ROLL
1
WBmmmmm^
Vf*
f
\
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 0 G I C A L SO C I E T Y
OF SALT LAKE
. ■ ■ .1
C A L I ^ 0 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 0 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 and
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 and'
/ 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
0
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^^^
0 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
_ PERSONAL AND STATISTICAL 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 tIEALTH-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. 0 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 . 0
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 0 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 \% 0 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">\» 0 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 190^^^-
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
\(X^v>va '
„_ AJX^^WX^W
Resiiled in San Ftanrisfo
^
Dl'RATION ^ Years Months,
Days
( ^1
(SIGNED) Ur\-trvaA;vJ
LLv^I tqo'a (Address) Ln^\Jl>>^ V |U<:i.>>.
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutlois, TraRslents,
or Recent Residents, and persons dying away from home.
> ><T If
.\f,>,ifhs
/hjv:
THK ABOVE STATKO PRRSONAI, rARTUMLARS ARK TRlK TO THE
BEST OK MY KNOWI.EIX.E AM) BEMEF
flnfoiniant
(Add
A..Bi .0/Cvct<) V<t.^
iHc^a
or -A
Residence O^
Former ^ ^ ^^ ^
Usual Residence 0£^V)^^-\^
ll
\i
X f ll«w l«R9 at I
vli/rvVd vaV Place of Oeatli? l Days
When was disease contracted. ^, ^^^^ ^.o^
If not at place of death ? CJ O^li^a^^Vt >
\t«.
0 h
PLACE OK BIRIAI, OR REMOVAI,
^
^CVCt\>v8.->
vU ^qX_
DATE of BiRIAL or REMOVAI,
I90H
.U^v^a.l.
UNDERTAKER
Clod v(K^.t!:
(Address .
(9 1 X- b ^H Aj cw:\v.
.v-^
N. B.— Bvery Item of Information .houid be carefully supplied. AGE should »>« •i-^^jJ^EXACTLY ^"Y«»CIAN8 should
•fate CAUSE OF DEATH In plain terms, that It may be properly classified. The Special Information for pr-
sons dyln^ away from homo should be 4lven In svory Instance.
I'
i|!iij|
II
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoard of Healtli~F Xo. i^ "^
H&PCo
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Date Filed,
I lOO'i
Deputy Health Officer
Registered J^o,
71^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
PLACE OF DEATH
0 . .0
: — County ofvJ
( TH. S. StanDarD )
(Xy\) 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 0 •
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^ IQO H
rNDKR/AKKRMT\ 0 /(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. 0 Jdu. icjj
vt\j
DURATION
(SIGNED)
}'cyirs : .^fouths Pays Hours
JJk\X^<x,L^ M.D.
fi [Ci M (15 ^ .
'h\ iQoH (Address) \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 in 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.
ss) 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 0
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/>^' 0 ^^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 0 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 PARTICULARS
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)
llu^ % 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)
0
)\'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
0
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 0 A<XA^euiCCCity of CJ/Oav 0 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) 0
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)
LUvqi %
Years
IC)0
% O'
Mouths Days
I)
Hours
M.D.
f A<ldress) 5 I 0 \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 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 0 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 0 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 Stni 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 0 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.
iLulQ :^ 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 0 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 0 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)
iALv,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 • 0 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\} 0 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 **' \ 0 .
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* 0 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 0 *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 0 ''"
\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
(IaaO 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 INSTRUCTIONS
!
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 0 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 0 AX^rCU^' cUaXN^ j, .-
^$-\ VmAAA.v<rvv...3i
(Address
, ~ .PE .hould !>• stated EXACTLY. PHYSICIANS should
,t.on should be carefully supplied. AGB •»»»"'«» ^J* "Special Information" for pr-
N. B.— Every item of Information should oe carc,«.., •--"— properly classified. The "Specli
atate CAUSE OF DEATH in plain terms, that it may t>e prop
;or. dyfng -way from home should be ^iven in .very instance.
%^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
741
H&PCo
Hoard of llenlth— F No. 15
Jh(te Filed, \Lk.^jOu\j^ 3 VJO S
Registered J^o,
Li-uvvo "Lxvu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(Tevtificate of Death
( Ta. S. StanOarO )
: — County of^loLA^ 0 A<]L^rL>CyUl^Gty ofVJ/Om, OAXt^VCA^'C^
PLACE OF DEATH
( •' %''^:.^..i'%iii::.v:r^^^^ :r.ii^.';s.'iorir.v.\ name ..»tc*o o. ..n... ..o .u...n. ;
■)
FULL NAME
.O.^^utLcL L(r.ta
ih;.
SKX
PERSONAL AND STATISTICAL PARTICULARS
COI,OR
(niju
lO.Lii.
DATK OF BIRTH
iM^lith)
Ar.R
) V«i » .»
1
(Day)
Months
r 1.0 .H
(Year)
X H ^«''*
SINr.I.R. MARKIKI).
winowKi) <)K nivoRi'Kn
(Write in social dtsijfnali«>t»)
HIRTIfPLACK
(State or Coiuitry)
NAMK OF
FATHKR
llli
UL-vJiVv^^v
C^AJ
BIRTH Pl.ACR
OF KATHKR
I State or Country)
• '
MAIDKN NAMK
OF MOTHKR
BIRTHPI.ACK
OK MOTHKR
(State or Country)
«*
OCCUPATION
Rf$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>^ 0 /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^PARTICULARS
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 in 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.
(Lcg.X 190H ^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' 0 . ^. 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
0 ^
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 0 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 CERTIFICATE 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<
0 ^
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 0
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 0
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 TO 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 "' '•" ' 0
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 CERflMCATE 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 PARTICULARS
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 (AchlresO 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 STATISTICAL 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 0 -. «v -N
'lO.Lu
xr.K
12l v, U
M.mlh^
11
Al V:
MEDICAL CERTIFICATE 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 FOR 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 DEATH
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 place 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 BACK OP CERTIFICATE rOR INSTRUCTIONS
,.fM,-„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 HEALTH-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. ^ 0 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 death? —
-.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 PACK OF CERTIFICATr 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 CERTIFICATE 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 0 0 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 PARTICULARS
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 0 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 190 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 Htalth-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 0 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 ■
0
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. /
0
)
-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 BACK OF CERTIFICATE 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 place 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.^ OP 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 PARTICULARS
CO I. OR
(!lvU
kdt
DATK Ol- UlkTM
ACK
(Month*
(o 0 )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 INSTRUCTIONS
I ,1 J „ lo/iu Registered Xo. 776
"Lrvvv* "ilv-M Deputy Health 0?ncer
DEPARTMENHF PUBLIC HEALTH-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) -- ,
ilvVQ^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 Botatplaccofdeatli?
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 CERTIFICATE 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 0 ^ ' '" '
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 PARTICULARS
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. PARTICULARS
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 0
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-
0 ^
: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 CERTIFICATE FOR INSTRUCTIONS
I , ( 1 -L u 79/94 Registered ^''o, V^'^
I Ihde tiled, LUvOLwaX H ^^^^
1,..^ i^. Deputy Health OfHccr ^
DEPARTMENT OF PUBLIC HEALTH=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.
0 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 0 .^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 0 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^^ ....
iW-^ TcpH (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.CATr 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.Mrcss ^^ . ^^ 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 BACK OF CERTIFICATE FOR INSTRUCTIONS
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 0
(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 )
0 (B^
No. a^ 0 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 AND STATISTICAL 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. nrefully 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 HEALTH=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 FOR 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)
MEDICAL CERTIFICATE 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
REFER 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
0 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 OF 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 ^''!''^\,
0 (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
REFER 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.
0
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 BACK OP CERTIFICATE 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
'0
.i-^ A
SKX
PERSONAL AND STATISTICAL 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 0
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
WEFER 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 0 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 HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( la. S. Stan&arC» ) .
of^ou^v viiva/>xc^<iA:^Gty of 0.a/>v 0 ;va/> V cc^^cc.
PLACE OF DEATH: — County
<n\j
St.;
Dist.; bet.
and
— )
(Ar DEATH OCCURS AWWT FRO
0 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 HEALTH=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 BACK OF CERTIFICATE FOB INSTRUCTIONS ^
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 0 )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) <^'«»^^
MEDICAL CERTIFICATE OF DEATH
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. .^refully 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
/ 0 , ^
(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
Citytjf
(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 igcr^-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( 0 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 CERTIFICATE 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: — Cuunty ef ^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. ( 0 .<>. 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 0 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 CERTIFICATE 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:-County 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 ViMrcss
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. T90H
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) QlVa^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; — Cuuiuy 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
0 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 deatli ?
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
REFER 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; — CuuatT 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 PARTICULARS
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 0
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 ; — County otVll\.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 — County
♦^^^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
0 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 CERTtPICATE 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 0 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
^ 0 ,,.„.
(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^ 0 /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 \ 0 \
(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) >? 0 ^ 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
'^^ ^ 0 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 ' 0 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 0 \ ^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
REFER 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
RCFER 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
0
\ 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
REFER 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 STATISTICAL 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*^- TooH (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
REFER 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
REFER 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 0 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
(.\(Mris«
N. B."
— — — ■"""""■■■""""■"^ TT! Th Af^ should be stated EXACTLY. PHYSICIANS should
-Every Item oi Information should be careVully •"PP'''^' jt^^J. classified. The "Special Information" for p«r-
•tate CAUSE OF DEATH in plain terms, that it may be properly Uass.i
son. dyinft away from home should be given in evry instance.
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
, ,.,n„.„„„ , NO .*rl?*.H^I'Co REFBR TO BACK OF CERTIFICATC TOR INSTRUCTIONS
Begistered J\i'o.
Qorv
l),ih' hllr<l,XL^aAjjd^ ^ i'JO'\
i^vwa U/V.-A, Deputy Health Officer
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
-Ccvtificate of H)catb
( xa. S. StanOar^ )
0
; 1
^
PLACE OF DEATH : — County of
St-
No.*-JX.\)
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 0 \\\^
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) ^^ 0 ^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.
\%\
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:|.:
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•-
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«
:ii^
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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 0 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
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i 1 1 1
I 5
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3.
■f !
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.»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 TO 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
0
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 0
.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 TO 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 STATISTICAL PARTICULARS
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
WKFER 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 ' 0 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
REFER 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 ^190
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:
0 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 0 R V Vl \A. k. %T^
J /our
i,-W:fr\r»J:^.W.-.„
MoHt!n
DTRATION Ytius
A A 0
(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 0 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 0 (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 0 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 0 .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
^ 0 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
0
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 0 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
0
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 0 ^ ^
^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) 0 /ux^AyC^-*.^:^ City of 0/Qv>v 0 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 0 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 0 -^ CX "W K *CV
i
' X.l.lross . L ^ '^ i >'V^ > W 0 ^. ^->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^'-\
ggy
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 0 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 CERTIFICATE 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
PERSONAL AND STATISTICAL 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 irii. - ,■,, ' ),,/;> *" 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 INSTRUCTIONS
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^\^ 0 '.(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
0
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 0 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 INSTRUCTIONS
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 0 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 INSTRUCTIONS
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 0 Xcu-n-C-i^CtCity of C'<X^w 0 /^<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 0 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
0 \ 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. /
0
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"
0
(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 0 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 • jqo-rrrr .
that I hist saw h ~ — alive on —.-...: :j, .iimiumnui.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
REFER 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 CeRTIFICATE 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 )
0
PLACE OF DEATH: — County of v^Cr^^vCVOj
CtV'CU Lc)-^Xo..* City of
JLv
(^
(XKK^'^^JLri VCLU.........
0
'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>^ 0 ,^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 0 ,CC>x.-.^^_li.
sj:\
tTP
PERSONAL AND STATISTICAL PARTICULARS
^, 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 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
WgFER 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 CERTinCATE 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
IUvOlI h^H (Address) 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.->\' 0 '^. '^ 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 0 )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 BACK 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.
0
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\' 0 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
0 \
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 CERTiriOTt rOBINgTWUCTIONa
884
U&PCo
7)(tf(' /'V/^^^/ , U..CA.<iAA^ I 0 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 0 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 TgOrrrTTrr
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 CERTIFICATC 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 0 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>
0
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.
0 .^
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 0 ^^v 0 ^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^^^^ 0 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 0 - W, iL'- IsJtLcVvvr ..M.D.
clccQ 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
190 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
0 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
RCFER 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
REFER 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 0 &'\^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 0 ^ 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
0 -.^^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^«.£
0 ^ ^ 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 PARTICULARS
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 0 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
0
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
0 ■ ^ ■
•)
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 PARTICULARS
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
0 A
CX./-VX.
,dL
SKX
PERSONAL AND STATISTICAL PARTICULARS
' ' 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.. 0
Su
I
(1
Dist.: bet* "^ CJ
CSVy^i
I 0
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)
0
"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
REFER 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
0 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 T90H
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
0
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 (Address) 0 ^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 0 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 Dist; 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. )
0
\
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 -^ I90H
"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' (Address) ^^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
REFER 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 STATISTICAL 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 0
'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
^•> .«-^
REFER 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
0
^
UJUULL^.
PERSONAL AND STATISTICAL PARTICULARS
'"" 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 0 &: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^ 0 ^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 back 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 0
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 geRTIFICATC 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 alive 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
0
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 0 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
0
(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 CERTIFICATt 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^^' 0 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:\
0
PERSONAL AND STATISTICAL PARTICULARS
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
REFER 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^ 0 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 PARTICULARS
/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 INSTRUCTIONS
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^ ;
0 (^ ■•
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 TO 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
-— — — 190 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 CgHTIFICATe 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 ^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 PARTICULARS
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
REFER 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 CERTIFICATE 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 0 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 CERTIFICATE 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 0 OL^^v J;v<XavC. o -City of^'CU^ 3 AXXov^^-^i-^
itv of^'
0
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 Tc)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)
0 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 back 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
0 xXy
COI,<JR
'I
'a^' ivvU
( Mouth >
M.V.
0 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
RtFER 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 PARTICULARS
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 0
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^.' 0 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 CERTIFICATE OF DEATH
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 t90 —
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
0
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 CEWTIFICATC 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.^ 0 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-
0 (\> 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
0 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)
0
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 0
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 reH 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 0 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
0 \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 0 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
0 -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.
LLv.M:> ^X too ' '■ ( Address) 0 ^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 0 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 0 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 >■' olive 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
REFER 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
^
0
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 0 190 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 0 0 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
0 >^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 .idrcss) 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 0 )Vij»> 0 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 0
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 CeRTIFICATt 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>
0
(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
0
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 0 )>«»».'
(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
0
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^^'
0 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" 0 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 0 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
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I
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^HJi
pf^^^B '
Br,>^:-<->w>^
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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
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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 0 (\ '
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 {
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J
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: 1 M
mis
^•-i^'
WPH^ti it^sak
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. ,^ 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; 0 AXX'^'V.Ca^ C^cCity of
Ojy\}
0 ''^
"^ ^-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
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^..
'■-£-■'
^^Vl
*l
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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 0 /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
0
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
0 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.
^ 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' 0 .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 0 .^ p fi J 4 0
^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 0 N _ ) cars _ Mont /is ( 0 /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.
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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>^ 0 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 (^
0 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
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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
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ae
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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 0 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 0 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
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,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;»
0
./■//
/'./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 0
'^
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
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V
'V-l
, I
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if
1^
Ill
S;
ii:
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''■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 » 0 190 .
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
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l«
Wl
jL'm
>-"
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V
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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>^ 0 'va^veULtc City of 'CL \v vJ
(^
K (X >'VCA^^ a i
\
4 I SU H Dist.; bet. 0 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 0 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
REFER 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
.......JLi^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 \^
0 A/xr,\M'. City of O CLrru 0 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) JCHH 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
0
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 ^ 0 ^ rvA^<U^ ^ M ^^-
MEDICAL CERTIFICATE 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
RgfER 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 0 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 0 -^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>^ 0 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 0
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 0
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.
/CtciO ..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 crRTiriCATE 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 0 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
0 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 0 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 0 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 0 .'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
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.
LIuX^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-tUs: 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 0 -VCL ^ V (^vss. rcCity of 0 <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
^ / 0 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 0 (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 0 /CX/V\J vj ^vOl/YVC. VaL a 0
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 0 ^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
REFER 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^vtigA.
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 '\ 0 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 0 > ''? ' "'
}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 0 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 BACK 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. 0 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 0 (^ 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". 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^ 0 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 0 0 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 OP 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?.
0 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 DEATH
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 INSTRUCTIONS
" 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 0 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 0 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 place 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 0 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
0
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^^ 0 ^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
REFER 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
HEFER 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 0 <lA^ 0 /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)
0 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 0
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 0 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^
0 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. 0 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
0 jt^^'> ^- -'
^'^
<A)
OCCIFATION
. >
0 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 ylaf 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
^^ REFER TO BACK OF CERTIFICATE FOB INSTRUCTIONS
\^t,^K^ iuiATv. Deputy Meal-h Offif^f^r
DEPARTWENTOF PUBLIC HEALTH-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 0 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 CERTIFICATE 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 0 ^ 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
0 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 BACK 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. 0 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)?
...■ 0 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- ■; > .»..-"-
I
I
:-»-^.-^>.''
4. M
'>;'.;.v/-' ^■^-^'
^•»
<r3^
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 4eath . _
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
..*%«-■
^p^
•«#'
^0
.•»
»
*:
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