>F 1) I! AT 1 1 was as follows 

(7CS 
».) . 

1^ 






A-VV^^V 



oULv* oi^xcC 



Dr RATION X Years 



Mouths 



/hjvs 



Hours 



CONTRinrTORV 



Pays 



/fours 
M.D. 



DURATION Years Mouths 

(SIGNED) Xnl L'. Lvvvat' 

LLa-Q H ,c>o I (Address) 3>^l (o ' j^Uv ^ 

SPECIAL INFORIVIATION wly 'or Hospitals, institutions, Fransleiits, 
or Recent Residents, and persons dying away from home. 



Former or 
tJsual Residence 

When Aas disease contracted. 
If not at place of death ? 



How ionq at 
Place of Death? 



Days 



I'I.ACF: OF BIRIAI. OR KKMoVAI. I DAlIwif Hi HIAI. or RF:MoVAI, 

(Addrrss 



I ndf:rtakf: 



1651 f'jL Q^V<L<LcfrV 



JS. B.— Every item of information .houlcl be carefully supplied. AGE .hould »- •»«*^^J^'''.^^CTLY ^"Y8ICIAN8 .hould 
•tate CAUSE OF DEATH in plain term., that it may be properly cl-wifled. The Special Information for pr- 
ar»n« dyinft away from home should be ftiven in every instance. 



f . 



i 



.t 



'* •[ 



If 



t 

M 




I ." 



If 



1 



i: 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

779 



)t.,:,nl of U.:iUh- V No. i ^ ^.'.^gSg 



IKS^n&rc'o 



-^ ^ Deputy Health Officer 



Registered J^o. 



'\>M 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Beatb 

( TX, S. StanOarD ) 
PLACE OF DEATH:-Coun.y of^O^ J A^^'^^^^oCity of <^^^>v JAXXAvau^ac 



No. 



ms i^U^-^•^- St.: '' DisUbet. ittw and Vl 



) 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTI CULARS 

COI.OR 



vj, 



D.XTJ-: nl- lURTH 



loJvvU 






(I)ay> 



./1.5.'i.., 

(Year) 



.V.K 



) Vii » 



.1 /.»»////.* 



/>« V.V 



SINT.l.K. MAKK1KI> 
WIDnWKD <»K DiyoKiKn 

'\Vtit»-in •."K.ial ilt-ii>riiati<»ti) 



lllKTHri.ACK 
<Stat» or Country^ 



I- AT I IK R 



^loJ 






MEDICAL CERTIFICATE OF DEATH 
1d.\ TE OF DKATII ] 
ll 



(M.mlh) y 



A.... 

(I)ay> 



(Year) 



I ^IKRUBV CI:RTIFY, That I attcMidcMl deceased from 
JkclH- '^.Ci, igo'i to Ua^CV. .'i 190H 



..^ 



that I last saw h ■• alive on 



a 



1- 



^ 



.3. 



n/3 ' 






JttlvLLAj- jVc4.4^^e 






lURTHPT.ACK 
«>!• I ATMKR 
(St;it« or Country^ 



MAIUKN NAMK 
or MOTIIKR 



lUK rUPLAi K 
<>» MOTHKR 
(Statf <ir 0«mtitry> 



(5^\.JL 



\L 



r^'YVJL 



A.JL 






and that death occurred, on the date stated above, at i W 
J M«. The CArSIC Ol' DIvATII was as follows: 



Hours 



DIR.^TION Ytai^s Mouths > l^ays 

4>jl1^1^ ^ 

DIR.XTION Vci^rs Mouths Pays Hours 

(SIGNED) Ll \IIUJU3 



OCCl TATION 



)'rtii 



\r.>i,tfi' 



Pn V. 



TMK AHOVF STATK.O PKRSONAI. I'AR TUr !.AK«^ AKH TRIK T.) THK 
HKST OF AuLKN«>\VI.Kn«;K ANp IlKIJl.l- 

(Infonuaiit vJ^\vO-<5 ^ J- 



IQO 



(Address) o'XO 




M.D. 



A^ 



SPECIAL INFORMATION only for Hospitals, liistitullMS, Traiisleits, 
or Recfol Residents, and persons dying dnay from lioiiif. 



Former or 
IsudI Residence 

Wlien was disease contracted, 
If not at place of death ? 



How lon^ at 
Place of Death? 



Days 



f \«Mrexs 





DATKof m RIAL or RKMOV.AL 



.\A-Q. r:i 



■ m RIAL OR KHMOVAI. 



1 



190 i 



INDKRTAKKR 

(.Addr^s 



Ibl ^H 



V«L4,Wt >i 



""■"^ VI AGE .houid be utated EXACTLY. PHVvSICIANS should 

nformation .hould be carefully •uppl.ed. ^^^^^'''1:^^^^^^, The "Special Information" for per- 
»F DEATH in plain term., that it may be properly cla.«mea. P- 



^1. B. Every item of i 

state CAUSE OF ^ ^ . ^ i„-*«„« 

•on« dyinft aw»y from home should be Itiven in svory instance 



I 



-i> 



i 
I 






* nil 



» i 



r 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 









7) 



(dr Filed, LLlvQ.^a^ H l'^0\ 



Re^isterecl JSTo. 



780 



d^^^ 



^MXt.. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Bcatb 

( 13. S. StanCarS ) -^ 

PLACE OF DEATH = -County of6a v J^va/>^^aClty of'" <)..v «J^ua^ vca,^^ 

No. Jbcn>vur^voJJvc^ '"^cv^vOLlr\u.A.Su — Dist-jbet. •-::::;-:-; ;„^,.„:.:n ^ 






FULL NAME 



X\.L.. 



.^ 










PERSONAL AND STATISTICAL PARTICULARS 
DATK «U- IUKTU 



iMotillO 



ACK 



H? .V,,,,. II 



5 

(Day) 



Mntllhs 



(Vear) 



>0 



/).; vs 



SfNf.I.K. MAKKIK.n 
W I1)M\VKI» OK niVoKi KI) 
U iil« in "MK-ial «li-.iv:iiati«>n) 



BIkTHIM.ACK 
<Stiitr or Country^ 



hAAX<L 



NAM1-, «>l 
FAIIIKR 



HIRTHIM.AOK 
OF lATin^K 
'State or Cmintry) 



MAIUKN NAMK 
Ol-- MOTHKK 



mKTHIM.ACK 
OF MOTHKK 
'Siatf or CtniMlry) 



OCevi'ATloN (^ 




medical certificate of death 
date of dkatii /^ 

\Xa-\^oa-v-aA3 ^ 



(Day) 



(Year) 



( Month M 

I HEKUBV CI'RTIFV, That I attendcMl tlcocased from 

.1 




;xi 190^ to 

that I last saw h -^V alive on 




190 H 
190'' 



SJV^^^-.' 



j[ iLcui^ 



aiul that <Uath <)crurre»l, 011 the date state*! alnne, at I 



Ov M. The CAISF: OF DHATII was as follows 



1)1' RATION Years 



'K- 



Mouths 



CONTRIHITORV 





Days Hours 

0-TW 



n 



nr RAT ION Years 

op 

(SIGNED) 



Months Pays Hours 

^ 



116^X^X0^ U\. lL<x\.ci. 



[ SIGNED ) iJU^X^-kVO^ VI i. lL|X>wCi. M.D. 

Uwa S TQoS (AcMress) ^0^ "^^cJUa. jJ. 






,\^v4ii^' 



-^ }r,>,if/is 



tu 



THF xnoVKSTXTKDl'KKSnWI, l-AKTUt l.\KS AKI-, IRl K I«> 
linsT OF MY KNOWl.F'.IX'.K AND HF.I.II.F 



THK 



{Inf'itmaiit 



( X.Mross 






SPECIAL INFORMATION only lor HospiUis, Ustitutioiis, Iransltits, 
or Recent Residents, and persons dying a*»ay from homf. 

Ksidencel' ludLuu^l lt^.\t K^eWatl,? Bays 

When was disease contracted, 

If not at place of death ? 



I'UACK OF lURIAI. OK RKMo\ AI 



DAPKof HI KIAJ. or RKMOVAI, 
vA^A^Q.. k 190 S 



, NDKKTAKKK O.lvit^tiW. iJ-A^wV^w!^ , 



'AcMns'i 



N. B.— Bvcry Item of information .hould be carefully -"PP'-^' J^^^^^ ci«..i««d. The -Spccl.t Information- for p.r- 
•tate C4USE OF DEATH in plain terms, that it may be P'*«PJ'*'y 
«on. dylnft away from home should be ftiven in every .netance. 



I. 

Si' 



lii 



i 



• fl 



2"*=:^ ( 







S : 



Hoard iif Ut:>l 



WRITE PLAINLY WITH UNFADING INH-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,1,-1-No n-s^K^ lift r 0.1 



Registered M'o. 



,)i 



11^ 



Dale Filed, LLvMXvUL"t H ■^^^'H 

i.yvov^ itv^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiticatc of Death 

( •Q. S. StaiiDarD ) 



4 ^ 



PLACE OF DEATH:-County of^XX^ ivXL>v^C.^G.y of )£^>- Jaxx^CU^CC 






^ 



l^^ 



'* HV^ 



li 



No. -^^ '»^<XV'-V--i .. o^.TnyNCEO,.! r.CTS C.ttEO .0» UNOtl. •SFtCl.t .NrO.M.T.oV-) 

,0. . .,. ^.^^ 



FULL NAME 



)\ 




A 4- 'xiCtvc 



,<xv«wAva! 



u. 



PERSONAL AND STATISTICM. PA RTICULARS 



SKX 



^\^L 



coi.ou 



iLl 



iwXji 



UATK Ol- UIK III 



Month) /| 



ACK 



cStX'l 'i^ 



J Vrt » . 



<I>ay» 
Months 



(Year) 



Da \s 



^ 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH f\ 

lLuux s 

f Month) K 



i Day) 



(Y«ir) 



SINT.I.K. MARRIKU 



Wrilr in MH-ial ilt-u' nation) "^ I 



I IU':R1:BV C1:RTII'V, That I atteiKkMl «lcccasea from 

ClvvCL '^^ 190"^ to . CL^-.^ 190 H 

that I last saw h .^>v: alive on (Xwc^ -^ 190 H 

and that iU-ath occurred, on the date stated al>ove, at 1 
Ct M. The C^t'SK OF 1)I:ATII was as follows: 






HlkPH FLACK 
'State or Country) 



NAMK <H' 
I ATHl.R 



niKTMIM.ACK 
OH I ATHKR 
^tatf or Country) 



MMUKN NAMK 

ol- m«)Tin:k 



lUKTIIPLACK 
<»l MOTHKR 
^Statt or Country 









vJtVO- 



^ 



:ausk u 



•t (VVA.^6-^ 



DURATION JVrtri .lA>;////5 Days 

CONTRIIJl'TORY ^^'" 

mwl 



Hours 



DERATION 



Years Mouths Pavs 



(SIGNED) UX^VXC 



All -5 



^' 



H 



TC)0 



( 



Addrts.) bib M1U^\1<VV 



Hours 
M.D. 



4 



1 



\i 



UCCIPATION 

f^f-idrd ;/! Siitr /'iitihi^rn 



^ 



)'i'lT! 



M. ■,>•!, 



/),? 1 



vnr AHovK sTxrr.i. i>hk^onm, i'aktu ri ar- akk tkik to thk 

HKST OH MY ^.OWIJ.IX.K ANI) lU.!.!)-)' 



(InfoTniant 



SPECIAL INFORMATION only for Hos^Uls, InstituHoBS, Transients, 
or RfccBl Residents, M persons dying a*ay from liome. 



Former or 
tsual Residence 

When was disease contracted, 
If not at place of deatli'' 



How I0R9 at 
Place ol Death? 



Days 



'AfMrcss 



5^1 



"riACFOH IltRIAl. OK KKMOVU. I DATKof llr«,»>. or RKMOVAI. 

'ckojLo^. I U-^H^^ T90H 

t-M,KRTAKKR b.<XU,>J-. yl\(X^^>^ "' ^ 



-—------—----■'-'""■■'"■■■■■■"" ' 7Z Ire should b« Htated EXACTLY. PHYSICIANS .houid 

N. B— Every item of lr.?ormation .hould be CBrofuIIy -uppl.ed. J| ' ^ . ,,a,.lflcd. The "Special Information" for pr- 
•tate CAUSE OF DEATH in plain term., that .t ma> ^« P^"P 
son. dylnft away from home should be ftiven .n every instance. 



« * 



i 



III 



^ .>^' 



rSBff^ 



n,«,r.l..nkaHh >• No ,. 1^^^^ lU^ »' ^•^' 






WR.TE PLAINLY WITH UNFAD.NG .NK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

I , ( 1 -L u 79/94 Registered ^''o, V^'^ 

I Ihde tiled, LUvOLwaX H ^^^^ 

1,..^ i^. Deputy Health OfHccr ^ 

DEPARTMENT OF PUBLIC HE ALTH=City and County of San Francisco 

Cevtificate ot Bcatb 

PLACE OF DEATH:-County of ^ O^' 3/.<X.vC..aGty of ^1<^- J AX. ..^ C. 



Plo, 



uXu 



-) 



FULL NAME 




A i 



X^vVo ^);C^VVAw^CXA.'Y 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 




oJLx 



COI.OR 



UllvvL, 



I>Al H 01 HIRTll 



A«.K 



I Month) 
b 1 y.;ns I 



"I 

(Day) 



M.niiln 



(Yfiir) 



as 



MEDICAL CERTIFICATE OF DEATH 
7)ATF: oh I>KATIi "^ 

(Day) 



(Month) \ 



I go ^ 

(Year) 




FRF.BY Cl'RTIFV, That I attc!i<kMl deceased from 



An 



\viiM»\vi:i) OR i»!voK<Hn 

• Wiit'- ill MHJai (h sivrnation) 



JUKTM'M.Al'K 
(Statf or C'Mintry) 



NAMK OF 
FATUKR 



niKTiin.ACK 

(>l- I-AIIIKR 
(Stale or Country^ 






\AAjiJX. 



.c^ aa up\ to >v^-^^^ ^ '90 ^ 

that i last saw h -Unw alive on lUvC^ A 190 H 

an.l that death occurred, on the date stated a1>ove, at W^^ 
\! M. The CAl'SK OF DI^ATII was as follows: 

yjv,wv\^v-^a- 



DF RAT ION )V«U^^ Months^ Days 

CONTRIBUTORY Lkrv^r:v^.^.^ J:U^^^k 



Hours 



:V»>; 



MAIDKN NAMK 
OF MOTnF;R 



hiktmim.aif: 

01 MOTHKK 
(Statr or Country) 



R^sidfd in S.nr I'uni. i-« ' -^ )>'?'> 



DURATION 
(SIGNED) 



fa. % 



Mont ha 



Pays 



vc\ '-' 190 



9^ 

(Address) tX^^ U .^IVm^ 



% 



Hours 
M.D. 



y 
I 



/>,l\. 



niV. XUOVKSTXTKDl-KR^ONAM'AKTU-rj.AKSAKKTRrK TO THK 
HKST 01 MV fcLNOWI.KIX'.K AND Hl-.MI-.f- 



(IiifoTtnant 



QhJu Cl^ 







H. 



vCCo^t 



■ SPECIAL INFORMATION only for Hospitals, Instilullons, Transieiils. 
or Rwcnt Residents, and persons d)iny d»»dv from liome. 



n m^>vA 



Former or 
Usual Residence 

When was disease contract, 
If not at place of death? 



v<x 



Hovi lonq at r^ 

Place of Death? 



Days 



n.ACK OF BiRiAi. OR ri:m«>val 



D.Vl'V.iii Ht RiAi- or RKMOVAI* 

LLvvol ^ 190H 



.vV^uff>-\ 



■— — — ■— ^ H K« t t i EXACTLY PHYSICIANS should 

IN. B.— Bvcr, ..em ot info.'mn.lon .hou.d be c„r.«»Mx .-PPl>ed^ ^*^^"..i«"<'- '^h. "Sp^^'.' ■nfo.n.a.-on" (or pT- 
-»«»/c4imF OF DEATH in pinin terms, that it may t>c proper , 

:r;/,i«» .w« fro™ ho^, ',h,u.d *. »...» ■. > •.".«.-«• 






I. 



I 

. 1 



II 



••! t 



%^t 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

..«,^ REFER TO -'^'' ^^ rrBTlirieATE FOR INSTRUCTIONS 



j<.^^.^^.^'^^\ Deputy Health Officer 



Re^lsterecl JS'^o, 



783 1 






rkvucv,.^ ^kJL-xM.1 WCJIuvy .-,r.c-,%M w.,.^..-.. 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Bcatb 

( "U. S. Stan^arO ) p, 

-4 ® -^ 



^ 



^ . ^^ r . of "^ ai^-*^ ^a^vOU ^0 City of "^^^^v .^OA^^^^^ 
PLACE OF DEATH: — County of ^^^ ^^ ^ 



No. 




, Hi k}<X'^\^^Oc< 



St. 



q 



Dist.; bet. 



ittl. 



and 



hiLtu. ) 



^^•» ' I^'ISU* "*'^* ,„_',, i^orR "sPtC«*L INFORMATION* \ 

/,/ OCH OCCU., .^ 0« USUAL "ES.Oe_N« 0,.,^.„'«TS «Lj^CO -^^^^-JP „%«J, .,„ ,„,.„. J 

^ IF DEATH OCCUWHtO IN 



FULL NAME lIo^^L Ituru i!vcK\va.^..cl. 



SFX 



PERSONAL AND STATISTICAL PARTICULARS 



VOJv^U 



i»\Ti-: oi niRTii 



\<".K 




u 

(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK OV ni'AT" ] 

^ .„ iXwa 

(Month) J 



(Day) 



/go \ 

(Year) 



FlIKRKRV CKRTIFV, That I attenaed .leccascd from 
Q».l 190H to lU^CV •^- 190*^ 



) i-n » 



M,tuths 



a?v 



Pa 1 . 



I 



U inoWKD OR niVOKiKI* 
'Writi'in «*<K-ial «lc'siv:iiatioi») 



;! 



lUM.AOK Qr\ 

or Couiilry' -^ h I ' 



lUKTIUM.AOK 




N\MK OF 
FATHKR 



BIRTH IM.AiK 
01 lATUKR 
(Slatr or Country) 



MAIDKN NAMK 
«>I- MOTIIKR 



C) s^ \x 



UvsJLmu 

that I last saw h -^-^ alive on LUv^ 3^ I90 H 

an.l that death occurred, on the date stated al)ove, at IX 
M The C\rSK OF I) I- AT II was as follows: 

O'OL.AX'VtJ W>^A-«A.<^Xv^. 



lUKTHPT.ACK 
<»F MOTHKR 
(State or Country) 




DIRATION >V«''^^ 

CONTRIIU'TORY 



MoNlhs H Pays Hours 



DIRATION 



years 



%■ 



^ font lis 



Pavs 



Hours 
M.D. 



(SIGNED) VJ) . V . Ml WvV^^ .... 

i W-^ Tcp H (Address) 150^ ^U^4t.n W 

EdlAL IN 



TQoH 

SPECIAL INFORMATION ?."1L 'jL"f •*"*''' '"^"*''"«'''' ^""'''"^'' 



A «f 



or RfTfnt Rfsidfflts, dnd persons dying a»»«y from iiomf. 



f^) 



t)CCri'ATION 

Rfsiiif(f III Still /'iiiii,i>'» 






) fUJ I » 



7 i. 



r.lKX1U>VKSTAIM-n.'KRSONAl,rVRT|Cr;,AKSARKTRrKTn TMH 
HKST «)1- MV KN<t\VI,i:i><".K AND HKI.IIM 



flnforniant 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How loRf at 

Place of Death? Days 



t \<l(lrcss 



r..ACKOFB,HlA....K..KM..VA..| ..A^.f ... »,A,. or KKMOVAI. 

U "3)1 vTy'UAA^v*-*^ rJl 



■^— ■-»««»^-ii— ^-^— ^^—^^"■■■^^■^'^^"'"'"'^^"^^^"""^^"^^^^ t d EXACTLY PHYSICIANS should 

.. B._Bver. Iten, o. in.on„,„t1on .Hou.d he carefuM. suppHcd^ ^^^^'p^enX.^^^^^^^ '-^^^^ •*«'-^'-« Information" for p-r- 
•tate CAUSE OF DEATH in plain terms, that .t ma> .^ P ^ 
son. dyinft aw.y from home should be ft.vcn m ..cry -nst-n 




\i 



\ 



t' 



u 



li 



i\l 






ii 



1^1 



l: 



f 






'I- ' 



■V-, 



i 



^.i..^ iiuK THIS IS A PERMANENT RECORD 
lAiRITE PLAINLY WITH UNFADING INK — THIS IS A Ktrt 

WRITE PLAIIM ^^^^^ ^^ P.. K OF CERT.F.CAT r FOR INSTRUCTIONS 




iSfH 



Registered Xo. 



784 



leer 



i "ijLAj^ Deputy Health Offl 

DEPARTWENTOF PUBLIC HEALTB-City and County of San Francisco 




Certificate of K»eatb 



( H. S. Stanoaro ; 
PLACE OF DEATH:-County of ^^^^ Iva^vC^^^ty 



, . V I ., f^ pi,t • bet. i ^l^^^ --^ :h^<^^^ 



FULL NAME ^^^^ dt^^'"- 



^I^ONAL AND STATISTICAL PARTICULARS 

I COI,t)R 



5J I 



Uj<'kAijt_ 



1>\IK Ml IIIKTU 



iMi.nlh^ /T 
1^ >Var.v -^ 



IS 

(Day) 



(Year) 



MEDICAL CERTIFICATE O^ DEATH 
nATlKnF DKATH \ 

V.lu.<\ / ^ V 

(Day) 



(Month) ^ _ 



(Year) 



.\/,tHt/lS 



n 



Alls 



•^IVt.I.K M \RKn'.l> 
WIDOUKU «»K DlVnKv KI» 
iWritein wx'ial lU-siprtiation) 





IllKTin'I.AOK 

(Stiitt or <*oiintryt 



NAM I- Ol 
FATlll.R 



lUKTIU'I.ACR 
O!' lAlHKR 
'Stiitt «>r CoMJilry I 



MAIUKN NAMT. 
«»l MOTIIKR 



lURTUri.ACH 
<»!• MOTIIKR 
(Sl:(t« nr ToujUry) 



OCCl'l'ATIO: 






I 



rn^RRBYTKRTIFY, That I atteiKk'.l dcccasea from 

^-^\^ '^* to ^..U..^-.^ ^ >90_^ 

that I last saw h-v^^w^ alive on ^v^x^.-V. .......... up . 

an.l that acatlt orcurrcl. on the .late stated above, at 

M. The CAISIC Ol- IH'ATII was as follows:^ 

1,1 K AT ION ^ Ve-ars Mo.//rs Pays 

CONTUIIUTORY U.^tll A.tc^ ■ ~ 




J lours 



DIRATION 
(SIGNED) 



Ytars 



^fouths 



Pavs 






f fours 
M.D. 



lUvk' 



I 



\XK,\/X ?■ Tc)o' 



(A<l«lrcss) 



^ $5 



ai^-*' 



■ .SPECIAL INFORMATION o-lyl"'"'^""*- 1»*«'""«"^- "'«""*• 
.,1««Ue*nls. " d Ptrs..^ iyi», «a) fr«™ horn.. 



1 X>V'V-WOL'>'U-t 



I , » 



M,.i>tli> 



/),/! 



TMK AHOVK STATKn ''KRSONA. ^AKT,^^;.^K^ AKK TK'K To THK 
HKST OF MY K.N<)\Vl,KI)<-.h AND in-.l.llt 



Formfr or 
I'sual Residence 

When was disease contracted, 
If not at place ol death ? 



Now lonq at 
Place of Death? 



Days 



190'i 



I>Ari". '»! in KIAI. <»r RKMOYAI. 
rSDlCKTAKKR ^^ (\\\ 



(Ad.li 



(•S»S 



^\n \n\v^'4.v6^\ 



N. B.- 



(A.Mrc ss ^^ . ^^ TTf^ACTLY. PHYSICIANS should 

...„. Ue. „. ,„W.-.o,.H.»M .. .«.c^. ..pp.- ;- •X:;^.:""Vh: •spec,-. .nW™.Uo„" .0. p..- 



1^ 



« 'I 






< i 



>\ 



,,l Ikalth »■■ N" I 



WRITE PLAINLY WITH UNFADING .NK-TH.S .S A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INST RUCTIONS 

Registered JVo, ^OO 



, -S-^l^S^S^-. H&l'^' 



I l)((h' Fifed, (Ia^oa-^ H ^'^^"^ 

i(^ ^"l^v^M Deputy Health Officer 

OEPARTWENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



Certificate of Death 

( XX. S. StanDarD ) 

PLACE OF DEATH:— County 

'^^ K) f, o,. ir Hist -bet. n -^X'Ck, and X^.>VxL 

V ir ot«TM occunnto m » MOSPiT«t on i"» (1 V B 






) 



FULL NAME ibx^-v^^' 



^ 



oJlMX^ro 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 



^. 1 

l»\TK Ml IMRTII , 1 







11 

(Day) 



(Vcar> 



MEDICAL CERTIFICATE OF DEATH 



DATK OI' I>KATH 



• l>KATH -1 

..„ „..Ll^A.q. 

(Month) A 



.5 

(Day) 



(Year) 



\<.K 



^ 



J III I 



W 



M.mth.y 



I''- 



Aiv,< 



-!N«.I.K MAKKll'.O 
WllHiWKn i>R l»IV«»mKI) 
tWrJteiii smMsil cU ^ijfnation) 



"IjL-^riXx 



HIKTHIM.AOK 
isiiitf or Cotijiiry) 



NAMK Ol- 
FATIIKR 



lUkTuri.Ai'K 

<>l I ATIIKK 
(Stale or Cimiitry) 



MAIDKN NAM1-: 
Ol- MOTIIKR 







ThKRKRN' CI'RTIFY. That I aUcii.Ua dcccascil from 

Wc^. 3C. 190 to , L^ 190H 

tiKtt I last saw h .-^ alive o.t ^W^ ^ 190^ 

a„.l that .loath .>cot,rrecl. on the .late stat.Ml above, at I ^ ^ 
M. The CAlSFv OF 1) I- AT 1 1 was as follows: 



DIRATION ^ >V«/^ 
CONTRIRl'TORV J-^^ 



^ Ycar^^ Jlouths ^\ Pays 



Hours 




'XV^^vCw>v«. 



\ 



,y-4jy\} 



lUKTHPI.ACK 
ni MnTHHR 
'Statt (ir Cotnitry^ 






DURATION ^ y^^rs 



(Signed) t 



(A<l<lre*<'*) 



M(>n//ts Pays 



flours 
M.D. 



^ 



M 



OCCri'ATlON 

/;. .,.. ^ ^ 

rm: xucuk statki) t'Kks.)Nai. lAKTiori aks akh tki k n> 

HKsr 01- MV KN()\Vl,i:i>».K AND lU-.I.ll.t 



QPPCIAL INFORMATION only for Hospitals, lastitotions. Transients, 
or ReTcnt Residents, and persons d)ina a**ay Iron. home. 



Former or 
Usual Residence 

When v>as disease contracted. 
If not at place of death ? 



Now lenq at 
Place of Death? 



.. Days 



PLACE OH BIKIAI, <»K Ki:M<-VAI. 



(iTifuiniant 



C.Uq^u|^.-..; 



( \<Mr«.ss 



n 




'J^Alt'v 



I) \ 11% of HVKiAi- or RI:M0VAI. 






190 



rNI»KRTAKKR ^^^^'^^^fVu 

(AU.lress. l^Cl^MrVv^^^': . 



— — — — — " . pvAcxLY PHYSICIANS should 

""■— ""^ V. I 1 h. cnrefuliy •uppUed. AGR «H"ulJ *? ** ^he •'SDCciai Information" for p«r- 

N. B. Every Item of information •hould be -«'-«*""y '"^^ ^^ properly classified. The Spccai 

state CAUSE OF DEATH in P««'" »-''•"»: 'j^^lJ'^rcry instance, 
son. dylna away from home should be ft.ven m c.cry 



i 



t 



7- '-ydp 



rr 







'' ;|l 



f 



* I 



\\ ' 



^ 



WRITE PLAINLY WITH UNFAD.NG .NK-TH.S .S A PERMANENT RECORD 

WRITE PLAIN ,„ , , n T- -'"-"^ ^"^ 'N8TRUCT.0N. 

..,1 ..f u...nh-K No. 1^ ^^Sr^ ''-'^ " ' 



:J' I'o 



l)(ffr Filed, 



.vOlvv 



■^ 5^.. 



i.90H 



Kegistered JSI^o, 



786 




llx-^u Deputy Health Officer 



Jl<rv^vfl Uvu, Deputy ne^ivn v^.-v-^. 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX. 5. St»nnC»arD ) 



(B^ 






No. a^ 1 iVvv.<,c.d.^n;. ^ JJ^-.d^.^i^'cS 



./YW.tnrV and 



llUi 



) 



-V C r\^CV O^Ki ^f*5 ^ I-'ISXm *^^» UNDER "SPECIAL INFORM 

V. IF Ot»T 



FULL NAME 




XCVO-Vlfc 



3C 



^X<X 




SKX 



PERSONAL AN D STAT ISTICAL PARTICULARS 



DATK nl lURTII 



L l"""lOlJu 



iM«»nrh> 



.1 



a«;k 



b^ iv.i»> ^ 



(Dav) 



M.,nlh^ 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH O 

vLvux 

(Month) 5 



,...H 

(Day) 



(Year) 



71T171inuiYTi:RTIFY, That Latleii.lc.l .Kcc-hsc.I from 



a 



-L^ 



xr 



n,n: 



1- 



.190 H to 



LLa^^< 



S1N«.1,K. MARKn:i> 
WlDoWKI) OK DIVOKCKI) 
•Writfin s.Kial (l« •^iirnation) 




UIKTHPLAOK 
(Slate or Of»«iiitry) 



NAMi: (U 
FATHKR 



01 

St 



RTHPl.ACK n 

I ATMKK V 

t:\tt nr C<«intry ' 






190 H 

that I last salv h X . alive on V^^<V ^ ^<P^ 

ana that aeath ocourrea. cm the date stated above, at 
..ADLm The CAI'Slv OV Dl'ATII was as follows: 

A5U/vvLv^ts^<^v,v^ LX>vojuy>x^^ 






D.-K AT ION ^ )Va^^ . ••"'""'»■ ^ ''"•' """'' 




MAIUKN NAMK 
uj MOTHKR 



lURPHri.ACK 

<>l- MOTHKR 

' stall or C'nintry^ 



ocerPATioN 




DIKATION 
(SIGNED) 



Vciirs Afo'iths ^ Days 



Hours 



4 



H 190'^ 



M.hlress) I. OC3 QA^ 



M.D. 



iprciAL INFORMATION only for HosfMlals, l«stit«tl.«s. Transients, 
or RfrcM RcsMenls, and persons dying away Iron, home. 



^4 r-.;> i^ 



THK AUOVK STMKn PKRSONAI. V^^RTirr J- AKS ARK TRlK T- • 1 



(Iiif')'niant 



KNO\Vl.KI)«-.K AND l»>.«.i''- 



formfr or 
Usual ResMewe 

When was disease contracted. 
If not at place of death? 



How lenq at 
Place of Death? 



Days 



V 



;t.CKOKm-RIAKORRKMoVA.: UATKof ,.«,... or RKMOXA,. 

(1 . 1 Of ■ Llvu:t S T90H 



I NDHRTAKKR 

(AtMifss 



^'^'^"""' ILL PHYSICIANS should 

u . I H. nre fully HuppHed. AGB should »>«»*» ''jj^ -Speclai Information" for p*r- 
N. B— Every item of Information .hould be -"^"^^''^ ^'^ ^e properly cl.««.*ied. The 8,>ecla 

.tate CAUSE OF DEATH in P'"'" !'jr:;;; „ ,very instance, 
son. dylnft away from home should be ft.ven 



r. i 



H 



A\ 



/lUir ^£^9 



..k, '^•^••y,^*"^ 






- -iN- , 



.^ 









tf.-. "■ ^fc 



(.' 






I 






n 



WR.TE PLAINLY W.TH UNFADING .NK-TH.S .S A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



ll.,i,i<l .,f H. :iltll I 



N., i^-t^j^nfiycn 




lOOH. 



787 



, ^ 7<y^i-i Registered JVo. 

It^vcvAt^u Deputy Health Officer 

DEPARTMENT OF PUBLIC HE ALTH=City and County of San Francisco 

Certificate of Death 

( -a. S. StanDarD ) ^ ^ 

^ % i ^ 



PLACE OF DEATH: — County of 







J crLci. 

Ll^luJL .^3^^-w-<^^^ 



FULL NAME 



m;x 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



^ 



vlX^^\txXjL 



IcJ 



DATK ol IMKTH 






\r.K 



) ■«•«/ / . 



(Day) 



Month ^ 



,RDH 

(Year) 



1^ 



Havs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




1. 

(Day) 



(Year) 



(Month) [T 
TTFRRHiN"^ CERTIFY, That I attciKled deceased from 

— .rrrrr— -T. 190 



190 



•to 



SIN<'.I.K. MARKIKI) 
WIDiiW '"D <»K DIVoKiKD 
tWriti- ill ^<Hi;il <l<-iKiiati<»ii) 



niRTiU'i.AOK 

(Stall- <»r C«»untry) 



N \Ml-: OF 

I atiii:r 



111 



HIKTHPI.ACK 
«)I" I ATHKR 
'SIm(( or Cotintry) 



that I last saw li -■ alive oil 

an.l that death occurred, on the date stated above, at - 

_,™__^j ^1,^^. CAT SI*: Ol- 1)I:AT!! wa«; as follows: 

ciiW^CV. YVS^V' 



190 



rvmo. 



DC RAT ION Years 
CONTRIHrTORY -• 



Months 



Pays 



Hours 



MAIDKN NAMK 
OF MOTIIKR 



niRTHPl.ACK 
«»1 MOTHKR 
(Slate «>r Country) 



oCCrPATION 

Rf^iihd ill Sail /'i iim is/;y 



]'ttii 



.\r,'iitfi^ 



lhi\ 



\\\V xnoVEST\TKD»'KKSONAl,lV\KTUri.AKS AKKTKrK Tn THH 
HHST Ol- MY KN«)\V1.i:D<.K AND Hi: 1. 11. 1' 



DURATION ^ Years Mwths^ ^ Pays 

( SIGNED ) Lc*VQ»Jin^O ^^^^ 




flours 
>vcL IMI.D. 



LLca 



(U 



<\ X I go 
C1AL INF 



\ (Add res-) WL>0^>\J/V^ 



%, 



SPECIAL IN FOR MAT 10.. only 'or Hospitals, Institytwns, Transkiits, 
or Recent Residents, and persons dying av»ay from home. 



Former or 
Isual Residence 

When was disease contracted, 
If not at place of death ? 



How long at 
Place of Death ? 



Days 



(Informant 



n 



V 



r^ddrcss 



I'LACK OF niKIAUOR KKM«»VAI, 



r^ 



,Lv^V>v 



> -1 



I ni)f:rtakkr '^' 

(A«Mrrs« 



l)ATF:.>f niKlAI. cr RKMOVAl, 

LvcvQ 5^ 190 . 

Sb-diHtk ■^^- ^ 



.. B.-Every i.e. o. .n^o.^Btlon .Hou.d He c^.e^uHy -uppMed ^^^f^'X^.s^lk^r^T^^^^^ .nZ^Juo^'MorpTll 

state CAUSE OF DEATH in plain terms, that it may be properly ciassmea. h- 

«on« dylnft away from home should be given in ev«ry instance. 




r. 



J: 



', . 






M 









ii' 



• 



i 



WRITE PLAINLY WITH UNFADING INK 

4 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFlCATg F OR INSTBUCTIONS 

Jteo'i.stered Xo. • oo 



i va'IjL'v Deputy Health Officer 

DEPARTMNT^F PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of ©eatb 

( Ta. S. StanOarD ) 



PLACE OF DEATH,-Co...v J^.l'x— -«,Ci.v o<^-- •i^A" " , ' 



vaj.tujA 



■No. 1^ ^ ^ „l^^i .,.,3.,. r.^T^l-I'7,?Sv.^«'."^S^ ) 



FULL NAME 



a 



>vrvAJt. 



Iji.j^ 



It 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 



^ } 






l^lLt 



J^lr 



tVontlO 



'X'X /"^^-L 

(Pay) IVear) 



MEDICA L CER TIFICATE OF DEATH 
DATK OF DKATH H 



(Month) ^ 



H 

(Day) 



(Year) 



A<*.K 



SI ,.,.„., ■5" 



M.tulh 



II 



/)«! v.? 



>|\<.1,K. MARKIKI*. 
WIUOWKD »»K DlVoRCKI) 
Wiittin MKJal «lesiK"i«t»oii) 



RIRTmM.AOK 
(State or C«»untry) 



NXMF or 

» ATUl.K 



lUKTMlM.ArK 
(>»• » ATMKR 
iStatf or Country^ 



MAIDKN NAMK 
«H MOTMKR 



\j. at lJL<xcu 
U")vcjyL<X' 



" 1 IIKRI'HV CI:RTIFY, That r attemled aeccasetl from 

Q\v>V It I90^ to J^^ ^^ "^ 

that I last saw h... alive on LU-<^. ^ 190^^ 

a„<l that .Uath cKTCt.rrea, oi, the .late stated above, at 1 



M The CW'SH OF DIvATlI was as follows: 



Or DIVA I II wa: 



DIRATION - ^''''"?rN^^ 

. ft 



CONTRIinToRV 



Vj 



.Vonths Pays 



Hours 



^\ArV^'^.^ 



DIRATION >''''^''^ JA"/M.v 






lURTlirUACK 
<)l- MmTHKR 
(Slate or C«)untry> 



''"'h 



Pavs 



(SIGNED) CI J MVm, 



Hours 
M.D. 



fl 






SPECIAL INFORMATION onU for Hospitals, lustltytiws, Transifiits, 
•r Recent Residents, and persons dyinq dv»ay Irom liome. 



• HCri'ATION QiV 



R^sidnl ill <'.'»' A'"/'/' '" 



5 I ii I 



\f.,ii>/i 



/■ 



MHST OF MV KNOWXKIX.K AND Ul l.ll » 



finfdtiuant 



V KNOWXKD' 



forfljer or 
Usual Reskfence 

When was disease contrafled. 
If not at place of death ? 



How tonq at 
Place of Death? 



Days 



l)Ari:uf HrKiAi. or RKMOVAl. 
^ OwVv^CJ ^. 190'' 



CuwAJUy^ 



\«l«lrt»is 



ilH 



V-<i^CM,< 






\f 






' ' ' TZ Ice should be •tated EXACTLY. PHYSICIANS .hould 

:S. B.— Every Item oi InWmBf.on .hould be carefuHy «uppl.cd AGE « ^^^^^^^^^^ ^^^ ..^^^^^^, ,„for„,»tion- for pr- 
^ -. /-»i!eF OP nFATH in plain terms, that it may "c i»> k 



' I 



I;' 



i' 



I 

I 



.1 




■<y^:^h 



;• , • * 



;j^ 



-,< 









/» .-v. 



^, ,:^r^nr 



T 



I 



F 



■i . 



f-J. ! 






^ 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Itnnr.l of Health I" N<> !^ "^-CHir*"' "''^'' ^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begistcred J^o. 



ih> Filed, Livv,<lvv.^t S 100 H 

1vCrLcv<> XsL^u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

CcCity of ^^'O-A'^J ^ 



\ 



PLACE OF DEATH:— County ofHa-rv O/VOoVCVA/CcCity of ' 'O^V 0/vCVVxt^tO 



No. 



II 



'"I 



i\k. >-v^wi:v>tH 



St.; 




Dist;bct. iW'C)l\.VVKMrvv and ^^/UA/0./Yvt ) 



C\ L w ,_^^ iicilAI nr^lDf-NCE GIVE FACTS CALLED roR UNDER "SPECIAL INFORMATION" X A 

lir DEATH otCURS AW*V FROM USUAL R E 5 I D t n I, t Gl ¥E rm-io ^'"-" ,„_-£■«« nr c:TarFT AND NUMBER J I 

I IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / IJ 



FULL NAME rUJ^y^^^ 



PERSONAL AND STATISTICAL PARTICULARS 



SH.\ 



^'WAs. 



COI.OR 



iL'Jkvtk 



1»ATK 4>F lUR Til 



• Month > 



AC.K 



"^IN'.l.K MARKIKn 
WllMiW i:i» UK IHViiRtKI) 
(Writf in «»<K-ial dc»*iKi»«'iti«»n) 



niKTllIM.AOK 
(Statf or Country) 



^'A^fK or 

t'ATHi:R 



niRTHPI.ACK 
«>l' lATHHR 
(State or Countrv^ 



MAIDKN NAM}-. 
<>l- .MOrilKR 



HIR nil' I.AC K 
<»F MOTHER 
(State- or Country* 



.Day 



M.mlh 



<Vfar) 






/>il\S 



K \A^^'V^.r>\j 



n 



'^.^uLcv^-.'^- 



occrr A rioN 

Rf^tilfif III S(j»/ /'i iim i.wo 3 k )ttti< 



yr.uitin 



ihi\. 



TH1-: \HOVK ST\ rr.I) I'KRSOXAl, I'AKTICn.ARS ARi: IRIK To THK 
HKST Ol MV KNOWI.KIX.K AM) HKMKF 



(InfoMuant 



'\<l«lrc 






.Kyy- 





MEDICAL CERTIFICATE OF DEATH 
DATK Ol- I)I-:ATIi -I 



(Month) fj 



'i 

(Day) 



I go \ 

(Year) 



I IIICKICBY CI:RTIFY, Tliat I attcmlod «lcccase«l from 
V^^-W "^^ 190'^ to MAA^a H 190 H 

that T last saw h X- . . alive on SA^A^Ol ci. 190 . 

anil that ilcath occurre*!, 011 the dale stated above, at -■.^■■^- 

- M The CAl'SH Ol' I>I':ATII was as follows: 



.'"W^-OLi 



Dr RATION 
CONTRinrTORY 



Years Months -1 Days 

jJLL&:.>:>-<L 



Hours 



DURATION Years Mouths 



(SIGNED 

AC 






Days 



Hours 
M.D. 



LLlvOJ^ iQo'i (Address) 'Xl vfcrW-^'^^ 



\ 3 iqO 
iAl INF 



SPECIAL INFORMATION only for Hospitals, Inslllutlons, Transients, 
or Rfcfnt Residents, and persons dying away from fiome. 



Former or 
Usual Residence 

Wl»en was disease contracted, 
If not at place of death? 



How long at 
Place of Death? 



Days 



I'l.ACK OF HTRIAI, OR RF:M<»VAI. 






DATf:.; HtHiAl. or RKMOVAI. 



^ *w. 190'^ 

INDKRTAKKR CcXAJLWT H^ L-VX^Y^"-^^^ 

(A<MreH. X^V^'^V ySX^l^ Ua-- 



N. B.— F.very Item otf in?ormBtJo„ should be carefully HupplJed. AGE should be slated EXACTLY PHYSICIANS .hould 
•tate CAUSE OF DEATH in plain terms, that it may be properly clawifled. The Special Information for p«r- 
Bons dyinft away from home Hhould be given in every instance. 



i' 



'I 



• \ 



:1 



. ♦'] 







I \i' 






T 



S 




'. 



ii- 



t 



i 'I 



6 I 



it 



I t 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

BegLstered JVo, 



H.,,nl of Health -!•• Vo. .. T»-?I»i^ lUS: 1' Co 



Dulc /^V/f^^/, LLc^^VA^ T i^^o H 

l(^v^v^ iL^o^j. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccitificate of H)catb 

( Ta. S. Stan&ar^ ) 
PLACE OF DEATH: -County of '^Va.^v -l,\.a^vCv4,Cc,Gty of '"'O^V a^UVWilv*^ 
IM \'^0(^ vl ()-l4,A -VAV St.; S' Dist.;bet. R X-K' and \M\> 

FULL NAME .B.fr:-|U\.vX. i.-aJL^Uy^vl-Uou.^. 



) 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 



Jl »X<X IJI 



DATK OF IMKTU 



iDldc 



Alonth) 



(Day) 



(Vcar) 



A<".K 



b V )v,i.> I 



Mouths 



\1 



Pars 



\Vn>n\VKI> <>K DIVoKcKO 
(Write in Hocial designation) 



HIKTmM.ACK 
(State or c'lMintrj') 



^ 



^ 



(xv^-U^cL 



NAMI-: Of 
FATIIKR 



!X>wrU3L'VUu^- 



ULIaXtUL/tu oJaa^aa 



HlRTHI'I.AtK 
Ol- I AT I IKK 
(State or Country) 



{( 



MAIDKN NAMK 
OF MOTHHR 



lURTHlM.ACK 
oi- MOTHHR 
(State or Country' 



li I ^ 



/hn 



Till- AHOVKSTXrHI) I'HRSONAl, PAR lion. ARS ARK TRIK To THK 
BKST OK \IY KNO\VI.i:i)('.K AND BKUKF 

(Informant vIWVCA^-^-O^^^ vj CX.l\XX^^k» 



-V,. 



(A(Mrcss 






MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH ^ 



(Month) \ 



H 

(Day) 



(Year) 



TTnrKi:r.V CI:RTIFV, That I attcn«UMl .Uh -ascd from 

.vlvjL. 3.1 I90M to LVLV<JL H uyo H 

thaM last saw h..:^^ alive on vUa,(^ 3> 190 1 

ami that «Uath occurrea, on the tlate state«l above, at W 1.0... 
GL M. The CAUSI*: Ol* ni:.\TII was as follows: 



Dl R.\TI(>N years Moniks ' />>ar5 Hours 



sU5l. 



nr RATION ^ Yiars 




Months Days 



Hours 



( SIGNED ) dV^X^vvu \ '3V^^a.^.t/l. , . . ' L . M.D. 



cIaL INI " 



SPECIAL Information o"ly lor Hospitals, InstitutlMS, TransirRts, 
or Recent Residents, and persons dying anav from home. 



former or 
Usual Residence 

When was disease contracted, 
If not at place of deatli? 



How lonii at 
Place of Deatli? 



Days 



PI.XCK OF BIRIAI. OR KKMoVAl. 



DATK of Bt-KIAI. or KF:M0VAI, 



I90H 



INDKRTAKKR ^^^ ^^C W "^^ U 



(Ad.lres* 



11^1 (^>v 



r 



.\.^4<\,ir>v 



state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for p«r 
sons dyln4 away from home should be It'ven in every instance. 



>^i^ 






\ 



■4-.* 



if 



: i 



n 



'« 



I, 



r 










WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

HEFEH TO BACK OF CERTIFICATe FOR INSTRUCTIONS ^ 

791 



Moar.l .. flhalih V Sn. i. f^^^l^ScV C 



IDO'i 



Registered J\^o. 

DEPARTMENT (fp PUBLIC HEALTH=City and County of San Francisco 



A^v-^iX .. 5^ •• 

Deputy Health Officer 






Ccvtiflcate of H)eatb 

PLACE OF DEATH: -County of O.CL.v JJUXAXC^ City 



( 



itV of*^3/CU>V\jXXX'>V'CAA-C.C 

^^\vM^\H and ^-'i^^<^'^> 



No. 15 k '-lo^voW- St.; '1 Distjbet. 



FULL NAME 





PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



DATi: HI- HIKTH 




iMontli> 



lUay) 



, 15 X 

(Year) 



\«".K 



O '^ ) Ht t » 



M.ihI/is 



Pa \s 



^l\<.l,K MAKklV.I* 
\VII»o\VKI» OR IHVoKtKI) 
• Writf ill MX-ial iU«»!>rnation) 



RIRTHI'I,AV''K 
•Sialf or Cnuiitry^ 






DATE OK DH 



MEDICAL CERTIFICATE O F DEATH 

-:ath n 

lI 



(Month) J 



(I)ay> 



(Ye«r> 



I HICKl'inV CKRTIFY, That I attcinlc«l aeccasetl from 

190- to 190 "^ • 

that I last saw h alive on • '9° " ' 



an.l that <Uath occurred, on the «latc stated above, at 
-M. The CAISP: OF DI^ATIl was as follows: 



I 



NAMK or 
FATHKR 



niRTiiPl.ArK 

or lATllKR 
'State or Country) 



MAIUKN NAMK 
OF MOTHKR 



niRTHPI.AOK 
OK MOTHKR 
(State or Country* 




W&^UTr-V 



• KCrrATION ^ , 



Rf>i<ffif ni StiH Ffc 



n, 1^1 1> 



" Yfatf " "^f'l'fli- 



fhn 



Tin- AHt>VFST\TKni'KRSOXAI.rAKTI0ri.AKSARKTRl K !•) IHh 
HKST Ol- MV KNOWI.KDC.K AND HKI.IKK 



(Infnnnant 



\^ . Ujvd 



's^w' »J 



v,,„o«. 1 1 b VnUmtn ^^^ IV. . ^ ' 









1)1' RAT ION y^ars 

CONTRIIUTORY 



Mo fit /is 



Days 



Hours 



DURATION , Years ^''!''^\, 

(oj) ^'^ ^ " 




Days 



/lours 



(SIGNED) L^^rvUA' J- ^^UJ. (ixLa^^vcL M.D. 



( 



-r-f- 



SPEC1AL Information only for Hospitals, iRstitulions, TransifRts, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



Noiv lonq at 
Place of Death? 



Days 



I'l.ACK OK mRIAI. OK KKMoVAI. 



U 



VLjAv*V4u«i. 



A> \<Xk'.- . 




IiATKof lU KiAi. or REMUVAI, 



T90M 



'% 



tr>^viH.*^ 



(NnKKTAKKK W CbC^V^cC^^ ' ' ^' 



•' ' rr\ .rP .hn..lri he stated EXACTLY. PHYSICIANS should 

N. B.— F.very Item of informBtlon .hould be carofuHy .uppi.ed J^^^^^^^/.^'^Yfle^^ .i'speci.l Information- for pr- 

state CAUSE OF DEATH in plain term., that .t may he properly cla.sitieo. 
Hon* dyini away from home should be ftiven in every instance. 



UFTtV* 









^^ 






It 



^t 



I* 



:i 



. « 



! 



T 



tl 



li 



ICm 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered JSTo, f 5?.^ 



,,„.!. .f 11.. Ilh I- No i.»r-«K34)lU«vl-Co 



Xo^^^ ^^iU\^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtitlcatc of Bcatb 

( XX. S. StanDarD ) 

St ^ -V 



(^ 



PLACE OF DEATH:-County of ^^^ 'W>X^U^ity of ^^V JA^xC.A.^C 



'cAji 



No. \X\\ ^UcsL^tU J'dl....?^^^}^l\.^^^^ 

/ ,r Ot*TH occults *W*y FROM USUAL RES^DENCE^<i^,v^c^..CTS C^*J-LtO OR^^^.J ^^ ^^^^^^ ^^^ NUMBER. ^ 



.Ayw ) 



^^--R^^v "j:^^t ?^?:?^;i:^^-;^-i -- ^^o; s?:..;-.o .u.e. 



FULL NAME 




V0L/1V^\^/1XW 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



OftwL 



C()I.«»K 



loJLt. 



DATK Ol- lUkTIl 



M'.V. 



>ih<)iith> 




J V«/ » A 



(Day) 



M,>Mlll> 



<Vear> 



a!> 



/^rt r> 



HTNr.l.R. MARKIKI). 

WIDoWKl) OK DIVnkfKn 
'Writrin stnial <!• sitr'iation) 



BIRTIU'U.^OK 
(State or Country i 



N'.XMK Ol- 
F ATlir.K 



HlRTIiri.AiK 
«)l lATHHK 
iStatf or Country) 



MAIHKN NAMK. 
<»K MOTHKR 



mKTHlM.ACK 
Ml- MOTHKR 
(Slate or Country) 



OCCri'ATION 



(?n 



Aid. 



op 




^^JtXX^ou ^ cryv<LL^^<> 



i 



'5^ 



J^'OL/^A^ vJ^^UX^^V/CA.^^.^'C 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH , 



(Month) 



± 



(Day) 



/go H 

(Year) 



I HRRKBY CKRTIFY, That I attciuka deceased from 

4j, igo'i to LLc\.a..*i 190^ 

CLvA.4...H 190 H 



sAAA/xy 4J. 190 ■• 

that I last saw h A- ^rv alive on 



and that death occurred, on the «hitc stated above, at 
^ M. The CAT SI-: Ol' DlCATIl was as follows 

X^ ^VVi-^L'-ivLCKvi 



DC RAT ION *" JVrt;-5 ^ Motiihs ^ Days ' Hours 
CONTRIHITORY 0.r:>vcL\.a-Ca.L^c vx 



DT RATION ^ Yeats " Mouths 



(SIGNED) 



^ l\iys * Hours 
TD) -J^. ^. CI^A^'tcU. M.D. 

lUvQ S TooH (.Address) W^^ IWctvx dl 
SPECIAL Information only for Hospitals, institutions. Transients, 
or Recent Residents, and persons d>in.j anav from home. 



AV.v/i/c*/ /// S'lf'/ /'; (7 »/. />/■(> 



)V,M 



!/„»///- '^.'" />'•' 



THK MM)VK STATK.n PKRSONAI. I'AKTICTI.ARS AKK TRCK To TIIH 
HKST Ol- \1V KNOWI.KDC.K ANJ) HKIJKF 



(Address 



l^'la ^)ivv<i,<u.U -' 



former or 
Isual Residence 

When was disease contracted. 
If not at place of death? 



How I0R9 at 
Place of Death? 



Days 



OF m RIAL OR RKMOVAI. 





DATKot Hi KiAi. or RKMOVAI, 

LLvvO- b T90H 

IXDKRTAKKR 3^/OLOcWcVv ^-A^A^U-^^Sv U 



La>^3^ 



(Address 



\c 'V. \ h ruC-CV cLvv-r.^vy.. '^'l 



,. . 7pc «h„uld be stated EXACTLY. PHYSICIANS should 

IN. B. Every Item of information should be carefully supplied, ^^"i •""",. jj^j. yh^ -Special Information" fer pr- 

•tate CAUSE OF DEATH in plain terms, that it may be properly class.md. ne j 
sons dyinft away from home should be ftiven in .very instance. 



t|k 




1^ I 



Lil 






f rf'" 



;!l 




<il 



WR.TE PLAINLY WITH UNPADING INK-THIS IS A PERMANENT RECORD 

REFER TO BAC K OP CERTIFIC ATE FOR INSTRUCTIONS 



r 



Date Filed J 

1 




Deputy Health Oflficer 



Redisteved JSfo, 




I 1* 






^trvcv^ :U^^Wi ^^K--J -v«*-... w...v.^, 

DEPARTMENT OFPUBUC HEALTH=City and County of San Francisco 



Cettificate of 2)eatb 

PLACE OF DEATH,-c».,r or^a,..1'ux«c..« a„ o,?!a^ ^Ia^— " 



li 



No. 




ftxUv. ^£LAvaUvc.v.n _ . JU^^-— ^Di^^^b^t;^ 



and 



•) 






FULL NAME 



9 ■ I I ^ 





'0 




.i-^ A 



SKX 



PERSONAL AND STAT ISTICAL PARTICULARS 

I coi,c 



li 




^WL 



U),^^JU 



DATK or lUKTM 



< Mo A 10 



a<;k 



0% »«»'> ^ 



lb 

(Pay) 



M.tu/fts 



rlbi 

(Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OH I>KATll 



(Month) J; <i>"y^ 



(Year) 



TTnTTfuJ^TcHRTIFY, That I atten<lea deceased from 

X to LLc^CL H J90 *^ 



.|vJ^''Xi. 



1 '. 



Ptl vs 



SINCI.H. MARKIKIV 
WIDOWKI* OR niVOKvF.I> 
(Write in social (iesijrnatJon) 



^ 



niKTHPl.ACK 
(Stall- or Country) 



NAMK <»F 
FATHKR 



niRTHlM.ArK 
()!•• I ATHKR 
•Statf or Country) 



MAIDKN NAMK 
«H* M()Tni:R 



niRTHPLACK 
01 MoTJIKR 
(Stat*' or Country) 



OCCIPATION 








e\KOLAaXll 



IgO'^ to UwC^CV^ H 

that I last saw h-V^n alive on LLca.1^ H. 190^ 

and that <lcath occttrred. on the date stated ab«ne, at I s -C 
OL M. The CAl'SK OV DHATII was as follows: 

iLttULA^. 






\>.x\. 



DIRATION )Var5 .1A>WA. Pays T //onrs 

CONTRIBrTORY lUJk/^^x.«v^v 



DURATION 
(SIGNED) 



)'ears 



J/on//is 



Pavs 



^iryvcv\±^rvv 



Hours 
M.D. 



[90 



( Address) bl 



.^(T^VV*ti^U.: 







Resided in Sav /•>hi/< / "' 






.\r.>nfh> 



/>,M 



THH ABOVE STATKI) PKRSONAK VAKTICl^KAKs AKK TRlK To THH 
BEST OF MY KNONV1.f;1)<.E AND HKIJ^f- 



" SPECIAL INFORMATION only lor Hospitals, InslituttoiS, Traiskits, 
or Recent ResMenls, wi pers»« <>'«« «»*> ''»'" •'•'^- 



'ihVe 5 0tU(l^^^ M^k? ^ toys 



■^tl 



(Inforniatit 



Qflnrv* 



( X'ldress 



5 



vdwA^^ 



U 
4 



,^l^ 



Former 
llsval 

Wken was disease contracted, 

If nfct atjla^ofdeathj 

PLACE of BIRIAT, OK KKMoX AI. 



DATHof Bt RIAI- or REMOVAL 

UlA-vO. '^. T90H 



I NDKRTAKER 



' ' " r7"TnE .hould be .tated EXACTLY. PHYSICIANS .hould 

N. B.— Every Item of information .hould be carefully .upphed AGE • ^^^^^^^^^^ ^^^ .^^,,,, .nformation" for per- 
* * %»ii«f= flP DFATH in plain tcpme, that it may ne prtf|» j 
:r. d".» -w« f~- hi. Should b. .W.n tn ...r, .n...nc.. 



# 
» 



i ! 




!<i 




i 



M 



i t 



iH ■'! 



r»i 



)' 



f 

\ 






■ kf^ 



I 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„..,., .,r „..U.- . NO ,. *^H&.Co REFER TO BACK OF CERTIFICATE FOR ■NSTRUCTION3 



Registered JVo, 



?94 



Dale Wf'^^ LUvOA-v^ 5. lOOH, 

Itrcc^ U^, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Certificate of S)eatb 

( "0. S. StanDarD ) 



A ^ 



PLACE OF DEATH: — County ofH/OAV vl >UXAa/CAA/CX) City ofOxX^ vJ A^c/>vCA^ex 



(No. OJA»v>OL/>\) *Jvch^ 



.vv^^laJ 



St.; 



Dist.; bet. 



and ""^ 



/ ,r DE.TH OCCURS *4.y FROM USUAL RESIDENCE Give r*cTS c*llco 'onvuotn Jlrtr'^l.^o'HvllUlm'*" ) 

V IF DEATH OCCURRtO IN * HOSPITAL OR INSTITUTION CIVC ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




.■Qyyyj).... 



t' 




'JX^x^V^X'.. 



si:x 



.».\TK ni Ml K Til 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




0- 



u 



Oi, 



• Mouth) 



<I):iyl 



vaJx 



/ l±\ 

(Year) 



M.H 



V)9w JV«i».^ V) yfonf/i.K A I />rt«v 



SINT.I.K, MAKklKIJ. 
\VIIM)\VKI> (IK I)IVi»Ri"Kn 
'\\rit«tn s(km:i1 «l»*>«iiftiatioii) 



^ 



'\a^■•v^JL•cL 



1i! 



i i 



\ i 



lUKTHIM.AOK 
(St.'itf «»r Country' 



NXMI-. OF 

I AT in; R 



HIRTMPI.AlK 
OF l-ATHKR 
(Statr or Country I 



^. 






I 



t 



i 



MAIDKN NAMK 
OF MOTIIKR 



jjyxnrwcJx' 



HIKTIIFLACK 
Ol- MuTMKR 
(Statf or (*ountry> 



4Jx rv^T-wO-vk 

f\'ri(frif in S^nt I'l ii mi^i-it JL." 5''"' 



\l,,„tf,- 



lhi\ 



Till-. AMOVK ST \Ti:i) l'KKS()N\|, FA KTIC F I. \ K ^ AKI! TKFK l<> MIF. 

HF;sr i)\- MY kno\vm;i)<.f: and uf:mf;f 



(infoTuiant 



U-l.lr* 






MEDICAL CERTIFICATE OF DEATH 



DATK OF DHATH 



LVU.CL 

(Month) r 



H 

(Day) 



(Year) 



CLc- 



I HRRKBY CICRTFFY, That I attended deceased from 

M.I . L . I'l ,^s ♦« iX*-va....H 190 H 

. VCL..."\ 190.H ■• 

and that death <Kcurretl, on the date stated above, at I 15 
LI M^ The CAISF? OF DUATU was as follows: 



MtJLu.. '^Jw 190 '-» to 

that I last saw h A.vi, alive on 



v<X^.<^WY^„fr>:vvou. dp t^laMAx 



Dr RAT ION 
CONTRIHUTORV 



Years 




DURATION Years ^ronths ^ Pays 



Months p^tys I fours 



Hours 
M.D. 

i 



rV!\ 



(SIGNED) . ,. _ _ , - — ^ — - 

l^Lccq. ' Tc>oH (A.ldresv) 'uXVwLa->A. IbLViV.^ 

Special information only for Hospitals, liistitutitns, Transifiits, 
or Rttfiit Residents, and iKrsons dying dway Iron home. 



Former or 'n t <? . 1 a t : ♦ "•* kw^ at . ^ 

Isual Residence ^5 l> > ^ V / piaff oi Death ? I 6 Days 

When was disease contracted, 
If not at place of death? 



n.ACK aF* BFKiAi, OK kf;movai. 



;* 



rN 



\AX/vv^ 



tX^ 



■\i7> 



nATF;..f III KiAU or Rh:MOVAI, 



a 



WQ 



(! 



T90H 



fni>f:ktakf:r Ifc.^J. MxUv«.4^v. 



IS. B.— F,v.ry item of l„Wm«tlon should be CBrofully supplied. AGE should »>« •^-'-jJ^^'^.^^CTLY . ^"^^Jf/^^^^^ 

state CAUSE OF DEATH in plain terms, that it may he properly classified. The Special Information for p.r- 
sons dyinft away from home should be ftiven in every instance. 




I \ 






I 



V 

! 



ft f 

I,; 






, I 



* 

'I: 



1 



ir 



i 






M 'i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

WE FER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

"^ 795 






lo Fih^(l ,\XxKOA.^^ S ^^^ H 

i>vvv<5lji/v^u Deputy Health Officer 



RegLstered J\''o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



of^O^YU OXXt'>\x:uX'. City of '^.COv n^^X-VvCvi. CO 



No. 



( Ta. S. Stan6at& ) 

J? % 

PLACE OF DEATH: — County 

llHl >) CrlA^Cn^V) SXa t Dist.;bct. 

^ ^ * , ,-oM USUAL RESIDENCE GIVE FACTS CALLCD FOR UNDER SPECIAL INFORMATION" \ 

IN A MOSPrrAt OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



X^ 



\A\) 



and Ao 



tL 



) 



(IF OEATI 
IF DC 



H OCCURS AWAY 
ATM OCCURRED 



FULL NAME 







O.Wt'^vaA.lnv 



t 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
A ^ i COI.OR 



vniaU 



lui. 



t- 



DATK Ol- lUKTU 




a<;k 



Id J, »v,i»A 



(Day) 



M»*4lfl^ 



(Year) 



1 ^3 



Pa vs 



SINT.I.K. MARKIKI*. 

\vn>«»\vi:i) OK i>ivmkiki> 

iWritf ill MKJal lUsiKnatioji) 



Ql 



VOw'VVaUw^ 



lUKTHlM.ACK 
'Statf <»r Conntryi 



N \MI OF 

» \tim:r 



lURTnri.ACK 

OK lATMKK 

'St;tt« <ir Oonntry) 



VAIDKN NAME 
.<U- MOTHER 






niKTHIM.ACK 
OF MOTHER 
(State ox Country 



Rf^lllrit lit Slltl /llTH,l.ti> 1- ) r,! > > 



MEDICAL CERTIFICATE OF DEATH 
D.\TE OF DEATH /-| 



(Month) .] 



H 

(Day) 



(Year) 



I IIKRKRY CKRTIFY, That I atteiukil ilcoeasctl from 

ULa^cOu SL 190H to IL-VCJL H 190 S 

that I last saw h -^^ » . aUve on LL\^Cjf,....H 190 -1 

aiiil that (loath fK-curred, on the ilate stated alnne, at v -^ « 



^T M. The CAl'SH OF Dl^ATII was as follows 

.1) -'kh.<rY^.x.!b-frr^Lv^ Lx^ULb xaA. 



nrR.XTlON * Vt-ars * Months^ Pays Hours 



DURATION 5^ 



W 



Mouths 



Pars 



lu. J . ^av^aJ. 




'0 



Hours 
M.D. 

-A. 



(SIGNED) 

CUcQ H ic)oH (A«Mres>;) l^lO -3 C^V<^C^->^v 

SPEOIAL Information only for Hospitals, institytiois, TriiisieRts, 
or ReccBt Rfsldenls, and iwrsons dying av»ay from homf. 



M.,„lh' 



I la 1 



THK AKOVF STATl'D I'KKSONAI, 1' AK IHT I. \KS \Ki: TKI K To fHI-: 
BEST OF MY KNo\VUF:D«.E AND lU.l.Il.F 



(IiifiKiiiatJt 



f \iMrrsH 






Former or 
Isual Residencr 

Whfii was disease contracted. 
If not at place of death ? 



Now loR^ at 
Ptare of Death ? 



Days 



I'l.ACE OF niRIAI, OK KK.M«'v 



I'l.ACE OF niRIAI/oK KKM<»VAI. 
l-NDEKTAKER Ov€U) | Vf^ S^ 



DA if;. if IMHiAl, or REM«>Y.\I, 



T9O 



'Address 



L'h'Jc VO CVA^vvc>v<:vtt^. '^ 



• •I APF -hnuld ha Stated EXACTLY. PHYSICIANS nhould 
N. B.— Kvcry Item of information .houid be carefully auppi.ed. AGE f «"/** ^ "*"**.Jj,^ ..^^^ Information" for per- 

•tate CAUSE OF DEATH In plain terms, that it may he properly classified. The S,Mrci«l intormat.on 
sons dyinft away from home should be ftiven in m'^mry instance. 






n 



I 



U' 



;ii 




,^^ 



1 



• 



I 



\i 



<i: 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BEFEH TO BACK OF CERTIFICATE FOR INSTRUCTI0W8 



„, ,,,r,\. . f II. 1.111. -I- No . >*^SS*"'^''^'" 




Jk c- lOO'i Registered JVo. Yl)6 

'l(^c^v^1u^^ Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( -a. S. StanDarC* ) 



PLACE OF DEATH: — County of ^1 ' lCL\.^>x 



Qlv 



J! 



City of HOav 



,"UJIa>^^ voJj 



^No. 



St 



Dist,:bet. 



— and- 



) 



( -^ -v^^vi:::;:^-v:^^ :-sj^^^;^^;r^if^ ^^" :::it^i::—^r- ) 



(?^ 



.XjujUaa.^ 



kxX) ^XOL'^ 



:\XXA.^L^, 



PERSONAL AND STATISTICAL PARTICULARS 



f>^wOLAJL 



loJx.-u 



DATK OK IUKTH 



I Month) 



AC'.K 



b H ,-.,„ 



(Day) 



.V.»m//i.> 



/IHC 

(Vcar) 



n t/ 



A/ 1 5 



STXr.I.R. MARKIKI>. 
\VII>i»\VKI> «»K DlVoRiKO 
Writf ill .social <U-«i»^n.-«ti<>n) 



HIRTHPI.ACK 

(Stale or Connlry^ 



NAMK or 
FATHKR 



lURTHIM.ACK 
OI I AIHKR 
'Stntr or Country) 



MAIDKN NAMK 
OI MOTHER 



Id 






UXWwCX'V^u 
lJUrJk>vcr%An^ 



«KCri'ATION <?5\C , ^ 

k'r^i,!r,f n, Sun /■,4in, i>ro ?5^ )V,n -^ 



MEDICAL CERTIFICATE OF DEATH 
DATK OF D1:ATH 

,H 

(Day) 



(Month) J 



(Year) 



I HRRHBY CICRTIFY, That I atten«le«l deceasea from 

— to -rrrr- — 



190 



that I last saw h "live on 

and that death occurred, on the date stated al)Ove, at 
M. The CAl'SR OV DKATII was as follows 



ngo 
190 



ff'' *-•----"- ,75V) 



^\.^J\X~. 



DIRATION years 

CONTRIHrTORY 



Mouths 



Days 



Hours 



IMKTHPI.ACK 
• >F MOTHER 
(State or Country > 



M.nfh^ 



Am 



THE ABOVE STXTEI) PHKSONAI. I'ARTlCr I.AKS ARE TRIE T< » THE 
BEST OF MY KNiiWIJ-.IX.F: AND BhlJEF 



' XfMress 






DIRATION )V<i>-^ Months 



Pays 



(SIGNED) 



go 



(Address) O 



/CLA\j 



( 



Hours 
M.D. 



> ^ 

SPECIAL INFORMATION ••»•> Im Hos^tals, listitytlws, Tratsie«ts, 
or Recett Residents, dfld persons dying a*»a> from li««e. 



Former or 
Usual Residence 

Wken was disease contracted. 
If not at piar e •! deatfc ? 



Now I«ii4 at 
PUretf Oeatk? 



Days 



I'l.ACE OF in RIAI, OK KEM<»VA1. 

% 



nArF:of Bi kiai. or REMOVAI, 






rc)oH 



(Ad«lress 



■~"~""^ VI ACF should be •tated EXACTLY. PHYSICIANS should 

N. B. Every Item of information should be carefully supplied. ^^^ « classified. The "Special information" for pr- 

atate CAUSE OF DEATH in plain terms, that it may be properly ciassitie 
sons dylnft away from home should be ftiven in svery Instance. 



11 



,1 
|i 



■^ 



i-'' 
^ 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

, ,„ „„,_,.„ ....^-„.... CO ,r»»TOBACKOrCE.T.r.CATe.OR.N»TRUCT.ONS 

ih' AV/f^^/, LLwcvi^^t S^ ^^^^ ^' ^ 

"l^rvcv^^vHi Deputy Health Officer 

DEPARTMENT # PUBLIC HE ALTH=City and County of San Francisco 

Ccvtificate of Beatb 

( la. S. Stan&arC» ) . 

of^ou^v viiva/>xc^<iA:^Gty of 0.a/>v ;va/> V cc^^cc. 



PLACE OF DEATH: — County 




<n\j 




St.; 



Dist.; bet. 



and 



— ) 



(Ar DEATH OCCURS AWWT FRO 
ir DEATH OCCURRED IN A 



^ ^^** -^^. In rftB UNDER "special INrORMATIOM" \ 



FuLL NAME OAmviav 




PERSONAL AND STATISTICAL PARTICULARS 

COI.< 'R 






«... 

(Month) 



Ikilvdx 



( Day) 



(Year) 



M'.V. 



^ I ,...„, 1 yh,«iks ..\ 



Pay 



MEDICAL CERTIFICATE OF DEATH 
1>ATE OF DKATH 

. X 

(Day) 



Ci 



(Month) ^ 



(Year) 



I HEREBY CERTIFY. That I atten.Ua ileccascil from 



Wlu. .. /xi 190H. to .... ULcvo. X 190H. 

that I last saw h ■-'^^ ' -ahve on LL^-vX3^ X 190 



'ilXr.M?. MARKIKD 
WlIxnVKI) OR niVnKfKD 
tWrilfiii «i«KM:il iU«»it^tiati'm) 




ancl^hat .Uath (xrcurrcl, on the <hite statc.l alK.vo. at 
^^ M The CAl'SE OF DlvATII was as follows 



t 




1 1 [« 



D 



BIRTH PKAOK 

'StiUf or C'ninti V 



NAMK or 

F.\Tin:R 



iuRrniM..\rK 

OK lATHKR 
(State or Country) 



MAIDKN NAMK 
01 MUTHHR 



lURTllPK.XCK 
Ol MOTHKR 
(State or Country) 




op 

^ iJ 



lUJk/^ 




Il>vI^ 



VVC^CXATW 



XXa^ 



DURATION Years 

CONTRIBUTORY 



Mouths ') Days Hours 



DURATION 
(SIGNED) 



Years 



^fonths 



Pavs 



Hours 
M.D. 






^ 



SPECIAL j N FORMATION only J»rHos#ltis, liblilytioiis. Twiskils, 
•r Recent Residents, and perwns dying a«a> from htnie. 



OCCI r.»TION 



CLt. 



£K/cJvv(V- 



Rfsidfd in Son I'ltituiifn 



) Vi)/ 



}r,>iifh- 



/),i ^ 



THK AHOVE STATl-.n I'KRSONAI. I'AR TUTLARS ARK TRKK TO THK 
HKST OK MY KNOWI.KIX.K AND HhlJKh 



f Informant 






r\«l(lre«4S 



'Tn^ 






Former or 
Usual Residence > 

Wlien was disease contracted, 
If not at place of deatti ? 



kaM. 



•A Now I«n4 at 



PUrenf Deatk? 



Days 



PI \CK OK lURIAI. OR RKMoVAi. 



.'>^V<^ 



DATKof in KIAI. or RKMOVAl, 

LLca^ ^ 190H 

rNDI-RTAKKR l^D ^UUA ^^HC LC 



(Address 



v,C ■» 



■""————""— ^ . . APF .hould bo stated EXACTLY. PHYSICIANS should 

N. B.— Every Item of Information should be carefully •«PP''«^- ^^^^^^y cUsslflcd. The "Special Information" for per- 
state CAUSE OF DEATH In plain terms, that it may ?« P;^^*-"' 
•mis dying away from home should be given In .very Instance. 



w 




I . 



^* 



M 



I 



■1 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



}?(',(!'! "' 111";'"" ' • ' ^ tur^rif^-^ 




Date tiled J \X^k^Oj^^'Do .5. 



100'\ 



iUvwaA^^-M Deputy Health Officer 



Ke^istered JVo. 



798 



DEPARTMENT OF PUBLIC HE ALTH=City and County of San Francisco 

Certificate of 2>eatb 

( -a. S. StanDarO ) -^ 
PLACE OF DEATH:-County of 6^- k<V>X^UC. Gty of ' )a^ ^ A.O^--- 
No. 1 ^\ txcLvu. H V-- „^ J?J.:„,,1,.. ^^^1"^^}^^^^^^ ' 

^^°- / .r DEATH OCCU.i .WAV -"O- USUAL «ES^Df,^«^^JV.VE*';i NAME instead or .T.EET AND NUMBER. J U 

V ir DEATH OCcUbRED IN A HOSPITAL OR INSTITUTIO /7N ^ 

^^" ^ v i'L.J..vi\....(]A- 



FULL NAME 




hJXZJL 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.<»R 



wu 



bl^u 



liATK or HIRTH 



a. 



I Mouth) A 



Ar.K 



) ■«•<; » 



(Day) 



M.'ulhs 



(Year) 



Ai v> 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



(Month) (TT 



H 

(Day) 



IQO 1 
(Year) 



^INni.l*. MARKIH!>. 
WinoWKI) OR IHVnKvKI> 
tVVritcJti «uKia1 ii»'*-ivrn:»li<>n) 



.1 



CJ^vs.a/U. 



TiTkRKBY CI-RTIFY, That I attended deceasea from 

dvvcy -".. 190 ^ to Gw^tx H. 190.H 

that I last saw h .'- ■ alive on LUv^ .M.- I90 ^ 

and that <U-ath occurred, on the date stated al>ove. at t Aij 
j^ y^ The CAl'SI' OF IHtATII was as follows: 




lURTinM.Ai'K 
'Slatf or Country) 



NAMK Ul- 
FATIIKR 



lURTlin.ACE 
01 FATHKR 
(State or Country) 



MAIDKN NAMJ: 
0» MOTIIHR 



lURTHPl.ACK 
<>J MoTHKR 
(Slate or Country 1 



oCCri'ATION 






V(XV 



LlL 



^J^Jatx ^^j)A.v 







t 



OnrvCLT 



.^^\ 



0\ vwa 



)V,f 



\f.>nfh' 



/).:x. 



TUV \HOVF.ST^T»-I>PKK^ON-AI.rAKTIcri.ARSARi: TRIK n> THK 
HKST OI- MY KNOWI.I-.IX.K AM) nKM»> 



(InfoTmant 



(\.Mrt 



VtXO C 
I5l 



'(Jb.vc-k-frXM ^'^^^^ 



DIR-XTION Vca,:^ 'V.,/////. l^ys ^"^ //ours 

'I ^>v<>^ - 

(SIGNED) ^-1"^^^^"^^ l'*^' 

QLcvQH tqoH VAddr.ss)1aO JbWaV<C dl 
■ SPECIAL INFORMATION wly far Mospilals. lnstit«Hfiis. Traiisicits, 
or Receil ResMcnts, and Rcrsens dying d*d> from bwic. 



Pormfr or 
Usual RfsWfiice 

V^Tif n was dispase contracted, 
If not at plarr of deatk ? 



How lodf at 
Place of Deatk? 



Days 



ri.ACK OK BIRIAI. *>R RKM<»\ AI. 



A^vnmX 



DATKof nt HIAI- or RKMOVAl, 
(.Address X°i V Ctw 



,a u 



' .. . .pp .h„„,d be stated EXACTLY. PHYSICIANS should 

IS. B— Every Item of information should be carefully -"PP*-;^- ^^^perly d—i"***. The "Special Information^ for psr- 
state CAUSE OF DEATH in plain terms, that it ma> p« P P '^ 
son. dying away from home should be given m .very instance. 



I 




1 

I! 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Honr.l..f Hffilth -1- Vo_l^ 



H&PCo 




iii 



lOO'i 



Registered J^fo. 



799 



l)((lr Filed , \A^.v/CW^^-^ ^5^ 

i^M^A.^^ \3LA^M Deputy Health Officer 

DEPARTMENTS PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "CI. S. StanDarD ) 



PLACE OF DEATH 



Jj 0^ 

: — County of ^^'CC'^ ^J. 



A % 



((X-Yu vJ /UXAVCvi CtCity 



City of' ''CUiV) OAXVoa-CM^^c 




A Mi 11 '\ 



-) 



FULL NAME 



O.'TWL^ Vl-^^^-' 




PERSONAL AND STATISTICAL PARTICULARS 



HI' 




SKX 



HATK or IllKTIl 



A<'.K 




"^ I Years 



M 



\,nlhs J H. An 



MEDICAL CERTIFICATE OF DEATH 
l^TE OK DKATH ,^ 



(Motilh) (\ 



H 

( Day) 



(Year) 



' M 



WinnWKD OK DIVoKiKH 
iWrilr in •^'H-ial <l»-siviiali<Mi) 



HlKTHl'I.AOK 
(Statt or Country) 



N'AMK OI- 
FATHKR 



rirthim.ack 
of jathkk 

tState or Country^ 



MAIUKV NAMK 
Ol- MOTHKR 



lUKTm'I.ACK 
«>|- MOTHKR 
(State or Country) 









ninREBY^CKRrTrY, That I atteiukMl ilcocasca from 

0(\\^rl\^ 190 H to ^ijW ^ '^ ';^ 

that I hist Is h .U»xalivc on AW^ ■ H igo X 

aii.l that acath cK-ctirred, on the date stated above, at \'\ ^ 
v.Lm. The CAl'SK OF DIvATII was as follows: 



Dr RAT ION yt'ars 

CONTRinUTORY 



A/on/Zis 



Days 



Hours 



•'>vO 



a. 



VmavcvcNAxti \ 






DURATION 



/'onlhs 



IhlYS 



Hours 
M.D. 



(SIGNED) U).>vlO.^/W .-- 

^f<\. INFORMATION «•»'> 'o^ Hol^tals, Institulloiis, Traiskils, 



AX 



dL 



OCCri'ATION 

fs'r^ntr,! ni San I'unti isfo ^^ > ''" 



\f..,itli^ 



n,i \ .< 



THK AHOVK ST\T»-n PKKSONAI. I'AKTIOri AKS AKK TRTK T. > THK 
nKST OI- MY KNO\VI.i:n<.K AM) Hhl.U-.b 

(Informant v) ^CC V I XxxL ^ 



or Recent ResMents, and persons dying awdv from home. 

When was disease contracted, 
If not at place of death ? 



Days 



ri,A.cE OK m RiAi, OK ki:m«>vau 



I ndkrtakkrM'w V). 



I)ACK'»^ 111 HiAi. or REMOYAI, 
b 1 90S 

r -I 







'^"•i\,<.l^v 



(Ad<lrcss in I Al riV^lAA^TX 



■^^^^■"""^"^"^^^^^^"^"^^^^"^^^ IK » t d EXACTLY PHYSICIANS should 

N. B.— Every Item o« Information .hould he carefully -"PP";J; p^^p^eHr"l«..i«ed! Vhe "Specl.'l Information" for p-r- 
.titte CAUSE OF DEATH in plain terms, that it may he proper y 




i 



ii 



■I 




V^ 



WR.TE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

RtrER TO BAC K OF CERTIFICATE FOB INST RUCTIONS ^ 

800 



FNo. i^-^r^^HM'Co 




- -+ X. 



I 



1-! 



-r V , ,^ , Registered JS'^o 

l)(f/r Filed, ' ' - ■ -^ 

DEPARTWENT 0? PUBLIC HEALTB-City and County of San Francisco 



-^-Vcv/) 



^xNu Deputy Health Officer 









Certificate of Beatb 

( TU. S. Stan&at£> ) 



% 



PLACE OF DEATH:-Countv of Ao^^^VC^V^. -Oty of^X^'ixC^™ 



) 






FULL NAME 



tVO-VO-TV 



^V 



.<x.^.y?u 



-\.\ 



PERSONAL AND STATISTICAL PARTICULARS 

i COI.OR 



I i 



I)\TI-: OF lURTM 



(iluL 



Lv'J"^^^^ 



(Month) 



IDay^ 



AC.K 



CvJUv .5 )Va.> 



M,>n//n 



(Year) 



Da vs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ft (j /, . 

(Day) 



t 



(Year) 



^INC.I.K. MARKIRD. 
WinoWKD OK nivoKrKD 
Writt i!i s«KMal «ksiv:nation) 



llA^k 



W^VaJ^^IV 



'■ t 



HIKTHrM.AOK 
tSti«lf «»r C">uiitr\-^ 



NAMK Ol 

hatiii:r 



niKTHIM.AOK 
OF I ATIIKR 
•Stale or Country) 



MAn)F:N NAMK 
OF MOTMKR 



lURTHPUACK 

«>F mothf:r 

(State or Country^ 



(H CFFATION 

Resiitnl tii San /'i mn i-r.f 



H 



>> 



i IIKRRBy'cKRTIFY, That I attcmUa .Icocasea from 

190 to »90 

that I last saw li alive on »90' 

and that .leath occurred, on the .late stated above, at 
M. The CAISF. OF DI-ATll u:as as follows: 

%Vl' - . t 



Dr RAT ION V'^ars 

CONTRIIUITORY 



Months 



Days 



Hours 



DURATION >V<?/-5 



Mouths 



PilVS 



Hours 



) V<7 ; 



Mn.'th- 



Ihr 



t^ 



THHAH«.VKST\TFI.PKKSnNAl. F\Kruri..V»<>AKF:TKrF: fo IMF. 
nF:ST OF" MY KNO\VI.F.n<".F: AND UF.UIF.l- 

(Itifuvmant V^A,/^^WX^V^ 



(SIGNED) CcVtnvlA,.^ % U." ItL^.d. M.D. 



lie. 



g '■ iQo'^ 



I., t., u«r«i»stc iHctifuliiiac Tr^H^iratv 



■ SPECIAL INFORMATION only lor Hospitals, InstltylJtiis. Traask its, 
or Reteiit RfsWfnts. and persons dying a*»ay from home. 



Former or 
Usual Residence 

When »*as dlsea^' contracted. 
If not at place ol death ? 



Now loif at 
Place of Deatk? 



Days 



\^ 



'\JL 



(Address 



DA if: of Ht RIAL or RKM<»VAI« 

B, y LLa-^V^ I I90H 



n.ACKOl- m-RFM, OK KKMi>VAI 

fndf:rtakf:r 



3knx- '.H i^-j it 



(Address _^.^^^^«»^ — . .^ 

■^^-^^— — — — . . » * rf FXACTLY. PHYSICIANS should 

.. B._Bve.. Ue. o. .n^o.^-Oon .Hon.. .e ca.c.uH. -uppUed ^^^^^--^^^^^^^^^^^ ..,^,,.. ,,o.....o„'' fr p..- 

•tate CAUSE OF DEATH in P'»'" *^^^'"';;j;" J'.^^^^y rn.t.nce. 
•on. dying away from home should be ft.ven m .vry 




4 



i ( 



^1 



i 






ii 



li 'I 




; I 



-i ! 







WR.TE PLAINUY W.TH UNFAD.NO .NK-TH.S .S A PERMANENT RECORD 
WRITE PLAINL -- .....Tr roR .N»TRUCT.ON» 



/)^</r' /wVf^f/, LL\A.CJAV^^ 5 ^^^ 

-^ r. DeDwtv Health Officer 

d^t^^'u^^ Ki.^yj^i^ ^^r 



Registered J^'^o, 



DEPARTMENT OF PUBLIC HEALTH=City and Counly of San Francisco 



Certificate of Deatb 

( Ta. S. StanOarO ) 






( XX. S. StanOarO ) 
PLACE OF DEATH: — County of ^ ) O^^^. ^w 






St.; -*::^"~ DJst.; bet. 



/^h M.l\^^'..ClA- St.; ^* V^irn rOR UHOEH •'•PECAL I N roRMATION" \ 

V, ir DEATH OCCURRED IN A MO»PlT«i. ^ ^ ^ A 



FULL NAME 



-I, 



.ouJujl' 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

0^ 




KATK <)l- IIIRTII (?j?\ 



VOi\Alil^ 



AC.K 



5A 

(Month) 



I'J, /..I'iH.... 

(Day) <^'«»^^ 



MEDICA L CERTIFICATE OF DE ATH 

DATE OF DKATH ^ "^ 

(Day) 




(Month) 



tz 



190^ 

(Year) 



M.mtin 



n.% 



Da 1 < 



SINr.I.K. MARKIi:!) 

\vn)owKi> OR nivoRiKi> 

Write in Mnial iksiKnalion) 



lURTHPI.AOH 
iStatf or Country^ 



XAMK. 01 
FATllKR 



BIRTH IM.ACK 
OI- J ArilKR , 
istat*- or Conntry) 



MAIDKN NAMK. 
<»1 MOTUKR 



HIRTHIM.ACK 
«>F MOTHKR 
(State or Country) 











rin'TlMrrtHRTIFV, That I atten.U-.l .Icocasc-a from 

LUvq., ,^H t"|Hr5 "°s 

that Ilast Lv h x-u alive on tl.CV£^ ^"^ ""^ *» 

„,„1 that .Uath .K:c..rrc.l. on the .late stat>-.l al«,ve, at 1 
CL M The CAISI'; OK 1)1;ATI' «•»" «" follows: 



% 



r 




DURATION >Vflr^ 

CONTRim TORY 



Months 



Pays 



Hours 



.l> 



DURATION ^ y^^rs 
(SIGNED) >J 



Mo/t//is 



Pays 



yAxiXou 



4 



/fours 
M.D. 



Kesidz-.i III Sail li,iii<i»" ^^ ^ '" . • ■ 



occr,.AT,ON '^j^^J^^j^ 



Kfsntrii III ^<"i I """ '■•■• •rill,"' 

TMKABOVKsrAT.U.PKRSONA> |-AKT,or.;AK>.KK TKrK T- • 

IIKST OF MV KNOWlJjIX-.K AM> ml."' 



GUvQ H..^. f A.Mres.O Ob AvctU. V* 



■<iPEC.AL INFORMATION fy t.r K«^Uh. l«Ht.«..s. Ir,.sk.ts. 
or teiert Rrshlrnts, »1 Krs.«s 4>lt><l «* Iro" h"*- 

Diys 



ii How l«M » 
tvAWUThPtafe of Deal 



(Informant 



KNOW »jiv'" 



^ 



Vvo-^^ 



Ia^aJLa^^ 






DATKof m KlAi. or RKMOVAU 



vvt.A:ytrY>>Jl*u^ 



(^<^<^rcss O^-^ \ \ , I I II II r PHYSICIANS •hould 

t. tA K. .^r efully supplied. AGE .hould *^ •*"**" ^ ••Soecl.l Information' for p«r- 
N. B.— Every Item of information .hould ^e c«rcf"«ly «upp ^ ^^^^^^,^ .....ifled. The Special 

.fate CAUSE OF DEATH in plain J*''"'';;;; „ .,,4 in.t-nce. 
.on. dyinft away from home .hould be g.ven 



1 



V: 



• I 



f 



r_r 



i 



mii 



-I 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hoar.l of Health-K No. i. -^^^^H^^Co 




Registered JVo, 



80;2 



Dale Filetl, \X>^XY^^Ji^ '> I'^O'^, 

*l<^v^v.5 "Wu. Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Ta. S. StanDarD ) 



No. 



PLACE OF DEATH:— County 

l'^'l^ 'l<XAvQtt.>\. St.: 'i Dist.;bct. l(rL^tn>V and OL ^vo- 

10 l,^ X. V«w^ \ VU/ V V. TV ,.^,,., BpeiDrNCEGIVE r*CTS C*LLCD FOR UNDER "SPCC.*L 1 N ro R MATIO N" \ 

( " rr"o;:T°Hi^"=u%rcV.;"rHo".^P?T".t ?« ?,;?"?u^4°;^o.;r.;i name ..ste.o o. street *.o .umber. ; 







a^yd. 



FULL NAME 



>^'UlalU<xLl 



PERSONAL AND STATISTICAL PARTICULARS 



DATK Ol niKTII 



oJjL 



COI.OR 




V 



aJjL 



t Month* f] 



A«.K 



?,1 



) Vii » > 



(Day) 



M-tith 



(Year) 



A; 1 . 



SINr.I.K. MARKIKH. 
WIDOWKI) «>K niVoRfKI) 
tWritf in Mx'ial «lf«si»:ii:itioii) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



a 







tgo \ 

(Yenr> 



(Month) 1 U>:«V^ 

I HI':R1:HV CI:RTIFV, That I attcnaeil <lcocase«l from 

jgo — to iyo 

that I last saw h ..r-r-.alivc on '^- ^9° 

ami that ilcath occurred, on the tlatc statc.l alnn-c, at 




niK r»irM,At*K 

iStatf or Country^ 



NAMI-; OK 
FATIIKR 



HIKTHIM.AOK 
OI- I ATHKK 
'Stair or Country) 



MAIDKN NAMK 
Ml MOTIIKR 



lUKTllPI.ACK 
ol MOTHKR 
'Striti or Country) 



^ .VcC CL/VvdL 



(»*crr \ rioN 



kVsiilfd til S'liu /'i 4llii tuo iU )'•<"* 



M.'iifh' 



/>.n- 



rilK M5.)Vi:STAri:i» i-KK-^nWl. |\KTUMI aks akh tkik to Till-; 
IJKST Ol iLV KNOWI.I.IM'.K AND m.l.IJ-.l- 

mnnt v ) ,rL/0-»A.O^ LU CX^V^Jtv 



(li 



(A(l.lrc«is 



c^% \CWoJyjuuCs % ^ ^ 



t 



^ 



M. The CAl'SK OF DIvATII was as follows 



A^V'VS.^i^ 






l 



.Jt:lCL.'!l.t.. 



Dr RATION Years 

CONT Rim TORY 



Months 



Days 



Hours 



M>))iths 



DT RATION Years Mntiths Pays 



(SIGNED ) 

V T90H 




( Adilrc'ss) 



Ltr\ 



Ow4V> 



i^ 



Hours 
M.D. 



SPEdiAL Information on'y 'o^ Hospitals, institutions, Transifiits, 
or Rfcent Residents, and persons dying ai»ay from home. 



Usual Residence 

When was disease contracted, 
If not at place of death ? 



Place of Death? 



Days 



I'l ^CF t)F niRIAI, OR RKMoVAI. I DATK of Hi kiai. or RKM(»VAI. 

" %Xu^<y.... I 0.c^^ .904 



'A(l<lress 



^. «._P,very It., o. Information ,Hou,.. he c«rcfu..> supplied. AGB .ho..d ^^^^^^^^^^!^11^;^;, ZV^^lo^^^T:^^. 
state CAUSE OF DEATH !n plain term., that it may be properly clai.«ifled. The Special Informat.oa for p«r 
Kon* dyinft away from home uliould be fti%en in •very instance. 









■rt^'^JA 




*^ 



• 



w 



\\ 



\ 



n 



I'l 



I 




I 



II 




noar.lof Hcallli »• No i'^ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^ 

Registered J^'o, oQ*3 



]{&rco 



^(/<> /<V/<'r/,iu,vavvAt '5' -^^^"^ 

L^v^iwu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccrtiticate of Death 

( H. S. StanDarO ) 



PLACE OF DEATH 



^1 

: — County of J vA^' 



c' 



% 



.U^.\h.Oj. VCXv-^- City 



(0 j 

ity of ' O-^ 



( 



M^ 



CL'VmL\.<X 



^No, 



St. 



-Dist.; bet. 



-and 






) 



FULL NAME 



K..<X- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
, j COI,<»R 

l»ATK «>1 JURTH 

/ 

I Month) <»^«y* 



ULllvv-t. 



ACF. 



Vrats 



M,>n/ks 



\VII>o\VKI> •»R niVOKiKIl 

'Writ*- in v<HMal dt— ij^nation) 



niK THJM.ACK 
fStt«t« or Conntry^ 



KATIIKR 



BIRTHPl.ACK 
<M- I ATHKR 
(Hlate or Country > 



MAinKN NAMK 
OF MOTHER 



lUKTHPLACK 
o»- MOTHKR 
tStatf or Country* 




(Venr) 



D.t M 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

(Month) ^^^^\ 

I HEREnY^l^RTIFY, That I attendtMl rlecease<l from 

• IQO -— 

— — — —190 



I9O 



-to 



alive on 



that I last saw h " 
atvl that «U'ath occurrea, on the «late staLcMl a1)Ove, at 
M. The CAISn or UKATII was as follows: 



•••/TS 



nr RAT ION Years 

CONTRIIU'TORY 



Years 



Mouths 



Ihus 



Hour's 



Months 



(SIGNED) Va U 4,.VlLt<.v^Jj^A/vvvil 



l\1\ 



Hours 
M.D. 



T(»0 



XfMri'is) 



1 ,1 



)m I'M" ION 



'\^^ ' 



Rf}-idfd ill Sr.11 I'lain nr.i 



5V.;' ■ 



\f,,„>h' 



/)..' 1 



TUF ^HOVKSTXTKDl-KR^ONAI. rAKTICri.AKSAKKTKI F, TO THK 
HKST OF MV KNOWI.KIX.F: AND HF.I.IF.F 

/ , ^ 



(Informant 



^^^ c a. "^jo^ 



\.Mi 



h 



<XA.^'w,^ 



SPECIAL INFORMATION anh lor Hospitils, InstitiilioBS, Traisiwts, 
or Recent ResWeiits, itnd persons dying d*»ay from home. 



Former or 
Usual ResMeiKf 

When Has disease contracted, 
if not at plare of death ? 



How l«iN| at 
Place of Death? 



Days 



I'l ACF OF BrRMI. OK KFMoVAl, j DATFof Ht kiai. or RKM<»VAI, 






ini)f:rtakkr 

(Ad<lrt"*s 



N. B.- 



'1 .. . -^p .K«..M he Mtated EXACTLY. PHYSICIANS should 

—Every Item of Information .hould be carefully supphed ^^^^^•^''"'^.i? '^^ Information" fer pr- 



-Every item of information .hould be careVuHy •upp..ea. --" " ,,,.,if|ed. The -Special Information" fer pr- 
state CAUSE OF DEATH in plain term., that .t may be properly wla.«niea. h- 

.on. dying away from home should be fciven in every In.tance. 



I 



t 



* ♦ 



t I 

I 



1:^-.:^ 



JtMSt. 



'' ^ 










- 


i 

'■ 



1 



; ^ 



I 



;f ^ 



I : 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

804 






Ddlr Filed, VA^vOlA^^ 5: I'^O S 

ifrvcA.^iv.tv;^M D«P"^y Health Officer 



Registered J\''o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Xl. S. Stan&arD ) 



PLACE OF DEATH: — 



No, 



J\L JuLrvuxtx^ 



St.?— ^ Dist.;bct 



City tjf 



(louyvx ~ ) . '.> 



and 



FULL NAME ^" v^in ) 



vvj y c \. ^^ A'v.A 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



IJATK Ol IJIRTH 



lO,kd 



(MontliJ 



ACK 



)Vii»J 



(Day) 



Mnulh^ 






<Vear) 



/ 



A/ 1 v 



SfNf.I.K. MARKIKI) 
WIDOWKI) OR I)!Vnkii:n 
IWritf in smial <l<-vij»iiati<>n) 



BTRTIIPLAOK 
(State or Country) 



NAMK OF 
FATHKR 



niRTHPI.AOK 
OF FATHKR 
(State or Country) 



MAIDHN NAMK 
Ol- MOTHKR 



niRTHPLACK 
OF MOTHKR 
(State or Country) 




MEDICAL CERTIFICATE OF DEATH 



DATK OF 1)1 



■'r 0)u.>v 



(Day) 



(Year) 



(Month) 

I UI^RI^BY CERTIFY, That I attciulcMl «leccasc«l from 

— to i gcr^-r- 



190 



that I last saw h • -i»live on --.r,,--r,T^ -^-^ 

ami that death occurred, on the date stated above, at 
■ZZ:..:.y[. The CArSl? Ol- DI^ATII was as follows: 



190 



DIRATION Years 

CONTRim'TORY 



Months 



Pa vs 



Hours 



DURATION 



Years 



Mouths 



(SIGNED) 



a \ \ %- a 



Pays 



Hours 



M.D. 



OCCll'ATION J( I 



Kf>.idfti in San I'laniiuii 



) tUl I 



\r,>iitfi' 



/>,7\ 



TUF MIOVFSTXTFDPFKSONAI. PXKTICII.ARSARK TRIK TO TIN- 
BKST OF MY KNOWI.KIX.K AND Hhl.IhP 



(Infoiuiant 



. Ik^ g i- i^ 



Ol x^^ A 



SPECIAL INFORMATION on'y '"^ Hospitals, iRStitMtiMS, Transifits, 



'^X 



0-L\ltic)oH (Address) 



^w^U^X 



or RfCfBt Residents, aiMJ persons dying away from liome. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Deatk? 



Days 



PI.ACK OF lURIAI. OR KKMoVAI. | DATKof HtRiAr. or RKMOVAI, 

V\A.A»<5, 5" 1 90 S 



ACK Ol- m IM.M. "". r>. ■ 



FNDKRTAKKR 

(Address 



IM.i)^^ 



\ 



\i 



1. M ACF .hnuld be Stated EXACTLY. PHYSICIANS should 
N. B.— Every item of information should be carefully suppi.ed. J^^^ ' / ,^,,.^,^d. The "Special Information" for p.r- 
state CAUSE OF DEATH in plain terms, that .t may be properly class.tiea. P- 

sons dyinft away from home should be ftiven in every Instance. 



l; 



tl 



I * 



fi. 



i 




IMnnl 



M 



WR.TE PLAINLY W.TH UNFADING INK -THIS .S A PERMANENT RECORD 

RCFEB TO BACK OF CERTIFICAT E FOR INSTR0CTION8 

805 



of Hcalth-F No. .. -ft^^^H&I^ 




loo'i 



Date Filed , 

l^w^liL, Deputy Health Offlcer 



Registered JVo, 



i\ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( la. S. Stan^ar^ ) 




PLACE OF DEATH: — Cuun ty e f ^OoClCULj 



Viiiy or 




(?, 



f? 



CUl ^^ ^ ;v(rov>\ct 



No/ 




o. , Dist • bet — and 



^ 



FULL NAME 




.i.\i.jL..i.\Axt . 



SKX 



DATK OF IlIRTII 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ 




<x 



u 



VAi-^V^i^ 



(M«)iith) 



(Day! 



Ar.K 



/ 



) V«i # .« 



M.tMlhs 



(Year) 



Pa \s 



M 



EDICAL CERTIFICATE OF DEATH 



DATE OK DKATII (H . ^ 

(I>ay) 



(Month) 



(Year) 



I 



SINC.I.K. MARKTKP 
WinoWKU OK DIVORCKI) 
iWritf in s«x'iiil ilesiv:"aticm) 



HIKTHPI.AOK 

(State or Country^ 



NAMK 0|- 
FATMKR 



niRTHn.AOK 
or FATHER 

I Stall- or Country) 



MAIDEN NAME 
OF MOTHER 



., it} 



I X 



* <!Hlii 







I IfKRICnV CHRTIFY, That t attended deceased from 

190 to 190 

that I last saw h alive on ^9° 

and that death occurred, on the date stated ahove, at 
M. The CAlSFv OF DIvATII was as follows: 



-\ 



'V^.w^^^Ltht UJ.frvv^vcL ^x^cvcU 



^- Yean 



Moulhy 



Ihn: 



HIRTHPT.ACE 
OF MOTHER 
(State or Country) 



OCCUPATION - ^ « 

RfsidfJ in Sn» Fratifhfo _^ 

THE AHOVE STATED PERSONAL I'ARTIC-rLARS ARE TRIE TO THE 
BEST OF MY KNOWUEDC.E AND BEMEI- 



Dl'RATION years 

CONTRinrTORY 



MoHlhs 



Pays 



Hours 



DURATION 



K'''''i 



M()fi//is 



Pays 

i\JL 



IIou 



rs 



(SIGNED) 'K \i>. r>.AllLC\n>Vv\%X ,^ M.D. 

^TlW. ( .<>. H I A.Mrcss) mtVTvJU M :^ 
SPECIAL INFORMATION only for Hospitals, iHstltBtloPS, Transkiits, 
or Rfcent Residents, and persons dying a*ay from liome. 



Former or 
lisaal Residence 

When was disease contracted. 
If not at place of death? 



How lonii at 
Place of Death? 



Days 



PLACE OF niRlAL oR REMOVAL 



VjVocU^cr^vcJL 



DATE of HfRiAL or REMOVAL 



(A 



H 



XDUV^- 



INDERTAKER 

(Ad<lres« 






N. B.— Every item of information .hould be carefully •"P»»'''^^; ^^^.^^y cla..ified. The "Specl.! Information" for pr- 
state CAUSE OF DEATH in plain term., th.t it may ^* f^^^*'*"' 
•on. dyinft away from home should he ftiven in .vry in.t.nce. 



X 




! 



%}* 



\\ 



% 



. I .1 

. it 
I 




i 




t 




Honnlof Ilt-alth- FNo. l^ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J^o, B06 




H&PCo 



l)„le /-7/^^MU^QA^«i ■>" ^'^^"^ 

i^v^v. iov^ Dep^^y ^^«^'^*^ ^^°«^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate ot Death 

( "CI. S. StanDarD ) 



PLACE OF DEATH; — County of 



i4«^M,cCt<xX^ 



City of 



y<Xr(y^ 



X 



,. n 



No. 



-St. 



■Dist.; bet. 



-and 



-) 



/ „ Dt.TH OCCU.5 .W.Y PROM USU.L ""'"?"';"'/, /t"; 11 
(. ir Dt«TM OCCUmilO in » HOSPIT.I or .NSTfTUTlON GlVt 



FULL NAME 




TS*CALLED roR UNOCB "SPECIAL I N rO« WIATION ' \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 

1 



\jXj Cr\.xv^\X 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR /^ f| f 



""' (^\cJL 



L CL e V 



DATK «i! IMRTH 



Ar.K 



/ / 



I Month) 



)'tUti : 



(Day) 



M.nilhs 



(Year> 



Dii I 



SINCT.K. MARRIKD 
\VnM)\VKn <»R l)IVnKtKl> 
(\Vril«- in «K-i;iI (l««.i>?tiatiot>) 



lURTHPI.AOK 
(Siatf or Counlry^ 



NAMI-, ol- 
FAT I IKK 



niK THPl.ACK 
Ol lATHKR 
(Slate or Country) 



MAIDKN NAME 
OF MOTHKK 



RIRTHPI.ACH 

OF MOTHFIR 
(Slatf or Country) 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




(X.C 



(Month) 



1 



(Day) 



(Year) 



190 



•to 



I IIP:Rr:nY CHRTIFY, That I attended cWccased from 

J igo~^~^"~ 

^— --^'^^^-^- — — — 190-^rrr- 



that I last saw h 



alive on 



and that death occurred, on the date stated above, at 
M The CAl'SI-: OF 1)I:AT1I was as follows 

: i). 






OCCri'ATION Jn. i) , 



DF RAT ION Years 

CONTRIBUTORY 



Mouths 



Days 



Hours 



DURATION 



Ycat's 



Months 



Days Hours 

(SIGNED) V^ V^). A. \jVu..U-tMUU^V^ _W.p. 

OfKo-Ci I C TooS ( Ad.lress) XH V<X^>V^<X V^ A 
AL INFORMATION only for Hospitals, Institutions, Transients, 



SPECI-- - . . 

or Rrcfnt Residents, and persons dying d\»ay from home 



Rfsidfii in Situ rminisro 



) ra I 



Mntlth^ 



/'(M 



TUF AHOVESTXTF-.UPHRSONAI.PARTIcrJ.ARSAKF. TRTK To TIlK 
PF.ST (M- MY KNt>\VUKI)<.K AND HHMF-l- 



(I 



nformant M fVcVV^C^V VVA- .U- 

I 



Former or 
Usual Residence 

Wfien was disease contracted, 
If not at place of deatli ? 



How long at 
flaceof Death? 



Days 



PI.ACK OF niRIAI. OR RF:MoVAK 



DATKof lU KIAI. or RKMOVAI, 

LL\.v^ 5r 1 90H 



rNI)F:RTAKER 

fA(Mress 



'^vt 



t 



■^ Tm iT.H age nhould be stated EXACTLY. PHYSICIANS should 

N. B. Every Item of Jn?ormation should b-- cnrefully supplied. J^^ " classified. The "Special information- for pr- 

•tate CAUSE OF DEATH in plain term., that .t may be properly classiiiea. 

j....-^ „ ff-««. li»me should be feiven in •^•ry instance. 



sons dyinft away from home should be ft 



f 



1' 



'! i 



,1 



\\ 



! I 



J ' 

I 





ii 



I , 




■»' 




WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

^^ errrp TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

Registered J\^o. o07 

Ddic Filed y 




^ 5:.. 



loo'i 



cLtrVcvc djc^vr PePMty Health Officer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of Beatb 

( tl. S. StanDarD ) 



^ \L<x/>>Ou^ 



PLACE OF DEATH:- Co u nty et v^wt^^'-^>^C»-, Gitr^ 




?l 



>v(vcx/>va^ 



rNo. 



St.; :r— - Dist.;bct. 



-and 



-) 



.ouxxLl^vv. 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



■"^ ^Xoh. 



lu.Lfci 



DATK OF lUKTH 



(Month) 



AC.K 



} ■»•<» » .« 



(Day) 



Mofilhs 




SINC.I.K. MAKRIKI). 
WinoWKI) «>R DlVORl HI) 
iWritf in social «U«»i»fnation) 



HIRTHIM.AOK 
(State or I'ountryt 



FATIIKR 



RIRTHIM.AlE 
Ol lATHKR 
Stall or Country^ 



MAIDKN NAMK 
Ol- Mt)TnKR 



lURTUrUACK 
of MOTHKR 

<St.'Ut' t)r Country^ 




Da V 



MEDICAL CERTIFICATE OF DEATH 
DATE OF 1)P:ATH 



(Month) 



11. 

(Day) 



/go- 

(Year) 



I HI 



'.RKBY CHRT'FV, That I atteiidca ileccased from 



190 



to 



190 



that I last saw h rr — alive on 

ati.l that .leath occurrea, on the <latc stated above, at 
M. The CAISK OF DICATII was as follows 



r-^gO 




Di; RAT ION >'<'<"'^ 

CONTRIIU'TORY 



Months 



Days 



Hours 



DURATION 



Yeat 



'I 



Mouths 



Days 



Hours 



( SIGNED )ALl0- A NjfljLC^rWv^Y^-i- M.D. 



.wOl- 



ki. IN 



190I 



SPECIAL INFORMATION only for Hospitals, iHstltuHons, Trawkiits, 
or Recent ResMents, and persons dying a*>ay from home. 



oeClFATION JK ^ \ 



Rfsidrd in San Framiffo 



"" Ynits - Mont'i' 



Ihn 



THK ABOVE STATKl) PKRSONAl. ''ARTU'ri.ARS AKK TRIK TO TIIK 
BEST OF MY KNOWUKDi.K AND »Kl,n%F 



(Informant 



^ 



C.li^-^J. 



(Address 






Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of death ? 



How lonq at 
Place of Death? 



.. Days 



PI ACE OF HrRIAU<»R RKMoVAI. I DATE of BrKlAl. or REMOVAL 



INDEKTAKER 

(Atldrt'^'i 



I J'. 01 111 KlAI 

LLva.^_ 



— ^i " T"! ATE .hould be stated EXACTLY. PHYSICIANS .hould 

N. B.— Every item of Informaf.on •hould be cBrcfuily ""PP'-J' ^^^^ ' ,,.„|«ed. The ^Special Information" for per- 
-♦«♦.. CAUSE OF DEATH in plain terms, that it ma> he propc 3, 



n 






i\ 



n * 



' )i 



1^ 



f 



i ■ 



> :| 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BfKiru of III all n i -^i'- »'- o,.*-^ 




/)(f/e Filed, 

i 



Registered JVo. 



808 



^ l9o^ 

\xa>^ Deputy Health Officer 

DEPrRTONTOF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( TH. S. StanDarD ) 



PLACE OF DEATH; — County of 



■Ci^y oi 



UXavlIa) ^i' 




No. 



—St 



-Dist.; bet. 



-and 



■^ 



( ■■ :".;-.,-:".-:.-.-.v:-:-..vr.; :.-!;f-s.v.".-..-;^r. ".■;« r..-.-.-;; ..•.•.■;;•:.■.■•.•.■:.■;•." ) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^JL 



COLOR \ 



lak^u 



DATl-: ni HIRTII 



A«*.K 



i>!oiith> 



(Day) 



mVHT.K. MARKIRD. 
WIlMtWKD OR DIVDRTKI) 
(Write iti mh-imI (lisiKHatioii) 



HIKTin'I.ACK 
•State <»r Country) 



NAMK OF 
FATHKR 



RlRTHPl.Al'E 

OF FATHKR 

• State or Country) 



MAIDKN NAMF: 
OF MOTHKR 



lUR THI'LACK 
»)F MOTHKR 
(Stnt»- or Conntry) 




/(Year) 



Pa 1 . 



MEDICAL CERTIFICATE OF DEATH 
DATE t)F DKATH (\ 



(Day) 



(Year) 



rm^RHRY CKRTIFY, That I atten.led (Uceasetl from 

190 to 190 

that I htst saw h Trr—alivc on" -ssssrrrrsrsrjrrrrrr--^^ 190 



and that <lcath occurre.l, on the date stated above, at 



— M The CAl'SH OF DHATIl was as follows: 

t 



.^A^v->x/. ..CrA^^^j -VH-v '^^'"^^^fc *-- 



or RAT ION Years 

CONTRinrTORV 



Mouths 



Days 



Hours 



Vicars 



Months 



Pays 



Hours 



DURATION ^ -^..j. 

(SIGNED) J^A ^ *lAj\jUAn)-^^ -.^... ,M.D. 



OOCri'ATION 



n|YL<dL4.X^. 



Resided III Siiii /'titMiist'o 



) 't'ti I 



M.,,tlli^ 



/>,n 



THH AHOVESTATKDPKKSONAI. I'XRTUM-I.ARSARKTRrK To THK 
HKST OF MY KNo\VM:I)(.K AND HF.MF.F 



(Informant 



5 



f V i Mrcs s 



h 



ai. u) 



.CXw? 



SPECIAL INFORMATION only for Hospitals, listitotiois, Trauskits 
or Recent Residents, .nd persons dying a^ay Iron home. 

How loiHi at 
Plareof Deatk? 



Former or 
Usual Residence 

When was disease roitracted, 
If not at place of death ? 



Days 



rUACK OF lURIAU OR RKMt>VAI 



INDKRTAKKR 

(Address 



DATKof ni RIAL or RKMOVAI, 

LVXArO. ST. T9 0H 



c»„.„.., .up.n.-. A«^-- - r-^Hf^s^it.:. .rrj?r.v:"p:'.i 



N. B. Every item o? information •hould be caretujiy »upm— -• "- , ^laMified. The '•Special 

•tate CAUSE OF DEATH In plain term,, that .t may be P'-»P^»-'> *='"•" 
.ion. dyinft away from home should be given .n .very instance. 



I ' 



1] 



) 2 




m 




#i 



I I 



ll 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

Registered J^o. 



ixile Filed, \XK.'^<X\J^'ik: 5" l'^0'^. 

J? Jf^ 



Xfrwvo Xtx^v. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot Beatb 

( "d. S. StanDarD ) 



PLACE OF DEATH 



: - Cuuiily A K cJl CL W va 



c: 1 I -if 
^11 y ui 



^. 



r vdLoi'.vxxo ' 



fT^. 



No. 



^t 



Dist; bet. 



— and 



^ 



t ir DEATH OCCURBtO IN A HOSPITAL OR INSTITUTION GIVt 

FULL NAME ' ^^^&^C^^ '^^- ^^^^^ 



^^'X^^A^.-C'^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



QflicjL 



\L . i wbL 



DA IK nl niKTII 



AJ.K 



I Mouth) 



tUay) 



Year) 



Af v.< 



SIVni.K. MARKIKD 
\vn>o\VKI» OR niVoK<KI) 
iWritfin sttcial th-sijfiiation) 



BIRTMIM.AOK 

(Statf or Cimiitry^ 



NAMK OF 
I AT UK R 



HIRTMPKACK 
OK KATHKR 

ist;it( or I'ountry) 



M VIDKN NAMK 
ol MUTHKR 



HIRTHPLACK 
OK MOTHKR 
(State or Country^ 




MEDICAL CERTIFICATE OF DEATH 



DATE OK HEATH ^1^ 

(Month) 



J jL\r 



n 

(Day) 



igo '■ 

(Year) 



firRRERV CERTIFY, That I attendea decoasea from 

- , 190 to - - — IQO 

that I last saw li alive on ^'^ 

and that death occurred, on the date stated alM)ve, at rrrr:r 
M. The CAl'SH t>F DKATH was as follows: 



U)^ 



/J^JU^ 




nr RAT ION »'"'J 

CONTRinrTORY 



Months 



Days 



Hours 



DIRATION 



\ 



lAL IN 



^ font lis 



Days 



/lours 



(SIGNED) '\ ^. dkAirijLUjAM^o^'vX ^ M.D. 
^VIICU. iL ,00'^ (Address) QlV a^XvU>i -i. 



SPECIAL INFORMATION only 'or Hospitals, Institatiws, Transients, 
or RfCfBl ResMeiits, and persons dying anay from home. 



) '/if / 



Mnntfis 



Ptn 



OCCll'ATION J^ n 

Rf-idfd III Son Imiii is»'o _^ 

THK ABOVE STATKD PERSONAL rAHTUTI.ARS AKK TRKK To THE 
HKST OK MY KNOWI.KIX.E AND HKMK.h 



(ItifoTiuant 







h 



LC- ^- ^' cc^* 



V 



former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



rUACE OK IURIAL<»R KKMoVAK 



KNDERTAKER 

(Addrtss 



DATK>»f IHRIAI. or REMOVAL 

LLa^vo 5^ 190 H 






f 



Q . .. ■■ I Ire .hould be Mated EXACTLY. PHYSICIANS should 

N. B. Every Item of Information .hould be carefully .uppLed. ^uo « ^ ^ ^^^ •'Special Information" for per- 

•tatc CAUSE OF DEATH in plain term,, that -t may be ^J^J^y 
«ons dyinft away from home should be ftiven in every Inntance. 




I 



% 



' 't 



I ■ 



ill 



>i 






i 

I ■ 



i M 



t 



.1 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

, ,„„„„ ,.„.,*S^„.,.C„ BerCRTOB.^>c»..»rT.CATerOB.NSTRUCT,ONS 

n.n.FiM,\L.O^ T lOOH Registered ^^o. 

X^^vvv^ Ix^-^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH; — Cuuiu y o< 



Certificate^ of Bcatb 

( "a. S. StanOarO ; 

[M aoJl ClLx^ va Cily ef 




AwW 



cLa 



^VXX.<j 



(} \ 



No. 



-St 



— Dist.;bct. 



— and 



) 






FULL NAME 



-^..^^vc^ U: ^yv^'vv.- 




PERSONAL AND STATISTICAL PARTICULARS 

COI,i»R 



""' ^\A. 



l.lJ.k^lU 



I>ATK <>I I«IK 111 



'Month) 



\<.K 



(Day) 



Months 



TV car) 



Davs 



SINJ.I.K. MARKIl-.n 
\Vm«»\VKI» <»K IM\«»Kt KO 
'Writt in vcx-ial (i« si),'nati<in) 



lUHTIIPl.ACK 
Siatt or Country) 



I \Tin;R 



HIRTHIM.ACK 
nv I ATMKR 
(Statt or r«inntrv' 



MAIUKN NAMK 
ol- MOTHKR 



mRTnPI.ACK 
Ml- MOTIIKR 
'Statf or Conntryl 




MEDICAL CERTIFICATE OF DEATH 



DATE OK I>KATH t^Vj^ 'i 



J 



(Month) 



n 

(Day) 



(Year) 



rilRRKBY CKRTIFY, That I attendetl (leceased from 
______ ___ ,go-^ to ..^———"- —190 

that I last saw h ^ive on "^^ 

an.l that death occurred, on the date stated alK)ve, at -—r-rr 
M. The CAl'Sl': OF DICATII was as folU»ws: 



,Lxj\ju_ 



(Kcri'ATioN "( y 



h'f'iiitit III Siiti /'i mil i^'.i 



).;ii 



i/n„f/r 



Am 



THKAHOVESTVTl-.DrF.R^ONAI. I'AKTIiTI.ARSARKTRrK TO TIIK 
UKST <)1- MY KNOWI.KIX'.K AND 15 HI, IKK 

L a t ^^..... 



Dl'RATION years 

CONTRIIU'TORY 

DURATION 



J/o>i//is 



Days 



//ours 



(SIG 



NED) \ ^ - "^ - \^LtuA^v^ V. ^ 



Pays 



//ours 



M.D. 



CLm i- \qo' ( 



A<ldr.s.) ma^wU>) A 



SPECIAL INFORMATION on>y '»r Hospitals iRStitMtlons, IransiMts, 
or Rfcfiit ResWtiits, and persons dying «»»ay from homf. 



(InfoTinant 






I 



Formfr or 
Usual Rrsidencr 

Whfn was disfasp contracted, 

If not at place of de atli ? 

n.ACK OF nrkiAuoR kkm'»\ u. 



How I0114 at 
Place of Death? 



Days 



Vl WO<X^*^'^">V O^ "^ 



rNKl'.KTAKKK 

(Address 



I)ATlv<'f H' KiAi. or RKMOVAI, 






N. B. Every Item of Information U^uuld be carefully supplied. AGE • ^^^ 'Special Informaf.on ' for pr- 

•tate CAUSE OF DEATH in plain term., that .t may be properly cla«».».e 
•on. dyinft away from home should be ftiven in .very mutaacc. 



I 






ll i 



T' 'I 



I r 



5 



J 



h ( 




i 



I?o;iril 



]>(ifr File!, U 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

810 



,,f n,;ilth \-So. I'. ■*•=„??«>- 



»&l'Co 




190 \ 



Registered JVo. 



Ivwv.'Uv-^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( •©. S. StanOarD ) 



PLACE OF DEATH: — County of 



City of 




^\.^La.. 



<v. 



'No- 



- St. 



Dist.; bet. 



and 



■) 



FULL NAME "^X<r^y \1 l\tv-.v-uc ■.. 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



■"' V^lol. 



^ 



DATK <•! I'.IRTH 



\«-K 



• M.nith) 



) .•(/ » ' 



uu 



(Day) 



.\/on/fi< 



(Vear) 



Pa vs 



SIS'r.l.K. MARRIKI). 

wiiMiWKn OK nivoKfK.n 

\Vrit< in v.K-ial <lf'«i>fii;itJ<»n) 



HIk rHIM.AOK 
State or I'otnitry) 



fatmi:r 



niRTHPr.AfF. 
Ol lATHKK 
•Statt- or Country) 



MMDKN NAMK 
Ol- MOTHKR 



HlkTIIPr.ACK 
«»| MOTMFR 
'Slat* or t"«»uIltI^ 




MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH ^ 



(Month) 



*1 , 

(Day) 



(Year) 



I HHRKBY Cr:RTIFY, That I atteiuled deceased from 

rrrrrr— — — — r- "^90 ' 



igO to 

that I last saw h 'alive on 



T90 



and that death occurred, on the date statt*! above, at 
: :.rr..M. The CAl'SIC (»!•' DIIATII was as follows: 



X. M^ C^^virVC^H--^'. 



Av /,//•,.' /(/ 'siin /'i irn' .' ill 



) ,,i> 



\,r.,„f/i' 



/>,,. 



TMK \UMVK '.TXTJ I> PKRSONX!. !' \ KTir I I. X k ^ Akl. Tkll- l<> THK 
liKsT o» MV KNOW Ij:i>'.K AND l!I-.IJl.f- 



(Iiif'jnnatit 







I) r RAT ION >V<7r.f 

CONTRIHITORV 



.Vopiths 



Days 



Hour 



M,)uth% 






/)<ns 



diration 
(Signed) 

^av^ 15 ic^H (Addn-ss) 'M(V<V>wJLo_ ' » 



Houfi 
M.D. 



^Oa^ id ic^H r.Xddrf 



SPECIAL Information only lor Hospitals, institutions, Iriositits, 
•r RfCfnt Rfsi<Jfnts, and prrsons dvinq d*»a> from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at }^»t^\ deatli? 



How \w% at 
Place of Deatk? 



Days 



I'l.ACK OF lilRIAI. «»K KKMM\A 



< 



FNDJ.KTAKKR 



OATlCof Ht KiAl. or RKMOVAI. 



I90H 






N. B. Rvery Item of information •hould br ca 

•tatc CAUSE OF DEATH in plain term 

Hons dying away from home should be given in •^•ry iniitaiice. 



refully .applied. AGE .hould b« .tated EXACTLY. PHY8ICIAN8 .hould 
; that U may he properly cl...lfled. The •Special Informafoa" for pr- 



^* 




W 



1 
4 




I! 



I 



I 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noar.1 of lUnlth ~K No ,. ^^^ BScV Co RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

811 



i)(f/r /^y/p(/, \Xj^\jx^^^^ S; i^^ H 

-^ A Deputy Health Officer 

dLcj^cv^ <^M.A>u 



Registei'ed J^'^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX. S. StanDarD ) 



PLACE OF DEATH; — Cuuat T e < Vi^^ AHrCX^ti City uf 



XvM'ti 



^No. ^^>\.'.^^vv 



.. vCCUHS AWAV FROM USUAL RESIDENCE Gi 
[*T^t OCCURRED IN A HOSPITAL OR INSTITUT'ON GIVE 



f 






/ IF DEATH OCCURS AWAY FROM USUAL B E S I DE NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \ 
( "rE^t orruRRro in a HOSPITAL OR INSTITUT'ON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 



\i)X'>v' 



SKX 



PERSONAL AND STATISTICAL PARTICULA RS 

I coi.oR \ , ^•j 



^\oL 



OATK «)»•• HIKTM 



(ill 



I Month > 



av 



J 



( Day) 



AOR 



•\1 



) 'ra I 



A/.'Mf/l' 



1) 



(Year) 



Pi! 1 s 



\Vn>o\VKI) OR DIVoRi Kl> 
(Write in MH-ial ilt».ijriiati<)U» 



HIKTIUM.AOK 

'Statf or t'onntrv' 



NAMK f)r 



BIRTH PI. AC K 
C>\- lATMKR 
'Stat« or Country) 



MAIDKN NAMK 
OF MorilHR 



HIRTMPI.ACK 
OF MOTHKR 
'Stat* or Conntrvi 



oeCVPATION ,\ 

Kf^ldfil III '•',111 I ii'.ii, 






m ""w. 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DFATII ^ ] 

^j.Jfo>jL,i} It) 

(Month) (Day) 

I HERICBY CI:RTIFV, That I !iIUmi«UmI .kreasca from 

^LUjwl: V 190 . to LL^tlA-nX \\> icpH 

that I last saw h .va>> alive on vU W*-(j I ^ 190 'i 

ami that <lcath ocnirrcd, 011 the ilate state<l aliove, at ' A H 
v'w. ^. The CArSI«; Ul- I)i:.\TII was as follows 



(!. 



^CCvcLvocc ' av(X.W^a^ 



>\JL-W v^ vcr^ V \^0u 



}X.^U\X 



.v> 



I'vK.^xtrLU^v 



)V,i 



M., II III' 



n,i\ 



THF. ABOVK STATF.I) I'K.KSONAI, I' A K f nT' I, \ KS AKl. TKIK TO THF: 

HFST 01 Mv kno\\t,i;i)c.k AM) in:i,n:F 






nr RATION Vrais 

CONTUIIUTORV 



Months 



Q^^iL 1. 



Da vs 



I /ours 



DURATION 



Years Months 



/hlVS 



(SIGNED) 






/fours 

M.D. 



Special information only for Hospitals, Institullons, Fransifiils, 
or Recent ResMents, and persons dyin'j di^dv from home. 



Former or 
L'sudI Residence 

When was disease rontractetl, 
if not at place of death ? 



How lon^ at 
Place of Death ? 



Days 



IM.ACK OF lUKIAI. OK KF;MoVAI. 



}; 



.CV*-.: 



DA IF'.* Ml KiAi. «ir R1:MoVAI. 

J- ^ T =^ 



I NDKRTAKKR 

'Ail<!i.—< 



i vh\ u).cv.t 



190^ 



W- w 



JN. B.— Every item oif inf«rm«tlo„ .hould be cnrcfully Hupplied. AGE Rhould he Mated EXACTLY PHYSICIANS nhould 
state CAUSE OF DEATH in plain terms, that it may he properly clasRifled. The Special Information for p«r- 
Rons dyinft away from home fthould be fciven in svery instance. 



•y 


m 


m 




li> 1 


\v\ 




11' [ 


. 


^f jjj 


• 


1 


1 


H 


1 


H 


rrrj 




- i 



IM 



' li 



II 



' t 



r 



^i 



1) 







' • / 




p -'A' ; 



>;rf> 



>-^w 




1 I 






li 



II 





1,1 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

1„„„1 ..f llcallh- I- No. u»g^>ll&l-C.> RBFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

/>.^/,' /-V/^"/, iLcvcyv^v-vt S" n^OH Re gi staved ^'0. 81 -3 

Xt^u-A^ ioyvvu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. 5. StanOar? ) 
PLACE OF DEATH ; — C o un t y ot Vll\.cLUa) LcuVO- CUy ul ' ' "> iv 



1 






'No. 



-St. 



■Dist.:bct. 



and 



/ ir DEATH OCCURS AWAY rROM USUAL R E S I DE NC E CI VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



1 



FULL NAME ^*J)X>x<.a 




I 



II (I- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR /*j^ 



^\oL 



hie • i 



DATK OI- HIRTII 



ACK 



I Month* 



(Day) 



) I a I * 



Motilhf 



An 



SINT.i.K. MARklKI) 
WIimWKH OK DIVnKCKI) 
'Writf in social rU'^ijrnatinn) 



HIKTHIM.AOK 
• Statr or Conntry 



\AMK OF 
HATIIKR 



BIR TUn.ACK 
OI I AIIIKR 
'State or Country) 



MAII^KN NAMK 

OI MoTHKR 



HTKTHPI.AC'H 
OF MOTMKR 
{Stalt or Country) 




.ear) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



(Aonth) 



■/-■ ' 
(Day) 



I go - 

(Year) 



occri'ATlON i p 



Rrstilfii in San /'t un, tro 



V 



U,./////. 



/hi 



TUF: AHOVK ST^TF.I) I'KRSONAI, I'AKTIcri.ARS ARK TRIK To THK 
HKST OF MY KNOWI.KIX". K AND BHMHK 



' Infoiiuant 



VO^ fr\' 



dJjtv-trv 



v44«*ss Ayu vV % ^ 



I HKki:BV CI:RTIFV, That I atteink«l «lcceasetl from 

„ •- 190 to 190 

th.it I last saw h nr— alive on ~ lip 

and that death occiirretl, on the date state«l al)ove, at ~rr— tt.. 
M. The CAI'SP: ()!• I ) I! A Til was as follows: 

DTK AT ION Vtars 

CONTRIIU'TORV 



X.J 



Mouths 



Days 



//our 



DT RATION Vt-ars Months. 

(SIG 



..o,^]ltlA 



/hjYS 



/lours 



Lvv^lh-v^w . 



'ifVaHiC) looH (Address) Mllo^ruJlaM J 



M.D. 



X 



Special information onf> for Hospitals, institutions, Translfnts, 
or RecfPt ResMfits, and persons dying dv^ay from home. 



FormfT or 
Usual Rrsidencf 

Whrn ^i% disease contracted, 
If not at place of deatti ? 



HoH lonq at 
Plarcof Death? 



■■ Days 



IM.ACE OF HIRIAI, OK KHMoVAI, 



rNI.KRTAKKR ^4.. VlVl ^J ^^Kt 



DA if: of Hi KiAi. or RFIMoVAI, 

Cj 190 i 



^lvv.r 



IS. B.— Every Item of Information should be carefully supplied. AGE should he stated BX4CTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special information far per- 
sons dyin^ away from home should be feiven in 9\mry instance. 





ii 



!■! 



i .' 



*l 



I- I 



>l!i 



t 



M 



ii 






rl 
if 



I 



■^1 



I . 

> • » 












.^^; 



tvN 3, 







•*.V 






»s V'^ ■ 



•Tr 




■f'y-i 



^^^\y^ 




■i 



ii • 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Honnloflkain, ,■ Vo. .. i^g^^ M&l' Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

812 



itc /v7/v/, iL^^cyv^^t T /'^6>H Registered JSTo, 

\t^u.u^ Xl^m Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Xa. S. StanC>arC» ) 



PLACE OF DEATH I — C o unty 



♦^^^Vll 



e 



cctAhOj LCA^v :v €it7 



itv ot 



r\ 



\ .. 






<No. 



St 



•Dist.:bct. 



and 



/ ir OtATM OCCUHS *W*V mOM USUAL RESIDENCE Give FACTS CALLED rOR UNDER "SPtCIAL INrORMATION- \ 
V IF OCATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

(I 8 f? 



FULL NAME 



/Ct\.a^ 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



^cL 



COT,<)K 



\ 'aLaci; 



DATK ol IlIKTU 



AGR 



I Month) 



) V(f I 



(Day) 



Mnulfts 



•^IN",!.!-: MAKUIlin 
WIDoWKK <»K IUVnktKI) 
(Write ill social dc^iiKiiatioii) 



lUKTIiri.AOK 
iStatr or I'otnitrv' 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Year) 



NAMI-: «>F 
F ATI IKK 



HIKTIIIM.ACK 
<>»• I-AIIIKR 
'State or Country) 



MAIDKN NAMK 
Ol- MOTHFR 



HiKTurr.ACF: 
<n" m«>thf:r 

(Statt or Conntrv^ 



(HCll'ATIOX i ft 




(ttoiitb) (Day) 

I UKRlvBV CF:RTIFY, That I atUMulcMl .Uciase<l from 

— r— — — -—190 — -—to — 190 

that I last saw h alive on — - ' I90 



ami that lUath occtirrcil, <>ii the date statcil ahove, at • 
M. The CArSI<: Ol' DliA TII was as follows 



ri,) 'Wi^L.^ \-wLjil\.a.| 



or RATION Years 

CONTRIIJUTORV 



Mouths 



Pays 



Hours 



nr RATION 



) 'cars 



Rrsiifrd in San /'i iiiii /.^r<> 



) V(7 I . 



,1A.'////v 



/hn 



rm-, \noVF. STATF,]) I'KK^ONM, rAKTUri.AKS AKI: TKIK TO Till-: 
HKST i)l" MV KN()Wl,i:i)«". K AND HKI.IF^F 

(Informant Vm VcLV ^^ V» vL U^' -t A.'^irV 



< '\H4ress ^l^U V\. V 



Oa- 



(SIG 



NED) Ka:) A. Mil 



Mouths Pays 



(irla^ic) u^\ 



( 



xa.iress) \i lVcV'>\cla ' .i 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, institutions, Transifits, 
or Rttfnt Residents, and persons dying anay from liome. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at place of deatli ? 



Now I0114 it 
Place of Death? 



■■ Days 



I'l.ACK OF Ml KIAI. OK KFMoVAI. | DATFof lUkiAi. or KF;M0VAI, 



rNDl.KTAKFR 

(All. Ire"* •• 



u 



\ lnform«tion should be carefully supplied. AGE should bo stated EXACTLY PHYSICIANS should 
OF DEATH in ph.in terms, that it ma> be properly classi«ed. The Special InWmation for p«r- 



N. B.—— Every item olf 
state CAUSE 
sons dyinft away from home should be ^iven In 9\9Ty instance 



«' 



i: 



.« 



,' ' 



I 






i 



ir 




.< 




1 



•> •- 









Vs& <4. 



v->. 



.^ -L 







\ . ■ \ I 



■-^;. 



^:v^6« 



» r 



■..■1^: 



I 




» ) 



I' 

■I 



Hoard n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

f.U.„Uh-.-N-o ..l»^?».I.M'C.. ReFEB TO BACK OF CERTIFICATC FOR INSTRUCTIONS 

l>„li- FUeAl, iLvCWvAi S l'^)0'\ Registered ^''o. 

Ifrtc^lt^H Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of ©catb 

( "Cl, S. StanDarD ) 

Itv of ^h<X^^\<\^x• ' ^ 



PLACE OF DEATH: — County 



ofX 



CC'ClvvCWU 



City 



No/ 



St 



Dist.: bet. 



-and- 



• iJUt j-/^iai»f fc^** — . 

..<>••>• Brcinc-Mr r riur tacts CALLED rOR UNDER SPECIAL INFORMATION" 1 
( '^ .VrE-AT^H^I^C-uNrcV/NTHO^S^rT^t O^R^ f^ ^T^^^T^O*;' ^O^ ;eTt1 NA^ME INSTEAD OF STREET AND NUMBER. ) 



-) 



FULL NAME 




v..a^Lu 



I 



K^.J.^. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

j COl.OR A 

DATK Ol lUKTU 




,i. 



(Month) 



A<.K 



(Day) 



}f,>M/flS 



Pa rs 



sINJ.l.K. MAKKIKn 
\Vn>n\VHI» OR niVMKt KI> 

'\Viit< in MK-iiil <U •.i^'iiatioti) 



lURTHPI.AOK 

'Stat«- or I'onntryi 



NAMK OF 
FATIIKR 



niKTIIPI.AOK 
OF FATHKK 
(Statr or Country) 



MAIDKN NAMK 
OF MOTHKR 



lUKTHrLACK 

oi mothf:r 

(Slat< or Countrvl 




"HjjJUUjx 



OCCl PATIOX 

AVt///A/ III SiJ>r /'/ (7"i />'■" 



)'<•(!! 



\f.„i>li^ 



n,ix 



Tin: AnoVKSTXTF.DT'HKSONAI. 1>\KIU-FI.\KS AKF.TKI K To THK 
HKST Ol- MV KNo\Vl.i:i)<;.K AM> lU-.IJhl 

rinformant VITLCCJ^V V . V^ U.)xV-e^-V 

1 4 ^V 



f A^Uxc- 



DATE OF 



MEDICAL CERTIFICATE OF DEATH 

OA. 5 



...K..... ^ 



(Month) 



(Day) 



I go 

(Yenr) 



I HKRHnV CI^RTIFY, That I atteiultMl deceased from 

— - 190 to ^igo — 

that I last saw h -. alive on " '<)0 

and that death cKTCurred, on the date stated alw^e, at 

M. The CAT SI-: OF I » i:\TH was as follows: 



■\ 



1)1' RAT ION Years 

CONTRIIU'TORV 



Mouths 



Pays 



Hours 



I )r RAT ION 



Months 



\cars Monh 



Pays 



(SIGNED) W. '^- VflU^UtVw-UL 

xm<XMlw iqoH ( Address) I fl-O/l VOU> ^ 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitils, Institutions, TransifRts, 
or RwfBt Rfsklfnts, and persons dying away from li»iiif. 



Forrof r or 
Isudi Residence 

When was disease contracted, 
If not at ^are of death ? 



How jonq at 
PliTf of Death? 



Days 



i'i,.\£K OF nrRiAi. ok ki:mov\i. 



I NDKRTAKKR 

(Address 



I)\Ti;<)f Hi KiAl- or RKMOVAI, 



190 






* .. 1-1 APF .hniild ha Ktated RXACTLY. PHYSICIANS should 

of Information .hould b:. carefully RuppI.ed. AGE should »? "^^''jj ": .:'^ ' . , ,„formatlon" for p«r- 
F OF DEATH in plain terms, that it may be properly classified. The Spec.l information for psr 



N. B. Every ite 

state CAUSE OF DEATH in p 

sons dyinft away from home should be ^iven in every instance. 



\ 

•■•i 

' _ I 

.J 



HI 



< I 



^k 






if 



% 



i i 




% 



•1 



ik, 



1 



l) 



^ ^\ 



Honrd of HeaUh— I' No. i^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

Registered J^o, 814 



H&I'Co 



Dale /<V/<''/, ULvvOvc^ S" ^^^1 

"l^wvfl Uv^ DeputY Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( 'd. S. StanDarO ) 



PLACE OF DEATH:— County of 



City of > ^^^ Xt^v VC J '* 



u 



« 



— St^ 



-Dist.; bet.- 



and 



^^ ..»••>■ DreinrNrr riwr FACTS CALLED rOR UNDCB "SPECIAL INrORMATION" N 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



"'" ^VoJL 



COI.OR 



V 



DATK OF ISIKTII 



AOK 



(Month) 



(D.'iy) 



Mum tin 



'^(Vear) 



A/ 1 . 



SIN(.|.H. MARHIKD 
WIDnWHI) OR DIVoKiHI^ 
I Write in «4<»cia1 (U'^ijrnation) 



HIKTIUM.AOK 

'Stat«- or (."ountry^ 



N'AMK Ol- 
J-ATHr.R 



lURTHIM.ArH 
OF I ATHKR 
(Statf or Country* 



MAIDKN NAMK 

Ol-- Morn IK 



niRTiiri.ACK 

O! MOTHKR 
'Slatf or Country) 




^O^tLvw«^^ 



occri'A rioN 



r, ,/i » 



.\r>ntfis 



/',/i 



THK MtOVr ST\TJ:I> rKKSONAl. IV\K T liM" I.AKS AK 1. TKl K To TMK 
IlKHT Ol- MV KN«»\VI.i:i)r.H AND hki.ii-.f 



(Informant 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ^ \ 



I V 
(Day) 



J 90 

(Year) 



(Moilth) 

I ilRRKBY CKRTIFY, That I atteii(lc<l «UH«.ase(l from 

,.: ^r-TlgO to 190 "" 

that I last saw h nlive on ^90 

and that death (M:ciirred, on the «late statctl above, at - --"— 

~ M The CAl'SK t)I' DIv.Vril was as follows: 



Dr RAT ION Years 

CONTRIIU'TORY 



Months 



Days 



Hours 



DT RATION 



(SIGNED) 



n\ 



Years 



Months 



I^axs 



vlW\MX; 



KrwJL 



Hours 
M.D. 



^^lKaM ltlc)Oi ( Address) \i lVa/.V\.A>.la.\l.., J> 



SPECIAL INFORMATION onlv for HospiUls, Institutions, Transirits, 
or RfCf nt Residents, and persons dying away from lionif. 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of death ? 



How I0R9 at 
Place of Death? 



Days 



PI.ACK OF niRIAI, OK KKMoVAI. 



Qut 



190 t 



rNDKKTAKKR 

(Athlress 



DATi:of lU KIAI. or RF:M0VAI, 



. . . 7T ,. . AHF nhould be stated EXACTLY. PHYSICIANS should 

N. B.— Every item oV' information .houici b. c«reVuliy Huppl.cd. ^^^^^ •^^.^^ ' 5^^^ xhe "Special Information^ for pr- 
state CAUSE OF DEATH in plain term., that it may be properl> ciaMitied. 1 ne op 
son* dyinft away from home should be Itiven in overy instance. 



I* 




.' I 



' tj 



' t » 



^^- 



1*' 



>r 



ill 



!f 









J*. 



jjj.-* -* •* 



^ 



'> ■,i.j-^V 






O ' -"* 






i 



n: 



•li 



♦ 



fclu 



fi 



' I t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,...M ..f „..,v.,-r NO . ^rg ^H^HCo REFER TO BACK OF CERT.F.CATE FOR INSTRUCTIONS 

100\ Registered Jio. 



815 



Dale I'i led ,\Xk.<^<X\^'^ ^ 

:iUwo *L^vu Deputy Health pfricer 

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 



( "a. S. Stan^ar^ ) 
PLACE OF DEATH:— County of*J<XAV'l.V<X>vc 



City of O/O^w vT A.a/>vcc4 c. c 



^No. 



;i?> 



a 



(X^a- 



St 



Dist.; bet. 



VTU 



and 



i 



..eM«l Br«mrNCC GIVE FACTS C*LLCO TOR UNDER "SPECIAL INFORMATION • \ 



FULL NAME 




} O-VVn 






PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^ f 



COI/IR > 




DATK OF lUKTII 



a<;k 



(Month) 



(?H ,>.,.> 



\^ 



(Day) 



.1 /.»»////.« 



V 



cLl 



(Year I 



Pavs 



^WiW.V.. NfARKIKP 
\Vin«»\VKI) OK niVORCKI) 
(Write in siK'ial (le«.it'nati<.n) 



RIKTHPI.AOK 
(St;it«- or Country' 







NAMM Ol" 
FATMKR 



RIRTMPI.ACK 
OF FATHF.R 
(Slate or Country) 



MAIDFtN NAMF: 
Ml MOTHKR 



rirtmpi.acf: 

<»F MOTHKR 
IStatf or Country) 



OCCI I'VTION 



1 



OwVVcO 



-k alVvVtvU 



^ 



I 






I iVa/vaoLVUo vO^tLa 



^ 



A 



(AML^UX 



t" 



r> 



^v 



cL 




0-\A.^QL^v--v A »>- »^ ' 



Rrsiiinf in Sou f^tainisr<i ^^ ) rot 



M .III fin 



n,i\> 



THF ^ROVF STMF.I) I'HKSONAl, rAKTIdl.ARS AK K TKlK T< > TJIH 
HF:ST OF MY JiNOWI.KIX'K ANl) HKl.IF.F 



(InforTn.int 



/oXhs^<^ 



(A<l(lrc«i>' 



3.1^ 



Ci 



'1 



•OJvCC 



OM*^ 



4 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Month) \ 



I 



(Day) 



(Year) 



I HICRICHY CHRTIFY, That I attended (U'cease«l from 
<o 190^ to nAaa<<3l S 190 H 

that I last saw h X* ^ alive on LLva^ "^ 190 ' ' 

and that death occurred, on the date stated above, at I 
Cl M The CAl'SIi^OF I)I':ATII was as follows 



' TVp Ji^cwt X^ . v.<ijucs.^ix Ij'OlI . > ■. ^ •-> '-. 



nr RAT ION )V<fr.v 1 Months Days Hours 

CONTRIIU'TORY wLAXOa. 



AAVVa. 



Years J^ Months 



Pax!^ 



(^.Idress) ^Hb - Htk 




Hours 
M.D. 



DIRATION 
(SIGNED) 

^■Uw-CO, w. IgO ' 

SPECIAL Information «"•> '»r Hospitals, institutions, Transkits, 
or Recent Rfsidrnls, and persons dying v^X) from home. 



former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How long at 
Place of Death? 



Da>s 



l.I..Ji^h; OF BIRIAU OK KKMoVAI. 

HA.. 



.ACH OF BIRIAI 
l-NI.KRTAKKR W vl/OUULt^V^m^ 



DATi: o! Hi Kr.Ai. or RKMtlVAI, 

LLc^wD L 190 i 



(Address 



\r,\ vfllv^i-v^^x .^* 



^ .. ,. . ATF «Snuld he Stated EXACTLY. PHY8ICIAN8 should 

N. B.— Every item of laformation should be carefully «uppl.cd ^'^^i:r'Z^,^\X^ ..Specl-I Information" for p.r- 

state CAUSE OF DEATH in plain terms, that it may be properly class.tiea. p- 

sons dyinft away from home should be given in svery instance. 



* n 



I : 



IM 



t 

* ( 



Jil 



\ 



I' 






'■^ 



r-<: - '^- 



\V*i. -• 



•» - i 



in 



>? I 



il 



I 



m 



w 



I 



m 

I I. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H..anl.-f ne:,lth-FNo u^-T^H&FCo ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafr Filed, iLcaL^t b i^^H Registered ^'o, .81 6 

c^^vA^c^ ^Vc vi^ Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( "a. S. StanOarO ) 

PLACE OF DEATH: — County of ^/Cf^ (1 XOA^Cuieo City oi^^O^^ JACc^wcc^ c ( 



.. a. ^ ^. ' 



SU ^ Dist.;bct.U.OLUL^^C^.XX; and U.cU.\,\X\C ) 



(\r ocATH occuns away from USUAL 
\r OtATM OCCURRCO IN A HOSPITAL 



RESIDENCE Give rA 
OR INSTITUTION CIV 



'ACTS CALLED rOR UNDER "SPECIAL INFORMATION" "\ 
C ITS NAME INSTEAD OF STREET AND NUMBER. / 



^ 



FULL NAME 



l.L 



.ct^ 



nvcr>x 



/cL. 



'v\.\.OL yv: 



SKX 



DATK Ul- HIKTH 



PERSONAL AND STATISTICAL PARTICULARS 

I COH)R N 




CL 



u 



Ax^Jjl 



iM.Mith) X (Day) 



/B..I 

(Year) 



M.V. 






J V<i » « 



O 

-s 



M.»ilh\ 



Ptn 



Writiin Mnial lU stvtiatiou) 



JA^^X 



.<vU 



lUKTHIM.AOK 
'State or Country' 



\AMK oi- 
HATHKR 



mKTHI'I.ACK 
or lATHKK 

iStatt or lOvititry) 



MAIUKN NAMK 
OF MOTIIKK 



IMK rHIM.ACK 

o»- MOTIIKK 

f Stale or Country 1 






^t> ''M'Tvd^-^' 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH ^ 



(Month) j 



S 

(Day) 



(Year) 



I HRREBY CRRTIFY, That I attendeil «lercase«l from 
.U.OlA)>\. d^^vq^ " 190 '^ to li..O(\\...iliuu:\. t) 190 '. 

tliat I last saw h - alive on U,\.vC^ ■:. igo H 

and that death occurreil, on the dale- statet! alK»ve, at \ 
j^ M. The CAISK OF DI^ATII was as folU.ws: 



DVR.vnos 



Pays 







mvu 



ti 



<HcrrATi(>N 

AVwV/a/ /;/ Sdfi I'liUf. 




<XLo. 



)■-•,;; 



M.nitll' 



/i,M 



TMK AHOVKSTXITJ) I'KKSoNM. P \ KTUT I. \ kS AK K TKIK T< > THK 
lUCST 01- MV K>i>\Vlj:i><.K AN1> HKIJIJ- 



'Inf-i'tuant 



U.Mr... "^5 ^^ 



Cl. 



-4^ 



ft--^ "\'V 0_ ^x.' 



1^1 IV .A I iw.. Years Mouths 

c < ) N r K I m • T ( ) R \' ^ 'Jjv ivLki.'N-^a 

1)1" RATION Years Months 5 /><n v 

f SIGNED ) .. \jXkj^^ V' U ^ ; • 



Hours 



Hour 



\} 



(Addre<^) iOb'T (fl^VV'-aV<t 



M.D. 



SPECIAL INFORMATION onlv for Hos-^tals, Institutions, Transients, 
or Recent Residents, and persons dying away from tiome. 



former or 
Isual Residence 

When was disease contracted, 
If not at place of deatli ? 



How lonq at 
Ptareof Deatk? 



Days 



I'UACK <»l- m KIAU ok kHMoVAI. 



i I 






DAlI.of Hi KiAl. or KHMoVAI. 



190 



(Ad.hf 



X^ \J .CH^^v ^' U^iOaL. 



.. B.-Bvc.y Iten, o. in.on.etion .Hou.d H. c^.er'uM. supplied AGE -^^-\\^,^:'^^^^^!^l^^^^^ .nZL^ro^n" w'^rl' 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Inlormation for p«r 
sons dylnft away from home should be ftiven in every instance. 






■?- 



1. 



i I 




. I. 

<• 'I 



^'! 





.'v>-" 



Lr-:. •; 






-ft: 



»^^. 



^i;r 






f^^^ 



B^ 



-.^ ' 







'*:>. 



iiii4 



t I 






I '■ " 



I 



«>«! 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„„„l„f II..M1.-I- Vo ,.*^^H&.-C.> REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

817 



Eegisterecl JVo, 



Date Fih^il ,\!U>^\JU^ ^ l'^0\ 

\truv^ \l\)-M Deputy Health Officer 

DEPARTMENT OFtUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

{ "d. S. StanDarD ) 
PLACE OF DEATH: — County of^'CClV J ,\.a -ixCAiaCity of '"'CX^V OVC^^Xt^^ cv 



No. 



l^ 



HHl ^Ua^-' St.; "X Dist.;bet. \Mla<Lt.V;.. and iaci\.t 

/ .r'oCATH OCCi^S AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED ;OR ;iN"R ,^;";*i 'J"°'';;j;°'* " ) \ 
C ir DEATH OCtURRCD IN A HOSPITAL OR IIISTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

]\ 'w:S..C..l\J. Ww<. LcLhA.\X^-L4 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



I).\TK Oh lUKTH 




COI.OR ^ 



llUxctt 



• Month) 



\C.V. 



?>C) ,V.,. 



(Day) 



Mttuths 



Xi 



(Vear) 



Da V. 



SI\«;|.K. MARklKn 



HlKTHri.\rK 
(Stjite or Country) 



\viiM>\vi:i» OK invokt j:i) y 

(Writtin s<K'i;tl ilisi^riialimi) "^ 

(1 
K'<x^^^^ 



NX Ml-: «M- 



RlkTHI'l.ACK 

f>l" lAlirKK 

• St;iU or (Ntmitrv^ 



MAII>HV NAMK 
OK MoTIIKR 



IlIKTinM.AfK 
nl MoTlIKK 
(Si;it< ur Cminlry) 



occri'ATn>N 'OT^ 




0.' 



r^ 



AV^/i/c// /// .s'<(>/ I itxtiii"! 'y ) »'<M 



M.oifh- 



/'.; 



Tin-. AHOVK STXTIH fKKsONAl, !'A RTir r I. A K< ARK TRIK To THK 
HKST OF MV ^No\VI,j:ih;K AM) \\\'.\.\\:V 

i4l 'JxcvVci ' 



' \'li1rr«is 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I>I:ATII \ 



(Month) A 



5 

(Day) 



iqo \ 

(Year) 



I HKRKBY CFCRTIFV, That I attondiMl ilcccased from 

A KlO to SjsJ^ 




up to \-w-v a^ Jt i<^ ^ 

that I last saw h w . , . alive on LV^^VC^ H up . 

au«l that tlcath ocourrcil, on the ilate statid alK>ve. at 



vL M. The- CAISRUF DHATM v.k as follows 






AfoHths 



DIR.XTION V Yiars 

C ( > N '1' K M U "T () K V \r V4. Cl-Lx. 



PaY>i I /our a 



DIRATION Viars Mo}ilhs Days //ouk 

(Signed)./^ m)\ L^^VJ • ...^ ,. M.D. 



V KA 



• 1 n 



I(>0 



( 



SPECIAL Information only lor HosfNtals, InsUtytioRS, TrMskits, 
or Recent Residents, and persons dving d>»ay from home. 



Former or 
Usual Residence 

When was disease contracted, 
H not at place of death ? 



How lenq at 
Place of Death? 



Days 



I'l.XCKOl- niRIM. OR KKMoV Al. 

U 




^rijuL ^Vck^"^ 



I»\TJ;.>; Itt KiAi. or RlCMoVAl. 

a 1 190H 



vLwa 1 






(.VMre-s. ^ IH ^ fe V(^ CL l^V CV.L.^ "^ » 



» .. ti J APF .hniiltl Ka iitntctl fiXACTLY. PHYSICIANS nhouid 

JS. B.— Every Item of Information .hould b. cnrefuiiy RuppHed J^^^^^^^^l^^^^^^^^^^^^ Information*' for pr- 

state CAUSE OF DEATH in plain terms, that it may be properly classmea. 1 nc ^t^ 
Rons dyinft away from home nhould be ftiven in .very instance. 



.:*^. 



f4 



' ^1 



m 



i ' 




i ■ H 



t 



I: 

I I 
|l| 



I 



Ir^I 











! 



II' 



s 



i 







i'; 


jM 












1 * '^1 


': i 


i 1 

.i 11 





I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoanl ..f lU-aUh- K No. u 1^^^ H&P Co REFER TO BACK OF CE RTtPICATE FOR INSTRUCTIONS 

818 



Registered J\i''o. . 



Dale Filed, LLu^ai.v/4.t W I'd0\ 

l.^vvv> cL\'^v| Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( H. S. StanDarD ) 



% 



PLACE OF DEATHr-County of'^a^'^^Ct^vCv^cc Qty ofUO^^ d;^<X>xav^^^ 
'No. iD'ib I'X A^tr^>X SXA H Dist.;bct. ^Xk. and T -Uv 



'/ ,r ot.TM occuns .w.v r«OM USUAL RESIDENCE o.vc r*CTS cllto ;o" ";•"« aT%%%TiNTNu"MB*ci.°'*" ) 

\ \f OC*TM OCCURRCD IN A HOSPITAL OR INSTITUTION GIVt ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




,t \lr^L 





■4- 



SK\ 



DATK nl niKTII 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




oJjL 




« Month) 



a<;k 



^ ,,.„. 



(I>ay) 



Mom III' 



(V«ir) 



1^ 



A/1 



^INi.I.K. MARKIKIV 
\VII)0\VKI» OR D'Vi'Ki HI) 
iWritfin •i«K-ial <l«*ij^tiatioii) 





lUKTHIM.AOK 

(St.-i.tf or (.'ouiitry^ 



NAMK Ol- 
FATin:R 



niRTHPI.ACK 
111" I ATIIKR 
istatf or Country^ 



MAIDKN NAMK 
nl- MOTMKR 



HIRTHPLACK 
<H- MOTHKR 
(Statr or Ct)nntry ' 



""'"■^■'■'""' 0>VocU 






Avcl 



ct^^ciw 




Kfsidfd ill Sail l'itiihi>fii ^\^ 5' 



V,M« L 1/-.,//// 1 I 



/'.; 



THK MIOVKSTATKDI-KRSONAI. I'ARTItri.XKS ARI. TRIK To THK 
HKST t)l' MY KNOWI.IIX.K AND HKI.IKK 



fliifoMuant 



r\d(lrcss 






lO^bV 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DEATH r\ 



(Month) ] 



(Day) 



rgn \ 

(Year) 



I IIKRRBY CHRTIFY, That I atttMukMl ilcccascMl from 



^VVU-y I 190S to *^ V ^ T<>0 S 

that I last saw h a. aUve on '" ^ ' \ ^ ^^J.-Aj. up 

ami that iloalh occurreil, on the date stated above, at ^^V>-^ ...H.. . 
\ M. The CArSfv OF DFATIl was as follows: 

LKv<n^^C \I\l\vIv\.v1^. .Ui^)rvt^V4.1 Ajj<tL 



I) r RAT ION y'rars 3foHtks 



CONTRIIirTORY 



Pays 



Hours 



Months 



Days 



l:l 



L 



,l\^^a.. 



^ 



I()0 



Hours 
M.D. 

(A.hlress) "^Ib M^lavVy^t ^.l 



I)r RATION^ Years 

(SiGNcD) 2l:•^vc'-a^.:i. A)-v^^^.^^c^ - .v. 



SPECIAL INFORMATION onlv for Hospitals, institvtions, Traisieits, 
or Rccfnt Residents, and persons dying away from liomf. 



former or 
Isyal Residence 

When »>as disease contracted, 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



ri.ACK «)I- lUKIAI, OR KKMoVAI, 



Of>u 



w*^-^ 




DArivo! niKiAi- or REMOVAI, 

V^^vix . 190 



INDKRTAKKR 

(Ad«lrfs«« 






• K-y 



•^A, 






1 .. •• I ArF ahould h« fltated EXACTLY. PHYSICIANS should 

N. B.— Every Item of Information should be carefully «uppl.ed. AGE f °7* ^ "*"**i!/; ..g_|., ,„form«tion" f.r pr- 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The Special Information .r ps 
sons dyinft away from home Khould be ftiven in svsry instance. 



fTi 



; I 






\k 




% 



it 






m 



?i'i 



V - 



>V^ 









+- -.^ 



,-.-^ »--^ ..» • 







1 



» 
I 



i :■ 



i 



M 



Ff I 



•I 'J 



4ll 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H„...,.l of lU.nu » NO .. -i^r^nScVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



|- 



/)((/(' Filed y 




w4. k) 10 o\ 

Deputy Health OfTloer 



lie^Lstcred J\'*o. 



8J9 



v^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( 'd. 5. StanDarD ) ^ _ 

PLACE OF DEATH: — County of Oa^ /va^XC^ C City of <X/>\' 1 ^a^v^C^ e < 
.No. r^C^l llau.^.^ St.; S Dist.;bet.l>Xvv^acliAt and ^ 'D \^:cU>vvC'k ) 

/ ,r oc.TH oicu».s .w*y trom USUAL RESIDENCE G.vc facts c-llco 'OH^^ozn '^^Ill^'^'-^^^'^^^IY;*''' ) 

t ir OEATM^CCURHtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




'JX'yxKu^ .vA.vLt<l\i 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



1^ 



ILlcJU 



COI.OR \ \ 



DATE OF r.lKTII 



AC.K 







(Day) 



M.iHlllS 



I h 



(Year) 



Da I A 



SfN«;i,lv MAKKIKl* 
WIDOWKP nK IHVOKiKI) 
'Wiittin stHJ.il <l( siv'tiatioii) 



HIRTHIM.AOK \ \ 

(State or Country n j\ |1 In 



NAMF OI- 
I- AT I 111 K 



BIRTH I'l, AC H 
OF l-ATIIKK 

'St:iti- or Coiiiitrv* 



MAIDKN NAM»; 
OF MOTHKK 



iirtv^v 






DATE OH DKATH 



MEDICAL CERTIFICATE OF DEATH 

.1 



(Montli) I 



5 

(Day) 



4 



(Year) 



i ' «...i..,.....u.i:i 

til at I last saw h •• 



T HrRHRV CERTIFY, That I attcmUMl decoasetl fnmi 

IgO.wTT- — to 1 90 

- alive on - — up - - 



an. I that death oconrrcd, on the date state«l almve. at —r—r- 
~r.. M. The CAISH OI' DIvATII was as follows: 

.ct w-tv> iDXcL CLq^ . 

DT RAT ION Vtats .VoHt/is Dais 



Hours 



CONTRIIUTORV 






mRTIllM.ArK 
<M- MOTHKR 
(Statf or Country) 



1 L ^ 

Rf<idfd in S,ni /i,i>hi^r<> -3 v }>ai- 



yfnufh' 



lhl\> 



TUF: AHOVESTATKI) PKKSONAI, I'ARTiril.AK^ AKi: TRl K TO TMK 
HKSr OF" MY KN0\VUF:I)«VK AM) HFI.n-.F 



Informant \i\ LtrV^AA^L^CX LVct wAx.V' 



' V.lrlrc 







nr RATION ^Vi'tirs 



J/ont/is 



(SIGNED 






Days 



lL 



c 



■"\ ^ TC)0 



i) 



Hours 
M.D. 



( Add rc-ss) >? ^ dL.'-i/\J-V<L cv rtt\,c ^ 



Special information oiK for Hospitals, InstitutioRs, TransifNts, 
or Rfcfnt Residents, and persons dying dv»ay from hon»e. 



Former or 
Isual Residence 

When Has disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



I'l.ACK OF 



k&m 



RIAL OR KF:Mo\ \l. 



nrRiAi. OF 



nxri.of in KiAi. or RKMOVAI, 



190 



rNI>F:RTAKF:R 

(Address 



^^ \> \ . <\~ *w W w, V- w 



^ 

< 







/ 



^S!^^. 



! I 

% 

fl! 






< 



t I 



\ 



I ill 

II' ( 



< 



I 



i 



.tate CAUSE OF DEATH in plain tern,., that it m»y he pi-opcrl, cla...fied. Tli. Special In.orm.t.on lor p.r 
aon« dyinj away trom home shoulil be ftlven In av.ry instance. 
















■k ., 



! : 



it 



1 <* 






\%ii 



■P 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M„.,.l.,fM.:,l,l. .No ,.l^-??E?*>MScl'c<o REFER TO BACK OF CERTIFICATC FOR INSTWUCTtONS 

Re^iisici'cd JVo, 



«J30 



"-LtH^v. > 4sx\vu Deputy Health Officer 

DEPARTMENT OF t^UBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanDarO ) 



n 






and 



PLACE OF DEATH; — County of ' ) a/^vOXa>vc.L^;:f City of ^ Cl^v 1\XX.^v c^v^ e.o 
'^^ ^ O^tCAVcLLcV^ vL^i.tdt<.V.•.St4 Dist.;bct, 

FULL NAME \w.d..O ^^^v^t^t-cl, OVDa^trid l'. 



r or.TH occups .w^r-'OM U»U«- RESIDENCE G.vt r*CTS cLuro '^^ "n«>cj. «%%^;*i^'J^;;:;:';"*' ) 

ir DEATH OCCURKCD. L A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTtAD Or »TRCtT AND NUMBER. / 



X.O^^ 



:CL^\r\A 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OK 



nlau. 



la' 

DATK Ul BIKi Jl 



\r.K 



LCtfv^ie 



M^>ttth» 



J '»•«! » .V 



(I)nv) 



J .V.>»//// » 



(Yfiir) 



< I 



Ai 1 . 



SIVCI.K. MAKKIKI). 

\\ in<)\vi:n ok divoriki* 

1 Write- ill ••<Ki;il <h»'iv'n:it ion) 



c 



^C>V0 




niKTIMM.AOK 

(St;it»- or Country^ 



NAMi: <)|- 
FATIIKR 



niKTMIM.AOK 
Ol- l-ATHKK 
(State or Countrj') 



MAIDKN NAMK 
OF MOTHKR 



HIRTHPI.ACH 
»>|- MOTHKR 
(Slatf or Country) 



<>CCl I'ATION 



a 



MEDICAL CERTIFICATE OF DEATH 



DATE OF nKATII 



lL^v. 



(Month) J 



(Day) 



(Year) 



I IIIvRnnY CliRTIFY, That I attfiuUa jU'oeased from 

N^W^vi. X.\ ujoH to LUvOl A. IqO S 

that I last saw li - alive on CLv^^^q -^ 190 

and that death occurre*!, on the «late state«l above, at & 

^ M The CArSi: Ol- DliATII was as follows: 



V^vtr^' "^^^' 



n 



)'/•(?/ 



\f,<)tt>n 



fhn 



THK AMOVE ST^TF.I) I'KRSONAI. I'ARTIlT l.AKS ARK TRl H To THK 
HF:sTOI- MV KN0\J11,KI)<-F: AND nKMl-F- 



(Informant 






"it 



nr RATION yt'iirs 

CONTRIIU'TORV 



Moutlia ' jyays Iloun; 




nr RAT ION )'<V'.y Months Pays 

(SIGNED) /m^ ?^ Vn\ax^!va.Ll 



lUu:^ 



'-4 



\ 190 



I. 



(A.Mrcss) A^OC 



oxC^^w 



\ vv^rV*^ 



Hours 

M.D. 



cp^QiAL, INFORMATION oi'^ ^^^ Hospitals, Institutions, TraRsifRts, 
or Rrcent Residents, and persons dying dnay from home. 



Former or 
I'sual ResideRce 

Wlien Has disease fonfracted. 
If not at place of death ? 



Noiv lonq at 
Plate of Death? 



Da>s 



I'I„ACK Ol- lURIAI, OK KKMo\ \I, 



I ^CK O 



J.VV"vv>Vk^ 



190 



DATI. of HiRlAl. or RKMOVAI, 

.NI.KRTAKKR \xXX^^ ^"^ ^Ccq^tV.>V 
(A«l<lr«>^s 



'""C w > 



te CAUSE OF DEATH in plain term., that it may be properly claa.Wed. The Special I...orm.tion tor p«r 



N. B.— — Evei 

state wr.^ — "- 

«ons dyinft ViSvBy from home should he ftiven In every instance. 



I ' 



I 



m i 



f 

















■^''t. 








f^^T^^ _f^'^ -•*" "T*"** • ^^H 


^^^H^ iM^- *,JPS ^^^^^^^B 


"^■I^IHK .3.^''— :--^H 


■^rj^jfll 





i^i^^r.^'iM 



.'* 



'ir 



I 



w 



;l ' 'I 



I 



^i 



t 

i 






ft 



11 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoanl of Hcal.h . No .. 1^-^^S^US.V Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(( 



te /V/r'r/, lL^cla^v^ W 100\ 

A ' "1 A Deputy Health Officer 



RpcHstcred J^o, ^^ t, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)catb 

PLACE OF DEATH:-County of 0/a^ OAa/TV<i^aCity of -'a^V OX<V^-vx<lc^.tc 

-A ft '1 M 

Nn 3l>lU - atii\. .. St.; 10 Dist.;bet.'^an.]tnLiiU-and ^WvU^.t ) 

/ „ o,»,M occu.s .w»v >noM USUAL BtSIOENCE oivi r.CTS c.Ltto -on ur.Dt» -SHCIAL i«roRM«Tio«" ^ 

( ""e.TH OCCU.-.O ,"° HO.Pr,.L O. ,NST,TUT,ON G,«E ,T. NAME .NSTE.O J .T.tET .«0 NUMBER. J 



FULL NAME Hlh^<-CL 




c 



a^ 




^ 




si;x 



DATK OF HIKTH 



ACK 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



tx 



L 




0\ 

(Month) 



a\/ 



lb 

(Day) 



vllt 

(Year) 



'11 s 

Z'* V ) 'It » ' » 



Moiilhf 



Pa \s 



'^IN<".UK. MARKIKIi. 
WIDOWKI) OK niVORCKI> 
(Writrin wK-ial dcsiKnation) 



lUKTHPI.AOK 
iStatf or CiMijitry^ 



NAMK OF 
FATIIKR 



niR ruI'I.ACK 
Ol" lATIIKK 
(State or Country) 



MAIDKN NAMK 
OI- MOTHKR 



iurtiipi^acf: 
of mothkr 

(Slat*- or Country) 




MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATIl 



^^ 



I go 

(Year) 



1 I 



(Month) \ 'I>«y^ 

I IlKRIUJV CI'iRTIl'V, That I atten.lcd dcccascMl from 
vVw^ 190 :- to iLwvCL-.. S 190M 

that I last saw h .Ui:i:x4aive on LLw^CL H 190 i 

aii(Lthat «kath occurred, on the date stated alxjve, at A....V v 
U M. The CAl SI-: OF UiiATII was as follows: 



Dr RAT ION Vt'OKS 

CONTRIIU'TORV -^OJ 



Months ^^SX^ J/oNfs 



Dl'RATION Years 



Months /Viv 



OCCri'ATION /^ . 






Rfuiifil nt San I'laiu i^r.t A V) \,aif v 



Mnlltir 



I Ul 1 



THI- AHOVKSTXTFI) J'KRSONAl, rAKTKTl.AKS AKF TKIK To TUK 
UKST (>!• MY KXl>\Vl.i:i)<".H AND nFI.IJ-.l' 



(lufoiinajit 



r\(l<lrc 



3b lb- 'Xb .tk '^ ^ 



(SIGNED) \J . -^ (Xlnrvtt M.D. 

(Address) 5 \ ^Xv.tb<.^j Cl ^ 



tl 



L^ 



A^ ^ T<)0 



Special information only for HosplUls, institutions, Transirnts, 
or Recent Residents, and persons dying dway Irom home. 



Former w 
Usual Residence 

When *»as disease contracted. 
If not at place of death ? 



How I0114 at 
f>laceof Death? 



Days 



FLACK OF !U KFM. OR RKMoV \I, I DATKc.f MrHiAl, or KKMoVAI. 
I NDKKTAKKR ^VVCVVUwO V ^ J .V-V'w ^AX-O. ^ . 



.. .^ ^ w II -..««I5^.I AGB should be stated BXACTLY. PHYSICIANS should 

IN. B. Every item oi mformation should be carefully supplied. Al.t. «""7" "' -SDeclal Information" for p«r- 

•tate CAUSE OF DEATH In plain terms, that it may be properly wia.sitied. The Special intormat p« 

sons dyinft away from home should be given in every instance. 







i^.tN; 









* 
-r*- 



'.0,sjmf 



r'^M .y^ 






.>• -d '» . ~^ ■''■'-' -^^ 

rL «t ' - »*i ■ via 



h"^ 



\\\ 



41 



f!ii 






IB 


n '1 


' ' H ^ ' 


^B{ 


}; 






1 






1 


^H 


= ^l 


^^H 




1 



11 f 



iif 



/>^//^' Filed y 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ho:ii.l..nf.:.llh »•• No i^ ^-t^T^ H&I' Co 



Be^istcred JVo. 



'^^/*W 



.v^ lo i^^^H 

Deputy 'leajin ORlcer 

DEPARTMENT 0^ PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( XX. S. StanDarC> ) . . 

PLACE OF DEATH:— County of '^^ a^V >-^XC^^VCU<^0 City of '^Ojyx' J.VO/lv^Vi to 







I'M- 



kvL 



at St.; 



Dist.; bet. ..•...«•..".< •"•"• and 



VV-L YVV'.I V ^"'^^^^"'^■^'t.^-^'nrNCr G.wr t^CTs'cALUED rOR UNOtR "special INrORMATION" N 



) 



FULL NAME 




<;L.aOj J /CL'VKXL/lb- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



DATK 0|- llIRTIl 



L 



COLOR ^ . ^ 




(Mmith) 



a<;k 






<l)ny) 



Motilli'^ 



(Vear) 



Day 



SIN(.I.K. MAKKIK!) 
\V!I)0\VKI> «»K DIVnkv i:i> 
I Writ*' in srH'inl <hsii,'u:iti'iii) 



HIKTMIM.AOH 
(St.'ttf or Counlrv 



^ 



UO .vcLtrvc 



NAMK or 
l- A Tin.K 



HIKTIIIM.Ai'K 
(>!•• 1 AIHKK 
iSt;it«- «>r <^"«»uiitry 



MAIDKN NAMH 
Ml MuTlIKK 



lUk rm'I.ACK 
(>l- MoTllKK 
(Stat< ur Country' 



• KCIPATION 



I 



V^/^ -'- 



^ >\ 



cLlv.kxx 



cL Kx.'yK/^- 



•utdLu 






AJLvK'Cacu 'T 



U 



/1>V<X^"^ 



^J-. 




o. 



1 



aj 



Rfsitifd in Sott fujiuisro ■ ' : ) '«" 



\h»ith< 



I h1\. 



THK AHOVE STATK n PHRSOXAl. I-AKTUM' L AKS AKi: TKrK TO TJlK 
HKST OI- M\: KN»)\VI.KI)C.K AND HMMl-.J- 



(Informant 



JJU> 




r 



(Address 



Lcu, ■'•' 

r 




(K-k^tat 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 1 

I . . ^ .5 

(Day) 



LUcn 

(Month) \ 



(Year) 



I JWKRI'IHV CI:RTIFV, That I attendiMl .lercasc-a from 
,nXul 1^ 190I to ^Lcwt^ ^^ 190 H 

that I last saw h -^ alive on ^Cvv-flj^. 190 

ami that death fx:ou rred, on the date stated above, at U I "^ 



y\. 



M. The CAISIC OF DI-ATII Ma«* as follows: 

...cw:.>^..d.>...U..fCu.cy..VA.x-ix- 



nt 'RAT ION l^ Vtais 
CONTKIIU'TORV 



Months 



Days 



//oum 



DT RAT ION Years 

(SIGNED) lb (V*\J. Mil 3v 



Days 



flour 



Lv\.^w 



3l 



IQO 



(Address) 



Months 

cuc^^i«^w M.D. 



"iils 



J. 



SPECIAL INFORMATION on'y *or Hkpltals, InstilutloBS, TriBslfBls, 
or Recent Residents, and persons dying a\»ay from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



bo Ctava ' 



How lonq at 
Place of Death ? 



Days 



^1 



n.ACE Of HIKIAI. (iR RKMoVAI, 
t-NDHRTAKER 0^^ Cl^^VM V U 



I)\ri:.>t U: KiAl. or REMOVAL 



190 



(Address 



CVVKvt 



' TT. .PF «hn.jld be stated F.XACTLY. PHYSICIANS should 

N. B. Every Item of information •houlcl be cnrefully «uppl.ed. ^Ut « .,. ^ ^.^e 'Special Information" for pr- 

state CAUSE OF DEATH in plain terms, that .t may be properly class.nea. 
«r>ns dylnft away from home should be fciven In every instance. 




.1 A 







i 



/ .. ' -i. 



;. Jk 



i*- 






■-/ 



1 • A 



^ 



I 

V 




1 



I 



.1 ' 






1 






1 ' 


t 


I '^ 


i 


1 


i H ! 


1 ! 


m 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



„..Mr.l nf IKalth- »•■ V... t^ ^-^^l:^' HM' ^*" 



X^v^^ iLt^M Deputy Health Officer 



Be<^isterc(l Jfo, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



( 'U. S. Stan&atO ) 






<^ 



PLACE OF DEATH:-County ofO<^.v ^^va/vvecACGty of Oo.>v JxaAvev^^c 




IvaJI' 



15^ A.cl.. 



and 



, No 1^1^ ^J^ Ol/^>v^va^vv>U. St; ^. Dist; bet „,.orm*t.on- a 

*^0* ^„ iieiiAl nrSIDENCE GIVE FACTS CALUED roB UNDER SRtCIAL I N FOR M ATIO N 1 



%H...iJ 



FULL NAME 




vSAx/vOj 




» *»• vJ»t Jbrf-^ft* • • ™'^^'' 



s|.:x 



PERSONAL AND STATISTICAL PARTICULARS 



1»\TK n|- HIRTH 



^-axxXx 



COI.OR 




^v'KcLl. 



(Month* 



\r.K 



Mv 5V./» 



(n«y) 



V'f'tili' 



r%^..l 

<Vear> 



Ai 1 * 



SINC.i.Tv MAKKIKI) 
\Vn>u\\ Kl> nk I>IVt»KiKn 
"Writfin s^K-ial il«-si|rMalioii) 



'Stittt or roiiiUl V 



N \MI-: ol 
FATHKR 



HlkTJU'I.ArE 
Ol- JATUHR 
(Statf or Country) 



MAIDKN NAMK 
iW MOTMKR 



\jcd. 






1 



.^J^L€o^'cL 




^ 



[\ OL^^CXVC OJ iWv'v W5 



lURTllPI.ArH 
nl- MOTHKR 
fStatf or Country) 



orcri'ATiON QfVf , I B 



Rfsidf<i ill Siift Fiiiiii i'^'i' 



)r,r 



Mn.lth^ 



I lil\.' 



■VnV MiOVESTATKDPKRSONAI. rAKTUCI.XKSAKKTRrH To THK 
HKST Ol- ?.n\KNO\Vl,i:i>C.K AND HJ.I.H.f- 



(informant 






MEDICAL CERTIFICATE OF DEATH 



IQO 

(Yfar> 



DATK OK I)1:ATH ~\ 

(Monlli) * <!>«>•* 

._. __ ... * 

I Hl'IRHBV CliRTII-'V, That I :iltentlc<l deceased from 

.Qu-VV IL loo t.) wLlA.<l. .^. up'- 

,v alive on tCwCL ^ I90 i 

aii.l that «U'ath oocurre«l, on the «late stated above, at - 
M. The CAl'SIv OF I)I':ATII was as follows: 



.^'y^^m.^^vw'^ 



nr RAT ION JVrf;.J 

CONTRIIUTORV 



Months 



Pays 



Hours 



DURATION 
(SIGNED) 



Mouths. l^avs 



JV'</r5 



iJ 



Hours 
M.P. 



:.l^ lt)0 






SPECIAL INFORMATION only '«^ Haspilals. Institutions. TranslfBts, 
or Recent Residents, and persons dvinq i^i) froni tiome. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at place of deatli ? 



Ho«» lonq at 
Place of Death? 



Days 



I'l \r K OF lURIAI''*** KKMoVAI 



DAI'Kot lit KiAi. or RHMnVAI. 



\ 






190 



fAiMtt'^'; 



N. B.— Every Item of inWrnation .hould be .aretully supplied AGE « "Special Information" for p.r- 

•tate CAUSE OF DEATH in plain term«. tha .t may be P-^P^-'^ -"«"'»'<^ 
•on, dyinft away from home should be fciven m every instance. 



1 

i 
I * 

I I 



I'll 

I' 



\.\ 



I 



It 



ii 



Ml 



» I 

I 



t 



ri! 

II 










'■•I 




1^^*.. 






^.^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R CFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Jteo'Lste/'cd JS^'o, H*^4 



„,,.,M of H.Mlth V So. 1. ■'S'^sjV^TM&l'Co 



!)((((> Filed, LLv\^aA.v^t V ^'^^^'^ 

^^uv^ "ij Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( tl. S. StanOarD ) 
PLACE OF DEATH:-County of'O.^^^Ki^^^^'- City ofU/CV^V v1/v(X vxc.... or 



(^ 



.ei-.-^»-.M»- 



i%i^ i^)t^ \a^ iJ Ia k ^ AD>^^ •'^ '"> ^' St.; Dist.;bct. and 

Wo, y,>A) . V-tK^^^^ V^^ V VTV . \;^,,.. REsTdENCE give F*CTS C*tLCD rOR UNOCR -SPECAL . N FOR MAT.O N' \ 

( -^ rA;:T!.^occ^VHro^rrHo"."pr.t o%'?^?t'.?'t^o^"o.vc .t, name .n.tc^o o. street ..o .um.er. ; 



FULL NAME 



Xj\0>X^^J^^ M.£L.q.l^:>3,?..-.. 



ii. 



^'-•^^ ^ 



PERSONAL AND STATISTICAL PARTICULARS 

i COI.DK 



tv 



DATK OF IlIR i II (jr^ 






U] 



Jv\1a 



tMuiilh) 



AOR 



HINT.I.K. MARKIKP. 

\vn>o\vi:i) MR nivoRrKi) 



lURTHPI.AOH 
iSlatc or Country 



Mil ^ 



(Dny) 



Months 



,/..i..ka.. 

(Vear) 



Ikivs 




CU^^UJ. L 



w 



FATIIHR 



BIRTH PI. ACK 
Ol- FAIHKR 
(Statf or Country 






e 



ii 



«>rcri'ATU)N i 

k'r-idrJ ni Sun /'i <tiinsr,i 



MATIlKN NAMK ;^ ^ 

OF M(yniF:R v- '! 



BIRTIIPLACK 
<tF MOTHKR 
(Statf or Countrv) 



V^'vV 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH r\ 



(Month^ f 



.T 

(Day) 



iVcurl 



I ni:Ki:BY certify, That I attcinUMl (IcccascMl fruiii 

|vA.:k.V^ 'X^.. 190'- to ... WL^....S 190 M 

that I last saw \\ Mx: aUve on LLvcty up • 

and that <ltath ()cctirre<l, on the Mate stated above, at 
M. The CAISK OV JUvATIl was as follows: 

!jL.VN^tt>^^Cto 'l^LoA,^-^%vQ }b^^iU.ha^"U^.>.v 



-ft!u.-.L Ol VtAl^'^-^^^^ClX aA...&i. 



IK' RAT ION 



Yt'ars " Months 



Pays 



'/lours 



CONTKIIUTORY ^A^cCU^. ^k:)-....^^^. ^. 



DIRATIDN 



' Yt-ars ' Months ^ Haxs • Hours 
(SIGNED) -K-n -At^dx^ ^ M.D. 



KXK^Kjy (, I, 



Ki 



(A«Mress) 



, ^ 

-^ 



)V<f » 



M.<nfh> 



J\i\ 



IHFAUOVKSTXTFDrHK'^oNAl.rAKTU-ri.ARSARF TKl F To TMK 
HKST t>F MV KNo\Vl.i:iM.F AND MFI.lFh 



(I 






^v 



\.Mr< 



SPECIAL INFORMATION onl> for HospiUls, Institulioiis, IranbifBts. 
or Recent Residents, and persons dying d*»ay from home. 




r 



former or 1 1 I * - • ««., of Death ' 

Isual Residence *• 1 ^ _ "*^' ®' '^*" • 

When was disease contracted. ^ . \^^^h:i , "^1 

If not at place of death ? -^ ' ^-^ ^^^^ 



Da>s 



PI.ACK 01 lUKIVI. o** Ki;M«»\ \I 







\ 1 



DVl'F')' m KiAl. or RF:Mo\AI. 
^Vv^V Q . , 1 90 



wVvv \ 



'AcMrcs? 



^ 



.*k I 



; C5A,v\ 






— — — — ^ —————— — — -- ^^j EXACTLY. PHYSICIANS should 

M. B.— Every Item of Information .houUI be caretuHy f»PP'-f ' p^rpeHyTl— ''^tcd. The -Speci.l Inform.tlon" for pr- 
•tate CAUSE OF DEATH in plain term*, that it mn> l e propeny 
«on. dyinft away from home should be ftiven in every .nstance. 










; i 



ii' 



in 

IK 




fii 



^ ** 



.1 



H 



ofT^ 



jt 



I 



m 



I 



•I! 

4 

il 



W' ' 



1 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






^/r /'V/^'^/, vLu^aA^^t' Id i'^t^H 

"dUrv^v^ lu/v^i. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Cettificate ot IDcatb 

( X3. S. StauDarD ) a /^ 



No. 






'h^X ^ta 



St; ^ Dist.;bct. 'iM.V.q: ^ 



I 



and 



b« \^ 



tLaxh-LO ) 



H OCCUHS *W»V rnOM USUAL RESIDENCfc_G_IV_t _F«t^» ^amF .^.eTFAn Ol- STREET *ND NUMBER. / 



( '^ r.-or.T^H^O^rjRrcV.-rHO^.^VT'it rR^r.ST.TUTTo. V.VE .t; name .NSTE.O O. street ..O number 



FULL NAME ^vc\cc^ 



OwL'V xIhiIL h)JX^vy\^^^sX'>J!L^-^yxdJ\i 



DATK OF IUKTH 



PERSONAL AND STATISTIC AL PARTICULARS 

I" COLOR , , J 



ar /..MS.. 

(Day) (Year) 




i Month) 



AC.K 



JV<;»' 



o 



M,,uHi< 



\ 



tktys 



SIN<-.1.K. MAKKIKH 

WIDOWKD OK I>lVoKtKr> ^ 

'Wiitt ill *<>vial «l««iij.'natii>n) 



\Sj vcLfe^v- 



lUKTHPl.AOK 
(State or Country' 



XAMK or 
FATHKR 



HlRTHPLArK 
«>l l-ATHKK 
Str\tf or Country! 



ns 



-VI 



MAIDKV NAMK 
OF M«)Tin:K 



luKTnri.AtF: 
i)F mothf;k 

(Staff or Cotuitry^ 









UCCITATION "^^ j^2^ 

- '^ ,. 

h'rsiiifd III S,in !'iiiii,i^r>t } r.rt 



A 
1/.,..//,. 



/'■M 



THF MiOVF ST\TKI) I'KKsONAl. TA KTirr I.AKS AKI. TKrK T- • TIJK 
liKST OF MV KNOWI.F.IX.K AND HFIJIF 



•Intormant ^-'V. V v.>^ > 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH r> 

L\'^s-q. 5; • •• 

(Month) \ <Oay) 



rMr) 



ThURKBY CHRTIFV, That I attetKUd <Ucoasea from 

.QcUn^..3.a w^ to d.\.v^..5: 190 H 



igO^. to 

that I last saw h ■* ^ alive on ..».W%A.s-<X. J3 



T90 ' 



an.l that (Uath occurred, on the .late staled above, at '' OT 
CL M. The CArSI*: OlvplCATII was as follows: 

"Luj^.. iS.,awA-CL-aJ:. 

Dr RAT ION Vrars 

CONTRIIUTORV 



Afouihs 



Days 



I lout 



Mouths 

c -A 



Pays 



11 our < 

M.D. 



Dl'RATION , J'''^''^ 

^ SIGNED) lI^V^xCU Sw ^^\>;Uwt 

tlcvc*^- To oH (Address) ^^ H ^i a\v>tt vl>Mq 



X 



SPECtAL INFORMATION «nl> 'o"^ Hospitals, Institutions. Transients, 
or Rerent Residents, and persons dying anay from liomf. 



Former or 
Isoal Residence 

V^hen was disease contracted. 
If not at place of death ? 



Hovk lonq at 
Place of Death? 



Days 



>^ s-^^J^^. 



'^'Mr.'^-i 






A 



'^O^J\.K. 



V 



ri,4CK 01 lU RIAL «JK RKMoVAI. 



i)\ri. •>; Ht KiAi, or kf;movai. 



190 



I ni»i;kiakhk ^ 

'AcMifss 






OV . A^. ?>v 



■"~~— """"^ ^ ,v.l AGK should be «toted EXACTLY. PHYSICIANS should 

^. B.— Every item of information should be c«retuily «uppl.ed. ^'^^^, ,,a»«,r.ed. The "Special Information" for pr- 
state CAUSE OF DEATH in plain terms, that .t may be properly Uassitie 
Aon« dying away from home nhould be feiven in e^ery .n«tance. 



I- 




\ 



<. .1 



I'i 



\ 



P: 



1; 



(■ t 



Hi 




■III 






r^'. 



^ssm 



> » 



fi^ :a. 






rfff^ 



ii 



I 1 



PP 






I, • 



1 1 



If i 



N ^m|.- 




4V- 



-' < f . 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Mn:,nl ..i 11... -.Uh J- No. i^ *^^^^>hScVCa 



Ihtfr Filed y LL/^v\J3jt b ^'^0^ 

d^VV^^ isjlx^^V "^^P^^V Health Officer 



Be^istered J\'*o, 



*^*:!6 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)eatb 

( -a. 5. StanC»arD ) 
PLACE OF DEATH:-County of HO^^A. Ji^a^ VCAAUCity of ' 'a.>v JAC^^^x Cc^ Cc, 




? 



(^i? 



:'MJ/vla.'St.; 



Dist; bet. - • and 



( '^ r/re:;T:^i±%rcV.t"rHo"."r.t o%^?:?^.?J;^o';'V.;r.;i name ......o o. st..c. ..o .....n. ) 

FU LL NAM E J- \x^^^JX^ (!.y..a^.\ax.t:Y.u 



— ) 



SKX 



PERSONAL AND S TAT I STMCA^L PARTICULARS 

COLOR 



IVtxl 




DATK OF lUKTH 



lUJk^ 



1 Month) <I>">'^ 



./ »■ 

(Year) 



Ar.K 



CUUv" ', '. y,in 



MuMtks 



An> 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH O 



(M»)nth) I 



(Day) 



IQO 
(Year) 



I ni':KlUiY CI':RTIFY, That I attcn<U'<l .Icceaseil from 

— — up to •■-•- lyo 

that I last saw h ::^~" alive on — ^90 



•^IN<;i,K. MARKIKD 
WnXkWKD OR DIVOKt KD 

iWritrin scKJal (If^iKOitt'""^ 



HIKTHIM.AOK 
(State or Country) 



/ 



/ 



NAMl OF 
lATMKK 



niRTHPl.ACK 
OK lATIIKR 

'Statf <ir Cuiiiitry) 



/ 



--. / 



^7 



MMI>KN NAMK 
ol MoTllKR 



inRTIIIM.ACK 
OJ- MOTHKR 

'Statv or Coniitryi 



OCCl TATION* / 




ana that death occurred, on the date stated ahi.ve, at 
.JJ The CAISK OF HICATII was as follows 

vl vVol/cXa^oxj^ 0--'^ '^^ ' -^ u 

Months Pays 



nr RATI OK Ytars 
CONTKIUrTORV 



J/oitt s 



DIRATION 
(SIGNED) 



/)<7t'V 



Yciifs Months 



Hours 
M.D. 



C 



«vX„ 



r()0 ' 



(A. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dyinQ andv from liome. 



AV>/(M^ :H Sdl! f'l nil, i>>-,i 



)V(7r. 



\/,<,'f/t> 



Ihn 



THK ABOVE STATKD J'KRSONAl. I'AKTU ri.AR- A k K TRrH To THH 
HKST UK MVKNOWIJUX.K AND HKI.n.l- 

(Infonnant L.<r*Vr^^X*V5 ^' ^ 



i ■- 



r\<l dress 



former or 
Usual Residence 

When »vas disease contracted. 
If not at place of death ? 



How long at 
Plare of Death ? 



Days 



I'LXCK Ol niKIVI. OR RKM<»VAI, 



.LL^^ 



I NDKKTAKI.R 



I)\Ti; of lliKiAi. or RKMoVAI, 



~^. 






'^W •' '^' 



o^'y ■>- ■ 



^AiMress 






N. B.— Every item of information .hould he c«re»ully f"PP «^''- ^,'^^ ,|«»sifled. The •Special Information" for pr- 
•tate CAUSE OF DEATH in plain term., that ,t m«> .^^ P;"^*'*'^ 
«on. dying away from home should be given .n .very .n«tancc. 





IPE 


.O' 


'^^Cs 


if-fC 


--^j^ 


• • 


. -.: P^^M 




iS^* ^ 







^ " 

«■-*.** 




4HHRt 



^' f 



•I 

t 



I 

J 

III 



i 






Tt^' 



i' 



•\\ \\t'\ 






ii 



i 




I- 



!! 



'i i 

'It 



k . 


^m 


V 


tf\ f 


W 




■ \s 


1 ' 




a 'm 


1 ) 


Iw -1 


i 1 




1 





CKanya^ 



uritt 



iMl 



!i..ai<l of !l<-ii1tli 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTinCATE ^0" - N S^Q U C^' G^iS 






iLfrv^A"ix\Ku Deputy Health Of^cer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "U. S. StanC»arC» ) 
PLACE OF DEATH:-County of ^^AX. .Kcvvv..^-Cty of ~^a>x. ^^^ Va^^xC.^^c 
., Hut^^.s-fc St.; "^ Dist.;bet. '!L'a^Vv4,^n^ and ^u-VO — 



FULL NAME 




<xxQ avjct 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 COI.OR 



i 



vi X^'VWOlAA 



CvJ-vvU 




n.ATi; »»!• UIKTU 



Ar.R 



(Moiith^ 



»-^f"> 



) V<f I 



(Day) 



M.'ufhs 



r lit. 

(Year) 



A/ 1 .« 



SINT.I.K. MAKKIKO 
WIDnWKU OR niVoK».KI) 
I Writ* in «i<Ki:il «lt«.ivrnati«)n) 



HIKTHIM..\CK 
t Stale or Countrj*^ 



NAMJ-: »)l" 
lATHKR 



lURTHI'I.ACH 
OI- lATIlKR 
(State or Country) 



MMDKN NAMK 
«)J- MOTHHR 



lUR rulM.ACK 
ni MOTHKR 
(State or Country) 






(Year) 



MEDICAL CERTIFICATE OF DEATH 
D.\TE i»K PK.XTH > 

^U^a 

(Month) f 'I>ay' 

I lI^:KliBvTT^RTIFV, That I attenactl aeccascil from 

,ci . a 190 , to ...ua..n^. ^^ 



\A 



190 \ 
tliat I last saw h ...'^'•. alive on LVV^\,C^' 190 

aii.l that death occurred, oti the date stated alwive, at "^ 

M. The CArSIC OF DI-ATII was as follows 



,V.W 






I 



DIR.XTFON 



Yeats, 






Months ^ Pay 



/louts 



DURATION W''^*'^ 



Months 



n\\\ i' 

(SIGNED) si. IV. Ve^\.v *.. 

llt^-a b TOO . (Addn-ss) ^Si^ S^ 



Pays Hours 

M.D. 

'^avvv^o vv ..'1 



<H CII'.ATION 



k 



)',ai 



}f,„i//i> 



//,;i 



Tin-.AUOVKSIVXTKI.rKK^^ONAI. IV\KTlCi;i.AK>ARKTRrK TO THK 
HKST (H- MY K.VOWM: I )<■.!•: AND Ul-.lAhl- 



(Informant 



'Lvc-v'oANctA *L^',^^-^^*- 



8 



' \(l(lrc»;s 



4H5 0,c\.^ 



k 



SPECIAL INFORMATION »»•'> *«^ HospiUls, Institutions, Tf«sifiils, 
or Retent Residents, and persons dying away from home. 



Former or 
IsudI Residence 

When was disease contracted. 
If not at place of death ? 



How I0R9 at 
Place of Death? 



Days 



IM.AgK t)J- lUKlAI, OK KHM»>V.\1 



^v.cvC\ 



tNDHRTAKKR ^CWO L^a-iv\,<X>> 



DA 11: of m RIAL or RKMOVAI, 

Lcc Q \ 1 90 



'AtMic^s 



— ''- -^'-V^Uv.-^' 






-———"■ ' T7 VI AGE should be Htated EXACTLY. PHYSICIANS .hould 

IN. B.— Every item o? information .houlcl be CBretuIly «"PP'-^- J'^^J classified. The ^Special Information" for pr- 
state CAUSE OF DEATH in plnin terms, that .t ma> be properly 
sons dyinft away from home should be feiven in every instance. 



I i 




\ 



1 



1^ 



,• t 



m 



V 









J' < 



'■». i 



^'-. ^, 



^.^^' 



imfi> 



H! 



V ' 






;l ' II 



If .' 



i 



1 



11 



^ 1 



I 



n ■ 



m 

m 



M":i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,.,Mr.l..f Health -!•• No ,. "fr^g?^ K&I' Co 



Date Filed, CL^cyw<Lt k> I'^O'i 

"L<rvcv^iuLv-u Deputy Health Ofiffcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX, S. StanDarD ) 



No. HH 



PLACE OF DEATH: — County 



of '^^a^\' lVQL.i,v:wA.x..C.LGty of JO.AV A^Axc^^ ec 



St.; 






Dist.:bct/iiN^'<XA.\.\^.fc and 'uhx 




,,«.,., bPsTdENCEGIVC F*CTS*C*LLC0 rOR under 'SPECIAt .NrOBM*T10N''\ 
( •' r."o;:TrOCc\%ro\rrHO^.^PyT".!: ?"n?t'.?u" "'o.VE .TS NAME ..STE*0 Or STREET .NO NUMBER. J 




FULL NAME 




LcLVa a^U-^t. 




C^lxiA. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



COl.OR > 



V 1 x^"v vcxXx 

!»\TK OP lURTH 



iM.)iith» 



At'.K 



•^7 



) V 1/ » 



LU 



(l>ay^ 



MoMths 




/IXt 

(Year) 



Aj 



SINT.I.K. MAKKIKH. 
\VI1)«»\VKI> OR niVOKl"KI> 

(Wrili in «^Kial tU •.ij^jialioti) 



HIKTHPI.ACK 
sStittf or Conntryi 




L<X.N/X 



i^ 



klL 



0C^ 



NAMJ-: (H* 

I- ATHKR 



BIRTH ri.ArK 

(>!• FATIIKR 
'State «)r C'ountry'i 



MAIDKN NAMK 
OH MOTIIKR 



,'■1^ 



HIRTIirUACK 
OJ- MOTHKR 
(State or Countryi 



OCCVPATION 






Kf>idri! in Stin /'i inn i.u-i> 



)'r i! I 



\f,.,if/i' 



/>u■^.■ 



THK AROVK STA TKI) PKRSONAI. I" VKTUri-ARS AKK TRTH To THH 
IIKST OH MY KN0\VM:1)«".H AND HI-I.ll-.l- 



Inf.muant WVV' V^C^VNC^^ X^ ' '< " '' 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ^ 

.Uva- - 51... 



Lies. a. 

(Montli> f 



CYenr) 




KUBV CI-;KTIFV, That I attcn.Ua dcrtasctl fnmi 



O. 190M to 

that I last saw h MiJ alive on 



cu. 



wo. 



i<p s 



aii.l that (kath occtirre.l, on the tlatc statcil alMU-e, at 



.S- 



M. The CAISF*: OF DKATn was as follows: 

\0\^\ trCOL^J. ciA.lv.'i. . C^v\^^. :v^v-.t:. 




1)1 RATION )Va''4 

CONTRlUrTORY 




1 



Months *w />>tf;'5 

:>X..D -.a. 



Hours 



^Ycars Mouths 

NED )... J..- Uw . L^^ >^' ^ 



DURATION 
(SIG 



Pays 



iLva L iqo ^ (A,i,ir.-ss) ■'^(^S .'V-'avvv*^.. 




Hours 
M.D. 



SPECIAL INFORMATION onl> 'o^ Hospitals, Institutions, Transieiits, 
or Recent Residents, and persons dying a\»ay from home. 



Former or 
Isual Residence 

When was disease tontrar ted. 
If not at place of death ? 



How lonq at 
Piareof Death? 



Days 



ri.ACK 01 m klAI. OK KKM<>\AI, 



^c^ Cv^"^^ 



DA 11: of Hi KiAi. or RKMoVAI, 



^Ccv q. 



190 



' \<l.lre>is 



445 



'I, 



W; 



\ 



-\ 



rSDKKTAKKK W L^ VU^ "WV ^rv ^.v .v 



f information .hould be carefully «uppliecl. ^^^^ "^^^'^^ ^*,.^^^ Information" for pr- 

OF DEATH in plain terms, that it may be properly ciaM.tieo. P- 



N. B. Every item of 

•tate CAUSE V. »'.-"• ^ . . :„«fnce 

non. dyinft away from home should be ftiven m every instance. 



X :f 



t 



K^ 



fV^^l 



»ii*?-^ ^' 






' II 



I 

I 

t 

( 

I 

i 



jina| 



i: l'f 



> 






"V5>^. 



._T 



■'> 



-*- 



»-V ♦ 



K»-.. 



. iti ;■:: 



)',,,:. 1.1 ..f H< :'llli »•■ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

. s„ ,. *r^$^ H^r c .; REFER TO BACK Or CERTIFICATE TOR INSTRUCTIONS 

QpQ 



Dff/c Filed y 



W0\ 



Re^isteved J^o, 



A.^w^o . Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(Icvtificate ot 2)eatb 

( Ta. S. StanDarD ) . 

1 % ^ 



(^ 



PLACE OF DEATH:-County of nCwW;uX..^^^UlC.Gty of '^W>^. <T 'Va.vv^U,^* 



No. 



;.; *-l DisUbet. ViV 



U'r)jinAv..H. . St.; M Dist.;bet. M ^IV^- and 



Lcvilvt 



) 



FULL NAME 



i: 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.OR 



DATK nl- lilKTU 



a<;k 






lOJLu 



Month* 



>^ Yriit 



(l>ay) 



Mouths 



/...,a..O...C!.. 

(Year) 



1^ 



AfV5 



sIN«.|,K, MARKIKI) 
\VII>n\VKI) «>K DlVnKrKI) 
iWiitr in ^.K-ial <k*.tt.Mi;itiini) 



HIKTHri.AOK 
istatf «ir Country* 



NAMF OF T\ 

I \riii:R Vy 



\XX^^ 






MIRTH PI. Al'K 
or I-AIHKR 
(St;»tr or Country) 



MAIDKN NAMK 
OI- MoTIlKK 



lUkrmM.ACK 

oi MOTIIKR 
(State- or Country* 



OCCl TATION 



^' ) I 







/C-K«.rv\' 



r\ 




. H^! It 

lac du'^Ht 



MEDICAL CERTIFICATE OF DEATH 



DATE t)F DKATH fl 

\X 



(Month) n 



.S... 

(Day) 



I go 

(Year) 



T HHRKBY CKkTII'V, Tliat I attcndcMl (IcihjiscmI from 

OL.\.a H 190 ' ' to .....U.^^ 5:... 

that I last saw h.^-^ alive on LvN^VA "^ 



190 \ 

ana that (Uatli occurred, on the «late stated alnive, at ^ 



^- >I. The CALSK Ul' DUATII was as follows: 



KjojJkr^ 



\LSK Ul 



XA. 



VVC| 



vL 



.■V.4... 



DIRATION 
CONTRir.lTOKV 



DURATION 
(SIGNED) 

lUA..n L 



Years M on tin 

JJw-^k 



Days 



Hours 



'cars 



Pays 



190 \ 



^. ..,- Months 



Hours 

M.D. 



SPECIAL INFORMATION only '«r Hospitals, Institutions, Iransifnts. 
or RfCfnt Residents, and persons dying av»dv from tiome. 



Rf>ii!fii In San /'i tntifr'} 



X 






THK AnoVKSTATKni'KRSONAl. rAKTIcri.XKSAKKTRl H TO THK 
HKST OF ^iv KN«)\VUF.J)C.K AND lUXH-.I- 



(Info!jn:uit 




( \(l<lrc>ss 






Former or 
I'sudI Residence 

When was disease contracted. 
If not at place of death ? 



How ions at 
Place of Death? 



Davs 



I'l \CE OF HI- RIAL OK KKM•'^ Al 



D\ri-lo: Hi KIAI. or RF'MOVAI, 

^.vva^ol 'I T90H 

FNDKRTAKHR tko/vU^ ^ .\ ^ ^^. ^^^ 0. ^S 



',^t 



(.\(Mris« 



N. B." 



— — — ■"""""■■■""""■"^ TT! Th Af^ should be stated EXACTLY. PHYSICIANS should 

-Every Item oi Information should be careVully •"PP'''^' jt^^J. classified. The "Special Information" for p«r- 

•tate CAUSE OF DEATH in plain terms, that it may be properly Uass.i 

son. dyinft away from home should be given in evry instance. 



> c* 



aV 



r^^^fS'^ 






n 



t' 



« 1 



^'1 



1 



. il 



hi 



1 

\ 
I 



%1 
i-* 

*1 



ill. 



V s^ 



« 



W ' 



(I' 



!i 



' 1 



H 

t 

fl 



ii 



> H 



t 



I. 

:f'. 



II 1^ 



[■»>► 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,.,n„.„„„ , NO .*rl?*.H^I'Co REFBR TO BACK OF CERTIFICATC TOR INSTRUCTIONS 



Begistered J\i'o. 



Qorv 



l),ih' hllr<l,XL^aAjjd^ ^ i'JO'\ 

i^vwa U/V.-A, Deputy Health Officer 

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 



-Ccvtificate of H)catb 



( xa. S. StanOar^ ) 







; 1 



^ 



PLACE OF DEATH : — County of 



St- 



No.*-JX.\) 



LLla >> vccL a.. ' 1 aca V c su^^ -''^^'■Dist.; bet. 



,a/^vJrva^xwUi.cLGty of^.o^ru ivo.>vcv^ ^r 



and 



'^^*^ ' ^ V-'w-W'Vv.V. "^""' I,-, Br«TnrNCE GIVE r*CTs'c*LLCD FOR UNDER "SPECIAL INFORMATION" \ 

( " r/*o;".T-"cc"u%;*v,"r-o".'t'T*.t ."fn"?-" «";"" name ,n,t»o or .T.ct, .»o «uM.c.. ; 



FULL NAME 



k 1 



,a.>^\U\.a 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

j COLOR A 



VlllJjL 



X 



va > 



■Mn.ith) J ^i*^^ 



(Year) 



ACE 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

(Day) 



..LLvvq 

(M<»nth) r 



(Year) 



) 'fa I . 



.1A,«/// V \\\^ 



Pmi 



SINC.l.E. MARKn:U 
WMMiWED «»K DlVnKlKD 
i\Vrit«in «H-iiil <K-i»^nati<ni) 



UIKTHIM.AOE 

iStfitf or r<>mitr\ 



NAMl-: <»! 

FATin:R 



niRTHIM.At'E 

ni I AIHKR 

• Statr or Country^ 



MAIJ>i;>J NAME 
OF MoTIlKR 



IMRTIIIM.ArE 
•M MOTHER 
(State «)t Country) 



vKCri'ATlON 




VTUVVvCX, 




i^Ow 1 - 



AVv/*//-?/ i» Siifi /'nuh /u-'> 



)',tii 



M.nith' 



/hn 



THK ABOVE STATHDPKRSONM. I' \ K rirf I.AK- AK K TK ( l" I" THE 
HEST OF MY KN()\VIJ:I)<.E AND MF.MKl- 



(Informant 



'' Xddrrss 






■0L'"V>\.A. d.. ex.. 



I HKREBY CERTIFY, That I atteiukil «lci cased from 

id, 0^)1 lLv<v.a^l 190 1 to LLu^ ^.3^^^^ 190 S 

tliat I last saw h.-i<Ci:»'aliveon LLc\.^.X 190 

and that death occurred, on the date stated above, at i 
0. \L The CAISI-: (M* DIvATH was as follows; 



? 
UP 



DTR-ATIOX )Va;.v 

CONTRIIU'TORV 



Afout/is 



Da 



vs D 



J fours 



nURATION ^^ )Vv;r5 .Voyf/rs 

(SIGNED) ^^ ^t C) 






i- '^ 



/><7 1 .V 



A 



//(>NPS 

M.D. 



Special information »"•* ••'^ Hospitals, iBstitutlons, TriRsifiits, 
or Rfcenf Residfnls, and persons dvinq awd> from home. 



Former or 
Isual Residence 

When was disease contracted, 
If not at pla< e of death ? 



HoM I0R4 at 
Place of Deatk? 



Days 



I'l \CV 01 lU KIAI. OR KI;Mo\ VI, 



im)):rtaker A-iJULAA. 



W>>.^-v^^ ^ "" 



DATK of Hi KiAl. or RFIMOVAI. 




(Aihlrcss 



ai 3- 



C 






190 



I 




r~^ 



>3^ 



, i7^ .f^F „K„,.i,i he Rtated EXACTLY. PHYSICIANS should 

N. B— Every Item of Information .hould be caretuliy - PP«-J- ^^^^^.^^^..^Wled. The 'Special Information" for pr- 
•tate CAUSE OF DEATH in plain term., that .t may be properly cla««i»ica. p- 

none dyinft away from home should be ftiven in every instance. 



\%\ 



ji:! 



:|.: 















vc^ 




•- 



><^1 



'•''.-.Ji 



«' 



g 



« 






:ii^ 



I ii 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hoard of IlL-alth— l" No. :5 '»'^a^^ H&T Co 



1) 



(tie Filed , LL 



c\^,^^v.^> ^> ' 



\^acv,4.t io 100\ Registered J\'o, ^oO 

Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvttficate of Bcatb 

( la. S. StauDarC* ) 



% 



PLACE OF DEATH: — County ofdcL^r^ JxCLTvaL^cc^Gty of C)/CLW 0Xxcovcc4. e <: 



(No. 



...5t-?^ ^X 



\X. 



1\ 



St 



(IF DEATH OCCURS AWAY FROM USUAL 
IF DEATH OCCURRED IN A HOSPITAL 



A^ist.;bct. '^^''vu.a./^x'.j and )jfva.^A./>A.a , ) 

:TS called FOR UNQER "special INFORMATION" \ 
ITS NAME INSTEAD OF STREET AND NUMBER. / 



>: ^ Dist.: bet. A^^\ Ma. ^ xt 



RESIDENCE give facts 
OR institution give 



FULL NAME 




l/CLA>:l.A^dX \|...IlOw-lVClCX w.. 



PERSONAL AND STATISTICAL PARTICULARS 
DATK OF lUR Til 



CXAA 



COLOR \ ;v 



I Mouth) 



(Hay) 



(Year) 



AC.K 



MEDICAL CERTIFICATE OF DEATH 
DATE (JF DKATH i 



(Month) f 






(Day) 



(Year) 



I HHRrCnY CKRTIFV, That I attended electa scl from 
LLwvCL- .S 190 H t«> ^ " 






J V<; < 



Mntllhs 



Davi 



SIN«.I,K. MARKIKU 
\VIlH)\yKn OK OIVnKrKI) 
• Writf ill «iocia] (U-^>iKnatioii) 



BIRTH PI. AOK 
(State or Cojintrv' 



N'A>fK OF 
FATHKR 



RIRTHPI.ACK 
Ol" I ATHKR 
tStatf or Country) 



MAIOKN NAMK 
"I .MOTflKR 



KTRTIIPI.ACK 
<»I MOTHKR 
■St;ite or Countryi 






n '-> 



tnvvy^ 






that I last saw h •• 



I90 
alive on ' * lyo 

and that death occurred, on the date stated alnive, at 
M. The CArSH Ol- DliATII was as folhms: 






M 



vvVv^V^^-^' 



n 



K 



A.v. 



(\ 



\^Col^vcL 




Ckjy^/^-^ 



Curu ^^/C:.^i 



Dr RATION Years 
(.ONTRIHrTORY 



Months 



Days 



Hours 




P 



9- 

r' 



//out s 



f\ 



'"? v\j^^L cx- ^ V c^ 



*>CCri'ATION 



V 



DI'RATION }\',jrs J/i»i//is Days 

(Signed) ^. 11*. o&-trcLouUv ^ m.D. 



iL 



is 



SPECIAL INFORMATION onU for Hospitals, ln4itutions, Translfiits, 
or Recent Residfnts, dnd p^^rsons dyiny dHd> from tiomr. 



yr.niih^ 



ihi 



TMi: \HOVK STA ii:i) J'KKsoNAl, I'AK T UT I.A KS A K K TKIH To THH 
IIK.ST Ol MV JLNO\Vl,i:iM-. K AM) FUII.II.F 



'Iiifortnaut 



(.Xdilrcss 



S^^3^ r k t! 



Formf r or 
I'sual Rrsidencr 

Whrn was disease contracted, 
If not at pla< e of deatli ? 



How tonq at 
Place of Deatli? 



Days 



I'l.ACF «»!• lUKIAI. OK KK.Mt»\ \I. 






'^ 



V 



\^'^Va,'( 



INK V. K r A K F K -J I V Cl (JLcU. > V M U >; ' -V^ aV*-Vi ^ ^ 



liXTHof lit KiAl. < KFMOVAI. 
<^. ^ 190 ^ 



fA<l(lress 



!N. B. Every item of information •hould be carefully supplied. AGB should he stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for per- 
sons dyinft away from home should be ^i^cn in every instance. 




--;** 1 



if 

i! 



i 1 1 1 
I 5 



;■ I 




r 

3. 



■f ! 



\ • 



H 



^}\ 



f 



I 



l4 



\ 



\\ 



I ' 



\ 



'W 



■\ 




\\ 



li 



I 



< i. 




M 



m 






i ! 



.»1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noar.l of H.-tlth 1 No i^ l!"^?^^ H&l' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



HUrw>w^ ^^^M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( H. S. StanC>arO ) 



PLACE OF DEATH: — County 



of' ''0L^\^ vjxa^>\cvcLCcCity of ^ '<X'>v g,AA/wt\^.ao 



^ n 1 



No. i^^TO nAXc^VcC^.rJv St.; 1 Dist.;bct.'Tva>\-Klvrv and 

(ir OtATH OCCUHS *W*V rROM USUAL RESIDENCE Give facts called roR under "siitCIAL INrORMATION- \ 
ir OCATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

IK 



Oa^^vvu^i.^ ) 



FULL NAME 



;VwL^.cv4 



Mn^A.<X^\. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 




xU 



COl.OR 



DATl-: OI HIKTU 



Ar.K 



(Month) \ 




(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



H 

(Day) 



(Yt-ar) 



^ 



I ) 'iti » .^ 



% 



MoMlhs 



PllX 



^I\«. I.K, MARRIKD 
WIDoWKI) OR I)IV«>RlHn 
I Write ill wkmiiI <U-sijrnati<>ii) 



^vX 



lUR rm'i.ACK 

(Staff or Country^ 



NAMK or 

fathi:r 



HIRTHIM.ACK 
<>l I ArilKR 
(St.itf or t'ountrv' 



MAIUKN NAMK 
OI MOTHKR 



lURTHPI.ACK 
o|- MOTIIKR 
(St;»t(- or Coiinlrv) 



VlTU.vvcUX MUUAn^xa 



Illa-U-vi. 







DATE OF DKATH ''I 

„„ LI t<c CL ...„...„„ 

(Month) (J 
I IIERRBY CF':RTrFV. That I attemle«1 rleceased from 

.N^^jLijL. %\ 190 \ to cLvwa H. KK) H 

til at I last saw h^^^v alive on ^VWCl \ up \ 

ami that death oceurreil, on the «latc state*! alxjve, at i » v 



SwIm. The CArSI*: Ol- DI'ATII was as foni)ws 

r 



C4 we>A.<-'t, Vn\\.v^ c (x.\.dL^L\^s> 



I )r RAT ION % ' years Monlhs Days 

vL4."Llv"kv\.CX 



I/ours 



CONTRim TORY 



I )r RAT I ON 4**^ Years Jf<>n//is 



/)ays 



(SIGNED) 



:W 



Hours 



M.D. 



\ 






t 



Kfsidrd ill Sail /'laiii !>,■,> 



) ,,: , 



Mnlltfn 



fhn 



THi: AHOVK STATKD PKRSONAl. P \ K lirr I. A K> A K l-! TRIK To TlIi; 
HKST OI- MY KNOW I.KD<.K AND nKMllF 



(InfoTiii:ii«t 



L\ . dLu^L 



'\'V.<i 



1 \iMrc>;s 









V^^ 



-;\ 



lU 



h 



^ iMoH (Aii.iri-ss) tXoc u.a>v 



0.a>v^Vii<^lv. 



SPECIAL Information nniy for Hospitals, InsmutloRs, Transifiits, 
or Rfcenl Residents, and persons d>in(j andv from home. 



former or 
Isual Residence 

When was disease contracted. 
If not at place of death ? 



Now lonq at 
Place of Death? 



Days 



ri.ACK 01 HI KIAI. OK KKMoX AI, 




JJL' 



INDKRTAKKR MV ^ ) XOw^A. .''» V 



IrVrivu: I5i KiAi, or R1;MoVAI., 
^VA^VQ 1 T90S 



(Address 






V 



'^,K.^kX.^-. -^^ [ 



IS. B. Every item o? information •houlcl be carefully supplied. AGB should b« stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
8f>n« dyin^ away from home should be ^iven in every instance. 



|- 



'1 

ii I 



1; 



II 



|i; 



IN 



ii > 



ti 




'•I 



.:^' 












'.gm- 



I ,; 


1 ' f 



l( .* 






li I 




, .1 



is 

4. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HoMnl.fii.uiih . v.. i.i^^SSj^n&iro REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc Filed , 



/W^ 



1 lo 



100\ 



(^^trwvo 



4sA.v M Deputy Healtiri Officer 



KcgLstered JSi'^o. 



^S* j*^^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

(Tcvtiflcate of Beatb 

{ Til. S. StanDar^ ) 
PLACE OF DEATH:— County of^' a^\. >J.\.Ou-VX<CAACCCity of '■ ' CL.>\. O^Vavv t,ui. to 



(No. vLcLLIA' i^' 



t^ 



CL^\.vX<XVa.AwV^^v St.; Dist.;bct. and 

RESIDENCE GIVE facts c*llc_ 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNOCR "SPEC I AL I N FOR MATION \ 
( IF OEAThIcCURRED IN A HOSPITAL = ""• --r ITS NAME INSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 



^iKx 



8KX 



^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.UK 



DATK l»l- IJIK 111 



a«;k 



L 



UUJxvtt 



a 



■a\^j^ 



I Mouth) 



y,iit 



( Day) 



MoHfflf 



/ {i..A...i 

(Year) 



A>«; r.v 



SINi.I.K MAKklKD 

\\ MM)\VKI> MR DIVORi Kl» 

\\ iit«- in MKMiil tli'siirnatiuii) 



HIRTHPI.AOK 

iSt:«t« or Country^ 






FATIIKR 



HIRTMIM.ArK 
0|- lATHKR 

<StaU- i)r Country^ " 







.a^LL/-;^ ^^u.! A J..O'r VXN- 1 M \JJ^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII r\ 

„ ^V^v,CL 

(Month) ^ 



(Year) 



• •■••*•■ •••«^ ••■»« •^». -'^v- 



(Month) \ (Day) 

I HERKHV CI:RTII"V, That I attciukMl ilcccasca from 



that I last saw h -i<^v alive on CL.U\.<^ 190 



Ol i — • 190 i 



to SX<'s 



\ 



I 



\ 



.C^v^cCLlca' (Jx^v^-^va 



MAIDKN NAMK 
OF MOTIIKR 



iurthim.acf: 

ni- M<)TnF:R 
iSt:it« or Country^ 



m^ 






^A„ 



"1 ■' v. Ov_ 



AC CrWv;-- 'r • 

f\'r^idr<f 'If Siiti /'i ,!Hi /i-t> 

THK AHOVK SlATHn I'KRSONAl, 1V\ R lUr I. \ R S ARI. IKl K T' » 
HKST OF MY KNo\VI.i:i)«".H AND llFl.Il-.F 



) ,.l! 



M.'iillr 



/hn 



IMF 



Infoimant CvDw^<X^Ax C?«». . O 



(Address 






ami that (Kath occurred, on the <latc stated above, at 
M. The CAISI*: OV DICATII was as follows: 

Dl'RATK^N yraf.K Afonths 1 /)aYS Hours 

CONTRIIUTORV 



DIRATION 
(SIGNED) \^ 



Yeats 



L 



.lA';////.v 



.[ 



\.K\^^ 2 



IC)0 



(A.l.lress) ^^ 



X« 



Days 



.a'v',. 



Hours 

M.D. 



M^ 

3P£Qf/\i_ Information only ^o^ Hospitdis, instituNons, TNOMents, 

or Rfffnf Residents, and persons dying away from home. 

former or f , 'i ] \ ^ "' 1 How lonMt 

^ I L ! ,C t '>>-. ' I ' Plare of Death ? 



Isual Residence 

When was disease contracted, 
If Rot at place of death ? 



Days 



rr.ACK »)i m KiAi. ok rkm'»vai. 






V 



DA IF of ]t< RIAL or RKMOVAU 

Lvvva ^ 



i\. 



'^ 



190H 



t NDFRTAKKK V 'CLU-^'vLc >i • vCXV^. %\.v 



(Address 



I V. V C t 



N. B.— Every item o.* inV^orn^allon should be car«»u,l. supplied. AGE should »>« «-*«:J^f .^y^^^J ,„211!fw'Vr'::l.l 
state CAUSE OF DEATH In plnln terms, that 5t may be properly classified. The Special Information far par- 
aons dying mway from home fthould be given in svcry instance. 






f- 



*> 
^ 



r 




' I 








.y 



-.^- ^• 



V. 



5r>t^..v 









?* 






^^: 



*4^:- 




. <^;^ 



ft ♦ 



• ••'»". * ' — - 



i t 




• I 



n iy 



11 



i| 




WRITE PLAINLY WITH UNFADING INK 

|U.:n.l ..t II.;.ltli I' Vo i . ^-^^E^. lUt I' C*u 



l)((t(' Filed , \X\jJX\jU^ W' 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 



100\ Registered J\^o, 

■i.trVco'> "La," Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

Op 1 

PLACE OF DEATH: — County of M WO^YV a Gty of 



% 



\il/a.rv<x; '^al 



No. 



SU 



Dist.; bet. 



and 



(ir OfATI 
ir Dt 



H occons »w»v rnoM USUAL RES 

ATM OCCUflHtD IN * HOSPITAL OR 



FULL NAME 



SIDENCE GIVE TACTS CALLCD rOR ONDf R 'SPECIAL I N FOR M ATIOW "S 
INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. / 



) 






\LL 



UAi. 



-4- 



PERSONAL AND STATISTICAL PARTICULARS 

i COLOR 



^lul. 



luj 




DATK «»I III K Til 



a«;k 



iMnnth> 



-: ,15:5 

(Dny) 



A.. 
(Year) 



'^ ^ ).,n 



M.,ulfi^ 



A/ 1 .' 



sivr.i.K m\kkm:i) 

\VII)(>\Vi:i) OK l>!\<»KiKi> .T 
'Writr in sfK-ial «l«sijriii»tii)ii) 



n 



W 



vCV'J-'-. 






\. 'I 







f^A^fe-iAnv 



M 



IMKTmM.M'K 

(Statr or (."ounti \ ' 



NAM!-: «)I 
l-ATIIKR 



IMK TMJ'I.ACK 
0|- lATIIHR 
fStal«- or Country) 



MAIDIvN NAMK 
nl Morm-.K 



HIRTHIM.ACK 
<)|- MOTHKR 
(Statr or Cotmtry) 



<»CCri'ATU)N 



THK AH()VKSTATi:i.PKKs..NAl,rAKTirri.\K- AKHTKIH H. THK 
HKST OF MY KNt»\Vl,i:nr,K AND lU Mlf- 



dnfortiiant 



^\^ 



W -Vt'^-v 



Xy^ v»- vX *w I w> '*w ^ 



ij 



( \<l(lross 



MEDICAL CERTIFICATE OF DEATH 
DATK i)F DKATII 

(Day) 




(Year) 



(Mof^h) 

I HI'iKIiBV CIvKTII'V, That I alltu«kMl «let lasca fn»iii 

— . — ■ — — ngo to .......;......■.....-....►.."—•"".-• i</5 

til at I last saw h-^ssr^s .«li%c on — 190 

anil that <Uath .K-t iirrc-.l, mi the «lati- stated above, at - 

_M. The CAISI-: UJ* IHIATII was as follows: 



nr RAT I ON years 

CONTRir.rTORV 



h 



Months 



Days 



Hours 



Months 



DURATION Years ^ 



SIGNED) ^ 



d 



^wVC 



KjO 



( 






/)ays 



Hours 
M.D. 



' 1 I ' 



Special information »»»ly for HospilaK, InstilMlloiis, TMBSifBts, 
or Rfcenl Residents, and persons dyinq a>*dy from homf. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of deatli? 



Ntw hmi at 
Ptare of Death? 



Days 



ri^ACK Ol" HIRIAI. «»K KKM<»\ AI. 



I NDHRTAKKK 



DAIKo! Hi KiAi. or KKMn\AI, 



't, 






190*1 



State CAUSE OF DEATH in plain terms, that it may be properly ciassitled. i ne pc 
«on« dyinft away from home Hhould be feiven in every instance. 



\ ' 






iit^ 




4 



i 



ii 



<t4 



iH 



,S« 



.1 ► • 



■J .»• 



"•■*■ 



fir ^ r V 



• r- •■ • 










•^T"."" J 



■* 



li 



t \ 



r-: 




Ik 



I 






II 



:| 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, .v^ ^.r^r^.HS:PCo REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS 



!)((/(' Filed , 

( I 



cL^-VA/U^ 




lA^A^ \C 



lOO'A 



Registered J\'*o, 



>.\v^4, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( tJ. S. Stan&atO ) 

PLACE OF DEATH:-County of 0<J^ JXO^A^^-'City ofHa^ >1/vaAVCU C C 
:No. .S.k'^ t.qlvti St. -5 Dis..;bet. ^JUavLt .Ml 



l^'tA^) ) 



1 „ iisilAI RESIDENCE Give FACTS *C*LLC0 rOR UNOCR 'SPCCIML INFORMATION • 'V 

( •' rF"o;iH"o^c^^r.v ."rHo^.^^At o%"nSt'.?Jv^n v.vr .ts name .n,tcao of ...... •no nu.bcr. ; 



FULL NAME 



..n.aA.(x!\' ll crt^cLw\>:<:^X'Ci 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

DA rs OF niKTii 



A 



MoiithT 



A<.K 



7 M 



11 



(INlir) 



Month ' 



/111..... 

(Year) 



A.' > 



Hl\<.i.K. MAKKIHI* 
\VIl)«)\VKr» «>K IHVt»KiKI> 

iWritf iti MH-ial »U>.i^'iiatJini) 




L 



cL^-vo- 



niKTHPI.AOK 
(Stall or '■•Hintrj'^ 



VAMK OK 
FATHKR 



niRTMri.Al'K 

OF fathf:k 

'Statf or t"<»untrv^ 



MAIUKN VAMK 
OF MOTMKK 



niK ruiM.ACF: 
OF mothf:k 

(stair or Co\intrvi 






VOJv 



'hj 



\) ,A 'l 



>VJt>^ 



] 



m 



•H'Cri'ATION 



X ^ v>vt 



_X- 



-? 



) .•..' 



,M,.,illi' 



V /'.,■ 



rMKAHOVKSTATFI)FKKS.»NAI. PAKTUM-I.XKSAKFTKl K To THH 
HKST OF MY KN<UVI.FI)<".tANr) HI.l.IF.H 






ou 







ll 



( \.l<lrc^«; 






^^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH -\ 



( Month) 'j 



(I>ay) 



(Year) 



iTlERIiBY CI'RTirV, That I atteiulcil «kHHase(l from 

W^yL 1'. igo'A f. A-Luca.v 190H 

that I last saw h ' alive on L^^^^^:^ :' I90M 

an<l that ikath (KHMirrcl, m\ theilate stated above, at ^ ^ ^ 
M The CMS I-: Ol- DliATII was as follows: 



wVt^U 



1)1 RATION 



) cars 



Months Pays 



Hour 



CON T K I lU TOR V UXd.VryX:^ 



Dl'RATION 



Years 



Af,ipiths 



Pavs 



(SIGNED) lUiVy\,. -iJ vLoaJ^ 
LLcUV ^ iQoH ( Arl.lre'ss) 3l V 



.S^ 



OJ\K\J^K JA 



Houra 

M.D. 

\ 



SPECIAL INFORMATION *»"'> ^^^ Hospitals, lislitutlOBS, Tratslfils, 
or Recpnl Residrnts, and persons dying at»ay from hoiw. 



Formff or 
Usual Rfsidcncf 

Whfn *tas disease contracted, 
If not at place of deatli ? 



Now I0R4 at 
Place of Deatli? 



Days 



FI \CF: 01 m KIAI. OK KHMM\ A!, 



.Vv«r-i^ ^'\<x>v^i- V.a 



i»\rj:of HiHiAi. or kf:movai. 

V V. v 'v. CY I. 



I90" 






r 'v-v ' 



(A.Mif-^- 






A^^t 



—"■^ .. , APF «hnul(l be stntecl KXACTLY. PHYSICIANS nhould 

N. B.— Bvery Item of InformHtion .hould be c»r«fully MuppI.e.l. J '' ^ « c,„,i»ied. The •'Special Inform.tion" for pr- 
•tate CAUSE OF DIIATH in plain term., that it may be properly cla.-.».ea. h- 

nnnm dylnft away from home nhould be ftiven in .v.ry m.tance. 






!;: 



\. 



' Til 



- I 



S 



i'- 



I 






i 



\ 



w 




■• V 



A 







A? 



I • /-^ 



i; If: I. 
,. ill- 
I, ■' 



• » 



I 



i 



ft 



iMil 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

R'55 






/>^r 



1 



n 



^-W'V 



V.V<L/' 



'M 



i 1 



iy6' ^ 



Be ^i. sic rod J\''o. 



Deputy '-'''alth Officer 



No. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of IDcatb 

( "a. S. StanDar^ ) 

PLACE OF DEATH: -County of H^vv l^XVW^cCity of '"'c^>v 1 X<X;>^.C.^ C. '. 

IC^I "^ ■ -i»« ^-' St.; ! Dist.; bet. U .a-lU-V L and ^.ULAA 

<3^ > ^ .«.,..>..-.., T _.„,^ ^...rn rnn UNDER pPtCIAL INI 



• O. ,."il-'..t ..en*, prsTDENCEcivE f*cts*c*ilco roR under -^pecal information- \ 

( '^ rF"DrATrl^C^';rD^;''rHo"s^p"T"L o"r":s"t'.t't^'nV,VE its name instead OF StRCET AND NUMBER. ; 



FULL NAME 



laxq ^.a-^\AAx.-..MJ.L CL^ 




■^ 



PERSONAL AND S TATISTICAL P ARTIC ULARS 



SKX (^" 
DATE OP HIKTH 



L 



^IXat 






V 



AGR 



)■/ </ J 



(Dny) 



\f,>n//n 



(Vear) 



/></!. 



siN«.i.K MAkk ii:n 

WinoWKl) «»K KIV • tKv i:i) 
'Wiittiii MHial .Usj^Miatiiiii* 



lUKTIII'LACK 

(St.'iti- »>r I'ountry^ 



NVMl" <»1 
HATIIKK 



HlRTHlM.ArK 
<»I I ATIIKK 
'Siatr c)r Cinnito*^ 



MAIUKV NAMK 
OK MOTIIKK 



lUKTin'UACK 
OF MOTIIKK 
(Stat< iT «.'oiintry> 







^<x Vt c vxu 



\ (X' w«w, ■» 



w 






Kfuiir,! ill Satr /'i an, i>r.i' 



) '>•{! t 



•\r.,,itii^ ' ' /'"' 



Tin- AHOVKSTVTKDl'KK-oNAI.rXKTKl I \K^AK1, TKIK TO \\\V. 
IJKST Ol .MY KNO\Vl,i:iM'.K AM) HI.I.H.l 



(Ilifu:m:nit 



,cCu 



( \.Mi. 



JU.XX* 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII 



Month) \ 



(r)ay) 



I go 

(Yfnr) 



I IIHKKBY CI'RTIFV, That I atUMuKMl .livcascd from 

^;:::r::rrrrr— — I9O to rrrr---^ - • lyo 

that I last saw h alive on ^'P 



and that death occurred, on the date stated above, at — ^ 
M. The CAlSFv OF Dli.XTII was tks follows: 

_w.\xj..-.-!U*^;^ 



DIR.XTION Years 

CONTRIHrTOKV 



Mondi 



Ihns 



Uoiiys 



Drk.XTloN 



Years 



Months 



(Signed) L(r*LtAv^\ 



Davs 



l> Uj. Ajiia\^.d 



I lout \ 

M.D. 



lLvQ> ic)oM (Addrcs.) UVCrvvi^^Xy^rh-^-^- 

i ^— _ . ._i. L, U/.cnit>lc iHclituliAnc fraa 



cppQ|^l_ Information «"•> ^^^ Hospitals, institutions, Translfiits, 
or Recent Residents, dnd persons dying away from home. 



Former or 
Usual Residence 

When was disease contrar ted, 
If not at piare of death ? 



How lon9 it 
Rare of Death? 



Days 



l'I,AC>: Ol- lUKIAl, ok Kl-.Mo\\I, 
INKKK I AKhK > 



i)\i"i'..; It! KiAi. or kj-:movai. 



4- 



T9O 



A(Mic«-< 









. .,,.. . I 1 I.. «»,.»i.,l r.XACTLY. PHYSICIANS should 
„.„ „,• i„,Wn.a.lon .houl,. h. c„.e,uM> ..ppne... '^:Xutt^i^r^^^"il^'''^ In,'orm..i..n" .or p.r- 
CAUSE OF DIIATH in plnJn terms, thnt it miiy he properly uaHnmcu. 



N. B. Every 

Mtate CAkjr»i- v> •-'•-<- ■ — . ,_^^_ 

«->n. <l,in« away trom horns -hould be ftiv.o in .very ,n»tan«. 



I • 



I i 







,1. 11 







1 




*)i 



"..yoxr- 



^y^ 

-!*^ 



^-. 



/ ' : . .•■ 



^j*^-'N»i 






^ 



■l 


I 

t. 


1; 

'[ \ 




i 


1 

■ 



ti 



■i 



■f ■! 
Pi 



III 




■»li 



fti > 



ill 
■■I 



'tti til 



i « 






1 1 »» 
C. 













WRITE PLAINLY WITH UNFADING INK — 



n,y.,\<\ ..f ll«;illli l" ^'" I*' 



v5*IUtl' Co 



/)(f/(' Fih'f/, sXcvCi^'^^ "^ 



190^ 



THIS IS A PERMANENT RECORD 

WKF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

830 



lie^istered J\'*o, 



,^VCV/^ 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccrtiticate of 2)catb 

y XX. S. StanDarD ) 



PLACE OF DEATH: — County of 



City of C)i). cL(^vcA.A 




a.o. 



No. 



and 



_ ^ St.; Dist.; bei. ^^^^ "^^ 



-) 



FULL NAME 



(T-. 



aXvv-/c.H va'>^^x^ 



al 



.wctc^M 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



QUcl. 



DATK UP IMRTII 



AC'.K 



^\ 



'MoMth> 



■CL^\, 



( Day) 



T 






} >.» 



\ ) I'll I 



SIxr.l.H. MAKKlK.n. 
WIDoWKI* OK DIVoKrKO 
iWiilf it! 'MH-ial <l«sij^nuii«»n) 



M.oifh^ 



L 



(Year) 



An 



HIKTHPI.AOK 
(State or C«nintry) 



NAM1-: «>!• 
FATHKR 



HIKTHPI.ACK 
OF I ATIIKK 

I Stat I- or ("onntry^ 



MMDKN XAMH 
«•» MOTIIHK 



niRTHlM.ACK 
Ml- MOTHKR 
(State or Country) 



iKLli'ATION 









/\Vsi,if>f in S.tit /'i an, 



)-,•,;: 



M,.„'lr 



/hi 



MEDICAL CERTIFICATE OF DEATH 
DATK t>H DKATH A A 

(Day) 



(Miiith) } 



(Year) 



I HKRKBY CI':RTIFV, That I atUiukMl «leccasea from 

IgO to I')0 

that I last SJtVV h -. -alive on immmmmmmmmmmmm^ 1 «/l 

aii«l that (Uath occtirre*!, on the ilatc statetl above, at 
M. The CAISP: OI' DIvATII was as follows: 






Dr RAT ION Yi-ars 

CONTRIIUTORV 



Months 



Days 



Hours 



DIRATION >V<irJ 

;iGNED) U) 1 i/ 



.)/0H//tS 



Pavs 



(SI 



T()0 



( 






/fours 
M.D. 



(yvw. 



Special information onl> J»^ HospiUU, institutions, IransifBts, 
or Recfot Rfsidrnls, and persons dying away from home. 



Formfr or 
Usual Rfsidencf 

Whfn was disease conlratted, 
If not at plare of deatli ? 



How lon^ at 
Plareof Death? 



Days 



TnKAHOVKSTATl-I)PHK^.»NM.rVKTIv-ri.AKSAKKTKrK n> T.IH 
HHST OF MY KNO\Vl.KD«.H AM> lU.MKl- 

(Infonnant JL - > '^ '^ C\ '^ ^^ 






<■ \(l(lrc<«5 






n \CF Ol HIKIAK OK KHM"\ Al. 




I NDKK r\KKK 



i>ATi. of itiHiAi. oi ki;movai. 
V^Lwn, w) 190 • 



(AdWr- 






IS. B.- 



.. , TpF should be stated EXACTLY. PHYSICIANS iihould 
-Every item of Information .hould be cretully f"PP»"';'- ;^^ " ,,a„ir.ed. The -Special Information" for pr- 
•tate CAUSE OF DEATH in plain terms, that .t may be properly claaa.i 
«on. dyinft away from home should be ftiven in every .nstance. 



!' ' 




1 

1 








1 





i t 









il 



^ . 



,<( 



i 



m^ * <* i- - 



•k« • 1 - -J ••^* 



/^Sfe^ 



v*^ 



*. .;^»» •*•- 



4 






<. 



i^' 



1 r 



i 



■: It 



' I 



tfi 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



' il 






lOO'i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^ 



•>^ 



-Uvvo U^M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



,^ 



'^ 



Ceitificate of Beatb 

( XI. S. StanOatO ) 

X i^'i] \\ r \ 

PLACEOFDEATH:-Coun.yof'^a.vUlUva Gty of lU.^v.^ ^CK,^ 
,No. -l O ' mAvsIo.1 „ St.= — - Dist.; bet - »nd 



^ 



( ■' :^3™vH^^i :-si^;:ji^<:^";^^n ^M^ :^^jr ■^:^i:v=r 



) 



FULL NAME 



I llctvaaKxIj -. hj.Ji/Y)n^.x\.^. 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR N J 



I»ATK OI' niKTII 



\(X\ 



' Month ^ • 



A«.K 



I ■«» )>«!».« 



(Day) 



(Year) 



Af V 



3 



MEDICAL CERTIFICATE OF DEATH 
DATE OF PKATH i 



u 

(Month) 



t 



(Day) 



jgo 

(Year) 



I HEREBY CERTIFY, That I atUndea <leooasca from 

^cL>v x;. ."o.' to IL.^ 



igo 



to SAeCwO.. b. 



iqo H 



SINT.I.K. MARKIKD 
\VII»n\VKI» <»K DIVORi Kl> 
(Wiitf ill MK'inl (Usiv'iiation) 



niKTHPLAOK 
tStatf <ir Country^ 



^iXcv-. 



V^ 



\\rs, 



moLv 



NAMK Ol- 
FATHKR 



BTRTUri.ACE 

<)» I ATIIKK 

• Stale or Country^ 



MMDHN NAMK 
OF MOTHKR 



lURrHPI.AOK 
OF MOTHKR 
(Stale or Counlrv) 



.trK^x 



U 



^l 



'^ 



4. 



'■KjJk.cx. % ^v^- 



W 






\ 



OCCUPATION (^ 

Residfd HI San /'lan'i.r.i 30 ^ '' 



II <■ 



Month' 



/'<M.> 



that I last saw h ^'^ alive on lLccX^ *o ic^ 

and that death occurred, on the date state«l alM)ve, at 



vL M. The CAl'SH Ol' 1>i:ATII was as follows 



"Z 



I 



1)1' RAT ION Years Months 

CONTRIHITORV J Vrvx^. 



na\s 



Hour 



DURATION 



Years 



Mouths 



(SIGNED) t LV A-»^~-' 

LW..1^, V IQO^ (Ad.lros>;) ^L C\ 



Days 



f fours 
M.D. 



AN-jLWw' 



r L 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



\ 



^ 



THKAHOVKSTATKI.PKK^oVAI.rXKTIcri.AKSAKKTKrF To THH 
IlKST OF MY KN0\VI.F:I)<.H AND llKUU-.b 



(ItifoTinant 



rAd.lre- 



y)S\ - s ttv " I 



Former or ^ "> Q 

Usual Residence ^n ' 

Wlien Has disease contracted. 

If not at place of death? ^_____ 

I'KACF OJ HIKIAI, <»K KKM«»\ \I, 



HoH lon<) at 
Place of Death? 



Days 



rNDKRTAKKR 

(Ad<ln-*i> 



I)ATF;<)f Hi KiAl. or RKMoVAL 

LL^w^^a i 190' 






N. B.- 



-Evcry item oi information .houid be carefully f"PP';*J; ^^;l^e;y7l«l^^^^^^^ InLm.tion- f/r ^r- 

«tate CAUSE OF DEATH in plain term., that it mn> be propeny 
:or. dytli away from home should he ftiven in .very Instance. 



1 » 



>ti 







I |l 



< I 



I 



Itj 




-#,-•' 



li^ 



-^ .'■•» 



X.1. 



%^ 



i^/.rt^. 






■»A 



.A^-- 



»s' 



"u ^ lA^lWc-*^' • 






!■: 






!i 



II 

II 



W! 



Ml 

'4 



itt. 




,J'^-v.^ -. ^. , 



*T-^ ♦ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REfER TO BACK OF CERTIFICATt FOR IN3TRUCTIOWa ^ 

Begistered J^o. H'>S 



,,,«,„1 „f M,..l.l. I- S" .« ^^fe^l"^''*'" 



^^^^^/\ , \ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Beatb 

( "Q. S. StanDarD ) 



On 



PLACE OF DEATH:-Countv of ^ X.. 3x<X..v.^.oCty of -^ a>. -^^;— 



^No. 






^^X \j ia^L^JLl^^ ..^nr,,cL.vcHcTh^;o^R under •spec.al.n.or^^^^^^^ 

T; ocath occurs away rROM USUAL «f S.DENCE o.v^c^rACTS ca^^^ ^^^^^^^^ ^^ ,^^^^^ ^^„ ,,^3,,. y 



) 



FULL NAME 




l- 



.-^^VlA ij C'iViA.L.v^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



^Ujx 



COI.OR ^ . 




DATK «H' lURTII 



a<;k 






J V«i I > 



(l)Hy) 



y/.,n//i' 



....,./,.a.£>..H..., 

(Year) 



Pa vs 



•<!N<*.1.K. MARKIKI) 
WIDoWKI) OK niVi )Kr»:i) 
(\Vrit«- ill '•'K-ia! <1« >;iv>i;ili'tii) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DK 



iATH n 

SwL\.v-q. 

(Month) ] 



k 

(Day) 



(Year) 



HiKTnri^ArK 

(Statr or Country* 



NAMK OF 
FA THKR 



RIRTHPl.ACK 
OK FATHKR 
(State or Country) 



MAIDKN NAMK 
01 MOTIIKR 



niRTHlM.ACK 
OF MOTIIKK 
(Statf or Coutitry) 






TTTrREBYCKRTIFY," That 1 atUii.K-.l ,lc..asi<l from 

d^CV-l .90^ to U^VO^..'! looH 

1 111 

that I last saw h ■^t>v^ alive on .MnM^-^ ^'P 

ana that death occurrecl, on the date state.l above, at ^ 

CI M. The CAl'SK OF DHATII was as follows 



Years 



Monihs ^ Par^ Hours 




DIRATION 
CONTRIHl'TORX 

lirRATION ^ ^'^'-^ .^^roHths t Pays 



(SIGNED )i. 5}, fc-^xtUc^-^^^^ ^ 



1 c^ i;_*, 



IC)0 



./lours 
M.D. 



"special information only lor Hospildls. Institutions, Transients, 
or Recent Residents, and persons dying a^ay from home. 



5V„M 



\/.,>if/n 



fh! 



«)CCrPATION 

AV.>/</a/ /»/ A<"' /-'nJiti r->-<> 
TMK AHOVF STX TKI) ''HRSONA. FARTirr, VKs AKK TKrK To TMK 
in:ST Ol- MV KNoWl.FlH.h AM) IJKUn' 



(Iiifoiniatit 



IV^v 



(\XaXc. 






.1 ^ 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of death 1^ 



How lonq at 
Place of Oeatli? 



Days 



I'l.ACH 01 lUKIAI. OK KKMOVAI, 
I NDF.KTAKFR ^'^ vj -U-w^- - 



I) \ IT. of III KiAi. or R1:M0VAI. 




VuwOw^t^ 






1 



K -^ 



■— — ^ ♦ t d EXACTLY PHYSICIANS should 

.. «.-Bv...i- ------::;: .;::"- "^r- p--" -••-'•• '- •-— • '"'-"•""°"" '*" -'- 

state gAUi>l-. *Jr l»l« • •■ »- , . ^j. _„ :„ every instance, 

sons dylnft away from home should be fe.^en m every 



4 



I ♦ 

'i t. 



^ 



u 

! 



i 



11 



1 ; 



' 



ihiji 



If 



[ 

m 






.^ \ 



• n 



t ,: 



I 



lioar.l ..f II. alth 1 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




lOO'K 



Registered J^''o. 



pale Fi/etl , \Xk,'^QA'-^ T 

Ivv^.'Lv-L pep"*y ♦^^^'^^ °^'^^'' ^ . 

DEPARTIWENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of a^O) 



Cevtificate of IDcatb 

( XX. S. StaiiDat? ) , 

^~ -- J.'ux-^xcueoGty of ■ '-a^v ■J,fua>vtu.ti 



m 



n 



No. 



"^^^ 



A 



Ct'AX 



r 



) 



St.; \ ^ Dist.; bet. 



%, 1 ryxd and IS. A..(^ 



/ ir DEATH OCCURS AWAY FROM USUAL RES 
V. IF DEATH OCCURRED IN A HOSPITAL OR I 

FULL NAME 



S?^^;^^u 5^ir^ .^^" s?;e^-:o r::Er • ) 




\jA/)i\jlLu^^- . l/..(rv.xtYba\.\. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR > \ 



_Qllc.L 



ill 



\.VJvCLl 



DATK OF niK III 



\C,K 



M^nth^ 



)Viii 



(Day) 



Months 



(Vcar) 



Pii V.V 



SINCI.K MARRIKO. 
WIDoWKD OR DIVnKrFO 
Writrin •social <1« vivriialioii) 



HIKTHJM.AOK 
' State or Country) 




\ 






MEDICAL CERTIFICATE OF DEATH 



DATE OF I)P:aTH 



(Month) ] 



(Day) 



IQO 
(Year) 



I IH'RKRV CHRTIFY, That I atteiulcil .Uccascd from 



W 



<Xka 



\ 



}^\.ya^...XU 190^ to v.vx.U^... A 190 M 

tliat I last saw h v- • alive on \ »*>o 

a„,l that .Uath ucourre«l. on the .late state.l alnn-e. at 
" M. The CArSIvl)!' DlvATII was as follows : 



tl 



NAMF «>l 
I- AT UK R 



rirthpuaok 
01 jathf:r 

iStatf or Country) 






% 



^KXX' 



KXXOu^ 



WW 



MAIDItN NAMF: 
OF MOTHKR 



lURTHlM.ACK 
01 Mi>THF:R 
'State or Country^ 



OCCIFATION J , 

•^1 








Li 



/Ow 



DIRATION 
CONTRIBirORV 



Years^ .Votiths 



pays 



Hours 



"^ A.ULv Ou.C.«^J^»- J..Ol.^L^-v1a^. 



DURATION 

(SIGNED) 

1 . 






rk/^ 



I<)0 



(A«l<lress) 



1" ■ 



/)<n'.^ Hours 

M.D. 

V 



x'^ 



SPECIAL INFORMATION only for Hospitals. Institutions, rranslcnls, 
or Recent Residents, and persons dying away from home. 



Rfsidfd I" Sail /'mill ■>'" 



7 r. 



)'rin 



.\f.<iith^ 



Pin: 



THF AHOVH STATFD ^^'^^^'^V'^U^l^''^-^^ ''''' ■'''"' '" '" " 
IIF:ST OI- my KNOWIJ-.IX.F- AND MI.Ml.P 



(Iiiforniant 



\] iXccvci V 



' ./ 






Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How long at 
Place 0! Death ? 



Days 



l'I.\£h' *^'' m KIAI, OK KHMOVAI. 



DA 11 



n- luAi. 01 ki:movai. 
190 



■.lit ir i< w 






(A.hli' 



. ^, ^. wC ■ 



— — — ^ ~""~~~"^ !~"! Itf .hould be .taUd EXACTLY. PHYSICIANS .hould 

N. B.— Every i.en. of i„,orn...lon .hould b= c„reM., -uppl-d. AGB -, ^^__^_^.^.^_, .^^^ ..g^^.„ ,„(„,„..•.„„• Ur pr- 
* * r'*ii«F OF DFATH in pinin terms, that it may oc p. 1 
:r.'d>-n?.Z "o.:: ho.. :ho„ld ^^ *.v.„ > > ln...ne.. 



I I 



I * 









■t* 






..;???; 








k 









t' 




«5e^:r 






WRITE PLAINLY WITH UNFADING INK 

H.iaril "f III!'!*'' ' >" "^ *• ". — "^ 

1V0\ 



I half Filed , L^CvCXxxAX 1 

DEPARTMENT OF PUBLIC HEALTH 



— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE TOR INSTRUCTIONS 

840 



Registered J^'^o, 



cer 



=City and County of San Francisco 



Na 



Certificate of 2)eatb 

^LACE OF DEATH = - County of -^O^ •'^'-^<— -- ^'^^ of ^^ O.^ -i.^V^X > v 



O ( 



St.; 



Dist.;bct. 



and 



■) 



C ■• r.;;.r-i^v.-.-,-.-r.=; ^.r=.r.■. ;"n -.vs.- ,r s-i; ;=-."=:r' ) 



FULL NAME 




\<X 




LQuUL^y- 



\ 



si:\ 



DATK nr IMKTIl 



PERSONAL AND STATISTICAL PARTJCULARS 

COI.OR /^ ^ '^ 




CUCC 



ilU.k 



I Month' 



I Ar.K 



■^C) )>.;»> 



(Day) 



.!/,-«///■ 



(Vear) 



All'* 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH , 

(l>ay) 



il 



[onth) \ 



(M« 



(Yeari 



MlFKr: BY CERTIFY, That I attciuka aercasca from 

to — ~~~ 



n^go 



SINHT.K MARUn*n \ 

WIDOWKD OK DIVoKiKI) \ 
tWritfiti siKMiil (U-ivriiation) 



HIKTHIM.AOK 
(Matt- c)r Coniilry' 



NAMK <H' 
FATHKR 



lURTHrUAOK 

OF lATHKR 

I State or Country) 



maii)f:n namf: 
«)»• motuf;r 



hiktium.acf: 
ni- m<»thf:r 

(Statt or Ctnintiy) 






,^vC^^vr>^' 



— r ^1 90 

that I last saw h " alive on • " " ^'^ 

ana that death occurred, on the date stated above, at 
"— .M. The CAISI- nV DI-ATII w-aj as follows: 

civviLLt^ A.^^^^<-^^^^^ 

1)1' RAT ION >''<''^ Montin i u}^ 
CONTRIHITORY 

DURATION >V^^''^ 



Ifontha 



/htvs 



I lout 



OCCFFATION "^, 









)'i'(j I 



.l/<»;////-< 



/)rM, 



•^,KA,U.VKSTV,■K,n.KK.ONM|•^KT,0^.,AK^AK^,KrK T,. T,...: 
HKSTOl- MV KNil\VI,i:i>I.K \^>' »l'-">^ 



( SIGNED ) tr'UnviN. J '.H 10 "Ul^V.vci M.D 

\TION only for Hospitals, institution^, Translefils. 



QpFCIAL iNFORMAT.w.^ 

or Rercnt Residents, and persons dying anay from home 

(\ A I How lofl^ at 

^"""5?^ M AVQ Ll^ccU l^ct ^ - Plare of Deatfi? 
Usual Residence^ >^^^^^*-^ ^"^-*' 



Days 



Wlien was disease conlraded. 
If not at place of deatli ? 



(Inf<>Mnant 



\^^^t^\J-*^ ^ 






(Adtlrcss 



IM.ACK OF HI RIAL OK RKMoVAI, 



C<.d\.*U.A^ 4-^, 



datf:"! Ht rial or kj:movai, 
vCvvq v 190 i 



..Jrtakkr ^^^^ ^ ^ ^^-^^ r^^ 



(Address 



)^^l?. UVwA^^^Ufr^s 



._^^___.— ^^ — ^— ^— ^■^— ^— , FVACTLY PHYSICIANS should 

state CAUSE OF Of. a in m h vHven in every instance, 

son. dying away from home should be fc.ven 



.-^ 



.. -,'£: 




* », 





* 



\* M 



p'l 



I 



A 



-1 



>r 



lii 



.1 



• \A 



I! 



i .J 



I 



'«! 



1 



■*4 



I 



if 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



J'.oar.l ..f Ht:iltli-I-No i^ "S^J?^^ lUt I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



190"^ 



Date Filed , vAwV^vavud: T 

ft^vcv^ \.v > i Deputy Health Officer 



lie mistered Jfo, 8 J I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of IDeatb 



\ 



( "a. 5. StanDarD ) 



A ^^ 



PLACE OF DEATH: — County of (X^^^ v1\a>^'tUlCv.City of ^^ ■a>V vl^a^vCt^ t.c 



No. r^C) 



^L 



I. 



Dist.: bet 



^'lA St.; *-«.., 

ilDENCC GIVE FAC 
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



L:Cn-^-a\cl and 



/ \V DEATH OCCURS AWAY FROM USUAL R E S I DE NC E Gl V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
V, IF nr*TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. • 



A 



FULL NAME 







A 



aCLcL 



r4 






PERSONAL AND STATISTICAL PARTICULARS 
SKX (V^ ^ I COLOR 



Lv JvCtx 



DATK OH lilRTM 



AOK 



:i 



I Month) 1 



Ynit 



Day) 



Montks 



r^ 



s^l r 



I Year) 



Af I .V 



SINr,|,K. MARklKI*. 
WIDnWKn OK DIVOKTHI* 

iWiilf ill ««H.'ial <l«-.i^uati<)ti) 



niRTHFI.XCK 
(Slate or Country^ 



XAMK OI 
FATMF.R 






A 



r ^ 1 



CX'VV^,<X 



RIRTMIM.ACK 


OF- 


1 ATHKR 


(St: 


«tt' or CoiMitrv) 


MAIDKN NAMK 


Ol- 


MOTMKK 


HIK IIIPLACE 


< •! 


MOTHKR 


SI: 


itt or Country' 






^ 

^ 



OJUu\\> 



X 



i 



cccLa^ 



\( J \jLw C*V^ 



OCCITATION 

AV>/i/i^i.' in Siiir /'i tir, i\i-'> 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATII ^ 

Lvs^uq ^- 

(Month) \ Day) 

I Hh:Ri:HV CI;RTIFV, That I atleii.k'.l ileccased from 

vVcvq. L 190 ^ to w 

that I last saw h * aUvc on 'M.|:tfU- A^^AAJ(v 



lA^flL k K^S 



190 
ami that cUath <H:currc<l, on the <latc stated alnn'o, at A 

iX. M. The CAl'SF^ ()!• DMATII was as follows: 

r, 



it 3^(xWv^ 



...i.t^^Lv. JUJLh^A>^^ ..I.ifer:<JiAkfc^ ^ 




vCA^"!; 



I )r RAT ION }'tars Mouths Days 

C ( ) N T R I lU r R V Vl \A. k. %T^ 



J /our 



i,-W:fr\r»J:^.W.-.„ 



MoHt!n 



DTRATION Ytius 

A A 

(Signed) \ : o-e^'Lo.cx 



Pays 



M.D. 



±a. 



rqo 






li 






^ 



Special information onlv for Hospitdls. institutions, Transiriits, 
or Rfcent Residents, and persons dving a*«jy from home. 



]V,M 



!/'»;///;< 



- n,. 



THI-: AHOVK ST\Ti:i) PKRSONAI, I'AK IFtT I.AKS AKl". TKt K 1 « » llll-: 
IIKST Ol MV KNoWM.DCK AM) lU-.I.IKF 



fInfoMn:nit '~)XX-'^>V^. C j 



txX^ 



V\ 



\.l<lrr>i« 






Former or 
Usual Residence 

When Has disease contracted. 
If not at place of death ? 



•lOM lonq at 
Pljce ol Death ? 



Days 



ri.ACH Ol- HIKIAI. OK RIM«>\ \|. j DXIJ.-.f ItiKiAl. f>r KI:MoV.\1. 






rM)i:RTAKi;K 

'A 'I'll' 



• \j^crctc\' V. A^^,vv_ 






.t \ .. 



IS. B. Rvery item of information •houlcl hi cnrefully supplied. AGE should be stated EXACTLY. PHY^ICIA?<i8 should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
sons dyin^ away from home should be i^iven in every instance. 



^ T 
* 


f 






1 


•i. 


f 




^^ j 




1 
1 1 


i 


! ' ^ 




1 1 





; i 



( I 



:l 






II ti 



11 



\ I 






.rr' i ■ I 






."^ 







* .-. ^^ « 



til 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Iloanl ..r Health 1' No. i •; t^-?J^^) I'.S: I' Co 






190\ 
'\jiy^\^'^ :U^wii Deputy Health Oflflcer 



Bogisterorl J\''o. 



m2 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



© 



Certificate of 2)eatb 

( H. S. StanC>arC> ) 
PLACE OF DEATH: — County ofOctW OXCXAV^AXlCi City of ^ CL^v XCV^vaw, 
^No. VwL^WVClI) LA^xiLVaV%v<:4,. Jvi C>-;sit:tvt<X-l-Dist.;bct. -and 

IF DEATH OCCUBS *V^V FROM USUAL R E S I ^E NC E Gl VC FACTS CALLED FOR UNDER "SRCCIAL INFORMATION" N 
IF DEATH OCCURRtlD IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



( 



FULL NAME 



^td^..- i^ \- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ok 



(JfriouU 



UJi^vl^ 



DATl-: ni HIKTII 



M'.V. 



;-\ 



i^ct 



iMiMith) 



(D:«v) 



.■>• 



J /•</ t 



<\ 



\ 1 



Mouths \ i 



(Year) 



Da I . 



MEDICAL CERTIFICATE OF DEATH 



DATK ()»• DKATII | 



(Month) r 



(Day) 



I go 

(Year) 



SINi.I.K, M\KKIKI> 

U n)«>\VHI> UK l»I\oKtHI) 

Wtitrin MM-iiil il( >.iv'iiatioti) 



HIKTHIM.AOH 
'State iir Cotiiitry> 



NAM1-: OI 
»ATm:R 



niRTMI'l, ACK 
<>l" I AIHHK 

iStat« or Cotnitrv) 



M Vnu-V NAMK 
<>l MolIIKR 



lUKTHIM.ACK 

<»l MdTHKK 

< Slatf or Countrv) 



OCCII-ATION y^ 



^-^^AJt 




I IIICKI'inV CI:RTII'V, rimt I atten.lcMl <lctHasc«l from 

_^ — -— 190 to .....igorrr- 

that I last saw h •• ^ alive on - — — - — ■■ ...u.-i.^,.- — 190 

an<l that lUatli occurred, on tlie date stated above, at 
:::::zr:rSl. The CATSl-: Ol- DI-ATII was as follcws: 



UK^-.t-wwc _txM-^.<xvd ' 



UX\.^\vi \-v t . Luvh^i 



1)1 RATH) N Years 

(.'ONTRIIU TORY 



,^ftr-AKV^..O:t. ...:*». i^rv,*: 



Mouths 



/hivs 



DTRATION ^ )'t'afs Months 

( S I G N E D ) A,C*Uy> Vi^ 



/hiys 



I lout s 

/fours 
M.D. 






KjO 



( \<Mress) ^^VCr>viV 






Special information ""'> '«r Hospitals, institutions, Translfnts, 
or Recent Residents, and persons dyinq away from home. 



Rr iilfil III Sini /'iiinii'ti 



)iai 



M.nith^ 



fhix 



rm AuovF. sT\ ii:n rKKs,()NAi, par ihtlaks aki-: rRii-: t<» tuk 

HKST 01 MV ^>()\VI,i: IX.K AM) Hi".i.n:F 



(Infiiunant 



' \.Mi.<s 






A 



■cv^v rv<xv<xL)Cj \.o 



^ i^ ' 



Former or -^ 

tsual ReskJencf 1 ^ . 

When was disease contracted, 
If not at place of death ? 



How long at 
Place of Death ? 



Days 



I'l.ACK Ol" lURIAI, <iK RKMoVAI. 

I) 



I ni>i;rtakhr 

(A«Mt(ss 



|)\il of Ml KiAi. or RHMo\AI, 

1 .. .. 

T9O ' 



'CvVV1 






N. B. Every item of inform«tion •hould be carefully supplied. AGE should .»c stated EXACTLY. PHYSICIA1N8 should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
sons dyinft away from home should be Jl^iven in every instance. 



\ 



J. 




f- 



, 



I 



I:'! 



' \ 



i • ' 



n 



I ••*-•<* '-'■ 



If^M^ 









* i/" 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoard .>f !l. rillh- )■' So !», "C-T^^^ IJSil' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Eeglsfered J\^o. 



843 



/h,/r /7/rv/, Ua^v^<»1 1 190 4 

Xtruv*^ Aji^v^, Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Cevtiffcate of Wcnth 

( "a. S. StanDnrD ) 



PLACE OF DEATH: — County of JOv^-u J AXuo<vC.ULC City of (X>v 3. 



VOw>x^\.«i cc 



('No. U^ cULxrv- '"^ 



CU^A.vXOLV^ 



St.; 



Dist.; bet. 



and 



/ .r DEATH OCCUHS AWAY FROM USUAL R E S I DE NC E G I VC FACTS CALLtO FOR UNOtR "SPtOAL I N FOR M ATIO N • 'N 
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FU LL NAME L<LA^u-.a^'vcL ' r '•.. ^ L.a-::i:.u 



PERSONAL AND STATISTICAL PARTICULARS 
SKX r\ ^ -I I COI.OK "^ 

I».\T1-: OF UIRTM 






Lv^l ^^v_L>-. 



I Mouth* 



A <*.!•: 



k)H )v</i> L 



11 

< Day) 



Mouths 



(Vcar) 



s^Wl fhiis 



SINT.T.K. MARKIKI). 
WlDoWKI) «>K I)IVoKti:n 

|\Vtit» ill MKJiil (hsivrualioii) 



1 f V'Cx>vv^u3c 



Hik rnj'i.Ai'K 

istatf f»r I'miutt y^ 



FA'niKR 



n 



C-^ 






niRTTTPT.ACK 
<)I" J AIIIKR 
(Slatf or Cimntry) 



MAIDHN NAMK 
«)l MOTHKR 



lUR IMIl'UArK 
Ol- MuTHKR 
(Statf or Country^ 



<»CC11'ATIUN' ^ 



V ft . 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



LLvvwO 

(Month) r 



<I)ayt 



(Year) 



I HI'iRl'HV Ci:RTirV, That I atteiKk'd decease*! from 



I9O 



that I last saw h • > ■ aUve on UvAwva i 



up 'a 



ct i 190 

ami that death occurred, nii the date stated above, at 
JwL M. The CAISI-: Ol- DI-ATII was as folh)Ws: 

mh^xx. 



\,L 



K. 



i 

DIRATION )'t^rs ' J/ofi//iS^ '\ Days I/ours 



IL'^xL 






hVs/iff'if I If Sillf /'l 1IH1 l>)'i> 



)\-,f 



yr<>it/f 



ihi 



THK AI{()\ H STAIl'I) PKKSONAI, I' ART lOT LARS ARi: TRIK To TIIK 

iu;sT oi- MY kno\vij:i)<".h and iu:i,ikk 



(Informant (lu X^>wt'-^-^ "^ 



(Address \%'X'h o^^rXoo ULan^o^ L'^ • 



^M^ 



.-i^ 



years*' "^lofiths 



nr RATION 

(SIGNED) 



Pin- 



's 



\^ U^cc-ivu 



I/ours 
M.D. 



^- '' 1 



go 



(Address) W&-Cl-^>-LV ^ '(.d.C^, 



Special information ""'y ^^^ Hospitals, institutions, Trdnsients, 
or Recent Residents, and persons dying anay frorn home. 



How long at 



Former or , 1 ■ . J ^ """ ■"■"«-• ^ , u 

Usual Residence I VLa ^ . ^. ^ "^ -V v O Place of Death ? 1 

When was disease contracted. 

If not at place of death ? 



Days 



I'l.ACK Ol" lURIAI. OR RF:MoVAI, 



DATi; ot Hi KIM. or RFIMOVAJ, 

1 



I ndi;rtaki:r ^H>vaJU.u ^ -OwtVCX.Cv -' 



190 A 



(Add: f^s 



^v^^o.. . -.v^c*.. a.. 



:,, B— Every Item oi? information .hould be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Intormation for per- 
sons dyinft away from home should be ftiven In every instance. 



i ' 



' 1 



I ! 



I 



n 



i 



I* 



M 



♦ •11 






w* 



^ L- 







t v 



«" ,• "A^ 




erf 



- ^**» . - ■ . «^- . 



r. I il 



'■ I 






-=»'^y-^--o" H 




'" - '•'^■•'fff 




^•^■•^-^^•^ 




Hli^ • r z-^^** 


-^ -*• - * - 


^H>' - 


« . ■••'-* 






Btf va -i* -'jr^ 


Ki^^<^ 


^HH" - fl 


HIk ^dl 


^^^^^^■' .'• ^^ 


^^^n <^ i*.'j 


^^Mafl 


PR'-;. .?* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Itoiinl ..f II.nlHi- I' No 11 ^l^ajji^) U& 1' Co 



Ihf/r Filed, 




WO'i 



Registered J^o. 



844 



Xtrvw^ ^ou>u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Ta. S. StanOar^ ) 



ofd 



% 



l) 



31^ 



( P*n. ^C 



PLACE OF DEATH: — County 

rLi^^ Lo-Vv l^tu VLl . . v<L ' ^ St.; Dist.; bet 

V rnoM USUAL RESIDENCE Give facts 



OL >\; 07VCL/AX£.UIC. City of CV<X'>V O .'VCL ', X/O-Cv 



^ and 



(ir DCATH occuiis *w*v rnou USUAL RESIDENCE ciwt r*cTS callco for unocr "sr>eciAL information- "\ 
IF OCATH OCdURRCD IN A HOtPITAL OR INSTITUTION GIVt ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 






SKX 



PERSONAL AND STATISTICAL PARTICULARS 

^ /^ A I COI.OK ^ 



t 



U' I LCCU 



Ll'.kuU. 



I).\TK OF lUKTII 



MEDICAL CERTIFICATE OF DEATH 



DATK or DK.XTM 



LLwNwCL 
(Month) r 



(Day) 



IQO 

(Yt-ar) 



AOR 



(Mbnt)i) 



kj U iv«>.* 



'I>av> 



Mnniha 



(Ytar) 



n, '^ 



An 



SINi-.I.K, MAKUIKI) 
WinoWKD OK HIVoKiKH 
(Wiitrin s<K-i;»l (!«-ivn;itii)n) 



0) 



HIKTHPI.ACK 
(Statf or Country^ 



N'AM»: «>j- 

HATni:k 



lURTHPI.ACK 
OF" lATMKK 
(State or Country) 



MAIDKN N'AMK 
HI MOTMKK 



HIRTHlM.ArK 
HI- MOTHKR 

(Stiiti.' .)r Country) 



OCCri'ATION 



L 




UO.C 




\oj\j-\.\jl6^ 






CCO^r*.' V^<:L^irXX.^ 



^ 



I Hf:Ki:nV CIIRTII'V, That I atten.ltMl deccasctl from 

U^ • to V^VWaL.....n. 190 1 

an<l that death occiirreil, on thi- dati- stated ahovo, at '• '^ 



to L^UvCL-.n. 
that I last saw h alive on L^-CvC^^ i 190 



v' M. The CAISI-: Ol" DI'.XTII was as follows: 



CK.\jt C*CV>^d 



i>, 






DIR.ATIOX )'rins 

CONTRIHrTORV 



Mouths 



Days 



Hour. 



or RATION Yinrs Mouths 

(SIGNED) lL '^^ . l.^•^^X. :^ 



Days 



Hours 
M.D. 



r<)0 



( Ad.lress) 



A^^UCC ^ 



Rf^^idtui ill S<!>/ / I tiiii i.'-i'o 



\^ - 



)"/ (? ' ■ 



M. ,:fl< 



n.n 



THK AnoVK ST\Tl"n PFR-iONAI, TAKTICr I. \K•^ AKH TRl K T« » THK 
HHST OF MY KN0\VIJ:I)<".K AND HKI.IKK 

^ }, il 4 P * ^ ■ 

< Informant .VO^-W'K VV ' ' C A.^ 



(\.l.!!.-^ 



SPECIAL INFORMATION onlv for Hospitals, Insniutions, Tr«iislf«ts, 
or Recent Residents, and persons dyinq i^nA) from liome. 



Former or \ 

Usual Residence ~ - - -^ 

Wlien *vas disease contracted, 
If not at place of deatti ? 



Hov« lonq at 
Place of Death ? 



Days 



I'l.ACK <»l- m RIAL OK Kl.MoXAI, I ItAri;<»! HiKlAl, or RKMOV.AU 



^ 



'VS. 



I NDr.RTAKKK 



V*-^V 



^ 



I90H 



\-C^ivi 



^ 



(.\tl<ln**^ 



N. B.- 



-Every Item of inforniHtion shouhi be carefully Kupplied. AGB should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information'* for psr- 
sons dyin^ awoy from home should be fciven in every instance. 



H 

i 



•ii 




^< 



-\ 



- . ^••* ■., 



' 



-I 



(: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Uo.-inl ..f Hctlth- »•• No. M, tti^^a^^]\8iVCo 



Dale A'/7^^/, iL-.m. 



1 



190 1 



Registered .A^o. 



845 



Deputy Healttt Officer 

DEPARTMENT # PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( xa. S. StanDar^ ) 
PLACE OF DEATH: — County of JO^rvvlA^OLAvCi^Ct City of C'/CXw •JXa/WCcO-Ci. 

("4% r ^ Hi 1 

^du K Vw(H.c^vtu Vvl^w^Kv.'.^.- St.; Dist;bct. and ■' — ) 

A /if Ot»TM OCCUMS *W»Y FKOM USUAL R E S I DE NC E Gl VC facts CikLLED FOR UNDER "SPtCIAL INFORMATION • \ 
\) V IF DEATH OCtjuRRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME ^-iDX:>-u.a.'^^vc^\j VCVv^-»r 



1 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR \ A 

10. 



^cL 



fV^ 



u 



DATK Ol" IMK Til 



a^ 



I Month) 



% 



I5> 

(Day) 



/ 



AGK 



) til i 



M„»lhs 



UVar) 



Pay. 



SINT.I.H. MARKIKI> 
WinnWKI) nK OIVoKiKO 



AinnWKI) nK OIVOKiKO \ 
Writf in siR'ial «ltsi^'natJcin) | . 

LUxdLcrvv 

\ r i 



SJ^J^J 



lUKTHTM.AOK 
st.itf >iT Country) 



NAMK 01 
KATHHR 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I)1;ATH '» 



(Month) ([ 



4 



a>ay) 



(Yfarl 



I(>0 T 
190 



I m{Ki:nV C1:RTII'V, That r attcmUMl ^leceascMl from 

>^\.UU.^ A3 190 •. to vLvA^C^ 

tliat I last saw h ~ alive on C^-\^v,0 

ami that <Uath oroiirrcil, on the <late state«l above, at X-\ --^ 

w'. M. The CATSh; Ol' DliATIl was as follows: 



\ 



iv. 



HIRTIII'I.ArK 
0|- lATMKR 

(Statf or Coiititrv) 



MAIDKN NAMK 
<M MOTHKK 



HIKTUFM.At'K 
Ol- MOTHKK 

< Statf or Cotintrv) 



OCCri'ATI(3N 










Ur RAT ION Yeats 

CONTRimTOkV 



Mouths I b l^ays Hours 






^ 'ra I 



Af.<,if/i> 



I hi 1 > 



THK AHOVE STATKI) I'ER^^ONAK rAKTHMI. \ K'^ AKI! TRIK TO TMH 
BEST Ol- MY KNOWl.KDCK AM) HKI.IICK 



'^ 



\.Mress L\JLmX^ VVt '- V' 



Dr RAT ION )'rijrs 

(SIGNED) LO V 



I()0 



}fouths Days 



Hours 

M.D. 



. V 



Special information «>nlv for Hospitals, institutions. Transients, 
or Recent Residents, and persons dying a^ay iron home. 



Former or 
Usual Residence 

When Has disease contracted. 
If not at place of death ? 



HoH lonq at 
Place of Death ? 



0«ys 



I'UACE OF nrRlAI. OK Kl-.MOVAI. 

5 



-u 



J 



DATlvoJ Hi kiAi nr REMOVAL 

'O^ 190 



VVn«v< 



^i.^ 



INDHRTAKER 




q.. 



H 



•J ' 



N. B.- 



-Bvery item o* information should be cnrefully Hupplied. AGE should b« stated KXACTLY. . PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it miiy he properly ciassiiried. The "Special Information" for psp- 
sons dyin^ away from home fthould he ftiven in every instance. 



* 



4r 



rii 



->• -:;; 



^05, 






^-^ - .■ ■ 



i^i. 



W 



_^ ■* '^•^-•^ ' l~r. 






:;'t*x 




' 



.'■. I 



h 



> I 



h 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.inl ..f n.Mltb I- No 1^ ^'^J^^, lu«vl'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



iXilr Fileil, CUvq,vv^l 1 VJO'i 

A_«-\^v^ * Deputy Health Officer 



BegLffcj'fd JVo. 



846 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)catb 

( 'd. S. Stan^arC» ) 



r^ 



PLACE OF DEATH: — County of Oa v ' X^CLo v caA cx City of^ '/CL/>V 



,T 



i 



^ 






Xe^A/C/C 



[' 



Wo. 1^L).H dlcvw^.!.-. St.; ^ Dist.; bet. ''^'''^AA'\va'>X'>v and 1 

(If OtHTM OCCUNS AWaV FROM USUAL RESIDENCE give facts CALLCD FOU UNOCH "special INFORMATION" "N 
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME Vf Tl<X^.u \^Lv.:,CL.l>i.t.iv v^v ' 



stJ. -S 



SKX (jp 



PERSONAL AND STATISTICAL PARTICULARS 

COl.ok 



|1 



DATi: Ml- lilKTM 



lo. 



ivc 



,u 



^' 



< Month > 



ACF. 






) .,,, 



'X 



(Day) 



Months 



7 



(Voai) 



A/ r. 



1 



\ 



MEDICAL CERTIFICATE OF DEATH 



DATE OP I) HATH 



,1 



(Month) \ 



(Day) 



(Yi-ar) 



I iri'iKI-IlV CI-RTII-V. That I attcmU-.l dcroascMl from 



'^INc.I.K. MARKIKD. 
\VI|M»V\ KD OK niVoKiKD 
(Wjitiiii s<H-i;il (h vi>.»iiation) 



mKTHlM.AOK 
(Statf or Oonntrv) 



NAMK n|- 
FATHllK 



niRTMPI.AiK 
n?" lAIUKK 
(State or Country) 



<»1 MOTIIKR 



HlKTmM.ArK 

OF MOTHKK 

' Statt or Country) 



o^ crj'A riON 




i C,0 



190.'^. to \Xa.a>Ol ^ 190 S 

alive on HA^v^ "ia-»L 1 5 i^o • 



..AOL-YV 1.5 
tliat I last saw h • 
iWjA that «lcath cxrcurred. on the date stato«l ahove, at « \ 



li 



^I. The CArSI<: 04;' DKATII wa*^ as 



foil 



OWS 



iJvlk 



\-^V{> 



J'VwC>%vi ; 



nr RATION Villi s X M out ha Pay 



Hon 



/ A 



CONTRIIU'TORV 



1) 



\.C«.\.-Dc- 



i > .'. v. 



or RATION ..^ Yiats Mouths ^ I\i\s 

(Signed ) v ^ v<^a.m 



Hours 



Lvt'. .(^ L 



ic)0 



( 



M.D. 



Special information «nl> 'or Hospit.jlv. institutions Translfnts, 
or Retrnt Residents, and persons dying a\*dy from home. 



■. - ^- V^C^^ OU ' 



Kfsidfii III Scill /'l illh !'i,> 



^',■nl 



n 



yr,,„th- 



/!,M 



Tin-; AHOVK ST\ IFD I'KRSoNAI. I' \RTIcr I,^RS AK K TRIK Ti > THK 
HHST Ol- MY K XjJ \VU HI )(;K AND m;Mi:i- 



(Itifotninnt 



• \i1illcvs 



^ L Kx^J^^<x 



Former or 
Usual Residence 

When Has disease contrar fed, 
If not at plare of death ? 



HoH lonq at 
Plaieol Death? 



Days 



I»\ri. ..' IUkiai. 01 RHMt>VAI, 



a 



I'l.ACH 01 m RIAL <>K ki:m<>\\i. 
ini)i:rt\khr I vJ V V.^VL >V^' 



T90 ^ 



(A(l<li isv 



N. tJ.- 



-F. 

St 



-.very Item of information should be carefully supplied. ACJB should be stated EXACTLY. PHYSICIANS should 
tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 



Rons dyin^ away from home should be It'^en in every instance. 



I 
0. 



t:l 



1', 
Hll 



ill 



L-*:r..nlV 
















:> -y^; 






I\ 



i' 



I 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I'.uMi.l ..f n»-.'ilth -I- S<,. IK '^-S^Jfc H&I' Ci, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)((/r Filed y sXvvaA.A^ ^ 



100 "i 



liegLstci'cd J\'*o. 



847 



^^cwo 



, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( H. S. StanOarO ) 






No 



PLACE OF DEATH; — County of Vai\ 'XCL^vCUCi. City of "^avu X'V<X^-v c^i C-C 



ivvt 



L ^V-^tLOvtu JVChlUvlOLl St.; -— Dist.;bct. and 

1 / ir ocATH occurs AWAv rnK>M USUAL RESI DENCC Give facts called roR under "special information" N 

J V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



\ 



1X0-l\JUi... ^^ 







4- 




SKX 



DAri-. ul IUKTII 



A<'.K 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR > 



a 



U, 



^\. 



Uik.tc 



M..iith> S, 






(Dav) 



Mnlllhy 



>C 1 
fVear) 



Pa 1 



*^IN<.I.K. MAKKIKI). 
\VirM)\yKI> OK DIVnmKD 
Write in >.<Hial ih situation) 



niRTHPl.ACK 

'Statf or Oountrv' 



VAMK OV 

FATIIKR 



niRTHlM.ACK 
<>l" lATIIKR 
'State or CiMJiitrv* 



maii)}:n namk 
of mothkr 



niKTIIPI.AOK 
Of" MoTHKR 
{State or Cotnitrv) 







n 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATH i 



(Month) i 



(Day) 



I go 

(Year) 



I IIi:Ri:nV C1:RTIFV, That I attcndtMl .IcccascMl from 
V 190 '^ to vL\.vcu V 190 S 

that I last saw h >-' ahvc on *wVWCLia. ......... 190 

ami that death occiirreil, oti the tlatt.' stati**! ahove, at 1 C oO 
., M. The C.U SIC Ol- I>I:aTII was as folh.ws: 



■)• 



J 



4)^\ciL' 



k 



DIRATION Vtuits 
CONTRnUTORY 



Mouths 



Pay 



Hours 



DIRATION* f^f^Vears ^ Mouths 

• \ ■ 



/^avs 



. \ 



VcLoLAvdw 



OCCri'ATlON ^^ 



'CV "v V V i 



AvtjL 



,^t- 



h'f^iiifi! Ill Sini /";<;//, ,'.>//i 



) III 1 > 



.\fnnlhs 






(Signed ) 

TalTnfor 

or Recent Residents, and persons dying away from home. 



Ifoitr'i 
M.D. 






SPEC 

r Rece 

Former 



M ATI ON only lor Hospitals, Institutions, Transients, 



/'./I 



Usual ResidenceUJt\^^< ^C 

When was disease contracted, 
^ If not at place of death ? 



> V 



HoH lonq at , 

f^are of Death ? 



Days 



TMi: AHOVl-: S|\ III) I'HRSONXI, PAK T KM" I.AKS .\ K 1 . \'V.\ V. 1' • 1111. 
HKST Ol MV KNO\V1.i:d«.H AND F{HI.II:F 



( Informant 



^S 



X^VCl. 



,LsxT:<i 







Aildrtss VA*.V,L 






i'i.acf:of mRi.Ai. ok kkm<>\ \i, j i)\ri; -r m kiai mt ki;m(>vai. 

JLc-U- VXc--r^ I ^^^vo I ICO 



m»i;ktaki:k ^L>A-CU-C^ cL .v ."LcsCvci. 



N. B. Every item of information should be carefully Kupplietl. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for per- 
sons dyin( away from home nhould be ^iven in every instance. 



f 






-li 



I 



\' 



1/ 



"11 




V* 



^l« 



I -v. 






>v^ 



*y?" .f 




^«.:- 







I 



t 










III 



til 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H...ir<l..f ii.alth IN'o i^ ^-^^^ H&l' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n 



Date I'^ilcil ,\X/,.\j:\\,^u^ % 



Registered JSTo, 



848 



mj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

1 "KX. S. StanDarO ) 



^ 



PLACE OF DEATH: — County of^'a-^^ ' Xa>xCc^acCity of ^'CtVu Vcovoc^ :< 
fNo. 10 ^^XW>V(r>\b l(o.. ..• cL : .St.: ^ Dist.;bct. Vn\U.O/Nd and ■:'^\a>vrir> • ) 

(\r DtATH OCCURS AWAV FROM USUAL R E S I D E NC E CI V t FACTS CALLCO FOR Uf|oER "SRCCIAt INFORMATION" N 
IF OCATH OCCURRED IN A HOSP^rhAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME U 






PERSONAL AND STATISTICAL PARTICULARS 

COI.OR > j 

OATK OF lURTII ^ i\ 






(Month) 



15 

(Day) 



a<;k 



L^ >v.„ 

*^IN<".I,K MARKIKIV 
\VII)«»\\ KH OK IUXOR^ HI) 
(Writf in viK-ial fUsiK":«tion) 



I y/<nttfis 



II 



(Year) 



Davs 



MEDICAL CERTIFICATE OF DEATH 



(Year) 



FURTUPI.AOK 
I State <)r Oomitrv' 



NAMK OI 

katui;r 



HlRTMI'l.AiH 
OI" I ATUKR 
'Statf or t'omitrv 



maii)i:n NAMi; 

OI- MOTHKR 



1UKT!11M,A0K 
oi MoTHKR 
(Slatf or Couiitrv) 



4 f 

\U4 . ,^J[^ ^lio-t^li. 



DATE OF nKATH , 

(Month) I (Day) 

I m<:Ri:nV CI:RTIFV. riiat I atten.UMl dcccastMl from 

IV^O.*-' ' 1901 to ^.LuvOl k IgoH 

tliat I last saw h tiu^' alive on L-Li-vXI^^ I iip 

and that <U'ath «)COurre(l, on tlic datt- stated abovf, at L 
..;^.. M. The CAI'SF-: OI- Di: ATlf was as follows: 



<xXj 










DrRATION }'ears 

CONTRIlirTORV 






/hn 



//()//;. V 



Dl'RATION 



y'euts 



.t/i>f///lS 



Days 



(SIG 






OCCIPATION 



L 



Il\-C 



NED) V * ' *^ '^>v.CH' 



//on PS 

M.D. 



% 



190 



f 



A.l.lrcs<) ll!^ ^ ^^ 



»i -^ 



SPECIAL INFORMATION only tor Hospitals, Insfitytlons. Translfnls, 
or Recent Residents, and persons dyiny dHdv frooi home. 



M,'t,th^ 



/\n- 



Tin: AHOVK ST \ li:i) I'KRSONAI, I' \KTI(II. \kS ARK TRTK To 111)-: 
HKST OF MV KNo\Vl.j;i)(.K AND HKI.Il'F 



\.<J 



[Informant Lv ^-^'V W,^*\>jC C^ ^V C-^ % 






-v. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at place of death ? 



HoH lonq at 
Place of Death ? 



Days 



I'l.AtZK OF FURIAI. OR RKMoVAl 



^^' 



) 



V<. 



V 



rSDHRTAKKR 

(Ad 



l>\Ii; )! IJ( Ki.Al. or RIvMOXAI. 



N. B. F.very item of information •houhi h.> cnrefully Hupplied. AGE should be stated BX4CTLY. PHY8ICIAM8 fihould 

state CAUSE OF DEATH in plain terms, that it m:iy be properly classified. The "Special Information** for per- 
sons dying away from home should be given in o\cry instance. 



:w 






I n' 



■; 



• I 



I 



I 



i« 



lii 

I 



i 






IV s^ii^' 



l<^ 



: *^l 



▼•'« 



.-^'k^- 







.4 > . 









'^^- 






■^-^^ 






< 1^ 

i ( III 

I! ' i 



II;,: 



# 



IN 



l ? 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Itnnr.l .-f II. ilth I" v.). i^ ■»*f]'»^: 15^:1' i* 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/e /v7r^/, LL^ 



A^A^Ct \^sj^ 




-vl 



.i 1 



^V^^^> 



IfJO'i 



Beglstered JVo, 



849 



.e-v^u Der-jty 

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 

Cevtificate of 2)catb 

( "a. S. Stan^arC» ) 
PLACE OF DEATH: — County of'"\(X^'JAa^ve\.<^ City of''^^<X^^^ \VCX>ve^<i. 



U»»S 4W*V TROM USUAL RESIDENCE GIVE facts CACLCD ron UNOCH «^CCI»L INrO«M*TION ■ \ 
H * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



1 



AxLlX-^ St.; 



Dist.; bet. 



and 



(IF DE 
If 



ATM OCCI 

DEATH OCCURRED II 



\T\ 



FULL NAME 



.rv\.a. 



1 



A.L 



:\ : 




si;x 



i>.\ri-; 1)1 iiiK rii 



ACK 



PERSONAL AND STATISTICAL PARTICULARS 

COI, 



oXx. 






xaJLc 



• M.inthi 



b^ }Vii».« 



(Day) 



M.ntlhs 



( Vtarl 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



(Month) \ 



(Day) 



/po '\ 
(Year) 



Dtl V! 



siNT.i.K. MAKKn:n 

WIDnWKI) OK DIVMKrKn 
(Wiiti- ill s<Kial iU»ii.Miatioii) 



^ 



niRTHPUACK 
(Statf or Country 1 



N'AMK O!' 
FA Tin: R 






< t H 



'^1 



mRTHPT.ACK 
OI- FATHKK 
(State or Cojintry) 



MAIDFN NAMK 
«)!• MOTIIKK 



HIRTIM'I.ACH 
oi- MOTIIKR 
(Statf or Couiitry> 



(1 ■ ^ 



^ 



I in:Ri:nV CI:RTIFV, That I atU'n<U'«l (kicasca from 



to \-Luv 



>V\.. . \^. v. IgO : to VNA-V-CL . 

that I last saw li ' - alive on Uwvv^ H 

ami that tloath occiirre«l, on the «la(i- stated above, at 
M. The CAI'SIC OF DI. ATII was as follows 



Up i 

190 - 

t "J, ■ 



JX,*^ C^^A x/CU 



•t 



or RAT ION Vrars 

CONTRIIU'TORV 



Months 



Pays 



J /ours 



oeClFATlON 



h'fUiifii in San /'i iHh !.-<•'> \::s )>ii. 



M,n,th' 



1 'r. 



\'\\V. AHOVF ST \ ri-D I'KKSONAl, I'AKlirri. \K< AKl" TKrK T< > TMK 
IJKST OF MY KNt»\VM:i)<;F: AM> HI. 1. 1) I" 



(III forma Jit 



^S. j-^vo ^ ^ , CcOLo 



-4. 



V 



' .V--Ci. 



t ^. ■. 



Dl'RATION 
(SIGNED) 






tais J/0U//1S 

1 ' \ ^ > ■ ^ 






(A.Mress) 



\,CLt\^ ' ■- 



/\ivs 



\.-t 



Hours 
M.D. 



Special information only for Hoispitdls, Institutions, Translfnts, 
or Recent Residents, and persons dying a^dv from fiome. 

Former or ^ Hon lonq at ^ , . 

Usual Residence w L L V.^s. ) t .. . v . • piare of Death? ^ Days 

Wl»en was disease contracted. 
If not at place of deatti ? 



I'l.ACK 01 lUKIAI.OK KI:Mm\\I, 

'4 '^ 



I)ATi:..f Hi KiAi. or KFMoVAI. 



a 



190 1 



INDFRTAKFK 



\^CLC4 



^ 



f'Ad-l- 



!4 11 



N. B. Every item of Information should be carefully Huppliecl. AGE «houltI be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special InVormation" for per- 
sons dyin^ away from home Hhould be ftiven in «very instance. 



;i 



i 



„ < J . 






7ir. 



'♦--% 










A4-V1 



-^^^^ 



I 



1^ \ 



in 




it 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Il„Mi.l..riI.^.lil, I- No ;---fcR^ti.llS;l'0,) WEFER TO BACK OF CERTIFICATE POR INSTRUCTIONS 






Beglstci'od JS^o, 



850 



I)((h> AV/^v/, U,,>,^v>^ 1 10O'\ 

Xtrwv^ doi/v-u Deputy Health Officer 

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 

Certificate of 2)eatb 

PLACE OF DEATH: — County ofCj.CLVu-J-Va^ vCtiC^ City of CVccvu O.Va.-vvt.i^cc 



''No 



.151 




xXA-q, 



I t 



St 



.: M Dist^jbct. J-^ 



t\ ^v 



and 



"4<^.t 



i 



f \W DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \ 
V, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I CO I, OR 



« 



vX^^v 

DATK OF lUkTM 



oXx 



\}dU 



lltotith) 



(Day) 



( Vejir) 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DHATH 




(Month) 



c^. 



J 



(Day) 



IQO 

(Year) 



M.V. 



bO y.in> s. 



Mnulfis I 



^% 



Pa \s 



STNC.I.K. MARKIKI). 
WlDnWKD OK niV«»K(*KI) \ 

iWritf in MH-ial (U-iiv'Jiatioii) 



HIKTIIPI.AOK 
(State «>r Country) 



NAMK OF 

fathi:r 



RIRTHI'I.ACK 
OJ- I ATIIFtK 
'State or Country) 



MAIHKN NAMK 
Ol MOTMKK 



HI KTH FLACK 
OF MOTHKR 
(State i)r Country^ 




\ 



F t A 

I A 

m f 



I HIIRI'HV CI'RTirY, That I attemlcl «lectastMl from 

\\. .'.'... I90S t<. iX^^^.q , uyo\ 

tliat I last saw h - ahvo on w\-UwCV * I90 

ami that (Uath <>ccurre<l, «»ii the «latc state*! alnn-e. at 
M. The CAl'SH OF I)I':ATII was as follows: 



I >r RATION - 
C()NTRnUT(>R\ 



)'t'ars Months 



Days 



//ours 



r\.XAXU-- 



^X 



^ 



'^ 



OCCIFA TION 

f\'r- !i/c-:f 11! Silt' /'linh.'M'l 



L^v^a'-O^wd^ 






)V.M 



'>/.,i,.'/t' 



/i,n 



TMl*. AHOVF: STATl-.I) !'KK«^ONAI. I'A K lltT I. \ KS A K !•: TKrK T< > TIIK 
HFIST OF MY KNOWIJ.IX'.K AM) Hl-.I.IICF 



(Informnut Vl iVv^ L) • W . J^^- ' 



^ 



.A,i,u,>s 15""^ (^b-a^aKt "H 



jP ■ 



1 



DIRATION '^ Vtars Mouths 

(SIGNED ) Lct>va 



/^ays 

V I \.J. .iv- 



//ours 

M.D. 



Special information only for Hospitals, institutfons, Transifiits, 
or Recent Residents, and persons dying anay from home. 



Former or 
Usual Residence 

When Has disease contracted. 
If not at place of death ? 



HoM lonq at 
Place of Death ? 



Days 



ri.XCK 01 RFKIAI. OR KJlMoVAI, 



^Vv A A v<x W'v'.., 



iixiFo; i»i KiAi. or rf:moyai. 



V 



190 



INDKRTAKKK ^^* 






(AtMv.-<>. 



' \ i,v<i. 



IS. B.— Every item of information .houlcl be c«ret'ully supplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special ln»ormation for per- 
sons dyinft away from home should be ftiven in ^vevy instance. 



t 

' 1 





^^m^p*^ 


<^^-^^z^\^.-^- ^- 


i : 


mlOL-^^>^irr^ - 


■-:. ^ 


^^^^^^ -> 




'-^.MiKV 






^MVU. 



»- *. 



^^- 



•* ^.v^x: 



^ '■•'■ 






%y^- ^^ 



n r 






M 



..li 














WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no.r.l of iKr.ltl. J No !^ ^?^aS^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



190 "{ 



Beglsfej'cd A^o, 



851 



I)(tf(' FlJrd , LLvuXA^Aw^ ^ 

dUchVcv^ A^tAvu Deputy Health OfHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( XX. S. StanDarD ) 

^-."f ..,., A 



^ 



PLACE OF DEATH; — County of a^v J XO^^vdUr City of '<X>v ^.Xa 



L \ 




No. l.'^l K..h\X,^-sJU^Ja St.; \t Dist.;bct. V^'^X>>vva and M lki\' 

(ir ocATH OCCURS *W*v rnoM USUAL RESIDENCE give facts called for under "special information" "X , 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



A 



FULL NAME N-O-uu^Xx > x^c 




,VA,;'CI. *..A».*, 



SKX 



DATK «H in K 11 1 



PERSONAL AND STATISTICAL PARTICULARS 

I Cf)I.t»R N 







AHK 



1 



(Month) \ 



\ 'tUI t > 



(Day) 



.!/.»»////* 






?- 



I go 

(Year) 



ir) 



I'i 



. A/r.v 



SIN<*.|.K. NfARKIKI). 

\vn>n\vi:i> OK i>rv(»KtKi> 

(Writfin kikjuI <U*>i>fiiation) «^ 



niKTIflM.AOH 
( Slate or 



i.Arh; 1 

Country) M 

H 






\A>fK OI 
I". 






>\ 




it 




i^ 



BIRTHPT.ACE 
OK lATIIKR 

*St.'«t«- or Coniitrv) 



\ 



MAIDKV NAMK 
OJ- MOTHKR 



HIK'ruri.ACK 
Ol" MOTHKR 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATM \ 

(Month) I I Day) 

I m<;KI':HV CI:RTIFV, That I atU-iKUNl deooasca fnmi 

\«Lv^,Q.W 190'; to ^.VVVCL Jl icjoH 

that I last saw h • ahve on V^-S^v-Cy I- 190 

am! that <lcath occurred, on the «hitc »<tatcil above, at l 
M. The CArSr: Ol" DI'ATH was as follows: 



Dr RAT ION 






>!• MOTHKR I fv t :\ 

Statt or Country) Hi 1 P t '- 



^)dv^^ ' 



iHCl TATION 



) V (/; 



M.nitU^ 



/»,f. 



THK AHOVK STATKD I'KKSONAl. I' ARTH* f 1. ARS ARK IRIH T< > THK 
BKST OF MV KNOWIJJXVH AND ni:iji:i" 



(Informant 



-\ 



-s^^CrX>«^ ^o^ 



X. 



U.l<lr<"is 



a'^ I 






Monlha o Days 

w^VnIA^LaX-UL )vVN.A.A>.Co Li ^1. 

nr RATION Years Months W Days 

(SIGNED) v..UJctVdw Lc 



Hours 



VvLV 



i 



IqO 






Hours 

M.D. 

U 



Special information »nly '«r Hospitals. InstiluHoiis. Translfiils, 
or Recent Residents, dnd persons dying dway from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



HoM lonq at 
Place of Death? 



Di)s 



I'l.ACK OI HIRIAI, ok KKM'tX \I, | liXli: .! IJihiai ..r RKMoVAI, 



<bU t.tvv^ 



^ 



190 



r.VDKR'lAKKR 



.0 M ^ 



'-CV- ^N-KjtA- ^V 



( A«MirHs 



,LL 



' A - 



» vv < ■ ™ V. 



N. B. Every Item of Information should be cnrefully Rupplied. AGE should be stated BX4CTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain termn. that it may be properly classified. The "Sijecial Information** for psr- 
sons dyin^ away from homo should be ftiven in 9\^Ty instance. 



Is 






H 



;'rt 



I'M 



\\\ 



< 




t 

# 


9 

i 




1 .1 






r^v 



J\ 




» i^ 



- . i ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

It.n.lof IkMltli J No i< TJ-g^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



290 "i 



])(ife Vilody \Xk.^o^^^J^ \ 

Xc^v^^ "-LtaM.; Deputy Health OfHcer 



Bcgistcrecl J\''o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^ 



No. 



Certificate of Beatb 

{ "CI. S. Stan^ar^ ) 
PLACE OF DEATH: — County of ^ CL^^' J VO.'^vCU.CiCity of ^ Ct^v tVo./>vac4^ c^ 
OCH- '^C.L'U vlv^A "^C. St.; A, Dist.;bct* -^.^.r^^ and .^^^ ) 

(ir DtATH occuns «w»v rnoM USUAL RESIDENCE Give r*CT8 callcd roR undeh "special iNroRMATioN- "\ 
ir DC*TM OCCUKRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. / 

FULL NAME Vt -L<X^i^x^L 



^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I coi.oR ^ 

DATK OF i;iR ill , ^ 

l^ct o 

<Momh> (Day) 



QUcuL 



/.11! 

<Vear) 



a<;k 



Id !X JVa#.t 



10 



,> 5 



.!/.»«///> .\J. A/i> 



SINi-.I.K. MARKIKI) 
WIDOWKD OR I)IVnRrKI> 
(Wiitf in social <ltsJv:":itioti) 



)l 



O^'WvX cL 



IMRTMPI.AOK 
(Statf or Country) 



NAMK OK 
FATHKR 



HIRTin LACK 
OF FATIIKR 
'State or Country) 



MAinF:N namf: 

OF MOTHKR 



HIRTmM.ACF; 
OF MOTHKR 
(State or Country) 



n /c o^LocAx.-d. 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

1. 



(Month 



a 



(Day) 



IQO 
(Wart 



I IIUI 



I IIHUHRV CI'RTII-V, That T atU'n«le«meriase«l from 

\ 190H to \wL\-vrL 1. igo4 

that I last saw h '^ ' alive on W^-VA^qL 5 190 ; 

and that death occurred, on the date stated a1>ove, at ^ ^ 
^Lm. The CAISI' OF DI-A'PII wa^; as foll.ms: 



0>x dLfr tL cv^w cLct.\^ 




X^^\} 



AXX/rrJj-u. 



^/C^ijLo 



A 






I) r RAT I ON Yrars 

CONTRim'ToRV 



Moutha 



Davs 



Hours 



DIRATION 



(SIGNED) 



Yearn 



Mouths 



Davs 



\^-<uJf^ 



Hours 



M.D. 



! 






r-L 



/C.<rV'^a. 



nCCri'ATK^N 



!V 



O-A 



^ r 



Resiiifd in Siiii /'i tiii< /. > " 



fr 



) V.M 



\r.>iitfi^ 



/)./! 



THK AROVF: STAT1-.I> I'KRSONAI. I'ARTIiC I.ARS ARK TRl F! To THF 
DEST OF MY KN0\VI,KD«;K AND BKMKF 

(Infoiniant V<XX^ ' ^JL^-A./^ V.'*^ ^V ' "N*<X 



(Address I C)C)H- ^0 



\J^ vVvM. 






SPECIAL INFORMATION only ior Hospitals, Instityllots, Transifiils, 
or Retrnt RrsMrnts, and prrsens dving away froin bomr. 



f ornif r or 
Usual Residence 

When was disease contracted, 
If not at place of deatli ? 



How lonq at 
Place of Death ? 



Days 



PUACK OF BIRIAI. OR RKM«>V \I, 




INDltRTAKKR 

(AtUlrcHH 



^ 



IiATI of liiKiAl, or RF:M0VAI, 

^'^^^c^ ' 190 






IN. B. Every Item o? information should bs carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information" for psr- 
aons dyinft away from home should be given in m\9rv instance. 



\ 



« 
# 






I • I 









% 



i 

{ 



'-^*i'.- 

'•^: 






.t: 



■I ! 



% 



» 



! ;' 



i 



it 



??ii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ho.-tnl of HtMini- !■ N'o (^ ^'C^f:^ '*^ '' ^'> 



Dafe Filed, L 




1 1 190'\ 

Der^utv Health Of^eer 



Begistered J\^o, 



853 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certiftcate of S)catb 

( TH. S. StanOarD ) 



PLACE OF DEATH: — County ofC<XAA) /ux^AyC^-*.^:^ City of 0/Qv>v Vcuvvt-^.^*^ 



1 



^No. U,dJuLhj d 



iCU:vXAXou^ wV. L .-^ St.; Dist.; bet 



and 



(ir OtATM OCCURS *W*V FROM USUAL R E S I DE NCC GIVE FACTS CALLCD rof* UNOCR "SFtCI»t IMFORMATIOW "\ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



M. iLoaUxo! \MjlKL' 






PERSONAL AND STATISTICAL PARTICULARS 



.KX 0^ 



JX'^v^' 



-^UXAX 



COl.OR 



DATK <>l IMRTH 



A(.K 



0,^ 



\})L: 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH 



(Month) 



,H 



ll>ay) (Year) 



Month) 



< Day) 



( Vt-ai 






O 



M.'tit/is 



^ r^. 



/)</! 



SIN<".I.H. MARK IKU. 
WIDOWKD OK DIVORTKI) 

• Wtitf ill mn'ial f)f«iiv:nation) 



lURTHPI.ACK 
(Slate or Country) 



A 



[la' 



NAMi: Ol" 

J" AT hi; R 



RIRTMIM.ACK 
OF l-ATHKR 

'State or Country^ 



MAIDKN NAMK 
<>I- MOTIIHR 



niRTIIIM.ACK 
OF MOTHKR 

(State or Country) 



oeCli'ATION 



n 



u1 



I in:Ri:nV CIIRTIFY, That I attcn.UMl (UHtast-a frniii 



LLv^.QL..b. 



VVV-^„CU L 



Xifi 



\V\„Lu :- V I90 : to 

tliMt I last ^a\v h v- alive on V^V-a^cX-- ^ I9O 

atul that tlcatli occurred, on the date »«tate«l ahovt-. at '^"^v^X 
M. The CAI'SFv (H- DI'ATII v/as as follows: 



•^^-..t^s.M 



-A. «- ; 



vJUW.t \ 



^ m 1 



J J V. 



^u-^' 






'^V^OU 



DT RATION '^ Yiars i Mouths 
CONTRIUrTORV 



Days 



Hours 



DTRATION 
(SIGNED) 

L 



Years 



^ 



Montfi.y 



/)avs 



a 



W ^Vl 



^ • V'*^ 



t 



Rf^iif^i! ill SiUi /'i ,1 Hi i^r.t - V.' )<i7;' 



M.„f'li^ 



hn 



rilF, AHOVK STA T»:n PHKsONAI. rARTHCl. \K- AK). IRl K T< » Till-: 
HKST OF MY KNO\\ I.KDC.K AM) iu:i.n> 

(Infoinianl Aj JkJ^K) oLV''^ wCLlV. 






lf)0 ■ 



llfrv^-\i> 



(Address) ii-^ i^ ^'C'^^d^ ^ 



Hours 
M.D. 



Special information only tor Hospitals, institutions, Transifnts, 
or Recpnt RcsWents, and persons dyinq away from homf. 



Formfr w , ^ K \ , "•*' 'o»fl «* 

Usual 



r w , ^ , \ . now lonq ai 

Rfsidfncf ICi 1 Vj a.^V ^n. w^ >, Piarc of Death? 



Days 



When was disease contracted, 
If not at place of death ? 



IM.ACK OF niRIAI. OR KKM(»\ \I. 



I>\lLo; lit HiAi. or KKMOVAI, 



INin KTAKKK 



.A ^- 






1 



190 



^Address Wt, \' .^ v ^., , 



N. B. Every item of information should h: cnrefuliy nupplled. AGB Bhould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it m»> he properly classified. The "Special Information" for psr- 
sons dyin^ away from home should he ftiven in 9\9ry instance. 



i 



|| 






f 



r 

r \\ 



''I 



•ft 



r:i 



Lrs-^: 



♦•» V 







W' 



. €f^^ 



i ;;. 



! "; 



;!r 



■U 



/.I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Unifl ..f H.ilih )■ No 1^ ^-^^I^) n& I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ref^isfcrcd J\''o, 



854 



"^trvvu-N "vcA>u Deputy Health omcer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Cevtificatc of Beatb 

PLACE OF DE ATH : — County of (X'>\;OA.a.>VC(.iCi.City of •'(X 'tv I.^vCV > vc*.^ Ct 
(No. I "i'A ivv-LU\. St.; •. Dist.!bet. '' and ^ O . ^ , . 

(ir OCATH OCCURS *W*V FROM USUAL RESIDENCE Give facts called for UNDCR "special INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



Ad^.U'i^ 



s 



PERSONAL AND STATISTICAL PARTICULARS 

DATK ol lUKTU i 

tMoutht ] (Day> 'Year) 



MEDICAL CERTIFICATE OF DEATH 



I>ATK Ol- DHATH 



Month) r 



*< 
k. 



(Day) 



/QO '. 
tYear) 



J '/ «; > 



Am 5 



WinnWKI* OK DIVoKDI) 
iWiittin s(K-ial tU— i(.'!i;itiim) 



HIRTinM.ACK 
(State or Oountr\-^ 



VAMF OI* 
IATni:R 



niR THPI.ACH 
<>I" lATHKR 
(State or Comitrv^ 



MAIDKN NAMK 
(>I MOTHKR 



lUR ruri.Aii-: 

<>»" MOTHKR 
■^l :it« or ro\intryt 






Y 






I IM'iKliHV CI:RTII'V, That I atU'ii(lc«l flcrcastMl from 

V-wA. I90 i to V.LwCL .1 KID'S 

lliat I last saw h • alive on V^vs^vQ lyo 

and that death occurreil, on the date ».tatiil ahovc. at '^ 
M. The CAISH OF DI-ATII was .,- follows: 

C- i'vx-^:^ v-v.\-.iL.A^<r>x 



X 



\xXa^^ ^ 



5 



d-cv 



"I 



Dr RAT I ON )'tars 
CONTRIIU TORY 



.^/onihs 



/)avs 



Hour 



or RATION ^)Vi7/5 Months 

(Signed) ^ '^"v^^-" " 

Leva ■- T« 



Days 



V. 



f> 



(Address) W. C ^ ^\ 



Hours 
M.D. 



c 



C^- ^-^«- t V. W 1 - 



«>v\Tl' A TION 



I 



)>',! I S 



\1.;,fh- 



/•■•l 



TH7" AHOVH ST\Ti:n PKKSONAl, !'A RTirC I.AK < A K J! TKrK T<> THK 
BHSr 01 .MY KN«)\\ 1,1.1 X'.K AND lUvIJlCK 



(Iiif'iMiiatit 



( v.\- 



( \.l<1r< sv; 






&,-! 



V 



. \ 



Special Information onU lor Hospitals, institutions, Transifnts, 
or Rrcrnt Rfsidrnts, dnd persons dving dv^dy from homr. 



Fonwr or 
L'sual Rrsidrncf 

When was disease contrarted, 
if not at plare of death ? 



How lenq at 
Ptareof Orath? 



Days 



I'l.ACK 01 HlKIAl. «»K KHMoVAI, 



rNI)i:KTAKKR 






l)\ri;of lit KiAi. or RKMOVAI. 






190 



'> *> v< 
^\d<lrc«<i .T^ .-.^ A 






IN. B. F.very item oif information should b-- carefully supplied. AGE should be stated F.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for per- 
sons dyin^ away from home should be ftiven in every instance. 



m 



ii 



I 



If 



^■: 



I '»4^»'' 






.e««.w* 






»•.-' 



^^.f. 



^•^ti 








,-• »■ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



B«wr(! of Utaltli I" N'o i^ "^^/^J^. WkV Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Filol, lUvcivv^it 'I l'JO'\ 

r)^^,^^ , Deputy Hclth OfHcer 



Registcied J\''o. 



DEPARTMENT OF PUBLii HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( Ta. S. Stan^arC» ) 



rNo. 



PLACE OF DEATH: — County of^ 



CX^-V 0,VO^"> X CU. C City of C ' (X > V 0. 



VC,\.A'^ 



^lA^aM\.Mv.c. .St.; 



Dist.: bct» 



and 



(IF Ot«TH OCCURS AWAY FROM USUAL RESIDENCE Give FACTS CALLCD FOfI ONDtR "SPtCIAL INFORMATION • \ 
IF OCATM OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTCAO OF STREET AND NUMBER. / 



) 



FULL NAME 



w 



PERSONAL AND STATISTICAL PARTICULARS 




SK.\ 



I).\TK OF lUKTU 



AtlK 



<X 



U 



COI.OR 



LilivcL 



(Month) 



) I'lj I 



I Day) 



M,mlli!> 



(Year! 



f\n 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATII \ 

u 

(Month) \ (Day) 



/go 

(Yt-ar) 



1 Ifl'iRIiBV CJ'RTIFV. That I atten«1e«1 «1erease<l from 

to .lL.UuQ»....Iu 



SIXr.T.K MARKIKI) 

\vin<»\yi:i> ok divori i:i) 

(Write in s«)cial dcisivrnation) i 



'^ 



U.c 



^' 



niRTHPI.AOK 
(State or Couiitrv^ 



N'AMK «)I 
FATHKR 



niRTlUM.MK 
OI" lATHKR 
(Statr or Tomitrv) 



MAIDl'tN NAMK 
<)1- MOTHKK 



lURTmM.ArK 
Ml MorilKR 
<St;(ti- or Country^ 









1 d 



iqo V 
190 



> ... >. > 190 

til at I last saw h • alive 011 
and that death f>ccurre<l, on the date stated above, at U H 
1 M. The CAISI' Ol* Dl-iATIlwas as folU.ws: 



OriX^ 



Ck\i„l 



^ 



vJ^X^wCLo c 






^Ky\AX^ 






nr RAT I ON Yearn 

CONTRIIUTORV 



Mouths 



/hi IS 



J tout s 



DIRATION 
(SIGNED) 



Years Mouths 



/)./|V 



H)on 



fAddnss) CL^ ^ vah 



I lout \ 

M.D. 



OCCri'ATON 



\ 



Kr^idi'd HI Siifi /iiiiiiiuii 



) ,,n. 



.1A»/////« 



/>„■. 



Tin-; AHovK SPA II I) rKKsoNAi, r\Kii<ri.AK> ARi; iKi i: TO tin: 

UKST OF MY KNO\Vl.i:i)«; K .\M) r.i:i,I I!!" 



(I 



tifoimant J -*VCC\"wK ^^ O. 






1 



SPECIAL Information ««!> 'or HospiWs, Insllfyllons. Iranslfiits, 
or Recent Residents, and persons dying away from home. 



.1 



Former or 

Usual Residence W*w ^. 

When was disease contracted, 
If not at place of death ? 



How lon(| at 
Place of Death? 



Days 



I'l^ACK 01 mKIAI. Ok kl Mo\ \l. 



^» 



ItXTI.Mt Mt Ki.Ai or K1:m«>VAI. 



I90H 



.^ 



(\>\i\ 



rcss 



w V 



rNI)i:RTAKKK 

(A<MTfs^ 



.^r ^ '•^\ 



^V 



•- -X 



IN. B. Kvery item olf informntion should be carefully Hupplicil. AGfi Hhoulcl be stated fiXACTLY. PHYSICIANS should 

state CALISI: OF DEATH in plHin terms, that it may be properly classified. The "Special information** for p«r- 
Rons dyin^ away from home should be It'^^n '"^ «very instance. 






'< 



,1 


I' 


ii 



I 





• 


^^HT ''^i '-' 





» . • «^ ?- . ^ . . . 




:- ' ^ *,. 



.: i' 



i 



ii 



! 












r^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.>.ir.l ..f iic:.ltli I No. I ^ ^*^^^ H& I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Filed, U 




A.^ I.. 100^ 



ReglsteTcd J\^o, 



856 



^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of Beatb 

( "Q. S. StanC»arD ) 
PLACE OF DEATH: — County of^ a^v v"^ VCL^xCuiCOCity of Ua>V' 



^^cxavcc^co 



(No- ^Ctu ^ L^Wvd.>u, U^L/TAAk: St:: 



U ^^ ^C-VWLA.>u, U^VyTAAAX: St4 Dist.; bet. and 

M / IF DCATH OCCURS A^AV mOM USUAL RESIDENCE Give FACTS CALLED FOR UNDER "SPECIAL INFORMATION" X 
^' V ir DEATH OCCURnko IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



~J. 



JL\.Z.LL.}s}..rUJ:^(Uj.. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



licet 



C01,0R 




DATK «)!• lUKTII 



mi 



(Month) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



(Month) : 



i 



a)ay) 



IQO 

(Year) 



r\ 



(Day) 



( Vca r ' 



a<;k 



J to I 






*»v% . -> 



Pa 1 



S INC. I.I?. MARK li:i) 
\VII)n\Vi:i> OK DIVoRiKI) 

<\Vtit»- in >«<Miiil fU-^i^'iiation) 



CJ 



HIKTMI'I.AOH 
I Statf <»r CDuntrv) 



NAMK OI- 
FATin:R 



niR iniM.AiK 

<»l' I AIHKK 

( St:it«- or Conntry) 



MAIDKN NAMK 
OI MOTHKR 



RIRTUPI.ACK 
OK MOTHER 
(State or Country) 



OCCII'ATIUN 



Ml • 



^ 



1 IIliHlilJV CI:rTIFY, That I atten<kMl deceased froui 



V^wUl^ ab 



t 



190 H 



to 



..Uv.u».A."-2l. 



190 



that I last saw h ^i^VA alive on LA.^v.<L %, up 



and that death r>ccurred, on the datt* stated aliove, at 1 ^ 
M. The CAISH m< DIIATII was as folNnvs : 



(?. 



VOU^^V 'J .U^Jy^J^UL 



k^ 



Vmj^clvj 




I. 



h 



DTRATION Years 

CONTRIIUTORV 



Months I Days 



I tours 






1 



^^\-*w<L^_CV_ , 



Resided in S,in /'i iin, i -, ,> 



DTRATION Years 

e 
( Signed ).wL ^ 



A/oNths 



Pavs 



I four < 

M.D. 



-Cv. 



C^ A iQol (.Address) 



.A-VV.ft-V^4^ 



SPECIAL Information only for Hospitals, Institutions. Ir«s»fiits. 
or Recrnt Residents, and persons dying a»»ay from liome. 



) la I > 



\/..>iths 



/'.,• 



IHK AROVF. STATKI) PKRSON M, !' A RTU- T l,A R S ARI! TRCK To TIIK 
BEST OF Ali" KXOWI.KIX.F: AM) Hi:i.ji:i- s 



Informant -^ CX "W K *CV 



i 



' X.l.lross . L ^ '^ i >'V^ > W ^. ^->i^-^ 



Former or | 

I'sual Residence 

Wften was disease rontrarted. 
If not at place of death ? 



How lonq at 
Plare of Deatli ? 



Days 



PI.-ACF: OI" lURIAF. OR KI:m<»\ \I, j Dxri.i.r Hi KiAl. or RFMoVAI. 



-V 



INDFRTAKKR 



N. B. Every item of informntlon should be cnrefully nupplied. AGB Hhould be Htated EXACTLY. PHY8iCIA!N8 should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for p«r- 
sons dyin^ away from home should be ftiven in every instance. 



! ,r 




1 






.w ^ ... 

^. f -■ 

X. 



*^' •'*>>": -V '■ A^'-\ 



gg y 






ift 






II 



ii 



H 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noirlof n.:,uii » No i - ^??g^ H& l» Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






lOO'i 



Regiaterecl J^o. 



85? 






c r -J ty. • ' - - U.h.,.Q.r .- 

DEPARTMENT OFIpUBLIC HEALTH=City and County of San Francisco 

Certificate of Bcatb 

{ "d. S. StanDarO ) 
PLACE OF DEATH: — County ofO/OAV vJyUX/A\ ^L<LecCity of ^'O/tv 0.^u(X^ vc,ui.i,c 



^IVo. 



jvv^vQ.^ ^'a^L^oAvti 



i\ 



CLLK.Q,h\\X\J^ (lUCnY^.>. St.; 



„ - r Dist»; bet«- ' ■ ' '- and 

r DCATH OCCUR^ AWAY FROM USUAL RESIDENCE Give FACTS CALLED FOR UNOCR "SPCCIAL INFORMATION" N 
IF DCATH OCCI^RRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




.cLLvOt'^'vx 




1) 




SKX 



DATi; Ml ItlRTH 



AC.H 



PERSONAL AND STATISTICAL PARTICULARS 

I COI/>R\ 




\}^Jr\jXj>. 



MolUhl 



bl ),„, 



\ 



(I)ny) 



MoMlfiS 



/I 



1.^ 



fV«ir) 



Pa I 



MEDICAL CERTIFICATE OF DEATH 
DATK OF UKATH 



(Month) I 



(I>ay) 



I go 

(Yt-ar^ 



^I HI;RI<;HV CI:RTIFV. That J attemled .leroased from 



.U^i 



I90 \ 



to LL^ 



i</)H 



'^IN'.I.K M \RI< Ii:i) 
\Vn>uVVKI> OK l)!\<»K«Hr) 

iW'iitciii «.<Mial (!«— ivrnatioii) 



lUKTMl'I.AOH 
State f)r Coiintrv^ 



VAMK or 
FATHKR 



RIRTUPI.AiK 
Ol" KATMKK 
(.State or Ctmiitrv) 



MMDKN NAMK 
01 MOTHER 



r.IK IHIM.ACK 
OK MOTHER 
(Statf or Conntry'i 



OCCrPATlON 



? 



1 



A 




.u^....1 

that I hist saw h A^'>>.v.alive on L\^^v<X. b ... igo 

aiifl that <Uath <)cciirrc«l, 011 the «latc statc«l above, at 1 
wV Al. Thf CAl SP: Ol- l)i;.\Tir wa-^ as follows: 



» V 



MUU^ MJl ^k 




nr RATION 

CONTRIIUTORV 



Years 



Months 



Days 



/fonts 



h.A.\.s:j^'tc^\... 



i 



^.S^b^,. 



DIRATION Viars 

(Signed) wL ^ 



c -^ 



Afont/is v3 /></r\ 



IIourK 

M.D. 



\|ljtcC"\iat'w 



I 



\J^KA^O. 



I()0 • 



( 



i / 



Special information onlv for HospltdU, Insntutions, ffinsifnts, 
or Recrnt Rfsidrnts, and prrsons dying d*»ay from fiomf. 



KfSldfil lit S'l;;/ / I il III ix'ii 



),,/;. 



!/..<////. 



Ihl\ 



phi: AHOVr. ST \Tin F-KKSONAI, PAKTI(TI.AKS AKI IKl K to 

IJKST oJi '^'v kn<>uij;i)<;k and hi:i.ii:k 



I in-: 



(\A,h 



■v<'< J\A/VoCX/3 <^ 



ccwvcvivLu 



former or -'ii \4^ 

Usual Residence JV\. wcto "^ . 

Wlien Has disease contracted', 
If not at place of death ? 



HoH Jong at 
Place of Oeatli ? 



Otys 



'^ 



K- 



PI.ACK OF HlKrAI, OR KHM«iVAI. j DATi:-)! IJi kiai. or RKMOVAI, 

CcuKLa -^ .. ■ I ^-'-^^ -: T9o't 



!N. B. Eivery item olt Inlformation should he carefully supplied. AGB should be stated HX4CTLY. PHYSICIAINS should 

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information'* for psr- 
sons dyin^ away from home Hhouid he J^iven in every instance. 



I 

I 
I 



•| 



til 



♦ t 
It 



I 






1 1 1 



f .. r 



1 ♦ a^ 

±3 






y* - •; -i^. • 



- ' • • •, > » ^ f r- ^ . . 4 ■ 



•*■ ^>■ /- 



!ir 



I < 




M' 




■I 
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

norinl of Health- !« No i^ t^f^^ M&l' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((fc Filed y 




Registered JSTo, 



858 



vaI % lOO'K 

Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^No. 



Certificate of Beatb 

( Ta. S. Stan^ar^ ) 
PLACE OF DEATH: — County of ^^ an\; v);vcv:>vct^t(City of ^'Ow>v ■ \a >vCLAet 



^md- 



(ir DCATH OCCURS *wVv FROM U^UAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



FULL NAME 



ITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



'Vt : 



PERSONAL AND STATISTICAL PARTICULARS 
>^HX A /* I COI.OR 

u.vii: (»i niKTii 




4 '' lOi 



^ MEDICAL CERTIFICATE OF DEATH 

DATK III- DKATII 



"Month* 



A(".K 



oM ^^ 



J V i; I 



(iJav) 



Mi>MlflS 



) Year I 



Pa vs 



(Month) * 



(Day 



/QO 
(Year) 



I IIIvKlvlJV ei-RTIFV, That I attoiukMl fleceasoil from 

■" ~ 190 to ■ - ■ : ' .:- ' 



that I last siiw h^ 



-alive on 



-190 



SlV<:i.R. MARKIKn. 
WIDoWKU OK IMVoRiKI) 
IWritf in MK'ial «U'«»i)L' nation) 



BIRTIin.AOK 

(State or Country) 



^ ■ - X 









CVw 



XAMH OI' 

KATIIKK 



HIKTHPI.ACK 
OK lAIIIKK 
(Stall- or Country) 



MAIDKN NAMK 
«>l- MOTHKK 



niRTHPLACK 
«>l MOTHKR 
(State or Country 



<iCCirATU)N ^ 

Rfsidfii in Situ /'iinhi.y 




\ 



and that death occurred, nw the date state«l ahnve, at 
^ M. The CAlSi: Ol- l)i; A Tll^ was as follows 



X t'V-N^^"V\_ 






DrRATION Yrats 

CONTRIIUTORY 



Motiths 



Pays 



//outs 



DrRATION Years 

(SIGNED) ^CVOV.. 

I > 

^v... > i,,o • (Addrrs^) V^^t^^-■• 



Mouths 



/htVS 



//ouf s 

M.D. 



SPECIAL INFORMATION onlv (or Hospitals. Instilytwiis. Translfnts. 
or Rrcrnt Rrsidrnts, and persons dyiiij dvid) Iron homr. 



y,-,i 



M.'iith^ 



I I,! !> 



THl': AIIOVK STATi:i) F'KRSONAI, I' \ K IICI I. A K s AKl IK IK !« » THK 
HHS T oi- MV KNo\VI,i:i)r,K AM) Mi:i,H.F" 



(Inf 



onuant 



V^^Vft^V^w^-A. 



'■ \rl.lrevs 



Formrr or 
Isual Rrsidrncr 

Whfn was disfasf contracted, 
If not at plarr of dfath ? 



Now lonq »[ 
Pldcf of Dfath ? 



Da}s 



ri.ACK 01 lU KIAI, nk KKMm\aJ, I I»\li;.' Hi KiAi. or RliMoVAI. 

LLc<.n ^ T90S 



\ 



»v*v ^ 



in"I)i:rtakkr 



'K 



.^CA^^ ^C 



» 



^. 



-'"y 



1 i »- 






!^- B- F.very item olf information should hi cnrefuily supplied. AGR fihould be Htated EXACTLY. PHYSICIANS nhould 

state CAUSE OF DEATH in plnin terms, that it may he properly classified. The "Special Information" for %>mr' 
sons dyin^ away from home Hhould be i^iven in «\ery instance. 



« 



I' 



1 1 , 



''■i 



^:s&^ 






t.ir 



..>^^, 



i* 






1"..;^^: 



> 



> , 



iir -,. ;i ' 



V h 






u 



fc 



im 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li.Kir.li.f IIc.ilili- l-Xo K t^^^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I90H 



Itegistercd JVu. 



859 



<X.CJ-v^v/i oUam^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Ta. S. StanOarD ) 



PLACE OF DEATH: — County of^'a>\ W<X. 






J\^X/y\, eAA.c . 



ivjo. ^^t Ax^ku 




c^^ 



lvc\ 



CL 



(IF DEATH OCCURS AW«V mOM USUAL 
IF DEATH OCCURRED IN A HOSPITAL 



su 



Dist.; bet. 



and 



RESIDENCE Giv 
OR INSTITUTION C 



(^ 



FULL NAME 



E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 

;ivE ITS NAME instead of street and number. J 



.cn-vx^X^/ 



^w 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



^)la.U 



LLvkvc 



,u 



i>\ ri". in r.iKTii 



M'.K 



I Month » \ 



MEDICAL CERTIFICATE OF DEATH 



DATE OK 



'' DKATH 1 



(Month) ' 



I 

(Day) 



(Yrar) 



.">:i 



JV«( 



I Day 



Motitfis 



\l 



» earj 



Davs 



> v_V^^ 



«iTNr.I.K. MARKIKI) 
WIDOW HI) OK DIVnKrKD 

tWrit«in -<K'i:il «lr«.JKn;»tion) 



4) 



X'V^X^LX^ 



lUKTHI'LAOK 

'Staff or C'Mititryl 



XAMK OF 

HATUHR 



HIKTHIM.ArH 
<M I AlUHK 
>t.i1> or Ci.untrj*) 



MAII»KX NAMK 
Ml MoTHKK 



HIKTIIl'I.ACK 
(>l MoTmCK 
(State cjf l^)UIltr^■ 



•HCl TATloN 



^ 



'1 .^CrVL J ^ 



I HF':RI{nV CIIRTII'V, That 1 attt nc1<M! deceascMl from 

to WAA.A.a_ k 190 H 

an<l that <U*ath occurred, 011 the Mate stated a!>ove. at 
M. The CAryi^^ t*'* I) i:\TI I was hs followv;: 



that I last saw h-V-:^* \ alive on 







Y^X^'i'WfUO. 'S.AJ-V 



Xm. 



.fflL^^^LwLa. V CCVV<: ^ V. Cr SA,?^au\t. A^^J-Ax,v.C.k oifrM.A\<^ 

Pays 



nrRATION % Years Months Pays Hours 

C O^ T i< I H r T R \' V Kyy^. A<^-^J^q.MwA.a.h.■ i\.irv 



UlRATION 



Years 



Mouths 



Pays 



Signed ) ^ vc . >h <xvq.cv 



'fours 

M.D. 



h'fiiird III S<j}i I liUuri: 



)V.;/ . 



M..iifh^ 



CLocQ % 190 H 



f Addnss) 






Special information »Bly tor HosplUls, Institutioiis. iMisieiits, 
or Recent Rtsidcnts, ind persons dying v*^\ from home. 



Former or >{ 4 

Lsual Residence . W ^ v_L . 

When Has disease contrarted, 
If not at plare of death ? 



How long at 
^»t of Death ? 



Da>s 



THK AHOVF. sT \T1-, I» I'FKsdNM. P \ Klh- f I, \ K s \Ki: TKIl-: T' t llii: 
Hi;sT 01 MV KNitWIJUX'.K AM) P.JI.II.K 



1 ^ A 



' \f1<lT.-vS 



A 



Xa>-v^ v^ Ow \K> 



ri.xcHoi- in KiAi. <»K ki;m<'\\i. I i»\ri 



IMHCK JAKKK 






'^\ 



1 



IS; kiAi ■«! k KM* >\ AI. 

t I90H 



va< 



^.ll' 



vV^ - 



I>i. B. Kvery item o»* i n form Ht ion should be cnret'ully Hupplicl. A(JB nhoulcl be stntecl liXACTLY. PHY8ICIAM8 nhould 

Rtate CAlJSi: OF DIIATM In pinin tcrrms. that it mity be properly ciasRified. The "8f>e«;iMl Infurmation" f«r p«r- 
nons dytn^ away from home should be Ht'^en >n every inntance* 



!ii 



r 

'■:' 



I, 



■^t*l! 



V 



I ■ 



' : ♦^J 



'^<* 



> * ' •' 












»;;•■ 



j.'i 



ip 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hofinl of Health- F No. k "^f^l^^^ »&1' Co «,„ 

"^ REFER TO BACK OF CERTIFICA TE FOR INSTRUCTIONS 

Dale Filed, xLh^xjO^^u^k % 100^ 

^trv^^ ^^ Deputy Health Omeer 

DEPARTMENT OF PUBLIC HEALTH=CKy and Connty of San Francisco 



JRe^Lstered JYo. 



860 



Certificate of ©eatb 



A 



( "U. S. StanC>arD ) 



PLACE OF DEATH: — County oP' a ivj A.CU>^\X^ c <. City of 0.a>V ^ .Va > 






\ 



Dist.; bet. 






«/-.,», V L -^^^~ -.JiM j^isT.; OCT. -rrr and 

" C T nrl.!.*'«""' r*^ "'°** ^»"*'- RESIDENCE GIVE r*CTS C*LLCD roH UNDtR " S-CCAt .NrORMlT 

V .r DEATH OCCURlicD ^H . HOSP.TAL OR .NST.TUT.ON G.Vr ITS NAME .NSTEAO " STR E eI AN O N U M BE ) 



ON- 

R. 



FULL NAME ^bx^^xh. 







SKX 



DATK OF ItlRTII 



a<;k 



PERSON AL AND ST ATISTICAL PARTICULARS 

COI.ORX 



L 



OLLi 



'Momh> K 



U' 



1' 




) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF I)1:ATJI 



fM<.iUh) T 



iC )Vtf>A 



II 



(Day) 



.1/oM/// 



(Ytnr) 



rhn 



\\ n)n\Vi:i) OK DIVOKCKD 
iNVnt«iii v.HJal .It sjtr„ati.iii) 



HIKTHI'r.Al'K 
'Statf <»r I'oiiiit r\ 



VAMI-: nj 

FATIIKR 



niRTFII'I. \0F 
oi- I ATirKR 
'Statf or Country) 



"^'AIl'KN \\MF 
<M .M<>Tin:R 



I'lH rifl'l.ACF 
"I M<»THKR 
Stat. .,r Coiintrv) 




I /go . 

I HI;RI:HV CI:RTIFV, That I atten<UMl <leccaso<| from 

that I last saw h alive on W v«> v ; ,^^ 

an.l^hat ilcath <KvurrcMl, on the .lati- stated ahovt-, at ^ 
M. The CAI SK Ol- DliATII wa^ as follows: 



W VA.A.^Crv \. VC V J >-V^ & ^ <X»v'ci^ 



/>VCi 




'Vu.<i,t<rWr\JL^j 



l^ 




I>I R.XTION 



) 'e'ars 



w, .......,., ftj4f.y Afnnths /)ars J lours 



OCCII'ATION 






I/XcUvu, '^i^>'vC 



^%. 



nr RAT ION 
(Signed ) 



\^. 



)'i'ars 



a 



^1 cn- 



Mouths 



Days 



Hours 
M.D. 






Special information onU lor W^spiUls, InstituliMs. Iransifuls 
or Rpcent RfsMenfs. and persons dying ^v,a\ from homf. 



loioLUcLih^ 



Formf r or 
I'sual Rrsidfncr 

Whfn was disMsr ronfractrd. 
If not at plar r of dfatfi ? 



How lonq at 
f»laf f of Oratfi ? 



Days 



f^''-iii'-'f "I Sati I ir ii. - ,■,, ' ),,/;> *" 1/ </'//> ''^ /., If not at plaf p of dfatfi ? 



I 









. n. hvery item olt in^trmntlon ahould be cnrefully nupplied. AGB nhould he Htateil KXACTLY. PHYSICIANS sho Id 
•tate CAU8I: OF DEATH In plain term*, that It may be properly claiifiifled. The 'Special Information" for Mr 
«♦>«• dying away from home Hhould be ftisen in e%ery instance.. 



ill 



(• 



• i 



'^'i'. 



w».r 



.»! "*.J«- •-»*»• 




•«t 



VL 












n 



:;>'. 



I 




hj 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

)t..;ii.l ..f Ilt.ilt)! - F No. In T^f!^?^ hSi.V Co 






290^ 



REFER TO BACK OF CCRTIFICATE FOR INSTRU CTIONS 

Regi.ste/ed JVo, 



860 



Dale Filed, lI 

i 

H^trvuv^ AXamj Deputy f 

DEPARTMENT OFTUBLIC HEALTII=City and County of San Francisco 



om 



cer 



Certificate of IDeatb 

f "U. S. Stan^ar^ ) 
PLACE OF DEATH: — County oC <X^\^ '.(Xv.C^^C. City of "^ a > V «"* 



VCA,4 



1%. ^Ctct. '^^v V- trtL \vtu 



'\ 



P ^ ir oc*TM OCCURS 4w«v from usual 

V ir OC*TM OCCURRtO \H A HOSPITAL 



Dist.; bet. 



•♦ DC I. and 

RESIDENCE Give facts callcd for under srccial information- 

A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OF 8TRCET AND NUMBCR 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



11 A 



) 



Vt'UL^X.sLA. 



\ 



^K.\ 




LclCl 



L 



COI.<»R\ 



IJATH OF IlIRTH 



AOK 



SINT.i.K. MARKIKI) 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII 



LUco 

XMonth) T 



(Hay) 



• Month > \ 



I U J '»•«! » .\ 



II 



HJay! 



( ■»■« ill ) 



Ji„ 



rgo 

(Year) 



I HKRI'IIV CICRTIFV. That I altcn.kMl .ItHvase.l from 

LCwaS 190 i to LLvua 



190 H 



wri)<)\vKi> OK ni'vdRCFi) A 

'Write in MKJal .It-iKnalion) «Jr 



KIKTHPI.ACK 
(Slate or Country) 



NAMi: OF 
I ATM MR 



HIKTm-I.ACF 
*»f' I ATHKk 

'Staff or Countrv) 



MAtnHN VAMF 



Hik rniM.ArH 
01 M(»tmf:k 

'Stat, or Countivi 



XAX 




•ncri'ATiox _^ 

f^''>:dfui III Siiit /■ I iin> isnt 








that I last Sit w li alive on C^^rQ, ^ ,,p 

anil that dtath occurred, on the date state<l alxne, at ^ 
y M. The CAISH Ol* DI-ATII wa^ as follows: 



C I vx-^rv ^v^ U.) W^5-^:u<xAxtct 



vs. 



Dr RATION 



J 'ears 



Motif /is 



Days 



CONTR I lU TOR Y ^J^wt-k/A vtr-\V<XW .1)^^^^ 
DTRATfON ' Vau'S Mouths 

(Signed) wL^^\^ \Ji\ -^ 



//oufs 



Lvw 



^1>- 



Days 



Ilor.rs 

M.D. 



VQ.I K^H Mddrt-;s) LJ,^ "^ ' 



.' s. 



5 I ii I 



1/../////. 



/',/i 



Special information only for »f«spitals, InsUtuHons, Transiriits 

or Recent Residents, mi persons dving dM<i> from home. 




lih^r oi- Mv KNowi.i.ocK \M) i!i:i.n;F 



'^IiifiMnaiU 



,-^. 






Former or , 
L'sual Residence 1 U 

When was disease contracted, 
If not at place of death ? 



CLi^a 



HoH lonq at 
Piar e of Death ? 



Days 



'^'\^*y' "^^'x '' "*^ kKNUA Al. I DATKof lUuiAi. or RKMOVAI. 






^JLCV^s^ < 



Ad.irt-ss iTu '\j i\\,<i,<u.^<r>- 



~Jr . I 



^' Every item of information should be carefully Kupplied. AGB Khould be atated EXACTLY. PHYSICIANS should 
•tate CAUSE OF DEATH in plain terms, that it may be properly claiiaified. The "Special Information'* for D«r- 
«'>n» dyinft away from home nhould be ^iven in overy instance.. 






I ' 



"(I 



ifcrte* 



. -V-. 



■,^-M 



'r*>. 






^•-^^ 



V /- 



^^^i^mt 



m 

r 



I 



' ■ ti 



It; 



'il 




r \ 



1! 



r 



I . 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho.iirlot llffilth- I" No. !<; "S-^^art^i I$&I» Co «_ 

""'•^ REFER TO BACK OP CERTIPICATC FOR INSTR UCTIONS 



I)(f/r Filed, LL-v^q vvJ: T 

1 



'^VCVO 



lOO'A 

affh Officer 



861 



DEPARTMENT Of PUBLIC HEALTH-City and County of San Francisco 



'No. 



Certificate of H)eatb 

( Ta. S. Stan^ar^ ) 
PLACE OF DEATH: — County of S-OU^ W^O ^^ City of "^tcrcLt 



(^ y 



<r>v 'v^CL'.' 



St 



♦t 



Dist; bet. 



-and 



( " ,Vo;:.°„'te"c"„%;r„',7?:„".'t-t o",=f^?^"j;^r/,;-74 5.vi.7 ,;v,»vs? .?.%%T.Vo"'i;^';r ) 



) 



FULL NAME 



ULci/o^'UdJL 



PERSONAL AND STATISTICAL PARTICULARS 

-'■:^ Qn ^ I COLOR ^ 



■T: 



d,U 



<^x/^'\.''^. r 



^^y\joSjL 



MEDICAL CERTIFICATE OF DEATH 



I) V\'V. «t| lUK III 



\< l". 



Ou^vt 



lOJvoU 



(Moiitli) 



II 
<I>ay) 



/ L 



O ^ JVa*,* 1 Sh 



<Hlhs 



*r I 



(Veaii 



Pa 1.V 



DATK OF DKATH "I 



(Month) K 



(Day) 



/QO '. 
(Year) 



I HI:KI;HV CI;rTIFV. That I atUMuk'.Meoeased from 
^ __,^ jQ .... , „ ,^ 



"^rN'.I.K MAKKIKI) 

w ri><»\vKi» OK rnvoRt 1- 1) 

(Write in s«KMal <U".ivr„;,,j,,„) 






lURTHPUAOK 
Statf or Couuti V 



NAMK <M 
FATHKR 



lURTMPl.ACK 
<>l lATIIHR 
(Htatr or Oouiitrv) 



MAIUKN NAMK 
nl MOTHKK 



»IKTIIPI.AtK 
Of MOTHKR 
*Stat< ..r Coutitrv) 



a.. 



(??i 




that I last saw h-~ alive on 



— 190 



and that «Ioath occurred, on the date stated alnnc at 
^ M The CAl^SR OF Dl-ATH wa. as follows 



r . r .,v-. 



J 'Vcrws^^Xo C'AXv'^ 



vM^-v\,a,Cr>Ai 




DIRATION }r'afs 
CONTRIIU'TORY 



Monihs 



fhxvs 



Hour. 







DIRATION 



(Signed 



•»Cri'ATl<)X 

Rriifnf III Situ I'l ,u 



C>,vcXol 



■^A. 



6^ 



K 



I 



Yearn .^fotiths 

r<)0 f Address) 



^ <)1:> U).^<X^ 



Pays 






i> /► 



I four < 

M.D. 



) >,f / 



1 A. /////> 



1' 



in-.sroF Mv knovvij:i)(;h AM) iu:i.n;i- 



?^^9'<i'-J'^fO'^'^'^''''ON only for Hospilals, InstituMofls. Iransiciifs 
or Rfcenf Residents, and persons dying away from fiome. 

former or -\ ^1 

Jesidence O/CV^Xi J 



llsual Residence 

Wlien was disease contracted, 
If not at place of death ? 



A-C. 



flow lonq at ; « 
^^ Place of Death? i ... v.... ^^ 



'iMf, '111. lilt 



%.Q^ ^ u 



\'l<lre<««« 






I'l. A 




HrR|AI. ok KHMo\ \l. 



nAI'Ko! »t KtAT. or RF:M0VAI. 

T90 






I ndhrtakkr LAj. \Xj. VJ / l<X\.t<^^*^. 



u 



. < I f 



''* "*~.^t7t7c'lr^FUp^n7rxH":***7'** ''' ^"-«f""y HupplJed. AGB nhouid be utated BXACTLY. PHYSICIANS •hould 
!«nl%^ / c I **!"'". !"'"•• '*""* '* •""* ^^ properly cl««.i«ed. The 'Special Information- for pr- 

i»on« dyinft away from home should be ftlven in every instance. ^ 



'. 



11 



T' :! 



If 



!•' 




if 



-':! 



r.f'^ 






r 



*^^nr'^» " 




1; 



■» 



Jl 



!i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I'...aril if III :i]tli »■ No K ■»'^?a^5^ iiS:I 



Cc. 



D<(fr /v7^^/, LLvv.<Vv\„^l t 100^\ 



REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 

Jiegistered J\^o, 



862 



A^Cr-uc'.,^ LtM-u 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



No. 



PLACE OF DEATH 



c A 

I — County of ' 



( "U. S. StaiiDarC* ) 



St.; I Dist.;bct. U C^VvaK' and L tto 



( •' "oI^t^o^cIr^-.-- -------- -^^^^ 



FULL NAME ^IH^Mvu^^x OL CLVV.L-yvat(r-^\, 







I>ATI-: «il- lUKTII 



PERSONAL AND STATISTICAL PARTICULARS^ 

»MmAh) 

Ar.K ~" 



1?^ 

(Day) 



1 



WEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 



1 



(Month) 



-^' /go '; 

^nay) (V«ir) 



) lU t 



<^ 



Months 



rear) 



A; 1 



u rno\yi:n «»« DivoRrKO 

Uritc in s«H-ij,l (I< oi^'tiiitMii) 



BIKTIII'I.ACK 
(Statf or Coimtrv) 



N'AMi-: or 

FATMHR 



HIRTHPl.ArK 
OF lATHKK 

(Stntr or Coimtrv) 



Nt\n»i:\ NAMK 
"I MoTMKR 



HJk iHi'r, \< }■; 
••I- MoTHKK 
'Statt or Coiintiv 



O'-CII'ATUJN ■^,.'* 



I>. 



L<XX-V^^ cC 



hx 



^<r 



I m-RIiHV CICRTIh^V, That I attcm led deceased from 

-^^ • »90 to ilwn to ic^ H 

that I last saw h .. alive on UwV^v.q o ^^ 

ami that death occurred, on the datt- st.,ti,l alx.w. at 
Mm. The CAr;,!-: or DI; ATII was «s follows: 



.Cyi-WX^.A» t ta^tv.<r> V 



(^^> 






•N 






Ko ' i J 



I > 1 K A T 1 o N 1 C ) Va,:j j/„«m. />„ ,. //,,;„-, 



Davs 



I )r RATION o^ )V4/rJ 

(Signed ) 

(Addr...) '''^^)\0.\.V.r?. 






Hours 
M.D. 



IC)0 



Special Information nnu tor Hospitals, institutions TraiisifnK 

or Recent Residents, and persons dying di»dy froni home. 'rinsifiits. 



M V 



fyf^idfd III Sun ft ail, I 11} 



) V.i ; .. 



.yr.,„th.- 



/hn 



'^'^^\'^)^,\l}yp-^^r vn:u vFH^iys \i. F'\k i uri. \ks akh tkii: t.. tiik 

HKsr OF MV K.Vnwi.jax.H AM) iii;i,n:K 

(Informant 4 ^^\^ X\^Lu ll..:. 



rX-Mrr 






Former or 
I'sual Residence 

When was disease ronfrac ted, 
If not at ^lare of death ? 



HoH lonq at 
Plareof Death? 



Davs 



I'l.ACK <)| HIKIAI. OK KF:Mi.\\I 



1 V 

a 



im)Krtakf:r 

^A(!.!i(«< 



oh^ a 



I>\l'i:o: HiRiAi. or RKNfoVAI, 

» i 

"^^ 190 



Ol 



\Hy<. 



n. 



]-. < ^ 



N. B. 



'l\Z7c\7sEofDEVTZ:^^^^^^^^ !;' '""''k'" r"''^'"'^^- ^^''^ «^-'^ »»- «»«^-' EXACTLY. PHYSICIAM8 .hould 

iitate CAU^t Oh DEATH in pl»in terms, that it may be properly s;la8sif;ecl. The "Soecial lnfor™,«t:..«" ff« 

«on. dylnft away from home nhould be given in every in«t«nce. Information for pT- 



ii 



*! I 



.f' 





iji! 

ill 



f'u 



i 



r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IJoMr.l .-f Health - F' No. is •**^„:^?^^ HS^I' Co 

I)((/r Filed y 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




2i 190 '\ 

Deputy Health OfTicer 



Registered J^'^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificatc of Bcatb 

( "0. S. StanC>arC> ) 



PLACE OF DEATH: — County of ''a^\i^^ KOj^x^^^^ City of "^ a^^^ ' "\J^J^\,Z^JL Cii 



ia^^,i 



No. 



^^' 



\r\. 



La 



att^^-" 



St 



♦t 



Dist.; bet. 



\^L\ 



V 



and 



(ir DEATH OCCURS AVW«V FROM USUAL R E S I DE N C E Gl VC FACTS CALLED FOR UNDER SPECIAL INFORMATION 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



I1.:U 
) 



FULL NAME 







PERSONAL AND STATISTICAL PARTICULARS 



SK\ 



IIATi; or lUHTII 



AC.K 






COI.ok '^ 



LV^'|:\aA-L-_- 



Month) 



11 

(Day) 



/ u 



' ) 'ill 



M.'vtli- 



(Vear) 



/'in 



SIM.!. I* MXKK!1',I» 
\VIIii»\Vi:i) OK IHVitKt Kl» 
(Writf in MHial cltsiKnation) 



]) 



\(X,\.'^\Juk 



uikrm'i.At'K 

'St. It- '>r •■MintryJ 



■^1 



x>uy 



VAMK Of* 

FATHKR 



i't) JX^-^ vet >V' L'/OU>V 




MEDICAL CERTIFICATE OF DEATH 



DATK OF DEATH 



(Month) j 



(Day) 



(Vear) 



I III'kf'RV CKRTIFY, That T attended deceased from 



..lLwa^ 



..a 



Cl >. 190H to — .v^-A-vcL. 190 

that I last saw h" * alive 011 ' ^ 190 

atid that death fxrtirred, 011 the date stated above, at 



^ >L The CArSIv ()1< DI-ATH was as follows 



..X...^Ow<X ^X-ft-^AJ^J ,YV\CX.cLit 4r 



Vo 



<^L4.»ux. *^^ ..><v,?if .Lw' 



I)r RATION 



5^ 



Months 



Days 



Yiars 
CONT R I HI TORY ^CUX-cL/UXa '.:^^.yv :ic . 



*_ :iX^'^^., 



Hours 



RlKTIiri.ACK 
o|- I ATHKR 

'Matt- nr Country) 



MAIDKN SAMK 
<>»• MOTHKR 



j',iRTm'i,\rH 

'•I MoTMKk 



Rfiihil in Stin /'i ilii> r III 



's JjcVvvvOl . ^, 




)'r il I 



Mnnth' S.\ /''.'I 



THi-: MIOV1-: sTxri'i) phrsonai, i'\k riiii. \ks aki-, tkik to tu}-; 

HKSr 01 MY KNOWM.IXiK AM) lU.I.Il.r 



-\ 



'Iiif<)ini.iut 



\'Mt. 






A 



or RATION ^ )x.7r^ Mouths 

f Signed ) .J ' ' L .w jt LI 



Pays 



Hours 



M.D. 



a,,. 



IQO ■ (A«ldrtss) 



.. ■^..tu-.. ~^^ 



SPECIAL INFORMATION only for Hospitals, Institutions, Translfnts, 
or Recent Residents, and persons dying awdy from tiome. 



Former or 
Usual Residence 

When was disease rontratted, 
if not at place of death ? 



How lonq at 
Plare of Death ? 



Says 



I'l.ACi: ol- JUKIAI. OK KKMoVAI, 



-^ ^.^ 



vi IV ; ^ 



X 



I)AI'i;<)f Ml HiAl, or KKMoVAI, 



I90H 



rNIillKTAKKK <X. 

'A(Mi. ss 



^ ^wL--Y'^^<_'-.' 






.1 \ ^^)Vv, 



i 






1 



. .11 " 

11 

! 1 


1 1 

1 


i n 

Il y 






. 



\ 

p 

J 
^ 

P- 



X C 

3 



«. 



•I 
'1i 



IS. B. Bvery Item of Information should be cnrefuliy Hupplieil. AGB nhoiiltl be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The ''Special Information" for per- 
sons dyinft away from home Hhould be ti^iven in every instance. 






'^. 



C'«i^ttr'' 



js- "■<•%.■; 



.- - . ♦*^" ■'•'"-' 






'^^ 




^^^nt: 


''i S&^ '^■•^B 


\^.*' 


> «^^^--^" 


- - ♦- 


■* '" ■■■■"■ ^ -■ - ^^ 




*. i. m._ •» •.-. «- ^4^ 



}■ 



i' 






( 



ti 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H.i;ir<l ..f IU;iltli »• N'o i^ 1^'^^^. H&I' Co 



i^OH 



XtrULv^ doi^vv, Deputy Health Officer 



Registered J^'^o, 



864 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Beatb 

( la. S. StanDarD ) 

4' (^ J? 



PLACE OF DEATH: — County of'O^^Aj Xcu-n-C-i^CtCity of C'<X^w /^<X ^vtvc 



'No. 




M 



/^ 






,. Ll) . d Uo ^ UX^^.tVoJJ lb (S <^ \\<J^. ^ \ St.; ^ ' Dist.; bet. 



and 



(IF DEATH OCCURS AWAV FROM U8UAL 
IF DtATH OCCURRCO IN A HOSPITAL 



RESIDENCE GIVE FACTS CALLED FOR UNDER "SRCCIAL INFORMATION' 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 



1 \^^V 



n 



I I 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \, ft 



DATl-; nl IMKTII 



i\xti 



tC>vK. 



iMdiith) 



A(,K 






rars 



(Day) 



MoHtAs 



(Yt-ar) 



Par: 



SINi-.I.K. MARKIKI) 
WIDOWKI) OK DlVnKi i:i) 

iWritr in «K'ial «1tvi^ijati<>tj) 



HIKTHPf.AOK 
(State or C'Mintry) 



\AM1- <>t- 
FATHl.R 



HIKTHPr.ACK 
Ol- lATHKR 
istatt nr rtumtry^ 



MAinKN NAMK 
OF MOTIIKK 



HIKlUl'I.ArK 
(U- MoTirKK 

(Str«t( or ('(iiinti> ' 



nCCl TATION 






^ 



L 



I 



MEDICAL CERTIFICATE OF DEATH 



DATFT nr nKATlI 



(Month) J 



(Year) 



% 



(Month) 1 (Day) 

I IIJ'KIUJV CI:RTII<V, That I attended deceased from 
Igo i to ....LV\^VCU S '— "^ 

alive on s-WVA... .a. 



I 

tbat I last saw h 



t 



190 k 
190 . 



and that death occurred, on the date stated alKn'c, at 10 
J. M. The CATSI^ ()!• DI'ATI! was as follows: 



AVv/(/a/ /n S<tif I'll! Hi 



),-.i, 



M..„n, 



Ih. 



VnV. AMOVK STA IJ:I) I'KK'ioNAI. I'AK TUTI.AKS AKI! TKI H TO THK 
llKsr 01 MV KNOW 1.1. D(.K AM) HHI.Ii;!- 



Ill foi 111:1 lit 



a. i CI 



< 



^Jys^' 



(y- 



i\. 00 



(\<h]Vi- 






DrR.XTION 

cqntriiu 

diration 
(Signed) 



) V*<7 r J Mouth s Da vs 

TORY d^rnJt^'^.A.t.AIL^-OU^^ i\ 



Hours 



Years Mouths 



Days 






Hours 
M.D. 



.tvQ 



IQO 



(.\ddriss) 



u rl^^ 



SPECIAL INFORMATION only for Hospitals. Insmutlons, TranslfBts, 
or Recent Residents, and persons dyini] awdy from fiome. 



Former or I f) ^ l 

I'sual Residence ^ v >^aOc J U 

Wfien was disease confracted. 
If not at place of deati) ? 






How lonq at 
Place of Death ? 



Days 



rj,ACH Ol- HI KIAI. OK KKMoVAI. 



\» L^lidL^n V C». '-s. 



DATJ;..; lit KiAl- or KKMOVAI, 



190 



INDllKTAKHR 



i.^)l 



\ 






V r\X 



fAd.lrtss 



IN. B. Rvery Item of in?ormHtlon should bs careifuily supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be ftiven in every instance. 



I i 



ll 



I 



ll 



H 



i ! 1 



'^■'-'>, 



t^'' 



'r|. ^ 



5;r. 



i^Ol^ 









Wtuf 



I] 



I < 



I • 



II 



%1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noi.nl.f H.Mlth KN'o i.t'^^^^lU'tlcN, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




,>^rvcvo 






i^(9H 

^4 Deputy Health OfTicer 



Registered J\^(). 



865 



l)(tf(' Filed, 

1 

DEPARTMENT OF PUBLIC HBALTH-City and County of San Francisco 



^No 



Certificate of 2)eatb 

( la. S. StanDarD ) 

PLACE OF DEATH: — County of O/CXax^ J . V(X > V e ' v City of O/CX-^v lACv 
,. M (Xol\u '^<XUwe^\- Ut :-^|v>AC\ ' St.; - Dist;bct. and ~ 

/ I* DEATH OCCUnS aW*V rWOM OSUAL RESIDENCE give facts called rOR under "special INrORMATION- \ 
V I IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 








iLa.:.. 



■0-^1 



PERSONAL AND STATISTICAL PARTICULARS 
DATK OF niRTH 

1% r%k>S> 



; ct)i.t>R \ A 



10 




iM<»nth> ( 



(Day) 



Ar.K 



iv jv<f» 



MuHtks Xi 



(Year) 



An 5 



SI\«.I.K. MAKKIKH 
WIDOWKI) OR I)IV«»KiKI) 
iWritf in •itxial dt situation ^ 



HIKTHJM.ACK 
(Statf or Country) 



NAMK Ol- 
I- ATHKK 



HIKTHPI.ArH 
(»|- lATHHK 

'State or Coiiatrv) 



MAIDKN NAMK 
OK MOTHKK 



HIKTHI'I.ArK 
(»!• MOTHKK 
(Stall or Country) 











o-^ruxo. 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII 

I 

(Day) 



(Month) ^ 



/go '. 

(Year) 



I III'RI'BV CICRTIFY, That I atten.kMl deoiased from 
\Xl.vO 1 IQO to LvA.^i-'j 



iQO to VVA-A-'CL t ic)0 ' 

„. ^'^^^ ^-" igo'- 

aiyl that death tKCurred, on the date state<l above, at 1- oO 
AJ^... M. The CAI'SIC Ol' I) I! AT 1 1 was as follows: 



t\yC^Vv<Y'VV' 



Dr RAT ION ■ )'i'ars Afont/n; /yays 

C 0>; X R I Hl'T( ) R Y LXX^ cLAJCtdt ...vL^lL i ^ 








DURATION Years '^krl!^^''^ ^''"^'"^ 

( Signed ) LI . M llv^Lu J 'O.qA^rV 



Hours 



Hours 



WK^K.X^ I iqo \ (Address) 



\\\ 



^jLav< 



(KCri'ATlON ^J 



Rf^idfii ill S,ni /'i lUii i^rii ) I'lii 



M.nifh' 



n<i\ 



TMK MJoVF: STATi:i) I'KKSOXAI. I'AKTUrLAKS ARI". TKIK TO \'\\V. 
HHST OF MY KN<)\VI.F:nt'.K AND HFJ.IHF 



(DifoMuant 






X 



M 



M.D. 



Special information only tor Hospitals, InstitutlMs, Transleiits, 
or Rfcfnt Residents, and persons dvln(j away from home. 



Pormer or ( r 4 

Isoal Residence J JLA^O^^-^ • ^ 



How loii(| at 
Place of Death ? 



Days 



When was disease contracted, I i 
If not at place of death ? v^. 



^v' 



DA'IICof HrkiAi- or RKMOVAI. 



PI^ACF: OI HIKIAL «»K KFM«»VAI. 

INDKRTAKKK VCUVM^^^'^'^VXAXV ^^CVvDwO 

(Address ' "I 5 ^JVvwM-.Os "'..d.', 



TQOH 



N. B.- 



-Bvepy item of information should be carefully supplied. AGE should bo stated EXACTLY. PHYSICIAJNS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be it'i^en '" every instance. 



i 



li 



i',i 



I > 

w 

rl' 1' 

• r 
(' 



:t^ 






yi-: 









, I 



M 



1 ! 



h: 






i;^i 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li„,,„I„ni, .111. IN.) ,.,VP^S4,iiSl'lo WEFER TO BACK OF CeRTIFICATE TOR INSTRUCTIONS 

866 



IfJO'i 



Dale Filed , LLlvcvvUIX '?> 



Registered J\^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "d. S. Stan^arD ) 

i..i^ .c.,% 



PLACE OF DEATH: — County of ICLA^O A.a>V/CAA.ecCity of a 



a. 



CCv 



\ i 
(No. LaIIu -^ V^VLAvtc 




VLAvtu ;v^-^K'•^'<^• St.; Dist.;bct. 



A / IF DEATH OCCURS MMAV FROM UlBUAL 
I] V IF DEATH OCCURRED IN A HOSPITAL 



and 



RESIDENCE Give facts called for under "special information" N 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



LLl^TUT^: It 



-V-VL^O... , . .A 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.DR ^ 



I>.\T1. »'I niKTII 



I 



\ 



\X..\\xkj^ 



•Month) 



AOR 



^ckt Yeats 



SINCI.K. MARKIKI) 
WrnnWKI) OK l)IV<»Ht i:i) 

'Wiiti ill ^<K-ial (Ifsiv'iiatioii) 



HIKTmM.AOK 
(st.'ttf or Ofiuiitry^ 



U'vc 



cL 



(Day) 



.MimUiy 



b^<r 



/i::,i 

iVt-ar) 



Jv C Days 



NAMK Of 

i-atiii:k 



HIKTin'I.ACK 

oi" I AIHKK 

< Stat»- i>r lutintry t 



MAinKS NAMH 
(H- MOTHKR 



urKTiii'LArK 
• >!• M(rrnKK 

(state or CouJJtryi 



m 



\)Ji\j:y<^ 







A^LA^^a 



. / 



i 






occi ^ATIoN 



'^A. 






) I a I 



yr.>„ih^ 



Iht\: 



rm-: \hovk statkd i'kk^onai, rAKTuri,\Ks akk tki k r<> thk 

linsr OF MV KNOW l.l.IxiK AND mWAV.V 



(Infoimant 






MEDICAL CERTIFICATE OF DEATH 



DATK or i)i:ath 



LLvcq 

(Month) ' 



5 

(I)ny) 



igo 

(Year) 



^ 



I III{RlvHY CliRTIl'V, That I attfti<kMl .Icccast-d from 



that I last saw h 



1 90 % to 

alive on 






dv ^ 



190 ' . 
190 



and that tlcath occurred, on the <latc stated al>ove, at X olw 






The CAl'SK OF Dl^ATII was as follows 



1 J . I "CL i^vQuV<> J JuJL: 



>^ \^ 



I )r RAT ION Years 
CONTRinrTORY 



Mouths 



Days 



DIRATION 
(SIGNED) 



)'i'ars Mont /is 

1 t%^^ 



Days 



I /ours 

/fours 
M.D. 



00 



( 



Address) V<^\U *^ ^-v^ ^ •- | ' 



SPECIAL INFORMATION only for HMpitals, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 



I 



Former or 1 ^ , i v V y *d J ""^ '""1 ** » 

Usual Residence ' Al ^ -'-' -VA ^T Place of Death? ' ' Days 

When was disease contracted, 
If not at place of death? 



ri.ACK OF lUKiAi. OK kf:movai. 



^Ja^wyw 



b zxh 



DATFIof Ml RIAL or KKMOVAL 



V.' 



ini)i:rtakkr 

(A<l<lr<'ss 



:UL^ V \ 



-% ■' 



T 90 \ 






N. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The ''Special Information" for par- 
sons dying away from home should be given in every instance. 



* i' 



r 



■I 



■\\\ 












..*r 










w^^ 




. I 






l^'' 



™ 




^^ \ 






it: 



i':! 



k 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H":.).! cf lI<:iHh »•■ No i '. -^'Var^SX; US: I' Co 






lOO'i 



Registerpd J^o. 



867 



DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco 

(Tevtificate of Bcatb 

( Vl, S. Stan^ar^ ) 
PLACE OF DEATH; — County of a>vlAa.>vC^. City of CV \ * ^^ 
No, Uii'l LloLu St.; 'X Dist.;bct. ""'Uck"Lfr>v and ^^VOv. 

/ \f Ot»TM VOCCUHS *W»V FROM USUAL R E S I D E NC E Gl VC FACTS CALLED rO« UNOCR "SPECIAL I N FORM ATIO W \ 
V IF DEATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 








FULL NAME vU 




^ 



I K 



'1 



PERSONAL AND STATISTICAL PARTICULARS 
SKX A.» ft I COLOR (U 

L 




■CL' 



a 



v>\.___ 



DATK OF lURTII 



(Month* 



Ann 



5^ 



JDay) 



A/.inf/i'^ 



rlSl . 

(Year) 



rfa\ 



SIN'.I.H. MARK I HI) 

(Writtiii SfHM.'il «lv.i^riiali«»ii) | . <^ 



niKTflPI.AOK 
(State or Countrv* 



NAMi: Of- 
lATMKK 



RIR lUfl.AfK 
OI I ATHKK 

iSlat< ur Coiiiitrv^ 



M MDKN NAMK 
<»l MOTHKR 



HIRTHPLACK 
()»•• MOTHKR 
(State or Counti v 






\J^^^(X 



v.C:-'^'S 



c 



IK ^:l■l>ATU)^• 



/\'t'-!i!r,I in S<iii ft an, lyri) •. v J'''" 



Mnnlh^ 



/hi^.' 



THi: AROVK STA IKI) PKR^ONAl. !' \ KT hT :. A KS ARK TRTK To THH 
BHST OF MY KNoWI.l-.DOK AND UlCI.II.l" 





(Iiifotinant 




fO 



Afltlrt'«<*< 



qcn 



/^vi. 



i t 



MEDICAL CERTIFICATE OF DEATH 
DATK OF I) K AT II 



Month) 1 



(Day) 



(Year) 



I HHR1:HV C1:RTIFV, That I atteiulc<l <lcrcasc«l front 

______ j^p jj, ..- ...190. r^r— 

that I last saw h alive on — igo ^"^ 

and that «Uatli f)cctirre<l, on the «late stated alnive, at 
:r~~ M. The CAISI*: ()!• I) I- A Til was as follows: 



'-4..WV/^-\^^tr^ 



-131-^^+. ' ■^Cn^'CwVC^' 



DTK AT ION 
CONTRIIU'TORV 



}'t'ars Months 



Days 



/lours 



Months 



DIRATIUN Years 

(Signed) .^Aj^^j^Ajj^j^^^ '.. ^- '^ 

LLuw<\ 1 Tc)oH (A.l.ln-ss) UC I ^ 



Days 






Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



PUACF: OF lURIAI, OR ki:M<»VAI, 



-x 



^ CC^v 






rtxc L'. 



DATFlof lit KiAi. or RKMoVXl. 



a 



^va 



>.> 



190 



NDFRIAKFK i / L<X N^ W ' C^K 



(A.ldi 



I 



li 



i 



t 



\ 



r 




ir^ 


9 


.A> 


C'^ 


'„> 






r 


P 


r 


^ 


^ 



< 1 



I 



^. B. Rvery Item oi information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" fop |»«r- 
«on« dyinft away from home should be feiven in cvory instance. 



'^■^::^:i^^, " 




t :i:i^w' 



.^^ ; -. 



-1 • . 7 







L-**'r'v. 



* V 










<Mr-^- 



^■P 



jf ■ 




. 1* 



hi 



If 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Iloanl of Health 1 No .. t^^^m^uS^V Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




± S. 



lOO'i 



Registered JVo. 



868 




])a/e Filed y VAvlO/Va-^' 

Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "a. S. StanC»arD ) 

fOa vu \1 \./(X ^vcuico City of 0,<X/vs^ Jxa ^ v e ^ ; 



PLACE OF DEATH: — County o 



H 



rMo. ^Ctlr^ Wv^C^vlu 'X'-' St.; 

\ f \r Dt»TM OCCUnfe *W»V FROM USUAL RESIDENCE GIVE facts called rOR UNDER "SPCCIAL I N FORM ATIOW '\ 
] \ IF DEATH OCCPRRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Dist*: bet. 



and 



\ 



FULL NAME 



v-^ 



4. . 



PERSONAL AND STATISTICAL PARTICULARS 

1 COI.OR 



I).\Ti: nl HIRTH "^ 




f t 

i 






Ai.K 






\ r 

il>ay) 



V.>M//i> 



(Year) 



Pa 1 > 



SINC.I.K. MAKKIKI* 
WIDnWKU OK IUVmRCKI) 
(Wiittin MH'ial «1« vi^Miatioii) 



MIK rillM.AOK 
sSlatf or Country^ 



^la- 



n 1 



^» k, w 



NAMK OF 

I AT in: R 






BTRTTfPI.ArK 
Ol I ATHKR 
(StJilf or Couiitrj-) 



MAIDKN NAMK 
ol MoTIIKR 



lURTHIM.ACK 
Ol- MOTMKR 
I Slat< >>r t onijti \ 



A 






\l 



o 



OCCri'ATION 



A,< 



Rfsiif^i! Ill Still t'l iiih I 'I <> 



) .-,: 



-if., nth 



/^M 



THK \HOVK ST \ ri-.D I'KRSnNAI. I'AK II'M" I, \KS Akl". IKri" lo 111}-: 
»KST ni- MY KNo\VI,i:i)C.K AND HKI.IKK 



(Infonnant Vv "V>V ^-' ' V A^i 






'A.ldri'ss VA^Lu ^^ ^--^ 



1 






MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATM 



1. 

(Month) 



(Day) 



I go 

(Year) 



I HI:KI:BY CICRTH^V, That I attcMnkMl (letvascMl from 

Haa^^V^w 190 to WLv,\.c:^. 5. 190H 

that I last saw h • • alive on -- • -—• ^ - I90 • 

and that (U-ath f>ccurrc«l, <»ii tlie «latc stated above, at i i-^ 



ril| ilini. «ivrii.ii «r\.\iiiiv«t, I'll *.ii\. vtriLV -»i«i.v»» €ii/«F»v, rx\. 

W M. The CAlJjIv Ol- DI'ATIl was as follows: 






J. . . JLs w)irS4c^^ .2U*« wLi6tr.>i^" 



1)1 RATH)N Years 
CONTKIIUTORV 



Mouths 



Days 



J /ours 



DURATION 



Years 



Mouths 



Days 



Hou 



rs 



( SIGNED ) ... lL -l^V ll CX^Ct . v^U^Nj .. 



1 



■U^q, 5 looH (Address) 






: \ v/O'^v^l' 



M.D. 

,5L4 U 



SPECIAL INFORMATION only 'or Hespilals, Institutions, Translfnts, 
or Recent Residents, and persons dying away from liome. 



Former or i/>-.*^4 

Isual Residence ' * ' 

When was disease contracted. 
If not at place of death ? 



How long at 
Place of Death? 



Days 



I'l.ACK Ol" lURIAI. oK RF:MoVAI, 



A 



INDKKTAKI 



I»\Tj:of HrKi.Ai. or RFMovAI, 
* ' * ■" 190 



.:r U tx<w^ >CLv, J ' ^O.X\. 



f.\(l(lrr<«s 






N. B. F.very item o*' InV'ormBtioti should be cnrefully Hupplietl. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSK OF DIIA TH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home «hould be ftlven in every instance. 



liMl 



u: 






ii' 

i 



II 



' 













<' 



"rrs 



vii-i 







K'^iir 



'^m 



ii 



.r. 



I' 



? 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)to:.r.l .-f Hi:. 1th »• Nf. is l^-T^^ l'.i«t 1' O 



RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begistci*ed JVo, 



869 



Dot,- /V/^-'/, uL^,v^ "^ 190 S 

^..Crvcv^ Ajla>-c( Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Ceitiflcate of 2)eatb 

( "Cl. S. StanDarD ) 

of a >\' '^\a. , . .- ^" ' ' 



City of 'CL"» V 1 h^O^ 






c 



^No. ^ ^ 



• ' '^ H 



"^ ^VU^-^ VA.'vn.^dk . St.; ' Dist.; bet. CV i v <L tr ■> \ v.s. and M 1 1 C ~> \.L CX. ". ) 

f ir Dt»TH occuns *w»v rROM USUAL RES I DENCE civc facts called ron unocw "s^ccial iNroRMATiON" \ ,^ . 

V, IF OtATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




,,J.V.a. ^\. 



/1^ 



R 



Qua.^.^1.' 



PERSONAL AND STATISTICAL PARTICULARS 
DATK OF HIRTH 

•T ,..'\0.H, 



1 Month) r 



U, \v.t 



AC.K 



(Day) 



Mouthf 



(Year) 



/>«/!> 



SINT.I.F.. M\KKIKI> 
\VFl>o\VKI> OK IMVnKi KI> 
(Wnttin MK-ial fi< •«i;/n!iti'>u) 



niKTHI'LAOK 
<Sl!ite or CiHiiitry) 



I ATHKR 



FilKTUPI.ACK 
OF I ATMKK 
(Stale or Country^ 



MAIDKN NAMK 
«W MOTUHR 



lUKTHrLACK 
oi MOTIIKR 

IStatt i>r Countrv) 






S^OL' 




II y 



LcLU. 



i 



WVW^VOU 



'iUXIm. 



(\ 



(KCirATlON 

P/'.uitfif in Snti I'l iiti, luti 



I 



'. ^-l I -^ 



) ,,;; 



M.„i!li> 



/',: 



THK AHdVF, STATKI) PKKSoNAI, rARTICr I.AKS AKi: TKIK T< » THK 
BKST OK MY KNOWMinCK AND HHMKH 



(Informant 



(Ad.lre 






XX'i 



'\aX^» vVVXC- 't\ 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



il 



I go 

(Year) 



(Month) - (Day) 

I HICKI'inV CI:RT1FY, That I attcnilcMl (kHxased from 
L^vOU b I GO to LLvA.CL. 



that I last saw h 



190 to 

alive oil 



a. - ^- 



I<|0 1 

190 * 



vsra-......1. 

anil that «lcath occurred, on the tlate statetl al>ove, at ' C H5" 

SX.. ^ 



rhe CAISI- ()!• DIvATII was as follows 



M. The CAl 

0^'>x<x^ 



DT RATION 
CONTRirU'TORV 



Yeoiis M<)n//is ^' •^<' Days 



Hoii»\ 



nr RATION ,,^ Ycar^ 



Months 



Pays 



Hours 



(Signed) 



Oi' 



1^ M 



I()0 






M.D. 



SPECIAL INFORMATION onlv for Hospitals, InslltuUons, Trauslfiits, 
or Recent ResWenfs, and persons dying away from Jiome. 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of death? 



How loR<| at 
Place of Death ? 



Days 



a 



PJ.ACK OF BIRIAI. OR KKMOVAI 



i)Ari:o; m HiAL or rkmo\ai. 



190 



rNDKRTAKKR 

' Addrcsf! 



N. B.- 



-Evepy item of inforrtiHtion should bs carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
sons dyin^ away from home should be feiven in every instance. 



. 



■ t 



• I' 



\\ 



I'l 



..III 
'' '(111 



% 



llil^ 



f.'l 



'♦ i 



. -I 
»1 












^.«i...^/^ 



-. V 



'V 






*-V-'-pt 






'1 '* 



Ri^ 






1>: 



•II 



) 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n.«...l..fTh„hl, rs.. ,-, ^fJffiSs liSlT,, RtFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 

870 



Re^i.stered J^fn. 



Dal,' nii-'i, LlwQ uvat a 1!fO S 

Xtrvc^ "^W Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of ©eatb 

( tl. S. StanDarD ) 
PLACE OF DEATH: — County of Oa >v JXC3L/\vOt4 C City of'"''O.Av vJ,^\UXTv^^wA.e^ 
__ ' Dist.;bct. '"'/CV >Vs1.Cj^^vX andM'l 

(ir orATM occuns aw*v rnoM USUAL RESIDENCE Give facts called for under "special information- '\ 
IF death occurred in a hospital or institution give its name instead of street and number. J 



(No.llH.'^J;)w4^>VV\^vC>L. St.; ' Dist.;bct/^.0.>VslC;_^^vX and^^ ) 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

nut !"■"■" lu.Li. 




\CXjaAA^*JU-C^ 



DA 11-: (»I IMKTII 



\nK 



'M<nith> y 



) I a I 



(Uay) 



r R OH. 

(Year) 



FHtx: 



SIN'.l.K MAKkIKI>. 
\V!lK>\\ Kl> "»K niVnRiKI) 



BIK rHI'l.AOR 
(Statf or O'liintry'* 



NAMH OF 
FATIll-.R 



BIRTH P1.A0K 

OI- lATIIKK 

I St;it«- or I'onntrv^ 



MAIUKV NAMK 
OI MuTin.R 



BlkTMlM.Ail-: 

<M MOTHKR 

' ^lati or Cotiutryi 










•\ \ /> 



tV 'v 



0^:Cl TATION 

Rfshifii in Siiii I'l nil, !^i-i> 






M.u,!h'. 



/),M. 



T H 1-: A IU)V F. ST A T >; n P K K SON \ I. I' A K r U r I . A K S A K J^ '^ « I' ^ 1' ' '" " ^• 

hf:st OI- MY KN t\vi.i:i)<".K AN^ ni:i.ii:i 



MEDICAL CERTIFICATE OF DEATH 

DATK <»F DFATH j 

Uw^' - ^ 



(MoiitlO 



( Day) 



I go 1 

(Year) 



I IIi:Ki:nV CI-RTII-V. That I attiMuU'd «lcceascil from 
r-rrrrr. 190 tO - 



til at Ttast saw h 



alive on 



ngor 
-190 



ami that «Uath occurred, on the date stated ahovc, at 

^ M. The CAISK OF I)I«:ATII was as follows: 

^ f1\ ■ 



K 



TAJw^"^vc5L.tvvN^ Cp,s,^:Liv 



Dl'RATlON Years 

CONTRllU'TORV 



Mouths 



Days 



nrRATION , )'cais . Mouths 

,NED) )-^V0>vA^^ A Lt. < 



IhiVS 



(SIGI 



Ajl- 



v- 



Hours 
Hours 

m.d. 



a^ 



ll>0 



( Address) Lc-'V^^^ V<\^ L .^f! •. '; • 



Special information «"'> for Hospitals. Iiistltiitloiis, TraBsifMs, 
or Recent ResMfBts, and persons dying away from ho!»e. 



Former or 
Usual ResidfBCf 

When was disease contracted. 
If not at place of death ? 



How len^ at 
Place of Death? 



Days 



(iTifoiniaiil wV 






•A.l.lrcss 5. XH ^--NwCt ^VVV^V Ck 



ly.ACK OF Bl'RIAI, OR ki:Mo\AI. 



I NDKRTAKFR jVCVWi. ^ v ^ ^ 



l>ATl-:ot H( KIAI. or RKMOVAI. 



[90H 



^\d<ltes*4 






\ , 



r>j. B. Every item o* Information should b.- carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly wlassiried. The "Special Information" for per- 
sons dyinft away from home should be ftiven in every instance. 



li 



1 I' 



I"! 



1; 



If I 



1 



li 



.<U! 



?» 



* 4 



\.\ 



i^>C2.- 




C^' 



♦T 



•♦ *• 



V ».. 













•'t' 






f 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noar.lofiicalth . NO ..*^^^^H&I'C<. REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dafe Filcff, LUvCWL^t ^ I'^O H 



Begistej'cd *A^o. 



871 




^A.>Ky^^ 




.xH-4, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. StanDar^ ) 



PLACE OF DEATH: — County of ^ ' 0^ 



1 rrl 



LCL>V^ 



City of VA^t) L VsLV 



Oj 






A . 



No. 



SU 



Dist.;bct. 



and 



/ \r DEATH OrCURS AWAV FROM USUAL R E S I OE NCE CI Vt facts CALLCD for UNDCR "special INFORMATION" 'V 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



(?n 



FULL NAME 



.Vw 



hj:>uy 




c 



.ClA,4.^Y^_0. 



PERSONAL AND STATISTICAL PARTICULARS 



sKX 



DATl-; or IIIKTM 



M.V. 






COI.OR 



V±. 



b 



Month) 



^ 



IVrtiA 



(Day) 



Months -5 



/. W... ,; 

(Year) 



An 5 



siNr.I.K MAKKIKP. 

W II>o\VKI> OK I)IVoK«i:i) 

iWiitiin v(H"iaI (h -iv'iialion) 



HIKTin'I.AOK 
I State ni I'outitry^ 



NAMK OF 

I A 1 1 n : K 



MiK rm-i.ACK 

O! lAlflKK 
'St.it« "ir CDiintryV 



MAIDKN NAMK 
ol- MoTHKK 



niRTHPI.ACE 
Ol- MOTMKR 
'StaU or »."<)untry) 






fi< 



(X^Ivjv>v 



cue w VWCX/^ A^^^' 



-^ 

^ 



d-A.^^.'^V 



^l^^VX^Ow 



1. ^ 



^CU vx<^. 



? 






OCCll'ATION 



k'fsitirii in Son I'l iiii, i i ■■ 



^r ..f/n 



/;,/!. 



TH1-. AROVK STATl'I) I'KRSONAI, rAKTUTI \ K >- AKJ- TKri-- TO IHK 
IJKST Ol- MY KN0\VIJ:I)«.K AM) Hi:iJKK 



lnfi>nnaiit v\/ »^^^^ 



'' W^ ■* ^ "'' 



■■7\ 



4 ^K 

(Address H 6 I C/Ct-^ V 'D X^V ^ 



MEDICAL CERTIFICATE OF DEATH 



DATK OK I)I:ATM 




I Hi;Ki:nV CI;RTIFV, That I atttii.UMl «Uh tasea from 

-— 190 • to • j qo-rrrr . 



that I hist saw h ~ — alive on —.- ...: :j, .iimiumnu i .uijin..i ' . i igo 

and that «Uath (K^currcd, mi the date stated above, at 
M. The CArSI*: OFni^ATII was as follows: 

WvC/CA.dLL^'vfcx.A. X 'w.?^ u'.j . .... ...V 



DIRATION years 

CONTRinrTORY 



Months 



/)ays 



I /ours 



Years 



.'^foHlhs 



\ 



DT RATION*^ }cai 



KjO 



/hlVS 



(SIGNED ) 



Hours 
M.D. 



(Address) -^i - 



I -1 



SPECIAL INFORMATION only t»r Hospitals, Institutions, Transifiils, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 
Plareof Death? 



Days 



I'l.V^K Ol lUKIAl. OK R1:MoVAI 



DAIICuf HiKiAl. or KKMOVAI, 

L . :> 190 



rNi»):KTAKi:R 



N. B. Kvery item of inSormntion .hould hi ciirefully Hupplled. ACR Rhould be Rtated EXACTLY. PHYSICIANS should 

state CAUSE OP DEATH In plain terms, thnt it miiy be properly classified. The "Special Information" for p«r- 
sons dyinil away from home nhould be fti*en in everj Insta.ice. 



' 11 




1 ''^ 



■t^ 



. •* . ■■*■■ 



nil 




r 



.^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Uoar.1 of l!t:il!h 1- No i <; t^^^JlUtl'Co 



I)a/c Filed, LLcva^uut ^. 190^ 

X^vw^ l^xHo^ Deputy Health Officer 



RE FER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 

871 



Begistered JSTo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "0. S. Stan^arD ) 



PLACE OF DEATH: — County of U CTL Cl. yx.>0 City of 



n 




I) 



t, 



A^^A^OU 




No, 






( 



St.; — Dist.;bct.- 



and 



\r Dt*TH occuns »wav from USUAL RESI DENCE Give facts callcd fob under special information 

IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



) 



FULL NAME 



....J..AXX/^ 



A C (S 



Ct^\. "v.^.:v..CLa.:u.>nu.. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 



vTiVcU 




VA^ 



DAIl-: O!' I'.IKTM 



AHK 



<la>^ 



• Month) 



<Day) 



,1.11 

(»fcr) 



) I It t 



Xfamiks 



Da v. 



•^INt.l.K MARKIKP 

\\ II)o\VHI> OK IHVoK« Kl> 

'Wiitciti •'•H'ial <l«'<ii'iiatn>tj) 



OlAA \X>v 



lilKTHlM.Xi'K 

I Statf or •■otinlr\ 



NAM!-: OF 
KATMKR 



MIK'lllf'I.ArK 
«>l- I A I'll HK 
(Stat*- or Country^ 



MAIDKN NAMi: 
«»»• MOTHKR 



MIKTHIM.ArK 
Ol- MOTHKK 
(Statt or Ooimtr\ ) 



iKeri'ATlON . 

k'r^idrd in Situ I'l o n, i rn 



c. 



.(^ 



OJ^^^y^ C5L''> v^v-w 



MEDICAL CERTIFICATE OF DEATH 



igo 

(Year) 



DATK OK I)I:aTH ^ 

Li^^uq, 5 

(Montli) \ (Day) 

I IIHRI'HY CRRTIFV, That I atUn.lcd .lecease«l from 

190 to /.■■ : :.^u I90 — 

that I last saw h -- — alive on ' • :..i.mii.'i. . uM..fm.i..w- i^...-!CTrCT 

ami that <leath occurred, on the date stated above, at - ■■•"—•;•■. 



— — M. The CAl'SU OF DKATII was as follows 



nr RATION Years 
CONTRIIJI'TORY 



Mouths 



Days 



Hours 



C3 ^vn^t^Jw^vL 



CXwC\^ 



r^Jru^xx 




)'/■(?/ 



M.'nth- 



/ht 



TUl", M»()VI-: STXCKI) »»KKs«>XAl. I'A KTUM" I.AKS AKi; IKI i: T« » IHH 

m:sr oi- my KNowi.iinr.K and hiiukk 



(I 



iif )rmant \JsJ 



TW 






.\k.K.-^\^ii.\. 



Dl' RATION,^ , Vtars 



(Signed) 

LAvL-...^ .. T90 



4 \1 -h ; 



Jf()N//lS 

^ 



Pavs 






Hours 
M.D. 



(Address) VIVlc ^ vvLo. L:^ 



SPECIAL INFORMATION only for Hospitals, Institytions, Transients, 
or Recent Residents, and persons dying away from home. 

Former or How lonq at 

Usual Residence Place of Oeatk ? Days 

Wlien was disease contracted, 
If not at place of death ? 



PL.^CK or BrRIAI^OR KKMOVAI. 



.^- 



INDKRTAKKR 

(Address 



* '¥ ^,.Jv. 



DATHof Burial or RKMOVAI^ 

V.Ll . ^ ' T90 



ij^-i .u)i\.4.aj.,^^ :*! 



N. B. Every item olf In?ormntion should hi CBrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for per- 
sons dyin^ away from home Hhould be ^iven in 9\9ry Instance. 



'I 



\ 



i! 




I> 



I' 



I I 

i.'! 
1'^ 



!! 



i^i 






V ' 



i 



♦ 



He 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

«,r„„f,U.aU.,-..N'o,= *gl3|.,*rCo WeFER TO BACK OF C eRTIFICATE FOR IN8TRUCTI0NS 

873 



l)a/e File<l, LLwa^v^ ^ 1^0 H 

dLfr^uus XtAjM.! Deputy Health OfTicer 



Registered J^''o.. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( la. S. StanDarD ) 





PLACE OF DEATH: — County of v^Cr^^vCVOj 



CtV'CU Lc)-^Xo..* City of 




JLv 



(^ 



(XKK^'^^JLri VCLU......... 







'No. 



St. 



Dist.; bet. and 



/ ir DEATH OCCURS *W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
i. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

(A) 



) 



FULL NAME 




.>^:y\:>u^i...S^\^:S,^.s^s^^ 



PERSONAL AND STATISTICAL PARTICULARS 



SHX 



(^loL 



"■"■ U)i 



\jduL 



I>\T1. Ml- IMRTM 



\C,V. 



I Month) 






(Day) 



vttl 

(Venr) 



Mouthy 



Pa V! 



SIN'ril.l?. MARkIKI> 
WIDOWKH <»K I»IVOKrKI> 
<\VrJt«iu «-<x-i;il «U^i}.'ii:iti<Ju) 



^ 



<Xh^\x-^cJw 



HIKTHri.AOH 
(Statt" or Cotmtryi 



NAMK OF 
FATIll R 



HIKTHIM.AOK 
«M I A I'll HR 
'Statt or Country) 



MAIUKN NAMK 
Ol- MOTHKR 









1 



ll i ^ 



RTRTIIPI.ACK 

«>J MoTHHR 
(Slate or Countrv) 



OCCIPATION 



Aa/O 



L\^*^ 



Resided hi Son /'i ,ini /M\) 



) i(j I 



^f<l,^t^lf 



/hn. 



IHK AHOVKSTATKI) PKRSONAl, I'AK P UT LAKS AK K TRTK To THH 
BKST OF MYJCN«»\VI.KI>r,F: AND BKIJKF 



V' 



'Iiifonnant 



d 



(Afhlrc^ 



*> 



s^*Wv^ 






MEDICAL CERTIFICATE OF DEATH 
DATE OF I)F:ATII 



ll 



-W.A^.a L.. 

(Month) n (Day) 



I go 

(Year) 



I HF:RI:IJY CI«:RTIFY, ThHt I attcmknl deceased from 

to -t:.: 



IgO to •^' 190 

that I last saw h - alive on — ■ -■■■■ I90 

aiiil that death occurred, on the date stated above, at "^"^rnt: 
The CArSI*: OF Dl^ATlI was as follows: 

■ A^or^^r^<;:, V wv^l ' .- . . 



4 



DrRATION Years 

CONTRIia'TORY 



Months 



Days 



Hours 



Dl' RAT ION Yiars^ Months Days 

(SIGNED)...^ ^i^ LcW<rtl_. ..* 
UvAa^ .1 Tc)0 H (Add ress) Vl / LaKlc vxXv ^ 






Hours 
M.D. 






Special information only for Hospitals, Inslltiltloiis, Transkats, 
or Rpcent Residents, and pt rsons dying anay from home. 



Former or 
Usual Residence 

When was disease contracted, 
if net at place of death? 



Now I0R9 at 
Place of Death? 



Days 



PI,ACE_0F Bl'RIAU or RKMOVAI, 



DATl^of Ht KIAI, or RHMOVAI, 
M 190 . 



ly: : 



rXDKRTAKKR yV^CCCvLctX 

^,SL ^\^^.:%^,.t.^ 



(Address . 



N. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" f«r per- 
sons dyinft away from home should be ^iven in every instance. 






^ ' * 



i 



1 ■■ I 

V ill 

.•til 



wmmUmmmm 



# 



\' 







\ 



i 



i P. 
j, \.. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ „, ,„.,.,. K s .,,.^^S?i..„..Co RtrER TO BACK OP CE»TT.C*TE TOR ■N»TR»CT.ON« 

873 



..vLa^a^^ 



,^wa a i^^H 

Deputy Health Officer 



Registered JSTo, 



I )((((' Filed y \XA.A^q^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



'\M.f 



Certificate of Death 

( Ta. S. StanDarO ) 



'V. 



Na 



PLACE OF DEATH:— County of'J^^^^ >^- - Gty of'''a>^ ,^UX'>x^^<l c. 

115 \cld.t>^.'^ibl ll\'^~ St.; 1 DUt.;bet.l)ji-A>^ct<W> and vDfl-fri.v- ■ 

J .CtV^v<LL.^'-tr^X 



on 



FULL NAME ,CC>x.-.^^_li. 



sj:\ 



tTP 



PERSONAL AND STATISTICAL PARTI CULARS 
^, I COl.OR > ^ .^ 

................. Q^^^^^ .^ ^ 

iM..jith» 



A4.K 



C 1 JV<ii 



( l)ay> 



Months 



(Year) 



/)./ 1 



WmnWKD OR niVuKv KI> 
• Writf in mkm.iI fUsitc""*'""* 



lUHTHl'I.AOK ^'^ 
st.-iti or roinitry^ f '' 



nitryM' I' 



v'<xtvw 






CVx-v^i-.-d 



0..'>">vivU">.0 



!, 



:w^ 



NAMK Oi- 
l-ATM I:R 



niRTHPl.AOK 
OI- I ATHKR 
(State «»r Country 



MAIDKN NAMH 
l»F MOTHKR 



lURTHPUACK 

n|. MOTHKR 

• St;iti or CouiUrv^ 



OOCITATION 




1X^ 



IVVs -^ 






^ 







Otv^CLe^vi 



_ UXV>>\.fc^v 



I 



Rfsitff)! in Siin f'l ani isii> 



)V(M • 



M.oifh- 



Ihn 



THK AnoVF, STA Ti:F) PKRsoNXl, rVKTHri.AKS AKK TRIK To THK 
IIKST Ol- MY KNoWIJ.Di.H AND lUCI.lKF 

(Inf'.-matit <S,/O^V-\^ Ou V s-* •>...■ 



1 



1^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII H 

LvL\.q 

(Month) [ 



(Day) 



igo 

(Year) 






I HF':RUBY CI':RTIFY, That I attcinled deceased from 

LLs^^w^o....?.. 



...la^u ;t- 



190 



to 



tliat I last saw h - V alive on XAAa^CL.. I ic/) 

and that death <jccurre<l, on the date stated ab«)ve, at 
_ \I. The CAUSK Ul' DICATI! was as follows: 



Dr RATION 



Mouths 



Years 
CONT R I urTORV Z..r^LoX<xL^c:>: 



Days 



Hours 

'^.NC, 






nr RATION % Years 
(SIGNED) DK '^b 

r> 190 ( Ad<lress) 



^f()utf^s 



/hivs 



-cV iv o^.^-: 



c \ 



A., 



f i 



Hours 

M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death? 



How lonq at 

Place of Death? Days 



I'LACF: of HIKIAI, OK KKMoVAI, 



X ti . 



DATFlof Itl KtAi. or RHMOVAI, 

.. LLwv.-.^ ,...!. V 190.:. 






FNDliRTAKKR 



U CrCU.' 



^1, 



.•x^ 



(Add 



re 



s. 11.3»,. '^K.d^:Av..:\),aL.^.^^ 



N. B. Every item of information should be carefully aupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for per- 
sons dyinit away from home should be given in every instance. 



' < f 



n 

m 











w 








If 



■i- I' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Wg FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ll..;,r.! of Henlth-H No. i ^ 'ft^*^:^ H& P Co 



lJ(f/e Filed, LLL-A^x:t^wA.AJt ^ 



jOO^ Begistered JVa 

"^1^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



•x-trvcu^ ,>wJUvM.< 



Certificate of 2>eatb 

( "Q. S. Stan^arC* ) 



PLACE OF DEATH: — County of ^^(X^v OXC - av^ . C 



^C and 



No rri5 .^Idcw.'^.atx U^>^ St.; .^ Dist.;bct. 

/ ,r ot.TH occurs .WAY rROM USUAL RESIDENCE G.vc r.cTS CM.LCO ^onuHOtn «;";*i 'J^'^j;!';*'*' ) 

( ir Ot*TH OCCURRtO IN A HOSPITAL OR IMSTITOTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

I? 1 



UU)r. ) 






FULL NAME OXLa^^^^ 



.CtVvx/O^cu 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^ 



DATK OF niRTH 






COI,OR ) 



wi.^-i%jy^x. 



<X*V' 



I Month) 



A<.K 



^IN«.1.K. MARHIKT) 
\VII)<»\VK1» OK DIVOktKH 
(Writf in Micial dt'«*iKn:«li»>n) 



HIkTmM.A«"K '> 

St.iti o! Coimtiv 



}■»(/» 



( Day) 



\faMtky 



(Yt-ar) 



/hi » 



^m 



O 



NAMl <»F 
FATHKR 



RIKTHIM.ArK 
Ol I ATHKK 

.'StaU- or Coiintrj-1 



MAIDKN NAMK 
OF MOTHKR 



HiRTHPi.AtF: 

OF MiiTHHR 
stalv or Country i 



OCCn-ATION 

Rf>,dnf 






)<X>iv!\^iwL* 






-1 



cv<Vu^^vou 




'wcUUtr>x. 






1- 



>,.•>/ /"; till, isi'i' 



)V.M 



yf..,ifii' 



I III 1 



THF. AHOVE ST^ rF:r> l'KK»^ONXl. FAKTUri.AKS AKK TRIF: To THK 

nF:sT OF Mv knowi.f.ix.f: and bhi, n:F 



'Itif'>-inant 



,A.Mn-.s nn& v)cr^.i 



/~1 



MEDICAL CERTIFICATE OF DEATH 



DATE OF I)F:ATH H 



(Month) \ 



I 

(Day) 



(Year) 



V 



I HKRUHY CKRTIFY, That I atteiulcMl deceased from 



Xxxi l.^.tli loo to WVA^^-. C 190 

that I last saw h •' - alive on \taA^\.^qL I left 

and that death <KCurred, on the date stated alnn'e, at ^ 
M. The CAl'SU OF DI-ATIf was as follows: 



y 



C^^'vjL^OA.cx.t .W^yx.i^'^wCv'Vu 



DTK AT ION Years Mouths Days 

DIRATION % Years Mouths Pays 



Hours 



(SIGNED) 



Ok *^:b^v>^^ 



Hours 
M.D. 



icp 



( Adilress) 



■:, c\ 'DA.vt'., 



SPECIAL INFORMATION 9nly 'or Hos|mUIs, InstittttlORS, TransifRts, 
tr Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death? 



days 



placf: Ol- luKiAi. OK kf:movai. 



T 






I)ATF:uf IK KiAl. or KKiMOVAI, 



190 



FNDHRTAKKR O &'VL,' 









JN. B. Every Item of information should be cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for psr- 
sons dyinft away from home should be i^iven in every instance. 



'•J 



? 

^ 

^ 
^ 



1i! 




•;l 



' if 



r. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noanl. . f Health--.- Vo..^^gg^»«^^- CO REFER TO BACK OF CER TinCATE FOR INSTRUCTIONS 

874 






^^^v\^ 




'^ 



lOO'i 

'V "--llhQ 



Meglstered JVo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiftcate of 2)catb 

{ XX. S. StanOarD ) 

PLACE OF DEATH: — County of C)/a>v vJA.a./i\/e.ULC.City of O/O/^x^ vJAXX^^vCUi c 
'No. Ol vL^JL/»VCnvt' VA'^>-^. -St,; ^ Dist; bet ^IVCCUAa^cA^ and LL^ClII 



tv- 



/ ir Ot«TM OCCUBS *WAY FROM USUAL R E S I DE NC E CI VC facts CALUCD for under "special INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRICT AND NUMBER. / 



Oil 



lV 



FU LL NAM E ...L'l\.JL..cl. .^'r .. ^ywXj^ '''^. 




PERSONAL AND STATISTICAL PARTICULARS 



I)\TK Ml- niKTM 



I COI.OR ^ 



4vcLk. 



I Month) n 



(Day) 



(Ytar) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH /^ 

(Day) 



(Month) ' 



(Year) 



\».K 



)V,M 



M, Hit In 



Davs 



\vinn\vj:i) OK i>!\t>K»»:i) 

iWritriii •iinial tlfsiv'nati'»n) 



niKTHlM.AOK 
iStntf or t'oimtrv 



NAMK OF 
FATHKR 



mRTuri.ArK 

OF FATIIFR 
!Stat« or Coiintrv) 



maii)f:n namf 
of mothkr 



I'.IKTHPKArK 
o|- MOTMKK 
(Statf or Country^ 



'WvxCjA..^ 



A 1 



XX c^1 



r 



\ U 



K K 






OCCIPATION 

RfMih'if i)i Smt I'lavi ism 



)'< iT I 



Mn>lth< 



I 



/></ 



THH AHOVK STATF.D PKR^-ONAK PAKTIOr I.AKS AkK TRTK To THK 
nF:ST OF MY KNOWM.DCK AM) HKMICF 

(Informant C- \"V"V^''*»^ 



c-vo ■ * 



i 






LL^s^CL L 190 

til at I last saw h 'c»-^>% alive on 



190*1 
190 H 



I HKRr^BY CERTIFY, That 1 attciKlcd (leoeased from 

S to U-I^vOl !>. 

and that ilcatli occurred, on the dato stated above, at <?v 
LL-M. The CArSI? ()I« DI'ATII was as follows: 



,v.'.: 



Di; RAT ION Years 

CONTRIIU'TORV 




Mouths Pays j ^ Hours 



■(?^^t.vv.^ %^-^^^-^ ^'^V-,," 



nr RAT ION 
(Signed) 



)'cars 



Mouths 



\^\\rv\j 



/)ays I ^ Hours 



I UvOlI h^H (A ddress) ICl liavCtow. M 



M.D. 



SPECIAL INFORMATION onlv for Hospitals, InitltBtloBS, Transkits, 
or Recent Residents, and persons dying a^ay from lioiiie. 



—1: 
sTiSt 



former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of death ? 



How lonii at 
Place of Death? 



■■ Days 



PI.ACF- OF nrklAI, OR KFMOVAI, 



DATFoJ" »i RIAL or KKMOYAI. 

'^i 'On f 

rNI)FRTAKF:R ' - Vn V C> ^. '. oU-* ^ *- '" 



,\ V. 






190 M 



'All dress 



^^aS^x^ 



AJt\.v 



'Q-^vC:^.: 



4 f 



N. B. F.very Item of Information should be carefully nupplied. AG6 should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for psp- 
sons dyin^ away from home should be g^ivcn in every instance. 



f 



l-ll' 4 



"'i 



\ 



% 



lid 



! 



H< .:(!<! of !l. :iHli- »■ No It, '*^! 



'hi,, 
1: * 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„S: 1' Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

875 



Registered J^To. 



Dale /'V/<v/, llvvoWt S 100 H 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ceitificate of Death 

( "U. S. Stan&arD ) 

PLACE OF DEATH: — County o£C)cL'>aj JX<X->^^uiC(City of Clo. > v vX^^KX/vv C>l/^ c.c 
(No. l^i^ *LccL\.Vt>vC) St.: '^. Dist.;bct. 1 3 XL^. and 1 1 li..v 

/ ir Dr»TM occuns »w»v fhom USUAL RESIDENCE Give r*CTS caulco ron UNOti* "s^rciAL information- \ 

V IF DEATH OCCURHeO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRECT AND NUMBER. / 



) 



FULL NAME 



■CV SA^.L^Xfrl/yjO.. 






PERSONAL AND STATISTICAL PARTICULARS 

sHx A ^ I coi.oR ^ 



I)\ I i: «>»• IMKTJI 



AC.K 




i 

(Day) 



r ^ '^ 

(Year) 



W )•/.;.. 



M.mili 



/Vl.v 



SIN<.l,K. M \KKn-l» 
\VI1M>\VKI>«>K DIVoKiKO ) 

• Wiittiti OHMal <U <is.'natJ<>n) 



lUKTUI'I.^ri-: 
St.'itc or I'ouTitrv 



V\Mi: Ol 
I- ATllHR 



PIR TUri.Al'E 

OI" I ATHKK 

t State tir C«uiitrv) 



MAIDI.N NAMi: 
Ol MoTUKK 



luk rin'KACK 

|>1 MoTMKK 
ISlalf or Country 



OCCIPATION 









V w' 



- V V 




2 /<Xc\j"v4v^v>^vt 



wL^vrL 



\xc w'/". u 



^^a 



o 



II 



cL 



.<vc 



i 



%V iv 1 vi^jwi.:^r ^ 



Krsii!fd in Sun /'i iin, i.uii 



) t<l I s 



Months 



l\i^ 



rHK AHOVK STATKI) l'KR<.()NAI, TAR riCCLAK^ ARK VKVV. TO THK 
KKST OF MY KNOWl.KDC.K AM) HHIJKF 



finforniant 



^/cLco m Clv^. 



\XjL V"W<^. *s. -\ 



I 



(Address 



ttC ''^wCNAX^<; 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATII I 



(Month) \ 



I 



igo \ 

(I^y) (Year) 



I HlvRHBY CIvRTIFV, That I attendtMl deceased from 

— to 



tliat I last saw h 



190 to :;...igo 

— alive on ^ •. ■ 190 



and that death occurred, nii the date stated above, at 
r- M. The CAISIC OF DIvATH was as follows 






nr RATION Years 

CONTRIIU'TORY 

DURATION rears 

( SIGNED ) A^XcrvAwAA) 



Months 



Pays 



Hours 



Vont/is. 



nki 



Days 



) 



:SjLX<X'\^-A. 



Hours 
M.D. 



U 



tqo 



(Address) L^r*Un\JUv>5 KJ.J^V 



SPECIAL INFORMATION only for HospiUls, lnstilyti«Jis, Transknts, 
or Recent Residents, and persons dying away from home. 



Former w 
Isuai Residence 

When was disease contracted. 
If not at place of death? 



How long at 

Place of Death? Days 



ri,ACK OF lURIAL OR RKMoVAI, 

(Address i.lH . U .. J /tX^.AJwJUw ill 



DATFIof Ri'KiAi. or RKMOVAI, 



T90N 



N. B. Fvepy item of Information should be carefully Hupplied. AGE tthouid be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in »jlain terms, that it may be properly classified. The ''Special Information*' for psr- 
sons dying away from home should be given in every instance. 



■ 3, 






!i 



■t ! •■ 



I 



li 



J' 

•it 



• H 



i 



li 



I If 



j^L 



( 



\ 



i I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boar.1 of Ileauh 1 No .. ^^^^^^ V.S.V Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1 ^^ 



190H 



Registered A''o. 



876 



.WW\J5 




i Deputy Health OfTiccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( Xa. S. StanC>arC> ) 

; — County ofCj/OL.->\' '^. '^ Vv.CL^.:...City of'"''0^^ OJvXV>V'Ca^ 7 



PLACE OF DEATH 



V 




/ ir DEATH OCCUl»9 AVW*V FROM USUAl R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "SPECI At' I N FOR M ATIO N • 
V ir DEATH Ociu*|»RtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET Afi D NUMBER. 






^ 



FULL NAME 






A, 



Ti 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR \ 




^ 



CV 



U 



ILlkdt 



I)\tj: Ml lUKTn 



• Month) 



ACK 



I )Vttrf 



<nav> 



Xhmtkf 



Aim... 

{\ ear) 



Pav: 



•^i\<*.i,r:. MARKii-.n 

WlDoWl.I) OK IMVoRiKU 

'Writrin «.<K-i;»l il« — ii,'n;tli'>ii) 



I St.iti or «."'t\iiitt % 



1 ATIIKR 



UlKTin'I.Ai'K 
Ol- lATHHR 
(State or Coinilrv^ 



MAIDKN NAMK 
nl MnTIIKR 



RTRTTIIM.ACK 

••I- MuTIIKR 

' Stat* or Countrv) 



OCCI I-ATION 

fx'f'.^ritfif III Siiti /'i i! Ill IS' •> 




M 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATH 

...1... 

(Day) 



(Month) J 



190 \ 
(Year) 



I .1II:KI;HY CI:RTIFV, That I attemlcd deceased from 

.190 S 



\,cLv^ ^X \Kp to LLv.iw.CL ^ — * 



that I last sa w li J^^^>> al i ve on v^-V vcL L . 1 90 

and that (loath occurred, on the «late state»l above, at 
^ M. The CAISI' OF l)i:.\TlI was as follows: 



IM' RAT ION Years \^- Months Days 

CONTRIIU'TORV 



nr RATION Years Mouths 

(SIGNED) LL a. -<,' V<X.| 



/)ays 



H. 



)' III 



y/.iiif/i.^ 



/hl\: 



THK AHOVK STAII-n I'KRsONAl, PAR f IT T I.ARS AK K TRl K To THH 
HKST OF MV KNOW I.l.lx.K AND T.FMl.F 

(Infovmant \J /Vv^ ^ NXv^OhXl^ 

(A.Mr.ss ID dt Mvavu. 



k.1* ^-Q^ I uyo X (Addrt-ss) OLC^ -wO.\ 



Hours 

I Jours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Translfits, 
or Recent Residents, and persons d>ing anay from lionif. 



Former or 
Isual Residence 

When was disease contracted, 
It not at place of death ? 



How ionq at 
Place of Death? 



Days 



I'I.ACF: OF HIRIAI. OR RKMOVAI, 

1 



\ 



\ 



^ DATHoJ UiKiAi. or RHMOVAI^ 

NDKRTAKKR vL VvCLc^*,. ^^^^.^Lt^^ iX. '»*V-«^ ' 



(Address 



N. B. F.very Item ok' informution nhould \^z ciircfully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be ppopcply classified. The "Special Information** for psr- 
sons dying away from home nhould be given in 9\^ry instlince. 



\ 



tli 



I 



♦1 



I • 



A. 



mmmm 






Vi^ilk 



\ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no:.ni.,fn. .Ill, . vo ..iS-t^PH^IOo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dnfr hllcd, LWoA^v^i ^ lOO'i 

d<.^r\j<^^ sXoM^ Deputy Health Officer 



Registered JVo. 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of LC'^<X/VAXtXCL 
^No, 1 "^ ' ' - St.; ^Dist.;bct. 



Certificate of Beatb 

( *Cl. S. Stan^arD ) 

cLcL' City of V Culi.LcX'^A.d. \.'Oju. 



cCLl 



-and 



/ ir Ot*TM OCCURS *WAY FROM USUAL R E S I D E NC C CI Vr r*CTS CALLCD for UNOCR "•PCCIAL INFORMATION" \ 
V 1^ DEATH OCCURRCO IN A HOSPITAL OR INSTITUTION CIVC ITS NAME INSTEAD OF STREET AND NUMBER. • 



) 



FULL NAME 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 



M 



DATi: nl- KIKTH 






a 



<\^^ 



i 



.lk..l 



I. 

• M..iilh) 



a<;k 



WIlMUVKI) OK mVokiKI) 

(Write in mkmuI tU-^iv'iiatioii) 



)''tii ' \ 

P 



(I>av) 



Mntlfhs 



T ^0 h 
(Year) 



Pit M 



lUKTHlM.AOK 
(State or C'HUitrj-'' 



NAMK ol- 
FATHKK 



HIRTHPI.ArK 

OF J ATHKR 

I State or Country) 



MAIDKN NAMK 
OF MOTHKR 



iukiupi.acf: 

•»1- MOTHKR 
^tatf or Country) 



if} I M 





^ 



\ 



CUu^VAv 



t 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII "1 

.„ LAr\,S^Q. i 



(Month) 



(Day) 



(Year) 



I HHRnnY CKRTIFV, That I attcndeil deceased from 

— to 



190 to 190 

that I last saw h ~ ~~alive on - •-.- ...„.......„....',.- 1^ 



and that death <x:curred, on the date stated above, at 
M. The CAISK OF I) I-: AT 1 1 was as follows 






'Jv.tl^^^^^-^' 



C 



^vvalv 



WW '•.^W (t '■.- 



(KCri'ATION 

f\f>idri{ ni Sat; /'i tiih />fi> 



)'rir t 



v.. »////. 



/hi 



THF AKOVK STATl.D PKRSONAI, T KRTIcr I.ARS ARF: TRC K To 

nF:sT Ol- MY knowi.hdc.f: and kki,ii:f 



THK 



(Infoinirmt 






\ 



aKt:^ 



DC RAT ION }'ears Months Days 
CONTRIHITORY 

DURATION Years Months Days 

(SlGNED)...LU. jL}-"^\^\.c^.a 

n}] 
A d<l ress) V O.^x-VO. ^ v i.^ 



Hours 



/Jours 
M.D. 



190 



f. 



Special Information only for Hospitiis, instituUoRs, Transieits, 

or Recent Residents, and persons dying away from home. 



Former or 
Usual Reskfencp 

Wfien was disease contracted. 
If not at place of death? 



How lonq at 
Place of Death? 



Days 



DATHof RiRiAi. or RKMOVAI, 



FI.A^K OF m-RIAU OR KKMoVAI. 

V N I ) f: R PA K K R AA. >"\^\."VC cC tL> V cCl\A. Ow, '. 



I90H 



N. B. Every item of Information should he carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnin terms, that It may be properly classified. The "Special Information*' for per- 
sons dyin^ away from home should be It'^'cn in «\«ry instance. 



1^ 





1 








\ ■ 




1 


1 


1 



p 



V I 



i 



III 



!(' 



III? 



■)'• 






I 



' u 



M 



\i\ 



H| 

I -I 

I'll 
Ik' 



I : 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

»«,r,l ..f >„ al,l,-l- so ,. *CS4i>..&l' c„ HEFtR TO BACK OF CERTIFtCATC FOR INSTRUCTIONS 




14 



/),if<- r//r</,\Lj^^^ °[ lOO'i 

1 ^ 



Registered JVo, 



878 



.M-A^C<i 



Deputy Health OfTlcer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Death 

( H. S. StanDarD ) 



J^ 



(7\p 



4 <3I^ 



PLACE OF DEATH: — County ofC'<X-»vdv<X>vecACC City ofO.CU>v J ;x.CC >v^v^C.ix 
- J.^L^vcIv (jb Cr^K^"^'^^ St>; Dist«;bet> -and •.- ' 



(ir OCATM occurs liwAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N FORM ATI© W N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

v\i ...... jL'.. Vj aaa-cJ.v 



FULL NAME 




SKX 



H\Ti: nr IMKTII 



A<.K 



PERSONAL AND STATISTICAL PARTICULARS 

I COI. 



CL'JL 



J.OR \ , 



du 



'Months 



(Uny) 



A5^ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 1 

vJwV.M>. 

(Month) K 



h 

(Day) 



(Year) 



lO )>.;» 



MmMs 



An. 



\vii)n\vi-n OK n:v«n<i'Kn 

'Wtittiti s<hm:i1 fU'*ijrtiation) 



,4 



V -\ 



HiK rni'i.Ai'K 

Suitr i>r c'mintry* 



VAMF <»r 
I \Tin:R 



BIRTH PI.ACK 
OK » ATHKR 
(Slate or Country) 



MAIDKN NAMK 
«>J MoTHKR 



HIKTHPLACK 
«»H MOTHKK 
'St.Ttt or Countrvl 




^'-^ 






v^\^u^x 



• Hcri'ATioN-f v\a I X 



Kf^nifii in Siin /'i iini /u-i> 



)'>i! I 



y!.'>tth> 



n,}' 



TM1-. AHOVK STXTKI) rKKSONAl. I' \RI IiT I.AKS ARK TKIK To THH 
HKST OI MV KN<t\Vl.KI)C.K AM) HKI.Il'F 



(Itif<iTmant 



Ol.H 'Kftv' - 



I \.Mnvv 



1 • L 



\ 



^-K 



I 



I II H RUBY CKRTIFY, That I atteiuled deceased from 

\v,uLu ll 1901 to .w\.Vv.CUb 190 ^ 

that I last saw h A*>«.i. aHve on LA»^vv.Cy ^ 190 

an<l that ilcath i>ccurrc«l, on the tiate stated al)Ove, at 
-^ A.Xm. The CAISH OF DUATII was as follows: 

nr RAT ION Ytois Mouths Days Hours 
CONTRIIU'TORY VvLlcUxjlXv^ ULicA.vQ„', , 



uu 



nu RATION ^Vcars Mouths 

(Signed) 

vLcva % iqoH (Address) 



} cars 



Davs 



xLa 



Ql/l.^^ 



Hours 
M.D. 






Special information only for Hospitals, Institations, Traisieits, 

or R(crnt Rcsidrnts, aad persons dying away from honie. 

Formff •»" *1^ ( I 3 How long at 

Usual RfsMfnce CS.^^ vV^ vOJtAj^ v^ pi^f of Death? 

Wlifn was disease contracted, ' 
H not at place of death ? 



Days 



rip\CK OF BIRIAI, <)R KHMo\ AI. 



Uv 



\ 



rNI)F:RTAKKR O .^rVJC^O-Ow Cr'X' dj JUL-K'rj:. 



OATKo! IM HiAi, or REMOVAl, 



1.0. 



I90H 



^\ 



(.AiUhf ss 



N. B. Every item of information should hs carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information** for psp- 
sons dying away from home should be given in every instance. 




\\\ 



, V 






fi 




( 



n 



ill 



I 



5^ 



I 



"I 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoiir.l i.f U.iilth I" No. !^ <^»«>n&l'Co 




I)(ffc FiJod , 

DEPARTMENT OF 



l.t), lOO'K 



REFER TO BACK OF CEWTiFICATC FOR INSTRUCTIONS 

879 



Registered J^o, 



Deputy Health OfTicer 



UBLIC liEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. Stan^arD ) 



PLACE OF DEATH: — County of 



-^^l 



ex ^-vt 



:ity of O.oJULcjLO vccl 



^No. 



— St; —r—^ — Dist.; bet. 



and 



(ir DEATH OCCURS *W«V rROM USUAL RESIDENCE GIVE facts CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



..d..a.^.(xk IL 



Cj...CL^.(X V\^ LL'>X<Li.^a..fe..>:xi.. 



PERSONAL AND STATISTICAL PARTICULARS 



\...J^ 



WVVV. OF lURTH 



a<;k 




(hVa. 



(Month) 



I 



(Day) 



/t^t 



i C )>,/»« A 



M.tulMs 



3C 



lhl\S 



'^ISr.l.K MAKKIKn 
\VIIM»\VKF> UK I)IVnK»Kn 



\ 1 1 M » \\ !•, n n K I > I \ « » K * K 1 1 » 

Writ* ill •siK-ijil ih-siynatioii) i 



lUkTm'KAOH 
(Stiitt or C"o»iiitrj'> 



NAMK o| 
I ATHKR 



niRTHIM.Ai'K 

0|- »ArHKK 

• Slate or Country^ 



MAII)1:N NAMK 
«>1- MOTHKK 



HIRTIIPI.ACK 
<>|- MOTHKR 
estate or Ci>untry> 



(KCrPATlON '?!V 



XA>^ 



ll.v! 



medical certificate of death 

datp: of dfath 




n 



igo 

(Year) 



(Month) \ (Dny) 

I hi: RUBY Cr«:RTIFV, That I atten<k'<l ileccaseil from 

to 



190 



nqo 



that I last saw h ~-" ' aUve on ■r-.-..^ : ... -.TnTr::- igo 

ami that death occurred, on the date stated above, at 

"M. The CArSfvOF DHATH was ^s follows: 



..U'ClLv^-vv^VCW^j , dU. 



A.<U^r<Xa^ ri 



I 






Dr RATION Years 

CONTRIIU'TORY 



Months 



Days 



Hours 



Kfsuifii III Siin /'i tit/i nri) 



),,'> 



M,>iitlf^ 



I hi 1 , 



rm-. ahovf: ST\ Ti'.n I'KRsoNAi. tar ritri.Aks akk trtk to thk 
HF:sr OF MY KNOW ij'.nr.F: AM) iu;i.n:F 



(I 



nfoimant ^ ' \ ^ 



' \<l'lrc»».s . I o t O 






I )r RAT ION .^ Vtars . Months 

' '1 » ' ' ' , L 



Days 



(SIGNED) 



.\>^0s. 



y 



Hours 

M.D. 



iqO 



(A.ldress) V CVXtLyt ^-<X>. 



Special information only for Hospitals, Institutions, Transi(its« 
or Rfcrnt Residents, and persons dying away from home. 



Former or -i u q I 1 i j , How lon^ at 

Usual Residence^ V \ V^A.V\haxaa.^ piare of Death? 



lays 



When was disease contracted. 
If not at place of death ? 



I)ATF:of Ht KiAi. or RKMOVAI, 



ri.ACK OF niRIAI, OR RF:\tOVAI. 



190 ♦. 



(AtMrt'ss 



N. B. Kvery item oli infopmBtinn should be carefully supplied. AG6 should he stated RX4CTLY. PHYSICIANS should 

state CAU8E OF DEATH in plain terms, that it may be properly classified. The "Special Information** f«r per- 
sons dyinft away from home nhould be 4iven in %\9ry instance. 



1 > 



f 



' ' ;, . 1 



» . 



' ■ ♦ 



i iWB 






{ i'^'' 




i 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR IN3TRUCTI0N8 

880 



Hoanl ,,f llfMlth- K No. i^ '^'Z'.^S^' "'"^J* ^*' 






Registered J\'^o. 



rL^A.A^^ cLtoM^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( U. S. Stan^ar^ ) 



PLACE OF DEATH: — County 



of ■ '^-C.X<XA^'VilvdL^ City of 0MV>vcLCv4.V0L'>x<Lval 



No. 



St.; 



Dist.; bet. 



-«iid 



/ IF DE«TH OCCU»»S *W»Y FROM USUAL R E S I O E N C E Gl Vt FACTS CALICO FOR UNDER "SPECIAL INFORMATION • \ 
\ IF DEATH OCCURRtO IN A HOSPITAL OR INSTITUTION GIVE .T8 NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



LIvOl^vLu \yX\.L.'L.:i 



V.- 



-■J'.X 



PERSONAL AND STATISTICAL PARTICULARS 
» ' COI.oRX , 



DAI !•: t»J I'.IK III 



AJ'.K 



CTUxt 



)V.?* 



(Dav) 



.y,7mtks 



(Year) 



D,i 1 > 



SIM, 1,1-: MAKun-.n 

WIlHiWJ I) (»K I»!VoKCKD 

iWiitt in -iM-iiU dr^iiMiati-itl) 



Ike 



CVXXuLd 



lUKTHri.ArK 
statt or Country^ 



NAMK ol 
I ATHICR 



lURTHri.AiK 
<)| I AfUKK 
fStato or Coutitrv> 



MA1I>i:n NAM1-, 
<>J MOTHKR 



I'.IR IHPLACK 
<>I %!<)THKR 
tStatf or c'ounlrv) 



J 



^xv 






oCOr FAT ION 



r> 



nccLc 



^V 



f\'f~i,!r.' ;/' ^ Jii /> i!»< 



)V,!, 



\r.»itii< 



/hi 



TH1-: A HOVE ST ATI" I) I'KRsoVAI, PA K f ItT I, A KS AKK TKIK TO T H K 
nnST ol- MY KNONVI.l'.IX, K AND !n:i,nF 



I'lnformatit 



"^VojbL (Jj^iAjLv 



-w 



(A<1ihc>.s 



^ 



V<X>v<v 



^v-^^JLo^- 



wH^ 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 1 

ll 



(Month) 



I /^H 

(I>ay) (Yenr) 



I in<:Ri:HV C1:RTIFY, That I attemlcd <Uocasea from 
190 to 



that I last saw h 



-alive on^^^ 



190 



and tliat fUath occurred, on the date staled above, at 
M. The CAISIC ()!• DI-ATII was as folhnvs 



w|a^^ %JU«;^ ^^ 



or RATION 
CONTRinrTORV 



'Ji^<K\L. A^O^sX^.- 




J/oNrs 



DURATION - (J''^^^'^ Jfof/Z/is 

(SIGNED) i lb. AXW->Vw'J aiV 



/\7rs 



d^A. 



2l 



Hours 
M.D. 



Ic)0 ' 



(Ad.lre^iv;) 'vLct) VArtc^\o 



SPECIAL INFORMATION only for Hospitals, Institutions, Translfpts, 
or Rrrent Residents, and persons dying away from home. 



Former or -\,4 J M S '^•^ I®""! ** • 

Usual Residence JiVa^. ;^...MXa ^ Rare of Death ? V 



Days 



When was disease contracted, 
If not at place of death ? 



ri.ACH «>!• RIRIAI. OK KKMoVAI. 



\CH OF RIRI. 



'VO-Q^ 



DA Tli of Hi KiAi, or RiJMOVAl, 

'J-^ n ' ^ T90M 



INDICRTAKKR 



(Address 









^. B.- 



•Every Item of information should be carefully Rupplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for psr- 



sons dyinft away from home should be given in overy instance 



K 



* I 



ir 



> t 
4 



I 

I 

ll 



i 



*, 
I » 



ll. * 



r 



II.,:, nl ..f HiMlth »• N 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.,,.^^^,^VC., WtFER TO BACK Of CEWTIF.OTE FOR INSTRUCTION* 

881 



D/f/c /v7r</, ULvv.cyvA^t' 10 



Registered JSTo, 



:tfrvv>vo "Iwvu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




Certificate of Beatb 

( xa. S. StanDarO ) 



of 11^ 




XX -^x 



<L 



u 



'No. 




PLACE OF DEATH:— County of ^A.UX/^.>^x.<:*wO City of ^ <X 

I IK. l^q \t. St.; Dist.;t«t.MlTlaU: and"^iuLli 

."^i.4tk 



FULL NAME 



.11 



.A^AJLa^Ow/»v 



SKX 




PERSONAL AND STATISTICAL PARTICULARS 




clU 



COI.OR' 



rW 



,U 



I>ATK ul- lUKTII 



Ar.K 



rCL>v 



*--! 



i t IVar.* 



'1 



(Day) 



Months 



/■iS,;i..., 

(Year) 



Ai » . 



WIDOW KI» OK DIVOKtKD 
Writfiii MH'ial ih-nivnatioii) 



HIKTinM.ACK 
(Slatf or C«niiitry> 



^\ 




NAMK (H* 
FATHKR 



JlIRTHPI.ArK 
«U- l-APDHK 
(State or C«»untry) 



MAIDKN NAMK 
ni- MoTUHR 



lUKTmM.ACK 
<>|- MOTHHK 
ist:it« or Oouiitry> 



uCCri'AlION 



^. 



1 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DHATH i 

IL 



^wq 

(Month) \ 



(Dav) 



(Year) 



I HI':R1':HV CIvRTIFY, That I atUiuUtl (Icocasetl from 

.1 — — — — igo to — -igo — — 

that I last saw h " — alive on igo-rrrt.- 



and that death occurre«l, on the date stated above, at 



T 



M. The CWrSI*: <)1* DHATII was as follows 



.Ojl 




L 



■n 






F'rn'ilf(f III Stiff f'l ijHi isrn . )riji< 



MnlltlK 



Ihn 



inH \iu)VKST\ ri:n pkrsonai. par tkmi.ars ark trik to thk 

HKST OK Xl\' KNO\Vl,KD«".H AND IIKMKF 



(Infonu.itit 






M 



1)1 RATION Years 

(.•ONTRIIU'TORV 



Mouths 



/^avs 



Hours 



Dl'R.XTION 

(Signed) 



Years 



Months 



Days 






Hours 
M.D. 



clcvcyA ur\ (Address) u a,k.La>^^d voA 

Special information only for Hospitals, Institytions, TraiskBts, 
or ReccRt Residents, and persons dying away from tiome. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



Now lonq at 
Place of Death? 



Days 



ri.ACK OK BIRIAI, OR RKMOVAI. 





DATK of BiRiAL or REMOVAI« 

L-^wn • ^: . 190"'. 






INDKRTAKKR 

(Address 



,9».bA»..^J^.VLvi<^. 



^. 



.v,<tr:Yx. 



\\ 





N. B. Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information" far per- 
sons dyinil away from home should be ^iven in every Instance. 



H 



1 


i 


i 


> 


1 , 

. 1 


1 


1, i 


. 1 


1' v. 


i \ 


m ' 


\\ f 


t 






I 



If 



Ul 



I 

i 



^1 

I* 



IH 



I: 



'■» 



it 






t' 



H 



II 



M 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^.trSi... ,* ,Mo REFER TO BACK Or Ce ..TIPICATE FOR .NaTRUCT.ONS 

Registered ^'"o. Oo8 



leFiU-il, LUv<ivAjd: IC) ^'^'^'< 

"t^vcv^ ii^M Depu^v Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of Beatb 

( 'U. S. StanDarC* ) 



PLACE OF DEATH: — County o 



No. 



'1 









'OL>vKa^--^^'' 



St.; 



^ 



Vru 



b. 



n\ l^^v.v^ T. j^ft Dist; bct. ^ '^VV and 

.. ..«IIAI RPBIDENCE Give FACTS CALLED roR UNDtR •sPtCIAL INFORMATION 

( '' t;::.^:\t^.:::: ::TJ'o^''.\'i o^'T^^n^'T'o^^Jivt it, name instead of street and number. 




) 



FULL NAME 




OA^UX 




PERSONAL AND STATISTICAL PARTICULARS 



SKxOOi 



,u 



cni.oR 



DATK OF ItlRTH 







A<.i-: 



O i )Va# 



(Day 



Mofilh 



/ 1 5 ?.. 

(Vear) 



/ 'iiy 



SINT.I.K. MAKUir.I) 
\VlI>n\VM» «>K DIVMKi KJ> 

Writt in -oiKil -!< -jj.Miation) 



iiik rni'i.xoi-: 

(Stale «»r <.')iuitiy> 






niKTin'I.ACK 

M! 1 \rin-:K 

^tat< or Country 



M \!in N NAMK. 
n|- M!iI"m-:K 



lURTIIl'I.Ari-: 
«)I \5i»THKK 
'St:tt( or Coiinlryi 



Decri'A'rioN .'Vv 



T 






MEDICAL CERTIFICATE OF DEATH ^ 
DATK «)I' DKATH ^ 

Lv^v..q ^ 

(Month) 1 'I>ay^ 



(Year) 



I ni^KICHY CF.RTII'Y, That I attemUMl dceeastMl from 

to vXa^VO^ 'I 190 H 

a, ^ 



iwLvv.a, ^ 190 



190 

that I last saw h ' alive oil SJV'w.i^'CV- T90 H 

C» i /s 
anil that lUnth occurred, on the date state<l above, at i ^ v 

CLm. The CAT SI-: C)I- l)i:.\TII was a^ follows: 






mv 



.^X ^-^vcc- 




1 







Ol<^olV^ 



■; V 



0>. n 



Dl* RAT ION 



) 'eavs 



.lfon//is 



/\ivs 






Hours 

.S.A. 



fT 



Rt iidfif ill Sttn /■') iini iM--> 



jL > V ^a^clV V- ^ 



]■ ,i> 



\r.>il r 



n<!\ 



TlIK AUOVKSTATi:n I'KRSONAl, I'AK lUri-AK-' AKH TKCK To 
BUST OI" MY KN()\VI,i:n(.K AND IJKI.IKF 



THK 



1) 



(InfoMuruit .iC . C<X^^vljVb-*=- 



%. I 



^,,,,„.«s s'ii0cJ^43x*^-^il-. 



Dl'RATION )'r(7rs Mouths H Days 



(Signed) 



.".^ 



Hours 
M.D. 



A.. 



^X- 



TOO 



(Addre'^K) 1 'b S_^-t2Axirjl 

, institutions. 



SPECrAL INFORMATION onlv for Hospitals 
or Rfccnt Residents, and persons dving i^'i^^s from liome. 



TransifRts, 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of death? 



Hen lonq at 

Place of Deatli? Days 



DATE of Hi KiAi, or RKMOV.M, 

iLvv^ iC: T90H 



ri.ACK OF niRIAI. OR RH.MOVAI. 

vnu UL^.^ 

INDKRTAKKR ^Vw^Jt^ (% 'O^CV >V ^^*. '. 
(Address "l^^ S A. 5)Lvkr^^.>iN- 



N. B.— Every Item of information .hould be caret'uUy supplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special InVormation for per- 
sons dyinft away from home should be lii%en in every instance. 






* 



'' 11 







,M 



tl 



1 1 



'I 



11 



:'! I I 



|Vi 



i 






I'l . ! 



iiW 



:t 



• . t 



lU^itr.l of llcnlth— F No. i^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RgFER TO BACK OP CERTinCATE FOR INSTRUCTIONS 

oo3 



H&P Co 




.1.0.. 



190\ 



Date Filed,. 

\j^K,iju:^ kx^ M Deputy Health Officer 



Registered J^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( m. S. StanDarD ) 



A ^ 



PLACE OF DEATH:— County ofCj.aor\' A.a.ivC.A_^.:.Gty ofClo/^vJXXX >veui.C^ 



'No. 



(IF OCATH i 
if DCAT 



SU ^ 



Dist.;bct. U 



A^UL\AJL\.0 



and 



?) 



(1 



OCCUR, .w.y FROM USUAL RESIDENCE G.vt facts callco ;o" on " .•"j;*i •j;^^**;;;^';*-'* ) 

H OCCUBRtO IN A HOSPITAL OR INSTITUTION GIVl ITS NAME INSTEAD OF STUtCT AND NUMBCR. / 

A) 



,crLcVLc^ ) 



FULL NAME 



^:i..v^L.s^c^v. 




Sl.\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI, 




L 



DATK Of lUKTII Qf?^ 



""" lOJLvti_ 



U 



n 



iMonth) 






/I.H.C. 

(Vrar) 



Ar.K 



t*M jv.,, 



\l.nitln 



lUi I .« 



siNr.I.K. M.XRRlK.n 
\Vll>n\VKI> OK DlVuKrKI) 
i\Vrit< ill -(XMsil dt-MKimtion) 



mRTmM..AOK 

istat*' or Country^ 



N \\%V. OF 
I ATHKR 



mKTnri.ArK 

<»l" lAfUKR 
istatf or rountry) 



MAIUKN NAMH 
OF MOTHKR 



HIRTIiri.ACK 

OF MOTIIKR 

' State or Couiitrvl 



<H CIPATION 

Rfi-iilfil in Siitr / I (! ih :.'<>> 








MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



Ql. 



(Month) 



t 



(Day) 



igo ' 

(Year) 



I HEREBY ClvRTIFY, That i attcmkMl «k'Coascd from 

l<X>v IQOH to Ls.i..vqL....i.L.^.... igo • 

U^v<u.*i 



that I last saw h •'* alive on 



190 



an<l that death occurred, on the date stated alK)ve, at A^^ 
llV M. The CAl'SE OF DEATH was as follows: 

.vlXx^^w^^rV^v^c- LL^vcx..• 



) ixtt 



Month'' 



/hn 



THK AHOVK STATFI* PH.RSONAI. PAR lUr LARS AK K TRIK TO TIIH 
BFIST OF MY KNo\Vl.i:i)«.K AM) HKI.n:F 



( Informant 



IV. 

% 



(Adilrcss 



IbHO 



MXX-cJ^' 



4 



I)rRATH)N 



}'rars 



Jv 



AfoHths 



Days 



Hours 



CONT R 1 lU 'T( )R Y wfw.tr»A^X.. ^^ . Vi > %. C 



DIRATION A Years Mouths 

( SIGNED )....'i2 • v>\' V A, ^A-^s*^^.' 



Days 

\ 



Hours 
M.D. 



,A.^^.0,, 



iqo 



(Address) bO^ V<XAAXftV 



% WC!. 



f 



Special information •»•> tor Hospitals, Insti^tifns, Transients, 
or Recent Residents, and persons dyin^ awi) from iiome. 



Former or 
Usual Residence 

When was disease contracted, 
nnotatpUceof deatli? 



How lon(| at 
Place of Deatk? 



■■ Days 



ri.ACK OF BIRIAI, OR RF:M0VAI. 



INDKRTAKKR U 'CULc^S^tx \l/UXVv^ 



l)ATF:of HfRiAi. or RKMOVAI, 



^A- 



(Address 



.0-^ 



\ f 



N. B. Every item oi information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Inffopmatlon** f»p per- 
sons dyin^ away from home should be 4iven in ^v^ry instance. 



. I 



1 



U 



t 
•1: 



r 


< 


\ 


■; i 

1 

I 


1 




H 



Mfi 



■?i 



II, 

I 






\f 




)i 



f ^ 



™f 



Iin;,i.l of lltalth— F No i^ •^^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

BertR TO BACK or CER TiriOTt rOB INg TWUCTIONa 

884 



U&PCo 



7)(tf(' /'V/^^^/ , U..CA.<iAA^ I 2'^0 H 



Registered J^'^o, 
Js^v^\^ Xita>^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Ta. S. StanDarO ) 



% 






PLACE OF DEATH; — County of^ ^ .v X<X > v ^ULCCity of CVCC/^' J >ucXYX/a^A. ^ c 
No W^^-^^«^^' it ;>nv<^..OU?r^vW'^(p St.; X Dist.; bet. ;; and »■ ) 

^ / ir DEATH OCCURS AWAY FROM USUAL .CeSIDENCE GIVE TACTS CALLED 'OR «N0„ '"J'^i ' 'J "»"^;J'°"" ) 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITl NAME INSTEAD OF STREET AND NUMBER. / 

il 



FULL NAME 




,\^QL/.^k^V'. JV:CL.:>:>.AJLA .V/CX.^OL.^ . 



si:.\ 



DATK ni niRTII 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR \ 




lU 



vvtt 



I Month) jT 



.\<;k 



Ma 



\x 

<Dny) 



Mouths 



/l.L'..i 

fVear) 



/)u V* 



SIST.I.K MAKKIKI» 
WFIHiW KI> OK IHV«»RrKI) 
iNVrJtfin wx'ial <lt -i^rnali'm) 




niKTHl'KAOK 
(Statt or Comiliy' 



VAMK (»F 
FATHKR 



RIRTHIM.ArK 
0»* FAPHKR 
(State or Country) 



MAIDKN NAMK 
OF MOTIIKR 



lUKTUPLAOK 
n|.- M()THF:R 
(State or Country^ 



OCCI'I'ATION f^ 






v^ 









/Cfsidrt! si> ^iiii I I it II. I 



)'r III 



Mmilhs 



Day 



THK \H0VF: ST \ riin'KKSONAI, I'VKTHM I.ARS AKF: TRl K T< » THK 
^lF:S'r OI- MV KNOW MCIX.K AND HFtl.IKF 

rinformant VAJ A>X V W< 



(A.Mnss 



,(XNJ^ 



^ 



-^ 



b\C> dljtv^'W^trvv * 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



ilv 



(Month) \ 



(Year) 






(Day) 
I IIURHBY CI:RTIFY, That I attciidcd ileceasetl from 

to T gOrrrTTrr 



190 



that I last saw h ahve on 



190 



an<l that death occurred, on the chite state«l alxjve, at~ 
■""""^M. The CAISF. OF OFATII was as follows: 

U toJ<j\f\jJL/oj\j 6V^Jkyo<xk) oU^^.^Lx.ou-4-iL 



1)1 RATION Years 

CONTRIBUTORY 



Months 



Days 



DURATION 



Years 



( SIGNED ) .WvfcVos-V s 



Afofti/is 



Days 



Hours 

Hours 
M.D. 



iqo 



(Address) L<y\^Vvi.\.^ V <i S 



SPECIAL INFORMATION only for Hospitals, JRsmHtiois, TriRslfits, 
or Rccrnt Residents, ^nd persons dying away from fiome. 



former or x 's ^ 
Usual Residence v k v 



As 



How l0«f at 
Place of Deatk? 



Diys 



When was disease contracted, 
If not at place of deatli ? 



DATF;of HiKiAi- or RKMOVAI^ 



ri.ACE OF HIRIAI. OR RKMOX AI, 

INDKRTAKKR ^ 3 M A,^0^ O.^.^; Ar Cl .. 



190 



(Address 



.\J^fi..Ut . 



N. B. F.very item off Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for psr- 
sons dyin4 away from home should be given in every instance. 



i '' 
I 1 




1 I 



i 



i 



I Hi 



I 



t' 



r 



m 



! 



I • 



h 



HI 



Honr.l uf IU:ilth-l'? 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Vo ,,*^fSR5^n.<tiM2^ WEFEW TO BACK OF CERTIFICAT C FOR INSTRUCTIONS 

885 



Daie Filed, LLaw.UV^v4 

-5 V 



.t It) 



i£;OH 



Registered J^o, 



\KiL Deputy Health OfTiccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( tl. S. Stan&arO ) 



(M 



,T 



PLACE OF DEATH: — County of "^ Oa v vj /LO^VLC^C^City of ^^W>v Vxx wC 

(No^^Ctu "^^ L^V^>vt^ ^ O-U^vla.'. St,; — -rr..Dist>; bet ;;-- •^- Andrrrrr=. 

A / ir ot*TH OCCURS kw»v rnoM USUAL RESIDENCE Give facts callco won uNOtf» «prci*L inronMATiow' A 

i ( "rt*TMlcc!.»VtO.N J HOSPITAL O.. INSTITUTION C.VC ITS NAME INSTEAD Of STKCET AND NUM.CH. J 






FULL NAME 



1 \ i^' 



DATK ni HIKTII 



PERSONAL AND STATISTICAL PARTICULARS 
^ I COI.()k> A 



.cvU 




\.Ow 



«Mon(h> 



i 



\ < . K 



Hi ..,.,, ?^ 



11 

<I>ny) 



MoHlhi \ 



r%S..2. 

fVrar) 



An; 



W IIM»\VHI» <»K I)!\<»k( »-.I» 
tU'ritt- in "HnMal <U!*i>r"J«t'<"»' 



Lt'A^dUrtv»-t^\^ 



lUKTfMM.Av'K 

Slat* or f'MMiti V 



NAMI-: <»l 
FATIIKR 



HIKTHri.AiK 
<>!• lAIMKR 
(State or Cmintt y 



MAIDKN NAMK 
<)I- MOTHKR 



lURTIIPI.ACH 
nj- MOTHKR 
(Statf or Co\intry> 








An .^1 



t 







XiLAvt 



J. 



• KCri'ATION 

Kesiiird ni Son /'> ,uh !^i'> 



0..K %-^*^: • N 



Vfii I 



M.,„th^ 



l),l\: 



Tin-: AHOVESTXTKn PKK«^ONAl, TAR lU! !.\KS ARK TRIK To THK 
BKST OF MY KN<>\VI,KI)C.K AND HKI.niK 



(Info'inatit 






X 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH I 

LL\.va ..t. 



(Month) 



^ 



(Day) 



(Year) 



I JIIiRICHY CERTIFY, That I attcii<lc«l (Icccasctl from 
HV.^.i^ -I 190'' to Uw\.'L.a....io iQoH 

that I last saw h 4i-'>t.^ aUve on Vv.V.a^. to 

ami that ilcath occurretl, on the <h»tf statcil alxn-e, at 
^CLm. The CArSr*: or 1>I:ATII was as follows 



190 
190 



i^d 



>\va"wc>.*vv 



V- 



T 



^.v\r~<.»\.c 



nr RATION Yeats 

CONTRIIU'TORY 



Dl'RATION ^ Years _ 
(SIGNED) ■ \ 



Mort//is 



/)ays 



Hours 



Months 



Day 



T90 



( 



A<hlross) V^A^ "^^ ^ 



A"' (>% 



Hours 

M.D. 

f 



SPECIAL INFORMATION only for HospiUls, Institytlons, Traisknts, 
or Rfcfnt Residents, and persons dying away from home. 



Former or , ^ ^ ^ ^\\ t . f i,"®* '•"« »* 

Usual Residence HX w I J t<XV*Ul npiare tf Death? 



Usual Residence 

Wken was disease contracted, 
If not at Hereof deatk? 



Days 



IM.ACE OF BIRIAI. OR RKMOVAI. 
INDKRTAKKR 



DATE of IUriai- or REMOVAI, 

d. 



f Adi'.tess 



3wil- I'vU. -^> 



N. B. Every item o? information should be carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
sons dyln^ away from home should be &ivcn in •xmry instance. 



h 



w 



h 






»t» M 



■Bssan 





iWi 



« i ' : 
» r t f 



m 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

RCFCR TO BACK OF CCRTJFICATC FOR INSTRUCTIONS 



H..nni of lUMith-r No. IS -^r^^n&i'Co 



1 




\o 



190^ 



Be^istered JVo. 



886 



M.^.^^ 



Deputy HeaUh Offiwiif 

DEPARTMENT of PUBLIC HEALTH=City and County of San Francisco 



Certificate ot Beatb 

( tl. S. StanOarD ) 



PLACE OF DEATH:-County of O.-.^' J.^CL-^vav^City ofV \<X>v OX<V>A.t^a. 



of "'<X'T\' J 



.4 ^s 







&-^lv\Xo.A: 



St4 - Dist«;bet« 



and 



W^v^^^-:^ :^^:^^:^>:^"i^^ :^^5? ;?~?'^:«r ■ ) 



FULL NAME 



.2jUA,n«a,.fc,,-,..X 



M^i 



PERSONAL AND STATISTICAL PARTICUL^S 

COl.OR 




SIX 



DATK OF III R Til 



A<".K 

SlNC.l.K, MAKKIKl) 
\VII>o\VKI> <»K I>!\nKiKU 

iWritrin MKial iU«ii>?»>ation) 



loJ 



lUKTin'l.AOK 
fStati <>r C'lUtUiy 



NAM1-: <»I- 
FAT III. R 



iurthpi.acf: 

Of- FATHKR 
(State <ir Country^ 



MAIDKN NAMK 
<)l M(3THKR 



lURTHPLACE 

OF M<»THKR 

I Stall or Country^ 



I) 



C^v>v 



(Day) 



M.'ntli." 



L 



(Year) 



Atvj 



MEDICAL CERTIFICATE OF DEATH 
DATE OF i)f:ath I 



(Month) 



■\ 



(Day) 



rgo 

(Year) 



I HHRICBY CIvRTIFY, That I attenileil <leccase«l from 

ft, . 5 . . ^ looH. to LL\^.tx.,..x 




190M to v,Nw\^.a^.a 190 \ 

that I last saw \i alive on L^A„uCl, 1 190 v 

ana that «leath .iccurre«l, 011 the «late stated alnive, at bA.5 



% 



Xhw^^^^'^^t. 



.^ 



JwL. 



% 



The CAl'Sr: OF DlvATII was as follows 






.f-«W->, 



I)rR\TION Yeats Months Days Hours 

V QXclI 



> 



U JL\, 



.0 
_ U 



1 



CONTRIIUTORY 

DIRATION 
(SIGNED) 



Ol.^u.\-SX.«w. 



. w«..'. ./J 



IQO 



Vrars I .^fonths ^? Pays Hours 

, . .% .'... h^^^zMXJU^ M.D. 



SPECIAL INFORMATION w'y '»f Hospitals, Instititlois, TraRsifits, 
or Rfccnt RcsMwls, and arsons dylnq a%a) from homf. 



,^A VC^% V 



OCCVPATIGN^^^^ £^^ ^ l^^ ., ,..1, ^^ i^,^ ^^ 



krsuffii I" San f-miuisio }',ni< 



M.oiths 



Da 1 



THF ABOVF STXTFD PF.RSONAK PAR T KT I.ARS ARK TRIK To TIlK 
BEST OF MY KNo\VI.F:i)<iK AND BFMFH 

(Informant. \j^^r^^O- \D.V^^tJkJui4.^ I . . •. 

^0 05 a'L^c^v^tfcvv ■ 



(Address 



ForMfr w ^ ^ 
Usual RfsMence OXk^X» 

When was disease costracted. 
If Rot at ^t of drath ? 



J( . 1 ' HoDf I0R9 at 

a Itr Lkl t .\. Plare of DeatI ? 



Days 



» '*v. 






i 






PLACE OF niRIAL OR RKMOVAI. 



U).atjtvl> 



,>ViAA.l V .A,>\_ , .{ 






DATK of Bi RIAL or RKMOVAI, 



190 



(Address 



l'iT>'^ VVVlv^,^. 



■^ 



VftA-v. 



^ ir~] .r-F oKr^..iH l>« Ktated EXACTLY. PHYSICIANS should 

M. B.— Every Item oi Inform.tlon .hould be carefully .uppi.ed. 'l^^J^^'^l^^)?^.^^^^^^ Inform.tlon- Ur pr- 

•tate CAUSE OF DEATH in plain term., that it may be properly wl8»«.»iea. me pcv 
sons dylnft away from home should be ftiven in svery Instance. 



♦♦I 



' t 






\ 



I. 










WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,.r,l nf llc:. Uh-»--No , . "^^g^ H&P Co 



J)((ti> F 



100 "i 



Registered ^''o, 



887 



^r 



it 



1!^ 



II. 

i 

it 



iLfc-vvv^ *lx^u-M ^^'^"^y Health Officer 

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

{ TX, S. StanDar^ ) 

PLACE OF DEATH:-County ofOcL^ ixC^^C^w^Gty of ^^v ^uCV^vCV^^a 

( '^ r/r.'ix^H^occ-uNtv.rrHi's^pr.t :^^:.°s^.';.%^orLr.Vs name ..sxc*o o^ ,t«ccx *.o ...s.n. ; 



FULL NAME 



Vkm/ V LvLL^va-rvi^^-vv! 



SKX 



DATi: «>i- lUK in 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR^ ^ 




oXjL 







'Muntht 



AGR . 



VOo jv<i»> 



(Day) 



M,>»lhs 



(Year) 



(Yenrt 



/)<! f* 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH ^ . 

LVCCQ ^- 

( Month) {[ __f^*''' 

^flll'lKliHV CI;KTIFV, Tliat I atUn.ltMl (UivastMl from 
wUvC^ :^ 190 H to CLvv^.l 190 H 

that I last saw h^"v.aliveon LC'wvq^^ 1<P 

aiul that death occurred, on the date stated alM>vc, at O 
I 



\VII»n\Vi:i> UK 1)!\ »)Rri:i) 




lUKTHPl.A^'K 

vi;it«- '>r •■'•.iiiitrv 



NAM1-: »>1' 

» ATm:R 



niRTnpi.ACK 

Ol- I A 1111: R 

'Stiitr or Co\ititry) 



MMDKN NAMH 
Ol- MOTHKR 



lUR 1'HPKACK 
ni MoTMKR 
tSlatf ttr C ountry^ 



«KCri'ATi(>N (\Y\ 






v.. M. 'pie CArSiC or DKATIl wj 



[IS as follows 
\ > 



v^^O^A-l B^. 



^ III' '' 

DIRATION ^ JV(;;-5 



Months 



IhlYS 



vJtx^^ 



^1 '^ 



CO.NTRIHrroRV 



ONTl 



W V > V O.. A.,A-^tr= 



.w.' 



I )r RAT I ON 



)V(7/'5 



"5 b % 



.Vonf/is 



Pavs 



(SIGNED) vl.\A.l OU'a^V^^^ 



\.L. 



( 



Address) SC5\ 



uo^iiu 



Hours 

.4 

Hours 
M.D. 



vt^o. 



1 ^ 



■vq '. iQo 

oprciAL INFORMATION o"''^ '"f Hospitals, Institytions. Transients, 
or Recfnt Residents, and persons dying a^av Irom home. 






•- M„„tli^ " /''" 



** HKST Ol" MY KNO\VI,);iM.H AND HKLH-.l- 



Former or 
IsudI Residence 



When was 
If not 



^g llxXVvk^^J^CL- VolL Plareol Death? o Days 

was disease contracted, (Vu ->,.L,^^ I. l\^y 
at placeol death? 1 T V.<^^^^v»^tv.> ^ ^^-<^''" 



(A'Mn- 



IM.ACK Ol- m-RIAI, OR RKMOVAI, DATK of HfRiAi. or RKMOVAI, 




rNDKRTAKKR Y^^^^ V^^ <XC| O.^ '^^ U 






' ir\ .fiE should be stated EXACTLY. PHYSICIANS should 

N. B.— Every Item o? Information .hould be carefully Bupplied. ^^^'*^^^^ The "Special information" for pr- 

•tate CAUSE OF DEATH In plain term., that .t may be properly classitiea. 

•on. dylnft away from home should be ftiven In every Instance. 



,V ' 



li 



1 1' 






f 



lift 



\l 



1^ 






■^j 



1= 



^1 




. t 



> 'It 



;n,n<l -f Il.nUh- !• No. i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^fSX, mv On REFEB TO BACK OF CERTIFICATt FOR INSTRUCTIONS 



T)(i 



/(■ Filed, \X>^^.J2iA^KjiX \^ 



lOO'i 



He^istered •N'o. 



888 



i 



(rvcv^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of IDcatb 

( H. S. StanDarC* ) 

J ^ ^ ^ 

PLACE OF DEATH: -County ^O^^ VCV^^vCc^C* Gty ol^O^ J ^(X^tvXx^ t-^ 



■T) 



NcHl-^ Vl. 



CN--/. 



Dist.; bet. A^< 



and 



FULL NAME 



St.; Dist.: bet. ' VwJ{^OJvAA.H. 

?R TwSTITJ'TTo'N'GIVc'iTS NAME INSTEAD OF STREIJt 



M lW>vt'GVM 



, .;>;;at;:occurs awav from OSU.L REsT^ENCE^v. -cts'c^^o f<^^er ^-^J;- ------- ) 1 I 

V IF death occurred in a hospital 



- ) 




-M- 



PERSONALAND STATISTICAL PARTICULARS 
~ COI.OR \ 



1) \ ri: oi r.iKTii 



a 



• Month) 



1 



\<;k 






(fe 



<I)ay> 



ytnttttn 



♦ 



\.AA<4 



(Yrar) 



Ihi 1. 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATU 1 

lLc\.cl... -.. -^ 

(Month) f[ <Day) 

"~Yin:RI:BV CICRTII-V, That I atU-nikMl (Icccasea from 



I go 

(Year> 



190 



-to 



WIDOW! l» 4»K lMVt»Kri:i) 
Wviti iti -.'..ial «l«si;'!i;iti<»n) 



,^ 



that 1 last saw h nrr-:. alive on - -^" ' ^ 

ati<l that death occurred, 011 the date stated above, at 
y[^ The CAISI; <)!• IHvATII was as follows: 



-190- 
190 



lUkTHi'i. \vM-: 

(Stati or •oiiiitt V 



NAMI-: 01 
lATIIKK 



mKTHTM.AOK 
01 I AIMKR 
I St;Hv or I'otintrv 



M AIl»l.N N \MK 
ul MoTllKK 



lUKTHIMArj-, 
Ml- MiilHI'K 

^l.itt i.r i'<ntiiti V 



i' If 



ll. 






DT RATION Years 

CONTRNU TORY 



MoNi/is 



Days 



Hours 



DIRATION 



Years 



M0H//1S 



Pavs 



flours 



( SIGNED ) L-CrVrvvCV - W, iL'- IsJtLcVvvr ..M.D. 



clc cQ S TooH (Address) C^\>tr>VJlXA U^ V 
iAl INFOR 



\ '^ 



oecv rArioN- 



VxiX* 



)V<7I f 



M.oil/n 



IKn. 



T.IK ^».»V,^^TXTKI..•KRS.>NA. rAKTirrLARSARKTKrH Tu THK 
UHST tu MV KNOWM-IX.K AVI) ni-.Ml.J 



(Itifortnant 



(Address 



HX'^UA.'N>wt di. 



SPECIAL Information on'y for Hospitals, institutions, Iranslfots, 
or Recent Residents, and persons dving away from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



Hew lon(| at 
Place of Death? 



Days 



n^ACK <)I- niRIAI, OR RHMOVAI. 



QA^W^V^TLii 



I>\rK'>f in KtAi- or KKMOVAI, 



*— 



(AcMrcss 






N. B.- 



.. , .^,r „s«,.irl he Htated EXACTLY. PHYSICIANS •hould 
.F.v.ry Itcn, «t i.!orm.,.ion should .„ cnroSully -uppl.e.1. *°'; '^^.'.''..^'...'i!* Th= "Sp.clal Intorm-tlon" l.r p.r- 
■tate C\USE OF DEATH in plain termn. tliat it may he properly naa.me 
■on. dyint away from homo should he ftiven in .v.ry instance. 




♦ ; 

J!' 



f 



H I 



!! t 



• 



|H( 

! 



•i 



Ml 

i ,. 



4 




!J 



l!.,ai<l of H.Mltl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,.s„„,C'=?^,>.(t,.c„ REFER TO BAC^ Or CERTinCATE FOR INSTRUCTIONS 



li)0\ 



Ir Filed, LLu.<V-^-4!t ICl 

cV.,^vu^ viUwH. Deputy Health Officer 



lie gi tit e red Xo. 



889 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



PLACE OF DEATH:— County of 



Ccvtiticate of 2)catb 

( "U. S. StanDarD ) 



and 



I ( " ro'.".T°-"o^c"u%'."cV,i"r„o".'pr.t c%'f-:s°f.?J=4';"'c',vV74 n.me ,«.t»o o. ...r.. .»o HUM.... ; 



-) 



FULL NAME 



( 1 1' 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 






DATI-: «H llIK III 



L 



I CUI.OR 



lL'.KajU 



/ 6 c?w.v 



• Month) 



A OK 



1^ 



JVrt»A 



(Day) 



MoMtks 



(Yeai I 



At V 



SlN'i-.l.F. MXKKIl.I' 

\vii)M\vi:i» OK divmk* r.r> 

iWriti' in «.<Ki;il lU <»ij.Mi;ili"<n> 



lUK rillM, \"'l'. 

I St:it< '>! '"oiiiUi ^ ' 



N\M»: oi 
f \Tn».K 



niRTIU'l.AOH 
^^\^ I AIHKK 



A 1 



DA 



MEDICAL CERTIFICATE OF DEATH 
TK ol- DKATIi r\ 

VA.VV.CL ^ 



(Month) r 



tl>ay> 



(Year) 



1 lli:Ui:nV CI:RTIFV. riiat I iitlcn.UMl <lcoeasca fnmi 

to VAwAA-^^Cl. Jo. TcioH 



I90 



't 



T(jO 




'Statr or Conntry 



CXyvvcL 



MAinKN NAMK 
OI* MOTIIKK 



HTRTHPLArK 
OF MOTHKK 
(Statf or Conntryi 







VOw 



tliat I last saw h^^ alive on CLa.a«^ ti 190^^ 

an.l that death occurred, on the date stated alnn-e. at I U 6v 
M. The CAlSIv (H- DliATII was as follows: 
(jXv (X ^^ ^ ^ ^ jLoJtx dL i ,v»% fr Vol! J V 



'^ 



Dr RAT ION 



}'tui/ 



uirs 



Mouths '^ l^aya 



Hours 



Xj.CL AX 



4 



CONTRIIU'TORY -'<W ->x ^Na,>^^ 

Mouths H /><?i.? 



P 



i" 



1 " 

i!1 






1)1 RAT ION 
(SIGNED) 



Years 




n 



\J 



iMl INF 



'1 rM 



Hours 
M.D. 



H (Address) I \ 'i ^-W^tLuv 



^^ 









O 






OvVC^cv^x dw 



OOCITATION 



Re 






M.'Hths 



ft,! 



THK AHOVK STATIC) PKKSONAI. ^It'^^il^wl-i'''' ^'''' ''''''' '" '''"" 
IIKST OF MY KNOWl.KIX.K ANH nhMhl" 



(Informant 



rxddrcss 



IHH 






SPECIML Information on'y for HospiUls, institutions, Transkits, 
or Rfcent ResMcnls, and persons d)ing away Iron homf. 



Isual Residence 



\HH 



Ptareof Death? 



Days 



When was disease contracted, 
If not at place of death ? 




INDKRTAKKR 

(Ad<lros< 



T ^ . ^ rvv 




0^"vw-ft\ 



ib-i OfV- 



-tr>v 




"■■"^ fl .. •• I APF .hnulil be Stated EXACTLY. PHYSICIANS should 

son. dyinft away «rom home should be ftiven In every instance. 



i 



if!=M 






F 



^• 



II 



I I 



i 



\ 



I 




if 



i 



¥ 

^ 



i m 



Hoard of llritlth- KNo. IS 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

890 



H&l*Co 



I)(f/(^ FilefJ, [LuuXA^U^ ICi ^^^H 



Registered JVo, 

DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



.^-vw^ 



Certificate of Beatb 

( "a. S. StanOarO ) 

i ^ ! 

PLACE OF DEATH: — County of C) Cr>-w(r-»x.Ou City of ^JJLAy 



QU:d.^(A'u^ V 



a.'„ 



'No. 



St 



Dist.; bet. and ^ ••••) 



/ .r oc*TM OCCUI.S .WY mom USUAL RESIDENCE cive r*CT8 c.LLto ;o" "Nocj JlitT^Ho^HUmiln**" ) 

V ir OCATH OCCOHHCO IN A HO«PIT»L OR INSTITUTION CIVt ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



,^ 



\..OJ\JLUJ' 



\A' \J...uX'-^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI. 



^]\oL "■"luj^ 



DATK <)l- HIRTM 



AC.K 



U 

If (tilth) 



1 



U 

) ' 



I^i 

(Day) 



Mamtks 



(Year) 



X.£) 



All A 



SINT.l.K. MAKkIKI> 
WinoWKIi <»R IHVOKvKn 
iWritf ill Mx-iiil ilf«i>!:nati')ii) 



HiK rni'i.AOK 

(Statt <»r Crmiitry^ 



NAMK OF 
FATHKR 



BIRTH IM.AOK 

Ol- l-ATIIKR 

t State or Couiitrv) 



MAIDKN NAMK 
OF MOTHKR 



niRTH PLACE 
<»F MOTHER 
(Stale or Country) 



1 fXcx^uv^u^cL 



LAyv^K. ^"w 



t^ 



•t 



OCCUPATION 



^C' 



Rf<^idrd 1 1' Siut /'mm isro 



^'t'lii < 



yr,.„th:- 



nii\ 



THK AHOVE ST\Ti:i) PKRSONAI, PARTICTI.ARS AKK TRlK TO THK 
BEST OF MY KN«)\V1.KD('.E AND nF:MHF 

(Informant 



b i . U "50^-^.' 



i 



' \<l<lrcss 



n.xX'-<x vl,^\.<A Ca ^' 



L 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



( Month )jT 



% 

(Day) 



(Year) 



I HRRKBY CHRTIFY, That I attended deceased from 

1 90 to 190-:^:^-: 

that I last saw h • alive on ■ • 190 

and that <leath occurred, 011 the date stated aV)Ove, at 
M. The CArJ>1^0F DFATH was as follows: 




(' 



XOuXAj.. . sJ...CL v.L\_iw.>w>. 



DURATION Years 

CONTRIBUTORY 



Mouths 



Days 



Hours 



duration 
(Signed) 



LLw 



Years Months 

I -k \ 



Days 



w^.:ua.. 



Hours 
M.D. 



Cy.*^ TQoH (Address) ^xLa^'L(>^^<yri L ^ ^^ 



SPECIAL INFORMATION only for Hospitals, Nstltdtloiis, Traisie«ts, 
or RecfNt ResMents, vA persons dying away frtni borne. 



Former or 
Usual Resi4eice 

Vflieii was disease contracted. 
If not at place of deatii ? 



How lonf at 

Place of Oeatli? « Days 



KJ.ACE OF Bl' RIAL OR REMOVAL 




OATI^of BURIAI. or REMOVAL 

i.S^. 190 V 



L. i. A) loLt3L.\^, 




(Address . 




\\ 



...\Mt.hAM.»». 



N. B. Every Item of Information should be carsfully supplied. AGE should bs stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be propeHy classified. The "Special Information*' far per- 
sons dyinft away from home should be ^iven in every instance. 



•:.1 



»r 



II 



I» 



I 



" l» 



, 1 



f 



\' i 



* lit 



lU,:ir(l of lUaltli — K No. i^ "t^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCF ER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 

Registered JVo, ^^4- 



li&PCo 




Iti ioo\ 

trvvc^ Itl^--. Deputy Health Oflflcer 



Ddfc Filed, 

1 

DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Certificate of Beatb 

{ Ta. S. StanDarO ) ^ ^^ 



A 



Ull 



PLACE OF DEATH: — County ©r'a^v dX<XAV<:.vAC<.X:it7 of ' '<X>\' nAXV>A.Coa - c 



A 



No \.H0O M^.v^vv. -^ St.; ^ Dist.;bet•^)AJl^.CJl ^ltiA^^ 

( .r D«TH OCCURS .W.Y FROM USUAL RESIDENCE C.VC r.CTS CM.LtO ;OR r|,°" .T:jr;*iJrNUM«'lf ""' ) 
I IF OE*TH OCCURRtO IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTCAO OF STRICT AND NUMBER. J 



FULL NAME 





Oaj^vcL u.C^^.(L» V .ar.rL; 



PERSONAL AND STATISTICAL PARTICULARS 
Si:\ ,\^ A I COI,OR 

vvtt 



'^o.l 



DATH «)! IIIRTH 




(Uav) 



/.,^..0.H.... 

(Year) 



A <■.!•; 



J t'li » . 



Mouths 



\X 



Pavs 



>^IN(.I,K. MARKIKIV 
\Vri)0\VKI> OR DIVOkvKI) 
iWritf in MK-ial «k>.iKiii»ti<»ii) 



MIRTHFKAi'K 
'StJ«te or Comitrv^ 



NAMI-: or 
I AT III. R 



HIRTMHI.ArK 
Ol- lATIlKR 
•Statf or Country) 



MAIDKN NAMK 
OF MOTHKR 



HIRTMPI.ACK 
OF MOTHKR 
(Slatf or Country) 






'X 



^' 



I 



^^y^r^y^^^ :" 



A 



0^ 






C1dwC'vou>^xx 



/"> 



OCCri'ATION 

Kf>idfii lit Siin Fiutirisro 



) ra I 



M„nth> 



Par. 



TflK ^BOVK STATF.I) I'KRSONAK PARTICn.ARS ARK TRIK To THK 
HKSr OF MY KNOWhKDC.K .V>'0 BKI.IKF 



(Informant , 






(Address 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



(Month) 1 



\h 

(Day) 



(Year) 



I IIRRnBY CERTIFY, That I attended deceased from 

LL\.vCL-..-.'ci iQol to ..U^A^q,..>:i 190 H 



.\.vCj^.....Ci 190.^ to .>AA-A^qL-.>-^ 

that I last saw h^" • aliYe on \AA^a, .S 190 ''- 
and that death occurred, on the date stated al>ove, at J ^ a? 
L%..-M. The CATSH OF DKATfl was as follows: 

, NJ l\.aLA.CX<*»<:>-:^::)L^^«^ 



nr RAT ION years 

CONTRIBI'TORY 



ISIonths 



Days 



Hours 



Years Months Days 

90" (Address) b \ C) (foyt^ -Li. '^t 



Hours 
M.D. 



DURATION 
(SIGNED) 

""spECIAlTTn FORMATION only for Hospitals, fustltotloiis, Traiisleiits, 
or Rfcrnt Residfnts, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of deatli? 



How I0119 at 

Place of Deatli? Days 



PJ,ACE OF BIRIAU OR RKMoVAI, | DATF: of IHriai. or REMOVAI^ 

VJ. Ujl>nvcvUxu I ^Aw^,<^>^.■■U 190 





r ndkkta k krvLxvL<A.>v UvU-^dAAx^^vv g -4A,^v\jL^uxiL..^.h_ I 

(Address 11 XH.. a) 4^\>V:^C^^<i^.^ ..3i 



N. B. Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' far par- 
sons dyin^ away from home should be (iven in svery instance. 



» ' 



! . 



»f» 






t 

.1 



.i* 



l 

i 
1 » 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 
1 j ^ IK ^^^^lt -O^^^ c>intiOfl i\rn 0\jfi 

J)((h' FilnL VAVw^QAA.^ ID 



,.,,.,,.1 ..f UcMim - »■• No. I- ^^^*r->''»S:l'(V) 



Registered J\^o, 



i^^H 

Ajuj^, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of Beatb 

( "a. S. Stan^arD ) 



PLACE OF DEATH: — County ofClO/^A M / tCV 



-i 




(B 



tec cay of ^-^V^M^^^^ '^<^'^ 



X) ^ 



fNo. 



-St.; 



Dist.; bct.- 



— and 



-) 



( - -;^:r^^:3^vrj:^^t :^^±^::'i-^ T.\ii ^^o: s^;^^ri:o-::;ir • ) 



FULL NAME 



^tuiXv>;v &'\^cl.u- 



PERSONAL AND STATISTICAL PARTICULARS 

COl. 



"" ^oL 



COI.UR \ \ 



I» \ IK «>I HIKTH 



M'.V. 



(Month) Y 



n 

(Day) 



(War) 



1 }V«»> '^^ MiiMfAf J%..J^ AivA 



srST.I.K. MARKIH1>. 
\vn><»\VFI> UK I)!V<»P.iM> 

Write iti •itH'ial di •»iK'<ati'-ii) 



mKT»n'i.\(*K 

"-■iMti 'It <."iiiiiit r v' 



NAM) Ol 
}■ A r ! 1 1 . R 



HIKTH I'l.AVH 
c)|- lATHKK 

statt or t"iiniitrv) 



MAIUKN NAMK 
nl MOTHKK 



niK THIM.AOK 
nr MOTHHK 
(State or Country) 



1 



O Ct'> V ^ O 

I- ^ I 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH 



(Month) K 



.1 

(Day) 



(Year) 






I HRRKRY CICRTIFV, That I attended deceased from 

1 90 to rrrrrrrrrrrrr-rrrrrrrr---' igo 

that I last saw h — aUve on 190 — 



A^Ow^X^C 



-.^^xx % 



<w _ 



oeCll'ATlON 

Rfsiilfii ill Si}i> /'i (I !■<:-> ■' 



.v-^-X. 



1 *^- 



IhlM 



THK MIOVKST^THI) PKKSOXAM'ARTICrLARS AKi: IKl K 1«> fHh 
llKST OF MY K.N«)\V1.HI)<".K AM) HKI.IKK 

fv) 



lnf,.:mant (> <XC.^AJLX^ 4J AM.^»^ ^^^ >-< 



f A(l(lre«;s 



^\^ 'i>'vthcv.v^^ V--1 V. ^^ 



and that death occurred, (mi the date stated above, at 
M. The CAVSH Ol" 1)1:ATII \va<; as follows 



1)1' RAT ION )'rars 

CONTRim'TORY 



J/on//is 



/)avs 



Hours 



DURATION )'t'ijrs Mouths Pays 



(Signed) 



/■CX.\A-A^ 



a 



wc 



^t-^. 



00 



(. 



(K 



/lours 
M.D. 



Ad.lress) ^ ^^XC*,<v^-^fe-1^cC Wo.',. 



SPECIAL Information only ^or Hospitals, institutions, TranskRts, 
or Recfnt Residents, and persons dying awav froni home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How lonq at 

Rare of Death? Days 



PI,.\f K OF BIRIAI, OR RKMOVAI, 

A C^ 



INDKRTAKKR O Ow ^C^xXA^ <sL' 



I)ATF;4>f HiRlAL or REMOYAI. 
t) 1901 



h, 01 HI 



-C^^'C. 




'vv 



(AtMress .. 



ip/k^ VO ♦Uft^^Sc.iLvv'-CW 



A 



L 



\ t 



N B Every {tern of information .hould be cBrefuily supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special Information** for per- 
sons dyinft away from home should be ftiven In every instance. 



t '♦ 



1; 



H/ 




U 



; \ 










M 




'H 



j{,,i,nl of Hcnlth— F No. i^, 



Dafc Filpil, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



B&PCo 




s.^,jdc It 100^ 



Registered JVo, 



M^v-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( la. S. StanDarO ) 



rM 



'3 



PLACE OF DEATH: — County orVa-.x ' J VCVTLCaA CoGty of ^O.IV J.Vay>xtv<LC 






'1 






1^ 




No X<^% ^^ <1o\AJtVA SU 1 DisU bet. \J Cr^w.^^H^VA). and 

/ ir Ot»TM OCCUPIS *WAV FROM USUAL RESIDENCE GIVt r*CT8 CALLCO rOH UNOCR "S»itCI*L INFORMATIOM" A 
( ,r rt.TM Ic"rRCO .N . HO.P.T.L OR INSTITUTION GIVE ITS NAME .NSTtAD Or 8TRCCT AND NUMBER. J 



CL^Ur>v ) 



FULL NAME 







PCRSONALAND STATISTICAL PARTICULARS 



SKX 



'^A 



COI.OR ^ 



I>ATK »»F HIKTII 



M.K 



Month) 



v^; 



(Day) 



.Kvt*- 



^l I^ 



fa^s 



M,>Mths 



z 

(Vear) 

Da 1 v 



^Isr.l.K NfARKlKI) 
WllMiWKI) <»R niVoRTKn 
sWritf iti MK'ial <le««iKnati«>n) 



4 



A 



niKTMl'I.ACK 
fStat«- or CfMititry 



XAMK <»! 
FATHKR 



BIRTHPLACE 
OF FATHKR 

(Stall or Country) 



MAIUKN N\Mi 
OF MOTHKR 



hirtmpi.acf: 
of mothkr 

'Statt- or Conntrv 



ov » TI'ATION 



l^ ^ 



»• 



kv 



^•wau 



exxciL 




a 



^^u vx ^,-^^^\.c^>^ 



Rf^iiiri! Ill Vrr»/ I'laiui^fn 



) '»!? ; 



Mnllth^ 



1hl\ 



THF. ABOVE STATKO I'KRSONAK rAKTUMl.AKS AKK IRIH T<> THF: 

BEST OF MY ivN<>^vi.f:i)(;k and bf:mf:f 



(\w 



informant 




( \<1(1ress 



llH 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



lie 

(Month) 



.n 



(Day) 



(Year) 



I HEREBY CERTIFY, That I attended deceased from 

V\.Lu,..Xu. igo'l to Ui.^C.i:^..5. IQO H 

that I last saw h ••. ^ alive on LA-" 



.v.v/.tX....5- .. 



igo 
190 



and that death occurred, on the date stated alxjve, at 
^ M. The CAISE OF DEATH was as follows: 

Di; RATION years Months . Days ^ Hours 



c;qNTRIBUTORY 



Aj'^-^"^ 



.A.^wJLCV? >'\ t 



1> 



A 



Cr'r r^>-"Lk J.-1 



Davs Hours 



Dl" RATION Years Months 

(Signed) .^> A. ^i/crK vv^.vr>^ M.D 

LU^:^ - loo*^ (Address) ^^^ "^ .K.kXXjJ-JM 



SPECIAL INFORMATION only lor Hospitals, iRstititiMS. TrMSlMts, 
or RrcfRt RrsMfits, nA ^rsois dying away from home. 



Fomifr or 
Isual RrsidcRCf 

Wfirn was dKrasr coRtractH, 
If not at place of df atk ? 



Now If 114 at 
Ptare t f Death ? 



Bays 



PLACE OF BT RIAL OR RKMoVAJ. 



DATE of Hl-KIAL or REMOVAL 
vC\.A^C^....i.Ju I90H 




INDERTAKER Vw'VWiLft >i f C O 

(Address ^VH L. C^rLl^...!-.! 



A./wyw, 



""^W 



N. B. Every item of Information should be carefully suppHed. AGE should bs stated EXACTLY. PHY8ICIAIN8 should 

state CAU8E OF DEATH in plain terms, that it may be properly classified. The "8peclal Information** far per- 
sons dylnft away from home should be ^iven in svery instance. 




*!1 






}■ 



i 



t 



't^wT 



■i I 



^ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no.n, ..f M.aUh-K No .^ RgFER TO BACK OF CERTIF.CATE FOR INSTRUCTIONS 

Registered J^o, 




894 



JU^v.^A/> ~Hjt/\jM.i Deputy He slth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 



( m. S. StanDarO ) 



PLACE OF DEATH:— County of ^^OL^' 0/UX/>\ tii^cGty of '^''CXyrv JAyam.C^«.£ 

^ ^ hTII illl 4, 



fNo. 



4' 

H dc 



:>"\-i^i ) 



FULL NAME 




;\i.a tn-v-vL^uM .fl^:-Cr::LA.>:ri. 



a 



PERSONAL AND STATISTICAL PARTICU LARS 

I COI.OR \ 



""' (nicJL 



DATK OF IlIKTU 



Ai'.K 



^ 



a: ( ..u 



xkt 



iMonth> 



%0 ,-, 



eat$ 



ti 



(Day) 



. Mumlks 



(Vrar) 



Daxs 



SINT.I.K. MAKKIKI) 



\Vri)«>\VHI> OK DIVoKi HD N 
<\Vr:t<-in Mn'ial «l«"»i»niation) 1 i . 



vdl^^'VA>-U\; 



mKTMIM.ArK 

'Statf or t."i>ui!lryi 



NAM1-: «»l 

FA iiii:r 



niRVIIfl.AOK 
<»r I ATIIKR 
(State •>r Coiintryi 






crVc 



% 




\, ~ 



\ ' 




M 



MAIOHN NAMK 
OF MoTHKR 



niRTuri.ArK 

OF MOTHKR 
(State or Country i 



ore f PAT ION 



\^ <xAw ^ <^ vv ^lX 



^cOuvOl 



Ffsitlftf in Sati t'mtuisfo 



* . ) V<r; <■ 



»/..»////■ 



/>rM 



THH ABOVK ST\TKI> I'KRSONAI. I'AKTIiM' I.AKS AKF", TKCK To TIIK 

HHST OF MY knowi.kdi.f: AM) in;i.n:F 

{Informant LAA^Xz-O^V--. ' ' -^ U^^ V'>AA./a >n J^ 

1 r^ -K-'- l.a.i) 






( AfldreKH 



QkHl-S 



LcL^LcL 



•fiVvvsn, 



\ 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 



.LLa,.v 



(Month) 



."^ 



^ 

(Day) 



(Year) 



I HRRRBY CERTIFY, That J attended deceased from 

J..l\.<Xvi, l.C) igoH...... to ^X\^Ct,....a 190 H 



that I last saw h - alive on 



CI, 



-V-.V.CL, . 190 

ami that death f)ccurred, on the date stated al)ove, at ft 
...S-^ M. The CATSK OF DI^ATH was as follows: 



O rwLA„ 



.^.^L'il.v V. ^ 5JLi CL 



^^ 






tr^.Vi.C^.yxLtSLlx >; 



>~tJi.... 



nr RATION 



Years 



A 



Months -v Days 



Hours 



CONTRIIU'TORY ?^ 



V.!w.*-S..t 



Months 



nr RATION Years Months Days 



Hou 



rs 



(SIGNED 



M.D. 



Oav c 



%- 



190 



(Address) 



iss^Lo^i^:^^ 



Special information only for Hospitals, listitHtiMS, Traislfits, 
r Rfceat Residents, and oersons dvino away from home. "* 



Former or 
Usual Residence 

When was disease contracted. 
If not at piare of dratli ? 



How \h% at 

Place tf Oeatk? Bays 



pj.ACK OF niKiAr, OK rf:movai. 



I)ATU,of BrRiAi. or REMOVAI, 

I90H 



\A,\^Q '.!. 



*^rUA/xJL..^. 



(Addresji 



N. B. Every Item of tnfformntion should be carofully nupplled. AGB should b« stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information** for psr- 
sons dying msvny from homo should be given in ovsry Instance. 



i- 



\m 



Vu 






I' *i 




<i 



'\ 



M 



m 




WRITE PLAINLY WITH UNFADING INK — THIS 18 A PERMANENT RECORD 

, ,„r ,„„„h--..s». ,.*^..)fco ntrtn to back of cewTiriCATc fob tN»TwucTioN» 

895 




ID 



IfJO'i 



Regiatcred JVo. 



Dale Filed, 

i^^cv^ ■Ic'x^M DeP"*y "««''*^ O^'^®'' 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( "CI. S. StanOarD ) 

PLACE OF DEATH: — County ofC)/OL/>^v L\.CUvxa\^c<:City of ^O^^v A.O^/-^v^v^cl 
rp^. cn%. .^crVUv,vvcUci '^^-0\.u St; 1 Dist^ bet VJ CrV^>^iX and M Rcv^tnv 

/ ir DEATH OCCUR* AV»|kv FROM USUML R E S I O C NCC OI VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" A 
( IF DEATH OCCURRtl) IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



LUj^t OsK^\yx^'sJ>^. 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR ^ 



'" 0)wU 



\kjX\J^K 



DATK OF HI Kin 



A<*.K 



(^< 



• Month) 



V * »tf»* 



«I)ay) 



Mtmtks 



iXh,.!.... 

(Year) 



C> 



Tkivs 



SIsr.l.K MARKIKO 
WIDoWKH OK DIVORVKI) 
I Write in s«H-ial (U-iiK"atiuii) 



HlKTHPl.AOK. 
(Statf or Country^ 



\) 



NAMK <»f 
FATHKR 



RIRIMPI.AOK 
OK KATHKR 
(Statf or Country* 



MAIDKN NAMK 
OI MOTJIKR 



RIRTHIM.ACK 

OF MOTHKR 

< State or Country) 




\cUW\jLd- 



t \} 



X>V>^^^^vV O^ . .-CU 



lu J.. , ' 



) 



Rfsidfii in Sa>r I'mtui'-ro \ )'riu .^ 



M,>„fhs 



f I 



/hiv: 



run ABOVE STATF:n PF.RSONAI. I'ARTICri.ARS ARK TRTK TO THK 
HKST OF MY KNOWUKlHiK AM) BKMKF 



[Itifonnnnt L\/1t\JU'Lv^ 



V^ 




( Address 






JP 



I 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Month) y 



^.-9 

(Day) 



(Year) 



I HRRKBY CKRTIFV, That I attended deceased from 

T90 to 190 

that I last saw h :~- alive on ■■ ••••iqO 



and that death occurred, on the «late stated aljove, at 13.— ^ v. 
- M. The CAUSK OF DHATII was as follows: 






\^vv-VCC^ 



-A».-*a.A.cw<M-. 



1 



ii'.,.J.b.:!UX,»jL. 



Dr RAT ION JVarj 

CONTRIBUTORY 



Months 



Days 



Hours 



DURATION ^ Years 





Days 



Hours 



Months 

( SIGNED )A^<rV<rvvX^j0.fc.lpA^^ M.D. 

LU-V-q IC TOO*' rAd<lrt.ssl L^X^\^^^ WMa,:^ 



ql^ TQO^' 




SPECIAL INFORMATION only for No$#itals, listititlMS, Traisieits, 
•r Receit ReshkNts, aii4 fttywi tfyiin iway from boine. 



\\o\'\'^ 



Formfr or 
Usual RnMfRce 

WhfR was disease c«iitracte4, 
If Mt at place of tfeatn? 



-A-'OLh.^! 



flow toil at 

Ware»f Death? Bays 



PLACE OF BURIAL OR RF:M0VAI. I DATF) of RlRiAl. or REMOVAI« 

(\>\1 U^Usv^i I O^^-^ ^x^ 190H 



UNDERTAKER 

(Address 



551 y-^.tU*:u.3l 



N. B. Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** far par- 
sons dying away from home should be given in svsry instance. 



4 



i^ 



i 




u 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

896 



i.,,Mi.i ..f n.-.iUi.- »• No, I- •^'^:^'HM'Oo 



Registered J\^o, 



r 



H 



/)a/e ?yiefJ,[jju^,<Y'^^ ^^ ^'^^^ 

'l^vw.'t^/v^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccitificate of Bcatb 

( Xl. S. StanOarC> ) ^ ^ 

PLACE OF DEATH:-County ofOom. 0.^<V>X'^VA.tf City ofHoAV O^VO^^X^-.i ^< 



No. Vd.^^ 



II 



tr\^<^'w'tM, sb (SA,K>-i.O.. '. St.; Dist.;bet.- 



and 



I' ^ 
t 



V^ I iiiBiiai Bc-einr Mr r r lur tacts CALLED FOR UNDER SPECIAL INFORMATION" 1 

■ ^ ■ 



•) 



FULL NAME 




i.trrwiCl.,v\4jL/:vv 



m 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



l>\li: ol MIRTH 




n 



I, 



:oi,<)R \ 



(Month) 



ACR 






>\ 



II.: 

(Day) 



M..nth'- 



(Yrar) 



t\ 



Ai I v 



SINi.I.F. MARkli:i» 

\viiM»\vi:i> OK n!v«>k« ID 

(Writ'' in «-iKMal (l«si',' nation* 



HIK iin'I.AOi: 

(Stat' i.r '.in; ti \ 



'i^vA 




CAVOy^ 



MEDICAL CERTIFICATE OF DEATH 



D.ATE OF DKATH , ^ 



(Month) 



I 



...a... 

(Day) 



I go 

(Year) 



I nrCRnnV CI':RTir^V, That I attenrled tlcccasetl from 
VVA -A. b ivoH to !sAa,a^.^ 



crV. 



t ' \ 



I 



I- A IlllR 



lURTiiri.Ari-: 
^^v i\rin:R 

■ S!:iti or Conntry 



MAn>»:N NAMK 
(H- MOTHKk 



lUKriU'I.ACH 
Ol M«"TUKR 
(Slatf or Country) 



OCCUPATION -V 




'\'>\j \trvvo. . 






t 



> V 



e 



.C\wKW^, 












t /..//'// - 



/■,: 



THK AROVF, STATKH PKR^oXM, I'ARTim.AK^ \KI" TKl }■ r< » 1111': 
P.KST OF MY KNo\VI.F:I)C.K AND MKMF:1' 

(Infonnant Lv PO^ • Vm\ Xo^v-" ^' 



(Address 






190 H 

tlia\ I last saw h ..o>-. alive on LLvs-Oj, ', 190 + 

ami that <Uath occiirre«l, <ni the date state<l above, at » 
M. The CArSI<; Ol* l)i:.\Tn was as follows: 



..v.: 



DT RATION Vt-ars 

C(^NTRnUTORV 



A/ out /is 



PiUS 



Hours 



duration 
(Signed) 



Mojilhs 



lbxx>db 



/^avs 



U'- g -^ TQO ' ( Ailil ress) CCl^^^ Lc h ^ - \^ 



Hours 
M.D. 



Special information only for Ht^pUals, InstituHons, TMnslents, 
or Recent Residents, and persons dying av*ay from home. 



Former or 1 1 , (Vl ^ I "Vl "'^ '•"•' ** ^ Q 

Usual Residence nl \/\aW»^.0^ 't Mace of Death? l\ 



Days 



Wfien was disease contracted, 
If not at place of death ? 



I)\Ti;u} BiRML or REMOVAI, 

U.\,>s^. Ik I 



IM,ACF: OF" lURIAI, OR KFMoVAI. 

m Ljl^^t 

INDKRTAKKR vXy\aXjL<V \X/ 

(Address \ t> (c \Y Y\'\..<t^t.A.,^r>v 3i 



90H 



N. B. Kvery Item of Information •houltl be corefully supplied. AGE -hould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information" for per- 
sons dyinft away from home should be given in every instance. 



! 






''< 



■1 1,/- 



.< 1 r 



^^ 



M 



^ - 1 

1^ 



jr.*; 



> 



f ^ ^ 



iH 



i I 

t 1 



\4* 



Ho.inl of HcaUh—l' No. 15 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RgFER TO BACK OP CERTIFICATC FOR INSTRUCTIONS 

897 



H&I'CO 



/)(f/e Filed, LivN/ctv^o^Jt 10 lOO'i 

X^vvlxjIxuah Deputy l^ealth OnTicer 



Registered JVo, 



DEPARTMENT OF PUBLIC HEALTB=City and County of San Francisco 



oi^Ojy\^ 'jrvOL/>\c^^t>b City of 0/CX/>A.^ \j rvCk/y^/^^^^^y^<i 



(No, 



Certificate of 2)eatb 

( Ta. S. StanDarD ) 

PLACE OF DEATH: — County 

LtTdbvoJj C'\\\X\XU/\^/Cu llbM^Wt^LL. Dist.;bct.' - - ^ 

J..X'.vA.a. JUx\-^.c^\-U 



and 



-) 



FULL NAME 




SKX 



PERSONAL AND STATISTICAL PARTI CULARS 

I COI.OR 




wu 




DATK OF lURTII 



A<*.F. 



•3) 



(Month) 



1 

(Day) 



r 1.13 

(Year) 



SIN«.1,K. MARKIKH 
WIDOWKD OR DIVORVKI* 

iWrittit) siK'ial drsiirnatio!!) 



HIK THIM.AOK 
(Statf <ir Cotintryi 



4" 



NAMK OI 
FATIIKR 



RIRTUPI.AVK 
OF FATHKR 
(State or Country) 



MAII)F:N NAMK 
OF MOTHKR 



birthi'i.acf: 
OF mothh:r 

(Stall- or Cotjiitrv* 



AfOMtkS 

1 



/>ll YS 



r: 



JLouv 

•^1 



,^^\\mL\X% 



XVVvVCJCO J. 



_ v'xv»v<XA- 



OCCri'ATION 

Rffiitfii in Sttn f'iniiiisi'it 1 T )/.;/ 



r 



.\r,>nth.- 



n,i 1 



TMF: AnoVKSTMKI) I'KRSONAl, I'ARTH I I.ARS ARl*. TRTK TO TMK 

HKST OF MY kno\vi,f:i)<;k AM) nF:ijF:F 



(I 



nforniant Q\) 



^ 



{ \(l<lrc'ss 



^ \\o 







MEDICAL CERTIFICATE OF DEATH 



DATE OF 



LLvv^CL t 

(Month) £ 



(Day) 



(Year) 



I HKRHRV Ci:PTirY, That I attemled deceased from 

\ ^~r-r-r- tO IQO — — ^ 



til at I last saw h-" 



-iilive on 



■190 



and that death <x:curred, on the date stated al>ove, at 



M. The CAUSp OF DKATH was as follows: 




DIRATION Years 

CONTRIHUTORY 



Months 



Days 



Hours 



DURATION , Years Afonths Days Hours 



(SIGNED) 



Vw^O^X^rvxJt^v 




<x >ujL M.D. 

LL'i.'.q. ' iqo ' (Ad.lress) L(rVtr\Xl.^J^ UJki '. «:4. 

\ » ' 1 ■ 

;PECIAL INFORMATION only for Hospitals, Nstltilltiis, Tr 



or Recent Residents, gndjiersons dying away from home 



iransifits, 



Former or I 1 1 

Usual Residence VD I So 

When was disease contracted, 
If not at place of death? 




\ 



Now lonf at 

f*laceof Death? Days 



PI,ACK OF BIRIAI. OR RF:MoVAI. 



". I _ 




I' N I) f: r pa k h r "^ Ow/vJt.'>x.t/x' vP \ ^<,i ^ 

(Address \X^^ \(^\k^'la>.^.\,'^:: ! 



N. B. Every Item o? Information should be carefully nuppiied. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information** for per- 
sons dyinft away from home should be fciven in •\mry Instance. 




1^; I ! 









U 



B«wrd of Iltalth— I' Vo. i^ "V*^ 



r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFER TO BACK OF CERTiriCATg FOR INSTRUCTIONS 

898 



H&I»Co 



l)(i/r Fihfl, LUv^v^^c^ VC) lOO'i 



Registei'sd JVo. 
"Iti-vvvfl "Ll/xnm Deputy Health.omccr 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "d. S. StanOarD ) 

PLACE OF DEATH:— County of '^AXvu >1/i.<X/ivev*i.fi< Gty of '^''CU^v J 'v O.' v\. e l <:. c<t 



<l,. 



\ 



No. X \ Ci C) ^ ^uC-CLcLcu a' 



St.; 



Dist.: bet. :JlCv/Ch./OLr\xa 



..y'v.. and U^'xi^^Luv.. 



'i 



1 



/ ,r 0«TH occurs .WV r^M USUAL RESIDENCE Give «CT« CALLCD 'OR "N„^ ""CIAL mrORMATION" \ 
V ir DEATH OCCUHHtO IN A HOSPITAL 0« INSTITUTION GIVC ITS NAME INSTCAO OF STWCCT AND NUMSCR. 7 

\ '■\ I ^ 



FULL NAME 



A 








CX./-VX. 



,dL 



SKX 



PERSO NAL AND STATI STICAL PAR TICULARS 
' ' I COLOR > ^ 



+ 



DAT!-: HI MIRTH 



()K 



(Month) 



cxv 



A<.K 



W. V Vt'ais 



K 



(Day) 



MoMlhs 



/ Ci.,-v..1.... 
(Year) 



Davs 



SIN'C.lJv MARKIKI) 
\VII)»)\\ KI> OR IHVoRtKI) 
iWritf in s«k*j;«1 «U«*ijrnation) 



niKTHlM.AOK 
iStatf or Coiinlry^ 




CXWULCL 



NAMi: OI 
FAT I IKK 



niRTHPI.ACE 
OF I'ATMKR 
(State or Country) 



MAIDHN NAMH 
ol' MOTMKK 



lURTHPI.ACK 
<»F MOTHKR 
'Stale or Coxmtry) 



1w 



IsJ^cx-^vcL 



LL"r\^T>> 



\^ V ^ — ^ *^ 



! \i 



I I i!: 



OCCUFATION 



jLaxX'^'L'^ 



Rf.<itifd ill Sail Fiaurisrn 1 }r'<7if 



\/,>nttis 



Days 



\\\V. ABOVK STATKI) PHRSONAI, I'AR IICILAKS ARK TRKK TO THK 
IJKST OK MY KNO\VI.f:I><;K AM) BKMKF 



(Informant 



(\(l(]rf 



W^^ ^vJ[>..\.^CV dl V.A.-tX-v^ '31 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATIl 



(Month) ; 



(Day) 



(Year) 



I HRRKBY CIvRTIFY, That I attemletl deceased from 

il\..Lu....|.t 190'n.. to .U-V:V.CL..l 190H 

that I last saw h - vj...alive on LL\-^^qu....l».... 190 . 

and that death occurred, on the date stated alwve, at 



M. The CAl'SK OV HIvATII was as follows: 



4 



^ > V V 



L^U. 



Dl" RATION Years 

CONTRIBUTORY 



Months 



Days 



Hours 



DURATION 



Years 



(SIGNED)^ 10 O'l 

a 



Months Days 



Hours 



A.^.q, ! iQO- (Address) 



M.D. 



SPECIAL INFORMATION only tor Hospttals, iRsUtMttoiS, Traisletts, 
or Recent Resktents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



How long at 

Place of Death? Days 



PI,ACE OK BKRIAI, OR KKMOVAI, 

1 



4 



DATKof Bi RIAL or REMOVAL 




c 



(Address 



N. B. Every Item of Information should be carefully supplied. AGE should be stated EXACTLY. PHY8ICIAN8 should 

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information** f©r per- 
sons dyinft away from home should be given In every instance. 



14 



Vl 



i.r 



ii' 



^ 



Hoard of Health- J" No. I «. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

«*S5i> ,.<i .. 0„ REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 

899 



Registered J\ro. 



Lrvw^lLw^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 




LACE OF DE ATH : — County o 



Cevtiticate of Beatb 

( XX. S. StanOarD ) 



((^ 



Ct">^JL 




Ch<L 



IwLo^l 



St 






Dist.; bet.- 



and 



— ) 



f jH 

rjif til 



1 iieiiAi BreirkClMrr riur rACTS CALLED rOR UNDER SPECIAL I N TOR M ATION " \ 

( '^ r."D»TroCc"^R;rD\N"rHo".^VT'At ^R^f^Sn^JV^'^'o.vYTs ^n\^ME instead or STREET AND NUMBER. ) 



FULL NAME 



LAVA^Ld oV UJ cll^-^OLmv ..!^^.. 




f\j...dU.A'\..dfiL*jr 



O; 



ft* 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 
DATK t)F lilKTII ^ 



lOJv^u 



'Motilh) /T 



(Day) 



(Vcar) 



A<-.K 



Yttit s 



MoMtAs 



'^ Prf.V.V 



StVr.I.K. MAKKIKP 

\\n>«»\vKi> OK T)iv<iKvi:r> 

iWiitt in stM-ial <1« >i{.'iuili«)ii) 



» !• 




'Stntt or t.'>niiUt\ -»^ \U I ■ ^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATIi , "1 

LlvvQ. ^"^ 

(Month) j[ 



( nay) 



(Year) 



HiK rinM.Ari-: 



NAMl n|- 
lA I MKK 



HIK THPI.AOK 
OF I ATHKR 

'State <ir Country^ 










M \II»KN NAMK /"O 
ol MOTHKR y^ 



,ti 



lURTIiri.ACF, - ^.^ 

oi MoTifKR (/ nrs 

(Slalf i.r Country) "A v|' 






CdLuJk) 



"K'Cri'A'l'lON 

f\'r ■ ft'if III S;'/ f't itiii !^i'i> 



)V,.' 



M ,11 III 



h.is 



XWV \H()VF. ST\'n:n PKKSONAI, PXRTIOfLAKS ARi: TRIK Ti > TIM': 
IJKST oi MV KN'oWl.l'IX.H AM) HKIJKK 



fl 



Address 3LHHH 




.'cL'tj^A-'" 



I lUvKlUiY Cl^RTIFY, That T attended rleceased from 

LL^^^CL ^ 190H to Us.^.^MX a 190 H 

that I h»st saw h .:il.?^. alive on LLva^ '^^ 190 . 

auJ that death f>C( iirred, on the date stated a1x>ve, at i 
M. The CAl'SI*: OF DMATFT was as follows: 



.-♦-v% 



DT RATION 



Years 
CONTRini'TORV W 



Months 



/yavs 



Hours 



I/VRATION Years 



yfouthi 



-VX-vA^tX'- 



(SlGNED) 



Ul 



WvK^ 



Pays 



Hours 
M.D. 



cixxH T 



H icK)* 



(Ad.lre<v) 15 I 



dwtu^ % 



SPECIA'L Information on'y 'or Hospitals, institutions, Transients, 
or Recent Residents, and persons dyini away Irom home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death? 



How long at 

Place of Death? Days 



IM.ACK OF lURIAU OR RKMo\ AI. 






'-jLOl-ClX 



(Address 






DATKuf Hi KiAl. or KKMOVAI^ 

CVvvo ! C T90S 



N. B. Every item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The ' Special Information'' for per- 
sons dyinft away from home should be jjivcn in every instance. 



t' ■• 



* \ 



tl 




I 



(■ i\, 



I' t 



H«mn1of lUiiUh— FNo i^ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^Jf:gJt,,„S,PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

900 



'!• ^ 




n 



\.\j{X^ v.fc. 



100^ 



Bsgisteved J^o, 



<.'S^^\.KyU^ 



i^yxM.^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Xl. S. StanDarD ) 



4 






<No. 



JK 



PLACE OF DEATH: — County of^ CUTV vW<X^A^^^City of Oay>v 

i.^ . St.; 1 Dist.;bct. OI^^'Li^r^v and J Crv 

/ ir DEATH OCCOH« AW*V mOM USUAL RESIDENCE Give rACTS CALLCO row UMOCtI '•^CCIAL INroRMATIOM- \ 
( ,r rCATH OCcI/pTcO .H A H(.«...TAL On INSTITUTION CIVC IT, NAME .NSTtAD OF •mZtr AND NUM.CK. J 



FULL NAME 



ex. vvd^CL^C^ 



n 



) 




±'::^:^J)u^L.Us-<x. 




si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI. 



01^ 



L 



I.OR \ , f\ 



L 



DATK ()i niK rii 



AC.K 



I Month > 



(Day) 



55 



J 'I'li I 



^/,>M/fl\ 



(Year) 



All* 



SINT.I.K. MARKIKI) 
WinnWKD OR niVOKCKD 
iWiiif in MK'ial iltHitrnation) 



niRTIIPI.ACK 
f St;itf or Ootintryt 




NAMH OF 
FATHJ-.R 



niRTHPI.ACK 
Ol' lATHKR 
iStalf or C<»untry^ 



>fAlI>KN NAMK 
Oh MOTJIKR 






4 



C-tr 




^<X^c 






lURTlIPI.ACK 
OH MOTHKR 
St;ite or Country t 



^ 



-o. 



Rfsitlfd 1)1 Stiti /'i an, ism O^^ )V(?/* ^ }r»nfhs 



nay 



THK ABOVK STATl-.n PFRSONAl. PAR riOlKARS ARK TRIK TO THK 
UKST OK MY KNO\VIJ-:i)r,K AM) BHMKK 



(Informant 



^ 



f A<1«lrcss 



1X5 J. A. 



i) 



v^''. 



4. 



\ 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



Ou 



(Month) 



^^ 



IC 

(Day) 



(Year) 



I HERUBY CKRTIFV, That I attciuled deceased from 

^^^J^. X°i. 190H.. to CLvw.'.aL....ii.^. 190 H 

that I last saw h -*-*- alive on LL\.xV^ lA 190 

and that death occurred, on the date stated al)Ove, at . w. 
M. The CArSR OF DICATIl was as follows: 



CjL%jJLrVcJl LL^|A. 



«^',VC«. VV! 



\ 



nr RAT ION 



)'eQrs Months 1 -X Days , Hours 



t 



C (} N T R I WV'KO R Y O jL >A-jLV 



O-^-La^IA;,. 



DURATION 



Hours 



Years Mouths Days 

(Signed) A. X/ w^o^c-vacuL^^^ju M.D. 

L\^v r> •. r T^' c Address) 10$ U <vL\Xa,o '"'"^ 



^'^C\.0. 



T90 



( 



SPECIAL INFORMATION only for Nos^tals, Instititiwis, Traisleits. 
or RfCfit Reskleits, and yerMiis dyinn awi) from home. 



Pormfr or 
Isual RrsMfRce 

Whfn «yas disfasr contracts. 
If not at plareof death? 



Now lonq at 
Place of Death? 



Days 



PI. ACE OF Bl'RlAU OR RFIMOVAI. 



r)ATF:of niKiAl. or RKMOVAI, 

CvVA».cr IX 190 H 



INDKRTAKKR 



^\S^^.>u 



-(3— 



(Address 



3S 1 6 .K*J:Xxf\,..LL 



N. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** far per- 
sons dying away from home should be given in every instance. 



\ 



\ 



V i 



I 



Ibt! 






It 



i^ 



r 




;ti 



1 ,i; 



t •!* 



!^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



ll„;,r<'. .)f He.-iltli-W Vo. IS ^i'^^^H&I' <^-0 




10 



100'\ 



Ddtp Filed, 

"rUhV-L^ AxovM^ D e pu ty H c a ! t h Qffi c c r 



Begistei-ed JVo. 




DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco 

Certificate of 2)eatb 

{ Ta. S. StanOatC> ) 
PLACE OF DEATH:— County of^"'<X^ ^JA.OL^\CUiC:Gty of '<X/>V v7 ,V<Xa XC^ te . 



(No. 1 ^ 



I M't ItL.. 



Su 



I 



(1 

Dist.: bet* "^ CJ 



CSVy^i 



I 




and \ I '.a..>w/riX^. ) 



/ .F or.TH occui.. .w*Y mom USUAL RESIDENCE G.vt r*CTS c*llco roj» un^cr "»;";*;^ 'J"»"^;!'°'*" ) 

V IF OC*TM OCCOHRtO IN * HOSPITAL OR IHSTITUTION GIVE ITS NAME INSTEAD Or 8TNCET AND NUMBEN. / 



FULL NAME 



^lTSA. 





r„Miw 



\^:y\i. 



UATK OF lilKTM 



LLvVv^J^ 



PERSONAL AND STATISTICAL PARTICULARS 

t! COl.OR 

lUoiith) 



(Day) 



(Ytar) 



A«.K 



5 I Vrafs ^ 



ri 



M»Ht/lS 



Pavi 



"-.INT.I.K. MARKIKU. 
WIUOWKI) OR niVoRiKI) 
iWrJtfiii s<K-ial «ltsi>f!uitiun) 



f\cX"vV^wC^^ 



lUKTHIM.AOH 
(Stat<- or C'Miiitrv 



NAMK OF 
FATIIKR 



HlRTHPI.ArK 
Ol- lATIIKR 
'Stall or Country) 



MAIUKN NAMK 

or- >H)Tin:R 



lUKTHPI.ACK 
Ol- MOTHKR 
(Stale t)r Country 



OCCri'ATlON 



^L^lr a^vcv ^K 



n 



^j 



\ 



\wi 












M„„fh 



/)</i 



THK AUOVK STA'n.n PHRSONAl. TARTU I'l.ARS AKK TRIK TO TIIK 
«KST Ol" >4Y KNOWI.KIM-K AND HIUJKF 



fl 






rXrldress 



111 



MEDICAL CERTIFICATE OF DEATH 



DATK OI- DKATH 



a. 



(Month) 



3 



(Day) 



rgo ^- 

(Year) 



I HRRKBY Cr.RTIFY, That I attended deceased from 

u\.cv\^...tii iQO •. to lL^ 



r\cv\^..iii 190 . to 

that I last saw h ^ alive on 



,\-V.CV-^ 



'^L^i.ait 



190H 

at 190 '■. 
and that death occurred, on the date stated alK>ve, at i v .:) 
J M. The CAl'Sr: OF DIvATII was as follows: 



or RATION 
CONTRlBrTORY 



Years -^ .Vofiths Days 



DURATION ^ Vears Months 

(SIGNED) J-VCLAvk r '„^".v 



Days 



Hours 

^J 

I fours 



M.D. 



LL<^k.q ': 



a. 



iqo 



(Address) ^H 



^. Cc.( "\^ 



SPECIAL INFORMATION only for Hospitals, iNStitittoRS, Transieits, 
or Reccit ResMrnts, and persoRS dying away froni iMmc. 



Pormrr or 
UsHal ResMfice 

When was dlseasf rontrartH, 
If not at place of death ? 



How ionf at 
Plate of Deatli? 



Days 



DATK of IU:riai. or REMOVAI, 



.CC^ 



PI.ACK iW BIRIAL OR KKMOVAI, 

I NDKRTAKKR ^V ' ^A.clx\; ^^\.^ 

(Address 11 "^1 U^Vv,'Q,A^^tr>x...al... 



190 



N. B. Every Item ot" information should be carefully nuppiieil. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information'* for per- 
sons dying away from home should be given In myry instance. 



%\ 



I 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



vt ' 



i{..:,i<i "f n. 



,„„_ ,: So. ,. t*.gggfclUS:l'C.. 



REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



Ihdr ViJrd. LU 



|4 \ 



.. vowit to I'JO^ 

\^JL^. Deputy Health OfHcer 



Begistered J\^o, 



903 






11 

■I I 



(Xcvtificatc of Bcatb 

( tl. S. Stan6atti ) 



PLACE OF DEATH: — County of"'a-Y^ J.VtV>vt\AC 



C City ofC'/O.'W 0. 



No. 



bt)\ Wc^^^.d 



St.; ^ Dist.;bct.'^l^rva>v'>va'>\ and^Vv^nrvA.t'^xdo 



■» 
' 4 




FULL NAME J c^t)!-£X\,irv>x \| U-CC^Va.^ 



I 



PERSONAL AND STATISTICAL PARTICULARS 



■'" 'kJL 



UJv 



\ 






I 



l.\ 1 K OF lilKTU 



\<-.K 






(Year) 



v., 1 1 



,\/„M/kS XSk ^tf** 



STNT.I.K, MARKIHI>. 

wiDowi.n <>K niVMKvKr) 

tWrJtt ill »><Hi;«l lU-si, nation I 



Hik riu'i.xv'j". 

istntf or i'ountrv 



»■ A I hi:r 



KIRTm'l.Ai K 

' St.it < '.t v'.iiiitrv 



MAIUKN NAMK 
«>F MOTHKK 



niKTHPf.ACK 
«»l MoTHKR 
(St;iti- or Conntryi 



J f 



MEDICAL CERTIFICATE OF DEATH 

DATK nl- DKATII 1 

LUv 



(Month) * 



(Day) 



(Year) 







"tCClPATION 

A't-Miirif iff Sntt riiniii<ri> 



^ 1 ^ 



I HHREBY CERTIFY, That I attendotl deceased from 

'\vv.lu X*-^ 190 H to CLvv<Y^ 190 "^ 

that I last saw h W > >% alive on vi^VvX^l 190 '< 

an<l that <Uatli occurred, on the date stated ahove, at ^ 
AX. M. The CAISI-: <»F l)i:.\T!I was as follows: 






Dr RAT ION )'i\if'S .I/0//M.V ^0 /hns 

(.ONTRIIUTORY 



PiTVS 



Hours 



Yi'iM 






Mnnfh 



P., ^ - 



•nil- Aiun-K STXTKI) PHRSONAK PARI Uri. XRS ARK TRTK Tu THK 
IJHST t)F MY KNO\VI,i:i)<'.K AND BKMl.F 



DT RAT ION yt'iifs Afouths 

(SIGNED) JXtrV<y^ d. dX<,wVv^* 

jLc^a^ ^ooM (Address) icri nmIv^^^^^v-'^^ 



Hour!: 
M.D. 



ClAL IN 



SPECIAL Information on'> 'o"^ Hospitals, InstitatlORS, Translfnts, 
or Recent RfsMents, and fti^MS dyine aii»ay froni home. 



Former or 
Isual Resldencr 

When was disease contracted. 
If not at place of death ? 



How ionq at 
Place of Death? 



Days 



PI \CE OF BrRI\U OR KKMoVAI. I DATK of Ht kiAr. or RF:MoVAI. 




rXDHRTAKKR ^ 1 ^^vK^/ "^^^^ Li 

\ I ^1 Olf\A.^A^>.X .M 



f Ad«lres«« 



N. B.-F.ver. Iten, o. infor^-llon .Hould he cnrefuU. supplied. AGE should ^^^^'-'^'^.'^^l'':^;^ ^2r^l':lTurZ'r^ 
state CAUSE OF DEATH in plain term., that it may he properly classified. The Spew.al Information for p«r 
sons dyinft away from home should be ftiven in every instance. 



f 









fif 



I ' 



♦ . 




iiiA 



r 






ii'^ 



I 



,,,,,,,1 ,.f u,:,ith 1- No i'v ■»-..*:. 



.!^*r^_>., „jv,M'„ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

ii 



lie <;ii stored JSI^o, 



\j^.... Xj^u Deputy Health Omcer 



1 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Death 

( Vi. S. StauOar? ) 



n^ 



PLACE OF DEATH:-County of'^C^^v ^^^^^^^ of CVa >v ^^-^^y-^-- " 

( '' rr'^c".""".'.*;',"""-".^,"*' r-'f^^^OH^.t ,TS NAME ,HST.A or sT.cex .HO^«uM.t.. ;• 



FULL NAME 




a'vaaN-Lfc 



a 



>v>\xMl^dA^iLXu 



4 



PERSONAL AND STATISTICAL PARTICULARS 



i.\T»: or I'.iK rn (^ 




^ llil.L. 






\« .»•; 



XH >... 



«r 



(Uayt 



MoHtk^ 



,li.c, 

(Year) 



Da vs 



\vii)ovvi;i» OK i»:\okmki> 

|\\nti ill -iK-ial il« •iy n.tli" 'H) 



MEDICAL CERTIFICATE OF DEATH 

DATK «>l lll-.ATH -^ 

LLv^. 



(Month) (j 



1 

(Day) 



igo 1 

(Year) 



I HRRr-:RY CKRTIFY, That I attetukMl acccase<l from 
\J.lv*-. /. ....190H to LL^vA- '^ 190*^ 



that 1 last sa%v \i ^^ alive on WWVV^IV '^ ^'^ ' 



a.. 



,4 



\ 



nmTinM.\«'K 

St.'itf 'iT v"'<utitrv' 



sxMK or 

lA rilKR 



HIK IMPLAVK 
(»»• I ATHKR 

st;U< or C"Viiitrv" 



MAIDKN NAMK 
OJ- MoTHKR 



luk rm'r.AiH 

■Statf ni Cminlry 



Ov^Cl TATHIN I 



V^^^OLwC 






Ccx 



■-'Li 



-4 



A 






aiuUhat .loath ocourrea, on the dato stated above, at 
M. The CAVSI*: ()I';^J)1':ATII was as follows : 



l)r RATION Vcar;^ 

CONTRinrTORY 



Months 



Davs 



Hours 



(Signed) 



Hours 
M.D. 



Vi^ (>r-t- . 
Kffidfd '» ^iin /'>,rii. ,:> 1 b > '"<" " 



M. ufh- 



Pfty^ 



THK XHoVKSTVrK.nPKK^oNAl, TARTU riXHSAKKTRrK To THH 
iJKSr OJ* MV KNO\VIJ-:i)<.K>^M> HI-.UIl.l- 



(Itifi)rm:iiit 



5). 'IVfrCt^vLv. 






(Addre'^s 



IH vlcX.Kvt(-l LW-:- 



IH' RATION >V</;-5 Months Pays 

\Xkj^'\ tooH (Acl.lress)^^. VjSv^^<t J'^ 

Special information tnly for Hospitals, Institutions, Iransients, 
or Recent Residents, and persons dyinj away from fiome. 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of deatli? 



How lonq at 
Place of Death ? 



Days 



rr,ACH OF nuRiAT. (tn ki:m(ivau I datko;" luiuAr. or removal, 
" ■ ■ ^ ' " .. 190H 







^^.W.QL....i 0. 

l-NPl-RTAKKR VXXVU^'^ ^*^ L/JNaXSAA^K 



"H- 






. ~. , „ .„„„ij,j AGE should bo Btated BXACTI.V. PHYSICIANS should 

N. B.— Kvery item oS i™torm»tion .hould be c»r«>ull, .uppl.cd. ^^'^^2l*»\%\<:i. The "Specl.! Information" fee p.r- 
statc CAUSE OF DEATH In plain term*, that it may be properly classitiea. ne op^ 
sons dyinft away Srom home should he ftiven in svery instance. 



•j! 



fif 



M 

" 



W^ 



», 



r I 



I 



m 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RKFER TO BACK OF CEWTiriCATg FOR INSTRUCTIONS 



IU .:.r.l nf nc;.lth-K No. i^ THj^^S^mV Co 

Drffr Filed, ^^Xajuoaj^A. it) 100 S 



904 



Registered JVo. 
"ivvvc^ 'Ajuxj^ Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

{ "a. S. StanDarJ> ) . « /^_ 

-^ <^ i ^ 

ofC)a^\. 0.njX'>vcUL-S;': City of Oo^^v OA-'a/yvCvAA^) 

,IM ^TC^l .Kl* v.^ -'■ ■ SU ^ Dist.;bet. J-uXto^ andM llillUal^O 

'INO. V ^' I J . W . I ■ ..e,,-, orQinPNCC Civr r*CT8 C*LLCO rOR UNDER 'SPCCIAL INrORMATIOH" \ 



PLACE OF DEATH:— County 



FULL NAME 




si:x 



PERSONAL AND STATISTJ^CAL PARTICULARS 

I COI. 




OU^ 



"■" loj. 




DATK OI HIKTU 



AGK 



|Sfoiith) 



b3 



Vrats 



(Day» 



Mouths 



,..1.1.1 

(Year) 



Pa%: 



SIxr.l.K. MARKIKD 
\VII)«nVKI> OK DIVORl KI) 
(Write- in social iltHi>?:nati<<u) 




BIRTH PI. ACH 

(Stati- or Country^ 



Oi\JLa\f 



NAMK Ol 
FATHKR 



BIRTH PI. AOK 
or FATHKR 

'St;itf or Cotintry^ 



MAIIHIN NAMK 
ni MoTHKR 



BIRTH PI.ACK 
«H- MOTHKR 
(State or Country* 







MEDICAL CERTIFICATE OF^DEATH 
DATE OF DKATH 

..a. 

(Day) 




(Year) 



I IIKRI^BY CKRTIFY, That I atteiKled deceased from 

- igo-..'^. to ...LLA-A^ .^ I90H 

that I last saw h -wa» alive on UwV\^c\> . .B^ 190 

and that death occurred, on the date stated al)ove, at 1 H^U 



1 M. The CAl'SK OV DliATII was as follows: 



la^ 



.1 



J tXCtvruca C)\' X'xLac'-^ 3 



u 



(i 



,OtV^-OL 



OCCIPATION 



1 






oc-JcCCLi.'- CL' — *~ 



CVOLA^U-^-f-^^v; 



Rfsitieil in San /^inri.^t'o ^ Y,ni<i 



yf.utf/i- 



Ihl V. 



THK ABOVE STXTKD PKRSONAI. PARTUni.ARS ARK TRl K TO THK 
BEST OK MY KNOWI.KDC.K AND BKIJIIF 



(Itiformatit 







I)rR.\TI()N Years 

CONTRlHrroRY 



Months 



f}a vs 



Hours 



DURATION Years Months Pays 



Hours 



(SIGNED) 



-tnxLaO'Wvx.^u M.D. 

(Address) '^01 V /Ql^ \njU>>ft ^MM 



SPECIAL INFORMATION only for Hospitals, Inslituttons, Traasients, 
or Rfccnt RfsJdfnts, and jifrsoBS dying away from homf. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



Now loRd at 
Place of Ofith? 



Days 



^X-Mress 



,1 



PI^CK OK BIRIALDR RKMoVAI, 

INDKRTAKHR N' ^ "-^ -X^CXA^ r<^\^ 



DATK of BiKiAl- or KKMOVAI, 

4 



190 



(Address 



N. B —Every Item of Information .hould be carefully •upplled. AGE .hould *^ •i»»«i^EXACTLY. PHYSICIANS .hould 
.tate CAUSE OF DEATH in plain term., that it may be properly classified. The -Special information" far pr- 
Rons dyin4 away from home should be ftiven in svsry Instance. 



V ^ 



Hoard of llealth—FNo. l^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H&FCo 



. \ 



,' I 



905 



* 



/)W/. File^I, OL^Wfc 'b l^OH Registered ^o. 

\^ty^^t^\^'Xxro~^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( TH. S. StanDarD ) 
PLACE OF DEATH:-County ofC'cc^^v Oxo^xc^c City ofO),CU>v J;v<Vvx.caa..^l 



i 



No. '^^t ic^d vivo :1b ^<^ KvU . ^^^^^^^^}:^—z:::r^::^i^.^>o.:-) 



) 



FULL NAME 



LoiJ 






SKX 



PERSONAL AND STATISTICAL PARTICULAR*^ 

I COI,»tR 






ICJ J. 



DATK iH lUKTII 



\i.V. 



QKc 



« Month) 



etc* 



(al 



JVlTI.* 



\ 

(Day) 



M,nilh! 



4 '5. 



(Year) 



Davs 



%■ 



SISr.I.K MAKKIKU 
\VII>o\VKI> OK I)IVnK»KI> 

Writ*- ill •i«H-ial <lr-i)?nati«»u) 



l»IKTin'I.\OK 
SJatt or rountrV 



\ \MK Of 
I- \ IMKR 



lUK rillM.ACK 
0|- l-ATHKR 

Stat* or Country^ 



maiih:n namh 
oi- NurniKR 



HIKTHPUAOK 
o»- MoTHKK 
(State or Country* 




MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 



(Month) t 

♦I 



,. - .1. 

(Day) 



(Year) 



I HRRRBY CnRTIFY, That I attemletl deceased from 

.d.\,:uQ. -^ 190H to LLl^Ol. S iQoH. 



190 



T90 



-uCy -^ 

tliat I last saw h «i./vi alive on 

anil that death occurred, on the date stated al>ove, at A 
J M. The CAl'SK t)K DHA Til was as follows 



D^^^a^\jtA 



C^/vcLo.W'CL 



T) 



c 






Va. 



KJU' 



<JCCrPATlON 

Nfsidfd it} Sail I'ltuh !s,i> jO )i-ai< 



}foiilh^ 



Da I 



THI- \B()VESTATKI)PKRSONAI, fARTUMKAKS AKi: TRIK T«) THK 
HHST or MY Is,NO\VI.HD<>,E AN^ BKUIICF 



(Infornumt 



/Ofc > 



f Xddrcss 



KNOWI.HDiiE AN^ 1 



iD^ 



tc^ 



.L-^rv^; 



.c^^> 



v^ 



Dl'RATION 



Months 






Davs 



Hours 



) 'ears 
CONTRIBUTORY . ..WO.«?V CA.>x--«r:* >^^-<x^ CU 

DURATION ^ >V<7ri • Mouths Days 

^L^S^n ■'■ 190 ■ (Address) %1^ 

SPECIAL Information Mly for Hos^tals, InstitHtitis, Traisients, 
or Receiil RcsMeiits, aa4 per»«s <y'n§ «*'«> *'«'» •»•"*• 



(SIGNED) 




Hours 
M.D. 



«i*« Hl^ J^ll- •-•J 



Formfr 

Usial ResMeicf 

Wkfi was disease contracM, 
If Rotatplacetf deatli? 



How \n% at 
Plarcof Deatk? 



Days 



PI.ACJ^OF Bl'RIAI< OR REMOVAI, 



DATE of HuRiAt. or REMOVAI« 

U-cvtx. IX T 90H 



I NDER' 



tiJix/vctx Mryvo-K.vvuu^ /^^^ 



(Address 



^:L^1lJ8Jw&:V^.. 



N. B.-Bvcry Iten, of ,„fo.„,-llo« .hould he careful.. -ppUed AGB •^-'*« ,^ ••-^•-.f .^f^^^^^^^ in^oVnfJtTot^^f.:"::!.! 
state CAUSE OF DEATH In plain term., that It may he properly claaslfled. The Special Information far per- 
sons dying away from homo should be ftlven In •s9ry Instance. 




f! 



! 






■ f 

r 



:•■■! 



i 





,,,,.,1 of lU:,Hh- »•• No. .. IF-Fw^i?^-. H&PCo 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l()0^ itegisieretv ^yu. 

AjLA.-a Deputy HealttvQIf^cer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of Death 

PLACE OF DEATH:-County of J^Ko^^^VO^ ^Q^r^ J.VV^^<V>v 




No, 



St: 



Dist.; bet. 



— and- 



(ir OC*TM 
ir DC* 



,. OCCURS AW»V FBOM USUAL RES 

ATM OCCURHCO IN * HOSPITAL OB T 



FULL NAME 



5IDENCEGIVC FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" ^ 
N?Ti?UT.ON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



-) 



rtl^^xJ^-.^ \ C' 




^<X. 




'w* 



PERSONAL AND STATISTICAL PARTICULARS 



^iJ. I" "U)J 



'wtjL 



DATK «U- lURTIl 



AP.K 



(Month) 



( Day) 



(Vt-ar^ 



HC) 



)•,./, 



Months 



Davs 



SINCI.K. MARKIKI) 

\vn)<»\vi:i) OK n'VoKrK!) 

iWiiti in <«KMal <1( «i>.'n;iti<>n) 



I i\cx^h^A^u:l- 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 

1 



(Month) (A 



(Day) 



(Ycar> 



I ITKRKRY CKRTIFY, Tliat I atteiKlcil <lcceast'(l fnmi 

— -rrrrrrrrrrrrrr— I9O to - -If-f) 

that I last saw h alive oil •• " *90 



an.l that <U>ath occurred, on the dale stated al)Ove, at — 
"M. The CAI'SP: ()!• I ) I! AT II was as follows: 



niKTHri.ACK 
I Slate or Country* 



NAM»-: Ol- 

I- ATni;R 



lUKTIiri.Ai'K 

01 I \ rni'.R 



MAIIU'.N NAMi: 
01 MOTIIICR 



lURriiri.ACK 

<)l" MoTIIKK 
(Stale or Country) 



OCCl TATION 








i/0L»^-U3 c)/C/Va^>v<xcLc^'- 






^^ .M . 1 lie V.-vv .'I, »'• .'.,.%. 



I)\ RATK^N Years 

CONTRIIU'TORV 



Months 



/\iys 



iL \x.k/> 



1 



'X<^uv^\. 



i t 



Rfsiiirif in Sair /■> ati, i^ro \ '- ) '' 



yr.oith' 



/),n 



THK ABOVK ST\TKn ITRSONAI. TARTK r!,AKS ARK TRTK To THK 
HKST OF MY KNOWI.KDCK AND BI-.IJU' 

finfonnant t^dUjlio^ Q A^^^^O^dU^^^ 



I 



I)r RATION 

(Signed) 



Years 



Ll 






Mouths Pavs 



Hours 

Hours 
M.D. 



C^a M TQO 1 (Addr ess) ^V 

A — 



.' cv^ ^o- >v Ha* 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying and) from home. 

Former or !!r ''*?''.**.. , 

Usual Residence Pla. e of Death ? Days 

When was disease contracted. 

If not at place of death ? ^™™^ 



IM \CF OF niKIXT. OR RFlMoVAU I DATi: of HiKiAl. (»r KKMOVAL, 



l-NDHRTAKKR Kd <XSJ:djL<L ^< Lc 

(Address ^ H \j M'^ Vv^^V<c«>X. . dl 



sons dylnft away from home should be fciven in every instance. 



' I 



I 



r \ i 



h \ 



. t 




I.) 




ii. 1 

4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RtFER TO BACK OF CERTiriOTC FOR IN«TRUCTION« 



Mnanl ..f lK;.lth-I-- No. I« »-^g^ll&l'Co 



Dn/r hlli-d, (XlaX^L/Vo*! 1 1'-^O H 



Registered JV*fl. 



907 



DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



No, 



PLACE OF DEATH: — County of <XAV 
\^&M '"^^ LcrL^-^\iu ' V CK^kv-toJ.SU D ist; bet. 



Certificate of 2)eatb 

( *a. S. StanOar^ ) 



o^^a.. 



and 



'M '-'-vA ,,-,,*■ Br«irrNrrriwF facts called roR under special informatiom* i 

1 ( •' rr"D;:T:^0^"rcV.;"rKO^s"prT*AL ?r'?:St^^*V^O^"o.;e7tI ?.VmE .NSTEAD O. .TREET and NUM.ER. ) 







\ 



FULL NAME 



dvvy^ cf\.^ djLt...LL D.a:v.\.CLI 



PERSONAL AND STATISTICAL PARTICULARS 

I C01.i>R 



■"^ ^licL 



1 



DATK OF HlkJII 



a«;k 



<\|liiith) 



■5 



^ Jv^tx. 



s 

(Dny) 



(Year) 



W \ I 



fa> 



M„nlh 



Ha V. 



sINT.i.K. MARK1KI> 
WinnWKn OK DIViiKv Kl» . 

Uritf in onial (U-si^tiatioit) m\ 

d 



HIK TinM.XCK 
st:ilt iiT Coniilrv 



N'^MK OF 
FATHF.R 



RIK TMPI.AOK 
OF lATHKK 
(Statf or Country 



maii»f:n namk 
OF mothf:r 






u 



MEDICAL CERTIFICATE OF DEATH 

I>ATE OK DKATII i 

LLv>^ 



(Month) f\ 



h iQo'i 

(Day) (Year) 



I HEREBY CERTIFY, That I atteiKletl deceased from 

„....\i JL^.> V . ll IQO \ to LLn^vO^X 190 H 

that I last saw hA^*»i^ ahve on k/VUv^c^ t 190 v 

and that «leath r>ccurred, on the date stated above, at u %>. v 
SI. M. The CAUSE OF DI^ATII was as follows: 

„ s.O-'vtvsL LVv.^..' 



,>%Xr_V.V\..V>i, ■> >.V ^ I 



V 



^ 




iwrthpt.acf: 
of mothkr 

fSlate or Country 



-f. 



^c^^^ vv .V 



» . - t 



OCCFPATION 



.1/,-/////.. 



/hi\. 



THF AROVF ST\TFI) I'KR'^ONAI, I'ART ICF LARS ARK TRFF: TO THH 
IJKST OF MY KNOW I.I.IX.K AND BKIJFF 



{informant U) .»^ Hi H^<X.A.vrVt^ 'M 









1)1' RATION )'ears X^ Months Days Hours 

CONTRIBUTORY /•Jc^v^VCcC \k.\XJJ\^^ ■C}-.z^^^^^■^ 



DURATION J'"^ Years Months 

( SIGNED )...\A. A-^v UiatrL 



Days 



Hours 



1 



^IX-A.-.^ 



iqo 



nr\\i VAJ CXA^A_ M.D. 



(Address) IXCiO VCLNV 



SPECIAL INFORMATION only for Hospitals, InstitutiMS, Trins.eits, 
or Recfiit Resklfiits, and pfrsons dying away from home. 



Former 

Usual Rrsidencf 



rsidfncr i--"L^ 



How loRQ at ^ 

Jt ^ X xvv*V' > &- v.A,C piare of Deatli ? ^ v» .6. „v Days 



WhfR was disease contracted. 
If Mtatpliceoftfeath? 



PLACE OF BIRIAI. OR RKMOVAI. 

s 

rXDFZR TAKER 

(Address .. 



DATF'of Bt RIAL or REMOVAI, 

dxA.^ \ X -^ I 90H 

"XjUlLu ^ J w cxa ct , 

Ikh... l^±'- "^.1 



N. B.— Every Item of Information .hou.d be carcfuUy .applied AGE .hou.d »>« 7'':J.f .^_^^^^^^^^ InZrjtTot^'Vr"::!.^. 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special information for per- 
sons dying away from home should be ftiven in svsry instance. 






i 



I »- 



i 








V \ 



ll 

I 



« i i 



, t 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.,„, .r„.,m,-.-No...^^H^PCo REFER TO BACK OF CERT.r.CATE FOR .NSTRUCT.ONS 

908 



IdO'i 



l^vc^'Lv^ Deputy Health Officer 



Registered J^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County 

'0 ~ i^ { 



Certificate of H)eatb 

( Ta. S. Stan&arC> ) 



ffo LcUi '■'^ V^VV-^A.'tu ^ ^':ikvl X (:St4 — — Dist.; bet. --■-- ■ ;; - -and ^ 

^^^* ^^^^V -wv^-w w»^ ..te,,., orcinrMrF riwr r*CTa CALLED roB UNDER SPECIAL INFORMATION" \ 



) 



c 



FULL NAME ^^^^ 



ri a 



&'C^'X.O..r4.V v.Vt.. 



PERSONAL AND STATISTICAL PARTICULARS 



DATK Ml- HIKTH 



COLOR \ 



^iJi-.di.. 



< Month) 



Ar.K 



SINr.I.K. MAKKIi:i> 
\vn)t»\VHH OR DlVnKvKI) 
iWritr ill vH-iiil «lfsi»rnatinn) 



HiK rm'i.ACH 

iStatf or 0< unit IV 



lATHKR 



BIKTHPl.ACK 
Ol- I'ATHKK 
'State or Cnuiitry'i 



MAIDKN NAMK 
OF MOTHKR 



HIKTHIM.ACK 
Ml- MOTHKK 
'State or Country! 



OCCrPATlOX 

Rfsidfd in -^nti /'nrn,i^t'ri 



(Day) 



!/.»«///. 




)'>iji 



M.'ttfh' 



Ihl I v 



XnV XB()VEST\TKI) I'HRSONAI, rAKTUMI.AKS AKi; TKIK TO TIIK 

iJKST OF MY kn«)\vi.f:i)<;f: and !iHi.n:F 



f Infoiniant 



^ 



'^^X, 



Q^\ \^.\.sJ^^ ' 



TS 



r\'l«lre«J«« 



\.aXm 



^ C^ V' ^>i-K^<^- -*- 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 



.' DKATH .n 

LL\.\.a 

(Month) V 



1.. 

(Day) 



(Year) 



^. 



I HKRKBY CHRTIFY, That I attcmled deceased from 

to A.t/Lvq^....^ igo H 



.!^\.V.LuL..j»..L.... 

that I last saw h 



190 V to .^vv.:waL 

alive on \AAA^X1,..L... 190 

and that death occurred, on the tlato stated above, at IX o 
'f M. Tlje CM' SIC OF I) i: AT 11 was as follows: 



•r 



i;-Vw«r:w«w.«. 



or RAT ION 
CONTRIIU'TORV 






Months 



Days 



Hours 



t.r^rft^.'X.^. 



DURATION Years Mouths Days 



(SIGNED) vAirv>\> 



.^\j 



>, - 



Hours 
M.D. 



lAvA_ai lOigo' (Ad dress) ^^H -<<.. Lc 'ikj^^.V- 



SPECIAL INFORIVIATION only for Hospitals, Institutions, Traiskits, 
or Recent ResMents, and persons dying away from home. 



Former or | i | , 

Usual Residence s-vVui^ 



XAXO-v^-^^v 



How lon<| at 
Place of Deatk? 



Days 



When was disease contracted. 
If not at place of death ? 



I'l.ACE OF BIRIAU OR R'VoVAI, 

-\ V 5 * 

I N I ) f: r t a k f: r v.L V-*v i 



l)ATF;of IJiKiAi. or RF:M0VAI, 



{Address 






190 t 



\\ 



t \ . \ • 



N. B.— Every lte« of information .hould he cnrefuHy supplied. AGE .hould ^'^-'^^F'.^^l':^' .r^.^Ton^^r*'^!.! 
state CAUSE OF DEATH in plain terms, that it may he properly classified. The Special Information for psr- 
sons dying away from home should he ftiven In every instance. 



tS 



tij.. 




t 
I 



% 



.t'" 



1 1 



>|.' i 



'\ 



vss 







r 



*M 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

909 



|i,,at.l..f lli.,lllv- l-No ,.-»-g^;S^-.H«:l'C.1 



RegLstercd JVo. 



l^vw^lta^v, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ceititicate of 2)eatb 

PLACE OF DEATH: -County ofC'cL^' a^V^^VO^^aGty of ^^OAV Ox^^vcc^ ^. ^ 

No. ^il'X LLi^^ '^ '>^"' •- - '^ 



rwt"r>J,'--. 



St. 



H Dist.;bct. 4,tk and ^ t', ..■ ) 



'^ ~ ^ ^ iiciiAl OTQinrNCE Give FACTS CALLED FOR UNDER SPECIAL INFORMATION" \ 



FULL NAME 



^ i: \ 



PERSONAL AND STATISTICA L PARTICULARS 

COI.OR 



'TO 



I 



DAIl-: nl lURTIl 



AOK 





;^\A. 



.•b. 



'VOL 



iMAnlh) 



O I )>.7». 



(Day) 



Mnnth ' 



(Year) 



Pars 



SlNi-.l.K. MARK I HP 

\vii>M\vi:!» <»K inv«iKi in 

'\Viit< iti -ixial ()f-i|/:i;iti'>ii) 



niRTMlM.AOK 
(Stnteor Country* 



lA rilKR 



niR rnpi.MK 

0|- lAIHHR 

iSt.itt or fi>iiiitr>' 



M\II>HN NAMH 
nl MOTHKR 






HIR rUPLAOK 
0|. MuTHKR 
(Stall- or Covjntryi 






occrrATioN (>V|> A 



A',-^^/^./ /> \.;" /•'./»/.-'- " '^■'■^ >■'•'"> *■ ^^""^'^^ 



/hn 



Tin- AH(>VK^T\ri-,I> l>KKS(>\\M'\Klirri.\KS AKI-; TRIK TO THH 
HKST <)1- MY KNOWI.IUX.K AM) liHIJhl- 



(Inforjuant 






.xcJUtL'vv 



./Crvv. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATIl "^ 

'Day) 



(Muiith) i 



/go 

(Year) 



I HRRHRV CRRTIFY, Tliat I attciukd ileccased from 



H\.v>'\j^ .:j*.l 190 • to 

that I last saw h wl.*^". aliYC on 



a 



'L\JX. 



L 




190 H 
190 ; 

an«l that death (KHurred, on the date stated above, at ^ H 
't M. The CAISI- OI' I)i:.\TII was as follows: 

CoUXcLa. c3w% Vl.(X.XJL«^'-< 



I) r RATION * y'rars 
CONTKIIUTORY 



Months 



Days 



Hours 



nr RATION Years Mouths 



Day 



(SIGNED) ' ^' CX.VV 



Hours 
M.D. 



fAd.lres*;) X^X LLv>%^^^.a4 



i^ . 

Special information onlv for Hospitals, Institutions, Triinsipnts, 
or Recent Residents, and persons djinq away froni home. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



1'I..\(:K Ol- Bt'RIAI, OR KllMoVAI, 



DATKof Ht RIAL or RKMOVAl, 

a. It T90H.. 



TK of n 



(Ad<1ress 1 AoT . . NJ YWl^ v^ > ^ 



N. B — F.very Item of inWmation .hould b. carefully supplied. AGE should bo stated EXACTLY PHY8ICIAIN8 .hould 
.tate CAUSE OF DEATH In plain term., that It may be properly cla.slfied. The Special Informat.on" for p.r- 
Bon* dyinft away from home should be ftiven In every instance. 



!?■■ 







?•♦ 



' if 



l. 



i; 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hm;iI<! ..f ll.':ilth »■' No- !=; 



tJ£"«^i4, Hftrco 



^•> .«-^ 



REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

910 



Megustered Xo, 



Da/r Filed, iXt^OL^^^ *l t ^'^O'i 

XcH^v/> ^Ijlanm Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Bcatb 

( H. S. StanDarD ) 



(?? 



Hi "A ^V 

OACL.-VV"' .."'City of *^CC-.v ^^n./c^.^x i(_<i- c 



PLACE OF DE ATH : — County of ^CL/>^ 

in "* ^^ 

iNn \L'V.^_>.^-J. X' -L'\.v.-, 'l^v^-"^' St.;- . — - . 

^^^'' ■ ^^^ 1 w . .,^.,», arcmrNrr ^lur r^rTfi CALLED rOH UNDtB SPECIAL I N FOB MATIO N " 1 

( " r."".T°H'icc"u%'.ro',;"r«o"s^,yT*.t o^'T■;.^^"u" «". "4 ^NVt.t° ,.ste.o ^ .t.eet .... -uMec. ; 



Dist.; bet. 



and 



) 



FULL NAME 




.r>va 







^ 



UJUULL^. 



PERSONAL AND STATISTICAL PARTIC ULARS 



'"" vkcL 



U\t...t 



1>ATK 1)1 HIKTII 



At'.K 



CxUt 

tMuifth) 



Hk^ ,.„, 



'.5 



(Hay) 



.V.>M///« 



/^5.i 

(Vcar) 



Ai' 



SlVr.I.K. MAKHIII* 
\Vin«>\VKn Ok IilVtiKi Kl> 

Willi ill <«<Ki;ii «U— i!.Miiitii»n) 



niUTHPI.ACK 
(State or Country) 



VAMH ni 
I ATIIKR 



RIRTHPI.ACK 
*)f lATHKR 

<St:itt or Ctmntrv^ 



MXini-.N NAMH 
oj MoTHKK 



uiK I HIM. \ri-: 
stall .)! Couiilry) 




W > vcv. 






t^ 



'\ 



n*,\ » J-AIION 



Rf^nird III S,n: /> c n 






MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH ^ 



( Month) \ 



...a.. 



(Year) 



I HKRHBY CERTIFY, That I atteiuled tlcccased from 

^LcvC^. G 190 A.. to LLv^vCX^.^i T<)oH 

that I last saw h . alive on Lv.*wV cy \ 190 '^ 

ami that «U-ath «>cciirre«l, on the «latc statc«l above, at ^ 
' ) .^M. The CAl S!*: Ol- DI-ATIl was as follows: 



or RAT ION 



CONTRIlHToRV &:VtXju^ 






•^ 



A/ou//is 



/\iv 



Hours 



nr RATION Years 

(Signed ) wL ^ 

(,0 



Mouths V^vvT Pays 



0)1 



Hours 
M.D. 



OLcva q ic,oH (A.Mn>.s) SxiVnlo-vk^t 'I 

SPECilAL Information onl> '»«^ Hospitals, institutions, Transients, 
or Recent Residents, and per5>ons dving avvav frou home. 



^ 



^ 



? 

Si 



^ ' 




o 



t 

^ 




/)(n. 



rm MiOVF sTXri-n PKKSONAI, J'AK riiT! \K< AKi: TRIK TO THK 
r.HST (H- MY KNOWlJ-.ur.K AND HHMJ.F 



(Itifo-niaiit 



lo^vQ Qu 






Crvvf 



Former or ^ 1 \ \^' 

Isual Residence vl Ctvv4Vw'. 



-u 



Hew lonq at 

Place of Death? CrrsA^.. Days 



When Has disease contracted, a 
If not at place of death ? vw 



1 1-. ">: jn K 



T90H 



PLACE OF lURIAI. OK KKMoVAI. I DATKuf ISrKiAi. or REMOVAL 
rXDl-RTAKER \X v, ^ 

^ ( i) 

(Ad.lrt-ss W'\ w(wCL\.^ 






S 



N. B.— Every iten. of 1„for„,«tion .hould be carefully supplied. AGB «hau.d »>« "^-^^^.f .^5^«:^; .rrj^/^t^.^r*'::',^. 
state CAUSE OF DEATH in plam terms, that it may be properly classified. The Special Information fer per- 
sons dyinft away from home should be ftiven in every instance. 



t 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1?""' aWx**") 



l,,,.u.l ..f 1!' nlth- I^N'o. i-^ '"Li^iS' 



^f<54j Hftr Co 



f t 



■\ ; 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

Registered A'^o, 9XX 



Date riled, \Xu^\^^^ ^\ ^^^"^ 

rU-w^ IxAj-H Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX. 5. StanOar^ ) 
PLACE OF DEATH:-County of OO.-^ -1xo.>vtwc0ty of^'CU^ ^OAVC^^CC 
.r»-. nt M iLcthAi/ ^^!)-slk«.A.O..'. S\.v — — Dist.;bet. and— - ) 

l^^^ I - ..eiiAi oreinrNrr rii/r rACTS CALLtO for UNDER SPCClAt I N rORMATIO N" \ 



FULL NAME 



- I f 



'•■i^ 



A,C\ ^..CU 



■t*' 



PERSONAL AND STATISTICAL PARTICULARS 



ir 






SKX 



'^ 



DA n-: < "I i:iK I'M 




""■""lilLu 






• Day) 



(Year) 



a<;k 



U '> 



r,-.n 



MnHlks 



Pit \ 



SlNi.l.K MAKKIKn 

\vnM>\vi:i» OK inviiKt i:i> 

'Writ* ill x<HMal tJ«-.i>niation) 



HIKTIII'I.AOK 
(Stall or Comitry^ 







NAM1-: <>l 
KATHKK 



BIRTH I'f.AOK 
<)l' lATHKR 

'St:(tr .<r riillfllrv^ 



\J A 1 1 > 1-: N N A M I- 



r.lKTHIM.ACK 

• •I M«iTni:K 

(Stat«- Ml fovintrv) 




we w« 



» Kcri'A'no 



N 4 



h'e idfd III S)til /ill II, 



• . )V.n 



M, >iHi^ 



/>., 



TMI- MIOVF '^TXri'D I'KKsoNAI, P \ K IHT I.A RS A K K TRIK T< • THH 

linsT oi MY Kisowi.i.ixvK AN I) iu:i.n;K 



(Info:in:mt 



A^ 



Sn^^%„A^' V 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

U 
(Hay) 




(Yfai> 



(Month) A 
I HKRiUiY CIvRTII'Y, That I attciKkMl (kccascd from 

.^j^Lv^ 190 1 to LL^w<v.qL,..u,.... 190H 

that I last saw h alive on \AA*^r:ty..^ I90H 

an«l that lU-ath ocoiirrcil, oti the <late statetl above, at ^ 
jJL M. The CArSI*: OI" DliAPlI was as follows: 



a. 



Dl' RAT ION 
CONTUIIUTORY 






/hivs 



//ours 



DIRATION 
(SIGNED) 



}\(irs 



Afi>fi//is 



/)tivs 



Oivtkv^^r i))v ^u ' 



/lours 



M.D. 



<»»-'V»V^*-^ >, 



a . ■ 190 . f 



A « M rrss ) ?lX J f L<XVct.a '• V ^ "^ \ 



SPECML information on'y tor Hospitals 
or Recent Residents, and persons d>ina d^ay from home. 



>, InstitufioRs, 



H^O'^jUv 



Former or . 

Usual Residence 1 

When was disease contracted. 
If not at place of death ? 



Hfw lonq at 
Pidfeof Death? 



Transients, 



Days 



«A<!.lrfs« 



Wh^ < 




<^^\^K.K.' 



ri.ACK oi- lURiAi. OK ki;m<»\ai. 



OATFof HiKiAL or RKMOVAI, 



190 



^ 



vc vl 



(AddriHs 



^\^ Mriv^^ 



v<n 



N. B.— Every Item of Information .houhl be c«rcf«Ily •applied. AGE .houlcl »»«-t«ted EXACTLY PHYSICIANS •hould 
•tate CAUSE OF DEATH In plain term., that it may he properly cla.alfled. The ^Special Information" fer pr- 
«onc dyinft away from home nhould be ftiven In o%ery inntance. 



T 







i \ 



(' 



I ) 



k 



r 



I I 



l« 




1 



i 



II, 



I>.,,:iT.l of M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„„,-„. v.„ ,. ^.r^^. ,.«.H c„ RtFER TO BACK OF CCRTIFICATE FOR IN8TRUCTI0N9 

9i;2 



Registered J^o.. 



pfffr tyh*(/, \L\A^^^ II i'^0\ 

"oLM^vUi XtxNu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of SanFrancisco 

Certificate of TDcntb 

{ XX. S. StauDarD ) 

J Q!p "^ ^ 

DEATH: — County ofC^OAV i\.a>\CUl^ City of ^J'O.^ OXa.OA.CC4^0 



PLACE OF 



(no. 






CK- 



kJ.-'. 



St.; 



Dist.; bet. 



"^and 



-) 



• •eiiAi DP ei nr Mr r r-iwr rACTS CALLED for UNDER SPECIAL INFORMATION' 1 



FULL NAME 



./avow^ 



^U. ^JjO-ih^.W-i^J.. 



PERSONAL AND STATISTICAL PARTICULARS 



^»:\ 



(^ 






COI.OR 



1>\TK «)»• lUR III 




\ 



w 



,u 



iMnllllO 



AC.K 



lis 



i'mts 



% 



( Day) 



M.mlhs 



(Year) 



i'\ 



Davs 



^I\«.I.K MAKKIKI) 

W n>n\VKI> «»K |»lVOKri:i) 

Wiittiti sm-ial f!tsit.'n{iti<iii) 



HIK IMI'I.AOK 

St,!. ,.; (."■nintiv 



N \M1- 0»- 

I A rni.R 



TURTHPI.ACK 

()i- I A rnKK 

f St;(t» or Counttyli 



M\Il>KN N\MK 
<H MorilKR 



HIRTHIM.ACK 
oi- MoTHKK 
estate or Country 



«HCI TATION 




trvv^v 



) Q<XJ\j^^y^<x/ 



e 







ri.vcLcx.. 



'VucL 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH T 



(Month) n 



Ifc, 
(Day) 



(Year) 



1 in:Ri:HV C1";RTIFV, That I attcmUMl deceased from 
lL^^V^CL ^ igo'i to LLcA^a. U IgoH 

vXv^-CV H 



that 1 hist saw h «^^' aUve on V^\-V^.c^ n up 

and that death (k curred, on the (hite stated above, at 
i\ M. The CATSI-: Ol- I)i:.\TII was as follows 



DIRATION 
CONTRinrTORV 

nr RAT ION 



Mouths 



Days 



I lour s 



Years 



Years 



Mouths 



Pavs 



(SIGNED) LL^l.AVO.^' •• NlH^ •i'w>vt^ 



.1 



VVCCO ^^ IQO'. 



(Address) at Anl 



av( 



ai 



I. 



Hours 

M.D. 



Special information only for Hospitals, In^itutlMS, Traasltiits, 
or Recent Residents, and (jersons dying away from home. 

II9W ivni| Ol 

Days 






\ ■, 



•<f ; f 



\f..ntli< 



n,! 



THK \noVK ST\ riF) PKR^^ONAl, I'ARTICrL\RS AKK TRIK To THH 
IJKST OF MV KNn\VIj:i)C.F: AND HKLIKF 

(Itifuin.aTit W'L^' ^ "^ ^^ 



f A (111 res* 






Former or aNC* "M.^, r^ ' 
Usual Residence OO^ vj J-vvC^ . 

When was disease contracted, 
If not at place of death? 



How lonq at 
Place of Death? 



ri.ACF: OF m RIAL or rf:m«>vai. 



l)ATF:ot MfKiAi, or RF:MoVAI, 



Lv^.A.^'(X, 



T90 



f Address 



Wi-w ^^ 



-\ 



NuQ-«^A-<(r>v 



N. B.— F.very Item of i„form«tion .hould b. carefully supplied. AGE should »>« stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The Special information for Rsr- 
sons dyinft away from home should be ftiven in every instance. 



N 



. Ir I 



i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„...,., .,fi....u„-Hs-n.,.^4g?^..<^-t-o RereR to ba ck of certif.catc for instructions 

])„h'Fn,-d, Clwavv^ u VJO\ Registered ^'^o. 913 

'd.^Crvcvfl Xt^-uMj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( "a. S. StanDarD ) 
PLACE OF DEATH:-County of^'^^ J /LC^ >vac4C( City of O^V^v- l^CXivav<iCC 



(^ 



\ 



^THo. 



u^dtLL"'^^^VV^^^ Ibo-i-lvclaA St.; -Dist.;bct. 



■and" 



/ .r DEATH OCCUP,S>W*V FROM USUAL R E S I DE NCE C. Vt FACTS CALL CD 'OnUJ^OtB „%%";*i^' J ^"^JJJ'^" " ) 
V ir DEATH OCCUnUtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. • 



FULL NAME 



lIa-'LL 



S^OcWX- 



n.'w\,v.>N-i.- 



PERSONAL AND STATISTICAL PARTICULARS 



■■" ^])\J. 



COI.OR 



ll^JvcU 



UATK Ml- r.IKTII 



)>f<inth) 



AOK 



b^ jv.„> 



(Day) 



.1/..M/At 



, 1 H t 

(Year) 



Pavs 



sIM.l.K MAKHIi:!) 
\VIl»»\V»",I> OK niVoK* Kl» 



lUK riiiM.xt'i-: 

'Stiiti- i>i I'oiinti V 






\AMl-: nl- 
FATIIKR 



HIRTHIM,\»K 
<»!•• I \rHKR 

iStiiti or v'oniitrv* 



<>i mothkk 



RIR TIIIM.ACH 
OF MOTHKR 

(Slatf or Country^ 



4 






"wS. 




Ct^v<:L 



cLc\A.X 



OwVx^cL 



Rf<idri1 ill Sun I itnni-ra 



'„ )''".?; 



yr.»ifh' 



I hi 



THK \BOVF ST\Ti:i) PKR'^ONAL TARTUMLARS ARK TRrK TO THK 
HKST Ul- MY KNOWI.KIX'K AM) HKMKK 



'^JL^--'^..- 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

Lvv\,q A 



I go \ 

(Year) 



I 

(Month) 1^ (Day) 

I IIRRRBY CKRTIFY, Tliat I attendiMl deccasetl from 

to 



■190 



that I last saw h alive on — — — - 

ami that death occurred, «>n the <late stated above, at - 
M. The CArSI<: ()!• DIvATII was as follows: 



-190 
-190 



\ , 



K. '...'-. ' 






Dl" RAT ION Years 

(.ONTKHU'TORY 



Months 



Days 



Hours 



DIRATION -, Years 

iW 




I\l\S 

a. 



Mouths 
( SIGNED ) ..L«r\^rnX'v 

'^Uvq 4 iQO-< (A.ldrcss) \js\xr\-\V\A 

SPECrkt Information only for Hospitals, institutions, Translfiils, 
or Recent Residents, and persons dying away from fiome. 



^ 



Hours 
M.D. 



Former or a nn '^ } f ' "'* '®"« ** 



Usual Residence 

When was disease contracted. 
If not at place of death ? 



t ' Place olOeatli? 



Days 



I'l.AQt: Ol- HIRIAI, OR RHMoVAI, 



VQK 01 




INDK.RTAKKR M fW^VoJlvCW^ U OVJ 



I)ATK.<)f III RIAL or RKMOVAI, 
LLv\,CL, » W T90 A 






(Adilress 5>35HA 



0>v 






jv 



fiwA.^v4rv\ 



IS B Bvery item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special information" for per- 
sons dyinft away from home should be ftiven in every instance. 






1 



¥ 



il 



;i 






V 



X 



r 




Dftfr nicfl, \j. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

914 







IfJO'i 



Regiatcred J^l'o. 



X^^^^lx^v^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiflcate of Bcatb 

( U. S. StaiiDarD ) 



PLACE OF DEATH: — County ofU/CWu OX-O^XCUW:' City ofO-OAV OA-O.'^'UlAAA-t. 



4 * 



^3f 

(No. -^H"! Ox 




^'"Vv. O 



Htlv 



>. ^ r V.V.X. . . St.; ^ Dist.; bet. ^ ^^ and 

/ ,r or.TH OCCURS .w*y trom USUAL RESIDENCE G.vr r*cTs c*llco ;or ^"R ,^%%";*i 'J'°;;*J'„°'*" ) 

V \r Dt*TM occurred in » M08PIT*t OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

^/^A,<<X^t.C)u^^»^C^. VCX^lxJLL. 



tJi\} 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



"" «f 



1)\TK nl |;IK in 



<xX^ 



COW>R 



IoIju 



•M.iiJth) 



(Dsy) 



(Yearl 



AGK 



HS 



Vftiti 



MoMlhs 



i. 



l\r\ 



St\C,l,l* MAKKIl.n 

\vn><)\vii> <>K i)iv«»Ki j;i) 
Writ' Ml v,«ial ilcsijfnalion) 



'St. it? It! ioHHtl \ 




' cLo-V\M^cL 



vt 



O^hxLo^ 



\\\\Y oi 

i-A iH j:k 



ft f % 



RIRTMI'I.ACK 
ni- f-ATHKR 
<Stat«- or Country 



MAIDKN NAMH 
(•1 MnTMKK 



UlR'rniM.ACK 
<»! MoTUHR 

'StMtf or Coiintryi 



OCCrPATION 




VV'>v 



n 



\ 



iJL. 








O^AA^XX 



^\-i 



Rfsiilfi! tt! Sa» /'i iin./^,-i'> .'^ ^ Tr ,f / < 



M.oifh' 



/),.■! 



TMi: AROVF. ST\ ri-.l) PKKSONAl, rAUTiriLARS AKl', TRIK lo THH 
HKST Ol MV KNoUI.I.Df.K AND HHI.IKF 

(A.Mr,-.. 3 H'l J X^VCX.'^ ^ VtX .• ^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII "1 



(Month) (Y 



...a... 

(Day) 



(Year) 



I IlIiRlvHY CIvkTIFV, That I atten<le«l ileccased from 

•^ *~ T90 I to vL\«A^^ ^ igo H 

that I last saw h -&A; alive 011 LLvwOl .!-l., ic/D '' 

am! that <lcath occurre«l, on the «late stated above, at 
1:1 M. The CATSH Ol* DKATII was as follows: 



DT RAT ION 
CONTRIIUTORV 



Years t> .}fontfis 



Days Hours 



DrRATION \ y^*'^r^ Months 



Days 



(SIGNED) 



Hours 
M.D. 



f)0 



fA.hlross) (j OAA-^ti ^X<i<V 



SPEdlAL INFORMATION only for Hospitals, iBSlilutioBS, Transkiits, 
or Recent Residents, and persons d>ing Vhi>s ^^^^ ho""'- 



former or 
lisual Residence 

When was disease contracted, 
if not at place of death ? 



Htw lonii at 
f»iaceof Death? 



■ Days 



ri.ACK OI" lURFAI, OR KKMoVAI, I DA'D; of IHrial or RKNfOVAI, 



V. (^ 



.:r > V w yo-^vv^v^^ '^^^^ 






T90H 



INDKRTAKK 



(.Ad«lrcss 



item of information should be carefully supplied. AGE «hauld be stated EXACTLY. PHYSICIANS should 
CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for p«r- 



N. B.— Every 

state CAU! 

sons dyinft away from home should be ftiven in every instance. 



iv 



\ 



r 



•i' 



t 



-I I 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.,a „r n..Uh- .- Vo . .^^r^P^nS^ REFER TO BACK OF CERTIFICATE FOR .NSTRUCT.ONS 



Diffe Filed, U/^vavv4: W lOO'i 



Registered J\^o, 



915 



^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( U. S. Stan^arC» ) ^ ^. 

^ — J Va'>x~'.--. 'City oV^y<x^\> JA<X^ 



PLACE OF DEATH: — County of^ CL>V 



V^A^i 



No.u.vAval I 



VAVi^O ^ ^ V C» : '• C' M.5t4^CA,<..' Dist.; bet. 



and 



' ••eiiAi oreinrNrr nwr facts c*llcd for undcr ' sptcial iNroRMATiow \ 



FULL NAME U-CTt 



"^U ^^ r^ f, Co. WuY ^ - -^ 




+ 



PERSONAL AND STATISTICAL PARTICULARS 



" '^^wL 



COLOR > . [\ 



\aX'. 



DATK (H lURTII 



AC.K 






I 



5 

( Day) 



fVear) 



"\ )V*/i 



A/oH/fl> 



/),/i 



^!\<.I,r MAKUIKI) 
\VII»o\VKI> OR I>;V«»Kt HI) 
'Wrilr it! MKMril «U <*i}f nation) 



i 



'^^^-arUu 



A 




BlkTHIM.ACK 
iState or Country) 



WMl n! 
I ATin:R 



HlKTm'I.ACK 
(•I- lATUHR 
stuu or v"<»nntry) 



MAinKN NAME 

"I M(>THKk 



lukTm-i. \CK 
«>i m(»thi:r 

Mntr or Counti v 



OCCr PAT ION 



'?n> 



'^•' 



'V 



n,OL^>x' ^'. v<x^ 






ol'v cv axjCt out vv 




^ r 



1 



\kXo^ 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DHATH "I 

(Month) fl (Day) 

I 1II:R1:HV CI;RTIFV, That I atUn.UMl «leciascil from 



I go *. 
(Year) 



I9O 



to 



that I last saw h alive on " 

an<l that tkath •xoiirrctl, on the <late stated above, at - 
— r— M. The CATSIv t)l\ DliA Til was as follows: 



■190 
-190 



DT' RAT ION Ytars 

CONTRir.lTORY 



^V>V-t%r 



%.^ 



Mouths 



Days 



I /ours 



DIRATION 



Viiirs 

'1> 



Mouths 



(Signed) \wCr\.cn\^v 



3^ ;. 



1 



^U.'. o. 



I<)0 



Days 
A 



/fours 

M.D. 






gp^QII^I_ Information on'y ^^^ HospiUls, institutions, Iransifnts, 
or Retcnt Residents, dnd persons (l)ing anav fro:n home. 



) 'ra ' 



.1/'-"///' 



/hi 



THl- \ROVF STAT)-,I) I'KRSONAI, rAKTirtl.xKS AKH TKI K T' > THH 
IJKST OF \U" KN0\VI,KJ^«".F: AND^HFl.IICF 



Infonnant \l 





LnjLA^ 



'\,1.1r.- ^ I'i ^ >J >UVytX, >xt 



(^ 



-\. 



?b^ 



Former or 
Isual Residence 

When Has disease contracted. 
If not at place of death ? 



A.L»w- 



H«vt lonq at 
Place of Death? 



Days 



PI ACH OF RFRIAU ok kI,Mt»VAI. I DATF: of Hi RIAL or RF:MoVAI, 

r N I > 1: R T A K f: r Vv a X^^^^ - ^- Lv^ A, cL^SA^^ i\JJ\j:: 



(Address 



N, B.— F.vcry Iten, of Information should b. CBrefu.ly Huppllcd. AGE should »>« «'«^-:J ^'^^.^^^J^^^^ . ^"7»'|:'^^^^ 

•tate CAUSE OF DEATH In plain terms, that it may he properly clarified. The Special Information for p.r- 
«on« dyinft away from home should he fciven in every instance. 



IP 



I 



«•,.> 



I, i 



I' 



^' 







s 



B. ,:.•.! ',f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

U..Hh-VSo...i^^^US.VCn WgFER TO BACK OF geRTIFICAT C FOR INSTRUCTIONS 

/>a/r Filed, iLvavv^t il ..J^O^ RcgLslered ^'o. 916 

ds^M^v^ '^^a.^v-^i Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH-=City and County of San Francisco 



Certificate of 2)eatb 

( H. S. StanDar^ ) 



A 



PLACE OF DEATH: — County of 



-City of '^ xlvdcxL-. 



,._ toi 



No. 



St.; 



Dist.; bet«- 



and 



") 



/ .r DC.TM OCCURS .vw.y FROM USUAL R E S I D E N C E G. V t r*CTS 9*;-i/i> ;° «";*"" ^';;":\'„^^ 

\ IF DEATH OCCURRED IN » HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STBEET AND NUMBER. / 



FULL NAME 



( 




k 




JLAf^- V C 



■^ 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



%\oL 



i»\ii: or itiKTii 



a<;k 



• M(inth> K 



) ,,! 



loJ 

(Day) 



MoHlhs 



VvXi. 



(Year) 



Dti I . 



<IN«".I,1v M \KI<n".I» 

wnxiwKi* OK DivoKT j:i) 

' Write in sm-ial ik-sijftiatioii) 



HIKTHPI.AOH 

Mjitf 'it •"ountrv^ 



4 






NAM J. t>l" 
IATin;R 



HIK THIM.AOK 
ni lAIHKK 
'Statr or Ooiinti y 



MAIDKN NAMK 
nj MoTHKK 



lMkTHPr,AtK 
»»1 MnTUKK 



occrrATioN 




^n^^:^ XJ XartrL<j 



] 



Ci 



i 



Rr>l\lfif in Situ Fid II •/■''<> 



)>.7; «.• 



Mnllfh^ 



Ihl \ <■ 



Tin-: M«)V1<: STXI'I-.I) rKKSOXAI, l'AKTfrri.AK-« AKI-: rKIK Tt) TIN-: 
liHST <>!• MV KNn\VI.KI)<!4-: AND H1:1.I1:K 



(InfoiniMiU 



L-'C^^ 



{\iV\ 



rcss 






.\ 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- i)i:atii r\ 

^VA.'. 



Month) ' 



IQO \ 

(Year) 



"{ 

(Month) ' (Day) 
I IIIiRIiBY CIvRTII'V. That I atteiukrl •kccasc«l from 
— — 190 to— — — ~ up 

til at I last saw h a live on • - 190 — 



ami that death ocourretl, oti the date statt*! ahovo, at 
^Z^ ^l. The CArJil*: Ol" IMvATII was as follows 



Ikxl 



\,\,^\^J^ 






» A.^^ V cx,=iL^«<' 



I )r RAT ION Years 

CoNTRinrTORV 



Months 



Pays 



I louts 



DT RATION 



Years 



Jfo)iths 



fhlYS 



(Signed) v) o-^ ^Cv^^v^n ■ t ^ vtr^ vAi\-4L c > v 

, ', \ A 1 



/fours 

M.D. 



vl^^v^ 



IC)0 



( 



AiMress) ^ oJkd 







Special information only for Hospitals, institutions, Transirnts, 
or Recent Residents, and persons dying dv*dy from home. 



Former or 
lisudl Residence 

When was disease contracted. 
If not at place of death? 



HoH iomi at 
Place of Death ? 



Days 



ri.ACK OF HIRIAI. OR KHMoVAI, 

,VCX>A. 
I NDHRTAKK 



,.\Cl'- OI- m t 



DATK of III KIAI. or KlCMoVAI, 

^wArW all T 90S 



^ 






(Address 



IN. B.— Every item of information should be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for psr- 
son« dyinft away from home should be feiven in every instance. 



i 



r 






I 







it 



f 






I 




Rnnr.l 



,,t II alih 1 N" 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■C-f^arTlJ.v. I'.iS:l'C() 



UWi 



Dale l-'ili'il, LLwCtv\AX U 

ivvvvo "Iji^xvo Deputy Mealth Officer 



ReiJixtci'ed J\''o. 



917 



/V-M 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)catb 

( "U. S. StanDiU^ ) 
PLACE OF DEATH: — County ofCWv J .VCV^vc^'M City ofO Ctvx.' a,\,av^t - 



IH«. ^^ .<X'>V V O- AV t. v-^„ tU3 V*) ^ .a.'. ' .. St.; 



-Dist.; bet. 



-and 



^ ^^"^ ' ^ ■•" - - ~ ' _7i*l nrcsinVNCC GIWC FACTS CALLCD FOR UNDER "SP'ICIAL I N FOR M AT lO N ' ' N 

( •' rF^rrlT°H"oCCU%rcV.rrHo".^yTlt o"r ?^?f.?u" "'o-VcVs NAME ..STCAO or ST...T A.O .UMBCR. ) 



FULL NAME 







(XvV"v<:>Ai vvv^ *\.a 



L 



>« »: \ 



PERSONAL AND STATISTICAL PARTICULARS 




^0 

i» \Ti-: or niK III 



'' "ML J. 



Mollttt 



\<'.K 






^*r».« 



(I)ay> 



V"»////' 



«Ytar> 



Ai I .< 



--iNi.i.r M\KKn:i> 

\\H M I W » . I » OK 1 1 i Vi I k I I . I ) 
Wiitr ill •■•K-ial <lf.iK»;>ti«»il) 



IlIKTIII'l. VCK 

>»t:itt i.r '■ luiitry^ 



r 



MEDICAL CERTIFICATE OF DEATH 

lL 



(Month) \ 

rilKRi;r>V CI'RTIFV, That I attcn«UMl deceased from 



...i.. 



I go 

(Year) 



190 



•to 



tliat I last saw h rr^ alive on • * 

and that death <iceurre«l, on the date stated alwne, at 
^M. The CArSI*: Ol" DICATH was as follows 



•190 
190 






^^wO-U-^V^ 



\AM!v Ol- 
!ATin;R 



KIKTIIPI.ACR 
Of » ATIIKR 

Slutf or Country ' 



MAinKX NAMK 
OK MoTHKK 



HIKTIIIM, \» 1; 
»M M«»rni-.l< 

' *>t;it< lit I Untitl \ 



CHXlTAriON s- -' , 

hV'!i!rif III .s'<?»/ /•■/</"-■ ' 

Tur \Hovi-sT\TKn PKK*^<»N-\i. !'\K ri<ri,\ks \ri; TRrK T«) TIIH 

HHsT i)\- MY KNOWI.KIX.K WD MI;MIJ 



r. 



■\r.„f/i^ 



/hl\S 



V 



(Iiif.i! mnnt 



'^^OXCr^-vtA^^ V 



u w 



0>vou 



VCLr^L-AdDw 



-Aw%^^VAjk^VN,'^-V,A/->- 



VA-^u^."i) 



Dr RAT ION )'t'ijrs 

CONTRir.rTORV 



Months 



Pars 



I /ours 



1)1' RAT I ON 



SIGNED ) 



)'tars 



Months 



■"l « k ■ .- 



/\U'S 



/fours 

M.D. 



SPEcf^AL INFORMATION on'y ♦•f Hospitals, Institutions, TransifBts, 
or Recent Residents, and persons dvlng anay fronj tiome. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



ri.,\CE OH lURlAU OR K1.M"V\I. 
INnKRTAKKR 



DATK of lit RIAL or RKMOVAl. 



JU. •»...., ^ ^ 



^ 



T90 



XiMn-vm 



fAd«lre«<s <dib A ^ * i i .L.i\.i . '• 



N. B.- 



... ^ .. !• I irrF sSniilrl he stated EXACTLY. PHYSICIANS should 

-F.very item of information .hould be carefully supplied. AGE s.iould °« «*"**"/^'^r^ ' !„?„..„„»;«„" ffor bt- 

•tate CAUSE OF DEATH in plain terms, that it may be properly claw.fled. The Special information for per- 
sons dyinft away from home should be ftiven in lix^ry instance. 



1 



r 




I' t 





t . * 



i i 



I 



,jm^imk»^g^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CER TIFICATt FOR INSTRUCTIONS 

917 



IKir.l ..f ll> iiMh - !■■ No !•- '■«.:gy»^"'^'''-" 






/i/OH 



BeQ'istered J^''o. 



"l^vv^ iot^vM Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( n. S. StanOarC* ) 



(h 



PLACE OF DEATH: — County of^OAvi'V.O^^vcciM City ofC3 avv> Ja^a-- 

V (X \V t. V,<5. -0 _^ -^ nrcsYnENCEGIVE T^CTS^aIlED rOR UNDER "SPECIAL INFORMATION' 

( " °,"„r.T":,'iccuV.ro',"rHo".'r.t o%"~"?u"o°""v.'ts name ,»,tc.o or s,«et .«. «„«.». 






P4^ C ' (<X^^' V (X \ V t: 






St.; 



Dist.; bet. 



-and 



) 



-) 



FULL NAME 










PERSONAL AND STATISTICAL PARTICULARS 



^l.\ 



QUx 



.L<xcJk 



i> VI1-; ni niK 111 



.Month* 'I>av^ 



\r.K 



a 



k 



o i> ) Vvr » > 



!/..»////' 



iV<ai) 



/'w 



•^INr.l.K. M \KI< !!".1» 
WinnWKI* OK IHVoKi i:i) 
Wiitriii 'i'M-ial ik-ij^natinii) 



niKTHri.Ai'H 
si:it< iir Country* 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DHATH O 

Uv<.vq, 



/QO 

(Year) 



I 

(M..niii) ;\ (n«y^ 

I lil':Ki:HV CI-RTM'V, That I attfiidtMl dereascd from 

I90 to — ■ ■"" ~itp 

that I last saw h - — alive on - ^*P 



ami that «kath occurred, on the date stated ahove, at 
' M . T he C MS H C ) l* D I • AT 1 1 was as foil* )w s : 






v^w^.'^w 



N \Ml t>I- 
I'ATIIKR 



HIKTHfl.XCK 
<)l- 1 Arm-.R 
iSlatt 1,1 vountryl 



M\Il>KN NAMK 
<>1 MOTHKK 



niKTMIM.Al'K 
n\- MmTHHK 
• Statf or \.'()unti V 



OCCITAI'ION S- ^ i/ I 



Kfsiiifif ill S,i>i /'i iiiii ■S''i> 



'rn I <■ 



.}/..iifff 



/),^.^ 



TUl- \HOVl- STATl-l) I'KKSOXAL P \ R TUT I.A KS AKI' TRlK TO THK 

iJKST oi- Mv KN(>\vi,i:i)».K, AND in:i,n-.i- 

(Info,nK,nt '^^^^TVC^-VCV^ W -t. « ' • 

I' w 



or RAT I ON )'tiirs 

CONTRHU'TORV 



.]fon/hs 



Day 



Hours 



nrUATION 
(SIGNED) 



I 



v) 



Years ^^ Mouths 



vA^VCl^ b TQoM 



I'D 



Pa \'s 



^vcy l> TO 
ecI'al in 



( 



L^r*v^n 



^JOyJ^ 




Hours 
M.D. 



A-t,*- 



SPEC^'AL Information on'y 'o^ Hospitals, institutions, fransifnts, 
or Rerrnl Residents, and persons dyinq away from home. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at place of death? 



How long at 
Place of Death? 



Days 









i \<Mrc>is 






DA 11; of Hi KIAI. or KICMOX'AI, 

V Lw C\ .L T 90 



r N I ) 1: K r A K 1: R ^ \.x^\. -u ^ V ^ O^Oy O^^^' 

<A.Mrc«s Sb^'X- IH.L 



^..c^c 



•tatc CAUSE OF DEATH in plain terms, tliot it mny he properly cla.sified. The Special Inlormation for par 
«nn« dyinj away from home should he tiven in every instance. 



Ijnnr.l of HtMlth-F No. i«; "Mi:*^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^■. liSiV Co 



/),!/(' Fi/i-'f, WwA^vv^ U i'^0 '^ 



918 



Be^islcved Xo, 

i x!^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



m 



i 



i 



I . 



Certificate of Beatb 

( H. 5. Stanv>ar^ ) 






PLACE OF DEATH:-County ofC)^L/>v ^A^IU^^C^^^ity of 0^^ vJX<V>A^v^^ 

I^. CdL"^ LcrwwL h CKikdaA Su — - Dist.; bet. •■ - and 



I / IF OE»TM OCCUH^AW*Y FROM USUAL 
\] V 1^ Ot*TM OCCynRtD IN * HOSPITAL 



RESIDENCE GIVE FACT 
OR INSTITUTION GIVE 



FULL NAME 



TS CAtLCD FOR UNDER "SPECIAL INFORMATION • \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



M' 



>i:\ 







PERSONAL AND STATISTICAL PAR TICULARS 

i C(H.«>R\ 



DATK tH ISIKTII 



L 



'UjJxvt 



(Month* 



(Day) 



, lia 

(Yettr) 



Ar.K 



S5 



r,,; 



AfoMfMf 



l\i \s 



WIHOWKH OK PIVoKi KD 

Writf ill •iotial de-i^'iation) 






mKTHIM.AOK 
'State or C«Muitry 



N WW n} 
lATllHK 



BIRTHPI.ACH 
<»f I ATIIKR 
'St.tte or Countrv 



MAII^KN NAM1-: 

■ •i- \j.»TnHR 



lUKTm'I.AfK 
<>I VOTUHR 
(State or Country 



OCCriVXTinN ^^ 









XaJLola 



axt 




vw 




\x '. :>- 



A 




A 






Rrsiiffif in Sill! ruiii.iu,} 



V) 



) I ai < 



M nifll^ 



IK! 



THI- \I«)VK STXTKH PHKSOXAI. r\RTUri.\KS A K K TRTK To TIU- 
llKST t)l- MV KNOWI.I'.IX'.K AND iu:i.n.h 



■n 



d^ 






MEDICAL CERTIFICATE OF DEATH 



(Yenr> 



DATE OF DKATK "^ 

Laa.vq ' ^ . 

(M.Mith) J <nay) 

I liliKIUlV LI:kTII'V, That I attcmUMl «lcceascMl from 

NLa^aoO. X^ I90H to LU^a. .lA TqoH 

thftt I last saw h ' ■ alive on vXvA,Cy l^ 190% 

anil that .Uath .HHurrcd, nii the «late stated above, at ^X ^ 
V M . T he C A r S I •; ( ) 1 • D 1 '. A T II was as f ol lows : 






<VwtA». 



lAivi..,:iv.^.- 



Ul RATION )V<?/-.y 

CONTRinrTORV 



Months 



Days 



Hours 



nr RAT I ON 
(SIGNED ) 



Years. 



yfonths 



Davs 



JAjL/cC sj UI'V^xcLa^v'^vc^' 



,1 



Hours 
M.D. 



A£L 



IC)0 



A.l(lrcs^) LClu,^ L^ ypN-K^ 



SPECIAL Information only for HoipUals, institutions, Iransicnts, 
or Recent ResWents, and persons d>inq away from home. 



Former or 1 , . 

Isual Residence i >^ » 

When was disease contracted, 
If not at place of deatli ? 



a>-jC^ 



Hew lonq at 
Place of Death ? 



Days 



I'l.-iCli <)I-. lURIAUOK KKMOVAI, 




DAPKof HiKiAi, or RI:MoVAI. 



CL. 



'% 



a 



TAKKR U/wJbuiw liAvciJL^^'C^Jkc^ 



190 



u 



(Ail<lrf>is 



state CAUSE OF DEATH In plain terms, that it may be properly classified. The Special Information for p«r 
(tons dyinft away from home should be given in every instance. 



\Ui 



i ( 
i 



I)f(/r /'V/r^/.GL- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

919 






^u^JX' 



IfJO'i 



Re^listci'od Xo. 



"^^VAA-.^ *HxH.i Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of IDcatb 

( U. S. StanC»arD ) 
PLACE OF DEATH:-County of^Ou^v J.VC^^v^^CC. City ofOx^>v vlXay>v^v4.C c 




.OLifc 



lA .\ t^ . s rl St.; '^ Dist.;bct. MILO.^. 

O* ^ ^ I - - .,e,,., orcSinPNCE: CIVt FACTS CALLCD TOR UNDER SPtCIAL 1 N roR MATIO N ' \ 

( " r,"o'»Tt,"o^c"u%*.r;,»"r-o".^r.t c%'?:^',t"JvU'"o',;c";u name ,«st»o », sT.ctT ... «.-u». ; 



FULL NAME 



-.^ iV 






4 



4^ 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ciR \ 



%\oL 



li\ IK «>l- HIKTU 







i Month > tl>ny^ 



C l.cU 




A<".K 



OUrV ^ 



Months 



I^Vi-:ir> 



nit\ 



i^i 



t I 



\A 



SINdM.F.. MAK«n-:i» 
WIlMiWKl) OR DIVnkiKn 
Write hi •*<H-ial ilr-.ikMiatJon) 



HIkTHJM.AOK 
<SlHteor Country^ 



N\N!V <>I 
FA IHKK 



HIKTIIPT.A(*K 
(H- I ATHKR 

'*^t;«tt or vontJtry 



VfAlDKN NAMK 
<>1 MOTHKR 



HIR rm'I. \rK 
oi MMl'lIKR 
>Stat< )r Counlry^ 



<K CITATION 



m^w 



"v^w^O^^* 



MEDICAL CERTIFICATE OF DEATH 



K in- Dl'ATII ,0 

„ sXu^Q 

(Month) Q 
I IlI'lKlUiV ei:RTIPY, That I attciukMl «k'rcascMl fnuu 



1 C. igo H 

(Day) (Year) 



Up 



Ho -^ 



-alive on 



U.I.Jll.lJ I'.' 



190- 



tliat I last saw h ^^ 
.•m<l that «Uath occurreil, on the date stated above, at 
.%[. The CArSIC OF I)i:.\TH \va>^ as follows: 

DlRAfu^N )V«i;'5 Mouths Pays 



Hours 



M ^r'll- 



n<n> 



rm- XHOVKSTATKI.PKK^nXAl. lAKTUM ! XKSAKK TKrK To TJIK 
llKST OI- MY KNt)\V:.i:i)(.K ANO I5x-I,!l.l' 



(Infonnant L^C^CTVX C-'V^ W 



(X'Mrrss 



CONTRIIUTORY 



DIRATION Yi-ars 

(Signed) Lc-x^rv-^x^u 



a 



MoHlfis fhtys //i>iirs 

/] vb.UO-XjLlOuAv'H 



1 M.D. 



VM3i > TooH (A«l.lresK> Le\-Crv^UA^V_y 



SPECIAL INFORMATION on\\ for Hospitals, Institutions, TrdnMcnts, 
or Recent Rt-Nidents, and persons dying a\ ay from home. 



Former or 
lisudl Residence 

When was disease contracted, 
If not at place of death? 



H«w ionq at 
Place of Death? 



Days 



ri.ACK O}- ISIRIAI. OR KKMo\AI, 



UAIK ..: lUHiAi, or RKMOVAI. 




■""^ a „ I'-a ACF «houiil be Mtated EXACTLY. PHYSICIANS should 

■on* dyin* away from home Hhoul.1 be tiv.n in .very mstance. 



I 



h 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hnar.l -f HfMlth-r Vo. >^ l^-^f^J^H^JMN 



J'Vf. 



Dale Filed y 

J 



d^^^r^KJj) 




Regisfeved J\f*o, 



920 



11 iou\ 

~^^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 



( 11. S. StanDarD ) 

L 3 



PLACE OF DEATH:-County oAcO^ l'v<X>vc...C . City of <V^ A^^-^r^-^t^e^ 



,4...>'y 



No. 



■X^SI ' X'SK'^ 




Ij 



St.- "^ Dist.!bet. U^'LCLb-a.y-.\/a.and ^^^'0-^•^''w4'^l:> ) 



%< 



') 



• •oiiAi DE-einr isirr r lur rACTS callco ''OR UNDER special INrORMATION' \ 
( ■' r.^orATricC^u'RrcV.^THo's^rTlt ?R'?^?f.?J;^0^:^0.;E74 J^AME .N»TEA0 O. street ANO NUMBER. j 



FULL NAME 



K\\/>v vC^'«^^-^^-^<3u^^-^ 



PERSONAL AND STATISTICAL PARTICULARS 
>,,.v A - rx I COI.OR 






^^ (^luU 



i)\ ri". ni MiK rn 



.\«.K 



'M. .Mill I '\ 



10 r,„,. 



lOJ 



(Dav* 



M.tHlll ' 



vcL«- 



(Veai) 



/V*IKi 



SIN«.I,1-: MXKHll'lV 



'^ . ii- 



\VnM»\VKI» OK DIVOkrKI) \ 

iWritf in •M»cia1 fl»--ij?nati<MiJ \ » x 



BIRTHPI^ACK 
State or Conntiv^ 



-^XcU-OuA.t 



NAVU- ol 

FA iH i:k 



niKTll!'!. MK 
or FAIUKK 
iStiito or Cotintry 



MA 11)1 N NAMK 
ol M«)THKR 



1UK IHIM.ACK 

Ml MnTIIHR 

' St.itr or Cinmtry) 



< >v*vrr A iioN 




I 



!V^\; \!nV>VQ,«>^' 




lUv 






«n 



^ MEDICAL CERTIFICATE OF DEATH 

I>.\TP: f»F DKATII 



d' 



(Mouth) 



(ftay) 



(Yenr) 



I: 



1 III;K1:HV CI:rTII'V, That I attcn«UMl «kHcasoa from 



LLa^O. 10 



iqoH 



,Cv.>Xi .. 190 ' to 

that I last saw Ir^-^ti^ alive on SAa^wCJ. -l - igo ". 

aii«l that «Uath occurred, on the date stated alnnv, at VP ■ AsS 
\J M The CAISH OF I)I^AT^ was as follows 






i\j\.\JL^,^ 



ttA^«»V' >>vVOL to-t(^ l-^A-^t »i. y^^., 

DTRATION }i'ars .Vontfis Dan 

CONTR IHl'T( )RV VC^rLvvOL,\» -ff:C^.^JLrVv'\^ 



Hours 



DURATION 






•f 



^Signed) U. ^3 JCa^xNit.- 

-t4 



Pays 



M.D. 



cU.\ 



a>] 



yg U TQoH f Ad.iresv) ^33> -jJLa\A.^ 



Special information o"') '^^ Hospitals, Instilttions, IranslfBls, 
or Recent Residents, and persons dying anay from home. 



L C^XA^'^XC^ - 



"^ 



Rfsidft! 11! ^'-.11 /■! ,tll. !■■•■,> 



),-,tl 



M .nth 



n,ix 



Tin- \!U)VKSTATi:i) PH K snXM. !• XKIUT I. \KS AK F. TK I K To THK 
HFST or MY KNOWIJ'.IM.H AND FU-.l.IlJ- 



(Iiif' iMiirtTit 



f NfMrcss 






«"^ 



Formff or 
Lsual Residence 

When was disease contracted. 
If not at place of deatti ? 



Hew lonq at 
Place of tkath? 



Days 



i'1,\cf; •)f HiRiAi, OK kf:movai. 



.■CCv^^V' 



DA IF -r Ui KIAI. or KF:M0VAI, 

LI', c^. 190 



r N I n: K T A K f: K U oCdX^v^ v^ 'CsJJL L V\^ cCo 



,\^k^^j^^^brrs\. 



fS. B.- 



-F.very iten, of infor„,atio„ .hou.d he canefu... suppHeU. AGE should ^''Tr^^'Z'^^.X Xn^T^llTi:rZ't 
Itate CAUSE OF DEATH in plain terms, that it may be properly cla«R.f.ed. The Special Informat.on for pr- 
isons dyinft away from home should be feiven in every instance. 



r 



I 






r 



I 



'I 



i 



, \ 




fit 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,,,„, „f ,u. n). vs.^.-i^^^u^t^vco REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 

921 



luo'i 



Dale I'ilcil, \^J^^~OA,^^ H 

"Iavvv^ Axxvu Deputy Health Omcer 



Regislcriul Xn. 



-H 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( xy. S. StanC>ar^ ) 



% 



No. 



PLACE OF DEATH: — County of'^'a-^"^.^X>^"rVCv<-•C;ty of ''0->\' ^] ^CC>V^^ ^ 

lO.'tL and l^U- 

:ts c»llco for under spcciau information' \ 

ITS NAME INSTEAD OF STREET AND NUMBER. / 



Ibll \n\ ',4. i. • - r-^r St.; '■ 

/ IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V C FACT 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



FULL NAME G<X*vCu^ 



J 



si:x 



PERSONAL AND STATISTICAL PAR TICULA RS 

/V\ A . v:<U,nR " . ^ 



"i 



DAIK Ol- ItlKIH 



L 



iwl.ivLti 



I Month) 



a<;h 



■ % Yt-ai. 



(Day) 



Mtnilhs 



(Year) 



n 



',t\ 



SINt.l.l* MAKHIIK 
WIlmWKn OK l»iVMRCKr> 

Wiiti ill -<ifial rlv«iivrt3;iti<>u) 



lURTnri.AOH 

'State or Country 





j vd^^rwM^'CL 



CCivC^ 



F ATI IKK 



RIK 1 HJM. \v H 
OF 1 AIHKK 
(Statt- «>r Country^ 



MAIDl.N NAM I, 
<M MOTHKK 



K!k rnpi.A('K 
• •I %5ornKR 

State- or I'ouiitry 






.e V. 'J 



a .^u^Low > 



w-^-* 



•' ' ri'ATloN 



1/. .;//// 



/'-,- 



Tin- XHOVI- ST\riI) 1M-KSONAI. ^\KTIr^•I.\K-^ \KK TKrK To THH 
IU:ST Ol MV KNoUl.l.lJoK AND HJJJK.l" 



,' .\,^,1r,.>;»; 



bli 



Ql\ 



v.^^A^r>\ 



f 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol DKATH ^ 



(Month) ' 

y 



It 

I Day) 



1 90^ 

(Year) 



I HKREBY CFRTFFY, That I atteii<UMl ileceasctl from 

/^VA-U^ 190 . to A^^^v,vC)u '^ *■ '90"^ 

that T last saw h --* - alive on VA^lX.C\^ '• I90 • 

ami that death occurreil, on the date stated above, at It 



M. The CAISI*: Ol' I)I:ATH \vm^ a*. foll.m»; 



, <„ v. »?».*"*.. 



U xtv-uOLo^ !}\jjuxvt '^^ 



DTRATION Years 

CONTRIIUTORV 



Months 



Days 



Iloitt 



''% 



Dl'RATION 

f Signed) 



Years Mouths Pars 



M.D. 



Special information '»"'* to^ Hospitals. Institutions, Transifiils, 
or Retcnt Rfsldents, and |>er>)Ons dvinj d»»ay from tieme. 



Formrr or 
Isyal Rrsidrncf 

Wfipn was dlsfasf contractH, 
If not at placr of drath ? 



New Jonq at 
Pldfcof Dfatb? 



Days 



prACK 01 nrKIAI. <»R KKMOVAI. 






DArHof 15! KlAi. or KKMOVAI, 



1 90 S 



t ni»i:rtakkk vCcVtXA-" ^ C^vc^VA^^jJk 



N B — Fvcry item of in?orm«tion .houlcl b. carefully supplied. AGR should be ntated EXACTLY PHYSICIANS should 
ftate JaUSE OF DEATH in plain terms, that it may he properly classified. The 'Specl-I Information" for pr- 
sons dyinft away from home should be ftiven in excry instance. 




.£] 



f I 



h 



' I 



I 




; i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,oanH,f...:.Hh-KV> ;.Ngrg>^.HMT,. REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIONS 

Pa/r Filed, tWqw<tt W 100^ Regjslrred ^'o, 922 

"Lcrvwi "ILvNu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( "U. S. Stan^ar^ ; 



(^ ■• 






PLACE OF DEATH: — County of 'a^v ^.Va.>vCx^C tCty oi'^^OjlXi J,fva/>xCc4.at 
No. ^1^'iO.I\clLLu "^-t- St.; 10 Dist.;bet. '"^a^X't^W and \H M, 



) 



FULL NAME LkL^l.i.4 W^^^^^'^''^ 



1 



PERSONAL AND STATISTICAL PARTICULARS 






coi.«»K ^ 



LL J vajLi 



I).\TK «)H lilKTII 



A<.K 



< Month » I 



r. ..• 



1\ 



Mfn.'li 



,^0h... 

(Year) 



Ihtv 



siNi.i.iv makhihu. 

U Il)«>\\ l".I» «»K I)l\oK» i:i) 









lURTHPI.AOK 

'Statr <>• ''•.•nitry> 



N \MK OF 

iatiii:r 



niKTHri.ACK 

Ol- lATHKK 

• State or Cmintry* 



()i M<)Tm:K 



niKTH!M,ACK 
ni >!mTHKR 
< stall . iT I'mmti > 



• >CCri'\ lluN 



^ 







VVt^v,^»"w>^w^ 



(JD 






<i /xkX-^^y^ 




DwA. -^ OL/t^'^VM^.^J^t 



)V,; 



\r,»i'h^ 



n,! V. 



rm- \n.)VK sr xtkh fkrsonai, r\K ruri.ARs arm TRri: to tmk 

liKSr (»!•■ MV KN()\V!j:i)r. K AM) HlM.n'F 



(liifonn.itjt 



3 









MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



.L.w*w\..a 



(Month) 



u. 

(t>ay) 



/QO 

(Year) 



I IIF.RnnV CT-RTirV, That T attended tieceased from 

\,A»^/N-n l.L Mm'. to sAa.a-1 



-C\^ l.L 



190 ' 



to WVA^CU,.1.L 190 H 

tliat I last saw h ' alive on V-^^^>v.<^ 1 1 T90 . 

and that death occurred, on the date stated a!)ove, at ^^ 
U. M. The CAISI^ Ol' DHATII was as follows: 

OvOtxl 4vOk^ XsAJUy^ xLLQ^d, ^. ^>.-vvUk'w^ .|rfl%Ai.^^VX' 
DrRATION )'{'ars Months Days Hours 



Days 

-Is 



i< V .>I-AJU>^vv^tX-tN^\rh.X...*SjD-A,S-Li._ 



CONTKIIU'TOI 



DTK AT ION Wilis Months Days 



bl 



(Signed) i<t^^>u^ 

V^lALl :; iqoV TAddresO 31^?^* 






//on IS 

M.D. 



Special information only for Ho';pitals, Institutions, Transifnls, 
or Recent Residents, and persons dving anay from fiome. 



Former or 
Usual Residence 

When was disease cont rted, 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



ri.ACK OF RIRIAI, OR RHMoVAl. 




SI) K R r A K K R Y'C^^^^xUi 



DAIi:..!" MrKiAi. or RlCMoVAI, 



% 



190 1 



N. B.— Every item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The 'Special Information" for p-r- 
sons dyinft away from home should be ftiven in every instance. 



I 



1-^ 



^ 




^J 



■II. 



)' ■ ! 



> t 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

923 






Bei^isfrred J\^o. 



nfr riled. ^tvvO^v^t U I'f0'\ 

'd^t'VA.^-^i auJv-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccvtificatc of Bcatb 

PLACE OF DEATH: — County of'^'o^v 0,vct-.xcw: City of '^ CL>v 0.'va.> 
No lC)Ol Vn\c<L<LV.C^V St.; H Dist.:bet. b -Vtv _.„ and liiv 

INO. »VV V >.W>*- ..-,,-, orcsinriSirr riwr FACTS CALLED rOR UNDER SPtCIAL INroRM*TION'^ 



VCV^C-C 



FULL NAME 




INSTEAD Ur s I n c B. i «r»u r» v/ •»••»•." . ^ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI«OR^ 



■'" ^\oL 



'IliLu 



i>\ IK •»!• niKTn 



Mnnth> l\ 



A<.K 



iDav) 



^t.'Hlll 



, "X t!.H..., 

(Year) 



lKi\ 



\vnM)\vi:i» OK i»i\ <>R»i.:r> 

(Writf ill «iocia1 «|t--.vn;in«iii) 






N \\n: oi 

FATHMR 



HiRTni'i.ArH 
oi- I \rm-R 



MATHKN NAMi: 
OF MOTHKR 



IMR ini'I.A( K 
nl- MoTHKK 
Stat' iir ('otintry^ 



t ,^ I 




Ow >'V^^" 



&^v 



CcLi 



v<X 



va^ 



rcJivLOL^VcL Lctl 



(H I IT A l" ION 



•- ]V,r(. * M.'tilh 



/',M 



Tui- \novr sT\TKn pkrsonai. pxrihtlmo aki- tkik to tmk 

lii;sT ol- MY KNOWM.Di.K AND HHI.U.F 



(Infottuant 



i \iMress 






Ql 



I 



V^<i VOv 



MEDICAL CERTIFICATE OF DEATH 
DATH OF DKATII | 

tU^.Q.. M 

(Month) \ "l>ay' 

I miKliBV CIIRTII'Y, That I atlcixliMl .ktvastul from 



(Yea I' 



Cy ^ 190 H to '^ 

tliat I last saw h * alive on — 

an«l that «Uath iKCurrtMl, on the <lato stated above, at 
^ M. The CAl SH OF 1)I:ATII was as follows 



up 



DT RAT ION >Vtf/ 

CONTKIHrTORV 



Months 






nr RAT ION Vvars ^ Months 



Ddys 
Pars 



I /on rs 



(SIGNED) L^^W^ 



,^Vv^'" ^ 



flours 
M.D. 



.n Kio 



(A.hlress) 



SU LcCd.'. 



'± 



SPECI/^L Information onl^ '<>'' Hospitals, institutions, Iran^ifRts, 
or Recent Residents, and persons dyin^ away fron home. 



Former or 
Isual Residence 

When i*as disease contracted, 
If not at place of death ? 



How I0R9 at 
Place of Death? 



Days 



IM.ACH OI- lURIAI. OR RKMoVAI. 

1 



om aLv . 



DXIK..; HiRiAr. or RHMOVAI^ 



A^vOL ^^ I90H 



INDKRTAKKR IvD <xL^Ll^ '^^ 



tT 



(Acl.l! 



^u yOi\ 



K^^Sr^Z \\. 



N B —Every lien, of information .houhl he cnrcfully supplied. AGE should He «t«ted EX ACTLY PHY8ICIAINS .houid 
.tate CAUSE OF DEATH In plnln term,, that It may be properly classified. The "Specal Information" for pr- 
aon« dylnft away from home should be felven In every instance. 



m 



;^ 



S' 



m 



} ' 



t 1 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

..„, ..r HeaUh - .• No -. <^^ H.«.P C._ REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

924 




I[)0'\ 



Be^istcrcd ^N'o, 



Date JuJed, ^wVa^w^ \ I 

DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco 



d^,«rvc\^ dLXv-^-i, Deputy Health Oflflcer 



Certificate of Beatb 

( Ta. S. StanC>ar^ ) 



(^ 



PLACE OF DEATH: — County of')<X-r^ ■l/vcc-.v-tv^^ecCity of<^/a/>vO/VO^A-^iA^et 

( " •'*;".n;c"u%;"v,"r-o"s'r.t 0%'T^p^u"";'";";! name ,»stc.o or ......... ....... ) 



) 



FULL NAME 



vu. 



-^i-:n 



PERSONAL AND STATISTICAL PARTICULARS 



) V*i7 I 



- M.mtfts 



fV»iu) 



/)rt1.v 



NiM.I.r M\KUIKI>. 
\Vn>n\VKl» OK IKVORt'KD 
• WrJlf in «oci«l df^lirnaliotj) 



IllKTfiri.XOK 
\ Slate or Cmnitry 



NAMK ol- 
lATHKR 



niRTHPi.ArK 

OF I ATHKK 

iStatt or Country) 



MAIDKN NAMK 
OF MoTIIKK 



lUK IHPI.AOH 

<>1 MOTIIKR 

f St.«t< or Country 5 






(?.LLiv 



(W^ 



,1 



.^viMf 



vOwWvM 



r 



. vCXr 




c 



VOX VOwWwL/UC-i 



,V\ 






IK Cr PAT ION 



•- \r..vih- 



/' 



THI \noVF STXTl-IJ J'KKSONAI. J-\KTI<r;.AKs AKi; TKIK T< » T HK 
HKST OI- M\>kN"\VI.in«.K AM) HHI.n.J- 



^N« ) \V I . }• IX . K AM) M J- 1 . I J . t- 



U.l.lrt-'is 



4H^ i^cuvM, 



'V 



MEDICAL CERTIFICATE OF DEATH 



DATH Ol- DHATH ~\ 

lUvQ 

(Month) \ 



(Dsr) 



(Year> 



1 in:RI':nV CI:RTIFV, That I atteiuU<l dcccasca from 
—190 to — ~~~ 190 



that I last saw h ~ 



alive on 



ngo 



an<l that tUath occurred, on the «latc stateil ahovc, at — 
— ~~ M. The CATSh: OF IH^ATM was as follows: 

y.AJL>" vCvLv^\.v.tvi 



t 



or RAT ION Year^ 

CONTRinrTORV 



Months 



Days 



J lour 



Mouths 



or RATION- Years 

(SIGNED) ""•■ LtV^^vcX vl- W.L C^^.< 



A/1 



'S 



Hours 
M.D. 



Ulw^ylt) u^\ ( Address) WQb ^A^jtU^ H 



SPECIAL Information onl> lo^ Hospitdls, institutions, Iriinslfnts, 
or Rfcpnt Residents, and persons d>inq away from home. 



Former or 
Usual Residence 

When ^as disease contracted, 
If not at place of death ? 



HoH long at 
f»lareof Death? 



Days 



DATF, ot niKiAI, or RKMOVAI, 



^ 






I'l.ACK OF lURIAI. OK RF:MoVAI, 

FNDKKTAKKR <- > O^t^C^^U.^^ ^A.v^ji-ft-^^^ V 



190^ 



(AcUlress 



►V^L. 



,S B — F.cry item of Information .hould b« cnret'ully supplied. AGE should be stated EXACTLY PHYSICIANS should 
rtate CAUSE OF DEATH in plain terms, that it may be properly classified. The Specal Information" fer pr- 
mr*n% dylnft away from home should be ftiven in every instance. 



•J 

••n 






' 1 J 
t 



; ' 



Ip' 



r 



^r 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Ddh' Filed y U^Aw^UIlvAwA^ II 



Registered J\^o, 



925 



19 0\ 

"Xjjy^i, D e p uty Hea It h Offi ce r 

DEPARTmENT OF PUBLIC HEALTH=City and County of San Francisco 



<>^O^V-A^A^ 



Ccvtificate of 2)catb 

( XX. S. StanDarO ) . ^^^ 



PLACE OF DEATH: — County ofOa^^'^ AawCwLc City of ViO<^^\i 



V a\^Mt^ 



IHo, 



. Idu. '^ Ww>vtM ^0 ^\y.(X0J. St.; 



Dist.; bet. 



and 



i ( " r; 



y --^»- iieii&l nr Qinr NCE GIVE facts called »'0R under "special INFORMATiON" A 

IF DEATH OCCURS ^WAY FROM USUAL « E SI DENCE GIVE FACTS C^^^^ .^stCAO OF STREET AND NUMBER. J 



• EATH OCCUrtMo IN A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 



t.^ 



jL^Ul.\} 




OUNX-L 



PERSONAL AND STATISTICAL PARTICULARS 



""^ ^\A. 



™" III! 



xkXx 



i)\ 1 1: «•» iiiK III 



AC.K 



(Month) 



(Ilay) 



(Year) 



H I )Vll»5 



M.mths 



Da I -v 



SfNi-.I.K MAkl<Ii:i). 
WIlMiWKn <»K DiVMRrKI) 
iWritf in siK'tal dc*<iv";it '"' 



BIRTliri.AC'H 
(SUiteor t'onnti v) 



A 



-WX 



f 



rV 



h ATni:K 



BIRTH PI.ACK 
<)!■ I AIIIKR 
istatr or 0()iintry'> 



MATDKN KAMK 

<H- MoTUHR 



liiK rni'i.ACK 

<»! MoTIIKR 
Matt' or I'ounti v"^ 








C5L^ Vw 



d 



(iVcL^VM L 



.L.v<X<Xq 




^x 



dL 



occri' 



AlHtN / U 



(ft 






MnnllK 



lu;x. 



THl- AHOVKST^TK.I) I'HRSONAl. 1 \ KTir r I. AK S AKi: TKrK To THK 
linsT OF MY KN*)\VM:i)<".i:_ANn HHIJl-.h 



(Iiifi>vmant 



Uvvv^ ^)VJl 



i V.Mrcss 



^H^l 




^ 



^vvKXAxL 



<^s^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DHATH 



a 



(Month) 



u^q. 



) 



(Day) 



(Year) 



~ I HIvRIUJV CI:RTIFV, That I atteiulcil ilcccascd from 

-— — — 1 90 to I90 

that I last saw h •:• -alive on 190-^^^-^— 



ami that (Uath occurre<l, «>n the ilatc staled above, at 
' M The CAl'Sl-: OF DKATIl was as follows 

i 

Dl'RATION Years A/ofiths Pays 

CONTRIHrTORV 



nr RAT ION ^ Years ^ Mouths Days f fours 

(SIGNED) L0X<nU.^ J V^" UJ kxX'? . ^ M.D. 



Hours 



i 



LLu 



I Tcjn 



{ 






SPECIAL INFORMATION on'y (or Hospitals, Institutions, Transients, 
or Recent ReMdents, and persons dyinj anay from home. 

Former or i* "•* 'o"? «* 

Usual Residence Place of Death ? Days 

When was disease contracted. 
If not at place of death ? 



I'KACE OF HIRIAI, OK KIMoVAI. 



DATFol m KiAi, or REMOVAL 



190 



fn-dfrtakkr"^ TKjjLiu ^^ tU9'(Xqa.>^u 



IS. B.- 



-F.very Item of l„V'or.naf.on should be carefully supplied. AGB should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special informat.on" for per- 
sons dyinft away from home should be feiven in every instance. 



i^ 






r i 



i» 



I 




! 



flf 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n.l,rn..Uh-i NO i.tJf^S^LtHftlOo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jh(/r nicd . Uv\ 



AwVCtW^' 



1 



X w. 



100 \ 



Ite^inlered A''o. 



926 



X-^r^^ ^v^^ Jeputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of IDcatb 

( H. S. StanDarO ) 

J ^ Jj ^ 

PLACE OF DEATH: — County ofC CLO\' OA.Ou-^vtAA'tf City of ^. ''CLAV OMX-^VC^^CO 



No. -vbK < 



St.; 



Dist.; bet. 



qtl 



\>. 



md 10 



/ ir Dt*TH OCCURS »W»V FROM USUAL RESIDENCE GIVt r*CTS CALLED FOR UNDER -SPECIAL INFORMATION \ 
( IF DEAThIcCURRLO in a HOSPITAL OR .NST.TUT.ON GIVE ITS NAME .NSTEAD OF STREET AND NUMBER. J 



FULL NAME ^^^"^ 




IdL.dllUll^^ 



/O 



.\1 \/y:>\/Yr^..a... 





^ 



LL.i- 



^K\ 



PERSONAL AND STATISTICAL PARTICULARS 

i:t>i,oK 




VcvU 



I 




. f 



i»\ri. oi III k Til 



A«.K 



' Month t jT 



'Day) 



(VfUt) 



J V<; I <■ 



!/,.»//// 



/>./ 1 



^iNr.i.K M\KKn:n 

WlimWKl) OK IUVMhTKO 
<Writein social <itHJ^nali«»ii) 






lUkTHlM.ACK 

(Slati or C<>ntUr\ 



BIRTIiri.ACK 

OI- lAiUKk 

'St.itt or Coll lit 1 N 



MAinKN NAMI-: , ij 
nl MciTIII.k \^ 




x^x'.o^ 



\JXLd^~ 



.t',:^. 



lUK'rnri.Ari: 

<»! MuTllKk 

^St.'it" ' If Couiitt \ 



l> 



/x\- ,,/r',f iH Siltt f'l llUi ll'O 



\ 



)'rill f 



Mn.itir 



Da 



Tin- \I10VK <,T\T1.I> I'HKSONAl, 1' \K P HTI. \ K> AKi; TKlK TO TUlC 

iJi;sT oi- Mv KN<>\vij:i)f.K ANH Hi;i,n:f- 



(Infonnrint lU JLLv a -% V. M i I WCWvLc 



Jr' 



' \(Mri -v 



Skli^'DcrVv ^ 



MEDICAL CERTIFICATE OF DEATH 
DATK OF I)K.\TH ^ 

IwLa 



.LLv\. a 



vCi /po" 

(Month) ^ (Hay) (Year) 

I H1':RI':HV CI:RTII''V, That I attcn«U'«l deceased from 

•^ • "190" to .* " Kp 

that I hist saw h alive on ' ^-^ - tqo ' 

ami that dtath fxrcurred, on the date stated above, at . *" 

M. The CWrSr: or DI-IATII was as follows: 

Jk 



t 



nr RAT ION 

CONTRIIUTORV 



Years 



JSSU^ ^ X.'.:. 

Mouths Pays 






11 ours 



nr RAT ION* Years 



( Signed ) 

ili.A n .: T()0 



MotltfiS /hivs 



Hours 

M.D. 



Special information 'tnly (or Hospitals, Institutions, Transients, 

or Recent Residents, and persons dying away from homf. 



former or 
Isual Residence 

When was diseas? (ontracled, 
If not at place of death? 



How lon<| at 
Place of Death? 



Days 



rj.ACH <M lU klAl. OR KKMoVAI, 



c 



I)ATi:of Hihiai. or kKMOVAI, 



,CV. 



^ '■'•^ 



T90 












JS. B._F.very Item of inform»f.on «houId be carefully Hupplied. AGB should be ntated EX4CTLY PHYSICIANS Rhould 
•t«tc CAUSE or DEATH In plain terms, that it may be properly classified. The Special Information for per- 
son* dyinft away from home should he Jliven in every instance. 



M 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„.,.„l..flU.a„l,-KN-,. ..It^^^^Kf^l''-- REFER TO BACK OP CgHT IFICATe FOR IIMSTRUCTIONa 




<#t 



I 




Date Filc^l, iX^o.w^ H 100\ 

ds^^^v^vo iUv^ jeputy Health Officer 



Registered J^^o, 



DEPARTMENT OF PUBLIC llEALTH=City and County of San Francisco 



Certificate of Death 

( "Q. 5. Stan&ar^ ) 



1 



(» 



' 



PLACE OF DEATH: — County of ^CL^x JXOx^^^tL^City of 'O^^x vJ-^-a.^^c>^^cc 



IHo. 




■}i\ 



CHi^^^v^LowU 



^aX^^cv"^ olS CHi^K^'^ O-^ St.; — — Dist.; bet. ;; and — - 

/ .r Dr*TiI OCCURS aw*V from USUAL RESIDENCE GIVE facts called for under SPECIAL information- \ 
( ,r deIth occ^RRtD inTho.p.tal or institution oive its name instead of street and number. J 



OS) 

FULL NAME l^^«^^^-^v 




V 

V 





PERSONAL AND STATISTICAL PARTICULARS 
SKX A . I COI,OR N ^ 



DATK t3F niKTII 



\<.K 



iMoiithl-r 



k>5 y.a. 



(I)av) 



V.tMlhs 



(Vtar) 



n,t 1 : 



sINT.I.K MAKUIKP. 
WIDmW i:i> OK niVnRiHI) 
(Writf in wKMal «k-si>ftmtJ<»n) 



lUKTnJM.ACH 
(Statt or Country) 





NAMl-: nl 

I AT hi: R 



lUKTHlM.MK 
ol- I \rHKR 

' st.it' or Contitry) 



MAIDKN NAMK 
<>I MOTHKR 



niR Tni'LArK 

ol MOTUKR 
fSl;tt<- or Country) 




ud 



VXXjU 



I 





'yj^' 



Ivi 



cxa^w'cL 



^ 



.R 



A^v^cLo iX 



(\ 



^1 



-Ll*^. 







M 




orcri'ATioN { 



\'\\V XHOVH STATi:n I'KKSONAI. I'A RTIC ! I. \ KS ARK TRTK To TMK 

linsT Ol- MY KNOW !,i;i>f,K AND in:i,ii:t- 



u,i,„,.- '^'\%\h 



A^ 



i. it 



O-^v' 



. MEDICAL CERTIFICATE OF DEATH 
liATK OF DKA Til 

10.. 




igo H 

(Mi)nlli) ] (Hay) (Year) 

I III'iKlUJV Ci:RTirV, That I atteiuU«l deccascil fn^iii 



N^VsJLo, 



I lyO^ to U^^UwrCL 10 I9O H 

that I last saw h .wy\ alive on \A.^a^O^ it T90 ''■ 

ati<l that death occurred, on the date stated alM>ve, at 10 
CL M. The CATSK OF ])I:ATI1 was as folU»ws: 



T)r RATION 



Years 



%' 



Mouths 



Days 



//ours 






Dl'RATION y'tars ,Vo»//is /hiys /lours 

(Signed) A./dLwAo^'^cC J o-^\-'»\.cc>^v M.D. 



I 



<5^. 



\^tuvq. C u)oS (Addre'^s) 31.n(/VsX\^ U 

, InslituNons, 



')m:^x 



SPECIAL INFORMATION onl> lor Hospitals 
Of Rectnt ResMfBls, and persons dying away fro;n home. 



a. 



Former or ^ , 

Usual Residence ' 



When was disease contracted, 
If not at place of death ? 



,CL>C 



How loR(| at 
* Place of Death? HO 



Transients, 



Days 



ri.ACK OF niRIAU OR RF:Mo\AI. I DATFtof HVRIAL or RF:NfOVAI, 



LAxaX^ 



INDKRTAKKR MR 0^>N^V \ib \.^<. 

(Address XV\ QOa' QllwU' 



\x 



T90H 



N B. F.vcry Item of information should be cnrefuliy supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAL'SE OF DEATH in plain terms, that it may be properly classified. The "8i>ecial Information** for per- 
sons dyin^ away from home should be 4iven in e\^ry instance. 



I 



I 






i 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



|!..ai<l ..f llenlth 1' No i^ t-s-^ws;^. H&T Co 






Dafi' /vVr^/, tl^vaA^At U ^-^0'\ 



• , WVA^'V^/C^W'H-^ li • •=» 

X^^cco "IjtvM^ ^eputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( H. S. StanDarO ) . 



^ 



PLACE OF DEATH: — County ofOO/^ O-'V^^ V.Cl^ ;<Gty of'^'CC^^■ ^0^>^<^* '^- 



«! 



'^ 



'No 



(IF DC 
If 



St.; '^^ 



.t 



and l'>vd. 



Dist.;bct. ^^' 

.TU OCrUPS AWAY FROM USUAL R E S I DE NC E Gl V t FACTS CALLED FOR UNOCB •SPECIAL INFORMATION" \ 
OEATm"cc!rRCD.N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 



r,lt 



■VO^>A^ 



\ ^\c v% 



CX^VIUAA^. 



PERSONAL AND STATISTICAL PARTICU LARS 

COI.OR \ ft 



Ox J 



SKX 

I>ATK i»r IJIKTU 



IVkJt. 



(MoiAh) 



(Day) 



r IH C ., 

'Vcar) 



AGR 



V \ JV«».<t V 



Mnttlhs 



Da\ 



sI\«.I,K M^KKll'.M 
WinnWKH nK DIVuKiKO 
I Writ* in ^. Hirji (lfitvMiatif>tl) 




lUK rill'I.VOK 
(Slat- 'It <"'>unli\ 



NAMI <>l 
JA TMl.K 



lURTHri.AfK 
f>l- I ATIIKK 
'Statf «ir iOuiitiy 







MAinKN NAMK 
OF MOTHKR 



lUK'nil'l.ACK 

(H- mmthkk 

(Slatf or Cimtitry^ 




f ^ 



xcL 



o^rvcL 



nvVrPA rioN 



R^siiifJ ii' S.itr I 



)V,r 



\!.„itli^ 



/hn 



riir Aiu)VF sT\Ti:i) j'Kksonai, rxKTii'ii.xKs aki: tki k to thk 

BKST or MV KNOWM-.IM'.H AND l?i:i.Il".»" 



MEDICAL CERTIFICATE OF DEATH 



DATE OF Di: 



f Month) \ 



(Day) 



(Year) 



I m;Ki:nV CIvRTIFV, That I attemlca «lcceasea from 

LL^VCV ^' ^9°'^ **' CLl^-H 190 S 

that I last saw h .J*.^:*^ alive on wva-a^....." up 

and that <Uath <x:curred, on the "late statiMl above, at li 
vl M. The CAISH Ol' 1)1^AT^ was as follows: 



Dr RATION Vtars 

CONTRinrTORV 



Months 



Pays 



Hours 



Dl'RATION 

(Signed) 



Years Mont 



Months 



Pa vs 



IC)0 



{ A .1(1 ross) "\ D D CU 'OAVv«.>e> 



/fours 
M.D. 



Special information only f'^r Hospitals, InstitutloRS, Transirnts, 
or Recent ResWenl^ and persons dying anay from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How lonq at 
Place of Death ? 



Days 






DATlCo! IUkiai. or KKMoVAI^ 



ri.ACH OF BIRIAI. OK KKMo\ Al. 



190 ■ 



!S B —Every item of Information .hould b. carefully suppiJecl. AGE -hould be .tated EXACTLY PHYSICIANS should 
rtate CAUSE OF DEATH in plain term., that it may be properly classified. The "Special Informat.on" for pr- 
sons dyinft away from home should be ftiven in «\«ry instance. 






i' ; 



r 



I 1 • 



f 




t ^ 



f* 




«<*l" 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CEWTtFICATE FOR INSTRUCTIONS 

929 



Jl.,ar.l of l!.;iltli I' V'V i« »•■?__ ;ar'^'rM> MS: 1' r., 



Jtro^isfcred Xo, 



luih- Filcil, UxA.auv^t li ^^<^'^ 

dsj(i'\^j.j^ dJuv-M. ^eputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Bcatb 

( 'a. S. StaiiDarC* ) 



^ 



No 



PLACE OF DEATH:— County of^'a^V O.fUX/^VCvA ' ' City of ' CV>v ■! Va -.Vtci. Ci, 
Jx*.\k St.; I Dist.; bet. . O^^) \i "-U-i. and 'J "^CV^V 

DEATH OCCU - 

IF DC*TM OCCUHRtO IN * HOSPITAL OR INSTITUTION GIVI 



,. TXO 



/ ,r OE.TH OCCURS .WAY rROM USUAL RESIDENCE give r*cTS c*llcd ;o« 7"« IV^XV^^nVnlT'^zr'' ) 

I ^ ^^^..--^r, .1. . ..r,«BiT«L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUIMBER. • 



< I 



FULL NAME 



oXa.v-c :v>uvco 'J. 



xv^^Lcx. v-c 



ccq. 



PERSONAL AND STATISTICAL PARTICULARS^ 

COLOR > 



■" ^licL 



ll'lvU 



ii \ ij: t»» niK rn 



.\r.K 



-^ivr.i.K NfAKkn:i>. 



Ml.nth* \ 



>■(<;»» 



(Day) 



Months 



(Year) 



J\i\. 



W lt>o\Vi:i» «>R DIVOROKD jA* 

4 -I 



HIKTHPI.AOK 
(State or t'.mntrv'* 



N \M1" «>» 
I ATHKK 



'wV^TrX 



niKTHPi.ArK 

O! I ATHKR 
St.U*' or Country) 



OF MOTIIKK 



lUKTHIM.Xri-: 
Ml NtnTHHK 

««: i!' 'iT c"> iintry' 



oCCri'ATION 



Rf idf'ii in Siif! /■;.;'.. 



K, ufl,^ 



WW \HoVH SIX ri !» PKR<o\ M, l'AKTUri.AK> AK} 1 KTK 1<> TlIK 

ni-sT (n Mv KN' "W ij.ix.i; AM> mki.ii:f 



(I 



nformant 'I fVv^ ^^^vtkcV 



i'Addrt"s»; 






e*n[ 



-WvV 



± 



MEDICAL CERTIFICATE OF DEATH 
DATK t)J ni'ATH ^ 

tUv 



(Month) (I 



I L. 

(Day) 



IQO \ 

(Year) 



I IIF.RIvBV ClvRTIFY, That j atUiuUMl aeccascil from 
that I last saw h -^ alive on LLv,u. 



to LLlv.OU Iti 



TqoH 



• A- 1*. It/D 

ami that «lcath occurred, on the date stated above, at I 
Jil M. The CAISI-: OF DliATII was as follows: 



DIRATION ^vv Ytars 
CONTRIIUTOKV 



Mouths 



Days 



/font s 



DURATION ,^ )j!W5 



(Signed) 



Pays 



TC)0 



J /<)>// /is 
fAddress^ 'XiC txs.tL- 



/fours 

M.D. 



SPECIAL INFORMATION on'* 'or Hospitals, Institutions, Transiepts, 
or Recrnl Residents, and persons d>ing a^a) from home. 



Former or 
I'sudI Residence 

When was disease contracted. 
If not at place of death ? 



HoM lonq at 
Place of Death ? 



Days 



I'LACK Ol JU'RIAI, <»R KKM«»VAI, 



l*\Ti: of lit KiAi. or RKM«>\AI, 



V 



^ 



^. 



rVDVRTAKKR '. V^^O<Co'V ^-i^^.-JCV^K^ 

S5-V O^Vu:^, ^-. '^'^ 



(Adtlrcs*; 



'Uw«i.Vfi-^V^ 



N. B.— Kvery item oJ information •houid be carefully supplied. ACE should »»««;;«*' 'J J^'^..\CTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. Th« Special Information for per- 
sons dyinft away from home should be ^iven in every instance. 



'I 



1 



. 



i; I 



I ' 1 

,1' I • 
I 





I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.,.,t.l nf Mi ;ilth I No ! 



« ^-f^^ar^ H.«t I" 



r>, 



1 )((!<' Filed , LLcvavv^ I i 



REFER TO BACK OF C ERTIFICATE FOR INSTRUCTIONS 

929 



100^ Registered J\^o, 

'^.v^wVA^ iLlx^r i^eputy Health O^Rcer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

PLACE OF DEATH:-County ofOa^^ aVO.^VCU..ttCity of 0,C^^ >l/va>VCLi ^i 



No. 



110 vl.c^vk 



V A, ^^ 



St. 



D;st.;bet. . Olaaj M lu,4. and XCVtvfLL >.a ) 



" ' " - ,,-,,,«, or-einr Nr r riwr facts CALLED FOR UNDER SPECIAL INFCRMATIO W 1 



FULL NAME .^.UiXaAM. ^trvc^ \J.cx.qj. 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

' COI.OR \ ^ 



\]\cdjL 



lUivJu. 



DAli: ul niKTM 






10 

(Day) 



(Year) 



^ I M. !.»•■. MAKKIKI> 
\\IIm»\VJ:I» ok IHV<»Kt J',I» 

'Write ill >«Ki:il ilisi^Mi.ttion* 



IVats 



MitMths 



Pa \: 



\\\ 



OAVvccL 



IMkTIU'UAt'K r D 

* Staff cir C'limtryt .-^ "^A 

\\ \ 



NAMK t>!" 

I ATm:R 



niRTl!rT,A('K 
Ol I AIIIHK 
iStiitf or I'mnitrvl 



M AI I • v. S N \ M K 
Ol- .Morm.R 



lUKTHri.ACH 
ol MornKK 
'St.itt or Country^ 



oCCl'l'ATION 



/^ 



Rf^iiirif i)i San f'l r.n, i^ro .' L 5 Vim 



M.„ifli' 



I 



Tin- AHovK sr\'n-i) i'kksoxm. i'aktumi.aks aki-: i-kik to tiih 

IJHST Ol" MY KNOWI.HIX.K AND IJKMllK 



(informant ' I VVVO n^jIaXKcV ^^ . 



MEDICAL CERTIFICATE OF DEATH 
DATK OF 1)1:AT1I 

(JMy) 



dvv 

(Month) 



1 



(Year) 



I HRRHRV CIvRTrFV, That I atteiKkMl dccoasecl from 

vj'iVa.Ly. -^i i.p' to LLll-cx. lii 190 H 

tliat I last saw h . alivt- on LLvuCy iC i</) \ 
aii«l that <lcatli occurrctl, on the Mate' stati-tl ahovc, at I 
M. The CAl'SI-: OF DIC.XTII was as follows: 
V.I I^ULtJ-^OLN^rLvtAra. 



^? 



I ) r R .\ T I O N U.'V-.lV'rt rs 
CONTRIHl'TORY 



Mouths 



Pa YS 



Hours 



DIRATION -^ iV*"'^ 

,1 < ' A 



(Signed) 

-V ^ ^ wq i<)o 



( 



Mouths Days 



Hours 
M.D. 



SPEC^IAL Information onlv for Hospitals, institutions, Transirnts, 
or Recent Residents, and persons dvinq away from fiome. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How ionq at 
Place of Death? 



Days 



I'l.ACH f)l JUKIAI. OK K1-:Mo\ \ 



^ 



\ 



DATK of Hi KiAi. or RHMl)V.\I^ 

^^' •, K-^ 190'v 



<. 



fA.Mress '^ 5 "^ Vn\v5:.4.1^<rvv 



M. B. Every Item of InformatJon should be cnret'ully RuppHed. AGE «houId be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The ''Special Information" for per- 
sons dyinft away from home should be ftivcn in every instance. 



' 



t 



i 



\^ 



A 






/^^ 



!•., ,;U.! '.f Il'-itltll 1' N' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

. ^rSX, ,„. ,. ,-„ REFER TO BAC^ OP CE RTIFICATE TOR .NSTHUCTIONS 

Re^Lslercfl JVo. 930 



Diiic nic'i. UAA^vvAt; 11 ■/•'•'^'^ 

1L«^u^^^ JoL^u deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( 'U. 3. StanJar? ) 



3!) 



PLACE OF 



DEATH:-County of OL^^v J;v<XavC. o -City of^'CU^ 3 AXXov^^-^i-^ 



itv of^' 







N0.131H 



i.^aKlr^' 



St.; 



1 Dist.; bct.Vu V^O. cLtf.^av.i and 





..c-iiAi DB-einrNCr rivr FACTS CALLED FOR UNDER "SPEClAi; INFORMATION ' \ 
CATM OCCURS AWAY FROM USUAL « ^ SI pENCEG.VE FACTS ^^^^° .^STEAD OF STREET *^ D NUMBER. J 



f (F DEATH OCCURS AWAY FROM U&U*!!. "«■ = '" "^ "*' -^^' ', J. 
I, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVI 



^r 



FULL NAME \X^ 



CL, 



V^^VvOL.L 



sj:\ 



IJAIK «H- lUKTIl 



PERSONAL AND STATISTICAL PARTICULARS 




'oSx 



lOivdLc_ 



Vl>Ok^ 



iM«intti) 



Diivi 



A«.K 



OLV^u v?S j 



fan 



M„»t>i< 



(Vcnr) 



Havs 



i i 




SlNt.l.K MAKKIKI* 
WtnnU i:i» OK niVnRtKI) 

Uiitt in stK-ial ih -ij^iialiou) 



HIKTHPI.ACK 

(Slatr or t'onnt ! v 



IXA-Jk- 



V'X-.d^^' 



« 



MEDICAL CERTIFICATE OF DEATH 
DATK OF 1>1:a III r\ 



(Month) \ 



(I):«y> 



(Yt-ar) 



I III'RIiHV CI:RTIFY, That I atteiultMl deccascil from 
— 190 to 190 ~ 



that I last saw h "r:^— alive on - 19°" 

an.l that doalh occurrc<l, on the «late statt-d above, at - 
-.^r M. The CAlSlv OK DI^KTII was as follows: 



A 



,\.^«Lx.. 



>?VCL.^^C->L 



N \M1' 01 
1 ATIHR 



lUKTHI'I.AiK 
o|- I APHKR 



\! V 11 > I : N N X M 1 : 

ol- MOTHI.K 



lUKTniM.ACi: 
oi MoTHKk 
• Slate or Count! \ 



1 ■ 



k 



.A wC 



It 



orClPATloN P^ 






\r.'>>th' 



n,! 



Till" A MOV I-: ST\'ni> rKRSONAI. 1' \ K lU" T 1. \ RS AKI", TKt K To TIIK 
in-:ST «U- MY 10.0WI.KIX.K AND BKlrlKF 



(Info; ni.int 



Id 



' X-l.lrcss 



or RAT ION Vt-ars 

CONTRinrTORY 



.l/()fl//lS 



Days 



Hours 



Dl'RATION 



)'cais 



(SIGNED). wC^ r^--' 



^ 



AfoNths 




P 



/'<;.i-.t 



//ours 
M.D. 



Lu- wty -l T c)o'' fA>1.1r<<>^) W^V^v^\^ VU 



gp£Qi;^l_ INFORMATION nnly f<)r Hospitals, Institutions^ Transients, 
or Recent Residents, and persons d)ing i^A) from home. 



Former or 
Usual Residence 

When was disease lontracted, 
If not at place of death ? 



How lonq at 
Place of Oeatli? 



... Days 



DATKof Hi kiAl- or KKMoV.AI, 

T9O 



1 



.A. 



I'I-\CK OK HI KIAI, OK KKM«>VAU 

INDKRT.XKKK JWUUy ^ (AD ^CVO/^^ 
(Ad.lr.ss l^Ah' l^ Uk. lil 




N. B.— Every Item of information ,hould be carefully aupplied. AGE should be stated EXACTLY PHYSICIANS .hould 
•tate CAUSE OF DEATH In ploin terms, that it mny l>e properly classified. The Special Information for per- 
sons dyinft away from home should be given in every instance. 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

WEFER TO BACK OF CEHTinCATt FCR INSTRUCTIONS 

931 






IfJO'i 



'd<jL->M -deputy Health Officer 



Eeilstcved J^o, 



1 



0-CA^\^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( •Q. S. StanOarC» ) ,. 

PLACE OF DEATH: — County of ^^ ^0^^\> ' 1.>utV>Vt^C<Gty of 'OA^ 






lAA ; 






riM '^mrJb.aVV^O.C » St.; It) Dist.;bct. IS t^ and 11 -Ik' ) 

'No. -^ l'^ UV'VA^;, U>-U- V. > MCMAI rfsTdCNCE Give FACTS CALLED rOR UNDER "SPtClAL INFOBMATION- \ 

.^.^^cLQAiJ. J\.CrCV<lV\' - - 



FULL NAME 



I 



PERSONAL AND STATISTICAL PARTICULARS 



cJLl 



iLlfv.U 



DATl. »»l IMKIM 



\(.K 



I Month) 




t5 IV«r 



1 
(Uay) 



Months 



r%-h\ 

(Yea 1 1 



/'<» 



HTNT.l.l" MAKWII.It 

wiumwjp ok iuvmki i:o 

(Wiittiu ^<«i:il lU -iv'tialioti) 



lUR riiri.M'i-: 

(Stiitr or C'ouiltty) 



I 






MEDICAL CERTIFICATE OF DEATH 

D.XTK «)I" Dl.ATH 



a 



(Month) 



1 



tl>ay) 



(Year) 



I ITF.Rr«:RY CICRTIFV, That I atternletl tlcceascd from 

QftVCLuv I I90H to LLA^Opl I90H 

tliMt I last saw h ^-*'- alive on LLa^v C^ C '9° 

and that death occurred, on the date stated ahove, at 
^ M. The CATS I-; Ol' DIvATII wa^ ax follows: 



LjlajUt" 



> JL/\^ v^W ( \ . CV. 



^- ■- 



Cx, 



'<X 



MM 



NAM I- «H 

|- A I" I n; K 



inKTMPi.xrE 

()|- I AllIKK 

• Strilt or C»nintry) 



MAIIU'.N NAM!-. 
01 MOIUKK 



lUKTinM.ACK 
OJ- MoTHKK 

estate or Country) 



o^l^vcc^ Wou 



C4v 



\ 



O^kxXjx 



A 



CL^VCtVOj 



] 



:^ 



r^ 



'w a > 



-i 



DC RATION Years 

CONTRIIU'TORY 



Months X /^ays Hours 



I)r RATION Years 



J/o?i//is 



/yavs 



Hours 



(Signed) 



UVCA^ 



5 X "' 



M.D. 



Address) 1*^ ^ ^).CctVv*-v. 



•f 



Special information only for Hospitals, Institutions, Transirnts, 
or Recent Residents, and persons dying away fro:n home. 



OCCITATION 

h'esiiifti in Si!n Ji,ri>,iuii .. )'<;'> 



M..„lli- 



!hi 



Tin \n»)VF sr\ II- n tfrsonai, tak iirri.AKS ark TRrK to thh 
iIkst ov my kno\vm:i)c.h and iu:mkf 



(Infornianl 



II 






Former or 
Usual Residence 

When was disease contracted, 
if not at place of death? 



How lonq at 
Place of Death? 



' Days 




I ndkktakkr 



I)ATi:of IUhial or REMOVAI, 
LLw.a 11 I90H 

lAal QKx/^.l.tfr^. ":^.* 



N. B.— Every Item o? InWrnation .hould be carefully supplied. AGE should »»« •'«**i^^'^.^CTLY PHYSICIANS should 
state CAUSE OF DEATH in plain term*, that it may be properly classified. The Special Information for per- 
sons dying away from home should be feiven in every Instance. 



I 

t 



! 



* t. 



I 



V 




■f ' 




I,' 



^m 

p 



t Si 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,..,.,1.1 nf II., nil, !■ N... :■> 1^-r3;^- MM' «■'> 




v^t U rJO^ 

^.„^ Jeputy Health Ofncer 



Res^Lsfcred •A^'o. 



932 



l)((lr riled. \X 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Bcatb 

( H. S. StanDarO ) 



^ 



PLACE OF DEATH:-County of'"^C^>^ 4 ^UXAXC^^ity of^O^v .1 ;vap.C c<. c C 



rNo. l'^C» V' ccK 



St.; 4 Dist.; bet. ^ ' A.<X >v WLvw and'^CrV VCIT.. ) 

-.^^..^r -...- r./.-r. <>>iirn roR UNDER "SPECIAL I N rOB MATIO N • 1 \ 



iieiiAi nrCinVlMCE Give TACTS CALLED FOR UNDCR "special INrOBMATION- '\ A 

( " .VrE-AT^H^OCCuNreV.^rHo's^pVT^At Jr T^ ?t^^"o';"o.;C 74 NAME .NSTEAO OF STREET A.O .UMBER. ) J 



FULL NAME 




VvYv lU .cLl>uX'> Yv !l<r(M.\.LL 



>C5>V 



>>i:x 



PERSONAL AND STATISTICAL PARTICULARS 




<xLi 



a.k.t. 



ItATJ-: Ol UIK 111 



A«.K 



i%Aitithi 



1 

(Day) 



(Year) 



bi J""^ i Mouths D 



/1<7 r 



SlNT.l.K. MARKIHn. 
\VIHO\Vi:i> OK I)IV«»Kv !:i» 
Wiitriii s<Kial tli sii-'nat i' lu) 



!MRTHri,\OK 

(Stat* '•>% '■' 'intry) 



NAMJ, <»l 
FATin.R 



TllKTHl'l.AlK 
OK lATIIKK 

'State nr Oouiitry) 



MAIDl.N XAMK 
ol MOTHI'.K 



JUKTHTM.All-: 

t>i Mnrm-.k 

*si;it» or CovuUry 



inv rrAiioN \j 







MEDICAL CERTIFICATE OF DEATH 

DATK Ol I)1:ATH I 



(Month) A 



It 

(Day) 



(Year) 






I mU^HRY CKRTIFY, That I atteiukMl (Icccascd from 



1 



LLc-u 



c^ ■, 



up X 



to 



a 



VUCL i.C). 



-0^ 



190 4 
,CL .ID.. 190 "1 

aii.1 that iloath occurrcil, on the «latc state<l above, at » v 

xsrc 



that I hist saw h A^ * .-alive on LA-^n-CL ifc 



...1 ,M. The CATSrC OF DIIATH was as follows 



r'\ r 



.KOL ^/C^-V-A^iX 








<XJV-\^v<V 



AV- 7^/ ,'*/ .V,/>/ /■; iiiii :'■'- 



Y- 






)V,;; 






/),; 



I HI. \HOVK ST XT in PKKSONAI, I'AR lUT I. \KS ARI-: IK IK To TMIC 
in:sT 01- MY KNOW I.KIX.K AND UVAJVl- 



(Itifurniant 



^Xddrc-is 



lit 0^{x^4 



nr RAT ION 



)V<7;.9 .}/nft//is b /)ays Hours 



CONTRIIUTORY W^vC* 



Dl'RATION Ycays Months '^ Pays 

(SIGNED) AS mK J^'.V^m^ 






Hours 
M.D. 



Special information ««'> J*"^ Hospildls, institutions. Transients, 
or Recent Residents, dnd persons d>ing anay from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



How lonq at 
Place of Death? 



Days 



I'l.ACK 01- lURIAU OR RKM<»VAI, j n\Ti:..I Hi kiai. or KKMoVAI, 



INDKRTAKKR v) 



.\>wA._ 



t 




^ 



'VC v^ T"W4X/w» 



(AcUlr.-s W^\ TyVA^^^iA,* >\ .3,i. 



rgoH 



N. B.— Every item of in?ormBt1on should be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for per- 
sons dylnft away from home should be felven in every Instance. 



1^ 






<t 



\\ 



r i 



! 



I»l 



^'¥^, 



» 



M 



il 



t 



H..:it.l ..r I!(;illh I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

... ,.^*-^>..„^..co wereR to ba ck of certificate roR instructions 

933 



/>^//^' AV/fv/, UA/wOi\XAjb w ^^<9H 

^Wuv^Xvv^ Deputy Health Officer 



Be^istered J\^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanC»arO ) 



PLACE OF DEATH: — County 



ofn,a->vWowQLA.A.^> . City of ^'l<K^Kl<rv^ ^O.' 



St.; 



Dist.; bctr 



-and 



^O* ■•Biiai DreinrMrr riwr facts CALLED rOR UNDER "SPECIAL I N roR MATION" "\ 

vLLUn: 



FULL NAME 






-w 



PERSONAL AND STATISTICAL PARTICULARS 



-.i:\ 



DATl-: ol ItlRTII C^ 1 

xXy 



COI,<JR 



'I 



'a^' ivvU 



( Mouth > 



M.V. 



O J Vrf I > 



IS 

(Dav) 



M.iHths 



(Year) 



Pit V. 



\vii>«»\vHi> OK i»iv«»Ki i;n 

Wiitt in <i<H-!al «lt ««ij.'ii:iti«iii> 



lUKTHIM.AOK 

»^i;it<- or Country^ 




o^.touLu 



NAMi: Ol- 
FATlll.K 



niRTHIM.ArK 
OK lATHKK 

(St:it« or Country^ 



MAn>KN N\MI. 
OH MOTIIKK 



lURTIirKACH 

Ol MoTIIKK 

I Stall- or ».'(miitr\'^ 



\ 



H 



V*-V^^ 



d-^^v 







oOCri'ATlON 

/yfMifi'if III Sill! /'inil.is,-i> 



■^ 



) V(? J 



M.oith- 



n,i\> 



rm: ahovk statki> phrsonai, i-aktuti.aks ark trtk to thk 

IJKST Ol- MV KNOWl.l.Dt.l-: AM> WVA.W.V 



(InforniaTit 






MEDICAL CERTIFICATE OF DEATH 
DATK C)I* DKATH O 

vLvAxr Ai 

(M<»nth) f 



(Day) 



igo \ 

(Year) 



I HF.REUiY CI'RTirV, That I atteiuUMl deceased from 

, — 190 to \(^ -rrrrr. 

that I last saw h alive on ' ~" 190 



and that death occurred, on the <late stated ahove, at— 
M . The CATSI*: Ol- 1)I:ATII was as follows: 



CvX'x.iv^-A.A^ jrt- i^v.\M.v 



I )r RAT ION Vt-ars 

CONTRIIU'TORY 



Months 



Days 



DURATION 
(SIGNED) 



Yvat's 



Jf<)n//fs 



Pays 



iqo 






Hours 

Hours 
M.D. 



Ad<lress) ''VW^k^trVx ^. 



SPECIAL Information onU for Hospitals, Institutions, Transients, 
or Recent Residents, and persons d)ing i^^fiA) from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



IM.ACH OK BIRIAU OR KKMoVAI. 






I)ATi;u! MiKiAL or KKMUVAL, 

v^VvOl .1 i 190 H 



■\fMrev;s ^ 




X-tov ^ 



.LuvCU. MTUx.' 



1) 



.Vv^v 



(Ad<lress 



!5:i.H Hl^^kt 






rfr^v... ;..'/. 



^. B.— Every Iten, of Information .hould be carefully supplied. AGE should ^« •*«»*:; ff.?5[,^^; .^l^'^LIi^.Vr*':;!.** 
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for per- 
son, dyinft away from home should be jllven In every instance. 



.' I 



)► 



I: 



T 




^ 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R tFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be^istcred JVo. "«-*4 



|l.,„r,ln(llcriltll-l'Nn 1^ I^E^^J^H&f Co 



Ihifo F^c(l,SX^Juo^.^^ ll I'-^O'^ 

l^^v^iLv-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Ta. S. StanOarD ) 
PLACE OF DEATH: — County ofOOL/>\^ 0A.(V^XC^.C6City of ' ^CX^^ ^^<X/^^^^C 
'jcCtl^>\' JVcHL^Atfi,^' St.; 




IH0.M I L<X^^H 



Dist,; bet. 



and 



-) 



att. 



FULL NAME 




,cv^u 



PERSONAL AND STATISTICAL PAR TICULARS 

i COI.OR \ 



I)\TH OJ UIRTII 



L 



u - ' . t 



Mouth) 



.\«;k 






• Day) 



M mth 



o. 



(Year) 



An 



•^iNt.i.K. M.\RKn:i». 

\VttM»\VKI> OK H1V«»K* Kl> 
Wiitt ill M»iial »U '»ivii'iti"'i' 




HIKTHIM.ArK 

^t if' "V •'■luntry 



NAM1-: <>I- 

I A rill. R 



mKTlM'I.ACK 
<»»• I \THKK 
Sttti or Ooutitrv'i 



Ml MorHKK ^ 



niK ruri.AvK 

<M- MtiTMKR 
Stall <>i iOunlry) 



OCCI l-ATION- 








Rf^'lJeJ III S,ni /'nniiisi-o l )rt7i 



\r„iif/is 



/)<.M, 



Tin- MIOVKSTATK.n I'KRSONAI, PXRTICn.ARS ARK TRIK TO THK 
IlKST OF MY KN0\VM:I)C.K AM) BHUIKF 



(1 



i.fotniant OJ . O • MtrVVjU 



' \(1drc« 



MEDICAL CERTIFICATE OF DEATH 



DATE OH DKATII r\ 

LLsv^q. 1 \ 

(Month) K (Day) 

LEREBY CERTIFY, That I attended deceased from 



/poH 

(Ycnr) 




^U ri 190 n 

that I last saw h ■*» " alive on 



to 



.A^O^..i.C). 

LLLA,.-qL \.h 



190 ^ 
190 ■ 



and that death occurred, on the date stated ahove, at 6 O 
y^Jrsi. The CATSI-: i)V DI^ATII was as follows: 



nr RAT ION 

CUNTKIIU' 

0,^ 



Months 



• U -wJb-<A/.CVvLfr^> 



Days 



Hours 




DURATION Years ^ M nut lis 

( Signed ) Vvv>v VI t\. LL'xlIl ^ . . 



XX H: ' 

Days Hours 



iLcwail TQoS (Address) 1 1 it 5-V^'^ii'Hf 

SPECIAL INFORMATION only lor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away Irom home. 

Former or c ^ '^ V 4 J -\ "**' '""^ ** 

Usual Residence <^^ ^ WCV<Xa^ \ piare oi Death? Days 

When was disease contracted, 
II not at place ol death ? 



PI,ACE OF BIRIAI, OR RHMoVAI. 




DATHof IMriai, or RKMOYAL, 






(Address 



N. B.— Every Iten, of information .hould be carefully auppUcd. AGE .hould be .tated EXACTLY PHYSICIANS .hould 
•tate CAUSE OF DEATH In plain term., that It may be properly claa.lfled. The Special lnformatlon'» for per- 
sons dyini away from home should be ^Iven In every Instance. 



I'* 






m 



k 



"Kfi 

■I- 

■ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,uM ..f II.Mllh-rNn. ,,-tS.g^?^l>y:»'C.) 




.t il 



y,90H 



Besiistercd JVo. 



935 



Date File<l , \A^u^CVVs^^ 

ds^^trVv^oA^ vh^ Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( •©. S. StanC»arC> ) 



PLACE OF DEATH: — County oVJ^^<L<X^ L^^C^VO- City of ^J^O^^v. HtS^ 




LcxL 



No. 



SU 



Dist.; bet.- 



and 



-- ,-«». IKSIIAL RESIDENCE GIVE r*CTS CALLCD rOR UNDER "SPECIAL I N roR M*TIO N" '\ 
( " :*/rE';TH"oCc"u%rcVi;''rHOS^rT'lL 0%"N?'?J'T^0^'a.VE ITS NAME INSTEAD Or STREET *NO .UMBER. ; 



FULL NAME 



Yt^^^ '^^^' ^ AA,<l.<i 



^CXA/n.. 



-u- 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR ^ 



f^c^L 



^UjJv^^t^ 



DATK «)| lUKTIl 



a<;k 



9A 






(Day) 



(Year) 




O i^ )V«»#J 



Mnuth.- 



^ 



na\.^ 



SIN( ! 1- M AKKIHU 

wiiH.w 11) OK n!V«»krKi> 
Wii;- 111 -ocial <J.^iv"i»tioii) 



lUKTMlM.ACK 
(State or Cmtntry) 



<^i 



ojvxvjw cL 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATIl 



(Month) 'If 



(Day) 



(Year) 



I HFKICHV C1:RTII'Y, That I atteiuliMl deceased from 

—190 to 190 " 

that I last saw h :::-- — alive on — 190 ;; ' 



ami that death occurred, cm the date stated above, at - 
M. The CVrSK OV DI-ATII was as follows: 



■v-M.'.. 



VwLw^^AA^A^ tX. 



NAM!" 01 
1- A TIIKR 



HlRTinM.Ai K 
<»1 I ATIM'.R 
iSt:it« or (.'ountry^ 



M \n»KN NAMK 
Ml MOTIIHR 



lUKTIiri.ACK 

Ml- MmTUFR 

I Stale or Countryl 



C\ 




<x_' 



i 



KAJu^ '^j.C^O^OLv^x 









vX\j\..<iX 



h^^O^ 






Rrsideii in San I'lun,! lo 



)'tti I 



M.<n>li^ 



fhn 



THl- \HOVF. ST^TKI) I'KKSMNAI, rAKTKTI.AKS ARKTRrK To THK 
IlKST Ol- MV KNOWI.KIX.H AND BKI.H-.H 

(Inf.nmant ^U.^->^V.cLcV '^Lwv^^VtX-, ^>. 



' Xddrcis 






"^t 



I )r RAT ION }'t'ars 

(."ONTRIIU'TORY 



.1/, •'////.? 



/)ars 



Hours 



DIRATION 
(SIGNED) 



Years 



Motiths 



Pays 



Hours 



CIAL I NFC 



.1 ^c'w^ '::.>■•.:_ M.D. 

Address) J CV>vH V^U» ^a^ 



( 



SPECIAL INFORMATION only tor Hospital^, InstitHtiMS, Triiisifiits, 
or Recent Residents, and persons dying a<»ay (rem home, 

Ml How lon<| at ^ . 
/%^v.^^v ' '^ Plare of Death? Aw Days 



all 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death? 



PI.ACK OF BIRIAI. OR RKMoVAI, 






DATK of Ht RIAI, or REMOVAI, 
^" ^^ •^••^ T9O.H 



(Address 



^JL^-xJwXtrv^ 



IS. B.— Every item of Information .hould be carefully supplied. AGE .hould b«,»«t.d EXACTLY PHY8ICIAIN8 .hould 
state CAUSE OF DEATH in plain term., that it may he properly eiasulfled. The Special information** for iMr- 
aon« dyinft away from home should be given in •v.ry instance. 



1 

I 



y 



n 

^ 



r 



f 



i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

936 



Hn-n-l ..f II.-Mlth I- Vo i^ ^'l.'*:^'-^ 



i*.?"-ar"Xi) MM' Co 



Dff / r Filed , vL\-vCyL. 




I 



II i.v^;H 

Deputy Health Officer 



Registered JVo. 



m 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( H. S. Stan^arO ) 
PLACE OF DEATH:-County of^^CLAwJ^UOm^UtCO.. Gty of^^Cuy^^^'^^^^-^^^^ 
M UIlVU ClJv ^^at'v^^• St.; 1 DUt.!bet.Xco,V>vM and MRft^xtoJu. ) 

No. V) AU) W ^\.<^ r V-w^ w.\.V .^.- > ..-.,., or<sTDENCECIVE rACTS CALLED rOR UNDER -SPEqfAL INFORMATION • \ ^ ] 



FULL NAME 




U). 



OJ\.''>^ULhj....S\j \XJji/y^j(XKA.^\Jj 



PERSONAL AND STATISTICAL PARTICULARS^ 

COI.OK 



■'" ^\oL 




W^ 



tL 



DAT J. ol 151 RIM 



iL-v^ik 



(M.Mith* 



m 



i 







A«-.K 



GLl-t 



-^jb 



) Vi» » 



(Uajr) 



MoHlhs 



'Year) 



/)«! I 



vINT.KK, MAKUI1-.I> 
WIDnWKI* «»K I»;\<>ktKI> 

'Writt ill -Hi.i'. 'li •.ij.'iiation) 



d.L^^Q.U 



lUKTfU'I.At'K 
iSl;it< «ir <'<)nntrvi 



NAMV Ol- 

I- A Tin: R 



niRTHIM.AOK 
<H lATIIKR 
'Statf i)r Country) 



M \ii>i:n NAMK 

Ml MdTin-.R 



lUK rm-LArK 

Ml MmTMHR 
(St:iU or Country 



iKCll'AllON J? 

Kfsitlrif m Soft /'iiittti"i> 






MEDICAL CERTIFICATE OF DEATH 
DATK OF I)I:aTH 1 

LLA^A^n ,. i. 



(Month) f 



(Day) 



(Year) 



y,-.i> 



M,>,itli< 



1>,1\S 



THr AHMVr ST\Ti:i>rKRSMNAI, r\KTlCr!.\KS akktrck tm tmh 

HKsr oi MY knm\vi.i:dc.k and hi:i,ii.i- 



(InfoTuiant 



TllUKlUlY ClvRTIFV, That I at*cMi(k(l deceased from 

— 190 to ^ i90 

that I last saw h -r^ alive on ' l^^- 

and that death occurred, on the <late stated above, at 

~:— M . T h e C A r S !{ ( ) l* D i: A T 1 1 was as f ol I* > ws : 



nr RATION Years 

CONTRllUTORY 



Months 



Pays 



Hours 



DURATION . Years 



Mouths Days Hours 

(SIGNED) Lcr^^r^\Jl^.' b iL. 'ijJLo.Av-'... M.D. 

1 • ^ 



\.0 



iqO 



( A <M rcsv ) UcVfr^vJL^.6 wJiLv./ 



SPECIAL INFORMATION only lor Hospitals, Institullohs, Transients, 
or Rfcent Residents, and persons dying andy from home. 

Former or H«w \w% at 

Usual Residence Ware of Death ? Days 

When was disease contracted, 

II not at place of death? - 



ri.VCK OF lURIAI, OR RI:MmVAI, 



^W^>^ 



rNDKRTAKKR 



rXiMress 



(Ad 




klress . .?l.^jl.%i'....l.^ AA 




I,. B.— Bvery item o? Information .hould b. cnrefully supplied. AGE should be stated EXACTLY PHYSICIANS should 
Itate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Informat.on'* f*r psr- 
son« dyinft away from home should be ftiven in every instance. 



; 



t 



I 

•I 



\gM" 



t; 



r 



Iv 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ncpcn TO BACK op ceRTiricATC for instructions 



|l..:,i.l ..f ll.i.lllv 1- S'<1 X ♦•C'*?*' »"'''''" 



937 



Da/r /'7/../, CUowa ll. 100\ Registered J\ro. 

"i^vw. i>cxw. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



P^, 



PLACE OF DEATH: — County 



Certiffcatc of 2)catb 

( "Q. S. StanDarD ) 
ofC^CL^V J.V<X^^CxACoCity of n<^>v JX.CX/>v C.^.^Cii 



(If OtATH OCCURS AVIrtkV FROM USUAL 
ir DEATH OCCURRt© IN A HOSPITAL 



-and 



■) 



RCBldcNCC Give FACTS CALLED FOR UNDER "SPECIAL I N FOR MATIO N" '\ 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

(? id 



FULL NAME 



LcLw^CXA^cL ..-.Jj rv.Cr:U\.nx... 




personal and STATISTICAU PARTICULARS 



"" (hwU 



COI.oR \ , ft 



I)\TK ol IMKTII 



\<-,K 



(MonthT 



(Uny) 



/ l5 I . 

(Year) 



\ ^ } 'lit I > 



10 



M.tfilhs 



SINC.1,1-: MARkll".!). 
WIDnWKD ok HIVoKrKO 



WIDnWKD ok HI\«>KVKI> ^ 



.\,<^-v 



Vi 



dl 



I hi 



Hik rmM.^v'K 

(St;it< or Country' 



I- A lUI-.R 



nikTHiM.xrK 

<»1 lAIIIKR 
I st.itf or I'onntrv 



MAIDKN NAM1-; 
t)I- MOTllKK 



lURTMPUArH 
<)l- MOTHKR 
(Slate or Country) 



? 






L 



ruxvLu 



iA,tr\^cnfXi^ 



I 






J iW.CXL 



i 



A L^. :\ 



(KC IT AT ION 



MEDICAL CERT IFICATE OF DEAT H 

DATK OF I)i:ATn ^ 



(Month) 



It.... 
(Day) 



1 1 

igo ^ 

(Year) 



I III'RIinY ClvRTIFY, Tliat I atteinUMl ileceased from 

- j>.ajj». 190 to t 90 — 



that T last saw h alive on ~^ 

an.l that death occurred, on the tlatc statc«l above, at 



-igo 



^ 



^I. The CAlSIv 1)1- DlvATII was as follows 



^•v^ 



.v!. oJLv O-^-w >lA.XX^v>^-''VVvJtnrsX 



DrRATION )Va;-.v 

CONTRIIUTORV 



Months 



Days 



Hours 



nr RAT ION 



(Signed) 



Years 



Months 



Days 



^ 4i u I 



P 







Hours 
M.D. 



QO' (.Address) VdVfr^U.^^^ V.<Li\.T^ 



SPECIAL INFORMATION only for Hospitals, listitytlws, TransifRts, 
or Recent Residents, and persons dying away from home. 



Former or 



%. 



R^sidfil in Sar /'innriM-n ^ O 1V<j/> 



M"nlJi< ' ' . /'.M> 



THK MU)V1- ST\Ti:i) PKRSONAU PARTICri.AKS ARK TRlK T<> TUl-: 
HKST OK .MY KNOWI.KDC.K AND HKUIKK 



(TufoiuKint 



f -\<l<lress 



ini 



Qlv 



v^^wcr^x 



^! 



t"" j How loRf at . 
Usual Residence 3\^CUj.uu<X,\.d^ v(X\ Place of Deatli? ^» Days 



When was disease contracted^, 
If not at place of death ? 



PLACE OF BKRIAT, OR RF:M<»VAI, | DATHof HtKIAI. or REMOVAI., 



190 






f.Ad<lress 



llll^\A^^^<nv^.tL 



IM. B F.very item of in?orm«tion .hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information" for psr- 
sons dying away from home should be given in every instance. 



\\ 






i 



m\ 



s 



4? 



■i 

4 



m * 



\ 



u = 



'*!» 






I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.1-a^„..„c^ HgFEH TO BACK OP C EWTIFICATC FOR IN8TWUCTIOW9 

938 



Registered JSTo, 



Jlnfe F/7^r/, LLu^ci^vd: IX I'^O 4 

iv^hv.^u) isXovu Deputy Health Officer 

DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Ta. S. StanDarO ) 

J ^ 4 ^ 

PLACE OF DEATH: — County of ^O.^ x^>xcv<^ CcGty of C'/CVvv OA a^x Cc^a^ 

rNn. ion U ^X\>i} ^ SU ^ Dist; bct.li' aA.kl/Vvoi.iYV and X\€lu ) 

^^°* / .rOC.TH OCCURS AW*y FROM USUAL RESIDENCE G.VE "<=;« ?,Vi^^NVT«0°o^ ST%"f!*iNrNu";«^^^ 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or '^REtT AND NUMBER. y J 

LL J^ crl iltftvcu.-^^ hoAJl la^ \.LlU 



FULL NAME 



PERSONAL AND STATISTlCAt PARTICULARS 

""' ^xoL '"■■"■ III Lu_._ 



DATH <>I- lURTIl 



A'.K 






y.<n 



U 

(Day) 



M,>vths 



(Year) 



Pavs 



slN..l,l-: MAKKIKI>. 
\VII)o\VHI> «)K IHVoRvKn 
'Wiitfin s<KMal tU'-ij^ naliuii) 



HIKTMIM.Ai'K 



O.c^vaU 



HIKTmM.Ai-K i iV\ \ I 1 

(State or Country' -^ M! V i ,| 



NAMJ-: «)!• 

»• A r n i: R 



lUKTHlM.ACK 

(ll- l-ATIIKK 

I State or Country^ 



maii)i:n namk 
of mothkk 



RIKTIIPLACK 
<>»■ MOTHKR 
(Statf or Country) 




ayLJ 



Xt-Vvjl 



t 






OCCri'ATION 

h'f>iiUi! in Siiif f'l oil fsi'it 



) ViM 



M,nitln 



Ihi\ 



Tin>: MU)VESTATKn PKKSONAK PAKTIcn.ARS ARK TRIK To THK 
nKST OF MY KNO\VI,Hl)('.K AND UKMKF 

(Infornmnt LUryVS.- W €xXW^\^ 

^0^ U 



(A<l<lross 



^VCLV^vvcx 



^ 



VJl 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Month) 



S 



I! 

(Day) 



vooH 

(Year) 



I Tir^RKBY CIvRTIFY, That I attended deccaseil from 

LIa-V^OL tl 190 S to •^ ^ 190 • 

that I last saw h*^ alive on *" "" 190 ~ 

and that tlcath <iccurred, on the »latc stated above, at 



- M. The CAISI; OF DI'ATFI was as follows 

AAvic^^dt tix.JiA. "a.tai..iE 



Ci\ .. .„ 



Dr RATION Years 

CONTRIBUTORY 



Months 



Days 



Hours 



DURATION Years Months Pays 



(Signed) 



^V 



Hours 
M.D. 



IL^(^ 11 iQoH (Address) 15 1 OA^tLlh. .^ 

SPECIAL INFORMATION only for Hospitals, institutions, Traisifiits, 
or Recent Residents, and persons dying away from lionie. 

How If 119 at 

Plartff Dratk? Days 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



OATKof HtRIAl. or REMOVAL 
CNDKRTAKKR UJvULvaA>\ lOcLLt-U/- 



PI.ACK OF niRIAI, OR RKMOVAI, 

gV- o-tu _ L v^^'( 



in 



190 



(Ad<lrcss 



% ^ ^ V^V'VOL VVV.V.flL..LLvVC. 



IS. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information** for psp- 
Rons dyin^ away from home should be ftiven in every instance. 



■'I 



'i--\ 



tl 



ii^:l 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,i,,,! ..f lUalth-I-No. l> -J-^^aiH&PCo 



Registered JVo, 



Date riled, LLiA.au^t \X I'^O'i 

"L^LCA^o ioiv-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDarC> ) 
PLACE OF DEATH:— County of O/OAvOACVvuM-X^C^jCity of" '/OyVU OAx:»-/>v<C.V«^.eO 



(\f Dt*TH 
IF DC« 



St.; ^ Dist.;bct. vO 



<lWiA^(rvu 



and OO^IA/O-^vu 



OCCURS .W.Y FROM USUAL R E S I D E NCE C. VE FACTS "«-i/i> ^O" ^";'"; ^ f;*iJ ^N U M It R^ '*" ) 
*TH OCCURRtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



^ 



I'XVUL/V^Uyv^ 



vT. Uk-Jla 



r>:x 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 






COI.OR 



DATI". lU UIRTII 



Ai.K 



Vivictt 







(Dav) 



(Vear) 



JV«I#JE 



M.>»//is I Jk A»« 



SINC.I.K. MARKIKI) 
WIDOWKI* OR DIVoKi Kl> 
iWritf in MM-ial cU«'iv' nation) 



lURTIUM.AOK 
Stilt f or Country I 



WMK or 
FATMi: R 



niRTMlM.AOK 
Ol lATIIKR 
'Stafr or I'oiintry) 



1 



A. 



AV 




CL>V vjA^LW.'CCa CO 



.LvTkAJ 






Ol MOTHKR 



lUKTIII'LACE 
Ol' MOTUKR 
'State or Country^ 



«)CCl TATION 



j-C- 



(\> I 



Rr-iiffi! ill '^'inr /■'> inn i^rn 



I 



) V-fr; 



THl- \BOVK STATi:i) rKRSOXAI. TARTUTI.ARS ARl! IRTK To THK 
HHST OF MY KN0WM:I)<.H AND HHI.IHF 

Cvtv^JL>v' ' ^^X^Jt CtvL-t^tr. 



(Infonnant 



< \-lilress 



^^ I X - X 1 .4+ 



Hi" 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



f Month) iC 



1 1, 

(Day) 



19^ H 

(Year) 







I URRKBV C1:RTIFY, That I attended deceased from 



^\x.Ul It 



190 H 



1904 to LLu^O: U 

tliat I last saw h •A.'v alive on vLvvCjL ' i 1901 

and that «U'ath occurre<l, on the date stated al)Ove, at O O 
CL M. The CAlSIv Ol- 1)I';ATII was as follows: 

\ I rVxX V ex ^ -^ VA-V^.^' Oa vlr cv vlaa,Ll 



)'t'ars 



Afotiths 



, \ 




DIRATION 
CONTRIBUTORV 

DrRATION }f<('-fN " 

(SIGNED) V. J. ViriuLLa 



na\s iJ^ Hours 



Months 



Days 



Hours 
M.D. 



SIGNED) V. 0. \I/IULJUx\ M.D 

lluQ 11 190H (Address) ll^VnlavLd ^t 



SPECIAL INFORMATION only for Hospitals, InstituHoiis, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of death ? 



How I0119 at 
Place of Death? 



Days 



DA ri; of Htkiai. or RKMOVAI, 

LL\wvn ^^ 190H 



I'l.ACK OF lURIAI. OR RKMoVAI. 

1- viii.-«r A ic VK V 1 C^^wC\J2/W _ . ^ 



.C^Vt. 



fAddi 



N. B. Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin& away from home should be ftiven in every instance. 



■i 



!■ 



: 



, it 




rll 



•.il 






nii^ 




""HT" 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R E re H TO BACK OF CERTiriCATE FOR IN8TRUCTION8 

940 



Hnj.r.l ..f Ilcnlth-F N'o. i^ ^-tTSi^' ^^^^' ^'" 



J)(f/r Filed , LLtvauv^ I X 



200^ Be^istered Xo, 

^ "' -^-— ^— -- 

i& lA-v^ ic v^u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



'No. 



Certificate of Beatb 

{ "a. S. StanDarD ) 
PLACE OF DEATH:-County of^^ a^V t Va ^vCU ccCity of '"'^VAv Va.vCc<.CC 

Hl'X Jx'vAt St.; ?» DUt.;bet. .1v:/a\.VUUr>V and 'macwxt ) 

_«-.« iieiiAl orQIOFNCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATION '• \ I 



FULL NAME 



^IrUt vYl\a^±..v CI 



t 



XCALct 



PERSONAL AND STATISTICAL PARTICULARS 



D.\TK Ml in Kill 



(1 



COI.OR 



L 



C.t 



Ic Lit 



>M(iiitli> 



Af'.K 



Hi >>.,. 16 



(Day) 



1/..M///' 



(Year) 



/>ii li 



>-l\i.I.K MXKHIKI* 
\Vll)n\VKI> «>K DIVnKiKI) 
iWiitrin siK-ial (hsivriiatioii) 




lUKTHPl.AOK 

(St:it«- or (.'oiintry) 



\.\MK ni 
lATIlKR 



\vt^>v<X5 LlWc^lc?. 



BIRTH PI. ACH 
<)l- 1 ATHKK 
(St:it«- or I'ouutry) 



NfAIl>KN NAMK 
01 MOTHHK 



HI R Till' LACK 
()»• MoTHKR 

(Stat< iT rountryi 






'' Ji 



acrtl 



\ 



<X ^ X cL 



Kesidftl ill Smi f'linhiWu 1 v )-•<?/»- 



yf,>iif/t' 



/),/i 



rilK \HO\ F STATKI) rKRSONAM'ARTHTI.XKS AKi: TRIK To TIIH 
HKST OF .MY KXONVI.KIX.K AND MKl.IKK 



(I 



fA,Mr...s 4ia - I '4t d± 



MEDICAL CERTIFICATE OF DEATH 
DATK OV DKATH ^ 



(M«)nth) /T 



II 

(Day) 



(Year) 



I HKRKBY CI':RTII''Y, That I atten<k'«l «lecoasc«l from 

V^iu vV lyo'i to 11 CL^A^ I90H 

lliat I last saw h ^ " • alive on I vLCvO^ 190 H 

ami that «kath occurre*!, on the <latf stated al)Ove, at 10 
CL >f. The CAl'SH UF DHATII was as follows: 

Cch-Vvvo-o^vo crjr^ _t^jL "icv-^h; V\.prvv.v 

DTR.ATION ^ )'rars ^ J/onf/is Days Hours 

coNTRinrTORY LLcLCA.tx<> LLw^ti^r>>vw»^<\..i 

3w Vfe^v^i^^ 



nr RAT ION J'*''''Jv_^ \fofilhs Havs Hours 

(SIGNED) 11 ■) "^i tCt'LilCKV M.D. 



a 



wall Tc)o4 (A.Mrcss) IS'^la^H 



f^ 



/€L II Tcy 

cUl in 



SPECUL information only lor Hospitals, Instil 
or Rfccnt Rfsldfnls, and persons dying anav from homr. 



tltlons, 



TransifRts, 



Pormf r or 
Usual Rrsidrncf 

When was disease contracted, 
If not at place ol death ? 



NoH lonq at 

Place of Oeatk? Days 



riJVCK 01 BIRIAU OK KI;m«>\ AI. I D.ATK of HiKlAL or REMOV.AI. 



N. B. Every Item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for per- 
sons dyin^ away from home should be ftiven in every instance. 



I 



It 



• 



1i 



l*i 



r-t " 



1 



IL 



t: 
ft 
I" 




I;' 









til 



*ii 



'a 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H.,:,r.l ., f ll<alth-r No. i^ ■t^^.^aE.S^ HS: 1' Co 

J)(( t V Filed , . . VwUaXXAa^ !..l 10 0\ 

r 



Registered JVo,. 



941 




^>\4 Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "a. S. StanOarD ) 
PLACE OF DEATH:-County of Oo^ J 'VOA^^.c-ac City of O^L^ ^(-'VXXAA^^C.c 
M '^OR i^'ci -X- - St.; *^ Dist.;bet. J-tUj and U iXK 

( " rr'rr^^Scc'u'-rcV.'-'r-o.^y^t ,%"«""o» o,vc ,t. N»ME ,n.tc.o or .T.tcT .NO »u-..-. ; 



) 



FULL NAME 



^Vr^Xi. 



IXoJL 



PERSONAL AND STATISTICAL PARTICULARS 
ll.XTK n»- niK 111 ^ 

oxWt 

It) .v„,, n 



I Day) 



Mntilks 



(Vt-ar) 



Days 



SINT.I.K. MARklKD. 
W llMtWKl) OK »)!V<>Rti:n 
Wrilt iti s<K-Jal tlesij.'ii;UJ"n) 



A 



lUKTmM.AOK (Ts iAiJ A 

(Stattor Cotmtry^ li I I I 

J/'vv'YvvcL<xcL v<ri<rVaxLc 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH i 



(Month) K 



Day) 



190 ; 

(Year) 



NAMi: of 
FATHKR 



BIRTHPT.ACK 

01 I ATMKR 

t Stale or Country^ 



MXTDKN NAMK 
i»i MOTUHR 



HIRTHri.ACK 
OF MOTHHR 
(State- <»r CouiUi V 



-jUv^v^^^vcl 



(kcii'a rioN 



V 



n 



I inCRlCBV CI^RTIFY, That I attemU-d deceased from 

HvJUi. at 190 h to yLcuCy..-A.1 190 -A 

that T last saw hu>^^ alive on Lv\^^-i-^ 1* 190.H- 

iuul that death occurred, on the date stated above, at 
; M. The CAl'SF*: OF DIC.XTII was as follows: 

Q 




\jC.l'wivv.C*-\_^ 



I ) r R .\ r I ( ) N ' } V(ir5 ^' Months 



,f^ 



CONTRinrTORV w^:v^:v».v, 



Dr RATION Years \ Mouths 

iNED) J.'kx^ VTuXv 



Days Hours 

\\A\^s.jJL.\^.... 




Days 



Hours 



(SIG 



\jj\jii 



M.D. 



L Lv.M:> ^X too ' '■ ( Address) ^VvVWQ U 




iB.i 



do 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying anay from home. 



Rfu'iJ^J in S<!» f'lOUiis.-it I \. V'-iii 



yfonth^ 



/),:i 



T H 1 • A R( )V E ST \ I- M > 1' K R SON A I . I'A R I" U" T I . A k > A R l- T R t " K T( ) TW K 
llHST Ol- MV KN«)\\ I.jUX.K AND BKMKF 



(Informant 



A.Mr,- \%i% Vj^-y^^. dl 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



Htw lonq at 
Place of Death? 



Days 



PI.ACK OK BIRIAI, OR KK.MOVAI. 



ffi 



V ^ vCl 



DATK of lURlAL or REMOVAL 

vLvui, l.H..^ 190U 



_%aL., ^ . 

INDKRTAKKR \l V . \) A^ <X Vi ^'V V.^ 

fAcl.lri-ss s5^ V XvvLA-'V 



N B —Every Item of information .hould be cnrefully supplied. AGE should be «t«ted EXACTLY PHYSICIANS .hould 
.t«te CAUSE OF DEATH in plain term., that it may be properly cla.-ifled. The "Special informafon" for pr- 
ison* dylnft away from home should be ftiven in c\ery instance. 



I 



1*11 



. *•( 



1; 



Ifc- 



- > 






.N^ 



^^IX^JMIL^ 



H) 



if ? 



■ -^ K 






^T^**^ 



>».* 







7»^ 



il 



I 




ft 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,..,„..„,,„-.^s.,..€l^..<..co nereR to back op certt.c.t, tor .nstruct.o.s 

,>„lr FiM, iLcyw^ IX l^m Registered Xo. 943 

iVCrvvca rLtAM.^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of Bcatb 

PLACE OF DEATH:-County of CCL^JAO^^^A^City of ^^^CVvv AX^ vca.si^<) 
rTNJo TlS fc^W^vd. St.; 5i Dist.;bet. SaxL and HXXv) ] 

'No. I <^y yW ir>./^ ^/»- WV/W' _^^ ,,-,,.. ppsiDENCE GIVE r*CTS CALLED FOR UNDER "SPCCIAL INFORMATION- \ 

( '^ rF"D»T°H"0C?u%;r;.;''rH0.^rAL o%"n?"i?u"o"n"g.VE its name instead OF STREET AND NUMBER. ) 

CjvCUvCXAv L/Onyvs^ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

! COI. 



d X^^VoXl \X)AK^AX 



I> A IV. <-! I:IRT1I 



AOR 



Ml 



• Month) 



31 V) )V'i" 



(Day) 



.\fonffis 



(Year) 



Pars 



SIN«;i.K. MAKKIKI* 
WIDOWKD OK niVoKiKI) 
tWritr in ^iKJiil <U>-u''J:ition ) 



niKTin'i.xrK 

iStJttf «»r Country) 



NAMK OI 
J- ATIIHR 



BIRTH PI.ACK 
OI' 1 ATMKR 
f Stuti or r<»intry 



MAIMKN NAMl 
OF MOTHKK 



lUKTHPLACK 
OF >!oTUKK 

(Statf i>r Country I 






txxv^u. 



^VOL 



V>CrVArv>J 



Ou 



avo-wtvaj 



oCC 



rr.vnoN O^f p 



///> - /'<! 



THK \noVK ^T\T1-I) )'KRSONAI, I'AKriCn.ARS ARK PKrK To THH 
IIHST t)I- MY KNoWI.KDC.K AND BKIJlCF 



(Infoiniant 



f \'l.lrr<is 



11% lb (^vL^<x^JL '^t 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DEATH 



a^v 



(Month 



i'V 



11 

(Day) 



(Year) 



I HKRKBY CKRTIFY, That I atteii«lc<l «leccase<l from 

— — ^ — — 190 to ' 190 "^ 

that I last sjiw h > ■' o live on '90 

ami that «Uath occurred, on the date stated above, at 



M. The CATSK OF DICATII was as follows: 






DT RATION }'t'ars 

CONTRIIU'TORV 



Months 



Days 



Hours 



I>r RATION ^ Years Months 

(Signed) \.^c:\xrY>JA>0. __ 



Pays 




\JUu^\\ iQO 
»PECllkL INF 



H (Address) LC\.frV>jlM 



m^ 



Hours 
M.D. 



s? 



Special information only for Hospitals, ln$tituti«RS,''TraRsifnts, 
or Recfiil Residents, and persons dying av»d> fro-n home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at plareof death? 



How lonq at 
Place of Death ? 



Days 



ri.ACK Ul" lURIAI. OR RKMoVAI. I DATK «>: IHkiai. or RKMOVAI, 
INDHRTAKKR J •KI.-ML^ ii.'Vw«>Uk>0 p 

q SI vVVtui^v^r^ dt 



(Address 



N. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The ' Special Information for per- 
sons dyinft away from home should be ftlven in every instance. 



.1 






1 
I'jj 

^^1 



h 



y£ 



> 'W'^ 1 



nosinl of Hiiiltli-KNo i^ 



t 




[ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered JSTo, ^^^ 



lUt I' Co 




Dale Filed, iX^A^v^^ VI l''^0\ 

X^vvw) luL^-u Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( tl. 5. StanOarD ) ^ ^_ 

PLACE OF DEATH:-County of^-a^ 1 XO/^vC^tO City of '"J^ >v J/vCtA veui^co 



vvi^^.) ^vu^rvwww.^w St.; Dist.;bct. and 

V< I WV\; V !^ ,_^„ , ,«.... p-siDENCE GIVE FACTS CALLED roR UNDER "SPtCIAL INFORMATION- A 



) 



FULL NAME 



O-'YVO-l. 



L<rA 




PERSONAL AND STATISTICAL PARTICULARS 
s,X /> . I COI.OR 



^a.lL 



k-kdi 



I>\TK ol- I'.IKTII 



a«;k 



(Month) 



(Day) 



(Year) 



O ^ y,ais 



Moulks 



Pa Ys 



^IN<.I,K. MARKIlvI* 
WIIHiWKI) OK IHVnKl KI> 
(Writi-in Mnial fU*.ij^iiation) 



lURTMI'I.XOK 
• State- <jr Country^ 



WMF. OF 

F.\Tm;K 



HIRTIIPI.AOH 
«)1- I ATIIKR 
(St.itf or Country) 



M\II>FN NAMK 
nl MOTHl.K 



mklHIM.ACK 
«•!• M«»THKR 
'Stnt«- or Country 






C 



IIa vk \ 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DK 



'"" a 



cvqL 

(Montli* ri 



11. 

(Day) 



(Year) 



I HICRlUiY CI'IRTIFY, That I attended ilcccased from 

OLvvCu it) 190H to LLcmx U 190H 

that I last saw li <L''»a alive on LLla^CV lA^ I9OI 

atid that death ocoiirre<l, 011 the «late stated above, at i • v 
VL M. The CAlSfv Ol- DIvATII was as follows: 



}\^^^"r^;;7>^ 



Dl'RATION Years JlouthJ Paxs I /ours 

CONTRIIU TORY LA^^w^CXXOOWdL/ O^wCV 



-V.3 



or RAT ION )i'ars ^ ^fonths Pavs /fours 



(SIGNED) 



(A«ldress) 




M.D. 



.A.ku }b^4^:■i 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 



OCCri'ATlON ^^ I 

1 jLCV^v^vQAXMj 



R^yidfi! ill Situ I'lauii f'> 



)V,r; 



M^«ltlt< -^ /''M 



KWV MU)VF STATFD I'KRSONAI, FAR lUT I.AKS AR1-. TRFK TO TUF: 
HKST OF MY KN0\V1.F:DC.K AND HKMKF 



Ui 



f X'lilrcss . 






Former or /-/> q L « ^ ^ .^ P "^^ '""' ** ^kx\ ^ 

Isual Residence 5 ^H L^VWYVUVtC^O^L pjare of Death? At iv\^. 



Days 



Wiien was disease contracted, 
If not at place of deatli ? 



V\ \CK OF HFRIAU OR RF:MoVAI, I DATK of IltRiAi. or RKMOVAI, 

■(nU iDLvv^t I Cl.ca .1 

rNDKRTAKKR IXtuXLcL VVWfL 



(Ad<lt<- 




N. B.— Every item of inWma.lon .hould be carefully supplied. AGE ahoulcl be atated EXACTLY PHYSICIANS ahouid 
state CAUSE OF DEATH in plain terms, that it mny be properly classified. The Special Information for per- 
sons dyinft away from home should be fciven in every Instance. 



! i 



1 9 


i 


\ t 


\ 


1 

i 


1 
t 

r , 

! 




1 



I 

n 



i\ 






f" \ 





U * } I 



> I 



t ', 




"AT 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



|;.,.,,.l ..r llialUl I- So, n t™_7Rlfe. ll&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lUO'i 



Registered JVo. 



Dale Filed. LL<-vCt»^'^ '^ 

"Ic^cco tt^K. Deputy Health Officer 

DEPARTMENT of PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of ^catb 

( "a. S. StanDarD ) 



PLACE OF DEATH:-County of ia^V 1 Va>Vtv4oGty of ^'CU>V vJ^a >VCC4 CC 



^ 







Q 



^A 



Mo r^S Ll wtxat UA^ 5t.; S Dist.;bct. ACU; and 

INO, I ^^' >^'- TVV VVVV V ,,_,,-, oreinFNCE Givr FACTS CALLED FOR UN|A:R "SPCCIAL INFORMATION- \ 

( " .v;rAT:"o^c"u%reV;N"rHo'.^VTit o%'?:?t'.?Jv^o^n v.v7^;i Sia^me .n.teac;^! f .trcet and number. ; 

FULL NAME C^ a\.OLk cl-(M.uj<^vLKa 



PERSONAL AND STATISTICAL PARTICULARS 
s.-x ^ r\ I COLOR \ A 

DATK nl- 1.1 KTH 




\<. 



h. 






Ar.K. 



bH .v»,» '^' 



a5 

(Day) 



y/.oif/n 



(Year) 



L Ait> 



SINr.l.K MAKKIKI) 
\VII)o\V):i) OK I>!V»»KrKI> 
i\Vrit< ill sinial <lt<ivMiati<Mi) 




HIK lHI'f.AJ'K 
Stat- <>i Ocmntryi 



1 ATMl-.K 



lUKTUri.AOK 

<>l 1 XIHHK 

t Stale or CoJintrv'* 



ol Moll I IK 



I'.IK lliri.Ml'. 
(•I MuTIIK.K 
(Statt or Countr> 



(KCII'ATION 



?l 







CLVuco 



(?rl 



<x>v 



dl 






AV>/.//-f/ ;■;> .S",7»/ /'i iltri i-ri 



'3.,'? 



3V,M 



.1/.'//'//* 



/>, 



Tin- \H()VK ST\Tl-J» PKK-;o\Al, PA KTUT I, \KS ARK TK IK T< » TMK 
MKST t>I" MV KNOW 1.i;I)(;K AND HHM!:i" 



flnformant ] j\x\Aj>J 



rx.Mr.vs 



mn 



QOVa-vkd ^ 



^t 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 1 



Ltwa 

(Month) r 



ICi 

(Day) 



(Ytar) 



I HKRHBY CKRTIFY, That I attended ikccasod from 

^L ^ c .'. . 190 i to iXcvcr 1 190 H 

that I last saw h ^' alive on LL\.VCy ^ ^' iqO \ 

and that tleath occurred, on the ilate stated ahove, at O ^^V . 



1? 



M. The CArSr-: OF l)i:.\TM was as follows: 



0<xtlu ^.^cy^r^viLVo.CA.rvv 



.u, 



t 



A.<X\. 



1 



DT RAT ION )'t'ijrs S .Vonths Days Hours 

CONTRIIUTORY 



nr RATION 



(Signed) 



Viars 



\\^(l 



Months 



ars 



Days 



Hours 



M.D. 



JLu.c\U TooH ( A<Mress) 5 u a w mUi^ lb.' 



% 



SPECfAL Information onl> for Hospitals, institution^. Transients, 
or Recent Residents, and persons dyiny anay from home. 



Former or 
Isual Residence 

When was disease contraeted, 
If not at plare of death ? 



How lonq at 
Plare ot Death? 



Days 






i'LACJ*: OF HlKIAl. OK KI.MoVAI, I I)Ari-:ot liiKiAi. 01 KKMoVAl, 

^<xU/»v I ^<^-^^ '^ 190H 

r.VDKKTAKKK ^ ^\XXSj "S^ \A) ^AA^ 



'A«l«lnss 



N. B.- 



-F.very Item of inJormation shouhi be carefully nupplJed. AGE should be stated BXAGTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ''Special Information" for psr- 
sons dyinft away from home should be ftiven in every instance. 



^^^ 



t 



♦ 



II 



\\ 



■ ■]! 







I ' 

I 

) 









It.- '■'■^■i 



k ti . ..; 



I 



It 



k 



1 I 






II 



n 

'I 





ll 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

..,..M,.„..,-...V.,.^-!^-H<^.'C. B.reR TO BACK OP CERTT.CATe TOR .NSTRUCT.ONa 

j>a/rFin./, iLvc^^^ IX 1^0\ EegMered A'-o. 945 

X^vcA.o 1xaK4 Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of Bcatb 

( "a. S. Stan^arD ) 
PLACE OF DEATH: — County of OO/w OA^X/w^^>«A:«Gty of d-CX/wJ "UX^A/ti^ co 

?io^vQt^i St4 ^ Dist.:bet. dUy^^' andl-tA^Wiu 



lib 



. 1^)/v^_nV^X St^ " Dist.;bet. iXA-yonrv ana>.-v^»v 

J , W^».^l^ . '^'- ,,«„.. RCSIOENCE GIVE r«CTS C«LLCO FOR llNOtB "SPtCl»U I N FOR M»T10" " \ 

( " ,Vrr".,»"oi"RRcV/R"°" «."*t 0%"«T,?u" N 0„C ,T. N.ME .-..T^.D OF .TR»T.«0 NU-.ER. J 



v<) 



FULL NAME 




V- 



s^ 



dj d 



A^fla^!tk• 



'H 



(?!i^ 



A) ^ VJvh^<X^X 



i<nl 



Dl.C^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



DATK or lURTII 



a<;k 




loivvu 



10 

( Day) 



(Year) 



t^uU(B. 



JV.ji 






Par 



sIN<.l,K. MAKKIKU 
\VIl»o\Vl-.!> <»K DIVtiRiKn 
•Wiittin ».K-J:«1 <li>t»i' nation) 



HIKTHri.ACK 
'State or Coutitry' 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH ^ 

a 



it 



(Day) (Year) 



(Month) y 
I HKRHBY CKRTIFY, That I attendetl deceased from 



•^ * 190' to -..• ^ - 190 

that I last saw h ••' ahve on ^ ^- T90 

and that tlcath occurre«l, on the dato stated almve, at ' 

M. The CAISI-: OIVniCATII was as follows: 



NAMH nl" 
FATHKR 



>^U(X/w 



niRTHPI.ACK 
OF FATHFR 

' Strttf or r<>uiitrv* 



MAIDF'V NAM! 
OF M'tlllFR 



mRTinM.ACK 
01 MoTHKR 







r n 

'Slatf or Country! i |^ U 1 Vl 

11 iX^lvcAvCvtov -L 




(Kcri'A rioN 






)V.7» >-♦ 



M ■nUi^ 



/>(/' 



IMF xnoVK STXTFIM'FKSONAI. r\RTH'ri,AR< AKi: TRVK To THH 
IIKST OF \1Y KNOWl.KIX'.K AND UKUF:F 

(informant %JL-^V\^ K.^ jb avt AjTI "^ 



'A<lilre«!«< 



or RATION )Vrtr? 

CONTRird'ToRY 



Mouths 



/)a]'S 



//ours 



[)r RAT ION .)\ijrs 
(SIGNED) nDi. VV\u 

ID iQoH (Addrtss) II?) 





gpg^Qf^^ INFORMATION only ^oi* Hospitals, Institutions, Iransients, 
or Recent Residents, and persons dying away froni home. 



Former or 
L'sual Residence 

When was disease contracted. 
If not at place of deatti ? 



How lonq at 
Place of Death? 



Days 



I'l.ACF. Ol KIKIAI. «)K KHMoVAI, 



DA r !;;<)♦" Hi KIAL or RFCMoVAI. 

.At tXtv^ CL^ \A T90H 

rNDFRTAKKR %\i JxtxVA.C'^ ^ ^. 



N. B.— Every item of information should be carefully nuppHed. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for per- 
sons dyinft away from home Hhould be given in every instance. 






,1 

■'i 



T ; 



I 



^1 



r^ 



fw- ^\ ^~''.'' ' 



r 




» I 



i 



'!»l 



It 1 





f: 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE TOR INSTRUCTIONS 









t i:x 



rJO\ 



Be^Lsterod J\^o^ 



Deputy Health Of^cer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "U. 5. StanDarD ) 



4 ^ 



PLACE OF DEATH:-County ofic^^^ J/va V.CU ^(Gty of 'CL^V vl\.a.YVCUl.C,c, 



FULL NAME 




^ ''^.Tv<S.<lQA-'t N KcL-Lcn^^, 



ft 



PERSONAL AND STATISTICAL PARTICULARS 



^'•■■^ ^V\ 



v1j^'>^XCV^ 



u 



COl.OR 



KaX^ 



DA IK <)!• IlIRril 



AO.K 




iM>'"th» 



sivr.i.K. MAKkii'.n 
\Vri«)\VKI) OK l)lVnRi*i:i> 
iWiitiin HtK-ial «l«siKtiati'«n) 



(Day) 



M.'nlh' 



flV:^ 

(Year) 



n.t 



Lv^^cL 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII ~i 



It 

( Day) 



(Year) 



(Month) \ 

I HIUillHV Cl-kTlFV, Tliat I attcMukMl ileccascd from 
.QjUW/ri 1 iQoM to CLa^n^CL IL 



'^ 



'1- 



lyoH 

tliat I last saw h -*•■■ alive on LLva^<^ '^ '9° H 

aiul that (loath «TCCurre«l, on the date statt^l above, at 
' ^ M The CAl'SIit)!' I)I:ATH was as follows: 



\jij\jLXy^' 



^w 



HIk l!nM.Ai.'K 
(State ur Coimtryt 



NX Ml" o! 
I ATllIlR 



^ 





HIKTIUM.ACK 
Ol- J ATllKR 
iSt:it< .IT i*ountrv> 



MAII»KN NAME 
OF MOTIIKK 



HIRTIMM.A*. K 
(II MOTIIl^K 
' >t;tt<' ir (.'oiiiiti y 



occrrATioN 



1 Vtr^^^/cui OC u aa vrc^ 



AJL 



CJU'^'vck 






DC RAT ION Yt'ius 

CONTRir.rTORY 



Months 



Days 



Hours 



Dl'RATION 

(Signed) 



C ¥ ^J; 



Months 



Pavs 



Hours 



2l 



H)0 



.VwV K ^- >^- M.D. 

A r j; 



( A.l.lress) '^ 



X\ 



SPECIAL INFORMATION o"') '"^ HosplUls, Institutions, Iransifnts, 
or Recent Residents, and persons dying awd) from home. 



M.'nth 



Da 



Tin- AHOVK STXIKI) PKK^oNAI. 1' \ K TIiC l.AKS ARI- TRIH To IIIK 
HHST Ol- MY KNOWI.I-.DCK AND llin.lhf- 



(liif.iMn:int 






( \(Mrc«i« 



l\lb 



CXA.«rA 



,<rX.v.<:C r%. ^ * 



Former or 
Usudl Residence 

When was disease contracted. 
If not at place of death ? 



Hew lonq at 
Place of Death? 



Days 



ri^CK Ol HIKIAU OR RKMo\ W. 
rNDKRTAKi:R 



D\ll >: in uiAl. or RlvMoVAI, 

CLva-Ol <*^ T90H 



(Athll'ess 



It 



- 0> 



V V- iL^'ii^Vft 



•^ 



^ 



N B _P,very Item of informntlon .houUI b. carefully supplied. AGB nhould b««t«ted EXACTLY ^"YSICIANS «ho«ld 
.fate CAUSE OF DEATH in plain term., that It may be properly classified. The Special Information for pT- 
«on« dyinft away from home nhould be i'ven in every instance. 



I '^ 



i 



I. 



till 



( 



' |! 



i 



% 



*i 



i 









iX- 



^-^- 






■y, 






vgr.'i*- . 



^ 



! ! 

i 
j 

♦ 



r 



I , 







f 



H 




II 



■I ' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,;,n1 of !U-Mltli »■■ N«. '^ ^•^'??^_'^^^_[^ 



1^0\ 

■\lth O^r-r 



Bci^istcred J\^o. 



947 



Dale I'ih'd , VvVN^vv^Tt '5. 

"Wvco Ixv^ Dep-J'-; • ' r • 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^ 



Certificate of ©eatb 

( Ta. 5. StanDarO ) 

^^ ^ 

PLACE OF DEATH : — County ofOa^A 

n Q '-^ \ , St . ^ Dist 'bet. ^ ^ \)^\) and ^ \ AXj 

No. '^ ^ '-V^V^^w-'-S.^ ^.... oremrMCEdlVt r*CTS*c*LLEO rOR UNDE9 -SPtCIAL INrORM*TION- \ 



ofia^ JaC5l'%\ t C4 -- ' City of Cla>v Ivcx-rxeUi tt 



) 



FULL NAME 




AaxL oaI' M I V CxtLivc' 



^ 



PERSONAL AND STATISTICAL PARTICULARS 






A<.K 







(Day) 



M „i;ii 



f* '^ 



(Ytart 



n.l^ 



SINT.I.K. MVKHIKI» 
WIlMiWKH «»K I>iy«»KtM) 

\Viit« iti -<Hial •U^-iirtialion) 



IURTIiri,\«"K 
'stiitror C'MUitryi 



NAM!-: «»! 
I- A Till-. R 



Ql\o 






MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



(M(»nth> ' 



igo [ 

(Year) 



(M(.nth> A (I>'»y^ 

1 IIi:Ri;nV CI:RTIFV, That I attemlol <leccasea from 
^D. >v 190 H to 5;Xvv<Ol U igoH 

that 1 last saw li alive on LVVv.<V - ^¥^ ^ 

ami that «Uath occurreil, on the ilato statecl alnn-c, at . A- IG • 
M. The CAISI': Ol' 1»1:aTI1 wa^; as follows: 



^ 




(A) 



^'O^'yyO^ 



V 



\\JJ\) 



RiRTnn.ArK 

0|- » AllIKR 
(State or Country 



ma!i»i:n namk 
<»k motiikr 



lUKrmM.AtH 
«»» MdTHKK 

(Stutt or Country) 



OCClTATloN ^i 






(>.\JlLol • vr^- 



DlRATION 



Vj^if's 



W 



3fouths 



nrvs 



Hour$ 



' ex <.is*-^ , . 

Years • C* Mont ha 



lilRvTIoN 



Pays 



(Signed) 



/(X\. "VA.*-^ 



/louts 
M.D. 



Vc^ 



:CfAL IN 



(A,l.lrr.<) SOS iy,O^V>6>tl ^- fe. Cd ->, 



SPECIAL Information only '«f Hospitals, institutions, TriRsicnts, 
or Recent Residents, and persons dying av»dv Irom home. 



Kfidfd ill Siif I ■ 



♦ - N 



) .,;/ 



1 ',.»/:'//. 



/),/) 



THK xn(.VHST\Tl-I.fKR-..NVl.PXKIirri.\KSAKi: TKrH TO THK 

liHsTtii- Mv KN<»\\ i.ri»'.»-. A^" m.i.n.i- 

1 



\.M!.-«^ 



R^l JjL^WAXJi^'A_i-^ 



Former or 
Usual Residence 

When Has disease contracted. 
If not at plareof death? 



How len^ at 
Place of Death ? 



Days 



I'JL^KCK 01 m RIAL ok Kl.MoVAl. 



I>\i;i:<'* in HiAl. or KKM<>\'A1, 

LLs-^v^ \H T90H 



!S. B. 



, rm W%^ ...ooli^d AGE should be stated EXACTLY. PHYSICIANS should 

— F.very item oV' information should be c«re?ully suppi.ed J^^'^ "^""^ ^,,5.^^. ^he -Special information" for per- 
stote CAUSE OF DEATH in plain terms, that it may be properly dassitiea. me v 
sons dyinft away from home should be fciven in every instance. 



.1 



I 

: 



m 



% 




\ 



?r 



I' 



4 



I1 








y r-s- 








fi 



I 



% 




S| I 




mammHitiff 




lif 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

HEFER TO BACK OF CERTIFICATE FOR IWSTRUCTIONa 

948 



Bird of Hw.llll- I- N-o K »gi^CH&l'Co 



Ik,/,' Fi /('>/. {Ju^a^xA^ »^ -^^^'* 



Be wintered JVo. 



"Wwo"i-^v^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( tl. S. StanOarD ) 
PLACE OF DEATH: -County of Y^^^^^^ City of V^ 



c/k^o-^^vvn^ULc w/u 



No. 



-St.; 



Dist.:bct. 



and 



..«..iil RESIDENCE GIVE FACTS 'called FOR UNDER •SPECIAL I N FOR M ATION" ^ 

( " rF^*0rATrO^c"uVRr;.;"rHo".^yTlL 0%'?:?t^?U^4^ O-E .TS name instead of STREET AND NUMBER. ) 



FULL NAME 



ax.^<r • 



SKX 



UATi: ol 111 Kin 



PERSONAL AND STATISTICAL PARTICULARS 

COI.<»R > 




clLv 



lUu-.r.. 



« 



Month) 



(Day) 



/ u '. ■... 
(Year) 



AC.K 



\ \ JV.r» 



M.'ntfis 



Pa v. 



SIN«;i.K MARUrKI> 
\Vll)<>\Vi:i» OK IUVnKtKO 

(Wiitr in "•otiiil <U«.ii'ti;iti«>n) 



niKTHPi.AOK 

(Stat< "T <'<»untry) 



NAMK 0|- 
I ATin.K 



HIKTIIl'l.Al'H 
(>|- l-ATHKK 

iStiitt or Country) 



MAIUHN NAMK 
OF MOTHKK 



lUKTHIM.ArK 
OF MOTIIKR 
(State or Country^ 






MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH 

.\.0, ii I.M.I /90 



iL 



(Month) 



(Day) 



(Year) 



FilHRliHY CI':RTIFY, That I atteinleil deceased from 

190 to 190-^-^ 

that I last saw h rtrrrTTTT. alive on -^..^-^-r^— — -^- ,,,,,^1^0—— 



and that death occurred, on the date stated above, at 
"" — M. The CAl'SR OF DliATlI was as follows 



■7 




ti 



«« 



w^o vs.*:*- 



DrRATION Years 

CONTRIIU'TORV 



Months 



Days 



Hours 



DURATION Years ^ Mouths Days 



flours 



(SIGNED) V ^^- ■'^-^^^r^"^^^^-'*-*^^ . '^.;^- 

lU ^ ,Q it> TOO '\ f A .i drcss) HlxU^<nv\n.lu....U;.. 
;iAl in 



OCCn'ATlON 



O^Vi.-vJ - < 



RriiirJ tn S,nt I't ,i>\i i-i-,> 



) 111 I 



Month; 



PilY 



Tin- AnovK sTvn:i) phrsonai. i'aktkti.aks aki: tkik to thh 

KKST Ol- MY KNO\VI.i:U«".K AND BKI.II-.H 



(Informant 



r\.!.hi"*s 






VXl,t."\. 



^ .VAw/C^iv<X \vO^-vv 



^ 



SPECIAL INFORMATION only for Hospitals, Institutions, Transieiits, 
or Recent Residents, and persons dying anay from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



Hew lonq at 
Place of Death? 



Days 



I'l.ACK OF urKIAI, OK KKMOVAI. 
V 



iba-A-L- V X _ 



INDHRTAKKR 'i V vj . ' .3 AA^ r 



(Address 



DATljLof HrRiAi. or RFIMOVAI, 

LvvA^q .1.1 . . 190'i 



„ ,. ,, , App ahnultl he stated F.XACTLY. PHYSICIANS should 

N. B.— Every Item of information should be carefully supplied ^^^^J;;,^^;^^^^^"^^' ^he "Special Information" fer psr- 
state CAUSE OF DEATH in plain terms, that it may be properly classitiea. nc op 
sons dylnft away from home should be ftiven in every instance. 



J' 



r 



t ■ 






r*»*A 





m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\^o, "4 J 






„lr l-'ilf<l, (Xwauvftl \X ^'fO\ 

■Wvcv^"W.-M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cettificate of Bcatb 

( Xl. S. StanDarD ) 



(^ 



PLACE OF DEATH:-County of "V^^ l^VC^^Ul^cCity of'"'0^>^ 1 ^O^^^^*-^* 



INO. IV J V L ^V ^^. V - „„,,_„-. BtSIDENCEOlVt r.CTS C»LLID FOR UNOIK •SHCIJI. INrOXMATlON- ^ 



FULL NAME 




^\ 



v>\' M I tvA.^\.^v^. 



d. 



PERSONAL AND STATISTICAL PARTICULARS 

-" (^icd. '' let. I. 



DATl-. <»l niK IH 



Af.K 






1 

( I>tty) 



Months O 



, 1 5 H ., 

'Vf.-lTl 



/)« 



1.\ 



SINT.I.K. MAKKIKH. 
\Vin<»\\i:i> OR I>IVnRlKI> 

iWiittiii ^iK-ial ilr^it^natinn) 



lUKTinM.xri-: 

' St:it( <ir t ■•Hint t \ 







NX Ml-: ni- 

I- A r J 1 1 . R 




nTRTIin.ACK 

<)»• lAIMKR 

I Slat«- <ir I'oiMitrv) 



MAinKN NAMI- 
<H- MOTHKR 






LL Vy^V^-VW^-ViJ^W 




MIRlHIM.AfK 

nl MoTlIKR 

• State or CovMitrv) 






J\>si(fn! in Siitf I'mn.ix'n ^ 



\ y,„: - • .\r.nf'h< * !h!\ 



VnV MUAKSTMl I.I'KRSriNAl. I'ARTUri.ARSAKi: TRIK To THH 
HKST OF MV KNoWMJX.K AND JlKMII- 



MEDICAL CERTIFICATE OF DEATH 
DATK «>|- DKATH ,^ 

Ll^q I ft 

(Mc.nth) J (I>ay) 

I HHRIUtY CIIRTIFY, Tli.it J atttiidcMl deceased from 

.0 



I go 

(Year) 



T90H 



that I last saw h - ^ alive on LVSA^t^ K, 190 v 

and that cUath wcurred, on the date stated al)ove, at 1^)0 
lI M. The CArSi: OF DIvXTII was as follows: 



.v,'i 



nr RAT ION 



Yea 



^ 



Mouths 
(^NTRIIUTORY V^V^./^-^rv^^'^ 




Hays /fours 

X Z,\aX..1X\'..... 



Dl'RATION -^ Viars 



(Signed) 

a.. 



Months Pavs 



/fours 



^ 



Tt)0 



(. 



Address) Osl^^ 



,5x- 



W^vrw. 



M.D. 



Special information nnU for Hospitals, Institutions, Transients, 
or RfCfnl Residents, and persons dying a»»«> from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



Now lonq at 
Place of Death? 



Days 



PI ACK 01 m RIAU OR RKMoVAI. I DAIi; of Hi KlAI. or RHMOVAI, 



(li 



mVWvA.^ 



/Ox. 



f \'1.hr«»^ 



Hfi ' 




\ 



I j 



cM-v-cw^cC n:i 




,^^^ 



rMn:i 



V^'VV^ 



WL^V^ 



Vh 



ygoH 



!N. B." 



oi information .hould be cnrcfully -uppUci. AGE should be stated EXACTLY PHYSICIANS .hould 
E OF DEATH In pinin term., that it may be properly clarified. The "Special Infformat.on- for pT- 



-Every item 
state CAUSE 
«on« dylnft away ?rom home nhould he ftiven In every Instance. 



I 



I 



•■> 



« »l 



1 \ 




A 



\ 






f I 



jir» 



~ ' ^ 



:l'»«? 



t^;.*^ 











WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOB INSTRUCTIONS 

Be wintered •N'o. y4 J 



ii,„i.i,,fiui.iiii-i-No i''>Tr?sgfc"'^'''^" 



Ddli- Filvii, CUvauv^l i X I'-^O H 

^^ccw "L • ., Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Ta. S. StanDarD ) 



PLACE OF DEATH: -County of ''^ 0.^ O.rvC^^XCUL^ity of ^'O/^^ .1 .'VO^^A/C^VC^ 

St.! H DiLbet. ^"^ tk. and b-Uv ) 



'No. \ >0 O 'V ^M^rCU^O ..-,,., BretfoENCEGIVC TicTs'cALLEO rOR UNDER 'SPECIAL INFORMATION" \ 



FULL NAME 




1^)1 



V"yA.' \l I lu^\A.^^ 



J. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COL 




I 



0.U 



|)ATK «'l IIIKTM 



v»l 



""k.«vi- 



Ct^.' 



I Month I 



(I)ay> 



(Year) 



Ar.R 



O )Vij»> Mntilhs \J 



Pa v.« 



"^IN'r.i.K MAKKIKI). 



\vii)o\vV:i» OR DivuKiKn A 

'Write in Mxial iU«.i»^iiati«)ii) \ Y\«\ I 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DEATH ^ 



(Month) Q 



(Day) 



(Year) 



I HEREBY CERTIFY, That I attemkMl deceased from 

Q['\\<Xv^3> 1901 to CLcv-a...LO 190 H 

that I last saw h *- » - ahve on LVVVt^ ID - 190 • 

aiitl that (Uath occurred, on the «hite stated aI)ove, at ^ o 



KIKTinM.ACK 

iStati 'ir «oiuilry 



NAM1-: <>J" 
» ATM IK 



niRTMPI.ACK 
Ol- lATMKK 
(State or Country 





w\,\xxu 



MAIPKN NAM I". 
Ol- MOTHHR 



HIRTHPUACK 
Ol MOTHKR 
(State or Country) 



VyS 










/),/i 



THI- AHOVKSTXTin PKRSONAI. PAKTIcn. \ K^ A K K TR T K TO THK 
HKST Ol- MY KNoWI,i:p«".K AND HHI.IKH 



(I 



'\fMr<- 



Sb^ 




L'. M. The CAl'SE Ol' l/KATII was as follows: 



I)rRATI(3N 



i/*;^ 

tW 



Months 



CnNTR IliUTORY CVv^-trWV^ 




Hays Hours 

\. CrV<viC.'ja..\'..... 



lU 



t 



Vtv^Vyx/Ov. Lv<L^'\'w. 



in' RAT ION )V</r5 

(SIGNED) O.Vcd. ^*^ "^ 



cu 



V15 ,' 190' 



Mouths Pays Hours 



(Address) 'X \ ^ ^ M M. V^>^^(rrv. 



SPECIAL Information on'y '»•■ Hospitals, iRstitutlons, Transkiits, 
or RfCfnt Residents, and persons dying anay from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



Now lonq at 

Place of Death? Days 



PI^ACK OF BIRIAI. OR RHMoVAI. 

k^v^^^v^ ^ 




DA 11; of IJi RIAL or RKMOYAI, 

J3> 190 H 




INDKRTAKKR 

(Ad<lre<i's 






^ B —Every item o? Information .houid be carefully supplied. AGE should be stated EXACTLY PHYSICIANS .Would 
.tate CAUSE OF DEATH in plain term., that it may be properly cla..lfled. The "Special Information- for per- 
.on. dyinft away from home .hould be feiven in 9\^vy in.tance. 



\ 



■'■V 

\ 



II 



« 



' 



if 



\\ 



r 






% 





i^'fF'l' ~~ 



I 

I! 

il 



li 






l< 



• II * 

( 



4 






\ll 



a 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

950 



}U.anl of He:iUh-F No. i-s ^ClSa^ hSiVC 



190\ 



"iv^L^ iuxK. '^^P^^^ Health Officer 



Registered J^o, 



DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco 



Certificate of ©eatb 

{ H. S. StanDarD ) 



% 



PLACE OF DEATH:— County of JCV^v 



,->^.Xc\/>v«i<!.ccCity ofv '/a/>"u v' 



/v<vvvc.cO-Ci> 






) 



I 1N»' 



FULL NAME 



.{T'W^VXXA' 




.1 



' ll\cL^ 




PERSONAL AND STATISTICAL PARTICULARS 



si.\ 

M I tec 

I>ATK «>l- UIKTH 




U 



COl.OR 



llJxcL 



ilIotith> 



a«;k 



H5 



Yeats 



^1N«.I.K MARKIKH 
WinnUKI) 1)K DIVoRtKI* 
• Write ill >i<»cial ek-*i}?iiation) 



i 



WV 



( Day) 



MiiU/^i 



1, 

qdjL 



(Year> 



IH 



Pa vi 



lUKTHPI.ACK 

iSt.'itf or Oouutry^ 



lATIlKK 



AclU. 



vm>v^x 




UIKTMIM.ACK 
or I ATI IKK 
(J^tale or Country) 



MAIIlKN NAMK 
Ml MOTIIKR 




axcL 



C 



Ct>v^v(X 



niKTinM.ACK 

Ml MmTIIKK 
"^t.iti Ml «.",Mititry* 



< nil TAT ION i^ 






L i~ 






yf.'iiih' 



Ih! 



THl- \noVKST\Tl-I) l'KR«^o\Al. IV\ KTUT I.AKS A K l-. IKIH To TMH 
IJKST Ol- MY KN«)\Vl,i:i)«".K AM> lUCI.IKl- 

(lufonnant UOa^X./^nl \o.\XHUx^ 



(\.Micv>; 



'utt^V 






Lo Ko-^K^t 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 

XOL ^"v ^9o\ 




(Monlhn^ 



(Day) 



(Year) 



1 I IIV K 1 



I in':RKBY CKRTIFV, That I attcndtMl (Uccasctl from 

190H to ll.t.i.€U 3 190 H 

that I last saw h l^.'Vv^ alive on LLcvtX^ ^4 I90 \ 

ami that «U-ath <»roiirre«l, on the «late stated above, at t. I ^ 
AX M. The C.AJ SI':C)F DI^ATIl wa«« as follows: 



Dr RATION Years 

CONTRIHUTORV 



Months 



Pays 



Hours 



Dl'RATION 
(SIGNED) 



) 'cars 



^fotlths 



Pays 



Uw^ 



Hours 
M.D. 



ll 



U^a 10t()oH (A (hire 



lAL IN 



k,aLLKr\jr\) M.D. 

N only for HtspiUJs, Institutions, Iransifnts, 



SPECIAL INFORMATIO 

or Recent Residents, and persons dying away Iron liome 



Usual Residence 

When was disease contracted. 
If not at place of deatli ? 



now lonq ai r^. 

,>Q^Tr^>\ jMace of Death? O 



Days 



ri.^CK Ol- IHRFAI. OR RKMO\AI. 




c^l ^^ 



I)ATi:f)f llrKiAL or RKMoVAI, 

v^VviX .\.n5- igo t 



rNDKKTAKKR vl>VAwti<X lLA\X:ijL'vt^X.i'^ 



(AiMr.-ss 



Ibb 0^\V41.i 



tv■^ V 



^4 



N. B.— Bvcry Item of Information •hould be cnrefully Hupplied. AGE .hould bo stated EXACTLY PHY8IC1AN8 .hould 
•tate CAUSE OF DEATH in plain term., that it may be properly cia.«i1.ied. The 'Specal Inlormat.on for pr- 
nnn% dying away from home should be given in ovory inHtance. 



» 



I 



1 



1 



\ 



1 



t 



' 



I 



i 



S I 



U 



I 



%i\ 



■■ 0^^^ffW 



\ 



I I 




\ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, , „, „„„!,- ■■ NO ,. <SS«»I&''^-" WEFER TO BACK Or CeRTIFICAT t FOR INSTRUCXrONS 

Registered J^o. 



Dale Filed, LLwavvAtr \X 



100^ 



"Lruv^, iLto^ Deputy I • ■ - !th Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of H)eatb 

( "a. S. StanC»arD ) 



PLACE OF DEATH: — County 



o, %. 



4 ^ 



Ow^VA^ City of ■ CLTO vAAX>Uwi >">rxo. vai 



No. 



St.; 



-Dist.;bct. 



and 



/ ir or.TM OCCURS »w«v rwoM USUAL RESI DENCE Give rACTS c*llcd roR under "specul information- \ 

( Tr DEATH OCcJrrTd.N * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. J 



FULL NAME 




L^LoJva' \Xa^vct*^€L.^ll(^-^^-4.. 



\^ 



SHN .7O1 



iQ<it 



a 



PERSONAL AND STATISTICAL PARTICULARS 

^V ^ ^ V CV ' 

DATl. <H- HIRTH 

(Day> 

.\<.K 



Mtitilhi 



Year I 



61 )>.f» 



it 



M.mt/t<^ 



Pa vi 



WIDnWI-.n OK I>iVoRl"Kn 

Wiitt in «KiaI 'lfii^n;«ti<»n' 



HIK I IHM.Ai'K 
I st;it«- or C'lUiitry^ 



NAMI-. OF 
l-ATIll.K 



:Ll^' 









'^v \^>"v^wLq/w\A 



RTRTlin.ACK 

of I ATIIKR 

• st.'iu- or Country) 



>fAII>KN NAMK 
ol- MoTHKR 



niR TUPLACK 
o|- MOTHKR 
'StMtf of (.'ouiitryt 



OCCl TATION '\, 






V 



t 



^v^a^atvu 



I!:' VLO 



-\ V 



Kfsidfd in Siiv /'iiiii.ii 



) •,! 



yr.>,tfh' 



/)<n 



THl- \H0VK ST\ ri:n I'KK^oNXI, r\K lUMI.VK- AKl 1 K( K T' > IHH 
lil>T Ol- MY KNO\VJ,i:iM-.K AND lU-lMl-K 






(lnf..;ii»:int O.^Ct-«/V>JL 



MEDICAL CERTIFICATE OF DEATH 



DATK OF I)F:aTII 1 



(Month) i 



(Day) 



(Year) 



I HI':KI:HY CI':RTIFY, That I attcn(le<l deceased from 

— to 



-190 



that I last sjiw h ~- aUve on — ~ 

and that death occurred, on the date stated al)Ove, at " 
" M. The CATSP: ()I;1)I<:ATH was as follows: 



-T90 
190 



Dr RAT ION }'eaf 

CONTRIIU'TORV 



Months 



Pays 



Hours 



IH'RATION ^ yean 
(SIGNED) 



Months Days 

t 



1.. 



V.U...n 



H)0 (A ddrcss) 



Hours 
M.D. 



Special information wly t«r Hos^tals. institutions, Transifnts, 
•r RfCfit RfsMents, and pfrsons dylnq away Irom home. 



Formff or a »-» n ^ ] 

Usual RrsMence " ^ A .VC\ ^ -C \\± 

When *as disfasf contracted, 
II not at place ol death ? 



^ 



\ 



Hfw lon(| (5 1 
Place ol Death? 



Days 



I'l.ACK OF lUKIAl. oK KFMOVAI. 



^i'j^jlb^'^ ^ 



I)ATj:of Ht RIAL or RKMOVAI, 



^ 



rNinCRTAKFK 



(Address 3j S 1. O Js^v.tl.X^v .^„1 



N. B F.very item of information should be carefully .upplicd. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The * Special Information ' far per- 
sons dying away from home should be ftiven in every instance. 



1 




i\ 



' ii 



a' 



«n 












M & 



b 




II 



♦ t 



**: 



HI 

i 



''^- 



I 




ill 



f'-i^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Moan, .,f HcaUh-. No ,. ^Sh^^8.V Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed y 




^d. \x 10 o\ 

Deputy Health Officer 



Beiisteved J^o,. 



wt 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( U. S. StanDar^ ) 
PLACE OF DEATH: — County ofC'OL>v iva ^vcu- City of ' a'>V .1.1. a v. vt.. :o 






No. 



io... 



IIIH tcl'iu Su\ Dist.;bet li^VClaarVa and lamC'\v<:U) 

/ ir DEATH OcduHS *W*V rROM USUAL RESIDENCE GIVE FACTS CALLED rOR UNDER "SPECIAL INFORMATION • \ A 
( Tf DEATH 3cc!rRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) J 



FULL NAME 



-\ V-C 



■¥■ 



PERSONAL AND STATISTICAL PARTICULARS 



"" ^ ' 



COI.OR 



cuUl 



lllcU 



I>.\TBOI* HIKIll 



AGR 






L 



) Vi? I 



(Day) 



M,.t,!f, 



, V\ 1. 

(Year) 



Da\s 



SIN«.I,1- MAKKII-.n 

W innWKD OK DlVoKi I!!) 

Wtitiiti MHi:tI »Usivn:iti<»!i) 



lUKTMPI.AOK 
stittf or I'Miiiitry^ 







\ \MI* <H 

»■ A 1 1 1 1; K 



niKTiirM..\«.'K 

<>!• I-ATIIKK 
iSt:tt' or Country) 



MAIDKS NAMK 
OF MoTHKR 



HIKTIIPI.ArK 
oi MitTHKR 
'State nr Country) 



I' f 



njxovi 







a\a<vM 




.^vtvt^v 



NjlLcX^vc^^ 



Ml rti'A ri»)N 

h'f-i,fr<! Ill Snii luuui^f'i < 'O )/f/» 



\f..ntfi^ 



lia 



Tin-: AH()\ r si- xrin i'kksonai, par iuii.aks ari; tri k n> int- 

HKST Ol .MV KN<»\\ I.IUXVK AM) lti:iJJ> 





(Infotjuant 



l\<h\ 



rv^s 



llbM. *cd 



^" ■ .i. i I 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII | 



(Month) (T 



II 

(Day) 



(Year) 



^xi HEREBY CERTIFY, That I attemle«l deceased from 

d^r^lr 190. to XLvl-ol IL 190H 

that I last saw he alive on LvCCCV ^l i</3 H 

and that death occurred, on the date stated above, at i csC 
. J^ M. The CAl'SK l)l' I) I- ATI! was as follow.sj 



. v-vcL OL V cC . v^.A^<x -^x 



^|iL'^kaa. 



nr RAT ION )'('ars Mouths 

LL.^.c<<i-^. 



I^avs 



Hours 



CONTRIHUTORY 



dtration 
(Signed) 



Years 



^routhi 



VJ LV wLcAvLc \V 



Davs 



a 



'(..(y 



Hours 
M.D. 



u..:^ u TQoS (Address) W-A. H :i\::^Mvva\A 



Special information only for Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dying away from liome. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of deatti ? 



How long at 
Place of Death ? 



■■■ Days 




RIAI, OR RKMoVAI 





i 



.^,^^ \> 



ini)i:rtakkr 



DATHof III KiAi. 01 RKMOVAI. 

Uxvcx IH 190H 



N. B. Every item ot' information •houid b: carefully HuppiieU- AGB should be «tated KXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be f^iven in every instance. 



* 



'I 

(l| 



I. i 



I » l! 






■ I 



I 



I 









"^m 



;^.-.^. 



v^' 






-wrr" 



V 

1 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nnnnl of Il.-altb . No .. ^^^ H^l' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihffr Filed , \L\JUX\K. 



d: \X 100 "{ 

^^ Deputy Health Officer 



Registered JVo, 



953 



DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco 

Ccitificate of Death 

( "a. S. StanDarO ) 
PLACE OF DEATH : — County of^'^a^O ^a-nCUCO City of I/OavvI Axx >vci.a -t 
No. I^HT'^'H •■lrU^^^^' St.; H D;st.;bet. b llvi and 't tk 

FULL NAME Mllavaav^l iu.a 



fl 



PERSONAL AND STATISTICAL PARTICULARS 



sj;x 



v1X'»vOlUI 



'■ "liiLu 



DATK t)K lUKTIl 



\<.K 



Month) 



1 )>«»».' 



(l)av) 



Monthf 



/•bbH 

(Year) 



Davs 



siNi-.i.K. M.\RKIKI> 
WrOoWHn OK DIVORCKI) 
t\\rit«- in Mxial (l«-«.it^nj»lioii) 



HIKTHI'I.AOK 
(Statf or Country' 



^ 



w-t\ '■ d. 



D 



I 



cv 



NAMK «U" 
FATUHR 



HlKTHri.AfK 
oi I ATHKK 
'Stair .11 v'onntrv' 



MAIDKN' NAMK 
<H MuTMKK 



iJiRTnrLACi; 

n|- MOTHKK 
(State or Conntr\ 



Jl 



IcUv 







vcrwxtc^ 




av 



.\aJUo^>v 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(Month) r 



ID 

(Day) 



(Year) 



I HR;R1*:HV Ci:RTrFV, That r attended deceased from 

^vUl IH 190 'i to LL 



.-L.vrL 4.0. 190 4 

,. LAr<X ^. 190 

an<l that <Uath «>cciirred, 011 the <late stated a!)ove, at 



. V 



M. The CAlSr: OF DIvATH was as follows: 



■^ 



I)rR.\TI()N fears Mouifn 



CONTRIIHTOR 




Days 



Hours 



U^A^c 






• KCri'ATION 

Kf^itlnf III Sail /'ill III ' ''> t V ) '■<" 



M.uith^ 



Da 



rm: \B(ive statku pkrsonai. iwKTicn.AKs akh rKiH t<> thk 

HKST (H- MY KNOWI.HIXU-: \M> intl.lHK 
nformant v\vOU> M /l^^MXt rU<r>VVU 



II 



' \'1<lrf«i« 



I5b1 



Di; RATION 
(SIGNED) 

1 



)'t\ir5 



lo A. a 



Mouths 



a 



r 



\^\.\X.CS, 



X 



iqo I 



(Address) "ISH 



cy^ ^- VCLi-l a I i.^..k . 



Days Hours 

M.D. 




Special information only for Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death ? 



Days 



(Address 



DATK of HrKiAi. or KKM<)V.\1, 



I'LACK 01 HIKIAU <iK Kl.MoVU. 



,V.ii<!LL-^-v 



^ / 



N. B.- 



-Kvery item of ir,?ormaf.on •houlcl be carefully Bupplied. AGB should be stated EX4CTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home should be ftiven in every instance. 




i( 



y\\ 



N 



ii 




'k 



■rj 



%■ 










^fri 



• v^ 






'kiA, . -^^^' 






f ' 




i 



tmn^^^^^T 



*'* 






m 



H 

Mi 






IJ. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 

954 



H....!.l wf n.:.,lth I X<>. K -^-fjtt^i) US: I' Co 



Registered v\^r>. 



X^^vv^^Ijlxm^, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of Beatb 

( "U. S. StanDarD ) 

PLACE OF DEATH: — County of J/a-r. J/w<X>A.CA,<iCcCity of O Cu>v J A^Oa vai.^/fi^ 



No. ^'^'^ isJcv^^-vqtr^v ll\»C 



St 



Dist.; bet. 



isli,. 



u* ^.. and 

^ t, a I i^c. n V c v*i¥t rf«\,iS Cwi-ww .^.. — .._ — -■ — 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



% 



lC) .U . . 



/ .r nr.TM OCCoVs AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION • \ 

f IF DEATH OCCUfS AWAY '^ •* " "" "' " " 7 "_ .«- ,-.ur .xe NAME! INSTEAD OF STREET AND NUMBER. / 

V, IF DEATH OC<jURRCD IN A HOSPITAL 



) 



FULL NAME 




i- ^^f 



1 



A^Q/'kX^ 



PERSONAL AND STATISTICAL PARTICULARS 



KAIK »H- IMKTll 



'oi.lva. 



S)-.. -. 



Month) 



A<.K 



ix 



Yettif 



HINC.I.K MAKKIKI>. 
VVIlntWJ-Ii ok I»I\'nk*KI) 
WnU' in -<>< i.-d fl« -iviialioii) 



HiK riiri.AiM-: 

Matf or Country* 



wva 



an 

iliay) 



MnMtllS 



L 



(Vfjir) 



/).M 




NAM J, «)l 
I ATM IK 



' oTOv^w^^' 



A q . ' 



IMRTIffl.ACH 
(tl lAIIIKK 
stait i.r Cunntrj-) 



MAIJ)i:\ NAMH 
«»l .Mi»ini:K 



(k, 



QAX^LcX 



^^ 



dL 



D 






lUKIIIl'I.A* I". 

'»i M«»rm:K 

' Slat' III ( <nnitr> 



h'ri'iiil III Si!H I I ii II' 



t } ' -.' ; 



M, nth 



l),l\ 



THJ- \H«)VK SI\TI-.I) I'H-K^oNAl, r\UTIi ri.AKs XKI-TKn; in TMK 

iu:sr«»i MS* KNou i.i.fx .1'. \^i» \\\•^^\^• 



lull! inant 



^ — 



MEDICAL CERTIFICATE OF DEATH 

DATK or hi:atm "i 

(Month) ] (Day) 



TQO 

IVear) 



I HI'iKI'HV CliRTIFY, That I atten«U'«l «lccease(! from 
^CL/>?Vi...a.'v 190 H to lXvv.0. It 190 H 
that I last saw h •-' alive on LI.Va^C^ i D 190 
ami that »Kath occurred, on the ilatf stated abovf. at ii 
'sk. M. The CAl SI-: Ol- DIvATIf was as follows: 



mRATION 



Days 



Ytqrs Months 

CON T u 1 1 { r i" R \' wv wr>.\..viCr U {x^-t^-v^t, (wi > ^ \ ^ 



Hours 



Dl.'RATION X Vt-ars Mon//is /hiys 

(SIGNED) 0. X9-\ij<xJLUi 



a- 



/fours 
M.D. 



Special information only Inr Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dylnq away Iro.n tiome. 



former or 
Usual Residence 

Wtien was disease contracted, 
If not at place of death ? 



Hew lonq at 
Place of Death? 



Days 



I'l ACH nl lUKIAI. nu ki:M<)\AI. 




CkV^< vX^O^a 



DAIJvof lit Kl.\i. or KI;MoVA1. 

<Aa^v a I ? 1 90 S 









N. B.— r.very Itc^ .i ln.o.^«tion .houici he cn.efuliy HuppHccl. AGB should \^\-'^^'^''^'t^'^'^^' ,ir„fan' n"l"*'^'r^. 
•tote CAIJSI: OF DEATH In plain term., that It mny be properly cla8*..tlcd. The Spec.ol Information for p«r- 
«on« clyinft away from home Hhould be ftiven In ovory Inntance. 




i 



!( 



Ill 



'i 



'i 



• I 



tl 



^J 



<-> 



V^,-. 



»*. .vf*. 



^ > 






..^ 



^ *, 



^^"' 



7Wp 



'-^r>. 



'Wm- 



v>. 



•1. ' 




\li' 




i t 




V 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTfON3 



JIM' C, 



1...AA ^\ , Deputy Hea|. 



VJO\ 



Ee^Lstcred J\'*o. . 



955 



^ L^A^A^o 



.vx 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)catb 

( Ta. S. StanDarD ) 



PLACE OF DEATH: — County of "'a>v1,Va >XC^^ciC;ty of 0,0.^ aX<V>^Cc^CO 



No. 



-\tQll 




\ 



Dist.; bet. 



and 



OLVLI^ '.V CS^IvlLclV St.; . — - . 

'"*' f i„ .«^„ iieiiAi BrciDrNCE GiwE r*CTS callcd row under special information i 



) 



FULL NAME 



I 



CUvVhCXXOj 



1^, III) 



v<^ 




c\x^. 



PERSONAL AND STATISTICAL PARTICULARS 

Ii\ I K <»I HIKTIl 



Lv JxAjix, 



A(.K 



iMf.iith) 






(I)av> 



.lAw/// . 



(Vear) 



Dovi 



SINT.I.K MARKIKH. 
WUmWl I> nk IMVnkrKI) 

(Wrilfiu stK-irii i!t '«ii.'»t:iti<'n> 



^ 



niKTin'i.AOK 

iSt.Mtf or Country^ 



nvmj: <»i 

J AT HI. K 



niKTIIPT.ACK 
<>l I A 11 IKK 
(Statt or Country^ 



MAn>l':N NAM I'. 
OF MOTIIKK 



HIKTHri.AfK 
«»l- N!«iTHKK 
'Stall- -ir «."<i\iiitT\ 



occ ri'ATioN C^\Q 







tx^utx 



a. X^Chdi. 









Ktnffd ni Sati /'mm i^r<> it v*,.// 



M.'ntfi^ 



n,!\: 



n\V \Hi.Vl- sTXTl 1) PKKSOVAl. 1V\ KTIT T LA KS AKK TR IK H » TFIK 
HKST Ol MV KN«)\VIj:i)«VK AND Hl-.I.IKF- 



n 






WEDICAL CERTIFICATE OF DEATH 



l>A TK n|- DKATH ^ 

LLwcL 

(Month) jT 



1\ 
(Day) 



(Year) 



I HI':KI':HY CKRTrrV, Tliat I atttii<U«l «Uitased from 
LLwOL. I 190 '. to ^La.^ol il.- 190 H 

that I last saw h alive on Ln^Vw-V^Ou It' I90H 

and that death occurre«l, on the date stated above, at 1^ H5 
y M. The CAISI*: OI' DIvATIf was as folliuvs: 

O a^>V:C^.^cLu:> WCvvL..- 




nr RAT ION Yt'ars J/oft//is ^ Days 

Cil N T R 1 15 r T ( ) R Y LLCuvXiL sAA,t^x^L-\, W ».* v. 



//ours 



X^sA^rr-^., i/V U./V\jLN.||Vcy'\X'Vv<^. 



Dr RATION ^y. }ttjrs M out ha /hns //our a 

,1. 1 

T()0 ^ 

SPECIAL Information on'y ^^r Hospitals, institutions, Transirnts, 
or Recfnt Residents, and persons dying xi>i;) Iron home. 



(Signed) 

a 



Mouths 



0. Uj. V^^^v^vfr-vi^^ 

lAL INFOR 



. - - % 



M.D. 



t ■• 



or I > i L ' "'^ '""' ** 

pOilpnre N^ ^ v-U/wa^ vV . , , X Place ol DeatN ? 



Former 

Usual Residence 

When was disease contracted, 
II not at place ol death? 



Days 



I'l.ACK ni lUKIAI, OR R1:M<>VAI. 



Oxt ^)^^^^ 



DATlvof IUriai, or RKMoVAl. 

\ X 190 ^ 



I ni>i;ktaki-:k 






^ B — F.very Item of informHtion should be c.refully supplied. AGE should »>« ^^B^'i^^'^.fL^TLY PHYSICIANS Rhould 
Ttate cluSE OF DEATH In plain term,, that it may be properly cl«««.«cd. The "Special Information for pT- 
Hon* dyinft away from home should be ftiven in every instance. 






\ 




1 



iii 



!fc 



ri 








I' t 



r 







f' f 



♦ I 



ii: 







i 



sj 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l,.,nTc!..nualth . Vo ,.i!-5'^ H&j'co REFER TO BACK OF CERTIPiCATE FOR INSTRUCTIONS 



10 0\ 

t\yu Deputy Health Officer 



Registered JS'^o, 



956 



Date Fih'il , lXwQ/\-v<i-*t 1 3» 

DEPARTMENT OF ^UBLIC HEALTH=City and County of San Francisco 



Cevtificate ot Death 

I "Q. S. StauDarD ) 



(^ 



PLACE OF DEATH: — County of '"'a>V 0\a tvCU - City of "'/a >v VavvCc^Cf 



No. 






•1 



A 



St.; 1 Dist.;bet.Ul^Cklt^V and '^UXA-l ) 

(ir OCATM OCCUHS *W»V rROM USUAL RESIDENCE give facts CALLCD for under 'SRECIAL INroRMATION" \ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



On\av^ll.dl. 



rMJiiitht ^ 



lUfxcU 



PERSONAL AND STATISTICAL PARTICULARS 

>>»:\ rV>| i cni.oR 

DAI I. ill niKTII 
Al.K 



(Day) 



(Year) 



)Va».« 



Motilh . 



n 



All* 



>!N<".I.K. MARKII'.D 
WIDoWKD <»K I>IV«>K<'KD 
'Wiilf- ill •MH'isil il»-<«i>fiiali<»n> 



niKTHlM.MK 
'Statr or Coil tit tyi 



N \M» nl 
I- AT MIR 



lUKTHIM.ArK 

ni I ATMHR 

• Statf or Cduntry^ 



MAIDKN XAMK 
nl M«)THh:K 



lURTIIl'r.AOK 
OF MOTHKK 
(Slate or tVmntry) 



OCCII'ATION 






^.£X >vcc^ CO 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH | 



(Month) n" 



II 

(Day) 



(Year) 



HHRiaiV CI'iRTIFY, That I at tcmkMl deceased from 
U^LcjL ^^ 190I to . ...^LLccC^.U 190 S 






tliat I last saw h ^^-^ alive on LL-CVCL I L 190 \ 

aii<l that death occurrcil, on the date statecf above, at VD 
UL M. The CAISP: DI- 1)I:.\TII was as follows: 



JL U 



DT RAT ION' Years 



Months 



CONTRIUrTORV 



^^ 



L 



Days 



Hours 



S^ OL^L.'Uia-M-^X 



Kfsidfd III San r>,ni.iu-,> "" )V,:/v "" M.>„th^ \\ /'-' 



Tm-. AHOVK ST\'n-,I) I'KK'^ONAI. I'AKTIcTI.AKS ARl- TKIK To THH 

iJKsr OF MY k.no\vij:i)(.k and hhmkf 



(Iiifotmaiit 



(A«^lr^s^ 






DURATION 
(SIGNED) 



Years 



i 




Months 



^\.\J OJ 



Pays 



Hours 



M.D. 



I 



Xcl a 



^ 



I 



I(»0 



f 



Address) ?N^Al ^'A.A.rU''. M 



Special information on'y tor Hospitals, institutions. Transients, 
or Recfit Residents, and persons dying away from lioroe. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lon^ at 
Place of Death? 



Bays 



IM.ACK OF lU'RIAI, OR KKMoVAI. 



DA'll. ->; Mi KtAl. or RKMO\AI. 

:\ 1 ^ 190 H 



\,V\x,o, IX 



INDFRTAKKR 






IS. B.— Every item of in?orm«tion .hould be carefully Rupplled. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The Special Information for per- 
sons dying away from home should be given in ^vry instance. 



j'Jh 



i 



!i 




I 



Ii 



I 
t 

.r 



^1 



.•4."> 



^HJi 





pf^^^B ' 




Br,>^:-<->w>^ 


£% 


^-r- 



•/-^ 






r.t^' 



.^ . .-^ I IF a T 



I 



N 




It 



a 
k 



r 



f 



I 



= M 






1 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,:M.l.>f!l,...th JN.. ,.tuf^!^Ju<^»ro REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

" 957 



1)11 



/(' rih'<i, CI' 



\,vC\LC^ 



^ 



% \X 



lOO'i 



Registered *A^o. 



ir'^r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. 5tanC)arD ) 

4 ^^ 



4 



(^ 



PLACE OF DEATH: — County of ^ a'^\; J Va.^va^4. c City of 'CV^v OXa ^ve< v 



No. b'^O^fe 



Xcl >v^xcl > . 



St.; Ic Dist.;bct. blA\, and "^^ tv 



/ ir Dt«»TH OCCURS *W»Y FROM USUAL RESIDENCE GIVt F*CTs'c*LLCD for under "SPtCIAL INroRMATION- \ 
I, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




IVOL^VCC 



KX 



PERSONAL AND STATISTICAL PARTICULARS 

COUOR 



^]lcJU 



VlJ. 




MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 1 



i> \ii-: Ml- r.iK in 



A<.K 



M.iith) 



c<? 



V. ),..-. 



(Dav* 



V. '»////« 



(Vearl 



/hiv: 



^INc.l.K MAKKTKn 

U n)t»\\ l-.li «»K I>:VnKiKI> 

iWtitiin v'Kial il»-si»»nati<«ti) 



HIHTHIM.AOJ-: 

'St;itf or C'liintry) 



NAM!-: OF 
J ATI IF K 



lUK Tnri.ArK 

<>l" lAIUFR 
■-■tate or Country' 



MAIUKN NAMK 
ol M()riIi:K 



lUKTiirr.ACF; 

Ol MnTHKK 
(Statr or t'oiintrv) 



occrrATioN %^ 



a 



I 1 x 



cv 



(Month) ' 



It 

(Day) 



/pO \ 
(Year) 



I IIICKIUJY C1;RTIFV, That I attcMnkMl «UH:eascd from 
• I90 — to • 190 — — 



tliat I last saw h — alive 011 - T90 

and that death (occurred, on the date stated above, at 
—---- M. The CAl'Sr: OF l)l-:A'ni was as folhms: 

C<Xvb-trL^-^ LLc^^c-cC .1 ^^atrvv- 



DrRATiON y^ars 
CONTRIIU'TORV 



Mouths 



Days 



Hours 



DURATION -^ Yeats ^ Mouths 



Ha xs 



( SIGNED ) A.tr\.Cr^v.l\' 



\ hVi ^v.'.a....x 



Hours 



M.D. 



\} 



l\.^. n J. I 



a 



()0 



(Address) 






Special information onW tor Hospltdls, institutions, TNnsknts, 
or Recent Residents, and persons d)ing away from home. 



AV 



yiiifj ill V,.o; JiiUiii^^o ' \ ) ikI 1 < 



M..iith^ 



]\}\< 



TFIK AHOVK STAIi:n l'KK«^ONAL I'A K lU' T I, A KS AKl", IKl H T' » THK 

HKsToF Mv KNOW i.i:i)<-,H AND in:i.n:F 



:iiifoin:nit \l VV^w^LLcLNwC^ vU- ^ 



V <Xcv > ^->'- "^ 



\ 



'Address 






I 



Former or 
Isuat Residence 

When was disease contracted, 
If not at place of death ? 



Htw I0R4 at 
Place of Death? 



Days 



I'l.ACK OF lURlAU OK KFMOVAI, 



INDllKTAKFR \XwnJ\UxL LL\x,cCX'VC 



DATFoJ IMkiai. or KF:MoVAI, 



T90H 



D- ''■' ^'~%j. 



(Address 



i.b.^ 



OXv^ 



A^VlTix l.t. 



N. B. Bvcry item of Information .houicl be cnrefully Hupplicd. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may l»e properly classified. The Special Information for iwr- 
«on« dyinft away from home should be given in every instance. 



i' 



) 



J 




^1 






^■w- 



1. 



S -It!'' ■ 






-JV 



i 



U' 



1 I 






'^S 



*'^^H 




I 






f- 



» ■ 

! 4 



r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.M,.l..ni< alth I v.. .^ ^-tr€?* l'^*^ »' ^^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)ff/r /'V/^'^/, LL^uaxv^tt 






jRc^isfcred A^o, 



958 



s '—'T'" 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County ofUCC-vx 



Certificate of Beatb 

( H. S. Stnn^ar^ ) 

O.XaovcviCiCity of 'J CX/Yu OA<X/-)VCv.i. :^ t 



'^ 



,^ 



A 



rNo. H?^l\- 'X5 .0., St.; 10 Dist.;bct. ^a^U^u and oL^'>La.'^>^r , :V) 

/ ir DEATH OCCURS AWAV r«OM USUAL RESIDENCE give r*CTS called fob under -special INroRMATION • \ 
^ ir DEATH OCCURRtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME ^U^^^o. 



n\. Li 



^i 



-u. 



PERSONAL AND STATISTICAL PARTICULARS 

V 

DATK ol HIKTH 

5 

(Dav) 



a. 



lOiv.U 



I Month) (T 



aci' 



\(.K 



)V.;i 



Mouths 



\ > :\\ 



n,i \ . 



^IM.I.I* MAKKir.O 
Writi- in MM'ial tk'«4ii?nati*>n) 



^' 



,1 



MlkTIIlM.Ai'K 
Matt ifT <.*<»nntry* 



N WW Ml 
I A I Ml K 



ItlKTHI'l.ArK 
Ol lATHKK 
■^t.it*- or Country) 



(\acp-. -. -^ JJ 

V 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATII ^ 

d 



AWCL 

(Month) /] 



w 

(Day) 



(Year) 



I m:RI«:HY CI':RTIFV, That I attcMKkMl (IcceascMl from 



190N 



^ 



to LU-N^O. lA. 



190H 



that I hist saw h ^V alive on vAXvCV. It 

anil that <U'ath <»courre«l, on the <late stated above, at A 
Wl^M. The CArS!{ OF DIvATII was as follows 



190 



H. 



W 



T^ 



X auvXA.^ua S iXx/fr^n^^XtrVvv' 



k-W 



1 


r 


1 


\ 


t 


■ 


.'1 

1 

1 


1 



f 

1 






^ I 



1 



1 " / 



DIRATION 
CONTRIIUTORV 



Years Months ' A/i.v 

...VX\rirvx-i. 



Hours 



MAIDKN NAMK /\ k (\ ' 

Ol MOIIIKK /J y \ y \ 1 



HIKTm'l.Al'K 
Ol MoTMKR 
'St.it' ot i'ountry) 



<)«:<:i TA rioN 



^, 



_ ^ iX-VVkVCx N uL 



•> 



AVv/i/a/ //' .V,7jf I tiitr, n<-'i 



Y'.t 



yf ,>:llr 



r>.!\- 



THH MJOVK STA'n:i) I'KRSoNAl. I'A KTI*f I, \ K^ AKI-. TRTH To THK 
HHST Ol MX KNOWI.J.IX.K AM» Hi:i.n:i 

(Inf.HUjant ^ A, OLA-4 ^-> V-CTA V t!** LV'^wf 



^\<l.lrcss HX^l^ X^ Ci 



y 



\j 






nr RAT ION 
f Signed) 



}\(irs 




Months 



Hours 



^ 



L 



VL.V,: 



% 



I()0 






Pays 
V\j M.D 



-1 ( 



Special information on'y for Hospitals, Institutions, Transients, 
or Recent Residents, and persons d>ing ai^ay from home. 



former or 
lisual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



ri.iCK Ol- m RIAL OK KKMO\ AI 



DATKo! m RIAL (jr RHMOVAt, 



vCcvcv 



I NDHRTAKKR O CCAATt^yXX^U j^ \.0-^ 



T90S 



(Ad.l 



N. „._Kvcry Item of Information .hould be cnrefully supplied. AGE nhould be stated EXACTLY PHYSICIANS should 
•tat/cAUSE OF DEATH in plain terms, that it may be properly classified. The "Specal Information for per- 
sons dyinft away from home should be ftiven in every inslaiite. 



1 { 



d> 




J 



»i 



•r 



: 1 M 



mis 



^•-i^' 



WPH^ti it^sak 



. r 



. ,^ V'' s'-? 

■■'■ ^?fe" -r^^.S^ 



I 12^ 



h 



11* I 




r 



* 



«i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boar.l..f lliiilth I Vo n »-^^fc)l*r r,. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Fil<-<l, ClwQv^4±; 13. 100\ 

dUv^^ "Ix^M^ Deputy Health Officer 



Registered J\''o. 



959 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — 



Cevtiflcate of H)eatb 

( "a. S. StanC>arC> ) 
County ofOcX'-yA; AXX'^'V.Ca^ C^cCity of 



Ojy\} 



''^ 



"^ ^-vC^-1i,f" i 



No, 







{y-<L 



ka 



St.; 



Dist.; bet. 



and 



/ if DCATH OCCURS AWAvlrWOM USUAL R E S I O E NC E Gl V t FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




/CU\^\.u 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



^wL 



\ 



\X Jv^U 



MEDICAL Certificate of death 



DATK «»I Itik III 



ACK 




• Mojilh* 



I 



lal 



I V«i » > 



(Day) 



M,>nth' 



fVear) 



Pan 



\viiM»\vi:i» OK invMKOKn 

Write ill <-<KiaI <hsivfti.iti"ii) 



V 



\ 



HIKTHIM.ACK 
IStatf or Country) 



WMi: CM 
FATIIKK 



MIk rillM.Ai K 
0|- lATIIKK 

'St:»t» or ("omitryi 



MAMtKN NAMK 
«)l- MOTHKK 



HIKTnri.AeK 
<•! M«>THKK 
iSlatf or Country 1 









DATE OF DEATH :^ 

(Month) J (Day) (Year) 

1 UKRIiBV CI:RTIFY, That 1 atteinltMl ileceasetl from 

L\X-vCU ^ 190 'i to 

alive on La.Aa^j 



that I last saw h •- 



1 (llkVilllVt 

OsA.A^..l.X 



T90H 

190 H 



ami that <leath occurred, on the tlatc statc«l ahovo, at 
V ,M. The CACSI<: OT DIIATII was as follows: 



- V M. 1 ne ». A\^i 



a 



O>^JJL/0o'^ 



v^ 



xxiL 



WAV- cL^ 



Jt 



C-Vu 



o 




r\jd^ 



occ 



AV' :il/,' III Silt' / I ,111, I rn O ^ ' ' '' 



DIRATKJN 
(.ONTRIIUTORY 



}Vtf/-\ Months \ Days Hours 




k'Vufr>\A^^... 



DIRATION 



VV^ %\J[^t^V>,,'^V>i • 



Years 



Months 



Days 



Hours 
M.D. 



(Signed) LU . v . VJivJL<;Lti;vx m.d. 



1 



Special information only for Hospitals, Institutions. Transieiits, 
or Recent Residents, and persons dyinq d*»dy from home. 



Former or 
Usual Residence 



il^i Ciava 



t 



HoH lonq at 
Place of Deatk? 



Days 



•- .1/,. .,///> - lni\ 



rm-: mjovk stati-.d i'kkhonai, i-xk riiri.vKs aki: fki k to nn-: 
HKST oi- Mv KNowi.i.ix.K AND in:iji:i' 



(I 



„r,.:„.a„, ^X'VO Q^JlIL^ ClXiL^ 



\<1(1rfss 



m 



ULco^ 



\ 



-t/VX5 



r\ 



When Has disease contracted, ,; -4 i\ 

If not at place of death ? ^"-^ ^^ '^ ^^* 



•^A^ 



II, ACK OF HIRIAI. OR KKMoVAI. 
(t) 



DATliof Hi HiAt. «.r KKMOVAI, 

,cv a. . '. 190 i 



iKo; 






^'Vc., t 



(A(l«lress 



N. B. Every item of Information should be carefully nupplicd. AGE iihould be stated EXACTLY. PHYSICIANS iihould 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special information" for per- 
sons dyin^ away from home should be ftiven in %\9ry instance. 






"Ji 



\ 



5 I 



M 



\ I 



: 






»i 



f !! 



If'} 



, 111 



, I 



.r 



^.. 






'■-£-■' 



^^Vl 






*l 





i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I',..:.r.] if II. .iHli r \.) I. "^-^^W:?^ MS;rCo 



/)ff/r Filed, CI 







wQ^^t- 13 100 \ 

Deputy Health Officer 



Registered J\'*o. 



960 



>^i 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "U. S. Stan&a^^ ) 
PLACE OF DEATH: — County of CL VuO ^^CLTVCOQ-^^City of Oa >-u JA.Q.>vci,>i <^ c 
No. JXCL^vd- 'lLcrtj^l;MlLaV/kxt St.; O Dist.;bct. 3vAvdb and 3.Vc) 

(ir DCATH OCCUnS «W*V FROM USUAL R E S I D E NC E CI V t FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME L^^^cuu^xSu ^ 



j Nyj^^w^^L^CAjO 




SK\ 



i>\ I j: «»i niKTii 



AT.H 



PERSONAL AND STATISTICAL PARTICULARS 

COI.< >R 



L 



<X.KJL 



l\\.d 



tM..!ith» 



Ho,,,,, 



(I>av) 



l/.i//// 



fVtar) 



A J ti 



^ I NT. I. J* MAKKIi:i. 
'Write in «4M-ia] il«>«>i|.riiali<>ii) 



lUK IIU'I.AOK 
• Siat< '-r •■■tnnlryi 



NAMI. nl 
FATIIKR 



0|- I AIIIKK 

'St.itt or Ci)initry) 



MAIDHN NAMK 
<»!• MOTHKK 



inUTMPI.Afl-: 
'Stair ■>! lojiiitrvi 



li i 



MEDICAL CERTIFICATE OF DEATH 
DATE Ol DlvATH nt 

LL^^vya li 

(Month) J (Day) 

I HHRI'BV CIvRTIFY, That I attctnled deceased from 
— — — .—: 190, to 



/go ' 

(Year) 



that I last saw h 



alive on 



190 
190 



and that <U'ath r>ccnrred, on the date stated al)Ove, at 
-r: M. The CAl'SIC Ol' DiiATII was as follows 

'AA.;V<:rA,<<:Lx. 



' ■ . r? 



DIRATION y'fars 

CONTRIIU'TORV 



Mouthfi 



Pavs 



I /ours 



%\ 



" dttc^cc a 



" t 



<)i < I (• AlloN 

f\r'iif<,! in S.iit !'i iiiii I <<i 






DIRATION 

(Signed) 



Years 



Months 



Days 



Hours 



O^ ■'- T<)0 






Special information «n'y for Hospitals, institutions, translfflts, 
or Recent Residents, and persons dyinij dMd> from liome. 



/>,;. 



I'll}- XMOVK SIAI l-l> I'KKsnS A?. I'XUTHt'I. \KS AKI. IKt H T» » TFIlv 
l!i:>.T 01 MV K NnU l,j;n<.H AND I'.lCI.n-.l" 



niifi.-mntit 



« 



% 



i \.l<ln ss 



1- n li).^<xl(L dt 



Former or 
I'sual Residence 

When was disease contracted, 
If not at place of deatfi? 



HoH lonq at 
Place of Death? 



Days 



ri.ACK OJ ItlKIAI, UK KKM<»VAI, 



^. 



DATIvo! Hi KIAI. or KKMOVAI, 

Lv-A^v-O I t> 190'', 






I 



IN. B. Bvery Item oV* ln?ormHt1on •hould be cnrefully «uppliecl. AGE Hhould ba ntnteil EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be ftiven in every instance. 



> 



li 



V 








- - ^ I , 



■ I 



' 



I, 




W- 



«.-»YIF» 







i: I 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;. ai.l .,f I!. :.llh t V-i ' ' '**t,3:p^ HS. I' T. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Bo^istei'cd J^^o, 



961 



Xo-i-vA^ Axaj^ Deputy Health Offlcer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( XX. S. Stan^ar^ ) 
of UOLTV OX<XO VCv,>iCcCity of OCCA^ <^ \.0^-\\ Vl. ^^. c. < 
No. AoL (Iv 0-\.( • . St.; 1 Dist.;bet. J^CX.\,H_A_.>v and 

(ir oc*rM OCCURS *\««v rnoM USUAL RESI DENCE Give facts called tor undcr "sPtciAL information" \ 
IF OCATH OCCURRtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME cL<X\.s^r\x>A.t-x^ V.Ol\>^vxju^. 

— — — — — ii 



PLACE OF DEATH: — County 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI. 



^Ak '""""lok.t 



^x.. 



MEDICAL CERTIFICATE OF DEATH 
DATK 01 I>i:.\TH 'I 



n VI I. 01 |;IK ill 



\ < . I" 



\\ nth' 



"•IN" l,l" MXKKTKn. 

( 



• Day' 



1/ Hill 



(Vtar^ 



/',/ 



VVrilr in mmihI <I* oitriialioii) 1 . 



V 



lUKTHIM.Xri" 
'Slatf or CfiMiiti \ 



^-0 

(Month) i\ 
I H1:KI:HV CI;RTIFV, That r attcniUMl lU-ccasetl from 



(!)av) 



(Year) 



L 



-^^A.A^ 



\ 190 \ to ^VWQ. ['X uyo H 

that I last sjiw h ■'.■ alive on V.t VvO icp 

ami that «U'at1i i)C<Mirre<l, mi the ilati- •<talc<l above, at ^^ oO 
si M. The C.MSI- ()!• DIv.VTH was as follows: 

JL)AJLccttxX^<rv^ Cry ju-c<xvt aa^-v'Lk 



ns 



yb..A.^ft'r>'vc*ri^.Ct<v^ 



NAMK OK 
F.^TIflR 



lUKTMIM.XOK 
nj I ATHKR 

'Statv or Country) 







C 



V^^^ V^O^V^xX 



> 



c^ 



MAIUKN NAMK 

«»J MOTIIKK 







DIR.ATION 



) 'tuirs 



Afonths 



CONT K I lilTOR Y ^.^VtTV-wC iwvLs^ 



Days 



//ours 



FUR l*MIM.\<K 
01 MoTHKR 
'Stat*- i.r Countrv't 



X\J^tX.%xJLvj 



DrR.XTION 'i Vtars 
( SIG 



A I lO.N o } ia$s Ji 

• NED) \x^ IC fL 



Months /^ays 



fA.Mn<0 5'.' "X "Vlv-V' 



-i..^ 



-A -v. 



//ours 

M.D. 



f^r- :dr,l iv S,7» F) ..• 



/' 



rm-. AH<)\K sr \ ri'i> i'Kk-o\ \i, r \k rut :. \K'^ \k »•: iki i-; r« • \\\ v. 

1U:ST «M MV KNOW l,)!)!, I. AM> lU I.IJ I 



fliif.)-iii,iiit 






%} 



' \.Ml(Ss 



X^\X Jv CVc. 



SPECIAL INFORMATION on'y Inr Hospitals, inslitutiofls, Tr*iisifiils. 
or Recent Residents, and persons dving ana) from home. 



Former or 
Isual Residence 

When was disease contracted, 
if not at place of deatti ? 



H«« lon<| at 
Place of Deatk? 



Days 



ri.ACK or in RIAL ok ri:m<>\ \i 



!>\M. -t HrHtAi. or RKMoVAI. 



yAM. 






I90H 



rNin-.RTAKKR nIiV vJ (xdtlcv \j}l vDAXaU^A^ ' 



■N. K. Fivery Item of Information should be cnrefully nupplied. AGE should be stated EX4CTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
sons dyin^ away from home should be ftiven in ms^ry Instance. 






4 w 



•i 



J 



)\ 



*l 



t 

I 

1! 



\ 






V, 



9£^^k. 




^ 



1 I 



i 




^nmrnf*^^ 




u? 



III 







i 



Vj 



It. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

f ll-.ltb ! No 1. «-^*>X H^lTo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1 v 



RegLstered J\^o, 



902 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of S)eatb 

oV ^0UTWvLVCL/>vCc4C. City of '-Ct^V /u CX/>X ev4.C C 






H). 



No. bOl \ack.CiC > .. St.; I Dist.;bct. 'ViaVAVU and ^X^^lve-vvt 

((jir DtATM OCCUnS AWAY rPOM USUAL RESIDENCE GIVr facts CALLCD roH UNDCR "SPCCIAL INrORMATION • \ I 

\\ \T DCATM OCCURRtD IN A HOSPITAL OH INSTITUTION GIVt ITS NAME INSTEAD OF STRtfJT AND NUMBCN. / 



FULL NAME _S.J"U,v.-»\/, J.L..ClrV|. 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



i»\ ri: ()!• hiKTii 



\ « ■ I-; 



%\A>. '"■"•"iUL 




I Month > 



^ » 



MEDICAL CERTIFICATE OF DEATH 



n. 



Tl 



'PilV^ 



y,*n/ks 



v< 



(%Var) 



An 



"^INt.!.!". M \kl<IJ:i). 

w ii>o\vHi» MR nFVomir) 

'Uiit'in s«K-iril il»«iij.'ii:iti'iii) 



ItlRTHI'I.Ai'K 
' St:it«- «»r v"<miiirv^ 




l<XW"w^cC 



».\TK OK MMATH j 

LLlcq i c. 

(Month) k (Day) 

I in:Ki:i{V CIIKTII-V, That I attcmlca «leccasca from 



(Year) 



I90 



to 



that I last saw h 



ahvc oil 



I<|0 



ami that lUath <H:ciirrc<l, o?i the <latt> stated above, at " 
M. The CAISP: ()!• DICATII was as folU.ws: 







\ \M» of 
J A 1 1 1 } . K 



lUkTHIM.VrK 
ni I AIIIKK 
(State or Con lit I \ 



MMDl.N NAMl. 
01 MornKK 



IMkTiIfKACK 
<>l- MnTHKK 

'St.itr or t'c)iinti\^ 



«»CCri'ATloN \a^ 




I 










I )r RATI ON )'t'ais 

CnNTKIIUTORV 



.VoNtlis 



Pay 



l/oitrs 



A font/is 



Pars 



(n^Q 



^ix. 



K.^ 



'^ 



^A 



O \V 



\ V ^- 






(Signed) 

a. 



Hours 
M.D. 



« <i 



-^ 



iqo 



f AiMress) 



W C L \:.A.Vvlt„<S. 



Special information on'y for Hospitdls, institutions, rrdflsicnts, 
or Recent Residents, and persons dvinq a*»a> from honif. 



AVi/,//-./ ,1? S,ni /'i.iii, /wM \ V- ) ,,i 



M.-.'fh 



/>,n 



rm-; amovk <.r\ ii; n i'Kksoxai, tau luri, \k^ ari: iki h 10 in i-; 

UKST ni \JV KNoWlJ.nC.H AM) lUCI.IlJ- 



f\<1.1ros^ 



TOb 






Former or 
Lsual Residence 

When \»as disease contracted. 
If not at place of death ? 



How lond at 
Place of Death ? 



Days 



I'l^ACH <)l' lUKIAI. OK KHMoVAI, j DATi;.! MtiUAI. <<\ Ki:Mt)VA^ 

I ni)i:ktakkk ^^..A_A-^'C^>vo- : 5-'^ ' <^ 



C\ 



190 



(AcMress 






C\. CWK •^.■^ 




¥. 



< e»j 



!N. B. Every item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

«tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
Mons dyin^ away from home should be f^iven in every instance. 







.2.^ 



I 



— -"^ 



y 



r 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H.. .(.! ..f 11. .lUh 1- No \ K f'l^'^^. UK. \' i 



KJO'i 



l)((tr hailed, LlA^o.i^A^tj IX 

Deputy Health Officer 



Ilogistcred J\^o. 



963 



^^VA^V.O 



DEPARTMENT OF^UBLIC HEALTH^City and County of San Francisco 

Certificate of Death 

PLACE OF DEATH: — County of'^Ct'W'L'vaAvCt.O.C'.City of ^''Ct'>\' ^ J ^'^-CL/rv Cv4yC-t 

3. bClH^ivi 



vack.i.C St.; 1 Dist.;bet. .'Vt-aV^Vu and iJ-^.'-kt-iv^ 

(jir oc^TH occurs aw»v rnoM USUAL RESIDENCE give facts tallcd for under "spe4ial information- "X I 
\\ IF OCATM OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS .AME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



0,1 ( 



a 




.Cri.1 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



^IXcU 



DATK t)h ItlK III 



\ ' ■ !•: 












'Dav^ 



M.nilks 



(Year) 



An 



^IVi.l.I" MAKKII-.I) 
\Vn>o\VHI» OM IHVoRvl- l> 

Uiit' ill -.iKiril (l««^ji'it:iti'>!i I 



i!iK rniM, \»*H 
' statr or » ouiitry^ 



I Arm K 




^<X^v\.^cC 




> \wW i V 



WW 



n 



MEDICAL CERTIFICATE OF DEATH 
DATK Ol- DHATH 1 

LLtva iCi 

(MoiitlO V (Day) 

I III-KI-HV CMRTII'V, That [ attcn«U(l ilcrtascil fnmi 



igo 

(Year) 



190 



to 



that I last saw h alive 011 



T90 



ami that iKath (H:curre«l, 011 the date statt'tl above, at 
M. The CAl SIC OF I ) I- A Til was as follows 

...S^:.'^,rv.\Xctu 

1 



rj 




A^cCVn 



lUKTun, \rK 

'>» I ATHKK 
< stair or Count rv 



>t MUKN NAMK 
<»! MDTFIKK 



HIRIHrUArK 
<M MOTIIKK 
'Slate or i'oiintrv! 









Dr RATION Vt'ars 

CONTKIIU'TORY 



Months 



Day 



I Jours 



nr RATION 



)'t'ays 



Mouths 



Days 



Kf-idei />' S'xv /'i nu,i>'>^ 1 *^ )',,ii< 



M.nth^ 



(Signed) •'^.XxcLjivn^c^i ^. v<x^a\x^j 



L 



U. 



-1 



I(;0 



f A.hlress) W i. W 



^ 



//ours 

M.D. 



V 



Special information nn'y f«r HospiUls, institutions, Transients, 
or Recent Residents, and persons dying dv*d> from home. 



Former or 
tsudi Residence 

When Has disease contracted. 
If not at place of death ? 



H«H ionq at 
Place of Death? 



Davs 




\ 



1MI-: NHovK si-\-n: I) phksowi, tak ikt!. \k>- aki: ikik itt rm-: 

Ui;sT (H MV KNOWLi:i)<".K AM) UKIJII- 



(Infonnnnt 



!L 



V.t'^V 



Xddrt-ss 



^- ^ 



■ .Ob 



^ r >\ 



-^ 



1 -a:. 



ri^ACK (»1" in RIAI, OK KKMi>\U 
rNI>i;KTAKKK 'A.A.A.'-trWCL^ 



IiAII, ..; Ill KiAi. or K1-:M0VAI, 



LL^^s. o . 






( »-, 



190 



«i-»~^ 



N. B. Every item o* information should be corefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classi^ed. The **8peci«l Information" for per- 
son* dyin^ away from home nhould be ftiven in every instance. 



M 



A- 



■■'U- '■' 




I I 




» 







r 



t 





^sm 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M..ar.l Mf 11. alth » No i^ ■*?^?< M*"^ I' < '• REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS. 






Deputy Health Officer 



liegLstered J\^(). 



9G3 



I 

DEPARTMENT OF PUBLIC llEALTII=City and County of San Francisco 



VM^ 



Ccvtificatc of Beatb 

( XX. S. Stan^ar^ .) 



m 



PLACE OF DEATH: — County of^CLxv^ J/w5^vcv<iyCoCity of 0.<X.^ru J 



No. Av-^-wOA ^ a.v*^q.A^t?\^ CV^e^ St.; Dist.;bct. — — — - and — 

/(ir oc»TM occui^t *wov rnoM USUAL RESI DENCE Givr facts cacled for under special information \ 

Vj ir OCATM OCCWRRtO IN • HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



and 



- ) 



FULL NAME 



ft.ME Uj aaXa/Cu-vv^ \^t^ 



•■\JL\j.. 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



QIlJc 



I0iv.t- 



MEDICAL CERTIFICATE OF DEATH 



DATE OH HKATH 



1»ATK n| UIXTM 



<)\ 



Month) 



(Day) 



(Vtar> 



\« .i: 



1^ . 



*>rN«'.I.H. MARK ii:i» 

W'titf in ^iM i.ti (I'xi^nation) 



^ 



'\^ 



n.n. 



b 






^ ^A-.-C 



vJw^^-W^^-^' 



HIKTIIfl.AOH 
'State or Country) 



N'AMI-: <>l 

I ATin;R 



niK TIlPI.AlK 

•Statr of i'oiinti V ' 



M \I1>KV N'AMI-: 
••1 MOTHKK 



HIKTHPr.ACK 
'•I MMTMKK 
(Siatf or Counti> I 



«K 1 ri- KTION 

Till-: AHOVK ST \ IJ !> rKK«)\ Al. I'AK lUTI. \K< AKi: TKt K To IHK 
Hi;sr <»!• MV KN» •Ul.l.Dt.H AM> njiiji-i" 



(Mutith) X 



1^ 

(Day) 



IQO '. 
(Year) 



I UrCRnnV CKRTIFV, That I atteii.led lUuvased from 

I I90H to LLv.A./OL I Ql H)0 H 

alive on LA^Viw.0^^^ i'X 




T90 



'"1 

that I last saw h 
an»l that «U"ath f)ccurre<l, on the «late state*! above, at I 

lL M. The CArSK W DICATII was as follows: 







Months 



CONTR I lUTOR V L^^VT^^VC. \I.iX^-A.^^^^^^^^ d-i-tt.. 




Pays 



Hours 




nr RATION fl^O Years Mont /is 

,NED)..ll). Xd. ukjU\iJL 



Pays 



(SIGI 



^x^.. 



(^ 



I /ours 
M.D. 



LLvQ »^ iqoH fA.Mres.) It?) Lb LcV^bv . • ^.- '^^^ 

SPEi^AL Information obU for Hospitals, Insfnutlons, Transients, 
or Recent Residents, and persons d>inq av*dy from liome. 

HoM long at 

Pfareof Oeatfj? IC' ',►>. feys 



/).; 






^ 



4 



Former »r 
Usual Residence 

Wlien Has disease contracted, 
If not at place of death ? 



ri.AOK <>i juRiAi, (»K ki:m«»vai. 



DATHof HiRiAi. or KKMoVAl, 






. 1. 



rM.l.KTAKKR "lu /CUUJDuL ^/^ ^ 



T90 



fAdilrt»;«: 



tZ'«hould be carefully supplied. AGB should be stated EXACTLY PHYSICIANS should 
\T\\ in plHin terms, that it may be properly classified. The Special Information for p«r- 



N. B.^— Kvery item of in for 

state CAUSE OF DEATH in p 

sons dyin^ away from home should be given in every instance. 



> 



\ 4 . 

. 1 ,: 



t: 



!•! 






i ' 






I* - » 
I 



I 



! ^ 



1 



\ 



\ 









fe'si 













1 




i 



■» 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IkMir! ..f HcttUh— I" No n ■»'^i»^- H&l' l*o 



I)f(/r F/7('ff, lAa-vxii A^^^A^ li 

1 ^ 



Jieglslered A^o, 



964 



A>-u Dep. .J 'leclth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^r\^*^^^^ 



Certificate of 2)eatb 



( Vi. S. Stan^ar^ ) 



J? <9i) 



PLACE OF DEATH 



: — County of C'CL>^ 0,V<X^\coaco City of v'OL'W; v 



Oloa; vAxx/v\^'t;-A.^ ^c 



No. 



nsl 



( 




n 



0^.\.\'.<. ^ 



St.: ^ Dist.; bet. 1 S AJ\j 



and 



i -1 ,Uv 



(tr OCATM 
ir DC* 



OCCuns AWVAv FROM USUAL RES 



ATM OCCUnnCD IN A HOSPITAL Oft 



FULL NAME 



SIOENCCCIVC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "X 
INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBEN. / 



) 




Q 



<x 




A.<.. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

Jo'N-v^ vJLlL 



Itl 



CkjL 



MEDICAL CERTIFICATE OF DEATH 

DATH OF I»K.\TH 



1> \ 11". el l; I Kill 



\<.»-; 






3.1 



(I»ay> 



Mouths 



(Year) 



Tktvs 



(Month) f 



(Day* 






IQO , 

(Year) 



I MI'RI'HV CICRTII'V. That I atUMidcl .Uocasetl from 
aii«l that «lfath f)cciirreil, on the ilate stated above, at 



190 \ 
lliat T last saw h •a-'v alive on 



r 



190 



>*IN'<*.1,K. M\KI<n,I> 
WII»0\Vf:ii OK DlVoKi KI» 
\\ lit*- ill -(K-ial lit Nij.'iiiiti'di I 



HIKTHI'L.WK 
(State or Countrvi 




CVVv>.'-'^ 




ft 



■■^ 



NAM I- 01 
f- ATM Ik 






CL^L/<XA 



I5IK inn, ACK 
oi- I A I'm: K 

■ Sf.it« or v'ountrv 



m\ii>i:n nami: 

01 MoTIIKK 



HIKTUfM.AOK 
<»| MOTHKK 
iStatt .>: i'ouiUiv* 



A. I J. 



M. The CAISK (>1< DI-ATH was as follows 



^ ^JCtX/^'v^4^-. ^, \. 



~X- 



DIR.XTION 



) 'ears 



Months 



CONTKinrTORV ^' - vO- 




Duys 



I lout s 



lAXOy- 



:i 



XM^a 



v\ 



I 



a, 



,CW V- 



v<X 



«>ccri'.\ rioN v>^ 



\J\.LcuLci 






I )r RAT ION _ Years ^ ^font/ls 



(SIGNED) XD.. 

Ll<v<v<:\^ \% T()o 






Pavs 



/fours 

M.D. 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons d>lnq dHd> from liome. 



A'rnffJ 1 1' '<i! It I'l 1! I- 



\f,.„lll^ 



J ,. 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at plaff of deatfi ? 



H««» lonq at 
Place of Deatli? 



Di>s 



rin: \h<»vk st \ ri:i) pkksov m. r\K ririi. \ks aki: pki k to imh 

15 1: ST 01 MY KN( "W 1,1- I« .K VM» lUI.IlCF 



'Iiifoimant OA..^rV*^CX A 



1'^ 



'•*J .CC-'VN-V.O,, ^ -.: 



i'A<Mrc'<-^ 



1$^ 



\ 



ctvv« <i 



190 \ 



ri.ACK OI- HIKLM. OK Kl.MoXAI. I DArj-.f Ml Ki.Ai. or KKMOXAI. 



(.Ad(h 'ss 



!N. B. Bverv Item of informntioo should be carefully suppHe.l. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSF: OF DEATH in ptnin terms, that it mny be properly classified. The ' Special Information" for per- 
son* dyin^ away from home should be given in every instance. 



^ 



M 



|i 



It 




M 



u 






k 



*^ 






ffw 



,'^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ii,.Mn1..n!. th IN. c >?5^^ '•'''' ^' REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



4^ M 1 



v^^ 



.t r^j 



c>w<rvcv. ^ *< '- \'u 






n)()\ 

•- Officer 



lle^islei'cd A'^o, 



9G5 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No, 



PLACE OF DEATH: — County 



Certificate of S)eatb 

ofOOw->-u OAtX^A^CA^CCCitv of 0/CL/>\y 0. 



^ 



ACL^A^CA^CCCity of ^'O-^'O vJ.VCL^-vCv^Cc. 



I St.; 



Dist.; bet. 



.md 



(ir OCATH OCCUnS AWAV rHOM USUAL F^^S I DENCE GIVr rACTS CALLCD roR UNDtR ° SPCCIAL INrORMATION ■ 'X 
ir OtATM OCCUNRCO IN A HOSPITAL Oil I N STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

3. ilA^V^cLWi 



FULL NAME 




JXVl 



PERSONAL AND STATISTICAL PARTICULARS 

r« »i,ok 



I>.\TROr UIRTH 



IO-Ll- 



^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OV OK ATI! r 



CI 



I Month) 



\ ' . »•; 



OO ),,;, 



(Day) 



v../.'//- 



(Ytar» 



Par: 



Write in sinial tlfiivnitlioti) 



L 



MIKTIU'I.AOK 
'Statr or t*>)nntry* 



XAMF Ml- 
FATIIKK 



niRTMI'LAiK 
Ol- I- ATI IKK 

'St:«t«- (ir Coil tit rv 



MAIDI.N XAMK 
OF MOTHKK 



niR rilPI.ACK 
<»!• MnTHKR 
Siatr or Oovinti \ 



• KCirATlON 

A'f'-iJrJ ;n Stil' fiaii,. 






(Month) 



1 



(Day) 



(Year) 



I nrrRnPV CIvRTIFV, That r atteiuUMl deceased from 

..,..^,,..... ....«, 190 to I90 

that I hist saw h -•■ — alive on -— 190 



and that «lcath occurred, on tlie dale state<l above, at 
M. The CAlSlv Oh* DliATII was as follows: 



>uOjLs-.-<rv\. \y^ '- C.) X VCUwo^d^.L 






DrR.ATION Vcars 

(.ONTRIHrTORY 



Months 



Pavs 



Hour 



u 



DURATION Years Mouths 



Days 



LI V ^ -?. 1 ! igo ' \ { A dd ri'ss) LtrVc^i U V. V i V 



Hours 
M.D. 



y^ 



Special information only for Hospitals, InstituhoNs, Transients, 
or Recent Residents, dnd persons dyinq dv»ay from Itome. 



) \ .; 



M-oith^ 



nay. 



Tin-: AHOVK STATFl) »'KK«»NAI, r\K 11011. AK^ Xkl" TKIK TO TH K 
HKST o} MV KNOW I.I.IM.J-; AM) JUI.Il-K 



\<l<lrtsx 



former or 
Usual Residence 

WIten was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Deatii ? 



Oavs 



DATF. of Ht Ki.M, or KllMoVAI. 

I90H 



UI.ACK OF mklAI. OK KFMoVAl 

ok) <xJ 



LVv,.A^ l"?) 



rNi)i:RTAKi:K 

(Ad.lrtss 



N. B.— F.very item oi inform«.ion should be cnrefully supplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified The Special Information tor p.r- 
sons dyinft away from home should be feiven in every instance. 



i 



i' 



1' =^ 




v\ 



1^' 



"• v: 



•^Vi 



'■- . » 







f^ 







1* f f+ 





< > * 



M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

It . !. f H. .!i'i » V' 1. 5^5^14 I AIM- , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 




13» 



100 '\ 



Registei'ed J\'*o, 



966 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( H. S. Stan^ar^ ) 

PLACE OF DEATH: — County ofO CL>X' .h^O/^x/CCNiCiCity of Q tX^rv J>Vxx. >A^av<i.c.c 



No, 



I* CK 



.ACh Ur UhAlH: — County ot ^J UL>X' vi .xCL/>x/ti.c>iCii^ity o\^'<-^^^^ ^ /\^AX,Y\y^\^<^^<.. 

^0 cA^^rVvts^. St.; 10 Dist.;bct. VXL^VaJLo^ and U V<Xr-rJl>a' ) 

(ir OtATM OCCUnS •«»«*¥ FROM USUAL RESIDENCE GIVE facts CALLCO for uAiDCR SPtCIAL INFORMATION' "\ X 

IF OtATH OCCURRf O IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / (J 



FULL NAME 




CJ- 




PERSONAL AND STATISTICAL PARTICULARS 



^l.\ 



^ 



1»\TK «>F IllK Til 



N ' ■ » ; 



L 



I 



COI 



■""lOld. 



Q^Wr 



(Month' 



) V,; 



o 



1 

(Day) 



M.<„;1,' 



(Year) 



A/1 



*«IN«.I.lv MAKKIKI* 
\VM)o\VKI» OK I)!VoKi Kl) 
'Wriff in Miciril <i< •<t}rtmtion) 



lilKTMPI.AOK 
iSt;it« or Coiintrv' 



NAMl-: lU 
F ATI IKK 



BIR TinM.ACK 
<>l lATIIKk 
'St.it« or Country) 



^^ \ii)i:n nami: 

'»! MOTIIKK 



lURTmM.Afi: 
"I MOTHKK 
''^lati ur Country) 



OCCri'ATIOX 






MEDICAL CERTIFICATE OF DEATH 
DATE OK I>KATII /^ 

a>ay) 



(M<.nlli) ,T 



(Year) 




I HKRr-BY CKRTIFY, Tliat I altcn.lol .lcocase«l from 
i'X 190 H to CLa^a^ l^ K^H 
tliat I last saw h ^ alive on VAa^vQ. ' X 190 H 

and that death fX!Curre<1, nti the date stated alM»ve, at Id- lo 
L'.- M. The CATSi; ()!•_ DI-ATir was as follows: 




O-/ W A>. V 









vJ -A^V 



DC RATION 
CONTRnUTORV 



C-C.W\-^^a.<i— a 

Yeat's Months 



Day 



Horns 



(Signed) 



nays 

' A 



DIRATION Years Mouth 

90^.0.^^ Ill) 

TOO'I fAddnss) ^^ ^'^A^kd 



.W 



C|X '. 



Hours 
M.D. 



SPECfAL Information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying anay from home. 



AV>/./r.7 /;' S-, ../■/,;-/, /.-•,. '). 5>'"* *■ t V" /^//^ i<_^^ 



TMi: MIOVK ST\ III) I'KRSONM. J'AK T IiT I, \KS AK K TK T K T» • \'\\V 
HHST (H- MV KNoXVI^KIHiK AND Hia.lKI" 

(Inf.„mant Uj (AD- JOuVXAX^' "^ ' ^Ct- 



3- ■Jo 




MV--*0 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of death? 



How lonq at 
Place of Death? 



Da>s 



I'l.ACK OF niKIAL OR RKM<»\ AF 



DATKof Ml KIAJ. or RlIMoVAl. 






(.\ih\TVS-i 



N. B._Every item of information .houUI be cnrefully Hupplled. AGE should be stated F.XACTLY PHYSICIANS •hould 
state CAUSE OF DEATH in plain terms, that it may be properly class.ried. The Spec.al Information for per- 
sons dyin^ away from home should be fci%en in every instance. 



[ 



1 

'J' 



* I 



f i i 



l-t, 




;v 



1 



i4 



»i 



\Mh- 



.-w. •" ■ i^ 



I 



I 



i 



}(f' 



ilUitfi 




t^9l< 




It, ,'.! ..f II. ..Mil 1 v.) 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^■^'5^.nfi,\'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJO'i 



Begistered Xo, 



967 



dot^LVM Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of IDeatb 

( XX. S. Stan^ar^ ) 

i ^ A ^ 

PLACE OF DEATH: — County of^'<X>v OVOvcvit, City of *^''0^^v J.>v<Xax<m_<i.cc 



N 



o. 



I SI tLvv. 



St.; V Dist.;bct.L<wLaX/>'\.kX vU'^and ^^^}/V>\J2Axx'^Clo) 

/ \r ot»TM occuns away rnoM USUAL R ESI DE NCE Gi vt r*CTS CALtro roR UNdeb "SPrciAL information ■ \ 
V \T DtATH OCCURRCO IN A HOSPITAL OR INSTITUTION CIVC ITS NAME INSTCMO OF STREET AND NUMBER. / 



FULL NAME 









v<xtd. 



PERSONAL AND STATISTICAL PARTICULARS 
SKX QT^ ^ { COI^R 



D.VTK «»» HIkTH 



\< .1-; 







A\j<Xjl 



MEDICAL CERTIFICATE OF DEATH 
DATE t)H DKATH 



a 



.U-O 



Month) 



1^ )-./. 



I 



1 

(Day) 



M.vfh 



fVear) 



/ './ 1 A 



■-IN' IK >T\KUn-I» 

U ll)«(V\ Kl) OK iJSVokv ID 

(Writf in MK-ial «le**ipnali'>!i) 



lUKTHlM.ACK 
^tite or Coiintrv 



NAMl <»| 
lATHl.R 



MIK inri.AvK 
<>l JATHKK 
iStatr or Cojnitrv 



<•! MOTIIKK 



lUkTmM.ACH 
<»l- MnTMFK 
"^t.itf or Country 



^xCVVX 






(Month) 



-U- 



(Day) 



/QO \ 
(Year) 



I HEREBY CERTIFY, That I atten«le<1 f!eceased from 

^VaJL^ \H I90*i to (XswA^ I'.v 190H 



that I last saw h 



alive on ^^w\^Ql \% igo 



and that death Dcciirrcd, oti the date stated al)Ove, at *^ X fc 
.: M. The CATSP: OF DHATII was as follows: 

!ViA V .^ p fi J 4 



^Ic 



-j^ <XV*-. 



A 



/> V<X::v:wAX4ir> \ 




DIRATION )V<7/\y 5v Months Days 

(.ONTRinrTORV CJ^^VO. >>wr-^ 



Hours 



.tt>.; 



•ncri*ATh)X 



I ) r R A T 1 N _ ) cars _ Mont /is ( /hjys 

(Signed) CctciDw\; 






3 



LUv-O 1?. ir^^ " r Address) '"^ '^ ^"^ ' ' ' ^ "^^ 



UL.U.. 



/fours 

M.D. 

■I 



SPECIAL INFORMATION on'y for Hospitals, Institutions, Transkfits, 
or Rfccnt Residents, and persons dying away from home. 



MnVth' 



/), 



THK MU)VK ST\li:i) I'KKSONAl, P \ K f !<• 11, \ KS AKI". TKI K To THH 

ijj:st oi- My KNOW i.i;i)(,KANi) ni;i. n.K 



^\.Mr,-«s 



Ra 



Former or 
Isual Residence 

When was disease contracted, 
If not at place of death? 



How loRQ at 
Place of Death ? 



Days 



ri^ACK OI" lUKIAI, OK KHMoVAI, 



DATJ^: of Hi KiAi, or KKNfoVAI, 

IH 190H 







N. B. Every item of information should be ciiret'ully Rupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pltiin terms, that it may be properly classified. The "Special Information" for psr- 
snns dyin^ away from home should be It'^en in svery Instance. 



» • 



» 
t 

'I 

J • 



. \ 



'fi 



< I 




t 






MA^: 




I 



* 

> 1 



n^ 



ii 





'MS 



f^ 






* 






1 i M • 1 IV 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^-^^SJ^ I5S; »• Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



4 <1 



ck-^CrVA^v^ 



Deputy H 



100\ 

nfTicer 



liegLsfei'od J\^o, 



9f>8 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Bcatb 

PLACE OF DEATH; — County of J,CL^x> J AXXAvC-ui/CcCity of ^ CXy>^ A.CVy>-L.av.^tLo 
No.VLtu7^'^W\A.^\Xu ObcHtK^^<>-^' SXa ^^-"^ Dist«; bet. :—:-:: and ^~:r-r— - 

/f / ir Dr»TM occow9\»v»*«v rnoM USUAL RESIDCNCC CiVt r*CTS called rom ONOCW "s#»eci*L iNroRMATiow "\ 

\ V ir OCATM OCcJAntD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

(^0 X, 



FULL NAME ..vy^.<ruL'r^<jc U/a^T>A-<xc^^'. 



PERSONAL AND STATISTICAL PARTICULARS 



^KX (^ 



4^>jow<xAJl 



COI.OR 




AA. 




IiAl 1 «)F IttRTlI 



a<;k 



M.-tJtht 



M5. 



)'.. 



I>ay 



M.mlh^ 



r%h[ 

(Yearl 



/'./I 



MEDICAL CERTIFICATE OF DEATH 
DATK »>l- DKATH -^ 

IWo \X 

(Month) C\ (Vmy) 



I go 

(Year) 



^I\«.I,K MAKKII.I*. 
WiiMiW KI» <»K ItrvrtRCKD 



\\'\U ill 



iukTni'i,\t*i-: 

( Statf (If i,"'Hiiiti > 



V VMI-: «u- 

FATIIKR 



niK riii'i. \K V. 

fSlale or Coniiti v 



NfAii)i:N \\Mi: 



fURTIfri.ACK 
••I- MoTHHK 
"^t.ii. -r c'ountrv) 



I'littlioii) 




r\ 



^O ' 



1\ 




'' If ^\ 

ill ^ ^^ 

Ik ^ ^ 



/^ 



I HI«:RI:1{V Ci;RTn'Y, That I attemled deceascMl fruiu 

LLus-'Cl IL tj^CVYvigoS to ... w«Awa_. \'X 190 H 

that I last saw h -CA; aUve on vA-<^.,A^tx i.X. 190'. 

and that <Uath occurreil, on the date stated above, at C: 



V.I-M. The CAISI': ()!• DI'ATII was as follow? 



^ 



\k\JUs 



-v \- v 



])l RATION ^'X'-^ Mo)iths Days J /ours 

CON r R 1 lU'TC ) R V wlNw^.^>r\^-iCli^ y^ 







DTRATION 



(SIGNED ) 



Viars 



Mouths 



Pavs 



Ll 






Vs^/C^ i TCjoH (Adilress) 



vC.¥ 



I Jours 

M.D. 



SPECMl Information only for Hospitals, institutions, Transients, 

or Recent Residents dn<i flersons dying away from home. 



% 



f\f':ilrif in Siiv /'i ,: in :' ro -i. , )r./) 



1/../''//. 



/),n 



THK AHOVH ST \ l)I> »•!' KSONAI, l'\K lUTI. \ K -> AKI! IKrK T« » IHH 

lUvsr OF Mv KNon i,^;i)c. K and iu:i.n:i- 

v3 -CXyWAXJ^^C-^ Ax^Aj^bv.' 



^Illfn-lU.int 



■' \ll(llt<-S 







Former or , , , u "/lU ^^ ^ J "^^ '•"*' ''* 

Usual Residence U 1 1 ^ V:) ^^v^a^. X pjare of Death ? . l 

When was disease contracted, 
If not at place of death ? 



. Days 



ri.ACK <>l- HI KIAI, OK RHMoXAI, 
■ ^ 



<^ 



L 



DATK of Hi KiAi- or RHMOVAI, 



190 






(AtMifss 



S 'K '1 



otf inWmatJon .hould be CHrefully supplied. AliB nhould be stated F.XACTLY. PHYSICIANS iihould 
I: OF DEATH in plain terms, that it may be properly clanfiified. The "Special Information" ?or per- 



N. B.— -Rvery item 
state CAUS 
«on« dyini away from home nhould be ^iven in every instance. 



i 



J 



^! I 



i 



I 




Ifcj 

1 

I 



:n 




\-v. 



14; -y- 



Jo ' 






TH 



/^r- 



vskixt. 





't i 




r 






m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\\, ' Hh- 1* Vo I^ ^^J^-iiJ M.'t V Co 



l)((h' lulled, LLa^v^v^v-^X; ^?> 



y.v^yn 



lleglsteied J\^o* 



969 



roF 



No. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of 2)eatb 

( Xl. £. StaiiDarD ) 
PLACE OF DEATH: — County ofOc'VuO.^.a YVCVA c<City of Cl<XorvvJ.\.<X.>^t^c^ cl^ 
Mlb'X - astf- St.; !0 Dist.;bct. VflcMj andV^XXilvx 

/ .r or.TM occuKs •«>*¥ rnoM USUAL RESIDENCE civr r*cTS c*LLto roR UNOtR "special information- \ 

\ ir Ot*TM OCCURRtD IN A HOSPITAL OR INSTITUTION GIVt ITS NAME INSTEAD Of STREET AND NUMBER. J 



) 



FULL NAME 



lWCL ^wLo. 



t. 



LLdLiJCv 



( 



^o^ 




<x.v\. 



- A 



44- 



PERSONAL AND STATISTICAL PARTICULARS 

} c<»i.Mk 



i>\ ri-: i>i itiK III /'T\ 

M.iith 



UJ 



■K'Jji. 



'I>av> 



) -./» 



!/'.»/,'// • V* 






/>,M 



u ii>« "W i:i» OK i):\ < tw. i:i> 



HIK I'HIM.XfK 
' Staff <ir i'limti \ 



\ \\!l III- 
I AT Hi: R 



HIKTm'I.XlH 
«>l I ATHKR 
(State or CouTitrv 



MMI»KN N.AMI-: 
«»» MOTIIKR 



•M MnTHKH 

^t.lt' lit V'.iVUltl v) 



OCCITA IION 






MEDICAL CERTIFICATE OF DEATH 
DATK OF PKATH 



(Month) a" 
I m^KJCHV ClikTIPY, Tliat I atUndod «leceasovl from 



(Day) 



(Year) 



av.c 



(hat 1 last s;»w h 



I90S to 

alive on 



-OL...I..X 190 H 

.^.A^ IX 190 '■ 



(l^ 13. 



ami that «U>at1i ocoiirreil, on the «late state*! above, at ' V 
L M. The CAISI*: OF DICATI! was as follows: 



n 



(^ 



v 



DC RAT ION i'rars 

CONTRIIUTORV 




Months » A, lyays Hours 

•cuLaL.^uA^.<x. 



or RAT [ON 



) 'cars 



Months Pars 



Ffou rs 



Rf>iihti III Siiv f I ii i!> :-i'ii 






(Fnf 



THi: AH<»VK STATKI) I'FRSON XI, r\K lUM J. \Rs A K I-! TKIH TO fin: 

in:sT 01-- ?.iv kno\vi,j:i)(.k and iui.iij 



'nn.nit 



(SIGNED 

cialTn 



) V. A. OAXaoVLi |VI.D. 



Lvcq i?s ur>^ fA.i.iress) : - 



L<XvU^ '^ 



SPECMl Information only for Hospitals, institutions, Transients, 
or Recfnt Residents, dnd persons dying anay from home. 



Former or 
I'sudi Residence 

Wfien was disease contracted, 
If not at place of death ? 



Hew lonq at 
Place of Death? 



Days 



ri.ACK OF in RIAL OK KKMOVAI, 

U^'^x^^iL^-^ In.... 

INDHRTAKl 



i)Ari.:o! Hi KJAL or rf:mov.ai. 



,..K Wc. ^' ^ 
(Address as. \ A V 






-V^'VAA- 






IS. B.— hvery item of information should be cnrefully «upplied. AGE should ^-^1^'-^^'',^^'^^'': , ^''^'^'''^.l!!'^;;!.*' 
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for psr- 
sons dyin& away from home nhould be ftiven in every instance. 






1 



I 



I 






I ' 



# 

I 



1 # "• 







II 



* -i 



fi" # 



? ■,#* 



il 



liiil 

i 



I 



I 



iH. 



• >u 



ii 



i^ii 



£* 



ae 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

II t'i • v- ,. i^t'T^-t"^'*^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

970 



/hf/r /'V/fv/. L\. 




Tt 



vv.^ 



± 13 



/.V6>H 



Re^istei'cd JS^o. 



C^V^ V 



Deputy Health nfflcer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



PLACE OF DEATH:— County ofC'CL-ru 



Certificate of Beatb 

( "Q. 5. Stan^ar^ ) 



o 




^^A<^.'0l^OLLU^u^lJ>0JLlL( I St.t I Dist.;bct. -_ and 

V\ ir DC*TH OCCURRtD IN A HOSPrAL OR INSTITUTION GIVt ITS NAME INSTtAO OF STRCET AND NUMBtR. / 



) 



FULL NAME 



%. 



5L^\\.CL,^ 



JVc 




^-Y- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



1) \ 1 I. «t| II IK 111 



Ar.K 



M-nlli 



) 






(Year) 



iKl 1 - 



^ I N < . I . J* M A k k 11" I » 
UIlHi\VI-U nk IiIV<>ktKI> 
\\;ti ill ^-Mijil I I**>itr nation) 



lUkTMI'I.Xt'K 
statf or •."■>nnlr\ 






% 




NAM I. <U 
FATHKR 



lUkTIII'f.Ai K 
<»r lATIIKK 
'Siritr «»r r<iinitry) 



maii>i:n namk 

«»l MOTHKR 



HTk rillM.ACK 
'►1 MoTHHk 




h JWuuL 



\.OVvCLX.^ 



"V^\J 



a 




.\.V 



La V 



"vcL 






RAEDICAL CERTIFICATE OF DEATH 
DATK OF I)1:aTH '\ 

AAaa,cl IDk 

(Month) \ (Day) 

I ni':Ui:iiV CI:RTIFV, That I attcmUMl decoased from 

— - — igo to -— — -r-rrrrrrrrrrr- i</) 

that I last saw h ::: — alive on — I90 



ami that <leath occurred, on the <late stated above, at 
M. The CATSP: i)V DIIATH was as follows 



f 



U IXVV 0- "^ OA.<i. -LyLwft 



DTK AT ION )'ears 

CONTRiniTORY 



Mon/As 



Days 



DTRATION 



(SIGNED ) 



Years 



Months 



Days 



CL 






Hours 

Hours 
M.D. 



orcri'ATiON 



' ' ' 1 - 

Kf uifd 111 SilH /'l.lii,: '■■> i }r.!l 






1/ ,»///> 



THI-. MJOVK ST\Ti:i> 1'Kk»<»\ VI. rxkTU ri.XkS AkK IKIH l" THH 
r.i:ST (>! MV KNoWI.I.IX.K AND iniLN.K 



['^ TQoH (Ad.lress) L()-VCr>\JcAA ^^|/ 

SPEG'IAL Information on'y ^^^ Hospitals, Institutiohs, Iransirnts, 



or Recent Residents, and persons dying a»»dv from home. ^ 

Former or r^ t r. /i^ J AiHowlongat 

Iku^l Rp^idrnre 'J H A V? (K^^1X\<X ^ tpi^rf of Oeatll ? 



I'sual Residence 

Wlien \*as disease contracted. 
If not at place of deatli ? 



Days 



ri.ACK <»»• lUklAI. ok ki:M<»VAI 

^ ^^^ A A 

INIUCRTAKKR M » W O^CC<XX^Nj 

(Address > I \ - V! l\ 



DA 11: of I!t KIAI. or KKMOVAI, 

I90S 




V.'^'^ VOt. 



IN. B. 



.tate CAUSE OF DEATH In pinin term., th.t it m»y be properly cl»...fl.d. The Special Inlorm.t.on fer p.r- 



•Rvery 

state CAU; 

Ron« dyJnft away from home should be Itiven in every instance. 






If 



( 
« 



I 



i 



f 

t 

« 



t 






.i/<' 



• /' 



L. V - 









f I 



: ' 



\ 














i 



If 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,f H. al.h . vo .tjuT^^Hf^tM-.. REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 

971 



<7^^^ V. ^^ V_ > 



uu.ll i^ ^'^^H 

Deputy Health Officer 



Registered J\^o, 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Certificate of Beatb 

I TX. S. StanDarC* ) 



^i 



PLACE OF DEATH: — County 



of JO-">vv'.\.CX-'ivCoJ.'CO City of ^J O^V vJ 



G 



on 



KjO^^ \.'Ca^' ti, c 



Dist.; bet. 



1 / .r oi*TH OCCUR, iw.v r^OM USUAL RESIDENCE G.vt r*CTS CM.LCO ^O" "N^DER ^J^^/i^'^^^J^^J*;*'* ) 
\ \ ir Ot*TH OCCU»»Vo IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

LLsL 1 v^^c k- jVv^'^'>^cc\-<X...-. 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



•KX 



^\oL. 



c< 



H.OKA 



\ 



{TXrx.cx^^JUL-^ 



I' \\y Ml HI KIM 



\'.l. 



MMitth* \ 



s 






(Yian 



H t) JVi;» 







./■// 



/'./l.« 



\VII»n\\l-.l) «»K l>!Vok«KH 

W'litf in vikimI il«-«i»'U.iti<'n) 



lUKTIItM.XrK 

fstatr or t"iiiinti v 



NAMK ni 
I A THKR 



lUR IHPLAlK 
<>» I A I'll KR 
(Statf or Country 



MA 11)1 .N NAM): 
<>l MOTHKK 



I'.IK lUl'I.AlK 
<»1- MoTHHR 
(Statf i>r Coimtry^ 




clxw-m:^ 



MEDICAL CERTIFICATE OF DEATH 



DATK OF ni-ATIl r\ 



,CUQ 
(Month) T 



11 
(Day) 



(Year) 



I IflCRI'liV C1:RTIFV, That I attetKltMl <leceasc<l from 

VJLu ITk it/oH to iXvMD. ..U T90H 

tliat I last saw h alive on uL^«wQ' II 190 l 

ami that death occurred, on the date stated above, at vs O 



'^ 



C^VUj 



occri'ATioN ^ ^^ ( 



f\e^it!ril ••> >i/>/ /;.;;'./>'•'> *> 



)Vi/» >" 



\r»it/f 



/hn- 



Tin: AM(»VKSTAT1-.I> l'KK>^oNAl. VA KT UT I.AKS A K K TKl K To TIIH 
HKST 01 MV KNOW l.i:i)C.K AND HKLll".!' 



(1 



tif..!tn;nit LaJo^V^. Vi 'V &^,AX.\J^^&^ 



i^ 



(A.l.lnss 




\< 



e< 



%' 



:J,-.J^'^^ 



LIm. The CArSI<: OF DI-ATH was as follows. 

..VJ.riLL'.Lc^-l-<-A/ 

1)1' RATION ^''V> Mouths Days Hours 

CONTRIIU'TORY AiD.A-<r>>-/cJk^ Mnr^^ -t? 



DTRATION 




(SIGNED) V^A^Vu 

a 



)'iars iVofif/is Davs 



.^x^.vHUj'x 



Hours 
M.D. 



^<wLCt l?v iQo'; 



SPECIAL INFORMATI 

or Recent Residents, and persons dying away from home. 



Address) Cctu V Cc JoC^^^vJ 
IXTION only {or Hdkpitals, Institytions, Transients, 



Former or , . ^^ 

Usual Residence L I v) 

When was disease contracted, 
If not at place of death? 




I M , How ion^ at ^ . 
<^ <JK. Place of Death? aH Days 



IM ACF OI" lURIAL OR RKMOX AI. I DATK of HiRIAI. or RKMOV.\I, 

(A,.,i,..,. 2>t.T3- - \'\tL ^'%:. 



^ ? .. !• 1 AHF «hoiil(l he stated EXACTLY. PHYSICIANS should 

N. B. Every Item ai information .houicl be carefully supplied. AGE should ^.^ *7**il^''.rs ' . , ,„fformatlon" for |l«r- 

•tate CAUSE OF DEATH in plain terms, that it may be properly clasa.t.ed. The Special Information »or p«r 
«ons dyinft away from home should be 4'«ven in every instance. 



I 





I 



IV ' il 



V 



,•• '-,- ^» 






V 



'V-l 



, I 




i 

if 



1^ 



Ill 



S; 







ii: 



t f 



''■f 



,! ..f Health I N'<> ! 



1. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



*-f>rir^i. IUS.I' I'o 



^ 



1A.XL 



Deputy Health Officer 



Registered J^'^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

< TX. S. Stan^ar^ ) 

J? ^ i ^ 

PLACE OF DEATH: -County ofO<X'>V J .VC^avcv*CCGty ofaa/>X' O/^CX^-v^v-^^ 
No. -5 He ] ko.;^ St.: 3. Dist.;bet. Mb^^V^cvvCt 



..■>••>■ oreinrNrr ri\/r FACTS C*LLC0 rOB uAoCR "special INFORMATION" \ 



and ^ Aw'CV-'W'YV<X,-i v) 



FULL NAME 




X u,-a^ «. 



d 



duLcnjL.^ 



V:^ 



PERSONAL AND STATISTICAL PARTICULARS 



'M..nth> 



\'.»-: 



Voo »,»i. 



ir 



< Day) 



V ..,,'// 



(Vtar) 



/}.; t s 



-iNi.I.K MARklKI* 

\vii»« >\vi:i» »»K i>!V«»Kri:i) 

Writ* in -.«Hi;«] '!» -ivtiiit ^ui) 



(^1 



l\<XWv,Lct 



IlIK TIIIM.XOK 
st.iti fir Country^ 



NAMK OF 
FATIIKR 



lUKTni'i.ArK 

Ol I ATHKR 
ist:it«- or Country) 



MMIM'.N NAMK 
HI MOTIIKK 



lUK llllM.Ai'K 
<»l MoTHKK 
>tat« of r«>nntr\ 



OCCll'ATION 






^ 






fht 



Tin-. AllOVESTATI n I'KK^nWI, I'AKTir I !. \KS AR K TRlK TO 
HKST Ol- .MV KNOWI.I.IX.K AND lU.I.llf- 



THH 



(Informant 



/<XV'VA vX 



OfXcX-vll 



I 









MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

IS 

(Day) 



(Month) J 



(Year) 



I IIKRKRV CI:RTIFY, That I HtteinkMl ileceased from 

<..L\,Vr\ .- 190 t to ^M-VOL 1.3 190 H 

i 1 ^ I a 
that I last saw h • alive on '^Vva » 190 . 

ami that <Uath (»coiirre<l, on the «late stated alnn-e, at v? >J5 

jjL M. The CAl'SK OF DliATII was as follows: 

\jk^v<r>A.^*/ti vnXYvvv^-^tvA 



DIR.XTION y^itfS .Vofii/is nays Hours 

CONTR I lU 'TORY ^JA.<vX'Y>^v<rY^MOw\XA, L^^^cL^^^ 



Dl' R A T ION ) 'cars Months % Days 

(SIGNED) LO. O. VMvY^^.^ . ^ 

OLcvn ;?. ICO'. r.Lues.) lUdD\ia-.J 



Hours 
M.D. 



SPECIAL Information on'y f«r Hospitals, institutions, Translfnts, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



How lon(| at 
Place of Death ? 



.. Days 



I'l.ACK <»I- BIRIAI. OR RKMnVAI. 



SDKRTAKKR vJ oJLX/^V^v-^ m ■ -w^ w^ , 



DXTI'.of Hi KiAi, or RKMoVAI. 



f 



">-vu 



c 



'f 



, rr. ArF ohrinld he Stated EXACTLY. PHYSICIANS should 

N. B.— Every Item o« ir.form«tion .houlcl he carefully «uppl.ed ^J^^^^^^J^/^^,^^^^^^^ Information" Ur pT- 

state CAUSE OF DEATH In plain terms, that .t may he properly Uass.tiea. 
sons dylnft away ?rom home should be feJven in every instance. 



' H 



i 



1 




1 

• 
t 


f 


t 


} 


] 


l« 



Wl 






jL'm 
















>-" 



i t 



I 



Bit 



> 





V 
li 



'^ 



III 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



..,1 . f lUaMh-l-No n ^^y^J^ HM'C 



JfJO^ 



XiM.^v^ kil/x^M. Deputy M^ nf-h omcor 



Registered J\^o, 



973 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



PLACE OF DEATH: — County 



Certificate of Beatb 

( "a. S. Stan^ar^ ) 
of Cb^W J AX?L^vcuiX:rGty of C/.Oy^A; J A^ix-vvc^^ <? l 




^CL^^V^C 



^^vCL*L 



St.; 



Dist.; bet. 



and " 



) 



.>I.Vj 1 WV V-A. I V,*^^ ..«,,-, nr^lDCNCE G.Wt r*CTS C*LLCO rOR UNDER ' SPtCtAL INFORMATION ' N 



FULL NAME 




cLd 



^k.k 



^^A^' 



^K\ 



PERSONAL AND STATISTICAL PARTICULARS 



^.V 



J X^-NX ex 

i<\ ij Ml r. Ik III 



LL M.±i. 



M.tith* 



3» 



(Vtari 



\ ' . »•; 



slN«.I,K MAKKIK!* 
\VnM»\Vi:ii OK IMVnKiKI) 



IC 



i r 



/)./ v.. 



iiiK rifPi.MM-: 

Siiitt or Country* 



N\\f|- Ml 
» A I MI.K 



mRTMI'T.ArK 
OI- I ATIIKK 
(State or Country) 



M \II)1:N NAM1-: 
<n MOTHKR 



lUKTFin.ArH 

<>|- MOIMKK 
(Stalf or l'ountr>' 



over TAT ION 






lcx^.(iio 



<XKKJL^\j 







dl. 






ir / I ill)' : >''^' < *" ' '"'' 



M.'illr 



/Kn 



Tin, AHOVKSTATl-.I> J'KR^ONAI. PAKTUM I.AKS A K K TRrH TO THK 
HHST t>I" MV KNOWM.lx.K AM) iu:i,n;i" 



Infonnant Uj »^ • ^ \l »^ 



<h^iX<5 



(^ 



'A.Mr, .s \f)\<x^^^y^K<. \Ji/yy^jX^ 



rl 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DHATII H 

(Month) a <^y^ 



(Year) 



~ 1 IN'UMRV Ci:RTirV, That I attended deceased from 

^LvN,<:^....ii. 190 \ to AAvvo. .1.^. 190 H 

tliHt I last saw h alive on LUvC^ 13, 190 

and that death occurrctl, on the date stated alK.ve, at A OV 
J M. The CAl SI*: OF niCATII was as follows: 



DC RAT ION y^^'s Months Days ^\ Hours 



Pavs 



Hours 



nr RAT ION Xcats Months 

(SIGNED) U/^i U)-^\ -• M.D. 



.k>.^.<:\ 1- TQO 



SPECIAL INFORMATION »»'> 'or Hospitals, Institutions, Transients, 
or RfCfnt Rfsidents, and |>ersons dying away froni homf. 



Formfr or 
Usual Rrsidf nee 

When was disease contracted, 
If not at place of death ? 



How long at 
Place of Death? 



Days 



ri VCF OF- BURIAL OR RKMoVAL I DATK of Kt RiAl. 



or REMCJVAI, 



1 9o'i 



I NDHRTAKKR 

(Atldress 






, ,. . .pc .hoiild be stated EXACTLY. PHYSICIANS should 

N. B.— Every Item olf infarmation .hould be carefully supplied A(,b s ..^^^ ^he "Special Information" far par- 

atate CAUSE OF DEATH In plain terms, that .t may be properly clasaitiea. p- 

aons dyinft away from home should be ftiven in avery instance. 



V, 

t 



ri 







r 







~^'t. 






r-. 



mwmf^'^fl^^ 




'<V 



r-' 



\ 



yt 



1| 



t 



! -4 



/> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„..,,„ ,.vo M^sC^l.fi.'. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

974 



dh' riii'fi , \K' 



i 



C*-^^ ^^o 



:ri 






l!)0'i 



Registered JS/*o. 



• y 



f*-^ 



3fTinf^r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "a. 5. StanDarC> ) 

J? ■ (^ 4 ^ 

PLACE OF DEATH: — County ofUO/^v -3 AxXAv.coiCx.City of Clay>v Jaxl^wc^^c l 

No. MP. ^^cu 



St.; '^ Dist.;bet. '(IVC'Cu^<i. and CjA-txM, ) 



-- ,^r.^ il«llAI RFSIDCNCE GIVE FACTS CALLED FOB U N DE rV ' S PEC I AL INFORMATION* \ 



FULL NAME 



Cl.LL4H^^«5).ti.W]; 




\j^\.aM.. 



t 



^HX 



PERSONAL AND STATISTICAL PARTICULARS 

fiwt ' '■ To.Lt. 



DATI «'l 111 Kill 



\ ' . r. 



Month' T 



)-.n 



(Day) 



1A.»/.'//' 



( Vrar) 



P.J»: 



VVIDmWKH ok IUVmRvKO 

Wnttiii MH-iaJ lU ••iv'tKiti'Mi) 



ci 



fSt.itfor (.'unntrv -X 



NAMK or 

I ATIH.K 






A 



V 




V>V 




flv 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



(Month) j] 



1 X 

(Day) 



(Year) 



I IIRRKBY CKRTIFV, That I attemled (Ureased from 

Sin>\j LI-cvq X 190 H to - ' 190 ' 

that I last saw h ^ ^ alive on *^. - 190 

an«l that «kath occurred, on the date staletl above, at ^ 



^ M. The CAISH Oll^Dl'ATI! was as follows: 






niKTMI'I.ACK 
o! I ArUKR 
(Stall- or Country 



M \ii»i:n' n ANtr 

<»1 MoTIUK 



luk rniM.ACK 

<»l MoTHKR 
St.'ttc ur Country) 



JLvxo y 



V 



i! 




iX' A 



_Cj cr>^<y^Oj 



.0 



V 



oCCrPATION 

fyr^iiirif III Siui I'lam : '■> 



— ) fii I 



M.'vth- 



Da \> 



TMK AHOVK ST\Ti:i) I'KKSONAI. !■ A KT IC T l.AK^ A K K TKl H T« > THH 
IlKST Ol- MY KNOWI.I-.IX.K AND Hl-.IJlvf'" 



(I 



. vva. \ 



nfu,m.-mt ytr!v>\.; i) \J I \ O^vt 



'^ 



DT RAT ION )'t>^f 

CONT R I P.rTO R V ic^^il^^... X'.-«A,A-^ 



Months Days 



Hours 




nr RATION ^ )V<7;'5 

( SIGNED ) ...ud.^A.^^/'>v 



Mouths Davs 



Hours 



a 






V<^Q 



L_—i— - 

IaL INF 



^Address) ' "Xl ''a,O..V<- 



Rons, 



SPECIAL INFORMATION only for Hospitals, Instiluttons, Transifnts, 
or RfCfnt Residents, and persons dying anay from fiome. 



Former or 
Usual Residence 

Wfien was disease contracted, 
If not at place of death? 



Now lonq at 
Place of Oeatli? 



Days 



DATi: of IHkiai. or KlvMoVAI. 

^L^vo. I'' 1901 



ri.ACK OF nrRIAI.4)R KHMOVAI. 

INDHRTAKKR U- tO. M [\^vU>v M.} i 



, ., . .^p »u„..i,l he Rtnted EXACTLY. PHYSICIANS should 

of information .hould be cnrefuMy «uppl.ed J^^^'^^^^^l^^^^^^ Information" for pT- 

E OF DtATH In pinin termg, that it may be properly «.ia«8mea. f 



N. B.— Every item 

state CAUS^ ... ^ . . . . 

sons dyinft away from home should be ftiven in .very instance. 



r^ 



li ' 



! ft 







;^: ;'"»•• '^. 



KJ' / 



K\ • 



) 






^r 






i f^ 



'\ 



i 




-fif 



• I 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



llrallh I- N'l I* ^'t:7S^ 



■^'V^m-Z-i. liM' •• 



n 






^ 



A^<^-^ 



I3enti»-w Hepilth Officer 



RCFER TO BACK OF CERTIFICATE FOR tW3TR0CTION9 

975 



Re^Lstei'od JS'^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



PLACE OF DEATH 

'2 1. ^ 



Certificate of IDeatb 

( "U. S. 5tanC»arC> ) 
. — County of )<X>^ 'va^veULtc City of 'CL \v vJ 



(^ 



K (X >'VCA^^ a i 



\ 





4 I SU H Dist.; bet. Crl^tr^>v and (lL^/aVVv4Q > ) 

..CUAI RESIDENCE GIVt FACTS C*LLtO roR UNDER "SPCCAL INFORMATION • A 



MV 



FULL NAME 



,.J^-.^ V 



^ 



*'VJ. 



PERSONAL AND STATISTICAL PARTICULARS 



I' \ I » Ml HIK IH 



\' .». 



♦ 
%!. nth 



IH 



rly^. 

(Yt>ar) 



/',,M 



*^i\«.i,i M \Kk ii:i> 

\Vrit( ill 



'. --■'•1.'t'.>M' 



K-. 



», V. 



niiiT!iri,\t*K 

!Stat« or I'Muntry* 



NAMK <>l 
FATHKR 



lUkTUri.AVK 
<>l I ATIIKK 
IStateor Cr»uiitry> 



MAini.N NAMK 

"1 mothi:k 



HIK lIMM.ArK 
Ml MmTIIHK 
' Sl.itf or loiuitt \ 






'r . . . 



Mcrri'A iiMN 



\^ 









-> 



AV-;,/^,' //; V.;>.' / '.'". ■••'• 



5 ': l! I 



M,,>iffi' 



/',.•! 



rm: \hovf. st\ ti-d pkksmn m. rxKTuri. \ks akk iki k to tmk 

llKST *)1- MV KN'mW 1.1 IX.K \M> lU.I.Il 1" 



( IiifoMnnnt 



:^^V \^ V' 






-^' 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DKATIl 1 



(Month) 



(Day) 



/9« N 

(Year) 



I~i7fRKI{V l I':RTrFY, That I at Uiu Km I «Uoi asetl from 

.vLl.S.U '\ \vf> \ to WL^^A^a ^'-^ Ttp'l 

that 1 last saw li - mHvc on Lb^v.5^' li 190 

aii.l that ilcalh »)rcurre<l, «>ii the «lato statol al)ove, at i 
Ov, M. The CATSIv Ol' I)I:ATH was as follows: 



I )r RAT ION )Vv7/.T 

CONTKIP.rTORV 



A/of///is Pays //c»wr.? 



DIRATION )V<7/-5 



Months 



(Signed) v-d-^A^o.vcL A.' 

LL^O ^^ TOO (A.l.lress) ^"tH^ 



Days 



Hours 
M.D. 



A 



a 



\t 



SPECIAL INFORMATION nnlv for Hospitals, institutions, Transients, 
or Recent Residents, and persons dving av»dy from liome. 



former or X'x^ ^ 
Usual Residence ^ 

When was disease contracted, 
If not at place of death ? 



HoH lonq at 
Place of Death ? 



. Days 



n.ACH <>i- I'.rKiAi. mk ki:mmv\k 



Olu . 



T^ ~f 



DAllvof Ht KlAI- or KI;MMVAI. 

v' • ^, . 190 



INDHRTAKKK 

(A<l(lress 






% 



M. \.L 



VuL^V^v.v. -'.L 



^ ,j ,,^ stated EXACTLY. PHYSICIANS should 

IS. B. Every Item of information .hould be carefully supplied. J*;' *; "',^„i^^j^d. The "Special Information" for pT- 

•tate CAUSE OF DEATH in plain terms, that it may i« p r P 
son« dyinft away from home should be given .n every .nstance. 



I 



• f 



If 



w 

li 



i 



• i 






s 



^ 



s *- 



.V, / ^ i. •— » 



> V. 



^^-. 



■ \ •^. 




} 



! 1 



I I 




M- 





•»f 




r :'•} 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

976 



f Hrn!lh-P Sn It ♦'ti^r*^ '♦*^*' ^^ 






\.>s..<i^ ^2) 



li)0'\ 



liedisfercd A^o. 



cLcrwU ^v^^ Deputy Health Officer 



N^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of Bcatb 

( XX. S. StanC^arO ) ^. 

J ^ ^ ^ 

PLACE OF DEATH:-County of "'a^ O^^^^^^j^^ity of Jo^^^ OXO.^ 
Hft H]^J ■ t St.; ^ Dist.; bet.lL a<lK.c->-Lalft>v and V-lo-l 



C-*-<^CO 



FULL NAME 




^ 

-^ 



M- 



PERSONAL AND STATISTICAL PARTICULARS 

i COI.OR 



ojji 

I'MK OF liiK I H \(5?) 




IX^U-cvc- 



yj- 



M..Mth' 



A«*,K 



35l . 



5 



X 

(Day) 



\I.,»ih 



9 



Yf ar) 



/'M 



"^iNt i.i* M\Kkn.r> 
wiixtuKii nk i>:\«»Kii:i> 

(Write in sticial «li-»itf nation) 



lUKTHI'l.XrH 
*^t tft 'ir I'onntry' 



NAM J- <»l 
PATH I R 



HIK TMri.MK 
Ml- I A rill- k 
iStatf ot Cull lit IV 



MAIDKN NAMK 

<»i M(»riii:R 



!UK rin'i.ArK 
"I M(>rm..K 

^t:it> I fdUlltt \ 






>x.-i 




W^VU 



f\,.C^- 



Vw I ^- V 



Ov'OlTA rM)N 



•^ }I,„'fh- 



fh 



THK MIOV!-: Vr\TKl.l'FRs<.NAI. rVKTUri.XKSAKi: TKIK Tw TMH 
lli:sT i)I- MV KN(t\\ I,i;i)i^.K AM) '*']^il- 



'liifufnirint 




■^' 



I X'Mrf^s 






MEDICAL CERTIFICATE OF DEATH 



fQoH 

(Year) 



I.\TK OT- I>r.ATH ^ 

(Month) J <I>ay> 

I in:KI':r.VCi:RT[FV. Tliat T attcn.UMl deceased from 

.......JL i^rrr^— to 19° '~^~~ 

tliMt I last <aw h alive on " '■ ^^ 



an.l that death occurrcl, on the date statt-.l ah«ni', at 
— ~ M. The CAlSlv OF DliATII was as follows 



Dl R.\TI()N )>ars 

CONTkinrTORV 



1)IR.\TI()N >V(/;'5 



Mofi//is 



Days 



I /ours 






Mouths Pays 



I/ours 
M.D. 



( SIGNED , - „ , 



SPECIAL INFORMATION only for Hospitals, Institutions, Translfnts, 
or Recent Residents, and persons dying away froii home. 



Former or 
L'sual Residence 

When was disease contracted. 
If not at place of death ? 



tloH lonq at 
Place of Death ? 



Days 



lU.ACK Ol lURIAI, OK KKM'»\M. 
I NDKRTAKKR ^AJ 



nxi'i; nf 151KIAI. or RKMOV.-\I, 



190 






i i 



I; 

i 

i 



r 






,f. 



* 




^^' 




<^ 



•1 








!N. B. 



^-^— — — ■ EXACTLY. PHYSICIANS nhould 

Rvery item of Information nhoulcl be cnrcfully f^PP''*;"; J^i^^^cZ^clLsir^'l The 'Specia'! Information" for p-r- 
state CAUSE OF DEATH in pinin terms, tha .t may ^^ P^^^f •''^ 
«on. dyinft away from home «ho«I.I be ftiven in .very instance. 











m 



!«|f'^ 



: i 



:| 



': I I 







■ 



> t 



m 













m 



l'.,.r.1 -I! '\h IN'' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

' »^*r' '"■ '■ ' ■ REFER TO BACK OF CERTIFICATE fOR INSTRUCTIONS 



1 -^ 



l!>0'i 



Be mistered J\i''o. 



.Crvcv-Xi 



V Kj\y<^ Deputy Health Officer 

DEPARTMENT OF PUBLIC IIEALTH==City and County of San Francisco 



Ccvtificatc of Bcatb 

PLACE OF DEATH:-County oPa^v Vcuwt^cc City of 'a. 



No 



l'^^-'^.-^ll St.; 'I Dist.;bet. ^Ji-^^'^H. and Jv 



0- vll' 



FULL NAME 



d^WOL' X jUlA-Cit 



PERSONAL AND STATISTICAL PARTICULARS 
llXTK «'! MIKTII A V 



\< I- 



"-^ 



5 ,.i 



.l/f.wM> 



At:. 

lYtiii 



An 



-'IN'.l.i: M \KkIl t» 

w nn»\\ I- 1> MK i»n • >K» I i> 

Writ, in MK'tal «lrvt|ftiat»«iM! 



stMt* ..T Ciiiiitrv 





VAMK III 

1 \in 



n'n^ <1D 



A^Y^VC ^ 



Hik riiri.At K 

<H- I ATIIK.K 

' St;ltt or lolUltt V 



\t \1I>»N NAMK 
<>l Molin-.K 



IMKTmM.Ari-: 
'•I NlnTllKK 
■^t.itt or (."ouTJtjyl 



CLXVU-cL 







1, 



s^ 



^ 



V iXK^^q^..-^' 



^\ 



«>*. Ill' A rioN ^> , 



M.oiffr 



lh!\ 



TMKAH.)VKSTATKI>1'KR^«>NA!.r\KTU-ri XKSAKrTKlH To TMi: 
BKST <)J- MY KNOW!. MIX. K AND lUIJlJ- 



(liif >:ni;»nt 



rvMn-.. 1^ Cil '-^^C OU 



MEDICAL CERTIFICATE OF DEATH 
PATH OF DJ-.ATH I 



(Month) \ 



IL 

(Day) 



I go 

(Svnr) 



r llIiKKRV CI'RTFFV, That I atten«UMl ilecoased from 

cL^^a 1 190 '• to .. _^ II 



IX X 190 '. to ^A.'c.^w<a ii igoS 

that T l;mt saw h alive oil Lk.^-\-C^ up 

aii.l that death <>c<urre<l. «>i! the .late <lMti<l alxne. at u' 
J M. The CAISH ()^M)HATII was as foll..ws: 

DrRATK^N ' Vtars Mouths Pax^i 



Hours 



CONTKII'.l TOKV 



DTK AT ION , >V<^''^ 



Months 



(SiGr 






Pays 



Hours 
M.D. 

UU^n i<,.H (A.Mress) ^^0 ^.^vtt,C'^. '^l 
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dvinq dwav froni home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How lonq at 
Place of Death ? 



Days 



UI.ACK 01 lURIAI. OR KKMOVAI. 



i)\ri;<>r in ki.ai, or ri:movai. 



^\ 



\'S 



T90H 






— — — --- — ^^ ^^^^^ , EXACTLY. PHYSICIANS should 

N. B.— Every item oV Information .hould b. cnrefully f^PP'-;^' properly classified. The -Special Information- for p«r- 

•tate CAUSE OF DEATH in pinin terms, tha .t m»» .^^ P^ ^ ^ 

son. dyinft away from home should be ftiven .n every .nstance. 






I 



I 



t 



11 



4 



m 




j! 


'>^. ji 


i 


tt 'I 


■ 


lu-J?, 



:il 


Wki'--^^^M 


■ 


^^B^mH 


BPm 


r» ' ■> 




■ 


BIF^^^^^PI 


|B5^^ 


_ 


'•>' **'':. 




■'■^it-^ '-^--"^^j 


_^5l'> - 


- • 






- y^->^:i-ji 


^^^^^^^^^^B"^ .< 


- 


r 




w'-r - ^» ^ 


.1.^^ Lr 



I 



i i: 



¥ 



} f 



< I 



pi 



I 



I; 



't 



k 

^ 



t 




II 



f llraltli I ^■< 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



*-'; -s -i, !!\ )• 



/ht/c lllt'^l , \Xa^ 



^ 



J: \^ 



K^l 



^' ne~ ^ '^--^Ith Officer 



l{e(!i,stered J\^o, 



978 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S^eatb 

( H. S. 5tanC»ar^ ) 



% 



PLACE OF DEATH: — County of 

AM 



.\ 



I \^ 



A/xr,\M'. City of O CLrru Xxv> vai^^ 



FULL NAME OXfrVat "Vtcc^rt' 



) 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



'^))l 



^ ;} 



<5L^« 



i»\ I I' «»i itik III 



M..iitl}' 



IS 

il>:iy> 



\ 



1 I 



\ ' . K 



•^ 



Vrai I 



An. 



">»iv<;i,i.: MAKf<ii:i> 

\VIl»n\V|-:ii i»k !i!VMkrKI> 
\\?il» ill Micial <l«»ii'!i;tli<Mi> 



iiiu I MiM. \ri-: 

>.t.it« iir c"<mntrv 



NAMK nl 
HATH IK 



HIRTHri. \*K 
ni I ATI IKK 
Stair or C«Minlry> 



M\n»KN NVMK 
<>I M(»THKK 



«»» MmTHKK 

^^t.it' oi VtniJltt \ i 



(hhtpaiion ^ 









v^jlC 



t ^ H 



.. ^.' 



Kfidni in *^.;»' /'' <?"' ^^•'<' 



) V<r ( 



yh'iiths 



nti\ 



Till- Am^VKSTXTKDrKK^ONAl. rAKTirri.XRSAKi: TKl K T' > THH 
IJKST t)l- AIY KN«>\VI.i:iM-.H AND Hhl.IKf- a 

(inr.nna,,. ^"^ ,^ ^ , ^ ^ ^ .CK A > ^ '= ' -^ O xJ^ 



(Iiif .nnant <' ,^ . r* , ' Uw "J /C V 



\ 



(Ad.l 



„0 






MEDICAL CERTIFICATE OF DEATH 



DATK «>l I>i:ATII , ^ 



I go 1 

(Year) 



(Month) ] 'I>ay> 

I lli:Ki:nV (.l-RTirV, That I attcn<lc«l deceased from 

]^ ^ r .: ,t^:s to )>wLo^ U TQOH 

that I last saw h alive on llvv<^ -IL 190 ^ 

aii.l that «Uath .xHurrcl, mi thi- Matt- stated above, at O 
UL M. The CATSIC Ol' DI'ATII was as follows: 






\X!C^^rv^- a 



DrRATION JV^'-J 

CONTKIHrTORV 



Mouths >' ^ />'tfj.? /A>wrv 



DTRATION 



Yeat- 



Months 



Pavs 



V 



Hours 
M.D. 



^ n 

(SIGNED) lO. V). V^^vlcL^ 

Cl^^Cti^ TooH (Address) lU ^ -t V^- ' V ^ • • - 
SPEcTaL information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



r «, n (\ D Hew loiiQ a! 

SV*n«llUA^W^wM. Place .. Death? 



Days 



When was disease contracted, 
if not at place of death ? 



ri.ACK OF lURIAI, OK KKMoVAI, 



DATKof Hi RiAr, or KKMOVAI, 



r 



Ceo. "" 



' """^ rr ItF should be stated EXACTLY. PHYSICIANS should 

N. B.— Every Item of InfformBtion should be caretully «"PP«"^;«- ^^ , clarified. The "Special Information" for pT- 
state CAUSE OF DEATH in plain t«rrm«. that .t m»> « j;"'*^*^ ^ 
son, dylnft away from home Hhould be fciven m every mstance. 






i 

\ 



! I ' 



I 







'iVl- 



,.j' '•: 









*J 



' i 






I t 



i ■ 



I 



m 



.^/^ 



M 




II, ''»!■ I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Vo :. *^£X n.tl' r.. ^ WEFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 

979 



Begisfered J\^o, 



X<rv^^^ Jvlv-i^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

» "a. S. StanDarC* ) 



PLACE OF DEATH:-County of O.a^ vWc^^xe^cXity oi^CX^ J A^.:^ ^-.o 

No. i^5>^ ^ cvLLcu 



St.; \ Dist.; bet. 




,d (flDxi,^ ) 



'^ ^-^- V-\-C\/ ., nrcinFNCr Glut r*CTS*c»LLtD row UNOtn "SPCCIAL INFORMATION' "\ 



FULL NAME 



Ul. 



tl 



o.^ . 



Lvs_^a Ua^WU 



(\A^\^s_\_a 



Va-A^ • 



PEnSONAL AND STATISTICAt PABTICULAHS 
SK\ A \ i COI.OK 

Villas 



\Ia 



1> \ I 1 «•) t.lK 111 



ACK 









\f.WfA' 



I ^ 



\VIIH»\VKI» OK 1»!\mK» i:i> 



!UK TUIM.XOK 






V« ar J 



A» li 







'YWV\.VA^>^ 



lUKTHPI.ArK ^ /j 

«»l MOTHKK fl y 

^l.iti or Counlryt «*. ^ 



NAMl Ml- 
FAI III.K 



lUK Mri.XVK 
<»» I \rilKK 
'Statf or Countryi 



M\II»KN NAMI-: 



^,.: 






M.nith 



/>,l\ 






Tin: AHOVKSTXTI ni'HR-^ONAl.PAKTirri.^'K- ^»^'" '»*''•- '* * '""*" 
IlKSTOI MY KN»>\VI.1.IH'.K ANI> lUIJlf 

(In for ma fit vJL'^V-V/>V/0^ V' LV\V^'^ 



MEDICAL CERTIFICATE OF DEATH 
UATK OF IH'ATM '^ 

(Month) J <I>a>'^ 



(Year) 



I III:K!^RV certify, That I atUmle*! deceased from 



A-A-^ 



nr RAT ION 

CONTRIIUTORV 




Hours 



.Q I 190 H to L\AA^ iX 190 H 

that I last saw h - alive on LU^<^ I ^ I90 '^ 

aiul that drath tKCiirre«l, nn the date stated above, at O 
0^ M. The CAISP: OV DIIATII was as follows: 

(WW.k^^^-t^4 ■ 

Monthn IH l^ays 

DIRATION ^ Years Months Pays 

{ SIGNED ) UjUJ^.WvVJ . XoJlIL^' 

GL^^q IQOS (Address) JCH H UvL^lhA^t 1^ 
SPECIAL INFORMATION only for Hospitals, Inslitotlons, Transleiits, 
or RecMt ResldMts, and persons dying away from home. 



A^VVVflXft^A^^A^... 



Hours 
M.D. 



Pormf r or 
Usual Rrsidf Rcr 

Wlifn was disease contracted. 
If not at place of death? 



How I0R4 at 
Flare of Deatli? 



Days 




AxMA.^ 



J'l^CE or niRlAU <>K KKMoVAI. 



I NDKKTAKKR 



. V. 



DAIi;-*! I»i KiAI. or RKMOVAI, 

VXwCj^ \H T90H 



(AcMrcss 



Ibl 



V^'^-'. ^^^- 



f\^ 



"^ '^ iT^ ItE should be stated EXACTLY. PHYSICIANS should 

N. B.— Every item of Information should be cnrctully f"PP«-^; ^^^^^ classified. The "Special Information" for pT- 

.tate CAUSE OF DEATH in plain term., that .t ma> ^* PJ^PJ*^ "> 

so^. dying away from home should be given in .very .n.t.nce. 



f 



t I 



sit 



i 



I 



tu 




«# 
















'I 



M. 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CgRTIFICATE FOR INaTBUCTIOWS 

980 



. r ]i ..nil I ^'^ '■ "**;.3f-r 



i) \Mk\' *'w 



/i XJ\M^ Deputy 



d^^^A^A. 



alth Orffcer 



Be^Lsiered J^'^o^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



1 


i 




\ 


1 




\ 





Certificate of Beatb 

r •a. S. StanOatC ) 
PLACE OF DEATH: — County of^CL^x 0,^ /-• /v>^. o i 






\h J c*. i Disfbct V^'clcv-.-^^- and cL(Xa\.^^vvO..) 

VJ^\CKV<X^V>CV*.( M^; ^ i-'»ST., DCI. -SPCCIAL INFORMATION \ A 

FULL NAME J -UrVy fc Xcuxv-tx^v^ 



No. 1"^^^ VjS\cKVcl^.v.-<X*. 




PERSONAL AND STATISTICAL PARTICULARS 



• I . \ 



A 



\ 



^ 



> 






'-"" VL 



\ 






AGK 



H 5 j>rt,, io 






Mottlki 



? 



I . :it 



A#w 



\\|IM»\VKI» OK DIVoKrKI) U 

Wiiti in •MHial <li^u'ti.tti<»ii' "A 

HIkTHIM.AOK 
(State or cNwintry* 



,1> 



1 



L 



NAMK n» 
FA IHl.R 



HIKTHIM.M'H 

<>»■ I AIHKR 

' St:iti -ir Country^ 



MAIUKN NAMi: 
nl MoTHKR 






Oa 








tt 



CV^^"^-^<^ 



lUK THPUACK 
»M MOTHKR 
(Slatf or Country) 




Krulcd III N".7>/ / ;.r>/. /w.' \ U ' "" . 



(^ 






I SDKRTAKKR 

(AcUlre! 



nriilri! in ></'/ iiiim''- « — 
TMK AHOVK STXTKl. PKK...NA1. »' K KTU'r ';AKS ARI- TRlK TO TMH 
l»i;sT Ol- ^Y^ KNOW 1.1. IX, K AM) Hl-.I.ni 

(Infonnant ^^-A^^^^/'OU JVO^OMX 



(Address • v w w -^ - «-» ) ^^ — ^—— i^^^ ..^,« . u 

-^— ^M— i4— , pvACTLY PHYSICIANS should 



(AM.lrcss R ^ ^ rvA^<U^ ^ M ^^- 



MEDICAL CERTI FICATE OF DEATH 
DATK OF l»KATH 




(Month^ 



11 

(Day) 



(Year) 



I.IIKKI-HV Cl'RTIFV. That I altemUcMtH oascd from 
^ ' to LUa^OL i ~ 



^iV^wW ^1 I90H 

that I last saw h .^^ ' alive on 






ICjOi 



»v 



a,ul that cUath CH-ourrecl, on the .late statcl alK.ve. at 
(j M. The CAISI': OF DIvATII was as follows: 



up 

10 






CONTKIIU TORY 






I /ours 



Dl'RATION 
(SIGNED 



Years 



/lours 



Mon/Zis 1 3s Am 

SPECIAL INFORMATION only lor Hospitals, Institutions, Transients 
or Rercnt Rcskfents, and persons dying anay from home. 



Formfr or 
Usual Rfsidcnce 

When was disease contracted, 
If not at place of death ? 



HoH lon9 at 
Place of Deatli? 



Days 




A I, OK KKMOVAU 



l)ATI)of HiKlAL or RKMOVAI. 

CXcA^q, \ '\ 190'^ 







i 



f 



I 



>1 



P^5 



^* : 






,^ 



pi 



i 



1/ 



I 

II' 







«i 



IwW^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R gfER TO BACK OF CeRTtFICATE FOR IIMSTRUCTrONS 

981 



jv«,rri i.f ii«Mit»> - r vo 1 ^ ♦x^£i>*> M\ J ^ 






7~ V < -* » » ■^ ».♦ 






Ee^istcred •A^o. 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "U. S. StanDarO j 
PLACE OF DEATH: — County of V <X^^ J AX>^>^<X.4 t(City of^OvYV AXV^^.-c^v^eo 



, , ± 



Nn ISl'i'il \J iLouvf'v.e.T' St.: ^^^ Dist.;bct. 1 1 Uv and ' pv 

/ .r ot.TH OCCU-. .w.. r.OM USUAL RESIDENCE G.vc r*CTS c.lleo ^O" ^o,, ^'"C-.^^'^^-^^JJ';"" ) 

V ir Dt*TH OCCOf.PtD IN • MO«P.T*L 0« INSTITUTION GIVE ITS NAME INSTCAO OF STREET AND NUMBER. • 



tL 



FULL NAME 




(pvttVCC' 




UNTi: nl lUKTII 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR \ 



(Month) K 



IL(-A 



Ar.K 



ab 



) Vii » 






(Day) 



MoMlh." 



JL 

(Year) 



I\i 1 . 



sfNC.I.K MXKNir.I* 
WllmUJ.li <»K I»!V«»Kv»:i» 
iWritr in MK-ial «iiHiirnation> 






!UK rHI'I.AOK \ /A A 

'*it;it»- «.r «;.>untry^ | ' I \M 



NAMK n|- 
FATIIKR 



HIKTHI'I.ArK 

Ol- I ATIIKK 

• Statr .)r Country) 



MMUKN NAMi: 
Ml MoTHKK 



niRTHIM.ACK 
«>l MOTHKK 

f St:it« or roiintry I 




MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 



Month) /T 



1.1 

(Day) 



(Year) 



I in:Ri:nV CI:RTIFV, That I attemlcd deceased from 

LLv-\-cy ^ 190H to LLvw<i. s.'X 190 H 

that I last saw h - ' - alive on L^-A-a^Ol ^"^ 

and that fleath oceurre<l, on the date stated above, at 



190 



■" M. The CAlSIv C)K DHATII was as follows 




ctvLiv 



C>AxJUx 



■> 



^v<i^ 




rY\j 




Ou 



\ vwdw 



OCOrPATION 



Tni: AmivK statkh i'Hrs(inai. far rim.ARs arf: TRrn id thk 

HHST OF >1V KNOWI.HDf.K AND MlMJllF 



(Informant Vj iVAxJfvCOuL \j R? ULv^.'N^ 



4^ 



(Vddrrss 



■f 



DT RATION Years 

CONTRIIU'TORV 



Mouths 



Days 



Hours 



DT RATION _ y^ars .»/< 



af 



Mouths Days Hours 

(Signed) Awi -^oe-xCrv^LXXAxi. M.D. 

1^ I0o\ (Ad.lress) WaX<X^)nuyjXxi..iX 

Special information only for HosplUls, Institutions, TrMsients, 
or Recent Residents, and persons dying away from fionw. 




Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How loR9 at 

Place of Death? Days 



ri^QE OF BIRIAI, OR RF:MOVAr. 




DATU of Mt RIAL or REMOVAl, 

CLwq IH 190H 



INDHRTAKER V Aj . U WvV'^^.XA^ ^^ 



N. B.- 



.hould be carefully supplied. AGE •hould bo .tatcd EXACTLY. PHYSICIANS should 
in plJin term., that It may be properly cl«..WIcd. The "Specl.l Information" for por- 



-Every Item of Information 
otate CAUSE OF DEATH in p 
Bono dying away from homo nhould be given in ovory Inotance. 



II 

'i 








I i«Kr i. 




' >, 



i> 



li 



i.»i 



h 



\ 



; « 



WRITE PLAINLY WITH UNFADING INK 



I' Vi) 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



JfJO'i 



Ke^Lsfef'cd J\^(), 



982 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( XX. S. Sta^Oar^ ) 
PLACE OF DEATH:-County of'^^ a>^ JX<X>VCc4CcCity of OxV>^ A.<V>v e.c^ ^.. 

No. i -^^^H 



l-UU 



Iv^Lo. 



St.; 



Dist.; bet. 



and 



( " r;rr:.r:cc^v.?o^7^Ho".^r.i ?"-;s't^'.^°/c'^.vc .ts name ..stc.o or^.c.T ..o .umbc.. ; 

FULL NAME ^a.u».ut/rvc^ 





PERSONAL AND STATISTICAL PARTICULARS 



Ni:\ 



<^1uL 



K ' »1.«»R 



IojLu 



l>.\Ti: ni lUKTII 



At.K 



iM«iiUh> 



LL 



ll)av> 



\f .hffi' 



Ail 

( Vcar t 



/'.; 



WflMlWKH ''K I>i\oKv Kl» 
Utitt ill •Mwiiil «\» •iifiiiiti-'H* 



UIKTHIM.AOH 
(State t»r Cmtntry' 



iathi:r 



nikTiiiM.ArK 

f>F I ATHKK 
'St.Mtr «>r romitry) 



MMPKX NAMK 
nl MoTIIKK 



lUK rillM.AVK 
"I MOTIIKK 
st;itt or v'ouTitrv ' 



«HCri'ATU)N K^ 






X/^ x/Crv\r>x; 



O^AJuLcL \ vd- 






}r'iif^i' 



n,j 1 . 



Tnr. \HovK sTMin vkksonai. r\K i i»t !.\k- AKi iRri-: lo 
HKsT oi- Mv KNOW i,i;im;k and ui i,n > 



Tin- 



."^ 



(Infoiniruit 



\f rv>w^ J -Cwv^ 



u.i.i 



rrs»; 



XOH 



I h 






MEDICAL CERTIFICATE OF DEATH 



DATK «>l- ni-ATM ^ 

(Month) n 



I I 
(Day) 



(Year) 



L 



I m-RI-HV CHRTIFV, Tliat I atteiukMl (lecc-a,std from 



V % . <-> iqo to LvVAXX- il 

n 

that I last saw h ^>»jUivc on 



iXw.a....ii. 



190 s 



a^.ti 190 

au.l that doath <TCcnrrc<l, on the date stated above, at 1 AC 
7 M The CAl'SK Ol' DIvATII wHs as follows: 



or RAT ION 



}'ears 



^'"^ To 

CONTRIIU'TORY Qj^^fr^t-tv 



A/on //is 




Days ^ /lours 



DrRATION ^ 

(SIGNED) W. V-) 

iqo ^ 



Viars A/ouths 




/hiys I Hours 
A^tPvx/ M.D. 



LLlv^O 



(Address) dfc.XLA^VU^ foM^"fc 



SPECIAL INFORMATION only 'or Hospitals, Institutions, Transients, 
or Rfcent Residents, and Dcrsons d>ing away from home. 

% -^ ' How lonq at ^ J 

SResidenceiC)\l fclKvKJLVi ' Place of Death? ^A^v- Days 

When Has disease contracted, t- ,^ -. 
If not at place of death ? >J ^''^-«- 




l'I..\CK OF nr RIAU OR RKMOVAI. 



/Ct ciO ..AM^frtrv- 

\.\, *^I)ATK of IJiRiAi. or RE 



^ ' ^ 

INin-.KTAKKR 



(AddrVss 






MOVAI, 

I90H 



Li 



N. B. Every Item of information should be carefully supplied. ^^6 ^^^ "Special Information" for p«r- 

•tate CAUSE OF DEATH in plain term,, that .t may be P^oP^^-'y ^•»"' 
•on. dying away from home should be feiven m .very .n«tance. 



I ! 



■■^ 






I 



) 



Il 







[■J 





f II. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„_P v. „„.r^„^l-Oo REPE., TO BACK or c rRTiriCATE rOR .>.9TBUCTI0>^» 

983 



HWi 



liegLslered Xo. 



Diilr I'ili'il , LXcvOLvvaX >H 

L>uc^^ii.x^^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



X U. S. StanC>arC» ) 



PLACE OF DEATH: — County 






of O.CUTV J,\,a^xC4^c<.City of VJ- 

_ 5 \Mj and t' ,11^ 




No. H 'iH V Ll^-i ^^ ^ vl V . vCL St.; * DIst.; bet 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




L.V.^<xOj 



nKX , > \ 



^u 



roi.t iK 



X . > a. ^ • 

I*\ I I-. <i| UIK I II 



[X^A\\Xj^ 




1^ 



/ H H 

fVrar» 



\' . I 



}Va»: 



1,' „f/i 



H 



/'.n. 



'^IV'.I.K. MAkHII.I*. 
\VM»o\Vi:i» «»K IMVO«0HI> 

Uiit« ill -MHial il« •.ij'natioii' 



lilKTHIM.VOK 
'State «r Cmintrj ' 



WMl" «»! 
» \ I llhK 



RiR rmi, \« K 

OF lATIIKK 

'St:it» iir Vmniti v^ 



M \inKN NAMF 
«tl MnTHI.K 



lUR THI'I.ArK 
OF MoTHKk 
'State or Coiinti > • 



OCCri'ATION 



J 






l. 






/VW'C^/a^ 



v^rvcuxXiu LI). dAA^cuvt- 




-WXAj 



<XA'V J AxX/\^tM-<J- ^^ 



AVa/i/a/ /» Siin /'laih >•• 



)'ri! : 



}/.;/f/l- I H P"*" 



THKAMOVKSTVri-l>PKKs.,NXl. rXKTirri.AKSAKr. TKIH To THK 
IJKST <)l- MY KN«»\VIj;i)<.H \^M> H1-.I.^> 



(1 



i^JvoL/JjL/5 10. 3:txA^<x/vfc 



fA<l(lrcss 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



OL 



(Month 



^ 






(Day) (Year) 



I III:KI':MV CI:RTIFV, That I atteii<UMl deceased from 
V^-Ui ^^^ 190 '^ to . UwVua_ l^^ 190 H 

that I last saw h.^' alive on LUa^ 1^ 190 'I 

atid tli.'tt death «Keurre«l, on the tlate stated ahove, at 
M. The CAISH OF PICATII was as follows: 



VI )VcxA>CUiu^v^*^^A**-a^ 



1)1 RATION >V«//J .1A»//M.v ^'i /)ays Hours 

CONTRIIU'TOKV 



Months 



I)|- RATION >V</rJ 



Days 



(SIGNED) 



'■\'\j^ 



a 



Hours 
M.D. 



A.VC> )? Tqo'^ ( 



..Idrc-ss^l^^"" ^<>-W^3.t... 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persMS dying away from liome. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death? 



Days 



ri,ACKOr in RIM. OK KKMuVAI. I path of H.k.a.. or RKMOVAl. 



UUvubuL UjvvdUACta.Jr 

(Ad.lress ^^Jo NjYUXlA.A.Xn.v 



N. B. 



■■■■■i^^^^^^^B—Bi^^i^— — ^^^■'"^■'■"^^^■'■■'^'^"^"" IH K« t ted EXACTLY. PHYSICIANS should 

— Rvery item of Information .houl.l be carefully «"PP"«^ „pl^Hy7la.«i?led! The "Speclai Information" for p.r- 

.tate CAUSE OF DEATH in plain terms, that It may »^ PJ^P*'"'' ^'"" 

Kona dyinft away from home should he ftiven -n every Instance. 



> ; • 
I 



^' ■ »! 



ii| 



V 




'<,■;''■*• • 



,.-k.» 





\ I 



M 



1 1 





r'i 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H,«inl. f H. .ith J No n^-f^^HSclTo RCPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(( 



h' Filed, LLcoa^AXb 1 5" 



190^ 



^^^cv>o doi>>u Deputy Health Officer 



Registered JSTo, 



984 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDarD ) 



% 



PLACE OF DEATH: — County ofUCL^-u 0/LO.^XCi.iCoCity of 0<X/Vu Va.>x^c«.ct 



:ity of 0, 



^ 



No. 




tl 



\\\ M Lo^ St.; "^ Dist.;bct. IH XJf\^ and 15 

(ir ocATM occuns awav from USUAL RES lOCNCC civc facts callco roll UNorn "spccial iNroRMATioN" '\ 
IF DCATM OCCunnCD IN A HOSPITAL OR INSTITUTION CIVt ITS NAME INSTEAD OF STREET AND NUMBER. / 




) 



FULL NAME 



,l: 



A^XX^WVj 




"VX.CC/'J.A. 




SK\ 



nviK nl lllKTU 



\'.K 



PERSONAL AND STATISTICAL PARTICULARS 

COI. 









p 




M..nth' 



JVrfi 



% 



It 

<I>:iv> 



M.itiihs 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF I)1:aTH 



a 



(Month) a" 



I'v 

(Day) 



(Year) 



lLl^ 



I IN'KI'BY CHRTIFV, That I atteiideil deceased from 



1^ 



Da t . 



^IN<.I,J" MAkklKIi. 
\VllHt\Vi:i) OK IMXokrKU 
'Writi-iii sticin] lit xi^iiatioii) 



niHT!Tri,\*'K 
St;it«- or i'"iuntry> 



NAMi: Of- 
» A rilKR 



'>» I AIIIKR 
st.itf (ir c"(»utitry) 



MMUKN NAMK 
<>J MoTHF.K 



MIKTHl'I.ACK 
<M- MoTHKK 
'St;tt( or t"<»untr5') 



occri'ATlON 

Rf'i'dfif ill Siiii Ft iint isri) 



A ! 

Ml ^ 

^ CL\-»^v<'^> VA.-/OL 




^ 



190H 



to 



LLul/Q. 






190X 

that I hist saw h 'i^'^^cv. alive on v^.a„\.<o^ * % . j^q \ 

ami that ilcath occurred, on the date state<l above, at I 
CL .\L The CArSi{ OF DI-ATII was as follows: 



V^^ vCu^^.^ 



oMX^^^Oj 




DTR.ATrOX years 
CONTRIIUTORY 



Months Days I f/oii,s 






Dr RATION Years Mouths /)aj's 

(Signed) v. LaJ. vxx'x.d- 

vWAwOr ri u)n'\ (Addn-ss) 5" 0*1 X^JIa>v.^o.cU w\f | 



Hours 
M.D. 



SPECIAL Information only for Hospitals, Institutions, Transifnts, 
or Rrcrnt Rrsidrnts, and persons dying away from home. 



TMK AHOVKSTATKI) PKKSONAI. J' \KTIC C I, AKS A K I! TKIK To TriH 
UKST <)|- MY KN«»\Vlj;i)<.K AM) IM-.IJKK 



(IiifumiMtit 



U.1.1 



1 1 X Vli>x. dl 



( - f . . 



rrvs 



Former or 
Usual Residence 

When was disease rontracted, 
If not at plareof deatli? 



Now tonq at 

Plareof Oeatli? Days 



PI,A 



K niRIAI, OK KKMOVAI. I DATX; of Hikiai. or RKMOVAl, 



a -> 190 H 

inV Qf>WL4L>V-<y>V "^1 \ 



(.Address 



N. B. Every Item of information should btr cnrafully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special information" for per- 
sons dyin^ away from home should be gtlven in every instance. 



/ ;. 






III 



-" ,v 




r 



*v I, 



li 



e^ 



} 



[I 



'" 



!'! 



1. 

> r 



ti 



' «-: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ii,:,.,!..f ii.mUJ. I v., h ■*^5S?*^»'^''*" WgrgR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Diitr FiJviL IWcLv^^ 15^ VJO\ 

dL^vA.^ Xl/xmu Deputy Health Officer 



Registered J^o. 



985 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 



No. 



PLACE OF DEATH: — County 

^ 

lis ^ <xc* , ^z '. '^ 



( XX. S. StanC»arD ) 

ofC ■CL'yv J A.CL >vcu^aCity of ^<Xyvu 0AxX/yv/11\^ ao 



St.; 



Dist.; bet. 



1% 



t 



I 



A) 



and 



i'^ 



ii 



(ir DEATH OCCUnS »(**¥ rROM USUAL RESIDENCE Give mCTS C*LLC0 for UNDCR "SPECIAI. INFORMATION" \ 
ir OCATM OCCURRrO IN A HOSPITAL OR INSTITUTION CIVC ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




"v^X><Lf<OX' 



si:\ 



DATK »U HIK I'll 




(<U,nR \ 



LL^VVaXc. 



MEDICAL CERTIFICATE OF DEATH 



a. 






\ ' . »•; 



)>(/» 



Willi III Miiial ilcMtriiutiuii) 



11 

• Day) 



MttHths 



I Vtar) 



H 



/).! 1 



nik IMPI.AOH 

' Statt or t'<Mintrjr) 



d 



NAMK OF 

I ATlll 



k'^ (^ 



HIKTIIFM.VtK 
«M lAIHKR 
'Statr or Coil III ry) 



MAini:N NAMK 
«>l MoTHKK 



HtHTmM.ACK 
«»» MoTHKK 
'Statf ,,r l'«>imtr\ 



nvHrpXTloN 






DATK <>i- i)i:ath r\ 

(Month) ff 



Ibi /p^H 

(Day) (Year) 






I HI':Ki:r.V CI:RTIFV, That I attcinKMl decoased from 

0-V\,Q I \ iQoH to vAaa/CL .1.5: iQoH 

that I hist saw h A, • . aHvc on vSAa^. IH 190 H 

an<l that ilt-ath occurreil, on the date stated a1>ove, at I 
CL M. The CAl'SF^ Oh' DICATH was as follows: 

VwXS'Vv.'V'^v.Uaus<r(rvv^ 





DIRATION Years Months ^ Days I Cl //ours 
CONTRIIU'TORV 



DT RATION 



(SIGNED) 



Months 



Years Mon 



Ll<^VQ IS 100 S (Ad<lress)l05" 



:IAL IN 




Rf^ufrd III ^i!H /'i tiiii I'l'i' 



)'flT I 



M,„itll^ \ lht\: 



VnV. MU)VK STAT 1:1) I'KKSONAI, I'A KTUM' I, \ K-> AKi: IKl K TO THH 
HHSr OK XIY KNO\VI.i;i)C.K ANF) inM.Il I- 

A V-CL Cr N v. 



(Itifotmatit 



(A<Mrf^s lib U CjUL^y\A^\,0^ '-'a 



Special information only for HosplUls, institutions, TriRsknts, 
or Recent Residents, and persons dying away from fiome. 



Former or 
I'sual Residence 

Wlien was disease contracted, 
If not at place of deatii ? 



How long at 

l»lafe of Oeatli? Days 



rj ACK OK nVKIAL OK RKMOVAU I DATKof BtRlAl. or KEMOVAI^ 






PKof Bi 



'^ 



Ik 



I90H 



INDKRTAKKR U OVcLi/VV "yOAX lLw<:C:a Lc 



(Adilrcss 



N. B.— Bvery Iten, o. i„for„,ation should be carefully supplied. AGE should »-»t«tcd EXACTLY P"/«J|;'^^^r 

state CAUSE OF DEATH in plnm terms, that it may be properly classified. The Special Informat.on for per- 
sons dying away from home should be ftiven in every instance. 



^fp 



r.! 



• I 



» 




9 


1 





i i 



»Y^ 






« J 



s 

f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H,.;.!.1 ..f II. .Hh- »■ V'- ' 



; n!k I' To 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



I 5*-.... 



If)OH 



Begisfercd JYo, 



986 



d<j^T\,\.\^ dUL^wu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( XX. S. StanOarD ) 
PLACE OF DEATH: — County ofCJCL-tv JA.<X-^vc.tiCoCity of U.CC-w .'vD^wavxs.CO 



No. 



V ] .... ^ \ _ St.; X Dist.; bct.Cj .l^<::.ivtto v and VJ C^-Vu-UJC' 

/ If DfATH OCCOII5 aWAY r«OM USUAL RESIDENCE GIVt r*CTS CALLtO rOR UNDER 'SPECIAL INrORMATION- \ 
( .ricATH Oc"rRCD .H a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 




,A.Mii;> 




XXLi H)^ 




L. 



"^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

A i COI.OR 



<^l 



I>\TH OF lllk 1 11 




'M..nlh» T 



. W'X. 



\' !• 



IV«» 



n 



»*IN<'.I.K M \RKIK!» 
WllMiWKIi OR IMVoK»|-I> 



ci 






M-mths 



k 



Sc , 



i>ai 



An^ 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- ih:atii 



Month) K 



I'i 
(Day) 



(Year) 



BIRTH!M.\OH 
'Statf or Country) 



SAMK 0|- 
l-ATIIIR 



lURTMI'I. \<H 
oi I AIHKR 
'State or Country) 



MAIDHN NAMK 
Ol- MOTHKR 



niRTITPl.ACK 
"I MoTMKk 

' "^t.!!' I If C«)Uiitl \ 






I IIHRKBY CKRTIFV, That I attended deceased from 

[X\AjOy \'^ 190 i to vXAwv<a,..l.H 190 H 

that I last saw h *- alive on L^\a^, l\ iqO H 

and that diath (jccurrcd, on the date state<l above, at v 
LL M The CArSI*: 01' Dl'ATH was as follows: 




DIRATION 



) 'eajs 



CONTKIIU'TORV 




Months \ Days Hours 



rvrw. 



^rwxK^^zsuL'. 



x^'vx. 

Years Months Q. Pays 



Hours 




)><.'/ 



\r,n,tlr 



Ihn 



THK AMOVK STATl-n PFKSONAI, I'A KTUT I.ARs AKI- TKlK To THH 
Hi:ST OJ- MY KNOWl.KDr.K AND HIIMIJ- 

V3 O^XjiJxj^rt'^^ vXX^v- 



flnfonuant 



^ \«Mre«i«« 



DIRATION - 

(SIGNED) AuArl. Uk^Ld^ J^'^ 

lit)! LIavu^^x ol 



LV\/^o \'\ ic)o' 



d. 



(Address) 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 

Former or **•*♦ '®''fl ** 

Isual Residence Place of Death ? Days 

When was disease contracted, 

If not a« place of death ? 



PI^CK Ol" HI- RIAL OK KHMOVAI, 



T90 *. 



DATIlof BiRlAi, or RKMOVAI. 

'vLwc\ IS. 

l-NDl-KTAKKR ^ ' >- -' >VO^,. ^<~ V,.ti 



(Atldtcss 



.. . T^p «K„..|M he Rtatetl EXACTLY. PHYSICIANS should 
N. B.— Every Item of Information should he carefully suppi.ed. ^^^^^^^/^^.^^^.^J^*^ Information" for psr- 

state CAUSE OF DEATH In plain terms, that it may be properly ciassitiea. 
sons dying away from home should be ftlven In svcry instance. 






' ■ i.'' 






U^JVI 




4)1 




i 



f! 



5.1. 



I talc hlli'fl , LL 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

WCFER TO BACK OF CERTIPICATe FOR INSTRUCTIONS 

lOO'i RegLsterecl JV'o, 987 



f iii:ilth » v<« ;^ *'t:? 



WKV I'm 



CVCt\_A-. 






:1 



<L"t 15^ 



c^*- 



^ 



O f*1 -^ A ^ 



No, 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 

Certificate of H)eatb 

[ "U. S. Stan^arD ) 
PLACE OF DEATH: — County ofClCL^ J ,Vc^ ^vc^c<:ity of ^^X^' OJvou>A-<t^e,o 
Tlo'il U.^vtvOL.l II.--- St.; ^ DUt.; betN IT lt'ULuttx\; and O-uXlc >v 



FULL NAME 



rVCXj 



.U.>\^ ^aXHj 



PEBSONAL «ND STATISTICAL PABTICULARS 

COI.oR 



!» \ I K 01 III KIM 



Month) 




C 



u 



AC.F. 



1 



\ ).... 



(I):»vi 



1/. .,'/•/ 



rVrar) 



1 



/Tfll* 



^iN'i.K M\KKii:n 

\\ llMtVVI- I> nK l»!\«>Ki 1- l» 

*\\riti 111 viKiul il«-«»i|rnali«»>i) 



lUHTIIlM. VOK 

'^t;ltt t>r <".»iutti \ 




,^ 






u 



N\M» Ml 
FA Tin. K 



HIkTHIM.ACK 
«»K l-ATHKR 
'Stiitf or Cotuilry I 



MAIDKN NAMK 
<>l" MOTHKK 



IMR'rnlM.ACK 
«>l" MOTHKK 
'Statf or rountrv) 



-k 



lO (dxCvv 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH /^ 



(Moiitli) K 



13) 

(Day) 



(Year) 



J ni':RI':HV CI:RTIFY, That I attended deceased from 
(XjvXv.i I I90M to LUa^ J'i iqoH 



a 



t 






190 



that I last saw h ' ' alive on 

ami that death occurred, on the .late stated above, at ^ ^ 
0^ M. The CAISI-: OV DliATIl Mas as follows: 



-LV\L~^'.- 



>j-. c 



DrRATION 



Days 



Hours 



I 





vA^Crv^Cuo 



M>:Hfh^ 



/hi\ 



oCCri'ATlON 

h'r^!,f^,f lit ^,:n /'i <rni f't<> O ^ ''<^ ' ' 

thf: ahovk statfp pkrsonai. taktui i.ars ark trik H) tuf: 
nf:st of my know m-ix.k and ufuiftf 



(Info 



tniant 



*;u3,a 



Or? 



ljw^>^ 



CONTRIBUTORY J AA.i»v«.A-,xiAA^L>:^.v.? (TV... .J«!.0:\<^a.L.. 



DTRATION 
(SIGNED) 



)'iU7rs 



Mofiths 




\H TOO S (Address) X^'W ' \b 




i: 



Flours 
M.D. 



SPECiAL INFORMATION only for Hospitals, institutions, Transients, 
or Recent Residents, and persons d>ing away from home. 

F«r-.*r«r ^ X fl H0Wl0B§at 

KReVeH^ OXiL»v^^ lUFIace of Death ? Days 

When was disease contracted, 
If not at place of death ? 




N. B. Every item of information .hould be cnrcfuily •applied. AGE ^^ "Special Information" for p«r- 

•tate CAU8E OF DEATH In plain term., that It may be properly claa.ified. 
aon« dyinft away from homo should be given in .very instance. 



.1- 



n 



\ 

i 



t 



\ 



I" 

i 



.1 



11 


1 

h 

1 


It 


1 

1 


II 


1 




I) < 



}■ 



^ 



II 



I- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

J „,,„,, vn . *r'5:XHM -. RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lOO'i 



Begi'Stered J\^o, 



988 



hah' I'^ilrd, LLv^ctw^'t 1 5^ 

^v^^M.^*^^ *X^v-\.H Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( Ta. 5. StanDarD ) 
PLACE OF DEATH: — County of ^ KX^-v VvCO>^^^^ City of 0<X^' J AxXy>vCca.ac 

\ Xlv and ^ A^r 



No. 




ity 
l(o VJl^^vacl--^^ St.; ' Dist.;bct. b Mv and 



FULL NAME 



<^ 




-y^ \-^<X^y\/y'>-\^CL. 






PERSONAL AND STATISTICAL PARTICULARS 



loJv.L 



I)\ I 1 «•! I.IK 111 



lu- 






(Vvari 



\' . I-. 



15 



5 . ..• 



M.,,.!ll 



A; 



^IN«.I,K M^KKIKI^ 

w n>o\vi-:i> i»K i»;\ok> I I) 

\\nt« ill •.•KiMl <1« «iU'!i.iH"!i ' 



lUKTMlM.Xt'K 

I St;it«- or ("'itiiilr \' ' 






namj: «»i 
I AT hi: K 



HIKTHIM.AfK 

Ol lATflKR 

! State or CiMUitryi 



MAIDKN NAMJ-. 
<»!• M«)THKR 



lURTHIM.ArK 
nl MOTHKK 
(Statf nr C'oiititr\ I 



OCCl rATlON 




^ 



CCLO 




k^kA) 



W » 'wU 







v^X' 




h>^ii{r,{ in Son /'i nil, !•■'•,> 1. ) '(M V 



\/,>,if/n 



n,i\ 



Tin- AlK.VKSTXTKn I'KKSONAI. P XKTini.AKS A K )• IKlK T<> TIH- 
UKST <)l- MV KN«>\Vl.i;iM,l-; AM) uKi.n-.i- 

Of? 



, CV\JL^ V^^SJL U) .S^4^^/<><rUt 



f \<l<lrcss 



\AAy^A./cycr^ 



MEDICAL CERTIFICATE OF DEATH 



DATK or DllATII 



M.uilh) K 



1^^ 
<l)siy) 



IQO 'i 
(Year) 



I nivKI'HV Cl'RTIFV, That I attended deceased from 
L\-v^r» 1 icioH to vAa-\^1 



that I last saw h 



I90H to 

alive on 



l.3w 190 H 



\Jw^.^CL . l.3w IQO H 

VA-VwA-^Cl i .*. 190 4 



^ 



and that death .)ccurre«l, on the tlate stated aI)Ove, at I 
J M The CArSI*: OF DICATII was as follows: 

'4).ocJUXc. OluilcUs^ 



>N 5" ]\'at]i 



I )r RAT ION -> >Vrfy ^^ 



Months 



Dar^ 



Hours 



DTRATION 
(SIGNED) 



Yrars 1 Mouths 



Pays 



Hours 



M.D. 

L IuX^JSiqoH (Address) 1310 ig-Ufc^vB.t 



SPECIAL INFORMATION only for Hospitals, Institutions. Translfnts, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of deatli ? 



How I0R9 at 
Place of Death? 



Days 



n.ACK OI- lURIAI. «)K RKMOVAI. 



L/U>-^^ 



PATKof HiKiAl. or RKMOVAI, 

CLm^. 15 i90\ 



Lxfr^OcAxVV 



.T"/^' 



(AchKfss 1-(a1 



Ox 



\/Q>AA.'^ryv 



it. 



N. B. Every Item of information .hould be cnrefully supplied. AGE « .j, ^ The ••Special Inlrormatlon" for per- 

•tate CAUSE OF DEATH In plain term*, that .t may be properly vl—.ti 
•on. dylnft away from home should be ftiven m every instance. 



:* 






f \ 



>4 t 



/ 1 



^ ^ ' '^ - 



K, *% 



\iy ^ 



'I 
I' 



1 1 



I 




i" tpi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



U..ar.l . f llt-aUh- I* Vo i» 



i- MX. I' C, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Registered JSI^o, 



989 



lUO'i 
Deputy Health Officer 

DEPARTMENT OF kBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( U. S. Stan^arD ) 

■^ , CL^i-C" City of^'^^^^-zvu oyv<x> vci^4C.o 

M S ICav-^vlu -^lo.-- St.; '- Dist.;bct. X^'^4^-^^^i' and 

No. V1 V.N^.Vk.X'^^VU V.V. _. ....,., Br^lDCNCEGtVt FACTS CALLED rOR UNDOB "SPCCAL INrORMATION- \ 

( " :r::.x::::o\Tr.^^'!^\'i o%'?:?nrJv^^'^o.v77Tj name .nstcad .f stre.t and number. ; 



PLACE OF DEATH : — County of^JCL>^ 



I civil 



A 



FULL NAME 



\Ji\Lr^\} 



\\XXhj 



J crL<; - 



PERSONAL AND STATISTICAL PARTICULARS 



sK\ 



II \ 1 1: t»i iiiK I'll 



\« I 









5S , 



H 



10 



1/ . '/, 



<V«ar> 



Aj » .. 



siNr.i.K \fAKKII.I> 
WIlHtWHI* nK I>!VmK> I ;► 
s\Mt< 111 <>(>cial <i«*M|f«ation) 



iiiH rniM.M'K 

St.^t. • .' ( '••Milt t \ 



/^ 



C) ^^AXyUL 



I V 



NAMK 0|- 
FATHKR 



HIKTHIM.Xi K 
Ol I AIUKK 

'St;it« i.t i"«inntt\ 



M \ m I ■ N N \ M I 
«>1 MnTIIKK 



lUKTIIPl.ACK 
Of MnTIIKK 
iStalf of v'«iuiitt> 



>' ill- \T ION- 




MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATIi , I 






I?. 

(Day) 



/go '■ 

(Vear) 



I HlfRi:r.V CI-RTII-Y, That I atteiukMl •leccased from 

— 190 to '-^^^ ^90 -^- 

that I last saw h alive on — — — rrrrr- 190 

aii.l that death occurred, on the date stated al)Ovc, at 
M. The CAl'SI-: Ol' I)1':ATII was as follows: 



,/Ou^•^-^.-A^^ 






]\. 



(1 



,*^<^0 



T}' ^ 



.w^ 






yf,>,it/n 



/>,M> 



TMK AHOVKSTXTKl>.'KK^.)NAM'AKTU;ri,AK^AKl- TRtH T' » HIH 

ni:sT Ol- MV KNuwi.iiix.K ANi> -fu-.i.n-.i- 

ii -^ 



niifotniMiit 



Cr-v^^ 



/v-^-^^JLu 



I )r RAT ION J>'<J'-^ 

CONTRIIU'TORV 



Months 



Days 



Hours 








Years 



Mouths 



'i AJtcUA/^cA J 



DIRATION 

(SIGNED) v^w^ u > 

CLcg IHtc>oH (Address) JgOb AB^CC-t Us: t 
SPECli\L INFORMATION only for Hospitals, Institutions. Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death? 



How long at 
Place of Death? 



Days 



I'l.ACE OK nrRIAI. OK RE^toVAU 



DATK of IJiKiAl. or RKMOVAI, 
sT 190 A 



Laa^^ 



SSJ 



rXDKRTAKKR UJ ^^./VAXI J^ '^ * ^^ '> 

(Address .t» irf O O^tlAXX/^ vv/- ivI.C -..• P 



r 



■^\ 



^ 



^'^^^■■^■^■^^^■■'"^"'^r""'"""'"^^"'"'""^'^"'"'^^ Id h t ted EXACTLY PHYSICIANS should 

o? Information .hould be carefully «"PP"«^?; „^?f,Hy7lB«.ifled? The "Special Information" for R.r- 
E OF DEATH In plain term., that It may be P^^P^'y 



IN. B.—— Every Item 

•tate CAUSE OF DEATH In P-"" -." .,;;^„ .„ ,,^^y instance, 
sons dying away from home should be fti^en m .very 



t?^>- 



. ^V 



XiV^{ 



1 . •^;--Vd 



ill 



r. 



,11 ' 









lit 

1% 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„.,,„ , s.. ..^^^^aS^^nKVr., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hf 



fc I'll ('(I , L\.< 



Cn^CXCAw-^I, 






\ 



1 



± 



IS 



I'JO'i 



Jicifi.s/ciuuf A''o. 



r 



)00 



1 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccitificatc of IDcatb 

PLACE OF DEATH: — County of'''a>v J.VCL ^vcvi CfCity 

»re.nE-»i«>r niur r*rTS CALLED rO« UNDER SPCCi 



'"' a > V -VCL ^ V (^vss. rcCity of <x/v^ J/v<x ■vxcca.^c 
Mo I (M ^^ "^ U ;l 'r U . St.; Dist.; bet. a. <X^\\k.^O{-^' and Y^^'^ 

No. IV^VV V^^.^^..C. ^ „.iU*L RESIDENCE GIVE r*CTS CALLED ro« UNDER •sPCcUl .NrORM*TI^N-\ 



FULL NAME 



'Xr^A^q. V » ^<nv 



iXJUb 



» \ 



PERSONAL AND STATISTICAL PARTICULARS 




;• \ I I Ml lUK I M 



\r.H 



^ / b I 



M. nil) 



I»;i% • 






(Yiar) 



Aji 



\\ iiMiWKp MR ii:\«ikrKl» 

W • tr III v., -iiMi if M* 



Hik rniM,\t*K 

Vt.if, ,,T <*..iltltf \ 






\ \MI MI 

FAT III, K 



lUK TMIM.ArK 
or I ATIIKR 

'Slate «»r Country 



Ml MmIIII k 



luk iHi'i.ArK 
«M MurnHR 

'Stat«- or CoutilTvt 



iXV/^VOL' 



"N V 



CL 



MEDICAL CERTIFICATE OF DEATH 
I) \ IK «)1 IH'.ATH 



I Month I T 



(Day) (Year) 

•J 

I IIi:i<i:nV ri:jjTlI-V. Tlml I mIUh.K.I «loceased from 
lyo t*) ^<>o 

thai I l;«^t ^MW h • alive on ^90 

aii.l that .Kalh .icct.rretl, cm the .laic stated al.ove, at 11 OO 
CL M. The CAlSr: Ol' I)I':ATII was as follows: 






ll 







/\Vi,fr,f III >,:>! /'uniii ••> 



\Ay>A/OL- 



,\r,,„th^ 



/',' 



TMKAIU)VKSTATr.I)PHK^«>NAI.»'\UTUri.XH-Aki:TkrK Tm TIIK 
liHST ^^V MY KN<»WI.):i>«".H AM) MhlJl'- 



(Infotmant 



vt 



I UK AT ION Virars 

CONTKIIU'TORY 



Ytdt s 



Mouths 



Days 



I louts 






Mouths 

/A) 



Paxs 



Hours 



DIRATION 

(SIGNED) h .\XAJJ^.^JJ^ 0. Lo. Y^yv^-^<..j ^'^' 
15 I«>oH (A.Mress) (o ( o Q^^vtU^ C t 




"special information only for Hospitals, Institutions, Transients, 
or Rfcrnt Residents, and persons dying anay from tiome. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at place of death ? 



HoH long at 
Place of Death ? 



Days C 



I'l ACK OF lUKIAI. OK KKM,o\ AI. 



DMFiof HrKiAl- or KFIMOVAI, 

a 






.^vo I b 190 '1 



* i 




.% % 



N. B. 



.^^Ml 



— ^—^^^^^■^— ■^^""^^"■^■^"**^'"'^'^'^"^'"'^"^"''"""^"'^"^^^ i FXACTLY PHYSICIANS should 

r.ver. iten, of lnfor„,«tion .hou.d h. carefully supplied ^^^J^^f.^^.^^ %He -Specie*. Inforn^atlon- for pT- 
.tatc CAUSE OF DEATH In plain term., tha .1 ma> \l^^^Z^^ 
•on. dylnft awy from home should be ftiven m .very Instance. 



^€ffZ 



«^3iit 



A « 



m 



'[■ 



4 • 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H .r.luf ll.alth I v.. ..*-?;5?*>liMM - REFER TO BACK OF CERTIPICATg FOR INSTRUCTIONS 



1 







\)<\A 



Dep 






Megli^tered J^'^o, 



991 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of S)eatb 

( TX, 5. St»inC»arO ) 
PLACE OF DEATH: — County of^' (X-»\;OXa-^<X^Co City of 0/CX/>V J K<Xrw\^^^^^.< 
No.^^Vv\xCL>^' 0CO-<LK^ia,l St.; 



Dist.; bet. 



and 



-) 



/ ,r of.TH occu... .V^.t r„o« USUAL RES I DENCC CVC '-C''' "^-^/.^ ";« " ,7°" .»;"/^^^^ 

V ir OfATH OCCOBBtO .N * MOSP.TAL 0»» INSTITUTION GIVE ITS NAME INSTEAD Or STHtET *ND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 
liATK oi niKTH 



.Iltll' 



At.K 



^ 



It 



yi >,i/i 



<Yinr) 



i I 



/J,7» 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATM 



(Month) \ 



I'v 

(Day) 



(Year) 



W IlMiWKIi i»K IMVMK. Kli 
'Writrin ««icln1 ilrxiirmuinti) 



3 



HIKTmM.\i*K 

Stat. ..' '■.nilltry* 



N\Mf- OI 
I ATHKR 



HIK IHI'f.XtK 
Of » xrilKR 

' St;it<- or I'oUIlt T \ 



MMhK.N NAMK 
o| MOTHKK 



lUKTIIIM.ArK 
'•1 MOTIIKR 
'Siatf or Country) 



(^ 



k. 



x> 



n 







^1 

I MI:KI:1{V CIIKTII^V, That I atten.kMl «k'ccasc<l fnmi 
OLv.^.Q I 190^ to Al'^Y ^"^ ^"^^ 

tliat I last saw h ^ ' alive on Lv^w\^. '< 190! 

ami that iloath occiirreil, on the date stated alwne, at »A10 
OL M. The CAISI*: ()!• DIIATII was as follows: 



DIRATION 



Years 



Mouths 



Pays 



Hours 



CA.txxU 



1 



iJU/YO.> ^ f\a\/:.^ uJILj 




CONJ'J^nUToRV 

DIRATION > rars Mnnths 



Pays 



(SIGNED) 

LL^^-v^o I H ic)o't 



( 



A.l.lress) lUAt iJ\X4v<UAvt ^1 j 



Hours 
M.D. 



ccU 



ore I • PA T ION 

h'f^iiifii III Sim /'mnin'-'> 



1 



l.,M 



}f.'Hffn l^{ P"^ 



Tin: AIloVKST\Ti:i)»'HKSO\AM'AKTUM I.AKSAKi: TKlK To TFIH 
HKST o|. MY KNo\VI,i:i><".K AND Ml-.I.n-l- 



(Info! maiit 



UL. dUcxX Cjcrvlo 



(A«l(lro»«s 



ycL/cJkAv^rvu 



SPECIAL INFORMATION only for Hospitals, Insfifulions 
or RfCfnl Rfsiafnts, and persons dying away from home. 



ions, TransifNts, 



Days 



place 



n XCF OF BIRIAI. OR RKMOVAI, I I) ATI- of Hi k.ai. or RKMOVAI, 

rNDKKTAKKR U olil/V^t)t WOJ^A^^ 

(A.Hre« I 5 XH ^ X^T^JkX^r. d± 






.«:^ 



J . .. ^ APF should be stated EXACTLY. PHYSICIANS should 

N. B. Every Item of Information .hould be carefully •"PP"«f- ^Co„erly cl...ifled. The "Special Information- for per- 

•tate CAUSE OF DEATH In plain terms, that It may »»* P;"^;'"^ ''"'* 
sons dylnft away from home should be given In svry Instance. 






il 



l>i 



t, \ 



H 



'i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M..l,h IV.. c *?®l«) li\ JM . REFER TO BACK OP CERTIPiCATE FOR INSTRUCTIONS 



liO^istcred J^o, 



993 



"cLo-v^s^ iLxxvM Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccvtiticatc of S)catb 

11. 5. StanC^arO ) 



PLACE OF DEATH: — County of -' CV^^v Jn.Ct>\Cc4.C<i City 



inty of'0 0->v vl 



itV of /CX/V\J vj ^vOl/YVC. VaL a 






cc' 



St.: 



Dist.; bet. 



and 



-) 



( " ,vr.:,^^occ-%;ro',"r.o".''r.t o".'f:?f,?.',^";'";";i 5.vi.7 ,;- »on: .?.%%Ti::r:.';r- ) 



FULL NAME 



rlLa.,. '^X ^i) 



CX.\rvc^i^iy>A.' 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

!' \ 1 I <»l illK III 

I Vrar) 



^Ict. 



kVO 



.U 



M-mh 



\ • . I : 



wt 



> tit I 



\y.\\ 



M ,.:h 



/'.; 1 « 



WIlHiWi;!) iiK IHVoHfKn 
(Write in tttn-inl »lr*ir>uition) 



HIk TIIIM.Ai'H 
•Hisiie of C'MHittx 



V\MI I.J 
I \ Til IK 



\ 



Ua^^ 




lURTHff.ACK 

oi- i\tiii:r 

■Stiitf «>r C«Hititt V 



MXini.N NAM!* 



lUKTHI'LAlK 
<»l MOTIIKK 
fsiali i.r fituiitryi 






MEDICAL CERTIFICATE OF DEATH 

DATK oi i)i:atm 



(M 






(Day) 



(Year) 



I in:Ki:HV CIIRTIFV, Tlmt I attcMKkMl 'IcHvased from 



to 



^■ 



cu 



"t 



^ 






HVNwiu, 7x^ I90H 

that I last saw h ' alive on 

aii.l that «Uath occurrc<l, on the <late state.l aluive, at 
U M. The CAl'SH OI- I) I! AT 1 1 was as follows: 



i()oH 
190 ^ 

I. 



>v<;AAr.vO::^u^Sf« 



V* 







ni'RATION I Years ^ Months 



CONTRinrTORY 



Days 

D 



Hon 



rs 



'\vv 5-:^- Ow'^cLv.t.va .L.i^.^C.i.:wA,.C 



DIRATION 



Years 



Pays 



Hours 
M.D. 



^-^/vx.<rv^^^^^ 



ovcn 



tCf-tdfd in 's.ttr I 



A..-,.v 



) V <M 



cL 



Mnnfh^ 



l\n 



THKAHOVKSTXTHDI-KKSONAI, rXKTUri.XKSAKKTRTK T< > THK 
IlKST 0|- MY KNOWI.KIX.K AM> IU-.l,n.l' 



(Infotniaiit 



f \.lt1re«;s 






d 



iQib 



I cur J /"S A 

(SIGNED) lO. L. Lk^-lUe-vx., ^ 

ECIAL INFORMATION only lor Hospitals, Institutions, Transients, 



or Recent 'RfsMeilts' 'and persons' dying away from home 



U^vk 



Tormer or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



vvC-^-^n-^ 



Now loiid at 
Place of Death ? 



f( 



Days 



n.ACK OF BIRIAI. OK KUMoVAI. 



DATK of HiKiAl, or RHMOVAI, 






(Address 



.k^i. 



-— — — -^ — — -^- ^^ ^^^^^j EXACTLY. PHYSICIANS should 

N. B— F.very item o? Informntion .houlcl be cor.fuHy «"PP''«J- ^^^^^^y cla-Wled. The ^Special Information" for p.r- 

•tate CAUSE OF DEATH in pinin term., tha .t may »« P^"^" '^ 

ann« dying away from home should be given in every Instance. 



i • 



i 



TT^.-ifM 






; , 






I. 

I? 



^' 



■If: 



;t 



M 



f> 



r f 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

fli. t), rv.. '^-r»Jk)MM'.v, REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 



IfHJ'i 



Begi^tered JS'^o, 



998 



Xoa^^a^a,-) ^JsjC-' Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH:-County of ^^a^x.-3xo..vc^^c,. City of Q^VVx. ^ KX^^<^^^.C^ 



No. 



1?)a1 \I I IcvCC . VA 



^ 



\ •-.-4 



5i^ ^ Dist.; bet. vi.\xdx\A.CV\ and 



,L CcUlX'L- 



..eiiAi orttinrNCE Ciwr r»CTS called for under "special INFORMATION' 'S 



FULL NAME 



■»^cA.<^ djL 'Jcrv\-UL-Y 



I \ 



PERSONAL AND STATISTICAL PARTICULARS 
» j OU.mR 



<5 



liVIF Ml lUKIII 



ji/^'\^^^< 



llJv.b 



M..tnh> 



V ' ■ K 



It 



S 






yt.iHifis 



rVtai » 



1^ 



Aji 



•^INT.!,!.: M\Kk!i:i» 
\VI1M.\VKI> OK IMV»»RrKI» 
iWritciu MKial tU-MinialitJn) 



"^XnXv or «."<nintr%-^ 



N \Mi: ol 
FATIlHk 



HIKTm'I.AiK 
OF lAIIIKR 
iSt.itf or I'oinitry) 






MEDICAL CERTIFICATE OF DEATH 
DATK »»»• I)J:\TH 

• Day) 



(Month) 



1 



(Year) 



I IIHRKRV CT:RTIFV. That T atten.k«l <leceased from 

A^^^ 190; to C*-VvOl L'i 190 M 

that I la.t .aw h alive on CL^v.ry ^ 190 

afi.l that .Uath orcurreil, on the .late- ^tatt-.l above, at ^U 
if M. The CAISK or I)I:ATII was as follows: 

OTUaJjU^vL .Jk^^cdX c^v^vSUm^ 

t.!L\jJ^\^ 



M xmKN NAM1-: 
«'l MnTm:K 



lUR IHJM.ArK 

»»i Mnrin-:k 

( st.itt . ,1 (.*<>initi > 



) 'ears 



Months 



/yavs 



/Ion IS 



DIRATION A ) -| n 

CONTR I nrT( »R V ul^ U-<V*> t A.UJ^^ B.cbA^a. 

O rvx/Cc^wAA.^-c-> X. 

Months Pays Hours 



DTRATION' ?> )V«;/5 



1 « 



00 0-»-aXLXa.^O^aX-< 



Till XHoVKSTNTKnrKKSONAl.rAKTirri.AKSAKi: TRIK TO THK 

iu:sr <n MY kn«)\vm:i)<'.k and uhMi-.i' 



(ii 



VJWcMV/OcA^^L 0-v,> 



f A<1<lre«s 



\ ^ 1 'X Vi I \/CXA^CrYW.'C VA.'vM^ 



(SIGNED) |UJ4A\A^ V- JVSXuX^nwO„ . M.D. 



SPEcIaL information only for Hospitals, InsWulJons, Transients, 
or Recent Residents, and persons dying aivay from home. 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of death ? 



How long at 

Place of Death? Days 



PLACE OF- nrJllM, OK RKMOVAI. 






(A<l.lres, lV.2.^Jto^-^-«^'-^^ 



DATHof Hi RIAL or KP:M<)VAI, 



190'^ 



tiSlwii 



^■^^■i"""— i""-^"""^"^""""^"^^""^"'""^"'"^'^"""^^^^'"""^"^"""^^'^ A u fr t I EXACTLY PHYSICIANS •hould 

N. B.— F.v.r, Item o» l„«orm..lon .hould be c»r.fully •"M'«^; ';^^,^''°"l„,xnJ. Vh. "Spccl.'! ln!orn...ion" l.r pr- 

.•.>. C*IIHF OF DEATH In plain Urm», that It may ne P'-"!' 

:::*. d^fn» .w« f^llo,.. Hhoul- b. ».v.n In .v.ry Ina.anc. 



•'! 



W 



» 



r 



; 



i 



VI 



u .».«.' II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

994 



,t, IS *-^ ^ifrXi) UK. I' C 






Re^islcrcd A'^o, 



(k.b^^^^^ .ioLv>-u Dcpu^ 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of Death 

c to J (^ 

PLACE OF DEATH:-Coun.y of '^ <X>x i Va.vc.^cc City ofO,CV>v J.V<Xav^».^ 



) 



-) 



FULL NAME 



- ' ^i ^l^e... 



L^^crcCL 



rc< 



•»! \ 



l»\rK «>F illK I 11 



PERSONAL AND STATISTICAL PARTICULARS 

a 



ll, k^u 



M. 



A.VC\ 



\' .1 



2.1 









A.M 



SlNi.l.F M\KkIII» 
\VJI)n\VH» ok l»iV.»K« » I» 



lUK rniM.\*'K 

'Stat- • 'iTitt\ 






.V 



S\Ml- ol 

f- ATM IK 



.oil 



»C^ 



(Year) 



^<X/^y\^ ^ ^^^^ '^' 



JUk rmi, \i }•: 
oi I \rin:k 



MMI>KN NAM) ^ 

<»» MdTIIKk ^ 



"1 MoTHKk 
"^littr or <"«>uutr\ 







CLVAA^v.''^^^ 



)V.?' 



\!.>„th' 



/).?!- 



oiilP \ 1 inN , 

• t>., ' . ■( ~ "^ ■ 

AV /,//■!)' /" ^.111 I < ''"■ ■ •''' 
Tin-. MU.VKSTXT.nrKK^nNM.rVKTUr! ,^KS VKI-TKIK n» TIIK 
in:ST nj MV KN.»\VIJ.IK.K AND HJ-.I,n.»- 



informant ^ A\jJ\XAJOo 






<' \<Mros«; 



\X\^ 



MEDICAL CERTIFICATE OF DEATH 
DATK «»!•• DKATII ^ 

( Month) g 'i>ay^ 

I lll-KI-BY Cl-RTirV, That I atten.lol (Icivasod from 
Cl^^^q U 190S to LLvvQ I3v 190 ^ 

tliat I last saw h ^ ■ alive on LUva ■■ :^ i^p 

.Mi.l that .Uath occurre.l, nii the .late stated a!)ove. at 
M. The CAT SI-: Ol- DIIATII was as follows: 

Ill- RAT ION )Va/^ Months 10 /^^r^ Hours 

CONTKIIUTORV 



DIRATION 



Years 



Months 



(SIGNED) J, UUXA^lui VC^vW-v^t^ 



Days 



Hours 
M.D. 



fA.Mres.) V\\ OA^vt igA. 



d.^^-q '•^ too'- . - 

SPECIAL INFORMATION o«ly lor HospiUls, Institutions. Transients, 
or Recent Residents, and persons dying dwa> from home. 

(7 , - \ . Mt* lonfl at 

'J rrU\ j" Plare of Deatfi? Days 



Former or '\ 1 U 

Isual Re^idenfe c< =x i v 

Wlien was disease contracted. 

If not at place of deatli ? 

PI.ACK OF BIRIAI. OR KHMo\ AI. 
INDKRIAKI-.R \l I V ^ , 

.1 H Crx" culLau.' 




(Ad«lre«5S 



— i— ■—■—■— —■^——^■"""■■'■'■"■■■■■■■■"""""'"""^'^"""'^'""^'"^^^ K * t d EXACTLY PHYSICIANS should 

IS. B.-5v.r, ...n. of in.„r„.»..on .hou.d be careful., .upp.ied p^^^p^^tTi'-..'"'-" 'tH. •'Sp^ci .™for™..io„- f.r p.r- 

..a.e CAUSE OF DEATH in P'-'" '""Vj-; ^'.r.^J ^.^n^. 

■on. dylnft away from hooio nhould be »i»en in . « » 



I ! 



I « 



S ' 






i^^nr 



. I 



« 



'■■ 1,1* 

ri ' "J 






': t 



k \l 




WRITE PLAINLY WITH UNFADING INK 



hale hllefl, LLv^a^^-^^ '^ 



VJO'i 



THIS IS A PERMANENT RECORD 

WgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

995 



lle^istei'cd J^'^o, 



L 



J 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX. S. StanC»arD ) 



Nt>. 



PLACE OF DEATH; — County 



M 



(X^^vjL/d^Cx, 



City of 



Vs^'<xJkXxx^'^x:L V^clAj 




e.^^.v.St.; 



FULL NAME 







VjU. \^(X\X\.k^'\\^^ oU^U^Tv-x/^A^crvv 



PERSONAL AND STATISTICAL PARTICULARS 
DATK or HIK > li 

CL 




rX^.- 



;t.. 



< Mont It) K 



il)ay» 



(War) 



\' !. 



3C 



M.-H'ln 



Ihn. 



sivr.l.K M\KKIKI> 

\\ II><»\V1-1» MK IUVnK* |-l» 

W'll" in -—t.i*. .l« "»ivtiat«"n' 



HIK rm-i. \»*K 

(St.-il' '.T < ountT% 



I A rH!:K 



IllKTHPI.AiK 
CH* FATIIKK 

t Staff or 0<. itv 



m\iih:n nami; 

«»1 M >THKK 



lURTHl'UArK 

«»|- mothkk 

(RIalf <>r Coiintry 






^CYV 



X, 



%. 



C^A-»*CX 



1 



Ox^vo^o.. NLC^at>v<L^v 



•KCri'ATION 



Otcn- 




OVoo n 






M 



)'r,ii 



- }r.>,iffi- ^ /''" 



THI. XHOVF.STATl-I)PHK^ONAI.lVVKTU;ri.AK«.AKKTRrK TO THK 
HKST Ol MY KNo\VI,i:iM*.K AND UKI.I1> 



(IiifoTinaiit 



^■^^\Hb 






MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH -^ 



(Month) j 



(Day) 



(Year) 



I IllvKliHY Cl-RTII'V. That I atteinled ilcceased from 

___ _ — ■■ 190 to 190 —^ 

tliat I last saw h jilivc on ^9° ~^' 

an.l that ilcath occurred, on the »latc stated alnn-e, at 
M. The CAl'SI': Ol- J)ICATII was as follows 



Q. 




sj.vJU^> 



,fc <i. ..^ 



Dr RATION yt'ors 

CONTRIBITORY 



Months 



Days 



Hours 



Dl'RATION ._ Vt'iJrs 
(SIGNED) V^ 

l^ uyo\ ( 



^aAo..liL 



Months Pays Hours 

<Xy'\y\^\j M.D. 




\y<Okxxxvv^. LaL 



SPEC^IaL information only ^^^ Hospitals, Institutions, Translciits, 
or Itecenl ResWcnts, and persons dying away from homf. 

Ksldence 1 1 1^ v^^xw^ d*{!|' 

When was disease contracted, 4. ^ 

If not at place of death ? O «^^- ^ 



of 0eatli?0.>V»O^. B«ys 
CVvv vJ" AXX^^v/C-A.^Q^'C-^ 







(Adtlress 



II ii 



(K 



v^./Ju\,^<r:vx. 



-^1 



lUm of ln?orm«tlon .hould be carefully iiuppllecl. ^'[|^ •^7***,^|*|'i"*^^^ "Si.eclal Information" for per- 
CAU8E OF DEATH in plain term., that it may be properly cia..it. 



N. B. Bvery 

atate CAUSE OF DEATH in pi 

aon. dying away from home should be ftiven in every instance, 






4 ' 



k 



i 






w 



\{ 






I: 



,1 !• 



m 






,1 '■] 



. i 



I 




n 



r 



M-iilil 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CgRTtFICATC FOR INSTRUCTIONS 



,f lUaltli-l- No. 1^ -^^aJ^H&lT 



/)((/(' Fi/rf/, 




\^ 



190 "i 



Be^istci^ed J^'^o, 



996 



i ^ ^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "U. S. 5tan^ar^ ) 



FLACE OF DEATH:-County of VJO^YV JXa>v^- : ^ City of 0^^' J/v^^v^c^. 



Wo. ^ 



( " r/rr':x°H^^occ^^;ro^;''^Ho".^r.t o%'?:s^.?u"T^o';'V.;r^J name ..stc*o o. ...ccx ..o .um.c. ; 



Ucttil^vc^^^ ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.OR \ 




]-\^K^rJ..: 



WL 



Mj^Xx 



I»ATK Ol- UIRTH 



M'.K 



0^ 

(Mo!ith> 



10 



(I)MV> 



M,,ulhs 



(Year) 



IH 



A? 1 .V 



SINCI.K. MARKIKI) 
\VnM)\VKP OR niVoKiKl) 

iWrittin MH-ial iW-sijriiatioii) 



UIRTH PUACK 

'Strttr or Country^ 



j\^KjiA^ 



NAMK <)l- 

hatmi:r 



HIRTHPKACK 
0|- lAPJIKR 
(State or Country) 



MAIPKN NAMl- 
()l- MOTHKR 



niRTHPl.ACK 
()»•• MOTHKR 
(State or Country) 




&'>v<i.AA/va. 



cnxcL^'^.'uxo 



orcrrAT.ox Qp^^, 

Re:'i,1rif ill SiUi /'nui, isro I > ''? ' "' 



}r.>iith 



/hi\ 



THKAHOVKSTATKI)PKRSONAI.rAKTICri,ARSARKTKrK n. TIIK 
1U:ST Ol- MV KNOWl.KIX^K AND Hhl.Il-.f- 

(Informant tX^U/^V Lv^Ia. ^-^^'"^ 



Ad.lro-^s O O ^ 



MEDICAL CERTIFICATE OF DEATH 
DATK «)!• PKATII 



(Month) y 



(Day) 



(Y«ar> 



ThKKI'HV CI-RTIl'V. That I attcmU-.l •Uccasccl from 

that I last saw h ^ > • alive 011 UA.v.q I •^. I90 i 

an.l that <Uath occurred, on the .late stated al.ove. at 
lX M. The CArSK Ol- l>l':-^'Jj" ^^'^ "'' follows: 



.|vwvvv.o.^^<^^-<^-*^ ^L<>^v.:^-v^ 



Mouih% 



Pays 



ci. l4t ^ 

DIRATION ^^^ )V«;/.s 
CONTRIIU'TORV 

1)1' RAT ION >''"'« Mouths /hiy^ 

(SIGNED) ^<x/\r^<^ ^ cvcLcL. . 



//.'// 



; V 



ffou 



; V 



SPECIAI 



M.D. 



SPECIAL INFORMATION onlv for HosRit.K. liMititlws, Iransifnts. 
or RfCfBl RfsMrnts, and pf rsons dying away from lio«e. 



Formff or 
Isual Residrncf 

Whf n was disease contractH, 
tf not at plaff of dcatli ? 



How lon4 at 
Plare of Oratli ? 



Days 



,ACK OV niRlAI. OR RHMoVVI, 



tM,I.:RTAKK.R Ht^^^.^ ^^ '"^^"^ 

l' 1 1 n i«.i M ..•►•NT 



nATi; '>; m KiAi. <>r ri-;mo\ai. 



(A<Mr»-ss H'^ ' S" t 



,Cv,U •> t:^ ^ 



^^"^■■'■"'■■'■'"■'""'"^"'"""""'""^"^*"^^"""^^^^ ^ k t t d EXACTLY PHYSICIANS nhould 

information .hould be carefully supplied. J^^^J^^^^l^^^^^J, Vhe "Spccl-'l Information" for pr- 
OF DEATH in plain term., that It may be properly vla.s.ne 



N. B. Every item of 

•tate CAUSE OF DEATH in p , -^...-ce 

son. dyinft away from home should be ft.ven in every .nstance. 



1 « 



i 



f 



f 



mmwi - 



li 



"ii 



li ■■ 



1 



V 



I I 




v^ 






- 4 



WRITE PLAINLY WITH UNFADING INK — 



M„!M.l of UtaUh- K No- i^ ^^^^^"^''^'" 



/>^W/' Ff/r(/, 




15- 



7.90 H 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTtONS 



■Lro^^> X^^ Deputy Health Officer 

DEPARTMENT OP'^PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( X\, S. StanC»arD ) 

9 QS^ -? 



PLACE OF DEATH:-County ofO.Ctov J,^c^^^-a:i.y of d.CU>^ JA-Cc^v^^ c.c 

ist.; bet. jJ-lxAi and ll-VN-^-t > -- 



No. 15H0 




' Cvl-VC^A- 



>CCURS 



/ ,r or.TH ofccuRS .w.y from USUAL «"' J,^,?J5^o*;•"J.v7'" 
V .r OtATH OCCURHCO IN A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 



St • I Dist * bet. "J xA,\HLA^vj and 

'^*** TS**CALLCD rOR UNDER "SPECIAL I N fOR M ATION" \ 

TS NAME INSTEAD OF STREET AND NUMBER. / 



) 




PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



(^L 




\ 



V^ 



tc 



DATK OJ- lURTll 



ACK 



SIN«-.I,K. MARKlKn 




}''UJI 



lie 

(Day» 



M, mills 



r a.c.^..., 

(Vear) 



oC 



/)<n. 



:^ I > ' • I , r. . >i .A IS r» 1 1-, I » . -» 

\VI1>0\VKI> <»K niVoKiKO JL' 

(Writfin Mx-ial .1« siv'tiation) "^ 

HiRrnn.AOK (^ ft 

(Statt or OoutUrv^ »-^ AM' v 



L 



.<) 



NAMK nl 
I- ATM 1-: R 



vJwAxt^-^O-S^ 



HIRTIIfM.AiK 
OF lATMHR 
(State or Countryl 



MAIDKN NAMipfS 
OF MOTHKR Vij!' 






) 



* 






lURTHPUACK 

ni MOTHKR 

I State or Country^ 



_ Li^v<LV 



>^<, Oj 



occrrATioN 

Rr.idf,! Ill S,:n f-iin'' >''" 



)VlT' 



•\f,„itln 



/'„M 



THK^HOVKSTATK.>PFRSOV^,^AKTUMM..K.AKI•TKtF m THK 
nKST OF MN- KN«)\VI.KI)«.b^I> lU.I.Uf 

(Infonuant LU'Al<r^^ iA^^V^^^vdv 



{A(Mrt»i** 



I5HC 



jL/A>s^yv^r^^^ 



J. 



MEDICAL CERTIFICATE OF DEATH 



I go \ 

(Yt-sir^ 



DATK OF DKATIl , 1 

(Month) J '^''V^ 

f^n]7KP:HY Ci;RTirV. That I atton.KMl .leivasol fn.ni 
CUvO 4 190^ to lUc<^ \H ic;oH 

that I last saw h -^ » ^ ahvc oti Ll^vX^ ' - I^/> 

ati.l that death occurrcl. .ui the .late stato.l alK>vo. at ^ ^ 
(P M. The CAl'SIC OF DI'-VTII was as folloxvs: 

c^^ 



!y' 



I)rR.\TION 
CONTRIIUTORY 



Years Mouths 



Pars 



I fours 



IH RATION 



Yea IS 



Months 



/hiys 



//oNrs 



(SIGNED). Co^nXc- "^CX^-.^l^-O-tU 

il.^ r. .^.M rx,hire.s) ion ll<x^^ 

;pe6iAL INFORMATION ontv for Hospitals, listit-ritis, Frasif.ts. 



M.D. 



SPECIAL I WfUMiviM.i ■'-'•' ,"•,.»-, 
or Recent Rfsidents. and persons d>inq ai»a> from home. 



Former or 
Usual Residence 

When was disease contracted. 
If not at place of death ? 



How loM it 
Ptare of Death ? 



Days 




\ 1 r. o 

a. 



"V 



niRiAi, OK kj:m"V u. 



ii\ii. <»; It' KiAi or kf:movai. 
1 ^ 190 * 



(Ad.lress 



. pvACTLY PHY8ICIAN8 nhould 

.. ... ^Aiicf: np nFATH In plain terms, tnai n ••■«■* ►- 

state CAUSE Oh Ut« • " '" »* *iven in svery Instance, 

sons dyinft away from home should he ft.ven 



w 







f :•! 





t ■ 






ft I . 



.1} 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



}<<.;ir<1 of Ili!iUli~l" N'o. n, 



H«:!'Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J)a/r I^y/p(fr.(l^LxAY■^^ I 5- 2^W H 



Eegisterecl J^'^o, 



998 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eath 

( "Q. S. StanDarD ) 



PLACE OF DEATH: — County of 



City of C/cLx/>v' 



LcrLc 



V ex d. 



rNo. 



St 



"Dist.; bet." 



and 



(\r Ot*TM OCCURS AW*V FROM USUAL R E S I DE NC E CI VE TACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRCCT AND NUMBER. / 



FULL NAME 



,aSu 



k.\ 'Jx| 



Xj'^JJx. 



i 



-4- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ . r^ 



■ <XAJL 



DATK «)l 111 Kin 



a<;k 



I Month) 



loJ 



(Day) 



\.JU_ 



r\^\ 



' MEDICAL CERTIFICATE OF DEATH 

DATK <)l' DKATM ^ 

(M«»iit!i) K 



(Dav) 



(Year) 



.\ V. J till ^ 



M.oit/is 



(Y»ar) 



Pit 



SIN<-.1.K. MARKIHD 
WIDoWKD OR DIVoRiKI) 
• W'ritfin MK:ial tIfsiKnation) 



^ 



>LAA^ 



rfrthpi.aok 

I Stat 



rnpi.AOK /-TN 

f or Country' j ^ 




'Vcii 



NAMH OF 

F'ATHKR 



BIRTH ri.ACK 

OF FATHKR 
(State or Count rv I 



MAII»KN NAMK 
OF MUTIIKR 



BIRTIII'I.ACK 
Ol MOTIIKR 
(Statf or Country) 



occrpATION 






I in:ki:i5V CliRTirV, That I attemltMl dcHcased from 

- to — 



that I last saw h 



I90 



alive on 



lt)0 

190 



ami that iK-ath occurre<l, 011 the ilate stated above, at 
— M. The CArSiv OF DIvATII was as follows 

© 



A^CrW->A-vrvx-cO 



f 





.CL'V 



I 






\^VwU>^' 



I) r RAT ION Years 

CONTRIIHTORV 



DTRATION Vtat 



A/onths 



Days 



I /ours 



) t'ari 

(Signed) Vj . 0". /<x\yL 






/hlVS 



^^.AX\ I icyn 



0(7 PI p f 

( A . 1 .1 ress ) J -C\-cAr Ui V . <> 1 r. 



//()urs 

M.D. 



UX\. V^VCX'^A.M 



Rr.^idfd ill ^r» /'niii, i->;i ^ )">'■ t .'^hmth- 



I >ii 1 



TMF: AUOVK STAIIl) I'KKSnSAI, }• \ K T ICC I.A K^ AKF, TKIH T' > llli: 
IJKST OF MV JvNoWI.HIX.K AND ISFMliF 

(Inf..rniant a>^^0-'VvA.^^>0 Cp. J -«-/|vJAw.<Xt; 



V-<. 



Special information onl> for HosplUls. institutions, TransifRts, 
or Rfcent Rfsidcnts, dnd persons dvinii .iwdv from home. 

-V j ^ H«H lonq at 

dx »^ vl -plarpof Dfatli? 



Pormfr or e- 1 ^ i 

Usual Residence ^^^ <Vv>\ 



Days 



When was disease confrarted, 
If not at plare of death ? 



I'LACK Ol" IHRIAL Ok KJ:m<»\\I 



i)\ii;<.; H' KiAi or kf:movai. 

LL<.^^^ .1^ igO'( 






» .. I- J APF ahnulfi be Mtatetl EXACTLY. PHYSICIANS nhouid 

N. B. Every item of Information shoulcl be carefully HuppI.ed. AGE «bould "l" *7'*" ^' .7^ , , ,„formiition" for per- 

•tate CAUSE OF DEATH In plnin term., that It may be properly cla^.^led. The Special informat.on for per 
Kon« dying away from home should be given in every Inntance. 







fl 



Rl 




II 




|i 


1 


r 


. 


1 


f 


r 




|, 


' 



'I 



r; 



ii!i 



II 



'5 



t» 



R 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)!. ai.l ..f II.Mlth I' 



V(, i> •*^J^5iji luS:!' C'( 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/(' fu7('f/, LLl/wXXvv^ 15^ 



If^O'i 



Be^istri'ed JS'*o, 



999 



^\^><^vo 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. StanOarC> ) 



PLACE OF DEATH: — County of ^ CU>A^ A.<X/'rLCc<iC( City of VJCt^^ JX.cx-^vav<i ti i 



'No. 




LOL^^cl-N^LLL|C)/a">X^Xa\cu.VHSt.; ^ -Dist.;bct. 



and 



f \r or*TH occUs *ww»v rnoM USUAL RESI DENCE give facts called for UNOtn "si»cci*L information- A 

C iVoEATH oJcURRCO IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




^x-^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl. 




..Otrt^cL^^vO ^. 



^ 



olU 



1>\TK o»- lUKTII 



a<;k 



Qaw 



" lOidx 



iMonlht 



\ 






IS 

(Day> 



M.'tith' 



fYear> 



Pavs 



MEDICAL CERTIFICATE OF DEATH 



(Month) 



=1 



(Day) 



I go 

(Year) 



^IN<'.T.H. MARKIKI* 

\\ FlMiW KI) OK IUVnKi KI) 

'Wtitrin -^fHiMl ilr«iiK"atioii) 



A 



HIKTHI'I.M'K 
'State <»r Cotintry' 






NAMK Of 
I- ATHKR 



HIKTHPI.AOK 
<>l" lATHKR 
'Statf «>r Country) 



MAIDKN NAM I 
OF MOTHKK 



niKTHPI.ACK 
ni MOTHKK 
(State or Co>intry) 




7 « 



1 1 



DATE OF DKATH 

I U'-KlinV CliRTII'V, That I atU-ii(K'»l dccLastMl from 

to LvA--cCL 5 '\ ujo H 

ami that «liath occurred, on the date stated above, at ^ ^. 

\Kyi, The CAl'SI-: Ol' DLATII was as follows: 



\ 



thj»t T last ?wiw h • alive on 



2). 



f 



I«jL^-^ a.^'>^wL/-.ol.' U .<x*>w a-L^'Lua 



DIRATK^N 
CONTRim'TORV 



Years Months /hi\ 



IIou 



rs 



DIRATION 



)\ins AloNt/is Pays 

(SIGNED) ^ ^' Xc^<LtA.(^ 

1 ( ^4 J -^ 

lc^n.=-. Ton' (A.Mrcss) ^ ^O^-^-K 



Hours 
M.D. 



■t 



THK ABOVE STATI-D PERSONAL I'AKTKTT.AKS ARE TKlE To THE 

nF;sr of mv knowi.edc.e and heijef 

(Informant U^^-^^X^/V "^ 0-<rcL-r^'^^a/>\^ 

(Address iH vb-A^V^' Ot 



SPECIAL INFORMATION onl> '^^ Hospifdls, Inslifufions, Transjfiits, 
or Recent Residents, and persons dying a*»av fro:n home. 

When was disease contracted. 

If not at place of death ? ^^^^ 



prXCEOF ni RIAL OK REMoVM, I.ATJ:..; Mr«,A.. or REMoVAl. 
INDERTAKER U)juiXX^^ U..^^^ 



IN. B. Every Item o? information .houid be c«re»ully supplied. ^^ , .^j^j. The "Special Information" f*r p«r- 

•tate CAUSE OF DEATH in plain term., that .t may »>^ P^^^;-''' 
•on. dying away from home should be given m .very instance. 





\ 






m 




•&' .■ t 



r 

1 


n 


1 

1 
1 


t 


! 
i 

> 
t 


1 

i 



»' 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M,,.,r.lof IL-Mlth IN.). isi>^^ti>ijS:i.O.) * REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Regisfci'ed J\^o, 



1000 



io-wO^ "It^ Deputy Hearh 0'n--r 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH:— County of OO/^x. «J.'vxX/>vcu.c.(City ofO<Xy>\) J-^ux-.vec-CLCio 



NcHcLl^.d 



1. 



XX-AAXo.h.^'^v.>'v>^ St-; Dist; bet* ;; and 

• TH OCCURS AWAV rnw™ w^«r,w . - ^.^-r- .^.,r.,» «. 

OCATM OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Ol 



/ ir DEATH occ^r'^Tway Tr^^IT USUAL REsTdENCE oive r^'c'rVc^lito ;«« 7"" l?^ltr'').Ho'uu!:rtr'' ) 

( ,^ I ^....>» .^ a MncDiTAl OR institution GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



— ) 



FULL NAME 




) 




\\ 



,<x. 



U„ 



PERSONAL AND STATISTICAL PARTICULARS 






DATK nl III R Til 



LL^vWa^L*. 



Laaa^CL 

• Month) jT 



x\ r Iwa. 



.\r.K 



O \ ' ''■(» » .5 



11 



(Day) 



M .utfis 



'^ 



X\ 



(Year) 



Pa I .- 



SINC.I.K. MAKKIKI). 
WIDoNVKD <>R niVuKl'KI) 
(Write in Micial <k-sis.»nation) 



niRTMIM.AOK 
'Stntf or Cotintrv* 




f LOUWv-X.cL 



i 



MEDICAL CERTIFICATE OF DEATH 
DATK v)F DKATII ^ 



(Month) (T 



(Day) 



(Year) 



I IM:KI{BY Ci:RTn"V, That I attfudtMl (Uriascd fn»iii 
CLa^CL H 190H to..^U^>-QL IH i(,oS 



that I last ''saw h..-A-^ alive on LA^A-a^OL - i«/^ 

an.l that death occurred, on the date stated alMive, at 
M. The CAl'SI-: OI- Dl-ATM wa^J as follows 

^1 






u 




NAMK 01 
I ATI I). R 



niRTHIM.ACK 
OI- lATUKR 
'Statf or Country' 



MAIDKN NAMK 
ni MOTIIKR 



lURTHPUACK 
nl- MOTHKR 
(State or Country I 



OvCn'ATlON 




a.k a 



A^"voL' 




Uiv^o 



Ol/vm 



lor. 




l^ 



■1 



jcl/VL.C'X; 



Lt 



DIR-^TION >V'a/J Mouths l^ay% 

CONTKini'TORY 



Hours 



DIRXTION Years Months /></» 

1 




Hours 



cOlc \ N vc V w£X.q,v M . D. 






\fo)ith^ 



luis 



THKAnoVESTATl-Dl'KRSONAI. I'AKTICri VKSAKI-.TRIK Ti. TIIK 

iiKST oi>\iY knu\vi.i:dc,k and Hi.i.n.i- 



IIKST t>»Y>MV KNOW I 
It.r..Tniant dvD . dUl\rv^^rL^4u^>-VXi 

Ua.a^xaa.€ 



(Address 






H (A.l.lnss) 5^0 OaJIU'v 't. 



SPECIAL INFORMATION onl> fA'^ Hospitals. Institutions. Traiisif«ts. 
or RfCfiit Residents, and persons d>in!| rfv»a> fro-n tiomr. 



[;TRe'[idencel)^^tJL<^ CcJ t^llLv. 



»«>s 



Wlirn was disease rontrar ted. 
If not at place of death ? 



*^v^v. 



n.ACK OF lURIAI. cK ki:m'»vai 

INDKRTAKKR jt ^xl^^tcA ^ ^ C' ^.^ 



Dxriv'jf lu KiAi nf rj;m<»\ai. 
.Lcv.n ' '- 190 



'Address 



N. B.— Every Item of information .hould be carefully f"PP' *?• ^^^^ ci...ified. The "Speci.! Information" for p.r- 
.tate CAUSE OF DEATH In plain terms, that .t m»> »^ P^"P 
•on. dylnft away from home should be ftiven .n every Instance. 



I 




\ 






. 't?*^ 






[• • 



H> 






i 



1 

1 
t 

V 

• 

( ,- 


. 1 



n 



liosi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,„,,„.,..,-. ■N....*^;^"'^-" REFER TO BAC.1 O P CeRTIFICATI rOR INSTRUCTIONS 

1001 



!)<(/ 



c /'V/fv/, LIa-vCVa-^laX7 15" 



VJO'i 



Be^isteved A''o. 



■Lyvw>Xe/v^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(Xevtificate of 2)catb 



PLACE OF DEATH:— County 



( Ta. S. StanOar? i 



^ 



St.; 



DIst.; bet. 



ecGty of ^J 






and 






c i't 



FULL NAME 




<\.Vi, 



■t- 




.CCl'tX. A 



\ 



PERSONAL AND STATISTICAL PARTICULARS 
SKX on ^ \ COLOR 

.J?. 



jC^v^ 

DATK or HI R Til 



'^\./CX-AjL 



(Month) 



Ar.K 



L''U >V,f» 



(Day) 



M., til In 



,^% 

(Year) 



/).; 1 A 



Slsr.T.K. MARKIKI> a 

WIDOWKO OK niVi»KiKI) V ^ 

(Writf in MK-ial iksi;j'iiati<>n> "^ W 



lUKTHIM.AOK 
'Statf or Conntry^ 



NAMK »»r 
FATIIKR 



BIRTH IM.AiK 
OK I ATIIKR 

• Statf nr lounlrjj) 



MAIUKN NAMK 
<H MOTHKR 



HIK in PLACE 
o|- MoTIIKK 
(Statf or Country^ 



OCCri'ATION 








K<\ O-A^ 



.^JLLcv -wcL 



-VXXj 



? 



XJL\-<X * 



.-H 



v^VslX >"> ^^ 



RrsitUif ill San /'i ,iii. r^''> -''^- >"'' 



i;..*/.'//- 



/>,.M 



riiK A...,vH STATIC. '"^K-"^*';!;]^;,;^,!;^- ""' "'" '" ''"'■■ 

IlKHT OI- MV KN«»W1.KI)<.K AM) HKI.Il.H 



rA<UlreRS 






ihL 



,<\ o_ -^^ 



a,kjL/% v^^fr^x 



4. 



MEDICAL CERTIFICATE OF DE ATH 
DATK OF DKATIl ^ 

(Month) ] 



15 

(Day) 



/QO \ 
(Y«-ar) 



I90H 
Up 



I HI':Ri:nV CICRTIFV, That I attfiuUMl .k'Cfasea from 
^UV^^WA. \ I90H to LUa^O. i.S 

that I last saw h - -' alive 011 vL\.\^CV ' c 

an.l that death occurred, on the datr staU.l ahnve. at 
LI M. The CAISH ()!• m:ATII \va-^ a< follows 



DIRATION X }>ars • 

CONTRIIUTORV VrU.]^k>v.vj:. 



Von //is /hiv.f 

NuQ... 



Hours 



DURATION 
(SIGNED) 



Years 



%\ 



Q-,^ 



Months 



Pars 



rix> " 



Hours 
M.D. 



a.c ^ /til X iUH J o-^^^^^ ^t 
Lectin T*»o^ (A.Mrrss) ^^'^ ^^ 

SPEcilAL INFORMATION onl> lor Hospitals, Institultans, IransifPts. 
or Rfccnt Rfsidcnts, and persons dyinq a\*d> Irom horor . 



Former or 
Usual Residence 

When *>as diseasr rontracled, 
II not at plare ol death ? 



How lonq at 
Piare of Death ? 



Days 



PLACK <^l- m RIAL OK RI-MoVAl, 










l)\TI. of II! Ki*i. 01 KKMoVAI. 
LLv^vQ 11 190 5 



— ^_^___^-^^^^— ^^i^^^mmm^^nai^^^^^^^^^^^^^^^^ \a \stt t t tl EXACTLY PHYSICIAMH •hould 

N. B— Every ..em o. •,nfo.n.».io» .hould b. c.r.Jull, .-PPll.-- ^l^^ZZ,,^^,:. *Th. •Spcci ln«.,.n...-.o„" I., p.r- 
.•.*» CAUSE OF DEATH n plain term*, that it m»> oe p m 



i • 



!1 



i 




■> I 



i I 



if 



J'? 



i ♦ 



' I 






)(,,;, 1,1 of lli:ilth-l' No. I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.U^^rSfcMScl'Co REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 



" 7r F//r*^r. aXawaXXa-^-^ ^^ 



!)(( 



lOO'i 



Registered J^'^o, 



lOOi,^ 



"d^o-w^Jo dXv-u De,->uty Haalrh Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)catb 

( tl. S. StauDarD ) 
PLACE OF DEATH. -Couniv of o^onn^a, iovtav, Gl» o( U...aA.n^^,v^^-^ 



(0 J 



No. 



— St.: 



Dist.; bet. 



and 



( '^ -*;:^^cc!^v.";:i^^^ ---^^;i;-;^^;f-- ^^" s?;^^-^?-:::er • ) 



FULL NAME 



ULaXL fc-ou^Jk^ 



PERSONAL AND STATISTICAL PARTICULARS 



JjL/>^o.xxX^ LLJ^vaJLl 



DATK Ol- niKTM 



A«,K 




5.5 

(Day) 



(Vt-ar) 



Sn Y'-'t' 



L 



.M„Mlhs 



\% 



An 



«5|Vr,l,l-. MAKKIKH 

t\Vtit«-it> -mial thM^'tiatioii) 



HIKTHri.ACK 
(Statt- or r<mntry) 



NAMK OF 
} ATHKR 



lUKTIIPI.ArK 
«)!• I ATIIKR 
(State or Country) 



MAIDI'.S NAMK 



lUK'inri.ACK 

Ol- M(»TIIKK 
(Stair or Country) 








L 




(^ 








^r.'nth^ 



V'li \ 



occrrATioN 

Kfudftl III S,iu /mil 

T.M. A,«.VH STATK,. '■-«-.-, rxHT,>_r.,AKS AKK ,K,K T< ■ T,,.-: 
IIHST Ol- MY KNOWl.HDOh AM) Hl-.I.n.f 



(Informant 



a. a. %<x.w.. 



(AfMrcss 



I go . 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH pi 

... Ll.^u:t '^"^ 

(Month ) J 'J'«>'^ 

fTiKR^^Y ^T^ RTI F Y, That I atUnad «lcoeasea from 

-r=-iQO t.i - • ^"^ 

tliat I last saw h ::: alive on up 

an.l that death occurre.l, on the .late stated al.ove. at 
'"~ M. The CAISI-: ()!• DI-ATII wa- as follows: 



Dl' RATION Vt'^Jf^ 

CONTRIIUTOKV 



.l/on/As 



Pav 



J lout 



s 



DIRATION 



Years 



Mouths 



Pars 



Hour 



(SIGNED) iA.<X-.^^"iADl>C>^WKv^^ M.D. 



SPEc'lAL INFORMATION onlv for HospiUls. Institutions. Tr^nslfits, 
or Recent Residents, and persons d>ing a>»d> from home. 



-Pi H»\»loiif«t 

evidence I i^H^^^^^^ "-' «' ^'''' 



Ms 



When was disease contracted, 
If not at place ol death ? 



ri.ACK Ol III KIAI. OK KKMOVAI. 



e*-. V 



I»\ll r Mi KIAI or KI';MoVAI, 






(Ad'lK'"'' 



qsio ^^\v<^ ^ vtj > V. "^^ 



__^ » I FVACTlY PHYSICIANS iihould 

•tste CAUSE OF Dt>* • " •" »* AUen in •very n»tance. 

«on« dying away from home nhould be ftiven m . • y 



»** 



*; 



,1 



f 




iltll 



.1'^ 



JisSL 



WRITE PLAINLY WITH UNFADING INK — 







100 'i 



THIS IS A PERMANENT RECORD 

WEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1003 



Be^lstcrcd ^''o^ 



Officer 



DEPARTMENTO^PUBLIC HEALTH=City and County of San Francisco 



Certificate oi ©eatb 

( Ta. 5. 5tan&arC> ) 



J (^ 



PLACE OF DEATH:— County o 



fO<X/>^0>vO^'>vc^ctCity of C)<XAV J^aA^cv,4.^o 



■"' "" ?~J™vlv,"r.=; .-.■%.: 



FULL NAME 



I Dist.; bet. 






i 



jd. 



and 



15 U 



\j 



Vr TACTS CALLCO .OR UNDER ' ' '^ '^l^''"'-':^' °^Zl\T ' ) 
- INSTCAO OF STREET AND NUMBtFf X 



GIVE ITS NAME M 




J nt^t> 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




I)\TH nl IIIKTII 



AC.K 



"^INT.I.K. MARKIKI) 
WIDnWM) OR I>!V<»KiKI> 
'Writr in ■««Ki:il cU -.ij-'iiatioii) 





ai rll^ 

(Day) <Vear> 



M,,nffiy 



11 A/t> 




HIKTIIIM.AOK 
(Staff or Country^ 



NAMK Ol- 

kathi:r 



liiR riii'i.ArH 

()|- lATJIHR 
tStatf or C<miitryt 



MAIDKN NAMK 
<>1 MOTMKR 



HIRTliri.AOK 
Ol- MOTHKK 
(Statf or Country) 



Ki KI> 9 ft 

lation) -A y 

J? (^ Q 



MEDICAL CERTIFICATE OF DEATH 
DATE OF Di: ATll , ^ 

(Ihiy) 




(Month) 



I 



(Year) 




b.CtuA 






I irp'Kl-IJV CKRTirV, That Iattcn.UMl.UTcnse«l from 

\A^ IS Ic^?^ to a^<^iH »90H 

that I last law hu.^. alive on LU-<^ 1 3> up' 

an.l that death occtirre.l, o„ the .late stated ahove. at 
Ol M The CAISH OF DKATM was as follows: 

CONTRIIUTORV l/l^^V-..-^ 






/foitrx 



nrRATION I JVrf/i 

( SIGNED ) ^OLA^^X. U. ^%^^oL^ ^.D. 



"special information onlv t«r Hospitals, hstitutions. Ir.nsk.ts. 
or Rcrent Residrnts, and persons dying d.ds irom homf. 



Formfr or 
Usual RfsMfBCf 

When was disease contracted, 

If not at pl ace of death ? . 

oj XCKOl- BIKIAUOK KKMOVAI. 



How lonq at 
Place of Death ? 



Da>s 



DATKof m wiAi. or KKMoVAI. 

O^v-cr lb 190H 



OCCII'ATION 

•r„KA»OVKSTXTKn.KK^N.,rAKTUM.,VKsAK...rKrKTo 
BEST OF MY KNt)\Vl.hD(.h ^^''/v^n ' 

(Informant Ul>-e/V>Jta^ ^ 

fA.l.lre.s I ^ I g <X.^<V<: -A>-^ ^ . PHYSICIANS -hould 

; -, .,„„,rf He cnrcfuliy supplied. AGB f -;^.,V„:i"''Th; •^8p«-b1 lnt'orn,»tW>„- for pr- 

IS. B.— Every Item «*'"»-•- fi'"";*;7j,t. Url, th»t it may be properly clo...«ed. The 
•tatc CAUSE OF DEATH In *»'»'" J^^,,^ ,„ .very in.t-nce. 
Hon* dying away from homo -hould be ft.ven 



iNDhKIAM-.R vv ^ 

'Addirss cx l VJ ^ 






JJ' "* 



V 



» 



If 



•I 



1 



\^ 



'» 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



H,,:n.l of H. Mltl. »•• Vo <^ **r5?^"''^»' ^■" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






lOO'i 



Registered -A''o. 



1004 



J ' ^ CI %. i-" " 

DEPARTMENTS PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( tl. S. Stan^ar^ ) 

[0\ 



No. 



PLACE OF DEATH: -County ofCVcV'^^ JXCU^^^^City of 






CS, 



(''>."ob 



c* . • Dist.- l)ct.UO OA^ixA-'Vvalcnx) and 

, ' »• ^^W>^CU M^ - ^ * 1^ r«B UNDER • SPEcAaL INroRMA 




Q,i-I 



) 



FULL NAME 




cnxtJil"L<n^ll '^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



L 



COI.OR 



DAT J «>! IllKTII 



\«.K 






(Miinth* 



O C |yj,. 



(Day) 



1/ '>//A» 



I Year) 



/)«?V.v 



SINi'.I.E. MAKKIKD 
WIDOWKD OK I>1V«»K» KD 
(Writt ill "^Kial «l«-^UMiati'»"> 




OlW^C cL 



UIR TUPI.Al'K 
(StaU- or «.'«mntry' 



NAM»* «>l 
lATHKR 



HIRTHPl.ACK 
OF FATHKR 

'Statt or Coniitrv' 



M\n>KN NAMK 
Ol MOTHKK 



Ci 






MEDICAL CERTIFICATE OF DEATH 

(MonllO T "»"V> 

I i||.:KHnV CKRTirV, That IaUcn.K-.l.lov;,.o» from 

— — " lip **' 

til at I last saw li " »livo oti "" 

a„,l that .Uath mnn.rre.l. on the Uat. ^tatol a!>nv.. at 
CLm. Tin- CAlSIv or ni'ATM wa^ as follnxvs: 



fY«ar> 



1^5 

ItjO 




nr RAT ION IVrtr^J 

CONTRinrTORY 



.Vonihs 



Pay 



I'.V 



/A'/<^ N 



/^(/i'5 



doUL 




4^ 



lURTHPI.ACH 
OF MOTHKR 
(Statf or Country* 



tx 



iK'Cri'ATKJN 0[\p 

IJKST OF MY KNOWl.F.D'.K ^>" "'^'' 



(SIGNED) a/v;.cLiL^.vxi.K ^^^ 



Hours, 
M.D. 



r' 



•^' 




"special information onh tor Hospitals, l«sl.l«tions, Ir.nsicMs. 
•r1«fS^esldrnts,7nd persons dvinq ...> Irom homr 



M.nifh' 



/hl\ 



(Infortuant 






Former or 
Usial Rfskk nee 

When *ns disease cdfilraf ted, 
If not at place of death ? 



H«M lonq at 
p]^e of Deatli ? 



Days 



riACKOl m-RIAI.oK KKM..VAI. 



UATFof Ht KiAi ..r KF:M«>VAI. 



'A<Mr''«s 






,CK-M 



^ ^ f J FVACTLY PHYSICIANS should 

E OF DEATH In plain V-.-"!: **•":'«» in.t.n«. 



N. B.— Every item 

.t.te CAUSE OF DEATH In P'"'",;^ -::,;„" in .very '.n.fnce. 
««n. dyinft .wy from home «hould be ft. 



1 



Ui 



t^' 



U' 



,{.; 
'H 



I, ft 



if 



r?' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






lOO'i 



Registered Xo. 



1005 



1 ^..^ ^ .x^u Deputy Heal^h OfH-^-r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

•Q. 5. StanDar^ ) 



( -Q. 5. StanDar^ ) . ^^ 

Si % -AT 

PLACE OF DEATH : - County of O CL^^ ^V<X ^x co Uty 



15 tk 



FULL NAME yi.cW^dL V^.^cU-. - JU^v<la.lv 



) 



PERSONAL AND STATISTICAL PARTICULARS 




SKX 

DATK OF lURTII 



^. 



"•■■'■■ \}oLx 



•MoiitlO 



\«.K 



b1 >Va».v ^ 



(Pay) 



Months 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DFATH 1 

(Miititli) \ 



< nay> 



iYcar> 



^ ^ 



/)•;!, 



SINT.l.K. MARKIKO 
WIPOWF.I) OK niVoKVFI) 

(Writi in MK'ial il«-»UMiati<»n> 



K. 



,hJw^C<X 



HIRTHlM.ArF: 
(Statf or CoMiitry^ 



NAMl- oj- 
FATIIFIR 



RIR rmi.ACR 

oi- I \IMKR 
iStatr or Country^ 



^ I 






it 



e 



n ^ \. 

1 

•n.K ...ovK srvrK,. n<H^.s... r -rKr;. -^ -- rK> k 

HF:ST of MV KNO\\1,F.I>oF. AM) hi.i- 



MATnF:N; namf 
<n mothf:r 



HiKTnrLACF: 

OI MoTnF:R 
(Slalf «)r Country* 



/),M 






ufonnaiit VJA^V^^^-^^^ 

^ \<Mrf-« ^J ' ^ 



1 IIFKIMIY CI-RTIFV, That I attcn.UMl .lectasol fruiu 

that I last saw h - nli ve oil \X^^^^ • ^^P 

ana that .Uath occurrcl, o„ the .late ^tate.l above, at 
Jj! M. The CArSI«: Ol' Di: ATM was as follows: 






nr RAT ION 



Wars y Months 



PiU 



■V 



Hours 

M.D. 



( SIGNED ) \'^- O^v-itcV-O- .V 

g... ro S. (A. ..T.S.) ^m^ - n. 

■ SPECIAL INFORMATION ..I. I«"»^P"-I^- •"'""^' ""^''"'^' 



■t 1,^ ■'^■f 



Formff w 
Usual Rrsidf ncc 

Whfn was disfasf confractrt. 
If not at plaf f of death ? 



HoM lonq at 
Plaff of Ofath ? 



DaNN 



IM.ACK OF BIRIAI. OR KKMoVAI. 



DXTFo!" Ml KIAI. o» KFMoVAJ. 



u 



-1 



190 






.«„<»,<-<•>' 



" , II I I I I -|- PHYSICIANS iihould 

E OF DEATH in pln.n »--•; r.»l« 'ir^v in.i.nce. 



""• "• TtaV/criTsE OF DEATH in »>;"'";-"::,;„";„ every in.t.nce. 
„on« dyinft aw.y from home -houlU be g.ve 



11 



il 



. X 






h 



WRITE PLAINLY WITH UNFADING INK 



Hoanlof Health 1- Vo. ; . 1^^^*.^ H& P C 



I)(i/i' Fih'(/, 



\^ 



100\ 



THIS IS A PERMANENT RECORD 

REF ER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS 

1006 



Registered J^'^o, 




Deputy Health OfTlcer 

DEPARTMENT OF f'UBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( H. S. StanOarD ) 

:ity of ^^ 



PLACE OF DEATH: — County ofOo/^v J ;ux^^<^^ City of ^<^^ 0/vcv^xxivXi.co 

riM \'\\'\ - IH tL St.; t Dist.;bct. 0-^V^^<^^-^' :,nd Xcu-w^iX 

^NO. XOl.-S A\ .V^TV; „„,,-.,., prSIDENCE Give r*CTS C.LLCD FOR UNOEH 'SPtClfcL INFORMATION N 

( '^ .V«*T°H"oCC^^ro^;"rHo".^PrT**t o"?^?'?u"o*;'oiVC .TS name INST»0 or ST«»T *.0 .UMBC.. ; 



IaxxLl': 



SKX 



DATK «>1- ItlKTII 



PERSONAL AND STATISTICAL PARTICULARS 
Month) jji 




•'tXAJL 



(Day) 



(Year) 



a<;k 



T 1 )V.M 



M.mths 



I 



/).? 1 



»AI\<.l,K MAKKIKH 
UIlHtUJ-.n OK I>IVnK*KI> 

'Wiitf iti >.'H-i.»l .l< siv'iiatioti* 



niK rm'!.\«'K 

(Sliiti- or C'limti V 



NAMK <M 
FATHl.K 



RIKTHIM.Ai K 

<>l lAIUKK 

( Stilt r or Country) 



MMDV.N NAMK 
Ml MOTHHK 



lUKTMl'LACK 
<)| MOTUKK 

(Statf or Country) 







( 



OCCri'ATION ( ij -I I 



^,-, 



1 ' I 



)/n,!fff 



/>ll\ 



ni;sT «)»• MV KN«)\vi,i:i>«.K and in.i.n.i 

(Infonnant UJUIm^- JU-^^^^JL 

3.3 1-^- an .tJL '^t 



( Xd.lrcs^ 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATII 



(M«)nth) ,\ 



(Day) 



/90 \ 
(Ytrar) 






I III'KI'HV CIvRTIl-V, Tltat I attended flcceastnl fr«.iii 



V 



,kXu is 190H to CIavcl. i^ 190 '\ 

tbat I lastLw h L-.v, alive on Llv.v.C^ » 1 190 < ^ 

an.l that ikath .H:curre.l. on the .latr -tati-.l ahnve. at U S b 
L\ M. The CAISK Ol' DIIATII was as follows: 



nr RAT ION >>«''^ 

CONTRIUrroRY 



Mouths '^ Pays Houts 



lM.JUxAj C^/VV4i^-UrK 



<1^VX^X.CU4 



Months 3 /)<m 



Hours 
M.D. 



nrRATioN J. JV*"*^ 

( SIGNED ) 6.^ct^^-A^ LUcr^tv w^ . - 

SPECIAL INFORMATION onlv for Hovpitals. Institytlons. TrMsifBis, 
or RfCfnt Residents, and persons dying jv»dv Iron home. 



Former or 
Isual ResideiKf 

When *as disease rontracN, 
If not at place of death ? 



How I0114 it 
Place of Death? 



Davs 



IMACKtU- HIKIAI. <»K KhM< \ M. " ' \' J^ 



1901 



<A<l<lr«-^s 






3.0^ 



CV.^^Vt V 



"■"^^"■^""^^"^'""^"^"^^'^^'^"^"'"^^'^"^^ Ik t d FXACTl Y PHY8ICIAM8 nhould 

o. InformBtlon .hould be curofuHy -uppllcd J^^f;;,;;";;;..^^,:^! Vh: -Spec-.-; Inform.Hon" for .^r- 
I: OF DEATH In pIhIh term., that .t m,.> he ^^'^J 



^St^ ;^o: ;«:: =."He .;v.n .n ev.. In.t.nce 






i 



* 

I 



;. 



I 



f 



II 



h! 



;K 



W 



II' 



I 



3 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HE FER TO BACK OF CERTITICATE FOR INSTBUCTIONa 

1007 



n.«M.i of !Ki.ith-i- No. 1^ -t^^^^nscr^'o 



Date F/h'(f ,\X.L\^A^\j^ \S 



(3^.xr>--c<^ 'ckjL/vMj Depu'- 



190'{ 



Bee^lsfered JVo, 



DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco 



Certificate of ©eatb 

( tl. S. Stan^arD ) 






^ 



PLACE OF DEATH 

No. dLC^^x.^ ^ ^>^' 






VvOs.CV.-i 



St.; ^rrrr- Dist.;bct. 



■ and 



V^VC 'VJ ^^AL^Y VV- S.V•^..■^. •-'IM — '...-- e«B UwnrP "SPtCIHL INFORMATION 

( '^ r/;;:Tr^ocL%r;.-r.o^s^rT'it rR^f^^^^^.^oro^ri;! T.)ii :::^:^v: j...^ ..o n.^ser 



) 



- ) 



FULL NAME 




'^XA^xJb... S 



PERSONAL AND STATISTICAL PARTICULARS 







DATK nl- IlIKTII 



■ Month) Q^ 



(Day) 



(Year> 






ACR 



HH r,,,, 



M.nilln 



1 



Ai 1 > 



SIN..I,I-: MAKUIKU 
WinnWKI* «»K DlVnkv KH 
aVritii«i Micial dt-si^nation' 



MEDICAL CERTIFICATE OF DEATH 

DATK or DKATH 

IB 




(Month) 



IQO 

( Yrat 




.<XA_v.oLx:lw 



lUKTMIM.ACK 

(Statf or Country* 



NAM1-: <>H 
I- A Tin. R 



RiR rnri.ACK 

<)!• I AIIIKR 
'Stat»- <ir iounlrv 



mai!»»:n NAMK 

OF MOTH IK 



lUKTHPLACK 
()J MOTHHK 
(State or Country) 



/CXX^^^ 



^^ 



n 







^ 



TlllvKHliV CI-RTIFY, That I atU-mUM .UhcuscI from 
CLIc^ ^ 190H to LUvqj 12. icp^ 
that T last saw h ..- ' alive on lU^n ^ ^^ ^♦^ 

aii.l that (kath occiirre.l, on the »1atc stalol al.ovc. at I 
1 M The C\rSI': OF DliATII was as follows 



»/CVO^S^ 'C->C^N-' 






ur RAT ION )•.'.".« ■""'"''" '^T ''""" 

CONTRIIUTOKV "Ua.^U!^^^v^ -J"^''*"^''^ 

(SIGNED) \aa%.'^<^ * "".•"• 



/VCCAVC-X 



\l,„ith^ 



/),M, 



OCCl PATION Qru> . 

imsT OF MY KN<)WM%n<vJv ^M' HI,I.n.. 



(Infornmnt 






SPECIAL INFORMATION onlv lor Hospitals. l»stitttllo»s. UinskuK 
or Recent Residents, and ^lersons dyinq awd> from home. 

-A H«w lonq at 



former or 
Isual Residence 

When was disease confrar fed. 
If not at place ol death ? 



Piare of Death 



'\ 



Days 



,M ^CF Ol- lUKlAI, OK RKM"V\I. 



DAJl."- H'fMi IT H 1:M< »\' AI, 
C incl T 



)A Vl. •>■ li' t"^ 



190 



A 






._^^^_i— ^ ^1^^— — — '^— ' , pYACTLY PHYSICIAMS nhould 

OF DEATH in plain term,, that -t m„> J 



IS. B. Kvery item ni 

.tate CAUSE OF DEATH -n ^■;'" J-'^i/.^in .very innt-nce. 
ftons dyinft away from home «hould be ft. e 



i 




5^|^^lM» 



I 

I i 



\ 



H.i 



«P 



d 



stmt 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nonr.l of HtMlth » No ;> TS'^jSvJ^; Mfc I' (\, REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 



Thifr /uh'^, {Jua^y-^ >^ ^'^^^"^ 



Ecgitilcred J\i'o. 



1008 



dU^^*^^^ 



Deputy H 



' : h n 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( H. 5. StanOarD ) 

jA.CX>TVCA^C(City ofO 



PLACE OF DEATH: — County of <lA^ /uO^TVCA^CCity ofCJ/O/^^^ OAXXw^^oCi^c 



1 



(^No. 



^lO ' 111 



St.; 



5 



Dist.; bet. 



1 1 ,t!v 



and 



U. 



/ ir Ot«TM OCCUHS AWAY FROM USUAL RESIDENCE GIVE TACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




Jj-y\j\j^. 



I 




cy^^jL\. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



(SOwl 




DATK nl- IUKTII 



A(.K 



(Month) 



(Day) 



(Yt-ar) 



I JViJ»> 



Months 



Ha 1 



\vrn«i\vi:i» «»k inv«»KiKH 

iWiitfiti v.kjmI ill si^'imli'iji) 



HIKTIIl'L.XOK 
(Statf or Cninitry 




V \MK Of 

I- A I m: K 



,D 







MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATII 



F DKATII r\ 

(Month) ^1 



(r»ay> (Year" 

I III'iKIiHV CI:RTIFV, That r alteiKltMl deceased from 

LL%A/cv .W 1901 to LLwc^ ; -^ n/5t 

that I last saw h .t-^-i-s. ahvc on Lv-v^vcy i \ itp '• 
and that death occurred, on the date stated al.ove, at '• O w 
LIm. The CAl'SK OF I)I:ATM was as follows: 



LL'C^^w^.X-L \I J\x^^w-^-^r^'a. wU 



fXVAwA^A^^-^^ >^.' 



lURTIlPl.ACK 
Of lATHKK 
(State or Country) 



MAIPKN NAMK 



HIRTHI'I.ACK 

ol- MoTllHK 

i stat«- or Country) 









A^ 



cO 



h'f idi-ii lit '<tni /"' (" 



1;, / ■ ■'.' 



'1 



) .,// 



\f.»itli' 



/),.M 



inr Am»VKSTATKI)PKKSONAI. r\Kluri,VK«>AKi:TKl K TO THK 
IJKST Ol- MV KNOWl.lllx.K A\l> lU L,I1J- 



{Inf'i:m;iiit 



~^' ^ • CJ.cOXe^.-.- 



f \(Mrc*»s 






\^ o,i,.<r%Aj '^ 



-1 



CONTR I lJrT( )RY ^/ r V-OJLQw'*V.v-oJ^ »J -^ 



//«»// 



; V 



or RATION 

(Signed) 



)Vur, 



c e.(i 



Mouths 



na\ 



'V 



<X^K,4^ 



//out N 

M.D. 



il....„q^l^ T<K^'^ r.Xddress) 1110 ^0^^--^ 



Special information «nl> 'o"^ HosplUls, Institytiofls, IraisitRts, 
or Recent Residents, dnd persons dyin? d»»d> (rom home. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at place of death ? 



How lon^ i\ 
Place of Death ? 



^s 



I'l.ACH Of- nrKI.XJ, OK KHM"\A1. | DVJl-' H't'io ..r KKMoVAl, 






(Aildf 



-ex. 



■"— — """""""""""^T ,. a AGE should be stated F.XACTLY. PHYSICIANS should 

of informHtion .hould he carefully supphed. J^^ '^^^j^^,.^ The ^Special Information' for p^r- 

E OF DEATH in plain terms, that .t may be properly uassme 



IS. B. Rvery ite 

:"rdyfn'iM.:i; r^:™ hom; ;hou..rbe *!«„ in .v.ry in...nc.. 



'ViiS 




.-^.•••-$J^ > 



^^^ 



r»T^ 



N :. -.t^p^ 



__fii 



^-^uj;- 







^^mKim 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I„,,,i.l..f 11,1.1.1, I No ,<->#Wa*liMCn HtFER TO BACK OF CERTIFICATE fOR INSTRUCTIONS 



Megiatei-ed ^'"o. 



1 009 



io^A^ doL/v^ Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH^City and County of San Francisco 



PLACE OF DEATH: — County of JCL"i^ 



Cevtificate of ©catb 



\cu.c<<:ity ofvJ/Cu>^ OXo^-KV'Cx^ c 



Dist.;bctM lb 



No 5Sll ^ ^H >tlv St.; ^ Dist.; bet M I LA^^lvcrvv and L AJLt/wc 

i>,0. ~^VJ <^ or»TH OCCURS »W«Y FROM USUAL R E S I DE NCE Gl V t FACTS CALLED FOR UNDER -SPCCAL INFORMATION • ^ 

( "death OCCURRED IN r„OSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

\q^.1.. Mil ^-2.^; 



FULL NAME 




\ 



PERSONAL AND STATISTICAL PARTICULARS 
SKX (jp » I CO....K 



DATE or III Kill 




CUv- 



I Month' 



10 

(Day* 



(Year) 



.\<;h 



bo »><!»' 



•\ 



M.'Mlhs 



Pars 



slN».|,K MAKKIKP 
\VI|M»\VI'I> OK lUVOKiKI) 

<\Vjil» iti -(M i.-il <!t xiv'tKitioii) 




fl<XW'_-^ 



IlIK nilM.XiK 
'Stiitt or Conntryi 



NAM I »»l 
FAT I IKK 



Vw^CX/>' 




BiR ruri.xi K 

or I ATIIKK 

• Statf or Country) 



M \IIH:N NAM1-; 
O! MOTHKR 



HiK rnpr.ACK 

«M MoTIIKK 
(8tat»- or i'outitry) 






^AJL 







ocrrpATioN 



M,„itli^ 



rh 



THK M..VK STATKI. '•HK:.>NA. rVKTHM^J.AR. AKK TKrK To TMK 
ItKST <»I MY K>-o\VM:I)<.K ANH Hhl.IlI 



f InfoTiuMnl 






MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



.OcCvQ 



(Month) ij^ 



(Uay) 



/go 

(Ytar) 



I IIHRnnV CKRTirV, Tliat T attended «lea?ft«e«l ffi" 

I up. t.)AAA^o„ iS" 190 H 

that I last saw h • alive on V^N-A^C^ ^ i»p 

and that death (iceurred, «>ii the date stated alxive. at V3 
UL M. The CAl'SI-: Ol- DliATIl was as follows: 



!ll 



Xa^.' 



.t (B. 



■tx-^uC &] 



K.<y 



DTK AT ION f*« Veaij 
CONTUIl'dTORV 



Months 



na\ 



"\ 



J /ours 




Years .^fonths 



DIRATION .. 

(Signed) Vw. J. dUUs'^^-cxA.cL 



/)</iv 



Hours 
M.D. 



Clvs^q l^ Ton '-. i A.Mrr^>.^lVvtt^>^' ^Ma<^ 



SPECIAL INFORMATION only lor Hospitals, Institutions. Tr-nslfnts, 
or Recent Residents, and persons dyinj d»»a> from home. 



Fornier or 
Usual Residence 

When was disease contracted, 
H not at place of death ? 



H»M lonq at 
Place of Death 7 



Days 



UATl", '-; III KIM. '>r KKMoVAI. 

n 190H 



n.ACKOl- lUKIAI. MR KKM..VAI 



""'^"■"■^"■■■'■'■^"*'''"'~"''"'"~"'"''"""~'''''''"'"'^ II h t t d nXACTLY PHYSICIAIN8 should 

* informstloa .hould h. carefully -«ppl-^ 'f^J^^f.lJ.^J, 'tu. "S^ci.l Inl'ormHtion- for pr- 
OF DEATH In plain term.. th«t .1 m»y ^^ P-^*;''' 



N. B. F.very Item o* 

•tate CAUSE ui^ un/» . " ■" *"-• :."..„ •„ ,^,py instance, 
•on. dying away from home -hould be <i.>cn 



n 



■4 



'5* 
^- . 
i 



■■■| 



.<' :'- 



'X-* 



« • 



^ ^ 



'J- 




h't 






W 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 









5- 



100 \ 



REFER TO BACK OP CERTiriCATt FOR IN8TRUCTI0Na 

1 01 



Jieo^i, stored J\^o, 




Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate oi 2)eatb 

( Ta. S. Stan^ar^ ) 



J 



((D 



PLACE OF DEATH: — County 



of C'<X-W J.\.CL'>^CA.^.cCity of O/OO^' O.V 



v^ C c 




iM^ iC^.'M \J rX<n\la Cr^>x-i^Vt( St.; 1 Dist.;bct.\i)AA<:^^.^^<^H ^"^ 

[No. I U O I \J / V\) V V>V.V^. U N-%^ ..k.... „^„.,^^K.r.r ^..wr r.r.TS CALLED rOR UNOEB -SftCIAL ifirORMA 

lEET ht*if NUMB 






SRI 

STRI 




TION" "\ 
ER. / 



FULL NAME 




cu v)xooca^'^\-«-'^La-^ 



PERSONAL AND STATISTICAL PARTICULARS 



SFX 



^0 f 

DATK Ml IlIKTH 



COLOR 







(Day) 



(Y«-ar) 



a<;k 



MnMlhs c^ 



All.* 



•^INT.l.lV MAkkIKU 
\VII)«»\\ i:i) nk DlVokrKI) 
iWrite in s«K-ial ilr«.ijr«»ali<>iii 



iiik rniM.ArK 

(Statr or <'<)tnilr> 



NAM I «>l- 
FATI! J.K 



KlkTHlM.ACK 

or lATllKK 

• State or Cotintry' 



MAII>KN NAMK 
(H MOTIIKR 



UIRTHri.ACK 

«>l- MoTHKR 

( State or Coxintry^ 




'°„) 



'Lu 








4 ^ 



try^ -\ H)p 



c-a 



)V,; 



.^f„Mfh.<: >. i /''•' 



OCCITATION 

Rr-uifd III S,!V I'lao' r,;> v. ^ ^ 

■r,.KA■,ovRsr^T.,.,.KHs„^A,P^KT..^^^H.AK..^K^K T.> rnH 

BKST OF MV KNONVl.KIX.K AND LI I.Hf 




MEDICAL CERTIFICATE OF DEATH 

datp: OF i)f:ath 



(Montli> \ 



(Day) 



lYt-arl 



I lIKRHnV CI:RTII-V, That I atteu.UMl «leccasnl from 

OLvo^ vh 190 '\ to >J-^<\ I ^ ^^^ '^ 

that I last s^iw h ..•• alive on Cl^v^Gl. I H 190 ' 1 

aii.l that <U-ath occurred, «ui the .late statcK above, at 
Cl.M The CAISK Ol' DI'ATII was as follows: 



dJ aJ(\Jv\^ 



Dl" RAT ION >'''"'^ 

CONTRinrTOKV 



Dl'RATION ^ >Vrfr5 



.Vonl/is 



Days 



JloUfs 



Mouth: 



Pay 



Houyi 



(SIGNED > LcC^^^^^^'^''-*^^^'^ 



M.D. 



■ SPECIAL INFORMATION "n!> tor HospifdMHMitutions. FrWsifnts. 
or Recent Residents, and persons dvinq d^av Irom home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death ? 



How lonq at 
Place uf Death ? 



Da)s 



I'l.ACK <»I lUKlM. OK KIM<'\ VI. 



!»\ri:>; in hiai «>t ki.moxai. 



L Wv '> 



T901 



{- 



-^^— i— — ■^-*^— — ^™'"'"*^ ^ , FVACTLY PHYSICIANS nhould 

state CAUSE Oh Ut.A i n m i» v.5. *« in every instance. 

«on, dyinft away from home ahould be ft.ven 




;iJ^' 







I I 



¥ 



I 



I 



I ; 



1 ; 



IloaKl of H<-.>Uh I 



WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOB INgTRUCTIONS 



V„ .jJ-gjgtiMiftl'Co 



I Ihilf Fih'il , LLcoCvv^'iXJ 15" 



100\ 



101! 






\ 



\' ^ 



Deputy HeB^- 



r^ -'"^ 



^r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiticate of IDcatb 

( ■a. S. StanPatC ) 

J?' P -A 



(?11 



PLACE OF DEATH:— County of J,a > u ^A,a^ .^.- outy ot 

( ir DtATM OCCURRCD IN A HOSPITAL OR INSTITU 

A V A I 



oo 



- ) 



FULL NAME 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR >^ , ^ 



i 



(trWov...b d/CLVc^c-'^ 




ojU 



iJjyKJb. 



I)\ 11. «»l UIKTII 



A<.H 



iMi.nUn 



11 

(Day) 



(Year) 



1 r Mtmlhf 



Da ys 



DATE OF 



MEDICAL CERTIFICATE OF DEATH 
-• DKATH 1 



(Month) (I 



(Omr) 






"ThHRI-HV CI:RTIFY. That I at^^-"'»^''^ .IcctMsca frrMU 

OuIIq VI 190H to ^l^ 

that I last saw h^v^\ alive on 



a. 



SINT.I.K MAKKll.n 
\Vn>o\VKI» OK pI\<»Ki hi) 
iWiit. ill -<hm:i1 «lcsii.Miatt..n) 



lUKTm'l.A».'K 
(Slati or Coutitiv 



^^HXcLhJxAXd 



1 \ 



NAM1-: «>> 
FA TllKR 



iuKTnri,At-F: 

OI- I AI-HKK 
(State or Country 1 



MAn)F:N NAMK 
(II MnTin:K 



iiiK rmM.ACK 
(M mothkk 

(Statr or Covintrv 




fV>V 



V 



i 



<x^.acrcrcL 



r 

111 that acalh .Kourrcl. o.t the .late stated alnno. at . 
Ll M The CAI'SP: CU- I)i:ATIl^was as follows: 



LL*-v.Le^x.*' L 



DIRATION 



)Vrf/f 



.VoHths 



na% 



I'V 



//<>//» ^ 



N 'v^ "v^/^-XX-* 




.L'\^w^^xx^ fl^ 




U\v\v'\.Awtu) 



DIRATION 



(SIGNED 



\^l'^^C^ i'^ IQO'-' 






M.D. 



( A.Mrv^'-* ^ ' 









AV>/./a/ ." >■"" '■■"•'"' 



)■'■'" 



/'.. 



^^>^'^^'^ '" xwiTRlK TO TH»- 

RKST OF MV KNOWl.KD'-^. ^ _ . 

J aJ\Xo 



"sPECiAL INFORMATION ;«>v torHospiUK ..™«s, I....ts. 
orlrTfla^esldenK and persons dving a.a> from h(MPe. 

Pomifr or \\l[ LjjJCijx.', cH: P!^« 

Wlifii *»^ disfasf contracts. 
If not at plar f ol death ? 



bdy 



X.Mrrss ^l^ 



tX--^'-'^'^^%p '^ 



f 



TQO 



VSUKRTAKKR Y^'^.y-' ' ^, 

,,,,,,1 iLi.ouk,ca^ 



^"^^^^ .^.-^.LL. PHYSICIANS fihould 

rH in plain ..rn... ♦•-••■"» r',^.„». 



M <> Fv*rv Item of in?oPmat _ 

"• "• ...ucluSE Oi= DEATH In P'-'"J'^-;:;."„-;„ .v.r> -.n,...-". 
'on. dylnft .w-» S™" «•»"•« "•«•""' "« *' 



. -.v. 



i-^^y 






it 



it 




WRITE PLAINLY WITH UNFADING INK 



„,„,1 ,,f U.al.h I- No .. ^^^nScVCn 



/)((/(' Fileil , 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Re^lsfcrcd ^''o, 101 *w 



f^T' 



•^ ¥ 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( tl. S. Stan^arD ) ^ 






No. 



PLACE OF DEATH:-Coun.y ofSo^ kc..v.o .<^Gty of C^^^- ^ A-<X... 



C/^CC 



Q . 1 -^ ^ ,4. SU ^ Dist;bct. a^tla^i 

"> ^ ' ,.oil»l prSIDENCE GIVE r*CTS C»tLEO rOR UNDER 

( '^ r.^o^.T^^rcc-uNrcV/.THO^.^VAt o%'?-;St^^t.o. C.VE .XS NAME ..S.E*0 C S 

"1 . X M Jt 



LLv<xA; a<»' 



-) 



FULL NAME 



^JLlx/ou-^-^^ Cj.X'<;:J\.:U./>^ 






SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



^Xdx 



LLJkA,ijL 



I>\TK ol- IlIRTH 



I Month* 



A«.K 



) V,; » 



IC 



(Day) 



^/.^»ffl• 



(Vcar) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



vXwO 

(M«>nth) T 



(Dav> 



./pO \ 

(Y.i«r> 



A/1 



SINT.I.K. MARKUP 
\VII)0\V!:i> nK niVoK« hi 
(Writ, in «-Hial .It •.itr"ati..n ) 



niK riiiM.AOK 

«^tatf or Country 



NAMK o! 
FATMIK 



HlKTHPf.ACK 
(»l J ATHKK 
(Stat*- or Country 



MAIUKN NAMK 
Ol MUTHKK 



HI KTH FLACK 
OF MOTIIF.R 
fState or Countr> 






~I IIMRI-HV CIlRTIl'Y. That I attiMi.Wa acrrasiMl fnm. 
OIIa^ i"? tc^H to (Xv 



.^Q i^^ I90H 
that I last saw h-i- > ^ alive on 



LL^vV. 



A.A-C1 IH. 



°s '' 



H/0 v 



an.l that death rKCt.rrecl. on the .Into stated alx.vc, at H HS 

i:.\TII wa 



VA 



jt^^'> ^- -' 



^'^ 



<A) 



OCCIFATION 



. > 



XV>^^o-"^^H. 



^M. The CAlSr- tH- '>'^^''''J ^*"*^ "^ ^°"'"*'' 



CjyNTRimT(»KV^a^V^---^^^ 

) CI >- a (rtx^ 



/font < 



Hour 



(SIGNED 



1 roo \ f.\.Mu>^>-) 



'1 



M.D. 



tiv A 



i 




Special information .»» i««.spiuis, i.s.it.ti«s i...*.is. 



Formfr or 
Usual RrsMf ice 

When *>as disfasf confrac te<. 
If not at yla f c of <lf atli ? 

IU.ACKOI lU KIAI.«»K KFM..VXI. 



How loo^ at 
ptarc ei Oratli ? 



Da%s 



I.Ml. '.' !«' VIA' •" KFMMVAI. 






,„,,,„.<. •j.^i^- ^'^'-^ "^* 



,v„.,... u-ii O^v 



^^n 



,V.4^'^'-«^ *"^ 



f X.Mr. - «^n I ^ ' ,1,1111 PHY8ICI A-MS •hould 



5 



\ ! 






n 



WRITE PLAINLY WITH UNFAD.NG .NI^-TH.S IS A PERMANENT RECORD 

^^ REF ER TO BACK OF CERTIFICATE F OB INSTRUCTIONS 

\^t,^K^ iuiATv. Deputy Meal-h Offif^f^r 

DEPARTWENTOF PUBLIC HE ALTH-City and County of San Francisco 

Certificate ot Bcatb 

( Xl. S. StanOatO ) 
J <^ -A 

PLACE OF DEATH:-County ofO£^>v ^ A^>^ii^ ^^ity of - 




No. ^^^ 



a 



t!. 



FULL NAME Uvc^du dxcLc^.^^-^ 



) 



XcLq/ 



K 



SKX 



PERSONAL AND STATISTICM^PARTICUU^ 

COI.OR \ 



^\Ax 



^\^Xx 






DA IK Ol niKTM 




(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATIl . ^ 

(l)ay> 




(Month) ^ 



(Year) 



rill-KIUiY Cl-RTll-V, Tlmt I .Uen.U.l ,U«asi-.l fr..m 

.« \-). 190H to Aiwt^ •■^ 



•V.K 



) f'fl » A 



j yt.tnlhs 






/J./1.V 



«41V«*.l I" M \KKIKI> 

(Writr in mkm.-.I .ItM^'nation) 



xdLai-u-v 



VJkxxxAXo 

MAinKN^VMK p ^ I 



HlKTIUM.At'K 

(Statt Df Oonntiv' 



N \Ml. «»» 
|. ATI UK 



niRTuri.ACK 

OF I ATIIKK 
'Statr or Coiuitrv' 



r- r 



A:. 



t„at 1 last L h ^ . alive on ^^^-'<\ ^^ ^'^ 

a„,l that .loath cK-currea. nn the .lat. .tate,! alnnx. at 
CI M. The CAlSI-^or I)I:ATI1 was as folhms: 



IMRATION >V'"^^ 

CONTRiniToKV 

Yean 



Months 



Pan 



II0U 



; s 



Months 



Pays 



Pouf^ 

M.D. 



mRTHPI.ACK 

01 MoTHKK 
fSt;«t<- '"■ C«mtitry> 



( 






BPECtAL INFORMATION .»!. Ij^'^P""^- "^"'""••^- '"•*"*• 



formfr or 
Usual RfsMence 

Whrn was disfasf contractH, 
If not at plaf f of df atli ? 



|f«M lonq at 
pUrr oi Ocatk ? 



Oa>s 






(Infornuinl 






,Ou\^<^^^ 



i 



V^jjt/VVOL/^ vt^^^ ^' 



\ 




uAi-L.t lUHiM o, ki:m.«vm. 
OwVV^Q 1^ 190H 






f A.Mr. -^-^ O \ ^ ^^ -■■ I, ,. Y PHYSICIANS •houiti 




Y^ 



V 4 



WRITE PLAINLY WITH UNFADING INK 






Unit' Filt'd, LLaXV*-^ *^ I'^OH. 



THIS IS A PERMANENT RECORD 

BCFER T« BACK OF CERTI" ^"r FOB IN8TRUCTI0r.a 

1014 



liegistcrcd J^o- 




Deputy Health OfHner 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of 2»eatb 

( la. S. Stan^ar^ ) g 

1 % -^ 



, ■Q. S. StanOatC" ) „ ^^ 

PL ACE OF DEATH: -County of ^CV>vvJ/v,cv> y , 

i, ^ c. 1 Disfbet. JJ-^K^^'^ and lUo^NAX 



St.; ' 

iTI 







) 



FULL NAME 



SHX ^ 



'personal AND STATISTICAL PARTICULARS 

COl.OR 




DATK «»J- niKTU 



L 




iMontli^ 



<l)ay) 



AM 

(Year) 



AGR 



\ 5 y^arf 



"^ Months 



MEDICAL CERTIFICATE OF DEATH 
"l^XTK OF DKATH r\ ^ 

li^^ ^ 

ThRRRHV a.'uTlFV, That Iattcn.U..l.lcc.as.<l fn>n, 

^^^ i i-^ to. U^1 



(Yt-ar^ 



Ai 1 : 



aVriU- in -Kial .U-^t»rnat.on) 



(Stall or •'.initiv 



SAMl". <»' 
HATin.R 



'P 



XXX-^^ 






tbrtt I last saw h^v alive on 






antl that death .-eurrea. on the Mate stated al.>ve. at 
' M. The CAISH O^ UKATII w.|s as/oll.ms 



% bC 



\}<xiU^^<^' 




Months 



/>avs 



IIOH 



CONTU..U roKV Cc^^vcU-- ^.oUU-t.-c . - 



HIK THIM.AO^. 
Ol- I ATHKK 

'Statt or Contitrv 



M \n>KN NAMH 
01 MOTIIKK 




..Njutxx 



-A 



xt(i). 



IX'CUvXV^'^-^'t' ^i^-^^-^^^ 



IllRTHrLAi K 
or MOTIIKR 
(Slate or C<)Uiitr5'» 



(HcrrATioN 







M.D. 



i,KA.>v'.i 



orlefeS^esfde^t ' and persons d>lnq ...> from ho".^ 



A . '.^ 



Former or 
Isual Rfsidence 



H«M lonq at 
Plaf f of Death ? 



Oa>s 



AV.w./^.^ "■ '^■'•" ^""^"'^"'" ' ^""- 



\r.„fi,. 



Pf \ : 



I ''!"•■ ■ ■ __— — — ^ •III* 

— — ^— ^~"~"^~~^^^^^^ . i> f T U I ■ 1* 1 ' > .Ml'. 



(Ill forma 111 



M-->^^ r ^- 



\ 







T 00 '1 



I NDl.K lAKl K 



AiMt'--- 



30 5 QlVUr\vt::\v'. - 



H/Xl O ^X^^^v^--- .- --,,,T,v. PHY8,C.AN« should 

, information .hould •;^;»-;;'^» ?, ^^„, he properly das-.t-d. Th 
: OF DEATH in P «'" r:^!: V? „ .very inst-nce. 



^- «— ^Cr\:^E OF DEATHJ^ :r^jr;;^:in .very in.t.ncc 
«on. dy.nft away from home «houi 



'Va 






r t 






<- -. jw 







• '- V 



• <• 






.m^ 



r V 



.' ^ 



1 



'I 



WRITE PLAINLY WITH UNFADING INK 



n,,n:\ .,f II. :.lth - F No. . '^ l^^g^^M&PCo 



\i)(i/(' /wVf'^z, LAAAXVLA^fc IS: ^^^*< 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICA TE FOR INSTRUCTIONS 

Registered JV^o. 



1015 



1^,^^ kjL^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEAlTH=City and County of San Francisco 

Certificate of Beatb 

( xa. S. StanDarH ) ^ 



iNo. T ^ U CLAv 



\|\la.sv U-' 



St. 



t Dist.! bet. v' -C^ivH 



and V-cLd. 



) 



^»'» -_- ..»r.ra "eiprClAL I N TO « M »TIO N •" | 



FULL NAME 



Cl 



Q? 



/Y\,>aX)U J 'C^.^0 



' 




PERSONAL AND STATISTICAL PARTICULARS^ 



MEDICAL CERTIFICATE OF DEATH 



SHK (Pi 

J_ ^rvA. 



DA iK OF r.iK in 



\c.v. 



(Month) 



UjyK*-tx 




(Day) 



(Year) 



D.\TE OF DKATH ^ 

.Ww\^ 

(Month) A 



1^ 
(I)jty» 



/QO 

(Ytar> 



TllHKl'HV CI:RTI1V, Tbat I atU'n.loMcivascMl fro.u 

Q'VWv. too n to y-^^-q^ ^^ -'^ '^ 



190 



4H IV..- ■^ 



Miiulhs 



b 



An: 



S|N<.I K MAKHIKO 
\VIDO\VKD «»K D!V<'KihI» 
,\Vnt.- in -<Hial .1. -nfnaliuu) 




OJv^v^^-^^ 



that I last saw h-.^'^ alive 011 \X<^^C^ ' ^ »'P 

atul that .loath <>ceurre<l, on the .lato stat.-.l ahov.. at 
OL M. The CAlSi:: OF 1) I -.X Til was as follosv. : 



'f^ 






niRTnri.Av'K 

iStatt or i'ottntry" 



N.XMK or 
FATHKR 



BIRTH PI. AC K 
OF I ATHKR 
(Statf or Country) 



MAIDKN NAMK 
OK MOTHKR 






-M 






ys v^^^^^ "£) ,A^^.«^ ex. - 



)<i^;,, S Months S A/VA 



nr RAT ION 

CONTRim-TORV '"foxV>-.v^ 



Hours 






HoHt s 

M.D. 



lUKTHlM.ACh 
nl- MoTHKK 
(Statr or Country) 



OCCrPATlON 9^ • • ^ 



fA.hlrc-ss) ^" ^d^ 



4 



"special information ™i. t«r H..^UK i»^tii«ii-. "«*«'^' 
„ te«nt ResMrnt^, a«d pfrsoi-s d>i»l »«> l.om liomf. 



/),n 



„„f.,rmanl oUAJ- U- O. * 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of dfatti ' 



H«i» lonq at 
Place of Death ? 



Davs 



n\i J.,,: !l; hiai. <.r KHMoVAI, 



■■V 



a 



^ 



INKIK 1 AKJ-.K V ^ . _ 



190 







' ♦ 



fX,Mrt-s IV,- '--' , ,1 I PHYSICIANS Hhould 

,tate CAUSE OF fE^^" '" ^^ouid be ftlven in every instance. 
«ons Hyinft away from home «houia n 



■ 1 y : ■- 



■ V 






-*v» 



^. 






y;. v! 




tr 



-! 



i 

!'!» 



WRITE PLAINLY WITH UNFADING INK 






-B t^ 1? 



DEPARTNENT^ PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CEWTIFir /^Tr FOR INSTRUCTIONS 

llegLstercd ^'(h lOlo 

=City and County of San Francisco 



Cevtiticate of 2)eatb 

I 13. S. StaneatO ) 

J) ■ ,T,->, J? ^or 

..^ a .^'-^ fv.0. wc^.s,c City of C' CX/tv >? ^v<X.>v cvx^.c. 
PLACE OF DEATH: — County of Jcx.>x. A.<x.>vc.vi y 



<^ 



o 



No. \\\^ 






) 



FULL NAME 



.\lXa>vx^ Itc^, 



pERSONAt AND STATISTICAL PART.CULABS 



<X\Xjj 



r^/voJU- 




DAIK Ol HIKTII 



S) 






% /^Sii. 

(Day) <Vear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATll -i 



(Month) ^ 



1 2x 

( I>ay> 



rgo 

(Y.-ar) 



ACK 



Hi .v.... "^ 



M„Mlhf 



ik(y$ 



mN«.l I" MAKklKD 



HI 



„,„1 ,l,„t .Ualli ..ccurre.l, .m tl,c .lato statcl kI-v. ^.' 




C7=^ 



n-v 



- M The C\rSK C)l-- IH'ATM was as folhnvs: 





Stat, or .•...miry^^Ul' |) 

JaArtraa 




SAMK 01 
KATHKR 



f\- 







niRTIHM.WK. 

<>| I ATHKK 

• State or Country I 



M Ml»KN NAMK 
.11 MoTllKR 



o» M<»THKK 
-^titi 'ir Cotintryl 



IS 



V. 



Ol. ^XJU^ 



JU 



0'CU 



DIKATION J>«'-^ 

CONTKIIUTOKV 



DURATION 



Mouths 



/hns 



Hour 



p 



Months 



YCiirs 
(SIGNED) LLcMI^^^^ 

ccq i- loo'i r\.Mr.<>>) • --^ - 



i) 



jt. Ll. i)^^^^ " ■ 



Hour 



M.D 



(T^, ,^U 3:^ 



„ccr,..vn„N ^^^._ , 



H«vk Iohq at 
p|«f f of Ofatfi ? 



Dd>s 



V"'// 



/',n- 



(ItiforTttant 



i^^Vi-.^' ' 



ft 



i 



ipEC AL INFORMATION ..» '»' H».piUK l»s.il«...-. •'-'"'- 

Porroer or 
Usual Residence 

When was disease contracted, 

If not at place o(deatt)? 

...■ t \ r (lit i;l-'M<>^^!. 



TQOH 



,,xTi...; H' HiAi. ot ki:M'»vai 



>v.V-tX 







.vMre. WIH^ ^ 7 ; , ,,,cTLV . PHV8.CUNS ^Hou.d 

•.^« «« •,n format ion should ne chfo ^ properly «.l»«»«"«"* 

a.1 u ^__K%/*i»v item 01 nii«»"""' , »___-, thHt it mJ«> "^ » ^ 

"• "I^...? CAUSE OF DEATH in P'"'"'""':: •''",„ ...., !„..«»«. 



r.%%?.^^°r - - ::::r;;";i;en- ■; > .»..-"- 



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I 



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'>;'.;.v/-' ^■^-^' 






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WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 

«CFER TO »ACK OP CERT.r.CAT.rOR INSTRUCTIONS 



liegistcrcd M'o. 



10i7 



du^^^^ Ix/vM. Deputy Health Officer 

DEPARTMENT OfVuBLIC HEALTIl=City and County of San Francisco 



Cevtificatc ot Bcatb 







) 



FULL NAME 



i-Jk)'' ■'•■M yUxac^.oi.U^ 



PERSONAL AND STATISTICAL PARTICULARS 



%JL 



UjJkAAjt 



DATK «»! HI KIM 



a. 



.Mnnth) J^ <»»>•* 



.,.^0H 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

„.vrE OH ..K.U- -^ 



VY»ar) 



A<.K 



^^l(B^- 






•^ Ai.v* 



1 im.:ki:iiv ciunn-v, rhu. . atu,..i..i .w.-.-ascl fr.m. 

. ? ■ ■ Up 

190 - — to ^ 

that I last saw h •-— alive on "'^ 



Writ, i.i ■*•*'«! acHl»rnatioii) 



^ 



^-VA^O^ ^ 



„„',, .„a, ,l..al., .K-currcl, on Ih.- .l>..c stat.-l a.,.,v., a. 

. ..... ■ .... Ct^\ \m \\X%. 



M The CALSK OF DKATM w.^ as follows 



HiKrinM.wi-. 

(Stat< <'T ('nintrx 



N\Ml-. «►! 
l-ATUKR 



niKTnri.Ac k 

of I ATHKK 
(Statt <»r Country 



MXIPKN NAMK 
nl MiVrilKH 



lURTHri.AOK 
,U- MoTHKK 

(Statt <'r C"Uiiti^ 



(KCri'ATlON 



^M^^^ ^-' 



.(^\-\A 





DIRATION >Vii/5 

CONTKII^FTORY 



Months 



Pay 



Hours 






Mouths 



/hns 



/fours 



►, » V- 



.ca 



. ^ V. A 



M.D. I 

rs i 



r-yx v-O- 



DIRATION >V*/'^ 

(SIGNED) lUAC ■JXX,V<rc. 






/livw.f'.' '" >■"" f'>'""' ' 



\f.,>,!h-' 



p.! 






Formfr or 
tsual RfsklfBCf 

V^hen *»as disfasf contracted. 
If not at place of deatli . 



lt«vi lonq at 
Pl^f of Death ? 









(l„f..:iuant 







, ^.,urc.. ^ .- ^^^T^lLll. ^' r » t.d F.X4CTLY. PHYSICIANS nhould 







^^.. 







4 . 1^"^ r* 



:x" 



1 . 1 

I 



I 



..^ .MK THIS IS A PERMANENT RECORD 
.,^ »• aiNiV WITH UNPAD NG INK — THIS i» » >- 
WRITE PLAINLY WITH ur. ^«tific»te for inst 



„ 4,.tM....l. |-No..^»€^""^'"^" 



«EFER ^^ »CK OF CERTirlC^r .OR ,N8TRUCT.0N» 







Jli'ditilcrcd .A'*o. 



1 01 H 



i ^n Deputy Health Officer 

DEPOTENn?P«BllC HEMIIWity and County .f San Francsc* 

Cevtiticate ot IDcatb 

( Ta. 5. Stan^ar^ ) 
PLACE OF DEATH:-County ofUCX^^^ 



No. 







txxt 



and 



-) 



^ IF DEATH OCCURRED IN » HO« ^ ^ ^ \ 

11 , JL ' 



FULL NAME 



,;i.vcrvx.' 



-;;^;;;:Z^^ STAT.ST,C.L PARTICULARS 

COl.oR 



SI A 



^Wlx 



Vulva* 



I)AT»: OI HIRTH 



q). 



(M«>nth) 



Ar.K 



V^ O y,ar$ » 



51 



.U.»m/A' 



(Year) 



\? 



A/ » •< 






(Stat. <'r Cnntrv' 



N \M1" «»' 
lATin.K 



MiLol^ 



MEDICAL CERTIFICATE OF DEATH 
DAT^OF DKATII /^ .^ 

,M^^ : Ili^-rL 

i n J.- ....... .«ve on aw^--^ ;^ 

J. M. TlH- CAIS.. Ol- l":.VriI «a. as foM..ws. 




CV 



i 




3 oJt^^rrv 



,St.t.. or .ou.trO \^^^<XO^ ^^^-^' 






//(»//» 






I.- 



I 



OF M(>Tin:K 



(SIGNED^ t.MlUv.vUA. 



l^ 



(Aaa 



rt<«^ 



wCX.^^ 



> V 



mRTin'i..vVJ*' 

,»|- MoTHKK 
(Stalf or Country) 



(KXll'- 






„^«rS M«.'.V»d p.^s..^ *,in, -"> <'"" "•"'■ 

/p ^i Htw long at h ^x 

f ormrr or , a, i (J ^ s *, , . ^ * Place of Death ? »> ^^ 



Davs 



M..M!h- 



fh: 



„.,.„.,,.. ;<^'- ■■ ''J.,,,'.;",\K-un, iii.K r.. Tin-: 



(liif>>:i'>:*"* 



( \(Mif^* 






jormfr or ,/i. 

tsudi RfsMfwe ^* 

When ^as disease contractH, \ \^ ^^ va a- 
If not at ^af e of 4e ath . _ 



IH - ^'^ ^ *^ ^ ^ i • rrTIcTLY. PHYSICIANS should 

7.W.«t,on .H,.U. He^.c^.^ «upp..ea. ^^^^^^,^ ^,....,,, THe Spe. 
OF DEATH In P «'" -Hiven m every in^t.ncc. _ 



^•"■'SS^=--^--^'--^"-'"""''' 



y^ 



^%v 



^'r» 



A 






!.'>?^ v^\ 



1 1. J . 




f » 



^.::»- 




^^im- 



i»^:.*^ 



:S » 




locality' of 



RECORD S 



SAN FRANCISCO 
COUNTY 

s an francisco 

california 

healthIdept 



TITLE 



OF 



RECORD 



DEATH CERTIFICATES 



1/ 



M I CROF I LMED 



FOR 



THE GEUrBA LOGICAL SOCIETY 



•» 



OF SALT LAKE 



C I TY 



UTAH 



C A L I FORM I A 



DATE 




APRIL 



1 



1975 



PHOTOGRAPHER 



MAX JOHNSON 







CAMERA ■N02683B RED 1 




i m 







VOLUME 696 



1018 




YEAR 



904 



% 
♦ 







f 












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^p^ 







•«#' 



^0 



.•» 



» 



*: