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

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LOCAL I T Y 



RECORD S 



RECORD 



SAN FRANCISCO 



COUNTY 



CERTIFICATES 



..) 




r 



•v ,' 



M I CROP I LMED 



TH E GENEALOG ICAL 



SALT 



CA L I FORM I A 



DATE 




APRIL 



PH OTOGRAP HER 



MAX JOHNSON 




CAMERA 




no2683Hred 1 



yo 



''"«N>. 



EGIN 



)'iW^' 



i 



t 



5t. 



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« V 



t / ;* . 



•• 











i,b«r <^ ^' 




V <. '*^~WV. 



/\ 




Jj/ 



DfiFUTY. 



I 



rfl- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of fUalth- I- No i- "^-^^S^UiKV Co 



REFER TO BACK OF CEWTiriCATC FOR INSTRUCTIONS 




IW. 



290\ 



I)(ffr Fi/e(/, 

(LiyoL.^ cLov-t<. Deputy Health Officer 



Jie^istcred J^o, 



1010 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "CI. S. StanC»arC> ) 



4 



% 



PLACE OF DEATH: — County of OOyW; JA.'avvc\.acc. City of'^'-O-A^ >J.>UX-v-a^ 



'No. 




A SO MUvtlA.Mcv,.i 



^^. c_ c 



St.; I Dist.;bet. cLCL>\^VLla\; and OvLVicL- 



/ .r OC*TH OCCURS *W*V FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "S PEC I AL I N FO R M ATIO N < \ 
V .r DEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E J! AN D N U M " « ) 



FULL NAME 




oj\.A.cL' v^Ll 



PERSONAL AND STATISTICAL PARTICULARS 

DATK ni Itik 111 

A(.K 



fVear) 




\X\JX^^\ 



MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH /"I 



L 



(Month) \ 



(Day) (Year) 



i 



I )■-.;, 



11 



M.mth 



/'< 



/ 1 A 



'^iNi.i.K MAkun;i> 

\\ iDow i;i> (IK iM\ I >krKi> 

(Writtiii siH-ial <lt si^'iialion) 



MIK llll'l.Ari-: 
' State or l"i)unt r\' ' 








NAMK <U 
FA I 111. K 



lUk lUlM.ArK 
Of- lATMKk 

'State r)r CiMiiit r \- 



MAIDKN NAMi: 
<)!• MoTHKk 



nik riii'LAr}-. 
<>i M< nil Ilk 

'State or t*(»miti\ I 



I HI'KI'HV C1;RTIFV, That I attetided tleceased from 

•H "^ Itp'- to LL.^...|..^ T^p'l 

that I last saw h •. alive on LL"..\„n • j^q 

ami that death occurred, on the date stated above, at 1 
\i M. The CAISK OF III^ATII was as follows: 





rOLh-xCrL 



<1 J 'I'.'AA. 




i 



JL'^'v^*>va/v 



1 



-I 



I )r RATION Yt'ars 

CONTRIIU'TORV 



Mo)iths 



Da v.v 



Hours 



\^ \ 



V, r V<.. ^ 



1 . ^ . 



DTRATION 9v r/V7;'5 JA>;/M.? 

(SIGNED) Jyi^-ft-^VUX^ WcrL^ci 



dv.., o 



I()0 



Pays 

T Q . V 



flours 
M.D. 



( A d<l ress) (o ^H U 3 <X\.N„L-l if'. ■ J '^ 



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



OCCrPATlON 



M;>,fll^ 



/),n. 



IHI-: MjdVK sTAri:i» I'KksoxAi, i-xk ri.ri. \ks aki; rki k tm rin-: 
iihsT OF Mv kv()\vkj:i)(,f: and iu:i.n:i- 



'I 



"f..rinat.t UJ OjLdLX'^V> 



^^ 



\<l<Ii( 






former or 
Usual Residence 

Wfjen was disease rontrarted, 
If not at plare of death ? 



Hew lonq at 
Place of Death ? 



Oavs 



DATlv (jf niRiAr, or KKMOVAI, 



wq i'!. 






I'l.ACK OF" lUKIAI. OK KF:Mo\ \1, 

indf:rtakf:k VI V O A-<Xvi . '^'^-^ ■(. 

(Address 5..S.1. 0-^\XLjL^ .C!± 



o ^0 



190 1 



^- ^- Kvery item of infopmution should be carefully 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 p«r- 
«on« dyin^ away from home should be |»iven in every instance. 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

J<n:ii(! <if !!( :ilt)i \' Vo. i ', *'^v5«?^5^ US;, I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihf/c Filed, 




I V 

Deputy H 



100\ 
Officer 



Be^Lstcj'cd J\^o. 



1020 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Deatb 

( XX. 5. Stan&at? ) 
PLACE OF DEATH; — County of J<Xa\) J/v<X >VCt^C(. City of OoyTu 0;uX/>vculcc 



'No. 



blo 



v(X,\.|^J. 



St. 






5^ Dist.;bet* ll ^ and IXfrXXk. 



r \r Dt4TM OCCURS *w*v rnoM USUAL RES I DENCE Givt facts called for undfr "special information- \ 
V if death occurred in a hospital or institution give its name instead of street and number. ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




SKX 



DAi}-; «>1 IllKTlI 



OJJL 



COI.OR '\ 



\ 



? 



1 



•Moiithl 



A<,K 



I 1 )ra>> 



(I):iv) 



M..iilfts 



(Year) 



n,i \s 









OJUu 



SFNi.I.H, MAKKIHI). 

W inoWKI) OK DIVoKiKl) 

(W'litriii >-<)ti,'il <ltsij.'ii;iti<)ii) 



lilK rni'l.ACH 
(St.'itf or i/oiiiitry) 



\AMi-: Oi- 
l-ATM i;r 



HIK rHI'LAiH 

OI-" iAini-:K 

(Stat( or I'oiiiitry) 



MAM)I-:\ NAM I. 

oi" .mothi-;k 



HI KT HIM, An-: 

OI-- MnTin-;K 
(Statt.- or Coiiiilry) 



OCCri'ATlON 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH -^ 

(MoiUh) (| (Day) (Year) 

1 HIvRHBY CERTIFY, That I atten(T^.r(lcrca^>(rfroni 
up - to LL*.^oOb ^^ 190 H 
that I last saw h.7AL>\J alive on vAa^^a^q; IC- joo'i 

and that death occurred, on the date stated above, at '0-^0 
U^M. T^ie CAUSK (.)!• DIvATII was as follows: 

1 




•C L ^. 



DTK ATI ON Id )'ears 

CONTKIHUTORY 



Man tin 



Da vs 



I /ours 




A. 



hi 



O 



CL^^^V1 



DIRATION 

INED) M/L 



(SIG 




V 



dU 



:iAl in 



}'cars Jfoj/Z/is Days Hours 

90 1 (Address) S.JoS UXX^v A.>{Xvl<N. 



O /CX^^j^kxM_ M.D. 

?''^9'^^ Information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



VM-V,A. I '^- T 00 ' 1 r A d d ress ^ 1 (c S O /a/^^ s \J\X I /V (J, . 



Mnuth^ 



Ihl 



rm-; ahovk st\ti:i) pkksonai, paktuti.aks \ki-- tkik to tiii-- 

IIHST Ol- MY KNOWM-DC.H AM) UKMl-iF ' 



Former or 
Usual Residence 

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



Hew long at 
Place of Death ? 



Days 



ill 



Q%v. 



VOlm 



r\fl dress 



bio 




Vh.KQV ()!• lURIAI. OR RHMoVAI, I DA'IMv^of Hr«,Ai. or KKMOVAI, 

^% Crlw-L^uo-^i^ I CLwv^....a. T9o'i 

INDKRTAKER 



^^ 




(Address 1^1 \l fAA-^^A-V^^O 



t 



""' ^'~^tBU CXU^t Ov7r^^^^ 1" '■«-«*"">' Hupplied. AGE «houId be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH m plain terms, that It may be properly classified. The "Special Information" for dt- 
son.dym^ away from home should be ftlven in every instance. ■mormaiion for per- 



f 



! 



t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoai.1 of Health » Vo I ■. T^^|S^ H& I' Co RCFCR TO BACt{ OP CERTIFICATE FOR INSTRUCTIONS 







|(<5 lOO'i 

cMro_A^ ckX'XMH^ Ljcp'ut, - . , Officer 



Begiatered J^fo. 



1021 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( XX. S. Stan&ar? ) 






PLACE OF DEATH: — County ofOoL/\X) vJAXXAvcM-^/C^City of ^^O.yVu J XXX >V/Ca.<l.c<. 



^No. 



JL\yY>xxx>v 




(KL. 



■\0^ 



O. 



St,; — — Dist; bet/ 



and 



f IF DtATH OCCUBS *WAV ^ROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION'S 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

•'^HV A ,. A I COI.OR 




XL>^^LC 






:t 



DATK nl HIKTII 



AC.K 



^■OJ 



CAJL 



MEDICAL CERTIFICATE OF DEATH 



^V\j 



<M<)iith) 



\- N ) I II I . 



(Dav) 



.!/.»;////> 



Ml 

(Year) 



/)>n> 



SINC.I.K. MAKKIKI). 
WIDOWT.I) OK DIVom K.r) 

lU'iitt ill >.(>cial dtsij.riiatioii) 



lUKTHIM, Xrj-: 
(Slatr or c*<nintr\) 



FATin.K 



lUK rniM.ArK 

()!•■ I ATHKK 

• Stal< or l"oimtr\> 



maii>i;n namj: 

«»J- MOTHF.K 



HIRTHrUACK 
1)1- MOTMKK 
(State- or Countr\ 




DATK OI" I)1:ATH /"^ 



(Month) ^ 
I 1II:R1':HV CI':RTIFV, That I atten.lc.l .Icccased from 



(Day) 



/go 

(Vtar) 



-V. \ \„^_ 



i I f 



190 



to 



tliat I last saw h -^i/vw. alive 011 




I 



^ 



Uw..A..A^ 



190 H 

and that death occurred, on the date stated above, at X-'^L 
-^ ^I- 'I'lK- CAISH Ol' I)I-;aTII was as follows: 



}'ears '. Mouths 

.'ONTIillU'TORV \J 



DIRATION 



Da vs 



crV ^SsAA^'v-.o, 




Hours 



occ 






nr RATION 
(Signed ) 



^O.yftw^VW^-:^. 



)Vr7;-5 Mouths ^ /^//v.v 




'vKa/vv^ 



/fours 
M.D. 



VAx/^q^ 15 TQo 1 (Address) UXVwvQ^v K ^v'J, j. 



f\f^idfi{ ill S(i>/ i'ltiu, 



) V(M 



Miiuthy 



I >a \ 



TUK AROVK STAT)-,I) I'FKSonm, J' A KTI.T i. \ k S Xkl- TKIK To 
IIKST OF MV K\o\VM:I)(;k AM) in:MKF 



TH1-: 



(I II forma lit 



O X^v/^^vA/cx^v Jb 0-<i.'i'V\jtvtx.l.' 



?''^9^fi^."^^Of"^'^T"'ON only for Hospitals, Insfilutlons, Transients, 
or Recent Residents, and persons dying awav from home. 

., .n"^,. (O I." D Howlonqat 

Usual Residence WoJkXo..v-^ ' Place of Death ? . .. Days 

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



'X.Mrt'ss — 



I NDl.KTAKHK 

(Address 



T90 



y/^-^^^'''j> "IK'-^I. OK KFMOVAI. DATKo; Hikiai. or KKMOVAI. 

m (? y 

(D 'cvk.itx,.>x^ Lx.L, 



"^' "■~rt«Te''clr*s?Ap*nTri'M" •*'7'*' "^^ ^"-«»^""y «uPPi-d. AGE «houlcl be stated EXACTLY. PHYSICIANS .hould 
state CAUSE OF DEATH m plain terms, that It may be properly clarified. The "Special Information'* for D.r- 
«on« dyinft away from home should be ftJven in «very instance. 



r 



WRITE PLAINLY W|TH UNrAniMi^ iiviv 



I k #* » • • 



Ho;t!'l of Ifc.'iltli !•* No. i^ t*^^5S^ WScV Va 



l)(((r Filed, 



'^UV'V^ 




RgFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 



\h 



190\ 



Registered JVo. 



1022 



AM^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 



Certificate of ©eatb 



PLACE OF DEATH: — County of vJXa.cxx.\ 



City of 




(No, 



St.; 



Dist; bet. ~ 



and 



( " ,v.r.,:%c"c-!.;ro',^-r„<.".-- t^^:^^^-:-^'iti^i:::.-v; ,;%%%Ti„TS;r- ) 



FULL NAME 




A.<VxLcui I.: 





L- 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



'f 



DATK nl' MIK 111 



AC K 



LUJva 



Ll.lvVA.i 



I Mont'li ) 



1 






) III I 



H 

(Day) 



M.-ut/is 



JL 



(Year) 



I (; 



n,7 v.s 




SIN(.I,K MAKKIHI) 

\vii)n\vi:i) OK i)!\()Kri;i) 

(Wiitriii MK-ial <l«sivMijiti<.)i) 



lURI'ni'UAOK 

'State or Coiiiiti v) 



NAMI-: <)} 

fatiii:k 



HIRTMI'I.AiH 
OI- l-ATUHR 

'State or Country) 



maii)i.;n namk 

<H- MOTHKK 



niR'riiiT.ACH 

Of MOTHKK 
(Stat.- or Cotintry) 



'^-XxJ^CL^y^^J 




MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH 

(Day) 




(Month) 



(Year) 



I HIvRIvHV ClvRTIFV, That I atte„<le.l .lercased from 

^90 ■ to T90 — 



lliat I last saw h .Tr-r-r~ralive on .. ^^ 

and that death occurred, on the date stated al)ove, at - 
.^^n '^^^ CArSiC OF J)|.;ATII was as follows 



'%ju^>Oi^ ^I^. 



Dr RATION }'(^ars 

CONTRIIU'TORV 



Mouths 



Da vs 



//oius 



DTRATIOX 



y't'ars 



C ^'■J<.U 



\\jJLaxs x ci 



Over PAT ION 

^'f^idfii ni .S\i,r /'nnui\,;> C>\> )'r,n y 



(Signed) 

ECIAL IIM 




.Vi)/i//is 



Pa vs 



JVcva. Y\.t 
^1 



90 



(A(Mress) J Xa^.> a4^,« J, v . O ' . 



//ours 
M.D. 



."^^'iifh^ 



Ihn 



"'''r^^^'i'i^i:.^'^^::^^^^^::^:^^^ 



flrfprrn^^P^i;;J'^„J'°'''^?T"ON ?"'y f«r "ospita'S Insfitutlons, Transients, 
or jfcent Residents, and persons dying away from home. 

Former or % () P H«v 

Usual Residence \J Kk^^JL^^JUL, Kxxh pi^j 

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



.a 



y^« Days 



f rnfotniatit 



.9 



Address O A.A.,A^-Q^HK_C 



i'i.A^y>K mRrAx „k rkmovai. | D-vaCof H.-k,.,. or kkmovai. 



.<u 



I • N D 1 : R T A K I.; R jfo oXaXjlS^ 






I90H 



(Address ... 






r » 









-^^dSS. 



i^x 



m 



i| 



i 



WRITE PLAINLY WITH UNFADING INK— TWic: i 



tk DCDtmAKlPKI-r- r% w» ^^ ^s. r* w^ 



Mo.-IIil of 



Hr.iltli- K No. K "^^^^^ US: I' Co 



REFER TO BAC»^ OF CERTIFICATE FOR IN3TRUCTIONS 



Deputy Health Officer 




Registered J\^o, 



1 02; 




DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( la. S. Stan^arO ) 



PLACE OF DEATH.— County of Clcx^ AXXoxCvaccCity of 0,CU^3xa.^ 



'No. 110 5 \i n. 




'V<lCvlC.(. 



-A<i V. c > 



.d 



FULL NAME 



St.; Dist.;bet. IT .A^\; and 

► IDENCEgive facts called roR under "special informatio 

OR .NST.TUT.ON GIVE ITS NAME .NSTEAO OP STR E ET AN D N u M " « 

I. n 



( " .v*o;".,°„=^c"c"j,;ro\;."rHo",^pr.t c%^fj^^?u';Li"/,/«:!^.vi.^° -".--!' i--- .-o".t..,o... ^ 



\IU 



\, 



) 






si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




>J, 




1/ . 




iJx 



i>Aii- <)i liik ru 



AC.K 



iMoiitli) K 



] 



MEDICAL CERTIFICATE OF DEATH 



!'■ 



) ra I > 



Moulhs 



(Year) 



n,t\ 



DATE OF 1)K.\TH r\ 

(Month) K 



i:i 

(Day) 



(Year) 



I HKKICHV ClvRTlFV, That I attcmlcl .IcHcased from 



..U^Q U igo S to SAA/vn 

that T last saw h .. alive on LL 



...IH. 



SIXC. 1,K. MAKKIKD 

wii)()\y}:i> Ok i)[voKri:i) 

(W'titi' in v.,HiriI il< si^'iiation) 



lUK'rm'i.AOH 

'St.iti- or Comitrvi 



\\M1-: OI 



HIKTIllM.ArF: 
OI' I ATMKR 
iSfatr or Couiiti v 



<4 I 



aiKl that death wcurred, on the date stated aln.ve, at 1 \ 
M. The CAlSlv OF I)1;aTH Nvas as follows: 

()v>^\.ivJL>''vjt 



vXXAXx.v 



CL'-^ 



* -V\ i^JC'''> 



.V^: 



\ 



ihr.\tion 






MAIDKN NAM1-: 

oi- M()thf:r 



nikTiii'i.ArF: 
oi- m()Thf:r 

(Sialt or Cojiiitry) 






-^ '^font/is Days 



//ours 



AJouth^ 



l^avs 



//ou 



<r^\ 




I )r RATION . Years 

( SIGNED ) Aj^j^A, U UA..av> M c 



^u^a il ,( 



■<\ Iv I()0 



Address) V.^ 11). O 



M.D. 



■A- V^X^-> X ' 



«r?''^9'^^. "^^O^'^A'T'ON »"'> f"*^ Hospitals, Institutions Transients 
or Recent Residents, and persons dying away fro.-n home. '"nsients, 



Kf.^idnl 1,1 S,ni /'i ,ni,/.u;> ['X ),-,r 



^■>iitli< 



/hi v. 



rwv. amovf: sta ii-.d i'kksowi FXR-rrriM au< iot.- i-Di-t.' ■,. — ~! 

lU-SToF MY KNN.\VlJ.:iM-.K AN,) MHilij.ii'''^ ^'*^- ^^^ ^- '<' 'IIH 



Former or 
Usual Residence 

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



Hew lonq i\ 
Place of Death? 



Days 



(Info/maiit 



'Address ^lOS \l /U^^ 



v\; 



I90H 



N. B.- 



'"'f7^7' ""l "^'%''' '"" KK.MCVAI, I nAi;F of HrK.A,. or RKMOVAI, 



.on. d,i„g aw», fro™ h„„e Should hTtiven ?„ '.v.'.T uZT. ' '""''>"'■ ■^*" "«-"-' ""fo—ion" for p.r- 



#*«"■ 






WRITE PLAINLY WITH UIMFAniNn ink -ruie 



• •«»• » %^ f-» I ^r-iiTir^i«E.ivl 



laa M Ikl r* iki^- m^ mm ^^ ^m. mm ^, 



Jtoiiid .if ll(;ilt)i I- Vo n -^'^^SiOj^I^ H^l' Co 




REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Registered JVo, 



io;24 



'XAjx)^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HE ALTH=City and Counfy of San Francisco 

Certificate of 2)eatb 

( m. S. StanOarD ) 
PLACE OF DEATH: — County ofCJ/a-^ J.fLCL^n^^ivxw^oGty of Oo^vv i>La.. vci-;i.cc 
'"^^ ' '^ .V,;:.:: ;cc„.s ^t.: I Dist., bet. O KXX^x^^L ^nd J -cll L- J . 



'No. 



) 



FULL NAME 



dA.^'v"J- ^ . 



PERSONAL AND STATISTICAL PARTICULARS 
'^'•^ (J?) (j j COLOR \ 

n.\'n-; <n- iukiu (y>j a 



x^ 



I Month) 



AC. F, 



) Vi/> > 



(o 



1-5 

(iJav) 



Motilfif 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH , 1 

U,A. v.,n 1 5- 

(Month) ( 



(Day) (Year) 



(Vt-ar) 



/hi v.v 



siN'r.ij.:, MARun:i) 

WIDOUFI) OK DIVoKiFI) 
iWiitrin M>rial <h-si^^iiatioii) 



lURPMlM. M'F 
(Stall or rotintiv 



NAMF »H- 

fathi:k 



niKTHI'I, \(H 
OI- lAIIIKK 
(Statt or I'oiintrv) 



MMDl'lN NAMF 
<»1 MOTFIHK 



niRTHI'I.ACF, 
oi- MOTMHK 
(State or t'oiintry) 







I HHRI-:i'.V CKRTIFV. That 1 atten.k.l <lcr.ase<l from 

^^^-C^ V 190 'i to . .LLi.v.CL LL i^ , 

that I hist saw h ... .■ alive on UoVa^c^ ' i^o 

and that death occurred, on the .htlc stated above, at ^ 

A] M. The C.\rSH OF DIvATII was as follow.s 



^^^CX-Ivv-^UL-Ol* 



I 



'-^ 








occri'A riox 






cjO 



'<X '^vv-L 



.L 



nrR.ATiox 
(Signed ) 



Years 



OIL I 



3 (.Athlress) H'ia T^U A \ I O-M -J 



Hours 
M.D. 



44- 



/^</ 1 A 



Tin: AHOVF STAIl-I) I'KKSONAI, I'AKTItM" I AKS XRFTKI-V n » rii.^ 
HKST (>!• MV K.NOWI.FDC.K .\nI) nKMKF ' ' ' * ' " '*' 



nr?*L^?'M^J'*^f^'"^'^TION only for Hospitals, InsfitutW Transients 
or Recent Residents, and persons dying away froii home. '"nsients. 

Former or 
Usual Residence 

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



Hew long at 
Place of Death ? 



Days 



fx> 



^X'Mrvss 



l^^oviWvK.iirit- 



ri,ACK OF BrRIAI. <,R RFMOVAI. I DATHof n..... or RFMOVAI, 






K 



190'! 



1 



'^-^-^-A.O^vl 'H,...L<. 



(Addres.s.. .\dX% ^Jl) 7v^ OU rU^v-tX^ .^^ ^ 



N. B. K%'ery item of Information should be cnrefullv suDnilerl ArR-I , , . . _ ' 

..a.» CAUSE OP DEATH .„ p,„i„ .,.„.. ,C U "J 't p*opeHr:,L*'.,''u,:i"''.;!h^'^^i=^7; , ^"^SICIANS .hou.d 
«on, dyint away from home .houlil be tiven in ,»,ry Instance. ""••'"«•'• The Special Informsllo.i" fop per- 



i^akiiM. 




Wmt WRITE PLAINLY WITH UMrAniivir^ iKii.r i-Ljie> tt^ «. .n.-^.« • ii...... » 



/>^^/^' /•>/<''/, LLu^Aa-v^ 




Lb., 



f\ A 



190 \ 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Registered J^o. 



1 025 



V^V^A^ 



-u Depuv 



DEPARTMENT OF PUBLIC HE ALTH-City and County of San Francisco 

Cettificate of 2»eatb 

( la. S. StanDarJ> ) 

J? ^ J? Qj^ 

^^^/^n ^^ ^EATH: — County oiOcuy-o AXX/ixo^CcCity of C)<X^k\; 1v<X.>v^^<l o.l 



No, ^3.lo U[\xxtl 



Ot/O. 



St.; 10 Dist.;bct. 1 I ^t 



and Jv,Qs 'V(A.' 



FULL NAME 



) 



s !•: x 



PERSONAL AND STATISTICAL PARTICULARS 

'Month) (Djiy) 




A^O.:. U NXLcLc. 



1 



Vw 




\<^ 



XJL 



rl%X. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

date; ok dkath 



Q, 



IS 

fDay) 



(Year) 



A ( ; V. 



ll )v.,« U; 



M.ivtln 



Pit 1 . 



SI\(.1,I-: MAKKIIvI) 

wiix >\\j:i) ok i)!\-oKrj:i) 

lUriti in vojj.-il <1( >ii>^!i;itioii) 



HFRTHl'I.AOK 
'St.itt or t'oiititrv^ 



NAMI-; «)l 

I A thkr 



lUKTHI'F.AlK 
Ol- l-ATMHK 
'Stale or I'oiiiiti v 



MAIDKN NAM1-; 
<>I MOTHKK 



HIKTMIT.ArK 
•>l- MOTIIKK 
'St.itf or Coiuitrv) 






(Month) J 

rjp I IIHRHBV C1:kTIFV, That^r atteti.lc.l deceased from 

A"^ Xt 190 H to . 

that I last saw h ^^iA; alive on LXa.- 




IS" iqoH 

'^"Cl • ' 190 ; 

and that death occurred, on the date stated above, at ( • 2> 
LIm. The CAlSlv ()]< I)I<:ATH was as folI„ws: 



-C-^ 



<c 




oK<x^aj .\ <X <it / 




^ 




.-^^ 






i:- 



Ij 






DIRATION )W,;-5 1 ;,«„;//;^ 



(SIGNED) .L<iA.^>cuvdL 0. ^i) 




DCCr NATION 

AV.\ /(/('(/ /;/ S",,->/ /'i ail, isi-i) ^^1 JV-,/; 




A^v^c^ 



Days 
Days 



Hours 



^ IQOH (A«ldress^ IHH^ 0^0^'. 



Hours 

M.D. 



orf.LrJ'^'-J'^f^^'^'^T'ON ""'y f«r Hospitals, Inslifufions, Transients 
or Recent Residents, and persons dying away frcn home. 'f-nsienrs, 



1 A <;////. 



/),n 



Former or 
Usual Residence 

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



Hew lonq at 
Place of Death? 



Days 



THi: AHOVH STATi:i) PKKSONAi. PAKTICri \KS \K1- THIK r. , rtiu- "77777! " . ■ - 

HKST OI-- MY KN<.WIJ.:i„-.K AM, nKMHF"''- ^^' '" '" ""-■ ^'^'^K '%,"''''A'' ' "^ ^HMoVAI, | I.ATJi^of M, k.a,. or RHM(,VAI. 



(1 







A-^CrO-O, r^; 



^ 



i 








T9o'( 



'^' ^' J^very Item of information should be cnrefullv a..»»i:.,i A/>«r^! TTT """■■■"■ 

«»«to rAiicp: rkc nuTA-ru . """ "e cnreruiiy Huppliecl. A(jF. nhould be stated EXACTLY. PHYKiriAisia i. ... 
state CAUSE OF DEATH m plain term*, that it may be properly clasiiified Th^ ••« • . ^"^^'^'ANS should 
«on. dylnft away from home should be ftiven in .very instance '""'"*'*• ^^^ «»>«^'^'°' '"formation" for p,r- 









«i^«» 






^•y -A -i" 



•'^ ■ /•*' 



..^■^. 



f 



^B^ WRITE Pi AINI V \A/ixu iiivirAniiu^ iiui# — . <t-i-iie> »«. m r^i-i^ 

i — ^ ITT IT n T I ^ ... . ...... 'vivtriaviiv >M ll«l« llll «ii3 I «3 *» r" C l~» 



Hoard nf Ikulih -■ I" N'.i. is, 'i'f^'s^^^^ H&l* Co 



/)((/(' Filvil, \ 





• *=» « f-u mviMi^ c. 1^ I ncv^V^KU 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



l(c 



wo\ 



Re^iNfcred JV7;. 



1 0J^G 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of 2)eatb 



( "CI. S. Stan^ar^ ) 



(^ 



A % 



PLA^ ^P" DEATH: — County oiO lO^y^j AyO^>VC^4^f Qty of Oclaa; AXXaa^cia.^ 



e 



ao 



;v<lr 



Dist.; bet. vA.'V^A 

( '^ "'!^l",°*'^"r.®A^*''.r''°** .^.®^*'- RESIDENCE GIVE F*CTS*CALLCDrOR UNDER 




r,^..,.. I T""- . r,^™ wwwF^i. nt^oiL/ciiv^E. dlVE F*CTS CALLED TOR UNDER SPECIAL I N ro R M ATin m •■ \ 

DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR Ee/'nD N UMBER ) 



v(h-*U) LlAM.y ) 



FULL NAME 




> vx\. ^ vo... UA>CH;L^rLo 



PERSONAL AND STATISTICAL PARTICULARS 

Cni.nK ', A 



i» \ ri". <>»• III R in 



iLvvcU 




M.jiith) 



(Dav) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



15... 
(Day) 



/go • 

(Year) 



Af, K 



H? 



5 Vi/» 



M'nitfn 



Da y. 



SINf.I.K. MAKUIKI), 

\vii)(»\y):i) <»K i>!\i »Rri;i> 
'Write ill social <1( sii.Miatioii) 




MIKTHI'L^CK 
' '^tatf or t."Miiiitr\' 



FA riii.K 






DATK OF DKATH r\ 

(Month) K 

I JJHRliHV CI:rTIFV, That I atten.lc.l (lecease«rfr(«i; 

^^- 190'^ t.) CLv^Mrj. )..S: 




190 H 



[90 
tliat Ilasrsawh :.' alive on VAAA-O^. ■ j,p ; 

and that .loath occurred, on the date stated above, at 2> .... 
^J M. The CAUSH OF DIvATJI wis as follows: 



^ 
& 

e 



X \>-VwOL/CXA-» 



> \.K 



HIKTin'f.ACF: 
0( J-ATIIKK 

(Stiti- or Country) 



MA1I>)-.N NAM! 
<H .MoTHKK 



MIKTm'KACH 
01 MnTlIFR 
(Stiiti- or Countryl 



OCCrPATlON OfVP 



'XV L XcC\^ O V j (n-^XO- V »v 



T R \' X/KA/(in^.\.^ 



Mo)ilhs 



Days 



Hours 




^ 
^ 



r) 



C 




^\L\d~ 



DrRATIOX - Years 



/Mrs 



X/Cr LU ) \j 



*^ J -^^Ayyvux-^xq 



(Signed) 



^ 



n 4 'V V ; 

190S (Ad.lrtss) 1 n dUUXv>^-^A.>L.o trxltv :\ f 



Hours 
M.D. 



nr?p^„^?!!fl^, "^ir^'"^'^"'''^'^ •^"'y '"^ ""''P'^^'^' Institutions, Transients 
or Recent Residents, and persons dying away from tiome. «"^«-.u^ 






f\f>ulfii in S'tn/ 1^1 ttn, i^f',> \ \ ' J>/m^ 






/>,.'i 



* "V;. ■>?!!.* ^'''- ^'''^'''>-J» '"HRSONAI. I'XRTFilLAKS ARF TKrK To TU K 
Hi:ST OI- MY KNo\VIj:I)<-,H .AM) in-IJl-F ' 



(liifornKiiit 




> .■■■ ' >» I, 1 , 1 »i I /-, .1 .-s I / 

.\A.A../^wO \Jj. h^'CHQ^'VV v-O ^ 



Former or 
Usual Residence 

When was disease contracted, 
If not %{ place of death ? 



Hew long 9\ 
Place of Death ? 



.. Days 



\i 



190 \ 



r:X''!';.'0^ '^"'"' ^'^ '^^^^"'^■^'' I DATK of I.rKi.K orKKMOVAI, 



I i..^^r. ui- lu KIAI, OK RK>r()' 
IXDlvKTAKFK V-XCLaX) V^-^t;:^ 




^VM.. 




.on. dyinft aw«y fro™, home should be tiven in .v.rt in»t.ll«. "'""""'• ^'" «"«'"' '"formation" f.r p.r- 



■i'j^BI^ 






;«*'? 

r-;^ 



>-♦ /' 




"^-^.l 






"-'■nl..fH.....,„.-..N-o.K:»^.g^lU^,>Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/(' FiI(^(l,iLu<XYJ^ Up 




7.96^^ 



JRegititcred JVo, 



\ o;37 



Deputy Health Officer 



^No. 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of H)eatb 

PLACE OF DEATH: — County oK'Ct'w AXX^^vxcwco City of OaXat^ OivxX'^'c<^ < 
M' Ua. .^ 11: (y^ Ixx '. - \- St.; — - -: Dist.; bet. -=r^ and 

A IF DEATH OCCURS AWfV FROM USUAL R E S I DE NCE CI Vt FACTS CALLED FOR UNOtR "SPECIAL . N FO R MAT.n « ■• \ 
V .F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD oP STR E E^ AN D N U M B t «° '^ ) 




Cl C" C 



FULL NAME 



\AhXX\j:Xj. vAA^;X.4y|.v, . ' 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 



'■1 

DA'I'I-: nl- HIHTII 




-Month) 



ACH 



y,\i., 



a 



(Dav) 



M. '),/>!' 



(Vt-ar) 



/)<7 1. 



SINCI.K. MAKUn:i). 
WIDOWKI) Ok IHVoKiKI) 
'Write in social <l«sij/ii;itii>n) 



HIKTHI'UAOK 

(St.itt or (.'omiti \1 



N\Mi-: Oi- 
l-ATM i;r 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATM 1 

L'Ll^^o is 

(^<'"th) ij (Day) 

I IJl'iRl-HV Cl-RTIFV, That I atten.lcl .kTcasod from 

"^^' ^- TOO' to . LL\.^ra. \S., up\ 



(Year) 



I9O ' 



^ 






that I last saw h alive on \X. 

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

^■'^ M. The CArSH Ol' DJCATIl Nvas as follows 



1(/D 



niKTUF'i.ACK 

f)I" lATHKR 

'State or Country) 



MAIDKN NAMl-- 
01 MOTHKR 



lUK Tin- LACK 
ol" MOTUKR 
'Stiite or CouTitry) 



OCCri'ATlOX f}pU? 




//ours 

rCi 



DIRATIOX 1 Years Mouths /)ays / 

C()NTR IIU-TORV L'i>^.<ll^A„^..clv^..^ 

'>''RATI()X rears ^ Mouths Pays //ours 

(SIGNED) LLv.\.n • (3. 



Res id fit ill Sat/ /-'i ,1 1/, /.',', 1 



- - - -y 



lL 



'^ 






M.D. 



^ ^, '^ TQo' (Address) 1 '^ 5 J jLO..'\^.« 




) 'I'li I 



M.oith' 



/)./ 



Tin- AHOVK STATi:i) PKKSOXAi, I'A K P KM' I,A KS \RK TKIF To TFIK 
Hl-ST OF MY KNOWI.FDC.K AM) lU" AV.V ' 



(Infoiinaiit 



ck^<j-v^<^^ 






^ \fMrcss 




nr?.L^9*fi^J'^!r°"'^^"'''0'^ ""'> '""^ "o'ipitals, Insfjtutlis, Transients 
or Recent Residents, and persons dying away from home. «"s«rniN, 

fTrV-. %^ f. HoHlonq at 

Isual Residence (lW>a.^v|c ' Plare of Death ? Days 

Wtien Has disease contracted. 
If not at place of death? 



190 



■CV'-w.IUjXcL V^ 



n.ACK ..I- HIKIAI. OK K1.:moVAI. I DATFof HrniAr or KFM,,VAI. 
INI ) !•: R 'l- A K F R J -Aa^^M^I^O-X' oLll r ' '^ 

^•■^'^'iress .n.5.' nXvA-'^rr^rr^rw c].l. 



IN. B. '^^^••yjt/';" "^ •"f«;''"«t.on should be cnret'ully nupplled. AGE nhould be stated KXACTLY PHYSICIAN* u .. 
«t«te CAUSE OF DEATH in plain term,, that it may be properly clarified The -S„T J 1 . ^"^^'^'^'^^ «»^«"«d 
Ron. dyinft away from home should be liiven in .very instance ^'""""'**'- ^^^ «''*^^'"' '"formation" for p,r- 



.^n:^ 



T 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HomkI (J Ili:'lth I-' No ! r '^•sTiSRS^ USiV Co 



/)((/(' Filed ^ 



^^ V. 




.t lb. 



VJO\ 



REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 



10^28 



vu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( U. S. StanOatO ) 



% 



A T -A ^V 

PLACE OF DEATH: — County of vJOyAV JA,(X-~> vcoft.ci.City of ^) lO^ywj J A,<X >^.X-v^ C 

; 1 Dist.;bet.\I)^-CK>.d.c^icx.u. and UciLUXtt, 



'No. lOl^VnU^lqt ,-.v.. 

(IF Dl 
IF- 



r OCATH OCCURS *W»V FROW US 
DEATH OCCURRED IN A HOSP 



St.; 1 Dist;bct.\l)^"^-<K>.d.c\.'CXLi and VQl 

UAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
•ITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AiIiId NUMBER. ) 







FULL NAME 



.dA.l'k. 



,£\. 



ik 



<x\.xx. 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 
^ I COI.OR 

i).\ri-: «>i' I'.iK iM r\ 



-u- 



\l \, 




,r 



w 



Ai.K 



..iith> \ 



\^ r..... 



<I):iv) 



1 A '.,.///' 




L O... . . <. 



MEDICAL CERTIFICATE OF DEATH 

DATE OF nivXTlI /— , 



(Montli) \ 



^Vcai) 



/'•n. 



Sl\<.l.i:. MAkKIKD 
WIDOUKI) (>K niVORCKI) 
'Wiifcin "-iH i.tl (l( vi;Mi;iti<tn) 



lUkTHIM.Ai'K 
(St.itf ur «."<)Miiti V ' 



XAMK oi 
FATM) k 



Hik rm'!. ACK 
OP lAriiKk 

(State or c'uiiiili \ 



maii)i:n' NAMi; 

OI- MOT I IKK 



HiK'nn'i.Ari-: 
OK motin':k 

(Statf or CoviiUryi 









' I go . 

'I>.-iy) (Year) 

I ni':RiaJV CI-RTIFV, That I aUcti.kMl .leccasea from 

> ^ 190''^ to L:WvwriqL.....I..S iQoH 

tliat I last saw h alive 011 l^l.v^..a_ 1'^ |oo 

aiidLthat (Uatl) ocrurrcd, 011 the .late stated above, at ^ 

^M. The CArS^{ OF Dl-iAXH was as follows: 



■^^UL' 



■V .i v_0 






DIKATION }\'ars 

CONTRinrTORY 



Mouths Days ' o I /ours 



I 



A 




DURATION Vrars 



'^Y\Ar\^^'y\j 



Mouths nav< 



V ' Aj:iJ^-\ 



sJ^A 



occri'A'iTox (Jj^ 

kVMilril III Sail f''iaiiri>fo 



N-L'D^LU 



( Signed ).L<x^rpuJLL<i \ 
U- \. ■■■ n i i iQo ' ( A >i(i i-fssM ric--^ vt<:(.t V ^ 

?''^9'VJ'^^0'''^'^"''I0N only for Hospitals, InstUi 
or Recent Residents, and persons dying away from home. 



//ours 
M.D. 



>'i! I 



}F.>„th' 



n,n 



rill-. AllOVK STATi:!) PKkSoXAl, I'.\ KTIC K I.A K S Akl- rkCK To THI- 
HKST OK MY KNOW I,};i)C.K A.M) HKI.IKK 

" a 



Former or 
Usual Residence 

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



How lonq ^\ 
Place of Death ? 



ranslents, 



Days 



Oiifor tn.-int 



a^^^\^\^\^ 



\ \.. O 







J. 






V ' • I > V IN I .A 1 



[90 



I'l.ACb: OK niRIAU OK KI.M..VAK j DATK of M,K,.vr. or RKMOVAI, 

^^ I AJ-^vo 1.1 I, 

(AddresH I 5 1^ jt^tt k-^ c ,. 1*. 



N. B. F.very Item onnformatlon .houlcl be crefully supplied. AGE «houIcl be stated EXACTLY PrtYSICIAIMK u .^ 

lTn:^'\ "%''^^T" '" »*•»'" *— *»•«» '» -»> ^'e properly classified. The ••SpTcili InZIatlln^' C ^^r 
sons dyinft away from home should be Itiven in every instance. ■nrormation for p.r- 






I < 



.*^' 



^♦' i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PE RMA NENT RECORD 

""""'"'" "^■'1"' ' N'^ i^t-g^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






I'JO'i 




Reglstet'ed J^o. 



1029 



Deputy Health umccr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

PLACE OF DEATH: — County ofO CL/YV OAxXAxcc^Ct City of CJ <X/>\; X.Ct/>x aui o <. 



(No* JaJL^WC/A'V' ( 

(IF DEATH 
IF DE* 



OCCURS 



St. 

Dl 





Dist.; bet. 



• WAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION • \ 
ATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



[^ 



'\0 



\ I 



LdxAj<^_''..'.l 




^ 



L^ 



and 

lU 

I. 



s !•: \ 



DAIl". «)I- lUKTM 



M'.K 



PERSONAL AND STATISTICAL PARTICULARS 



iK 



M..tiih) 



] 'rii ; 



SIN'(,I.K, MAKUn-;i) 
\\II)»»\V}-:i) OK IM\()kt,-KI) 
iWiitriii >-orial dcsivMijitioii ) 






1% 

iDiiv) 



Months 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DlvVTM 




/ 



(Vfur) 



II 



Da 1 . 



lUk TMIM.AOK 
'St;itf or I'ounti V 



NAMK Ol' 
FA TMHR 



niKTIlIM.AOK 
<)I' lAlMKK 
(St.'ttr or Coutitrv* 



■vvoaJL 



(^ 



— ^c^q 

(Month) \ 



I'l 

(Day) 



igo 

(Year) 



I IIHRl'HV CivRTlFV, That I atten.kMl ,lccease.r7roni 

>-^-^^CL \'X 190' i to LLa-A^Q .i.'.\ igo . 

that I last saw h ■'• alive on LA.s_ua '. ' t 190'. 

aiul that death occurred, on the date stated ahove, at i . I L' 
L . M. The CArSl- Ol" DI-ATII was as follows: 



k 



kJ-CYX^' 



..'-..... X. '..... C//^rw\.v,\.^.^v,.v.<i t-^lv^ ' 



K.\J'^i. 



DC RATION 
CONTRIHUTORV 



)'i'ars Mouths -^ Pavi 



Ho lit 



MAIDFN NAMK Q 

OI- MOTHKK wY 



iuktmi'i.acf; 

o|- MoTHHK 
(Slate or Country) 



V^ 



duration 
(Signed ) 



}'r(jrs 




Q 



AMo)iths O Pax^ 



Hou 



rs 




-(r\<wvcn 



OCCUPATION \ 

h'cyiJrd III S.ni /'/,;;/,/>,■,> j )V-<mc ] .M.nilli- \\. f'hivs 

I'ln-. AMOVK STA rKI) I'KKSONAI, 1V\ K TUT I,AKS AH I- TKVV Po ruF 

ni;sT Ol- Mv KNOW i,i;i)r,i.: and i{kmi:i- 



'O^ ^'^ i()0 
ClAL INF 



(Address)! C) ?j 



M.D. 



Special information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from tiome. 



Former or 
Usual Residence 

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



flow lonq at 
Place of Death ? 



Days 



( IiifoiinanI 



* 



?^..«i. %_,.lt. 



(Address 



aa^ 




v.<t'^ 3.1. 



rr.ACK OF HIKTM 01? KKMoVAI, I DATFof M.hial or KFMOVAI 

VnU ^1^^M^' I ^L^^-^J:^ '90' 




INDICRTAKHK 

(Addi.ss 



Mil 



(y)\ 



v<t<ivcnv d.^ 



N. »•— »;-Y*^riT«;i-^n"Jnni'M" •''7''' '"■* -"""f""*^ ""PpHecI. AGE should be stated EXACTLY. PHYSICIANS should 
state CAlJSfc OF DEATH ..1 pla.n terms, that it may be properly classified. The '♦Special Information" for D.r- 
sons dyinft away from home should be ftiven in every instance. 



fstfj^tmk 'i'-JF' 




write: plainly with unfading ink — this is a permanent becord 

n.Mnlof HiMlth J No I .; *-5?~^ H& P Co REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



])<(/(' Filed, 




voot It l'JO\ 

Ocpuiy ('iOu^iLii. O-i'iiwj:'' 



Registered J^o, 



1030 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



{ TU. S. StanDarO ) 



% 



On 



PLACE OF DEATH: — County of ^CLA\;OA>a/lvCLNiaCity of U/CUWj ^CXyVL^<^cc 



-No.3l\lK 



f 




(\ 



( 



O-Vu-A K'iV<1.1\aA.,o..I' St., 

IF ocathAjccurs away iTrom usual res 



iAAA..O..l' 



Dist.; bet. 



and 



y^V 



IF DEATH OCCURRED IN A HOSPITAL OR I 



FULL NAME 



ilDENCEGIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



/ 



si:x 



DATK or I'.IK'IH 



AC. K 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 







> 



(WJJ^ 



h 



I Month 



/VV 



U 



'-7 



)V,/, 



I \ 



(l)av) 



Minilhs 



(Year) 



Pay: 



SINCl.i:. MAKKIMI). 
WIDOW KI> OK DIVoKiKI) 
(Write in scxMal desijf nation) 





I$IKTm'I.ACK 

'St.iti- or CVmntrv) 



NAMi: 01 

I-' A r 1 11; R 



RIKTm'F.ACK 
Ol' I-Al'UKR 

(State or Country) 



MAIDHN NAMK 
01 MOTHKK 



lUKTJnM.ACK 
Ol" MO'rnKK 
(State or Conntryl 






vvo. 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 



Ll 



(Month) \ 



(Day) 



/go , 

(Year) 



. 1 IIKRKBV CivRTIFV, That I attended deceased from 

M.V^sA,^^.. !i. 190'! to ..LvL^s..^ 1.1.. uyo\ 

that I last saw h •• . alive on Lv^.^vCl ^ \ 

and that death occurred, on the date stated above, at 
sA. M. The CAISR OF Dl-ATII was as follows: 



It/) 



1 1 t. 




L 







Dl'R.ATION Years 
CONTRIIUTORY 



Months 



Days 



Hours 



T' 



X 



occrrATiON J? 




O 



X.C4vcrO 



-4 



Dl'RATION 



(SIGNED) 




}'iars sMouths 



Pays 



a>... 



ail 



IC)0 



( 



(XW:) 



Ad<iress) at VnL 



Special Information only for Hospitals 

or Recent Residents, and persons dying awdy from home. 



, Instifutlons, 



//ours 
M.D. 



4xt. 



Transients, 



,ii 



Former or 1 \ 

Usual Residence U A.-O.D.. 



'^-0 



Rfsidrd ill Si7 H I'l iiiii iM'ii 



) 'tUX I . 



1 Months ' *. 



/J,n 



How long at , 

PJareof Death? 1 ^. Days 



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



THI. AHOVK STA'n:D I'KKSOXAI. I'AKTICn.AKS A K K TKIK lO TIFK 

iiKST Ol" Mv k.n<»wm:d(".k and HHMHF 



(IiifoiniaTit 



\\ \ 




(^ 



A.A-CX-^'V^v.tx^ 



l'I,ACK Ol- BIRIAI, OK KI:M(»VAI. 

rN'DKRTAKKK Jc . \L. <xLL<X^kX' .. 

Address ^ aO - 5 1%. 4* 



DATKof HiRrAi. or RKMOVAI, 

L'Lcvq I'., 



TQO 






M. B. F.vepy item of information should be cnrelfully Kiipplied. 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«p- 
Rons dyin^ away from home should be j^iven in every instance. 






mm 



r 




ii^i 






Hnai.l of Hialth - V N(V i^ t^'^l^^^ USt J' Co 



•vi_iie> ic* ii t3 r emii A ivi c ivi *T' iaxrr*f\tir\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lUi 



((' /^V/fv/, IJ^a-^axV-aA^ f^ ^'^^ 



^>(9H 



Registerecl JVo, 



103 1 






cMrLwo Aju 



\>^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( xa. S. 5tan^ar^ ) 
PLACE OF DEATH: — County ofCVO/ru J /vcv>vcuiccCity of CI/CL/Tu /VC^^vcA^^ac 



No. 1 C)C)1 ll->\.v.,c--^ 



^. 



St.; i Dist.; bct« 



o 



and 



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



RESIDENCE GIVE FACTS CALLED FOR UNBER SPECIAL INFORMATION 
OR INSTITUTION GIVE ITS NAME INSTEAD^JOF STREET AND NUMBER. 



) 



a.Aj-voi.1 ) 



FULL NAME 




11 



^ c- 1 V. 



K 



.t...--^ 



SHN 



PERSONAL AND STATISTICAL PARTICULARS 



'iLo^lx 



UJyVVA.tjL 



DA 11-: nl- HI KIM 



Ai.i-: 






t 



C ^ 



J v.; 



II. 



10 

Dav) 



}f.>iitfn 



/I HA.. 

(Year) 



Pars 



SIN'C.I.K. MAKUIHD 
WIDdWKI) <»K I)IVi)KrKI) 
'Uiitiiu "iiKMal <Usijrnatioii) 



HIK rni'LACK 

(Statf or (."MUiitivl 



1, 




ojxaaxxI 



'VCU^XClA. 



N\MK OI 
I- A Til l.K 



lUKTllI'I.ArH 
Ol- » AIMKK 

(Slat< or i'<iiiiitT \ 



MAII»i:n NAMl 
<)!• MOTHF.K 



niK rni'LAOH 

Ol- MOTIIKK 
(Statr or Coiiiitrv) 



(XXrPATlON 




on 

^ /vex. ^'^<UL 







MEDICAL CERTIFICATE OF DEATH 



DATH t)l- DKATII r\ 

UwA.V/Q 

(Month) K 






IS., 

(Day) 



7pO I 
(Year) 



I HICRICRV CIvRTIFV, That I attended deceased from 

^^.^A^"v k<: 190 to iJsA.A,,/n )..^. 190H 

that I last saw h-^ y> . aUve on LXa^v^CL- ' -^ igo 1 

and that death occnrred, on the date stated al)Ove, at 
_ M. The CAI'SK OF DIvATII was as follows: 

.rfij'^-.fr-Wu VAw^v,<\Jk^<>r-^,A^ .:>... 0:W... J^ 



/O'V^rCU-yv 



ev-^-f ^ • 

DIRATION S Yt-ars Mouths, 

CONTRIHUTORV La/vaJ^ 



Days Hours 

V<yAA^...01r.....3wAA,S^.;.! 



I )r RAT ION S Years Months Pays Hours 

(Signed) 0--Uj Ja.,.^hi^;i. m.d. 

\ Xv.uq. .15. iQo'i (Address) 3X^ JULQJvaa^^ lit. 



SPECIAL INFORMATION only for Hospitdis, institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Rf sided in Sap I'l tiiii iu'it v> )'roi> 



M.nlih, 



/',/!.- 



THK AIU)VK STATI-.I) I'KRSONAI, I'AKTirn.AKS AKK TRl K TO TIIH 
HKST Ol" MY KNOWI.KIX'.H AND IIKMICK 

(7. (^ 



(Informant 






-V.Mir^s OOo 




frixA^a c-^mjLV-o 



a.. 



Former or 
Usual Residence 

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



Hew long at 
Place of Death ? 



.. Days 



PLACE OF UrRIAI, OR RKMOVAI, I DATK of III KIAI. or RliMOVAI, 

i\KV\xvL /^OS \l 'L(r^AX<xV Lls^^:, 



N« B. Bvery item of informotion should be cnrefuily supplied. AGE should he stated EXACTLY. PHYSICIANS should 

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



■'H^i^syt 




'jmb.. 



. •• v« Ba«l^ir«lki< 



1 i 
t i 



ii 




WRITE PLAINLY WIIM UI>I^MUllNVJ mr\ — inio lo m 

MnM.infii.aitJ, FNo Ki^-gSJ^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihtfr AV/rr/, (Xu..OL^^ |(o JOCi 



lieglatered Jfo, 



1 Q'Vl 



<j^^.^r\..^<,A^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of Beatb 

( xa. S. Stan^arD ) 

J? ^ J ^ • 

PLACE OF DEATH: — County of ^ CCo^ J-^xxXz-v^^cuirCcCity ofO/(V>^ JXXXAve.A_>^c.<. 



^No. 




b\l \l KOL<i.Cr^v St; I Dist; bctA. a.A.A u ^ and ■JA..U...) 

/ \r Dt*TH occults AWAY FROM USUAL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "spCCIAL INFORMATION ' "\ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STiicET AND NUMBER. / 



■^\ 



FULL NAME 



I) e 



PERSONAL AND STATISTICAL PARTICULARS 

s):\ (K\ \ I coi.oK 



"J' 



1 



DATl". «)1' III K Til 




yW^^ 



\ 



Mouth) K 



AC, 1-: 



) V-,; 



(Dav) 



Mniithy 



I 



(Vcar) 



Oti \s 



SI\<; l.K, MAKKII.l) 
\VII>t)\VKI> <»K DIVOKrHI) 
iW'ritt in sot'ial dcsijj^tuitioti) 



lUKTMIM.Ai'K 

(Statr i>r I'miiitrv* 



NAM1-: (H- 
FATin.K 



RIKTmM.A^H 
OI" lAPHHK 
(Stitt«' or C'oiiiit ry* 



MAII)I:n NAM1-; 
<)1- MOTHKK 



inKTHl'I.ACH 
oi" MOTHKK 
(SiaU' or Country) 



OCCrPATION 









vcc^^.^^ 





'>\.0„ .' 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATII 




\ 



(Month) 



(Day) 



igo 

(Year) 



I H!<:RIUJV CICRTIFV, That I attended (Icoeased from 

LLvA^^ IH 190'', t(i . . AAa«a^....1H loo'i 

that 1 last saw li •: alive on LcV\,\^A:y. W up . 

and that deatli occurred, on the date stated above, at O 

■J M The CATSIC OI- Dl'ATI! was as follows: 

O nf\yCK,y^^^.t,^^ t . s. 



DT RATION )'ears 

CONTRIIUTORV 



Mo}itln 



Days 



Hours 



\^oJLkJ^ ' w \ V '_ c 



Di; RATION 



(SIGNED) 



/ C U / J 



Months 

'0 




\X^ 



LLv.^q W i()o'. (Address) .iS.5.^. 



Cf 



Days Hours 

O^bJr:. M.D. 




SPECTAL information only for Hos;)itals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Resiiifif in S(in /'i itm i<ri^ 



) I'll I 



:/,»////.< 



/)<;i. 



rin-: ahovk stati;i) i'kksonai. pAKTicri.AKs ari-: tkif: to tiif: 
nF:sr of my knowi.kix; f: and lua.iKF 



Pa 

(Informant w^CV 



f Xd.lrcss 




<X<I. ^ , 



■\ 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



PI.ACH of BI'RIAL ok KICMOVAI, I DATF: of m-KiAr. or RKMOVAI, 






'V^A_ I 






190 



r\(Mrc«s 



n).0..5. yX(r^l/c\;\^....Li»A,>^ 



.>^. 



N. B. Rvery item o? information should be cnrefully 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 p«p- 
sons dyinft away from home should be ^Iven in mvcry instance. 



xAiotTc Di AiiMi V lA/iTu I iMrAniMr^ iMK xu I c: I c: a Dr BMAMP NT orrtr^nn 

n..;ii.l .r il.Mlth- I No u*^^fc5H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)n/(^ F//fV/, CL^OL^^ l(0 ie9^i 

oUi-vx^^ d^x^>-u Deputy Health Officer 



Be^Lstcred J\'*o, 



1 083 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



"a. S. Stan^ar^ ) 



PLACE OF DEATH: — County ofOxX^ru AXXwcuiCij City ofO<X/-r\; vJXOl/>v<<^v.nLC.o 



f No. Uiv^LdAJy^ 




xxi UO O^Y^tccL St*; " 

(\T Dt»TH OCCURS AWAVifROM USUAL R E S I D E NC C G I V C FACTS CALLED TOR UNDER "SPECIAL I N FOR M ATIO N •' "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



Dist.; bet. 



and 



) 



FULL NAME 




JLC^aL^.'.. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
fv I COI.OR \ 




^ 



DATi: <)|- lUKTH 





Monih) 



i 



V 



<Xjl 



Q ,- 



\f. K 



I 



) ■/■</ 



H 



(I)av) 



M, mills 



ir) 



MEDICAL CERTIFICATE OF DEATH 
DATE OJ" DKATII 

15- 

(I)iiy) 



(Mouth) a" 



(Year) 




n,i 1 .V 



SINi.I.K MAKklKI) 
WIDOWKI) OK I)I\ <)K( i:i) 

(Write ill s«Hi;il (|( si>.'ii.it ion) 




m 



HiK rni'i.ACH 

'State or *_"ountr\' 



NAMK Ol 
KATHKR 



mkTMPI.ArK 

<>l" I ATHKR 

I Stale or Con tit ry) 



MAIDHN NAMK /7\ 
Ul- MOTHKK L 






I nrCRHBV ClvRTIFV, That I attcndcMl (UHoased from 

\>J. Q^S 190 't to . UwA^A^ IS. 190 H 

tliat T last saw h i., . . . alive on LA-'^^~0^ VS igo i 

and that death occurred, on the date stated above, at 
AX M. The CArSH OF DIvATII was as follows: 

C3./C/Ow>JLcjfc .vl..r:C.V.-.^:..\' 



kA^V^X 



as 1 01 lows : 

X <5^Jw^V\>-v.':>. v.Q. 



or RATION 



" } 'ears 







O-^ 




HIKTHI'I.ACK 
<>1- MOTHKK 

(State or Count rv) 




oJLu 




Mouths S Days 



Hours 



OCCrPATION 

Resided ill Sav /> mi, isro I )V'<7/> \ Af>>>/l/is ~ 



CONTRIIUrrORY 

DURATION Q^^'''^''^ Months 1 5^ nay.\ 

(SIGNED) h) . y Gu<xJlA\.X^ 

Vit^^Or \^ iQO^ (Address) UJXwdvt-y 

SPECIAL Information only for Hospitals, Institutions, Transients 
or Recent Residents, and persons dying away from home. ' 

Former or 
Usual Residence 



XA 



Hours 
M.D. 



Pa 



TJIH AHOVK STATi;i) PKKSONAI, TAR iUT I.AKS A K l-, TKrK To TIIK 

HhST oi- Mv kno\vij:i)«-.k AND ni':Mi:F 



Hiifoi niaut 




(A (1(1 res 






1 ^0 MOM-<xcUv a^/ ']\ Place of Vath ? 1 ^> ^ y .. p^yj 

When was disease contracted, x 1 I) 1 * i) 

If not at place of death ? oX) Jr\)L<k.cJL 0:\r CU-coJk, 



I^'ACK OK niKIAI, OK KKMOVAI. I DATK of Hiriai. or RKMOVAI, 

c\r>v I vJv\A^qi lb 190H 




KNDKKTAKKR 

(Athlress 






N. B. Every item of Information should be cnrefuliy Hupplled. AGE should be stated fsXACTLY. PHY8ICIAN8 should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ♦'Special Information" fer psp. 
sons dyinft away from home should be given in •\9ry instance. 



(J 



r 



•I 









tl 



WmMLi .ItBSrf' 



ki r» iki««> i^i^^«^^^ 



1 



i 






WHI I t. KLMIINLT Wl I n Ul^irMUmVai ll^r\ imo la #n r-cnrnmi^ci^ i nuwwrik^ 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Hoard uf Utalth— KNo it. >*i^^) 1J& P Co 



Thifo Filed , iJ..XAyOi/\^x.^ 



Ho lOO'i 



Reglsteved J^o. 



1034 



.-CrV^^-^VwO 



, D e p -i.e./. He a It h.. Off! c c r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiffcatc of H)eatb 

( Ta. S. StanC>arC> ) 



PLACE OF DEATH: — County of Ci Cn^^^r^-^ \^cx 



City of O crvx.<rwv/cx,' 






(No. 



St.; 



Dist.; bet. 



"and 



(IF OCATH OCCURS AWAY FROM USUAL RESIDENCE CIVC 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 



yj KJL6^sJLKj.,y^Jy\yOj 




PERSONAL AND STATISTICAL PARTICULARS 



sKx ny\ 



' 



DATK OF lUKTM 



AC.K 



L 



COI.OR 




.VW 



\JL 




Month) 



n 



^ 



IS 

(I>av) 



yfnufhs 



(Year) 



Pa \s 



SINCI.K. MAKKIKl). 
WIIXAVKI) OK DIVOKC'KI) X 

(\\'ritt'in s(K"ial (W-sivtiation) i . ^ 



HIR TMPI.ACK 

(Stritf or Countrv^ 



NAMF. or 
FATHKK 



BIRTH PI.ACH 
OF FATHKR 

(State or Country) 



MAn)F:N namf: 

OF MOTUHR 



inKTuri.ACF; 
t)F" mothf:r 

(state or Cotmtrv) 




Lv \.cC^^ 



IX\ •> >vrL 



'>vev^' 



MEDICAL CERTIFICATE OF DEATH 

DATF: OI- Dl-.ATM 

I..5 

(Day) 




(Montfh) 



7ooH 

(Year 



I in':Ri:iiV CICRTIFV, That I attended (Iccoascd from 

— to 190 ~"~~ 



190 — 

that I last saw h ".:- alive on 



190 



and that death occurred, on the date stated al)<)ve, at 
:^~j M. The ^^'-"^K OF I)I<:ATri was as foIIi)ws: 

ab-Jia/vA' d.^x^Ju^/vA^ ^Va^ix/^vvA-c 

...\j../QJLsJ^^V^JL.O./A.: 



. ' 1 

I 
I 



DURATION Yeats 
CONTRIBUTORY 



Months 



Days 



Hours 



DURATION 



occ 



U PAT ION (Jplf 



f) 



Rfsidfd ill Sail I'l ,1 in 1 m n 



(SIG 



CL 



^TION , Years 

NED) J. \ a<J 



Mouths 



Pays Hours 

M.D. 



\.\^a l!.^ u)0 'i (A.ldress) O (rYvcr>-wA<<cc V^^C^X ). 



cIalTn 



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



)■/•(/; 



Ar»ii//is 



n<n 



THi: AKOVK STA if:!) PKKSONAI, P A K IICF I.ARS ARF: TR I'K TO THF: 
HHIST OF MY K NOW I.i;i)< , K AM) MFI.IliK 



(Inforntant 



oio. Iro. CcwjL ... .^AA^vt 



(^ p 



SJL'^^JL^ 



T\^-iLV.t\A. 



i 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of deatli? 



Hew long at 

Place of Deatli? Days 



190 V 



PI.ACK OK lURIAI. OK KHMOVAI, | DATK of IJlRlAL or KKMOVAI 

cNDi-KTAKHR V yy\jL^H:Lft^ ^ ajLaJk^ 

(Addres.s ^..^...l...Al..r\A^lAA^tn.\.....D.,t. 



'^' **• Rvery 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 |t«ven in every instance. 






I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

» 

n...r<l..f iic.ui. » No i.^*^^i)i{&pro REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Ihdo Filrd, 




.Ait It.. 



7^i9H 



Registered JSTo. 1 0o5 



u.. 



t 



II;!.''" 



;.ealllb...aiSir - - 

DEPARTMENT ofr PUBLIC HEALTH=City and County of San Francisco 

Certittcate of H)eatb 

( in. S. StaiiOart ) 
PLACE OF DEATH: — County of^^Oyvu 0AxX/>vCMi<>0 City of ^OOyvu OA/Cu>vq.c^ccj 



No. T H 1 



Q^V 




Lv.<UlOv 



1 



St4 ^ Dist.;bct. Ohx^V^u 



and 



%A 



f ir DC*TH OCCURS *WAV FROM USUAL R E S I D E N C E G I VC FACTS CALLED FOR U N DE 1^ " S PEC I AL INFORMATION" \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 0« STREET AND NUMBER. ) 



Oj^y\.<x. ) 



FULL NAME 




itx 



rx/.yxj.. 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




U)ivoLi 



DA'IK <»»• lUK in 



AC.K 



% 



I Month) 



(I)av) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH /O 

vjIaa^q 

(Month) K 



lb. 

(Day) 



(Year) 



) I'O I . 



5: 



M.intfis 



S 



Da I .V 



HI\C.I,i:. MAKKIKD. 
WlDnWHD OK I)F\()R(KI) 
(Write in scH-iri! ilt>iij.'ii.'if ion) 



HFKrHIM.AOK 

(Statr or Country) 



NAM1-; OF- 
FATIFHR 



RIRTFlPI.AlK 
OF- F-ATHKR 
(State or Country 



MAFDl^N NAMH 
OF MOTHKR 



niRTMPI.ACK 
OF- MoTFn':K 

(State or Country) 



'X 










I HRRHBY CKRTIFY, That I attended deceased from 

vXu^Ol i^- 190 '( to LLv.-i.x3u. .1.(0 190 H 

that I last saw h -.t ^ v\ alive on LAa^v.-q 1 V jgo '4 

and that death occurred, on the date stated above, at ?) XO. 
AL The CAUSrC OF DKATH was as follows: 




DURATION Years 

CONTRIIiUTORV 







OCCri'ATFoN 




Mouihs 1 Days 



Hours 



duration 
(Signed) 



Years 



Mouths 



f^ays Hours 



Rfsidfd ill St\ti I'muiisi-o O Yrai .< -^"^ Months i 




190^1 (Address) 2)S I 3a.vUjUv Bl 



M.D. 



?^^9'?i^J'^r°"'^^'^'ON only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 



i\i\. 



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



ftew long at 

Place of Death? Days 



' "l;,^!ii*^ ^' ^'•'^'•■f:i> f'krsonaf. i'artfcii.aks akk trik to tuf 

llhST OF MY KNOWI.KDC.K AND IJFMKF 
(Informant \i y\yC^AjLcX Cd . J (iAhVA V 



^Address 



:i4i 




UXlAAyUAj dl 



pi.^E of; bfriai. or rf:movai. 



l^-^'I^of BiRiAL or REMOVAI, 
^ T90H 



UXDERTAKKR \ Vj . U \w,<n^yVLVV ^^"^ 



(Address 



""' "'~rtaVe*'cl7sF*Ap nTrxH"."*"?'** **" ^"-^^^''^ supplied. AGE should be stated EXACTLY. PHYSICIAN 
-inl H 7 - OF DEATH m pla.n term,, that it may be properly claimed. The "Special Information- 
sons dying away from home should be ftiven in every instance. mat.on 



8 should 
for per- 



I 



d . .Mi 



\f 






^'1 



■« 



•1 



!|| 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H«Kir(l of llcjilth-F No. m T^-^Jw^ H& I' Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed , 





ij[ 190'\ 



Registered JVo, 



10*16 



duJv-u Peputy Hearth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( 'Q. S. StanOarD ) 



PLACE OF DEATH: — County of 



-P 



City of UuXOL/WOj CJ^CUXA'vu CV.Qv 



(No. 



St 






Dist.; bet. 



and 



(IF DEATH OCCUHS *W»V FROM USUAL R C S I D E NC C G I 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 



Vj /CLfov^ok LU 



\JJ\.^r\j 



PERSONAL AND STATISTICAL PARTICULARS 



s};\ 



riojui 



COI.OR 



IjO'I^u 



DA IK o|- HIKTH 



AC.K 



/ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)I:aTH ,0 h 

.JL .10.. 

(Day) 




r\A.v 

(Monlh) 



(Year) 



/ 



I Month) 



!''■(( > 



tl):ivl 



.^/.mt/is / 



(Year) 



Am A 



SINC. I,K \!AKKIi:i) 
WIIXiUKI) OK I)I\( >kr)-:i) 
(Writr in M)ri;il <l(sii.rnittiim) 



lUKTHPLAOK 

'St.it' or (."oiiiitr\'> 



NAMI-: OI 
KATIIKK 



lUK'llll'I.ArK 
<)»•• I-AIUHR 

I state or C'oiintrv) 



MAIDHN NAMK 
<>!• MOTHKK 



inKTHI'[,ACH 
<U" MOTHKK 
(State or Cojuitrvl 




I HHKIUiV ClvRTIFV, That I attended deceased from 

— to 



190 
that I last saw h ~ — alive on 



190 
T90 



an<l that death occurred, on the date stated above, at 
M. The CAUSH ()!• DI-ATII was as follows 



DIRATION Years Months Days Hours 

CONTRIIU'TORY 



DURATION 

(Signed ) 



)V</rj Jfont/is 



IqO 



( 



Address) LL . a. 



oceri'ATioN (Vu 



f\f>iiir(f ill S(jn ridih isi'o 



5 'I'ti I . 



Ar,uif//s 



Dcvs 



Special Information only for Hospitals, Institutions.iranslenls. 
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 



rnr: auovic statkd pkksonal rAKTioii.AKS akk tkik to thk 
hhst oi- MY k\o\vm:i)ok and hhi.ihi-- 

a. IT) 



(I 



r\rW«:^SS 




<XV-vo 



;^M.ACE OF buriai, or kkmovai. 




ini)f:rtakf:r 

^■\<l<lrcss 






DATK of BiRiAL or REMOVAI, 

JX ... 190H 



'^l 




u. i , a 



-jl\\X 



^' ^' rtrJcArsF^Ap^nPrTS""*"?'** ^" ^"-*f""> «uPP'5ed. AGE should be «tated EXACTLY. PHYSICIANS should 
«inl H • . c I '" **/"'" '*'•''"•' •^^^^ '' '""y *"" properly classified. The "Special Information" far per- 

sons dyinft away from home nhouid be ftiven in every instance. ^ 



L '^: 





-f4 it 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hnjtnl (.f Utrtlth-I" No. i«; S-F^J^^H&p Co 



jT 



ow(rvAA^ 



10 0\ 

Deputy Health Officer 



Registered J^o, 



1032 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



( "Ul. 5. StanDarD ) 



fU 



'Na VC 



PLACE OF DEATH: — County of 0/CL"r\; O^uX/W^cuic.c City of C)/CL^.; A^Oy^x^M^^^x 





\X 



()0(H.W.to_l:.St.: 



Dist.: bct« 



and 



/ IF Dt*TH OCCURS AWAV FROM lllSUAL R E S I D E NC E Gl V E FACTS CALLCD FOR UNDER "SPECIAL INFORMATION ■ \ 
\ IF DEATH OCCUrt>«CD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




:Yv-rvsJ. 



DATi: OI lUK 111 



PERSONAL AND STATISTICAL PARTICULARS 

<3^ 



„<x. 



I 



J JLAr 



I Month) 



(Day) 



(Year) 




MEDICAL CERTIFICATE OF DEATH 

DATK OI- DKATH 

(Day) 




(Month) 



(Year) 



ACK 



I ^ Win < ^ Months y. \ 



Da vs 



SIN(.I.i:. MAKUIKI) 

uii><)\\i-:i) OK i)i\< »Kv i:i) 

'Writt in Mninl dcsij^nation) 



lUKTFIlM.AOK 
'State or Country^ 



NAM!. OI 

i-atiii:k 



HlRTMPI.At'K 
<)»•• 1-ATHKK 
(State or Conntrvi 



MAIDKN KAMI, 
ni- MOTHKK 



lUKTHPI.ACK 
OI- MOTMKR 
(state or Country) 




I HPtRI'HV Cl-RTIFV, That I attended deceased from 
LL^cAXi l.X I90M to vU.AxCL..l.b.. 



that I last saw h ^^i-^v alive on 



1 niicui I 




I90H 



l.i. 



190 



'i 



and that death occurred, on the date stated above, at IX-^"^ 
4I M. The CArSB OT DICATII was as follows: 

\J -AAJL^VVV^'V^XXAA^ 




DIRATION Years 

CONTRIBUTORY 



Mouths 



Days 



Hours 



OCCri'ATlON 



% 






"JLo^ 



£) 0-<-C^lj4.A.VM.iUi' 



Resitird in Stiti /'> am /wi) 



)'f til V 1 l/.'^////N 



DURATION 

.NED) UJ rrru \l7\ 



(SIGI 




}'ears 

cyy\j 

^^ 190 H. (Addresf 



Months 




Pays 



Hours 
M.D. 



SPECIAL INFORMATIO . . 

or Recent Residents, and persons dying away from home. 



Lvss) Ld:uX.^^.Q m CKO.|.vt. 

N only for Htkpitals, Institutions, Transients, 



Former or 

Usual Residence ^ 



hiiv 



THK AHOVK STATi:i) I'KKSONAI. I'AK Tlcr I.ARS A K F. TRVF To THF 

iihST OI- Mv kno\vm:i)<-. H AM) nHi.ri:i- 

(Informant LU rVVA.) . \l /\. Os^VAATA^^CA^ 



(Address 




<X-^yAyCL VX) . 




Wfien was disease 

if not at place of death ? 



contractei^ 



Hew lonq at 
^'^ Place of Death? H Days 



I'LACH OF m-RlAT, OR RKMoVAI, I)ATi;,of lU r.ai. or KKMOVAI, 
^-M/lfVAOA/S^^CC-CV-^-x- I ^^'^^^^^^^^^^ \% I 90H 

^Ad.lress !i.^.'l.l....>4^^ 




^' "■ TtaVe^^Ji^irsF^Ap nTri'r •**7''' **" ^"'•«f""y supplied. AGE should be stated EXACTLY. PHYSICIANS should 
!«^1^^ . OF DEATH in pla.n term*, that it may be properly classified. The ''Special Information" for dt- 
sons dyinft away from home should be ftiven in every instance. 



- '- 



mi 



f'n' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Hoard of IlfiiUh- »• No. !S *^E^ H*^!' Co 



I)((fe Filed f 




A^Xl^ 11 



100 "A 



Registered J^o, 



1 0.'^8 



Deputy HeMvh Officer 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



Certificate of Beatb 

( Xa. S. StaiiDarD ) 

— County of O/CUvu /L-CL^v^^A^c^City of CjKX^Vu X^<X/>ax:.^s.<l-C c 



PLACE OF DEATH: 



(No. 



Sos'iiiuJ^ 



\X^\) 



St. 






\ 



Dist.; bct.^' OJi.rLvw.ql^ ^> \. and 



A.^^> 



CI 



(ir Ot*TH OCCURS AWAY FROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "SPBtlAL I N FOR M ATIOH '• \ 
IF DtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRt-ET AND NUMBER. / 



ai 



li 



(<) 



FULL NAME 




'\Xkjy\j. <X/mj \Ltv.A,jL:y\: 




SKX 



DAT!-: oi- lUK rn 



ACK 



PERSONAL AND STATISTICAL PARTICULARS 

COL 



(5;^ 



""Vli^.- 



'SA 



<Mo!ithl 



'"^ I JV,/;,v 



\^ 



1. 



(I)iiv) 



Mouths 



(Year) 



Da r. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ^ 

(Day) 



I go 

(Year) 



SINC.l.K. MAKklHI) 

\vii)<)\yKn OK nivoRiKi) 

'Uritt'jn S(x-ial «Usivr nation) 



niKTMFI.AOK 
'State- or Country I 




I 
i 

i: 



y' 



NAMH OF 
FATUKR 



HIRTHI'LACK 
f)l" lATHKR 
(Statf or Country^ 



MAIDKN NAMK 
o»- MOTHKR 



lURTin'LACK 
OF MOTHKR 
(State or Countrj) 







VAw/W^CX^ 



(Month) J 
I IIHRHRY CICRTIFV, That I attended deceased from 

— to : ■ 



190-—— 

that I last saw h •• - alive on 



190 
190 



and that death occurred, on the date stated above, at I ?v 
AJ M. The CArSR OKDJ'ATH was as follows: 




-Q.^ 



— ^"^ \ I 

r 






DURATION Years ^ Mouths Days Hours 

CONTR IBUTOR Y 




0^ 

vl AJl 



w 



i. 



'* 




>JkjUL 



vtx 




duration 
(Signed) 



Years 



AlfoHi/lS 



Resided lit Sav /'i nii, isr,} I ( )',-,i i ^ 






Days 



Hours 
^AJ.<^. M.D. 

^>A/q, 1^ 190'^ (Address) (pOb d^Ottuy. dl 



PP 



f^^^'fi'-J'^f^^'^'^'T'ON only for Hospitals, Institutions, Transients 
or Recent Residents, and persons dying away from home. 



v../////. 



/',n 



Former or 
Isuai Residence 

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



How long at 
Place of Death ? 



Days 



''""\k^J^-r*y.^'■«'.^ '•"'■'" »"»^K^'>NAI, I'AKTU ri.AKS AKI! TKIK To TH H 
HhSr OF ^V KNO\VI,HI)<;kaNI) HFI.IKF 



(Informant 




(Aria 



ress 



10b 



(J 



(Ow/Cx^^ 



p 






FI.ACE OF-^BIRIAI, OR RKMOVAI. DATK of Ht-RiAi, or REMOVAI. 
INDERTAKKR oL/L<OCr>- 



/ 
7 



^ t 
K ^ 



HII 



<;■ 



I90H 



(Address 1 ^ 



JCrVk d^^c^ 




rH 



^' B* Every item of Infor 

state CAUSE OF DE 
«on« dying away from 



^ri-'r. •*'7'.** ^^ '^-'••^"'•y supplied. AGE should be stated EXACTLY. PHYSICIANS shauld 
EATH m pla.n term., that it may be properly classified. The "Special Information" far a.r. 
om home should be given in •very instance. 



♦ ■ 1 



r 



> %.i 



> 



d 



1 1 'I 



m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.o.M.l ',f n< :i!t!i- I- No. K t?^'^-'^- I'mS; J' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(f/(' Filed J 




H IDO'i 



Beglstcred J\^(). 



1 0*59 



M Dcp'.-, •■'■ ■„, Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Beatb 

( tl. S. StanC»arD ) 

i Oil) -^ ^ 

PLACE OF DEATH: — County ofv.'/Ou^x^ 0> v<X. >^c^ui^City ofCj/OLA^ ^ KXXyy\.Al^<y<^<:^i) 



No. 



l^'i 




OAy~w<X' 



St.; ^ Dist.; bet. 



^ 



md X C^xAj 



(IF DCATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E 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 




sj;\ 



PERSONAL AND STATISTICAL PARTICULARS 

rjn ji I COLOR 

*\\i{ oi iMK 111 jr\ 




M-.ntli) 



A<.!-; 



H^ r,.,„, S 



(I):i\l 



1 /,.;////< 



(Vf.'tr) 



Ay^w^cLcueJo 




MEDICAL CERTIFICATE OF DEATH 

DATK oi- I)i:.\TII 

It. 




XL 



/>,n^ 



-^iNt .1.1-: M \K K n:i) 

\\ IDi >\\l-l) OK DIXoRiKI) 
^^'' it'- in ' <li -i;.MMtiiPii I 



lUK IHI'I.ACK 
'St.itL- or Coll lit r V 



1 \ IIN-.K 



lUKTIlIM, ACK 
o)- 1 A I' III-: 1< 



MAIDIIX NAMi: 
Ol- Mo'lin;K 



Mikinpl.Aci-; 
Ol" Mothi;k 

'•^t.it. ■,] Co\intrv) 



'Hcr]'\-ii(»N(gy) ^ 

RfFiilfif in Still I'l ,111. i^rt) A 





a)ay) (Year) 

I IN<:ki:HY CKRTIFV, That I attcMi.k-.l .IcHX-ased Tr^n 

3-'^ 190H to. La-\a/CL 1.5^ iQoH 

that I last saw h^'i alive on LLwQ ^ iS 190 H 

.111(1 that (kalh occurred, on the dale stated above, at 
M. The CATSI': Ol- Dl-ATH uas as follows: 



DCR.ATION Years Months Days Hours 

^fonf/^s /)ays Hours 



1 M K .A 1 1 () .\ ; , ars . Mon ilis Days Hours 



f)rRATI()N Vcars 

(Signed) lU. Li. .L) c^^.^xJ\X^^lu m.d. 

U ^vQ.n T90M f\ddr<-ss) il^\jilJU^.(DJ<in 

EC^AL Information only ' " ^ ^ 



Special information only tor Hospitals, institutions, TransienJ^ 
or Recent Residents, and persons dying dWdv from home. 



31 )>„•;. 



1 /.-»'///. 



Former or 
Isudl Residence 

Wljfn wa« disease contracted, 
If not at place of deatli ? 



fioM long at 
Place of DeatI) ? 



Days 



rin. \Ho\j-: nt \ n- i. i-kksoxai. i-ak ncci. \ks \ki: thd- t. . thj.- 

IJhSI Ol- MV KX0WIJ:I>C.K AM) UICI.IICK 






J'l^CJC OI; lU KI^I, OR RKMOV.M, 




rNi)i:RTAKKK \.\j.\J \J^i-^\\yY\j^^ 'H K, 



HATJ;;^.,! ]U uwi. or ki:m()\-ai, 

l^ I90H 




{■ 



N. B.- 



Ttrt^c'rir^rUf nTri-'r**'"."''' "' carefully supplied. AGE nhoulcl be statc.l RXACTLY. PHYSICIANS «houId 
VI A '\* «» Dr:ATH m plain tcrmn, that it may he properly classh'ktl. The ♦'Special Infformntion" for dt- 
sons dyint away from home Hhould be <ilven in every instance. 



m 



\ 



t] 

-if) 
■ »i 






«! 



i.,' 



* 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.):ii.l nf HiMlth l-'No. 1^ 1*^^^^n&PCo 



RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'; » 



b 






I)(f/r Fi/cf/, 



L^ 




1.1 



100 H 



Registered ^''o. ^ Q40 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "CI. S. StanDarC> ) 
PLACE OF DEATH: — County ofO/<X/>\. 0;vcxa^.^^l^cc City of ^"^'^CUV^ /vxXoa^v.,Aye c 



Wo.\ 



i. 



}JL 



>\sK<xXj K.^^\\.^\.al: St.; 



Dist.; bet. 



and 



(ir OCATH OCCURS AWAY FROM 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 




J\XX.^r\) 



si:\ 



DATK OI- lUKTU 



PERSONAL AND STATISTICAL PARTICULARS 

C<)I.()R \ 





ll'>Ajk/ 



M..iilh) 



ACK 



bS 



Yrai 



<I)ay) 



^/>»lf/l^ 



(Year) 



Pii ys 



MEDICAL CERTIFICATE OF DEATH 



DATE OF ni 



UwAA/ 



(Month) 



r 



•I t 



II ■■ 



SINC.l.K. MAKKIKI). 
WIDOWKI) OK DIVoKi'HI) 
(Write ill sfK'inI (K'sij^iiatimi ) 



BIRTH IM.AOK 

(St.'itc or Couiitrv) 



NAM1-: <)|- 
FATllKR 



HIKTHI'I.ACK 
OFV^ATHHR 

• State or Ci)uiitry) 



MAIDKN NAMH 
Ol MOTIIKR 



IUkTni'l,At'K 
OI MOTIIKR 
(State or Country) 








(Day) 



(Year) 



KRI'HV CI{RT1FY, That I attended deceased from 

Qv\d I90H to LAa-a^. I.hl i^S, 

that I last saw h •.*.-< i^ alive on LMwA^Q 1 H T90'; 

and that death occurred, on the date stated above, at 105 

.0 M. The CAISH OF DIvATH was as follows: 



..<X 



^^ 



M 



►CCI'I'ATIOX fd . ~? 



DURATION ' }'ea/'s ' MoNi/is" Days Hours 

coNTRimrroRY >J!ir^J^.Ar)nJ>.^..0>.c:^ 

DURATION ^ Years Months Days 

( SIGNED )"^,.^J/OAJkJl^i cDjJuUttxj 
LLc^O, IH iQO*\ (Address) U', 8. Lv.vJjl/vJL W.CH^^ 



Hours 
M.D. 



.^ IH iQo* 

ecPaTTnr 



Rf^idfd in S\in /'i iin, i^rn 



) 1 III 



M.uifhy 



Ihn: 



THl", AHOVK STA'n:i) PHRSONAI, I'A KTICn.ARS ARK TRl'K TO THK 
HKST OI- MY KNOWI.KDCK AM) IIKIJ1:F 



informant \K^ (j . LL- Vj 



Ji/^r>JU^^.<^. 



Jc OK) {y<4^vt txt 






(A.l.lress 



Special information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from liome. 

Former or -V ^ P f How long at 

Usual ResidenceO Oyyu JAxx^vuCA-^Co uxq»iafe of Oeatli? CLC Days 

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






PI.ACE OF BIRIAI, OR RKMOVAI. I DATK of BlKlAI, or REMOVAI. 



r.NDKRTAKKR Hk . \J T V - oLJ J^^txt 

' U. i CL 




(Address 



^' B* F.very Item o? infformation shoulil be CHPe?ully 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 dyinft away from home should be ^iven in every instance. 



m 






I 




•'i 



("■^ulJ^ 



r 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Jloai'l of llr.-ilth I" No. i^ 



n& I' Co 



RCFER TO BACK OF CERTIFICATt FOR INSTRUCTIONS 



iXtfe Filcil, (jLa^^va^ la I'^O 4 

"^ ' '^ - Deputy Health Officer 



Ee^lsteved J\^o, 



1041 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiftcate of 2)eatb 

( la. S. StanDarO ) 

% J t % ^ 

itv of £J v) CPv\XKAaJ(.xv 



(No. 



PLACE OF DEATH: — County of 



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



City 




St 



* 
♦t 



"Dist*; bet/ 



"and 



RESIDENCE GIVE FAC 
OR INSTITUTION GIV 



FULL NAME 




'ACTS CALLED FOR UNDER "SPECIAL INFORMATION" "N 
E ITS NAME INSTEAD OF STREET AND NUMBER. J 



^\.^' O 




PERSONAL AND STATISTICAL PARTICULARS 

^KX A _ : I COI.OR N A 



^maJ. 



kx 



DATK ol- IIIKIH 



.\<.H 



0\. 



MEDICAL CERTIFICATE OF DEATH 

DATE <>1 i)i:atii 

(Day) (Year) 



OiLith) 



L 



• Month) 



3 rllS... 

(Day) (Year) 



J^t^ Yra,s h 



Months 



Dii r.v 



SINC.I.K, MARklKD 
\VI1)«)\VHI) OK DIVOKiKD 
(Write in scxMal <l<si>.'natinn) 



KIKTHPI.AOK 

(Statr or Countrv) 



VAMK ()|- 

fatmi;r 



HIRTHIM.ACK 
Ol" FAPIIKK 
(Statf or Cojintrv) 



MAIDKN NAMK, 
or MOTHKK 



HIRTIIPLACK 
Ol- MOTHKK 
(State or Conntrv) 



XA'AJrU> 



VCr^U->v 



, ) V. 



d 




(^"y^M-U-^-v 



I HHKl<:nV CI'IRTIFV, That I attetidcd deceased from 

— to 



190 to 190 

til at I last saw h alive on 190 

and that death occurred, on the date stated above, at ' 



M. The CAUSE OK DIvATII was as follows 



.'^.«<L/*w/-vv^ft<.:'V^^ L\J. .^tA-a^-w^cL, 



DURATION Years 
CONTRIIU'TORY 



Months 



Days 



Hours 



\y 



•« 



i9|^cxv iL- i. a 



OOCrPATION 

Rrsiitfd ill S(jv f'l ant isro 



cars 



Mouths 



Days 



DURATION ^ 

(SJGNED) UtlOl-^ A.U^XxJkAA. 

I iqoM (Address) (ibcr->M)XA^J[^ ^.A.. 




Hours 
M.D. 



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



Yrai 



M.niHn 



Da 1 . 



TMK AHOVK STATi:i) PKRSONAI. I'ARTICrKARS AKK TRIK TO THH 
IIKST OK MV KNOWI.KDC.K AND BKMKK 



(I 



nfonnant \l /UCXa^C^ V' • IA • oUjLA.rtr\.' 
(Acldrcss X>-U \A.- C^^ dU 



XX/\hv^ 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



PI,ACE OK RlRIAr. OR KKMOVAI, I DA'i;K of Bi RiAi, or REMOVAI, 

iL. -^ a' 



UNDERTAKER 

(Address 




^' **• Every item o? 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©p per- 
sons dyin£ away from home nhould be ^iven in every instance. 



S\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I 



lU.anl of Wealth K No. in 



H& P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Duto AV/^v/,XL^^ 1.1 IDO'A 

oLx/v-u Dep'^jty Health Officer 




Registered J^o. 



104 



o 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 




Certificate of ®eatb 

( "a. S. StanOarO ) 



% 




PLACE OF DEATH: — County ofOcL^^ 0.>vOLVLCc0.cc^^City of ^€U>X/ 0.\xx^^i:iA><i. 



cc 



^No. 3 b Cn^vUrixxCLi VI. <: CJxX/vuxLr VcStv; ^ -^ v Dist.: bet. 



and 



r \r Di*TH OCCURS *W*V FROM USUAL R E S I DE NCE C I VC 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 



SK.\ 



DATK «)|- lUKTM 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OK 




u- 



a^Mr>v 





VC 



±JL 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



a(;k 



iM(iiUh) K 



\^ 



Vrun 



% 



lb 

(I)av) 



Mont//.' 



(Vt-ar) 



(Month) 



1 



(Day) 



(Year) 



An.v 



SINC. I.K. MAKUIi;i) 
\VII)»»\VKI) <»K DIVORCKI) ^ 

• Wiitt ill ><(H-ial (li'si^natioti) 



HIK TflPKAOK 
(Slatf or C'otintrv) 



NAMK or 

fathi;r 



RIKTm'I.ACE 
^)r- l-ATHKR 
(Statf or Coutitrv) 



MAIDKN NAMK 
OF MOTHKK 



rtrthplacf: 
of mothkr 

(Slate or Countrv^ 






^I HRRERV CI{RTIFV, That I attended (leceased from 

^^ 190 "i to .LUaa- .1.1 190 H 




that I last saw h A. S. alive on 




^<\- \^- 190H 

and that death occurred, on the tlate stated above at ^ 3) C 
A M. The CAUSfv OF DHATII was as follows: 

^ "^ - • -- V/CXA^<lA./-VX^cr^v\.rCU 




f\AJL 



^^y\J 



Kd 



'CC^JL'<ry\j 



DrRATION 1 Vearp^ AfonU^s ^ay/ Ho, 
CONTRIBUTORY L<X^^..dLA./lX^ i /a..vlA,Ajrv^. 



Davs 



Hon 




") 



c^-v 



cLo, 



M 



OCCIFATION O 

Rfsidrd ill ."^u f'lan.isrit 




T^ 



) V-,,- 






1A. ,////, 



DURATION ^»^A^ ^Mouths 

(SIGNED) y. bU. Vjtfti^ M.D 

^^ rqoH (Address) (9 Ob OAvtU^U 3l 



« ^^^ D uK "^f^^'^'^T'ON »"'y 'or Hospitals, Institutions. Transients 
or Recent Residents, and persons dying away from home. 'ransients. 



/)(/1,v 



J 



HKSTOF Mv knowi.fdc.f: AM) iu:i.n:F *' 

(Infunnam \. & Am^OLA.v(6-C C, K 



Former or 
Usual Residence 

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




How long at . 

Place of Death? I Oays 



.'I, ACE OF niRIAI, OR RKM 




e 







I)ATF:of HcRiAL or REMOVAI, 
^'^ T90I 







li 



t 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



'f 



2?V:. 



, • 



Honnl of llialth- I- No, !«; ■5*er':St'3ri5 ){& I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I , 



l)nh> /vV^^r/, UwA^^^-O^^^ 11 



WO'K 



dv^r^-^'-'^-o 



Registered JsCo, 



043 



Dep jvV Heafth ? 




■j. 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of ©eatb 

( 11. S. StauDarD ) 



PLACE OF DEATH: — County of vJ CTWXrry^wOu City of VJ Crvy^^CTYlOyOu 




No. 



St.; 



Dist,; bet. 



■and 



f IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E 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 



PERSONAL AND STATISTICAL PARTICULARS 







-:n (^ 



0X/»\X5j(jL 



COI.dR 




rVAAX 



I>AIK OJ- lilKTU 



Ai.l-: 




HS 



)V:,V 



1 



H 

(Day) 



1A';////> 



fVear) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

(Day) 



sA^<-^WQ 



(Year) 



10 



A/r. 



sr\C. I.K MAKKIHD. 
WIDOWIID OK DIV( »K» Hr) 
tWritrin social (Itsij.'iiatioii) 




OJXXXX/CL 



J«'l 



i 



lukruri, \ok 

'Slate or I ■' Hint !■^• 



NAM1-, ol 
I'A'IIU'.K 



IUK'n(l'I,A<K 
0|- lATHl'.U 
'State or Cimiitrv* 



m\ii)i;n NAMi-; 

•)I MOTMKK 



UTKrifl'LACK 
Ol- MOTHHK 
(State or Country) 



occri'ATioN Qy 






(Month) ^ 
I HI<:RI<:HV C1:rTIFV, That r attcMia^rck'ccase<rfroni 

■ 190 to • 



that T last saw h 



alive oil 



190 
190 



an.l that death occurred, 011 the date stated above, at 
M. The CAUSK OF DI-ATH was as follows 

vJ -^-A^\JL<r>AAiA^ 



CL/>X' vj 7VXXy^ry^x:.o^a o 

1 f 



1)1' RAT ION Years 
CONTRIIUTTORV 



Mouths 



^ays Hours 



M 



or RATIO X 



ll 



Years ^ Mouths Days Hours 

(SIGNED )..\]/OL/cL O. "QLjvXXOL^*^ 

i^ 190 H (Address) O CTv-uirvv^^^ Cal; 




M.D. 



?^^9*ftK "^f^"'^'^"'''ON only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



'•i'.fd i,> S.I)/ /■'} ,ni, i-rn -^ )',-,i;< 



M.,„lh^ 



n,n 



hi: MIOVI-. STAIJ-.I) I'KKSONAI, I'A KTUf I,A KS A K I' TKD- T« » Till- 

m.sT OJ- Mv KN«»\vi,i:i)c,H AM) hi;mi:f 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



(Info: jn 



I 



( X.l.lrrks 



T90H 



'^- R' fivery Item of iii?ormHtion should bt 



^Ji'^*^^' <>»^A^KIAT, OK KHMOVAI. DATK ,,f HnuAi. o, KKMOVAI, 



r.NDl'iKTAKHK 

(Ad(htss 






^4 



state C\IISF or nr ATM ! . . '"^ '="''«f""y f"PP'"=^«- AGF. should be stnted hXACTLY. PHYSICIANS should 
««n. 1 -1 c T" '" **'"'" **^'''"'' *''«* " '""^ •'^ properly classified. The 'Special Information" for psr- 

«on« dymft away from home should be liiven In every instance. 



t 



i' 



';..■ 



I f 



'if'-' 



r 



i\ 



.Ji 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n. tnlnf n.tith- h No iii^^^H&J'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r FiJrd, 





^ OsJi/\)^^ 



...1.1 



lOO'i 



Registered J^o, 



1044 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of H)eatb 

( "Q. S. StanDarO ) 



(^ 



PLACE OF DEATH: — County ol'^OJW) J .>\^Cl/>\/xa«(. City ofOcVrvj dAXX/>vC-A-^<:u; 



'No. 



:i.: 



.c^t^jcL..^ <]\: cr<i.^ 




^|vX<xl 



St 



Dist«; bet«- and 



-v.n_. I ^^.j J ^_ u >a^' v^^^^v^.^. :>t4 .JJist*; ben- and - 

/ ir DC»TH OCCURS *W*vl FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SRECIAL INFORMATION" \ 
V. IF OtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




SJO 







Xi 



DA'll-: «)l- lUKTII 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 





N 



K^- 



ijL 



^ 



<XKj 



I Month) 



AC !•: 



So V,a,s ^ 



n 

(I)av) 



M.tHtfiS 



r 'I H L . 

(Vcar) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

l.L, 

(Day) 




(Month) 



A? ij 



"^1N<.I,1-: MAKKIKD, 
UIDOWKD OR DIVDKrKI) 
'Writiiii siK-ial <l«.-»;i>^n:ai<)n) 



niKTMlM.Al'K 

(State or Country) 



NAM!-: <)|- 
FATHI-.R 



lUKTHIM.AcK 
ni lAIHKR 
'Statf or roiintrv I 



MAIDKN NAMF 
<)| MOTMKR 







i9o\ 

(Year) 
I HKRHHV CivRTIFV, That I attciKkMl <leccased from 

^Jp^M 3^^ I90H to .LU,A^...l..(c itp^ 



1 111 

that I la.st saw h ^.vS' alive on LCvs-<V ' 16' IQO '1 

and that death occurred, on the date stated above, at 3- XC 
U-M The CAISIC OF Dlv.ATH was as follows: 

\>J<\:^\^^rY\.^S<:L .vrXxkJvx^utXo 



niKTiII'LACK 
()!• MOTHFK 
(State or Countrv 



oocrr'ATioN 




Years Months 



Days 




v/VU^L/Lciyi^^ 6~ 



I)l'R.\TION 
CONTRIHUTORY 

DURATION Years Mouths Days 

( Signed ) Uj.- \j CvvJL^i^-'trvv 

U. 190'! (Address) at. 





Hours 
M.D. 



ly^^i:. 



Rfsidnl in San Fiaiiii.^ro W )'iuii s 



U>>i/f//s 



n,i 1 .> 



'"" ».^"^^^'^^ STATKD I'KRSONAI. I'ARTICr I.ARS ARK TRFK To TUF 
llhsr Ol- MV KNO\\Ma)C.K AND HICIJKF 

(Informant xL . o(d JOojJL 



SPECIAL INFORMATION only for Hospitals, Institutions. Transients 
or Recent Residents, and persons dying away from home. ' 



Former or 
Usual Residence 



When was disease contracted, ICl 4- 

If not at place of death? \J..^ ^3j>.^ 



Days 



\<1(lrfss ^l^ 




ii 



PLACE OF BFRI.M, OR KHMOVAI, 

INDERTAKER db /oJuLtX-'dL ^ Cc 

(Address .C\Wq >ftVA^^x<L^.,:(r>A...B^^ 



'^^''"'<<>f HiRiAi. or REMOVAI, 



190H 



N. B. 



rtflVe^^C^ir^F^Ap nTri-M".***?'.** ^" carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
!«- % r^ OF DEATH In plain term., that it may be properly classified. The "Special Information" for per- 
«on« dyinft away from home should be ftlven In every instance. 





^ 


f 
















J 


1 




t . 


'' 






} A 

m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



■( 



■ < 



i: 



If H' 



1^ H 



I . 



M » 



m 



If. . ,11.1 ..r llraltli- !•• Vo. K f'-^-a^^'. H& I* C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(f/(' Filed , 




^y\J<^\A 




11 



lOO'A 



Registei-ed J^''o. 



Deputy Health omcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of E)eatb 

( XX. 5. Stan^ar^ ) 



No. 



PLACE OF 



DEATH: — County ofO/Cb^ru J AXX/>vC>c<l/CcCity ofC)<X/>^ J -^XX/vvytM^^i/c^o 



VA.KX v<:^^ 



( 



SU ^ Dist.;bct. b 




\' 



and 



1 




I F 



ATM OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N '• \ 
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




.CL;V-V<L iJVl'AA.4^' 





^(m„) 



Ni.\ 



1).\!"1" < >l lilKllI 



PERSONAL AND STATISTICAL PARTICULARS 

t'ol.oK 





M..nt!i) 



A (■.!•; 



(dO 



)■.,// 



(Dav 



lA <////. 



< » far) 



/)<M, 



MEDICAL CERTIFICATE OF DEATH 

I).\TK <n- DIvATlI 

15- 




190 H 

(M<Mith) /T (Day) (Year) 

I ni<:RI<;HV CI-RTII-V, TIimI I attende.l (Icccased from 



\M^ 



\*p 



tu 



S!N<,I,K, M.AKkll'l 

\\ ri)n\\i-:i) OK i)!\'( >Ki i:i) 



Write ill vooial lit-iviiatiDii) | 



iiiK rniM. \ri-: 

state or (.'1 mnti \ 



NAMI': 01 
!• A THICK 



P.IKIII I'l. Ml-: 
•»!■ lATHl^K 

< State or Coiniti \* 





A^VXLaLvXXj 



^v. 



liat I last saw h rV^^^ alive on yVA./% 






■vJL iC 



IC)0 - 

I90M 



and that <katli occurred, on the date stated aluive, at 
^ M. The CATSlv OI- DIvATlI was as follows: 







• "^ ri'A'i'ioN 

Rr.iifri! lit Sr.t' /'niu.i-.-n J^O )'rii i • - M,.):tJn 



MAID); N NAM1-. 
or Mo'IMIi: K 



IMK I*HlM,Al"l-: 
ol- M()Tni-:K 
(Stale or I'oiintrv) 



DIR.VTION )'rars 

CONTRIHUTORY 



M<nit/lS 



Days 



Hours 



Cj AA^cL/cL.«>^vAj 



I )!' RATION 
(SIG 



)'rars 



jV>);////s 





NED )\1 itojvt^^v ^XlLqX-vwLo 



/)(7 rs 



Hours 



v<|x>v ^ M.D. 



i^ iQoH (Address) "feO^ <0 J^ttiK. Q^t 



Special Information only for Hospitdls, institutions, Transients 
or Recent Residents, and persons dying away fron fiome. 

Former or 

Usual Residence 10 



ihi 



Hil)&w<iva.ib!!,r:;vi,h; 



Wfien was disease contracted, 
If not at place of deatfi ? 



Days 



fi 



iin: AH(>vi>: sia ri:i) i-kkson \i, I'AKTicn.AKs aki- tkik to thf 
iiHsT oi- \\\ kno\\t,i;i)<;h and hi:mi:k 



f \-Mress 



^ SH 




!N. B. H 



ri,.VCK OF RfRIAI^ OK KKMoVAI, 




I)\rHo! Hi KiAl. 01 Kl-:.MO\-Ai^ 




n 



ni>i;ktaki:k Jo OJLciXc<JL ^^ Co 



T90 V 



Ad.hess ^Hb VjrtvA,/^^ 



s^-w, ^±. 



Hvery item of information shoulil be cnrefully Bupplied. AGB Hhould he stotecl EXACTLY. PHYSICIANS should 
state CAUSL OF DEATH in plain terms, thnt it may be properly classified. The "Special Information" for o.r- 
«ons dyini away from home should he Jiiven in every instance. 



* I 

I 



p 



1' I 



r 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.unlof HcMlth- KNo .s*^^H&i'Co RCFCR TO BACK OF CCRTiriCATE FOR INSTRUCTIONS 



Deputy Health Officer 




Registered J\^o, 



DEPARTMENT OFPUBLIC HEALTfl-City and County of San Francisco 



PLACE OF DEATH 



'No. 




Certificate of 2)eath 

( Ta. S. StanOarO ) 



: — County ofO;CL/T^ OAXWuCAA^ City of C)OL/ru JAxX/vv<i.c><ML<)t 





5 ?) C) cL<JLh6\Xi.j St.; I Dist.; bet. WLLA^Uvo and '^1 L.{SX 

f \r OE*TH OCCURS AwAV rROM USUAL RESIDENCE GIVE facts called for under "special INrORMATION- \ 
V IF DEATH OCCURI^ED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

si-:.x Qo^ jj I coi.ou^ 

DATK Ol- lUKTU 




)M^OJl 




iMotith) 



(Dav) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 

,15, 

(Day) 



nAa.^,1 



(Year) 



A(.K 



V \ VliD > c^ 



Months 



^' 



Da 1 : 



SINC.I.K. MAKK IKD 
UII)n\VKI> (»K I)1\'MK( HI) 

iWritf ill MK-i:!l (hsiiMiatioii) 



MIKTHPI.AOK . 

(Statf or Comiti v' 




\Xax^v.o-^cL 




(Month) C\ 
l^HKRHHV CICRTIFV, Tliat I attended deceased from 




190 o to 

that I last saw h -V-^J alive on 




GU.^ 



190 H 

^ 1 190 'i 

and that death occurred, on the date stated above, at 3.3) 
Uk. \l. The CAl'SK OF DKATil was as follows: 




VAAje, 



^VVU 



NAMK OI 
FATHER 



MIKTI!I'I<A(F: 
OI- l-ATHKK 
istatf f>r Country) 



MAIDHN NAMK 
OI- MOTHKK 



lUKTH PLACE 
<)1- MOTHER 
(State or Countrv) 



(^ 



^ Jb'y^M^^^YWX/W) 



O/cJlsi^j 



DURATION I ^ea,r^ i^^^wXT^^^ 
CONTRIIU'TORV 



oys Hours 





i^jiXXjs 



MfloAxXr Lcrvl 



x^yy\) 




ty^ 




DURATION }^ars Mnnths Days Hours 

(SIGNED) MfWuuL ^aj3un\s M.D. 

n TQ O H (Address) 111 "^X^t^A^ Bjt 



OCCUPATION 




^^^^^y}^^OnfAIKT\OU only for Hospitals, InstituUons, Transients, 
or Recent Residents, and persons dying away fro.u home. 



M,„ilh< " Dn\ 



Former or 
Usual Residence 

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



Now lonq at 

Place of Death? Days 



'''"V:;^"i.^^'*'' STATED I'KRSONAI. PARTICn.AKS ARE TRIE To THE 
IJhsroF MY KXOWI,EI)C.E AM) BELIEF 

(Informant yCUWvJL/) LULvl/vO 




PI^CE OE niRIAL ()R REMOVAL I l)ATl< of IJtKiAi. or REMOVAL 
rXDERTAKER 0&V<AJL/TV U /CXAX 



I90H 



jAiMress XH-S. '^ .,.\fi\«A.XLAA.<r:YV. ^..^t^^ 




^' "*~rt«V/cl'im2*A"JnTri?M" •*'7'.** ''*' carefully supplied. AGE •hould be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH m plain term., that it may be properly classified. The "Special Information" fsr i»er. 
«on« dylnft away from home should be given in every instance. 






r 



■ 1 



w, f ' 



"A 



\^ 



I! 



m- 



V. 

i 



'^' 



' 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ho;inl of Health- FN 



o. i^ 



H&l^Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Drffe Filed, 




11 190 "{ 

Deputy Hf^afth Offioer 



Registered J^o, 



1047 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Beatb 

( "Cl. S. Stan&arO ) 

J? (5} . \ ^ 

PLACE OF DEATH: — County ofCj/CU>v J/uX/TtCiAOCity of Cj/O^^nj J J\yO<jy\S:AJ^<U. 



''0 



^No. 




D^!-^ 



oAXxxiCi 



St 



Dist; bet. and 



/ IF DEATH OCCURS AWAY fROM USUAL R E S I D E NC E Cr V t FACTS CALLCD FOR UNDER "SPECIAL INFORMATION" V 
V IF DEATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 

^P J? -^ 



) 



FULL NAME 



\^\JLu 



PERSONAL AND STATISTICAL PARTICULARS 




U^la 



DATI-; <)I- lUKTlI 



Ar.K 



tMotitli) 



In I 



(|)MV) 



M.'ulh^ 



fYcar) 



Ji 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)F:ATH 

' ' I.b,^ 

(Day) 




(Year) 



A; I '.« 



SIN(.KK. MARKIKl). 
WIDoWFD OK nn'oKCFD 
(Writiiij •^(K-iHi (lcsij.^niitii>iil 




K^Ji-. 



,a. 



mKTMPUACK 

(Stiite or Coimtry^ 



NAM)-: or 

FATUFR 



HIRTMI'I.AC K 
OJ- lArUKK 

'State or Country' 



maii>i;n namf 

«>l" MOTHHK 



niRTjrpr,ArK 

OF MOTMHR 
(Statf or Couiitrv) 










I HKRKBY CKRTIFV, That I attended deceased from 

^ 190'"^ to ....UwA,.MX.....l.!b. 190 H 




that I last saw h-^vn alive on VAa.aX3l \ b igo H 

and that death occurred, on the «late stated above, at 
^ M. The CAUSK OF ])1':ATH was as follows: 

^^-^^^:-Aw\AX ^ ^JCOwt/od^^t^-v. fe..re.-OLAJL 

U<Lf<:L.^ir^r^,jA,^.ry^ 



DIRATION 



Years - Months ^ Days X Hours 
CONTR IIU'TOR Y '-i-^i/^^X/V^A^Jl<^^ 

DURATION Years Mouths 








OV 



P 



occupation ^ . () A 



(Signed) 



k)., ^i. CJ I 



n 190 4 (Address 




f\f>idfd ill Sim li ii III isiit 



) til I 



.lA»;////.v 



/hi 



^^^,<i^^,^,^^^ORM/KT\OP* only for Hospitals, Institutions, Translfnts. 
or Recent Residents, and persons dying away from home. 

Former or M | 

Usual Residence dJxx/vUi/YyxUA^xj w>^x ^^ff or ueatli7 U Days 

Wfien was disease contracted, 

If not at place of deatfi? 



u 



How long at o 
Place of Death? h 



THF. AIU)VKSTATi:i) I'KRSONAl. I'ARTICF I,A RS A K I". TRIF To TIIF 
IHvSl OF MY KNO\\l.i;i)<-,K WD Mi:!.!!:!.- 




:}% 



o 



^'^'tf\5 '^'V^'^Io'' ''^ '<»^'^"»^-^I' I IMTFof HiR.Ai. or KEMOVAI, 

INDKRTAKKR LvWAjtt^i^ 

(Address 0..(a lo. M'\A-/<5^'<L'U<rVx ,3:^. 



N. B.- 



-Bvcry Item of information should be CRr«fully supplied. AGE slioiild be stated EXACTLY. PHYSICIANS should 
state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information" for Dsr. 
Rons dyinft away from home should be t'ven in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoard of Health— I-' N'o. i^ 



H 



1 I 



M 



fii 'I 




fr^H&PCo 



REFER TO BACK Oir CERTIPICATr rOR INATRUr.TIONA 



!)((/(' Filed , LLooOL 




Registered JSi^o, 



1048 



A.v^t va ioo\ 

M^ Deputy ' ■ fth Om-cr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( "U. S. StanDarO ) 

PLACE OF DEATH: — County of OkX'^\; v) AXVYVCA^cxCity of O/Cuw A/CWvc^.^^<. 



(No. ^^t^r^L^w^xt^, 'db CH^KAial'. St., 




-^vvvYvv^t ^'^^>^i-"U^Ci.'... M.; — — Dist.; bet. r and — — ■ 

/ ir otATH occuRsUwAv moM USUAL RESIDENCE civc facts callcd ron under "special iNroRMATioN- \ 

V \r DEATH OCCUf^RtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



■) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 





<X<X/sLA.; 



^i;\ 



flwL 



COI,(>R 



DAI i: «>l I'.IKTM 



A<.H 



lUvvi 



M..ii\)i) 



(Day) 



V 



oU 



U-far) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




^'\ 1V,„. 



% 



M.iulfis 



at 



Pa ) : 



'^IN'.I.K. MARK IK I) 
WIDOWKI) OK niVoKrKI) 
•Write ill s<Kial •hsiti'nation) 



niKTn»'i,ACK 

'StMt«- or Coiiutrv^ 



NAMK Ol- 



HIRTHPI.ACE/l I 

OF FATMKR A 

'State <,r Country) V ^ 




(^*""th) (J (Day) (Year) 

I HICUl-HY ClvRTH'V, That I atteii.le.l .leceased from 

. Ll^OAA^i IC 190*^ 

that I hist saw h 



to >.. l.A^.Q,....l.L 



o.- 1-^ 190 H 

alive on V.AAA.CIL 1 V 190 -H 

andthat death occurred, 011 the date stated above, at O. QLO 
^^^ M . T h e C ACS \\ 6 V 1)1 < A T 1 1 was as f ol lows : 

%Mr<lX^VOrcOj . O^ct VI )WtrC>Cu\ycL<^/C^ 

(d v3-v>A.lN^'du 



S) 




'1' 




<XAA. 



I) r RATION 
CONTRIIU'TORY 



Years Mopit/is Days 

LiXc<m.£rVA 



Hon PS 



r.\.^a^.7vx. 



MAIDKN XAMF 
Ol' MOTHKK 



hirthit.acf: 

Ol- MOTMKR 
(Statf or Couiitrv) 




occri'ATiox (^ n 



_ XKrv^^ <Xyy^ 



A font lis 



Days 



V'. 




Hours 
M.D. 



Rfsidfii in Sat) I'l a>\i iso '^\. Yrai^ 



yr,niiii^ 



n,t\. 



'"'' HF^ST nr'^Tv'u-l!' !;»^K.^'>^"A'. I'ARTICFLARS ARl- TKIK To THK 
iJF.sroi. M\ KNo\V1.1-;D('.f: AND IlKMFtF 

{rnformam UJ />>\; . \H\ - Xo-^^^^Lt V 



DIRATION Years 

(SIGNED) LUm\;.m- axx.^v^L\; 

'"^ 190H (Address) LuLXc Cq. fe CML^^;!- 

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



Place of Death? 116 Days 



i\iU 



rc'ss 



N. B.- 



W^%L Co . iV) CHi.^vvt'OLi 



190H 



PLACH OF HIRIAI, OR RKMoVAI, DA'i;Kof H, k.al or RKMOVAI 

JM, Qivv^ I (W...i t 

INDKRTAKKR OX) ■ O. M / C<X <VAXi/ L<; 



(Address 



•tate cIirSE OP nTrxH I . carefully •upplied. AGE should be stated EXACTLY. PHYSICIANS should 

««nr,i : ^ DEATH In plain term., that It may be properly classified. The "Special Information" far Mr- 

«on. dylnft away from home should be ftlven in svcry instance. 'ormation rar psr- 






'11 






< i 



•J 



'1: 


'ii 


,. i 1 


1 


jJII 


{ 
J 

1 




\i 


■Bl 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!.,:Mfl ..f Hillltll -I-' No. U 



-i^^^!^: 



HJX:!' (V> 



Dale Fileil , 



m 







ifcrfcniw anv«r\ v»r v^cn I i p iv^A r R. r'Uli INSTRUCTIONS 



11 



lOO'i 



Registered JVo. 



1 



Deputy Health Omcer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccttificate of Death 

( Ta. S. StanOarO ) 

Jj 07) . -^ ^ 

PLACE OF DEATH: — County of ^'<Xa-u -J-'UXAveA.AAU.City of Ooyru AXVyvca^-O-CC; 



'No 



.l\% 



.<X' 






St.; Dist.; bet U OU>x<L(r»\ji.; 



and 




( *' ?J'V** <'4'="''* ***^ ^"O** USUAL RESIDENCE GIVE facts CALLED FOR UNDER "SPECIAL INFORMATION • N 
V IF DEATHJOCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 



{TK 




FULL NAME ^J.■^L/yx<iJUy^^a/:^ 




If!' 

\ 

♦ 



1 '^..iv 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR \ 



I 




UoJuL 



MEDICAL CERTIFICATE OF DEATH 




DATE OF DKATH 



n.M 1-; n\ lUKIH 



Af'.K 



I Month) \ 



I 

(Day) 






M.oiths 



(Year) 



/hiy. 




(Month) 



(Day) 



i9o\ 

(Year) 






^IN'.I.K MAKKIi;i). 
WIDnWKI) OK DIVomKI) 

tUiitt ill s(Ki;il <ir«.i>.Miati()ii) 



HIK rniM.ACK 
'St;itf or Coimtry'i 



NAMK Ol- 

iatmi:r 

niRTTIPl.AfH 1/ 

Ol- l-ATMHR 
<Statt' or Country) 




I 



<X/vN-^jui. 



.^-(X'Lo 



.o^a 



I irrvRHRV CHRTIFY, That I atteiide.l deceased from 

190 "-rr- 

190 



that I last saw h 



190 to 

~ alive on ~~ 



and that death occurred, on the date stated above, at - 
f /rhe CAl'SR OF Dl^^TH was as follows: 




?wA.. 




Dr RATION Years 
CONTRIBUTORY 



Months 



Days Hours 



MAIDHN NAMK 
0|- MOTHKK 



HIRTHPt.ACK 
OF MOTMHR 
(Slate or Country) 







J 



DURATION ^>V.7;'5 ^ Months ^ Days Hours 



(SIG 



NED)..J..-iE..ljQ.ljLLx^. 



LLa^S^Q Q TooM (Address) Lfr*UfVaA-^\!Jv 




-all iQo' 
iCIAL INFC 







\i M.D. 



^^^Jt^'^^^^^ORfAIKT\0^ only for Hospitals. Instituhons, 
or Recent Residents, and persons dying away from home. 



Transients, 



OCCUPATION 

^^•"'tM in Sdn J't^tuisro I S )>«?;. 



Mnnt/ia 



Par. 



"ll 



'^"HK^T y^^^lvV:/^;!* T'HK^^OXAI, I'ARTICn.ARS ARK TRIK TO THK 
HKSrop MV KMOWJ^KDCK AND BKUKF 

(Infonnant \J \y-^^UU^ M)XcX^<L/Cl^x>oJU^ 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



(Add 



ress 



.oJLXju^ *3j: 



PI.^CE OK lU-RIAI. OR RKMOVAI, | DATK of IUriai. or REMOVAI 





IINDERTAKKR L oJlC/VnXx ^TK^XA^Ovvvj '^M. 



i'O 



(Address l.S.XH 




m. 



mm 



""' "* .^t^/cll'sE'^OF dTItSI'^ *' '""•^"J'" f"'*'*""'*- ^"^^ •''""•^ **• •*-*'^ EXACTLY. PHYSICIANS .hould 

«oni dyfn Aw«r from^ome ^i" M K •":.• "' '* """^ !*' '"•"''*''*^ classified. The "Special information- for p^r- 
• • u^'inn away from hpme should be (ivcn in svspy instance. 






u 



\ 



•If 




!1 

I. 



I. 



* 



I! P 



)■ 



f 



: 1 



^ f 



it i 



[ UB^H^fl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M.iai'l.'t lltriMIi- I- No. n ^^OTJj^ »«: I' c'o 



REFER TO BACK OP CERTiriCATE FOR INSTRUCTIONS 



/>(//(' Filed , 




II 



lOO'i 



RegistereclJ^o. 1,050 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Ta. S. StanCarO ) 



PLACE OF DEATH: — County of ^ '<^^^' ^ Axxaaxxa^cc City of 0/Ol^W; A^O.yTva<..<:L/C.c 

1, % , .. fl 



'No. Jc Vvr^<X'>\; dbcKL' 



^'\.JL<xX:' 



St. 



Dist.: bet. 



and 



( IF DtATH OCCURS AWAY FROM USUAL R E S I D E NC E CI VC 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 




Xa 



V.<l/\^^A^O^' 



SKX 



DMK ul FUKTII 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 




'\jy\T 



I Month) 



XX /iHO 

(Dav) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DHATH 



AC.K 



t)^ V.,n, \ 



.1 A -;////.< 



ai 



(Vear) 



Da Ys 




lb 

(Day) 



190 \ 
(Year) 



SINC.I.K MAKWn:i). 

wiixtuKi) OK i)iv()Rt'K[) n 

Write in s<K-ial (ksijciiation) Jc 



lUKTMPl.AOK 
•Stjitf or Country) 



NAMK or- 
J ATIIHR 



lURTMIM.ArK 

Ol- FATMHR 

• State or Country) 



MAIDKN NAMK 
<>»•■ MOTHHR 



HIRTHPLACK 
Ol" MOTHKR 
'State or Countrv) 






I IIRRKBY CKRTIFY, That I attended deceased from 

LL^a a 190H to LL-^....l(o 190..H 

that I last saw h'<^v-rx alive on LLv-a_^ lb. igo H 

and, that death occurred, on the date stated above, at 9 



^M. The CAUSK OF DIvATH was as follows: 



vVx^^rv-v^ \ 



OO'u.v^v^vH., Q. 



.^. 



o-v<i,,<rvu^.<<%: 



^. 




-t. 



DURATION Years ^\ Months \'\ Days Hours 

CONTRIBUTORY 




nccri'ATiox 

fir.^ided in Sav l'tatiii<fo 10 Vfata 







DURATION 



)V|^rj 



Months 



( SIGNED ) ...UJ. , (h C^4Jk.^./v>^ 

n -^ 

^>^^^^q 1^ IQOM (Address) V) 
SPEdlAL INF< 



Davs 



Hours 
M.D. 



) "^-^^-Vyyvo/^x/. ..m 






^fnllt/l.y 



Dn \s 



'^" nvJ-r^y.?.';!;^''^^''' •'HK^'^NAU PAKTICII.ARS ARK TRIK TO THK 
Ilhsroi. M\ KNOWl.KDC.K AND KKMKF 

(Infonnant J^CV/V^XOw^W 



D . D .^ . IfORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 

Former or ay "1 1 How lono at 

Usual Residence ^ UU^vvi^^LU (Jl piare of Death? 10 Days 

irv^ryv 



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





(Add 



res.s 



PLACE OF BURIAI. OK RKMOVAI, DATKof Hir.al or REMOVAI 

.__tob_ mlZ^ I ulCx a 



UNDERTAKER 

(Address 



YDL/^rrU^a Ik) 



190 






N. B. 



rt«Ve*'crim^*n"Jnrfiu^**'7',*' **' carefully supplied. AGE .hould b« .tated EXACTLY. PHYSICIANS .hould 
!! % . ^ DEATH In plain term., that It may be properly classified. The "Special Information'* fer u.r. 

«on« dyin4 away from home should be given in •x^ry instance. 



i' ',1 



1, 

V 



\ w 



t 



'if 



\ 



41 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lln:(i.l..| llcilfh— I" No. 1 1; TP^jH«R^3 Hffc P Co 



¥ 



n 



I 



I 



I • 



i'% 



( f 



t I 



(! 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ff(' FiJeil, 





n wo'i 



Registered J^o, 



CA^ 



DerJ-^^^y '-J-^n'-*- Offlicer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( TO. S. Stan&atO ) 



% 



PLACE OF DEATH: — County ofO/CLoo; AxxavCc<lc<- City of OxXAV J Vou>vCA.<iXU 



No. 



IH 



'.^\.v<:> 



St.; I Dist.; bctX 



and 



r ir Dt*TM OCCURS *W*V FROM USUAL R E S I D E N C E C. V t facts CALLtO FOR UNOCR 'SPCClJl I N FO R M ATIO N • A 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREEtIJiND NUMBER. ) 




u (■ 



FULL NAME 




J..X;:>x^^ca\.j 




UAJ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




1 





yr 



.<Xjl 



I>\T1-: oi lUKTII 



A OH 



'Month) i] 



11 
(Day) 






/iO.M 

(Year) 



Da ) .V 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII 



LAaa^ 



(Month) 



1 



l.k,, 

(Day) 



i9o\ 

(Year) 



SINC.j.K, MARKIi:i), 
WIDnUKI) OK DIVOKiKI) 
'Uiitr ill sorifil «Usijf nation) 



HIR rniM.AOK 
(Stiitc or Country » 



NAMK OI 
I AT Mi: R 



MIRTH PI.ACK 
OI' I ATHKR 
(State or Country 






x^ 



I IIHRKRY CivRTIFV, That I attended deceased from 

-^-^^^^^-^ l^ 190H to LUa^ Lb 190.H 

that I last saw h'<^-.v^ alive on LLca^^X , 1 lu igo S 

and that death occurred, on the date stated above, at \X, I 'o 
A; M. The CAUSrC OF DKATH was as follows: 



•■'^jAJL>v;. S....o^-wiu>.AAAiZXa 






fVVv<y-QL' 



MAIDKN NAMK HCS 
OI" MoTHKR '()l) 




Dr RAT ION Years 
CONTRIIU'TORY 



Months 



Days 



Hours 



DURATION Years 

a. a 



Months 



Pays 



inRrm'i,A(M-: 

'M- MOTHKR 
(stall- i,r Country) 



CCCiAAJ 



Hours 
I (SIGNED) LI. 6J-^ A.AA,^Ov^^ M.D. 

^<^ n 190 H (.Ad(lross) '^^'^ yiWv-^ 



1 



a. 

?^^?'ft'-J'^f°'"^'^"'"'ON only for Hospitals, Institutions, Transients^ 
or Recent Residents, and persons dying away from home. ' 



i^lAL INFORI 



v^fca^l.L\^4'. 






'HCri'ATlOX 

. ^'^'''f^'f "I S<i„ / ,,in, i.u'it - }V,ns - yf.uitfis "^ /hns 

' " nrJ'r^r7.'^-^J,V'''-'> l*»':«^ONA I. I'AKTICf I.AR S A R K TRCK TO TIIH 

Hhsroi. MN kno\vm;i)(,k AM) Hi;iji;i- 

(I'.fonnMnt O . \l l\e W^^Oth^ 

(Address l^i \cyJtwo at 



Former or 
Usual Residence 

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



How long at 

Place of Death? pays 



fi OH BURIAI, OR RKMOVAT. D.VlH of ntK.AT. or RKMOVAI, 
olu Gut^<l^. I vL-v^ \'l igoS 

r XDK R TA K K R U <xXx/^<XX \^^Ux^.A/YVV "< Lq 

(Ad.lirss IS'^H C) ^tv^L>|^^jt«ry:\^.....dl 



"' "* rt7t7cMr8F*OP n7rTH",*''7V' **' carefully supplied. AGB •hould be .tated EXACTLY. PHYSICIANS .hould 
^nnl H 1 / e T ^'"'" '"'""' **""' '' """^ '^'^ properly classified. The "Special Information" for Jr- 

«on« dylnft away from home Hhoiild be Itiven in mvory instance. "^ 



^■(:l 



'iJi; 




'1 

* .'I 






I ■ 



ti 



' 't 



1, 






1 .li 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



l; ,1-.'. ..f flea 1th -J" No >«. t-^^^^HS:!' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Didc /vV^v/, LIa^w<u^^^ II 



100\ 



.>&-VC>CCi 




Registered J\^o, 



105-2 



DP"^'-/*"*' '.'->-> I* ». r-. rrr 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of ©catb 

( Vi. S. StanC>ar^ ) 
PLACE OF DEATH: — County of LlLa>-> v<.d.<x City of 



M3X>JkjLLvi Let I 



No. 



St. 



Dist.; bet. 



and 



/ ir DtATM OCCURS AWAY mOM USUAL RESIDENCE GIVE FACTS called for UNDER "special INFORMATION 
V IF DEATH OCCURRID IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRrrT AMn Miitiar. 



FULL NAME 



IK 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 



I 






) 



■) 



^ 



mc^L 



I'M K »>| ItlKlH 



AC.K 



J 




1 



KC\^<. 



MEDICAL CERTIFICATE OF DEATH 



'^VXcLO 



.t. 



Month* 



is ...... 



(Day) 



i Mo„!hs 



^f 



V 



(Year) 



DiJ 1 .V 



DATE OK DHATH 



1. 



(Month) 1 



11 

(Day) 



(Year) 



"-INt.I.K MAKKIKI). 

w n>o\yKi) «>k n;\»»Rt"Hi) 

N\ riff ill <(KiaI iU«.ij»n:itiiiii) 



HIk rilPI.^t'K 
St;ttt <ir Cmmti \ 




K<L<y\x>^\) 



i^ 



I ni^KHnV ClvRTIFY, That I atteiulea (lecoasoa from 

~ to 



T90 — 
that I last saw h ^alivc on 



^90 
190 



ami that doath oconrrctl, 011 the ilato stated above, at • 
M. The CAJLI^SK C)l< Dl-ATII was as follows: 



\AMl-: n|- 
I-ATHKR 



lUKTMI'I.ACK 
oi" I-^IMKK 
'Stale .,r lNmntTv> 



MAII)1:n NAM!" 
<»I MOT! IKK 



lUKTMI'LACK 
<M" MoTHKK 
'Statr or C«)uiitrv) 






DVW, 



\.A^> 



DIRATION Years 

CONTRIIU'TORV 



Mouths 



Days 



Hour. 




>vcrv<vrv\. 



DURATION 



Ytiir 



Mouths 



/hivs 



ii 



0_^.<x.yc>v\ 



*» 






(Signed) ♦ 0, J.ix\.vo.. .. 

Ua\0. tl Too't (A.Mress) \DxV.VU.Uci La..». 



f fours 
M.D. 



% 



Special Information only for Hospitals 

or Recent Residents, and persons dying away from home. 



i, Institirtlons 



fCrsiifnf in San /'rain isrn 



)'rnt s 



y^niifliS 



Du r> 



"",;,:^"r*^'^'' ^'''^'''J--l> »'KRS<)NAU IWKTICrLARS ARK TRIK To THK 
Ithsroi< MY KN()\Vl.Kn<*.K AND IJKI.IKK 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Transients, 



Days 



Ml 



(.\<lclress 












(Address 



N. B. Every Item o? information should be carefully nuppiled. 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 ••r. 
«ons dylnft away from home should be &!ven in evory instance. 



V' 



li' 



. .41 



I 






1'. 



M 



■ w 


> ■ 


1 




} 






t 


•t 


V; 


i 

1 





b. 








i\ 



.1^ 



: I i. 




!l 



|,-V,J-!.;(i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



:it,! .,f Hr.lltll I- X<' I- •t>'^^^''-; li.V I' C, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Fi /('(/, (X.^v/cyL\^ n 




lf)0^ 



Registered Js'*o, 



1 



Deputy Health Officer 



DEPARTMENT OF PUBLIC ilEALTH-City and County of San Francisco 



dcrtificatc of ©catb 

( U. %. StnnI>arC> ) 

^ ^ J? 



% 



PLACE OF DEATH: — County ofvJ/O/w OAXXy^xccvtCt City of ^<^>v Axx^ yv<^a.xl ti^ 



IVo 



.5t m 



OJ 




CK- 



|\AA/X. 



St.; 



Dist.; bet. 



and 



f ir dcatA occurs a\mav from USUAL RES I DE NCE ci VE facts called for under "special information' \ 

V IF DC^TH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



SIX 



PERSONAL AND STATIST 



FULL NAME 

ICAL PARTICULARS 



^jy\f>(\KX> vJLlo 





(rirbny^v/) 








aJU, 



M- 



i» \ 1 1-: < »i r.iK rn 



\t.i-; 









Y,ai 



1 






M,niths 






(Vcar) 



H 






lilKl'lIl'I. Ai'l-: 
'Slate or Comitrv 




\.\Mi: oi 
!• \'i"iii;r 



lUKIill'I.Ar 

oi- i-Ariii' 

state or (."ounli V 




Ux\A.^ULdL 







MEDICAL CERTIFICATE OF DEATH 

DATH (»I- Dl.ATll r^ 

^Mdiitli) ,r (Day) (Vc-ai) 

1 in':ki{l!V Cl'iRTll-V, That I attcu.k'.l (Iccvascd from 

HW-U 1 t up H to CLuwQ_ L& i^o H 

lliat I last saw li-A,^' alive on LA^Ays^ 1.1 loo 'V 

and that .k-ath occurred, on the date stated' above, at '^ 
U. .^L TIk- CAlSTv ()!• I)i:.\TII was as follows: 




DIKATIOX 
CONTUIIUTORV 



) 'cars 



MAn)i:N N\Mi: (^ a /Tv 

oi- M()Tiii;k L 1| [V 

HKiiii'i.Ar}-; X 

»i Morm-k A y 

State or eoiiiitryl Ij ' 



HI 



OCC 






Years 



Mo)ilhs 



.drouth: 



'1 



^ 



Diiys 



Hours 






1 )r RATIO N 

(SIGNED) Ll>Ctivuav ^; . vi^ v.^^v^o^ 

\X<^X>, IL rcjo'i (Address) BtrXHlxX.' 

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



Days Hours 

K^^u M.D. 

dl'ft-dixi.. 



t. ^ M J Ut^aXcvM U. V . piare of Deatfi ? 






f\r>'iffif ill S,ni /'i ,!ih /m;i \[ )>-,// c 



^rniiflf 



n,i\s 



'''"',';,>'!' '^■'•" ^'l'\!"l-I> PKKSOXM, I'VKTU-fl.ARS A R !■: TRrK T< » Till- 
l.l-.sl OI- MY KNOW I, i: DC, H AND HHUIKF 



(1 



b<j±^\niy(uX 



V/>A^ 



'\^l.!r.-.s C>C)'i 




/(n'>'VJL\x/ 



Lwa 



Former or 
L'siial Residence 

Wfjen was disease contracted, ^ ^ 

If not at place of death? 



Days 



n.ACH ())• HrklAI. OR R}:mo\AI, 



DA'I"K<)!" IliHiAr. or KIvMoxaj, 



TQOH 



(Address 




' . B. F.very item oil inltormation should be carefully supplied. AGB should be stnted EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The •'Special Information" for D«r- 
sons dym^ away from home should be feiven in every instance. 






f 



m 









I 



41 



11 



1 






I 



¥ J 



te" 




I 



' ♦ 



m 




r 



1-1 ! 



«! 






^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,:,T-.l ..f II.:ilth ^ V Sn m ^-F^^iiir*' '"'^ 1' ' 



dLcr\^A.o iiLa>v. Deputy Health Officer 



Registered J\^o. 



1054 



} 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

{ TX, S. 5tan^ar^ ) 
PLACE OF DEATH: — County of /CU^rv J/UXTL/CXaC^j City of 0/CL/Tu oAXXy-v vc.c<teo 
NoAt'i ^J(xYVyJlOx't\>A-0.' St.; '^ Dist.; bet. 2);v<L and H t4\; 

(IF DE«TH OCCURS AW«V FROM USUAL R E S I D E N C E G I V E 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 OcLcAvKVv<ij .>\x>djAx<:^ UJLrux.lvcv>>v 



PERSONAL AND STATISTICAL PARTICULARS 




OLv 



DA'l'i: <»! KIK 111 



V . 1. 



\ 




\ 



^\^ 



■■u 



yavv- 



I);iv) 



<V(;ir) 



4t^ 



b 



1/ ' v.- 



X^ 



-IN' !.i: MARlvIi;!). 

\\'!i)< t\\i-:i> OR i)i\'(>ri'):j) 

W'l it' in >.<)ri;il (l<-ii.rnati' m ) 




lUKTII IM, \rv 
(Stilt. ■.! '•..:;;;lt \ 



J-ATHJ-.R \()n 






MEDICAL CERTIFICATE OF DEATH 

1 1 ATI". • »!• i>i;a TH 

n 




^kxAjc 



Kx.O 





w.Cuy'Y^- 



lURTHlM.ArH 

«)i" I \ riiHK 

' St.Mtt (.1 ('> ^niitr\ ' 







maiiii:n \ami-. 



HlRTllI'LA'/l-: 
nl' MoTHKR 
'Slate or roiuiti \ 



OCCT 



f<?cA 

(Month) (\ (Day) (Year) 

I lli;ki;HV Cl-RTIl'V, TliMl I attt'ii.UMl ileceased from 

VlrVo^ Xl 190S t.) Caa^q. 1(q 190 h 

tli.'it I last ^a\v h *w .>v alive on nJ^A^v-O. \^ 190 'S 

ami that <U'ath occurred, on the date sta1e<l above, at v- o5^ 
LL M. The CATS]-: Ol" I)1:ATII was as follows: 

DlRA'noN )'rais Mo>i//is;Wi'X fhiys Hours 

CONTRIIUTORV 



1)1 RATION 



/?) 



Years 



Mo)ith> 



Pavs 



(SIGNED) ^vK.^'^l.(J)XV.vcLt 
LAxvQ \'-l T(,oH (Address) 1^^ CrUl 



Hours 
M.D. 






t»v 



SPECIAL INFORMATION only tor llospitdh, Inslitiitions, Transients, 
or Rrrent Rrsidriits, and persons dying away from home. 



AV.,',,V(/ /;/ V,;)' / / ,;;- 



1/ -////. 



/ ',,■ 1 



Tin-. AHovK ST \'i'i:n ckkx' »n a 1. y\ ki-ut i. \ k-^ a k 1: i'r i 1: r< > rii i-; 
m:sT Ol' Mv KNiiw i.i:i)(,i.; AM) in:i,n;i- 



e 






Former or 
Usual Residence 

When was disease confrarted, 
If not at plare of death ? 



HoH lonq at 
Plare of Death ? 



Ddvs 



ri,A(."i-: <ir iukiai, ok i.;i;M< i\ai. 



T90H 



KAIl-.o;" in KiAi. or R1-:M()\m^ 

rNi»i:R'rAKi:R '0^/^vvt>rvjL^u \>J -K,.<>-'<V 



(Address 



IS. B. Kvery item of informiition •thoiild be cjii'cfullj MupplicMl. A(IF. «ho;iltl be stated r.XACTLY. PHYSICIANS should 

state CAUSE OP DEATH in pljiin terms, thnt it mjiy be properly clossifieil. The ''Special Information" for per- 
son* dyin^ away from home should be (^iven in every instance. 



? V. 



w^ 






fH 



I ■ ' t 



fill 



1 '' 



I; 



WW 

■' '1. 
■ ■ \ 





.V 



I ^ * 




.1' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



llr,:,!,l ,.f II, , lit!) !■■ No ;- "?-r\ia^;. V.SiV Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\l 



IfJOH 



Date Filed , LI.a^v.<xva.<iAJ 

X<iAAA.^ \kjxy^. Deputy Health Officer 



llc^istei'od Ko. 



105^ 



^ 




DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 

Certificate of Beatb 

{ XI. 5. Stanc>arC> ) 
PLACE OF DEATH: — County ofCJ/OAV J ;uX/>\/OUlCC) City of C3/ayru AxXox/Ci^vA^o 
NoA^D'i Ulxor\\X/^vtAAA-tX' St.; ?^ Dist.;bet. 2)Kxi> and \XX-\3 

(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME C<iAA^<xvcl.' AX<LiLA.vc4^ UJlruxJ['VCL/>'>v 



PERSONAL AND STATISTICAL PARTICULARS 




oJU 



C<U,uK 



Lixvlji 



A 11. 1 11 iiiK rii 



AT, i-; 






4?> 



!V,; 



t 



ai 

m.-iv) 



I/..////" 






MEDICAL CERTIFICATE OF DEATH 

DAIl", < M" I)1:A'1'1I 

n 




(Day) (Year) 



(Month) 
I ni;ki:i?V CI^RTIFV, That I attendod deceased from 

vTyvoA^ x^ 190H to Ow^.^*^^ lb 



■xt 



l\iy. 



-'INt.I.i:. MARkli:!), 
WNioWKI) OK I)[V< »Kvi;i) 

Wiiti ill <i)ci;(l (li>.ii.']i;it i' 111 ) 




vXMI' OI-Wn 

•atiii:k ^Qil 



luk rniM.AiM-: 

'Stall- ur (.*oniitr\' 





rV<xiva'>TV' 



r.iK ini'LAO}-: 
oi" i\rin--.K 

St.Mtc 1)1 r.niiitrv 



maii)i:n XAM1-: 






ic)o H 
and that di-ath oceiirred, on tlie date staled above, at \. oS" 



lliat I hist saw h '^ >>\ aHve on 



a 



NI. The CAISI' OI" Dl-ATH was as folhnvs 



1)1 KA'I'ION Years MouthsW'X Days 

CONTKIIUTORV 



Hours 



>..• MCTMKK (T\ 



V^^' 




V>Y\XX/'W 



iiiK rii I'l.A'/i-: 

ol' MoTlIKK 
' Siatf or eounti \ 



\ 

:cii>ATi()x (T^ . K 



I >r RATION ^ }V<7r.v 



Mouths Days Hours 

Signed) OV.VIil Ob. xyx^^^xLt) m.d. 



i 



SPECIAL Information onl> for llospitdls, institutions, Transients, 
or Rerenf Residents, and persons dying away from home. 



AV' • uU'd / II San I'l i! ' 



) 'I'd I 



^l.:lfh^ 



h. 



Tin". AIIOVK S'i'A'ri-I) i'HKsi »NAI. I'A RT IT r I. A R S .VRl". TKri-: T< ) I'll )•; 

m:sT oi- Mv K. Now 1,1. 1 x,}-: .wd iu:i.ii;k 



k\^^ 



' \<l(lr<-ss 






Former or 
Usual Residence 

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



Hov^ lonq at 
Place of Death ? 



Days 



I'l.A*.!-: (>I lURIAI, OR Rl.MoWM, 



n\ri:.)f HrKi.Ai, or KKM<)\AI, 






T90H 



(AcKltfvs 



N. B.. 



-F.vepy item of information should he cin'ofuMy supplied. AdF. Hhoiild he stated FiXACTLY. PHYSICIANS should 
state CAUSE OP DEATH in plain terms, that it may he properly classified. The "Special Information" for par- 
sons dyinjj away from home should he ^iven in every instance. 



■H 




I ;)i 



* .!, 



I't 



J 



' i\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



It.Mid ..f Hciltli ]■' No. 1=; t-^«-«.->, H<<t J' CV) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



mp 



Dff/e Filcfl , 



C\..V^^>^->s^>0 





li 



190\ 



Regi.stcred J\''o. 



i 055 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( XX. S. StanDarD ) 
PLACE OF DEATH: — County ofC)/0^\;OXxX^rUMw^LeoCity of O/CLAV O AXXAOX^CA. a^ 



No. 



io^l 




<^^\y'y^<Xj 



H 



1 




^tl- 



St.; "^ Dist.; bet. I /V^^TO and C) A^A\j 

ilDENCEGIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

VMlcJu U)J\Aix 

I) A ri'", ( 11 IlIKTII 





(Mr)Mtir! 



AC.H 



S'l 



)V, 



ID.MVI 



.1/.-;////. 



I ■/car) 



/',n. s 



MEDICAL CERTIFICATE OF DEATH 

DATJi ()1- DlvXTH /O 

(MoiiDi) r (Day) 

I IIl{RI-;nV CivRTlFV, That I atkii. led deceased from 

- to ~— — T-rTrrr-rrrrr 



(Year) 



1 90 



SINr.l.K. MAkUIl'.I) 
\\II)<>\VJ-:i) OR I)I\<)K»i;i) ^ 

'W'litriii social ilt^itMiatioii ) 



Mi 






lUkTui'UAri.; 

'Statf or ComitrN I 



NAMJ- 01 

i"A'nii:K 



Hik rni'i.ACH 

01 I'AIHF.k 

' "^tatc ()T- Coiiiitrv 



MAIOllX NAM)' 
01 MOTHJ-.K 



liikrin-LAci-: 

oi" MOTHHK 

(State or Coimtrv) 




tliat T last saw h ^^ alive 011 



190 

T90 



and that death (jcourred, 011 the date stated aliove, at ■ 
~_ M. The CArSP: ()1- 1)I<:aTII n-^is as follows: 



1)1' RATION }'rars 

CONTRIHUTORY 



Months 



Days 



Hours 



oceriv\Ti(,x ri) , ::? 



DI'RATIOX Vrars Mouths Days 

(SIGNED) J. \Jj.U).XJLcL/>v<3L U\^VA 
l^ 190H (Address) LvurvMA-^ U 




//ours 



Jih) M.D. 



Special Information only for Hospitdis. insdiufi 

or Rpunf Residents, dnd persons dying away froin home. 




Rf'tdrd ill Sail /'i <; in m-,i 



)",„ 



M..iith- 



/', 



Former or 
UsudI Residence 

When was disease contracted, 
I 'f not at place of deatti ? 



Hovv long at 
Place of Death ? 



nS, Transients, 



Days 



•nii: XHovr: s-|-\ti:i) i-kksonai, I'VRiicri.Aks Akj-: rkti- i-o tin- 

Hl.SI Ol- MV K N( I W 1,1: 1 )(•.;;; AND \W.\,\V,\- 
(IiifnMiiant \; iVv^ 

'\.Mrc.^ bOl \l rLc/>V>VOuOt) 




DAI'Hof P.riuAi. «.r RJCMOVAJ, 



% 



I'l.Arj-; Ol- iMRiAi, OR ki;m()\ai, 

rNDl-.KTAKKK (fvD . J- OxaJKA/^^Co 



T90S 



fAdflrt-ss 



N. B.- 



-Hvery item of information HhouIJ be cnrefully «uppliecl. AdR HhouftI be stated EXACTLY. PHYSICIANS should 
state CAUSn OF DFATH in pli.in terms, that it may be properly claHsified. The "Special Information" for o.r- 
Rons clyin^ away from home should be ^iven in every instance. 






!' ll 



1 

i 



141 



I 



i 






1i 
itJii 



1: 

ill! 






4' 
ij 



i 




.1 > 



I, 

r 



H 



/ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lioilKl nf lit ;il|)i I" Xo. 1 



'*^^'*? 



S^'}-.*-. HvSiI' Co 



Dfffc n/rd , LLL^>L..oQ:fc 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\% 



I!) OH 



L^ 



Reglstei'ed J\^o. 



I ^^n 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "KX. S. Staii&ar? ) 
PLACE OF DEATH: — County ofVJ/Ouvu ^J/u<X/>vcA^a/cuo City of CJ-CL/tu J A/Cl/>a./Ca^<^o 
No. UT Uldo St.; X Dist.; bet. XaAJkA./>^ and VJ Cr(J\ 

( '" °"'f^l°ccuRs Aw*v rpoM USUAL RESIDENCE give facts called for under "special information- \ 

\ IF DEAjTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 



FULL NAME 



'^:^:\.> 



>i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

(^ ft , ^'-I.-'K 



^'^r^XxXjb 




I> \ I !•: < >!• UlK'llI 



\f. !■; 



iMoiitli) /| 



) V(/) 



lb 

(Day) 



Mouth ^ 



fVcrirl 



fhn 



^iNt.i.K. M.\kuii;i) 

wiiM >\\ i;i) OK i)[\( »R»i-: 1) 

'Writ.' ill M)<-i;ii .K sij,'ti;iti..ii) 



HiKriiiM, \ri-: 

'Statf or Coiiiili vi 



NAMl-; ()!• 

iATin:R 



HIR rill'I.ACK 
'>!• l-ATMIvR 
iStiitf or (.■()initr\ 



MAII)i:X NAMl- 
<>I' M()TlIi:k 



HiR rin-i.Ari-; 
•»i- M(»tii);k 
'Sl:itc or Country) 



(3f (1 



MEDICAL CERTIFICATE OF DEATH 
DATK OF I)1-:aTII r^ 

^^^^-^-^-o n. j^o'\ 

f^""t'i^ (J (Day) (Vcar) 

I HHRIUiV CJ-RTIFV, That I attended (IcccaseTrfr^oni 

'^ 190I to ^^-^-^ n 190 S 

tliat I last" saw h -r^^.' alive on LLl.^ H t^q M 

and that death occurred, on the date stated above, at S.3 




'Ip^r- '^*li^' CAISIC (.)!• I)|{ATn was as foil. 



)ws : 



CS^jtxXA) 





K.^Y\^ 



J? Oj) 



1)1 RATION Years 




Mofitin Days 



I /ours 






Dl'RATIOX 



{ Signed ) 



)'cars 






out /is 




OCCri'ATlON 

AW^ /;/ ,V,7„ rt,!)t, !-r,, — )■,,;/- ^ M.^iitli, \ 1 





Davs 



-\^<J^Jf^ 



//on 



rs 



M.D. 



f ^^?'fi'-."^f°"'^'^'^'ON only for Hospitals, Insfifufions, Transients 
or Recent Residents, and persons dying away from fiome. 



'""'.;, ^J-r' Vw •';'!". V'"'"" ''»'-'<^<'NM.l'\RTICri,ARSARI-. TRCK To TIM- 

iii-,si oi- \\\ K>:<»\\i):i)c, K \\i) mi-:mi:f 



(lMf');inrint 




Former or 
Usual Residence 

Wtien was disease contracted, 
If not at place of deatti ? 



How lonq at 
Place of Death? 



Days 



' \'l.lr. 



loO'l 




^ 






''''•\iii'l,*''"J^'''^'^'''»l< 1<i;m.,VAI. I)ATK,,f n,K,,,. or RKMOVAI, 



INI 



)i.KTAKKR LoJUJUrVv"y^A/Ou Uw^vAxilo Co 



"' ''■ Itrt7c'l\rSF^OP nTrTH" "^^^^ '^^ carefuny suppliecl. AGB nhould be ntntecl BXACTLY. PHYSICIANS «houId 
•in. civfni „ ^'^f "^A^" '" •»'"'" f*^'-'"«. th«t it may be properly cla««iiiied. The "Special Information" for per- 
sons cl>ini away from home Hhoiild be feiven in every instance. 



t 






1 1 



li' 



\\\ 



TA 






PS 

i 
i 

I 




/ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



*■!!?>' 



)t";it(l of H<;ilth »•■ Vo K 'f-si: ."*./'"'♦ Mi"^ 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihffr F/7rf/, [X^^x^yu^ \l mO'i 



Begistcred J\^o, 



< 057 



,<rVA.-^--o 



>^{ 



N 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDcatb 

( Xk. S. Stanear^ ) 

PLACE OF DEATH: — County ofOcL^^; vj;LCU\vCAXLao City of d/O/ru ^L/O/vurx^^ e-t 
o. \^'KaJLc\AXa\^ 

( 




St.; 



IF DEATH OCCURS AWA 



Dist.; bet. 



iUAL RESIDENCE GIVE facts called for under "special 

IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



"and 



FULL NAME 






lAL INFORMATION" \ 
T AND NUMBER. / 





S !•: \ 



PERSONAL AND STATISTICAL PARTICULARS 

DAii-; (ti liiKTn 





\'.i-; 



1 



U 



null I 



) Id ) 



5- 

'I):tv) 



.1 /.->////> 



\x 



(W ,11 



/',/] 



HINCI,!- M \ K k I i;i). 
Wiitciii x.iiial (1( si(,^i);(tioii ) 



x^y^ 



'St:i!' '.• ''nititrv' 



N'AMl' <)1- 

F \thi:k 



lUR'IMIM.ACH 
f)|- I-ATIIKK 

'St;it> <)1 ("nnilliv) 



maii));n xamk 
of mothhk 



niRTUI'r.AOF: 

'>!•■ MnTHI-,k 

( suite or CduiiIi \ ) 





OCCrPATlON 



[^ ] (J p |0 



MEDICAL CERTIFICATE OF DEATH 

datf: of DicATH r\ 

'^^-^^ n /(?r>H 

( Mouth) J (Day) (Year) 

m:KI';HV CI:rT]I'V, Tliat r atteM(k-<l deceased 7mm 

l^ 190 H to LXm^ 11 KpC^ 

that I last saw h XV alive on CLlaXV H ^d 0\ icp H 

atid that death oc(Mirred, on the date stated above, at 10-2)0 

U. M. The CAISI^)!- 1)1-:.\TII uas as follows: 



IM- RAT I ON Vrars \ Mouths H Days Hour, 

CONTRIIU-TORV VIax^ccJLlW^ Ull 



■!OXX\jy: 



Lt\r 



I )r RATION S Vrars .mouuis 

(SIGNED) It). J . Ijuxiji^UX 

^^^^-^-^ n i()o'-\ (Ad.itvs>.) UI^JUl\Jt^\^ '()b(S4.lvt 



Mouths Days Hours 

M.D. 



112: 



^P^^^'f^L INFORMATION only for Hospitals. Institutions, Transients 
or Recent Residents, dnd persons dying awdy fro.ti fjome. 



■> ) . 



'./ / 



lA. /////> 



'" n,^ ",V^'^. ^''' XH' I » 1' F k ^. )\ \ 1 , 1- M< I I . • r I, \ K ^ A K F; T K I I-: T( . Til }■• 
I'F.SI OF >,J^V KNOWI.l.Dt-,}.; AM) in- 1, 1 1 ; 1- 

fii>f":"iriiit ds^-^rVLA^ VJj XxX> 



former or [\ ^\ P 3 Hon long at 

Isual Residence M kKaJSTYTsjO^ \JXXj pjace of Death ? P 

was disease rontrarted, (v (^ [) 

at place of deaffi ? VJ CXJL^rywXK) LxXv 



Days 



When was 
If not 



.\J^ 



^'i'i'<'«'^ ^J X^>-^AJL\aXX) L<U(Jt^^OvOU^ L< 



TQOH 



I'I.AC|:oF MrJ<lAI. OK '<»-^'"VAI. I,An.:,.f p.rK.AK or KKMOVAI, 
(Address 3 IH iD ' J <X>UuJl dl 



I ndf; 



N. B.- 



-Kvery item of information hHouIcI be cnrefully Rupplie.l. AGR «houltl be stated F.XACTLY. PHYSICIANS should 
state CAII8E OF DEATH In plain terms, that it may be properly classified. The "Special Information" for o.r- 
Rons dymft away from home should be iliven in as^vy instance. 




;r 



i T i 



•t 



) '] 



11 



/ 



I 









i.4 



'^ 



mm 



II i. 



1^ 



4 
1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H-Mi.l ..f Hiriltli I- No. !«; ■*-^''ra^.;, lK<;tl'Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health Officer 




Bogi\si('i'0(l ^^r;. 



lOi 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

PLACE OF DEATH: — County of vJCL^>\.) O^^vCl/^^/Caa^co City of O/Cla^ J AxXy->a.CA.<iXi c 

St.; H Dist.; bet. db CK^J<XAydL> and O-lA-tn-W 

i AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



No. dlD .a,^.»vvxl' 



FULL NAME 




SI 



PERSONAL AND STATISTICAL PARTICULARS 



'! 



DA II-: ol' lUKlll 



.\^.\^. 




JJxVAX 







/UCr\Ary\; 



MEDICAL CERTIFICATE OF DEATH 

DATH OI" I)i;A'i II ^-^ 

(Month) (V (I)av) 



IH 

il):i\ I 






) III I s 



Mnlilliy 



a 



/),/ 



SINC.I.i:, MAKRIl-l). 
WIDoWKl) OK DIVoKaIJ) 
iWritcin social rltsit'iiiiti'iii) 



d 




HIRTHl'I.ACK 

' -^ritc or (."oiii'.trv' 



NAM}; or 

I-ATIII-R 



niRTMl'!. AiK 

Of I'ArnKR 

fSlatf Ml rouiitrv) 



MAIDI-.N NAMl-; 

<>i M<»rm;R 



IMRIIII'UACI-: 
Ol- MorilKR 
(State or Countiv) 



occri'A rioN 

f\t' idrd ill .S\ni I'l ,1)1. f ,-,i 






XX/^X) O ^vXX^VVX^A^^CL/C^ 



(Year) 
I IN'RIvHY Cl-RTIFV, That I attcii.led deceased Yroiii 

'J-^-^ IH 190H to CLaw^ 1.H 1^4 

that I last saw h :^*V alive on LLa^/Ol 1 H Kp H 

and that death occurred, on the date stated above, at 1^ 

^ -M. The CArSl<: OI' niCATII was as follows: 



r f I 



DCRAriO.X }'tU7rs 
C()NTRII5rT()RY 



IMontln; 



Days (0 Hours 




\y\Jb 




DI-RATIOX Years Mouths Days 

(SIGNED) lO. d dvJjLx 

UoC\^^ iS'iQoH (Ad.lre ss) ^ 3) ( ()b 0-Uj<t\xi^ Ot 
PEC^AL IN 



Hours 
M.D. 



?''^9^'S'- Information only for Hospitals, InstituNons, Transients 
or Recent Residents, and persons dying away froni fiome. ' 



) I'll I > 



"" ^r..||fh^ 1^ //,; 



THr. AHOVK SI-ATI-I) PHRsoVAi. 1' \ RTirr l.ARS ARi; TRD-: To TIN- 

ifhsi OI- Mv KNo\\ij:i>(-,h- AM) in-:Mi-:i-- 



Former or 
L'sual Residence 

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



flow lonq at 
Place of Oeatfj ? 



Days 



f Iiif'i-iiiaut 



U). a 




M.d.lif^-; 



S^l 'db Cru^KXVdL cjt 




ri.ACK OK IirRIAI. OR RI-:moVM, j I)\Tl-:.,f liiKiAi. ,„ RHMOVAI, 







rNi)i-;R'rAivi-:R 



^^cMrrs'; 



SbT^- l^ 






^' "• ^'^^^y 'tern of informntSon should be cnrefully supplied. AGB should be «tfited EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for D«r- 
8on« dyinft away from home should be jiiven in every instance. 



\ 



f 



I ;' 



!; 



«•;! 



> t 



.1. 



■f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



V.r.-jv] .f !!' ii'th- I" No ••• "^"'i.^?/^*' HS.I' C-, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Bogisfd'od J\^o. 



' 059 



cLci-ccvo kju\>-\j Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of jDeath 

( "U. 5. Stan^arC> ) 

J? (?T^ A % 

PLACE OF DEATH: — County ofC'CL^^- 0/VCX^vC^si C^City of C)<X/>v O.h^CU^vCc^c^ 
Ne. 0.\JL^VcJk) ()bcHtix\l<x( St.; Dist.; bet. and 



(ir Dt»TH OCCURS «W*V TROM USUAL R E S I D E N C E G I V E facts called for under "special INrORMATION " "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME 0.t>viXcvcL«- 



-) 




•1 A 



PERSONAL AND STATISTICAL PARTICULARS 

i> \ ri- < ii r.ik Til 

" 1 









15- 

'D.-iv* 



\' .1', 



3.^ 



/'(M.> 






^OAX 



nil;-'-:i;M v.-j- 



F'ATIU: R 



HIk rui'i.ArH 
'»i- fathi:r 

'^' iti or i,"<)ni)tr\' ' 



maii>i:n NAMi-: 

or MoTUHR 



iJikiin-i. \<i-; 

OF- MttTHi:K 

! Stall- <jr (.'<iinui 



' »■ > I lAlIoN 






MEDICAL CERTIFICATE OF DEATH 

' Ml null > [\ (Day) 

I HI-:RI-:iiV C1;RTIFV. That I atUMi.lc.l .IcHiMse.l from 
VvOLvv_ '^ looH to LLum3i_ l"^ 



(Year) 



■y ^ 190H to ywA^^s^ It KjoH 

that I last saw h -»w/u alive oil v^^A-a^CL 'I 

ajid that (U>ath occurred, cm the datt- stated above, at io 
(X M. The CAISK C)l- 1)I-;AT!I 



was as follow^ 



I ) I ■ R A r I < ) N 



}'<•(/;.? 





CONTRIIUToRV O-r^^ 



M (tilths Pays 



I/oitrs 



DTRATloN 

(Signed ) 



)'i'ars 



Cb. LIa1..<^X3. 




n 



Xj^X) ij . \j 



kVidf,! in S,ni I'iaii< '^»•'> ,JL Vj 



?. 



v^A^^o il> ic)oH rAddris<) i£^2) UxxXXx 



:3JJlL22_L_ 

:iAL iNFORi 






Pays 



Hours 
M.D. 






/'.'l. 



rni' AHovK ST \ri:ii rKRSiiN \i. !■ \K ihii \k^ \ki- trii- ri • I'ni-' 

in-;sT •»! 'iJV KN<i\\I,l-:i)r. h AND lU.l.lI'.i 
(It. forma nt Obj2^'>'^VM, ^ CC^W-aJL^A^ 

(p a 

4 



\.Mv. 



SPECIi^kL Information onU tor Hospitdls, institutions'! Transients, 
or Recent Residents, dnd persons dying av»a\ from home. 



former or "^rJ^^T^?^^ ^'^^ ,t; fioH long at 

Lisual Residence vj <xJk>v/o^/-i^cxA^ ^-a-. place of Deatfi? H I Oavs 

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



rLACl-: ())• lUKIAI, Ok K1-:Mi i\AJ, 




CnLu Uv 



^r^^ 



I)Arjj:(>f 15! i-i.Ai, (,r Rl-:Mn\Ai, 

^"^ I90M 









(Ad. 



•^^ ^' f"'vepy item olf infurmHtion should h.- cnrcfully siipplle«l. AGK Hhould be Htateil F.XACTLY. PHYSICIANS Hhouid 
•tHtc CAUSE OF DEATH in phiin terms, that it may be properly classified. The "Special Information" for p«r- 
Bon* dyln^ away from home should be ftiven in «very instance. 






If 



■1 

'I; 






•:U.] 

J .: 
i k \'' 

t I 



U 



; ft 

11- 



Ml. 
Mi 

;• t 



( r 



it I 



I I 



• t 



^M 



r 






I \. 



m 



fr'^r-^,'. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hm:M(1 of II( :ilth I' V< 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)f(/r rilrd, LUaXX^^aaJj 1% 



lOO'i 




Jlrgi.s/crcd jV(h 



1 fi(\0 



tj-\A.A^ 




^ 



^fj^ty Hcahn (jffi 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 

( U. S. 5tnn^nr^ ) 

^ (^ J? 



% 



PLACE OF DEATH: — County ofO/(Vru v) AXX/^x<>L4C(City ofO/CUOO; OAXX/YvedX^c 



I^. 




iiu X 



^A.sLi\>0^<LiSt.; 



~ Dist.; bet. 



and 



rt /' ir DEATH occunaTAWAv FROM USUAL RESIDENCE GIVE facts called for under "special i n formation-' 'X 
J V 'P death occi^red in a hospital or institution give its name instead of street and number. / 

FULL NAME 





.^w^ 




Uv^Crur 



f 



Utu 



PERSONAL AND STATISTICAL PARTICULARS 




--I'.X 



I) A ri'. < »i HI Kill 



^' . }■: 




M..Ath) 



,aJu 



UJJvctji 



Avi 



51 .,.., H 



il);iv) 



M.'utli 



' '\'f,\\ 



MEDICAL CERTIFICATE OF DEATH 

DA'ri". nl- Di: \ III 

n 




(D.iv) 



11 



/', 



I vs 



\\ !!« »\\i<: I) ( )« iti\i )Rri: 1) 

' W'l it' ill -i.( ial (!(sij.Miiit i.ui ) 



luk riii'i, \<^}' 

'Mill' l)T I Mllllt I \ 




|'ATiii;k 



HIRTHI'I.ACK 

«>i- i-ATm:K 

'Sl.itc oi Coiiiiti \^ 



MAII)i:\ \AMl-. 

"!■ M(»rin:k 



inKi'iiiM.An-: 

<>l- Mit'llll-.K 




'-0 



I Hi'RI'lJV CI'IKTII'V; That I .iltci.U.l .lc«xasf,l fm,,, 

IvaXu ^0 up^\ to CX^-vq. 

tliat I last saw li ^'^ ' > > alive on 



(Month) 






up\ 



ami that diatli occuircMl, on tlu- datr stated above, at S" v) 



M. 'Ihe CAISI.; OI' I)i: \|-il was as follows 



, ;n . •" • ' '"^ v.Yi vii, wi I'l. \iii \\^is as I OIK 



A^A^-VN. 



1 



.'Y^^J L^uO-U.rlx^ 



A) 







ct 



1)1 RA'i'lON Years 

CON'i'Kir.rTokV 



}'i'll IS 



Months 



\l 



Pays 



J/oin 




f\'f!lll'<! Ill Will I I ,1 II, I -I'll »■ )V,M» "^ 



DIRATION 

(Signed) UJ. Xd . L<r^\X_ 

VA.\ ^txr; i()o'\ (Addn-^s) UJLy\'ya.Iv^ 

dPal Infor 



Mon/Zis /hns 



//ours 
M.D. 



SPECmL Information "nly for llospildls, Instilulions, Irdnsients 
or Rerent Residents, ,ind persons dyini) dway from fiome, ' 



Former or 
llsudi Residence 



? 



How long df 
f'Idre of Oedfh ? 



1/,.;//'// 



/>.n 



llir A)|()VK ST\ Til) I'KKSONAI, l'\l< IH TI.AKS AKl! VRl }■ Tn nil- 
lU.Sl (»|. MV KNUA\|,l,I)C.|.: AM) i!i;i,ii:i- 



Onf>j;iit;iilt 



< X'ldicss 






Wfien was disease ronlrd(fed, 
If not at pidfe of deatli ? 



Days 




<i \^^C. 



I'l.Ari- ()i- lURiAi. Ok ki:M(.v\i, I datk,;- hiiuai (.1 kj:muv\u 

h) Op ^. %" ^ 



MMKM 



N. K. Kvery item of infoniiHtion Khotilcl be cnrefully supplied. AGK should be stjited KXACTLY. PHYSICIANS should 
«tatc CAlISi: OP DliA TH in plnin terms, that it may be properly classified. The "Special Information" for par- 
sons dyinii away from home should be feivcn in every instance. 






M 




\ • 






if 




.1 . 



w<-y 



"I 



» i 



" 



I : 






^. 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



t)*""^"*. 



j;n;,lrl of II. ;iltll I" N'o. H t-- » --i) ){& P ». 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc Fi /('(/, 



cLcrOu^ 




\i 



WOH 



Reo'istered J\i''n. 



^ OG 1 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeath 

SI ^ J? 



^ 



PLACE OF DEATH: — County ofCJ/CL/-^ 0A^<X>vc.c4.C( City of Cu v\j U AXX/'VX'C^^ C 



o 



ncSRIpSIl^ 



■OM^'^A^^Cj^*^.' 



St.; H Dist.;bet. (o 



\\) 



.-It! 

and I Ot' 



(IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



a 



X-^rV 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 



!).\ 1 ! Ml Hi Kill 



\i 




JJJx^LiL; 






<X<.<^r- 



MEDICAL CERTIFICATE OF DEATH 

DATK ol' 1)i;ath 



|\!Mntli 



^ 



Ob r,„.. 



li 



II):ivl 



M »/.'//• 







\% 



(Momli) rt (Dayl (Yrnr^ 

I m:Ri;r.V CIvRTIFV, That I attcMidcl (Iciv.isc.l from 



a^ 



/),.' 1 



<I\i'.l.l" MARRIl".!) 

WIIx >\Vl'It OK I>I\'( iKT I'D 

(\\'ii!i in s<n.-i;i] i!< v'<.Mi.it imi ) 



lukruri, Ai'i" 

'Stilt I (ir rrnint I \ 




1 H 



NAM)-: or 
I'Aiiii:k 



lUKIH IM. \iV. 
«)! lAriM'K 

(St.-lti- (It I'dUIlt I \ 



^M II li.N \ \M I 

<'i Mi>rni';K 



I'.iRiin-i.ArH 

oi' Moi'IIlvU 
'Stale nr C'ouiitrvl 




.0^<i 



u 



XXX 




I I I I , I\ I , 1 1 



190 H t 



\^p\ 



OLCcr 




V>U 




lxXv> 



that I last saw h I- i>\ alive on \J^^CQ ^ 11 190'! 

and that <Uath occiirrcMl, 011 the datr "^tatetl ahove, at H 
VJ ^\. The CAl^h; ()!• 1)1<;.\TH wa>^ as follows: 

1)1 RATION )-fars Man //is /hfvs J lours 



CONTRir.rTORV 



1)1 RAT ION Years 

( Signed ) J. <i M 







XOL v^ v<i.yUt^.> 



Months Pays Hours 

u^rw-w^x^ M.D. 

Lww^Q ll loo'i (A.l.lress) I I 1 6 H iXcuJkjob 



It 



SPEOIAL Information only lor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinij away from home. 



M.nilf,' 



IK!\ 



I III' AIJOVI-: sr \ 111) I'KKSONAI, I'AKriCl I.AKS AKl' rkri-- )•( > Til F 

luvsr oi- Mv KNOW i.i-.Dc. H AM) in-:i,ii:i- 






Former or 
Isufll Residence 

Wfien Has disease contracted, 
If not at place of deatfi ? 



Hovv long at 
Place of OeatI) ? 



Days 



I NDl.K lAKl-K LvV\aXC<X V,^^A V-C^_XA^V'CCV\jLV/i 



l)\ri^)! Mi HiAi (.1 KI'iMOVAI, 



'A.i.Ilr 



N. R.- 



^■i- il—i 



-F.vepy item of informHtion should b.- cnret'ully supplied. AdK should be stated fiXACTLY. PHYSICIANS Hhould 
state CAUSr: or DTATM in plain terms, that it may be pr<»perly classified. The "Special Information" for par- 
sons dyin^ awny from home should be J^iven in every instance. 




J 



I'M 

J I 



m 



1^ 



i 



!! 

: 



4* 

m 



• pi 






I 



f ? 



■m^^^ 



VcJ 



1 




i 



i 



< 



M 



■w 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



*\>''*^%f 



!!,.an! of ll< ;t!lli l" Vo. i '^ '^'t'^^jr^ "'"^ '" ^ 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



mmmmmmmmmmmm 






I )((((' Filed , 



oUcrLx^Vw^ 




A 



ii)()\ 



ItcgLslcrcd J\i'o. 



1 0G2 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 

( "a. 5. Stan^ari) ) 
PLACE OF DEATH: — County ofO/Oy-vx' ^Lh.XX/>^,/Ot^x:.cCity of ^'^^>v J /ucx^ x c>Aw<ixt 



o 






1 



'Xa\j 



'No.'XVX dJlXv/VAXvCcT^v \X\>A} St.; 5 Dist.; bet. IS XA\^ and lO 

(ir ttATH OcAuBS AWAY FROM 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 



tl 



FULL NAME 



M ]\<x\^^.A^^ db /Cu'^vfc 



PERSONAL AND STATISTICAL PARTICULARS 



Ctx 



:> \ I i: tu- I'.iK III 



\<", K 



(k. 






lie 



) '•(/; - 



5^ 



3.5 

iDayl 



,1 /.;/,'//> 



(Viar) 



MEDICAL CERTIFICATE OF DEATH 

DATli »>I I)I;ATH 

(I)ny) 



CL 



9.3) 



n,! 



SI NT. I.I', MAKKIi:!) 

\VII)( iWKI) OK I»:\i (l-Ti:!) 

iWiit in ■^uriiil dt sii.' n.it ii >ii ) 



IMK'PHIM.ArK 

fSt.'itt or Cmniti \ » 



iATin:R 



I'.IRTHIM.ACK 
<)I" I AIMIvR 
istatf or (."'nititrv) 



M\ii>i:\ Nwii; 
• >i' m<>|-|ii;k 



lUK rniM,Ai'j-; 

<>l- MM'riN-'.K 

< Slatf or (,"oujitr\ > 



occn-A Tlox 




I'Montlii i'l" 
1 IIliRl'HV Cl.kril'V, That I attLMi.lfd (IcM'c-asLMl from 



(Year) 




190 '\ to vXw<3L n KpH 

tlial I last saw h -^J^' alive on vA-VvXV ^1 H/D H 

atul that iliath ori-tiritMl, on tht- tlatc statt'd ahovo, at O v> 
V M Thi' CAISI' ()!• I)!-:aTI1 wa-^ as follows: 

>LX/CV/vvfc -^^-^dX 



I )r RATION Yrars Months 10 Days //out 

C()NTRii;rT()kV 




Ol> 



t'>r\^>^' 







Vf- ii/rif in S',n,' I'l ttvi i^ri) \ 



A' 



)>,,• 



^ \J.>,>lh< 



I' 



DC RATION )\'ars Months /\ivs //ours 

iNED) M iIolW \, d/Ou^vvJk.t4u M.D. 

l^t r()0^( (Address) 2.(0 S C)/CV>v VxXAXcy^vXv-C 



(SIGI 




SPECIAL INFORMATION only for Hospitals, Instifutions, Transients, 
or Rerent Residents, and persons dying away from liomc. 



liii: AH()\ K sr \i"i:i) i'Kksonai. iv\Ki"irri, aks aki- rKn-: ro tmi': 

lllCST ()!• MY KN()WI,i:i)(",H AND lUvI.IllK 



'Iiifo-niMiit 



X'W' 



yVDoJvfc 1-cxjUkjtX) 




Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



ri.ACK ()!■■ niKIAI, OK KI:M( t\AI, 



DAI^of !?i KiAi, f)i HHMOVAI, 

^0 T90H 



(Address iH^'i \MU.^U<LA.'Xrv\ 3t 



N. B. Cvery item f»** inlfor'niation uhoultl be cnrefully supplied. A(]B Khoiild be stilted HXACTLY. PHYSICIAINS fthould 

Htnte CAUSI: OI' DKA TM in plnin terms, that it mjiy be properly clussiltied. The "Special Information" ?gp pap- 
song dyin^ awny (from homu should be i^iven in every instnnce. 



"-1 



'i 

M 

"If 



(vtl 

.^1 



h 



m 



'I' 



1 1 



1 



ni! 



fi-: 



• 



III; 



|l I 



^1 




I 



l>i{ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H":i!-1 of II. m1I)i I" No. i c, 1v'- ■!? ;i4i lUS: 1' C, 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Uuu^^cx^^^^.^ \h 700^ 

Deputy Health Officer 



Registered J\^o. 



^ £~\ -/'» ^-*. I 

S? f p c s • jr 



nafe tife(t , \x 

DEPARTMENT Of PUBLIC HEALTIKity and County of San Francisco 

Certificate of 2)eatb 

PLACE OF DEATH: — County ofUcu^v. J>v<X/>x/Ouu;cCity of O'O-'W JAX3.-^v<M,.<i.<^<i 
No.a^^'cU-p^vx^Urv IUk^ St.; 5 Dist.;bet. R ll and aoiJv 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

fl);(v) 



Jx/^^'v<xAjl 



DAii-: (II I'.ikiii 



MEDICAL CERTIFICATE OF DEATH 

DAll-; oi" DICATH 



M..nth 






\< .1-; 



lb ;,.... 



5r 



1A /////. 



5.^ 




/',,■ 



^IN<.l,l', M.\UKIi;i) 

uii)(»\vi-;i) OR nivoi-TiM) 

'Writ" ill ^<)ri;il (]( siviialioii) 



I IK riii'i, Ai'i-; 

'St;if< or Coiiiiti vl 



\\\tl. I)!- 

1 A riii.K 



l'.IKT[H'I,A("H 
<>l' lAI'IlIlK 

'^t.iti or i'')uiiiiv 



M\II)i:\ NAMI- 



lUKIIIl'LACI-; 

"I- M()Tmi.;k 

'Stall- i.r Coiuitrx I 



1)1"' ip \l-|n\ 




I HI-;RI-:I{V Ci:RTlI-V, That r attm.lol ,lccvaso<l fro, 
190 1 t.) A^^ im h;oH 



« I I I . IN i , I > 

thai I last saw li ■^J\-' aVwv 011 



II 




MiM that .Icath .H-ninxNl, n,, tin- .late stated above, at S 5 
-^^''O'"" ^'/^^'' ^"' '^'-"^''''^ '''■" ^^ follows: 



-'^-^^-'tYvvt -^-A^diw*. 



cr>v 



A>Kx 



cnx'i-Riur'j'oRv 



/A;// 



/,v 






I) r RAT I ON 



)'i'ai's 



M(>)i//is 



(SIGNED) m<XW Y 0<X.'yJi\Xu M.D. 




.'VvJf-^ 



/'>avs 



//ours 



v-C 



Rf^ulcl i)i Si/ii /'i in/, i-i ,1 \ 



)>.:; 



C 



or RccenI Residents, and persons dyinij ,iwdv from home. 'finsienrs, 



!/../////> 



/',,• 



ifi.M (ii. MS K\()\yi,i;i)c,K AM) i!i:i,ii:i 



'Info'iiiaiit 



I 




Former or 
Usu.il Residence 

When was disease rontrarted, 
If not af plare of death ? 



How long at 
Plate of Death ? 



Days 






I'l.ACl-: OI- lUKlAI, (Ik Ri;M(t\\!, 



fA(i,h-.s 3.4^^ (hx- "^ 



^^ ^^ I90H 



I'AIUi.if Hi lUAl, 01 K »;M(»\ai^ 



N. B. fivcry itc 



Htr/JVusr'of n^XT^^^^^ '"■ ^••"'^•'■""> -PP"-«. AGE «houI.l be Htnte.l HXACTLY. PHYSICIANS 

sons civfni « f I '" ',"'" ''"'""' *''"* '* '""^ ''" pr.M-rly duHsh'iecI. The "Special InV'or„u.llo„- f 

sons dyinft away from home should be 0,]ven in every instflnce. 



fihould 
for pur- 



il 






' »1 

ill 



f 



^r 






Ill 



■f 



M 



f . 



f 



> 




WRITE PLAINLY WITH UNFADING INK — 



Hoard of Ilialtli 1" No. i> *•« ; tsr 2i4 \\Si.\' Co 



n 



1 )((/(' riled , LLu^^^AA^ I?, 




IfJO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Re^isteved JVo, 



\ Of ).3 



Deputy Health Officer 



DEPARTflENT tfF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Bcatb 

( "U. S. StanDar^ ) 
^ ^ J? 



No. 



-y (fl?) J? (^ 

PLACE OF DEATHr-County^ofClo/.^ Jyv^x,:^e,Gty oiOo^ Jx<^v<^v^cc 



X ox <tu (h C^^ WtlcLA > Dist ♦ bet J 

/ IF DEATH OCCURS AvtAY FROM li S U A L R F qW" fU r r " "^^S^** ^ I* ^ and 



I 

FULL NAME U 



Xi^v. 



dc 



vj 





s !■: \ 



DVV]-. Ml- l;ik in 



\<". j; 



PERSONAL AND STATISTICAL PARTICULARS 

i"'»i,<)k 





M.Mlth 



rill 



MEDICAL CERTIFICATE OF DEATH 

DA IK oi- I)i;.\TH 



Ii:. \- 



Vtar) 




I m-RI-HV ClvRTlFV. That I atten.lcl dcccascMl frn„, 
190 to ■ — — 



aa 



\\n»< m HI) Ok i)iv( >kii:i) 

' ^^ ' " ""ial il< siiMiat ii >n) 



MiK rni'i. ACH 

' Slate or (• lint r\- 



i 



I 






tlial r last saw li r alive 011 



r-r:iQO - 
~ 190 — 



■ni'l that .Icath occurre.l, on the <latr ^tate.l ahcvc, at 
~ r^'' 'T7"^"n^ '>'^ATI^vasa. foll.nvs 

■6. 



NAM J- <»! 
lA THlk 



inKTiri'J.ACK 
<»l lATHHK 

'Statr or t'ouiitrv 



''IMIM.V NAM) 

<•! M'>rin-,k 



li'k riiiM.ACi': 

<M- MorilKK 

''^l;itr i.r C.Minti \ 



A\A^'<} 



'AAXiX/ayv JV<r^ 



?! 






ITkA'llON 
CONTkllU'TOkV 



}'c'<7rs M,))iths 






Pars 



Iloins 




I )I RAT ION 



)'('ai-s 



.'^finillis 



Pays 



' " *■' I'Vl'ION 






'jmiL, 

ICML IN FOR I 



Hours 



(SIGNED) LcY^^X/vO.^AL.oUi^,.vv<JL M.D. 



SPE 



v-v-tX 



^ 






)V,n 



^ 1/,.-,,'//- - /;,, 



'InfuMnrml 



I 



yi^KN<.\\l,i.;i)C.H AM) Itl-l.IlvF 



yv. 'I'l » riij- 



When Has disea'.e ronfrarted, 
If not ill plat e of deatli ? 



I'l.ACI': OI' IMkl AI, (»R k l.M()\- \l 

I N i)i-: R r A k 1 : k UCvou^ H- • vfc. \)|UJL' 



l>ATlj..f iii KiAi. ,,i K>:M()\-Ai, 



!N. "— ^;V';''y 'tern on„fon,„„tlon nhoul.! I,. c.rcV'uIly supplied. M\V. s,,„.,|<| , 




«tnK CAUSr or DI.ATH in plain tc 



.e state.l fiXACTLY. PHYSICIANS shoiiM 



-on. .„i„, ,.„„; ;;■ ,„ ■ ::: r:,.;;:";;;.";-;:*,::;:: ;:;r::r" ^'"""''"'- "^"^ ■'*'-'■" '"" -"•• '» 



r p»*r- 



^1 






«i 



t 



1 1 



s 



1 



^!f 



•i 



h 



! I 



[•♦i 



i 



' 



II 



1 j 11^ 



i» 



' . 



^- 



H"^' 



f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!l..:n.I ..f FI. ilili l- v.. I-, f-^^^W^) HSc\' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r I'ihd, \Juu<x>^y^AXj \\ 100^ 




liei^isfei'ed JVo, 



I ncvi 



\A 



Deputy Health Officer 



DEPARTMENT OPPUBLIC HE ALTH-Cify and County of San Francisco 

Certificate of IDeatb 

( H. 5. 5tan^arD ) 

PLACE OF DEATH: — County of C'/(X^\; 0/UX/'>VCAAC€City of C) CUVi/ 0XXL/Y\'C,v^/C<3 



No. 



•'CX^CL-r^ ^JXCV.ti.K' 



St.; 



Dist.; bet. 



and 



/ IF DEATH OCCURS AWAY TROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATION- \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ST RE eI A NO N UMBER ) 



FULL NAME 




<X/vuJUj 




"-i: \ 



i> \ 1 1-: oi- i;ii< rii 



\<'. !■: 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ok 



Q? 




'yVvCtx 



JWL<UyvX/>v 



Jx\r 



MoiiDi 






3 



,V^ 



I go \ 

(Year) 



3 



t 



i;. 



ni;h s 



\x 



\ car) 



/), 



^IN'.I.i:. MARK II- I). 

\\n)t>\v}:i) Ok DivoKn-T) 

U'ritc in «)ri;il .!< -iLMiat i.>n> 



iiiK rui'i. \rK 

(Stiitt.- or Couiiti V 



^^-V' 




MEDICAL CERTIFICATE OF DEATH 

DATK oi- i)i:ath r\ 

LWOL 15 

I ni:Ri:i'.V Ci;RTn-V. That I mUcikUmI .loroasd from 

— — 190 to - i Qo 

that r hist saw h ' — • alive on : — \ ^^^ 

and that (Uatli orciiried. on the date stated above, at 

M. The CAISK ()!• DICATH nas as follows. 




N.v.Mi-: III 
i-Aiii i;r 



IMkTlII'l.Af}- 
'>!• lATIII-.R 

'St;it< 01 Ciinti v1 



MAlI)i:\ NAM}- 

oi- MoTin-;k 



I'-IK I'HlM.An-- 
OI" MOTH I -.R 

'Stair I.I- <.-oiint!\ I 




C' vu< cL-. ^ -.j 



X 'VA.cr^^' 



«• 



M 



IMRATION Years Mouths 

CONTKIIirTORV 



>"*-0-^-\Ji V'OL<a^ c . . Lv<r>>-^, 




A-XXv^v Jt>vtjl>wvva 



Pay 



'S 



J lours 



DC RATION 



)'(ars 



.^fi^uths 



(SIGNED) WumJiX; J.lc.Uj.XliLou 



Pars 



n rqoH 



Ad.lle^s) \js\.- 



Flours 
M.D. 



^\JJA^ 






"' cri'A riuN 



-<Jl^ 






V.'.v//,.. 



/',;i . 



or Recent Residents, and persons dyintj away from home. 
Former or ^ Py^ J How long at 



"'nrJTy.l^';^ •'"'■'* I'KK^ONM. I'ARTUTI.ARS ARl- TRIK T. . TIIK 

H h ^ r 1- M N K \ ( ) \v\ 1 ■: I X ; }•: A N ! ) in-: 1. 1 h k 



p^" ' '^ ^' '*» i, 1-. IM .1-, .\ N 1) JUM.IJ 



I'sual Residence 

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



-A^ ""« ionq at 
.Ou(Mr>v or Place of Death ? 



Days 



190H 






(\<\A 



io»;,s 



5-61 




tPOAJLh^ 



3t 



f Ad(hcss ^ H XH O <rCcLil/W " 



V^ 



-'V^.., 



^' "* TtaYe^'c i'l^virUr nTr^M" "''?'*' ''" --«''«f"">' supplied. AGK should be stntccf RXACTLY. PHYSICIANS should 
!o^^l • . 01 DEATH 1,1 ph.m terms, thnt it may he properly claHsified. The "Special InformHtion" for per- 
sons tlyinft «wny from home should be ftlven in every iiistnnce. 




!l 



it 



i vl 









i I 






f.^ 






<^i 



■-^-^ f 



-■% « * 












■y !V -'i^:i!>^' 



r, 



I . 




#; 



li 



lal 



^-«ji 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



)!m;,1.1 ..f lh:illll I- V<>. I^ *'-'_'5;^'i- I!S:l' ('.. 



Xtn^cv^i dOL^xhu Deputy Health Officer 



JivgLstcred J\^o, 



1 065 



DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( tl. S. StaiiDnrO ) 



QK) 



PLACE OF DEATH: — County of 0/<X-y^ 0/)^O^%OL^ecCity ofO/CLA^ AXV^-VCaAXI^ 




No, 11013, X'xdvt^vt St.; ^5. Dist.;bet.C)ae>vayYvvt>xto and VAXXU. 

/ IF DEATH (|)CCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER ■'SPECIAL I N FO R M ATI O N • ' \ -1 

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




FULL NAME ^^JU. 




o-ooo 



^AA. 




'i:\ 



1 ' \ I 1-, < .1- !;1K 111 



Af.K 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




^yUjUUr^^ 




H 

(I):iy 



i •: i 



MEDICAL CERTIFICATE OF DEATH 
DATH ol- DHATH 

' ' It 

(Day) 




Moiitli) 



TQO \ 

(Year) 




an 



) - 



H 



M.'iilh \ 



\ t ail 



/',; 



-iNi.i.j". MAkun-.i). 

\VII)t»\VKI) OK I)!\-()k( I- •) 

' \V: it- ill - • ■. --i^Ml;il;..ii) 



lilKTHlM.ArK 
(State or Conntrv! 






O^A^a/Lo 



I [ll':Ri-;nV Ci:kTIFV, That I atU-n.kMl deceased fn.m 

~ '9° tn TOO 



tliat I last saw h alive on 



and that death occurred, on tlie dale state<l ahove, at - 
■" j^' M. The CAISI-: OF DI'ATII was as follows: 




1 \ rm-:K 



r-ikTinM,\«K 

"I" I AlUHK 

(Stat( or Ciiunlrvt 



oi- M«)j-in;K 



<>^■ MoTm-.K 



I'Voa^O^ 



djLX. 



.\^A^.<rwQ 



nr RATION Years 

CONTRHd'TORV 



Mouths 



Pays 



II am 






MJlXj 



DIRATION 



'W 



)\ars 



Monl/is 



(SIG 



NED ) JAJxIx>vaxJi 0. Cou- 



Days 



, 




Rrsi, 



s!ifr,f ni S,i)i /'i (! II, f^.'it ^\ 



-VOj 



\ lie i()oM (Ad.lre-><) icO^ C 

Special Information only for Hospitals, institutions, Transients, 



lAC^^/q, lie i,)oM (Addre^<) (cO^ 3-'«-vttjl'X) Cjt 



or Recent Residents, and persons dvjng away from home. 



r. 



1 A /•'//. 



/',/! - 



Tin: AHovi-. sTA ri;]) pkr^on-ai, p xKTicri. \k>-. aki' vkvk 'j-o rin; 

l.J-.sr (>]■• MV KN-<)\Vl,i:i)C,H AM) lil'Ml.l' 



Former or 
Usual Residence 

When was disease rontracted, 
If not af place of death ? 



How long at 
Place of Death ? 



Days 



fiiif 



o; iii:i!i 



\<l.Irr>;^ 



I'LACl-: t)l* lURIAI, OR ri:m(.\-ai. 



DATKuf" IM HiAl. or KKMOVAI, 



(Ad 









t 



-5 



■ ^' fivery item o»i iriformjition shoultl bs cnrefuily supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSr OF DEATH in plain terms, that it may be properly classified. The "Special InforniHtion" V'or pur- 
sons dyinft away from home should be 6'ven in every instance. 



^'^ 







' ''J 










I 



■Is 1 



ii 



!,» 






ll 



ti 









m 



i 



1 1 



' c 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!l.,:ir.l nf IlinUli I'" No. i >; <?"r=r; •»;-*■; |u«tl' Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



JiegLs/e/rd A^o, 



lono 



d^jyu^^^ji doL/v-u Deputy Heafth Officer 

DEPARTMENT OF PUBLIC llEALTH=Cify and County of San Francisco 



Certificate of Seatb 



X\. S. StnuDarD ) 



-? ^ 



^ Qm 



PLACE OF DEATH: — County ofOcLA^^ J Axv>a^^:.^^<1/Cc City ofOcLA^ oAxx. 



a 




>VC^V<t''C^O 



X^-XJ 



No. 10 II MfU-vA.Ax<x. St.; .^ Dist.;bet. I 1 X^^ and li 

r IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS 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 



-^lA 



IiAll-: ol- I'.IKIII 



\«'. !•; 



PERSONAL AND STATISTICAL PARTICULARS 

I Coi.ok 




a, 



iM.itith) A 



);■„> 



(I):iv) 



M.nilh' 




\^y\ 




cLu/^v-' 




\\,K 



(Vrar) 



I hi 



MEDICAL CERTIFICATE OF DEATH 

DATK <)I- DliATH 

,1 

(I)av) 



CL 



(Moiitli) A 



T9o\ 

(Year) 



\VFI)n\VI-:i) OK ni\<»Rii.;i) 

\\iit> ill social (l<si>.Miali(>ii ) 



IllKTHl'I. \ri-: 
^t.i'i 1,1 I'oimti V 



NAM!' (»|' 
••Allll.k 



lUk IMI'l. \< 1- 

*»i- iAini:K 

'State (.1 Ciiuntl V 



"^1 Mlii;\ N AMI- 

Ml M()rin.;u 



lukriiiM.An': 
()i- M()Tni.;k 

(State or Count! V 




T90 



1 IIf:KI<;i5V CivRTIFV, That I Mllcii<k'd deceased from 
'^^'-^-^ l^ up'i to Clvupi ll TC)oH 

tliat I last saw h ■ ' alive on 

;i!i(l that death occurred, on the dati- stated ahove, at 
'^ >r. The CAISK Oj- 1)!-:aT11 was as follows 

'>II^\TI()N Years A/on //is /)ays 



Hours 



V'^w^-\..*.^:;>.-vw 



)'cars 



MoHt/is 



C.C.^xm'..,. 



/^a vs 



<K"crrAii()x 

AV' ,',//■</ /// S,;ti f'l ,: 11, 



a 



0^'>v<\. 



diratiox 
(Signed ) 

iXwQ il i()oH (Address) 1 6 I U ^xv M Um- LLkc 



Hours 
M.D. 



Special Information only lor Hospitals, institutions, Transients 
or Recent Reslilenfs, dnd persons dyinu awdy froni home. 



}V„'/ < 



1 A ■/////- 



Former or 
Usual Residence 

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



flow long at 

Place of Death? Oays 



"",;.V!V^''"* ^■'"'^■'■i--i> ''nksoNvi, i'\k rhTF, \Rs \\<v. rkii' To 'i-ni- 
lii-.si Ol.- MY KNo\vi,i:i)c,i.: AM) in: 1,1 1'.!' 



' Iiiriiiiiiaiit 



Wny>^ (/b. dLu/-.A^ 



< \.l.ln-.v ( I i 



Q. 




I'l.ACK OI" lUklALOk ki:Mo\AI 
IMJl'.kTAKllk 



^\d<li 



DA li;,i.f Him XI, ,,, ki:Mo\Ai^ 



■ '^' Kvepy item of Informiition shouhl be CiircV'iilly siipplietl. \V,\', should be stiiteil F.VACTLY. PHYSrCIAINS Khoulti 
state CAUSE Of- DEATH in phiin terms, tl.nt it msiy be properly cluHfiiV'ied. The "Speciiil Informntion'' for p«r- 
nons dyini^ nwny from home should be jiiven in every instance. 



t . 



'^^ 



m 



1 1 ri 



t< 



«ip^ 



It" 






I 



/ 



t ■ 



I 



•*■'■ ''■! 



::^i 



\ • 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;,„,i,l ,.f !li :ilHi \ \'< 



^<» ••*«*, 



i- nf^\' c.) 



I) 



((fc Fih'f/, LA.aa.1 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1% 



HJO'i 



ifruvv^. A-e.vvi. Deputy Health Offif^-r 



l{rgi.stcrc<1 J^'o. 



i Of)? 



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



Ccvtificatc of IDcatb 



PLACE OF DEATH: — County of^'cL/^v vl\<x>v c< <i q< City of Cl<X>\' 0A.O^>veA^cc 



N( 



o. 5 VJ)lA/>v<V^.cl' 



(Jil 



St.; 1 Dist.;bet. Oacc^C5\' and VO>\Jl> 

/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E & I V F FACTS C A H F D FOR U 4d F R "SPECIAL INFORMATION \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTFA^ OF STREFT AND N U M B E f| / 



FULL NAME 



IVL 



xxkkju 'h. Va/>\, Mil. 



<X\.\- 



si;\ 



\- 



' \ 1 1 < i| i;i K III 



\ « . V. 



PERSONAL AND STATISTICAL PARTICULARS 



\t-nth> k 






n 



t 



r 



'■ >S i^ >\< >\,^/'w^ 



MEDICAL CERTIFICATE OF DEATH 

i» \ 11-. < II- i>i; \ in /^ 

f Month) ,V (Pay) 

I III.1':I.I:N I I.K'ni-\-. 'IMiat I Mttciiik-.l .Icrrasr.l fi.-iii 

t li.il I l.isf saw li ' ' ali\i' on 



(V.'.-it) 



U)0\ 



i\>.i,i:. M\Kkii:n 



Wi 



[!• ; a -. )i-i 



liiK I iii'i.Arj-: 

'Siiilf or Co'nili V 



lA in i;k 



i'.!Ki"ni'i,\(i-; 
'"' I'xrnr.K 

'>t,i|. 1,1 ('(iiintrvl 



MAIIU-.N NAM}-; 

«»)• Morn I-; K 



iiiki ni'LAr}.; 

<>1' MOTHI'.R 



' ' ir A 1 ION 

Kf'-iilci III Snii I 






I 



Cl'^x, 




ami lliat <1< illi occiincil, nil llir .lalt^fafnl ahovc at U '.^0 
M. llH' <^^\|■Sl•: Ol- |)i;.\TII wa^ as follows: 






Q^ 



AyO. 






CoNTKIiU'iOKV 



Mouths 



> >> s 



/^'/rv v> l-fours 




/t) 






DiR \ri( )\ 



)j'(;/.c Mouths 



(SlG 



NED) ^IH. lb. Lt/tivi 



/hws 



lion 



Is 



t/vM.X\ 



.\^<X >V^«L 



Lltcq n i<pH (A.i.irrss) H(>li.> )Ai.ll>:.s. ' Vi 



,<\ It T<)f 

dllAL IN 



1 



M.D. 



SPEd^AL INFORIVJATION "'I'v (or M(is|ii(,iK. Inslilnlinns, rninsienls, 
or Recent Rcsidrnts, and prrsoiis d\iiii| ,iw,i\ linm homr. 



M..,,il,s 



lK-\' 



fornipr or 
Usiidl Residence 

When was disease ronfrarled, 
If nof at pjai e of death ? 



How lon(| at 
flaie ol Death.' 



Days 



I 11 1 \ HoVl.; s r \|-);i) IM-' kso\ \ I. }• \ R r |t I ! Nf- \!'! ri<' I- To Till' 
lll'.^T Ol- MS KN(t\VM-;i)<,|.: \\l. It, 1,1! I 



InfMMiKiiit 






.^LO<y>r^ 



^- 







I'l, ACI-; ()!■ r.iKiAr, ok r i,\T( >\ \ i, 

i 



II, \l I', I >!■ lil K 



Wv 



IQOS 



! N I » 1 : R T A K i-: R 

^\(!.lt. -s 



I> \ ri: m! Hi i-i \i ,,i R i;M( )\- \[, 



r 






•^* ^- Hvery item o»* inH'oi'nmt inn Hhoiihl be cnret'iilly Riippriecl. AGP; sho-.ild be stntcil l.\ AC TI.Y. PHYSICIANS Rhoiild 

Htiitc CMISr or ni.ATM in |>lnin terms, that It mjiy be properly clnHHili'ietl. The "Speclnl Inltornmtion'" Inr par- 
sons (Ijin^ iivvny I'roin home sliould be 6'^^" '" every instance. 



fi 

I' 

» \ 

I 

» >i 









'r.\ 





» . 



i 



««n|M 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



»>r 



)l,,:iT.l ..f nr;i;t1i !■■ V" '- t-.-ix_^>i: Itftl" (V 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\/)afr F//('f/, LU^qu^vCt \% /^V^^H 



llcgLslcred JS'^o, 



ior>8 



Deputy Health Oflflcf r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




Certificate of Sheath 

( n. S, 5tnn^arc> ) 

S! (^ J? 



(^ 



PLACE OF DEATH: — County ovJfXrr^ J/ucx. \^-ev-(^c(. City of CJ/tX/>v. J /v_<x/N^tv<i,-ac 



No. 5 'vh 



.'iXAw'^vOu'vcC' 



St.; 



\ 



Dist.;bet. Jo^v^Cr\. 



and W^AJl^'5 



(ir Dr«TH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U nA) E R "SPECIAL INFORMATiAn' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAli]oF STREET AND N U M B E W. ) 

/-Of ^ 



) 



FULL NAME LK JLd c [. M WoJx^^Jb^^ V<Xo^ 





si;x 



1» \ . 1. < I! 1; I kill 



\' .1-; 



PERSONAL AND STATISTICAL PARTICULARS 

ft t^oiok 



■^xX'^ 



ll. 



i^^^\^L 



h 



^ 




I — 



MEDICAL CERTIFICATE OF DEATH 

DATl-: ()!• Dl.AlU 



\Xj^\ 



MMiilhl K 









v,,/. l^./nH 



) ^i**.^ . 



: i.i: MAkk n;i) 

WIImWHI) OK I)IV()K>):i) 

^' • ■'■ ill voci.'i' \ -'-n.il I'.ii I 



Iilk IHJM.ACK 
'State or Coimtrv^ 



1 Alllllk 



lUkriii'i.ArK 
'>i- i-\rin-;k 

"lit' 'If C'i.UIltl\- 



MAinMX NAMl- 
<'!• M()THl-;k 



liik riirLAci-: 

OF MoTinCk 

'Stat'- or Tduntrv 



ir Alli IN 




iH 



^MoiUli) ,J ^Day) (War) 

1 III-;RI-:RV CI;RT1I-V, Thai I attcinUd .UvcascMl fn.m 

LLc^o n lonH to . LLlvcl n too 

UwA^^ 1 . up 

and that lUalh orrurrcd, on the (hiU- stated alxiVL- at l^ 
^i M. The C.\rSl<: C)I«' I)i:.\TII was as follows: 



til at I hist saw h -^ '>x alive on 



DIRATK^N ]'cars 

CONTRIIUTORV 



Moulhs /)a\s \X//ours 



/\.0 ^ ■ C<L 



I ) r !>: .\ T I < ) .\ ) V.7 rs JA V////.V /)avs I 'J. Hours 

(SIGNED) \l/\ \ CtcJ'VtM-«>uHAj M.D. 

LL^v^a ri T(,o'i (Adduss) HOb Cj-v»JXt>v> ^:i 



a 



)t 



SPEciAL Information only for Hospifdis, institutions, Transients, 
or ReienI Residents, .ind persons (l)iny away from fiome. 



/ 



in; \v )\'}-: si' \ I) II )'i-- kx )\ \i. i' \kihm- i. \ks ak i-; tr vv. to rii v. 
lii'.sp oi- >i\- K N. iw ij;iM , 1-. \M> i!i:i,ii;i-' 




Former or 
Usual Residence 

When Has disease contracted. 
If not at place of deattj ? 



liow long at 
Place of Deatli ? 



. Days 



ri.ACi; ()!•' lukiAi, ok ki;mo\\i. 



DATi:..'" Hi iMAl, or ki;M(»\-Al, 



) y 



IQOH 



N I ) 1 : k !• A K V. k >V,*JLa^ V>? *^ ^- O'tLc 



CLA.\J 



(Address 3)0 5" VnXfr^-vtcyA.. LIa>jL . 

N. B. livery item olt i n form :it ion should be cnreitiilly .supplied. AGB .should be stated HXACTLY. PHYSICIANS should 

Htntc CAllSf; OP DEATH in pljiin terms, thnt it mj>y lie properly classified. The "Specinl Information" for per- 
sons dyin^ away Prom home should be given in every instance. 



■■\\ 
•I 



^ 
* I 

I -d 



^ 









' d 



» 1 







1 



T 



II 



I 



It 







L, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!. .;il. 



Ilr.iUh I- Vo I- ■? 



f^r^'\- 



USi. V Vn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lir^istered J\^o, 



10G9 



Date Filed. CLa^o^vxiI) \\ 10(n 

^rvc^^ XiLxv^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

f 11. 5. Stan Da rO ) 

of ^ ^ ^ 

PLACE OF DEATH: — County of^/CLA\^ ^UX/T\.c>ui.cc City of vJcl/>v OAXX/yve^^XL^o 



No. 




J? 



f IF DtATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" 



vv.<: CjKX'VcaJUA.c^St^^x.- Dist.;bet 



land 



IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE rTS NAME INSTEAD OF STREET AND NUfMIBER. 



FULL NAME 




) 



PERSONAL AND STATISTICAL PARTICULARS 
•-l-X (^ A j COI.ok 

i'\ n; ( n iwK rn -^ a 







M 



.1 A. >/,'// 



% 



I Ti-iir) 



/',/!> 



MEDICAL CERTIFICATE OF DEATH 

DATH K)\- l)i;.\TH 




(Month) 



a)ay) (Year) 



^i\' i.i; M\ki<n-:i). 
\\ii»< )\vi-:i) OK in\()K('i:n 

' Wi iti in -ix-inl •!» s-'v it;it i'Mi ) 



HIR rill'l. \kM': 
'Stati or i.'i iiintr\' 








ia'ih):r 



lUR rniM,ACK 

' state oi OomitT vt 



MMDI'.N NAMl- 
OI MoTlHiK 



I'.IKIHl'I. Acr: 

OI' M«trin-;R 

fStat'- oi Cuiintrvl 



oiATl'A'i'n )N 




I HI'RiaJV CIvRTlFV, That I attcii.lcl .Icccased from 

Laaa^o 190 1 " to LU-<v/Q^.n up \ 

tliat I last saw li -^^^ alive on LXa.a.x^ '"1 i^o M 



aii.l that (Katli occurred, on the date stated a])ove, at I 3..0 
V M. The CAlSiv ()!■ l)i:.\TH was as follows: 



^ 



'S\ 






XA 



'^'^WLry>,AJ\A>^iA.AryK 



0^'W<i. 



Rfsidrd in Sav i'lan. i '■,> \o ! - .m v 



DIRAI'lON ]'i'ars Moujh!; Pays //ours 

CONTkllU'TORV 9.<^>-oJLc 

at ()ox<x^t 

DIRA'I'IOX )\'ars .}roNt/i.s Pays Hours 

(Signed ) vjX^)\jI/^^./qx Ml. \X'<x>v^ MD 

J? ■ ' 




\\ rqoH (Ad.lrc-^s) toOb QJA^fctx\. 6t) 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyiny away from home. 



Former or ^-, 
I'sual Residence ->0b 




M,.>,th< 



na\:- 



'\'\\v. \U()\-i.: s'l" \ri'. I) i'i<:ks( »\.\i. r \rii rr lars a r i'. I'Kri-; r( » rii v. 

nKST OI- MV KNo\\I,i:i)C, H AM) I'.l , 1, 1 1! 1- 

'i'>ro;,„,u,t VlfUvo 0. vi\ Qi\jUx^<:^a.-y.,. 



Uddnss 3>C) b 



0^^<X..\^\J\JlXj 



jLl. How long at 

CTL Place ol Death? I 'Y^ -ftjys 

; disease contracted, 'I i 

place of death ? \XJy\M/w^b^^''y>o 



ri,AC};oi' lURiAi, OR ri-;mo\ai. 



(jIdCtIu Vv'fe-^^ 



rNDl'KlAKKK 



I)\'n-;o!' I'.nuAi. or Ki:.Mo\AI, 






(Address 



Tt~i M)Vva^v(„tr-i-o ai 






^- '*• Kvery ittm olt information should bj .iircfully supplied. Ad'B should be stated F'.XAC TLY. PHYSICIAINS should 

state CAUSE OF DliATH in plain terms, that it mny l>e properly clussiltMed. The "Special Information" for per- 
sons dyin^ away from home should be 4iven in every instance. 



i 



I • 



i:^ 







I,.; 



■s 



h\ A 



Id 



I 



(1 






f 



t ! 



fl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!:- .:!! 



1 ,,f Ilc.ilth 1" No. It. 



•t^'-ar^; iiS:!' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed , 

i 




\% 



IfJO'i 



BegLsfet'od Xo, 



^ OTO 



Deputy Health OffT-f^r 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( 11. 5. Stnn^ar^ ) 
PLACE OF DEATH: — County ofOCL^O; vLn^/O/TV/e^ULCCCity ofO.<X/vu AxX/W'Ouiyeo 



Ox/xti' 



No. 5 0b Ox/xUt^' St.; H Dist.; bet. MU ^J^vOla^ and VyUKXXAWUXm.' ) 

(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U rA> E R "SPECIAL I N FO R M ATI O N ■ • N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAbJ OF STREET AND NUMBER. / 

FULL NAME U^JL^cl^- Wvv^^JuxaaXkx; 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 




UcJlx 



i"< »i,i)k 



kllxjt. 



i 






^ 



• 'I lilKTIl 



\JJ^K 



Moiithi h 



lb 



\'.i-: 



t V< .11 » 





M \K \< ii: i> 

\\ ID! )\\ 1,1) (»U lil\( (R'KI) 
iWiitfiii '■iM-i.il (It -i^MiMlioii ) 



Ml Ml ■ \ 



NAMI- (H 
!• ATII J- R 



I!IKIII1M,.\>1-; 

<)i' i-\tiii:k 

"^!:it'- .11- roimtivl 



<»i M(»thi:k 



liiu riii'i.An.: 

(Stiiti' or i'(»iiiili \ I 








" - 1 I'A rioN 



J? ^ (J 

\ \\ 



MEDICAL CERTIFICATE OF DEATH 

DATi-: oi- i)i;ath r\ 

(Muiitli) K (Day) (Yt-ar) 

I 1II;RI;I{V CI;RTII-V, Tli;it I altended deceased from 

^ (1 

lli;it I last saw li l .. alive dm LA.Aa,<V 15^ 

and thai dealli occurred, on the <late stated above, at V.' 

M. The CAISI'; OI- DIIATIF was as folic nvs : 



Tcpi 



DIRA'IION 



)'fV7/-.V 



Mouths 



/hivs 



Jlon 



rs 



(ONTRIin'TOkV 



1)1" RATION 

^Signed ) 



)\-(fr.<; 



JA '////' s- 



d . Uj . cy^KLoJLxj 



I^ays 



/fours 



M.D. 



iXcCQ IS rpo'l ( A dd r. 'ss ) '^O'S UjAvcv/O^vxt ;.Vi 
SPECIAL INFORMATION "nH l')r Hospifdis, rnsfitutions, Irdnsienls, 



or Retrnl Residents, and persons dyinrj dway from home. 



rJIl' AUOVK STAI'l" I) I'I'KSox \l, I'\K 1*1(11. \k-> \K 1 
HK.ST <il" MY K\< »\\ !,I l)i,i; \M) HI';!,:) 



K II-: To vwv. 



' Inf.,: iiiMiil 



' Vl.lrc.v. 5" b ^ Cs XJi\> ot 



former or 
UsudI Residence 

When was disease rontrd( ted, 
II not at plare of death ? 



How jonq at 
PIrii e of Oeatli ? 



Days 



I'LACi: <»!• HIRIAI, ok RI'.MkNM, 



DAIVK'-: i;- II \i ,,i k ):.M< »\-..\i. 






I90H 



^'. B. Hvery item oil* Jnformj.tJon should »>e csirefully Kuppliecl. ACIK should be stated LX4CTLY. PHYSICIANS Hhoiild 

state CAllSr or DI;ATH \n pljiin teritiH, thnt it muy be properly clusMified. The *'Specittl Inforniution" for p«r- 
R^n* d>m(> fiwny from home should be iltiven in every inHtnnce. 



4 



'*.i 



P' 



' J 



■I; 



' i! 




I!' 



»ymm 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



P 



'f 



i 



);. .;l!' 



,f II. :illll - 1' V( 



f^m ''''•'"'^. 



■art.y^i- ]>f;^i> c<> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)a/r riJrd, [Xa^<yj<J^ \\ 290\ 



Jfrd/.sfrred A^o. 



1 0? 1 





u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate af 2)catb 

( XX. S. StanC>arC> ) 
PLACE OF DEATH: — County of U /CUcn^x^-v^OcJ^^AXi) City of ^ <XAi/\^<:x./-yy^JUy-dio 




No. LCrVAy>\Lu, (J^>Ci-<U^xLcu. 



^ 1 



St.; 



Dist.; bet. 



and 



/ IF OrATH OCCURS AW*Y 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 



si:\ 





PERSONAL AND STATISTICAL PARTICULARS 

i> \ii-; < ii I'.iK I'll 




X.'^OxJL 




MEDICAL CERTIFICATE OF DEATH 

DA ri-: ()!• Dl'.ATH 



Month) A 



C 

V.) 



I I 



I go 

(Year) 



NUknthi 



XX 



1 



<I»:iv 



Mn'llfl^ 



;n ) 



n,!\^ 



^i"-«.i,r M\ki<ii;i) 

u iix »\\ HI) i>K i»i\'<>Kri:n 

' Wt iff ill wi„ i-,1 ,1, ^!;Mi;iti<iIl) 



I!IR lllll. \r\-\ 
(St.M' • ' ■iiinli V 




Ia^vaAj^ 



nKiiii'i, \c}-; X 

>i- M<»Tm-:K I) 



'Moiittil A (Day* 

1 III'RI-r.V CI:RTII«'V, That I atU-ii.lr.l (ItTLascd from 

to 



1 90 



lliat I last saw Ii ^"^ alive on 



T()0 

190 



and that deatli oi^-urred, 011 the date stated ahove, at "" 
•"- M. The CAlSlv ()!• Dl-iATIl was as follows: 



•I if 



V <X/yvdL 



NAMl-: ()! 

i"A riii:K 



I'.IK rill'l, At M 
<>1' lATin'K 

•^t.iti- nr <'(iiinti V ' 



MAIDl.N NAM! 
f>I- Morniik 



1)1 RATION )<ars 

CONTRIIU'TORV 



A.-A^>VX 



Moil //is 



F^ays 



/louts 



DIRATIOX 



)\i1)-S 



Moiilhs 



Days 





^K >\^0. 



' ii'AriMN S) 




h'/'idfif ill Siiii /'i iiin I 'f'o OS c\ )'rii i ^ 



dL 



M., lllll' 



(Signed) mttl/yx; ck. UOJ^ujtt 

n I 5 fo'T 

LLv.V/Q lb T(,o H (Address) (j/O.OvXX/^'vJywto \_,ckX) 



Hours 
M.D. 






SPECtJAL INFORMATION only lor Hospitals, Instilutions, Transients, 
or Recent Residents, and persons dying .iway from fiome. 



rill \i!o\i: s r \ ii- 1. pi- kson - -, r •, k ricn. \ks ari, ri< r i'. i' » 111 1 

lil-.sToI MV KNdW I.I.DCK AM) l!KMi:i- 



niif.i; ni-iiit 



V KNdW I.I.DCK AM) IIKMi:!- 

\.Mnss \ \\ \Jx>V/Qu\XX^ VA\>-L 



Former or 
I'sual Residence 

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



Hdvv long at 
Place of Death ? 



. Days 



HI-' lAi. Ok k i:m( i\a I, 



i»Air,..; Ill KiAi. (,i i<r:M()\Ai, 



190H 



I M 



) I •: K T A K i- kM I I <xxiAx/vo \| iV mViLaviu ^ 0\Jli/>\' 



i^' I*. livery item <>V* inVormiit ion Hhotild bj cJire»iiM.v siippliecl. A'JH kJv)iiI(I be ntnted HXACTLY. PHYSICIANS Hhoiild 

state CAUSI: OP DIIATH in pljiin terms, that it miiy be prf>pcrly classified. The "Special Information" for per- 
sons dyin^ away from home should be ftiven in every inHtnnce. 



t 

A' 1 






I 



m 






^^, 



»''i 



«i(i 



II 




J 



f 



I 



- - Id I m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



r.oanlof Hfiilth I-' No. i> 



,t?!^J!*v 



i; nfkV (' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc I'^iJcd, LL<wA^Q,>uv.<£t 1*^ 



(X./()-AwA.-A^O 




l!)0\ 
Deputy Health Officer 



Beg i tit c red J\''o. 



< ^72 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 






4 % 



PLACE OF DEATH: — County ofOo^/Vu ^Oy^vo^Ci; City of O-CLArv OA.<X/^x^v.^i/c 
ISk>, VwCtu,^L(rV^^Ajjj ^b CK^vCto..!' St.; Dist.;bet. and — — 

I /if death 0CCU*S away FROJM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
\1 V If DEATH OCQURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



o 



FULL NAME 




X/' 




o<yyT\j 




]XXAJ\Jj 



1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

, Col.oK 



(W 





i) \ ri". <)i' iMKrii 



A <■.!•; 






' MMiith) 



IdO 



) 



I I);i\- 



!/.,»////. 



/\,\ 



^I\«", i,i: M\KI<Ii:i) 

IfsifiKit ii III ) 



lUKTmM.AiM: 

'Sl.'itf or Count I \ 



NAMl' til 
lAllll.K 



HIk THIM, At)-; 

<n- lAini'.K 

f Stiilf or l"ounti V 



M \l!>i:\ N AMI-: 

"; M'trin; K 



lUKTHPI.ACl-: 

<»!■ ^:l>'l•Ill■•,k 

(St: < .niiitr\i 




(Voar) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH | 

(Mouth) A (Day) 

1 HI:RI-:15V CI'.RTIFY, Thai I :itten(lc<l (IcHvased from 

Vl (Uxu l\ 190"^ to LA^aXL i1 I90 H 

that 1 last saw h Ay > > \ ahvc oti vA^vvC^ I ' ^ j^o ' i 

and that lUatli oicurrcd, on the (hitt.- statt-d ahovc, at Ci ■ I 
Uj M. Tlu' CArSij;^()I' DI-ATII was as follows 

^^^-A,V^.A„/C;A^O0t>-^sl.<^w>0. 




1)1 RATION )'('ars 

CONTRIIU'TORV 



Moulin 



Days 



1)1 RATION 



Years 



(SIG 



LL\xAi\jLLv% 



Mouths 



Days 



LIa^Q ri i„nM (Xd.lr.'^O '^vtu/^ VJ). feo^ 



:iAL 




Hours 

Hours 
M.D. 



^ 



OCCl TAIION ^ . 1, 



^ / 



I' HI'. Miovi-: sTA'n-'.n im-'k^^onai, p akiuti.ar"-^ ari". IK I1-: !■•> Ill i: 

l!i:sr Ol' MV KN't)\\Ij;nC. H and jniMlO- 



Oufo-jnant VwaJ rwv.' . \/ /a 






Special Information only for Hl^pitals, Insmutions, Transients, 
or Recent Residents, and persons dyinij dwd> froui home. 

? 



Former or 
Usual Residence 

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



HoM long at 
Place of Death? 



? "M 



Days 



I'LACl*. <»l" IM'KIALck KIMm\ \I, I ItAI'i;.!; lUmAi, oi Ri;M(»\\i 

INDllRTAKKR ^^TL^CtX^ lLA^cLJt^X<xJkxV 
(Address ob^ Vj lXAw/iLA.\.^Cr>V. O .t' 



N. B. F.very Item of informntion should b. cirefiilly supplletl. A(iB should be stnted RX4CTLY. PHYSICIArSS should 

«tnte cause: OP DIZATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
«on8 dyin^ away from home shouM be Jii>en in every instnnce. 



\-V: 



I i 









A I 

' «i 



I'f'l 

i 






i: 




' i 



'-^m 









J 



Hi 



I 



■M 






WRITE PLAINLY WITH UNFADING INK 



***'*'"»» 



.1" llinU 



h 1" N'" :■■ ■?'-^, .'».■-:-» li'^l' * 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)((/r Fi/r(/, CL.v.<Y./^t \% I'^OH 



Ko^istcred J\^o, 



1 07.3 




^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of IDcath 

( 11. 5. Stnnc>ar^ ) 
•^ Oil) ^ -Y ^Uli 

PLACE OF DEATH; — County ofOoi/Vu AXu^X^^ULCCCity of Ool/Vu J AXXy^VC^ULC^ 



-9 ^ 



No. 




I 



<X\^< Vi<X 



AA-Cr>\^ (jbchAl/K^-t'oX St.; 



Dist.; bet. 



and 



/TiF DEATH OCCURS AWAY FRoWl USUAL B E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
\\\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




^!.\ 



PF.RSONAL AND STATISTICAL PARTICULARS 




" \i\Li^ 



I • '1 IMK 111 



vA,/"v>^r 



■ Month' iDavi 



\<.K 



b 



)■- 



1/..I/'//- 



t \ i;ir 



/^<M, 



•^INi.l.l-" MAKKIl-.n 

wMx i\\i:i» I >K Divi tKri-:n 



I'.lKTHI'I.VOl' 

' Stilt'- or I "< ■lint ! \ 



N \M1- ( 11 

i-.\tiii;k 



lUUTHIM.AfK 
(H I xrnHK 
< St;itf or Coiinti \' 



M\!I)I:N' NAM1-: 
-'' MoTlIl-.K 



Hiu rniM.Aci". 

(Slittf oi v"oiint t \) 



J ^ ft 





.\,m£L 



c\; 



190 'i 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATi-: oi" i)i;atii ,^ 

iMoiitlO 1 (Day) 

- 

1 Ili;Ri;nV CI;RTIFV, That I attended deceased from 

i^JO 10 icjoM to LU./c<1_. 11 T90H 

tlia't I last saw h rV\j alive on LAa.^vo • \ icp 'l 

and that death occurred, on the date stated above, at \ 
Ob M. The CVrSl- OI'" Dl'.XTIl was as follows: 
,.O^JU-O\/^l>oJ<L-0-<k^*^^ Crir o^-Vwr-vr^X 




>^ 



I ) r R A T 1 N ) 'I'ars C> .}/o)il/is /hi ys 

CONTRIIU'TORV dJ ^^■OJf\.KA\^■■^<:^.J 



J/OIDS 





J? ^y J 



O^A^ AXX^'V ^lyLA.'CC 



' ' I I'ATinx 



1 , 



\r,nitll^ 



/>.;^ 



I'm-: Alio VI-: st xd-: i> i-kk-onai, pxk rnri.ARs aki-: rKti". k • i' 

H1-:ST OI' MY KNoWI,i:i)(",l«; AM) Ml-J.Il'.K 



Infi-ni.itit 



vJ^yO^vCU) ^ 



(A«l.lu- 



CtX) ^ A-^-^A.^'v 



..aJl 




H— -4 




I lours 
M.D. 



I) r R .\ T I ( ) X ) '< '<? r^v \ Moil t/is /Mys 

rsiGNED) ^^. Js ()ocru>cuv^ 

lX<.A^ ("L looS (Address) 3Hl ^,0^^1jI^' 5)1 

SPEciiAL Information only tor Hospitals, Institutions, Trdnsients, 
or Rerenf Residents, and persons dying away from tiome. 



Former or k 

Usual Residence 

Wlien was disease contracted. 
If not at place of deatfi ? 



flow lonq at 
Place of Deatfi ? 



Days 



I'l.Aci-: OI- r.iRiAi, OK ki-:mo\ai. 



I)\rK.)t iiiKiAi. or R1-;M()\A1, 




\Xj<J^yO, \^\ 






i9o'\ 



N. 



R._nvery item of Information «houUI b. cnret'ully supplied. AGF. should he stated CXACTLY PHYSICIANS should 
Htntc CAIISF: OP DIIATH in plain terms, that it may he properly classified. The Special Inlormat.on kor per- 
son* dyinfi away from home should be g,\yen in every instance. 



' li 




* 



i 









1: 



if: 



11^ 



* ' ■ 



i'SB^P' 



I 



f 



(, 



•i'f 






i 




^ iliii 



WR 



ITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



illh )■■ N". I 



•'"Z^ . 



." '"• ''3f'. 



Wis. 1' <• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



li)()'[ 



IlciHislriuul J\^(). 



1074 



hale hllcd y LL^-a^qa^^a^Ij" \\ 

■Wc^o cL^u^ DeDutv Health Offi,.^. 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate ot 5)eatb 

( XI. 5. t5tnnc>arC> ) 

J? (to A ^ 

PLACE OF DEATH: — County ofCjCt/Yu 'J.\.<X/^a.,C^<i cc City of OcUYo OAXV>vcuiyC^ 




i 



XX-'>'v<xl,c\.c«>-c'A>v' St.; 



Dist.; bet. 



and 



H /OCCURS AWAY FROM USUAL R E S I D E N C E & I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION • \ 
"^ I INSTEAD OF STREET AND NUMBER. / 



OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME 



FULL NAME 



• l.\ 



PERSONAL AND STATISTICAL PARTICULARS 



t) 



I 



Kt^<Lt.4vAv' 




hJLAX 




>i i; I Kill 



Month* 



Ai .]•", 



) r„ 



I l):i\- 



M.nilh' 



S 



'»■« :il I 



n ! 



s|\(,l.l-. M.\RUIi:i> 

\\ ii)<>\vi:i) OK ii!\( >Rt" i:i) 

•Wiit. ;n -ori.-il dcxi^'iiat i< >n ) 



lA^ ^ V 



HIKTHPI.XOK 



\ \MI- (»l- 

I A III i:k 



MIR rniM, \ri-; 
oi- lAiin-.K 

' Slate <ii Cntinli \ 



MAIDI'.N N \Mi: 
"1 MoTlll'.K 



iMK rni'i.At'K 

"1 NtoTIIKR 
' Stale (M r<i\ititi \ 










MEDICAL CERTIFICATE OF DEATH 

DA Tl-; «>!• Dl.ATlI /O 

(Mniilh' /T iDav^ (Year) 

I III'IR I'.I'.N' CIvRTll'N', Thill I atti-inU.l dci ».;tsc»l Inmi 
W^VCL \'i Iqo'1 to vXv./U3l. 1% IqoH 

^ ■ Q ^ ,^ 'i 

tlint I last saw h '• '■ alivcon VA-Va^ It k^ \ 

and that (kalh oct-iirrcil, on the date stated aliovi-, at ^5 
^ M. '\'\\v CArSI-; Ol' DI'.A'ril was as follows: 



I )r RAT ION 



)'t'ars 



M,>n//is 



Days 



CONTRl 151 TORY \J AjL^^^^v./CX.C\,^.A^ Vi)j.A-VAl.rvj 



//our 



nrRATION 



h 



)'iars 



J -^CU ■j'V'CJL 



< H'Cri'A'IKiN 

h'r- :,lr! ill V,.-;/ /'/ ,,'/,', 



)V,.M 



- \[,,iti,< s 



l>.:\ 



I" HI", AUo\•I^ Sr \l"i: I) I" KK SON A I. 1' A KTir I" I, \ K > A K I ' TRI 1" 'l'< » Til l'. 
H1-;ST ()1 -^IV KNOW l,i:i)(,K AND IJllUIIil' 



\.Mr.-^>^ 1 10, 



VI Kxx-OLxm 



(?1 



<Xti,j£-' 




^f,}lli/!: 



Par 



//ours 



(SIGNED) "^Su^ (]lj. NIVwaJUL^ M.p. 

CL^O i'^ T<,nH (Addn-ss) l^O' H (Po CKA^OA^O.t 



cA,^C\, lb T<)OA (Addn-ss) 

PEcmL Information »ni) 



Special information »nly lor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinj away from home. 



Former or ,( 

Usual Residence l ^^ 



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



CVV \ (T)(] Howlonqat 

.\J I UtxXXM VJ^ta <l.fL Place of Death ? 



Days 



i)\Ti:«i! HiioAi, <)i ri;m()Vai, 
11^ VO^ IH 190H 



rL\ri': or imriai. ok kisMoxa:, 

I ni.i:rtaki:r >-^- CK^LjUx^^^ 



N. B.— Every item of information should ho cn.cfu..y supplied. AGF. should he stnted J.X ACTLY . ^"/J^j;:;^'^,:!^^;;;;';* 
state C AllSr OP DLATH in ph.ln terms, thnt it may he properly class.^.ed. The Special Informat.on for per- 
son* dyini iiwny from home should he jiiven in every instance. 



> • I 

-f " 



t .'•1 
^1 



n 




\'\ 



>.JI 



1; 



% 



\ 



JL,>^. 



Iff 



u 



\U>i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.,.,..,,i..lil. , No uiJ^^H&l'Co RCPER TO BACK OP CEWTIPICATC FOR INSTRUCTIONS 



l)<(le Filed, 




vx^ in 100\ 



Begistered J^o. 



1075 



, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( "U. S. Stan^ar^ ) 



(^ 



PLACE OF DEATH: — County ofC'<x-iv O^Co~.xcv«ict City of C',CL/>v OAxx^/wcva^c^ 



r?».' 



u C^V»y>axLLc^xQ Us-^-^^CVA-vv.Sfc; ------ Dist.; bet. =^ and 

t ir DOTH OCCUKS .*«» f»OM bsUAL RESIDENCE OIVC r.CTS CALltD fO« UNOEO -SPtCI*!. 1 N »OI< M.TION " ^ 
(. ir Dt.TM OCCU.^" '» • "^•"'«'- O" mSTlTOTlON GIVE IT» NAME 1I..TE.0 OF STREET .1.D NUMBEH. J 



FULL NAME 



■) 




::>.\/ 



^'••" 'W 



"J 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



DATK Ol" IMK TH 



A • . H 




y\xut^O 




M< iith> 



(Day) 



I ■/•</; 



sIN(,!,K, MARK IK I). 
WIDnWKI) OR IHVOKiKl) 
iWritiin scxMal (UsivMiatiou) 




niRTHl'LAOK 

'Statr or Conntrv) 



NAMl". <)l- 
I-ATIIF.R 



HIRTHI'UACK 
OK J-ATHKR 
(State or Country* 



MAIDKN NAMK 
«)1- MOTHKR 



HlRTIiri^ACK 
<)J- MOTHKR 
(State or Country 



OCCUPATION 



^ 



/^/>r^ 



M.iHlhs 



1^, 



■■^ -- ' i 



( Vt-ar) 



Pa \s 



C'/(X >v Axx^o^Ok.>^eo 



MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH 



(Month) 



(Day) 



IpO : 
(Year) 



I I]!':kI<:BY ClvRTIFY, That I attended deceased from 

Au.. \'\ 190'i to LwoL i.i 190 H 

tli^it I last saw h "SA; alive on lX^.<^-a. I "I 190 M 

and that death occurred, on the date stated above, at 5 
V M^ The CATSIi OF DIvATH was as follows 



^ ..^ ^ 'A I'lv.Aii 



V/O 



DURATION }'ears 

CONTRIBUTORY 



Mouths 



Da vs 



Hours 



wJAj^-K^^sx^j^yxj 



)'i\ii f 



M,»if/i^ 



/>,n. 



imj: aiu)vkstati:i) phrsonai, kartutlars ark; trkk to thh 
ijkst ok mv knowkkix.k and hkmkk 

(Infonufint \l iV . Q \J y\oav>^iJU..O^U(j 

Ov^OC) JxJul^X'trNJl.at 



(\<l«lress 



DURATION 



) 'cars 



Af()f///is /^ays 

<xXJj. 

A.\.q,. lb. iQo'-. (Addre ss) ^^ ^ ^ ..^jJJuy\\A!\Jlj.\}i. 



(SIGNED) 

a 





Hours 
M.D. 



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



Former or 
Usual Residence 

rthen was disease contracted, 
If not at place of deatli? 



How long at 

Place of Death? Days 



I'i,ACK OK BIRIAI, OR RKMOVAI. 

UNDKRTAKKK J^JlXJLu ^*^ (JV) <XOy-a^^ 

:ss 'hS!>^.'X- I'^iJv \ 



DATK of HiKiAi. or REMOVAI, 



IQOH 



(Address 



of Information .hould be .^rofully .upplicd. AGB should be Btated EXACTLY PHYSICIANS •hould 
E OF DEATH In plain term., that it may be properly cla-ificd. The 'Speci.! Information" far rt- 



N. B.— Every item 
state CAU8 
«on« dying away from home should be given in every instance. 



%\ 



I. .> 



1* 

'I- 



y\ 



A 



■1 1! 

( fl. ■■ 




1..' 



;i'' 






(' 



I, H f 



i>\, 




ti 




I 



MMjL 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I to; 111 



1 ,,f M<!iltli F No 



)&S3k) HS: r c 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffe riled, CLu^a^v^t l^ 100\ 

X^w^Jl^o^u Deputy Health OfHcer 



Registered J^o. f026 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



( U. S. Stan^ar^ ) 



A '^ 



PLACE OF DEATH: — County of CVO-'>v OXOAx-CvAccCity of O CU>v AXL/vxAiA,<i,ao 



* 



'No. 




lu "^^ '^^^'^^i^H. 'Jl^O-<l 



AvJ. 



ri. 



<xl St. 



DisU bet. and 



(IF DEATH 0< 
IF DCikTH 



CCUni *W*V FROM USUAL RESIDENCE give facts called for under "special INrORMATION" N 
n . . __ ,..,.«», ,-.«r .TS NAME INSTEAD OF STREET AND NUMBER. / 



OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 11 



) 



FULL NAME 




iUAUx/yxAj 



si:\ 



I)\TK Ol- lUKl'M 



AC.K 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.OR 





X)^VA.Xl<. 



t Month)' 



1^ ,..„, 



(l)av) 



M.inlfts 



r V'\ 

(Vi-ai) 



/></!. 



^INt'.I.l". MAKKIi:i). 
UII><>\VKI> OK I>[V«>RtKI) 
'Writtin «<M-i;iI iW-sij^nation) 



niKTHPI.ACK 
StMt( or (.'oMutry ' 




NAM1-. Ol 
KATIIKR 



HIKTMl'I.ArK 

Ol- lATMKR 

I State or Country^ 



MAIDKN NAM)-: 
<H- MOTIIKK 



HIKTIllM.AOK 
«U- MOTIIKK 
(Statf or Country') 



(^ 





X d-^^^'^-'^A; 







Oy^v 



A 



a 



OCCri'ATION 



d^<XA>-< 







Krsiifn} in Siin /■'> iiin isf<> C)\. >Vi;;> 



,1/../////' 



/ilM.v 



phi; ahovk ST \Ti-n i'Kksonai, i'\k rirn.AKs aki; ikik to tjik 

HHST OF MY KNO\\m:i>C.K AM) HlM.IlvF 



(Informant 




rrw) 



I \<l<lress \^K^ 




!y<i\\.\X^oJ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH /'^ 

La 



(Month) ,f 



„ n 

(Day) 



(Year) 



I HIvRI-BY CERTIFY, That I attended (leccased from 

lL\^UCL iX 190 M to LLa^<vXIL. \1 190 H 

that I last saw h -^ ■ ' alive on LL<,^c^ . 190 '\ 

and that death occnrred, on the date state»l above, at J I 
Qs M. The CAl'Sn OF DI-ATII was as follows: 



.A^. 



or RATION )'fafs 

CONTRIBUTORY 



Months Days Hours 

:Y:\:.\..\Ay^ 



DURATION Yiuus Mouths Days 

(Signed) Uj^JU[vwvvv VL.oJsAjj^yi 

yiv ^Q 11 iQoH (Add res 

ClAL INFORMATION 



V 




-V^l^tl iqoH (Address) L 

SPECIAL INFORMATION only for Hosi)ltals, institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Hours 
M.D. 



\ 




Hew lonq at 



UsuTReTidence 503^ IdJ^i 01 Piar e orOeath ? '"^ Days 

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



I'l.ACK OI" lURIAI.OK RKMOVAI, 



I)ATi:of niKlAL or RKMOVAI, 



rSDKRTAKFR J\X.ULjL^ OO O^Ct^' , V 



190'i 



N. B.— Kvcry Item of InformHtion .hould he c«rcfu.ly supplied. AGB should ^T-'^'^t^^'^^''^'^' ,Z^^'^lo^^:^'':^t 
•tate CAUSE OF DEATH in pinm term., thot it m»y be properly cla.s.f.cd. The Special Information for p.r- 
aon« dylnft away from home Hhould be ^iven in every Instance. 




\ ' 



ID 



» t 




m 



\ I 



« • 



rfiSEjw 



ii ^ 1 



} 



V 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H 'nn 



1 ,,f lliiillh !•■ No- I' 



*?^^ 



HS:l' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lOO'i 



l)((lc Fih'd , Llo^QA^^^'fc 1^ 

,Kj^ Xlom^ Deputy. Health Officer 



Registered JSTo, 



" 4 « i ^ 




DEPARTMENT (ff PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "CI. S. SfanDar^ ) 
PLACE OF DEATH: — County of Oou^v^ O.^.OLy>vC^<i,5(City of O /CX/^^ ^ AXXy>AyCAA.e<; 



-M 



No. 



St.; S Dist.; bet.X'x/VM.^baAiAx) and d/C/CiAlv) 

/ ir Oe»TM OCCURS AW*Y rPOM USUAL RESIDENCE give facts called for UNDER "special INFORMATION- \ 
V. IF DtATM OCCURRf D IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




II 



V 




PERSONAL AND STATISTICAL PARTICULARS 

DATK <H- lUKIII (\ h 

[..nth I \ (Day) (Vt-ari 




AC.K 




•J 



Vtiii 



Mnuthy 



ai 



Ha 1 . 



^IM.I.K, MARKIKI) 
W IDnWF.I* <»k I)I\(»krKI) 
Writf ill sotial <U«i!.'nati<)!i) 




MEDICAL CERTIFICATE OF DEATH 

DATE OV DKATH 

(Day) 




I go 

(Year) 



(Month) 
I HI;KI<:BY CKRTirV, That I attended (leceasetl from 

/La-v<CU l^v iQo'i to Uo^ 



LU-v<CU i^- iqo'i to Uo^^e^^ l^ 190H 

that I last saw h ahvc on VAA^^..AX_ > ^ up \ 

and that death occurred, on the date stated above, at v3 

LIm. The CAISI-: UF DIvATII was as follows: 



a, 



A'VOw'^'XA^ 



X--Ofcr 



r>\. 



iKiMii'UACK n QC\ 

l:it. or Couiitrv^ X ^(J I ' ^ 



NAMK <H- 

i"ATin:R 



lUKTHI'I.AOK 
Ol- I AllUvR 

'Stall- r)r (.'oiuilry) 



MAIDKN NAMK 
Ol- MOTIIHK 



lilK'nri'I.ACK 
01 MoTMKK 
'St:itf or C«niiitry> 



ore r I' AT ION 




jJULxxx/wo^ . 




kfsitirii in Siin J'ldih/M'n 



)'fii I 



^h'llths X. \ ^^'':' 



TMi: AliOVK STATKD I'KRSONAl, TA KIKT l.A KS A K I", TKIH T« ) THK 

iiHsT OF MY KN()\vi.Kn<".K AND ni:i.n:K 

'' : ljO/cJlLA...C^t. 



r\<l dress . 



DTRATION Years 

CONTRIHl'TORY 



Months 



Days 



Hours 



Dl'RATION 
(SIGNED ) 




)'citrs 



i 




^font/is 



Davs 



T90 



'X^QLAX 



Hours 
M.D. 



'■ — 

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

Former or "»**' 'OM «^ 

Usual Residence Place of Deatli ? Days 

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



I'KACH Ol- HIKIAF, OK KKMoVAI, 




fiA^o Uu^<i--'' 



ITNDKRTAKKK W^ \I R^ \l J^^ 

(Address I 0. 5 ^ \(\\^Jii^^.JyL ■\ 



DATlvof Ml HiAi- or RKMOVAI, 
LLCVXX l^ I90H 



IS. B.— P.vcry item of Information .houlcl be c«rofully Huppllccl. AGH nhould ^e stated EXACTLY . ^"/^'^J^^^^l^J^^'^^^ 
state CAUSE OF DEATH in plain term., that it may be properly classified. The Special Informat.on f.r pT- 
Rons dylnft away from home should be ftiven in svory Instance. 






'.M 



.. . », 1 



Ir 



«»^ 



i 



f 



\ 



W 



li 



1 

I 






Vdl*.. 



t, 



WRITE PLAINLY WITH UNFADING INK 



^Wt-nllh !■ V. 



-ft.'?^5*^;-, !!X: 1' (* 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((li> Filr(l , \Xk.ajOAJ<aX) 1*^ 



lOO'i 



JRe^istei'cd J\^o, 



10T8 




\jo^>u Dep.M.ty.Ms.» ' • »' .Off - - r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( "CI. 5. t5tan0arC> ) 



-? 



PLACE OF DEATH: — County ofOa. , O/va/YvCAXi.cc City of*^Wru AXXy>v<MAl,C<j 



^ 



No. C) "LvAj ^^ 



Crvc^'VAi^LA V 



a. 



SU; H Dist.; bet. 



and 



-) 



/ IF 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. J 



FULL NAME ^Ui\ 



•-i:\ 



DATl 



\<.]-: 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 





RTIl 



ctWr f "^5 ^" 




Mciitlil 



oJ.t 



Hi 



I ),./' 



Day) 



M.'iitif 



i Vtai'i 



n,n.- 



^INt.I.I* MARKIKl). 

\\':t' 1 ;i '.ocial (li>-i>.';»atii)ii ) 



I'.IKTIIIM.AOK 
' State or <.""initr\i 



N \MJ-: ()!• 
FATIIHR 



IMKIMPI.ACK 

<M lAl'UKR 

' Mat( or Country I 



^T^iIll■■.^• nami". 
"! MoTHl.K 



lilKTHI'LACK 
«»!•• MoTHKR 
(State or Country I 









OA-^Li/^-X^. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DICATH 



(MoiitlO i\ (Day) 

1 HI:R1;15V C1:F<TIFV, That r attendcil (leccaseil from 

• — ■ \i)0 t(i ' — — — ~~ — — up 

tliat 1 last saw h alive on — — — — — — — -up 



and that death occurred, on the dale' stated above, at 



M. The CArSI';_()l' Dl'.ATH was as follows: 
CL/>vi 






d 



A-V-A^ 



/CA,^iL 



^r^^^trVATYV 







"1- 



.'v/^^^CrVA/^-V' 



IXVyvxO^ 



n 



yjnuth^ 



/),n 



<»i Cn-ATION ^ j 

f\f--i\lrif ill S,;>r /'i i! n, /^■•o J, \ )..;. 
IHI-: A HOVE STATin PHKSONM, I'A K llCf I.A K S A K 1 : I" K T K To 11 11-: 

JiKsT OF Mv kn()\vij:i)(;h and nv.ijy.F 



InfMiiiiaTit 



r\<l(lre'is 



HS-'X 



^Ow^^^^c^wr 



VjV OwX-^-v^Axv o h 



I )r RAT ION )'i'(irs 

CONTRIIU'TORV 



DURATION ^ y't-ars 

1^ 



Months 



Days 



//ours 



Mouths 



(SIGNED )..Lt5U- 



,.. ^.ftlulL.. 



Pays 






vcL 



//ours 
M.D. 



inj 



ULt^a 1^ TQo'i (Addre-^s) L<r\^-Ul^vO Li.^t'-^^- 



oalTn 



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



Wfien was disease contracted, 



Former or (, 
L'sual Residence A ^' 



Place of Deatfi 



Days 



If not at place of death ? 



VI XCl-: ol' lU'KIAI. OR ri:m"\ai. 



l)A■p,^..! liruiAi. or RI-:M<>\A1, 

l^ i9o'i 




IN 



Dl.KTAKHR ()vD . VJ . ^^ Ji^X/^.AJL^^ 



(Addresv 



.Htion should be cnrcfully HuppU.d. AGE should bo ntnted RXACTLY PHYSICIANS «hould 
ATH in pl«m terms, that it m,.y he properly classllfied. The Special Intormat.on for p.r- 



!^' B.—— Every item of Inform 
state CAUSE OF DE 
sons dyinft away from home should be feiven in every instance. 



'1^ i 



!«» 



S 



i 
M 



If 



m 




k 






WRITE PLAINLY WITH UNFADING INK 



\< iMTcfiifWtStttt— ^f*^ ?»s. 



/)(ffr Fi /('(/, 



.lefi^'v 



?% I>C. I» fr\ 



THIS IS A PERMANENT RECORD 



RFFPR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




n 



lOO'i 



Be^ififercd Xo. 



1079 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( H. 5. 5tan^Ar^ ) 



J? 



J? 



On 



No. 



PLACE OF DEATH: — County ofOOyrv' J,\.c«-avCvaco City of ^O^^r^ O 7vo^vvc.v-ilci 



oJfcAUl 




(XKkju^ 



St.; 



Dist.; bet. 



and 



/ IF DCAThAoCCURS AW*i FROM USUAL R E S I D E NC E G I V E FACTS CALLED FOR UNDER -SPECIAL INFORMATION" ^ 
i, IF Ot»^H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME VOA^^i^ cUCkaj 



-1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.OR 





^oL 




!t xTi: i)i' r.iKi'ii 



\ «■.!<: 



M..titlii 



H4 ),./;> ■" 



il):tv^ 



M ,„th 



I Year) 



IKi\ 



^iNt'.i.K. M\Kuii:n. 

'\ MX twin OK i»i\"ttK<'}:i) 

1 -'niiil (Ic'^iviiiitioii) 



i;iKTiiPi,.\ri<: 
^titt or (.'Diintrv' 



NX Ml-; <)l' 

i".\tim:r 



lUKTHI'I.Ai'K 
ni- lAlllKR 
'Statf or C'otintry) 



M \iiii:n XAM1-: 

'>! Mo'l'HKR 



IMK I'Hl'l.ArH 
t'l' MOTIIKK 
(Stat- .1- Country^ 



OCCMl'ATION 




c 





/Ou^^\^<X' 



rvTv^^^o^'A.' 



MEDICAL CERTIFICATE OF DEATH 



DATK OK UK 



i9o\ 

(Year) 



(Month) (T (Day) 

I Hi:Ri:r.V C1':KTII<'V, That I attciKUMl <lc(vase<l from 

LIaa,Q_ lb KpH to LL\-v<v 1^ H)OH 

that I last saw li-^ • ^ alive on LLa^*^ i I 190 l 

and that death occurred, on the date stated above, at xo' 



LL M. The CAISK ()!• DIvATir was as follows: 



.. \ 



u 




kXV\j 



I ,ni, I ^ri> 



);■.;> 



\r.,,iih^ 



/),M 



rm- MJOVK STA'Pl-.I) PKKSONAI, I'A K'II<- r I,A K S AKl'. VRVV T' • I'll 1% 
H1-;ST OJ-" .MY KNOWIJ'.IX.K AM) lUlIJl'.l-" 



X'Mrcss 



I)rR.\TI()N ' )'i'ai 
CONTRinrTORV 




Moni/is I)a\ 'S Ho n rs 



..CVX.OC <i/o. 'v r^^txj. . 



} 



nrRATION }'r(irs \ Months Pay!; 



(SIG 



wCaj 



//ours 
M.D. 



LvMX\.\H TqoS (Ad.lress)dfe.\J/LQAxyi ()V'&-^vt. 

FECIAL INFOR 



Special information only (or Hospitals, insnfutions. Transients, 
or Recent Residents, and nersons dyinq andy from fiome. 

^'roJ(OLcL->^NycC ^-o-^Piare of Death? 



Former or ^q 

Usual Residence 

Wfien was disease contracted. 
If not at place of deatfi ? 



Days 



ri.Aci-: «>i luKiAi. OK ki:movai 



vJoJ{00cv>' 



T90H 



INDl-.K fAKl'.K 

(.\d<hcss 



DA 11; of III KiAi. 01 ki;M<»\AI, 



^. B._Hv,ry Ue™ of l,„„.,n„,io„ .houl.l be cnrefuMy ,>,pp.U,.. AGB »h„.>,l bo ..aUH EXACT1.Y P"^«''='^^~« f ^^ 

8totc CAUSE OF DRATH In pinin term., thni it m..y he properly cla.-.tied. The !,pe..al Intonnat.on for p.r- 
«on« dyint awny from homo ahouUl be (Siven in every instance. 




I 



V \ 



w 



I i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,;).fn;i!th f No u^^^H&rCo REFER TO BACK OF CERTirtCATE FOR INSTRUCTIONS 



i\ 



Dale /v/^^/, GLuvo^v^t \.H 100 ^ 



Registered JV'o, 



1080 



.'0■\.A-^^^ 







Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. StanJ>ar? ) 



PLACE OF DEATH: — County of 





ro 



>'"W>L/cLou City of VKJL'\)<X.\jCXu6^^ L<X' 



No. 



(\r DEATH OCCURS AWAY FROM USUAL 
IF OtATH OCCURRED IN A HOSPITAL 



St.; 



■Dist.: bet. and 



RESIDENCE Give FACT 
OR INSTITUTION GIVE I 



TS CALLED FOR UNDER "SPECIAL INFORMATION" "X 
TS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




JU:. 



:y\aa^. 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COl. 




I.OR \ f\ 



\xXl' 



\Ti: nl- I'.IKIM 



Get 

iMiMith) 



U- 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

(Day) 



L\aa.< 



(I)MV) 



(Veur) 



'^ ' . !•: 



I J 1V.;;.> I .!/.»////> I ''t 



/)(; vs 



■^INt.I.K MARK n: I) 
W IDOXVKI) OR DIVdRCKI) 

Write in s<Mial <UsivMi;iti<>ji) 



luk rm'i.AOK 

(Statr or Country'* 



h. 



N'AMH oi- 
JAIUKR 



lUKTHI'I.ACH 
f>I I AIHKR 
'State or Country) 



MAII)i;x NAMK 
<»» MOTMKR 



HIRTHl'I.ACK 
OF MOTHHR 
'State or Countrv) 



••'■eri'ATlON <^ 






Q 

(Mouth) A' 

I mCKl'IBV CI-iRTIFV, That I atteiKk-d deceased from 



(Year) 



190 



to 



190 



that I last saw h nr— alive on v ■ .. ■ - 190 

and that death occurred, 011 the dale stated above, at — 



M. ^hc CAl'SK OP DJvATH was as follows: 



O^J 






V 




\^s-^u^^ 



(« 



DrRATION }'ears 

CONTRIIJUTORY 



Mouth a 



Pays 



Hours 



<XJ^^ -^■■>rUU-\j 



t^e^idfd in Stin /> d in imU) 



) '»■<; ; , 



Mn„ths 



l>nr 



diration 
(Signed) 



Years 



Mo fit /is 



Pays 



TQO 



(Address) MLJLL^ LoJL' 



Hours 
M.D. 



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



'"nt^J•r^y^.^''"'^ ''♦■■'* ''HRSONAI. FARTIC F I.A RS A R I-; TRFK TO TIIK 
"F.srOF MV KNOWI.KDC.K AM) HKMKF 



(Iiifoiniant 



O^xJLu >^^kj^WW^Jir\y^Oj^ 4^JL^.yv>^vtr 



fAddress 



# 



Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



FI.ACH OI- KFRF\1. (►R RF:M»)VAI, 



I)ATF:of Hi KiAi. or RKMOVAl, 
a A^^ I90'i 



CLa^O i^. 



d. u). t). i - Ujla^vocUvu ^ 

FNDFRTAKKR J ^KX/0-<Wv oU.AULaJK^ ^ 

(Address S>.5..1>. \ryV\.^i^o.^^A. .3;^. 






IN. B. 



•Kvcry item of Information should be ciirefuily 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 psr- 

Anna ^..!_A e l • ... .. • .. 



«ons dyin£ away from home should be ^iven in ms^ry instance. 



' I 



! 



II 
il 



J* •. 



^4 






iri 



> 



i 



11*1* 



u 



( « 




> 



Ir 



« 



I 




i 



Moil 1 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,, ,1. iith I N ' i^» ^Sg^ H&»'Co RCFCR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)(ff(' Filed , 





H 100 "{ 



Registered J^o. 






.^vv^ ds.L/x>A. Deputy Health Officer 

DEPARTMENT OF IpUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( xa. S. Stan^arD ) 
PLACE OF DEATH: — County of CIcl/yv O^CUivx^U-cCity of "OAX/yv OAXX/rvCAAxto 



St.: 1 Dist.:bct. 




(IF OCATH 
\r DC* 



' s*.. 1 L)ist.;bct. v I wu./^^AJYAJ. and /CU.{/L^ 

OCCURS *WAV TROM USUAL R E S I O C NC E G I VC facts called rOR UNDER "SPECIAL INrORMATION" "X 
ATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




^'W).. 



PERSONAL AND STATISTICAL PARTICULARS 



s,.:x Qjp 

nXTK «)!•• lUKTII 




C01,()R 





C 



U 



19^ \ 

(Year) 



10 

(Day) 



\ ' '. K 



\ >•(! I 



Mi>n//i.>. 



(Year) 



/hi vs 



^IN'.I.K MAKKFKI). 
WIDoUKI) OK DIVORCKI) 
'N\iitt iti S(K-ial <l«->jit^iiati<)ii) 




1»IK ruPKAOK 
(Stutc or Coutitry^ 



NAMK OF 
FATHKR 






THRTMPl.ACK 
Of lATHKK 
(State- or Country) 



MAI1)1:n NAMK 
Ol- MOTHKK 



lilRTHPUACK 
OF MOTHER 
(Stato or Coiintrv) 



VJ.CL/W 




MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH ,'^ 

LW) il 

(Month) T (Day) 

I 1II':RI<:BV CICRTIFY, That lattendcMl deceased from 

LLcM^r *^ 190'i to .. LLwA^ {%, T90 H 

that I last saw h Ji-hj alive on VwAAAX:l iX 190!^ 

and that death occurred, on the date stated above, at 10 o.v 
CI- M. The CAUvSK 01- DlvATH was as follows: 



nrRATiON 

CONTRIBUTORY 



}'^ars_ ^ I\fonths J^ Days ^ Hour. 




DURATION 



) V<7. 



OCCrPATlON 

fffsidfd ill Siin I'liiiiiisro 






) '/■(/) 



1 Months t) Por. 



'^h 



AFont/is o Day. 



Hours 



(Signed) .oU U .\X'\nyv\-<i M.D. 

LiAA.a lliqoH (Address) iOlb M^^VU^ilX at 



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

How lonq at 

Plare of Death ? Days 



Former or 
Usual Residence 



' "«T^J!I?^^^ STATKD PHKSONAI. PAKTICIKAKS ARK TRIE TO 

«KsroK MY kno\vij:d(;k and hkmkk 

% \x). Jj^^-\^^\..<yxx "d^ 



THK 



(Info 



iinant 



(Address 



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



PIJ^CE OK BURIAL OR RKMcUAI, 
UNDliRTAKKR 




DATKjnf Hi KiAi. or RKMOVAI. 
la I90H 



(Address 



i ^- -^ 




o-'cUto^A.^' 



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

•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" f©p per- 
sons dyin^ away from home should be (iven in every instance. 



I - 






'4 



?1 

t •• ♦ 



. 1, 



m 



A\% 









!l if 






)l 



,M 



! w 



i 



It 



Hi 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board of M« alth- \' So. k 



H&l'Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hf/c riJcdrS 



cUcrLA^ui d' 




IS 



lOO'X 



Registered JSfo. 



108J^ 




Dep"^-''igrvhOmcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( 11. S. StanDarD ) 



PLACE OF DEATH: — County of 



City of 




tpwou 



No. 



St. 



Dist.; bet. 



and 



(IF DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET ANO NUMBER. / 



FULL NAME 



■\ 



!».\TI-; OI- lURTM 



ACK 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




.UAv\Jaj 





\. (lb Cr\^vcx.>^cL 



iMotUliI 



(Uav) 



MntilliS 



SIN«.!,K. MAKKIKl) 
M IDUUKI) OR niVOKCKI) 
Uiittin »i(Hial (lesijjuatioti) 



IHKTHPl.ArK 

'State or Country) 



NAMK Ol" 
lATMKR 



HIKTMPI.ACK 
<»»■ I'ATMKR 
(State or Ooutitry) 



MAIDKN NAMK 
<)»■ MOTHKR 



IHKTirPr.ACK 
<H- MOTHKR 
'Slate or Countrv) 




/■ (Year) 



Da r.v 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

(Day) 




190 \ 

(Year) 



I in<:RP:nY CI<:RTIFV, That I attended deceased from 

■ ■■■"■'■ ' 190 " to •••' ■ 190 — ""■ 

that I last saw h •.^:~~~ alive on ■" it^ rrz—: 

and that death occurred, on the date stated above, at ~~ ■■ 



M. The CAl'SFi OF DHATII was as follows 



jb X<X^vjt .A-.^C^aJL: 



A»,.w.NJL, 



DURATION Years 

CONTRIBUTORY 



Mouths 



Days 



Hours 



OCCUPATION 






Hfsidfd in Siiti I'l am ist't) 



(SIGNED) 



\.KJ^^\ IX \qo 



:!- 



Mouths 
(Address) 



Hours 



DURATION Years Mouths Days 

Al....]cL.l.MU^v.Hl>-t\/>x^ M.D 

k 




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



) V'<r;. 



M,»ith< 



Da\. 



THK AHOVK STATKD PKRSOXAI, PARTICrLARS ARlv TRIK To THK 
JlKSroF MY KNOWMCDC.K AND BKMKF 

(Informant \l fCOLA/tl^V VJ . LI. jJ^^^V^tX 



(ArWrrrss 



L a , i/i) 



\ 



XX'Vuo 



Former or 
Usual Residence 

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



Hew lonq at 

Place of Death? Days 



PI.ACE OF BURIAI, OR RKMOVAI 



rXDKRTAKKR \w'<X)Wr'fc'V/"i"*-AXX; - > T" 

tlres.s ^ H.C). S. Cfo-V^.^-ciL .y±.. 




(Add I 




■^^ **• Every item o? information should be carefully supplied. AGE sliould 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 ^iven in every instance. 




SAX 



•:i 




11 



7 
■I 









\ 






t1 



I ' 1 V\ 






1! 



\ 



'i > i i^ 



( 

t 

V 




r*<, 



■: i * I 



I 1 



J' 



I I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hojik! ..f llr;iltll- »•■ No I«, 



H&PCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihf/^' Filed, [\ju^'u<^ l^ 100^ 

\j:r^A^\jiL^ Deputy Health Officer 



Registered J^o, 



.108.3. 



DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 



Certificate of 2)eatb 



si 



( "a. S. StanDar^ ) 

'5^ 



J 



% 



PLACE OF DEATH 






: — County ofCJo>/YV AXLAAXAACcCity of O /CL/^-^ OAxX/YVCl\Aac 



No. V.OLV 



.-K.^v 



'tr\.\,oxLu 




C^ 



U\.lI 



O.'/.St. 



Dist«; bet. 



and 



(ir DCATH OCCUnS/kwAV FROM Usual residence give FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCUI^CD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




Uj 







PERSONAL AND STATISTICAL PARTICULARS 

^i:x QC\ ^ I coi,()R i'^ 



Ox 

»N I H Ol- JMKTH 




Oc^H 



a, 



Month) A 



\ « . I", 



6 IV,;; V D 



■A. <J\ 
(Day) 



yhniths 



(Year) 




VO. ^.V> 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATM ~~1 

lL 



(Month) A 






AX 

(Day) 



(Year) 



ai 



nii\. 



^IN'<.I,I>:, MARKIKD. 
WlDoUKI) nk DIVnKc HI) 

Uritiiti sfK'ial rlt.si;.rnati()n) 



lURTMIM.AOK 
'St;it« or Country) 



f-ATHKR 



RIKTHPI.AOK 
n|- FATHKR 
'State or Coiijitrv) 



MAIDHN NAMK 
'»»■ MOTHKR 



niKTHIM.ACK 
OF MoTHKk 
'State or Coiuitrv) 













I in<:RnnY CIvRTIFY, That I attended deceased from 

LLv^^a ^^ i9o2> to .LLaw\^ l.l 190 .H 

tliat I last saw h rVv alive on LVx^^^/Ol 11 190 ; 

and that death occurred, on the date stated above, at 1 30 . 
LL M. The CAUSR OK I)I':aTII was as follows: 



k^'\ v.A^<X 



]'dars 



w 



Man (/is b Days 





1 
( 



i 



DT RATION 

CONTRIRUTORY .J..AA.<CA..^..^.\^<i....j 
r'Ui/^'V.ec^ 




/)avs 



hVsiilrd ill Sun /'i an, i.^nt [ )V<?;.v 



.^rniiffi.y 



I\l\ 



DTRATION Years Afont/ts 

( SIGNED ) J... Aa. dt) OL>vt' 

Llvva itiQoH (Address) Ljtu,^ L^. 



tt 



Hours 
M.D. 

o-<..(.J:.. 



SPECrAL INFORMATION only for m\>M%, Institutions, Transients, 
or Recfnt Rrsldrnts, and persons dying away from home. 

Former or How ionq at -v^^-e^s 
Usual Residence Place of Death ? io Days 

When was disease contracted, 

If not at place of death ? 



' "l^^!V?^'^ STATKD PKRSONAI. PARTlCrLARS ARK TRFK TO THK 
ISF.SI OK MY KN()\VIJ-:D(;K and JIKI.IKK 



(Info; 



nia 



N. B.- 



nt U ) rWu Vf /\ d^/CXOLTUjV' 

< \.i(ire s LaXu/^ ^ nD O-Cilxlt: 




I,ACE OK BIRIAU OR RKMoVAI. I DATK of IHriai. or RKMOVAI, 





^D _ igoH 



INDKHTAKKR 

(Ad 



dress. ^.lol^X' \^ kk^AAk, 



<X-'CVCXy>'V^ 



-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- 
Rons dyin^ away from home should be ^iven In m\^vy instance. 



*ITI 



! 


M 




Hi 




Hi 







« » 



N 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFtR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Boai.l nf IKnlih I" So. 1 «; •^x'wj^i US: I' Co 



/h,fr Filed, (XlaXm.4^ 1<^ . . lOO'A 

d^^o-^^x^^ dUL/v~u Deputy Health Officer 



Registered J\''o. 



1 f^'^i 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of E)eatb 



( "U. S. GtanC>nrC> ) 



Ji «p 



.fd 



A 



^ 



PLACE OF DEATH: — County of^<X">^ AxiAv<:.\,<i/c>t City of OO-oaj Ax«-/yvca.o,cc 



No 



.1111 



^ 



.VA.\.K 



St 



.; b Dist.; bet 




Uc/vuXj and ^-^J^^XCUwWyxx) 



(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR uVl D E R "SPECIAL I N FO R V ATI O N '• \ 
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEHD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 
'"'A A -^ ft j coi.oR 




\^} 



XUJb 



i'ATi: Ol' I'.IKIll 



\' .)•; 






(l)av) 



fV.;ir) 



(Yf.'ir) 



Tl 



) r.i 



a 



.!/..;////> 



11 



/>.t ) .^ 



WrDOWKl) OK l)I\»)K(Kr) 
Wiitiin siK-ial lU si.^Miatioii) 



I 



i'litlt- 



» 




'■■IK'TlllM. \i*l-: 
St.iti (ir (.■<nnili V 



I A I- III.; K 



lilKllll'l. \i]- 

Ol" iAriii-:K 

' M.iic 111 r.iiiiiti vt 



"I Morill'.K 



niK rin'i,\ri.: 

«M' MnTil|.;H 
'Siati- (ii ('(iiiiiti \ 



Uaxtv-v^c^ (TV dLx. 



ftAEDICAL CERTIFICATE OF DEATH 

DATi-; Ol- i)i:.\Tii 1^ 

LLla^O I'i, 

(Month) iT (I)ay) 

1 HlvUJvHV Ci:RTn<V, That r attende.l deceased from 

IwLuL .1 icp'i to ...LIaaXV i% Kp H 

tliat I last saw h A.WV alive on LCvvQ l*t 190'^ 

and that death oreurred, 011 the date stated above, at 1 1 
LL .M. The CAISI'! OI- Dl-ATI! was as follows: 



Cj^/W./O^-x'XA.AlA.-trvv. 



A^'YV 



^-^^rvvAXO jUUL/vv<iX 



oMr^A-VtX/ 



OL/'^X/W 








(? 



i)ik.\'i"i().\ 



/)<ir.' 



Hon 



lUvi 



> V C UC» % \j 



)'cars \ Moil //is ....,.,., 

It /is 

\j , jULo^o-JOs. 

Li^UuD I'l looH fAddnssHllt Ja^.>Jk 






f^avs 



//ours 

(Signed) \j, JULo^oxXsXKx^ m.d. 
I'l i()oH (.\ddrrss) lilt OA^.>vk dt: 



SPE<ilAL Information <»nly for Hospitals, Inslilutions, Transients, 
or Recent Residents, and persons dyin-j iiway fro-n home. 



'•'■^■ri-.\Ti()N (^ P /'j) 

1^1, 1,-, f III ^,1)/ /'i ,111, lui) .l)\ij )Vi;/v • l/.'i/'//. 



/',/1 



Former or 
Usual Residence 

When was disease contracted, 
If no! at place of death? 



Kow lonq at 
Place of Death ? 



Days 



I '1', \Mu\-,.-, sr\|-i:i) I'HKsoxAi, I'AKrim.AKs Aui; i-KrK to Tin«: 
"i.M ()(■• Mv K\(»\\i.i;i)(,j.; \\i) Mi;i.n;(- 




ri.ACK oi- HjLi<i.\j. OR ki:Mit\\i 



M m 




I)ATJ\<if lit i:i.\i. or RIvMoXAl, 

^^^'r:^- _j-^ • 190 'X 

(Vi li 1 % ~J^ ^ 

rM)KRT.\KKR M I - U /VCXa^ M. \^ 



(Address 






.JkuJuiUik 



K. Kvepy Item of 1nformntlon Hhoiild be carefully supplied. ACIB should be stnted KXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in pinin terms, that It mny be pr«M>eHy classified. The "Special Informution" for per- 
son* dyinft away from home should he feiven in every instance. 




I , 






II 



I 



« 



11 

m 






»l 






\ i* 



iti 



.4i ; 



V 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Bnar.l .'f U<iillh- F No. I «, ^»^ 



H&J'Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafr AV/fv/, iXv.x^^ 15 l'JO'\ 



cL-CrV-AA^5 



Registered J^o. 



1 085 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



( "CI. S. Stan^arD ) 



PLACE OF DEATH: — County of' 



vJCUTU OACLAVCAACcCity of 0/CWu J A/X/V^Xl^-CjXl^ 



Na 



3C) VJ ,axT^,\Ot. J Ju'v^<u (IbiKkAistI' ' S Dist.; bctmU^cJkxXmXXA^ and XouQA^y tXXi ) 

(ir OCh^H OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ A 
IF O^ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / (J 



FULL NAME 




■ioaA/. ! 



SK\ 



S»AT1-: OF niKTll 



Ai.K 



PERSONAL AND STATISTICAL PARTICULARS 

I coi. 









% 



Mouth) 



^Xc't_o 



XI rllX 

(Day) (Year) 




MEDICAL CERTIFICATE OF DEATH 

DATE OF DHATH 

' ' il.. 

(Day) 




190 'i 
(Year) 



I HHREBY CKRTIFY, That I attended deceased from 



LAjoM 



a 190M 



11 



CS c*v ) ra f > cK 



Mouthy 



1\ 



Da n 



sixr.i.E. markif:d. 

WinoWKD OK DIVOKCKD 
'U'lil* in s(K-i;il drsiv^tiatioii) 



lURTflPKACK 
(State or Couiitrv) 



■^ 



m 



*ii 



NAMK OF 
FATlUiR 



inKTHI'I.ACK 
Ol" FATUHR 

(State or roniitry) 



MAIDKN NAMl- 
OF M»)THKR 



hikthpuacf: 
of mothkk 

(State or Country) 




^Cr \..l I90M to UU.AX3L i.^ 190 H 

that I last saw hi — -alive on LAw^-^a lb 



i.'l. 



1 



190 I 

and that death occurred, on the date stated above, at iV 

s| M. The CAUSK OF J)1{ATH was as follows: 

^.y:^JUu..\i^.\/y.^ 




OCCUPATION f^ DO 4. 






tuj- VUt^uH 



DURATION Years ^ Months 

4.'ONTRII]UTORY 



Hours 






Days 

J ^ 

DURATION Ye^rs Mouths 

(SIGNED) (b. "u. OA.<.>^(hu£ 






"r^vUX; 



f\r\idfd in .Stiti /'laniisfo 



)'ra 



., R 



.\ro,iths 



Da V. 



Days I i Hours 
M.D. 



"^"'.^M!!.^^'^ STA'-KD PHRSONAI, PARTICILARS AKK TRIK To TMH 

15F.ST OF MY knowij:d<;h and hki.ikf 



(Inf. 



>rmant 






\JL\^ 



% 



Ua.VX>....1^ TqoM (Address) i b i U/gm^M U^.-^ LLvn 

Special Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from home. 

Usual Residence ^'H'i) (lb OAXXAxt dil Place of Death ? 3. 

When was disease contracted, , ^ } } 

If not at place of death ? b /YrU)-0 -lMt|t.\i. 



Days 



PI.ACK OF Bl'RIAI. OR RKMOVAI, 

..^SX^\.\j^XXL 



DATF; of lU RIAL or REMOVAI, 

.IX s.^ ^.0. 190 . ^[. 






rNDF:RTAKKR Q ctVcUl'vv U oJaj?^ LL^xxLo \^^<j 



(Address . 



ii>,^, 



^' ^' 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 ^iven in every instance. 




iij 



i: 



H 









i -f 



IS 



I: 



I 

\ 



m 



'ilil 



I . 



Ilii 



' f 



'li, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I1...1V ! ..f Ihiilth «•■ So. n >^ 



HM'Oo 



nCFCR TO BACK OF CCRTIPICATi: FOR INSTRUCTIONS 



II 



Dafr AV/^v/, Uaaxxv^ IS IfJOH. 



Registered J\^o, 



1 nc^6 




^rr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( Ta. S. StanDarO ) 

PLACE OF DEATH: — County of ^/d/^v JAXLAa/CA.<L/C< City of w/ay>^ \j K/yy^r\Al.^,^lSl.<i 



^P^ VwA. 



~ Dist.; bet. and 



A / ir DEATH occunsAM/AV rnoM USUAL RESIDENCE give facts called ron under "special iNronMATioN- \ 

\J V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 





.coyvru 





SKX 



l»\ 1 ». «»l lUKTM 



\ ■ . V. 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




l)L)lv-K' 



Uxm 

(Month) r 



n 

IDav) 



M.mlhs 



(Year) 



O 



Davs 



SINi.l.K, MAKKIKI) 

\vri><»\yKi) OR nrvoKcKr) 

iWiitfin s(Hi;il <l«»iiKiiatiuii) 



niKTHJM.ACK 
(State or Country) 



-i^ 




di 



NAM!-: ()V 

» ATin;R 



HIKTHPI.ACK 
<>l" FATHKR 
(State- or Country 



MAIDHN NAMK 
<>l- MOTIIKR 



lUKTHPLACK 
<>l- MOTHKR 
(State or Country) 



OCCri'ATlON 



C<L^aJ-/YV 




MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATU ~j 

vXc^n IJd. 

(Month) K (Day) 

I IIIvKHBY CKRTIFV, TliaW attended deceased from 

M«u_ .Q»..Si 190 H 



190 \ 

(Year) 




I90H 



that"! last saw h.^<- • < i alive on AAA. 

and that death occurred, on the date stated al)ove, at ->• «L0 
UjM. The CAUSK OF DICATH was as follows 



DURATION Years 4 Mouths Days Hours 
CONTRIHUTORY 



DURATION ^. 

(Signed) J , 




Days 



(Address) 



vC< 



Hours 
M.D. 



^<l\:X: 



Llv.\.Q \% 190'i 

SPEcIpaL Information only for HoMtals, institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 

How long at . 
^>-vuUL Place of Death? X\ Days 



Former or 
Usual Residence 



AAXa^x^lJkv 



AVsnirtl in S<in I'niini.uo ^O )><;;> 



M,»ifhs 



Da « , 



When was disease contracted, 
Ifnotatplaf' 'death? 



"".;A!?i?^'^' STATlCn PHRSONAI. PAKTICri.ARS AKK TRIK To THK 
HhST OK MY KNOWI.TCDC.K AND HKMKF 



(Informant 



lO^.^.lc^l 



<>^| 




. .TO (^-oAv^-txX 



Pr,ACE OK h RIAI, OR RKMOVAI. I DATK of HiHtAi, or RKMOVAI, 

-1) H % % "> 

INDKRTAKHR >J\JLA.VA^ "*<^ OO O-OL^Q^VU 
(Address 3>b..rLX - . l^ .Itl.. 'Jl 



N. B.- 



-Every item of information should be carefully supplied. AGE nhould b« stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for psr- 
Rons dyin^ away from home should be fiven in •s^ry instance. 



- 



li 



1^ 



?; 



t ■ 



i 






.(III 

ill: 



m 







'(I 



J.vi 



t .1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hrwird of ll(alth-K No. Il^ '5^ 



»& V Co 



REFER TO BACK OP CERTIFiCATC FOR INSTRUCTIONS 



Da/r hied, U.o.xxia^ i"^ ^^^"1 

d^<y\ju^ dJU\>^^ Deputy Health Omcer 



Registered •A^o. X 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( 'd. S. Stan&arO ) 

J? Of? J? 



H, 



PLACE OF DEATH: — County of JO/YV 'A^OAvtM^cc City of ^J^CU>\^ v) /v<X/Tvt:.A^ cc 







fffO 



1' 



No, 



(ir DC 
IF 



/CU">vJw<X.Vu„<y\i St.; -- 

ATH OCCURS AWAY FROM USUAL R E S I D E N C E CI VE FACTS CALLCO FOR UNDER "SPECIAL INFORMATION" '\ 
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Dist.;bet« 



and 



FULL NAME 



.OU^C^ 



U/ci\J!x<juUL\j. 



PERSONAL AND STATISTICAL PARTICULARS 



DATK «>|- HIRTH 




COI.OR 



X^'JxuJi 




iMoiilh) 



ACK 



11 IV,;; > 



(I):iv) 



Mnul/if 



A^5 

(Vcari 



MEDICAL CERTIFICATE OF DEATH 

DATK OI' DKATH 

' ' A.O Il 



LLl^ 



(Month) 



'\ 



(Day) 



igo 

(Year) 



U) 



Daxi 



^INC.I.K, MARKIKD. 

W IDdWKD OR nrVORiKD 

'NVritf in sm'ial iU'sit.'nati<)n) 



HIKTHFI.ACK 
(Stittr or Countrv^ 




NAMK OI- 
lATin:R 



lURTHPI.ACK 
OI- lATIlHR 
'St.'itf or Country 



MAIDKN NAMK 
OF MOTHKR 



inRTlII'I.ACK 
OF MOTHKR 
(State or Country) 



>Uvou:L 




I HBRI<:nV CI<:RTIFY, That I attended deceased from 

,\.^^^JL A.l) 190H to UwA^V^....!.^ 190H 



that I lavSt saw h ^^*\.! alive on 




190'! 



and that death occurred, on the date stated above, at o 
VV M. The CATSH OK DIvATII was as follows: 

U <X'<iX/\./^'^ VwOLA.yCx^:^c'v.<r^yW/OL/ 



DrRATIOX 



) '€(V'S 




Mouths Days 



Hours 



CONTRIBUTORY "^ 0..<dLNJLaL(rv:^^.'U UAA/a..ijQ...llC.\.. 




Years 



Mouths 



XTPATION (>p |\ 



DURATION 

,NED)ILll'U.dM^' 
vAA^Q ll 190 '\ (Address) ^y\^>.-^k 1 1 



(SIGI 




Days 



Hours 






M.D. 



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



Rf.u'dfd ill S(7n Fiamisro Q.Q. )V(M « 



MiHitlis 



n,i \y 



rm: AIJOVR STATIM) PHRSONAI, PARTUTLARS ark TRIK TO THK 
«Ksr OF MY KNOWKKDC.K AND HKIJICK 

(Informant V] |VV) V' O /^iXxA^Vt- \\) 



Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



190H 



PLACE OK BURIAI, OR RKMOVAI, I DATK of Bt'RiAL or REMOVAI, 

itndkrtak^:r Oo. 0^a..*^W\j ^^ v<) 



(Address 



N. B. 



Every Item of information •hould be carefully supplied. AGE ahouid b« stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' ffer per- 
sons dyinft away from home should be ftivcn in every instance. 




fi 






I 



i I 



J 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Mn.ir.! ..f iiciitii- I'No. i«i •<^2^wi)n&rc<) 



l)(ffe Filed , 




o^jyu^y<J^ (kJi/\. 



\% 



WO^i 



Registered JVo. 



1088 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( XX. S. StanDarD ) 



-^ m 



A Qi) 



PLACE OF DEATH: — County ofOa/>\^OAXL^\<^UULC City of Ocl/vu JAX>yvy^c.A^<LXit 
No. H Uc/UJ^^^i' cL<X/-^\^<L' St.; ^ Dist.;bct. I^Wxi^ .l.tiJ.\; and ^crLr>oL^ .) 

(IF DEATH OCCUnS AWAY FROM USUAL R E S I D E NC C G I V E 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 



PERSONAL AND STATISTICAL PARTICULARS 




.. U C^V'CL^C.ii 




^i:\ 



I'Al i; Ul JtlKTH 



\ ' •. !■: 




COI.OR 



(\f|>nth) 



Diet-. 



y\Jb 



1 V4; I 



(Day) 



M'luths 



/HO'l 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH /"^ 



(Day) 



7pO V 

(Year) 



%.. 



190 



H 



^ 'S 



Da ys 



>^I\«".Mv MAKKIKI). 
\\Il)<»\yKI) OR DIVORCKI) 
Uiittiii MH-ial (Usiviiatioii) 



MIKTin'I.AOK 
(Statf or Country^ 



N'WIK <)» 

1- athi;r 



inkTMI'I.ACK 

<>l" lATHKR 

< Statf or Country) 



■^lAIDHN? NAMH 
<»I- MOTHHR 



lURTMPUACK 
<»K MOTHKR 
'Statf or Country) 



oCCri'ATlON 







(Month) \ 
I IIHRKUY CP:RTIFY, That I altciKled deceased from 

Lix-ua \"1 190H 

that I last saw h^' alive on \_/v<v/v<va„ ■ ^ i^o 

and that death occurred on the <late stated above, at b-v)' 
CL M. •n..CArS.01M.K.VrM«.asasfo„o«.s: 




U 0^^j^.AA^^rv"u<r"nwA.X5c \1) A/Ct^vC'K.a.^cl.I 



a 



D 



I)r RATION Years 

CONTRIIU'TORY 



Mouths 1 Days Hours 








DURATION 



Years 




Kffuifd in S(iH /'lanriyro "" )></;.< 1 .yfoiithsJs.^ Pu 




^fontfis 

(J 



Days 



A^> iqo^ (Address) 2)'^'^ 




Hours 
M.D. 

'k 



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



Former or 
Usual Residence 



Hew long at 
Place of Death ? 



... Days 



r.v 



' "V;.^'!1*^'^ STATKl) PHRSONAI, PARTICTKARS ARK TRIK TO THK 
IlhST OI- MY KNOWI.KDC.E AND UKUKK 



(Informant 



dlxLcx^-A^ d 



O^Ou^i^'tiX) 



^\<l<lress 




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






PI,ACK OF BURIAL OR RFIMOVAI, I DATK of HtKiAl. or RFIMOVAI, 
(.\d(lress 15 XH, O X;^KcJ<lX^rV\. . .0.1. 



IN. B. 



^vcry 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 psr- 
nons dyin^ away from home should be given in uscry instance. 



f 



I . 



t \ 



■t(i 



1 •■ 11 



♦ 



1, 



'I 



(! 



*^t 



II 






I** , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



p., Kit. I. f Ilr,iltli-»-*No. i^ *'^"»]J^v)lUS:l'Co 



1)1 lie rih'tl ,\Xju<yOA^<^ ^S 






Deputy Health Of:i-er 



Begistei'od A'^o. 



lOr O I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "U. S. StanC»arD j 
PLACE OF DEATH: — County of CJ/CLO^ AXXOvCA^CCCity of ^Wro AXX/vvCv<L/t^<. 



IVo, 



t 





')^A 



kdal 



St.; 



Dist.; bet. 



and 



(IF DEATH OCCURS 
IF DEATH OCCU 



s awa|^ from usual residence give 
RRED IN A HOSPITAL OR INSTITUTION GIV 



FULL NAME 




FACTS CALtED FOR UNDER "SPECIAL INFORMATION" \ 
fE ITS NAME INSTEAD OF STREET AND NUMBER. / 

11 



') 




Cii'uxv.l^'^ 



i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I'Al i: (•! lUKlH 









iMoiilh) 



.\<".K 



3?^ 



5 'I'it i 



Day) 



M,.„lin 



(Year) 



Pit 1 



•^INJ'.I.K. MARkll-.I). 
W'liti-iu social di si-.-natiini) 








I 



r\'\^y\ 'V\. tj ^^Jr \ 



H 



P.IK I'm-i. Aoi-: 

Stall or t'l mnti \- 



WMi: <)i' 
iatiii:r 



IMR TIlI'l. At}-- 

'>' I Aiin.:K 

'Siiit( or roniilrv 



"^lAIIiJ'.N NAMl-' 



''•I RT III' LACK 
<>1- MoTUHR 
(State or Coutitrvl 



OCCri'ATiox 



MEDICAL CERTIFICATE OF DEATH 

DATr: nl- DllATM 

It 

(Day 



01. 



(Moiitli) 



/] (Day) (Vi-ar) I • 

I INvklvl'.V CI;RTII'V, That I atteiKiod deceased from CZ^ 

,v^Lu 2.x 190 H to. LU.va.ilo 190 H ^ 

tliat I last saw h r> \' alive on LUwVOl I'c 190 

and that death occurred, on the dati.- statt-d above, at H-3v.O. 

(T 



M. The CAlSlv Ol" DICATII was as follows 

Sx^vt LLL<l ' ^ ^ ( ir> 






r 



'j: 



m-QAi-a., 







J 



)<v7r.?. Mouths Days Hours 



CONTR ir.l'TOR V ^-V^^_^^AJL^XO..t-<r^x...frj^^^^ 



u 



M 



Dl'RATION 
(SIG 



M.D. 



M'>;>h^ 



/',n 



I'iU'. \UoVK S'r\l'KI> )'KRSoNAI, I'A RIUM' I.ARS AKI", TRII-: T< ) \'\\V. 

•iKsT()i-;^v kn()\vij:i)c.k and iu:mi:f 



)'cars Afoul /is 1 Pays 10, Hours 

NED) V\m\n^ 

cIaL Information on'y for Hospitals, InstjUuMons, Transients, 




Special information only for Hospitals 
or Recent Residents, and persons dving anay from home. 

Former or ^ . ^ ^% M ^4 ""*^ '<'"•' ^^ i 

Usual Residence vO V W d OAAJJUO OI Place of Death ? b 

When was disease contracted, 
If not a\ place of death? 



^ 



Days 



Informant 0/V/OL/>aJ!^ VJL\.'<M' 



A^XX/V^cL<l^<J "> V' 



\.i,ir.-.s Hot. vj jxxxajlL'u "8tj 



•I.ACi: Ol' lU R;.\I, OR RICMoXAl, 



•NDHRTAKKK vL UJ- v)rto.vl^^»^/^..L:j 

(Address 3) 1 H vj OJV^JLlL>L; ol. 



i)\ri;o: mi kiai. fu rhmovai. 



190H 



^- B. Every item of inforrrmtion uhoulil be cnrefully supplied. ACiB shoulil be 8tate<l F.XACTLY. PHYSICIAINS should 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from liome should be i^iven in every instance. 



V 



r 



tfc 









[ 






i, 



I 






« z 



ii' = 1 



i 



,1 



I 



« >.. 



1 



», 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ikunl nf ll«;iltli »•■ V«) 1=^ '^^^^H.S:!' Co 



l),ih' Filed, lL^\AAtj 1^ VJO H 




XLv-u Deput 



Registered ^o. ,1,09.0 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "d. S. Stan^ar^ ) 
PLACE OF DEATH: — County of ^-JCLAvOj'uX/Yur^ULCO City of UCUrv AxX/>X/C-c^c.c 



No, 



.lb 




It 




ChAl,' 



Kd. 



<X 



St. 



Dist.: bet. 



and 



(ir DEATH OCCURS KwAV FROM 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. / 

cm. JLuOj. C5\.' 



FULL NAME 



^\ 




u^o 



PERSONAL AND STATISTICAL PARTICULARS 



S)"\ 



fluU 



C( 



DATK ni' niRTM 



.\..|.; 



\U.LAJU^cr 



Month) 



(Dav) 



O JL 1 lii > V 



Mmitln 



(Year) 



Da 1 A 



MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH , ""i 



(Month) if 
I HIvRHIiY Cl'RTIFV, That I attended deceased from 



.1.1 
(Day) 



190 \ 
(Year) 



190 



to 



tliat I last saw h r— alive on 



190 
190 



MN'.I.K. MARRIKD. 
WIIXIUKD (IK DlVoKiKD 

Uiitriii s<Hial <i»-sij.'iiatioii) 



HfkTm'l.ACK 
'stiitr or Cotintrv) 



iatui;r 



HIKTMPI.ACK 
f>|- FATHKR 
Stritf or I'onntrv) 



OI- MOTHKR 



HIKTin«I,ACK 
<'l" MOTUKR 
(Statf or Cotinlry) 






'^'^-V,^ 




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



..kAAAJL..,,<'\^ .sJ..<C>-<<j4.\JL.-.k.VXU:Utj.> . 0^ 




AAraW, 




3vX\JC>-Cr*% 



'•rcil'ATlON 

Kf^idfi{ in Stin /■') t!ii( /u<> 



-L wet' 
^\.Oj 



DC RATION years 

CONTRIIUTTORY 



Mouths 



cU 

Days Hours 



Dl'RATION 



Years 



Months 



/Mrs 




\ ■ ^Jj.UJ.XiLLcXyvvdL 

UX> li ic>o't (Address) Lt'UryxXA^-:^ U^^^;. 
ECI'AL IN ' ■ ^^ 



( Signed )....UJ'Ur\\j2A' 

a 



Hours 

M.D. 

Xy'U^ 



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



Former or 
Usual Residence 



How long at 
Plare of Death ? 



Days 



)V,; 



M.-ntln 



n.i 



' "'.;.^'!9^'^- ^TATKH PKRSONA!. I'AR'f IC TI.ARS ARK TRTK TO TUK 
HhSl OF MV KNOW IJvDC.K AND nKIJi:F 

"f-Mmant It) KA\, 6fc ()t (y^^UATtoJu 



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



fi 






'\.l(i 



rrss 



IT^ACK OF BFRIAI. OR RKM<»VAI, I DATKof HI'riai. or RKMOVAI, 

^ -i H % % ^ 

INDKRTAKKR JVi^AAAA. ^ (J \D /CXXytX^yV/ 

(A.Mr.ss. Sb.lk^ \'\k)J *dt 



N. B. 



Every Item of information ahouid 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 Information*' f«r per- 
sons dyin^ away from home should be (iven in every instance. 



IS' i| 



«i ' 

I 



5 ■;.! 



'^ 



J' 



.IBTT 



f^ 



■1.' 



« I 




I 



I 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M.„. ! t II. alt). I No .^ ^-^E^HSii' <„ REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Ihilr FiJrd, \Xx^^^J^ \^ 19 0\ 




Registered Ko, 



fOOl 



VA^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "U. S. Stan&ar^ ) 
PLACE OF DEATH: — County of CJxXo^ JA.a.'>Ayev^,c< City of Cj/ClaX' JX/OLO-veyUL/e.0 



r^. ^X/:K.rr<kj 




^^tAj'X.K^ 



St.; — — ■ — ^Dist.; bet.- 



and 



(ir DEATH OCCufs *W«V FROM USUAL R E S I O E NC C Gt VC FACTS CALLCO FOR UNDER "SPECIAL INFORMATION * \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



■) 



(?i1 



FULL NAME 



(1 



PERSONAL AND STATISTICAL PARTICULARS 
IN /A - A I COI.OR 



I' \ Ti: o|- 111 KIM 



\f, K 





\ I » 



X I L.'J.A- 

(Day^ (Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII 

-<-Q i.i„ 

(Day) 



: Month) {{ 



190 'I 

(Year) 



Hb lV,/#> 1 



Mouths 



H 



n,i\ 



SI\<.i,i.:. MAKKIKI). 
W n)(t\Vi;i> (>K IMVnKrKI) 
Writ! in social <lc>iij.Miiiti(»n) 



MFKTmM.AOK 

fStatf Df Coimtrv' 



(^ 




oui; 



NAMK (>l- 

I- XT Mi: R 



HlkTHPI.AOK 
Ol- I- ATI IKK 
State or t'ountrv) 



MAII)1.;n NAM}' 
01 MOT I IKK 



HIRTMPF.ACK 
}>»•■ MOTIIKR 
(State or Country) 



(3? 



.OLA-vL^n 



^\JLu 





I4.II':Kl{IiV ClvRTIFV, That I attended deceased from 

-^ to LU..vOL...I.i IqoH 




t 



190 



that I last saw h A. > alive on 



LvXA^ 



and that death occurred, on the date stated ahove, at D 
LI' M. The CAl'SH OF DJvATH was as follows: 

vuV^wULtUx-U. O'. 





' <X.A.tL^rW\.XL;. . 



I)r RATION I Years 
CONTRIIUrroRV 



Mouths 



Days 



Hour. 



DURATION 



\^ 



Years 



Months 



^(r^K 






(Signed) 

L I t^y [ L iQo '( 
»EcmL Info 




Days 



(Address) <>^<X/\\JL 



h C^^\J:.ai. 



Hours 
M.D. 



?-. 



^ 



r^ 



J 



OCCUPATION 

f'^'^>idrd in Sou /'i on, is,;> X i )'rois t A/,>iif/ts I . 



/;,n. 



SPECmL Information only for Hospitals, institutions, Translrnts, 
or Recent Residents, and persons dying away from tiome. 

Former or q , ^ ^A 4. 

Usual Residence v)l^' dJXx.' \^-\\Xj 



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



"aj How long at 
'^ Place of Death? 



\\ 



15" (Ty-vcrr 



\Ajk^ 



Days 



"'Vi.M^'^^'P-^'I'^ '"»•"»> I'KKSONAI. I'AKTIi ri.AKS AKi: TKIH To 

lu-.sr ()!• MY kn<)\vmvI)<;k AM) m:i.n:i- 

^nfonnatit LU -^^^V^^O u\d 

(X.l.lress ^ ^ ^ O /OuZKXXy'yy^JU^rdji 



TIIH 



'AJ 



11 



C'O^xi 






PI.ACE OF niKIAI, Ok K1;m«>VAI, I I)AT}v)f Ht RIAL or KEMOVAI. 



I ni)i:rtakf:r 

(Address 



N. B.- 



-Every item of information ahould 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 dyin^ away from home should be ^iven in svery instance. 






f (j 'l^ti 






* 



j 






i 



i , 



it 



1 



'. 






11. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



II. :iltli !•■ No. I', f 



'"=^I?>f 



^•. WScV Cn 



REFER TO RACK OF rPRTIFirATF FOR I N ftTRIir.TiniM^ 




Registered J\'*o. 



f on^ 




Dale Filed, (Xo^ctvcA."fc l^ 100^ 

.dU/v-^ Deputy Health OfTlccr 

DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 

Certificate of H)eatb 

( U. 5. StnnC>avc> ) 
PLACE OF DEATH: — County of C^CL^ru J A.CuTVCuic^ City of 0/(X^vu J AX^LO^Ul^cV cui 



IVo. Lctu/V 





)(K.ivvjioJj St.; 



"Dist^bet. 



and 



(IF DEATH OCCUpA AWAV F R O ijl USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCt^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



D 




LxXWro 




PERSONAL AND STATISTICAL PARTICULARS 

i Co I, OR 




1 ol l;|R 111 




N J 



A 



•f 



M..nth^ 



H 

I);iv) 






MEDICAL CERTIFICATE OF DEATH 

DATH Ol' I)i:.\TII 

(I):iv> 



CL 



(Year) 



^' .I': 



bo )•,„;> I I Mnvl/l.^ I 



Pi! I .^ 



"^'N' i.i" MAKk n:i). 

v\ ii>o\vi-:i) OK i)ivoKi-j-:i) 

'\\iitiin ^oci.'il (It — iLMiatii 111) 



I'>IK•rnl'!,.\^•l•; 

St;itc i.r r<)iititrv> 





NAMK ()|- 



!'-lk llll'I.XiK 
^"•" lATHl-lR 



^^AllM•;^• \\mk 

OF .MoTIll-.K 



"J" mothkk' 

<^t.itc or Coiintivi 






(Month) f 

1 lIi;i<I';r.V CI{RTIFV, That I atU-n.Ud .Iccoased from 
VAAA.Q. l\ iQoH to CLo*.^ \% 



^O^ W 



1 90 



.'J 



that I last saw h -'- • > » alive on 



IQOS 

I9O '. 

ami that ilcath occurred, on the date stated above, at A- 3 
*^S: -^f- '''J><-" CArSl<: Ol- I)i;A'riI was as follows: 





^X-^vVAjdXcL^ 



DIRATION Yrars 



CONTRUU'TORV 



Dr RATION Vrars 




i Signed ) 



crr\) 



^v 



OCCUPATION P 



c-t 




a 



Cvq l^.TQo'i C Address) 



lAL IN 



Mo}iths /hirs Hour. 

.'>JLK.dJkJ'..Ar^^ 



\ft>nt/is /hiys Hours 




SPECIAL INFORMATION on!v lor H^spitdls, Institutions, Transients, 
or Rerent Residents, and persons dying awdv fro-n home. 



Former or lUA^iM Jj M 4 il How lonq at 

L'sudI Residence I \^^ CtUUav 0/aU UvK pjare of Death ? I 



Days 



Mouth' 



I hi 



'""V;,^'!,?^'»*- ^■'"\'I'»"I' I'KR'^OWI. lV\KTh-ri.\Ks AKi; \-KVV. 
"l-.sl o).- Mv KNo\\ij;i),;h aND ina.Il'.t" 



i<) Till-: 



n 



•"'"""■■".t UJrv^. VmI. X<x.a.>o4^^ 



f X.ldress.. 



N. B. 



Kverj 
state 




Xt-vlc. obo^kAltaX 



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







I'l.ACH Ol' JU KlAI, OR K]:Mo\AI. 



I'A'ij:..! i'.i niAI. .ji KJ^Mi »\,\J, 



ot 



1 



TQO'i 



(Addrc'' 






>■ item of information «houl(l be cnrefuMy supplied. AGC should be stntcd F.XACTLY. PHYSICIANS should 
CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information" for p«r- 

Ciyinli nv%'flV from hnmn shniilil ho atiion in <>%/<>r>%^ ' • not •• nr». 



sons dyin^ away from home should be Aiven in every instance. 



^m 



.< 



i 






*; 



I J 



V' 



h 






'iii 



I 



I 



i 



i 






II: 

III';; 



Pi ' 



I 



ii 



' *WS^ 



\i 



\i 



n 






^i 



J I I ' : i , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 , f ii< ..i»l,--l.' Vn It ««>lltt<Ski li/C- 1' (' 






/)/t/c l''il('(l , LU_A..QAA^ 1*^ 



190 H 



to^c^ tiLa)-M Deputy Health, Officer 



Registered J^o. j./>93 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "a. S. Stan^a^C> ) 

SI ^ J? 



% 



■X 'Op -V H)l) 

PLACE OF DEATH: — County of Ooyvu J XXLTUMA'Cf City ofOovYu AXX/Vu-CA^ ex 



No. 



(IF OCATH OCCURS AWAY mOM USUAL 
ir OCATH OCCURRCO IN A HOSPITAL 



St 



. ^ 




i 



Dist.; bet. ^^ ^^^Uf*OJ\j and cL(.ytn\; 

RESIDENCE Give facts CALLCD roR UNOCR "sPCCIAL INrORMATION-TV 
OR INSTITUTION GIVC ITS NAME INSTCAO OF STREET AND NUMBER. ]/ 






FULL NAME Oo/^^^a^ulJ 





>^xi' 



PERSONAL AND STATISTICAL PARTICULARS 




I 



Ou^ 




.'Ji'A^vjtjj 



DA'll-; oi- HIKTII 



\' .!•; 



iMoutli) 



'J) H Yr,,,.. 



(I)av) 



Mouths 



(Vcar) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH r\ 



(Month) 



Da I'j 



^IN'<.I,K. MAkKIKl), 
\VtI)(»\V}.:i) ,)K DiVoRCHI) 

Uiitt ill MK'ial (l»-siKiiatinii) 




nrKTni'i.ACK 

'State or Coiniti v) 



NAMK OI- 

I- ATn-:R 



'>IKTIIP!,AI-K 
Of" I ATMKK 
'Stntr or Couiitrv^ 



MAIDKN NAMj.- 
OI- MOTIIKK 



'nKTlIPI.ArK 
OI MoTMKR 
'Stat< or Country) 



H 



o<y\j\.Kju6. 



tn>ou CJ /C<rL^^x>j 



(Day) (Year) 

.1 HKRKBV CivRTIFY, That I attended deceased froiii 

jCLOrV. ^ I90H to AAa^^MD^..]^ i<jo*1 

that I last saw h ^- • *\ alive on 




^...A 190 1 

and that death occurred, on the date stated above, at 1 
Uj^M. The CAI'SIC OK I)I«:.\Tn was as follows: 




'©^ 






OL^VO^ 



\ 



i.../a-y.-.i^ 

Dr RAT ION Years 1 Mouths Days Hours 

CONT R I HI TOR V iL'xvw.^xjLVv^i.A,<o... 





CLAvd^ 




I)rR.\TI()N 

(Signed) 



V 



Years 




Mont/ts 



/CO-A^l 



li<A.a l^. iqo'l (.Address) be '\ 



OCCUPATION 



ffrs'iilfd in San J-'iamisro H H )></;» ' Months 



n.iv: 



-q i^t IQO \ 

iOIAL INFORI 




/lours 
M.D. 



-tVvwa (J t' 



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



' "^l.^J^*^''^.^'''*'^'''^•'' ''HRSONAI, I'ARTICn.ARS ARK TRIK TO THK 
"f-.ST or MY KNOWI.KDOK AM) WVAAVW-' 

(Informant NPlVUi O 0<yyy.^KjX U) ivuXcX^X^ 



f X'Mress 



^^SH (l.v^vx di 



Former or 
Usual Residence 

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



How lonq at 

flare of Death? Days 



PI,A 




RIAI. OR RKMOVAI, 



DATK of Ht KiAl. or KKMOVAI, 



INDKRTAKKR O (JVcLtVw UOlAX LL'WCt<:iX 



I90H 



(Address ^HV^ 






N. B. 



Every item of informution should be c 

state CAUSE OF DEATH in plain term., ^ . 

«ons dyin^ away from home should be tiven in svsry instance. 



ape?ully supplied. AGB should be stated EXACTLY. PHYSICIANS should 
ns, that it may be properly classified. The "Special Information" for per- 



mmm 





• 



m 






< I 










s* 



l!l^ 



^i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n,^•.^,! .,f IN mHJi I" N'o. m 



ji&r Co 






/>.//r r/hff, \X^uuQj(u<j^ n loo'i 




Registered J\^o, 



1004 



Depu^'v ^' 



OvTincr 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( la. S. StanearO ) 



PLACE OF DEATH: — 



No. U 



.cL IL 



County of OOyyv JAXX'-YVCULCtCity of C /OlA\; A.cX/v\aia.<L'C<o 





\X>^>^<1) J^A^UX' St; S Dist.; bet. M 1 lAAA^Ura) and 0^ CrUX)L\d ) 

/ ir DtATM OCCURS AWAY FROM 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 




■rXX/^U 





Lh.. 



PERSONAL AND STATISTICAL PARTICULARS 

^^••■^ (JP "ft I COLOR 

I Month) (Day) (Vear) 







Xi 



rVcX.je. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH /I 



(Month) A 



n 

(Day) 



190 \ 
(Year) 



'^' i-; 



Id IV,;,. V 1 



Mofilfis 



1:1 



Pa r.v 



'^IN'.l.K. MAKKIKD, 

U IDoUKD OK niVOKiKD f) 



IUKTHI>I,AOK 
< State or CcMmtrv 



NAME OK 

»atmi:r 



»IKTMI»I,A('E 

oi" iatmek' 

'Statf or Oomitry) 



MAIDEN NAM I" 
«)» MOTHER 



HI KTH PLACE 
<')" MOTHER 
'State or Country) 






I HKRKBY CKRTIFY, That I attended deceased from 

w..^ X 190 ?. to .CLa^ i.:x 190 4 

that I last saw h ^\.' alive on LA>Aa^. 1 lu iqq ^ 

and that death occurred, on the date stated above, at 
M. The CAUSE UK I)I{ATII was as follows- 

txAAh^AjLcLV' ^..\j^iju>^sijK.. ai.:LiLiL..^jL<cL/.ut.. 



. \-kLL%. 




VkXju 



D r R A T ION } 't-ars i Months 1 T Days 



Hours 



CONTRIBUTORY 




« 






UA,<Uc 



Xi2y>\Xu 



CLvAi 



DURATION 
(SIGNED) 



-L{pr\^A'\XcLuccct; 



occrpATioN J n n A 

Vfsiifnf ill San /■'niii,/J?ti | I, )',,// v 



)'r(irs Mouths Days 

SPEC^L INFORMATION only for Hospitals, institutions, 



Hours 
M.D. 



or Recent Residents, and persons dying away from home. 



Transients, 



Months 



l)ii\. 



'"i;rJ'r*y7.'^J^ '''■•" J'HKSONAl. PA KTICC KAKS AK E TRIE To TFIE 
i'EsroF MV K.NOWl.EDC.E AND MEI.IEF 

F n 

(Address II O A^XX/^^cL \Xj 



Former or 
Usual Residence 

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



flow long at 

Place of Death? Days 



\>^„ 



ri«ACE OF RFRIAI., OR KEMoVAI. 



DATE of Hikiai. or REMOV.^I, 

\^/\^<y^ :) Lu.,x^_^ XC) J 90^' \ 

INDERTAKER M ' V \iKry\^>r\, ^^Kjy^' 




-t 






(Address ... 



ixu Ofla'CUUL^tL^it 



N. B. 



Rvery item of infnpmation ahould 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** fer psr- 
«ons dying away from home should be given in svery instance. 



^1^1^ 



I -J 



, \ 




i 

i ■ 

t 

( 



1 



• » 




n 



• I 



^.i 




uu • 



it 1 






WRITE PLAINLY WITH UIMFADINQ INK — THIS IS A PERMANENT RECORD 



WiarMcl lliaiin I- .-^lu. i> -»-^z"gg jH »^pi m.x i v.«* 



REFER TO BACK OP CERTIPICATC FOR INSTRUCTIONS 



/)(f/i' Filed ^ 




la 



lOO'i 



Registered ^''o. \.9.D.D 



Deputy Health OfTlcGr 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( \a. S. StanOat? ) 
PLACE OF DEATH: — County of OCLn^ vJACL/^ruiAA^lx^City ofO/CX/ru JA^0l/>TX1c^c.Ci 
■No. ntU \iri^-^^c<nv St.; S Dist.;bct. 15^ .fcn. and \ikl\ 

/ ir OCATH OCCURS AWAV FROM USUAL R E S I D E NC E G I VC FACTS CALLtD FOR UNDER "SPECIAL INFORMATION" ^ 
v. ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



11 



• n 



) 



FULL NAME 



o^Va^l 



Uu 



XAA,^^jy\j 



■i,\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI/)R 



0. 



I»\ 11. ol- HIRTH 



<xXx 



Uj>lviLv 



MEDICAL CERTIFICATE OF DEATH 




I Month) 



\ ''.»■: 



t 1 lV,/». 



(Dav) 



Motith' 



0-. • 
(Year) 



Da I .s 



'^I\'.I,K. MARklKl) 
WIIMIWHI) OR DIVORCKI) 
'\\rit. in scH-ial <lcsiKnation) 



lilKTMPI.ACK /-\ « . 

(Statfor Country) (^ \ P 

NXMI-: 0|. 
lATHKR 



"I k Til PI. AC F 
'>'■ I ATHKR 
iStatr f)r CountrN 



MAII»i:n NAMl- 
<>1 .MOTIIKK 



'ilKTHI'I.ACK 
<•»•" MOTHKR 
(Statf or Countrv) 



'»* crpATiox 



% 







DATE OF DKATH /O 

Uxu:i 

(Month) k 
X HHRKIiV CI':RTIFV, That I attemlc.l .lecca.sed from 

So. igoH to LAaA. 




tliat I last saw h •• 



..^UwA^OL i: 



n 

(Dav) 



n 



igo^K 

(Year) 



190 H 
alive 0!i LAwC^Ol 1 1 itp '( 

and that death occurred, on the date state<l above, at 4 

v.: M. The CAl'SK OK DI^ATH was as folIf)ws: 

....X.qJw<v. 



.t„v.L 



^i^ . ..i 



"i (S^V H d^CLM/^ . .4AA>Xy»A.^->-v>i.' 



-i \.^ V 



Tv 



DrRATION Years Mouths \nays Hours 

CONTR IIU'TORY U Xd/. .LL.C 



T 



> ud.. 



Hours 



DURATION Years Months Days 

(SIGNED )...\Lri. U. xXxajlLa^xj M.D. 

II iqoS (Address) ?)?) ^ (0 - R jj^, -^^t 



CL/'y^cL 






M,H,tln 



/hn 




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



'"nvc'r^y.^- ^7"^ '"'■•" ''HRSONAI. I'ARTICn.ARS AKK TKIH TO TIIK 
Hhsr OI- MY KNOWI.KDC.K AND HHMKK 



(Address 



Sll 



N. B. 



cUhx 



Former or 
Usual Residence 

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



Hew lonq at 

Place of Death? Days 



PLACK <)I niRIAUOR KFMOVAI. I DATK of IJi kiai. or RFMOVAI. 



.'V-t 



1 : R T A K K R <) ^rLAjo-v\j a <xtx Uw-^ V<3Lo 



I90H 



(Ad( 



VI rLv;CyCLA..<rv 



^^fcry item of information •liould be carefully Hupplied. ACjE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in ploin terms, that It may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be ^iven in every instance. 



1 ♦ 







T 

11 



I 



\ 



I 






mm 



. 4 



<m. 






4T 



L^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 ill .. 1 * t. i; N'-* 



.^^gf^'V . 



1 ) C. I i f * 



-t ••%«.• 



MfehtM ro HACr\ OF CERTIFICATE FOR INSTRUCTIONS 








IS wo\ 

Deputy Health OfTlccr 



Reginlcred J^''o. 



f 0^>fj 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of E)eath 

( ■a. S. StaiiJar? ) 



PLACE OF DEATH: — County ofOoyro OAxxyrvCAA,<Hi City of CVq-a^ Axx^-w^cA^o^tjc, 

St.; Dist.; bet. and 



/ IF DEATH OCCURS AWAY TROM USUAL 



(IF DEATH OCCURS AWAY FROM 
IF DEATH OCCURRED IN A H 



RESIDENCE GIVE facts CALLtD FOR UNDER "SPECIAL INFORMATION ■ \ 
OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

1 coi,()k 



Vyi/YV^-lJLAj 



:l 




\i 




A li-: (ii KiKi'ii 




iM.-ntJi 



as 



) 'ii I 



(Dav) 



M.mlli^ 



Mat 



(V.-ar) 



Da 



MEDICAL CERTIFICATE OF DEATH 

DATIC ol' nivATII 



a. 



(Month) K 



(Dav) 



I go 'i 
(Year) 



^INt.I.i:. M.\RRll.-l> 
WIDnWKI) (»K niVoKri:!) 
'\\i iff in ^.K-ial di^ivMiatinii) 



'Slatf or Comitry^ 



\ WW. oi- 

I- A III j;k 



-i ^ 

JWULO ' 



I IIIvRllHY C1{RTIFV. That I altcn<le<l (Icccascd from 

\^^Xu 11 190H (() LLl.i/ql .11 T90 H 

that I last saw h^i^nv alive on vJ>wVA-a \'\ ^p \ 

aii<j that iKatli occurred, on the date stated above, at il 
!^ M. The CAISI- C)l- I)|;aTII was as follows: 



"iK'nn'i.ACK 

"!■ I-AIHKK 

I stair or Cdiuiti v' 



MAI1»K\ NAMJ- 
<»)• >toTHKK 



"IKTHi'i.ArK 
'»;•■ MOTHKR 

'Slatf nr Coiuitrv') 




'^x.CrWrvv 



DC RATION Years (o Mouths Days I /ours 

C N T R 1 1 ! r T ( ) R \' U^X^uCt(rruJ:AJ^ J JuJLL^/<iA,AjU. H. a. 







Days 



II'ATIOX J. 
^^^^ f^rsiilnl in San /'i ,rii,is/-,i " )'>,r/< O .1 A ;■///> 




)?(7rj U, Mouths 
N ED ) fc . M ; UxLcUjUl.'CL.'L< 

I'i rqoH (Address) 5^0 5" ^AAJMnat ^1 



DI'RATIOX 
(SIG 



Hours 
M.D. 



5^ 



/>r7). 



"nrJ-r'^T-^'"^'"'''* '•'^•HSONAI. I'A K T IC T LA K S AKi: TKIK To 
'5'-SI OI- Mv KNOWI.l-nC.K AND Hl-I.n-f' 



Tin-: 



fliif'Tiiiant 



'Address 5^0 5 i)x.v.j^.^AX CJI 



Special Information only for Hospitals, institutions. Transients, 

or Recent Residents, and persons dying awny from home. 

Former or i ^ /s [ \ \ \\^^^ '^"1 ^^ 

Usual Residence iOO VXXXUrCx yuvol atpjare of Death? 

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




3(. 



Days 



I 



I'LACI-: OI" IHRIAI. OR RHMoVAI, 




I)ATi:<)f MiRiAi. or RHMOX'AI, 
INDl'.RTAKKR LAj • LU VI Fl/X^jX^^'^VV. ^<^ L^O 



r 



fAddrt-ss 



N. B. 



Hvepy item of iiiforitmtion should be carefully supplied. A(jB should be stated EXACTLY. PHYSICIANS should 
state C.4USE OP DEATH in plain terms, that it mjiy be properly classified. The "Special Information" for per- 
sons dyin^ away from home should be feiven in every instance. 



t ! 




1 ' 

mi 



■ i 




r 



'!■% 



• ,» 



I! 







« 



■i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



II 111. • • V 



> .-- -ft---- -?, ..:. II V- l> (>,. 



ncrtn iw i3M«-r\ ur utKHKiCAfE FOR INSTRUCTIONS 



/)((/(' F/7r(/, U^^LA^xiyu^o^ ICi 




Jf)0'i 



(y\A..\^ 




Bcgii^fci'ed J\^o. 



J097 



'A 



Deputy Health Officer 



DEPARTMENT OF'PUBLIC IIEALTH-City and County of San Francisco 

Ccitificatc of IDcatb 

{ "U. S. 5tanNuC> ) 

PLACE OF DEATH: — County ofCjCL/w JAXI/^XCoiCc City of C' CLA^ /VCu-^^ca^Ic^o 



St.; 



Dist.; bet. 



and 



/ IF DfATH OCCURS Afl/AV FROM 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 



I'V^'V 



^. 



'cL 



o:i 



PERSONAL AND STATISTICAL PARTICULARS ^■' 




i "I I'.ikrn 



' Month* 






MEDICAL CERTIFICATE OF DEATH 

DATK (>1 I>i:.\TII ,o 

IS 

(Day) 



^Moiitli) /' 



(Vt-ar) 



\'.). 



1,1 \' 



M.nitl,^ 



l\t 



'>vii». »u i-:i) UK i)i\c)Kti.:i) 

' \\'l itl- ill -n(i;il ,1, v;.f.,.,ti,,,,) 



'niitr\i 




.ucLct^amAj 



NAMJ-: OI- 



''■IK'I'HI'I.ACH 

Of' i-.\rm:K 



MA1I>I:N NAMl- 
'>!•• M()Tm:K 



J5iiniiiM,\c,.- 

iStiilc or c"(>iiiiti\t 




^A. 



c». 



I III:RI:15V Ci:kTn-V, That ^ allvn.lc-.l .lecoascd from 



tli.it I last saw li •■- alive oil vAwV\,/Ct, 11 Too S 



ami tliat <loatli orrunt'd, on tlic «latt- stati'd alx.vL- at 5 
y .M. TIu- CArSI-M)I- l>i:.\TII was as follows: 



^v^C 









I )r RAT I ON I Yearn X Month 



X 



CONTRIP.rTOkV 



c 




^rotlth} 



ocerr. 




/\f'lifrif ill Siiii /'i III/, rr.i c*^^ ' 



(Signed) j /^vcn^^ou-i 

a 



/hJVS 

0. 



/>ays 



Hours 




//on 



I )r RATION' i )V,/r.? 

J /^VCrv^^ou'i ' 7.^r\^^>v<X.^v M.D. 



.U^O X\. r<,o 1 



JaL iNFORi 



f 



SPECIAL INFORIVIATION only tor llospildls, Institullons, FMnsienls, 
or Rpfpnt Rfsidpnts, dod persons dying dv^jy fro:n homp. 



lA'/z/Z/v - /*,, 



•n'sroi Mv KNOW ],i;i)(,i-: and i!i:i,ii;i- 



formpr or 



Isiidl Rpsidencf i H :) X^j O/Vy^^i) Vct'vu) Uuf i^re oi Dfdth ? 3 



lioH long iit 



Days 



Whpn Has diseasp ronfrac Jpd, 
If nof at plarp p f dpath ? 



(I 



'f'>nim„t lij . (i . "jU./>-.J[>^ 



\-l<ln-ss Xl.5 ^ 






:::u 



/<x-\^X jXj 



I'l, AC}-; < »1- ]UKIAI, (»(^ kl.M«i\AI, 



HAD-; ..! Hi Ki.vi. oi Ki;M()\-,\f^ 






TQOS 



fA.Micss 



' • * fivepy Itom «.>• iiif )rmiit!on should be cnrcfully suppl5<.<l. AfJIi Hhrmld be Ktiite*! r.XACTI.Y. PHYSICIANS Hhoiild 
stntc CAlJSn OF DI:A TH in plain terms, thjit it mjiy l>e pr<.pcrly cluHsiried. The "SpccinI lnJropmiitt(m" for pep- 
sin* riyind "wny from home should be l^iven in every instfince. 



m 



»! 



II 



■f 



f ' t 




'VI 



j 3 I'l 



m 



\h 




''f 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

* « - ncrcri lu ciMur\ OK CtRTIFICATE FOR INSTRUCTIONS 



I)ff/r riled, LWxx^v^ ^0 100\ 

Deputy Health OfOcer 




RegLslered Xo, 



1098 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( *U. 5. Stanc>aiC> ) 



PLACE OF DEATH: — County of LAXa/vv\JU:LcL City of 




^ 



J /vAA.AX^^oJLX' LxxX 



No. 



St.; Dist.;bct. 



^5T1^ 



r " °"":" OCCURS AWAY TROM 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. ) 



lA 



FULL NAMEvrU 



\Xk} 



CML. 



i ^wA^ 




'^v/cLoV^xn-\' 



PERSONAL AND STATISTICAL PARTICULARS 

rnl,(»K 





JL 



j\\.OJb 



■I I'.IK I'll 




\)\^kX) 



I NToiiili) 



)', 



H 



IS 

* I):iV> 



M^.utll^ 






4 fit I 



MEDICAL CERTIFICATE OF DEATH 

I)\ri-; ol- DliATH 

(I)av) 




( Month) /" 

I 

1 in{RI-:nV CI-RTJI-V, That r attc-n.kMl <ltHvase<l from 



(Vcai) 



■S^ /„, 



4 



\ litOUKI) OK I)I\-(>Kri;i) 
111 sociril ih Ki^'iiatioi! I 



'■■IK rui'i.Aci-; 

M'ltc or Ciiuiiti y 



\\M1 <>!• 

I Ai im:k 



'"■ I \rin-K' 

■ ' .■.inti\i 



M\II>1<;\ NAMF 
'" MOTIII'IK 



I^'KTlll'I.ACl.- 
OI" MOTMHK 

'^t.-it .1 r.,niifrv) 



"' * I f \1'1<)\ 




1 90 



tn 



tliat I last saw h ■- — ~ali\c on _ — 

aii.l tliat (k'ath orcurreil, on the date stalid ahove. at - 
~ 'h^- l'^^'"' ^■^^'^^'' ^•'•" '^i: \'l'n was as follows: 



190 
190 






y^i'^'K! 



Aji\AJsy\j 



DC RAT I ON Yearn 

C"()NTRini TORY 



Mo}itlis 



Days 



//on IS 



1)1' RATION 

(Signed ) 



)'(\7rs 



Mouths 




/Xns 

(0 ' 



/fours 




U)W^UAJ M.D. 



O.C i(,oH ( 



A.hlrtsv,) U.CXyVLLou^vdw v^. r 



Special information «nl\ for Hospitals, instilufions, Transients, 
or Recent Residents, and persons dyin-] .may fro.ii home. 



A'/'. /,//■,.' /;/ Siw / I .;/,, 



)V-,r 



,lAu////« 



'•' --l ')|. MN IsN<)\\ij.;i),;h ANI> Hl-I.Il'F 



Former or 
Isual Residence 

Wfien was disease ronfrarted, 
If not at plare of death ? 



Hgh lonq at 
Plare of Death ? 



Days 



1M,A(.1-; ()!• ItlKIAI, OK k};Mo\ \I, j I )AI"I%_t.f IUkmal m ki;M<»VAl. 



^'•'''•■'^'^ h^^^AXX/\><)<JJL L^CuL 



^jrvAX' 



■^y^iJ (^../Ow-A-A^f-', \^ 






i9o'\ 



'?, I 



A^ 



Aaa./W'v^->v '^ Lc 



V^^u<r-V V 



N. It. 



-ivery item oV infopmiit W.n Nhould b.- »;iiroY'iilly supplied. A(IF. K^oiild he Htnteil F.XAC TI.Y. PilYSiCIAISS hHouIcI 
Htntc CAlISi: OF- DI^ATH in phtin tcriiin. thnt it mjiy Ik- properly cluHsilticii. The "Special Informntion" for p«r- 
Ron« clyinft away from homo should be aiven in every instnnce. 



I '}!? 



I ! 



i iW E 



h 




I 

I 



Hi' 



lfl» 



1 



^' 




•J 



'i» 



f ^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



*1 



REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 



1099 



XAr^.^..^^ S<ju\>\jL i-^eputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccitificatc of Scatb 

i ^^ J 



(Jl^ 



No. 



PLACE OF DEATH: — County of 0/a.'>v ayUX'>\A^iA^cCity ofO,<X^v AxX-N\'C^iL-ec 

T \\ d\XtA^^^c t. St.; 1 Dist.; bet.U^^U>Jul andMlV^ltaM tlv •) 

( "^ ,7*1" OCCURS .w.y TROM USUAL RESIDENCE cvr tacts CALuro tor under 'srecal intormation \ if T ^ 

V .r OrATH OCCURRCD ,N A HOSPITAL OR INST.TUT.ON GIVE ITS NAME .NSTEAO Or STR t ET AN D N U M B t R ) d 

FULL NAME oL',auLM. iJ (rwdx^^c 



PERSONAL AND STATISTICAL PARTICULARS 

07) A i COI.oR 






I'ATl-: (•! liIKTil 





t 



V^C<,k_ 



©^ 



iMoiitli) 






, "^.l 



Day* (Vc:ir) 



» <':ir I 



l-x 



S 







M- MAkun:i) 
'* -" >Ai:i) (»K i)ivi)krj.;n 

Ml >..H-i,-il (It sivMi.'itioti) 



lilKTlll'I. \k'\: 



iiiiiti \ I 



NAM}- (»l- 

I atiii:r 



niKTiii'i.An* 
'>H^ iatiij:r 

'Statfor Coiiiitrv" 



MMI.i:\ \.\M}.- 

"' M'>i"Mi:k 



''•n<Tin'r,\cK 









'WO. 




-Oj 




MEDICAL CERTIFICATE OF DEATH 

i)\Ti-; oi- i>i:ath /"^ 

J HI:RI;1',V Cl-:kTll'V, That I alu-ndrd .Iccoased from 

\Xkj^ X ic^oM to CLvux i% iQo^ 

tliat I la^t saw li • ' alive on V,Aaa.<T^ \\ iqo'; 

iiiid tliat <K'at1i occurro.l, .>ii llio date statocl al.ove, at ^ 
'W '^''" ^^AISI-: Ol- I)l-:.\Tn was as follows: 

1)1 RATION }V.j.9 JA.;////,. Day, H J/onrs 

CONTRir.rTORV 0<X/^t>v<i L/>^tcA,vtvv 

'*' ''^•^'''^*''' r\"'/^ ^ Mouths Pay, Hours 

(Signed) i. 6j . vb.CLava^cx.^cU ^u m.d. 

pecIal infori 



Special information onlv for Hospilals, Institutions, Transients 
or Recent Residents, and persons dyinq .mjy from home. 



.lA.;////' 



//. 



'".M <)!• M\ KNowij.-ncK AM) iu;m!:k 



Former or 
Usual Residence 

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



How lon<) at 
Place of Death ? 



. Days 



A^-0^/>x\>vrv. 



Uo, B: 



I'l.ACK OF niRIAI, OR RHMo\AI. I r>Ari-:..r KiKiAi, ..1 R]:.M()VAI, 



.very Item of ln?orm?ition should b^ capot'ully supplied. A(7B Hhniihl be stnted KX \CTLY. PHYSICIANS should 
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Inforuiation" for per- 
sons dyinft away from home should be ftiven in every instance. 



I 



il 



. ■ f 












tf fli 



# 



V ^v 



r'l 



•^jgg- WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



-*■ 



r Jtentth-'t' Nn. n v-v.-wi w*,; riiv r r. ■ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



b 



Ihf/c n/rd , LAAAX^LAAfc 3^0 



liJO^ 



lt('(^i,s(('i'p(l J\^(). 



1100 



,>0-^^><^A>0 



Deputy M 



-- f * 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of 2>catb 

PLACE OF DEATH: — County ofOO./^^ v) AXX^-vcuicCity of CCoaj J /L/<Xo've/oa.c,o 



No. 




/<xCurV\j 




4- 



^1^ 



Ch-<lK^ Va.l St.: Dist.; bet. - -— and 

f l|t DEATH OCCURS AWAY FROM |U S U A L R E S I D E N C E G I V E TACTS CALLED TOR UNDER •'SPCCIAL INTORMATION ' \ 
V (J ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME V l^lcuva^xKjdj l) 



PERSONAL AND STATISTICAL PARTICULARS 



i 

i 



^J-^./»^^oJLx 




i;!K rii 



Llx' 






Si 



! I 1 \ I 



X\o 



; I 



i' 



' l.J". M \kUIK!) 

'' "-ij-'lKil : 



■ itr or Couiltl \- 



Ml 



I atiii:r 



ISIKTHpI.ArK 

■ t.'iiiniti\- 



NfAIDKN XAMj.- 



'-K lill'I.ACI-: 

' *'<il1 lit ! \ 



w . 

Ox-wcJoL 



rXAjtx 



1 



A,t*-«J- 






MEDICAL CERTIFICATE OF DEATH 

I' All', Ml- I>i:a TH .-^ 

'Muiithl K (Day) 

I III-RI-P.V CI-;KTI1-V. That I attcMuk-.I ik-ivascl from 
UL»^VO r^ uyo'i to (Xla.Ql l^ up 4 

tliat I last saw Ii .-•-.. alive on L\A.a^D i6 im''. 

aii.l that death oi-rurrcd, on Ww date statL-d" ahovc. at "^ 
Ja ^r. The- CAISI- (>!■■ I)i:.\Tn was as foll-.ws: 






<xXvv/CL,^'^ 




/ -\JCL\.^ 




'O^'^Y^CA^ 



I )r RAT ION I }\ars 
CONTRIIM ^()RV 



I)^K.\TI<»^■ 



JAv///^? 



/''./j.v 



/\n 



MnvcL/>voc'\l ' loJury\ji>., 




J 



i; 1 f 



»ii.^ 



r \'i ii ).\ 






( Signed » H^1X^ (ft), ax-upv^^wv- 

LU cQ 11 T()o's r\ddns.) Ho^3) -aH.tL Bt 

EGIAL INFC 




Special Information «nly for Hospitals, Institulioas, Irdnsienls, 
or Recent Residents, and prrsons dvin.j dWd> fro.n liomf. 



Former or lo^^ Ai+f "^4- How lonq at 
L'sual ResidenceoO OA " ci^H ^C^Vv O.t Place of Deatli ? 



i 



Davs 



"■^■' 01- -MS kn')\vm:i)<-.h AM) i5i:mi:f 



r.iint 



.^\JL\^r' 






When Has disease tonfrarted. 
If not ^\ plare of deatfi ? 



ri.ACK OI- niKIM, OR Ki:M(.\\I, I DXIK.,;- P.iiuai. .,1 kj:m()\ai 



'm.< VV 



^^^ 




1 



/■> 



INI 






190 H 



fAtMrcv> 



N. B. 



A-— < 



-Fivery Item of information shoulil be carefully supplied. AGK should he stated BXACTLY. PHYSICIANS Khould 
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 j^iven in every instance. 



i ! 



>. 






Vtk 



m 



t 



I • « 

I I 






..f 



'1 






giT WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

'"""'"'"'""" ''•^'^■^^ ^'^^^"^'•^•" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dill 



(' Filed , LIa^vO/wV^ 



"XO 







10()\ 



Beiistered Xo. 



1101 



Deputy Health Officer 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Scath 



J? ^ 



JPLACE OF DEATH: — County of CL/>\; O^CL/YVCo^bexCity of (JXX/>V J-^LXXA-uCAA^ac 



A / IP DEATH OCCURsJTaWAY FROM 



( 





vcL 



Cul St.; 



Dist.; bet. 



~ and 



USUAL RESIDENCE give facts called for under "special information • \ 

IJ \ IF DEATH OCCUf»RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 




Cr' 



ucLc' 



■)\. 





. 1 i; < 'I' IMRTII 



^HH 



MmiuIiI 



loO y..u 



'Davi 



Mm 11,^ 



I\i 



i .E 



♦t : , 



-i'-'.l.i;. MAkklJ-i). 
H!I)n\VKI) OK l)l\( »RC ).; d 

^^ ■ ' ■ ■ il ill si).M);iti'ili) 



'Stiitc or roiinli \ 1 




I 




• ( 



' ■ ! r III 
1 Alii Ik 



'^'•" I \Tiii-k' 

' ■ mil I \ 



"^'MI'l'.X NAMl- 
Ol M«iTm;K 



I"Hllii-i,\ii.- 
<>!• MoTIIKr' 

"^i 'II- or C".miiti\'i 



m 







MEDICAL CERTIFICATE OF DEATH 

^M.iutli) I fl);iv) 

II^«;RI-:i:V CM^RTII-V. That I attcn.U-.I ,lc(x-ase,l from 
IS up'i to IAaa.^ l*?i 

that I last saw h j'v. mUnc oh vAaa^Q 1 1 



(Vtar) 



T90H 

and that (k-atli oc^-iirred, on the- <latf statc-d ahovi-. at W'h^ 
^^ ^'-^r^^' ^^\IS '':,<> I- l)l-: ATII uas MS follows: 
il9 XA^»^V^LtCt\.tU 



(rvvo 



lOJ 






DC RAT I ON Yrars 

C()\TRli:r'l"()RV 



Mouths 



Hays 



Hon 



IS 



OX'WaX. 




Ol/yx-cL 

? 



or RATION 



Months 



^' 




OiCll 



•ATlONigV? 




(SIGNED) Uj/Vv\;Mri/X,Cu^^vrLcA^ 



Pays 



I lours 
M.D. 



.vx:^ l"i i.)oH ( 



Xddrfss) vaX^, X Lo (/l:^-^^^. t 

iTION only for Hiftpitdls, Inslifiitlons, Irdnsients, 



Kfsidnf in Sdii /'nun;.,;, 'X% )',■,,• 



1/-./////. 



/',/■ 



1 ■ 1. ^vl V !.','•• "i.V"'-'* '''''^^''NAI, PAkl-UTI.ARS A k l'. Tkll-: To T ! M : 

'■'>i <)i. ^1^ KNOW! i.;i)(;i.: AM) iu;mi:f 

c.a'tciZjL, 



SPECllAL INFORMAT 

or Rt'rent Rt'siiltnfs, jnd persons dyinij dw.iv from home. 

Usudl Residence k)05 ^JJ^^KX^<LLA^a^ jt PLirp of Deatfi? l^^ 



When was disease rontrac ted, 
If not af plare of death ? 



■] 



Oavs 



I'l.ACi-: oi' itrkiAi, Ok ki;Mo\\i, 



\iMm 



M XI'J-; 11! i'.i in.\i. .11 k I'lMoVAl, 






ll 



— '' 



T90H 



I. very item <.V inlformiition should b.- cnrofully siippMuMl. Ad'li Khould ho Htiiteil riX^CTLY. PHYSICIANS Mhoulil 
stntc CADSn or DLA TH In pliiin terms, thnt it m:iy he pr««M>erly cIoHsilfied. The "SpecinI In^'ormiili.m" for par- 
xons dyJn^ away from homo Hhould be ftivcn In every InHtnnce. 



H« 



m 



1 

V 







1 



I' * 



i'\ 



* 



f 



1 1 



■' 



.1 



I 



I 




i^MI 




.1 / . 



;c 



^1 ,. 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M..=,nl.,t Hcaitir I- NO i^-^^^iit^y^n RCFCR TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



I)((fe Filed, 




ao 



190^ 



Re^istej^ed J^o, 




Deputv Health OfTicer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of 2)eatb 

( Xa. S. StanDar& ) 

J? ^ 



J? 



^ 



PLACE OF DEATH: — County of C'/CLo^-O Axu^vov^c^City of C'<X^ru AxXyv^/eA^si^cx) 



Ncisaq 



cLoyx^ 



(J/OAjL LI 



St 



.: .1 



Dist.;bct. ■jXX)\.XJL 



and d/OCr'U 



/ IF OtATH OCCURS AWAY FROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "•RECIAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



si:.\ 



PERSONAL AND STATISTICAL PARTICULARS 

rjp A I COLOR' 

I'ATl-; »)!■ lUKTM 




U CTL^V 





yy 



,\ 




I 



(\^{)iith) 



A»'.K 



i 1V,;;> 



(Day) 



Mnnl/l^ 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATM 

,1.1.. 

(Day) 



(Month) j' 



(Year) 



Q 



Days 



>>IN<.I,K. MAKKIHD. 
WIDnWKD OR HIVOKCKr) 

'Wiitiin mKJal (]«-si>f nation) 



151 k Til PI. AC K 
'Statf or Country) 



N'ANfK OK 





\xx.<Lc!u 



HIRTHPI.ACK 

or lATHKR 

fSlatf or Country) 



^^AII)K^■ namk 

OF -MOTHKR 



HIRTHPf.ACK 

oi- mothf:r 

'^tat.- or Country) 



OU' 



kXj^ 




I Ifl'RICHV C1':RTIFV, That I attended deceased from 

— to 



I90 



tliat I last saw h — alive 



on 



"190" 
190 



an<l that death occurred, on the date stated above, at ^ 3C 
^Lm. The CAUSE OF DlvATH was as follows: 










DTRATION Years 
CONTRIBUTORY 



Months 



Days 



/Jours 



OCCtTPATlON 

fff'^idrd in Suv /'i iini isrti 




-o^/yxcL 



DURATION ^ Years 



Mouths 



,1.(E,li).iJL 



Pays 



( Signed )..Lc-'uy>v£/v» O.VD, LU. AjLl<X'>vd. 

Llc^A^g. i^ TQoH (Ad.lress) WurvvfA^ ' 

SPEci^AL INFORMATION only for Hospitals. Institutlo^sV Transients, 
or Recent Residents, and persons dying away from home. 



^ 



Hours 
M.D. 



Former or 
Isual Residence 



How lonij at 

Plareof Death? Days 



) \ a I 



M.;,fli^ 



/)n\: 



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



"^"iU^vI't nv^*T.^T-^''* PHRSONAI. PA RTKT l,A Rs A K F TRI F To THH 
UhST OF MV-KNOWIJvDCK AM) MFI.IFF 



lliifi 



orniant 




(Arid 



ress 






ri.ACE OF BURIAI, OR RKMoVAI. ( DATIi^of Ml hjai. or REMOVAI, 

XO 190H 




undf:rtakkr 



(Address . 



JaD oXcililcl V \,Q 




• • Every item of information ahouid be carefully supplied. AGE sliould be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' fsr psi*- 
«on« dyinft away from home should be ftiven in every instance. 



' I 



ir 



t 



M 

« 1 

n] 

t'i' 



Iff 



fii 



i 



—Wi"iW 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



». -. ) . 1 



l-,ot*W 1? V*% It -fr.tf-iS^y. H.Vrl' <« 



"Er ER TO BACK OFCERiiriCAit. rOn jiSiai HUCTioNS 



/)a/r lull' (I, Hv^^/Qa^^^ 5,0 /.V6''-l 



Iie^istercd JSI^o. 



1J03 




0<-A^ 




>'v... 



Deputy Health Of.lcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

i *a. S. StanDarO j 

J? (3^ J 



(^ 



PLACE OF DEATH: — County ofOCLO^ JAXLoox^UL'CoCity of C/Olav 



CLAV JAXXA-XXtv^-C^O 



No. SO^N 




X''V\JL<L(7 



T^jQi} 



(IF DtATH 
IF DEA 



St,; Dist,;bet. H I lxX^^ru^<La 




OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER 



and 



SPECIAL INFORMATIO 



ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



lU 

" ) 



^\J 



FULL NAME 



^XAJ-OW; K)XKXX.' 




■,\ 



PERSONAL AND STATISTICAL PARTICULARS 

C<iI,<»K 




LcJuu 




.UJl 



• '1 III kill 



%s-i 



MEDICAL CERTIFICATE OF DEATH 

i»\ri". oi' DiiATu r\ 

(Day) 



(Month I \ 



I M'Mllll 



5-3 



iDav 



1 A. ;////> 



\ I'.'iM 



/ >,; I . 



-^iN'.i.K. MARun:i) 

"" '\Vi;i) OR DIVoKiKI) 
ill MK-irtl (l\-sii.'natinii) 







NAM!' (»!• 
I- ATI 11-; K 



fHRiiin.ArK 
<>'■ i-Arin-.R 

I State or Co'inti v) 



MMI)}:\ XA Mi- 
ni- M(»'i-iii-:r 







(Year) 



1 ni'RIvr.V ClvRTlI-V, That I atteii<k'.l deceased from 

U\(yv 9.^ x^o'h t.) VTUv- a& Kp^ 

0%^ 'Xl 



that I last saw li-0">>v alive nti 



T90 



and that death oreiirre<l, on the date stated aliove, at I ^. 
-^I. The CAISI-; ()]•• l)l-;ATn was as follows: 



a 



A^^^VC/VVvX 



A_.0 



\y 



<L 



5) 




h 




% 




1)1 RAT ION )\ays 

CONTRIIU'TORV 



Moulhs 



Dm 



'.V 



/fours 





l\r-idr(J III S',!,! /'i 111, : rn |0 )'.,ii^ 



"IK rni'i.Aci.- 

OF MoTHHr' 
(Stall or Coumr\-) 




DC RAT ION 

(Signed ) 



)'.j/;-.v 



a'?^ 



Months 



Pays 




\ \ U)0 



(•■ 



c%JUrvvOL>>-cL 

\(1(iress)VJ^^0LLcXyYu MD. 



Hours 
M.D. 




Special Information nnly for llospitdls, Institulions, transients, 
or Rercnt Residents, and persons dyin'j .may tro;n home. 



y.'i'ih- 



/Kn, 



Ml. \linvK STATl-:i) I'KKsONM, 1' \ KTIiT I.A KS ARI-; TRIl-: To Till-: 

I'l'.si «)i \j^v KN.)\\i,};i).-,i.; AND iu-:iji-:i-- 



(iiif,. 



'inrint 




\■M^■^« T b i 





It 



Former or 
Usual Residence 

When was disease rontraffed, 
If not at plate of death ? 



Kow lont] at 
Plare of Death ? 



ri<At:K OI-" lU'KiAi, OR ki-;m(ivai. 



;iAU OK K 1-, 



rxDi; 



KTAKKR NL-\j. L/ \,yO''W/y\^(y\) 

(Ad.livss 1(d^ Vi fVv^^^ "" 




B. F.very item of in?ormnt!on should be cnrefully supplied. AGR should be stated EXACTLY. PHYSIC! \INS should 
stnte CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per- 
«'>n8 dyin]^ awny from home should be j^iven In every instance. 




\w%, 



f 



if 



y 

i 



m 



\ 



*; 



I 






.i^ 



h • 



f 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 




u,.„.,l ..I II. lit h 1" Vn 15. ■?'? :3->'5.«; !!X:I' Cn 






/)ff/(' Filed , 




'XO 



100^ 



llcgisfercd J\'*o. 



1104 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiticate of 2)catb 

( 11. 5. 5tanC>arC» j 
PLACE OF DEATH: — County of UTVaX/vOj L{y^Lo. City of 





No. 



St.; 



Dist.; bet. 



and 



/' IF OtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E 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 



a 



y\/y\AJb 



PERSONAL AND STATISTICAL PARTICULARS 



JjLa- 



\. ol iUUTlI 






\/^a-\iXO^. 



lEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



Mciitli) 



111 5V.M. 



(I):ivl 



Minilli> 



'Year) 



l\l\s 



V. 






Ab TQo'\ 

(Day) (Year) 



I ni:Ri:i5V Ci:RTn-V, That I attended deceased front 

to ..— 



that I last saw h :^ — — alive on 



1 90 
190 



'-l^■ 1,1" MAkKii;!), 

u idmw j.:i) OK div()K(i:d 



M.it( or I'liniiti \1 





XAM1-: 01 

fa'iiii:k 



i''ii< riii'i.ArF 



^1\!1)1;n NAM)- 

"1 MnTm:k 



ink rm'i.Acj" 
<>i' M<»iHi:k 

fStaU' (ii rouiiti \ 



• ' i I'AriON 

f\''>!(ifil In Stui I'l an, i^r,-> 



\yQJ\J\^JLA^ 



<i^<i.CrV^^-^0 




ami that death occurred, oil the date stated ahove, at 
■ ^L The CATSr; ()!• I)i;.\i"!l Nvas as follows 



{\j 



nr RAT ION Yi-ar^i 

CONTRIIMTOUV 



Months 



Days 



Hours 



I ) ( ■ R A T !« ) N 



)'i'ars 



^fo)llhs 



Pays 



\\ 



«< 



Hours 



(Signed) b . ^^3) h>xxx:»/cWv-u' m.d 

KAJ^^n rl i()oA (Address;) M f LOAA^^^^^ Louv 

SPEdlAL Information onU tor Hospltdls, Insfitirflons, Transients, 
or Recent Residents, dnd persons dviiiij avvd) fron home. 



) V<; 1 



M.OltiK 



Ihiv.^ 



' '"iM^'^r*^ '■• '^■'''^■|'>"" I'KksoN Ai, i'\kTicr!,\ks Aki-; TkiH T.) riii-; 
'•i-.^roi- Mv K.\(i\\i,i;i)c,H AN!) i!i:i,ii;i- 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



' X'l.lif^-^ 



I'j.ACi-: 111- nikiAi. ok ki;Mi)\ Ai, 
rxniikTAK i:k Ow 

(Address 



l)Al"}:.o; ill KiAi. 01 kl-;M<»\\i^ 




S^t 



IN. B. F.very item of informiition hHouIcI be cnrefiilly supplic<l. Ad'K shoiilcl be stnted liVACTLY. PJIYvSICI ANS Hhourd 
stnte CAUSE Ol' DEATH in pinin terms, thnt it m:iy be properly classified. The "Special Int'ormiition" for per- 
sons dy!n^ awny from home should be 6<ven in e\cvy instance. 



• 



I 



♦.1 



i '. 



•111. 




rt \\ 



'-H 



:■ «;.. 



k 



'4 



'.? 



f; I 



f, 



.«», j 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I 1 ..f il*.«Uh-^I?Xn. ic t"-1^^»!^c H&. r Co 



RPPTR TO RArK nc rPDTirirATr rno iMQTsiir-rirkN« 






Xo 



IfJO'i 



llegLstcrod ^7;. 



11 05 



Deputy Health Officer 



till 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County ofLtm. 



Certificate of "S)eatb 

( 'Q, 5. Stan^arD ) 

JJuOu L^-ClLc; City of 






No. 



St.; 



"Dist.; bet. 



and 



(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME ^ 




'AyCOLhj Wv^/>v<Li. 



PERSONAL AND STATISTICAL PARTICULARS 




i>A 1 1: < »i- iMK rn 



ljJ|\jt' 



I Ml. n't lit 






^ I 



i )V„- 



^ 



(Drivi 



M-niH, 



\ rai ' 



l\l\ 



•''VVK OK DIVOK* KI) 
■I'ial ill 'ii^';!!;!!!')!!) 



HFRTnri. v'l: 



c^' 



NAM I', nl- 

iA'nii;R 



HiK riii'i.ArK 

'>!• lATHl-k 
'^tatc or Comiti \ t 



s NAMH 





j^V'^^^A^O.' 



'>ayCrvA^nv 



MEDICAL CERTIFICATE OF DEATH 

DA Tl-; < »l 1)1. A III \\ 

m<>nih) (Day) (Yrar) 

I HI':RI;15V C1:RT1FV, 'J'liat r attended deeoased from 

— to 



190 — 

thai I last SMW h ": alive on 



T90 
190 



ami that death occurred, on tlu- datt- stated above, at 

— :\L The CAT SI-; ()!■ DI-.ATII was as follows 

i 



m 



t t 



r.lKTIITM.ACK 
')1- M'llMlJ'K 



' '' > ir XTloN 



M 



'I 



I * 



DlKA'llON 



CONTRIIUTOUV 



}'euir. 



Mouths 



Days 



J/Ollf s 



/>''■■',/,■•,/ /// ,S',,')> / !,;n. -in 



) 'r,l I 



!/.•/,•///- 



/h! 



1)1 RAT ION )'r<!rs 

(SIGNED ) 



a 



/ 





.1/0// //r 



r\ 



/hivs 



to 



I lours 



M.D. 



{' 



U^q '■^' KjoH (Addnss) Cj<X>v C)AX>^"yA.CAAt:L<A..at 



Special information onlv for Hospitals, Instifufions, Transients, 
or Rctenl R<'M(Jfnts, and persons dyinj away from fiome. 



former or 
Usual Residence 

When was disease rontrarfed. 
It not at plaf e of deatti ? 



lioH long at 
Plare of Deati! : 



Days 



1 UK \Mi)VK STATl'D 1'KRmiN AI, I'A Rl' IT T I.A RS ART! IRl)-; r< » \'\\V. 

iiK>i oi* MY K^-o\\ij;n<-,i.; and hi:mi:i" 



' \(l<lr»-ss 



3AC1-: OI' luRiAi, OR ri:mo\ai 



190 \ 



INDl-.RTAKHR 

f 



DA Tl', 'i! ill ui.\i. .1 R i:M» i\- \i. 



N. «. 



-hvery Item t)f inlformjition shouhl b.- carefully supplied. AGB «lioul(l he stated F.XACTLY. PMYSICrA'NS Hhould 
state CAUSF: OP DFATH in plain terms, that it may be properly clossiified. The "Special Informutian" for per- 
sons dyin^ away from home should be jlivcn in every instance. 



%. 



I 



1 j ^ 



m 



fa * 



\ 



I 



; M^ 

til 



I 



ili 



« 



!i 



1'^ 



•»> 



^p 



um 



I 



(i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



. . .. t. tJ V 






rjc-r-c-o •rr\ o a /* u <^ c /^ c ta-r i ri ^ at r rrMS t w e-rcs 1 1 ^ti<^ m «» 



/;^//r n /('(/, 




'ko 



//y^n 



Jiro'i,sf('/'ed J\^o, 



11 06 



Deputy M-,ith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Bcatb 

( n. 5. 5tan^ar^ ) 



PLACE OF DEATH: — County 



No. 



b^d 



Crvc- 




/OL'V/K 



St; S Dist.;bet. wJ/UXmywouvu and U)/U.t/Ou wl' 



(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



.irCL/ox/^'Yo.' Jlx 




■i \ 



PERSONAL AND STATISTICAL PARTICULARS 

C«)I,t»K "N f\ 

h 






'I i; I Kill 




iXA^f^ 




OJ^J 



Month' 



bS 



)V,,M 



H 



t I):ivl 



.1 A ->////- 






1^. 



-^iM.l.lv. M.\KI<li:i>. 

ni ^oi-ial ilt-i;'ti:itiMn) 



I'.iR riipi.xiM-: 

' M:itc or (.'oiiiitryl 



lATll I'K 




^cJ^^cj-^^aMxL 



>VCi 






mKTllI'l,.\i-H 

OI" ••.\riii-;K 

(SIrite- or Coiintrv^ 



maiu!.;n namf. 
"! m<)Tiii:k 



inu THI'I.Al'K 
"K MOTIIHK 
(Slatv or roiniti v) 




MEDICAL CERTIFICATE OF DEATH 
DATK Ol- I>i:\TII 

n 



'MmiiHii fC 



(W-ar) 



I ili;ki:r.V CI.RTII'V, Tlial I atu-n.Ud <lcH\a^o<l from 

LLcv/Q n 190H t.) IAx/wk:! R i,,oH 

lli;i1 I last saw h -^>' alive nil vXva^CL \'^\ l()0 'i 

iiid lliat iKalli Dccuircd, on the ilak- staU-il ahove, at 
~ M. 'flu- CWrSI'! OF I)i:.\'ni was as follows: 



OiT 



^""^%, 






I )r RAT ION )V(7/-.v 1 M 0)1 tin 

CONTRIIUTORV 

I ) I 1< A T I O N Ai'' ''■^" ^ ''^" '' ^^^^ 

(Signed) VA-J- dsX^n-voX-cL 



Ihxv 



Hours 



Pars 



LLcv 



uJklLx^ 



I lours 
M.D. 



Special Information '>'»'> '"r iiospiidis, insiifntions, fransicnts, 

or Recent Residents, dnd persons d>ini| .iw.iv from liofne. 



■I \l!o\|.; >T \ ri'l) I'KWSox \i. 1' AK|-nri,AI<S AKl! '1"I<I )•; To I'll I", 

'•' ^T 01 \\\ KNMUij;i)(;i.: AM) in;i.ii:i- 



'Itlf-lMllMllt 






Former or 
(Jsiidl Residence 

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



lloM lon(| at 
Place ot Death? 



Days 



I'LAn-: (»l- HIKIAI, OK K l.M< '\ W. 



I) \ii: ..:" !;■ iM \i. 01 K I'.Mt »\ \i, 

CLa-v>ol XX 190 H 






(Address 



N. B. Hvcry itom of inV'ormit ion should h.- cJirefiilly supplied. \<;ri shr.;.hl he st.ite.l EXACTLY. PHVSICI VMS should 

Htntc CMlSn OF DI:ATH in pliiin terms, thiit it may he properly clnssirictl. The "Special Infoniiiilion" for p«r- 
sons dyint^ nway from home should be J^iven in every inst«nce. 



■V 



I 



'W 



(> 



It 

''A 

4 







! > 



>J 



.'^ni 



* 




yv 




<■% , 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 , 1 ; M' r .NO, : ^ 






■ • ^ • ^- 



icrcn t \j ciM^r\ v/r v^cniiri^' 



/;////' Filed , 




^0 



y-V6>H 



J?rgi,sfrre(l »A7>. 



1107 



Deputy Health Officer 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



Certificate of H)eatb 

i on 



PLACE OF DEATH: — County of Q/a>X) 



N( 



(IF Dt ATM OCCURS 
IF DEATH OCCU 



S AWAY 
RREO I 



\/(VYVeAa/CC City of^^CUVu vJ A<x/vu:.ocixto 
St»; 5 Dist.; bet. 1 1 ^tJk; and 1 i Lrv) 

FROM USUAL RESIDENCE give facts called for under "special information" \ 

N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



WJu 



C( )I.( »K 




y'X\Xjj 



liiK 111 



/ 



^^^ 



M..i!th» 



b5 )/./,, 



I):tv) 



1 A. »////« 



• Year) 



/'„■ 1 



<o rvryj LA.). 




MEDICAL CERTIFICATE OF DEATH 



I) AT}-; < ii- I 



n 



)i:atii r\ 

I Month" a 
I Hi:ki;i5V CI:RTII-V, riiat I attc-iKkd (Icieast-.l from 



'Drtyt IVtarl 



■-INC.I.l' MAKkn:i) 
NVlii. >\Vi:i) ( )K I)l\(>Rr )• I) 
!i ^'H-ial (li-iv iiat ion ) 



liikTin'i.AOi-; 

Mate iir <*onntr\ ' 




\^dLtr\A>-'iX^- 






HIRTMF'l.ArK 
"i lATIIKK 
' ' '' "I rountrv) 



MAIDl.N NAMl- 
<»!' M(»Tin;K 



"IkTmM.ACK 
<)1" M(»Tni-:K 
(Statf or Conntt v) 




lip to 

that I last saw li alive on 






and that (U-atli ocrnrred, on the date statfcl above-, at 
M. TIr- CAISI-: Ol" I) I {AT 1 1 was as follows 






O-^-^Mrv-w^^ 



-V^VwA-^ <i^\^-xKjL . 



IX RAT ION 



)'':(7rs 



Mouths 



Days 



//ours 



C'( )NTRir.rT()RV 



TVCr-UJ^vO; 



)'rais 



M 



M 



occ 



:cri'\T!()N fO , I 

^^^ h'ru'd^'I in S,U! /'i nil, ■ ••,) 3^0 )'>tli 



^r,n,fh< 



/>,! 



1)1" RATION 
(SIGNED ) 



Months 



/\us 



a 



z6\ 






Hours 
M.D. 



Special Information nnlv for Hospitals, Inslitunons, Transients, 
or Recent Residents, cind persons dving d>vd\ IroTi home. 



Former or 
L'sudI Residence 

Wfien was disea^p contracted, 
If not at place of deatli ? 



How lonq at 
Pidi e of Dpdtti : 



Oav^ 



1 H): A Ho VI.: STAli; 1) I'KKSONAl, I'A K T IT C I, A k s A K I : TRIK I'l i rill'. 
HI'.ST OF MV KXOWIJ-DCK AM) IU:M):k 



(liiffriiianl 



lA^.A-1 






I'l.At'l-: nl' urRIAI, MR Kl",M'i\\I. 



daim; of I'.MMAi, or ri;m()\ai. 




rNni:uTAKKK 






^- ^- F.very item of in? .rmntion Hhoulcl be cnrefully HiipplieH. AUB hSojIiI be stntc-il HXACTLY. PHYSrCIANS Hhouid 

Rtnto CMISr Of- nriATH in phiin terms, thnt it may be property classilficd. The "Siiecial InVormjition" for p«r- 
^'^r^% dyinjt nwiiy from homo Nhoiild be feiven in every instance. 



.E 



1 i 



I. 



^. ! 



'Si 












h. 



lil 








yf 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






■k tm ^» ^ ^ ^m ^ ^% J> ^ 1^ ^K rt ^% P« ^ ^w ■ ^1 1 ^ a ^P^ V w^^ ^a I At <*> ^^ ^ ■ ■ ^ ^w ■ ^ bi 0^ 



/^^/r AV/r^/, LL^AXJ/L^vXit; aO /'V6'H 



cLx>-^-^V.A^ 



llegisfeted J\^o, 



1108 



Deputy Health ORIccr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 









% 



v 



PLACE OF DEATH: — County of^CU^^ A^<X-yvCA^^c.< Qty of '<Xa^ vJ.\yay>Aya>o(i.C0 
'No. ^Ib CjljLCnvCV St.; S Dist.;bet. V) CUrpl' and U-CuK 

(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UnAeR "SPECIAL INFORMATION" '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAIxloF STREET AND NUMBER. / 



FULL NAME 



^J 



iV^r^-WCM 



rwi 



V<X/A-\' 



PERSONAL AND STATISTICAL PARTICULARS 





/ 



xc 



III i; IK III 



\'.1\ 






I I'll I 



\ 



n 

(D.MV) 



1 A. >////> 






> I ai 



/', 



MEDICAL CERTIFICATE OF DEATH 

!» A 11. < il' Di: A TH 

Dav) 



L- 



(Month) 



/go : 

(Vf;ir) 



• '.i,»' MAKi<n:i) 
'>"Ui-.i» OK i)i\()Kri: i> 

-•"•ial (!< >-i'..>n.it imi ) 



I'.IR rHlM.ACl'". 

'Statt ui Cinniti \' 







M 1 1)1- 

.\ I II 1. K 



niRTin'i.ArK 

-^' it' ur ('(niiitrv^ 



I I IxXAX^wAo; 





VOyWj 




I UliRl'P.V ti:RTll-V, That [ aUeiide.l dccoa'^cd fn.iii 
Vt.-t '^^ 1900 to ^ c^' 'X't IC90 3 

that I last saw h'- ' > ah've (Mi U t. v .I'v Kp 3 

ami that doath ociurrcd, on the date sta1f(l al)o\-i', at 
^ M. Tin- CAISI- Ol- Dl'.ATII was as follows: 



DIR.X'riON I }','(US t M on I In Pays 

coNTkir.rToRV 



Hours 




MAn)i:\ \\Mi-, , 



niRl'HIM.ACl', 
<>1" MmTII1<:r 
(Statf or C'oiimr\) 




1^ 



^^^ ct'^^u/va- 




"> ^ . 




O. ( 11 






)'(■(/ /■.s■ 



.lA';////^• 



DIR.XTION 

( Signed )Aa. J XiL<rvva.*v<:L 



i:t 






F lours 
M.D. 



c*. 



i 



Special information "nly for Hospitals, Institutions, transients, 

or Rt'(ciit Rt'sldcnts, diid persons dyin;} .may lro;n home. 



M.'ulh^ 



/)., 



Former or 
lsu.ll Residence 

When was di^^easr (ontra( ted, 
II not at plare of death ? 



How lonq at 
Place ol Death ? 



Od/s 



'lllf.iMn:iut 



I in; \Ho\i.: st \ri:i> i-kkson \i, I'arihti.ars ari". rRii-: ro 

lil-.sr ()|- MV KNv\\ l,).:i)C.H AM) lU'LIlIK 

V . Vi rLuJLoLAA^ 

Sib ^\Ju.yY^JO\, ^.t 



in; 



(\.Mrrv^« 



IM^CH 01- IMRLVh OK R i; M( »\'.\ I. 



CrVu- v-V^-^ «i 




i)\i'i;..: HiKiAi. oi ki:m(i\-.vl 



S, 



N I ) !•; R T A K !• R nI f\^ odlcLtyvv M H? VO.VjLahXuN. 



.\.l<lrc«*s ini \l rUA^>unv 3l 



iil 



AJ2J/YV 



N. K. hvery item olf mformntlon should be cnrct'ully supplied. .\0K s!i!)iil<l be stated liXACTLY. PHYSICIANS Hhoiiid 

Htntc CAlJSr. OF DKATH in pinin terms, thnt it nmy be properly classilfied. The "Speciiil Im'onniiti on" V'or par- 
sons dyin4 iiwny from home should be feiven in o\ery instnnce. 



^ 




^ 
^ 







C. 



I 



•4 
•fi 






ii 



■'p 



f 4 



' «*J 



^'1 



\ 



(i'i 



{ 'i4 




m 



life 



,..:^%..\ 

■%'^^wm^^' 



(■' 






Ml 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ui);il>I "I MCiUIti r ><) IS 



r.i?5a?%^ 






trE-K *ipi-\ B*/«w r%ff r«rD*ricir'ATr vnn IN^TDUr.TinNil 



• vito* ^>V t 



Dft/r Filled , 



4 







-Xft 100^ 

Deputy HcGith OfHcer 



Registered JVo. 



1109 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( xa. S. Stan^ar^ ) 

J 0?) 4 ^ 

PLACE OF DEATH: — County ofO/CL/Yv OA^O^xcuiicCity of 0/O^^ru Axxyw<icA.<:.c 



N 



o. [^^OkjJjL. 




H St.; H Dist.; bet* H Uk* and 5 > 

(IF DttlhH occo»»s *WAV rROM USUAL RESIDENCE Give r*CTs called roR under "srecial information- '\ 
IF DF*TM onfcURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Iv 



IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 11 



FULL NAME 




si-;\ 



I) \ I K Ol ItlKTU 



Ai.K 



PERSONAL AND STATISTICAL PARTICULARS 

I COI^OK 





s- 






I Month) 



I O JVr/».v O 



A 



1% 

iDjiy) 



M.mlhs 



^WJL 



/ L^...l 

(Year) 



x\ 



DiJ ys 



MN'.l.K. MARKIKI). 
WIDOWKI) OK DIVoRfKl) 

'NVritf in stM-ial <l«sij);natii>n) 



UlkTHPI,\OK 
' Statt or Ci)niitry ' 







NAMK Ol- 
J'ATMKR 



HlkTlll'I.ACK 
Ol JAIUKR 
(State or Country) 



MA1I»i:n NAMK 
"I MOTHHK 



HIkTHI'UAOK 
<»F MnTHKR 
'Statf or Country) 







MEDICAL CERTIFICATE OF L £ATH 

DATK OF I) K AT 1 1 r\ 

LLuuo \%. 



'\ 



(Month) A (Day) (Year) 

I HI<:RI:P>V CIvRTIFY, That I attended deceased from 



a 



.0^X3L 1^ 190' 




\%. 



cu 



190 H 



iH to 

tliat I last saw h -L >^ < alive on \-M,V^' iA up 

andthat death occurred, on the «late stated above, at \0 



\% 



I) (RAT I ON i Years 
CONTRllU'TORY 



1 / I .."V 1 II V»tl> il 



Months 



Days 



Hours 




occr 



_ djjijyx^yy^ 

Rf.sidfd ill Smi I'l ant i.^ro I Jl, )'riii s 




Years j) font /is 

NED)..U)., ^. 'Q\jL\>JL-^\Ji 



DURATION 
(SIG 



/)avs 



IH iqoM (Address) llO^ 




SPEd^AL INFORMATION only for Hospitals, Insmutlons, Transifnts, 
or Recent Residents, and persons dying away from tiome. 



M,»itln 



Da vs 



Tin: AHOVK STATKI) I'HKSONAI. I'AK riClKARS ARK TRl K To TH 
J«KST OK MY KNOWl.KDCK AM) MIUJKK 



K 



'imant 



(A.ld 



rcss 



iHip 



'JKaJoJuu^. 



Former or 
Usual Residence 

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



Now long at 
Place of Death? 



Days 



ri.ACH OK lURIAI. OR KKMoVAI, I DATKof Hcriat- or KKMOVAI. 



(Address 



ax% QfX^ Clllv^ w^ ii 



A 



N. B.— F.very Item of information .hould be cnrefully «uppliccl. AGE should be stated EXACTLY PHYSICIANS should 
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for pmr- 
Rons dying away from home should be given in mx^r^f Instance. 



1 



^i;-i^ 



id 



f 



M I 



*. 1 



m 



. s 

f ♦"■■ 




7 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






rarT-c-Es ^r\ o n r^ u <% r r* r bt-i b-[ ^ A-r c pQp i ^j CTO ij r^y I ^ W 5 



hnlc riird, Uo^^v^O/^^^ XO l'H)\ 



Ilrgislcred J\^(). 



1110 




f 



-•th O; 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "U. 5. Stnn^ar^ ) 



ro 



^0 



PLACE OF DEATH: — County of L^CpKt/v^ W^to„ City of 



VI I taAL<^ 



^JLA ^<Xl; 



No. 



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



St.; 



Dist.; bet. 



Und 



RESIDENCE GIVE fa 

0=^ INSTITUTION GIVE 



CTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



(Vjd 



D 



.CL/^'ya^vaJL/'^ 



/CXv\L<r>"v-\i. 



PERSONAL AND STATISTICAL PARTICULARS 



^ 




C(>i.< »k 



1) \ i'l-; < •! Ill-: III 



M..iithl 



n 



) ,-,1, 



i). 



;i),iv 



M.>tilln 




Al^ 



\ I MI 



Pd 1 . 



wrt»(»\\).-i, ( »K i>i\'i iRi)': I) 

' I ! 1 1 1 ^ i i- 1 1 ; 1 1 i 1 1 1 1 ) 



inkTm'i.Ari-: 

'Stall, or CountiN 








\ \ M I I li 
»• A III l-.K 



niR rnri.AOK 
01 i"aiiii-;k 

'State or r,,inili \ 



MAII)h:N NAMH 
<»I MfiTin-K 



iiik iinM.A'"]'", 
<>i- Moriii-.k' 

(Stale ,,r (.:(>unlrv 



occrrATioN 






v-CrV^Tv^ 



MEDICAL CERTIFICATE OF DEATH ■ 

DA 11-: nl- Dl.AllI , 7\ 

oUxo a 5 

fMiinth) (Day) (Vt-ar^ 

I II I:K i:i',V C!:RTM'V, Tliat I attoiuU-il dccrascd from 

— to 




/QO 



I (/I 



til at I last saw li 



alive on 



T()0 
\^)0 



anil that death (uH'iirred, en the date' statt'd abow, at 
M. The CAISI-; Ol- 1)1-; AT 1 1 wa-^ as follows 



C 




A.^<PW' 



DC RAT ION )V(7/-.v 

CONTRIHl'TORV 



Mouths 



/hiv^ 



//on 



/ < 



)'('(! rs .Vo>////s 



DIRATION 
(SIGNED ) 



/hry 




I /0H)S 

M.D. 



SPEcIJAL Information «"'> >"r llospitdls, Insntiiftons, Iransienh, 
or Rert-nl Rfsidenis, dnil jiftsons d\inj ,)h.)> Ifo.ii homr. 



)■,•„■ 



M '>in,< 



ih>\- 



%^X\ 



# 



HI. MtoNl'. ST \ri: I) i'K KSONAI, |'\KliriI.AKS AK V. \\<V\-. T' » III l'. 

iii-;sTni- Mv KNo\vi,i:nc.H AM) i{i-;mi:i-" 



'■inant 



CTyOLm -'\Jt/v"vv.^^.^<xJC vVaJLA./A'^aaX' 



• X'Mrcss 



Formrr or 
Usudl Rfsidt'iKf 

When was discisp ronfrarted, 
If not dt plate ol dealh ? 



Hnv* lonq at 
Pld< e of Deatli ? 



f)ays 



!) WV. ol" IIiKiAi. 01 K l{.M( »\AI, 

OwV^cO QvO T90S 



ri, VCl-, (H- Ml'KI.M, ''R ki:m<'\\i, 



(AcMifSS. 



.N. H. j;,,^.^y u^.,„ ^,^. ;„f,,^,„,,t;„„ should li.- cnrcfully Hupplied. AdK should be stnted f-WCTLY. PHYSICIANS should 

state CAlJSr OF DrATH in pljiin tcri.m, thiit it m:iy be properly tinssified. The "Special Information" for per- 
sons dyin£ away from home should be jiiven in every instance. 






\ 


•1 

*■■ ■ 




lii 




th 




i 




Pf 


y- 




\ 


■■ ft 




r t 



> 



iH!'* 






p% 



'tjutliili 




•t 'i 







:i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 









t> I'n 



RrFFR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!)((/(' tailed , IAa^v^Pla..^^^ XO 



190 \ 



Registered J\^o, 



11 10 





DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeath 

( *U. 5. t5tan0ar^ ) 
L<pK1jvOu M> <^^t^O. City of ^1 I UxaX^^ 



PLACE OF DEATH: — County of 



'Axa 




Na 



St.; 



Dist.; bet. 



Und 



/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E 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 








CJ 



.<X'^'>^>.^' 




/CuvXL-cnA.^.' 



' \ 



PERSONAL AND STATISTICAL PARTICULARS 



.• . . i. « •!•■ Hlklll 




MEDICAL CERTIFICATE OF DEATH 

DATK (>!■ I)i;\TlI 






(Day) (Year) 



>!oiith 



x\ 



! ..u 



iDnvi 



M. in I In 






/',/i. 



^iM.i.i- MARK n-; I) 

win* i\\ )• i» ( »k ni\< ii.', ).■ I) 

" ^' icial (Ic-i : ■ ■ : i 



riii'i.Aci-: 
'!■ Ill Conmi \ 




NAM) 1)1 

iaiiii:r 



IHR rill'l.ACK 

*)|- I \iin-,K 

'St.il( 1,1 I'nuilliv 



"^1 \ii)1-:n namh 
11) m(»thi;k 



I'-lk riiiM,.\ii.; 
fM- MoTIII-.k 

(Stilt.- m roiiiiti \) 



/\''^iilfil ill Sitii /'idihi'iii 







[ 11 l-i'l i:i;\' C!{K'ri l-\', That I alttMidcil <U-(H-ase(l fn.iii 

up to Icp 

tlial I la-^t saw li : alive on I90 



ami tlial iK-alh (nH-uricil, nil IIr- ilatt' stalt-il abovf, at 
M. Tlu- CAlSIv Ol" l)i;.\ril was ;,s follows 




DC RATION )((/;-.v J/ai/ZZ/s Dav'^ Hours; 

CONTkllil TORY 



I ) I ' R \ T H ) N ) '01 rs Moil His Pa vs Hon 



/'V 



H 



^rr^j 



(Signed) (d . ^ JjA.x\xx,<i 

li^Q i^l i„oH fA.l.lrc-ss) Vl'l 



M.D. 




SPEcIJaL Information on'v for llospildK, institutions, Irdnsients, 
or Rorenl Residents, and persons d)inj dH.iy from fiome. 



Yr^n 



M.-iifli^ 



I hi 



I'm. \H')\i.: ST \|-i:i) im'. rsonai. i-xk ru i i \ks ari; ir i j-: r<> 111 1. 
in-isT ni- MS K Now 1,1; I )(,}•: AM) n!:),ii:t- 



(iiii 



■' iinlll 



CrV\J^<^ ->\jL/»^\^dA/"<x3C >AJL^^^^A.S t- 



X.Mi.'Ss 



Former or 
UsurtI Residence 

When was disease rontrarfed. 
If not at plac e of death ? 



How lonq at 
I'idi e of Death ? 



Days 



I'l.Aci'; <»i III R lAi, I »K R i:mi '\AI, 



M.l.RTAKl R fo oXaXj^ V 



I) \ \'V: of Ml KIAI. i,t RJ'.Mi i\ Al, 



\ 1 1 . 




(A(l<lrc-'is 



MH*. 



Olv^ 



\A.<i.<.,<rv\ S} 



N. U. 



-Kvcry Ito.n o^' informntJon «h<.ul.l h. cnrcfully Kuppll.,1. \W. slv.uld be HtHtecl EXACTLY. PHYSICIANS Hh..ulcl 
Htatc CAUSi: or DIIATH in ph.m torm^. th;»t it mM> ».o p.v.pcrly cloH«ineiI. The ' Spcc.»l ln»ornu.t...n »«r p-r- 
Rons (lyin^ nwny from home nhoiild l»e ^iven in every inHtnnce. 






X\ 



1 



I 



- 1 
1: ♦ 



3i' 






I 



1 1 



4 



t II 






ii' 



I . I 



k 






^WT 



l!?*t 



III 




^ 
fl 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



111 MM It- 1- >>• '-^ 



^'!Z!*>r. ,.o 






/)((/(' Filed , 



ck-^r'^^AA^ 




10 7.vf;H 

Deputy Health Officer 



llo^Lslei'od J\^(). 



1111 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. 5tnnC>arD ) 



A 



^ 



^ 



PLACE OF DEATH: — County of a~>v J.VO^->\x:A.^ec City of vJ Cb-^v A.CL/^xca,0. e c 
o, HSt) vnAA.<i.k St.; 3s Dist.;bet. OUL<X\^'^^vu and dJxvlvcnAX 

/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVC FACTS CALLED FOR UNDER " S P Gfc I A L INFORMATION • \ I 



/ I F DEATH 0( 

l^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREl^T AND NUMBER 

1 (?Jl t 

FULL NAME 'J .<X'^\y\^'ub M xXaxxA-vx'u 



-■) 



PERSONAL AND STATISTICAL PARTICULARS 

V ft I 




JJt^OJ^ 



>\ IMKI'H 



rl 



M.ii>tli> 



^1 



),.,-. 



il);iv> 



1 /•■.////■ 



/>■! 



> i.i" M\ki<n:i> 




>ccL^''^< ■ 



•r t( 111 tit I y! 






Mi: <»!■ 

Ill IK 



liiki'iii'i, xci-: 

• lunl I \ 



!■! ■. N \ M i; 

M' M II i: K 



Of- MOTIM.U 



\ 1 1< I.N 



^J XAy\X/ij^\Xo^ 



4 



V-' \-- 1^ 



MEDICAL CERTIFICATE OF DEATH 



\ri-; oi- Di-.ATH r\ 

(Month) f 



(Day) (Viari 



I 11 i-R i'l'.N' Ci;U'ril'\', Tliat 1 ;ittc-ii.lc-.l (k-ct-ased fmiii 

■ IiyO to Tc;0 ■ 

tliat 1 la^t saw h "" alive- on ~ ~ It/D " 



aiiil tliat diatli ociiiri til, (M) the ilati- ^tati-'l al)o\-i', at 



_ .M. Tlu- CM SI-; (»1 I)i:\'ill was as follows 



O-v-^O'v 



-f 



^*'^/CXa,>^^0 L^-C 






\jC\jL<x^- 



s 



^ 



' >(ArCtoXAX<X, -^ru dw 



I )l RATION )V</rs 

CONTRir.l'lORV 



.lA^;////.v 



/Kn s 



//<;// 



; .s 



D! R.\'ri<>\ 



)'i iirs 



.?/,';////.' 



fSlG 



;0 



/hiys Hours 

\XN M.D. 



■VQ I't TC)0'\ 



^ 



(A(Mr»-sv) L^r\xrv\JiA^ ^i > 



SPECIAL Information f*"'^ '"r Hospitnls, InslilulifOls, Irdnsients, 
or Rerent Residents, and persons dving dv\,i> Iron home. 



Rf:.ii 



•■t'tif<f ill Wnr /'i ti III im'i) O tS 



1/, /^'//- 



'111, \H( >\1.: ST \ 11 II l'KR>^()N" \1, r A Kl" UT 1. \K>^ \ K 1 '. I" R I }•: 
ln:sT Ol- MV KNnWI.I-.DCK AND m.I.Il.l' 



I » I' 111-: 



'Inf,,-ii, ,nt 



' X.Mlr^s 






Former or 
IsUfil Residence 

When was disease (onfrarted, 
if not at pla( e of death ? 



How long .it 
Place ol De.!fh ? 



Oavs 



ri.Ari-: <»i iti k i \i< «>i.-. ki;mm\\i. 



%x G.Lv^. 



I) \ 11-: of lit in M. "I K);M()\AI, 



...vx:^ QsL 



TOO 4 



I ni>i-ki\ki;k O's/CX^'^ 



(A (Idlest to 






X'\ ^^ 



N. ».- 



-livery Item o*" inf.rm.tion hHouI.I be c»rciuUy s..pplio<l. AlJJi .hoi.ld be stnteH F.Xi\CTLY. PHYSICIANS Hhonl.i 
«t«te CAlJSr: or DHATH in pl«in terms, that it may be properly cluHHiHetl. The Spccu.1 In»orm.,tu,n »or p-r- 
R'>ns dyin^ away ifrom home Khoulil be given in avory instance. 




; ^1 

i' ' 



'Hi 
^•■*ii 



' ■1 
i'i i[ 



i 



1 i 



V 



u 




l«k. 



tig?^^ 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



';.'!ll 



K 1 \ , , , -. I'- - 5.- • ^i- I Il\ i ' * 1 ) 






^^ V^ I Mm • 



I hi lie Filed, \Aju^yOiA^\.j:ikj O^Ci 



rjo'x 



Rci^istrred Xo, 



i\rz 



r-' 



^li 



docr'^-^-^^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eath 

( "CI. 5. Stnn^nl•^ ) 

J? % 



(h 



PLACE OF DEATH: — County ofC'aiv 0,^CV>\CUi^O0 City of^'CL/vv J XXXyTVCA.XiyCvo 



No. O.^t^'-v/^ru flb (y^lAx^LcxX) St.; Dist.;bet. 

/ IF DfATH OCCURsIaWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLFD "^O R_ U N 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME 1 




and 



-OR UNDER "special INFORMATION" \ 
NSTEAD OF STREET AND NUMBER. / 






FULL NAME 



AXUn^Mi VjX^^XXO/^/Ij 



PERSONAL AND STATISTICAL PARTICULARS 

a II, I 'K 




X 



■<X.> 




I'.IK I'll 



, % k. 1 



MmimIi 



\«,i.; 



Hi 



)'f,i I 



I):iv» 



M.nilh 



/' 






iUKTHPI.AOK 




VxXAX.ou:^ 



1 ■ . i ' I K 



nikTlMM.AiK 
<p ' ^ ■Ui-'.K 

'"'iimtrvt 



■■■i'ni:R 



iiiK niiM.Afi-; 

OI- Mo'I'llI-R 








1 i- y 



,.v,,„s (y^ 




XfY\JiJ\^ 

)\t'' uh'il III Si! II limii ' <■') 




r,-,M . 



1 A, .,///< - /■■ 



Till- \!{. )\I.: STATl.:ii I'KKsoNAI, I'AK riCII. \KS ARi: TKri" Ti > Till- 
lil'ST OI- MY KNoWl.lIX'.K AM) lU". I, I l-.l" 



(liif 



•niirnu M \W\J^ \| fLO^VA^XV v) 



' \'l(ln 



N. B.. 




JtXXX.a.--yO 




MEDICAL CERTIFICATE OF DEATH 



<I)av) (Ycar^ 




IJI 1;R i;r.V C"i:U'riI-'\', 'I'liat I atUMuUMl (Iccfasc-d from 
S I(;nH to LLl^\^ ICi U)oH. 

that I last saw h'0>>\ alive oti Laaa^Q. i Kp H 

ami that death niHMirrcil, nii Iht- datr ^tati-d ahovr, at " 
vj M. The- CAT Si: <)I' l»i;.\'ril was as follows: 
MryWXoJl NclLfrVUt bcJC\HA,Lv*v lojAc^rvv 4 .Jt^a\X 



.V<1 



MOU//IS 



/hns 



C N'l" K 1 rd • '1' () K \' \J AAA/>"vA.>CrvA,^X>uM v<0^"vOliL41 



I lours 



./•ur^v 



DlkXTloN Years Months /hiis Ilonr^ 



( SIGNED ) 



Cd, UjvXaxia-vX^ 



M.D. 



Ll<^^<\. \\ ic,oM f AddrfS->) ^Xh U/C^t(Xv i:> 

Special information »"'> ^^'f Huspitdls, In^titutians, Transients, 



t 



or Reient Residents, and persons d>ing dway fron tiome. 

Former or 
Usual Residence 

When was disease rontrarN, 
If not at plare ot death ? 




r \ \ \ Hov^ long at 

LOA'vvyxj LaX: Place of Death ? 



Days 



I'l.ACI'". <»l^ IMKIAI. t»R R1;Mo\ AI 



[» \ ri-. o* r.iMi \: .1 RlCMnWM, 



cl AX>JL^' — .V. » 

(AcMr.ss ?>0 5^ \)OX<r»Al.CyU LLvkC 



TOn'i 



.<X«.*v 



fiver,- „.„, of i„!„.T,„..lon ,h„„..l h, c,.re,-„M.v .upplu-.l. Acjr. s- 1,1 "-.'"•"'^'•^^^■''■r; , ';''.''''',i''^. ^'D^r- 

»tnt. CMISE OP nnATH In „.„in ter,,.,. th,,. It .n.y 1.-- ,......cH, cl..-Hie<l. The 8,„c,„l In,..,-,,.,...,... for p.r- 



sons clylnft nway from homo should be ji'iven in every instntice. 



Ui 



( 1 



.4- 






1 1 



If 



\ i 







ni^ 



t 

I » 



ji ! M' 



' I 



it^^^wWPa ft 



siM«%± 



w 



RITE PLAINLY WITH UNFADING INK 




!1. ..ll!' 1- V... I 



* "^^ 



;;\ ;■ '■• 



THIS IS A PERMANENT RECORD 



..^.^ ^r^ /^r-riTiri/-^ A-rr cno I IM ^T R U P-TI O N S 



r K^ w. t 1 



'\ji^^^j^ Deputy 



if)0'i 



Jlesff.sfcrrd J\^o. 



i i 13 



,-^-A.AA^ 



» 



» ^ - » 



'"> r». 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( XX. S. tr1tan^ar^ ) 
PLACE OF DEATH: -County of O^av O/vC^xcu^oCity ofOct^x. K^<^^^^ 




No. ^oil 



ll! ,a.l.LL^.• 



St.; ^ Dist.;bet. MAXA^CJl; 



and C3/C^ tl 



) 



^ /V^V-Vx^ V.^N- *. ,,eiiAi orcTnVNCE: nVE FACTS^CALLED for UNOTR "special INFORMATION ' ' N 

( ■' r".»roc"uVpr;,;,"r„os"p"*c :» ?.^',tu" ';'";*"i name .nstc.o or st«..t .«» ».«».. ; 

FULL NAME ^ A\^ny\.<XA 




PERSONAL AND STATISTICAL PARTICULARS 




i\^ 




J^'TVaJjI' 



IK III 




\j 



M..iUht 



1 ,„. s 



n 

l);iv) 



.1 /.'////.' 



t ">iai ) 



n 



■> ■ ■■ ■ I 1 ' . OK [H\'t tk>.' 1.1) 
iiil <Ksi)J:ii;»ti"n) 



"~' ■■ ■ I ■>in!liv 



111 i: R 



mRTllI'I, MK 

«»!■ i-.\Tm:R 

- Stiitf or Cninitry' 



M Mill- \ N.Wll-: 

"': MD-nil-.K 



l'.!R rUl'I.ACH 



occir \ri()N 



! r 



MEDICAL CERTIFICATE OF DEATH 



(I)av) 



i).\ri-; oi- 1)1 .AT II O 

iMontli) /[ 
1 !li:Rl-:r.N Cl-.R'ril'W That I atlcmkil <lcccasc<l from 

that I last saw h -^ .>- alive ..11 Ltu^ ri I90 H 

:m,l that .loath o(-rurrc-.l, on tlic .1 itr stat^-.l above, at X- ^ ^ 
*s.Lm. I'hv CAISI-: Ol' DIA'I'II \va^ as foll.)\vs: 



(ViMil 





O^Tu 







<X/>vcL 



'cJk^^rtro 



Rt'.^itlfi! in S,!ii / 1 1! Ill i't'ii [ 



\ 



'.:.■'/,. X / 



■iiii' Miovi-: s'l" \Ti".i> ri<'R^(ixAi, I'AR rirri.AKs arI', tri i: r< > i'" i" 

I'.l'^T Ol- MV KNOW 1,1: DC. H AND lU'.I.Il'.l-" 






(Xc^-vfct 



T 



.<^ 



1)1" RATI ON )V(/r\ 

CONTRIiU'roKV 



Moiilhs \X /^n.v /A' 



itrs 



nr RATION 



.1 




.]f,uiths 

vile 



/?<?!' 



O. 



(SIGNED ) . 



M.D. 



) 1 
^ 

SPECf^L INFORMATION f>n!v litr llnspifals, Inslilufions, Irdnsients, 



PECmL IN 



ur Recent Residents, and persons dyinij away Iron ti(.me. 



Former or 
Isnal Residence 

When was disease ronfrai ted, 
II not at place of deatfi? 



lioH loni| at 
Place ot Oeatti ? 



. Days 



I'l ACi- 01 r.i Ki \i. <"•; ''^ i:m"\ '^1. 





e 



h^^>;L^, 



DATlj^.l' \\\-v \i • Rl,M.t\ \1. 






1 NDlR'i'AKl'.K 



..e.et- 



A^ 



vC^ 



(A<l(li(>^< 






, 11 h» t te»l r.X4CTlY PHYSICIAN'^ Khouhl 

N. B. F.very Item oV JnJormation shoiiUI he c.irct"ull> svippUed. A'JIi s v>uhl he s *i •..'.•, ,„i-„^,„„tion" for p«r- 

8tntc CMJSt: or DI:ATH in pl;.!n terms, that it mM> ho properly cla«s.t.ed. 1 he »p 
sons (lyinji iiwny from home shoiihl he jiiven in every iiistnnce. 



1! '■■ ;i 



! 






; ♦ 






^i*f 








lum 



> I 



m 



^' 



• 



-. ^ 




RITE PLAINLY WITH UNFADING INK 



W 



J , .,.,ith-F xn. ' ^ ^^'^'::r^ ^^^^' *-*" 



THIS IS A PERMANENT RECORD 



REFER TO BACK OK CLHl imv^mi c r 



,,_.^._.. .__ ^»km 1 Ki <>-^>r« I I /«^| /^ M Q 



\jr\ ii^Nrfiiiv#v*>i»» 



pif/c Filed , AXaaXiv-v^ '>.C) 



//Vi^VH 



Jlvilistered J\'*o> 



1114 




.C^-A.^LAx<5 cLiLA^ 



De 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Gcvtificatc of 2)catb 

PLACE OF DEATH:-County ofOJ.OAV O^v^^^c^Cc City o^J'Cb^ J .^v^V^v^a^oc 



FULL NAME 



<Xr\ 





V 




PERSONAL AND STATISTICAL PARTICULARS 

V ( tl.MR 




.UIJL. 



1 I', I Kill 



,^^t 



\!. Ml h I 



I '. \' 



• ■ '\ i:i) ( tK I)IV( »!•'.» l.l) 
n social (l(sij.'nali'))i) 



. 1 M ■ I . \ 1 ■ 1 : /?\ 

M.lli ol '.'mmiiU \' I \' 



!• \i'iii:r 



1'.IR rill'I. ACK 

oi^ i-Aiin;K 

lst;it< 111 rnunt rv 



M\1!»1,N' NAMl 



MIR in iM, An-: 

<)!• MitTlII-'.K 

'Stall .1 roiinti nI 



M,,t,tlis 



/',.• 





C' OU'^^vu 







MEDICAL CERTIFICATE OF DEATH 

DAI'l-: «»1 lU'.Alll 



d. 



(Monlli) K 



Davl 



(V.-ar^ 



I lli;Ki;iiV C i.U ril-V, riial I aUou.K-.l .U-roased from 
lL^-v-C '1 i(>oH to Ux.^Q 11 up\ 

tliat I la^t s;,wh.^ ... iilivon LL^v^Cl '. iQo'l 

•ni.l til. it 'K-alh niM-urre.l. on tin- .latr staU-.l alx.vo. at 



a 



M. 'rill' CM SI'! Ol- I>i:A'11I was as follows 



A/vCVA/-^-v.cO 



.AVA^iv 





\ri()N rc> 








'\'f' n/rif HI S.nr / iiii/.: I'.t O V_. !'"i."'- 



1/..-/'//- 



/i,M 



I Miovi-, sr \'n.:i> im':u<.<)\ \i. p \inicri, \ks a hi: ruri: I'l > ii! i'. 

lM.;sr (»!•• MV KNOW I.IJX.H AM) IU-: 1,1 1!!'' 



(Inf..-, 



'.'• ^'1 .»l I |-V.-»^F\* Ifi. !'<•■( -».'•' «>».■, 

unit M iLxXVm t). Vj Jn^*wk-V 



DTK AT ION )V,^/\ rJo>////s /^ns 

CONTKIIHTOKV 



//Oitf s 



( SIGNED ) LO-^aa^M' l\ ^.aA,vUs. 



/hivs 



IL., 



,0 



Hours 
M.D. 



Kl'i 



SPECIAL INFORMATION o»lv l'>r I' 
or Recent Residents, and persons dyini xm\) trom home 



~~~~ iHtspitdls, Institutions. Transients, 



When v^as disease fontr.irted, 
11 not at plate ol death? 



Hovt Innq at 
Plate ot Death? 



Days 



iM,\ii'. "1. Ill Ki \j. « 'K ki.;m< "X ai. 



DATi-: of 111 KI \i "1 ui;m<»\ai. 



'^V 



mo'l 



iL,..,..Wc.<i<u,.^\4x.uv^.s., 



'Ad.lK'ss 



llll 



%\ 



^^<IA-<!'^V 



-^,4 1 



"""*"' . I t teil r.XACTLY. PHYSICIAN'^ hHoiiM 

IS, W. livery Item olf JiWoriiirttlon shoiihl be ciiroVully Hupplic*!. A*. J. k i<>.' ' ^? J" [ ^ri,' "Snccinl InV'oriniiti >n" for p«r- 

HtHte CAUSE OF DEATH In ph.Jn terms, thnt it rn^.y be properly cIi.hm.^.cU. 



BOit* flyinft nwny from ht.mc Hhoiild be tiven in every in«t«nce. 






11 



I n : 



\ 



"III 
V J»'l 

, \. 

% 

i 

< < ^1 

■I*. 



',■' 






r 



\\y-\ 



.;!'? 



• ■'I 



lllHl 



liiji 



4 I 

I 



\ l-l 



r 



I: 



7^fa*' 



4^ J I ,^^. ^^_ 




8 



. i 




HI 



Hov 



WRITE PLAIN 



LY WITH UNFADING INK — THI 



S IS A PERMANENT RECORD 



^' 






REFER TO BACK OK L.fc.n i ir iv^/^ . w . 



/)(//(' Filc^l . 




10 



rjo'i 



Redjstci'pd J^'^O' 



I i 15 




DEPARTMENT^ FIBIIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County ofU/CX/W 



Cevtiticatc ot IDcatb 

I XX. S. StanJavC j . ^.^ 

Si' ^ A ^ 

3aa^ ivcc^vxc^ City of a<^^ jAO^vev^Co 



k 



No. 




OaK^^-- St.; Dist.; bet. 



and 



'JXWYVCLA^ -- - ,,<;UAL RESIDENCE G.v 



( 



r rACTS CALLED FOR UNDER "SPECIAL INFORMA 
O.VE -TS NAME .NSTtAD OF STREET AND N U ^, B 



TION' \ 
ER. / 



FULL NAME 




sjrxjyxMj 




(Xy >\^ 






PERSONAL AND STATISTICAL PARTICULARS 





\ 



IK ni 



All 



MEDICAL CERTIFICATE OF DEATH 



viv. oi- Di'.ATn r^ 



V^ 



Month' 



) 



■ l):i\ ' 



I/.'"///' 



( Vr;il I 



/*, 



, HI-.Rl-l'.V C1:kTI1-V. That^^ attL-n-lc.l .Urc.isca fmn. 
llw.ri las^ia^vll■A-^ alive on 



^IM.l.l-. MAKKll-.n 
\v\\u i\\TI> ( U< I)IV< >K'' l-'.!> 
: i! ilc^i'^Miali'iii ' 



lUKTlUM.ArK 




• 

(^ 



„M that aoath .H-cM,rrc.l. nn the .lat. <ta1e,l above, at \^^- 
M. The CAISP: OF 1)1;AT1I was as^ol lows: 




-Ml 01 

\iii i-:r 



lUR run. \rK 
or i" \rii i:k 

St .!( .,1 r<iutitfy 



M \ 1 1 i . \ M 

III Mil! III-. R 



I'.IRI'MlM.Ari-: 
nl- Mol'lllvR 
fStiiti ■)] Odniiti y'> 



> -CvJ~^^ 



UCCl TAl ION 




DTK A TION ^'"^ 

coNTKir.rrni 



Monl/is 



/hns 



I lours 






dVDCrAOk. 



(SIGNED) VI I ^^ ' 

UAA^n \q 100 H (Aa.lrcss) 



Moulin I^^^y^ 



^Q \H !(>( 

:diAL IN 




Hours 
M.D. 



Rf'uilfiJ III Sail /•■»,///-/>'•,» ' ^)V(r) 



III. AUOVI*. STAT)-.n I'KK^ONAl. 1V\ K T U' T I A RS A K l- rRlK T« ' 
lli:ST Ol- .MY KNOWIJUX'K AN D nivljl-l' 



III)' 



'liif<.ni;itit 



IX^yVWOw^VN' 



OVd Ch^-KAXoJL 



c^prdlAL INFORMATION on!, lor Hospitals, Institutions, l^ansients, 
or Rerent Residents, and persons dyinq av.d> Iron, home. 

(T) ^ f] Hfl\* lonq at 



How lonq at . 

Former or l K j \^^^x,- pjnre ol Oeatti? Vo Days 

Lisual Residenr VU tviAJ^y^ - ^ 



place 



.'J^-\i 



ruACK (.»•• nri<iAi. OR ri.movm. 



(Xu W)-^i^ 




( \<l(1ri's,s 



i,\i 1 .,; w KiAf. -.1 ri:mo\ai. 

LLos^ ^v'3v T 90 H 



>Cna/aAJ'u:ti 



!N. B. 



' , pv^CTLY PHYSICIANS Hhould 

«tate CAUSE OF DEATH in plain terms, that .t may .^; P^^^j;'^ 
«on, dyinft away from home should be ^ivcn in every instance 



ft 



Vil 

hi 






'\i 



I 



I 



[|!iri 



1! 



It* 



ii, II 



x<m 



11 



., r^,^ 



iii' 



li 



1 1 



:il^ 




Te PLA.NLV W.TH UNrAD.NG ,NK-TH.S .S A PERMANENT RECORD 



WRI 

u,/r Filed , \sXx^J:^y^^^^ ^^ 



.- r.n-r.pirATF FOR INSTRUCTIONS 

REFER TO BMV^fN v»r N^...» 



100^ 



Registered J^'o- 



11 16 



ih 



^ \ Deputy Health Officer 

DEPARTMENTol^ PIBLIC HEALTH-City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH:-County ofCla^- a^xx^^a^r.. Gty of 



No. ^t*^ 



a. 



. , , ^ a Dist . bet. Lol'-k^^^^ ^"'^ LUyovv^^-t ) 

f^r,!} - 'i S H UL'WIL ^^' ^ UlSX.,tX\. 7„„ „^„1, •special INTORMATION- \ 



FULL NAME 



.^^ 








PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



w 

HI Kin 





^'VU 



io 




' NlMiithl 



55- 



5 v.;/ 



^ 



I 

(I):iVi 



M.itilh^ 



9 ' 



MEDICAL CERTIFICATE OF DEATH 



I'-l 



(Year) 



IS 



/',/i.> 



^i3x^ 



l- MAUUn-.l) 



• 1 11. \'' »' 
r 1 Mimti %■ ' 





NAM I- ol- 

1-A rin:R 



iMK riii'i. Avi-: 

ni lAIHl-.K 

' Si.itf (If Country* 



M\nil-.N NXMl-./OPS 
•tl MoTin-.R ^Ul' 



^\xxvvoixL 



jJLolv^^.^vw 



(Month* f "'='^-^ 

I iii.:Ri:r.V CI-RTIFV, That I mIUmuK-I .UTrasd fnm, 
TcpS to CWoi IH TcpH 

,„athat.Wathoccnn-rea. onnu-.l.t.^t.tc.l ah^v.. at 
- M The CAl-Sh: Oh' Dl.ATll uas as follows: 







l,r RATION 5''''^''-^ 

CoNTRir.rToRV 



/-N-v -O..- 



Moni/is 




Hour 



vj OLaJOv.^vAJL 



^t^ '^A 



lUR rni'i.Ari-: 

<)!•■ MoflUvK 
(Slate or ContiliA 



flours 







:crPATi<)NQ^ . 5 



(SIGNED ) civ. V 

CLvA. l ^ TwoH ( . T ■ , 

"spec AL iNFORMATlblTT^tor Hospitals. Instituhons. Transients, 
orlere^^esfde'-nts and persons dying a.a> fro. home. 



Tin: AUOVKSTATKI) rKR>^..NAl. l-AKTICr I \KS A K l". TKri. To 
in-.srol- MV KNOWIJ'D'.H AM) HhUll'.l' 

(Inf.Mniant \] |V^ ^J . ^ A jW/V>Jut 



HI", 



Former or 
Usual Residence 

W'tien was disease contracted, 
II not at place of deatti? 



How long at 
Place of Deatfi 



Days 



ri.ACKOl: HIM<IAI. OK Kl-MoVAI. 



-.1 T90S 



LAa,-*^' 



1 



/v^^ 






,^_^_^_^ "^ . , rXACTlY. PMY.SICIANS should 

statc CMJSH OP DEATH in ph.m terms, that .t m»> ^^^^^^^^ 
son« dylnft uwny ?rom home should be feiven in ever> 



ll 






»^ 



-f»q^i-:> 



inf^^ 



^'H^'" 



4r % 



'^'">-. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ilmr.Iorilcr.ll). \ s... ;■ *-^i^K HSif Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



f >,!/,' lu'lcil. LLv^QvVA^ XO HJO^ 



llcfii.sleii'd jVo. 



111? 



ck^^-\.iwA-^ 



Deputy Health OiTicer 




DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Death 

PLACE OF DEATH: — County of UAt^O; Oaxx/>'vCa^oc City of OxX/-v^ JAxX/w;^o<iyO. 



N.] 



kV\ 




t 



UL^^(ry^j St,; 5^ Dist.;bet. \XXX\^ and 13, 

r :r DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G . V E FACTS CALLED FOR UNDER "SPECAL INFORMATION- \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 




FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




od 




MEDICAL CERTIFICATE OF DEATH 

i» ATI-; « ti m; Ai'n 



i< r 






H 



r\^\ 



» 1 \ 



I 3^ )■■:,. 



w 



l-T 



> I MI 



/),/ 



GL. 



1°, 



/9o\ 

(Year) 




! MARK n:i) 



lURTHpI. \C}-: 

'Stair .)r Cminti v> 




'v/Cuv>v.ot<;^- 



\ \ 




I Ili:ki:i'.N- Ci;UTll'V, riiat I atk'n-U-.l .Icreased from 
UcVxV.Oi l*^ i<;oS I,, LLwvQ it U)oH 

tliat I la<t <a\v h <- v , .ilivx-on LLAwV.<V \% l< MD ' ( 

aijj that (Kalli omirred, on tlio date statc(l almvc at I 

( I 

'^^ M. The CAISi-; Ol- I)I-:a ril wa^ as follows: 



CI 



i. i K 



v»f 



i 




•t» 



m 



-^ 



IHRTHn.ACH 



MAII>i:\ \ \Mi 

•»'■■ MoriiiiR 



•■■•> ' M i'i.At'K 
OF MOTHKR 

' ^'''iintix 



^1 '"^^'ri) 



JU\ 





^ 



aLC.^ 



I )r RATION )'rajs 



CnN'I'kllM'lOR V 



Months 



nays 



Ilonrs 







DIR ATfON 
( SIG 



rriON )■<</; s .\/\<>i//is 

NED) UJ . Vl . ^i^.CAw^o^Jk.CL»• 



/>r/r 



M)/^ 



/'V 



M.D. 



AV>/,/,-,^ /„ V, „/•,,,„, /.,-,, I-V )•-■,?; 



CML INI 



SPECML Information "nly for llospitdls, ln^(ilulif)ns, frdnsunJs, 
or RtTfnt Rtsiddils, dnd persons dvinq dWdv fron home. 




1/../////, 



/),.• 



■ ' "1 ..n KNOW 1,1, Df.].; AM) lU'.I.Ii: I- 



formrr or <y 

Isiidl Residence I bb i 

Whrn v*ds disedse (ontrdcted, 
If not at pldfp of dPdth ? 



d. How long at 
t Pldre of Dpdtfi ? 



f)dVS 



liiiiit 






.\<uir.-.s H?) LUULrunv IXv^ 



ri^AcI-; (»!• HTRIAI, (>K R1;M(i\\I, j KATi;!.; Ml KiAi, (., rj:m(»\ai. 






/CL-a OL » ^ ^^ Lc 



IQOH 



.very Item of ifif>rmHtion shoiil.l he cjireV'ully supplied. AGR sho ild be stated HXACTLY. PHYSICIANS should 
state CAUSIZ OP DHATH in plain terms, that it mny be properly cl«ssi>ied. The "Special Information" for per- 
R'>n« dymft n%vay from home should be Jiiven in ever> instance. 



5' 




; i 



I 




if. 



rIv'Jii 



^at^ 



^wfi 




ill 







i 



I 



WRITE PLAINLY WITH UNF^'^i'M'^ "^•- 



J5(i;ii'! it lli;iitli I-' N'ti. k f--' 3f>,>L;- |{,''vI'Co 






THiS IS A PERMANENT RECORD 

REFER TO BACK OP CERTinCATE TOR > Nc.tpm^^.^..c. 



I'JO \ 



Registered J\''o, 



11 18 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Prancfsco 



Certificate of IDcatb 

( "U. 5. 5tn^^nr^ ) 
PLACE OF DEATH = -County of dct^! \ .^.^-^^ city of ^Co^'^ 



C ir or*TH OCCURS AWAv rpoM USUAL REsTorNrr ^^^'^ ^^** "^^ ^X5^^rurUCU>^; and J *>V^ 



^^^■^.... > -Cl) 



FULL NAME C^x\. 



^ 



PERSONAL AND STATISTICAL PARTICULARS 






L) 



Ojyx) 




iKTil 




loi 



MEDICAL CERTIFICATE OF DEATH 

i> A Ti-: ()) i)i:.\Tii 




rJ^ 






; I )M 




fMoiUh) 



w 



">-'v' (Vcar) 

I 



> ni.:ui.:i!v ciiRTiKv, ri,,,, . m.c.k.,! ,i<...„,sc.,i f,„„ 



,^-1 



1 1 1A<;/,'// 



N 



?:i I.' 



^' XkK I 1.1, 

■ -ii'iiiilioiil 



"1. \rj.; 

' 'illlltl VI 



i /' 



'»'■ I- \ nri-i; ' 




lli.it I hist saw h .=.' alive- on LLv^O i' 



^ 



i': 



1 90 



<XV>^AoLxi 



Mn.1 that .Ictl, o,-.M.rrcMi. ,„■ 1 lu- date- statv.l ahcnv. at t^- IS" 
U. M. TlH- CAISI.; (^' OHATil was as follows: 




^'AllU^N NAM,. /T) 



rin;k 






F I 



I )rK.\'r ION 



^ Signed ) 



>''"''V Mini I lis Day 



Hon 



rs 




iUi ,. ... 



yxfrs Mnnlhs 



/^/rs 



1.^-vOL' 




' I<(oS f 






I lours 
M.D. 



C: ^\\ 



O ( I ]. » 



!:< 



.i 



n „ ^^^^±::i^"- ^- '-•^a^,>.„. 1. „ 



'"" ^-^—v<^b^ '^0,^^x11. 



or Rerenf Residents, .ind persons dving dHd> Iron home. 'r^nsients. 



Former or 
l)sii.il Residence 

When wds disease rontrdffed, 
II not ,i( pidfe ol dedfh ? 



How lonq df 
. fd« e ol Dedth ? 



Days 



\.M,...s 30^1 




JI.ACKCF iirKM,,,,K ;y:M-VM I nvn.;,, „,,„, .., kkM.,V\,. 



im)i:ki" \K j:u 

CAdiltrs^' 






190 *< 



n 




U'' 




(•'I 



^i" r»^ 



"i/s: » 





u 



write: PLAINI V IA/itu I iMr-M f>«....^ 



!!..:m.! ..( II ^,'ih -1* No. !>:, ■^^''^^^- 



5:^--? W^V r 



.a-xlXJ 



X^ 



100 ^ 



X(hv.ov^ Jvji v>-M Deputy Health Officer 



THIS IS A PERMANENT RECORD 

REFER TO BAC K OF CERTIFICATE FOR INSTRU CTIONS 

liegi.sh'icd ^Yo^ 



ill9 



DEPARTMENT 01^ PUBLIC HEALTIWity and County »f San Francisco 

Certificate of H)eatb 

( 11. S. StnnOarC> i 
PLACE OF DEATH:-Countv oi^^3^^,^,,,^,,^ „, i^;......^^ 



No. cLay>Aji dbcy-^douJLo. 



St.; 



Dist.; bet. 



( .r DEATH OCcJrs AWAY FROM USUAL R F «? I nV M /- r ^-^^St.; bCt. " -——____ J _ 

FULL NAME iv^C^^ l), lO(mi>vJ[,- 



- ) 



PERSONAL AND STATISTICAL PARTICULARS 




III 





M.Mlth ' 



.^ 



Iv 






I go H 

(Ve.-ir) 



\i 



> ■ :i I I 



I'-l 



% 



1,',,, 



^I AK-klll) 



l'( 



Tit 

tli.it [ last saw li ^A^-^ ;ilive on 



'"""•n, s,„-,al .l..i,M.,,ti,,nl 



'"^:- "I <'..niilrv"i 



'•■\thi;k 



f>i" i"\Tin-:i<' 






niKTtipr.xrp 







MEDICAL CERTIFICATE OF DEATH 

i> \\\: < ii- ni: A III r-K 

^Mo„7jy^ (Day) 

:^mpHHV CHRTrrv, That I atten.k.l deceased fro„, 

190 H to LUa^ iq, 1,^0^ 

iM that .Iralh occurred, (.,, the dale siate.l above, at S 
^ ". 'n'^'CA,SK(),^ ni^ATH wasasfolWs: 



IXRATIOX Qi^ r,viy-.v 

C()N'rRn!('i()K\- 








\\ 





Vonlln /)ays Jjonrs 



d^. 






OrRATlOX }V..;-.v 

(Signed) C>-yv^'\vidb Uw^^t^vdl^ 

^^ r<)o'A (Addnss) 11<^5 




ttsVwt^^ \ 



I fours 
M.D. 



^^^^fi^'^}'}^^ORU\tKT\OH only for Hospitals, Instirttions frdnslprifT 
or Recent Residents, and persons dying anay fro;n fiome. ' "^''"''^"'^• 

Former or [ ^ 

Usual Residence \JX. 



k'vJ^Jj^JLi 



)•,,'/ > 



■'////\ (o /J,/i 



■I'll'' \,„,vr •" '"' "■"">' Vo /^'M> 



Wlien was disease contracted, tA ( 




ej, 



Days 



,JUU 



flse coniractert, -A 
If not at place of death ? O Oyy\j \^\X ^^jj^^ 

Y^M or HIR.AL OK KKMOVA,. I CxTi.; .,, „ „,, .,, „ jT:;^;^!^ 

aaAv|iKJi Cxi I (^'-^-Mi iL 



IQOM 



«t«te G\l"ir^oy/np\'TH" *''''."''' ^'^ ^«''e'?"'«y supplied. AGE «hould be stated EXACTLY. PHYSICIANS «h«. ^A 



I 












'■'fimi^^is^- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 





^'°^'^^. 



HoMnl'.ni.MlHi IV... ,.■*T:W^J^,^S:I•(^. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



; .i 



Ihllr I'ilcii, (J^A..V<W.^ X\ iUO\ 

\j^^\j.yu^ XloMj Deputy Health Officer 



llegLslcrvd JVo. 



1120 




DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of H)eatb 

! 11. t5. 5tnn^nr^ ) 



PLACE OF DEATH: — County of 




a..K,aj 



^ 



N<v ' /^ ■■ >. 




CMl, 



wx 



City of M Loi-x-ou v.a„l 



.<xv 



St.; 



Dist.; bet." 



and 



^r 



t 



(ir DEATH OCCU|RS AWAY FROM 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. ) 

1^' 



FULL NAME 



UIxoaJLu a. v£ 



PERSONAL AND STATISTICAL PARTICULARS 




ri »i,i Ik 



II 



% 



LL ,'kv.O- 



■J xJx 



h 



'MMnlhl 



Ar,).; 



^fiH*l 



H:-' 



I);i\ 



1 /.>/,'// 



» ( ;i!' 



/',■' 



!X 



MEDICAL CERTIFICATE OF DEATH 

i).\ri-: op Di.A 111 



a. 






ri)av) 



(V.-iii) 



' i,i:. M AKRIl.;!), 

-iviiatiuii) 




,» , >. 









N\M1 ()]■ 
FATIII-R 



HIKT (!!'!, \(1.- 
^V" I" A I llF.k 
(State or Cduiitryi 



MMDKX WMi 

"'■ ^I'>'i'iii:k 



'*"< iIlIM,ACl-' 
OI' M'iTiihr' 

(Stat. ; r ,,:,,, 



•H:cri'ATiox 







I lIlvUI'P.V n:i<Tll<V, 'I'liat I .tltciidr.! ilcccasi-d fn. in 

1^^^ h^ to (Xca^Ol l^ icpH 

lli.it I last saw h ..V>^^:tli\•c• on Llx^^/Q IH np'\ 

aii'l that (K-atli ocrurrcil, on tlu- <latc stated aliovx' at \D- A.5~ 
V M. Tlu- CAISI'. ()]■• I)i:.\'n! was hs follows: 



Dr RAT ION )',a/s 

f () N "J" u I r.r 'I'om' 



M out In 



Days 



Hon 



rs 



1 








(Signed) 0. uvj. O.U..^^ 



Months 



PiU 



'.V 



a 






M, 1 (^ i' 

'^ (. T(,o'l (Ad.ln^O \i L<X-lvQj VO,(' 



fA 




I hutrs 

M.D. 



AV ; ,',,/ ,,i S:nr /', 



I (HI, nri> 



5 ',•,/; . 



yr..:,fl,. 



/'„■! 



' " II. M-r'yw'iT^ '"'•'" ''KU^ONAL rAKTUTI.AKs A K I". IR!-]-: T. . T1!K 
'■'-^l <>!• MV K\. i\VI,!;i)C,H AM) lU-Ml-F 



SPECIAL Information nnl\ for llospitdls, institutions. Transients, 
or Recent Residents, and persons dying awa> fro.ii home. 

Former or ~\ ^f Hov\ lonq at 

Usual Residence 'J <Xnru O'Xa ^ ~ - pue of Death? o rv|/>.... Days 

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



ri,ACi': ()!•■ nrRiAi.oK ri;m(i\ai. 



DAl'l'. of liiKlAi. or R1:M()\- \l, 

a. 



.-<.^wQ- A 1 



I .ni>]:rtaki-;r vJ<XCA-i-v/C. LL/vvcOlAXoJr 

1^1 QO\v^^c^ cS:l 



T 90 ; 



r\(l. lies'; 



N. B K 



Kvery item of itiformntion should be cnrefully suppIi.Ml. AJJE sho ilil he stated H\ \CTLY. PHYSICIANS should 
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Informjilion" (for per- 
son* dyin^ away from home should be feiven in every instance. 



.1 



i 





^1 



:i)!»i: 







•.^A« 



!A.^»! 




i?tfK- WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,.M.l .{ IK i!lh '!■ Vn. i^ ■t>-f';'r»';X- wS^v Co 



^^v<y-^cAt a I 



I!JO\ 



Jieo^/.sfr/'prl jYo, 



1121 



Deputy H 



Officer 



DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 



11. S. GtanC>ai^ 



m 



PLACE OF DEATH: — County of C)/0^>v C/.VCL>\cuic^ City of O^u^^' J.'UX^v^ 



<w^C.<. 



N 



o"^ (ll:'Crv\>avd 



St.; 



Dist; bet. 1 1 




and 



I a) 



\) 



(IF DEATH OCCURS AWAY FROM USUAL R E S 1 D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



cLmaa^ \x) 



xcNiyrvj 



PERSONAL AND STATISTICAL PARTICULARS 

Ci il.t »K 




DA 






.0.Vl,<^O- 



MmIiIW' 



t 



(l):iv> 






MEDICAL CERTIFICATE OF DEATH 

1) \ri{ (>!■ i)i;.\Tii 1^ 



5vC 

(D.'iv) 



' VlMI 



IH 



) 



II 



/ 1 , 



\\ II 







♦I 



I'.iKTir,'!, x.i: 



f-A riii;R 



HIKI'IM'I \K.V 
f>!' i-AlliKk' 
'St.itf or 0..inilr\' 



\"\M1 



'oinitix- 



V J XWVVOL/-YX^Jl_ 



(Month) ,\ 
I ni:Ri:i;\' Ci;RTn-'V. That I alU-iuUMl dcivascl fn.n 

tliat 1 last ->a\v h X'Wv. alivt- oti LCvvol '^ C) iip'l 

ami tliat dcatli ncrurrcd, on the ilalc- stati'd ahnvo, at I 
(X M- 'I'll*-' CACSI-; Ol' I)i:.\'III was as follows: 







DC RATION "i )Va;,v 



CONTI^: IIM'IORN' 



Mouths 



Days 



//on 



t s 



nr RAT ION 



)'((irs 



M.oitli> 



/hrrs 




V^V*/ >v 



'X-'^-'ll'Miox 



' ■Xj\y^^-'^0^-\ 



\. 






1 



SIG 



NED) VjV(rlsJll\t) (MJ.UaK' n 

^1 i.,o'-\ (Addn>.0 'k\^\ JbowMXvA 3< 



'/// ^ 



M.D. 



dlAL 



SPECi'lAL Information «n!v (or HospltdK, Instilulions, Irdnsienls, 
or Rcrenl Residents, dnd persons dyin;j d\*dy from home. 



1 ' ■///// > 



"'prJi!.*^''.-^''^ ''"'•■'* '•»*■'< ^ON.M. r\UrHT!.\KS AKi; TKl J- T<> Till' 



'"f'Mnant \J fVu) 0»v/Vn^Oo JUV<^'C 



\-Mr..s X\^% do Ch^-V^CX 






former or 
Isufll Residence 

When was disease rontriifted, 
II not at plat e of death ? 



Wm ionq at 
PIdre of Death ? 



Da>s 



I'l.ACI-: <>I- lU RIM, UK KI;Mi'\ 



1, 



i) AX'- "' 1" i-i^i "I '< iySU »\ AI, 







N. R. 



Kvery item of ijifopmation should he ciircfully suppIKmI. A(iB should be stnteil HXACTLY. PHYSICIANS should 
«tate CAUSE OP DEATH in pliiin tcrm.H, that it muy be properly classified. The •\Spccial Inforniiition" for per- 
son* dyin^ awny from home should be <>iven in every instance. 



f 




r 41 






i ^ 



, i 






« - 

* * 
t, 

.V 

w 



I ■ 



U 



!'! 



11 



|. \ 



• \ 



, -f^U*. 



h 



n 



c 



( 

r 



v! 



''I 



' J 



i 



)• 



•:\ 



< * 



Ui 



i^ \ 



*l«fP^" 



.«*•*.■ •■■v^>^. -/^ ■'. ■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Bor.r.l of 1 1. all hi- No. i<; t-?.;«';- *-^ iit^i' ^'• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(//' AVAv/, vXL>wOyL^^AX Qvl 




kaj^ 6uu\xa 



J!JO'\ 



♦« p r-v 



lloiULslci'ed A'^o, 



ll2ii 



DEPARTMENT OFPUBLIC HEALTH-^City and County of San Francisco 



Certificate of iDeatb 

( 11. j5. jr»tanOai^ > 



No. 



PLACE OF DEATH: — County ofCla^x- O.^CU^A.'a^^<Mj City of CJ^tX^^ A^<Xav<^^^CO 




'Ill lt,^,v.- St,; X Dist.; bet. W a>vhjU^ and V.A^.V-^^ 

ir DEATH OCCURS A\Ntiy mOM 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 



.U^AixXy 



CU 



,- ' s 



AJ^'-V\, ^ v, V 



^1 



PERSONAL AND STATISTICAL PARTICULARS 

: :k 111 



J ^> 






Dav) 



A^.l 



roo H 

(Year) 



at . 



^ / 



/>■ 



""iN".!,!-:. MARK nil) 

un>< '.^\^v\^ I >iv i)!\-( iKri:() 

1' -it'iiat i'lii 1 



IHIMIU'i.ACK 



■ 1 o 1 
i i IK 




Ayv-(rvoL/d. 




MEDICAL CERTIFICATE OF DEATH 

i» A v\-. I M- i»i;A'rii r\ 

fMontli* /] (Day* 

I lll';RI-;r.\ l i:R'ni"N", That f atk-mU-d .IcM-casd fn.iii 
Y^M '^^- Kyo . to LLuM3. aO U)0 H 

tliat r last saw h X^u alive on ^Vv^Q 'Xb up ' 

and that (K-atli i ic'ii ricd. mi thr ilatr staled al>M\-.,-, at I 

\) M. 'i'liL- CMS!': OI" l)I-;.\ Til was as follows: 



HIKTUIM.Ni I.- 
I.I . V . I||.;^ 

''iiititrv 



IM-.K 



«>J- Mo'iiii.-r' 



Id. dl 






to 



DC RAT ION - );^ 



^~ 



- M,uilln 



Par 



'S 



(.' () N T R 1 1 '. r 'r < > U N' XAJUx^^CAAX^tX>v \l AJLavv^wclv Iv. . 



1 lours 




t ! V 



'"■'I I'A.Tlox 






DTR-ATION )'<■<>>■ 



SIG 



NED) VAA'AjUAJ. \tn 



Mouths Pays 




XO Tc)oH 



Addrrsv.) OXclNA) JV/V^vQ V^bAd 



Hours 
M.D. 



SPECFAL INFORIVIATION ftnlv for tjospi 
or Recent Residents, and persons dyini) iiwav fro:n home. 



)itdls, Institiifions, T 



-4- 



M->,!h:~ 



n.i\s 



III \lii,\-K sT\ri:i) I'KKsOVAl. r.\Kl-UTF,\KS AKI'. TKri'. To \\\V. 



former or 
IsudI Residence 

When was disease conlriifted, 
If not <if pU e of death ? 



How Innq at 
PIdre of Death? 



ransienfs, 



Oavs 



fli!f'>Mii:mt 



(A.un.s iHHo U'oll "at 



VXV 



ri,.\ci'; (»i lURixuoK Ivi:mii\ \ 
:^\ U- ly. 3 . CvX/^-vvCLtyvM 



1) \ i"i; ■■: li' i.'i \i ..I ri:m()\- \i, 
^''*^ 1004 






CNDl'.K'IAK]: R 




% 






N. B. livery item of 1n?ormntJon should he cnrefully supplied. AGK should he stnted f.XACTLY. PHYSICIANS should 

«tntc CAUSfl OF DHATH in plain terms, that it mny he properly classified. The "Special Informntion" for per- 
sons dyiniJ nvvny from home should he ftiven in every instance. 



id 



4 

t 



.>si 



J, 



• 1 



' I 



>«- . 



f I 



I « 






dUi 



\\y\ 



M^sissi^^^s^ 



iL^M 




1 'l, '^l' 






'm 



.n^' i 



ifi' 



t. 



,.r 












ij 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



liD.i;. 



- Isl^'ar^tolUS:!' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J? 



7,Vf^n 



llcgLstci'ed Xo, 



jL\ ^.^<5 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 5)eatb 

J? ^^ J? (^ 

PLACE OF DEATH: — County ofCJCL'^^ 0,tv<X/'>xc.c4.C(.City of C)/0-/-rv O AXlo-v^v^ -c <. 



INo. I V \ 



J ^ '...J St.; 1 

(ir DC^TH OCCURS AWAY FROM USUAL RESIDENCE Gl 
IF bCATH OCCURRED IN A HOSPITAL OR INSTITUTION 



Dist.; bet. 3^'Ax.J/\..trrCl) 



and Ut<>- 

IVF FACTS CALLED FOR U n'd E R "SPECIAL INFORMATION" \ 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




\Xtr>v ) 



FULL NAME 




Al} 



PERSONa-XL and STATISTICAL PARTICULARS 




Cni.ok > 



^ i! 



:■: \'\\ 



u 



Month* 






MEDICAL CERTIFICATE OF DEATH 



<I);iy 




Mi.ntlil 



(Vi;ir» 



M..ul/n 



^ 



/',/!.. 



SIN.,I,H. M\KKIi:i) 

:il (U'sijrnatioii) 



ni:.- 



N \M1 (II 

'•atiii:r 



'I : \ 



I 1 



'ii;-: i 111'! ,. .. 
IStatf lit- Cutititrvi 



MAIIi) v WMj- 
<M Mm III J. K 



''■"<i'in'r.ArK 
"1 ^^■■^!^•K' 

iiiintiv' 





UJ 






1 Hi:Ki:r.V Cl.RTirV, That r alUn.U'.I .Urease. l frmii 

— • I(;0 ti ' ■ ' ^-■ ~ H)0 

that I las! ^:i\v h •■ - -ali\iMiil " ~ lip' 

ainj that lUath « ircurrt'il. <>ii thi- datr statt-d al)(t\\>, at ' 

M. Thf CWi Sl{ Ol' l)i: ATII was as follows: 



d^rv^-^-^k 



CV_Avd- ' J^ -C^->^<rVvKccciLX' Xv-crvvv 









IXRA'I'ION }V<;;',^ 

C( >NTkir.r'r()RV 



DTK AT ION _ )V(?/.v 



Mouths 



/hiys 



Hours 




(Signed ) L<r\^rk^i2A; o. vij.llj. cLuLcl/aax:)- 



I^ay 



/ /ours 
M.D. 



SPECiAL Information nnlv for Hospitdls, institutions, fransients. 
or Recent Residents, and persons dvinq a\*av froni home. 



^r,>>,ili- - rh^ I 



»'»-.M OI- MV KNUWIJ.-.DCH AM) M1-:m1-:i- 



fliifoniiant 







Former or 
Usual Residence 

When was disease confr.irfed, 
If not at place of deafli ? 

ri.ACK ni- HTKiAi. OK i;i;mo\ai. 



How long at 
Place of Deaff) ? 



Davs 



DA'm; .)! Hi Ki.-vi, -.1 Ki:M(>\ \|, 







T 90 "-l 






F.very Item of information should be carefully supplied. AGB Rhoufd be stated RXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain term*, that it may be prc.perly classified. The "Special Information" for p.r- 
"f^n* dyinj^ away from home should be ftiven in &\ery Instfince. 




i? 

< M 

' If 



'.fi 



I I 



» ( 




m 




*W5(C!?. 



m«mi 





i lllil'-' 






I Wi 








I 




ill 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n.,;,,.!..! li...MI: IN" '^ ^•^';^-. it>.lT.. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I) 



life Fih'd y KXx^Quy^^J^ X\ 



V)0'\ 



liCgisfcred J\^o. 



1194 



i 



Deputy Health OfTlcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtiticatc of IDcath 

( tl. S. StanC>arC> ) 

J? (^ SI % 



lo» 



PLACE 



OF DEATH: — County ofO/CLTu J.Vao^e\.<ie( City ofCJ/CL/Vu 



A^Cu^vc^^Ai e,o 



^' CL ^aa^LolX-a^vv. -^ ^ ,. 



St.; 



Dist.; bet. 



(IF DEATH OCCURS *WAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



!i 



4^ 







-U 




|V/. t 



MEDICAL CERTIFICATE OF DEATH 

DA 11. (U ni'.ATn /"> 



Moiitli) 



45 



) ,.n 



!I):i\ I 



Mnillr- 



/his 






"il< 1 !l IM, AOl-: 
(St;i1r <i\- rountrv* 



N\M 






X^^vKX^WM 






\% n^o \ 



u 



Dav^ 



(Vi-:ir) 



I HJ':ki;i;\ i l, U'ril'\', riiat I attcii.K.l .Iccrasd In. Ill 




tliat'T last saw li .ilixroii vvA^vcy. i v. jtp 

aiii] tliat (Uatli < >tHMiiic'il, on tlu- daU- ^tatc-il ahovc, at ii. \0 
M. '1'Ik' CAISI'; <)I- |)1-:.\T!I was a< follows: 



\w CXAyCA^-W,^rv" WO^ 



OV itO v.v .'^^-cLLAxi 



'V>uic>'T» 



y 



HiKrni'i.xcF 

OI' I- \T!II-K ' 
(St;U< 





^ 



' ; \ 



^'Ali.i:\ \AM). 

OI- Mornj-.k 








'VCr^^v^ 



■ 1 n , i 1 ', 



4 



i 1 o N 



f^'f!(!r,f III S,i)i I I 



Ux^^"n^vOw-KV' 



, IB )v,. 



I )r RAT ION )V<7r.? Moiith^i Pays J /ours 

Dlk A'l'K )\. )'r •///•? Mouths, ^ Pars Hours 

f SIGNED ) OAxAxVLcJk LU. oU tv^iwYo M.D. 




% 



SPEciAL Information '•"'> t'»r Hospitdls. Instilutions, rrSnsienls. 
or Recent Residents, dnd persons dyinj .m.iv Iron fiome. 



former or a.. ^ "M f J - "M i i I ""^ '""^ •^' 
L'sudl Residenre^^O \^^\.O^Sa^ OClUUvvPUp oI Death? 



Ddys 



/<,^'. - 



' "prJ','*^ '• '^■'■'^■'''•'■!> !•>• USONAI. P \ IM' IT I " I,A K > AKl- T!<I I' To TIN'; 



«l!if ,:„,,, 



' ^<1llress 




1 



ru. 



When was disedse ronfr.iffed, 
If not at plafp of death? 



QUfe 



ri.ACl'; ( >1' 111 J^l \^l, oK K1,M(»\AI, 

rM)i:RTAKi:i; Vx^^^xiU 




>\I'Km! Ill imai, or K l'.M< i\AI, 



0-Cv~x^'\ 






N. K. Kvcry item oV information hIioi.I.I be cnrefully Hiippliccl. AGK shoiil*! be stnte.l LXACTLY. PHYSICIANS hUouM 

«tiitc CAlISn or nr:ATII in pUiin tcrmn. tfint it mji> he pr.M»er!y classified. The "Specii/T InformjHl.n" f..r p«p- 
K^ns (lyin^ uway from home- should be Jii\en in every instnnce. 



'I 



I; 



I 

■'in 



It ? 



t. 



<; I- 



i 



I f1 

1. ' I 

! 



^ 












'\ 



'.'.-I 



M 






^. •* 



,^^J« 



.■.-v^ 




\ : i 




u': , 






u ' 






„ 



■ 



.b 



!1 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



nn:,nl..fll r'. rvn ,- t^^^;^^^^)l{S:l^CV, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J) 



II I c I'^ilt'il , LLM^xyL/v-^^iX Q^l 



rJO'X 



llegisU'i'ed jYo, 



\ i 25 



ck^CrVCA^ ci 



Deputy Health OfHcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( 11. S. Stan^arc> ) 
PLACE OF DEATH: — County of ULL<X->->^^cLo.; City of U/0^kX<X/-vvd. 



No. 



l'^'^ 



■,ti 



A.- 



St.; 



Dist.; bet. 



and 



f IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECrAL INFORMATION ' ' \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



oX^oc/l'l ooji^-y-K-^h.. 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 





(■()I,( >R \ 



bjl.t 



i< 111 



M.,n:l>. J 



\^^. 



/ 



^ '' (. 



IdH 



/,///' 



/),/ 



w iM.-' . .) (^^^ I,!Vt)|•^ i';i) 

'^^ Hi:!] (li sij^Miiitiiiii) 




III 



-lis-) 



N \M1- <)! 

iatiii:k 



liikrui'i \> }•• 
'^"' >'atiii.,r' 

"^tatc .,r O.iimtrv) 




LcuuvoocL 



ol/>^^. 



^Ou^rnjL^ 




MEDICAL CERTIFICATE OF DEATH 

DATI-. Ol- Dl.ATH '~\ 

;M.mth> A I):iv» (Year) 

I II i:i< i;i;V CliRTH'W 'I'b.il I atU-iKkMl dcci-asfd from 

— — up to I()0 

that I 1.1^1 ^i\v li .~ alivf on lip " 



ami that tUath o(H-urro<l, on the dali' statt-d alxni-, at 
M. The- CAT SI- ()!■ I ) I! AT 11 wa^^ as follows: 






M\:!n \ NAM).- 

<ii .Mo)-ni;K 



inkTiii-i.Aci." 
'>i' M()Thi.:k' 

estate or Coujitrv^ 



'" ' ' i \rinx 







Lw o. 



I )r RATION }■<•(//•.? Mouths Pays Hours 

CONTRird'ToRV 



I ) r R A T K ) N ) V(?;\v Months Pays Hours 

(SIGNED) ;'. . vfc.y l'UJvA./->^v.o., M.D. 



V A>^C\, :.'. i()o'\ (Address) v^',0^<^X<X>\A Wt 

SPECJiAL I NFORIVl ATION "nl\ lor Hospitdis, Institutions, Fransipnts, 



or Recent Residents, dnd persons dvjni] dwdv Iro-o home. 



''■'':>lr,l ill Si:>' /'iinni i-,> '~~ )',■,; i 



\J..n'l,- 



/',' 1 



""..,^'•1.'^ ''• '^■'■^■'■'■■'» I'KKSONAI, l'\R'rifri,\KS AKl' TUT I! To Tl 

i.i'.sroi- Mv KN«.\vi,i:i)c,}.: wd hi-j.ii:i- 



1 1: 



Former or 
L'sual Residence 

When was disease ronfrarfed, 
If not af place of death? 



Hum loni) at 
n,i.e ol Death? 



Dd>s 



I'l Vfl". nl' lUKIAI. OK UI;Mi >\ AI. 



\J^Jii-^'^ 



I N 1 . 1 ; K T A K V. K U 0^^r^Xyy\JJ^ ^ 






TQO 



A.^^.^^ 



^Xd.ll.-.'^ I'ivO'^ 



(Y)\v^ 



i/s-^ 



'.t 



N. B. 



r.very item of Information .houlcl be cnrefully supplied. AGE bHouIcI be «tnted EXACTLY PHYSICIANS should 
«tnte CAUSr OF DEATH in pinin terms, that it may be properly cla«8ificd. The Special Information for p-r- 



S'>n« dyinft away from home should be ftiven in every Instance. 







I ' 



1 



;il 






u\\ 



I . 






<<l 



J -. 



J 



\A 



j.f. 







4;f 



#(S^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



% m) 




li 



m 



I 



u 



•^^m 




t 







¥\ 



II. .'til 1"N(V I :; t^*"' =r''-i»l;. HS:I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






190 \ 



llci^istered J\^o. 



Jv^A,^v^ J^JLvKt Deputy Health OfTIcer 



-5> 



1 1 26 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of E)eath 



[ 11. 5. Stnn^arC> ) 



No.L 



PLACE OF DEATH; — County of <X/yv J XCL/ixcxA ao City of OoLAX! OX/<X^xau^cc 



X 




yxM 




CK-^vCt 




St.; 



Dlst.; bet. 



"and 



/ IF DEATH OCCURS *W*y FHOW 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 







PERSONAL AND STATISTICAL PARTICULARS 

r( )I.i >K 



/ lXXXI\_v cVC 



!K III 




(5^1 





MiMltllt 



as 

(I):iv) 



r 



\^:- 



iS 



5~ 



1/ .;■// 



ll 



^fV«.l.K. MARKIKI). 

n-i:.. ,\\-i.i, , .w i)i\-()H(.-Ki) 
<i'. '•ipii.'itioii) 



I! IK 



'unti \- 



O-c^k^o/Lt 



FATFlKk 






'•r C()untr\ t 






<>I- M'TIIKr' 



O^Cri'ATlON 






MEDICAL CERTIFICATE OF DEATH 

PATH ol' DJ-.ATII f\ 

(Month) A (Day) 

I m;Ri:HV CI-RTII'V, rii.it I attciukd dcvcasod from 
O^^'i i9o3i to LmsA^Ql XO 



ii 
(Vear) 



til at I last saw li 



LLa^/w' 



T()0 H 



an.l that death occurred, on the date stated ahove, at *^- 15" 
LL M. The CATSI-: Ol- Di; AHI wa-^ as foll..\vs: 



VxXAyC/w^YXxCry^'^^'Ot' VAAjL\a^ 




Mouths 



Pay 



// 



OlftS 



DlkATlON ^ );.// s 

I >r RATION 3, Viars Mouths /h7v< Hours 




(Signed) h\j. J 



a 



L>ucJi>-' 



KAXk QlC) TQoH ( Addns^ 




"'■'-; /// V,.„ I'l r.n, i-,-o 



K.<^ 



)v,,. 



I! v..n.- a^l I 






SPECML INFORMATION f'uly for Hospildls, Institutions, Transients, 
or Recent Residents, and persons dving anav trnm fiome. 



Former or 

Isual Residence ^' " X^Vs^C 



Plarp of Death 



Wfien was disease con icted, \ P "H i* 

If not ,it place of deatti ? ^' ^V^Ax<yVA. ' ^^.^ t ^ K. 



->- < Davs 



Vyj.., vn\. :]La^>..w, 



Lva^ 




CK^xaXolL 



ri.ACK OI- lU- RIAL OK RKMo\AI, DATKuf MfKrAl. cr ki:.M<i\\I. 
INDl'RTAKKR Mv- , VCUyi ''^^ ^<. 



N. B E 



stable* CA*I?«! •"^'^'•'"ntlon should b;; ciirefiilly supplied. AGE should be stated FiWCTLY. PHYSICIANS 1 
son *^rf . ^^E OF DEATH in pinin trrms. that it mnv be properly classified. The "Special Inltorinritian" fo 
« nyinft away from home should be fei%en in every instance. 



should 
r pur- 



# 



\. 












X\ 



ii*' 



! 



4- 






.1 




Ifl^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 




•fi 



f' 





i^^. 



Jt.ur 



![,:,! I h — F No !- -f'S^^^^^-, H&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ddh' Filed , \XAy<JX\.^U^ X\ 



lOO'A 



Registei'cd J\'*o. 



1127 



d^,Jy\J<JU^ 



Dep^^t 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

PLACE OF DEATH: — County ofUO-'^vX' 0.;uxm.^XAicc City of ^<XyVu 0/\a)^vC^^CL 



( la. 5. Stan^ar^ j 

J? (^ 
"1. 



No. 



S5s(hi^u. -^ 



.\Xky^\Jc SU H Dist.;bet. i 

IDENCE GIVE F 

EAItH occurred in a hospital or INSTITUTION GIVI 




and 



S 




(ir deathI[ OCCURS away from usual R ES I DE NC E gi ve facts called for under "special information" "\ 
IF deAIth occurred in a hospital or institution give its name instead of street and number. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

■ coi.tik 




\/r\j 







i.:k 111 



M.mtli) 



(I):iv) (Year) 



1-: 




>n:\.-,'v.:.nutq 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DI'.A IH 





Q 



^<.i.K. MAKi<n:i». 
nxiWHi) (IK i)i\< )Rri;i) 
;itt.' in surial (lcsij.'iiatii)n) 



IiIKTiM'l, \ri-: 
' Si.iti or e'l.uiilrv) 



,1 /.->/.'// - 



/),n. 





VX-CV 



'Ml' ()(■• 

\'nii';k 



■ :i<!'iiri,ArK 
J'i i-vriii-.R 

"^tatf or Comitrv) 



■^I Mi>i;\ X AMI-- 

"' Mi)Tiii;r 



liiKTin'r.ACK 
"I m<)Thi.;k' 

'state or roiuitiv 



KtX/»^Jl^ 




VCVOVCU 







J 



Mniitli) (\ (Day) (Viar) 

I IIl{Ri;i5V Cl'.RTII'V, Tliiit I attcMidcd deceased from 
/4^^ 1 \,p\ to LLu/O. IT. i(,oH 

lliat I last saw h -'.yi •■■ alive on VA.O0O ^^< Up H 

and that death occurred, on the dalr stalivl above, at 
" >L The CAISI-: OI" DI'A'l'll \va > as follows: 



Dl'R A'ilON 
CONTR [IMTol 



)V(;/_v \ Mi)nths i {Days I/oios 







•>^ *'t I'ATK.x 




AV' !,!fJ ni S,ni !'i,ni.!r,> ^<^ )',,!>• "^ 



(Signed) y&^v^- v ckxx. q. 1^.'>-^-. 



I lours, 

M.D. 



4 



' ' I((0 



rx.ldrrs.) lSa^'l'A\j)\\.',LCiA^-.v J-^ 



Special Information only tor Hospitdls institutions, Transients, 
or Retent Residents, and persons dyin;] away from home. 



i/.w/'// 



- /I 



/ h\ 1 



'•J.SI <>!• MY KNOW 1,1. DC).; ,\\i) m; 1, 1 1, l" 



VV. I'd Til !•: 



Former or 
Usual Residence 

Wtten was disease contracted, 
If not at place of deatli ? 



How lonq at 
Plat e of Death ? 



Days 



I'LAci; OI- m KiAi, OR rj:mm\ai. 




DXTK of 

(1> 



n 






Hi Ki \I. 01 R1-:Mi >\ \I, 



"XX TQOH 



>. B. 



F.very item o? !n?.>rm.ition should l>- cjirefiilly suppliecl. AC;K hIv.uIiI be stiite.l i;\\CTLY. PHYSIOIAMS hHoiiIcI 
state CAUSIi OF DI5ATH in plnln terms, that it mjiy be properly classified. The "SpecinI InformHtJon" for per- 
sons dyinji «\vny from homo should be ftiven in every instniice. 



'■'■A- 

• ' d 

A 



i 



" t. 

id 



f!. 



1 1 > f. 



i'^^ 







\ 



M 



I ■ 



I' 



i; 



iliiii 



if 






f / 



M 



t 



f{ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H •,, 1.- X,-,. , ^ t'^:^^ HS: !• Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J}((/r Filed, Lm^aX^aa.aX' ^l 



lOO'i 



Begi^stei'cd J\^o. 



1 128 



cL^r^^A^^^ c^ 



Deputy Health CfTlcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



% 



^ 



»5. J a 



Certificate of S)eatb 

( XX. 5. Stan^nrD ) 
PLACE OF DEATH: — County ofO/CL^ru AXX^^ CU^'C^ City of UOyvu OA.<X/vu^a^^cm:) 
^- ^r^hx^'^oJ' St.; Dist.;bet. — ~ and 



IF OCATH OCCURS «W*Y TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



(ino 



FULL NAME J 



H 



yrV'Crrrvct'O \j^w^.^^Jf 



PERSONAL AND STATISTICAL PARTICULARS 

Moiuh) I Day) ^V( ar) 




bH 



) 



Mnu'll^ 



fh> 



'1 "-ncial ik'si«n);ili')n) 



!;i': nn'i, \c\; 
^\:'\< ..r i.'uniitrv 






^ 



in-UACK A 

''•TUKR Q I] 




lUKTllI'l. \iK 
'•^tatc nr C'liinlrvl 



MAIDI'.X NAM}- 

"' Mifi'in-.R 



lilRTHI'UArK 

Of ^ 




MEDICAL CERTIFICATE OF DEATH 



Vax\ 



M.mtlil I 



iDav^ 



(Year) 



I in;kl{I'.V CI'iRTli'N', That I attc-ii'lc. I deceased from 
LLwOQ 1'^' looH to 0-vvq 1^1 

lliat I last saw li-i.. ■>* alive on \J^wCv<a,. ' >- 

ami that <Katli occurrol, (mi tlic dalr ^tatL(l alcove-, at ^ 
Ci M. The CArSlv CM- DI'ATII was as follows: 



T(,oH 



\.JO\JLXyvXxX> UJ^-V<^iiL/>44 



I) (RATION 



y'cars 



CONTKir.rToRV vJa^Uo^ 



Mouths 



nays 



a 



Hours 



-v-N.><nx.'CX>iuu VJC<AJL'>." o. 




'"' 'I'X'riox f?) 



<X^ 






m^XxxxclA.^ 



/\'' !(!r,! ill Siii) I'l iJ III I r.i ■ r,,;; 



or RAT ION )\'<rrs Mouths I Days ^\ Hours 

(Signed) 6 . V <j xx-\.cLa\jlnj M.D. 



o 

-4- 



SPECIAL Information <tnH lur Hospildls, institutions, Tramipnts, 
01 Recent Residents, dnd persons dviny .jh.is tro;n home. 



1,'. iiiii^ 



i hi: \MuVI': ST at I'D I-KR^ONAI, I'XRTICfl, ARS AKl-. TRri-: !•( » riii-; 
in.sT OI-- MV\i<No\\ i.l IK,F. AM) lU-.I.I i:i<' 



'Iiif't-iuant 




-'-s 



A.i.ir.-s Cj<Xy-vA^ \J rVoCtxo L'OJC; 



Former or "a. , , , , , 

L'sual Residence ^Oy>^^\F I va' 

Wfien was disease contra^^ted, 
If not at place of deatfi? 



t 



\\m lonq at ^/ 

I'Ue of fJeatfi? ^ i'X Days 



I'J.ACIC < »l- lURIAI. OR Rr'.Mo\ \1, I DXTi;..; IIikiai. or RI:M<)\'\I, 



\jLT^. 



INI 






N. B. p.^ery item o9 informHtion should be cnrefully s-.ppli<.cl. ACJB sho.ld be stHte.l HXACTLY. PHYSICIANS hHouUI 

state CAUSE OI- DLATH in pljiin terms, that it may be properly claHsified. The "Special Information" for per- 
sons dyinji away from home should be ftiven in every instance. 



.1 






\\ 






t 



> V 

- < 1 •■ 



W,v 



II 



f< 



i!il5 



I 



. I 



I I 



t\ 



% 






» 



hi. 

I 



4, 



m* 



m^ 



n 



i 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



II. :'ltli 



). Vo 1 ^ •*-ti'^|.<^ lift 1* Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)^//^w-v/rr/, LLvAxyL/^ aa I'^o'i 



BA'^istei'cd J\^o. 



1129 






Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

J? (^ ^ % 



PLACE OF DEATH: — County 

No. X\\\\J J COvM. 



St; Dist.;bet.l'-JiAnXL<XxLt>\.o and ^-^>^dxA.L/CyV\ ) 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E 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 



PERSONAL AND STATISTICAL PARTICULARS 

' c:<>i,(tK\ 




y\/^ 



'xxXXx} 



M 1 






111 luKrii 






'M.iiitli* 



51 



)' ii I 



I):iv) 



Mnvlll' 



( Vfiir) 



n,n 



^IN'.I.K. MARRIKI), 

W IDmWHD ok I)I\-(»Kv1-:I) 

'Willi- ill social <U'sij;n;iti<>ii) 



lilkTlllM.ArK 

'St.itr or rourtry"' 



1 \ iiii;k 



l'.IKTlIl'!,,\rH 

<" lArm-k 

istiiu or Cnmitrv) 






lilKTm'I.ACK 
"!• MnTHHK 
(Staff <ir Coiintrv^ 







d 




'Y\y6^ 








XJU:iJO\: 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:aTH 







iDav) 



/90 s 



I ni';Ri:HV Ci;RTn'V, Tliat I atlciukil «lc(«.;»sf.l iKiiii 

LLo^.^ 1*^ 190H to . U^cvo^ xc i()0 ■'. 

that I last saw h -■'" alive on LLcvn ClO k/) ", 

ami that (k-atli occurred, on the date >-tate<l ahovo, at \ 
M. The CArSi<: ()!• Dl'A'I'll was as follows: 



1)1 RATION )'ears Mouths Days I /ours 
C( ).\TRII5rT()RV JPsXXA^CAxvvXTk'VA./cu...*^ 



DIRATION 



)'cars 




A/o)iths 



Davs 



//ours 
M.D. 



X.hlress) lOSHVt(S<Lt c5t 



Special information ""'y '"^ Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away fron liome. 



I' in- AMovK srAri:i) i'kksoxai, i-ak ruri.AKs aki-: tkik t*» jih-: 

lii.ST (JF MV KNOW 1,1: DC, K AND IU;i,n;F 



"iifoiniaiil 



V'Mr.ss civ I I I U J 



/CXAA,' 




\ dh 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



rj.ACi: (>l- lU kiai, ok ki-.movai 




(Address 






nAQ'."' i!i lOAi. 01 ki-;m()\ai, 
'^ X 1 90 ' i 




>. K. Kvery item of Information •hould be carefully supplied. AGB should be stated liXACTLY. PHYSICIANS should 

HtHtc CAUSE OF DEATH in phiin terms, thnt It ms.y he properly clossified. The * Special InVormat.on »or per- 
sons dyin^ away from home should be ftiven in every instance. 






t t 



I 
■ » t 






ij! 









I 

1 tj 



iUifi 



( 




I 

i 

■J 



H(«»'"*- 



]i 







i« 






ijfiii 






ill 



i 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•tl' !■■ Vi> 






■ « Ik*. I k» ■ « 



T^N DA^K r»P rPRTiPinATr FOR INSTRUCTIONS 



/;^//r n/cf/, Uo^vuiij ao. ^'>^c>H 



Ke^lstered jYo. 



1130 



N 



"l,^rVA^^ itA>iHL Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

J? ^ 4 ^ 

PLACE OF DEATH: — County ofO.Ct^ /vOyV^c^Ci Gty of O O-Aa. A-Oj^-v^v^- 
o HOt'k VJ J,CVV>Oull St.; a Dist.,bet.UAX^ and J XXvvUX 

-^^ »^ -w ,,eiiAi DrcinriMrr nur facts called Mor under special information" \ 

( '^ :ro\^..i'iTci::.'o\Trj^'!.\': ^^.Vui^r.^.'-.o^^^i.^^'^^i "ame jIstead of stre.t and nu.ber. ; 




FULL NAME 



^XAJIAJL 



AJs'\.\ry\.' 



PERSONAL AND STATISTICAL PARTICULARS 



J 



\ 



. ! I Ml !;[KriI 




C<1I,<)R 




JwaXj- 




XXJ>j 

Month) 



\'.K 



o\ [ JV</<> 



I 

(Day 



M.oilli- 



r 



Ui 



5.0 



(Vear) 



/>ar.v 



MNf.i.i:. MAKKIl-.l), 
WIDOWKI) OK I)IV( tROKI) 

W'vitiiii social ili si}.' iiat ii ni I 



rUKTHIM.ACK 

'Slate or roiiiiti \ 




^^VAJLCL 



NAMi: ni 

I'A riii;K 



nik'niiM.ArH 
f^i" iATin-:k 

state or Coiiiiti \ t 



MAIDl'.X NAMI- 
'»!■ MoTID-.K 



lilK rilI'LACK 
OF M()Tin-;K 

<Statr or Countrv) 




X^<X^ 




KXV'CL 



] 







occri'A'nox m 

Rrsidrif ill Saii f'l iiiii i^ro J^O r.^M* 



Mntith^ 



lh!\. 



I'ln: M'.ovi-: srATj-:!) i-kksonai, rAU'iirti. \r< aki-; rKiK lo tin- 

Hi;ST OI- MY KN()\VI.i:i)<',K AND IU<:i<IK.F 



Hn 



f'.nuant vJlLUjtcoX; \n\ ■ ViT^ 



^.^v.*w^->^^ 



(Address 



.HOb'lx J <xa..^ol11 3i: 



MEDICAL CERTIFICATE OF DEATH 

DAPK c)l- ni'.ATH /O 

(Month) K 'I)av) (Year) 

I H1';R1':1'.V CI<:RTII<*V, That I atteiKU'd deceased from 

to vAA-A.x::i^ 3lI up H. 




c^ 



'h\ 190? 



tliat I last saw h - ' alive on 







ai 



190 



'y 



and that death occurred, on the date stated ahove. at H 
\J , M. The CAUS!-: Ol" Dl'-ATIi was as follows: 



IjAJUAA.t 



n VjCCV/'A a V<> *> W CL 



DIRA riON 



)'ra)S 



Monllis 1 Pays /lours 



^l^ 



I )r RATION • )V<?;-^ 

(SIGNED) LOrraj. ^. ti^<XA.<LOL^ 




Months Pays Hours 

M.D. 



a^TooH (Addresv.) 5 a"^ dx-^tty^N; '"'.j 



SPECIAL INFORMATION only foi^ Hospitals, Institutions, Trdnsients, 
or Recent Residents, and persons dving 3wa> from home. 



Former or 
Usual Residence 

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



HoM long at 
Place of Death ? 



Davs 



I'l.ACl-: Ol" lU-RIAI, OK Kl-MoVAI, DATlio; IHkiai. or Kl-MoVAI. 

vAaaX)l. Ov'2) 190H 



QTiiDL.a 






rxni-KTAKKK CI. VU . Ml^WAtv.'^x. ^ U 



N. « 



II \rF «hniil«I be stnteil F.X4CTLY. PHYSICIANS Khourd 

Kvery item oV* information nhoultl he curefully supplied. A(.F. shoulU »« stnteu .. w ,„j„„„„„:on" for Dt»r- 

«tBte CAUSE OF DEATH in plain terms. th«t it m»y be properly classified. The Spe.inl Intormation for p^r 



■V.y 

«tBte (rfAUSt: UH L>t A IM in pi 

sons dyinft away from home should be ^iven in every instnnce. 



, tl 



1 



T 



' f ■. 



» f • 





^&fi 






!-' 



.;■: 



' 



m 



I 



rj 



I? 



^.v 



i 



l » 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



J) 



• • w t ^1 ■ « 



• PB -rn BA<«w rtc rPBTirir.ATr PQR INSTRUCTIONS 



ill 



Re^lstei'cd vVo. 



i 131 



iilc Filed , ux^i-^-^ '^'^ lOOH, 

,trv^ i^v^ 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 Cj/aA\J 'J .MX/vvtV4C(iCity of OxX>v jAXXyrxX^UL-cc 



^ 



'««, 



,.ll). 






X ()l:^cK4\v-t<xit.; 



Dist«: bet. 



and 



/ ,r DE*TH OCCURS AWAY TROM USQAL R E S I D E NC E G. VE FACTS "'"h," ;*>"";*"; STR^tl^iN D 'n°U M bI R^"' ) 
(, ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




^J^JsX. 




N.' 



PERSONAL AND STATISTICAL PARTICULARS 

1.x A ^ ^ I COI.OR 






\\J^ 



Xjl 



DA IK »)I- IMRTII 



A<".K 



LL>^^KA^\^ 



Month* 



O 1b lV,;».v 



<D:iy) 



M,. tit lis 



(Vi-ar) 



Da ) : 



^IM.i.i:. MAKRIKI). 
\KII)<»\VHI) OK I)IVi)RrHI) 
Wtitt in sot'ial <lfsi>j;nation) 



lUKTMl'I.Al'K 
•stati- or Conntrv^ 



NAMK (M 
FATMHR 



HIRTHI'I.ACK 

f>I JATHKR 

t State or Conntry) 



MAIDKN NAM1-: 
ni' NJOTIIKR 




JU\\y^^^j^\^Ay'\yo^'y^'-^ cv 



ii 






W^K 'VN.Xr VAj^yx/ 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH r\ 



(Month) /T 



(Day) 



190 i 

(Year) 



I inCKIUJV C1<:RTI1'V, That r attended deceased from 
Cuu. I iQoH to . LLa^ci 3w0 190 H 



tliat I last saw h '.-> ahve on \J^^>^<\ A.. 190 

J Q 

and that death occurred, on the date stated above, at D 

CLm. ^The CAUSH C)l' DlvATII was as follows: 



■*: 



DIRATION 



C 



Yea'.'^ ^ Months 




Days Hours 

JLry:y^r.^K'\J^j..r. 



A\X}^i 



HIRTHPr.ACK 
Ol" MOTHKR 
(Statt or Country) 



occrpA' 



Kesidfd ill Sun /'itinrfsY,) " )V,ns 3 .^fonf/rt 1 " /^<> v> 

Tin-: AHOVE STATl-:i) I'KRSONAI. I'ARTICr l.ARS ARK TRI 1% T« > THK 
in:ST OF MY KNOWI.KDCK AND ni:iJi:F 



(Inf 



..mant LL. O.UL- \3 J^^ ^J^A^^CcL (JV) O-^ !|A.Ct>CxjL 



( Afldress 



..Dl.-«- 

DURATION }'i'ars H Jfofi/ZisX^ Pars 

( SIGNED )"o . VJ OAJkiA^ oU-cuL(: > . 



Hours 
M.D. 



JU<\, %^ TQo't ( 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Deatli ? 



Days 



ri,ACE OK HIRIAU <>R RKMoVAI, 

INDKRTAKKR 

(Address 



DATKof IMKIAI. or RKMOVAI, 
LLov-Q X?^ I90'\ 

U 1 cx^ 



M k 



N. B. 



-F.v.r, 1„„ o< i„!„.„».i.n .hou.d be cnr.SuM, supplied. AGB .h.uld b. .....d EXACTLV , P"^«'<;'*?!''j''::',t 

Mate CAUSE OF DEATH in plain term., th.l it may b. properl, cl...l«ied. The Special Inform.t.on far p,r 
Rons dyinft away from home Rhould be ftlven in avery Instance. 



•! 



I M 




^M, 






' t 



( ' 







Ik 







r 



I' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, , , ,, i- x„. , , t"'^^»-> BSi V Co 






Jhi/r AV/r^/, lixAwCuv^Aij ^Ov W0\ 

Juyv-u Deputy Health Officer 



Ilegistercd J\'*o, 



1J82 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificatc of S)catb 



( *a. S. StanDarO ) 



J? 



(3i^ 



PLACE OF DEATH: — County 



of 0,ay7v J A^Ol^vCULCc City of Oo^^^' ^ XxX/-^^^ci,^^.<i..€ 



il) 



^No. 





CK^K^^^- St.; 



-Dist.; bet.- 



and 



(••c>iiAi DC-e I r\r Nrr riur TACT^ CALLED POP UNDER "SPECIAL INFORMATION" | 
/ IF DEATH OCCURfk AWAY FROM^USUAL RESIDENCE GIVE FACTS CALLtJ? .^oTFAn OF STREET AND NUMBER / 

\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



M,\ 



I>.\1 1-. (»1- ill K Til 



PERSONAL AND STATISTICAL PARTIC ULAR S 

COI.oR 




'V'W^ 





M- 






10. 



A(.i-: 



5.H 



)•,-,/* 



<I)av 



M.tnlln 



/ ^*^C .... 
(Year) 



io 



Ihn 



MM. 1,1*. M\RkIl-:i). 

\vii>(»\\i.:i» (Ik i)i\'<)Kri:i) 

'\V;itriii social il(>^i>.'nali<>ii) 



HIK IIIl'I.xrK 

<Stat< ur C'umitrv^ 



1- \Tm;K 



I'.iKTuri.Aci.: 
oi" i-.\rm-,i< 

(Stale or (.■oiiuti \ ) 



M MDI-.X NAM)-; 

"1 M<fnn;K 



iiiK rm'i.ACK 
oi- M()Thi.;k 

(Slatf OI Coinitrv) 




^TOUOj 



7 ^ 



cxAAAA^ ■ 



f\i'M(!fif ill Sail I'liiiiii^rn J,H IViMa 



M.'iilh- 



l),i\: 



Till". \n()vi<: sTAri-.i) i'Kksonai, par ruMUAKs AR1-; rKii- 

l!i:ST OI- MV KNdWIJ'.lX,}-: AM) Ml-;!.!!'.!'" 



I'd I"!!!'. 



'IllfiiMllMIlt 



C,(?,%, (!LvX 



' \.l.lu-ss 



\ 






MEDICAL CERTIFICATE OF DEATH 

DATE oi- i)i;.\Tn r\ 

(Motith)T (Day) (Vt-arl 

I HKRI^HV CI;RTII''V, Tliat I altcMukMl (lecoased from 
OwWvA^lo b iQoH to LLvwq. \% upH 



LL*.Ax:^ \L up 't 



b 1 90 H t(j 
tliat I last saw h Ay>>A alive 011 LL^ax:^ 

ami that (kath occurred, on the dale stated above, at I O 
1 M. The CAl Si-: Ol' l)i:A'ni was as follows: 



^ AxJl>-t^^:iA.vJ06-slA^0 ^ X^A^ 



^V^V^' 



o^ 



DrR.X'l'ION Years 

CONTKIJUTORV 



Moulin 



Days 



Hours 



I )r RAT ION 
(SIGNED) 



» 



)'rars 







fhivs 



/fours 
M.D. 



CLu) gfe TOoH f.\.ldress)Utu^U) JbM.)tA.t 

SPECIAL INFORMATION "niv lor H^spitdls, Institutions, Transients, 



or Recent Residents, and persons dying away from home 

Former or 1 u (VVl ^ , ""i( ' ""^ '""*' '* 

Usual Residence » v M I UXA^rYu O 

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



i Plare of Death? '^H Days 



l'L\CF ol- IMKIAUoK K1:M'>\A1, 



DAI'}-: of Hi Kl.\i or KKMoXAJ. 



(Address,. 2)Un X - I ^ ti^. ^t 



I90H 



N. B.— Hvery Item o^' Information •houlcl be cnrefuHy Hupplle.l. AUfi «hou.d »>««»"'*=;! J'''. i'i^'^^L InWnr»'tTun-l"*'p-r- 
•tatc CAllSi: OF DEATH In ph.in term«, th„t it m«y be properly claHS.t.ed. The Special In^ormut.on ^or p-r 

• *ion« dyinft away from home Hhould be HUcn in ia\cry instance. 



f 



.,-^ 



f 



\* 



V 









U 



! > 



i! 














m 



m < 



m 







hi 



w 



RITE -PLAINLY WITH UNFADING INK 



1, l-So, 15 »-j.ir;;--uiM'Cn 



THIS IS A PERMANENT RECORD 



•r/^ oA/^w f\e rrnTiriCATr FOR INSTRUCTIONS 



I E> I W I « > «•• 



Ddir l-'ill'il, 



aa 



uxj'i 



Ro^i^ifcrcd J^''o. 



1 J 33 



cL^-AwA-Aw^ 



Deputy Health OPIcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDcatb 



■a. S. Stan^ar^ 

4 % 



J? 



PLACE OF DEATH:-County of 0<Xa^^ Jx^vixc^cc^City of 0<X^^ J.;ux/>x^A^t.< 



Nn. 3111 H'-'^- tivAvCnx; 



St 



.; T DJst.jbet.^'^'-*^*-'^*^^^^'-*- a"'^ 



.0 O-Laa. i 



y V^^^'w ......Ai orCinrNrPriWE FACTS called for under special INFORMATION- "V 

( 'iV"o7ATr^OCCU%ro\"rHO^?prT^At o%'?:?.^^'T^O^'V.Vr.;i NAME .NSTEAO OF STREET AND NUMBER. ) 



FULL NAME 




iO^XsXAXA.^^\.: 



PERSONAL AND STATISTICAL PARTICULARS 



■r 



C()I,OR > 



\^OJ' 



, ^ 



^. 



LLvi '- 



C'^-- 



i).\ 



A I .!•: 



Ill 






^ t J-,-.;; 



^IN' l.K, MAKKIi:!), 
WIOdWHI) UK I)I\"ORri:n 

Ml »in'i;il (U --i}.'n;itiiiii) 




10 



,>L/CL 



>;i\ 



M..u!ll^ 



/in.. 



1^\ 



/',; 



^^^^^ 



-4 



'State or Coiiutrvi 



Ml «>l- 

I \ iii i:k 



I'.iK ini'!,\rK 
ft! I \i'in-K 



MA1I»KN NAMF. 
ni- M<»'lin".k 



IllK lIll'LArK 
<>I' MuTHKR 

'"•■ • ■'!■ ri.utitrv") 






X' 







■^' 





n./CrvwV^o"v 



1 



\]xKj^ 



<H\'i I'\'1I()X 

I ^ 




\r,.i,th< 



/hn 



15HST oi- Mv kno\vij:i)<;h and iu:i.n:i-" 



MEDICAL CERTIFICATE OF DEATH 

DATK t)l Ii1:ATH 




^ I 
(l)av) 



IQO 

(Ycai> 



( Month) 

I mU-ilvHV CI'IRTIFV, That I attendtMl dcccascl from 
CL^^O 190 \ to '^U,^^ Xi- 190 H 

silivr. on V.*^<,VQ iH 



that I last s'aw h 



^ 



up 



and that death occurred, on the date staled above, at 
~ M. The CAl'Sh: Ol* DlvA Til was a^ follows: 



^ 






g Aw<x€\.vA.^%JL CI- 



m^ 



nr RAT ION Vtijus Months Havs Hours 

jONTKim-ToKV Uk^v^rv^-^/c.M/0^vx^^ 

)'t:/?r5 Monf/i.'i Piivi //ours 

M.D. 



DTRATION 



( SIGNED) 






c. 



[LA._^ax.<x>n (.\.i,iu..o i5ib U<^.^vMU^O-■■ 



SPECIAL INFORMATION '>"'!' *<"^ Hospitals. Institutions, Transients, 
or Recent Residents, and persons dying away froai home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



. Days 



ri.ACK Ol- nrkiAi. OK ki:mo\\i 



.)UL/'\'> V' 



O ex.. 

INDERTAKKR 



IiATI. ■>! HiKlAl. or RI:Mo\'\I. 

\sJ<^K^^.yQ 'X y T 90 ' i 



N. B.— r.very item o? -.nform^tion should be cnret'utly supplied. ^^^Jj';''"/*' ^*."*"**The^*^^^^^ Information" for p!Ir- 

state CAUSE OP DLATH in plain terms, that it may he properly classmea. 



sons dylnft away from homo should be feiven in every instance. 



i I 



•- '■'J 



m 



■.ti 







in 



^'i\ 



;ii 



tsam 



^WkU 



t? 



f^^^ 



(1 












i. 




f 






'f t ' 



!•! 



! i 



WRITE PLAINLY WITH UNFADING INK 



Bonrd 



i- \(>. i^ ■*4.'*''i^' "''^'' ^'" 



THIS IS A PERMANENT RECORD 



.«« »./^L# Af> /^e-B-ririr^ A-rr rrtR I N^TPIJCTIONS 



ncrcn i v» tar^wtx ><• *-< 



n 



nlr /v/rr/,(l^<^.cvAtr aa i'^O'i 



lleiistcvod JVo, 



I J 34 



-f - n[^ Deputy Health Officer 



DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( tl. S. StanDarO ) 



PLACE OF DEATH: — County of 



J op ^ '^ 

a'7\j ;uam.cc^a€ City of ^ -co^^ ;v<x/Yvev<L-c.c 



Ch^' 



i\j>Jt^-Ow/\.; 



St.; 



Dist.; bet. 



and 



r^.UAj V \AXj\X\A ^^ *^^^^T^^^ ^J"' ., or«?YnVNCE GIVE facts'called for under "special information- \ 

FULL NAME O^tW^'tv^ m2A^.a/Txu 



/CUlA- 



A 



vmJU 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR N A 

I»\ n. ()|- HIKTII 



M.mihl 



\i . 1 



HS 



yra>> 



10 



(Day) 



M.nilh^ 



:ic 



fVc.-ir) 



Day 



MN<.I,1':. MAKUn:i). 
\V!i>n\VHI) Ok l)I\'t)Kr}: I) 

' 'Ml in >.(Hiiil (Usiv:natit)ii) 



HIRTHPI.AOK CT\ 
(State (ir C..uiitry»{J|l 






J /Ow(y>VOu'YV^ dwlX^CXX; CjX'O- 



\ \M1-. OI- 

i-.\'nii:K 



niKTHlM.AfK 

oi- i-\ihi<:k 

(State or Country') 



MAIDKN NAM1-: 
'»)• MOTIIKR 



HIUllll'LACK 
<>»• MOTHICR 

(Slate or Connlryl 




1 



/CLCy^vOu^'Vo 









Kfsidrd in Sau f'l ann'si^n \ I )'<\n < 



\r.:n'li' 



/)./! 



nn: \hovi-. srAri:i) i-kksonai. par iiiti.ars akh TKrH to tii»-: 
i«i':sT oi- \iy Kx»»\vij;n<'.K and hi:i,ikf 

:mt J . 'OXIA VO^^WJ 



(Info 



(Address 



XW 'j<x.cJL'C ot 



MEDICAL CERTIFICATE OF DEATH 



DATIv OI- Dl'Aril r\ 

(Month) A^ 
1 HI':RI';HV C1*;RT11'V, Tli:»t I alloipkd ileccascd from 



(Day) 



l9o\ 

(Year) 



1 90 



to 



^90 



that T last saw h alive on 

and that death occurred, on the date stated above, at 
M. The CAISIC Ul' I )i: ATI LNvas as follows: 



nr RAT ION Years 

CONTRIIUTORV 



Mont /is 



Days 



DTRATIOX 
(SIGNED) 



Pays 



)'rars Monl/is 



Hours 

Hours 
M.D. 



LfrVtrvAjA^ 



-vcx 



SPECIAL INFORMATION only lor Hospitals, Insfitulions, Transients, 
or Recent Residents, and persons dyinq away from fiome. 




Usual Residence laiU'.C^ vc dl Se'7oelth? 

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



Days 



I'l.ACKOF lU'KIAI, OK RI:M<>V\1. 



DA TK of HI KiAi. or KHMi>VAI. 



1 1-. o; 

cu 







IN. B. 



... *np „u„,.i,l he «mtecl BXACTLY. PHYSICIANS should 
of informntlon should be carefully supplied. AGE should ''« «*"**^/:''.!'^ * ^^^ Information" for p.r- 
E OF DEATH in plain terms, that it may be properly class.V.ed. The Specal Intormat 



-Hvcry item 
state CAUS 
sons dyinft away from home should be feiven in every instance. 




•I 



I . 



|l«'^ 



?»1 






♦ ' 



11 



*ff 



W rt*=ssammmtKmm 



■FM^^TWW^lWW 



If 



1 



I* 1 



^■l 



n . 



■i 



*!] 



« 



-1 


! .i 


i 1 


i 


1 
1 


t 


i 
t 

1 

( 


' 


( 

1 

1 








I t 



Mthtn I O OM«^r\ \Jr v>L.ri 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

B«,rd of Hcnlth-F No- i^ 1^^J^ H&P Co 

Dull' FilOtL LIXA-XVL^AAJ XX li)0\ 



D iMe-rQiir.TinN<% 



Be^isfered Xo. 



II -js 



0\^^y\J<./<^ 



Deputy Health Officer 



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



PLACE OF DEATH : — County 



Cevtificatc of 5)catb 

( 11. S. StanOarD ) 

J? (^ \ ^ 

of C) .Ol y\j J AXX^-rxCAA ccCity of O/CX.^ AXl^tv^la^'Ci^. 



J^<xX) 



St. 



Dist.;bet. — 



and 



\.AJ^\.A>^ OPCinFNCF GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' "^ 

( '^ rF"4rH^occu%*Riv,;''rHo"s"rAt :^v.i]rr^.^.oro.:rs.\ name ..steao of street a.o .umber. ; 

^0 V^ji^/^axxaA-o 



FULL NAME 





PERSONAL AND STATISTICAL PARTICULARS 

",11< 111 




\Xy-wsJ¥0-^ 



(M..nlh> 



'I 



0.5" 



J '/■(,' I 



(Dnv"! 



Mnilh 



r 

I Vfai) 



na\ 



^iNt.i.iv M\Kun-.n 
wiix'U i:i» (IK i)i\<>Kt*i:i) 

icial (li'iij.Miation) 



lUK run. voK 

' ^i.itr 111 1 '..iintrv^ 




\kjy\)^ 



\ \Mi: oi' 
lAiii i.k 



HIKIIIlM.ArK 
Ol' lAIMIKR 
(State or Coimtrv^ 



MAIUKN NAMH 
Ol MOT I IKK 



HIK llll'l.Al'K 
• '•' MoTllKR 
fSiiiic or c'oi.ntrv^ 



h'f-^iilfil III Sail I'l i> I'l I ^rn 



vv^^s-^v,^^' 



\« 



<l 



5 V'(? / 



\J,.„th^ 



Pav: 



MEDICAL CERTIFICATE OF DEATH 

DATl-; t)l'" DI'.ATH 






a 

(M..ntli) jj 'I>''y) 'Vear) 

J IIIvKl'lHV CI'RTII'N', Tliiil I atteii<lt<l <Uri;ist'<l fr«»iii 



10 

Day) 



LLtv 



^ 



b 



190 s 



\XxA.AX^ 



to VAAA./CL. XO 



tliMt I last saw h A. , ,x alive on ^^^^ ^^ up 1 

and that <Kath orciirrcd, on the .late state-l ahove. at 10, HS 
0. M. The CM" SI-: ()!'■ I) I •: A I'll was as follows: 



Months 



„rKATK.N Vr^ - 



CONTRII'.r'lOK 



Pays J Ion IS 

oJ\/:^<x^ 



1)1 -RAT ION Vrars 

(SIGNED) 

'11 Uyo\ ( 



\\aLJ^W 



Mitnt/is 



/hrys 



//ours 

M.D. 




\.l(1ress)g1jAI'^<X.>UY 
^TION "n'y l<"^ Hospitdls, Insfit 



<fv:'0-^\t 



SPEd^lAL INFORMAT 

or Recent Residents, and persons dyinq dway (rom home 

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



^tutions, Transients, 



/U 



How long at 
Place of Deatli ? 



Days 



111, .VllDVl', STATlvI) I'KKsONAK I'A U 1" I>" T I,,\ K S AKi: I' K ' I'". Tt > I" HI'; 
IU:ST Ol' MY KNu\Vl.i:i)(".H AND lu;!.!!';!' 



(] 



'r'lnanl LAxX^k^AAj vJ . \lR vi. 



Ct 



) 



(A.1<lrc-ss Ofc.MrUxAj^ (]\0{y<J^JlxX.l 



l'I,.Ul': Ol' lUKIAI, OK KI.MOVAI 



D.\ri', ol lii KiAi. i>r Kl-".Mo\'AI, 



!1 




^^ 



% 



? J 



I90H 



<XOL.-tX- 



ind1';ktaki:k o v-x>^wN-v-y - ""^^"^"^^ 



^ „ ^ TT^ ,. , Arr «»v) lid be Htntc.l I.XACTLY. PHYSICIANS Hhoiilcl 

N. B.— Hvery Item o? in?orm«tJon «houl.l be .i.rofutly HuppI.ed. A(.l. s^ , ' !^fjL The "Spcciul In^ormaHon" for pT- 

stntc GAlISn OP DEATH in plain terms, thnt it muy be properly ciussineu. 

son* dyinft away from home Hhould be ^iven in every instance. 



Mi 
I 



■ii 



M 



1 r 



: "3 



m 



'f,i 



ill 



I 



M 



tr< 



'^— »- 



liipf 






n 

I 

\ 






■^1 




11 .'«t 





''I 

I 



i 



■ M 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ho:n.l ..t lI.Mtth- V Vo. i.?t;??:^^"^'-^" 



■rrk oari* nc rrPTIPICATE POR INSTRUCTIONS 



!)f,fr /v/f>r/, (XvUVL^ ^Xa ' lfW\ 



Bo^istei'cd J\'*(), 



11:36 



ca^^t^-^^^*^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( XX. S. StanC»arD ) 



PLACE OF DEATH: — County of \llx/\^<X.cLa City of /bO^U. 




St. 



-Dist.;bet. 



-and 



^0% ~ ~ ,,eii«l orQTnPNCP GIVE FACTs'cALLED FOR UNDER "SPECIAL INFORMATION' \ 



FULL NAME CJcn^ 



t I 



I :l 



' \ 



■ 1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

coi.oR p n 

1 , _ I 



C^'^wL 



tM<.nlli> 



\' 1 



5^ 



) I'll) 



(Day) 



M.nilhs 



'Vt ;irl 



/'./!> 



WIDoWKI) (»K I»IV()Kl"l-:i) 

i W' ■ -' irifil cl(>.ij.'iiat ioii ) 



IlIK riU'I.ACK 
(SUito or Countrv) 





I'.\T1I]:k 



HlkllU'I.AOK 
*>'■ ! \riIKK 

' roiuilrv) 



MAll)i:\ N'AMK 
<>!■ MOTin<;R 



HiK rni'LACj-: 

OI- MOTHKR 
'Stntf or Country) 







>^Oj 



9 




Ac/\\^<X 



ucri'i 



f\^>iil/'(i ill Sail /'i <iiit isi'i} '" ) iii i 



.!/-/;////< 



■'iii: \U()VK sTAri;]) rKusoNAu rAKiuTKAKs AKi: rkri-: i" ii"' 

Hi:ST Ol' MV KX()\VI,i:i)C.H AND HI-.I.n.F 



'I"fo:ni;nit 




AJLa.^^^-0''\MXA -^UjEK. » ^ N-vL 



'Address 




,1 



— lJ — : 

(ICAL CERTIFICATE OF DEATH 



MEDI 



DATK <>I' I)1:ATH /O 

(Montht r 



Day) 



(Year) 



I H1';R1':BV C1:RTII-V. TIimI l Mtti-iiiU-il deii-a^ol from 

— [ lip to ^^P 

tliat T last saw li ":: alive on ~ ' ^9° 

aii.l that (loath occurred, on the- .late- stati-d ahove. at 



M. Tlu- CAl'Slv OF l)l{.\ril w:»s as follows: 



1)1 RAT ION )V<7/-.? 

CONTRIlUroRV 



Mouths 



Days 



Hours 



Years Months 



I )r RAT I ON 
( SIGNED ) 



Days 



Hours 



■^ 



M.D. 



Special information only for Hospitals, lnstitutions,'Transienfs, 
or Rci enl Rfsidents, and persons dying away from home. 



former or 
Usual Residence 

When was disease ronfracted, 
II not af plare of death ? 



Hew lonq at 
Plare of Death ? 



Days 



I'l.ACl*, ol- lUKIAI. OK KHMo\AI. 




r: 



I)Al\Hof 111 KiAi. «)i m.MoXAI. 



(Adilr.'ss 



iv.i AGB 8'noi.kl be stnted EXACTLY. PHYSICIANS Hh.u.1.1 



'^' K" livery Item of inform 

state CAUSE OF DEAT 

Ron« dyinft away from home shoulil be ftiven in every instance. 



i^ 



I 



M 



< ' i 1 



Hl^^ 



f 







i 



! , ' ^ HI 








>dUbi*«MpawMta 




;(l 



<< 



) 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ivvii.1 of Ht;.UJi- » No 1.; -^^^^ H&r Co REFER TO BACK OF CEWtiriCATC FOR i niaTRUCTJuNS 








IX, Ic /'V/^v/, LLu^.oM.^^ 'XX lOO'i 



Ttegistcred ^'"o. 



11.37 



cL'^'LA.A^ 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( la. S. Stan&arD ) 

J? <?5p -5 (5j) 

PLACE OF DEATH: — County ofOaAAj ^vao^x^AAC^ City of ,0^^ A/O/wc^a ^ 



No, 



. JJA.'>v>.xx/>^ ubc^^^AjL' 




St. 



Dist.; bet. 



and 



/ \T DEATH OCCURS AWAJ 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 



PERSONAL AND STATISTICAL PARTICULARS 

•-I A A I COlA)R 




T\^ ()bxa'AxiAAyCL^l.<ix-> 



I' ^ : r ol- lilKTU 






iM.mth) 



\ < . !■• 



3^ 



\ ra ) > 



I 



•^IN'.I.i:. MAkKIKI) 

W MX »\yKI) OK DIVORiKl) 

'N\iit( in social dcsijniation) 



'A^ 



luk rMPhAi'K 

(Stall or Country) 



I'ATIII;r 



lURTlll'i.ACK 
'>!• lAPHlCR 
'State or C'ountrv^ 



MAII)i;\ NAMK 
<>!• MOTHKR 



HIRTHPF.ACK 

<>i" M<)Tni':R 

'St;itc or rouiitrv'l 



•»CCri»ATlON 



(^ 




(Day) 



Motillis 

A. 



(Yiar) 



fhi ys 




MEDICAL CERTIFICATE OF DEATH 



DATE Ol 



LLu^Q 

(Month) \' 



11 

(Day) 



190 I 
(Yenr) 



I IJIvRinJY C1':RTIFV, That I attended deceased from 



that 1 last saw h v^iv*. alive on 



\.X 190 H 



to 






T90 



and that death occurred, on the date stated above, at 
y M. The CArSr: C)i' DIvATH was as follows: 



\i ]\<xJL/CO\y<^o^ 



/ yr\^.0.. 



nr RATION )\'ars Mouths iO Pays Hours 

CONTRIHUTORV 



M 




Hours 
M.D. 



DURATION Years Mouths Pays 

(SIGNED) . G. ly. \tllu>V.«J^. 

LLccq ai 190 M (Ad.iress)IS ( 9-<.UXf.;v Jl 

^i^AL Information only for Hospitals, Institutions, Transients, 



fy'e.^iiifd in S,in /'laniisio O )V<mv "^ 



MnlllllS " Hti 1 



"'nrJ-r*!?,^^,T'^''*''"'* '"HKSoXAI, I'AKTIcr I,A KS A R !• TKrH T( » TFIH 
lll.Sl ()|. MY KN()\V1.i:d<;K AM) HKMi:i- 



' \(Mr 



ess 



SPEC 

or Recent Residents, and persons dying away from home 

Usual Residence H 11 U/CU:VA/>>UA\A(i;H place of Death ? t 

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



Days 



I'l.ACK Ol' IHRIAI. OR KKM«'\AI. J DATllof HtKlAl, or KKMOVAI, 



Kxxy^xx \^^r^ZA\^\.^o^M^^ 



(Ad<lrrss..'i.lB.. "u dfU^^ v v) /CxXjL LLv 



N. B. 



F.very Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

•tate 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 4iven in every instance. 



m 



\ 



'1^1 






!1 



I '^ 




ii 



I 1 11 



1 



♦ ( 



F'^^ 






;! 



^'^ftf^m 



fMT 



«# 



^■1 r:, 






■ ■ I- 



»!' 




If' 

i 

1 ' 

i 



*l 



h ■ i 



h 



' f 



I 



'•4 




WRI 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I !l<;ilth - »•" No. !«; 



nt.rt.n iv 



?,!! 



n 



i ^i: 



Ihf/r Filr(/, 




Registered J^o, 



i i m 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "CI. 5. StanOarO ) 

PLACE OF DEATH: — County ofO-CL^^ J vVo-^v^a^co City of 0<X/>v Axx.>v/aoQ. ^ ( 



INb^OwLJUvYVvXX) K^Lr^\jiX.oS: (lb^^4^.iSLA-l Dist.;bct. 



and 



ll/' \r OtATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IjV If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 








"^ KjJLrr^\.0 



PERSONAL AND STATISTICAL PARTICULARS 

'"Y?^ ^ I coi,()R' 





I>\ II-; III- MIRTH 



A<.K 



©^ 



I Montlil 



(Day) 



/111 

(Year) 



?^l 



Viii I . 



10 



r \ I 
M.mths .K \ Ptir:, 



SIN(.I,K MARKIKI) 

\VII»( »\\ HI) OR I»IV(»R(.'KI> 

tWriti- ill social dcsit^tiatioti) 



lURTMIM.ArK 
(Sl.itc or (."ontUrv) 



N'\Mi: Ol- 
I ATI IKK 




niKTllI'I,A(*K 
<»F l-ATMKR 
(State or Oouiitrvl 



MAIUHN NAMK 
Ol- MOTHKR 



I'-IRTIII'l.ACK 
•»!•■ MOTHKR 
'Statt or Comitrvt 



"^ <l TATION 



/VCX/wcLl;v' 



lU^iKAj 




MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH /O 

LWq iCi 

(Moiitli^r (Day) 

I IIIvRIUJV CICRTIIV, That I attemUd (Iccoascd from 

— to — 



(Year) 



I9O 



that I last saw h^:r- — "alive on 



iqo 
190 



and that death occurred, on the date stated above, at " 

^^ M. The CAl'SI-; UI- DI-ATII was as follows: 



1)1' RAT I ON Years 

CONTRIIU-TORV 



Mouth% 



Days 



/Jours 



DURATION 
(SIG 



I /ours 



}'i'ars JA'/////.? /)avs 

<X/'v\xL M.D. 




Rfyidfd ill San I'laiiiisfo XH )'iai s 



Mniltll> 



rhi\ 



III)-: AHOVKSTATKI) I'HKSONAI. I' A RTICl' h \RS A K 1'. TRrK TO IHK 
ll»:ST ()}• MY KNO\VI,Kn<;K AND HKMKF 



(I 






( A<lclrcss 



NED) Wun^JlA^ J 

SPEC^'aL Information only lor Hospitals, Institutions, Translfnts, 
or Recent Residents, and persons dying away from home. 

Usual Residence 3. io CuJULKXX. cH- 



Usual Residence 

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



How lonq at 
Place of Death ? 



I'LACK OF UlRIAI^OK K1:Mo\AI. | I)ATi:of Hikiai, or KKMOVAI. 



ic...-,. i '-^^^ 

l-NDKKTAKKR vJ J'ViUrll^^^ JjAxOk^ 

(Addrt-sv R5"n. \irtv<L<S.V<r-kV c5X^ 



M. B. 



Bvery Item o? Information should be carefully Hupplled. AGR nhould be stated EXACTLY. PHYSICIANS should 
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special Information f«r psr- 
"ons dyin|l away from home should be (ivcn in 9\9ry Instance. 



; { 



> 









i ■ '■ 






^Bj 



1 • 



'\H 



I ■ 

I 



% 



it 









I 






/*■ 




-J LJUl. 



.^ 

J..I 






14 



'} 








"I 



WRITE PLAINLY WITH UNFADING INK 



.• 11- allli" !• NO. \-- 



^ f^T"*^ 



iJl.V 1 VI) 



THIS IS A PERMANENT RECORD 






/^//r /v/^v/, lXcv.qA.\At7 a3L i'>'6>H 

0^.^^ JUam^ Deputy Health Officer 



Ilogisfcrcd J\'*o, 



i j ;39 




DEPARTMENT OT PUBLIC HEALTH^City and County of San Francisco 

Cevtificate of Bcatb 

( 11. S. StanDav? ) 

PLACE OF DEATH: — County of C! Ol^^ JX(XA^ec<LC.c City of O^Xaa^ vJ.\Xl/rvc\^^c 



,Q 





/No. ACiM VXo-y'vLr>Aj VJ OaJK St.; '1 Dist.; bet. UaaJXAJLA^ and cU CTUVjL^ 

/ ir DEATH OCCURS AWAY 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. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

COJ,()R 




,aU) 




^^H' 



■>] 



i'\ ; 1, « 'I iiiki'ii 





1%^ 



kjL 




)■/■,; 



(I):iv) 



M.nilh^ 



(Year) 



/5,;i,v 



>^IN«. I.l- M.\KUII-:i) 
\V[I)u\\):i) OK l)!\-nKr|.:i) 

' \^' ' '■ ■ i -1 -' '<i:il <lf^i;Miati'>ii) 



'Statior r.iiiiitiyi V \ij\] 



A/^'-voAx 






NAMI-: ol- 

I'A riii-.K 



niKTilI-I.ACK 

'>'■ I \iin-;R 

■"' '■ "t Cduiitivl 



<'l Moi'IllCK 



'ilKlfll'l.ACK 
;>1- MOTIII'.R 
'^t.itc or Country) 







MEDICAL CERTIFICATE OF DEATH 

i).\ri'; Ol- i)i;.\rii 



^ 1 



(Montli) ,4 
I Ill'klinV CI^RTII'V, Tliat I attc'iukMl .Iccoased from 



(Day) (Year) 



I9O to 

lliat I last saw li ~ Jilive oil 

ami that di-ath orciirrcd, on tin- dati- stated aliovc, at 
M. The CAISI- Ol" l)i;.\TlI was as follows 



I(>0 

T90 



) V 



I) IR. ATI ON }'riirs 

CONTRHU'TORV 



Mo)ilhs 



Days 



Hour 



DIRATION 



)'t'ars 



^^<luihs 



l\r\ 



'V 



( BIG 



NED) ytPV^V' J OxsJLX. 



IL - - ^ ■ 



a 



XX 



A^V-CX ^ 



nou}s 



M.D. 



TQO 



\ (,\d.lrcss) 'bHlb ^ \\ 



il clt 



Special information ""'^ *<••■ Hospitdls, institutions, Iransicnts, 
or Recent Residents, and persons dying ciHdv frotn fiome. 



I'm: \ito\-i.-, s'i-\ ri: I) i-kr^on \i i- \kiut i, \ks ari-: I'Ri r: To iiii-: 

l''l.M" O! MY KXOWIJ-.DC H AM) lUlMl'.F 



Miif,, 



lUMTlt 






Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Davs 



I'l, U1-; Ol' HiRiAi. OK ri:mo\ AI, 




I) A'n-: of III lu.Ai. 01 ri;mo\'.\i. 



N. B. 



— Kvery item o>' information hHouUI b. cnrcV'ully supplied. A(.'B Khould be stnted RXACTLY. PlA'SICIANS nhould 
«t«te CAUSE OF DFATH in pinin terms, thnt it m»y be properly classified. The ' Special InVormation *or per- 



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



fc 



\^ 



I ! !^'i 



- J ^ ' 



r 



«. 



; ♦ I 



il^ii, 



l! :J 



I 



*»#^ 



i 



t> ' 



i 




"y.' 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board of Il.altn I- >o. i-^ ^-^-ugrg^ n<.^ i y. 



n»f«ipn -^/N B«r>i« /nc r< p B<ri Pir> ATP rr%B l NQTBIir^TinN^ 



11 i^# •rf*-*^*'^ ^i*« 



RegistcTed J\^o, 



1140 



/>,^/(' /-V/^v/, (Xu^^cM^^tr 'kX lOO'K 

JLfroc^ XiL^ Dteputy Health Officer 

DEPARTMENT OF PUBLIC BEALTH=City and County of San Francisco 

Certificate of Death 

( tl. S. Stan^ar^ ) 

PLACE OF DEATH: — County ofOcL^X; A.O^^vil<>ie(. City of Cj.O^ao^ J.KXLo^ca^^^c^ 
(No. I'iHt JA.Uv.Iv St.; ^ Dist.; bet. 1 JuUvvc^a . and IbxlvAA^'x. ) 

/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \ 
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBEJR. / 



FULL NAME 





DOU CLCL^.-U; 



M.\ 



PERSONAL AND STATISTICAL PARTICULARS 

J COl.OR 



OX/YWoJui 



1)\ i ! ( >! lUK'I'H 



Ai.K 



a, 



|^t(.uth) II 




i V(j J 



M.»,l/,.' 



Pa Ys 



SIN«.1.K. MAKkn:i). 
WHxAVKI) OK DIXOKii:!) 

iVViit< in sorial (l<>«iKiiatioii) 



HIK rm'l.AOK 
'Stalf or Comitryl 






4 



^ 



0- 



NAMK or 
»ATHKR 



HFRTHl'I.ACK 
0|- I-ATMHR 
(State or Country^ 



MAIUKN NAMK 
<>» MOTHKK 



HIKTIU'I.ACK 
»>»■■ MOTUHR 
(State or Conntrv^ 



OCCri'ATlON 

_ Rfsidfd ill Sail /'imiiisri 



,Ojy\j A-XX/Y^'C.'L.^ c>c 



k}crU/txxL 






-tr 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH 

(Day) (Year) 



A^-LO 

(Month) K 
I HI'lKliRV CIvRTIl'V, That I attendtMl (Icci'ased from 



I90 * to 

tliat I last saw h :• alive on — 



I90 
ii.yo 



and that death occurred, on the date stated above, at 
M. The CAISH OF DIvA Til was as follow?- 

; JlJi'w^z.: 







f L<xaaa.<. 



V<X ^\J 



)V'(7i 



DIRATION Years 

CONTRIIU'TORV 



Months 



Days 



Hours 



}'rars 



.^Tonths 



Davs 



M,>iilhs 



/)<M. 



TMi; AUOVK STATJ-l) I'KKSONAl, PARTKT I.A KS A K !•; IKrK TO THK 

HKST '>i- MY KNowi.Knr.E AM) in:iji:K 



(Aclil 



rcss 



DI RATION 

( S IGN ED ) L'V . M LvaJ\>^K a.'Lo^ 

10 iqo H ( Address) HClM (kI B.t 



Hours 
M.D. 




SPECIAL Information only tor HosplUls, institutions, Transirnts, 
or Rfcfnt Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How ionq at 
Place of Death ? 



Days 



PI.ACK OF HIRIAU OK KHMoVAI 
rNDKRTAKKR LV>\^\- 



190' I 



(A<l<lr(•^s 



DATK of Hi KiAi, or RHMOVAI. 



N. B.- 



-Rvery Item o? information .houid be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain term., that it may be properly classified. The Special Information f*r per- 
«on« dyin^ away from home should be t'ven in every instance. 



n 






\% 

* *l 

m 

I' ; 1*1 






M . . , 



il 









,i' 





< 



m 



n. 






'■3 
It 



'f. 





■i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hn;ili 



1. -th V No- 









/;(//(■ /-'//(v/, 




ax 



7-9 (?S 



Rn^ififcrcd JVo. 



J 1 11 



Deputy Health Officer 



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



Certificate of IDeatb 

( Xa. S. Stan^ar^ ) 

PLACE OF DEATH: — County ofOcuo^ J;\^cv>\.-cui.coCity of CJ/O^^^aj J.\-XX.^ vc^^iL^-e. 



•C) 




No. ^"iO db/a^oAx 



-t. 



St,; S Dist.;b€t.MD-U.-^\va.>^^Avand tUJL 



0. 




/ IF DEATH dfccURS AW«Y FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
i, IF DEATH '^'-^"«»'"^" IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




V 



PERSONAL AND STATISTICAL PARTICULARS 

I) \ 1 i nl- lilKTJl 



I Month) 



Ac.i-; 



SS 



) ra 







(I):iv) 



Mnnlh- 



4 



(Vrar) 



/'</ 1. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



a 



.c\x:i 



(Month) 



T 



11. 

(Dav) 



(Year) 



'^IN'.I.K MARKIKI). 
WlDoWKD OK i)[\-( »Kvj.:i) 

' \^■ 1' in >-'n-ial (lfsi;.^iiatiini) 



HIKTm'I.AOK 
(Statf ur Cunntry) 



NAMl- ( !•• 

i-.\Tin:K 



nii<TiiiM.\i"K 

'>l' I ATIIKK 

(Stal<' i)T (."(iiiiitrv 



m\!i»i:n nam 17 



"IK 11 IP LACK 
<V" MOTHKR 

'Statf or rouiitrv) 



OCCri'ATlON 



SI (^ fi 

i 




•t, 




./OLXUyYV^' Vv^co- 



1 iUvUIUiY CICRTIFV, That 1 attLii.UMl (Iccoased from 
skx.-^' 190 3) to LXa^cl XI TOO H 

til at I last saw h .^■"- alive on OL^-vO 1 X 



I()0 

and that death occurred, on the date ^tati-d ahovr, at o 
VJ M. The CAlSh: ()!• Dl-ATll was as follows: 




.CL-Lxrvvv 



.t<V*v Q>aA^\.^X 



XOv\,t' 



u 



S.<'E^V-J?^>V^<J <^ vvt^ 



1 



DTK AT KIN • )V<7;-.s' Months 



Pays 



1 1 our Si 



CONTKIHrTORV 



Dl'RATION >''''^''l 



Months 



PiU 



.'S 



(SIGNED) 



LXXA./>A.AAJ-trtKL 



Ilours 
M.D. 



a 



RrsitU'd iu San I-uuu iy,:^ x\ )>.?;> 10 Mo<itl,^ '^\ /'.n> 



in \iu»vi*. STA ri;i) i'kksonai. i-ar tuti.aks aki-; TKri-; lo tin- 

''■I.ST ()!• MY KNOW I.KDC.H AND HKMl'.F 



'I'lf'JMnant 



(Addri-ss 




ECmL INFO 



(Address) cLoL'>\JL fo 0KlK.v1<<X.L. 



SPECf^AL Information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

Wfien was disease contracted, 
If pot at place of deatli? 



How long at 
Plare of Dealli ? 



Days 



I'l.ACH ()!• jn KIAI, OK KJCMOVAI. | DATJ^o!" It! lOAi. or KHMOVAI. 



ri.Aei-, oi' ji^ 

mm 



1 I', o: II 



rNDKKTAKHR J J\JL>Crt^.-'e^.• '^AJL/Of-Ui 



^ 



'^'^ 



TQO 






. oV' informB^on\hould be cnrefuHy Hupph.cl. AGR «ho:.l.l bo Htatec. F.XACTLY PHYSICIANS nhould 
^E OF DEATH In plain terms, that It m«y be properly .l»«Hi)flcd. The Special Information for p.r- 

«..._.. i?_. 1. „u I.I u— At.-.n in <a«/ox%/ inatfince. 



'**• **• F.very item 

state CAUS _„ ^ _ 

«on« dyinft away from home should be ^iven in every instance. 



iiii: 



11' 



% 



'■f! 



I ^ 

iiji'i 



' Mi 



( r 



^1 



'f" 



, f 



!rv 



\\r ? 






I 



r 
f 





.1 : 



i:i< 



I 



f < 



T?i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



j5oMr.i -!■ i!. ."Ill I- NO. !«; -v:??rr" "^^' ^" 



Dc-rc-D T-r. oarK np rrRTirit^ATF FOR INSTRUCTIONS 



])(( 



fr Fi/rfl, XXa,^^ ^X I'^O'i 



Begistercd JS^o. 



UA2 



CMS'^w^A-^^w^ 



Deputy H?-.'=^fth Officer 



DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Cevtiftcate of Beatb 

( tl. S. Stan^ar^ ) 



-No. 



rv' 



PLACE OF DEATH: — County of 

M. Co ibcKivd^' St,; 

/ IF OCATH 4cCUBS »W*V FROM USUAL RESIDEI Ki««=- 

^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME 



1 



Dist.; bet. - '"• and 



S AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
S AWAY FHOiv. <JO««u ^ INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




Oj\r\.6^ Vtn^Ji4' 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.oK 





^ 



{■\jJ<JL 



DATl, i»I- illKTll 



Ai,}.; 






5^ 



5 (•(/ I * 



1 



H 

iDav) 



M.niUf 



(Year I 



a 



Pay. 



SI\<W.K, MARK M:1), 
WIDOW HI) (»R IH\OKil-:i) 

'Uiit. ill -nial (U sit'tiatioii) 



iiiK rm'i,ACi<: 

iSt.itr (ii Ciiiiiitry^ 




NAMl oi' 

I- \ 1 iii-;r 



HlUruIM.ArK 
OI- 1 \rHKK 
'Stat, or Covinlrv) 



MAIDI'.X XAMF 
OI' MoriU-.k 



'nKTin'K.xrK 

OI' MOTHKK 

(State nr CDUiilry) 



V 



MEDICAL CERTIFICATE OF DEATH 

D.XTK «)!• DlvATH Hi 

(Moiitli)T 'Day) (Year) 

I HI'RIUiV CI'KTIl'V, That I attciKk'd (leceasetl from 

W 190 H to Uvwa X\ 

tliat I last saw h^.\-»'^ alive oti LIaa^Ol. 'X\ 

:iii(l that <lcath occurred, on the date stated above, at 6 C 
.J M. The C-U'^'*' ^>'' l)I':ATn was as follows- 






1)1 RAT ION ^'rars 

CONTRIIU'TORV 



Months 



Pa )'.? 



Hours 



DIRATIOX 



Years 



Months 



Pay 



oeeri'ATioN 



vj\yCVAJuv.<>-0'^/<^ 




o^^-vd. 



Kf>idfi{ in Still /■') (itti i>r/i oH )■/■(?;- Monttn 



Dii 



(I 



III \H()V]<: sr Ai'i: I) i'Kksonai, tar rut i. \rs ari-; pri 

l!i;sT Ol- MV KNOWM-.DCH .\NI) lU-.l.ll-.l- 



)•; Ti> Til »• 



X.Mhss a.Vj. \J^ . JU ^^^XV.t<XA 



^ , Hours 

(SIGNED) lU. VJ. ^ 'OJr^^y M.D. 

CLa.'Q Iv ,c,oH. ( Address). O-^l l-< %(Ml1-v^U.^ 



^O^ A.'v i()0 
:cAaL INF 



i 



SPEO^iAL Information «"'> for Hospitals, institutions, Transients, 
or Recent Residents, and oersons dyinq awav from liome. 

Former or .a \. "^ !V .., 

.U%, cH PIdfe of Deatli ? 



Usual Residence ^H" i'^ 

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



Days 



I'l.ACi-: Ol' nrKiAL OR ri:mo\ ai. 



OJkJLc^. 



T90H 



(Address 



iLXTKof H. Ki.M. or RHMOVAI., 



N. ». 



Hvery Itcn of Infon^Btlon .hou.d be cn.eful.y supplied. AGF, nhou.d »>««*« '-^l.f'^.^^^'*'^;,^: ,rrJtTo^„''l':'p;I.' 
state CAUSE OF DEATH in plain tcrm«, thot it ,n«y b. properly classified. The Special Informat.on for p.r 
son« dyin^ away from home should be feiven in every instance. 



I I 



m\ 






7 1 







i 








i i ■ 



Il t< 



:ii!: 



!H<'' 



i 



JiJ 



I!n:nil '■'^ 11' altll- »• >" l^ - 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i**!ZrVx. ,.o. ,.,^ . orcro rn BAr.K OP rFRTinCATE FOR INSTRUCTIONS 



i 



11 



4* 



Begi.slcj'cd J\''o, 



1113 



cL^KAAl^ijL^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. StanDarD ) 



PLACE OF DEATH: — County of 




(^ 



<X-4^ 



City of^JXCL/Q^l 



)XJLh 




No. 



St.; 



"Dist.: bet." 



and 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ 
C .F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




''\A^. 



PERSONAL AND STATISTICAL PARTICULARS 



a 






COIA)K 




,\iji 



Ai,)- 




5 

(Day) 



O 



(Vc.l! ) 



Slo 



) 'in . 



{ M.>ul/i< 1 O 



PilX: 



- . • . . r . M.\KKIi;i) 
\Vn»o\VKI) OK niVoRv'KO 

'^^ : ' •!-■.! i:n il< ^ii'uat ion) 



i'iK niiM.Aoi-: 

(Stntr ox Cf)iintrv 






I" \TiI l.R 



UIK 1 Ill'l, ATK 
<>l' lATin-K 

fStal. .i; (■..initr\- 



MAIDl'N NAMl- 
♦»!• MOT I IKK 



RlRTHIM.AlK 
J>1- MOTHKK 

(St:i«.- or Coiuitrvl 



<H'^ri'.\TlON 




(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol'- DKATH /O 

(M(.nth) A 
I IlI'lRI'iHV CI{KTn'V, That I atteii(lc<l (leccascd fmin 

up to ' — icp 

that I last saw h "-- alivi- oti ~~ 19O 



and that (It-ath occurred, «'ii llic dato statt-d above, at 
M. The CAI'SP: OI- DI-ATII was as follows: 



DC RAT ION )'cars 

CONTRIIU'TORV 



)'i(ltS 



Mont /is 



Days 



I /ours 



f\^M<ii'if ill Sijii /'i(in,i>i'ii 



)'f n I 



^r.>ntll' 



/hiy 



'III, \H0VK STA'n:i) I'KKsONAI, I'A K l' IT T I.A KS A R 1". TK I l-l To TH}-: 

in;sT OI- Mv KNowi.Kix'.K AM) in:i.ii:i- 



(II 



f""ii:int \) rVoLKAyOO'-VV J, 0>U2_^'>^ 

X^rc^^ycxcLiA^ '.!A 



' Xildress 



^l 



DIRATION 

f Signed) 



Mouths 

6j . Vl)A.v^/v>-^.'^.^^^X\. 



Pavs 



I lours 
M.D. 



\ddross) C)xxLuwiX/> LCtv^ V'QwV 



Special information onlv for Hospitals, lnstifufion< Transients, 
or Recent Residents, and persons dying away from fiome. 



Former or 
L'sual Residence 

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



Ifow lonq at 
Plare of Deafli ? 



Days 



IM \CK OI- nrKIAI. «)K K1:M<>VAI. OAIKo! IHioai. OI KKMOVAl, 



rNI)i;KTAKKR 



Ad'h i'<~s 



N. R. 



^.veny Item oii infonmetion should be CHrefu.ly «upplie... A(iH hUouIcI be «totcd KXACTLY ^^S';:;^';;^^;";;''^ 
>tate CAUSE OF DEATH in plnin term,, that It may be properly classified. The Special In?ormat.on for p-r- 



state ^Aust Of- UEA IH In pi 

sons dyinft away from home should be feiven in every inHtance. 



•4 



o 



■ il 

■P. 
HI 



S « 



\\l 



i . ' 




R^> 






"* 'I 



;;-ii 



* 



I 



t i 



I III I • 



W 



I 



i 




' 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Boiir.lof Il-;i!lll- V .^< 



? » O. T » ("^ . 



Dcrc-D -rri tmr^u nc rPOTlCirATF pr>R I N^^TRlirTIONft 




I)(t 



fr /^y/r(i, \X^.x<Y-udi "XX J'^O'i 



Ee^Lstered J\'^o, 



1144 



()^,^)-o.A^ JmA,> 



Deputy Health Officer 



No 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Cevtificate of H)eatb 

( la. S. StanDar? ) 
PLACE OF DEATH: — County of^O^^^^ JXxX/Yv<;:<'t4.ccCity o{^O^rr\j J AxX/yvca.a.cc 



\.u/i 





St.; 



Dist.; bet*- 



and 



/ ir deaW occurs awVy from USUAL RES I DENCE give facts called for under 'special information' \ 

V, IF oiiATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME «A-«-^ 




PERSONAL AND STATISTICAL PARTICULARS 




COI.oK 



L 



\< w \ « u- i;ii-;i'ii 



\' .1-; 



VI.. nth) 




XX 



) rii I 



1 



lA-;////.' 



5 



/>,n: 



SINi.I.lv MAKKlIvK. 

WiDi A\'\'\\) OK I)IV()Kii:i) 

'\\;;t' ill -ociril iKsij.Mi:tti<)ii) 



itik rm'i.AOK 

(St.'itt or C-iuntrv'l 



on (S 




NAMlv Ol- 

J-atii!;r 



nikiiii'i.ArK 

<>l" lATHhK 
(Slat' i.r t'omitry) 



MMI>i:x NAMl' 
<»1- MoTHlvR 



nn< ^HI>I,A(•l•• 
'Slate or Country) 



Ajuo 





MEDICAL CERTIFICATE OF DEATH 

DATK OV Dl.A'rii 



a. 



10 ipo'\ 

( Diiy) (Year) 



(Month) ^ 
I ni'Kl'lHV ClvRTM'V, That I attcii<k'»l dcceascil from 



1 90 



to 



TqO 
T()0 



tliat I last saw h • ^ alive 011 
aiul that (loath (UXMirrcd, on the date statiMl above, at I 
\J M. The CAISI': OV Dl-ATIl was as follows: 



I)( RATION }'i'<irs M out In Days I /ours 

(.'ONTRIIU'TORV 




?? 




nr RATION 



)\'ars 



Mtntl/is 



/hiv 



^ 



A'N^O^ 



n 



\J?X' 



cu±. 




"'ATl-A TioN 



AAXXj 



*• )V,/ 



^ lA'/z/Z/v / b />:■' ^ 



(SIGNED ) ^ -KJidjiKJi/di< U. ^'O^'YX. >\.-.M, 
[Xu^<X ^3^ loo'l (A.l.lress)t£)C)b a^v.tUK ■ nj 



I lout s 

M.D. 



iPEC^IAL IN 



t. 



Special information only for Hnsplfdls, Institutions, frdnsients, 
or Recent Residents, j^nd persons dvin'j awny fro.-n home. 

Former or j^ ctn ■ n\ { noH lonq ai 



rd 



Tin: M'.OVJ- ST\Ti: I) l'KKs,,)\ \|, 1' xKiiiM I, \K>^ A R J-; IRII- T" • 1' 1 1 1'. 
"I'.sroi- MS- KNnW 1,1 l)(.l.; AND I!) , 1, 1 1". !• 



'iifoiniatit \yj 



cnAXjL WlA^nxx^, 



V'Mioss V 



.\^^^X^ ^ 




.AX^Li- 



Dsual Residence 

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



n Pidce of Death? 



II 



Days 



I'l.ACi-: <»i" nrKiAi.oR r i:Mit\- \i. 



/\J fUxXx 



190H 



ini)i;rtaki:r 



DAi'i; of MiKiAi. oi rI';mi)\ai. 

/A.Mn-ss %W^ UOa^Ly at. 



N- I'..— hvery Item otf 1nfo.„„.t1on should he carefully supplied. AdF. should be Htatcd KX4CTLY PHYSICIANS should 
Mtatc CAlJSn OF DIZATH in plain terms, thnt it may be properly classified. The Special Informat.on for pT- 
sons dyin^ away from home should be ftiven in every instance. 



»' 



I V f ; 



■„ i 



, I ' 



m 







r 




i»i 



■ H ' 



I *! f^ 



T 



W 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



liontd 



111,- !• No. IS -^•':i^^ 



v~; iKxr *. <) 






I* ii«^rfiii«^^^ii^^t« «^ 



I 



I i^ 







^^. 



7.9 6>H 



li^'gislcred J\^o, 



1145 



Deputy H?alth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( "Q. S. Stanc»arC» ) 



PLACE OF DEATH: — County ofOcdA. 0;vxx^vcv<i(u.. City of ClCL'^nj v) A^CL-->vC'-^yC 



N 



0.1V 



# 



.LA.<iX 



Dist.; bet 



^ 



^ 



dj/YN/ UvOX-u and 



v^ St,; t) 

(IF DEATH OCCURS AWAY FROM USUAL RES 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 





Oj^\ 



ROM USUAL RESIDENCE GIVE facts called for under special INFORMATION" \ 

TANDNUMBER. / 



FULL NAME 




cc/vxc 



>vcl 





cnaju,{. 



k 



PERSONAL AND STATISTICAL PARTICULARS 



si:\' 



i).\ I 



ACK 




COI.OR N n 



Kill 




M.mthl 



lb 

Dtv) 



'Vtar) 



I 5 )>,;; 



1 /,.»////> 



5- 



/.'./ 



' -it'iKiliuii) 



I'.IK THl'I.AO-: 
'St.it. or Contilrx' 



V\M1 III 
1- '.ill i-.k 



lUK rin-i. ACK 

<"" lATHKR 
tst.itc Jir C(»\iiitrv 



O! MOTHKK 



H!KTin'I,\fl.- 
OF \5(iTllKK 
'St;it( ur (.■<.niitr\ 




MEDICAL CERTIFICATE OF DEATH 
DA TK ()!• DKATH Pj 

LUXCL ^i 

(Month) /| 
1 Hl':i< !':i5\' CI-RTIl-N'. Th;it I ;itt(.'n<U(i <kHcasf(l fn.m 




(Day) (Year) 



tliat I last si'iw h '.. alive on iJ^A^vCy V.O up H 

and that death orcurreil, on the .lali- ^tati<l jihovo, at W 
wL M. The CAlSf- OI" l)i: ATll was as follows: 

DlkATION >V(;/-i -Months b /;«[)'.? Uvur^ 



LoJU 




f^fsitifif ill San f'l aiirisro 5>« ) ' '" 



-'AJAj^'vVJl 

SI QA.^^ 



CONTRIIU'TORV K,^(y^^OJU^X^^.<r>^ Cjjf 



' V 'V 



DTRATIOX )Vr7/-5 ^f,))ll/ls /)(7ys Ilour^ 

(Signed) Vj- >. LcrAv\..o^.v' M.D. 

(jL^o 'rATooH %A.i.ireso io^sVinn.ojJut cit 



:a 



Special Information «nlv tor Hospitals, Instilulions, Fransienls, 
or Recent Residents, and persons dying away fron home. 



1/..-////- 



I hi \ 



111 Miovj.- sr \ri-. !) i-KksoNAi, I'Ak ^h■^•,\K-^ aki: rkii-; lo 'iiD': 

Hi;ST OI- MV KNi)\VI,!;i)(,K AM) lU-.I.I l". l-" 



'I'lfi'-mrnit 




(AcldresH 






Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Davs 



,,, ye,.- ,,, i-i KIM ok ki;Mo\ \|, I l)\'li;of UiHiAi. or KKMoV.M, 



INDLRTAKJ-.K 



.,,i.,. ibi 0>u.- 



,<iuA V C-^^ 



N. \\. 



■Kvcry 1,.n. oV infornu.tion should b. o.rcrully supplied. ACJf: .h.u.UI he Htated nXACTLY PHYSICIANS nhould 
Mate CAlJSi: OP DIIATH 5„ pl,.!n terms, thnt It m»> be properly J»««ir.cd. The Special Information for pT- 



Btaie ^,M.j.>|: |»|- Ul A I H in pi 

«on« dyinj^ uwny from home Hhould be feiven in every instnnce. 






111 






f ! 



V ». 



f . 






M' 



) 



vt 



f 





II 
I. 






►'V 



1' iil 



» . 



1 



Wl' I 



I, V 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECqpD 



}!o: 



:il(l of Ht*!lllli I >" • "••.-^-v* 



«,^P.,.n -..^ na^LT /N E> /^ C B-T I P I r> AT P m R I N CSTP I I TTI O N ft 



Be^isfcrcd Xo. 



i146 



luilr FiU'il, \k^.^.o.AAAJJ XX I'^O'i 

DEPARTMENT OFPUBLIC HEALTH==City and County of San Francisco 



Ccvtificate of Death 

( "Cl. S. StanDarC^ ) 



X % 



PLACE OF DEATH: — County 



of CJOL^A; A/CLA^C^U^C^cCity of U/CX/^OJ AXX. 



St.; 1 Dist.;bet. cLcx^^tv\.'.\ 



and 



( 



,. DEATH OCCURS AWAY r^' O M USUAL R E S I D E N C E G . V E TACTS CAL.ED ;0" ^^N^" J " ^j^.^D ^N U M ^E r" 
IF DEATH OCCURRED I 1^ A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



N.) 



FULL NAME 





(^ 



■^ 




0-trVX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.oK 






A. 



u 



'II 



(ly^ 



\> : ! 



^ Jilr 



M..nth' 



3vX )-.,:> lo 



lb 

( I):iv) 



A /.>„/// 



IVvnr) 



/),M.v 



-. •.,,;. MAkKn;i). 

WIDOWKI) (»K DIVOKrivl) 

■ :i ^' " i.-i! il'^i V II, it inll ) 



iiik ! tii'i.AiM-; 

'Sttitf (If t"i)initl N* 



\\M) ol- 

' i II ru 



I'.IK 1 III'l.Ai'K 



MAII)1;n XAMi- 

Ol- M()Tni:K 



HlkTIIlM.ACl-; 
;>!• M<tTMi:R 



\ 1 It iX 




O'U- 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATl-: (>»• Dl'.ATH O 

vXu^a ^^ 

(Month) K 'I>'»y^ 

I IIICRMHV CI'RTII'N', Tliat I atk-iKlcMl .Iccc-ased from 

xYVuxA^ 190H to IW^OL '^^ ifp "^ 

that I last saw lit >. alive on U-Vv.<ai 'kb Tip '\ 

and that <k-ath orcurrcil, on tlu' .latr statd al.ovf, at vu 
(j M. TIk- CAl Siv Ol" l)i:.\rii was as follows: 



nr RAT ION ^ )V</;--? 
CONTKM'.r'roKV 



MoHlhs 



Dav^i 



J /outs 



DIRATION 
(SIG 



)'t iirs 



M,t>it/is 



NED) d. UJ. ^ C^^^CX.^ 



/></!■ 



h'f^ldf.i in S\ni /'mill />■>! ol'X 5 ■-•<;( - V \h,iith< O /^'/ 



Tin M',M\-I.: ST \II-I» I'KRSOX \|. l'M<IICri. \KS AKi: TK! J-: To THl", 

i!i:^r oi Mv KN(»\vij;i)<-,i<; and I!i:m)".i" 



vAJ aJLLv/CC/>\v 



' \.l<lrr^^ 



I'iQsO Vl) ,\>CKVcb-v<XA| 



\+ 



XI Tc)o'l (.\.Mrrss) I'X^H Vb..VHX^N^M:'.<-^ "^'^ 



(^ 



I lours 



M.D. 



^- 



SPEClivL Information on'y f<»r Hospitals, institutions, Transients, 
or Recent Residents, and persons dvin'i dwdy from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



. Days 



PLACK Ol" lURIAI, (»k K1;M<»\ A!. 



iiAn;'.; ip ioai. oi ki;m«>\ai. 
Ov?) T90H 







r.NDl 



N. P.. H 



.. . Ktr. »i,r...l.l ha Ktnte«l fiXACTLY. PHYSICIANS Hhould 
.very Item of Information «houl.l b. cnrcfully suppi.ed. A^•^:;^"•'„''^^^^,.:i"*^;he. "Special Informnf.on" for p^r- 
Htnte CAlJSf: Ol- DLA TH in pluin terms, that it m»> be properly cIoshi^icU. me pa 

"on* clyinft away from home shoiiltl be aiven in Q\firy instnncc. 



i 



»■ 



fi' 



41 



1 » 



Up 

! '^ ' 



^ < . 



\ .1 






«■ 



t . 



i! 






!i ii 




ir^opr 



i. ± 




I 




li ill 



M i 



II 



T,\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board 



i; vn. ic t^-5-'3r:-:5t4, \\^\' C 



REFER TO BACK OF CERTIFICATE FOR I NSTRUCTfONS 



J)(lh /'V/r^/, IXxAyOLAAAA; X\ 



If) a 



lie<^islcre<l J^'^o. 



114^ 




\y\ji 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of Beatb 

{ xa. S. Stan^arC» ) 
PLACE OF DEATH: — County of XX^X) .>v<X/-yX/CA^coCity ofO^X^^^ O.^O^o^c^^^^o 



^ 



.1^.. let J^ 




...1. 4- 



CHU\.v^V,CL.\.) St.; 



Dist.; bet. 



and 



-) 



^ f \T DEATH occursAawav f r o n* USUAL RESIDENCE Give facts called for under "special information" \ 

\] V IF DTATH OCriiUiRFr. in a HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



cUUrr^CAXX; vJ y«^OLAlLtrVcx.' 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I CDI.OR 





,kXjl 



'!• UIRl'll 



Moiith'l 



A ( , 1 : 



?. 






) I a I 



W 



I Day) 



M. ,„!>,• 



r %1 

(V<-iii) 



/'(M 



'^iNi.i.i': M\kkn-:i>. 

"i.'il (ksi^Mialioii) 



HIK riM'I.AOK 
(Strife or riMiiitrv^ 



i- NTH i:k 



niKiniM.ArK 

'>'•■ I AIHI-.K 
'Siat( ci r.nintrv) 



a/vxxyU. 




MAIDl'N NAM J.; 



''iRrni'i.Ai-i.: 

<»!• MnTllHK 
(St;itr .,r r.iuiitiv ) 



(^ 



JL\X-^Oo 






? 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH r\ 

ULu^/Q 

(Month) A 
I H1{R1{HV CI'IRTIFV, Tliat I .ilteiulcil dcooascd from 

to LlxA/CL IS i<)oH 






(Vfar) 




Qs C) 1 90 H 
that I last saw h-C .>v alive on 




:^ 



^^p 



ami that death occurred, on the date '^tati-d above, at o \o 



A1 M. The CAlSlv Ol" DliATil was as follows: 



^' 



m' RAT ION 



)'riirs 



Moullis 



/)avs 



J/oit) s 



CON T R ir> U T ( ) R \' O /0_'>^.-O/U.^v^-^ ^- A^^Jl. . A^»./vvq^. 





f\^sidr,1 1)1 Suit Fiaiiristo " )V-mv jL M.^nth- 



nr RATION A~J'''''x.v 

(op 

( SIGNED ) 




^rolll/ls 



/hiVS 



r 




go TQOH (Ad.lress) 

Special information ""'> '"^ HHspltdls, institutions, Transients, 
nr Recent Residents, and persons dying away from home. 




y^ Co lo O^^vt 



/fours 
M.D. 



Former or 
Usual Residence 



vj(yvu<.UL at 



^ I ^ Vj (yv»>JL 



HoH lonq at ^ 

Place of Death? VI Days 



/ '(/ 1 > 



fii 



lIi; \U()\-]; sTAI'i:n rKK^ONAI, I'AR I'nri.ARS AR1-; TRrH To 111)-; 
lilvST 01-* MV KNOW 1,1: DC K AND IU:I,I1:f* 



ll 



rvdclrcss 




-ii-^-^AjU,!^ 



^^ \J0 . (AO Cs^Vwi^-OyX 



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



ri \ri-: ol- lURIAI. OR RI'MoVA! 



rNDJ-.KTAKKK aJUL. ^ (ib <Xxya, w 

(Addrc-.s Sio^'a- \^LL C3t 



DAri:<)! ItriMAi. or KHMO\AI, 



T90H 



Ion should be cnrefu.Lv supplied. MIP. should be stated F.XACTLY PHYSICIANS should 
'H In plnin terms, that it may be properly classified. The "Spec.al Inform»t,on for p.r- 



'^' ^- r.very item of informnt 

stnte CAUSE OF DEAT 

sons dyin^ away from home should be jiiven in every instnnce 



% 



i i 






'I t . 



• < 






* <\ 



i 



Mh. 



i "< ■ : 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Bo:i 



:,r,lof llc:.llli- !• N<>. i^ 1^'^^s:^- WScV C< 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






^ I' 



! 



* 



\ 



•; 4. 



!)(//<■ Fi/('f/, 



ck.^r^-^-'^^ 




"XX. 



190\ 



llogLslcred JS'^o, 



J H 48 



Deputj/ Hea^^^^^^ Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Xl. S. StnnOar^ ) 

J? (3ji i ^ 



PLACE OF DEATH: — County 



Noilvd 



mUoa. 



(MP 



\y>\JL 



DiH- 



xCl,' 



a.1^ St.; 



Dist.; bet/ 



and 



/ IF DEATH OCCURS AWAY FRdM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
\ IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





kA. J /CLci/'vCr\' 



PERSONAL AND STATISTICAL PARTICULARS 

^i:\ A _ A I coi.oR 





XjaxjJjl 



\i\ .1. \)V I'.IK Til 



A(>i.; 




n 

'Dav) 



Alt 

(Vt-ar) 



4 



medicAl certificate of death 
date of dkatii 

I Day) 



(Month) , 



) 



/QO \ 

(Year) 



::)x \ )V,/;. 



.M..>it/i.- 



'\ 



I\i\: 



"^IN'.UK. MARUn:D. 

W IDttUKD Ok DIVOKTl-.D 

' W'l ;(■ ill siK'ial <lt -ij.'iiat i' >n ) 




I i 



I 



I' r 







'^tate riT Comitrv) 



N \MI' (>! 

1 \tiii;k 



''■IkTil I'LACl-: 
'•I' I A I' 111' R 
'Stall or Coinitrv 



MMIM'.X XAMl- 

<"■ M')Tm:k 



•'■"M'm'I.ACK 

'•I' M(iTin:R 

(StatM or (.Viuntrv) 



•>* 'II'ATIOX 

fyrsidrtf in SiUi /'> a)i, ?-,ui O )'rtns *" }f>')illf~ ' /hi\^ 

■I'M)- \!u»vi-: SI' ATl'I) I'KR^oXAl. I'A R I' U' T I. A R> ARl'. TRrK To I'll)-; 
lU'.ST OI' MV KNOWIJ-.pCK AND HKUI1-:f<- 



I I11':R1':BV CI;RT1I'\', Tlial I alteiKKMl (U-ccasfd froiii 

kwLu SLA i(,oH to LLvA^ ai iqo H 

■1 ^ (1 ^ '1 , 

tliat I last '^aw li wv^xalivf (Ml VAa-a.^ X^ np 1 

n IT 

ami that (U-atli occurred, on the ilale stated above, at <K- 13 
\X ^^. The CAlSlv OI" I)i:.\TH was as follows: 



TM'RATION )V(//-.<r I Mouths Days I/ours 

CONTRIBUTORY 



DTRATION 



}lciirs 



Months 



/\i\'s- 




//ours 



M.D. 



(Signed) LU. U ux»^'vvx.lv<i.ti-.v,' 

Address)\J 'UXA.^-^^^^ ()bo-^}\AXai 



2>.l ino'A ( 



/VQ_-Cl >x^ 



'I"f"mant UJ . ^ . d iA.^'VVAJ'^ 



Special Information onU tor Hospitals, institutions, Iransienls, 
or Recent Residents, and persons dying away from home. 

Former or i^ n t(^^'^ \ ""'' '"?^^' . , 

Usual Residence ^ o o N.iUyw>vo. )i pi^re of Deatli? 

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



Days 



iMjiCi: OI- niR^Ai. OR ri:m'-\ai. 



1 



DAXJvof IUhiai, or KHNJo\Al, 
Q.^ 190 l 




N D 1 ; r t \ K i •: rM ^ J CUi<Lt/w H iV Vjj XJLOAjku K J 



KXXrsx. 



N. B. 



■Hvepy item of InformntJon nhoulcl be carefully supplied. M.V. nh-n.!.. be stated RXACTLY PHYSICIANS should 
«tnte CAUSE OF DEATH in plain terms, that it may be properly clH^sif.cd. The Specol InVor.nat.on for pT- 



■ 



'ri 



.r^ 



._ i 



. ♦ 



i: -I 

it 



i 





» ' I 




sons dyin^ away from home should be ftiven in every instance. 



ir 1 .' i 



I 






w 



? ■ 



m 



^n 









WRITE PLAINLY WITH UNFADING INK 



1 f II, 1 1th 1' Vo : ;'?•."■. ^3:"">i~> Hit 1' i"<) 



THrS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/v/^v/, (XwQA,^^ XX 100 H 



Ecg/sfrred jYo. 



1149 



■L_ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtiftcate of Bcatb 

( XX, S. StanDarC> ) 

J? Op i % 

PLACE OF DEATH: — County ofCJCL^>a' J A.Cu'va.cc^ ccCity of U/CLA^ vJ^\XXA^^^4.e,o 







JX.\j^^ St.; 



Dist.; bet. 



and 



/ \F DtATH OCCURS AwAv FROM USUAL *^ E S I D E N C E GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITALER INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



-^l \ 



I' \ 1 i "I IliU TM 




COI.OK 



Q? 



J JLAT 



I Moiilli) 




t-vj ,- 



A^ 



\i .!•. 



'-IN'. 1. 1'. %;akrii;i). 

WIl»i )\\ J.-.I) OK I)I\'( >KC)-:i) 

'\\' ' 111 socinl flfsi>.Mi;it ion ) 



HIK IIII'I.AOK 
(State i>r Cuiinti v) 



L 



1 /."////< 



n 



(Wnv) 



Ihn. 



'■ \TI1 l,K 



HIKTIIl'I.ArK 

OI- i'\rin-;u 

IStat*' or f<)\iiiti\-) 



<H- MornKR 



'ilKTMl'l.Ari-' 

'>'• Mnrin.:K' 

(St:itr ill roiiutrv^ 




MEDICAL CERTIFICATE OF DEATH 



a 



Months 




3.0 IQo''\ 

(Day) (Vfiirt 



I H1";RI:HV CI'RTII'N'^ That I atUMKlod <lcocasetl from 
190 to 190 

tliat I last saw h ■ ali\i- on up 

an<l that death occurred, uii the date stated ahove, at ^ 
M. The CAT SI-: OF DliATII was as follows: 




)F |)1;A ill was as loll 







DTK AT ION }'ta/s Mouths Pays J/onrs 

CONTRIIU'TORV 



1)1' RAT ION' )'iiJrs 



Mo)it/is /^avs 



(Signed) OAJ^cLiLvx^A ^ Low'>%^-y%Ui. 

^l ic)oH (Address) ioOb Q.U^l^A; nj 



/fours 
M.D. 




'>'-'<'ri'\Ti()N 



-? 



/\fs/'ifr<f ill Still /'t (tin i\/-t)^ 



Ay^VOL' 

II )Vnis - 



iam////, 



/>,M> 



I'm, xHovr: stati-i) i-kksonai, i'aki'uti.aks aki-; rK\}", ri> rn)". 
iM.sr o).- M\' Kx* i\\ i,i:i)c, K AM) Mj;i.n:i" 



(Inf,, 



niant 



^ry\j 






Special Information ""'y f"r Hospitals, institutions, Transients, 
or Rpcpnt Residents, dnd persons dying anay from home. 

Former or r,r,\\\ l) (? P ^^^ '""'' ''' a 

Usual Residence i^o UJ<X;A.'^X\JLu^ A' Plare of Deaffi ? o Days 

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



ra 



r^ 



? 



I'l.ACK Ol- lUKIAI, OK ki:M<»\Al, 



DA'n-; o!' MiKiAl. or ki-:m<)\ai, 

LIaa^q %'X T90H 



^AAyW- 



rAdih'-.'^ 



N. B— l.very item of inf<>rm..ti„n .houl.l h. c.refully Hupplie.l. M.V, Hh..ul.l be Htated EXACTLY PHYSICIANS Khould 
state CAlISr OP DI:ATH in plain t.rmH, that it may he properly cl«H«iflcd. The Spec.nl Information for p^r- 
Rons dyin^ away from home should be ftivcn in every instance. 



i 






^.'A 












\ ■ 




I 



t »; 



I 



[>«,; 



!|' 



!»! 



'Jill t 



f 




WRITE PLAINLY WtTH UNFADING INK — THIS IS A PERMANENT RECORD 



H< 



,„,i,..i!, ,uh i-vo. ,,-»-y^gr^-^n&i-Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







a3> 



lOCi 



Registered »A7;. 



1 1 50 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( H. S. Stanc^arO ) 
PLACE OF DEATH; — County of C'OL/^r^ Axx/>-^yCvxi.^oCity ofO/Oyrv XCUYV^av,^ ri.<. 



m \'\\^ \x]J^' 





SXa ^ Dist.; bet. 

UDENCEgive facts calle 

H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 




and M.UyaJ- 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UND^R •'SPECIAL INFORMATION" \ 
V. IF DEATH "^/-i.oorr, im « UORPITAL OR INSTITUTION GIVE ITS NAME INSTEAD ^F STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




-x\jl.k: 



A. 





V 



vd 



J. 



H ■ 



ra 



•L 




COI.OR 



I'.IKIH 



.1 Lt 



xUJl 






\' 



IS 



)'/•(/) 



IC) 



U 

(D.tv) 



M.'>illi> 






(Year) 







na\ 



■^ :.i M\KRii;i). 

Willi >\V}-,I) OK DIVnKCKI) 



luk riU'i.AOK 

(St.'itf i)r Country 



A.tX<^Vvr 



NAMi; OF 

J-ATin-R 



(^'' I AlIIKR 

iSt;itf .ir Cnniitrv 



MAll)i;\ NAM}.- 
Ol' MOT I IKK 



IHRTHPl.Ail- 

oi- mothi:r 

(Stale or r<iuiitivi 




\ 



MEDICAL CERTIFICATE OF DEATH 

DATH oi- i)i:aiii ,0 

(Month) \ I Day) 

I HI'IKI-HV CI-RTli'V, Tliat I .ittL'ndc.l -Ictx-ascd from 
!l iqoM to Ia^VXX. X\ 1(>oH 

tlKit T last saw h v.."- alive on LA^AA-Q^ '.•-! \<p' ■ 

and that «U'ath occurred, on tlie date stated aliove, at 1 J. 1 
J M. The CAl'Sl-: Ol- Dl'ATfl was as follows: 




Di; RAT ION 



^ ]\'ars ^ Mouths 

CONTRIHl'Tf^RV UXaJLa^ VI TLL . , ' 



Hays 



Hours 



Pays 



Dr RAT ION n^ '"'/>> '■'A'^/M.s 

(Signed) G. "o. ^.ka^'' -■ 

Addivss) lUoOa^vMl 




^ V O- 



OCCrPATlON 

^''■^nf/-,i ill SiDi /'i,iihiu-,t OU )V,Mv - M'tiflr 



/', 



THI-: ahovk staii-.d ckksowi, i'\k m^ri, ars art. iKrK to thk 
in:sr o).- mv knowij-.dc k and inci.iiu- 



(liifoiinanl 









%'\. iqo'l 



{. 



i<L^ 



M.D. 



Special information onlv for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyin^j anav from home. 



Former or 
Usual Residence 

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



HoH lonq at 
Place of Death ? 



Oavs 



DAT^')!" Mtkiai. or K1-;Mo\AI, 



iu.acp: OF lu-RiAi. OK ki:mo\ai 




TQO \ 



N. B. 



F.very U.™ „f l„(,..,„„ion .h„ul.l 1,= ..,ref,.My .applied. AGP. «h„uUI be s.a.ed F.XACTLY , P"/*'*;'*!:'' "''""'t 
Mate CAUSE OF DEATH in plain term,, thnt it m..y be properly clawiSied. The Sp.cal Informat.on for p.r- 
sons dyinft away from home should be feiven in every instance. 



f 



!■;': 






v\ 






I 






i- 



I 

I 



\m 



u 



ri< 



II 
11 



m 



I. i 






K ' 






i-,> 



4 



in 



[1 

r 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



RoMPl..! II' :'"!'• ''^<^- '' 



TV.t^Jr?S.;i lutr Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Diih' I'lleii, Clu..xy^,.v^ ^3 /'"^^H 



Registered jYo, 



1151 



i 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 



PLACE OF DEATH: — County ofUQyvu'J 



Ccvtificate of Bcatb 

on J (^ 

AXX/waA^<LC^ City of O'CL-v^ A^O^/wCa-A-C-O 



.;> 



N<> 



Vx >\t^ 



-V 




A^^JlXOUL^v CM ti VD Cs4 K V. '^Sm ' 



Dist.; bet. 



and 



f ,F DE.TH OCCURsiVwAY FRoJil U S U A L ! R E S I D E N C E G . V E TACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \ 
C IF DEATH OCCulfREO IN aOhOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




SjxxXxXJ 




X/lxxi UJx^X.-a.vA>iu. 



ri) 



K.f^. 



PERSONAL AND STATISTICAL PARTICULARS 
T> (\ . I COI.OR 



i niuTn 





^ ' 



V ' 



ll^i 






S^ 



) :■„■< 



M.mth- 



( Veil I 



/',/! 



'^^ MAKKll-.I). 

W Ii»" lU l-.I) OK I)IV<»Rv-J-:i) 

(Wlit- ill v.,.i;il •lc>.i",r|l;,(i,,,l) 



lUR'!"!! 1'! X,- ]• 



•1 : \ 










''■li ■ ;i I'l, \rK 
<M 1 \ !in-:K 

'■' ' '"iiiintrv^ 



M Ml II. N NAM!'" 
<»•• MOTIUIR 



'iiKriii-i.AD-; 
<>!' M»iTin<;K 

'stall- iir Coimtrvl 



K.^'\ V' 



I Xhyv%^<x % "^ ^ 



>CrV<-^^A^ 



MEDICAL CERTIFICATE OF DEATH 

D.ATK OI" DKA in 

3.1 




iM()iitli> 



(Vc:ii) 



I liliRl'iHV Cl-;RTn'''V, 'riiat I atlciuUMl dcn-ascd fmiii 

— 1(^0 to ~ U)0 

tliMl I last saw h ~ alive on ~~ I90 

ami that (loath occurred, tni the dati' >^tated above, at 
M. The CAl'SI-: OH I) l". .XT II \va< as follows: 



Drk.xriON Yeats 

CONTRir.rTORV 



Months 



Pays 



Hours 




M 



' H (T I 



h\-udfi'. ill San I- ttiii isrit W )V(// > 



lA nth- 



/':.M 



Tm-; MiovK sTAri:i) {'Hrsonai, PAuruThAKs aki'. vkvv. to Tin- 

lU.sT OJ- MV KNo\VI,i:i)C,K AND lU:!,!!'. I'" 



nrRATloN Viars Mouths Pays Hours 

(Signed) LcrVcrrui\; J. mD. LL^^^^^a^^ M.D. 



ao 



i^ 



-i T()o'a f 



.X.Mresv.) L 



.ft^l^rwlA^ W-VV^-^.-l 



SPECIAL Information "nly lor Hospltdls, Institutiyin, Transients, 
or Recent Residents, dnd persons dving Hway (rom home. 



How long at 



tsudl Residence^ ^ ^^ L<xLfc-\\\Ou Cjl- Place of Death? 1 ■ - "^ Days 

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



ruACic <>i- luKiAi^oK ki;mo\ai 



I) \ 11: ')t Hi 10. A I. .>! ki;m< »\ai, 
(J.AAX1 ^H T90 1 






N. B. 



■ 1 %rK «hr...lil he stiite.l F.X4CTLY. PHYSICIANS Hhould 
.very item «f information .houhl be o.refally supplied. 'y'flj^^^/;'^^^.^,.^" / * ^he "Special InformHtion" for p-r- 
tate CAUSE OF DEATH in pinin terms, that it may be properly wlaHsi»ic<i. 1 ne o, 



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



1 f 

• A. A 



ll'fl 



\^ 



I 

'. ! . 
♦ \ 



' »t i 



I. 




\\i 



>1 



! » 



1-1 



«< 



hi 



^««^- 






'- %,. 



1 ^ ^^ 

hi 



i-i 



! 



,1 






f 



III 



fir 




^k 



: I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Boanl -if II 



,!t!i I- No iv "^"'S^r^' '''^'' ^'" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J)a/i' riJrdy CL^xyuuit X2> I'^O'i 

Deputy He^'th r\^i^x> 



Bei^isfci'cd J\'*o. 



1 1 5J^ 




DtPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 



( XI. S. Stan^ar^ ) 



N 



J? QT) A (^ 

PLACE OF DEATH: — County of OcL/^v 0,^^XXAa<i^ULCo City of O/ClavO Axu>v.c\.A/oo 
o. 'ISi CW>XxLl/>a; LLx^-e^ St.; R Dist.;bet.JA.O^->vkX<^V) and U^tCOyf-^ 

/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ A 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J 



FULL NAME 




.KJXj^^'s^'Oj Lc I l ■. 



PERSONAL AND STATISTICAL PARTICULARS 

m:\ a a ^ ! coi.oR 

WA ; > ■! r.iRTii 




N 5 



\~:V 



' Moiithl 






(Year) 



A(,] 



41 ,..„, 



A M.nilh^ Jv I 



Am 



^IN'.l.r.. MAKRIl-:i). 
WIDoWKI) OK DIVOKri:!) 

' ^^ ■ ■' ' ■' li "-ii'iiatioiit 



IWk 1 ill'i.ACK 
(State or Coiintrv^ 



NAMl- <il 

fatiii:r 



iiik I'lilM. ATK 
■"' ' ■ ^''>iintrv' 



MAII»}.;.\ NAMH 
<>'•■ MOTHKR 



<>1- MoTlIKR 

(Stati- Mr Coiuiti vt 



'" ^"t I'AI'IDN 






VA 




NXAyvo 



OL 



OJ\AyO^A^ 




\ 



MEDICAL CERTIFICATE OF DEATH 

DATl-: ol' Dl'.ATH 



(Day) (Year) 



(Month) .j 
I UI{R1;BV (.■ I". RTI !• V, Tluit I attc-iKkil tlcorased from 

to LAa-^-Q "^^ 




up H 



M v^^ 








-^ 



that"! last saw li ••^' J alive 1)11 LLv-VO^: >. 7(p 

and tliat duath occurred, 011 the date stated aliove. at I 
CX :M. The CAISI' Ol' DI-ATII \va>^ as follows: 



DC RATION ^ )\ars A/oni/is /hus J/oiiPS 

C ( L\ ']• R I I'd ' T R \' LclAxL^<X^ dJXO^'X,^^ 



'^v_Ow.>vA^.y:v. 



or RATION ^ )'<■<//-.? Months Pays: //dius- 

(Signed) \. 3 cr(>-cr^^- 'v. - M.D. 



Special information onl> t'"^ Hospitdls, institutions, Fransients, 
or Recent Residents, dnd persons dying dHdv from liome. 



(y^Ji/y\j Kj Mx.y^vw/Q^'^^A 



I 



f\fM'(irtf III \,i)i I'l ail, isi'o f<0 )Vr//y *" M,<iilli< 



/'(/) 



I'm; AH')\-i'. ST \ri:i) i-kksonai. r\Ki-uMi,ARs ari-: trik to tid-: 

''l-.sroi- Mv KNo\\I,i:i)(,H AM) HHI.n-F 



Or 



f'-:mant M iVv^ Q. ~0 ^\Xa\^kj^\^^ : \ 



\'l(lrt?ss 



io'X'l "d\X>AJk./.rvx; ^i^ 



Former or 
Usual Residence 

Wtien was disease contracted, 
If not at place of deatf) ? 



How long at 
Place ol Death ? 



Days 



I'l.ACK ni- lilRIAI, OR R1:Mo\AI, 



DATl-'.ii! Hi KIAI. nr R}-;Mo\AI, 
LIa/^ X^ I go's 



rNDHRTAKl-R J Jkj?.'CV-cUrV X)-U-V.>VVCi 



'A.li'.K sv 



N. B. 



-Kvery item o.' infor.nntlon «houlcl b. cnrefull.v supplied. A(1F. should be stntecl BXACTLY P'^YSIC.Ar^S Hhou.d 
Htate CAUSE OF DEATH in plain terms, that !t may be properly classified. The Special In^ormat.on »or p.r- 



Ron« dyinft away from home should be feiven in every instance. 



»5 



\ ■ 



J . 1 



r 



I 




I ' • 



\\\u 



V. 



ji'h' 



■^■v 



'vHf ;:.\ • 



i-t 








I 



ph 



f £ 



ilil 



ii 



'n 



'i ' I 

\ : 

t , 

r 
'I 



I 



il! $ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



noanl I 



f ikmHIi I- 



V,v 1^ t-^^^sSv^: lutr C) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((h> hlli'tl y xXx^^-^YJ^J^ 'Xh. 



100 \ 



BegLsfcj'Pcl J\'*o, 



\ 1 53 




^-JUV 



:i 



Deputy Health Officer 



'^k). 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "U. S. Stanc>ar? ) 
PLACE OF DEATH: — County of C)/0L'"r\;v1/L€u^\CA_4^C.c City of O^jyx, vJAXL/^\Ca^ ex 



Dist.; bet.' 



and 



i^ VwAJ\a/Ymju u\JO-<L^\>^/ax\ ot.; i^ist.; oet. ana 

/ ir DEATH OCCURS /IWAY FROM JU S U A L RESIDENCE GIVE FACTS CALLED FOR UNDER "'SPECIAL INFORMATION" \ 
\ IF DEATH OCCUnhED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



■-1.-. 



ir 



\' I 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ok 




V 



XC'^ 



i;iK III 






LL/yOk/y- 



oXx.^ 



Muiitli) 



J "/•<;»> 



^1 ■' ;.i' M.\i<kii-:i) 

WIDOW HI) OK DlVoUrHI) 
'^^ ' " ' ill ilf^i^'iiati'iii) 



nik i in'i.Aoi-: 

(state or Oniiiiti y) 



N'AMI-. ()|. 

I•■^TM|■.k 



I'lK riiiM,\rK 
'>'■ I \rin:k 

IStal. -,i i-.,niitt v' 



*>' MnTlii.;K 



"IKlHPi.Ac,.- 
<»!• MiiTin-.k' 

'Stilt, or f,,Miiti\ ) 







> <;ir) 



/></!. 




^CA/W'^rvj 



MEDICAL CERTIFICATE OF DEATH 

(Month) ([ il)ay> (Yiai) 

1 JIIvRI'iHV CIvRTII'N'. That I alteiKlfd (Icooascil frnm 
\i 190 H to LLla^ OvCi i()oM 

tlifit T last' saw h t , alive on LLmvX^ ,^L up H 

atid that death occurred, on the date stated ahove. at V3 o C 
O- M. The CAl SI- ()!• i)l';.\TII was as follows: 




]'t'ars Mo)iths Ihiys I/oi(rs 

) N T R 11 ') I "I' () R \' ^ -OJwOL^^-vaXi vJCi A^'vw'qM \.A.t !..< . 





'" '1 |-\| IDX 



cc ^^'d-^ 



AaxLoA-V U iXXj\^JL^ 



ex V V. L. ^ 




*3s.>cxXmAXA' 

l\f~i,!r,f in Sun /'nniinrn ^0 )V,m> 



1)1 'RAT ION - )('ars M. nit /is 



fSlG 



NED) J.Vr\. Jbouhjb 
UajM3 :X?> iqoH (Address) U:1m '^-^ 



/hn 



'A' 



I lout < 

M.D. 




Special information <•"') ^'"' llospild^. institutions, Irdnsients, 
or Recent Residents, dnd persons dvinij dHdv Iro.-n home. 

Former or %-^ ^ '^^''^^ ""^ """V* ., '^^ 

B^JL.T.'v.QL.vvc. Plare of Death ? oo 



J/Ck^w.^ 



l/-.y////> 



/),/!. 



I'A.Ari; oi- inKiAi. OK ki-:m«»\ai, 

J 




I Ml-, \i(ovi-. s'j- \ rr.i) i'KKS(t\Ai, r\R rut I, \Ks AK1-; iki}'; t«» tiU': 

Ill-.M ((I MY KNOW l,l.:i)(,l.; AM) l!!'. !, Ii: I-" 

N. B.~>Hvery item of informntJon should he cnrefully supplied. AdF. nhouhl be «t"t«^«;j^'^.^CT''.Y; PHYSICIANS , 
«t«te CAUSE OF DEATH in plain term«, thnt it m»y he properly claHHiHcd. The 8pec.nl In»orm«t.on to 
sons dyin( awny from home Hhould he ftiven in every instance 



IsudI Residence 

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



Davs 



DXI'lio! Hi \'.\.\\. or K1-;M()\'AI, 
-V<^ "k\ T90M 




rXiIdo'ss 



^ioia- \'^ 



PHYSICIANS Hhould 
r p«r- 






» » 



m 



I •■ 



» t 

« 



li!' 



•I . 



• } 



j^W 









■ IT 



■i- i 



I. 




! 



f^- 



^Cw™ 



i 



i ■• >' 



■ 4 



I 



I 



i^ 



" ■* r-^! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!,,;iV.! .1 !I .':'ll 



Jhffr FiJi'd , 



cL^Cr^.^*^^*^ 



^'■^^ Qjl 



. ! K I' U 







REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




as 



1V0\ 



Regi.slcrcd J\''<i. 



1 154 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of Beatb 

( XX. 5. StanDarD ) 



,.XX/W\JUcL<X' City of 





VJt<Loo \^<XJ 



Dist.; bet. 



■nnd 



/ \r DEATH OCCURS AW*Y 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 




.Ly\! U /CX,UL<xa 



^ 
J..-., 



PERSONAL AND STATISTICAL PARTICULARS 





aXo 



MEDICAL CERTIFICATE OF DEATH 



n 

'Month) X 



5t 



) I'd > 



il)av> 



1 /...////■ 



f Vrar) 



.'? 



/'.; 1. 



MAki<n-:ii. 

W llM A 1,1) OK I>I\(iKt'Kn 



niK 1 , ]. 

(Stall- or Country) 





CU^V<i; 



,u 




] 



Hlk liilM.AOH 
f'.'- » APHKR 

'>^t.il( or rumitrv 



MAllii-.N NAMl-- 
'»'■ MnTHKK 



OI' MoTHICR 
(St.'itr or Countrv) 




^y\j U /O^ULoLCyvia-'u 



(Month) 1 



/go \ 

(V. Ml 1 






fl)ay) 
I H1':RI':HV CIvRTIF-V, That I att(.Mi(lo(l (lect-ascd from 

up t(i -— — — — — — — icp 

tlial I last saw h ":: alive on — — up - 

aii.l that (K'alli occurred, on the dale state<l above, at — 

M. The CArSF* OI" D I {A Til \va^ as follows: 




>.Xa. covet 
tojvxxo^\xtj 

<X.vvcL 





1)1 RATION Years 

CONTRIl'.rTORV 



}'(•(! rs 



Months 



Days 



I /ours 



dtratiox 

(Signed) oL LL'. c;>Lv^cUK ^^ . 

LLa^.. Ov^v loO^V (.\<l.lress) VX.U X>->vJ-d.O.' V ^A 



Mouths Pays 



,'!> 



Hours 
M.D. 



Special information ""'y ^nr Hospitals, Institutions, Transients, 
or Recent Residents, and persons dvlny away fro:n home. 



h'r !,!,■,; in S,ii> /') il». />»■ ' 



M.'iitli^ 



l\n 



IHK MtovH STATI-.D PKKSONM. I'A KI'K-I- LA KS A K J". TKrK To THK 

lU'si ()); >,y KNOW i,i:i)(ji.; \\n I'.i: i,ii:i" 



Vi . "O <xXX.<XX)A\JJ\} 



\.Mi, s.. 



^<:xJ\J 



Julka 




Former or 
Usual Residence 

When was disease rontrarted, 
If not at plare of death ? 



HoM lonq at 
Plare of Death ? 



. Days 



I'LACK OI- m-RlAI, i)K I<1:M<i\AI. 



J\,^<y^ 



DAi'i: o! liiKiAi. OI ki:m()\ai. 
0.5 







TQO 



■inlo CAlISi: OP DEATH In plain .crn,s, that it m„> h. properly cla».i.-ied. The Special lnfor,n,.t,„„ for per- 



son* dyln^ nway from home should be jtiven in every instnnce. 



■I 



\iX'\ 



« I 



; I 



I 

■t 



I 

^ I 



I < 



♦ , 












'■' V 




•w 



i:i 



•'i^^: 



«^: 



mmi^ 



v-«»^-«p*- 




» 






l"S 






ill' 



h 



11 



ilii. 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H-.i- 



\i 1 r. !■■ Nil 



»'-*-:r>. 



) ItN; 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ro<ii,slci'C(i ^Vo, 



i 1 55 



Ihil, filed. (Xu^.A-cJ: 13 1'fO^ 

Ifrw^lt^wM Deputy Health Offic- 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of IDeatb 

( 11. S. StanDarD - 

of CICC'^AJ JXCL/^XCc^CCCity of 0,<X-»V) ^(XAx<t>.v<i. n c 



No. 



( 



X^tVvCvc St.; S Dist.;bet. 

__ . IIDE 

IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVt ITS NAME 



^tw 



and 



s;L 



IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 

I INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




VD <x\.\^ . O'vl o.A.v.e.N 



si;\ 



DA 11 



A(.l- 



SIN' 

\vi; 

(\Vi 



PERSONAL AND STATISTICAL PARTICULARS 

KIK III 

V\ \ 





/^'IS 



Month) 



?^l 



) ra I > 



^ 



(Day) 



M.'uHi^ 



l\i\. 



M \K k 11" 1), 

I <>k i)i\'(»R>-}:r) 

- H'ial lU'sijfiiiiti.di) 



CJ^c^x/cyLil 



niR rm'i.xoH 

(St:it. ,ir I'oniitrv) 



NAM I- «>}•• /T^ 

l-ATiii;R L 

lilKrill'l, AClv 

ft 1 



MEDICAL CERTIFICATE OF DEATH 

DA ri". '»1 Dl- AlH 1 

i Month' A 'Day) 



(Yfur) 



! Hi:Ri:r.N' CI:RTII-*V. riial I nUoinUvl dciHasrd from 
thai I last <a\v h v . alive on V.Lv,a.O 9^3 



an.] that death ocrurred, mi tin- .laU' -^tati-ij above, at A- O 
U M. The CAISI-: 01; l)i:.\TlI was as follows: 



n 




■v^C 






h 'TN 



|x^U^ 



.C^_t 



.}/on//is 



• ^l 



^Ji 



; 





o ,cx W^<^ 



'V lAlllKK 

'St;it( ,,v I'otintrv'i 




M\nii:\ NAM)-- 

o|- Morii^;K 



"nMUPI.ACK 

01 m()Thi:r 

(Stale or Coiiiitrv) 



occri'A riox Qr> 










Dli; Ai"I()N r' )''Vr 

coNTRi r.rr«)RV 



I)rR.\TI(»N .^ )V</;i Mouths 



/>(7r. 



//ours 



J . QVV\.'^ A 



v/Ol^.V- 



//ours 
M.D. 



Signed) J .AA^-cr>^v<x>3 



Special Information <»"'> '"'^ Hnspitals, institutions, Transients, 
or Rerent Residents, dnd persons dyinj .mnv [ro;ii fiome. 



A'/' ■.!/■,! ill S',111 /^ ,;;/, / -rn 



]>,;; 



1 M,.,if/»- Xi / 



A; I 



I'HK AltOVK STA11-I) I'KKSONAI, J- A KT KT LA KS AKi: rKlK T* » I'lIK 

J!)-,M' »)i.- Mv KN(»wi,i:i)(.K AND iu:un-:F 



(liifo'iiiaiit 






^ \ili'. rfss 



Former or 
L'sudI Residence 

When Has disease rontracted. 
If not at place of death ? 



HoH long at 
PIdi e of Death ? 



. Days 



VI \CH Ol- in KlAI, »>R K}:M<'VA! 



1) \TV. (.! Hi KiAi. 01 Ki;Mi>\Al. 






rNl)i;K TAKl'lK 

fAdilress 



Ol Ov\ T90H 



N. B. 



». . , ,..1,1 ArF ahnild bc stiitetl F.XAOTLY. PHYSICIANS nhould 

-F>very item of m?orm«tion .hould be cnrefuMy supphed. ^*'^- f"\ '^'^^^^^^^^^^^^ T^^e "Special Infor,n..tion" for p-r- 
state CAUSE OF DEATH in plain terms, that it mn> be properly cIn««iVietl. me op 



sons dyinjt away from home should be feiven in e%ery mstance. 



'k j^ :."vij 



I 



« ■ 






^ 



1 

i! 



if. 

■■•■ > 

I 



I 



-lit 

;r 

4 



I, 



!ii" 



>i 



ifij:-! 




i^A 



w 



RITE PLAINLY WITH UNFADING INK^*^THIS IS A PERMANENT RECORD 



lin.i;. 



, , , I. Vo. ! ^ 1*-?^w^J^ lK<v 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



])((!( Filed , \Xxj^jo^juO^ 



X^h 



100\ 



Bogistci^ed Xo. 



i 1 56 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. 5. 5tnnC»arc> ) 



PLACE OF DEATH: — County of - 

■ No. J \X<Ll>vyljlA.A./o^>-v db (yvl., W y. I ':^ . ' St.; 

/ imOEATH OCCU 

V IJlF DEATH OCCURRED I 



City of 




13 VK 



V.1 



Dist.; beU 



■^nd* 



/ IF^DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
V, IjlF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 







FULL NAME 



!'Y^.'^..\.X.A. 




I0.uv4. 



PERSONAL AND STATISTICAL PARTICULARS 



si;\ 



\\oli 



(:•>!,( Ik ^ 



I)A 1 i; Ml- ItlKTH 



A<,1, 



OS? 



I 



OxAr 



iMDiith) 



O 1 )•-■,/;> 



I 



(Day 



M.,„lli' 



rlk^'l 




lt> 



I V tat I 



l\:\: 



SINr.i J- MAKKn.:i). 
WllH.W i-K OK I)IVuKri:i) 

'Wiiti ill MK-iril (Ifsi^riialiiiii) 



HIK 111!'!. \C\-. 
(Stall <,r Coiititrvi 



FATin-.R 



"IRTlll'I.ArF 
f>'" IAiin<:R 

(Stat< or Cuuntrvl 



MAini-.N NAM}-- 

• ii m.»tiii:r 



'ilk rupi.ArH 

<»l" Mni-UHR 
(Stair or r<)\iiit!v 



OCCn-Aiiox 







MEDICAL CERTIFICATE OF DEATH 

DAri-: <>i" i»i;ath | 

LVA.V.C! lb zoo' 

(Moiitli^ ! (n:iy) iVi-aii 

I HIvFvI'ir.N' C'I;RTII'\', Tliat I aUc'ii(U-tl (ItHiasftl finm 

— up to "■ " i<)0 

lliat I last saw li alive on Mp 

and that death occurred, on the date stated above, at 
M. The CAlSlv ()!• DIlATII was as follows: 



,.<k.L 



(>v vi Jka-^o- ^ct 



DTK AT ION Vi-ars 

CONTRird'roRV 



I )r RAT ION Viiirs 



Mouths 



Pays 



Hour 



M()>ii/is /hiys //ours 

x^^ M.D. 



\.Xr^u-v-Nj 



l\f'>iilf(! Ill Siiji /'i t! II, / 'I'lt I \ )'<iti 



1/,./////. 



/',, 



'Hi XHOVK ST All- I) I'KRSONAl, PA RT IC f I, A R > ARl-. PRri- 1' • IHi; 
•II.^T <)I- MY KNOW Li: 1)1 -.K AND UI'.Ml-.P 



'Inf.. -1,1:1111 



\iMic 






..^^-UUAj 



:)± 



SIGNED ) Vj . H- ^^-^^^-^^^^^ 

\,l,lr(.<^) \jlX>^^ \L\,0'v« 



/u.,^n [\. 



Tc)n 



( 



4- 



SPECIAL Information onU tor llospilnK, Instihiflons, Transients, 

or Recent Residents, and persons d\inii dnny from home. 



Former or 
Lsudl Residence 

Wfien was disease rontrarted. 
II not at place of deatti ? 



How lonq at 
Place of Death ? 



Odvs 



I.ACl'! <>l' lURlAI.oR K1-;M<)\ \I, l»All',o: !!. lOAi. 01 R1:M<)\\I. 




INDl.K'l'AKl-.R 

(AiMrt-ss 



N. B. 



.1 %rH ».ho.ilcl he stilted F.X4CTLY. PHYSICIANS nhould 
ntJon «houl.l be cnrefuMy suppf.e,! J^;^;^'^^^^'%uc -Speclnl In.'ormaf.on" fur p-r- 
\TH in nhiin tcpm«. that it mny he prcpcrly ciassmcu. . 



Kvery item ot' Inform 

Htjitc CAUSE OF DEATH in p 

sons dyinft away from home Khould be jj^iven in every instance. 



' • r 

■ ' } ■ 

r 



in 



! I 



i* 



1 . 

4i i 



P-' 



1^! 



n 



i 






I 



\h 



I 



h 



t t 



■i 



1 


\ 


i 




't" 


1 


■■ » 


1 : 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



.„r,|M Il.:,l.h l-Vo. ..-^-r^^HScrc- 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health Officer 



Eeo^lsfered A^o. 



1 1 57 



DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)catb 

( 11. 5. Stan^ar^ ) 
PLACE OF DEATH: — County of O cxx>^ J.\^<X/>^tiA.ar./City ofU/(Xyv\; JAxXvv<i^xj_>ci.c 
\S)XAJ^I\J SU D'lsUhct (j/0.yy\AArY>^Jb and \l I W>vto^X« 

(ir Ot»TH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION • '\ \ 

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



fjil 



FULL NAME 



rvo^^ou^i 



PERSONAL AND STATISTICAL PARTICULARS 

n \ . : ' 'I i;iK Til 



LL>Ok/>^ 



"Month » 



S C) JV.nv 



I Day) 



Mn,il>iy 



(Vfiir 



Iht 1 . 




(T'tY 



MEDICAL CERTIFICATE OF DEATH 

DATH Ol- I)i:.\TH 

n):.y) 




(Month) 1 



(Year) 






.^s-OJ-^-^ 



I III'RI'HV ClvRTII'V, That I attt'>i(li<l ilcroased from 
\'U/>\X 10 iqoH to LLla.Q ^0 Icp'-i 

that 1 last saw liX... ahvf on VA^a. t!y .-.o k/d ^ 

aiijj that death occurred, on the dali- state<l al)c)ve, af 1 oO 
. M. The CArSi' Ol" DIvATII was as follows: 



A 



X^-^-L\X3o 



I OjlI 



\JJ\^^ V , -...'rx; 



DTK AT ION )V(/y.v Months Pays Hours 



CONTKIIU'TOH 



1)1" RAT [ON ^ Years 



M,niilr 



Day 



Vj cs-'xtx^j 



occrpATiox 

h'fsiijfti ill S,!u /nun ism 




(SIGNED) U). d.MK UrvAyvvJuU. 
LL ^q X^ iq o '\ ( Ad.lress) l0$ qA^^-^Uj-K) 'jl 

cJal in 



M.D. 



SPECIAL INFORMATION "nlv tor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinq .inay from fiome. 



) '/■(// 



- Mnitli- 



I hl\. 



'■id: \m<»\i.: ST at i: I) i-kksov \i, rxuiicii. \ks aki; I'Kri". i' • rii )■; 
I'.i.sr Ol MY KN()ui,i:i)c,K AM) iu:i,n;i- 



Former or 
Usual Residence 

When W3S disease contracted, 
II not at place ol death ? 



Hou lonq at 
Place of Death ? 



Davs 



rij^XCH <»!•• H( KIAI. OK K J. .Mo\ A I. 



b.^' 



INDl 



I)\l»: of IM RIAL or KKMOVAI, 






Hvery item of inf.rmHtion should be cnrcfuMy supplie.l. ACIfi hHouIcI be Ht„te.l »iXACTLY P1IYSICIA>I8 «houlci 
state CAUSE OF DIIATH in pinin terms, thnt it m;.y be properly classified. The .Spec.al InVormHt.on for p-r- 
sons clyin^ awny from home should be iiiven in every instnnce. 



j*^ 



t ' 



■| 




li 






m 



m 



i 



I • 



l!> 



iff 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ihifr /v7r'j,..CU^aL^vA^ ^^ nJCi 



Bogistej'cd J\^o. 



1 i 58 





Deputy He 



er 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( "U. S. StanC»arC> ) 



PLACE OF DEATH: — County ofv^'^CL'^x- J ;V>Cu'>XCAA.CyC City of vJCLAV 0.\XIy>xc^AC.c 



No, liHlo 




St.; ^ Dist.;bet. \^ 



CURS AW 

OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 




ind I? 




/ \r DEATH OCCURS AWAY 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 



\JV/>^vJL4A3 







SI'.X 



DA I i < i| lilKTU 



A'.K 



PERSONAL AND STATISTICAL PARTICULARS 






iMoiilli) 



V) \ )>,/;> A 



1\ 

iDav) 



M. a, I lis Q. b 



/ is c 

fVcar) 



Pa \: 



: 1 MAkKIHI). 
W !i). i\\ KI> OK DIVoRiKr) 
'Wiili in -()ii;il (U-si^iKilioti) 



I'.IKTHPI.ACK 
(State or Couiitrv) 







NAMi: OP 

fatiii:r 



I'-lKTllI'l.Ai'K 

<»'■ iATin.:R 

'^'•'ti- or (■>)ii)itrv 



MAMU'.N NAMI- 
•" MOTHHK 



'HR IHl'LACK 
<>»• MnTUHR 
(Stat.- or Countrv) 




1 



MEDICAL CERTIFICATE OF DEATH 

DATK ol" IH-'.ATH 

IDav) 




(Year) 



I IIi:Ri;r.V C1:RTII'^V, riiat I atten<U(l .Icivasol from 

ULoun \^ i()0 H to LA.A>ca ^l * it)o S 

lliat I last saw h .'- > alive on LO^-A-Q ^! T90 \ 

and that death occurred, on the date •-tated ahove. at -^ 
vA M. Tlie CAl'Slv Ol- Dl'.A'll! was as follows: 



C/NA. 



\\.<ruj-^v 



OCCrPATlON 



^a 



KJLK^kj^^^' 



Dr RAT ION IC) )\'ays 
CONTRIIU'TOK 



Months 



Days 



i\ Ovvoci.A-0 t4rA.^^LA^X/^ LL(r'\X 



Hours 

CLL 



DIRATK/N 



)'i'ars 



Mouths 3l Pays 




0X'Vc'j\-O 



rm 



J? 



(SIGNED) 

J-^-A.o gg^iooH (Addres.) qn^ LcC<iM dt 

L Information onU lor Hospitals, In^itutlons, 



Hours 
M.D. 



SPECIA 

or Recent Residents, and persons dying anay from home. 



h'e- ■!,!,•, I ill S(! >.' / I III 



"y 



1 1 : ■,,) ,< v.. 



;. }',,/ 



M,;,fh< 



/'.■•i 



THl-: AHOVK STATl-n I'KRSONAI, I'A R TIC f I.A RS AKi: TRTK To IMl-: 

HHST Di- Mv kno\vi,];i)(;k and i!i:i,n:F 



(Info 



rtnatjt 






' X'Mrrvs 






Former or 
Usual Residence 

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



How lonq at 
PIdfe of Death? 



Transients, 



Days 



I'LACH Ol- lURIAI. OR K).Mm\-AI, 

fNDKRTAKKR fo - J • 3.>UoW ^VC 

'Address I I'i'T Nj iLoC.A-'Mrvv Ot. 



D\ri-: ot i!( ki \i. 01 ki-;Mi i\Ai. 



N. B, 



Rvcry Item of lnform„tion •hould be CBrefully supplied. AGB nhould be stated fiXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly claHsilTied. The Spec.al Information for p-r- 



staie UAUSt Uh Ut A I n in pi 

son* dyin^ away from home should be jiiven in es^ery instance. 



jTTT^ 



t 

» 
i » 



'Itl- 






' 1 




!||i 



' 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,5,„,,I . !l.:,Hh-rKO. IS^C'ir^^nS^I^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



11 



1)^ 



»i 



<:«lV.^r 






])((/(' /'V/^'^/, aXa^axIa-a^ CL?i 



IfJO\ 



Rp^isfci'rd J\^(), 



\ 1 59 




• » — ., <> jW 



DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 



n. S. Stan^arD ) 



PLACE OF DEATH: — County of 



/CL'Tv JAyo^'>v^uixio City of ^' Oyv\; 0/v.o^>^c\.<i^<r, 



L 



^ 



No. i'^'X^ 




/VNA-tVO 



St.; 



. % 



<r\,AA.^Ow and V' ^ '^ 

( IF DEATH OCCURS AW*V FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNci^R "SPECIAL INFORMATION" \ 
V IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD\5>F STREET AND NUMBER. / 



Dist.; bet. 




FULL NAME 




M',\ 



I)\ M Ml ItlKI'II 



At 



PERSONAL AND STATISTICAL PARTICULARS 

1 COI.oK 





/>\.Ol."v 





iMDiith) I 



l« 



(l):iv) (War) 



( 



■J J4,Vi> 



>I4 % 



\ 4 

r 



J 'ra I 



,1 A -»/,'//> 



■^ 



/),/ V. 



SINf.l.K. MARUIKn. 

\vii)n\vi-;i) OK niV()Rk)-;i) 

'N\;it' ill -ooial lUsij^tiatioii) 






niR IFIIM.ACK 

"^' • . .1 r<niiitrv^ 



lATiniR 



I'lKTIII'I.ArK 
Ol" 1 ArUHK 
'Sl:it< or Countiv 



M\Il»i:X NAM)-. 

•»!' m<>i-iii;k 



(State iir l".iniitr\ 



• K'crpA ^l(l^• 






> \vx,^ JuLL^wOL/^fV; 



MEDICAL CERTIFICATE OF DEATH 

IIXTI". ol' i)i:atii 



(Month) 'j 



'I>av') 



(Ycari 



I III':KI{HV CI'RTII'V, That I ;ittt.n(K-(l (Icci'asL-d fn.tii 

Uu.A^_ 'iH 190 H to y-^^ ^^'^ i^p'^ 

that I last saw lii-^v>. alive oil LL^^^n ^ ^v i(p'\ 

ami that ikath occiirrcil, 011 tlu- dali- stahMl above, at I'- 1 A 

^ M. The CAISI-: Ol" DIlAI'll was as follows: 

\w^Cr'V\/^J^A,^JL^.'^--<>--^'^^. 




^\?UL.<Crrw.f.^. ^I'wQJLrv'WXli. ^ 



1)1' RATI ON ^''li''^ Mouths ^ /\iys Hours 

e" N T K 1 1 ! (' 'H) R \' d x^Jj- t^^A^t/O^ 

)V(//'.v Mi>>it/i 

\» 11 ( 

rSlGNED) 



UrRATION 




/:>,7i 



'V 



//oil 



IS 




W<1 



, w.«.,w^ „ ^^\^ M.D 

Ll'^v-q 1? iQoM r\.l,lrcsO lObS" fcoA^vnxa.. .J4 



:a. 



Special information onlv tor Hospitdls, institutions, frdnsifnls, 
or Recent Residents, and persons dvinij dwdv Ironi fiome. 



f^/'''!iirif III '^'ii'i i 1 ,1 III i ^I'li 



)V..' 



^■.Ht/l' 



h.l\ 



I III \H(»VK ST \'n:i) I'KRSONAI, PAR Tim.ARS \R1. 1' R I }•". 
in.sT Ol- MY K NOW 1,1; IX. 1% AM) J51:I.IJ:k 



Td Tin- 



'liii'i'inaiit 




J\JULy^ 



A-^CX^'VA. 



^\(l(l 



revs 



HX'X 



v.JLAywoL^ 



'\^A.\ywAX. *.JX 



Former or 
Usual Residence 

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



Hew long at 
Place of Death ? 



Days 



ri ACH oi- inKiAi, <iK Ki;.Mit\ \i, j nAii'.ui r.riuAi, 01 ki;m(»\a:. 



J\.<y^ 



(Address.. "Ill \l VU.^^ 



N. R. 



' 1 



-Kvery Item of in?»rmHtlon «houIcl b. carefully supplied. ACK Hhould be Htnte.l EXACTLY PHYSICIANS Hhould 
state CAUSE OF DEATH in plnin terms, tbnt it mny be properly cluH«ilfled. The Special InVonuHtion Vor per- 
sons dyin^ away from home should be fciven in every instance. 



i^ 



'■\ 



1 . 



I 



'I 



ir 





rms-: 






1,^' • 



r 



N 



I' 



IP 



Ph 



I! 






I i 



% -yi 



t>l . 



I«: 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



nn;i!.! .;' 11' :iMh- »" NO- 1 "^ 



*.!; -K^:2E^. n&i'Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jhf/r FiJcd, [Xk^^^^o^^^^ X'h l'W\ 

Xc^^^cv^ \sLri^ Deputy Health Officer 



Be^isterrd J\'*o. 



11 GO 



DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 



Certificate of IDeatb 



tl. 5. StanOarC^ 



PLACE OF DEATH: — County ofUXXA^ OAXX.'A'v^\^ccCity of vJcu^O; OAXX^-^x/av^ 



, r^ <' 



p^. 



■^t- 





DCMl 



4\A.A, 



<x. 



St.; — Dist.; bet. 



and 



(' 



F deathAoccurs aw*y from usual residence give facts called for under special information 
IF oe4th occurred in a hospital or institution give its name instead of street and number. 



) 



FULL NAME 





A.'^VM 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR > 



•\ 



.oJ^ 



10 




MEDICAL CERTIFICATE OF DEATH 

i>\ it; ()I I)i; a III / 

A A I (JO 




DA . i 1 H l;!KriI 



Ai.l. 



VKjQsJX' 



'Month) 



1 "^ ):iu.- 



5 



);i\i 



Mnitlr 



/lb I 
(Vear) 



ll 



lhl^ 



-K'i.'il tksiviiali'iii) 



BlkTMlM.ArK 

(Sf:,», ,>r rnuntiv^ 



\ WW ( ti-- 




^^■ 



cL<r^-A>-^cL 




'CX.-v^- ^ 



'OwVaAJLA^lXIA 




'VX/A^A 



HIRTHIM.ArK 
Of l-ATHKK 

fSt;(tef)r Country) 



MAIDHX NAM)-: 

'>!■ M()rm;K 




(Month) 



I'J 

(Day) 



'Ytar^ 



I HI;RI':1JV eM:RTll'V. ti .t r alton.Ud dc-rr.ist-d fn.ni 

\Sj^kx\^ \'\ iQo'\ to vLvvq^ XV-v up H 



n 



that I la>t -^aw li - ' alive- on LA-Vv/O. X.'X up' . 

ami tliat fh-ath <>criirrc<l, on llu- <lal«.' stated aliovt.-. at 1 1 60 
M. Tlu- CAISF-; Ul" Dl.ATII was as follows: 



DTRATION Years Mouths H /^n.v 

CONTRIIH TORY LJkA.^tnrA-^/c. LLLllXrr^XS- 



I lours 




HIRTHPT^ACK 
OF MnrnKR 
(Stale or Conntrv') 



'Y\J 







KcrrATinx . 



h'f^iiJf.J J n Sii>i J iitiii;^i'i 




nrRATioN 

(SIG 



Years 



Mioiths 



NED ) LL^JJkA^^•' J . \j K 0-' 



/)<n'.s- 



>^OCS./^' 



't 



IIOU) s 

M.D. 



t: VmIol\y ^'^M^A- 



s, Institunons, 



/'<?) 



•II \hovi-: sTA'n; I) i-kksonai. r \k ruTLAks aki. ikik lo iiii- 

1:HST OH MY KNoWIJ-.DCH AM) HIIMIIF 



'Iiifi..,nrint 



(Address V) (>Aw/>-^ VA.AyCjK/VV^-'Crvvxi^ V^CU\. 



LvXJ -v': i«)oM (.-\<Mrc^^1 

SPECIAL INFORMATION "nlv tor Hospital 
or Recent Residents, dnd persons dvlny d^Hv froii home. 

Former or n u n r 4 y A^ How lonq at , 

Isual Residence A " - ^ \Jc^ CJX Plare ol Deatli ? ^ 

Wfien Has dise ise rontracted, 
If not at pUeot death? 



Iransients. 



Ddvs 



ri,ACK<»l Itl KIAI, <iK ki;mm\\i, 
(Address 



1) \ 1 1. of i;i 1.1 Ai. ..I K }.Mi tv \l. 



OLv 



a 



^.OL "^- A. 1 90 \ 






F.very Item oV mformation shoul.l be cnret'ully supplied. AGK should be stnted F.XACTLY. PHYSICIANS should 
Uate CAUSE OF DEATH In phim terms, that it m»y be properly claHsilfled. The * Special Intormation tor p«r- 



N. B. F.. 

state v*AU»t Uh UtA I M m pi 

son* dyin^ away ?rom home should be fciven in every instance. 



r'; 



'II 



Ll 



Hi 






m 



! n 



|i '! 



|l 



I . 



.•(^iJMvt 



irif 



)■' ' 



i 



\\ 



\n 



ii 



H 



ii • 



hi 



I ; 



I > 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Rnanl ' ( II' :iHli 1- V". i "s 



t!-?^'^ar>^-, HM' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dffir /v7r^/, (Xcvxioc^ ^3> I^^O'i 

X^rv^.^v^ blx/v-M. Deputy Health Officer 



llegi,sler('(l J\^(), 



1 iri 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( "U. S. Stan^ar^ j 



PLACE OF DEATH: — County of C'/CXax^ 0/vCL/^Ayt^^^ooCity of O^cco^ J Axx/>^.A^v>(L^e.o 
N. . V lIu. ^ ^Ka/\<Xu Ob CK-KvXolA St.; Dist.; bet. and 

A ( ir DEATH OCCi/rS AWAY FtjlOM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 

\J \ IF DEATH O^JCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME cU\aa.^ 




LooCajla.' 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OK 




U)ixc' 



1> \ i : n|- lilK ril 



.\«'. }•• 




as 



(Vf.'ir) 



MEDICAL CERTIFICATE OF DEATH 

DATl-: Ol" DllA'llI 



CL. 



fMoiitlil A 



(I);iV> 



/go \ 

(Year) 



55 



O ) 'i-ti I 



10 



}f.->!l/iy 



Vy 



/><n 



^IN'". I.K. M\KUIi:i) 
\VII)n',\i.-n (»K I)IVt)l-(i-HI) 




JHKrupi.ArK 

'Silt, ,,V (>,„,„Jp^.) 



\'\M1 n). 



niK riiri.Ai'K 



mah»i;n XAMi-- 



'*ii<rinM.ACK 

nt- MfiTHHK 
(Slnt. .,, Coiiiilrvl 



h'f'iilf:! iu San I'l ,i 






I IinRI'BV CI'.RTII-V. Th.it I Mltt'U.lc.l .Icccascd fn.ni 
LUwA^ n upH t() CAa^^. 2L1 ux)4 

tliat T last saw h-.^»v alive mi U_a.a^q_ ,k\ up i 

.iiiil tliat dcatli occurred, on ihv «lati- '^tatt-d alxivf, at ^X Ob 






'v-A_ M The CArSI- ()!• DI'ATII was as follow*^ 






2 



d^,<rv> 



<X.^' 




CONTRIIU'TOkV 



Mouths 



Hays 



\ ) t'li I •• 



\fn„tll^ 



l\l\ 



(Signed) J 



AX 



i\ r: 



Mi)nths 
r()o4 fAd.lrrss) U^Ui ^"^^ 




Pay 



//oin s 
//ours 

M.D. 



SPECIAL INFORMATION only for llbspitals, Institutions, Fransients, 
or Recent Residents, and persons dying away from fiome. 



L \i!nvi.:sTA'n:i) i-kk-^onai, 1'\r rirn.AKs AKi-: TKrK to Tin- 
"•>i oi' ^.u- kn()\vij:i).-.h and hi:mi:i-- 



flnf, 



i-iii 



'"I Uivooc^. Nl. 



(Add 



ress 



N. B. 







Usual Residence HC)'iViDA^a<i>c^>o^ 

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



\ , How long at 
M -1 Place of Death? 211 



Days 



I'LACi: ()!• lUKIAI, OR kKMo\AI, 



'Xx/w./'y\^^ 



rNDKRTAKKR 






^Address 




l>A'l'JKof liiKiAi, or R1-:M()VAI 



IQOH 




O^^xx. . 









-Kvery Item of inform»tion should be corefuiiy supplied. A(;F. should be stated EXACTLY. PHYSICIANS should 
«tnte CAUSE OF DEATH in plnin terms, that it m»y be properly classified. The "Special Information" for par- 
sons dyin^ away from home should be jtiven in every instance. 




'I 



i< . 



f ! • » 

1/ 






; 1 



5-w 

) 

r 



i 



h ; 



f 










* "^1 



J i 






f-.- 



;:i I- 



i: i 



h : 



III f 






I 



\i 



i . 



\\ I 



' ¥\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



jt,,:iv.l . t' I' I'f' >' '^■'> 



1 ;, l"«'-.^K"«ui) HSlF Co 



ncrtn iv^ cj»*\rfr\ v^r «>»fcr»iiriv>««w. r>*t» ■(««i«iaiw'wii>^t««i« 



J)f(/f' Fifed , 




\j^y<^ 




a?> 



VJO\ 



RosHNfcvcd J^''o. 



i m2 



y^ Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



'N( 



Certificate of E)eatb 

PLACE OF DEATH: — County ofO/CLoA; JyVccovcolcC City of 0/<X/"rv 0/UX.^xCA>a a<. 
lO C^ U.-Lobtx^v . St.; X Dist.;bet. (XJl<X/v-VY>JJu^t5^^ 



/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORWATit N ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N U M B E ^j / 



'V^JLCi; 



FULL NAME 




d ^i IjMi'cAj \l IM \\ ''< d A.C4.£L ■» V 



yOX 



■4- 




-l^TjT 



■± 



■'" ^ 



PERSONAL AND STATISTICAL PARTICULARS 
A I C()I,(»R 

I'.iiv rii 




^ ^ 



yKct 



■I 



M..nthi k 



a^ / ^t e H 



}V</; * 



(l)av^ 



^ '■>////' 



( S'fiii 



H 



-TJ\.N 



/•■*f*-^. 



\y\\>i '\Vi;i) OK DIVnKrKI) 

'**■"■■ ■■ i.il ilt^-iviiatinii) 



HIK riilM.ArK 
'St.it. i.r ri.miti \ 



\"\\T) Ml 

1' A I II i:k 



A 

(^ (1 



MEDICAL CERTIFICATE OF DEATH 

DA ri-; <»i- DivAiii r> 



iMotitlll A 

I III-RI-l'.V CIvRTIFV, That I atten.lo.l <lc(vase(l from 



(Day) (Year) 




Qv^ T9o4 



tf) 



that I last saw h-r*-^ alive on vAxa^Q ^'6 t..^ l 



OvSi IC)0 H 

CC 'Xcj Tip ^[ 

ami that (kath occurred, on tlie date stated ahove, at C o C) 
I 
^l^I. The CATS I- Ol* 1)1{ATH was as follows 





''•IKTlii'i, \cj,' A 

'*' > Villi; K Oft \1 

iS.t;itt' or Cunti v) W r\ 



M \!l>i;\ NAM}-- 
'•I M'TIIKK 




'tiK riii'i.AeK 

Ol- MoTilIvK 

''"^tit.- or (.•uiuiti V 



^'f iiffi/ lit Sati /;,;/;, />,■,! 






DIRA'IION ]'t'(irs Months Days^ \'^- Hours 



DIRATION 




)'ca)S 





r 



V 




Mi>ut/is /hrys 



//oin s 
M.D. 



LACA.^ X?> T()o'( (Address) I 5 I QL U XXm^V|\jU^ LI. v ■. 

SPEfelAL INFORMATION only for Hospifdis, Institutions, Transients, 
or Recent Residents, dnd persons d>inij .may from fiome. 



) V'(/ , 



M.'itlh^ 



n.i\ 



1 "''^';'>\ ». SIATi;!) l-HKs(t\Al, I'AK'ricn. AKS A K }•: TK 
'il-.^l <»|. M\_KNnWl.};i>r,H AM) Hl-I.n-IF 

0- O. VJ^JL^ 



vv. •i< » riiK 



!'■ ■ niiiit 



vxJtA.' 



' X'lchrss 



I 



\rK./ou\JkA!fc 



Former or 
Usual Residence 

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



flow long at 
Place of Oealli ? 



Days 



ri.ACK oi- niRiAi. OK ki;mo\ai. 



dLa>u<w^JJl JaDaJLIu 



DATK of HrniAi. (ji ki;Mo\Al. 

vUaxj X2» 190 'i 

(Address "i^l O 'LjlLuv "$ir. 



N. K. 



-I. very item of {nforinntion •hould be cnrefully Bupplieii. AGE should bo stated EXACTLY. PHYSICIANS should 
HtHte CAUSE OF DEATH In plain terms, that it may be properly claHHifled. The "Special information" for par- 
sons dyinft away from home should be itiven In every instance. 






I 




\ 

1 

1 



:\ 



:i: 



} 



"tX 



m- 



ii 






.1 



I'M 



W^ 



'»; Ki 



II 



\m 



n 



V 



Iv • 

IM 



Ji i 



\- 



:I|I' 



t 



t ! 



WRI 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



})n;i-.! r 11 



. altli I So. \K -S-ST^^ Hit I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ff(' FiJPtl y 



(A^Cr\.^^-^^w^ 




Xh 



I'JO'i 



Registered JYo. , 



1 1 m 



T~S .•-*-> ^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ceitificate of 2)eatb 



( H. S. Stan^arD ) 



PLACE OF DEATH: — County ofUOo^^ J^vyOLAv^^o^ccCity oiO/O^^ OAXX/vx/^^A.A.^^i^ 



No. ^LccVO^ ViD .€L\t<rvu 




0-^kd.oJ-. St.; — 



T)ist.; bet. 



and 



/ ir DCATH OCCURS AWAY 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. / 



^1 ■ 

FULL NAME JJCm\AA 




si:x 



PERSONAL AND STATISTICAL PARTICULARS 





>!• I'.IKTll 



I Moiitli) 



C^ 



^ \ Vra, 



uu. 



(Day) 



M.. tit In 




MEDICAL CERTIFICATE OF DEATH 

DATK Ol- I)I:ATH 




I go I 

(Year) 



(V«;,r) 



/)<; r.N 



SINt.I.K. MARKIKI). 
WIDnWKI) HK DIVoKiKI) 

tWritr in s(Kial flr-^i^Miiiliou) 



HIK THlM.Ari.: 
(St;it« or CoiMitrvi 




X 



Cl\ 



fatiii:k 



Hik riiri.ArK 

f'l' I ATHHK 
'Sl.ili or roniitrv 



MMDKN NAMF 
<•) MOTHKR 



III M(»THKR 
(Sta(«- or Coiintrv 



OCC 




(Month) K (Day) 

I HI;R!:1{V CI:rTIFV, That I attendcMl deooased from 

LLuvX^^Jo 190''- to LAjwA-Ol. .OnX 190 H 

that I last saw h •• aHve on VA.a»a.^ /^.l 190 S 

and that death occurred, on the date stated ahove, at VO 
Uw M. The CAISE <>F I)I':ATII was as follows: 



) /^/ W.'&.^CLAL'oJtA^i: 



rv^OL^_A„'^wv- V tr'ys^w O- 



Hours 



t^f^ldfd III \iin /'i mil iuii \ ]',tll^ ~- yfi'tltll' 



Special Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyinq away from fiome. 



Ihn 



"'l;,^'!?^'''- ^1' '^■1*1:1) I'KKSONAI. I'AKTirri.AKS AK1-: IKIl-: TO riiK 

»n.si <u- MY KN(»\vi,):i)(-.K AM) ni:iji:i- 



(Inr.inirint Ijj ,' 



^YY\J 



< \.l.lr<-ss S 'X\ 





(^u 



1 



Former or 
Usual Residence' 

Wl»en was disease contracted, 
If not at place of deatli? 




Hew lonq at 
Place of Oeatfi? 



Davs 



y.ACK OF HIKIAI, OR RKMOVAl. 




\JX.K/s>a)^ 



I NDHRTAKKR 

(Address 



Vil- v}axx>c^ ^^ \Jj 



DA TKof Hi KIAI, or RKMOVAI, 

LL0.XV '<X\ 190H 




r^ 



9 



DURATION ^''^''^ MoNl/is "X Days 

CONTRIIU'TORY J &'%Ol>\'^.'VVa-<X CAa^^ 

1)1- RATION Years .Souths Davs Hours 

n ^ ;^ 

(Signed) \x J. O/Ol/^^Uv-v , M.D. 

ULuX\ O.Xi9o'\ (A.ldrrss) IS I CJaaJUja. 3.1 






N. B. Kvery Item oj? information shoultl 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 dyin^ away from home should be £iven in svery instance. 



4 

III 



•■? 



;l 






• 



I' 



;■ 



r' 



44 



m»^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)',n:i; 



I I . ; ; ! t ll - !•■ V" 1 '^ '^'.^^ ^^^ •' *-"^' 



Kcr&n lO BmCK Or CERTiriCATE rOn i N3TnUCTiv/i^I 



f 



iij. 



f f : 

m 

It .' 



■\' 



h f- 



IpfH^ 








XZ 



locn 



Registered J\''(). 






Deputy Health Officer 



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



Ccvtificate of Bcatb 

11. S. Stan^ar^ ) 



J? ^^ , I ^ 

PLACE OF DEATH: — County ofQ-Cy^-v J Axvy>vCMiC(City of 0/CL^w J AXXa^x/cla^ <:^ 



<) 




'Cul; 



St.; 



Dist.;bet. — 



and 



/ IF DEATH OCCURS AVWAvIfROM 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 




JUy\j\^' 



PERSONAL AND STATISTICAL PARTICULARS 

C<>I,«»R 



I KIKTH 





M\ 



>+> 



V 



M.iiitlO (Davt 




OL^ 



IVCX.CLa^>4 



MEDICAL CERTIFICATE OF DEATH 

DAI'l-: Ol- Dl-.ATH 

a.o.. 

(Day) 




(Year) 



AC I- 



HS 



) I'tU - 



M.-mh^ 



(Year) 



n,i\: 



"^IN'. l.K. MARK n-; I) 

WllH .\\ 1:1) OK DIVi iKt*)-:i) 

<N\i:|i in <(»rial <lc>i>.Mialii)ii) 



(Stale iir < -MiMit rv' 



NAM I- OI.' 
lATM IK 



Hik tun. \<\- 
'»!■ J atiii.:k 

(State- .11 Ciiuiiti V 



MA!In.;x N \M)- 
*)I- MOTIII-K 



niKTHIM.ACK 
Oh MuTlIl-.K 
(Stale or Ccmntiv 







\^^y\j 




(Mouth) i\ 
I ni:Rl<:i{V CI:RT1I'V, riiat I .-ittcn.UMl (lecvased from 

LMvAwO U;o'v to LLL/A.yQ« A.D KpH 

f n '. . 

lh;it I last saw li '• > alive nn \.A^*wA-Q ^^L- lyo A 

and that (U'atli occurred, on the date slated above, at H O vj 



V.i M. The CArSI' Ol" 1)1-: ATI I was as follows 



A . ^.\ 



DIRATION )V<7; 

(.ONTRIIUTokV 



Moulhs W Days //our 

.....O.JL^.-ii.^k 




I )r RATION 



oc 



f^'''iJf,> ni Stni I'lamisrn 



H 



^ 



//ou)-s 



(Signed) lU cOIXxaj d. J JL<yv-|.Aj-. m.d. 

ll 100 H (Address) ^ I 3i UA>JI1jUm Bl. 




Special Information only l«r Hospitals, institutions, fransients, 
or Recent Residents, and persons dvini) awa> from tiome. 



Former or 
Usual Resident 



e\] I U/Y>JU) VJ /OAJ^v v.a^ pidfe of Der 



Death ? 



Days 



)'(•(/ » 



M.>titli< - f>,t\ 



' '",';,^'!V^'^'- STATi: 1) TFRsONAl. P A K T h" ( I. \ K S AKP f k • i-; f, . llli: 

'''■>' Ol- Mv K\.)\\ij.:i)(-, K, AM) in:Mi:F 



(Inf.,: 



bo.Qm ^ 



0\.^^^\^\^ <K^<^o „ < 



\.l.it-( 






When was disease (ontrarted. 
If pot at place of death ? 



ri.AOH Ol- ni"KiAi< OK kj;mo\au 



(^u OiL.^ 



INDl'lKTAK 



nxri'df jtiKiAi. (.1 ki;m()\-ai. 



T9o'\ 



A.i.h-.ss ^ HO^ O^cA^v^cU *" c5l 








N. B. — . 



F.very item of informtition fthoiihi h;.- ciirofnlly supplied. A(1B should be stnted HXACTLY. PHYSICIA>JS should 
Htatc CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
S'>n8 dyin^ nway from home should be ftiven in every instance. 



k 



n 



t 

,t . 



I 



. i L 



'd 

: ( 

W 



■ t M 



i . 



% 



\V\U 



\. 



ii' 



ife^^»^ 



■'"'^ 



m- 



l|lf 






U 






f! 



^ 



i|! 



IWI 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.MKi oTHr^ 



HS. l> Cn 



■ rrrn Tn RAr.K nr rpRTirirATr POR INSTRUCTIONS 



lutlv Filed, (Ja./.<VLA^^ /^^ 10 0\ 




Registered J^o, 1 1 65 



,v^ Deputy Health OfTlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( H. S. StanDarC* ) 



PLACE OF DEATH: — County ofO/<X^w JAx>^^A.^ui.coCity ofCV^X^v 



No. ^ C) lo dL cL^\ , \k'^>-^ 



( 



St.; H Dist.; bet.^/U.Xl/Vva/VY^Uvv and 

ir DEATH OcfcuBS AWAY FROM USUAL R E S I D E NC C G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMAT 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE 



i 



-'^•io 



N) 



FULL NAME 



O^'^rrx.' 




>AAj-CX.A^?v:\j. 



--1 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




'>! HlKfH 




iMc^iitli) 



b'^> »„,. \^ 



W' 



(Day) 



.1/- -,//// A 



\ 



, I'A-H 

(Year) 



Da 1 



MN' .1,1". M ARklKI) 

Wllit >\\l.:i> OK I)I\()krKI) 

\^;.■■ Ml v(.ci;il <k'si>.' nation) 




ItlR rilPI.ACK 
' si:iti- or (,'<nniti \ 



N WIl- OF 
»-A IIIKK 



HIKTlU'l.ACK 
Ol 1 ATIIKK 
(State or Country) 



MAn»K\ NAMF 
<•! M'lTHKK 



RiRTirrr.ArK 

<H' MnTllKR 
'St.it.- or C'(inntry) 



<1 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Month) 



'J 



XL. 

(Day) 



I go \ 

(Year) 



I IIIvRKBV CI{RTIFY, That I atteiuled deceased from 

•'.:.-■■■: 190." — ~- to IgO ■ ■" 



that I last saw h - alive on 190 "^ " 

and that death occurred, on tlie date stated above, at '. 
a: M. The CAl'SH ()!• Dl-ATII was as fallows: 



1)1" RAT ION Years 

(.ONTRIHUTORV 



Mouths 



/Jays 



Hours 







.\.«^OkjL 



"'^'"I'ATION 




<xj^n.j5^ 




DTRATION 



Years 



Mouths 



Days 



Hours 



(SIGNED) ur\.cn^Ji^^ oAij.UJ.X^ M.D. 

\Xkxj^ H rr)oH (Address) V-^\^Vu\\<) UXlv.t.X 

H i >. I " 



:dlAL IN 



Special information only for Hospitals, InsmutllJrts, Transients, 
or Recent Residents, and persons dying away from home. 






M..nflr 



/)rM. 



,:,M!'*^ *■- ^'"'^ •■»•■." I'HKSONAI. 1' AKTICn.AKS AKI-. TKrK TO TFIH 

nhsr OF Mv^^•.)\vI,):^(•,J^^ and ukmi:f 

^I'lf'iMuant 



r\.i<i 



n -^s 



-I 



Former or 
Usual Residence 

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



Hew long at 

Place of Death? Days 



1»I,ACK OI" m'RIAI. OK KHMOVAI, 



DATl^of nt RIAL or KKMOVAI, 




CrnjG iDi^A>^ 

(Address i X C) ^ \| |XA.,^<;L^^L^-^<nyv 



.X^. 



i9o'\ 



^Ka>-^;u 



N. B. F.very item o? infformation 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 psp- 
«on« dyin£ away from home should be (iven in svcry instance. 



I! 



It 






'FJ 



;|i 



i| if 



k. 



. 1 I , 

I i •« 
t « •. 
I 



I 



4; 



I 



1 .. 



\i 



l! 



•■1 



i n 



* t ■ ' 



, ft 









N 



r I 



I,; r 
1 1 ' ' 






II 



1* » 



ii|l|H^j^ 



i> 



p '.' 



, • I!, Mifh - !•" N'o. !«; '^'V.^i^'' »'f ' ^'o 



Dff/r /'VV^v/, LLL^xyLv^t; CL^ 



c*>^'CrL>cA^ c 



PERSONAL AND STATISTICAL PARTICULARS 

vl JUy-^r\.<yJLx Uj JvaXx 

I! I Kill 







REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health Officer 



liegLstei'erl J\^(). 



um 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of H)eatb 

( Xl. S. StnnC>arC> ) 
PLACE OF DEATH: — County of U/Cl/y\; AyCL/Yv.'C.i^c.l City of O/Oyvu ^v^Ciy va„-.\,><lc-0 
.. ^OL-yvLA\; St.; '1 Dist.; bet. XUAAJlA^ and jJ (rl^\>U 

( "" .°/*;tl°*''''"'^ *'~*'' ''''°'^ ^SUAL RESIDENCE GIVE facts called tor under 'special information- \ 

V IF DC^tH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



V^iLA- 



FULL NAME Vyg/v^o^di L,<u 




% 




I 



HO ,v,„,- a 



(I)av) 



M.oilh.^ 



MEDICAL CERTIFICATE OF DEATH 

DATH oi' DI'.A'III 



(Month) 



'Day) (Year) 



/ 1 Id H 

(Vear) 



'AS 



/)<M.V 



^iN' li". \t.\KRii-:i) 

W!!'i i'\ ID , ,iv' in\-, iKTI-: I) 



"-ii- Hat i. ■n I 









5F{HV CliRTlFV, That I atteiidcl doccascl from 
'1 Icp'^ to LLa^^. /XO T(p'-( 

wli ^'' alive on LA-Va^O. CV up V 

and that dtath ..ccurred, on tho date stated' al)ove, at 
31. Tlie CAlSlv OI' DI-iATII was as follows: 



1)1 RATION )\ars 

CONTRIHUTORV 



Months 



Day 



Hours 




Afou(/is 



nr RAT ION' )\uu'S 

(Signed) J. J\, kjxaXXjlIx.' 





/^ays //ours 

A^- v^ M.D. 

XX TQoH (Address) I C)^'^ U <X.UL/\v<iA.o.- n 



lt__ 

SPECIAL Information only tor Hospitdls, institutions, Transifnts 
or Recent Residents, and persons dying imay froTj fiome. • 



lu.M (,i. M^ KNOW i,i;i)c.H AM) i!i;i,ii:i- 



s AKi-: TKii-: Ti} rin-: 



<r>v 



former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



A.Mn.s. l^^^O - 15 tlv.. '&i 



I'W^CK ()]• MIKIALOK RHMOVAI. l)An.,,,f IUkiai. <„ Hl-MoVAI. 

R H ^ \rrtui><Lv<rvx dt 



'A.ldi.'ss 



•very item of inlformntion should he . jircfully supplied. MIK should he stnted KXACTLY. PHYSICIANS should 
Htnte CAIISI: OP DEATH in plnm terms, thnt it miiy he properly classified. The "Special Information" for p«p- 
'^ns dyinft nway from home should he <iiven in every instance. 



•l< 






li 



ii'i 



«: 






!#;. 






, ■« 



' \ 



\ 












r 



Uit 



h 



ft 1 



I' f '■ 
I' 



i 



; 



*. 



II 



1 1 ' 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,;.,.,,.! ■ !l '''i 1- No. ;^ c"-:_-5k;--^-. MivrCo 



(ffr /'V/^^/, UwV«w/CVuv^<iJtj 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK \ 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ItJO'i 



Bpgisto-ed JVn. 



110? 



j^ 

/v-^ Depu r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

{ "U. S. StanC>arC> ) 



PLACE OF DEATH: — County ofO/CLo^ J A>CX/Yv^\^C(City of Q/CL/ru J^^XXyy^.Al^^<i.<l.o 



urs/Tawav from usual RI 



(IF DEATH OCCURS/IaWAV FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




Dist.; bet. 

CAL 

NAI 



and 







^'1 

(Dav) 



1/..;////- 



(V.ar) 



IC 



/\! 



I go \ 

(Yt-ar) 




that I last saw h X- . . alive on 



Xjysj^iXj^ 






MEDICAL CERTIFICATE OF DEATH 

DATi-; »)!• i)i-:ATii r^ 

^Montli) K (Day) 

I in;RI{l>A' Cl-RTIFV, That I altin.kMJ .Icccased from 

Ov5 190 H to AXo^.^ l^ TQoH 

LA.AX<3 . ' Tip ', 

and that death occurred, on the date staled above, at UXO 
y ^r. The CAISI-: Ol- DI-ATII was as follows: 

1)1 RATION }V<7;-.? JA »;//// v /^<7j'.s- 

C" < ) N '1" R IP, r T R V J juJ^AJ\jqj^kXjqC \j UwdUyvvJU^.. 



.NJ ~ 



Hours 






DIRATION ^ };v7;-.? 

(Signed) J 



YVO/'^ Cu 



.4 



'-'''' 'I'-'f III V,,„ /•,,,„, /,H-„ n )■■„-;. >i 1/.. ,'///- iO /' 



CL 



A^X:^ ^C TOO 



.^foiit/is 
(Address) 




/hrvs 




ve. 



flour:; 

M.D. 




CH^Ut. 



'•'>i oi- .\n, KN(i\vi.i:i)c,}.: and i!]:i,i};i- 



O-CL/rv.v-tcx.O 



Special Information only for HHspltdls, institutions, Transients, 
or Recent Residents, and persons d\ing anay from home. 

Former or ? ) J %^^^^^^^^^^^ ''^fioH long at 

Usual Residence v^Ve4\X) 0\D frvvCiX Place of Death ? T. 

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



Days 



o rill-; 



ri, AC}-: Ol' HIRIAI. OK k}-:mo\ai 



i 






rNDl-.KTAKl-lK 

(A<lrll<"iS 




DA'I'lj..;" Hi KiAi. or Kl-'.MnXAl, 



-very item ui irilr\)rm»ition 8h«>uld be carefully supplied. M\V. hJiouUI be Htiite.l liXACTLY. PHYSICIANS Hhould 
'tHte CAlJSi: or DI-A TH in phiin terms, thjit it miiy be properly clasHificd. The "Special InyormHtion" for p«r- 
i'>n8 (l\ ini> nwnv (mm hnmo uN^ai.i.i k.. a:..... \,% ^.,..., ino^nn^o 



«ons dyJnft nwny from home should be feiven In every instnnce 



MP 



.1 



n 



' >,i 



"1. 

Id 






! 



I 



11 , 

I! 



I ■' 






'li 



, I 




JiHIt 



f^l^ i .^ ' 



' j y 



:' ( 



j. ''•} 



V 



w 



u 




'MY' 



■-s",'.'| 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



tu-F'sr&fT*; ^*^=*i:r«p "'^ '' *-" 



Dale Filed . LLuvxaAyLAi) X\ 



d^.-<yV-AA^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




(IF DEAThAoCCURS AWAVlFROM USUAL 
IF DtAmM OCCURRED IN A HOSPITAL 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK ^ . ,^ 




<I)av 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1U0\ 



Begisfcred J\^o, 



1168 



Deputy Herlth Officer 



Certificate of H)eatb 

( Xl. S. Stan^ar^ ) 

Si % . J? 



m 



PLACE OF DEATH: — County ofO/CL/YV JyV(XAXC<vXiya<: City of 0iO.yy\j J ^UDL/wCA^^yXM^ 



Dist.; bet. 



and 



RESIDENCE GIVE facts called for under "SPrCIAL INFORMATION' 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



OlVVi 



/lIH 



MEDICAL CERTIFICATE OF DEATH 

DATK ()!• DKATH 

a?) 




.i/.-»////.. 



(Vt-ar) 



/',n 



( Month ) A (Day) (Year) 

I in-iRI-RV CI'RTH^^V, That I atteiKkMl deoeased from 

'^5 1 190 I to LLva./Ql Q>.'^ igoH 

til at"! last saw h ^'- ' - wilivc on La_a.a^ vvl 



rep 



aii.l that death occurred, on the date stated above, at ?)• ^ 
LL M. /rhe CAISI- OI' DICATII was as follows: 




<:x^^j\M 



CXw>^v\ycL 



I) r RATION )Vv7/-.? 

CONTRIlilTORV 



)'t'ars 



Mo)i(hs 



/hivs 



I /ours 



^^o}lths 



U ^O^^V' v< 



1 



DT RATION 

(SIGNED) LL\i^KA,v\.' JAf iT 0- 

LLo^QX^DoH (Address) "at 



/^avs 




SPECIAL INFORMATION only for Hospltdls, Insmutions, Transients, 
or Recent Residents, and persons dying away froni home. 



i/..y////- 



'llh \It()VK STATJ-I) I'KKSONAI, I'A KrUTKAKS A K )•: TKfK To Tin- 
iil-.M «(i' \1\- KNOWI.I.DCK AM) nia.Il-.K 



Former or 
Usual Residence 



? 



HflH long at 

Place of Death? Days 



When was disease contracted, 
If pot at place of death? 



A'-vXXA^ 



■.A 



[ 



ruAci-: OI" nrRiAi. nk rj;m()\ai. 



■1, \(. J'. < >!• Ml 



rNi>i:KiAKi;K 



^AddKvs 



"^'"liof" HfHiAi. 01 kHM()\AI, 
^^^^^-^ ^% I90H 





■ • Rvery item of in?opm,ition should be cnrct'iiMy supplied. AHF. should be stnted HXACTLY. PHYSICIANS nhoulcJ 
«tate CAUSE OF DEATH in pinin terniH, thnt it mjiy i»e properly classified. The "Special Information** for pwr- 
?on» dyin(l away from home Khoiild be Jii^en in every instance. 



Tfemiia 



i»«pi# 



w 



l! 






•I I 



I 



m 



•A\ 



. I 



» 



r 



I i 



u 




it^mmrmi^i'mi^- 



~ 



fT" 



I' 






* 



• 1 '*' 



! 






:!< 



^^: 



M. 



1 



BMMHn 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I, ,,,1,1, 1 Vn :: f-'-i^'se^^.USiVCi, 



Dnlr nird , IXo^vvxit; X\ 100\ 



t\.K.^^ dsjiAj-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eath 

( X\. S. StauDarD ) 
PLACE OF DEATH: — County of Cj,CL vw OA,<vwtv^r.<<;ity of 0<Xaaj AxX/>A./CAj<i,o,t. 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



IdJxJ:. 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



llegistci'ed J\'*o. 



1169 



St 



Dist«; bet — and 



/ lA DEATH OCCURS AWA^ TROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\ 
V U "" DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



XAJi.tr>Aj 






n,n 




MEDICAL CERTIFICATE OF DEATH 

DATK oi' I)i:.\Tll r\ 

(Month) A (Day) 

I m<:kl-:nV CJ-RTII-V, That I attendcMl (leroased from 



(Yen) 



vAaa/o ^^ 190H 




^'X 190 H 



that I last saw li *- » > ^ alive on KJ^-XXj^ 'X'^^ i(p 'H 

and that death occurred, on the date statecrabove, at *" 
M. The LWrSlv OI- Dl-ATII was as follows: 






\ 



-CXi 



T)r RATION 



) 't'ars 



Montha 




"u A<Cr\>s^tJk. 



Pays 



Hours 



DI'RATION 
(SIGNED ) 




^.^CA.A.^orV'X 



fUb-' 



V/tx^..<r\.^'Vw\4 



Pavs 



.\.^C^VvX 



VAy>^'X<XA-VO0u 



^ f^'iiied ill Sail /"; ,n/, /.',•,> ^ )V,7/> D M.»ifh< \ 



/)<7I. 



""pvJ'p'Y '5^''"^ '■'■■'* ''HKSONAI, 1"\K rirri.\KS AKi; i-Kl 1-: TO 




. 0. cxXoHoit/Cr^^ 



Xh\i)C>\ (Address) 1^)1(0 0/CL-V\; 



U /CL.'V\; ML14A. 



//ours 



M.D. 



SPECWL Information onl> for Hospltdls, institutions, Transients, 
or Recent Residents, and persons dy'-tg awdv from fiome. 



Former or u 1 1 ) -f M ""** '»"•> ^f r, 

Usual Residence i ^ ^ U.O^AXw\. KkA^L Place of Death ? A 



place 



IAaaaLv/v\ 



Days 

1 



vnv. 



ri.Acy-: oi' iukiai. ok kj:mo\ai< 
'OjuL/vvv 



DA^Jlot HiKiAr. or KKMOVAJ, 

^H 190H 




rXDl'.K'rAKI'.K 

(Address 






-r.very Item otf information shoul*! b^- caret'iilly supplied. AdB should be stated BXACTLY. PHYSICIANS nhould 
state CAUSE OF DEATH in plain terms, tbat it may be properly classilficd. The "Special Information" for per- 
sons dying away from home should be feiven in every Instance. 



m^ 



.i 



i\ 






:'.!i 



:i 



f 



I';' 



'!| 



J* 



In*' 



■I 



- \ 



-\ ^jlU'. 



■^S^^^^^ 



■■HM 






Si 






\ < 



> t 






'ii 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,.,,,,,1 , f ll,.,ltl> I- No. i> -rt-fi^-^iiH&PCo 



REFER TO BACK OK ctHFiKiCArt run ir^a i nuo i iu«^» 



I)(f/r Filed , 



(y\^>^y\.y^-\y^ 




an 



ioo\ 



Reglsferrd JS^o, 



1170 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Vi. S. StanJ>ar^ » 



(^ 



PLACE OF DEATH: — County of ^<X/Vu AxXAAAMi,£(City of C)<X/~.^ 0^<X/>xa^c<^^o 



(ir DEATH OCCURS »W*V FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATION" "\ 
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




Cr 




PERSONAL AND STATISTICAL PARTICULARS 

!>A1 I', (II- lilKTIl 




(Mouth) 



\ ' . }•; 



o 



) '(■(/ 1 



( D.^v) 



M.»i//i^ 



rlSH 

(Year) 



A; 1 . 



^^IN<.I,K. MARKIKI). 
WIDOUKI) OK I)]VnKvi:i) 
'Writf ill s<Ki;il (U•>^i^.•Il;ltil)^) 



lUK riii'i, \('i.: 

' St.'itt (ir Ci)iiiitr\i 



-^^^^vj^<L 



namj: oi- 
iatmi;r 



iiik riiiM.AOF. 

<>|- |-ATIIHk 
Sliilc (It (.'oinitrvi 



MMI>i:\ NAMl 
'" MnTin-:K 



niKriiiT^ArK 

Of' MoTHHK 
(Slatf or Couutrv) 




.U<5VMX^^X/W<u 



\J 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DIvATH /^ 

U-VaX^ 0x1)., /9o'\ 

(Month) /| (Day) (Yt-ar) 

I HIvKlUiV ClvRTII'V, That I attendtMl (Icicascd from 

LLuux '^'^^ 190 H to ^olLl 

that I last saw h - '^ alive on vAa.\X5 ^^ I90 i 

and that death occurred, on the date stated above, at b oO 
J M. The CArSl^M)F DIvATH was as follows: 



KpH 



Dr RATION 
CONTRIIU" 



) lar. 



Moutin 1' Days ^^ //ours 
\.XX>v/cL\,/(Xa: d,.<OL<wLs-v>sJC 



Xxx) 



r\ 




Ou 




CuVcOj 




diration 
( Signed ) 



Vi'iirs 



M<^nt/is 



Pays 




oc 



X^oJLu 



^caov) 






La^a^' 



,\.XXA<-.iA.' 



//ours 
M.D. 



:)oM (Ad<lress 

SPECIAL Information only for Hospitals, Institution^ Irdnsients, 



Q.'^IQOM (Ad<lress) (o 1'^ U <:5U 



[(iiiAL In 




or Recent Residents, and persons dying away from liomc. 



^ .\!.>>itl,^ 



/><! 1. 



1U-,SI '>' -^JY KN<)\Vl,i;i)C. H AM) Hi:i,Ii:i- 



Former or 
Usual Residence 

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



Now long at 
Place of Deatli? 



Days 



ri.ACI-, Of- lURIAI. OK Kl'MOVAI, 




^ 



CXy>^ 



OA'I'Kof IJiKiAl, or K1':Mo\AI, 






t ; 



T90'\ 






Kvery Item of inform»ition should be cnrct'ully supplieil. WA. shoiiltl be stntecl F.XACTLY. PHYSICIANS hHouIcI 
state C.AUSt: OP DTA TH in phiin terms, thnt it miiy be properly claHHik'ieil. The "SpecinI Information'' for p«r- 
«ons dyinjl n\*ay from home Nhould be fciven in every instance. 



!; 









il 



\ i 



I 



•"Vttfi 



mm^- 






', t 



im 



ft' '. iki.' 



1 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



, . ; ! 1 . . i i I h 



V ' 



'."*?• 5!*.'A'«^«! Hoi 



r Co 



H tr en I *«» t3MV-r\ \JT N.. u n I 1 r i v^« i t_ i 



^f II I t « ^ f i:^^^^! i^^i 



/><'^/r Filed , \j\XA,X)u\juAi IH 



/,9/^;H 



FiCilLslci'C.d' 'Xo, 



117i 



I 



t_. 




Deputy Health Officer 



I DEPARTMENT OFTUBLIC HEALTH==City and County of San Francisco 



Certificate of Beatb 



% 



PLACE OF DEATH: — County ofC'CL^^ AXXaoX^a^^lCa: City of CJ/CX/yv >J/UXA/x^v<iX^o 



'J 



No. b 





St.; 3^ Dist.; bet. 




(IF Dl 
IF 



SPI 



and 



EATH OCCURS Av/ftY FROM USUAL R E S 1 D E N C E G I V E FACTS CALLED FOR UNDER SPBtlAL INFORMATION 
DEATH OCCURpip IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 




\ 



vl.. 



X\ 



) 



FULL NAME 



• i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



C01,( »K 




Mrvo-w.' 






Kill 






\^ .V: 



<1\T 



cxJU. 'i I 



N!..mli 



)V,/, 



I);i\i 



\ • ,11 



I M \ I-; I- 1 1 I ) 



I;' !• I'lllM. \ ,• !' 
•'i^iic or '.'' mill I \-^ 



!• \Tm;K 



lUKTllPI. \. !•: 

'"■ 1 \rin-.K 

->t.it< or (.'((luilrv^ 



".' Mi>Tili;K 



''•nrnii'i,.\cK 

I'oiinti \ ? 







MEDICAL CERTIFICATE OF DEATH 

DATl-: (II" 1)I;A'III r\ 

iM'Mltll* K il):iv> iVriirl 

I II i;k!';i'\' ci:rtii* V, rii.tt i aucniid d^c asr.i (t,,m 

~" 1 1/) to ~ i()n 

lli;it I last saw li " alive on i(;o ■" ' 

and that <lfalli occurred, on the dale slated ali<i\-e, at 



M. The CAISI-: OI" I)I:a ril.was as foil. .us 







T)''R.\'ri(1N Yrars 



CoNTRUU'iOUV 



Mouth> 



Haxs 



I lout 



( Signed ) uAxrwtx 0.^0 iJO dOuLoL/\v<JL 

-COll i.,o'\ (' \ddnss) Wv^Ovil^ UlL.^ 

SPECiJAL iNFORrVIATION on!\ for Hospitals, InstitiitiVnV, Transients, 
or Reicnt ResidiMils, dnd ppisons dvimj ,ri*.iy Iron home. 



[L. 



//(>//rs 

r/i.D. 



IV 



.^r•>l'/,■ 



III! AliOVK ST ATI-: !) I' l-" R >^( >N A 1. I'ARinTl, \RS ARI' T R I !. l'- < Till 
I'.i;ST <)1- MY K.NDW l,l.;iK'.K AM) !!I".I,I1:f 



IiirMunant 



x<rX.<rvuuvA 



. ©||.^ 



(AiMri's^ 



Former or 
L'suril ReMdencp 

Wfirn wds diserfse (ontr.iitrd, 
If not a! pldi e of di'.ith .' . 



How lonq a\ 
Pl.j( e of Dfdth ? 



Dd\s 



PI„\cp: I II |;[ r : > I 



CL^wV- A-V. A wU U .CxOs. 



s I 



nvri';..!' nriMAi. .,i ri:m()\ai. 






I \\<: )-, I \ 1. i 






TQOH 



!\. B. livery item of In^irmntion shoiihl h.- cnrofiilly supplied. MJC Hhoiild ho stjiteil EXACTLY. PHYSICIANS should 

stntc CAUSE OP DLA JH in plsiin terms, that it mjiy Ik- properly cIjihsU' icd. The "Spccinl Informnlion" for p«r- 
Kons tlyinft nway from homo should he Jiixen in every instnnce. 




I 1'^ 



1 « t i ; 



J ■, 






I 
^ I 



i i 




■!#*•' 






'^■'^\1 



" "^^t fit 






i 



S ' 



\yf 




I*' 



r; 



I f 



I 



s-l 



"t^ 



^Sl 



ti » 
I 



■m^ WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ll<:ilth VSn. !> -*'i:^i;ii^ i''^ '' ^ " 






Dftfi' tiled J 



C\.<J-V^->^^-^ 




an 



7.9^4 



JfcQ'i.s/crcd Xo. 



il7S 



Deputy Health Oflficer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( *a. S. Stan^arD ) 

PLACE OF DEATH: — County of C' /CX^nj AX>^/v^A>ui/CfCity of O/CL/Tu AXX/vs^C^oft.^c^ 




No. I C) 0,5. UXoJj-Ol/y>vOu (.-'VjUOA.) St.; 5" Dist.;bct. 11 rWcL and IS Axi 

f IF Dr*TH OCCURS AWAY 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 



<i:x 



:'\ 1 1-; Ml lUK Til 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



XJ^S\jOJj 




^ 



'XjJ\yy\j^ 







M<.nll\ 



(I):iv) 



At.K 



) I'll I 



M.»i///< 



I V.-ai ) 



/'(M. 



-i\< l,l". MAKUIKU. 

W IlKtWKI) OK DIVORCKl) 

Wiitriii <i)ci;il <U>^i j.'iKitioii ) 



0>L/v\.XVVJL 



inKTm'i.AOH 

-■t;iir or t'Diintrvi 



\ \M1-' oi- 
1 ATin-.R 



iilk llll'LACK 
<>!• FAIUKK 

'St.iic or Comitrv) 



MAlDlvN NAMK 
t)F MO I'll KR 



1{IKTHPI,ACK 
oi' MOTHKK 
fSiatf or Conutrv 



J? (^ ft 



U (SI 



XAJx^^n^ 



6 



m 



m 



/<Xyy\j Kj Ax>^^y\j:ia^<lai^ 




OTU 



'O^jyxj A>cu''w/^.^wAx:^ 



OCCUPATION 



MEDICAL CERTIFICATE OF DEATH 
DATK Ol' DKATH O 

(Month) (T (Day) (Year) 

1 m<:Rl';i}V CI':RT[FV, riiat I attended .leccasc.l from 

LLu^O %\ up'\ to .. LLaAXU 1.^. ic)o\ 

tliat I last saw h <^ ■ > alive on LAvAa^<X. ^^ 190 'i 

aiul that death occurred, on the (hite stated above, at vc 5^^ 
\} M. The CAlSlv Ol- Dl-ATII was as follows: 



Dr RATI ON )\'(irs Mo>ii/is Days I/ours 
CONTRIIU'TORV \Xo.xAX ^ 'CX..AA>uo 



nrRATiox 



)'t'a)S 




( Signed ). (I VDAA./yk Axx.>cyo^> 

W rqoH (Address) Ib'^^ d\00-UMX>v<Lc3± 



Mouths Pays Hours 

M.D. 




Special information only for Hospitals, Instilutions, Transients, 
or Recent Residents, and persons d>lny anay from home. 



AV 



^idrd ill Sdv /'i iiin i>ii> O )'riji\ "^ .^/mif/zs I O / Ki 



I'lII-". A!U)VK STATl'l) 1M<:K<.<>N \1, TA K T If r I. \ K S A K 1 : rRll". I' t 111 I-] 

ii};sT oi- Mv KNOW!,): DC, J.; AM) hi:mi".f 



'Itiforniaiit 



-A-AJV-vA^ 






Former or 
Usual Residence 

Wfien v^ds disease contracted, 
If not at place of death ? 



HoH long at 
Plare of Death ? 



Days 



i;|^ACl-: til' lUKIAI, OR Kl-:MnVAF. I DAI'l-iof IUkiai. or Rl^MOVAI, 



IN I 



> 1 •: R T A K v. R O O^-vxX-.^aJL/ v; -^ -\.<i-<V 



N. B.- 



-F.very item nt inform.ition shoultl »>l' cjirer'iilly Huppliecl. AGE should he statetl EXACTLY. PHYSICIANS fihould 
«tate CAUSE OF DEATH in plain terms, that it may he properly claBsified. The "Special in?ormation" ?or per- 
sons dyin|^ away from home should he i^iven in every instance. 



• • ' .' <<■ 



i i ! 






* *i 
1 



itr 



; « : . 



^•1 
' 'I 



I ■ 



-"' 



)! 



' i 



li- 






lit 



'^ 



' '' ?^' •.-„ ";.! 



;i 



'-: 



* 



WRITE PLAINLY WITH UNFADING INK 



!?,-•.! .iT 






.. *.**-r"5:.-. us, I. 



<v> 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Duh' nii^d, lA^AXiAA^ an I'^o'i 

Deputy Health Officer 



Registered J\'*o, 



1173 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)catb 

( "a. S. StauDavO ) 

J? ^ -^ 



% 



PLACE OF DEATH: — County of 



C)<X/Vu A/XAVC^oCLC^ City of O/CL/ru KA^^yy^j^iA^^^L 



No. 




cLou\)^vcu 



HTl JjJUL) St.; ^ Dist.;bct/-^ OUX/\)-v<Jj and 

/ IF DEATH OCCURS AWAY 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. / 




^Y\^.' ) 



FULL NAME 




\yr\) 



PERSONAL AND STATISTICAL PARTICULARS 



-1 \ 




COI.OR 





H I'.lKl'll 




a^aXa 



\' ■)■. 



\xxyy\j 



(Day) (Vt-ar) 



Ti 



).,i 



1 



M.nilli^ 



w 



r>,t 1 .V 



^iNt.i.K M \KKn-:i) 

WIIx iW I-I) UK 1)I\( >R(i:i) 
• •\i\\ (k»iij.'n;it ion) 



I 




>uJL 



^Cruj- 



-Ov/WV/CXyW<. 




HIKrHPI.AOH 

^i:!'« or Coniitry 



NAM}'. OJ- 

FATin:K 



ItlRTMlM.ArK 
')I" KATHKR 
'State or Conntrv 



Nt \n>i:N namj: 

<•! MOTIIKK 



I'-Ikrui'LACK 
'•! MOT! IKK 
Statf ..r Cotiiitrv 



orrfi'ATioN 

AVv/(/r--/ /,/ S,;>' / 1,111.1 1,1 I )V(M > 



(J XKyVwXXo vu 




MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 





^Month) A 'Day) (Year) 

•Rl'iHV CI:RTIFY, That I aUciuUtl (Icccased from 

'bo loo \ to LLsA/a XH 



I90 



\X»wA.A_ 



i(p H 



that f last sa\v h -^?^ alive on VJ^AwA^O. 'X*?.' Kp i. 

and that death occurred, on the date stated above, at 
•' M. The CArSl- ()!• DI-.ATII was as follows: 



DIKATION Years O Mouths I Days Hours 

C'ONTRNU TORY 



DIRATION 



)'cars 



(SIGNED ) vjrux/Y d 



Mouths 



Pays 



I lours 
M.D. 



M„>ilh^ 



n,!\ 



I'm, AliOVl-: STATi: I) PKKSoNAI, I'AK lUri.AKS AKi; IKri-: To I" III-: 
in:ST OI- >4N' K\(>UI,1|.I)C. K AM) \\yA,\V.V 



A<ldn-.s \\ \ J 




)t 




'\ I 



\ i<,oH i 



Addriss) ^IH U-<^^JliA>v "ot 



SPEOIAL Information «nly for Hospitals, institutions. Transients, 
or Recent Residents, jnd persons dying .may troni home. 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of deatfi ? 



How lonq at 
Place of Death ? 



Days 




11- lURIAI. OR RI-:M(i\AI, j OAl'lLo! IJiKiAl, or KlCMoVAI, 

jISUn^-^H ' ^^^^ ^<" '90S 



^•Vdilrc'ss 



N. K.- 



-Bvery item of Information should be cnrcfully Hupplioil. AGB should he stated RXACTLY. 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 feiven in every instance. 




^#1^ \ 



•^ 



i 1 %l 






^•>! 



• i 

Ml 



\^'- t' 
) - 



\:\' 



J ' < 



i :| 



« 



l! 



i! 






=t 



'-^sm 



'•»'K^ 






1 



( 



<i 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



! ! or HeHttTT— T ?<w. t> -^ 



Ihth' Filod , 




V:i 100\ 

Deputy Health Officer 



Be^istcved M'o. 



1174 



No. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "U. S. 5tanC»arO ) 

J? op -^ ^ 

PLACE OF DEATH: — County ofO/O/-.^ ,rvciywt<ACcCity of^'-CX/w. OAXXy%-viLvA.C'0 
^■\o5 LILo^ St.; "l Dist.;bet. cLaX^*^\.O.i and ^A^UX^vO/^ 

/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR Ur*i)ER "SPECIAL INFORMATION- ^ 
( Tf DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTE*<JoF STREET AND NUMBER. ) 



FULL NAME 




'VCXA-^Aj 




Kjy\Sj 



PERSONAL AND STATISTICAL PARTICULARS 



111. 



COI 



Ol/V 



DAT I". (II ItlRTIi 



\<.K 




KxAj 



'"' loivju 



M.iiini 



^ 



) ra> 



H 



b 

(Uav) 



M. mills 



'Vt-ar) 



Da r.v 



-^IM.l.l'".. M\kKn:i) 
WinnWl- 1> (tU I)IVnKvi:i) 

Wiitciii "-iK'ial (l«sij.Miati<in ) 



lilKrill'I.M'K 
StMtc <ir C'nuitrv) 







lATIl Ilk 



HIRTHri.ACK 
')|- 1 XTIIl'lR 



MAIDJ-.N NAMl, 
<»I MOTIIKK 




-vu^^ 



t 






MEDICAL CERTIFICATE OF DEATH 
DATK f)F DKATH 




• Day) 



IQO '1 
(Year) 



fMontli) 
i lIl'RlCr.V Cl'RTII'A', That I attciKkMl deceased from 

' 'V up H 




Ha-^JLu '*^ iQo'A to 

'' Q • • n 

thAt I last saw h-t/>n alive on ^^^v-v-O 

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

Ll :Nr. The CAT SI*; Ol- I)i:.\TlI was as follows 



CI 



Wxrw^^w'CL 



% 



J.JiU'^.AX^tiJi- 



Crv dtjuxhjb 






Dr RAT ION Years Months ^ Days 

CONTRIIU'TORV ^ciJL^::vA^<X/ .c4 .A^■V.^,^:!^ 
P 4- ■ ^ 



Hours 



DIRATION 



)'iars 



Months 



Pays 




lUKrui'I.ACK 
OF MOTUIvk 
(Stale or Comitrv) 



OCCTPATloxAo- f) \ 



AVa',/^,' /;/ S',;;/ /'i (1 Ih ism 



) 'riU s 



Mn„lll 



n,i\ 



i'lll'. \Ho\I*. ST \1")',I) I'KK'-nNAl, I'ARl " T 1. A R S A K l. 1" R r l'. l* » 111)-: 
lUvST ()!• MV KN<>\VI,i:i)C,H AM) lU-.MI-.l- 



'lllfiiMlKltit 



V^-N \_X 






(Signed) i]\^X/y^j^ ^-^^Jo^y^yy-^-^Y^ 

IHiQoH (Address) S lO VJoiil dt 




Hours 

M.D. 



Special information only for Hospitals, Institutions, Transients, 
or Rfcent Residents, and persons dying away from liomr. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



i)\ri;o! lu KiAi. oi ki-;m(>\\i. 



I'LACi-: »>»• lUKiAi, (Ik ri:mi»\ai, 

ten cr\ f 



^Xddifss 



1 



N. K. 



-livery item otf inVormation shniild h.- csirct'ully Hiipplieil. A'lfi shoiihl he stiite«l FiXACTLY. PHYSICIANS lihould 
HtHtc CAlISn OF DEATH in plnin terms, that it miiy l>e properly clussiTied. The "Special Information" for p«r- 
Rons (iyin^ away from home shoiilti he ijiiven in every instance. 




i_t:» 



' » 1 



r 



la 11 



\ • 



■tl 



»4' 



y 



V 



. '.1: 

% 



til. 
I 



ill 



.' I 




iMU: 



#*^r*^' 



••*; 



^: 






■i 



il^ 



* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•n*' 



f TT^ntrh^i^^o I V ^^^22'.^^ "*^ •' *• '^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1 '^ 



Rrgisfci'cd A>>. 



1J75 



/VKo Deputy Health Officer 

DEPARTMENT OF ^BLIC HEALTH=City and County of San Francisco 



AVA>V^ 



Ccvtiticate of H)cath 

SI (^ Si 



(^ 



PLACE OF DEATH: — County ofOcu'^'\j O.^CX^^VO^CcCity of O/OlaO; O^V<X/%A.'e.c<L'C-<:) 
No. Illio 3^(rv^'vlv'a.\,cL St.; 1 Dist.;bet. cL<XX.k,c^^ and V) CnJ\ 

(ir DCATM OCCURS *W*V FROM 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. / 

a, L^iJl, 



FULL NAME 



.ly^L 



v^ 




sj:\ 



i> \ ri-; oj inK III 



\ - . I-: 



PERSONAL AND. STATISTICAL PARTICULARS 



<x.L 










'Day) 



/ L 



SO. 



•-INt.I.}". MAKkli: I). 
U IlXtW Kl) OK I)l\< »K» I I) 
Wiitt ill v.HJal ilioivnatiMii) 



' State or (.■oiiiitrj) 



NAMl-. ni 

» ATin;R 



inKTlll'I.AvK 
<)!• lATMKR 

'Stat.' or Coiintrvl 



MAIDKN" NAMK 
»M- MOTHKK 



lURTHPr.ACK 
<>!• MoTHHK 
'Statf or Countrv) 




I Year* 



/>,n 



MEDICAL CERTIFICATE OF DEATH 
DATK ()!• DKATH :'~\ 

11 



(Month) jf (Day) 

L m-RIvHV Cl-RTII'V, Tliat I attcii.kMl dccoasctl fnui 



(Year) 



LLc^C^ iS i^H to Uv-CCQ 11 



(T 



.'Mid that <lcatli <>cciirrc<l, on the date stated above, at 



that I last saw h ^• alive on 



a. 



M. The CAlSIv ()!• DI-ATII was as (ollnNvs: 






vA^Lgla v<L 



1)1 RATION y'ciirs Moniln Days I /ours 



•^ "^ IJ'A IIDN /7) 




X. 



<x>x^>cL 




h'fsiiiftt ill Stin /'i tiihi.^fo lO )',,ii< 



diratiox 
(Signed ) 

a 




}'cars „ lo Months 



\ 



Havs 



L 



0-K.^ti\.' 



■X 



K^KJX X'h iQoH ''(Address)HSb Vl ll^n^o^A ^. It 



I Ion IS 

M.D. 



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



M.niili^ 



Former or 
L'sual Residence 

Wtien was disease contracted, 
If not at place of deatli ? 



H«w long at 
Place of Oeatli ? 



Days 



TIIK AHOVH STA'n:i) I'KksoxAl. I' \ k f U t I. \ K » \ K 1- IKl l- T< » llil- 

in-,si (»i MY KN.iw i,!;i).;k wd iu-:i.ii:k 



niif.iMuatit 





V-^^IjlaX^ 



''\'Mn-;s I'X'X^ 




it 



n.\(,i;ni lUkiAi, Ok rkm<»\ \i. 



\A^ c 



DX^J-o! ItMMAl. oi Ki;.M»i\AI, 
'^5 I QO " \ 




(Ad.ltfss IS 1H OJwO-^^td^v OI 



N. B.- 



-Kvery item of inforniHtion fihoulii b- ciircitully supplied. AfiF. sMould be stated fiX \CTLY. PHYSICIANS should 
state CAUSE OF DEATH in phiin terms, tluit it miiy he properly classified. The "Special InformHtion" for pwr- 
8on« dyin£ away from homo should be ^ivcn in every instance. 










I 



■■ !' 






1 T4-I 



,ih 



ji^ 



: \ 



ICJ. 



>-^*^ 



'^>M»fl. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



»**jr^j 



'/. ..o 



i; (TTt nfTfcHitii- r' No ^ ^ ~ '^,,Z-',i~*' "^"^ 



HK,ht.n lu »Mv;r\ ui- vjtH iimca r& kum insihuctions 






It 

t 






lutlc Filed, (Xu.a/L^t XH ^^6>H lie gi sieved J\'o, 1176 

Xo-c^.^^ Xii^vo Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of 5)eatb 

1 11. 5. StanDarD j 
PLACE OF DEATH: — County of 0/Ct^ro J^UXAVtAjH^c^-City ofO'CU'-ru Z J-^^<xyy\^:i,Kj^'r^Ai 



No. 1 IS 



( 



St.; S Dist.; bet. 



IF orykTM OCCURS AWAY FROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNO 
irlptATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 




and Ua^Lola;'VO,< 



'special INFORMATION" N 
ITREET AND NUMBER. / 



FULL NAME 



sd^jo 



\i 



PERSONAL AND STATISTICAL PARTICULARS 




!' 



A«,K 



I HI Kill 




Month 



1^ 



) 



II 



'T 
(Dav) 



M.nith' 






I / 



Vi'iir) 



/'„'■ 





'^IX'.I.I" MAkUn-.I) 

w n>o\\i.:i) OK iM\< »Ki}:i) 

'Viitc ill MM-i;il <lfvij.'ii;iti(iii) 



iMirnii'i, \i-)- 

' St:iti or t.'iiiinti \ 



1 



WMl' (>I 
I* AT HICK 



IWk I lll'l. A,).- 
<>l" lAllll.R 
Statf or (."ouiili \ 



"•I MOTMI-'.K 



inkruiT.ACK 
<>i' M<)Tm<:K 

(St:il< or roiinlrv^ 



I r AT ION- 




MEDICAL CERTIFICATE OF DEATH 

DATK (»l- I)I;aT11 /O 

(Month) /\ (Day) (Year) 

I HI'RI-HV CllkTIFV, Tliat I attended decoased from 

LLu^. X'h 190 i to \Aa-v^ X!i. i<pH 

tliat I las't saw h-O^^x alive on vJwAa.-Oi A?> y,p \ 

and that death ocenrred, on the date stated above, at VD • O 
Vj M. The C.\rSl<M)l- DliATII Nvas as follows: 



Dlk.ATION Years 

CONTRIIU'TORV 




Months Pays 

DrK.ATIO.X Years Mouths Pays 

(Signed ).m/A'vxju 0. Vjaju^Julm 



Hours 



flours 




V\ iqoH (A.ldress) ^Ob O.A^U:ijLAj ot 



M.D. 



VJ (y\jfcjL>u 



/^iilrif III Sail /'i nil, iK,(> Ao )'i(}i 



}h>ii/hs 



Den 



SPECIAL 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 lonq at 
Place of Death ? 



Days 



nil- \1{()VK STATKI) PKRSONAI, I'AKTICrUAKS AKI-: TKIH TO Til)-; 

'n-.M oi.- Mv KNo\vi,i:i)c.H AM) mi:mi-:i' 



I'lf'iniiaiit 



lis M /o^y. Ot 



^X.Mr^Ks 



I'l.ALi-, OI- in 



OvCyAi,/QL. 



JM^\CK <M- lUKIAI, OK KI-:MoVAI. I DAD'ol Miki.ai. or HI;Mo\AI, 

\l rLa.x>.v<}.y^ Uc. 



(.Ad. 



• •*• Kvery item of Information should be cnreV'ully «upplieci. AGhi should he stated RXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for per- 
sons dyin& away from home should be ftiven in every instance. 




it 



r';3 



U.. 



: 



li 



j-i 



■ »■ 



I • 



! t 



t, 






• ■ 



II 



! '■ i 



il 



1 



.; 



J ' I !i\ 



! 



1( •• 



''W< 



% 



I 



>'>«H^ 



li 






^U 



h*', ,i. 



R,'.. 



Kj'^'if" ' 



j-^ 



:-■; ;^( 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



'I II t-«t II'' 



'<,»- ,-, J*fcffr%n.5L: 



II V- I> I • 



iprc-D -r/^ BAr>u <-»e r^eoTtcm atf eno i m qtoi i^ti/^m< 



/iii/i- Filed , 





X\ 



190\ 



liegisfcred JVo. 



1177 



^x^j^^K^ ckji/v-i^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Bcatb 



( *U. S. StanOarO ) 



4 



% 



PLACE OF DEATH: — County of 0/CXyvu J^uxoo/CUi^C^ City o{0,0<yy\) A.CUtxx:\.xl^c 



No. 



150^ 




(^ 



fs 




.^XA^VvvAW St/, "). Dht.; bet. U /CLCVOLA^^ilA'vU and 

(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N " N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




FULL NAME 




Aju 




XXy^rx.'TlyO 



PERSONAL AND STATISTICAL PARTICULARS 

i:\ ()r\ ^ \ coi.oK 



1' • ' 1 ' >1' 111 Kill 



oJuL 




K^tx 




Muiitli) 



\' .1-: 



X\ 



)>,/<- 



5 






M.>tilh 



(V.-.'ir) 



/^MA 



■-IM.I.i:. MARK li:i) 

\vii)(t\yi:i) OK DivoRiKn 



lUK ruiM.Ai"}-: 

' St;if(.- or Coinitrvi 



N \M1- ol 
I Ain j;k 



HIK llll'LAiK 

'»' I \iin:R 

--t It' Ml rMMiiti\' 



MAIl>l-.\- NAM1-, 
"1 MoTHHk 



llIK'lHIM.ArF 

<»» MoTin;k 

'Stalf or Coiuitrv* 




\ (lit) 



190 \ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATi-: Ol- i)i;ath r\ 

^Month) A* <I):iv) 

I lU'iRl'J'.V C1;RT1!<V. That I attondc.l (leot'ascd from 

I Ic/d'\ to O^AA/V XH. i()oH 

that I hist sViw h -'-^o aHvc on vAA-^V-^ 3. H up . 

atid that death occurred, on the ihite stated above, at \'X^ 
LX ^I. The CArSl-: OI- I)I:AT11 was as follows: 
AAXM-N./e^jJLeH3.Au> U AAX/YVV/CrvV-Ow^A, , 




K.<X^ 





I >r RATION \ Years 
CONTRIIU'TORV SrW. 



,:vaX 



Da \s 



Hours 



DTRATK^N 



cars 



Months 



Pays 



oJlLuL 



^i^^^/W'C.Ou-,-- 




O^^^^-^CtA-AAaj 



• '^HTPA'I'ION 

fyrsidrd in Sim i'l tin, i^fit ^^ \ )V,;;> 




(SIGNED ) 

LLl^'Q iHiqoH (Address) 

:ilAL Information only for Hospltdls, institutions, Transle 



SPEC 

or Recent Residents, and persons dying away from home 



lelits, 



\r,uiU- 



/',,i < 



Tin: AHoVl*. STAri-D I'KRsoNAI. r\R llil I \Rx AR )• !' R T }•; li » 111 1! 

iiKST Ol M\;^ KNo\vi,);i)c. !•; and iii;i,ii r 



1 nt'oi maiit 



juy-oo-JL C!d. jj. 



Former or 
Usual Residence 

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



Haw long at 
Place of Death ? 



Days 



I'l.ACH Ol' IMRIAI, OR RKMo\\l. 



^^J^y^>vaXwu 



DA^llof IHkiai, or KKNH)VA1, 




I M)l 



•; R T A K 1 -: R vJ oaXjl^j \^ LU Jl-V". J- _ 

'Address HX'i jcrLdlx/vAj "^ /cvAx ULa/A,. 



>. B. 



-Hvery item of informntion fthouUI be cnrefully supplied. \i\V. should be stated EXACTLY. PHYSICIANS should 
state CAUSF OF DEATH in plain terms, that it may be pr»)peply classified. The "Special Information" for per- 
sons dyin( away from home should be given in ^\^ry- instance. 



II 






I 



» I 



'? 



if' 



■I 



iT 






1 1 \ 



• : 









II 



\ 



wiikH.-^ 



WW 



W^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



. mfr-^rO:^ 1)6- l< 



.■*l«^i^i^> »• 



IKl^^^ti ^'mm ■ ^^ Ai i 



>urt.ri iv^ b><>%\i>r>%^r v.<wriiiriv«>iiw r%rfii |i«^rirtv\^llV/i^<9 



■( 
4 



I 



. 



/yc//(' F/7,"ff, 



i ■ 




a^ 



^^t^'i 



Bcglstcj'ed J\^o, 



1178 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "U. 5. Stan^ar^ ) 



PLACE OF DEATH: — County ofOOU^r^ JAXJ^/rvc^^c^ity ofCJo^'>x' i KAX/-Yy^fL^.J^^^<> 





'■^^. 




ChJ|W..O^I 



St.; 



Dist.; bct.~ 



and 



(ir 6CATH OCCURS AWAV^ 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 



PERSONAL AND STATISTICAL PARTICULARS 



-1 \ 



' \ I i: nl III Kill 




COI 



UJaxaXji 



Motilht 



Ai.K 



Id?, 



)><,■» 



(I)av) 



!/..>////> 



(Vear) 



/',,■ 



^IN«.I,K. MAKUIKI) 
WIDOWKI) «»K 1)IV(>K( Kl) 
\\iitt in social ilc-i^'iiatioii) 



lUU rui'l. \rj-: 
M:it( (»T iiiiuitiy 




MEDICAL CERTIFICATE OF DEATH 

DATK <)l' Dl'.Aru /'^ 

(Month) /T (Day) (Year) 

I Hl'iUIUJV C1;RTII'V, That r .ittciidcd ilcccasod from 



a 



190'i to vJv^^/^>Q_ Xlb 190 H. 



NAMI- 01 
I'A rill-K 



MIKTHI'f, ATK 
'>! » AIHllR 

' St.itc or I'nimti \ 



MMDl-.N NAMI- 
<»I .MnTlIliK 



niRTMl'[,ArK 
<»H MOTHKK 
(Statf or Count rv 



'^ 



n 



xCayiV<X.L'V». a-r. 




y\A^ 



that I hist saw h - > > alive on vAA...^^xx 'X'i^ icyo H 

and that death occurred, (mi the (hite stale<l above, at b ^:> C 
LL M. The CArSlv OI- I)I{ATir was as follows: 



Hours 



nr RATION l. Yiuirs Months /hivs 

CONTRIIU'TORV \f rVxX^LXX.^- 



1 



OCCri'AlioN (A) 




DT RATION )\ars Mont /is Pars 

I N E D ) . w rvvu . ^ /OwV^^'v^^a^Dvj^i^^ 

1?^ T90H (Add ress ) O te . \W>CuJp^ lo (HL^xt 



(SIGI 



Hours 
M.D. 




^--Crtrl 



h'r-niftl ni Siiii /'i 1! Ill iMi) '' )'f'ais 



Months 



/ 111 1 



I HI-: AIIOVK ST ATI", I) 1'KKSONAI, I'A KT hM " !. A K s ARi; Tkl)-; To IIU-: 
lU.sroi. MV KN< (WIJ 1)(,H AND Hi;!,!!",! 



Informant 



SPEC^AL INFORMATION only for Hos) 

or Recent Residents, and persons dying aw-»y from fiome 



itals, Institutions, Transients, 



Former or 
Usual Residence 



5^H' \tJ\j 3ir Place of Deatfi? "I ...Days 



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




JLa-A.^q-v>v 

\'Mr<ss i 3) ^ s3 cr^Aw^I>UkJ ~$^'k. 




I'l.ACK Ol" HTKIAI, OK KKMoVAI, I DATI-.o! Mikiai. or KHMoVAI, 
'Address I'X'^H VmXX^^J^Uljt ' '^ ^ 




rNDl-.R'rAKKK 



^' ^' r^.very item of informntion Rhniild I).- ciirev'ully supplietl. XCV. Hhould be stnted F.XACTLY. PHYSICIANS should 

state CAUSE Of- DEATH in phiin tcrmM, thiit it m:iy he properly clussified. The "Special Information" ?or p«r- 
Bon* clyin^ nwny from home kIiouKI be |ii%en in every inHtnnce. 



I 




, «• 



I 



:|ii 



'll^ 



ill'') 

Hi 






■•T'4>^ 






C'^ 



'-^limM^.. 



I.I 



I 






•nmm^ami^^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



r ttt»itft=i* ?^v ;- ^'x;^ 



fJ^SSlfe*, 



us. i> r« 



ncfcn ff\ B A /^ ly /\ n ^ e- BiPi ■••/% *^r p/N B I lu o^Bi ■ /*^i /^ i^i ^ 






IfJCi 

Deputy Health Officer 



Bogistered J\^o, 



11?9 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No, 



h 

. 



Certificate of H)eatb 

PLACE OF DEATH: — County ofO<X>^ OAXX/^vc^C/toCity of Clcx^ru vJ AXX/-^A^<u.A.ac 



X/v/T^x<X/v^ 




'^ 



(y <u \aX< 



St.; 



-Dist*; bet. 



__ .^^^ 



(IF DEATH OCCU RS A 
\r DEATH OCCURF 



WAY Ifrom usual residence give facts called for under "spe 

RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRE 



CIAL INFORMATION" \ 
ET AND NUMBER. / 



FULL NAME 



\ 



<lDUTY\JUi 




PERSONAL AND STATISTICAL PARTICULARS 

-^J-x A A I coi.ok 





MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DHATII 



\'\ 1. «>i i!ik in 



\».i-: 



<^ 




MoiitH* 



(iJav) (Viar) 



ai 



) Vi; / 



11 



M.nilfis 



w 



/ ',/ 1 > 



SI\«-.I,K. MARK n: I) 
WIDOWKI) (»K DlVi »K»}:i) 
(Wiitiiu smial ilt>.i;.7nati<)ii ) 



luk riM'i. \ri-: 

(State iir I'lmntrv ' 



NAM I' (tl- 
FAl Ill.R 



ItIR lllI'l.AiK 
<>!• I A rill': R 

'State or Tomitrv) 



MAIDI-.N NAMH 
til- MoTMKR 



lURTlIIM.Al'K 
OF MOTIIKR 
'State or (.'oiintrvt 



OCCn-ATlON (JT* 





igo'K 

(Month) ^ (Day) (Year) 

I UIvRI'HV C1;RTIFV, That I atteiickMl dect-ascd from 

LAc^MI)! IC) H)oH to IXaw/^XI^ X'2>. 190H 

that I last saw li ^ *•> aUvo 011 vA-^^^^^Ol -^'^ 190 '\ 

atuLthat (Icatli occntrrcd, 011 the dati- stated above, at I- vO 



5 



0^' 



:\I. The CArSI{ OF 1)1«:AT1I was as follows: 



XA/lA.Jl'V.OA.xi^ Or 



J?^>-«.>V 






DC RATION Years Mouths W Days Hours 
CCINTRUH'TORV oU CtvJIhuL A..^^ 



DTRATION 



)'rars ^^ouths > Days ^^ //our^ 

% 

^-^^ M.D. 




h'fiilnl III Si!u I 



nil isrn 



)V•,7;^ M,<lllll< b /''"> 



(SIGNED) VliL. 0. obo-jOkA. 

LtLVA,.Qw\ u)oH (Address) U 



^ 



JlAywv<X/vu 




i 



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

for-nf^or ,u:^f^Y? ^T^ Howlonqat 
Usual Residence IH l3.~ 1^ Kh\, O, 



>^ Place of r)eatli? ^ .. Days 



I" 111'. AMOVE ST ATI", I) I'KRSONAI, 1' \ K T It ' r I . \ K "^ A K I '. 1" K I }■. Id 111 I"! 
IIHST Ol- MV K\i >\\ i.i;i)C. K AM) Hl.IJl.l- 



(h 



'f""'':"'t \J iV/OvaXXn^o^ Vj . J 







JLa.,^^vv\-/CU'Wj 



Ob Ch<i>U^'fcxx.l. 



Wlien was diseaf*" contracted, 
If not at place of death ? 



I'l.ACH Ol- HTRIAI. OK REMoVAl. 



DATl'.of HruiAi, or RHMOVAI, 






im.i;rtaki-:r AD oJu1jU:L ^^ \Lo 

(Ad<lrtss S..*i.^. \JM-A>«_A^V.^^V ajt 



N. B. Kvery item c.lf inV'ormHtion Hhotilil h.- cnrefiilly Hupplie.l. AGfi Hhoiild be stateil F.XACTLY. PHYSICIANS should 

Btntc CAUSK 01- DEATH in plnin terms, that it mjiy be properly clasHified. The "Special information'* for p»r- 
«on« dyinj^ nway from home fthould be given in every instance. 



!l 



{ • ' ■ 



t y-' 



• 'I 

I! 1!'" 

■. \' 



h' ( 



ij. 



l! 



I! 



It 



I 

; lii 






I?* 

fi I 






' ^^ 



ll . I 



iijil 



'Ml 



ii]:i 



l ^ 



♦ < 



i 



k 



If 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



II. .;nn I iT Tfcrt ttH -" P ?»«X; > ^ ^"siss 



.itgssa^t^ 



XtS. U (*^ 



• •«» • 



Mvt«B-e» fr\ BkAAW <%» /% mnPI »l/^ « Y'V V/%S I Al »1PBI l/^'Vl^ai * 



Dfffp /v/^^^/, Uoouo^^^ an ^^6^H 



Register'ed J^o, 



1180 





No. 



/\H^i Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( xa. S. StanC»ar^ ) 

PLACE OF DEATH; — County of 0/Ol^'>\; AyOo^ruCA^^LOiCity of Oo/TX^ AxX/^tlXI-c^Oo 
b^ OxtoK; St.; \ Dist.!bct. OvD ^^A^A/Cnr\' and VDaA-H/OlxwI 



■n 





Dist.;bct. OAD (QA;vAA/Cnr\' and \UAa. 

(ir d^Vth occuns away from USUAL RESIDENCE give facts called for under "special information" \ 
IFi^CATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




) 



FULL NAME 




^i.j<:r\. 



PERSONAL AND STATISTICAL PARTICULARS 



^j;\ 






L 



Col.oK 




MATi: »)» lllK IM 



A<.K 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH ^ 



Mouth* 



I O J,„,> 



( I>.-i V ) 



M.inl/is 



.'V«-:ir) 



Da 1 .V 



•^INi.l.K. MAKKIKl) 
UIDOWKI) OK DIVoKCKr) 

UTit« in v.xi.il fh-^ifiKitiuu) 



lUkTm'i.AOK 

(Statt' i)r Coiiiitr\ 




N^MK Of 
JATMI.K 



Y 







(Month) 



,13... 

(Day) 



(Year) 



I UKRICHV CJvRTIFV, That I atteiided (Icceased from 



r^ 



that I last saw h-^i^ alive on 



to 



.%.% 190 H 

vAA-^V^ 'A.'d 190 'i 

an<l that death occurred, on the date stated above, at 11 HS^. 

LL M. The CAISK OF DIvATH was as follows: 




xuU^. 



\'\.^y^Yy\JXJii 




<r^^. 




^yy^ 



dL 




HlkTin'l.AOK 
ni- lATMHk 

state or (."oiiiiti v> 



MAIDKN NAMK 
OF MOTHKK 



iukthpuacf: 

<»»• MOTIIHR 

'statf or Coiuitrv) 



M Cri>ATlf)N 
f^'fsuifd in Sun /'i mtrisro \ ]V(ii < ^ y/nnf/r- 



Dl' RATION }'ears Months Days 
CONTRIIU'TORY LL^XXJUvo^r:v-\-Ow 



Hours 



crw^crv^- . 



\. ' 



DURATION 
(SIGNED) 

LLlux X^. 190 'i 



)'cays Months Days 



I/ours 
M.D. 



(Address) 



T6\ i(^U^^ at 



/><n 



IHH 



Tin: AHOVE STATf:I) FHRSONAI. par TICri.AKS AK1-: TRIK JO 
BF.ST OF MY 'xXOWI.KIKVK AM) HKI.IKF 



(Add 



ress 



SPECiAL Information only for HosplUls, Institutjoiis, Transients, 
or Recrnt Residrnts, and persons dying away from fiomr. 

Formfr or ^ ^1 How Jon^ at 

Usual RfsldfncfU<X/>v AXXyYvC va CU; |»life of Deatfi? Days 

Wlien was disease contracted, 

If not at place of deatfi ? 



PLACE OF lUKIAI. OK REMoVAI, I DATEof Bt kiai. or REMOVAI. 

UNDE RTA K E rM I L /(XdldUZ/Vu M iV VU AJUXAJbu ^ OAJLitV 

(Address U/'i.l M rU><LA>^^trYv.3.±. 



N. B.. 



of information should be carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should 
E OF DEATH in plain terms, that it may be properly classified. The "Special Information" fsr |»«r- 



-Every item 

•tate CAUSE i3V DtATH In p 
ffons dyin4 away from home should be ^iven in every instance. 






n 



'1 ^^-i 












\\\v\ 



1: 






I 






■\\ 1 






I 



V.I'. 



I 



't 






^.t^f^nir 



^;' 



•#s**^ 



r, i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



9 9-^„ f»W -> ^ -t J ^J i » - ♦■«- 
1 I f. it I ( *( • . *•'. • ^ 






UR, P C'n 



Br-PCB T<^ B A r« U /%C" /^ C BTI l•l/^ ATr" C/^ D I lU 6 ▼ B I I /^"Tl /MU C» 



/yr//r /v/^^/, Uaa^XVU^^ an ^^t'H 

Deputy Health Oflflcer 



Registej'ed J^'^o, 



1181 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Vi. S. StanOar? ) 



% 



PLACE OF DEATH: — County of Cl/Oy^o; J-Vay>\yCAwA/ac City o{^ <X/y\j A^CL/^-LA^oi^ tio 



(ir DCATH 0( 
IF DEATH 




xCi.; 




CMl|\J^'i 



Dist.; bet. 



and 



ccuns A\MAV FMOM U S U A Li R E S I D E NC E Gi vE facts called for under "special INFORMAT 

OCCURRED IN lA HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE 



ION" N 

R. J 



FULL NAME MKJlJ 





. U KXX CU. 



PERSONAL AND STATISTICAL PARTICULARS 



' VI 1-; <»i- itiKin 



Ai .1-: 






31 



J V(f i 



1 



\ 

n:iv> 



.}/.»//// ^ 






MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 




X\ 



Pit 1> 



--!\' \.V. M,\RkIi:i), 

\\ llx i\\i;i) OK DlVoRCHI) 

'U'iit( ill social (ksi).Mi;iti'>ii) 



lUU lin'l.Ai'K 
t State or fotiiitrv 




K\Ju6^ 



% 



<XyY\) A/Olx>'-v'C..<^aalxo 



WMi- or 

I- ATIII-R 



I!IK IHI'LAiH 
f>f I ATHKR 

'Stat< Ml roimtrv 



MAIDI.N NAMI-; 
<>l- MnTMHK 



"} M<>rm':K 

'Stat( or roimtrvl 




.0. 



A^OA^^A. 





VUJ^A^ 




Vl^"vOL 







(Month) rt (Day) (Year) 

I lII'RICnV CI-RTIFV, That I attciKkd dcivascMl from 

~- — ~ " 1 90 to -rr--—— —————— — Kp ■ 

that T last saw h :'^^ alive on " — ~" t<>o 

and (hat death occurred, on the date stated above, at ~~ 

JM. The CAUSI-: OI' DIvATII was as follows: 
J WcJk ^^^^ (K^JL'^'vv<>^^AJk<^^^ cLajuL Xo 

nr RATION )'cars A/ouNis 

CONTRIIU'TORV v^V^^^VK^.^^v'i^ 



Days 



Hours 



nr RAT ION Years Mouths Pays Hours 

(SIGNED ) Ur\Xr>Jlhjl\^.u).XiU^ M.D. 



">■*■' r\Ti<»N ((O 

JL<X./W^.^ Aji J^J 



'v/cL 




l^Tgo H (Address) Ut\.Crv\X^^ Wl-U-^L. 



SPECFAL Information only for Hospitals, InsmuWoWs, Transients, 
or Recent Residents, and persons dying away from fiome. 



Former or U ^ c- i> 4- y ~A j ^®**' '®"*l ^^ 

Usual Residence V V >i ^ O vLK CJX Plare of Dea 



Deatfi? 



Days 



K'^siilfd in Siiii /'i nil, /',i> 0I )>(M' 



M,nilJi^ — Day 



HI AHOVK SIAri:i) I'KKSONAI, I'A K T lO f F, A R S .\RI'. IK IK It) TIIK 

Hi-.M'oi- MY k.\<»\vm;i)c.i.; and iu-imi-.k 



'Illfi>ini;itlt 




-^ 



K/o^y^LJ^ 



(\<i(i 



ress 



lOH'5. UkAAAytJL dl 



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



ri.ACH <»!■ lURIAI, OK KKMOVAI, 







DATlvof IJrkrAi, or KHMoVAI, 
fAd(h-css %F\ U<X/VX7 VrVjuLi; SjsA>rr^v. 



N. R. 



-Hvery item of information should he cnrefiilly 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- 
Bons dyin^ away from home should be ^iven in ^\(»ry instance. 



'; % 



:|r 



M 



1 



. .1. 







1 1 



i •< 



•» * 






• i I 



|. i'^'l 



■; ♦ 



I 



h VWi 



**'-'^'** 



'1- • •- 



fm^ 



xAZ'i 



1 



111 

III 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i ; . i,!ttr--t* N».t- , >i::sr 



i^ ii«r i» r 



■ rrro yrs narM nv r.pnTirir.ATr rnn iNftTnumnNfi 



/)(f/(' FiJod , 



L^ 




<Lfc ^H 



2fJ0\ 



Registered J\'*o, 



1188 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "Q. S. StanDar^ ) 



PLACE OF DEATH: — C o un t y e f 



;ity ofU).d. Uj. J. dJkjAAxLo.Av 



No. X/>\j .\AtO 



Xltc 




"?i 



ex. >X\.^<X' 



St.; 



Dist.; bet. 



and 



r DEATH OCCURS AW*V FROM USUAL R E S I D E NC E G I VC rACTS 



(ir DEATH OCCURS AW 
IF DEATH OCCURRC 



O IN A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 




O 



JL^: 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR \ P| 




I oi r.iKrii 



VL^ 



()v 




TS CALLED FOR UNDER "SPECIAL INFORMATION" "X 
TS NAME INSTEAD OF STREET AND NUMBER. / 



)^x 





MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH r\ 

LLv^i 



MDiith) 



\: 



O d\ Viiu 



s 



a)av) 



Motitin 



iVt-ar) 



Da 1 -v 



-:\t.l,K MARKIKl). 

\\n><»\\Ki> OK i)i\()Rri:i) 

'\Vrit< ill s.H-i:(l (U sii.^ti:iti«m) 



(St.itf or Coiititrv 



? 



\ WW OI 

I \iiii:r 



HIKTlII'I.AtK 
OI" l-AIMKR 
^tatr or I'oiintrv 



MAIIU-.N NAMK 
Of MorHKR 



Hlk IHIM.Al-K 
Of MOTHHR 
"^t.itr or Comitrv) 




(Year) 



.1.3... 

(Month) K (Day) 

1 HHRI':HV ClvRTIFV, That I attended (let cased from 

to 



that I last saw h 



TgO 

"" alive on 



190 

190 



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



M. The CAl'SH C)l- DIvATII was^as follows: 




DC RATION Years 

CONTRIIH'TORY 



Mouihs 



Days 



Hours 



M 



"^'^T PAT ION J( 5 



I\[onths 



Days 



Hours 
M.D. 



DURATION Years 

(SIGNED) UJ.Vk. 

ULuvXt, JH iQo't (A(l(lress)U..^.U., J. ajKjL\A.xLa^x 
EC^AL Information only for Hospitals, Institullons, Transients, 



SPE 

or Recent Residents, and persons dying away from liome 



Kfsidfd III St! n J'l ii iti i^i'o 



) 'lUI I . 



}/»nf/ls 



/hivs 



1 MI, AROVK STATi:i) PKRSONAI. TAR fHTLARS ARK TRIK T« > THK 
IJKST UK MY KNOWl.KDC.K AND HHMHF 



(\4 Hn! 4 . s 




CU\h\^ 



Former or 
Usual Residence 

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



Hew long ai 
Place of Death ? 



Days 



PXACEpi' lURIAI, OR Rl'MOVAI, j DATKof ntRtAl- or RKMOYAI, 

LL-^^ ^H 190 H 



IJL IQl 



INDKRTAKKR 

(Ad<lrcss 



N. B. Every item o? informatJon should be carefully 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 |»«r- 
«on« dyin^ away from home should be ^iven in •very instance. 



I' 



I'll 

I 

I 



•1*4. 



■ 't 



1 



i 



in 















' < I 
' til 



.1 •,«•■ 



III 



1. 



fi 






:r 



li 



! 



I 
I 

r 

I • 




r 'i 






^ 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;, , I rit nt ricti tt i» 



'*ittT^.' 



^. •^.Eofln.Xi- ufi- 1> (\^ 



RrrPR TO RACK OP CFRTIFICATE FOR INSTRUCTIONS 



HegLste/'ed JVo, 



1183 




\A.KA 



/)a/r n/('d, [hu^xx^^ IH l^W\ 

d^xr^Aj^ Deputy Heslth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH; — County of 0.^X4.>A,C City of ^OLA^^^a^ 




No.- 



(ir DEATH OCCURS AW»Y FROM 
IF DEATH OCCURRED IN A H( 



St.; 



Dist.; bet. 



and 



IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACT 

lOSPITAL OR INSTITUTION GIVE I 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




TS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



. i *'l lilK 111 



L 




W\Xx 



M..ntlil 



\' v. 






(I):iv) 



M.mHi 



(Year) 



/'.n 



-' 1.1. MARK ii:n 

\\"Mt< in '^iici;il <1< "-ii' n;it ion) 



niK III I'l. \ri-; 



I" AT Hi; K 



ItlKlIIlM.XrK 

oi' 1 xriii-.K 



MAII)|:n NAM}. 
'•I MoTIIKk 



l:iK IHl'l.Al'K 
"I MOTHKK 
'St;it< or Couiitrv) 



•HiTl'ATloN 




Wo<j\j^<j^<L 



t 



CK<LL>crru 



f'K 



<XA-^ 



% 



y\j >^^xa^*^aaXu 




C 



O^ vaxL 




K^^-\^^ 




L 




MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII /H 

(Month) jf (Day) (Year) 

I HI':R1':I5V CI^RTIFV, That r attcMKkd (Iccoased fruni 

■ 190 to 190 " 

that I hist saw h alive on 1()0 



and that death occurred, on the <h»te state<l above, at 
M. The CATSIv UF DlvATII was as follows 



i'^ 



^^O^y^ 



A^cX^-vj Cr 



I* 



A_iUX^, 



1-, 



DIR.ATION )'ears 

CONTRinrTORV 



Months 



/\iys 



Hours 



nr RAT ION ^rfe''^/-^ ^font/is 

LO J. vDaaaJ^/^ 



Days 



Hours 



(SIGNED ) 




rwcL 



Kffiiifd III Still /'i iini isi'ii 



)'t<ii 



.}/''ii//i^ 



/)./!. 



rni: xnovK staii-.i) pkksonai, iv\k luri.AKS aki. rKiK ro tin-: 
in-:sr 01' my KN'i)\vi,i:i)(.K am> Hi-j^n:F 



'Infi>tin:n\t 



ULcn^-ojLMjti>j o 



/'O 



-(Addn--^ 







(^ \] 



M.D. 



X}^ iqo'l (Adtlress) .. J .\JUl^^.^ V^<xL 



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



Former or 
Usual Residence 

When was diseaje contracted, 
If not at place of deatli ? 



Hew lonq at 
Place of Oeatti ? 



... Days 



ri.ACH ni" lUKIAI, OR RKMOVAI, 






DA 11; of Ml KIAI, or RKMOV-Al, 

LLc^Ki, ;i.H 190H 



INDI-.RTAKl'.R 



Ad.lie>*s 3>IH U .<X/\J\JUUL». .3.1 



N. B.- 



-F.%ery item of Information should be ciirefuliy supplied. AGF. should be stated F.XACTLY. PHYSICIANS should 
Htate CAUSF: OF DFATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin£ away from home should be feiven in every instance. 



ilu^ 



' I 

■.,T; 
■<. I' 

Mi 

I ^ 

t . 



H^i 



i 



/ i J " 






I i . ^ t^ 



'5 



■ 

1 






(ii;l 



1 1 

I 



■ ! 



mtTiOL 



fe^- 



i/W* 



I 





w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I;,,,p! ..f n.nllh 1 V.) !-^ l^-'-^^^^-nfcVCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



JReglstered J\^o, 



1184 



Duir Filrd. [Xj^j^^O^^^^j^ V\ 100\ 

Xc-i^vo "cL/v-u Deputy Health omcer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)eath 

( *a. S. StanC>arC> ) 



% 



PLACE OF DEATH: — County of^<X.^^r^ J-ZuOL/TV^eAAcCity ofO/CLA^ >^wy(X^vA./Ti^v^<i^<^0 



No. \H 0-C'CV-K^^ 



St«; 3v Dist.; bet. 



( 



ir Dt*TH OCfCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FO 



IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 




i 



and CJAwXX/rJj 



■OR UNDER "special INFORMATION" "X 
NSTEAD OF STREfT AND NUMBER. / 



FULL NAME 





•^i:.\ 



\)V\'\-. «)1- 111 KIM 



\' . I-: 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OK 





-^yvA^' 



u 







as- 

(Day) 



Aw 

I Vtai ) 



b^ )v.„« 1 



Mi»ilJis 



x\ 



MEDICAL CERTIFICATE OF DEATH 

DATK (>!• I)1;a TH r 



[Day) 



190 '; 




ihi 



^ivc.i.i-:. MAKkii:i) 

\\ ii><)\vi:i) <>K i)i\<)KrKn 

Wiitriii voria! <lisii.Mia( i< »ii ) 




AxL<5-\A>-OcL 



lUK riii'i, \ri.; 

(Stall '(I I'liiniti \ ' 



NAM}-: or 

I A 11 11: R 



iMKriii'i. Aci-: 
<)i- i-Aini-:k 

'Slate or C'diiiill V' 



MAini.N- XAMK 

t»i- Morm-.K 



liiui'm'i.Ari-; 

<>!• MoTHKk 
'Slate or Cou!itr\-^ 



ncMi'AiioN r\ 



/\'rs idr, 




C^^X<^>^J 





'tr'^Ar^^' 




(Moiitli) I (Day) (Year^ 

I{Kl':nV CI'RTII'V, That I attended dcivascd from 

0^ IgoH to LLCV/CU ^^ T{)oH 

n T 

tliat I last saw h •*- ' -v alive on vAXaxX, 'X.l Kp '\ 

and that diatli occurred, on the date stated above, at b lO 

VJ M. The CAlSlv ()1< DI'ATIl was as follows: 
LJKa^^>-^,a_^ CVy>Ztje.Aw<jtAjIX<\X) Vi ULAAJk/'uCtX-'^ 



DC RAT ION % Years Mouths Days Hours 

CONTkllU'TORV XXjXj^XJLry^nK,*./^ L<«:rY», 



rV<CV- 



Dl'RATlON 



)'rars 



.^fout/i} 



/hiVS 




V^'utrVAKw 





/■'i il III I til I )V,/;k ,i^ y/,iiifh^ 



_ _^ - - -.... Hours 

(SIGNED) X . V;. \I)\eyv\xJLXA M.D. 

XH Tc)oH (A.ldress)S.lH% ViK^UKcUa.^ cSi 




Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



/Jm 



111 I'. \M()\1.: sr \ li;i» I'KRsoN \1, l'\K Ih I I. \Ks AR 1". I" K T K. To Till-; 

Hi;sT <)|.- Mv K Nowi,i;i)(*,K AND iu;iji;i-" 



till 



r %.^ Q>^ (k= 1.. 



<:x_ 



u-id 



re-"^ 



IH 



•XjOJ^^aj^ 



ix 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of deatti ? 



How lonq at 
Place of Oeatli ? 



Days 



I'l.ACl-: ()!• HIKIAI, OK KlvMoVAI, 



rNDi;K TAKI'.K 

'Addrrss 




DATi:.)!" l!riM.\i, or KJiMoVAl, 

CU^ an i9o*H 



^- **• livery item otf int'ormjitioii Hhotihl 1).- cnrcfully Hiipplieil. Adli shfiiild be Htnted EXACTLY. PHYSICIANS nhoultl 

Htiitc CAlJSn OP DKATH in pliiin tcrniH, thut it miiy he properly claHNified. The "SpeciHl Informntion" for par- 
dons dyinjt tk^Nny from home Hh<tiiltl be ^iven in every inHtance. 



>ri 



41 






< 



- 



j: 



Jf 



' ; 



» ' I • 



.\ ■' , 






■ ''\ 

I'lr 

! I 



!l 






11 



i 



■ '( 



ISJ 



ji 



» » 



m» 



mm. 



I 



' :!' 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•»^ 



,U.anl M- II.Mltl. - I- N'o. I^ -fr-Ei^K^ I5«^'' ^' 



REFER TO BACK OP CERTIFICATE FOR IIM3TRUCTION3 



XJvK^ Deputy Health Officer 



Regi\stcre(l J\^o, 



1185 



CV'Cr^-A.vo 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( XX. S. StanC»arO ) 

of Ooo^r^ 0;\^/OL/V\X^VXtCoCity of 0/CL/TV OXO^y^O/C^LXi^^U) 



PLACE OF DEATH: — County 



No. 



OoLo^ajlUv^ 



^OM- 



St. 



Dist.:bct. 



and 



/ \r DtATM OCCURS AWAY 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 




cu 




r\Al.^ 



PERSONAL AND STATISTICAL PARTICULARS 
SKX (K\ f\ I COI^OR 





A'\^^' 



t^ 



l»\l K <i| lUKIH 



Al'.K 




ID 

D.tvl 



rv.-ar) 



)■-,/. . 



1/,..////. 



bJ 



/',;^.- 



WinnWKI) OK ItIV( »Kri:i> 
Wiitriii v(H-i.'il (lr^i;'iiati'>ii) 



xj^\y<x. 



HIk rui'I.AOK 
'Statf (ir Coiiiiti \ t 



N \Mi; Ol 

I- A 11 1 i:r 



HlKTnri.AfK 
OI" l-ATHHK 
'State «ir CoiiTitrv' 



MAIDKN NAMH 
<)l- MOTHHR 



IMRTHl'LAOK 
<»f- MOTMKK 
(Statf or (.'(innttvi 



1' 'Tl' \TI< >N 

/\f\u!f<i in Silll ]'i i\ )i, n,-<i 




X 



Jj Q^ 



<^c '^ ^. 



) "v. I V 



X ) 




MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

(Day) 




l9o\ 

(Year) 




I III':K1<:HV certify, That I attemlcd ilcceased from 

XCi iQoH to LAwA^v^ Xl ...._. TOO H 

that I last saw li-*!-'^' alive on vAaa-O, VvO 190H 

and that death occurred, on the date stated above, at I X 
^-' M. The CAl'Sli t)l' DlCATIl was as follows: 






\/W\j 



cJ-u^t^-^stj. 



Ur RAT ION 




wo„C 

\ 



■^JLO 



Years Months 
CONTRIHUTORV AxaM/cL c^j^^G:v^l. k).....r 



Days t) Hours 



nr RATION 
(SiG 



Years 



Mi>uths 



Pavs 



) . 






in. \HO\K ST ATI" I) I'KKsoN M, I'A R lUT l, \ R «, \Ki; 

Hi-.sT ni- MA- KNti\vi.i-:i)(". H AND ni-:i,n:!" 



Rfi". I'l > Til)-; 



IiifoMiiritit 






V 



/CXX>uo-\j ujULoj- 



NED) \J lU<X>\ju LI- JJ/0^^vXX^^^ 
LL^^n %[ icpH (Address) '^ H Vb A^tKtx, rL c) i 



Hours 
M.D. 



^ 



Special 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 lonq at 
Place of Death ? 



Days 



I'LACl-: 01 lURIAI, OR ki;M<)\ \l. I I)\ri;of Mikiai, (ji RKMo\AI, 

iNDHRTAK i:r \J /oJuLAaAJL VI lvCXAA.^r\jo ^ yo 



>>• K. Every item oH* Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CADSK OP DEATH in phiin terms, that it may be prf»perly classified. The "Special Information" for per- 
sons djing away Vrom home should be Jiiven in every instance. 




<:. 



< . 



i 



(Nl 

i ! . 









% 



V j 



t 



I 



'( 



i*i 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H<i:it'l I'f H 



I, ,1th |- No n -S^^^j^H&J'Co 



REFER TO BACK OP CERTIFICATE FOR IN3TRUCTI0N3 



Ihife Filed,. \hj<x>^^ V\ iOCn 



Registered J^o, 



il86 



X^ 



AjLA^ dL.^M.| Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( tl. S. StnnDar? ) 



PLACE OF DEATH: — County 

No. 11 \ft CrvL>vlvtrvv. VJ Xcxc^^ 



Si ^ ^ ^ 

ofCloo^YAj JxxX/\^cu_xi.c.cCity ofOO-/^^ '- 

St.; ^> Dist.;bct. cLiv^ otj^ and ^^^jlt^^'L aXj>.. ) 



(ir DEATH OCCUnS AWAY FROM USUAL R E S I D E NC E Gl V E facts called for under "special INFORMATION" '\ 
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




0^ 



si:\ 



IiAlK ol lUKTU 




CO I, OR 




VA>jtj. 



0^ 

(Month) 



\<.K 



1\ 



\'( o> 



10 



tl)ay> 



M,»iths 



(Yf-ar) 



MEDICAL CERTIFICATE OF DEATH 

DATK ()!•■ DKATH 




(Month) 



Ao igo \ 

(Day) (Year) 



Da \s 



^INC. !,K. MARKIKI). 
\Vint»U}.:i) OK I)IV«)Ki'KI> 

'W'litt in siMJal <U"iivnati<>n) 



HIK rnj'I.Al'K 
'Stair or Country^ 



NAMK 0|- 
FA IMliK 



HIK'niPI.AOK 
ni- FATHKR 
(State or Couiitrv) 







UAxiOk) U oVxxL 



MAIDKN NAM1-: 
UI- MOTHKR 



IHKTHPLACK 
<M- MOTUHR 
(Statv or Country) 



OCCl 




€cA^vxl_ 



v->v^ 




>-u 



I HHRI':HV CIvRTIFV, That I atteiKlcd dec cased from 
V- I 190'i to LLla^...CL3 190 H 




that I last saw h r^^ alive on 



and that death occurred, on the date stated above, at IC) oO 
CL^M. Tlie CAISK^)!' DIvATII was as follows: 



^Ud 



"VA-XiyW) 





DC RAT I ON Yeaxs ^ Months 

CONTRIBUTORY _ 

DURATION ^ Years MontJis 



Days 



Hours 



Jt/>A-A.^\AJA^<X. 



Days 



(Signed) 



cCa^^^v 



Hours 



M.D. 




:crpATioN (7i j a 

Rfsidfd in San /'laiitisrit X I )V<f>.v \^ Munlhs \ /htvs 



THK AnoVE STATi:i) l»KRSONAl, I'AR IKM" LARS AR1-: TRrK To THK 
RKST or MY KNOWI.KIX'.K AND HKMKK 



(Informant 




Vv^ U 




( Vddrcss 



5vl ViD crvuNj(j-tr>v VJX(X 



^x 




<N 



^^ i()oH (. 



Address) ^^^ D'ar^^rljUA. \X\<L 



SPEOIAL Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from liome. 



Former or 
Usual Residence 

Wtien was disease contracted, 
If not at place of deatli? 



How long at 
Place of Death? 



Days 



ri^CE OK BIRIAI, OR RKMOYAI, I DATKof lirRlAI. or REMOVAI, 



INDERTAKER VI I I Kjj^/y\y^r\, ^^>y^^-<l> 

(A<Mress 'kX\ QfYl^ QULLx^Ix^, ..^X. 



U-V\^ ^.^ i9o'\ 



!^. B. Every Item of informRtion 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 dylnft away from home should be ^iven in every instance. 




r 




r. ,< 



'. 



i*l 



111 



n 



=1 



*»feStt" 



iPilA 



-JMIfcP»- 



"^i^ 



tZ. iT"-; 



i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTfONS 

1187 



n ,..,,.1 uf Hf;ilth-I- No. i^ l^!*?^"' i^^^' ^<> 



Ihffr FiIe<L LL>^.Q^>cAt XH ^'>6> H 

iL^K-^owi "Ix/vKH Deputy Health Officer 



Rcglstei'cd J\^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 5)eatb 

( TX. S. Stan^arD ) 

J? Qi) tX ^ 

PLACE OF DEATH: — County oi^OuY\j XXL^vo^^.^City of O.CL/^v 7vCXa^^^^^-c 



I^. vj o^OoVv^- 





CkAxaJLoJ; 



St.; 



Dist.; bet* 



and 



— - ) 



r OE*TH OCCUnb away from 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 



FULL NAME 




/OAJU-XT \J/OJv^(5- Y\^J 



PERSONAL AND STATISTICAL PARTICULARS 

Si:\ A - A I Cf)I,«»R 




I> \ TK ()» I'.IK'IH 



CL 



M.mth 




a(;f. 




1!? 

il):i\i ^Vtar) 



/\'h- 



Ti 



)-.<: 



M.-tiHn 






Pd \s 



<IN<".I,K. MARKIi:!). 
WIDdWKI) (»K DIVoRvHI) 
'Wiitt in ><<Ki;il (1< siv:ti!iti<)ii) 



lUKTUPLACK 

(State- or Coimtrv^ 



NAM!-: OI 
I ATHKR 



TUR'IIIPI.ACK 
0|- I- ATHKR 

' Statf or Cmintrv^ 



maii)i:n nam I". 

<>1 MOTHKK 



HIKTHI'LACK 

<»l MOTUKR 

i State or Coiintrvi 




1« 



\i 



MEDICAL CERTIFICATE OF DEATH 



DATR OF DKAT 



■" CL 



(Month) A 



'Day) (Year) 



I Hl'KI'liV CI'RTIFV. Tliat I aUeiukMl dcct-ased from 

N^i^uLu IH 190M t() ...Lm^^^.....2^2). 190 'i 

tliat^I last saw h-^- alive on lA.A./i./CV '^'^ 190 ^ 

and that ik-alli occurreil, on the date stated above, at b XC 
Vj M. ^he CAISI*: Ol- DI-ATII was as follows: 




r" 



DT RAT ION Years, 

CONTRIIUTORV 




Months Days 



Hours 



■\ 



DURATION 
(SIGNED ) 



Years 



Months 



Pa \s 



X 




>^ )r^ 



Hours 
M.D. 



OCCUPATION 




^'V.XXXW' 



f\''.:ded III Still ritiin/M'i} v..) ) i<i i 



M'lith^ 



l>,:\: 



rm-: ahovf, STAfKn i-krsonai, rxRTiccLARs aki-: tkik 

Hi:ST OI- MY KN0\\M:1)C. K AND nivI.IKF 



TO TH1-: 



'Itiforinaiit 










Addr.^^s) ^Hi oxvtix^. d;l 



SPEOIAL Information only fur Hospitdls, institutions, Transients, 
or Recent Residents, and persons dying away from liome. 

Former or A'T . i; it \ < "»>» 'o"? at 

Usual Residence lb(Xb v 0. 



b lb Vj d <XX\JLLI ) t Place of Deatli ? 



Days 



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



ri.ACK Ol- lURIAL OR RKMoVAK 




DA Ti: of IJiKiAi- or KFMOVAI, 



rNDi:RTAKKR V V "J \AXaa^ n ^^ 






190 



'Address 



N. 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 per- 
sons dyin^ away from home should be feiven in every instance. 




♦ I 



i: 



: i 



i'i 







, I 






'111 



,l 



(:•: 






m 



^^' 



f 



i] 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,,„,.,,.lof U.-AHh- I- No !^ l^^ao^hS^VCu 



I 1 



I)fff(' Fih*(l , 




an 



100 \ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1188 



Jf,eo^Lsle/'cd J\^o. 



dUrvA^^ doi^v-M. Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificate of Death 

( xa. S. StanDarC> ) 



(^ 



PLACE OF 



DEATH: — County ofC)/Ov*Y\J J A.Oi/'A-^^AA.ocCity oiO<Xyy\j O/uo^-v/CA^c^i 





No I b H I 1) Cy^^XX^vA St.; S Dist.; bet. ^ ^ XJk and 1 ?^ 

/ ir DtATM OCCURS AW»Y TROM USUAL R E S I D E NC E Gl VE FACTS CALLED rOR UNDER '•PtCIAL INFORMATION- \ 
V IF DEATH OCCURRED IN A HOSPITAt OR INSTITUTION GIVE ITS NAME INSTEAD OF STBEET AND NUMBER. / 



|\J 



FULL NAME 




./QJL^W^.y^^<YC{ry\) U/UcLcf\j 



<^^UL 



PERSONAL AND STATISTICAL PARTICULARS 




I 



[jjJrjJuL 



i)\ri-; <)!• mRfii 


vH 






oL)xc- 


^0 




>M<)tith) 


<I)!«y) 



(Vfiir) 



\ ' . K 



S^ 



]'itt I 



1 



Mnnth^ 



ao. 



/)</ r.v 



'^IN<".I,K. MARKIKI>. 
WIDOWKI) OK I)IV(>RCKt> 
(Uiiltin '"ooial (lisi).Mi;it ion ) 



HIKTmM.AOK 

i Statf or (.'f)nnti"V^ 




<XAA.OL/cL 



iat!ii:k 



lUK IHri,\CK 
0|- lATIIKR 

'St:itt or Tomitrv^ 



MAIDKN NAMK 
OF MOTHKR 



lURTHl'I.ACK 
<>l MOTMKR 
(Stale or Couiilr\ i 




^^Crv^XTTU 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH /O 



(Mouth) \ 



(Day) (Year) 



X III", 



.^J 10 190 H to 

that I last saw h a^>> ^ alive on 



I UKRICUY CIvKTIFV, That I atteiuleil deceased from 

LLxA-XX. ..^\ IqoH 

Uaa^ QlV 190 S 

and that death occurred, on the date stated a])nve, at ^ 
J M. The CArSH OF Dl-ATII was as follows: 
\| I Uwy(KCL^OLA>Xx.A-AA^ /Ol/vwcL. C/ < 

,03^i-<cd .Aj^JUt 



rVA./CU>&->^VA\JiXjLVw:tJ.. 



1)1' RATION 



Years H Months II Days 

■I 



CONTR inrTOR V UL>L(KA,orrvA/\\.*jJv-s- OV JVvd^^JiA. 



(^ 




occv 



l\/-iilr(l lit Sou /'iiiuii rn cn i, )'.//^ 



\/,',ith< 



/>.n 



rm-: ahovf: stati-:!) rKRsoxAi, i-aktuti. aks aki-: tkif: to rin-; 

l!i:sT ()!.• MV KNOWI.I'I )(".»-: AND III-:!,!};!' 



h 



itoMMant \| ^LoJV^^ O^^XyrCfc vIXv^uC. 



r\(i.i 



rrss 



1)1' RATION r^ y'orrs Months Pays 

J. \l RxX^LA_A^^JL^ . M.D. 



Hours 

t 

/fours 



(SIGNED) ^ -'>n 

LLu\ a?) u^oU (Address) ^ OO" U^^-VaMaX OJ 



eS 



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



Former or 
llsudi Residence 

When was disease contracted, 
If not at place of 'leatli? 



How long at 
Place of Death ? 



Days 






ri.ACH OF" Hl'RIAU OK KKMoVAI, I DA TF! of MriuAi. or KKMOVAI, 

(Address 15 /XH. 'OX<y^iX\Xjtryyj^ Clt 



N. B. F.very item of in?orm»tlon should be cnrefully 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 par- 
sons dyinft away from home should l)e ftiven in every instance. 



\ 



P: fT 




'W. 



f 



^ 






.1 ; 






!l 



!• 
I 

. > 
i 

I. ( r-J 

I 
\\\ 







"iiii 



'< 



f 



lift 



II 



i 



k 



WRITE PLAINLY WITH UNFADING INK — 




..I II 



,,„,,.. ,.• vn. ^^ ■J^S^ ^^^^' ^*" 



i)((h' Filed, Uaaxl^^ an l'^0\ 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

llei^istevcd J\^o. Xjlo9 





/V-M D^P^^y '"^^^!*"^^ OfHcer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Bcatb 



( U. S. StanOarD j 






(^ 



PLACE OF DEATH: — County of' 



CU-o.' .^X^,'-^^^CAAXlcC;ty of O /CVTV J X<X/->v.c^«.<^ 



No 



. \^\\ 




.KJ^\ 



A\J^'Y^J 



St.; 'I Dist; bet. 



and 




J .w ,»^.- iicilAI nrc; I nr NCE GIVE FACTS CALLED FOR U N D E R V S PEC I AL INFORMATlOj 

( '^ rF"o;:TrOCCURrEV;N''rHO^S^VT"At rR"r;ST'.?u"o"^C.VE .XS name ..STEAO OfUtREET A.O .U.BERJ 




Cj»^ ) 



FULL NAME 





SKX 



DATK «>l lUKIlI 



\' .I-: 



PERSONAL AND STATISTICAL PARTICULARS 

I c'oi.ok 





f tnlltll! 



Slo 



) Vim 



1 



(Day) 



M.^nlh:- 



r%h\ 



^ 



(Year) 



/:>■/ is 



SIN<-.I,K. MAKKn:i> 

\\ii»» i\\}:i) OK i)!V(tKrj:i) 

'Write in ^urial dt •»iv'ii;tti')ti ) 



niK'rniM.AOK 

'Statf or Country) 



NAM!-. <)I- 

fatiii:r 



Hik'nii'i.ArH 

<)I- lA IMII-.K 
(State <ii' Cdiititi v' 



MAII)|:n NAM)-: 
<)1" MorilKK 



lUU Iliri.ACK 
Of MOTHKK 
(Stat*- or Co\nitrv^ 




Y^<yj 



occrpATioN n 

h'fsided in San Fiamism 1 b )<■.);> — 1/"" 



///■ 



iKn 



Tin', AROVK STATl-:i) 1'KRSONAI. PAR TUM- LARS A R J". rRII-! l' • IMI-; 
HKST OF MY KN()\VI.i:i)C.K AND lillMI'.F 



(Inforniaiit 



Q 



(TVo 




n 



(Address 



10 l^ ^J^^^/U^oco^jfc dl 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DKATH /^ 

VwAjwAX^^ ^^ igo H 

iMontli) \ 'I>:iy) (Year) 

I IIl'lKI'iHV Cl'R'riI'N'. Tliat I attciKU'tl deceased from 

to ———190 " 

-—190 — 



190 



that T last saw h :: alive on 



and that death occurred, on the tl.ite staled ahove, at 
— — — M. The CAl'SK Ol' DI^A TH was as follows: 




1)1' RAT I ON Years Months Pays Hours 
CONTkimToKV ^>-. , ...: v,.^Cr:>:x...4^.'>^^.. 



DrRATloN".^ )'i'ars 



^fofil/is 



Hours 



Pays 
(Signed) JXX^O^l;^/^ U. KJ^jy^/yxM 

LUuy'b iQoH (Address) (^ ^ ^^ . . . j) \U . . 

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



^ M.D. 



Former or 
Usual Residence 

When was disease contradfd, 
If not at plareof death? 



How lonq at 

Place of Death? Days 



ri.ACK OF" lURlAI, OR RF:M0VAI, I DATi;of III KiAl. or RKMOVAI, 

l-NDHRTAKKR M l\AXAy-W jJ oVk ^Vw \^ 

1.ZX M lO^yCAjLCc. C)± 



(Address 



N. B.- 



-Bvery Item of information •liould be carefully Hupplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information tor per- 
sons dyin^ away from home should be ftiven in every instance. 



kp'i 









'1 



:* 



if i /a 



41 



Iff 



WRI 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lUtfr riled, CL 



Wffi V Co 



PiUeTiONS 








^H 



I'JO'A 



REFER TO BACK OP CeWTIFICATC rOB IW»TBUi;Tim 

li90 



Registered J^o, 



!lh Officer 



.'v-u Deputy !' 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "a. S. StanC»arD ) 
PLACE OF DEATH : — County of C)<Xy-.A; 0/v-XC^»^cv4A:-oCity 



% 







t» 



No \io'X 0(nAXJkVJ.a-^v.k St; 3 Dist; bet. ^ O^Vti and '^K.^^ 

^^^* ( .r oc*TH OCCURS *w*. rROM USUAL RESIDENCE eve r*CTS callco ^o" undcr ^^H^^^'^^^^^^'^H^^^;'*' ) 

C IF DCATH OCCURRtD IN * HOSPITAL OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. • 



FULL NAME 







PERSONAL AND STATISTICAL PARTICULARS 




t 



UJ^^aJjl 



I»\ 11, <»l- »IK III 



AC. K 



^W>Jlj 



iMo*it)i) 



O C> iv</'> \ 



(Day) 



Mouths 



(Year) 



Dii V, 



SIN».|,K. MAKKIKI) 

\\ innwK.n OR nivnkiKi) 

iWiitc ill s<K-i;U (k»i>f nation) 



HIKTMI'UACK 
(Statf or C'mntry) 




AxLcrVJ- 




.y 



> \xL 



! '! 



NAMK Ol 
}• ATI IKK 



HIR THPI.ACK 
Ol' KAPHKR 
iStatc or Country^ 



MAIDKN NAMK 
Ol- MOTHKR 



HIRTlirUACK 
OF MoTMKR 
(State or Country) 



e 



(^ 



dLou"ojv/cL crlxu. 

(I 






AaxLouLAj ij CPrurvKX/>v 




OCCIT 



(aO 0-v.y^-<iJLA.A>^-|Lx 



M,»ith: 



fhiv.- 



THK AHOVE STAri-:i) PKRSONAI. PARTICl'LARS ARK TRTK To THK 
RKST OK MY KN()\Vl,Kn(^.K AM) BKIJKF 



(II 



(Afldress ...iJ© 'X O CTwUk 




MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH r\ 

\Saj^ 



(Month) a" 



(Day) (Year) 






I IIRRHRV CIvRTIFV, That I attended deceased from 
^.IjL'IX^V' IgO . to LtM^/q^ 190 H' 




190 '\ 



190 . to 

that I last saw h -*-•' alive on LAaa^ 
and that death occurred, on the date stated above, at 1 1 4.5" 
CL M. The CAl'SK OF I)I';ATH was as follows: 

\_,/|x^v.xrrv-A>/t .\r\j^^^ 



Di; RATION I Years 
CONTRIBUTORY 



Months 




Days Hours 



DURATION A Years Months 



Davs 



(SIGNED) 



190 



H 



i 



: Address) W 5" 



do y.oAJk 



Hours 
M.D. 



SPEcVaL Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from home. 



'X) 



Usual Residence 

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



Days 



PUACE OK Bl'RIAI, OR RKMOVAI, 




u; 



(Address 1. 



DATK of m-RiAi. or REMOVAL, 



A I iLvA^iA^trYV 



^^ 



information .hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
5F DEATH in plain terms, that it may be properly classified. The Special Information for per- 



N. B.— Every Item of 

state CAUSE OF 

sons dyin^ away from home should be ftlven In every instance. 



( . s 



II 



J 



fW 



i: ''5 



ii.j 



I 



I. 



■( 






I Si 



' ! t,' 









■\ ' 



$ 







]f 




T 



f' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



_ .___._•>«• -^p- r-.^ry I ai ^^Tl I I /^"n <^ M O 



!'.\ !■ Ci 



REFER TO UACrv Uf v^cniiri»^(-»iw i v>" i .■« ^ ■ > ■ »> «^ ■ • ^ 



7)/-//^ Fi/cf/, 





as^ 



/e76>H 



Jteo'i.sfe/'ed jYo. 



1191 






Deputy Health Officer 



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

Certificate of Beatb 

( 11. 'I\ Gtan^ar^ j 
PLACE OF DEATH: — County of OOr^ AXX.yv^^OUL^ City of O^CX/vv 3 Axx^a_ai^^ 



No, HHC) a Axi/>x<yu-^ 



St,; I Dist.; bet. 




and 



iic^iiAi DCCinFNrF riUF FACTS CALLED FOR UNDER SPECIAL INFORMATION \ 




FULL NAME 





r 




PERSONAL AND STATISTICAL PARTICULARS 



SI A 




L 



C< '1,< 'K 



i. \ 11, t •! i'.lR I II 




A^^kXx 



Vl ftoL^v 



N!..iith 



( I);ivt 



/ISO 



> r.'ll 



A I ■.I-; 



5H 



) . ■ 



w 



-i\r.i,i-:, MARK ii'.n. 

A iix »\\i:i) <»K i»iV(»Ki"i".n 




iiiK I'll iM. \>;i': 

(Sti'tc or (.■')nnli \ 



lA Til I'R 



r.iinii I'l, AC}-; 

0|- lAIIIKK 

' St.il r 'ii r<nint 1 



MAIDI'.N NAM1-: 
<>1' MoTllKK 



I'.IKI'UPI.Ar]', 
OI- MoTHlCR 
(Sl;it(;' or Co\uitryl 






1 




/^^/CrVAT'Vv^ 



•Co 




OC( 



^'.•' 1,1,-,! HI Sill! I'l .ni, !}(■'• O '^ )V(M 



- M.nilh' - /Vn 



Til I- \i!n\i.-. sr \r):i) pf rsmnau iwrtum-laks ar}", rRn-: r<> Tin-: 

in'.sT ()| MV KNOW I,i:i)<".K AM) inn.ii"!'' 



(Illf-r luilllt 






MEDICAL CERTIFICATE OF DEATH 

DATl", nl I)I;aTII 



I'Moiith* A 



iDuy) 



(Yf;irl 



1 90 



H 



I lll'Kl-r'V CI'RTII'V, Thai I all ciuled deceased fmin 
CLuL^ "^ icpH I.. ibwA^ 'X\ icpM 

lliat I last saw IiA^ava alive on \Aa.,a.^ 'X'J 

an<l that (Katli (leciirrcd, on tlie dale stated above, at 
M. Tlu' CATSI'* (>1' |)i;.\'PII was as follows 

Hours 



.M . 1 in. V . 



DT RAT I ON ^Yiars Mouths Dovs 

/ w iv 'ri> I !>i •'rMi> \' ^Jft-wX J\/»-'^-W~ 



1 ) I " R A T I ( ) N 



Years 



Mouths 



Pavs 



(Signed) LxxaX^ O Oo^rrJu-tyvLc) 

^k^-iqoH (Addrc^^.) ioC^l U3 <W^^^-^vClt>>^^ 

SPECiy^L INFORMATION 01'y '"^ Hospitals, Inslitution", Iran- 
or Recent Residents, and persons dyinq away from hoiie. 



I lours 
M.D. 




Former or 
Usual Residence 

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



How long at 
Plat e of Death ? 



Days 



ri.AeH nl' HIRIAI, OK RICMoXAl, 



NDKRTAKl'R U /CJut/^^CtX Vj /\XXA>/./VA^ 

fA(Mi.<- I5"XH O txK«LJ!sX<rw 



DAii; of lit i.-i.\i. or ri;m<i\au 




N. B.— F.very Item otf in?,>r.mnt1on Hhouhl b. cnrcfvUy supplied. AGF. Hho:.ld be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Spec.nl ln>ormat.;>n kor per- 
sons dylnft away from home should be <*iven In every instance. 



I 



m 



'f'. 



iM 



111 






; 



i 



i 



1 




WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,,.,:,nl..tii.-:'iti, IV., :: n-v^.^; n^^l^^., 



ntrs.n i v^ u*mwn ** • 



T cnn iN«»TRijr:TiONS 



7,V6>H 



Jien'is/cfcil ./Yo. 



1192 



"Su^^Ia^ Deputy Health Officer 

DEPARTMENT 6f PUBLIC HEALTll=City and County of San Francisco 



Certificate of Beatb 

( 11. 5. StanC^nrD ) 



PLACE OF DEATH: — County 

4 



ofO^OL'^x^O/vOL/^^'v^^uiyCt City of C)/CL/>A; J;v(X/yv<^>UL.<M.^ 




^ Cj/CuY\.oXcV»^<St;tv Dist.;bet. 



— and 



/ ,F DiATH OCCURS AWAY TROW USUAL R E S I D E N C E G . V E FACTS CALLED TOR UNDER "SPECIAL 'NrORMATIO 
( .VdEATH OCcJrR.D .N a hospital or institution give its name instead or STREET AND NUMBER. 



N.) 



FULL NAME 




KAXA/- 



'>^UL 




® 



PERSONAL AND STATISTICAL PARTICULARS 

C<)I,<»K 



i r \\-\:_ I li :.; 1< I'll 



/oJU 




^15 



v\ 



< V ;ii 



/'„-i 



\\ Mm •wj-I) «>k ih\< ti", ri; f) 

!i -i;.Mi.itio!i ) 




\j<x/d^ 



iUKTm'i.Ai'i-: 

'St:itc or (-'oniil I \ 



'n- S Mi. ' >! 
I '.XT II I-K 



lUkTinM.ACH 

" ' \rm-:R 

■1 t'ouiilrv' 



'i; Ml ''I'll i:k 



isiK iiiiM, An: 

Ol- Mo'rHl'.R 

-■ 'i Mllit 1 \ 



Mcri'AiioN Qj\p 






) X\yV/\XXrYV/^rv 



Aa^^Xo/A'^^^^^'^^^'^ 




rAj 



A'' 



/ <' S,/ J/ / '; ;/ Ih 









1 ■ <',//^ 



rni-: xhdvk st \ti-. d i'i<ksi>\"ai, rAkiuTi. \i<-. aui. tk i )•• ii » i ii i: 

HKST i)l- MY KNOWl.liDC 1-; AND in;!.!!'.! 



■ lllfiMlKIIlt 






I 






MEDICAL CERTIFICATE OF DEATH 

DA Ti: (11 Dl.ATIl 



Laaa.< 



U)av) 



(Yfiir) 



T90H 



MontlO K 
I lll':i< I\1*>N' C1:RTI l'\', That I ;ittoii<U(l <k-(x-as«.Ml from 

that I last saw h -^"^ alive on Lm^AXJ; ^'^ 
anil that .leatli occiirrc<l, on the date stated aliove. :i1 I 
W M. The CWI Si-: Ol" DI'.A Til was as follows: 

KCRATloN i Years Q. MdhI/is /Kiy^ Hours 

l>rR.\Tl()N )■,<;/ V Mouths \^ Pav^ Hours 







M.D. 



Special INFORIVIATION only ''"^ llospifdls, institutions, Irdnsients, 
or Rerfnt Residents, diid persons dyin] awd) fro-n liome. 



' \J /U.-'Q^A^c^ox 



. Days 



Whf'n was disease fontr,)fted, 
II not at plare of death? 



I'l.Ari'. < »i i;t K lAi, I 'K ki:m< >\ ai. 



vAJl/>w/cxi 



-\. 



DA'llI'. "i' !'•■ i^'i \i- "1 K i■.^T' i\'AI. 




(Addrt- WW ^\\\KJ^\^^.^rw ol 



vij\X/aAtuL 



3AJUl^rv 



N. B. Rvery item ui information shouhl b.- cnrufiiHy suppliefl. AflT. s'v.ulil be stated KX4CTLY. PHYSICIANS Hhould 

state C4lISr or DliATM in plain terms, that it may b.- properly clasHified. The "Special Informuti jn" for p«r- 
Ronu dyin[^ away ?rom home should be ^iven in every inKtiince. 





<| I 



'I 



( \ 



i;| 



< I 

I 



-T 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



!;..;im; "I 



II. .ilth - I-' N'^ :• 



u^*- ■ — * 



_.-.. _. ^_>.i^ir.ir^>^r- r-rso llvier'TDII^TiriNi 



rs" -■-, !!N:1' *''! 



REFER TO Bm^K of \^trsiiriv^/-.it> 



IX«I» l<«^^t>)«l* 



■ca..wiM — 



/>^//r Fih'fl y VAaaxdl/u^^^ ^S' 



/ryf^ys 



Re^istpfcd JS'^o^ 



1193 



(>^..<rv.A.^N-o 



Deputy Healvh OfHcer 



DEPARTMENT (iF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( la. 5. J^tnn^arD ) 



PLACE OF DEATH: — County of 



— City of Oiy>x{rvoj 




'No. 



St.; 



Dist.; bet. 



—and 






; 




FULL NAME JUCsVL'^kv Y) V.XX/v-oxy^^^'^^^ 



si:\ 



i »A 11 ' 'i i;: K I II 



PEIRSONAL AND STATISTICAL PARTICULARS 







M. :!Hh 



\< .]•: 



i^c 



i . 



1 






■)/ ' I'l 



AS'i 



■>■■ :il ! 



n 



>-!\«.i.i- MAui<n:i». 

WIDoWKn OK I>!\< •!• II) 




liiK rm'i.\(*K 

st,it( 'ir Coniitt y 



I \ I II i:i< 



I'.iKTniM.vci-: 
<•!■ 1 \ rm: u 

v''iiiiilr\- 



M \il>i:N NAMl-: 
<il MnTIM-.K 








? 



I'.M; llll'I, M)-, 

'M M(>r!ii-:k 



< I ■ I ■ i : I N 



AV ■ /, 



^5 K,.- 



1/ , /// 



1 III- W.nV]-. S rATI-D CI- K->'>\ \l, 1' \K ri«M"r. \K!^ AKi; TK IK 1' > THi; 
lU'.M" Ol M\' J;^ N( i\\ I.l'lx.l-; AM) Hl'MI'l" 



Hiifo' ni.'iiit 



• W I.l.lx 



(A<Mr.- 



l\o\% 



^0-VAw<iA\; CjI 




MEDICAL CERTIFICATE OF DEATH 

DATi". <•]■ i>i:Arii 

,,„il,i A ip.iy) (Vf.-ir^ 

I ni:Ri:r.\' Ci: UTIIA. Tliat I ntteii(U-<l dcccast-d fp.in 

— — ^I(/) In ~~" I<P 

lliat I la^l ^a\v ll ali\c on T<p 



aii'l tliat (U-atli occiirrcMl. on tlu- <latv ■^taU-il altovi-, at 
;\I. 'riic C-MSI-; Ol' DI'IA Til was as follows: 



jS a_a..<yvva:^ jJ .*^^^ji^o^<^ 



I jC RATION )'r(i/s 

C()NTRil!l"r<»KV 



1)1 1-J \TloN 



.U,>>///is 



fhns 



Iloitr 



fhiy 



( SIGNED )U). fe. "O^^^JUUm 

LLvQ 1'; r.,oH (Ad.ln-ss) M\jUAr XU^m 

'E^IAL INFORMATION ""'y f^^ llospitdls, Insiitutions, Transients, 



SPI . , 

or Re( ent Residents, and persons dyiii:j away from fione. 



Former or '\ / ■ « 
Usual Rpsidcntc^^ l^ 



O^VUvVv Cj AT Plare of Ocafli ? ^^ Days 



Hhpn Has disease contracted, 
If not at place of deatli? 






ri,Ari-;^(>i- imkiai. or rkmovai. 



1-, Ol- m K I 



INI 



DA ri-: '>; 111 Ki \i • i: i-:movai. 



T90S 



(Addrtss 



(E 



Co'XH VjSrv^Kayd 



A^^ 



22 



^f 



IN. B. Hvery item of inf ,rm,n5on «liouI(l h- c.rcn.lly supplied. AHK h^ ..Id be Htnte.l HXACTLY. PHYSICIANS «hoi.ld 

stiitc CAUSf: OF Dr.ATH Jn plnin tcrm«, thnt it miiy be properly claKsiticd. The "Spe^iHl lnlfo.'.nuli .n ' for p«r- 
HotiB dylnil^ away from home hIiouKI be ^iven in every iriHtanee. 






I 



1 



m 



J 1 



I < 



I 









I 



! 



ft 



I t 



tn 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD TPf 



, f 1I.:,M!> I- No :^ t -.^rwT^ HK: »' C 



REKtH ro l3A<_r\ UP v-cniiriv^( 



I 1^ r ^ 1^ t»»^»»»^^'»»^'**'"* 



lle<^isfcre(l jYo, 



1 1 94 



^^/c AVVr''/, iXc\^'LA^ aS" l'-)<>\ * 

X<y^A.^ "Ixa;-^! Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



XX. 5. StaiiCiaiO ) 



PLACE OF DEATH: 



County of O^O^^Tyj J AXX/Tv^tAA/CUi City of 






N 



o ^^0 IJLv^cL^:^ St,; 5^ Dist,;bet. 5v tL and ^ I -U> 

r ,F DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION \ 
( ,F DEATH OCcJrRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 



FULL NAME 




'>i \ 



PERSONAL AND STATISTICAL PARTICULARS 

CO I.' »K \ 



(^nJL 



vX'ykAX.iJ 



■ i- i;iK 111 




lo 



YvJl 



X 



\ 






x-s 



>-l\< .1,1",. MARK II 1) 



r.ik rni'LArH 

(stale or CuimUvi 



' ■ • ; Ml 
1 A Tli l.R 



lUR'niri, Acic 
o|. i\iin.:K 



>» X ! I ) 1-: N N A M 1-: 
«)1 Mnrm.R 



lllRTlil'I.Ai I". 

oi* Morm-.R 

' '-' ' ' C'l Hint I A I 



'I ' i i \ r K iN 



A' 



"wxyAJL 








., /-./-/. ' ,.. 5l^ '■'■"> 5l .'A''///' X3 / 



',/ 



III!' \!i. i\i- s r Ml- 1 1 i'l.; RsoNAi. 1" vRinr i.AKS AK1-: TKri; I'l » I'lii-; 
Ki,-.! (ii M\;^x n<»\^i,i-;i)<;k and r.i.i.u;!-" 



Oiif'i- mint 






^.Wxt. 



( \(l(lrfss 



^ao jJU^a/cLolo: 



t 



(Ycar^ 



MEDICAL CERTIFICATE OF DEATH 

(M.)iitli> jT 'I)ay 

II I'.I'J I":i'.\' C1:R'I"11"N. 'I"li;it r atUnkMl ilcccasfd frniu 

C to vAAAXX ^H i*;oH 




.CV/V up C to 

tli;it I la-;l --.iw li'O > > ' ;tlivL- on 
and tliat '1 
«^ M. The CArSI- ni" DllATll was as follows: 



s.iw li'^ > > ' ali\ L- on UV-A^\-0|L '^v ^''9^ 

Icatli (ircurrecl, on tin.- ilatc- statL-il above, at CKjyX 



1)1 RAT ION 



)'('(;/ -.s- 



Mouths 



l)a\ 



s 



Ilou 



rs 



DIRA'I'ION )V,7rv .lAv////,s- /'>(jys Hours 

(SIGNED) \j. \A. LwYvfetr^V M.D. 

0.S ic,oH f A.ldrc'ss) ^l-<Lt <V>\xi JlOlHAKXVt*.. 




Special information '»n'y f'"^ Hispitdls, Instifutions, Trdnsicnts, 
or Recent Residents, and persons dyinj ,iw.iy lro;n home. 



Former or 
I'sudI Residence 

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



How lonq at 
Pl.)(e ot Death 



Days 



I'LACi: Ol- lU RIAI, OR ki;M<i\Al, I DA'lJlof UfKiAi- or RICMOVAI, 




rXDl'.KTAKI'.R 

(Addrtss 



^. K. 5;vcry item of in? .rmntion should be cnrefully supplied. A(JB sli^uld be stated EXACTLY. PHYSICIANS should 

Htute CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par- 
sons dyin^ away from home should be ftiven in ox^ry instance. 






-'I 
i.ii 



' Ii 



■i'l 

I, tf'i 

I;] 

'«o 



i 



W 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



! !• iiM i' 



z^/ — . i,.v r *■ 1 



REFE.H ru HAUrv wr v^cr>i<riv.>^... .».. ■■ • 



Uei^L'^tercd -^^^ 



1195 



w 



ir^ 



Itr.^.'Lv^ Deputy Health OfHcer 

DEPARTi^ENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "U. 5. 5tanC>arO i 
PLACE OF DEATH: — County of QJxX'^ O-'^cx^out^c City ofUAX^ ^^^XX^^^^^^- 



O 



NoJ 



L.d 




(y^l^vXOulSt; Dist.;bet. 



" and 



v. 'O-*^ r >-^ ww<^ „.. AeiiAl aresmrNCE GIVE FACTS CALLED POR UNDER SPECIAL INFORMATION' \ 

( ' ';r:^.i'iiii::':: ::TJ^'^.\'i o^^nst'itJv^o^n'o.ve ,ts na.,e .nst.ao or stre.t and nu.ber. ; 



FULL NAME 





Osj^rro 




ij CLW^ 



PEIRSONAL AND STATISTICAL PARTICULARS 



^cJL 




DA 



LL'>On^~v^c^- 




■^5 



K l< 11.1' 



MIRTH PT,A('l-: 

111' 1. \ I" 1 1 1." I,' 



MAIDKN* 

( 1' ■ ■> • ■ ^■^• ! 



HIR I iil'LA< \'. 
OK MflTHFK 




">■*'!■ r sTii i\' 



yronf/ts ^ Pays 



/'i (iiicisro 



Yrars 



in: An<)VKST\Ti:i) I'-'K-^ONAM'ARTICrr.ARS AKHTRrH TO THK 
HKST OF MY KXOWI.KDOK AND nEL,IKF 



h 



ifMniunU UL- 3. LI . "^Jl/VUlA-oJL V>0 &-^V^t>oJL 



f Address 



tEDICAL CERTIFICATE OF DEATH 

M-.titlit i^' Davt V.,M) 

I ni':UI{I'A' CI-:RTli*\. ThMt I atU-iuUMl deceased Inmi 

ilive lUi VA-(vA.^ A.6 Tt)0 ' 

iM.l Ih.it .ItMlli oc.-urre.t, ^n the iliitv stati-il above, at O b 

— ^ 

\[ Till ; \! ^1{ i)!' I)1''.\'I'II \va< as follows: 




-l\V 11 



-C^YV 




JlKrtXv. Ju>-'Vv<3/<5 



k^v-/CL/xAJ 




1)1 RAT ION );w;-f 

CONTRiniToRV 



Month!i 



Days 



Hour'; 



DURATION 






.]f>^ith^ 



/\iv 



( SIGNED ) UJ . J . JJ <X/\^xxiLA.^'vx/ 



M.D. 



Os'i* iqoH ( 



Ad<1r e>^--)U. "^-U^. <i-g>^ %(v^><p. 



SPECIAL Information only tor Hospitals, Institutions, Transients. 
or Recent Residents, and persons dying away from home. 



Former 

Usual ResMence 



esMence NJ • GN- 

When was disease contracted, (-? M 
If not at place of death ? VJ- C?v, 



How lon(| at >-v 

f»laf e of Death ? M 



Davs 



PI, ACE OF nilRIAI. OR K1;M()VAI, 




DATlCof HiRiAl, or R1:M<)\"AI, 

u.^ a 



(Address 



wrwrmm^-irmmmmmmrjr% 



mm 



N, B.— -Fivery item o? Informntlon ahould be en 
stBte C\USE OF DEATH In plain tern 
Rons dytnit flway from home nhould be 



ppicd. AGFi HHdilll !»• stated EXACTLY. PHYSICIANS should 
may be properly CTa««lflad, The "Special Information" for par- 



may be prope 
-vary Instance 



I 



!! .t] 







ll 



isasm 



IT 



i .;■ 

i 








WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



_ . . . •■» «- w.rf^»« itti^k -m ^ I I /^ *^ I ^\ tki I 



.,-,1 .,1 Ih :.;iii 1 



^. r,\ !■ '•• 



REFER TO BAC»S 0»- LitM I IM<-m i t r\->n i ii s? » nw^ i »v^'» 



/>^//r I'll ('(I . U^^^OA^VwXijfc ^S" 



/V^VH 



lle^lstei'cd J\'*o. 



it 96 



dvw>t)A^Aw.Aw^ 



Deputy Heakh OfTicer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate ot Beatb 

* { XI. S. 5t.1n^av^ ) 

PLACE OF DEATH: — County of OxXm; JAaxy-rV<^c<iC(; City of ^<Xm; AXXa^x/CAA,<M) 



No. IHOl i 




L; Dist.; bet. 




and 



( 



Cav.^JLA^^ St, 

_„„.. iiciiBi D r =: I nr Nr E" r.i vr facts rAHPD for under special information 




«^/wiX^ ) 



FULL NAME 




O^L^Vu 




X^Y\a^\Xyv\i 



PERSONAL AND STATISTICAL PARTICULARS 

xAk ""■""IdI^-u 



1. > '1 i; iK I'll 



\' .I''. 



55> 



M. !l'll 



) 



5- 



^ 



\^ 



(Year* 



/),;!> 



u iiM >\\i:i) OK DivoKci: t) 

Wiit'iii vni-iiil di ^ii'tKit i' 111) 



I'.!!-: rn IM, A'"!-: 
I state or Ciiutitry 





y 




!• ATii i;k 



p.iKriiiM, \(K 
<M ixriii'.K 

"^; 'i ■ '1 (.'(Hint I \- 



MAIDI-.N NAM!'. 

<»i- Moiin;R 



iMK-rii iM, \ri-; 

"1 MOTHlvR 

' ^t;i!!- m (.'iiUIltlX^ 




Oo'>^ 



a^Xaj oUxa^vx^^^CUIa.. 




< I'AI'l'Al |()\ 



h't'sidf'f in Sijti /'K'Uii^r.} lo )'■••!! 



Mnitlr 



nr\ 



liii: AHox}.-, sr \ri:!» rt<'K>;( »\ai, rA:<i"u"f i, aks ak j; I'RrK to tii )•: 
I'.i'.sr ()i- MY K\()\\i,i:i)(-,i': AM) iii",Mi;r 



'Inf.,- maiit 






(Vtrifl 



MEDICAL CERTIFICATE OF DEATH 

Dx'ii', (»!• m: A I'll r\ 

ULvCL IH 

(M.)iitli) /T (I)ay> 

I II i:1n i:i'.N' Ci: UTI I-'V, 'I'liat I alteiKlcd deceased from 
MtXy^V rooH to LLucO "^^ i<;oH 

3 n (T ^u u 

thai i la-.1 ^.t\v h A^'Y>^ ah\i-oil VAA-A^CL ^ »■ Kp " 

and that .U-atli oociirrcil. on tlie date stated above, at O • OU 
M M. Tlie CWrSi', ()!■ DI'.ATII was as follows: 



XXX/\x« 



nr RATION Ov )\'ays MouHn Days 

Cr >VTK' MUTOR V dU >OCXA?-<XJLa 



Jloiti s 



DrKA'l'loN 
(SIGNED) 



)Vi//'v 



Moiit/is 



VJV. dv. MVAxytLcrv 

XH. i(/>A f .\ddrt-s<) 



fhivs 



M.D. 




Special information '»nly for llospildls, institutions, Transirnts'', 
or iierent Residents, and persons (lyin;j dwa> froii home. 



Former or \UK<i 
Usual Residence I" ^^ 

When was disease contrarted. 
If not at plareof death? 



o^xamXI' 



Days 



I'X All-: oi' luKiAL ok ki:m<>\ai 




HA'l"K ')}' HiKiM .'1 RKMnXAl, 
<UJXA!t£A/w LXxlAAjtA.^rvv OAA.'we/vXxJo djK^ 

(A.i.iie^s H'XH JLJ-tA>x^ux<ijLM) at 



N. ij. Hverv item of iM?<.rm,.tion shouUI h. cMreV'ully suppllvMl. AHR «^ioul«I be stated RXACTLY. PHYSICIANS should 

state CAUSE OF DFATH in plain terms, that it may he properly classified. The "Special Information" ?or per- 
son* dyin^ away from home should he g^iven in every instance. 



i 



,! 



I'J' 



I I 







it, 



fl 



111 



it 






»^M 



1 



:X ■ ■ 

■I 
4, 



f 



1 



»ll 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,,!,,! IK, .nil I' ^ ■ - ^T'^-;r' i'^''^' 



REFER TO BACK OF CERTIFICATt HJM I ins i nuo iiui^io 



Duh' riled, \\x^<X\^^ %^ ^^'^^^"i 



Reciititcred .A7;. 



il9? 



Ov^tr^LA-^^^ ^ 




Deputy Hi. * OfHcer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDcatb 

I 11. S. 5tanC>avC> ) 

J? QSTl ;S ^ 

PLACE OF DEATH: — County ofOcL^ru OXXX^p^ca^^o City of (l)>CL/vu OAXX/>AX^<tX^c> 



No. lo^^ 



and 




.^C. St.; 2. Dist.; bet. dJxA^' 

r IF DEAT*\ OCCURS AWAY FROM USUAL R E S I D E N C E G ! V E FACTS CALLED FOR uioER "SPECIAL INFORMATION" ^ 
( Tf DeUh OCCU"*- - I wn<.P,TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



OJ\J~\\. 



IRRED IN A HOSPITAL OR INSTITUTION GIVE I 



1- 



FULL NAME 




XXLy^\) 




.1 



PERSONAL AND STATISTICAL PARTICULARS 
QO| ft I C<„.,,R 



si:\ 



|\11 nl l.lKril 






N!..n\li 



^tja($. 



11. 

. I)avi 



Cr*VA- 



qoH 



V I ai ) 



^i\«.i.i:. MAKk ii:i). 

\\ iix iw i-:i) OK r»!vnKri:i> 



■W-if i;i - 



luk 111 I'l. xt'i-; 

' St:iti' or I'lniiiti \ * 



N \ M i 111' 

I \T1! IK 



lURTlIl'l.MK 

OI- I Ni'in-R 

'Sl-it. .,t (■.iiiiili \-' 



■iiat I'lMJ 








MEDICAL CERTiriCATE OF DEATH 

DATi'; i)i- 1)1".. \rn r\ 

(M< lilt 111 /T (Day^ (Year) 

I H I'ik i;i'.\' C!{RTI1'\', That I attnukMl (Icol-mscmI from 
LLu^ 'X'b 190H to LLlAXD. '^^ KiO H 

tliat T last saw h alive 011 • T<p 

aii'l that (irath i)ccurre«l, on the ilatt- stattMl ahovc, at 
M. Tho CM SIv Oh" DhlATlI was as follows: 



DC RATION 



)'i'tIJ-S 



J/, >>//// s 



/fays 



//o/ns 



C0NTRI1U'T()R\' ^<0(nAA>v/QJL \J Kv^^OAA-^-XX-OX 



M.\Il)l-:x NAM!-: 
<•] Morill-.R 



niK |-nri. \ri-; 

o|- MOTIII-IK 

'St:Mi c.r <"cpiiiitiA- 





,01 V) U5-VAA/^.XOwXX.cL 






)■.,/, 



M.nlll, 



'\'\\V \Hi y\V. SI' \ !'i: I) 1M.:kS(>\ M. 1- MvlI'T 1. AkS AK 1', i'K ll'. I'l > Til V. 

i'.i;sr oj- MY K NOW i,i: I )(.}•; and i',i;i<n-'.i' 



''!:if" lii.itit 



1 



I ) r R A T [ O N 



^SIGNED 






Af.'Nt/lS 



00. VlJlLu 



fhu 



'\ 



Li-^a XH. looH (A.l.lrc^ss) 0.^0' 



d 



:CIAL INFORI 



t 



ft^AVOAct 



I Ion IS 
M.D. 



SPECIAL Information only tnr Hospitals, Institutions, fransients, 
or Rp(ent HfsiJfnfs, and persons dyin.i anay frnn Iiotip. 



Former or 
Usual Resldenrc 

When v\as disease ronfrdcted, 
H not at plare of death ? 



Ho\s long at 
Plare of Deatfi ? 



Days 



I'l.ACi: oi- nruiAi, (iK iovMuxai, 



l»Arj; m! I'.ikiai, or KKMOVAI, 

LAaax:i 0v5" T90H 






Adit. 



IN. H. I.very item ot* inf)rmiition Hhoul.l h- ciirot'.illy svippHv-il. A'lK kS. ild be statcil I.X4CTLY. PHYSICIANS Khoiilii 

«t«tc CAUSn or DI:ATH in ptjim ttrms. thsit it m:i> h- pff)i>Lrl> classified. The "Special Information" for par- 
sons ciyin^ away from home shoiihl he given in every instance. 






' TiFwr 




I JjwjfiMj 




ii, 

1 


■. ■( 


II 

•1 \ 

'■' j 








! 



<^m<^- 






i 



•^ 



I 









I ^ 



Wwmt 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



ii.riiil ;^t" 1!. :i'i!i 



,. -ifX^-^'r-^i ii\ i' C, 









//>^>H 



2ieo'i\sfej'e(l Xo. 



1198 




No. 



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

Certificate of IDeatb 

( 11. %, 5tanc>nv^ ) 
PLACE OF DEATH: — County of 0Oy>^ 0/u:xy>vc^-4.C.o City ofO/CL^r^' /\^<X/'>a/C\^<m:) 

UJoJLdjUL-k v^ , >.-., — .- .. . 

r IF DfATH OCCURS AWaI FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION • \ 
( ,F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 




St.r 



"Dist.; bet." 



and 



FULL NAME 



IjJjlA; 




m:.\ 




PERSONAL AND STATISTICAL PARTICULARS 

CCI,«>K\ (J 

: ■ \ I i' I If i;lK 111 ^ (^ 




1 l:i\l 



\' .}•; 



HI 



)•-•,/; 



( Vcai I 



Da 1 . 



-I\(,l,i;, MAKl.ir.l), 

U l!)M\\!-: I> ok DIVi iK*'!-:!) 

W: ■• ' -1 -ori;il il • " .t i.m) 



itiKiiin. \oi-; 

'Sl.'itc or (.'ouiiti V 



\Mt' i>!' 



lUKTlli'l, ATK 
(St./ ' Miinti\- 



MAI!»i:\ NAMH 
<t|- MdTIIl'.K ' 



I'.iK'nnM.Ai].: 
Of" M<>Tin;R 




Jij'^'xnX) 



XKrr\jwX 




IQO 

(Day) ( 



9o\ 
Year) 



MEDICAL CERTIFICATE OF DEATH 

DA ri-; « II' Dl'.ATH /~^ 

I M l{R l'".l!\' e' I-: RTI I-*\ , '\'\\a\ I atU'JiMf.l lU'ccasc'd from 
CXa^oO, ^"^ KpH to LLaaXV 'X\ Dpi 

that I last saw li .<l/v^ ali\c- on UsAa^Q '^1 up ^ 

and that death of<-urreil, on tlic datr stati-d above, at \ 
LL M. Tin- C-MSl-: Ol" I)I';A'riI w.-is as follows: 



DIRATIO.X )'i'ars 

CoN'rkilU'TORV 



Months 



Days 5 Hours 



1) r R .\ T I () N 
(SIG 



)\'ars 



NED ) Ij. dU- M/l OJttluV>- 



Mi)}tths Hays 



/fi)urs 
M.D. 



Rr^iifrd in Siin /'i iwi i ,'i> 10 ) ' •' 



^ Mifth'^ 



/),n 



rm: aiu ivi-: s r A-n., d i-i-k -i i\ \i, c \ki iii ;, \ks ak i-. ikii". k > 'lii i". 

Hl'.S'l" Ol' MN- KNDWIJ'.Di . )■■, AND lU; 1, 1 1'. !• 



'ImT. ,.,,,.,„, 






an D,oH (Ad.irrss)0.a?, Vj6-u>Jl dt 



Special information on!v lor llosiiitdls, institutions, Iransicnts, 
or Recent Residents, and persons dyin?} dway fro-n home. 



Former or 

Usual Residence' OciA 



When was disease contracted 
If not at plafeol deatli? 



•\ ij) How lonq at ^ 

(MXXA>^AXAAhtyUJk' Pldfe of Deatli? ^MhA Buys 



I'i n^H 



I'i,AC"K <)1' IMKIAI, OR RI':M()V.\I, DAI"K-): i!r kiai. oi R l^MOV.AI, 



r.ND 



i:rtak),r \JCr\t«A) ^ UOixAilil 

'Address HX'i J O-LcLt^ro CxXe. W^-M, 



^'V'^mmimm^rt. f 'mm i m t 



N. H. !;very item of infirmiition should hj viircfully siipplkil. Adfi s'l-mUl be stnte.l HXACTLY. PHYSICIANS Nhouid 

Ktiitc CAUSn OF DLATM in plsiin terms, thnt it m.-iy he pr.>|>crly classified. The "SpecinI Informtition" for pur- 
sons tlytn^ away from homo should be ftiven in every instance. 





-i 



' 1 -;• 



' i • ! -' 









w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;,,ai.! '■ !!■ .I'th I' N''> ■ 



•■•;. •s-;. .-.;. i;.V 1' I ' 



REFER TO BACK OF CERTIFICAFL hU H »rN:3i Huv^i (<wn^a 

■ ■■»ijiiiiiiini.»iiiiii» iiiiiiw^— — ^— «i— i».a— — »^ri— — —— — — 



'.. 



M 



I />.//./••//,./, CLv<Wt -XS- l!>0^ m-gLsfcred A'-o. 11.99 

"cL^vA.^ "1jla>-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Gcvtiticate of IDeatb 

( "U. S. t^'tan^nvC> ) 

Jj ' ^ A ^ 

of ^'CUTu hJXn^ZAA.xu> City of O/O^o^ J A^XXyY\K:>^^^<^^ 

'\ f (? 

^-v^ St.; 9n Dist.;bet. ^^^:»-^K^-<rvv; and ^ ^ 

/ IF DTATH OCCURS A'VAv rnoM USUAL RESIDENCE GIVE FACTS called/for under 'special information ■ N 

(, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N A M E |jl N ST E A OT STREET AND NUMBER. / 



PLACE OF DEATH: — County 

No. 1 I'^s^ 





FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



M.MUlit 



'p.ivi 



aa 



/hi 



'-INt.l.K. MAKk !)•■.!' 
WllXiWKI) OK I)!V< ' 1 M 

■'■ • ■ •■ - :••-■■ :iatl(.;ii 



li!l< riM'I, A'-]-: 
' St.itc or I*. iiiiilr\ i 




.j^Aj-^rV^uixx 




■> \ ^1 r III' 
1 \iiii:r 



IlIKTlllM. \('K 

"!• 1 \rii i-:r 

'untrv 



m\i!u;n \ami-; 



HI- Mt)Tni:K 

'•' .' 1 CMllHtlN-t 



; A 1 n >N 




A.) 



'vx^rvu-'w 





MEDICAL CERTIFICATE OF DEATH 

DATi-: ()!•■ i>i;ath r^ 

(MontlO A^ (I)avt iVcar) 

I 1 1 i;i'i I:P.V CMF-iTll'N', Til. It I atU-iiiK'<l (U'i'L-,isL-(l fr.mi 
UUax:i a i(,oH to LLoco X'X u,o H 

tli:it I last ^a\v Ii-.«-^v- alivi' on vJ^A.^«^X3. 'X'X Tgo H 

aiiil llial (liath ot'currcil, on the 'lat*.- statt-il a1u>\-<.-, at W 
LL M. 'I'lic CAISI-; ()!• DliATlI was as follows: 




(."i'N'rivM'-l'n >RV 



DIR ATH )N- 
i SIGNED ) 



Months 10 /;,/iA- //(;//;-.s- 



Iliilir:^ 




^^ 



k 




Rrsiifni III Siiti /'niih ■ - » o ' 



1/ ./f/i. 



Ihi\ 



Hh> 1 <il MV KNOWIJ.D' .1-. AND lU-.I.Il.l-" 



•:i:int 






Os.,Aw^-,-<lA.JrvX 



\.l.li 




/cJkA^crru Q'i 



}\\iis Mouths c) /)<n'.v 

NL. O. VIjaxA^ pOL M.D. 

( (VVi -f n 

^^ i<)oH (A.ldn-;^) HloO \] rUnrXQA^LL/vO. 



Special INFORT/IATION only fur H.ispitdN, lnstitutions,^Transients, 
or Recent Residents, and persons d>inj anav from liome. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Davs 



I'l, \r )■: oi- lUKiA I, < >i< !<i-:mi i\m. 



Q%b OJU^ 



!»A1K..: I!iki\i, (,i KI'.MOVAI. 
Llx.A^ X^ T90H 

.\i>):k 1 aki:r NKaJLo-a^ C) vJ CrcUc<Xvv.' 

(Add; - 3>C)^ \I lWv^X<YH ^*-*^-^ 



N. R. Kvery ifcm oV inf jr-m^tion shouhl bj carct'ully sujipH.-d. A^Ih s'loilil be stated [.WCTLY. PHYSICIANS Hhoiird 

Htntc CAlISr OF DIZATH in phiifi terms, that it m:i.v be properly classified. The ''Special !nf«)riniitii)n" for per- 
sons dyinjl away from home Nhould be j^'^e" '" every instance. 



>Ti 



m 



i 



'Ul 



I 



.4 

tI 

A-l 
\ 

• .1 

'I 

1 til 



y 



m 






liiikc 



i 



t 

I 




I f; 






f5^ 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I 



Ihtfr /'7/r^/. 




nu/'i 



REFER TO BACK OF CE RTIFICATfc FOH t rMa i hul. t iui>i o 

1200 



Jice^isfri'efl A^o. 



CX.<^<A.^^^ 



Deputy Health Officer 



DEPARTMENT OF rUBLIC HE ALTH=City and County of San Francisco 

Ccvtiticatc of Bcatb 

, 11. 'I\ iIitan^nl•^ 
PLACE OF DEATH: — County ofCj/CXA^' AXX/>\CUi Cx City of Ooyy\j 3K^^^<^^^<:^^ 
No Lvlu,^ L^VU-^xtu (5^^ ^ lvda.l St.; Dist.: bet. and " — ) 

/T / ,r nrATH OCCURiAWY TRoJ USUAL RESIDENCE CVr facts called rOR under special .NEOPMATION \ 
( .rDE.THOCcijRRVD IN A HOSPITAL OR ,NST,TUT,ON G.VE ITS NAME INSTEAD Or STREET AND NUMBER. J 



FULL NAME 




« 



U XXXiV<X/W\i 



Sl-.X 



PERSONAL AND STATISTICAL PARTICULARS 




uj yixcti 



!K III 



\\':;!t Ml - )i i.-il ili'>.i !.'n::l '.I til 



"■; ^ r]- 



(Statt 



NAMK ni- 



"in. \v 1-, 

NTHHK 



MAllJl.N NAMl-: 
in- Mt»THHK 



niRTui';. , 1 

<»F MOTH Ik 

<Slatf or C' limit \ 




MEDICAL CERTIFICATE OF DEATH 

DA : 1. ' i! : 'I '. i i' ; "\ 






ij 



iVcrtr^ 



1^ 

■ IViy' 
I II !•■. Iv I'. r.\' Ci i;ill\. That I attni'U-il (Urr.ivi-,1 Itoni 



that T lavl <:i\v li " " i' x* <>n -~ TqO 

ami that ilcath (U-cnrrod, t'li tht' di'i ^taliil alioM-, at 
" Tvn ^^- ''^^''" ^'-^' '^''" *^^' ni'iATH was ;!•> follMW^: 

DIR ATION )V<?/-.v Montha Pays Hom^ 

(. ( )NTRnur()RV 



i' XI'IMN 



/,■ 



V^/0^\J|AjLy^'vAL,cV- 



•- 1,', - '//- 



Tin", MiOVI-: ST \ II-' I) l't"'K>i«)N \1. !'\K ri*M"!. AK 

lu-.srni- Mv KNi'Wi.' ' ' \M> ni:i.n:K 



K i 1 T< > "I" 1 11" 



' Inforniaiit 



Lxr'Vcrv^jL^v/i vj 



VVv t^-A. 



'\.Mt,.^c ^ 



1)1 I-J \'ri( )\ ) V(?r\ .]/.»;///;\ 

( SIGNED ' UjVO-Vvjyv J, . 

a 







Hours 
M.D. 



IH T<)(^H ^ \.h1n-;v) UrVCPk-vXA^ 



3ec8al Information ^nw for 



iD^y 



V '^v 



Special information fn'v lor Hospitals, Inslitutrobs, Transirnts, 
or Rnenf Rfsidents. and persons d\inq dwav from home. 



Formpr or 
Isual Reside ncp 

When was disease rontrarfed, 
If not at plare of deatli ? 



HoH long at 
Plare of Dcdtl) ? 



Davs 



PLAll-: or lU KIAI, ok RF.MOVAI. j I>\ll 






rNDKRTAKKK JaxLIm ^^ fo O 



^.1 



^. B. T;very item <.» informit Jon KhoiiM be cnr-eV.iIly Hupplied. X^W. shouM he stated I.WCTLY. PHYSIC! \NS Rhould 

state CAUSr OF DI:ATHI In pljiin terms, thsit it m:iy b- properly classified. The "Special Information" for per- 
sons dyin^ nway from home should be j^iven in every instance. 



I 



■1 

vA 

^ 'V-.H 






I 






' [I 



. *< 



I 



t J 




-.-^ 



A^ 



'•'^^a^ 



Tfi 



li' I 



ni ; 



^i*^*ft 



WRITE PLAINLY WITH UN 



FADING INK — THIS IS A PERMANENT RECORD 



,,1 II. .;lt!i IV. 



l}(ff(' Fiicil , 



;.V!' t' 



cMj-^^aa^ 




as- 



u)(n 



REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS 

" 1201 



Resist ci'cd Xo. 



Deputy Hccfth OPIcf^r 



DEPARTMENT OF PUBLIC HEALTH==Ciiy and County of San Francisco 



Gcvtificatc of IDcatb 



( "U. S. t?tnn^ar^ ) 



PLACE OF DEATH: — County 



J asp \ (^ 



m 



Ng. 




St.; 



Disl.; bet* 



/l/T DEATH or. CURSAWAVFROliL, ., ... r 

^ \) IF OEATM OCCURRtD IN A JtOSPlTAL OR INSTITUTION GIVE ITS NAME I 



aiiJ 



USUAL RESIDENCE GIVE facts called for under special information \ 

^ nstead of street and number. J 



FULL NAME 



ijJjLAj 




AwAw-CL/U 



t) x\aA- 



Ct<i-Cnk 



^i;x 



PERSONAL AND STATISTICAL PARTICULARS 

' CnioK 





-^!'v\iji 



■;; K rii 












A' .!•: 



5^ 



T ai 



WIDnWKn (»K I> • 




lUK 1 li I'l, \>M-: 
'St;iti' or C'umt I v' 






wMi-: oi 

1 XI'liJK 



I'.iR'nii'i.ArH 
"'■• 1 \rm:R 

-■ ' ■.nl!\ 



M \II)l':\ N WIl 
OI- MOTHl'.K 



lUR THI'l.Ari-. 
(U" MOTHHR 

"-^t:it- or rnuntrvi 



» cri'A ill IN 



AaaX-'ClaJ" A^/YVsy^^^J^JV^U^y V 





IV»EDICAL CERTIFICATE OF DEATH 

DATI-. Ol' 1)1. AlH 

V\ 



d 



I MoiiHO X iDav^ (Vt/ar) 

I II I{K i:i'.\' c; i;R'ril''\', 'rii.it I ntU'iiKtl «Uih-;iso«1 frMm 



1 1 /) 



to 



tli.it I l:ist saw ll -^ alive oil 



I()0 

I (/I 



ami that tirath mccu rrc.l, «>ii llic diU' stati'i] abnvr. at 
M. 'riu- CWrSIv Ol" I)l{.\ Til was MS follows: 




QP> n ou 



1)1 RATION )\'ar% 

CONTKUU'roUN' 



4 ^J^.^U. i4tG<v^i 



-X'.; 



^Vv.A-O-VA^'CyA 



Moil tin Pays 



I Ion IS 



\'',:lll' 



11!' M'.DVl', SI" \!1I) IM'", !<S< i\ \ 1, )■ XKrUT I. \i;s AKi; rK!!-". i* ) 1" 1 1 1 

i:i-;sr ()!• .MS KM >\\i,i:iH-, 1-: anh hi:i,ii 



, lilt 



^\<Mlr 






1)1 l\.\'ri<)N )"''/r\ .7/W/////S- /^/r.s- IliUirs 

f SIGNED ) UyVXrvUA; J. MJ.U). X(L^^ M.D. 




oLo i()'i H ( \M<1 ii- 



SPECIIAL Information '»nlv Inr llnspitdls, Inxtitutions rrdnsicnls, 
or Rerenf Residents, and persons dvini aw.iy froii homo. 



Former or c. i i) (0 D ' ""^ '""*' ''' 

L'sudi Residenre I C) I H ^ a% \. ^ \)^^ 



>AX/x. H^'i.K e ol l)e.ifh ? 



. Odvs 



When was disease rontrai fed, 
If not at plat e of deatfi ? 



r!,ArK<»i m'KiAi, ON ki<;m(»v.\i, iiNir, 



U/oJkXxx^v^^ 



!<i:mm\- \i, 



U-^-^ ^5 T90H 




N. B. F.very Item ..»' i-i? .rm;it ion kIioiiIiI b.- ciircfully siipplictl. \'\\\ shouhl bu Ktiitccl KX \CTLY. PMYSICI AMS Hhoiild 

state CAUSr OP nilATII In pbiin terms, tbiit it msiy be properly cluHHil'ieii. The "Specini IiilTormiitlan" for pwr- 
Rons clyin^ nway from Iiomo slumlil be J^iven in every instnnce. 



■**!*5*4 



Wfm 






: ( 





l^^] 
1 1 i 



I • 




I; 
I 

■ * 1 



!((i 



ilia 



\ , I' 



simnw 



un TT 



i 



■ 



\"\ 



w 



I 



. ' , 






WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD TPE 



1 • ■ i I ' 



l,:i;ih iv^ 



1!\ 1' t' 



Date Filed , \X^kj<XD^j<^^^aXj 'X^ 



rJ0\ 



REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

i202 



l\e(^ish'i'e(l jYo. 



DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of Bcatb 



( 11. *In *IitnnC>aiC> j 

PLACE OF DEATH: — County of ^O-rr-^ OAXX^^-vc.^a<:ity of 0<Xyy>^ J .>v<X/vv^oci'CO 

1^ 



No. lA^tu^^' 



A / IF DLATH OCCUR 
U \ IF DTATH OCC 





<Xh SU 



•Dist.; bet. 



and 



R-alAWflY FROI>* USUAL RESIDENCE GIVE FACTS CALLCD FOR UNDER ■SPECIAL INFORMATION ' \ 
RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




<L^ r\ (VULt 





K^Ou^'yxA 






X^'>^<X'' 




?) 



M nth ' 






n.'v 



'Viarl 



\ ' ■ ! ■; 



HI 



1 



lo 



:.; . MAR !^ 11.1>. 

\\ • ■'.■ ill -'.ri:,! i.v;....-.' ■...,! 



i: I; llll'I. \i"l-: 



! \l II 1 K 



I'.IKIIIIM. All.; 

<>'■ I'xrin-.R 

-' ' • 'omit I \ 



^t \ii>i:n- nam i: 
«w Moini-;K 



1'.!!; i iil-KAr}'; 
'»l MtiTMI'K 

! ^hil' '>i OotmH \ 



(^ 




>L/'>'\XxX^ v<>- 




,^<X'»V; (JID/CL'^-V-CUL'^V' 



il5i^ 



.laOOoo^^ 



ft) 




A'> 



a. 



XJZyW'dL 



MEDICAL CERTIFICATE OF DEATH 

nAii-; ni- Di; \ I'M 



LLlv,^ 



il):iv) [\\-.n) 



Month I A 
1 II I'.K I{1'.\' CI'.R'rn'W TIlMt I lltUMl'ltMl .IcHWlSod ffoMl 

lli.tt I last ^a\v li -^'^' alive on vA-V-AXX. '«^^ 1<)<1 '^ 

,JS 

aii'l that (k-alli occurred. >ni the date stated almve, at i v; 
Lv M. The CM S!' oi" DI'. A Til was as follows: 



1)1 RA'IMON )V<//-.s- 

C( »\TRird"r<)UV 



Monlhs 



Days 



//tKirs 



I ) r R A T 1 () N ) '(Vrv Mojitlis 



/)</! 



'S 



( SiGI 



^ 




' HA'i r \ 1 |( »\ 



f^uii-'. : II S,u! ■ 'I O U 



I'll }' \li( iVl', Sj- \:-!l> 1"I-K^( )\ A 1. !• \K ri'I I, \ K-> AR1-: TKfl-: '1'" > T! II-'. 

I'.i'.sr (>i MS' K Nowij; !)(■}•; and 1!i:mi:i' 



' I n li !■ nri ii I 



c.(?.%euju 






(A '1(1 



r<- UXu^Co. Ob(yA.^vXcJL 




an looH 



Adil res- i 




ve. 




1 1 out s 

M.D. 



SPEoIAL Information '»nly for llispitdls, institutions, Transients, 
or Recent Resiilenfs, and persons dvin] .r.vdv fro-n tiome. 



Ilsiidl Residence oOSM lUcu^v 'TH 



Usual Residence 

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



How long at ^ 

Place of Deafti? O .. Davs 



I'l.ACi; ol- lU'KIAI. OR Rt;Mo\ \I. I ' A T 1 



LIa^< 



. ; i<i;m<i\ \I< 
'^^ T 90 H 



r XI) K R T A K 1 ■: K OvD . Vl . VJ jlIxa-^uL'v .. 



'A<l.li' 



IN. n.- 



-Hvtry Uem uV i-iVormjitlon Hh,.ul<l I..- ^Mt-cViilf.v suppliea. Af^F. «S.»vil(l be Htnted F.X4CTLY. PHYSICIANS should 
Htiitc CMJSfZ OF= DIZATH in plnin terms, thiit it miiy l>e pnjperly classified. The "Si)ccinl InV'ormntion" for per- 
son* dyin^ nwny from hfntic Hhould be ftiven in every inBtnnce. 



'« 



/ r 



, I 



i l: 



h 



; f "A 

■■\\ 



I 

li 



^!f 



'lit. I 



• I' 



II' 



I 



1 


1 


1 



i 



1 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I It. :,-y\- 1 "N. 



, ^■••^:X:- i;\l' r 



l)f(h' Filed , \Xk.\.XX^JoOZ. QwS" 




Deputy Her!**! Offin^r 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1303 



Bc^ii.sh'rrd -jVa. 






DEPARTMENT OF VUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 

PLACE OF DEATH: — County of C:W'CA.<X'V>xX^rA."to Gty of C3 0.<l/vx:^^^>^X/T^±x> 




No. 



( 





V 



C^ix^Xcx,!) 



St.: 



-Dist.; bet. 



and 



,. o^TH OCCURS Uw^v TRO. USUAL R E S ■ D E N C E o > v_r _ r.CTS c--,^;- ^^^J ;,%%-'.%^'rr^^^^ 



irlbcATH OCCURRLD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME 



FULL NAME 







-i.\ 



PERSONAL AND STATISTICAL PARTICULARS 






L 





1 \ ! i , 1 'I 



\' .I-; 



Kill 



r%^^. 



W' •1\'\ 



( V<-;ir) 



a? 



1/ •'■/.' 



M AK I 1) ! t 



WIDoWKI) OK 



I'.ik iuiM, \r)-; 

' St:it( or c'Dimtrv^ 







Oo' 



<1 



(^ 



Cj /Ol/>^ X.Ol/-a.<:a^<:ix.- 



NAMl (M 

I \'rii i.K 



i!iK III I'l, \ri-: 



MAII)i: \ NAM J". 
<)1- MollH'.K 



iilRI 11|M.A> l'. 
'>1- MO'IIM'.K 



'' I' 1',^ il( »N 



/; 



yCC'^^xJUi 




\ 



s 



vJa/yv>-W 



aX/-oJ(j 



OAX 





<KX, 




X^^^y\/XJ<X' 



1 




S,iii I I 



/■,; 



1 III' \iso\-i-; ST \i-ii) I'l' !<s. )\ \i, i' \K 111!! \KS Aki; I'Kr I-: 'I'o I'lii', 

lU'.-iT ()|- \\\ 1>L.N< )\\ l,i; DC. !•; AM) lU'.MI.I- 



' I:ir .•iM.illl 









IV»EDICAL CERTIFICATE OF DEATH 

PA'1'1'. « »1 ! )! \ Til r\ 

UaaXV ^i r9o\ 

(Montli)^ 'I)riv) (Yf.'ir^ 

I Ili'.RI-.l'.V C i:RTII'\', 'Pliiil I atUiuk-.l <kH\asc<l from 

tn • I(p 

_ — j^p 



I(;0 

- \\\\\V <M1 



tlial I l.r-1 sa\s h 

ami that tk-ath ( iCfurrfd, oii tlu' <lalr ■'Atak'il above, at 

M Tlir C \rSI': (>!■ I)i: ATll wa-. as follows 



J ^A^'jAJk-X^-A^cL 



1)1 RAT ION YtaiR 

C()N'l"Kir.l'i"()I<V 

DTK AT [ON 



Mo II I /is 



/hiv 



//(>in s 



SIGNE 



i)N ^''"i^ 



M.'iilhi 



/hiv 



u 



-« 



//I'urs 
M.D. 



\,l,!,-,.<,s) O/CLt.VO^AAX^yvU V-<V 



Lm^v.c\^ 'XH i()o*A 

SPEci'lAL iNrORMATION "nly ior Hospif,ils, Institutions Transients, 



or Recent Residents, .ind pprsons dyinq .iw.iy froii tiome. 



Former or 
Usurti Residence 

Wlien was disease contracted, 
If not at plai e ot deatfi ? 



How loni) at 
PIdcf of Deatfi ? 



Davs 



ACl". <tl- lU'RIAl, t)k ki;m(»\ai, 
I M)];R TAKI-.K V- VJ . \J 




1) \'\'l^'>\ 111 itiAi. or K1-:M( iN \I, 
3^b TQOH 




^ 






N. H. viverv item ..f inVo.mi.t Jon shonl.l b. cur«t\.n> s..p,>l1.-.cl. ACIP. h'i,....M be Htnte.l HXACTLY. PHYSICIANS «brn.l.| 

Htiitc GAlISi: Ol- I)I:ATII \» plnln terms, thnt it m:iy be properly cIiiHHilficd. The "Spcciul Iniormntion" for p«r- 
Kon* <]yin(;t nwiiy from home shfuilil be ftiven in every iiistJince. 






I 



I 






u 



t; 



i«*f*. 



-w^ 



r^i' 



I 



\ i 



i 1 



I i 



1* 



■I 

I 



WRIT 



E PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



|. M'l 1 \-' 



'.•"-I'^II&IM'd 



X(y^.^>^ ifi.^;^ Deputy Health Officer 



REFER TO DACK OF CERTIFICATE FOR INSTRUCTIONS 

J 204 



lioilisfi'ird 'jYo. 



DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 





Certificate of E)catb 

SI % , A ^ 

ofCj-a-v^ A./O.^'CvAAMj City of 0.<X'vv J X<x/>A^^<.xi^« 



N 



cOfc. 





St.; 



Dist.; bet. 



— and 



/ .r DEATH OCCURS avLav fpow USUAL RESIDENCE dVE tacts called roR UNDER -SPrCAL '^^°";;f*J'°~" ) 

( ,r DEATH OCCURRED IN A HOSPITAL OR .NST.TUTION GIVE .TS NAME INSTEAD OT STREET AND NUMBER. J 



FULL NAME 







- r \ 



PERSONAL AND STATISTICAL PARTICULARS 

r< »l,t iK \ (\ 

'.iK 1 II \ (^ 




IvvOiVv- 



?)1 



M..tHh' I>:'V 



M.iiHi^ 



r. MARKli: !• 

w i:i) OR nivoKcM-:?) 




^ 



} 



I ATii i:r 



lUK 1 li IM, \ci-; 

'■<Miiitrv' 



M\ini:N NAMi: 

OI' MOIHHR 



!UKl-!iri. ATI' 
OK MorHHK 

fmrtt"' '>y C..', 1.1.1 1 



A'- 





\J-^-\> 



H 



M 






/'.■ 



ui->r(ii. .>i\ KN'i )W 1,1 .i )(■,]•: and ni'.i.M.i- 



(ii 



)f ■ni.nit Ot). X^cOkjU J\9 CHL^X*wi--oJb 



A.I,': 



MEDICAL CERTIFICATE OF DEATH 

i).\ Ti: ' 'I I'l.A I II 



a 




3LI 



NT..!itli> A 'n.iv 






I Ili':Ri;r.\' fllRTIl'N', IMml 1 attLMi'Kil .U-cca^c.l hnm 

CLo^ 15 T90H tn LLawVQ 'X\ T.pM 

that I lavt s:ixv li A, ,> . alive on L\A.V^ '"X I i,p 'h 

;md that iK-alh ocourrdl. on the <latr <talOil ahnvc, at 3 
VJ >[. 'Ihr CAlSlv Ol' DI'ATil wa-^ as follows: 



rrOZ-'LA,/^'^ v.'^y^WA.^Os. 



1)1" RAT ION )\ars 

CnNTRIIU TORN' 



Moil tin l^ /^/iv Hours 



DTRATION 



) V,/;".v 



}[o)itlis n^ys 

(Signed^ hj vl. vaa^v-tuq 

PE<^IAL Information onlv for Hospitdls, institutions, Trdnsients. 



//ours 
M.D. 



SP . , 

or Recent ResiJents, and persons dyinq anay fron nome. 



Former or 
IsudI Residence 



■ WvOk 



/W^O^v^N.*-^ X 



Whm was disease rontratted, H 

If nnf hI niare of death ? LLvA.O, 

iiiKiAi, OR ki:m<>v.\i. 



HftH lonq at 
Place of Deatfi ? 



t: .. Days 



•ri.ACi-: t>i' r. 



^ Oiv.^ 



rNi)i-:RTAKi;R 



V . '. . ; • 



i).\ii'. o; !:■ iM \i. (11 ri-:movai. 



305" 



N. B.— F.verv Item of information hHouIcI h. cnrofully suppH-d. ACE should be stnted RWCTLY. PHYSICI ArSS «houId 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special fntormation ^or per- 
sons dyin^ away from home should be ^iven in every instance. 



1 



'' "a 



'i 






\lA 





m 




n » t . 


X 


n TW 


"• 


vi 


\ 


1 '1 



I 

« » 






!f 



m 



I \ 



I 



I 



f 






M 







^. 



i 



-•^ 



write: plainly with unfading ink — THIS IS A PERMANENT RECORD 



}{.Kir<l <,f Ihaltli I- No. :> t-f^T^; ]{& I' C<. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




KJO'i 



Re^li^tered JVo. 




Deputy Health Officer 



Dafr Filed , 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Certificate of Bcatb 

( "U. S. StanDarC^ ) 

of C'/CL/Vu Axxaxx^ocl C.C City ofO/CV/^v^ OAXXy>X/a\.AyC^ 



PLACE OF DEATH: — County 



'>k). 




f IF DEATH OCCURS AvAv mOW ufe U A L R E S | D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
V IF DEATH OCCURR^p IN A HOf^PITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 





Dist.; bet.- 



and 



FULL NAME 



si-;x 



n wv. I >i I'.iki'ii 



PERSONAL AND STATISTICAL PARTICULARS 

j COI^OR 




VOL' 





M..111I1 



\''. !•: 



OUrt \ 



\ y.ai. 



;l\-i 



.1 A. ;////• 



I '/■•lit 



/>,n 



MEDICAL CERTIFICATE OF DEATH 



I) 



ATI-; Ol' Dl'AIII r\ 






(Year) 



^1\< I.I- M.XKRI}';!). 

wiix »\\i:i) Ok i>i\nk(i.:n 

'Wiitt in >.(<ria1 <!rsi<.'-nat ion 



lilK ri!!'l,.\0|-. 
(State or Cotmtrv 



NAM)- <)I' 

ia'i-!ii:r 



lilR rilll, \r|-; 

oi- i-Ariii'iR 



MMIi|-;N NAM}' 
01-' MOTHI.R 



i'.iR'rnp[,ACE 

<H- AIOTHKR 
'Siatf or Coinitrv) 




(Moiitli) 
I m:Rl-;i;V C1:rTII-V, Thai I atU'n.k.l .k-rr.isol from 

^ I9O to — K^o 

lliat I last ,sa\v li " alive on 



l(p 



ami that death oeiurrod, on (he date- stated ahow, at - 
T M. The CAl SI- Ol- I)i;\TII was as follows: 



IMR.\ri()\ Yrars 

CONTRIIU ^()RV 



.lA^;////.? 



Da )'.s- 



IIou 



rs 



m RAT I ON 



)'('(ir.s 



(^ (J^ 



Vo/z/Z/s 



/^ars- 






( SIGNED ) UV<o^M; J. \h. U). lxLcLAA..<JL 




lloii} s 

M.D. 



<:.i 



Special Information "niv for Hospitdis, insiitutVoiis. irdnsicnis 

or Recent Residents, and persons d>in!| .nv.tv frnni fiome. 



1 .' ,.'/, 



i.i'.si f>i- ^I^ KNOW 1,1. i)(,K AND Bi:iji:i- 



Former or 
Usual Residence 

Wlien was disease rontracfed, 
if not at place of death ? 



How lonq af 
PUe of Deatfi? 



Days 



ri.Ari-: (»)• lUR 1 \i. di-' k i:m( )\ai. 



nnfiTiuaiit 






-V^LX 



V'lihfss 




i/ixJC^ 



IaA-vQ Qvb 190H 



i__.^^ 

NI.l-.RTAKHR JuXL-^ N^^ 0\D .O^Cy-O.-^ V 

(A.Ulress 'h\o\X ^ 1 *\ JtL 'hx 



' ^mmmmrwnm^ 



nte CXi?sr or nTlT^^^ ^.-c.ul|> sur>pned. AGG HhouIJ he Htntcl F.XACTLY. PHYSICIANS sh 

in, ,1 -1 "^ f^^^l" '" '''""' *-'-'-• »•'"» 5t may he properly .I„HsJtled. The ••Special Information" ?or 
ons <Iy,na awny from homo should he ftiven in every instance. formation »or 



Oil Id 
p«r- 



t, 






;' M 



I 'I 
► \ r 

i • 



'1 



^ 1 



f ; 






f rl 









iL. i.''. 







vn 






^'tx^ 



w 



'*ip' 



;, . 




if 



■>*-^ 



WRITE PLAINLY WITH UNFADING INK 






THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



DEPARTMENT OF 



as:. 



7!)0'\ 



Ma^istcrcd J\"(). 



J206 



Deputy ^ Uh O ' r 

BLIC HEALTIi=City and County of San Francisco 



Cevtificate of IDcatb 

! 11. S. StanOav^ ) 

^ Q^ J? 



^ 



PLACE OF DEATH .- — County 



ofvJ/CL/^v AxXa^^c/Ca^Cc City of C)/Ol/Vvj ^O./w^^t^^-co 




St.; 6'. 




lU5yv and 



No. C)C)"\ ^\JUOJ\j^'-\^<A St.; 0^; Dist,;bet. - 

(IF DFATH OCCURg^AyWAY FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECAlAL INFORMATION ' ' \ 
IF DEATH OCCU.lRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE^ AND N U W B E RL J 




^ ) 



FULL NAME 




^i;\ 



DAII 



At .!■; 



PERSONAL AND STATISTICAL PARTICULARS 



i.( >I.( iR 






I Kill 



\Xwk/-v 





Q\jQU^.^.yoA 




V 



MEDICAL CERTIFICATE OF DEATH 

I'ATi-: oi- i)i:\rii 

(Day) (VL-ar) 



Lm^i 



Month) 






Tl 



M. ■>/>//• 



1 : :iri 



/),M V 



^iN« i.i-'. MARK n:n 

will" >\\i:!) ( »K iii\ ( >kri; I) 



HI R I" 111' I. \ii 

I State I iv y'' -tint I \' 




AxLctV-lMAj 



NAM I'. (M 
FATIll.R 



lUK rn iM.Ari'; 

'>! I AIMIICR 
(State oi Coiinti \ I 



M \ i Di; N NAM i; 

t)i Morm'.R 



lURriMM.ACl': 

*)i- M<»rm:R 

(Slate <.i roiinli \ 




MontlO (T 
I I1I-;KI-;I',V C1;rT11'V, 'riiat I attemUMl (Icccaso.l fn. iii 



I (/ ) ti > 

tliat I last s.iw li ■" alivt.' on ~ 



r(>o 
1 90 



and that flrath <)rciirrc<l, on tlie i\niv stated al)ov(.>, at 

"— - M. '\'hr CWrSl-: Oi" Dl'lATH was as follows: 



LL Crv^^w,^ CrV >} A\J\..<yi>\ Q 



VAV 




< »i rr I'A ill )N 

/\'l''l(fl',f : I! Si! II /'litlhi'i-' 






I )r RATION }'rars 

CONTkllU'TORV 



Months 



yOA-A.'CAxcLx. 



Pax a 



//. 



ours 



1)1 RATION Years Moulhs 

( SIGNED )U*UnvilA/ J If: '*^ 



^ 



Yr,: 



M.nilh-- 



r>,■^ 



III I-. AIlDVl', ST \Ti:i) I'KRsoXAl, I' A R T IC f I. A R S ARI' TRil- li t llif 
ni'.ST ()|- MV KNoWMvDr-.l.; AND lU'.Mia- 





Days 



l'^> KjoH f A.l.lr 



Special informatio 

or Recent Residents, dnd persons d)in!| dHfiy from tiome. 



N onl\ tor ll(ivit.ils, InslitiitMrt's, 



Hours 
M.D. 



Cju 



Former or 
Usual Residence 

Wlien N\(js disease rontracfed, 
If not at place of deatti ? 



MoH lonii at 
Place ol Death ? 



, Iransients, 



Days 



% 



v.l.lievs \%^'~\ ViD A^^CkCmIa-attx 



A 



I'LACl-: Ol- lURIAI, Ok R1-:Mo\\|. 



N I J !•; R •]• A K l', R JxjUULm ^K ()v) 'OUX' 



" Vll^' I, VI , : R1-;M()VAI. 

vXAw\yO, "Xk) T90H 



0.^>V' 



IN. K. livery item oi? inV'ormiition shoiiM be cnrut'ully supplieil. AGB Hhr>iil(l be stilted EXACTLY. PJIYSICIAINS should 
state CAUSi: OF DEiATH in plain ttrrms, thjit it msiy he properly classified. The "Special InVormation" for pur- 
son* dyinji away from homo should be ftiven in every instance. 



i.ai 

I <t 










'1 



iijii 



't'^ 






? if 






• i 



m 



:• ' * 
oP 



iii^-'m 



^^' 



' 



i 






I 



i 



H 



« 



:■« 



I 



\A/ 



RITF PI AINI Y WITH UNFADING INK — THIS IS A PERMANENT RECORD 



r.orinl i,r 11. ;i!lli !■ No '" *":'»'..:'->■ HcS: 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/r Filed , KXj^^^^Qiyu:^^ OvS' 



1U0\ 



Ilrgislefed JS'^n. 



J 207 



i_ 



Depwi 



DEPARTiyiENT OF PUBLIC HEALTH -City and County of San Francisco 



Certificate ot Beath 



( 11. 5. i5tan^ar^ ) 



Jl ^ 



JJ On 



PLACE OF DEATH: — County oiO<Xyy-\> J A/0./Tr^CA.A^x<;ity of C)'<X'Vi^ J Axv^>-v_^vc<i,c>o 



No.aiH 




*Wv. 




St; ^ Dist.;l5st nrviuuv, 



U(>\AXl\;UAH!a 



M- 



(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E TACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




'CX^A.| 








PERSONAL AND STATISTICAL PARTICULARS 





ii.\ ; i: 111 



.\(,i-; 



III 




Ji/C 

M..lUll I 






b^ 



% 



SIM, I, I" MARK I!.;i), 

UIlx )\\ J'l) ni< !)!\(>KtKI) 

iWiiti ill s((ciri! ili >is.:nalii)ii) 



liiuriir: \'i'. 

( St;itc nr (.'nil lit I \' 



NX Ml-: <»]• 
i".\'nii-;R 



r.iki'iii'i.Ar]-: 
"! i-\rin:R 

S? If' or Tmii iiir\ 



M \ IDi: N NAM i: 

<»i Nil I'll! i;i^ 



lUKTIiri, \C]'. 
Ol- MOTIIKR 

(Stat', or Ciainti vl 



■■-% 



OCCUPATIO 




MEDICAL CERTIFICATE OF DEATH 

DATi-; Ol- i'i:\ III 

' Dav^ 



a 



Monllii ^ 

I ii!:ki;i>.v ci:r"iiI'\-, ru.a r .tiuMi.icd .icccascd I'mm 



(\\-ar» 




II 190 H 

Ili;it I In^l ^aw li »^. ^J ali\c on 
a 11 1 

U M. tik- cai SI-; ()!• i)i;.\rn 



LU>^ ^^ T90H 

1 lliat tlcath (jccurreil, nn the date staled above, al C> lo 

was a< follows : 

1)1 RATION I )Vr/;-s io Mouths Days Hours 






ru^rvAA^ . 



1)1 RAT ION 

( Signed ) 







Hays 



IIou 



IS 




M.D. 



SPECIAL INFORIVJATIOIM ""'y for Hosintdls. ln'^fitu!ioll^, fninsients, 
or Reccnl Residents, dnd persons dvinj ,iH,iy fron home. 



SLO )>,/.'> 



.\r,,>,!/i. 



/.', 



TH1-; AHOVK STA'n: I) I'KRSONAI, P \ RTK" |- !, \RS ARl! V\< \]'. To Til ! 

Hi-;s'r ()]•• Mv Kxowi.i: DC, H and iucmi;}' 



(Inf.r ni:iTit 



(k)ji >^^^v>u, ^ 



\.Mr. 



xw 







Former or 
L'sual Residence 

When was disease confriirfed, 
If not .it plare of death ? 



How long at 
Place of Death ? 



.. Davs 



AdcHLu 



T90M 



rUACK Ol" IHRIAI, OR Ri;Mo\AI. DXli:-.' I'.^iOM. (1 ki:mo\\i, 

i)i:rtaki:k YCLa^wjuNII ^juw/wj "^m^ L<> 



INI) 




N. B. Kvery item of iii?.irm«tion should h.- ciiroV'ully supplied. AfiR sS^ild be stnted FiXAGTLY. PJIY,SICIANS Hhoiild 

stote CAUSE OF DEATH in plain terms, tli:it it msiy be pr<»perly classified. The "Special Information" for p^r- 
sins dyini away from home should be feiven in every instance. 



'J , 

i 

,1 



""I 



f 

' • » 



.i^\ 



" I 




[ItU 






"B^m^ 






'i 






1,1 



m'- 



; I 




-*^. 



WRITF PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



r,..:ii'l ..f H. .'lith !•' N'- •=; t--; '2-:. .•-.- !i.S:I-('.i 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



■auvasHHi aH 



/)(f/(' /'V/rr/. IXuMX/U-ATfc ^S' 



ifjo'i 



Jirs^isfe/'Cfl A^o. 



1208 






Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificate of IDcatb 



( 11, S. i5tnn^aii> ) 
PLACE OF DEATH: — County ofO/O^-r^ i/xJL/CLt 



J? 



' No. al 1 ?) X 



City of 0<X>^v^ dJj^JUQ.i 




St.; 



(I F DEATH OCCURS 
IF DEATH OCCU 



"Dist.; bet. 



and 



s AWAv FROM USUAL RES I DE NCE GIVE facts called for under "special information 

RPED in a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 




Vt/\' 




KJ^^^rW) 



PERl;ONAL AND STATISTICAL PARTICULARS 

si;.\ A A (.(ii.dK 





i»A 1 1-. I )!■• r.iK rii 



A< . !■; 






M..ntl\) 



5S 



(I):iv) 



.1 A •>////. 



i 'i< ari 



/>..' 1 



MEDICAL CERTIFICATE OF DEATH 

DA'I'I-; OI- Dl.Alll ,0 

'M')nlli) fT (Day) (Year) 

I HI{Ul{r.V Ci:irril'\", TIi.H I atu-n.k-.l deceased fr.-iii 



SI\t , I.1-. MAK \s II :• 

uiDowKi) (>K in\(iKri-: r) 

I, W'ritf in socia! (U'^i^'tialion ) 



lUK Tnri. \rt-: 

(Statf or C'liint! yi 





Xn-X^YV^^O^ 



kJa 



XAMi: ol- 

i-atiii:r 



niRTHi'i, \ri-; 
oi- i-atiii:k 

' St.'itc or roiiiitry I 



MAIDr.N NAMI-; 

»>i .M()rui-:K 




I 90 to 

tliat I la^l saw h ■" — alive on ' 

and that (U-atli occurred, on tlie date stated alxive, at 
-ZT" M. Tlie CAISI' ()I^-J)1■.A■I■|I \Nas as follows: 



up 
190 



or RATION )V,;/.v 

CONTklldTORV 



Months 



Days 



I lours 



DI'R ATION 

(Signed ) 



.^fi>)it/i< 



/>,/!■ 




//, 



lUkTmM,ACK 

<>i' ^!()TIn•:K 

fStatt' or Cotiiitr\ 



)\ars 

Ux^ q .X"j i() oH (Addris<) 0/avu dj 

IGIAL IN 




oJ.' 



SPE<tlAL INFORMATION "nly for llo^pitdls. InslilutMns, frdnsicnfs, 
or Rerent Residents, and persons dyinij awdv from fiome. 



rtii-: \H')VK ST \ ri:i) im':k^(>\-ai, r\Kricri.\Ks AKi- rkij-" t<> tin-- 

lU'.sT (>]• MV KNmWI.IDCK ANP IU", 1,1 J", I-' 



(InfoMiiant 



<^>*JCu .Ajeyv^A^/CrvKxX' i\jL>v.^^^x^ 



(\.M!r 



Former or 
Usual Residence 

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



HoH lonq at 
Place of Death ? 



.. Days 



ri.ACK OV HrUIAI. OR ri;miivai. 



k^mz 




I'AT);..; lii KiAi. (.1 K}-,M<)\"AI, 



IQOS 



I .\I)i;rtaki;r J >V\X,^c^^<r^ ' ^aJL>ovU^ 



'**'• ^' livery item of information sliould be cnrefully supplied. AGR should be Htnted fiXACTLY. PHYSICIANS should 

state CAUSE OF DFATH in plain terms, that it may be properly classified. The "Special Informjition" for per- 
sons dyinji nway from home should be ^iven in every instance. 



. * 
i 



m 



I 1 '■ 



m 



I 



ill 



1 ; 



■ » I 






t 






II 






!l: 



I 



'^% 



' '11 






t 



■ 



m 



VMprfMH 



f*^ 







■% k r^ .1 



•^ ^m^^ 



IIN 



il 



m 



I 

"1 



m 



fiiji 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ff/' /)'/('(/, LLcvciaaaX 'SvS' 



I!J() H 



Be^isfei'cd J\'*o. 



i209 




/xH., Deputy Health Officer 

DEPARTMENT OFTilBLIC HEALTH=City and County of San Francisco 



Certificate of iDcatb 

\ 11. 'Z\ i5taiic>ai^ j 
JP ^im J? 



On 



PLACE OF DEATH: — County 



A m J( von 

nty ofO'CL'^^v ^J Tv^XAA/t^A^ c.<:City of Cj/Cl/TV nJ JV<Xy>Xya'VA./c><j 





Oil 



'J' 




No. I'iK '^oJi\> St.; S Dist.; bet. U /CLAo^ M UJUi/ and A/Oy-yxKlvw.) 

(IF DEATH OCCURS AWAY FROW USUAL R E S I D E N C E G I V E 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 




((0 % 



vj 




PERSONAL AND STATISTICAL PARTICULARS 




II 



HAII-" (il IMk'ni 



\' .)■; 



^ 



JJ 





\% 



t 



I IbH 



M..!llll 



Oj-^^JLK) 



MEDICAL CERTIFICATE OF DEATH 

j)A Ti-: ( 'I ni: vvw 




'I);tv) iV..;ir) 



HO 



) ■-■,,'/ 



L 



^iN<". 1,1*,, MAKKIl'IV 

W(l)i )\VI-:i) OK !i;\( i!.Ml-I> 

' W ! i t ' i n V , : 




itiurnri, \cv. 



\ \ M I (1! 
1 \ 1 I! IK 



lUUfllPl. \v\: 

ni- i\iiii-:k 
iStritf or CoimtrN 



MAM'!- ■ \M 1 
' iI Ml 1 1 HI i; 



i!iR I'll ri.Ai')'". 

IStat. .1 '■- iiii!' 



Cj/Cla>j J.\XLAx/eA^^a^ 

Off 1^1 



^ 1 Ili:Ui:i'.\ (. i;i< ril"\'. That I attc-HiK-.l .If.rasr.l f,,,m 

thai I last ^a\v h A.- » . . ali\ii>ii vA-Va^^^ 'X'^x l()0 H 

and tliat ilratli n(aui rr<,-«l, on tin- d.iir statL-<l ;i1hiw, al 'X C!A> ?.• 
U M. '\'hv CWI SI'! (•!•■ i)i; All! was a- follows: 



y-\^C. CL\^^ 



/>.nv 



I lour. 



1)1" In A'lK >N ^''M^ Months /'iivs iiours 




QT^ 



' >>■*■ 11' XT It )N 



OxJk 






/V/OUA/V'C^ 



H r, ,// VD 1/ „//,,. O 



I )r RATION );v;.v ^ JA';////\ /),/|.v IfoiirK 

I Signed ^ ^isXcAj-v^ u. \i i Lrv<^c^ M.D. 







Special Information "nU lor Hospitals, institutions, Irdnsients, 
or RcienI Residents. dOfJ persons dyin) dv* i\ lro;!i tiomr. 



Ill' \!{i)\J-, S r \1 I'D fKU SON A I, I'AR ThTI. \RS \R 

in: ST oi MN KN<>\vi,i;iJc. H .>0Ln hJ'.i.ii;!" 



!•: i"Ki i: 1' t I'll )■■ 



lufu- •-•ml 



MN KN<>\VI,i;iJ(.H .>OLI 




U<1.1n- 



X'yix 



0^-i 



t 



N. B.- 



Former or 
INurt! Residcnre 

Wlirn was disf,isp (ontr.i( ted, 
It not at plare of death ? 



HoH lonq at 
PIa( e ot Deatfi ? 



Davs 



UJ.ACJ: OI- IMUIAl OR R1:Mo\'AI, "^A' ■' i'li'M- 1,M..\\; 



-livepy itom of informiit ion «houlil h.- ciiroV'ully Hupplioil. AfJK hIiouIiI be Httiteil I.XACTI.Y. PJIYSICI ANS shoulil 
state CAUSr or DfZATH in pliiin terms, that it mjiy hv.- properly cI«Hf»ilfictl. The "SpcciHl Informtition" tfor p«r- 
Rons (IjinJi nwny from homu shouM be (iiven in every instnnce. 



1 ■ •■ 

■v.; 



'^i\ 



; f 






I 



i9<«^«l^ 



w 



:i f 



I ; 



ii 



II 






I « 



11 



--S!!. 



Ji 



I 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!.,:,r<l of" Jh :iU!i- I- No. !^ •!!"■-• «r.^~; lUti' C') 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



WKimrsarmmmi^BmimM 



■ajMV SB 



/>^/ 



/r Filed , LLlaXX/l^-^X 



as^ 



7.9^; S 



Jlc^islcicd Xo, 



1210 



I 



<:7Vw<J-A^A.A^ ctOL 






Deputy Heslth OfHc^r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of £)catb 



( 11. 5?. '3tnn^arC> j 



PLACE OF DEATH: 



County ofO/OLA^ OX^CX^v^v^t^^cc City of Q'^^^-'^^ . V/OyvV/avCL/tMi 



I 




a^v^<l-i. St/, 

(It- DtATH OCr. uJps AWAY FROM USUAL RESIDENCE GIVE 
IF DEATH odcuRRED IN A HOSPITAL OR INSTITUTION GIV 



Dist.; bet. 



and 



■ ) 



FULL NAME 




FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
fE ITS NAME INSTEAD OF STREET AND NUMBER. / 



KX ^> 




PERSONAL AND STATISTICAL PARTICULARS 



^M 



I).\ : 



A<;i-: 



III K Til 



cJuL 



*,'< II, < »K 




jJk^ijl. 



%x^ 



W !ilh' 



'»i:iM 



MEDICAL CERTIFICATE OF DEATH 



1) \ ii'! oi" Di: \i II 




(I):iv^ 



'War) 



^^ 



<iNc. i.i* M\Rkii:n 

WI In I'A I- ! 1 ( il,' I I '\' 

' W 1 ■. • 



I'.iuriit'!. \«'i". 



fatih;k 



lUR Til I'l. \('K 
OI' I'A II IKK 
(State or Coiuiti 



M \i DI'.N N \ M 
"1 MuTIIIlK 



I51R rin-i.Ai'H 

<>!■■ %;"•;■ 11 1-:U 






J IIi:Ri;r.V (. i: KTI1"\', That I atUMuU-.! .k-rc-ast-.l fn. iii 

llial I last saw h ^V alivf on \Xk^^^ 'XX \(f) \ 

;inil tliat lUatli occu rrcil. on tlu' dale stalnl aliovr, at O- 10 

vJ ->i. Tiu' CMS!-; ()!• i)i-;.\'rii „... , 



foil 



as as loilows 



(ONTRIIlC'roRV 



Months \ /}ays 



//ours 




6J .^><X/i^^iy-v'\--'^yoJiAZX>\^' 



DIRATION 



)\'.ir 



SIG 



NED) U). V). V^O-^^vL 



UiUit/is 



/)./r 



SPECIAL INFC 



M.D. 



a,^-^-v^L,C 



FORIVIATION '>n!y for Hospifdis, Insfilutions, Transients, 
or \\nn\\ [Jesidenls, and persons dying dway fron home. 



AV ^.'.A-/ /» V/</ / 



'\'\\ V. \HOVI-: STATI', I) I'l'-Rsox \], ]• \K ibtl, \Ks \K i: IK ! I! r< ) lH !■; 

Ju.sT ()i- MVK v(»\vm:ih,i-: AM) !'.!;i,n:i-' 



f\'M 



r< ^s 



vAJL^\w<l4 



^^'tK. A.><L<^ 



former or 
I'sual Residence 



LwvvvOl 



HoH lonq at 
V^6^vA.«- pij, f of Deatfi ? 



Davs 



Wtien Has disease ronfrarted, 
II not at plar e of deatli ? 



i'l. AC)-, oi- inR i.\i, ( Ik !•: r.\i< .\ \ I, I i>\!i 



Of>uOJLv^ 



LAaaXD 



1 ni»i-:ktaki;r 






Ki.Ai. or R i;M()\ \ I, 
^5 TQOH 



^- '^^ F.very Item of informntion uhoulil b.- ciire^'ully Huppliecl. \^\\, s'lrmld be stilted EXACTLY. PMYxSlCIANS Hhoiild 

statL- CAIISI: OF DIIATH in pljiin terms, that it mjiy he properly claHNificd. The '\Special Inforinntion" for pur- 
son* d>inji nwtiy from homo should be (iiven in every instnnce. 



ti 



' 1; , 



X 



* » 

5 . 





ll 



'III 






■«*^''<m 



I 



M 



I f 



I 



"^i^- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



);< '-ii '1 ■ ■ : i 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



HJO'i 



llci^islci'cd ^jYo. 



1211 



Dif/c Fili'il , LLcvCiA^^c^ijt ^nS" 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




OfTictr 



Certificate of IDeatb 



I 11. 'I\ ^4nn^ar^ ; 



% 






(3^ 



No. 3. 



PLACE OF DEATH: — County ofO/CU>^ >u:u-»XjjOUL.C^City of 0/CV>^ AX^./^'V^a^ t>^ 
'V\) LcjVAAJj S^.; T Dist.tbet. dvXX,x:^/^^^^xx». and ^fc^O^^cAv, 



,V^^-C>u 



<X/V^t\A> 



(IF DEATH OCCURS AWAV PROM USUAL R E S I D E N C E G I V E FACT5 CALLED FOR U N Of R "SPFCIAL INFORMATION' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 






\ ' . 1 . 



I'll 

M.iiitln (T 

2> , ., S 




MEDICAL CERTIFICATE OF DEATH 




Soi 



0^-^ 



^ixf.i.i-:. M.\KHii-:n. 

W'l I>< iWi' I ' 111-' I > :\'i .1.' 1 ■ '■ r » 
lUi- 



L 



'St,-it> Ml ' .,miti \ 



lA 1)1 J-.K 



I! IK I 

•M- lAlIil-. I< 
StMtc or luiniti \ 






3vH roo'A 

M"ntli> /T I Day* (Vi-ar) 

iii;MP:r.v ci;i<tii-\-, That r atu'iiad .1cihmsi>(1 fn.m 
\5 i(,oH to (wlv^/cv_ XH. 



^ 




that I last s;i\v h^ , . . ,■,!!' 



and that fUatli oihu ircil, <mi tin- datr staird aliov*.'. at ^ 
Uv M. 'I'lu- CAI SI'! Ol- 1)!:.\1II wa< as follows: 




M 



\M i: 



<>i Miii'ii).; K 



n'k rni'i,ArK 



' I *<'ri' \i"ii>N 






Dlk A'lK )N 

C( (NTiv I i;r'i( 

IdkATK ).\ 



)V(//-.s- MoulJi^ \. nays 



/A 



'/^/A" 



)", ,/; 




U/CLorv; J AXX/wc^.XL/a<j 



I Signed i vD, n\. UkAX<l^ 

:C1AL l!M 



M.D. 



Special Information "niy for Hospitdis, insfiiiifjons, Trdnsients, 

or Rpicnt Residtiits, and persons dyinq and) from home. 



;/ / ' /;),'. ,■ wM O 



); ,: 



O V „'// 'X?! /'■• 



I'll I-. \H( )\1': ST \'!'1-I) IM'KSON \l, I'AKrUT!, \Rv \ i; 

in;sT oi' Mv isxn\vi.i;i)f, !•: and i'.i:i,n;i" 



(liifir mini 




y>o 






Fiirmcr or 
L'sudI Rpsidrnce 

Whfn was diseasf ronfrrirted, 
If not n( pidre of dfdih ? 



How lonq al 
Plarcof Dfitfi? 



Days 



I'l.Ari" ' ii in K 1 \i, < ii' 



ubcrW. \j\.jb-<u^ 



\ 1, 



a. 



: K i;Mi .\ \|, 



IM)!', 



CV/Q OvId T90'\ 



npw^c^.-'^^Kav^K 4 



N. B. Jivcry Item of irifor-ttvition Hhould h.- cjirctully KupplkMl. AdF. kHd ild be stJited F.X AGTLY. PHYSICIANS hIiouM 

»tatc CAlISn or ni: ATH in pliiin terms, that it mjiy Ik- properly cliiH«it'ic«I. The "Spewinl Int'ormjitirjn" for p«r- 
v.ins flylnji (iwsiy from liomo slioiiM be ^iven in every instiince. 



Ii 



' 'I 




i: I 



p 



t: 



Hi 









■■*:■■.: I 






If > 



V '1 

't 



^ 



1 

I 



m 



i 







i: 




WRITE PLAINLY WITH UIMFADING INK — THIS IS A PERMANENT RECORD 



]U-\u\ ..f II. ••'! i- N"- 






Iff W' IK'ic I' C< 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■ ■[■■TWJl^M— » 



Br(f/\s/('/'e(l J\^o. 



1211 



DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco 




Certificate of £)eath 



[ 11. 5. Stan^ar^ j 



QD 



J? 



(3^ 



No, 3. 



PLACE OF DEATH: — County ofO/CX/rv; >UX^ax^A^'C{)City of C'/CXy^ru ^^^/Cl/^-vc^a.^ t>^ 

CA)-^V Lo'UJvt) St.; T Dist.;bet. Axxxw^-^^^^cu and ^ij^V^-^^o. va^cv^- 

(IF Dr*TH OCCURS AWAY PROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U N Of R "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



CN^XXaajAX^^^'A. -^1^ 




- 1 \ 



I) A II 



\' .]• 



PERSONAL AND STATISTICAL PARTICULARS 

ri Ml )iv 





,'K III 



M.ntlH (j 




MEDICAL CERTIFICATE OF DEATH 

DA'l'l-: ( )!■ l>\'. \ I'll ^ 



«tOl 



5 



^INC.l.l". M\KHII".I> 

W!I>' >\\M-Ii ( »R |):\'t )'■'' )■ [» 



Jl 



,1 /,.;/,'// 



L 



!?« 



murin'i.Ao: 

fst;fi, ,,i r,,initiv 



\ \M 1- I )l 

1 \'ni i.K 



I5IKTIIIM 

' " ' \rii I In 

■ I ^"' 111 r; • \ 



M \ IIM-.N ■^: \M 1 
<>! MitTillK 



il' Kill I'l.All': 

<"'iinUr\- 



I (Tr \ TK tN 






'H.iyi (Vi-ar) 



Mi.iulit /T" 
III;1M:!;N' t i;uril-\', That I altLMdr.l ilccrascMl fn.iii 

li . ,,!iv. on Lm-a.o Ok'i 

and i lial <K alli iir( iiin-il. ( hi t lu' dati- ^(atrd al)(i\-t.', al ^ 

U^ M. Tlu- CAlsi.; oi" i)i;.\idl was as foll.,\N 




llial I la'^t <a\\ 



l.^oH 



Lao^aax \hjJ^W\Ai.>v^ 



, s : 








DC NATION )V,/;.v 

coNTkinrToRV 







//(>/// s 



diration 
( Signed ) 



)'<■(! rs 



JA';////s ^ /l/]< 



M.D. 



Jj Ql) 



Ua^qIH r«)oH ^Addrrss) IXCl IU\A.^>\ Ui 

SPEcftAL Information "nly for Hospitdls, institutions, Irdnsients, 



or Rfu'iil Residtiils, diid persons dvin) .mii) froii tionif. 



Tin-: XHON-I-: STAT i; I) l'i-.Rs,,»\ \i^ I>,\k fhl l.AKs \K j- V H r }■ I'l > ni 1- 

iu-:sT (n- Mv KNKwi.i;!)!; }■; and hi-;i.!i;}' 



Former or 
L'siidl Residrncc 

Whrn w.)S dispa^p r onfr.n tpd, 
If not fli pli»(p of dp.itt» ? 



HoH lonq al 
PIdfC of Dp illi ? 



0.1 \s 



(Itifoni'iiit 




>\ 



UO^ojL^JL 



\ ' :!.-s % vl/X^\>X^J ^^^-O-VA^t 



•i.A<'i': ( )i la k I \i, OR !<i;Mt >\ \i. 



i> \i'i 




VI 'I k i;m( i\ \ I, 
0.(0 T90H 



I'l. \< !■. I )i ia k I M 



^- '*• Jivery item oif iiifr)rmTition Kli-mld hj ^airctully Kjpi>li'^«l. AfiB whrjultl be stntetl HX \GTLY. PHYSICIANS hHouI.I 

«lJitc CMJSF: or 1)1. \ TM in phiin tcriiiH, tluit it mjiy l>w- prop^^rly cInHsit'iecl. The '*.Si»cciol Iiilformjitirin" for per- 
sons (!yin<i nwny iram home slioiiltl bt- jiixen in c\cry instnnce. 



VVH 




•i 



t 



li:- 



I 

I 

( ' 



I i 



.M 



»; 



?>'' 



,v\"^V 






■^\- 



'.M 



^ I 









■« 



771 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!;..:n.i .,f llciini' 1 \'. 



IKtI'Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/c r/fcf/. 




L^a.^voaa.<lX QvS^ 



Jf^O\ 



lie <^i, sic red jYo. 



1212 



.V 



DEPARTMENT OF PUBLIC HEALTK^City and County of San Francisco 



Certificate of IDeath 

1 la. ir. J^»tan^ar^ ) 



PLACE OF DEATH: — County olQjO^JW^ OAXXA'VCAACcCity cf O/OUVu AXXA^OoayCC 



N 



o.^H^ 




/CX^4 VA^A^CVVt", y V 



St.; d\ Dist.; bet. 




and 




Axiv^rwL 



(;r ntATH OCCURS AwftY FROM USUAL RESIDENCE give facts called for under "special INFORMATION" "\ 
IF DfATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMDER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




Cr-1 




i> \ i!-; I '1 i; ; K i' 



\' . !■: 




! n ! 1' 



1 rl'\'\ 



as 



1 



II 



/'. 



SINCI.l- MAKKIIIt 

U'llx A\i- I t 111.' t 1 ■ \ 1 ii' . I ' I 

I W ; i I . ■ ■ 



IMKTl! !'l. \.' !• 



!• ATM I'.k 



I'.IRIIIIM, AD-: 

<>i 1 aiiii:k 

"^t:{li . .1 i.', ,uilt I V 



<■; Moriii'K 



lUKrnri, wv, 

or McTlM-R 

■ I '( iiiiiii \ 



VAJ .'OlA-'Vv^ 



I'A rioN 

A'' ■/(/c'l/ ,■'/ .Si, '/ /';i!i^ ■>('( 




MEDICAL CERTIFICATE OF DEATH 

DA li: « >1 Dl.AllI /-^ 



M.Milh' n 
\ l[i:KI';r.\' CIIRTU'W TIi.U I :itton(UMl .lic.-asc-d limn 






lc)0 to i(,o 

that I last saw h alive- on iiyo 

a:i'l that iKath i tci-u rrcd, mi thi' tlai.c s(afL-<l ahovf, at 
M. Thr CAISI-; OI' I)i:.\'ril was as follows: 



])rK \ll( )N 



t'ONTU li;i'r< )R\' 



) V./y 



.!/<'/////.? 



/)ins 



Dik \ rioN 



^ 



} V,.'/,v 



JA"////.s- 



( SIG 



NED^ J.\JUiXA^v^OVl J. VOy-v 






LLu.A.^s I on'* (A.Mnso bC)b dxctbi/u at 



EC^AL INF 




1 

. 1 

1' 

1 


i 


1 


1 


1 


' 1 


:| 


t 


f 


■ 




i 



/,-.'//. - /),,•! 



iiii'. Mtovi-: sTAii: i» im-:k-;onai, par rini.AKs ar i. i'r i)': to tii r 

I!i;ST OI' MV KNOW i,i;i)|-.}.: AND lUll.IJ'.F 
(Infi.-niaiit LAJ CT^^-'^X^ 




U'lilrc 



o \A3 'Ouv^-CaJLm vJLol/^lA 



Special Information <»nly for Hospitals, institutions, Ir.jnsients, 
or Rpicnt Residents, dnl persons dyin ) dw.iy from home. 

Fornifror Oc,^ \l\ . A, How lonq ,it 

lSu,il Residence OT(k UJ/OuftJk/^\. ^t Pi.ire of Death ? 

When was disease contracted, 
If not at plar e of death ? 



I'l.Aci-: OI' m RiAr< OR ki-;m(i\ai, I nxri;..!' r.rui.M. >.i ri:movai. 



iNDi'.R I' \ki;r \X) 



4 



f 



(Ad.; 



A.A'VOl 0-A..a^-\^ 



I CSS 



^IS. ^^Lxx^, ^t 




iN. K. F.vepy item olt hifiirmition should b.- ciiroV'tilly siipplieil. X'JF, .sh'>,ihl he stnteil KXXCTLY. PHYSICIANS Khoiiiti 

state CAUSt OF DliATH in (>l>iiri terms, thnt it m:iy ho properly cliiKsil'ied. The "Spcwinl hiVoriiiiitlon" for per- 
sons flying nway from homo Khoultl he i^iven in every instiince. 



■4^^ 



Pi' 






)•' 








\% 



'm 



I Hi 



.L 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IJo.'inl ..f Ilialtli -I- N(J. 1^ *-:;'»>A' hSiV Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Fi /{'(/, LLv^^<y\-/^AAj 'Xk) 



n)o\ 



Be^Lsleiecl ,jYo, 



12\^ 




\ 



Deputy Health Officer 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of IDeatb 



U. 5. StanDarC^ ,i 



^ ^ 






% 



(^ 



PLACE OF DEATH: — County of C)'CL'>^' 0.\XX^^^:i^ACoCity of 0/CX/>v J X.<X/->^./c.a-4. c^ 






10 



Ne»^^^xUv<xAj vryy>JiAj^jb-Y\.<i\,\ 




CKLl 



(IF DEATH OCCURS A)^«V FROM ulSUAL 
IF DEATH OCCURRED IN A H o(e P I T A L 



kuJ^ 



Cul Dist.;bet. 



and 



RESJDF NCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUVBER 



- ) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

II 'I.I iK 



^'^^ ^ ft 

DATi: (•!" I'.IKl 11 












)/v^<xcL 



1 



MEDICAL CERTIFICATE OF DEATH 

DA TK oi' I)i:a rii 




IH 



\>.i-; 



11 



1 /-.»/"/ 



•^iN* i.i" M\Ki<n-:i) 

WIl»i >\V)-"I) nR l):\-i I'.-, IT) 



r.iK rni'LAcM-: 

St.'iti or C'Minti V 







M.>Mlh> A 
I lli:m;r.\ Cl.kTII'V, rU.a I aUtn-lcd ilectascil fi-Miii 



'I):iv' (Vc;ir) 



■I (j< ) ■ 



t(i 



tlial I last s.iw h 



'alive oil 



•1(,0 
^^^)0 



iihl that death < xTurrcil, on i]\v tlatc stated alto\-«.-, at 
~— M. Tlie CAISI-; Ol' DllVl'il was ;,s follows 



CX_^> 



v-v 



NAM) (»! 

fathi:r 



HrRTHlM.ACH 

ni- i-ATni-:K 

'Stat I.- or CdiintT V 



M XiliJ.X N \Mi, 
<'l Mol'lli: K 



lUKIHTM.ACK 

«•!■ M(t'rin:R 

(Slatt : i".,initrv! 






<X/>^'<:L 



DC RATION 



}'r(7js 



Mouths 



Pays 



Hours 



coN'rKii;i'i-()k\- 



DIRATION 



)'<•(// 'V 



X\/W(PrV 



AV 



d- 



^(JAD (Vy.^^.^uJkxJt^'^JlK) 



occrrAiioN 



- .Vn/////s /),!] 

f Signed ) Lc\^mJl^; J. vj.Uj. IuiIolaviL 

U-^^CtX5" T,,oH f Arl.lr.ss) M3:\|n^JlA^ 



//o/n< 

M.D. 



ii 



In '. 



THi: XUOVl-: ST ATI, I) I'KRvoNAI, I'A K T If I " I,A KS AK)! TKI i: r( » TW]-. 
l!l<;s T OI" MV KV< •\\I,i;i)(*. K AN!) lU-.MllF 



(Infovnintit 



Vj OL^t^wA^cJ^ Uj 



l\'hh< 






SPEcCaL Uniform ATI on nnlv far Hospitdls, In^firutions, [ransienls, 
or Recent Residents, and persons d\inj dw,tv Iroii fiome. 

Former or le-Q ^ J ""A -4- How long al \ 

Usual Residencf Ion a.AJ./vvJ2A> OX Place ol Death? aJ^Wa .. Pnys 

Wfien was disease contracfed, 
If not at place of deatti ? 



I'l.ACi: 1)1 IHKIAI, «ik ki:M(«\\I. 




rXl/llKTAKllK 







I kl'MoVAl. 
'-Xl I90H 



(Addrc 



^' B' Jivery item of information should be ctirafully «upplic«l. AflK Hhoultl be «tateil nXACTLY. PHYSICiANS should 

stntc CAUvSn OF DfiA TH in plain tcrm«. thnt it may be properly classified. The *'S}>eciiil Information" for per- 
son* dyin^ away from home should be ftiven in every inHtnnce. 



if 1 



ii 



m 



■ J 



ii> 



f,f. 



■( 1 



:l(*yi^- < •- 









ki^ -> 




'M 



11'' 




*fl^ 



'i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HoMi'l -f !h:i!th 1 



s r-'^'^-ntv, IKS: !'(.•< ) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I) 



((/(' Filed , \X<^^yo^A..^J&J 



3.(0 



1V0\ 



Begisfercd JVo. 



IS1 







Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

(Icvtificatc of E)catb 

( 11. S. *5tanC>ar^ j 

PLACE OF DEATH: — County of O/Oy-v-v .VOlao/^^uloc City of CJ/Cl/Vu OAXXA-L/C^-Cbec. 

M:^,. UXm,^ Ww>ni::u do CkU^a1x>J.' Su Dist.; bet. and ) 



(IF DEATH OCCUlTs AWAV FROM USUAL R E S I D E N C E C I V E FACTS CALLCD FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCqURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



,/TV 



^i:\ 



i>A ri'; < ii- i;iKTii 



PERSONAL AND STATISTICAL PARTICULARS 

r< ii,( »R' 






KjJi 



cJ>Jb 



M..iith 



.\<; }•: 



CU 



It 



:j ij r 



1)M\ 



yi.nillr 






l',l^ 



•^IN<. I.J". M\KI<Ii:i>. 

w i i)( \\\v I) ( >k" r I '\'i ii' ■ "i' () 






i 




-^^^cy^ 




^. 



MEDICAL CERTIFICATE OF DEATH 

i» A ri-; 01 i»i;a 111 ,0 

\^WVAyVJ/v-A.Ai.A/ c/vl 

■ M'.iit !i I A 'I);iv) 



IQO 4 



1 III-, k i:!;\' t Ijnil'N, 'rii;it I .iIK-ipIimI (IcccHscd from 

that I last saw li <^* ' ■•. ali\ (■ nil vAAA^Q 9^1 loo ^\ 

aii<l tliat <kath (khu rretl, mi \\\v daU' stated altovt-. at b- -^ ..^ 
U M. 'I"lu' C.\I"S1<; ()!• DI'A'rH was as follows: 



\ \M )■ t '1 
!• AIII \ M 



lilRI'IlIM, ADv 

<>!•■ I A iiii:k 

•St.itc or (."oiuilT V 



M \ll)|". .\ NAM 1. 
ol- .Mi'TIIl'.K 



i!iRTiii'i,Ari<: 
Of Mo'ini-ik 

''0UIltI\i 



' '''ir.x riox 




Vo 




DIRA'IMON 



Mo)ilh<^ 



vouL'CCYv 




d/OA^ 




A'/'- !iil l! ill Si! I' / I ,■ 




/>XXV 









fhn 



I loiiy^ 




DIRATIOX 



^ 



)V(/;-.v MiDilhs 



Hays 



XJL>> 



n »■ 






1/ */.//;. 



(SIGNED^ J . VJ\. db/OAt: 

1?^ rc,oM rA.l.]rrss)UX'Lt^^O JW^vX 




SPEClJAL INFORMATI 

or RprrnI Resiilt-nts, and persons dyin-j .ihhv frmi home. 



iON only lor m)spitdls, 



M.D. 

<Xv. 



Former or 
L'sUfil Residence 



nstitiitions, frdnsienfs, 
Ut) UU/WV«yT vt OlDotllf |,,re ol Death ? 



\ 



Days 



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



rm: nhdvi", stati: d rKK'Sowi, i'.\i< ri(ri,.\K-- \kj. i'ki i. i > > i in. 

lii;.sT <)!•■ MY KNn\\I,i;i)C, K AND Hl'.I.Il'I' 



r\<i, 






I'J.ACl-; (M lilKIAI, (iR R}'.M(>\AI, 

;rtaki:r "jVjLULu^^ ob Ou<Vo-^»^ 



I» 'ill' '<'■ !'.' Ki.\!. «j[ R );M( i\' ai. 



T90H 



\iu: 



' --a* 



^' '*• F.very Item o4t inV'ormiitinn shoiiM b.- csircftilly supplied. M\F, Kho.ild be Htiiteil F.XACTLY. PHYSICIANS Kboultl 

Htiitc CAlISi: or DliATII in pl;iiei terms, thut it mjiy be properly chissified. The "Specinl InV'ormnlion" tor pur- 
sons flying nvvny from home should be ftiven in every instattce. 



!F- 



H.I 



' « 



' i 



i:^ 



;t 



H 



' I •. I. 



ll 



l> 



I 



!i'l 






^^m^"^ 



w*>' 



•W"^ 



:1, 



T 

I 
I 



' ' ■ n 



r-it ' ^ 




I.' It 



lf> 








V 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n.):ir<i of H(.!iiih I" No -- '^t:yj^-' '*'*^'' ^'' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



pN/r /7Av/. CL^MX^oCLt) lb I'^OH 

P oT 



Jie<^i\s(cre(l jVo. 



Jlrr^iO 



I 






Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccitificate of IDcatb 

PLACE OF DEATH: — County of CJ/CUyvJAxx^x^^l^cc City of Cj/tX/>^ vJ^<Xy>xyc.A.^^c 





No. a LU/CLU'dfc 

(IF or ATM OCCURS 
IF DCATH OCCr 






Y HnoM USUAL RE S I DE NCE give fac 

RWlto 101 A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 



4^^' St.; X Dist.; bet. cLuXA^J^AUA^trXtJk; and dlS^i-cU 

TS CALIED FOR UNDER "SPECIAL INFORMATION' "\n 
TS NAME INSTEAD OF STREETT AND NUMBER. ' / 



PERSONAL AND STATISTICAL PARTICULARS 






\ 



'VA 



n \i'i-; t>i i; IK I'll 



At.!-: 



,l5t 



SI 



M.-mlii 



\ 



it.i\- 



1/.. ;/.'//> 



(Year) 



/.',/ 



(VCMI > 



"-INt,!,!.:. MAKKIi:n 

' Wtiti- ; II ■-• >iirr -'at ion ' 



1 St:itt nr •.■|>utltl \- ' 

N\Nn or 

lURI'UI'I.Xt'H 

')i- 1 \rm-R 


\ 
( 

'4 


Jj 


Ok 

? f 


M\il>I",X N\M1' 
O!' MoTIli: K 







MEDICAL CERTIFICATE OF DEATH 

DAIK »»!• I)i:.\TIl /O 

(Motuli) jT (I)av> 

I ni{UI';r.\- CI;RTI1-V, That I attciKkMl (Iccxasc-.l from 
AaXm U I90M to LLa..a^ 15" l(,oH 

tlial 1 last saw h -t- v% \ alivt- on v-\.Aa.>C« "^^ T(jO H 

ami tliat tk-atli i iccii rreil, on tln' d.itr stat«.-<l almvi', at I VJ 
vl., M. Tlu' C.\ISI<: ()!• I) i; A Til was as follows: 



Dlk A'l'loN )',ai 

CONTRll'.r'roRV 



Monlhs 



/\n's 



I /oil 



rs 



r.IKTIII'I. Ai'i-: 
''I mi»:'!Ij-:r 

Sl;itr I ii ('( 111 lit I \ 




1 ri-1 



\jXxDo<jjtx> 



<X/^"vC^ 



!) r R A '!' !( ) N 
SIG 



)V.// 



NED ^ G). dj. 




M.D. 



Vu^-Q Os^ i(,oH rA.Mrrs<) bO b 0\JtCL^ywA^ dt 

SPEcflAL INFORMATION only lor Hospifdis, liistifu(ion<{ Transients, 



nr RtrenI Rcsiilcnts, .iinl iicrsons (|\iii| .iwav Iron home. 






Mull: 



l',:^ 



Til I, \Hi »\i-. sr ATi'ii ri--Ks(>\Ai. TAR Turi.AK-^ A K ) : i'kr i-: r< » VW V. 

I!1>T (»1- .MS' K Ni )\\Ij;i)C, )<; AND lU: 1, 1 1", I" 



( 1 nf. jni:iiit 




\ l.lrc'.s 



1^X0 U^.Oi.^t^a^ CJ, 



* 



Former or 
I'siitil Residenre 

When was disease rontrarled. 
If not at pla(e of death? 



fl(»»A lon(| at 
Place of Death ? 



l)a\s 



ri.At'i-; < »i' liiKiAi, OR in:Mo\Ai, 






-t 



INDl 



i> ATI': III !!• KiAi. 1,1 ri;m(»\- \i. 



J ft (p 



>"'• B. Rvcry item ot' inltormiit ion Nhoiilil he ciirefiilly siipplie«l. ACJB slioulil he .stiite«l liXACTLY. I»ll YSICI \!NS should 

8tnte CAlISr OP DTA TH in plnin terms, thnt it msi.v he properly clasKified. The "Special Int'ormiition" (for per- 
sons dyin^ away from homo should be (X'^e" '" ever> inHtnnce. 



:t 



*Pfr 



I, 



^^ 




■M" • i 



"^^fl^^A^^^ 






A '? -^.J 







•-(>. 






'*"i^: 



-. i,'r, 




'i 



■ .*t , t 



' > 



■ J 



; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i'.Mar.l of Health— F No. is t-^rS'-- H^il' Cm 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!)((!(' Filcil. LX^.v^avAXfc g.b l'^()\ 



Jlegi^tei'cd J\^o. 



1216 










DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtificate of IDcatb 

( 11. S. Stan^arD } 

3 % SI 



% 



PLACE OF DEATH: — County of Vj<X/>^j J AxX'-wCA-axu. City ofvJ/Oyw /ux/vv<::A^a^eo 



No. H'il V^-<^Vi, 




IF DEATH OCCURS AWAY 
IF nCATH OCCURRED I 



St.; IC Dist.;bet. IH 




and 3vO 



"u 



FROM USUAL RE S I DE NCE GIVF facts called for under "SPECrAL INFORMATION" \ 
N A HOSPITAL OR INSTITUTION C I V E ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




X^K' 




PERSONAL AND STATISTICAL PARTICULARS 

ft t. < >!,( iK 



[)l 



<xJ 




-O 



JjL 



I) ATI-, < >!•■ I;IK 1 II 



Ai.F. 




1 



HH 



a 



l):i\-i 



M.nilh- 






It 



U'; i: ' -11 - ii i-i ' ;iat ii 111 ) 



luurm'i.ArH 

' Sl:ii < I .r < ■« 11! lit r\'^ 



I- A Til 1,1< 



lUKTIIl'l.MK 
n|- ! AIin-K 

ISfatr iir t'oiinlrv' 



M \ I I)i: \ N \M i: 
<>1- MMllil'l; 



iiiK I ni'i.An-: 

«>l M<'TH!:k 

■' ' ' ' > ■ .'lilt : \ 




MEDICAL CERTIFICATE OF DEATH 

as 




T9o\ 

(V.-ar) 



'NTontli' \\ (Day 

1 III-:R1';1!\' CI;RTI1'V. Tl)at l aUeiKlcl dccLascd inmi 

~ I9O to 

lliat I !a^t saw ll "" alive on - 



I()n 
T«)0 



aiiil tliaf ilcalh oith rtfil. 011 tin- i\\\W statt-il aliovc-. at 
~- M. Tlu-CWIM': Ol' l)i:.\TII was as follows 



^XVVi-'wCU CO-vv 






qvvJjuIv^jl U.^U^^ AI )Xct\xxA UaJUnJLcuv JUAj(iii.<x-*-<. 













I )r RAT ION )V«//-.v 

CoNTKNMTokV 



DI'kA IK >\ 
( SIG 



Mouths 



Par 



Hour 



Moil //is 



/hivs 







Hours 
M.D. 



<K\) r((0 1 { 



SPECIAL INFORMATION '"'ilv for llospitdls. Inslifutlifls, Transifnfs, 
or Re(fnl RcMilcnls, and prrsons dvinj <iwdv fron home. 



lA.v/// 



/',. 



Ill 1: V ii, )\ 1; si- \rj.;i» i'j<: i<->oNA!, f \ k ruTi. \K> ax i; TKi- 1: 

r.l.sl' oi M\ KNo\\l,i;i)<".H AM> lU-.I.Ii;! 
'Inf.,!,., Ml VJ /VCX/V^ 



'I' » 11! 1: 



( \.l(ln 



HljQ, 




formfr or 
L'sucil Rpsidcncc 

When was di'>fasp rontrarted, 
If no! at plafe of dpafli ? 



HoH lonq af 
Plat c ol Dralfi ? 



Days 



ri.Ari". 01 nrki \i, < ik k i:m< >', \i. 



i» \'\'v <\ III I.' I \i, <.i k i:m( i\" \ I, 

vAaavc\ al 






I90M 



N. ».- 



-Hvery itt-m nt' infornml ion kHouIcI h.- cjirolfully supplkti. A'lK «h')ul«l be ntiited li\ VC Tl.Y. Pil VSICI ANS Hhoiiiti 
HtHtc CMJSi: or D!:A I'll in pinin Icrins, tluit it rnjiy ho pi'..pcply cItiHHiricd. The •\Spccijii Int'orinutioir' for p*r- 
Ron* (lyini^ oway from home Nhotild be ^i\en in every inHtnnce. 



« 




V 



I 



% 



r 

i.. 
« • 



.' I 

^ . I 



I 



f f 



r1 






Ml 



'i.i»:£- 



4V 




r 



It I 



'M 



m 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



! 11 



t ^. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



If)f)H 



lie^i,s(ri'C(l jYo. 



1217 



Deputy Health Officer 



I hdfc Filed , LUwAXy^^LAA} 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( 11. 5. 5tan^arD ) 

o\\j0^nc\j .VXWuC^'CC City of vJ/CU^ryj ./VXXa^u^a^^cX) 



r>k), 



PLACE OF 





( 



DEATH: — County 




IF DE 
IF 



\a.^\Lm vUc/VVVAyVVCrix^LSt.; Dist.; bet. and 

ATH occurA away from USUAL RESIDEr^E Give facts called for under "sPEcrAL information" \ 

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



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



V < •!.< iK 







DA n: I 'i i;iK I'll 



\''. !•; 



^ 



hxM- 



M.ntli) 



lb 

(Dhv) 






\d\ ).,/' Id 



5 



/ ',/ 1 . 



siNT.i.r M\Kuii':i) 

\\\\M IWI- I) OK Ii5>( )K(.i:i) 

' \\i ;!■ in ->ri;i ' KiliDii) 




inKTui'i. \r )■: 

( stall ■ r; I ■. r, i;! i \ 



\\M1-; nl 

FATH i-:k 



HiKTii iM \ri-; 
iw iArin-:u 

(St;ilc iir v'<Miiiti\i 



M \ll)i:\ NAM !•: 

<'i- M<>ini;R 



luR'i'niM.Ai'i-: 
<>i- M<)rni:K 

'SlMli- 1)1 (.'olilltl \- ' 







MEDICAL CERTIFICATE OF DEATH 

DA I1-; oi- Dl'.ATII r\ 

'M'Milli) K (Driyt (Year) 

I m:RI-:i5V CI-;RTII>\'. Tlml r .iltm.U-.l .Icreased fr.mi 

0-C T(p \ 



10 i.)oS 
that 7 la^l ^a\v liA, • i alive on 



^ ' ' ' ' '" vAa>\ux 



and tliat (Katli < xaai rrcd, on tlu- <la1«- stati-il ahovr, at ll HO 



a 



>r. 'riu' CWl^^l' Ol" I) i; A Til was as follows: 



CWurv^v^ Ljl^JLA^'Va.i aavtx^- 



DlKAl'ION 



)'(V7/.s- 1 Moulhs I I /An.v 



Hours 



C<>NTR!i;i"l"(>RV 



/ 




1) I ■ R A Tl () N 



)'('(} r 



J/("////,s- 



/\JV 



<>*ri TAIloN Q 



SIGNED) Uj . V) . W»X<X ' >x.i 



I lours 

M.D. 



V4J1 



Special Information "nly for Hospitdls, institutions, [ransients, 
or Recent Residents, and persons dyin!) .m<iy from home. 



former or 
Usual Residence 



\XX/Y\f>J^ 



How lonq at 
\0-LA-<UL Place of Death ? 



Days 



f\'' nil! Ill Si!!' / ii!i/</^-'o 



r,-..; 



,1A-/////> 



/',n 



HI". \M()V|.: ST \ri"D ri'KSOX \l, I'AR TirCI.AKS A K ]•; IK I i: It ) riN- 



in';sT ()!• M\ kn<)\\i,i:d< .]■; and i'.i;mi-:i" 



( Infrii in.iiit 



o^vcLAOk LL. 




Ox.' 



k\<L 



\.Mr. 



LAjLA''\A-,^jA.><yVVwa...<L 



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



I'l.ACl-: OI' IHKl.M, OK K1:mm\ \|, 



'"> 



!) \ 11 



j\jLiXM ^^ (h •' 



■ I lAi or ki-:mo\\i. 



TQOM 



r N D I", k r.\ K ]■: R J OC-VA^ "<V UVl) ^XCl -CV/^y^^ 



!***• B- F.very item o? Information should l>- cnrePiilly supplieti. MW. shoultl bo .stntcd RXACTLY. PHYSICIANS nhould 

«tate CAUSE OF DFIATH in pluin terms, thjit it miiy be properly claKNilTied. The "SpecinI Informntion*' ?or p«r- 
pons dyinji away from home should be feivcn in every instance. 




I' 



J , 



. ; 



1: 



i: «. 



1^ ). 



k^^f 



'I 



». I 



^1 ' 



« 

I 

1 
• ( 

... 




"TWK 



Mti: 






i 






I 



" 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n i ■ N ' 






/)((/(' rih'fl , [Xx.^xx^<aX x^ 



cL^CrVovu^ 



Deputy Health Officer 



lie<:!i\^fcre(l A^o. 



1218 



DEPARTMENT ()F PUBLIC HEALTH^City and County of San Francisco 



Certificate of IDeatb 



( 11. 'Z\ ir»tnnc>nvD 



Q^ 






^ 



PLACE OF DEATH: — County ofO<>.n^ 0,V<X^^/tA,^x:(City of C)<Xo^ O^VxDl/yvc^x^-c-o 



-14* 



No. ?)bn.':L - la Ik 

(I r DEATH OCCURS 
IF DfATH OCCU 



St.; 



M 



I 



Dist.;bet. 0.uJ7v\XA^ 



and 



P 



crL^\JU. 



S AWAY FROM USUAL RESIDENCE give facts called for under ■ SPEC 
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



^ 



lAL IN FORMATION' "\ 
T AND NU MBCR. / 



FULL NAME 



J 0-CvA^^ 



PERSONAL AND STATISTICAL PARTICULARS 



>i;\ 



^ 



J-O^o^oJU 



mi.< )R 




,t. 



i).\ 11: < '1 !.;;< Ill 



\<.i-; 




M..n 



\J^ 






^iNt.i.i: M\ki<ii:i> 
\\ii»« )\\i' i> ( »K ii!\"t »k\ I-; i» 



iMi-' rniM. \'-i'. 

M.'itc ( 1; I ■ ni nt I \ 



I" A Til I.k 



i;iK 111 I'l, \i 1-; 
<»i i\rin;K 

' '^1 .lie I If ».'' .imt 1 \ 



^1 villi, \ \- \ M 
I M M' >T1I 1 !■■ 



HIKTUI'I.ArK 
"I MoTHKK 

' '~l:ili ' .1 Ooillltr\- 1 





MEDICAL CERTIFICATE OF DEATH 

DA ri", < >i in; \Tii /O 

'M"iilh> A 'Dmv) (V. ■;(!•) 

I iii:i<i;i',\' ri.in'ii-N-. 'I'l!;!! i .iitiniUd .loco.iscd iinin 

- (.. 



i(/) 



that I I.i'-I s;i\v h ,ili\i nil "~" 

.iii'l lliat diatli occiinfil, on tin- "late ^talrd altovr, at 



1 ( f) 
I(>0 



M 'I'lir CAI si: 01 Dl, \l"il wa-^ m'^ follows 



1)1 k \II( »N )'(iirs 



C < >N Ik IIMTOKN" 



Miuilhs 



Pii) 



'.V 



JIo 



tl) < 



IH RATION ^ );<// 
1^ 



M.'nlhs 



\Jir\Jrw\SJ\j o.Vj.vU).~Xil 



l\l\ 



/ fiili I s 

^SIGNED) V.^X^J^'Xil^ J.VJVUJ. c:UX<:U'VA.dL M.D. 

V'^ i.,oH u.i.ii.-.^) Lc■VCrvvil^^ U^iv^J. 




Special Information "hIv tor iiosiiiidis, insiiiuiions, irdnsimis. 

or K('(cnl K<s|ilcnls, .ind persons dvin-j .mny fron h'lmc. 



I\'li{f':l III '^flll I I, nil '-I'll 



\< 'Itl,^ 



f ormfr or 
LsudI Residenrf 

Whrn HHS discdsp (onfrdfted, 
II not dt iddir of dfdth ? 



lloH long dt 
f'Idi f of Ih'dtli ? 



Ddvs 



Ml. \H()\i.: sr \i'i:i) i'i':um>\-Ai. pxriuti. \k-, \ !• \ 
i!i-;sr «ii- Mv KN< )\\i,i;i)c,i.; AM) i5i;i,ii:i' 



vv 



nl 



\J2\^r\^jLy>^ 




.^<u^ 



\.!.!i. 



I'J. \> I, ' >1 I '.I K I \ I, iiK 1; !.M( i\ \ I, 



n 



) \ II 



I M'l 






' I I M ■ I K l,M< (V \1, 



looH 



^tVAA^ 



^' K. r.\'.ry item o(f infirniiit ion fihould h- .. iirciriilly Hiip|>II<-<|. Adii hHohIcI lia Ntiited I.X ACTI.Y. PHYSICIANS hIioiiIiI 

Mtiitc CAIISi: or ni A III Jn philn tcrtnM, that it miiy Ik- properly cluNNirictl. TIk "S:»cwiiil Itn'o 



!>cwiiil Irtt'orinfititiri" for 



son* «l> inji iivviiy from Imitic Nhotild be ftiven in every inHt»incc, 



pwr- 



\\ 







'; 

I ': I 
( 



!<' 



< I 



tl 






^ 



' " I I ' 



III I |.,^ 

1.1 



I 






.a 



7f 1^ f'W 



m 



f 



y ! 



'\r 




t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



..•iv'l •■(' II -ilth I- V- :- -^-'-/^^'-i- 15M' ( 



/)(f/(> rifrd , \XK^^\y^Ak. 3Ho 



n)o\ 



BegLslrred jYo. 



1S19 



i.^il 



Depuiy ("ieaith Of«lcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeath 

( 11. 5. 5tanc>nvC> i 
PLACE OF DEATH: — County ofC'CLA^ J AXu>\/Cui.ao City of 0/CX/>^ J AyOu^v^^uOu-co 



No. ml 




St.; S Dist.;bet. lb 




and 



n 



ti 



/■ IF Df AT H AoCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPrCIAL INFORMATION" \ 
V IF DEAfH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUVIHER. ) 



FULL NAME 



X^ 




VOU 



XXJjir>rv^ 



? 



PERSONAL AND STATISTICAL PARTICULARS 

I C()I,< iK 





W 



kXjl 



1) \ 1 1 ( 'i liik'i'ii 




H 



( Vtar) 



<x<^y.eA' 



MEDICAL CERTIFICATE OF DEATH 

DATi-, <)i i)i;.\Tn 



vXla^< 



(Yc;ir) 



n 



)-. 



a-^ 



^INf. I.l" MARkll'Ii 

\\II»i »\Vi:i) < IK I»!\ttKMj:i) 

Wiiti-in SDcial <UsiviKiti<)ii) 




M^-<rv^^J^cC 



r.iK iniM. \t-i-: 

stat<- iir (.''Hint I \- 



\ \M1. ()1 

1- A III i;k 



HI!-; lii I'l. \i- 1-: 
oi I \ ; in: K 



MA I 1)1;n N \ M 1, 
111' MitrilKH 



luRrni'i, \' 1. 
<>i M(>riii-,K 

<Sl:itc i»r Couiiti \ I 



i^ 








Month) /T 'Day) 

I MI'RI'il'.N' CIK'III'W 'I'h.it I ,ittiii'K-.l (ItHvascd fr-.m 

tliat I la'-t --aw li -i.-"\ alivi'oii vAA.^wO_ 'Xb l<p'\ 

aiwl that tlratli < >ccii rii'il, nii tlu- tlati' statcal ahov*.'. at i 

vJ M. Tlu- CAlSI-jJM- l)i:.\'ril was as follows: 




.^-vx,^^^ 



>-v 



i'A'no.N" 



(J XX^'\'VCX^AA^ 

f i '1 » 

UXh^/YW<X-v^ 



DC RATION O )V(/r.9 
CONTRlI'.rinRV 



Moutir 



f^avs 



//i 



ours 



1)1 RATH). \ 

( Signed ) 



)( >l I s 



Mi^ittlis 






/)<71 



vs" 




i 



//om s 
M.D. 



1 



Special Information '»niv t^r iiospifdis, insmutions, rrdnsients. 

or Recent Residents, dnd persons dyim) <m,iy from home. 



);■,//■ *- 1/ ,;'//. 



/'./I 



ill 1-. XMOVK ST \'n:ii I'KKsiiN \i, 1' \K lirr I \KS \k j; | ki j i , . rm 

r.i-;s'r oi- my knowi.kix.i-. wd mi,!! s- 



III !•'! man I 



^?fw. Gv OJUU^. 



•A>w>V. 



\.'.l'. ^- 



n'^?. 



\Jj A^HktX/^ 



^1 dt 



former or 
Isual Residenrf 

When v*<js disease (onfrarted, 
II not .it plHieof denth? 



HoH long dt 
PIdrp ot ne,ifh ? 



Odvs 



ij.Arj; (.1 i!ik I \i,,()k hi-:m"»\a:. 



ilVlji^of llii.;i\i. Ill KJ:M(i\ \I, 

'^0 I 90 ^ 



<3u-rv W^J^ 

1 NDliKIAKI-lR I) V) . . O-oJrUV "^ ^ 



A, I. 'I 



!*^- B. r.very item of lnformfit!on hIiouM Iu csir-ct'ully siipplieil. >\\\\\ Nhould be stnted K\4CTLY. I»ll VSICI \?^ S Khould 

HtntL- CAUSI: OP DIIATH in pfnin terms, thnt it mjiy he properly cliiHHiliied. The "Spcwiiil Information" for per- 
son* (iyin^ uwfly from home should he (^i\en in Q\cry instnnce. 



i 



< : Ml 



• y 
> ' 



i'< 



4 



< J 

I 



1^^ 



c 



%. 




i 



rr ' • 




m ! 



1 



I 



• .V' ■' ^. 






'.■A^ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I 



P» 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I fhf/r Fi/cf/, LuAXyLA.A:tr aia J'U^H 



llegi.slcred jYo. 



A.<^f^\j 




dJL/\>\x Depu 



OfHc^er 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeath 

PLACE OF DEATH: — County ofCj/CVru J A^O/wxr^^C^City of OxX^vu J AXX/>-lA1a_-^ <i.o 



N«. WXaX' 




(iF DEATH OCCURS 
IF DEATH OCCU 




C^v-(^cx\u. St.: 



Dist.; bet. 



and 



s AVA^AY rROM USUAL RES 

RRED I IM A HOSPITAL OR I 



FULL NAME 



IIDENCEGIVE facts called for under special INFORMATION' "\ 
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



A.A^A^^, 




PERSONAL AND STATISTICAL PARTICULARS 






-i;x 



;> \ ii: (M I'.iKi'ii 



\' .ic 



■'" (Ul 



C-VA^r 



/ 



l5a 



M. M'lll* 



sivi.i.i-: MAkKi!-: i> 
\\ii)(»\\i-;i) OK i):v< iK*. i;i> 

(Writfin sociftl (hsiKHation) 



r.iKi'iu'i. \('i-: 

•^t^iti It! f' imilr\- 



I);i\i 



.1/..;////. 



> t ar 



/',/i 





MEOrCAL CERTIFICATE OF DEATH 

'M-nthi K I Day) (Year^ 

I III'IRI'P.V t i:R'I"I!'V, Tliat I atten(U-«l .leroascMl from 
Ho UyoS to L1.A.AX21 Qvt KjoH 

that I la<t <a\v li <La-va alivt.' on LAa^\.0], '2L 5" Up H 

aii'l that (Kath ocnirrcil. on the dati- statL'*] alxivr. at ^ 
^ M. The- C.MSI-; ni" DI-.ATII was as follows: 






<-^. 



.\^ 



SWW ()]■■ 
lAllll.R 



U\\< I'Ul'l. \r 1-; 
oi" I AlllJ'k 

;s|,-iti iiT ri.iint ; \ 



"I Morm: K 



MIKTIIl'LACK 
in- MOTIIHR 
(State or Country) 




\y"\A^Ou 



(Prvxi Mj|/o'V\; 



Qjub 




or RAT ION 



I }\'<irs n 



Mouths 



/hiv.^ 



IIou) s 



c < >N'iRn;r'r()RV 



i)IR.\TinX )'c,irs 



Mi^nths 



l\n 



Hours 




Ri--iiJt\l III Siiii /'miiiisiii dk )'(/.'■ ■ Miifti- 



(SIGNED) LI). CD-VJcrcrVJ. M.D. 




Special Information only {or Hospitdis, institutions, irdnsicnts. 

or Recent Resident*), and persons dying away fro.n home. 




j (I 



. i 



I: 



,; I,' ■ 






?! 



t. ' 



s 



!l|J... 






i ' 







Former «r (y P (^ ^"^ '""'' •*' L/ 

Usual Residence v) -^>a^<j-V^ \^oJ0 pjare of Death ? lO .. n 



Days 



/'./! 



riii', \no\-i': si'ATj-n i-kksonai, rAK'ruTi.Aks aki; I'Kt}: n > rni-: 
in:sr oi- ms' knowij:!)*". i-: and in:i,ii:i" 



'Info; niaiit 







When was disease contracted, ( f i) [ i) 

If not at place of death ? VJ -V^x.O^U. VO^l' 



1M,.U'I-: <tl lURIAI. (Ik kl-:M(»\"\I, 

9 <X^v VnXcJtx^ Co 






l»\'ll-;ot' I'.iin.Ai, or RIvM()\ Al, 

C^-^A- .'3wW... T90H 



'\.l.lr. 



'CXXlA.XX^^v-vAJl. 



-*^^ d: 



1 



1 



M. B. Kvepy itom of information whoiiltl l> > carefully s«ipplie<l. A'lK shoultl be stalled liX \CTLY. PHYSICIANS shoultl 

stnte C MISE OF DliATII in pltiin It-rniH. tluit it mjiy ^»- properly cluKMified. The "Speciiil Information" for per- 
sons clyin^ nvviiy from home sliouhl be (^iven in every instnnce. 



rZ-ri^'' 



i^^ 



^m»jiA 



rr^>4#f5». 






-f^^^ 



"T'T" 




I 



Wl 




>li 



y^ ; I 



iM 



WRiI£ PLAINLY WITH UNFADING INK — THIS IS A PERMANgf^X^ECORD __ 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






\ nu/c Filed , LIa.a_/0:/UC^ 3lId 



/.v^y^ 



lie^isti'red jYo, 



\^A 



0^..^^\J'>J^J^ 



Deputy Health Officer 



N 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Ccvtiticatc of Beath 

PLACE OF DEATH: — County of^JOyTL .\^CL'>^c.^.^c^City of vJo^^ru OAxxz-y^c^A^^^i.^^^ 
o. I 5 ViD JLXATvxxA^/dj St»; \ Dist.; bctcLe>OLAj-CAax.oWlJk and V^-^nJU^ 

(IF DEATH OCCURS AW*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N U M B E FK > 

FULL NAME bJo (lb C^v.u<)L^xi cIxX/^axj. 



) 




si;\ 



i)\ri: m iiirtii 



A '.I-; 



PERSONAL AND STATISTICAL PARTICULARS 

^ 1 )!.< )R 





i. 



rVA^C^ 




^M.nith 



\ 



SI\<-.lj:. MARK 11 ! > 
WII)(>\VKI> OR I)!\ I \\-.< i:i) 
'Write in social (h -iv iialinii) 



3 



(Diiv) 



1/ ,,,'/'. 



(Vt-ar) 



MEDICAL CERTIFICATE OF DEATH 

DATi-; ()i~ i)i;ath 

^ I 

'Driv) 




I go \ 

(Year) 



X\ 



I'.ikrniM, xt").; 

(Statf <>i (/i )U 111 1 V 



N'AMl- ni 
l-ATHl-.K 



i!iKrni'i,A<'H 

'»|' I APIIl^R 

-,! ,'. ..v c .Miitrv 



M \il)i:\ NAM 1 

'>! .m(»thi;r 



lURriin.ACH 

<»l- MOTIIICR 

( stair .)!■ ConiUrv* 



% 1 

r 1 1 



1 lli:ki-;i',\' C!;RTI1-\-, That r alUn.liMl <l(>rcaso(l from 
LLo^ lb iqoH (.. vLmwO, ^b ic,o H 

that I last saw li -'- .>. alivf on LA.A<\X3l Q; 5 T,p "-^ 

and tliat ik-alli ocfunxMl, on tin- <la1r stated al>i)vt>, at D 
vL M Tlu- CAI SP: Ol" Dl-ATII was as follows: 






^<^^"\'\J 




or RAT ION )'ev;;-.s- 3 Months ^^ /^^nv 

coNTkir.rToRV 



I lours 



orcri'ATioN 




)V',/ 



O v'...//... 0,1 



1)1 'RAT ION );•<?;-,? Months 

(Signed^ M-- uajui/w 

0.b i(,oS f \ddiv^^) IbKo 



/>^/i 



'S' 




Special Information f'it!\ tur ho 

or Recent Residents, diid persons dvini d>vdy Iron home. 






I lours 

M.D. 



fill-: AHox'}.: sTA'n-:i> pKRsovAi. tar rim.ARs \ri- i'r; ]■■ )•(» \\\\- 

lil'lST MI.' MVKN< »\\lj;i)(- K AM) IIl'I.M'F 



Former or 
Isiidl Residence 

Wfien was disease contracted, 
If not at place of deatfi ? 



How lonq at 
Place of Dcdtfi ? 



. Davs 



nrijil 




"\ 



\ Mi.- 




^ 



(OS ViDjLTv/YvxxxAot 



■ '■■I ^ I U I J 



IT.Al"]-: ()I- lURIAI, OR r];m.)\-ai, 

,0 




''K^vJ^ V' <^CK, 



V,A.*— VV^ 



r N I ) ; 



fA(M! 



DATr: .,!' IJiKtAl. M! Ri;M( i\ Al, 



^''^' Kvery item of informntion should \m ciirolfuny supplied. AfiF. sho-.ild be stated F'.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnin terms, thnt it mjiy he properly clussificd. The "Special Inlormation" for per- 
sons dyinJi away from home «shoidd be 6'^ en in every instance. 



I 'I ■ ■■' 



i:; 




!■ 



i.j: 
ilJi 

I 4j 












^1•■;Y 




f?l 



WRITE PLAINLY WITH UNFAmWG INK — THIS IS A PERMANENT RECORD 



I{,.;it(! ..f !h;ilt!i I-' No. I. "C-? IS. *;'.: !!X:l'r.. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jico'/.s/crcfl A^o, 






d^^vv^os^ ^dOL-a-v< Deputy Health Officer 

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 

Ccvtificate of Bcatb 

( 11. 5. t?tnn^ai-C> ) 
PLACE OF DEATH: — County ofC'CL^^u OAXX/TVCXv^cc City of^'CL^r^ vJ.^vCX/>^'C<w^-co 
No. 1 1 '^ v]j/UXoa/-yX.OL'>A.' St.; '1 Dist.; bet. iXJoj and 5 AJv 

(IF OEATH OCCURS AWAY FROM 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 




Si; \ 



PERSONAL AND STATISTICAL PARTICULARS 

1> \'i 1' I '1 ;;; i: 1 



CXAa^ 









A^oJL« 




MEDICAL CERTIFICATE OF DEATH 

i)\ii-; < n- i)i;.\ I H 

2.S 




CMMiitli^ 



(Pavl 



J0(^ '•■ 
\' .11 ' 



AC.IC 



an 



M..!!"!)! I 



! 



H 



lb 



SIVt.l.l-. MARK II' I) 

Ullti tWJ-.It < >K I)i\« »Kv|';i> 



MIK I'll ri. \^' 1-: 

' S1;lti r>I ( '..lint I \ 



!)l 



<X^'V/UL<i. 



V\MI'. (»!• 
lATllliR 



i:iKi'iii'i,.\v'i'; 
<>i" i.\riii-;k 

'. S;:i!.' ,,t t",)iiiitl \- 



^^ V I i ii; \ x \m )•; 
<'i M')'nii.;!< 




r\y\j . 




I Ill-;i^i;i;\' Ci;i<'ni"\-, Thai I alU-ink-il (Utl-.islmI In. Ill 

thai 1 \:\<\ ^.\\\ li • ' ali\roii \>AwV\.X^ '.i,H n^o ; 

ati(l that (iralh i x'ciii iid, (M1 thi- «l;itr statvl ahM\-(.\ at l-OL) 

M. '\'\\c OlSh; Ol'' I)!-:\'ni was as follows: 



^1 rA^^C'-^iiyCv^Nw/^^wCAw^^^} 







I'.lKTliri.ACl", 

op MolHI-'.K 

' Stall Ml t'duiit I % * 



< H'l 1 r \ i' h i.\ 






1)1 k \'ri( »\ );,/o' 

c( )\ !"k nil Ti )i 



I fours 



.... Months 10 navs ...■„,., 



.■/A"////s- 



/hn 






SlGNEI 



Uxc< 



\ 



X5" I()riM ( 



g ^O |,)r,M ( \,l.lrrss) 

diAL Information "nH 



\,i.iivss) S N ri-a4.c'>\, Ot 



I hull s 

M.D. 



SPECIAL Information "nH lorllospilHls. Inslidilions. Irdnsienh, 
or Rpirnl Kcsidcnls, .md persons dviii'i .iw.iy fro:ii homf. 



f (inner or 
Usuiil Residence 

When w.'s riiseiise ronlriii ted, 
If nnt .it pl<j( T o[ dedtli ? 



Mom lonii A 
Pldcr ol ne.it h ? 



Ddvs 



riii-: \i'.()\-i-: sr \ri:i) i'»':ks<)\.\i, ivxurit ri. \us \ki; tki !•; Tc > rii p; 
Hi'.sroi' \)A_K Ni (wi.i'ix'. !•; \\i) iu:i,ii:i- 



( Inf. ■■ ni:mt 



'^ 




a 



\'i,hr^^ 5^ 11 ^^ vu .h^cL/>v-Y-vxx'>v d:^ 



3. 



ri.ACI". (>1- lU K 1 \1, itk k I.Mi i\' Al, 



1) \ 11:..! r,i 1.; I \l ..! K I'Mi )\' \I, 



a 



r.NDl'KrAKllK 



o^ 11 L 1 90 S 



N. B. Hvery Item otf iriformsition Khould be ciirov'iilly hii{»i>I««^«'« ^•Jfi Hhtnild he Ktnted FiXACTLY. PHYS!CI\.NS Hhoiild 

stHte CAUSE or DfiATH in plain tt-rnis, tlint it rrmy bo properly cfuHNifieil. The "Spcciiil Inlt'orniiition" for per- 
sons dyin^ nwny from homu should be dtiven in every instnnce. 



I 

« I, 

1 : 









i I 



\' 



■t 



S 



1 ' 



ilif 



\\ 









If 



i 







i 



\ 



m 



WR1X£UBJLAJJ>JLY WITH UNFADlMg Li JiK — THIS IS A PERMANENT RECORD 



!;,>,•,! ..f Iliriltli 1" No. i^ ■r*'*'^«'^^C*: HS:I> Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







tj 'Xio 



If)OH 



Eegisfercfl J\^(). 



X.f^f^tS 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Bcatb 



[ li\, J?. Stan^arO ; 



^ 



<Xyy\j Axxo^»^/Ca..^^o<> 



I^. 



PLACE OF DEATH: — County ofC'^Xo^ Axx.^v^o^-^x:o City ofvJ' 

A / ir DfATH OCCURsAAWftY F R O IvA USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \ 
y V IF DEATH OCCJ^JRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



'Ch.Vwtu db (Kiv^'ta.1 SU Dist.;bet 



and 



FULL NAME 



•Jt' 




IX/^Ty'VC^ro 




ZJ^^ 



SHX 



H \ 1! I ' l;iK 1 II 



PERSONAL AND STATISTICAL PARTICULARS 





A'^aIjj 



ixWfc 



^!.)ntIli 



(D.ivi 



,\\i' 



\ (Ml 



\' . 1-. 



\o'h 



)..l. 



10 






si NT, l.I' M \K\<\ I l» 
\\ ID" •Ul.D ( »K l)!V(>hHl-:i) 
Utile in Mifial (It'^ij.'natiDii) 



I'.IK TH n. \i' 1" 
I Sl;it( <ir (,'i 111 nt \\ ' 







NAM J (»1- 

I- \'i'iii;k 



lUKlll PI. AT}-: 

i>i' I AT in-: R 

■~1 iti 111 C'dlUlt I \ 



M \1 KIN NAM I', 
til- M()Tm-;K 



lURTMPLACK 

<)i" ^t()T^^:R 

(SUitc nv Coviiitvy 




MEDICAL CERTIFICATE OF DEATH 

I) \'rK ol- IM'.ATII r\ 

m-:ui:i!V ci;rtii"v. Thai i aitiMidf.i .!c.xmv;i.,i r,,„ii 

LA-OLO 11 i«)oH to LA^CvCv 'X'h 



11 I(;oH to \J^L.\,Cy 'k'^ U,()^ 

lliat I la^t 4aw IH- ' -•> ali\c'oii VA^^a^ X"^ k^o ". 

ami lliat (k'atli ocourrcil, on the (latr ^tatnl aho\f, at : • 



M. Thr CAlSlv ()!• I)i;.\'ril wa^ as lollops: 



,\-<j.. 



DlkATloN )'rars M on tin Pax 

CONTR [I',r'r< »RV u\0MA^^-^O-<3^^^*^'<i. \J< 



i-cyW^O-^ 



J loin s 



DlRA'PfON 

( Signed ) 



(w 



ViUirs 



j«:% 



a' I 



/'/I . 



OCCri'ATlON 



.(^ 



\ 







<i^« 



Sion'i (A.l.ltvKs) 




ve. 




/ lours 

M.D. 



^Aiifi. 



Special Information "niy for iitV^pitdis, insiifufions, Transients, 

or RciTnt Residents, and persons d\in) avsay (rom home. 



Former or 'I'-iQ t-fV "^4 Hov» lonq at . 

L'sual Residence ^ ^ I ^ O 1>\; ~"n P!d« e of Deatfi ? to 



. Davs 



M.'uth> 



/\n. 



rm-: auovi<: st \Tj:n pkrsonai, rAKTirri,ARs aric iRri-: i( » rn i-: 
lu'sT (>i- ^L^• KN<)\\'Li"i><'. !•; and i!i:m}:f 



I Iiifiniiuuil 



Q. X etx...^ 




Wfien was disease rontrarted, 
If not at plare of deatfi ? 



ri,ACi': oi' lURiAi, OR ri;m(>\ai, I i»\i!_^.; '. r \i .,t ri;m(>\ai, 
Ni»i.RrAKi:R v'VJL'OLu, ^ 



T90H 



r 




.'/CuCycv 



N. B. Kvery item olt inforniiition should be cnrefully supplied. Mir. si >iild ho stjitcil f;\ AG TLY. PHYSICIAINS should 

HtJitc CAlISr. or DI:.\TI! in plain terms, that it may be properly chiKsili'ied. The "Special Information" for p«p- 
sons dyinjj nway from home should be feiven in every instance. 






■ h 



i 



■M 



|i| 



I N. 



5.<l 



iij" :i 
' I 



't * 



hi 

i'i 
.1;! 



■^S«» 



^a%\i 



m^ 




^P; 




WRITE PLAINLY WITH UNFAJBIIMG INK — THIS IS A PERMANENT RECORD 



I'.cvii.l iif IlinUh -!■■ No. K t- 



• Ii>S:l' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Filed , LLu^c^Q/v^^^^aX X\q 



l\)()\ 



lle^ltitcred JVo, 



\.'i^'\ 





DEPARTMENT OFTPUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 



11. S. StanDarC^ ) 




PLACE OF DEATH: — County of C'<Wu AXtywcA^co City of vJ/CLav )\Jxr>nj^tA,^^<:, 

1^ *' 



D(y<L 




St.; 



Dist.; bet. 



"and" 



/ IF DEATH OCCUwfe AWAY FROjM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ 
V IF DEATH OCqtRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




y^ 




c 



PERSONAL AND STATISTICAL PARTICULARS 



1 : .\ 



> \ 1 i: 1 'i 



lUcJL 



COI,' iR 




U'vda 



ii 



/"^(o? 



.\!nlllll' 



\( .!■: 



3>q 



y. ,.••• 



n.iv 



M.'ti'lf 



/hi 1 ^ 



W IDt t\\ l-lt ok I)1V< >Rri.l) 
'U'ritciii suiial (k'^U'iiatioii) 



luK rm'i,.\ri-: 




olVvoixL 



i'.\ rin:R 



oi" JAIIIl'.K 



M\Ii)i;N N.\MK 
<)!• .MOTHF.K 



ItlUllll'I, \CV, 
<»F MOTHHK 
(Statf (ir c'oiiiitrv 




aXx^o 



MEDICAL CERTIFICATE OF DEATH 

iNIontlP K il);iv) (Vi-:ii) 

I iIi;R i;i',\' C"i:i<TII-\'. That I attcn.U-.l (lt(\;«scMl from 
vAa^UDl ^"^ 190H i<. LXaa/Q 'X^ Kp H 

that I last ^aw h ^^Vv ahvf on vA^V.a^CX 'X'h Tip 'i 

and tliat <kath occurred, on the ilatt,- ^tatc(l ahov*.-, at iHo 



J .M. The- CAISh; ()!■ I)l':.\'ni wa^ as follows 



DT RATION )'cars 

CONTRir.rTORV 



Mouths 



Pays 



IIouis 



^ ? 



US /oJruUv' 



^Lcu^ 






(Signed^ . VJI. 00 /cuvt M.D. 



I )!' RATION ,,v^)V<L/-.v 

55. 




I 



^b i(,oH rx.Mrc'^O 




V(!<^%(Vvl.^t 



SPEC'IAL Information ""'^ 'ur Hospitals. InsHhitions, Transients, 
or Recent Residents, and persons dvin:) a^'iy fro.n home. 



Ji. 



O^oJt^''^ '- 



HoH ionq at 



I y,;n^ I 



,1/,. '.-'// 



/',,■ 



'in I'. MJDVK SI" A '!"}•; 1> S'KRSONAl, I'AR rUTI.ARS ARi; I'Rri: 

i!i:sT <>i' Mv Kxowi.i: I )(■.}•; \\t) ni:i,n:i" 



•<) fin- 



'Info; inant 



^ 



X-tr^^XX^ vjX^xtti 



I N.l.lrr 




Usual Residence H 'XH Vj O^ojt-^t ^^ji pi,ife of Vatti ? 5 

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



Days 



riwXCH Ol- lURI.XI, OR RHMoNAI, I !)\1K.>! K<ki.\i. ,,i ki:M()\-AI, 



d 



:i)i:rtaki:r J^uJLiu ^^ (TO 






M. B. F.very item of informntion should he carofull.v supplied. A(]K should be stated RXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, thnt it may be properly classified. The "Special Informnlion" for par- 
sons dyin^ away from home should be jilven in every instance. 



I 



,.|! 



\'>: 



■I 



1 » 

I'l 



i I 



<.. 



:!^ 



< t 





<« 



» 



i 



^SifiJ^ 



-■,*•'■ 



"""P^ 






f 



i 



N 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






/><// 



r /'V/^'^/, \J^A./c4W-At Ovlo 



REFER TO BACK OF CERTIFI CATE FOR INSTRUCTIONS 



IfUJ'i 



Bo(^isf('i'(>(l .jYo. 



I OOP: 




^ 



\ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of Beatb 

of vJ/tXo^j A.Ou>x<^UL<^o City of 0<X/y\j AxX/TvCA^y<^t 



% 



No. lb n C3-<^ttx.'vi St.; Dist.; bet. MD (OJ(lX>' and (Lcytprv 

/ ir DEATH OCC'JRS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J^ 







FULL NAME 








Wti 




si:\ 



DA'l 1 ■ '! 1!1K 111 



\' . I'. 



PERSONAL AND STATISTICAL PARTICULARS 

r( ii,< )k" 




\\xLi 




'I):iv) 



/L ; 



MEDICAL CERTIFICATE OF DEATH 

DA Ti-: ( u 1)i;a rn 




(Day) 






1 



a 



a 



■^I\< .I,!" M \ i; In I II) 



i;ii-.' i iiri. \>' r 

'State or C'nuitl %■ 



N'AMl-. ni 

!• \ 11! i:k 



I'.iKTiiri, A't: 
" I \riii'K 

~-' ' ' ' ' ,; 111 • >. 



M \ ii>i-:N N ami: 

•M MoTlll'.K 



iiikTii ri. xri'. 
Ml- Morm-.K 

fSt.'ltr or Couiilivi 



' H * cr \ 'I i< IN 



/■,. ■,,•',,'• 




(M'.iith" 

I Ili:ki:r.\' CIvRTII'V, Tlml I Mttm.kMl dcci'asod {vmu 
" I (/J U> ~~~ Ii/D 
lliat I last saw h alive on ]^)0 



and (hat death <KH-iirred, nn thr datt' slated ahnve, at 
M. The CMS!', oi" hi; AT I! was as follows: 



DIRA'I'ION ]\<irs J/<>//7/fs /)u\s I/nnrs 

CONTRilUTom' 



d 



OJ\jOlXxJ\j^^^ X ' I 



A 




y<^.^\ 



<OCrVA.o.-> 



n 



\\,\ 



A^CrV i-^tr^^ 



1)1 k.\'ri()N )V./rv Mn}itlis Pays //oins 

I SIGNED ) L<)•\Xr^^JL^u J.vlj.Lb (^ M.D. 

A.hin ss) Wurv>aA>c> V. 



Special Information "ni^ t'>r ti'ispiinis. ii^iiiuiiort'srrr.insipnis, 




^UL 



or Rercnt Rfsi'lpnts diid persons dyinj HWdv Irnm home. 



5. y-"th X I- 



Former or 
IsudI Rcsidrnre 

Whfn Has diseasp ronfrarfed, 
It not a! plan of drafh .' 



HoH loni| al 
I'la. f ol llfath ? 



Davs 



THl'. MtOVl': ST \Ti:i) rKKsMN \ !, T \ K f U" f I. \ K ^ \ K i: IK ' l' Ti » Til 1-; 
m:sT ()|- MV KN' >\\ l.l.lx .K WD III" 1, 1 1 : !• 



' Ii' r. :■ iii.-int 



\d.ll( 






lioll d^^udlAjA, c)l 



ri.Ari-: <»iv.r'! rial mk i:i;M't\\i, 



I l..\V I'. 



D \! 1 



loo't 






IN. B. livery item of iiit'oriniition shotilil bv- csirct'tilly supplied. AdH Khmlcl be Htiite.l I.V ACTI.Y. I»IIVSICI\NS should 

Ktntc CAIISI: Ol- ni-,\TH in i)ljiln terms, thsit it m:i> be properly clussilficd. The "Spe-iiil Inforiiiiilion" for per- 
sona flyinji nwny from honic shotihl be given in every instnnce. 



IM 



> 



mi 



M 



\ ; 



i! 



< I 



i 



■I 'I 



l<! 



!| 






I 



il: 






\' .'. ■ » 






.'*vy 



m : 



,-y 






"ffr 



^1 



I* 




I4i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANETNT RFCORD 



I'...:i!.l •.r Il'.;i!th I'No :-. ■0-*7'=^-:..:-4: !!5;:r Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((fe /-V/r^/, IXcvXI/C^aI' llo 



itn)^ 



Ecgislci'cd J\^o, 



22Q 



cK^<r^^A/^^ 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Gcvtiticate of IDcath 



( "U. S. 5t^n^al•^ ) 



PLACE OF DEATH: — County of O^lA^ OAXUvxCv^lcc City of 0<V>^ AxX/->-vt<.A.. 



J QJ 



C-L 



No. 



,fc 




\XA 




OaLK 



(I r or ATH OCCU RS 
IF DEATH OCCU 



.KX.<X,h 



St.; 



Dist.; bet.- 



and 



AWAJv FROM USUAL R ES I DENCE GIVE facts called for under "special inforvat 

RRED IN A hospital OR INSTITUTION GIVE I 



(^ 



TS CALLED FOR UNDER "SPECIAL I N FO R V AT I O N ' ' \ 
TS name INSTEAD 0¥ STREET AND NUMBER. J 



FULL NAME J^^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ 

f 

I 




<rY\ywcr\j 




L^(a>jL^ 



DA ri-; ' u i;iK I'll 



\ ' . 1 : 



l^\ 



l:i \ 



To 



)..! 



^IM.I.J-. M \ KK 11 :> 
WIDOWKI) (»K DP 



mk iiin, \ri-. 
'Stjttc or CuiiiUiv 



\ Ml ( )! 
1 \ 111 l.K 



I) 

i) 




MEDICAL CERTIFICATE OF DEATH 

DA Tlv ol- DlvA Til r\ 

iMoiilli) /T (Day) (V.-ar) 

I II!-:ki:i;V i.!;i<'ril"\-, TIimI I .ilUtPka .Iccrase,! In. Ill 

\X\^<x y^. Dpi i<, 

that I last saw li -V . > \ aliw on 



3.H ic,oH 

aiiiltliat (U'atli occii rrcil, on tlu- dati- ^(atnl above, at 
\S .\[. Tlir CArSI'] Ol- I)i;.\rii ua- as foII<.s\<: 




liiKriii'i. \i K 



MAIDItN N\Mi: 
<»1- MOT I UK 



lUK TlllM.At 1-; 
Ol- MuriiKK 

''-la?'- or (■ 



' ' ' ! ! ^ I 1 



AV 




'^lili'if in '<<nr I'l ,t n, : • i-it ^\ 



D'RATION )V<?;-.9 Mouths \ Daya IIouk 

L" o N T R M ; I ■ T <) K \' L vWcA.<XWr>v A ^-OurLv^X % v^ 

I )l RATION )'i\irs Months 10 /J^/i-.v //r>i,r^ 

NED ' UJ. Vj vJlAA.Ul>crv\ M.D. 




^ SIGI 



A^ DKi'l 



'M.*^ t 



Special Information "nu for iiospiidis. insijiutions fmnsifnts. 

or Re(ent Residcntv. dii'J persons dyiiij drt<)v fro'ii homp. 



former or 
Usuiil Rcsidenf 



Plnre ol Oedfh ? 



II 



Ddvs 



Hi: A!{o\I-, S'l" \l I D I't- !<«.. i\ \l, !■ \|,'. Ill- i ! \ !<^ \ |< ;. tk I 
'*5'>l'': M. I X' t\\],i:Di.I>: AND iiri.Ill- 



When was disease confrac ted, 
If nol af plare of d?dffi ? 



■< » 11! )•: 



' Inf..- !i, lilt 



WTVAV LchLLo^' 



^\.i,i-. ^, 






I'l. \i;j;: ( ir imr i ai. < ^\- i' i ^T' i'/ v j. 




fc 



(axj Uuna^ 



(\ f ot 

f NDi.k'r \K i;k v-VJ. V v^ 



^ - I90H 









'^' **• livery item ui inltoriniitloM fihoiihl hv carct'iifly suppilt.tl. \(\V. s'lf.iild be staled FiX ACTLY. PHYSICIANS kHouIcI 

stHte CM'Si: of: DI: a TM in phiin terms, thjit it m:i> l>j prt.pcrly cloHsifietl. The "Spcciul liiiormriliin" for p«r- 
«on« (lyinji »wa>' from hf»:nj should he feiven in every instnnce. 



Ti 



)! 



n 







i 



"Pi 

}ih\ 



. t 






li 






II 









fcii 'iitiii' 



*^*^. 




I 



»l 




#i 




I 



I 





!;. .,,;,! .,f II. :;Uli 1' N 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ii\:r c 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






/)a/r F/Irff, U^UwaA./^t. llo J^^O^ 



IiOi^i^fci'cd ^A^o. 



J 236 1 



cLxr^cA,^^^ 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=-City and County of San Francisco 



Gcvtificatc of iDcath 

( U. 'Z\ 5tan^al•^ ) 
PLACE OF DEATH: — County of O/dAV OAXX^'^'CvxiCt City of C)/(X->\; AXX-^X/Ca.a.c.-o 



f*«. 



d.fc 





o^K 



(IF Ot ATM OCCURS A\ 
IF DEATH OCCU RR 



.aX<x1) 



su 



Dist.; bet.- 



and 



wa|v frow usual RESI DE NCE GiVF facts called for under 

ED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S 



(^ 



FULL NAME 



yU^ 



.•^i;\ 



1' \ 1 1, ' 'I i;ii< 111 



PERSONAL AND STATISTICAL PARTICULARS 

C(»I,((K 




"special INFORMATION' '\ 
STREET AND NUMBER. / 

T 





la 



XA.^t 



,l^\ 



M.Mith* 



\ ' . 1 ■: 



^> 



iO 



1 I):t\- 



\hnith- 



Ihr 



--IN'.l.I-". M\K1<II-1) 
\\IIH)\\ l-l) OK |)l\( iRi).;!) 

' Writ' : , : !t -i-^' n;it i( iii ) 



luu rniM.Ai'j": 

' ^t;itc iir CoMiili VI 



^ Xj^-\.\ 



N \M !• oi 
1- \ III l-.K 



lURTIII'I. \i'!-: 

'>'■ I \rm:k 

'Still '■ i il (.■( illDt ! \- 



MAIDl'lN \\M1 
"!■ MOTIIIK 



P.IKlll IM.AC 
'»! M or III-; 

IS!;:t. -,| (■, ., 







MEDICAL CERTIFICATE OF DEATH 

I) All-; oi- DivA'iii r\ 

iMonth) K (I):iv> 

I III'KlvHV Ci'KTil-V, Tlial I :itlL-ii.lr>l .Iccrascd fmiii 
\^-' upi to CU.>U>. M 



(V.-ar) 




IqoH 

q 

aniltli.il tlfatli occurred, o;i tin- datr ^tad-d above, at 



tliat I last saw li -\-- '^^ alixi-oii 



VJ .M. Tlic CMS!': OI' I)i:\'IMI was as follow^: 




^ 



CONTR M;rT()k\' L vUjA.<xAAXrvA. irWUru^^-v- 

or RAT ION );v/s- Months 10 /W.v /A»///-.s- 

( Signed) Uj. \j . U[\a.Ia.c^\ m.d. 

Add rc'^>^ ) 1) XuJkJ14 fe iV^^) .1.' 




OvS i(,o*l (A 



Special Information "nly for Hospitdls, Instiliilions, Transients, 
or Recent Residents and persons dyin;| dway fro:ii liomc. 




Former or 
Usual Residence 

When was disease confrarted, 
If not at plareof deatti? 



r\JX) 



LoJC 



How lonq at , , 

Piare of Deatti ? 11.. Days 



'nn: amovi-: st.\ ri:i) pkuson \i, i-ak ricn.ARs \\< i; iKri': to th i- 

lUvST Ol- MV KNOW I.l'DC I-; .WD IlI-.M!",!-" 



niifiiMjirmt 



f V.l.l 






wrmmmtm^ 



v\,\(^(n luRi.M, OK m;Mo\Ai, I dxtj;.,.'- in ki.\i. ui ri;mo\ai. 






VlrUxLOAxrvx 3^ 



'^- ^' Every Item of information should b ciircV'ully Hupplieil. AGR Hhould be stated KiXACTLY. PHYSICIAT^S nhould 

state CAlISf: OF DflATH in plain terms, that it may be properly claHHified. The "Special Inltormation'* for per- 
sons dyin^ away from home shotill be (iiven in every instance. 





< r 



'•I' 



i 



!■ 



m 

'i : •» 



, I 
. » I 



I 

fit' 






ii-.jy 



'W^i£S 



uk3Rn4^ 



PH Ifl lll i 




ili 




I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PFRMANr 



NT atrnr\or\ 



!«.,.•,! .,|- I!. ,,'ih l- \-,, 



t-"^""!- 



IlXiI" c, 



VHu Deputy Health Officer 




_____ _^^^R ■''O B^CK OF CERTIFICATE FOR INSTRUCTIONS 

/.'^^n Jiro/^fcrrd A'^o. 1227 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 



( U. S. Staii?ar? ) 



PLACE OF DEATH: 



County of Vj/a^^' JA,ay>xeA.A.^i^ City of 0/CL/>v A^O^-n^XM^^C^ 



ll 



N«.UL>vt\.<x)b U"^ve.\,q'C/vvCu (lb(V<ll\AjtoSt; 



Dist.;bet. 



and 



/ ir DEATH OCCUflJk AWAY r^OM USuIl R E S I D E N C E G ! V f FACTS CALLTD FOR UNDER 'SPECIAL INFORMATION' \ 
V IF DEATH OCclj^RRED IN |A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E eJ AN D N U M B E R ) 



FULL NAME OjUrXa 



loJ 



x<X/»v \J )v.^zLt'v 



Lt\) 



PERSONAL AND STATISTICAL PARTICULARS 



QfUcoL 



I' '. .1 ' 'I l;iKrii 



\' ■ I 



Qli^ 






M.'iiliii /T 






rli^ 



%\ 



MEDICAL CERTIFICATE OF DEATH 

(M..iitlil I iDny) 

I m;RI-:ilV CI:rTII-V. That I atlcn.lc-.I ^Ic-ccascd from 



(Year) 






\l 



n.t 



'^ i" ' . i.i:, M\KKii;i) 

\y\\u >\\i.;i) OK divord:!) 



■ Miiti. Ill) 



VV'it. in 



lUK rui'I. \('K 
' Slatr or Cdiinti \ 



I V ill l,k 



I'.IKTHI'I, AfF 

<>i- I \ i"ni-:R 

iStat. ,,i I . ,,,,,1 , ,. 



Mxn)i:\ XAMi: 



ink ruiM, \( ).; 

<»!• Mori IKK 

'*-!.!, , ,1 I'. ,11 lit! \ 



"■ '"li \ IK >X / 




^0-trVA,>^*V 



that I last saw li 



1 90 l(» 

— ali\c (111 



ic)0' 
190 




and Ihat diatb « .ctii rrod, on tlic daU- statoil ahovo, at - 
pp^I. The CArSl<; ()].' DI-ATIl was as follows: 






1)1 'RAT ION }-tU7rs 

tONTRIIU'roRV 



'Tt^CV/V' 



Moulin 



Days 



I Jo 11} 



nays 




«n 



r^' 



!^f^ 



-v^ 



IXu. 




//ours 
M.D. 



1)1 RAT ION ^ }\'ars ^ Jfnnt// 
(S^IGNED^ U3\>Cr>\J2A' 

Special Information only for Hospitals, InstitiHions, Trdnslents 



H InoH 



C^. <A \ I()0* 

STalTnif 



cV'CU 



or Recent Residents, dnd persons ddng dWdv fron fiome. 



1 !V,,'- (,, I,.',////. 



/'. 



UAxXX^rvo 



How lonq .it 
Plareof Deatti? 



When was disease (ontrarted. 
If not at plareof deatli? 



Days 



U^/CucL^ UunrLu LcxX I wU-vc\_ Xl» igoH 



Infonuani 



LU. Uj. UaNjeAjL<rv^ 



r\.l(lr.-.s 



I'^b c3 A^v.fcLjt>u 



it 



rNin:RTAKF,K \l \. O Axxa^ ^<C ^<i 



via ^ 



. B. Kvery item of informiition shoiiltl !>.- corefully supplied. AGE s!iovild be stated EXACTLY. PHYSICIANS should 
state CAUSE OP DEATH in plnin terms, tliiit it may be properly clossilfied. The "S,)ecinl Inform»tion" for per- 
sons dyinfc away from home should be 6«ven in every instnnce. 



!1 



. ■ n 



..V' •'■; 






^^ 




u 



V 




i 



A 



'9' 

hi 




1 




\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






/>///r /v7r^/, LicvQA^uA^ 



0.1:) 



/fn)\ 



X^A^v^ JoLv-H- Deputy Health Officer 



Boi^isfrrcfl jYo. 



1228 



I 



DEPARTMENT Ot PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeath 



11. 5. 5tnMC>arC> 



n 



1 1 
1/ 



om 






^ 



PLACE OF DEATH; — County ofO/CU^rv J A_XX/^\/CA^t/City of 0/CX/^y^ J A^CLz-wx^ca^cx) 
(T. . V I rw. . ^. f . . /tin (y<.W:CLl St.; Dist.; bet. 



N<;. ^KXu. ^'^\^<yv<yy' 



and 



/ ir DEATH OCCURS jCwAY FROM S U A L RESIDENCE GIVE FACTS CALLFD roR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCUI^JREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




• \ 



> '\ . I. * '1 ill Kill 



PERSONAL AND STATISTICA 

C< iI,mK 



FULL NAME VOrnxU 

L PARTICULARS ^ 



\J 






XjA^\Xji 




M"nili> 



H 



/1(^i 



u iiM)\y)':i) I >i< i>i\ < tk(i-:i) 
Uritcin mwial <lr«.ii/ii;itioii 



lUiv ill iM. \.-!; 

fSliiti' nr I'oiinli \ ) 



^ ■< Mr: ni- 
I \rin,k 



I'.IK IHPI, \t}- 
HF 1 AT III-: R 



M \ii>i:n n \mj. 
<'!• .m<)Tiii;k 




'U 




IVtEDICAL CERTIFICATE OF DEATH 

DA Ti-: oi I)i:a I'll /O 

I m':KI-;ilV n:RTll'V, 'rimt I ntlen.lrd .UHva^rd from 
tli.il I last saw li .L ,», ;ilivc- on 



(Vf:ir) 



\()0 ^ 
190 'i 



and (hat .K-alli ofriinx-d, on tlic date stated above, at ^- 15 
^^ AI. The C\\rSl<; Ol' |)i:.\Tfl x^as as follows 



.^<^ 



t^^^^r>A.-(x>VM J^w[m.^^^iaaJL<kui^. 



^./y\/y\} 



DIRAl'ION )\-cns 

CO.NTKIl'd ToKV 



J/(>>////S 



Days 



//ours 



I U- RAT [OX ^''A!' (>\ ■^^''""^' 

(SIGNED) 0. VjV. ()l9oc>ob 



/^avs 



//oins 



niRi-iii'i, \ci-: 
<>i M<>Tm:R 

(Sh)' or r<)inilt\ I 



• '' '"i I'A ridx 

A'' i/c'i/ /;/ Sail /'i (I III isi'i) \ )V.,';> 



LiV-UQ XS^ IQOH rXddresoLClu^ 

Special Information only loi^iiospitais, insiitutions' rnmsienis, 




M.D. 



or Rcrcnl Rfsidt'nfs, dnd persons dvini) awdv froni home 



Miiiith' 



1\!\ 



Tin-: \ii<»\i.: sr \ ii:i> im-rsonai, i-xrikti. ars ar i-: TKn-; To \'\\ v. 

I'-l-.M' OI MV K No\V|,i:i)C, H AND in;i, 1 1, 1-' 

n..fM-,„:„,t \Jje^ vT X/ojbo 



Former or \n^\\ 

Usual Residence I I b \J XVvm 

When was disease lonfrarted, ^ 

If not at plare of death ? 



A 4- now lonq ar 

^'^ Plareof ')iath? n 



. Days 



Ljtui ^ v^ (jb CH^v Jbxi 



'"'•^'''- A^'« '''J<'-^'' "1^ KI'.MoXAI, DVTl^,! \\vn\\\. or R]-:Mo\AI, 

U^^i^ ' (^''-^ ^1 190S 

r\Di:RTAKi;K U <xJ!j./>a^ M iXoJv^s^^vuo ^<^ 






^' ^' fivery item of itiV'ormntion shoiihl be ciirufiilly su|>plio«l. \V%V, should he stntcd F.XACTLY. PHYSICIAINS should 

Htnte CAUSE OP DEATH in pinin teriiiM. thnt il mii> Ik- properly cliiMsilfieii. The "Sjieciol Information** for p«r- 
Ron« dyinjl nway from home Khould he (^iven in u\ur.\ instnncc. 



}f 






I 

m 



i 



If 



1: 



4 



!'i 






ri« : 



■ I 

J 



I ' ' 

i 




^nm. 







4 



*A4 



l! 



I 



I 



I 
1 



4 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



: Mi.l ..f II. :.'th I- V. 






-"■ •; HX: !• (■ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihdr Filed, LU/^^^a^^^ :Xlo l'^0\ 



lle^istvicd JVo, 




1229 



Aw^Ci 



Dep* 



y„t ^ , . » •, 1.^ 



rOfTT 



DEPARTMENT OF PUBLIC HEALTK-City and County of San Francisco 



No 



Ccvtificate of E)catb 

( tl. i5. 5tati^arC> ) 
PLACE OF DEATH: — County of dcLA^ vJXX)u-rx^o<LCc City ofC), 






^^V St.; 



Dist.; bet»- 



and 



^ ( ' ,r nr'lTH^nrftM»*J*'*r.' '^°"' USUAL R F: 55 I D E N C E G I VE tacts called roR UNDtR -specal .NFORVAT.ON' \ 
\J V IF DfATH OC(JlJHRCO IN A HOSPITAL OR INSTITUTIOM GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



) 



FULL NAME 




I 



xolaJuu \JL<x 




^i: \ 



PERSONAL AND STATISTICAL PARTICULARS 



1 




./ 



r.IKTU 



\ 



\' .!■: 




|(i..iii!ii y 



.1 

n 



\ 



1 



''»\ar) 



MEDICAL CERTIFICATE OF DEATH 

i> A I1-: < »i- i)i:.\rn /O 

(M'.iitht A (Day) 

I 1M{RIJ5V i;i:RTII-V. TIi;iI I atlL-n.k'.l .Itvc-asc.l from 

- I,, _ 



(Year) 



luO 



I 



^iN<. i.i:. MAKi<ii:i» 

UII»« >\Vi;i) Ok I)!\«)Ki }.;i) 

\''': .'■ !i ^■.. • ■• 1. i$ri)ation) 



MIRTH I'l.ACK 

■^ii'i "V '"'iiijitrv 



\ 




lliat I last saw li ." alive oii ' 

■ in«! Iliat (Kalh (uciirred, on tlu- dale staU'<l ahovo at 



■l(;0 
I(;0 



V \ M 1 ( )!■ 
! .TIll-.K 



HiK'nii'i \> 1' 

Ol- 1 AriM.K 

'Sfiitc or (.•(-iiiiti v» 



M \il»J'. \ \ \ M \: 



HIR rillM.AC!- 

<>!■ M<'i"iii-;k 

(Stil'i. .1 I'l.iMitl \ I 



^tryv>v 




VAax/^*^ 



M. The- CAISK Ol- 1)1;a'1'II was as folL.ws: 



QJa^^CtXiJ^ OL/>x.d. db-^^-v^.tr*v^J(- 







1)1 RATION Years Months Days 



Hours 



U 




\ 



^\,<xa)a^^ 



C(».\"TRIi;rT<»RV 



) \ars 



Monf/is 



Pays 




1)1 RATION 

(SIGNED ) \j^\Jn\JjM 0.^3.1)0. dUliUxy%.x/dL 




//t^urs 

M.D. 






SPECrAL Information <>nU tor Hospildls, InslilulKo^s, rransimls 
or Reicnl Rfsidenfs, dnd persons dvinfj dHdv from home. 



Former or loO ^ / f 8 ^, How lonq af 

I'sudI Residence ' vO b ^A-.-K; jX Place of Death ? 



V. ■////, 



Wfien wa« disease confracfed, 
I If nof at pla'^e of deatfi ? 



Days 



Tin; xHMvj.: sr\i-i:i) i'Kksonai. rAKTirrLARs aki: i-rm- 



11' iiii; 



'I"ri.:in;Mit 



( \.l.!r.'ss 






IM.ACJ; ni. lilRIAI, Ok Ki;.M.iV\|, DATI-..'- MnnAi. ui RllMoVAI, 



dwAyVvCCr\yYAj 



I m>i;rtakkk 



M V\\^,/^>(w*- 






'^^ ^* fivery item o? Information should be carefully supplied. AGR should be stnted KXACTLY. PHYSICIANS should 
stiitc CAUSIZ Ol- DliATH in pliiin terms, that it msiy he properly classified. The "Special Informution" for per- 
sons dyin^ away from home should be (>iven in every instance. 




! • 
' I 



!^! 



« I 

[■'■■ 

\ 

1. 1 



;K 









if 






f* 



% 

V 



i4> 




( 




f 



il 




l! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



■! ..f II. :i't!l 1' Vo. 






/)((/(' Filed , LU/a>A/o<^ 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



aio 



lf)0\ 



Registci'iul ,Xo. 



\ ^m I 



Deputy Health Officer 



DEPARTJIENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccitificatc of S»catb 



tl. 5. 5tnnc>arD 



PLACE OF DEATH: — County of U/Cb^va-O/uo^-v-vCAA-ooCity of O OL^a, J y'i_0.^x^\^<i,o 



No. 



(I r DEATH OCCURS 
I F D TATH OCCU 



n 



<i 



St.; Id Dist.;bet. 

S AWAY FROM USUAL R E S I D F. N C E G I V E facts CALLED FOR U rVl 
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAb 



and 



ER SPEC 
OF STREE 



FULL NAME 




lAL INFORMATION" \ 
T AND NUMBER. / 





x> 




\.\ 



\ . ! I -1 liik III 



.\(.i-; 



PERSONAL AND STATISTICAL PARTICULARS 

r<ii,<>K \ 





MEDICAL CERTIFICATE OF DEATH 

DAT]'; t>i iii: \iii 




M :ith) 



5S 



^ 



10 

1 I ■ \ 



lA',//// 



. U4 



IH 



!">■. .11 ) 



/)</ 



Month) 




3vH 

'l):iv) 



(Year) 







W 



HIKTIIl'I,\i*H 

' >>t:it<- ..r ( ■, ,,nii I \- 



N \MI (tj 

|'ATiii;k 



lUK'IIMM. \. l-- 

01 i.\riii;R 

'Stale- or I'oniiti v 



M\!!ii;\ \\Ml 
"I M<iriii.;K 



iMRrnpi, All-; 

<>}• \!(''I-HI"R 



'fsi}.M)ati< n I 




•x/ULcL 



I III'RI'PA' ClvRTlI'V. That I attcti.kMl .leivased fn.m 

190 t.. KjO 

"^ T(;0 



tll.'il I last <a\v ll 



alivt' oil 



ail. I that (liatli occurred, on tlic date- stated above, at 
^ M. The e.\rSl{ 01.^ I)i;.\Tll was as follows 






/CLA^ vJ AXWVCAA/tl^O 



^JLJ^v 



U 




Ll) ii-^u^\Aj ot-US&^LL Xl.*^>a^ -c4x1jlv4-^vv>q 



VMtvw v3A>*w0.v<jJfv»^ 



/"] 



'^^a^aaaX 




.^■^ yi 






/T/Oj "^yLu^'vw 



1)1 RAT ION }'airs Months /\u 

CoNTRinCTORV 




//on 



IS 



DCR.ATIOX 



)'('<//-,s 



Mo)iih> 



i.t'i 






'-^-^w>'am:5l/> 



^^^ 



f SIGNED )U\XrvotA/ J. Mj.Uj.djJLoL 
'^Aaax^ 0,5- j,,o^ f.\«1drfss) UA-^rv 



\^cL M.D. 



Special Information "niy lor iiospiidis, instifuyii^s, irdnsienis 

or Rf( ent Residents, dnd persons dyini .mdy fro-n home. 



^ 1/w,'/.- I ^ /, 



'\'\\V. AHOVIC STX'll- I» I'KKnoN M, !• \ K T IC C I. A K S AKi: IKl ! !■ > 111 

in.sT ()!• .M\ KN( i\\ i,j;i)C. I-: \n;» ni-J.ii-i-" 



Former or 
L'sodI Residence 

When was disease (onlrdrfed, 
If nof ,)f pidte of death? 



How long at 
Piare of Death ? 



Days 






^A 



.rsy-K 



190 



1M.ACI-: HI I'.IKIAI, MR RKM<.\ \l, I.ATl-.of ItrHiAr. o, R1:M(,vai. 
r.\i)i:R lAKi.R (AD. J. 9-ovJ[v\j ^^ Co 



N. 15.- 



-rivery item of niforin<i(inn whouUI b.- c»ir«V'ully sii|>plic<l. AfJIi Hhrnild be fltnted RXACTLY. PMYSICI ANS Nhoultl 
«tatc CAlJSr or Di;\TII in phiin termH. tbat it mjiy be properly clusKifietl. The "Special Informatiun'' ?or per- 
sons (lyiri^ awny from home should be jjiven in ^K^ry instance. 



.! 



< y 



.1 , 



'■I 



li 



i,( 







i 



jF^^ 



jrm^L 



m 



Ml 



ii fii< 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMAIMENT RFCO.RD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jfro^/.s/r/'rd A'^o. 



1 231 



Dale Fih'il, LU-vQA^Uit 2.1 l''W\ 

ck^^K^uv^ cLtoM^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTK-Ci(y and County of San Francisco 

Ccitificatc of IDeatb 

PLACE OF DEATH: — County ofU/CL/Tv J .\XX^YVOv.^coCity of CJcL^ru J AxX/^^Tyyc^^^^i^^t^o 






No. 



'iOl VD ^^ra.d^^J^XA( St; I Dist.;bet. 

/ ir DtATH OCCURS AWA1* FROM USUAL RESIDENCE Gl 
\ IF DEATH OCCl. RRt D^JlN A HOSPITAL OR INSTITUTION 




and 




IVE FACTS CALLED FOR U*DER "SPECIAL INFORMATION" \ 
GIVE ITS NAME INSTEAii) OF STREET AND NUMBER. / 



-v-^ ) 



-'■' (5?i 



FULL NAME 

PERSONAL AND STATISTICAL PARTICULARS 

f\ t.'<>l.(iK 

ouLa 



O /(Xxk^\JL 



y 



/<Xaj^a^v\ 



i»ATi-: "I i;iKi-ii (Y7N 




U\aX£ 



JXAr 



/ "1 H 



■111 



MEDICAL CERTIFICATE OF DEATH 

1) \ ii: t 'I i>i \i'ii 




(M..nllii 



(Dav) 



(Vf.-ir) 



*> U 



MN'.I.l". MARklllH 

\y\ IX >\\I<*|) ( »U !>!\'t I'.'i' I" I ) 



Hiurm'i.A'M-; 

■ ^t;ili' . >! 1 •, ,,1 ,,) , ^t 



I ATII j:k 



lUk i II I'l, \iK 

•>i r\riii:i< 



ti| Miillll-. K 



HIKTlllM, All-; 




I III-:K!;I5V C1-;RTII-V. TIimI I atU-n.U-.l .Unvascl from 

tliat Mast saw hrt^ alive on LLccO ^5" i,p S 

and th.it ikatli ..ccnrred, on the date staled above, at %H5 
U. M. Tlu- CAISI-; (U- I)I-:.\TI1 was as follows: 

C3 OCLNXjLtj yJL\^JO\.- 



••'■^'II' ATloX 

A'.' i.lri! I II Sit II I '' ii 



I "^ ' 

b 1/,..-'/., "X^ /'■■> 



DCRA'i'ION 



CoN'i'KII'.ITORV ULAJUUA.XXX 







//our 



-vx.. 




l.M' RATION );vr;-v 

^p J 

' Signed ) vL4vf>^ c 




^b KjoH ( \(i,|ress) I'lOb 



MoNt/is -' /)(irs 




SPEG'IAL Information "nly f«r Hospildls, ln\fi(ulians,"lrdnsifnls 
or Rfient Residents, nnil persons dvinq <m.)y fro.Ti home. 



ih : ti< 



- )V 



iin: A novi-: st \ti: n i-kksonai, r xkikilaks aki; ik i j- t« » iii i 
i!i;sr()i' MN' K\(t\\ 1, 1.1 )(,}•: and i!}:i,ii;i" 



former or 
llsudi Residence 

When v*HS disease confrdffed, 
If not af ()la( e of deafh ? 



How lon(| .it 
Pld<e of Oedfh? 



Odvs 



infill m;iii( 



' \.!(h. ss 






V 




^ 



i 



I M 



\n'''(\ '" 'i'^'-*"'^ ki;M«.\ \i, I i.\ti:m! \uhi.m. ,,i h]:\u>\ w. 



'\.l,l!.■^v 



^' ^' Jivery item of !n?oriii(itIon Nhoiihl be cnrefully siippliL'tl. .\(iF. Hhould he Btiited HXACTLY. PHYSICIANS nhould 

stntc CAlJSn OV DI:A TH in plnin terms, thnt !t mny be properly chiKNifietl. The 'Speciiil Informu tion** for par- 
sons dyln^ nwny from hrunu sh«)iild he ^iven in overy inHtnnce. 




i'^ 



:i^' 






1 i 



I 



m 



I* 



iM 



•'^J^ 



— 4 -«• 



i 



I 



1 

s 

i 



\A/R!Tr Pi A t Nl V \A/ITLJ I I ivi r A r\i ivir^ i Mir ,„^ -»-lj •<- • «-» » r«r-»^< 



^^••1 »-»»^II^N^ 11^1% 



i;..-i!.l •.( M- :.l!li 1 \"w \z. t'-Tss-^-". liSiV Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dnfr /vAv/, lLcc<5^^ ab IfJOH 

dU-L^^ dsJO\y^. Deputy Health Officer 



Jieo^i.s/e/'ed A^o. 






I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( X\. S. i?tan^arC> ) 
PLACE OF DEATH: — County oiUfO^/y\j OAxX/^v<XAec)City of 'd^Cu^v J >^lXwxx^v1<l •c,-c. 



No. 




.t 




1 F DEATH OCCURS 



-vaXc 



h 



St.; 



Dist.; bet.- 



and 



KkWAv FROM USUAL RESIDENCE G'VE facts called for under "special information • \ 
IF death occurred in a hospital or institution give its name instead of street and number. J 



FULL NAME 



.^.^'CMj\; OorYVAAXA.^i'^A; 



PERSONAL AND STATISTICAL PARTICULARS 

"^'■•^ A . r(il<>K 




.u. 




\ 1 1. "I lilK III 



,S0O 



MEDICAL CERTIFICATE OF DEATH 

' \ 1). < ii Di: \|-H 




'Monllii 



\' .!■; 



H 



M..}itli^ 



/', 



--iN'i.j': MAKKiri) 

W'llx i\\I'I» MK !>'\ . I' 



I'-IKTMf'I.ACK 

' St.'ltr or <,''.iillt t s 




oJj^j^^^-Y\M\x M r^K 



^^ I go M 

'I)av) (Year) 

I m-:Ri;i;V Ci:kTIl-N-. That l atlcn.U'.l .Uhvmsc.I fn.ni 
\Xa.\^ 'X'h T<;oH to CLawVO a^D T90H 

tliat T last saw liV^^> alive on LXaaXL QxS" np^i 

ainl that drath orciirreil, on Liu- datt- stati'.l above, at 1. 
V M. 'I'he CAISlv ()!• I)I:aTII xva^ as follows: 



I \IMI.k 



niKTiii'i. \t )•; 

' " I N III i-k 



"I M'iriii:K 



iilKIHI'I, ACJ- 
"I* M*>Tm.;K 

-l:iN m! r.iimt I \ 



' " ' ' r \Ti' ).\ 






DCUA riON 



( ( >\TR I l!r'l"( )R\ 



}'t'iirs 



J A 



\>nUn n) Pays 



I lout s 



•^V.^<1 ^^O. 



% 



C^vlO 






Months /lav 



5IGNED > kjUi. 6s..\iY\jLKyy\A^^ 
O^AL iNFORfVIATION 



//(>/ns 

M.D. 



SPECHAL INFORfVIATION «n!y tor Hospitals, institutions, Trjnsipnts 
or Recent Residents, and persons dyinj dway fron liome. 



^W^^V/X 



AV ill',! ; I! S,l t> I 



I i' 11, ! 'I'll 



C^ 



)-r„ 



M. iilh 



1 ' 



I'lii: \novi-: ST \ ri:i) PKu>-.(>v\i, i'\u-|-irri, \K> \ki- jri ; ].. iiu- 

lU'iST OI" MV KN(»\\ l.I.IXVI-; AN1> 15I':i,I l-! I' 



former or 
l'su.il Residence 

Wtien was disease 'onfracted, 
If not at place of death ? 



flow long at 
Place of [)eath 



Davs 



niifMnnriiit 



( \-l.lrcs^ 






1;^<ACK ())•* HIKIM, OR ki;m(>\\i, 

)Crw\X 




LfccAAvojl Jb 

xinCK'i-AKKK JyKjLMiw-^ ^J^XhJAJb 



■ATKof Hi Ki.At. or KHMOWAI, 
'^'^' T90M 



N. B.. 



-Kvcry item of informntion fthniilil be cnrefully supplied. AdB shouhl be Nttiteil TiXACTLY. PHYSICIANS hHouIiI 
state CAUSE OP DLATH in phtin terms, thnt it miiy be properly cla»Ri1fled. The "Special Information" for p«r- 
Bon« flyini^ away from home Hhould be jiiiven In every instance. 



Si 



i$3 



!■» 



4 t 






I '. 
I 




I > < 



! .1 




'3?!*? 






•I 

r 



lA/DITC Dl A I IVll V \A#l*rUf I I IVl CT A r\ I Ki r* I M i# _^ 1-Liie- • 



■ «*■•« 



■ viiif ^^ivir^i^ii^ ^1 I I « r% 



Hc..i!.l i,{ llt;i!th- !•■ No 1 5, S"-'3af:..-c-ii MS: I' (.'0 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dn/r- n/cff, [Xj^AyCiAjuik Xb 



/fJO'i 



lic^istcrod JVo. 



i2.33 




Deputy H^^afth O^^rer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Seatb 

( 11. S. StnnC>arD ) 

J? (^ jp 



% 



PLACE OF DEATH: — County ofO/CL/T\' 0^uX/VLX:A^e<^City of U/CL/>-o J X.cl/^-^'Ca^ 



CO 




No. bt: UJ CtCkLvajmxA^ LLx^. 



St.; ■S' 



Dist.; bet. 



IH 




and 1 5 



/ O^ DEATH OCCURS AW«V FROM USUAL R E S I D E N C E G I 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 





PERSONAL AND STATISTICAL PARTICULARS 






kXju 



1' \ I I. < i|- lUK Til 



\' .: 



[ Urvr 



\!..iit 



0.5 r\ 

I I );i V ) 



as 



s 



.1/..*, 



IS 

'/(•.tr) 



lhi\. 



MEDICAL CERTIFICATE OF DEATH 

DATi-; oi" I )i: A I'll 




(Moiilh) ,1 (Day) (Vtarl 

I III-RI-I'.V CI'RTII-V, That I atU'u.k-.l .leccascd from 

to -r-r——— -:———. 



--l^<.l,l■ M\Klvii:i). 

\\ii»i >u i:i) OK i»!\(>K(i:i) 

'Wiitiiii >i<iii.'i! (i(^i«.Miati<>ii ) 



MIK I'lii'i, \ri-; 
<Stat< or (/. iiiiiti \-^ 



N \M1' I )!■ 

I- A rm.K 



liikiui'f, \( ].; 
<»i" 1 Arin:i< 

' State or roiiilt! \-i 



MAIDIIX XAMi 
OI' MoTHKk 



lUKIIII'I, Ali; 
•>l' M(>'niI-:K 

'Slati' «>r r.iimtrv) 







LUrrw 



~ 1 90 — 

that I last saw h ~ alive 



oil 



1 90 



and that <Kath occurred, on the date stated ahove, at 
~" ^I- 'I'lH' CAISI-; OI- l)h;ATl[ was as follows: 







DIRAIION 






y 



/)ar 



Hours 



X)\/y^'\X\y^ 




? 



1 




CONTkllU'TORV 



IMR \TI()\ 



M()uths 



^ CUi 



1 I'AI'IOX p 

KfyiiU'if in S<ni /'i ,iih '^ri> 



XJ\j^r>n^<Xy^ 






J. \9->. UJ. kjiX/X/wAj \Ai\jtr\\j^ M.D. 
► FECIAL Information nnlv tor Hospltdls, Instilutions, Fransienls, 



( Signed 





or Rpfcnt Residents, and persons dyinj dwdy froii home. 



/h, 



III ! \if()vi<: Si" \ rii> i'1":ks( »\ai. p \k iuti, ars ,\ki-: i'rik 

i'.l.sT oi' Mv KN< •WI.I.DC )•; AM) IMJ.Il-lF 



Former or 
IsudI Residence 

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



How ionq at 
Place of Death ? 



... Days 



•|() III)-: 



' !lll<i' tllMIlt 






I'l.AC}-; «>i- liiRiAi, (»r ri';m(»\.\]. 



DAT^loj' IM KiAi. or RI':M()\AI, 
'^1 TQOH 



(Address ll "^ 1 M^Vv^J^.-^.^^.^^^ ^-j^ 



I Ni)i;i 



IN. B. 



-I. very item olf informiition should be carefully Kiippliecl. A(iK should be stated CXACTLY. PHYSICIAINS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for p«r- 
Ron« dyin^ away from home should be (^iven in every instance. 



V. 

1:: 



)■■■ 



V}- 

V 



1. 



ii^ 



I , 




m 



it ' 



\A/PITr PI AINI V \A/ITM lIMrAniMn INK 



!»..:il<l..f ll.rilth \' So i- t^^"^ HSil' Co 



TUic: ic: A or OA/iAiMr M-r cixrr^r\or\ 

• • • • ^i^ • ^i^ • • ■ MM* • «■••• •• « w^ ■ « • ■ K ^am ^^ ^(^ ■ V M^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



:! 




1<J0\ 



Bc^istered J\''o. 



i234 






Deputy Health Officer 



i( 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Gcvtificate of IDcatb 

i 11. 5. 5taiiC>arC> ; 

J? ^ A % 

PLACE OF DEATH; — County of 0<X^^ J^CU-yvCAl^cC^.r ^fO 



No 




CHi. 




<\X 



ty of^^XA^ OA/CL/>^.Xi>v^-Q.'0 



St.; 



Dist.; bet. 



and 



(If DCAt4 OCCURS AWAy FROM USUAL R E S I D F! N C E G I V f FACTS CAILFD FOR UNDER "SPECIAL INFORMATION ' \ 
IF DeJ^H occurred in a hospital or institution give its name INSTEAD OF STREET AND NUMBER. / 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



Ju^Y\-^cJL.^ 

\ri. « ii luk I'll 



I, 



ji 



»l^ 



Pf 



\' .1-; 



^I\<. lI- W \\i K I I'D 

\\ii)( )\\ 1- 1) MK n!\< »i-'.ri- !» 

'W'lil' ill ^mial di si<'iiatii >ii ) 



IMKTIIIM. \ri-: 
(St;iti. <>i I". HI lit I \ ' 



lA rm;R 



I'.ik ill I'l. \ri-; 
<)i" i\rni<:K 



M \iiii:\ \ \ M ]■ 
1-" Mi>'riii:K 



lUR run, AC!.: 
OI- m«iiiii:k 

I St.itf or t"(,iiiili \- 



' '• >1 rA'llON 

h'flJfi! Ill Silll /'l.llh.''i 







MEDICAL CERTIFICATE OF DEATH 

iJAi'i-; oi- i>):Aiii 




'Yi-ar) 



yLT%'\.<X''Y\ 




I III-RI'IJV C1-:RT11'\-. 'iMiat [ MtteiKk'.l (Icivasc'.l fn. in 

lli.'it I last saw h ^s^'v. ali\e on \-AXa-X3i Xb t^o H, 

and tliat dratli orrurrcd, on the date- stati-d aliovc, at 1 HO 
y^ M. 'I'hc CAISI-; ()!• I)i; ATII was as folldws: 



t 



I )r RAT ION )'nns 

C'ONTRIIUTORV 



Mo)iflis d^ Pays 



//oitrs 



rvLo>\; 



DIRATION )\ors J/o>////s X Davs 

^Signed ) UAilixA.A/v 0. vfL^ Oa/^v 

^^ i(»oH ( Address) Ofc 




flouts 
M.D. 




Special Information oniv for iiospii.iK, iiRiitutions, rrdnsients, 

or Recent Residents, and persons dyin!) rtway fro:ii home. 






Vwoou 



y- . 



M."!lh' 



% 



]'■ 



'\'\\V. AMOVI-: STAri:i) PKR^^nNAI. I'A KlIiTI, \ R S ARI". PRl}-; To III 1". 
r.I-;sT oi- MV KNOWI.l'DJ'.K AM) Hi:i,iv;i' 



' Infi'inaiit 






Former or 
Isiidl Residenff 

When w<is disease fontrarfed, 
If not af pidfe of death ? 



lloH lonq at 
Plare of Death ? 



I 



Davs 



'''"\\7)' **'f^ I!''»<IAI. OK ki;M<i\ AI, I DAI-i:.,!- Hini.ai. ..i R|-;M(»\ai, 



N. B. Kvery item of Jnformntion hHouIiI Hl- cnrclrully supplied. AdJi k'iouIiI bo Htntetl HXACTLY. PHYSICIANS Hhould 

state CAUSE OF DEATH in pinin ternm. thnt it may be properly cltiHHified. The "Speclol Information" for p«r- 
Ron« (lyin^ nwny from home should be (i<ven in every instrince. 



,'j 



1^! 



.1 

w 

1 1 






I. 



t ; ,; 



1 . ... 






\ 

A^ 



I 



, 



I 






-*^! 



% 



p 

'~-\ 






\ 



iL JE -- aA- j^^smmii 



rmr write plainly wit h unfading ink — this is jlj>e:rmane:nt record 

l'.,rn.l -f !»' ilfh 1 \o ir *-^^^X-;iuS:l'Oo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



It 



Da/c Fi/('(/, [XA^^yO^AAJ^ X^ 



lf)0^ 



lleghtcvejl JS'^o, 



1235 



cL^-v^^w/^ 



Deputy Health Officer 



DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco 



Certificate of IDeatb 



( 11. S. Stanza r^ j 



PLACE OF DEATH: 






K f IF DtATH occursTawav troiJi USUAL 

\J \ ir DCATM OCCjIpRtD IN A HOSPITAL 




County ofO/Cl/Tu J .\xx^n^<iA^<:^ City ofO/ 



^ 



O^j'W) -J AXX<o^v/e-A^xj.Ai^ 



<xl St.; 



Dist.; bet. 



"2rrKt 



L RESIDENCE GIVE 

OR INSTITUTION GIV 




mgjic 

jlnriF 



II 



i 






\ \ 




FULL NAME 




FACTS CALLED TOR UNDER "SPECIAL INFORMATION" "\ 
rE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



XXy 



^y\Jl 



PERSONAL AND STATISriCAL PARTICULARS 



"^ Q'TvL 




^V 



ajL^ 



i» \ I i "t r. I Kill 




\' .1 



IX 



X 



5- 



M.oitin 






MEDICAL CERTIFICATE OF DEATH 

DATi-; oi- i)i;\rii r\ 

(M()!iHi) i\ (Day) 



r9o\ 

(Year) 



\% 



/',/! 



^I\< .I.I". M AKIv ii:i». 
uiixtu I'D (»K i>i\()Kri;ii 

\\'iit> ill v,,iial <!< sij.' iiat i< •'! ' 



itiK riiii, \i-j-; 

IStaU <ir foiiiitrv^ 



N.XM)' (II 

!•• ATM IK 








IvRI:P>V CI;RTII-V, That I attfiickMl (lecx^ased from 
5" TqoH t(. LIaxxj. Q^.'i T90 S 

lliat'I last saw hA/>w alive on UsAA/Ql. '^'h 190 H 

and that <U-ath occurred, mi the <hite stated above at ^-S^O 
J M. I he CArSl-: ()!■ I)i:.\rn was as follows: 

\J AA.JO-VN' 



-O-'VvA ^ -vv-A^-Ov/O^-AX^-'aA.x) 



^1 



I 

Hi 




e p r 

' " 'IT \ lloN S[ 

ck^T3LA>-VNwil>V 

/\f'^:ilrtf III Siin /'i ,1 in i^f'tt <Tv )'</'» 



MIK IH I'l, \i)-; 
<M I \ llll'K 

^; il . i ,; I . .11 n I I \ 



M\II>i;\ NAMl 
01 MOTllliK 



MIKrill'LACl-: 
<>l- MOTHI.K 

'*^tat. ..r (."(Hint 1 V ' 



DrRA'i'lON )'rurK 

C'ONTRIIU'TORV 



(Signed) J 



J/ou/Z/s 



/)(!].' 



'S 



Hours 





^b T()o'^ r.\(Mrts>>) 



Mouths Pays Hours 

^cvvt M.D. 

vCo" 




0-<L^ 



i± 



Special information «nly for HMipitals. InstitiJlions, Irdnsients, 
or Recent Residents, and persons dyinq ,ih,j> froni home. 




Former or 
UsiihI Residence' 



(Vu L ^ How long at ^ ^ 

e\J I UrVyXO/WCL ffO ^vc^pidre of Deatlj ? II Days 



Monti,. 



l\l\ 



I'll I'. Miovi-: s r \ ri: I) i-i-; rsonai, tak rhiiAKs aki". TKri': r<> riii-; 

ni'.sl' nl' M\ K N( )U l.l'.DC.H .\M) m'.lji:!- 



' 111 f'l, ?iialil 






Wfien was disease contracted, 
If not at place of deatli ? 



I'UAri', 01 lilKIAI. OK R1:M()\AI. j DATI.o! I!iri.\i. oi K I-:.M( »\- A I. 



r M » 1 . k r A K !•: K 

( 






N. B. F.very item olr' inltormiitlon nIiouM I».' cjirefully supplied. AOfi hSoiiI«I he stnteil fiXACTLY. PHYSICIANS should 

stntc CAlJSr OI" DI'ATH In pinin terms, that it mjiy ht* properly claHHili'ied. The "Special Information" ?or p«p- 
•ons dyin^ awny from home Hhoufd he f^iven in every inHtnnce. 






f: 






\ :■ 



\\ 



I I 






H 

:i^^ 




If 



i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•=■■ -■-' US:!' ('- 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Boi^isfrrcfJ jYo, 



XQ06 



\jy^<j^ JouvM^, Depjty Health '^ cer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



PLACE OF DEATH: — County of^^a^v .3 Va 






No. 



Certificate of Benth 

( "U. ^^ ^4nn^nr^ ) 

^\cc'i.c< City ofv.'<X>^' A.a.^xo<.c\ c r 

% 

W\d db <X^^^^^ c X St.; 5 Dist.:bct. I C) Uv and 1 I .t] 

(ir DEATH OCCUR*; AWAv rRQv USUAL RESIDENCE Givr tacts CAiirn roR unper speciai in'-crmation N 
ir DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTFAO Of STREET AND NUMBER / 

FULL NAME ^cIwkxvcI' H ' '-^<:^.v<xLl Jaa\^x>a 



Iv 



PERSONAL AND STATISTICAL PARTICULARS 



\\\ols 



loLtc 



MEDICAL CERTIFICATE OF DEATH 

n \ n « >i i>i' \ 111 



1 ' \ I I 1 •! l;!K 11! 







t 






M ;S 



iMoiUlO (J 






I iii:ki:i'.\ ri:!<Tii'v, rii.u i ;iti, n.K-.i ,i, . , .^.•.i imm 



lb 



:i 



M \Ki< n:i) 
\u i'« »\\ j:i» ok i):\oKri-:r) 



i;;i< 111 I'l, \ri-: 

(SUitf or C'uintrv^ 






liiK 111 fi.A'i-: 

<»l- 1 AfllKR 



M VilMvN N WW 

<'!• M<»rm;K 






<1^ 'iH l.,nS 1o LLc.VO 'XS 1<)0S 

.ili\. I'll vA^CV-<3 3k S T()nH 



Ili.l1 I l.isl saw li ' ^ 

Mill that (K-Mlli Oil II! ic.l, nil tlu- .l.tlf '^tatotl m1>ovc. at S 



AI. '\'\\v C\l Si'! Ol- Dl.xrii was ;,-. Inllous. 



!> 











"^^ CrLch^o 



in K \ IK )\ 



C ( t\ rU MM T< > 



I » r R \ r h ) \ 



)'.//^ l/.'7///s I /).n s 1^ //,v^;v 






) , ns 




(^ 



SIG 



NED ) dtv^. '}VlIUv.\ nv 



M.D. 



HfK III IM. All- 
•»l' MoT||!:k 



' »' >■ I r \ii< »\ 



■CUXCyCV>OLAj V^<X^Jjji 




SpecKal Information '•"'* '<>' H'isni(.iis. inviiiuiions. it,insipnis. 



cI/al INFOR 



\.Mh.o S5 I - ?, vd. \\ 



or RnrnI Kcsiilriils, .mil prisons dvini) ,m.)\ Inin homr. 



/\r' hll-il III Silll /'l(IH,l'/'i> 



)V,M- I 1 



10, / 



111' \!!i »\ I" s r \iTi) ri-Ksi )\ \i. r \ I-: rnr I \Rs A K I-. rk r ]■; k » riii: 



I'.i'.si" m M\ Kx» »\\i,i: !»<■. !•; AM) iii:i,n.i 



' NiMtcsv; 



IHlio 




/OJAjVA,XL^rV\; > Jt) 



lormrr or 
lisii.il Rrsirfrnrp 

Whrn was disp,isr i nn(r,i( Ird, 
If not .il plrfrr ol dcdlh ! 



lloH lon(| ill 
I'Um- ol DrHlh.' 



n,i\s 



i'i,\ri: Ml r.i I-: I \i, t »k K i-Mt»\Ai. I i>\'n-..' lucivt m ktmoxm. 




r\i»i',K r \K i;iv 






>"• ». livery item cif iiifortimtion should I).- cnrcnill.v s\i|»pluMl. A(if; h'iouM I»o stilted I.XACTI.Y. PHYSICIANS Nhotilil 

Htiitc CAIISF: OF DHATII in pljiiii terms, thnt it miiy he properly cliiMHili'ied. The "SpccJnl Infonniil ion" V'or par- 
sons dyin^ away from home should be t^iven in e\ery instonce. 



I :1 
'I 



! . 



1 / 



■ .1 i » 



IP- 



'ii: 






it i'y 

''lie 

I 

. < 

• ri 

I I- 



if •. 

• 

1 








jrtfSSMKL 



i 



.! 



f 




If 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!• i!.' . ! II ''1; 



"^i'^. 



HM- C, 



hafc Filed , LLoLXXA^^^Atj 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







X\ 



VJ()^[ 



Tieo'isfcred J\^(). 



1 2^7 



<KAA^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 

Gcitificatc of S>eatb 

( Xl. 5. 5tan^nv^ j 

PLACE OF DEATH; — County of ^ ' Ct^^- vJ/y^<X^vc.\^coCity of O ^x/y\j J Axx^-yx/e^^ ^ o 
No. le^ll vJ^'lt St.; ^ Dist.;bet.UjxWtj2A; and Oxa1/>VV<jVC ) 

r IF OE«TH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALUEn FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCC'JRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 

FULL NAME 




.M; 



A.' 



aJIAxx. 



/>\) 



PERSONAL AND STATISTICAL PARTICULARS 

COI.iik > 






^ > • < ■: i;IK 111 




.L'. IxCt^ 



I):iv' 



1 '^ I 
/ I ■ ^ 



MEDICAL CERTIFICATE OF DEATH 

DA 11. ' 'i I»i: ATll r\ 

LUm3 XI 



(Vrar) 



\' . \ 



1% 



X^ 



/v 



■-I"'-' .1.) \! \ k K 1 1 1> 



liiK I Mi'L \ri-: 
' St;it<- or (.■'.untrv ' 




OJ\Aj^JI^<^. 



N.v\n . Il- 
l-ATI n-.K 









IlIR IMl'l, \( H 
<>I" M'»TFI1<"K 





I m;Ui:i;\- CIUTII-W Tli;it I .illcmk.l .Ic-cvast-.l In, HI 



lli;it I last saw li XHj alive- on 




IqO 



ui'l th.i! iKatli nccurrc-d, cii tlu <\aU- stated ahovt-, at i-^ 
LLjI. Tlu- C ArSl-:x»l I»I-:ATII was as follows 



'\.xxJO 



DC RAT I ON 



) 'fiij-s 



Mo)illi> 






il 



Ciyv^'^Nxo. 




4-<r1a, 



CoNTRII'.rToRV 




f\ns lo //ours 



\\ 



1>IR.\ TION 

f Signed ) 



A\' 



■I INTioN 






)V<//\v .}/(^N(/is 10 /;,/,. V //ours 

M /\<X^ Q.ccWwx^A^- M.D. 



LU^Q ^1 l.,riH f\.Mnss)5>oO 

SPECMAL Information onU for Hospitals, InsllHitions, Transients. 




It 



or Recent RcsidentN, and persuns dvini ()w,iy fro:ii home. 



M -nllis 



I 



I'm: A!!t i\j-, sr ATI!) i-kus,, )\ai, i- ak ricri.AK'- aki rkii' To rn i-* 
i;i->r 01 Mv K N()\vi,i:n<,K and iu;mi-:k 



Former or 
L'sual Residence 

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



How lonq at 
Place of Death ? 



• Ddvs 



'lii *"■ ■■in-iiit 









( Vrldl. ss 



I'l.Aci-: (M- inki \i. (u: i;i:Mf\Ai, dati-;..: m kiai, <.i ki.:m()\ai^ 

L\jLA^k^.x^:twM Laa/^ X^ T90H 



INDICR TAKI.R 



N. B. Kvcpy item olf inf irnmtion should be cnret'ully supplied. AGE should be stated FiXACTLY. PHYSICIANS should 

state CAlISr OF DEATH in plain terms, that it may be properly dassilfied. The "Special Information" for par- 
sons dyin^ away from home should be tii\en in every instance. 



M 






I < 



' w 



I 



t 



1 • : 



I • 



I • < 



I • 



Il:i 






^ ! 



MlA^CWLt 



^< I 



u 




* 

V 



WRITE PLAINLY WITH UNFADING INK 



ti^^.t ..( II .'ii, 1- Vo 



^ ■<•«;: liv^l' C 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lid^lstei'cd J\^(), 



1 2:>8 



Ddir Filed. LLvvQAAAfc "XTX 100^ 

i^M.,*.^ iou>^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH: — County ofCj<Xy>X' X.(X'> vc<.<n.c.c City ofO/Co^. A.<X/w Cu^ c o 
No. 5^ Lfr^x^\HL/x.<Li... St.; S' Dist.;bet. ()b OJv>l>UL^>\, and vD.>jj^/-> t ) 

/ IF DEATrt OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION \ jl 
V iF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J (J 



P 



FULL NAME 



CL 



o 





I 



cxX 



\X.\.C 



PERSONAL AND STATISTICAL PARTICULARS 



■ i:\ 



■ro 



1) A 1 1'. < li r.iRTii 



\< .!•; 




i< II, » tK 



IvIvv.'Le 




\l..iii10 




1 



),,n 



•J 



!l)avl 



!'.,,/'//< 



> ■ :il I 



/■,; 1 



>>l\t.l,l-: MAKKll.Ii 

I W'l iti in VI ii-i:i 1 di -' ■ .11) 



X 



^X/^^uOAJL 



liiK iiiri.Ai'i-: 

< Slati- III ('oMiiti >'^ 



\ \\n: « II 
»• A III i:k 



liiu riiri.ArH 

<»!■ 1 \ fill' u 

( ■. .'1 hi I V 



MAI hi'. \ NAMi; 

ni Morin: K 



I'.iK 1 iiri.Ai 1. 

••I MoTiniK 

' Si' ' <.'>)ll11tl \ I 



<H\1 !• \ rioN 









MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

as 

fDavl 



^S~ i*,o't 



(Month) /f fDayl (Year) 

I lli;kl';il\' Ci;UTil'V, Tli.il I attcn.U-(l (Icciasod liom 

LLla^Q 1% npH to LVaa^ 

tll.'il I l.ist saw li i. ■ alive oil LLv,\^Q^ ' k"^ l(;o'^ 

ati<l that (k-atli occunc(l, 011 tlu- dati.- staled aliovc-, al I 

U^ M. The- CAISI". ()!•■ hl'.ATll was as roll.iw^: 



J 



^\Xl.*wV.A-^ S!.. 



1)1" K \ rioN 






VJ 






)'(ars ^ Mt)ntln 

c N T R I lU r ( ) R \ \>(y^.Xx,^'\..>S. 



Pax 



//ours 



DIRATION 



(SIGNED) lOAyj. 



)'tiir.s J A '///// .V 



Pay 



rioH 



rs 




Rf!!iiff(f lit Siiii I'liif, ' (-.) .X, 



) , 



^ M.u'Jr- 



! 



riir. \H( »vi: sT \!'i- 1> i'i'i<«^< i\,vi, !• \K rini, \ Rs \ki: i'ri )•; r< » riii-: 
iu;sr(»i- Mv KNM A i,i:i)c, 1-: and iu'.mi,! 



(Inf^ M 







Ir 



U.U M.D. 

f) i.,o'i (Add ass) ^ -5 lXvl<X>vh_^Uj Vi),t<^..,q 



SPEOIAL Information only for llos(iif,)|s. Institulions, Irdnsienls^ 
01 Rt'ifnf Residents, dnd persons d)ing dw.iy froii home. 



Former or 
Usiiiil Residencf 

When was disrasp ronfrarted, 
It not al plare of death ? 



HoH lonq al 
Plare o( Deafli ? 



Oavs 



I'X, \ri-: (»I' HtKlAI, <»!< Ki:Mn\AI, 



CrLu \Ka 
K 



DA 11: '.) Ml RIAL .ri K i;M( i\AI. 



T9n'\ 



I NDi: I 






N. B. fivery it.-ni of in)t'<MMniition hIiouM \v: CJireV'iilly .supplied. WiV. s^ mlil bo Htnteil EXACTLY. PH\'.SICIANS nIioiiIiI 

Htntc CAIISF or DI;A I'M in plnin tcpins. that it m.iy I)l- properly cliiMNiified. The "Spcviol Inliorimili'm" f«>r per- 
sons clyin^ Hwuy from hoinu Hhould be ^iven in every inHlnnce. 



'tl 



1 . 



H^ 



' ii'- 



I .>-|. 






^:i 



li 




I 



mc^ 



W'- 






% •••««•»« 



!i 






I 



'f* 



i\ 



i. 






i I m ■" 



n«iirtVr^»» • • «■» 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






lln^usfered J\^o, 



i^^9 



Ddlr AV/fv/, (X^,.^^cv^^ ^1 J'^O"^ 

eputy Health Officer 

DEPARTMEiNT 01^ PUBLIC HEALTH=City and County of San Francisco 



J^^^j-A^^VA^ ckjw^\>U 



Certificate of ©eatb 



11. S. ii'tnnDarD ) 



i 



^ 






Ol^ 



PLACE OF DEATH: — County ofCloL/w- /vXXx>^^v^'c€ity of *^Cl/>^ . ^xx^kvam^^o^c^ 
No. l^V; \J\JiAy<Ui^'y^ LLvO. St.; lo Dist.;bet. VJ Cr\Xx^ andvD^X. 

/ IF DEATH OCCURS AWAY FROW USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M AT 1 O N • ■ \ 
V, ir DFATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 

C<il,nk 





\ 



D \ I i I >i r. IK I'll 





I Mi.iifh I 



\i . 1-; 



) , 



H 






M.'iilh- 






\ < A\ 



u 



^i\< 1.1".. M\Ki<ii;i>. 

1 W t i t . : ■ : 



A^'^^^ 



' St. ill- Ml < '> milt I \ 



\\MI nl 
l.\ 111 l.k 



lUKIIin,.\iK 

M:i!< III (.■(ilinllV 



M \iiti:\ N \M 1 



Itik Til IM,.\('l': 
•>1 Mol'lll-.k 

' Mat"- 111 Count 1 \ ' 








x\ 

(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

D.vn-; oi" DivVTH r\ 

I Moiitli) K 

1 lll{ki;r.\' tl'.UTII'V, 'riiat I attciuUMl <ic'roastMl from 
HAjJLu l^" ItjoH to LA^^A.^ ^1. TqoH 

that I last saw li-i-<^^^\ alive on UO-''^^ Xt ujo ^ 

ami that ik'ath ocrurrctl, <mi tlu' datt- statt-a above, at *" 

M. Till- C.\l SI-; OI' l)l':.\'ril was as follows: 



DIU A riON 



)\at:s I Mo)iths I A Pays 



Hours 




' •' I'l !■ \l'|( )N 



) , ,,-; H yi. nths 10 /'. 



IN, \i!f »\ i", ST vn-: !> iM-: k<.( »n\i, I'.xKrirr i, m<s \k i: rur i". r< • rii i: 
iii.sr OI Mv KN(»\\ij;i)<; !•: .wd in:i.n:i 



f InriciiKiiit 



CONTRIHrTOkV 




DrU.xrioN Years I J/<';////.s 1^ Pays 

iNED) OX^ Vj. vI .o^AjLtU^^^ 



(SIGI 



l^L^ 



^ 



UUv/Ol'X'1 KioH rx.MtvsO HOH- ivd.' Ot 



^v/0, Vs I 
FECIAL 



i 



Hours 
M.D. 



SPECIAL Information "f'y for llospitdls, institutions, Transients, 
or Rorcnt Residents, .ind persons dyinj .iwdy Iroin home. 



Former or 
lsii.ll Residence 

Wlien was disease rontrarted, 
II not at plare of death ? 



HoH long at 
Plare of Death ? 



Days 



ri.Ai'i'. • >i- iMKiAi, (>i< !< i;M< "V \i, j i)\ri'. Ill m in,\i. m ui;m( )\'.\i, 
INI ) I ; K T A K 1-. k OVO . . O-^^/^JhJv ^*^ Lo 



N. 1$. I.very Item ui intform,iti(»n Khoiihl be cnroViilly suppHlmI. \V,V. should be stj.teil liX AGTLY. PHYSICIA^IS should 

Htiitc CAlISr. OP DI A Til in pliiin lenns. thni it mjiy be properly claHsitied. The "Specinl liiformntion" for pur- 
Bnn« (lyin^l tiwtiy from Ikmtic should be ftiven in every instance. 



A 




1" 






'■(■■ 






ill 



I I 



1!SWf 



"^W*" 



•^\r\ 






^&7 



.5 1 \q 



l» 



ii 




WRITE PLAINLY WITH UNFADING INK 



J»ft^'-'%t, liiS: I' Co 



THIS IS A PERMANENT RECORD 

r 

REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

1240 



Ecssi, stored J\''n, 



/>,./r /7/rr/. (Xouxw<i±i 3.1 l''0'\ 

l^^^lwM, Deputy Health Officer 

DEPARTMENT OFf UBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( tl. S. Stan^niC^ ) 

PLACE OF DEATH: — County of /Ol/^a; J AXX^ vvt^..,^L^ix City of ^/O^^^ A^v^ <^va.'^-^ 



No. ISOlo 




St.; to Dist.; bet.Mx^rv^^^^VVvKXAV^^ and 

CALL 

NAM 




v-vW. ) 



/ ,F DTATH OCoVjRS away FROW USUAL RESIDENCE give facts called for U N DER T SPCCIAL INFORMATION' \ 
( °F DEATH $C-!rrTd IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OfI^TREET AND N U V. B E R . J 



FULL NAME 




.Ouy^^^ouO^'Ou V 



\: 



>l:\ 



PERSONAL AND STATISTICAL PARTICULARS 




xrVCLc 



Ii A ri". < U I'.IK III 



\' . !•: 



'JOZ. 

M.Mltlll 



1% .,„,. ■( 



as 

( Day) 



M.'nilr 






\ cur 



//,/ 



winow i:i) OK i)!v<)Kii-:i) 

^Writf ill -uciiii <1( — iL'tKition) 




-V'Xajl/cL 



lURfHi'I, \'lv 
'Stat' ■■■ '■Miuitrv 



NANTJ- ()l 

l"A rii};R 



r.IR TIIl'l, ATK 
OI' l-AIHI-K 

fStatf or rmiiitrv) 



MA I DI-.N N \M1', 
ol MoTHl'.k 



t)l- Mi)Tin:K 
(Stilt'.' or Coimtry) 






O^^y^y&j 





<»c 



crpA rutxCMP 







/•',.' 



iin: xiiovF. sTAi"i:i) rKRsoxAi, r\Rrn.M'i.ARs ari' rRri*, to tin'. 

HKST Ol' MV KNn\Vl<i:i)r, K AND lUn.nCK 



(Info;ni;nit 



S b Lbv/^^-vu, Ot 



f \(Mn-ss 




4 



MEDICAL CERTIFICATE OF DEATH 



3vO IQO '1 

(I);iv) 



(YCMI 



DATE OF Dl.ATH /""l 

'Month) K 
I II i;R i:r.V CI.RTII'N', That I aUiinKd lU-ocascMl from 

LLl/l/Q ?v i<)0^ to \Xx.\yOi Qsb T(,o H 

that r last saw h -^>^ alive on LLowXX ^0 Kp H 

and tliat .Kalli occurred, on the date stati-d al»ov<\ at O • 6 C) 
\J M. 'flu- CArSI'! Ol' DI'ATll wa^ as follows: 



I ) I ■ 1>J A T I ( ) N ) V(^,s- 1 Mon th s /)ays I/i. ) ii t s 



I )r RATION 



^t'o}lt/^s I^avs 






/fours 
M.D. 



Special Information only tor Hospitals, institutions, Transients, 
or Recent Residents, and persons dyini] away from home. 



(Signed) Vj . o.vijA>.^oh 



Former or 
Isual Residence 

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



How lonq at 
Place of Death ? 



Days 



PI \CF or HTRIM, OR Rl'-.MoXAI, DAri"..;" P-ikiai. or R1:Mo\\I, 



!N. B. F. 



ivery item of Information should be cnr.fully supplied. AGE should be stated f.XACTLY PHYSICIANS should 
tate CAUSE OF DEATH in plain terms, that it m:.y be properly classified. The Special Information for p-r- 



sons dyin^ away from home shoulil be Jilven in every instance. 



;l 




w 



\\ 



I »l . 






I H' 



I! 



r 



,1' 



I I 



1' 



>4»A« 





^1 




>< 



n 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



iyi=5&x 



\ik]' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



t" 



/)///(' h^l/cd , 



(X.^^'VAA^ 




'X\ 



lOO'i 



Be^islcred J\^o. 



I2il 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( 11. 5. 5tan^ar^ ) 

J? (^^ Si (^ 

PLACE OF DEATH: — County ofCj^OyYv OA,cX/^vcui.uCity of d.O./w OAo^^'AyCUixOe 
rNo 10 CoJ.JlA.- St.; I Dist.;bet. 3.5 11^ and ayUA^ 

/ ,r DEATH IoCcIrS away FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION ' \ 

( .r deaIh o^c!rrTd ,n a hospital or institution give .ts name instead of street and number. J 

FULL NAME Wiv. , OX<L^i^^-J^ OAJl/>^' 



) 



''\J 



-^ 



PERSONAL AND STATISTICAL PARTICULARS 

rol.i »K 





I 



' A'\ ( 



4 



DAI 1-: t>l- 111 K Til 



\' . »■: 




M..ntli 



lb 



,*\ 



n 



14 



) 



1 ',.;/,'// 



/ I'M. 
■>■( ill 



/»,; 



^ INC. 1,1-: M\KKIi:i> 



I Wi itr i 



lUK Till'!. \fi; 

' Stati ' .1 I "■ 'iinl I \ 



\ WW: t •! 

iaiiii:k 



UIK'll! !■!. \r}-: 

ni- iArm:k 

I Stiitt or Country 



M \!i>i:n nam 1-: 

<>!■ Mit'l'lll.K 



lURTHrLACK 
ni- MnrmCR 
(state or Contitiy^ 



< HI I I'A TlnN 



l) 





<^ 



A/vvX<LX!-'Vaj 



ex. w ^ 

J? 



J AyCu>xALJU H I- U/CU-Y^-WOI. 



'/ N" 




1/. /,///. 



/',■ 



THl'. XltoVl*. ST ATI. I) I'K K-^* )NA I, r\K TIvri-MO A K I ". rKll-; T( » Til l' 

iu:sr oi' Mv kno\\ij:i)«;k and iu:i.n:i' 



IIiiroMnrint 






( \.l<1r.'^s 



(W-ai) 



MEDICAL CERTIFICATE OF DEATH 

DAT I", oi di;ath r\ 

LLc^o It 

(Month) /] (Day) 

I 11 Ivk I'iliN' (>.' !;R'ril-'V, Tlial I attc-iulcd dcrcased from 
NtAjULc*. Q^^. i(,oM 1(1 LAaa/CJ^ Xb i(,o H 

tliat I last saw hA- ..« alive on L*-*-v,n Al jcp '^ 

and that death occurred, on the date stated above, at ^.^ 
y M The CAl'SIC OI" DIvA'I'H was as follows: 



^' 



])\'K.\'V\OS }\'ar.s- I Months O Pays 

C C) N T R 1 1? U '1' () R \' LI y>J>l/v: 



I louts 



v.^-«:.^«^-r:v^^ 



I )!' RATION )V(/y.s- Motilhs Pays 



( Signed ) 



a 



CLQ '^'l U)o' 



a. 



O Ol/*>a^*n_U.i 
Address) ^'o5'C)<X/W 



Hours 



M.D. 



La\X^<i Ia.\- 



SPEcilAL Information on'y '("■ Hospltdls. Instilullons, iNnsients, 
or Recent Residents, an-l persons dying dway frnn fionie. 



Former or 
Isudi Residence 

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



How lonq at 
Place of Death ? 



Days 



IM.ACIC OI- HIKIA;^, OR K1;M(i\AI 



^uW\JLA>' 



^Ola-O-O'^ 



DA 11'. of I'.iKiAl. OI K1:M()\\I, 
Address .Q^H\'s5 M f\A><lA>A.-<r\X ^ J.l 



N. B._F.very Item of InformBtlon «honld be cnrefully suppllod. A«H sV.uM be stnted BYJVCTLY PHYSICIANS should 
«tntc CAUSE OF DEATH in pinln terms, thnt It m;.y be properly classified. The Special InVormat.on Vor pT- 
sons dyinft away from home should be [ftiven in every instnnce. 



If 



( . 



\. • • 



V 



l^i 



i^ 



iii 



f ' 



I I 



I ^ 




, < 



I. 



il 



iilf 



I 



i 



WRITE PLAINLY WITH UNFADING INK 



^■ r i* ^^ ^*-- ' 



IXf) :^ t-^^^r.'^'-^; lU^ r C*o 



— THIS IS A PERMANENT RECORD 



lEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Eeo^Ls'fe/'pd J\^o. 



1242 



l)>i/,- Fi/rr/.iXj.^^-^^^ XI l^'C"^ 

Lr^^lc^ Deputy Health Officer 

DEPARTMENT OT PUBLIC HEALTR=City and County of San Francisco 

Certificate of H)eatb 

( XI. S. j5tnn^nr^ ) 

J? Qsp A ^ 

^PLACE OF DEATH: — County of CI^La^ J .^v^u^c^a^ City of O/Oa^ OaxVyx^a.<l^o 
N^ 0^\^ JUxi^'v^.^^ ULvOL V \^ cu.,, St.: \ Dist.; bet. 



and 



^^ A \, iiciiAi ^rQinrNCP nvE facts called roR under special information • \ 



FULL NAME 






oo 



' I . \ 



DA ri-; n) lilK I'll 



\' . 1-. 



PERSONAL AND STATISTICAL PARTICULARS 





IX' 



,kXjl 




M..iUh! 



il):ivi 



(Vcn) 



)•-„•/ 



:^ 



1 ' >/'//. 



si\«,i.iv MAKi<n;i) 

\\I IX >\' (• ' ' ' "■' I • '\t >»•' k' 1'. I) 



Wli! 



MiKi'iM-i. mm: 

'Sl;!ti' <)! '-Mllllt 1 \ 



N \M1, » »!■ 

I A Til i:k 



i;ik III ri, \(i-: 
<M lArm'.k 

St;U<- (It Ir.MllIt V' 



M \I1>I,\ \ \ \1 I 
Hi Murill; K 



Ml.lt i'Ml) 



(371 



vi).oux 



to?. 



u 



^ 



n 



)'\.^r^ 




.LC 







UIUriMM.ACI", 

<>!• Mt>Tm-;R 



I' ION 








/ 



llli: \H()\J'. STA ri- i> IM-.K-^ONAl, I'VKlliM I,\KS AKl-. IK IK I'd i" i H : 
lU'.ST ()1- MV KNi i\\ l,i:i)C. !•: AM) I!i: M J-". 1-" 



nnfM-m.'nit 



ySoL/vtoL H. <5vJuL<^ 



\.1.1p 




,VALUa,x(i)o^ tit 

4 — ^ ^ 



MEDICAL CERTIFICATE OF DEATH 



DATI-: Ol" DKATM r\ 



(Day) 



/OoH 



(Vi-:irl 



(Month) /f 
J Hi:RI":r>V CI'.RTII'N', 'I'hat I attciwU-cl (lercastd from 



tliMl I last Saw h -0%^a alive oti LL\..\^ 'Xb up 

aiiil that «lL-atli ocruric<l, on tlu- datt- <tat(.-(l alxivr, at 



M. Tlu- CWrSJ': Ol' Dl'lATM was as follows 



nr RAT ION )'riirs MiUilln Pays 



//ours 



CONTRIIU TORY 

DIRATION 
(SIGNED) ^ 



,v^ 



)'rars M<>n(/is Ihivs 



vJLwvtc^ro 



LL^ -^^n i.,oH (\,l.lns.)ll><tt VJb 



^ 



//ours 
M.D. 



SPEci^AL INFORMATION ""'> '»'' Hospildls, Institutions, Irdnsients, 
or Raent Rt-sidents, and persons dyinj .iwhv from home. 



Former or 
Isudl Residence 

vvfien was disease rontrarted, 
II not at p!af e of death ? 



How lon() at 
Pla( e of Death ? 



Days 



n.At"!-: ol HI \< I A I, OK kl.MtAAI, 



) \'\'V. "I r.! iM \i. iM K I'.Mt i\' \I. 




N I ) ]■ K T A K 1-; K I) oJU/vdjL M rUuVA./VV\j^^ L^ 

(Acidise ISX^i uLiyTJkXio 



>, .. I- 1 \f'|- ««i.,ulil he stnt'MJ i;\'ACTLY. PHYSIC! \NS Hhoulil 

N. B. nvery Item of Information hIv.uI.I be crcfully Hi.p,»I.ecl. A(.!. k i.ul.l »^.^..« 7' *-:''::. J* .. , ,,„.„^„,at5o„" for p.r- 

statc CAUSE OP DI:ATH in ph.in terms, thnt It m^y he properly cl»H«.^.cd. The Spcal In.ormat.on »or p^r 
«on« dyin^ nwny from homo should ho feiven in every mHlnnce. 



f-'fll 






I* 









1 1 



\m\ 



|ii 



i I 



I I 



-I 






f 



I. 1 



i^iKv 



flhi ^ 



tiiPi 



I 




ii 



lit 



i. 



I ^ 



(I 



i 



(if 



P 



WRITE PLAINLY W 



ITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 N. 



•'^"^X^Wb^VCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Fi/c'l , vJ^aa^OA-v^ '^1 



loo'x 



Re (ii, si ('red J\i''o. 



1243 





.^^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of ©catb 



( *a. S. Stan^arC> ) 



-p 



^ 



PLACE OF DEATH: — County ofO.a,^ J.V<Xa^^c^c.c. City of ^ '<Xa%. J A.<Xov<:a^^<. 






N( 



i 4 



fP 



St,; 3. Dist.;bet, OX^cJcU^v and ^ CKA> 




-\A>V^ \^V^_ V ) VJO T - -V. oF«?IDFNCEGIVt FACTS CALLED FOR UNDER "sPtCIAL INFOHMATION" \ 

( '^ r."o;ATH^OCCUrEV,;"rHo's^yT'At o""N?.',TU^4"^0,Vr.Tl NAME .^STEAO OF STREET A.O .UMBEH. ; 



FULL NAME 



C^lOXO.: 




it 



\.0l<L^<Xa1.\a. 




Xx/^^vcu^ccL I 



PERSONAL AND STATISTICAL PARTICUBARS 

^ (1 ^""-"MoJ ^ 



vJX/ 
HA 11'. < )1 I'.iK I'll 





K-KX 



I MEDICAL CERTIFICATE OF DEATH 

DA ri", Ol- I»i;A TH , , 



M|.;ith' 



Ai .1-; 



\% 



) ■ 



I 



IS 

II).1V> 



,!/.■;/.'/' 



I Year) 



X 



/'. 



SIN<, !,,' M \UK ll'.n 

wii)( twi-.i) ok i)!\«>Kri:!) 

iW'iitt in MK-ial (Usij.Miati<in) 



i;!K rm'i. \r)-: 

St.-iti- ' '• ' '■ ill III ; \ 



N WW. Oi- 

I AC II i:k 



I'.IK riMM.At'K 
(>!• FATHlvK 

'■ Stal'- 'ir <"'Min1i %'^ 



M MDI'.X XAMi: 
(»1 MDlin-.K 



lUKTnri.Aii-: 
Ol" M(>tiii<:k 

f stall- or Coiinlrvi 











•nrri'ATloN 9 n 






\ )•,-,.'< 



1 A. /////> 



/',;i 



Tin-: Anovi*: sTA'n:i» phrsoxai. i'akiuti.ak^ aki'. rKii-; t<> rm-: 

IU-:ST Ol" MV KNo\Vl,i;nC. K ANP Itlll.Il'.l'" 



f Info: in.'uit 



%. 



^^.kJL 




( \.l.lrc^s 



i 



H I ^ CJ /OiyC:/\XX^ry^\Ji^v\X< 



^ 




(Vnnih) K <I)ay) (Year) 

I lilvKl'.nV Ci;U'ril"V, That I altoiidtMl (Icci-ascd from 



^ 



-\ 



tliat'l last saw h •>••' alive on LX^-^ 0.1 up H 

aii.l that .hath < .(■currcd, on the tlatf statc-il ahovc, at 
M. Tlu- CAI SI', Oh' i) MAT II was as follows: 



1 



DTK AT ION 



CONTRIIU'TORV 'uJ-ryyJ^r^y^^ 



Ddvs 




J Jours 



DERATION 
(SIG 



)'i'ijrs 



Mo)it/)S 



/hrvs 






CLv^ o.n Ton't f A.hiu-.^) Hob 3:c^tu>v< i.t 



Hours 

M.D. 



»E:dlAL INFORI 



SPFdiAL INFORMATION «"'> for Hospitals, Institutions, Transients, 
or Reien] Residents, and persons dying avv.iv from home. 



Former or 
L'sual Residence 

When was disease rontracted, 
II not at place of death ? 



How lonq at 
Place ol Death ? 



Days 



I'J.ACK Ol' nt'KIAI. OK kl'.MoX \I. 



dbcrW 



Ou^AA' 



DAl'i; 'i!" lii Kl\l. or KI:M<»\'AI, 

1 1 






(A(l<hess ^ XH 




.N 



II ATF ahoultl be strtteil RX4CTLY. PHYSICIANS should 
. »._-F.very Item of Information should be cnrcVully suppl.ed. ^''^'l^^^'^l^^^^ ..Special Informntion" for p-r- 

Htate CAUSE OF DEATH in plain terms, that it may be properly classified. 1 ne ^i 
Rons dyini away from home should be j3>i>en in every instance. 



% 



\ ■ 



li 



r. * 

r 




m 



'ill!. 



i I 



li 



m^^ 



-^^mtk/ 



.^^%9^ 



WRITE PLAIN 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



II 



)i 



,! ,.f Ur;iUh— 1- Vo, IJ5 T* 



■*.' 



^o •«<«», 



•-; HX:l' ^" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jip^f'^sfrred J\''f)- 



1244 



cer 



ty 



Hair niol, \X^J^OA^J&i Xl I'X''^ 

\Jy..J^^J,\x^ Deputy Health Off! 

DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco 

Certificate of IDeatb 

( tl. 5, ♦r1t^n^ar^ ) 
PLACE OF DEATH: — County of Oa'^JAxx^vtv^Co City of^J/O-A-v 0/uCX/YVXi^A.cc 

f+s,.r. ^ni,._.i _„^ __.„, 



No. 



V.Lt ' '^ 




'>V^V(yU,A.^t.; 



Dist.;bet. 



i. 'I'*! 



I 



FULL NAME LcUa-^^ctvx:^ 





:(.; 



>:■ 



PERSONAL AND STATISTICAL PARTICULARS 

1 • ; I ' ii l;lK 111 P 






15^ r%'\'\ 



"1 < a r 



\'.i'; 



Ho , 



\\ 



s 



>>I\"<,|,K. MAKRIl-". IV 

WIIM »\V1-!) OR 1H\'< >Kvi:i) 

I Writ' ! n -. . i;'. I ill -''.'iiat i')!)) 



in K Till' I. \>"i". 

■ St:it< nt I ■ >imt I \ 



N \\U ( tl 
rATIll'.K 



MK rill'l.ArK 
oi" l-AIHKR 
(State or CDiiiiti \^ 



Ill Morni.R 



lURTni'LAri-: 
<H' A:t)'!in"R 
(St:i! 



' t-ClTA'l'IOX ^^^Sk^ 




fi/VW<X 



:aXXA'V- 



AXVW^C-X 



"J 



k'r~',frJ ill S,ni /'i ,1 II, ; )-ri — ) .'<m 



M."!f!l' 



III-, \1'.()VK S|- A ri:i) l'KR-;oXAl, rARlUlI.^R^ ARK rKlK TO iH J'^ 

i;i:sT *>i .21N' KN»)\vM-;i)«'. ic and }'.i-:li1':i' 

Address \JCL/\^/>u:iJv\Ay■\.'SJiUi. 



'III riiiin.iiit 



MEDICAL CERTIFICATE OF DEATH 

DATi-; < >i' I'l WW r\ 

(Montht r (Day) (Year) 

1 II i:U ivi'.N' C" i; Iv Til'N', Tlwit I iiltenikMl (Iccrasod from 



LaJj^JVaX 






that I last saw !i v > ■ ,ilivc- 011 \JokA^ '^.'i Kp H 

;in.l that death orourrcd, oti tlu- datr stated above, at o. 5 5 
Vj M. The CATSI". <>1' Dl-A'l'll \Nas as tollows: 

> 

DIRAriMN )',ars \ M,)uths I 3 />,?i\ 

CoNTRir.l roRV 



IliUlt s 



DIKATK »N 
(SIGNED r 



) V./;'.<r 



.1/."//// 



UU. X9. L^nrAXo^A. 



/\?r 



/fours 
M.D. 



_ A 5 I ( lO V f 



vAAyvw^Jt" 



SPECIAL Information ""'^ ''••^ Hospltdls, Institiilions, Irdnsients, 
or Rffcnt Residents, and persons dving a\sa) \-.m home. 



yjJ^yy^AJrx^ 



How long at 
V^--a.->^ Plate of Death ? 



. Days 



When was diseasr rontrarfed, 
If not at place of death ? 



I'LACi-: 01 r.TRiAL OK ki;m<)\ AI, 






DAii:.; I'.! HiAi. or ri:m<»\ai. 



... .' .. II APF «Hr.iil.l be stated RX4CTLY. PHYSICIANS should 

N. B. Fivery item of infarrtiHtion should be carefully supplied. At.F. sHoi.I.I ".^^.^y'^^ "J^ ^^^ i„f„n.««t Jon" for oer- 

Htate CAUSE OF DEATH In plain terms, that it may be properly class.t.ed. The Spe.-al InVormat.on for per 
sons dyinft away from home should be ftiven in every instance. 



W" 



H 



{ ; 










i 1 



(I 



f! 



M I. 



B'l 



'* 



^ 




WRITE PLAINLY WITH UNFADING INK 



iu^«l^4ii;i'.tli 1' 



fi"*^*"^ 



l)^^^^' Filed ^ 




THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i,9(9H 



li(>(^istci'C(l J\^(). 



12 m 



CX.'tr^.A.^v^ 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( "U. 5. tr»tnn^nrD ) 



^ 



m 



PLACE OF DEATH: — County ofCJ,<X^r^ J A.a.-yx^A^-oCity ofU C^/>x/ . Vo.^a.'e.^.^^ 



St.; 



/ ,r orATH OCCURS AWAV TBOM USUAL RESIDENCE a.vr pacts called ^o" ^.^^rR '^^^ll^'^^^^'^^Zl'^''' ) 

t IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^ OF STREET AND NUMBER. / 



FULL NAME 




.UUv\xo 0\D^Uw\^A.. 



PERSONAL AND STATISTICAL PARTICULARS 



AJ 



4- 



y 



l;lK 11! 



r I '- ■'! 



M.iiil!! 



\' . !■: 



45 



)■- 



1 Dm VI 



.U.»i///~ 



■,'v:i! I 



■-IM.J.i: MARKU'I) 

\\ Mil iwiTi < >u i);\'Mvr i", l> 



111 



\\!i! 



1UK rui'i.x^M': 

st:it>> ( ,v t ■ unit I \ 



NAM J, (>1- 

I- \Tin:R 



luR'iii I'l, \t }•: 
or i\rni:R 

' St.ttc or C'otnit I \ 



M MIU'.N" N \M1. 
'il MdlMll'.k 



inurnri, M'K 
<»i Mi)Tni:K 

(Slate or Cnnnliyi 



'■ ' I I'A ri» IN 



OS?) (j 



^c 




)V 



M.'iit/r 



/ ■ .M 



TH!'. XHOVH ST ATI- I) I'KUsONAI, J>A K T HT I, A KS AKl' TKIK Ti • nil', 

i5i:sT oi- Mv KNowLi-.ixiH AND r.i':iji:i' 



f Illfn:n);iTU 



^ 



fA'Mress 







\X/\>^. 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATH OI Dl'ATIl /"^ 

(M.)iitli> A (Day) 

I Hl'iKl'J'.V CI:RTI1<'V, That [ attLMnUMl dcHxasotl fioiu 
CLla^q ab looH to LLv.^^ Ovla H)0 H 

that I last saw li •«-■ alivt- on *^\.A.vV,Q >.v;. 



itp 'I 



iiii.l that (Iratli occiirrcMl, on the ilatc statt-tl al)o\A'. at ' '• ■oO 
^L M. Thi' CM SI' Ol' I)i;.\'ril wa"^ as HjIIows : 






DIKATION y<ai 

CONTKlIIi roKV 



.\/oii//is 



I^ays 



/Ion IS 



I)1I< \TI()N Y''^'''^ Months 



Pav 



//(inr^i 



(SIGNED ) 








Special information on'y for Hospitals, Inslilutibnt, frdnsients, 
or Recent Residents, and persons dyin!j away from home. 



Former or 
lisudl Residence 

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



How lonf| at 
Place ol Death ? 



Days 



'LACK Ol lUklAI. OK Kl.MoVAI. 




)JLv^1 



I) A I'l; -))' I!! iMAi. or ki-;mo\ai< 

\J,A>«^ O '^% I90H 



INDl-.K TAKI'.K 

(.- 






« .. I- I APF «Soiil<l he Rtiited r.XACTLY. PHYSICIANS kIiouIcI 

N. ^^, Rvery item of JnformHtion should be cnrefully HuppI.ed. AGE should ^l*-.***"'^;: ' \\r, . ,„w.„-,„„ti„n- ^^ p-r- 

state CAUSE OF DEATH in plain term«. thnt it m»y be properly class.^.cd. The Spc.ol Information lor p-r 
«on» dyinft away from home should be U'vcn in every instance. 



I 



I ! 



ii 








4i r 




I 



m 









1 1 ' 



It 



ii. 



H 




« 



WRITE PLAINLY WITH UN 



.! ..r iic'.Mii I V' 






FADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)/(/(' Fi /('(/. 





ai 



VAA^ 



rs 



!o:?fth Officer 



lle<:>i,sicrc(l J\'*o, 



1216 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County ofVJ<X/>v 



Ccvtificatc of Bcatb 



J^ 



4 



St.; X Dist; bet. 




vuJ^C5\-U\jand 'ktPAX^ 



No. ISSH Cjo^cA.ayY>'vJi'^vl.c ^.„ . ,-- ., _, . 

/ ,r DEATH OCCURS AWAY FROM USUAL RESIDENCE ClVr FACTS CALLED POR UNDER S P E C. A L 1 N FO R M AT I O * \ 
( Tf DEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUN.BER..J ) 



\ 



FULL NAME^X^^vv o 





Om^dU. fl^JUAJAA-^^O/rv- 



i) \l i ( u- i:!K ni 



PERSONAL AND STATISTICAL PARTICULARS 

, L"< '1,1 >k 






t . 



X 






%• ■ ■! 



1 :i! 



\' .1-; 



^INT. I.K, MAKUn.n 

\\ • itc in - • - ) 



^ 



'\ t 



I'.IK I"!I I'l. \>' I- 



NX Ml- (»!■ 

lATii j:r 






r.iR'niri. \f!-: h 




Oxc ULV -^ '>^u,a_/T u' 



'State or lOuiiti v 



M \1I))'X NAM 1, 
<i! Ml III! i: K 



IMRTHri.ACK 
"I MUTHl'.K 
-tate or Coiniti \ 



V • 



MEDICAL CERTIFICATE OF DEATH 

DATK »>1 Dl'.AllI 




Montli* i 



(Day) 



I go \ 

(Year^ 



I IllvK Ivl'.N' C IIKTI 1"\', Tliat I ;itUMi.U-il <lc(H'ase»l from 

CLoon iO i9o'\ to LLv,v^ 0.5^ . TOO S 

that r last saw li ••' alive on LL<-uQ. X-^ up \ 

;inil that (U'atli orciirrcMl, on t lie <lalc stated a1)ove. at I- Ao 

M. 'I"1h' cat si-: Ol' Di: ATll \\a<i as follows: 



DT RATION Yrars 

coNTuir.r'rokv 



Moiif/is '^ /)avs I/oitrs 



Di- RAT ION 



)'t ars 





JL/C/kVCL^-V- 



t 



^ ^ 



I )• \l'li»N 






llli: \I«)\-K ST \r}'I) I'KRSONAl, !• \K riiTI.AKS AKi: I'R! !•: I'* T'"-: 
1U-",ST ()!• ^IV KN( »\VI,i;i)f.H AM) lU-'.l.U^K 



Moil tils 



^\ i, (^ 

Signed) J/vcin^^xx^ O.v.-, ^^^,.o 



:cSal in 



vt^<^a 



f I ours 
M.D. 



SPECIAL INFORMATION t^"i^ ^"r Mospifals Instilulions, Transients, 
or Rcrcnt Residents, dnd persons dviny ,m.jy from home. 



Former or 
L!sudi Residence 

When was disease contrarted, 
If not at place of dealt) ? 



How long at 
Place of Deatli ? 



.. Days 




I \C"K t>l' lURIAI, OR RI:M<'\ \1, 

-? 



I) ATI', il r.! -MAI. nr R i:M( )\AI, 
LA^VA_/C< Ov b T QO H 






rNDKKTAKllR 



wmr>,mmmm^m' 



IN. 



B.-.Kveny Item o? Information «hould be cnrefully supplied. AHB «hou.ci «- ^V'^^^SJ'"'.!^!' ^, ,„Zm„Uon'' for 
«t«te CAUSE OF DKATH in pfnin terms, thnt it may be properly cl««H.».ed. The Specol InVormnt.on for 
son» dylnft away from home should be ftiven in every instance. 



PHYSICIANS should 
pwr- 



I 



'3 



if 




li^ 



■'r 



ill' 



I 
I 

III; 



it I 



I' 







li 



WRITE PLAINLY WITH UNFADING INK 



tditssUh^^^'S^ i'- *'^lr?J^"- I'^'^i' **'• 



/)((/(■ t^ilc^l , 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



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



Ccvtificate ot IDeatb 



( *a. S. J^'tan^ar^ ) 

St ^ 



-f m 



y (0.1 -\ ^up 

PLACE OF DEATH: — County ofOcm^ X^C^vvcvo.c^. City ofOcu^ ^<x^-v-c^.r^<^ 



No. 







■\_L 



St.; 



^ 



Dist.; bet. 



'^o 




and 



,e^'\X 



■ •ciiAi orciinrNrE ri«E facts cailfd for under "special information" N 

( '^ ?roZrTorc^.::.v ::r.o^Z[ o^'?Ns^^"J;■o^N^o.;rl;l name .nst.ao of stb..t ano nu.b.r. ; 



FULL NAME 




<x 




i: 



f"V; 




ro^v>Aycx 



1^' 



t 



» 1 



\i \ 



' « 



I • 



ti 



<1.\ 






]> 



PERSONAL AND STATISTICAL PARTICULARS 

HI Kill ^ ^ 



l.K.i 



^■ 1 



iol 



H 



\'.,)lth: 



\X M \ k K 1 1- ' 



(Writ 



.1< 



LU -^cLt^^^^-'-^cL 



HiKi'n ri, \>"i- 

iStatt ■ ' i'l:\ 



I \tiii:k 



HikTiin. \' 1-; 

<il" JAPIIKK 

I Stat I- or i"< Ml ut 1 \- 



M \i!m:x N \M1-, 

t»l MdTIiJ'.K 



lURlMiri.ACH 
Ol' MOTUHR 
fSiaU' >ir Country^ 



I orri'ATioN 

Kr uh-J I" S,ni I' I a II I 







)■.'„•; 



yfniiUi.-- 



Am. 



rin- AHovK sT\Ti;i) i'krsonai. rAR-ruM'i.AKs ARK VKvy. r«> iHi- 

Hl'.ST <)I- MV KN'i)\Vl,i:i)(".K AND HI'.I.Il'.F^^ 



Qf>w 



n 




' \(i.iii'<'^ 



(,.^ Li 



15 01 IX Jyv^o^' 



It 



MEDICAL CERTIFICATE OF DEATH 

DATJ-: nl- Dl'.ATll 



I'Mon 



as 

<nav^ 



(Ve:ir^ 



I II i;k I'.liV Cl'.KTIi'V, Tlial I aUcMKlod (Ucc:tsc'(l fmiii 

I (p l« > ~ J 'P 

that 1 la<t saw h - alive on ~ " T90 —— 



aii'l that «H'ath ( iccurrccl, 011 the ilaU' ^latc(l abow. at 
M. 'I'lu- CAI'M". <>!' DI'lAl'II \va< as follow'^: 

(X-AXV^^^ 'J-^C-^^'V^U^ xXK\vvdL .^V-Ow4' /\L'Cva.x,aJL 
nrRATloN >"'''/^^" Montin Pixvs Hours 



,NED V J>V<K> 



Monlhs 



na\ 



(SIGI 






Hours 
M.D. 



SPEfelAL Information "nly for Hftspitals, Institulions, [rdnsicnts, 
or Retent Residents, and persons dying a^^ay from home. 



Former or 
Isual Residence 

Wtten was disease rontrarted, 
If not at place of death ? 



Hov* lonq at 
Place of Death ? 



. Ddvs 



ri.ACK <>I' I'.rKIALttK ki-;mm\ai. 



JlocrW 



^ /"D 



INDIORTAKI-.R 

(Adilrrs 



e 



Ow^w4.AAj" 



xsb 



i)\ri'. ■>!" liiHiAi. «.i ri:m<ivai, 

WJ ... 



Ou^->-' 









V ^'m; 



y 



I \\ 



\' A AP.F ahoiili! be stntetl liXACTLY. PHYSICIANS hHouIiI 

N. li. Every Item o? m?ormntlon should be cnruVulIy HuppI.ed. AGB f "7'" ^^^V "Soecial InformHlion" for p.r- 

8tate CAUSE OF DEATH in ph.in terms, thnt it m»y be properly cloBs.^.ed. The Spe.ml P 
son. dyinft away from home should bo feiven in every instance. 



i'.i'l 



J9i^ 



■• f- 





I 



Mi 




I 



& 



WRITE PLAIN 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



^P4iist 



it?^^"^ U&i> Ca 



REFER TO BACK OF CERTIFICATE FO R INSTRUCTIONS 



/>((/(' /'^/f('(/. 



cL^rlA.O«i 



\^Xaax:]^a^vaX XI 



100 H 



Jfp<j/\sfe/'cd Xo. 



1248 




Deputy Health Oflflcer 



DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of IDcatb 

PLACE OF DEATH: — County ofO a->^ Oxa/^^^^^^XM)City of Uo^Tv JXa,.^x.c...<i, ^.c 



No. \1^ 





\ Dist.;bet.U)X,-KLi 



and 



'vA,v.>^'Cy\X' VJAcxr^;. St.; 7 — - ., r \ 

V^v- w- ^-^ ,,e,,«, orQinFNCE: GIVE FACTS CALLED FOR UNDER S PEC I AL/jl N FO R M AT I O N \ 

( '^ rF"o7A.°^occu%r;,rrHo"s"pyT*.^ iiv.i^r.^L^r..:'.'^.\ name -.stead of street a(jd .umber. ; 




FULL NAME 




n 



Dx 




.O-A 





I 



^ 



\ 



PERSONAL AND STATISTICAL PARTICULARS 





DA rj-: oi I'.iu in 



\i .!•: 



Miintlfi 



1 



.l5'l 




'iH ,, , 



n 



^ T 



I \ \-.\\ 



Da 



(Writi ill "^orifil iK«.iv.'tiati>ii ' 



UK I'll I'l. \«'i-. n 

St:il< or « "iiiint i \ -A 

A { 



N\M1'. OI 

!•• \iiii:k 



lUR riii'i.Avi-: 
OI- lArm-iR 




M \ll)i:\" NAM I 
<i| Mol'Hl'.K 



i'.iK'i"iin,A> I 

(SlaU' «ii Ooniit I \) 



' " * I PAI'ION 





h'f.idril ,11 Sou f'i,ui, irn Ho '■""■ " !/,./////> 




/i-M. 



IHJ-. AHOVKSTATJ-:!) I'KR'^ONAI, J'AK'riiM' I.ARS AKi; TRl l". r«> |■"'•- 

r>i:sT OI' Mv knowijcdcl; and hi; 1.11". I-' 






UrMlCS- 



(Vt-ar) 



MEDICAL CERTIFICATE OF DEATH 

DAIl-: '•! Dl-.Aril ^ 

I lIl'lKl^IiV Cl.kTIIA', 'iMiat I allLMuk-d iltH-cascd truni 

CL.v.'CV ^-^ i^P'^ ^" LLu^ as i(,oH 

that. I l.'ist saw h . alive on ^^^-^^X^ Ao tc>o i 

:iiul that <kMtli nn-uircd, on tlic date stated aln-ve. at 1 1 

\J M. Tlu' C.M'SK ()!• i)I:A'I"II \va< a< rnl!..\vs: 



DC R A'riON'^^^^^'^^J'''^'"'" ^ Moulin 



^ 



Pay. 



I lou} :\ 






\x.i 



DrR.A'PION 



Q 



) V(/^.v 



<I^J;////.^ 



Pars 



M.D. 



(Signed ) OlD. o*. '\.'^\vi dix) cLxCLvv 

FECIAL Information ""'v for llospit<)ls, institutions, Imnsicnts, 



or Ketent Residt-nfs, dnti persons dyinj mA\ from home 

Former or ""^ '<»"" '^^ 



Usual Residence 

When was disease rontrarted, 
If not at piare of deatti ? 



Plare ol Oeatfi ? 



Days 



wi.Aci': Ol' i!rRi\i^<'R ki;m">\m. 




INDI'.K 



n-AKi'.R CcLa^aXWtL 



(.'\(l<h< 




l» \\'\'. ..r 111 KM \i. «ii Kl'.NK >\AI, 

Q. 



K V,0 



11 ACF «lv,tilcl he stated HXACTLY. PHYSICI.ANS should 
,f 1„f.,rm..t5on should h. cnrc^ully .supplied. \UT. sho, I.I '»« «*"^'^ -Socciol InformHtion" for p-r- 

i OF DEATH In plain terms, that it may he properly classified. The Special 



N. B. Hvcry item «> 

state CAUSE . . 

sons dyinft away from home should he feiven in every instance. 



/ . 



#> 



U 



\ 



V^' 



;«■«: 



!■■' 



5^^- 



ir \ 

i' 



h 



! I 




T^ WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

|.lfS:^n&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCT IONS 




ino^ 



Bci^istci'cd Xo. 



1249 



f},^\A.^ Jo^.\> .( Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of £)eatb 



PLACE OF DEATH: — County 



I "a. S. 'I•tan^>at^ ) 



% 




4. 




No l(ilH Vllw<iyKxu-^\ya./vv St.: "^ Dist.;bet. T)C>^cLilAa; U-oXtand 

iNCJ. ' '^ V v^_ w ..eiiAi orCinrNrP r.lWC facts CALLtD FOR UNDER SPECIAL INPORMATION \ 

( " ,7*;:T°-^i^cu%7cr,;"r„o",'pr,i^ o%'fN."?u"4'L'";"74 name ,~s.»o o. st«..t ..o ..»..,. ; 




'La.aXa-V 



V^La,\' ) 



FULL NAME 



<X/T\ 





'XA"WCX.'\X 




~!.\ 



i> \ 11, < ii i;iK 111 



\ I . I ■; 



PERSONAL AND STATISTICAL PARTICULARS 




^uixA^U.. 




IH , ,. 



a 



10 



), .' '/ 



/^^O 



lb 



--I\' . !.r MA KI< II 'I 
U ll)( >\\ 1. 1) « H< I)!\ < »Ka 1-. I> 
W'riti' in vixi.-il ih--ii.niati<>n) 



r. ! K r m • ! , \ V ■ 1 •: 

' St.iti- or <'iinili \' 







N wti-: oi 

I- ATI! IK 



lUK riiri.A'i-: 

OF FATlii:K 

.^. .... ,., (•,.,, lit- \ 



M \llil-.\ NAM!'. 
<il M()T!IHK 



IMUrill'; ^' I 
Ml' M()11I!-,R 
(Slate or C(j\inti \ i 




i^WXX. 



1 V 




/\a^cX) 




f\'r^i,lr,! • i< S,i>r /'niih /'''>> i oC )'''!' 



- 1/,..,///- '^ / 



'..■ 1 



IMi: A15<)VI<: STATKI) I'KK^ONAL TA KT UT I,A KS AKi: IK 1 l' 1' > l"'" 

i!i-:sr <M' M\ KN()\vi,i:i)c. K .wd iu:i,n*,i-" 



(Titfoniiatil 



i \.l'1lrs 






MEDICAL CERTIFICATE OF DEATH 

DAI"!-: ()!•■ Dl'.ATll /O 

(Month* A (Day) (Year) 

I HlvKi.l'.\' C!;k'rn'\\ That I atlcmlrd (lt(t.a<f(l fr<>iii 
NtwLu ^'l iqo3 t.) LL^XAy 'XS i(,n S 

tliMtl last saw h^'^v alive (Ml LL^-^ ^- 5 i(,oH 

,111(1 that .jratli orciincMl, oil tlu- date state*! above, at o.\0 
\J^ M. The CAl SI{ Ol' 1>1"..\TII \\as as follows: 



CONTRir.rTORV 



1)1" RATION >''(ir.s- 



.]/i>/;//is 



Days 



I lour 



Mmil/i 



/hjys 



(SIG 



(K^ 



Wa^^ 



\XiM^> 



Si 



J lours 

M.D. 



(x^a^^ .'.')H ( \,M.v-)Un 6xJlji/v Bt 



SPE 



dAL INFORMATION '>n!v lor Hi 



or RtMpnt Rfsidcnts, .iiiil ptivons dvin;) .n'.,iv frn:n home 



Hospitals Institutions, Transicnls, 



Fnrmfr or 
Usual Residence 

When Has disease rontrac ted, 
If not at plare ol death ? 



HoH lonq at 
Plare ol Otalh 



Oa\s 



I'l.ACK OI" r.r K lA F, (»u k):m"\ \i. 




I ) \ ri" (I* I- !■' iM oi k i:M( )\' \ i. 




X\ 



TQO 



(Ad<lr« ss 






isn^B-^^^xxx^ ^1 



"' ■ ITT Kcr k],oiI<I bo st.ited I.XACTLY. PHYSICIANS shoiird 

N. B. livery item of information should be core»ully suppi.e.l. At.i. si .. "Soeciiil Inform ai.n" for pcr- 

«tntc CAUSE or DtATII in plain terms, that it mny be properly claHH.^.ed. The Specnl 

son« dyinft away from home HhoiiM be <iiven in every instnnce. 






I'll 



*i 



?•*!'( 



i^ 



\ I 




^!.. 



I . .. ■ 






•i 



• '~i^fl9 ' ^' 



\U ) 



I 




'i I 



« 



.1 




':wm/ 



ilrefj 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



;: nSi\' C'l 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J}(f/(' Filed , 



dV'Cy-^^A/v^ 






IfJO'i 



fivc^ah OfTlcer 



Bo^isld'cd J\^<). 



1250 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of Bcatb 



( 11. 5. 5tau^a^:^ ) 



^ 



PLACE OF DEATH: — County ofOcc^ lv<v^>-Cc^cCity ofO.C^^v J;vX^^<^.^to 



N 



o. H^^IX flVJ^CycL 




St.; '3n Dlst.; bet. 




and 




\ I ^.. .iciiAl orejinFNCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION' \ 



FULL NAME 



OO 



-<X/vrvcL 






PERSONAL AND STATISTICAL PARTICULARS 



si:\ 




'■'"■" UJJ 



X^OC 



tx. 



1 <»I III K I'll 




^! .nth' 



■ l);i\l 



A^^x 



Tl 



M\ ; i M \KK n-*.i» 

v\ii)t lU 1-. I) (»K i>iV( tKv i;u 

iWiitriii sni-inl <h '^i'/'iiition ) 



I'.ik rii ri. \ri' 

I Stiitf i)T r>iiiiit ; \ 




NAM)' 1)1- 

I- All! i:k 



HIRTllil.Ari-, 

o!-' i'.\Tin:R 

S'Mtr <r, ('oiilltl >■ 



MAIDl-.N NAMI". 



r. IK I' HI' LACK 

•>1- Mi)T!n:R 
(StaU- or C'oiiiitJ y 



J .odUr-^-A>-CcL 



X/y'\/'>r>U^^^V\/\^ tX'^'^^v 'CC 





^y^.Jj^ 




^\yy\' 



JL/-Y^^^/^v^oOA.yV/V<X/>x^^XX; 



/\''\ l,!fi/ III "uHf /'l I. ,h / ''< I A ''' _____——— 

rilJ'. AliOV].: STAI'l'. I) I'KK'^ONAI, J'AK TUT I, A K s AKl, IK' i'. It » I IN'. 
I'.l'.sl" OI' MV K M )\\l,i:i)( ,1<; ANI> lil'.I.n". !•■ 



1', v,'//. 



/i,!\: 



dill"')' nianl 



VJ IxaA-ajl X) ^oou 



I \.!.b. 



\X^l% 





i 



t- 



MEDICAL CERTIFICATE OF DEATH 

DA 11', « »1 I)1-:A Til 




,M,,„tJ,) /j' (Day) (Vc-ar) 

I II i;K I:i;N' Ci:R'ril W I'liit I attciulcMl ilccfascd from 






Ih.-it I list saw li A- .. V alive on \^aa-\^H.. *^ "^^ i'/^" 

.111(1 tliat (Kath orciirred. on llu- daU- statial above, at 



UwA.^'Q '^-■'•'^ 



H 



/'O 



^ M. Thf CAISI'; OI" DI'.ATII was as follows: 



vj A-yL't'Vv «- v^'i.^ crv- oJL^'v-wv<^,<<i^ 






I )r RATION I )'r(irs IC MiVilln Pars 

CONTRIIUTORV 



I lours 



I )r RATION 
(SIG 



)'(•<? r.v 



Mouth- 



Pavs 



/ /(Uirs 

NED) H UU jJU.<r^ oJaajX^ o'^"^' 

Gj^q ^n i.ll>H (A.Mivs^) ■^HC)dxJduLN; dl 

SPFCIAL Information ""'> '">■ HosplUils, institutions, Fransicnts, 
or^RecenT Residents, and pprsons d\in;| dw.i) from home. 



Former or 
Usual Residence 

When was disease tonfrarted, 
If not at plare of death ? 



lioH long at 
Plare of Death ? 



Da)s 



rKAcr: (ir HruiAunk ri:m'>\ai. 



lr\ ri". o! I'.riM \l. I'l K 1-.M< )\'AI. 






(.\(lilrcs- 



■«• iBsa m 



^ ,. . »(^F. sh....I(l bo stnteil F.X AGTLY. PHYSICIANS shoultl 

N. B. F.very Item o? informntion «ha,.ltl be cnrcti.Hy Huppl.c I. ^^.r. nn -Special fn»'orm»tl..n" (for pT- 

8t«tc CAUSr: or DI:ATH in pli.in terms. th;.t it mi.y be pr.,pcrl> claHs.^.etl. me «, 
«on« clyinjl nway from home hHouIiI bo jiiven in every instance. 



im.A 



-m^^f^ 



f 



w 






' t ' 



. 1 



r \ 



4r 



iiiis>ji 



!« 



WRITE P 



LAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



-^&. 



. -A 



f^rv- 



ij' lis- 1» (• 



REFER TO BACK OF CERTIFICATE FOR INSTRUC TIONS 



ii 



I ^ 



i 




t ^1 



I!U)'\ 






ISI^l 




l)(il(' Filed . 

DEPARTMENT OF PUBLIC HEALTR-=City and County of San Francisco 



Deputy Health Officer 



Ccvtittcatc of Bcatb 



^ 



PLACE OF DEATH: — County ofClo/^^ JkxX/>^<^^cc City oi^O^y^ Axx^^v^^co 



TSk). 






Ch<t\wL.oul: St.; 



Dist.; bet. 



- and 



I liicllAI orQinFNrEr.lVE facts called for under "special INFORMATION' ^ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



[fLouLfi 



\x - v-v jU- 



I) \ 1 1 I >i i.;k 111 







10 



11. .\ 



,lt,Hn 



55 



"^iNc.i,!-:. M.\Kuii:i> 

\\ ii»uwKi> OK ni\t ii'v in 

iWiilt ill -oriril (hsij.'niiti<)ii) 



^ l/..>^'//^ L) 



/',M.> 




II IK . ; MM, \r l- 
i Slatr 11! ' '■ m lit : •> 



NX Ml-. <»1 

lA TH i:k 



iMurii ri, \> 1-: 

Ml 1 \ 111 l-.K 

s| ill I ir Ci HI III I v* 



M \I !>I'.N" N AMI'. 
"I Moriii.; K 



niRrinM,.\ci': 
«>i- M()Tni:R 

(Sl.'iti' or (.'.Muitty^ 








1 •'I'rp.xllnN 



- M.'iif/.'- " /' 



Tin', .MtoVJ-: ST ATI" I) ri'-. KSON.M, 1V\ K f tc C !. \ kS A K 1 '. 'I'Rri-; l< I rill'. 
IU:ST ()I- MV KN«»\Vl.i:i)t'. !•: AM> lU.I.n.l'' 



( \.l.!i^ 



^ 




I Month) 



/on H 
(Year) 



MEDICAL CERTIFICATE OF DEATH 

DAri', 111 1)1. A I'll 

lb 

(Day) 
I lIi;ixi:i'.N C'liR'ril'N^ riiai l atlcipU-d -U-rcasL-d from 
CUaxv in. lc,oS t.. LU.\/Q "^-^ Ti,o H 

that I last ^a\v li A. v\^alivr on U^A>^ 'Xio 190 H 

aii.l tliat death (.criirred. «'ii the dair slatod ahovc, at O- D J 



r 



M. 'Phi' CM SI^Ol" Dl'ATlI \va-> as follows: 




Dlk.XTloN 
CONTRIIU" 



)'t\7rs 



Months 



/hns 



I loins 



LLW..cKK-A-i/S-^ 



l\ivs 



l«c i.,oH f Addtvss) 




Hours 
M.D. 



<^ Lc Ibft^^vvC^ 



(SIGNED) . ^ <^^'0^ 

LLtt^c^ I'c I.) 

gp^^j^l_ Information onlv for llolpiUils, InNfifulions, Irdnsients, 
or Recent Residents, ,inil persons dvinj <m.iv frmi home. 

Former or ^'^ t -l \ \ 

Isudi Residence O J.D O .<,A.\.A^tnrv 

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



o 



Davs 



iM M')-" 01' r.rKi.xi, OK KiiM' >^M. 



i).\ ri: -it r.i 1' i.\i oi k i;m( iwai. 



(Addi 



^ T^, .p.- «u„,,|.i be stiiteil FiXACTLY. PHYvSICIANS should 

!N. B. r.very item oV inform.ition «houlH be cr.rotully suppl.ecl. ^^"^ . i..K«ir.ecl Th" "Special Information" for p-r- 

state CAUSE OF DIIATH in plain terms, thnt it mny be properly cU.Hs.t.eti. 

«ons clyinft nwny from home should be ftivcn in every mstnnce. 






m 



t-: 



I. 



^. 




4'.i*ii 



'■S 



I 

i I ) 



ill 



I 



i 



li 



! 



« I 



1 1 

1 



^ 



WRITE PLAINLY WITH UN 



N ) (. : N 



•^-Z"*"w 



UB. H <*rt 



FADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIONS 



/ht/i' Filed , 





ai 



li)0\ 



jRsiilstei'od jYo. 



X's^O^ 



ou^ 'kjOxMj^ Deputy Health Officer 



6\Ji/\XA 



DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Ccvtificate ot ©catb 

Xl. S. 5tnnDarc> ) 



PLACE OF DEATH:-County ofOo/^v ,V^^cv^^.c City of O /C^-r^ ^v^x^^^^^^ 



No. 





:^ 



v^<l U AX'^ vCV- V, c\ uSt.T> > 



cl 



Dist.; bet. 



-and 



( " rr;;rH"occ^%ro\"rHo^s^"*t o%'f^?n?J;^o';"o.vc .ts name .nst..o o. st^.^t ..o ^u.o... ; 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



"^^- QSp 



• \ ! 1 < i|- I:!K 111 




1 ' i!.' 'K \ 



vJjJv^JL^ 



^. 






(Day I 



I! I 



\' .I-: 



Ha 



! V,; 






iiiu riii'i,.\ri-. 

Stiitf or Country 



11 LO^VX,VwK.C^ 



/).n 




VAMl. < il 
I" AT 1 1 IK 



nik in I'l, \ri-: 
< >i 1 \ rii i-,K 



M \II>)-:N N AM)', 
nl MoTHHK 



iiiKriiri. \t 1-: 
'•1 motiii:k 








J.kXxj^'''~> 



III I I 



i\lI*»N (j\ 




Rfsitlfi! in SiiH /'i mil i-i'i) ),,;/ 



- yr.'ittii^ 



Ihiv 



111 \I',..VK ST\ri.I> l'KK>.<)\Al. I'XKI-Frri.AKS AK1-. TKrK T. > TIIJ- 
r.l-sT oi \\\ KNOW l,i:i)C.H AM) lU', I.Il'.I^ 

(Acldn■.^ ISSL U)xJUtiL>v ^ Cll^»^-^^-^^ 

,. ■ .(.p «,,„^,|il be HtHte.l fiKACTLY. PHYSICIANS «houlcl 

N. B. Rvery Item of informntion .hould be ctiroVuMy Hupplicu. . • ^.,„_„;f5ed. The "Speclnl Informiitian" for p«r- 

«tBte CAUSE OF DEATH In pinin terms, that It mny be properly cl»«H.V.ecI. 
son, dylnft away from home should be ftiven in every instance. 



MEDICAL CERTIFICATE OF DEATH 

\)\\'\- <>l ni.ATM 



a> 



(Vf.'ir) 



'Mont 10 h ''>-''V^ 

tliMtllMstiinvli^^'v; alive- OM LU^ 'XI up\ 

.■m<l that .Kalh o. rurrt-.l, ..11 llu> .latr ^tak-d ahnvi-, at 'i-H-S 
Q M. Tlu' CAISI-. 01" Dl'-Alll was as follows: 



LL'V^^XX-J^'i-^ 1 v-v.<^. '.- ^'' 






DlkATloN y''^i-S 



Months Pais H Si I louts 



^' ' • ^.LuvX^l-<rv% 



C()NTl<iI!r'i()I<V ^\:'<^^■ 
(SIGNED) J JU\JlAA.4aM'l Ia. .^^^ 



Hours 
M.D. 




o.n 



I()0 



H ( A.Mi-r^s) bOb Qa^Ix^^v 3/1 



SPEJJCIAL information "nly lor Hflspitdls, institutions, rp.jnslents, 
or Recent Residents, dnd persons dying dWdv Iro.n fiome. 

How lonq at . 

X PId'e of Dedlh? o Days 



Former or -d 
Usual Residence U Ou' 

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



U 




X^^aaAJA 



.^kK\. 



I'l.ACH Ol' lUKFAI, (tK kl-;Mt>\AI, 



I) \! 1: ot III IM \I. nl U IvM* »\' \I, 

TQOH 









/P^ 




n 



63 







/ 



I ( 



H 



M«S 



« ; 






fUT! 



Ml 




I. 
i 



h 



1 1 

I' 



li 



"I 



I' 



w 



RITE PLAINLY WITH UNFADING INK 



f-*^"***? 



in r .^' 



Dfffc nii'd , 





THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 



an 



liJO'i 



Hcilisfrred J\^o. 



1253 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc of IDeatb 

^ 11. j5. StanDavD ) 
ofj CL^^ K<X/y'K.^:AA^ City of ^ ^^^"^ ^ .V<X'->-vc.a.<l ^,c 



PLACE OF DEATH: — County 



N 



o.^H5 




4 




\) 



and 



L^<i-"^V-'(r>-\..' RrSlDENCEG.vr FACTS^CA^LtD FOR UNDER "SPECAL . N TO R M ATI O N • ' \ 

AWAY FROM USUAL RESIDENCt-Givj FAt.1^^ NAME instead of street and number. J 



h'X.' 



( IF death occurs away from U3UML. "'-^■"-■', - ^ _,^p 
\ IF death occurred in a hospital or institution give 



FULL NAME 




I \ i I. • »i- r.iK I'll 



\' 1'. 



PERSONAL AND STATISTICAL PARTICULARS 

j C<»l,tiK 






\ 






"IS 



X 



« I):ivi 



!• -•■/. 



■>'t ar' 



'X5 Da 



^IN'.l.i:. MAKkll'.D 
WlKnW'KI) OK l)IVnKri-:i) 

Wt il' in sociiil fl.-.i'-" <i :"ii ' 



KIK llIl'hAi'J-; 
(St;itf or I'oiiiit I > 




,JodL<r-v\>X/<^ 





^xi_v„cLj-^^ 



MEDICAL CERTIFICATE OF DEATH 

DA ri-: ' »!• ni-.A Til 



3.(0 

(Day) 



igo'\ 

(Year) 



I Month) A 
I III'.RI'r.V Cl'RTll-V. Tli.it I altcii'lrM .U-ceasc'd from 



\ WW. Dl- 

I \iim:r 



I'.IK IIIIM, All". 

<>i- i\iiii;k 

' SI. lie nl Coniltl \') 



M MIU'.N N AMI", 

<ti Mo'nii'.k 



I'.iui'iiri.Aii", 

'II MOTHlvU 

'■ '-tiitc nr t."<)nntt y) 




' •* ( I I'A THIN 



fy'fiifrif III S.ltl /'l illh ixil )i-tJI.^ 



^r•nlh< 



/hn. 



Till 



flnf.,: 



• Minvi.-. SI-ATl.I) I'l.-KsoNM, )■ \ R I" UT I.AKS A K i: T K T H T' ) THH 
;!i:si' <)!• ^\\ KNoUl.l-.iX.l-: .\M» lii".!. 1 1" »' 



— lip to "~~ " 

that I !:i>-t saw li " alive on 

;,ncl tliat .K-alli (.crurrcl. on tlif date statcil alx.vc-. al 
M. Thf CAISI-; ()!• I)i:.\ril was as follows 



I(>0 
T()0 



CONTRHU'I'ORV 



Mont/is 



/hns 



//ours 



I )r RAT ION 
(SIGNED) 



(W 



}'<ins 








Hours 
XsXol/>vxL UiUvv^lN- M.D. 






SPEcllAL INFORMATION only for flospit..ls, InslifuthiAs, Irdnsients, 
or Recent Residents, and persons dvini .iw.iy frnni home, 
r „, Hov* lonq .it 

Usual Residence 

When was disease ronfrarfed. 

If not at place of death ? 



T90 



,., ACKor HIKIAL..K KHM'AAl. LU"...., HnoM. -i Kl-MoVAI. 
hire... H0% \5 0^^>UJL t^t^- 



(Atlt 



' ,. , 77^ «Hould be stHted KXACTLY. PHYSICIANS Hhould 

N. H. i.very item of nWorniHtlon should I,, cnrefully Huppi.ed. 'y^ cla«».1f5ed. The "Special lnform»tion" for pT- 

stHte CAUSE OF DEATH In plnin tcr.n«, that It may he P' '>P«'"y 

sons dyinft nwny from home should he ftiven .n every .nntiince. 



i -J. i. 




t 



r^^ 



r: 



I 



!■! 



li 



I ! 

I 




J. 



iff 



W 



RITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



);,,,,;,! i ifrrrTtlT— 



_>v HS.- P Crt 



REFER 



TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1 )((!(• hllrtL 




X\ 



io(n 



]lr(:i.s{ci'C(l JS^o, 



1 254 




^ Deputy Health Officer 

DEPARTMENT # PUBLIC HEALTH-City and County of San Francisco 



Ccvtiticatc of IDcatb 



N«. v^ttn'^ 



iSl.'itt.' or Conutry* 




I 11. S, jT'tanC^ai^ ) 
PLACE OF DEATH:-County of Oct>. i/VC^^^^ City oi^^^ AXX^^c^o. 
Jv^l/^-^A., l^b CV<s j^^-l- a '■ St.;— -4)ist.i bet. ' ^^^ . 






-■) 






PERSONAL AND STATISTICAL PARTICULARS 



FULL NAME hTWv^ 'd)XKA>^^^ 



■J Xy^rv^^o. 'v,^. 



col, OK \ ^ 



ill urn 




Dnv' 






■ V. .ir) 



:i5 



- , ^. .,,; MARK 11. 1). 

W ll>(>\\ l-:i) OR DiVOKCi:!) 




MEDICAL CERTIFICATE OF DEATH 

l»Al"i: < il IiT.A Til 




as 



190 '\ 

Month » A <r>-''y> '^'^•=''' 

I lii:Ri-;r.V C!;RTI1-V, That I attcndc<l dercascd fr-.m 

TTT- 



TTT 



I(p 



\ \M1 . >! 
I A'i'il IK 



I'.iK rniM.ACH 

Mr ! \r!n:K 



MMDKN' N^Mi: 
«>l- Mn'nil-K 



i'.:u nii'i.Ari.: 
'<! MoTHKR 

^1 • ■ I'l.iintiy^ 



'"'"^ % 



i 






■!!V: \H<.VK S-1-\T1-I) PKK-oVM. )• \ K T U" f I . A K ^ AKl'. TliVr. Tn T H !• 
I'.I.sToi- MV KN( i\\ l,i:i)C. }•; AND Hi'.l.Il-.l' 



: iiiMtit 



^K^r^^mmmn^mm^'ir^^ 






that T last saw h alive on ^9° 

and thai .Kalli occurrcl. mi the (h.tr <tatc-.l alx.ve. at 
- M. Tlic CArSl". or DI-ATll wa^ as follow^: 



V 



(I 

CUi- 



iJLy<L,<:,A_dLji/VNZtxtxX C>-/tYvvAltA.xr>- 



LONTRlI'.rToRV 



Monl/is 



/hivs 



IIOll) ^ 



M,)>il/is 



/hns 



DTRATION '' '-'-^ 1/-)^////^ /"o.^ //'^//'v 

SIGNED ) Ur\xi^^4>v 1 ' i3. UllxW M.D. 



(-v-cJL 



SPECIAL INFORMATION oniv lor Hosj)itdls InstitiiHons, Transients, 
or Recent Residents, and persons dvinj dVN.)> troin home. 

\^lien was disease rontrarfed, 

If not at place of death ? ^ 



Davs 



l-l^CK Oi HlKIAl. <.K KKM-VAL I I'AT. U'u.u ,„ KI.MoVM. 



^^(l(hr^' 



•' ' "* TT T-F s'iov.1.1 be statea f.XACTLY. P1IYSICI\NS hIiouI.! 

IN. IS. Kvery item of niformntlon hHouI.I be o.rct'ully suppl.-Ml. ^^ ' . .|„„„inetl. The •'Special Inform if.on" for p«r- 

«tatc CAUSE or DLATH in plain terms, that it may h. properI> 
. - « . 1 1,1 K.. rt:v#.n in every instance. 



state CAUSE OP DLA I M m piam ierm«, »..". 

sons dyin4 away from home should be feivcn m every instance. 



!i 






j 



<♦». 



I •> 



I 







) u 






■ 




I 



. V! 

i 



'^^■n 



I i 



I 



I- 



«***'^ 



** 



«r 



in 



II 



li 



ii 



!•! 



i i 



Hi 



'• . 



' « 



H 



ri 



^'i^ 



WRITE PLAINLY WITH UN 



FADING INK — THIS IS A PERMANENT RECORD 



d '•^•^ 



ITTinn: 



r:^^^i:]\Sc\'Cn 



REFER 



TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I /)(//(' Filrd, 





'r\ 



ltl()\ 



Beili^'<f('rc(l Xo. 



1255 



Deputy Hcwai^r 



DEPARTMENT OFPDBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of Bcatb 






PLACE OF 



i-^ 



No. ^>^> 




^1 



DEATH:-County ofOcu^ 0,>v<Xy>^c^^Gty of U,<XAV OXO^vv-^^ '-- c 



r\ r\ . /-.aVI' St.: Dist.;bet. - , 

?t^:^.,. .w.v .no» USUAL R5-.?5^a^-".^:;74 =.am" .'."A- " sT.^.^riJo '^1"'.°- ) 



(■r nrATiM OCCURS ti\N t^^ FRONI VJOw»^i. . !•---'■>--■• 
Tr Dtt" O^^^""^^ "- * HOSP.TAL OR .NST.TUT.ON GIVE 



FULL NAME 








x^vvwC CrVLCvv. 



~! \ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.nK^ 



1 i'.lKlll 



d ^^-^ • 




M .!lth ! 






51 



^ 



1/ .K.// 



«-i\t .1.1- M \KK n.i> 



St:tt«- or Ci)unlr\ 




MEDICAL CERTIFICATE OF DEATH 

DA 11-: <u ni:\ Til ,0 









Vjo-A.' 



Month'! j 

.A l". ujoS to vLc^O^ ^Xlo 

w on ^^ 



U)oH 






'Ixxvv^^-rL 




\ \M 1 t >; 



HiKTiiri.Ari-: 
«>i" 1 \riii-R 



M \ IIil-N NAM}. 

'I! Morin: k 



I'.IR rill'UAt )•: 
or MOTlll-'.K 




V-3 



V^ 



^^z 



RfM'i!r:f hi Siiv I'laini'srit 051 ' ' ■ ' 






m: Ai'.ovi-: sT\ri;n i-kk^oxai. r\K ti'Ti. \k> aui'. rRi}-. p. riii'. 

I'.HST Ol- MY KNOW l.l.IX.l". AM) lU.l.Il.!- 



' Inf<i!iiinnt 






r\d(lress 



^,„.l tl,at ^Uath ..(rwMol. on tlu-lal.-tatr-l abnvr. a1 



<)\vs : 



..V/5 



,,, RATION i )-,^/X^-y""^^'' ^'''^ ^^"'" 



CoN'IKlHtroRV 



loLOi^L-^vxxX L^rvA^tX-'CiL'w* V V, 



DIRATION 



) Vjr.s" 



V^ 



Mi^uths ^ Ptivs Hours 

SIGNED ) M 'ULLLoL/>^. '-X^,>c\^ ^ ^ M.D. 



" SPEcJaL information "nly for llospitdls, Instilutions. lr..nsi.'nls. 
or Retenl Residents, and persons dving HH,iy fron hnme. 



Former or 
I'sudI Residence 

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



HoH lonq at 
Plare of Death ? 



. Dav* 



iM,ACi-: oi- m-RiAi-cK ui;m«>\\i. 



1 1 \ !1 . ,; !',! M I \i t'l 1< I'.M' »\ A I, 
i 1 



Lv^^A, 



zh!w^o.AA^^'^4^''-^^ 



^ 



r,x,i.h-.- nil mYLa^^-xl^-cax ^1 



T90 \ 

\jUyvv 



"- " r— — " r\ TpF «h n.ld be stated EXACTLY. PHYSICIANS should 

N. B.— F.very item «V' inf.rmntion should h. o.ret'ully «uppl.ed. '; ' ; ^.^^^..^iecl. The "Spcciol InforniMlion" »«r p.r- 

«tatc CAUSr Of DEATH !n plnln terms, that .t may ^^^ J*^^''^ 

r.on» dyinft oway ?rom home Hliould he given .n every .nHtonce. 



'^'^^'^ 



s 



I '^ 



i '. 



.1 









wm 



<ahE^ 






I 



li 



!» ' 



h • 



I 

''1 




w 



RITE PLAINLY WITH UNFADING INK 



; .4 llfultii' K No. T. "*^^i^ 1»&H Co 



I idle Filc'l , 





IUO'\ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CER TIFICATE FOR INSTRUCTIONS 



I ^■■nBr^ww 



DEPARTMENT 0?PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



PLACE OF DEATH:-Coun,y ofCcmv J ;^..v^.^<^ City of O^C^ Jxcc^vvc^ 



<^t' 



N 



o. Hi Lljyl\-cL"v"vjUA 



J ^^ , , ^.. , , . St.; I Dist.; bet. Ux^VcJi '. and <X >^U^ \ ) 

J A\^^<\j^ KJU^\ ^ro.ArMrr riur facts called rOR under "special INFORMATION' ^ 



ALLED FOR UNDER SPECIAL INFOHMAIiui 
lAME INSTEAD OF STREET AND NUMBER. 



FULL NAME 





,^"i'^ \X^ 




^^x o. 



<^^ 



PERSONAL AND STATISTICAL PARTICULARS 

C«il.' iK \ 



II 




Lv. VvCtx. 




1 



11 



1,1 M \ !•• I- 1 1 



r.iK 1 lll'l, \»*l" 
'Stiitf or ("•iinit : \ 



'I ( 1 1 
I i 1 K 



I'.iHiii i'i,.\«i.: 

'•!• r\riM-K 

■ ' Mini I \^ 



MMDl-.N \\\n. 
<>l M» II" 1 1 1 K 



lilk I'M I'l, \r i: 

n\ M(.rni",u 

' '^i I ' 1 1 ". .\i 111 I 



1 



X 



MEDICAL CERTIFICATE OF DEATH 

, |i|,|. |.i;\ . I Kill V. TImI ! inrii.lr.l ,lc-..;i.c.l ri..m 



/ iV > . 



v^L\.\UT. ^ '-' 



,),:., ll;,s't.,ush >l--'n LL-C^ ^^'^ 1<P' 

;,,„lll,;.t ,l.-,,l!l.HrMM<.l. .•■! tlu-lMt.-t;.1r.l aliovr. :.t 
^, -| 1,,, t' AISI'; < H' l»i' \ni wms as |V,]1,,'as: 



J A^U-L^CXAX^Mi.^^ -J ' ' 






^^' 




XhJv/^^ v.'cJL^"^ 



x/cL 



1' . '/.' 



> /',,M 



' ' ' I !• \ IH»N 

A'f hfnf in Sit II ft ii I 

TIIK Ml.iVi- Sr\-n-I) IM^Ks.r.M 1' \ K T h . " I , \ K - A K 1 • IK' 1' '" '■'"• 
lSi:ST nl' MV KNt>\Vl,i:i)' . 1 •. 1 » I'.l 1,11,1 



Mint 



^ 



tXKA^ JnjJLLu, 



i \.l.li 



.... Hi 




/\J^ 



j^-rAJL' 



Vw^, . ^•'- ^^- » ■' -' 



coNTi^iin'roKV 



.</y\y 






.1/, <;//// v 



/^^/v 



I lours 



DIK.XIION 



)V(/r.s" 



LU JC4/<rvo 



Mo)itlis 

3J <X"> " 



/'<n s 



ICVAL INFC 



{ 






o 



^o. 



M.D. 



( SIGI 

LIa- - . .^ ^ . 

SPECIAL INFORMATION "nU tnr llospilHls. Inslituli....s. Ir..nvirnls. 
or Rrrcnl Rcsi.lrnls, .inil persons (him .lv^..^ ii..;n li"mr. 



formrr or 
lsu.il RpsidcntP 

Wlipn wds disp.ivf (ontrd(fpd, 
|( nol .il platr nl (le.ith ? 



tlitw lonq .it 
I'j.i.c ol Ocilh 



()<iss 



,.,,.X(I': <•} lU KIAI, OK H1-M<'\M. 



1 \ X'V. <p!' I'.l I' I \l. Ill K I .M< i\ \ I, 

I f)0', 



)Kj 










r:' 



^ + " TT MIV, HW.UI be HtMte.l f.XACTKY. PMYS.CI ANS .h.n.hl 

N K._,;very item oV nn'o.,«..t Ion nhouM h- carofuMy s.ppl.- • ^ ^ ,,„«H5,'iccl. The '•Spccl..! I,n-.>nn,.t .on ^.r p-r- 

HtuU CAlISr. or OLATM In in terms, thnt .. nu.y ^ P^^;^^ 

sons clymft ..way from home KhooUl be ftWcn .n every -nHtnn. 



1 . ^' 



U*'! 



,^) ; ,1 1'r 



H^ 



' I 



I ! 



M 



•niife. 



"'.;:i 



^ii£X?* 



#»«*-* 



If 1 





r4 



i 



K 



ll 



I- 



I 



ii 



tn 11 






a. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RFPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



•vtf&lM 



■n-^BMaiai 



JlJO'i 



Jl('o'/\sfe/r(l J\^o, 



1257 



DEPARTMENT OF PUBLIC liEALTtl=City and County of San Francisco 



No. 



Ccvtificatc of IDcatb 

( 111. Hi. tritnii^avD ! #. 

PLACE OF DEATH: — County ofCjCL^- 0>^<X^\x^4c.c City of Cj<X/>\' .\X>. \a^c.<xuC^ 
15 ll \1X^^':^^->-- St.; 1 Dist.;bet. cLc^^Kv/>-v. and ^ Cri^k 

/ i DTATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V F FACTS CALLED FOR UNDER •'SPECIAL INFORMATION" \ 
( I .F De'ItH OCcJrRFD InThOSP.TAL or INST.TUT.ON give its name instead OF STREET AND NU^.BER. J 



FULL NAME 




.t 



^ 



KAX.^\J vj 




O^CJL^^JChj 



PERSONAL AND STATISTICAL PARTICULARS 



^lA 



:>A 11. <ii i!ik in 



r< >i t »k 






Month 



1 1,.'. 



S\ 



Iht 1 



! ' l.i MAR km: I) 

Will. »\\ i-;i» OK i)i\'< (Rvi:!) 

\\')it< in vi,,i:il il(sii> t',,it ii 111 ' 



l!Ik''"mM \i-)- 

(st,- 




o-^v^x-d. 



XAMi: «»! 

I vni iR 



I'.iK in i'i,Ai')\ 

<M- lArill-R 

■ r r. mil! : \' ' 



MMIU-.N N\M}-: 
Ol- MOTMI-.K 



I'.iKriiiM. All-; 
<M- M<iriii:R 







MEDICAL CERTIFICATE OF DEATH 

DAI"!-; »)1- Dl.ATH 

(I):iv) (YfMr) 



I'Mojitli^ K 

I lII'lRivr.N' Clvk'ril-'\'. That I attcii.Ud (Iccvascd fmiii 





at 



190 ^ 



\% \()0\ to 

that I last saw li ■ "^ alive- on vX^^VrCV ^t 190 v 

ami that .kath occurrctl. on the date ^^tatcMl above, at '• vO 
J M. The CAISI- Ol' i>i:.\TII was as follows: 

VlVx^i^<,v^JL<:L .caJlmxX vlAJUXr-%v<x^'^vA^M 




1)1 RATION Yearn 

CoNTkllU'ToRV 



1 



Months H Dayy 



1 1 our 



^rr\^ 





»JL-^- 



JvD 0-a-«-^.Xa,<^y*- 



h'r^,,h-J 



) r,:, < 






■rm, \nn\ 1-. s 1' \ii-i) I'l'Rsox \!. rAK'iuri \Ks ARi; rkii-: 'r* » in i- 

Illlsrol' MS' KNOW 1,1: IX". K AND ni'.l.Il.l- 



'Inf.i' niiit 



a.c.iju 



/O. 



r> v,c ' V.' 



nr RAT I ox 
(Signed ) 



) V(/;'5 



Q.livW 



Mn}iths 



IAa.^Q lie i9o\ (A<l.lress) l^ l^ 



Pays Hours 

-M.D. 



./^Aa.^- 



Special Information «"'> for Hospitals, institutions, Transients, 
or Rfcenf Residents, and persons dyintj away from home. 

Former or (9 I "M ^ n f i ""^ '''"'' ^* t 

I'siial Residence^ CLC'M^'*^ M5V-^ UV-t' pjare of Oeatti ? 1 

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



Davs 



ri.ACH (11- lURIAl, OR KI'IMOVAI, 



I>Ari:o!' HrioAi. or Rl^MoX'AI, 
(Address XW^b M iXv^^u-V^Xrvv 0% 



N. ».— r.vcry Item o? information should b. cn^cVnlly supplie.l. A(^F. simuld be stated EXACTLY. PHYSiaANS should 
state CAIISII or DEATH in plain terms, that it may b.- properly closs.lficd. The * Special InVormat.on ?or p«r- 
Rons dyinji away Ifrom homo should be feiven in every instnacCt 



■sM 



I ; 



la 




1. 




' I 



{'■ 



1 •! 






t i '> 






■3^^ 



^4iJfttHCAai^^F '^ 




^]!QRinti& 



■ip. 



*^ 






s W..J 



,1 




Tr 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'•• ■ -y: lli. 115; IT 



/)(///' I'^i/cd , 



^M.A.A^ 




XI 



lUO^ 



ItcgLstei'cd J\^o. 



1 258 



u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot iDcath 

' W. ill. t^1tnn^av^ j 
PLACE OF DEATH: — County ofC)/(X->. v 0.\.OU-yxC^^^XoCity of O/O/vu AXt'-rvd-O.Cc 



St-). 



Dlst.; bet. 



and 



(IF DfATH OCCURS AWAV f R O M USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION" "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

cm.iiK \ 

J 



ft' rv 



.o^ \ 




.L.vvOvl^, 



)■,:,, 



^ 



[):i\ i 



Moilh 



1 i;ir 



Ha 



MEDICAL CERTIFICATE OF DEATH 

vX^^A^n lie 

iMoiithl K (I):iy) 

I Ill'KI'IiV c;i-;rTII-V, That [ attcii.K'.l (Icccasc-il lioiu 



IQO \ 

(Vc;ii I 



^:"' 1.1 MAKIvDIi 

w ii'i '\yi-;i» OK Divi >Kr}-:j) 

Write in mx-jal tl( -.ii'iMt i'Hi I 



.'L^'X^Q/^- 






1 >'n! IK 






"I" Mi>TIIKK 



HIK THIM.NCJ. 
••I- Morill-.K 

•Si;itt ur r'luiitrvt 






e 







UjO ti 1 — — — — — — 

that I last saw h ■ — aHvc <»ii ^ — 

ami that diMth nccurred, nii tlu- <lat».- stali<l ahovi', at 
M. The CMS!-; Ol" l)i:.\TM was as follow^ 

1 



^90 
190 



I 



. ^r (/b.-v|A>JL^./tXJL^vrvx^cv oi- Xc>c%vtY3.AjL\X\hV0 

'' "" " Days Hours 



A 




1 1 Lccv^tx 



nr RAT I ON Yi-ays 

c•o^■TUlIU•ToR^ 



Months 



DIR.XTIOX Yrars Mo}iths 



Hav 



CX' 



vl) 




1 






<^^ \yVvJULCr\_ CL 



t. 



SIGNED ^ UAX-^^JiA; 



.U.A 



L\xu:^ X'; T()o'\ (A<liln-<^) 




//ours 

M.D. 



'AjUUi 



:V<iX 



)v-,MA- o lAu////- r [ / 



rni. M'.(»\-K s|-\-i-Mi I'KK^. i\AI. l'\K I ini. \ks \ r i-; TKI 
lil.M '»' ^1V KXuU lj.:i),,H AND lilvlj].!- 



1: i"" 1 III)' 



SPE6^AL Information only for Hospitals, Institikihns, Tmnsicnts, 
or Recent Residents, and persons dvinq awav from fiome. 

®? \ ■\, Hew long at 



Former or ic*-t( 1 \ \4. 

Usual Residence 1 o 1 b a.cV4v J A pi^re of Death ? 



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



(? . ■ ^ 






ri.ACi-: Ol- lURiAi, OR ki;m(>\ai. 






»\Ti;<i; I'.i i;i.\i. 01 K ]•;,%!< i\' A I, 






T90 \ 



^' ^- T^.very item of iriformiition shouM be cureuilly supplied. AGB should be stated HX4CTLY. PHYSICIANS should 

state CAUSE OF DHATH in pinin terms, that it may be properly elassified. The "Special Infonmition" for per- 
sons dyinji away from home should be j^iven in every instance. 



f1 i V 




t ' 






\\ 



A i 



II 



f 





M 


■! 


''. i 



,1 



i1 



■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I No. 15 ■^•T:?!L.^ ">^ !• Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



I 



Ii)()^ 



Ji('gi\stered jYo. 



1 259 ' 



Xlrvcv^ Xbv<^ Deputy Health OfTlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticatc of IDcatb 

PLACE OF DEATH: — County ofO,<X'-irvO,vuX/\xi:^u^<^ City of 0,0.^10^0 yVcxy^VOi^cc 



No. 



k\ 



CrvCL/W VJ /OJ\JP, 






S*.; '^ Dist.jbet. l,^\d,' and c^/vd, 

(\r DEATH OCCURS AW«V FPOM 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 



lW 



ft 



\^1\^- 




/Cl^wx-Aj-V C cu 



PERSONAL AND STATISTICAL PARTICULARS 




.0^ 

"1 HIK 111 



L 



iiii.'iR ^ 




UClvL 



MEDICAL CERTIFICATE OF DEATH 

I)A1"K « »!■ in: ATH 



a 






\' ■]'. 



•i; 



'i'V 






JX IQO \ 

'I):iv) (Ve:ir) 



5^ 



an 



■ rvr. r.j- M \iv i< ii.-i, 

• ' ' VORiKI) 

-iv ii.il ii (ii) 



SI;il 







N'AMI-: <)|- 



i;i iv ; i i ri.Ai i-; 
"1 1 \rjiHk 



ola/J(j vjj OlOItl 



t^a. 




o^ 



X^LA^ 



^!Ali>J:\ VAMl- /» 

"I- M(»riii.:K ((ji) 



"i' 



iiikTiin. xri- 

<'l- MniHIvK 



' " ''^I'A ri« t\ 



AXX/^^^Jl 




I IliiK i:i'.V C i;KTIi'N'. That I atteiidcl .k-nascd frniii 

!(/) ti) — —————— —I(p 

1 hat I la^t s;i\v li ah\ c on TQO 

aiiil that ik-ath (iccurred, "H the (laic stated above, at 
M. The CAISI-; Ol- I)I';.\'l"n \va<; as follows: 

DC RATION Ycius Moiilhs Days I lours 



Co.NTKir.rTORV 




\A/w\AAA.A^/Oo 



/\'f iliuf III S,ni I'l ,1 II, I ,1) 



),-,ll ^ 



Mniiflf 



I)rR\ri')N )'tiirs Mouths Pays Hours 

(Signed ) Wur\xiL>v J. yj-UJ-dJll/cx/vu^ M.D. 

X\ if)o H ( Addn'sv;) Wun^JAlA Ui VL<a 




Special information only for Hospitdls, IfiNtitirtibns, Transients, 
or Recent Residents, and persons dyiny dnay from home. 



Hi: \tu)\i.: si'A ri:i> i'Ki<sn\ \i. i-au nrr i. xus .\ki-; tkii-: to thi': 
'•i."^r Ol' Mv k.nowm; I )(,!.: AND i!i:i,ii:i- 



(Inf.,- 






Former or 
Usual Residence 

Wtien Has disease contracted, 
If not at place of death ? 



lloH long at 
Place of Death? 



Days 



im_,.u:k oi' m'KiAi, <»k ki:mo\.'.i. 



% 



Zv 






i)Ari:<)f MtKiAf. or ki;mo\ai, 

(Address KX^'K^ ^^[\\jO<KkjX Of 






'S. li.. 



A. 



-Jivcpy item o? infopm»tion shoulil hi: cnrefully Hupplietl. AGR should be stated RX4CTLY. PHYSICIANS should 
stiitc CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Iniformation" for p«r- 
8on« dyin^ away from home should be j^iven in a\^ry instance. 



i' s 



i , 



f: < 



i f "^ 



]'■ 





♦;' 



,;;) 



h 



I 



, Ni# 



I '< 






it : 



• 

> • 



I .-'I 



WRITE PLAINLY WITH UNFADING INK 



^"'^v- 



WlkVCi} 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/h//r hailed , 




o\^ 




al 



l!)()\ 



Regislcred J\^(). 



1 200 



No. 



v-M. Depuiy r\A^ic.'.\\\ Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of Beath 

PLACE OF DEATH: — County ofO-Cu^^ J , VO-'^vc^^^^^^ City of Cj/Oy^v \^ K,<Xy->i^^^^A^^t 
I LcL.tut-^X'VV^ n. St.; % Dist.; bet. U,^cXcL/V-\-<X; and L 

:ATi/. OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 



( 



IF OEi 
I F 



EkTM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 




FULL NAME W 



PERSONAL AND STATISTICAL PARTICULARS 



' -v 




.OJu^t^^ 



A^J 






v( »!,< )k 



^ 



l\(v.,tc 






(I).'(V) 



/ V 



i lar' 



l?l . 



% 



• i 1 M \ U ; ; i 

'I 'W i: i» (Ik i)i\ < iKi-j.;}) 

1' in •.o'-i;i! iIi-vi'MKit inn ) 




IU!.'-^-|!!M \r I- 



•It ; \ 



1 \ 1 



'■•'.1 111 I'l. \ri.- 
' • I \ III |-k 



<" Mt»Tlti.:K 



HlUi'in-j \( i- 

•»i- .m<>tiii;k 

'St:Ur ..! Cuiinll \ 






MEDICAL CERTIFICATE OF DEATH 

It ATI-: ol DI'. \i'll 



(L 



(I)av) fVc-ar) 



'M(.iith) t 

\ Ili;Ki';r.\' Cl-; RTII'W 'rimt I altcndcl (Icrc-ascd from 
VOL/W' ri l^'l'l i4ja to LLuA^ Q^Id 190H 

tliat I Ia>t saw li XNj alive oil LAXaX3 '^^'- Kp "l 



and thatdcatli ocrurrcd, on tlu-datr statrd aliovc, at o 
VX M. Thf CAISI-: Ol- I)i:A'riI was as follows: 




Vy 




<^ 



I ] . I ■ I 



\ rioN 



(J X^y^^^Oo^'VM 

1 



T> 



fsf^iiirif ill Sdv I'l ini, : -i-.i C) )■'■<.■' ^ "^ M.'iitli- 



l>r\. 



1)1 RA'IdON )'i'(jrs J/on/Zis i /^'U'-^ Iloitta 

"ONTR Mil TORY jJ/woJj-O^ M I buLtAXcc-iV 

Dl' RATION Years Months Pays Hours 

(SIGNED ) VI fUVu^ fc^h^jy^^^ M.D. 

XI T()oH (Address) %0l ' "O-vOXa^ 01 




SPEuIAL Information onlv tor Hospitals, Instituflons, Transients, 
or Recent RcMdenls, and persons dying away from home. 



'III!"-, 



1 MtDXl-: ST \ ITD I'KKSMX \i. )• \i< in II.Ak^ Akl-, 1" K T }•; T* » TH)". 
I'-l-.^r 01. v|V KNOW i.i;i)(-, |.; AND in- I.Ii: I- 



i'"- i',l:int 




Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



L'l.ACi-: 01' HrKiAi,j)R k1';mi>\ai, 






DA/i^lCnf HiKlAi. or KI<;^t<)\■A^ 

Xb 1 90'! 




M yVv4A-A.-<r>^ 



N. 15.— livery item o9 mt'ormatlon hHouIH be carefully supplied. AGE shm.lcl be stated f.XACTLY. PHYSICIANS should 
state CAlISn OF DEATH in plain terms, that it may be properly classiltied. The ' Special Information ?or per- 
sons dyin^ away from home should be given in every instance. 



'^ 



i , 

1 ! 







|: 







i.!\ 



iMr 



t\- 



ll 



ti' 



m 



,■■,, I 



I'- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Dale Fih'il , 




v^X 'Xc) 






D 



IU()\ 



o^ 



llvilisfcrcd .N^o, 



12()I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



11. S. Stan^arD ) 



PLACE OF DEATH: — Cou 



nty of^ CL ^^' J ,^L<X ^ vc^^ coCity of <X/Vu yV<X-wc.A„AL<:^c 



N<). LviL X 







Cy<L 



kJ 



vO., 



St.: - 



Dist.; bet. 



and 



\ ( IF DEATH OCcflPS AW»V FfOM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' ^ 

' V IF DEATH oQcuRHfD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



. \\M^''Y\.<:XJk) 




'y^ ■) vCr 



PERSONAL AND STATISTICAL PARTICULARS 

V I ti,< >k 



'^IcvL 




'd^' 



M !;th ' jf 



Ii,.\' 



Ha 



1 



MEDICAL CERTIFICATE OF DEATH 



' • X K- K 1 I ! I 



\\^ 



iiri. vri- 




I t 



i \rin-R 



\T!IHK 



"1 MoTHI'-.k 



iiiu I HIM. \i ]■• 

•'I MoTlIKK 
'■^tali- or ('..iiiitiv 






in.iv) 



/C^r> ^\ 



I iii:kl.l'.\' c. I.I-'.'1"II\', 'I'hat I attfii(k>l (lc( lascd from 
Lw^<:U '-^'-^ J^P'* to \X^LA.X\^ XI i()0 H 



<:^ -lu 190M to ... . LLcA^xx. 

(1 ",, . ,, 

that I last saw h -v.', alufoii V,Va^a.x^ J. , jcp "> 

1 that (k-atli orciirrcil, on tlic ilalr stated above, at i • "O 



am 



V.L M. The CAkSh: Ol" DIvATil was as follows 



^wCL'T^ vXC 



A 



'-\ 




I)rR.\TinN )',ais 

coN'ruir.rToRV 



Months 



Paxs 



Hours 



Mo)tths 



'■111 



4\ 



.w/ /;,//; 



.•; > — 1.'" .;//// - 



DIR.XTION )Vr/;-.v 

f SIGNED) 0. U\. fc<X\l.^ 



I\u.< 



K. 

Ad.hv 



I Ion IS 

M.D. 



N only for Hispitals, Institutions, Transients, 



i H1-: Anoxi-: s,'r \ iid i-kr-^' >\a i. i-ARrirn, \ks aki: iki i: r<> riii-; 

'•'.-I'oi- Mv K\i )\\ i,i.;i)C. J.; AND lU'.I.n;!- 



\<l.ll,ss 



N. U.. 




^^VwC . (Jb 0-^^aX<X,L 



SPECIAL INFORMATIO 

or Retfnt Residents, and persons dvin;] away from fiome. 

f ormer or ^ „ S^ J 4, "«>* lonq at 

I'snal Residence i -jM O^^Ou^rvvv CTf Plare of Pedth ? 

Wtirn was disease contrarted, 
It not at place of deatfi ? 



Days 



I'l \CH Ol" niKiAi, ok ri;m(>v.\i. 



D.XI'i: oi" liiKiAl. or r}-:movai, 

a"i T90S 







(Ad(lic><s 



Jon shouhl he carefully supplied. AGIi sMoulcl bo state.) EXACTLY PMYSICL4NS «hould 
'H in pL.in terms, thnt it m:.y be pr<iperly classified. The -Spec.ol Intormat.on Vor p«r- 



-Kvery item of inforniiit 
state CAUSE OF DHATH 
son* dyinfe uway from home should he jiiven in every instance 



"^ 



.: ;.* 



: \ 



^■\ 



l"'^. V. 



-t^V, 



'■'*^- 






W" 


r( 


ii 


' i 


•'. 


■ 1 




M 


• ' 1 


i I 


!!^ 





! i m 



iFf 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

f ,,,,,,,,_ KVo 1- r^;*^ii:\ !•<•., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(f/(' F/'/ff/, LI^vQa^a^aA; 'X^ 



lir<2i'Sfri'r(] JS^o, 



I *-» * 3^^ 



v^ Deputy Health Officer 

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




Certificate of Death 

PLACE OF DEATH: — County ofO/O/^Aj O^VO^^vo^^aCity ofOcX/^-u OyV<Xvvc^r- c 



on 



N 




(jTv 



-^1 

and U.V.rvNC 



o. T \ iL .^WtjLV St.; S Dist.; bet. 

/ ir DEATH OCCURS AW*V FROM USUAL R E S I D E N C E G 1 V E 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 




-OLhJ 



PERSONAL AND STATISTICAL PARTICULARS 







LL 



1' + 



U III 




a^ 



a^' 



S 



rli^ 




hJUL^ 




IQO ^ 

(V.-;ii) 



' ' K 1 J 
ial fit" 



! • \ 




^ \ 



\ \M1 t»|" 
1 \!!! J-.K 






I ' ' \ , 1 .' 



.1 ' • \ 




■'.N N\MI- 

^•:<)Tm;R 



illRTHPI.Xi I 
'"• MOTIII-R 
'St-Ut- f>r i'.Minti \ 




MEDICAL CERTIFICATE OF DEATH 

DA I 1. < M I'l; \\\\ r\ 

I II i'.K i:rA' C l-.RTl I'W 'I'liiit I ;itlciiiK-.i (U-tL-asctl from 

lli.it^' I l;i->t <;iw ll '- ,ili\t<Ml LCv^Mli 'Xf) K)0 ' I 

1 that tlL';i'li I H(-uri(.'il, <>n llu- il.iU- staU'il abovt-, at v 



a 111 



M. TIk- CAISI': (»I' DI'.A'rn wa^ as follows 



hlRXTION )V(7;-.s- ^ Mo)tlhs'-l Pays Hour>; 



c( >NTK [ r.r 'I'oi^ 



/^yVAJl 









DTK AT ION i )V(//.s 



SIGI 



^vV\X^ ',^-^ i()f, 



" f. 



rx.i.ircso bos cH 



Hav^ 




k\.C\^ 



Tliuirs 
M.D. 

■^1 



Special information on'y ''''■ Hospitals, Institutions, Transients, 
or Rrrrnf Residrnts, and person*; d\in!j away from home. 



) 



•■Hi: AH()\i.'. <.i- \ 111, •,.»• K s, )\ \i. !■ \K iirt !. XK-' \ K J ! I" K ' 1-: T" ' I'lir; 
'•'"'■"■ '!N i^^•« 'W i.i: III. 1-: AM) r.i;i,n',i- 



Former or 
L'siial Rcsidenre 

Whrn was disease conlrarled, 
If not at plate of deatfi ? 



How lonq at 
Plare of Deatfi ? 



Oavs 



l'I,ACl-: 111 !'.r KI \I, < "<: KllMii'v'M. I DATKo! IlrKiAi. .a KI;M(»\AI, 



(A.i. 






N' 



. ».— Hvcry i.cn oV uifoiMn. tn.n «h.u.I.. b. ..rcn.Ily suppli..!. Adf. sV>uhl ho stnte.l KXACTLY PHYSICIANS nhoulcl 
Htnu- CAIJSI: OF DKATH !n pl;.i„ terms, thnt it m:.y he properly cluKsified. The Special Information for p-r- 



Kons dyinft awny from home shoulil he Ji"ven in every instance. 



1 '' 



' ' I 



'-) 



•i 1! 



.1 



J li * 



i' 



I •• A I 



I . 



K b C K U S 



TITLE 



RECORD 



SAN FRANCISCO 

COUNTY 
S AN FRANCISCO 



CALIFORNIA 



DEATH CERTIFICATES 



I CROP I LMED 



FOR 



THE GEN EA LOG I CAL 



SOC I E TY 



OF SALT LAKE 



C I TY 



UTAH 



CALIFORNIA 



DATE 




APRIL 



1975 



PH OTOGR AP HER 



MAX J OHN SON 




CAMERA ■N02683 



k ED 



VOLUME 1019 — 1325 



904 



ROLL 



t 



L C A I, I T Y OF 



RECORD S 



TITLE 



OF 



R t CC • '_ 



SAN FRANCISCO 
COUNTY 
S AN FRANCISCO 



CALIFORNIA 



DEATH 



CERTIFICATES 



I CROF I LMED 



FOR 



THE GENEALOGICAL 



SALT LAKE 



C A L I FORN I A 



DATE 




APRIL 



SOC I E TV 



CITY 



UTAH 



1975 



PHOTOGRAPHER 



MAX J OHN SON 




CAMERA ■ NO 26831 RED 




VOLUME 1019 — 1325 



904 




.if 





ifl 






if 



Iti 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H<i:ir 



,1 of llcM'th- 1- No. i> ^•^•..«— ^v lU'vl' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((fo Filed 



\Xkkjo^kju^ 



"xx. 



V)0\ 



Bcilisivred jYo. 



12G2 



io-cwi ILv^ Deputy Health Oflncer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 



( Xl. S. Stan^arc> ) 



. PLACE OF DEATH: 



County ofC'/CU'^AJ AXX/^^vCA,>CLCtCity of CjCLO\; O.V<X-vve^.^e.o 

.; S Dist.; bet. J^aJCutyv and U VftA^X' 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \ 
i, IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



\ 



FULL NAME 




si:\ 



i> \ ri- oi I'.iK 111 



PERSONAL AND STATISTICAL PARTICULARS 




\XX' 






VA^ 



ix 




\.' 



MMiiih' 



AC. K 



o<. O ) I at » O 



10 

(I»;ivt 



M.mth' 



r\%\ 



5 



( '/t;il ) 



/'.; 



sixr,!,).;, M \KK ii:i> 

\\ n)<>\\i:i) nK i)iv<)K(i';n 

iWiit) in '.iii'ijil (livi;.'niiti')ii) 



Sl;iti or C'jiinti V 



\ WW ( )l 
1 \ I 11 l-.K 



lUK'nnM, \<-K 
OI- i'.\Tm-:K 

(Statf or t."'iuiil ! V 



M.\ii)i;\ NAMr: 

ni' MoTMI'.K 



HIR'niI'I,At"l-: 
<>!■• MnTlM'lK 




LL/vwcxxL<r\j N-<^ v^<x) 



KXJuy^u<Aj<kX) 




MEDICAL CERTIFICATE OF DEATH 

DA'n-: ni- i)i:\TM r\ 

(Montli) (T (Day) (Year) 

I ni;i<i:r.V CI;R'1*II'V, TImI I attcndiMl deceased from 

tliMt I last saw li'i-^^v alive (Ml LC\.^Q XG Ti>o '\ 

ami tliaf dealli (iceurred, «>ii the date stated ahove, al v 
\J M. The CAISP: Ol- i)i;.\ril wa^^ as follows: 



DIR.X rioN 
CONTRIIU'l 



)'rors J. Mo'illn \ /hiys Hoiii 



M,t)ii/is 



1)1 RAT ION 3L )'riirs 

(Signed) ^JvOl/cxxaj h /\olaa.>m(^^ 



/hry< 



ic)o"i (.Address) b0 5 




I lour a 
M.D. 

^1 



SPECIAL INFORIVIATION ""'v for Hos|>itdls, Institutions, Frdnsifnts, 
or Rfirnt Residents, dnd persons dyintj .may from liome. 



"' >1 TAllON P [ i/\ (1 



);,n,//,. 



/i.n 



rii 1" \!'.o\ 1*. s r \iiii i'i<Ks. »N \i. r \K 111"! I. \Ks AK }■, ri< ri'; ii > tin-; 

IU:ST<)1' .MS K.\o\\ l.i:i).-,); AM) Itl.l.Il.I- 



1 1 11 !' !• nriiit 



\f)\AA ^ ^-^^ ^ 



-^'^ 



\,M..ss Toi UJjLAMiXj^ Ol: 



Former or 
L'siial Residence 

Wlien was disease confrarted, 
If not at pla(e of deatlt? 



HoH lonq at 
PJare ol Death ? 



.. Days 



n.Aci-: ol- liiixiM, OK ki:mo\\i. 



LaJLcx/yv^xkLoj v-/cJu 



TQO'l 



I ' 



KAI'Koi HriuM, or Ki:Mo\Ar, 
LIa^'CL. ll 



IN. Ii. r.vcpy item ni 'iriformution Nhr>iil«l b- csiruiully supplied. MIV. s'lould he stjiteil I.XACTLY. PHYSICIANS Mhould 

Htiitc CAUSn OV Dr.ATH ill plnin terms, thiit it may be properly cluHtiiritfd. The "HpeciHl InliormHtion" for pwr- 
Rons dyinil iiwoy from home nhould he iiiven in every instnnce. 



I 



t 'i 




^■1 



I' 



n 

I' * 



• 



i 

»' ,11 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,,,,.,,,,,,,-, I, ,',h !• Nn \s^^:*y'i:-nScV( 



Da/r Fih-'l, LLaxx^^ Q.1 l')0\ 



Begistcred J\''o. 



1 2G3 



Q\Jr^^^^KJs 



Deputy Health Officer 



DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Bcatb 

( 11. S. Stan^arC> ) 

J? (?!} -\ ^ 

PLACE OF DEATH: — County ofU/Ct^ro 0.\XX^\C>UIC^ City of 0<>^^^ ^ AxX/>a^Ca.^C<j 



P^ 




CHlir^/^txXA ^ 



St.; 



Dist.; bet. 



and 



/ ir DCATH OCCURS aUaY FROM USUAL R E S I D E N C E G I V f FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF OEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



xm^vu db 





/CUYl 




o'>\' 





\\.^ 



-h 



i» A ri: « II i!iK III 



\<'. }•: 




M..iith' 




t 



)•-,,■ 



'S 



'I):iv) 



\r.,,,ih. 



(Vt-ar) 



l\i 



>iNt,i,i-:, MAi<kii:i). 

UIDOWKI) OK l)!\(>Krj: I) 

• Wiiti in '«<)ri;(l 'If-it'iKitiMii ) 



r.Ik IHl'LATH 
(Stall or Countrv 



X.' 




VAMlv OI" 

jathi;k 



1UR riii'i.Aci-: 

OI- I Allll'R 

iSt.ili ..! I'duntrv 



M\II)I-:\ NAMI". 
'>l MOI'Ul'.k 



!;ik riU'i.A*)'. 










MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH /O 

(MoiitlO/f (Day) (Vt-ar) 

I Ili:Ui;i'.V C"I;RTI1'V, That I attended <lcrcascMl from 

to r-— -TC)0 



1 90 

that 1 last saw h ~ ahve on 



•T90 



aii<l that death oceurred, on the (hite stated al)Ove, at 




M. The CAISI-: ()!• I)i:AriI w.is as follows 

Dr RAT ION )'iu}rs Mouths /hjvs Uonys 

CONTkllU'TORV 



• K ( r 1' \ TioN 



A' ijf'if III Siiii /'i ,!ih ! .-.I ' 1 , ,■ . ■ .lA-',7//>- ( /></r 



)'i(irs ^^ .1/'>f///is Days I/ours 

NED) Ur\>cr^vii^^O.'€).lXV"ljl^ 

-0 



DIRATION 
(SIG 



A.ldrr^s) L^\.CrvaA^ VAi 



"wdL M.D. 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



Former or 
Isual Residence 




L. [ , flow lonq at 

OClVwJw^ V.<XU piare of Deatli? 



iin-; Miov}.-. STA ri-i) i-kk-on \i, i-xururi.Aks aki-; trii-: t« » riii-: 

IIKST oi- MV KNOWIJ.IX. !•; AND IWIJi;!-' 



niif'>;inrmt 



f \<1.1 



S^x- x^ iiv at 



Wfien was disease contracted, 
If not at place of deatfi ? 



3 



<3? 



Days 



I.ACl", 01 lUklAI, OK Ki:Mit\AI, 




I)A'li;<if Hi 1M\I. 01 ri-;mo\ai. 






TQO'l 



N 1 1 1: K T A K 1-. k \] l\ XXcULtv^ \ K VSj AX/XAtu \ U.t'^V 



N. B. Hvery item of iiiformntion shoiiltl be cnrcfully siipplieil. A(]fi sJioulil be stntecl F.XACTLY. PHYSICIANS Hhotild 

Htote CAUSE OF DEATH in pinin terms, that it msiy be properly cloHsiltied. The "Special Inforinution" for p«r- 
snns dyin^ away from home should be given in every instance. 



: ■it 



i; 



t • 



I 



i<I 



M 



I' 



w 



n . 






i 



:..[ 






i if 



M 



ii 





WRITE PLAINLY WITH UNFADING INK 



HJ*'*'*^ 



}!m:ii(1 mF I!r:iMh -I" N'o. l^ ^-V'^-^-^ l\ScV Co 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)ff/(' Fi/cd , 



cMr'^^LA^ 



v^AaaXY^aaXT Os?> 



lf)0\ 



Begisfcrcd J\^o, 



Deputy hiealth Officer 



DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "U. S. StanC>ar^ ) 
PLACE OF DEATH: — County ofO/Oy^^^ OX/<Xy>^.xuAc.<City ofOo./^A^ J ^cx/-yxx!.\^.ci.o 



i ]Ve.VAjtu ^ Woo^yxLv^, ub C^i^vtoa: St.; Dist.; bet. — — and 

A / IF DEATH OCCURS, AWAY r R O M lu S U A L R E S I D E N C E G I VC FACTS CALLED FOR UNDER •'SPECIAL INFORMATION' 



(IF DEATH 
IF DEAT 



H 0CCU|»RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 



/OaXIvtO. > \ <J^' 




u 



!) \ I I- <>i I'.iK rii 



M. l''. 



PERSONAL AND STATISTICAL PARTICULARS 





M.inllil 



^\ , q 



ilhiv) 



yf.nil/is 



rVVX 



'^ 



(Vfar) 



/Ki\. 



■^iNi .i.i:, M\kKii-:i). 
\\ii)( »\vi-;i) OK i)ivnR(.i:i) 

'W'litriii social il(si<.riiatioti) 



(Statr or t'oimtiy^ 



NAM!'! HI- 

1- AIM i:k 



r.lKriIl'I,A>K 
n\' I AIHKK 

' "-^t.it f ' r (."ciuiit 1 \ 



MA[I)I:n NAM)". 
Ol" MOTHKK 



<>!• MolllKR 
(Siatf or Couutrv 







A 



MEDICAL CERTIFICATE OF DEATH 

DAri-: Ol- i)i:atii 

Xi 

iDav) 



vAa^^ 



(Yi-ar) 



(Month) A 

1 IN'iklU'.V CI'RTII'V, That I attendcMl dccvascd from 
IXcvQ 'X'h I90M to LLla^ 3.1o 



up H 

that I last saw h .<• >>> aHvc on V^Aa-a^' 'X^ up H 

and that death occurred, on thf date stated above, at -^ ^5^ 
^v. :\I. The CAISI- Ul- DI'A'III was as follows: 




DIRA'IION )'ci7rs 

C ONTkll'.rTORV 



Months 



Pax 



I lout s 



\j<kAj:xj 




Cr>A^xrv<x,-. ^ 



9 



l\i'>iilfd in Siiti /'i iiiii isi'n 3> I ^ ' '' 



;)r RATION o(^''"A (^ -' 

SIGNED) J . VJV. ()\j 

LV^^V-Q^'l T (p\ ( A d . 1 ress ) 



/hiv 




Hours 
M.D. 



obcs^^^xlj 



Special Information only forHttpitdls, institutions, Transients, 
or Recent Residents, dnd persons dying .mviy from home. 



former or ^ ^^ 
Usiidl Residence <^o I 



\1/<CA,XX' 



VA./CL 



How lonq at 
Place of Oeatfi ? 



Davs 



'1 .1A.^////.V P, /'.'! 



'nil'. MKtvi-: si'\ii- 1> I'l: K-;<)\ \i, r\R iirn.AKs a hi-; •I'Kri". n • 'nii-: 
r.i-.sr Ol- Mv KNuw i.i:n( ,1-: and i{!:i,ii;i" 



Infoiiiiant 



I-jL^ ^ J Xccto 



f\(l<l 



ress 




^V. 



t..\ 



^-^L-Wt 



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



i;i,ACK Ol' luRiAi. OK ri;mm\\i. 



DA'll'.o! I'.i KiAi. or K1:M0\-AI, 



IQO^I 



; NDKRTAKKK yO-t^VU^ \. O <xJ!Xcv^V\J?A; *^<) 



''Adrln-ss 



ao ' 5 JU> 



N. B. F.very Item of information should be cnrefiilly supplied. AtlB should be stnted liXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pljiin terms, that it my be properly classified. The "Spccinl Informntion" for per- 
sons dyin[^ away from home should be (^iven in every instance. 



■A i'«y 



w 



w 



« I 



\< 



"^^ 



fT"^ 



;*• 



1;' 



HH 



■ * 



" i 1 






,#:, 



WRITE PLAINLY WITH UNFADING INK 



HmiikI of nc.'ilth )■ V' 



liljw^*»%. 



liX: 1' C<, 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



B('(^ii<terc(l J\'*o. 



iJ2G5 



lUilr /-Vyrv/, LUv^ vv^t X% l'^0'\ 

Xfrvv^ Ix/v^u. Depu- , •t?' Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDcatb 

( U. S. StnnC>ar^ ) 
PLACE OF DEATH: — County of CJcu^aj 0.\.CU>x<^L.^c<iCity of CJ/CXo^ .^<X/vve,^.4.c^ 







/^^ 




'^VXCM 




OA^ v<St.4xX Dist.; bet. 



and 



/ IF DEATH OCCURsAaWAY FR<X USUAL R E S I D E N C E G ! V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N '■ \ 
V, IF DEATH OCCuUlRED IN JjHOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




\XXXycL 





;V 



PERSONAL AND STATISTICAL PARTICULARS 



'i:\ 




OAX 



COI/)R 




,\jJ<X 



t 



i»\ii': tfi iMKiii 



A I ,!•: 




MEDICAL CERTIFICATE OF DEATH 
DATE C)l'- i)i;ath 




pIv; I go H 

(Day) (Year) 



I Moiitli 



•Davl 



( Vrai ) 



?)^ 



) ,■ 



.!/-■;////> 1 \ P'lv. 



uii)i i\\j-:d Ok ni\'(>Kvi:i) 

Wiitcin ^'K-ial di vi}.'niUii m) 




iuKTniM,\oi<: 

' Statf or t."(iuiitrv' 



!■ ATH J-:K 



niKTtn'i.Ar}-: 

Ol" lATHHK 

' ■'t.iti (ii Co\u)trv 



ol moi"iii;k 









Kikiin'i.ArK 
oi- MoTm':R 

fSt;iti' nv ('i)untry) 




A'y\j 



o^>ucL 



/OAaaK^ciX 



'0 

(Month) /' 

I 1II':R!';BV CI^R'rri'N, Tlmt I attc-n.K'il (U-ivased Inmi 

-to — 



up 



that I last saw h alive- on 



■l()0 
I()0 



and that (Uath occnrrtMl, on the dato statrd ahovt-, at 
— M. 'Jdic CAl-Slv Ol' 1)1 -A Til was as follows: 




^1^ 



DIRATION 



C ON T R I lU'Tl ) R V i.'PvLl: ifVO^>V 1^ cl.cL'^.:\ 



Mo)iths 

V 




/)a\ 



< KATl'ATION 0. '^ /) 

h'fsiile'ii ill San /^i am i.-''i> ol U )V(M ■> 



}/.>i>f/i< - />. 



THi: AHo\ i<: sr \i"i:n im-'kso\ m, i'ari'hti.aks ah i; tkik to rui-: 

r.HST ()!•• MV KNO\\"!,l.I)(.K AND ni-.Ull". F 



(I 



(Address I ^ ^ ^ "1 Xa\} O't 



nr RATI ON )'rars 

( SIGNED ) L(r\CA^n 



'^ ^ 



H 



Mo tit lis 

\ 



Pavs 





^\ i(,o^ (A.ldrrss) WuHAjA^ 




Hours 



M.D. 



Special Information only for Hospitals, institutions, Iransicnts, 
or Recent Residents, and persons dyini) away from fiome. 

Former or ^.^ . (W \ ^ How lonq at 

s VI rWroo^ya ^ piare of Deatfj ? 



Usual Residence ' 

Wlien was disease contracted. 
If not at place of deatli ? 



Days 



ri.ACl-: Ol' jnKlAI. «>R R!;Mo\AI. I DAlIi^.l i'.iKiAi. <.i U1.M(»\ \I, 

I LAa.VC\ 1^ TQOH 

(Address " H^- 5 I T)^W vW-V 



ri, AC J'. < II' y,\ K i.\i. « Mx. I' 



INDl'.K TAKMK 



IN. B. F.very Item of information should be cnrefully supplied. AGC should be stated F.X4CTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, thnt it m»> be properly classified. The "Special Information" for per- 
sons dyin^ oway from home should be feiven in every instance. 




I ! ' 









i' 



*■ . 



!' 

i' 



*t 







r« 



WRITE PLAINLY WITH UNFADING INK— -THIS IS A PERMANENT RECORD 



I!. .-,! 



,1 ,,f II. .iltli !•■ Vo. l^; 



■*'^'owr'^' ]'.^V C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i' 



II 




' ,( 



Bc^Lstered J\^o. 



\2m 



rrtf-^ • 



Ihilr Fih'il, CLwcv^^^il X\ V'tO^K 

{ \^ - 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of ©eatb 

( 11. S. ♦5tan^nr^ ) 
PLACE OF DEATH: — County of U/OL/^rv ^^CX^ruCUIi/^oCity of CJ/CXA\; ^^/(Wt'CA.c^c <j 
O^^^MUaa Llv-t St.; ^\ Dist.;bet. U/oJk nnd 

/ ir DTATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER -'SPECIAL INFORMATION ■ ^ 
V, !F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



No. \\ 




FULL NAME 





Ow>-v 



PERSONAL AND STATISTICAL PARTICULARS 

OTN a ' rnl,(iK 



>i;\ 



i»,\ri". oi- liikrii 






(K<r^r 



NT.iiUhl 



I):iv) 



rVxl 



\ ' . 1 ■; 



15 



)■<■-■» ^ 



^ 



M.niih- 



M 



'•>■. Ill 



/',/. 



>^i\«",i.i-:. M\Kkii:i» 

wiiM i\\i:i) (»K iii\'t iKri;i) 

Wiiltin social (lcsi;.'nalic)n) 







lUKTUri, At'H 

i 'stai,- or <"Mniiti \-^ 



iMxriii'i, \ri.: 
OI" lArm.K 

(SlatL- or I'otiiitrv 



M mim:\ n amp: 

<'!• MoTlll-.K 



HIKriil'I.Ari-: 

<>i- Mn'rin:R 

I stall- or Country') 



ovTri- xrioN 



ty\A) cLc-v^ui ^j^'O^aoJUr^ 




a^Tv' 



\AxtL 




VX'W 



>s v 



MEDICAL CERTIFICATE OF DEATH 
DATK (>!• ni'.A 111 




at 

(I):iv) 



(Yffir) 



fMoiitli) 

I lli;Kl';r.\' CI-RTII-V, Tlmt I attciKlcd .Icci-asLMl from 
CL^ 'W 190 H t,, 0^ 'Xb i<,oH 

tliat r last saw h -V^.^ alive- on U-^-va Xb 190 'I 



"(f 



tliat iliatli occurred, on the date stated above, at • O 
M. The CAISh: ()!• Dl-ATII was as follows: 



DC RATION 



)'(•(/ r.s" 



Mou/hs A /^ars Hours 



DURATION Years 



(SIG 



.\CU>V>Cll 



Kr^iilrd ni Sii>f I'l atii : •■i'(i I >A ) rii i 



1/..///A.V 



n,i\ 



THi-: Mu»vK sr \'n:n i'kksonai, rAkriiM i,aks aki' rkri': ro 1 iii". 
iU':sT m- Mv KN<)\vi.i;i)('.K AM) in:i<n:i- 



(I 



nfoMnnnt fcx/Wh^ dUv' VA VJ JkjJLa.^^ MfX/oU 



)JUWJ\AJi 



( \.l(h.'^s 



1 1 U /cx/>v \j\jL<lo LL 



VhJl 



Mouths fhiys 

NED) v\ - \jxAj^.j<J-<xXXy0^6u>J\.> 



Hours 
M.D. 



LAaa.<:\,?k'1 i()oH 



( 



Special Information "hIv for Hospitdis, institutions, rransients, 

or Recent Resident?, and persons dvinij <m.iy from home. 



Former or 
Isudl Residence 

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



How lonq at 
Place of Death ? 



Days 



J'l.AD'; ol- IM'klAI, ok kl'.Mo\AI< 



DA'ri; o! 11- !-• I \i. oi ki-;M( )\ai. 



VI I, ' 



1 



Ni>i:kTAKKkM U J CuL(U/Yv NK^vij^JUXAli^^ J\X^\ 



!on Hh.u.1.1 he caro^'i.!l> suppH.d. ACfi s'louhl be stnte.l EXACTLY. PHYSICIANS should 
H in i.hilfi terms, thnt it miiy he properly clnssiried. The "Special InVorm.ition" Vor p«r- 



IN. B. Kvery itein oV inforiiiiit 
stnte CAUSF: OP DEA T 
sons dyin^ nway from home should he fiiven in every instniice. 



Ill 



11 



• 1 




\ 4 

I ■ 



p 






r I 



I 



i.i 



It 



Hi 

I'* 

• ? 
; > 



f:i 



fe 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i(! ..f n.-:i!!!i- I" V<i. !< "^""li^j/""' Hi'viPc" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1 



O^^'V-^'3 




ai 



7,9/9 H 



Bvi^isid'cd J\^o. 



126? 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of IDeath 

( U. S. StanDnrC^ i 

jj am ^ ^ 

: — County ofO/CUYV J A.<XA^C\AC'.City ofUo^/>'\j J /\^€LAA^Cc4 C < 



PLACE OF DEATH 



No. 1\1 




VWk-N; 



St.; 



^ 



Dist.; bet. lU O. 






and (]v)-<XA.QA\t 



(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V ET FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



>i:\ 



i» A I'l-: I )i r.iR 111 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.oR 




Wy^ 




OL\i 



Wvj 



C^- 




'XCOX: 




; \'A t T I' 



lilt h 




(I):tvt 



.\<.I-, 



X\ 



) I ll I 



.!/./;////< 



h 






/>,n. 



MEDICAL CERTIFICATE OF DEATH 



^!\< i.i" M \ki< ii:i). 

W MX tWI- I) i\H I)l\"(>Ktl':i> 

Wiiti in <oci;i; (1< sif.Miation) 



lUK riiiM.AvM-; 

(StntL- or I'omili \^ 



»•■ \riii:i< 



liiR rni'i,A(.K 

St;itc or Coiiiitrv'i 



M \II)}-:n n \mi- 
<>i M()Tiii;k 



i'.IRl-UIM.Ail-; 

<>i" Morin-.K 

(Stiitf or Count rv I 




^ 







CUi 





<x>'v./cL 




I)ATI<; ol' ni-ATH /O 

(Montli) jC (Day) (Year) 

I Ill'kl'lJV Ci':RT!I-\'. That I attrii.U-.I .Icvcast-d frntn 
vAx^x3i X'l ]()0^ to VWw^ 'X% up H 

til at I last saw h -^ >>v ali\c- on \A^^-v^ '^X.h up ^[ 

aiij that death ocrurre<l, <iii tlu- <lat«.- statcfl ahovr, at I . Ho 
■0 M. Thr CAISI': ()!• Dl-ATIl \va^ as follows: 



DrkATfON }\urs Mouths % /hiys IIoux 

CONTRIIUTORV 



1)1 RAT ION 

f SIGI 






M out In 



NED)Ll). 0. O.^AXcLlvCrWv 



/\}Vs 



■TVCLAAj 



l\fsidrd III Siiit /'/(;;/( /v<> JL' 1 )',-,! i^ [ .y/->ii//l- i) 



ATI'ATloN (TTJ 

A>uK-/VVA, "■« 



\j 



//ours 

M.D. 



fN. > I<)0 \ ( 



\.Mri-SN) i^S'^T* lb>Uv) Ot' 



Special Information "niy tor iiospitdis, insniutions, ir,insienfs. 

or Re(ent Residents, and peisons dyini) .m.iy Iron home. 



/>,! 



I'll I' \H()VI' ST \!-i; I) !'K K'^DX \I, r \K I I.I I. \k^ \KI. rkii 

iu-;sT oi' Mv KN()\\"i,i; ix; i: and ni.i.ii;!" 



: Ti • Ml 1-: 



' Iiifo:in;tiit 






former or 
L'sudI Residence 

When was disease rontrarfed, 
If not al place of death ? 



How lonq af 
Place of Death ? 



Days 



I'I<.VL"I-- '•'• lilklAl, Ok kI-:M<»\AI. 



\i.\'l'2:. of UruiAJ. or ki:M<(\AI, 



I 



\(1<lri'.is 



N I ) 1 ; k T \ K 1-; k VXXAJUaT ^^ W\^^X>Aa^'(Jv\j 



N. B. l-,very item o»' informtition fthould he cfirofiilly siip|)lie<l. Adfi should be stilted fiXACTLY. PHYSICIANS Khotild 

state GAlJSr OF DLATH in pinin ternis. that it m:iy be properly classiried. The "Specin! Inlrormiition" Jor p«r- 
son« djinft oway from home should be iS^iven in every instnnce. 






f 



i . J •■; . 



lit 



I •! . 



P^ 



17 



i 



■t 









1 



i i 



pf 




> 


1 
i 1 



'lift 

nun r 



i 



(< 



(I li 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;,.:inl ..f Hr:i!tli -I" Nn 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Filed , 




X\ 



U)()'\ 



Begisfci'cd J^^'o, 



1268 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "a. 5. Stanc>arc> ) 
PLACE OF DEATH: — County ofUOAv OAXX/^vCv^xU) City of OxX/>x> OAXVrX'^co cc 



a 




AJro 



•tti- 



No. l^C)1 VJ rL^'>A.^x.CX' St.; H Dist.;bet. T ^LA\) and o /^vxj 

(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E 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 



si;\ 



PERSONAL AND STATISTICAL PARTICULAR 

I COI.ok 




^^UoJU 




'XA. 



ti 



1> Nil". <)!' K I Kill 



\(.i-; 




\til.iitht 



X 



%2, 

fl):iv^ 



!/.'»'///■ 



(■/(•:irt 



MEDICAL CERTIFICATE OF DEATH 

DATl'; Ol- DlvATJI 



LLl^ 



n 



(Day) (Year) 



^I\«.l,»:. MAKKIi; I). 

U IlM»\\i.-,i) OK I)!\'oKri-:i) 

Wiittiii >.(n-iril il»-^i-.'ii:il !■ in ) 



lilKI'Ul'I.Ari-; 

'State or (.'oiinti \i 



NAM)'; ol 

i-.\Tni;k 



HIKIIlPI.Ai}-: 
Of- I'ATIII'K 

'SiaU' or r<nnitr\ 



MAII)1:n NAMi: 
Ol- MiiTIIKK 



inurni'LAri'. 

<'!■ MOTIIHR 
'Stiitc or Oounlrv) 






(Month) A 
I 1[I-:RI:1'.V CI;RTI1-V, riiat I .itUii-K-.l (lovasfd from 

LLc^wOl %1, 190 H t() CUa/Ol. M iiK^H 



•% 



tliat I last s;iw ll ^>^^ alive on \-A.-\.ax:\^ '>hI> 190'i 

and tliat death occurred, on the date stated above, at v> 
VV. M The CAISI-: 



Ol' l)i:.\TII was as follows: 



DIRATION 



) 'rars 





.1/0/////S -i Days Ilom. 










.'^JL^i, 



■S ^- .^n^Ht/lS 



DIRATION )',iii 

,NED) U). U- . Xuit 



/h7\ 



'S 



( SIGI 



CjL 



«)t.i:ri'ATi().\ 

Rryiiird III Sat! /'i ii ni !>i',) )V(f;> ^^^ Miiulli^ (Q 




Hours 



M.D. 



W TooH (Addtvss) '^'ii '(fb^c<Mx.vfC ot 



Special Information "nl> for llospitdls, Inslilutions, Transients, 
or Recent Residents, and persons d>inij dHHV from home. 



Former or 
Usual Residence 

Wfien was disease contracted, 
If not at place of deatli? 



HoH long at 
Place of Death ? 



Days 



'rm-: xnoxi-: sca ri'n im-ksi )\ \i, !■ \k ricfi. \ks ak i; {■Rn-: lo riii'. 

ni:ST (H- MY KNoUI.l.Ix.l-; AND luaji:!" 



nnf..;ni:,nt 



Yc4v>v \LcL'v\^lj!)-duL 



^\.Mi,-. Ipon. M Jtv^w-^v^o. ^H 



iy,\ei;ni liiRiAi. or ri-.moxai, 
iNH)-; Ki 



rj, \i )-, • >i m K i.\ I, < »K K I-, :> 



DATI'.o; \\y\i\\\. or RilMtiVAi, 
^-^U^Cl 'iO T90S 






(Ad.li.-. 



II 'i^ Qi^'V^.^i.^v^x. ot 



iN. H. Kvery item of information shouUI I)l- oircfiill.v siippliiMl. \(\V. slioiild be Htnted F.X4CTLY. PHYSICIANS Rhotild 

state CAUSE OF-' DEATH in pliiin tf rms, thnt it mjiy he properly classified. The "Speciiil Information" for par- 
sons dyin^ awny from home should he ftiven in every instance. 






\ 




'It: IP.^ 



S4 






n -' \ ^ 



hi' 



I ^•'' 



i i 



B: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;,,,i.l ..f Il.iilth »•■ No : - -^'f^^^^i:. ]Mk V C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ill 



ii:; 



D/f/c Fi /(>(/, LL^v/O/CA^ 3.S 



100 "i 



Jiro^i.sfr/'cd A^o. 



1269 



cU^...,^ "Ix^vM. Deputy HccJthOflfloer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beath 



( U. 5. Stan?arc» ) 



^ 



'(5Tl 



<^ 



PLACE OF DEATH: — County of -' Oy^ru -^'a/>vOL-5.co City oi^Ou^^ J A.<X/>Ayt^v^c<5 



Na cl3.3>'( 



•< ^ll 



m 



OUCLt . 



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



St.; I Dist.;bet. 0)LXX^TVCa^^U) and ^Vt^'t>VL«^l ) 



RESIDENCE GIVE fac 

OR INSTITUTION GIVE I 
« 



TS CALLED FOR UNDER "SPECIAL INFORMATION • "\ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



r 



Ou 




Q.> 



PERSONAL AND STATISTICAL PARTICULARS 

I' \ I'l: I "I- iiikTii 



XjaxjJ 



■'y\\j^.y Kj 



\>.K 




%1 

(Dav) 



/I 6 



MEDICAL CERTIFICATE OF DEATH 

DA ri". Ol" DllATH 

1% 



(Mnllth) 



I(c 



) ,. -; 



1 



.1A>;/.'//> 



/'(/)A 



^iv. i,i:. M\uKii;i), 

\\"llM)\VI-:i) OK DIVOKCi:!) 



liiRTnri, \0K 

' Slatr or (/oimtrv^ 








XAMl' Ol 

I- ATI 1 1 :k 



i; 




I Dav) 



(Year) 



lllvRI'HV Cl-;kTII-V, Tliiil I :it(c-ii.lc(l (IccoascMl from 

^OQ ll 190 H to U.vv<X. '^"^ KpH 

that I last saw h .*-'u alive on L^v<v 'X% jcp 'i 

and that (k'ath (irciirrcd. on the date stated ahove, at 3v 
AJ M. The CAISI-: ()!• DI-ATll was as follows: 



O-uto-Ol^ 



HIKTm'I.ACK 
<>l' I-AT!IKR 
' State .)]• Couiitrv 



MAIDl-;\ NAM)- 
<>J" MOTIIl.k 



inkTiiiM.Aci-; 

<»l- MoTHKK 
(State or I'oiiiiti v'> 



<>' 1 Tl'A riox 

/\'f .'iffif i II Sail I'l ii ■ 




^^ ^ \.tci'<xo^tr^ 



DIRATION )'rars MoulliR 3 pava \X //<>tns 

CONTRIIU'TORV -CjAvn<<^vcC J^vsi^v 



nr RATION }'rars Mi^ulhs ^^ /),/is- 1 lloun^ 

NED) 1). V^.^i). 



(Signed) cU. Vd. ^^'»<xcA^aoXA.vi\u 



M.D. 



eJi 



ufii 



SPECIAL Information <'"'!• f"f Hos|»ildls, Insfilufions, rrdnslcnls, 
or Recent Residenis, dnd persons dyin;j <iw,i:. Iro.ii home. 



*- M.nlll,^ 



n,i\ 



\'\\V. \\\n\'V. S'l" \ l"l"D I'KRSONAI, I'AKI'lif I. \Ks AK I-, TK II': To TM l- 

iu;sr Ol' .MN' kn'owm: D<". K AND^in:i,ii:i' 



'infci'iuatU 



X'l'ln^^s 






wx\ 




Former or 
Usual Residence 

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



How lonq at 
Place ol Death ? 



Days 



DA I1-: o! lit KiAi. or K1;Mo\-A1, 



L\.>-vx:l "^l 190M 



i'l.ACi: Ol" MIKIAI, OK KI:MoVAI, 

t • X D 1 • K T A K I- K U oAjU^T^XjL \J j\ O^^^ A./WO ^^^ K^ii 



N. B. 



iJiMLik 



-r.very item ni informiition should be cnrot'ully s ipplied. AdB should be Htiiteti r.XACTLY. PHYSICIANS nhould 
state CALISn OF DEATH in pljiin terms, thjit it mjiy l>e properly classified. The "Special Infopmation" for pur- 
sons dyinji awny from home should be (Jiven in every instance. 



I '•}^l 



< 




:|.. 



I." 




i 



; ii 






oi 






Ml 






iJu.^. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l>,.:,i(l of n. ;iMh »■• No. - - t>-*"^ar;._^-~i. I!.'^ )' C* 



Dff 



/r rifrd, \X 







wo'i 



Be^istcred J\''o. 



1270 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeath 

( 11. S. StanCarD ) 
PLACE OF DEATH: — County ofOct"r\j J /VO/VuCXsU:^ City of Q CUYV ^UX/TVC^^A^C c 
No. 1151 J CrUL<rY>v St.; H Dist.;bet. T Ajk) and %J 

(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N '• N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME ^i) <xaJUulaX JyTUrrruXA \jOJ 





PERSONAL AND STATISTICAL PARTICULARS 




SKX 



I' \ii' < )i );iKi!i 



x<.i% 



Coi.tik 



IdJLu 



MEDICAL CERTIFICATE OF DEATH 



(k 



Motit 



n 






)'i\t I 



l 



M..),lli^ 



•k\ 



l\i 



\VII)( iWK.I) «>K I)!\<)RrKI) 

'Wiit<'iii s.»ri:il (l«-<iiMiali<)ii) 



lUKllll'I.Ari.*. 
'stale DT Couiiti\) 




LAaa^< 



11 

'Davl 



(Year) 



(Month) Y 

1 1I1':KI{1'.V Ci;RTn-\', TIimI I aUciKkMl dcHvasca from 
UU-A^ XI UjoH to LLuw^ al U)o\ 

lliat I last saw li i-"^•^ alive on vAaa,Q "^ 

atijl that (kalli luHnirrcd, on the date stateil above, at O 



T90 M 



M..Tlie CArSl{ Ol" DI'.Aril was as follows: 



a 



\A>ti-: Ol- 
I'A'iM i:u 



Hik iiii'i.ArH 
ni- ixrui'ik 

'Stall 111 C'tuiitiA" 



MAII)1:n XAMl- 

Ol' Morm-k 



I'.ik riii'i. All-; 

<•!■ ^!^>'|•||l■;k 

'Slal.' Ill Coiinf ! v I 



• " I r I' \ I'K (\ 



^ 




Oy>v J AXWV'^I^L^ C^ 



OJ^ 




^ 



'/<X/w» AXX/> vc^^-vc^ 



m" RATION 



) 't'ar\ 



Mouths ^ Days Hour 

C()NTRIlU'r()R\' V.X'C^aAJI \j<xaXaaX^ 



lx^J>uv^^ VD,Ol> 



J QSTl 




I ) r R A 11 ( ) N 
(SIGNED ) 



)'('itrs ^ M ("it lis 

% 

Cr ^-\^V\) 




<vo 



Piivs 



\Xk^<\ 1^ic)0^ (Address) UIH. 0&VL<r>W O.i 



I loios 
M.D. 



^ 



Special information "nly tor Hos(iildI>, Institutions, Trdnsienls, 
or Rercnt Residents, and persons dylnfj .mny from home. 



/\'f'^ idf'il in Sttii I'liiiui ' 



) - 



v\ 1/ .;//-// vOv I 



' ', 



'II I'. \ii( )\i.: ^i" \'n: I) im'Ksi in w, v \k iut i, \ks ak 1: I'k vv. ro rii v. 
iii'.sr Ol- >.Lv KNo\\i,i-i)(;i-. AM) r.i-;i,ii.i- 



(h 



Ill'.Sr 01- >.LV KNO\\i,l-I)(;i-. AM) III 

'fonuant J ytx<rv>A.x>^ v^<xaA-xs-aX 

crVA^rvA; Ot 



i \.Mr<-KS 



\\%x 



Former or 
Isudl Residence 

When was disease fonfracfed, 
If not at plare of death ? 



How lonq at 
Place of Death ? 



Days 



I'LACl'! OI-" IMklM, OK kl-Mo\AI, 




V 



(ibcrw La>6-M' 

N I ) 1 ; k r A K 1-; k OvD . J . O-'U^ 



r\.i. 



I) \ l"l. ..; li! luAi. or ki;M<»VAI, 

LU/^ x^ 190H 



N. K.. 



-\\\cry Ucm «.*' informnlion should b^- cnrclfiiliy suppMcil, AdK should be stilted I.X4GTLY. PHYSICIANS should 
stntc CAUSf: OP DLATH in pinin terms, thnt it mjiy btr properly cinssilflcd. The "Speciol Infornuition" for per- 
sons dyinft nwny from home should be ftiven in every instnnce. 



I ill. 




'Mk# 




\l i 



f:,;i 

'ji 



' f 



ii 



'I' i\ 

H' .1 



.1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1!. ..•! 



nl ..f ncjilth I" No. I- "^-^^^^"^ 15&1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







as 



I'JOH 



Kc^iKlcrcd J\''o. 



1271 



Deputy Health OfTlcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 



PLACE OF DEATH: — County of 



City of U /OL/^^^CXTL VA>X>>J 



No. 



St.; 



Dist.; bet. 



and 



/' IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N A IVI E INSTEAD OF STREET /> N D NUMBER. / 



FULL NAME 




O/Ol^) 



0. 



^x<s\HX'y\j 



s};\ 



i>.\ 11-: <>i' HiKTn 




PERSONAL AND STATISTICAL PARTICULARS 





K<.KA 



i: 



AC.K 






D.iv 



:/'»///!.- 






MEDICAL CERTIFICATE OF DEATH 

DAi'i': <ii i»i:\ I'll 



a^ 






(I);iv) 



IQO H 

(Year) 



0.1 



/'.; 



^IN»',1.I-:, MARKIi:!). 
WinnWKI) OR DlVoki}-;!) 
'Writt-in social iksi^'iiatioii) 



lURTlU'LAiM" 

(State or (.''niiiti \ ^ 



NAM1-: ()!• 
I'ATlllCR 



HiRrilPI.ACK 

<M- lArmiR 

'State or Conntrv' 



1^ f^ 






MA11»1'.\ N 




1 Jll'ik i:i'.\' Cl'R'i'I I'\', Tliat I attciKkil (U'ceased from 

-^ — 190 \.o 190 " 

lliat I last saw h alive on — — — — : — - — - 190 — 



aii<i that (K'alli 1 )iH"itrr(."(l, on tlu' i.\.Ak: sl;ite(l alxn-c, at 
Tv.M. TIk' CArSl<: Ol- DI-ATII was as foUnws : 



~ M. Ill' 




DC RAT ION Years 

CONTRIIU'TORV 



Mouths 



Pa \s 



Hours 






IMRrniM,ACl>: 
oi- MOTIIKR 
(State or Cotmtrv) 



r 1 1 



OCCri'ATlON 

Rfs'dfij in San I'lnii, : 



rVTLAXX) 






DT RATION 
(SIGNED ) 



\A^v< 



Yrars Mouths 

1". r(,o'\ (..\.1.1rvs^)U^<X>. 



Pa vs 



Vi:-'trA^v^vMX' 



Hours 
M.D. 

(EC 



Special information "nly for Hospitdls, institutions, Transients, 

or Recent Residents, and persons dviny dwa) fro^n home. 



)V,M 



M.'lltiK 



IK: 



Tin-: AH()\'K sr \ri:n pkksonai, i-AKin'ri.AKs akI'! rurK it) •imi- 

I5K,ST OI" AK KNOW 1.1 ;i)C.F, A N I )Hi;i,l l! I-" 



^InfoiiiKiiit 



\.Miess V 






Former or 
Usual Residence 

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



How long at 
Place of Death ? 



. Days 



rr.ACK OI" lUKIALtiR Ki;Mt)\A!, 



CcU 0^ 



DATI-; 



1 



rXDHRTAKl-.K <3jLAjfc<Jkj ^ (/VX^^daA^A. 

OoJlLvw^c Let 



; Ri.M. 01 K i:M( »\- M, 

^1 1 90 H 



fAcl(lr( 



N. B.— Hvery Iten. of Information should be cnrcfuMy suppr...ci. AGB should be stntcd F.X ACTLY. PHYSICIANS Hhould 
state CAlISn or DEATH in plnin terms, that it mjiy be properly ciussified. The Special Intormiiti >n Vor p«r- 
Rons dylnft away from home Hhoiild be Ji'ven in exery instance. 



* ■? 




\ 



I til 

|i^ 



' >' 









w 






1. 



f 



p 
I' 



w 



hi 



I 
i 



4 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



|'...:ir.l >■( 1I« ilili •■ 



V,,, ;-, •?■--• -=.-.^: IKS: 



1* (■(! 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Regisfcred J\''o. 



i^?2 



ihUi' ri/cdXl^o^A^^^ XH /'"^^^^H 

dUyvcvo Xitovu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©catb 

( H. 5. Stan^ar^ ) 



ro 



PLACE OF DEATH: — County of NLf LCL^V-n. >x' 



City of 




cr\t*i H I l<xcLi\.a- La' 



No.- 



St.; 



Dist.; bet* 



-and 



/ ir DtATH OCCURS *\A/*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
l^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME 0(Vfvlv^. OxcO ' ' 



U)l.t ~ 



PERSONAL AND STATISTICAL PARTICULARS 

MX (^ 0.,...K 

iiA ri-: <•!• r.iK in /P\ 



MEDICAL CERTIFICATE OF DEATH 

DATK til- Di.Aiii ry 



a'i 



(Month) K 
I ni;Ri:r.\' C'I:RTI1'N', That r attcii<UMl dcreascd from 



(Day) (Year) 



> ( ;tl i 



bl 



/),;v 



'-INC. 1. 1". M.\kKii:n. 
wiix i\\i:i) ( iR i>:\( iRri:i) 

Wiili ill v,„i;il il. --i^'nat ion ) 



IMRTMfl.At^K 

'~'t;it !■ I ir < "iiti nt t >' 



\\ 



<xsjv>-^cL 



iX" 



NAMi; (»l' 
FATin.K 



iiiKTnri, ATK 

<)!• I-Aim-.K 
I Slat r or Count i\ 



M \I DI'.N NAM1-. 
01- MoTin-.K 



Hiurni'UAci-: 

(State oi roniitr\^ 



lL>vk 



1 90 ti) 

111 at I last sMw li -■ alive on — 



190" 
190" 



and that diath occtirrcd, on the <hiti' stated ahovo, at 
M. The CAlSIv Ol- hIiATII was as follows 




DC RAT ION Yrais 

CONTKir.rToRV 



Moulin 



na\!i 



Hours 




OOCII'AIMON 



T 



Mouths Pays 



or RATION"^ Years 

(Signed) J/lxxav 



Hours 
M.D. 



ecTalTnfo 



Special information onlv lor Hospitals, Inslifutions, Trdnsicnts, 

or Rfffnt Residents, and persons dyiny dway from home. 



\'f'itlrt! Ill Si;;.' /'iiUh: ('w O '^ )'..',' 



M.'iilh^ 



h.:\ 



Till': AHOVl-: STA'n.O I'KKsDNAI, I'AK 1 MTI, \Ks AKl IKD-; To III l- 
1U:ST OI' MV KNo\V!,lI)(.H AND I5i: l.Ii: I' 

(Info:niaiit Nil. \l<\. <^ JL/&JO^ 



Former or 
Usual Residence 

When was di<.easf (ontrarled, 
If not af plac e of death ? 



How lonq at 
Plare of Death ? 



Days 



ri.ACK Ol- lURIAI, oK Kl.Mo\AI, 



INDl'K TAKl'.R 

(Ad 



1 



itA'L}'"! li! HiAi, or ri-;mo\-ai, 

^^ I90H 







N. B. 



— P.very ite. of infor^BtJon .hou.d he cnre.'u.,. supplied. AGB shouU. «>« «*«^^;l^^->^.^i^^»'.^. .rrjul^' Vr'::!.- 
«t«te CAUSE OP DEATH in plnm terms, thnt it mny be properly claHH.t.ed. The Specml Intormat.on for p,r- 



«on« dyinft away from home should he Jiiven in every instance. 



I 



ii«.^ 



\f^ 



1 1, 



11 






;;■< 



!n 




L_ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



)i,,;,i<i ..f II. iitii I- N" 1^ ■^^:."=^:'?'•• li^i'^ 



nnj'i 



X6<A.A_xi Ai?/NM. De"-rtv MonftH r>pq-^«r 



Be ^ isle red J\^(), 



iS73 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of Beatb 

( tl. S. Stan^ar^ ) ^ 

PLACE OF DEATH: — County ofO/Ct-^Aj J^a >vcv^e{ City ofO<X/>^^ ^vOci v C cA, c o 





ivCLa..! 



St.; 



Dist.; bet. 



and 



/ IF DEATH OCCURS AVWAyIfROM USUAL R E S I D E N C E G I V E FACTS CALLFD FOR UNDER SPECIAL INFORMATION \ 
V IF OEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N'JMBER. / 



FULL NAME 



)XcCt/VA.XLX 




(X\-<^o\.(. 



PERSONAL AND STATISTICAL PARTICULARS 

i>i i'.iKrii 

It 



+ 



^- 




,0 V- 



]-' 



,1 ) 



\«.I- 



)',,M 



S 



M,,)illn 



I'i 



/',/, 



SI\(,I.I-. M\RUIi:i» 

u'lix »\\»-, I) ( »u i)i\ < >i/i i;n 

Wliliin s.iri.il <lrvi'rii;it iiiil) 



I'.Ik rillM, M'l". 

St;M< .Jl I "•iiuill \'l 






. \ \1 1 Oh 

I \tiii:r 



lukini'i, ATI-: 
'>!■• i\rm;K 

'State nr C'ntiiitrs 



M\II»i;n- NAMl. 
'>!• Moilli: K 



iilU'IlM'l.ACJ-: 
"I M<»riII'"K 

-1 '1' ■ •! (''(Ullt 1 \ ' 




OuVvwo 



MEDICAL CERTIFICATE OF DEATH 

1. A i").; * ii Di; \ III /O 

\XXXXX. '^^ IQO^ 

'Mniith) K (Day) (Year) 

I in';Ki;H\ ^ l, ••J'III'W That I atlmik'il dccrasod from 
^jKaAaa '\ ii/j^ to LLla^ Xt» KjoH 

tliat I last •^aw h '.'v; alive on 'sAa^VCv n\ k^o"- 

and that (U-atli o(H-iirretl, on tlu- datt- stated above, at i 

.; M. The- CArSI{ Ol" DI'.A'ldl was as follows: 

jluWucaaJLc^.\.' LaJj-^ -tLXA^ 




4(S 



Ow^i-X 



DIR A'l'IO'N 
CONTkllll'lORN' 



> )V(/;.v 



.\/nii//!S 



fhns 



/ fours 



DIR \TI< »\ 



/hivs 






' lit ri'A rioN 



f/oius 

(Signed) ^^ \X). ^aX^.-> '^ M.D. 






■4- 



I,,o'l rXddress) 3lH lo QaALe^^ 



Special information •»"'> '"^ Hi'spH'ils, InstHulions, frdnsu-nts, 
or Kt'if-nt Rcsiijcnls, .init persons dyiii'j .iw.iy front homr. 



I- 



) - ,7/ 



1 1/,,,////. it/' 



TIM' \!l<»\)-. ST \i"i: I) IMrKsOV \I, f \ K T IC I I. \ K -^ AKi: TKIJ-: In Til I- 

lil'.sT <»l MV KNouij-.m; !•; am> I!i:i,m.i' 



lsu.ll Rpsidcnrp I D I ^. \JUyY\j O A f'Ue of Dedth .' " 

When was diseasr ronfr.K ted, p. Qi 

If not dl plarf of dcdih ? ^ 0^\) ^ ^VCVv\yav<L.^'^ 



Ddys 



Pixrj-oi lUKiM, Ok Ki:\io\Ai, I KNiK": m i<i,\i, -.t ki;m(i\ai. 



I Nl 






^\,I.l,.^s 15 'X^ a1jtyO^\X^>-o Ol 



N. B.- 



-Kvery item otf JnW.ni.tion «ho„l.l he cnroVully suppUecl. ACK Kh,n.M he stMle.l I.X4CTLY PHVSiaANS Hhould 
Htntc CAirsi: OI^ DIATH In ph.m terms, th„t It may he ,>r..,.crl> cluHnhicd. The "Spccu.l Intornu.t.on for p-r- 
nons clyinji nway from home Hhould he fivcn in every instnncc. 



'■■[ 



i: ( 



1 



\' 



^f 



1\ 









M 






4 

n 






I,; 



( - 



1^. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

; llc..!th i v.- 1^ ^•tr^?-'!*''^'''"" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.r 



is 



^^ 



JfJO'i 



liOgistered J^o, 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDcatb 

( XX, S. J5tanC>arC> ) 



(3T) 

PLACE OF DEATH: — County ofOa^^ v1/ua--v^c.^c«City of 0'<X^^ J x.cu-v^^^<i co 



r 



Ne. ^^>UUL 





.1 



U^yxX'V^^iO.' ' ' St.; 



Dist.; bet. 



and 



/ IF DEATH OCCURS AW*Y| FROM USUAL R t S I D E N C E G I V E FACTS CALLED FOR UNDER 'SPrClAL INFORMATION' \ 
V, IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 








• I \ 



I) \i l: oi liiK III 



A< .}•; 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 







(Month* 



/QO H 
(Year) 



M..nlir' 



L.5- 



r- 



M.<nlli> 



1 rai 1 



l\: 



^INt.I.lv M\KI<Ii;i> 

\\ii>()\\i:i> nk i)i\'«)Kri:i) 

'Writ- ill siicial ilrsijj'iialion) 



lUKIHPI..\i>K 
' Statr iir i."i)iititi \- 




N \M) (»1 

jaiiii;k 



iiiR riiiM, AD.; 

<>l" I'ArilKK 

' Statf or Coiinti vl 



M \I1)1;n NAM!-; 

t»i M()rni-:k 



inRrmn.ArK 

'M Mo'lMlKR 
^StaU- or C()untr>) 



Rf-^'ilr'! Ill '<.iii I 
'\'\\V. XiiOVl', STATI'I) I'KRSONAI, PA KT KT LA RS A U I". TR' l' I'l » III)' 

iu;sT oi- Mv KN<>\vi.i:i)**.K AND in;i,n-:F 



MEDICAL CERTIFICATE OF DEATH 

DAIH (>1- DlCATIl 

U 

(Hay) 
i illvKlvUV e" i{R'ri I- V, That I nttcmKd <lcrr;isiMl from 
LAa.\.X5_ 5> 190 H to L^WwOl Qv"l \^^^ 

that I hist saw h ahvc- on VAA^V/C\ ^< \ ic)0 i 

and that death orciiiti'd. 011 the (hite stati-d ahove. at » \ 

a 









J 

I )l RATION "^ Years 
CoNTkllUTORV 



Months 



Pay 



I/oii 



) s 



//ours 
M.D. 



I )r RAT ION )'('(?/-.v J/<>f{//is /hiys 

f SIGNED) lO Xd. VJ 0-Cr^.-, 

'^lAL Information only (or llospitdls, institutions, Irdnsients, 



.&>^ 



or Recent Residents, dnd persons djin^i .iwdv from home 



/>.! 



nnfilMUMlll 



Former or 

L'sudI Residence -r — 

When was dise.ise contracted, 
If not at place of death ? 



r\ () p 3 How lonq at ^ 

\Lt\jJnw^CV^ ^CvX PLire of Death? <^ 



Days 




cu V<xX 



ri.ACK 01 lU RIXL'tR RL;M<»\AL I>\TI'..! Ill kiai. ,.i ri:m(»\al 

X rv\^ i^ P I CL^vo M T90H 



^nmmmmmji^ymrm 



X.l.ln-.s ^ I O^X/C.A^Oc^O'XX.'VA^tci * I 



INIH-.RTXKl-K UJ,A^^XX> (lb _ 



« -J 



iU 



, ,, 1. ,1 \rr whnilil he ntiited r.\J\CTLY. PHYSICIANS should 

N. B. F.very Item o? information should he cnrctully supplied. A(,r. slio. Id ''.^,.'*Y''*^;: J* ^^^ • ,„f„.,„„t J.,n" tor dt- 

8t«te CAUSE OF DHATH in ph.in terms, that it muy he properly cipss.ned. The Special Information tor p.r 
«on« dyinft awny from home should be Jiiven in every instance. 



'^■'■:ri 



H], 



I 

h 






I, 



» 




f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



llr:.Hll-F- No. i> "^-t:"*'-^"' i^'^l' ^" 



REFER TO BACK OF CERTIF ICATE FOR INSTRUCTIONS 



JfJO'i 



dlo^^v^ \sL\y^ Deputy l-^ea!th OfTlcer 



Brgislcrcd J\^(). 



1275 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Ccvtificatc of IDcatb 

PLACE OF DEATH: — County ofO/a>^ vlAxxy^ve^AiyCi City of'Jo^^^ J'V/CX^va.ev.i>c.c 



N 



oM\ 



.KJ<XX) andVIl 



rv>MxdL\_o-o./i St.; ^ Dist.;bet.Vj CrVv>CA^^> and M I t<X^crvA. 

r ir DEATH OCCURS A^AV FROM USUAL R E S I O E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
V IF DEATH CCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




■UA.C . 



KLkA 



■l.X 



PERSONAL AND STATISTICAL PARTICULARS 



Ml HIKTII 



5^ 



t 



MEDICAL CERTIFICATE OF DEATH 

DA ri-; I )!• i»i: \ I'll 












SIN'.l.I" M\KI<ll-:i> 

\v'hm»\vi:i> (»k i)i\i iKti- 1) 

'Write in sixinl di ^iviH'ti"'!' 




lUKTHfl, xri- 

' St;it» III < I iiiiili \- 



I'A riu-.R 



luuiHi'i, \ri-; 
ni- lArm-.K 

'St.itf I.I (•..iint t v' 



<»l' MOTH IK 



HIR'nn-f.AOK 
or MOTIIKK 
(Stale or C(»milr\ > 







Ol/>v\^ 



o 





<X yv 




1 II I";K i;i'A' C I. IvTI 1"\'. TIi;it I ;ittriiik<l lift rasf.l {\<m\ 

\Kju<XJI 'iS Iiy')'\ to L\-\-vC» ^\ np ^ 

1" ( 1 ^ - V u 

tli.it I la^f saw h -»-'w' alixcmi V^^a>OL_ ■* ^ Tcp^ 

ami that (Katli > u-nirrnl, mi llic datt,- statc-il ain \(, at I A-oO 

LvM. Tlu- CAl SI; Ol" I) i: A 'I" 1 1 was as follows: 



,vo 



•i 



DIRATION 



vv> 



)'taix 



Mn>it/is 



roNTKir.ri'oi 



<L 




\^ 



.^\X 




^■OdjfV^Xu 




omi'ArioN Qv) 



/^(/I's //ours 

DTRATinN ^''^'/^ .Voiths /^avs 

(SIGNED^ \. O. VD 

c 



\.^J\yOy^J^ 



M.D. 



itdK, Instifunon^, 



SPECIAL INFORMATION «nlv tor llospi 
or Rt-rent Rcsidcnis, dnd persons dyin j .m.'v Iron home. 



/• 



Till MtoVK S'l"ATi;i) rKKSONAl, 1' \ K I" H ' T I,A K S AKI. 1" K f 1 ' 1 ' ' i " I'. 

iu:sr Ol Mv K^o\\i.i:i)«",H a\i» Mi:i,n*.j-" 



(Itifo-iiKint 







Former or 
L'sual Residence 

When was disease fontrrtfted, 
If not at plare of death ? 



HoH Ion'] dt 
PIdfe of Death ? 



Transients, 



Days 



I'l \C1'" Ol- Id KIAI, < iK' K IM' |\ M. 



1 \ I r ..! ii! 11 \! M! K i:m< >\' \ I 



T90S 



r M 1 1. K 






f Addii s*^ 



N. 



, ,, .. I \f:F shniiltl he stated HXACTLY. PHYSICIANS should 

B.— Kvery Item of information Hhou d h. .nretulfy «uppl.c '^//J^^^^^^^^.^^ '^^e -S^.c-cinl In.'o.mation" for pT- 

state CAlJSn OF DIIATH in pl.-iin terms, that it may he proptrl> ciaHsmeu. • nc j 
sons dyinft away from homo should he feiven In every instance. 



wy. ■*'! 



1: I 






r 




im 



ijy 






IS^ 



il *' 




I » i. 



«' 



I ' 



■n 




H 



ii 




:li 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,,nl ..f n,:ill!i- »•• No. 1 <^ t^'^"^^- lUS: I' C. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Duir riJr<l, (Juu^x^LA^ a^ I'^O^ 

Xf- ^-^ "^ '^AM, Deputy Mealth Officer 



Bci^istcrod J\^(), 



1276 



(j-VA^^w^ 



^ 



No. 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccitificate of IDcatb 

( 11. 5. GtanDarD j 
PLACE OF DEATH County of C'CUTt' -J h„<X/">XCUlCcCity ofCl/CUYV' /ua^-r-uCo<L c <. 

ITilD U y\ /OJ\J'^KA: St.; C) Dist.; bet. AAXooa-{y\Xj and JAXL >UL>v 



A„0 V^ v_A_ ... 

/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V r FACTS 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 





/(X-'^^aj VXX\.v duj.xix>u-\xr. (ilD /CX. K)lV' 



^i:\ 




PERSONAL AND STATISTICAL PARTICULARS 



\. 



\<W\-. « )1 KlKl'lI 




vc 



,iu 







0.S 



■ ■rt-.-ir) 



^< . !•. 



TH 



v> 



.v.. ;////> 



/^,M. 



'Wiitiiii soiial »K>-i;.'ii;iti( 111 ) 



' St.'tt f or i.'i miitiv' ' 




NAMl-: <>1 
FATIIl-.K 



I'.iR rii i'i,.\rH 
oi- i\thi:k 

' Sf:it<' or ("■ .null \- 



M\II)i:\ N\MI-. 

"i .Mt»riii:K 



HIRTHI'I.ACI-: 
OI- MoTHKR 




I 

rVCrVU-v^ 



MEDICAL CERTIFICATE OF DEATH 

nvri; oi di.atii r\ 

iM-Mitl)) A" (IViv) (Vc.-ir^ 

I HlvRIvI'.V CI.KTII'N', Tlint I aULii(lL<l ik-crasid from 
YCX/>'v 10 190 S to LLvA/CL '^-^ ic>oH 



AwA./a d. 



that T last saw li i alivi on LLccCj, 'k I Tf/)'l 

an<l that (k-atli IK currctl, on ( lie date stati-il alinvc, at I- O 
LVM. Tlu- CM SI-: Ol" I)]-: ATI I was as follows: 



I )r RAT ION 



) 't'lirs 



,,, ,^.^,.,.., Moui/is I /></rv \ /lours 




1)1 RATION 
(SIG 



N E D ) M llO^ OlX^'^ \-^t » ' 



Pavs 



LLvO at i.,o'i ( A.Mrc.s) ?)bO OJKX^h 01 



Hours, 
M.D. 



.0 'J.b T»)o'i ( A.Mn'ss) O^U VJX'aVM JV 

SPEC?IAL Information "nly for llnspitdls, Instittifions. 
or Rerenl Resiilents, and persons dvin,] .iw.iv from liome. 






/',■■,. 



rin-: amovh spati'I) i'Kk^onak pxkii'Ti.xks aki-: \-\<\v. i" rm. 

in-:ST Ol' MN- KN< t\\ I<i: IX". H AM) lU-.MI'.l- 



nnfu!inaiit 






Mv, ..^ 



mo 



XA>A.^.xx<i.-^A^o or^ 



Former or 
Usual Residence 

When v*as disease rnntrarted. 
If not at plareof deatfi? 



How lonq at 
Plare of Dealli ? 



Transients, 



. Oavs 



i»\Xj:"'' iiii-'!M, <ii K i; M< iv \ I, 
-^0 



I'l.XCH Ol- Ml KIAI. ok ki:M«'\ \1, 
INI.I.RTAKKR ^ 1 VJ )Xa.O^<i.. C<, 




1 90S 



(Ad.l: 



N. B.- 



... I- I \cv Bhf.iild i)t2 RtJitctl hX4CTLY. PHYSICIANS Hhotild 

-Kvery item of i,iJ..rmHtion «hm,IH b. c..re»ull> sippl.^Ml. Af.f. kHo. I<l »»":.«Y '-u "W l„l fnformaUon" ?«r dt- 

Htatc CAUSE OP DfiATM in ph.in terms, that It mny be proj.Lrly .Iuhh.V.ccI. The SpccHl Intormat.on \ur pT 
sons dyinft nwoy from home kHouUI be aiven in cNcry instnnce. 



\ i 



Ki 



k* ; \ 



1 r '3 







1^ f \'- ' & 



HI 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)".,^i;.! , r II. .I'lll I' ^■' 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



• ( 



i. ' 



ill 

■5 ^^ 




illli 



!>((!, ' Filed , Ll.^vx:iycvAlb :X4 




v 



1 



.\XIl^>^y^^ 



//yi^A 



llciHistcvvd Xn. 



1277 



^rWA-0 o^X/V-U 



/-»/rvyi» 



DEPARTJyiENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( ^1. S. St^n^nr^ ) 






Q^ 



PLACE OF DEATH: — County ofO/Ct^v J.^OXAV^Mi/t:^ Gty of^^^'^ 0.\.<X/>va^ec 



u 



as 11 



so 



No. lb 11 oUCrt^\jL4. St.; 10 Dist.;bet. ^ k.^ and 

/ ,F DEATH OCCURS AWAY TROM USUAL RESIDENCE G.VE FACTS CALLED rOB UNDER S P EC AU . N FOR V, AT , O N ' A 
( .r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER, ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

SKX A ^ kt»I,oR 



l>\cJ^ 




I "A II Ml r.iR 111 






\' i: 



'^i\< ,1,1:. M\Kun:i). 

\\ 1 itc in '•lu-ia ' • liiti'iii ) 



I'.iK ruri.AcM-: 

' Stiitf or < "i lunt I V* 



1 '.i\ 



1 /,.;/'// - 



/^• 







^■\^t^ lu. 

I \Tii Ik 



r.iRTni'i.ArK 

(>»•• l-ATHKK 
(State or Country 



M \ii>i:\ N ami: 
"I M()i-iii-:K 



iiik riiiM.Ac'F, 
' stMti or (.'<»int I \ 







MEDICAL CERTIFICATE OF DEATH 

DAI"]-; (>i- i)i:a III 



(MuntlO 



\l>ay* (Year) 



I lli:ki:r.\' CI{R'ril'\'. 'riial I attLMi.U-(l (U-ccased from 

til at I last saw h w. > alivf oti WW>*^Cl A I icp . 

and that .K-atli occurred, on tin- dato statc<l above, at O 
\J M. TIk' CWrSK Ol" Di'A'lMI was as follows: 



vJy(vLAVv-<iA^^ VA./wX_'^-\x.. 



.•O-O'v ■^ \. 




oiLTI'ATIoN ^ . 

JLOO'V^-VA.Lt'X' 



DT RAT ION 3s )V</r.s 
CONTRIIU TORN' 



Mouths 



Pays 



I/oitfS 



DIRATION 
( SIG 



)'<</;-.? 



Months 



Pax 



NED) VI), Ll.M)la/v<lo^ 

eAiAL IN 



A 



I lou)^ 

M.D. 



Special information ""'y 'f>^ Hospitnls, Institulitms, Irdnsienls, 



ni RpienI Residents, and persons dvini) av^dv from home, 
lormer or '^•^ '""'' «*' 



Kf^idri' in Sdii /'i (I i>i ''''i> 



) 'I'lt I 



\! .nlh^ 



MI-: AIIOVH S-IATl-D l-KRSONAL rARII'l I, \ k -^ ARI, TRI]-, To Till' 
IU-:ST <)l- MV KN<»\\ I.i;j)<".K AND r.l.Mll 



'Infii-ni;int 




' \.l.lr.->.s 



\ka 



bXl JLJcrLj'^^ H 



L'sudI Residence 

When was disease rontrarfed, 
If not at place ol deatfi ? 



Plare ol Death ? 



Ddys 



I>1 \(F 01 lURIAI. OR R1:M«»\ \I. 



'I, \ch. < II m M 



I) \ II 



LLlax:3i ^0 



\! t ri:m(i\ai, 
190H 



r 






\,A'^.^\-^W O 






N. B.- 



-F. 

8 
8 



,•.,1 \(:n shoMhl be «tntecl F.XAOTLY. PHYSICIAMS should 
ivery item of inlform.ition should be cirou.lly supplied. .^ . ....,, x,,^. "Spewlal InformHtion" for p«r- 

t«tc C \lISn OP DEATH In pinin terms, thnt it m:.y be properly .laHS.t.ed. . 

on* dyinfe away from home Hhould be feiven in every mntance. 






I' 



'■.•) 



i 




f![ 



I 



;l 



# 



\^. . 





ft 



I 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!o:.nl of lU:.Hh I' Vm : ". ^''l"^?-' ''"'^ »' '" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihffr n/rr/, CLv^vvAt X'\ I'^OH 



llegisfci'cd JS'^o. 



1278 



a>-u 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eath 

( *Cl. S. StauDarO ) 

J? 05?) J? ^ 



PLACE OF DEATH: — County ofOctTA. 0/l<X >vc<^c(.City ofO-CV^ >vCX/w^v^cc 



Nf). 



( 




U 




C^> v'v.v 



St.; 



Dist,; bet.- 



and 



.r DtAT^i OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \ 
IF DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



fCrlw\j 




JLAAJL^. 



• i: \ 



PERSONAL AND STATISTICAL PARTICULARS 




■ "" loL 



i>l llIKfH 



Motlllit 



\' .!•; 



13l 



II 



( l);i\^ 



y/.»if//^ 



:.rl 



II 



/K' 



SINCI.l*, MARK 1 1: 1) 

winowHi) OK i)iv» >Kri:i) 

'Wiitiiu SKcinl ilt >^iJ.'1l:ltio^) 



HI K I" 1 1 n.AOl-: 
St.itc or C<»mitr\- 



U^ /ucL{rv^^-^<^- 




^<) 



NAM)-: <)1 
FATJIl-.R 



UIRIII I'l, ATK 

<>i- iAriii-;R 

• Sl.itc or i'oiitit r\-' 



M \ 11)»'.\ N \M1-: 

"I m«)Iiij:r 



HIRTliri.At'K 

• )!• ^!(»■nIl•:R 

(state or Conntr\) 



OCCri'A'lloX 





X.Cr Va-i 

V 



MEDICAL CERTIFICATE OF DEATH 

DA'll': ' 'I DI'.A'lll 




(Year) 



M 

(Month) i\ (Day) 

1 HI:KI:1'.\' CI:RTII'V, That I attomk-d (UhojisciI Inmi 

tliat T last saw h '• " • alivf ou \Xj^^<\ Xi up '\ 

aiul that death occurred, <in the <latc stated above, at I J* 
\J M. The CAISI-; Ol'" DI'Aril was as follows: 



Dt k A'l'loN 



)'((jr 



V 



i 



JU\,^y\^Oy^'\^\.' 



V 






//(>//r.^ 






DrUATION )'(ijrs Months fhjv 

(SIGNED^ V] I L b.UW/-YVv^.vvA:.UL 



A I T<)n I 



f. 



\ddresv)15'l d.VA.tLl/v Cjl 



ii 



I lour s 

M.D. 



Rr^iiU\1 !>' S.ni /'i </'/. '-' " 



M 



)V,;) 



M.oith^ 



/)</!, 



THi: \iu>vK srATi:i) i'Kk^<>\ai, I'AK rKti.AKs AK1-: i-kij: ro rill' 
iu;sT oi' Mv KN»>\\i.i:i)<". }•: and iu;i. n-:F 



(1)1 



rn,„K„„ (Jv<xa1^ MK'\cWJU 



■1 



{ \(Mrc--< 



iS^ov 



(?^^ it 



SPEOIAL Information on'y tor llaspitdls. Inslilutions rransients, 
01 Recent Residents, and persons dyin.-j aw.iv from how. 

Former or C^J . C^, 1 L ^ ""^"'"'' ''' 

Isiial Residence ^'*-^ ^ ' XfrjjUXO 

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



&'»v«. Pidce 



of Death? \ (U'v". Days 



I'l.ACK <H-^ 1!IKIAI< <IK K1:M"\M, 



V\ \(. I' < M' til l\ l.\ l< ' ov jv 1 , 



DATlloi' Hi KiAi, or RI-;Mi>\'A1. 



Lvu^' 



1- 



30 



I90H 



I N I ) 1 



KTAKKK 11. U). \n\0.>vlv>y >^ C 

A.he. SRG'^.O..V^iHt 



PHYSICIANS should 
r p«r- 



.1 \c\ «h,>iiltl he stilted HXACTLY. PHYSICIANS . 
^. K.— F.very Item of informntlon «houI<l he carctuliy .suppl.e.l. J 'J' ^^ ,!,3««i|'icd. The "Special lnform»tlon" Jo 
«tate CAUSE OF DLATH in pli.in terms, thnt .f may he properl> claHS.ncU. 
sons dyinft nwny from home should he feiven in every instance. 









I 

i ■ 



■i <# 









n 

I 




If 




li 



:.\ 



.1 

(i 



m 




1.. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

]le<^lsfcre(l jYo. 1-279 



Hoard of lli:.!th V Sn. i =. ■*'*:. ~,?--' i-*^ I'*"'' 



Ihilr niril, LLvO^vvXiJ:; 'k'\ I'>0\ 

l<^v^i-vx>^ Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticnte of IDcath 

PLACE OF DEATH: — County of Ca-^v 0;vCc.>va^^ ccCity of UO/^v OXO^x^c^cc 



No. Il'^ 




ckxXA^'VA.w St.; 1 Dist.;bct. \.C\>X .ind AA. 

,.o.ini Dc-cinFNrr riur facts called for under 'special INEORMATION \ 

FULL NAME VtlOAV M 1 1^ v^^c-na. 



\Xtn^.' 



) 



^^ 



^l. \ 



PERSONAL AND STATISTICAL PARTICULARS 

Lt 'I.mK 




a.< 




.'kCtx 



i» ATI-; <)i r. I Kill 



,Uh 



M 



iDav) 



11 



'\'c:ir) 



/',; 1 



^IM.l.I" MAkUIi:!). 

\vn)o\vi-:i) OK i)!\'» ikri:i) 

iWritc ill soriiil <U sii'iialiini) 



lUkiHIM. \t'l". 



NAMl, or 

i-.\Tiii;k 



K\X^<^ 



iukrii]M,AiK 
oi- i-ATni:K 

'St.'itf til (."iiimt w 



MAiiii:\ N\Mi-; 

n|- Moj-IiJ.R 



liikruiM.Ai'i-: 

oi MoTHJ-.k 
(Stiiti 111 roiinli \^ 



11 



k'r iilrJ III Siiii /'iiHh ■ ■<' 




MEDICAL CERTIFICATE OF DEATH 

DA ri-; OI- niiATii 

J^ /go ' ( 

(Month)/] 'I''v' (Yenr) 

I ni-:Ki:HV CI:KTII-V, Tliat I altenilcd ik-cvased from 

tliat I last saw h ' alive on LUa^ -aI U)o'\ 

,111,1 that .Katli nrourred, on the .late stated above, at I- aO 
Ul M. The CM Sl{ Oi' DI'A'IMI was as follows: 



DIR A TK >N -• }''tr/\ l/.'v///\ 

CON Tiur.ri'nRN" Co^-^a-^^ 



/),n< 



//(i/irs 



DTK ATION ^ yr<Jrs 



Mouths Hoy 

(SIGNED) VJV.U.- V^A,A.<yi'V<XA-^'.c ... 

')^ i„oH fAd.lres.) ^0 5 d^OAJi^ 



(tv-Cl- vhxvJ'^ 



I lom < 
M.D. 



)■,•,// - 



M..,i;h^ 



(1 



111-; VHOVK STATi:i) I'KUSONAI, P \ K lir T I. A K s AKi: T K t I ' T« » ' 'H" 

iu:si' Oi- Mv KNo\\i,i:i)(". i-: and iu.mi-.i- 



( \.l(lll <-« 



I 



^l\ Ida..cm1jl^w^ 0± 




>A.' 



SPECIAL Information «"'> '"^ Hospltdls, institutions, fransients, 
or Recent Residents, dnd persons dying <m.iy from home. 



Former or 
IsudI Residence 

When was disease ronfrarted. 
If not at plare of deatfi ? 



HoH Innq at 
Plare of Deaffi ? 



Days 



190 , 



,., ^C^■• 01^ HI klAI. OK KKM.^VXI, DA-n 1: • :o "V kKMoVAI. 

,N,.r,K. m;i:k "'ol: <xLcU^ ^ ^-<. 

(A.l.h.-s. ^Mt M>\a.^L^V<7>V yt 



' ' '^ 11 A'f h(»ul«l be stnteil f.V\CTLY. I>MVSICI\NS hHoiiIiI 

IN. B. r.very item of informntion should be c.rcfully suppl.^^il. ^ • , .j^;^j. xbc "Special Iniormution" V'or p«r- 

•tate CMISK OF DnATH in pl;.in terms, tbnt -t mi.y be properly ciasHU 
Ron. dyini ow«y from home should be feiven in every mHtnnce. 




'\ 




^ 



[.' » 



«*!i£3IV. 




^ii; 



m 



M t 




' t 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFI CATE FOR INSTRUCTIONS 

Bcillstercd A'o, 1280 



lt.„nl ..f n.-.-iUh- »■• No. ■■-' ^-c"^?-- ^•^^' ''•' 



l)(ih' rih'(L Luvo^u^ 9vH i'^^^"^ 

Xcr^.^^ duL\MHi Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



N 



PLACE OF DEATH: — County 

o, 'is VJ,n.^-<L^vv^J St,; ^\ Dist.;bet. 



Certificate of Beatb 

( U. S. tT'tan^nrD ) 
ofUcu^^ J A.Oc^-wc^ ^ -'City of ^O^-w AXX^^x^^^'ti,^ 



lb X/f\. 



and > I ^-^^ 



' ^^'^ 1 ■ ..cilfll Qrc;inENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • A 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

t"( 'I ' 'Is 




A.U. > 




'i IMKTll 







r'M. 



\' . 1-, 



SIN. 1 ; M \1<N Ii;i> 

W Ilx i\\ i;i» (»K IMNnKti: I) 

'Write ill social doif tiatioii) 



lUK TIII'I. \<"i: 
' Slati- or roimli \' 



1/ ../•''.' 



1 



Q? 



-C*> 




NAM!' OI 
l-A'IFIKR 



I'.IRI nri. MK 
Of- lAriM'.K 

' *^t;it (• I ir (' ' 111 111 r\ 



M \ 11 M.N NAMl. 
"1 M DTI IKK 



liIUIHlM,A('J-; 
<>l MMI|II':k 
'Stale or l"ouiitryi 



To b. U ^Kuuy\} 








OCCri'A lloN 

h'f idnl HI Siii! /'i'!>''' I ^^— ^ 

rill \Mi.Vl-. sTXTI-.I. l-KKsuNAl, I'A K T h" T I, V KS A U 1 '. T K T ) : To Tm'. 
Hl>r n|. MN' K Nt t\\|,i:i)('. !•; AND HI, 1, 11. 1' 



) , ,// - 



]/.„>/, i / 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DAIl". ul- I)i;.\'IH r^ 

(Montli^ !\ '":'V^ 

1 III:K1;I!\' C i:k'ril"\', 'I"liat I aUciKU'l 'Itcoased from 

CLc^cv %^ 190 S to ^-^-^-^ '^'^ "^o'l 

tliat I last saw h ^ .>^ alivr on Ua^. '^^ Up 1 

and that dratli occurred, on Uic <lalc stated above, at v> 
^ M. The C.MSI-; Ol" Dl'.X III was as follows: 



i \J^. 



1)1 K \riON )''V// 

CONTKIIU TOkV 



.]/(////// V f /hn< ^ IloutA 



I ) r R A T I < > N 



)'ii!r 



Mouths n(n< Hours 

^ n,>H ! .\ddr.ss) ^l U Cr-vv^li Ot. 



SPECIAL Information «"'y '"f llospitdls, institutions, rransients, 
or Reffiit Residents, dnd persons dyin<| rm,i\ fro-n home. 



' lllf'.! IllMlll 



\.Ml 









Former or 
Usihil Residence 

When Hds disease rnnfrdded, 
II not at place ol death ? 



HoH long at 
PKire ol Death ? 



Days 



n,\ci-: "I- I!' Ki ^>' "'-^ '■■ '■■'''' '^' ■ ' 




J-, ( li- 111 IV 

CrLa X 



i)\ n 

a 



VI .1 ki-:m()vai, 
.'CvOL .'^ ^ T 90 H 



1 



M ' 1 



, K T A K 1-: R Vi Cr\X0v "^ li^ i Vctx 



^N}^. 



-~------ ---------------------- 7^^ ,. . .,jj: ^U',u\A l»c 8t..te.l r.XACTLY. PHYSICIANS should 

N. B. F.very Item of JnformHtlon shoi.hl Hl- coreViMy nuppl. • «. , .j.^j. The "Special InformHtion" for p-r- 

•tate CAUSE OF DEATH In pinin tcrmn, thnt .t m:.> he properly claH«.t.c 
Bons tfyinft away from home should he J>iven in every m«tnnce. 



: t:^ 



i 



«rta?^ 



i 



"^-"-'- 



1^ 


■■TITI 




!i' 




' I! 




J ■ 




" 


1 


. 1 



\ 



I 



i 



11 



iti 



I'. 






I ' 



JS, 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

|;,,.-in1. • M. ,Mh \' So i - '♦v'^i^ii^ MM' Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/),,/r n/rf/, (JL 



rMianmmimtwam 










Be^Ls/ered jYo. 



1281 



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



Certificate of Beatb 

( X\. S. StanI>niC> ) 



PLACE OF DEATH: — County 



ofO.CL^YV J AxX/Yvcc4ccCity of 0(0-^0) ;-o<X/rvc ^..a. c c 



No. I5)ia 




-? 



DEATH OCCURS AW 
F DEATH OCCU RR C 



C.'R.CLt ^ L SU 1 Dist.; bet. cLtaA>tixA.utfuUand Ot^-U^rlx 

AY FROM USUAL RESIDENCE GIVE facts called for under 'special INFORMATION' "X n 

D IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OF STREET AND NUMBER. / 'J 

FULL NAME Jx^mx 




^A^VcLo. 



vv 



PERSONAL AND STATISTICAL PARTICULARS 

i) \i'i: » 'I liiK III A,^ 




I M.iiitli ' 



Av 




\'. 1-; 



51 



r 



/^ 



(!);(%> 



1/../'///- 



iVrar) 



/><; 1 .^ 



w iiM i\\ i:i) Ok i)i\< >RrKn 

'W'litf ill -iH-ial (lc«ii>.'iiatiiiii) 



iiiiv- III I'l. \ri-: 




I \i II i:r 



I'.iR III I'l, ad; 

•)|- lAIllKR 

' ""'t i' ' 'If ("oiiilll \ 



MAIlu:.\ NAMl- 

OF M(>tiii.;k 



I'.iRPM IM.Ari-: 
'•!• MoTHKR 
(Stale or Countrv 




'Va^CvO.rl 







MEDICAL CERTIFICATE OF DEATH 

DAij-; ni' i)i;\rn 

(Day) (Yt-ar) 

I lll'k i:i'.\- C I'RTIFV, 'iMiat I .ittiiiiltMl deceased fnmi 

LXCVQ it Up'{ to LLaw/V>0. 'X% TqoH 

Hint I l;is( saw h ' ■■ ali\-e on vA-CA^Xy. 7^ L 

and tllat dratli oreiirred, on (he date stated aliove at 

( ^^ 

M. The CAISI': Ol- DI'-.A Til u:,s j,'^ follows 



( Month 



upi 



LtAjiX'^ 



ol^>^\_»l\.' VjWo-vcL 



o 



niRA'llON 
C'ONTRir.l" 



y<''i/^' 



Mnuiln AO Pays //outs 




'\X V^^^cnv^ 



I)rk.\TH)N-_ )Vr7r,v Mouths /A/rs'l^^ I/our^ 

M.D. 



(SIGI 






\/,>iif/i.< 




Xa Ic,oH (Ad 



n . 



drc-ss) iltX Ujya^VV\^vqt<t>v. (J 



SPEOIAL Information only tor llospitdls Instilulions! Transients, 
or Recent Residents, and persons dyiny .may from home. 



I'ln: AHOVK STAT I : I) J'KRSn\ \l. l>\Kruri, \ks ARi: IRll-: To j'lnc 
lU'ST ()I- MV KNo\\l,i:i)(-,l-: AND ill.IJ}".!' 



(Iiifiii inaiit 




tX-AJut^ vJU^Xr^ 



i \<l]u 



\'h\X 




ts^^ 



^ 



i 



former or 
L'sual Residence 

Wfien was disease contracted, 
If not at place of deatfi ? 



floH lonq at 
Place of Death ? 



Days 



IM.ACI': OI-' lURIAI, OR KI:Mo\AI, J I>Ari%.; Hi iiai m RliMoVAl, 

im.i;rt\kj:r \J . H.. vJj. XJlXjctxCtV' 



IN. B.- 



-I'.very item oit inV'ormatioii should h.- cjircV'iiMy siipplioa. A(]Pi s'loiili! be stntcfj HXACTLY. PHYSICIANS Hhoiild 
Htntc GAlISt: OP DEATH in plain terms, that it may be properly chiKsiltied. The "Speciol Information" for pwr- 
Rons dyin|^ away from homo Hhniifd be Jiiven in every instnnce. 



{1^ 



i 



-^im9^.' i 



%' IJl. .- . . 



a . 'Jmi 



B JKPMH 



VJ 






f 



RM 



» 



li 



;) 



ii 



I'-Ilj 

I' ; 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



: II, Mlt'i 1" No !-- "i^i ~.7-'- Hi«vr Cn 



Dulr Filcil , IXcv^M^v^ Ql^ 



V.)0\ 



Rc^Lstercd JVo. 



1282 




v^ 



roF 



*» /^#¥7*%, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "U. S. Stnii^ii^ ) 
PLACE OF DEATH: — County ofO/CL^v) vJXCL^x^cUiyC^ City of C'aX'Vu 0>h^xX/wa>LA.ac 



No. 




^ 



Ht'^H ' ^5>XxJi. St.; to Dist.;bet. M l^^' andA-a^tn^' 

(I «■ DfATH OCCURS AWAY FROW USUAL R E S I O E N C E G I V E 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 




^v 



Lxx ->^t c 



PERSONAL AND STATISTICAL PARTICULARS 



X''^^^^<X/ 

i' \ i i; t>l lUKTU 




l.t 




x'.i: 



v5 o y,a>- 



X 



DmvI 



M>tiHn 



/ ^i 'i \ 



MEDICAL CERTIFICATE OF DEATH 
DATK ol" DKA'III 

u 

(I)av) 



a. 



(Month) (f 



N'l ai ) 



IH 



-iN'.i.i-: M.\kKii:i» 

U !I)» >\Vi:i) (tk DIXORlKI) 
'U'rili-iii -Mi-ia! (i,>-i^.iiat iini) 



lUkTiii'i, \>-i: 

ISlritr or Comitrv 





.- ,, ...... (Year) 

I Hi'lRl'ir.V Cl-RTII'V, Tli.it I atlL'ii.K-.l Uciasod from 
LiccCl X''i U)oH to U-^-vcr 'X% I, 



-n 



rqo 



tliat I last saw h : '-" Jilivi- on 



TCP H 



ami lliat (U-ath (iccurrctl, on tlu- «laU- statiMl ahovi-, at ^-10 
Ax M. Tlu- CM Si-: Ol' i)i:.\'||| w.iN as follows: 



-V' 



-OL^v V cL 



NAMr (I I 

!• \r\\ 1 R 



lilk 1 II IM. \r}-: 

Ol' i\rm:R 

->t ' ■ ,...,.■ 



MAMM.N NAM!" 



lUkllll'I, \C]-: 
<»F Mo'illl-lk 

'Stal.- or ('ouiit!\) 



CdxAxxvci 



, \\' { 



t) 




.^\ , 





Ol 



I»l RATION 



}'<'irrs 



I lour X 



K.'<y&^OjX> 




'"■'■'I'N I'M )N (>u} -j 



l>,;\ 



DIR.XTIOX );wr.? Months Days 



/fours 



(Signed) >ca-»^^x^ ()v 

.0. Xb loo'i (' Address) Hoa'^' ^M^iv At 



Special information ""'> for llospitdls, Insfifulions, Frdnsienfs, 
or Recent Residents, and persons dvinj dwa) lio;n home. 



Former or 
Usual Residence 

When was disease rontrarted, 
If not at plare of death ? 



How lonq at 
Place of Death ? 



Da\s 



rill- \!;« )\\.\ >^r xri; I) t'KRs,()NAi, r ar riri i. \k-. aki: TKri-; j'o iii )■ 

in:sT Ol- MV KN'owij; DC H AM) \W.\,\):\= 



^ 



I I'lfoniKinf 



Oyl'x.^-o 



Aav%\. 



W. \ Cr 






Xd<lrcs. HOIH- 'X^>^X^ Bl) 



i;j^ACH tti' liiRiAi. <tk k];.M'i\\i. 

(AddiVss T b "^ 



!> \ Tj ; ..: HiKiAi. oi k i;m< i\'ai, 
,CA.O ^0 190H 



I Ni»i-:RrAKi:R 




N. B. livery item of 1nf<.rmHtion «h()ul«i be ciirefully Hupplicd. AGB should be stated EXACTLY. PHYSICIANS fthould 

state CAUSE OP DEATH in pltiin tcrmR. that it moy be properly claH»ified. The "Special Infontiation" for p«r- 
Bon« dy!n4 away from home Khould be (^iven in every instance. 



i\ 



' i. 



:> 



i m 



M 



*m 



api. 




lilY 



• 



f : 



.! 



I 





.\ 


' H ; i 


*t 


r! v: 


'1 


1 

1 






m . 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ii..;n.l of Hi-Mlth I Nu. i> "^-f.^'r-^i I^*^ J' <'<' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/(' Fi/rf/, U<j^/UX\^^jit X^ 



10 0\ 



Jlegi.sfci'Ojl jYo, 



1283 





. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of "©eatb 

< 11. S. 5tanC>ar^ j 
PLACE OF DEATH: — County ofOa^\;0-^^Cu-ru'a>LA.cc City ofO/Oyrv ;vcx/>X/a^L^c:.>o 
No. T 11 O.VtX , >.v ■..■■./,;. :. St.; I Dist.; bet. J Ct^VUV andV^iVA. 

/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U fAo E R "SPECIAL I N FO R W AT/(d N • ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^ OF STREET AND^NUWQEff. / 

FULL NAME LLloOaa,<lX .^ .; J . 'Ia.LmL^' U!.' A\aj<Kxjl > v- 




^!.\ 



PERSONAL AND STATISTICAL PARTICULARS 



Dl 



<XJ 




L 



i ' \ I 1 < '1 ItlK I'll 




\' 



4^; 



h^Uo 



s 



h:.\ 



MEDICAL CERTIFICATE OF DEATH 

DA i"i-; (»!■ i»i:.\ III /~| 

uLuo 1^ 

(M..iitli» \ (Day) 



(Yt-ar) 



lA 



» rat 



/'wi ^ 



•^IM . 1. 1". M \I< 1< II D 

WIlM »\\ l-.D « Ik DI\oK* 1- D 

iW'iittiii stniril (l(sii.»natiou) 




<L 



MIR I'll I'l. \r}- 

' S 1 . 1 ' • • ' I ! 1 11 t I V 



WMl' ()|- 
lA'lIlI'.K 



I'.ik I ti I'l, All-: 
"I I \riii:K 



MA!Di: N NAM1-: 
"!• MoTIIHk 



iHkrm'KAri-; 

•H' MOTIIKK 
fstatf or Tomitry) 



6ul r ■ 



Aa>-*L cLc-vX 



I l!l{Ri;i5N' (^' i; K'l'I l-N , Tliat 1 attcii'lc! dcccMsed fnnii 

(liat I last saw li '- ■ alive on VAa^vO /^^ Kp''. 

ami that ilratli < )CHairre'l, on tlu- ilatr stat<.'<l a1>ovi', at O 
U M. Till' CAIS!': Ol" Dl'.yrH was as follows: 



/ CA^-^VA-^^-VWCV 



Crv O X<rv^AX^^c^v .- 




DC RATION l"^ }'iars Mont /is 



Days 



Hours 



(.oN'i'R n;^'^()R^■ 



or RATION )\ais 



(SIG 



I I'A ri().\ 






/'.■; 



I'll! AHDVH STA'n:D I'KKSOVAI, PA K T U" T I.A k S Ak I, Ik' J" I' • III M 
l;i;ST Ol MV KNOVnjD'. 1-. \ND liKIJllI-" 

Hufo mam N 'lAXi OOXlX'^X/ J.KwN^XAV 



NED) Vj/ivUOU^ VA. 
OIAL INFOR 



J/()////is /hns 

■ ^ 




//oi/f s 
M.D. 



LloL-a 0,1 D,o'i I \<Mn-.s) 5 0?^M)\^->af:>A, U.. 



SPEcJ'iAL Information only tor Hospitdis. insiiiu 

or Recrnt Residfnls, dnd persons dvini) .iwtiy Ironi home. 



jfions, Trdnsienh, 



Former or 
Isual Residence 

When Hds disease fonfrarted, 
If not at plare ol deatli ? 



HoH lonq at 
Plare ot Death ? 



Days 



DAi;^:o; isiKiAi. oi ki-;M()\"Ai. 
^0 T90H 



I'l^XCl-; < >!• HlklAI, MR kl-;Mi»\\l, 

INDlkTAKl-.k \J . yVD. >. A^-VW<X/>x; ^^ Lc 

\SOH MX.Aw^^<^^>v fit 




(A(l<lir<;s 



N. B. livery Item oi inVV.rm..tlon should b« cnrefully HuppHed. AGF. Hhm.ld be Htate.l HXACTLY. PHYSICIANS Khould 

state CAUSII OF DFATH in pinin terms, thnt it m:.> be properly cloHsitfied. The * Special InVormution tor per- 
sons tlyinft awny from home should be feiven in avery instance. 



I'l 




■ i 

['4 



^P^^^T 



^^m 



iir 



i| 



It n 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFrCATE FOR INSTRUCTIONS 






/hf/r riled, (JLv<X^Xi±; X'\ 



.Ol/Uc^ 



li)0\ 



Registered J\^o. 



J284 



itrw^ Xt-xM.* Deputy Health Officer 

DEPARTMENT k PUBLIC HEALTH-=City and County of San Francisco 



Certificate of IDeatb 



n 



% 



J/' von -V ^un 

PLACE OF DEATH: — County of J.CU .x' J.'X.ay^xCi^C/City ofU/ClAV O^vXXy-kXCv^ac 



' No J b 1 i Vj Cr Va^^<.cV St.; • Dist.;bet. OAXX'>v and 



LI "vv ^ , 



/ IF DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IP DETATH OCCURRrO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 



FULL NAME 




VO^^.Wr^ 



A'VCTV^^^-t 



\ 



-.i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

C<»I.nK \ -, 



"WoL 



llLv' 



! ' \ 1) I H I'.IK 111 




■ iltHl 



M.'iit'li 1 



\' .l'. 



H 



1 

' D.iv 



1 /.;//// 



1' 



/',/l. 



- : \< . 1,1- M \K k Ii: !» 

'V^'iit' in -■■i ial iKsi}.<-iiat ii Ml t 



n^ 



iMK rni'i, \ri". 

'St;itc (n I'oniitt \ 



~ \ M 1 111 
I XT II IK 






^J /VOuo^X.C-XA.'C^C 






MEDICAL CERTIFICATE OF DEATH 

iJA T]-: ( II- i)i;.\ rn r\ 

^ Month) /T (Day) (Vt-ar) 

I ni-:Ki:i',V CI-RTn-V, TImI I attcmUd .kir;isr.l fn.iii 

— i()0 t<)~~~ '- ~ I()0 

dial r last saw li "T ali\f >)ii Kp 

ami thai tKath orcuni'il, on tlu- ilali' statcil alxivr, at D 
Ll M. TIk- cat si; Ol' IH.ATil was as follows: 



r 



Hik r II I'l, xri-: 
<»i- I \ riii-.R 

--I ' : ' Mniitr\' 



Ol- M<»Tin;K 



r.ikiiii'i.Ari.; 
<H- MnrnKK 

' Stale ,,r CDUiit I \ I 



' "'«' I r.\ii< IN 



AV 



a 




DlkA'I'inN' )'tU7rs 

C(>NTR!mT()RV 



Months 



Pays 



Hours 



vJXX-vv^' 



ltxx> M uAxx^v^ 




DTK A IK >N ViiUS ^ Munl/i.i 

(SIGNE 



D ) LvUAUA; O.VD 




Llvva V\ i(,oH f A.Mrfss) UrV(r\\JUu wii^_ 



Vq^ «^.l i(;OA (Address) 

:c(1al Information "niy 



/hlVS 



Ilour^ 

M.D. 



SPEC 

or Recent Residents, nnd persons dvintj im.iy from home. 



ut! '. 

lor Hospitdls, Inslilutions, Transients, 



Siiv /"/,?;/. 



former or 
L'sucil Residence 

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



firm lonq at 
Place ol Death ? 



nays 



ii! 1, \i'.( i\]-. sr \ ri:ii i'i-kso\m, r \ k inr i. xk-^ ,\k i. i'Ki i: r^ > i ii i-; 
iii,>i"(n- Mv K N( )\\ i.i:i)C, I-: AM) in i.ii'.i- 



■ 1.' nil O /CXJL 






I'I,\(."I': Ol lUKIAi, ok Ki;Mt>\AI, 



CnX./ClX/V-.XX^W' 



Ii ATji^M! I!i I'l \i, ..I k i; M( i\"AI, 

^0 iQoS 




r N I ) 1 



: k T A K I- k U OjJ^'^r^XjL \1 / tOvx/^rsA; \^ 



c 



V ' J\j 



IN. B. i;vcr> lt,m .,f •.„f.,rmi.lion Hh,.i.l,I Ik- .;..'ct\.ll> supplJ mI. Adf. s'loul.l be Kti.le.l i;\AC TI.Y. PMYSICI 

KtJitL- CMISi: or DliATM ill pinm terms, thjit it maiy he properly cloHHirieJ. I he Spec.iil Iniormnti. 
Rons cl>in[i uwny from home shouhl be Jiiven in every inHtHnce. 



PHYSICIANS shoultl 



)n" for p«r- 






.1 < 



'^ ii 



II 



I 




^1 



f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

'-r'^>^i H&I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



N\ 






100\ 



liegi.slcied jYo, 



1285 



-v-t- 



1- 



aim Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Gcvtificatc of IDcatb 

I 11. 5. 5t^n^al•^ ; 



PLACE OF DEATH: — County 

No. 5 i .cL^^ 



V. >-V 



St.: 



Dist.;bet.OtM:^k,\.<: . . and oL'-C^n,Co\.t' 




( 



\f DEATM OCCURS AWAY FPOM USUAL R E S I D E N C E G I V E FACTS CALLED 
IF DEATH OCCUHRCD IN * HOSPITAL OR INSTITUTION GIVE ITS NAME I 



FOR UNDER "special INFORMATION" "\ 
NSTEAO OF STREET AND NUMBER. / 



FULL NAME 




,1 



CUv^a^Oj 



aXoJL 



Kj 



\ 



PERSONAL AND STATISTICAL PARTICULARS 



1 < > 1 ) 1 1 K r ) I 



OJMJ- 



11 



MEDICAL CERTIFICATE OF HEATH 

DA 11-: < •!• i>i; A rn 



M..iitli^ 



(Vi;ir) 



\' .l". 






I 



lA'V/// Ic 



Am. 



- 1 \ ' . 1 , 1 ■ M \ !< k 1 1 ■ I ) 

wiix i\vi:it <>u i);\nKii;t) 

Wiittiii soci.il (icvu'li.it ii >ii) 



' State 1)1 •.'on III I % 



\ pL-cx^v^cd 




\"\M) «.] 
I \l tl IK 



iilK 1 liri. At !■• 

<H- I \ nii-.K 

"^' ' • ('( Ml !l! I \ 



M \1I>1.\ N AMI 
"I- M(>Tni-;K 



i'.;KTinM,At J-. 

"1" MnTlli:K 
^lati' iir Cimiit 1 v 



J? ^'^ 

cx-A^^^O/V /Vex 



fMoiitli' 4 



11 

(I)av'> 



/go \ 

(Voai) 



J HlCRl'JiN' ri;k'r[l"\', rimt I attciuk'*! .kixascd from 
H'\a1o, iS. up H tn LU^ V\ i.,oH 

f last "^aw li ^-" >.' alivt on Uc/vA^ X{ T90 H 



tliat f last saw ll ^-"v.' alivt on VXvvxV 'X { 

and that ikath nccnirted, nn tlu' date stated a1)<>vo, at I ^^O 
M. The CAISI*; Ol- DI'IA'IMI was as follows: 



<^ rnjtX4t,c^>AvOvX 



o. -.v.-tL' 



'-^ 



CX>^<xl_L 




-Oj 




\ 



\J 



AvCXvx, Q !^<^<X/Li 



^\! 



!\ 



< ll ni 



^'">N ^ 



C^VA..o.xXA^Mv^ 






III RATION \ ^''''/»S 
C ( >N'i"R liU rokv J-^ 



\ 




Mouths Days. 



//ours 



1)1' R \'ri( >N )'iiirs ^ . I/. '///// V 



\^<X^JLc 'OuwwV-ts LA 



1 Signed ) 

LUxQ V; rooH (,\ddrrs<) loOS 






\ 



1 



<XMv"v\' ( j ,1 



/ lout s 

M.D. 



SPECIAL Information '»"■> '"^ Hospitals, Institulimis, Transients, 
or Re(enl Residents, and persons dyinfj away from finme. 



AV'w. 



,V,;,. /■;,; 



1/ .<//'//> - ihW. 



in; M'.ovi-. sr xri'i) i')<R-.ns \i, i'xktuti.ak^ \ki-: I'Rn: r- • tii 
i'i';s'r < II- .^l^■ km i\'. ij- in". i-, an'd r.i:Mi:i- 



(111 



f'.-mant U XA-OJLiL \3 



> ',!•,■- 



Sio 



A^^crvMX 



11L. 



former or 
Lsual Residence 

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



HoM long at 
Place of Oeatli ? 



Oavs 



•I.ACK <)]• JU KIAI, nu I;i:M"\ \I, 




e\La-Cv ^ - 



) \ 



) \ 1 i; . • ii! Ki.\r '.r K i:m» >\'AI, 






MM ; 1< T A K V. K U oJuL -»Aix ^J l\OJXA^>VU H V<i 



^Vfl-li- - 



5 X\ d,"WtJ<U>-. O^ 



. B.— r.v. .,. U.n, o.- 1„for.n..tion shoul.l he C'^--^uny supplied. ACF. sho-.M »- «t"ted RX 4CTLY PMYSICIANS should 
Htatc CAIJSI. or DEATH in pinin termn. thnt it mt.y ho properly cl«HHit.ed. The Spcc.nt I.normat.on W.r p-r- 



ROTi« dyinil iiway from home should he feiven in every inslnnce. 






i" 







ii 



[1 1 '■ 



;' ii 






'!'*• 

n 









if I «! 

It ^ 

• I til 



ii!" 



11 



^i 



1,1 



P 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!!,,;, ;.l ..f Il.;ihl'. I ^■' 



^J» "^ly. 



I'..«v ]• (■ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'X.^^^ Ijla.-^ Deputy Health Offlcer 






1S86 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeath 

DEATH: County ofC'a>^. /vCL-rL<i\.<ic^ City of CO^^vu OX'O^-^-cOul'C^ 



PLACE OF 



!sfe. LctuV Wu. 



^ 




Do^^ 



.OlI- St.; 



Dist.; bet. 



-and- 



/ T DE.TM OCCURS/lAWAV FROmIUSUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \ 
C Tf DEATH OCC?iRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

^ (Ik 

FULL NAME OiAiJLOj VKXKfYy\JM.V\: 




- .-^ 



PERSONAL AND STATISTICAL PARTICULARS 



1, 



1 I'.iKin 




KaXi 



/^bO 



M. •■A): 



I);(V 



4H 



];,!> 



n.n. 



^IV<". l.I- MAkKll.D 
\VIl)n\Vi;i» OK I>IV< tKri.!) 
'\\rit« ill social drsij^uatiDti) 



IUKTHIM.AlM", 

Ntatf or i."<)iiiit I \ 



N WW ni 

1 A in i:k 



HIK rniM.ACK 
'>! lAfUKR 

'"-il.ili lit (■•iinitr\' 



M M 1)1:N" NAM)-: 
"I MOTJIIIK 



inRrni'i.ACi-: 

"I- MOTIIKK 
Mat( or C'omiti \ * 



J^yy-^^/OAJL 







vtl 



■\KJJ\J 




n 



1, 



(l 



Wy\ 





7 



CO- 



MEDICAL CERTIFICATE OF DEATH 

DA ri-; Ol- DI'ATH /H 

^Monlli) [T <I)av^ (Year) 

I in:ix I'.r.N' C1;RT11'V, Thai l attendcil ilfccased from 

LLo\.a 'X iqoH to vXludl "^^ it)oH 

no >Y^ 

tliMt 1 I.i^t '^aw ll-Uvvv alive on '^/^AaXV ^^ up ; 

,iii<l tli;i( (IlmIIi occurred, on the ilate stated rdxtve. at v5- lO 
M. The CAI'Slv Ol" DIlATIl was as follows: 



1)1 RATION 



}'c(ir 



.}/o/////s 



Days / lours 

I) 1 I'i \ T I < ) N ) '('(^-s Months Pays 



SIGI 



Hours 
M.D. 



< 'vATl'A Tit 



3J O'^w^uiaX' 







M..n!ll^ 



Ihn 



Tin-. \H()VH STATJ-.n IMvK-^ONAI. 1' AKTItM" I,A K^ A I< l". TK I' H lO Till-: 
Hi;ST Ol' MY K\< i\\ I.l.lx'.K AND iu;i,li:i" 



f Inforni.-mt 



h 



^ , .. 1- 1 ATF .ihoiilil he stated HXACTLY. PHYSICIANS hHouIcI 

N. B.— r.very item of Info.m.f.on nhouh. be cnretully -ppl.e 1. ^ ;f;;^^X^^^^^^^^^^^ ^he -Special Information" for pT- 
state CAUSE OF DEATH in plain terms, that it may he pr<M>erly classitica. 
son* dyint away from home Hhoiilcl be ftiven in every instance. 



'■ \.Mi>- 




k\ I()0* \ ( \d 



SPECIAL INFORMATI 

or Recent Residents, dnd persons dyinij .md> Iro-n home 



ON f'"ly '"f H^spitdls, Institutions, Transients, 



Former or 
Usual Residence 

Wfien was disease contracted, 
it not at place of deatfi ? 



Hl^M V<XA^^rwvCU Place of Death ? Os^ .... 



Days 



!■! \C}- Ol- lUKIXI. «'K Kl'MoV.Xi, DATl-.:- I'.-io.Ai. <., k l! M( )\-.\ I, 
(A(Mr.« I I ^1 NiTlvQ^V^nN Ul- 



^^ 



i' 



I 




( ' 



..'« 



i^ 



«^^l^ 




I 



h) 






I 



^ 'I 



!f 



<i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



• II. I'.iii 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



]lpgi,stci'C(l Xo, 



1287 



Lv^ L^, Deputy Health OfTlccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( 11. S. jritnn^avO ) 



J? (to ^ m 

PLACE OF DEATH: — County ofO'CUvx^ J>^xx/TvcUl<:' Gty of vJa/7\; JAxXy^vcv-^L-c,!^ 



t^.LcLV 



i^ 



.C^u^o-' 




'T>X^LftV.^^«.St.; - 



and 



^^^^ - ^v-ww . w^^ w^^,. T Dist.; bet. 

/( / IF Dr*TH OCC»J*S AVWAY FROM USUAL R E S I D E N C E C . V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATION \ 

(j ( IF DEATH OcBJrR^ IN • HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 







8 



0. Vibxc^k 




,. , ,K\ 



<XAX 

' M..iilh' 



^^<. 



1 



11 



) . 



-^IN*.!,!' MAKUIl'.l) 

Wllx iw 1 ( I . ii.' I .(\-» (Kt' i;i) 

i Wi ii ii'iiiitiuTi) 



151k TMIM, \r» 

' Sl.it I I it I "i 111 111 I \ 




-CLWUL-cL 




\ \M !• nl 
I ATlll-.K 



Mik run, \> !•; 

•M I Allll.k 

St:itt 1)1 r<iiint I \ * 



M \ 1I>I.\ N \M 1 
"I Molili: K 



Mik rni'LAci-; 

«>l- MdTIIIsk 
(St.itc nr (."ouiiti y) 










^^Oo 



MEDICAL CERTIFICATE OF DEATH 

(Mdiith) n '!):iv) 

I IIi;Ki;r.N' t I.U'ril'N', 'riiat I attcmKil lU-ccMsid frniii 

lli;it I last >a\v h '- - ' alive <«ii \A.A^^^CL ' ^' 

and tlial (U itli nccii rrdl, mi llu- <lati- sfati-d al«»Vf. at *. 
'.) M. '|"lu' CArSI'! ()!■■ I)i:.\ril was as follnw-;: 



(YcMi) 



I()0 

up \ 



U C,t. 






(tPo 



/Iv, 



h 



' "■■. I r \'i'i( ).\ 






DI kATK >N 

^ ON rUlIUTOKV 

1)1 KAI'K >N 



)V(//s- M,<ii//is \^ /Kns //ours- 



)V, 



W /o 



J /,>>//// 



fhn 



'S 



(SIGNED) UJ.C9. L(r> vLo_/vv 



I lorn \ 
M.D. 



/v>v<l.n.^ vc-^'.. 



Special information »nly tor llosiiildK, institutions, Ifdnsienh, 
or Kcienl Rcsldrnts, and persons dyimj .rn.iv Jrom homr. 



\XkfY\\J^' 



Haw loni) dt 
PLire ol Dcilh ? 



Days 



M.>iillt^ 



I III Mtovp. STXri*,!) I'KKSONAI. l'\U rUTI, Xk"- Xkl'TKII- T" » IIM': 

iii.s r « )|- \iv K \i »\\i.ii)c,K AM) iu:i,ii"i 



'Inf.,Mn:n„ JAXX'-^k U^ - Q /cJkyV^A^Ct'X "O.C^ 






/VvA^-^-'<v^ ^aJL 



Whrn was dlsfasf ronlrarlfd, 
It not at pl.i(P ol dcilfi ? 



iMA(i:ni Kiuivi.MK k»;mi.\\i. dmi -t 111 I'lAi ..I ki;M<'\Ai, 



:* 



CL^v^o "^i 






IQOH 



I Nl 



\iMt'>^- 



T.. ,. ., A(;i. sho.,l.l he sti.te.l i;XACTI.Y. PHYSICIANS hIiouM 

N. 1$. Hvery item of InV'ormntion •li..ul.l l>c cJ.rcHilly H.ippl.cU. a ^ ,. .^^j.^.,, The ••.Spccliil Irii'orm.it i-.n" (for p.r- 

Ktntc CAIISI: OP niiATM in plnin tcrmn. thnt it m;.> he „ropcrl> cIhhh.^.c.i. 



son. dylim uwfiy from home nhouhl he aivcn in every instnnce. 



i 




I 






> .T 



1 1 



f I 



It 



% 



¥. 



I 



!l 



!i lif 



11': 
t 1 


'.; ' 


II. 



I!' 

: .1 



Pff 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



It,.;.!<l ..t llc.lth I' N' 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



BcilLslcrcd J\^o. 



1288 



Dale Filcil, CL^^ClvA^t. 3)0 V.)0\ 

W^ 

cWa^v,^^ doL^vvM Deputy Health Officer 

DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



Ccvtittcate of 2)catb 

( "Q. 5. i?tanDavC> ) 



e 



PLACE OF DEATH; — Cuuri t y rA 



Ci t y of Lvv-vvc^r-^^-rA- 




/-a. 



LUxvc 



No. 



— St.; 



Dist.; bet. 



and 



/ ,F Dr*TH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLFD TOR UNDER ■SPECIAL INFORMATION" \ 
( Tr DEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER, } 



) 



FULL NAME 




/ru 











4l 



PERSONAL AND STATISTICAL PARTICULARS 

•1 \ f\ V I i|,i )K \ 




\ i r I >i r.iK ru 



i 1 ^ 



4 



MEDICAL CERTIFICATE OF DEATH 

I) K Ti-; til 1 1 1, \ 111 

(I)av) 



ll 



I go \ 

(Year) 



rl^S 



M.^tith' 



nl 



1/ 



SINi'.M-: MARKn:i) 

iWiiU ill '^Diial lU ■«ir iiatiitn' 




}j\r^:f\^''^U^'^ 



lUR TIII'I, \(-j.: 

(Statf nt t'.iiiiitl 



NAM]- or 

I- \tiii;r 



I'.nrrii i-i. \« )■; 

"! I All 11-. R 

'■ St, it I (>r i"i 111 lit ! 



0-^ 





M \il)i:N N \M 1' 1\ 
<•! MoTni-.R 



HIR rniM.AC'H 
<>I" MOTIII'.R 
(Slate or C'oiiiitrvi 



OCCn'ATlON 

hf-idr^i III Sdn /'iiiih."' 



<X > -cV. 



>'\X>VAyY>Jl 



(W^ 



(\t.mth) a" 
1 lli;iv l.l'.N' I. i; R ri l"\', '\'h.\{ I altciuliNl {Icc-cased from 



tli;it I l;i-t -;i\v h 



lip to 

- alivf oil — 



■Up 



;iii(l that iliMtli oci'iirrcil, on \hv tlalv staU'd ahovc, at 
M. 'I'lu- CAI SI'. Ol" DI'.A'ril was as follows 



(•( )NTKir,r'r()kV 



Miniths 



Pay 



1 lou) < 



1)1 "RATION 
' SIG 



)'ray. 



.}rn>ii/is 



NED ) ILlcJ.bA. yj.cJ. 









//i>tii \ 
M.D. 



\\.kJ 




ccwcL 



)V,; 



M.'flUl- 



/)„•! 



I'Ml'-, AHOVK STATl'.n I'HRSONAl. !' \ K lUM' I,A RS A K 1' T K I )•: T' » r"!", 
l'.i:sr Ol- MY KNn\Vl,i:i)C.K AM) IU'I.Ii:i' 

(Iiif..:niant \j / VOUXA^ ^ WuCT^^O-^M 



^N.Mn.s lU V'^^-'^<^ '^ 



L INFOR 

ents, and pers( 

Former or ^ ^ ""^ '"'"' ''^ 



>EXIAL IN 



cc 



gpc^l^L Information ""'^ ''"^ llospit,ils, Institulions, Irdnsienls, 
or Recent Residents, and persons dvin;) <m^) troiu home. 



Former or A ^4 " ^ 

UsudI Residence 0<X,'^yv ^ hJX^x^txA.^.^ pidre ol Dcdth ? 



Days 



When was disease confr.icfed, 
If not at place of death ? 



PI \ci- oi- iMKiM. OR ki:mo\ \i. i)\n;..; i:. ki.ai. -.i ri-movai. 







,^Joc>v 



^ ,. . VHP. Hhoulcl be stJite.l liX ACTLY. PHYSICIANS should 

N. B.— F.very Item o? i„V..r,n»ti.>n -houlcl b. cnreVuHy -'PP'-'' . '^^ ' .^^ "UshMccI. The -Special InVoi-mation" t'or p-r- 
Htntc CAlJSr or DI-ATH in pinin terms, that .t m:.y be properly clas«.nc<i. 
Ron, flyinft iiwny from home shoiihl be ftiven in every mstance. 



i 






' I 







v't 



J|w»^ 




SI • • 

■I, 

' ■ . 



■ 

IS 



n 



I! 



II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



}'.., ,1.1 ..f III :iMh I- No I"; '^'^..yi'J-^' 1'^^'' •■ " 



!■• 






ck-^^-VVA.. 



1 



790\ 

Deputy Health Officer 



BegLslerod JVo. 



1289 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( la. S. i5tnn^avC> j 

SI % -^ % 



PLACE OF DEATH: — County ofOcu-rx; J .VCV>-vXM^c< City ofC3<<XA^ 0,/v<X/wci^co 



No« 




OAXX' v3 JXXV 



It)^ 




)CHL. 



\xkX 



av St.; 



Dist.; bet.- 



and 



/ ir orATH OCCURS AW*v 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. / 



P 

FULL NAME U^QA^^^ 




m:\ 



i> \ I i- t >i i;iR Til 



\' . I'. 



PERSONAL AND STATISTICAL PARTICULARS 






^r>\. 









1^ 



M..t<th 



) . ,,w 



1 



\ 



1 > 



\ ( :ii 



iKt 



MEDICAL CERTIFICATE OF DEATH 

DA Tl-: ()!■ iniATII 

' ' ,va 0.1 




fM(.iith) 



(nay> 



rgo 

(Yf.-u) 



-^INT.I.I-;. MAKKli;!) 

uii)<»\\i;i) OK iii\(if^ri:i> 

i\\"ritfin >-<)ci:il il<<i'./nal i' "t 



MlKIMl'I.AOl*. 
'State <ir Count I v 



\ \M1' ( >} 
1- AI'll l.K 



Hiu riii'i.ArK 
oi- I A I'm: R 

'-^' '! . < .T I'oiiiitrv' 



MAIDl'N N\M1-; 
OI- .MDI'IIKK 



HIR I'lII'l, Ml-; 
oi- MnTill R 

(Staff or Couiiti v: 




Cs'iX' 



I m':RI':BV CI-IvTII-V, 'J'hat I attendcil (Iccoast'tl from 
W-ob 15 I<)o:^ to . LLvA^ M looH 



that I last s:i\v h L. . . • alive on 



■'1 



rc>o 
190 



and that dfatli occurred, on tlie date stated aliovt-, at 
V M. The CAl'Sl': ()1- Dl'lA'I^II uas as follow^ 



vT .VO-^'tocLco't^n'v%.4 ^M. \Xk. 



^coe^-v^xvc^- 



) 'ears 



Mouths 



Days ' I loii) s 



\Xrs\A 



^U^rL/CrVAr>v 




O'ATl' AI'ION 



Rrsidr,! Ill S,i>i /■';„';.',/./.» 5 ^ ' M.nilh- 



Dl k.XTION 

cuNTRir.r'i'oRv M\xKk.^A^t\^ ^«^ L 

Dl'RATION Yiars \^ AfiOtths W Pays 

(Signed^ w oJLWvv VjajuX^t^ 
LLv,q ?.o ic.o'> f.\ddr.ss) H5H Tlxa^M -^1 



f lours 

M.D. 



O'lAL INFORI 



Ifbns, 



/',.■ 



Onf.ii Mi.'int 



llli; \l!t)\-l', ST Vl'l' It ri'lRsoN \1, I'AR iliTI.ARs A R l'. TRfl-; To TH V. 

i'.i:s 1" ()!■ M\- KNOW IJ-, 1)1 '.1-; .\Ni> iii:i,ii'f' 



SPEO'IAL Information *»nly for Hospitdls, Insfilulfons, Iransienls, 
or Recent Residents, diid persons dyinq dw,iy from liome. 

Former or 's^^.'inf' . A\ "o^ '""<» «'' , q 

Usual Residence <J^aX i lOwM-V^v^ JX pi,ire of Deafti? I Days 

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



lL 



vCl 



I'I<\CH Ol" IMRIAI, OR RI:M''\\I, 



jiATi:-)! iuki.xi. ui ri:mo\.\i. 



.-s 



T90 



-Aw/vy>x ^<- \^ 






N. K._Hvcry item .i informntJon «houM b. cn.efuHy supplied. AGF. nhonlcl be stnted KX 4.CTLY PMYSIGIANS nhould 
state CAUSE OP DIZATH in plain terms, that it may be properly doHsificd. The Spec.ol In^ormat.on ^or p.r- 
Rons dyinil away from home should be feiven in every instance. 




>u,. 







ir~ii' 

I •! 



h 



III 



I 






li 



\f 



11 



> '1 






t. 



i'l- 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f 11. j.th I- Vo !^ •*•*■ TfJ" tiM' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



pff/c Fi/cd. vX^ 



i^crw^ "X^ohM Deputy Health OfTicer 



IlrgLslci'cd J\^o, 



1290 



DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

i IK? J W 



' 



PLACE OF DEATH: — County of Ool^x- C);vO^-vC^^City of ^^^.-^^ A.cu>^.<i.^ ao 
No liHC ll.UL>v^l St.; 7 Dist.;bet. 0JLlJ-C^t and H'vA^^'r-v. 

/ ,c nFATH OCCURS Aw*v rBOM USUAL RESIDENCE GIVE facts called for under "special information- \ 

( .F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER^ ) 

FULL NAME w>A-OL C^ . a WrX-iA; ^ Xvt\A.vcU 



) 





•i.\ 



!» \ ! i 1 '1- r.ik rii 



A<.K 



PERSONAL AND STATISTICAL PARTICULARS 




a 




y 




M..nth> k 



) , .1 



'I):iv» 



.\f.Klh- 



■f I 



\ 



/lit Vs 



(Yf.ir) 



^1\'.I,J". M\KKIi;i). 
WIlMiWl-:!) <»K I)I\'< )R^ J'l) 

\\] !!• ! •! -' u-i.-ll ill sj^rlKlti' 'II ) 



lUR rniM, \CH 

Sliitt, or Couiiti %■ ' 



1 \II! i:i< 



liikTiU'i, \«H 
'" ' \ 'in-.K 

^■' mull V 



M N llii:\ N \\1 1 
<>1- .\U illl i-;k 



i;iK iiii'i, \( 1-; 

*St;it< ^ A r. iiinti yl 







MEDICAL CERTIFICATE OF DEATH 

DATi-: oi' i)i;.\in r\ 

(Month* (] (Day) 

1 II i;k !•: l'.\' C'l; KTII-\', 'riiat r attcii<]r«l (Ucoasrtl from 
(JuAX^ 3a U,oM to CUa^O. Xa K^O^i 

tliat I last saw h '•• • alivr on T90 

anil that di-atli occurred, on tlic <la!r staled al>ovc, at 

M. The CATSIv Ol' Dl! ATM was :i>^ follows:' 



DT RATION )'ruis 

CON'l'KIlUroKV 




Mouths '^^ Pays 



\ : '^ 



Hours 



(A^va/v^^v'. ; 



^ (YVAyO. 



I ) ri-J A T 1 N 




5 V-i7 ; 



M..,i!/i- 



/' 



< it'cri'A iioN 

1 in: VIloVI-. ST \rj:i) I'KRSON \1, I'XKTiCri.ARs AK1-; TKri-; to Illl', 
IU%ST Ol- MS KNOWMUX'.H AND WVAAVA' 



(Infotnir.nt ^- MftTrVVU VJ. X^ AaI i^ 
(A<l.lii-^s M H 




A 



(SIG 

a 



L 



..o, |.^J.QfK 



}',\irs ^ Mouths /hi] 



I Iou)S 



M.D. 



:)v^1tc)oH (Addrr^s) l?i\ 



:CmL INFOR 



^ maJut ^ 



i 



SPECIIaL Information «"'> ^^'^ Hnspitdls, institutions, 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 long at 
Place of Death ? 



Days 



I'1,AC1<: 01 lilKI \I< (»K Kl'.Mi iN M, 



DAI'i;"! ilrui.vi, or Kl". M<»\\I, 

^v-v/Oi ^^"^ T90H 



p 

A.M.-S a^ \) <^^>V 0\J^ Clx'-^. 



I N 111 



"" . ,. , .,., „,,,.. ,1,1 he Ktjited EXACTLY. PHYSICIANS Hhould 

N. B.—Kvery item .W inf.rmutlon «houhl be c.rcVulIy -PP'- • .'^ /, ;H;';,'^LHWied The -Spe.i... Int'ornu.f.cn" for p.r- 
state CAUSI OF DIATH hi plnin terms, thnt it ms»y be properly clUHK.nca. 
son« dy1n4 away from home Hhoiihl be ftiven hi every instnnce. 






\ 




'I . 



"•^P^IT 



'ri'i 



if' 



•t i 



• I 



;i 




I (, 







i;, ,..1 ,,r ir-.nh i' V' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



*JS'"^5wii> IKS: r Cm 



/hf/i' /•V/r^/.LLoc<XA.A^<Lfc So 



t 



^A^^ON^ 






r^^y^. Deputy Health Officer 



livi^isfrred J\''(), 



1 291 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

I 11. 'Z\ •?ta^^al•^ j 

J? cap \ ^ 

PLACE OF DEATH: — County ofOxX/^- l^vay^o^ccGty ofO/C^^' JAXV^^tLv-^c c 
^ki.(bc^^AXeW<xtK*.<^-6<X'^O.t>^^A.(St.r>v Dist.;bet. - - and - - 



FULL NAME 



(X-aoJo-Ltk vj. uAxt ^\.v.c^'Ct)cl' 



\ 



PERSONAL AND STATISTICAL PARTICULARS 



I (-t 



X 



\ 11 « i| liiK 111 



>-> 






1 

l':i\ 



/ L- 



\' . 1-: 



\o'h . 



■>i\' .l,l". M AK Iv I l.l,> 

\vii)i iwi: i> ni< i):\t )i.'» ID 

W'litf ill so(i:il i|i -«ii.' ii.it 1' "II ) 



luururi.AvM-: 

I St;itf or <."">iinti V 



•■. \ Ml . .; 

1- \ 1 1! ri< 




[q .y ■'-'^^ 



j^6<^^y'\A>-^<^ 



"»'i,ir 



/■',/i 



UlRIHI'I.ArK 

oi- i-Arni'.K 

• Slate iir iNiiinl I 



M \Iltl-:\ N AMI 
"! MiiTm'.K 



liiu riii'i.Aci-: 

iStat' ' uiiti\'> 







IVAEDICAL CERTIFICATE OF DEATH 

D \!1-: ()!• IH'.A III 

il>av) 



(Vi-ar) 



I Month) k 
1 III':Ui;r.V CI-.KTII'N'. That r attcn.kMl (UHX-ascd In. in 

CXc^-o 1 X 190 'V tn L\aax^ XH up H 

lliat I last saw h -f-' ^- alive on ^'^A.\-a X'l 

an«l that (iiatll orcurrcd. <>ii tlic date stated a1)<)V0, at ^ 



T90 t 



/'> 



M. T!k' CArSI'l (»1' Di^XTH was as follows 




CONTRIIU'TOUN 

cL/%v<C v,^ . . 



DIRATloN -^ )V./o Months Jl^^'^ 



/^</r.v 



Hours 

Hours 
M.D. 




4 



<Xa"»^'>''vO^>^' 



.^ 



IL 



< >•■( I r \i H )N 



GUi 




Kr-:,lrd in Situ I'l >i ", ' 



) ■.-.; ; ^ 



.L\AX. 



1 A. /////■ 



tu 



/),M. 



riii: \iu)VK sT\ri:i) rKt-t^^oxAi, i-ak tuti.aks aki' TKr;-: rn riii'. 

i'.i;ST OI- MV KNOW l,i:i)C.K AND HI'.l.Il-.l' 



V^OA^JWVS.^! 







i)rK.\'ri<>N )V(//'.v "^ .v,"////s 

(Signed) . mo->%x^ LI) . Uj CL^-d^ 

Q.^v.Q Isfl ic>o\ .A.ldresObOb O^^tUv Q-J 

SPECIAL Information ""'> ^"'^ llosiiildls, Institiitions, Irdnsk-nts, 
or Rcrent Rfvidenfs, and persons dying .may troii home. 



Former or innh 

Usual Residence lOO v 

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



'Jjm 



c 



— V I Hou Innq at . ^ 

;\X^ 'M; Place ol Death ? ' '^ ..Days 



n \cF OK nnuAi. OK ki:mo\ai, dai-l..!' \UHi\L nr ri;movai. 



"' ' V .1 ACr should be stntecl F.XACTI.Y. PHYSICIANS should 

N. B. F.very Item of informsitlon should be ciire^ully suppneu. • .... ^j^ •'Special Informiition" for p*r- 

«t«te CAlISr or DHATH in pinin terms, th„t it may be properly cla«9.t.cd. 
sons dyinft owoy ?rom home should be given in every instfince. 



. *! 



t 'W -'^ 



1 ^ 



'^^ 



>7 n. "O- 



•J'- jW'VrV'A 



it 



•d' 



i 

ill 



1 i 



]•■■■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

1 29i> 



»• \n - ^-^^^X'; MS:!' Co 







l!Jf)\ 



Jfpo^fste/'ed J^^'o, 



Xvv^^ Ijl^-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



"U. ^\ 5tnn^aiC> 






% 



PLACE OF DEATH: — County 



ofClCL^v o;va>veu5.c<5 City of 0/CLA^O .^LXX/^vc^A.C( 



No. 



t.; 5" Dist.;bet %XMj 



la'i'i MKt<L<LtC. St.; 5" Dist.;bet. ^ .LK^ ^^"^ „ . x 

1 PV vw- w X w^ «- ,,ci.«I DTQinrNCE: riVE FACTS CALLED FOR UNDER S P E C I A L I N FO R M AT I O N ' A 

( '^ .VorAT°H^OC:u%rD\;"rHO^s'rAt rR'f:?T',?J;^0^.'^0.;ETTl name ..stead of STREET A.O .U.BER. ) 



^ 



^tk; 



FULL NAME 



,\jlL^ou Ok)ojo\,<. 




t >^ 



PERSONAL AND STATISTICAL PARTICULARS 



:i 



' riKiii 



LAwA.^ 






3>1 






.1 /,.//;// 



/ VJ ^. 



IS 



A iI)n\VI-:i» OK I>t\oK ' !> 



lUK rin'i.AOH 

t '^tiitr or <."<miitr> 



1 \ I ii 1 k 



r.iRTMpi.Ai'i-: 

"!■ lATMKK 
■^t ii. 1)1 c'oiititrv 



"! XIDHN XAM1-; 
li MoTill-.K 



lUk 1 II l'I,A»}-: 



' I'xrioN 



AV 







,co^ 





0, 



,OAVv>vaL^ > - 




' .\LyLCL > -^ 




MEDICAL CERTIFICATE OF DEATH 

1> \ TK <)!•• I)i: \'l II 



iMoiitli^ I 



x [ 



I()0 



I lIlvRIU'V e" !• RTI l'\". Thill I atU-n.U'd "U-crM^c-d fmni 

lllMt I l.i-l saw li :- all\vn!i V^AA,V,Cy Kp - 

ai)4 that -Icatli «.ri-urre.l, nii thr «la1r ^tati-il ahovo, at 
\J M. The CAISI-: ()!• I»i:A Til Nva^ a^ follows: 



1)1 RATION \ )V<rri.v ^ Months^^ 



/:>(/!.? 



Hours 



DIRATIDN >V</r.? Months Pays //ours 

(SIGNED) VJ.VJ. VjTlr , M.D. 

Q LvQ ^>C. i.,rM (A.l.lns^> HOI \)€L-wNrU4.^Al ;.. 

CIAL INFORMATION «nly lor Hospitnls, Invlilufions, [ransients, 



o , -cL 



^,;/' / ; 



,„ v\ 



1/ - 



/>. 



Tin: Miovi-: STA ri:i) i-kk^onai. i-xk in i'. \k-- \k)-: tk' }• t<> rin-. 
Hi-:s r oi- Mv kn<)\vm:i)<".k am> r.ii.n.i- 



' In fii; iiirnif 



\% 



OwAA-^c/v^^ctv^rvv 



( V.l.lrcss 



a"^^ \i^\^^^^^^.^'^ 3^ 



^- 



SPEw."- ..,. _ - 

or Recent Residents, dnd persons dvinq a^as \um Itome. 



Former or 
LsudI Residence 

When Hds disease conlrdcted, 
II not dt pidieol dedtti? 



lloM lonq dt 
PIdce of Dfdtti ? 



Odvs 



IQO*^ 



I'LACi: i>) IMKIAl. OK RKM-'VAI. DMU'.; P.- ..•;ai. oi Kl'MoVXI. 



rx'Mi'- 



vTVVa.XIA.V'Cj^v ut 



N. B. 



" TT TT XGE Hhould be Htnted KXACTLY. PHYSICIANS nhould 

-Hvery item of information nhould be cnreHilly suppnc i. ^laHsified. The ''Speciol Informntion" ?or p«r- 

Htate CAUSE OF DEATH in plain terms, that it may be properly claBM^.eU. 

«ons dyinft away ?rom home should be ftiven in every instance. 



'■f 



i 







^^^^mt:xm:Mim9tt 



If 



!| 



n 



IW 



It 



§ 




js^j ^A<fM7 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

f 

ilI.Mltli I Nm I- ^-'T^'^^i luSclTo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((((' Filed , ULvaXXa^^-AX) 2)0 



lUO'K 



Eegisici'ed JS^o, 



i 2a3 



-p 



cMrouUi 



Deputy Health Officer 



DEPARTMENT (IF PUBLIC HEALTH^City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County of 



n. 



CX.^^'^Aj 



Ci t y o M ' 




(1 



, vO<^\JS 



No. 



St,; 



Dist.; bet. 



and- 



/ ir DEATH OCCURS AWAV TROM 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 



PERSONAL AND STATISTICAL PARTICULARS 

I' \ I 1. <>1 liiK III ip. 




\xA^ 




'X, 



MEDICAL CERTIFICATE OF DEATH 

DA ri; or i>i; \ in 






?>0 

(I);ivl 



r\^'\ 



'Vt;irl 



\' . !•; 



r^s 



s 



--I '.1 . 1 1 M \ K iv iri> 

W lilt (Ulvl) «»K I»i\t (Ki'l-:!) 

iW:iti ill '■Mi-iril il<viiMi:it )■ 'H ) 



I 



r.ik riiri, \r i-; 
si;it( ur <,'oiiiiir\- 



\ \M1 ( >i 
I A 11 1 1 R 



lUK riiri.An-: 
<>!• i-\rm:R 

^t.lt c I ll *'( .11 tit 1 \' ' 



>t\liu:x NAM)-. 

'•1 M()rni-;K 



lUK !"in'i,.\(i-; 

"»l MnrnivR 
I Slat-- Ml- roiiiUi \- 





< »<'ri I'AI'IDN 



r 




• Day) 



fVcar) 



iM(iiit)i) 
I Ili:m;r.\' Ci;U'ril"\'. TIimI I attLMuUwl .Icicasi'd fnim 

" lip tn ~~~ up 

tli;il I lasl ^aw h -: alive on ' I9O 

a-id lliat dcatli ocru ired, 011 llio dad- stated above, at ' 

" "-. M. 'i'lu- CAlSIv Ol" Dl'.xril was as follows: 

\JVo.aXa.-0-^>-<:^ Lv/C^Ov/djtTvt 



I)IR.\'I'I()N )\-ars 

CON'i'RIIU'l'oKV 



Mouths 



Days 



J/ou) s 



DrR.XTION )'rdrs 

,NED) VOX 



SIGI 






.trvAJL^/ 



Mout/is 



/hiys 



11 ou 



/T 



M.D. 



LtCCCL W r<,oH f Addtv^oCJAmj 



,.€L K\ uy 
:CIAL IN 



<\JUj V.(X.Kj 



SPEC^IAL information "nly ^f"^ llflspitiils, liKtitiitions, Trdnsienfs, 
or Rfrcnt Residents, <jnd^ persons dvinq .may from home. 

y A-i HoH long dt 

.Uj\^v'VvA i» pi^reof Death? .. Da>s 




) ,,M 



1 ', ., 



/>,n 



rni-: Aiiovi- sr xri; i> im--k^<»\ \i, r\K run. \ks .\ki-; tri }■: r< » im-: 

Hi;sr <)1- MV KNi »\\l, !.!)'. I", .\M> H). I.M.I- 



' liifii-mant 






I \(!<lic'.^ 




Former or H/NL 
I'sudI Residence ^^^ 

When was disease ( ontrac ted, 
If not at plat e of death ? 



IQOS 



J.- ()|.- iM^R I \I, (iK k i;M< i\.\I. I DATl-.iii I!i Ki.M. I'l Ri:Mt»\\I, 







N. »._j;very Item of i.W.n.„i.t!on should I.- cnroful.y supptle,l. AGfi shouh. '- ''*"*^;!,^'^:^'^'0'; , 'J"^'' r' n" w'o;;!^' 
Ht»t/CAUSI: or DLATH in pinin terms, thnt it m;.y ho properly classified. The Spec.ol Intormnt.on for per- 
sons dyinft away from home shouhl be feiven in every inHtnnce. 



t ■ ( 



^!^m 



^rv- 



' .< 






I * 



IM 

f. >; ,; 



m 



I <>!< 



f 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,l,,fH:.;th I V .^^^''i^- Ii.^1 ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



-T-'^ 



/)/f/(' Fi/rd , \Aju^^<xa^\^<^ 'iO 



jom 



lir^isfcred J\^(). 



1294 



d^,<rA..c\^ dULowA Deputy Health Officer 

DEPARTMENT (JF PUBLIC HEALTH=City and County of San Francisco 

Ccitificatc of H)eatb 

PLACE OF DEATH: — County ofCW-rv h.<Xo-LOv^<:'. City ofCVCCOrv 0>UX/>\/C^^<^o 



i'v) 



CXu^"^V.CrtC >vL 



■^\f, 



and 



No, VX^U ^^ V.Cr tC > VU^ J ^ (H^^Ax.ta,l St.; Dist.; bet. 

W ir DfATH 0CCURS4W*Y TROM lU S U A L R E S I D E N C E G . V t facts called rOR UNDER "SPECAL .NrORMATlON" \ 
] ( T DEATH OCCuJRiD ^H A HOSP-TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



-) 



FULL NAME^<^^v\.d (lbiy>\AA^^ 0^- 



\9 









PERSONAL AND STATISTICAL PARTICULARS 



."^ 



(' il I >R 



v)iWu 




k !li 



» 1 ;i! 



\(.K 



. : i " '\\ l-.l» (»K I)i\ « ihU i;i» 
Aiitrin sfn.-ial (h-si^'tuition) 



'I I 'flint IN 



FATID.K 



v."//// 




OJ\K^^J^<^^ 



iiiK'iii i'i,.\K 1-; 
<»!•■ I .\rni-:R 

' "^t'llt nr C'nilllt I \ 



M AiiK-N N \M 1 
<>I" MoTin-.K 



ink iiiiM.Ai I-: 

<»l Ml (Til J. K 
( State iir rouiit i \ 



; ■ \ I H ) X 



I.-, 




MEDICAL CERTIFICATE OF DEATH 



DA IK »>i- i»i:atii r\ 

Liu. 



MmuHi) \ 



(Dav) 



(Yf.Tr) 



I lllI<i:iiV CI-RTII'V,' That I attcii.K-.l .Icccascd Imiu 
-| \'h^.V ' •• n I "^0 CL O^x 

\Xj<J^<\ ^"^ I90H to ALCV-Q_. Xt- I()OH 

tliat T last saw li alive oit LL\.A^ Ovt KpH 

and that .Icath (KMurrc'l. on tlif <latf statt<l ahnvf, at I -60 
LL M. The CAISI'; Ol- hllATH was ;m follow^: 



nr RAT ION 



) 't'ars 



I )r k A T in N ) ■""'^" ^foul/l: 

,NED ) ^ ■ ^^ i^<X>\k> 



Mioillis Pays 

Ou- 



WJ£/wV\.^^ 



Hours 

at 



Pa vs 



f SIG 

a 



PECIAL Information only for Hospitdls. institutions, Tra 



I Ion IS 

M.D. 



/; S./;,i / 



r,,M 



1 /,.).,'// 



/! 



I' III-. \!«(»V1-: SlATl-I) I'KKsONAI, I' \ Rl" K' I" I , A K -- AKl". r K T } -: r« > IHl. 
I'.I'.sT (»| MV KNi »\\ I.l'.IX". I-: AND lJKLIi:i- 



' 111 f<. una 111 



h 






- \jXccfc<^ 



f \<l(lrfvs 



CMiiAJLA.<XX 



_ for Hospitdls, Institutions, Transients, 

or^RerfntlRr's'idpnts'Vnd persons dying awdy from home. 

IsudI Residence^' <^ vn/MAAAAAjl|AJtcOrp|d(e of Death ?C^'^>^'i'*vM)dys 



SPE 



no persons oyiny awdy nu:ii iiuinr. 
Uk/xkuAAjl|AJtcOt"Pldre of Death ?CuA) \h\ 



\ 

I 





When was disease rontrarted. 
II not at place of death ? 



i;lacK(»i- iu-rlm, nk ri;m<.\ai. I)ati:.>: imkiai oi ri.;m(.vai. 



(A(I^lr^s»^ 



ViVvs^4a.<vv^' 



l> .... *('F. Hhould be «tate(l T.XACTLY. PHYSICIANS nhould 

N. H. rivery item oV inf<.rmntion shoiihl b.- carutully supplied. « ^ .|..««;tf5ed The "Special InforniHlion" f«.r p.r- 

Htntc CAUSE OF DF: ATH !n plnln terms, that it may be properly doHs.^.ed. P 

son. clyinft nwny from home should be feiven in every instnnce. 



me-m 






^«S 



II 



Mi 






!tlt 



lit' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



* ^T 



I'.,Mr.l -I II' :'.:!li 1 '^■' 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy hleolth OfHcer 



Jlrg/,sfr/'('fl jYo. 



t2i)5 



I V 
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 



Certificate of Beath 

PLACE OF DEATH: — County ofCl<X^\- OAa/T^ <-■ i r-< City of^J^Xm. J^<X'^v<iA.«.-ct 




No. Hlb MLo_U , .. ■ St.: H Dist.;bet. S'LL and 

/■ ,r Dt.TH OCCURS AW. rBO»l USUAL RESIDENCE 01»E TACTS CALLCrj FOR UNDER 5PCC.AL INTORMATION \ 
( Tr DEATH IcCUR-Td.N " HOSP.TAL OR mST.TUT.ON CVE ,TS NAME .NSTEAO Of STREET AND N U « i. E R . J 



b XJ\.> 



FULL NAME 



.0 V^^^-'^'t 



XO^ 



1-. \ 



^^ 



PERSONAL AND STATISTICAL PARTICULARS 



XTi-^^jCL^ 







'1 HI k 111 




i'< >\,< >K 




Jn^ti 



. 1 



1 



,=; 



SIN' l.r \1 \KK I1"I>, 

uiDi >\\ i-.i) OK in\(>Kti-:n 



X 



A 



■< ■ ii 



/>,.'! . 




lUKTMt'l. \r)- 

(St.:' 



NAM I- ni 

I'ATii i:k 



lUR I III'I, A> 1-: 
<)I- i AIHKK 

' Stat I I If (.'( unit I \ 



MAllU.N NAM1-; 
'•) MOTHI'.K 



niKiMi'i. \rK 
<>i" M(»i'ni:K 

iSl.'itf Mf Coi I > ) 



OCCri'A TloX 






MEDICAL CERTIFICATE OF DEATH 

DAIl, < >l- Dl'.A III 



CL. 



^0 /c?nH 

(Pav) (VcMi') 



^M()iifli> 
I II I'K I;1;N' I I.1<TI1'"\', That I iitli'iidc-d <lc'ix-:iso»l fro 

that I la^t saw h ■-• alivrnii Lb-VOL 'i)C Kp ' , 

an<l that di-alli mccii t ro(l, on \hv <latv stati-<l above, at b 



in 



^[ 



M 'I'lu- C \rSIv ()1- DlvA'III w;is as follows 
■'0' 



V^!cx-Ia.aXc<XVu MJ 



A,^"v'^w<:^wX 



V\_A,N<1 



^ 







DIR ATION 



)'OJrs 






)/<>// ///s X /hiys Hours 



) V(i;•.v 




J^';////.v 



/?r^r.^' 



Hours 



KtsuU'A n, V,;.' />./;/./-" Cl )V.M- 5 V-'/^//' '^ "•' 



11 



l)-, \II0V1-. SrVTlD !•»•• RSONAl, I'AK TUTl XKS \K1 TKI)-' T' • T>ll 
r.l'.ST OI- MN KNi>\\IJ:I)<". !■■ \NI> HI 1,11. 1- 



DIR-XTION 

(SIGNED) Uj. J\- "Jtoa>[x^|^je/vJ(>C\^X'*v M.D 

SPECjllAL INFORMATION *>nly for Hospitals, Insfiliitions. Trdnsients, 
or Rcrrnt Residents, and persons dvini] dwd) froni ho-ne. 



Former or 
Isudl Residence 

When wds disease ronfrdc fed, 
It nol at pidc e of deaffi ? 



HoH lonq at 
Pidfcof neatfi.' 



Ddvs 



J. I \CK ol- lil RIAL t'R Kl'M' 'X M- 



IX 



0-^ 



!> \ tia .>; Hi Ki \i «ii ri;m< )\ \i. 
Oxjvtr 1 TooH 



rNi>i;R'r\Ki.i<>'^^ 

(A.M;- 



10 ST MVuA.<»-^t. vx Jl 



' TT ,v.l A(;B should be stnte.l fiXACTLY. PHYSICIANS should 

N. n. j.vcrv Uem oV in^'ormiition «houI.I b.- cirotully supplieti. _ Ossified The "Spcc'iBl Informatian" for p«r- 

stiitc CMISr or DI:ATH in plnin terms, that it nuiy be properiy .... 
Ron. dyinft Hwny from home should be ftlvcn in every instflnce. 





,i1 

I 



^^'^^ 






rr- 



i 



'<■' 




1'^ 



m 



iii 





1! 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



r.xu >• Nm !-. ?''*r???-^'''"'^ ''<■'' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



j)((/i' Fi/('f/, \J^^./v<:vcA^^'b 3o 



lf)0'{ 



lipi^isfci'rd J\^o, 



i2m 



{i-\.A.V<i 



•^ 



Deputy Hcallh Oflficer 



1 

DEPARTMENT ()F PUBLIC HEALTH^City and County of San Francisco 



PLACE OF DEATH: — County ofCla^^ yi 



Certificate of IDeatb 



m 






V'Cv<L'^0 



No. 3"^ L^kcxtl O, ^ x^CrtrO -x St.; I Dist.; bet. X\ ^aX and Tx ■ A, 

f ,^ DEATH OCCURS AWAvUrOW USUAL R E S I D E N C E G I V E TACTS CALLED rOR UNDER SPECIAL .NTORMATION \ 
( "death OCCURREOrA HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OE STREET AND NUMBER. J 

FULL NAME 



ivLld; o;. UL/vJtktnxJVOjLl . vxo. CJ^ 



PERSONAL AND STATISTICAL PARTICULARS 




I 




I 



! Ill I.IK 111 



a 



M. 






'bo 



iV.ai) 



t 



:al < 

0., 





MEDICAL CERTIFICATE OF DEATH 

i)\ I'l; ' >i i'l. \ii 

(Day) 



iVc-it) 



/',/ 



siNi , I, I- M \ K u n:i» 

\\\\u t\\ I-. 1) (»K I)l\< »K' l.l> 
'Wiitfiii --(HiMl (Itsivnatiiin) 



\-\u :'!i I'l \.- !•: 

1 Slat ' ; ' M nt I \ 



^\^t^• m- 
I" AT in: K 



lUK I'll! I. \ri-; 

<>l" I'ATlll'.K 

'♦itat" f i? ('..ni)!r\' 



M XllUN N \M i: 

"I' moi'mi;k 



i'.iKiiii'i. \(i-: 

<•!■ Mi»ini;K 
'Slal«- iir (."iiiuitl V 



^ (J 



( 




fM..iith) /f 
I ni.Ki:i;\' C IKTII'V. Thai I alUMuUd «lci\-asc(l from 






-Trjcr 



ami that .K;tth .HHiirrcl, on the datt- stated ahovo, at b 
\X- M. Thf CM Sl{ Ol' Dl'.ATII wa-. a< follows: 



'\Ji 



CONTRir.l TORN' 





yX^wA'^ w J- V \,^i 




' i^vM 1' \ IK i.\ 

k'f i.'rj >' S.iv I 1,1,:. ' ' ' ' 

I- 111- \M.>\ i- sr\ rii) I'KKsoN \i, i-\KTirr!,\K^ \ki- TKri-: to ^'w^ 

Ml'lsldl MV KN' »\\ ! l.:)(.l', \\!> HlW.M I- 



1 /,../'// 



'liifoniiatil 






DlRATloN 
(SIG 



) < </^v Months 

r, .... 



\ 1 K >.N ''A ' 

NED) U. "A. 3 (n>^ 



/></!■ 



Ilom ■i 



LUcO -^C i.»oH fA.Mn-) ^'*>:i'i ' XC 



:dlAL INFOR! 



M.D. 



SPEdlAL Information «nly tor llospitjis, institutions, Iransients 
or Rffpnt Rrsidcnts, .ind persons dyin'i aw.i) lro:n home. 



Former or 
iJsiiHl Residence 

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



How long at 
P!,ire ot Ocatti .' 



Days 



n.ACKoi- iu-i<iAi<">< i<i;m"V\i. | i.xit..- I!. KIM, .., ki;m..vai. 



fe O^L.^ 



I on 



IN 



)juJfi\y\j 



fA.Mnss I 1^1 mTU^»^A-^^ ' ^ 



" ' TT TT ACIFi «»iould he stntc.l F.X \CTLY. PHYSICIANS .hm.l.l 

N. B. r.very itom o*" n.^'...M.,:.t5n,i should he ci.retully «uppl.^ I. . , .„„^.,fjecl. The- "Spccii.! f.Honn,.li..n" tor p«r- 

Htatc CAlISr OF DKATH in pli.m tcrmn, thnt It m:.y he proper^ cl«H«M.e 
«on, tlyinji ..way from home should he feWcn .n every mKtnnce. 



'■• m 



j 







4', 



I!? 



% 



,' 



]■ 



1' 



13 irl 

r 1 '' 



P 



*\ 'I 



!• 



i 



J 




fl,«l 



n 



1 I' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



w 



»-7^•^^ 



I!.,;ir.l i.f Jl(riltli-»' No \=, t-'^'iK''^:. hScV Cn 



Dff/r /')yrfi,\j,j.^A^/nAJ^^ iO 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lf)0^ 




Rogisfci'cd J\^o. 



129 



«•' 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtificatc of Scatb 

( 11. G. 5rnnC>iUc> ) 

J? (I)? J? 



(^ 



PLACE OF DEATH: — County ofO/CU>vOAXX/Tv^A.4 c< City of Cjclav' vL^ua/>xc<^<L cl 



No, 



M\ 



OJ\J^\A 




C\ 



(Hu 



\XA. 



QJK: 



St.; 

SID 

INS' 



Dist.; bet* 



and 



(IF Dr*^H OCCURS AWI»V FROM USUAL RESIDENCE give facts called for under "special INFORMATION" "\ 
IF d\jatm occurred in a hospital or institution give ITS NAME instead of street and number. ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 
SK.\ A rt r<iI,<)K 



vi) CJ clvuxXiv.'Vvc 




^ 



\ 



I' A 11-; ( )| |:1K 111 




OJ\j 



M'iiitli 



i;:iN 



r b Cj 



\ ' ■ !•: 



\o% 



"IN«.|,1' MAKkll !• 

U ID* •WHI) Ok 1 1 I i> 



i'.iK rni'i, \ri-: 

' State ()T ("(Mint 1 \ 



fh 



OJV>^A^X4- 



N\MI 111 
I- ATli J.K 



»'.n< riii'i. \»"K 
MI' ! \i-i!i-:k 

' 'inl! s- 







M VIDHN NAMi: 
"»I M')Tni-:K 



liik iniM, \(i-: 

' -^^ '■ ■ ■ • ; m t 



" < I" I' ATI ON 

l\ r If,! Ill ^i: I,' / I ii I'l 




MEDICAL CERTIFICATE OF DEATH 

DAii', oi i>i:aiii /"I 

UX^ V\ /go H 

(Month) K 'Dav' (Vtar) 

1 Ili:kl-;i5V Cl'.R'ill'W 'I'li.H l attcipU-.l .U-Cf.isr.l Cnmi 

til. -it I last saw h '■■ < • .ili\( on VA-WO T90H 

and that fk-atli occii rred, on llu' daU- stalt'd abovf, at 11-^0 



^ M. The CAI SI' Ol- I)i:.\TII was as follous 



I >r RATION }'rars 

CONTKIIUTol 



-Nl^A^Xi 



Mo>itln 



^ U.kjLN.X»JX.A..<rvx .X<y*v' vLi- 



Pays Hours 



I » r R A T I < ) N 

(Signed ) 



)'(V7/-.y 



Mnnths 



LAaIJaX^A; 



/^^/r.v 



Special information <"•!> t'^ Hospiidi 

fir l^firnt Rcsidpiits, dnd persons dvinq (m.i\ (ro-n home. 



Hours 
M.D. 




xvu.^ yv( 
s, InsHlutions, 



C»A^.kt» 



1 '. ,//// 



//,/! 



I'm \iio\|.. Si" \ ri:i) iM-ksi)N M, I' \ i< III r I, \Ks \k 1: ii-f ii'. To rni; 
iu;sT OI-.MV KNowijiDi-, J-: ANi) in:i,ii:i- 



former or . ^ ^ ^^ 

I su.il Residence 1 o o ^. 

When H«?s diseasr rontrrfded, 

II nol <jt plarc of dealh ? 




V . How lonq af 
Jt PIdff of flMlh 



frdnsients, 



Dd)s 



111 



\^<XA V»w .^>w^ 







'N'lili 



I'l, All'". < >1 I'.l KIAI, I •!< ki:M< i\ \I, 



I' 






• \ ri; <>!' I!! iM.xi ..I k i;mi »\ai, 

TQOH 



\ 11 , 1 1 : I ! ! 



fAd.h.-. 



N. B. i;very Item «t' lnfr,rm«t5on «houl.l he cMrct'ully supplied. Af.'i; k'vu.I.I he stHte.l I.XACTLY. PHYSICIANS Hhonltl 

Htiitf GAlJSr or DliATII in plain terms, thiit it m:.> he properly classiit'iccl. The "Speciul In^ornnition" for per- 
sons cl>!n(l nwiiy from homo should he ftiven in every instnnce. 



9 







m 




tUki 






11 



'■* 



i 






1 • 



-» M^v 



|| 1^1 



11 

i ; 



-L 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



II.., Mil IN '•* -ar-A;- H.Sci' <*'. 



Ihifi' Filed , \XK^^JOiKKJ^ ?)0 



IU()\ 



llcilistered Xo, 



\ 298 




^, Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 



I 11. 5. 5tatit>aic> 



PLACE OF DEATH: 



No. 'iH 



/ IF OrATM OCCURS Uv^ 
\ IF DEATH OCCUIVI 



County of ^.^' CL^f^ /uCVwCUlClCity of vJ/CU'Vyj AXX/TVOa^/CO 
]nt^<LLr>v St.; 'i Dist.;bet. T lA) and % KA^ 

lY FRow USUAL RESIDENCE give facts called for under "special information" "\ 

D IN A hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





■Aj 




\.<xu 



PERSONAL AND STATISTICAL PARTICULARS 



• 1 \ 



QTji 



' \ ! 1. < »i r. ;k 111 




> :) 



Cnl.i .K\ 



MEDICAL CERTIFICATE OF DEATH 

I) \\V. ( M Di: \ I'll 



\X^J^\ 






a1 Ail 



I.I \ 



I ' .11 



%[o ; 



1 



\\llui\Vi:i> < >K DlX'ok' I I) 

N\';ii! ill >.ini;il (If>«i}.'ii.iti')ii ) 



IllKTHIM. XtM-: 
' St;it<- iif I'Dlint I >■ 



\\M| (»: 

1 \ I II i.k 



HlKTlll'I.AiK 
"!• 1 AIHKK 
•"•tatt ur t-'oimtry 






iiikrifiM, Aci-: 
"i ^^>■l■m•;K 







Moiitli^ jC (Day) 

I lli;ki.l;\ CI'RTli'V. That I attm.lr.l .Ui-rasr.l fnuii 



(Vtai) 



LLccq *^ ic^o'l 



tliat I la<l saw h-'i^^' alive- on 



to 



LLu^ 



5lI 



i()o H 

^-^wVCX 1^ up \ 

aiiil lliat death oi'dirrt'il, <in the ilatr stalnl alxivf, at *^ 



a 



kl. 'i'lu- CAl Siv ())• I)i:.\'l'II was as follows: 

v\.OJi viYVcv>L< 



)Ji/^^ 



,<X>5,>>xvA^j 



^ 



kllMToRV • 




C ( > N T U 



1)1' RATION 




Mintths 




Pays I hut) 



1 



Ycarsi 



SIG 



NED) vA OS . X' 



Mouths 



l\j\ 



'A" 



i 



//ours 

M.D. 



% 



'H ^ rp.xTiox 

Till. Aiiovi-: ST \ij<:n i-J'-rsonai, rAKruTi. \ks .\ri: TKri: ii • iii i: 
iti;sT oi- Mv KNt»\\i,i;i)<". E .AND i'.i;mi;i" 



.lA^v///- 



SPECIAL INFORMATI 



ION f»nly t'"^ tiospiliils, InstilJtions, 



or Recffit Resitknts, .ind persons dvin,] .iwdv Irom fiomf. 
Formpr or »«'<* '""'I "if 



Usual Residence 

When was disease ronlrarfed, 
If not at plare of death ? 



Pldie of Death 



Transients, 



Ddvs 



'111 fu: inant 






fA(M^r<^ 



•1 \c I' 111 i;i i\ i.\ 1, « 'tv K I 



I'LXC'l': <•! IMKI.M, (iK KI;Mo\ Al, I l)\l^.>;" HiRiAr. ..i K1"Mm\AI, 

^0 TQoH 

ll^n VlhA^^urvv at 



IXni'.KIAKl-K 

(Adflrcss 




^ .. II ATK bSoiiI.I he stnte«l FA'ACTLY. PHYSICIANS should 

N. B.— F.very item ni Information KhouUI he cn.efully -PP'-;^- ^^^'f^n;: '^LI^^^, The "Specinl Information" for p.r- 
statc CAUSfZ OF DTATH in pliiin terms, thnt it m«y he properly dassmeu. . 

«on« dyinft nwny from home should he ftive" '»' every instance. 



r'T ?i 



*:: 



■ ' "f 



'.J 

:( if > 
4 




t,] 



.1 

4 



'^< 






♦^f^i J- ' 






n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,.inl of Henl th I- No :^ ''^T.r.i'- "'^^ '' '"" 

/hf/r n/cd, iXv^^^^v^ ^0 /'>'''n 

A 'i ^ Deputy Health Officer 



llr^islci'cd J\^o. 



1299 



;* 



I 



fj. 



.•» 



M 



if» m 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 



4 (^ 



PLACE OF DEATH: — County of 






KL I i + i!^ WY-VA/\\.hi ib^4k\TaI^ St.r - - Dist.;bet. and ' 

P4f>. U^A^ ^ ^.^VA/> V.^U ^^^^J7,V.,.V-'- -iD^NCEG.VE TACTS CALLED TOR UNDER •SPECAL INFORMATION 
J ( '^ r/rE:TrOCC.tro\rrHO^S^VTlt rR^^ST^^JV^oVo-VE .S NAME .NSTEAO O. STREET ANO NUMBER. 

f-iiii iviAn/ir WiWv J.oLlJIa.a 



) 



FULL NAME 




■-i:\ 



PERSONAL AND STATISTICAL PARTICULARS 




(K 



ol.' 



iL .KCtt 



II A 1 1 « >\ ItlR I II 



/tl^^ 



M.mthi 



! Vt-ai 



\' .!•: 



'^ 



},' ■nf/i- 



^i\' .1.1" M \kK 11. It 

WllM iWl-D OR IH\» (Rii: I) 

'Wiitt in oociiil ilt— iv'iiiitioii ) 




<X\.'voL/cL 



itiK riMM, \*"i-; 

(Statr or Cotinti v 



\ \M1- < M 
I \ III I- R 



MIR Till- LATH 

oi- 1 Arm:R 

■^' it' ■! r<iniitT\-^ 



MAIIU'.N NAM I". 

(•I- m<)Thi;r 



^ 



j 



MJi^^ 

? 



^ 



V 



X- 



A,A^Lv'v>Ci 



lUR rii ri. Mi: 

«)l- MoTHl-.R 

(Slntf DV I'niinli \ 



OCCl 



hjuu'zx 

•r.vrioN /O (i 

/\f>i<ff<i ill Situ /'i i!ii< ir,i 



)',,n 



'^ 



M ^'I'l, 



/',,■! 



Tin- MU.Vl.- STXTini'KRSOXAl, I'ARTI.TI.ARSARi: TRri: T. • THK 

I'.i-sr 1)1 Mv K\»i\vi/.:n«".i-: .\ni> m.i.n-.i- 



(Iiif')nii:(!it 



( \f1(1rr'«< 






MEDICAL CERTIFICATE OF DEATH 

DA 11-. <>1 DMATH 



lXv\.( 



a I 



( Mont 10 n 'I>:>V* 



ti 
(Year) 



I lii:Ki;r.V Cl'K'ni'N', Tlml I atUMulcl 'U-cvascd fioiii 






that I la^t saw h ' alive on VAA^l^ 

;,n.l that .Uath occurred, on Ihc .laic statc<l alx.vc, at 1-0 5 
LL M The CM SI- Ol" Dl'ATH was as follows: 



I^C^lL'V-VA.^^Cn'VOL^^t ^jLM./vOLv'Uy ^i^'.y> 



I) r RATION y^'^^'-^ 

CONTRIIU'TOKV 



Months 



/hns 



Hours 



(SIGNED) J. ^J^ dvD/CX-nX 



\k.U^(X XI iQO^l f.Xd.lrcss) 

SPECIAL IfMFORMATIO 

or Recent Residents, and persons d)iny ^'^a) from tiome 

? 

Former or 

Isual Residence 

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



Pays 

it) 




r«j only Inr ffispitaK, Institutions, 



/fours 
M.D. 



Hov« lonq at 
Place of Death ? 



Transients, 



Oavs 



I'l ACl'" (H- lURIAI, <>K Kr.M"\Al, 



. . UcrW^.^*^ '^^ " 



) \ 1 1 • ; r.' !•■ I Ai "1 ^^ '■•^'' )VAi, 



Lvv^ 



TNI 



.KKTAKKK OUlu'^*^ 



■> 



a^^A 



QOH 



/Occxcc-^X' 



(A.l.h.ss3>blX^' la ti ">♦ 



" ^ (i TT TI,, x(;F. sho.lcl he state.l BX4CTLY. PHYSICIANS «hould 

^. B.— ^:very item o^' in? .rmHtion should h. cnrcVuJIy fuppi.e . ^^' |; Ja«HltficcJ. The -Special InformHtion" lor p-r- 

«tatc CAIISK OF DEATH in plain term«, that .t may he ^^J^2l^J'^ ^'«« 
sons dylnfc away from home Hhould he ^Iven m every mstance. 









? 






r 




ii 

!■ s 

"1 



i 



t'^tr ui^^/^tf 



I-' !'■< 



I' 



n 



^ 



1 

p 



¥ 



^S.i. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENI HtL.y«u 

^-ft. „, , REFER TO BACK OF CERTIFIC ATC FOR INSTRUCTIONS 

1300 



, »r1i~l-" N*^' " 



jf^fn 



Tii'^isfrrrd .;\V>, 



DEPARTMENT Of Pl'BLIC HEALTH-City and County of San Francisco 



c^^v^ Ux-u Deputy Health Officer 



Certificate of Beath 

XX. S. i5tan^ar^ 




PLACE OF DEATH: — County of UJL<X ^ -vOL^i.O. 
%a.J^>xa/b l^ac^ak'^^X'^ ^^ ^^ -v- St.; Dist.;bct. 



City of UojLLx.A-v<i- LoJ. 



"and 



TcL'CLC^q^^VA^XA ^^ ^ ...,nVK,rrr.vr taCTSCM^L^D rOR UNDER 'SPrCIAL INTORW.^ 

r nr.TH OCCURS .*.v rpov USUAL RESIDENCE G.vrr.CTS cml^eo ^ ^^^^^ ^^ ^^^^^^ ^^^ ^.uvger. ; 
,r DE*TH OCxfuRRfD s . ^OSPIT.L OR .NST.TUT.ON GIVE ITS ni« 



A 



FULL NAME V 

4- 



lUj' 



Vi, I ^ 



h ^\.^'^^<X-^vd' V- 



\ <. 



PERSONAL AND STATISTICAL PARTICULAR^ 



%\^ 






0. 



^ 



% 



- \« . i . 1- \t A k U 1 i . ■ 
\\'! itt ill >•>■ ' ' 



lUKTHl'l, \v"K 
Miitt or Coiinti V 



\ \ M 1 1 li 

\ A I II IK 



I'.IK THri.AlK 
"l- FATHHR 

>i.it( or Coiintr\' 



m\ii>i:n nam I, 

()) Mnlin; K 










CrvO'VCV >X'3^ 



liiK riii'i.Aci-: 

<»!■• MoTHlvK 

' ^tali- or CoiintT \ 







AV- - /. .'/•. ,' /" '^'<.''' / ' ■"■' •■''■'' 



) , .; ' 



1' ^/■//. 



/'; 



Tn.AH0VHsTAT.-I..-FKs0NM.PU<T,> rrXK^AKi: IK. K i- H.K 
Hi:sT <)1" MV KNoWIJ'.lx.K AM> HI. Mil' 



VJ Ol/Ol^ 



MEDICAL CERTIFICATE OF DEATH 



,.iitii' \ 



1 II \-\< I- i'A K \ \s \'\\ \ . 
__ — \qo 1 

tlial 1 l;i-: - - ' "" 

:iiul tli;it '1' •til' "> ' 



I I>rtv 



(Year> 



i.lr.l .Icrfa^cil from 

" ~~" lij'i 

T90 



;;, --1,,1(m1 :il>iiVi 

M. The CM :^1'. *'i "' ^ '' " ^^''^ ■'" follow^: 



"^s ULct) 



1 






V-x/ZZ/s 



/Viv 



I li^'l) 



IM K \TH>N 



) , ,;; ^ 



M.^ntlis 



Pars 



SIG 



NED' vl iD^tt 



V<X/T>V^ 



M.D. 



llcva:!'! ^<»nS _^v,,,,r....)Oa.lda^ 



1^ \ 



% 



"special information onU lor linvpitaK Invtif.ilions Iransifnts, 
or RpirnI Rcviilrnlv. and priMinv .Mnq .^uax Im.ti hnmr. 



Formrr or 
Usual Rrvldrnrf 

Whni w.}-^ dhf.i"^'' 'onlfaftfd, 
II nol .11 plarp ol drflth ? 



How lonq at 
Plat r ol Dralh ? 



Days 



,., vcF Ol- nrKjAi, OK ki:\t"v M. 



aoo'i^^'uj.vv^j^ 



1 



1» \ IT" o! Hi iJi \i ot R l',M< >\ V I. 

ULcA^Q 'iO ino'\ 



\j^\ 



M.I ; K T A K I • K ViU^CC A V,^^-'^ ^^ 



IN. n.—V...ry Ue,n o. ;,„-,..,n»,lon .h„„UI .... cn.efuMy supplied. ^^f^;;';™';'.,^;:;,: '\^ ■■f,^:^«^ ,„for„.».i..n- for p.r- 
,.a.. CAUSr. OP DEATH in pi...n •«-"';•';»; '^7;; J TJ^Jc.. 
«n„. dyint 8way Srom home Nho.il.1 be ft.ven In e>ery 



I 



••■■ 



I 



i 



^ 



ii.( 



1 K i 



t 



■ I l< 11 



<# 






r,|l- 






;'mB|j 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

_,.__ REFER TO BACK OP CERTiriCATE FOR INSTRUCTIONS 



}1 .,M.I . f llc.ltll I" No iv t"-^-!^!^-, H.'vl' (\ 



IfWi 



d^^M^A^ ijeAAu ^^P"ty Health Officer 



Be^Lstered J\^o. 



I .".Ol 






DEPARTMENT OF PUBLIC HEALTB-CHy and County of San Francisco 



Certificate of 2>eatb 

( 11. S. 5tanC»arc> j 



PLACE OF DEATH: — County ofC'o^^x- J A.<X/>vCA.A:i/e.<. City of -CWu J Axx./>x/tr ^>^^c,^ 
i) <-^ r\ 



No. 1 HIS d.c^tUAj 01 



St 



.; Dist.; bet. l^XA^\<^iXMix\^ and^ A^cLuvc'^. I 



r IF DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL I N FO R M ATI O N • ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



v.LcUrU' 





I 



4.4aJ„h.! 



PERSONAL AND STATISTICAL PARTICULARS 





I» \ M ' ■! I;!K I II 



Q)U>v 




JvlU 



WEDICAL CERTIFICATE OF DEATH 

DA ri-; ( •!• Di'A'rii 



a 



^^'O 



M.iiitli) 



M.iith 



0.5 

(Diiv* 



,V'a 



( 



^0 

'I>av) 



(Vi;tr) 



loH ,,., '^ 



n,. 



^INt.l.l". M\RUIi:i> 
'Wiitiiii Koi-i.-il (li sij.rii;iti,,ii ) 



lUKTIU'I, \i'K 

' St:iif nr c. iiinti \ ' 




NAMl o|. 

FAT 1 1 i;k 



lURiini, \ri.- 

<>l lATIIl'k 
Sljitf or r(iiiiitr\ 



'•I Moriii-.k 



HIKIIMM.AOK 
<'!•■ Mori IKK 



' '^ «rr \llii.N 




<xwajl6^ 






vto. 



/ 



fi 



I III-:R!:I',V (;i;uTII'\', That I mUc-h.Io.I ,U.,vascil from 

that I last saw li '• .ili\r on vLawAw/Q X^ ioq H 

ami tliaf drath oc(Mirre<l, on the date staled ahove at ' 



G 



M. Tlu- CAI^P: ()!■• I J i; AT 11 was as follows 



T) 



... C 



O'XJL\_A^'>^'V>0-^VTi, V'CL- V^^v-v \ \ . M . '^ _ 



nr RAT ION 



)'('(!)■ 



. \X.^\^ 



'\ I 








Mouths b Pays 



I lours 



Pav 



I »r RATION ^'''''^"nL^ M">itlis 

(Signed) Ajuajl»\. fo /L\a. olvK a va^. I ^ 

Llt^Q %\ i<,o*"\ ( Addir^^) *^'i'i ya!^<x\u. '^1: 



/ fours 

M.D. 



iNor 



Special information onU for H(»spildls, InslituWons, [ransients, 
or Rftent Rcsidpnts, diid persons dyint) .ma) from linnip. 



/ 1,' 



.,..■.- 15 



];-,n ' 



M.'Ht/l^ 



/^M 



I'ln-: \novi-: sr \Ti:i» iM-'KsoNAi, !'AiM'i*'ii,AKs \ki: rutj; id iiii': 
iu:sT (H' Mv K\(>\\i,i;i)C,i.: AM) i!i;i,n;i" 



f Iiifo-inaiit 



•aaxxo 



1 CIJ 



formfr or 
Usual Rcsidrnre 

Wfipn was disease confrarfed, 
If not a( plafp of drafh ? 



How long at 
Plarc of fhath ? 



Days 



^JV\) 



J 



■^■\■h,-. S^HlS" CJx-vtXt'v dl 



•I.ACK OJ- iUKlAI, OK k!;Mo\ AI, 



DATl 



INDl 



I 1 \i ..! \< i:m( )\ai, 
ktaki:k VjO-vtx^j ^\. LOJa^jIx 



' \<Wa> 



.M. 



IN. B. Hvery Item otf inf^rnintioii Khoiilcl he cnrolfully supplied. \C,\\ sho.ihl he stnteil fiXACTl.Y. PHYSIC! \>iS hHoiiIcI 

»t«te CAllSf; or Df: \ TH in r>ljMn ttrins. that it mj»> he properly cloHsiliieil. The "Speciiil InlTormiition" f<»r per- 
sons 'lyiniJ nway from hoaic should he ^iven in every inHtnncc. 



w 






ii i/ 



t vl 



m 



'^4 



t; 



it 



!'' 



h ' 



i f 



jft^ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)!,.:.T,1 ..f Ih-.iltll- »•' N(». H f*-*:^' l^'v: I' «.■ 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



/)af(' /'V/rr/, \X\jucyu^A^ '^ I 



IfJO'i 



Regisfd'cd jYo. 



1 30^> 



^3^^^CKU^-v<^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTn=City and County of San Francisco 



/^^ 



Gcrtificatc of H)catb 

PLACE OF DEATH: — County ofU/CXA\^ Ox<X/iv^^^cc City ofU<X/>v .\XX/Tv'a^^<^_^ 
.,^ . lLMA>avtu ObcyA^ixOv^O-l St.; 

/ / IF Dr»TH occubI^awav trov^ usual residence give facts called for under "special information \ 

' V ir DCATH OCCIIRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 






Dist.; bet. 



and 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

1' \ I i; < 11 lUK r<i 





.V^xA 




■ ntli' 



I I>;i\ ' 



^■bl 



\< .1'. 



?^^ 



)■,-.;. 



•x 



(Year) 



/', 



U IDnUl-: I) ( >K I>:\t iKv ID 



Wi it<- i II '.111 ! 



lUKIIU'I, \C\'. 
' Sl;itv or C'luntrv^ 



• 1 ;.' 11 : 1 1 1 o 1 1 




1 A III l.K 



m 



F'.IKTni'I.ArK 
<>I" lAIIlKk 

Slate i)T CuUIltl s 



M \II)}-:N NAM}; 
'•I MOTIII'R 



MIR llll'I.Ari-: 

<M- Md'rm-K 

' Stan- ur I'luiiiti \ 



^■^ 



A'fu'iffif it) S,: i: /' . ,: - 






MEDICAL CERTIFICATE OF DEATH 

DATi'; oi- ni.ATn / ~~| 

(Month) r (I):iv) (Year) 

I Hf^RICHN' CIvRTIl'N', That X attetidcNl dccoascd from 

., . Oi 190'i to ._\A-U^<X_ X^ I90 H 

that T last saw h t,"^ ^ . alive 011 LA-AAX> ^5 T90H 

aiid that death occurred, (»ii the date ^tati'd above, at V v^ 
\J —M. Tlie CAlSIv Ol- DI-ATII was as follows: 



nr RAT ION }'(•(! IS 

CONTRIIU'TORV 



Mo)itlis 



Days 



Hours 



DIRATION 



f 



)V.w-? 



MoiitJn 



Pays 



' " *irA tionQST^ a 



}h"itii< 



Ihn 



'\'\\v. \M()VK s'r\'n:i) i-kksonai, r\K luri. \kn aki: iki h if i" >•; 

l!i;ST <)!• MY KNOWI.L'.IX.H AND I5i:i,n;t- 



(SJGNED ) 

SPECIAL INFORMATI 

or Recent Residents, and persons dying awdv from home. 



in-so Lctu ACL(^. A-' 

ON only tor Iwspildls, Inslilutions 



M.D. 



' M.|\l 



. UyV^J/vVU^^-^' >x' 



Former or 
Usual Residence 

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



How lonq at , 
Place of Death ? " \. 



, transients, 



Days 



Info-mant VJ.VJ. 0\0 \jL<X.<^'^y ' I 



l'I,AC^<; •>! MrKIAI.itR R};MoVAI 



DATLLof HiKiAi. or RKMOVAI, 
1^1 TQO^ 




im)i:rt • ki:r 



} AX\0- > V 



Uddress ^bT'X— l^^ti^V 



IV. , I a(:f should be stated HXACTLY. PHYSICIANS should 
!N. B.^Kvery item of Information «hould be cMreVuIly supplied. '^/'f' *^;"; '^^^.,..^^,, ^he "Special Information" for p.r- 
8t«tc CAUSE OF DEATH in plain terms, that it may be pr<,pcrl> classified. I 

«on« dyinft awny from home should be feiven in ever> instance. 






f 




. it 



^Vr 



'•'"rT^ii" 



uMii^mmi 



'*^ 



I i 



u 






f^ 



n 



I 



r 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i>..M!.i ..f II' Mith IV.. 1' ■**f!':*'^i<''vi' 



/)((/(' h^ih'fl , \XxA^n/^K.JLk 3 



^\^'(y^^^K.j<^ '^kJ^ 



\x 






Deputy Health Omcer 



Regfstri'ccl J\'^(), 



I t\m 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH: — County ofC'CU'^^' J,\.Cu>v^^A^c^City of 0<X^w J/\yCx.-vv.c.^x:i.e^ 



No. 



5 X - 1 5 "tk- 



St.; *> Dist.;bet. lb CM^vKUvd 




and M ' Ut^>l^v.t\v ) 

,.WW.WW.,W .- -^ - - - N ^ 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



/ ir DEATH OCCURS AWAV TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R W AT I O N ' 'X 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



— w 



.r\ 



PERSONAL AND STATISTICAL PARTICULARS 

X^AXOwL^ 






! ' M r.lK I 11 




OL^ 



M.ititlii 






V 



\' .)■■ 



1'^ 



^ V<';it ) 



1K:^^ 



MEDICAL CERTIFICATE OF DEATH 

I) \ I'l'. i)]- i)i; A Til 



Mdiithl 



r^ 



/u<y "^ 



■'A 

(Via I 



-I\« .I.J- M \\'.\< ll.D 

\\ IIH »U J-:i) <»K I>I\'ttK. i-l) 

\ ■ '■' ■ '■<.'. - . la] <l<-vi<."iat i'.iii » 



(Statf or rontiti > 







\M) (H 
\ I II IK 



MIK lHIM.Ai'K 
OI" I-xriIFK 

(Statt ' ii <."i lunti \ 



MA!l)i;x NAMi: 

'•1 MoTin: K 



HiRiniM.An-: 

( Stall 111 Coiiiiti \ 





yO^X 




L<x<i ' 



(Day) 
I II I'lK i':i!\' Cl-.RTI l'\"/'rhal I atttiuU<1 dctxascMl fmiii 

LLvvn 'iO 

Miiil lh;it (Uatli (•(■cur rod, on flu- <lati' stali-d aliow, at v 



il 



\J^\\J>0 10 KpM to 

that I last saw Ii -^-^ alive on 



lc)0 H 
1 90 ' . 



M. Tlic CAI SI'! Ol" Dl'.ATII wa-^ as follows 



0-J2^'W^<^^ 



1 



DIR.VrioX ^ Years 
CONTUllU'TORV 



MoHiln 



Pays 



I/oin s 









^ v<^ 



Li 





< >»rri'Aii()N 



,!,t / I ,ni. ;-- .) •■>, •< ) "■•' ^ 



)'('(! rs Months 



Pars 



f/iuns 
M.D. 



DT RAT ION 

( SIGNED )U).\J.y3 - 

GL ^VX:^ ^'. r, oS fA.Mr. ss)n^^WCliLA^v'it 
FECIAL IIM 



SPECIAL INFORMATION ""'y ^^^ Hospitdls, InstMutlons, Transients, 
or Recent Residents, and persons dying .m.iy frnii home. 



Mmitli.' 



/■,.■! 



rin. \H()\|.: sT\ri:n im'Ksdnai, i'Aktuti.xk^ xki rKri-: T' > tin-; 

Hi:ST 01 \\\ KNOW l.i:i)(".K AM) ni-.U!".!' 



(Inf. 



iMiiaiit 




^.a 



Villi I <■<'-; 



Sox- l5 



tL it 



former or 
L'sual Residence 

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



HoH lonq at 
Place of Death ? 



. Davs 



ij.Ari-: Ol- HI RIAL •>!< ri-:mo\- \I, 



I) \T1-; of Ht kia; 'It R 1!M< ^\ W^ 

ax|vt I 190S 






N 



,. , .,.p „Uoiiltl be stated RXACTLY. PHYSICIANS should 
. B._r;very Item o? mform..tion should b. ...rufully f^'M^I--. _ ' ' ^..^^^jjjed. The '•Special Infornu.tion" for pT- 
8ti.tc CAUSK or DEATH Jn pl«.!n terms, thnt .t mn> be properly 
«on» dylnft awny from homo should be feiven in every instance. 



1 4 



.t • i 



, i 





•■s*^* 



*»«►-■ 



fl 



WRITE PLAINLY WITH UNFADING INK — 



,,,,,,„ IV.. ^ ?-t"T^>fcIlS:lM*. 



hflc Filed , vJw\^\^<l^.v,<iX 3>l 



y^>'(y'H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1304 



lie di, sic red jYo, 




'\>-U 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



i ^ 



^'^ 



Gcvtificate of IDcatb 

PLACE OF DEATH:-County ofO,a>A. O.Xawc^cc City of O <X>a. J X<X wa.^- ■ 
No loS^. U>vO St.: ^ Dist.;b£t.~In^CVA^ and lULUo.., 



FULL NAME 



o ^' 




^'^^ ^ 



PERSONAL AND STATISTICAL PARTICULARS 

1-^ r<tI,t»K 



Xy^'V<xL-C 

; . v I i; oi- r.iKi'ii 



X.4\*Jtx 







I l);iv 






s' )■ 



bs 



?> 



X 



Pii lA 



<.lN<,!,lv MAKlvIJ.l) 
W'litriti •«o.-i;il ilfiiiMiMti'iii'' 




lUK I'MJ'I, \C]-: 
( St.ttf tir (.'oiuitry 



NAMt <)l 
1 A III IK 



niKTHJ'I.Ml-: 
ni' I \ rill-.R 



M \I1H:N NAMl", C^f 
<>I MitTHKK >> 



lUKTm'i.An-: 

<>l" NTorHK.K 
( Sl:itc or (."(lUiilT V 



DrcrrA'noN Qj\p 








fr-v/c/^J-^ 



AVa/,.V,,' /;? .V.7" /'inui .'<'•" 



)'>,!> 



Tin:\H..VHST\Tl l.rKK->XM.r\KTI;;r;,NK-AKKTKl K T' > niK 
HKST Ol" MV KNOW l.i: IX.1-: AM) lU-.lJl! 



(Addn- 



b55^ 



MEDICAL CERTIFICATE OF DEATH 



(Dayi 



(Yfiir^ 



DA ri-; Ml ni.ATii , "l 

I II I:R i:i'.V Cl'.RTIl'^W 'I'liat I attciiiKd <Urfa^cMl from 
Oll<XV il 190S to Ll<.v<jL 'bl ic)oH 

tliMt I last <au h ■•• alivr m, iL^O^ ^l icp '. 

and that .Katli ocourrcl. on the <latr <taU(l ahovc. at O 60 
0.. M. The CAISI-; nl* Di'A rn \va^ as follow^: 






DERATION 



) Vr7;\T 



/^ 



Moiilhs H /?rfjv' Hours 



CON T R I m ■ T R N' - a. VC.v.-N v-<r^-v^<x^ 



DTRATION 



(SIGNED 












f/ours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons d>in:j av^ay from fiome. 



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of deatli ? 



HoH lonq at 
Place ol Death ? 



... Days 



,., VCF OF lU-KIAI. ..K K»:M<'VAI. \^\TX^'' H' kia.. or KKMoVAI, 



m^3t 



IN. B. Kvery item of int'ormnti 

state CAUSE OF DEATH in p ..instance 

son. dyini away from home should he fe-ven m cver> instance. 



f •. 



u 



• » 






m 

■n 



■f 2 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,f Il.i.Hh- \ So. 1^ ^'"..^i.-?-^' i'"*^!' ^"" 



Ihfff Filed, LLcv.q/^^-^Lb ?)l 

SI ^11 



CMy-V^^wA^^ 0>^\}- 






Deputy Health Officer 



liCS^isfcrrd ^Yo. 



laa^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



tl. S. 5tanC>aiD ) 



-? (» 



t 



PLACE OF DEATH:— County of 






N«. Ox>W\xa'>\; (jlS^<l-K^i-0.l St.; 



Dist.; bet. 



and 



-) 



.XCVV>U ^^^"^r USUAL RESIDENCE O.VE TaCTS CAru.D rOR UNDER 'SPeCAL ..rORMAT,0. ) 

( -^ .Vor.T°H"ocru%iro\;"rHo"s"r.^ 0^'".;ST'.r'4'N^0.V. .TS name ,.SX.«0 or STR..T ..O ^U.B.R. J 



FULL NAME 




X^-vA^. 



PERSONAL AND STATISTICAL PARTICULARS 




-1 \ 




i < •!,» 'K 




IV^ 



.-b. 



> \ n • 'I iMK rii 



(U 






Dav 



AHH 



\'> .11 



A'.i-; 



5; 



sIM.l.l-, MARK 11. I> 

\\ iiM (W i:ii OK niV(»Kri:i) 

i\\'nt> in -oiial <1< »<i',Mi:iti<iii) 



lllKTIIIM.ArK 
' stall- or (.'ouiitrv* 



N \\1 ) 1 >1 
1 \ ill IK 







X/>^^Vi 




UIKIIiri,\rH 

<)!• I \ihi:k 

Stal > 111 I' 111 lit I \ 



M \ ii»i:n N \M 1 
(•1 Mdrni: K 



Kiu iiii'i, \*"i-: 

Ol" MnlllKK 

'Mat' .,1 (.'.lunli \ "I 



(H\ll'A rH)N 



\^o^. 



XVYVVCC^'VLJ 




AV\/,/a/ /'/ S,ni / ' '■■"' ■"•' 



)V.M > 



!/,..////> 



/),M 



f\'fu,tr,t III -^ini I I ':>" •' •' ^ — 

TnKN...VKSTNTK..rKK.nNV,,PU<nr,_LXKSAK.;TKrKTn Tl .K 

lU-.ST Oj- MV ivN.>\\l,i:i>'-l-: ^^'> /Jr>p' 



(III r> M ni;mt 



(\i1<lii«>< 



1 ] 

MEDICAL CERTIFICATE OF DEATH 

DAT]' «»i- iii.\ 1 11 r\ 

(M.,nth) J' ■•^•'V^ (^■^■^"■^ 

I II!:k i;r.\' ei;RTll'V. riiat I .iIU'iuKmI .Icocascd frum 

(IaI^ a'^v K/)'". to CLu^ '^'^ '^'^"^ 

tlK.t I last sL h ..t'> >. alive u.i CL^ ^"^ ^^o ^^ 

a„.l that (Kath .uHuncl, on tlu- .lato statc-.l al.ove, at H^i^^ 
Q M. Tlic CAISl': <)l' Dl'.A ril ^v;t^ ■'•'^ fnll..\vs: 






Months 



Days //ours 

o.NTRun-rouN^ *^'H^<^^^^^^ I^V^^^v.v^i 
est J J'u.iA^vd. ox 



.a 






SPECIAL INFORMATION only hrflospitdls, Institutions, fransients, 
or Recent Residents, and persons dvinq d'^.iy from^home. 

A 4. How long nt / 



Days 



When was disease contracted, 
If not at place of deatti " 




IN. B. 



^_^-™««— ■■— ^■— ■■••■■^""^■^^■""■"'"""'"'"'""'"""'"^ ^ I ivAr-ri Y PHYSICIANS Hhouhl 

,on, dyinft ..w»y tro.n ho.no «h.,.il.l he fe.ven ... c>er5 



■I 

i 



1!ilffiai»' 



*^«^ 



n 



II I 






li 



."■ 




n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD "^P^ 

REFER TO BACK OF CERTIFIC ATE FOR INSTRUCTIONS 

1 306 



. iK:Uh-FNo i^ t..l^"T>-; IK^ I' ' 



n^o'i 



lie^istcicd jYo. 



"l^CrvA.^^ loL^vvi Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Ccvtiticntc of IDeatb 

( U. 5. StnnC>arC> ) 
PLACE OF DEATH:-Coun,y „fOcL-.^ 3 ^'ur^vov^o City of O^CV^ Ja^o^c^- 



II 



1 n )S 



FULL NAME 



r\.fi * 




,<uAy>A. 



-'lA 




PERSONAL AND STATISTICAL PARTICULARS 

.■..|."l-:"\ ^ fj 



1 1 \ ii: I ii r.iu 111 




Ml. nth' 



l);i\i 



t. 



\« .!•: 



H^l 



I. 



'S 



/'.M 



slM.IJ- M\R!<n.l> 

uiix i\\i:i) OK i>i\<tKii:f) 

\\ I itr it) <.» • ' '•-;;?n;ai<>ii) 



'State or t.'oiinti v 



I \ !ll 1 K 



I'.IKT!iri, \y\\ 

<)! r\rm:K 



M\I!)1:N NAMi: 

<'i m<>tiii:k 



luK rni'L Acv. 

Statr I )i rininti 







'""'■'"'""" (iLcJl t^:t^tit 



Mnijfin 



/',.' 



in-;sT oi- MY KN(»\vi,i:i)*-h AM) hi-.un.i 



I iifui inrmt 



Kjy'^-^^^^'^' 



(SxUx 



MEDICAL CERTIFICATE OF DEATH 

I) \ Tl-; » •!' Dl'.ATII 



(Year) 



(Montlil /| 
I I1I;KI:1'.V C1;RT[1-V. Tb.at I aUen.kMl .kcva^cd from 

Ql"KcbM ^H 190H to _LL^^ ^"^ 
that T last saw h ^^ alive on \kK^ X^ 

,,n,l that death ocrurrcl. oti the <late state.l above, at U 
U, M. The CAISI-: (»!■ Dl'.ATII \va>^ as_follmvs : 



T90 'A 



vv 



DIR A TION 
CON T 1^ 



)'rars 







//oin s 



X/vy^<:^^^^^^^ ^'^' 



) V<//'.s' 



Month. 



Pax 



Hours 



SIGNED)^. LOcL^^clUv^v.^. M.D. 




■<5Pe3aL information only loi Hospitals, Institutions, Transients, 
or Rerenl Residents, and persons dyiiij -mav from home 



former or 
Usual Residence 

Wtien was disease contracted, 
II not at place of death r 



How lonq at 
Place of Death ? 



Days 



P, \CF Ol- m-KIAI, OK RKMoVAI. 

(St OJLwo^ 



DA^I.of MiKiAi- or KHMOVAI, 
^JL\yX I T90H 






fAddress 



^— 1 ■— — — — —— , pvACTlY PHYSICIANS should 



;■> 



il 



.i 



t-i..t, 



■•*w* 



^^i^sadRi^ 



'-*' 



If 







^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



«^«'^"*, 



H..,ir.l.a" II.Mith I- V.>. !<; ■*x?f:;^*' "^^'' ^'•^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' riled, LLl^CI'UUjX 3> I 

'1 




ChVA-A^O 



.v- 



M 



Ls^pucy r.^iMi^n Omcer 



Reglstcj'pd J\^o. 



1 307 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Gcvtificatc of IDcath 

.; X\. 5. 5tan^a^•^ } 



No. H 



Olsb - IH iJL lv>A. Umt d ^ St.; I Dist.;bet LaAll'vO and M U-^ 

/ IF DEATH OCCURS AW*V (|hOM USUkL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
V IF DEATH OCCURRED I Al A HOSPItVl OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

i...-.iJ..„..,A,..!l, 



FULL NAME ^ .^xdiAJLC.j|va "^Us 




... ^ 



PERSONAL AND STATISTICAL PARTICULARS 



ii \ ri- < ii r.iK 111 




Mmith I 



M • I'. 



H 



(DmV 

,, ,, :) n 

' .'-7' :^» t-v 



rVA. 



\ f:iri 



/>..M.^ 



MEDICAL CERTIFICATE OF DEATH 

DA Ti-; oi' i>i:.\iii 




^0 

■I);iv1 



(YfMr^ 



\\ IDOWKI) OK I)!Vt)Rii:i) 

■Wiitfiti sofial ill ^i'.'Tiat •' itt ^ 



lUK rni'i.AO}-. 

st.itc or Coiiiitrv' 



Ox/^y^^O/VX 




\" v.Ml* ( »I 
!■ All! Ik 



HIR IHIM, At)-: 
OI- I \ II UK 

•^tMti Mt r. .11 III I \' 



M\ii)i:\ NAMi /7p\ 

<>l Moj-Hl-.K ^\J1' 



HlkTin'I.Al'}-; 

'U- m<i!'iii:k 

( '-'t:it'- or C'ounti >'' 



CUu 







iMoiilh) 
I in';Rl';i5V CIvRTII'V, 'rii.it I aUcmU-.l .Ucin'^cil frniu 

^ 1 90 It ) ~~ 1 90 ' 

tlint I last saw h — alive on np" 

atul that (Ifalli orcurrcd, <>n tlu- -litr "^tatctl abnvo. at 
M. TIk' C.MSI' OI' I)I;.\ Til was as follows: 



i)ru.\ri<).\ I'iUir.'i 

CoNTRir.l'TOKV 



Ub..Crti< 



r 



1 



Moulin 



Days 



Hours 







rvv 



t 



aaaXi 



(HCll'A riON 






DIRATION )\'ars Months /hivs //ours 



Ur 



z.i. 



(Signed) Mj^vtrvOA' J- VO.UJ. JaXo^^vvd_ M.D. 

SPECli^L INFORMATION only for Hospitdls, In 
or Recent Residents, dnd persons dyinij awdv from fiome. 

L l| ^i flov* lonq at 



Tin: AHKVH sr\Ti-.i) i'i-rson \i. i-AK ruTi,\Ks AR1-: Tkt }•: 1" Till', 
ni:sT ()i> MY KN<»\vij;i)i;ic a^d uJiU'i- 




(A.Mn-.. Ho lob - anlX e)t 



Former or M rsui '^ u 
Usual Residence VOV^Vd- c^n 

Wtien was disease contracted, 
If not at place of deatfi ? 



It 



Place of f)edtfi 



Odvs 



IXACI-:')!- lUkl.y. OR RI-;Mn\ AI 

.'CLwr>'\ 



NI.KKTAKKR Ij . ^ \. ^ 



'il 190S 







«tnte CAUSII OP DEATH in pinin tcrmn, that it may be properly JoH8.t.ccl. The .>pcc.n. 
sons dylnft nway from home should be it'iven in every instance. 



I 

1 • 

V 






' 






K 






.51 



til' , i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M..:,r.! ..f HfMlth I- No : = *x3:;r^ "^'^ '' ^* 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






IfWi 



Registered Xo. 



1308 



,{)-U<.^v^ 



ep 



^ i'*^' 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( U. S. StauDarD j 

Si ^ ^ 



m 



PLACE OF DEATH: — County ofOcUT\^ A^O/^^vCLXicoGty of ^^ v. A.<X/>^ e ^ ^ o 
No ^HH 'k iri^'^. ) .. St.; H Dist.;bet. H tiv and 5 .U\) 

/ IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" ^ 
( IF DEATH OC^^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




O-.^^'V y\Jb 



JX/»v 



.oJuL 



UuJ. 



I»ATI-: t)l HIKlll 



v. 1-: 



SIN(.I.|- M\Kkli:i) 



(K^^ 



M<.Mthl 



n 



Av. 



bl. 



r> 



/ Wl 



\\ii)t»\\ i:i) OK iHv< ►kii:i> \ 

W ritt- ill -oriiil «1. -ii'ii;iti<)i\ ) \ 



iiiKTiii'i.xoi-: 0C\ (7f?) 

Stiitr or I'ininti v^ V\ ' ^l 



MEDICAL CERTIFICATE OF DEATH 

DA'l'K Ol' IH'.A'Ill , \ 

f Month) ■] {!>•'» V^ (Yfar) 

I llijs i;r.\' Cl'IvTll'W That I atU'iidoil (k'(x-;isc(l frnni 
\n\<XM. 190 H to .. LLa^CL '^'^^ U)0 H 

tliat r last saw li ■l^> alive on \J^U.^ <k . 190 I 



,C^. 



and that death occurred, on the dalt- stated above, at 
M. The CArSi'] Ol' ])!•;. XT 11 was as follows 



DrRA'IION 



} '('(jrs 



J, (>)////S 



NAM) «il 
I- \ in I.K 



lUKlUI'l, ACK 

Ml" I vnn:K 



maiih;n nami: 

ni >n»inKK 




.^c<X/> vcL 






IM K .A I M '-> A 

C ONT I< 1 i!rT( ) K V Cn n^VCU-YVvlA-.trw 



/)avs 



Hours 



DIRATION 
(SIG 



Pays 



Lrw 



r.iK iiiri.AO', 

oi- MoTfll'.K 

'Slatf of Ccninti \ ' 



Of 

1 Mcri> A'lioN f l? 1 , 

Kf^i,U;i lit Sa}i l'i<nii -^m ^, \J ) > r. i ^ 






M >>itli^ 



Ih 



Till- XMOVI: ST\I1 I>lM'K-<>N-M.I'\l<ll'''-.\'^^ ^'^'•■■'"'^'■^- '"' ■'■'"■• 
lil'.sr ()!• MV KN«i\Vlj:i)C.J': am> lu-.i.ii-.i- 



(l!ll 






NED ) Vriv^v^^ 0.0 ^ ^ 

LU ^Q ;S(^ ICO ^ \ (Address) V^^ - "^ t > - 

ClAL INI 



Hours 
M.D. 



SPECIAL INFORMATION ""'y ^'"^ llospilals, Institutions, Transients, 
or Retfnt Residents, and persons dying away from liome. 



Former or 
Usual Residence 

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



HoH ionq at 
Place of Deatli ? 



... Days 



I'L^CH OI- lUKIAI, OK KI;M0\AI, 



DAP", of Hi KiAi, 01 KI:Mo\"AI. 






N. R._Kvery item of inf>r.n,.lion should be cnrefuUy «"PP''-'- 'f:^,l^^'tt^J,^\^^^^^ InformuUon" Jr p-r- 

«tatc CAlISn OF DHATH in pl»in terms, that .t m»> he proper y 



sons dyini away from home nhoulcl be ft.ven m every instance. 






1 



• !i 



1 » 



< i: 



i ! 

» 



• 



;f 









IK . I I 



"*4^ 



i;l 



l! 



■''I 

•'U 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,.^.,., ,.f „.,uh 1 V. ,.-^C^^"^''^-- REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJO'i 



^^ Deputy Health Officer 



1 30i) 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beath 



(^ 



PLACE OF DEATH:-County ofQa^v >J \^vvcc^-v City of L)cc>v 0,^<x^vc^<i,<ic 



No. 10.M OxULVVtVC 



St.; *^ Dist.j bet. 




LTtr'iX and 

OB INSTITUT10-. GIVE ITS NAME INSTEAD OF STBttT AND NOMatR, 



IH.lix 



) 



'^ ' - - - ,,e,,«i orcsinrNrF: nvr facts called for under " special INFORRflATION \ 

/ ,F DEATH OCCURS AWAY FROM USUAL R ^ S' ? EN CE_G. VE FACTS C^A^LL^ ^ ,^^^^^^ ^, STREET AND NUMBER. J 

V IF DEATH OCCURRED IN A HOSPITAL 



FULL NAME 



S I . \ 



PERSONAL AND STATISTICAL PARTICULARS 

C'ol.oR 




'Wu 



Ll 




■^^KA>'0^^ 






n 



i ]\x>jU 



DA 11". t >1 lilK III 



\' .1". 



lOJkJt. 




M..ntli> n 



IMS 



•/. » 



/ ^ u \ 



wiin »\vi:i) OK n!\'< iKi j-'.i) 

iWiiti ill ^oci.Ml rlisi^'uatioii) 



I'.IK riU'LATK Q 

(Slatf nr «.')\iiitry' «<\ 



NANtl. t»l 
I A III J.K 



HIRIMII.At K 
Ol- lAPHKR 

'st.iti <ii r<nint I V 



MAIIU.N NAMl- 
Ol- MOIIII'.K 



HlRTliri.Al I-: 
(»»• MoriU'.K 
(Stat*.- uT CoiiiUtN 




UC <X'"iV*^<X >v 






/,/;////• 



/',/: 



OvCll'A TION 

Rrsidri! In Su u I- inn, 

TnKAm.VKsTNTKnPKRS()NXl.rAKTirrKAK^AKKTKrK H) THK 
iu:si* ()!• MV KN<>\Vl,i:i)<".K AND I-l-.l-IJ-.^ 



f Illfoi IlKlllt 






I \'l(lrc«^»i 



X\ 



IQO \ 
(Yt-ar) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH j^ 

(Month) K '*^='^'^ 

1 lll';Ki:nV C1:RT1F"V, That I attenckMl .Icccasca from 
c\ ^^\ to vXuu5 35 1 



tliati last sLv ll ... ■ alive on \\^^ 61 k/, n 

:ui<] that death occurred, .-n the date state.l alxn-e, at V) ■ ov; 




i(>o H 



Ov M. The CATSIv <)1" Dl'ATII \va^ a< follnws 



nf\Ji,>'j^^'\ x^o-A vA-XX. 



1)1 RAT ION 

C ONTUIUrTORV 




Years Moulin ^i PiU-i Hours 

)V<?/-.? ^ Mouths '^ /?<?v.c //<>//;-.? 

(SIGNED) VJf-^-^^ ^- ^'^n^n '^r''^- 



I )r RATION 



(Xr- -^ --^^ ^■^'^'^'- --^ ^^^^ ^' 



,t^Q'c>\ iqqS (Add'- s) 



:iAL IN 



SPECl'^L INFORMATION only tor 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 lonq at 
Place of Death ? 



Days 



I'l.ACH ol- I'.IKIAI, t»K kl-:M<'VAl. 




DAIL"! I'.'i'ixi. or K1';M()VAI, 

OXjvt I T90'\ 



r.xJli.ss 1051 V)lV\^<^^->cn^ C>t 



IN. B. 



^^^-^— ^—M ^^^i»^—— — ^ * I ivACTI Y PHYSICIANS (thould 

F.very item of inform.tJon should be cnretully --^^'-^^^^ ^^^;^l^ ..a^^h'icd. The -Specio. lnform«f.on" for pT- 
Htatc CAUSE OF DEATH in plnin terms, thn .t m«> '^ [»;"'*; "^ *' 
«on« dyinft nway from home should he ftiven m every .nstnnce. 



.v» 






H 



■r 



i| 



Ih'J 






1^ 



■% 



i- 



Vf&S 






Ul 



'nu 



,,:,,.! ..f Jlmlth- »•■ No 1^ ^T.: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PLRMMIN t.i>i • ncww, 

.„o ,,.. REFER TO BACK OF CERTIFICA TE FOR INSTRUCTIONS 

~" 1310 



liro^f.s/crrd jVo, 



huh' Filed, LiAAXV-^t; 31 l'^0\ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



DcDurv Health OfTicer 



Ccvtiticate of Bcatb 

( "U. 5. StauDarD ) 



PLACE OF DEATH:-County ofO<X^ JxxX.>x.^^cGty ofO.C^ .Aux^^c^o 



"No 



.lu. 




Dist.; bet.' 



and 



<LtC.k ClCt^vCtoA'.'-' - V V St.; t:::rrrrED tor under -SPECAL .NrORMAT.ON >! 



\r DEATH OCCURRED IN A HOSPITAL OR H 



FULL NAME 




LO^ 





-to.) 




«>i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



%.JL 



!» \ ri-: (>i i!iK 111 



\<'. 1-: 



-^ 




.t 



Mi'iitn 




I •,'31 



w% 



bs 



) , .; . 



II 



V ■iillr 



■\'<iir) 



/^. 



u ii)»)\vi:i) <»K i>iV(>Kri:t> 

Wi i!« 111 -<K i:il .IrsiiMi.-ili'i'i ' 



lUK rniM.Ari". 

>t;tt( or t'oimti \ 



'll 



I A Til IK 



lUKTHPI. \l"K 

oi" I \rni-:K 

iStMti' 1)1 t'lmntr V 



MAIDKN NAM I". 
• M- MO'rni'lK 



lUk TUPI.ACK 
(»!• MolMlHK 
(Statf or C<miUry> 



OCCII'ATION" 




? 




/CVT^ 



<L 



* I 



fyV-.uU'! ni ^>!>i /'"t>h rrn .i < "l ' <" 



Mniillr 



/),M 



r 1 1 1 •: A w )v v. sr a r i- 1 » r k k ^< > n a i . 



m 



J, \ M >\ r, r> I \ 1 I " ' ■ -'^ , .. ; V- 1 , iM I lit" 
HKSTOI- M>;^N<>\VI.i:iJ^.K AM) Hl.i.H > 

CI. IoxoXh 



, PAKII.Tl.AKsAKKTKrK T. » Till- 



'^ 



(In foi iiKint 



3 



r\<l.lr.ss 60 O 



.^ 



MEDICAL CERTIFICATE OF DEATH 

I)\ TK III" I)I;ATII 

30 




Moiitlit A 



(I)ay^ 



(Yt-arl 



I III.:rI<:1',V CIIRTII-V. That [ atteiuUMl (Icrtasfd fn.ni 

that I last'saw h X. . .. alive <>m (Xm^ oO icp H 

an.l that .loatli occurre.l, <>n the .late state.l alx-ve, at 10- 0.0 
M. The CArSP: Ol" DI'ATIl was as follows: 



coNTRinrTORV UYur>^^cV^^ 

Dl-RATION )V«« .li-"//« /'".••■'■ //'""■•' 

( SIGNED )k)Jl-^--^'^^^^ p '«•^■ 

"spefclAL INFORMATION only lor Hnspitals, InstilJtions, fr^nsienls. 
or Recent ResMenU, and persons dying ayvdy from home. 

to! Re°sidencel9^iCC<U^<Ut^^-^ Ke'l! Vlth ? 10 Days 

When was diseasp rontracN, 

If not at place of death ? ___^_ 



im,.u:h ()1- juki.\i. <»k ki;m.>vai. 

INDI-.RTAKHK (/U • V ^^ 

(Ad.lross ^ ^C)' 



DAl'J". ot H' KIM. or K1-:M<»VAI, 

'OJi 




— — ^— ■4^^'^^^^"^'^""'^'^""""''""""'" I FVACTLY PHYSICIANS should 

«U«n «hou[!. b. cne^uM. supplied J^^f;;;;^;;^^:" Th' ••Special ,n.'o.«atlon" .'or pT- 
ATH in pinin terms, that .t may be P;"P«'-'>' 



N. B. F.very Item oV inlform 

state CAUSE OF DEATH in p...- — " "j . ^ instance 

son, dyinft away ?rom home should be g.^en 



t * 



t ,'! 




' I 



M 



1 P 



I 



••-« 



■|l 



mr- 



^•^ 



WRITE PLAINLY WITH UNFADING INK — 






/>r//f' riled, LUa^oa^ 3) 



11 



I f 




l'.)0\ 



THIS IS A PERIWAINtlN I Mtwnu 

REFER TO BA CK OF CERTIFICATE TOR INSTRUCTIONS 

1 3ii 



]?('<fis/rj'('il jVo. 



A\ji}>M Deputy Hc-ith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticatc of Bcatb 

PLACE OF DEATH:-Coun,y od<L^ J V^'^vCU.C^Gty of .Xav J X.a.>^ v^oo 
No.H icl4t>>V.lLviclUcrUc.. St.: ■ Dist.;bet. 1 tl. .nd 1> 



) 



7",; ;;.,; occurs aiv "o» usual residence <.,.r "CTrc;;::;p ;oj._undc. ,;,%%--j~-;:,';'„'"'- ) 

V IF DEATH OCCURf^i^IlN A HOSPITAL 












FULL NAME 



-l,\ 



PERSONAL AND STATISTICAL PARTICULARS 



——4; 



VI 



^ 



I'Ka^U 



L' J v^ul 



I ) \ I ! I • 1 1 1 1 K 1 1 1 



i 



!■ '■ 







CL\' 



\< .1" 



H 



M. .!);'! 



\ ),,..' 






1 f^ 



/■•J 



--INt.l.l-", MARK 11. !• 

w inowi-D OK i>:y< >'•',< J ".n 

Writf ill >■"• 1 \' (If^i'/i: • • ' 



iiiK ruri.ACi-: 

state or ».'>MMti v 



\ \M 1 < )! 
I- A III ),!< 



HIKTHIM.ArK 
111" I-vrHHK 
Statf i>\ (."oUlltrv* 



h,UL<L 



ii 



M MDl'.N N.\M 1 
ol Morm.K 



IMR rmM.ACK 

<»!• M(>iin-:R 

I Stat'- 'ir Cuunli \ ' 




^€lV*^CL' . 



t)Ccri'A ru 



"CJ. 




n 



Kr-nini ni ^ 



-,:„ /■,,,,'. ■ ,,< XO ^■"- 



M.'iilh' 



]\i 



TnKXl.>VKSTX-M.l>rHR:..NA, rARn;M.,XK.AK.:TKrK rn THK 
in-sT t)l- MY KNOWI.l-.lx.h AM) lU.l-Il.. 



(Infoi niant 



^ P fl 



V 



EDICAL CERTIFICATE OF DEATH 

i.Mi-: <>i- i>i:.\rii r\ 



( Day) 



(War) 



(M.intli^ A 

1 lIl-:Ki:i'.V C1:RT11'V. Thai I ,itu-u.k.l .Icccased from 



190 



— I.) ~^'P 

that T last ^a\v h-^ :Tlivc <ni " - "^'P 

a„.l that <lcall, occ-urre.l, o,. the .late staled alx.ve. at 
^j Yhe CArSl-: Ol- Dl-A'Pil \\a< as follows: 



(^ 



VxxAJLrtrVvt 



O-A.^Q^.crv'A^v^^ ^ 



J. 



( 1 < r 



^ 



1 



nr RATION y^'^i's 

CoNTRII'.rTORV 



Mo^ilhs 



Pax^ 



Hour 



DIRATION ^ >V..;.s .lA''///'-^- 







, SIGNED 1 WV<r>xi.-v J AU . V^' ^^^^^^^^^ '^■''- 

" <5PE<!llAL INFORMATION only lor HospifdK Inslituf^ohs, Transients, 
or Rerenl Residents, dnd persons dying d«dy froni home. 



Former or 
IJsudI Residence 

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



How lonq at 
Place of Oeatti 



Days 









(Addrt-;'^ 



^<L^'<-*^V 



__—————— —■""■''■'"'■■■"'■"^ ♦ I FVACTl Y PHYSICIANS HhouUI 

-^ r:"^ ..„„ «houhl be .nrcfuM, suppHed. AGK sHo...ld »^« ^*"'"^h'; ..s,,eciai Information" for p.r- 

N. B. F.very item o* 5nf.>rmnt.on shouhJ b. c^ ^^^ properly diiHs.^.etl. The .>,> 

.. /-*ii«r ni- nr 4TH in plmn terms, tnai n ■■•'»' 
state CAUhn «» "i -^ ' " •'. . , . „ a;.,-« Jn everv instance. 



«tate CAUSn OF U1:A 1 n m m..- ^. ■"" .,^ ^^^ instance. 

«on. dyinft away from home should be fe.ven 



,f 



-; ij 



i ■■ 






' (j 



mxii^ 



li 

^1! 



1 I, 

HI 



t 

W I 
I* 



i 



il a 



I 



4r-» WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

liMMi.lof 11..-.H1. 1 Vn i^ ^-^Ir-i I U'v !•(•,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihf/c Fi/cf/, LLcA^OAVstt; :5^i 






790H 
Deputy Health Officer 



liegisfcrcd jYo. 



1 31 2 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Gcvtificate of IDcath 

f 11. 5. 5tant>arC> j 
PLACE OF DEATH: — County ofO/CL/Y\^ 0.\/CX/^vxccA.<:<DCity of 0,€L>^ JA<X>xc^^oo 



No. 



f) 



■f 



I S '^ Vj L -^ - St.; D Dist.; bet. L'/Ct a.-L^v a. and a.a.'aLA.A^ o. 

(IF OtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 4 
IF DEATH OCCURRrO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / (J 



w 



FULL NAME 



bi/> 



PERSONAL AND STATISTICAL PARTICULARS 



(l>lc.U 



llkjL 





(X ^ i vc'v. 



MEDICAL CERTIFICATE OF DEATH 

DA Ti-: (u- i)i-:.\ III 



i)A ri; » II i;iK rn 






\<.l'. 



5H 



1 



IS- 

iDav) 



1/ fi!h- 



C 



/\r 



slNi.I.l-- MAKKII !> 

wiix tu }• i» OK ni\ < »Kii;n 

|\\;iti ill siKJal <1( >.ivnati"ii ' 



niK ini'i. \v'i-: 

iStatc or I .imit i \ 





\ \\n: ni 
1 \ rii IK 



lUK inpi. At }•; 

<)I- IXTIIl-.K 

'Stat' I'! loiiiiltv 



M MDl.N N \M) 
l»l- Morn Ik 



mkiiM'i. \i !•. 
<)i" motm};k 

' ^triti- (II roiint 1 \ 



1 



''XcUv/vOlXlL 



a 



u 



'Dav^ (War) 



(Month* (] 
I HI-:RI';1'.\' eiirril'V. That r atti-n.lf.I <lci-rased from 

that I last saw h A. > rv alive on vAaa^q 'XS iqo 

ami that (k-ath Dccurrcd, (»ii thi' dato stated alxu*.', at \ 



to CLvAwOL ^'\ IcpH 



M 




^^>^XV 




aX M. The CAlSlv ()!• I)i:.\TII was as follows 

nr RAT ION )'r</yv Months Days J lours 






CoNTKIliCTORV 



I )r RAT I ON 



)'iiUS 

Signed) Q.L<xnJUm u 



M,^ fit /is /h}\s //iifns 

vO-vo M.D. 




\ 



\)-^ 



/^'^ - 



,^^ 



v-^ 



I "Til 



n( l\j.V/tL-KtX-vvt 



lLu^q '^0 igo'i (Ad.irc'ss) lLlMrLa^K_ct cA 



§ 



Special Information onlv tor Hospltdls, institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



A'r^iJrf nr ^. 



^0 



.1/,.,////- 



/)„•! 



rm-: miuvi-: s r \ i-t-n ri-Kso\ \i. p xirni i i. \k-^ \ui. tk! i'. ro I'm-: 
i;i-;sT <n" Mv KN< »\\ !.i:i)c. !•; and p.ii.mi' 



' Inf. >-n)aiil 



*bi?> \jjL/>x^ Ox 



former or 
Usual Residente 

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



HoH long at 
Place of Death ? 



Davs 



I'l.ACK ni- lUKIAI, OK RI:Mo\AI, 




iNDi-: 



DAX'""! r.'KiM "1 ki:mo\ai, 

TQOH 




^ " 



rx.Muss 



.'Acl.lr.ss iS1 ^O^vl:tXV CH 



N. B.- 



ivery Item o.' I„,'orm..l«n should be carcfu1l> suppU..!. ACiF. shouM be stated nX4CTLV. PHYSICIANS nhould 
tatc CAirSK OF DLATH in plain terms, that it may be properly claBHh'ied. The "Spec.al Intormat.on ?or p.r- 
sons dyinft away from home sh.mld be ifeiven in every inKtnnce. 



-f; 

8 



I J 



I 



*^m 






1 V 



•' I 



L*i 



Jiff 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i:...inl ■■f Ml .i!lh 1^'. : '. ^-^ja^; liX: I'C, 



Dff/c h^/'Icd , \XuL/0,VA^^1} 



^l 



100 



lie^htei'cd jYo, 



1 31 3 



(7^.^^^-^^^^ 



U L, 






Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S^eatb 



( 11. i?. t5tani>ar^ 



PLACE OF DEATH: — County of 



Uf 



Ci t y i ? {Vv'.CLM gu U/a>\/ >JAcLAxCA^4^cij 



rt 



and 



No. C'LjLcx-. .v...'v - ^ St.; Dist.;bet. 

/ \r Dt»TM OCCURS »WW*V FROM USUAL R E S I D E N C E G I VE F*CTS CALLED FOR UNDER SPECIAL INFORMATION \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



\\ 



cvwi Jv'O-Nxy^. 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



X/^A ^<XX1 

I> \! 1. ( •!■ lilK 111 



• lUh' 



J. 



,L 



x\ 



i,i\ I 



1/ - :li 



A'^l 



^ 



» t ari 



n,i\^ 



SINT.!,).; MAKKIi:!) 

wiix lu i:i» <n< i>i\<>m in 

Wtiti in siM-i:il il«-«>i;.'n;iti'>ii ' 



lUK IHIM. mm: 
I Stair or roiinli \ ' 




r\jUL<L 



(^ 



I ATin-.K 






MEDICAL CERTIFICATE OF DEATH 

n\ 11-: oi- Di-.Ai'ii .'^ 

(Month) \ 'Day) (Vt-rir^ 

I IMvR I'l'N' C'liRTll-V, That I attciidtd dcHxasfd fidiii 

to -"""Tcp 

190 



j^ 

that I last saw h alive oil 

ami that «kath ofc-urrcd, 011 tlie «latr ^talL-<l ahnvr. at 
^.^^ M. 'J'Ik- CAISI'! Ol' 1)I{.\I"H was as follows 

nvt^vcU-t 



luk III I'l. \<i': 
01 I Aiin-.K 






1 1 



cx 



DlUATinN )\ar. 

CONTRMMTOKV 



Mont /is 



Days 



Hours 



DIRATION 



/t) 



Years 



Mouths 



MAini \ N\M» 

ni- Morm;^ 



Hiu riM'i.Ari-: 
<H- M(>iiii;k 

f Stal'' or t'outlt I \l 



( I 



^AII'ATIOX >'MP 






C^\a>xlAa-A''Mvj^ 



(Signed) Ui'V^^JA; O.'sO. IL Jjlux 



/?</r.? Hours 

wcL M.D. 



SPE04AL INFORMATION «nly for Hospitals, InstifutiU, 



or Rpcent Residents, dnd persons dyini) hw.iv Irom home 



Rrsiiifif ill Sini /"' (H'. 



^L )■-.■ 



M.,ifhs 



/>,n 



Tm-: AHovi- sT\T):i> i-kksowi. i'\KTicri.\Ks AK1-; TKiK ro rill-; 
nr;sT Ol- my know i.i.ix.k wd iu:i,ii.i- 



flnfo- maiit 






'1 



Former or 
Usual Residence 

When was disease ronfracted, 
If not af place of death ? 



HoM lonq at 
Pidfe of Death ? 



Transients, 



Da)s 



I'l^ACK <»1 IMKIAI. OK Kl'.MoXAl, 




DATJvot' l!ri<iAi. o! K):Mo\AI. 



I NDl 



'A.M.... Ll'il MVU<>.y^-^w<r>x al 



N. B.- 



^ r I Ar:F «houI(l be stnted r.X4CTLY. PMY8ICI ANS Hhould 

ivery Item oV information Hhould he c.-.retully suppl.e.l. ^ ' , jfj^,,. The "Special InformHtJon" for p-r- 

t«te CAlJSn OF DEATH in pinin terms, thnt it m,.y he properly cln««.Hc.l. 
« dyinft away from home should be J^ivcn in every instance. 



-I 
son 




«.;♦ 



ni 






ii > I 






'1 



I ! 



f ', 



P::: 



r. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li,.:,i.l. Ml>:.iil. IN" ::T!-^^:<nf^vrr, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dnir l-ilr<l. (JL^^v^oIt 3 1 100\ Beg Lsl creel A'o. 1 31 4 

. i 1 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "a. S. Stani?atD ) 

PLACE OF DEATH: — County of CV<X>^' vA.<x^vCA.<i.r.c City of Oo.'w J.V<x>vc<,^ co 
^ . K' '^ 1 4 I 

No. "^^ ^aX'VO-I- ^ ^XJL'^OJL^ VCM ^' <H.iStV^<X V' Dist.; bet. 



and 



-) 



/ ir DfATM OCCURS aLv trom fc S U A L residence give facts called tor under "special .nformation- \ 

( ,r DCATH 0CCUR.(>D IN • HOSPITAL OR INSjr.TUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME ^AxX'\Xu db cLua^u^ 



SIX 



PERSONAL AND STATISTICAL PARTICULARS 

, lOl.iiK 




LclIa 



ll ! .-> 



U A li I i| i;IK 111 



4l3 



MMiith 



\' .!•: 



(Day) 



lA)////- 



I \ t;ir i 



/ ',; 1 



^!Ni .1.1- M \KK Ii:i> 

\\ iix »\vi:i) OK i)i\ t >K* i;i> 

'\\tit< in ^<i« i.'il iii-*i>.'iiiit">ii* 



iMK run. \('i-: 

'Statf 'i! C'.Miit I V 



.0 






y 



\ \M \. < >l 

1 \i"i! i:k 



i!ik III ri, \> J-; 
ni I \rin:K 

(Slat( 111 finiiit I \ 



MMDI'.N NAMi: 
Ml Mo'ini-.K 



MIR llll'I.Ai i: 
<)l- Mo'lin.K 




MEDICAL CERTIFICATE OF DEATH 

DAT]-, oi- i)i:ath n 



in 

(I)av^ 



/go ' 

(Year) 



(MoiUlO A 

I lll";Ui:r.V CI.I'iTII'W 'riml I attLMi k<l .ItH^a^ol from 



U/1 



to 



that I last saw h ~ alive otl 

and that (Katli ofciitroil, on tin- <lat<.- statr<l altovt.-, at 



T<)0 



M The- C \l Si" Ol" IHiATII was as follows: 






vc . \ 



I) I" RATI ON )'ears 

CONTRII'.I roRV 



DT RATION Yiiirs 



Mont In 



Pays 



//ours 



.]ronl/is 



I >. err \ TiDN 






(SIG 



a 



NED ) WvCr\AJA^ ■ ^. U). (^<^ 

I'X) 



/^ays 



/lours 
M.D. 



A^VO -''" I(»0 1 



cI)al in 



f 



.X.Mrcsv) LvUr>AjlV^ 'B '" ^ 



Hotis, 



AVw,/r'(/ /» >>'('" fiiiii, 



'h 



1Am;//;> 



Tin- M'.c.XI.-.TMI IOM-K-^.)NA!.»V\KTI(M-!.AKSAKi:TRt !•: T. • Tlir! 



hllfo; DKlllt 




{ X.ldif^'^ 



"WvJ^ 



540 




V ' 




-V'VUX' 



■H 



Special information ""'y l<»r llospitdK. InstituMotis, Transients, 
or Recent Residents, dnd persons dvlng «iwd> [roni fiomr. 

Former or , T 3 Aj. ""^ '""'' "'' 

ElR^dence I ^b J.wJk 61 Plare ol Death? Da>s 

When was disease contracted, 

If not at place of death ? ^ 



i'i\ci':<)i" r.rKiAi^()K ki;m<>\ai 



DATJ'". <i! Ill !< I \i. "I R 



d jJ^\X 



R i:m(i\' \i, 
1 90S 






fAcMi'-^'- 



\n\ 



QfYux. 



A^.^ >'-- 



^..' 



>. B.- 



-1; 

81 



"""""■"■"""— ■"■"""""""""^ Tm •• I A(IF s'loulcl be stnte.l HXACTLY. PHYSICIANS kIiouM 

ivcry Item of inV'orm,.t5on «houl.l be cnreVuMy -PP'- ' ^^.^.f;,"; " „8«hMcd. The "Special Inform„tion" Vor p.r- 
t«te CMISn or DIATH 5n plnln terms, that .t mny be pr<M>erIy clu8«.ti 
on. flyinft away from home should be aiven In every inHtnnce. 




^ 



IH 



?»> 






1 ... 



I 






■ii 






y 



\':k 



L :i t 






4 



WRITE PLAINLY WITH UNFADING INK 



uoiini -f n- :'!ii' I ^■'' ■ ' ■-'*1:=^::~*' ^^^ ' 






10()\ 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. 5tnn^ar^ ) 






1 ' % ^ ^ 

PLACE OF DEATH: -County of Ou^ ^^A<^^^c^^c Gty of <X^^. O;^.^c.^c.o 

JvJLcUjLax^ fc (H^kJ^Ctl _St.; _^_ _,_;_ Pl^t.; bet. :^^;Z^:,rZo^^^ ^ 



yOJ\XA%^ yUU^'rVVA^V^^V YoENCEGivr facts called tor UNoeR specal . n tormation' \ 

FULL NAME U-'OJUDu cLavCi.^.. .■ ^ ^ • ^- 



PERSONAL AND STATISTICAL PARTICULARS 



i> \ I'l: < >i r.iK I'll 



l.l.v,U 




\c. I-: 



3,1 



) V(/ 






M.'ulh^ 






Ihn 



sIXC, l.lv M \KUIK1) 
\VII)(»\Vi;i) «»!< 1»!V< •Kv):i) 



niKTHri.AOK 

i Slate or c'oiuitrv-^ 




\.\M1-". <)!■ 
FATin-.K 



luu rnri.Ai'K 

()!• I APHl-.K 
(St, lie or Coinitrv' 



M MDl.N N AMI. 
ol- Mtn'lIJ'.K 



lUR rUl'LACK 
Ol" M<iri!l-:K 
( Slati' or (.■<)Uiitr\' 



cxA/wue^/cL 



UrX>^A''"'C^--i- 






a>v4^v s 




<X^^^- 



\[ uAaaxxa^ 



occ 



rpATioxQV J 



fCf^K/cd />' S,ni l'i,T)iiis'-o 



^ I )V,MV 



M.,nth- 



li.n 



TMKAm.vns■,^^T^:,,>■HKsovVvl;.^«•;;;;/,;:r"■"''•■ '■"" 

IIKST ()!•■ MV KNOWIJvIX.h AND lU.MJi 



(Infoviiiaut 



(Address 






MEDICAL CERTIFICATE OF DEATH 

DATi-: «'i- i>i:\ 111 n 

(Montl.l jr ''^•'^■^ 

I Hl':KI';r>V CI-IRTII'V, TIhiM attLMi.K-.l .Uvra-^*.-.! Ip'm 

M up H 






^VU^Ajl' '.l<-' 



up 



a. 



tb.^t Hast saw h--^ alivcnn lU^^ ?n^'. up 

and that death .KCiirrcd, .m, ihr .laic staled alxne. at ^-' 



M. The CArSI- Ol" DI'ATIl was as follows: 



•,-:) 



I )r RATION ■• )■'•<;/ 
CONTKII'.rToRV 




Months /^iU'S 



Hour 



Dl-RATION^. )^^y^-^ 



Mouths Pays 

(SIGNED) M- y ^X<X.(>;W-.„ ^ 



.cq .^ • u)o 



Hours 
M.D. 



SPEcJaL INFORMATION "nly lor Hos„il..ls. Institutions, fransients, 
or Recent Residents, dnd person;*^ dying jf^ny from liome. 

($ " j) HoH jonq at , ^ 

b tUv d.t Place ol Deatti? bl Days 



Former or r. ^. 
Isual Residence ok uvo 

Wtien was disease contracted, \\ ^ h 
If not at place of deatti? L^/^A^^^- 



,'W^V 



ri.ACK Ol- m-KIAL ('K Kl-.M"^ AI, 



1 TQOH 



)xjvt 






_^.— ^ —i ^M^— — ^^— — '*™*^^**^"*^"** . I rvACTLY PHYSICI-^NS should 

Htate CAUhL ui- uc^i" k ^Uen in every Instance, 

sons dylnft awoy from home should he fe.^en in every 



I i 



\i 



t-i- 









r'll 






i 



.1 







l«ftn 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoard <.f llv altl 



I - I- No. ; =; t-t''"^^ 1!^;: !' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Df/fr /vVfv/, Llwov^ %\ 7.9(9^ 



Boi^islered J\'*o, 



1316 





yj^ Deputy Health Officer 

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

Certificate of S)eath 

( XX. S. Stnn^ar^ ) 
PLACE OF DEATH: — County ofO/CL^ru J A.ix-v^ti^<i.x.o City oi^o^^r^ .^^o^^s^ti\.^t:,c 



No. ii^'iO ()b'tXW.^<L<x- 



>"v 



St.; 3) Dist.;bet. l^v<i 



and o/VcL 



(IF DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FQR UNDER "SPECIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



P 

FULL NAME Uy>a^-^>^^ 




VVAJOVk^QU 




U\> 



PERSONAL AND STATISTICAL PARTICULARS 



'J 



DA'li: (M I'.IUTII 



A' .1-; 



M..iitli' (T 




^ -Iv^jLl 



<l);iv) 



(Year) 



I? 



}■-,/; 



U 



^i\< .!.i: M \kkii:it 

\\ Iln »\\ i:i) ^^\^ IiIV« »RrKI) 



' St.itr or rmmli \ 



FA rni.R 



I'.IK THI'l.Ai 1-: 
Ol- lArilKK 

' Slate I il (.'ollllt I \- ' 



MAini'.N NAMl". A 
Ol- M<)TH1-:K \ 



niRi'niM.Ari': 

(Statf or v.'(miUr\ 






MEDICAL CERTIFICATE OF DEATH 

DATH Ol- i)i:a in /"^ 

iM..iith' K (Day) (Ytai) 

I III'iRlvHV C"I:RTII-N'. Tlial I atti-ii.lt.l .IcMc.iv^r.l fr-.m 

IXOCQ Xl 11)0*1 tn LIXA_<\ ^0 I()0 H 



/O Xl U)o1 ti 



that T last saw h ' ' alixcoii LAwV-\_a '.^.1 i, 



P 



hi tliat death ncoiirrcil, mi tlir il.itt,- ^tatnl ahovv. at I 
M.-M. Tlic CAI SI-; Ol" ig.ATII was as follows: 








I I 

AyOyO>vcLcr\X 



DTRATION )'('ars Months 10 /\ivs 



//ok 



rs 



MiOif/is 



/\ns 



avu 




OCCri'ATloN 

/xf.^nffif ill Siiii /'imn i-rn \ \J 




or RAT ION ^ )'riir<; 

i Signed > J Xo^/^^^cju VTv . OAxX^acy ■ 



//oil) <i 

M.D. 



Special information ""^ '"^ HospHdls, Instifufions, Irdnsitnts, 
or Rf(ent Residents, and persons dyinij dwdv Irom home. 



\ ■, 



lA,.///. 



/),M 



THV \HOVK STATJ'n PKRSONAL 1' A.RTUT I.A RS AK); TRIi; !"< • I' MI . 
I'.HST Ol- MV KNO\VI,i:i)i".K AND Ml-:i,Ii:!- 



nnfiitinaiit 






\<1;lirss 




<XA.\>^'si.'Crw 



It 



former or 
Isual Residence 

When Has disease ronfrarted. 
If not at placed death? 



HoH lonq at 
Plare ol O^ath .' 



Dd>s 



1-I,\("K < »l lUKIM, nl< k:i;m<i\AI, 



n jpX- 






IQO 



IMO'.KIAKIR 

'A(l(ln-S'< 



^. B.- 



hiverv Item of info.mBtlon «houhl be c«rc»'ully Huppllecl. AdB nhould He stated F.XACTLY PHYSICIANS hHouUI 
Lu CAUSE OF DHATH Jn ph.in terms, that it may be properly closKificd. The Spec.al In.or.n„t..m U.r p.r- 
sons clyinft away from home shouhl be feiven in every Instance. 



», 



-mfrm 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



»l 



i 






4 



1 1 ^i 



'fl' 






Jt.piird ..f M(.;ilth I- No. is 'tt'V^^^C }{vS:I' t"( 



^>' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



njo'i 

Deputy Health Officer 



Re^isfei'cd A'^o, 



MIX 



DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDcatb 



Ne 



( 11. 5. 5tan^ar^ ) 
PLACE OF DEATH: — County of Oiaw JXa^^xOUloo City of Oo/^^' /VXX'V\.C<_<i,cc 
. LcLu \J^\X/Y^Jm \jO<Ay\A.^\.k.i,.^U Dist.; bet. — and 



Jf / ir DEATH OCCURS /jhwAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
U V IF DEATH OCCUrReD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





o\,a 



■^ 



v,i.;\ 



DA 11 (M lllKTIl 



PERSONAL AND STATISTICAL PARTICULARS 

(JOI.OR 










\ < ". !•; 



5 b )•'•,/;> A 



M.oifh- 



1^ 



f\i\ 



si\( .i,i-:, M \KKn-:i) 

W I1><)\V}%1) ( >K I>IV( )Rii;i) 
I Write in social <lfsij.Miali<'ii) 



i 



lUKTIIl'I, \t*i-: 
' St;itr III r<innt I \ 



NAM!' »)]• 

I- A in i:k 



Mik riMM.Ari-; 

Ol" lArilKK 
'Statr or roiiiitry' 



MAim-.N N.\M1'. 
dl' Morill'.K 



luk'rm'i.AVi-: 

()!• Mo'lMIKK 
(State or Country 1 







MEDICAL CERTIFICATE OF DEATH 

DATl-: oi ni'.ATH O 

^MontlO K (Davl 

I 1I1{K i:i'.V Clvk'ril-N'. Tlial I altriwUM <lc( rasi.l from 



iVc:u» 



a... 



190H 



tliatl last saw h a. , r. alive on v^A,v.^^Q 

mikI that <Katli ttccurred. oii tlu- tiatr stated alxive, at d-oO 
^^ M. Tlu- CArSp; OI" 1)1 {A Til was as follows: 



ol ^\X %. 




OCCUTATION 



(?, 



x\.'>xcuvcL M f LcfV a^ > V 






nr RAT ION Yi'iir.^ 

CONTRIIU'TORV 



or RATION >''''^'^. 

(0 fL) 



JA'/////.v cXio /?t/)',v Hours 



Months 



(Signed) U). Cd. Lcr>\.t 

l iu^XS ic> oH (A.l.lre'.s) iXW 

FECIAL IN 



V. 



/\iv 



U, 



//oiti s 
M.D. 



Special information "n'y ^'"^ llospitals. institutions, Iransients, 
or Recent Residents, dnd persons dying dwdv Irom home. 



fi'f^ii/fif ill ^'i!>i f'l iiiiri^ro 



) V „•;.>■ 



.\/.<>ill,^ 



/),/! 



ri!|- MioVK STXTl-l) I'KRsONAL I'A KT h' T l.A K S A K l! I" K T K T< > Till-: 
IJI-.ST OI- >U' KN()\VI,i;i)C.K AND lU'I.DU' 



!:ST OI- )AX 
(Infonnanl J -h^/O^^rV-4^ VA^- 




dxAivt 



i Xd.lrcss 



LUL/VT^^A/I 



^..AVA-'^^. 



Former or 
Usual Residence 

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



n 5 H»H long at 

\XX'\\\jLAyJs\^'^M Place of Death ? 



Days 



ri ACK Ol- HIKLM, OR KJ-'.MoVM. 



0. 



'XV>\/WM 



U^iAX 



r .\ I 



.KKTAKKK XlLIm ^ ^' ^^ 



> \ ri-; •>: I!! Ki A! <i R i-:Mt ixai. 



T90H 



tx>v/ 



Ad.lrt-ss'il.lo '^TX ' ^^ ^J^ ^t 



fl .. 1-1 AHF Khoiiltl be stilted EXACTLY. PHYSICIANS should 

:;';;" rr: ";::r'r. r: ".t't p*:,":."':"...."^.^. th. -spec.. ■„.o....i,.„-- »». p... 



N. B. F.very item of inform 

state CAUSE OF DEATH in p 

Aons dyinft away from home should be Jiiven in every instance. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



'i 
III 



■M 



!!,.:,, ,1 ..f II. M'.th I' N.. '.- '*'l':^^^'i''^y('' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJO^ 



I)(f/(' Fi/cff ,[Xjuxy^^^^ ^' 

t^v^ Xi^v^ ^^?^^^'' Hf^a?th Officer 



llrgistcred Xo. 



1318 



DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( 11. S. StanDarD ) 
PLACE OF DEATH: — County ofC'/Oor-v ^^CLVlc^u.^co City ofC)-CWt' 0.>v<Xvve 



V-C. c^, 



No. irHb 




T.t) 



^tiv 



.K^y\/y^Oj St.; \ Dist.;bet. ^ '^^ and 

/ IF DEATH OCCURS AW-V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N FO R M AT I O N ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME V.<XAAaji 




K 




■\' 




PERSONAL AND STATISTICAL PARTICULARS 

-GST) f ^'■'"■"Mn 

.\».K 



MEDICAL CERTIFICATE OF DEATH 
DAl'l-; t)K DKATM 



O ; 



Vr.ii 



l/,.-/7/- 



\r;ir' 



A' 



^INC. I.l*. MARKIi:!). 

\vii)t>\vi;i> <»K i»i\<)Kri:i) 

iWiitt in »<»ci:il (l«.sij.Mi:<'i"ii* 




1UKTMPI,A0K 

(St.'itf or fiiiintry ' 



NAMM «)! 
I-ATHI'.K 



HIKlMUM.ArH 

oi" i"Arin:K 

(Stittf or Country 



M miii:n' n \mi-; 
OI- M(»rni:R 



lUKi'nrj^Ac'i-: 

OI' MoTIIlvK 

(Slate or ("ounti \^ 



nccrrATinN 

k'r^i,lt;f III ^\ni !'i .!», />'•" 









xOLli' 





W 



(MotitlO 



Dav) (Yfiir^ 



1 III'RI'IIJV Cl'IRTll'V, Tliat r atlcn<K-.l .lctiM>^<.'.l In.ni 
LLlvQ X"^ I90H tn LLcv/0[_ oJi 



tl 



!iat I last saw h •' 'v alive oti LXaa^Ol 'Xh iip'. 

ami that death occurred, on the date stated above, at V 
\X M. The CArSI- Ol" DlvATIi was a-^ follows: 



DTK AT ION ]\-(i)S .Wof///is v) / h/ys IIoio<i 

CONTKir.rTORV 




.<:\j ^cx.V'C^~x\' 



.■^\jy\A/:x, 



)V 



{ V,.7///- 



I\',\ . 



fl 



in- \H()VKST\Ti:i)rKKsoNAi.i'AKTirri arsari:tki K T" 
in:sT Ol' Mv KNOW i,i:n«''^ am> iu-.uj-.i- 



rii !•: 



Mouths Hayi 



I loui^ 
D. 



DTRATION )V<7;-v - - 

(SIGNED ) U -UrXOX vJ . ^kx.^^-^nr^ M- 

CLvQ 3)0 icn' (Address) 10 q NfVl^^A.v^^v Ot 

cpr^lAL INFORMATION ""'y f'"^ Hospitdis. Institulions, Transients, 
or Recent Residents, and persons dvinq away from home. 



Former or 
Usual Residence 

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



How Innq at 
Place ol Death 



Davs 



•I.ACKDI HIRIALOR KKMoVAI. 




1) \ii: ..; in loAi oi ri:m< »\ \\. 






" — , .. ,. , ATF sH.»uIcl be stnte.l fiXACTLY. PHYSICIANS Kh.nild 

N. B.— F.very item of infor.nutlon shouM be careruMy -'•>.>.-• ^ »^^^ classified. The ^Special Informntion" for pT- 
state CAUSE OF DEATH in plain terms, that it ma> he properiy 
son. dylnft away from home should be felven in every mstnnce. 







^ 



p'l 



'i 



ll 



hit 



I' } 

IN 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I{..:,,.lMni..lth \-Sn ■.■.<'t^^t^niSc\'C., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Fi/rff, {h..A^KAt Z\ 7'^0'i 



Eeg/.s'/e/'ed jYo. 



1319 



CX.^b'lA.^C^ 



lOL/v-M ^-P' • :.:-..ii...Off1cer 

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( 11. S. StanDarD ) 

J? ^ A % 

PLACE OF DEATH: — County of CVoav 0;vcl>vx^u.c^ City of O ^CL^ ^.OL^^>x^c<i.<^i) 
No H \cuJ/XJLA. M XxX^XlX St.; 1 Dist.; bet. ll^^A^^Cm^ andOAllT<\i> 

^ / ,r DEATH OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED TOR UNDER •SPECIAL I N FO R W AT I O N ' ' ^ 

( IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUVBER. ) 



FULL NAME 



sj;\ 



PERSONAL AND STATISTICAL PARTICULARS 




IXAju 





i» \ I1-; I 'I 111 KIM 



Month' 



I I):iv 



v".]-: 



v.- a I 



W 



1/ 



',-;////> i 






l>a\> 



SINt.I,!* M \KKIi:i>. 

WIlM »\\ 1 l> HK F)IV< >K»i:i> 

' \\\ ill- ill viH-i:il cl« -i'/nati'in) 



r 



.KTV^oK^ 



\ (^ (1 



nnn'nri. \oi<: 

' St:it» "I Cutinti \ ' 



NAMl". <»1- 



HiKrui'i.xrK 

<M- lAIIM'.K 
(State or Coil tit rv' 



MAIIil'.N N\M 
<)1 Mnllli: K 



l!IRrmM,A(l", 
(H NJnl'lH'.K 

(Slate <n roniitr\t 



oCCl TA'I'ION 

TnKAn,,vHSTXTKn..Kus.,NA, PXKTUMKXK. AK,: TKr..; rn TMK 

HHST Ol- MV KNOWl.I'.IX'H AM) M.lJll 




( I M fMiiiiaiit 



jJi^KJ 



( \ 






<iX. 



igo y 

(Ytai 1 



MEDICAL CERTIFICATE OF DEATH 
DATl". ()!■ Dl'.AIll r\ 

(Moiitli^ \ i!):iy) 

I II I'iK I". I'.N' ri-lvTI I'N', 'riiiil I attc'inlitl •Ic-fcasc'il fmm 
CjLuu:^. ?>b 190M to .lXcv.Q 'iO i(,oH 

that I las? saw h '• " ■ alive- on LLv-vC)^ ^ C Kp \ 

and that dcalh ocfiUK'tl. on thr datr stati-.l al.ovr. at \ 

\J M, The CM SI-: ())■ Di'.A'ill was as follows: 



^^?,^'., CV. 



DIRA'IION 
CoNTRMUTom 



Years Months 



Days » Hours 



I )r RAT I ON _ Years 

( u 



Months Pays Hours 

(SIGNED) LoL^v^^wJULo Mj^tXV<L^tAwV M.D. 

CLaxa -^0 r..oM fA.Mtvss) Q^^<^xWiii^i^c■i; 

SPEdAL INFORMATION "nlv lur HftspifdK. TnsTifiilions. rrnnsifnts. 
or Recent Residents, and persons dyin-j away Ironi home. 



Former or 
Usual Residenrf 

When was disease ronfrarted, 
If not at plat e of death ? 



Hov* lonq at 
Plai e (it Death ? 



Days 



I'l^ACK Ol' HI W I \I, <'K i< 1:M' 'V \I 



I'l A( K Ol' 111 I 



I 



:» \ ri', of Hi iM M, <ii k i;m< »\ \ 1, 



^|L^— ii^^i^^— ^— ^■^^'— ' t t I F.X4CTLY. PHYSICIANS Hhouici 

N. „._I-very Item of Informntion should b. carefully f 'i;;:;;^;'; /"^ilerir"! ««-''.-'• ^Th:. ••Specin'l Infor.nHtio.," for p.r- 
• „♦. C\l!Sr OP DFATH Sn plum terms, thnt it ms.> be proper y 



.) 



t; 



m 



f 



'! 



H 



h 



r 



N 



\ 



m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hm:,!.! ..f II. ;lUll 1' Vu \^,'^-f^y^ij\if^\'Cr, 



Da/r l-ilril, (XtvCtcUbb 3>l T'>0\ 

Lir^^^J» ioia^u Deputy Health Officer 



Ecgis/crrd ^"0. 



1 3J30 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©catb 



( tl. 5. Stnn^arD 



No. 



J? ^ ^ (^ 

PLACE OF DEATH: — County of Oa/>^' ^ K<X^\.<iK.<iCi City of 0/(X/>^ j;>.<X/\vec<i'- < 

11% • 13'ii'^• St.; S Dist.; bet. H lU^A^^m. and dl ^W n 



FULL NAME 




<il 





K. 



\\,OJ\^^ 



..-') 



PERSONAL AND STATISTICAL PARTICULARS 

SKX (^ A 0.1,. K 



DATl". < >1- lilK IM 



.\<.i-: 





\ 



i 









l^ 



)Vj, 



!/..»////> tf*^ 



/)<,M, 



SINt.1,1-:. MARKIl D" 

\VII)( >\\i:i> OK I»I\'' >Kri;i) 

iWiiliiii v,,ni;il (K sij.'iiali«>n 



mKlllIM, WK 

(Statr iiT rmiiiti V 



(^ 




VtTYWCU^ VjVv'CA VtXA^cU-N 



NAMl- 01 
lAIIIl'K 



HiKiiM'i, \rj-: 
t)i- I aiiii:k 

( state i>r fount I V 



MAim-.N WMI-, 

())• Morin-R 



luu ruri.Ari-: 

<M" MO'nU'.R 
(Slatf or t'oiuitrx I 



orcri'A TioN 




\j M rUfVCMX/v\/ 



'\/CXAyO./D.V<l 





Monlli^ 



„KAm>VKSTATK.>.M^K:.>NAI rAK.Mc.^,AKSAKKTKrK TO TnK 



(Infoiniatit 



( A<1(1n>ss 



MEDICAL CERTIFICATE OF DEATH 

DATi". oi- i>i:\rii 



(V. ar> 



(Month^ A" ">:»v) 

1 lll«;RI';r.V t'l'.RTII'N', That I :ittoii<K<l <lcit.a-^».-(l In.iii 
'JLC' Ujo'i to LIaa^ 'i I n^o'H 

tliat I last saw h •••■'v-^ alive »ui Lx^A-A^n 0-'\ i</> ' 

and that (k-ath ..tHnirrcl, on thi- .iati- stated abovo, at 5- lo 



i III', K 



Ar TIk- CVi^l- <>1- I>i".AI"H Nv.-i-- Ji'^ follows: 



'^ j^aJL 



'\'^r>,.Ar>. V, CX' 



.aJCmUvC> 



/><;r 



I )r RATION ^ J'(/rv Months 

CoNTRll'.rToRV LLvv..^ v . ..'..a.. 

Months Pays 



Hours 



[ ) r R A T K ) N 
(SIGNED ) 




Ycays 



<XX,^\\J^'^ 



Hours 
M.D. 



SPECMVL INFORMATION "nh for Hospitals, Institutions, rrdnslents. 
or Recent Residents, and persons dying dway Iroai home. 



Clv^a "M icoi fA.Mnss) Id ^S CLlU 



yQ M I()0 ' 

:mvl infor 



Former or 
Usual Residence 

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



Hew 'i^nq at 
Place of Death .' 



Davs 



l.I.ACKOF m-KIALOK RKMoVAI. DAjJ-r,.-; Uru.v. n, R.lMoVM. 
I NDKRTAKKK 




(Adflrc'; 






PHYSICIANS Hhould 
or pttr- 



>tatc CAUSn OP DEATH in P • term., tnnt u miij I" 

"n. dyinft a«., from home »h„u..l be tlv.n ,n .v.ry ■»».«««. 






:i 



f 




li 



I! t 



■iS' 



|:i 



^■^l 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BAC« OF CERTIFICATE FOR INSTRUCTIONS 



I'.M.ii.l ..t II. .,Mli IN.. . ^?''^X; !U's:)M- 



Ihffr n/rd, \X 



^ ii 



^VCXV^^tj 'i\ 



100 "i 



jRegisfrred J\^o, 



\'V^[ 



cMrvcc-5 .:U.A>u Deputy Health Officer 



DEPARTMENT Of PUBLIC nEALTH=City and County of San Francisco 



Certificate of 2)eath 

( U. 5. Stnn^arc> ) 

0^ 



% 



PLACE OF DEATH: — County of Cj/Cu^v VCt^v^Ui-C^ity of CLAV ^CV-k 



VC^<i.CL 



No 



. VCtu U ^HC^xtu L\.l/Y> VCLV. 



(\r Dt«TH OCCUR* *w*v FROM USUAL RESIDENCE GIVE facts callco tor under "special information- \ 
IF DEATH OCCyRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



\A-AVH^^^St.; 

E 
n 

D 
I) 

FULL NAME ^lu_^ 



Dist.; bet. 



and 



LlW. I^L 



M- 



PERSONAL AND STATISTICAL PARTICULARS 



illdx. 



i>.\ii-; ui HI kin 



At.K 



.?Ht 



M..111I11 



Dav) 



^ /■)//// ^ 



\ car 



/5,n,v 



\\I DOW I'll OK I)I\< iKi}-:!) 
iWiitciii '•oi'ial ilc>>tv"at ii'M ) 



HIK liUM. At'!-: 

(Stall MT i". Hiiiti \- 



NAMlv ol- 
lArUl-.K 



niKTlll'I.Ai. K 
nv V.WWKK 

' Stall I II ("iiiint: \ 



MAIIM'.N NAMi; 

oj- .Morni:K 



niK ruiM.ACK 

OJ- MOTIU-K 
(Statf i>r Coiiuti \ 






MEDICAL CERTIFICATE OF DEATH 

DATH Ol- I)1-:aTI! r 

LUux XS /po'i 

(Month ^ n (Day) (Year) 

p. I nivRIvHV CI:RTII-V, riiat I attcn.lo.l .Iccvascd from 

that I last saw h -^ alive on LLa-\^(3 J. i<)0 't 


ami that doatli ot'inirred, on tlu- <laU- '^tattMl ahovt-. at » 



^^ M. TIk- C^rSl- (»!•■ I)|;ATII was as foIloNss 



CI 



VX^Xv 



11 VsXVj^1^Vo^<. O O^flx^vv. > 



VQ 




1)1 RATION }'riirs 

(.'ONTRIIUTORV 



Mouths 



Pax 



I/oin s 



nr RAT ION 



10 



M(^n(/is 



€L >\ ^\X)uy\) 



<X/^wdw 



OCCri'Al ION CTA a 

oU ir\ >AJLXL L^- '" 






nj 



l.V 



( Signed ) 



//out \ 
M.D. 



4 



-w \aL iv<vvv-;u. 



Special Information nnlv for Hospltdls, institutions, Irdnsients. 
or Recent Residents, and persons dving «iwa> from tiomr. 



^ M. >:,'/,< 



I\l\- 



\XL'v\'V'Q^vu>a, 



THl" \HoVK ST \TI;D rKKSONAI, rAKTKTLAKS ARK TKIK To Til V 
lU'ST OI- MA" KNOWI.l'IX'.K AND lUvIJi:!" 

m 



(I 



nfovniaiit J A^<X/^^-^ N^V. 3 /tJ^V^ "W^jtl^ CJ.L\,^ . 



\.Mr<.'>;- 



au 



•> 



A^-sL^VA ' ' ^- • 



Former or 

Usual Residence VXL'VV'V'Q^^ 

Wften Has disease contracted, 
If not at place of deatfi ? 



v^_^„ 



HoH long at 
Place of Death ? 



Da>s 



I'l.ACK OI' lUKIAI, MK KKMoVXI, I DXII;^.; Mikiai ..t K1:Mo\\I, 






IS. B. hvepy item of information should be carefully supplied. AdK should he stated hWCTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
son* dyint away from home shoultl be (^iven in every instance. 







3 

i 

i 

. i 






'ftl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!..:ir<l ..f n<;(Uli- \' So. i> 1^-'^«^>i US: I' Co 



I )(//(' Fi /('(/. \Xk\, 



REFER TO BACK Or CERTIFICATE FOR INSTRUCTIONS 





31 2(J0'i 

Deputy Health Officer 



llegLstcf'Cfl A'^o. 



1 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of H)catb 

( 11. 5. StanOarC* ) 
PLACE OF DEATH: — County ofO/CX/->^ AX5L/^a>cv<i.<^<> City of Qoyw AXX/>ve\^'C.c 
No. I 10b O^OLX^TV' St.; I Dist.; bet. <xlAyV<AAXv-tr^Xkand K) X^Ax 

( IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECrAL INFORMATION ' \A 
V !F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /V 

FULL NAME OJUX^lX U) JlXu^ 






,A 



PERSONAL AND STATISTICAL PARTICULARS 




liAli- < •!■ r.!K I'll 



h 




^\aX? 



M..iitlli 



.\< .I", 



'k'h 



r. 



\\ 



II 

(Davi 



M.iil/i. 



/ao 



i^ 



! Vc;ii ) 



/',/ 



MEDICAL CERTIFICATE OF DEATH 

DAT]-; Ol" IH'.ATfl 

(I)av^ 



\Xa.k 



(W-ay) 



^!\C. I.Jv MAKkll'.n 

( W'l iti- i 11 -■ n \.\] il' >iv'i:ili>iii ) 



I'.iK rm'i.AcM-; 



NAM I <>!•" 
I-ATin-.R 



lUKl'IM'I.ArK 
0|- lAlIIKK 
(Statf or Coiiiitrv) 



M MDl.N NAMl'. 
Ill MojlIl'K 



lUKTIiri.Ai'H 
Ol- Mnl'inT 

(Stat'- <ir T'liuit 1 \ 




Moiiilil/T 
I Hi;i': i:i'.N' n.R'ni'N', That r aUcudi-d (k-ceased frmn 

\\aJL» 1 Up't to LLla^O^^SO I(>oH 

tliat I last saw h "^ .', alive oil \Ju^v.Q -'^ Tt/D A 

and that <l(.'at1i occurred, oti tin- date elated altove, at *" 

' .\I. Tlie CAISI-; Ol' ])!■;. \ril was as follows: 
Nj ^r\jtdrvv^<i-^-^ \J -wJC'^w^N^^rv-vC'-'^- 



DlRA TfON 



)'t'ar.i ' Mo)iths •-'U fciys 



-KU 



CONTRIIU TORY 



'I 



I lour. < 



-CVCiX^U^A-O 




i 








^V 1. 



1)1' RATION 

( Signed ) 



t'3 A 
.lA '///// v • ^^ *- /hiys lIouy\ 

Mnvvv. cL<XXXO_>v M.D. 

Special information "nl> tor Hospitdls, institutions, frdnsipnts. 
nr Recent Residents, and persons dving .iway Irnm home. 



1' ..'// 



Tin- \lu.^•^• ^rxTii) i-kk^onai. pau iuti.aks aki. tki (•; to 
HKsT ( 1' Mv KN')\vi,i:i)<.K AM) iu;i.ii:i- 



11 1-: 



I'lnf'i; iii:mt 



( Xddr.-s': 






Former or 
L'sudl Residence 

Whrn was disease contracted, 
If not at place of deatfi ? 



HoH lonq at 
Place of Deatti ? 



0d)s 



I'l \C1-" o| I!( K I \I. ' M-; )•; 1-'.M< '\ \I, 



.AT.:,. 



III i< I \i. Ml K i:.\t< '\' \ I, 

X^vti 1 IQOH 



I M 






(Ad.lr.'ss 



OcdJio...<^' ^^Vi 



IN. B.- 



-Hverv item o^ I.Worm.tlon nhoulM h. carefully supplieC. A(JH sh.uM »>c stnte. I.XACTLY •;"^ «'^' ^:!^ j;)-;;:^ 
Htntc CMISr: or DI:ATH ;„ ph.m terms, that it may he properly JaHshicJ. The Special In.ormut.on tor p.r- 
sons dylnfc away Worn home should he Jiiven in every instance. 



it 



ff 

'WW 



m 



w 

I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HoMi.l ot II. ii'ili I" \(). :- 5 



t-'^^_^'V 



r. IKS:!' Cr, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)a/r rileil, LLax1a>^ 2)1 1'^^O'i 



llci^is/ci'ed J\^o, 



132.3 



(3vw^AaA^ OJiAMj, 



Q C p Li .^' •. .K.v..4^i.».Jt.& ..'wT.l.fc.ii w <;; I 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



!'% 



■«'*■ 






Certificate of Beatb 



PLACE OF DEATH: — County ofvJ<X>v Oy^^CL>vCMlXM) City of vJ/CV^v A.o.y>xo^<».a<j 



'No* I 



54 5 ll)-cu^lvv 



St.; A Dist.; bet. 




( 



ir DEATH OCCURS AWA* FROW USUAL R E S I D E N C E G I V t FACTS CALLED FOR 
IF DEATH OCCURREDJiN A HOSPITAL OR INSTITUTION GIVE ITS NAME INS 




and cLO,\^'K 



R "special INFORMATION" '\ 
F STREET AND NUMBER. / 



FULL NAME 



iCL/» 



^.JuULA) 




si;\ 



DA ri" t .1 lUK TH 



PERSONAL AND STATISTICAL PARTICULARS 

! col, OR 





l\ 



<JjL 




MDiith) 



IS 

DmV 



(Villi) 



.\<.i': 



5?> 



) III I 



6 



M.oilfn 



fin. 



SIN*. 1,1-:. MAkUIKl). 

wiDi )\\Kn OK n!\'< »Kri:i) 

'Writfiii siK'ial <li si).Mi;itiim) 




(XAA^-XCL 



lUK rnfi.ArK 

Sliiti iir C<)iintr\' 



NAMi; or 
!■ A'lll IK 



lUKTIiri. MH 
OI- I-\lin-.K 

(St:it( or l"<'iiiU I V ' 






MEDICAL CERTIFICATE OF DEATH 



DATli ()I- i)i;atii /H 



(Mniith) /j 



lb 

(Davt 



(Year) 



I III':RI':BV CIvRTII-V, That I attfii.Ird .Iccrasfd fn.m 
W \% 190H t.) 0L>C<^ 'iO i,)o1 

that I last saw h-*-'^ ■ ahve on ^^< 



1 



'ho 



I<)0 
,C\^Cl OU lip ^ 

and that death occurred, nn tlir date sl;iti<l ahove, at '0 

a 

P ■ , J -< 



M. The CAISI-; (H- Di'iA'lM was as follows 



V^^Aw^laJtv-'^-'^-a^* Cri X< 



->^6-\»> 



M \!i>i:n" n 

ol MoTlIl 








or RAT ION" 9v );.//v 
CONTRII'.rToRV 



J/,>i////S 



/h7VS 



//ours 



JA )'///" 



lllK rillM.ACI-. 
o|- MoTllI'K 

(Stat. • « ■ ii"i 




TIM \iio\i-- ^r\ri n ri-Ksox xi. i-AKTim, \ks aki: TRri- to nii-: 

lll>rol MN Is NOWI.IIX'.K AND I'.l'.UII.I- 



till I 



„ OvdUX. mYV. 'QJiA^^-^'^<r\.^^ 







\.l(h(-s 15 ^ O 




-V\j 



4 



DT RAT I ON )V./'v 

,NED) OX^^ax. fc M/VoaI 

^ ^ J? 



( SIGI 



/hiys 



llotos 
M.D. 



Special information on'v lor Hospitals, Institutions, Trdnsients, 
or Rccfnt Rfsiilrnts, dnd persons dyini) dway from homf. 



Former or 
UsiJiil Rpsidenre 

When v*ds di'>''asp contrarted. 
It not at plare of deatli ? 



KoH long at 
Plare of Deatti ? 



Davs 



PI MI" (11 lit KIAI, OK KI:Mo\"A]. j DATIIot" MrinAi. <.r Kl-MOVAI. 



C 



iWajaa 



I ni>i.kiaki:k 



cL-Claa-'^wj 






looH 



■ , .. ,. , .,-,: „iw,,,i,i he Rtflteii F.XACTLY. PHYSICIANS shoiihl 

. „._,;very item of information «houl.l be cnrcfuMy s.ppl... • ^^^ ' ;;;;! ;;^^^,.: .^^ ^hc "Special Information" for p-r- 

Ht«to CAUSE OF DEATH in pliiin terniH. thiit it mny l.c properly ciassiticu. i 

sons dyinft away from home should be feiven in every inntnnce. 



« 



^JMN 



. 



I, J 

4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dff/r I'ilnL Ov^Cjy^.^^ Z\ J'f^'\ 



Registered J^o, 



13S4 I 



L_ 



Deputy Health OfTicer 



DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH: — County of^'A n- A^CL^Vl^CXACC City of 0/CL^^ J /vXX/rLCAA.o.0 



No. 





V 




^\yCAj^ (IuCHiKa^ICV- 



^k^ 



Dist.; bet. 



and 



/ ir DEATH OCCURS AW*V FRoVl USUAL ^ E S I D E N C E G I V E r*CTS CALLED FOR UNDER 'SPECIAL INFORMATION • \ 
\ IF DEATH OCcO}lRED IN aJhOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





rYY\j 




PERSONAL AND STATISTICAL PARTICULARS 





MW 



Xx, 



DATl-; (II- r.lKTII 



AC K 



, ^H^ 



iMoiith) 



5 1 ,.,:,. 



siN(".i,i<:. M\Kuii;i). 

\\II)t )\VKI) OK I)IVOKl"i:i) 

■Wiit>-in >-;i)i-i;il il<>.i!.Mialion^ 



HIKTHJ'I^ArK 

I Stall' or C'lUiitiyl 



(Day) 
M. ml lis 

I 



(Vi-ar) 



/'(tV. 



MEDICAL CERTIFICATE OF DEATH 

DATlv <)»• 1)I:A 111 

(Day) 



(Month) A" (Day) (Year) 

I ni':Ri:i!N' CI:RTII'\', Tliat I ;itten<k'«l (Icrt-ascMl from 



1 90 



tn 



NAM I", 01 

1- Ai'm:K 



HIRTHPI.ArK 
Ol- I-AI'UKK 

' Stall- or (."nunt! V 



NtAlDl'N NAM1-: 
ol- MO'nil'.K 



/^ 



/ 



lUKTIiri.Ai'l': 

Ol- MoTHl'.K / 

(Stall- or Coiintrv' ' 



'^•''■"■'■"'^' G'crOU 




lliat I last saw h • alivf on 



i(;o 



and that dcatli oroiiricd, on the date stated above, at 
M The CAT SI-: Ol- I)I;A Til was as follows 



^ 



\JU\JlXt 



Q^ 



)JO^-y\.Cs-\\. 



Kaa,; 



DTK AT ION )\iirs 

CONTKIHrTORV 



Mouths 



Days 



IIOH) 



K) 



Kesidr,^ III Still /'mm r-' 



);;r 



M,,iillis 



l\i\< 



VUV XHoVKSTXDa.l'KK-oXAI.l'MMKTI.AKSARKTKn-: To THK 

15KST01- niaLknu\vij:i)<-.k AND in:i,ii.i' 

(Inro,n,ant J. Ob '<X.<:V'C^ "> ^- 

M S \ 



DIRATION 



)\iirs 



Months 



Days 



_ I t U I .\ ^.^ - ■ 

(SIGNED) urVcrwsA; \l.yi).UJ. dJ2Xa.vvcL 



( 



,\,l,lri-ss) U>-\^A-^ 



I lours 
M.D. 



Special information only '"'^ Hospitdls, InstiluHons, rransifnfs, 






or Recent Residents, jnd persons dying dwdy Irom home. 

/Aa. ' >(rv 



Former or f K , \l^ 1 i ¥ \ 

Usual Residence ■1).UA.:' ^ :? ^ i - ^ t- ^ , 



HoH long at 
Place of Death ? 



. Davs 



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



ri.ACK Ol' lUKiAL OR ki-:mo\al 



DAIKo; lirKiAf, oi ri-;mo\ai. 



TOOH 



■NDHRTAKKR W<L£J[0^ 'Ofc<XQ^>V 



N. B.- 



state CAUSE OF DEATH in plnin terms, that it may be properly cla8«lt.ea. 
sons clyinft away from home should be l^iven In every instance. 



y 



yuw 



il 



$. 



m 



I n 



■ 



n 



M 



IVWl 



♦ ; 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



|{. ,;.!(! .,f HcfiMh (•• No. !'. **l'??ir^' 'i'*^'' ^'" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J,a/r /■•//,■>/, (L^<^ ii Z-'^^^H Itcgi.slcrcd Xo. ( ;>i5 

l^vvc^ IxivsM Deputy Hcalth.Ofncer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S>eatb 

( 11. S. StnnMr^ ) 

St % \ ^ 

PLACE OF DEATH: -County ofOa^^^ O.^v^^uev^CLCity of Oc^^- 0/^o^>vev^cc 



No. 1 vX^aM. V^u-vL 4a- ^ 



/^'vc>(rv 



V St.; T Dist.;bet. 



h 



r\^0<j and^y^'^^-^^^^^^-^^O 



.•ciiAi orCinFIMrP riWE facts called for UrAOER "special INFORMATION' \ 

( '^ .Vo;AT°H"occu%;m^."rHo"s^rAL o^'?r;sT^^"T^o^J^o.;r.;l name .nstea'J of street ano number, ; 



FULL NAME 



(xJ^d...cij^ 



SIX 



PERSONAL AND STATISTICAL PARTICULARS 

on . : o.MiK - 



DA ri- < )| IlIK'I'll 



A ( ■. J-: 




(L 






r,v< 



So 



.I/./;////' 



fVt-ar) 



H -A\V /J.. 



m\(,i,iv M.\Kuii:n. 

WlDoWKl) nK niVOKr}'!) 
(Wiitt ill xoi'iMl (!«. si>,'iiati<)n) 






P.IK rin-i, \c\-\ 

• state <'l •"ouiitl \' 



NAMl' <>I' 
I ATlll'.K 



()i.- iArm-:K 

(Stal< or roiiiitrV 



MAllO'.N NAM1-: 



ItlKTin'LAVI-: 
(StatL- 'Il i"(>iuitryi 



^ 





J^AJ.: 




-YV iX'<X>l^i 



MEDICAL CERTIFICATE OF DEATH 

DA ri', •»!• ni'.A'iH r\ 



Day) 



(Year) 



CJ Owy^ J .^^<x->x<^ ^^ •'^^ e 





/Cl 




v^ 



JO '(Ri 




'^Jl lwL'\v-> \. " " 



fMoiith) K 
I III;K1':15V CI-RTII-V. That ; .itU-a.k.l .Ucrasc-.l fiMiii 

tliMt I last si'iw li ^-^ alive on Ll^vCl. "^jC) i,,n' 

aii-l that .Itatll nrrurrcl, "H the .latr ^tatc-.l al).)ve. at 
M, The CAIS!-; Ol" Dl.A TH \vas a^ follows: 



DTK AT I ON 



)'t'ai s 



CON T R IIU • T O Iv N' ^^' X<X.Vv 



Mouths /hns 'i\ //ours 




r\jLU 






- }r.)itii^ 



Ihl 1 .' 



T„KXn<.VHSTXTKI.rKK^ONAl,rXKTK-^;;;AK^AKKTKrH T( . TH.. 



(luf'iiinanl 




\iM!f*iS CK 




\yv>A 



Uj^v-v 



t 



nr RATION 
(SIG 



)'rars 



J/o/l//iS 



/\n 



NED) MJ. Vll. UvJC'CLc* 



//ours 
M.D. 



Ou^x:^_^o looH (A<hi,vss) \acn lUxv^^v At 



SPECIAL INFORMATION "nly for Hospitals, Institutions, [rdnsienfs. 
or Recent Residents, and persons dying away from liome. 

fArmpr nr How lonq at 

SRe*nce PI«ol Death? n->s 

Wfien was disease contrarted. 

If not at place of deatti ? 



tl.ACK or 1URIAI< OR ki;M.'\AI. I)ATK..t lU im.x.. ... Rl-MoVXi. 









190 



v. A. 



'AiMics^ 



WW 



Cf»\ 



\>i.<i'C<rv\ 



31 



— — ^— — ^.^M — ii^^»^— — ' » t 1 FXACTI Y PHYSICIANS nhould 

rn';Ht'n?«way fron. h„,..o .hould he .ivc, in .v..> in,.-nce. 






^iSiM 



/ 



LOCAL. I T Y 



RECORD S 



SAN FRANCISCO 



COUNTY 

S AN FRANCISCO 
CALIFORNIA 



^ 



T I T L E 



RECORD 



I CRO F I L.M^D 



FOR 






THE GENEALOGICAL SOCIETY 



SALT LAKE 



CITY 



UTAH 



CALIFORNIA 



DATE 




APRIL 



1975 



PH OTOG RAP HER 



MAX JOHNSON 



CAMER ArBN02683 




RED 



VOLUME 1019~I325 



-4- 



• '_ ■ <■