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

ROLL 



■t ^ 



LOCALITY OF 



RECORDS 



SAN FRANCISCO 
COUNTY 

S AN FRANCISCO 
CALIFORNIA 



■t I T L E 



OF 



RECORD 



DEATH CERtlFICATES 



A.i' 



I CROF I LMED 



FOR 



T H E G E N E A L G LC A L S C I E T Y 



OF SALT LAKE 



C I TY 



/ 



UTAH 



CALIFORNIA 



DATE 



-~9 




APRIL 



19 7 5 



PH OTOGR AP HER 



MAX JOHNSON 




CAMERA ■N0 2b83M ^^^ 1 





VOLUME 1326 



1677 



904 





■'♦* 



EGIN 



■i' 




♦M/W*«*«^ 



,v« • « • • • • • t 



III*/ 

FEB I i»0*^ 



%«»t^ 



.--</ "•••'• 



Lib»r 








DEJHIT 



^ 



I' 



' « 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HoMnl of Hfiiltli— F No. !«; ■<'5^^^]S^ HS: I' Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



lUtfr Filed, dx^^pJb^-rni^ 100 \ 



Registered JSTo. 



1-3S6 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)catb 

( Ta. S. Stan£>acO ) 
PLACE OF DEATH: — County ofO/CWu J Axv^^y^A^ct City ofO/tX^^ J AXX^rvcM.A.^C 



^Ne. 








St.; 



Dist.; bet. 



and 



(IF DCATH OCCURSiTAWAY FROmIUSUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ 
IF DEATH OCCuiftRED IN A HOSPITAL OR IflSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



Kk/^oaJXxxA^ ^KKk^q^^^ 



SH.\ 



i).\ii-; (ti HiK III 



\<.K 



PERSONAL AND STATISTICAL PARTICULARS 

I COH)K 





I Month ) 



^^ 



J 'titl s 



<I)av) 



M,»ilhf 



(Veur) 



Davs 



MEDICAL CERTIFICATE OF DEATH 

DATH <)»• I)1>:.\TH r\ 

(Month) \ (Day) 



'i 



I go 

(Year) 




^I\<;i.K. M.\KK1KI>, 

Win* >\\'i-: i> OK i)i\« )RrKi) 

iW'iitcin "-luial ilcsij/iiat ion ) 



I f LcxvvoudL 



lURTHlM.ACK 

fStatt' or Country^ 



v A r I n: R 



^ 







I^in':Kl':i}V CI<:RTIFV, That r attended deceased from 
Xa 190H t() . UcAAX3L "^0 190H 

h.^VY\ alive on U^A-^cu '^*^ 190 . 

and that death occurred, on the date stated a1)ove, at I. lo 
M. The CATSlv Ol' DI'ATII was as follows: 



■^ 




HIR rn!M,ArH 

0|- I AlIIKR 
(State or Country) 



maii)i:n namk 

Ol" MOTHKR 



HIK rmM.ACK 

Ol' MOTIIHR 
(Slate or Coimtvy) 



(YyvvJ- 



Rf.iif^i! in Si!)i I'liiii 




DTK AT ION y('iu.s Mouth a Days / loins 

: ON T K I BUTOR Y yj>L.Cr>A^'cJk^ Ll.aAJU.^^>'vv<5 > >„v.i.x 



C 




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



MnlltllS 



n,T 



rin: auovk sT\'n:i) rKKsoxAi. tak iutlars .\ki-; tkii-: to riii': 
in-;sr oi- my knowij-idck and m.i.iiCF 



(Infotniant 



)JL^ 



K) XjxXa.^ 



O-^XvsXcJl 



Former or *\ ( m^ 

Isiial Residence <^'^ 1 ^ 

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



^AMy\JL 



How long at 
Place of Death ? 



3 



Days 



I'l^C^: OV nr RIAI, OK KKMoXAI. I I).\^'l-;of Hikiai. or RKMOVAI, 
La-^^^I; I OjL^ X T90H 



INDHRTAKKR 



yuJLuvA/5 Cj . O <M::LiUxx^ ' 



(Add 



Iress 2>C)$" 




N. B.- 



Every item o? information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 



sons dyin£ away from home should be given in e\Qry instance 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



noar.l <.f Mciillli -I" Nn i "^ "^T.?*!'.^' I*^'' t''> 




lOO'X 



Begistei'cd .A''o. 



1S27 



I )((!(' Filed y 

DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 



Deputy Health Officer 



Certificate of Bcatb 



( XX, S. Stan^arC> ) 






PLACE OF DEATH: — County of^'<X'T\j ^xcaxc^-^lco City of VJ-0_/yv /\^<x^-v^<^a.a.^ 



ofO 



A ^ 



.'O 



No. HO 



l^Q.- 



"D 




( 



^rv-U. WLxM^ St.; 3v Dist.;bct. ^J 

IF dea/Vh occurs away from usual residence give facts called for under 



SPEC 



IF d^ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



lAL INFORMATION" "X 
T AND NUMBER. J 




i,h 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



si:x 



^ JLTi-^XXXAJi 



""■"" U)JU 



:::i 



, \hAJUuyx' 



DATi: Ol" i;iK III 



oJvt 



iMoiitli^ 



A(,K, 



cJU bo 



J V'<;/ > 



I Day) 



M.nil/is 



(Year) 



Da YS 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 




go 

(Year) 



SiNCLi:, MAKUIi:i). 

\\"n>t)\\Hi) OK i>iv<>Kvj-:n 

(Write ill social (U-sirnat ion) 



HIKTHJM.AOK 
'Stall' or Country' 




AxLcrujUycL 



<X/\\j^ 



NAM1-: (»I- 
I-A'III Ik 



lUK THIM.Ai'K 

Ol" i-Arm-'.R 

(Slate or (."oiinti %•* 



MAIDKN NAM1-: 
ol' MOTIIKR 



lUR'lHI'I.ACK 
oi- Mo'l'UlvR 
(Stall' or Cotinlry 




(Month) (T (Day) 

I IIHRKBY CivRTIFY, That I atteiidcd dci cased from 

190 to I<)0 

tliat I last saw \\~rr- :alivc on" T90 



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




} 




<X/y\A^ 



ore 



TTATION (\ 

Rfsitfni ill Siin /'i <!ii( i>ri> J^^ )></»< 



M,.„ili^ 



n,n 



Tn J" \novi': sr\'n:n j-hrsonai, partkii, \rs ari-; rRii-: ro rin-; 

HKSr Ol- MY KNOWIJ'.IX. !•; AM) lil'MHK 



(In foiriant 




a 



AJUL/yv 



(Address 



HC^QvAM^ IWt 



DTK AT ION Years 

CO.NTRIHUTORY 



Mo)itlis 



Days 



Hours 



Years ,. Moiiths Days Hours 

M.D. 



DURATION 
(SIG 

?)0 i()oH (Ad(lress) Ur\.fr>A_iA^ UXi 



\TIC)N _ ) ears ^. Mouths Ihiys 

iNED ) L^rVCroJA; A)j.Uj.Xu-ay\\.c^, 




Special information only for Hospitdls, InslituniWis, Transients, 
or Recent Residents, and persons dying awdy from fiome. 



Former or 
llsual Residence 

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



How long at 

Place of Deatli? Days 



1M,AC]-: Ol" lURIAI. OR Rl.MoVAI 




DATUo! Ill IMAI. or RI'.MOVAI, 
(.Vldrcss ^ ^OSGoAAMii^ \ 



N. B. F.very item of iiiformsition •hould be ciirefiilly HupplicMl. AGK should be Htnte<l F.XACTLY. PHYSICIANS 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. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

}i..Mn1(.f n<MHh I No 1. f'^J^^jutl'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begistei'cd J\'*o, 



1328 



Ddir FiJol ,BjL}(Jzx^yJU^ 1 190'\ 

'dL,^)-A.->.^^ XtA^u Deputy Hcaltb Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( xa. 5. StanDarO ) 

U/O/YVO AXX/YVCAA/C^ Citv ofO- 



PLACE OF DEATH: — County ofU/O/YvO AXX/wcaA/C^ City ofO/CXA^O /\^/<X/-v^^i,^^^co 



^No 



.^'iS 




.1) 



St. 



1 



Dist.; bet. 




and 




ty\> 



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



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 
SKX QP\ ft I C01,OR 





DATl-: ()}• HIKTll 



a(;h 



iM.jiitli) K 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH r\ 



2.0 

(Diiy) 



(Year) 



4tJl(S 



}'t Of . 






Da vs 



-^iN*.!.!-:, MARuii:n. 

u in(>\\i;i> OK i)iv( »RrKi) 

iWiitiiii social (hsiK'i.'itioti) 



! i 



lUK'rUlM.AOK 

(State or Coiintrv^ 



FATHICR 



MIRTMPI.ArH 
OI" l-ATMKR 
(State or Coiiiiti vi 



m\ii)i;n NAM1-; 

nl MorilFR 



!UR rHIM.ACK 
OI' MdlHHR 
(St.(t< or I'oiintrv 



i 



^ (J 



(Month) ll 
1 ni{RI<:nV CI-RTIFV, That r attcMided deceased from 



^0 

(Day) 



(Year) 





2>C 190 M to 190 

tliat T last saw h alive on 190 

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

M. The CAl'SK OI- 1) I- ATI I was as follows: 

OXJll AD CJ^vvv.. ^cyyy.,^ 




DC RAT ION )'fars 
CONTRIHUTORY 



Mofii/is 



Days 



J /ours 



OCCtl'A rioN 



'/<X/vCmX 



■} 




DURATION 
(SIGNED ) 



)'ears 



Mouths 



Days 



U 





ex, U . Vflj <CVOv.q<x.tvvWo 



^l iQoH (A.hlrcss) IC^ 



Hours 
M.D. 

t 



SPECIAL INFORMATION only for Hospitals, Institutlttns, Transients, 
or Recent Residents, dnd persons dying away from fiome. 



Former or 
Usual Residence 



How lonq at 

Place of Deatfi? Days 



Rrsidrd in S<i>i I'l iiiii i ^lUt 



)V-iM c 



Mnxlhy 



Ihn 



VUV. AHOVK ST All! I) I'KRSOWI, PA RIUT I.A R S ARI' TRI1-- To TMI- 
HlvST OI' MY KNO\VI,i;i)C.H AND lUlI.llll- 



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



(Illfoiiiirint 




VxXAArtr 



">ViL 



(Address 



'^'is'UJlLvuA. 






I'LACl-: 0|- lURIAr, OR RKMOVAI. I DATl' of I?i kiai, or RKMOVAI, 
OA^^/WO-MH. I) ^txiU ' I ax|vfc 3. 190H 

INDKRTAKHK oV^aXu ^^^ QK) <0^/OijXX/\\) 

(Address 3jId1'^X ' I H tJL "Ul 






N. B. 



-Fivery Item of information should be cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information*' for per- 
sons dyinft away from home should be ftiven in 9\ory instance. 



t 



. ■ 



in 



•i I 

ii t 



■, ' i 

It I t 

.HI > I 

'■s ■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Il..;it(l of Il.alth -)• No. l^ *'|;;atf^»?;feH&l' Co 



/)(f/r FiJrd, 




10 0\ 



Begistcred JVo. 



J 329 




^cr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Beatb 

( XX. S. StanJ>arD ) 
J? ^ 

PLACE OF DEATH: — County of Crrur^-VVO.- City of 







«, 



'^No. 



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



St.; 



Dist.;bct. 



"and 



RESIDENCE GIVE fa 
OR INSTITUTION GIV 



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



FULL NAME 




^r\ 



PERSONAL AND STATISTICAL PARTICULARS 
SKX Qn jj j COLOR • 

DAii-: oi' niKTii 



tc 




A <■.!.; 



1 Month) X 



\ 



i \ Yr.ns A 



I Day) 



yfoHlfis 



I i'i.c 

(Year) 




MEDICAL CERTIFICATE OF DEATH 
DATE OV DKATH 

(Day) 




I go H 

(Year) 



I HF^RHBV CKRTJFV, That I attended deceased from 

— to 



..n 



Da v: 



si\(.m:. MAKi<n:n 
\vin«»\vi:i) OR niV(>Kci:D 

(Write ill ^<K-i:iI (k-si>.»^ii;itioii) 



HIKTMPI.ACH 

(Stxite or Coiuitrv) 




AxJL 



Crvvr 




NAMH O!" 
!• ATFIICR 



niKTMIM.ACK 
OI' lAlIIKR 
(State or Country) 



MAIDKN NAMK 
Ol" MOTUKK 







tX^rv^^ 



^Jy\Xry>^ 



— ~~~ — "190 "~" 

that I last saw h " ■ alive on 



Tqo 
I90 



and that death occurred, on the date stated above, at IV 
AJ ^^r. The CAISI-: OF DIvATIT was as follows: 



a /aA^c<trry.A.<<<x^ (rv /tikx U'-cX: 



\t\-.^.. 



DURATION Years 
CONTRUH'TORV 



Months 



Days 



Hours 



niRTIIPLACK 
OK MOTHHK 
(Slatf or Country) 



oCCri'AlION 



-]\xX.<x, >vcL 



DURATION 



(SIGNED ) 



Years 



^foHt/is 



CI, iD. LJmx^m- 



/\iys 



UA AA ISO T90 H (Address) "^^-^-^^XoJl^ Lcct 

cIal in 



Hours 

M.D. 



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



Prsiifftf in Suti /'i am i>rt> oO )'<■</;.<; 



M.nilh'^ 



Day 



\'\\V. MiOVF ST\'n:i) I'KKSONAl. l'.\ K IHT L A RS ARl-, TRIK To TIN' 
HKST Ol" MV KNO\VIJ:dOK AND UKI.IHF 



Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



(I 




iiforniant HrtTKVVO 

(Address ...T H WjxAj^^^^rrsj LvVN-i . 



PI.ACE OK BIRIAI, OR RKMOVAI. I DATl- of HtKiAi. or REMoVAI, 

QoiJ LvvvA. £ai I a^t 3, 190H 



t-NDERTAKER VJ OAXxA^ XcUJ.._ ^^ 



(Address ... 




^' ^' Kvery item of information should be CBPefully 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 9\9ry instance. 






'■ I 



"^ I 



fi » 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hnanl ..r H.alHi I N.) 1^ *tJS^^lUS:I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



RegisteTod JS'^o. 



1 330 



Ddir Fil(>(l , AjL^sXxr^'rXjl^ \ lOO'i 

dv<r^A.v« "ix^vu. Deputy Health Omcer 

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( xa. S. StaiiC>arD ) 

A ^ ■ I ^ 

PLACE OF DEATH: — County ofO/O/vu OAxx/vvcUyCO City of OXXa\; tS K(X/w^l\^^0 

St.; b Dist.;bet.'yC)^xijim; yxxXt andNLll Uj.uix' 



No. ^ 15 VjAX^veX 

(IF DEATH OCCURS 
IF DEATH OCCU 



S AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIA 
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A 



L INFORMATION" \ 
AND NUMBER. / 



>v ) 



FULL NAME 




si:\ 



DATl-: (>|- lUKTM 



PERSONAL AND STATISTICAL PARTICULARS 



COI.OR 





ACK 




Is 

(Day) 



b 1 y>a,s oL M„ulhs K) 



(Year) 



n,i v.v 



MNCI.l" MARKIl'.I) 

w ri)<)\\ i-;i) OR i)i\< (RvKi) 

' \\ I it< ill siK-ial (Usipnation) 



HIRTHI'I, ACK 

I State or (."ounti v^ 



\| iLcxaxax^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




(Month) 



NANt)-: (M 

fathi:k 



BIRTH PI, AC'K 
()l- KATHHR 
(State or Coimtry) 



MAini:N NAM1-: 
OF MOTHKR 




(Day) (Year) 

I III':RI<:BV CI-:RTIFV; That I atteiKk-.l (leceased from 

LIaA/O n 190 H to ULuuCv ^D igo\ 

that I last saw liA^>N alive on vAaa^Q ^0 I90 H 

and that death occurred, on the date stated ahove, at ^ 
VJ^ M. The CArSl{ OF DIvATH was as follows: 



DrRATION OlS" }\ars 
CONTRITU'TORV 



Mouths 



Days 



Horns 



M WaxKjjl OoOCOvX/CL/vru 



lURTHPLACK 

or MOTHKR 

(Statf or Coiintrv) 






/^ays 



Hours 



DURATION Years Mouths 

(Signed) U). \J. ^^LAA/wJkxx^-^-u M.p 

OX>i^A 1 Tc)oH (Address) 1 1 ^ b W (XIXulU^v Jl 



OCCITATION- 



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



THl'. \1U)VF. STA'n:i) fHRSOVAI, I'A K lU' T I.A RS A R i; TR T l" To THK 

lii'ST 01 MY kno\vi,i:d<;k and mkmick 

Sl5Vj.etVOL Ofc 



Former or 
Usual Residence 

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



Hew long at 

Place of Death? Days 



(A<1ilress .. 



PJ^CK <^I- m-RIAI. OR kHMo\AI, I I) VJ-i; of HiKrAt. or RlCMoVAI, 
INDKRTAKKR \K LAj. M / \xXjliA^'V\; ^^t Lo 

siaJD'f xx^wlU cit 



(Address 



^- R- Kvepy item o? information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«p- 
«on« dyin^ away from home should be (iven in 9\ery instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lioar.lof lUiiUh I \n is ^'tj^^ lut P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




190 ^ 



Registered JVo. 



1331 



I)(ffe Filed, O 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Deputy HeaCh OfTlcer 



Certificate of Beatb 

( Ta. S. StanDarD ) 



(^ 



-Y m -^^ von 

PLACE OF DEATH: — County ofO/CUYVj J/vXX-^AwCUlcc City of 0/CVY>j OAXV\v<tA^<U) 



No. Tas'b. 
( 





i/M 



St 



.; 6 Dist.; bet. 



IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C C Gl V E FACTS CALLC? FOR UNOE 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O 



FULL NAME 



K 



n 



PERSONAL AND STATISTICAL PARTICULARS 




A 




and UiCLoyvrva ) 

PECIAL INFORMATION" N 
nEET AND NUMBER. / 



si:x 



DAI'l-: OJ- lUI-rt'll 



A ( -, !•; 





\ 



(k. 



Vv>\A. 



\Ay> 



:x 



(Montli) 



X 

(Day) 



r% HI 

(Year) 



O I );a,s \ ^;,mths Xlb 



Da vs 



SIXC. l,lv MARKIi:i). 

\\ii)<)\vi;i) OK i)ivoKif:[) 

(Wiitfiii social <Usi>fiiati<)n) 



nikl'HI'I.AOlv 
(Sfatf or Country) 







« 



NAMIC ()!• 
FAIiniR 






MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH CS 

liu^ ^0 

(Month) I (Day) 



/go M 

(Yt-ar) 



I HRRKBY CICRTIFV, rhat I attended dec ca.sed from 

LLlx^ Qlj& 190 'i to LLuuX "iO i{)oM 

that T last saw h -i-^-' alive on vACv/Q "iC up , 

antl that death occurred, on the date stated above, at o 
■>^ M. The CAl'Sr: Ol- ni'iATII was as follows: 

V^A^AJk^-^h^.^^. ofc 



niRTMPI.AlK 
C)l- lAlllKK 
(St.ite or Cotintry) 



MAIDKN NAMH 
Ol- MOTHKR 



HlklMl'LACH 
Ol- MoTm<:K 
(State or I'oniitrv) 




Dl' RAT ION )'cars 



Mouths 



Da )'.? 



mNTRinUTORY (fo^ft^^-rc^crvJtLo^Q^ 



DI'RATION 



^ 



Years 



Months 



OCCfl'ATlON 



(Signed) J. J^AAycJ^x^^vv 



Days 




^l T()oH ( 



.•\<ldress) '^Sc?) VjMX J'l 



I fours 

\^ 

I /ours 
M.D. 



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



/hi \. 



THi: AHOVl-: STATi:!) I'KKSONAI. I'A UTKM- LA KS ARIC TRIK TO TJIl-: 
HKST Ol- \iy KN(»\\ I,i:nc. H AND nKMl-;F 



(In foiniant 



Former or 
Usual Residence 

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



How lonq at 

Place of Deatli? Days 




(A<l(lre«.s 









1'I.ACK OK IHRJAI, OK KI-:MoVAI, | DAT^! of Hikiai. or kKMO\Al, 

'^ 190'! 



INDKRTAKHR ()v9. <J. CJ-A.aJ(w ^<V \^ 

(Address 1 1^1 V rXA^^^^^-MrVV. ..Cl'l 



N« B. F.very item o? informntion 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 dyin^ away from home should be j^iven in o\9ry instance. 



M 
1'^ 



i 



'I I' 



< ■ 



if 



11 






il I j(H 



I'M ill 



^. 



^ttr WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



KoMid .)f Iltaltli — F" No. it -f'^^^ H&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/r Filed, 




I 



190\ 



Registered J\^o. 



1 332 



Ov,.<n..A^A^ dU2y 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( XX. S. Stan^arD ) 
PLACE OF DEATH: — County ofCjxX/>\) N|^KX/Cl |a-^-^^; City of CjtV(JkXcrY^ 




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



FULL NAME 



si:x 



DATl-: (){•■ lUKTII 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 





:'>A.' 




^ 




Jl^O 



iMoiitlil 



(Day) (Year) 



A <■.!•: 



O "O ]'i(iis 



% 



Motilh 



<^ ^ Da vs 



SIXCIJV MAKKIl-:!) 

wii)( )\\ i:i) OK i)i\"()Kr }-:i) 

(Wiitiin s(M-i;il ik*.i)^u;it iuii) 



HIK'nn'I, vol'! 
(Stiitf or Country^ 



\AM1-: ()!• 
1- ATII }".K 



FnU'nU'I.AOK 
<>l' I'A'rHHK 

'State or C'o'intrv) 



MAinivN NAMH 
()]■ MOPHKR 



HIR rHIM<A(^K 

'•I MornHK 

(Stall' or Couiitrvl 







MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




(Day) 



r,H 



(War) 



I HEREBY CERTIFY, That I attcMick-.l .Icciast-.l from 

I90 to — — — ic^ 

that I last saw h ■^^^"^ "alive on k/d 

and that death occurred, on the dale staled almvc, at ~ 

The CAUSE Ol- DIvATII wa^; as follows: 







Axxtx M K X) (TVUxLcL 



DERATION Years 

COXTRIIiUTORY 



Mouths 



Days 



Hours 



MiDiths Pays 

CLyV^/^w8.V<r>A.. 



Hours 
M.D. 



OCCT'I'ATIOX 



(?. 




'^'V. 



<L 



DERATION Years _^ 

(SIGNED) \. 2)^ oU 

VAAVC^ 'M K^ol f.\.l.lrt-ss) OX^KOlkAAVu V<XV 

Special Information only for Hospitals, institutions, Transients, 
or Recent Residents, and per>ons (lvin.j ,m.i> from home. 



Rfsidrd ill Sax I'l tun isro «. )'rnr.< ' M'i:iffis * /)a\. 



TH1-: AHOVK ^.TAI'l'l) I'KKSONAI, 1'A ki" IT T I,A KS A K l". fRll-: To THH 

HEST Ol- Mv K NOW I, ):nc.E AND Hi;i,n;F 



(In 



foiniant JVXXJOL ^U Kyir\\.0^- 



(A<1<1 



Former or 
Usual Residence 

Wfien was disease conlrarted, 
If not at place of death ? 



Hew long at 

Place of Death? Days 



I'l.ACH Ol' lUKIAI, OK K1'.M<»\\1. 

'ctIm-C 



l>\l^-;of niKiAi. or RHMOVAI, 



)ji\s% \ 



r.NDi-.KTAKi'-.K kX^WaXX/O^ \X/\\/kjiAXA\MJJ\'', 



T90M 



N. B. i;very item of Information should be carefully supplied. Adli Hhojld be stnted KXACTLY. PHYSICIANS should 

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



i«niMii«»a J 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

j?,,,,nl..f Hcalth-FNo. i > 1«^^^ U& I' Co REFER TO BACK OR CERTIFICATE FOR INSTRUCTIONS 



I 



Da 



fe Filed, 3 




V 100 \ 

Deputy Health OfHcer 



RegLstered J^o. 



1 3;5.3 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( "d. S. StanDarD ) 



J? Op A ^ 

PLACE OF DEATH: — County ofU/Cu^^ JAxXy>vCx^CM. City of O'CU"^ J ^cu-rAya<.,^L/CLx* 



No. 5H"l CjAXA.'-0>VLtrvv 

(IF DEATH OCCURS 
•F DEATH OCCU 



St.; H 



Ka\) 



Dist.; bet. ^ A^^ and 1 A^ b 

S AWAY rROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "N 
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




(^ 



SKX 



DATK (»1- HIKTU 




COI.OR 



VJrUvv 




iMimtli) 



^kctl 



(Day) (Vfar) 



ACK 



^11 iri 



VI );,ns \ .^/otilhs O ^ 



lhi\. 



SINt.i.K MARKIKI). 
WinoWKI) OK DIVORl'KO 

I Write ill '^•u'i.'il tlf^i>.'iiati<>n) 



lukTm'i.ACK 

(State or Country) 



LcvX>vOL<iw 



111 



if 



NAMH Ol* 
I- A Til KR 



HIRTin'l.ACK 
< ) !•■ 1" A r ! I K R 
(Slatf or Coinitry) 



maii))<;n xamh 

Ol- .MOTIIKR 



iurthpi.ack 

<»!• MoTHKR 
(State or C\)utitrvt 




MEDICAL CERTIFICATE OF DEATH 



DATE OF 



dhath r\ 

\kkAui 



(Month)/ 



(Day) 



(Year) 



I III':R1';BY CKRTIFV, That I atleiKkd deceased from 
\.l J^CtM- iQO to vLu^/CL M 190H 



vXm-CL '^^ti 



^Oaa 190 to 
that I last saw h -^.-'v. alive on V\.VA-Ol -j^-ti icjo 

and. that death occurred, on the date stated above, at L 
V Al. The CAlSIv OF DIv^TIl was as follows: 
^w^'w>vaJ!a.^C>-^.a^ ot dLxyxM^ 



di;r.\tion 
contriiu'tor 



} 'ears 



n 



Months Days 



J lours 



V \-<<XAxLA,./tXyC. U\).\^.V:i^J.^JX<<rVv 



IH'RATION ,. Years 

^00 



OCCUPATION fJvP 

Rfshifd in Sati f'l a in isro \\))'rn i s i }fiiiiths 



Mouths 

( SIGNED ) vJXjuI Uj- M>-' 

'h\ iqoH (.Address) 'XV^ 



Pays 



Hours 




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



Former or 
Usual Residence 



How lonq at 

Place of Death? Days 



ihi\. 



Till'. AHOVK ST\'n-:i) rKRSONAl. TAR riiMKARS ARl*. TRrK T« » Til )■: 
BKST OI' MV KNoWIJUXiH AND MKI.ll'.K 



(IiifoMiiant 




r\.1(l 



ress 






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



rL/\CH OI" IHRIAI, OR R|;MoVAI, I DA'p-;.)! HiKiAi, or RKMOVAI. 



•NDKKTAKKR H. • Vj . U L^T^V^TVO^ ^*<- L^ 
(Address 1. io 1 VrrVva,^.V^-vv 01. 



N. B. Every item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
.^ons dyin^ away from home should be jjiven in every instance. 




d) 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



li.xml of Health- »•' No. i<, "^'^^^^^ UScV Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



RegLstered J\'*o, 



\ 334 



l)((l(> AV/^v/,dxJpXt-.^U>Jt>v 1 100 H 

"l.cr\.v^:^ duiAvu Deputy Health Omcer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

{ 'CI. S. StanC>arC> ) 



St 



PLACE OF DEATH: — County of CPn^ir>-vA.<X; City of OxX^nJlOj VJI^Cj^^X- 





No. 



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



- St. 



Dist.; bet. 



-and 



RESIDENCE GIVE FAC 

OR INSTITUTION GIVE I 



TS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




^a 



PERSONAL AND STATISTICAL PARTICULARS 




SJ 



DATH ol lUKlH 



AC.H 




rVA^Xx 




Ntuiitli) 



la 

(Day) 



(Year) 



'li 



) V w 



HL MnutfiS 



Pa vs 




•^Ixr.l.H MAKKIl'.n. 
WIDOW l-:i) OK IH\'»»k( I'.I) 
iW'iitiiii >«(Kial lifsivrnatioii ' 



lUKTHlM.ACK 
( State or (."oiuitry) 



i, 



\\M1", <)!• 
I ATHICR 



HIRTHJM.AC'K 
<)I- J-AIUHK 
•State or Country) 



MAn>I%N XAMK 
Ol- MOTHKR 



IJlKTin'LACH 
or MOTIIKK 

(Slate or Countrv) 



OCCT'PATION 





Uu"kA.Ajtj 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH /O 



(Mouth) K 



^0 



(Day) (Year) 



I HRRI{RY CERTIFY, That I attended deceased from 

'.' 190 - to 190 ~ 

tliat I last saw h -• alive on ~~ 19O — -— 



and that death occnrred, on the date stated a!)<»ve, at 
M. ,The CAl'Slv Ol' DlvATlT was as follows: 



M. The CAl'Slv Ol' 1)I';ATIT was as fol 






Dr RAT ION Years 

CONTRIBUTORY 



Mouths 



Days 



Hours 



DTRATION Years Mouths 

(Signed) o^\j\rL^ (i^o-^^x 



Pays 



Hours 
M.D. 



vAA-^Q ^\ iqoH (Address) C3/CX.^»atxc vlW^UX V<xJL 



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



Rfsrdfd in Sttn I'l <ni< isro 



)'iii I . 



- .lA>/////« 



/)<n. 



rm: ^Ho^•l^ statiid phrsonai. i- \k iumi, aks aki: TKn-: To rm-: 
uKsr oi- MY^ KNowM,i:i)(.H AM) iu;i.ii;i-" 

(lufoMuaiit C/VJ) . (JKS> L.^XV'O:^ 



Ai,i:i)( 

W 



(AMd 



rcss 




(is? 



m 




Former or 
Usual Residence 

When was disease contracted, 
If not ?♦ 'lace of death ? 



How lonq at 
Place of Death ? 



Days 




INDICRTAKKR 

(Address 



^ 




K Ol-' inKIAI, OK RI;moV\1, J DATilof HiKiAr. or RKMOVAI, 



/0./WQ 



3 /ol/vx^^(x vJW^o^ \L<xX. 



N. B. F.vepy Kern of informntion should be carefully 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 per- 
sons dyin^ away from home should be feiven in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoard of lUaltli - l" No. i<^ "^^J]^^ J''&1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I M 



M' 






i)(f/(^ /v7^>o^ ...dx^pix^ JL^ I I'jo'i 

Deputy Health Officer 



Eegistered JSTo, 



1 335 



dC^O^^^^^^A^ 




,1 



DEPARTMENT OFPUBLIC HEALTH-City and County of San Francisco 



PLACE OF DEATH: — County 



Ccvtificate of H)catb 

( "CI. S. StanDarD ) 

o{^iOjy\) J Axxaxculcc City of Ooyvu J a^cxax/CxVAam:> 



St.; X Dist.; bet. 




(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" "X 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



and <=UAA^^^yWA^A ) 



FULL NAME 



S 



PERSONAL AND STATISTICAL PARTICULARS 
,KX (X\ A I COLOR 




■r\Aj.. 





n.\ ri". oi" iwK I'll 



AT, H 



iMoiith) 



» \ JV.;;> 



(I)av) 



Monlhs 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 1)1 



•"A 



30 

(Day) 



(Year) 



A/1 



siNc i.K. makuii:d. 

WIDnWJ'tD OK DIXOKi" Kl> 
iWiitiin sorial tlfsiKtiat iuii ) 



lUKTni'i.Aoi-: 

t state »)r C.uiiti v) 



k' 



/C^ 







' 



III,,' 



m 



WMJ' <)l 
I- A 11 1 I.K 



HIK I'HI'I.ACK 

<)i- I A rm-:K 

(Stat<- or Coiuitrv^ 



MAinilN NAMK 

<»i m<)Thi-:k 



IURTHPI,A('H 
<>l' MornKK 
(State or Country) 



lLvJk/> 



^\.xrv\rvu 







O^^-x^ 



cL 



- tux 

(Month) K 
HHRIUJY CERTIFY, That I attcMKU'd (Icceased from 

to vXwCL 




X^.Acp^ to UvVS^ 2>0 T90 M 

tliat I last sfiw h-t-^- alive on \Xw^ ^ Dpi 

and that <leatli occurred, on the date stated al)ove, at 'A XO 
^X M. The CArSl-: OF DlvATH was as follows: 



vVvtrv\.A/c.. 






1)1" RATION 
CONTRIiaTORV 



)'cars O ISIoulhs Days I /ours 

X. 




V^V.\.<! >.\ 



}'('ars 





^^ 



cL 



OCCI^PATION 






Months 




Da vs 



)oH (Ad.lress) S.Ol'i cU-eA>ULaxlj2\X) Jt 



Hon IS 
M.D. 



Special information «nly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Rcsiiifif in \<in I'i atnisro 



'S'luxi f 



M.^utln 



Ihivs 



VMV. AHOVl-: S'rA'n:i) I'KRSOXAI, P \KIICII. \Ks AKI", tki }■; To TH 1-; 
lJi:ST Ol' MY KN(>\VIJ;D<". H AND lU'.I.Il'.H 



(Infoiniant 



6 



UA^CutjUx) 



(Address 




<\. 



b I ViJj A,A.^i:Jk LLv-C 



Former or ( ri 

Usual Residence "^b G/VCA^^X^ 

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



L -V , Hew lonq at ^, 
vil/w-tiU"A Place of Death? 1 



Cmj^L. INjys 



ri.ACii OI" in'KiAu^oK ki:movai. 



(TW V\ 



DAT^'.of IJi HiAi- or KKMOVAI. 
^ TQOS 



k IM , o: III H 



i:ndi:i<'iakhr 

(. 



% 



Xddreis . V'l () "1 C) <VCA-^P^'>'WX^>X^ s.'.t 



N. B. Bvery item of informntion should be carefully Hupplietl. AGR should be stated BXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
sons dyin^ away from home Khould be [^iven in o\cry instance. 



i- 



» I 



M 



II 



( 



'1 



t « ; 



)( 






1,1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)?n,inl of n.;.lll» I- X... !^ -^.^|^:>I!.vI'Cm 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1 



Registered *A^o. 



1336 



/(' /'VAv/, dx^vtx'v\vLen. 1 100^ 

cLo-i-v^ dJL/v-u Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( XX. S. StanSar? ) 



^ 



PLACE OF DEATH: — County of O/Ou^^ JAXX^^^^cuUMi City of Cj/CWV JAXL/TVCv^ci 



■« 1 



No. 





Cm^' 



(IF DEATH OCCUrt^S AWAV FROM 
IF DEATH OCcluRRED IN A H 




St.; 



Dist.; bet. 



and 



USUAL RESIDENCE GIVE fac 
OSPITAL OR INSTITUTION GIVE 



;ts called for under "special information" \ 
ITS NAME instead of street and number. / 



FULL NAME 




'YW 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



'UJ 



I 




JvaJaji 



!).\Tr: oi HiRrn 



\ ' . I-: 



)l< 



v., 

Month) 



ss 



J I a I 



$ 



V 



la 

(Dav) 



.\r.ifitlis 



(War) 



1^ 



A; r> 



^ixr.i.iv MAKun:i). 
wiin t\vi:i) OK i)i\« iKii'.n 

iWiitiin '-ocial <l(>-iLMi.ilii 'ii) 



lUKrHPI, AOK 
'Statf or Coimtry' 




N\M»'. OI' 
1 A'lll ).R 



lUK'nUM.ArK 
OI lAIMKK 
(Statt" or Country) 








MEDICAL CERTIFICATE OF DEATH 



DATE OI- DKATH /O 



(Month) K 
I IIIvRI:BY CrvRTlFV, That I atleiidod <lecease(l from 



?)0 

( Day) 



i9o\ 

(Year) 




\'X 190 H to 

that I last saw li i-"^ > ^ alive on 




^ 15.0. ^U)oH 

and that death occurred, on the date stated above, at i \0 



JX M. The CAISK OJ^DICA'I'll was as follows 



MAIDllN NAMK 
«>!• MOTH MR 



lUKrilPr.ACK 
OI-- MoTHHR 
{Stale <jr Country) 




CUV\,A 



7 



DTRATION ]'c'ars 

CONTRIBrTORY 



M 0)1 ills 



Pays 



//ours 



(Signed) J. 



? 



i 



occi 



\J JUk^<kXjL\) 



Resiitfii ill Sim /'i ii m /.iit OO )V(7/f 



.\f»ll//lS 



n.ir. 



vnv. AHo\i<: sTATi-: I) I'KRsr )nai, i-ak rue i.ars ARi; TRri-: ro 111}-: 

HHST OI' MY KNOWI.J'.DC H AND IU':I.11';K 



(Infotmant V^ . V) . <AD . OL 



A 



(A (1(1 res 



AwCtu, 



'CXA-VM^i 





/^ays //ours 

M.D. 



.1 



SPECiAl Information only for lldkpitdls, institutions, Transients, 
or Recfnt Residents, and persons dyinq away from home. 

Former or ■^^Uxxa.^v^ ^"^^4, "»^ ^m at . ^ , 

I'sual Residence vty^-^x/^^^^wCA.^CA.xOl . 01 piare of Deaffi? ' v \ Days 

Wfien was disease rontrarted, 
If not at place of death? 



T90 t 



,^ri,ACH OK lU'RIAI, ok RHMOVAI, I DATI': of Uikiai. or RKMOVAI. 



IN. B. Kvcry item of ln?ormntion 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 given in every instance. 






ill 



IJi 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nonr.l ..f Health F No i > 1^?^^. H&l' Co REFER TO flACK OF CERTIFICATE FOR INSTRUCTIONS 




Registered J\''o. 



1 ^17 



Ihili' /'y/('</ , J3jiJ^sXjUy^JiM^ I I'JO'i 

i-fr-u^ ioAMJ Deputy Health Officer 

DEPARTMENT rfp PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of Beatb 

( tl. S. Stan^ar^ ) 

PLACE OF DEATH: — County of O-O/^rvj J AXV>vcaa C( City of Oxwv; d/UX^CA^'C< 

(lii^ ft 



No. Hoik 



(i 




KXA^'^O; 



and 



O^, St.; 1 Dist.;bet. 

ocqu 

H Occurred in » hospital or institution give its NAME instead of street and number 



J /CuXtX' 



/ 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 rtrrilRRFn in a HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



ISTIT 
to 



FULL NAME 





.\aX dui/^VTVU 



PERSONAL AND STATISTICAL PARTICULARS 




SK\ 



DAII-: <)l- lUKTII 



\<".H 



COI.OR 




.1 



4i'>iitiii K 



(I)av) 



(Voar) 



(Year) 



) 'i\i I 



.1/. .»////> 



0.1 



/><7 1 ,v 



S|N»,I,K M.\KKIi:i>. 
WinnWKI) OK I)l\( )R< i:i) 
'W'ritiin vooial dt- siirnatioii) 



lilRTm'I.At'K 
' Statf or CinuitrV 



NAM)-, <)1 
f A r H H K 



Hik'nnM.ACK 

<»1" l"\rHHK 
(Stat( or Country^ 



maii)i:n namk 

()l MoTHKK 



HiK riiri.Ari-: 

ni Mo'IUKK 
(State or Cotiiitrv) 



occri'A Tiox 




ft 



,MwA 




X^v'>x 




JUWvV€u'> 





MEDICAL CERTIFICATE OF DEATH 
DATE OF I)K.\TH /^ 

iWct M 

(Month) K (Day) 

I HERI':BY CKRTIFV, That I attended deceased from 
LAXCCL Ov^ 190H to VAAa^ /bl 190 H 

tliat T last saw h -^-''■' alive oti U-0-/CL '^^ 190 'i 

and that death occurred, on the date stated above, at 
^ M. The CAl'SI': OF 1)I':AT1I was as follows: 



CONTRIHrTORV 




Mi)}iths \ Days 



Hours 



DC RATION 
(SIGNED ) 



Ycixrs 



J. Vj\. oijoo 



Af<ynths 



Pays 



I/ours 
M.D. 



X^O. 



OXWy\XX'VL<.L 



f\fsi(if<i ill Siiu /'i iii/r/fro "" )'riii.< \ .l/";////> oC (^ /^<'i' 

I'm: A]u>vK STAT)" I) rKKsoNAi, PAR rur I. \Rs \Ki: rKii-: lo rui: 
HKST oi- Mv K.Nt >\\"ij:i)<", H AND iu:i.n:K 



(Iiiforniatit 




-Z/W.'yy^ 



(A<l(lress 1. V^ i ['K VSj /CCVA, 






HOlU 



St 



ULvvq '^M IQOH (Address) ^^l 

Special information only <"r Hospitals, Institiitlons, Transienls, 




or Recent Residents, and persons dying away fro:n home. 



Former or 
Isual Residence 

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



Hew lonq at 
Place of Deatfi ? 



Days 



ri.ACl-: OI" lU'RIAI, OR KKMoVAI, 



DATIiof HiKiAi. or KKMOVAI, 
i 190^ 






(Address 



N. B. Rvery item of information should be c.-.refully siipplieil. AGB should be stated EXACTLY. PHYSICIANS should 

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






Ui 



il 



rffl 



im^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IJoanl of Mcalth-I' No. 15 "^'^L;'!*^ J'-^'^ <^'o 



J)(f/r Fi/rff, 







I 190 \ 

Deputy He^^r. ^ Ticer 



Be^istered J\^o. 1 ooH 



DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( Ta. S. StanC>arD ) 
PLACE OF DEATH: — County ofCja>'V' JXXX/>'VOL4.C{.City of *3^€L/Vu AXXavca^Cc 



rNo. 



w lb 



D 



>^^A-trv\, 



y 



.. CX'-CL^, 



St.; I Dist.; bet. 




."LcYV 



(ir DC*TH 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. J 



and oUXC'VvCrv'XV ) 







FULL NAME 




WA/WJX) 




<X/Y\^^. 



s )•: \ 



PERSONAL AND STATISTICAL PARTICULARS 



^ JL/-yv\^^(xXjL \xA\.kX^, 



DATJ-; Ol- HIK in 



x*.!-: 



Get 



iMotith) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

Si 



(Day) 



fVtar) 



'[ 



siMijv m\kuii:t) 

fWriUin social (lesiv:nati<m ) 



HIKTHPI, AOK 
Stall' or t'oiiiitrv* 



NAM J Ol 

I- A III i:r 



IUkTHIM,A<K 
• II- I AIIIKK 
(Statt or ("ountrj') 



MAIDKN NAM}-: 
Ol- M or I IKK 



HlklHPI.ACK 
Ol- MoTUHR 
'Stall- oi rouiitrv 






/hn.'. 





(Year) 



(Month) A (Day) 

I HI-; R J-:HV C l-: RT 1 1' V/ That I attcndcMl deceased from 

LWx:j X^ icoH to lU^.CjL 



X^ lyoH to 

that I hist saw h «i-^vj alive on 



CL. 



io 



190 H 
v^ i)^' 190 H 

and that derith occurred, on the date stated above, at H 
^•v \^ The CAlSh: Ol- DhiATII was as follows: 

viD K/s^^y^A^^ \J/v>jlw\>v^'vnwa^.<^ 



DCRATION 
CONTRIP.UTORV 

I) I' RAT ION 
(SIGNED) 



]'cats Mo)iths o Pays I/oiirs 




r.VOAu 



Years 



Mo)itlis 



Pa vs 




AV 



OC'Cri'ATlON 

Rrsidfii ill Snii f'l tun ism 



ol^cux O/CuyVrvwwc 






rm-; aho\i-: srAri-.n i'Kksonai, tar i hilars ari-; irik to rii j-; 

IlKST Ol- MV KNOWl.KDC.H AND M1-:M)-;F 



(Iiifoi iiiatit 



\j 




1 



fAdd 



n-ss 



II 






IXa VA^-tryyu M Xxx/CA- 



J 



//ours 
M.D. 



t\^q '61 TooH (Address) 5 Hi? d-U^L\X\) it 



M 61 T()oH (Add res 

;IAL INFORMATION 



SPEClJiXL INFORMATION only for Hospitdls, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'l.ACK Ol-' lURIAI. OK kI-:M<»VAI. 



DATFo! I'.iKiAl. or R1-;M0\AI, 



r 



(Address , 15" XH. UXAr^LkX>try:u Bl 



!N. B. F.very lter« of information •houici be ctirefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pliiin terms, that it mny be properly classified. The "Special information" for per- 
sons dyin^ away from homo should be £iven in every instance. 



.t 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M....i.l..nir:,ltl. 1 No i^^-^'^^"'^"*^'"^ " REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)(t 



h' Fi/r(/ , 3jLJ^\XjL^^\AM/yj i IfJO^ 




Be^isfci'Cfl J\^o, 



1 339 



Deputy Health Officer 



DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( "a. S. Stan^arD ) 



PLACE OF DEATH: 



No. \\ 



ri^ iLa"^ 



County o{Oouy\) ^ KjOu^\j^kA<:a. City oi^OJTs) /vCXyv-vc^wAl^c^ 



^ 



Dist.; bet. 



(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I W 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 
M.X A . f\ I COI.OR 




A.>My>^,-^ 




■cJu 



LL'J^ujtx 



DAIl-; i)l IWKll! 



\ < ; V. 




(Dav) (Vfjir) 



S^ 



) 'tUt I !• 



1 



M.miii^ 



^t 



Pa 1. 



STN(.1.1-. M.\KUIi:i). 
WIDOWl-:!) <»K DIVDKrKf) 

'Wiitriii «)ri;il <!< -iv'iiat ii m) 



!UI< IMI'I.AOK 
' stati- or (."ouiitry) 




NAMR OF 

iATm:R 



lUk rniM, AiH 

ni 1 Alin:R 

I shitf or I'onntry) 



MAIDI'.X NAMI-: 
<>l- MolIlKK 



luk rui'i.ACK 

«)1" MOTHHR 
fstatc or t'ouiUrv) 



OCT !* PAT ION 



MEDICAL CERTIFICATE OF DEATH 

DAT}', Ol" Dl'.ATH r\ 

(Month) A (Day) (Year) 

J ni':Rl':HV CI{RTIFV, That I atteiKkMl .lecoascd from 



190 



to 



that I last saw h ~ alive on 



I90 



atnl that death occurred, on the tlaU- stated above, at 
~~ M. The CATSlv Ol- DI'ATIl was as follows: 

1)1 RAT ION )'L'ars Mont /is Days Hours 



CONTRIIU'TORV 



DIRATIOX _ Ytars .. Months 
(SIG 



NED) L^iVrrLUv 0, Vij ^■ 




Pays Hours 

Ola'vxL M.D. 



^f.Olt/f' 



Pa 1. 



Ill I. \Il()\-K STATl-.D IM-: RsON \i, V A Ri'Ur I, A KS AKl". TRll': To Till-: 

in-.sr ()i- MY kno\vij:d(". !•; and in:i.ii:i-" 



(iiif 



^'KJJyJi 






' Xi'.dress .. 



Ij^Vvt) I iqoH (Ad.lress) L^\-^-vA,£A^ Wi^^ 
SPECIAL Information only for Hospitals, Institutians, Transients, 



SP_ 

or Recent Residents, and persons dyinq away from fiome. 



Usual Residence 1 1^ ^ ~ H IL WxM. 

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



How long at 
Place of Deatfi ? 



Oavs 



V\ \QV OV lURIAl, OK K1:m<»\A1, DA'I1I% ot lit KIAI, or RKMOVAl. 



(Address . 



N. B.- 



-F. 

8 



ivery item of InWmaf.on should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
tate CAUSE OF DEATH in plain terms, that it may he properly classified. The ' Special Information for per- 



sons dyin^ away from home should be given in every instance. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



)(,,;, 1. 1 -f H.'iMii •■■ ^■" i> t"t:'*':;^'"'^''^"'> 




/)((/(' hailed , 




\ 



lf)0\ 



Rpgisfcrod J\^(). 



<340 




j-^ Deputy Hcnfth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "U. G. StanDavD ) 



PLACE OF DEATH: — County 



ofVJCL'-ryj .^XXoO/CAAOo City of vJCUTv A/O^-x^CA.^i. ci.<j 



-I 



No. ni^i M ll/OXLCAV St.; 1 Dist.;bet. .MX^i and UAXCtnO; 

/ ir Ot»TH 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 tEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




KAXhj 



>\-.\ 



) \i i; (ii r,iK 111 



PERSONAL AND STATISTICAL PARTICULARS 





xJa 




I Moiiih I 



U 

(Day) 



A^\ 



MEDICAL CERTIFICATE OF DEATH 

DAi'iv t)i' i)i:.\Tn 



\<.i': 



'I 1,1 




bS r,„.;. O 



.^filHlllS 



ao 



'Year) 



Pit V.v 



W !!>( »\Vi:i) nk DIVoRTKI) 

Wiitciii •^iKinl il<si>.Miati«in ) 




itiK rniM.AOK 

Slatf or Country) 



FAT II IK 



lUKini'I. \(H 
<>|- |- A III }-:k 

f "^tatf 111 v'onntrv) 



maii)i:n NAM1-: 

oi MOTIIHK 



luk rmM.ACH 
OI" M()Tm-:R 

lStat<- or Coiintrv) 



UXVWX€L/YVU 

1 • 



Moiith' [1 



< Hay 



(Yt-arl 



I m{Ri;P.V CI'RTII'N', That I atlfii.lr.l «Iccfaseil from 

tliat I last saw h -LTk^-v alive oti Vw^AA-O sS U k^ "^ 

and that (kalh occurred, on the date stated above, at " 
VJ - M. The CAl'SI' Ol- DI-ATlf was as follows: 



I) r RAT I ON )V<;/.f ^ Mouths b Days 

CONTRIIU'TORV Qj OrsuO^^rv^^^KXj^Ary^ 



Hours 



I 



occt 



TATIOX (\ 






\ 



Rfsidetf i)f San /'i uiii isro — )V(/;y "~ M<'nfh^ 



/hn. 



Till-: \lto\-l-: STAT)'.!) I'KR-iONAl. I' \R iUT I. \KS AK i: T k I l'. To nil': 

iiivsr OI- Mv KX()\\"i,i;i)<". I-: and ip.'.ij)-.!-' 



' I iif' .: maul 



fA.Mress Ill?> Ni f\yCLA.<rVyj 



■^ 



1)1' RATION }'cars ^ Mont/is ^ /^ays Hours 

GNED) LUL^A-jUL L^OoWLtNj M.D. 

Xj\<\y I TQo'i (Address) HHCO ^ \'\ U\^ cJt 



Special information onlv for Hospitals, Institutions, Transients, 
or Rffpnt Rfsidpnfs, and persons dyinq away from home. 



Former or 
Usual Residence 

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



Hew lonq at 
Place of Death 



Days 



190 t 



ri \CF OI" lU'KIAI, Ok kl-;MO\AI. j DAJl'.of l!i kiai. or kI-;M()\"\I 



(AtMrcss 



N. B. 



-h 

8 



ivery Item oV informHtion should be cnrcfully Hupplied. AGB should be stated F^XACTLY PHYSICIANS «houId 
tate CAUSE OF DKATH in plain terms, that it may be properly classified. The Special Information for p^r- 



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



I 












il'J 












WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. r„ uh ,. vo i.^-^^^ H^l'^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale hailed , 




\ 



10 (J\ 



Hegistered J\^(). 



1 34 1 



Depu 



t' *icer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 



tl. S. Stan^ar^ 



QfD 



PLACE OF DEATH: — County of 0.-.X -J .►UXz-vvca^c^ City of ^J'Cv->^ O/vawtA... 



f^ 



iv) 



f4o;rVaYtC*A^ ^^'-'-^VUi. vxi^l i-( I St.; 



-tu, V 



«i I i)^ 



Dist.; betr 



and 



-) 



I / iiciiAi Dr<; I nrisir F nwr facts called for under special intormation ■ \ 

( '^ r/rc;T°H^OCC^%Tot~"° --"' 0^'?^^f.Tj;U'^O^r.;i name ..ST..0 O. STH..T ..O .UMB.. j 



FULL NAME 



Ll>vt<rv^w^C) 




L<xcL(5 



V^^c^v 



si:\ 



DAT!-: Ol IlIK 111 



PERSONAL AND STATISTICAL PARTICULARS 






/ 



rVO' 



Ic 



M.)!ith) 



\'.i-. 



Hfc 



)'rai 



may) 



M.,ntln 



(Year) 



Da\> 



- \ , ; 1 M \kH ll-:i). 

U 11»< tU i;i» OK DlVoHt l\I) 

Wiitfin >.<Ki;il «U >i>.'iiati'>ti> 



liik 111 i'l, \>" )•: 

•~t.-it' or < •niiiliv^ 



N \Mi-: »>i- 
1 \ rii i.K 



I'.ik riiri. \i i-; 

<tl l-ATin-.K 
^t:it( or Cotiiitrv' 



\i miii:n n ami 

"I MuTlU-.k 



lilkTHlM.Xri-: 

<'i" Morm-.K 

'St;itf or C'o\itUr.\ 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



.^Q 



(Day) 



igo'[ 



(Month) /J 'l>:iV' (Year) 

TTThrI^RV CHRTIFY, That I attciulcl deceased from 

to ■ ■ I9Q 



IgO 



that I last saw h-tr— alive on 



190 



an< 



1 tliat death orciirre<l cii tlie dali- ^tati-d above, at 
M, The CArSI-: Ol" Dl'-ATII was as follows 



1) (x.i'xr^vXccv TOJL<x\t) ^^\jUL<x.<i'- 



"S^y<X-\>-trX^' >v.' 



oOCrPATlON 

AVu'i/rif III Sii n I'l aiii i>fo 



).,;, 



\f.'iilh' ' /*'" 



riM- \i!(.\i- ST ad: I) i'kknonai. r\KruTi,\K^ aki: luri-: ii» rm-, 

r.l -r<»! MV KN< t\\ I.l.IX.i'. AND BHl.li:i' 



Info; ni;inl 




<UL 



^\.l<lr. 



I) r RATI ON y^'f^y^ 

CoNTUinrTOKV 



Mouths 



navs 



Ho 1(1 



Years 



Months Pays 



f SIGNED )...L8. \h- \Ax>^ U^V>i> 
LKS>y A T,o'i fAd.ln- s<) vrunvi^^ 



Hours 
M.D. 




SPECIAL INFORMATION only lor Hnspitdls, Institulfo^. Transients, 
or Rerent Residents, dnd persons dying awa) from fiome. 

Hov> lonq at 

Piafe ol Death? Days 



Former or 
Usual Residence 



Wfien v^as disease rontrafted, 
If not at piai e of deatti ? 



,., \(,-V <)!•• I'.rKIAI. <'K ki:m"NM- 






^^iAL.^%y^_ 



!)\llJ\ot' HiiUAr. or RKMoX'AL 

Q) jJfCX. '31 T9oH 



>V 







■' » N —— 1—11— —^—^^^—■■—'—^— —"""'— "^^ f t cl FiXACTLY. PHYSICIANS Hhoultl 

!N. R. p.very item oV inform.ition should b.- cnrefully HuppHecl. AGh «''""'; l^.V %he "Special Information" ?or p-r- 

•tHte CAUSn OP DKATH in plain tcrm«. that it may he properly U»»*«.>. 

«on» dyinft away from home Hhould be feiven in every instance. 



it^ 







I 




iV 




m 



m\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n.,,Mr.l of HcMlth I- Vo 1^ ■'"tS?^"^ I'^'^l' <-*" 



Registered J\^o, 



134^ 



IhUc W^v/, dx\^te>^JLjLrv I 100\ 

\j^,^^j^\!U\j^ Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( Xl. S. StanC>ar^ ) 
PLACE OF DEATH: — County of Oo<jy\j /u<X/>^cv<i.ccCity of Occ/v^ Axx/>^t^^A^ 



No. 



IXo 




X'O' 



( 



St.; A Dist.; bet. 



H 



d 



ir DCATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPEC 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



sil 

lAL INFORMATION" "X 
T AND NUMBER. / 



and 



FULL NAME 



oJU. 



V 





OlVm 



SKX 



DATE OF lUk 111 



PERSONAL AND STATISTICAL PARTICULARS 

I Col.ok 





' Month I 



(Uav) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK t)I- 1)1;A TH / 1 

\AX^' 



Montli) [T 



1^ 

(I):iy) 



IQO 1 

(Year) 



a«;k 



I ex )'(/; 



Motil/l!: 



/><l\. 



siNr.i.i?. >JA K un: I >. 

WinoWKD OK IHYoKklU) 
iWiitt in siK-ial .I'-^iv'iiati'in) 



lUK I'Ul'l.ACK 
(State or Country^ 



NAMI-: <)J 
!•• A I' 1 1 } : K 



RIRTHPT.ACK 

<)!•" J AIHHK 
t State or (.'oimtrv 



MAIIu:n NAM) 

oi MoTin:K 



lUR'nilM.ACH 
OK MoTHKK 
(Slalf ur founti \< 




I in<:KI<:r.V CIvRTII'^V, That I attendcMl (leocasc«l from 
lb 190S to LitA^ XH 190 H 




that I last saw h LiJ\ alive on V^^^VCL. >- \ up '\ 

an.l that death occurred, 011 the date stated above, at "" 

^ ^ M. The C^\rSl': OI' I) I-; AT 11 was as follows: 

,i/un CixM. . . . ...v ».- 




DC RAT ION I )'t'ar.<! Mouths J^y^ 

CONTRIIU'TORV UAJkx\AVrL.atMA^ oUx<Vt\vt\ 



Hours 



OVlvCtilVOZ^ ^ JsjUcaaaJlmiK' LLb- 



DIRATION 



Years 



Mouths Pays 



V^Vivtcck 



A J 




y^6^ 



OCCUPATION P f\ 



/- 



'\,-iJ/-if m V,/;,' }'i (111, i^<-.> \/^ Will 



M.nilh^ 



/', 



IHI-: \HOVK STA ri'I) I'HK^ONAl, l'AK'rii"l'I,\KS AKJ: TKI}-: 10 THK 

iu-:sT 01 MY K\o\\i,i:i)<-. i-: and Mi:i,n:H 



(Infoiniant 




^ X'ldrcss 



.^Jl/3 



XC) 




f SIG 




^J</>/\\Xh 



, NED) liMrVy^Jl U 

Llu^ Q ^.>l T«,o'i (Addre<; <) '^^H Oa^CIUa; Oi 

OIAL INFORMATION 



Hours 
M.D. 



SPECjIiAL Information on'y for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyinq away fro-n home. 



Former or 
IJsudI Residence 

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



How long at 
Place of Death? 



Days 



I'l ACK OI- UrRlAI, OK K1:Mo\AI, j DA'I'J'ot IJiKlAf. or Kl-.MOVAJ, 
rNDl-.KTAKHR \'^' ^ LcTWWtjV "^Lc 



(Address 1 io^ \J rtvQ-^L/S-^CVv '^'k 



Rv<ry Item of information •hould be cnrefully Huppliecl. A(]B «hould be stBted F.XACTLY. PHYSICIANS should 
»tate CAUSE OF DEATH in piiiin terms, that it may he properly classificJ. The Special Iniormat. >n lor p«r- 



<^_- 



N. B. F.I 

utate CAUSE OF DEATH in pi 

«on« dyini^ away from home should be feiven in every instance. 






ii:ii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




I!,,,uM ..I ll.;ilt)i 1' V<«. !^ ■^T.'^i?''' '^'"^ '' '^^ 



/)((/(' Fi /('(/, 



\AAy^ 



m 






lf)0'\ 



Regisfei'cd J\^(). 



\ .348 



,^^ Deputy Mc2irh Officer 

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

Certificate of IDeatb 

( *a. S. 5tan^ar^ ) 
PLACE OF DEATH: — County of C' Ow/>\; 0/vcv^vi^\^ccCity of C3/0^-r^ JX 



^^%\t 



1^ ytrCLJLfJk^ LU.uA,cc>>^ St.; Dist.jbet.-- and ■ — 

/ IF dAjth occIurs away rnoM VSUAL R E S I DE NCE give facts called for under "special information • N 

V IfIIoEATH occurred in a HbSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

m ft -1 ^ 

FULL NAME J A.CLO'XCu> v) (AX^w^aa^^-ocuL a 



si:\ 



1 1 \ I I". <»i HI kill 



.\«.i-; 



PERSONAL AND STATISTICAL PARTICULARS 

1 C<iI,(»K' 





AA.^ 



U 




MEDICAL CERTIFICATE OF DEATH 

I)AT1<; ol" Dl.AI'll 



d 



(Moiitli) 




(Day) 



l9o\ 

(Year) 



( Day) 



(Vear) 



) '(•« ; . 



J, M,;it/is ... V. 



Pit \s 



sTNf*.r,T?. M.\kKn:i>. 

WIDnWKD OK ni\<)KrKn 

iWiitcin '^cK'ial <U>*i>.'^nat ion) 



lUKIIirLArK 
Staft- or Comitrv) 





^^^jL/dLcL LoJj 



I' AIH 1 R 



111 . 

ill t 



I 






lUKTllI'I.ArK 

oj- I Ariii:K 

(Statf or Ciiiintrv^ 



m\ii>i:n NAMK 
«u- .Mi>rin;K 



niUIHl'UACR 

nl Mo'nil'.K 

( Statf 111 ("()niitr\-^ 




I III<:RI-;HV C1';RT1FV, That I atU'n.Ud <lc(vasc(l from 
UvVaXX. I90'l i^^ .XXkaJIIX^ "hS \(p\ 

that T last saw li '->^ » alive on \Aaw\^o. :5l uj^'\ 

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

^ M. The CAISI-: OI* DIvATII \\as as follows: 
, \J AJt^k^»^^^CCtvv>vX mB-OvXJ^* 



1)1" RATION Years • Mont /is 

CONT R I lU'TOR Y ..™..... .- 



Days 



I lours 



)'rars 



nrCT^PATlON 

f\f>itl^il in Sii>i f^raMCis^o.. 



Y,,ii. 



M.<},tli> 



/;,; 



rm \i!u\i-: sr \ri:i) pkr^^i^x \i. r \k run, \ks aki-; rKiH to riii-; 

lU-.sr OI' MV KN( »\\M:I)(". 1". AM) Hl-l.n-.F 



(h 








DTRATION 
(SIGNED) UJLVUA 

I X^; 1 i(,o'i (Ad.lres.) ^^Ovi\.V\.li 




Months Pays 



Hours 
Wu M.D. 



Special information only '<"■ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyini away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



I'l.AClv OI- lURFAI, OK kl-:MO\Al, 




i)ArL;<)t" HiKiAi. or ki-;moval 
CJjJ^^Xi 3v T90H 



rXDKRTAKKK J\jJCXu ^ OKj CVOy^CV^V 



f information should be carefully supplied. AGE should be stnted FiXACTLY. PHYSICIANS should 
OF DEATH in plain terms, that it may be properly classified. The "Speciol Information" for pt.r- 



M. B. Every item of 

state CAUSE 

sons dyin^ away from home should be feiven in every instance. 



% 

111 

It 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



U...-ir.! ..r ll.Mltli I- No. Is lJ-«i;''af^»?^l<S:l'C.) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■I. 



':il 



i' : 



I • 



I I 







1!)0H 



Uegistcred J^''o. 



1 344 



Deputy Health Officer 



IS;' 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( tl. S. 5tanI>arC» ) 
PLACE OF DEATH: — County ofCjCL/Tu AXV-rvCA^<x^ City of 0<Xa^ J.VCU'ivCv.^tU) 



P^. 




dt^V^^ LLa.^ 'Jf'.^A-^vSt.; Dist.;bet. 



and 



•) 



(IF DB»TH OCCpPS AWAY FROW Op U A L R E S I D E N C E G I V E FACTS CALLED FOR UNDER ''SPECIAL INFORMATION' N 
IFJ DEATH OCCURRED IN A Hol(^PITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




a>tu. 



PERSONAL AND STATISTICAL PARTICULARS 
Sl-.X OPS A I CCH.Ok 

i>\ii-; oi itiK 111 



%^olXx 




.\c.K 



llMiith> 



)'/■(?». 



(Day) 



(Year) 



.OLh^aoAxt 




>vcrl 



OL^vcrai) 



WEDICAL CERTIFICATE OF DEATH 



DATE Ol" I)i:ATFr 



(Montli) / 



(Day) 



(Year) 



1 



Months \ t Days 



^IN<",l,i:. MAKkll-:!*. 

\\ 11)1 »\\ i:i) OK ii!\< >Rvj; n 

'Write in xii-ial fK-sit^uat imi) 



■ Statt or l."i milt 1 y) 



NAMl- OF' 
KATm;R 



OI" l'ATUi;k 

•Statf or lOuiiti v) 



m\ii>i:n' x.\mi-: 

ol MolHHR 



MiK ruruxrH 
Ol Moriij':R 

(Statf or I ()\intrv) 



C)-c/w<yLl 



? 



I irRRr'HV CIvRTlFV, That I attended dcroa^ed from 

U^^-cv XO 190I to LVw^ 'iA i(p*H 

tliat I last saw h ^^ alive on O^Vc^ oC 190'! 

.-md that death occurred, on the tlate *^tated above, at 
M. The CAISI-; Ol- 1) I! A Til was as follows: 

VwAvcrLL^^cw Ov>w^x^vt.v^^-- 



V-^ArJ .. 









I 






(OU(\Axyy\.^ 



nr RATION .--. Vi-ars Months It) /)ays 

CONTRIiU'TORY U-^'v^t'Lovr%.,«r:v^.»n«(V. 



Hours 



Years 



% 




DURATION 

d.' ' TQo'i (A.ldress) ^XO \K.\\. Lt 



iNED ) AM1\X^ 




IX'aJ 

1^ 



Hours 
M.D. 



Special Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying dway froii home. 



/),M 



iMii. AHo\i.: sr ATI" I) PKKsoNAi, I'.XK rii'ri,AKs .VR}-; rKiK r< > 111 )•; 

In-;ST 01 MY KNOWI.I.DCH AM) lUvl.li:!' 



(InfoinuMit 



(Add 






cwy\. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'l.ACH OI- IJl KI.\I. OK Ri:.Mo\-.\I. 




n.XTJ'.o! Hi KIAI. or K]';Mo\A1, 



(Address 5i^^lX- \^lA/v Jt 



ijjji^ll 



IN. B. Every Item o* information should be cnrefully supplied. AGK should be stntetl RXACTLY. PHYSICIANS should 

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



• ■ 



^i 



h 






h 



n . 

I'l' ■ ,1 



'tpl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i;.,,n.l "f flcaltli J No i^ ^^^. nSiV Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Eeglstej'ed J\^o. 



1 341 



Dale /'VA''^6-^vLo>-.^J^-t^, 1 1!)0'\ 

lu,^^^ 'L.v^ Deputy Health Omcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of S)catb 

( *a. S. StanC>arC» ) 

J? ^ , ^ ^ 



o 



PLACE OF DEATH: — County ofUa^u OiUX/^TLCUiCoCity ofJ/a/rv J.>va/>^o<.^ao 



'No.^ 



it 



(5]) 





cy^' 



l-vJ^; 



Xl; 



St.; Dist.; bet. 



-and 



(IF DtATH OCCURS AVVAvIfROM USUAL R E S I D E N C E G I V E PACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ ^ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 







FULL NAME 



XX' v-cn v.u<;iCL' 



/Oi-XO-CrvXi. 



PERSONAL AND STATISTICAL PARTICULARS 



DA II. «)!• Hlk 111 



COI.OR 




'\xXjl 




I M-iiilh) 



At.K 



Mb ,■,-„,, "i 



(Day) 



.V. -»///> 



(Vear) 



IH 



An. 



MEDICAL CERTIFICATE OF DEATH 

DATR OK 1)1;ATH 9 



(Monlh) 



1 



(Day) 



(Vi-ar) 



SINC.I.lv MAkRIi:!). 

\vii)i »\\ i:i) (»K i)i\< )Kri: I) 

iWiitciu •soti.il ^I^■^iJ.'n:llioll) 



lUK'nn-i.ArH 

(Statf' or (.""Miiiti v'* 







namt: oi- 

FA'III J.K 



inkTuri.ACH 

OI- lAlllHR 

( Statt or Country^ 





M MIO'tN NAMK 
or MoTUHR 



r.iK riiPLAi')-; 
<»r M(»rm-;K 

( Sl.iif or r<)uiitrvt 






? 



I Ifl'RKRV CIvRTIFV, That I nttcnrled deceased from 

hv 190O to ax^tj I up'i 

IM..L 1 .<..^t saw h-i^A' alive on UX^vt I T9o'i 

and tliat death oceurred, on the datr stated above, at o • H o 
CI SI. Thr CAl'Sfv Ol' l)l«:.\'ni was as follows: 



1)1' RAT ION y'rars 3> Mouths '{ Days Hours 

C< )NTR IIU'TORV \^lKA^Crvu\-^ A^ 



DURATION 



)'rars^ 



J/ou/Zis 



IhlYS 



I 



occri'A rioN 

h'fu'i{r({ in S,ni /'i a 11, isri> 



_ OX\yYWa/>XU, 



) '(•(// 



MouHn 



/),/! 



rni: nhovi-: stati: d i'Kusonai. i- \k iuti.aks .\k i; iKri". ro rn i", 
iu;sT OI" MY KNOW i,i:i)('.i- .\M) in:i.n;i'' 



Hn fii; luaiit 




.VM..SS iHiw GlIJLit^ c^t 



(Signed) .sJxcx/i (lb . VJUy^yrcU'val) 

1 if)oM (.xd.lnss) b?>bli),a>vj;vat 



Hours 
M.D. 




SPECIAL Information only lor Hospitals, Instifulions, Transients, 
or Recent Residents, and persons dyimj away from home. 



Former or --ro^Vl/l/l^ 




Usual ResidencelMl 1 1 L UXJUaaIAj ut Place of Deatli ? H ... Days 



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



ij,ACi<: Ol" m Ki-Vj, OK ki;mo\\i, j d 



INItl'.KTAKl'.K 

(Ad<lress S Hb 





I u 1 Ai, or K i;m» >\ .\ I, 
^ TQO'i 



v^orW) 



d 



N. K. 



ivery item «V inform,.tion •hoi.hl bs cnrcfully Hupplicd. AdB Khot.lcl be «tnte.l F.XACTLY. PHYSICIANS «houId 
t«tc CAIJSF: OF DFATH in pliiin terms, thnt it msiy be properly claHsiticcl. The Special IntormHtion *or pi.r- 



«on« <lyin^ nwny ?rom home should be ftiven in every inHtance. 






c 




1 






c 



. .* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,,,,.1 of ll.iltli VSo. y^-^'f^^^li^VCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






ill 



r. 



m4 



., I 



Ihf 



to FiJpd, dx^Atx^JLvv I lOO'X 



Registered J\'*(). 



1 346 




D e p u t r aji h "O • f "^ ^ ^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( Xa. S. StanDarD ) 



PLACE OF DEATH: — County ofO<XA^ ^ K<xrY\^<AZ^ City ofO/OA^ J Axl.-wca.<l/c o 



No. 





O-di-^ 



-vc 



txxl' 



St 






Dist.; bet.- 



and 



fls AWAY rhoM USUAL R ESI DENCE give facts called for under special informatio 

CURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



- ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

S}:\ A (\ I C<H,<)R 




V-Q; 





\)\V\-. Ol- lilKlIl 



1 


7 


1 Mmitlit 


(Day) 



7^5 t 
C/rar) 



a<;k 



HI 



} Vi/ > 



M.nilfn 



/>(!• 



sINCI.K. MARKIi:i) 

w ii)(>\vi:i> OK Divouv i;i) 

<\\tit«in social <ltsi>^nati<)ii) 



i 




lUK rUJ'I, At'K 
! State or (."ouiitrv^ 



NAMI-: <>I" 
I- ATni:K 



niKTHI'I.ArK 

()I- I'AinivR 

< Statt or Country) 



maii)i;n nami: 
of motmhk 



lUR'l'Hri.ACK 
()I MDTHHK 
(Statf or (.'onntrv^ 



4 ^ 9 

A^CrUw^cLCoAX)-' 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH /H 



KM 

(Mcinth)/] 



(Day) 



fgcA 

(Vt-ar) 



I inTRrvBY CKRTri'V, Tlint T atlriKlo.l (Icoeased from 
. iXcuq. .1^ 190H to LIa^^ 'il T(p H 

that I last saw h X'Vva alive oti VX<^v.-<^ 6 1 190H 

and tliat (K-ath occurred, 011 the date stated above, at v-o5 
CL M. The CArSf'! ()1< DIIATH \va^ as follows: 



^X'\...>crv%A^ 



4tAix<xi %xWaixt^3 Ib-JjAvO O/CJU V^-<J^2 

DT RATION )Va;.? Mouths Pays Hours 

CONTRIBUTORY LlVCXJL'^'VXA^tX 



duration 
(Signed) 



^ 



Mout/is 



Hours 
M.D. 



oc 



:cri>Ari()N [) A 

rm: \iu>vi-: spAri-.n i'Krsoxm, i'artuti.ars ari: iRri- I'l rm-: 
i}i;sr OF MY kn<>\vij:i)»", F and Mi:Mi;f'" 



!/,/»///. 



/ 1(1 1 ^ 



I}i;sr OF MY KN<>\VIJ:1)»", F and VAAJi-.l 
[nformant Vj . VJ . cKo . \jL<X.<Ji 



"t 



A.l.lrrss . LcLu ^^ ^ ^ Ch^vd.OX 



QjL^t; I TQoH (A.l.lress) LAt<.i\cG (UD (H^ v|aa t<V.l 

Special information only for liospitdls, institutions, Transients, 



or Recent Residents, and persons dying away from home. 

"-^ I Hew lonq at , . 

tux. Place of Deatli? IX 



Former or u . m 

Usual R sidence i » v 

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




Days 



I'l \CF ()!■ lURIAI. OR Rl-:Mn\Al. j DAIFiiI IMkiai. or RF;M0\AI, 
rNDKRTAKKR U <xLlAatx V] |\^DL\^ ^ L<) 

IS'XH Ot/CrtAl^OA. al 



(AcUhcss 



N. B.- 



-v4; 



H^t. 



-Rve 
sta 



rry item o^' informntlon «hould be carefully supplied. AGE «hould be stated BXACTLY. PHYSICIANS should 
te CAUSE OF DEATH in plain terms, that it may l>e properly classified. The Special Information tor per- 



sons dyin^ away from home should be j^iven in every instance. 



\ % 



1 tu 



r ^ 



" '' , HI 





llli 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 









liegLsf creel Xo, 



134 




No. 



DEPARTMENT CrP PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( TH. S. StanC>arD ) 

J? op ^ ^ 

PLACE OF DEATH: — County of^)/CX/^^' /uX/>vCa^ Cc City of OxXA-v 0A.CX>vac4.r ( 

b IX V^'CA^Cov St.; 1 Dist.;bet. obxJ|'Ur>xt and jVtOJv>xu. 

/iTlF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U N ti E R "SPECIAL INFORMATION ' \ \ 

\\\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / ij 



FULL NAME 



o.^\>. 



\\^y\^A 



SIX 



i» All-: < ti iMK rii 



PERSONAL AND STATISTICAL PARTICULARS 

, coi.ok 




(Moiith) 



I 




^<r 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH H 



(Day) 



/ 'J.s ^) 

(Year) 



ACiK 



^^ » )V,M« ^, 



Months 



Duvi 



^INCl.I*. MAKRIi:!) 

\\ jDi luj-'ii OK i)i\<»Kri:i) 

(Write in sofial (h >-i}.'iiatii m) 



L.. 



HIKTMl'I.AOK 

(State or (.'oniitry) 



NAM1-. <)!■ 
FAT}n;R 



UIKTHlM.At'K 

Ol" IATHKR 

I Statf or Coviiitrv) 



MAIUFN NAMK 

«»i- Mi>rin-:K 



lUK'iniM, \C\', 
<»r MoTlIJ'.R 
(State or CfWHitiT) 




C' X^^i^^/Dj 



(Montli) \ 



?»C IQO^ 

(Day) (Year) 



I Iin:RP:BV C1';1vTI1'\', Tliat I atteiKU-d dcooascd from 

.'. ' !(/) to — — — — -~ —190 

tliat I last saw h.trtrrrrr alive oti — •••" • ~~' 190 

ami that doath ocmtrreil, on the date <tatt'<l above, at 
M. The CAISI-: ()I« 1)1':ATII was as follows: 






1 



DTRATrOX Vrars Months /hns //oi/rs 

CONTRIBrrORV 



aa 




DTRATION-^ }'ciirs 

^00 



J/o/z/Z/s /fays Hours 

<X/Wa VX.A < M . D . 




<X 



OCCrPATION JP 

h'ryidfif ill Snii Fi(Uir''^,-n 'o )\-,ii< *" .y/"i!f//< ' /l<ns 



I'lii", \HovK siAri-:n i'Krsonai, i> \k iim.AK^ aki: TRn-: 10 11 1 1". 
iU';sT oi- MY kn()\vm:dc.k and Hi:i,n:t-* 



(A.MrcKs 



10b 




(Signed) OAX/cUi^vok 0. u^^ . .. . — 

LLvq.'^l Tc)o'i (A.l.lress) IgOl^ UXxAlx^v ^1 

PEC^IAL Information '•nly tor Hospitals, Institutions, Transients, 



or Recent Residents, and persons dying away from home. 



Former or 
Isiial Residence 

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



How ionq at 
Plare of De«th ? 



Days 



ri^xcK oi" ijiKiAi. OK Ki:\ni\Ai, 



rxni'.R TAKl'.K 

( 



DATlUo!' HiKiAi. or K1:M<i\\1, 



151 K ] \l. I >K K 1 . \n '\ w, 

vT/VcxtiU) Co 



N. B.- 



•F.very item ni information should be cnrefnily supplieH. AdR s-^ovhl be stated F.XACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for p-r- 
sons dyin^ away from home should be fiiven in every instance. 



P 



r 






^ 



r^ 



m 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H,,:,t.l <.f !I<:ilth »•• No 1^ ■^*?^«';r'«^ "^ »' <■"'> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






i V 



. I 



I 




/)(ff(^ /vVrr/, QX^pX^L-^wU-Uv 



nJO'i 



llegLstercd JS'^o, 



l.">4« 




,^u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( Ta. S. StanJ>ari) ) 



PLACE OF DEATH: — County 



ofO/Qyvu . VCu^ v'C.^^.^yco City of C'CV^v^ J A/X/^tv-ol/Q^oo 




No. ^\'^ X^ C^<3-\Jc.<i St.; 10 Dist.;bet. \X ry^<L and 1'^ AycL 

(IF DtATH 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 OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



OyK/CrTVL/O^^CtyAxi^k; \XJoJL<i^AJj 



•>i:\ 



i).\ri-; •)!• Ill Kin 



PERSONAL AND STATISTICAL PARTICULARS 





I 





MEDICAL CERTIFICATE OF DEATH 




(Day) 



/IIS 

(Vcar) 



AGK 



l^^ 



)Vl7» > 



.?0. M,ni 



l/i>. 



x-b 



n,tv. 



sixc.Mv M\kun:i) 

WIDOWKD OK I)IV«>Ki }•; I) 
(Writfiti social <ksi''tiatii)n) 



'Statr or «,"oiiiiti v^ 




i^ 



0<yy\j /uCO^K^^./CA.<i^'C>o 




DATK OV I)I;a TM 




(Month) 



(I)av) 



IQO 1 

(V.'ar) 



I irrvRHRV CI'RTII'V, That I atteii.U-d .Icci-asod fn.iii 

I f LCtu X.\ up'l t(i LAa^XX .'Bj I i()oH 

I last saw h-^ Viv alive on V^vvv^V '■*-*-^ l<)0 * 



that I last saw h-^ Viv alive on L/'LV\-<5l ' -^-^ I90 \ 

aiul tliat death f)cciirrc(l, on the date '^tati-d ahove. at V» 
^ M. The CAl si: _(_)!' DI'iATIi was as follows: 



y^ X.<X/W\^^.^^r\-^^JX)\JUi .vj -CVA>4-NyCwL^r-<!M^ 



\,-\j:xhJji 



II* 




I, "■'''■. 



JyfurwttxA \. Uj,<xX' 
OI- rATiiKK y (Tpy 

istat* ot Coiiiitryi -A \f[' 



ocrtX 



0/OUT\j ^^<X/>vt,>^ CO 




Dr RATION 



JV(7r.? 3 Mouths \0 ^Davs ? /lours ^ 



MAIDHN NAM}-; 
OF MOTHHK 



itiRriii'i.ArK 

01 MnruHR > 

(state or Country) 



occur 




k'r'^lii^if III Si! H / I It Ih I -III ** *" 



C ( ) N T R I lU'TO R V Ca n('\XjULA!^A^^v'v^<oJL 'J.AA.lN^A^CA-uL<^i:i-u"5 

dU AwX^AA-.rOl/Ow» . „ 4- V , 

)V(r;-:f o Mtinths Vo /?(;]■.? Hours 

NED ) \( IxxUruxAV 



I) i; RATION 
(SIG 



X^> I 



i()0 '\ (Ad<ln' 




M.D. 



ss) 5.0 w i oj\KXjX dt 




Special information only tor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dviny away from fiome. 



) 'rai 



M.iiilh^ 



/'</ 1 



III i: AHovi: SPA ri;n i'krsoxau tar tutlars ar]-: rRri-: m rn i-; 



lU'.sT oi-iiN' KN'(»\vij;i)c.i-: AN' !ii:mi:k 



'■(^' 



Uiifonnrnit 



d y\j(XyvOf< VJ . LO oJLcxrttj 



\.1.1th>.s H i C5 




\X4. dtj 



Former or 
Isual Residence 

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



How lonq at 
Place of Death ? 



.. Days 



I'I,.i^(.:i'; < >1- lURIAI. OR RHMo\Al, I DA Ti: ->!" HnuAi. or R1;Mi»\A1, 

i NDHRTAKKR \l lUrvuxJkxx-k^ U (fc/OAxx^^^ Lo 

Ulrcss dl'^HV N ]'\A^,^,^^J.^^,.^J-v^. wt, 



(AcU 



,«tion should be cnrcfully supplied. AGB should be stated EXACTLY. PHYSICIANS should 
ATH in plH>n terms, that it may be properly classified. The "Special Information" for p«r- 



N. 15.— — Hvery item of Inform 

Btate CAUSE OF DEa I H in p 

sons dyin^ away from home should be 6'ven in every instance. 



■>M>i 



w 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



! ;. , . I . 



of IK alth I' N.' 



\o i> ^-r^^^^iJ US: I' 0.) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



♦ 



I 






■U^: 



iff'* ,1 



I. 



i)(i/i' Filed, 




I'JO'A 



Registered J\i''o. 



1 ;i4f) 



•Wa^v^ 



Jjl^ Deputy H ". - "^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: 



T^ 



Ultcv^Ur^^ 



^^^-^^cu 



±. 




Cevtificate of Beatb 

[ 'Cl. 5. Stan^arD j 
County ofUayw J;v<XAV'Cul,'a.( City of OcuTf^ ^ n^O^ry\.'Z.\^^^0 



% 



r\ 



0^ 



Kct 



<xlSt.:- 



Dist*; betr 



and -" 

>ccuRS aiwAY rROM uisUAL RES I DENCE give facts called tor under -special information- \ 

f^ I _ __ ^^ ^^p NUMBER. / 



h f ir DEATH occurs /dwAY FROM MSUAL R E S I D E N C E G I V E FACTS CALLED FOR UNUtK !. f- 1 1, 
U V IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 






FULL NAME 




'Xuy^j... LLa^cLcLcox^^l^"^ 



V: 



-^I:\ 



i*\i i; »>l UlR IM 



PERSONAL AND STATISTICAL PARTICULARS 

; c<)i,(»K > 




iDixJwt 

vj JLAT S' /"fj^X. 



M.-iilli) 



tl):iv) 



AO« 



\\ )V,?»v b M.mihy X\ 



(Vtar) 



Pars 



^I'SniM. MARKIEn. 

u iixtwi'!!) OK r)iv»»RrKn 

\\iit« in Horial dt-^i^'nati'Mi) 



(State or Cmiiitry^ 



NAM I" Ol 
FATHl-.R 



I'.ik iiiri.ArK 

(>!• FATHI.K 

' stale (tr l"<)\iiiti \ ' 




f 



kJxAjx^ 



a^trvA^ 




^fATI)^*^* nami* 

Ml- MoTHKK 



!51kTHPf,ACR 
••I- Mf)THi:R 
(State oi t"i)iuiti\ I 



Cj/aA.oJa^ JU(>vvkLcI 




<X^l'^A 



OCCl 



^""■•"""•U)..tJ 



A''' tif-d III Sit U I I il III I 






yt, l!'Il■ 



l '.■'I 



MEDICAL CERTIFICATE OF DEATH 



DATK OF I)l". \'\'U r\ 



(Month » jf 



(Day) (Vtar) 



I IIKRin'.V CI:RTI1"\', riiat r attended deceased frmii 

CL^VO, lb UpH to LLw^^ X^ Up\ 

that I last saw h^/Y>\ alive on VA^v/O >v-\ up \ 

atid that «kath occurred, on the date stated above, at H.H 
CL M. The CAl'SIv ()!• dp: ATI! was as follows: 



i 



nrRATION Years Mouths 

C( )NTR IIUTORV = 



Pays 



Hours 



(SIGNED ) J . 




Mouths. 



Pays 



Hours 
M.D. 



vXv^ 



% 



^' ' I < 



;o" 



{ 



X.ldrcss) Lj ^yVC o ^O^V^t 
Tospitals, 



riir: xnovi-: sr \ ri.D i-kksonai, far ruri, xk^^ akk 'Mti'K Yu iiii. 
in-'sroi- M\- K Nt »\\ i.i.ix.i-: and in:i.n:i- 



'Inf.i; niatit 



' N'Mi.ss 




SPECIAL INFORMATION ""'y ''••^ nospitals. Institutions. Transients, 
or Rnenl Reslilcnts, and persons dyiny away from home. 

former or /s , ;«( 4- M "*^ '""•* ^* I 1 

Usual Residente^b Ua/C^wa/VVU^^xU Jvpidre of Death? I A Days 

When was disease rontrarted, 

II not at plareof death? _^^ 



I'l \CV Ol J!I KIAl, OK KI-.M' 'V \l 






DAT;,'.'); Hi K \i. HI K I-:M< »\AI, 

X. 190 H 



rXDl'.K'I'AKllK 
( 



Address. 3bli- l^ tL df 



V ,. , .^p „},,„. Ill he stnteil fiXACTLY. PHYxSICIANS Khould 

N. IJ.— Hvery Item of inform»tIon .houlcl be cnrefully suppi.ed. ^^J' "^^T^^^ ^he "Special Information" for p.r- 

8totc CAlJSn or DI.ATH in ph.in terms, that it may he properly claHH.^.cU. nc T»i 
fions dyinft away from home should be feiven in every instance. 



' !►; 



^^ 




;# 



iff 




if 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l;, :,,.! ..f n.allh 1 N'o : -. ■^'^'J^^l^' liS<.V C 



Dnh' Filed , Q 



CA^^^X/V^ 




I /.96>H 

Deputy Health Offin^" 



BegLsiercd JS'^o. 



I 'ITyO 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

{ *a. S. Stan^nrC) ) 

i on A ^ 

PLACE OF DEATH: — County of Octox' J AXX/^yvCuiLCxCity of Oclo^^j J \.(Xo\ov<i.c<. 



No. Vl^\^ ^^ WVLAAtu --- ^<Jf\jJ^OJc St.; ^rr— - Dist.; bet. ~ ----r-r--r--— --- and -— : 

ft / IF DC«TH OCCURS 1*W*V FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNOtR "SPtCIAL INFORMATION" "\ 
1) V "^ DtATH OCCUttRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




rx.Qu'rxrs-^Os.^. 



vl/.uLk 



u>\A..{rvx/. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS ^ 

! Cni.oK 



J 



I).\TK oi I'lK 111 





(vJu,, 



r%%\ 



(M.<iilli> 



\<".K 



It,. 

* V } tin .< 



I Day) 



M.'ulfi^ 



(Vcar) 



An 



U IDOWI-.I) OK DIVoRrKI) 

Wtit' ill •^i>i-i;il (It vi^Mi.-itioii) 



lUKTHPT.ACK 

Statt or Country* 



VAMH OF 

»Aiii i:k 



TUKini'i. \rK 
<>i- i'.\ihi-:k 

state or Coniilrv) 



MA1I)1:N NAM1-: 

()!• Morni-.K 



BTRTHPr.ACR 

<)l- Mo'fHHR 
fStatf or Countrv) 






a 





U.tcc^K 



-0 



MEDICAL CERTIFICATE OF DEATH 



i>ATi-: oi' in 



U-vLO 

(Month) K 



(Day) 



(Year) 



I II1':R1:I!V Clik'niV, That I attended deceased from 

^)^v<> X\ 190^ to UwM^ Ji-O. 190 H 

that I last saw Ii .«-V alive on U-*^<^ M 190 'i 

and tliat ikatli i.rcurreil, on the date stated al)ove. at U.-.^O. 

M. Tlu- CM SI-: OI' DIv.ATH was as follows: 



e. 



i^ 



-cvxx 



V.W^<»v. 




CONTRinrTORV 



Jfo/i/Z/s 



xct'^vn(va> 



^rp 



}- 






OCCUrATlOX 

Rfsidr,! in Sail Fuiiniu-n aX )Vr/; v *■ \h»ilh< ^,,/hn.^ 

TMI-: AHOV1-: ST \l) I) I'KKSONAI. I' \ K T U r I, \ K S .\ K I", IK I )■'. !< > TIIH 
HHST OI-- MV KNOW 1,1; DC)-: WD in-.l.Ii:!' 



'In f'limant 



\}JL^/\yOUL U^JLoJLo 



f\(1.1 



res.s 




VQ 




OCh^\ 



V 




D\' K AT ins y^ }'ears 

(SIGNED ) J........si-....'fcA.xfe 

Uoxa ^^ TQOH (A<l.lress)Ul>Y^^^ - 

Hospitals, 



[cilAL IN 



/)<7ys Hours 

M.D. 

')\:'^^-l^'^■ 



SPECIAL INFORMATION only lor 

or Recent Residents, and persons dying away from home 



Institutions, Transients, 



s va.-....w. 



Former or 
Usual Residence 

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




•\ . How long at . 

..U.A- Place of Death? v 



. Days 



i).\'rr. ot i?rKi.\i. or ki;mo\ai, 



I'l \CK OK HIKI.U. OK KI-;M<)\ Al. 



^-^ 



'i- 



be stnted EXACTLY. PHYSICIANS should 



N. B._r.very ite.n of Information .houhl be cnrefully supplied. AGE should %-'^'%^^!>^'^^;, ,n>or m tio^' for p.r- 
Htate CAUSE OF DEATH in ph.in terms, thnt it may be properly classified. The Spec.ol Information tor p 
son« dyin4 away from home should be given in every instance. 



hi'j^'ir 



i 



i 



I 



ill! 



I 



ill;* I 



II 1,1 




^. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



-,,,1.1 Mf II, ;.!lh I' \''> I 



t t"^^'X^^> USi !'<'<, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



llei^istct'cd J\''(), 



1351 



huh- Fili-d, Oj^-jtA/^^JUov \ V)()'\ 

XcM-A^ dui/VM^ Deputy Hccllh CfHoer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( H. S. StanCtar^ ) 
PLACE OF DEATH: — County ofO/Oy^v \)A>a/YVCUlCC. City ofO.CUTV Axxyrvo^.^ C t 



Ne. 





X^'^VtYv^lOAA^ St.; 



(\r OCATH OCCURS Awiv FROM U S U A L '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 pR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



-Dist.; bet. 

xct; 

it; 

ro 



-and 



^i.\" 



DATH OF HIK I II 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.ok 





L 



<xxx 



r .-,, 



MoiHll) 



(Day) 



tVfiii 



\«-.K 



CXX^t 3>0 y.,n> 



Mt'ulli; 



/h: 



STVr.T.K. MARK !i;i) 

uipowKDnR i)!voK(i:r) n 

iWritc in >.i>cinl <l»-<ii'n.'iti<)ii t .J( 

^ Q-V\A.O/ 

liiW IMI'I.AOH n\ r. A 

Statt-nr CNnuitry) V 

SAMR OP 

I ATm-.k 



lUKTinM. \iH 
oi- lAilll-.K 
(State or Coimtry) 



MAII)I:n NAMI, 



lUUTHPr.ArR 

'•I MOTinCK 

' Si,tt< m CDutitrv^ 



Rfsiiifit in San /'i ii in isf'n 




MEDICAL CERTIFICATE OF DEATH 

DATlv 1)1 DI'ATH /O 

„ IA^vOl 3)0 ipoH 

(MoiitlO A (Day) (Year) 

I Ill'kl-r.V CI:RTI1"V, That r attende.l deceased from 

.- ..J ' v 190 ■ to 



that T last saw h 



ahvc oil 



lip 
-T90 



and that de.i'Ji occurred, on the date stated above, .it H 60 
L\. M. The CArSl<: Ol- l)I':ATn was as follows: 

Ovv^rwvc o \.<X'V\A.AX'Ov^J V)\X'^aUx>vnXva 

GiM^^LCA/i fri Owoi 4 Quax 

DIKATION }'a7rs Mouths I^ays J lours 

CONTR nU TORY \J L<;> tI'VC^A^ 




DTRATION Vrars 

(Signed) \M\jr\\XJ>^ 



Mo ill /is 



Davs 



(^ 



/>V 



a. 



//ours 
M.D. 



dOuUt 
Special information only for Hospitdls, Instiluttons, Transients, 



.I xU) 3^\ ic)0^ (Address) \^\Xr^\V<A \JM 

_. ^CIAl INFORMATION onlv for Ho 

or Recent Residents, and persons dying .iway from liomc. 



[ufions, 



) V<7; >■ 



M.uilhs 



/Ki 



Tin'. \iu)\-i<: ST xit:!) j'i-rson m. j-xk in n. \ks aki; TRri-; to iiii-: 

1U:ST (H- MV KNOW 1,1. !)(,1-: AND lU-.Ml'.F 

(infn,,„,-,nt UJ trw/a \JY\yCry\ycx 



f \(1(1 




Former or + k a a iv 

Usual Residence ^ AJWiA\^ 

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



Uxi 



Wm lonq at 
Place of Death ? 



Oavs 



4 



InA, 



I'l \C1-: Ol- lURIAI. OR KKMOVAI. 
rNDKRTAKKR UJ -A^OA^^ OaA-.^^^ 



DA'CKo!" Hi KIAI, or RJ-:M<>VAI 

A 



T 90*^1 



C Address 



c:^t 





N. B.— F.very Item of in9orm„tion should be cnrcfull.v supplied. AGE should be stated RXACTLY P^^^'^''];^,^, f «"'^ 
state CAUSE OF DEATH \n plain terms, that it may be properly classified. The Special Information Vor pT- 
sons dyin^ away from home should be given in every instance. • 



■B 



1 






i 



•-1 



if 



^1: ir 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



« 






IJoanl ..f Iltaltlr- »•■ No. n *'^- ar[-^, lUt I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■r 






•t 



l)((fr /v7^^^/,. O J^^Jbu-^W^ 



100 \ 





Begistered J^o. 



135S 



\Mv( 



Deputy Health Officer 






1, ' ■[> 
P' I-.. 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of ©catb 

J? (o"^ 



0^ 



4 V A \ 

PLACE OF DEATH: — County ofO/<XoA "vaa-vCx^LA:^ City ofOxX'YL' A-<X/> v^^i-4. c. c 



No 



.Ot. 





)Ch<L 



IxJ. 



Ojj 



St; 



- Dist.; bet. 



OCCURS Awiv FROM USUAL R E S I DE N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL I N FO R 
H OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



and 



;IAL INFORMATION" N 
T AND NUMBER. J 



FULL NAME 




)\.<xn'\j^'\.<x 




si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.oK \ 






voJlx 




^ 



MEDICAL CERTIFICATE OF DEATH 



DATE or ni'.ATH 



DA ri-: ( )i iiiR 111 



AC. H 



I Month) 



/.^H5 



(Day) 



(Vf.-.r) 



O \ );■„,■ 



Mnuths 



r>a vs 



siN(,i.i-:. MAKi<ii:n 

Wlix "W i:i> Ok DIVt >K( MI) 
'Wiitt ill -social di'.ij.Miat ion) 



lUkTIIJM.Al'l-: 
(Statt or roimtrvl 



.'L'.^cLcrvA.^ocL_ 



■hJL- 




xWt 



<Montft) 



(Day 



(Year) 



.1 HRRF<:nV CI'IRTIFV, That I attended (Uuvascd frmu 



a 



to 6jc^A± 1. 



-CMX- 10 190S 

tliat I last saw h X\' alive on UjL 



^^ 



dL 




NAM1-: 01 
FATII i:k 



lUkTHI'I.ACK 
<)l" I A II IKK 
(Stat( or C(HUitrv) 



maii)i:n namk 

01 MO'I'IlKk 



Miki-niM.Ai-i-: 

01 Mnrm-.K 
(State or rom\tJ v) 




\jX^C\^w^^JL JVcOJv'w^ 




'^O. .-b 1 190 'i 

and that death orcnrrcd, <>ii tlie ilate stated above, at 5 3> 
\k.-^\. The CAISI-: ()!• Di-ATH was as follows: 
LLaJUtUL/^-SwAXX -r^rULA-CA-n./'vvXl. 0^1^JiA.<a:ll..^v... 

nrRATION )V<7/;e Mouths Days Hours 
CONTRIIU'TORV ciJ A^^^JLm-AJWl.. 




diration 
( Signed ) 



)'cars 



Mo}itJis 



OuiU.^, ^^kvd 



Days 



( u 



Kf'uifd 111 Will /'i iiiii iMi> lAO 



\.dfX 



loo'l ( 



Address) OIT . Mf UxhXJA 'fe (Vvl'. :.l 

s Insnti 



Hours 
M.D. 



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



Former or <^ '^ \ f r\4 

Usual Residence (^ '^ \AXX.\/Xj UX 




) I ii > 



^f,„lth^ 



/'. 



Wlien was disease contracted, a n. 
If not at place of death ? <> <^ 




How lonq at ^ /v 

Place of Death ? O 



Days 



rm: ahox-i-: st \'n:i) i-KkSDNAi, p \ urn ri, \ks aki" tkik to in i: 

MIvST Ol- MV KN<)\VIj;i)<'.K AND lu: I.I l".!' 

(Address ^^ V^JLcUVOj CJA 



IM.Afl-; <)l' ItlRIAI, OK K1:Mo\AI. j DATl'.of Hikiai, oi KI'.MOXAI. 

f.NDKRTAKKR ^-^^ ^ WvvAX^ ^^ L<i 

(Address 1k>1 \l VVui.^A,^r-yv Ot: 



'^- B. F.very item of informsition «houM be cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

stnte CAUSE OF DEATH in pluin terms, thnt It mjiy be properly classified. The "Special Information" for p«r- 
«ons dyln^ away from home should be jt'ven in every instance. 









B¥ 






*.<i 



H 



'•lillM'':'::! 



I ■ •I'l 



m 



u 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



jtoMwi of iii-.iitii- I No. 1^ '^•^'»J^'^ n&i* Co 



I )((((' hailed , O X>UjLAyvrJ!>-t>v 



X V^O'i 



Registered J\'*o, 



1353 




JL«yv-u Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Bcatb 

( tl. S. StauDarD ) 



PLACE OF DEATH: — County of 





rNo. 1 VjV^-sJlA.' v.V\^ 



OJ\A,^\J 



St.; Dist.; bet. 



City of 0/<X'>v IXoxU^lvMC V'Oj 



and 



(IF DtATH OCCUnS AWAY FROM USUAL 
IF DCATH OCCURRED IN A HOSPITAL 



RESIDENCE civt FACTS called for UNDER "special INFORMATIO 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



N.) 



FULL NAME 






lx<x\.lju , 'vu 



Kb\.KrYv 



PERSONAL AND STATISTICAL PARTICULARS 





DAT!-: (»l- IlIKIll 



MEDICAL CERTIFICATE OF DEATH 



datf; 1)1- i>i:ath r\ 



Moiitll> 



11 

(Day) 



vifoH 

(Year) 



AOR 



S'^ 



5 V(/; 



I i M^nilhs Vv D 



A/1. 



SI\(-,1,J<:. MARUIKIV 
WIDtiWKI) OK I)!\(>ki*Kn 
t Wi iti- in >^ixMal (k sivn.itioii) 



^ 



lUK rn iM.ACj-: 

i St.itf or (.■oiiiitry' 



\AMi-; <)i 
»athi;r 



lUKiniM, ATK 
OI- I AT I IKK 

•St;itf or *.'<)>ujtrv) 



maii)i:n NAM)-: 

OF .MoTIIlvK 



niKTIIlM.ACK 

<ii- m()thi.:r 

(Statr or Coiiiitrv> 







(Moiitli) A 



(Day) 



(Year) 



1 IIHRi:nV C1:RT1I-V, That J attended (lecca.sea from 



lLvo 11 



to LwvO. 'h\ itpH 



CL 



'6\ 



that I last .saw h l , , . ahve on VXCvX^l ^> ^ 190' 

and that death occurred, on the date stated above, at I ^- 10 
Ai M. Thi' CAISK OF DIvATII was as follows: 




ivtwyxj 



'\X 



/cL 



Dl' RAT ION )V^/-.? ^ A/0/////S ^0 A/j.? Hours 
CON^TRIIU'TORV vW\XX-Cr>'> X v^. <V>X<L 



^\^ 



Hours 



DTRATION -^ Years b Mout/is ^ t. A?v.? 

(SIGNED) J, J v<nAy\\..cur>^ M.D. 



XK\k 



no 



CU PAT ION pO J 

f\fMt/rif III Siifi /'ill II, I III O I )V(;/.v 



dx\x.t 



I 



T()0 



(A.ldress) H b 



d.CvCtxK; 01 



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



Days 



1A-^////> 



n,!\. 



Tin-: A IK )VK STATIC) PKKSONAI, 1' \ K'lirr !,A RS A K K TRTK TO THIC 
HKST Ol- MV KNo\VI,i:dc. K .WD in-lMKF 



(Infoniiatit 






Former or '\ ^'^t^ ^/jfn^K k ~\\ "*^ '""*' *^ '^ /^ 

Usual Residence^ ^'^'^'^^'^^^^^^^^ ^ Plafe of Death? <^o 

Wfjen was disease contracted, }\ ^ ^ ^ ( ^ k 

If not at place of death ? ^a/>v vJ/vavv^A^^o v.<VA. 



I'l.ACK OI- lU'RIAI. OR RKMOVAL 



N n f; R T A K K K vJ oXx'VN^ VI )\<X>LA^-rc\; 

(Addre.ss ISXH. a^^^KJwXcrW 



DATK of HiKiAi. or KKMoVAI. 
UJiy^vt 5) T90'\ 



.'t 



N. B.— Rvepy Item of information should be 

state CAUSE OF DEATH in plain term 

sons dyin& away from home should be given in every instance. 



carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
•ms, that it may be properly classified. The "Special Information" for p«r- 



m 



n 



II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

II,,;,, 1 f li.alth » No. is'*-^w^jHS:1'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



. I 



III 'I 



'1' 



y- .1. 






/)(i/r Fi/c'/ ,OjL\pXjL^^Ji^\, X lOOH 



Registerecl J^'^o. 



1354 



x'-u 



V. 7- >— - ; 



3l5.n mincer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 




I 



If 



Cevtificatc of H)eatb 

PLACE OF DEATH; — County of ^ J/CX^T- A.<x^v^cc4/Ct City ofvJ/CL/vu /uo^-^^ca^xmlo 
No. 5^'?^ \JcK<lt St.; ^ Dlst.; bet. M I^^O^^nA; and J -acJLc\. 

(ir DE*TH OCCURS *w*v FROM USUAL RESIDENCE give facts called for under "special information ■■ "S I 
IF death occurred in a hospital or institution give its name instead of street and number. J J 

e 

FULL NAME VVA^axx. b. 






PERSONAL AND STATISTICAL PARTICULARS 



DAii: t)j nikrii 



L 



Ct)I.nR 




X' 



aJL^ 



1 Month iT 



A'-.K 



Hi 



) III I 



(D;iy) 



M,-vth^ 



(Vear) 



medical certificate of death 
datp: of dkath 

(Day) 



x\\k 



i Month) 



(Year I 



I HHRi:nV eivRTIFV, That J atteink'd .Icceased from 



\R 



An. 



*^iN«.I,l" MARK 1 1: 1) 

\vii)«»\vi-:i) Ok i);\< tKr]-:i) 

•Writt ill «>fial «1< sit^iiatjon) 



ink rmM.AOK 

tSt.'iti « ir '."oiiiit !>■ 



I liSfi 




VAMI ni 
F ATM Ik 



nik iHi'i.xrF: 

OF FAIMFk 

' State or I'oiintiv 



M \ II > »•: N N A M I-: 

OF MoTUKk 



HlkTirPI.ArK 

<»F MoTHFk 

' Stiite or (.oiititrx 1 




. VCL/>V' IS lyo'i to 

tliat I last saw h rfl^--' alive on 






It/) H 
190 "i 



and that death occurred, '^>" the date stated above, at l^v 
A) M. The CAl'SF-: OT DIvATII \va^ as follows: 



DURATION )'cars ^ Months fhiys Hours 
CON T R I P. r T ( ) R V ^.XX.^y^lA.<'T^w-<^>~vA.^CU LiAJL^.AJ 



fKCUPATlON 

A' 






DTRATION I }'e(7rs Mont ha Pays I /ours 

Signed) > AxXAOL^yvcLoi^k M.D. 

vj ^^ifc at 



'Xii'vAT ^ r()o' 



(.\ddass) 10 5.^ 



Special information «"'> for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying anay from fiome. 



/'(M 



THl". AHOVK ST\ IFI) I'KkSOXAI. I'A kTron.A k S A k !•: Tkt'H To Till-: 
liF.Sr OI MV KNo\VIj:i)r,H AND WVAAV.V 

(IiifoMiiant (AD CUVVOtt) J . ybAxJL<L^rv-v 



Former or 
Usual Residence 

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



HoM lonq at 
Place of Deatli ? 



Davs 



DATliot HruiAF. or kFIMoVAI, 



I'l.ACI-: OF lUklAI, Ok kKMo\ \1, 

(St 0Lv^ 



T90 1 



^-*iUii. 



N. B.. 



-Every item o? inform«f.on should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for p.r- 



Bons dyin£ away from home should be feiven in every instance. 






if 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,1.,:m.1 -f H-altli- )'Sn i ^ "&-?,'^^^J IU«t I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' FiJedj 




X 



100\ 



Be^istered J\'*o. 



1355 



OFP 



r" 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( la. S. Stan^arD ) 
PLACE OF DEATH: — County ofOo-^^ 0;vo^a.<:AAoc City of 0/Cl^>^ ^ KXKy>^\y^iA^ 






.^Ou li) Cm\lrnJi J V CH(tKstA^"!. . Dist.; bet. 



and 



r DEATH OCCURS AWAY FROM USUAL RIE 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 




J\Mjy\/J<Js 




/\.'a_ 



I> \TK OF HIK III 



UOJ'vCtx 




iMondil 



lb 

(Day 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DA'IK <H" DKATH Jl 



cUkfc 

(Month) 



Ai.K 



H3> 



)'rii i 



\ M,,ul/is V* 



Da vs 



SIM.1,1:. MAKUIi:i). 
\VII)(>\VH!» OR IHVoKCKn 

'Wiit'iti «Kial <l(sij.'ji;iti'>ii ) 



TUK TirPI.ACK 

'Stiitc or Country t 







Hik riiri.ACK 

01 lAIMKK 
(Stair or Conntrv) 



M\ri»):N NAMl" 
III MoTllKR 



J'.Ik rnlM.ACK 
<»J- MoTIII'.k 
'St;it<- MI Coiilltl V 



OCCrpATlON Qryp 




VXa^ul^ 



^^^w\X; cL^X/^^Vv^b^ 






I IQO \ 

(Day) (Year) 

I III':ki;HV ClvRTIFY, Tliiit I MttendcMl deceased from 

LWo ^,0 190'i to pjJ^ .1 up\ 

that I last saw h <.'•.. alive on O^-^^jt: I 190 H 
and. that death occurred, on the date stated above, at b A,C) 
y M. The CArSK Ol- DICATII was as follows: 




•vJt . J\DJUx>\.t \X'y\/o>J^yo^\y^i^o^ 



1)1 RATION Years 

CONTRIHl'TORV 



Mouths 



Pa vs 



Hours 



\kj\yt^\XJ^ 




Dl'R ATION Years Moiifhs Pays 

OL- 



Hours 



(SIGNED) VJ, 




y"yxx.^AxL«.\. 



M.D. 



Add riss) CJxX^r^ J/vO-/w V<X^^- 



SPECIAL INFORMATION ""'y '"r Hospitals, Inslitutions, Transients, 
or Recent Residents, and persons dyiny away from home. 



^yv^X^^'cJ^^ 



Rfsidrd in Siin /'i niii nruX) * )'/'iiis 



1 III, A IK) VI'. ST\Ij: I) I'KkSONAI. I* \ k I" I ' ' C I, \ k s Aki; Ikl l'! TO Till- 

in-:sr «)i-^\ kndw i,i:i)«".i'; am» h):mi;i' 



'Q^ 



f Iiif'Jini;mt 



KXK^y^Jfi^ oU jeJ(rvJ-^vx^ 



(A<M 



rcss 








(U 



Former or 
Isual Residence 

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



Days 



IM.ACi: Ol' lUKIAI, OR kKM<)\AI. 



i)A'i:i;«»i MiKiAc. or ri-:mo\ai. 
Q)jLjfX 3. 190H 






!\. B." 



„.!„„ .h„ul.l h. crefuMy »uppM.d. AOK »h„,,..l be -.a.cJ F.XACTLY PHYSICUN8 »h„„M 
*TH in plain tern,,, that it ma, be properly cla..i«led. The Special Informnt.on for p.r- 



-Kvery item of inforin 
•tate CAUSE OF DEATH 
«on« dyinft awoy ?rom home nhould be feiven in every inHtBOce. 






'*«^.. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HoaKl ..f Hf.iltlt »• No. \^ -^^muZiyUftcV t 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



X ifJO'i 

Deputy Health Officer 



lie£f6'fere(l JVo, 



1356 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( XX, S. Stan^arC* ) 

Hi — County ofCjO^/Tu OyV<X/YVCX^Cc Gty of U/CLAV OAXX, 



PLACE OF DEATH 



No 



.^01 



O^'TKJ \1 KXAu^ 



''Vhi.' 



St.; % Dist.;bct. 



(ir DEATH OCCURS AWAY FROM USUAL R E S I D E NC E Gl VC FACTS CALLED FOR U N DE iVl "s PEC lAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OFtlsTREET AND NUMBER. J 



FULL NAME 



'^•■^v q^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 





and 







<L.sLUL m.. J aA^.O) 




,'<i^tr>^. 



KATK (M- HIKIII 



I 




\JJl 



tMoiith) 



.t 



A « •. K 



no 



) rn t .V 



^IN«.M-:. MARKIKl). 
\\II)»)\\};i) OK niVoKCKD 
■Writriii social •Ksivrnatimi) 



Mik rnri.AOK 

Stati or Coiintrv) 




(Day) 
C> Mouths . 


t 


(Vt-ar) 


clvvuJL. 







MEDICAL CERTIFICATE OF DEATH 

DATK C)I' DKATH 



(Month 




1. 



(Day) 



190 \ 

(Year) 




vc^-<a 



I ni':RI<:i}V CICRTIFY, That J attended (leccascd from 

sJ^^^o^ \\o 190S to ...dJ^xfc .1 190 H 

that I last saw h --» a-' alive on O-X/^xAj I Kp '\ 

and that death occnrred, oti the date stated above, at iO SO 
J M. The CAISH OF Dl-ATII was as follows: 

Urvv'CnxAw/t:, \J )^vij:^cl^x.^.,<cL^ 



)/C<rLLcxA^<:^> 






NAMI-: <»l 
I- AT I IKK 



niRTmM.ACK 

n|- l-AinKR 

' St:it( or (.'oiiiitrvi 



maii)i:n' NAM1-; 

<)I- MOTHKR 



r.IR'rHPKACR 
OI- MoTllHR 
(Statf or Cotnitrv) 



OCCUPATION 



DTRATION 



)'ears S' Mont /is 

CONTRIIU'TORV ATtCr^^JL 



Da Ys 



Hours 



DTRATION 



VaAo 



Years 



Months Pars 



>v\- 



Honrs 
M.D. 



'\JL^ cLCLy>'>X^^\]G 




vui- 



(SIGNED ) 

OX.^:\t 1^ T()o' \ (Address) \ 3lOO UxX/vvh\jU^ Uw 



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



) 'ill I 



yfniifiis 



/hn . 



THK AHOVK ST\'n;n PKKSONAI, I' A K 1" U' T I.A R S A K 1-: PKri-: To I'm-: 
HHSr OI- MV KNo\\I,i;i)C. K AM) lilCMi;!- 



\<Mrfss D I \J /<X/y\j 



I) /<X/^r\; xVuLn^ LI 



,A/V-t 



Former or 

Usual Residence 

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



Hew lonq at 

Place of Death? Oavs 



PI,ACK OF BTRIAU OR RKMOVAI, i DATit of IliKiAr. or RHMOVAI. 

(^.(9.©.<) -ilt'>^voJU-vH I o^i^ '^ '90S 

r.NDl-RTAKKR V I • U AX>^ ^^ V^O 

I Aihirt'HH .i51 ^ o >L^f./tI^jtv. y± 



N. B. Rvepy Item off information •houlil 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 given in every instance. 



I 



Hij 'I 



'\im. i 




mM 




^k 



«^^_ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



II.,., 1,1 of II. :i!Hi • 1" N'o 1^ t^-i;^^?^ Uft I' (V, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




\wA,-V>^ 




,^^ Deputy Health Officer 



Bc^istered Js'^o, 



1357 



Dale FiJvil , 

DEPARTMENT ot PUBLIC nEALTH=City and County of San Francisco 



Ccvtiticate of Beatb 

( H. S. Stan^ar^ ) 



r\ 



"I 



PLACE OF DEATH: — County of U/CL-^ J . V<X/r\^cui>c^ City of UCX/>\; A/a.wCAAye,c 



No. 





dAjLrUi UUCkIvOL 



.<Xy^ 



St. 



Dist.; bet. 



and 



(IF DtATH OCCURS AwAv FROM USUAL R E S I D E NC E Gl 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 OAXdxwcA JXxX/^^vt^ 



PERSONAL AND STATISTICAL PARTICULARS 

i)\ri-: <M-' lUK III A 



MEDICAL CERTIFICATE OF DEATH 

DATK OI' DIvX'IMI 

(Day) 



'l 



I go 

(Year) 



\C.K 



(Day) 



(■Year) 



) Vl/J v 



Mntlth^ O 



An.v 



SINC I.1-: MARUIKI) 
WIDdW i:i) OK DIVoRtl-:!) 

! Write in '.iiciri! (Itsi^'iiatinii ) 



lUK IIU'I.M'I-: 
' St.'itc <»r Coniitrv^ 






(Month) jf 
I HlvRIvHV ClvRTlI'V, That [ atteiKk-d (leccased from 

n f o., 

and that (Uath occurred, on the date stated al)()ve, at 1 3.-H.ii 
V M. The CAl'SIv ()!■ DI^ATII was as follows: 




11 190H t( 

tliat I last saw h '- » >' alive on 



190 H 
190 i 



\ I /Vo-Ay'ru^\AAAX 



vxr->x 



niKinpj.AOK 

0|- .1 ATHHk 

(Statf or Countrv) 



MAIDKN NAM1-; 
Ol" M«)Tin:K 



I'.IRTIH'KAC K 
01- MnTHKK 
(Slittc or Country) 



<H\ri'All«)N 

/\f'yiilr.! ill Sill! /> 1! i/i :u'i' 




I) I 'RAT ION }'ears 1 Months 'XS Days Hours 
CONTRIBUTOR V 



DTRATION 



)\un'S 



\X \j<xjy\} 




( Signed )MjJL<ww^ 

Liu^a V. i«)o'i (AddrrSK)U\JUlAJU^ (lbo-<lUs.\ 



SPECh 



M<)}iths Days Hours 

X<vM/>vj M.D. 



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



Former or 
Isual Residence 



;"\IWJrun.( 



Days 



TH i: -XMOVK STATl-:n PKRSONAI, PA RTICl' I.ARS A R »•: TRrH TO THK 

p.HsT oi- Mv KNOW 1, 1:1 )(•.!•: AND Hi:i,n;F 



(InfoinKint \|}VUi ^ \- \) /CuX 



( \<l(lrcss 




rj<j\j 



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



PI,ACK OF BURIAI, OR RKMOVAI, 







I A I, or RKMOVAI, 
3^ I90M 



N. B.- 



-Bvery 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 dying away from home should be feiven in every instance. 



I 



'/ 



il' 'I 



Hiiti. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I!(>:n<I ..f Ilcjiltli !•■ Xo. i^ **^^^«> H8: I* Co 



])(( f r Filoil, d JL|^jbL/>>xisJUv a 19 0\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JYo, 




1358 



v^ dJL'\> 



Deputy Hc*^ 5^'- Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( xy. S. Stan{>at^ ) 

A % A ^ 

PLACE OF DEATH: — County of ^lO^'W) ^AXX/YV^^A^ccCity of Q^O^^v O^^XWlCaacc 

rNoJUlo OAyCAXX/YrULTd^ SU X T>{sXAhcxA.OUs.l^\: and Tl LoA CPrx. 

f ir DEATH OCCURS *W*V FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UlioER "SPECIAL INFORMATION - \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^ OF STREET AND NUMBER. ) 

FULL NAME hjl±r^o^\)\jj^^j. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



Xrr\ 

DATK OF HIK rn 



A<.K 



\ 



lAIoiitli) 



lb 

(Day) 



fVear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 

Ixkfc I 



(Month) 



(Day) 



790 M 

(Year) 



V ^ Ytiits Jv U<in//is 1.5 



/)ii 1 .s 



SINt.I.K. MAKKIKI). 
WIDoWKn OR DIVOKCKD 
(W'ritf in sotial <1» si^fiiatinii) 



HIKTHI'I.ACK 
(State <ir Country) 




0^ 



<xw.kxxL 




I HHRICBY CERTIFY, That I atteiided (leccased from 

'^^ 190H to (Xu^ 5>.i igo H 

that I last saw h -^*> ' alive on Lmw*-<5 'iX j^q '^^ 

aii(l that death occurred, on the date stated above, at iQ.-'bO 
vIm. The CAlSn: UK DI'ATII was as follows: 






.^Xk Hl 



<x 



NAMF OF 
FATUHR 



lURTHPI.ACK 
()»■• l-ATHFR 
'Statf or C(»untrv) 



MAIDKN NAMK 
OF MoTUFR 



hirtmpi.acf: 

Ol- M<)TnF:R 
(State or Coiiiitryl 



i 



OCCrPATION (Tpw? Q 

()\d (y\A>i.XA.A>vLc 
Rf^idrd III S(iii /'i ii III i>,-i> \^j Fr//; ^ 




DIRATION Vc^'s Mofii/is ^ Days Hours 
CONTR IIJUTORY \JrsJ>.J^ry\^uZ L^cudu^^ 



rXRATlON 

( Signed ) 



Vears 




Months Pays 



V^X.'-VYX) 



QX^ 1 yqoH (Address) ^^H ^K^Xkxr^, Ut 



f/out's 
M.D. 



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



lA-;////' 



lhi\. 



Former or 
Isual Residence 

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



Hew lonq at 
Place of Death ? 



Days 



TMl'; AHOVK ST\Ti:i) I'FRSONAI, P A R T II" C I.A RS A K I" TRIF Ti > TIH' 
HF:ST Ol- MV KNOWIJ-DCK AM) I!I:i,II;f 



^'b\\V' ^T "^'U'^^' ^^^ RKMOVAI, I DATkof IJt RIAL or RKMOVAI, 



rXDlCRTAKF 



N. B. Every item of informHtion •hould be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in pl»in terms, that it may be properly classified. The "Special Information" for osr- 
«on« dyini away from home should be iiiven in every instance. 






'.••' I 



,.■ /; 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lto.it.1 of H.allh I" Vo. !!; "fr'Fiiap.S^ jj&P Co 



I )((!(' AV/^v/, dx^^JjL^mlvOvj X /'>^H 




dJL/\>M 



Registered J\'*o, 



1359 



n 



ricer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Xl. S. StanC>ar^ ) 



PLACE OF DEATH: — County of Cla^ A/Oo^vC/waCij City of 0/Cla^ OAxXa^i^v<lco 



No. 




J Cr ^'>\X 



St.; 



-Dist.; bctr 



-and- 



/ \r DEAfH OCCURS AWAY FROM USUAL R C S I D E N C E G I VE 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 




K).<X/yY\jYy\i. 



PERSONAL AND STATISTICAL PARTICULARS 

DAIl-: ni HIKril A 

M\t\r VX /.?>1H. 

Moiitlj) (Day) (Vtar) 

A(.K 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:ATH 




(Month 



1 igo\ 

(Day) (Year) 



^A )'tins \ Months ^ 



Davi. 



SFN(.I,K. MAKklKD 
UII)<)\Vi:i> OK DIXoRilU) 
' W) itf ill '^ixial <U-'<ivniatiuii) 



HFRTFIIM.ACK 

(State or Oouiitrv^ 




^a^/cLmaj^ 




CLA-/OaJw 



FATin.R 



HlRTHIM.ArK 
Ol J-ATHKK 
iStatf or Coniitrv! 



MAIDKN XAMK 
oi MOTHKK 



MIKTHI'UAt K 
Ol- MOTHKK 
(Statf or Countrv"! 




^toAAj 




I HICRI'HV CIvRTim-, That I atteiidcl deroascd from 
til at T last saw h 



P9©- to ^ A\^ 

X^ alive on 3-^^ 



? 



^ 190 H 

and that (kath occurred, on the date stated above, at \ \ 
U^. M. The CAl'SK OF DIvATH was as follows: 

sj YyNJ2A/<wOa'V.0''v^A/^ 

X^JpJu ^U'6-^iX^»\J 

DTRATIOX ^ Years Months X\ Days Hours 
CONTR I nUTOR Y Qjl^>A.^JLuL^ 




^OJ\y' 





? 



DURATION 
(SIG 



Years 



Mont/is 



Pays 



X}r\)^ \ Tcjo'i (Address) TS'l OAAytLiAj OA 



Hours 
M.D. 



Special Information only for Hospitals, InsfUutions, Transients, 
or Recent Residents, and persons dying dway from fiome. 



oi'Cri'ATlON 

f\f^iiffif III Siin /'i mil i I'ii V, O )'iiii<: 



\r,>iitlis *- Ihivs 



VWV. AHOVK srAll-.l) I'KKSONAI, I'A K TH" T I,A KS A k l'. I'KIK To J"HH 

jii':sT 01 MS KNOW i.):n<'. K AND in:i,ii:i* 






Former or 
Lsual Residence 

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



HoH long at 
Place of Oeatfi ? 



Days 



J^I.ACH 01 .HIKIAI. OK RKMo\U, I D ATI-: ol HnnAl. .)r KI-:moV\I 



(Address 



JIH 0"5',a^.x;Jli± 



rNDi:RTAKKK 

(Address . 



N. R. Kvery Item of InformHtion should be ciirefully supplied. AGE should be stated iiXACTLY. PHYSICIANS should 

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



,•» 



m 



1 



m 



% 



\ 



il' 'I 



llr :;';'!' 



i;' Hi)'. 







•1 

i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hn!.t-.l..r iic.-iUh- >-No. yK-^^^^wS^vCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((h' Fi/rd.A.JL 



.CJ-VL^C>5 




X. 



IfWi 



HegLstered J\^o. 



1360 



Deputy Health Officer 



DEPARTMENT ffF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( tl. S. Standard ) 



(^ 



PLACE OF DEATH; — County ofO.CLw JX<X/>"vcA^^(.City of 0/CXyVu j .h.xX/^vv/ciA.ci c ^ 



^Pic^^A.<.t"yxa! 



U AAta. Qj cu'>x<xt^\.i.^<.-\^ V St.; 



(ir DEATH OCCURS *WAV FROM USUAL 
ir DCATH OCCURRED IN A HOSPITAL 



Dist.; bet. 



and 



RESIDENCE Give FACTS CALLED TOR UNDER "SPECIAL INFORMATION 
OR INSTITUTION GIVE ITS NAME I 



FOR UNDER SPECIAL INFORMATION" "\ 
NSTCAD OF STREET AND NUMBER. / 



FULL NAME 





±- 



.vvA-'Lco 



SKN Q^ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 





Ja-\aXjl 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DK 



DAIl-: <)| lUK III 



\\^r^ 



"Month) 



Ar.K 



U 



) I'it t .< 



H 



'1 

(Day) 



Monl/is 



.,1.H.X 

(Year) 



•:ath P 

a 



(Month) 



I 



(Day) 



(Year) 



x\ 



/hi VA 



STVC.I.K. MAKHIKI). 
WIDOWK!) OK I) IVOR (• HI) 
•Wtittiii s(Ki.'il (hsijj^iiatioii ) 




lUK rHPI.At'K 

'Stall- nr Country^ 



NAMK ni 
FATIIKK 



lUKTllI'I.Ai'K 
<»( 1 API IKK 
iStatr ur Comitrv) 



MAII>j:n NAM1-: 
<)!• MOTIIKK 



niK'nii'LAi'i-; 
<»!■ M(>'rni:i< 

(Statf or (."0111111% 



OCCri'ATlONCAP 







I HKREBY CHRTIFY, That I attended deceased from 

Laa/^ ...H 190 H to 3jL.\:vte: I igo H 

that I last saw h a.'^ alive on CjJLyxAj [ igo ^\ 

and that death occurre«l, on the <late stated ahove, at IV- iO 
Q: M. The CATS I') ()!• 1)1-; AT 1 1 was as follows: 



A 



^Oy^hw't^tjrvvwa. 






k^ 



*\y7v:W'. 



I 



I>r RATION 
CONTRIHUTO 



} 't^ars V. Mouths 



Days 



IAa^^^Ow^v^i 



(y'L>^^AJLA.^/-^JM. 



J 



L 



Kfsidfd ill Siin /'i (UN iscii 



) Vit I s 



.1 A »;////,- 



/ ',1 1 



RY .Q.A^^^-<C|^v^:,^ Qj:>w:<^.:?:^k 

l^^AJub\M\/\\jCL U|>JAXxjL\^<rw 

DURATION }r(irs Mouths X Days 

(SIGNED) Lt. 0. dJx<X>./dLvJll 

JJ^xt Ov iQoH (A.hlress)M^/OAMytl) VJ j. 



Special Information only for Hospitals, institutions, rranslents, 
or Recent Residents, and persons dying away from home. 

Former or ^i 

Usual Residence vJ AXVWO 



LoX 



Hew lonq at 

Place of Deatfi? Days 



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



THl", AMOVK STATi;i) I'KKSONAI. PAK'IHT I.AKS AKF. TKrF TO TIIF 

i5f:st 01-" MY KNo\vi,i;i)c.F AND iii-:mi:f 



(Infoinianl 



'X^-vw 



(!!? 



\ 



JvO. VD /txonXK; 



r\<Mioss OXX^i-^rv^ 



KjdJo 



JM.ACK OI- lURIAr, OR RKMoVAI. I DATF of Mi KIAL or KKMOVAI, 

^ K^J^^r\A>..\joX I 0-M^' /^ T90H 



UNDICRTAKKR 



(Address .. 1*^^ 5 I UJ.A-J(^1y^t, SrWrr^. 



/CXXVOu^V 'V*v V-C 



N. B. F.very item of information should be cnrefuily «upplied. 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. 




irn 



i|..:lH<l 



►^•^..1! 



li 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^__ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lionnl of Jlcnitli • I-" Nf>. K ^'V^'Sgi.:?^ u^\> c< 




Keglstcvecl ^^o. 



1361 



Ihtfr Filed, aJL^xXjL^>>U.M^ X lOO^i 

d.Jtr\^^^,Aj^ Xt\vM Deputy Health Officer 

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



Certificate of Beatb 

( H. S. StanOarD j 



/^ 



PLACE OF DEATH: — County of 




<Xa)-V\.<x.^ 



City of Uc^ 




No. 



(IF DEATH OCCURS 
IF DEATH OCCU 



St.; 



'Dist.;bct. 



and- 



s AWAY FROM USUAL R E S I D E N C E G I V E facts called for under "special informatio 

RRED IN A hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



N.) 



FULL NAME 




C\A.<c. Cl '>A.' KJX. 



PERSONAL AND STATISTICAL PARTICULARS 

DATi-; oi iiiurn 



Woiith) 





KJX 




MEDICAL CERTIFICATE OF DEATH 
I>ATK OF DKATH /O 

(Montli) rt (Day) (Year) 



(I):iv) 



(Year) 



A ( . }•: 



I IIHRI{BY CI'IRTIFV, That I attended (leccased from 

to 



ID ),iiis 



yfouifi^ 



\x 



Pavs 



STNC.I.K. MAKRIHI). 
WFDnWHI) OK DIVOKrKD 

iWiitfiii «)rial dr^iij-Miatioii ) 



lURTHIM.AOK 
'Statf or Country^ 





a^A^^-'CtVaAa,' 



-190 to ■ 190 

that I last saw h ~ alive on : — 190 

and that death occnrred, on the <late state«l above, at 



^r. The CAl'SIv OF DMATII was as follows: 



XXA^ 




XANfi: 01 

FA TJIl-.k 



RFkTMIM.ACK 
ni- I ATHHK 
(Stat( or C'oimtrv) 



MA III}-: N' NAMl-: 



lUK rm»i,A("H 
or M(n-m-:K 

Stall- or Coiiiitry) 



OCdTATlON 




Dr RAT ION Years 

CONTRIIU'TORV 



Months 



Days 



HoKts 



DURATION 



(SIGNED) .. OJUV' 



)\'ars ^ font /is 



Days 



>GVVA,U 



\jOf<)^ 1 190 'i (Address) 





Hours 
M.D. 



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

^^^ How lonq at 
Mi Plare of Deatli? Days 



Former or 
Usual Residence 



^ 



^ KKJiAjj</ry\/>rsJL 



Resided in Sun Fi nni i^en " )'r<n 



y/nntln 



IhlV. 



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



rni". AUovF. sTA'ri-:i) pkrsoxai. i>ak ikti. \ks \ki: trik to tmh 

IU-;ST <)l' MY KN()\Vl,i:i)<".H AND JUIIJF.H 



(Iiifoi niaiit 



b , vj . X^" 



V-v^v-O 



f \<l.lrcss 



(^LlxXi^aJXol vXX-V 






ri.^CK OI" r.l^RIAL OR KKMOVAI, I DA'^'i;.)!" MlKiAi, or RKMOVAI, 

^t X 



i9o'\ 



Ad.ircss S.XH \nV UJjLAA,txA). cjt 



N. B. F.very 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 given in every instance. 



( 1 



i ' fi 



XM^ 



h' ' fl 



i' I. 't 




Li:«i' 



^«'l 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l!.,:n.l of II. ■■tlth I- No. 1^ t^t^]^ ns,v c, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihf/r /vV^v/, dxipjLi/>T>is^ X WO'i 



O^^^^WaA 



Registered J\^o, 



1362 



Deputy He c<!;, 7 Officer 



DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( tl. S. Stan6atCi ) 



% 



^ ^ 



PLACE OF DEATH: — County ofO CX/w JA/Ct/>xc^^ccCity of Q/CUvu A.CL/vxc-Mi.e^ 



^N©. 









C>^a 



^vJs<^)(j 



Dist.; bet. 



and 



IF DEATH OCCURS AWAY FROM USUAL P E S I D E N C E G I V E FACT 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



TS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



SKX 



DATH <)1- lUR in 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



MX/rrOA; 




/CLuj-<i.^trv\; 




<n V 





y 




Month) 



AC.K 



\ U )V./;.' 6 



(I)av) 



.^/of////s 



11 



i. 



r Is L . 

(Vtai) 



Days 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



slM.I.K. MAKkn:i). 
UIDOWKI) OK I)I\(»K('i:r) 

'Wiitfiii ^<H-i.'il il«si</nati<)ii) 



lUKTHIM.ACK 

(Statf or Coiiiitrv) 



1 rLojv.\.'Oui 



(Month) K 



31 

(Day) 



(Year) 



I HEREBY CERTIFY, That I attended deceased from 

sXxA^CL \ I90M to LLlv^ 2)1 IQOH 

tliat I last saw h -^^''^ alive on \Aaw«w<3 ?>0 up H 

and that death occurred, on the date stated above, at i 
LL M. The CAl'SI^ OF DI'ATII was as follows: 




^\ol^- 



/y^^j 



\AMi-: oi- 

I- ATii i;k 



lUKTIIIM.AOK 
n|- I ATHHK 

(State or Ooniitrv) 



MAII)1:N' namk 
01- MOTHKR 



lUKTni'LAc 1-: 

<)1- MOTIIKK 
(State or Conntrv) 




DF RAT ION 



Years 





Hours 




ION J p 

Kfsidfd in Sa)i /'i (ni</>r<) 31 C )Vim> " . !/-</////> 



Mouths ^ Days 
CONTRIUFTORY JvOw^'XA^ii. /O^v.^^. 

DFRATION )'iUirs Mouths Days 

(SIGNED )..Uj. M. y^AA/v/vvlAXX.^^ M.p. 

'^\ TQOH (Address) 1 1 ^ b W^ UJLl'uJa.Nj O^. 



/fours 



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



Usual Residence 'C^ll aIxxX^^h Ot^ Place of Death ? S i\AA... Days 



Former or 



Till', AHOVK. S TAI'i:!) PKKSONAI, PA KIR- T l.A K S AKl-, TKrH TO r\\\\ 

nicsT t)i-" M v^jsNowij: !)(.>: AN i> hi:mi;i'" 



When was disease contracted, y l ^ ^ 

/)„,> I If not at place of death ? OXH^^aA) .o^^^XVv^ 



(Informant 



(X.Mrcss 




PI.ACK OK BCKIAL OK KI:MoVAI, I DATi; of Hikiak or KKMOVAI, 




Ukxx\XjU Jo 



.V 



(AiMrt-ss 






N. B. Bvery Item of information should be carefully Kupplied. 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 dyinil away from home should be ft'^cn in every instance. 



! ! 



II" 






i II 



.n 






I t 



!'■ 






,1 I 



Mi 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Unanluf H.MiHi !•• Vo. i> ^^^^]U^]>Cn REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS 



/)(( 



/r Fi/r(/,^ 





X l^O'i 



Deputy Health Officer 



Registered J\^o, 



1363 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( TH. S. StanOarO ) 



PLACE OF DEATH: — County ofvJa/\x 0;v<X>vCA^/c;ACity of vJ /Curv J A.<\^^^t>,ocic,c 



^ 




/No. U-LV>>XO^^ (ib(H4w^XX.l St.; 



-Dist«; bet. 



and 



(IF DEATH OCCURS AWAy! FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "X 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




o^XxJij 



SKX 



DATK <)!• I'.IKTU 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR 






A"^ 



Otx 



i^t 



M..nth) 



Dav) 



(Year) 



A<". K 



^0 ,v<M. 10 



Months 



r'\ 



Pa r.v 



WHxtWKI) OK DIVOKC'KO 

'Write ill •>.«i;il (U si<'n;itinii ) 



lUKTnPI.AOK 
I St.itf or Comitrv) 



NAMK OI- 

I- ATI I i;k 



niKTUfl.AC'K 
<>l lATMHK 
(Statf or Country) 



MAII)1':N' NAMK 
OF MOTHHK 



lUK rniM.ArK 

Oh MOTHHK 

(Slati- or Country) 




MEDiCAL CERTIFICATE OF DEATH 
DATE OF DE:ATH J? 

d.xi\i. 1 7poH 

(MonthO (Day) (Year) 

IIIF^REBV ClvRTIFY, That J atteiidtd .Iccoased from 

1% 190M to ax^:. 3L 190 H 

that I last saw h A. . . ^ alive on <:j.JiJ^<X:.. SL igo i 

and that death occurred, on the date stated above, at ol 3» 
^*^ M. The CArSli OK 1)1-:AT1I was as follows: 

C^rvvtjLslXv>%'<xA U X-<tV'\A.Ayt)A.<A.^cnv^ 




DURATION Years Months X Days 

CONTRIIU'TORV LL-C^S-aA^ AJJ 



Hours 

"vwv<v.<> 



DURATION 
(SIGNED) 

XhjpSi 'X TQO'l 




Years 



Mouths 1 Days 

■Ka-^yv^ 

(Address) \) V\JywJX/\>^ 





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



DCCl rATR)N -^ 

Resided in San I'l airi isrd I )'riiis 



.\f.>>ifh> 



/'.M 



Wa/^^^u- 3 



Former or | u c: 

Isual Residence VO vo _ 

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



■ H»w lonq at 

X: Place of Death? Ht 



Days 



TWr, AIIOVK ST \ ri: I) I'KKSONAI, I'AKTHMI.AKS AKH TKrK TO THH 

ni-:sT OI- MY kno\\"m;i)c. K AM) Hi:i,n-;i-" 



(Iiifotinaiit 



\ 



(It) O-'^^'ovX'oJ^ 



f \(Mrc»is 



I'l.ACE OF BUKIAI, OR REMOVAI, 



DATE of Ht KiAi. or REMOVAL 



OjJ^ ^ 



UNDERTAKER ^ ykjUK^i->Cr^ oU-Oe..^UK^ 



I90H 



^Aildrtss 



N. B. Kvery Item of inPormHtion should be carefully suppiieti. 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. 



« 



,f-l,' 



I 



'! ' ft 



i 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l(,,n<l -f n.altl. 1- Vo 1^ •g^^Sr^^"''^''^'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r FiJrd,^ 





l^X^^ 



X 



vM Deputy Hv 



lOO'i 



h Officer 



I'iCglsfei'ed J\'*o. 



1364 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of S)catb 



( XX. S. Sta^^ar^ ) 



^ % J (Up 

PLACE OF DEATH: — County of C'O^^Aj /vCl-> vcv^cc City of 0/CUvo J /vxd^^x/c^a^C-C 
'No. SIH JaXI^a^VX St.; ^ Dist.;betNlll ltlU4.LN..' and U^lt<rv\; 

(ir DEATH 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 



^\^' 



0<J^^<X/Y>'\j 




1X>\ 




<.i;\ 



I) ATI-; •)» HiK 1 n 



.\(.K 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




VL 



■Xjl 



I Mouth* 



t 



a.5 

(Day> 



,%%k: 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
KATE OF DKATH J) 



dxlvt 

MoiitlO 



(Day) 



(Year) 



H^ 



)V,/;, 



iO 



M.ititlis 



b 



Da v.< 



'^IN'.I.K. MAkKIi:!), 
WIDoWKP OK IHVoKCKI) 

'Wiitt in "XH-iril flt<iv^ii:iti<nO 



HIK rni'i.ACK 

i Sl.itc or C'liintrv 



NAMH OF 
I ATHICR 



MIKTIIF'I.ACK 
Ol- I ATMKK 

' State r,r Cximtry 



MAIDKN NAM). 



HIK rm'j.ACK 

<»!■ MoTlll'.K 
(State i»r (,''niiitr\ I 



^ ^ () 



I HERKRV C1-:RT1FV, That I attended deceased from 

VIA-OLu O IgO^ to LLlA^CL '^'^ IcK) H 

! I '^ (T 

that I last saw h ;- ^ > ■ alive on vAa,a«o X*^ up ^ 

and that death occurred, on the date stated above, at ll-oO 

J^ M. The CArSl{ Ol- DI-ATH was as follows: 



"1- 



c) 



<X/>n^ vj /vOcO^^-^^Xt *OC' 



(^ 



y 




<XA 





y0.y>V' 



I) r RATION 
CONTRinrTORV 



)'tujrs Mo}iths o Days Hours 

^'Wnul 










DERATION Years ^roulhs Days 

(Signed) LOrryo; UJ/oJll) JXJiAA; 

OJ^\f^ X 190H (A.ldress) IQwDO U.<Vvun\jU/L vLvol 



Hours 
M.D. 



Special Information only for Hospitals, InstituHons, Transients, 
or Recent Resi(Jents, and persons dying away from home. 



OCCri'ATION ['^p 

Kf-idfd III S.iv ria>in>r,> \K) )V-.;;. 10 M.»,ths ^ Pm^ 



THK AHovK sr\ri:i) hkksoxai. i>\k ihti.aks aki-: tkik tu rm-: 
HKsT Ol- Mv KNt)\\ij:i)<Ali AND Hi:i.n:K 



(InfoMiiant 



(W."5 



CXddrcss 






Former or 
L'sual Residence 

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



How long at 
Place of Death ? 



Days 



PLACK Ol" KIKIAI, OK KKMOVAI, I l)A'ti:.)f }{t KIAI. or RKMOVAI, 
(Address 1.^ \j<3U->^ \j\jUji ^V\^^ 



!N. B. F.very 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 dyin^ away from home should be given in every instance. 



•I 



);ii 



I' 






I 



I I . il 









1 



i 



> i 






I 



■3; 
* 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

"""•' "^ n..-tlth t-Vo. 1^ T^-^^^HS:l'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




VJO\ 



Registered J\^o, 



1365 



l)((te Filed , 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Deputy Health Officer 



PLACE OF DEATH: — County 

(ir DEATH OCCURS A\A/AV FROM USUAL R 
IF DEATH OCCURRED IN A HOSPITAL Ol 



Certificate of H)eatb 

( tl. S. Stan&at^ ) 




St. 



Dist.; bet. 



and 



ESIDENCEGIVE FACTS CALLED FOR UNDER "SPECIA 
R IhLSTITUTION GIVE ITS NAME INSTEAD OF STREET 



■f^' 



FULL NAME ^) 



hJX,yx£JL%. 




iL INFORMATION" N 
AND NUMBER. / 



va 



.\.<i. 



PERSONAL AND STATISTICAL PARTICULARS 
SKX (Yr\ ft I COLOR 



X'Vv^. 



oJui 




nATi-; 01 HI Kill 



\<.K 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 9 

DxUt X 



(Montli) 



(Day) 



190^ 

(Year) 



iMoiUh) 



Hb 



J' (/> 



H 



3.0 

(Day) 



Months 



r % b H . 

(Vt-ar) 



/)<n.v 



S[N(-.I,K MAKHIi;i). 
WIDOW KD OK DIXOKIKD 

• Wiitfiii sKcial drsii'iiatioii) 



niK riii'i. 


AOK 


1 stall' f)r C" 


ounti >•' 


NAMH 01 




fatmi:k 




HIKTHl'I, 


\('K 


OI- I ATIIKR 


(Statf or C 


oil 11 try' 




I HHR1{HV CIvRTirV, That I attendod deceased from 

l5 innM to _VA,A,A,^ ^.l IgoH 




190 



that I last saw h-AAj alive on 






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




'^\ 



190 



I 



M. The CATSi^ OF DlvATlI was as follows: 



nr RATION 



<xx.cL 



e. 



MAIDKN NAMl". 
OF MOTHKK 



lURTM PLACE 
Ol- MOTHKK 

• Stall- or Comitrv) 



orcrPATION 




Jb^rv>\AlJLA^CLAaAXL 



y't'ars J\ Months Days 

CONTR IIU'TOR V \|y\JLXLL^^vix^,v l. J J\A./0:^ 



Hours 



L 




n 



^ 



Ct'v_.' 




DTRATIOX 



(SIGNED ) 




Years 



Bx. 



^^i:. 1 




^Tont/is 



TC)0 A 



(Address) 59^0 



I 



Days Hours 

M.D. 



-o^ 



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



A^V^CVo 



Resided III Sun /'i itiit isri) 



] III I 



^/,'n//r 



/'<; 1. 



Till-: ABOVE s rA'n:n pfrsonal i'aktum'i.aks akh tkif to iiii-; 
iif:st Ol' Mv KNo\\i,i:i)c.K AM) in-:Mi-:F 



Former or Z\ 

Usual Residence vJ /Oav \t>-^^ 

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



V^^ ^oX, 



How lonq at 
Place of Death ? 



Days 



anfonnant \J Y\\A vAj \J, J 



f X.Mress 



O/O-'Vv 




I'LACE OF niKIALOR REMOVAL j DATE of lit rial or REMOVAL 
C)<5uw V^ Col I ^^^'^' ^ 



6x^ «> _i90't 

rNDi:RTAKFK VX00JH5'\a<>wvxx; lX'YvcijL\XxxJkv\va 

(Address ^ H <i^ Q ^r^^^L ^t ^ 



r© 

I 

vc 



IN. B. Bvery Item of information should be carefully Kupplied. 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 given in every instance. 



m 
■ft 



i 



I 







11 



If 



/^U'fl^ 



WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



I!. ..ml nf II( I nil I" Xo. !!; ■*^^^^>H.*tl' Co 



Ihf/r Filed, ^ 



cL^-\>^A^ 




190\ 



Begisterecl J\^o, 



1366 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( vt. s. stall^at^ ) 

PLACE OF DEATH: — County olO^O^yx: 0/vco^^ou!,a.Oty ofO'O^"^ /vcx--»-v'CA.<t c^ 



No. 1 IH 



ckA^lu LL'V-, St.; 1 D;st.;bet.J- 

(ir OtATH.fecCURS *W*V FROM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" \ h 

IF OEAnH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / \j 



Dist;bet.J^O^wkAA/rb and U MAXVV 



FULL NAME 




'TVYVUL 






XJki 



PERSONAL AND STATISTICAL PARTICULARS 

COI.< )k 



I) ATI". <>l- itlK TH 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 




(Month) 



(Day) (Year) 



AC. K 



alt 



I Montli) 



^ )Vi/>- 



(Day) 



(Vear) 



MntiShs 



fhn. 



I IIHKI'RV CIvRTIFV, That I attended deceased from 

190 to 190 

that I last saw h alive on ~~~~~ ~ 190 



>i\c.i,K. MAKkn:n. 

WIDOWKD OK niVoKvHD 

iWritf in soriril 'IcsiiMiatioii) 



niK IIU'I.ACH 
' Stilt t or Country) 




AXL^A.A>^^ 



FATH I.K 



hikthjm.acf: 

<)|- I AlHICk 
(Statf or (."onntT \-^ 



MAII)I-:n NAMF 
OF .MOTMFK 



niKTHPI,ACK 
<)l" MoTlIHK 

(Stall- or Coiititrvi 




and that death occurred, on tlie date stated afjove, at 
~ M. The CATS]': Ol' I)1':ATII was as follows 



r^ 



n./0-<tA^ 01^ dL.^^AM'Sj 




Di; RATION )'t'ars 

CO.NTRIIU TORY 



Months 



Days 



Hours 



nrRATION Years Months Days 

NED ) UrVCrvjlA; 0. Mb. U). iiXo^vc^. 
(Address) LC)^UrVyJiAA 



(SIG 



I()0 




Hours 
M.D. 



occri'ATioN (7r\p 

Rf.'-idfd in Sail /'lain ism ^' 310 )'-•</; >' *" ^h>iitli< " /',; i > 



0-V-AA.JUw*-^V^ 



SPECIAL INFORMATION only for Hospitdls, Instilutlons, Transients, 
or Recent Residents, and persons dying away from fiome. 



rui: \iu)VF. sTAii:i) pkksonai, I'XKiicri.AKS akf tkck to thf: 
ni:sr <)i' m\ kxowi.iux; f and iu;i.n:i" 



(Infoiniant 



%.% 



\'l(1ro«s 






\LxtdLu o-t 



Former or 
Usual Residence 

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



Hew long at 

Place of Death? Days 



D 




HrKiAi. or RF:M0V'AI^ 



I'LACF: Ol" n'KIAI. OK KKMoVAI. 

INDl-RTAKFK MfCX/VVvJi/O Vf fV O^^/WyW ^^<*- V^ 
(Addirss 3LIH Od./cU^ Q'k. 



I9OH 



IN. B. Kvery item of inforinntion should be cnrefuily supplied. AGB should be stated EXACTLY. PHYSICIANS should 

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



ft ' r 



■'^ 



f 



M iii 






jITl" 





^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l>.,an]Mf Hc-r.Uli I- Vo. \^ *^^^i\fkv C<y REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)a/r Filed, d 




X ^190^ 



Deputy Health Offln<*^ 



Registei'ed •A^o. 



1367 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



•■? 



Certificate of H)eatb 



( "U. S. StanOar& ) 



PLACE OF DEATH: — County ofO/CX^^; J ^uCLa v aAACX^^ City ofO^C\/W J AxXy'>A^Cv4.^1 
Wo* 11^^ k LcrOV\icr^'A : St.; 1 Dist.; bet* U/CL^Ca1\. i;i and ytx^^^^Atr'vv 

(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR U N DE R] "S PEC I AL I N FOR M ATI|( • N " "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OC/STREET AND NUMBER. / 



FULL NAME 



SKX 



DATH OJ- HI KIM 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR/ 





i 



iMoiith) 




^155 

(Year) 



4 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 

(Day) 




(Year) 



AC.K 



\\ }V,/;« b M.»,l/is V?. 



n,j 



SINCI.K. MAKKIKD. 
WIDOWKD OK DIVoKiKD 
iWtitcin s(K-i;»l dcKii'iiiitioii) 



lUK ruI'UAOK 
(St.'tti- (»r Countrv* 



NAMK <)I 
I" A r I \ 1-; K 



niK'rm'i.ACK 

()!• lATHKR 
(Statf or Cotintrv) 



MAIDKN NAMK 
<)!• MOTHKK 



HIRTHPr.ACK 
OK MOTHKK 
(Statf or Country) 




(Month) ,1 
I HF':RI':HV CIvRTIFV, That r attcndcMl .letcascd from 

■•■■■ "■" 190 to- ' 190 — ~. 

that I last saw h alive on 190 ~ 

and that death occurred, on the date state<l above, at - -:.. . - .. ■ .:..: ... 
- M. The 



r::— M. The CAl'Siv C)I- I) I! ATI! was as follows: 

...•tft .V<\<N^\.<i(X.:^. (fo .Wr^X^J^V^^'vu 



1?' 



'} 



i 



^^ 



D I" RATION Years 

CONTRIUrTORV 



Mouths 



Days 



flouts 



nr RAT ION 



)'cars 



/>VCX 



OOCri'ATION 9 

Rfsiiifd i>i Son /'lain/yro 1 )'>,ns i \f,>nth.< I ^ J >a \ 



(Signed)...s]aj^ 



« oU^% 



Afout/is 



QjL^t I u)o'\ (Address) k) b J -^LA^ttxAi . UJ 







!J 



C 



a^ 



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



THK ABOVE STATi:r) PKRSONAI, I'A RTKM' I.AKS A K !•: TKIK To Till-: 
HEST OF MV KNOWI.KnC.E AND HIvMlvF 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



(Itifoinianl CXA^w^TWO ^ CrtT fx O/ 



(' 



\<l(lrc.ss 10b 




ot. 



ri„\CK OI' lU'RIAI. OR KKMOVAI, J DATE of BfRiAf- or RF:moVAI, 

rNDl-:KTAKER (>A^v^>(r\>-A- vJ CTtT^ Cjcv^-wq 



(A(l<lress. iDb 




IN. B. Every item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

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



mw i i i nii 



I 






ll ll# 



f .{6 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i;,.:iniof ilcMltli- FNo. ■ . "^ggg^ H^IM',, REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dfffr /07f>r/, 6Jo\^Xx/vvJU^; X 2D0\ 



Begl.stei'ed J\'*o, 



1368 



Os,Ar\j^-K^ 



Deputy Health OfTlcef 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. Stan^arD ) 



PLACE OF DEATH: — County ofQ<X/>^jtcu UuuvCu 



City of 



Ne. 



tojtx 




J (>-<t- 



i^A^VoJu 




CcJ. 



(IF DtATH 0( 
IF DtATH 



St.; 



Dist; bet. 



and 



ccuWs Aw*v FROM USUAL RESIDENCE GIVE facts called for under "special information • "X 

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



% 



FULL NAME 




^ 



L^ 



<VV^:^X^.' 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



DATI-: <)l- I'.IKTM 







iMoiitlil 



A < ; K 






(D.tv) 



M'ulhs 



4hs 

fVear) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

OjLkt I 

(Month) 



Day) 



(Year) 




Ditvs 



^IN<.1,K MARKIKI). 

wiix »\\ i;i) OK i)i\"nKrKi) 
'Write in social (K -^ivnation) 



lUK rUPI.AOK 


' state or Country) 


NX Mi; oi 


lATIUiR 


HIKTJIFM.ArH 


oi" 1 AIMKR 


(State or Country) 


NTAIDKN NAMK 


OI MOTHKR 


lUK'rHPr.ACK 


<>1" MoTIlKR 


(State or Country) 








X/ywyw/x>^^ 



HI<:RI:HV Ci;RTn'V, That I attendod deceased from 

QwC 190?. to OjOfC^. I iQoH 

tliat riast saw h -Ji-^' alive on C)-iJ|^Jb I 190 "^^'^ 

and that death occurred, on the date stated above, at l*L H.5 
V M. The CATSIC UV J)IvATII was as follows: 

Llt\jJLr\xxX dtoJi/YVAw^rVvivcJt^v-e. 







J\JUo~\Jr\/<.<i 



AA/ucj^fejU ci.. 




DURATION }'i'afs MmiiJn Days 

CONTRIIU'TORV vl 

nJ. /<x'voJLouaA-^ 

DURATION Years Motit/is Pays 

>je4^ X TQOH (Address) 



Hours 



(Signed) 



Flours 
M.D. 



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



OCCri'ATION (JU? A 

(7b (>VAw^cuL^Aj-^-jy2- 



Rfsidfd i)i Sav f'l am ism 



) 'id I . 



Months 



f>,n. 



Former or 
Usual Residence 

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



Hew long at 

Place of Deatli? Days 



Tin: AMOVK STATl-:i) I'KRSONAI, T \ K lIC C I,A KS A R 1 ! TKir: T« > Tm- 

iJHsT OI-' Mv kn'o\vm:i)<;h and in:Mi:F 

(Informant Cr>NXu AJL/W^^rvXxX- i>JL'WWA>t. 



f Address ."T 



PI.ACK of HIRIAI, or RKMoVAI. I DA'IXj; of Miuiai. or REMOVAL 



INDKRTAKKR OV) . \J . ^ JXjU\j(UL^r^ 



1 90 "I 



(Address 



of information should be cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 
E OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p»r- 



IN. B.—— Every item 

state CAUSE ^. , . . . 

sons dyin^ away from home should be given in every instance. 



< > 



f 



i 



t 



.f 



I 



It 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!!..,ti.l i.f n< .tltlr I* Vn ; - t^*'S^^^-. iu<v 1M\) 




Dfffr FiJrd, r 

i ^ 1 



Re^lstei'ed J^'^o, 



1369 



■I 



'i,''i 



If ^ 



':.: lOO'i 

Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( XX. S. Stall&at^ ) 
^PLACE OF DEATH: — County of O/CX/^aj ZKo - ^.utcxGty of 0<X>\; v) A.<X/vv.ca_a.cc 
No. vCtu, VL^TLC^vt 



Ut 



u i/UCK/|%A..L<X-' St.; 



-Dist.; bet.- 



and 




f IF DtATH OCCURS 4**^ FROM I) S U A L R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION 



lAL INFORMATION" \ 
DEATH GCCUN^IED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. - / 

FULL NAME J.aX'u^ok LUu.a'v„ , 



PERSONAL AND STATISTICAL PARTICULARS 
^'J.X A . . i COI.UR 



lX<xL 




MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATII 



I) \Ti: (>i itiK rn 



A< .!•: 



5 



M..titlii 



) V(/; > 



(I);iv) 



Ck'car) 



ckki 

(Month) 



1 
(Day) 



(Year) 



I HRRHBV Cl-iRTIFY, That I attended (Icccascl from 



S«L\A. C 



I90 



■\ 



to a^.^xt'. \. 



\ 



190 H 

190 



Mttulhs JhjV: 



^IN'.I.i:. MAKUll-;i). 



U nxiNVHI) OK DIVOKCHr) Q 

■W'litfiii ^cH'ial <h sij.'natioii ) —X 



lUkTHlM.ACK 
I Statf or foiiiitrv* 



a. 



that r last saw h • ahvc on 

and that death occnrred, on the date stated above, at 5- "iC 
;^..; ' :M. The rArSl-; Ol" I)I:aTFI was as follows: 



•!i. 




NAMl. OI 

i'.\Tin:K 



mkiiu'i, \»'H 

<'l lAPIIIvK 

' Statr or (."onutix' 



MAIIU'lN NAMl-; 
(»1- MOTHHK 



lilRTlIPLAOK 

OI' M()Thi-:k 

(Slate or Couiitrv) 



H<D^A'>"uU 




V-v^QAa\ 




DIRATION H )'c'ars Mouths Days 

CONTK I lU'TORV ...cU..O-VsJ[>Xl...i^^^ ■ . 



//on 



rs 



CX/>^X^ 



(jLl-. . . L{rUjt\j 



.VL-LO^'Wyi^- 



[)r RATION 



,y^}'i'ais Mouths H /^avs 15 //ours 

'1 I V \v 



T^L 1,^.1 




M.D. 



(Signed ) 

ax\\t i igoH (Address) Ut.| ^'-C 

Special Information only for Hbspitals, institutions, Transients, 
or Recent Residents, and persons dyina away from fiome. 



M|\t 



nCCri'ATION 



V. 



o 



'y^f.^idfif ill Still I'l iiiit isro 1 t )'riiis 



\ ^^ioft^<UkjUY> 



M,„itli^ 



n,i\. 




THic Auoxi-: sr vv\:\) pkksonai, r ak iuclars aki: TKr}-: to thh 
iti-;sr OI- Mv knowm:i)c.k and hi-;mi:i' 



(Iiifonu.tnt 



■l^ 



^JUt\.AXJL mX/cc"Lc 



Former or ' " ^ „ , 'S q. ' ' ' How long at 
Usual Residence ^AAX:t«T^^4.M >Xfa4*>M piare of Death? 

Wfien was disease contracted, 

If not at place of deatfi? 



• Days 



y.ACE OK Hl-RIAI, OK RKMOVAI, I DATI-: of Hikiai. or KICMOVAl, 












N. B.~Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ''Special Information" for per- 
sons dyin^ away from home should be f^iven in every instance. 



■! i 



i 



I: 



I ^f 



11 I 



!' Ilk 



1^:1 



lli 






i 1 !! 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






/^/'//r AV/fv/,.. Ox^^tj^ JfJO^ 




Kes^l^slet'ed J\'*o. 



1370 



a 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH-City and County of San Francisco 



No. 



PLACE OF DEATH: — County of ■a^^'vT\o -, 



Certificate of H)eatb 

( "CI. S. StauOarD ) 



•> (^ 1 



T 
J/ 



dt) 



St.; 



Dist.; bet. 



City of ^ ' <Xaa^ K)A.O^■^ - , 



and 



/ 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 \ 
\ IF DEATH OCCURHtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



\ 



FULL NAME 



OiuT\JdLA 



f 



PERSONAL AND STATISTICAL PARTICULARS 

SKX A . I Coi.oK 





^w.< 



DATl-; i)|- lUR III 



A • , }•; 



Li 

/go \ 

(Ve.'ir) 



Moiitlil 



15 r,v,« 



iD.'iy) 



M.mth, 



IVfiir) 



Da 1 > 



NiNt.i.i:. MAKi<ii:i) 

W'lix >\\i;ii OK i)i\()ki-i-:i) 

'Wiitfiti Hoii.il (I( ><irii.itiiiii) 



I'.IK rill'I.Ai'K 

I St:itf or (.■(Jiiiiti \ ' 




IxXAA^UUiw 



NAMl- (>I 

1 A'llI \\< 



niRTm'i.ACK 
<>i I Arm:K 

' St.it>- or C()\iiili v) 



"MAIDllX NAM1-; 



liiK'rm'i.AOK 
«)i- M()Tni-:K 

(Statf or C(juntrv) 







MEDICAL CERTIFICATE OF DEATH 
DATK OF DIvATH 

fM-'iitli) (Hay) 

1 lIl'Kl-r.V CI;RTII-V, TIimI J attcn.kMl .IcrcascMl from 

.uL\,UOL 1 I90'! to i^JL^-Jb. I Igo'l 

til at I last saw li ■ alive on CjJL.<^t up 

and that death occiirreil, on the date stated ahove, at O 
vi ^r The CArSl<: Ol- DIvATH was as follows: 



^ct 





nCRATIOX 



,0/^ 




Years \ Months 
C ( ) N 'J* R I li U TOR V \^OJ\.Aa^<X.<;l .... LL XO^ i-L:>: 



/hivs Hours 

y\JJLh. 



n 






I) r RAT ION 



^ 



Years 



Mouths 

.l4^t 'I iQoS (Ad.lress) ISa^'l 



Davs 



Hon 



rs 



( SIGNED ) 'ilrlv^'V 2^0.0 r« 

d 



■1. 



x%\k.^^ 



^V^AA 



M.D. 



OCCUPATION (Op p^ 



AV 



sided ill Sou I'l tuii I'u'd ■ \j )'rins ,lA»;////.> 



n,i v.< 



rill", AHOVK ST ATI-: I) I'KRSOXAL I'A K T U" f I, A RS ARl! IRll': To 
UHST 0|- MV KNOWI.HDC.K AM) Hlilji:!" 



Till-: 



(liifonuimt 




O 



J)7l Qylo.-dk 



(Address 






SPECIAL INFORMATION only lor llospitdh. Inslitutions, Transients, 
or Recent Residents, and persons dying away from home. 

Former or 9. ^ u i I w j- -f Mow lonq at 

Usual Residence ^v A wXi>-^iA.4^ piare of Death? ^ Days 

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




DAil-lot' MruiAi, or KKMOVAI^ 



< P 



'OjJ^ 



(Address H b.l Vl b.\^slA.<rvV Ul 






N. B. F.very item of informntion should be cnrefuMy supplied. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for p«r- 
sons dyin^ away from home should be fitiven in every instance* 



1 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

__^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



f.o.ii.l ..f Hcnltli I" Vn i'- ^^^^^USiV ('., 



290 "i 



BegLstered J\^o. 



1371 



r^ /^ ^^ ; I V . I 



DEPARTMENT k PUBLIC HEALTH=CHy and Counfy of San Francisco 



'ler 



Certificate of H)eatb 

PLACE OF DEATH: — County ofOcx-w vJ.\a->veuiC(. City of O Ct^^- O.VCL>vc\.^ 



(^ 



'No. niH ' ^il 



St. 



Q 



iM Dist; bet. 

FACTS CALLE 
OR INSTITUTION GIVE ITS NAME INSTEAD Ol 



and 



(ir DEATH 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-xdlN-^. ^.d_,. w 



^.^^^<>.: . 



\ 



PERSONAL AND STATISTICAL PARTICULARS 



^'■^^ '^-^ 



!>.\TK (>l liiK 111 



a-LJi 



COI.OR \ 



ll-(^.r 



QfU: 



M..nth) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH ^ 



:>]. 



rgn \ 

(Montrf) (Day) (Ytar) 



\«.j<; 



11 



) ,-,n 



9 



^\ ( / 
•Dav) 



M-niths 



<Year) 



If 



/'<n 



wnx lU i:i> OK i)i\t iKrMi) 

Wiitf ill ^()ci;i] <lfsiji^iiatioii) 



MiK rm'i.AOK 

St.itt or ••'■•iintrv) 



1 flawvxdi^ 



I irrvFM'HV CivRTrrV, That r attcii.lcM <lc(va^c(l from 

Lm^Cl "■^■■'. u>o . to QxloiA. 2> up H 

that I last saw li ■ alive on v.^JL-^Ajt. ':'. k^ . 

and that death occurred, on the date stated above, at O 
U. M. The CArSI'] Ol- DlC.XTIf was as follows: 



NA\T1-; (M- 

I- A'nii:K 



RTKTHI'I.ArH 
Ol" lATHHK 
(Statf or Cotitilrv^ 



MAIDHX NAMl. 
Ol- MOTIIKK 



BTRTHPI.ACH 
OF MOTIIKK 

'Stall- or Coimtrv^ 






Vi'VA. 




^ 



f> 



\ 



DIR.VTION )'t\irs 

C()NTkII5UT()RV 



}'i\irs 



Moiith<; 



Da j'.v 



Months 



Days 







l%hJj<j(X ■ ) \A^ ' 



DTRATIOX 

( SIGNED ) LL lb I U.^ vla^Xc. , 
.IlKA-'^ Tc,n'i (A<ldress) ?Ca (H, C^i 



//o/ifS 

Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Insfifutlons, Transifnts, 
or Recent Residents, and persons dyiny dwdy from home. 



OCCUPATION QfU) i) 

R^siilfil III Sit 11 /'i i!H( isrr) \ 5 '(■■(/ /A 



.^fnllfh.< 



/h:^ 



Former or 
Usual Residence 

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



Now lonq at 
Place of Death ? 



Days 



Tin-: AHo\-i-: st vn- d i-kksonm, i'\k ricri. aks aki-: rkri-: to tin-; 
iii-:sT oi-' MY i:no\\i,i-;i)<".h and hi-:i,ii;f 



(In foiinriut 



ri.ACH OI- lURIAI, OK ki-;mo\ai< 



% 




Ov^-<i^. 



DAriiof niKiAi, or kf:mo\-ai. 



r\(Mu-ss 



ixia- '^ .tlv U..- I 



rNDl-;KTAKF:R 

(Ad 



OXJvt i: T90''. 

.Irt-ss nil V) l\ois^V.{rr^...&. 




[N. B. Hvery item of informotJon should b;; cnrefully supplied. AGE should be stated EXACTLY. PHYSICIAINS should 

state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information" for p«r- 
Rons dyin^ away from home shoulil be feiven in every instance. 



i 




i' 



;,(• ' '\ 




1 

i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i; .;ii.l >,f H. Midi- !• No. i", t-rfar;.^) \iScV Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



/e96>H 



liec^Lsteretl J\^o. 



137S 



1 :il .' \ 



• Mi , 1 

I •* 



/>^//f' /vAv/, 0)X^^^-Uy^v[^^^;x; ,- 

DEPARTMENT OF PUBLIC HEALTB-City and County of San Francisco 

Ceitificate of H)eatb 

( 'a. S. StanC>arC> t 



(.M 



PLACE OF DEATH: — County of J<X-.v 



V, 



V ("1 



^ ■ City of ■^ ' 

No. '-^HH ^^.^l^:' SU " Dist.;bet. V)a..C'^_<:.a and'^lix 

(IF DCATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



iV 



FULL NAME 



., \ o 



i, 



PERSONAL AND STATISTICAL PARTICULARS 



A ^ ^ ^ 



I>.\ ri". ()!■ lUKTII 



\<.H 




J ■/•(/;. 



a 



,0 



(Ditv) 



.^/,^^rf/^\ 



MEDICAL CERTIFICATE OF DEATH 

I).\TK Ol" i)i;ath 



I 


.a.,(^..4.. 

(Year) 


.M 


Days 




"-IN". I.i:. MAKKIi:!) 

\vii)i iui:i) (»K i)i\nKri:r) 

\\iit' ill siH-ial (lfsivn.it i'lii) 



1 lllvRI'FJV CI':RTII'V, Tlial I atteii.led Icivascd from 

L.L^i^<:^. ' 190 to Cl^vt' .X i()o'\ 

that I last saw h • alive on CJ-^iLJ^ ..\ ^ xtp 

and tliat dcatli occurred, on the date •stated above, at 



•? 



jr. Tlie CATS I'! Ol" DIvATII was as follows 






I i. 



lUKTUPr.AOK 
' Statt- or Coniiti v^ 



NAMI-: (»J- 

»"ATni;K 



M1KT!!PI.A«'K 
01 l-ATHHK 
(State or CoiMitry) 









DCRATION 



Years 



MoNths 



•••"••f" 



Pays 



Hours 



CONTRIIUTORV 



J,-. 



h 



r» \ I 




MMDl.N N.XMl.; A 
01 MOTHKK ]/ 



.1^ 



Years Mouths Days 

'^ 



1)1' RATION 

, N E D ) LU..'Tr\. V V C <kjK >-wa:k:vu 



IMU'l-HIM.AllC 
'Stat<' or lN)Uiitr\) 



0-*-^c4X^iv|'VL/%'va' ^J) a^<i<ftUi 




jL<xi 



(SlGI 

A 1 

'...'..i.i... 



;...Tr\. 

I<)0 




(.Ad.lress) !HM Lla.., ' 



Hours 
M.D. 



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



t 



orClI'A'lION 

R\'\r(lril in Siin i'l <: III nri) 



);■,!, 



a 



M.'iilhy 



\ I 



n<!\: 



Former or I 
Isual Residence' 




1 1 How lonq af 
a OXAa' \. > pidre of Oeatli ? Days 



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



llaAcA-: 



<X' L<?.' 



iin; AHoxH sr \'n:i) pkusonai, pak rnri.AKS aki-; i^KiK ro 

Hi:sT OI' MY KNn\VIj:i)('.H AM) lil'.I.Il'.K 
(Iiifonnaiit JLVVji-2-. V V I A^^ oL .A./<jA\X'\XXVA.' 

fA.ldre.ss A*^ HH. 



Tin-; 




'vt ."^l. 



ri^VCK Ol" HIKIAI, OK KI;M(>VAI, j DA'IKuf Hiklai. ..r Kl-'MoVVI 










T9O 



(All. 



N. B. Every Item of information should be carefully Huppliecl. A(1F. should be stated EXACTLY. PHYSICIANS should 

stnte CAUSE OF DEATH in plnin terms, thnt it may be properly classified. The "Special Information" for per- 
sons dyin|^ away from home should be given in every instance. 



If 1 1 



I 



I 






^tl 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M,.,„i..n...Hh- rNo...l^>r^..H^l-0. REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



f M 






n)o\ 



liCi^istei'ed J\^(), 



1373 



\>-U 



eiii 



h ' h 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccitificatc of Scatb 



t' ' 



A cap 

PLACE OF DEATH: — County of ' <X'^^J xo ■ 



n 



No. 



\% 







.'^ 



City of 



J AxtX 



St.; -■*> Dist.;bet. ^i ' ^UAt^>x and 

(ir DEATH OCCURS AWftY Fft'PM USUAL R E S I D E N C E G I VE FACTS CALLED TOR UNDER "SPECIAL INFORMATION ■ ' \ 
IF DEATH OCCURRED I N^^k, H O S PITA L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME '- ■ .vaa.^ Ltc4."ta.i- ! v...." 



\ ( , . A 



( • n 



PERSONAL AND STATISTICAL PARTICULARS 

■-I.N r>r\ I r< >i .( iK ^ 






i> \ii. « •!• Ml kin 



^c.v. 



iMontli I 



*^ ).-,n 

^tN'< . I,l\ \! \K U Ii:i) 

Wllx iWl.Ii OK I)I\ iiKi i;i) 

l\Vrit< ill v<x<tal dfsijfiiation) 



o.^ 



(I):iv) 



M.nilhs 



I I 






MEDICAL CERTIFICATE OF DEATH 

DA TJ-: <)l- I) I', \ Til V 



(Montrf; 



VX^ 



Dav) 



(Year) 



Da \$ 



K K, cC 



' St.-iti I u < iiiiiit I \ . 



' J 



^ ^ ' I "^j 



CrVAw^ 



a. viVxxUw 



J m{Ri:ii\' Ci;RTiI<V, That I^attcndcl <lcccasc(l from 

wLlA^O^ i .. I(p'i to . O-L.iAX 1 KjO ' . 

that I last saw h alive on - VJ-^ixtj \*.p 

and that death occurred, on the date stated ahove, at 0. o 
U_M. The CAISI- OI" DI-ATIf was as follows: 




-rVN.x^r'W/Ow' 



n 






\A\u-: (»i 

F 



A MM (»1- ,xA 

ATHKK ^ , j^f 




HIk rMIM.AC'K 
<»!• l-ATMHK 
'St.ifi- f)! c"<)uutrv) 



M\I1H:\ NAMi: 
<»I Mori IKK 



I?Ik'l'HIM,ACH 
OI MoTHHk 
(Statf or ("omitrv 



OCCr I'ATluN 



I )r RATION Years Months 4 Days Hours 

CONTRIIU'TORV \^^^4M^<X.^\»d.. '„! ■...-. 



^^U^ 1'>X (X ■> X^ OL MiL^ K,(X 




DURATION 



Years 



Mouths 



(SIGNED) ^' X VCCLU4 J O. 'X. 



Days 




a 



A 



—L 



190 



^ .7) . 

(Address) iC^H ^Us^ ^y 



Hours 
M.D. 



SPECIAL Information only tor Hospitals. Insfifuhons, Transients, 
or Recent Residents, dnd persons d)in:| dwdy from tiome. 



f\r>iifiif III Sim /'t (I III i^iii 1 '. J'lf; 



M.'nth- 



f',i\ 



ill f 



III i: XimVH ST ATI", I) l'HK>^0\ \I, I' \K lUri.AkS AK 1. IKli: 

HHST OI- MY KX()\vi,i;i)c. i<: AM) in;i. n:K 



To Tin- 



Former or 
L'sual Residence 

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



How lonq at 
Place of Deatfi ? 



Days 



(Iiifi);in:itit 






rvdcln-^s 



ri<ACK OI- HiuiAi, OR ki;mo\ai. 



rNi)i-:kTAKi-;k 



DATJ^Iof IJiKiAl, or kl-;Mo\AI, 






N. B. Hvery item of itiforiiirttion should be cnrefuify supplied. AGK should be stated EXACTLY. PHYSICIANS should 

stnte CAUSE OF DEATH in pinin terms, thnt it nuiy be properly classified. The "Special Information" for per- 
sons dyin^ away from homo should be given in e\ery instance. 



M- 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I" '"1 "'■ MeaUh >•• N.). i^ •g"«;:Htr'^ '<^>' ^''> REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



' II 



I)(f/r /v/^v/,(3jlAaXx>^aX-Uv' 





<j<js 




10 a 



Registered jYo, 



1374 



Deputy Health Officer 

DEPARTMENT riF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. StauDar^ ) 
PLACE OF DEATH: — County of 0,Ou->X' A^O/VVC^ACC City oi^Ojy\j 0/vxX/>a.<iaxlc.o 
No. \ M ?^ ' - ^1 1 V. . .. ' St.; ' Dist.; bet.VJl.aA.A \,c A. d.^ and H H 

(IF OtATM OCCURS AWAY FROM USUAL R E S I D E N C E C 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 



%i\ 






PERSONAL AND STATISTICAL PARTICULARS 



SI 



I'ATl-: (H H1K)"U 



COI.OR >^ 



I 



UJruJji 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



i\ 



M(.iitll) 



Af. I-: 



?. 



J 'tUl I 



t, 



I r3.£l 

(Day) (Year) 



Mntitlis Davs 



r 

( 



iikl. 

Mont'h) 



I 

I 

(Day) 



(Year) 



^IXt.I.I' M \RRIi:i) 
\\ Ilx iWi:i» ( tK DIVi iKtl-;!) 
Write in social <1« >«ivMi.iti<iii) 



I I 



t| 



State <)r ' "i iimt ry 



NAM I- i»l- 
KATHi;k 



HIRTHI'l.ACK 
<>l l-ATUKK 

•State (ir Cojiiitry) 



MAIDKN NAMK 

<n- Moi'UHK 



niRrHJM.Ac'H 

<•! MoTHKR 
(State or Country) 



LcJLu, 



I irp:Rr':RV Cr-RTrFV, That I MttciKled .Icrcascd from 

LA.\A,:C\. I 190 \ to vArr\rfS,^, .6.1 190*1 

that I last saw h XHj. alive Oil v vV^vn ' jip 

and that <k'ath Droit rrcti, on the date stated above, at *^ 
J\I. Th^ CAISI*: Ol- DIvATH was as follows: 



Ct\jLAJ^^a.V n[ /\x>a,v.-».vol\.1'.. 



I ' 



DT RATION }'fars Mouths /\iys 
CONTRIIJUTORV Lv:>\A.>^^:^.•.. 



Hours 




occri'ATiox 

Rfshlrd in Sav /'lan.isr,) ^ )%\}i< L Mmithf 



Dl' RATION 
(3IGNED) 



Years 



Jfont/is 



Davs 




TC)0 



Hours 



(Address) 



{- 



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



Former or 
Usual Residence 



How lonq at 

Place of Death? Days 



Hav: 



\'\\V AUOVH ST\ TI-I) I'KRSONM, I' \ K I" U' f I. A R S ARl'! TRIK T« > THH 
J5KST OV MY KN()\VI.i:i)C.K AND HllI.II-F 

HSb - S liv LU-4 O 



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



ri.ACK Ol' lURIAI. OR ri;m(>v.\i. 
INDICRTAKH 



ajLcJL. 



I).\'l 1; of I'.iKiAi. or RKM()\-.\I, 

Jx['vt' H 190 H 



(.\<l<lrcss 



.:RUOL)U.^\.tjL JTl^N^-^^Aj VU 

(Address 15 IH Ov^oklLfr^A; U.I.. 



N. B. Kvery Item of informHtion 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 given in every instance. 







I 



". 7 



mil 




? n 



'i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I! ;,t.l of lh;ilth - !•■ N'f). !^ '*-5'.'!ir'?tii M.vtl' C, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ro^istered JVo, 



1375 



X^Crv^v. ^ L Deputy Health Officer 

DEPARTfflENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of H)catb 

1 "U. 5. StauDarO ) 
PLACE OF DEATH: — County ofOa^yv VCL^xcu.'et City of'^A.-^v 
'No. C ^ C^..^.. ^ ^ L ... ' - St.; Dist.; bet. — — and 



\j 



/UCC^XCA. 



vi '■ :. ;., 



(If DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N *• "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 








:^ 



;i 



CyXxQj 



' '• A. 



°i- 



PERSONAL AND STATISTICAL PARTICULARS 

; c(»i,<ik , 






I>Ari-; nl IIIKTII 



ACK 



UJ^aA^ 



MEDICAL CERTIFICATE OF DEATH 

DATK (>i< i)i;\rii 



LL 



Month) V 



n 

(Day) 



,^5-5 



^ » Ym*s 



M.nilhs 



\\ 



( Vear) 



n,i\s 




CMoii/li) 



(Day) 



I go 

(Year) 



^iN'.i.K. m\ki<ii:d 

\V II)<)\yi;D OK DI\'< >Kii;[) 
'Wiiti in social dcsi^niMt ion) 




'voixL 



MiKTni'i, VO-: 

' state or ("on nt i \ < 



N.XMl-; oi-- 
lATMKK 



niKTun.ACH 

O!' l-ATm-K 
(Statr- or c'onntrv) 



M MI>i:n N'AMl-: 

<•!• .M()'rm;K 



lUKlIIlM, Xt'K 

(»i' Mnrni-;K 

(Slate or Country) 



occri'.\Ti»)x \^ 



I HFCKIvnV Ci:kTI!'N', Tliat I attcii.k-.l «k-ccasc(l from 

.rrrrr- ii/) to ■• Kp 

thai I last saw li alive on ~ — k^ 

ati<l that <lfatli occurred, on tlie <latc statctl ahovc, at 
M. The CAISI': OI- 1)1-; ATI I was as follows: 

L<c^^w<t)r:Q■.-:L^..e....y^>^^ ..y.CHw^.t r.v...v...^...,..q 



l*.»^*»-»»*»»^M«#»-» •■••••••■ 



■■> 



^ 







\JS 



DURATION Years 
CONTKIIUTORV 



Months 



Days 



Hours 




(1 



DURATION 



) 'cars ^ Months 



Days 



Hon 



rs 



( SIGNED )..L:^\C. • J 4^ LL. Axla > ..r^., M.D. 

Special Information only for Hospitals, Insfitutlok Transients, 



'CSA.\ 



V 



I 



Rrsiiffd in Sijtr Fiain/s/'i) ■' )<'i7; 



1A'»///> 



/>,! 



or Recent Residents, and persons dying av^ay from fiome 



Former or 
Usual Residence 



How long at 
Plare of Death ? 



Days 



Tin-: MtOXK STATl-.D I'KKSONAI, J'A K T If l' I,.\ KS A K i: TK t" J-: To TlU' 
UHST OJ-" MV KNoWl.l-nC.l-; AND i!i:mi:i'" 



( Iiifoiniant 




.1 ^J 



(\<l<lress 



IHH5 






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



}'I,ACK OF UrHIAI, OK RllMoNAI, j DAT^JCot JUkiai. or R1:MoVAI. 



Q}ii_'Luv^a I ^^1^ H 190 



r.VDi:KTAKKR 




(Address ll.^.'l. 



V^A,!i.«\\ 



\f 



N. B. Kvery item of informntion should be carelrully supplied. AGE should be stated EXACTLY. PHYSICIAINS should 

stntc 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 every instance. 



> 



k 



U<4x,\ ,,f Hffiltl) »■ No. !^ ^'^^^^^: lu^l' (\, 



I , 

! I 



f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

h^f/r /•V7f>./, Bx^Wv^J>.^ ? IfJO'i Registered ^'o, 1376 



h' ■ (i 



or 



.^^KXA cLcwu Deputy ' ' 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



I \ 



' tt:.;ir!iiim»!: I 



Certificate of IDeatb 

i "a. 55. 5tnnc>nrC> } 



No, 



PLACE OF DEATH: — County of 



J. 



\,a/-vA.'C^4ct City of Oo. 



Q^ 



W 



VO 



1 M ^ 



InIJA A.^. . St.; Dist.;bet. 

(IF Di<ATH OCCURS *W«V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDE 
»t/DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O 



l^ 



and 



R "special INFORMATION" *\ 
F STREET AND NUMBER. / 



FULL N A M E ^ A. ) v o. , .Ia. o 



-'^ v.. 



PERSONAL AND STATISTICAL PARTICULARS 

C<iH)K >^ 



MA 1-^ 

I) A IJ- . .1 I!IK I'M 



ACK 




UuJvcU 



MEDICAL CERTIFICATE OF DEATH 
DATK OF m:\ 111 



(I)av) 



/HCH 



k cur* 



r\ 



xi\x 

(Monthl 



ts 



'Day) 



(Year* 



) 'ra I A 



M.niHn 



U 



Pa vs 



^I\<". 1,1".. MAKRIl-:!) 

\\ II»< >\Vi:i) OK DIVoKi i:i) 

{Write in six-ial desijrnation) 






lUKTMl'I.ArK 


^! lie or (."oiUlttA' 


NAMi: <»l 


FATin.K 


HIkTMFM.AOK 


0(- l-ATHKK 


'State or fonntry) 


MAIDKN XAMK 


<n- MoTHKR 



O/CX^TV O AXX/YVC -^ C^C 



rHHRI-nV CP:RTIFV, That I aUen.k-<l (Icrcase.l from 

Uv\.\X\ 'A. 190 H to 'pJU-'^-s^ Kp 

that I last saw h X-\.' alive on C'^r^AA '..-.. j(jo 

and that death o(u-iirrf(l, nii the date state<l above, at 
^r. The CATSI-; OI' Dl-ATII was as follows: 



Dr RATION Years \ Months i '' Hays 
CONTR I m'TOR V L^AA.i'^A^^ftr..■..,^. 



Hours 



v^. 




lUK'iui'r.ArH 

•»|- Mo'l'Ul'.K 
'St;il> 1 .1 Cotiiitrv) 



A 



\J 



^sy 







^ 



I) I' RATION Years Mouths Pays 

(SIGNED ) . LUl>0A''^^^^ "d^OucAXuJLvVL 

lxi(\t 1 T90H (Addrc>;s) l';iO ^K.'.Vll-A<. 0.0 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, InslituHons, Transients, 

or Recent Residents, and persons dying away fro.Ti tiome. 



OCCri'.XTlON „^ 



!V-,;; 



M.,»Hn 



/h,\ 



Former or 
Usual Residence 

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



How lonq iA 
Place of Death ? 



Days 



\ 



VWV. AU()\K STAri'I) CKKSONAI, I'.\ K I" FT T I,A K.-. .VKl". I^KIK I'D III V. 
UKST OK M\Y^N<)\VIJ:I)<". K AND JIIUJKF 



^Infoiin.'iiit 






(.\fMrcs.s 





lAxWcti > . ■ 



.^^ 



IM.ACK Ul" IJlklAI. OK kl,Mo\.U, I DArj;.)! Hikiai. or KlMoXM 

A . J < , 



•ni)i:ktaki;k JaxUIu VL uVOLOitX. 



(At 



N. B. Every item of infarmation should be cnrefully supplied. AGB should be stuted EXACTLY. PHYSICIANS nhould 

stnte C.AlJSn OF DEATH in pliiin terms, that it may be properly claHnified. The "Special InformHtion" for p»r- 
Rons dyin^ away from home should be ^iven in «\'9ry instance. 



' II 



!■* 



.ill 



i\ 



1 1 




M 



p 



Iti't 






! 1 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

|!...,m1 ..f Hiiitth - |- No i< "fr't^^ifi^ii IJ&I' Co 



!)((/(' Filed ^ 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^ 



VJO^ 



lle^istevcd J\'*o, 



1377 



v-u 



DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 



Certificate of Death 

SI Q^ i 



% 



PLACE OF DEATH: — County oij<X^r\j vj/>^ct-^vcc^ix;f<:ity ofO/<Vvu J A.CL/>Ay^^4^ c t. 







No. HS2) OcrlxU/>^ U.oX^ lli-i St.; \ Dist.;bct. OUXX.Alv>v andVirLK 

(IF DEATH OCCURS AW*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 / 

^ , is 



FULL NAME 



m;x 



'9 



PERSONAL AND STATISTICAL PARTICULARS 




1 



i»Aii-: <»i' liiKiii 



KV.V. 







\\ y.uus 



(IX-iv) 



Moiif/n 



(Vcar) 



MEDICAL CERTIFICATE OF DEATH 

DATH ()!• 1)1:AT1I 



MontH] 



X. 

) 



i 



(Day) (Year) 



a'^ 



Pa Ys 



^INt.I,!':. MARK IK I) 
U'l|)<)\\i:i) OK DIVoki }•:!) 
'Wiitcin --.H-ia! (It'siv'iiatiuii) 



niF<TmM,AOK 

i State (11 Coniitrv-^ 



XAMK OI- 
JAI IlKK 



Hik rniM.Aii-: 

OI" lATIIKR 
iStatf or Cimiitrv) 



MAII)}:n NAMl-: 
OI MoTUHK 



itikTm'r.Acj': 

OI- MoTIII-.K 
(Statf t)r iDiiiitrv^ 



^ 




cL' 



X.tXtrXAr 



r ill'KI-BV Cl'iRTIFV, That I attended deceased from 

LLlv..O Ik icp'i to ..).x|x.l' 190': 

that I last saw h •-<- ahve on '3 , i 190 • 

and that death occurred, on the date stated ahove, at 10. S^ 
IV ^r. The CArSF-: (>!• I) MAT II was as follows: 
\y0..ry\,^v:JJ\> cry . cL<wv,'>vci. AX>vci^ S J6.*\^:..o.-y'^' 



(J XV^^'VOL/V^Ci 



nr RATION Years Man //is * Davs 

CONTRinrTORV \j\^" 



/louts 



">\X. 



\>i 






DURATION 

(SIGNED).. .LU /v>^ \X) a. ti JXX^^ 



90 



)'cars Mouths Pays Hours 

nnno \AJ <X.\.\^ JOtn,^; M.D. 

Address) * 'U I l.O. ».. 1 JLA. ). i.L ' :.. 



(. 



oiHTi'ATlON 




Special Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying awdv from fiome. 



fso/drd ill San /'i iiPii isro 



)'rii > . 



A/<»////y 



n,n 



v\{V. AHovH sTA'n;n i-kksonai, p.xk rirri..\KS akic ikik to tiN'; 
HHST OI^MN' KNo\\1,i;I)(;H AM) ni-:i,ii%K 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



flufonjiaiit 




.kAa 



(Address 









ri.AClC OKIUKIAI, OR RKMoVAI. j DATIvof ItiKiAr, or KKMOVM 
UNDKRTAKKR 19 . J . Cj -V< 



^)j^^\h) ''"^U 



(Address 



I WVAUl,A.^r>V..C.II. 



N. B. Kvery item of itiformHtJon should be cnrefully supplied. AGfi should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnin terms, that it may be properly classified. The '^Special Information" for per- 
sons dyin^ away from home should be f^iven in every instance. 



I !{ 



r. i 



J^jh^^^A -Kf 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



11,.:,'. 1 ..f Id ;itt!l !•■ V')- !- 



■^Sf^!!!!;^, n.«t 



■m.,-^^ 



V Cr) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\^o. 



1378 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



"I"-; 



il'i 



I 111 



t ■ 



Cevtificate of 2)cath 

( *a. S. StanDar^ ) 
PLACE OF DEATH: — County of ^^'^ ~>\ ^ K(yjy -\A^': City of OxXav ^ Kcui\..r^.<i.'i<. 



N«. 



-w 



l' 




C (lb CSai\\aXo i. __ __., 

(IF Dr»TH OCc6bS *W«Y 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. / 



St.; 



Dist.; bet. 



and 



-) 



FULL NAME 







€L'y\X 



x: 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR ^ 



i> \ 1 1-: < >j niKTii 






1-^. 

(Day) 



? 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH Jj) 

axkJt:, 



(Monthf 





t ..<... . 

(Day) 



(Year) 



A«',K 



A V 5V,/;.« 



\l,»,lli^ 



IC) 



(Year) 



/)./ 



MNt.l.I". M\KKIi;i». 
WIDoUKI) OK I)I\()R(HI) 

'M'titciii '-ocial <U-siv'nalii)ii) 



liiK rm'UAOK 

'Statf or Cotiutrv) 






1 HRRRBY CKRTIFY, That I attended deceased from 

••••■■ I9O — to -rrrrr:. icjQ — — 

that I last saw h alive on 190 — — - 



XAMI-: Ol' 

1 \iin;K 



t'.IK IIU'I.ArK 
Ol" lAIHKK 
(Stall itr (.'oinitrv) 



MAinilN XAMI 



niRTHIM,ACK 
<>»• MOTIIKR 
(Stat<- ur C(iunlr\ 



OCCrpATlON 






and that death occurred, on the date stated above, at 
„ :vr. The CATSlv OF ]>I':AT1I was as follows 



LJL^^JQ3-^^<xJL JoX':v'%:-^Cr\^ 

Dl'RATrON Years MoJiihs Days Hours 

CONTRIBUTORY OXk-vv^Jk Jlmjl Xjti<LArYYsA?u^r'>JL....S^k. 

L'LL<^>/vv\ji.<i,.<x,. ..LxxL- 



ZA/v.? 



I ) r R A T I ( ) X ) \\i rs ^y^^'^^o n ths 

(SIGNED) Ltr^.tr^\x^; J / J6 . U3 . ivjj^^ 

Ox|-\:i. X TQo'i (Address) L(r\.fr^\jl\>^ V 4 1 \ 

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

Former or Q '^ '7 ^Jv k^ ♦. J vi '*"** '""A ^^ 
Usual Residence v) >- V ^W CrVA^uaa. ./t. piarc of Deatfi? 



Hours 
M.D. 



Days 



Rfsidrd ill Sun /'niin isfo 0,*5; )Vvr;.v 



Moulin 



Day 



Tin-: A no vK ST A 'n: I) i'kksonai, iwr riori,\Rs ari; trih to i'iik 
nivST oi- Mv KNo\\i,i:nc. H and wvaav.v 



(liifoiiiiant 






^A.,AJ^.xx^^L/C^^'■ 



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



rr.A^K OI- niRIAI, or RH.MoVAI, I DATJ-:.)!" Hiriai. or KKMOVAI. 

%.^. d-Uv. ^^-l!; " 



UNDKKTAKKR 

fA<l<lri-ss lA/i."!. 



vM^v^orvx 



..^ : 



N. B. Every item of information should be CHPefully 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«rj 
sons dyin]^ away from home should be (^iven in every instance. 



'i v ' '■'*■ • 





M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,: ■ 11, i!il', 1 N'o I> ■?"*!^J^i' Hftl' C 


o 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 


Dfffc Filed , OjLVvtl/v 

A /■ 


^v.XMA' ?5 


100^ 


Registered J\'o, 1379 


\ 1 


Deputy 


Health OfYlcer 1 


DEPARTMENT Of 


^ PUBLIC HEALTH^ 


=City and County of San Francisco 




Certificate of IDeatb 

( "U. 5. Stanc>arc> ) 
PLACE OF DEATH: — County of ' ' ' City of 




No.- 



St.; 



■Dist.; bet. 



-and 



(ir DtATH OCCURS AiWAY TROM USUAL RESIDENCE GIVt 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 
J N OOj . I COI.MR 



\>Vl'K or HIKTU 



V 

4- 




m 



1 ■ . Ht^. 



c> z" . 



ri-.u 



M'»|it}i I 



1 

(I);iv) 



.IS I 

(\'vnr 



MEDICAL CERTIFICATE OF DEATH 

DAT}-: OF I > HATH U 

-....\J.-.«4w/kX'Vj 

(Month)' (Day) 



(Year) 



AC.K 



J -„• 



i M-»itfis CSO /hi\s 



^IN'.I.I" M.\kKIl-:i). 

w ii)« »\yi;i) < >K nr\< tkcj;i) 

Uiitiiii sotial ilrsii'iKilimi) 



HIRTm'I.Xt'H 
< Statr or C'lmit J \' 




1 n ^, N * C '-^ 



^.i * 





I HlvRI-HV CIvRTII'V, That I attended deceased from 

190 to i90~~~:. 

that I last saw h "^^ alive on ~~~- ~" iqo 



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



M. The CAlSlv Ol- DI'ATIl was as follows: 
WCXrVA./?:!^:/ 



CXAA Cl CL/fV^ VnLa_ tLi 



tL 



NAM): Ol- 

I A rMi:K 



''•IKTIII'I.MK 
Ol- l-ATIIKK 

'•^t.ttf <,i I'oiintry) 



MAIDI-.N NAMK 
OF MoTHlvK 



liik'nnM.ACF: 
"I M(>tiif:r 

'State or Countrv) 



OCCll'ATION 



Dl' RAT ION }'tars 

CONTRIRUTORY 



Months 



Days 



I Jours 




DURATION Years Afont/is 

(SIGNED) U.Jsh a (y<i.tj2A; 

lAjfc" 1 iqoH (Address) 



Days 




Hours 
M.D. 




/t) 



U. 



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



AV-i,,'./c\7 /;/ Situ i'l ani i^ro 



) 'ill I 



M.'uHi^ 



Ih 



iJii-; A MOV f: ST A 'n:n p» ksonai, fauititlaks aki; TRrH to thh 
jJi:sT Ol- M); kno\vij-;i)c.f: and Mi-:i.iF;i- 



Former or 
Usual Residence 

Wfien was disease contracted, 
If not af place of death? 



How long at 

Place of Death? Days 



(ii 



r\'l.lr( 



La.\^- 



xxU^^ ^ -^y 



,^ 



vACf: oi- iukjai^ok kkmovai. 



Ui/*pJvJAA> d-0-' 



-W 



DA'lLFof MiKiAl- or klvMOX'AI, 



FNDICKTAKKK UCoAjk ^t vfc OVL^Ja. 



N. B. Every Item o? informntion should be carefully supplied. AGIi fihoiild be «tote<l EXACTLY. PHYSICIANS nhould 

state CAUSE OF DEATH in plain terms, that it may be properly clasnified. The "Special Information" for par- 
sons dyin^ away from home should be feiven in every instance. 






Ii 



,1.' 








.'1 



i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 



l)((f(' FiJe'l ,'Qji}^dU.^^-.ylh^ 



100' 





Registered JVo, 



1380 



<KA^ cU.\M^ Deputy Health OfTicer 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Ccvtiftcatc of 2)eath 

( Ta. S. Stan£>at? ) 



^ 



PLACE OF DEATH: — County of C)<Xo^ Oxa wcui.'Cc^City of d/Cc^^. 0,h„<X/>xcU,e'. 

/ 1 ) 



\ 



A^d.i\Af.V 



and 



%A 



( " .°/!i',".,°"^''""^ *"*'' '"°" "SUAL RESIDENCE Give r.CTS c.LLtD roR UNOtn •sprciAL inporm.tion-- N 

V .r Ot.TH OCCUR. £D ,N . „OSPIT.L OR ,»STm.T.ON CIVt ITS NAME INSTE.D OF STRtCT .NO NUMBER ) 

FULL NAME vIlJ^Aj it JLY\.,-n.,u. ajLa. 



i 



PERSONAL AND STATISTICAL PARTICULARS 



si;\ 




'la.L 



COl.OR 




DAIi; «t| IHRTH 



\ < ; 1-: 




'i^i:^s!^J.«iL 






IDriv) 



M,,„tl,. 



r iJ.' . 

(Year) 



Pa 1 ,^ 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DIUTH Jj ~~~ 

(MontH) 



(Day) 



I go . 

(Year) 



SIN<.I,I". M.\KKIi:i) 
\\nM»\yj:i) OK I)t\"< (RtKi) 
• U'liit in soriiil <l«>i>.Mi;it ioii) 



lUklMI I'l, MM-: 

iSt;ttf <.t <".(iiiitrv) 



. f LaV\A.eci^ 



J JIRRKBY CF-RTIFV, That I attended deceased from 

'-^-^ I'-i up'i to . Q ji^vt X 190 H 

that I last saw hi.. alive on 3 JL^rxi f^ ^^^ ' 

and that death occurred, on the date stated above, at ^ H5" I 
UVm. The CArSl<: 01- DKATir was as follows: 



y^^XAy 



.\^^^:t>^^S 



N'AMi: 01 
FA IHlvR 



lUK lill'l.ArK 

Of" i-ArmtK 

iStat*' or Coiiiitrv) 



MAinivN NAM}.- 



niK'nii'i,.\ci-: 
•>!• M()Tin<;K 

(stale nr Coiiiiti\ » 




F) I- RAT ION Vrars Mouths \^^Days J Jours 

CONTRIBUTORY kA.CL.'^ 







.^... 






DURATION . Years 



(SIG 



Jfont/r 




NED)....l,k/tKi lb. C)J 



'x-0„ 



^^<W^^ I /ours 



M.D. 



1 •.■^ )V,//. 



^^ '^I^ [Address) Xn on LaLL\.v^A,.a "^>. 



?^^9'^'- INFORMATION only for Hospitals, InstitutLs TransienK 
or Recent Residents, and persons dying away from home. """^"""n^. irans.ents. 



Rr\i(1riJ nt S,ni I'l ,;;/, 



Mnlllln 



IhlV. 



Former or 
Usual Residence 

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



How lonq nK 
Place of Death ? 



Days 



Ilhsl 01 :vi\ K.\()\VI.i;i)C.H AM) lUCMHK 



(II 






I'^CK ()..■ .UKMAI, OR KKMUVAI. I OATl- o! n.H.A,. orRHMOVAI." 
C\^^ I "^-^i^ '' T90H. 

^Ad.lress 1 lllAJ. )l^5L^,A^:vv..a^^ 



N. K.- 






> 



I 




m> 



|i 



If 



I *! # 



WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD 

___^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.;!i,l .,f II, ,1 1 til -I" Vn. !«; t-«^»!!'^-, !U<t 1> Co 



i 



JL: 




:1 



,3 7.9 ^M 

Deputy Health Officer 



liegisleved J^fo. 



1381 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiffcate of Bcath 



( U. S. Stan^arO ) 



J? 



^ 



X 



(^ 



PLACE OF DEATH: — County oiOcxrwi ' .'X<XAVCAi' City of O/cwu 3 Axx^vttv^ t^. , 



No. 



*t) 




\\x^ m^<X-KkoX 



St 



Dist.; bet. 



"-and 



/ ir ot*TH OCCURS A^«AY FROM USUAL RESIDENCE GIVE facts called for under "special information- \ 

\ ir DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



crillAjJb- XqXx, 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

coi.ok 



DAT1-: <>l- KIKIll , \ ^ 




MEDICAL CERTIFICATE OF DEATH 



DATE OK DK 



.vn. J 



(Montlj) 



1 

(Day) 



IQO . 

(Year) 






Mujith* 



AHK 



I I Vmti. \ 



(Day) 



Mntiths 



X 



/.ti.^.J. 

(Year) 



/><n. 



^ IN'. I.I-: MXKKii:!) 

u !!)« »\\ i-:i) «»k i)!\< >KCi;r) 

'\\'riti id sotiai <l<>.>i}.'ii:it imi I 



IlIkTHI'I.AC'K 
^t;itf or I'lniuti \* 



llW 



\J\^JL<k^ 



\AM1-- ()| 

faihi;k 



HIRTllI'l.AiH 
0|.- lATHKK 
(Sttitt Dr Couiitrv) 



JcX/T^vOw-yv- 



MAIDKN NAMF 
OF MorHHK 



I'.iK'rniM.AcH 

OI- MOTHKK 
(Slatf (ir Counlrv) 




I HHRHBY CI'RTIFY, That I attended deceased from 

^^^^^^-^^ l*^ 190'A to ..DjL^.I % i()o H 

that r last saw h •>- > )\ aHve on f 3. JL:|-vl, 'X up 

and that «leath occurred, on the date t^tated ahcive. at 1^ 
" M. The CArSlv OF DI-ATH was as follows: 



-A^^. 






DURATION Years Mouths % Days ^^...Hours 

COXTRIHUTORY "^ <^<-^il>^.AA^^. 

\^^JjLh^O ■ o 

Years Mo fit /is 5vC) Days Hours 



DURATION 



(Signed) 



m 



r 



IX|\1) :X TQo'v (Ad.lrc-ss) 



L^-V»Jl 



"Cn-ATION J) . Q 






),„l > 



M.'„th^ 



n,i 



Special information only for Hospitals, litl(itutlons. Transients 
or Recent Residents, and oersons dying away from home 




M.D. 



f;"Tn"^ S^^^ ^^t f J n Hovv long at 

Isual Residence v)UU VJ^v\XX.'>\CL \A\v piare of Oeatfj? 



Tin: AMOVH STATi:i) I'KK«-;«)NA1, PA K i' IC T I. A R S \K1- TRIK T< > TUF 

Hi-;sT ()!•• Mv kn«>\vi,i;dc,h and i!i-:mi:i'- 

(rnfoTmant\l T\)\A V\,^V\XA„lvA-Vwk^ JV^aXx^ 



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



Days 



(AfUlffss 



TQO i 



I'lACK OF RrRIAI^OR RFMoVAI, | DATi; „! HtK.Ai. or RKMOVAI 

r.VDKRTAKKR ub. J. Q.^CaJ^A' ^ C<. 

(AtMress li- '^.H... \U\a.^.'«U<..C^^ 






N. B.- 



-Bvery item of information should hi 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 omr4 
sons dyini away from home should be feiven in oxcry instance. ^ 



. :^ 



1 

m 




^% 



ill 

ill 



I '■ 'I 



H 






'" I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



M.l ..f |[. :.lth »■ No. i«, "**^«j^- H.Siil' ( 



/hf/r Filvil, ZjxXxl^-,^i^A^, a V)0\ 




Mcgistered J\''o, 



1382 






Hr - 



:C8r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccitiffcatc of Scatb 

( 'a. S. Staii&atO ) 



PLACE OF DEATH: — County of Ja >v 

No. ^- : ..' Lf>^ ■' St.; 



(^ 



City of O (X^\- 






\.o. > 



Dist.; bet. 



and 



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



) 



FULL NAME 





<x.'S^Ax .cLcu\ha„^.<i„,^. 



PERSONAL AND STATISTICAL PARTICULARS 

"''■•'^ ?V?) A I COLOR > 




X.4%Ujl 



'All-; nF niKTII 



(Monfti) 



\ < ". V. 



^t) ,v,„, H 



.5... 

(D.-iv) 



M.-ulhs 



^Vt-r.r) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATFI ^ 

^^.ijc 

(Month^ 



aX'iy) 



I go . 

(Year) 



I HF^RHRV CI'IRTIFV, That ^ attemk.l deceased from 

190 . to 0-*U:|V<W .:•.> IQO \ 



LLuu-Q. A.'i 190 ',. to O-ft^^vfe \k 



that I hist .saw li alive on 



£).-^.\,'.. 



Of 



Day. 



\viiM»\\i. I) OR nivoKTHr) 

'Write ill >.<)(i:il <l.-<iv tiatiuii) 



!)l 



(Stiitf or Cruiiitry) 



N.AMK OF- 
I- ATHI-R 



nrKIMllI.ACF 

<>i" iaiiii-:k 

'St.llt or roiiMt! v) 



MAIDllN NAMK 
<>!• .M()TIM-:k 



lUKIFIlM.AfK 

OI- M<»rm-:K 

(Siiilf or Country) 



OCCUPATION ,V; 



<X\. V\x d. 



(31^ 






1 90 



and that deatli occurred, on tlie date ••lated ahove, at '^ 
^^I. The CAISK ()]• OI-i.ATII was as follows: 

■ J--vULvvx<tr>A.^a.w_ .. ..si.riiA-iM, • • ' v..'lu>..si... 



DCR ATIOX Years Mouths Days Hours 

CONTkllJUTORY ...LXo.\ 



.'.V.QuorxA^; 



.V\,..V, vj.. 



1 



(?|) 



3' 



? 

4 



DURATION 



± 




Days 



(SIGNED) 

^.£.V^ a looH (Address) ^C^ 1^ U^cJlLvt cil 



Hours 
M.D. 



Special information only for Hospitals, Institutions, Transients 
or Recent Residents, and persons dvina dway fro.-n home. 



tLs, 



,1 






Mnuth.- 



Ihiv. 



'"'.';. V!?^'^** •'^''"^''"'•" I'HRSONM, l'\KlI(-ri,\KS AK]-: TKIK To TH1<; 
HI-.SI Ol-- MY K NOW 1,1-; DC, K AM) lU-llJl-iK 



Former or 
Usual Residence 



tOl M t Xo-ivo^) tlv.. piafcIfVeath? 



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



Days 



^ 



^^. ^X>'- 



U-Mross lbC)t? ^^.L't) "cL-C^i)^^^ LL:U>.^ 



J'^xi^CH 01-- IHRJAI, OK KHMOVAI, | DAT^-; of JUkial or KKMOVAl, 



A. 






N I ) ]•: K T A K K R M:\A,\AA.^^ 9 • jj 0- dLCO^-.V 



T90 



(Ac],f[ess 5..O..5 .^1)1 1 ") vtcyV^iW.^ 



t 



IN. B. F.very item of information should be curefully Hiipplied. AGE HhoiiUi be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in pbiin terms, that it may be properly classified. The "Special Information'^ for psr- 
sons dyin£ away from home should be feiven in every instance. 



\^ 



> 



\k 






I ■« 



11 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)i..,ii.i ..r II. iitii^ 1" V-. i"^ t-^^rs;.*) luv 1' Vi, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJO'i 



ItcgLsfci'cd J\^o, 



J 383 



Date Filed , C)«^l\.tjL>^\.lMLV ^ 

I 

DEPARTflENT Of PUBLIC HEALTII=City and County of San Francisco 

Ccttificatc of Seatb 

( tl. S. StanDarD ) 
PLACE OF DEATH: — County of' a>v J \a yvcc^co City of^^a^^ "^ Vo 



No, 



\| 



^ 



i/ 



St4 Dist.;bet.ljLa\Ml^>\AA^xl.' and i 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /■ 



1st.; bet. CKLOaMj^kkaj^XL. and .iiV^Al 

/ 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 



4' 



FULL NAME 



.O.-v.l.A..: 



I LLt' >\.tok 



<w'>,\.tOKl 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



!>. 



CO I, OR \ 

I 



XUl 



a.-kvU 



I'Arj. (>i itikrii 



iMoistli) 



A « . V. 



I r 



) Vii ; .V 



(I):(v) 



M..„lh^ 



r Isa 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATII 

'~-A I 

(Mont'h) (Day) 



l9o\ 

(Year) 

I HRRRBY CKRTIFY, Tliat f attended deceasedlv^i 

to : 7: . 



A/ 1 , 



"". 1 90 

tliat I last saw h trr7r:r...aU ve 011 



190 
190 



^IN'.IJ-:. MARK 11: 1) 
UIUoW }-:i) OK IHVoRv'KI) 
•NViiti ill v,„ial <))-sit£tiiitiun) 



'St.itr or Conntrv) 






FATHl.R 



lURTIIIM.ArK 

or- i-Aiin:R 

'State or Ooimtrv) 



MAini:x N\M|.- 

t>l MOTIIIIR 



HIR ruiM.ACH 
O}- MOTHHR 
(Statf or Conntrv) 



and that death occurred, «)ii the date stated above, at 
M. The CArSl-: ()!• DI-ATII was as follows 

..(il\^Lt aA^d^. 



. M. The C/ 



n 



nrRATrOX Years 
CONTRIIU'TORV 



Months 



Days 



Hours 






x\ 



DIR-ATIOX Years ^ Mouths Pays Hours 

(SIGNED) L^Wyv^ J AD..Jd).,..lxl.a.^-^^^^ M.D. 



X.{\X) '.'. T90 



(A.ldrc'ss) V^^.^-^^?^■^ I i 






V-<j-Cnk 



oecup.\TioN 

A'fnffi/ III Sail I'l ail, isi'o 



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



^'>at s 



Mniithy 



Da 



rin-: amox-j-: sr a ri:i) i'kr^onai, r xriuti, \rs aki-; trik to riii" 
in.sT oi' Mv KNOW i,i-;i)c, 1.; and iu;i. n:F 



former or \'\^ \ 
Usual Residence '^- «^ A J 

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



3ax J^hJk dt' 



ftoH long at 
Place of Oeatlj? 



Days 



(Infotmant 






IM.ACK OF nrRIAI, OK ki:M(.\AI, I DATJ-lof JRkial or RliMOV\I 



T 90 '. 



r.VDHKTAKHR 



^- 3 J cC^o..A.^.^ 

(.Address y ^.O.S. .. M^IX^r^^ 



^' ^' Rvery item of mformation should be carefully supplied. AGE should be stnted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information'* for par- 
sons dyin^ away from home should be J^iven in every instance. 



> 




' .1 



'^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

'"'■•'"■■"" '^^""''•^^'•"^'•''" REFER TO 3ACK OF CERTIFICATE FOR INSTRUCTIONS 



/)ti/r Fili'il, '"'xAa: 

1 



O JL\<Xju'rr\l>JO 



liegisteved JSI^o, 



1384 



-Crv 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



■I ■\ 



Certificate of Death 

( XX, S. StanDarC^ ) 



N 



PLACE OF DEATH: — County 

o. lO ll viV>vtjX' 



of --^ -.vOA.- , ■ . - City of 0, 



^ 



<Xjy\j vJ A.'<x v.. e^v 



Dt*T4 OCCURS A 



(IF Dt*T4 Oi 
IF DEATH 



St.; o 



D 



ist.;bet. ' ^^ iJv 



and 



v\ I 



w„^^ -WAV FROM USUAL RESIDENCE give facts called for under "special i nformatiow \ 

OCCURRED in A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



i; 



LLL^<X"n\ 



'h 



.^- C. ' L.L, 



SK\ 




PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR \ '■ 

1' \ II-. < •! liiK 1 n 



1 



iCJvJ:. 



\«'. K 



I ^!(.lltht 



3. 

(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:a TH 




V 



t: 



J 



(Day) 



I go . 

(Year) 



Mntilhy 



Pays 



■-fN<.i.i-: M.\Kkn;i> 

' W'vwr ill s<),-);il i!«->.ivMi:ili()ii) 



fStati- or t"i)uiitr\ i 



NAMI-: ()!• 
FA rm.K 



lUkTHIM.ACK 

<>'•■ lAPin-.K 

(State or Ci.imtrv) 



MAIDIIX NAMl- ' 
«>i- M«>riii;K ii 



HIKTMJ'I.An.; 
OI- MOTHKK 
fStatf or I'oimt I \ ' 



OCCl I'ATION 




i e 



I IIHR1U{V CIvRTlFV, That Lattende.l deceased from 

^-'-^-^^CL- ^^' 190'i to 'p.jl\xL- 1 igoH 

that I last saw h-*^ alive on Jjl|.xL 1 jgo 

an<l that death occurred, 011 the date stated above, at 
M. The CAUSH OF I)I;aTII was as follows: 



Dl'RATJOX }'ears 

CONTRIIJUTORV 



Mouths 



Days 



Hours 



Dl'RATIOX Years Mouths 

(Signed ).^irL^v J 

J 

T(>0 ' 



Da vs 




Hours 
M.D. 



eUl 



(Ad<lress) ^"^ I " M t I. \\ 



.buJux^-A-<cL 






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



) 1 a / 



M„„lh- 



/h!\.^ 



Former or 
Usual Residence 

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



How long at 

Place of Death? pays 



' "1;,^!!V^'''" "^'"^ ri:n i-kksoxm, i-xu ncii, \ks aki-: rKii'; 10 Tin-; 

in-.M oi- Mv KNOW 1,1,1), -.K AND ItllMlvK 



(Illf 



""limit \cKy^>''^^JLA 




"y\^\-\ :. , ^. 



N. B.— -Kvery it 



^\'l<lrc.ss X^ I % vDjXA/L.<>./-yxt "^t 



I'^ACK OF HIKIAI, OK KHMoVAI. I DATH of Hikial or REMCJVAI, 



M 



(Adiress 1.05.1 



% 

A^x^toix-Dr 



( .. 



ivery item oV information should be cnrefully supplied. AGE should he stated EXACTLY. 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 ^ivcn in every instance. 



i'l 






7 



1; 



I 



.'I 1 



]■' : 



■;1. 



'' r .*) 



':. / 



t • .4 



I * >Tit 



M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H^mk! ..f H( .tlili !•• No. le, •*'^!lar^.o US^V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r /'V/e(/ , JJL\\XJ^^xl)^r,J 3^ lUO'i 




Registered JVo, 



1385 



vu^.<5 ixx^^v, Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of 2)eatb 



PLACE OF DEATH: — County of Ua>v J \o 



Ne» 




, -V, ( 



J (jii 

City of O/CLA^ J/V.O. 



4X \/V\A 



VVAI.v'-'^^^ St.; 



-Dist.; bet. 



' and 



/^ ir DEAtk OCCURfe AWAV FROM US0AL RESIDENCE GIVE FACTS CALLED rOR UNDER "SPECIAL INFORMATION" \ 
k ir Ot^ATH OCCURRED ,N A HOSPlt*L OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E^T AN D N UMBER ) 

\ KV^p I] 

FULL NAME cLclol\^ovCa \J J «L: 



SRX 



PERSONAL AND STATISTICAL PARTICULARS 

C01,(»K \ A 




(Month) /T 



MEDICAL CERTIFICATE OF DEATH 

DATE {^V I)i; ATII C 

U JLirCt ^. 



Ai, K 



) '/•</; . 



10 

(I)av> 



MnUtl,^ 



I nOM 

I V<:ii ) 



(MonthD 



a)ay) 



I go , 

(Year) 



1 ni:kl-:nv C1-:RTIFV, That liitten.lc.l (leceasea from 



an 



/'.r 



-IV'-.T.K. MAKKIi;!). 

^^ II)t lU I-;i) OR I)l\-()Ri(.;() 

iWriie iw «ocia) dtsitrnation) 


\ 






^/>XOl' 


iHR rni'i,Ari.: 


/'I 


A 7 


iStatf or Country) 


VV 





NAM), oi. 






•• \i'in:K 






I'-IK rill'I.AOK 
OI' 1 ATIIHK 
(State f)r Country) 






MVIDllN NAMF 
<>1- MorilllK 


N 


^^ 


HIRTnPI,A(l-; 

(State or Country) 




p^ 


OCCUPATION ^- 


— 




Rrsitied ill 


Sail I'l ,nii isrti 


) 'lU 1 V 




^^ .''^.C 190 H to ^^d-^jxfc X 190 H 

that I last saw h ■- 1 1 alive on 



I 11. .41. 1 i.i.Ti. ,T,nY n — I ' • till \ t" (JII V, ; — ^^y., ^.^ IflQ 

and tliat death occurred, on the date stated above, at r- 

•M. The CAISK OF DI^ATH was as follows- 



A^.^/ >-x. a 



.a 



.^s_^ 



\JDJ^ 



Dl'RATIOX Years Months \XDays 
CONTRIIU'TORY U.. >A.4?...A.\.tr::^«A^.A. 



Hours 



DURATION 



Months 



Years 

( SIGNED )...\JyLA^JL'tL\JTC 

QA-X"- iqoM f Ad.lress) ^XC 





Days 

(1 , 



Flours 
M.D. 



'\.U 



Special Information only for Hospitals, InsmuHons, Transients 
or Recent Residents, and persons dying away fro.-n home. 



1 A '/////,« 



Dit'. 



"",''>!!,VV;;^'''^ ■"■»•'> ''»''< ^ONAl, P\KTICri.ARS ARIv TRIK To THl-: 
lilvsl 01. Mv K NOW 1,1: DC. K AM) lUvMHK 

Infonnaut C)a^<J!jL>v M )\ tX^U^ 

'' — y 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



J^.ACK ()F lU-RIAI. OK RKMOVAI, | DATi: of \^^^<^^^. or KKMOVAI, 

''"^" -kl^:^-^ I 9-^4^ ^ 190H 

(Address ....i,!b.:i..gs.-. la .±i\ Ql 



N. B. f^ve 

8 



r«T*VA7,«?U"r^^'kTrt'C". *''''"'*' ^^ ^""^f^Hy «uppHed. AGR should be stated EXACTLY. PHYSICIANS should 
tate CAUSE OF DEATH m plam terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home should be given in ^\9ry instance. 



I;i 



/rtb^iil^ 





1 > 



f 



.■ 11 



•^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li.Kil.l ■ ' II. ;!!l I Vn 1- ^'^^^S^) MX I' Co 



/)(//(' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\^o. 



1386 



Xtr^^A^A^ llXvM^ Deput; ' " jalth Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

. Certificate of Seatb 

PLACE OF DEATH: — County of JCL>^' /\XXavC\^ ' City ofCJO-TVj J A.CL/> 
No. 110^ ^m^■>^lQ.^•^ ,,..,.>,,,, St.; I 



> l^ 



, ' M.; > Dist.; bet. L O^^^Xl/D and 

f \r Ot*TM OCCURS^AWAV FROM UflUAL R E S I D E N C E G I V E FACTS CALLrO F 






DEATH OCCuNRED IN A HOSf»ITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ^TREET AND NUMBER 



1(\ 



OR UNDER l,SPrCIAL INFORMATION" \ 



FULL NAME 



u.U^, 



LLt.xu vi. 




C^ll'C^^^ 



^i:x 



PERSONAL AND STATISTICAL PARTICULARS 




i>\ I'l: <tl i;ii< 111 



M..iitJi) 



\Cb, 



MEDICAL CERTIFICATE OF DEATH 

DATI-: oi- nivATH 



,t 



as 

(I):.y) 



(Year) 



A(.|.; 



6xkt 

{Momfi> 



(Day) 



(Year) 



I Vii » .V 



10 Mfulfis 



T90S 
190 i 



/hi ) . 



(WTile ill scH-ial «lc>ivtiati<»ti) 



L 



HIRTin'l.AOH 
(State or Comiti v) 



VAMR or 

HATin;R 



I'.ik riii'i. \(K 

OI' lAIHlvR 
'State or CoMiilrs-) 



^I MDKN NAME 
'M MOTUHR 



liiK'nriM.Aci-: 

oi" MorHHK 
(J^tatc or Coiintrs'l 






I II1vR1':HV CliRTlFV, Tliat I attended dccoasecl from 

C)x.|:\-t I . I90M to 3^^ 3) 

tliat I last saw li :.. ^.i.w.alive on S>.-£^\jfc 2? 

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

^. M The CATSI-: Ol' DI-ATH was as follows: 

oU A/y\^.\,i^.^.A-^^^^ ql. 




Xcul^i 



nrR.VTIOX ]-ears Months '^ /)ays 
C( )NTk I lU'TORV J3v<X-\,^..ycn^.v.iC^^ 



Hours 



'H\ri>ATH)N 



{ 



DTRATroX Years ^fonf/is (^ Days 

(^IGNED) vL.. X'-i' ............ .v.. A 

JxIaA' ? Tc^o , (Address) H'^^ixh^tnxt 



Flours 



M.D. 



^ 



\\ 



v.\,V:/. 



Special information only for Hospitals, institutians; Transients 
or Recent Residents, and persons dying away fron liome, ' 



Yrais i ■ Mniifh- 



n,:\. 



' ''urJ-tVy.V^';'!"^''"''' '''<1<^'»NAI. I'XKTKTI.AKS AKi: TKIK To TMK 

'5hsi <>': ^l^ knowijcdcj.; and itj-:Mi:F 



Former or 

Usual Residence 

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



How long at 

Plare of Deatli? Days 



ri.ACK OI- lUKIAI, OK RHMo\AI. j DAJ'i: of I'.iKiAr. or KK.MoVAI, 

di.<X.L_D.;>-_ I O^l^ H 



^<:\.'tJ'^'^A,t^.Li 



i9M 

(Ad.lifss ic M AjD h.^^i<K^<.A> ':}.,kk^..'J^„ 



0-/CCC<lJhJLN^ oU AA.<'<;i<H>. 



N. B. Kvery item olr information should be carefully supplied. AGE should be stnted EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dymft away from home should be 6'ven in ^xvivy instance. 



N».. 




.1 » 




r 



:H 



■1. ■■! 

"'A 

V A 



.J 



ill 



^ 



I'lil 



^ 



^■■ 



1 '» 






■*A 



WRITE PLAINLY WITH UNFADIIVG INK — THIS IS A PERMANENT RECORD 



•^•"^■^r 



!;..ii.liiC ll.iUh I-' \n. i« ^■^^-^■Txj^M'.Si.V Ca 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






lle^iHteved JVo, 



1387 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of 5)eatb 



4 . -^ ^^ 

PLACE OF DEATH: — County of O, a ->v ' AXXavca-vco City of 0,Ol/>^ A^<X-w/t^«.^ ' 



t) HM.tk 



o^'\ viiA,',.Uv.>. St.: 



Dist; bet. 



f "" r/Tr*" °'=^"*'^ *^*^ '^"O** UiUAL RESIDENCE give facts called roR UNDtR "special information- ^ 

V IF qCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME TiXoXOA ^A^c^-i-v^' 




•^JlX 



!» \ I'l-: nl- HIKTM 



PERSONAL AND STATISTICAL PARTICULARS 

Cni.oR X {\ 

\ 



MEDICAL CERTIFICATE OF DEATH 




L;4\.ott.. 



'Violltll) 



5 

tl):iv) 



(VcHt) 



\<.H 



■ (Year) 



Yt'ats 



9> 



. MoHf/lS 



lAL /hivs 



\vii>()\vi.;n OK ni\(»Kii:i) 

'^Vriteitj ^ooiiil <l<sij.Mi:,ti.)ii) 



lURTMI'UACR 
' State or Oounttv^ 



> ATHllK 



4 (^ (1 



'•IKTHI'i.Ai-K 
'»' lATHF.K 
'Siatf or Count I y) 



MArDKN NAM}" 



nTRTlfJ'l.ArK 
)>'•■ M<)IH|;k 
(State or Cottntry) 



A'/'•w/('r,,'' III Sini /'i ,1 II, i\rii 




DATi-; oi- i)i:atm V 

dxki 5. 

^ rMoiit1»i) (Day) 

I HHKI-I'.V CI'.RTIFV, That J attemlcd .Icccascd from 

LLcoo 3s^..i9o'i to aji<^i. X Kp \ 

tliat I last s;fw h -t^ v >A.alivc on Q-CJ^Jt '}s. i, 

and that dratli ocfiirred, on the date statc-d above, at 
•"■• M. The CAlSlv ()!• DIvATH was as follows 



[90 







I) r RAT ION ]\ars 

CONTRIIUTORV 



A/ 1) /I //is --' Davs 
■y>^:flrS^^rr.s, 



Hours 



I) I ■ R A r I ( ) N 
(5lG 



Years 



Mi>fi//is 



/^avs 



NED ) LuLi^X<i\^K l^wcy^\Aw v;v. 



)X' 



i^t_ 



^ 



r<,oH ( 



Hours 
M.D. 



Address) VU, \]\.. ^K .lUo. .. C^ ' 



Special information only for Hospitals, Inslifulions, Trdnsjenls 
or Rctent Residents, dnd persons dying dway from ftome. ' 



Former or 
Usual Residencf 



\X^ "^.U , ib<^4^i Pldfe'rOeitfi ? 



) '1U1 1 



M.oith 



V ' \ 



iKf 



' "',;,^'!*'^ ''• '^■'■^''■j:i) I'KKsoN \i, i'\k I irtr.AKs \K i: Tkii-; ro rii v. 
ni-.si ()|- Mv KNOW ij:i)(; )•; and iii;iji;i-- 



Days 



When was disease contrJirfed, 
If not at plareof deatfi? 



(\\ 







J'l'^CK ()!• I'.IKIAI, OK R1-:M()\-\|, | DATi;,,)- Miuiai. or K IvMi )\AI, 



it'^^AL v^^^ <^><5^ 



hlress l%^'\ X- \^ik M 




(Ad( 



OXJrA± Z j^^qC^ 



N. IV 



Hvery 5tom of Informntion should be carefully supplied. ACIB nhould be stnted HXACTLV. PMYSICIAINS should 
Htate CAUSE OF DHATH in pltiin terms, thnt it miiy be properly clHssified. The "Special InformHtion" for per- 
son* dyinU owoy from home should be j^iven in every instance. 



i 4 




WRITE PLAINLY WITH UNFADING INK 





THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihf/c Filed , Ojuw 



Xx^v-Jl' 



M_>v 3 



1<.)0\ 




Hcgistciod J\ro. 



1388 




DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of H)eatb 

( *a. S. StnnDarC> ) 
PLACE OF DEATH: — County of vJa^v AX\/^VCC4C< City of ^^ Ccw ^ KCk.-^ 



0|1 



VC.^^ ' 



' . n '• 



St.; 



HI 



( ir Dt.TH OCCURS Aw-v TROM USUAL R E S I D E N C E G r vf facts called roR under "special infor 

V 'f- DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION S. K t C . A L I N FO R 



Dist.; bet. \ .\. 11: ai 

R "special INFORMATION" \ 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



I 



nd 5 .Li 



FULL NAME 



^1 1 l.CLLc>rv:vx!r:.. ^ 




jLo^\xl.Lajl. 



^HS 



PERSONAL AND STATISTICAL PARTICULARS 
A I COLORE, 




i'\TK OF HI Kill 



■a,u 



lontli) 



(Day) 



Jx_ 



MEDICAL CERTIFICATE OF DEATH 

DAT!-: (»i Di; \rn 

^ ajtl^ 1 



(Month J 



(Day 



(Year) 



A^S.S.... 
(Vear) 



\|.K 



^i 



^S 



J 'It I !• 



1 



M.nitfis 



Zl 



I in{Ki;P.V CJ<;rTIFV, That I attended deceased from 

-*-^ >'l 190'^ to ...^!).X^t X 190 H 

that r last saw h ■-. ) > i alive on UX^kJb. %.... 



Da 1 



^'V<".I.K. M\kl<III> 
U IDOWKI) OK I»r\(.KrKn 
Write in swial (Usiv:natiuii) 



'UKTIIPI.ACR 

St.'it<' or Country) 




-cct 



i 



' 11 j ■ ' 

1 WM" t''w 



VAVT- or 

l-ATin-.K 



i'-iRTHn. \^•^• 
•»'• l-ATMKK 
^titfe «.r Country) 



M MI>HN N'AMi- 
•>l MOTHHK 



"IR IFri'l.ACK 
•>l MOTIIHK 
(State or Countrv) 



c 



"•I90 



and that death occurred, nn the date' staled above, at 
.--U. M. The CAlSh: ()!• DlvATH was as follows 



h^ 



,vo 







IJIR.XTION 







1 



)\'a^rs '^^ Months Days 

CONTR I IJTTOR V da,.<)lAjJ:A^ 



Hours 



.^fon/hs 



Da vs 



'%rr>u 



l)l'R.\TH)X 5 Vcat's 

NED ) ..: ] )\ ^ mjLKAJT^X^^^',., 

if)0 . (.Address) XS 5 J,/LAA,'k Oi. 



ISIG 



Hours 
M.D. 



OCCUI'ATIOX HS 






Special Information only for Hospitals, institutions. Transients 
or Recent Residents, and persons dying away from fiome. ' 



V,./////- 



f\!\ 



Former or 
Usual Residence 

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



How long ai 

Place of Death? pays 



"",;,^ '5!?^ '■■ ^ '"'*'''"'•'" I'KKSOXM, I'AK riCn.AKS AK1-: TKIK T. • TJIK 



.<XrvC 



^A<Mre,ss 1 b C) \x \X(X\.0. ■ + 



ri..\CK Ol- lURIAI, OK Kn-MOVAI. J DATKo! Hikiai. .,r kKMov^l 

Qlu_^£Lx>^.^„ I ^A^^ I90'' 



^\d<licss .S'X'm UO^.'cLLa^ Jn-I^. l[ • 



N. B, 



F.very Item oi informjition should be cnrefiilly supplied. AGK should be stnted EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be given in every instance. 



N. 



> 



Ml 



m 



\ 




I 




!'.it , 




i f 



i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

__. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



>> 



M-iI-l «.f HtilltJl I- No >'. ^■^,^'S^t. \'.}<C\' Vr. 



Be^isieved JSI^o, 



1389 



d^^^Lcv^ 3^v-u Deputy Health OfTicer 

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

Certificate o( S>catb 



X 



PLACE OF DEATH: — County of ' CL^- M rl<xL x) City of O CX.-r^ 





C 



'"^ 



No. 



St.; 



Dist.; bet. 



"> •» and 



(% J? H p 

FULL NAME </.LJL>u<..vr>a.<x->v d.cixuJLdi 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 C(»I,t>K \ 



MOloL 



i>Ai}-: (.I- itiK III 



Ia« ynAXx 



'MMiitli) 



(Day) 



/,S?,<. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

nATI>; ()»• DlvATH C 

axA-vfc. 3 

(Day) 



1 QO 

(Year) 



\'.l-; 



(Moiitli) ' 
I III'iRF'IiV CivRTll-V, Tliat I atteiKlcl .Icrcased from 

"~~~ 190 - to 

lli.'it I last saw \\— — -alive oil ■ ■" 



^in<.i,t:. ma run-: I) 

\VII)n\VHl) OK invoki Kr) 
'Writi'in s<M-ial «lesij.Mjati..ii) 



\)\ V.ats *^__ M.m!l,< *■ .. ihi\s I •Hill that (leatli occurred, on tlie dati- stated ahovt-, at 






HiR'rniM.-vcK 

istatt' or Conmrvi 



NAMi-: or 

I ■ AT 1 11: R 



>l l-ATHHk 

'State or romitiy) 



01 Mnliij.-K 



I 



^ 



cx^v^^^cd. 



OX^^^w (X-Y vu 



M. Tim CArSlvOi- I)i;ATn was as follows 

.>sI/CXA^t 




r^i^^rA.. 




I>( RATION .. Years Months 

CONTRIIU'TORV 



l^ays 



//ours 



'>! MnTHlvK 
'Statt or Countryl 



DIRATION 

( Signed) 



Mo)iths 



Days 



)\'ars 

(Address) Q >CU>rv\l )La>^,A^j. L<>.>. 



Hours 
M.D. 



Special Information only for Hospitals, institutions, Transients 
or Recent Residents, and persons dyinrj a»^dy \\m fiome. 



' "nx.--,?^''" ^''" ^ ''"'■"'* i'hknovm, I'AKircn.Aks ark true To iin-; 

IJhM <))" MV KN«)\\l.i:i)C,}.: AND WVAAV.V 



Former or 
L'sual Residence 

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



How long at 
Place of Death ? 



• Days 



fAfMn-v.^; 



ri.ACK OF HTRIAI, OR RF.MoNAI, I)VTi:oi \^v^^x^^. or Rian.VAI. 
(5.0. 19 J C\JL^N^X<,'J \jL}f±. H ic)0S 

ni)i;rtakhk (/Id. vJ a J iXcv^XyQ^^ L:Ci 






A.Mirss A II \1 )\a.'^.<J^V<^\ ^^ 



• ». Hvcry item olt* information should be cjirefully supplied. AGK should be Htnted KXACTI.Y. PHYSICIAINS sh 
«tnte CAUSE OF- DEATH in pUiin terms, that it miiy be properly tiassiltied. The "Speciiil Information" for 
«on« dyinil away from homo should be ftiven in every instance. 



ould 
p«»r- 





> 



A 




'! ,1 



•» v 




H -h 



. *. ! 



i'^ 



t'lhiltli I- v.). 1- *-?;3r![]S^-, H.S: I' C, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 







,^^V,VA.A 



\ 



♦v 3> JfJO'i 

Deputy Health Officer 



1390 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eath 

( H. S. StanDarD ) 
PLACE OF DEATH: -County of O a w * ;.^ . Qty oiO.^y^ ^ .^^cu 



No. 5:..o..i,, \bjw.^4. 



{ 



St.; 



( "" °/*":" OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED TOR UNbER ■'SPECA 
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION 



\ 



Dist.; bet. Llvc \ vOxt' 

R "special INFORMATION" \ 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



and JA^ck 



ji:^c.k ( c 



FULL NAME 



.^}J<lL:! 



J 



\Ar:Q^..\J,ZAXUC::OJxJX 



PERSONAL AND STATISTICAL PARTICULARS 

'»\TH OF lUK I n 

"-^ I / h.X.D 

<L)ay) (Vear) 



MEDICAL CERTIFICATE OF DEATH 



\ « . i<: 




:)\ I'K (»!• i)i:ath 9 



(Mont hi 



l^otith) 



bi )>«/»> i 



(Day) 



ipo 

(Year) 



1 HIvRiaJV C1;RTII-V, That r attc-M.lc.l (Icrcased from 



M.nil/is ,.J^. 



lhl\ 



\\ ri)nu i:i) OK DIVORCKI) 
' \\'\\U ill sorial (Irsi^'iiati.Mi) 



lilKTHI'l. Ai'K 
iSiattor Country) 



NAM!-: (H 



I'-IkTUPi.ACR 
•"■" I'ATin-.K 
l^latL- or Countrv) 



M mi)i-:n xamf \ 

•»1 .MOTHHK 



nn<rMpi.ArK 

')l' MOTIIKK /) 

(State or r.xintiA i -f 




■ 1 90 

tliat r last saw h ."rrrrr.aUve on 



190 



aml_ that (katli ncciirrcl. on the date stated above, at 3.?) 
-U.^M. The CArSl<; or I)j.;ATir was as follows: 



(!. 



1)1 R.xrroX Yearns 
CONTRIIU'TORV 



Months 



Days 



Hours 



nrRATroX... Vcars ^ Mouths 



Days 



( 3IGNED ) . L(r\XrTai^ J^m U). klLo^r^:^^, 

QjJpX 'X. Tqo (Address) WVtr>A_^Vft I.' < 



Hours 
M.D. 



'^ 



'K'Cri'ATlox ^ 



h^'ulfi! :il Silt! /"; ,/;/, /./•,; 



Special Information only for Hospitals, institutions, Transients 
or Recent Residents, and persons dying away fro:n home. 



1/,.;////. 



/'., 



' " n,\''',V ^' I' ^'■'^ ■'■'■■" '''-K^oNAI. I'AKTrri-t.AKS AKi; P K I K TO Till-- 

'''•.M <)|. Mv K.\(>\\ij;i)(.H AM) Mi:i,n;K 



Former or 
L'sual Residence 

When was disease contracted, 
If not ii[ place of death ? 



How long at 

Place of Death? D^ys 



ri.ACK OF m-RIAI. OK R1-;MoVAI. j DAn;,,;- m uiai. or KKMOVAI, 

M^U iL5iA^..t I :ci)^..^L -h.... 



• N I > J-: R T A K I-; R Vj^V/CX^ . NL . IjiS VI \\jLL ijLv. , 



190 



. . 'lu' 

f Address t3.b...:|\A)..Ct.<LlxA^vC^^ 



hvepy item of information should be cnrefully .supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information" for D«r- 
«on« dyinji away from home should be j^iven in every instance. 



s. 



'. I 



I 'I 



f\ 






W ' JW ' LIB i» I M L t . m 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

- ^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






1 



lf)0'\ 



O-Aw^V^A^ 




lloiii.slcred Xo, 



139i 



v-u Deput 



DEPARTMENT OF PUBLIC HEALTH-CHy and County of San Francisco 



Certificate of a)catb 



' 11. 5. StaiiDarC^ j 



d 



PLACE OF DEATH: — County of'Jct-v^ ^ r\.o. 

No. i-i-* LL avi,i-L.\. vvoi^ . 



^ 






^•^^>vqL<^, St.; Dist.;bct/i5vi.>Jvam\. and l^^-W 

( ,''/rr'l.°''^'"'^ *^*^ '^''°"' USUAL RESIDENCE GIVE tacts called tor under "spec.al .NroRMATmN • \ 

V .F death occurred <N a hospital or institution give its name INSTEAD OF ST R E eI A N O N U V ^ £ R ) 




\.L 



FULL NAME 



o^ dJvxx Jl^. 



ux,^. 



^i:x 



i'\ n-: MF MiKTu 



\<.i-: 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR A 



A 







MEDICAL CERTIFICATE OF DEATH 



Yeats 



i-x 

(Day) 



.!/.'»//// V 



DATK OF DICAIH 

(WouihS 



a., 

(Day) 



(Year) 



(Veai 



l(^ 



./)</!. 



^IN<".1.K. MAkUni» 

U IDOUKD OK Divokt I- r) 

'\\'iitrin s«K-ial <K sij.Miiili..ii) 



IUKTII1'I,A«'K 
iStiiteor C*>mitrvi 



NAM I- ()| 

' athi:k 



''■IHIHI'I.AC'F 
•>'• I ATIIKK 
"^t.itr or c'l.iiiitrv) 



•»i motiii;k 



ink rni'i.AC)- 

<>!• MoTHKR 
'st.-itc nv Contitrvt 




I IlHRIUiV ClvRTII-V, That I atten<le»1 deceased fn.iii 

~ ^„_ ^^^ ^^^ •■•■: -.190 

tl).'it I last saw h alive on :... ■ .:. : —-. j^^ 

and that death ocenrred, nu the date stated above, at 
^ M. The CAlSlv OF DIvATII was as follows: 



1)1 RATION- Tears 
CONTRIIU'TORV 



Motifha 



Days 



Hours 



DIRATIOX -^ Years 



Months 

it 



Days 



Hours 



"^^ 



(SIG 




NED) .\A.diA^cC^^ J L.ai.L.>gu<„ M.D. 

(Address) (oO(o Ox^^l^iA. n**. 



IQO 



"3vw'<XA>-G^J 






VO^VO. 



Special Information only for Hospitals, InsUtutlons, Transients 
or Recent Residents, and persons dying away from fiome. 



/'f-iihui ill S,i>i I'l ,i>ii i>rii 



)V,M 



M^.iith^ 



/hn 



'"',■,,) j!,?^''" ^I" Vri:i) PKRsoXAI. I'AkTi. n.AKS AK]-: Tkl J-; T<. rill- 
lii'.SI oj- MV KNOW 1.1; DC 1.; ANI> iU'MHK 



f IllfoMllMJlt 






Former or 
Isual Residence 

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



How long at 
Place of Deatfi ? 



vo„. -v-w j:.^'> 



A'r 



PLACK ()!• iH KIM, or ri.;m(>\ai, I dati;,,; liiRiAr. .„ ki-;movai, 
r\ nr ^. , \0\ (xl-X^, L-<. 1_ ^ >^|vt 4 ^ ^^ ^ 



'>\;' 






!N. B. Every item of informtition should be carefully supplied. AGE should be stHted EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The •'Special Information" for D«r- 
«on« dyiniJ away from home should be j^iven in every instance. 




Days 



III 



. { 



'ii 



it M 



r'i 





i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



>-^ 



ll.ilih I Vn i: r-^^.'S^; HX;!' ( 



lUO'i 



]ie<^i\slered J\^o. 



J 392 



DEPARTIWENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S>catb 

PLACE OF DEATH: — County of 'O a' vJ '^o.^ , - cUy of CJ^OyTv OXCt-^-vC^^c <. 



No. "t 5. 



♦-4 



St.; 'X Dist.;bet. C3-C\^djL^< and '^-^^ 

/ Pr DC*TH OCCURS »WAV FROM USUAL R E S I D E N C E G I V ET FACTS CALLED FOR UNDER ■sPECrAL INFORMATION ' ■ \ 
V IF DtfJH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




d. 




,<s-.4^t.. 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 
J j COI.OR r\ 




MEDICAL CERTIFICATE OF DEATH 



n.\ii-: nj- luKi'n 



\(*H 






DATR OF DKATH 



(Moiitli) 



\fotitlll 



a^ 



) 'iin «■ 



(Day) 



Mnuths 



<Vear) 



(Day) 



I go \ 

(Year) 



I III-RI'RV CF-RTrr'V, That T atten.lc<l deceased from , ^-^ 

..Vw^U^VQ 190: to iS.-r^S^. I igo H I V'^ 



■^ 



/></] 



^INi-l.i:. MAKklHD 

U II)0\\KD OR DIVoKiKD 

'VViitciii social <Usii'iiat ion) 



l'-IKTHPi,,\CK 
Stiitf or Cotuitrj-) 



NAME OF 
I ATMKR 



''■IKTIII'I, ATK 
'>'" I Arm.;k 



"' MOIIIKK 



I'-'K ruci.Al}-: 
<»1 MOTHHK 
'St;itf or Coiiiitrv') 




that r last saw h 



alive on 



..o_?^:w1:! : 



aiid that death occurred, oil the date stated above, at I V 
^J"^. M. The CArSI-: ()!• DIlATIT was as follows: 



DCRATIOX X. ...Years Months Days Hours 

coNTRiiu'TORV y6..N^<jo^:\<-<:^l.::....J../.„ 




• Hx:r I'ATiox 5 



vtx. 



4 



Dr RATION Years Mont /is Days 

( Signed ) sA J \j^\KA:r\^o^s^^:<:> 

-^ I ^ ^ 

axkx ') TOO (Addrc.s) 3>ax'ia 




y/.nif/l' 



Dav. 



Special Information only for Hospitals, InslltuHons, Transients I ? 
or Recent Residents, and persons dying away from liome. ' I S 

Former or 



'"',';, )'!V^'"* ^■'■^■Il"l» I'KUSON \l, I'Ak IHIKAKS ARi; VRX K 1( » TMlv 
Itl-.SI Ol- M\ KN(>\VI,i:i)C.K AND MllLn-.K 

Infonuant VjVX^r. M- J (J^CXXt^i 



L'sual Residence 

Wfien was disease contracted, 
If not i\. place of deatli? 



( \<l<lrcss 



^OH 



CH2l1. .cjl 



IN. B.- 



ri.ACK OI- lU RIAI, OK KHMuVAI, | DATlv,o! Hikiak or KHMoVAI, 

O^^XJ^,JL I ^-'-^x-*- . .\ 190 



(Ad.l 



ri'ss 



-Rvery item of informntion should be cnrePully supplied. AGK should be stated GXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par- 
sons dyinjl away from home should be ji^iven in every instance. 




ffoH long iii 

Place of Deatli? Days 



> 

I 

I 



f^ 




A\ 



i 



■\n 




Jj.ui.i uf Hfiilth—K Xo. 1^ t-f^r^ri USiV t'o 



ti^- WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATe FOR IN STRUCTIONS 

BaiLstered J\i''o. 



Iiiilc Fili'il , 




■h 



10 0\ 



1393 

dsjy^K.A.^. kxj-\j^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=Cify and Connfy of San Francisco 



Ccitificate of 2>catb 



J? 



■^^ 



City of *0. .V JVa 



p 



PLACE OF DEATH: — County ofOa 

^^* '^V '• ' ••' St.; 10 Dist;bet, 3CL>xXl/I\X\.. and 'Rt^ 

f ir DEATH OCCURS AW«V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "s PEC . A^ I N FO R M at I O N ■ • \ 
V .F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME .NSTEAD OF STR E ET J^N N u ,^BE R ) 

FULL NAME C^i^.La-...\Jj.lcu.i. lO.CL>LAAy^x 



-v 




PERSONAL AND STATISTICAL PARTICULARS 



•l-,\ 



(^ 






t"t)t,< »k 



ii— u 



MEDICAL CERTIFICATE OF DEATH 



jl 




\>VVV. nl !;|Ki II 



A(,K 









lb 



J lUI i 



% 



1 

(I)fiv) 



Mon//i< 



(Vean 



DATK OF I)I;aTH 

8-^0.1 



(Year) 



Da 1 .V 



u riioxyKi) MK i>ivnKr|.:i) 
\Viitfiii s.KMiil fN-siji-natioii) 



'•IKTmM.ACK 
st.itf or Country) 





\\MI- Of. 
I- A r 1 1 !•; R 



''•llvlHI'I.AC'K 
<»l- lAIIIKK . 

(State I.I romiti v) 



MAIDKX NAMi.; 

•»i .M<)Tni;k 



liiKTmM.Aci-: 

(State or Conntrv) 



OCCUPATION 



yy\jUi 




.3.. 

(Month) (I)a5') 

I IIHRI':i}V CI;rTIFV, That J attended deceased from 

i^- '"'- ^ ^90 '• to AjU^. I i^H 

that I last saw h .:.." alive on 0-iL|'vl: I j^p H 

aiid that death occurred, on the date stated above, at 1 C 
\X M Tlie CArSr; Ol- 1)1;aTII was as 



foil 



< > ws : 








YVYVU. 



wvUCAAa.<yui 



1)1 RA'I'ION )Vv7/-.? b Montha 



CONTRIinroKV 



Dl'RATFON i Years 





( Signed ) 

CJjE^^x,! '-■ I 



Oh ff^ 



(>0 



Days Hours 



Hours 
M.D. 



(A<ldress) IMH J04/i.vO-YA\ |i 



Special Information only for Hospitals, Inslitutions, Transients 
or Recent Residents, and persons dying away fro:n home. 



former or 
Usual Residence 



/>■'• /7c// lit ^',1)1 /'i ,rii, /•,-i> 



7 



)V,M< 



1/,.;/'//. 



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



Now long at 

Place of Death? Oays 



' '"• ^"'.'Vi.; srAri:!) i-krson \i, !• \KiiiM-r. \ks aki; tki}; jo tin- 
"J. SI oi' Mv kno\vi.j;im;i-; AM) I!i;mki- 



'Iiifoitiirint 



(Ad.l 






I'LACK Ol- HIKIAI, OK RK.Mi.VAI, [ DATl-of IKkia.. or KKMOVAI, 



rcss 




\_^w' 



vNXsLaL' cLCU-aTv 



u 



:-...,a 



.'S 






1 90 '. 



N. K. 



-Kvcry Item of iiiformHtion should be c»ircfully Hupplied. AGB should be stated EXACTLY. PHYSICIANS Hhould 
«tate CAUSE OF DEATH in pli.in terms, thnt it m»y be properly clossilried. The "Special Information'' ?or per- 
sons dyinft away from home Hhould be ftiven in every instance. 



V. 



h 



'k 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hor : 11. :i!fli-- 1 \(i <.^ "^^rS^^: iiScV Co 







REFER TO BACK OF CERTIFICATE FOR INSTR UCTIONS 



1394 




dv-M^^-v^ A^v . Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of S>eatb 

( U. S. StanParP ) 
PLACE OF DEATH: — County of a ' ■ . ^.. .C' . City of 3 a. w ^ a,o , ^ --,.>" , 

^^•^^^■^ Lvn^D/v^ St; S Dist.;bet. H iL and 1^. tJx 



FULL NAME ■.jfk^yy\L:k 1 Axx/:Y\.'O..^....LLL^aX>L:tma. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



4 



()}laL 



I I i 



> \ I »•: Ml- niK in 



\<.K 



I.. mil) \ 

.1 



(Day) 



\.SJ 



Ll 



(MEDICAL CERTIF 
DATK ()!•• I)1;aTH 

dxkt 

(Montfi) 



(Vear) 



ICATE OF DEATH 

") 

(I)av) 



(Year) 



I V^ >'■</" 1 M.nith- JL 1 



1 HKRIU5V CivRTll-V, That I atten<k"<l .Icceased from 

^^^•■^ ■ — ^ *<) ^Xjrtt ^ 



190 : t 

lliat I last saw hA,^:>. alive on 






/hn 



WIDOWHF) Ok IMNOWrKI) 
\Viitf in soiial d-si^Miatioii) 



HIKTHIM.AOK 
(Slate or Comitiv> 



NAM)- (H 



V OJ\.\,\jL^<i. 




''•IKTIIl'I.ArH 
'»'■ l-ATHKK 
'State or Cunntry) 



^' MI»HX XAMF 
"I MOTIIKK 



IHklHiM.ACI-: 
"I- .M<t-nn.;R 
(State or Country) 




and that death occurred, on the date stated above, at 
v^ M. The CAISK ()1- DI-ATII was as follows: 



190 
190 



Z 



<X^^^<:UU\> 



4* 



>\ 



. O^-ry-v-CN, ■^-■L.Xh.L'A 



I J r R A T 1 X I } 'ears Mauth<; Pays 
CONTRIIUTTORY .U.^rVvJk.^-v^,.«rv.A^^ 



Hours 



i\y^'\Js^S^>(^ 



r ) r R A T r N ^ ) 'lars .iron t/is Dav v 



(Signed ) ...^t^o VA. 1^.^■^x\yA^:t , 

IX^^xXi 0.. T C)0 I ( 



Hours 
M.D. 



KxX<y^\\.&. 



OCCrPATlDX J? 

^^^^ f\r i<irJ III S,ui I'liiini^rn ^', )',(U ^ 



Addres s ) 1 ?il y JUt^X t-q t' ^ » ^^-^ ' "^ * 

SPECIAL INFORMATION only for Hospitals, Insfifuflons, Traif^jents 
or Recent Residents, and persons dying away from home. 



M.nitl,^ 



fh! 



"'mW^''.'^'"^ '''■'* '''^•»<^<>N"AI. I'ARTIcri.AKS AKl' T K T K To THK 
in-,si o|. Mv KNoWlJipC.}.; AM) MI-Ml-F 



'^IiifoMiiant 



XiJi- 






former or 

Usual Residence 

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



How lonq at 

Place of Death? Days 



'^•\*^^ ?^' IU-j<IAr, OR RKMOVAI, | DAp-of HtKiAl, or KKMOVAI, 



t><i-<l/ 



^-^^ ^ ,^9<n 



(A(!<1 



rcss 



N. B. Hvery item of informntion should be carefully supplied. AGR «hotild be stated EXACTLY. PHYSICIAINS 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 feiven in every instance. 



* 







,,'^.^':u ....■■■^:i'/ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.....,___._ WEPER TO BACK OF CERTIPICATE FOR INSTRUCTIONS 



Hf>nr(f «.i II. .'Ill IV.. 1'. *'*' !ai'"i») nS:I* l'<i 



If'f/r n/r(//dj^[xiji/YYxl)<^L^' H I!JO' 



CC'O'^^A.V^G 




H 



Begistei'ed JVo, 



1395 



x ' V 



V 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of 2)eatb 

( "U. S. StnnDarC> ) 
PLACE OF DEATH: — County of JxX/VuOn.(X^vCv^c< City of Oo^^v O.H.<X , ^:.K.i^r < 



Ne» 



, V, 



St.; 



Dist.; bet. 



and 



/ ir DEATH OCCURS AW.Y FROM USUAL R E S I D E N C E G I V E TACTS CALLED FOR UNDER " S P EC I A L . N FO R M AT I O N ■ • \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



Ni:\ 



PERSONAL AND STATISTICAL PARTICULARS ^ 



I 



(1 'J) 



nio. 



I' Vn- Ml l;|K III 



\«.H 




ML^Lt 



.-b 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH J^ 



< M..nth 



r %U' 



(Dav) 



(Year) 



/go \ 

(Year) 



LLlv 



) t'ii t f 



M.'vtin 



Ihi\ 



>^!\<.I.K, MAKKn;i) 
'Write in wK-ial .lesij/iialioii) 



inkTiipr.ACK 

Sl.iti or Cotititrvl 



»ATni:k 



(Month! (Day) 

I inUU'HV CIvRTIFV, That I attended (leceased from 



•^ 





nikrm'i.vcK 

'"•" lAllll-lk 
^tate or (.'omitry) 



MMI.IA' WMI-- 
"I Molllllk 



LCLWo^cL 



Mr 



\(p "^ to .CJ.rr^rrirVU. X. 

lliat r last saw h alive on . _a,. \ >.. •. k^q 

and that jleatli occurred, on the date stated above at I 



M. The CAISI- Ol' DIvATJI was as follows: 

L'Ow.Li^.tr>x...Crt....^yb.-i.<CU>^;(. 




4.^, 



lUKTinM.Ad-; 
• >!• Morm-.K 

(Stale or Coniitrv) 



OCCIPATIOX ( 




Di; RATION 
CONTRIIU'TORV 



J 'cars 





Mouths 




i^ays Hours 

.thca,!\.<<i\,L\^ 



ni'RATlOX 
(5IG 



Years 



NED) U^.AJ. Afc.-CX.k.K, 



Mouths 



Days 



Hours 
M.D. 



\,i\Ai 



190 



(Address) d.Vl^. Lc ^(^^xA.'ta.L .. 



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



Former or ou 1 H „ f t \^ How long at 

Isual Residence <)". . wX^MU .\. dX Place of Death ? 



f\f Shift! in S,i)i Fioihi^ro 



\- ) 'rur 



1 A ■/'///■ 



/),n. 



"'m-V-!.'' '.-'^''■ATi:!) I'KRSONAI, I' A K r IC" C I.A K S A K !•; TklH To Til)-: 

nhsroi- Mv kn(»\vm;i)(.h and i{i:mi:f 



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



• Days 






T I. f. .r ma ii t V.L ' . M V . M I JJ Ch^JW^-^'X^^• 
(A (1(1 ress . ^ H \j[j jJyA.Kj..r\^ «^ i 



190 



ri,ACK OF niKIAI, OR RF:MoVAI, I DAJi;.)! niKiAl. or kl<"Mo\\i 

Om LL.^t.^_ IM-' ' ■■ ■■ 

rNHHRTAKl-R \| V VCtu ^-V 



r\(Miess 



. B. F.very item of information should be carefully Huppllerl. AGE should be stated EXACTLY. PHYSICIANS should 
«tute CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home should be fjiven in every instance. 



1:1 



f 



'< 



i 




(I 



II' 



J 



*>' 



I 



f 





fi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ho'if! of flr.iUJi I' V«> It fr-f^wTll;- M.SclMV) 



Dfffc Fileil , nX-^\iU.-v>Jl' 



^KK H 



VJO H 



<Wc^^o Tlx'v-M Deputv " ■ S OffT 



Rcgisteved J\'*o, 



1396 



r> r» 



DEPARTMENT OT PUBLIC HEALTH-City and County of San Francisco 



Certificate of 3»eatb 

( U. S. StanOarO j 

n, 



% 



No. 



PLACE OF DEATH: — County of !a/>X' J^X.CL^^Cv<i^c^ City of ^^Ci/>v J/i^a ^\c<. 
^*^ 'r'' St.; A Dist.;bet. ^ '^<i4v andiAa^^N^ 

IF DEkTH OCCURS AWAY FROM USUAL RESIDENT 



/ IF DEkTH 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 •• \ 
V IF 5EATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



Q 



FULL NAME 



O.JJL.L:x\,i.... 



% 



J...'<X. 




u.. 



PERSONAL AND STATISTICAL PARTICULARS 

!'\TI-: «»I IilKTH 



bjj 



VvJu... _, 



MEDICAL CERTIFICATE OF DEATH 

DATK (»1 i)i:ath jP 

Oxivfe : -k 

(Moiit'h) (i)av) 



(Year) 



M..iitli) 



Dav) 



(Vear) 



AC,).; 



H^ 



I IIKRHBV CKRTIFV, That I attendcMl deceased from 



190 



190 



J 'I'lUS 



.^f0H///S 



Day 



WIDoWKI) OK I)!V«»kiHr) 
'Urit.-ii, social <It si^niation) 


nikTiiPi^ACH 

'^titf or 0'.iiiitr> 


A 




NAM).; 01 
1 Allll-.k 








LCXWnwCcL 




HiK rur'i.Ac'K 

•>!■ lATMHR 
Statf or Country) 



"1 M«)Tin.;K 



''•Ik rni'i,ArK 

<>l- Mdi'MKk' 
(State 01 <.N)untrv) 



orcri'ATioN (^ 




tliat I last saw h •.tt-—.. alive on - ~..:.^.,....: i:.;.:...;-.. xoo 

and that death rjccurred, on the date stated above, at 
M. The CAISH ()!• DI'ATII was as follows: 

...U,l.V.^A„^C^rr<^«4. 

DC RATION )'tars Months Days 
CONTRini-TORV 



Hours 



? 



I ) r R A T 1 N J ^cars. _ Mouths Days 



l\-\-o^nj 



J\fouths 

(Signed )...Ltf\.cmx>v J. \b iX' oUXo.a-vi:^.. 

QX'^vt 3 TQO H (Address) U\/r\xX\/> . Uji 



Hours 
M.D. 



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



f\r.siilrif III K„fi I'l ,111, •■.,■,) 



} I'd I \ 



M<<>iths 



f>,!V. 



I ormer or 

Usual Residence 

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



ffow long at 

Place of Death? Davs 



' "l;-V!V^'''- ^'''^'"i--'' ''KksoNxi, I'Ak ru'ir.Aks Ak]-: TkrK To thk 

lU-.hl <)1- MV K NOW 1,1; DC H AND HlvMHF 

(■in forma lit CjjL'l 






(Address 



o 



Sl^ (JlOA^.t d1 



I'I,ACK Oi-\J3rRJAI, OK KKMoVAl. DA:^'H of HrHiAi. or KKMOVAI 

.lMl.il....oUvH I ^"^^-t S: ,.0 ' 

(Address., '^^i U .o.. w, M XlA ^ L I. ^^ ".. 



^' Every item of information should be cnrefully supplied. AGR 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. 









id 



■Ff 




■ Ik.' 



!|lpfWS'»'": 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



II.. ,1th (■' \,) !5 ?*? Wf.Xi, I'.X: J' (. 



n 



Ji 



7,9/9 H 



RpgLstci'cd vVo. 



1397 



.1' ' 



V . 




dUrL^c^o TIx^m^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Scatb 

PLACE OF DEATH: — County ofOo.^X' OA.<X rv.t.A.ac'City of CUTV ^ X<y^^\jSiAA^ ^ 
No. LllH VJ/ac^/, - St; ! Dist;bct.JuUl\^^>\<LUtJ'\.Llland ,....^^ 

/ ir or»TM OCCURS »w*v trom USUAL RE S I DE NCE Gi ve facts called roR under "special informatioW" \ 
V ir death occurred \h a hospital or institution give its name instead or street and numberJ / 



FULL NAME 






:4l:QLu. 



HKX 



PERSONAL AND STATISTICAL PARTICULARS 

Coi.iiR 




I>\Ti: ol IlIKTll 



ACH 



'M'.iilh) ^1 




(Day) 



(Year) 



.. J><i>.? 



WII>()\V}.1) OK niVdKiKI) 
^Vritc in social liesit^uation) 



-Ox,! 



ii 



IHRTHl'J.ACR 
• State or Comitrv^ 



lA riii;K 



HIK Tlli'I.An-" 
<>'■ •■ATHHK 
'State or <.'oiinti v) 



MAIIti;\ NAM)-- 

oi Morm-.K 



iHRrni'i.Aci-' 

<>l MOTMKK 
(Statf or Cotintrv^ 



Miint/is 



L 



V. 



,^ 



MEDICAL CERTIFICATE OF DEATH 

I) ATI-: oi- DliATH V 

-^-dvt 3 

(MoTiTh) (Day) 

J m:Ri;iJV CJ:rTIFV, That I atteii.le<l deceased from 

to ....v::trT:r:rn; -rrrrTr: 



(Year) 



' ■■•■ - 190 

fliat T Inst saw h •:■ a live on 



190 
190 



Pax. 



(1^ 






.'Hid that death occurred, on the date stated above, at 
•'"-•■■•■ M. The CAUSlv OF J)I':ATH was as follows: 

:.... A. 



,.':v:v/Os,>rv: 



rW<^-i 



^K^'^L^S^Clk.l. 



I 



\)\ \< AT ION } 'ears Man //is Days Hours 

C NT R I HrT( ) R V 



yXV^^VXCVvVLl , 



nr RATION . Years 

it) 



OCCri'ATlON 

f\f'^i(ft'(f III Sail ri ,1 II, n,-,> 



ux^./w'\<x ~v 



^ 



Q ^ ^^"/'''^'•^ ^^^y'' Hours 

(SIGNED ) ...L^V<r\Vil^ V\b.iO.XLl.<X.\x..ci^. M.D. 
Dx|vi TQO^i (Address) LcVCrv\i/U l^''4|-lU 

^ — — ■ ■ 



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



y/oiifh^ \ /'.n. 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatli ? 



Days 



' ''',';,^'?V^ ''- '^'''ATl-.,) PKK^ONAI, I'AK TKM-I.AKS ARl'. rKll-; TO THK 
HhSI OI- MY KNOWIJU)0K AND HKI.IKK 



(liiforiu.int 



i\A/^^ 



PI, ACH Ol' IHKIAI. OK ki;Mo\ AI, | DATUof Mih 



fA.l.lrcss I'XT'H M A^Cvl^.1 ■ Vt 



* 



N I ) 1: R T A K 1-: K vj . >\X^MjL6\l X'-U "^KC: 



3 of MiHiAi. or RKMOVAI, 
-MvA;^_-__|; 1901 



• '^- fivery item oit informntion should hi 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" ?or pur- 
sons dyinjl away from home should be iX'ven in every instance. 



1 1 
If 



1 1 r 



H III 



■'»Jy 




>] 



I 







i 'f 



^ 





ffl^ 






1 » 




li 



I ' 







n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



F!...,! of !I«Mlth— !•■ V 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



"l^^w. i^xv^ Deputy Health Officer 



BegL^tered J\^o. 



1398 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of 5)eatb 

( "U. S. StnnI>arC> ) 



PLACE OF DEATH: — County ofOcXTv^ ."VCXy-vv-cvQ c l City of O/COv ' 



Pfe 






O^^A^-C^^T <. 



St.; 



Dist.; bet. 



-and - 



;j f ir DEATH OCCURS AWAY ^BOM USUAL R E S I D E NC C Gl V E FACTS CALLED TOR UNDER "SPECrAL I N TO R M ATIO N ' ' \ 
Ij V "■ OtATM OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME Ll^vUv^x^ M l\. di^dLd-Oi^-w:^ 



si:\ 



I' VI1-; <»l MlKTU 



\<.K 



PERSONAL AND STATISTICAL PARTICULARS 

<^-U LiJxdi^^ 

i'ct X\ rl-bX. 

Month) (Day) (Vear) 




MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII p 

Qxivt S 

(Mniitfi) (Day) 



/go 

(Year) 



•-IN<.I.K. MAKkll-'.I) 
U IlM)\yKI) OK DIVORCKI) 
^Viitfin social <lfsii.'ii;itioii) 



HrRTlfPI,ACR 
st;ii, ur CoMtitrv) 



J ATHJ-K 



'Ilk rm'i.AfK 
•>i- jatmi:k 

'>'t;i!< i)r l"..iintrv) 



M MDHN XAMI 

"" M<)Tin:K 



itrKrin-i.Ari-: 

<>»• MoTlIHk 
(State or Cotintrv 




I HHRI'IJV CIvRTIFV, That J attended deceased from 

LLL^^a ^.H 190M to U.jJpX .3) up . 

tli.it I last saw h wji-valive on O.JL^fxXr ^ jgo . 

.iikI that death occurred, on the date stated above, at (j 
LL M. The CAl'SH OF DJvATII was as follows: 
Cjb'V\jtx^Xv.^\A.-oJC ..A^^-iMilA--<uv..-lL^:U^.->a 



1)1 RATION 
CONTI 



., }'t'ars Months 10 Days Hours 

k I r5rT( )R V Oo.h.-'Cr^i^v.AJc.....^]^^ 



1)1 RATION X^ Years Mouths Days 

(SIGNED) ILLtVL^. . Cu'CAvLl^; 

IqO 



A 






Hours 

b r, ^ '^°- 






/\'r^iif/if in S'liii I'l >i III i'l'ii 



) V(// 



\l.;,fhs 



Da 



I H»: \H()VK sr \ TJ.; I) PKksoNAl, I'AK TFtll, \KS AKI". IKIJ-: l(> THK 
MI-.SI Ol MV KNOW 1,1, DC, 1-; AND |{KI,li:i- 



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

Former or '^ 'i Q Q 4 j ""A i How long at ^, 

Usual Residence < It V i.L4!^ Jl Place of Death ? ( Days 



When was disease contracted, 1 j U 
If not at place of death ? L V /^v \ 



Kv 



'\- ••: ) >.. 



I'LACK OI- BURIAI, OK K1;Mu\AI, I I)ATl-:..f Hikiai. or KlvMOVM 

' ■ ' A 



(A<l<lrcs« 



vjy\;b Ukx>^. I '^-^V^ '^ 

) 1 : K T A K Iv K (j V) . O . O^CVr\.>U ^ V>C 

(Address 1 1 'i'l ^niv<l<i.Otm. C^l 



190 A 



r M 



!N. K. 



-F.vepy item of iii?orm»tion should hi cnrufully Hupplied. ACiK Hhould be Htated KXACTLY. PHYSICIANS should 
«tate CAUSE OK DEATH In pinin tcriiiH. thnt it n\i\y be properly clusnified. The "Special Information" for p«r- 
Bon* dyin^ away from home Hhould be <i<ven in every instance. 



■i-'f 




U 



» 



I'' 







I .1* 



6 "Si^ 




(,* » 






i' 



H - 



^'''•^l 





fiiii 



1 



'■f- 



r##ii; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M.,;n.]nfii«-MUb-KNo ..TS-^.t^^^Hf^tTo RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\,j^^K^ iu.^vv.( Deputy Health Officer 



Registered Jfo. 



i399 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate oX 2)eatb 

( "CI. S. StanDarD ) 



>t 



'^ 



'ID 



PLACE OF DEATH: — County ofQ<XT\j J.h.CX^'vCA^c City of Cj CC^^ vJ.VOywtvazc^ 



\ 



A f\ 



No. LoaM-aCei.C H. St.; X D;st.;b£t. Bl.^k.'fev. and ^Ic^^^O.: 

/ ir DCATH OCCUnS 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 / 

"0 



FULL NAME 



JVaJJL 




L'.Nw<.^xiX.. 



PERSONAL AND STATISTICAL PARTICULARS 

^oX/yvxxxJU \ 

DATl-: OF lUKTII 



LUJxJtx- 



tMotith) 



iDiiv) 



(Vear) 



A « . K 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DKATH 

X 

(Day) 




I go 

(Year) 



W5 )V„ 



*s 



M.'n/fi^ 



fht V, 



W IlxtU KI> Ok DIVokCKr) 

I Writf ill s,)<-i;,i (IcsivriKttiun) ( 



HIK rillM.ACR 
st.itr or c'oimtrv^ 



NAMK or 

iathi;r 



"Ik rni'i.ACK 

'»!• lATirKk 
siiiti or I'oniitrv) 



"I MOTMKK 



nik rniM, MH 

'st.ifc or Countrv) 




I III'RlvHV CFvRTrFV, That I attemlcMl deceased from 
190.— .- to 190 

tliat I last saw h'.'~~' alive on .. .:■■■■:;;..::■:..■ - ■"-.::: ... rr-.nyo 

and that death occurred, oti the dale stated above, at 
.-.^".- M. The CAI'SK OP DIvATII was as follows: 







DIR.XTION 
CO.NTKinrTORV 



)'ears Moiii/is ''■"...• Days 



'wJLa^u: 



I /ours 



OL^vd^ 



? 



Mouths Pays Hours 



1)1' RATION Years 

( SIGNED )\jii\Jif\\3J\).^.^.\K^..d.J^^ 
''-"^ lc,o . (.Address) L^V&'^\^.^.^ 



M.D. 



:^xl:xl 






• HMM'PATION i 



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



}'ii) I 



Months 



Da 



' "'li.^?!!.*^ *'• '^' ^ '''" " I'KkSMNAI, PAkinri.AkS Aki; TklH TO THK 
"IvSI 01. .MV^K.NOWlJjx.K AND M1:M1;F 



Former or 
Usual Residence 

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



How lonq 9\. 

Place of Death? Days 



(Address 



^0^1 



VJ <XXl-c|U''iL "^,i 



190 



■ 



I'l.ACK OK niRIAI, OR RKMOVAI. j DATK of Hikiai. or KKM<iV\I 

(Address 2> 5" Vj /Xct-V-JLiOL S.W .'.. 



ini)k:rtakkr 



"^^ **• Kvcry item of information 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- 
•ons dyin^ away from home should be ftiven In m\«ry instance. 



"*5r^ 



J i 







I ' »" 1 



^khi 




|! * 







i ^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hn,. . t ilcnlth-rNo i.^^^Uf^VCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



X(y\,cv:> JLlxm^l Deputy Health Officer 



RegLsterrd J^o. 



1400 




DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 



Certiticate of IDeatb 

( "a. S. StanOarC* ) 







PLACE OF DEATH: — County ofJa-> ^ ^ux^xca^c City of 'J<X.^-\j 



QS^ 



vC\-«a.-e 



No.U^,Vx.^vL<Xl 4. Lv , . St.; Dist.;bct. and 

f \r DtaTM occuns aw*v from USUAL RESIDENCE Give facts called for under special information- N 
V If DEATH occuhred in a hospital or institution give its name instead of street and number / 

FULL NAME \J^\^^ .'x.^^.a^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

Coi.ok 







DAT!-; or I'.IK 111 



\ < . 1-; 



I Month) 






T 



n):iy) 



M.nif/is 



x-^ 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK ()!• I)I:ATM J^' 

(Day) 



....Sjj^. 
(M 



onth) 



(Year) 






Day 



"-IN". 1. 1*. ^fARk^-:I) 

n IlM)\yi:i) (»K DiVokvKi) 

^Vrittiii s(Kial desiVnatioii) 



HI R TUP LA OK 
State or Coiintrv' 



NAMi; (.» 

pathkr 



HIKTMPI.XCK 
•>'■ I ATMHr' 
'State (,r Oomitry) 



maii)i:n' n'amk 

<>l- MorHKK 



"TRTflPl.ACK 
"I- MoTHHR 
(State or CouiUrvi 







190 



^ I HIvRICHV CICRTIFV, That l, attended deceased from I ^^-^T) 

.....^;i.\.OL».|. ^; 190 ••. to q-^i-"^^ ^ 190 '^ 

tliat I last saw h alive on driL|\t >^ 

an<l that death occurred, on the (hite stated above, at 
^lL M. The CAUSK OF DFATII was as follows: 

w3L^iX\A^r:\x.Qj^.Cu.V:..., ,,...,......„ .„„. 



O 




DCRATION 



)'cats l JMonihs 



Days Hours 



CONTKIIU'TORV 



D U R A T r (^ N } 'cars . Man tfis 

(SIGNED) LO- X9...y..0rtrt._ 

'^.'..k.J, \.I; 'i Tqo . (Address) H Xl 



Pays Hours 

M.D. 






\.k 



.4jet J 



\ * 

..k'. 



h'rM(if<f ill Sttfi /'i inh iM-i> 



) 'ra > f 



'■) 



Months 



Hay. 



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

Former or I ■/ , \ How long at 

Usual Residence vVL<X'\:\a,iL a a MXV piar e of Death? b.jO Days 

When was disease contracted, 4 4 , j y 

If not at place of death? r^iXaLvcL twft 'n.a\«vft X^.^X> . Jl y^x.^^. 



' " li.^J'!.*^ ''- STATKI) PKKSOXAl. PAKIUiKAKS AK1-: TKIH To TMK 
lll-.sroi. MY KNOWI.HDC.K AM) inCUIlIF 

^lof'Mmant UJ .CA^^ (AD \» 

J \ J) 

^A.l.lress b I Q ^<X<:A.CL^^>xX^W t<i '. 




IXDKRTAKKR LUa^'VvQ ft A. 
(Address ..^..l.O.a 



.<^./<>^wOl,Ol'y^Jix>. 



<uA 



' ^' Every Item o? information should bs carePuily supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'' tor per- 
sons dyin^ away from home should be given in c\cry instance. 




Ill 



^^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

B.K.r.1. I ih.hh I N-.> i.-fr^g^Hfct'Co ____^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^' l\ 





Registered J\^o, 



'^r 



' ^(i 



L;,l II 



If i!| 




/)«/r /■'//(■>/, OjlJ^tjL^JixA, 5- JfJO'i 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Ccttificate of 3>catb 

( XX. S. Stant>arC) ) 
PLACE OF DEATH: — County of ' r ^ ' City of UcJ^Icl^vcL LqlI 



No/i'W m1\.^^.^ d ^ 



St.; 



Dist«; hct and 



(ir DEATH OCCURS *W*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED rOR UNDER "SPECIAL I N FOR M AT lO W N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 






FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

I'M I-; <»r I'.iKT}! A N 

Mlln,, 




\/.a; v) I Loj\-U, Jj'./CL..\J:..w.ilAL..c. . 




MEDICAL CERTIFICATE OF DEATH 




A(.K 



t 



M-.titlil 



rears 



I /.X...i ,1. ., 

(l)ay» (Year) 



DATE OK DKATH \j 



(Month) 



(Day) 



7po . 

(Year) 



I nivKIvnV CI-RTIFV, That I atteii.led deceased from 
190——.. to 



that I last saw h 



alive on 



Mnnl/ts 



X5 



Pa \s 



^\ iiMiUKn OK DivoRci-r) \ 

'\Vntf 111 siKMal clfsiynatinii) | 

LU.CcL(rUJ- 



IHRTHPI.AOI-: 
(Htateor Coiiiitr\ 



^90 
190 



and that death occurred, on the date stated ahove, at 
M. The CAUSK 01iI)r':ATH was as follows 




3 



N'AMi: <)!■• 
FATHER 



"'kTHlM.AOK 
•»l- I ArUHK 
•Statf or C(Miiitry) 




DC RATION )'t'ars 
CONTRIBUTORY 



Months 



Days 



Hours 



MAIDKN NAMK 



lURTHIM.ACK 
J>I MoTUHr' 
(Stat» or Couiitrvl 



OCCUPATION 

f\f'siiirif in Sim I'l a >i, i^in 



DURATION Years 

(Signed) LL... 

IjL.Ix.X: :'.: 190 ' I 



Mofii/is 




Days Hours 



M.D. 



(Address) V^Ow-KLcV A.xd 



1 



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



) VfM - 



M,>„th- 



n,! v: 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 




(\ 



" ui^?'V^'^- '^'l'ATl<:i) l'KK<.()NAI, PAKTICrLAKS AKIC TKIK TO TH H 

"I'.si iiv MY kno\\tj;ik;k and m:Mi;j- 



M;. ACE OF BURIAI, OK KKMOVAI. | DAIIE of Kiriai, or REMOVAI, 

. .. Tjxj\.t b 




^Xthlress 



(Address L .<X,!("l.Lct- >X/CL. ...LclL...'^ 



I90I 



N. B.. 



-Every item o? in?opmation should bo cnrePully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
sons dyin^ away from home should be ^iven in every instance. 



• ¥\ 





i' '. 




I ': 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ito;n<! ..f 1!. i!fli- !•■ No i <; ■^*^?S:^ US: I' Co 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^\' $■ 



IfWH 



Registej'ecl JVo, 



140J^ 



\>u_ 



DEPARTMENT W PUBLIC HEALTH-City and County of San Francisco 

Ccrtiffcate of Scatb 

( "U. S. StanDar^ ) 
PLACE OF DEATH; — County of a>x . ■ , c..^ .. City of^'o/^^ JXo. >v 



•..u Z (.. 



No. 



IM 



4^ 



. I X^ix^^A.qI(r^\.. LlLU-U St.; ". Dist.;bcti.U.a<L]\^.v:\..Q.ir , and iaC.-K4 

f ir DC*TH OCCU*S AW*V FROM USUflfL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "SpfccrAL 1 N FO R M ATf > N • \ 
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBEH. / 



FULL NAME 



'^\L:'^'\.Q., :J.A/XyAjL... 



PERSONAL AND STATISTICAL PARTICULARS 



'-J'X 



i»\ T»: «>r liik 111 



Ar.H 



MN'-.I.K. MAKKIKI) 

\\ IIUIVVKI) (»R DIVoKiHr) 

'\\ titf III social ill sJv'tialiMii) 



MIRTH Pl.ACK 

(State or C'liiiitrvl 



.^ 




MEDICAL CERTIFICATE OF DEATH 

DATK OI- DICATII )) 



6x1 vt 



(Mfnith) 



(Day: 



(Year) 




I HI<;KI;I{V (.I-RTIFV, That r attended deceased from 

__ j^ ^^^ _____ __ 



that I last saw h 



alive on 



.190 
.7^90 



r 



and that death occurred, on the date stated above, at 
_ M. The CAT SI*: ()!• i)l<:ATII was as follows 



NAMK ul.- 

i*atiii;r 



MlKTHI'i.xcK 
'>!•■ IAPIIKr' 
'^t.ittor Country) 



^'AIDHN NAMK 
*" MOTHKR 



Mrurnpr.ACK 

jn- MOTIIKR 
'State or Couiitrv) 



OCCUPATION 9 



AV^/V/^,/ /;/ Siitr I'l i-Di, i^,-i) 



\ 



D I ' R A T I ( ) X > } 'ears Mouths Days 




I ) r R A T I ( ) N^ Yea rs Mouths Days 

( SIGNED )..J.AJl,<LlVvcJ^ aJ.. La.::\.;.. ........:... 



Ju.^\,t- rj 190H.... (Address) bo I" dx^^tUhid 



Hours 
M.D. 



.^ 



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



Former or 
Usual Residence 



How long at 
Place of Deaffi ? 



Days 



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



' "m^J-r^^*"'^'" '"'"'■•'* I'KR^ONAI, I'AKTIcn.ARS AKI-: f K I »•: TO TMH 

lU'.sr 01- Mv KN()\vi,i:i)c.H AND hi;mi:i' 

(Adclrrss 7 C) b M O C ci ^ c H 



190 4 



PI^ACK OF BURIAI, OR RHMOVAI, I DATK of Bt kiai, or RKMOVAI, 

.Iress TOAO ^^ C..oJ..t; '\i '^ 



(Acl( 



N. B.- 



-Rvepy Item of InfnrmBtion 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 psr- 
«on« dyin^ away from home nhould be ftiven in every instance. 



»» 



rh 





^ 




P 

I:. 







i f 




. I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



BrKinl (.f ll<:iUh~K No. i^ I^V^arv^ uStH Co 



i 



I 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ffr AV/r^/, axlvtjL-v^x,t^<.\. 5 



IfW'i 



Registered J^o. 



■\ 



1403 



d<JU\J 



I ,1 



cvovA^<-^) c)<jtyx^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



!: m 



.,'!( 



'! I'. 



Certificate of H)eatb 

{ XX. S. Stan&arD ) 



PLACE OF DEATH: — County of 



No. 






')'i 



\]- 



St.; 



City of oL<XVt^\A.v^ 



"Dist.; bet. : ~ a nd 



/ ir Dt»TH OCCURS *W*V FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL I N FOR MATIO N •' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 

FULL NAME '• .y\JJ^^rYv.QJM\\•.-^:^>^^. 



'? > 



>t\ 



X. 



II 



PERSONAL AND STATISTICAL PARTICULARS 

Up i) 1 f(ii,«)k\ 

iMniifhi (Day) 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH V 

a,xl,vt: 

(Month) 



::\ 

(Day) 



(Year) 



/- iV-- 

(Year) 



) V,/ 



H 



M.nilhs 



15 



Pit 1 V 



\ ^ 



U IDOWHI) Ok DIVokt-KD 
'« rile HI social (Iesivr„;,ti.,ii) 



n 



"IKTHI'I.AOK 



m 



N'AMK <)I- 
FATMKR 






I IIHRHI5V CKRTIFV, That I atten.led deceased from 

190 - to 

that I last saw h ~~~~'alive on : - ■ . ■ .. r-r.-.- ;: -.- 



TQO 
190 



and that death occurred, on the date stated above, at 
M. The CAUSB OF I) HATH was as follows 

c»J-c<x.^vAJ..\^.C...ua-'^ 



Ia 



if 



'"HTHIM.ACF \ 

<>'" iatuhr' a i 

'!^tal, or Couiitrv) 



l>l< 



'trK^\.^{r>v__. 



DIRATIOX }Va;.y 
CONTRIIU'TORY 



Months 



Days Hours 



'l/fl'JJ 



llj 



!' 



t|]! 






inRTHl'LACF 

;•»' mothkk' rK 

'Stritr or Countrv) «-V Ol/ 



I 



1XtO,t.tL 



I 



DURATION _ ^JVrtrr Mouths Days Hours 

( Signed )....J O.lD.. J. J'u^v^.xLi^^ .. m.d. 



■ 



^..^.- 



190 



( 



Address) :x.<X^^i'-'w.^\.v.%.\- L.O,L.. 



dcL 



TAj ^ A^CC ) VCA.O-.e^- 



^1 




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



Former or 
Usual Residence 

Wlien was disease co,. traded, 
If not at place of deatli? 



How long at 

Place of Death? Days 



' ''Viu^J-r^y.V'. ^''^''"'■■'' ''^■*<'^'»"^^'- '•'^^ 'J^' ' ^«^ \»<'- '"t »'■ J'" '■"'•■ I J'l.ACK OK BURIAI, OR RKMOVAI, I DATK of HrKiAi, or RF5 

V r\ n UNDICRTAKKR AD . J . Cj A<aJ1 VV ^^ 

r\<l«lrcs.s .. On ?) \J )\.<r> 



i'\X/y,'^yY\ 



xX^wU / 



MOVAI^ 
1901 



(Ad(lres«5 . 



Il2i.a JtoUxLXU^:^^ 



**• fivepy 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 dyin^ away from home should be i^iven in every instance. 



m 



I : « 



III 




t"*l 



m 



IT'.: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Boiinl ui II. ilili \- No i\ tli^^a^^lOkV Co 



<: li 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



M//r /v7^v/,x^xivtjuvvvlNjeA.^ S^ 7." 





OO'i 



Registered J^o. 



1404 



^1 ' 



V' II 




.-lm.4 Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-Crfy and County of San Francisco 

Certificate of ©eatlD 

PLACE OF DEATH: — County of ^la,^-v' "".Vo. , •„ . City of J,a,>x- OA.<x%v 



No. lacUUllllLM iill.u 

(tr Dt*TM OCCURS awJav |^i|om usual 
ir DtATM OCCURRED 1^ A HOSPITAL 



u 



ixCvil. 



SU 1 Dist; bet. X^^XV-jxC .v.i.! and ' jl 

RESIDENCE GIVE facts called rOR UNbER "special INFORMATION" \ 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



I.e. I 



feC 



FULL NAME 



C 



"b 



^ v'.uuCc ...x...l...L.Qw!.u(r..;v.\, 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ok '\ 




<x 



aVLi 



'' '• !'»•. «»r lUKi'u 



Ai-.j-: 



V^i^iw 



t Month) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH Jy' 

liLlxt :i... 

(Month) (Day) 



IpO 

(Year) 



■1' I 



J V-./ 



(Day) 



Months 



/ 1 '.. I 



(Year) 



I HKRI-HV CI'RTIFV, That I attended deceased from 

190 1 to CljLJ.vJD S. 190 '■( 



/'</l.v 



^JN'.I.K. MARK 11:1). 

\\ iDuw Ki> OK i>iV(>Kri:r) 

iwriteni K<x-ial <l<-.i>rnation) 



IWkTHJM.ACK 
^^■.\U- <ir I'ruinti \l 



NAM J.; oi- rv-^ 

f^ATMKR Oil ) 

''■iktmpi.ac'f 
'"■ iatukk' 

'State or romitrv) 



L ^ V-O, - 






:j.jl^?Ju. 

that I last saw h 



alive on 



-\ 



:.UL.i: 



J- s 



■f *"■"-' • 190 i. 

and that death occurred, on the date stated above, at 
, M. The CAUSE OF DKATH was as follows: 

Xft.'....'r . ...X.CrL.L^v.v \ \jl:\^iAjU\,^<Xj.. 






4' 



Ci^O.. 



1 



I 



hi 



i 1 



^lAinUN NAMK 
"I MOTFIKK 



JJIKTHl-i.ACK 
"••• MoTIIFk' 
(State <ir Country) 



"^■^■IPATIOX 






i\c ■ 



DT RATION 
CONTRIIUTTORY 



O-.^vA. 

}'i'ars Moulhs 



Days 



Hours 



IH'RATIONV^ Years _ Months 



J^L 












Days 



..&:;>'\-^.<:\ -.vA.. 



^4' , 

(SlGNED)...\J..AA^^ 
"•xl d.. A 100 r Address) M ^ NU'lcvvla . vj, 



Hours 
M.D. 



190 



) Vi; ; 



}r,;,ffi^ 



n,r r 



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



titHis, 



Former or 
Usual Residence 



ffow long at 

Place of Oeatfi? Days 



' " lit^J^r'^ ^' '^''" ^ ''*>•- 1 > fKKSONAI, I'AK'lIiMI.AKS A K K TKIH To THH 
"»-.sr Ol--^- KNOWI.ICDCK AND lUCMllK 

s b CcxcuLL lLu 



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



(\ih] 



^Vt„l. 



1 90' I 



PI^ACK OF HIRIAU OR RKMoVAl, I DATJv of HtKiAL or RKMOVAI, 

^ALoJ^^cl^^^ ^._.. I ^-^^^3..^ 

UNDKRTAKKR U OJLi/Y\AJl M / UXAa^VVO ''^ \„t 

(Address I S.^H-.. 3JLc-t^HX<rvv.^....Ql.. 



^' ^' fi'^cry item of infopmation 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 dying away from home should be given in every instance. 



n 



n 



H 




r. 



! H 



*1 f 



I 



I 

1,, „ 



'illll 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho'in! of Ht;i!lh ■ I- N'o .c t't^_^^ IKt I' C-.) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da/c 



1405 



X<H.A^<) dUv-M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTB-City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of 5)eatb 

( tl. S. 5tanc>arC> ) 



- 



.V<X-kvc\.>l''- City of Co^-VX' vJ.^LC. ) 






\- c *. 



n 



! LL' * "^ *^' 



^'~'- ''^' '"^^ '' St.; b Dist.;bet .fc.Cv\A.^a<^-.d"- andlLlCLilC) 

A ir DCATH 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. / 



FULL NAME 



.^\. 




CXA..t:A 




si:x 



I»Mi: ol MIRTH 



A(.K 



PERSONAL AND STATISTICAL PARTICULARS 
'Mont 111 I (Day) 



;■ S C M.. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATI-: ol- DlCATil 

(Monlh) 



(Day) 



IQO 

(Year) 



I C y,a,, 



M.mth^ 



I i 



Hi. 



"^'V'.I.K. MAkl<Ii:i) 

^^ IDmWKH ok DIVoKiKl) 

'Write ill ^fKMal <1» -irtiati.-n) 



P 



inKTHPKAiK 
i State Of Count rv> 



»atiii:k 



'nKTHI'i,\(F 
"'"■" J-AIUKK 
'State or Country) 



MAfDKV NAMK 

"I ^t(»TH^;R 



'"HTHl'i.ACK 
'»!• Mot MICK 
(Statf or Cojintrv 




O.-^ ^ \ ' Vol- >x c iysiXL 



I ]n<;RI<;HV CI-RTII-V, riiat J attended deceased froni 

O-ti-i^-t 3» 190^1 to a.-<4x.t, 1 IgoH 

that I last saw h'... alive on c).r^^.vl'. h loO-.-l 

and that death occurred, on the date stated above, at ^ 
^l.M^The CAl'SH OF DI-ATH was as follows: 



DIKATION 



} 'ears 



CONTRHU'TORV 



Months Days 

'Sw;:^^,<J:^,^.!.... 



Hours 



niRATIOX 



Years 



Mouths 



i'\\XJi\i 



(Signed) X^/yvxaaX^Aj j . ^It >uv.v 

KX.XX.a/-\ igo'. (Address) M'Sb -In 



Days 



Hours 



M.D. 

lL^.<i.A<<n:v. .ul 



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



_ V A.VCt.C'^'V-COw 



oCCri'ATlON 

f^'fu'dz-.f III S,ni l'i,i„, i\.;) iO V'Oi 



Former or 
Usual Residence 



How long af 
Place of Death ? 



Months 



I J 



n, 



' " ui'V'^r'^ ''• '^'•''^ ''■»•■'> l'KK«^<)NAK J'AK riCfl.AKS ARi: TKIK T< > THH 

iu-.sr oi- ?.n- Kxowi.icDc.H and iu:i.ii;k 

r\.l,lress. ?)?)bS Ab -tyiv 01 



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



Days 



l'I,ACK ()!• lit KIAI. OK KHMOVAI. I DATK of l!i imai. or KKMOVAI, 
rXDHRTAKKK LL>A-^vtX<L LL^VcLxAjt 

.^.b b. .VDXA.^<t.^^->.:u c3.t:. 



(Address 



• '^' Kvepy 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 &iven in every instance. 



4 



W 



'4 



f 



lil 



' ,'[! 







fi T- 





,^ WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho.it! Mt IKiUh - F No. it. "S-f^^jfe^ H&F Co 



lh(/i> Fi/rft, 6xA^±JL/>-.^X^^, ^ 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIO NS 

J'^0\ Registeved JYo. 1 406 



DEPARTMENT OP i'UBLIC HEALTH-City and County of San Francisco 



dcitiffcate of ®eatb 



^ 



PLACE OF DEATH: — County of O a^v J 



Vo.. . 



4 '^ 

^: City of'-' CV->A' ^.a. v\.c.\_.^ 



^No. ^ I e 



Ldl'X.^\„1 



St.; 1 Dist.; bet.' J..i:^.U-U_l. andM H ■ 

f "" .Vrr'l,°*^^"''* *"*'*" '■'*°** 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 ) 



Dist.;bct.Ui 



a..At^:v ..: ) 



FULL NAME '^..^QJLL.Im 



]jir. 



\ 



^J v 



PERSONAL AND STATISTICAL PARTICULARS 

COI.(»R 



i>AT): or itiK III 



> 



Vw 



L. 



MEDICAL CERTIFICATE OF DEATH 



'Mouth) 



(Day, 



(Vear) 



A(,K 



'bo ):■„»> 



DATE OK DKATH ^ 

axkt. 

(MontH) 



:^ 

(Day) 



(Year) 



I HHRfCBV CI-RTU-V, That I attended deceased from 

^^-<3^ ^'l T90 ' ■ to .ajL^Ai '^ 190 "n 



.^.. 



that I last saw h i- • aUve 



on 



JU 



M.nith.^ 



MN'.I.K. MAKKIKD 
\VtI)n\VKI) OK DrVoK.-KF) 

'"ntf III s.K-ial tlfsivrnati.,11) 



'ilHTIIPI.ACK 

St.it,- «jr Onujitry) 



N'AMK OF 
I- AT 11 J.; K 



I hi 1 > 




XVl.^ d- 



\:X.. 



^ ..! 



190 




\^ 



HIKTIIPI.ACF 
'>'■ I ATHHR 
'Statf or Country) 



01 MoTMKk 



'^fKTHPI.ACl.- 
oi- MoTHKR 
(Slat«- or i'oMutrv) 




I 



W\X\ 



ami that death occurred, on the date stated above, at v. 

DlvATlI wa: 



,^M. The CAUS|^ C)I< DlvATlI was as follows 



rll^^^tl. 



I 



C^TLCX-VAj 




CXx 



DIRATION Years Mouths 
CONTRIHl'TORY 



Days Hours 




VvH 



tWk 



/(XA^^^-^VC/Wd 



DTRATIOX }>7;x Months Days Hours 

(SIGNED ) ..Ab 1.1 \uLavU^x....puLa... 

sJX^xAj.. I 190 






M.D. 



^-\ 



li 



_ LKT ^\Xt\A 

<'* CrFATl0X(O - r 1| 



(Address) bOb vl\,t,aA,aaxa_. (.ll 



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



M..„th^ 



fh. 



"",';,\!!**^''' "^'■'^ ■'■'■■'> I'KKSOXAI. I'AKTHTI.AKS ARi: TklK To THK 

j'l-.hr 01 MY KN-o\\i.i:i)«-.K AND i{i:iji:f 



Former or 
Usual Residence 

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



How long i{ 

Place of Death? Days 



^\(l(lrcss 



I'l.ACK OFBrRIAI, Ok RKMo\AI. I DATJ! o! UiKiAr. or KKMOVAI 

^^mL^...<>^..^^M^ '^ ■' 



190 



INDIIRTAKK 



(Address , 



S.51..07v^ 



<L^.'.'^^V...L^.l 



' • Kvery item of Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for per- 
sons dyin^ away from home should be i^iven in every instance. 




.•''> 



Ill 



WRITE PLAINLY WITH UNFADING INK — 






n„:n.!.'- M...!lli I No !" ^•t'^JSr^'"' "^ ^' *'" 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






: f.\ 






I 
III I 



;"ll:i 



I 



•i 





Jie^lslered M^o, 



140? 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

PLACE OF DEATH: — County ofOa.o\; 0X(XVVCc4C(City ofC)a/>\; A.<X->'v.C\_<lc ( 

^,1 > ^^ 




7 / ,r ot*TH occu«sVwv FROM USUAL RESIDENCE GIVE facts "J-y/i> ;«""'*"" ^^^^l*]^'^ 

(j V ,F DEATH OCCUljRCU IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



a 



d(rAMX.y\. 



PERSONAL AND STATISTICAL PARTICULARS 



i> \ IJ". <»I- HIKTU 



COI.OR 



\ 



LLJv'wt 



V'w^^x 



(Ntoiith* 



(Day* 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DKATII 



(MontH) 



'1 

(Day) 



I go ■ 

(Year) 



\<".K 



■« i 



i^P 



n 



) rat 



Mnlllfl! 



n,i 1 . 



^IN'«.I,K MAKKIKI). 

U II)«»UJ:I> or I)I\t >KOi:i) 

Wiit'iii >-i)fi;(] <lc-i^rn;iti'>n) 




nTRTlll'I. Ai'K 
'State or I'liunlry) 



I- ATHI-.R 



nTRTHIM.AcK 

n|- 1 ATMKR 

I St,it( or Coniitrv) 



MAini'.N XAMI-: 
'•I MOTIII'.K 



niKTlMM.ACH; 
'>1 MOTIIKR 
(St.'ite or (.'omitry) 







I IirCRFCHV (.IvRTlFV, That I attended deceased from 
.Qxv.a '^H iqoH to ci^V^t h I< 



.a^ \^H T90H to ^^.\x.\i .1 190 

tliat I last saw h •• alive on U -^4"^- ^9° 

and that death occurred, on the date stated above, at li.C'.* 
L M. The CArSlv Ol'" DICATII was as follows: 



T 



I )r RATION 9v )'f^.? Months Days Hours 

e' () N T R II ? U T ( ) R V J QL.\.JLA.^vAJi. rfr. . Lfit^.^vJf\JL^VA,iCL ?xt^C:>.v 



OCCUPA 



TION ^ 



i) l' rat ion 
(Signed) 



) 'caxs 



.-j~ > cars 



I\ro)iths 



Days y^ Hours 
V vw.XX'Vt' M.D. 

'6.J.\A: H TQ O'' (A.ldress ) Lctn^M U 'jkf^-^\: \ 



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



f\fsi,lr,i ill Sati /■'/ iiH(i>i(> 1 )''<;/x 



Miuilln 



Da 1 A 



I'm-: AUOVl^ STATIC) PKKSONAI, PA K'i' ITT I.A KS A K !•: PKlK TO THl': 
HKST Ol- MY KNOWJjax.K AND lUCMlvl" 

;inf„nnant \j ..\J... ^\^ . ^J^O^J^lt^.y 



(A<1(lross 






3io.55..A]X<X\.U.. .)!. 

Wlien was disease contracted, ^ 

If not at place of deatli ? 



Former or 
Usual Residence 



How lonq at . 

Place of Death? 1 A Days 



PLACK OI- lURIAI, OK KlCMoVAI, 



D.VnCof HiKiAl, or KKM(JVAI, 

rNDKRTAKKK ^S (Xn^d^-^JJ^^^ "^^ - 

(Address l/^ .0 S \jll\.^^.Un\....al 



li * ' 



^ . . . 77! 1: I %f:F should he stated EXACTLY. PHYSICIANS should 

«ons dyJna away from home should he i^iven in every instnnce. 



1 



•11 



i^ 



r' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

j,n.n.!. Ml. -Ith 1 No it'ft^sES4,it/tPCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!.': li 





»f: 



'% 



) 



Registered JSTo, 



1408 



X<^^v^^ Ilxa^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. StanC>arD ) 



■0 



PLACE OF DEATH; — County of ^CLOrv 



i' 



k 



* 



,v . -Ci.i.'. City of ^ ''<X->-v' .Va . V >- • .. 
No. \oS oL'.cavtC--VV • St.; ~' Dist.! bet.Vlllo-vkd and W'Ci 

/ ir Dt*TH 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. / 



FULL NAME 



^,vi 



/\.A„D. 




L C \ \. 



'4 



PERSONAL AND STATISTICAL PARTICULARS 

' COI.oR > ^ 



>\rK OF lUK I n 



A<.K 



lli.,k.^.U 



vK.v 



I Month) 



11 



) I'lt I 



(Day) 



M.nithy 



z'^'. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

I).\ TH OK Dl'.ATM 




C 



<X' 



(Month) 



(Day) 



I go 

(Year) 



Dii V. 



'-I\<".|,i:. MAKKIKD. 
\\ II)f »\VKI» OK DIVoKiKD 
\\iil«- ill xKMiil tl<sivtiiiti<in) 



L 



mKTHPI.ACK 
State or Coniitiv> 



\\M)-. (»I 
lATHKR 






\ I' 



Hik ruiM.ArH 

OF I'ATHHR 
'Statf or Countrv) 



^^Mn^:N namk 

•>i- MOTllKR 



HiK'rni'UACK 

oi" MOTHKK 
'Stiitf or Countrv I 



1 



J IFICKICnV CI*;RTIFV, That I attended deceased from 

CJJC;^t' 3>. 190 '\ to ...p-X-.^ 3 190 'i 

that I last saw h .•. alive on OjL.|.\J. 190 

and that death occurred, on the «late stated above, at 5. .'. .^. 
M. The CAUSE OF DIvATIl was as follows: 

*ar^'>^J?^^-^<'>vX v.^>^^?v;?^v<Lft.-.kXr-., 



Dl' RATION 



YcQrs 
CONTR IHUTORY C<;?X^.^^w^ ^ 



Months Day 

c^^.^,..i..v...r:...C; 



'S ^ 



Hours 



OCCUPATION 

Kfsuifil in Siin /'i ,!ih /^i-i) 



I) 




DURATION 
(SIGNED) 



)'tuirs Mouths 



.CI 1 h:Uu. 



Days Hours 

M.D. 



)0 



(.Address 



^V^;.^ 



ICi.lL ."dl 



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

How lon() at 

Plate of Death? Days 



) V'(// 



Mnlltfl- 



/hns 



Tin-, \HovK STA'n:i) i'Kksonau I'AKiicri.AKs AK1-: TRrH TO Tin-: 
in;sT oi- .MY kno\vij:d<;k and iji:mkk 



'Iiifi)rin:int 



^\<1(lrfss 



I'h^ 



IcJlKrCAAJ. 



V-^- 



Former or 
Usual Residence 

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



ri.ACH OK BKRIAI, OK KKMOVAI, 



5ft 




I)ATi:of IJiKiAl- or KKMOVAI, 

gjL^ .5 : 190H 



INDHRTAK 






(Address 



^. B._P,very Item of inWmBtion .hould be c«r«fully supplied. AGB should »>« «'«^-^^F.XACTLY , P"^«';^;,^„':!« J^^^ 

•tate CAUSE OF DEATH in plain terms, that it m«y be properly classified. The Special Information for per- 
sons dyinft away from home should be feiven in every instance. 




T 




'■y 







'^ I 



n 



' ir 



i 



! 



I r 



r 



/ 



.( 




/)((/(' Filed , 

i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1409 







Deputy Health Officer 



Registered JSI*o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

t Ta. S. Stan5atC> ) 



PLACE OF DEATH : — County o: 



fda 



^ 



o 



City of ^ J CL/vu J A.O 



* 



\ \. 



No. JA 






jJcV■^^vCx-'^x 



,n:n U.n^L- ' 



Dist.; bet* 



and 



/ ,r ot.TH occu,,s *w.y rROM USUAL RESI DE NCE G.vr tacts 9,^5/-° ''^ ""«;"" ^%%^^;^^^^^ ) 

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



f 1^ ^ 



FULL NAME 






A. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
A I COI.OR \ \ 






MMiiihl 



(Day) 



.%IH 

(Vcar) 



\''.R 



n 



) lats 



Moullis 



fhlV: 



\vii»()\vi:i) OR nixoKii: I) 



h 



!UR rupi.Aoi-: 

(St:itc or Country^ 



XAMI. <M" 
l-A I!1i:R 



J'.IHTHI'I.ACK 
<)l- I AlllKK 
'St,it<- or Coiititrv) 



MAII)1:n NAMK 
<>l- MOTHHK 



MIR rili'LACK 
OI- MOTHHK 
'State or Coutitrv) 



I 



^O^l'v^- 



UJo^^ > > ^-^ 



MEDICAL CERTIFICATE OF DEATH 

DATE OV DKATH J^ 

...1 

(Day) 



..U..Jt: 
(Monlh) 




I go 

(Year) 



I HICK \\ BV C !•: RT I FY, That I attendtMl deceased from 

Llcvq XS. 190 i to p.-^|vt .H ic/dH. 

that I la.st saw h •;. - alive on Q-^.^aX 190 ^ 

aiul that «leath occurred, on the date stated above, at 1^0 
A.\ :M. The CAl'SI-: Ol" DI'.XTH was as follows: 

OJL;>^'sJUXi.^ 




Dl'R.ATIOX 
CONTRIBUTORY 

DURATION ^i 



)'ears 





MoNihs Days Hours 

ix7.\,<C^::^.^~.^^....>^^.l?5^r.v•V^^^ 



Hours 



Years Mouths Days 
(SIGNED ).\1..M.:.0 O.U.Cr.|^R)w.Yx.^. M.D. 

^Axt. M too", rA,1.1res.0'y-^A/VA.<X'>V jt ^'4^..d,<?i 




|\t M iQo"v (Address) JX\,/>w<X^v 



f\f.yi<{r(f in Siiii /'i <t>!( iw<> ^_^^^^^__^_^_^_^-— _^— 

TnV. AROVK ST\'n:i) I'KRSONAU PAKIKMI.AKS AK1-: TRriv TO THK 
HKST 01- MV KNo\VI,i;i)C.H AND MHMl'.H 



i '^ 



),;j, 



.yfoiff/r> 



/),iy.^ 



Oiiforiiiant 



fA.Mt-fss IH'X^ ^ 







\^i 



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

How long at 

Place of Deatli? Days 



Former or m ^ v^ 
Usual Residence'"^ ■^' 

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



C\.v, W. \) 






D.\TK of Hi KiAi- or RKMOV.AI., 

:..\.,.(Lk.t A. 



]^t 



l'I,ACE 01* nrRIAI. OR RKMOVAI 



190 



^ 



,V_A,'\^H,_w 



(Address 



« .. It J ArF ahniild he Htfltetl EXACTLY. PHYSICIANS should 

of information .hould be CHrefuliy supplied ^^J^^'^^/^*^^^"^^^^^ Information" for p.r- 

F OF DEATH in plain terms, that it may be properly classitiea. 1 nc c»|» v a 



N. B.—— Every ite 

state CAUSE OF DEATH in p 

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



1 



,i I 






Ik, 






:!'' 



si 



ni 



/If 



J 



I I 



I I 





'.H 



H<);ir.l ..f 1!. illh !•■ Vo 1^ 



Ih 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^•?Sr^ HS: I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

" 1410 



lOO'i 



Registered JVo. 



Xt.vv^"WM Deputy H ', Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "Cl. S. StanDarC* ) 



PLACE OF DEATH: — County of^" a 



i '(!' 



CXy'l 



NoJON 



, f LtvvL 



n 



jJUi Uamj c^ll d av Lc > \ St.; 

A,W DtATM OCCURS AfcilV FROM USUAL RESIDEN 
\J IF DtATH OCCURR^I^ IN * HOSPITAL OR I 



City of^'C'^-^'^ 0.\.CXox^^A.^-'ac 
„.., . . Dist.;bet.U J a\:\.,,-J,..'.: and •Ll.t.a.Xu 

IIDENCECIVE FACTS CALLtD FOR UNDER "SPECIAL INFORMATION" '\ 
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



.K\ 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR ^ 




"^.rL-OA.' 




<XA^l 



'\ ri-: or- iuktu 



\ < . }■: 



I Month) T 



) r-ll t . 



(Day) 



M.nitfis 



/Son 

(Year) 



Davs 



^IV'.I.K. MARK I HI) 
\\ ID* i\Vi;i) i)K DIVoRrjll) 
W'littiii siH'ia! ilisiv'tiatioii) 



I'.IK riU'I.AOH 
St.itt or C<iuntryl 



NAMl". or 
FATHKR 



BIRTH IM.ACK 
OF I-ATMKR - 
'Statf or Country) 



MAIDKN NAMK 
<)1- MOTHKR 



HIK IHPUACR 
OF MOTHKR 
(State or Countrv) 







^QAX 







\J\_..„^..?. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(MontH) 



JS 

(Day) 



igo \ 

(Year) 



I inCRICHV C1'!RTIFV, That I attended «le( eased from 

LIx^C^ X^ 190H to O-^^ti Ss 190. 1 

that I last saw h-^> IV alive on Qxyct -5. 190 

and that death occnrred, on the date stated al)Ove, at b 
AJ. .M. The CAl'SR OF DHATII was as follows: 

<^WvJL-\^7>-;v. 




\.^(\> 



% 







in' RAT ION Ymrs Months '^ ^ays 

C O N T R I R I' T ( ) R Y \J AXo >.v,<X.\..v.<s.?:>>Kl....yj.AAJ^'( 



Hours 



\\... 



T.'wwcL' 

I)UR^TION y, years Mouths Days Hours 



(Signed) 



n 



i \jb\MXcLc 



occur 



Rf'iitrif III Siiii I'l aiii isrii 



n 



)\ai 



Mouths 



/),n. 



rm-: mjovi-: statii) pkrsonai. rAK'rrcri,ARs ari-: trih to thh 
in:sT 01 Mv kno\vij;dc.k and mhi.iich 



(In 



foimant V O . VAjL^Ov 






K 



J. 



1 IC)0 



C^.'\yYX*^-';'>.\.C^. M.D. 



(Address) ^V^-V^"\>a 



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 



iM^^cK OK iuriai, or ri:movai. 



DAJi: of HiKiAl. or RKMOV'AI^ 

I90H 



(Address I lC).^.....\DnuA^ft-^^<A^^ 



.^ .. I' A APF should be stated EXACTLY. PHYSICIANS should 

of information should be cnrefully supplied ^^^^^^''^/^^.^'^^j^i^' ^^ "Special Information" for pT- 
F OF DEATH in plain terms, that It may be properly classmca. i nc ^\* 



N. B.— Every item 

state CAUSE OF DEATH in p 

sons dyinft away from home should be <t!ven in every instance. 



'1 




'U 



' i 

\ ■ •; 



I 



i I 



! Vi 




WRITE PLAINLY WITH UNFADING INK — 



H.„.,. 1 ..f II. alll. !•• No. 1% li^^^nSLVCn 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1411 



">" 



Registered J^o. 



Dale Ju7e(I , aJl\\Xjt^^^t^ .5: J^O^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



M^v-<i 



Ccvtificatc of H)eatb 

( XX. S. StanDarD ) 
PLACE OF DEATH: — County of ,' 



Qm 



iva'-vvCUi.co City of OxX'~l^.■ AXovCA^ 



r' ( 



No. l'^^- V^^'f-W J^"^^'^'^ 



£L^ VvLa V^.A<w. St.; — ' Dist.; bet 



and 






/ ,r ot.rA OCCURS .w.r r«OM USUAL RESIDENCE G.ve r.CTS CALLeo ^o" "N«, :^%"^;*;^';'^°;;*J'„°'^' ) 
V IF De4tM OCCURRED IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



11 



FULL NAME '^ 



LcLv 



..i.J.zlV.L.j..l.a->^.\.. 



PERSONAL AND STATISTICAL PARTICULARS 



SHX 



llv! 



COI.OR '\ 



llk.b. 



i> \ii: or iMKTu 



AOK 



month) 1 



) t <i > 



(Day) 



Mnulfif 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



(Month) 



i... 

(Day) 



(Year) 



/ . ■ . . .. 
( Vear) 



B 



/?./r. 



>I\(.I,K. MARRIED 
WIDOWKD OR DIVMKfKD 
Writfin s<H'ial (lr««iirnatii)ii) 




lilK TMIM.ACE 
fHtate fir Conntry' 



NAME <U- 
FAIMHR 



HIKTMIM.ArE 
or FA r HER 

'State (ir Countrv) 



MAIDEN NAME 
<)!• MOTHER 



HIRTHl'UACE 

OI MOTHER 
'Statf or Country) 



OCCUPATION 

AV.W(/cv/ /;/ Sim /'i i!H( ru'ii 






V 




I IIHREBY CKRTIFV, That T attended deceased from 

L/L^uc^ 1.1 iQo'v to Sji^!j[^l': "i 190 'i. 



that I last saw h • alive on .d^^:a:. 'i 190 

and that death occurred, on the date stated above, at 5" 
JwL M. The CAV^Iv OI' DlvATII was as follows: 

'"fojUX/Jt-.J-.^X^^U^V^N^ 



DIRATION 



years 



Months 



! (■ 



Days i^ Hours 





CVvv^o. 



) rn I . 



yj,)}ith> 



9 



Da 1 . 



CONTRIBUTORY LL5;.rSA<0. ... .J.O^ 

. A^'\,/aJt^^A^ m\,^J^\^.a..''u\^.Lv.\ 

DURATION n Years Months \ Days Hours 

(SIGNED )....0.X0. .O.W) iVA...aXM. ^.^. 



M.D. 



d.jLl\l. 'r 



190 



(Address) 15 OH. 



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



TH1-. AMOVE STATED I'ERSONAI, FAR P KM' I.ARS A R l*. TRIE TO THE 

ijf;st of iiv kno\vi.i;dc.f: a:s,i> hi<;mef 



informant 




^^ 



\X. CjyVVcKLl*-. 



fAddrrss 



1(3 Ob 




0U<. 



4 



Vxi 



t 



When was disease contracted, ^ 

If not at place of death ? 



I L, \ J How long at r. ^ 

kL A," Place of Death ? a^:^ Days 



PIJiCE OF HLRIAI. OR REMOVAI, I DA'ljE of IlruiAr. or REMOVAI, 

iOf....l OxKfc b T90H 



[-NDERTAKER ^J CrLcLi^^X^ ^^/oijL lUvfio. V<^ 

JO* 



(Addres.s « 



-W0.>.U. 



^ \ . It J ATF <.hr...lrl he Rtatetl EXACTLY. PHYSICIANS should 

of information .hould be carefully -PP"-^ J'^^^;'''^^'^^^^^^^^^^ Information" for p.r- 

E OF DEATH In plain terms, that It may be properly classmea. 1 nc <^p 



N. B.— Bvery item 

State CAUSE _. 

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



,! I 



'J 



in 



X:l 



n 



I ""-« 



■II 



'/i^ 



11 



H «-i 



iHiiii. 



* 



i I 



1 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,^,,,,,,f ,,.,],!. ! NO ,.i?-gg ?»MM'ro REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1412 



Da/r /v7^>^/,..6.xi:v.U/>-.-J.v-i>v'...S lOO'i 



.t \wcv^:) 




Re^istej'ed J\l*o, 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

{ U. S. Stan^arO ) 



.1 



PLACE OF DEATH: — County of <^^-^ ^ \.ct>vc<XL^ City of Jo. 



01^ 



^ 



t 



J^^L 



Ia. A LcrV-c > vli. 'AL' CS'^ Iv ^IcL ( 



St. 



Dist.;bct. 



and 



■ , ft ^' J , 

^MX^.uk ,\ d..U<:\Iri.a-.',- 



FULL NAME 



■t \ 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



m, 



i»\ ri: or iuktu 



\ ' . 1-: 



X^'V^vXe 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(MontH) 



(Day) 



(Year) 



iNfoAth) 



a 

'Day) 



J^6 

(Year) 



n 



)'t(n 



5 



MiihIIis j^ 



Ihi 1 .s 



MN<".I,K. MARKIKI). 
\VII>(>\Vl.:i) OK DIVoKiKl) 

'Wiiti in stH-ial di-iv'tiati'iii) 



IURTIIPI,A('K 
(Stati- ur Cuniiti\ ' 



NAMK OK 

fathi;r 



lUKTHI'I.ArK 

oi I Aini'-.K 
(Stall ur I'tmiitry) 







>%^^ 






\MA) 



UCC 






I HI":RI';BV CMRTIFY, That Lattendcd deceased from 

CLv.^C^l'i i9o'> to ...Sj^Jfxt....!! 190 "i 

tliat T last saw h ..^^malivc on OJ^^t! H igo ■ 

ati.l that death occurred, on the date stated above, at i ^ -^ f> 

LL M. The CAl'SE OF I) I; ATI I ^yas as follows: 

Ur\A.<r\>»ArC.. LLi:!sX^W<X..lvv^ U -\vOx^<4,A-^ 



1)1' RAT [ON Years , Months Days Hours 

CONTRIHUTORY 



MMI>1:N' NAMi: 
01 MuTHHK 



I'.IK riliM.ACK 

oi- M(>Tm:K 

'statr i)r I'uuiilry^ 




AV.v/V/^i/ III Smi f'l mil isfit 



(o 



) lO I . 



M.,iilh> 



Da w 



Tin-: AUOVK STATI-.I) I'KK^ONAI, I'A KTK' T I,AKS AKI". rKlH T« > TIIK 

iti:sT oi- M\; KNowM^c.H AM) in:Mi:i' 



h 



'Iiifounaiil ^ J>L^ 



\J XjoJ^Aj 



f\<i.i 



rcss 




■\L\ 



chlK\X<x.^ 



DIRATION 
(SIGNED) 



Days Hours 

M.D. 

A<ldress) Utu'^U JbCH^.l 



^^^Ycars Mouths 

...J VA ()liia.>v-"^ 



»>, 



A 



■A- 



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



Former or n<< iu n ^ i ^ 
Usual Residence c<^^-''^^-^^^*^^ 

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



How lonq at . /> 

Place of Death? I A Days 



I'l \CE OK BrRIAI. OK KKMoVAI. I DATi;.)!- Hi kiai. .jr RKMOVAI, 



190 



r M ) 1 ' R T A K ]• K CrUiji/Yv O oJj. LL^^^d^OL W c 



(Address 



.hould b- c«r,!ally .uppli.d. AGE .hould b. .toted BXACTLV. PHYSICIANS .hould 
„ Pl,^„ trm. .h«^ it m„, b. properly clarified. The "Sped.! Information" .or per- 



N. B.— — Rvery item of information 

• state CAUSE OF DEATH in p 
«on« dyinft away from home should he feiven in «very instance. 



f 






f " 



m 



'Sii 



ill 



t 



i '• 



1, f ■ 'i 

• 't 



!ir 



J' 



; 



' t 



i 



il 



■ « 



I 



i i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ , ,„ ,.h .No ,.i^.r^J^lu^PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1413 



!)((/(> Fi/r(/ , 3jLWtjLy^^JisJi^^ S 



Crvx^^ c 



lf)0\ 



Registered JV*o. 




Deputy Health OfTlcer 

DEPARTMENT Of PUBLIC HEALTIi=City and County of San Francisco 



Cevtificatc of Beatb 

1 X\. S. Stan^ar^ ) 

City ofOxx^^ o.V<x-v\.a.vvi *' '■ 



^*L. \ 



Ch 



PLACE OF DEATH: — County of ^CL^ 
No %\1 L La . - St.; '-. Dist.; bet. lUa \a>v W and 1^^^ ^ c 

INC. U. » .^ ^^ ^^^^ ^^^^ ^^^^^ RESIDENCE a.vr .*CTS CAturo ^OR un " ^s^W .-obmat.on-. ) 

C IF DEHTH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRCtT AND NUMBER. / 



) 



FULL NAME 



.0 



cn\- 






-■i:x 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ok 



mA 



:> \ 1 K t»F" niKTU 



v"\ 



\<-.K 



F 



Month) 






(Day) 



O )V(i/> I M.mHis Jv \ 



(Vear) 



A/1. 



^IN'.I-K. MAkUIKI) 

U II)«»\\ Kl) OK I)IV(>Ki'Kr> 

^\'Iitt in »i<Ki;il <Uvi^'ii;itiiin) 



I.Ik THPI..\CK 
■State or Country^ 



NAMl-: (>l- 

r \Tin-:R 



I'.lRTnPl.ACH 
Ol- FATHHk 

(.Stiitf or (."ountrv^ 



Ca^ 




I 

1 



\yy\AX> 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DKATH 

. \ 

(Day) 



UxLt 

(Month) 



igo 

(Year) 



I in':RHRY CICRTIFV, That I attended (lecca.sed from 

: . to " 



[90 



that I last saw h-trrr- alive on '—^-^-rr-rrrrrrr-rrrrrrr. 
and that death (occurred, on the date state<l above, at 
-rrr- M. The CAl'SH OF 1)I«:AT1I was as follows: 



-1 90 
190 






^LiJ^ 



maii>j:n n'amk 

Ol' .MorilKK 



inkrinM.ACK 

<>l< MOTHKR 
(State or Conntryl 




\\jUL 



C>'\XX* 




DrR.\TI(^N Years 

coNTuinrToRV 



Months 



Days 



Hours 



DURATION ^ Years 



( SIGNED )..Ur*L<n:ViL^;. 



Mouths 




Days 



il'L.<x<'^.\.dL 



Hours 
M.D. 



rVlytj TQoH (Address) Lo^^^^J.M 



mi 



U- 



/Tn 



) 'ra I 



.!/";////• 



- n<ns 



OCCUPATION r^O , . ], 

IHK AHOVK SrAIJ-I) I'KKSONAI. PAR lUTLAKS ARK TRIH TO TUY 
HKST OI- MV KNOWIJ-DCK AND in-.I.lin- 

) 1 -^ 

informant \wWA/>'\-0. ' - ' - 






SPECIAL Information only for Hospitals, Institurtons, Transients, 
or Recent Residents, and persons dying away from l»ome. 



) 



p 

r 



Former or 
Usual Residence 

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



How long at 
Place of Deatti ? 



Days 



IM.ACK OF BIRIAI. OR RHMoVAI. 



190'! 



^^/^^^ 



(Address 



%.\3 



l)AfK(jf IlrKi.AL or RKMOVAI, 



At 




1 



.. J AnF oknolH he Mtntecl EXACTLY. PHYSICIANS should 
N. B.— Every item of Information should be CBrefuMy -ppi.ed ^«^^^",,^^^^^^^^ ..g,,,,!., Information" for psr- 

state CAUSE OF DEATH in plain terms, that it may be properly ciassmca. 
sons dyinft away from home should be ftiven in every instance. 



T- 



m 



i I 

. Il 

t ' 

I'. I' '< 



- :» 



i ,* 



i!«*;'il 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. ■nJT.Sry^, „S: 1. 1-», REFER TO BACK OF C ERTIFICATE FOR INSTRUCTIONS 

1414 






>A>t/U^ ^A, 



i 1 ^ 1 / 



V)()\ 
v-tL Deputy Health Officer 



lle^isteved J\^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of 2)eatb 



( Xi. S. StanOarP ) 



A 



PLACE OF DEATH: — County of^-a^v 






'No. 



11 \1 
( 



^1 



- w 



u 



\r Ot*TH OCCURS *W«V rROM 



IF DEATH OCCURRtD IN A HOSPITAL OR 



J >V<x^vcv^c^ City of ' 
St; b Dist.;bet;vL\Vlvd^ :Jk^la^uLd 

USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMA 
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMB 



CX- rvc.<.-^j. ^. t 




n 




TIO 
ER. 



N.) 



FULL NAME 




a' 



hMjL 




xAax^ 



PERSONAL AND STATISTICAL PARTICULARS 

C()I,«)R ^ 



- 1 \ A A 

UATK Ml JtlRlII A 



\% 

(Dayl 



ivJL*^ 



(Vcar) 



\ < . !•; 



Vfars 



R 



Moullr 



% 



/\ns 



^INt.l.K. MAKKIKI). 
iW'ritrin siu-ial (l»'<ij.MKif idii) 



State or Country) J/ (Jjl 'J 




lUk lUl'KArH 



NAM1-: oi 
FATin-.K 



HIK ruIM.Ai'K 

<n- FArin<:K 



'St;it» or OdiiiHrvi -\ 



MMI)i:\' NAMl-; 
•>I MOTHKR 



''•ik'rui'KACK 

•>I- MOTIIHK 
(Stalf or Oountrv) 



OOCIPATION 

AV>7(/^(/ />/ SiiH /'i mil iMi 






MEDICAL CERTIFICATE OF DEATH 
DATK OK DHATH 



axkt 

(Monlh) 



5 
(IMy) 



(Year) 



I HI':K1:BV CI^RTII'V, That I attended deceased from 

^j.\J: H 190M to ..^.c)xi.-i 5:. 190 H 

til at I last saw h J^^r^ alive on CX^ 5^ up \ 

and that death occurred, on the date stated above, at 3- S 
\j M. The CArSI*: OI'' DI'iATII was as follows: 

CoJtxx^A4v.cJ6...M nr^JU^A. 



f^- 




y i\hJM\\l 



DC RAT ION }'t'ars Mouths - Days Hours 
CONTRIBUTORY M.Lfcr:r.-<: 



W. I u s-- 



Ctw 



) 'l II I 



\l..>ltll^ i I 



Day. 



rin-, AMovK sT\'n:i) i'Kksonai, i'aki'kmi.aks aki-; tkik t<> thi-: 

Hi:ST OI-- MY KN()\VIJ:I)C. H AND lU-'.I.Il'.K 






( \<1(lross 



DURATION ^ }'ears Mouths Days I/ours 

( SIGNED )....ilD...Ll. LLavcLv£u>' M.D. 

^ '^ I ',_ lo"^ ' ' * 'I'l ♦'•"^^ I .31 U .^ ..*v ( ..1.. ,1 



rqo 



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

Former or "•'^ '""9 at 

Usual Residence Place of Death ? Days 

When was disease contracted, 

If not at place of death ? ^ 



IM \CF OI' UTKIAI, OK RICMoVAI. DAnCof IUkiai. or K1:M()VAI, 






(Address 



.2).5.."l.....u J^c 



t-U^.-lii 



state CAUSE OF DEATH in plain terms, that it may be properly classmcci. c , 

«on« dyinft away from home Hhouhl be ftiven in every Instance. 



I 



« 



\[ 



}■ 



;1 jk 



Ji 



:ss> 



M 



I -.'i I 



il i- 









,ln:.nl.f H.:ilUi- 1' N 



J)(f/e Filed, C 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

No . . ^•Si&^> l»& '' ^'^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1415 





b 



lOO'i 



Registej'ed J^'^o, 



KXJs C 



/\Ki Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "d. S. StanC)arD ) 






^^ 



A ^ 



-K kip -A ^V 

PLACE OF DEATH: — County ofOov-w^A/CX/^xCA^^^.' City of O/CL-y^ A.cx.-yx^^ 



Nn RlC) OLLo^t-^ .- ' SU ^ Dist.;bct. iK^t and 1^.^:> 

iNO. \ C^V yV.'V.V'w.V .. MCII*! PrSIDENCEGIVE facts CALLED FOR UNDER 'SPECIAL I N FOR M AT.O N" \ 

( " rF"D;ATrocc"u%;r;.;"rHo^s^PrTA!: :r"ns"?J;'o*;"c.ve%1 name ..stead of street and number. ; 



A 



) 



fD 



FULL NAME 




V:v..0. 



I! 
y 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 




CL^ 



COI.OR > ^ 

'LA 




JW 



1).\ II". OF' IMK 111 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DEATH jj 



(MoiiUi) 



.1 



Ij 



(Day) 



I go 

(Year) 






I Day) 



(Year) 



ACK 



) V<; I 



.M.,nt/n 



Da \s 



W IDnWKD OR DlVt »ki" i: I) 

UVritc ill >^(K"i;il <1< siyu.ttioii) 




ItlKTni'I.ACK 
'Stale or Country) 



NAMI-: OF 

fathi:k 



RTRTTiri.ACH 
<>|- l-AIHHK 
•st.itc or Country) 



MAn)KN NAMK 
<H MOTFll'K 



H IK TM PLACE 
<>» MOTHER 
(State or Country) 



OCCUPATION rjS f) 



kf^idfii ill Siiii /'iiniiniii 



? 




1 



I JIF':R1':BV C1:RTIFV, That I attended deceased from 
190H to .Qj^^ "1 190 H... 



A 



that I last saw h -^ alive on Ut^ ~^ 190 

and that death occurred, on the date stated above, at ^ 
CL M. The CAl'SH Ol' I) I {ATI! was as follows: 



V-V 



Dr RAT ION 



^^^^^^^ )'^ars Months X Days Hours 

CONTRIIU'TORY >vr^<X>^-^<:Au\AO.-<:c....\X4X^.:u^^^^^ 



or RAT ION 

(Signed) 



Years 



Months 



Ihiys 



X^r\j. 



/lours 



M.D. 



) ■/•(/ / 



Mmith^ 



Pay. 



rill. AMOVE STATED PKRSONAI. PA K lUI I.A KS ARIv TRCE TO THE 
l!i:ST OI- MY KN0\\IJ:D<". !•: and HEI.IICF 




informant \A/YV>"\AX ) C 



f \<l<lllSS 



<x. >-vva 






i. 



QxH g iJ-X (A.l.lrrssjU-U n.ti^ l:'H'>ff\<^. 



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 



da IE of HfKiAL or REMOVAL 



VI \CE (>!•' iJERIAL OR REMOVAL 



(.Address 



(O^k) 




I .. J Am .h.^..lH he fttated EXACTLY. PHYSICIANS should 

,• information .hould be c«ro?ulfy -PP"*^. ^^^^^^^^^^/.^..^fiei! Th^^ -8pecl-i Infor.nation" for p^r- 
OF DEATH In plain terms, that it m«y be properly ciassmea. t^ 



^' B."^— Every item ol 

State CAUSE ^. , 

•on. dyinft away from home should be ftiven in svery instance. 



■V- 




I, 

(If 



'I 






X'! 



';. 



1 i 

5; 111 
i' ■ 



i 



(5 ■ 



I ■ 1 
I 



i 



'«. 



»> 



m:^f^ !l' 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ , ,,, .Ith » vo .i!«-^^S:^!UtPCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Ha/e Fifr>l,AjL\^)U^^l^ h 100^ Registered ^'^o. HI6 

io^vA.^ 'i,LAvi.|. Deputy y\ calt.h OfHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( U. S. 5tan^a^0 ) 
PLACE OF DEATH: — County of Ocv^v J 'VO- ivc^v ; City 






,T\ 



i^ 



,h 




4 



5 



^<l\\-^'LoL 



St.; 



Dist.; bet. 



and 



(T^ft). VLV.U, V VVrV^ '^"-M. w w >v t '-^^'^'-^ orcTArNrr nwr TlcTs'cALLEO ron under "special information- \ 



FULL NAME JUAAvt.^ 



Tn 



.. .'....L-f^; 



PERSONAL AND STATISTICAL PARTICULARS 




si:\ 



DAll-; <»[• lUK III 



\ ' . »•; 



COI.OR 



a.u 




-\i^L«. 



I Month* 



;l)ay) 



(Vear) 



) I'o I s 



Mnulliy 



Hit IS 



'^iN'.i.i" M\Kun;i) 

W lltoWKl) OK DIVnKrHl) 

'\\rit( in '^(Kial dcsivMiatiim) 




HIk I MPI.AOK 
iStatr or Cotuitrv^ 



1 \Tin:R 



HIRTHPT.AtK 
OF I AIUKK 
'Htritf or Country'* 



MAII)1-:n NAMK 
<'l MOTHKR 



I'lK IMIM.ACK 
<'!• Mi>TMKk 
(Stall- or Country^ 







MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



(Month) 



.,..5. 

(Day) 



(Year) 



I III':RI*;HY CI^RTIP^V, That J attended deccaseil from 

'^ - -. - -^ ''i^-^-. '^ 190 H 



':hx\\^. ?: 190H to ...xi-4d. ^ 

that I last saw h • ■ alive on UJL.|.ut -.^ 190 • 

and that death occurred, on the date stated above, at A O 
. GL M. The CAUSK C)K DI^ATII was as follows: 

d>^ <r1j:^<X^J.AJ./:x^ 



DURATION Years Months Days Hours 
CONTRIBUTORY 



DURATION 
(SIGNED) 



i- '. 



Years 



Months Days Hours 

CU.^U;'xi M.D. 



OCCUPATION J Q 






Months 



Ihiw 



Till-: AHOVK STAT|-,1) I'KKSONAI, I' A KP UT LARS ARK THl'K TO THK 
lli:ST OF MY KNUWI.FIX.F: AND HIU.IF.F 

'Iiifoimant \j , SJ . OvO. \JL<X<LU^A 

rX.l.lress.LdoA, M.Alli. K : <> ^ ^ V.S.la..'* . 



.,) -A-.L.\-). 



iqO 




Special INFORIVIATION oniy ror nospltals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or f 'i (^ ^ o f, -| i 

Usual Residence -^ t>tf 6/V 

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



How long at 
Place of Death ? 



? X 



Days 



I'l \cf: oi" nrRiAi, or kkmovai 



l)ATF;<)f HriuAi, or KKMOVAI^ 



i^^- 



190 






(Address l.^.0..^i,y!)l.VQ.^LA^;vv...-. 



\i 



E OF DEATH in plain term., that It may b. properly cla.s.fl.d. Th. Special In.orn.a 



N. B.— -Rvery item 

state CAUSE 

Ron« dyin^ av,ay from home should be ftiven In every instance. 



1 



i y 



if 



a 



I 



1 ti 



I ^ 



,.V' > 



i: 



i' I 



m 



it 






JUtiirrl nf lit .lit 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,, , No ..^-SgJ^nM'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

' 1417 



lOO'i 



Registered J^o. 



J)(f/r /•V//v/vCJL^vbL-rW!>X>v b 

DEPARTMENT OFVUBLIC HEALTH=City and County of San Francisco 






Dep 



>N r% 



Certificate of Death 



i 



PLACE OF DEATH: — County of CX >v J X-O. 



( Ta. S. Stan^arC* ) 



^ . : City of ^^'CL ^v ;ucx 



No. 



\^txd. 



St.; 1 Dist.;bct. 




^ 



^ 



i\ and L'/:CL.>V\I. L»..v1.nl.. 



i- ) 



/ .r di:*Vh occ"u».s *w*y .-ROM USUAL RES I OENCE G.VE '^•CTS cau|^d roR urj^DC« "sPtc.AL .Nr^^^^^ 

V ir DEATH OCCURHCD IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



u >- 



\.LsL 



O-^i- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
?n 1 ! COI.OR \ 

0.) i) I 



1 ^ L .1, 



\j\lA\U^l 



i>\ 1 ). t>r itik in 



A« . I-. 



(M.mth) 



(I)f«y) 



(VcMr) 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH J 

'■^\ > 1 ^ 



(Month) 



1.... 

(Day) 



fpO X 

(Year) 



KS 



)'iiti 



M.mtlis 



Pa 1 A 



^IN'.I.I-. M \RKn-;i) 
WlDnWHl) OK DIVOKi'KI) 
• Wiitr ill s(Kial (IfsiKnation) 



I'.lk lin'I.At'K 
'St:it( iir (.'<ninir> 



\\\n oi- 

I \ I 11 1 K 



RIK rillM.ACK 
"I" I AIMKR 
(Statf or Coutitry) 






MAini-:N Nwtr 



ini< IMIM.ACK 
'>»■ MOTHHK 
(State or Country'* 




^.v,JL\.i 



I HERIUiV Ci:RTrF'V, That I attended deceased from 

to C)Jw.J-.x.t H. 190 >i 

AjL.\x^. '^ 



190 



tliat I last saw h • alive on J-K^^x^V 190 •• 

and that death occurred, on the date stated above, at ^ 
(j M. The CAUSE OF pivATII was as follows: 



nr RATION I yeai:sX Mouths 



CONTRIBl'TORY 



Days 

l<^,;V'.34.^^.\.^»-.^-.^.~ 



Hours 



DURATION 



( 



OCCI'PATION 



% 




. (Ka„AJL*^a. 
Kfsidni in Sat) l',iUi,i>ro I )><;/> "" Months 



Years Mouths Days Hours 
( SIGNED )....L.a.'>lAAXU ..y^.a/^,^i-^l.lL• M.D. 
gxki '. 10 - fA<ldress) ^ ^-^ )]l{r ^\t<\H • -^ 



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



;, Institutiotis, 



Ml 



!hiy. 



I'MI-: \HovK STATi:i) I'KRSONAI. I'AK TUT I-AKS AKi; TRlH To TUl-: 
HHST OF MY KNOWJ.KDC.K AND HKMltF 

(Itifotmant VA , O A/^A^V. l><xJC<7. 'J 



'A.l.lrcss I O >. \5..>J. C .. I . 



\ 



Former or 
Usual Residence 

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



V 

'1' 



.\A ^ K V.V . 



How long at 
Place of Death ? 



Transients, 

V 

Days 



P^ACH OK BrRIAI. OR KKMOVAI. DATIvoC \Uhi\x. or RKMOVAI, 






190 



(Address H.*^- .^ ^ 



N. B.— Every Hen, o. inf.>..„«tlo„ .hou.d he carefully supplied ^««^ •^'^/j^^^VfleT^^Thf '^S^^^^^^^^ infoTnfJtTor' Vr^'^r't 
•tate CAUSE OF DEATH In pl..ln term., that it may he properly clarified. The »pcc 
«on« dylnft away from home should be feiven In every instance. 



"T- 



1'' 



' 1^1 



M 



/ 



:i! 



m 



4 
Ml 



I 



IlOl 



II 



I • 






,1*^ 



I >i 



1- 



ii ' «| 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nnlofll. ,!ih- » No >^^^C^^'^«^''<'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1 4 J 8 



Be^lsfercd JS/'o. 



Ihilr rUrd, axiAii>rrL.L^ b 100\ 

!Liyu.o Aaam^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eath 



A 



( XX. S. StanCiatJi ) 



0^ 

K, I 



^ 



PLACE OF DEATH: — County ofO CU^ J X<X^<^^<^ City of C\a^-u OX<x^^^^c.l^>0 



No. 1l5 i^n^vWvd' St.; I Dist.;bct.M^t(X^t^V and J a.u 

/ ,r or*TH OCCURS *w.v from USUAL RESIDENCE G.vc tacts cacled ^O" ^^CR ™'ri*iNrNUM;ER°'*"' ) ' 
V IF OtATM OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. • 



list.; bet. M/Vc 



FULL NAME 



^ ex ■\aX<X' 




OO'TLUCU 



PERSONAL AND STATISTICAL PARTICULARS 
SI A *V> ^ ! COl.nR 



-\ 



X- 



L 



iiL 



Xi 



l» \i 1. < ii i;ii< III 



A '.I'. 



iM.itJtht 



5 

(Day) 



(Vffit) 



a?v 



) I in . 



I" 



M,i„ffis 



/),/i 




i'^"*^ l 



t 



i 



sin'.i.j:. m.\rkii:i) 

Wllx i\Vi:i> < )k IUVdKCKI) 
'^Viit. ill xiK-ial clesiv:iiatiuji) 



HIK rnj'i. 


A('K 


isi:it<- or C 


omttry) 


NAM!- Ill 
KATHKR 




HIK rui'i.xrF 
f>'' I'xriiKR 

•"Mt( or Coiintry) 


ma!hi:n namk 

<»! MOTHHK 


iHK rniM.ACK 

'»»• MOTHKk 
'^t:it< (,r Country) 







MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH j} 



5^ /poH 

(Day) (Year) 



(Month) 
I HliiRIUiV Cl'RTIFV, That I attended deceased from 

CLl\.>vvX 3i 1904 to ...^J^^^ 5". 190 H 

tliat I last saw h XhJ alive on ^Jl^fX- S T90H 

and that death occurred, on the date stated above, at 5 
\J M. The CAl'Sf-: C)I^)IvATn Mas as follows: 

' !^-cJ!>c\^CuJu^.U Ulu^L\AA/cryvaXw). 





DIRATK^N Years 1 Mouths Days Hours 

CONTRIIJl'TORY 



"^■^•n'ATlON(Vp ,1 (J 



/hn 



dtration 
(Signed) 



Years 



Mouths Pays 

'4. oUa/Ca^ 



I lout s 
M.D. 



T90H r 



a. 2), 

Address) '^V' '•■• Vj A/trVvtq'M LLv-v 

, Institutions,'^ 



SPECIAL INFORMATION only for Hospitals 
or Rccfnt Residents, and persons dying away from fiome. 



TMK AUOVK STA rj-I) PFKSOWl. I'A K IIC T I,A K S A K l- TKll': T< > 
HHST OF MY KNOwi.HDCK AND HHMICF 



r 1 1 1-; 



Informant dU O^NX^^^VOO UXtX^ V\.^OA^ 

1 1 S" <k^^vJ[j<VuL CJa 



(Address ,. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



ransients. 



Days 



I'l.ACK OF lUKIAI, <»K KFM«)\AI. | DA TK of »t KIAI. or REMOVAL 

hjd-X 1 I90H 




INDHRTAKKR /OJ^^'\AiX \ jl^^ 

^Address \%.V\ Uhs^hX^^SSk 



N. B.- 



.. J Knv: .h»..i#l He stnted EXACTLY. PHYSICIANS should 
f InformHtion .houl.l be CHrefuUy HuppI.ed. ^^^ "^^^/^'^^'^.^i^'^The ^Special Information" for pT- 
OF DEATH in plnin terms, that it may be properly ciass.tied. I he opec a 



-Every item of 

state CAUSE _. 

«on« dyinft away from home should be feiven in every instance. 



4 



I, 






1 1 



1 il 



N 



; V * 






^ 



.'1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Jloard of Mtiiltli — I* No. k *^^few»)n&P Co 



J)ff/c> Filed, 

\ 




REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Registered J\Po, 



1419 



rNo. 



..So ioo\ 

Deputy Health Officer 

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

Certificate of Death 

( tl. S. StanCarO ; 
PLACE OF DEATH:— County ofUaAx.ta. U.a'v.^ City of UL 



CV^xXaat 



La„ 







(ir DEATH OCtfU 
ir DEATH OC 



RS AWAY FROM USUAL RESIDENCE G 



St,; Dist; bet. 



and 



_ _ - — —".. ■. - >^f wbi^wE. olVE FACTS CALLED FOR UNDER "SPECIAL I N fob u a-rin u •■ \ 

CURRED ,N A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E ET AN D N U M b" R^ ) 



FULL NAME 




L' 



^-iL^ LO^:r.kA. 






PERSONAL AND STATISTICAL PARTICULARS 

1 ^^^'•''*' \ ^ I) 



DATK OF lURTII 



\<.K 



<Moiitl)) 



(Day) 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DEATH ~~^ 



(Monthll 



H 

(Day) 



(Year) 



^ \ y,a>s 



Moulh.^ 



Da 1 , 



«IN<*.I.K. MARKIKD. 
WIIXnVKD OR DIVORrHI) 
• Write in s<Kial iltsivriiatioii) 



niRTlU'r.ACK 

(Statv or Conntrv) 



I, 




AycL<rv.,vH^<:i 



■*^-^ ^^ I90 '■■ to 

that I last saw h • • alive on 



i^HKRRBY CIvRTIFV, That I attemled deceased from 

..,a-^.vt. .H 190 H 

-^— *^t^^ jgO .. 

and that death occurred, on the date stated above, at H- X ^ I 
^ M. The CAUSK Ol- DI^ATH was as follows: 



NAMK 0|- 
FATHKR 



hirtmim.acf: 

OI- l-ATHKR 
'Statf or Coiintrv) 



X'Vtt^.cl > VI 



^ 



Dr RAT ION- 
CO NT kllU TOR V 



Years 




Mouths Days 

:v.v.^.x.o:.L.u.a..... 



Hours 



MAIDKN NAMK 
"I" MOTMKR 



•HKTIJPI.ACK 
•»• MOTHFR 

''^t.'it<' or Coiintr\ 1 



'HCri'ATlON (>\,' 



V^T 



V? 




DCRATION 
(SIGNED) 



Years 



Months 



dx^vt 5^ iQot (Address) UC\ 



Davs 



'y\jLK.\r 



lal 



Hours 
M.D. 



\^ 



f^rsiilfd iit Sdti /'i nil, ism 



) V( 7 / v 



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



Former or 
Usual Residence 



H 1^ 1, I I How long at 

L /a^VvlXX/VVCV V. ^ piare of Death ? 



Months 



n,i\. 






"",;,>J!!,^\l^,'^''^''*»^J' I'HKSONAI, JVXRTKM-I.ARS AKi; TRIK T< » THH 
Itl-.sroi. MV KN(JUl.i:i)C.H AND MVAMW 

"' »". 10 "l^lL^.O-^x ^43 



(r 



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



Days 



190A 



rxddrcss 




PI,ACK OF niRIAI, OK RKMOVAI, I DATK of Miriai, or KFMOV\I 
V N D 1-: R T A K K R VJ (tLo^VU U 'O-'UL; LL VA.-dUa Lc. 



• B. Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIAIS8 should 
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for pmr- 
«on« dyin^ away from home should be ^iven in c\ory instance. 




■n .» . ::ii:V 



m 



! I 



^ 



•1 



* i'l! 



I 






.V 



1 1 



I 



:i! 



5: 






n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.„,.r,U,nu..l.l.-l-Nn...*^ l^nM.C,. BEFERTOBACK OF CERTIFICATE FOR INSTRUCTIONS 



Date hied, Q 

A 




b 100'\ Registered J^o. 1420 

D-puty • Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Death 



SI % 



PLACE OF DEATH: — County of 6xX>v 



)Ao. . vo.c^. City of UOwVV j.ivxx^vc 



^ 



\ 



No. 



5..^ Vi)x«4.'0.;.>\J.; 



St.; ^ Dist.:bet. S^.d- 



, 1 



and 



/' ir DEAtiH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
\ XT DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAO OF STREET AND NUMBER. / 



OR INSTITUTION GIVE ITS NAME INSTEAD O 



FULL NAME ^^<xUva\^xa; 




PERSONAL AND STATISTICAL PARTICULARS 



!) 



DATI-: or" HIKTU 




I'vI'VA^Lc 




Jl:XL^..(..a..i 



-\±..j:kj <:^.,^r\^..L 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH J^ 

1 

(Day) 



Motith 



at 



"Month) 



A<iK 



H5 .,..„ 



SIN<.I<K, MAKklKD. 
WlDnWKI) (»R DrVokCKt) 
iUrittin sfxial <I<>^iv'ii:iti<m) 



HIRTHPi.ACK 

'State or Coutitrv) 



'Dmv) 


/16...U 

(Vear) 

Da\.s 


<X:\y\.KX/^ . 





(Year) 



^1 



I HKREBY CKRTIFY, That I attended deccaseil from 

ax^jxt :.i 190'x to BjL^:.....'i iQoM 

that I last saw h alive on D-JLirvL *H loo '1 

and that death occurred, on the date stated above, at « • 'j t .' 
•aI M. The CATSK OF DICATFI was as follows: 

.r4<\.\,;d=f:\^ 



-^ 

^ 



^ 



lATUHR 



"IKTMFM.ACK 
Ol- lATMKR 

'Stiitf or Coinitry) 



MMr)l-:N NAMF 
<»! MoTHKK 



U-^ s 



\va.\y 




I'-ik rui'i.At'K 

(Stati- or Cotnitrv) 



occri'ATiox 



rVOyvu UJol<vynJI>u 



DrRATI(3N J>r7;.y ;]A;;////5 /^tf^^y ^^ I/our'. 



C ON 'J' R I Bl'TO R Y M AJL\Ww*:ScS^...(<X..V.La.a:;dlx.). .3^>^ 






< . 



DURATION rr. Vfiirs ^^ Mouths 



91 



(SIGNED) 



/-«. * c CI r o ' /vi^ i'l I.' n I It. 



Daxa 



\^^>Jkj. 



Hours 
M.D. 



CJXkij. ^ Tc)0 (Address) 4 ^^V" "^A-d^ dt 



f\>>i<ird ill Sim /'i ti>ii /M-i> 



] ra I . 



Mouthy 



Day. 



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



' " u.^!!!.*^ ''' STATi;i) PKKSONAI. I'AKTICr r.AKS A K 1% TKIK TO THK 

»w-,sr <)i' Mv KN()\vij;i)C.H and »kmi:k 

(Informant U\ . Uj oU -<X-W^lC„. 



Former or 
Usual Residence 

When was disease contracted, 
If not 9X place of death? 



How long at 
Place of Death ? 



Days 



U<1<1 



rcss 



N. B. 



t 



190 



IM,ACE of IURIAT, ok KHMOVAI, j I)ATi:of Ii KIAI. or KKMOVAI, 

rXDl-RTAKKK \J . v) . H- - AAA/^V>'V€L'>% ' ' 
(Address 1^ (y'"\ \u14a!A^«>\ 3 




(. 



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 feiven in 9\cry instance. 



i 



I mi. 



ir 



m 






4 '■ •. 



i 



': ii^ 



m 



i 




!i 



I 

i#." 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

J«..;ii.l <.f n<:(lth !•• No. K *^J!^^^HS:rOo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed, Ax. 




b.. 



lOO'i 



Registered JS^o. 



\A2\ 



■'^^PTT 



DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 



Certificate of Death 

( XJ. S. Stan6ar& ) 

SI m Ji 



% 



PLACE OF DEATH: — County oi^JCkywj .^.Ok. ixct-sriCity ofC'cc-yv J,'u<X , \ •- ■ v 



No, 



St.; 



Dist.; bet. 



1- (OL.vi,..kA..ti..>. .. and v 



ot.; Liist.; bet. Jvl <a.vu.kA,.ti > .. and v A«>x. 

/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INST^UTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



t...ii.) 



FULL NAME 



u 



.JJJUm aL/'jL::^.\A.>JU]L:.....*J. 



PERSONAL AND STATISTICAL PARTICULARS 



i-:\ 



DATK or HIKTU 




CO 



CO 



UlJxdL. 



MEDICAL CERTIFICATE OF DEATH 



A<.H 



(%Ji)iith> 



(Day) 



r l-b-} 

(Year) 



DATE OF DKATII 

Oxkt 

(Month) 



h 

(Day) 



{ 



(Year) 






Mntitfif 



Da vs 



^IN<.I,K. MAKUIKD, 
WfDoWKD OK DIVOKiKD 

'Wiitf in scx'ial (ksi^Miatiuii) 



niKTHJ'I.ACK 
iStMtt' or ContJtrvl 



NAMK OF 
FATHKR 



niRTHPUACK 
Of' lATUHR 
iStntt or Country) 



h 




\ 



CL'L^uOcO^ 



I IIHRI'BY CI<:RTIFV, That I attende.l deceased from 

.ax^-.\t; I icp'\ to ....O.jd^. .3>. 190M 

that I last saw h A.. - alive on ..V-L.^\L. ■^. Kp 

atid that death occurre<l, on the date stated above, at 1 i 
LL^M. The CATSi^ OF DIvATII was as followi 





\s 



W 



.J JL^U'»'VCXy> 



» '^ ) -i^LV'-. 



MAIDHN NAMK 
<M MOTIIHR 



»IKT!iri,ACK 
•'!■ MOTHKR 
(State or Country) 



(H'Cri'ATlON 




...X.(n>^vLl^CXxixcL.A.U.LLl\.... J Ay^A^ 



v.v^^. 



DURATION Years 



Months 



CONTRIIU'TO 



R \ .vi>.i\..i:v..v..v.fe.v:. 



Days 



Hours 



.X)U 



DURATK^X }'i'a/s 







U i' > 



U X' u'v\'\xlaa^ 



(Signed) 







Mo)ilhs 




Days 



LU'... 



Hours 



M.D. 



90 



(A.l.lress) \^^\\ JaJ-.Cvv.Cca 



f^fsidfd in Stni /'i am i'm'i} 'it )V'(7;.> 



A/n„//l.' 



I hi 



I HI, \hovh: sTA'n:n phrsonai^ PARiicn.AKs akk tkik to tiik 

I.I-.sr t)I.-MY KNOWIJCDCtLAND HKMKF 

(Informant VJxtjlAj \ . dL X-V Vii^VJL'v' 

a'i JbxA.<rvv.m 



Special information only for HospUdls, Insmutions. Transients, 
or Recent Residents, dnd persons dying away from liome. 

Former or How long at 

Usual Residence Place of Death ? Days 

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



r\fl dress 



P^ACK OF niRIAI. OK KF:MoVAI, I DAJiFuf Ilriu.^r. or RKMOVAI, 

' ' ^ ' AjiML 1 



^:rtakkr .A:0. r\X'y^-\^^ij>L.{y(:L' 

(Address ) .X.O. '^ .yjX4^'i^^L,<(r>rx....3.^t 



190 ; 



N. B. Every item oi information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

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



I 



f 



11 



I 



' I 



lii 



( 



> 



ill 



ili 






[f 



n 



'#i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.Kir.luflUalth- FNo ,. lg^^^ HScI' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffr Fi/efl, 







y\.hAhj. b lOO'i 

Deputy Health Officer 



Registej'cd JYo. 



1 4 ^'^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XI. S. Sta)l^arO ) 



PLACE OF DEATH:— Co 



iNo. 1-^ -x.a..lvA-ccL.aK'.. 



onty oiO'<X/y\j J.r\.a''>vct^j^c. City of O/CUr^' v1/\<x >\. e-uA- ^. t. 
St.; ^ Dist; bet* \%Li\i and lS....Lk 



wa.l\A.:cLcy<.. St.; ^ Dist; bet* WIa\i and 13. 

(IF bcATH OCCUVtS AWAY TROM 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. J 



FULL NAME 



^OjyyxiA L^Xa.ax.d: 



si;.\ 



1).\TK OF lUKTH 



.\«.K 



PERSONAL AND STATISTICAL PARTICULARS 

I COI^OR \ 




\ k.t: 



MEDICAL CERTIFICATE OF DEATH 



DATE OF I)F:ATH 




(Mouth) 



II /.i'l... 

(Day) (Year) 



ixkt. 

Month) 



(Day) 



IpO 1 

(Year) 



vN V. ) 'ra ; .^ 



^ 



Mnut/is 



J^ \ A;.i.v 



SINC.I.R. MAKKIKD. 

winowHi) OK i)ivokc'f:i) 

Uritciii s(K-ial (ksiv^iiiition) 



HIKTHPF.AOK (^ 

(State or Country^ V 



N'AMK Ol- 
FATHFR 



^KXXJL 



HIKTHPI.ACK 
Ol- FATFIKK 
<StMti- or Cotnitry) 



MAIDHN NAMF 
"f MOTIIKR 



hikthim.acf: 
t>»- mothf:r 

(State or Country I 




I HEREBY CrvRTIFV, That I attemled deceased from 

....Xkarw! IJ^ iQO 'i to qJi.\\.i L 190 ';... 

190 

and that death occurred, on the date stated above, at 
The CAl'SK OF J)IvATII was as follows: 

i.ViVAi,A^;:' , . 



190 I 
tliat I last saw h •■ alive on L^.^..^.ap...'J«..C 



^. The CAl'SK OF J)IvATI] 



DURATION 1 Years Mouths Days 
CONTRinUTORV k<L.>>Ji...\x.C.S-N^.i^. 



Hours 



DURATION Years Months Pays 

( SIGNED ) V1^V:>^ LvAr ll^^^^ 



v. J^..L V. 



.1, 



K^O 



(Address) \V\\ \. ^\.\...y. . ./:\/^ 



Hours 
M.D. 

4. 



occupation 

Kfsidfif ill Sdtr /■> it >h lu-n , i JV'(7(> 



Special information only for HospUals, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



Months 



Da 



Former or 
Usual Residence 

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



HoH long at 
Place of Deatfi ? 



Days 



Tin; AHoVF: STATFI> I'KKSONAI J-VRTIcrr \KS AKIvTRIK to rilH PLACK OF ni'RIAI, OK K1:Mo\ AI, I DATKuf HiHiAl. or KKMOVAI, 

HFST Ol- MY KNO\VI.i;i)C.K AM) HKI.IFF (\\\^ 1 1 - 1' n\nJ^*f ^ 



Otifiiiniritit 



% 



k..a.\: 






(Ad.lress I 5 cLA.'Av^(Xav . U. 



I90H 



rNDF:RTAKF:R 1/U ^ V^'- 



(Addres.s l.l.'il U )Ll^^<Ll.fv.:k\ ....ul. 



N. B. Every Item of inWmntlon .hould be carefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
«on« dyin^ away from home should be <iiven in «\9ry instance. 






% 




»v 



• .^., 



(l6.«1 






M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Mn.v.lnf H.alth-I No !.; l^-^^^HS:PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 









h i 



r 



Registered J^o. 



1 4^3 



l),(l,' Fih'<l ,AjL\^XxnnJ>h!Uv...h lOO'i 

'd^.-VvA.vo k.. ' J Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( H. S. StanC»ar^ ) 



^ 






VI 



li 






^' 



MM 



I, . 1*' 



!■; 



PLACE OF DEATH: — County 



.■-D 



unty of Cj/OL'-^-v ^' 'LCL ^ v.c.'.v ^/ City of OxX^\; 0.\.a. \ ..Ct^Vc ' 



^0' 



A f ir Dt»TH OCCURS A 
y \ irOtATMOCCUBti 



St.: r: 



Dist.; bet. 



and 



WAV rRoM USUAL R ESIDENCE Give facts called tor undcr "special informatio 

RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



I 



FULL NAME 



I 



Luxt,u.4.X) J..xax:C4i.^ 



" ) 



PERSONAL AND STATISTICAL PARTICULARS 

111, 



,a^ 




^w^ 



ix 



I>\rK or HFRTM 



A Li 

« Month) 



(Day) 



(Day) 



(Year) 



(Year) 



Ar,K 



),,/ 



M,nilfi> 



■J 



Da v.s 



SI\Ol,F. MARKIKD. 
WIDnWKI) OR DIVORCKI) 

IWrit* in v.kmmI dtsi^Miatioii ) 



niRTm'i.Ai'K 

-: iti or Country) 



FvniF.R vOU Am' 

A.u:Li/u^>cJ~. J , 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH H 

\JLLLCL 

(Month) j 
1 IIKRI'HV ClvRTlf'V, That I attemUd dccoaseil from 

LL^.-a :.'J 1 190 . to lLluv 30 190 H 

that I last saw h - alive on LL^uq ■ '- up 

and that death occurred, oji the date stated above, at i 

J^Lm. The CArjtjH OF 1) I! A Til was as follows: 




s^^ojxj^ 



ttK^J^^-.. 




i Ik 



niRTin'i.ACK 

ni FATMFR 

'*^t:tt.- or I'otiiitry) 



MAIUFX NAMF 
<iV MuTHFR 



<»l MOTirKk 
'Htatt' or Co\nitry) 



OCCliATION 



\ 



A/CX>(r*Aux J ,<XAA,t.Lrv 



Dl RATION Years 

CONTRinrTORY 



Months 



Days 



Hours 



'\, 



or RAT ION 

(Signed) 



/)ars 



HfO 



rs^Veat-s Mont /is 

Address) UL ^^ \i A;^^ 



Hours 
M.D. 



(. 



GO 

A ^' V ^ 



Rf'itfft! in Still /'i ti III / ri> 



],;!i 



Mnlltll' 



/)(1V 



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



rilK XUOVE STATi:f) I'KRSONAK I'A RIU'T- I.ARS ARK TRIF T< > THK 
HFST OF MV KNOWI.I-.IX.f: AND lU-AAV.V 



Former or 
Isual Residence 

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



How lonq at 
Plare of Death ? 



Days 



'Iiifonnant 










ri.ACK or MFRIAI. OK KFM<»\ \I, I DATFof HiKiAf. or UKMOVAI. 

^^-V "^ c. ^ ^ I O^VvL b 190:1 



^W\^; 



iJLvA.'t^Jf^t^ 



rNDi;KTAKFR 



(Address 







3.,bTaA ]H.iiu...iS£ 



^X^CvOww. 



N. B._F.v..y ,..„ „»• i„(„.„».i„„ .houl.1 b, ca-ful.y .upp.lcd. AOB .Sould '-.•<•"'' EXACTLY , P");f '<;;,*:*.«;;";;.l 
•tau CAUSE OF DEATH in pl«in Ki-n... that it m»y b. properl, cia..m.<I. Th. Special Information for p.r- 
«on« dyin^ away from home Hhould be ftiven in oscry instance. 



I I 



\ 



$ 






■ \'\ 



* i\ 



',•; 



r 



i 









m 



"i! 



*i 



J 




» , 



a 



' ■> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ri^ 



f(^ Filed, ..B 



l?Ma..l of IK alt h -I- No. ii -J^-^^t) »Si»' Co 
J)(( 





REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



b 1^0^ 



Registered JVo. 



1 424 



^^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=Cit)' and County of San Erancisco 



No. 



Certificate of Death 

( X\. S. Stan^arC* ) 

-J? ■ -? 

PLACE OF DEATH: — County of 



■ City of J.CL'^v O.Vo. 



St.; 



Dist; bet. ..J.w..L.a\. ... 



and .1. A.L...* 



(ir Dt*TH OCCURS AW*V TROM USUAL R E S I D E N C E Gl VE FACTS CALLED TOR UNDER "SPDCIAL I N FO H M ATIO N " \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME wi iwCi 



[^ 



LUi 



)\i... 




J{^. 



n 



..i.:..,.\ 



si:x 



^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR A ^ 



I).\TK or- lUKTIl 



I M-mth) 



y AM..^ 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 



IJ.VTH OF DKATH V 

a 



\<,i<: 



b^ )V.n 



M->til/i> 



/hi\.-~ 



SIM.l.K. MARUIKI). 

W IltoWKI) OR niVOKtKf) 

'Wiitrin social (Usi^natiuii) 



inKTMPI.AOK 
(Htateor Countrvi 



Ow'w^-^^-cd. 



VAMl-: OI- 
I ATHKR 



niKTMPi.ArK 

Of lATMHR 
'Stall- or l,'f)niitrv) 



OI- .MOTHKR 



'HKTHl'I.ACH 
<>»•■ MoTin-:R 
iSlate or Country) 



OCCM'I'ATION >U? 




X.lvt 

(Month) 



(Day) 



igo 

(Year) 



I Hf<:RI':BV C1;RTIFV, That r attendea deceased from 

' 190 -r-— ■ to - T()Q 

that I last saw h alive on - 190 



Mild that death <x;curred, 011 the date stated above, at 
..-r^-. M. The CAi;SIv C)l' DI'.XTII was as follows 



nr RATION Years 

CONTRIIUTORV • 



Months 



Days 



Hours 



DURATION-^ Years 'K'"'\l^ ^^'^'^'•' 

,ned)..JajuLi\.a^ '^ U 




'V^.'yXXX', 



C^V-^^wAX^-^-.J^vJr^- 



(SIGI 






Hours 
M.D. 



\ i 



iqO 



CAddn-ss) 



\ 



....t.l 



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



Krsuird in Stni /'iiiin 



) I'd I 



1A</////« 



/>,! 



Tin-: AIU)VH STATHI) J'KRSONAI, 1' A KTKT I. ARS A K I-: TRI I-: To TIIK 
IJHST OF MY KNOWl.l-.IXiK AM) inil.Il-lF 



(Info 



rmant 



Address ^. I <3L1LA.<XVyA.X<OvV<J v:.) , . 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



. Days 



i).\ri-;.»! m Ki.\i. or ri-:mo\'.\i. 



o igot 



I'l.ACJg OF- lURIAI. OR RHMOX Al. 

rXDKRTAKKR LUA^^-vOt »*^ 

(Ad.lrcs.s ^ 1.0 .' a (<XO^.XJ^>:>A-<^:T^vVi>... :Jl. 



■JV 



E OF DEATH In pIhI" term., that it may be properly ciassmca. 



^* B«— Rvery Item 

state CAUS 

«on« dylnft away from home Hhould be ftiven In every Instance. 






'^'■) 



1 



') 



Q> 



,j 



^ 



i 



"1 

kl 



: 1 1 



* I I 



V: 



It . 



If. li' 






WRITE PLAINLY WITH UNFADING INK — 



H,,:,i,l of Hi'Hlth-F No. IS ^agg^H&PCo 



7>^//(' /V/^^^Z, 




W i'^^^H 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1425 



Begisterecl J^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



I li 



I 



Ccvtiffcatc of Beatb 

( XX, S. Stan^arD ) 
PLACE OF DEATH:— County ofOao,^. O;. :^ City of O 






Dist; bet>-:::rrr^' ~-:::...:.; and 



' - .,«.,,A| BrQinPNCC GIVE FACTS CALLED rOR UNOtn "SPtCIAL INFORMATION- N 

" ,V»»T°»"cc"u%«V,"rHo"s^Pr" o^T^sfau" -".'"ts name ,«st„o or sx,„t .»o mumb... ) 



^ 



FULL NAME 



J I LL'iX.<J.U.U..O.. U 







•1 



PERSONAL AND STATISTICAL PARTICULARS 



I)\TK OF HIRTII 



y ; 



COI.OR N 



LL 



\ 



(Moiith) 



I 



(l>ay) 



J 



./...t. 



(Vear) 



AC.K 



j/t, JV«;.v 3- !/-'.////> .XiC' 



/'(M 



SIN<.I.K. MARKIKO. 
\VII)(>\VKI> OR DIVoRCKO 
'Write ill social <U si^'iialiou) 



HIR TMPKACK 
(State or Country) 



N'AMK OF 
FATHl.R 



I 1 LOL^L>^^wL<i. 



BIRTHPLACE 
oi" I'ATIIKR 
'State or Country) 



MAIDKN NAMK 
OF MOTHKR 



lURTH FLACK 

oi- mothf;r 

(State or Country) 




J 



.UL 



\JU</Y\K.QJL • 




occupationTTU 

I' 

Rf-itird in Son f-'mii. i^f,i 



)>.;; 



Month' 



Ih 



THF ^HOVKST^TKI) I'KRSONAK FA K IK'F I.AKS ARK TRIK To TMK 

in;sT OI- MY kno\vm;i)<',f: and im.i.ii.h 



'I1 



'Aflrlress . LU ^^YV/>^w4/>'VVA^:CXLXX....\r\X; 



MEDICAL CERTIFICATE OF DEATH 



datf: of dkath 




.t. 



H 



\X ^ ^9^ - 

) (Da 5') (Year) 



I in:RICHV CI'RTH'V, That |[ atteiKled ileccascd from 

0jLA.a .^x 190 'A to $JL)p^. ^ 190 H 

that I la.st saw h r^'v alive on .J JL.\-\.t 190 > 

and that death occurred, on the date stated a!Hn-e, at 2. 



. ^ M. The CAl'SH OF DIvATII was^s follows: 



.4 : 

nrR.XTION y*'ivs Mouths Days Hours 



Ct^NTKllU TORY 



I)rRATU>N 
(SIGNED^ 



)\ars Mouths 

i ^ "^^ . uu 



too 



\adri<-) '^0.1 



\JL^ 



Day^ I fours 

M.D. 



Special information onl> '»f Hospitals, Institutions, Transifnts, 
or Recent Residents, dnd persons dving dHd\ from home. 

Former or ^ " i' ^^^ '""'' ^^ I 1 

Usual Residenc A C % V > vc»\x,v-«.t.a M U Place of Death ? 1 » Days 

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



U 



PI..\fK Ol- lURIAI. OR KKM<»V.\I, 



DKTF. <)!" Hf KMi. or RF:M0VAI, 



.JX:^\.t' Wr i90_ 



rNDKRTAKKR V^ CrUiX'>^ Oltl Uw^vCLq y^- 

(.Uhlres.s . iH'i'^i M1\\.<L^^.<& YA. ..H 



„ „ . .^c «u„..iH he Ktated EXACTLY. PHYSICIANS should 

N. B.— F.very Item of infor„,ation .hould be carefully supplied J^^^^^^J^/^^^YfleT^ T^ Inform.tlon" for pr-i 

state CAUSE OF DEATH In plain term., tliat .t may be properly classitiea. m j 

sons dyina away from home should be ftiven In every instance. 



% 



^H! 



\ 
I 



1i 



J 



J 



ii 



I! > !l 



Jn 



\mmi- 



UV'^ 






>mi'- 






WRITE PLAINLY WITH UNFADING INK 



lfW\ 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J^o. 






.<)-\A.>US 



n ,^^, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of "©eatb 

( "a. s. stall^atc> ) 

PLACE OF DEATH:-County of ^n,>. ixa , ^ . :^hy of 0.a..v J x.a , 
., I Wd^^AJatt H^.-O^A^^■^ St.; A Dist.;b£t. J.atLlf.V and\^ 



.'J 



) 



(ir DtATI 
IF DC 



v/ .A V v^->j >,*...-. . ,__ ,,unra "SPECIAL I N FOR MATIOJN " | 

1 1 \ ^, ( t\ i) nil 1 



V) 



FULL NAME 



J..W.U.WS. 



..VVXlX. 



. dii. 



PERSONAL AND STATISTICAL PARTICULARS 



I»A1I-: OI- 151 RTH 



CC)1/)K 



Lear. 

I Month) 



1 

( Day) 



.,%2.L 

(Year) 



ACK 



b ! )■'•<"> 



1^ 



M, mills 



Da 1 



sINC.l.i:. MARKIKI> 
WrDoUKI) OK DIVOKiKn 
(Writf in s(K-ial <lt«i>):"ati<>n) ^ 



MEDICAL CERTIFICATE OF DEATH^ 
DATK OV DKATH 



(VfonlB) 



I 



V 

(Day) 



(Year) 



lUKTMIM.ACK 
'State or Cotintry) 



NAMK OK 
HATHKR 



lUKTIIPI.ACK 

Ol" 1- AT I IKK 

I Slate or Country) 



MAIDKN NAMK 
()1 MOTHKR 



lUK rnruACK 

Ol" MOTIIKK 
(State or Country) 



I 



AJ AAt&^ CX-d. 



AJLcL 



)XVY>x^O-/^ 






"" I IIKKI-P.V ci-RTIFYTriiat J attended (leceasea from 

y..a<x^v Ii. 190' . to oA-^^ ^^ ^90 ^ 

that I last saw h ... alive on ^A^- ]^P 

atul that death occttrred. nn the date stated above, at 
M. The CAUSIC OV DKATH was as follows: 

ii, LLixfri'\.>!wi.\<.! 



(^ 



LilAxir 



}'tars *^' J/ou/Zis Pny^ ^^'""' 



,t)-<LiLiv(\-v.>u duAXt^ - - 



LXn^-x^^^^ ^ ^^,^ 




J 



orCfl'ATION 

%[\ ,. 
Resided in S,ni li >tn, is,-o O V>^ ' "" 



] 



M,nitln 



/hn: 



fyrsilirii III .^iin II " '" ' " •- " ~ 
Tln:AHOVKSTATK,>.•KRSnN^...■^KTU;^LAKSAKl•TK.•H TO THK 

IU-:ST 01* MV KNoWMMX'K AND ln•.^l»•.^' 

(Infonnant Vj A^^V.-C Ci. 



DURATION 

CONTRIHUTORY ijJli^Vt^:^^^^^^ 

Uy^cLuww^.... ;.^e.^.^-.''...^ V',;.. 

DURATION -^ Af<Y^ Mouths 

(SIGNED )....\i/....0. AA.^^"^^-^ ^V^ ; 



Pavs 



/lours 



M.D. 



ic)0 



( 



A,ldr.ss) ^^ V Q^AvtUA; ^-^^ 



SPECIAL INFORMATION onl> tor Hospitals. Institutions, Transients, 
or Rerent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



.. Days 



PI.ACK (U- m RJAI. <>»< KKMOVAI. 



1>ATj;<)! in kiai. or KKMOVAI. 



:)x^^t 1 \9o^ 



A 



■I 



{.\cl(lress ' lA. V v vj 



_._.^___— ————— ———"■"—— —^^^^^^ I FVACTLY PHYSICIANS Hhould 

.. * ^miicF r»P nFATH in plain terms, thnt it may y^ h t- 
state CAUSE OF Ut a i n m m ASven in every instance, 

son. dylnft away from home Hhould be ft.ven m 






m 



1 inr ifcii 



tiki 






if 






ill 



m 



a 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

,,.,rA ..f IKMUh^F N o ..1>>SS^ H &l>Co 

' II I I O^ 

. n I V t OK I /9/^;H Registered J^o. l^^i 

I)((/e /v7f'^/,. aJ^vLtAWt>X\' L ^^^ V 

A ^! DeoiJ^*' Hr»n?^h Off?^^*' 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 

lO f 1 ^(] i 



Ccvtificate of ©eatb 

( tl. S. StanDarD ) 



J c^ 



\Ao; 



St 



City of ''Ouov .Xcx. V ve4.^c 



Dist.; bet. 



and 



) 






FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 





■ty\^.i 



SKX 




(\o^Li 



COI.O 



DATE OI BIRTH 



"UllIUv,- 



(Mouth) 



(Day) 



rill 

(Year) 



AC.K 



) Vv; # 



Mntllll! 



MEDICAL CERTIFICATE^ OF^DEATH 
DATE OK DEATH J( , . 



(Monti) 



(Day) 



(Year) 



"TTlERIvHY C1<:RTIFY, That latten.kMiaeceasea fn 

AjiJfX 1 190^ to BjL<p:fc 5 upi 



. Ihns 



SlNC.l.K. MARRIED. 
WIDOWED OR DIVORCED 
iSVritf in s(XMal (U-sij^uati<»n) 



niRTMlM.ACE 

I State or Country) 



fW_ YV<X 



NAME OV 
lATHER 



hirthpuace: 
01 i-apher 

• State or Country) 



MAIDEN NAME 
OI- MOTHER 



HIRTHri.ACE 
OI- MOTHER 
(State or Country) 




that I last saw h ■■ alive on J J^V^-^ ^ »90 

ati.l that death occtirred, on the .late stated above, at b 
M. The CAUSE UP DKATH was as follows: 

.luv..:^wiL..c.fe:.i5|..i-v.<^-*^^ 



Months 



Hours 



OCCUPATION 



)'iii) 



M.nilhs 



Dav 



THE ABOVE STATED PERSON ^ I. y )^■^^X''^^^'' '^'- ''"''' '"' "''"' 
BEST OE MY KNOWKEDC.E AND BEMEF 

(Informant UU-'O^V^^^A, ^ -O 



Duration : >v^- 1 ■'^""^^ '^ '"■>' """" 

f SIGNED ).lU b.'^:tV. **°- 

A pi.i 5 ,..H (A, s<^■v^^kA■■<y}. 

■ SPECIAL INFORMATION only lo'"«P"*. '"^«""'""^- "''"^'"'^• 
or R«fnl RfsMrnls, and persons dying a»ay Iron, iiomf. 

s lonq at « *. 

rf of Death? oO Days 



Whfn was 
If not at I 






Usual Residence ^'CUVu 



1.. '^< 



PI ^CE OE BIRIAU OR REMOVAL 

UNDERTAKER l\j A. ^ \^<^ j>- '^' 
(Address ^i.D UvtX- 



DATEgi" BtKiAL or REMOVAI, 

\ < i > - 



I 



yOu<:/v.cu-v>^wA^"^^^^ 



^ 



, FVACTLY PHYSICIANS should 

.. B._..e.. Ue. o. ln.>..a.o. «HouU. he ..r^^ ^^^^^ :'ZV::Zl'^^^^^^^^^^^^^ '— ' -^--*-"" '^ ''" 

•tate CAUSE OF DEATH In plain ;'7«:;J;- ^^J.^^ m-t-nce. 

son* dyinft away ?rom home should be Ji.>en m .ve y 



> 
^ 



r' 



-3 



^r J 



<r: 









1 I 

Hi 



^^ 



Ml 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

U,.;iril (it l it ■nut ■ ^^^^^^j*^*^^^^^^^^^^,,,,,,,^,^,,— — — ii— — — ^ - _ 1^^ 

/)^//r> F/7fv/, QA^WtiL/VA^l^ b ^-'^-^ \ 



Reiisterecl JSTo, 



- % -fc ■ -^ * 



No 



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

Certificate of Seatb 

< •a. 5. Stan^arD ) 
PLACE OF DE ATH : — County of^'Ct^ 



■l^'l'XV' 



1 / ir DEATH occuni *w*v rRO*. USUAL 

C "^ DCATH OCcCjBRED IN • HOSPITAL 



St.; 



Dist.; bet* 



and 



) 



RESIDENCE GIVE r*c 

OR IKSTITUTION GIVE I 



M 



TS CALLED FOR U N DER "S PCCAL INFORMATION- \ 

t\ name instead or street and number. J 



FULL NAME 




.{O^XCXA.H^*^ 



PERSONAL AND STATISTICAL PARTICULARS 
,, M^ ^\ A 1 COI.OR 




DATK t)F HIKTll 



AC.K 



0^ 

iMontlit 




y 



'uXu- 



(D.iy) 



(Vear) 




MEDICAL CERTIFICATE O F DEATH 
DATE OK I)1':ATII ^ . , -5 



(Moiitli) 



\J 

(Day) 



I go 

(Year) 



44 )v.,. ^ .v,,.//>5_^..l.k..-; i>^.'- 



SINC.I.K. MARKIKI) 



\VII)<)\VKI) OK DiyoRiKD 



'Writtiii s(KMal (k«iiK'i.'>ti<in) -J( 



I 



HIRTHPI.ACK 
(State or Comitiy^ 



NAM1-: <)!■ 
FA TMllR 



niRTHPl,ACK 
Of I ATHKR 
(Statf or Country) 



MAIDKN NAMK 

O! MOTIIKR 



TUR'IHIM.ACH 
ol- Mo'lUKR 
(Stntc or Country) 



OCCrPATION J" 







rilliRI^iv'cHRTIFV, Tlnit I attetiilcl .lerease.l from 

LL.UC^ i.L I90'- to 4^\^ -^ ^90 H 

that I last saw h-. alive on c3-4^ - ^90 ^ 

a„,l that death occt.rred. on the .late stated above, at \C 'it... 
M. The CAUSE OF DICATII was as follows: 






DIRATION 



Yeats 







Months /><ty-^ 



Hours 



Signed) 



Months 



/></v.^ 



Hours 
M.D. 




'., V 



v^TvO ' 



Ri-Milnf in Sun /'i iiii< i^ro 



) I'lt I s 



.}/,>iif/i> 



/ )<; 1 .^ 



T..KAnoVKSTATKI)fKRSONA..rAKT.rrrARSAKKTKrHTO TMH 
iu;sr Ol- MV KNOWI.KIX.H AND m-.I.HM 

(Informant '^ JlLtj^^'^- VJ.txxto 



(\<Ulre«M 



CVA '(■...(-'.-'' 



Hi 



iqO 



SPECIAL INFORMATION .«ly !«' ««P"-I'. '"^'"«''»"^- '""^'"''' 
or R«cnt Residents, and persons dyinj «ay l.«n> f™'- 

When Has dlscasf contracted. 
If not at place of death? 



HoH lonq at 
Place of Death ? 



Days 



PLACK (>»•• lUKIAI, OK RHMoVAU 



I 



INDKRTAKKR VJCA.\Au ^ ^ .^ 

(Ad<liess N?.«0.^ *• » ^ ^^^ 



Dvjivot lu lOAi, <)i ri:movai. 

lix^^ ..a _i9oH 



N. B. 



' ^'^''"''"^ ^-^v^ I ■ y PHYSICIANS •hould 

•tate CAUSE OF DEATH in plam J-';'"*:;J;" /,:;;^ Innt-nce. 
son, dyinft away «rom home shouUI be ft.ven In .very 



11 

( I 

4o 
11 



il 



iii 



^1. 



t: 




l,,;,r(l .f Ilcallh- 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^^ „„ .. _ REFER TO BACK OF C ERTIFICATE FO R INSTRUCTIONS 

Dale FUrd, 

\ 




\^ lOO'X jteoisierini^ ,,u. 

Deputy Health Officer'' 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate ot Beatb 

( H. S. StanOar^ ) 



PLACE OF DEATH:-County of^CU. J XCV..C...- Gty ofO.XA^. Jax. .v^.c. 

Si m . \) 



No. i.am-^ 'Jv'^A. 



i.k^Lo^ 



St 



♦t 



Dist;bct. 



and 



) 



r ^iS^E^vr- ^^t ^^^f^^-i:-^"^i .^ -■ 3™- -- 



- ) 



FULL NAME 



M-;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




f\\A 




Jytx^Ctt 



UMl". (>!• lURTM 



iMoUtli) 



A»,K 



o 



)'l'll I A 



1\ 



(Day) 



Motilhs 



fYear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ^j/ 

cmJ. ^ 



(MontH) 



(Day) 



/go 1 

(Year) 



na\: 



SINT.I.K. MARKIKD. 
UincUVKD OK DIVoKlKD 
i\\ titt ill social <ltsiv:nati<)Ji) 




HIRTUPI.AOK 

(Statf f>r ConiitJy 



1 ATHKR 



BIRTH PUACK 
O! lATMKK 
•Stalf or Country) 



MAIDKN NAMK 
<)J MOTIIKR 
















■Ol/'^' 



\xL 




r> 



vXA'Vj 



lUKTHl'LACK 
<>!• MOTHKR 
(State or Country 




.<X'>v 



vd 



rill-KlUiY CHKTIFY; That I aUcn.K.I ,l<-.case.l frnnl 

.a^^. xs .90 . to -.4x^1 .5. ..^ 't 

tl.at I last saw h alive- on O jJ,^. ^^ -^ 

,„„1 that ,k-alh ,K;c«r,cMl. o„ the ,latc stat.-,l al.nve, at 
M The CAISK OK DKATII was as foll.ms: 

coNrium:T.,RV%4-4^i---4^^^^ 

i)Ltva^.^^- xWV ■* W^.Y ^A^ ---- '^^- ' - " ■ 

(SIGNED) 

""special information only tor Hosp.tals, Inshlutions, Transients, 
orlerelu Residents' Vnd persons dying away from home. 



Hours 



"" ^ ) V^ft *^ ^foutlis Pays f fours 
TOO ■ (A.Mrcs<)^ At .).U. ..U.N 



'v/w^ 



/)<;i 



THi: AHOVK STATK I) l«KKs()NAI, >" ) « .'; I!;'''.:.'*^ •^'^''' ''"'*^'^' '" 
ni-ST OI- MV KN»)\VI,i;nC.K AND IU-.IJl-.» 

(A<l«lrcss 10. ' .i^-'< 



. l.L*..a.>^ 



former or 
Usual Residence 

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



V 



How lonq at 
Place of Death? 



Days 



^ 
^ 



P 



M 



o 







IM.ACK OF lUKIAl. OK KHNU»\AI 



DATJ". <'i BiuiAi. OI K1:M0V.\I, 



) \ I I'. <'• '*' '^ "^ '' 



I i,.i.y-'- -'■ - . 1 



",Ad,.rc.» lnii)^'uAA^vX it 



IN. B. 



*^^'''' "" PHYSICIANS should 



I 



» 






f ,, 



1 1 



I 



li 



'( 



\'i 



B 



r 






Iri 



N 



-»4 



\ 



II 



'f 



r I 



il; 



H » 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lV)ai'l-f Health- » 



N'o .^*^S^»*i^^ 



Registered J^o, 



\Am 



'A^v, , . 'l-j. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( la. S. StanOarD ) 



PLACE OF DEATH: — County of -O/Vu 0,\,L. 



J fTi^ 






City of ^J<^^^^ vj ;\.cu'>xC.U'Cl:'<vi. 



V 



n 



tSfo, )Xn^'^X<X/Yv' 



^ 



C^<LV'^^- '-'^ S*-» " ^^ * ^.rn rOR UNDER "SPECAL .NrORMAT.ON- >| 



FULL NAME 




J? 



0:XaX^Xi. 



L L-....^Lcx. 



„v~.. 



PERSONAL AND STATISTICAL PARTICULARS 

COI/)R 



DATK OF BIRTH 





xo. 

(Mouth) 



\f'K 



) /'(f t * 



%. 



(Day) 



Months 



(Year) 



,1 



Davs 



SINCI.R. MARKlK.n. • 
WinoWKI) OK I)IV<)RrKl> 

Wiitfiii s(K-i:tl (k^iv^nalioii) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH J? 

0.X|:U; 

(Month) 



.....4 190 

(Day) (Year) 




ThHRHBY CHRTIFV, That I attended .lereasea fron, 

190 H to A^k^- ^—'90 "< 

tl,at I last saw h .. alive on ^M^-^ '^ ^ ^ 

a„a that .leath occurred, on the date stated above, at X-^^ 
.S^M. The CAUSK C)P DHATH was as 



follows 



lilK THPI.ACH 
(State or Country) 



1 A'lUKR 



BIRTHPT.ACK 
OI" lATHKK 
(Statf or Country' 



MA!T)KN NAMK 

OF M(yrnF;R 



iurthpuacf; 

oj- MOTHKR 
(state or Country) 







I'QLJa^^^-^ :J.^ J.^^^u^-<^ 







0^ 



DTRATION 



Years 



Vonths .....^...Days 



Hours 



DC RATION '^''•' A 



Months 



Paxs 



Hours 



DURATION ^^ yt.^ 




(SIGNED) : 

'\ iqo 





(Address) 



...^ 'M,lVYV.a)v'^'»<^'4 



occ 



U PAT ION ^ 



Xjy 



(yvA_,4LXA-A^^-iVX 



K^siifrd in San f'xiniisro 



g 



)'riii 



Minith^ 



I)il\: 



IHl 



:AHOVESTATKl).-KRS(>NAM«AKTirrLAKSARHTKrH TO TUH 

if:st OF MY knonvm:i)c.f: and HI-.l.H-.i- 



'Informant 



■.„„css SHf^UiooLLvox 



■^^^lAL INFORMATION o-ly r,r HospM., Insm«li..s, Trasie.ls. 
.r1c«Swrnts,7nd persons dying a.ay \<m homt. 

""• """ '• J "iO D.,s 



f"'"'"„Vn„Hlo]X..a^^-^ ■' 



Usual Residence 

When was disease contracted, 

If not at place of deatli ? 




Place of Deatli 



.Kj^\jU\- 



OATKof nrHiAi. nr KFMoVAI. 



f l„!„rn...ion .hould be ^»"«''"'' ""'"'''t prop.rly cl...tSl.a. Th. 



IN. B. Every item of 

state CAUSE _. 

sons dylnft away from home should 



PI \CK OF lURIAI. OR RKM«>VAI. 

(A.ldrt-ss v<.«^^ ^' ' ^ 

. 1 FVACTLY. PHYSICIANS should 
"■..^•..!i''"TH! •*8„.cl.i ln.-.r„...ion" ..r p.r- 



) 






^ • 



II 



I 




I"! 




o / 



7 <^ 



2-/ 



/ 



'fA'^ 



WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

„„rB TO BACK OF CERTIFICATE F OR INSTRUCTIONS 

Ke^Lstcrcd J\'o. f 4oi 



/r AV/rr/, dxWtt>^vUi\^ ^ ^'^^^ "* 

I 

4 , V Av . Deputy '-ic. 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(Xevtificate of IDcatb 

^ 'CI. S, StanDar^ ) 



P^.^ 



PLACE OF DEATH = -County ofC^a^vtxX. OUa.CV G.y of Uo c-'vCUL 



( 



X O^W-CtyOjO St.; ^HVV^ho rOR UNDER -SPECAL .NTORMAT-ON' >) 

'^■r■^foCC^%-V.-^.O^S^PrAt 0%^?^?T^^^4rC.;E VtI ^.V^" . -TEAD O. .REET and NU.eER. ) 



FULL NAME 



^ (xXjj'y\x^y^^^^^ 




PERSONAL AND STATISTICAL PARTICULARS 



DVIK ul lilRTH 



L 



COI.oR 



Uii 



;xA^Lc 



(M.mthI 



(Day) 



(Year) 



ACH 



\Ci\ ).ii>^ 



M.,„'/,.<! ^. '^«.''* 



MEDICAL CERTIFICATE OF DEATH 



DA IE OF DKATH 




.S.. 

(Day) 



igo 

(Ytai) 



TuER^^iV CICRTIFV, 'l^u.t I altcn.loa .leccasecl fmn, 

(iU.......L 190^ to cUll. ^ ^.190 H 

that I last saw h - alive on ..---,- ^^ 

a,ul that .Uath occurred, on the .late stated above, at ^ t^ 



\' 



SI\C,I,K MAKKIl-'.D 
WIDiiWliD OR DIVnRrKD 
iWiitf in MH-ia! «U-^i>.':i>ati<)n) 



HIKTHPUACK 
(JStatf or Country^ 



NAMl-: <)|- 
1- \IIIKR 



niRTHPl.ArK 

0|- I ATHKR 

• Stntf or Country) 




MATDKN VAMK 
01 MoTHKR 



lURTHri.ACK 
Ol- MOTllKR 
(State or Countryi 






.xU^o 



M. The CAISI- OF J)I:ATI1 was as follows 



"tx 



\ 



DIRATION "^^^ars ^louihs W 

:0>TUI1UT()R\ J ^^^'^-^ 

3 O, V^Xv\'<t^-^ 



.Jrtf- 



C 



Vi-ars 



.]fo>it/is 



(SIGNED) b.U ^'^CU^H 

di^lvt b TooH fA.hlrc-ss)ll^ 



Days 



flours 
M.D. 



'^ 




OCCfl'ATlON 

Kf^idfd III Still 1 1 am IS,;} I U ' "" 

■ . I - 1 ■ i-i \ r 1 1 1'" 



Kf^Ktrd III .^(111 rid I K ISO' V V , 

TlIK AHOVK STATHD J'KRSONAl. '' ^»< '1^/; I-.t.*^^ ^'"- '" '^ ^ ^ ' 
IIHST Ol- MV KNO\VI,1:dC.K AND MI-.l.U-.^ ^ 

155" ^CA^Aiv at 



ii > r } I !•: 



(Iiifoiniant 



dX^: b TC)o\ 



.^■sX'..'-^ 



SPECIAL INFORMATION onl> lorWals, Institutions, Transients. 
or^eren^^esidents,7nd persons dying away Iron, home. 

Former or ,Qa^ ^ J.Unt VI i^ pia!e of Veath ? lOmv.ll Days 

Usual Residence H ^U v ^ 

When was disease contracted, 

If not at place of death ? ^ 



n.AQK vr m-RiAi. OR rkm"Vai. 






I)A;ii;oi lUwiAi. or RI';MoVAI< 



INDl-RTAKKR 

(Address 



^b L. axcuu.>. 



N. B. 



^"^^'^''"^^ ^^ ' ^ . FVACTLY PHYSICIANS should 

.tate CAUSE OF DEATH In plain J-'"«:;^»;« ^'^^e;. Instance, 
eons dylnft away from home should be fc.ven 



) 



,1; 



^J 



;• 



U 



1 

I 



■( * 




WRITE PLAINLY WITH UNFADING INK 

I fit ..mi--KVQ It lS*SB<r~*i I5Sil' Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered JVo. » 4->'^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( tl. S. Stan^arD ) 
PLACE OF DEATH: -County of Oct^ J.V<^^c^^c^ City of 0<X^ 0.^.x^^ 



•X C ^.sJ. c 



H) 



if^a 



A V 




.\.a?-aLv-.cv ^ , SU - Dist.; bet. 

SID 

INS 



and 



) 



( "^ i;^-:^^:!R^v.rn^^t :ivBi^^-^^^ ^^" s?;E^-^o^-3ir ■ ) 



FULL NAME 



^.i)j^.^^ llLcx.^^s.s.a. 



.V 



J^^^X. 



PERSONAL AND STATISTICAL PARTICULARS 

COI.(JR ■ N 




LlLk^U 



(Mont 10 



ACH 



6b )></»» V 



(I ):«>•) 



MoutJi} 



,u- 

(Vear) 



/),n. 



SIN(,I.K. MARKIKIV 
WnniWi:!) OK DIVOKCKI) 
'Write ill scxrial tit •^ivMuitioti) 



lUK rill'I.AOK 
'st;it« or Conntry* 



NAMK or 

FATIIl-.K 




■y" 



TUR IMIM.ACK 
<>I l-APHKR 
(State or Country) 



MAIDICN NAMK 
<>1- MOTIIKK 



IUKTHPI,A(^K 
OF MOTHKK 
'St;ili- or CouJitry) 



.tVVYu 



\\^Od>J\JU^<^^ 



1 1 lxxcXx.a.c 



jOlo^u-.-. 



.X' 



Q 1 







)'i It I < 



1/,,<///;- 



/),n. 



t-\j.... 




^t all 



/:v\4'- 



I'l ACF OF lURlAI. OK KHMoVAl, .'-M. 



DATV''^ I?i KiAi. or K1-;M0VAI, 

n jkJ^ V TQO 



occrrATiox 

Rfsidfif in Sun I'l an, im ',> — 

THi;Am)VKSTVrKnrKKs.>NAI.VAKTiriI.AKSAKKTKrH T«> HlK 
DKST OF MV KNO\VI,i:j)OH AND Hl-.l.IM' 

(InformaTit OV" vl . ..i..\.-]/'^^v. Z.k 



^—^— ——■■""""■■■''■'■■■■■■■""'"""""""""""'" ♦ I FVACTLY PHYSICIANS nhould 

•tate CAUSE OF DEATH in plain term,, th« 't -a* ^^st^n... 
«on, dyinft away from home should be ft.ven m every .n«t« 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



jlA\.:: 



(Montli) 



(Day) 



rqo 

lYt-ar) 



I HKRl'BV C1:RTIF<V, That I attcncled (U-rcased from 

Uls^S^A 190'. to .p.JJ^ I<P'- 

tliat I last saw li ■• alive on >... ~w^ } 

an.l that death occurred, on the date stated above, at ^. 
^I The CArSH OF DfvATlI was as follows: 



DERATION Years 

CONTRIHUTORY 



Months 



Pars 



Hours 



DURATION. years ^rouths Pays Ilotus 

(SIGNED ) JbAl.WhU^ "iuXV^.'J . M.D. 

•^ .\A r ^ Address) U AjIAA-aJa^ . LcXk. 



TQO 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



(Address 







8 



;iii 


















Bi: 



J 



I 



i I 



U 



WRITE PLAINLY WITH UNFADING INK 



H,,:n.l .,f ntMUh--F No. i«; ^raS? 



U&PCo 






• I 

1 
I 




hill 



/)^//r^ Filed, 





b. i^6>H 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1 4.'53 



Registered J\fo. 



VXi rklJ\: '.. 



Deputy Heafth Officer 



CN-'C'WUVXi cKJ^\::.i. — »- ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



( "d. S. Stan^arD ) 



•^ % 



PLACE OF DEATH: — County 



Wo. 



of a. >^'d /UX^^CiA^.c City of U/<X.nrv J A.<X^>a.^:,*^ 



St 



. ^ 



Dist.; bet. 




( " "d7aTh"cc!rrVd .NZHoVprT.^OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET 



and 



l^^\JL 



V\I; 



S AWAY FROM USUAL R E S I D E N C E GI VE FACTS CALLED •^0_«__UNDER l.f rf^:*^ J J '"^^^ J*J'„° " " ) 



FULL NAME 




.a. 




.A i 




(X.yxy:ys..ty.. 



SK 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR "\ 



X/»v<X> 

DATK OF BIRTH 




'AaXX 



(Mouth) 



- r.%kl 

(Day) (Year) 



ACiR 



n t 



) V(/ ; 5 



.Vinilhs T. Days 



SINC. 1,K. MARRIKI) 
WIDOWKI) OR DIVORiKI) 
(Write in s<x'ial (lesijrnation) 




\<X\J\XXjk 



lUU PHPLACK 
'Staff or Country) 



NAMK ()!■ 
FATHKR 



HIRTMJ'UACH 
OV FATHKR 

(State or Cotnitry) 





trV\AyaKA,'U^, 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH J? 

^ t 

.S,_v — .W. 

(Mont 



A 



h) 



( Day) 



(Year) 



dJi^ 



I HRREBY ClvRTIFY, That I attended deceased from 

^ ■ .d.J^.\:t. 4 ^. TQoH 



ioJb M :^ :.. 

that I last saw h • " 



to 



lOO V lO .w-w|.w.»< .^..^.... 

f ^ ( P (^^ 

ahve on OJc.\a,X;. 'I 



190 



MAIDEN NAME 
Ol' MOTHER 



RTRTH PLACE 
01 MOTHER 
(State or Country) 



occri'ATiox ifliVp ,) 

(AD Ov. AJ' A-am)- 




A'rsifirtf in Siui /■'i,iin/M'n 



)'rins 



Mnntli! 



n,i\ 



TMI-; AHOVE STATIC) I'FKSONAI, »' A KT ICf I.A K S AKl". TRTK To THF 

HF;sr OF ^n: KNo\\i,i:i)c.E and m:i.n:F 



(Informant \J yj 



Vtr"v\AX5uCi \l l"LCX./\\.'Vx.'^..'<r'YV 



( Adilres.H 



9k n- nii'vA. 



and that tU-ath occurred, on the date state<l above, at 
J M. The CAISI*: OF DlvATlI was as follows: 

Ll\A<:Li.^^s,i, LVLxx.l\.\-i..-.C.jx.uLL|.)w.l:V.CA.A 

.Q(:hx......t.,..::^..- 

in' RAT ION Years Months Days ^ J/ou 

CONT R I P.rTOR V LAx^uvvO^ a^tAiyv^.<L^<.<iJ.../VA/^A^L 



r w-v/t^'*^^'^*^ ■ 



duration 
(Signed) ^ 



Years Months Days 

'0 -j 




I /ours 
M.D. 



'^ 



lc)0 



(Ad«lress) O.b'1 



..,.., I ; n 



Special information «nly ^^^ Hospitals, institutions, Translrnts, 
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 



FLACF OF lURIAI, oR REMoVAI, j I)AT/^:of lii kiai, or REMOVAL 

, 190 \ 



VA^^aLA,' 

l-NDERTAKER V Ij . U K^^i^^^^MV .■ • 

(A.Mreds 1 IdI ^^nXxA-UXJ^V.. D.l 







^. B._p.v... H.n. o. in.....«t1„n .houlc. He cncfuM. Hupp.l.d AGB .hou.d ^e stated FXACT.v .^^^^J^J^^'^^^^^;;-;.-. 
state CAUSE OF DEATH in plain term., that it may be properly classified. The Special Information Tor psr 
sons dyinft away from home Hhoiild he ftiven in overy instance. 




-r? 



I 




i 

-jii 






In- 



ni 



Hi 



5 ■' 



y t 






l!'|- 



j?nar<l ',f Hi-;ilth--J" No. i'; '* 



I)(f/r Filed y... 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

^ 4 '>4 



H&roo 




Registered JVo. 



b 100^ 

\j^j^y^ Deputy HeaJth OfTTcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County 



Certificate of Beatb 

( TH. S. StandarD ) 

City of 0'Q</^\) O A<X ^ 






KO.. , 



\ 



L 



Dist.;bct, X'X.xy^A^. and l".^ ' 



i 



\ \ ' 



llNO« •^ "- A ^ "^ \, «V. .....). . ......Ai DCCinriMrf riwr r*CTs'cALLED rOR UNDER "special INFORMATION' \ 

( '^ rrTE^X^H^O^^R^.V^N^rHO^S^rAt o"r Tn S^X^^"';' ^O . vV Ts ^N A M E .NSTEAO O. STREET ANO NUMBER. ) 



FULL NAME 



..J.X<^\ya^....M..lleY\. YA..'.. 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 




COl.oR 



O-J 



.vJxCi. 



L- 



DATH OF HIRTH 



ni • 



.V^'^L B T%.'h'i 

I M.. lull) <i>"y> <'^'^**'"' 



a(;k 



b.b IVar* X 



Months 



IL. 



Pars 



SINC.I.K. MAKKIKI>. 
WIDOWHI) <>K DIVOROHn 

(Writf in sorial <l»'siKnati<)ii) 



lUR rupi.ACK 

{Stgte or Country) 





NAMK or 
FATiniR 



HIRTH PI. At'K 
<)!■ I AIIIKR 
'Statf or Country 



MAIDKN NAMi: 
ni MOTMKR 



lUKTIIPLACH 
oi- MorHKR 
(Stati- or Country) 







OX/O/^vCt-- - 

? 

(r^Xh ■ — - — - 




OCCUPATION 



) rii I s 



A/,,,,///^ 



Pur. 



TMl- M»()VKST\Ti:i) PKRSONAl, 1' \ KTHT LARS A Ki: TRT K TO TIP'- 
HHST Ol- MV KNO\VI.i:i)<'.K AND HKI.ll.F 



(Ii 



^)V= 



(A.Ulrcss ^.'ilb J.Cri^ ' 'V 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII 



(Month) 



H 

(Day) 



I go 

(Year) 



I IIKRKBY CKRTIFY, That J attetnlc*! deceased from 



:\ 



O.JU^J^ : 190 ■ to iJ^1.:.A ^ TCP 

tliat I last saw li alive on . Xy-vI up 

and that death occurred, 011 the date stated above, at ' 
...Q>„..M. The CAISIC OV DICATII was as follows 

_.LjU\-^ 



;':\.jLij..:x^:ar.k..,....U^.:v.<^-^^-^»««^->^'V- 



nrRATION Years Moui/is^ Days 

CONT K I lU'TOR V LL^lx.^.^UJ......CJ./^ 



I /ours 



.^^LX.^.^.^^ 



DT RATION 
(SIGNED) 



Y'ears Miiiiths 



Pays 




_ -,., ^ 



flours 

M.D. 

\ . 



\ 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons d>inq awdv from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



PI.ACK OF lURIAI. OK K1;M<»V.\I, 



J^iU- 



DATIvu! lU Ki.M, 01 ki:M«)V.M. 
)jj^ 190- 



1 ^ 

rXDKRTAKHR iV<. <,v 



(AcUhess iLb VHX^rnXqXA ^ ■ 



state CAUSE OF DEATH in plain terms, that It may be properly classlktcd. I he «p c 
«ons dylnft away from home should be jtivcn in .very instance. 



I 



M 



11 

I 



Ml 



'i I 



! U 



I 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFrCATE FOR INSTRUCTIONS 

14 '55 



„.,anl ..f M. altl. T No. ^^ rt^^t^lM^V Co 




naW Fih',1, a.^|x.L^^^:v.MA.. b 100^ Registered ^^o. 

Ifc-cv^ •-.^ . M Deputy HaaJt!^ Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDeatb 

( *Cl. S. StanOarD ) 

(^ J? ^ 



PLACE OF DEATH: — County ofOcc^v ;va.^x<i^c^ City of O-O/^v J Va 



tn 






,IM IVflMrA cl' ■ VL^l-v St.: " Dist.:bet.iCO;-v_».^C. . and ^IVlcy 

l)7lA)[kia..A:i...,U... 



FULL NAME 



M± 



\\}.. 



si;.\' 



PERSONAL AND STATISTICAL PARTICULARS 
DATE or- UlRTH (\\ 

U,)xo % /...'1..03 





AGK 



1 



)V<:i.^ « V.»«//i.v A.t. 



Davs 



ftlNC.l.K. MARKIKD. 
WIDOWKI) OR DIVORi'KI) 
•Write in MK-ial (U si^Mialion) 



HiR rnri.ACK 

(State or Country^ 



NAMK OI- 
FATHKR 



i 'I 



BIRTHPLACE 
OF lATHKR 

(State or Cotintry) 



MAIIH-.N NAMH 
oi- MOTHKR 




1 



OUTw X<X >A^<^v^<^ - 



U 



A.K 



lURTM PLACE 
OI" MOTHER 
(State or Country) 






UCCrPATION 

Rr.iiirii in Suti I'l tntri>rn 



) "<'<; ; f 



^ ^f.mfhn QlI /><'». 



THE AHOVEST^TEI) PER'^i>NAl, PARTUTLAK^ ARK TRlK To THE 
BEST OI MY KNOW I.EDCE AND BELIEF 



(Informant 



(Address 






MEDICAL CERTIFICATE OF DEATH 



DATE OP DEATH 



(Month) 



... 5 

(Day) 



(Year) 



I HRRKBV CKRTIFV, That I atteiuknl dcocasea from 

.OLCLa.....i 190 •.. to ..'^JL^-.S.. 190'^ 

that T last saw h i~ ■ .. alive on UJU^xX H u/) 

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



;J. M. The CArSIC OF DIvATlI was as follows: 




iXiL^rvrx-iL-Cu, 



-,,f>>a*>^»4«»*»**'< ••• 



DURATION Years Months. Days Hours 

CONTRIHrTORV Oxr:u<r^^5-^ -^ -^^ 

Years o" Jf,>i///is f^avs 



DURATION 
(SIGNED) 



^.^■\.L\i. 



Hours 
M.D. 



\s}^.h 



V 

igo 



(Address) [UH 



QO 



•1 ^ -V 



SPECIAL INFORMATION only for Hospitals, Instltuflons, Transients, 
or Recfnl Residents, and persons dying anay Iron home. 

•^ 1 -H . How lonq at 

"^S cLcL>xAV-^^ Place of Death? Days 



Former or n 
Usual Residence "J 



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



PLACE OF BURIAL OR REMOVAL 




DArifof BiKIAL or RF;Mi>\ AL 

CjJL^ ^ 'I...... 190 

_ ^ ^ -"'-^^^ ... u^., - - ^ ^ 

INUERTAKER LL^AAAXd- \X->vcLl\X<X-V ^ 



N. B. Every item of information •hould be careVuliy suppi.ed. A^E « -Spicial Information" for p.r- 

state CAUSE OF DEATH in plain terms, that .t may be P^^P'-^'y -'— "* 
«on. dyint away from home should be feiven .n every mstance. 



«» 



,1 



' -1 

■ .1 

.1(1 
■f 

\ 

s I 



i^. 



I f! 



Hi 



i ! 



'■ '( 









V' 



\ i 



ji 



H 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Bc^istered J\'*o. 



1 4.'>6 



/r AV/('r/,.djLV\tj^^TJ>^^!..b, l''^0\ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( XX. 5. StanDarD ) 
PLACE OF DEATH:— County of v. CXa^ 






I ., -y,. 



No. 



Hli 




stL. 



and v? 



r> A iv- St.* Dist.; bet. v 

iXA^^Tl I '-'^♦» ^^ ..^T=V«ii rn FOR UNDER "special INFORMATION" \ 

S AWAV FROM USUAL " E S ' ^EN C^^ O^' ^.^,?^,;| 5,Vm" INSTtAO " STREET AND NUMBER. ) 




( " rF"D;ATH'oCc"u%RTD.N; HOSPITAL OR INSTITUTION GIVE 

FULL NAME iUWu-V-- 



LxLL.i:.x...CXs\, 



SKX 



t 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



DATK or lUKTM 



.OlvJ 



VL-WL. 



At'.K 






H... 

(Day) 



/'l.fcH 

(Year) 



Vt'iin: 



..H.... Moulli!- . \ ■''•"■^ 



SINCI.K. MARRIKD. ,a 

\vii)«)\vi:i) OR i)!voK(i-:i) VI 

\\ litt in siK-ial (IcsijrtiatiMii) 



HlHTHl'I.AOK 
stat«- or Country^ 



NAMK OI 

i-athi;r 



lUKTiiri.ArK 

• )I- 1 APHKK 
'Statv or Country) 




iy^vCX^- 



;cttcx- 



MAIDKN NAMK 
<ti M()TH1-:k 



lUR'rHPI.ACK 
Of MOTMHK 
(Slate or Country 




yu 





■i 



AXMI 



oCC\tPATION 

R'e.siilrd in Satt /•'} autism 



5V<;/ 



Month- 



n<r\ 



THH\H()VKSTATKnrKRSONAI.l'ARTirri,XRSARKTRlHT'» '-'iK 
ni:ST <))• MV KNOWl.lvIX.K AND IU-.IJ1',I' 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH 




r 



v^. 



(Month' 



5 

(Day) 



■ IQO 

(Vear> 



I HHRIvHV CHRTIFV, That I atteinU-.l -lercased from 

to ■ :— -190 •- - 

- "- ■; . ' .^ :; • ■ " I^O 



\Kp 



that I last saw h rr— .alive on 



an.l that .k-ath ..rcurrcl, on the .lato stated alx.vo, at 
.-nr:-r:xM. The CAl'SI': OF J^IvATII was as follows: 

^y>ji£y:suS:JojO S:!i..oa^Sj^oc>i^^>f^->*^^ 



DTK AT ION Yearsi Afonths 
C N T R IIU ■ T( ) R V • 



Pays 



I Fours 



I)^RATU)^^■^■■•"•• JV'^'-^I^T^^^^^^ 
( SIGNED ) Ltj\.(nxil\) 



PtlVS 



■' S.(l.\i)..Ux.^A 



/lour a 
M.D. 



0..v.,^.l V. I()0 



P 



( 



x,i.irr<s) L/A(rA,^A^ \y4»,A.-^>. 



SPECIAL INFORMATION only lor Hospitals, lnsmut>ons, [ranslcnts, 
or Recent Residents, dnd persons dying away trom liome. 

HoM long at 
fof"""®^,. Place ol Oeattt? Days 

Usual Residence 

When was disease contracted, 

II not at place of death ? ______—— 



Informant ^ AA-^ M XJU/V\^<:^ 






ri..:\cK OI- lUKi.M- OK ki:m<'\m. 





DVJI'.o) Hi HiAi "I KI'.MOVAl, 







t-NDHRTAKKR . . ^ ^ i^ C^'-VX/^'^^^ T^^ 



tiitetl fiXACTLY. PHYSICIANS should 



N. B.— Bvery Item of information .houl.l h. o.refuliy « 'HP -'• p^,^^.H; c1aH«lflcd. The -Special InformHtion" for 
•tate CAUSE OF DEATH in plain tcrm« tha it m..> "^^^"^ 
«on. clyinft away from home should be J^.ven m «vcr> m-tance. 



t! 



11 



I «'> 






>l! 






* i'l 



N-, 



WRITE PLAINLY WITH UNFADING INK 



, r II ..nil I'" Vo m ^'•••^laij'sff^' H&P Co 



ii 



i 



) 1 



It . 



m 



i 



:■ * 



11 



I 



\ 



Dale Fifed, ( 




b. I'JO'i 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOB INSTRUCTIONS 

1 1->7 



Be^iiifcrcd' -^""o- 




DEPARTMENT 0^ PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( Til. 5. StanDarD ) 







PLACE OF DEATH: — County of 



\l r\x^vcl^e.u\xt City oi\jJ^^-^^ ^^^ 



No, 




AX 







St.; -■ ■ Dlst.; bet. 



and 



OJsjL yV.Ml1r\,VA.0-.A. „.e?iV^.rrrlvr^cTs*c'itLED^oR under -special information' \ 

( '^ r.-DrAT^H^OCC-jR^EVi-rHO^S^r.^.t rR^f^^^^^T^O^'^O./ETs NAME INSTEAD O. STREET AND NUMBER. ; 



FULL NAME 




'\a.Ll.\ 




XjJjX.D. \lJuU.t:Y:u 



-^m 



S} 



I).\TH «)F lURTH 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 





IC 




L 



XC/., 

(Month) 



.\<;k 



..2>:i 



. JVdKv 



%. 



vc 



\?J /Iti- 



,l/„»///.v X I ^'".'• 



SI\<-,I,K. MARHlF.n 
WIDOWKD t)K DIVOKCKI) 
'Writf in siu^ial (ksij-Miatioii) 



IUKT!IPI,.\rK 
iSlatc or Coimtry^ 



NAM1-: <)!• 
FATIIKR 



lURTIIl'I.ACK 
Ol- JATHHK 
'St.'itf* or Country) 



m\ii)i:n name 

Ol MOTIIHK 




1 



lUUTIlPKACK 
Of MOTHKK 
(State <ir t'oiintrv' 






orrt'PATioN 

Uf'ii/r./ lit Siiti /'iiiii./>ri> ! .-, )j2^ 






M 



EDICAL CERTIFICATE OF DEATH 



DATK OK DKATH V 

oAxh 

(Month) 



U 
(Day) 



(Vrar) 



rUHRKnV CKR-nrV, TliMt I attoti.UM .!t«o>asi-.l In.m 

■ ■ .:— -—: 1 90 - -' 



190 



to 



l«p 



that I last saw h — alive on " 

a.icl that death nccurrcl, o„ the .late state.l al...ve. at 
::-~:.M. The CArSI< 01' yi: \TM was as follows: 



J /(>>// /is 



Pays I /ours 



t •*•'«« **IF#** * *"' 



coNTRir.rroRV 

DURATION J ^^'"^t!(\ 

(SIGNED) l.U- UUt^v ^.. -If'--.^'^' 



Jfi)>l//lS 



Pays Hours 



M.'ittli^ 



/).; v.^ 



rm: miovi*. six ri;i) i'Kksonai. i'^'<'*l!"/'';t- 

llJ-.sT Ol- MY KNoWI.i:i)<'.H AND MKUn-.f" 



KS AKl- TKIK ro 111)-. 



' Inro'inant 






\XA 



SPECIAL INFORMATION only lor Hospitals, Instilulions, Iransients. 

or Recent Residents, and persons dyinq anay from home. 

, X .4 ^ . . How long at r\ ^ ^ 

Usual Residence i * .>v>^ ^-^ 

When Has disease rontractcd. 
If not at place ol death? 






I)\l"i:"t H'KI**' W RKM«iVAI. 



I'l.ACK Ol- lU RIAL OK KKMoVAI. 



(Addrt'ss 



I FXACTLY PHYSICIAINS hHouIiI 
N. B.— Every Uc™ o< i„S„.„,a.io,. .hou... b= c.r.fuM, «upp.l..L _,;«;« •;"';'.''.:;:,:i? %h: 'Speo.; Information" ..r p.r. 



state CAUSE OF DEATH in plain term., that .1 m..> >« 
"". dyVnft .»., Iron. h«n.e should he »iven in .vr, .n 



Htfince. 



m 






I i 



1! 



■ J 



I.' 



i . 



I 



*»i 



u 



h' 

If* 



n 




I 






i: 



^ 



I 



! it 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,,,,,,.! -r Health '-'^'^ ' 



5, '«^^^!S^iu«tri"o 




Be<!isterrd Xo. 



1 4t>o 



Xxry^^Xj^^ ^^^^"^ 

'l.^ro^ dUi^>M- Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificatc of Bcatb 

( tl. S. 5tan^ar^ ) 



PLACE OF DEATH : — County of Oo. 

( 



vu diuCu>VCAAC.:CGty ofO,CX.>V /^CVTOX^AAC-O 



V \n . I .. C4 T r);<:t • tiet ^ ^-^CiwO-tA^-OwU and V..<X.' 




FULL NAME 



1) 



,\jA^LLca^\; 




Vj..Ll'x..s^.tj.Aj 



SKX 



DATl-; Of HlRTll 



PERSONAL AND STATISTICAL PARTICULAR S 

COI.OR 




J J vlLl 






a /^.Xi. 

I Day) <Vear) 



AGR 



b.A. '>.//> 



1 M,>ullis \ 



Da v. 



M 



EPICAL CERTIFICATE OF DEATH^ 



DATE OF 1)1 



KATH V 

■ Qxl,^± ...I 



(MontH) 



(Day) 



lYtar) 



SINCLK. MAkUlKI) 
WinoWHI) OK DIVoKiHI) 
(Writfin sfX'inl (k-sij^ijiition) 



BIRTH PI, Ai'K ,X) 

'State or Country^ 



>JAMK OK 
FA rnKR 



R1RTHPI,ACE 
OK FATHKR 

(State or Covuitry) 



MAIDKN NAMK 

OF mothf:k 



I'.IKTHPUACH 

OF mothf:k 

(State or Ccmiitry) 




oOOr FAT ION 



(UuAIlt\i 

Vudr,/ in San /■> <,». ,^r,> -^ -A >>^»^_______ _ 



lllHRHHVCIvR'nFV, That I atte.ule.l <le<vase<l from 

%1ZjL 1 190 H to 4-^1^-. H 190 M 

that I last saw h ■.. • • • ahvc on -UJu^^-^ 9" 

an.l that death occurrcl, ot, th. .late- statol above, al b. C) 
iL M. The CAUSI> OF DKATll was as follow. : 
' ■ '-^ ...J...Dr:\AXt.v.^^.i 



/),;r 



T„K^,.„VKSTATK,M.KK...NA,,PAKT,,;r,,-,K--VKK TKrH TO Tm- 
HF.ST OF MY KNONVI.KDCK AND Mhl.Il.l 



Xxx/^rs^"^^-^^^ 



Di; RAT ION \ Vt-ars 
CONTRIIUTORV 



^. 




Montha Days Hours 

KJ^ 



Daxs , Hours 



DIRATION •. Years I Months 

( SIGNED ) . AU.^^ l^ l^^^^^^^^ ,, '^•^• 

\pECIAL INFORMATION onlv lor Hospitals, Institutions, [ransients, 
or Refent Residents, and persons dvinq av^ay from home. 

How lonq at 
Former or pjare ol Death ? 0«»y^ 

Usual Residence 

When was disease rontrafted, ...„..,..,,„... 

If not at place of death ? ..^^^-™. • 



(liiformatit 



i %. (S. 



.4JU\Ji^'^^^ 



( '- 



X.Mress r^ 6 1 




ri,ACK OF lURIAI. OK KKM"NM. 



DAlKo! HTKIAI. or RF;M0VAU 



UXA.' 






\i 



,„tion should be cnreffully supplied. A( 



N. B. Bvery item o^ intorniHi-o.. -..—-- - ^^ properly 

•tate CAUSE OF DEATH in plam -;-:;;;» J '.^cry instance, 
sons dyln^ away from home should be fe.ven 



"" ^ 1 iTVArTI Y PHYSICIANS nhould 



;V; 



»ri 






• ». 



1 t 



* 






hi. 



I' 



ri 



Mi 

r 



m 



u 



i 



. 



}k 






> ' 



I 

II 

m 

i 



ii r ■ '^ 



WRITE PLAINLY WITH UNFADING INK 



,,,,^,„, .,r .,..:.Uh-^fVo.-^^^^^'"-^^^''> 



/)r//^' Filed, S. 




io i^6>H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be mistered J^o, * \'^%} 



i , . Deputy Health ^m^er 

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

Certificate of S)eatb 

( X\. S. StanDarD ) 

J? 0^ A ^ 

^o'4 II ^t. 1 Dist • bet. "iu.a VTX..V and i. X^WtvI. . ) 

TVT U^ rtPl -^A C <- I > ' ' ^*** * .tr, TOP UNDER "SPECIAL INrORMAT. ON" N I 

No. cAvO (JU-L^X^).-.-.^..-^ _ ^^^^^^^ RESIDENCE G.VE '^*^,;j ^^^^^^.^^ , ^S^e^O " STrSeT AN D NUMBER. ) 



) . iiciiAl R F SI DENCE GIVE FACT! 

/ .r DEATH OCCURS ^WAY TROM USJJAL RESIDtlNO _ ^ ^^ _^^ 

V IF DEATH OCCUWRED IN A HOSPITAL OR H 



INSTITUTION GIVE V 



FULL NAME 



..J/: 



..ULUfV-CL 



Id 



PERSONAL AND STATISTICAL PARTICULARS 



L 



LLJxujl 



DATi-: or- niK ru 



(Mr)lltll) 



„,.- /.iH'i 

(Davl (Vear) 



AC.K 



Q O }>ats 



.M.iulhy 



Pa 1 A 



MEDICAL CERTIFICATE OF DEATH 

datk ok dkath J' 



(Month) 



'^ 



(Day) 



(Yt-ar) 




sIN(.I.K. MARUn:i) 
WIDOWKI) OK I)lVoK(i:i) 
'Write iti s<XMal <lt>ii>fnati<>ii) 



lUKTHPI.ArK 

(Statf or Co\intry) 



NAMi<: or 
FA riii-.R 



lURTHIM.ACK 
Ol' I-ATIIKK 

'State or Country) 



MAIDHN NAMK 
OF MOTTIKR 







i 





XX.Ci 



niRTITPLACK 

(>i M(>Tn»:R 

(Statt- or Country^ 




<i\iXL IX^VUslo^ 



HKRlnV CI-RT1F\\ That J attemlo.1 «lcrcasea from 

.^JL^JL 1 190H to ..AA^- ^ ^90 % 

that T last saw h alive- <Mt 5^^^ ^ 190-^ 

an.l that death orcurrcl, on the- -late- stat..! uhovo. at ..-^ 

- M. The CAl'SIv Ol' I)i:ArH was as follows: 

IJlXd^jv^ ^-^^ 

(St. J\-*-*-^'>'CM 





1)1 'RAT ION >''''^'-^ 
CONTRlI'.rTORY 



Lo^^^^^^^«=^^ Crt icAA^x 



Moutha A/.r? 



fhttra 



(•(US 




Months •—■ 



DC RATION 



(SIGNED) J . 





OCCUP 



ATION Q]\(? jj 



M.inlh- 



Pti 1 



THK AU<)VESTAT1•1)1■KKS,)N^1,^AU^^^I,\KSAKK 
H^;ST Ol" ?.L\- KNOWIJ-IX.K ANLL in.I.n.l- 
'^ltifDrmatit 



TKrH T»> '■"»'• 



INDICRTAKKR ^ 







"^^ECIAL INFORMATION only for Hospitals. Institutions, Transients 

or Rerenl Residents, and persons dying av^ay from home. 

How lonq at 
Former or pj^^ ^ „f oeatli ? 

Usual Residence 

When was disease contracted. 

If not at place of death ? •"'•"""• 



Days 



I'l \CK OF lU RIAL OR KKM"VAI 
(AcUl 



rcHs..,.k)..H.3> \jo.lti..yt, 



Dxii; ■>*" Mt KiAi. "I rf:movai. 



rvddrcss 



«3 

I! 



^ ^ , FVACTLY PHYSICIANS Hhould 

7"^ .. «houl.l be corefully HuppUd. AGB «Hou«d »»« "^"''^jf; ..s„,,j„; Information" for pT- 

N. B. F.very Uem of 5nfor.nHt.on nhoul.l He ^«'^« ^ j^^ properly classified. Thv ^pec 

_._. /^Aiicrr nP ni ATH in pinin terms, that .t mH> 1 



state CAUSE OF DEATH in P'" • . . . ^„ ;„ .very Instance, 
son. dylnft away ?rom home should he ft.ven 



y- 



%\ 



L«'-3 



'H 



'■ I 



m- 



; ' 






ID 



I? 



II 



I 



t^ i 



I 

1 

I 

I i 



WRITE PLAINLY WITH UNFADING INK 

^ L>. b ^^^^^ 




])afr Filed , 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Ec^Lsfercd A^o. 1,4:10 



ffh 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of 2)catb 

( XX, 5. StanDarD ) 



J 



PLACE OF DEATH: -County of .' O,^ ^ '^On.^^ex City of -Clav 






cua^.c< 



■No. 




1, ,v 



i 



fl 



^.XVV\/0_AJ V. > y>^.^ V-LV^- > ^-^;' orBinFNCCGIVC FACTS CALLE 



and— ~" 



• — . _«- .lunc-o "cprciAL INFORMATION" | 



FULL NAME 



.£lL^1/: 




(0 



.SJuX,'. 




Ni:x 



DATK OF HIRTH 



PERSONAL AND STATISTICAL PARTICULARS 

i COI.oR < (\ 




u 



\<",K 



iMontli^ 



)'fUli 



(Day) 



M.nil/is 



(Vear) 



Y)<iv.f 



M 



EDICAL CERTIFICATE OF DEATH 



--i^Xr" (Day) (V 



go 

(Year^ 



DATE OF DK 

(Monrti) _ 

rTniRlnn^TKRT7Fv7S^^ I attended deceasctl from 

190 ^~— 



■190 



*^I\<'.I,K MARKTKD 
WlDoWKD »»R DIVOROHD >, 
(Write it) MK-ial (k»ii>riialioii) \ 



TQ" to 

that I last saw h-:^— alive on - -'-'^ ~~ ^ 

a„.l that death occvnred, on the date state<l above, at 
-^\. The CAISK OF DIvATll was as follows : 



HIRTHl'I.AOK 
(Statf or Country) 



_ ciiuX<x>xc^~ 



NAMH OF 

FATHF.R 



lURTHri.ACK 
Ol- J ATMKR 
(Slate or Country) 



MAII)F:n NAMH 
<)I- MOTIIKR 



niRTHPIvACK 
OF M(>TnF:R 
(State or Country) 




I^^vJa^^ki^C) cri-..XA./^>>^ 



.JJX3.NX/\.auL 



DrRATION JVar.? 
CONTRir.rTORV 

Dl-RATION •;-• >V<7/-5 



kI lUILi^^-- A.^^^juxa^'^^- 



Mouth% Day^ 



I lour ^ 



^/'ofif^is 



Days 



Wu^-^vi' 



//out s 
M.D. 



(SIGNED) V^^vv^v V. ...W-.W.- - --^^^-, 

^Xkt H u^\ (Addres. ^VVl^V^^^^ VA, 

■ SPECIAL INFORMATION onU tor Hosp.taK InstitulioiH. Transients, 
or ReTenf Residents, and persons dyinQ andv from home. 



occ 



FFATION J* D 






r. .,'/ 



THKXHOVFSTXTK..-KR.oXA..FARTK;r.,AK.AKKTRrK TO TMK 
HF:sT 01 MY KNOWUl.lX.H AND lU-l.lli' 



^^.^^^^xry^J^*x^ 4\r 



Former or 
tsual Residence 

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



HoM long at 
Place of Death ? 



Days 



,., ACK OF lUKIAI. OK KHMOVAI 



)j^^A^.^^\^'V>U^ 






DATFof I«' KiAi. "r RI-;MoVAI, 



190H 



tnufrtakfr ^- 0-0^^^ "'^'^ ^ 




' '77 ' , f.'XACTLY PHYSICIANS should 

' ! u I 1 K. cHrefully HupplicH. AGB «hould »»« "^^^^^^JJ: ..jT j^', information" ?or p.r- 

:N. b.— F.very item of information •hould be -»;«»"'^y « ^'^ ,,^ properly cl«i.«i«ed. The Special 

«tate CAUSE OF DEATH in P'«'";*^.7':;,*;" /.^rt instance. 
«on, dyinft away from home should be g.^en 



» 



^y 



-ij 



Si 

I 



m \ 



l\ ■ 




I 
if 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^^ ,., ,. ,, REFER TO B ACK OF CERTIFICATE FOR INS TRUCTIONS 

„„„.,!, ,t II. alth FN... ..•*'^=gi;;^H&t ^<^ 

Bo iii stored Xo. 144! 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Xl. S. Stan^ar? ) 



N«. 



PLACE OF DEATH: — County 

( 



of^ a^^?v^>vet^<^ City of ^cv^^' 3 v^^.^vc^co 



^ 



St.; 



Dist.; bet. 



and 



r DEATH OCCURS AWAY FROM USUAL RES 
IF DEATH OCCURRED IN A HOSPITAL OR I 



^'^*» 1^1S> ♦» ♦ iiMnrB "special INFORMATION" N 



■^ 



FULL NAME ^tvvL^ 



V 




XCtAXAJ 



s 1-; \ 



PERSONAL AND STATISTICAL PARTICULARS 



^\. ^ 



^\^Xx 



1 1 \ ri". «»!■ HI Kill 



(Month) T 



(Day) 



(Vt-ai) 



AC.K 



3^ '^ '''"" 



MoHl/li 



l'\ 



Pa 1 . 



i 



-IXf.l.K. MARKIKI). 

W ilxiWHI) OK DIVokrKI) 

■Wtittin siocial desitfuatioii) 



HikTin'I.ACK 
' Stall' or Conntryl 



MEDICAL CERTIFICA TE OF DEATH 

DATK or ni-ATM J/ , , _ 









&t. 



NAMF OF 

iatiii:r 



lURTHIM.ACK 
OI" I'ATHKR 
'Statf or Coviiitry) 



MMDKN NAMK 
<)i MOTIIKR 




c ^XtuLu 



truot V'^cXrv^voAvv 




I HlvHl-HV ClvRTlFV. That I atteiulcl .UMva^^c.l fr-.tn 

...190 — t»» .-•■ ^QQ 

that I last saw h •' " alive on — tr— rrr-r-r-- 190 

and that death occurre.l. on the date state.l above, at 
W The C\rSI<: 01* DI-ATII Nva-. as follows: 

.3 ,O^LL X-vxnr^ 



^^-^-c ca.'v 



DIRATION y^ars 
CONTRIIU'TORV 



Months 



Pays 



JJoins 



DIRATION 



Years 



jro>///is 



Pavs 



r.^o^ '^^ 



nTRTHPUAOK 
oi- MOTMKR 
(Stale or (.'outitry^ 



c 



^XcJU' 



ru -~ 



OCCl'PA' 



.\i\j<AAJ^^^ 



^^JLA' 



] 



h'f>„/r</ ni S,hi I'iniiiisi-o | 



)'.(M 



Mnlttll.' 



n< 



rni-. AU(.VKSIV\IM:i)l'K.KSoNAiM'XKTirri.\R^AKi: TR' H TO 
HKSTOI- MY KNO\VI.Hn<-H A M) HI-. 1, 1 1 l* 

^ AC ^ 



(Informant 



(Address 



is-bV^' vy^vv(AX"c^t 



( SIGNED )U^^wiK- V 4:^.UJ.ajLLaAUS 
&^^ ^ ..oH (Addre,,)UH2}±lii^ 



Hours 
M.D. 



A 1 



SPECIAL INFORMATION onl> tar Hospitdls. Institutions. Iransients. 
or Rerent Residents, and persons dyiny dwd> from home. 

^ Vj Hoh lonq dt 



: u , • Vj HoH lonq di 

■ • . ^AM^r -irf Ail * 



Days 



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



IM \CK OI- HI- RIAL oK KKM.AAI 



I»\XI "• Hi KiAi. or RKMONAI, 

I90H 



Address \^^ ^U^^J^^^ 



^ , FVACTLY PHYSICIANS should 

ATH in plnin tern.,, thot .. m»> ^= P;"''" 



N. B. F.vepy item of inform 

state CAUSE OF DEATn m p.«... ;-■-": instance, 

son, clyinft away from home should he ft.vcn m evcr> 



) 



* 11 

i 






i 



r 



,1i 



m 



Ji^ 




!»■ 



1 



w 



:>1 



i^i 



1 



rt 



? } 



WR.TE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

,„ „„ ,.„....^„.-0., ,r...TOBACKOPC.RT..CATerOR,NSTBUCT,ONS 

n.,,v,1 .,f II. :>U h --!• NO- ' ^ ■•u,>jr^ ■ ■ | f f i> 



Registered J^''o. 



fe /ule(l3±.^pXjLrYy>J^ ^ ^^^"^ 

•^^^^^^^ ^ijLA>u Deputy Hc3?th OfTiccr 

DEPARTMENT OF^BLIC HEALTH=City and County of San Francisco 



. 1 



Cevtificate of Wcnth 

( -Q, S. StanDarD ) 
PLACE Of DEATH:-County of O O^ J-^VCXaa^^^:. Gty of Oa.. J. ^ 

-No. ^C) 5 '! 

( 



^< ■ -*■ -.I'lWt ) 



> 1 ex. ■ - St.; \ ^^^•'^*-ktt:^^'~^^ 

•;. ocx'^oiu. -»o» USUAL ..S.OCNC. ..v.;.c,s c^.^.u^.o ^o^-^--^ ^-=, „„ „„„„. ) 

IF DEATH OCCURRED IN A HOSPITAL OR INST.TUT 



«•■•••**»* 



FULL NAME 




si:\ 



!)ATK OF lURTH 



PERSONAL AND STATISTICAL PARTICULARS 

I COT.OR 





aUxd.: .B ..iCLl..- 

1 V rtvivH (Year) 



\<'.K 



; ivtjts 



M 



Moultis 



W 



/></ vs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(MontM) 



. N«»ii< ■ -wo*"^' 



.1 

(Day) 



(Year) 



ThFRHHV a- RTlFV.l^liat I attcn.lca accease*! frmii 

CLv^ X^...l9oH to |4-^ ^ ^90 - 

OJL.^rvt H up ■ 



.t 



^!N<".1,K. MAKKli:!). 
\VI1)(»\VKI) OR DIVOKCKO 
\Viit«-iii social (ksi^Mjatioii) 



4 



'I q ' 



I?IKTHPI,.\CR 
(Statf or Country^ 



NAMI-. OI- 
FA IHKR 



niKTHPUACK 
o|- JATHKR 
'State or Country) 



maii)i:n name 
of mother 



r.IK THl'LACE 
OF MOTHER 
(State or Country) 








that 1 last saw h-L.^-. alive on 

ana that death occttrrea, ott the date stated above, at - ^.-. 

(j M The CAUSK OF DI-ATH was as follows: 

. ..;i)..a^t^^. . V„'^^L^ • 













T»i-ij \'rr<iv )'eays — 


1 

Months 


':■ Pays 


Ilours 


\)\ K A 1 1V7a> — ' '"* 




CONTRIBl'TORY 



Days 



Hours 
M.D. 



^fUixHxrLoi-- 



) V-tr / . 



\ .\f,>ntli^ 



J'hl 1. 




OCCUPATION 

Residfd in Sa n /■'> n in /.•■>'<> 

THE AHOVE STATED PERSONAL IVtJ^^.D.Sbn'''' '"'' '''''' ''^ ' " ^^ 

iJEST OF my,kno\vij:i)«-.E^am) ukmkf 



.■.w....^Vi: i...tU^: -k 



(SIGNED) i .\IV....UM^L.a. 

'jLi\.':- ' TQO ( ^ . J 

■ SPECIAL INFORMATION ..ly 1« "«Pi'*' !"*'""»«• '™^'""*' 
or Refelrt ResMents, and persons dyinq a.av from home. 

Ho>* long at 
Former or pi^^p of Death? D«>y^ 

Isual Residence 

Wiien was disease contracted, 

If not at place of deatli ? 



(Informant 



f Address 






I'l.ACE OF TU RIAL «)K REMOVAL 



rNI)F:RTAKF:R > 



DATE"! IS.KiAt or REMOVAL 

fA c \vfc b 190 



LVMres* w v >w ^ i \ 




N. B.— Bvery Item of information •houici be -«;«*""y « ^»* j,^ ^^ope, 
state CAUSE OF DEATH in P'«'" J^/"'"*:;J;"V evTy instance, 
sons clyinft ow.y from home should be fe.ven 



, , FVACTLY. PHYSICIANS should 
.pplied. AGF. f-;^^:i:,:i-*^:;Hf '^Special information" for p.r- 
««v be properly classitied. I ne 



8 

) 



• 4 
1 1 



-H, 



Id 



i 



■] 



8 \ 



iii s 



i A 



i 



Il.iiltli- !■ 









WRITE PLAINLY WITH UNFADING INK-THIS IS A PERIVIANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©catb 

( Xl. S. StaitDarD ) 



Oil 



PLACE OF DEATH:-Coun,y of ea^.W.vC..<^o CUy of 'Vv. dA^.vc^c. 



JL3 \hi'\yc\\ AT ^-4WwOUV St.; ^*^*** * r«B UNDER "special .NFORM*T. ON • \ 



FULL NAME 



K 



LuO-MX^^^xo U.excAv^'va.^^^^'C 



PERSONAL AND STATISTICAL PARTICULARS 



<i:\' 



mUcJji 



C(>I,<»R 



vV^VLttX 



li\ 1 1-: ul lilRTII 






Ai.K 



15 



) 'nt » s 



.11 

(Day) 



M,>nlli> 



/m 

(Vear) 



IH 



Pins 



MEDICAL CERTIFICATE OFDEATH 
DATE OF DKATM -A , , ^ 

(Day) 



(M«)nth) 



70" ^ 

iVtarl 



rTlKUKnV CKRTIFV. That T :^ten<1o<l rkrcasccl fmn, 



to 



, .gxivfc Si- 



up 



>^iN<".i,K. MARK n:i) 

WIDOWKD <»K I)lV»)K*i:i) 
Writrin s<H-ial rh-^ij^nati-Mi) 






Cj.u^va 




HIRTin-KAOK r\ A A H fU A) A 

(Statf or C"<M\ntry1 , ^ . \ V Aa ' | V 



NAMK or 

lATHr.R 



lUKTHl'I.ACK 

oi 1 ArilKR 

I Stale or Cmintry) 



MAIDKN NAMK 

OI' M<vnn:R 



mRrnPLACK 

01- MoTHKR 
fstatt' or Country) 



^ 








lIva-cl. B-^ 190 '\ ' X \ 

that T last saw hi.-^^'- alive on O-c^vt 

a,ul that .Icath occurred, on the .late staid above, at ^ 
CL M. ./rhe CAISI.; Ol-" DI-.ATII was as follows: 

'\JU\\.<kAj:><^t/>^ >- 







( SIGNED )..yj.:. V 




Months \ /^'n'A- 



Hours 
M.D. 



OCCUPATION 

Kf^idni :ii S>in I HI II, ism 



^jjfccLU.^ 



t 



) V<f / > 



— M.wth- \ \ '^"'' 



■VUV. AHOVK STATKl. rKRSONAl. •') « ';|^,',^^'^" ^ '^ ' ' '''''' ^ ' ""' 
IIKST OI- MY KNOWI.KDC.K AND m-.I.Ul 



; SIGNED i..»^.:. V. v^ ^r 



SPECIAL INFORMATION only for Hospitals. Institutions, Transients. 

or Refent Residents, and persons dying away from home. 

ry . (^ How long at 

Former or , U ^.AjC \^oX Place of Death 

Usual Residence i-' iruv'^^ 



Usual Residence 

s dis 
plar 

PI ACK Ol- Hl-KIAI. OK KKMOVAI. 



Days 



Usual Residence ^ ^ ^^ ^; n 
When was disease contracted, vlSvdla CclV 
If not at place of death ? ^..rv^v^ 



i)\i:i-; of Ml KiAi. OI ki-:mo\ai. 



)JL\^ ^ 



(Address ... 






i9o\ 





OF DEATH m plain terms, that .t ma> ^'»*^ »» » 



N. B. F.very item of 

state CAUSE OF DEA in m p-h". 'V" "r: '" i„ every Instance 
sons dyinft away from home should he fe.ven m 



) 



n 




h\ 



i 



'If 



m 



i; 



WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

..™. REFER TO BACK OF CERTIFICATE FO R INSTRUCTIONS 

Be mistered Xo. I 



OO'i 



^ccr 



DEPARTlENTolf PUBLIC HEALTMty and County of San Francisco 

Certificate oi ©eatb 

( tl. S. StanDatD ) 
PLACE OF DEATH: -County of J A^ .^ sJA.O.'n e, a^ Uty 

V IF DEATH OCCURRED IN A HOSPn<". « ^ 






FULL NAME 



AXtdw^Or^vi > 




PERSONAL AND STATISTICAL PARTICULAF.S 

DA IK or IIIRTII 



ACK 




^Qp%^ 



MEDICAL CERTIFIC ATE OF P ^ATH 

DATK OK I)1:aTH _^ 

i 




UN 
h) 



(Day) 



IQO 



I in:K»:iiv 



cT'RTIl'V, That I attended deivascl trotu 



IgO^^-^ to 

. alive on "~ 



SINC.I.K. MAKUIl.l) 
WIDOWKI) OK niVoRiKH 
(WnUitv MK'ial <U-siv:niiti<>ii) 




UIKTHPI.ACK 
(Stiitc or Ooiititry^ 



N'AMK OK 
FATHKR 



HIKTHPI.ACK 
Ol' KATHKK 
'State or Country) 



MAIDKN NAMK 
(U- MOTHKR 



lURTHIM.ACK 
Ol MOTIIKR 
(State or Country^ 



OCOI'PATION 



\ . 



that 1 last saw h 

a.Hl that death occnrred, on the dale stated ahnve, ai 






— :;^..M. The CAl^Slv OF DHATH was as folUy : 



/ 




DIRATK^N * JV^'-^ 

CONTRIIU'TORV 



A/ofi//is A"'^ 



Hour. 



DURATION vis >V'^''-^ 



Mouths^ Oays 



NED) ij^\^^ 

(Address) l.^^^ ^^iA^ ^^^ '-^ 



Hours 
M.D. 




Rf sided in San I'lmui^ro 



V^ars. 



\!oiitli^ 



Ihiv: 



\\\ v. A n< ) V K sr A ri-. I ) r K R SO N A 1 , r A R I- 1 ; - K I . \ 

nKST OK MV KNOWI.KIX-.K ANH HKMIl 

'•0 



\Rs \Ri: TRKK TO THK 



(SIG 

-SPECIAL INFORMATION only i«'llo"^is. lnslilutio«s. Transients, 
or^ren^isfde'-nts, and persons dying away from home. 

How lonq at 
former or pj^fe of Death? w^y** 

Usual Residence 

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



Informant CtJ^^CP^Xi-A^ Ui-|A-^A 



(Adilrcss 



,,XXi: ..! M.Hi.u. or RKMOVAI, 



r^.ACKOr lURIAU OK KKM(»VAI. 

t-N,)KRTAKKR >- ^ ^V ^ ^ ^ ^ ^^ ^^ 

(Address ^^ *• ' 





— — ^ , .. i;-,i AGE should be stn 

N. B.— Ever. Iten, o.' ,„fo.n.«t1on should he --tuMy «upp. e^ • ^^^^^^^,^ ^,^^^,,,,,. 

state CAUSE OF DEATH in pl«.n -7»:;;; „ ,,,,, instance. 
J. j_^ „.„-„ «..om home should be fciven m 



. I FVACTLY. PHYSICIANS should 



sons dying away from ho 



IS 



i 5 






^! 



il 1 ' 

I 



1 



n * 



i i 



ll 




* I 



WRITE PLAINLY WITH UNFADING INK 






}i(i;iril 'if H 



, Mlth-F No. IS '*-t3^THS^TC< 



i i \.. 



b I'JO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

EeL^istered JVo. ? 44o 



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



Cettificate of ©eatb 

( tl. S. StanDarD ) 






-N 



o. 



PLACE OF DEATH: — County of 



^l<xl 



*AyOj City of 




\\.'<X:. \.oX 



Dist.; bet. 



and 



rO ^\W^ • <^^V^ St.; ■ L)ist.; bet. ^^-";;;-"::3„c>al .NroRM.T.oN- >i 



) 



FULL NAME cLun^ 



(ax.JUuw0 



PERSONAL AND STATISTICAL PARTICULARS 



si':x 



vn\. 



ex 

;)\ ri-: or- HIK TH 




COI.OR 




a\'^JLL- 







(Day) 



(Year) 



ACK 



Years 



.y.n,(/is "...: ^^"■'' 



MEDICAL CERTIFICATE OF^DEA TH 

nlTlTo^DKATH ; 

d.JLki ^^'- 

(Month'* <»*y^ 



igo 

(Year) 



riTl^RT'HVoiRTlFv/ThZT^tte.i.le.^ .Icccascd from 

— to - • "• 



190 






SIN«-.I,K, MARKIKI) - 

winowKn «>K nivoRCKi) ,\ 

Write in social (Ksi}.rnatu)n) \ \/ 



ISIRTHPI.ACK 

(Stall- or Connlry) 




.OJ\J^JsXQ^ 



XAMF or 

lA'lllHR 



HI 



niRTH PLACE 
O!- I-ATMKR 
iStatr or Conntry) 



MAIDKN NAMK 
OF MOTIIKR 



mKTHl'I.ACK 
oi- MorHKR 
{State or Conntry) 




that T last saw h ■ alive 011 ■-r-r---rr:rTTrr:rr::^^ 

a,t.l that death occttrrea, cm the .late state.l alxne. at ■. - 
y^ The CAUSR OF \n''.\'\\\ was as follows: 



.C^1 



DURATION years - Souths 

CONTRIHl TORY •• 



Days 



Ilour^ 



DTRATION 
(SIGNED ) 



Years 



J for/ //is 



Ptivs 






//ours 
M.D. 



OCCUPATION (^ 



•tJi^ 



/'./ 



THK AHOVK STATKI. ^'HRSON A 1 ^ J KTUr I,N,K> AKl, 
IIHST OF MY KN0\VM:D«.K AND lU.Ml.t- 

f,„f.,nnant \Ii)\CK^^ I) CX-^^XL^ 

1.0 loTcuu^oii) oi 



iqO 



( 



A.l.lrc'.s) \)\^^ka 



"special information «1« I«. «.sp,Uls, ln.lil.ti.ns. Iran.ie.h, 
,r RtfeS ReskieVs, mi persons d>in^ a*a, lr»™ Um. 



How long at 
Pla( c of Death ? 



Former or r'>, M^A^vi 

Usual Residence^^ ^^ Y^'^- ^ 

When was disease contract, ^^^ 3.A^>^<C«. 
If not at place of death? w.-vw»^ 



' ■ T- 



Days 



PLACH «)F lURIAI. OR RKM<>VA1. 



DVTl'-of m-KlAt. or RI:M0YAI. 



INDHRTAKKR 

(Aildress 






^'^*^'^"*^^^ -- ^ ' ' . 1 FXACTLY. PHYSICIANS «hould 




) 



« f I 



it't 






♦'4 



i 

i I'ill 



WRITE PLAINLY WITH UNFADING INK 

1 r 1 1 , ,, M 1i K Vn I < '1?^>Mift'3^ H&P Of) _____ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da 



.VLA^Ui 




Ecs^i.stered •A^'o. 



! 446 



Certificate of Death 



PLAC^ OF DEATH:-County oi^Cu-r. i^.o c. Gty of .-.'a^ ^Ia^O.--^"' 



) 



FULL NAME 




idLurt' 



\ 



SKX 



PERSONAL AND STAT ISTICAL PARTICULARS 

COI.OR 



Ofr.cJL. 




(-uJj.^ 



DATE ol" HIKTH 



(Monthi 



(Day> 



(Year) 



AC.K 



...l.L )v<j*> 



Mituths 



Pa t .V 



DATE OF DKATH 



MEDICAL CERTIFICATE OF DEATH 

ol 




(Day) 



(Year^ 



SINCl.K. MARKTKD 
\VM)<)\Vi:i) OK DIVOKiHI) 
(Write in Hcn-ial (UsiKnation) 



^ 



TUKTIIIM.AOK 
'Statf or ♦.■<)imtr> > 



UJ k. dLo uu-t cL^-^ — 




I- ATHKR 



,4.A.A>^M "wKaj 



niRTnri.ArH 

OI- I-AIIIKK 
(Statf or Country') 




MAIDKN NAMK 
Ol- MOTHKK 



lUK rniM.ACK 

Ol- MOTHKK 
(Statf or Country) 




FinrRKnVCI'RTIFV, That T attcn.U-.l <lerca<;e(l froni 

4 <iarf.^-X>.L !»ru5>^lJ:W' 190 to ... .„LLLl.Qp ..^C i9o'\ 

that I last saw h ... alive on U-'^^^ A:i I90H... 

an.l that death oceurrcl, .>t, the .late stated al.ove, at b.-^.O 
Q ^I. The CAl'Slv OF 1)I:AT11 was as/olhms: 



^-^ 
^ 




r 

I 

r 




DIRAtToN ^ )V'rt;'5 Months Pays 



Hours 



CONTRIIJUTORY 




XXckjl 

Years ^Months 



Pays 



X/> 




Dl'RATION 

(SIGNED) y.>/-v.'r^.^. -^ 



Hours 
M.D. 



^I3x^ 



yfotiih^ 



Kfsidfil ill S. Di J'i'hth l>rn ^ '''^' 

HKST OI- HY KNi)\VM:i)<'I'. AND IM-.lJl.l 
(Infonnant O i^ HtrAyYvl 



SPECIAL INFORMATION «nly for Hospitals, Institutions, fransicnts. 
or Recent Residents, and persons dying away from fiome. 



Former or 
Usual Residence 

Wl»en was disease contracted. 
If not at place of death? 



How long at 
Place of Death ? 



Days 



l'JL,ACH OJ lUKIAI. OK KJ-;MoV\I, 






Dvn-; of m uiAi. or ki-:movai, 

190 



rNi)i-:KTAKi-:K 



A^-CX- 



\ 1 

(Adflress .^..Lb... O A^. 













_^.,,^_^_i,ii.i—^—————^— ■■""■"■■■■■■■■■■■"■■'■■"" . , , L tatecl FXACTLY. PHYSICIANS Hhoultl 

N. B.— fiver, l.en, of .„!„rn,a.ion .hou... be c„r.Su.l, .upp.ie.l ^'^^'"^.'^Jnli, Th^ "Spcci.. Infor^.tion" .or pT- 
.i.tc CAUSE OP DEATH in plain lerni». that it miij He pr 'I 
"n. <ly*n» «w„ fron. home -houUi be ftiv.n in .ver, inM.nc 



I I 



1: 
I 

41 



■ i 



Hi , 






'f. 

I 

%■■■ 




1 



[ 



i 



i 



M 



il 



1 



u 



WRITE PLAINLY WITH 




f/r /7/^^/,....ax>^plx^mi^ -^^^'< 

-^ ^ DcDUty Health OfTicer 



UNFADING INK-THIS IS A PERMANENT RECORD 

RtFER TO ...r. . nP r.FRTIFICATE rOR INST RUCTIONS ^ 

11 ty 



Be^istcrod J\''o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County of 0.<X>^ ^' '-^ ■ 



Certificate of Bcatb 

^ ' City of a >v XOAVCAA^^ 



rNo. 



a J V^\% St.; k Da.,^bet.M IlU^^^t.- .^ ^Si^f^'^'^- 



•ist.; bctM m 



FULL NAME 



Liu^lj vli./ahAiJ:^^. 



Jxt\ 

DATK t>I' HIRTH 



PERSONAL AND STATIST^CALJPARTICULARS 

COLOR 





UxajLl. 









AGE 



,13. 



'mr$ 






M.tuths 



/.its, 

(Year) 



MFDICAL CE RTtFICATE OF DEAT H 

DATE OK DEATH 



M^t ......:^-^ 



I go 

(Year) 



- - K prrr- to '^ 

that I last saw h r— "alive on 



r— n/D 



11 



Da\i 



SINCI.K. MAKKIKI) 
WIDOWKD OR DIVoRiKD 
Write in stK'ial tUvij^natioii) 



BIRTHPLACK 

(Slate or Ootmlry^ 




NAMK OF 

I- athi:r 



HTRTHPI.ACK 
OI- l-ATHKR 
Stale or CotJiitry) 



MAIDKN NAMK 
OH MOTHER 



HI RTH PLACE 
(H- MOTHER 
(State or Country) 







that 1 last saw w • , 

,„„, that ,U-atl> „courrc,l. .m Uu- .1... ^t,....! above, at . -S-^ 
.. ..s) ,M. 'l-hc CAl Slv OK I.IC.XTII was as follows: 

5 I 4 - il^ { /vx vr^ v^^ \Jxx^.vW^AXv.o:)x.... 



.(iv..c^ &v 



.<^. 



DUKATION •• rears ■ mnths 

C ( ) N T U IliU r ( ) R Y •-' 



Pars 



Hours 



DURATION -Ti;:- ^'''^''^ 



...^..,cays ^^o^ths Pays 

AA^ ' Tc)o" r.^.l.lre>;s)U^t.V OL^.^^•fV-"-• 



//out s 
M.D. 



SPECIAL INFORMATION only lor Hospitals, Ins.it^rons. Transients, 
or^efen^isfdc'-nls, and persons dying a.ay fro., home. 



OCCTPATION 



; n<i\ 



.n,K.,..,VKST.VrK„,.K K:^.NAK.;AKTU;.,;,^K>AKI.TKrH To T„K 



Former or 
tsual Residence 

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



How long at 
Place ol Death ? 



Days 



I'LACEOP lUKIALnH KEM..VAL 




KXX', 



uwi..,' lit RIAL "^ ri:m(»val 



X 






INDERTAKER 






( X.Mress VJ/O^^^^ ^ ^ ^ " ' PHYSICIANS nhould 

' ..K -n.cfully Hupplied. AGE should ^t^.T^^Th. -Speclai Informalion" for pT- 

^. B.— Bvery item o? •.n*orn,Btion .hou d H^--;;'^^^ f^^^^. He properly da-s.t.cd. The Spec 
•tate CAUSE OF DEATH In P'«';;J^;;';:,t" „ every instance. 
«n^. dyinft away from home should be ft. e 



IS 

9 



r) 
11 






1, 



W'- 






in 



r ^ 

I 



w 



WRITE PLAINLY WITH UNFADING INK 




l)((/r FiJffh.D 



V^j 1 



lOO'i 



THIS IS A PERMANENT RECORD 

REFER TO — -" ^rPT.PtCATE FOR INSTRUCTIONS 

Registered ^'o, 1448 



Deputy Health Officer 



DEPARTNENT o}^ PUBLIC HEALTH-City and County of San Francisco 



Certificate of 2>eatb 



PLACE OF DEATH:-Coonty oAoj^i k<xv ^. . Gty of 






DEATH OCCURRED IN » H05Fii«i- v/ 

A A /it 



' ) 



) 



. 



FULL NAME 



si:x 



PERSONAL AND STATISTIC A L^AFmCUJ^^ 

' ^^^''^^^ ^N () . 




^:.TNa,.yjJLA:^'>^^^fc^^ 



1U< 



I)\ IH OF" BiKTH 




y 



i^-WsJL- 



t 



, .K^ixJi '^■^" 

.4,nthJ ___________L^^1 



.r%5': 

(Year) 



AC.F. 



_ 0,1 Vfats _;:i^ 



M.mths 



lA- 



/)(! I A 



^INr.l.i:. MAKKIKI). 

wiDowKi) OK nivourhi) 

(Writfiii social (Usivniitiuii) 



^!)V<XVvOLcL 



■——^ I^EDICAL CERTIFICATE OF DEATH 

D.\TE OF DKATH ;}( i i I 

OxvOa V 

(MontL ______-._iP^^^ 

irrr^Rl^V CKRTIFV, That I attenaca clccease.1 front 

\^ % ,90a to ... dj4^....^ ^90^ 

tliat I last saw h ^.>:>^ al.vc on ^-M- ' 

a,„l that .Icath .K:currc,l, .m tin- .lat. slat..l ahov.-. at 
.,,a,M. TUeCArsUi^..!- LL^VTII was^^as, follc.vs : 






. igo 

(Year) 



HIRTHPI.ACK 
(State or Country' 




.\JlL<X-^>'^"'CL 




NAMl-: OI" 

f.\thi:r 



HIRTHIM.AOK 

OI- lAIMKR 

• State or Country) 



MAIDKN NAMK 
01- M»)TUKR 



HIR rniM.ACK 

oi- MoTin:K 

(State or Country) 




I 









DIRATION ^ Jl''^''^ 
(SIG 



i}fouths 



Pavs 



NED).U3, ^ IjtCA^di. 



--.. .^5 0oV>J^^-'^-': 



flours 
M.D. 



ipECIAL INFORMATION -» l« H^P"-'^. I»^'"»"»-' '""^'""• 
.rimirt Re*nls, and ptrsons d>i«J a.d, Ir.m home. 



OCCl 



jtxJlAjJ'^j^^^' 



I,. 




„ , ■ Ovw \J0. Ubj!y>->-A,tl 

(Iiifonnant yu rVYv >«-"^ 

' AcldresH V v v ^ ^^^^^^ 



Former or 
Usual Residence 

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



tloH lonq at 
Place of Death? 



Days 



DA'n: "! ItiKiAi. or KHMOVAI, 




.-Ji. 



, ■ i-f 






:r a^/rw^: ^.0:^.::: :r,.r:. .;..„ •. — • 



9 



) 



r) 
u 



^1 



¥. 






4^ 



!i! 



I 



1, 






' 1 






WRITE PLAINLY WITH UNFADING INK 



H&l»Co 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF C ERTIFICATE FOR INSTRUCTIONS 



1 



190\ 



Registered J^o. 



\\V) 



IthD-fTfcr 



DEPARTMENT OF PIBLIC HEALTH-City and County of San Francisco 



Certificate of ®eatb 

( la. S. StanDarD ) 



PLACE OF DEATH; — County 



No, 



\j^.\ 



of d OL "rV 

St.; 



^ 



Q^ 



vj,\„CVTVcv.4,.c.(:City ot J /u^^^ ^ 






f^ 



c\H5 C 



^ Dist.;bct.O.AA.LU:rv 



LU.:y> 



and 





,„ rna UNDER "SPECIAL INFORMATION • \ 

„ USUAL BESIDEN" -vtJ.CTS «.J^eo --^-"IP 3,,„, .„„ „u„B... ^ 



FULL NAME 



:xXL^ m...^-L:Xu-^^ 






SEX 



DATK OV lURTH 



PERSONAL AND STATISTICAL^ARTICULARS 

COLOR 





k/Lix— 




(Moiilli) 



\± 

(Day) 



V..U.I 

(Year) 



\C.K 



^INC.l.E. MARKll-I) ^ 

WinnWKI) «)K DlVoRCKn 
Write in sjkmiiI «ksiy:nalii)H) 



1^ Vr^ns....^^:^^''""' 

L 



lb 



—-——'-■ I^EDICAL CERTIFICATE OF DEATH 
DATE OK DEATH -^ , . L 



(Month) 



(Day) 



(Year) 



Pars 




lUK rUPKACE 
'Statf or Country > 



NAME or 
I AT HER 



RIRTHPLACE 

(>|- FATHER 

• State or Country) 



MAIDEN name: 
OF MOTHER 



HI RTH PLACE 

OF" mothe:r 

(Statf or Country) 



I 



"1 



,<X>^x^-cLo_ 



'■hjL^ .90^. to i>.^i^~- -^ ^^ 

that I lastsawh.i- .'valivcon ■^ M ^ "^f^ 

a„,l that ,U-ath occurrea, on the ,.atc staU-l above, at i 

U M The CAfSIC Ol' Ill.ATll «as as follows: 

L.IS'.aJL^.^'-^:^'^-^-^^^ 



Xj'ysyyyJ^ 



DURATION 




CONTRIBrrORY 



'ears ■-^'- i'""-'"- a r\ ' 



Jfonf/is 



/hiys 



Hours 
M.D. 



( SIGNED ) C .%. '^''^^^")^":n 5 [ -[■■■'■; 

-SPECIAL INFORMATION "^'P""^' '"«" "^' '™"""' 
.r^ere«U«idrnts,Vnd prso»s ,lyi», a.« Iron, home. 






THE AHOVE STATED ^•HRS.>NA > FJ KT jC , J ARS A K F". TR. K 
HEST OF MY '<>V!JL^^\''^-'^V) »»•''"' 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



f'\^<yj\. 



HEST OF ^'\'^7Vv n' ^ 
(Informant V OlO . O A" 

r\,Mrcs« I ^^ vy^-v-A-^ 



UATi:..! m-KiAK or REMOVAL 

JLhp^ "^ 




190 



m,ACE«)F m RIV. OK KEMnVM, 

l(lress...Ny l*- ^ 



FNDERTAKER 

(Ad 






9 



r) 
II 



Ij 



I . 




WRITE PLAINLY WITH UNFADING INK 



„„ ,,,, ..fHealih^-H No- '^-^'^^SS^. 

j)(ile Filed, 



It&PCo 



WO'K 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FO R INSTRUCTIONS 

Registered J^o. »*^'' 



DEPARTMENT^ PUBLIC HEALTH-City and County of San Francisco 



Certificate of S>eatb 

{ Xa. S. StanC»arO ) 



J? 



PLACE OF DEATH: -County of6m^^<X) 



City of Oa^vtou V]ltv-<La. us. 




,1: 



No. -^ 



E>ist.; bet. "-:.....:„ ■cprc.Mt mr^v 



— - — St.; Dist.; bet. „_ y^^^^ •■spcc,*t iNroRMAnoN- ^ 

FULL NAME W-J^^:*-^^ 

MEDICAL CERTIFICATE OF DEAJTH 



SEX 



n.XTK «>F HIR ri! 



PERSONAL AND STATISTICAL PARTICULARS 





%\ 1%^-^- 

(Day) <^'^«''' 



.i>. 



<Day) 



(Year) 



xr.K 



HH )v..^ , _H; ;,-, -^'""'^--i:*!: 



Da\. 



'^INt.l.K. MARKIKI). 
\VIl>()\VKI> OK I)IVOK(KI> 
(Write ill social dtsivMiatioiw 



nikrjuM.AOK 

(State or C<«nitry> 






DATE OF DKATH J 

QxK.Ij 

(Month) ^ — 

Tu ICRlUiVCl-UTIl'V, Tlmt 1 .tU-„.1..1 .UaascMl from^ 

. , ^' loO •-"■ 

- — :■- 19O t«J "* 

that Hast saw h ■ - alive on ----r------'--''-''^^^ 

,„a that death ocotrrcl. <.n the .late slatcl ah..vc. at 

— — AI The C.USI-: OI' I)I-:ATU was as follows: 

ciw^^. a.w:,4,t. D.-.^-^ 



^90 



!• A'lni'.R 



yUKTHl'LACK 
ol- lAlUKK 
iSlati' or Coutitry) 



YciXis 





M ON I /is 



Days 



//()nr<; 



Months 



Pays 



h\}^%\o\k 



MXIDKN NAMK 
OI- MOTHKK 



lUK'nilM.ACK 
<»1- MoTHlsK 
(State or louiilry* 



oiCri'A TION 



LU 



a.>vL< 



^vy,.-..^ rlA->vLc^M^^^-^_ 



AjtMiOj ^^ 



Hours 

M.D. 

o ' 



„r^«Jisidr';i' a.d p«««s d,in, «-> I'"" *"«"■ 



Former or 
Usual Residence 

When was disease contrar led, 
•f not at place ot death ? 



How lonq at 
PJaie of Death ? 



Days 






(Info?mant 



,. IV). Lcu\.ll- 



cxn Mij X<rVo^. ..LL%^:-^ 






l,.\Ti:..l H< K.Ai. o. KKMOVAU 

190 









rvMrcss 10^ I ^J Aj '^ ■■ ^ ^.^. %Mg ,iio..ld 



NS 

9 



r) 
11 



"isfc 



I 



..'I 






H 



I 



u 



I 



i 



•■1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoar.l of Hcalth~K No. .5 l^^^U&F Co ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafe Filed,. Q 




.1 



lUO'i 



Begistej'ed JVo, 



I iri J 



-o-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "CI. S. Stan&arD ) 



^ 



PLACE OF DEATH: — County ofCJOy^v J^ucx'-n^^.Aeo City of V ) XX/^X' Ac , 



(No. It) (LmaKA; l.JLKhJX.^\ 



St. 



Dist.; bet. 



itL 



^\j 



and 






/ IF DEATH OCCURS *W*V FROM USUAL R E S I DE NC E GI VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION • N 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 






FULL NAME 




iAAAA;...vJ. X^U'C^\^.CLl).. 



: LiO/j 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



1).\TK or- BIK IJl 




\jxix 



CO I. OR 



otolith) [^ 




(Day) 



rl^^l 

(Year) 



■AC.K 



1 



) 'ra I s 



MiDilhs 



\X 



navi> 



SINC. r.K. M.\RRIKI). 
WrnoWKI) OK DIVORCKI) 
(Writf in sot-ial iksi^iiatioii) 



HIKTHPL.XCH 
(Statf or Country^ 






N.\MK Ol' 
FATHKR 






HIRTHP1,.\CK 
Ol- lATHKR 

(State or Country) 



M.MDKN N.\MK 
OI- MOTHKR 



lUR rinM..\CH 
Ol- MOTHHR 
(Statf or Country! 





7vraA<:n3ob„ 



OCCri'ATION _\ n D 

Kfu'dfil in Sint /'i tim i^ro ' 



^ )V,/;v 



Mntlth^ 



/hi v." 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DHATH V 



.Qxkt 

(MontHi') 



h 

(Day) 



(Year) 



I HKRI^JV CI'RTIFV, That I attendtMl .Ictcascd from 



dx^-Cl .fe. i9o"i to dx.yA...(o i()0 A 

that I last saw h i.- > • alive on d-A.^\l' A. 190 
and that death occurred, on the <late stated alxne, at i- o 
y»^ M. The CAl'SH ()!• DICATll was as follows: 

.0.X<L-O»/.^V\^i-<itJ. 



DIRATION )'fars J/ouf/is Days Ih Hours 



DURATION Years Mouths A^C' Pays 



(SIGNED) 



Hours 
M.D. 



I()0 



(Addrc-.s) IS I ^AvtitVL'^i 



SPECIAL INFORMATION only for Hospitals, institutions, Translfiits, 
or Recent Residents, dnd persons dying andy from home. 



IMi: AMOVE STATKI) I'KRSONAl, I'AK IKT I.AKS A K )■ IKll-: K » THK 

iii:sT OI- MY KNo\vi,i:i)c.K AND ni-:Mi-:K 



'iTiformant 



Former or 
Usual Residence 

Wiien was disease contracted, 
if not at place of deatii ? 



How lonq at 
Place of Death ? 



Days 



ri.ACK 01* lURIAI. OR KKMoVAI 



l)\Ti;of niKi.M. or KKMOVAI, 

OX/Vv^- ^ 190 i 



L\x\vt. 

IMH-RTAKHR ^OXr^"^V :V(AAJI LlAVcijl\i.CLVU'VAiC^^t 
(Address ^Ht^^Uv^l.^ Vt NY :N 



L^vxa^ 



N. B.— Bver. Ite. of i„for.natlon should be cnr.ful.y Rupplle... AGB should »>« '^-^^^^f .^5^J-,^;, .r^j.^W' Vr'^:!." 
•tate CAUSE OF DEATH in plnin term., that It mH> be properly classified. The Special Information for p«r 
Rons dyinft away from home should be ftiven in evory instance. 










' ^' 



11 



. 'II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„„„,, ,.r iUaUh-|-s-o...-8^g»HS:l-Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



M 



^ i 



Vale Filed,: 




.1, 



lOCi 



Eegistered J\^o. 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bcatb 

( 'CI. S. Stan^ar^ ) 



^^ 



(No. 



PLACE OF DEATH: — County of 0,<X^^ A.<x^vcc^ City of vJ ov <x/>^.c<.^i/c.c 



\0Lh.L{>Jl:)aAl\>;laJ.. St.; Dist;bct. .. -— - ^nd - 

/ IF DFATil OCCURS *W*Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER ' SPECIAL INFORMATION ■ \ 
( ,FD^TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




^Ll- 




Ol^l 



1 



PERSONAL AND STATISTICAL PARTICULARS 



DATE OF HlKTll 



COI,OR 




(xvix 



(Month) 



(Day) 



(Year) 



A(.K 



.25.H. .. J 



'ears 



Motith 



's ..a\.c^ 



Davs 



S1N«-.1,K. MARRIKD. 
WIDOWKD OR DIVOKCKD 
(Write in social desiK'uilion) 



xv^^cL 



HIRTHPLACK 

Statf or C'onntry^ 



VAMK OF 

FATHKR 



t 



HIRTHl'LACH 

(M- iathf:r 

(State (jr Connlry) 



MAIDKN NAMK 
()!• MOTflKR 



lURTHPLACK 
oi" M()THF:R 
(State or Country) 




_ L>.\ji/Louxwii^--^ 



:crPATiON "Xv' f| 

Rrsiiff,! in Suit /'idihifrJC O 1 JV^ 



rjt '^. ..jVi'iif/i' 



I hl\ 



THl- \H()VF ST\ ri-n I-KU^ONM. PART h" T !.A KS AK l- TKIK T< ' TIIF. 

iiF:sT OF MY kn<>\vi.i;i)<",f; and hi:i.if:i- 

(Inf<.:niant J .AyVv"\^MJt-VL^ ^^'-Ow.'' '' 

-A 

fA.i.ircss bbH }vDa>^AA^.t!>v Jt 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



(Month!) 



(Day) 



IQO . 
(Year^ 



'^ 



^4' I 



I HRRF^RY CKRTIFV, That I attciKkil ilcccascd from 



I90 V 



to 



UL..l\Ai...-S. \ip\ 



"t 
that I last saw h .. aHvc on Q^ivl Z' up 

v> 

and that (U-alli occurrcil, on the date statocl ahovi", at 

...y. M. The CAlSh: OI' Dl! A TH was as follows: 

LL^t^.lAJL:>^A.c^ ■■:■■- 



DT'RATrOX Vc^rs 




(."aNTRIlU'TORV 



Months Days 

\^X 



Hours 



X,SjiLS~ii. 



DTRATION Years Months 

( 31GNED ) V.\-VL^Va.aAj 



Davs 



ilvtix.^ 5. fc ^slv^^U 



Hours 



lt)0 



(Add ress) Q t A] IVaV^x^ JV C^ v 



M.D. 



s, Instifu 



± 



Special information onlv for Hospitals, Instifufions, Transifnts, 
or Recent Residents, and persons dying anay Iron home. 






Former or 
Usual Residence 

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



\ 



HoM long at 
Place of Death ? 



Days 



DA if; of HiKiAI. 01 Ul M()\\I, 

BxIaX V 190 



pi.\cf:oi" iuriai. or rfm<i\ai, 

UNDERTAKER NuAj. L Ur>V >X<3rV ^ V^ 



(aLss Ul QfX^^^C<rv^ ll 



■ •I ArF should be stated EXACTLY. PHYSICIAIN8 should 
IS. B.— Every item of information should be cnretully supplied. ^^^^;^^7,';^ J^j^^" ^he -Special Information" for p.r- 
state CAUSE OF DEATH in plain terms, that .t may be properly class.Vled. I he »p 
sons dyinft away from home should be feiven in .very instance. 



i 



\ < 



■I 



'11 



I 




i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, f ncalth-F vo .. i^f?S^ nS.V Co REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 



/>r//^^ F//^</,....c)xl\ix-^-vxUc^^^^^a ^^6^ H 

\j^r\.A^:^ IlXvki De!^v't" Her^^^h Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 



( *a. S. Stan^ar^ ) 
PLACE OF DEATH: — County of " a^A/ O.VO.>vOUCC City of ^^ Cva^ vawcc^ 



,^ VI 



rffe. 




\^ • ib 0-^ A^^^'-^ 



St 



Dist.; bet. 



and 



-) 



• ic^iiKi DE-c I nr Mr r r lur facts called for under special INFORMATION' \ 

( " rr"o»Troc"u%*.ro\"rHos'prT*t o"?:"?u" ■;'";"" name ,»st„o o, .....^ .». nu-=c,. ; 



FULL NAME 



iQ\,^:, 



♦ 1 



,0^'^A.Xx!;^^ lAj 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



M TloJjl 



i)\ri-: ni' lUKrii 



\('.K 



vl)w^ 



lllivJLi 



(Month) 



(Day) 



(Vear) 



HS' y.a,> ^ ■■'/,.»///> 'ad 



iO(f r.v 



^IN<;i,K. MARKIHI). 
W IDOUHI) OK DIVoKi'Kf) 
Write ill social <UsiKt'ation) 



iSt.itc or Country) 



\AM1-: OI' 
» ATIIl'.R 



lURTIiri.ACK 

OI- l-ATHKR 

I Statt or Country) 






maii)i:n namk 
oi" mothkk 



HIK'IMIl'LACK 
OI MoTMHR 
<Slat«' or Covmtry) 




S^JD.,,Ajj\j^-^v*Ayv\jC\ 



Rr^idfii ill S,ni I'laiui 



}■(■(/ 1 



Mniifir 



/>,/!> 



Tin- AHOVK STATKI) I'KRSONAl. I'A KT IC T 1. A K ^ AKl. IKl »"• T' » ' • "•■ 
MKST OI- MV KNOW l,i:i)C.K AND IM.I.IIJ- 



(Informal 



rvddrt- 






(Vt-ar) 



MEDICAL CERTIFICATE OF DEATH 

DATK OI" DHATH 

34 vt b 

(Month) *I>J>y* 

J HI<:RI':I5V CI':RTIFV, That ^I attended «kHH'asiMl from 

H$ix",^± :: 190'^ to .3^ io I<>o^ 

that T last saw h .■ alive oti C jJ\<t b T90H 

and that death occurred, on the dale stated above, at 
J M. The CArSIC C)l' ^Dl'.ATII was as follows: 



DIRATION 



Years 



CD N T u I H r T ( ) R Y ^ ^cu^\ivV0urL3;> va L 

nr RAT ION Vtiirs Months /hiys 

( SIGNED ) ^l^ C . -iS O.'^"^^ ^, . 
'^.jJ^ n TcoH (Address)d.li VX k^^^^'l- ' 



Ilou 



;v 



Hours 
M.D. 



SPECIAL INFORMATION only lor Hospildls, Institulions. Transifnls, 
or Retcnt Residents, and persons dylnii andv Irom home. 



Former or (0 , ; 

. Usual Resldentf ^ vLVV"wU/A*- 

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



HoH long at 
PJHf e of Death ? 



Days 



IM \rK OI lURlAl, OK KKMOVAI, 

Lo^>vvOl\-i^ VOX' 



I)\ll ■•! It' KiAi. or RlCMoVAI. 



r^j^^± 1 



190*1 



INDICKTAKKK ^ 

'Ad.lnsK 



JXl>-0\t '.B^KAn 



lf}<x.i'L.ta.^vH. CaA 



N. B.— Kvery item of Information .hould be ^'•-«f;"y r;';;,';;'"tc p'ro;r;Hy7laLVflci?**The''*^8^^^ lnform»l!on- fo"r pHr- 

state CAUSE OF DEATH in pi«Jn terms, that .t mi.> be P^^Pyy 



-Kvery 

state CAUbi- vr» ..n^/-. - ■ . :^„.-«r-* 

.on. dyint awa, from horn. »houl<l he ftiven .n .v,ry m»t»n«. 



iH 



I 






WRITE PLAINLY WITH UNFADING INK — 






pfffc Ff'/ed, 




.Ix^' 



^b ■.: i 



lOO'i 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1454 



Bc^istcrcd J^'^o. 




\ . . < 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificate of 2)catb 

( "CI. S. StauDarD ) 



'^ 



PLACE OF DEATH: — County of '^a^v J V<X\vCUeo City of CJ Ct^v --J VCt^ 



Ut-Ain: — »^oumy oi >^iu^ ^>~'--- "•/ -- - - 



) 



FULL NAME 




idrt 



PERSONAL AND STATISTICAL PARTICULARS 



SK\ 



>■ 



i^\V 




COI.OR 



.C 



vCtc 



i».\ri-: «>»• HiKTii 



.\r.K 



Month) 



an 

(I>ay) 



3^ )><"> 5^ 1/-.;////.v 1^ 



(Year) 



An 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH 



Bx'vt 

(Montii) 



(Day) 



(Vt-ar) 



.11 



<IN(.I,i:. MAKKIKD 

W II)(»\VKI) OR I)I\(tKl)<:i) 

'Writf.iu 'ioc-ial <U.siKnation) 




HIKTUI'l.AOK 
(State or Cotiiitry'* 



NAM1-, ()!• 
lATin-.R 



HlR'rm'LACK 
<H I-AIIIKK 
'St;it< or roiintry) 




J 



• 



maidkm namr % 

OF MurnKR ^ 



MlRTm'I.ACH 
«>l MOTMICK 
(Slatf or Coimti y 



OCCl 



CVVAvCt 




h'f'i,!/-il in Smi /'i a in i^'<> 



) 'ca 1 ^ 



MniHn 



Ihn. 



THKAHOVKSTATKDI'HRSONAI. I'AKTIOri.AKSAKKTKlK T« ' THK 
IlKST OI-" MV KN<»\VI-KI )<■«»•■. AM) lU.Ml-.f' 

(InfMiinanl VJ V? . ^ 



( \f!<lrt'ss 






I HI-Ri-nV CI<:RTIFV, That I iittciiiUMl (It'ccaseil from 

xvc^. A i9o:v to a-^vt L upH 

tliat I last saw h -^A- alive on cS X|^t i? !</) H 

:in«l that <U-ath occurred, on the .late stated above, at 
......r.^I. The CArSI'^OF DI'A ill was as folli 

U ayU^*'^-^- -^^^^ 



)\VS 



o /^ 



DCKATION 



Ycais Months ^*> />fnv 



Hours 



DTK AT I ON I Years Mouths Pays 

(SIGNED). Ch ^- J (XVcLivvx-V 



HoHr< 

M.D. 



-^Xix:tb n)o4 ^Address)S-l'XMa\.'Uvtt\aUl 

' _ _ ._i. I,..- Uni-nit ill Inititiitinn^ Tfjn^i 



SPECIAL INFORMATION onl> lor Hospitals, Instilutions. Transients, 
or Recent Residents, and persons dying dwdv from liome. 







HoH long at ^ ^ 

Plare of Deatli; ^ > ■ Days 



Former or 'A I ♦. yr> i i 

L'sufll Residence W /Uj\^VS.A, 



I'l.ACi: Ol lUKIAI, OR KKM'»\AI, 






DAJ'i: '>; Ml KiAi. oi RKM<»\'AI. 

I90H 



I \ J r. I > . 1 1 ■ n 1 n 1 



I 



v,„..k.,...sk,.:k '^ Wvo4va^v C"1( ava MU 



■■.^■««.»«-»ii«™i™M— »—-——— —-■——'■'"■■■"'■'■■'"""■■■■■■''■''"'■''""''"""" III t ted KXACTLY. PHYSICIANS hHouIU 

N. l5.~F.very item of Information nhoulcl b. cnrcfully «"r»P'''^;'- ^^.''J^HyTlassWIcci? The •'SpecSai lnf«rm»tJon" for p-r- 
«tnte CAUSE OF DHATH !n pln.n terms, thn -t m»> '*^ »^ »' 
«on. clyinft oway from home nhould be ft.ven m every mHtnnce. 



\\\ 



'h 



Ill 



It 



4 



WRITE PLAINLY WITH UNFADING INK 



Dafe Filed,.. AjL^f^lx^xl^ ^^O'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1 1 55 



Registered J\^o, 




\j^\j^ AX'yj \.' 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTlI=City and County of San Francisco 



Certificate of 2)eatb 

( *Cl. S. StanDarO ) 



PLACE OF DEATH:— County of eV<X/^ d;vc^>vc^cc City of t'c^^^' '^A.a > 



V.1 



r- ( 



No. 




C^t. M riav^vA fc ^^W 



\. 



\ 



St.; 



Disttbct 



and 



a<x.ll> 



FULL NAME J (1^^ 



:CL' 



PERSONAL AND STATISTICAL PARTICULARS^ 



SHX (^ 
DATH t)r MIRTH 



COI.OR 





(Month) 



(Day) 



./..^.l.a 

(Year) 



.\(.K 



..k?.^^ )Vvi;> *^- 1/""//'.^ 



no vs 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



(Montll) 



(Day) 



(Year) 



I HEREBY CERTIFY, That I attetidctl deceased from 

V r\"\ ^ . , ! I ino ' .1 to 'vSjL\<t 1 190 H 



IL jcp' 



SINC.I.K. MAKRIKI). 
WinoWHI) OR DIVORCED 
tW'riti' in social (ksiviiati')!i) 



HiR rnri,AOK 

(Statr or Coiuitry) 



NAME Ol- 
I ATHER 



BIRTH PEACE 
OF FATHER 
(State or Coiintry) 



it. 



i ' 



MAn)EN NAME 
Of MOTHER 



HI R TH PEACE 
OF MOTHER 
(Statf or Country) 




OCCUPATION, 

A'f.udfil in Sail I'liunisro ^_^l_L£!lll 



.Months 



/),n 



THE AHOVE STATED PERSONAE ^')^l\\-;\\'.^'''^ ''''■'■ '''''"'■ ''' '"'' 

I{f:st of mv knowu-.ix-e and in-,i.n.i- 



%XAA %cdX 



<r LOv. .V :w. 



that I last saw h .- ■ alive on OXyv" ' up 

and that death occurred, on ihe date stated above, at 
...v2 M. The CAISE OF DlvATH was as follmjs : 



..1 



CUV<0<L/^ A-tr'VVVIX' 



^ "• 



1 1 



DURATION yt'iJfS 
CONTRIBFTORY 



DURATION 



}'tU7t'S 



Months 



^4iB '4 «■««"*• 



Mouths 



Pays 



Hours 



Pays 



Hours 
M.D 



( SIGNED ) LlvtkAA\) \ W Ja vvtu M.O. 

...djL-.yA.... A.. K^o ■ (A<l<lrfss) .V.t. J \V\ \H1 J\. ■ N I 



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



, Inslfiutions, 



Transients, 



Former or 
Usual Residence 

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



A How lonq at 

^^'>V<i '^■- Place of Death? 1 .A C .. Days 



A 



A^ D 



(Address d./CVC^.:C^.^'>^^^■ 



.tc VO.' 



PEACE OF lURIAE OR REMOVAL 
l-NDERTAKER >-^ ^ ^VVA^^V 



l)ATl% of IJi KiAi, or REMt)VAE 



^— — ^» ^—^—^™^^— — ^^'^— ' t t I BXACTLY PHYSICIANS «hould 

iN. B.— Bv.ry Item „( information should be cnreful.y «"PP"«-- ^I^^ZIJ^J. Th^ "SP"'-'" >■"■<.--»"<"'" '»■• -- 
. *^ i-AiT«f= flF DFATH in plain terms, that it ma> nc pr ^ 
""*;.,"„'; fw^r.r'^hon.^ ^hou... b. tiv.n i , .".""«. 



■tF 



im:- 



iiii 



I 



I 



*i 



1 

mi 



m 



)t...ii(i i.f Ht!iiti 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,_,.So,.*?13te..<^rCo REFER TO BACK OF CERTIHCATE FOR INSTRUCTIONS 




Registered jV*«. 



115f> 



Dale Filed, Q)JL^fUjyysJ^^Ah..^. 100\ 

A A-\..^>_/i ~Xx/vM^ Deputy Hestth Officer 

DEPARTMENTot PUBLIC HEALTH=City and County of San Francisco 



(Tettificate of 2)eatb 

( "a. S. StanC)arD ) 



% 



PLACE OF DEATH:-Co«n.y ofOoA^ J;^^.u.cu City ofO^^ ^ K^^^. 

" rr'"ti"occ"uV"cV,"rHO.'tr.t :"»"?«"';'"-. ,ts name ,.st..o or sx,«T .NO N.-.». ; 



( 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




....OAJLL^"knJ^\X).u. 



DATK or- HIK III 




COI.OR' 



a 



iM«)]ith) 



I 



I 

(Day) 



(Year) 



M.E 



HC) )>„,, *i i/..»////.i Xi 



/;<f 1 . 



SINC.I.K. MAKKIKI) 
WIDOWHI) OK l)IV«)RiHn 
(Writv in ^Kiiil <l(siv:nation) 



I ri<x\Ku^6. 




lURTHVI.AOH I ■ 
(St:it»- or Cotintrv^ I \,'> 



NAMl-: Ol 

I- A Tin; R 



lURTHPI.AC'K 
0|- I-ATIIKK 
'Statf or Country) 



MAIDKN NAME 
ol MOTJIHR 



lUU IHI'I.ACK 
n|. MOTIIKK 
(St:ite or Country) 



^ 



Kca\X>vM. ■ a CO-tW > . C^ 




,^^ v^i'Vv 



uiLu. 



*' \ III 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



S^-vi 



(Month) 



(Da 5') 



(Yt-ar) 



rTlKRiSY CHRTIFV, TliMt I altcndcMl deceased from 

190 tu J^ 

that I last saw h alive on ^'P 

and that death occiirre.l, on the <late stated above, at 
M. The CAl'SIv Ol' I>1^^'1'»I ^^"'^ «^ follows: 



DIRATION Years 

CONTRIIU'TORY 



Months 



Days 



Hours 



DURATION 
(SIGNED) 



Vi-ars^ Mouths 



^xL i 190 '■ 



(\d.ln-ss) WVb^yg-^-^'^'^ 



Hours 
M.D. 



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



OCCITPATION i^' 






Miintli: 



/hns 



THE AMOVE STATKI)l>KR>.ONAI.l'ARTH;ri;AKS ARK TRIK TO THE 
IJEST or MY KNO\VI,i:i)<-.E AND Ilhl.Ihl 



(Informant 



(Ad.lress A.^ i> C) ^ ^ . -^ 



Former or 
Usual Residence 

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



How lonq at 
Place of Oeatli ? 



Days 



PLACE OI^^T'UIAT, OR REMOVAL 






UNDERTAKER 



I)\T1;<j!" Hi KiAi. 01 REMOVAL 




■— ^— — — '■■■■■"■"■■■■■^■■■"^""■'■"""^^""""""""""^*^^""^^""'"''"^ I I h t t I EXACTLY PHYSICIANS should 

N. B.— F.v.ry lun. o» ln«„rn.o.ion .hou.d be c„r.full, .upplled. ;«4;;;7,'.''„^'„:,? %h. "SpccLI l„for„..lon" .or p.r- 
-♦«♦.. CAUSE OF DEATH in plain terms, that it may oe p m 
:::*. dvtn* aw^r«rL hc„.. .hould be .Wen In .vr, ln...-c.. 



« •■ 



n« 



I ' '' 

r 






, t 



« 




j^ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

RBFER TO BACK OP C EHTIFrCATE FOR INSTRUCTIONS 

1 15^ 



,,„,„l.,fM.nUl.- I-- No. ..tC^g'-""^ ■'*-•" 



iy6'H 



Registered JVo. 



Dale /'V/^'/, dxlxtcw-Jf-^A- 1 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DE ATH : — County of 





Certificate of 2)eatb 

( tl. S. StanDarD ) 

am; 3 Axx.>xcdc^ City of 3 cu>v 3. vex >vcc^co 



^ 



Sf t Dist; bet. M lluA^^^i^^ and 



b clU. 



No. ^^-^ ^. ^,;,^i,:^,^-:^SS?^"H*^^^^i^^^ 



\CUX ) 



( 



FULL NAME 




C oJl\N^V4'^tr>-^ 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



Hi. 



1 



COI.OR ^ 



CXAA 

DA IK OI- HI K I'M 



AOK 



U}JivCU 




AV 

(itonlh) 



llo 

(Uay) 



.^6^ 

(Year) 



) Vv; I 



SINCl.K, MARkIi:i) 
WIDOWKI) OR DIVoKiHr) 
'Writvin «»cial flciv^iiatioii) 



HIKrnlM.ACK 
St.itc or Countiy'i 



NAMK OF 

1-A rni:R 



lURTHri.ACH 
<)»•■ KAPIIKR 
(State or Country) 



MAIDKN NAMH 
(II' MOTHKR 



lUR'rHlM.ACK 
ni- MOTHKR 
(Stall- or Country) 






I MiOiths <^ 



Da\.< 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH C 

dx 



..dxkt 

(Month) 



5" 

Day) 



(Year) 



^ f jfl?REBY Cl'RTIFV, 'i'l'-^t I atteiidea .leocased from 

■c^.xyJt X 190 H to ... c)-c.|A:t 5-. 190 ' 

that I last saw h .<.^>^ alive on OX^a: L^ up 

and that <leath occurred, on the date stated above, at 1 l SS" 
OLm, The CAUSK OF DIvATIl was as follows: 




'^ 



'^'a^V J XOL^vC^'^C<) 







Lavl a, hol\A\^rs\ 








civ 




.<lt 



occri'ATioN y 

RfsiJr,t III >ii" /Kiihi^"' I ' "" ^ , 



THKAm>VKST.ViM:DPKRSONA. r.XKT.cr.ARSAKKTRrKT.> THK 
HKST Ol- MY KNo\VM:D<.K AND lU-.I.n.t- 



or RATION JVa/;5 ^ J/o^lAs /)<ivs A Hours 



DrRATION 
(SIGNED ) 



..."iwoAvOA;. 



Years .^fonths ^ /><n'v 3> f fours 



uXl^A b D)o ^1 



..,.ir...on/)^ u.cdi:A :^:j. 



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



How long at 
Place of Death? 



... Days 



Former or 
Usual Residence 

When was disease contracted. 

If not at place of dea th? 

PLXCEOFBrRIAKORRKMoVA,/! DAH-.t .Ukmi- or RKMoVAI. 



f 



A.ldress t O 



Ulress 5.il'b U a\A4A<m..^....0l... 



N. B. 



— ii— i^^— ^^■'^■^^■^^"'""'■■■'^""^^"""^^"^"'"^^^^^""^"^ ^ K t t I EXACTLY PHYSICIANS should 

Every Iten, of 1n.on„,af.on .hou.d be carefu.,y suppMed ^^^^^J-'^^^,^",:,! %He "Speci-i Inforn^ation" for pT- 
state CAUSE OF DEATH In pln.n [*•;•"«• V;«;'^,"^;*y rnstance. 
sons dyint away from hom. should be ft.ven m every 



« 

I 

I 



I, 

■I 



r 



i I' 



Ih 



r 




WRITE PLAINLY WITH UNFADING INK 



Mor.r.l of n.nlth- K No. l^ '^^'iSg^ "^'' ^^ 



/)^//^' Filed, B. 





a i^OH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1458 



Registered Xo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH : — County 



Certificate of Beatb 

( H. S. StanDarD ) 
ofOAxxx:\/.A City of' 




XoJvl \Xj 



yOL^iV 



No. 



St.;—— Dist.;bct. 



-and- 



-) 



( 



ir DEATH OCCURS *W»V 
IF DEATH OCCURRED 



FROM USUAL RESIDENCE GIVE FACTS CALLED FOR C 
,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTE 



UNDER "special INFORMATION" "S 
AD OF STREET AND NUMBER. / 



FULL NAME 




) 



ju.LL<^^<^5L0^^^ !J.vJ.X>>w^:y:v.x<x<.>.^^- 




SKX 



DA IK OF lURTH 



ACK 



PERSONAL AND STATISTj^CAL PARlTICULARS 

COT.OR \ \ 



tlJvd..- 



vl Lcr\r. 



I Month) 



IH 



) '/•</ / 



..„a. 



11 

(Day) 



M.itiths 



r\VA 

(Year) 



.1,3^ Dav^^ 



SINC.KK. MARKIKI) 
WIDOWKI) OK I)IV(»Kt;i:i) 
(Write in siKial (lrsii.Miati<)n) 




lUKTMIM.AOK 
(State or t'onntry) 



NAM}-; «>I" 
FATllKR 



IURTHIM.A»*K 
Ol- FArHKR 
(State or CfMintry) 



MAIDKN NAMK 
OI- MOTHKR 



niRTlIPI.ACK 
Ol- MOTHKR 

(State or Conntryi 



LoJLut 




MEDICAL CERTIFICATE OF DEATH 
DATE OF UKATH J) 

djL.kl' s 



igo \ 

(Year) 



I HEREBY CHRTl FY, That I attended (ieceased from 

to "" .190- 

. . , : -rr :-:.. I9O 



I9O 



that I last saw h-—^ alive on 

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



^ 



I. The CAUSE C)E DEATH was as follows: 



tV">A^^wXX 








f)CCUPATION >. 



Ke^idrd in Sun /'nDuisfn 







A 



DTRATION years 

CONTRIIU'TORY 



Mouths 



Days 



Hours 



DURATION 
(SIGNED) 



Years 



Afoul /is 



Days flours 

M.D. 




\ iQO ■ (Address) ^-^^^tv w u v ^-m 

L INFORMATION only for Hospitals, InstltutMns, Translfnts. 



)V(7) 



1 



/hi 1 .' 



T„K An.,VE STATK,, I'KK.ONA, rAKT.cMM.AKS AKK TK.K To TMK 
HKST OF MY KNO\VIj:i)«.K AND Hhl.M.l 

(Informant L>VA^<X>i 0^ 



XA^»\.0.- 




or Recent Residents, and persons dying away from home. 

How lonq at 

^^^^"^\, Place of Oeatli? 

Usual Residence 

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



Days 



rr.ACK OF^Jil-RIAI. OR KKMOVAI 



rNDHRTAKKR J^ cJutX^ '' 



nVfF'of HiHiAi- or Ri:Mt)VAI, 



n 



TQOi, 



(Address 



S.Hb 



^ 






.IjL. 



(Address 3» V \^ ___— — ^— ^ 

^^^.^^_^,^^ ^^^M^^^— ^■^■^'^^'— ^^ . EXACTLY PHYSICIANS should 

.. B.-P,ve.. ,.e. o. ..o.^atlon .Hou.d He .•e.c.uH. .uppneU J^^:;;;:;^:^;:^ %He "Speclai .„.o....lo„'^ .0. p-.- 

state CAUSE OF DEATH In P'«'" **.7«' V;"J„ '""'^ 
Ron. dylnft away from home should be ft.ven m 



every Instance. 



I1 



iSI 



i < 



r I 



jtMMnl ..r H*MUh-FNo. 1^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^^„S,yCo WEFER TO BACK OF CEHTIFICATC FOR INSTRUCTIONS 

Ihifc Fifetl,i.jL\\Xjiy^^J^Mhj 1 i^O'i 



RegistcTcd JVo. 
■Lrvcv^ "It^Ki Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX, S. Stan&arC> ) 



PLACE OF DEATH:-County ofO<^' l^a.>vc..c. City of CW.v J.'v^>vc- 



'No 




Dist.; bet. - , •> "'^. 






UNDER "special INFORMATION" \ 
D OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SK 



OX' 

DATK OF BIRTH 




COI.OR 




?) 



(Month) 



AOK 



1 L )'r,i>s 1 



(I);<y) 



.!/..»////> 



/.i.L..^ 

(Year) 



r 



P,i v.y 



^INC.l.K. MAKKll':!). 
WIDOWKI) OR l)lV(»Rii:0 
i Write iji MHMiil ilesipuatioii) 



lURTHPI.AOK 

State or Coutitry^ 



NAMlv OF 
FATHKR 



l| 



1 



niRTHPl.ACK 
OI- I ATHKR 
(State or Country) 



MAIDKN NAMK 
OF MOTHKR 



lURTHPI.AOK 
OF Mt)rHKR 
(State or Country^ 




d 



^^^v^xOix 0. g;UL<^/q^ 



OCCUPATION 



3) 



f)\ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

...Dxi.\l' "^^ 

(MontM ^I>">'^ 

TiTeREByThRTIFV, That I attetidod dcccasea from 

190 — ■— 



(Year) 



I9O 



to 



that 1 last saw h.-- alive on """ '""■ 

and that death occurred, on the date state.l above, at 
^I The CAUSR OF DHATII was as follows: 

a-wc.V'<:.-.v^.<:^ 



[90 



DURATION )Vj/i 

CONTRIBUT(^RY 



A/on //is 



Days 



Hours 



DURATION ^ ^''''^''^ /V> r^'^H'^^^''- 



(SIGNED 

4 




)...Lc:^jn\X\;\l. i^^ 




Days 

. dxia.>^.i:L 



M.D. 



Qj4.vt....X . u)0. r Add ress) Kj^y^J^- ^' ^' 



U 



CL^VU. 



X 



Rrsidni lit Say! l-nnxisro \ i ^ <''^ ' ' 



yf, mills 



Ihiy. 



THK ABOVE STATFD ^'HRSONAl FARTICFI AKS ARK TRlK TO THK 
BEST OF MY KNOWM-DoK AND Bhl.H.H 



ti 



(Informant 



(Address 






nil 



SPECIAL INFORMATION onl> for Hospitals, lnstitut»«lis. Transknts, 
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 
I * Place of Death ? 



. Days 



PI ACE OF BURIAL OR RKMOVAI, 



DATFluf BiKiAi. or RKMoVAI, 



UNDHRTAKKR %)■ ^^ ^ ^^CT^ 



\t V 



(Address 



ll'il. 



,A,:^>!v^<ry.x.. 



^__i^^ . FXACTLY PHYSICIANS should 

N. B.— Bve., 1..m o. information .hou.d be ..-•.««.., .uppMed *«^^;;;;7,'.-..^',:r %h. "Spccl-i .nf.rn...ion" ..r p.r- 

.tate CAUSE OF DEATH in >>'»'" j""': 'J'" „''.""^ rn.«nc.. 
.on< dyin* away from home should be ft.v.n .n .very 



'111 






,1 



I 



?1 



^ 



WRITE PLAINLY WITH UNFADING INK 






/>.r/^' /v7r^^/,Cix\vtt>^vUv T ^'^^"^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

MGO 



Registered JVo. 



<W^ 



Deputy Health OfHcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of S)eatb 

( m. S. StanDarC* ) 

0^ 



PLACE OF DEATH:-County of dcL^ Va>vCV^C. City of Oo^v VC 







No. *^!i^ \'lutU 

/ IF ocAth occurs *w*v from 

V IF ic*TH OCCURRED IN A H 



St.! X Dist.!bet 



^ ft 

CIVVLVA^ and ^ 

CALLED FOR UNDER " S PEC^AL I N FOR M ATljJ N ' ^ | 



^ 



aVU-Ul' and JxaUi 



" o"s^V-r*' 0%"-;""." ";'";r"s «A«£ ,™-ST»n or stb.et .no »u»..- 



FULL NAME 






cL"^^^r>\tx 



"l:Mi 



ClxUy^TL 



SK.X 



PERSONAL AND STATISTICAL PARTICULARS 

n.\Ti. «)i HiK rii ^ > ^ 

nVav ■ ^ 



^\ok 



.\C,¥. 



3H 



J V(M 



(Day) 



M.mlhs 



, no .. 

(Year) 



lb 



Da I 



SINC.I.K. M.\KKIKI> 
\VII)t>\VKI» OK nivnmKi) 

iWrittin Mnial dt sivrnatioii) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF l)i:.\TH 



.dxki. 



(Year) 




HIK rUlM.AOK 
I Stat f or Country* 



NAMi: <)I 
FATHKR 



niKTHri.ACK 

^^\■ l-ATHKK 

I State or Cotuitry^ 



MAIDKN NAM1-: 
<)! MOTHKK 



lUK rUTM.ACH 
<M.- MOTHKK 
(Stati- <»r Country) 






fv^^i^^^ 



\ 



1 



, a. v.: 



Rfidf'l ill SiDi I'lai" 



■\r«iiths " />"> 



HHST Ol- MY KNOW 1,K1)C,K AM) l.KI.H.h 

„„r„,„,„,., Ic^cOil' lt.C^tokv.^0^^ 



r\(1 dress 



S^D^ 




i 



(Montfh) <I^«yJ. 

^lllKRKBV CHRTIFV, That I alten.kMl .leccase.l fn.n. 

Ww 1^ 190 ^ to .xL|x\. L 190^ 

thlt I last saw h ... :. alive on lUu^ 5^ ^.p^ 

and that <leath occurred, r,n the .late stated above, at I ^6 D 
UL M. The CAISK OF DI'.XTII was as follows: 






r- 



C 



...(:. 



.Ul\Ja^, . ^••'^ ■ v^^i^^^^ 






DFRATION >V«''^ 
CONTRIIU'TORV 



J/o>i//iS 



Pays 



DI'R.ATION 



}'iuirs. 



^ 4 ^ 



Mi)Nt/lS 



/hiys 



(SIGNED) A. ^J Xc J-^\>AA 



I /ours 
Ilout •< 

M.D. 



r>' 



•^i^jvLA lOC^... (Address) ?)a^ M ' cmv-^ 



SPECIAL INFORMATION only lor Hospitals, Institu 
or Recent Residents, and persons dyinq anay Iron home. 

Hov* long at 
Former or pjare ol Death ? 

Usual Residence 

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



iHoffs, 



Transients, 



Days 



I'l.ACH 01-\nrKIAU OK KK.MoVAI. 



i^'Vl 



1 



I)ATi;of HtKiAl. or KKMOVAI, 

OX^vt" ^ 190H 

,,,,Uess H I'i V (-vd^>V % xL...wLm.... 






-■RNl. 



.^_^^^_^_^^^^ ^^^^— j^^M^^^^^^"^^^"^^^^^^**^^ . FXACTLY PHYSICIANS should 

N. B.— F.v... ...n. of i„«„.n...ion .hou.d he .»..«-,., .uppMcd ^^^^^^J-'.-..^,,:;? ^h^ "S-.i-l .nfo....-.o„" ««r pT- 

.tate CAUSE OF DEATH in »'■""'"•"!.• '"L^Ty rn.«n«. 
•on, dylnft »wBy trom home »hould be fven m e.ery 



) 



% 



**i 



\ V 



\ 







WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lt'i:i"l "f 



„,,.Ub-F No >^ 3>^3g:^HM>Co 



Ihf/r Filrd , 




^^OV>L^V>ft 



190\ 

3lth Offlcer 



Registered Xo, 



1 1 61 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No.^^ 



Certificate of 2)eatb 

( tl. S. Stan^a^^ ) 
PLACE OF DEATH: — County of JCb^ X-C . Uty otw/v,^ 

.to? V V^L Y^t^ ft ^4. kL.l. a..'. St.: Dist.; bet.--— ---^^^:::::^^5«1 



^ 



— ) 



'1 (-•'-^^:^a^^r^^S^t x^5^:^i:^^i ^^" -^^;'i»»-::^-- ) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



DATK OF UIK Til 



AC.K 



COI.OR 




i) 



\\.K. 



.1jL__ 




.(r\r 

(Month) 



(I)MV> 



(Year) 



JftJ' 



IC) 



.1A-W///A "^ Dayi 



SINCl.K, MARKIKI). 
WinoWKI) OK l)I\nKrKI) 
Writ*' in social (Usii-'nalioii) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATIl --v , . , 

JXAxt ^ 



(Month) 



(Day) 



(Year) 



TrrERKHV Cl-RTIFV, That I atteiuleil dcceasea from 

— to -:■■: ■" 



190 






that I last saw h ■■'■— alive on - —r-r-rr-rrrrr-rrrr. 
ana that <leath occnrre.l. on the date stated above, at 
— . M. The CALSH OlvDlvATII was as follows: 



HIKTinM,A»'K 
(Stat«- or Country) 



NAMK OF 
JATm-.K 



»UR TmM.AC'F: 
0» lAIHKK 

fStatf or Cotmtrv) 



M\II)1:N NAMK 

OF mothf:r 



lUK rmM.AOF: 

<>l' MOTHKR 
(Stat«' or Countryi 







^ 



O^/^^v/OAJi^' 



CrL "dL^> 



iCU^SJ.. 



DURATION JVrt; 

CONTRIBrTORV 



Months 



Days 



Hours 













Miiiith^ 



I hi 



(KCri'ATION 

TnFX,M>VKSTATFI.FKRSONA. PART.rr..ARSAKFTKrF T< . THK 
HKST Ol- MY KN(>\VIJ.I)<.h AND BhUl.» 

<,„r,„ ,. Q(YUAAy>AA^ W.I^-1 e>> 



( SIGNED ) WvUX, ^^ T ■"•f^fln 



I /outs 
M.D. 



01ykl....'^L I()0 



( 



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



S)> 



Wlien was disease contracted. 
If not at place of death 7^^ 



How long at 
Place of Death ? 



..». Days 



DATi; "t m KiAl. or KF.MOVAI. 



(AflilresH 



IXACK OF lUKIAL OK KKMoVAK 

.1:rtakkr W ni^0yu.v.^V3c. 



1^— ^— ■— ■— ^— "■i"^'""™'"^""^'^^"'^""'^^"^'"''^^ J FVACTLY PHYSICIANS ahould 

OF DEATH In ploln tern,.. «••»; ■« ."•">^^ r.. „nc.. 



IN. B. Every Item o* 

state CAUSE OP Ut a . n .n ""■"■r^ •"•::_.,„ .^ery Instance. 
son. dylnft away from home should be fe.ven .n • e y 



) 



) 
J 



m 



^i 



\ 



I' '■ 



i 



M 






I 



WRITE PLAINLY WITH UNFADING INK 



„.,..,„i ..f n..ith »No ■'•^'SSg-^'^^'^^" 




1 



IfJCi 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\l*o. 1 40'*r 



Ihde Filed , 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

^ "a. S. StanDarD ) 



(^ 



No. 




PLACE OF DEATH : — County of 



Cict-Yv. iAXX-Y^/C^CoGty of O/CXyv^ JA.C^^^-c^o 



TmIcvU 1^'^^ 



St.; 



Dist.;bet. 



and "~^ 



iuCZ O.V. .*CTS CLLCO .^0_P_ U^N^OCP „SPCC... J . rOR M*T.O . - ) 



( - r."o;".°H-o^:u%tv.;"rHi',^r.t :^^:^::^^^-^ -m. ..s.^.o o. s..c.. ..o ...s.. 






FULL NAME ^^^^^ 




.>:yaa/'.>.:)JL.x.. 



s )•; \ 



PERSONAL AND STATISTICAL PARTICULARS 



«} . .. J , i " lo,U 



X-^>V' 



DATK <)F- lURTM 



ACR 



(Month) 



(Day) 



./n.H 

(Year) 



-^ y )V<7>.v 



,1/,„////.v ": An.s 



SINCT.K. MARKIKI). 

W IDOWKI) OR DIVttKCKI) 

Writfin social ilt- sij^nation) 



lUR rm'i.AOK 

(Statf or Cotijitry) 



NAMK Ol 
I ATHKR 



RlRTHri.ACK 

or lAriiKR 

(Statr or Ootiiitry) 



MAIDKN N'AMK A [\ 

OF MOTIIKR U U 

vhuX 

I5IRTHPUACK A U 

OI- MOTHKR (J U 







MEDICAL CERTIFICATE OF DEATH 
DATE OK DEATH J? 



dxlvt, 

(Month') 



..5 

(Day) 



(Year> 



nTEREBY CHRTIFV, That I atteti.lcl (Icccase.l from 

to nrrrrr^^rrrr: : T90 "^ 

..rr-rr— -■ ■;...■.» - lip 



190 




§ 



w^o 



Ou 



? 



(State or Country 1 



■"^^ 



OCCUPATION 

\J M 




^\laA. 



Cv 



that I last saw h - alive on - • 

ana that death occtirrea, 0,1 the date stated above, at 
— ;^i^ The CAl'SI': OV I)1':.\TII was as follows 

^jJf±^^Uirs:.^o JyX<>-v^.^■^^ 

LLb:^'^-^^^<«^^ '""'"" 



nr RAT ION Vt-ays 

CONTRIIirTORV 



Months - Days 



Hours 



Months 

\ ;. U),. 
I. 



Pays 






Hours 
M.D. 



nr RATION ^ )V^''^ 

( SIGNED )..Ur'umJ^ 

tx\xh.^ too:: (Address) V.^VC-^xX-X^ ^'-U 

■ SPECIAL INFORMATION onlyjorjospitalsjnstitut^^^^ Transients 



T/'fTTf 



Months 



Pa \s 



run AnovE statk,, '■^K->^^';!:^«;;i;;'il;f " ^"^ ''"" '" '" 

REST OI> MY KNO\Vl.KD<.h AND Hl.I.H-f 






(Informant M K\' . Njft'' 



^/VYA-AyYVi^Y 



or Rercnt Residents, and persons dying away from home. 

-\ 4 ; How long at 

Sr««id..« 150^ ixa^^^.-v^Plac< .1 feath? 

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



Days 



DATE of HiKiAl, or Kl-'.MOV.AI, 

O-i^Wj 'i TQO'' 



PI ACE or ni-RIAI, OR REMOVAL 

.^dertaJr AvJo^i. ^^ 

(AcUlri SOS VI^X^vHH.y-^^ 



:%^-*^ 



^^-— —— ————"■■"■"■■■■■— """"""""^ * A f^vACTLY PHYSICIANS should 



N. B. Every Item 

state CAUSE _- u i i k^ * 

son. dyinft aw-y from home should be 6 



S 



r) 
11 



-??! 



' 'ii 



i ' 









' i" 



WRITE PLAINLY WITH UNFADING INK 




i^OH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered JVo. ^ '^^'^ 



.-CrUwV^ 



__ ^ Deputy Health QflRcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of Beatb 

( Ta. S. StanCtar^ ) 



% 



PLACE OF DEATH = -Countv of^a^. ixcV>.X..,C. Gty ofOcc.. J ^cx^.c.. 



No. i-^ ^ \ 






St. 



Dist.; bet. cL a.*- 



>xt>i 



and 



-V-fV-V.. 

^ \ O ' ; '^**» "' '" /-^ r»B iiJnrR "SPtCIAL INFORMATION \ 

)rh::^'6cc -o. uso.. -"'-?,« --;-;! na^m" r.-^roJ s.%c.. ..o numb... ; 



ai^c^civi t. . .. ) 



/ ,r DC.TH <^^""Vp''rViNTHo''s^Pa*L OH Tnst.tut.on give its name inste 

V ir OtATH OCCURRED IN A HOSPlT«i. w" 



FULL NAME HA-tcvx^ 



•-j:\ 



PERSONAL AND STATISTJCAL PARTICULARS 

COl.OR 




DATK or UIKTU 



AC.R 




6 1 jv</'> ' 



Mntiths 



10 



/)<MA 




[eDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



(MonW 



(Day) 



(Year) 



SINT.l.K. MARKIKP. 
WinnWKI) OK DIVOKTHI) 
Writtin Maial (k«^ivn:iti<»ti) 



lUKTMPI.ACK 

'Stat«' or i'otnitryi 



I K a>v^AjL<L 



N WW. OH 
lATJlHR 



niRTMJM,\OH 
nj- lATnJ<:K 
(Statf or 0»)niitry 



M MI)l".N NAM1-. 
(>I- MOTIIKR 



lUK rillM.ACK 
oi- MOTIIKR 
(Stilt*' or Countrv") 




1 irHRHHV ClurriFV, Thar I attendea .leccased froni 

.,:::::-::^ ....:: .. .M^-^- to ..rrrr=n7r.rrrz=r:..i90— 

that I last saw h " alive on ^'^ 

a„a that .loath occurred, on the <latc stated ah.n-e, at 
M. The CAISIC OF^lvATH was as follows 



Ll-X^J-A' 



A 




.<wUuv< 



I 



Ur RATION Vi-af^ 

CONTRir.rTORY 



Months 



Days 



I louts 



Pars 



.H-KATU.X .V„. « 



A,1,Ir.ss) b^b^^Jrtx^ 



Hours 
M.D. 



SPECIAL INFORMATION only lor Hospitals, Inst.tutions, Transients, 
or Rcfent Residents, and persons dving away from home. 







OCCUPATION 



TMH AHOVK STATKH .•KK:.>NA. rARTj.rj.AKS AKK TKrK To NIK 
HKST OF MV KNOWM*.I)»^AM) Ml.I.n.l 

Unformant CTW/V/w vvM ^ '^^ ^ 



f \<lilrcss 



^ Ai 



Former or 
Usual Residence 

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



How lonq at 
Place ol Death ? 



. Days 



n ACE OF IHRIAI. v,K KHM«>VAI, 






UATi; o! lUKiAi. or KFMOVAI. 

T9oH 






I' . , pw.cTLV. PHYSICIANS ■hould 

E OF DEATH In plni" •"'"': •"".'•."t ■„.«««. 



IS. B. Every item o? 

.tate CAUSE OF J^E^TM^n ^;;^--;:—\„...ry Instance. 
«on« dylnft away from home Hhouici oc k 



^S 

9 



•1. 

ni 



►-5 



.1 ! 



i« 



PI 



? 



I 1 

I 



m 



'iii 



1^' 

Wl 




mmmmrnmrnamrmms 



WRITE PLAINLY W.TH UNFADING INK-TH.S IS A PERMANENT RECORD 

.mm^. ....... HCFEB TO BACK OF CCHTIFICATg FOR INSTRUCTIONS ^ 

J^^^^, ,, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( "CI. S. Stan^ar^ ) 

St (^ 

n, 



PLACE OF DEATH:-County of C^<X^ J .^.o^^c.Gty of 



CL/TV 



/VOU>^<M^C(. 



No. 




( 



ir DCATM OCCURS *W 
ir DEATH OCCURR 



Dist • bet. -J AJi^'CXA^ 



m UJ)<X^Ia.\.->\.OJ/U r _3;NCE0.VE tacts called rOR UNDER 




and cL/A,«^V vt 

kL INFORMATION' "X 
AND NUMBER. / 



FULL NAME 




.r)\a Atno.^ 



liXCr.'Nx.Cj^.. 



^K\ 



PERSONAL AND STATISTICAL PARTICULARS 

i COI.OR 




llJ" 



i»\ii-: or iJiKTii 



iMDHlh) 



a<;k 



I I )V,/»> 



I /Uo 

(Day) <Year) 



.}/n„ffiS.- " ^*''' 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH jJ 



(Month^ 



»-f 



(Day) 



/90 
(Year) 



-«IN«.1,K. MAKKIKD. 
WIDOWKD OR niVoKClvD 
Write iti MH-ial .ksiv;nati'>ti) 



lURTlU'LAOK 
Stiitc or Country) 



J riOwKAj^xd.. 



NAMK OF 
FATHKR 



RTR rUPI.ACK 
oi- 1 ATHKR 
(State or Country) 



MAiniCN NAMT 
01 MOTHKR 



niRTHl'UACK 
ol- MOTUKR 
(State or C«)untrj') 



1 



fC 




'VXOj - 



(1 

i 



c 



TITkRHBY CKRTIFV, That I attc.Hlecl dcccasea from 

that I last saw h -^^^ a^ve ou -~ -■ ^^ 

a,ul that death occttrred, ..n the .late stated above, at 
M. The CArSK()FI>HATH was as follows: 

L.1 cUol .Jb> O. a^JUr^^'*^^^-^^^ 







.t 



nrR ATioN nars V..M. /^-r^ //--- 

CONTRIIU^TORY 



y'rars 



(SIGNED) :l^<^'VVck^ L0.^VV^. ^ 



Hours 
M.D. 



iqO 



■special information only for Hospitals, Institutions, Transients, 
or RerenUesldcnts, Vnd persons dying away from home. 



x/y^M-, 



OCCUPATION 

Krsnlfd ill '<'>ii /•'<"" ''''" 



*- /)</>. 



HKST < 
(Informant 



imST OK MY^NO\Vl.KD(.h AM) Hl.I.n.* 



former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



PI ACE OF m-RIAI, OR RHMOVAI. 



Ad..re»s l^Xil<Xc4vt. J.'. 



DVTi: of IMKiAi. or RlvMoVAL 



rx.Mrss I c^c^ "i I II II I PHYSICIANS should 

■ , .Hould be carefully supplied. AGB •^^^V^.-^er'Thc ''Spe^ information" for pT- 

jS. B.— Every Item «* '"J-;-fi'S",;*;7Jit term., that It may be properly clarified. The 

•tatc CAUSE OF DEATH In P'«'";*^ .^^„ ,„ .^cry Instance. 

•on. dylnft away «rom home should be ft.ve 



MS 



9 



.H. 

it) 
ni 



-X 

S ?- .... 

'S 

/ 



M 






i>'\ 



•»- 



I 
k 




„,u..l-! ".•.i)th V V'v ' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

nEFER TO BACK OF CERTIFICATE FOR IN3TRUCTI0N3 

1 1 f »i> 



t -t^^t^^a^S:^, US: I' Co 



n„f,- /■v/r''/,,'d.Llvbu^UNi^'.'l -''^'^H 



Registered J^o. 



Deputy H " 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Beatb 

"a. 5. StauDarD ) 



PLACE OF DEATH: -County of J^^ J AXX/>vco. t Gty ot 



No. 



/ ir Dt*TH dcCUBS AWAY FROM USUAL 
V IF OEAT»i OCCURRFD IN A HOSPITAL 



St.- ^ Dist.;bet.U}-^^t;^ 

•-'**t ' . ..lunE-D <spr 






) 



^*'» _ ..^E. •iKinrB "special INFORMATION" A 

Jr^T^^^^^^O^.'^O./e Ts N^i." ^N^S^.-r" ST%%%T AND NUMBER. J 



FULL NAME 




'\<rvU ix." 



PERSONAL AND STATISTICAL PARTICULARS 



ViIIolu 



i 



LeixcL 



!i\ IK <»i- lUK in 



\'". K 



( Month) 



ll>:iy) 






5% 



) V(i». 



5" .i/.»»////5 Jo 



Dm 



SIN. ,1,1:, MAKKIKH 

\vii>»>\vj;n OK i»!\t>KrKn 

Writfiii s(Ki;«l fk>iKi>;'li'»"^ 



HiK Tin'i.ACi-; 

(St:if«- or CoMutry'l 




V<xxvw<:t 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH J( , , ^ 

?)X vt 5" 

(Mon\h) '>'''^'* 

IHKKl-HY CI-RTIFV, That I atten.k.l .lercasc<l fro... 

^s,:^. i 190 ^ t., . j3..\Nt: 5^ 190 H 

U,at Hast saw h:.. alive on M<^ ^ '^ '' 

a„,l that .loath occurre.l, on the <late state.l above, at : . ■ 
W The C\rSIi OF DIvATII was as follows: 



^1 



-^ 



,A^<XCX 



NAM I". Ol" 

J'AThi'.r 



lUR'rUIM.ACK 
OI" FAIIIKK 
(Stat«' or Country) 





nOCri'ATION(Y\A ^ V 4 



MMDHN NAMK 
<»I MUTIIKK 



ItlRT.IPI.ACE 
• U- M<)TnF:R 
(State or Country) 



,wv 






.\r,>nthf 



IhlYS 



HKST O.^- MY KNn\VIj:i)«'F. ^^'^ Hl.M»,t- 



}•,,„-.? .1A;;////.v ?) Mrr-^ ^^'"' 



DIRATION it-^f'-^ "•"■•' ' ^ 










Ycajs , I Months 



IhU'S 




Hours 
M.D. 



■^ /< 



fO 



DURATION 
(SIGNED) 

,.axiA.'- w ...... .- ^ 

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



r-\.1.1r.ss) L-C'). LCXA' 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



•I.ACH Ol- lURlAU OK RH- oVAI. 



(Iiifonuant "^ ' O^^' 

(Xddrcss ' O \ A 




I)\Tli«)! mKiAi. or RKMoVAI, 






f Address 



N. B. 



^^'^ "''^ ^ ' I I III I I r PHYSICIANS should 



^s 



9 



H 

tr) 

•ni 



rs 



». 



5, 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ho.ikI if n 



.;.Uh-J-No. „*^^^'>H&l'^*o 




lOOH. 



Registered J\^o, 



1 1 G6 



Ihife FiledyQ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of 2)eatb 

{ TX. S. Stan&arO ) 



I 




«> 



! 



PLACE OF DEATH:-County of 'l'v...i>.<X..c..^. City of Q.C..V d,^CJ. 'AS^ 

„,, ^ ;' ,-, Q r).,t.betb.OyYu\!liLil^ and i^<XAvKvi ) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



DATi: i>r- IJIRTH l("^ 



COLOR 




IL'^t 



(Month) 



KC.V. 



,'^9 



) 'ra I 



W 



s 

(Day) 



M.>ulhs 



Ah .A 

(Year) 



Pars 



SINC.I.K. MAKKIKH 
WIIXIWKl) OK DIVoKiKI) 

iWritf in social (U'siKiialioii) 



lUR TUlM.ArK 

(State or Couiilt v^ 



NAMl (>l- 
FATIIKR 



HIRTHTM.ArH 
oi- I-AniKK 

iStatt- or Country) 



MMDKN NAMK 
(»l MOTHHR 



mRTIirUACK 
(>1- MOTHKR 
(State or Country) 







MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH -^ | i 

(Montlf) <I>«y? 



(Year) 



190 H 

190 



T iniH HI^V C ^:RTIF^^^ attcn<UMl .leocascd from 

QllOLh. 190 H to .... JjLif^i. -^^^ 

that I last saw h ... alive on B^^^i:. ^' 

,,j^\ that death occttrred, on the .late stated above, at ^ 

(y M. The CArSKOF DKATH was as |ol|^^vs: 




DURATION ytars 

CONTRIRUTORY 



Months 



Days 



Hours 



DURATION ^ >Vrt';^ 



Days 



(SIGNED) 




Hours 
M.D. 



( 



.^.^•.. «niv for Hnsoitdls. Institutions, Tfa 



■■ SPECIAL INFORMATION only for Hospitals, Institutions, Tf'ansients. 
or ReTent Residents, and persons dying away from liome. 



OCCUPATION 

ReyNlf<f ill Sail /■•;.f;/./.w''» ■ ■ - ^''"" 



}f,>nth.^ 



n,i\. 



HKST OF MY KNOWI.KDi.K AND lU.MJ.^ 



JaaaA 



Former or 
Usual Residence 

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



How long at 
Place of Deatfi? 



.. Days 



ri..\cE oFvnrRiAi, <m rhmovak 



D.X'tl", o! IHKIAI. or RKMOVAI, 



(AtMress ... w i. *• *-' * *■ 



" ^ . FVACTLY PHYSICIANS should 

ATH In plain term,, that .t may be Pr p ;r 



N. B. Every Item oi Inform 

state CAUSE OF DEATH In P'""" r^' "Tj/^^-i^ ..cry instance, 
son. dylnft away from home should be fe.ven 



9 



) 



»r) 
•ni 



rs 



'S 



i. 



',;« 






1.: .« 



if,-»' 



! 



ilfj' 



i 



jiojii.l ..f Meali 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CEHTIFICATE FOR INSTRUCTIONS 

IIG? 




ll&FCo 



luife Filed, 




Registered J^o, 



1 lOO'i 

Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "CI. S. StanDarD ) 



4 % 



PLACE OF DEATH:-County ofO.C^^ i XCu.vc.. c^Gty of O^Cv>.. ^^ Ko^^.^.^ 



No. lolH 



St. 



Dist.; bet. 



and vCxX r 



) 



( " ?^^^^:t^-^^- -iSk^^^i^^i ^^" -i^;-iJ^=r' ) 



FULL NAME 







^^ 



J . 



LcL-lU-^J^^^'^^^''^^ 




lO.. -0./-> V: 



PERSONAL AND STATISTICAL PARTICULARS 



DATE t)I lUKTU 



COI.OR 




N ' 



VV>^ 



I. 



\<.H 



iMonlli I 



(I)Hy) 



/ ^.(uH 

(Year) 






/hi 1 A 



-'iNc.i.K, MARK n:n 

W inoWKI) OR DlVOKfKI) 
'Writtiii social <lvsi^Miati<>ii) 







X ^♦^cv 



L 



■>tatf or Ooutitryi — \ UP 

C^ <X>^' ,>v.<X"vxCo(l CO 




NAMI-; <>!• 
lATHKR 



HIKTUIM.ACK 



1 



VOL 




^V^AJ 



OI- lAIHKR V (l\i\ 

• Statf or Country) -^ ^Ul' 



MAIDHN NAMK. 
»)1- MOTHKR 



\ n^ 



,cl' 




(state or Comitry) "A ^H 



luKrm'UACK 

(II- MOTHKR 



• KOITI'ATION 

AV.snfnf in ><"' I'l .in* isro 



)'/'(// 



Month! 



/)<n 






^ MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH J , , 

dxUt f ^ 

(Montlh) ^^'^y\ 



iqn 

(Year) 



THKRHHY CHRTIFV, That I attc.uW .Icceased from 

^jd(A, :: 190 . to ..~6.A^. 5: TOO ^ 

that I last saw h ' aUve on ' ''>° 

and that death occ«rre<l, on the date stated above, at 
M The CAl'SH OF DI'ATII uas as follows 

(t) A I) 






}'t'ars ■■-- r- 

CONTKIHUTORY Ja^a^>>^ ^^^^^ 



DIR.ATION 



Moutha Days 



J /ours 



DURATION . Yi-ars 
(SIGNED) AJ-U) 



Months 



Days 



GX^.A 



Tf)0 






i 



/fours 
M.D. 



SPECIAL INFORMATION «"■> t«r Hospitals. Institutions, Transients, 
or RereS Residents, and persons dying away from liome. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



l-I^ACKOK HIRIAI. <>»« Kl-.MUVAI. 



DATl^of IMKIAI, or Kl'.MoVAI, 



f \<l<lress 






_^— ^^ n—— iii^ "" , pvACTLY PHYSICIANS should 

state CAUSE OF UtA in in m Ajven In svery Instance, 

son. dylnft away from home nhould he t-ven In . • y 



N3 

9 



■ » 
at) 

>ni 



rs 



s 



K 



*m 



i 



H 



'I 



•* »^»* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M(Kir<l i)f Iltiiltli - I' No. K t^^^^s^^^ IlSiT Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCT IONS 

BegLstered J^i'^o, 



n n r^ 



*G8 



il 



lie ^'//<''^ dx.|^ttY^x.'Lt'v 1 190 i 

l^yucvo "LtAMj Deputy Heatth Officer 

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

Certificate of H»catb 



( "CI. S. StanOarC* ) 






PLACE OF DEATH; — County of Oa-rv XUl^C 



^No. 






V. .-.' 



City of Ua-->\) J.'V 



CL-W-CK 



'i-Aj 



V-t St.: X 



Dist.: bet 




L/y\j 



and 



( " .°"o;".r°H's?"u%rer,^"r„o"s^pr,*t i^i:^^^:^^'"' ?'---'-° '°" --" -— ~".o„ 



lt{. 



GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME Ccl 




XoAxi M I wL 



il 



Lli' 



.\' 



PERSONAL AJ>ID STATISTICAL PARTICULARS 



;v 



DATK, <>!• JUKTU 



t 



A ( •■ H 



'Month) (T 



V-t IaaAjc 



(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATE iW DlvATH il 

azktr (p 

(Montli) (Day) 

I IflvRlUJV CI:RTIFV, That T attcn.K.l .lerease.I fmm 



(Year) 



IV«»-Jf *'. Mo>i/fis 



|V.| 



!^in<.i,t:. markiki) 

WIDoXVKD OK ni\(>RrK[) 
(W'litc ill ><ooial fltsit'tiatioii ) 



Da I . 



xrs 



lURTlIPKACK 
(State or Coiintrv) 



i"atui-;r 



lURTHI'I, AOK 
<)l" lAIIIHR 
(State or C'outitrv) 



MAIDHX XAMIC 
<>I" .MOTMHR 



lURTHPr.ACK 
Ol- MdTlIKR 
(State or Country) 



OCCrPATlON 







XM^ X^ 190 «i 

that I last saw h -^A; alive 



to 



on 






uroH 



and that death occurred, on the date stated ahove. at 7-3 
^ ^I- ;(lJ^^ CArSH OF DI'IATII was as follows- 

V? 



'^f^^JLu^jyy^^y-y^Sr.^k. 






i 



n 



lL' 



\jy\ 



\)X 



•V/UUc\> 





u^^Jk 



DCRATIOX X Ve^s M on ilia Pays 

CONTRIBUTORY Ai^,\X-Va\^xtlx^X AL^^t^v 

^ '>>V^^ 

DURATION Years Jfo„t/is Days 

( SIGNED )..4... UJUNc\t 'x/VlvU 

l!i4dl rooH (Addr.ss)'J'aAA.^tt (Sia.r 



Hours 

Hours 
M.D. 



% 



?^^?'^^ Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



Rfsidt'ii III Satt /'iiiiinsr,} *■ )',•(! ;s 



^/. 



o„th< ^ 



lhi\.- 



Former or 
Usual Residence 

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



How lonq A 
Place of Oeatli ? 



Days 



I 



'''"V;,>"J.^^'^' STATKD PKRSOXAI. PA U TICr I.A RS ARI- TRIK To TlIK 
Hhsroi- .MY KNoWMvDCK AND HKI.IICF 

(Infotniant vXcLwV^ Vl I iJUuA' 



(Address 






^''^^^'t^ KCRIAI, OR RKMOVAI. I DATK o! IJikiai, or RHMOVAI. 

^^jyj^^^ I i^|vt/J) 190H 

[ • X D 1-: R T A K K R QLavl^ H^ ^v Jj O-^tK 



(Atl.l 



rcss 



N. B.- 



ttaTe^cI\rSF'of dTath" l" ^"''•'""*' f^PP'-^' AGE «houId be stntecl RXACTLY. PHYSICIANS should 

«o^l Hvfni »' f I ''u"". J^'*'"'' '^"' '* '""*^ *^" properly classified. The "Special Information" for per- 

sons dyinft away from home should be ^iven in tts^ry instance. 



i 



ij 



i < 



/ ,,, 



II 



« 






l>K 






It 






I 



hi 



If 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H<i;ir(l of Ikaltl) l' No i <; ■J*'?^^!^^ }K«t P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ffr F//ef/ ,'^^'dJU^^Ji}^^, 1 lOO'i 

oUwvx^ JLx^vMj ^^t^^^V Health Officer 

DEPARTMENT OF 



Regi^stered J\^o, 



1 -1 no 



PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "U. S. Stan&arC> ) 

J? ^ ^ ^^ 



A) 



PLACE OF DEATH: — County of C 'Ojy\i J ,\xx^xcu.eo City of Oct^v J,XC 



^ 



rWe, 



.Ulu '^U\.^^\L ^(/Irj^Uial. 



^\ 



CL WCL^^- 



St 






Dist«; bet. 



USUAL RESIDENCE GIVE FACTS called f 

V IF DEATH OCCURF 



and 



(RED IN A HOSPITAL OR INSTITUTION GIVE 



FULL NAME 



TS CALLED FOR UNDER "SPECIAL INFORMATION" 'V 
TS NAME INSTEAD OF STREET AND NUMBER. / 



1 




m I 



PERSONAL AND STATISTICAL PARTICULARS 
"^^-"^ A ^ ^ I COLOR 





DA'IK or ItIR III 



a(;k 



^VuCU 



a 



. 1 

Molith) 







.. »<r».v 



I Day) 



A/,»/f/is 



^Vear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



Aa 

(MonthO 



s.. . 

(Dav) 



(Year) 
roll! 



12> 



Da vs 



SINC.l.K. makuii:f), 

niDoWHD OK DIVOROKD 
(Write ill social «lesitMiati()n) 



lURTHI'UACK 

' St:ite or Conntry 



NAMI-: Ol- 
FA'nil'K 



niKTm'i.ArK 
ni- I ATHKK 

'State or Country) 



MAIDKN NAMK 
OI- MOTIIKK 



cnxctldL 



UTRTIIPLACK 
Ol-- MOTHlvK 
(State or Country) 



O.c^va 

? 



I HICREBV CHI^TII'V, That, I attended dercased fro 
^-'-^l'^ 5^ 190H to .d^\\t..S U)o 1 



that I last saw h:i«''iAA alive on 



U)0 S 



an^l that death occurred, on the date stated above, at | 
U.^M. The CArSIvOl' DlvATII was as follows: 

DIKATION y^s Months Days //our, 

coNTFunrroRv U.\xX.cLuA-*L:d. tLk.u.A.; 






P 



DURATION 



^r,)nt/ls 



(SIG 



NED) J . AA mCU^^ 



Pays 

% 



I go 



OCCrPATlON J\ ^ '^ '^ 

Resided in Sau f'l (nn iu-n Q ^ )V'<m >- •" yhmths ' f),i\s 



fA«Mrc-ss) LVU^ MU .,^ 



Hours 
M.D. 



V. , 



i t 



Special Information onI> for Ifcspitals, institutions, Transients, 
or Recent Residents, and persons dyinq away from home. 

Former or .KaaM, t ». . A^ Hon long at 

Usual Residence ' oa v^^xVU^M) UX Place of Death? 






THI-; AHOVF, STATi:!) I'KRSONAI, PA KTIC C I.A RS ARK TKIF To TIIF 

in:sT Ol- Mv kno\vij:dc.k and bi:mi:k 



(Infonnant 






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



■ Days 



r^fMress . . 



,<a.. 



ly^ACF: Ol- HIRIAF, OR RKMOVAI. I DVT}:.)! IJi kiai, or KKMOVAI, 

IH'l^Oku^^uJSjl 



(A(l<lrcss 



■^' ^- Every item oli information should be carefully supplied. AGE nhould be stated EXACTLY. PHYSICIANS should 

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



1 


% 
w 


^'iH 


^m 


1 1 


.'If 


Igll 


J 


1 



M 



' i 



l^> 



\4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H,..n<l.,fnc:,Ulv-FXo...i>-gg^luS:,>Co REFER TO BACK OF CERTirrCATE FOR INSTRUCTIONS 



/)(f/r Filed, 




\.\,K/>> 




1,. 100\ 



Registered JSTo. 



i 170 



\Mi . 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Til. S. StanOatCi ) 



n 




PLACE OF DEATH: — County of LLLa \>aX<L<X City of \Jl)X 




OJt.) 



(No. 



St. 



-Dist.; bet . and 



/ IF DEATH OCCURS *W*V FROM USUAL R E S I DE NC E Gl VC FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATIO N " \ 
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




:^,\.:CX.... 




PERSONAL AND STATISTICAL PARTICULARS 

^HX A - . I COI.OR 




DATK OF" lUKTH 



Qxkt 

Mnnth') 



kxk. 



1. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DE 



(Dav) 



viii 

(Year) 



ATH U 

.Qxix-t. 



(Moiitri) 



,5. 

(Day) 



(Year) 



A(.K 



....(..s)..... Vfmrs .i...l .'\rmilfis Xs\ Da 



vs 



SINCI.E. MARKIKD 
WIDOVVKI) OK I)IVOK(l-;i) 
(U'ritriu social (Usi>.ri)ati'<>ii) 



HIKTFIIM.ACK 
(State or Country) 



NAMK Ol' 
FA'PHKR 



RIRTMPl.ACK 
OI" rAPHKR 
(State or Countrv 



MAIDI.^N NA>!H 
OI- MOTHER 



niRTH PLACE 
OI' MOTHER 
(State or Countrv' 





I irr-RrCnV CIvRTIFV, That I attended decoased from 

190 ~"~— to 



that I last saw li - 



alive on 



190 



and that death occurred, on the date stated above, at 
•••••p* M. The CAl'Sr: OI' DI^ATir was as follows: 



***»»»••*• 



)^\X.<JXjyy\> 



X^J. 




XtrVA— 



DIRATION Years Mon/Zis 

rONTRIIU'TORV ..., 



Days 



I /ours 



? 



DURATION 
(SIG 



)'cars Mouths 



Days 



uzD) .h%\^^ 



Hours 



/V^vol w'Yv. Lftl^^vvwi'w M . D . 



OCCUPATION 



^h 




lI-oVvla^ol 



Rfsidfd in Sittt Fi ant isro )'rais 



Mouths 



0_JjJ^ . i^o'i (Address) V. <xl!i.la\v(^- '..->. 



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



Day. 



THE AHOVE STATED PRRSONAl. PARTICULARS ARE TRUE TO THE 
BEST 01* MY KN'OWLEDC.E AND liEMEF 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 




\\\ W 

[Informant LU 'CCV\,XX^^VW ~^ ULA><l^trvV 



190 V 



(Address 



PLACE OF BURIAL oR REMo\AL I DATEof Hikiai. u\ REMOVAL 

UNDERTAKER fc ^xXxitc^L ^ Lo 

.S.Hb Vn\^<ULC.c:>,v .31... 



(.■\d(hess 



^« B' Every item of informntion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIAIN8 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. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoiird t)f Health— F No. k ^^^^^msR&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date /^//^^^ dxAvtiL-rvAiHl^v 1 



19 0\ 



Registered J^o, 



*iri 



.Cr^^-A-^o 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



J 



1^ 



Certificate of Death 

( m. S. Stantiat& ) 



PLACE OF DEATH 



: — County of ^ 'CXa-v -'\,a/vw:ir*^.!:i :. City of Ocv-vu JA.au.ivc.i_<i. f:.i. 



-No. H'X'X M\at<r>:,,->.r,. St.; H Dist.;bet. 5 iL a„d .b-ll' 

f IF DEATH OCCURS AWAY rROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



Lr.CLLixOv.^. 



'C 



.toi:) ^' 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



DATK or- lURTH 



\ 



)M • ' 



MEDICAL CERTIFICATE OF DEATH 



\ 



/ Month)] 



s-.„ 

(Day) 



r\S:'} 

( Vrar) 



DATE OF DKATH U 

Sxlxt^ 

(Moiit'li) 



(Day) 



I go 

(Year) 



A ( ; V. 



t -ok... JV'(7; > 



Moyitin 



Pa vs 



sin«.i.f:. makkif:i) 

\\II)()\Vi:i) t)K DIVOKCFI) 
• Write in sorial (hsi^'natioii ) 



HIK rrflM.ACK 
<Statf or Conntry 



NANfK OJ 
FATIIKR 



HIKTMI'I.ArK 
<>l I ATHICK 
(State or Country) 



m\ii>f:n namf: 

OF MOTHKR 



RIRTHPI.ACK 
<M' MOTHFR 
(Statf or Country) 




J I HHRi:nV CI'RTIFV, That I atteiuKMl dec cased from 
'o.JL\:^^. ic)0 . to pjL.\.vfc...b i<p'i 

that I hist saw \\^... alive on '^^ X^\."fc, '■' up . 

and that death occurred, on tlie »hite stated above, at 
M. The CAIJ^j*: OF I) I- AT If was as follows: 



\J JvLtvs.-AA^< 



-<WA^Cr^ \. O.. V -w-a..,. 



DrRATION Vears ^ Months Days Hours 
CDNTRIIU'TORY 



? 



\x 




DURATION Years Months Days 

(SIGNED) nL-M. 'h^K^SMXKi^ 

\±\sX k. uf," (Address) 111 - H t. K "^ > 



Hours 
M.D. 



OCCrPATION^MO 

(|bcVCVXi„JoA.A/-vJU 
K'r.Miirii in Suti J'l nm isi'ir- It) )'iiiis 



V 



dl 



Mnnths " />,i\ 



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



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Davs 



thf; ahovf: sta iivD i'kksovai, i'ak run. aks aki: tkif: to tuf: 
iJF:sr oi' Mv kn'owi.kdc.f: and nF:MF:F 



1 In for man t 



.CLOJVA^/Ct 



O't 






I'^ACF: OI- lURIAI. OK KI;Mo\A1, I n\|i;of Ui kiai, <.r klCMoVAI 

-A' . 

rNDlvRTAKK 



...J nun C^A -\4 



^' R- F.very Item ni Informtition •houlii be cnrePully supplied. AGE nhouid be stated EXACTLY. PHYSICIANS should 

State CAUSE OF DLATH In plain terms, that It may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be ^iven in every instance. 



\\% 






h « 



>1! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ho:irfl of Health— F .Vo. i«; *^S^Ei)n&H Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)a/e F77e(l,AjdpljyyyJ^ 1 19 OH 




Registej'ed JSfo. 






^^VA^VCk 



Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH-City and County of San Francisco 



Certificate of H)eatb 

( Ta. S. StanCatO ) 
PLACE OF DEATH: — County o^Oo^^\JX.^rY^^L■',A.fL City of 0,D.cA.<x/>-v->jiyWl<L. V<x) 



i 



(No. 



St. 



Dist.; bet. 



and 



/ IF DEATH OCCURS AW*V 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 NUMBER. / 



FULL NAME 



A. 



(^ % 



y^^kLL. 



'J' IJXa. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



i 




COI.OR N 



\ 



CUL.. 



y.i 



DATK (tr- MlklM 



AC.K 



/CLU 



<Mi)tith) 



10.^ 

(Day) 



./.i5..a 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DE- 



"" -^ 



l.kt 
(MoiitH) 



. H 

(Day) 



(Year) 



'^ I jv<7»> 1.0. v.>«M.v L!:^. 



Da vs 



SINf'.I.R. MARRIKI) 
WIDOWKI) OK DIVoKCKf) 
(W'ritfii) siK'ial (Usi).'ii.'iti<)ii) 



niKTHPLACK 

(State or Coiinti V 



I HERHBY CI':RTrFV, That I nttemkMl dec eased from 

— to 





CUvVaJLcL 

0<x.'y\JL 



NAMK <)| 
FATHKR 



niRTllI'I.ArK 
OI- l-AIHKR 
(Stat»- or Coutitrv) 



190 to ■■ 190 

that I la.st saw h • alive on ■""""""-"-"----———--—— jqo 

and that death occurred, on the (hite stated above, at 

~-:-r M. The CAlSIv OF DIvATII was as follows: 
AJ .Lcr>>X/OL.v-rN^.. .y^A-X<<td5r.?^ 



MAIDKN NAMK 
OI- MtiTHKK 



HIRTIIPLACK 
OF MOTHER 
(State- or Country) 




I)rk.\Tl()N Years Months 
CONTRinrTORY 



Days 



I /ours 



\n' KA'Tloy^ .^ Years ^ Mont/is 
( SIGNED ) J...4x^^ .SiL^rSi.;!. 



OCCUPATION C 



2). 



Resided in Son F'l aiu ism *- ) >(/; 



UX|al. 



Days 



Hours 
M.D. 



TQO 



(Address) 






Special information only for Hospitals, Institutions, Transirnts, 
or Recent Residents, and persons dying away fro.n home. 



•^ .1A./////V 



/></: 



THE ABOVE STATED PERSOXAI. PAKIKM- 1. A KS A K 1-". TKl K TO THE 
BEST OF MY KN-0\VJJ-:i)(*.E AND in-;iJl-:F 

(Informant V^LO-Ok /^^ VilS 0"t)-tdL 

fA.l.lres.s tlO^ b I Ql, ij /<X-YV .) Lt^U LL 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



S^V.\.^. 



PI,ACE OF lURIAI, OK RE.MOVAI. I DATlCof Hikiai. or REMoVAI, 







190 



' (0( 

INDERTAKER 

(AcMrt-ss b.lO - ^^X I) -tX^V Q\iliXi,...LL.\^.^, 




i 1; 



N. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHY8ICIAN8 should 

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



'A 

m 



w A 



I 
1*1 

m 



Wk 



V 



\ 'iJ 



; ♦ 







WRITE PLAINLY WITH UNFADING INK— -THIS IS A PERMANENT RECORD 

n<y,\r<] of Health I- N'o, i^ t>'v"-;wk^-, lut !' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)afr py/rr/ , AjL\\kx.^^L^\;. 1 290 '^i 



cL^^cA^ 



Reglsiej'cd J\^o, 



1 1 ^.* 



? 



DsJs^ 



^y Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(Tevtificate of H)eatb 

( in. S. StanDavD ) 



4 ^^ ^ ^ 

PLACE OF DEATH: — County of -JCtTt' O^VCX^p^C^^co City of ^ Ct"y\ J/va^LCvc v^ 



Wo, I C) 



T ixA^La. 



'.^. 




St.; d\ Dist.; bet. vj 0\A>-iCA^ and M / UCLv. * 

ILLED FOR UNDER "SPECIAL INFORMATIO 
AME INSTEAD OF STREET AND NUMBER. 



(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION • N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

^l'.^ A - (^ 1 COl.ok 



MEDICAL CERTIFICATE OF DEATH 




llliVcL 



DATH OI- HlkTU 



(L\tr 

'Mouth) 



(Day) 



r % lb 

(Year) 



DATE OF DKATH C 

BxIa^ 

(Month) 



(Day) 



(Year) 



I Hl'RJ-BV CI'RTIFV, That I attendcl ,lf(vasc(l from 



A(.K 



%1 ,■ 

\' V ) t'tr ; A 



It 



M<»il/n 



^ 



Mn 



SIXCI.K. MARUFKI). 
WinoWKD OK DnOKiHI) 

'N\'iitf in social <ksi>.'iiatioM) 



W ^^L^-W^^^w. 



FUR THJ'I.AOK 

(Statf or Cotintrv"! 



KATilKR 



inRTUPUACK 

OI" iathi<:r 

(St.itf or Cf)iiiitrv) 



MAIDKN NAMK 
OI- M<rrHKR 



lUR'rm'i.Ac'i-: 

OI- Mo'niKR 
(Statf or Countrv) 



190 X to "JU^.lijt 1 UyO^ 

that i la.st saw liU'Vvv alive on '^jj^lvt" \ itpH 

and that death occurred, on tlie date stated above, at 
^ M. The CAISJv OF Dl-ATII was as follows: 





'4A^A^ 



CL^^v 



'J-eAj^ 







'■««#*«»i»«B»«»9-4-ca:«*«*»t«**(»*^7«^>, . . 



or RATION 



• ■ •fc«*Mt*»J^T*» - 



)'eaf 





i[ 11 1I 



\avu jo^claxtic 






ore r PAT ION 



Mouths Days Hants 
CONTRIIU'TORY SJ.J>/X( LLcUL .<Xvv:CL 

DIRATIOX ^ Xcars Months Days Hours 

(SIGNED) a. J. \-.^va . M.D. 



"^X^vt-l TooH (.Address) !?)5^;^jlav.! 



S{ 



\ 



Special Information only lor Hospitals, institutions, Transients, 
or Recent Residents, and persons dying anay from home. 



ihi 



rill-; AhOVK. STATl-:i) PKRSONAI, tar nciLARS AKK TRrH To THK 

HHST OI-" MY kn(;\vm-:dc.k AM) hi-:mi-;i'' 





(Infotniatit 



s'o\vM-,D<.K AM) hi-:mi-; 



(A.hlress I D Ol V'^ 



Uoxcy et^ 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'I,ACK 01-- RlRIAl^ OR RKMoVAI, J DMi;.)! Hikiai. or RKMOYAI, 

a.Hb Olit^4.L^v.x3±-. 






(.Address 



N- B. Every item oV 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. 



< < 



^A - 



M{ 



t . 






. 



;i 



ii 



•t 



I 




I 



I > 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noam ..f Hcalth-K No. ^.^^^TiR^v Co pEp^R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

♦17} 



7:>fffe FUed 





a ido\ 



\XXA 



Registered JVo. 



i\x-_u Deputy He.-^Jf h f^^xcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

{ XH. S. Stan&ar& ) 



PLACE OF DEATH: — County of (j CPrA^-r^v^tx^ 



City of 



aJt 



Lr>^- vCL- 



Wo.— 



Sxa 



Dist.: bet. 



and 



/ ir DE*TH OCCURS *WAV FROM USUAL R E S i DE NCE Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
V IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




QUYX\) . . . 0. . iCLA-X' 




"^ 



l^^.^^^.L.\ 



si:x 



DATH OF lUKTH 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR V 




(Monlli 



\X.Md- 



xt 



1 



(Day) 



vll'" 

(Year) 



A<".K 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH J) 

9 xk-t ■ 

(Month') (Day) 



/go 

(Year) 



1 UKRHBY CI-RTIFV, That I attemlod .Iccoased from 

— to - 



190 



^90 



15 y. 



ears 



Moftlhs I Da 



\. 



SINC.I.F:, MARKlF:n. 

\\ii)<)\yF:n OR nivoRCF.D 

(U'ritfin sfKMal ik'sijj^iiatiDii) 



niRTMPI,ACE 

'Statf or Country) 



XAMK OJ- 

fathi:r 



'li 



CXJvVOLcL 




that I last saw h • alive on -: ^ : .>v-..:......„.. ^..i. — - — hjq 

and that death occurred, 011 the date stated above, at " 

^M. The CAl'SK OF DIIATII was as follows: 

OVOXo^t) J \^r 



•■••**f^*«*'«#.#«»f^*«(K4,t«C(p»«VC««#*4fe«B«.«M^^M> 



uCr^wM-^vxL 



BIRTH PUACE 
Ol" lATHFR 

(State or Country) 



ma!1)f:n name 
Ol- mothf;r 



hirthpuacf: 

Ol- MOTHER 
(state or Country* 



DTRATIOX Years 

C O N T R 1 1 J U 'J' O R V ....... 



Months 



Days 



Hours 



'^.44-;t*«^;fe«41«k«*a • < 



Days 



\^ 




10 



DURATION i'ears Moni/is 

(Signed ) .mil). \ij V{M.AJ-,^. jua)^. Ln-cr>^ 

UX|:>A ': iQo" (A.ldrcss) Jlc^-Jlt^rYu Lat 



Hours 
M.D. 



occttpation 



tM^. 



h'fsidfd in San t-ratfiheo ".V^j )V'(f;> 



M.nilh> 



Ih!\. 



Tin% AHOVE STATJ:I) PKKSONAI. I'ARTKTI.ARS A K Iv TRIE To THE 

hf:st oi" my knowm'.dcf; and hemef 



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



Former or 
Usual Residence 

Wl>en Has disease rontrarted, 
If not at place of death ? 



HoH lonq at 
Place of Death ? 



Days 



(Inforniant 



. % QX<xa.ll' 



«3 



(A<](lress 



)X' 



\j^udjLKA \jxk 



PI,ACE OF^RIAI, OR REMoVAI, I I)AT>: of JtlKiAi. or REMOVAI, 

INDERTAKER 'ils» CcL^AXcL ^'^ \^ 

9. M.k NJ )\^4i-Xi,A.^r>x .ui 



(Address. 



N- B. Every item olf information should be cnrefuily 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. 



* t.' I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoard of IIcaUh-F No. i^ -*^^fc it&l' C. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



2)(( 



te FiJed.B 




ii 



n!- 




K .1,,.. 



IVO'i 



Registered J\^o, 



I 1 75 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Xa. S. Stan6atD ) 



PLACE OF DEATH:— County of 




a 



A 





a 



^ \ 



City of ^v\KvCt N K' \.Q<A. 



TNo. 



St. 



Dist.; bet. 



and 



(IF DCATH OCCURS AWAY FROM USUAL R E S f D E NC C Gl VE 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 




X. 



PERSONAL AND STATISTICAL PARTICULARS 





tcyuJL. 



,tk 



.'.- 1 



SHX 



I).\T1-: OF niRTH 




I COI.OR ^ 



L\J^A\Aiji 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DK 



■ATH JJ 




'XC 

(Motitli) 



.11 /...IkX.. 

(Day) (Year) 



AC.K 



MontH^ 





( 



(Day) 



I go 

(Year) 



ob. »«>.? A 



MoiiHii. .... 



J,5.. 



Davs 



srxC.I,K. MARKIKI), 
WIDOWHI) OR DFVokl'KD 
(U'ritr ill s<M'ial <Usij.'nati<iii) 




cwvAjuL. 



!' 



lUKTHPI.AOK 

'Statf or Countrv^ 



NAMH OF 
FATHKR 



lURTHIM.ACK 
OF FATHKR 
(Stat*- or C«)untry) 



MAn))<:N NAMK 

OF motmf:r 



lURTHPr.ACK 

OF mothf:r 

(Statf or Coiintrv) 



. 7 



I Hr:RnBV CHRTIFV, That I atten.kMl .leocased from 

190 to ■ 190 — — 

that I last saw h -T~" ahvc on ...'.v.. k^ 

and that <lcath occurred, oti the <hite stated above, at — 

~~"^^ The CA.rSn OF DI-ATH was as follt)ws : 

Lt..CL,*:uCJLu^.:.....v 



^ 



l)r R ATION J 'earn Montha 

CONTRIBUTORY 



Days 



Hours 



^ 



II 



_- U -l/VAVUX^-VU ^ 



nr RAT ION Years Months Pays /fours 

( SIGNED ) - M.D. 



I«)0 



(.Address) 



OCCUPATION (0 fl , k- 

\iXjiJ\M (J 



SPECIAL INFORMATION only for Hospitals, instilutlons, Translfnts, 
or Recent Residents, and persons dying anay from liome. 

Former or 1 '^ < . j p, ^ L i/ . . '\x Hon long at 



Usual Residence 



i^bi iC'atiL'v Di ?,:;:;' 



Death 



Days 



l)n\ 



THK ahovf: sta ri:i) i'krsonai. I'Articti.ars ari-; trfi-. to tiih 
jiF;sr oi' M^- kno\\ij:i)of: and hi:mf;i" 

rxd.lress l^b I UJ ,<JUjl\. ..yi.. 



(Inforiiiant 




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




K OI--J{rKIAI. OR UFMo\-.\l, I nAJi;,,! I!i wiAr. or RIIMOVAI. 



rNDF:RTAKHR vV9 . J. OAA^'xA/ ^^*v< 



T90H 



''.Adilres.s 



N. B. V,yf:ry Item oil 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** fop psr- 
nons dyin£ away from home should be tiliven in 9\9ry instance. 



% 



■;« 



.^. 1 



7'; i. 
f'ftl 

'Mi 



M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n.Kinl of Hialth !■■ No. K '^■^^^X> !U<tr Co 







Da/,' F//r(/,MjL\\ijLr^\i>-^ :i H^OH 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begi^tered J\^o, 



f, I -"^ 



1 -•*-./-> 



k^' 



\^\.^ Xc 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




Certificate of Death 

( 'CI. S. StauSarO ) 



^■^^ 



PLACE OF DEATH: — County of J (X-vx. va^xCV4.C* City of O (XW 0-Va 



1 



\, ^"\ 



,-» I '. > 



. s. 



/ IF DrATH OCCUBS^AWAY FrJ^M U S U A l| R i 



u&qX 



Dist.; bet. 



and 



(IF DrATH OCCUBS^AWAY FR^M U S U A L| R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATIO 
IF DEATH OCCOdRCD IN 4 HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



FULL NAME 



^11 



N ) 



CLu 




V 



,CULra 



PERSONAL AND STATISTICAL PARTICULARS 

SHX \\ ^ I cor.oR \ ^ 

DA IK «)l- HIKTU 



IvajL 




ijioiith) 



n 

(Day) 



.Al5 

(Vcar) 



(Yt-ari 



AC.K 



(7S 1 )V</;.v J\. !/.»»//// V 1 \ 



/\i\s 






SINC.I.K, MARKIKI), 
WIDOW 1:1) OR DIVOKCKD 

(Writtin >-(H-ial (Icsij^natioii) 



FUKTHIM.AOK 
1 St.'iti- or Coiintrvi 



u 
II 

: iff- 



NAMF OI- 
FATni;R 



RIRTUPKACK 
0|- l-ATMKR 

(Statf or Country) 



MAIDKN NAMK 
OI MOTHKK 



niKTHl'I.ACK 
OI- MOTUHR 
(State or Countrv) 



CavoL 



-CtVvAjui. 



MEDICAL CERTIFICATE OF DEATH 
DATE OI' DKATH J^ 

dx'vt 3 

(Month^ (Day) 

I HKRUBV CI'RTIFV, That I altcn.kd .leccased from 

———-——-——:— 190 —to -: .■ 190 

that I last saw h-—- alive on ■ ■ ' •" -.i-. : - itp 

and that death occurred, on the date state<l above, at 
:sr. The CArSK OF DIvATII was as follows: 




V.V.^AJt. 



^ 



d-<L^»,„v^^\^QLt. 



n 



CV^v 



dl 



I 



I ^ 



^VQ L<WvcL 




DIRATION }-tars 
CONTRIIU'TORY 



Mon//is 



Days 



flours 



'<*^***ay*«*«**«i«.«k.* ■]!•»• • 



DURATION _ )'cnrs Months Pays 



^ 



( Signed ). Wt^vcAj 



^Ct\v4w 



^ f 



I()0 



( 



Addrt-ss) L^t%\X^V^ \^ ^uCa. 



Hour' 
M.D. 



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



OC Cl I'ATION \ I ^ 1 

Kfsiiird in Stjv Fi ilii, i\,-n 1 )r,ii^ 1/,. #////> / ),n ~ II IIUI dl |II«U C Ul UCdlll : 

Tin: \HOVK STATi:D PKKSONAl, rAK'IICn.AKS AKi: TKri: To THH I'l.ACK OI- BIRIAI, OK KKMo\AI, I DVTHot HtkiAi. ..i KKMOVM. 



r<-,,; 



V,, ,////> 



Former or "^^ .'-v *^ ^v "^-j- How long at 

Usual Residence t I Jw J \xAtVAVu ^T piare of Death ? 

When was disease contracted, ' 

If not a\ place of death ? 



Days 



iiivST OI- Mv knowij-;dc.k and in-:i.iHi' 



(Infoitnaut 



(Address \ 'X vVc'tXV^'XU C)T 



Ci-t'jvt 1 1 90S 



INDKRTAKHR W ^(XXM^tX \J )X<tVV^-t>U ^ tl C 



(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 ftiven in every instance. 



\h 



1! 

I 
t.ijl 






■* I 

■j 



M\ 



all 



1 - 



ii!l 



' ! 



« 



if 



T' 






K:!i 



[iyi 



^ 



II 



if 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lioat-'l (,f Hen all- I" No. i= "^-i^^^:^ HS: P Cn 



!)((/(' Filed, d 

SI 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



CkJ^\X..\Ji 




roF 



.W. I 19 0\ 

Deputy Health OfHcer 



lie^l^tcred Xo, 



II 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "a. S. StauDarC* ) 

A ^ J? ^ 

PLACE OF DEATH; — County ofv CX->x \,<x^xCl4 coCity of CcLw ^J VCX.^\ Ca^^- : 
^ No, ^ 5 X\ J iIl^L^^^ix St.; 5 Dist.; bet. 0. 1 ^t and X 1 A vd. 

/ 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 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




L<X/y\> 



I 



v^CLQXXh^-A 



PERSONAL AND STATISTICAL PARTICULARS 
Sl.X V*^ K I COI.OR \ 

DATj-; <u- liiKin 




4- 



(MoiAh) 



b /..aCH 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- ni;ATH 

dxlvt % 

( Month > /Day) 



AGK 



) fti I .T 



5 



.^/"IllflS 



1 



Da 1 > 



•-IN<".I.K. MARUIKT). 
iWiit'iii social (ksij,rnati,,n) 







' X'> vct vi 



iMk iiiri.ACf? 

(Statf or (."ouTitrv^ 



A 

3 



% 



o^ 



_____ (Vt-ar) 

I HICRl'HV CI;RTII-V, That I attcndcMl .loccascl fn.ui 

OJL^--^,. .H 190 '. to . . 6 JL^xt 1 uio H 

that r last saw h rtX. alive oti CJJL\i<k^. ,.3 uyo H 

and that death occurred, on the date stated above, at ^ 
LLm. The CAISI-: OI' DI-ATlj was as follows: 




'i' 



Nwn- m- 

F A 1 1 1 J . R 



/Ctv\j XCla-^l/Cc^ a 






d, 



iYA.A.<<<:U«)r:VU. 



luk rni'i, WH 
<>»•• iatm}:k 

(State or Ooitntrv) 



maii)i-:n namk 

Ol- MOTHHK 



lUkTJnT.ACK 
Ol" MOTHER 
(Statf or Country) 



orcri'ATION 




I>r RATION )'c-ars A/on //is 5 /)ays //ours 

CONT R I P>UT()R V U)X^cOlA^uuL\^ti 



,i^iX'ix. 



or RATION 



}\'ars 



Xj^Oi/XX/'W) 



A/o>iths /^ays 

11 



(Signed) Q. ^. jUa^^^Ka/vu 

Qxixt t> u,oS 



//ours 
M.D. 



n rUi- *?l .,,..S ' fA.1dr.<;s) llalb ll0LtcttsV>vva at 



Special information onU for Hospitdls, ln>,tilutions, [ransicnh, 
or Rfcfnf Rfsidenfs, and persons d)ing dnay irom homp. 



Kr-niri'. II! >■,.'>/ I'l ail. i si'i) 



■,,n^' ^ yf.nithy 



/hi 



VW]-. AMOVK STATl-:i) J'K K St i\Al, 1' \ R rirf I. \ K S AK1-; TKII-: TO THK 
nivST OF MY KNOW l.J'.DCii AM) HI:1J1:F 



former or 
Usual Residence 

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



How Innq at 
Plaie of Death? 



Days 



niifo-jiiMiit 



(■ \(].1tcss 






^ a^ 




I'I.ACF: Ol Ml UIAI.OK KH%to\ \I, J I>A I'l; o: lir imai or KKMoWM, 

ji^o<c* Gv^^Kt^ I ^-^i-^ "^ 190H 

r N n }•: k i \ k i-. k Ouc-aJ^^ c vXvsx:Li^\JL<x.'HJU\Xi 

^Ad.lrfHs 111 Vl l\\,^<t't>?rn Til 



-%. B. Rvery item of information should be cnrefully Kupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for pur- 
sons dyin£ away from home Nhould be Ct*ven in every instance. 



i;< 



< < 



1 



ij 



i. I 



.it 



w 



, I 



b 



h i 



/ 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i,„;,,,i.,rii.„iii. -I'N'o, isi-^ji^ii&PCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Registered JVo. 



iA-7H 



/)„/<■ FiIed,.s::ijJfJOiy-^-.JU^ I I'JO'i 

cUvvc. ixv-^^ Deputy KcafthC^Tlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( XX. S. StaiiDarD j 



i von J? ^ 

PLACE OF DEATH: — County ofClcu^^ JAa/^v^ui City ofOccvx. J/lcl. 



->^. CA-O-C. < 



'No. IHI CJ,A^L^„^-^.'^\.<i.cr^ V 



St 



Dist*; bet. 



5 \, 



a.. 



and 



( 



ir DEATH OCCURS AWAY FROM USUAL R E S I D E NC E G I VE FACTS CALLED roR UNDER SPECIAL INFORMATION • 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A.XD NUMBER. 



Mi 
) 



( \ 



FULL NAME 



.11 




WDLO'"k\' M.'.>.uu.xA. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.DR 



DATK OF lilRTH 



Lt^^Ok/^- 



Mtinth) 



(Day) 



(Year) 



AC.K 



OJW^ ' i ^ )Wn^ 



.„...ii 



Months , ,.., A/v.v 



SINCl.K. MAKRIKI) 
WIDOWKl) OK niVoKiKI) 
'Write in s(K'iiil (N-siji^natioii) 



lUKTMPI.ACH 

(Strttf or Couiitrvi 




^/<:Lc \.A^>-cd^ 



NAMK OI* 
FATHKR 



RIRTHI'I.ACK 
O}- l-ATHKR 
(Slatf or Country) 



MAIDKN NAMK 
OI- MOTtlKK 



inRfllPLACK 
OI MO'IMIKR 
(Statf or Country) 




MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



(Montlf) 



L.... 

(Day) 



IQO . 
(Year I 



<)0 \ 



I HrtRnnV CI-:RT[FV, That r nttendcd deceased from 

..AuJLu ).:^ IQOH to aJLki^. :.I U) 

that I last saw h ;. - alive on ....C)-£^^o^. ^ up 

and that death occurred, on the date slate<l abow. at \ 

\Xj M The CAISI' OI- Di-.A'rif was as follows: 



d>^ty^^^'<<irv^'y^tt 



,:-:^K./iX. 



Di; RATION- - )'t'ars Months Days Uoiiis 
C () N T R IB I' T O R Y M .[..V.XX^Ou«u.:>...>..^-.u..:; 



OCCri'ATlON 



■• Co <,-?». 



I\f sided ill Sail I'l aiu isfo 



) >(/ / 



MnlltJl^ 



Day. 



\'\\V. AHOVK STA'n:i) I'KRSONAU I-A RIHT LARS ARl". TRIK To THlv 
HHST OK MY KNOWI.iax'.K AND HIII.II'.F 



(Informant 



(Address .. vi L\JAJUL\^CV./-*rv-u OX 



diration 
(Signed) 




T()0 



Years ^ Months Pays 

'(Ad.lress) ■l^'^M^^-tK% 'M. 



flours 
M.D. 



Special information on'y '""^ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying anay from home. 



Former or 
Usual Residence 



How long at 
Place of Death ? 



Days 



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



I.ACK OF lURJAI, OR RF:Mo\ AI, 







rNDFIRTAKKR 

(A(l«liess . 




nATU'i; in KIAI. or RFlMoXAl, 

...QX^vii.....J.A...........^ 190 



N. B. F.very item o? informBtion should be cnrefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should 

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



\'\ 



'» 






I" 



r-'i , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

jioanl i.r Htilth-F No. 15 ^^^ REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



i)((tr /^/7^/'^.ax.ixtJL^^Al>-L^J ^ 



lOO'i 



Registered J^o, 



J 4^9 






(>.<^rVAA^ 




li Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "CI. S. Stan&arC» ) 

J? W) ^ % 

PLACE OF DEATH: — County ofjOjy\) OAxx/^txCa^cl City ofCj/<X^rx^ J ^Cl^vCa^^i^c o 



No. H^ VJLcUv.<Xj. 




St.; 1 Dist; bet. 



ib.tl 



and 



n.Liv 



(ir DCATH OCCURS HWAV 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] 



PERSONAL AND STATISTICAL PARTICULARS 



SI 



»* 



I).\TK OF H1KTH 




COI,OR 




^XK. 



Xx 



(Month) 



(Dav) 



r%^.\ 

(Vear) 



MEDICAL CERTIFICATE OF DEATH 

D.\TK OF DK.VTH J^ 



(MoutA) 



1 

Day) 



(Year) 



\C.V. 



T^ 



) I'a > s 



Months , Davs 



SINC.I.K. M.ARKIKI). 
\VII)t)VVKI) OK DIVnKCKI) 
(Write in social dt-siKnation) 



BIRTH PI,.\CK 

(State or Country) 




I HERHBY ClvRTIFV, That I attendcil deceased from 

AaIm^ Xl 190 H to "cJJL^^d: '!l 190 'i 

that I last saw h--'- alive 011 ' ' ' 190 

and that death occurred, on the date state«l above, at * 
_M. The CAJ^SI-: ()!• DICATII was as follows 



i»X. i U*. X„-\V-v> 



oi- aJxJL jta-JLcx.?\.L. 



V.AMH OF 

FATUHR 



RlRTnPI..\CE 
OF FATHKR 

(State or Country) 





Q^'yWj 






MAIDKN NAMK 
OF MOTHER 



in RTH PLACE 
OF MOTHER 
(State or Country) 



vJLoXt 




I AT ION 5" Years '^Months flay 



DURATION 5" 
CONTRIBUTOR^' 



Pays 



Hours 



AV 



<^ 




OCCUPATION 



^ 







DURATION . Years AL>ntfis Days Hours 

( Signed )^xvoX<L\. JxA^vaOHhc-vA . M.D. 

QX^vtj 1 TQO 'l (Ad(lreKs) Xl M(>AavU(JL QK 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 

or Recent Residents, and persons dying away from home. 



Rrsidfd in Suti /'i amisro v ^ )'riii .< 



M.ntth- 



1)0 \s 



THE AHOVE STATED PEKSOXAI, l'\K ilCF I.AKS \K\'. TKIK TO THE 
BEST OF MY KN'c^WI.EDOE AND Ui:i.n:F 

(Informant UJ - H. . V^X)o\JLa../V\^ 

^ h n 

(Afl.lres.s H^ WLOv^^CX^ .>vAr^:>w^T^ 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



PI.\CE OF" lURIAI, OK KEM<)\\I. J DAT>; of Hikiai- or RF:M()VAI., 



FNDEKTAKER \i I U 0X'>A/>A. \1) 



190 A 



-\.ft-<i. 



f.\<]flress .. 



xx\ QtyV^ OLRv^tiL^,. ii^Z.......... 



N. B.—Evcry Item o? information .liould be c«rcfulfy supplied. AGE should ba stated EXACTLY PHYSICIANS .hould 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The Special Information for psr^ 
«on« dyin^ away from home should be liiven in svery instance. 



W 



.!l 






M 



4 : \, 



..f 



I 



I ■ 



A 



'% 



Bl 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noaul of n.;,ith -I No i^ i^^^^uSiVCn REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Drrfr Fi/rd .AjJ^^JU^JLi^^^ I 190H 



Registered J\^o, 



1180 



i \ 



:s 



Deputy Hca?t!: CfHoer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Xa. S. StanC>ar^ ) 
PLACE OF DEATH: — County ofC3<XTv «JXO^/>\C^a.<:(City of "^ Olvv .\xx^xe\_Ax<i c 



<!. 




PERSONAL AND STATISTICAL PARTICULARS 

'K-^^ Qn A I COLOR ^ 



SK 



OX^-woJui 




DATK OI" IIIKIH 



ACK 



I. 



lMf)titlO 






(Day) 



Mouths 



(Year) 



Pa 1 . 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DP:ATH 

(Day) 



(Moiitft) 



(Year) 



SINC.I.K. MARKIKD 
WIDOWKD OR DIVORCKD 

(Write in social desip^natioii) 



HIRTHIM^ACK 
(Statf or Cotintrv) 




NAMK ()|- 
FATHKR 



RIRTMFM.ACK 
OF I'ATMPIR 

(Stale or Co\intry) 



MAIDHN NAMJ-; 
oi- MOTIIKR 



TURTHIM.ACK 
oi" MOTHKR 

(State or Coniitrv) 







I IIKRICnV CF-:RTrFV, That I attended deceased fr 

|vA..^>ji I igoa to . pjL^At....:^. HP , 

tliat I last saw h -* alive on OJIulvt; <o ^^ \ 

and that death occurred, on the date stated ahove, at -^ 
^-^\. The CATSfv OF DF-iATfl was as follows: 



roni 




\^vA-Oy'l 



r.utr^x 



_ a^JLlxx^ 



\Ak- 



OOCrPATION 



Rfsidfd in Sa>r /'t an, isi-'t \ v J'l/;' 



DURATION 1 Yi-ars 3> A/oNf/is X Days n 

C O N T R I lUT T O R \' Ovv.<r\XA/C M <XA.^-V^cJLu ~ 

DTRATION Ytars 

(SIGNED) UJ VTL, 

QjL^vt t> 190 H ( 



Hoiit s 



Mout/is 



Address) ^ I^ V 
XTION only for h() 




Special Information only for Hbspitdis, institutions. TransifBts. 

or Kecent Residents, and persons dying away from liome. 



M.nilhs 



/)<; 1 > 



I Ml-. AHOVKSTATKO I'HRSONAI. I'A R lior I,A RS ARi; TRIK To TH)- 
IJKST OF MY KNo\VM;I)C,K AND HKMi:!- 

1'^ " 



Former or 
Usual Residence 

When was disease confrac ted, 
If not at plare of deatli ? 



eOtjt^^vLo'%&M 



How long i\ 
v^ Place of Deatfi ? 



Days 



(Infoniiant 



t9(. lO Cclluv tV 



(Address 




mRIAI. OR RKMoVAI. j DAp-of Mi kiai. or RKMOVAl. 

190 s 



Ia^ 



<i,;L 



K 



R Vvj. L L^v'\A..<ru ^M.C<) 



N. B.- 



"^.^t7cI*i^^F*Ap'^nT^xM" "''7'*' ''" ^"-'^""y «uPPl5ed. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH m pl«,„ term,, that it mny be properly classified. The "Special Information" for pr- 
son« dyinft away from home should be feiven in every instance. 



4r. 



»»i 



»'* 






\ 






V 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n.,ar<1 of Hcalth-F Xn. i^ i^^^H&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date Filed, d 




ioA/. i WO'i 

Deputy Health Officer 



Eegistei'ed J^o. 



M8I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( la. S. Stan6ar? ) 



(^ 



-\ ^ -\ von 

PLACE OF DEATH: — County of ^ . OTUX/^xCi^CoCity of ClO/^^ OA.a^vc^^^ 







A / ir DEATH OCCUim AW*V FROM USUAL 
y V, IF DEATH OCciiiRncO IN A HOSPITAL 



"UrU . St.; --- — Dist.; bet. 



and 



L RESIDENCE GIVE facts called for UNDER "special INFORMATION* 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME ... ^.lri\/-\\! La/\^cxx^.•>x.a.^Ll. 



PERSONAL AND STATISTICAL PARTICULARS 

SHX A ft j COLOR \ 




t 



1 



DATK OF lURTFI 



(Month) 



AOK 



vo )>,„, H 



(Day) 



.yfntlths ....!S^..\. 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH _j 

'.xiJ. 

(Day) 



(Month) 



(Year) 



I JIKRKHY CI'RTIFV, That I attcn.lol de.vascd f 



Pa r.v 



SINC.I.K. MARRIKD. 

winowKi) OR nivoRCKD 

(VVritf in s<x?ial <lf.si>rnation) 



cIv^^v^q/Ia 



:i\.^Xcy.... 



.Sl. 



U 



190 



that I last saw h •.. alive on 



to .. ,d-Jil^\.vt "a. 



roiii 



niR THP^ACR 

(State or Country) 



NAMK OF 
FATinCR 



RIRTin>I,ACK 
OF' lATIIHR 
(State or Country) 



MAIDHN NAMK 
OF MOTHKR 



niRTHPLACK 
OF MOTHER 
(State or Country) 



II f 



190 H 
190 

and that death (^curre<l, on the date stated above, at L) I 
M. The CAl'SK OF DKATII was as follows: 



-c^. 




IH'RATION Years ^ Mouths 
CONTRIBUTORY 



Days 



Hours 



h 



(L 



IcuU 



OCCUPATION f iJ p ]^ 

Kf Shied in Sitfi /■') (iHi i.Uit 



Dl'RATION Years Moiilhs Days 



(Signed) 

UX[\t ^ TQo''. (Address) 



Mouths 




Hours 
M.D. 



■^\^A'. *^.-- 



Special Information onl> for Hospitals, institutions, Translfals 
or Recent Residents, and persons dying away from fiome. 



) '■(// .V 



Months 



l)a\ 



THK MIOVK STATFD PKRSONAl. l-ARTrrif.AKS ARF TRTF To TUF 

HHSTOI- Mv kno\vi,i:i)<;h AM) }u:iji:f 

(Informant J.VO^A^cA \X- C3 cJ V^WsjCbl c)^KjJ\ 



Former or 
L'sual Residence 

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



How lonq at 

Place of Death? Days 



\<K 



^VfiUu. 



PI^ACK OF IHRfAUOK KKMoVAI. j DATI- ..f Uikiai, or RKMOVAI, 



1 



J 

INDl.RTAKKR 



(Address hklX.- la .ttv jl 



N. B. 



"r»'lV*'cI'i?iF*A"JnTri?r.**'7'.** '"' ^"'•«f""»' -"PPH^d. AGE should bo stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The •Special information" for psr- 
sons dyin^ away from home nhould be ftiven in svcry instance. 



I 



■1 



*■!, 



tlr: 



,1 4 



t ', 



I 



I 







I I 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

)U)Mr(1 (if Hcaltli- F Xo. ic, ^-^pC^^ J}&p C(j 



Date F//e(/,AjL^tjUYTJL4^ i. 



190\ 




WEFER TO BACK OF CERTIFICATg FOR IN3TROCTION3 

Begistered Xo. I 482 



DEPARTMENT (JP PUBLIC HEALTH-City and County of San Francisco 

Certificate of H)eatb 

( *Cl. S. StanC)arO ) 
PLACE OF DEATH:-County of 0)a^^ Vc^vcc^CGty of 4a^1^.^.vw<x.. c_. 



'No. lllb K LLlo.(><XA>x<x, St.; (o Disfbet \'h^<L a 1^ \-\ 

/■ ir DI.TH OCCURS .w.v rnoM USUAL RESIDENCE g,»e7.ct;%^.,„.^ *"«• ^nH -L-l V 



FULL NAME 



SEX 



DATH Of lUKTJf 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR 




(Month) 




'yVvA^, 



.li 




-a. 



•MEDICAL CERTIFICATE OF DEATH 

DATK OF D1:aTH 



b 

(Day) 



A(;i^ 



Am 

(Vear) 



Qxkt 

{Montfi) 



(Day) 



.O/O.. )•,■,;;.« 



Moulin 



I 



/></ 1 J 



"^IN'.M:. MARUIHr) 
\V|I>(»\\ HI) OK niVOR(.HI) 
(Write in social dcsijru-ition) 



lURTHIM.AOH 
(State or I'ountry) 




'l<X\AA^Ld^..__ 



NAMi: oi 

J-ATin;R 



C 



JHRTHI'1,ACH 
f)|- lAlflKK 
(State or C'ountrv) 



MAIDKN XAMF 
<>l- MOTHKR 



HIRTHPI.ACK 
Of- MoTflKR 
(State or Conntrv) 



<)CCt'rATlON(?5?l 



CrV'^ 




I go \ 

(Year) 

I HKRHHV CFCRTIFY. That I attcn.UMl <lc;-oas;rfnjn, 

••••• 'J-^ 1 190 H to BuL^xi. 1 i,^H 

that r last saw h >^ > > . alive 011 0~JlL:i^\l: (.^ ^^ • ^ 

andthat death occi.rre.l, on the -late stated above, at H 
Hp^^- '"^^'^ ^'-V'^'-: t>I"' I>":ATFI was as follows: 



-<^. 



DIRATION Year, .V„v//„ /,„,,, //.,„„ 

CONTRlliUTORY . . 



7 



DURATION k'''>N ^'''"''^/'•^ /^''n'.^ 



^(X/wd-. 



....... t(?-(i^ 



Hours 



(Signed) 



QJL\(sk \ um\ (Address) l05^ "t] \XX^d-Q^|. 



M.D. 






nr^P^Pn^^AS •- I N FO R M ATI ON only for Hospitdls, Institulions. Translentt 
or Recent Residents, and persons dying iw^ay from liome. •">««^"i% 



KrsidftI i„ Sat) In a 



lu nrn 



' i JV<7; A M<in/ln 






Former or 
Usual Residence 

Wfien was disease confrarfed, 
If not i[ place of deatfi ? 



Now lonq at 
Place of Death 



Days 



N. B.- 



I'l^K OI-- ni-RIAI. OR RKMOVV,. I l.X|,:.,: ., k,.:. ,.r R f^M< .v Af. 



*i!*^^s-. 









i 



l,4i 



'1 



.If! 



*■ 



I 






WRITE PLAINLY WITH UNFADING INK 

I5o;ird of He;ilth--F Xo. 15 'S^Sj&^aH&P Co 




— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Ddtc Filed, QaA^jLi^v-^ojMA. Si lonu -^ . 

jT) ^■^^^^\^^^^>n^^^^^. \ 190^ Registered m. 

A,'<^vv^^ Aj^v-u . Deputy Heallth Officer 

DEPARTMENT OPkBLIC HEALTH=City and County of San Francisco 



.3 



( 



PLACE OF DEATH.— County ofO 

No. b H UrV<xllcL-\x.CrtrEl,-lx. 



Certificate of H)eatb 

( ra. S. Stanfiaro ) 



% 



i 



V^ 



nty ofvJa>v a,^.vcc<».CO City ofCJcc^, i^a,v 



ct.,i. a I 



C ir cr.TH occu.s .w.y rS,o„ usu», =r..i*i„ DlSt.;bet. il A.T' ,„J 11 \ 



FULL NAME LLLLLd. 



?^ 



V,,,: 






SEX 



PERSONAL AND STATISTICAL PARTICULARS 

hH^ I) I COLOR N 

^-t/Vyx^cJui 

DA r K OF H I R r H /-y 

U.U.01 IH ...., HOH 

^<M.)iith) J 




IH 

(liay) 



'^EPI CAL CERTIFIC ATE OF DEATH 

(Moiitli) 



DATE OF DEATH 



(Day) 



(Year) 



AOE 



y'rat s 



. !/'»////.( 



SINCI.H. MARKIEI) 
WIDOWED OR DIVORfFD 
(Write ill s.jcial <k'siKiiatioii) 



l\ 



(Year) 



r>or^ 



I HRRHnV CKRTrFV, That r atten.K-,1 .Ic:;..;^,;^!;^. 
^^^^■^- -^ .....»t^.H to ...^c\-^^vt k 100 \ 



niRTmM.ACE 

(Siatf or e'oitntrv* 



NAME OF 

i'atfii;r 



niKTMIM.ACE 
OF FATHER 

(State or Country) 



MAIDEN NAME 
OF MOTHER 



^l-^-^va/VX. 






90 

T90 



-A 
tliat I last saw h^..' alive on <J-^)j.vt. k 

and that death occurre.l, o„ the .late stated above, at b 

U M The CACSR OF DlvATIl was as follows 

C^^^"UO./-v:v<vXwfir:^.v 




HIRTHPr.ACF 
0»- MOTHER 
(State or Coiintrv) 



U /CL ^ V) d .\x:i^^-V'CA,^^c.o . 



— ^''wM h, ,s-„„ /■,„„,,,,,, - I-.,,,, . „^^^_,,^^ . 



DURATION.. Years Von//n Ih Days 

CONTRIIUJTORY 



Hours 



Mouths 



a.:Vt, 



Hays 



nURATIOX ..JVff,.j 

( Signed ) lljJbtA^ vv. JUaV^ 



Hours 

M.D. 



nr?.f!^9'fl'-."^f°f''^'^'r'ON only for HospKals. Insmutlons TransifnK 
or Recent Residents, and persons dying away from home. 'ransienis, 



/ '1/ 1 ' 

TIFE 



Former or 
Isual Residence 

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



How long tX 
Place of Deatli ? 



Days 



(iJiforiuatit 



(Add 



rcss 



iXSb 



N. B. K 

state 



i> 



x.\ 



I90H 



I^ACK OF HFRIAI, <,K KKMoVAI.I nv,-E of m k,.,, or R EMOVA,/ 

U.i^V\X^^ XjOaa..^:^ I 5.^|x t \ 

FXDERTAKER 1:3 Cui^txXl "^V L) 



(Address 



t«7cA'irsE'oF d7a"th".'''7''' "' ••■"•'■'""> -PPHe''- AOB .hould b. «.ud EXACTLY. PHYSICrANS .h„ I . 






I 



r» < 



'I! 



• fi 



'1 






f 



iii. 



III 



k i 



Ho.inl i)f HtMlth — F No. ic; 1^ 



J)& p Co 



WR.TE PLA.NLV WITH UNFADING INK-TH.S ,S A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATg FOR iNS TPHr-r.^.. 

Registered J\^o. 



Dale Filed, AjLkstxyyyJjJLh^ \ 



<KyCr\^^K^ 






If 



(Ne. 



DEPARTMENT Of PUBLIC HEALTH-City and C««nly »f San Francisco 

Certificate of 2)eatb 

( Ta. S. StanC)arO ) 
PLACE OF DEATH:-Countv of ^^X J^.^.,,.^, ^^ of do^lvc 



^\.CA_v, <.:.(. 



v:)>A, 



-i^ 



Dist.; bet — 



v-wuHlf^D IN A HOSPITAL OR INSTITUTION GIVE ITS N 



.Vl/.? .1° " "''°^'' "S'-tClAL INFORMATI 



FULL NAME 



AmV ,«V-rr.,. SPECIAL INFORMATION- \ 

AME INSTEAD or STREET AND NUMBER. J 

CI 



i\.ax.LL^ LlIa a 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 




COI.(1R 



DATK OK IJIK TH 




^J 



''\aXl. 



'MEDICAL CERTIFICATE OF DEATH 

DATE OF DP:aTH 



djikfe 

(Moil til) 



(Day) 



fpo 

(Year) 



a(;k 



«IN'<".I.K. MARKIKD 
WIDOWKD OK I)rV()RrFD 
(Write in stx-ial (ksiv^natio'ii) 



niKTffPI.ACK 

(Statf or Coujitrj-) 



NTAMK OF 
FATiniR 



HIKTHPI,ACK 
Ol' FATHKR 

'State or Country) 



MAIDKN NAMF 
•>F MOTHHK 



ihrtfipi^acf: 
of mothkr 

(State or Country) 




D. , ^'"""i"' _ ^ (»ay) (Year) 

^ /k 'a ' "^K^^BV CHRTIFV. That r^tt.,,^„eceased from 



I90.rr-Tr..., to 

that I last saw h .~ alive on : — ___ 

and that .k-ath occurred, on the date stated above, at 



190 
T(/3 



..^ ^ -M. The C^SH OF DHATII was as follows 

M^H^UJ^ 



r^-4. .-a.:>.vcL 



nv\ 



DURATIOX n^ars 
COXTRIJR'TORV 



Months 



Pa \s 



OCCrpATlON 



Hours 

I fours 
M.D. 

«,?''^9'f!'-. ' 'fORMATION only for Hospitals, instltutidn? Transient 
or Recenl Residents, and persons dying anay from liome. iransients, 

former or 
Dsual Residence 



nrRATIOX Years 

i ^ 

(Signed) .U-*t(n'U\; J. 



fhiys 

JJi\-X 1 ;c)o'^, (Address) L^\x-v\Xn„^ V ' j( ' 




'Informant LVV^T^-vXh^ 



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



HoH long at 
Place of Oeatli ? 



Days 



) Tui-; 




(Adflress 



PLACE OF nCRIAI. OK RK^.<.^ A,. I DATHof mKM,. ... RKMOVAI. 

dx4^x^rua-,y.oj(jl ' . ^.-^^zi:'^ T90'. 



UNDERTAKKK tAjJLio ^K^ ^^XXOt^vv 

(Address ..2>babw.-. i^ xl^, '.cSt 



•^t^Ve^'cAu'sF'np nTr;T. '^^^^^ ^^ ^""'^^""^ «"'>'"-^- AGE should be stated EXACTLY. 



son 



te CAUSF OP nrrA-TM • • . ' ""»'»'■"="• '^'J^* snouiu oe stated bXACTLY. PHYSICIANS .1 



PHYSICIANS should 
pmr- 



H 



t 



< (] 



W 






t .1:1 



I , 



R 



ii 






m 



' ' < 



Horinl of Health— K No. m 



li& 1' Co 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

MegLsfej'ed Ji'*o. 






Date File(l,..'^,jJ\f'Jji^ % jgg k^ 

XxiAAA^ Xt^c>\^ Deputy Health Officer 

' DEPARTMENT OI^PUBLIC HEALTH-City and County of San Francisco 

Certificate of Deatb 

( Ta. S. Stan&ar? ) 
PLACE OF DEATH:-Cou„ty of dc^^ J.,Vc......,c.G.y oli C^3 Ko^^<,^^ 

(No. m^S^ Oa-.^'. Si- ^ n-t !„♦ (Drt-^ 'i 

( .r ot.TH OCCURS .w., ,Ro» USUAL RESTOENCE ,>,„r ^i!."' **** '^^<X-U-VXU and cL<XCI,V. WVO "j 

-iTEAD OF STREET AJiO NUMBER. J U 



FULL NAME 



% 



f\. 



X^::y:\\.ol.<l.,. 







SK.\ 



DATK <)1- lUKTM 



''"^°'^^'- '^H^ STATISTICAL PARTICULARS 

COI, 




^K 



"""IjjJv.u 



I Month) 



1 

(D.'iv) 



(Year) 



Af'.R 



(q3» }W;,.v Iq 



Mi'tilhs 



lo 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII V 

axlxt 1, 

^^^"""l) (Day) 



(Year) 



HINCF.K. MARKIKH 
WIDOUKI) OR DrVORCKD 
I. Write iti social <l<siviiali<)ii) 



Da I . 



niRTHPI.AOH 

(Statf or Cotuitryi 



i " 




N'AMK <)l 

fathi-:k 



HIRTMPI.AOH 
0|- lATHKR 

'State or C'ountrv) 



MAIDKM NAMl* 

oi- m()thi-:k 



lUK THIM.AOK 
Ol- MOTHKK 

(St.-itf or Coiuiti vl 



'\A>UL/dL 



I HKRHIiV CHRTIFV, That I ^ttculcl ,lecvase<l fn,m 

'^"^^ ^ to^....B-L.jx:t \i xcp H 

that I last saw hA. .. . aUvt- on vWjCt, .2^.0...„ h^ H 

ana that death occurred, on the date stated ab.ne, at 5" 
^ M. The CAl'SH OF Div.ATir was as follows: 





F<tjZ>;'X<V/VvX3L.. 



n 



DTR.ATIO.V . Years 
C().\TkII?rT(>R\- 



^'^fonihs Days Hours 



DIRATION. 



)'enrs 




rV. 



(SIGNED) 'Jk.<X,^X. U) txd. ' '' 



I tour 



KLkx 



\jAXju^^Xa'\. 



\ 



Mi>nt/is J)ays 

, ^w ^.^v^<L<.<M>\.t|^, M.D. 

C^X^A-t ,c,oH (Address) UOM W^vOlxA^ IL 



„r?.r.n^?'^^J'^r°"'^?''''0'^ ""'^ '"' ""^P'f-*'"^' Institutions, rranslcnts 
or Rctent Residents, and persons dyinq dHdy from home. •"""cnis, 



OCCUPATION 



-t 



) V'rr/.c 



Mi»iths 



rhtrs 



'■''m^'r';;\^^l^:^;J:,^;'i:1^.;^^i--;;;;,:,-Hs..„,: ,K, . .,, ,MH 



fii 






Former or 
Usual Residence 

When Has disease contracted. 
If not at place of deatli? 



HoH long at 
Place of Oeatl>? 



Days 



K):M.»V\I. j DATHof Ml k,Ai, ,„ HI-MOVAI, 

^^ 190' 




r.Ni)i:RTAKi:K 



N. B.. 






"r*«V/r!l'imi^*I'^^*)r'""*'"" •*"""'•' '^'^ ^^"•'•I'uMy Huppllcd. AGB Hhould bo Ht»tc<l EXACTLY PHYSICIANS u ... 



tj 



it 



<i 



' ^ 



1 




'):' 



< ' 3 



Hi 






fl 









I 



m 



\4 






WR.TE PLAINLY WITH UNrAD.NG .NK-TH.S ,S A PERMANENT RECORD 

HojiKl of Health — F Xo. k '^^'^^^ n&l' Co 

~ WEFER TO BACK OF CERTIFrcATE TOR INSTBUCTIONit 








1 WO'i 

Deputy Health Officer 



Megiiitcred J\,''o. 



r^m 



DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 



Certificate of ©eatb 

( Ta. S. StanOar^ ) 



PLACE OF DEATH = -Cou„ty of^^?^,^.,, city oA^J^KO,- 



rNa 



^^UiXX^^n^ m.L<X.^{x: 



^IfX^OMM^-C 



(rr DEATH OCCURS AWAv ranu iieiiAi n .- » . ^ - 1-^lSuJ OCt* '• J.i.l.....;, — — -: irirt 

^T- ti.VC ITS NAME INSTEAD OF STREET AND NUMBER. ) 



((0 



FULL NAME 



vj 



:CL\.<^.i 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



m.. 



CLAX 

DATK OF lUKTH 



AGK 




MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 




(Monti/) 



b 

(Day) 



(Voar) 



I nHRHBVC HRTlFV, That I attended ,leccasecl7ro,„ 

190 — ■ to ...nrrrrrrrnrTTrrrnn— rnrr 

that I last saw h :r— alive on - 



)'t'ats 



Months 



SI\C.r,K, MARRIHD 
WIDOWKD OK niVOR(HJ> 
<A\ rite ill social ik-sivrtiation) 



Davi 



HIKTHPUACK 

(Staff or Coinitrv) 



N'AMT-: 01 
I- A I" 1 11-: R 



BIRTH PT,ACK 

OF fathf:r 

(Stale or Coniitrv) 




VAXcrV\^^A^c5i^ 



and that death occnrred, on the .late stated a!)ove, at 



^^^'' ^''^^-^^ ''^' '>'-:-^'ni was as follows 



190 
190 



MAIDKN NAMF 

<»I- MOTHKR 




DURATION )'cars 

CONTRIHrroRV 



Months 



Days 



Hon 



fS 



DURATION Years 

NED ) U\ 



fSlG 



.(n\j5A; 




^fouths Days 



,U),i^ 



Ux^KvcL 



HIKTHI'I.ACK 
Ol- MOTHKR 
(State or Country) 



OCCUPATION 

f^'f^'dfj in S„„ l-,ai,,is,n 



Hours 

M.D. 

i<i^ 

?^^9'^'- Information onlv for Hospltdls, institutions Irjnslfnk 
or Recent Residents, and persons dying away from liome. '"'*"'""»"''' '^^nsients, 



01}^ "■ roo^ (Address) U^^^^^^ ©li... 



%-^' 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



(Inf. 



onnanl 




lyCK OF nrRIAr. ok RKMoVAI, | nyKof HrK.Ai. or RKMOVAI, 






rX'Mrfss . ~ 



)jl\±. \ 



^' ^' "Every Item of Info 

state 



rXDKkTAKKR 0\XAXm V (lb CLCl.a^vv 



te cr^SE OrDTXrS" : pTali t:;:rth '^ •r""^K- ^""^ f ""." ': ••»''' exactly. PHYSICANS .hou.C 



! 



I 



i 



i 












y 1 



i^i 






^il^i^ 



\ 






ffs 



WRITE PLAINLY WITH UNrAD.NG INK-TH.S ,S A PERMANENT RECORD 

Ho.'iid of Ikiilth — F Xo. i^ '^^^^^H&I' Cu 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTION*. 



-MaJlx/y^' 



(:Xx^\A^<i (iw'lAj- 



ItegLstcred J\^(), 



i<\'^ 



Deputy Health Officer 



<:xxrwv<i ck,eyv-u ueputy Health Officer 

DEPARTMENT ()F PUBLIC HEALTH-City and County of San Francisco 




Certificate of Death 

( "CJ. S. Stan&arC» ) 
PLACE OF DEATH:-County of Oom; J ^V<X.^vc^^^ Qty of ^ 

^**' P!!t- ^t> and 






( IF DEATH OCCURS AWAt FROM USUAL R E S I DC NC F ^ . „r ^^'^ ^'^^^ and ^ 

^ .. OEATH OCCURRED .N A HOSPITAL O^R^ f J ^^ ^ "oro^V ^ ^ 5,V^7 .^A ^ ? s'T%7ET;NrN°:::;r • ) 

FULL NAME 



X:^XL^. ... 



SK\ 



''^"®°'^^^ ^^-B.^I'^'^'S'^CAL PARTICULARS 
^ n I COI,OR \ 

DATK OF UIK TH 



•V* • * ** •s*. W« , JLi^*-*. „ . . , 



•--^-vJkLtx 



MEDICAL CERTIFICATE OF DEATH 

DATK OI' DKATH 



(iilonth) 



MMf 



(Dav) 



.AlL. 

(S'ear) 



34xt 

fMontli) 



a)ay) 



IQO 

(Vtar) 



jCS. \ )V«/: 



I 



Months 



h.. 



SINC I.F MAKKIFl) 
WIDOUFI) OK DIVOIU'KI) 
tUiitviu social dt sij^iiation) 



HIKTHPr.ACK 
(State or Country^ 



Pa Ys 



N'AMI-: OF 
FATHKR 



HIRTHPI.ACK 
OF l-APHKK 
(State or Coiiiitrv 






,1 HKRHnV CKRTirv, That I atten.kxl <lccvase,l frcm. 

<^-^|^ H ,9oH to ....djL^xi: (c , ,^c^ 

that I last saw h.^. , alive on djL^^tr: > ^^X. 

anil that death occurred, on the date stated above, at X\S... 
^. M. The C\rS 



^. M. The^rSH OF DKATH was as follows: 




DURATIOX Years 



MATDKN NAMK 
OF MorriFR 



niKTHlM.ACR 

Oi- MOTHKK ^ 

(State or Coujitrv/ XV) ^ 



OCCUPATION 



ft 



Days iio //, 



)urs 



f^^-s/dr,/ /„ S„„ /nn/.is^o )Vv;.v 



Mn))fhy 



An 



a)XTRlIU'T()R V LlcAAijL U). JLj:.ojt.v.^:v^ M 

.... .fex.aA.tj t 

DURATION Yrars 

f SIGNED ).m. i.. l}&|vk..^ M.D. 

rJx\vt I- K) oH f■^dd^ess)VWdx.^t^Jlt^^^^^^^^ 

?^^9'^'- 'NF"ORMATION only for Hospifdis. Institutions frdnsienK 
or Recent Residents, and persons dyinq dwdy from home. Tdnsienfs, 

Former or ^, Ji Hon long at 

Isual Residence •^^4..,..dt Place of Death ? 

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



Days 



""f— .. ' -' JUvvvvouv^ X o^^ac^t_ I Milt Jil^^^^t .. _. J §.r^>t ^ 






\(hlres.s 



"^^ ^" Bvery Item olt in 

state 



iNDKRTAKKR Mf rUrwo- Vv^^^ Q^ 1^. a\/o^ V ^ 



I90H 



(Address . 



s^^Hi Ox 



V'^^i-vrw. 



^+ 



t'/cTj^E OP oTrTH" *''?•'' "" ""■''""" »"PP'-'"- AGE .hould b, «tae.d EXACTLY. PHYSICIANS 



S should 
for par- 



ti 



'lii 



U 



:h 



r 



"y^ 

,'•1; 



« , 



i 

ft 



-it 



ta 



ii 



4 



i: 



WRITE PLAINLY WITH UNFADING .NK-THIS IS A PERMANENT RECORD 

)!..;ir(l of Mf.-ilth- !•■ No. ! <, "^f^^S??^ lut P Co 

C ~ ' _ REFER TO B ACK OF CERTIFICATE FOR I NSTRUCT.QN^H 

C J ^ J^^u^ Bcgfsiercd J\^o, lA^^ 

X^i-t^u \cvM.| Deputy Health OfTlcer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Death 

( Xi. S. StanSatO ) 

PLACE OF DEATH=-Cou„.y of^a.Jxa.vc..ao oty of l>vlva^vac.c. 

/ IF DC.TH OCCURS AWAY FROM U «5 U a I o r oToV ^^ISt; bct. V /Ck^QjiL ^_J \^ X\ I' 






FULL NAME 




m 



L-V.A; 



PERSONAL AND STATISTICAL PARTICULARS 

•^K>^ C^ /| I COLOR 1 I 



DATl-: OF IiIKTH 



ixOU 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- I)1.:ath . ■ 

Cjxtvfc ^^ u 

(Monk) -.. \ ^"^"^ 1 



'Mr.iiflO 



A<'.H 



51 „.,, 



(Day) 



MotiUts 



A'i.'l ... 

(Year) 



(Day) 



'^IN<".M<:. MARK 11- I) 
WIDOW HI) ,)K I)[V(,RrK[) 
I Write- ill .social ritsi^. nation) 



Davs 



I IIHRI-BV CI-RTIFV. Th.t I atu-mlcl .Icceas;;!! 

■-■■^ 1 90 



(Year* 
roiii 



U) 



lilKTMI'I.AOR 
'State or Country) 



NAMK oy 
f-ATHKR 



'tlklUlM.ACF 

<>i- i-aiuhk' 

'Statt- f)r Country) 



I Woj 



\J\^<jlA. 




AX^Lo^'Wct^ 



that 1 last saw h ..-r-r- alive on - 

MiKl (hat .Irath occurro.l, („, the .late- sifted ahnve. at 



'I90 






-ftr^\,<&. 



OK MOTIIKK 



HIHTIIPI.ACK 
«>l" MOTMKR 
fStati' or Country) 



OCCITPATION 




DIKATION )\.a,s 

CONTRIJilToRN' 



Mo]itlis 



Days 



Hon 



t:s 



iNED) I, 



(SiGI 



//ours 
M.D. 



or Recent Residents, dnd persons dvinq dnay frnm home. Tdnsients. 

Former or 
UsudI Residence 



i 



f^'f-nl,,! n, S,i„ i;,n,,is*n ^' 



) '<U1 1 



M uith 






//,, 



K To J- UK 



' I II forma n I 



' \<l(l!.s« 






When Hds disedse conlrdcfed, 
If not aX place of death ? 



HoH long dt 
Place of Dedth ? 



Ddys 



i;i,ACK o.. IMKrAF.OK RKMoVAI. | I»ATK of BfK.A, o, RHM.nAI, 



i VN^i-.'i^ ^a^-CL^AZ-v 



1. 



^^DKR•,^^KKRU;J^^^.a4xLU. ^^'^w.vWvci D^xt^t ^ 



fAddre^s. 113.4 



^■Xvv 



ua.OwH. s.<, ^» 



«r/c'rsE'of dT^vs":;":.';: ';;;;::':k:^ -t-:::'-! _*"'^_':'"":'" '■.i-.-i-^^^'^-^'v. phvs,c.ans ,h„„,. 



-on. Hwnt .„a, ..o™ h":: r: "r.Ve'":::'.:.;: r:..";;:::'^ ^'""•"''"'- "■-^ "'''-'»' ""■•--»"■>"•• '- 



r pwr- 



'1.1 



ii 



t 



< I 



'I 



I 






'^1 





11 



1 



ENT RECORD 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMAN 

Hoiird of IlenltJj — !•■ Xo. i <; '^'^^^^) li&l' Co 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\^o. 



Date VvV^v/, Qx^tc^^vl^^ j 100^ 

Is^^K^:^ olxvM.< Deputy Health OHl^^^r 

DEPARTMENT 6f PUBLIC HEALTH-City and County of San Francisco 

Certificate of IDeatb 

( tl. S. Stan^ar^ ) 



1^9 I 



PLA^ OF DEATH:-County of ^ a^v i Vavva..^ Cty of ia>vlva> 



No 



I. 2> l^. L(volUa,wLa.?„1- f ^■ 



vac>ico 



St.; 



R> 



Dist.; bet. L-^^\/q,c^v::wA„cK.. ^^^ L<v\ i 



/' IF DtfTH OCCURS AWAV TROM USUAL R E S I D E N C E r I «r ;;:;"♦ ^^" "^"'^^^V^-^-^^-t.^ and V.C 



O -»vd ) 



i. 



FULL NAME 



Tr:iZSJy^1^.. 



PERSONAL AND STATISTICAL PARTICULARS 




SKX 

ecu 

DATK n|. lUkTU 



\\\. ' 



COI.OR^ 



lO.fv^-U 






1 



(Dav) 



\ ' . 1% 



} 'ra I V 



}fn„lhs Vq 



fc 



r'lm 

(Year) 



Days 



I go ^ 

(Year) 



WIDoWKI) OK DIVokCKi) 
(\Vrit< in «<(K-i;iI tltsij..ii;iti<.ii ) 



!) 



niRTFrrM.Aci-: 

<Stat( ur COuiitrx) 



NAMF (»l 

» atiii.;r 



'nkTHfl.AiF 

•>'■' lATMl-k 1 

'St.itc or VoiiiitryV \ 



^, ^ (I 

. O.oJl 



MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH C^ ' ~" 

"dxlxt 1 

(MoAth) ,I,.,y) 

^I UKRliHV CHiriMFV:ThaUatten.icMl.leccMis;;r7,:;;n7 

f^ '' '^' to..^^^....„ X..„..„.,cp^ 

tlinf r last saw h J.> vx alive on OJU\>± 7 ^^^ \ 

and that death occurred, on the <late stated above, at O 

'a ^'- '^''•^' CArSK OF I)I<:aTII was as follows: 

0^.>AXJuiU.^vx.<X.lu Uv^Lc^'V^-^N^A.H^ 




^-^cxq/-uLv 



MAHHIN NAM}. 
U|- M()TII}';k 



d 



(^ 



''* ^^•^'^'^^'^' ■■ >''''?'-^ ^fo,it/ts Days Hours 

'ji-lA-A^x^aJj....cjlcv>^\,o,iL?..iv.c.. 



CONTRIIU'TORV 




1' 



nrRTHpr.ACK 

♦>l- MoTlll-.K 
'St.-itf or i'oimtrv'i 







>^- 




(3^ 



Dl'RATION 

(Signed ) 



/\ns 



Years \ Mouths 

■■VAl... OLcVXUJ-.CUUj.„...„.,..„.. 






//ours 

M.D. 



OCCTTATION 



^Q^^\j OAxLna.cc<i.c-A 



«?^^9'fl'-. "^f°"'^'^"^'ON onl) lor Hospitals. Institutions, [fdnsienls 
or Recent Residents, and persons dying away from home. 






Mioith^ 



( 



Ihn^ 



'''m^^r;;nis^-^;!:,i;'l-;;-';-«,n;,r;,AKS..K. ,K, K T„ TMK 



Former or 
L'sual Residence 

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



How long at 
Place of Death ? 



Days 



'^Iiifo-iiijinl 



rA<l.lrcss All LL*..V<1.1 <., ^aAI A' 




PI.ACK «)I- HUKIAI, Ok kHMn\ \i 



DATliol I5IKIAI. or kl-;M(j\AI, 

r^^' 

T90 



^JLM. 



m>i;rtaki;k C\D . '4. CJ^\^W\; M V r 

'■^'I'l'-'^^^s f'^jl Jj1'\a^:^V-^,-:^.^..;;Ji 



I;rt7cru"sE'oF d7a%h1^ ^' "•"'';."^ r"»'^"^"- age should be stated EXACTLY. PHYSICIANS «hould 

«on« dyi„?aw«y f^omlnJ H . T""' ' "• '' '""^ ^ PropeHy classl^cd. The "Special information" for pT- 
*ing away tpom home Hhould be ftiven in every instance. 



^'^ 









..; ' 







M 



,^ 



I 



WRITE PLAINLY WITH UNFADING INK 



MoiiKl of Iltalth — »•■ No. 1^ T^^^S^feiH&p Co 



!)((((' /^V/6>r/,.Bx.^\tx<T^^i^JL^^ % 




lOCi 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTION8I 



Registered J\^o. 



< 400 



Deputy Health OfTlc 



-^wv^ x.ocm.M ufinuxy Health OfTlcer 

DEPARTMENT OF* PUBLIC HEALTH=City and Connfy of San Francisco 



Certificate of Death 

( 'CI. S. Standard ) 



PLACE OF DEATH:-County of ^.^'^^.c^^,, cay of ~^C.^'^X.o..^^^,, 



(^ 



'No. 



I 



^CyR,4L\>vv,>vo 



St.; 10 Dist.;bct. IXo^vdU. 



/ .r or.TH occu«i *w*v tbom USUAL RESIDENCE c.v. t}^}:*}^^* ^ AO^VCL and I'h K<^. ) 



FULL NAME 




V ■0,/^^yxa::YXf^^^^^ 



SKX 



HATK OF lUKTU 



^^^^^^'^^ AN D STAT ISTICAL PARTICULARS 

'^a 



iM.Dith) 



■^ /.lk.b 

(Dr.y) (Year) 



MEDICAL CERTIFICATE OF DEATH 

HATE OF DKATH 



o.jJp± n 

(MontA) 



(Day) 



I go \ 

(Year) 



ACK 



I HRRHBY ClvRTlFV. That I aUeiuled decea;,Z7,;;n7 

190 .~~ 



to ..::rr7r7z:nz:z 



WIDOWKI) ()K nrVoKiHI) 

*Ur!l( in social ilesij^nation ) 



>^^ »gj^_- (d V.mths X^\ 



that I last saw h^r— alive < 



190 



311 



.. Days 



TJIRTFTPT.AOK 
(Statr or Coinitry) 



NAMK 0|- 
FATni:R 




nrKTiipi.ACK 

OF- F ATHHR 
'State or Couiitrv' 



Ol" MCJTHHK 




.A^ t:L^ Xj^^JSUX^ 






and that death occurred, on the date state.] al)ove. at - 
M. The CArSlMJl.' DlvATII was as follows: 

i. ■ -• . . r 



190 




HIRTHPUACK 
OF- MOTIIKR 

^Statr or Comitrv) 




XJ\^CL\y^'\^'^<X^ 



DURATION Vtars 

coNTRiurroRv 



Mouths 



Days 



Ho 



urs 






'^^'J^-^TIOX ^ Years Mouths Day^ 



,'^ 



X/YV'. 



OCCrPATlON 







( ^IGNED )....UX(mjl>v "J .^lU.ij^ 
)X^ 1 iQ o'i (Ad<lress) Wu) 






Hours 
M.D. 



X. w./^A. 



«rf.rj^'^K"^f°"'^?T'ON only for Hospitals, institutloiK.^^ranslfnls. 
or Recent Residents, and persons dying away from liome. 



. \/\. (fO /Cu-»OA/-r\-v».t' 



nnajit 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not ^{ place of death ? 



How long at 
Place of Oeatfi ? 



Days 



rr^ACE OF RTRIAr. or RHNFOVAF, J DAIl^of Htrml or REMOVAI, 





N. B. 




S , 



l-NDJCRTAKER ^ J^^\Ji\Sj\J . %<. dUvA..:vvt 



90' 



r\( 



Every Item o? information should be cnrefu 



state crUSE OF DFATh"; 7 ^""^f""*^ supplied. AGE «hould be stated EXACTLY. PHYSICIANS should 

son. dyh. A^«r £f^I" '" ''!"•" V*'"»: *'^"? '* '"«*^ .'"^ "-^P^-'y classified. The -Special Information" for p.r- 
» "*inu away Vrom home should he Itiven In svery instance. 



1 ijl 



»»? 



1. II 






.1 



'I 



i*< 



'9 



1' 'f-^i 



i 



i 1 






WRITE PLAINLY WITH UNFADING INK — 



iionnl of H,;ilt!i--»-" No. it, 



lUt V Co 




^ 190\ 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATg FOR INSTRUCTIONS 

Registered ^o. ?49| 



-. -^ f* •■ 



DEPARTMENT ^ PUBLIC HEALTH-City and County of San Francisco 



Certificate of H)eatb 

( "U. S. StanDar& ) 



4 % 



''''''^n°\''^^-^»-County of ^a .v J Va.ve^coGty oiO^Jkc. 



'^ I 



■No.iL4^0 Jal^«,^ 3^^ 5 j^.^^_^^^ ^^^^ 



C If O..TH OCCU.S .W.Y r«OM USU»|. REsTdENCE o.v, r ' ^'* <^ »^ (>V Oj a„J '^ ; 



FULL NAME 




m' 




.d 



4.\A.K.^1 




I.^.Z.'..Crl,.^ir.lv.i 



and 'i3> ^.cL 



PERSONAL AND STATISTICAL PARTICULARS 

^^•^ T?> IJ I COLOR 




J)A IK OJ- lUK in 



Qxkt "^ 

'Munth (Day) 




a 




p 



is_>.. 



___^_ MEDICA L CERTIFICATE OF DEATH 

DATE OK DKATH ~ 



(Year) 



A<,K 



(Month) I 



.1...... 

(Day) 



(Year) 



) '«■•(/ > . 



M.nith, 



^IN'.I.K. MAKKIHI) 



Davs 



WIDOWKI) (»K DIVoKi I-r) f) 

'Write in social <Itsiv;„;uioii) Jf 



niurmM.Ac'K 

i state or Conritrvl 



VAMK OF 

iathi:k 



HIRTHIM.ArK 
<>'■ FATMKR 
'Statr or Comitryj 




MAIDRN NAME 

♦)F MOTflKK 






OuO 



^1 



lURTlIPLArp: 
<»' 40T1IHK 
'Slate or Countrvi 





I JIHRHBY CKRTfFV, That I attett.k.l .lecoas;;j7 

^-4^^ i 190 't. to....r. r^. ^ -..190- 

tliMt I last saw li^>.; alive on — rr:.. -^ -^ 

ami that .leath occurred, on the <late state.l above, at r... ' 

T"^^H ^^^'^^-'''^,^^'''' ^^''•■^■''" wa^ as folllws : 



roni 



►^^UvJlA.-., 



DT'RATrOX Years 
CONTRIIU'TORV 



I\Io)itJu 



Days 



Hon 



rs 







(Signed) .lj\.€uci 




UJL' 



--O^YXXi 






M<niths. . •* /JrMA 






OCCnPATlON 

f^^'i'f^'i ill S,n, l-i ,,,,, / ., „ — ) raix. 



I ^iiji'vc.u ) Vw^VU-^ V^^OJx^<?, 

a4\.t^. too'': r\,MrcK>.) Ill ■^A.av,, ^-f 



M.D. 



nr?.^^9'fi^J'^f^"'^'^'^'ON only for Hospifals, InsHfutions. Transients 
or Recent Residents, and persons dying wway from home. «">«-n(s, 



Former or 
IJsuaf Residence 

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



How lonq at 
Place of De^th ? 






Days 



^X'Mress SLIdIdO sJ Q.Ls^-yy,. JJ 



'J' 



N. B. fivery Item of informati 



PI.ACK 01- IHKIAI. (,k KHMOVAI. DATH of HtK.Ai, or KHMoVAI, 

.211^ I rWQ,^a.A^\.v i. 



(Adfl 



ress ... 






•tate CAUSE OF DF A'i'H"i„''r." '*' 'T """^^""^ ""PPli^d. AGO nhould be stated BXACTLY. PHYSICIANS should 

"on. dyin Aw»r f^omln ' i"'". l""': """' '' *""* ^^ '"•"^*'"^ classified. The "Special Information" for p^r- 
•^•ng away »rom home should be ^iven in 9\cry instance. 



1 



jiii 



* 1' 






\%m 







I 



■H 






'■j' 



J 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hi.nnl ,,{ Health I" Xo. : <; *"5;'asir'^ J5& p Co 



/)n/r AV/^v/, ,,d^lxtv->-Kvlv<>v I J90H 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Ke^istered J\^o. 



1.1 no 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( "CI. S. StanDarC> ) 



PLACE OF DEATH: -County of X^v ^i-vaAxCC^co City of "^ O^.^'Ivoa^ ^^ o« 



^. fc Cmv^ -fOV iL ijp .^ St.; — Dist.;bet. 



and ■■ ■ ) 



n 



FULL NAME 



( 



PERSONAL AND STATISTICAL PARTICULARS 

I <."(»i,(»k ^ 



DATl-: <»!■ HIK in 



IvllvJu 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1-:aTH 



B-vkt 



(Motirti) 



' Moiith^ 



(Day) 



(Vear) 



.\<'. H 



-b T )v,//.v 



■^^""//'s rr /hns 



•^Tvc.ij.' M\Ri<n:i) 

U"II)(>\Vi;i> OK I)I\-(»RiKI) 

t\\'ritc in >uci:il (IcvJi- nat ion ) 



HiRTin'r, \('K 

'>t;(tt.- or Cuiiiitiy) 



NAM I (>|.- 
lATlIl-.K 




HIK'-lilM.ArK 

Ol- ixrirKK 

'Stall r,I rouiiti \) 



MAFDKN NAMF 
<»l MoTIIlvK 



lUkl'MIT.ArK 

<»!•■ M()|'iii;k 
fSlatt iir i"otmtrv'> 



ncrt-pATioN 




Xj x.Cmj'Va;" 






(1 n ,^ 1 



(Year) 

^, I in.:Ri:BV C1:RTIFV, That Lattetulca tleccased fro,,, 

•■•-'-^4^ ^ 190 to d^\t:...: :.[ r<p ^ 

that I last saw 1i JIA. alive on ...."3-t/jat: .1.. i,p '^ 

and that death occurred, on the date stated above, at 10 

-^ 1^- 'I'lit' CAISlv Ol- 1)1;aT1I uas as follows: 



(Day) 



LuvjlX-\.^ CL|\^klj?.^. 



1 









DCRATION }V.7,-.v JA;;////^ i Mn-.v 

COXTRinUTORV (wiN^blAA^ g.^cL-^ 



//o//r.\' 



\-^.cw^ ,. 



,..-.,_. o 



DCRATION' 5 )Vv7;-.? 
(SIG 



.tfof/Z/is 



Pavs 



CX/OaX^^ 



T^^^ 



NED) i.'v^l.vJ^ 1. Ja,U'v^^^vx. 



\<k \ 



' 



iqoH (Address) Tl^ 



vXa^vlit. 



Hours 
M.D. 



^ 



?^^9'fi'-."^f°"'^AT'ON only for HospifdN, Institutions, Transients, 
or Recent Residents, and persons dying dway from home. 



StiH I'lnuii^i'n \\ )'tuii< 



lA-;////. 



/>„ 



Former or 
Usual Residence 



IxJud:! '''viHXk Uv. Plare'lfVeltt,? 



?•^^v^„©^^ 



''m^^Ty.r^']"v^Vv!''''''■^^**^^''''^'^■'■'•'"'-^»<^^»<'■ ■'■«'»•: To Til,-- 



When was disease contracted, n 

If not at place of death ? <t .k,l 



Days 



.1 



ex. ex.. % '^^a±h, 



( In foi maiit 



1M..ACK OI- m-KIAI. Ok KKMOVAI, DA'J^K o! Mi him. oi ki;M(.VAI, 

^C^L\^i^^^ \ ..a^Mxt a 

n f-o 




r.VDHK lAKKR 



C^ 






190 







IN. B. 



"It7t7c'MrSE'of dTIt^^^^^ T' "'"""'"u'' r"'*'*"*^^- ^«^' «'^-'^ »»« «*«^-' EXACTLY. PHYSICIANS „hould 

Ton! ,1 • i or DI.ATH ..I plH.n terms, thnt it m»> he properly cluHsilr'ied. The "Special Informution" ^or o-r- 
Hon« ,ly,„^ „woy from home nhoiihl be feiven in every ir.Ht«..ce. ormiiiion »or p«r- 



ill 



• <i 



■f 

« I I' 

■A 



ill 



/i 1^ 



i 

J' 



1 




! Jl 
! si 



WRITE PLAINLY WITH UNFADING INK 



liM.ii.l ,,f ll(alt]i • \- Vo. i> "t^-^v'swr.™^) ju<tl' Co 



fhffr ^V/r'^/,dxl'\iL^y>^JL^ ? 290^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




llegisfci'cd J\^o, 



tv^^^ 



\K^ 



DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 



Ccitiffcate of 5)catb 



( X3. S. StanDnrD ) 



PLACE OF 



DEATH: — County of <X^\j <^ K(X'^\^^m. City of Ox^yv J 



No. ! ii L 



( 



\r OE 

I F 



■'^^>v , .^.St.: 1 



I 



ty of ^w.X'l^^ ^' A.a/^^CA-.\UC^. 






and 



♦, - Dist; bet. U OVCQ /i\^ 

*TH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLrn rnn „^r.X, ' 

DEATH OCCURRED .N A HOSPITAL OR . N ST.TUT.ON cf.ur "^ ITJ^ .?A.".^.°5t _f J-ffl^K "^ "^^ '"^"'O ^ •• ") 



^ If 



>R INSTITUTION GIVE ITS NAME INSTEAD oV STR E ET AN D N UMBER 



FULL NAME 




■hJjyyJi.. 




\n^.yx.L. 






PERSONAL AND STATISTICAL PARTICULARS 



J-O-VAyCLAX 



DATH ()|- lUKTM 



i 



WJA^jJji 



(Month) 



AOK 



iv J-,.,,,, 



^ 

(Day) 

M, mills 



/ill 

(Year) 



datp: <>!• I 



MEDICAL CERTIFICATE OF DEATH 

)]:ath P 



(Monlll) 



i 

(Day) 



(VtHl) 



^ 



I HHRIvBY CriRTH.^V. That J attemled .Icrensed fn.„ 



Paxs 



•^tN'.I.K. MAKUIKI). 

\vii)(t\yj:i) OK DivoKo-:!) 

'\\'Tit(iii social (I(>i}.Miatioti) 



niKrnpi.ACK 

iSlatf or Conntrvl 



NAM}- or 
FA'rni:R 



MIKTm'I.AOK 
<>|- lAIIIKK 
<Stat«- or Comitrv) 



jj «f 1 



MAIDKN NAME 

<>!• MOTIIKR 




— -^r-^ ^ T90'' to "g.^lxir fc. np^ 

that T last saw h ^>x: alive on 'uXlvt^ X. 190^ 

and that lioath occurred, on the .late stated above, at | 
The CAISI- OF Dl-ATM was as foll.nvs: 

L-csx 



^^ .^^^• 




1- 



^^y\<^'n()y, Year, Months }pays Hour, 

CnXTR IBUTOR V U) XOw.^^uL.ui;..4-.ibxaJ^ 

MJIv.vL'JLc U-^rvxxc.vvvta.L 

DrRATION Years Months 



Da Ys 



HlH'ruiT.ACK 
'»1'" MoTiikr' 
(State or Country 



OCCfPATloX 






U 



^ IQOS 



. M H^ L|u4/>%Xu,, 

f Address) 1^0?^bn., T' v. 



//on 



rs 



M.D. 



Special Information only for Hospitals, institutions. Transients 
or Recent Residents, and persons d>ing d^n) from fiome. 



) iti I 



Mn>,tl,, 



Ihl 






Former or 
Usual Residence 

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



HoH lonq at 
Place of Death ? 



Days 



r<» Tin-: 



IM.ACK or m-RIAI. OR RJ.;M(.VAI, I !)\Ti:..! IU hiai. ,n Rll.MoVAl, 



rXDHRTAKHR '' WJUuJ- ^'C C^^^^qL,,.^^ 

I'he.sM 1;^ bo.>X/ V\i<L4 d..X^Hi..... 



T90 



fAd( 



Stat 
son 



.7e*'cMrSF^nr*nTT-I'M" *''7'/* ^' -"''^^'""y supplied. AGE shourd be stnted EXACTLY. PHYSICIANS , 
i« dvl„^ "» DHATH m plinn terms, that it m»y he properly classhicd. The 'Special Informution" fo 
»« d>,„i nwny ?rom home should he Aiven in every instance. 



should 
r pwr- 



INI 



M 



1 






'H: 



f . ii 




It 



v» 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lioiinl of Htitlth- F No. I"; **^;Wi^ H&H Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JVo, 



1494 



Ddh- /'V/^''/,dx^vtt.'v-,^i^JL^v '^ 190^ 

DEPARTMENT W PUBLIC HEALTH-City and County of San Francisco 



Certificate of 2)eatb 



( "a. S. Stan^arD ) 



PLACE OF DEATH: — County of 



City of lllU 



No* 




f) 



L' 



a_;L K.a 



St 



Dist.; bet* 



and 



r "^ D"TM OCCURS AWAY FROM USUAL R E S I D E NC E G I V E FACTS C ALLE O FOR U N OtR "si-CCIAL I N FO R M ATION'. \ 
V. .F DEATH OCCURRED . ^, A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E J! AN ^ N U M BE R ) 



FULL NAME - ci.(j LL.i-.vL.a wl.\.>)a.^ 




LL\.;^.:v..a. 






PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



t 




rwX 



-cb 



I Month! 



ACK 



(Day) 



v.lt-i 

(Vt-ar) 




>\ VV^LHCS .VX: 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



lL, 



(Month) 



■ •■A.5 /po-H... 

(Day) (Year) 



3^ )VV,.V LO. Mnulhs XX 



Da vs 



SINC.I.K MARKTKD 
\VII>o\\ IvD OK DiVoRTKr) 

Wiit<iii MK-ial (It-si v^ii.itio?!) 




nrk rui'i.ACK 

Statr or C'oiiiitrv) 



NAMK OF 
FATHKR 



nikrupi.ACK 

OI- lArilHK 
(State or Couiitrv) 



^XX\AAjLd^ 

f 






I IIKRKBY CHRTIFV, That I attcn.kMl (leceased froiii 

^^^^^ ^'^ i9oi to LLvx3l aS^ 190 H 

tliat I last saw h -.- alive on LLu,o^ .^^.. too • 

and that death occurred, on the date stated above, at 1 1. 6. .•h... 
....LL..M. The CAl^Sr: OF Die ATII was as follows 
Ll\jJo^vxxJl. 



'-C»Tw-<y\.\ J v.a,<i^_. 






maii)i:n namf 

Ul- MOTMHK 



lilKTHPr.ACK 
OF MoTMFR 
(Slatf or Oonntry) 



Oa\m_^cIx 



<Ll>V4L 



DIRATION JVar.9 Months Days 'Hours 

CONTRIHCTORY .Mlc^ULunv^a. 



^-v- 




(OAy 



IH'RATION U:''''^r 

(Signed) O.Lv. I 



Months Days 



OCCtrtATlON^ 



iiii 



ic>o \ 



(Address) HlS 'lay3/a.ke.>v 'Jt. 



Flours 
M.D. 



Vn„t!,. 



Da 



ui.hroi- \n KNowi.i-ix.K AM) iu:i.n;i- 

'l"fo-ma„t iJrb. (V) y^ (J\_^, 



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

Former or -\ i How lonq at , 

Usual ResidenceUav>j..sJ./La--rweiA^Ufi, Place of Oeatli ?I'>:>ia-a.... Days 

Wfien was disease contracted, \ ■ 

If not at place of deatfi ? Li^-v.\K.%v^^ -• 



n THK 



^^/^-vxt^rw/ 



r\d<lress ^ I 5 \\ 




t\ ^.' 



-it 



I'l ACK of HrKIAI, OK RKMOVAI. | I)AT^ of IUkiai, or KKMoVAI. 



VXl Yv^_£A^<i. 3%. Oa^x 



'^' rAAj ?!x J 






ixdf:ktakkr Uucu^x^l « wtJk.' 



90' 



l\Z7c\7sE oI^Df2tZ'''7''' '''^ '-"-'^^""^ HuppMed. AGR nhould be stated EXACTLY. PHYSICIANS should 



Roni 



I& away from home should be ftiven in every instance. 



M 



M 



11 



•f 




t ir 



li 



t 



• ♦**% 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

)'.,.. I, .1 of M> ■■■111. !■• So. I. T^-c»::r^- "^f <-'o refer to back or certificate for instructions 



Dfffr Filed , 





% 190\ 



Registered JSl^o. 



1 ! 1)5 



'^ (-A.,k. \>v 



\ 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of 3»eatb 






( Xa. S. Stan^arD ) 



^ 



^ 



PLACE OF DEATH: — County of^O/ysj XCt^XCAAOO City of O/CUTu Z \JXjy\j^Ajiu^t:^ 



No. 1^5 




XXA^A-W 



St.; 



J 



Dist; bct.w O.AyVXAyYV'Q It > and 







( '^°^^^r*TM^nrru»V"n'' "'°** USUAL R E S I D E NC E G. VE tacts called for under •speLal information. \ 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




i 



\\.:y\j. 




Vw.V'\\ 



SKX 



i 



PERSONAL AND STATISTICAL PARTICULARS 

^ Si)iA '™'"lii 

T)ATK OI- HIK III [A^ 

MllcLv, IX ./111 

(Day) (Year) 



\XK^' 



u 



MEDICAL CERTIFICATE OF DEATH 



'Mnllth» / 



AC. K 



DATE OF DKATir f) 

.....„..,.„...., C~) JLyvLi 

(MontA) 



(Day) 



I go 

(Year) 



V cA )',-ais .<r\... .V<>i////\ ... J...V.. 



SIN<.I,K. MARKIKI). 
WIDOWKI) OR DtVORi'KD 

tU'iitciii Norial »Irsi>.riiati<)ii) 



■Davs 



A 



I irrvRKRV CI-RTIFV, That I attended .leccascul from 

"to 190 — 

190 



• — ~ — ~" —.190 ■—- 

that I hist saw h — — - ahvc 



on 



atid that dcatli occurred, on the date stated above, at 
.-rz^^..M. The CAl'Slv C)l- DI^ATH was as follows 



nrRTiTpi.ACK 

iSl.-itf or Covintrv) 



N'AMl-; ni- 
JATlllvR 



fnRIIIIM.ACK 
01 » AI'UHR 
(State or Country) 



MA1I)1.:n NAMK 
«>l' MOTUHK 



HIRTHPLACK 
<>»•■ MOTHKR 
'Stall or (."otiiitrv) 



XV^^WOU VXA.L 




■h 



^"^"^-^^S^^-^"^ Cl X.CN.'V^V^XoUV ■ JJi\.</(^^CKJxAAA 



a 



...u 



DTR ATION ) V^/j A/o;i//is 

C( )\TR I lU'TOR V .„..„.. 



Days 



Hours 



\/\>-Krs'\j 



DURATION Yiais Months Days Hours 

( SIGNED ) LrLO'>\jL\; J . Mj.JjU- dxL< 
OX^ ^ iQoH (A.ldrc ss) Ur' 



O-aaA. M.D. 

) UrV(vv\iA. A 11 iI.v.. o: 



occrpATroxQ\ h \r ^ 

f''''''ifftl >>' Sati /■', a ,n , <■,■.> <^'^ )',ai. Mouths Da \^ 

lihsroj. M^kxowM-Dc.K AND m-;Mi:K 



Special information only for Hospitals, Institution^, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 

Usual Residence 

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



How long at 

Place of Death? Days 



)ini,-iiit 




IM,ACK OF I"'I<I-^'' "« RKMOVAI. I DAT!.: of Mi uial or KKM()V\I 



(Add 



ress 



Wl^X C\>L 



v^ V^<r>rv 



ll. 



IN. B.. 



Mrt7c'ru"sE^o"/DTATH" '^'T'*' \" ^"''"^"">' f"PP'-rf- AGE should be stated EXACTLY. PHYSICIANS should 
«on. dvf„/f ^^i^'^'^^" ■" P'"'" ^^•''"«' that it may be properly classified. The "Special Information- for per- 
sons dyini away from home should be ifciven in every instance. ^ 



^ J' 



M 










1 *■ 



. * 



i 





^1 











I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)t,,;ir.l ..f H.allli »•■ No. K '^--^^g^ HStP Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begisfeved J\^o, 



IJD6 



l)((h> /u7rf/ , 3jL[\tvyyyl^^Vyj. 1 190 1 

cL-^-A-A/^w^i oLc\>ti 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccitificatc of 3>catb 

( "a. S. StaiiSarS ) 
PLACE OF DEATH: — County of ' 0_>v J-VaivCuiM City of c\->v JXawcC'J.c^ 
^No. lOlba \Ralc>,v-> St.; 5 Dist.;bet. 1 1 0% and H I f 

/ ir DC*TH OCCURS *W*Y 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 

do (\ J II 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



lA; 



si:x 






vnict 



COl.OR 



liATi; (tl HIKIH 



ixlr 



r 

M..iith> 



iLlt^ 



I'V^La. 



(Day) 



vi'^.C 

(Year) 



,-C 



ILu 



^^MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH C 



aA^jc 

(Month) 



(Day) 



190 H 

(Year) 



A(,K 



2.i 



) lUI t 



M.tuths 



XX 



Davs 



STXr.I.K, MARKIKI) 
w I in »w i; I ) ok I n \-( > k r k r) 
Uriff in social <ksitrn;iti>>ii) 



niKTuri.Ad-: 

(St.itf or Country' 



NAM} oi- 
FATHHK 



ink rill'I.ACK 
OI- 1 ArUKK 
'Stale or Country) 



L 






p^ I HHRKnV CKRTIFV, That I attcn(U^d"<leccase<l from 
U.l.l^<^^' 15 iQo'i to OX^xt. .1.... 



190 



190H 
that I last saw h ••. ' . alive on C)^.\.t(. fo jooi 

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

UL M. The CAi:i^H OF DKATII was as follows: 

NJxKXvvA/iA^ V AAX^>-vv,trvx.aJL?.;: 






MAIDKN NAME 
i)V MOTHKK 



RTRTITPLACK 
OF N5i»THI-;k 
(State or Countrv) 



OCCUPATION 







aXwt 
CUNT RIIU 'TORY 



IMRATION Years » Mout/is Days 




■^^K-ft-A-Lift^XAv 



J /ours 



1)1 'RAT ION Yiuirs Mouths Days ffour^ 




( Signed ) 



\l fl Oio^^^trci^ 
JX.\VI i. ic^o 'i (Ad.lress) lO^S" 




M.D. 



<:k 



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



/I'>'vVf<»f/ hf .tTflw Pi am ly,-, 



) V„ 



Mnnth 



n,t 1 



"hsroi- MN KN()\VIj;i)C,H AND UKIJEF 



Former or 
Usual Residence 

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



How long at 

Place of Deatli? Days 



-<rYv.^-\^'X' 



'• ■- »^ ■■»< ' »\ 1,1-. JM • f. .\ ; 

nnformant M Kvi . ij C< 



(A(l«lress 



PI ACK OF lUKIAI. OK KKMOVAI, I DATJ- of Hi kiai. or KFMOVAI 



^Ad.lrrss. A*^ U.a/^Al\L4.a.. Ll.V, 



90 



rtrt?Jl\rSF^Ap nTr^M".'''?''' "' ^"'•^^""y «"PP'5eci. AGE should be stated EXACTLY. PHYSICIANS should 
«on, dvh!i L« c I '" P'«'"J*^;'"»' »»^«* It •"»* he properly classified. The "Special Information" for pr- 
8on« dylnft away from home should be j^Iven in cx^ry instance. *^ 



■i 



V\ 



. i-l 



\ t 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



)l.,anl of lK!iUh--J- No. i <, *^^^^ l\Si.V Co 




190'i 



JUuo^o 1j2a>u Deputy Health Officer 

DEPARTMENT OF 



Registered JSTo, 







PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 



>vc\.<tc^ City of n<X/^^ ^\XXAve^c^c^o 



( "a. S. Stan^ar^ ) 
PLACE OF DEATH: — County ofJ,<XOr\) \,<X>vcc<t<^0 City of OcL/^^ 
No. I'iH OJkAJ,%Xtu, St.; M Dist.;bet. 5 jJL and b .WX, 

UAL RESIDENCE GIVE facts CALLED FOR UNDER "special INFORMATION" \ 
ITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



(IF DEATH OCtURS AW/^V FROM USUAL Rl 
IF DEATH OCCURRCli IN A HOSPT 



FULL NAME 




■v,<. 



H 




si:x 



t 




PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



\ 



DATK (>}• I'.IR'ni 




A'XJ^: 



\j^^ 



■^ 



iMoiith) 



(Day) 



vUa 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

D.ATE OF DKATH 

\xX^ 1, 

(Day) 



(Month)' 



190^ 

(Year) 



I HF<:RI<:nV CI-RTIFV, That J attemled <lecease.l from 

:v.tr ...to. 



LLl,n 



% 



ACK 



IH..- 



JV 



iU > 



1,1 



M. nil In 



,s. 



Davs 



Wllx )\\ l-:i) OK DIVORTKI) 
'W'litcin ^iK-ial fUsiv^natioii) 



niKTHJM.ArK 

Statf or Country) 



N WW. Ol- 
lA THKR 




niRTMF'I.ACH 
Ol" I ATHHR 
(Statf or (."otintrvl 



MAIDKN NAMF 



,J^ 






'^CL I 190 to dX^^C.b. 190 H 

that I hist .saw h •-'. \) * alive on Q JL-VaA- .^ jqq 

and tliat deatli occurred, on the date stated above, at 
^M. The CArSE^JI- I)Iv.\TH was as follows: 

^Ci \J -Aw\JOv\A.^"v\XX,M^ 



^/yXXA\.^^A.\^^ 



-OLA^Owi cLCUXAiv^^/^vxlmx 



lURTiipr^ArK 

<»F MoTMHR 
(Statt or Country) 



^Krtr 




c^-^^d^. 



9 ol^.^CrCrV vfc 



X^wdjv va^^t n 



^X/y\A^ 



DUR.\TI()N Vears^ I Mont/is '1 Days 

CONTRIBUTORY .b^>^tjL^w*wt-A^. ..ILrC.A^^ 



Hours 



DURATION : Vears Months 10 Days 

(SIGNED) WWU , X<X<VC^^^- 



hVsitl^tl in S,in /'i ,11 rr'srn \ 



H^ )>.n. 



1 \ .^rn,/f^,s ^ /)„}.< 



>x 



jxt I X 



\) 



90 



(Address) I S"'^H [Ov 4 rVv4Ai^a J.l 



^t 



Hours 
M.D. 



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



HF.sroFMN KNOWI.KDCH AM) Hi:i.n:F 

^Infornuint W^»^ \J Xjl 



trwj 





Former or 
Usual Residence 

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



flow long at 

Piareof Deatli? Days 



I'r,ACK OF 




AI. OR RKMOVAI. I I)AT^:of HtKlAl. or RKMOVAI, 

190 H 



^U. ^l^x^ I • ^ -^b^3 



'^f 






.XX(^v-\j ^<*- 



tc. 



fA.Mrrss H XT "X) (>itijl>V \) -Owtx. ..ll .' , 



IN. B. Bvepy ite 

state 
son 



»*^*^r'l^ir *** '"^"•••"a»*'0" should be ciirefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS nhould 
. ^ . ^ ^^ DEATH in plain term., that it may be properly classified. The "Special Information" for osr- 
• clyinft away from home should be ftivcn in every instance. 





N \ 



-I 




ft 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



]U,nu] of Health— F No. i<^ 



»&PCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafe F/7e(f,BjL 





LV\;A 190 "i 



Begistej'ed J^o. 



1K 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccrtiftcate of Beatb 



( Xa. S. StanOarD ) 



^ % 



4 ^ 



No. 



PLACE OF DEATH: — County oiOcL^rsj Jjv<X/^^/CA>.:ic<City oiO/Ouy^ 0A/ct.Yx/^^A,.^t^i3 
O/V^Vllx^^ [X\^ St; 1 Dist.; bet. L<xXa<r\.:->:X.^a. and AX/^JvXX^vnj^^xi 

/ ir OCATH OCCURS AWAY FROM USUAL R E S I D E NC E Gl VC FACTS CALLED FOR UNDEi«l "SPCCIAL INFORMATION • \ 
V IF DEATH OCCORRtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD oW STREET AND NUMBER. / 



FULL NAME 



SKX 



DAT!-; OF niRTH 



PERSONAL AND STATISTICAL PARTICULARS 



tr:M.i\.la;. cL.C<xL(.\).. 




COI.OR 




(Momh) 



(Day) 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII 



AC.K 



OJi>\/ 'i\.. ]Vn>.y 



M.mtfn 



(Year) 



Da\.'~ 



< «*««**•••»•■•*<#■ ' 




(Month' 



...fc igo'X 

(Day) (Year) 



I HHRKRV CIvRTlFV, That I attended deceased from 

190 :~ to -r. 



«IN*(".T.K MARUTKD 
WIDoWHl) OR DIVoKiKt) 
'Urittiii social ili-sivrnatioii) 



fUKTHPI.ACK 
iSlalf or Country) 






that I last saw h 



alive on 



^90 
"190 



and that death occurred, on the date stated above, at 
»-rr-;- M. The CAUSr: OF DI-ATII was as follows: 



/^-^XA^cn 



\ \MK 01 
I \ 1 MFR 



X^v>x 



ItrkTMPI.Al'K 
01 I ATIIKR 
'Stalf or Country) 



MAIDFN NAMK 
01 MOTIIKK 



inRTHPI.ACK 
oi- MOTHKK 
'State f)r Country) 



orcT 



•"•"°-^GUJ 




*»-*• • -I JH i* -* «4 » *>• w 



Dr RATION Years 

CONTRIBUTOR V 



Mouths 



Days 



Hours 



Months 



Davs 



DURATION Years , 

(SIGNED) .Ur*Ur>\Jl>v o.vfc.lJO. iJLLo-^\^ 



Hours 
M.D. 




\^-.L 



Special Information only for Hospitals, Insmute, Transients, 
or Recent Residents, and persons dying away from home. 



Kesidfii in San l'ian,isr,> - Yrai^ 



■^ ^T,^nlhs 



n,i 1 > 



' " KKST of ';T^^'L^;!* J'KRSONAI. I'ARTKTI.ARS ARK TRTK To TMH 
Hh^r 01- MV KNONVIJ-DC.K AM) HKMl-F 

(Informant J . xjj . dO Oc^on^ 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



^\(l<i 



(W 



resH 



oVv\^<r)(>cnXLl J 



J^'yx/w... 



PIPAGE OF BrRIAI. OR RKMOVAI, I DATH of IH kiai. or RKMOVAI^ 



rNDF:KTAKER 



(Ad.ln-ss ^05" A/VbCn'YX^A-y 1 




F.vepy item oV information shoultl be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
IV'^^^i^ ^^ DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
«on« flying away from home should be ^Iven in svsry instance. 



f 



1 i 



' .1 




te 'm 



'■ '! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

" "■' '^ llci.lth- FNo. .^T^'t^^H^^»'^-o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 





t 
I 



I)(t/r Fihi(l ,d..JL\\XjL^^^JoJL\> % lOO'i Registered J^o, 141)9 

Deputy Hea Jth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( XX. S. StanSarO ) 

A ^ J? (^ 

PLACE OF DEATH: — County of O/CL^vu J .^V'O.r^/aA.AXM. City of CJ <XyY\; AxX/%\x^a^a c-t 



I. 

i , 



No. Vt X\JL'-r 




u 



A.<i.i 



\..(i/>XA.<X.hJ.: St.; 



Dist.; bet. 



and 



/ IF DEATH OCCURS AW*y .FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION ■ \ 
V IF DEATH OCCURRED IN A HOSPITAL O R I N STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 

FULL NAME cLia. m.L' 




'rv: 






ll 


^i . g 1 


' 1 


' km 



^"^^ Trices 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ORi 



iMonth) 



.LI,IHH 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII 



IDav) 



(Year) 



A(,K 



O O . } 'r<i t A- 



(MontH) 



1 

(Day) 



(Year) 



I HrvRKnV Cr-RTIFY, That I attendcl deceased from 

190 ■ to .^t: 



tliat I last saw h 



alive on 



-1A(///Av r>tirs 



•^IN«.I,K. MARHIKI) 

WIDOWHI) OR DIVOKCKD Q 

'W'ritrin sotial dt- sivrnation^ wV 



J! 



niKTMPI.AOK 

stall or Cuiuitrv^ 



\\M}- m 

1 \tiii:k 



<" I AriiivR 

i stall- or Coiuitrv) 



^^A!I)l•:^- xamf 

"1 MOTHFR 




^n 



^190 
190 



and that death occurred, on the date stated above, at 1 
...^^ M. The CAUSK OF DlvATIf was as follows: 






P 






i 




_ c 



lilR rilPl.ACR 
<H" MOTHFR 
(State or Country) 



m> 




DFRATION ..JVa;^ Jl/ofi/As 

CONTRIIU'TORV 



orCTTATlON' 

f^fsi'ifn/ ill Sail f'l aitrfs^r^ *' )'rais 



J->UM- 



DURATION Vcars ^Mont/is , 

(Signed ) .Lcr\^xl*v 0. 



ax.|\,.L '(. 



190 ' ( 



Address) W 





/hiys 



<Xn^\,c.. M.D. 



•1 

I 



) Ur%^>^rv?: 



n 



■^ 



tvt/^. 



Special information only for Hospitals, Institutionrfransienls, 
or Recent Residents, and persons dying away from home. 



- VniltJl!, 



/>,; 



Hhsr ()|. \n KNOWI.FDCK AM) HHIJHF 
(Info: mam UJ^^^Q iHo^O 

J 



III !•: 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



PI^ACF: of IH-RIAI, or RFMOVAI, I nvri;,,)- Hikiai. or RF:M()VAI, 

^jo^^^Jlkh.^^^^ I 3jl^ 4 190^ 



T 

rXDKRTAKKR AAJ,A^WOl 




(A(1<1 



N. B. F. 



tH 



M 



t T^^rl^i^ *** '"^"•••"ation should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
-«r^^ . ^^ DEATH in plain terms, thot it may be properly classified. The "Special information" for per- 

son* dyinft away from home should be feiven in every instance. 



f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H».u<l of Health-K No. i. -^^^^HSlP Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Da 



to ini ejl ,Ax)^sXx/Y>.J<yJ^ ^ 190 H 





Registered JSTo. 



in 



00 



M 



W> ii I i 4. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( la. S. StanOarD ) 



PLACE OF DEATH: — County of OOL^y^ \^ Kxx^^^^zul^ Ci 



Hfu 





^ 



I t ! 

3 CK.Kvl.oi.. St.; Dist.;bct. 



ty of O <X.^ru AxX/w^ 



.Aw^^/tlO 



and 



/ ir ocATH occuRs/j*WAv FROM QsUAL RESIDENCE give facts called roR under "special information- \ 

V if death OCCUiJRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




:aJ..... 




PERSONAL AND STATISTICAL PARTICULARS 



SK.X 



^ 



t 



COI.OR 




DATK OF HIKTFI 



,ot 



• MDiJth) 



lb 

(Day) 



, S .■? .1. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DF:ATH 

..._ CJJLki. "J 

(MontH) (Day) 



igo'X 

(Year) 



AGK 



y...A>. JV.MV 1.0. 



.!/'>»//// 



.. ,11 



(Vear) 



Davs 



uri)<>\yF;i> ok dixokchi) 

Wiitiin social 'IfsiKfiiatioii) 



lUKTin-i.ArF: 

i Stale or Conntrv^ 



.0 x^^^J:sS6>^A^^ 



NAMl-: OI 
FATHFR 






I HF^RHHY CI-RTirV, That I attended deceased from 

'^\-U.>:>JL....\.'l 190' , to "Qjc.^.....! 190. H 

that I last saw h X>\) ahve on OJ^-ivter.. ...1 xoo 'i 

and that death occurred, on the date stated above, at ^'i 
'^ M. The CAUSK OF DIvATH was as follows: 



■'\-*w!w.N 



^ 



J 



niRTHJ'I.ACK 

<H- i-ArnF:K 

'Staff or Country 



\^y\^^ Jul/ 



i 



DURATION ^. Years ...^^... Mouths Days 



Hours 



^\i 



I 



CONTRIIU'TORY 



MAIDKN NAME 

OF mothf:r 



nrRTHPLACK 

OF mothf:k 

(state or Coniitrv) 




occrpATioN r^ 



'^^yy\.<x.'Y\M 

Rf^ided in San /'i,i)hn,;> -A A )',•,ll^ 



DURATION .^ }'f:iirs 

(Signed) 0. ^'^ ''"'' 

f; 



I\Fo)tths 
(Address 




Days 






Hours 
M.D. 



6 i Ui 



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



.■|A//////> 



/),/! 



HF.hT OF M\ kNOWI.l-lK.F: AM) HI-I.IKF 



Former or f\ is r^'y 
Usual Residence ^0 k 

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




' J How long at Q /^ 
nru.UiL Place of Death? V!^^ Days 



•rniant 



r\<i,i 



rt'ss 



N. B. 



AwaJa.a^^ V^ q[d (X K^v^to....!!., 



PI,ACE OF "flRIAI. OR RKMOVAI, j DATf: of Ht rial or KKMOVAI, 

undf:rtakkr JJKjL^Crdw^c^ oU-vXAjys^^ 



(.\(l<lress 






-Kvery item olt information should be cnrefully supplied. AGE should be stated EXACTLY. PHY8ICIAN8 should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for psr- 
"ons dyinft away from home should be ftlven in svery instance. 




>* ^ I 



' 1 



ij 



JWidei;£A 



\J 



t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H..anl of ':.;.lth-F No. .. ^'gg^ H& I- Co ■ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r AVAv/,...c]x|aix-.^lNi>v X 190 H 



Re^i^teied J\^o. 



15 



^\>^\ 



\. 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



PLACE OF DEATH: — County of C)<X--v\; O Act 1VCM.4C0 City of '^'-Ct-vv J ^Cl-v 



v^C^-^L^^ 



No. IIM V) CTl-'R . St.; ^ .Dist.;bct. Cli.ct±x^. and ^. ^ 

/ ir DEATH OCCURS AWAY TROM USUAL RESIDENCE GIVt TACTS CALLED FOR UNDER "SPECIAL INFORMATION • ^ 
V -r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E ET AN D NUMBER ) 

FULL NAME U.a.v<x.L Ma^ 



AJ<^ 




PERSONAL AND STATISTICAL PARTICULARS 



^»^^ 



COI.OR 



> 



HATK (H IlIKTU /Ov 



\aX^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH 






I>:iv) 



rM:'l 

(V<-:m> 



ACK 




...L... 

(Day) 



(Year) 



.«*»! Years O 



)5r 



.'/<.;////> \\) Davs 



^IN<.I,K MAkKIl-:!) 
'Writtiii srK-ial fk*iipiiati<.ii) 



HIKTmT.AOK 
-il.itf ur Ciuiilrv) 



NAMl- ol 
I A IHliK 



HIK IHPI.Ai'H 
(»l l-ATlll^K 
'Statt' or (."outitry) 



^'AIDKX NAME 
'1 MOTHKR 



HFRTITPLArF 
'>1- MdTUKK 
(Siati' or CouiUrv^ 




I IIKRICHV ClvRTlFV, That liittended (lecoased from 

^ rui-*^ 1 1901 to ox|at L 190 M 

that I last saw h .-*^'v aHvc on ."oXl'vtr M 190 ^ 

and that death occurred, on the date stated ahcn-e, at " 

l^M. The CAISH OF DI-ATIF was as follows: 

\J -<XC>>AXr>^CCh^ J A^«-Ch^<^^.X^ 



Dr RATION I ]\'ars 
CONTRIIU'TORV 



MoNl/is 



Days 



/fours 



} cars 



OCCUPATlOIf 

f^f'fffrrf /n San /;■,,,/, /\,„ '^ 



\X'Loi/YvcL^_. 



) 'f'li I 



1A. /////> 



DIRATIOX 

(Signed), ^^kyw- i^dl 

■-■ ' • ' I' i()0 ■. (Address) bOX 




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



/',! I 






'w.M 01. M^ KNOW I.iiDCK AM) lUlI.IJCF 



former or 
IsudI Residence 

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



How long at 
Place of Death ? 



Days 



£>VAjr>nw.. 




^^«l.lress 115^^ 



QJl ^1 



I'l^CH Ol- lUKIA!, OR KKMOVAI, 



I)A'i:i:oJ' HiKiAt. or Kl'IMOVAI. 

i 

190 




(Address X^. [}iQ^y\,'^^AA.\j^:\!'.--A, 



t^t^C^AtT^^^ 'nformatlon should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
on. ,1 • ^ OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
'Jns ciyinft away from home should be ftiven in every instance. 



I 

.t ' 



' J] 



;! 



I I 



I 



5 



Ml 




<— »> tJIti— ■.■■. -ta«»»».*IWW ♦ -n^W' 



"^^^w 



A- 



♦ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.i.ird uf Henlth— FXo. \s 



n&PCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(f/r Filed, D 




lOO'i 



Registered J^o, 



1^ 



5.0.^. 



<— r 



DEPARTMENT OP PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( TJ. S. StanCarft ) 

A ^ A ^ 

PLACE OF DEATH: — County ofUCL-rx.- \OLAXtAA<:i City of /CX/^^ O 



No. U iA^^A-vOu-rv' .Ob Cy^ ! \ A i. 



.'.'CX/>^ J .Vex ^v<:^<^.c<<: 



St.; 



Dist.;bct.— 



and 



r IF DCATH OCCURS *WaV FROM USUAL R E S I D E N C E G I VC FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATIO N • \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 

FULL NAME xL(S4.A. AllaJLi... >. 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




DATi- <)i- niK rn 



\ • . I-: 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH 

i 

(Day) 



jxlvt 



(Montri) 



igo \ 

(Year) 



SINC.I,!*. MAKKIKn. 

\\'n)(>\vi;i) (»R i>!v<)KtKr) 

'Writtin s<»ciaJ «ifsi>»iiati<iii) 



-^ 



lURTmM.ACK 
Slate or Countiv) 



FATIIKK 



'UKTMPl.ACH 
<>1 I ATHKK 
'St.-ttr or Couiitrv) 



MAIDHN NAME 
0¥ .MOTm:K 



£ 





A^<:> 



Tnirrnpi.Ai'H ^^ 



••I- Mtt'niKk 

(state or Coinitrvl 




I HI«:Ri:nY CI:RTIFV, That I atteu<kMl deceased from 

190 to IgO 

that I last saw h aHve on ..190 

and that death occurred, on the date stated above, at 
M. The CArSr^: OI' DI-ATir was as follows: 



DrR.VTION Years Months 

CO.NTRIIU'TORV 



Days 



Hours 



DURATION Years Mouths 

(SIGNED ) 

u>o (.Address) 



l^ays Hours 

M.D. 



OCCrPATlON J} ^ . ~ 



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

Former or ( K ( ^ (1 How lonq at , , , 

Isual Residence ^^*^")aXXXXX \.<XX Place of Death ? 'H Days 

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



' "m'sT or1llv'KN^u'I;^aM•H ^ ""' '■'"''■ '■'* ''"'• '7;^^*^ '"' HTKIAI, OR KKM.)VAI, I I).Vj'K ..f lU r.al or RKMOVAI, 



^InfoTtnatit 



■t) 



X>v»v<X. 



"W/ 



% 



o-^W\^LcLk^ 



'\'1<1 



% 



Xr>/>JU. 



ca-^x^ 



IwoJL 



Oji\<^. .^ , 



90 . 



rrss 






i:.N-i)i;«rAKKK ^^<xLo(^Vv^,^^a.^UA^,dLl^^i!xOkA.vt,Q V,< 



. Every Item oV information •hould be carefully Hupplied. AGE uhoultl be stated EXACTLY. PHY8iCIAIN8 ahouid 
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for per- 
«on« dyinft away from home Hhould be Jiven in every instance. 






■r! 



1 



: ill 



I., 



•Hi 



I'll 



, n 



I 



w 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.,..^_____ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,;,nl ..f Hcaltli-K No. i^ '^^^T^ ^^^^' t!" 



Da/c /vV^v/, cJxlxtjU^\Ax^ 1 IfJO i 



Registei'ed J\^o. 



* 'lO-S 



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

Certificate o( 3eatb 



( U. S. StanDarO j 



i (^ 



/-^i 



'^ 



:ity of ^^ 



No. 



PLACE OF DEATH: — County of '<Vv\- J *U!t>vCL4.co City of '~' Cl >v J *vCL"»vec<l^Co 
• •• - >''''■■ St.; 3, Dist; bet AxcL\,K^vco-cvtl\)and h kk.^. 

/ ir Dt*T^4 occuBS *WAV FROM USUAL RESIDENCE GIVE facts called for under "special information- \\ 

V IF DEATH occurred IN A HOSPITAL OR INSTITUTION r.lX/r ITcs N A M T lue-rc-.r^ ^^ ^^^^^^ |l 



^^ 



'H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



FULL NAME 



-^I 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR ^ "1 




)' 



i ..V 




lO' (^ ■ 



^c^ 



Kkj..:\s. 






k 



ID.kctc 



(Month) 



J JLkr.. 



(I>av) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATII Jp 

- 2x\^ 



(Month) 



(Day) 



I9<A 
(Year) 



A'.K 



^ 



) ''■(/ ' . 



1. 



yf'Oiffn .. s). An ^ 



Writ! in Mnial <ksivrnatioii) 



l!IKTiriM.\t'K 
Matf or Cutiutrv) 




>LxLcr\>^>^<:C 




NAM I- Ol- 
FATHI.k 



•ilKTllIM.AfK 
«>I- lATHHK 
'Statf or C(Jiiiitrv) 



^'AI1)KN XAMK 
"»I -MOTHKk 



inRTTTPi,A("K 
"I MoTIIKr' 
(Statf or Conntrv) 



oOCri'ATlON 






.1 IIHRlvHV CHRTIFV, That I atteiidcMl ,lcceaso<l from 

'•'^^^<^'v 1.3. u^ to 'cJX'.^.Ob I up'i 

that I last saw h.A.!.^ ahve on "O-iLivt" L 190^ 

and that death occurred, on the date stated above, at LIS*. 
M. The CArSI<: Ol- I)1:aT1I was as follows: 



vxxx.xyc 



.'^'\J 



[\ 



DIR.VTION Years 1 Mouths IC Days 

CONT RdP.rTORY UJxi^^i^.. . J.ci^^ 



J lours 



v>U^. 



(3? 



4Aa^j 






1 I UCXa^ 



^-WJL 



IH' RATION -. Years -^ Mouths 



/'>avs 



'\r-wc^'K 



(Signed) 



Hours 
M.D. 



di.4a.t \u)o S (Address) lai vJ-^CLVx. 



w 



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



Rr uir,i ,„ K,,,i /;,,>/, r^.;, 



) 'r,i I V 



M,n,th- 



n,n 



"l.M Ol- .MN KNnNNl.ivDCK anI) Mi;i.n.;F 



Former or 
Usual Residence 

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



How lonq at 
Place of Oeatli? 



Days 



f\: 







—4 



ii: 



ri.ACK OF nrKIAI. ok KKMosAI. I Dyn-lof nt kiai or KKMoX ai, 

Dxiytr.. 



UXJ. J^.ijvi^^>\.oXc:\H 



10 



190 






.L 



i^» 



Kvery item of informntJon should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
« ate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for p«r- 
«'>n« clyinft away from home should be ftiven in every instance. 



. ^ 




.r 



tiff I 







» 



\ \ 

4 



i.i 



f 1 



ii 







^^^ 



if 

ii 



J 

If 



1^^ 

I ( 

H 



im 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i..,„ninfH.:.ith I--XO. i.^gg^H&i'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hf/c Filed , C 



1 ^ 




190\ 



Registered J\^o, 



V50,4 



DEPARTMENT OF PUBLIC HEALTH=Crty and County of San Francisco 

Certificate of ®eatb 

( H. S. StanC>arJ> ) 
PLACE OF DEATH: — County of ' a^v VCOvCc^c^o City of Ct^ru ^ K(X^\0^<L1:^ 



IS .d 



J? 



No. Ul"^ - I? tl'v St.; '' Dist.;bet. 6a^<JviUi and VH - 

/ ir Dt*TH OCCURS AW*y FROM USUAL RESIDENCE GIVE facts called for under "sPEcAl INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREElf AND NUMBER. ) 



FULL NAME 



Y\ 



^OJ\.\,JL 



..y\XX.:\.-.- 



\<'.K 




COI.oR 



PERSONAL AND STATISTICAL PARTICULARS 

i».\ii-: oi luu III 



.llkvtx 



(Month) 



(Day) 



v„l3..^1 

(Vear) 



J Vi/ / 



A/i>tif/is. 



MEDICAL CERTIFICATE OF DEATH 

D.\TE OF I)I:aTH [ 

)ji[xb.... 'I 



/90 H 

(Year) 



(Month) (Day) 

I HKRI'HV CI'RTIFV, That.r attended deceased from 

L'i looH. In .."ao^ivt. 1 



30 



/>(! I .. 



•^IN«".I,K MARRIHI) 
WIDOW KI> OK I)!V(mrKr) 
(Write iji soeial (ie'iij.'tiatioii) 



nikTifpl.ACK 

(Statf or '.'oUTitrv) 



A 



■ 'UxAXajuL 



N'AMK or 

i-A rin;K 



l''IK IHJ'I.ACK 

<»i" iArni:K 

'State or i'<iuiUi v) 



MAIDKK NAMK 
OF MOTHHR 



I'lKTlIIM.Ai^H 
(State or t"ountrv) 



\jlLc^^\xL 




H i-^ I90H. to 

that I last saw h ^.' alive on ..CJ^VCtT Hf 



190 
190 



and that death occurred, on the date stated above, at 1 1 SO. 
^L M. The CAl'SI': OF DI'ATII was as follows: 

L^^AJK^^i^<> . o:^ iJxi....A.u^ 

I 



\j 



-yV>VCL\xL h.LLQmJLA 



OCCUPATION 




/)ays 



DI'RATION }tars Mouths ^""^-. 



Hours 



I )r RATION 



Years 



Signed ) 



Mouths 



Pavs 



LCL>\. 



-•, 



fy'f^i.lr,! !,! S,;i, /',,!», /»•,, '• I )Vw/- 



^r,»lf//y 



djjfd ic)o'-( (Address) lOH$^ MK.a>J^ 



Hours 
M.D. 



Special Information only for Hos;.i(als, institutions, Transients, 
or Recent Residents, and persons dylnq away from home. 



Dax. 



' "lU-ST yM';Tv'','''v^' I'KRSOXAI, PARTICfLARS ARK TRTK To TH! 
HI, SI OI- M\ KNOWI.HDC.K AM) HHMHK 



Former or 
Usual Residence 

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



How long at 

Place of Deatfi? Days 



Oql.-.. 



X.ldress 3v1(d^ * I 



s aI. 1.1 



PI,ACK OF RIRIAI, OR RI:Mo\AI, 



)M.^S^ 



1-^^^ 






I)ATF;of MruiAi. or RICMOV.^I, 
vt i..Q T90 H 



)Xl/.v^ 



N. B.. 



-bvery item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain tepns. that it may be properly classified. The "Special information'' for par- 
son* dyin^ away from home should be felven in every instance. 



< J 



' t 



I 



'k 

i I 







4 




WRITB PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H...T.1 of Hoalth-F No. 1^ I^^^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale l^lle(l,Ax\<XjUYyJ^J(^ i. 



.100 "{ 




Registered J^o. 



1.50.5 



ij Deputy Hearth OfTIcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( ra. S. Stan6at& ) 

0^ 



No. 



PLACE OF DEATH: — County of CL>\; OX<x^vcl^co City of U/CLo^ OXCL.>-w.t:i.v^a'. 
LcttvV L^vc>\iM ob<v^i\.Lto..t St.: 



Dist.; bet. 



and 



A / ir Dt*TH occuBS,>w*v FROM USUAL R E S I DE NC E Gi vc facts *c*lled for under "special information N 

\J V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



(^ 



FULL NAME 



wjxyyxx^j^ dACxxz^^JL/Cr^^.-. I 



PERSONAL AND STATISTICAL PARTICULARS 



sj;\ 




COI.OR 



DATK nr-- lURTH 



AT.K 



^xlx 




I Mouth) 



(I)uy) 



r%5% . 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



]JL:Vxtj.. 
(MonthM 



(Day) 



igo \^ 

(Year) 



I HF.RKRY CI'RTIFV, That I attended deceased from 



^b ,v„,, *\ 



ytonUis 



Pa Ys 



^IN(.I.K MAKKIKI), 

W IIxiUKI) «)K DlVoKrKI) 

(Writf in sfx-ial <lfsij^iialioji) 



lUK rflJM.AC'K 

'Statr r)r Criunlrv) 



-C^V 



i 



T 



LL\^^q_ 1.3» iQo'v to ....oJL^xfc. 5. 190 H 

that I last saw h -i alive on Cj.j8^!^\.ti 5 j^ . 

and that death occurred, on the date stated above, at 3- 3> 0. 
^ M. The CAl'SB OF DFATII was as follows: 

LLcvsAX t^-v^<>xL.ftr:C^:CXA.dLct.^.\ 



NAMK oi- 
KATHKR 



tUKTHIM.ACK 
<>I lATHKK 
iStatr or <"oiiiitry) 



MAIDKN NAMF 
"F MOTHKR 



lURTnPI.ACF: 
<U MOTHKR 
(St.iti- or Ooimtrv) 



cS.VCLcx^xd- 



OCCUPATION i' 




DURATION Years 

CONTRIBUTORY ... 



Mouths Days 



Hours 



DURATION 'W'''^^ Yv ^^^'^'/^//^ Days Hours 

(SIGNED) J....,.VA.. lba.^;ut 

UxUt I iQo'. (Address) Ulu ^...U JbiH-jvi 



M.D. 



I. 



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



h'f billed in Sat) I'l iin,isrn ?, ." ]V,m < 



^r.'n/Zn 



Pa V. 



' " nrJ-r^y.?.";'!?'''^-'' I'FRSOXAI, I'ARTIOr LARS ARK TRIK TO THK 

"Ksroj. MY K.\mvij^n{;K ANi) hkmkf 



Former or 
Usual Residence^ 




i y ^ HpK long at 

LU\.^xoJs.>^^\.(xX. r-. HiKe of Deatf!? 



Days 



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



(Address 




V Co . Ob ^^kv.tal' 



PLACE OF BURIAI, OR RKMOVAI, I DATK of HtRiAi, or REMOVAI 

0>U iPJA.ui, I :.,^r^4^:_^:^r: 

I'NDKKTAKKR >wLM. D . />? !>'1:U^CU.V:'. 



igoH 



(Address 3) 5 A 



'AXo<tr>^:>^^-<^. . . LL .\.». .; 



. B. Every item o? information should be carefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for psp- 
aons dyin^ away from home should be ftlven in every instance. 







If 



'r'"^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Jtoard of Health— K No. i«^ 



H&PCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




])(ae Fi/ef/ , (Z\jJ^y:Xjuxy^ i 2^0 '\ Registered JSTo, ^'^O 

'Lcrwv:^ dot^KM ^^'P.^.^.y '^^MtH Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Ta. S. StanDarJ) ) 



PLACE OF DEATH: — County of 
(No. OA.Cl'' 




ClI V a* 



City of 




/V) 



vou 



CL^ 



Jlx llDM-kvwtal. 



St; 



Dist.: bet. and 



(IF DEATH occults AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME L 



cL.cLL<y. L.) 



li 



c4xo.^.x.<x..<L.\- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



^\JjL 



I).\TK or lURTH 



^ /tt 



'Motith) 



(Day) 



ixCti 



/llH 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



(Moiitfi) 



Ll^t^ 



1 

t- ■ 

(Day) 



(Year) 



I HHREBY CERTIFY, That I attcmlcd deceased from 
190 to •••■■ iqo 7::r::T:z 



AC.K 



3l^ 



) ra I 



II 



Miiiil/is fiavi 



SINC.m:. MARKIKl) 
WIDOWKD OK DIVoUCKr) 
(Wtitt'iii social <ksijfiiati<)ii) 




n\ 



niKTHPI.AOK 
(Statf f)r l.'onntry) 



N'AMi: OJ- 
FATIIKR 



niRTMPT.ACK 
Ol" lATHHK 
(Slate or Country) 



MAIDKN NAMK 
Ol- XKJTIIKR 



lUKTHPf,ACK 
o|- MOTHKR 
(Statr or Cotnitrv) 



J \ 1 




aX< 



that I hist saw h ~ ~~idive on 190 

and that death occurred, on the date stated al)ove, at — : 
M. The CAUSH OF I)r:ATII was as follf)ws : 





DURATION Vicars 
CONTRIIJUTORY 



Months 



Days 



Ho UPS 



DURATION 

'Ull 

(Signed) J. 



M 



Years 





3font/is 



Days 



I, 



OCC 



Resided in Sun /'i iii/</.^i-o jS\ )'(iiiy \ Mmiths 



Ihr 1 .V 



JL^vt. 1 



1 00 



( 



.•\(Mress) M Vayvt^.. V P.. i 



Hours 
M.D. 



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



Former or ic/>c-lO^ \\\i How lonq at 

Usual Residence 10 AO U 0.aV\XAJj Ok pjare of Death? 



Days 



Tin; A HO VK ST AT HI) I' KR SON A I. I'ARTIOr I.ARS A R IC TK IK To TlllC 
KKST OF MY KNOWMIDOK AND HHMHF 

(InfoMiiant (j\j (XX»Vu c) ^lv^VAvoJL\ 



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




.t.\ I l\ O! Ill l< I AI, 

NDICRTAKKK M /0>^<^^JU/T1 U^^ V cLjC^wVO^HX-V^ 



D.)i^Tl<:of niKiAi, or RICMOVAI, 

I90H 



(Adclres.s Hll. aU^\A.<U,^.Y... J 



M 



^. B.- 



-Bvery item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information'* for per- 
sons dyin4 away from home should be (iven in •\mry instance. 



% 






# 



I 



mm 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i-nnnl of iKiltli -I- No i^iS^»v]S.i H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\'*o, 



1 507 



ixil,- AV/^'^/, dJ^U.txrnJUr'v ,6 100\ 

"Xiyv^^o iol\Mji Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( xa. S. StanDar^ ) 

i ^ -? op 

PLACE OF DEATH: — County of CO/^vv ^xt^vcc«.<^« City of O/CWu JA-<X/>voc<.«^ 



(^ 



■ 



I 






0? 



No. H^^ Jxa. ■>^'(v.Ll ,' St.; "^ Dist.;bet. v),^-*^•-J!w and JX^ 

(ir DE*TH OCCURS AW*V FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O A " \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




(3 > 



) 



FULL NAME 



/cLcu^x^LxL \X-.^ry'\ O L^xxAA^lr. 



PERSONAL AND STATISTICAL PARTICULARS 



^i:\ 




CUJL 



COLOR 




vc 



hi 



1>\I1-: OI- lUKTlI 




CMoiitli^ 



2.1 

(Day) 



(Veur) 



MEDICAL CERTIFICATE OF DEATH 

\.. 

(Day) 




(Year) 



\<'. K 



> V'r; J 



,5. 



Months 



i,:i. 



Da vs 



S1N(,I,K. M.XKKIKI) 
WIDOWKI) OK I)[\«)RrKI) 

(Writf iti s(M-ial flesiKnation) 



HIKTUl'L.ACK 
(Statf or Couiilry) 



V.\Mi: OF 
F.AiTHKR 



mKTUF'L.ACK 
Ol- l-ATMKK 
(.State or Country) 



MAIDHN N'AMK 
ol- MOTHI'.K 



Hlk'niPUACK 
'>!• Mo'inivK 
(.Statt,' or (■o\intrv) 



ov'cri'xriON 







mr\, 



A 



m 




r HKRERV CI{RTIFV, That I attended decea.sed from 

A^.yyJi^ \ 190H to OJ^-Ct:....X 190 H 

that I last saw h ••.- • > >■■ alive on O.JL'ifsX. % icp • 

and that death occurred, on the date stated above, at "^ 
•^ M. The CAl'Slv OI' DI-ATII was as follows: 




DI:R.\TI()X Vi^at 

CONTRIIU'TORY 




Months Days 
\.aX*^ 



I Jours 



DURATION Vtars ^ Mout/is Days 



(Signed) 



^y\.<xA 



O^'Wj ^ .'X-CU'WC^^CC 



f\fsiiit\f III Siin I'l aiii isi'ii 



)%■,!!. <; 6 .t/oi/Z/is I '( /hns 



dXlat ^. iQoi (A«ldress) IS^ l(^.»>>x./J.< 



Hours 
M.D. 



Special Information only for Hospitals, Instilullons, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Isua! Residence 



How long at 

Place of Deatlj? Days 



I in; \novH sTATi'.i) i'Kksonai, rAKTion.AK.s ark trik to thh 
MhST oi'- Mv kno\vm;i)(;k and ijki.ikk 



(II 



. "■-»-•-- -,--.--- ...,.«.. 

f-.riuant LUrY>rX; /tvCX.A. aJlT' 



^ 



V.l.lress. H'i^ J AXX/WiOu/Vv Bl 



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



PI.ACKOHIURIAI, OR RKMOVAT, 




T 



n.\p|'Kof HtRiAi. or RKMOVAl, 

..UjL^aI..J - 



rXDKRTAKKR (AD. J- C3^,,JKA; *^L,Ci 

(Address I .13.1AJRv4^Q-^'--C>\^^^ 3^^ 



T9O 



N. B.- 



-Rvery Item of in?opmation 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- 
«on« dyinft away from home should be ftiven in every instance. 




60 




« 'u 



l\T\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ho!tr<l o! Health— F No. 15 



»&PCo 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 




Date FfIed,..(:^.jJfsXjUYy\J^^ % 290 \ Registered JVo. i T^'^H 

i<5AA^ *ilA>M Deputy Health..Offrcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( in. S. StanDarO ) 
PLACE OF DEATH: — County of Cj<X^ru A.<X/>^Ca^cc City of <X/w AXX^rL/Oucid 



No. biH M XX^^^V^C St.; I Dist.; bet. J^-iXL^.Aa^t and X'A-^^yU^'yU: 

(ir OCATH dtCURS AWAV FROM USUAL RESIDENCE give facts CALLCO for under "WECIAL INFORMATION" N ' 
IF OEATI^ OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STMEET AND NUMBER. / 



) 



\i 



FULL NAME 




;Sv/>:\.CA.A.>:r)r-:vi 




€l..:. 



SKX 



DATK ni- lilK iH 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




,U, 



^vaX-" 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



I Month) 



(Day) 



f%$.S. 

(Year) 



ACE 



OLUt H'^ ,-,.., . 



M^nilfis ■". . Davs 



m 



SIN(.I,K MARRIED. 
WIDOWED OR DIVOKC ED 
(VVritf in social desij^nation) 



HIK PFITM.ACE 
'Slate or Conntrv) 



NAME OF 
FATHER 



HIKTHIM.ACE 
Ol I-ATHER 
(State or Country) 



MAIDEN NAM} 
OF MOTHER 



!( 




.axkfe, 

(Month) 



(Day) 



1 



(Year) 



I HRREBY CERTIFY, That I attemled deceased from 

190 to -• 190 ~~ 

that I last saw h-:n— alive on • ~~" 190 —. 

and that death occurred, on the <late stated above, at — ~~ — '~- 
M. The CAl'SB OF DIvAI'II was as follows: 

. LUcA^/cC vj (>-v^-cr\\,.v-ov>w<:i. 

."a..A.A.,A<^N<^djL ^ 




Dr RAT ION Years 
CONTRIBUTORY 



Months Days 



Hours 



BIRTHPLACE 

oi- mothf;r 

(State or Country) 



OCCrPATlON 

Kfi-idfd in Stifi /■> <iin r^t'o 



DURATION }'rars . Mouths Days Hours 

Ur\.Cr>vil>v J.^.lp.Xdux^^d. M.D. 

Address) X^<n->.>' w V^, 




( Address) V^ <n%> w W^VuCa. 

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



) ><; ; 



yfonths 



Days 



the AllOVE STATED PKKSONAl, I'ARIKl' l,ARS AR E TRU F! TO THE 
BEST OF MY KNOWI.EDCE AM) BEMEF 



(I 



"fonnant K^^S^^sJTYKXJ^Jii \J XLv/tlJL 



(A «1 dress 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



pi.acf: of bfriai, or removai. 







DAJ'Eof BiHiAi- or REMOVAI, 

O^X^:^ ^ 190H 

itni)ERTakf:r julAAa^ ^^ (to <x<V;:t3L 

(Address. 3kT'^..-...J3.jy(\ "3.1. 



W 



'^' B* Every item of inPormation should be car«?uily 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 dyln4 away from home should be ^iven in every instance. 



■"a 



m 



u 




A- 



H§¥ 



■■k 




If I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,:,n! of Ik-.iltli -F No. !«> ^t^S:^' HftP Co 



j.-f 



i)((te Filed , 




% lOO'i 



Registered ^'o. 1 5^0 



dUuv^ Xto^ii C^c;;..ty Health .O.facer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( la. S. Stan£>ar5 ) 

J? l!^ ■ JP 



% 



PLACE OF DEATH: — County ofQ/CX,"rv AX>yYvtwtt.' City of 0/Oyrvj 0/\ya^^wo.A/Co 

A Q5\f , . i) 



No. cLou^vAjl lI l3 ChA-K V^-CV I 



^Kv'L-O 



St. 



Dist.; bet. • ' i. ..:.... ' ... and 



(IF DEATH OCCURS AW*Y FROM USUAL R E S I D E NC 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 



10 



CP^ 



PERSONAL AND STATISTICAL PARTICULARS 




ra.<L 




\w^ 



u 



I).\TI-: ni iilK 111 



l(l 



\<'.K 



vj-Jlr 



MMiith) 



«i^ I )>,// ' T 



a /%1?) 

(Day) (Vear) 



4 



igo 



Miiiil/is , Days 



«^INr.I,K. M.ARKIKI). 

\viih»vvj:i) ok i)iv«>Rri;i) 

'Writ* ill sfKJal firsi;.riiati<>n ) 




l!IKrm'l,\«*K 
• Stati- oi C")Uiitrv) 



I'ATin-.R 



I'.IkTllPLACK 
<»|- I ATMKK 
(State or CN»iintrv) 



MMOKN NAMH 
OI- McrrilKR 



HiK'rni'i.ACH 

*>l" MOTHKK 
■Stnt. or t'ounti V) 







MEDICAL CERTIFICATE OF DEATH 
DATE OF I)F:aTH J) 

O^lAjfc- s\ 

(Montn) (Day) (Year) 

1 llIvRRRY CKRTIFY, That I atteiuUd deccasecl from 

LLucct XH 190H to aj^^± 2). 190 M 

that I last saw h X\.> alive on aJL-|A.L -i^ 190 't 

and that death occurred, on the date stated above, at Ci-lo 

^y M. The CAl.'Slv^^OI' DI-ATFI was as follows: 

.xOV TvAv^V^^-cL vJ. 



H 



I 









I 






^{ 




r I 



DURATION )>ars 

contriiu;t(m<y 



Month 



. lo 



Days 



/fours 



DURATION 



^TUX; 



? 




X'CU 



OCCri'ATlON 

Kfsidfii it) Sou I'l mil isiit ri. \ )V(M.» 



VC CrV-V..x<LjL^*^>^.^-v|,Jl 



- Years Afont/is 

CJXWL S TQo'l (Address) 1 5^(0*^ UxXCV.OL-rvvil.>vlo .V 



/)ays 



//ours 
M.D. 



MniiUiy 



Ihn. 



Tin-: AHovi-: sTA'n-:i) phrsonai. ivvkthtlaks ari; trik to tiih 
HHsr OF Mv kno\vi,i-:d(*.h: and hkmicf 






.^\>CjA>YV; 



\ 



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

Former or '7 1 't P "^ i. ^®^ '^''fl ** / 

Isual Residence I I I wLCUx (jt Place of Deatli ? b Days 

Wlien was disease contracted, ^ \ I I 

If not at place of death ? sAmJVvv<HAr\\„ 



ri,ACE4)F in RIAI, OR RKMOVAI, 




indf:rtakkr WYVCX/i H.- vJj. 

(Address .b'^lb... V\) 



}.\ 1 I; O! n 



I).\Ti:oi HiKiAi. or RF:M()VAI, 

^c 190 H 

\XJ\i 

k 




MM 



Hfii 






N. B. F.very Item of information should be carefully iiupplied. 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^ osvny from home should be |t>ven in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lio;n.lof Hc.tltli J No. 1. •5-?^^^3n.«tJ'C.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Fne(I^Aj.\\kx^^Jo^ S 100 \ 

Deputy Health Officer 



Begistered JSi'^o, 



1510 



cvHm^co 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



Ji 



( H. S. Stan^arC* ) 



PLACE OF DEATH: — County of O 0^^\l OAxX^xot^co City of 0/0<.y\) JA^X^^vcc^^i^ 







No. 'i^"'. LKAAA..ck 



St.; 



Dist.; bet. 



((o 



tl 



and 



n 



± 



(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" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



. I Lcu\_<^ 




(. 



r'YvijX'^-.. 



PERSONAL AND STATISTICAL PARTICULARS 



ox^xoJu 



DAll-: i»J lUKTM 



\ <■.!-; 



t 



iMonth) 



7 

(Day) 



/J.:.ii 

(Year) 



7 



) 'I'a I 



I I 



Mittttki. I na\ 



>IN'.I,K. M\RKn:i). 
WIDOXVKI) <»K I)I\(»K(Kr) 
Uiitfiii >»(»cial di. sij.^nati<)n) 



ntRfllPI.AOK 
Slate or Country^ 



NAM)- <)I' 
l-ATlll.K 







MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATIi C 

Bxkt i /poH 

(Moutll) (Day) (Year) 

I inmrUiY Cr<:RTIFY, That L attended deceased from 

a-£4^t n 190H to .'c)XJ\i:. ^ 190H 

that I last saw h X^ alive on U-C|/\a: '^ 190 4 

and that death occurred, on the date stated above, at 1 1- if) 

V' M. The CAl Sl<: OF I)I':ATII was as follows: 

-^-A.XX:. 




Di; RAT ION 



} 'eqrs 



>A; 



HIklHIM.AfK 

"I" 1 aiiii<:k 

•St.it< or t'ountrv) 



maii)i:n namk 



HIRl'm'I.Al'K 
•>I' MOTHKR 
'State or Countrv) 



I 






CONTRIBUTORY 



DURATION 



Months ^ '5 Days 






Hours 



\\ 



..\J..CL!x^<X^!UuyCL.V.Cli 



OCCrPATlON 



O/cJ' 



Ov.nxux. 



cnjj 



A^V.XL 



Rr^uifil in Si!>i /'i iDii isro i )'t'ii)s (.. M,>)itli< Pay. 




Years 



(SIGNED) JkrW^ U-cJua.\;!-!C 

OSJ\\k q ,Qo \ (Address) ^Hll ^ IT ttx. 3^ 



^^o)lths Days 



Hours 
M.D. 



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



HJ: AnoVH STATKI) I'KRSONAl, I'A RlUT I.A Rs ARK TRIK To Till-; 
IllvST Ol' MY KNOWMax.K AND HHIJi:i- 



'liif'ittuant 



r\(l(lrc 






;."SS 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



IU,ACH OK lURIAI, OR RHMoVAI, DVli;.)! Hikial or RlvMOVAI, 



(Adilress .^.?>'55 .\u\>u«LA.4.xrvv. .C^ 




N. B. 



■^ 



.J-«J^ 



Every item of inforinntion 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. 









w^ 



I 



i) 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




nw\ 



lleglstered J\^o, 



1 511 



Ddfc Filed , 

DEPARTMENT 6F PUBLIC HEALTH=City and County of San Francisco 



Deputy Health Oflficer 



Certificate of Beatb 

( ■a. S. Stan^.^td ) 



4 



(^ 



PLACE OF DEATH; — County ofC)Ay->^ A.<V>x/<^s^c.' City of 0<X/>^ J Axx^>^yaAw<i.c,c 
No. 4 n v) CKtt St.; '- . Dist; bet. M CTUkJLL and M /la^c-\A. 

(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E C 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. J 



FULL NAME 





CUTiWXX.ci.. 



.,:» A 



^IwL 



DAIi: nl lUKTH 



A«iK 



PERSONAL AND STATISTICAL PARTICULARS 

CCH.OR r\ y 

(Day) (Year) 







I 



9>%.\ J til I > 



\ 



Mmilhs 



Ptn 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DHATH Jj 



dxkt 

(Mont A) 



1 

(Day) 



(Year) 



^IN<;i.K. MAKKIKD. 
WIDoWKD ok I)I\(>Kri:i) 
Uiiltiii siK-ial <U si}.Miatii>ir) 



lUKTHPI.AOK 

fStatt or Con lit rv) 



»athi;k 




BIRTH PI, ACK 
OP' F-ATHKR 

I Stale or Crjuntrv) 



1 ni-;KI-:HV CI;RTII<'V, That I attendtMl deceased from 

LLc^^c5^ ^^' ^9°"^ ^" pr^s:t:.j^ 190 H 

that I last'savv li • ' alive on J-L-^^vt. t) itp'i 

and that death occurred, on the date stated above, at A oC 
lL M. The CArSI<: C)I' I)P:ATII was as follows 




A,JJLy\'V^^,^b'^Y\/OLh^ .0 'VUCNi/v«U_*jL{Kft-^- •> 



DC RATION ' }'t'ars 
CONTRIIU'TORV 



Mouths 



Days 



Hours p 



MAIDHN XAMF 
OF MOTHKK 



IlIKTHIM^ACK 
OI- MOTHHR 
(State or Coutitrv) 






V.<Xy>Aj 



t>CCl?PATlON 



cCOLA> 



/ 



/clA 



A'/.'/if/.f tit Situ /'l ,1 It, /M'l 



VO--\v. 



).ai. 



or RAT [ON }'rars Months Days 

(SIGNED) M n Aj H^CLt^^-v.^.::^':^. 

CJ.X^\^ t Tc)o\ (Address) "t I WjCHJlt '^l 



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



M.>nth< 1 {^ /vi- 



'\\\V. \H()VK ST\Ti:i) I'KRSONAl, l'\ UTUT I, ARS A K H TR TH T» ) THH 
Hi:ST Ol- MV KNOWl.HDCK AND Hia.Il-.K 



(In I 



'•iiiaiit 



\.l(lross 4H \J (SXjjt 01 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



ri.ACK OI- lURIAI, OR RKMOVAI, I DATlv of IUkial or RKMOVAI, 

C3<vo^v<5w-y^^^^.t:o Ccui I c3jl^ H 190^ 

INDHRTAKKR \K ■ Lv . N / \.0AX«.'>\. ^ L<. 

fAd<lrt-;s 5.A S. \J i /OU^AJlJLL ..iSi 



N. B. Kvery 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 dyin^ away from home should be given in every instance. 




> I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of Healtli— I' So. n 1^^^§^^ lUtP Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafe J^y/e(l,^j0^tL^-,JjuiK S lOO'i 



cL^Ma^a^ 



Be^isteved J\^o, 



J 512 






^^ '^ "^1 ij 



^ ^ ^ O I 4. 1'l w JTi i C o I ' 



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

Certificate of ©eatb 

( "CI. S. standard ) 
PLACE OF DEATH: — County ofC'CLnrv- ^^o^-yvev^^c City of Qcco^ JAxu^^c^^^c^ 



rp^, 



.Oi 





0^^i^\X<X 



I 



St.; 



Dist.; bet. 



■and 



( "^ P/I^T-".^°^*''"'^ *'**'' ''''°** ^SUAL RESIDENCE GIVE facts called for under •special information- \ 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR EET AN D N UMBER ) 



FULL NAME 




IM..' 



^» V 




JL\/y^^rLrYT\jL\ 



PERSONAL AND STATISTICAL PARTICULARS 



/»v<xlx 



UATK OI- lUKTII 



AGK 



LAa/^q 

(Mouth) ^ 



\s)LdjL 



w /St'i.. 

(Day) (Vear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH J^ 

3x1 vL t 



(MotilW) 



(Dav) 



(Year) 



)'fni 



M-oitlis 



IC 



n,i\. 



SINCI.K, >fARKIKI). 
WIDOUi;!) OK I)!V(»RCKr) 
< U'l itv ill sorial (U si;.r)ijitit)ii i 



lUKTniM.ArK 
(Statf or C'oiiiitrv) 



^'A>n- OF A-\ 



niKTHPI.ACH 

OI- I'ATIIKK 

• State or C(»uiitry) 



maii)i:n namk 
oi- mothkr 



lUR'rinM.ACH 

')l' MOTHHK 
(Stiitf or Coimtrvi 



'^W^XVUL 



1 in-RlvHV CI'RTn-V, That ; attcn.le<l deceased from 

1-^^ ^ UyO M 




that I last saw h 



iyo'< to 

alive on 



1 



Kp 



and that death occtirred, on the date stated above, at % 
^^ M. The CArSlC OI-' I)f.;ATll was as follows: 






1 ^ry^^ ^-iX'.-v-ctoiU. 



J? Q^ Q 








OtHTl'ATlON 






DC RAT ION )<'^;-.y 

CONTRIIU'TORV 



Months ' 1 /Mi'5 



Hours 



Ol'RATION Years Months Days //ours 

(SIGNED) Ll). Ij IJ\.^-U.c^> M.D. 

CJX>^i ^ n)oH (Address) Oi: . XvJiLLO )W 



J 



)V,M 



!/.'/////« ! !>.: 



THK AMOV1-: STA'n;!) I'KKsONAI, J'A Kl' IC T I.A K S A K I" VKW To riij.- 
HIvST i^^MV KNo\Vl,Knc,H AND Iu:MI;i- 

(Iiif<i!iiiaiit 






a-ldrc 



<Xa.\a^ 




?^^9'<iK"^fO"'^^"r'ON only for Hospitals. InsmuMons. Fransjfnfs 
or Rerenl Residents, and persons dying away from liome. 

[,"""."„"•■ r\r. -\ f^w r '^'W long at 

Usual Residence J CL/^\AXX. V\,A^a Vcl\. piare of Death ? 

When was disease rontracted, (J 

If not at plare of death ? 



i( 



Days 



IQO'i 



IM.ArH .)J.- m KIAf. OK KKM..VAI, DATJ.; ot Mikia,. or RKMOVAI, 
UNDHRTAKHR (AD J. Oa^\>V V Lc 



fAdd 



rrss 



/^^fc™.! 



''* "'"rt^Jcllu" e'oF dTath" ^ ^"''*'*'""^ Hupplled. AGB hHouIcI be stHtc.l RXACTLY. PHYSICIANS •hould 

«tnte CAUSE OF DEATH .n plam terms, that It may i>e property classh'ied. The "Special Information" for nr- 
«on, dyinft away from home should be ftiven in tix^ry Instance. •niormaiion »or per- 






' 1 



n 



•>i 



! 
J 



1 t\ 




!!»■ 



""."ij iii m 




i 



;tij; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



]\<y.\r<] ,,f Hc.'iUh- !•■ No. 1 5, 'l^?;:*:;'^) lUtP Co 



J^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffe /^//^v/,.dx.^j^-.^jMA. ^ 290\ 




Registered J\^o, 



1513 



A-A.^ <L^\hu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and Connfy of San Francisco 

Certificate of H)catb 

( tl. 5. StanC>arc> ) 
PLACE OF DEATH: — County ofO/CUwvJ/u<XoA.c>ui.cc City ofCW'Vo 0.^cu^xt^\.<i,c( 
No. ! ^ 1 ^1 J.^.L.. , St.; ' Dist; bet. XxxOL^^ and M C^Lk 

r 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 IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 

e 

FULL NAME La, 



>^K\ 



PERSONAL AND STATISTICAL PARTICULARS 

(^ ^ I COl.oR 




L^XUCU 




"^X Y\ 



^'Y\^^oJLsL 



\ 



Kv 



u 



MEDICAL CERTIFICATE OF DEATH 



DA'i'K ()J- I'.IKTM 



AC.H 



Uxivl 

(Moil h) 



)'ra> s 



(Day) 



Mnuth^ 



T.^L 

(Year) 



Da I .? 



DATK Ol" DKATH _p 

(MoiitTi) 



I 

(Day) 



igo \ 

(Year) 



^iN<. i.j:, ma Run: I). 
\vii)i)\\i:i) OK i)i\"t )Kr};i) 
(Write ill social <lesijf nation) 



L 



HiK'nn-i.ArK n />>. A 

(State or Conntrv^ J^^ I (J 1 1 (J 



I HI'Rl-HV CI;RTIFV, That I atton.kMl .lecvascd from 

d^clvt L T,pM to . ...djL|Al \ 

aiid that death oriiirrcNl, on tlie (hitt- statcMl above at 

(? 



190^ to 

that I last saw h ■=' alivt- on 
lat death oriiirrt*«l, on tl 
M. The CATSI' ()!• Di-ATII was as follows 



190 w 

190 ' 



NAMl-. 01 
lA'IH J.R 




/A'^'^V 



DC RAT ION Years 

CON'IR IlilTORV 



Mouths 3 Days Hours 



MIKIin*I,A("K 
Ol lATIIKR 
(State or I'oiintrv) 



MAIIU:n NAMJ-: 
<>l' MOTHKR 



lUK'I'Hl'I.ACK 
«>l' M()Tm':k 
'State or C'omitrv^ 



l / I cL<XAAa. 




DURATKJN )',wr5 Months 

fSlGNED) Jj^ Lld,.X>.. 



Pars 








Hours 
M.D. 



SPECIAL Information only for Hospitals, InstituHons, Transients, 
or Recent Residents, and persons dying dway from fiome. 



OCTfl'AIION 

Rrsi(tt'(f ill Sail I '1 iuu f-,it 



) 'I'li I \ 



M.niU,^ 



I hl\ 



\'\\v. Aiu)\-i-: sTAri;i) i-KksoNAi. iv\k rin i, \ks ak i- ri<t i" i( > iii}-' 

HKST (>!• MY KNOWI.HIX.K AM) I5HMI;k 



Former or 
llsudi Residence 



HoH lonq at 
Place of Deatfi ? 



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



Days 



(In 



!• in- 
fo; iiiaiit J,n..<x>\J'^ \i . \i\x<x. 



">%/>%. 



(\.l(ln 



^m"^ Jaju-^tw Q\ 



IXACH (»]• lURIAI. (»K KI:M(.VAI. I>\TJ-ol \Uv\\\. ot RJ-MOVAI. 
I-NDKRTAKKR \A LU M ) VCLxLw y v Ac L<) 



(A(|<lre«ii 



IN. B. 






-F.very Item oif inforitiHtion Hhoiilil Ik- cnrctfully supplied. ACJK should he stnted KXACTLY. PHYSICIANS should 
state CAUSli Ol' DliATH in plnin tcrm». that it may he properly classified. The 'Special Informatioa'' ?or p«p. 
son* dylnft away from home should he (jtiven in ^\9ry instance. 



♦ 1 



t 



'•; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n.K.n1of He.-.lth -F.vo. i . l^^^g^. lu'^ l> Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered •A^;. 



1514 



D((fe /^/V^v/, Jdx^tX/yyJ^j^ f][ 100 H 

o^JsMx^ Xuwu Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( Ta. S. StanOarJi ) 

PLACE OF DEATH: — County of ^ XLTv 0\/ai\CUlC^ City of U Ct^\; J V<X^vCt^L<lo 
'No.b 0.\.Oy'>vdMXa<x^, ci^ St.; ' Dlst.;bct. uJ.U.k.<rnjj and JuLa.V.'> vu 

/ \r DEATH OCCURS aMv FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UnIeR "SPECIAL INFORMATION ■ A V 

\ IF DEATH OCCURRltb IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / /) 



FULL NAME ^ol/:v:n^ 



^JJ..: 



PERSONAL AND STATISTICAL PARTICULARS 

DATi; (>l r.IKTlI A 

mW is 7 S.c; 

'Month* (Day) (Year) 



lllfvCU 



a(;k 



J 'ra t s 



^ 



M.mffis 



II 



Pa 



SIM.I.1-: MAKRIKI) 
WIDOW i: I) OK DIVOKCKD 
'Utitein »;rH>ial dc^ij^natioii) 



lUKTHPI.ACK 

'State or Comiti \) 



NAMI-; Ol- 
FATHKR 



MIRTH PI^ACK 
0|- I-ATFIKK 
'Stale or Countrv) 



m\ii>i:n namk 

Ol MOTUHR 







MEDICAL CERTIFICATE OF DEATH 
DATK (H- DlvATH 

(Moi/th) I Day) 

\ Hi'KI-l'.V ti;RTlFV, That ^attciKkMl deceased from 
^ ic/) '< to 

tliat I last saw h << >'^ alive on 



(Year) 






^^tKxiOtv; M l\c<J-^oU. 



'uui\Xr. 5. igo I 

)jJ^' :'• up M 
and that death occurred, on the <late stated above, at 10 
^^ M. The CATSIv ()1< DIvATII was as follows: 




Dl RATION )'ears 

CONTRflU'TORV 



Moxths 



Days 



Hours 



DTRATION 



r.IKTIIFI.ACK 
«M- MOTUHR 
(St;ite or Coutittv) 




OCCUPATION 







Years 



Mouths 



Pays 



(Signed). U.^uux \hjLK\ 



ri:^f 



/O 



Flour'; 



M.D. 



., -A^ 



^ 



i(,o M (Addri-ss) IClVf) ^<^ A dvv/o u yi 



Special Information oni> for Hospiidis, insfifutions, ininsients, 

or Recenf Residents, dnd persons dying awdy from liome. 



AV'/(/^(/ /// Si\}i I i,in< 



)■ ill ^ -'l M.itilh^ I 1 /;,; 



Tin: A HO VI-: s'iati:d pkusonai, i-aktui i, aks aki-: tkik to thi-: 
nKsr oi-- MY kxo\vij;dc.k and wvaav.v 



Former or 
Usual Residence 



flow long at 
Place of Death ? 



Days 



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



'Iiif')!inant 




^■\^uAAx 



( \<l<lrc«s 



A.^Ol/w/cL 



vXoucJL 






I'l.ACi: OI- IHKfAI, Ok KI;Mo\ AI, I DATlCof IJtKiAl, (,r RKMOVAI. 

S^LojU.<y^ I ^^-4^ ^_ 190' 

INDl-RTAKHR L.<lAAr. ^^-<X^LX/tX a^-N.jct/Lc ^ Lfi 
f Address k)S.^ \) oJJjUa, Jt 



^- "• Kvery item of information should hi cnrefully nupplied. AGB kHouIU be stated BXACTLY. PHYSICIANS should 

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



I.i 



A 




f 



ii 



i^ 



I ' I 

H 



< 



i4 \ •' 



1 



if 



. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HcMi-.l ..f llc-alth I- No. r. -t^'S^g^H&l'Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Ihf/r /^y/efr,.6.JL^yljL^^Jj^ry,, a I^O'i 



Regisferecl JVo, 



J 515 



CN-^A-VA^ 



Deputy Health O^cer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( 'a. S. Stan^ar£> ) 



J( (JO A ^ 

PLACE OF DEATH: — County ofC'/X^^v J^vay^vcA,<i.c.t) City of C3/Cl/>^ i AuO^/^^^/^k^<lk, 



No. 1^0 "{> d^xx^V 



\„^.; x V 



St.; 3s Dist; bet. Vv- C <r '^ <^ix and ' '.O.^Cv.- 

(IF DtATH OCCURS *WAV FROM USUAL R E S I DE NC E C I VC FACTS CALLED, VoR UNDER "SPECIAL I N FOR MATIO N • "\ 
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME ^NSTEAD OF STREET AND NUMBER. / 



FULL NAME 





.XAaA^. 



{ ifXri\j\> 



s !•: \ 



I).\T1-: <)!• HIKI'M 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




qJ 



a 




M.V. 



(Month) K 



3...... 

(Dav) 



.%tl 

(Year) 



} ■/■(/ ; 



Moul/is. 



.Davs 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH _p 

axkt I. 



(Montli) 



(Day) 



/go 

(Year) 



I HF.RHHV CIvRTirV, That I^attemlnl .Icrtasctl from 

.^iJL I 



SINC.I.K, MARKTKI) 
\VII)()\yi:i) OK I)I\()K(i;i) 
(Writf in sf)cial (K si>^iiali<>n) 



IMRTHIM.ACK 
'Statf or Country) 



N'AMK ()| 
HATHKR 



HIRTm'I,.\("K 
OI- I ATMKR 
(Stat( or Country) 



m.\ii)i:n NAM1-: 

Ol' MOTHHR 



lUKIHI'I.ACK 
ni MOTMKR 
(State- or Country) 



OCCri'ATFON 

Rfsidfd III Sim /'i <i in iM'i) 




■rv 



1901 



to c)jL|:xt 1 190 '1 

that I last'^savv h u . ) . alive on U,xJ/\X 1 190 \ 

and that iloatli ocnirrcd, on the date stated above, at 3 
^ M. The CArSlv()I' DI-ATII was as follow.s: 



1)1 RAT ION )'ears 
CONTRIBUTORY 



A/ON//iS 



Dav 



Hours 






DURATION Ytars Mouths Pays Hours 

(SIGNED)... "j. II . v](^ t C^ oj... M.D. 

UJ^^vt % T9o'\ (Address) ll^H vi>rv,<ytxclwa.H. 



A + 



Special information only for Hospitals, ln>tltutlons, Trinslrnfs, 
or Recent Residents, and persons dying away from home. 



) Vv/ / .<• v-'i MniitllS 



Dux 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



Tui; .MtovK sT.\'ri-:i) i'kksonai, [-ar iki i, \us aki; tri h 10 thi-; 

HKST OI- MY KN«)\VI.HI)C.H AM) HKIJICF 



(InfoMiiant 



r\«1(lrc.H« 1^0% 




'VU5 




J 



.di 






i'l.ACI-: OI- m RIAI. OR Rlv.MoVAI. I DAI)-;.,! MtiUAl. or Rl-MoVM, 

INDl-iRTAKKR OVJ J. OxA^Wv ■! v^t 

(Ad.lrrss 1 1?)"! (yVtv.ft^<LM>^x.O;fc 



N. B. fi\cry item of information shoulil be cnreifully Hupplied. AGB «hotiltl be Rtated EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH in pliiin terms, that it mjiy be properly clasnificd. The "Special Information" for par- 
sons dyin^ away from home nhould be i;>iven in every instance. 



I 

( I; 






4 



n 



rll 






'% §t 




> t 



\n^ 



^'•X^, 



WRITE PLAINLY WITH UNFADING INK 



]:,.:, v,\ .,f !I(;i!tl\- F Xo. it, '^^^^^ USc V Co 



I)(f 



te Fi/ed,^ 



THIS IS A PERMANENT RECORD 

qgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 





100\ 



lies^i.sfci-ed J\'*o. 



1516 



.yu Deputy Health Officer 

DEPARTMEM OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of 5)eatb 

PLACE OF DEATH: — County ofOo . 0/^cu^cc^r, City of CKo.^ J A.a.^xcoi-( 
No. H^ OAX-v^A_tvxt 




St.; S Dist.; bet. vUykJlruJvAJ and vLcta'tcrw 

f IF DC*TH OCCUBS AWAY FROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER 'SPEcA^L INFORMATION' \ \ 

^ .r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E E^ A N D N U M 8 1 R ) \ 







|] 



FULL NAME viaAMiA.-y 



:\«iw 




J ( 



■<xX>^JJi\). 



.,m,. 



CrtJ'UL 



PERSONAL AND STATISTICAL PARTICULARS 

UAT}-; <>!• niUTH C 

'M<»tirii> (Day) (Vear) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)I-:aTH 




AGK 



1 



) 'r<i > . 



11 



^ /.'>,/// s . 3.0 



/><n 



^iN<.i,K. MARK n:i» 

WiDnWKI) OK I)[\ OKiKI) 
"Wriffin mh-jmI «k-^i>rnat ion) 



HIRTHI'I. \CK 
(State or iMiiiitrv 



namf: (h- 

FATm;R 



'!iK riin.ACK 

*»' I ATHKk 
^t.ite nr iouiiti\-) 



MAII)1:n NAMi- 

"■ M'>Tni-:k V 






(Uny) (Year) 

I ill-kliHY Cl'RTII'V, TliMt i atkn.kd ilcceased from 
LiA.^ua ^H up'* tjj Ojl^ :.l Tcp^ 



that r last saw li 



alive oil 




1.. 



190 I 



and that (It-ath ooi-urted, on the date stated ahow. at 1 oO 
he CAISl-; Ol' DIv 



•■ M. The CAISl-; Ol' DIvATII was as follows: 



DIRATION J'dV/o- Months i'l /A?r.v //^)//;, 
Cf)NTR IIU'TORV . X^^:da.^uJL^ ....„ 



cL(kL' 



O- VVi 



'"•IKTMl'I.ACF 

'»' ^^oTn^:K n 

'State or C<Mintrvi Jr 



k.KJx.-yymj^^ 



nrRATIOX Years M. tilths \'\ Pays Ilout^ 

(Signed ) ...LLL o , o .vol^cU vHx.»v, 



M.D. 






{ 



AddrosO lUl' U,tLiil 



'*^ •^'ii' vriox 



A^o-vi a LXiL : Lo^t 



Special Information »n!\ tor Hospitdis. institutions, iransients. 

or Recent Residents, and persons dyimj dHdy from home. 



f^'r^ii!r,f in S,ni Is ,i}i, 



1 
<4 



)■/,// . 1 i ,iA.,7///.v?>C: /;,/,, 



Former or 
Ijsudi Residence 

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



How long at 
Place of Death ? 



Ddvs 



"'■• ^'!*'^'''" ^■J'^'i"».i> cFRsoxAi, r\KTi('ri,\Ks Akj; TKt }•; To thf; 
in-.Nf oi- Mv K\»)\vi.i-;i)(,H AM) in:Mi;F 



:iiif 



"rinant 






^\.1.h-.ss 



^^ J Aj^-v^vfr^Ajt UA 



PI,ACK OF IJIKIAI, OK KI-;M(>VAI, I DAlJ.o: I!ikiai. or KI'.MoVAI, 

% Off j; ^ c, (ti 



N. B.- 



-Kvery Item of informntion should hi carefully supplied. AGR should be stated RXACTLY. 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 given in every instance. 



'1 



.1 



''I 



'til 



. ^ 




i 



mi 



^r- 



.^•u.^ 



H, ,;,,.! .)f }Ie;iltli--FNo. If ^-S^K^, H& I' Co 



WRITE PLArNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIO NS 

!)((((' hlJe(l ,.Ajl}^\Xjl^^^ ^ 19 ()\ Be g 1st c red A'o, 1 5 1 *T 



cL-^r^^A-AyQ ci 



Deputy Health CfTicer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of H>eatb 

( "a. S. Stan^arO ) 



PLACE OF DEATH: — County of LcJCa.^>J2^ v<X ;.. 



City of 




CX/^vw 



1 f ^ 



No. 



St. 



Dist.; bet. 



-and 



/ \r DCATM occuns *w*v from USUAL RESIDENCE give facts called for under "srecial information \ 
V IF death occurred in a hospital or institution give its name instead of street and number. ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

M-Ar'Jj^ ft [ COI.OK 



DATK <»l III K Til 




1_ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATH 



<^ 



\< 



I Month* 



ACK 



) V.7 



<I)av) 



v.. ;,///.. 



A^OH 

(Year) 



(MotWh) 



(I)av) 



I go 

(Year) 



I HKRI'I'.V CivRTrFV, That I atten.kd .k-rcased from 

' -Tgo — - to .- 



that I hist saw h n:~ alive on 



Dav: 



"-IN'.I.K. MAKKIi:i) 

W IDOWKI) OK DIVOKiKI) 

iWiitrin sfK-ial <l<<i>.'iiati<>ti ) 



HIKTHPI.AOK 
■Statt or CoiintrN 1 




NAMH Of- 
HATIIHK 



KIKTHFM.ACK 
ni lATMKK 
'State or Comitry 



^tAIDKN NAMK 
"I MOTHKK 



niRTlTPI.ACK 
'•1 MOTHKR 
'State or Countrv 



oCCrPATlON 

f^^^nffd in Sail /'i iiiu ism 









-190 
T90 



and that death occurred, on the date stated above, at 
M. The CAUSriOP I)1{ATH was as follows 



W>\.o,e.Ar\jiCL^J.. 




I i>» ««••!* »•-•->•■. ■•*i>*'>-(*.>»*>«*>«*<li««*'s*«i>«4*i««- - 



DTRATKJN Years 

CONTRIIUTOKV 



Months 



Da I'.v 



Hours 



■ ••»».»*♦•*•.•♦•*+ 1 



Years 



DURATION 

,NED)...oL y^- W 



(SIGI 



Months 



Days 



//oun< 
M.D. 




^.^..^■\^■ 



iqo 



I) 



^ ' ^ ' ■ •- " ^^ddr^•ss) LlA\x3i„i(. 

SPECIAL INFORMATION only for Hos|]«idls, Inslitutions, Transients, 
or Recent Residents, and persons dying away from home. 



)■,-,?/ 



M.uiths 



Ihiv. 



' "V- M!<^VHSTATKI) I'KKSONAI. I'AK I" KTI.A KS .\ K l-! TKlK To THH 
lll'.sroi- MY KNOWIJCDCH AM) Hi:i,n-:F 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



. Days 



'I 



"f-.,,nant LU yJ(JUw^/-^v \A,^><jL. 



T 



Xddrcss H I ULlxTyXXO) Lol/\'>xAx! ^''^. ^ 



PI,\CK OF Bl'RIAI. OK KKMOVAI, I I)A'|F: of UrwiAi. or KKMOVAI, 

rXDKRTAKKK H^\aJLaa«<^ Cj . vJ O-OXO-aa; 

(Address ^D^ ^DXcr^k^qL^U Ll:\»v.t. 



4 



IN. B. Every item oV information should be carefully supplied. AGE should he 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 i^iven in every instance. 



•\\ 



i? 



i;;: 
nf 







t 



,r'Nr- 




lifil 



■^s^. 



'■fsk^.:: 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

nn.iid of Ikaltlr 1' No. i^ ^-f^^i UScV Co 

'-^^ — REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfff 



r Filed, A 





Dep 



n loo'i 



Ecginteved J\^o, 



1518 






\' Officer 



DEPARTMENT OF PUBLIC HEALTH-Ci(y and County of San Francisco 



Certificate of IDcatb 



i 



,D 



PLACE OF DEATH.— County ofOa^ J/^^^^^ city oi'^ ^.^ ^c.^^^ 



■Hi 






.\.(xXj L 



»\XXqMvcu ^ 



'C^^ll^J 



^■'Su 



Dist; bet. 



/ ir Dr«TH OCCURJS AWAY rteoM USUAL R E S I DENCE G1 VE TACTS^CALLFD fop .,Mr>r 
V IF DEATH OCd^RREO IH A HOSPIT*. OB . k, «t .^.XT^ J \. ... *^I! ^.Vh/i" '^° " " '^ ^ *^ 



and 



.0 ,^ . „„sp„.. o, ,.sx,tut7o.v,vT ,;j nVm. ,;°s;."r^r sT%%%T.\'o"r:='^;," • ) 



FULL NAME 




Lu 0^.. . Cj/(^ayYvI^-l^, 



si:\ 



WJU 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR \ . 

DA ri-: <•! IlIKTII 

oJlt /IXI 

''^'"»"'' _ (Day) (Yeiir) 

\ i '. K ~~ "- -^ — 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DlvATH 

(Day) 



(Mont'h) 



(Year! 



T in-RI-HV CI-RTIFV. That I attendnl deceased from 

— up to 1^ — 



cx,\ 



^\ inoWKI) OR DlVoRiKi) 

'WritL iti s,Mi;,l il< siirnati.Mi) 



BIRTH Pr,A OK 
'State or Coiimrv) 



>JAMK OF 
I-ATHIIR 



RlRTliri.\,K 

<>'■ 'atiihk' 

'St.itc or I'l.iujtrvl 



^TAII>i:\ NAM).- 



M.-ulh 



Pa \s 




X.' x/x^\^\y 



vVLL<x->a c^ 



that I last saw h rrr*. alive on — , . 

and that death occMirre.l, on the date stated above, at 



Q^ M. The CACj^K OV Dl^ATII was as follows 



~i(yo 



.C).aAw<^^v./<:Jr. 




A 



/ 



niRTHFl.AOF 

oi' M«)Tin.;R' 

'^t.'it< .,r Countrvi 



OCCf 




DTRATIOX 
CONTRIIU'TORV 



) 'cars 



^ <^<X^v 

Mo fit /is Days 



//ours 



DURATION 

(Signed) 



JA± 



)'t'ars Jf<>n(/is /)ars 




U)0', ( 



(lud 



s, Institu 



//ours 
M.D. 



Special information only for Hospltdls, Instilulions, Iransienfs, 
or Recent Residenis, and persons dyinq away fro.-n home. 



f^'^si,fr,i n, S„„ /■>.,„, nr., 



)V,r> - 



U,:j///r^ 



n,iy 



Former or 
Isual Residence 




>Ax<rLA.r>-w 



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



HoH lonq at ^ 

Plareof Death? v* Days 



''''''^■^^^''y'^i''P^^ T..K I I^ACKOF HIRL^LOK RHM<.VA, I LA i^K .f MrK,.,. or R KMOVAI. 



^'"f'MllMIlt 



\,^JU\; 



U-Mrc 






N. K. 



VAjAva.^^^_^ O ^\J Alv I '^ -2-^^l. I 1 90 ' 

I • N DK RTA K H R M 1 1 vj <XA. rL<. > \J)f ^UJ AjtOAt^, ^^ O KSU^^, 



riHT/ciu^E^OF^nTri^^^^ ^" carefully .supplied. .AGE should be stated EXACTLY. PHYSICIANS should 

"on. dyinfi „ "r. T" '" P'"'" **^''""' "^«* '' """y ^"^ properly classified. The "Special Information" for p,r- 

» «>inft away from home should be given in every instance. 







m 



14 

"I 



14 



i 



( '1 



.^ 



ft! 



I n 






WRITE PLAINLY WITH UNFADING INK 



r 



f Ik:tlth-'KNo. K -fr-^}*;^ H& l» Co 



/)nf(^ J'V/ef/,nJL\<tLrry^Lji\j 



.trv\.<Mi 




D 



i^6>^ 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

i5l9 



Begistevecl J\'*o. 



■\»^\. 



V 



Deputy Health Omcer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 

( "U. S. Stan&arC> ) 
PLACE OF DEATH: — County of 3,a.>^ O^ux.^^ ^ ^ 



No. Ldu/V L' 



% 



City of CJ/Ctov J A.O^-i- 



^.'i^.i,!;'. 






<rv\^xtu Lllnvi.',\KL;_v St.;— — Disfbet j 



) 



FULL NAME 



L'Lt\i , cLcLrv'v.Q. 



PERSONAL AND STATISTICAL PARTICULARS 

si-;x A 



flwL 



COI.OK A 



"All-: OF Mlklll 



.\r,K 



k 



M')iit)i I 



MXcLlcrvv" 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol-' DHATII JJ 

Uxki 



(Monlh) 



? 

(Day) 



(Year) 



-^^. 



n 



us 



• n.'iv 



Mxtilhs 



(Year) 



^IN«.1,H. M ARKIKI) 
WjDnWKn Ok DrVoKCKi) 
i^^nt-ui s«HMal (Icsijf nation) 



ti'Jrnipi.Ari-: 

tSlatf or <,"<>iiiitry 



N'AMH OF 

J- ATI I J. :k 



Pil \s 



X-^TL OU X CX\lL<X *wAA.^ 




I IIKRKIJV CKRTIFV. That I attemlea deceased froii, 

*^^^ -^ 190 '^ to dx^t...!.: n)o H 

that I la.st saw h^ alive on J JL^-Jl L up 

an.l that death occurred, 01. the date state<l above, at S 3j 
4^.M. The CAISJ.; OF l)j;.\TH was as foll.uvs: 

iX<^vvU, "dUrv>-a>v....y/>vU.v>^ V ^ , ... 



^x<x 



'nkTHPI.XCK 

'V iATin-:K' 

ISlrtff or Coniitrvi 



MAIDllN N\M,.- 



':il<Ttll>i,ACK 

;m mi>tiii.:r 



1)1 R.ATION Years 
CONTklUrTORV 



Months ll Days Hours 



^^ 



f^ 



DI'R.XTIOX 



Years 



Mouths 



Pays 



(Signed) \.C t^. C(r> 



\A.^X>:u. 



"0^ 






ci^.^vtr...1>. 



TQO 



( 



Address) XhJj\^\A.\ 



I /ours 
M.D. 



l^^\A. V \,MA4.' 



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



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



llnfc 



(37^ 



inintit 



at 



i\ 



y^^^\\.^\.Kji,i. 



ri^ACK OI- lU-KI.AI, Ok RIvMoVAI, j DATI-^,.; liriuAi. or K1:m<)VAI, 



X^.^^^>^XK^ l)^ ^ I '^^^ .U.. 190H 



im)i<:rtaki':r 



N. B K 



I 



(Address 3 (oa.Ja, v IS JbJv '.M. 



:>V-- 



•trt^c'ru'^E^OFDFATH" '*"?''' ''' ^"'•«f""y «"PP'i-'. AGE should be stated OXACTLY. PHYSICIANS should 

«<>"« dylnft away from h '" u'^'t fY'"^' "'"' '* *""* ^^ P''«P«'-'y classified. The "Special information" for p.r- 
j HB away trom home nhould be jjiven In every instance. 



tif 



% 



i 

i 



ill 



v^ 



WRITE PLAINLY WITH UNFADING INK 



lio.iid of Ik.iltli-K No. K '^'i:'^^^ IKtP Co 




lOO'i 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIHCATE FOR (N STRUCTfONS 

Registerecl J^^o, 



i5l9 



frvv«w<> <*wJi"LK^^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of H)eatb 

( "U. S. Standard ) 



-? 



^^ 



A 



^ 



^PLACE OF DEATH:-County of dc.v X.vcc. Gty of 0,0.^ kcc..^.. 
No. ^CLjL X L<rvv>xtu LI t ^^vi. ', \ ^u^. i.^ St.; Dist • bet j 



.«./,- """ UNDER SPECIAL INFORMATION" \ 
lAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME ilk Ic. , . 



O 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



>i)uL 



CDI.Ok 



!' ATK OF niKTH 



ACK 



It 




^kk: 



MEDICAL CERTIFICATE OF DEATH 
DATK (»1- DKATH U 



^X<X.^^V\i.t)LV'V%.it4. / 



Sxkt 

(Monlh) 



.1 

(Day) 



igoX 

(Year) 



M..iithi 



1 }V,;/. 



'D.ivl 



Moulin 



fVear) 



Ar 



"^f^'I.K, MARKIKI) 

U rnoWKD OK I>t\t»KCJ-I) > 

^Wwu- It) s.KJai (h-iit'uation) 



HIKTMlM.ArK 
'Sfatf or Coiititrv 



N'AM) Ml 
'•ATllKk 



niRTllPi.ArK 
'>' J ATIIICR 
(State or Onuntrv) 






i:iK rnpr,Ai"i<* 

'^t.ii. ,,i (."omiti vl 






I illCRIUJV CKRTIFV, That I atteiKlcd (lecease«rfronr 

lAwq ..XI 190 S to dx^t.J,. icp '.. 

that r la.st .saw h .. alive on dxl^tA- C ^^ 

and that death occurred, on the date stated above, at S 3j 
.^r. The CArSK of DI-ATII was as follows: 



D I R A T I () N ) 'cars Mo^Uhs 1 1 Days Hours 

CONTRIIU'TORY 






J^^- 



^- 



v^ 



DCRATIOX Veens Mouths Pays 

(SIGNED) lU... t?, VCr^vdlcu.ru 

.y.^.KA^...l rr.n (\AAr...<.\ LaX\'V\A !^-«K.'.C>:. 



Hours 
M.D. 



).^:^a;^.. . I rc,o 



(.Address) 



'*''•■' I'VTioN^ 



■J A_A..A>Ct. Vj <^ ^ 



Special information onl> for Hospif^ls, Insfltutions, [ranslents 
or Recent Residents, and persons dying away from fiome. 



) ') a I 



Mnulhs 



\ I 






Former or 
Isual Residence 

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



How long at 
Place of Death ? 



.. Days 



^\»l(l 



rcs.s 



■^hi^m 




.\..\i_i. 



Vl^ilV. in- lUKIAI, OR KI.:.\J()VAI, I I)ATl-oJ JJrHi.M. or Rl-MoVAJ, 

OXvA-L^^ l)/oJjlI I I'^-M^z:!^ 190H 

r.N-Dl-KTAKHR JSoXiu. ^ it <X<1.13^^ 

(Address O W..a^.. I S. Jti ^.dl 



«^rt?cTl^E^OF nTr^H" *''7''* ''' carefully supplied. AGB should be stated CXACTLY. PHYSICIANS should 

«on« dyini awar ffi^ I '" **!"'". *'"''"'' *''"* '* ""'* ^'^ P'*«P«'''y classified. The 'Special Information" for p.r- 
y HK away trom home should be ftiven In as^ry Instance. 






n 






■1 



'^ 



iM 



1^ 






11 



IN I 



I 







4 .. 



)l(.:ir(1 nf Ilcjiltli - I- No. i?; '**?^^^i- JJ&P Co 



WR.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

A REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

'""'' ^•'{'•'^ Q-M^tt^vUv 10 190H ReMsfer.d A^r, 1 5.30 I 



1^ 



Deputy Health OfTicer 



DEPARTMENT ^\ PUBLIC HE ALTH-City and County of San Francisco 

Ccvtiftcate of Bcatb 

( "CI. S. StanDarD ) 
PLACE OF DEATH:-County of'V.J'Lcuw.:^.c.-.Gty of^<X^1^/vavvc... ^ 



No. 



.. lUn^l^a.^ 



St.; 



Dist.; bet. 



1 



^ 



and J .U 



f ir DEATH OCCURS AWAY FROM USUAL RESIDENrTriur r.,.,-e. ^ 

I .. DEATH OCCURRED .N A HOSP.AL O R^ f J S^^^^T^ O^.' V. vV ^T I T.T. .Z^ .\IT. ST^^^I^Vd^ ^ : ^^ ^ ) 

FULL NAME lltcx-rxtcu IL^cbucxcl... 



<'\X: 



PERSONAL AND STATISTICAL PARTICULARS 

I>ATi: OF 1!IRJ-M 





<I>av) 



\(".F. 






^ 



.!/.»»///// 



u in«nvi:i) <»« FnxnkrKn > 

i^\Mt. in wxial fk'sijfiiatioti) 



(Year) 



/>,n 



MEDICAL CERTIFICATE OF DEATH 

DATI-: <)I" I) HAT 11 JL/ 

DM. 

(Monni) 



(Day) 



(Year) 



lilK I'Jn'I.Ai'l-: 
Statf or Coiintrvi 



^"\^t)•: oi- 

fATllKR 



rnkTHI'I.xcK 

f" 'atmkk' 



<'i M<)Tiri.:k 



^' ''• 'I *"'MIIltlv) 








I HHRHHV CHRTIFV, That I atten-k-.l .leccaseif frniir 

f^-^^' 190 '1 to ..Qx^ 1 ,^H 

tliat r last saw h .v)U^i.'....alive on QJL^xX j^ , 

an.l that (U-atli occurred, on the date stated above, at S 
^J :vr. The CArSI-M)F Dl-ATII was as follows 





1)1- RAT I ON y,'^rs Mouths 7 Hays Hours 

CONTRIDrTORV \X\xJ^'\a, d4vw.>.>..:a.L C^.^eXjo^^ 





DlRATrOX I Years lo Months Pays Hours 

(Signed) WW- \ V > voLVA^.^<. • m d 

O^A.' . T()o'i /.X.Mress) 16H ^<yl-^^,^. \i 



Special information only tor Hospitals, Insfitufions, Transients 
or Recent Residents, and persons dying away from fiome. 



1/,./////. 



iht\. 









Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



''(1t\T '^l '''.[5'-^'- '*'^ Kl-:M<.VAr, I l^^JHu! HrK>AL or KK.MOVAI, 
fcxrWl;V^-<L4. ^ _ I g-^>^...... LO I go 






rXlJlIKTAKKK 

(Address 



ax^. 



3 b 5 




..d. 



.\S;k. 



«ra't7cru'"sE^o"F nTr-i-H" '''?'" ''^' ^"--"^'""y HtiPpUecl. AGE should be stated EXACTLY. PHYSICIANS Hhould 

«'>n8 dyl„4 awav^ ffin^I '" "!"'". f^'*'"''' *^"' '' '""* *''' properly classified. The "Special Information" for p«r- 
y ng away trom homu Khould be feiven in every instance. 



) 1.1 



|# 



I 



^J L 





it 






^_jjiji}ii 



l^r WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

i;ir<l of Hi-iiltli— I' No. I', '(•'■f'^i'^ynfk.]' Co «, 

' I . REFER TO BACK OF CERTIFICATE FOR INSTRUCTION S 

/Ju/r F//n/Ax\^Uy^Jst^ ID IfJOH Registered ^k 15^21 



d^..{^VA.v^ duu^u Deputy Health OfTicer 

DEPARTMENT of PUBLIC HEALTIWIty and County of San Francisco 

Certificate of 2)eatb 

( tl. S. Stanftar? ) 

iC'O^v 3 AXXa\x:aA-c<. City of C'xXo^ OXolvvc^.^. r < 



PLACE OF DEATH: — County o 



No. 



uIajl 



FULL NAME 



^t^ 



v.... 




) 



) 



/yy\jj^ 



.\ . 



■-Jix 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



DAIi; <>i- niKTM 



[)l< 



N 




X}.T^KJJL 



'Month) 



11 

(D.ivl 



\<.K 



r 7 /J 



) itU 5 



JO 



v 



'•lllllK _£>_ 



«IN'nr.K. MARNIKl) 
WFlM»\yHi) OK l)i\-()Kr|.;i) 
\\ Mt» III social <l(sij.rjiatioii) 



/ 1.5C 

(Year) 



Da\s 



MEDICAL CERTIFICATE OF DEATH 

DATK OI' I)I-;aTH 



(MoiitA 



4^' 
a)av) 



IQO \ 

(Year) 



A 



I nivRKHV CivRTIFV, That I atteiKk-.l .leccased from 



lURTHPr, \CH 
Statt or I'oiintry) 



N \M1- ni 



lUkrniM.ACF 

'" lAIHKK 
"^tatf or Coiiiitrv 



maii)i:n- namk 




,cLcrc*J--< 



.ax.^....b.... 



190 H 



4fl 



S-^-^t a 190S to 

that 1 last saw h i-.i^.v...alive on ^.*^^.u<w v loo 

and that <U'ath occurre.l, on the date statc<l above, at '^■^b 
^^ ^M. The CAl-Slv OF DEATH N..is as follows: 



>A/ 




DC RATION Years 
CONTRIBUTOR V 



I\/o)ii/is 



Da\ 



:'S 



Hotirs 



OI- mothhk' 

'•^Iril. or Coiintrv) 



OrCT'PATiox 






DURATION ^ Years .VoNt/is Days 

(Signed )....Uj . . b. L (r yvta-»v 

a-^|\t;..(^ IQO' I (Address) UX>a^\^i.<V-i A.^i.A. 



Hours 
M.D. 



cl.<x,iLhCA„«-N 






nrf ^^'m'-J'^T^^'^'^'^'ON only for Hospitals, Institutions, Transients 
or Recent Residents, and persons dying away frorn home. 



)V, 



■|M 



MnUtlf 



fhlV 






Former or 
L'sual Residence 

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



How long at 
Place of Death ? 



Days 



' IiifonDatit 



fAdtlress ... 



LL(av\aM 



'civ^»r>nucti xS^xA-yX 



\.'^u\.AX 



N. B.- 



I1.ACK OF m-RIAI, OK RKMOVAL I ^^^'^^-^ MfKML o, KJvMOVAI. 

C)A^-\^./:^:w__L,aA,._ I -gj-y[;vt< i.Cl i Qo^4 

rXDHRTAKKR JUJUU. ^\L Ob O-a-o. > 

^\dclrrs. .S.t.^a- ia.jLL...C)l 



ttrtTc'rUSEof dTat^*''?'^ '^^ cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 



I: 



"' 



-ui 



^ 



'■A 



' *'•'" 



I 



*«„ 



'^'^wlti' 



III 



.,># 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

H...'ii(l .if llt'jiltli— K No. 1^ 'S^^'^jJ^ J{^i» Co i^ 

=^— REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



I)((fr /^V/^^^ d-£.^\<ljt-v-^AiLe.\; IC 190 






i 



-\ 



Registered JVo. 






1 '^oo 

-J •>'^^V' 

trVA^ui cLj^vki Deputy Health Olffrcer 

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

dertiffcate of H)catb 

( "Q. S. Standard ) 

^ % Si i-^ 

I^"^ ""^ I^EATH:-County of 3^.v 3 .W.xc.o ccGty of dctvv Iva . - ...c. 
No3.i ^,Lu nV l^V.-/..- St.; Disfbet— .a 



FULL NAME 



.OL^ 




siU .Lt V ^ .. 



PERSONAL AND STATISTICAL PARTICULARS 



m;\ 



DATK (H HIKTH 




COl.OR \ 



lua 






I Month) (Day) 



(Year) 



A «■,].: 




:<...-a^s 



) '/'<; / 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DHATH ' 

3x1^1: - , , 

(Mon^h) ^fD^) ^^^^^^ 

I ilKRKHV CI.RTIFV, That I attended clecc^sedl^ 

190 ■ to 



roni 



e on 



Minilhs 



Ihns 



U IDnWi:!) ,,K I)lV()Rii.(, 
^\ iit»- III s,K-i;iI (I.si^nation) 






HI K Tin' LACK 
state ,,r Coiilltrv) 



NAM}-; (>|. 
'•ATIIKK 



hikth it. ac k 
<>'■ i-atmhr' 

'State or Countrv 



11 



UXAAAi.dL_ 



MAIDKN XAMJ-- 
<U- MOTFIKR 



»TRT!Trr,ArK 
<)l- MoTiu/k' 
'Stat,- or CoiMitrv 




that I last saw h .7— aliv 
an<l that death occurred, on the date stated above, at 
~ M, The CArSlv OF Dl^ATJI was as follow* 

Lu. 



"190 
"190 



vt\.u.")A.<xiurv \.., |vrv\v . ^Xxh':r^:\\x^A,L,t^x. 



Dl' RATION Years 
CONTRIIU'TORV 



DURATION 



-CW^OrVV^^ A 



Monlhs 



Days 



Hours 



Hours 
M.D. 



'"'^''"""no^ 



years. Afouths Oavs 

( SIGNED ) IfrUvav J. li.llj.. .ItL^-vdl 

:...A.^^\L. i K^o^ (A.ldress) {.HXt's ■■■.■.,\ 5 v)l^ 

„ fP^^'flL INFORMATION only for Hospitals, Instltuftens Transients 
or Recent Residents, and persons dying anay from home. 'ransients, 









) 'I'li I \ 



Mniilhs 



fhn. 



'"'^^^'i^^^Yi:!:^^:!:>^^]£^:^^^--^^r^^'^ •.•,. .■„,. 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not d\ place of death ? 



How long at 

Place of Death? Days 



fu 



^Inf.nn.a„t U-Vtn\XV^ ^ it 



.':1L*». 



'^A'lflress .. —■ 



N. B 



i:xi)i:ktaki.:k la^t^A:>.u;t U^v<iL^t^^^^ • , 

1<lressJ....^i.5...(?.c^^^V.:J..L f 



(Ac1< 



MaVe^CAllE^OF dTa%^^^^ ^'^ carefully Huppli.cl. AGE should be stated EXACTLY. PHYSICIANS «h„ .H 



' i:.': 



'.1»^- 



' 1 



'*^-*-L.. 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

I!, ..ltd i-f Hcriltli »•' No. i«; '^'^^•^■"■i^.liSi.V Co 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/>rf/r I^y/e(/,njOpXxr,^yJj^^ 200<{ 




K^\A 




Registered JVo. 



1 5'^3 



f 



Deputy Health Omcer 



DEPARTMENT Of PUBLIC IIEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "CI. £. StauDarC* ) 
PLACE OF DEATH = -Cou„ty oAo^ i^vc^x^c. City of ^ CX^'^ K.o....,u^, 

( - ^V..\ OCCURS Aw.v .ROM USUAL R E S . D E N C E c , V E ..'o^^'}^^* ^■^K^<K and 111 

V IF DEATH OCCURRED .M - o«o«r,.r Ti" T.' r5_ ^J" ° ' ^ ^ ""^CTS CALLED FOR UNDER "SPECIAL INFORMATION' 



Q^ 



IVE FACTS CALLED FOR UNDER 

I GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



FULL NAME 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR ^ ^ ^ 




) 



IXKJUl. .Uj^^^^^^ 



J-iAWCU 



K 



!> \'ii; Of ItlKTM 




(Month) 



AC.K 






( I ):i V I 



Mnulfi 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DlvATH '~ 



(Moiini) 



a)ay) 



(Year) 



I IIHRHUV CHRTIFV, That I attemlea"de;;;a;;;;rf,^n, 



That 1 
If) .O. 



^^rvC.T.R. MARKll-:!. 
W IDoWKI) OK I>!V(»Rri:i) 
W'wXr in social d.si^Miat i<.n ) 



nrKTFTPI.AOl- 

^tatf or Oonnti v> 



VAMI-: Ol 

• Aiiii'k 



Da vs 



RIRIIIIM \K^V 
'V" 'Allll.-.K 

(Statf or (."onnli v") 



MAIDKN' \AM1- 
Ol- MoTilKK 




dji.^t^ 



^ I90H 



190 



^^^^^-^: •'3>.l 190 ; 

that I Inst saw h ..-' . alive on 
an.lthat.U-athocci.rre.l, on the .late state.l above, at U-4S^ 
^ M. The CArSl.; OF Dl.lATH was as follows: 






C-CA-c^n^xcu.. 



'•f'^^as^.ta* 



^ o-r;^-;- •• 

nr RATION .1. Ycai 



"XXX/W; 



c 



ONTRIIUITORY ■■■hAjxt^..L^^,cXM.^^lu^^ 



liiurripr.ACF 

oi- .Moth J.; k' 
(Staff or Coiititrv) 






-ft<l:V^ ,... _ 

''''^■^''^'^^ ^Years' Months Days Hours 

(SIGNED) tltU. d.a_L^.L. 

QjL^A.il TQO ■ 



( 



M.D. 



occri'ATi,)x( 

/i \r\ *. . _ ^ r - I 

AVv,/,v/ /;, ,v„,, /-la,,, ,\r„ \X y,;, , , 



(A(l.lress) log ^fc O^aki '' 

„rf ^^'^'-.''^r^'^'^'^T'O'^ ""'y f«'' Hospitals, Insmutlons, Transients 
or Recent Residents, and persons dying away from home. 'ransienrs, 

Former or 
Usnal Residence 






lA'/////. 



/',/! 






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



How long at 
Place of Death ? 



Days 



(Inf. 



'•niant 






.•I.ACK OF niKIA,, OR RH.MOV.M. I DATK oMU k,.,. or R KMOVA,, 



fAddress lllL 




...^l.i 



»r,7MVrsE'opnTA"Tr*^"l'' '•■''""'■""'' ""^^^^^^ AGE »h„„M he «l„u.l EXACTLY. PHYSICIANS »h„. IH 



'i 



Hi 



* 



(■■ 



•'I 

I; 



i 



^M 



• t 



M' 1,11(1 of MciiltJ) - I' No. 1=1 ^^i^^^ 158: I* Co 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

"gfCR TO BACK OF CERTIFICATE FOR IN3TRUCTI0N3 

/>a/, /'V/../,i)*'pt^^vW»v ID WO^ Registered J^o. 1 5.^4 



dwfrvcvi (Le.\H| Deputy Health Officer 

DEPARTMENT t)F PUBLIC HEALTH-Cify and Connfy of San Francisco 



Certificate of H>eatb 

( XX. S. Stan&arO ) 



PLACE OF DEATH:-County of -l^^ IW^U City ofllUvctt^^ 



No. 



t 



Lai 



St 



f \T DEATH OCCURS AWAY FROM USUAL RESIDENCE GI 
\ IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION 



FULL NAME 



- Dist.; bet. - and 



SK 



PERSONAL AND STATISTICAL PARTICULARS 

■■'^ \^ \\ \ cor,oR > 



:i 



DATH or JtlKTH 



(Mouth 



ACK 



^^IN'f.T.K. MARklKI) 

w ii)(i\yi-:i) (iK ni\(>K( Ki) 

Write- in M)ci.il <lfwivr„;,tioii) 



mRTni'i.AOK 

Si;itf or Coinitry) 






'■■IKTHIM.ACK 

'>'• I apuhk' 

'St.itf or Country) 



MMI)1:n NAMK 
UF MOTHHK 








■vX-.-iw-.J! 



^UU^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH 



ixkt... 



, , a 

(Month) (i,3y) 

I HHRICBV CKRTIFV, That I attemU-d .Ic^enl^^rf 

■ n 90 — 



(Year) 



mill 



■to 



that I last saw h - — alive on -— — r- 

and that death occurred, on the date stated above, at 
:^M. The C^Ar^iK OF DIvATH was as follows: 



up 
1 90 



-K 



^-C^v .^... cLvx>.^ -^C^-^^^v^^s... dX^^i^va.^:^^. 



J) r RATION Vears 
COXTRIIUTORV 



Mouths Days Hours 



DTRATION Years 

NED) A. dl 



(SIG 



Mouths 



Days 



iHkTFTPr.ArK 
<>i- motmi-k' 

(Statf or Conntrv) 






■■dxjxl. ^i TQo'i - (A^lress) lilLltlvZ^. C 



Hours 
M.D. 



r> t 



«r?p^„^?J^^f "^f^'^'^^'^'O'^ ""'> '"' ""^P'^^'^' Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Fjrmer or 
Usual Residence 



h>si,f^,f i„ Sav r,n,„fs,'„^ '\ )ra, 



^ font /is 






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



How long a\ 

Place of Death ? Days 



iiiant 






(A.l.lrcss llH LclcLu ^t 




jV t\ m-, 

«tre*'cAu"sF'oP^nTr;^^^^ AGE «hould be stated EX 



r^.ACE OF lUKUr, OK RHM..VAI. D.U^^ of niK..,. orRKMoVAI. 
(Address kl^t CdlAi^.. .It 



son 



te CAUSE OP DEATH !n ^il- * ^"'"■""^ «upp„eu. aud snouiu be stated EXACTLY. PHYSICIANS should 



i 



i: 



i{ 
'11 



i 

i 






Pi 









f^* 




1-^. 



r^^^- 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

H";in! of Ilfiiltli !•■ N'o. K 3>i^^^5S^5i;^ USiV Co 

RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)ff/(^ /'V/^'^^ .Q.^^Jl.T^^J^ jO. lf)0 



H 



6^iry^\j^ .xX\hv Deputy Health Officer 



Registered JVo, 



1 525 I 



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

Certificate of Death 

( Ta. S. StanSatd ) 
PLACE OF DEATH:-County ofa^^JixaAvccACt City of Icu^x'^ 



No. Ibllv ^t ^^K.iv.la' St,:.— Dist.,bet. 

ALLE 

lAME INSTEAD OF STREET AND iTuMBER 

FULL NAME LLca^l ujx>\ 



and 



( " "•o;»:^ic"c".v.ro',^-:o".^.r.t o%^f-;^i-f^>:f,;«T™.° :--- :—«^j:— :•.<>»■■ ) 



PERSONAL AND STATISTICAL PARTICULARS 



si;\ 






COI.OR -w 



DATK OI niKTU 



il 



LL^^^VvAvc'Uv•^v / 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

dx^ - 

fMontii) (Day) 



igo 

(Year) 



I Vluntli) 



ACiK 



cU^t^ 0,5^ ,,.,„ 



(Day) 



M.'titliy 



(Vear) 



^vii)M\vi.:n OR i)ivMR( HI) 

\\ Mtt Ml MK-ial (Irsijfnatioii) 



MIKTiflM.ACi-: 
'^fat* or Country) 



Days 



A/^X( 



N WW. OF 

KA I hi.:r 



"IKTMI'I.XCK 

OI I athkr' 

(Slatfor Coiintrv) 



^lAJDHN XAMK 
<»l- MoTHKR ' 






U 



^\ \\VA<VM\ Cl^RTIFV, That I atten<1e.I deceased from 

•Igo V to CJ "Cjijt Jl. iQoH 

alive oil d-LJ.\^t7 1 j^y <^ 
an.l that death occurred, on the date stated above, at ?> 
^^ ^\i T^c CAISK OlvDivATII was as follows: 



..^:1w.v..\.\; ..4.. 

that I last saw h 








Wi^rvtrvv-cctv^. 



.x^„ 



'iu^e^. 



f 



.^^i5-a,ia 



t 



. »_. 




DIRATION S . 



^%f^ /TAj/////^. .....nays 

CONTRIIUTTORV Lii.vLlvv.il..u)i 




Hours 



^"^va- 



inkTiipr.ArF 
<»|- MoTin<:R' 

'State or Country I 



1 

CI 



nrRATrON 2, Vcars Mouths 

(SIGNED ) ljx4i.kL.kLuxii^ 



Days 



ax.iA.t 



Hours 
M.D. 



iqo'i (A.ldrrs^) 15M- S\/^ 



^^>-A^ 



nccrpATiox 



or Recent Residents, and persons dying away from liome. 



"^^^i^^^^^^^^ 



Former or 
Usual Residence 

When was disease contracted, 
If not 9X place of death ? 



HoH lonq at 

Place of Death? Days 






(Info: 



ni;i 






VLM:K of HCRIAl, <»R RKMOVAI, I D.VTl.; of Urni.M. or RHNKAAI. 



(^^'Idn'ss 



INDllRTAKKR 



\) ilatx^ Co 

(Acl.ln.ss...J.k'll:...iaA..ll: 



vt m 



190 H 






rtr/cAl"sE'oF dTa"t^^^ I"' '"""'"."*' f""''"-'- ^^f^- «»^-'" »>« «tatecl F.XACTLY. PHYSICIANS «houId 



m 



5j 

r 






i. 



< i 






I vl^'» 






i 





WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

)!.,:i!<l ..(" Hi'Mltli - l" So. J-; "^-f^^^^i r.S: I' Co 







REFER TO BACK OF CERTiPICATE FOR INSTRUCTIONS 



16 IfJO'i 



i<M.vu itoNu Deputy Health OfTlcer 



Begisteved J\'*o, 



1526 






DEPARTMENT OF PUBLIC llEALTH=City and County of San Francisco 



Ccrtiftcate of Bcatb 

( "U. S. Stan^nr^ ) 



c^ 



Vl.KQ^ OF DEATH:-County ofa<x.x, 'Ja,Cc.v<^.c< City of dcvvv J;v<X.-._a^v. . 



No. lO.^ 



a. I\ 



/ IF DEATH OCCURS AWAY FROM USUAL R E" S I H F N r r ^ . ^^^^** ^^* ^ ^^^ 

I .r OEATH OCCURRED . nTh o'^S^PyTAL o"r"n S ' ^JVf O N ' ' '"""'^ "^^" ^°'' "'^°'"' 



GIVE ITS NAME INSTEAl 




and 



SPECIAL INFORMATION 
F STREET AND NUMBER. 



FULL NAME ^ JUy^ssy^KX XJiXxXA. 






--i;\ 



PERSONAL AND STATISTICAL PARTICULARS^ 

I COI,OR 



vJjeywA oJui 



X/V>v 

l» \'\'V. «'! r.IK Til 




\("K 




AVi ... 

(3ft()iitlil 



1 rl^i) 

(Day) (Viar) 



MEDICAL CERTIFICATE OF DEATH 

n.\TE OF DDATII 



«..« dxkt 

(Montii) 



\ 

(Day) 



(Year) 



5'i 



) 'ra t s 

^IN<".I,i;. .M.\KkIi;i) 
WrixtWKDnK DIVOKiFI) ^ 

"^^ lit.- in ^O.-i;,] .l,vij.r„;,ti,,„) 



Moul/n 



1.. 



t>aM 



fHKTHPI.AOK 
(State or Country) 



NAMM OI- 
f'ATii j;k 



lUKTlfPr, \(V 

'>'" i\Tni:i<' 

'^t:itc or Comitiv) 



JJ .-lcUtlo-ccI 




uo. 



-cL'vw.^^^^^k^w/cL cLiAA^^^^ 



I IfKRHBV CI-F<TrFV. That I attcuKd <lccvased from 

^^-^^^ '-^ i9ot' to ..djL^. :t^ j^s 

that I last saw h .': ahvc on B JO^fe....!.. j^ , 

an<l that death occurred, on the date stated aln.ve, at \ ^\ 
M. The CArSlv Ol- DIvATII was as follows: 




■vK^'Vv^X/vCtl 



V-<X^AjLnps»^flt, 

I)rR.\TI()X )xars 

JONTRIIJUTORV 





(~i 




Mo)tt/is Days 



I lours 



MAIOFN- NAMK 



""< 'IIIM.ACK 

•>!■ M<)rm.:k' 

(Slate or Coiintrv) 



OCCUP.\TrON 




I )rR AT lox 



lA^-MyvJUAv^K^ 






n 



<aaaXLVcLcs 



)'cars 

(SIGNED) ^.Jb.AJ/UX^ vlllcL^i.., V 



Months 

1 



.1 I 



190 



Days Hours 

M.O. 

i .ctvuXt .;.k 



f^rsidr,i n, S,,„ F) an, ism ( )'/,mv 



„ f ^9'fiK "^f°"'^'^"'"'ON only for Hospitals, institutions, Transients 
or Recent Residents, and persons dying avvay froni fjome. "-"Mcnis. 



Mnntli^ 



/),n« 



■'■" ".""'o^; ^is^-^i!:,i;'^:^a;;;^,^'A^;,^/,;;,;,i;?«---^ '■-■■^ - 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



• Days 



•'In I 



!0 J X, 



X'l.lress 1X1 




I'l^ACKor m-KIAI. OR RKMOVAI. I DyH of M.-k.^,. or KKM.,VAI. 

l.ai', I Ox|vt__U^ ic)0^ 



CX/-^v 




OXX. \X.r 



r 






' '~ '".^JauSF OP;7,Tr::''„7'.'' ;■= '="--'""> r"-P'-<'- AGE ,h„ul<. be ,,„.e<l RXACTLY. PHYSICIANS „h„uld 



■11 



$ 



I!, 



"I, 

V 



I 



» t 



HI 



:y 



I, II 





I 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ho.iid 'if IU;il!li- ]■' So. 1 ^ 'i"^j'^y!>^i^ USc V C 



10 



X^ruuv^ Xt-Lku Deputy HeaJth Officer 



2^(94 



Bes^isfered J\^o, 



1 *> '^ ^ 



' 



DEPARTMENT l)F PUBLIC HEALTH-City and County of San Francisco 

Certificate of Beatb 

( "CI. S. StanC»arC> ) 
PLACE OF DEATH:-County of 0<X^ J ^.c^.^vc.. ~. City oiO<X.y^J J/vct>vc^cc 



Ne. lOu. K Itrvv^xt. TO (hK '.U I St • Di.t • lv.f ^_. . 

A ( I' Ot»TM 0CCV»S .WAyIfROM USUAL P E B 1 B V N (- r , . „ , "'"' "^^^ and 







FULL NAME 



AXMuyM. 




A^..Y:\t 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 



<hlcl 



COI.OR A 



'>A ri: nc liikiii 



(Month) 



(Day) 



tVLox^^ 



MEDICAL CERTIFICATE OF DEATH 

DAT!-: (>I- Dl'ATll JJ 

uxkt i 

(Montlh) (ij.,,,) 




(Year) 






O 



(Year) 



Af.K 



A O ) V'u * jt 



r IIHRI-HV CKRTIF'V, That I attciKlcMl (Icceasedf 






M-ti/fis 



Hit \ s 



'^tN'.l.i:. MAkKIHD 
WIDoUKi) Ok DIYORi-KF) 

'\\ Mt»- ill s.K-i.i] (I« «.io^i,r,ti,,ii) 



iUUTMl'r.ACK 
(State or Country) 



'•Arm-R 



KIKTirp!,\t'K 

<>'•■ lAriiKk' 

'State r.r Oniintrv) 




^ 



\.OJ\.'\^JL&^ 



/T\, 



V'VOVCC 



^■^t^^ "^ 190 H to ..BjJ^y.1: i ,^^ 

that I last saw li alive on 0-£,.|^.....? ^^ • ^ 

and that death occurred, on the date state.l ahovr, at io ^ ^ 
•Al M. The CArSlM)F OKATir was as follows: 



roni 







(X) 

'I 



■ 



t V, V 



DIRATIOX }-ears 
CONTkllU'TORV 



Mouths Davs 






oi' Mo r HER ' 



HlRTHPr.ACF 
<»l" MOTHKk 
(State «>r Conntrv') 



1 



Q^\. 




DURATION 



CSlGNED ) 



^ 



);v 



/•\ 



1.4.1 



J^^Jw^itM,^ "g., . . L<Xr: 



Months /?<7i'f 




Hours 



loo 



.rYvnr^j^u M.D. 

(Address) bOb QAA^tUv jj 



-.n KNouij^i),; K XM) in:Mi;i 



?^^9'fi'-J'^f°"'^^'^'0'^ •*"'' '"^ "ospitdls, Institutions, frdnslents, 
or Recent Residents, and persons dying HHdv from home. 



^ 

^ 
C^ 



ray: 



M.,„n,^ 



p.' 




Former or 
L'sual Residence 

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



(1 



« {yy Howlonqat 

XO^rjiv AJXae. pidfe of Death ? 



Days 




VV. To TllH 



ri.ACK OI- m-klAI. nk ki:.M(.\AI, I DATHof JU r 



'/(xav I ricuU-^ L< 



JJL 



!IAI, or RKMOVAI, 



^H^-YVA 



N. B. 



tL (fbo^jxd^nX. 



INDICRTAKKK 




l.t 



^ 



l( 



J (>trK O <v-%x.q. 



190 V 



^■\(i<iri-ss 10b ■Jo-c^Um-C 







d-l. 



..) -.. 



"IV^t^c'Au'sE'oF dTx^H^^ !:' '^""''""^ f"'"'"'^"- '''''^' "'""'^ ^'^ «*«*-• KXACTLY. PHYSICIANS «houId 

«on. d> ini awar fnomi" '^i"'", fl""': '^"? '* '""^ ''^ P-operly cla8«i«ed. The "Special Information" fo. 
>in8 away trom home should be feivcn in every instance. 



>r p«p- 



6K> t. 



i 



^1 

, 1 1 






^ 



I'^SS*' 



JUtfc^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Moai.I of UtriUh- F No. i«, f^^^:^^ H&P Co 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Registered J\*o, 



1 5^^8 I 



X>u^ duL\Hji Deputy Heailh Officer 

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

Certificate of H>catb 

( H. S. standard j 
PLACE OF DEATH: — County ofCxX^-v JAxX/>vc^.<l<^ City of Oa.'>v A.CUyxc^.^.« t 

No. % m^ddLL. _ . m" ^ 

(ir DtATH 0( 
IF DEATH 



St.; ^^ Dist.; bet. .'A.r..i. and ^ CLLui^\ > \ \ n > 

'' °/*:".,°""r *^*' '"""^ ''^'"'^ RESIDLNCEG.VE facts called for under special informat^n \ T\ ^ '-^^ ^ 

OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E e| AN D N U M " « ) U 



FULL NAME 







m:x 



PERSONAL AND STATISTICAL PARTICULARS 

■V I COl.OR 






[)l. 






MEDICAL CERTIFICATE OF DEATH 

DAT!': Ol" i)i-:atii 



I unr 



iMoiithi 



3-0 

(Day) 



/.'IC.?> 

("k'ear) 



\"". I- 



..QxAaI 

(■ Mod til) 



(Dav) 



(Year) 



J V(/; 



R 



Mouth <. lO ria\ 



^IN'.I.i:, MAKUIHI) 

W FI»o\VHI) OK DIVoRCHr) 

' W'titr in vociril (Itsi>.Miati<.ti) 



lURrnPI.AOK 
Statt" or Coujitrv 



^ 



1 HIvKI-BV CI<;RTJFV, That I attendcMl deceased froni 

■S-^K^' '^ 190 •, to S>.x<i^.t a up . 

tliat I last saw h X . . . alive on c)-i.^\I. : jfp 

and that death occurred, dm the date stated above, at '^ 
M. The CATSR Ol-' DI^ATH was as follows: 



\ \M1- OI- 

I- Villi; K 



'ni<rmM,AOH 

"I I- A I'll KK 
'Stale or Country) 



MMI»j;x NAMK 



HTRTJIPI.ACF 
'>l- MoTllKk 
(Slate or Coiintrv 






Uajutvo 



cCOvA. 



.o^\ 



occrpATroN 

f^^fsidi'd in Sun /'i ,ni,i 





DC RATION Years 

COXTRIIU'TORV 



Months 10 Pays Hour 



'0^^\AX. 



LtvVVvK^ 



DURATION Years Months Pars 



(Signed ) 



Flours 
M.D. 



'^A. 



) V'(// 



.^ 



Bx^l '\ ic)o'. (Address) 3ia feo-urkt >k 

?^^9'ft'-J'^^0^'^A"'"'0'^ *'"'^ for Hospitals, InAtulions, Transienls. 
or Recent ResliJents, and persons dying nnay from home. 



Mn„tl,. 



n,i\- 



'".'>l <)!• -MS KNOWMvDC.H .\M) HFMIM- 




Former or 
I'sual Residence 

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



How long at 
Place of Death ? 



Days 



Pr^KOH nrklAI. Ok RI-MovAI, I I).\r,.;of H.-hial or k^MoVAI. 



birlu Lh^^-MA 



• dxlxt l.L 



TQO'i 



(Ad.lress....l.llH - .X) JU>v^.<xdU.^y dt. 



N. B. 



"r»T*'rJA^.?l^U'J^^T""^''"" •*"""'•' *''' -"f-^fully supplied. AGE hHolIcI be stated EXACTLY PHYSICIAM«5 1, .^ 



I 







> i| 



< 



■I; 



''\\ 




m 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

]h>Au] of llcaltli l- No. i"^ ■?-^^r^) nSi.V Co 



/hf/r r//rf/,c)ji^ 




Ja^JL^-tl/Wv 



REFER TO BACK OF CERTiFICATE FOR INSTRUCTfONS 



10 




IfJO^ 



Begistered J\'*o, 



1 5i^9 



^vj Deputy Health Officer 



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

Ccitiffcate of Scatb 

( tl. S. StanOarO ) 
PLACE OF DEATH:^County ofcl^vw^.^vc^^cvvoo City oA o^J^ .^ .^.^^.^.^ 



St.; - 



Dist.; bet. 



and 









FULL NAME 



<4\.<rrwcu:^ 







Ur\Jj^' 



tt • 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 COI.OR \ 




DATH or lilKTlI 




WEDICAL CERTIFICATE OF DEATH 

DATE OI-' DllATlI j) 

^Motitli) 






(Day) 



(Year) 



(Month) 



A'.K 






(Dav) 



M nit In 



(Veai) 



Daw 



^\ nin\vi.;n ok DrvoKCKn 

'Aritc ill s<i<ial fhsivMialioii) 




HIKTin'I.AOR 
State or Coiititry) 



NAM).; <)}. 



•"• I A Tin: k' 

^'at.' Ill foiiiili v) 



^'AIIMIN NAMK 



'!II< 11I1M.ACI-- 
'»!■ MOTHIIR 
(Stale ur Cuuiitiv 



^ 






I HKRKHV CKRTIFV, That I atU-n.k-.l .U>.-c>hso.I frnn, 

1^-^ l^ i9o"i to .. d-e|vt S i,pH 

that I last saw h ~ alive on O-C^Cb 1 ^^ S 

and that .Icath occurred, on the date stated al)ove, at 
^M. The CAISK OI" l)|.:ATir was as follows: 



lvcrw^>(x^ 




DIRXTION 



) 'ears 



MoJiths 



Un-tL 




'.a./c^>hlIa.-^ 



Days 



Hours 



k.>:\,c» 







Dl'RATION 

(Signed ) 



}'('ars 



i.t^ 



J/(>f////s Pars 



T90 



(Ad.lress) l\'\l 'i^A^^dxAA^i ,d1. 



Hours 
M.D. 



/',/ 1 



OCCUPATION 

ntVM ()!• M\ K Now 1,1 i)(,H AM) lU-IJHl-- 



nr^.^pn^^'^'-f^'^f^^'^f^T'O'^ »"'> '"^ ^^^^K Instilutions, Transients, 
or Recent Residents, and persons dying away from home. 

Former or , , o . ( i^ -«- ■^■ 

llsuai Residence U 6b 




How long at 
Place of Death ? 



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



Days 



I'^CK 01-- lURlAI. OK KHMOVAI. r. AIM; of M, h,x,. or KKMoVAI. 

INDllkTAKKK L<XnjU.^ V U^X3uL^ 

(Address l'^ U 0..'>v \)\?i^.^ k\ ,. 



N. U. r.very i 



«r/curSF OHoT^Th'"''';''''' ^ '"-"'u"'' ""■"•"«"• *«f^ »•"••"<' be »ta,e.l fiXACTLV. PHYSICIANS should 



ft 



' 1.1 



?f 



', * '.>- 



/la ^ 



/ (. r i -^ 



■Z' / 



' . X 



m 



1 



h 4- ' 





-■■"•**'-*^ 



WRITE PLAINLY WITH UNFADING INK — 



!!..:,l.l .if n< iillll (•■ No. In T^'f-^W^-} JU<tl' Co 





THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

'""" /"''"'^-^--^-tt^vU ID 190H Registered A^o. 1530 

\H^ Deputy Health Oflflcer 

DEPARTMENT 6f PUBLIC HE ALTH-City and County of San Francisco 

Certificate of 2)eatb 

( "U. S. Stan&arO ) 

PLACE OF DEATH:-Coun., of ^ Ct^v^.V^..^^ Qty of ^Cc.vf'.c. 

No. S0"^1 Ocu.i,Ur\) 

( "^ !;^y OCCURS *w*v FROM USUAL REsTdenCE G. 

V If DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION 



veu^^tLc 



rjr^HoccuRSAWAv.ROM ......a. o.o?hL.^_._^^s*-jbct. ULIvs andl JaV\X.< 




IIVE FACTS CALLED FOR UNDI 



FULL NAME 




riur .TO iuiiu.r ^^^ SPECIAL INFORMATION 

GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



^:^XJJ^ Lx 



si:\- 



i>Ari-: «)i- I'.iKTu 



PERSONAL AND STATISTICAL PARTICULARS 
n 1 COI.OR 



CXO. 



V>Aj. 




llUvctt 



MEDICAL CERTIFICATE OF DEATH 



iMoiitlii 



3.5-, 

(Day) 



rl.X\ 



DATE OF DK 



•ATI! jQ 



(Moiit'li) 



.....1... 

(Day) 



(Year) 



AOK 

._ I 1 )>;i, 

^IN<-.I.K. MAkklKF) 

uiDowKD OK DrvoRrj-n 

'V\nte Ml MM-ial (ltsi>r,ia(j„ii) 



Vcar) jttfT.. 



% 



.1 A '«///,( 



15- 



/>u' 



I HRRHRV CKRTfFV, That I attemled Me^oas^^rfTo,!, 

190 *( 



(Year) I irtn.-. Jn.vC.v^^^t, oiMgo- to . J^«C4vtr. t 



that r last saw h v1a>% ahve 



on 



^ 



c'a.<^vtr % j^^^ 



I''IHTMPI,ACK 
Statf or Coiuitrv'i 



^\MF OF 
f ATin:R 



'••IkTHI'I.ACK 
<»l- lATUKk 
'••^tatr (,r Country) 



MAIHHN NAMK 
•»1 MOTIIKR 



lilkTHIT.ACK 

•»J- mothkk' 

(State or Country) 




^ 






9 



.•:inl that death occurrcl, on tlie .h.to stated above, at 3 H ^ 
•ff M.^he CAlSfv OF DJvATir was as follows: 

r ■ "■"• • 



DFRATrOX y.ars X Mouths \^ Days 




CONTRIJUJTORV ^.Vi^:^^'^-^-^to<n<v 



Hours 



m-RATIOX ^ y<a,s^X Mo,uhs \<i Pay. //„„,, 



( SIGNED ) . JUv^i, ..Lk^^^ 



^A^\: 



{% 



'qo'i CA<Mr.-ss) l'^?:^ 






M.D. 



'~l 



OCCVFATlON~Y*> 

f^Vulrd ni Sun I , ,un n,,, 






nr?^^9'fi'-."^r^'^'^^"'"'ON only for Hospitals, institutions, Transients 
or Recent Residents, and persons dying anay from liome. "r-nsienrs, 



Former or 
Isual Residence 



lkec£lt^ tci ""'^ '""'"' 



Yra,^ ,^ 



Months ^ 



Wfien was di«^?ase contracted, 
rtays I If not at place ot death? 



Place of Oeatfi ? L 



Days 



' '"'"niKint 



t, fe J^K^V^v«.>v 






190^1 



.-lAI^^Ok KHM..VAI. DA-p-of H, m.x,. or RKMOVAI, 

WV^^^tcv Led I "^^i vt I 3 

INDHRTAKKk it) . J . ^JjlaCU^Co 

^Address .'1..1.a..A]}lv^4^.<r>i M 



won 



te CAUSE OF DEATH In p „ „ ter^; that Tt m « h 1 .^ **•! «*"''^ EXACTLY. PHYSICIANS «houId 



f 



':l\ 



'■ »i 



M 



4 

r If 



I* 






"^1*1 



«. __A^;"*^*^*. 



M..,n,l ..f il.-.iini - I" Vo. 1^ T^X?!^^' ''^"^r' Co 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTinCATE FOR INS TRUCTION** 

HegLsfered A^'o, 



Ihifc h'/h^<l ,t).jJ^ALyyJo4hi. 



-r "V^ t^ Nnf '1*^^ t,^ V' 



10 190\ 

Deputy Health pfficer 



JLOt-* 1 



^IN<.M:. MAKRIKI) 

WIDOUKI) OK IHVoRCKr) "^ 

'Write in s<K-ia] disivMiation) 




DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of 2)eatb 

( XX. S. StanDar^ ) 
PLACE OF DEATH:-County of ?C... ivcvxc^c, Qty of Ac^J^^^^^ 
>. M lit j% y ^cl U iu LUxi I u. •. V. St.; — D{st • l,£t - A 

Z' IF oc*TH OCCURS AWAv FROMiUSUAL RESiDFisirr ^.w. * 3 ttd -rrTrTTrr 



-) 



FULL NAME 



ll 



1> 



PERSONAL AND STATISTICAL PARTICULARS 

DATi: n|. lUK 111 ^ 

■ vl^^^Q 

( Month )r 



n 

(Day) 



(Year) 



DATE OF DK 



M EDICAL CERTIFICA TE OF DEATH 

•ATH Q 

a^ 



v.. 

(Month) 



^kt... q 

(Day) 



(Vear) 



)v„ 



.Miiiit/is tf\ J 



J HKRHBV CHRTIFV. That F attemU-.I .le;;;:;;;::,T7n";,n 
^-^'^^ ^ i9o\ to .. L^^.^ ^ ,,^ vi 



that I last saw h ..»4A) aliv 



c oil 



/hi 1 : 



HIKTIIIM.ACK 

State or Connlry'* J/ 

rl 



-V^voiCl 



and that death occurred, on the date stale.l above, at * 



M. The CWrSf- Ol" DlvATH was as follows: 



..d 



-Xa.-0"'VX 



NAMK OF* 
I" ATllKK 



'nkTllI'I.MF 
'»' lATllICk' 
'"^t.itt or »"onntry; 



dJ^ 



0-U) 



-CCCIO^CL^V 



Ol- MOTHKK ' 



'nK'i'Fipr.ACK 
J" ^t<>T^^:K' 

'State or Country) 




JU.-\VA\XC)Lu 



ni-RATroN 

CONTRIIillTORY 



)-,-,7;-.! .)/,-;///;,5 13 /;aj.i //o/,r,t 



I)r-RATION- )•,„,,, .,/;,„,;„ /,„j,^ jj^^^^^^ 

( SIGNED ).. .lUv^uL *l]l'WvJXw 



r1 






4^t 10 TQoM (Address^ tit \lv (^^ • 



M.D. 



f ^^'fi"- Information only for Hospitals, Insfifuflons [ranslcnfs 
or Recent Residents, and persons dying anay from home. 'ransienfs. 



JJ1-: 



Former or 
lisual Residence 

Wlien was disease confracfed, 
If not af place of deafli ? 



ftoH long at 
Place of Death ? 



Days 



'X.l.lress Tilt At. Vo 



I-I^CKOF IU:KIAI, OR RKMOVA.. | HA",^. .,f H,k,^,. or KHM.^VAi; 



A^C 



V^<L^ 




V!V;6 




'SW 



•NDHKTAKKK JwLlxU "^ ot 



.......d-tlvt 

» K I 



ll 



IQOl 



(Add re 



ss 






^^^^^i;^;^tXL ^: -:rr^ --- -^;-:i:;;,:r'-^^'i^:- .rz:;^!!'; r:- 



nons #1.t».A n . -....^, i..ai It iim^ i,c propel 



y 



Jl 



-I I;, 
f ■ 

;ii 

■ ' u,. 



I 



t 






1 






If 









- < 


' ; i 


f 


'1: 


4 






♦ 1-, 


) 


■ik^ 


; 


/^ti 


•• 


M 


» 




'•] 




1 1 


f « 


/Ma 


1 


*4I 


1 


It's 


1 


^■fl 


- I ihL 


Jl 


\ mk 




i ' IM 




■ 



■:S*3B 






••1*' 



ENT RECORD 






WRITE P1..INLV WITH ONFADINO INK-THIS IS A PERMAN. 

Ho;, 1(1 i.f !(( .lltll )■' Si), i'. t'^^^^tf; nSi.V Co 

"* ' — ■ _ REFER T O BACK OF CERTIFICATg FOR INSTRUCTIONS 

_y , , ' ' ' ^ ^^ ^ Rogistcved JS'o, J 53^^ 

A.crvcv', XcxH^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTlKify and County of San Francisco 

Cevti'ficate of H)catb 

( "U. S. StanDarD ) 
PLACE^OF DEATH:-County of^ a^vlva..^c. Cty A^J^^^.^.^^ 



) 



FULL NAME lI'L^MII l^p^-^vjtt... 



PERSONAL AND STATISTICAL PARTICULARS 

I 'ATI-: «»!• IIIKTU 



\<.K 



^t^ 'cO ,■..„„ 



^fN<.I,K. MAkklKI) 
\\rn, HI MH-ial <l(viiMi;.ti.,ii) 



HlkTHI'I.AOR 
'Sintf or Coiintrv^ 



\\M|.: f)p 

iatui:k 



'•■'KTHI'I.Ac-K 

"I" i-A niMk' 

(M;it< <,r Cuuntrv) 



maidkk namf 

W MOTHKR 



"frrjU'r^ACF 
'htate or rountrv 






OCCrPATlOX 



' \il, 



h r-^s 




•^EDI^AL CTRTIFICATE OF DEATH 
DATK OF DKATH 

a^iA^; a 

(Month) 



(Day) 



(Year) 



I HRRKPV CKRTIFV, That I MUen.1.,1 .lecease.l fro.n 

^90 to ,^ 

that I last saw h ... alive on 

an.l that dcatli orcurrcl, 011 the .late statol al)ovc. at 

M. The CAI SJv OI' ])|;aTH was as folhms: 
C^cUtC ^WC CvU.^v<lt;^.xc^<^cUiuAwfe ^Lt.Lrvvv 

Dl'RATIOX ,>,,, ^,/,„^,, ' /,^^,,^ ^^^^^ 

CONTRIBUTORY '^<Ct Ccrv^^^rt. ^tk 4t>x<.L 



DPRATIOX ^^ Yeafs^ ^ Mouths ■-. . Days 
I (SIG 






Hour 



M.D. 



L -V .. www^^w p^ 

^-^4^-^ ^1 rooM (Ad.ln-ss)!5tM^l,ui..d..dl. 

nr?.^„^9'^*-» "^f^^'^'^'^'ON only for Hospitals, Inslitutions, rransienfs 
or Recent Residents, and persons dyinq away from home. 'ransienrs, 



Former or 

Usual Residence 

When Has disease contrartfd, 
If not at place of death ^ 



How long at 
Place of Death ? 



Days 






"■■' ^ ^ Ql^ux-vUvv I "^ 

111 (J,cu.iv T\t 




.\ I ) 1: R T A K }•: K it CLl^iA^ut ^ V c 

^AddresH Sib MlX^Aite^i ^^ 



190 1 



"X^CArSp'of DprTH" "''T'*' ''^ ^'"-^^""^ Huppliccl. AGF. Hhou.d be HtHtecl F.XACTLY. PHYSICIANS h .. 



H^ 



i 



y ) 



r- 



? 



-> 



"5^ 






ilf 



1 I 



U 



* 11 



il« 



s: 






I i;iMl .. I 



WRITE PLAINLY WITH UNFADING INK — THIS i«: * err.... 

"^ ^"'^ 'S A PERMANENT RECORD 

If. ..III. I N., .^-g-r^uiiM-c, ^Tl.^ 

HEFER TO BACK OF CERTIFICATF FOR rNSTRUCT.ONS 






cMK-'Cv:^ 




i^y^s 

vu Deputy Health Officer 



Registered J\''o, 



1 5;j3 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of H)eatb 

PLACE OF DEATH = -Co.nt. J^C^Lo^^^,,^ of ^^^^fva 



No. 






>'\ Cv^c^^i 



\ '' ,r„™v^/„^-^„ — ^-fS^^^^^^^^^^^ Dist.,bet.cJa.. 



and 



'^•CHU UF STREEt'ANO NUMBER. 



^ 



) 



) 



FULL NAME 



!Xt!'-L 



CLx. 



cr\:C.c„(.4. 



PERSONAL A_ND STATISTICAL PARTICU 



•>i;\ 



l'\ I 1". <'l l:!K|-|| 



\«'.i-: 



LARS 




COI.OR 



'Nt<)iith>' 



xaxkX^ 



_. MEDICAL CERTIFICATE OF DEATH 

DATH OI-- 1)1:a'IH ' — -^ 

axkt 

(Mo.ill,) 



X 



V J ><7 t s 

\ IDOU-KJ) (.K I>IV(»krKI) 

^^''t,- HI social .I.-si^Mi.-.ti-.n) V 



• Day) 



M'<nths 



.A:n. 



Q 

...k. 

(Day) 



(Vear) 



B 



/^(, 



HikTni'KArK 

'State or Cotintrv) 



^AMK op 

' \Tni:R 



»IKTHPl,\rF 
".'• lATMKk' 
'State or I'oniitrv) 



VrAII.i;x XAMi- ^ 

<»K MuTllliK /^ 






•U-okUvX; LclI 



I Jn-:R1.;HV CliRTll'V, ThatYatten.lc.Wle:.:::;;;;^? 

^^^"^ ^^- •• '90^ to ...|xi^ ^ ,^H 

tiiat Hast saw h-J..,x>. alive on QJL\\t:. 't. . j^^ 



(Year) 



roiii 



atui that death occurred, on the date state<l ahnve. at 
■ '^- '^'^ ^ArS^y)F DKATII wa. as follows 
V^.<C^^d. j.X\>^:X.*.v; 



^^ 








DIRATIOX JV^/-.? 

CONTR I lU'Tc )R V Vlk-Cry^ V..C 



V<>>///;s ").% Pays Hon 



rs 



;'•" m«>thkk' 

(Stall- or Countrv) 



OCCt-pATlOX 






^U'-KX^ 



^ 



'^'''-^''''^^>^ . ^'--^ - ^^;-'^^'s '^'^ nays 

^SIGNED ) V^^^ U..%.A^^La 



//i 



ours 



A 



4^^^ TOO M (Ad<lr.ss) :m% \)}U^.,, . o^ "^i 



M.D. 



.(X'^'vcL 



f^fr.f in S,n, F,-a„rh-rn 



)V„;> 



M.n-th< 



''''"•■^V;,5;^^^S,;;^;i^;;^f.ii:],«;,;;;;,;;AHSAK. TK, K T,, 



/)</ 



or Retenf Residents, dnd persons dying away from home. 'r-insients, 

Former or «„„ ,„„„ , 

^»"'«*"« "tlTLv. 

When Has disease contracted, 

If not A{ place of death ? 



•««. Days 



vh 



(Address. 3i?)^^ a3) /V<C Ht 



nn-: «'i.ackc.f nikiAi. <,k kiOK.vAj. \ uxty..^ ncu.. 



^>:^/CjU^...,..,... 




'- or k};M()\AI, 



N. B, 






'«t7t7cMrSE'of DTrTr*"^^ "' CMn.fulIy supplied. A(;B should be stated EXACTLY PHYSICIANS y. .. 









a 



I 



<:l 



ii 



f 



I 4 

■ ) 



\i 



^ P. 

ill fH 



"'* 



.iJk. 



"1 



WRITE PLAINLY WITH UNFADING INK 



llMiird of lt(:i!t!i I' X,). i <; 'C-^-.flBT-.Sli) J<^ j> Cn 



10 



100'\ 



THIS IS A PERMAIMENT RECORD 

/^gPER TQ BACK OF CERT.nCATg FOR INSTRUCTIONS 

Regisicrod ^''o, \ 534 



cer 



DEPARTMENT 6f PUBLIC HEALTH=Ci,y and C««nf, of San Francisco 



Certificate of Death 

^ tl. b. St^n^arO ) 
PLACE OF DEATH:-County of cl >.*?,., a>.c^c,. .... .. 1 _. "^J 



% 



>vcv^C^ Gty of Oc^v J .^a.^^^eo 

m ion Mi-^A o/ ;:" ^ ,; 

"osp,,.. .„ ,.s„T„.,o. c,v. ,Ts NAME .."."r.^.n? sT%%%T.vrr:=';„°-' ) 

FULL NAME L<WcLV<i 



PERSONAL^ND STATISTICAL PARTICU 




SI, \' 



J'X'i'H Of iiiki-n 



M.f-; 



LARS 



ecu 



C'KI.Ok 




-^ 



xdl 




MEDICAL CERTIFICATE OF DEATH 

iJATi-; oi. i)i;.\Tn 



l< 






.OX 



3 

(Day) 



A Hi '1 

(Year) 



i 

(Day) 



(Vt-ar) 



'^^1^^ -^^ '9°-^ to Ajl\-^. i, ,^^ 



Yea 



t s 



b 



-IM.r.K. MAKKII.:i) 

ninnuHDoK n!v.,Kri.;r) 






M »i(hs 



.^. 



n.at r last saw h . alive (^ii ^xAvt \ 



, , 1^- - T90 

An. ami that .i.ath ..ccurre<l, on the date stated above, at -. 



D 



Ow^u 



i'.\riii-:R 



MfKTFrj'I, M'F 
'>'" lATIIKk' 
(statfor C(.initrv) 



«»J' M()TII}.;r ' 



"iKTiipr.ArK 



OCCrpATioN 




O^O.A'v J ,V<Vv^..t.^.xtcx;• 
"^ (^ (■^ H 



m I''""^^^''^^ ^'V ^^'•■^'''" ^vas as follows: 



.Oj 




:Vs<r\rw,, 



it^^is: Months X Days 
CONTKUirTORV A)l{r;>:s^ 



I Jon IS 






Cru-tX^Yv 



^^ dLo^a.^ M.D. 



Signed ) 




Mvblt) 'jtftLua-\.<L..dl 



.riren^^^t';.'^„r$?,r ?.i,'r, z::::'"'- '-'''"""-.^i^^;^ 



VCA,4L«Ui, 



(Afltfress (05'I 



N. K 



five 

H 

S 



t\l\. Jl 



Former or 
lisiidl Residence 

When was disease confrarfed, 
If not af place of death ? 

I !•: n> J nr: ) i^.ack oi- hi 



How long af 
Place of Death? 



Ddvs 






fAddif 



ss 



in I 






t 



''^"^"^^"^ c\\Tsn oVTv;^^^^^^^ ''' ^'•"^^'^'""^ supp.ie.1. AfIB should be stated EXACTLY PHV«,r..^« 



I 






a 






if 



s ir 



I I 






i- 



WRITE PLAINLY WITH UNrAD.NG INK -THIS IS A PERMANENT RECORD 

)f...it'l of H( ;ilih- !•' \o. 1'-, ^tf-f'.-Safr^ u^j. (-fj 

™ '^g'^ER TO BACK OF CERTIFICATE FOR INSTRUCTION! 






10 ifJO'i 

cUu^s cUah^ Deputy Health Officer 



Registered JVo, 



1 .1.J5 



DEPARTMENr OF PUBLtC HEALTH-City and Coanty of San Francisco 



Certificate of H)eatb 

( la. S. Stan^ar^ j 
^PLACE OF DEATH:-Coun,y of^C.v ^kav.Cc^cc r.w „,?^' '^ 



y r ir OtATH OCdURS AWAY FROM USUAL RESIDENCF ri 

11 V .r OtATH OCCURRED ,N A HOSPITAL OR^NST^Itu^N 



^Cuico City of Hoax Ova^^^^ 



? 



e^ 



and 



St.; -:-— r- Dist.;bet. 



FULL NAME 



3^ 



\ 



iX.CrY>:\-CU 



CtVVxYVj 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 




In 



S 



COI.OR 






ICivdl 



MEDICAL CERTIFICATE OF DEATH 

I>ATE OF DKATH ^ ~~ 

C^xkt <i 

(Month) 



AC.K 



M'.TItlK 






(Day 



( Vear) 



(Day) 



(Year) 



MNni,K. MARkJKI) 
\\n)()\VHi, ,,K i)iv<)Rr».[) 
'\^rit.- in social .lrsi^r„:„j,;„ , 



Movths 



Da vs 



A 







nrRTFTi'r.At'K 

'Staff or Countrv 



N'AMI-: oi- 
• ATiriik 



C'^avqU -. 



^ 1 HERRBY CKRTIFV. That J atten,1c.l"d;:c^;;;;:rfn.„. 

•■'^^^^ ^ ^90 t to ...Aj.^ g ,,^ H 

that r histsawh ^. alive on a^yx.t" ^ _. j <^ 

and that death occurred, on the (h.tc state, 1 ahovc. at H ( 
■■■■^■^. The CA^'SK OF DKATH was as follows: 




'>!■ iatiihk' 

'Slatr or Countrv) 



■^'Aini-N' XAMK 



'''"<'ini'i,ArF 

(Statt or Country) 




V>x J /OlVV^av 

uUv 



^v^^vil ylX^i^^ccV rUtv^ 



I>IRATI()X.,.3. Years b J/,,,;//,, 

COXTRIIU'TORV 



Day 



Ilouys 



nPRATlOX 



a -• (T J. 






(SIGNED).. J VX,7|^vt. 

a^ia S ..H ^Addr.ss)tIk^H.(^^:^. 



/^'''J'^ F fours 

M.D. 









<> TIIH 



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



Days 



(Fnforniant 






190 s 






PI.ACK OK lUKIAI, OK KKMOVU I i,\Tl- f t,, " — 

,L J, ^••' '^^'' j I'A I l..,,f in KiAi. o. KFMOVAI, I 

W-^'wc^^.^Xa.^^x^x' I ^-^}v:ti i..O 



-n, c..i„^ «^3^ ,_ ,_^ should ;n;;c';:„"ir;;t in^r-r;:^ ^'"'*^'"^'- ^"^^ "«''--' mfo.n'^ult^'i 



should 






4 







M 



h 



WRITE PLAINLY WrTH UNFADING INK — THIS IS 

Hoard of Hcaltli — F No, i:; t"?[?5?S^ nScV Co 

'^^ ■ ^g^E'^ TO BACK OF CERTIFICATE FOR iNSTRUCTlOM^ 



— ^ 



A PERMANENT RECORD 






1.0 290'i 

Deputy Hes?th Officer 



Registered J\^o, 



Ne, 



DEPARTMENT OF PUBLIC HEALTH-City and Co«nty »f San Francisco 



Certificate of S)eatb 

( "Q. S. StanOar^ ) 




cc^eo 



ia\u.> XL^ivCtcx.6 St — n 



FULL NAME 






.uw-vvva J xa. 




»:. 



PERSONAL AND STATISTICAL PARTICULARS 

V I I cor.oR V 

I>AT}.; oi- niRTH A 

■ A'l*^" 1% ,uh 

— 'Month) (n-iv) /^- ' 



LlUvcU 



R^^EDICAL CERTIFICATE OF DEATH 
DATtC OF I)i:.\TlI > 

(Day) 



(Year) 



"^ i rears . .3.. 



\\ inoxvKi) ,)K ntvMRCFi) 



''-IkTHI'I.ACK 
'Statfor Comitrv) 



■y"»,f/>s ...Ji /,,, 




N'\MI-: OF- 

f"ATin:K 



RTRTFfPl.xcp 

<»'•■ i-atmi.:k' 

'^-l-'ttr or fouiitrv) 




^ , M 



(Monih) 

^^^^S- ^^ -^H lo £\xK - up, 

tliat I last saw ln-V alive on C^xjx.t 1 „ ^ 

ari.l that .leall, ..ccurrc.l the ,l,,te sImIc-,1 al,„ve al 

fh ^/'''^ ^■^■^L-si.: <„.■ ,.,.:.vn, „,. „, f„„,',„,^^ 

^^^X'CaAx-iS-^'vvCL.*- !* 



3" 



r 






1^ 



C0NTRIIH:T()RV Llv^U^WA^a 



/)av.<; 



Hours 



^ •» 



'"• M<)TIU.;k ' /;) 



'"KTnpI.ACR 

<>i- mothick' 

'i^tatr or Conntrv) 




^ctico. 



CccrULoLAvcL 

? 



3 




(Signed ),,lLu^. d"luvva.-v^ 



Hours 
M.D. 



''.ri 



•*{ ! •]■ 
PI 

i 

■ I 






ou^ivcL 



lA-;////. 



/></!. 






When was disease contracted, 
If not iA place of deatfi ? 



;! 



I'l.ACK or m-RiAi, (IK ki:m,uu I „,ti.„. ,„ ■ 

\\y \ "• I "^''-"' "' HI.*!. "I ki-;mi,vai. 

"11 L'U\>i,t I a-t|vt U ,-j>>, 

.•.xi..:rtak,.;r IVccUAvtc "i]U\c>v^\.f^ 
'A.i.h.«» J.,S,a.H tSlyoiite^^, ^t 






m 



r 



ENT RECORD 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMAN 

H(*;i!<l .if UiMlth I" No. Is "^'y ^a^^ fc }\Si.l' Co 

BEFER TO BACK OF CERTIFICATE FOR IN3TftOCTIOIMa 




.(mA' 



i i' 



oLt 



ReglHteved Xo, 1 5 *i7 

Hi Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTII=Cfty and County of San Francisco 



Certificate of 2)eatb 

( tl. S. Staii6ar5 ) 



vi^ 



PLACE OF DEATH:-Coun„ of "^ <V..>'j!va.vc^,,, Qty of i c...l^« , . ,,^, 



No. (Ill 



\x % 



±. 



/- ,^tt.TM1^u"*^s^w•, r„o« USUAL HES^DENC^, Dist.; bct. '^XJV ^nj / "L L 



FULL NAME Vldlx^cli... 




t^ 



UQ^^VXi., 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

i^ATi; (.1- niKTH ■ ' ^^•'^-^ 




V 



Mniitb) 



(Dav) 



AC.K 



/US . 

'Vfar) 



_________ MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH l' 

^Ajxt H 



(Vear) 



i JV«».T 



.^f.lH.'flK 



I HHRHHV Cl.RTIFV, That 1 attc.u.U-.l ,loceasedTrom 

^- ■■■•^ • ' ' ^90 - to 6.^^.l ^i„ ,,^ . 

that I last saw h .iai\ alive on cSx-lvt 



i(p 



U IFX.W Ki) OK IMVORCKI) \ 

WvMt: iti social .k si^riiaf i.,i, ) 1 



•WkTHI'l.AOH 
'State or Country* 



^v >ocL/^v^M./dL 



^^^£^^;^^_7^»^ I an,l that <U.ath occurred, on the date state.l above, at S- 30 



NAMK Of- 
•ATI IKK 



''IKTHI'I.ACK 

OF i-atmkr' 

'Staff „r Coiuitrv) 



ns 







LLWvOt>A^ 



DCRATION ^ Years^ Jl/o,U/>s 

CONTRMU'TORV Q.JU\x 



Days 



Hours 






MArOKX VAMJ- 
Ol" MOTHKK 



""<rnpLACE 

•»•■ MOTHHK 
'Statf or Country) 




\ 



I 

-vvcL 



DURATION ^><^ ^/^^«M^ 



\ 



^^uL 



'SIGNED) lI\^ i. (i^av(.Kd 

^ ! "i '1 _ vis [ 



Havs 



Hours 
M.D. 



r 



■^ .,x u 



I(>0 , 



( 



Address) i 3 1 C J 1)^4^^.. <3t 




.r?ere„^^^,';,s:?„r°?,^S°^, j;!!;'::!^'""^' •""'""»"^' '™^''"''' 



Mn„th< 



OCCUPATION S ^ 



hn 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



J". K) IMK I'l.ACK OF n 



X. ^-Ua Lvc-^j 



rRIAUOK KKM,.VA,. | OATK of n, .um, or K KM. .VA,/ 

: 190 "1 



rxOHRTAKKK jIY ^ A^cIcUav Oll^ (^^CLV 

(A<i.hvss I in.! ^llyi^.wm...dt 




:^wc- 



"on, d>,„4 o^ay y^o^ ,,„^^. ^^^^,^ ^^ ^.^^^ .^ ^^^ . in^r.^r *^ -lass.i.ed. The Special Information" ?or ot- 






< ' 



« "'J 



ic! 



I % 



1'' 



• i;tii 

• r 



lii 



(i.i 



mmmmm 



WRITE PLAINLY WITH UNFADING INK 

Hm.ikI nf H.'.ilth I" N'o. K tk-^Sri^^ uSi]- Co 



/)a/r />'//,'</ ,AjL\^tjL^d^, 



THrS IS A PERMANENT RECORD 

ntFKH TO BACK OF CEBTIFICATE FOR INSTRUCTIONS 




10 1.90 "i 



Registered J\''o. 



i 5;i8 



DEP 



artmentI 



Deputy I icaith ORlcer 



F PUBLIC HEALTH=City and County of San Francisco 

Certificate of Wcntb 

I Ta. S. Staii?ar? ) 



"^v^^o City of 'cv- 



PLACE OF DEATH: — County of 

No. Liwt<i\^Avo L ft^'vClat Sf n- f k f , 



vecACLo 



) 



FULL NAME cU 



Kr-Lv^.U^.. 



ij 




..\,. 



SKX 



PERSONAL AND STATISTICAL PARTICU LARS 

COI,OR \ , 

1 I ^' ! 



llL 









lL'.Ix..u 



A(,j.: 



i tti) 



10 



(Dav) 



MinilJis 



r^tl 



WEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH y' 

uxi^t ' '^ , .. 

(Monti/) ^j,_, ^ 

"'•*>' (\ear) 



<Vear) I tTllxi^rX! T>. 



;;'n<.m:. ma ku 11:1) 

\jn)<)\VKI) OK I»!V«.k(Kr) 
'\\iHf 111 .s<Kial .lrsi^„;,,i,.'ii) 



z:)*?! 



'StMtf '»r Coiititrv^ 



VAMI-: oj- 



•ilk llll'I, \('F 

<»,i' fatmhk' 

(l^tate or ronnti v) 



^'AIDllN N'AMF 
OF MOTUKR 



'"Hr!n»r,ACF 
•>»■ motiikk' 
'Statf or Count! v) 



^ 







? 



5 I IflCRIUlV ClCRTirV, That I ,„te„,U.,l ,k.«:a's;7rrr„,„ 

'^-'-^-i^^' '^ .</> to ti.x.\-±. S „^ ^ 

tllat IlHst sjuv h iilivcoil ax|ct % „o1 

ati^tl.at .Ivatl, .K-rurre.l, „n the .lalr slatc-,1 al,„vc, at ^1 30 
■^ M. TIK. CAISIC 0|.- IMiATil ,vas a. follows: 

^ ''^'^-'^-^.^^^"rvv.o^WiX 

\r.l/cu.j^cL..i i^v.LiUuLVv<x ., 

c- ( ) N T k [ I ! r T R \' ^^.^:l.^^^^.s.....dJLJ^^l. 



1-2, 



Hours 



DURATION 



^ cars 



(SIG 



^.'.-f c 



NED) iL:.,...4 



AFotiths 



% 



Da 



vs 



r 



— w. y'V'k 



1 rqo i 




.■ Lh^cUrbuUL 



flours 

M.D. 



OCCUPATION 



"v'\va>xva; 



.rfercn^^sSe'-„„":'„r°S^?,;'°N ?! t^'-^ '"^"'""""s. ,„,-s.^ 



""■"'"- ^!vV■J;J^;•;;s^;;^^■i-«-;i;,-K-u<K ,K,K ,-,, 



talV*„ceMj,llilaV>vu*vv^t?::e'7Dl7 ^ 
When was disease confracfedo ^{ 

An. I If not at place of deatli ? M 1 1 ,Cl 1 a\Vv^.ra ct 



Days 



Info: 



"lant 



...c^. ^Ib.cr 



Hp'>^^a/-v^.. 






P 



^■'•'^-" 3-S.H fc.avu.4^A,^,(jf 



rXDKKTAKFK J^ 
(Acl.hcss 



N. B. five 




v.r/crsn'ofDTA"TH" :;-:•: !::;:r'c rr-'^n- *"•"' --"■'.• -e ».».»„ kx*ctlv. p„v8.c.an, , 

-n. H,l„4 awa, >V„™ h„.. ^hou, JT^iv'.'a^V'.r.rJ t.T^ZVy "•"'''""'■ '^'" "«'""- >"fo.Jl.'lL*„"l' 



should 
p p«r- 



I ■ 




li'C^'' 






h 



I } 






^* ] 






"I, .Viii-iim 



m 



> 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS 

IUkihI of ilc'illli !•• No. i a^ '^'^m^ ]i{k]' Co 

"gl'SB TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A PERMANENT RECORD 



/>a/r /'''■/<■>/, d^-^ijoy^j^j^ 10 ;,y^ c, 



-V 



<k^<r\A'KA OvXoHa ^^ 



Kegislered ^'o, 1 5o9 



OH^ 



Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Cevtiftcate of S)eatb 

( tl. S. Stan&arO ) 

PLACE OF DEATH:-Cou„ty of4.v5^Va. vc..^ Cty ofC^C.>.. Ic. 

No. "Ill IcLLvt ^. I T. Oil ^ '] 

( •' ot.TH occi„,s .„.v rRo» USUAL REsmcNrJ Dist.j bet. J J L<X<inV' and > <Vt.( 

'^ULL NAMEUuLd..d,VDlaVHM0lL<...,1 



U\' 



PERSONAL AND STAT ISTICAL PARTICULARS 

iL 



'0.^-^-^< 



tCL'v^ViO. 



Ar.K 



.CO 

M'.iitli),] 



J^'i r%^\. 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:aTI£ ~~ — 

OxJAt : t 



(Vfail 



Vi'at 






'llKTHI'l.AOK 



M,>},th> 



D 



/',/ 



-i^ ' 



c 



'^'^"^Q'oi. 



1 IIHRliliV CI-RTlrv, Tl,.l I atle,,,!.,! .leT;;;;,..! from 
"^ '" - 190 



tliat I last saw h alive on ^ AX'X 1 

an.l that death (.ceurre.l, c, the .late- state.l ahnve. at . 
^^' r^' CArSH^OF Dl^ATH was as follows: 

}b 



^ JUxX" xiA^^^dcL^m. 



St.ifi-or Coutitrv) A ^^ 

^ ! V 



NAM I- (,!• 
»• ATHl-.K 



'!1K TMl'I.XrK 
".'" lATHl^k' 
'^'■■"t< or I'onntrvt 



^'AiniCX VAMH 
<)!• .M(>|-|IKK 



•>i- muthkr' 

IStatt or C<juiitrv) 



OCCUPATION 



^ 



^ 



^t^L tectum Lawui 



1)1' RATION 



y^ors Moutin Days Hours 

coxTRim'ToRv a.^A 



i.'>xai/^.-V' 




I>'i<ATI()X ^ Years 
(SIG 



vJ^i-y 



NED)...,vi.^^V. \I.|^J_^ 



^f^nlth.< /lays 



Hours 
M.D. 



rqo 



'ClIcU\ 



or Recent Resident, i^?r?onfS?.?y ?;!ii '"^'•"^'' '-'''"'-^^^^^^^ 



(Address) 



Special Inforj^iation 



lome. 



^^CCL 



u 






Former or 

Usual Residence ........... 

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



NoH long at 
Place of Death ? 



Days 




PI,.\CH OF HIKIAI, OR KF:m,i\ai. 



iJA'mo; niKiAi. ,„ K]-:.M()VAI, 

'jU.fX LD. 




1901 



N. B K 

son 



-. d.!n» o*., t.„„. Hon.. ^hou.j^nH';;?;' ,■",';:: i";, r;„Te"^ ""■"""'• • 



^•^-^'"■'■- ■^H.2^...b..ax!L^....S " 



d EXACTLY. PHYSICIANS should 
I he Special Information" for p«r- 



1 



I 



I ' - (' 



t / II ' 



Hi _ . 




! 



l\\ 



i! 



,1 



I' 




m 



f ! 



WRITE PLAINLY WITH UNFADING INK 

M.i.ik! of Hi;iltll -|.- \o. >;; f^'t^lS^^, nScV Co 




THIS IS A PERMANENT RECORD 

REFER TO BAC K OF CERTIFICATE FOR INSTRUCTION,^ 

Hegi.sfered A^o. 1540 



\Ki "deputy Health OfHcer 

DEPARTflENf Of PUBLIC HEAlTIWity and Co«nty of San Francisco 

Certificate of 2)eatb 

t tJ. S. Stani>nrC> ) 
P.ACE OF DHATH, Co».. „, l^^^^o..^^. ,„^ ., i^^^^^^^ ^ 



f N©. \jXkjl. ^i Wtv^a^t 






Dist.; bet. 



and 



~ * Hosp... o« ..s...u..o°.'^o%7^;i ^.vi.^.° ;- .".n? s.%%%-\^-r:e%^--- ) 



FULL NAME fca>L^U| 







'^\kJ. 



I'VC^.U ., 



s I ; \- 



"ATI-; (.1. filKTU 



PERSONAL AND STAjnSTICAL PARTICULARS 

!l 




wUu,tL 



t 

MEDICAL CERTIFICATE OF DEATH 



'Mo!ltll) 



\<'.h: 



(Day) 



. U.H 

(Vear) 



).X 



x. 



i. 



- <^ay) (Year) 

i HicRKMv c,:ktu-v, t.,.„ , ,,u;;;;?;j;i;;::;;;;;:,-f7o,„ 

■ 190 to : 



.10 )V,„V 



tliat r last saw h ...""^ aliv 



e on 



;;.1N«.I.K, M\kuii.;i) 

u iiM.wKi) OK r)rvnKrFr) 



-^'"xllis -r f)ay 



? 



HiR rni'i.AOK 

(Staft or Cnititryi 



NAMK OF- 
I ATni:R 



''•'KTllF'I.^rF 

•'.'" iatiikk' 

St.itf or C\)niifrv') 



"' m«)Thi.:k 



'*IKTFIJ>I,ACR 
•»!• MOTIIICK* 
(State or C.HUjtrv) 



an.l that death occurred, „„ the date stated above, at 



I90 
T90 



CXO'^cL^^ cc-vxtx 



^ M. The CAISK ^l^^i>ivATJr was as follows 

..._..4..A.^^e.tvv^ ..c i ikuJU. 




DrRATlON Years 
CnxTRIIU'TOl^V 



..'«,<CUV. 

Mofilhs Days 



Hours 



^SIGNED) .U^UmX^. J. d.lO liin 




/:><n' 



vxxl. 



vt ^ ic)oH (Address) C(^^.{nx^^:<i \)\ ; 



Hours 

M.D. 



Special Information onu 



OCCUPATION 



lAJ 






or Recent Resldenls, dnd persons dying dHdv from home. 

Former or 
I'sual Residence 



Jor Hospitdls, lnsfitu/ro)ls, Transients, 



O il. - 
tTo)ls, 



)V, 



" -IN '^<>N\ M-,I)C.K AND [{1-;mi;k 



M.'uths 



Ih: 



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



HoH lonij at 
Place of Death ? 



Days 



(Inf, 



'niiaiit 



V..^Vcr> 



'\JO\Jii 



V. 



VCA 



I'l^ACK OK in RIAI, OK KHM,,\AI, I i,x 




I,',!- "! Hi Ki \i. ,,i K1-;M0VAI. 
II 



C X'ldres 






I90H 






should 
Ifor p«r- 



' I 



t » 



^1 



» 



I 



7 



WRITE PLAINLY WITH UNFADING INK 



IiiKiid (.f Ih alt 1) I" N'o. ! > ^?^'a*f<S^ Hft l-" Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



:;^ 



lUdc /'V/efIr^..J^.\<Xj^^^JjJC^ 10 290 1 




Be^isteved Xo, 



1541 



v-M -deputy Heaith Omcer 

DEPARTMENT l)F PUBLIC HE ALTH-City and Corinty of San Francisco 

Certificate of H»eatb 

( "a. S. StanDarD ) 

\ ^^ 

PLACE OF DEATH; — County ofCVct^v J Vcx^ve^t^cGty of 



^W«» ^\JLrs\.zS\, 



«h^ 



^ 



J 07> 



vcc^c^ 



ivCLoA' 



Dist.: bet 



-SIDENCEGIVE facts C-..i.tu FOR UNDER SPECIAL iNrnou.-r.^ 
.OSH,,.. OR INSTITUTION 0,»E ,TS NAME INSTE.O " ST-tcTiN'o nu'mbJL 



( " °"o;:T°„^i^c^%rer ,;:"r„o^^K:L^^-s<i"j;fo^'v,;/^;™.° ,?ji -°!- :--._.N.orj!Ti„N.. ) 



) 



FULL NAME 



.L\^cj,\w\./iJC'Cu 



'^""(^ 



PERSONAL AND STATISTICAL PARTICULARS 
A ) C01,0R' 



1 



DATH OF HIRTH 









I 



^T^:u:r^\j 



MkoiCAL CERTIFICATE OF DEATH 

DATE OF DKATH C 

BxKt.., 1 

(Montli) 



(Day) 



(Year) 



AC.H 



^IN<.l,K. MARK n; I) 
WIDOWKI) OK I)[\()KiKr) 

'^^iiti-iii s(xial "hsij^uation) i 



HlkrillM, AOR 
I Stale or «.'<Mintrv) 



VAMK oi 

• Aiii j:r 



'HRTllIM.ArK 
•>|- lAIMKR 
'Statr or Country) 



MAIDHN NAMi 



'URrjFIM.ACK 
<>!• MoTHKR 
(Statr or Countrv) 




^I imRKRV CKRTIFV, That I attemled <leceas<;:r7r:,n, 

LLui^o^ fe:..i ,^.^ tQ ^x.^.vl, :\ ,^ 

that I last saw h.t. alive on d-iL^t '' ,90 

ami that .Icath occurred, on the date state.l above, at I 1 
-^ ^^\ '^''^ ^AISK OF DFATII was as follows: 

W*-u^i\^^^v.si..oi...i.uiwa-^ 



OCCirpATlONrj 






yLc^iwjUs, 

DURATION n.,». ,/„„,,„ ■/,;„ ,,,„^,,; 

i^.iii.ec. 



(Signed) 



M.D. 



: 4^ n xooH (Address) 5 - 1 Hl^.^^n^ :. . \i 



f^rsidfd III Sav Fi ,ni, ism \ )'ra, . 




M,>„tl,, 



na\s 



( 



Informant L ., U . W 

1 ^ 
^Address I^H% ' la. tlv lU^ 



I nr^-L^^'M"-. "^f^^'^'^'T'ON 0"'> for Hospitals, Insfltutions TransJenK 
or Recent Residents, and persons dying away from home. "^'"""""^ iranslents, 

IsialVsidence 1 5" HS MX t!v it ' ^ ""^ '""« '* 

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



'^H Place of Death? 10 . Days 



I'I,ACE OI- HCKIAI, OK KV\^^^\■ \\ | r.vii- ( „ " 

rV\* ,^ ^-^ 'v»-.M(.\AI, j DA I h of HcKiAt. or RKMOVAI. 



^\t i^i.:^t 






^" "■ «aVe''cA7sE'oF DeTth^: p7j' 1' '""''•"' T""""'"- AGE shouUI b. „a.e.. EXACTLY PHYSICIAN, u .' 




1 1 : 



^fi( 



t 

I 



4 



* 
I 



*fr 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

IJr>;inl u{ Hc-.'tHli -}•• Vo. k -J-f^l^^-j J}& p Co - 

'^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J)ff/(' /^y/ef/ , QjJpXxr^ iQ 290 "i 







Begisteved J^'^o, 



1 54J> 



.r\)-\ 



\ 



^J;y HeCii^i. Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Cettiffcate of Death 

( Ta. 5. StanOarD ) 



PLACE OF DEATH:-County ofOa.,v J Vct..c.^ Qty of '^^t. J^A^I^^ve^^^ 



'No. dl).ctc 



St 



Dist; bet. 



U\XOi JCiV:4l\,Llr. i 

>x^,v,cb KaJiA,l\. ..'. 



) 



FULL NAME ^ 



PERSONAL A^D STATISTICAL PARTICULARS 

IJATK OF in K III f) "" ~~ 

c)^>± H zSfco 

(MontH) 



MEDICAL CERTIFICATE OF DEATH 



DATE 



OF i)f:ath 

dxkt 



(MonAi) 



(Day) 



I go 
(Year) 



AC.K 



l\ y.ats 



(Day) 



.Mouths 



(Year) 



\\ rr)(>\vi<;i) «»k divorckd 

iHiitt. in s.H-ial disiKiiatiuu) 



Days 




inRTiii'i, \ri-: 

iStatf or Coiintrv) 



NAMFv OI 
'•A IHKR 



niKTMPI.ACK 
0|- FATIIFK 
(Stalv or Coiintiv) 



t'Lct^Axx^ _^. 



I HHRrCRV CHRTIFV, That I atten.Ie.l deceased fnm, 

•••^•M^ ^ 190 to dx|vt ^ ,90 1 

that r last saw h ..* ahve 011 O-C^vtr ^ joqI^ 

and that deatli oceurred, f,n the date stated above, at \ SS 



a 



M. The CArSl«: OF DI^ATH was as follows 



^wC>\-*-An-o. ' 




C:l\^.)A,q.wL..... 



maii)f:n namf 

oi- MOTHFK 



ItlHTHPf^AOF: 

oi" .M()Tin:K 

(State or Coiintrv) 



I 



D( RATION. Years 

CONTRIBUTORY 



Months II Days Hours 



? 



DURATION 



)'cars 



Months 



Days 



- vUA^VvCtX 



OCCrPATlON ^^ t 



' SIGNED ).LD I'-, .CiuiLl*va_ 



Hours 

M.D. 



Rfsidni ill San I'lam 



r.^ro 



)''<n- ^ U,>ii///s 



Jhiv. 



■'■"m"T);i5---;j;--^^ 



«r?.L^^'fi^, "^fO'^'^ATION only for Hosplfals, Institutions Transients 
or Recent Residents, and persons dying dway from home. 'ransients, 

Former or 
Usual Residence 

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



lU i A y A-f- How long at . J 
lU^UUv (Jt p,,,e 0. Death ? 6.4\.i Days 



(Info; ma tit 



Hm h^ 



(Address 



VCU 






^■\ddress 



.-i.i.oa M> 



UL'«i^<3,v^rv.\.j:A 



-\f 



«r/g'ru" e'of d7a"tS" n'";""-' ^ ^""'u'" ""-'""'• *«E ,h„uM be ,.„..d EXACTLY. PHYSICIANS h >." 



'--3 




•''.if 



t jfi 



it 



f^t 



H..:ti<l r,f llfjilth - J" No. in < 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



liftl' Co 



hate /v/rv/,. Ox|xtj^-vA.L^ I.D 




iA^ 




lOO'i 



Registered J^o, 




AK| Deputy Health Officer 

DEPARTMENT (JF PUBLIC HE ALTH-City and County of San Francisco 

Certificate of H)eatb 

( Xa. S. StanOarO ) 
PLACE OF DEATH: -County of to.^ J Ko.^^,^ City of Oa^x.^Va 



Na t^H Vt^U 




■>XCC4.<J^ 



(1 



I' Dt.TH occu.s .w.. r»oM USUAL ncsmrNrr ^'^*'' '^** ^ ^''^ »"<* ^ -t!' 



FULL NAME 



<A 





SKX 




DAT!': <)!•■ lUK 111 



'\aU 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 

Muuth) 



XUu 



(Year) 



ACK 



4: 



(Hav) 



(Year) 



^i ''•"'■' t .l/,-v///,v jo /J^^,,,. 



^IN'<.I.K. MARKIKI). 

\\ IDOWHI) OK DIVoRCKf) 

'W ritr ill social (iisi^Miatioii) 



l''n<Tm'I...\CR 
iSlatf or Countrv) 



NAM J- oi- 
HAlin:K 



fnkTnpi.ACF 

<H' l-ATIIHR 
'Statf or Coimtrv) 



^IAII)J:n NAM1-- 
OI" MOTHHK 



'nRTFIlT.At K 
«>l" MoTlUvR 
(State or Coimtrv) 




WEDICAL CERTIFICATE OF DEATH 

DATE OF DKATM L 

d-Axt 1 

(Moilth) nx-iy) 

I HRRrCRY ClvRTlFV, That I attendcMl deccascl from 

Wtc^ IS 190S to ...cUl^ 1 ,^ c^ 

that I last saw h ..m alive on 3x1 Ot 1 jgoH 
and that death occurred, on the date stated above, at ^5' 
•2 M. The CArSfv OF DivATM was as follows: 
^Loujt- V.ib.-\W.vb "sLluuLo^. 



COXTKIIUITORY 0. ai.\v^.i-L.cL\,.'i..-vi^ ^ 

I)1;RATI()X6c-^.1 y-cuirs Mouths Pavs 

( Signed )...Mv^l' "^' . -^ - -. 

jt ,' ' ,^ 

-^'^'v^'^ '^ TQo'i (Address) \ \) )la. 0.,> . 



//ours 



H 



//ours 

M.D. 



«,?^^9'^'-. "^^^^'^'^'^'ON only for Hospitals, Insflfullons Transienfs 
or Recent Residents, and persons dying dwdy from home. 'ransienfs. 



OCCrPATlON 



^OA.^Vic^ vtov 



M,n,tl,^ 



'■''mt^T;;i^';|^--,-;-;-'.-.<T.c-^ 



Former or 
Usual Residence 

When was disease contracted, 
/></,. If not at place of death ? 



How (onq ^\. 
Place of Death ? 



Days 






N. B.. 






ri.ACK OF HCKIAI, Ok RFMoVXI ITTTtT h i., — — — — _ 

ns •^t.>io\.\i. I I>AII-. of Ml KiAi. or KFMOVAI, 



• 



(Address ..Aw 



KV^'-Jrl.<finV.\.. .C)f.. 



«r/cAu" E*OF'DnrTH"i„'''„7''' ?" -""'"J'^ ""•"•""'• ^CB ,h„ul,. bo »,„u,l EXACTLY. PHYSICIANS K ,. 



m 



T 



^7 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M<>;inl of Hiiilfli - ]■ So. IK Tf^iSpi^ H&r Co 



REFER TO BACK OF CERTJFICATg FOR INSTRUCTIONS 

Begiatered Jfo, 1 544 



Dulc /vVrv/, .6jL|xte-r.^v i 190 \ 

c^Ji\^,.^Ji^ lsX\^u Deputy r'cafth Officer 

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

Certitfcate of ®eatb 

( 'U. S. StanDarO ) 
PLACE OF DEATH:-County of ^ a^v'^.'vcv^ct^c. City of ctx >v'?,'uct. . 



,-% 



i^vj, O ( 



No. 1^^^ v:r^.^oL„Vk^„.„,,„.,„,,^-^,,t^,„Dist.;bet. 15 tl ,„d :U.i; 



FULL NAME J.Ktn->vcu.^ ^ 



^j:\ 



PERSONAL AND STATISTICAL PARTICULARS 
A j COI.OR^ 




C^K 



111 



'>Ari-; oj- HIRTH 



ttU 



MEDICAL CERTIFICATE OF DEATH 



l^V .fv JU 



DATE OF DKATif 



^ 



ACR 



. I LCLu 

(Month) K 



(Moiiih) 



fc 

(Day) 



., U% 

(Vear) 



(Day) 



I9o\ 

(Year) 



'it JV,//.« '^ 



Mouths 



^IN<".I.I-; MAKKIKI) 

U IDOUHI) <)« I)rV(»Ki-Kr) 

'\\ lite ill s«Hi.-il <l(-i}.'nati<)ii) 



Da \s 



I HRRKRV CI:RT1FV, That I altc.kMl .leccased from 

Hto^ a i^ V to d.^vt:...l iQO M 



(Stati' or Count! v^ 




^1 n .AA vj 



UXA.Vw^ 



-U^ it .,^ . lu ....^.^|v.v. .u igo 

that I last saw h v-»^ alive on OXtxt^ ^ loof 

and that <leath occurred, oti the date stated above, at ' 
-^ M. The CAT'SK OF DHATII was as follows: 



VAMK..K >> ^-^^^ J.VCL^XCUl^C^ 



lURTnpI.xcR 

oi- iathhk' 

'Statf or C(Mintr\ 



MAIDHX NAM,.; '"J) . 

OF MOT I IF K I i^ 




DrRATlOX X Years IMoulhs Days Hours 

CONTRIBUTORY <^l^liJ<^A^V.^ 



1)1 RATH )X 



Years 



Afonths 



Days 



'«IKTni'l.ACF 

«>i- M()Tni.:K 

(Statf or CoiiTitrv) 

\1 II 

^'■'■''<f'-<f ni Sat, r ia,n i^,-.> Yra,^ 



(SIGNED) tox^4\.. cLa.a^ 

'^^^ ' r^o'^ (Address) :1b 0^ ^^...^. . 



Hours 
M.D. 



rc)o 



nr^.^n^^'^'-. "^!f°'^'^'^"'''ON o"'y 'or Hospitdls, Insfifufions, Transients 
or Recfnt Residents, and persons dying away from home. 'ransienrs. 



Mnnlhs 



/>it\ 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



(Info 



Muant 



^■^^MNu^ 



cy? 



^A'1<lrcss l^OX ^J.\A^.t ^l,y,^ 






IXACF OF m-KIAI. ..K KKMOVM. I I'ATF of nr« ,.,. or R FMOVAI. 

rXDlCRTAKFR W ^ ^<i^vM)l'(A,^,^vtu\i^,^^^ 
(Address ...!l.j[.l...^|Lui^ur>-Vc1l I 



«on. dyl„4 away from home hHouIcI be liiven in everv inHt-nL "'"""■^'*^*'- ^^"^ Special Information" for per- 



I 






1 



I 'I 



. r 



?H 



' /*"t« . 



"'w^y.. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

)!'.;ir<! of Il.alth f-" \o i <; "^•f^^^) IU«t I' Co 



Ihf/c /v7rv/,.3x|xti^T-^i^v...l.D^ 190\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.-CrUAO 




Begisteved J\'*o, 



1 545 



\M, 



\- 



^ f " 



"•i^... ;.. ^:^.'^il,fi...Q,01 ce r 



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

Ccitiffcate o( JDeatb 

( "a. S. StanOarD ) 
PLACE OF DEATH: — County ofCJa^^. Oa- , z^j^l ru.r .*^o ... i v 



Z{A.CL City of a^>v J V<X>vC<„w 

No. 5 V/a %^:d... St . D.t . ^f ^^^a > - f f ' 

/^ .r otATH IccuRs AWAv rpoM USUAL REsiDrNcr ...r ^^*' ^^^ ^ ^ 0^\X:.J.A: and _.^ a* 

( .. DEATH OCC.RR.O .. THO^S^PrT^^ O^^ f^' S^O^'^^. vV^^I S,Vi,V I^^TE^D^^? Jr^ eTa^'o^ ^ M^-^R^^"' ) 

FULL NAME LLt.X.<a.iKX'k. ^Lm^-nAu 



U.' 



I>ATK OF UIRTil 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ 



-u 



L 



MEDICAL CERTIFICATE OF DEATH 



^Li\\cL. 




iwXjL. 



DATK OF DKATH 



I 



^1 
'MoAth) 



it... 

(Day) 



(Year) 



AGE 



I ' ' - J 

......... Sw.-4^Ar.\^:^.... 

(Moirth) 



) 
(Day) 



(Year) 



..^ 



^ '•'" -^ -1 Muu/As 



■A. 



H IDOWHI) Ok DrVoRfFD \ 



Da%s 



(Statr or C')uiitrv 



NAMi: OF 
t'A'IHFR 



'UR riipi, XCF 

'V" i'Arin':R' 

<Statt' or Couiitrv) 






,|I IinRnRV CKRTIFV, That. I attended ,UH^oasc.rf;;n,; 

^^<-^^--^i3.^..>.-....lijO.± to ...4-^f^^• -^ 190^1 

that I la.st saw h ... alive on U.X.|\t:.. ^ ,^ 

and that death occurred, on the date stated above, at "i 3..*.. 
aT ^^' |T'•*-^f'^^■^''' OJ' nHATir was as follows: 



n 



f) 



^cctUxu^r- cLu 



^fAiniCV NAMK 
<»!■ MOTIIFR 



niRTlIlM.ACF 

'•I' mothkr' 

'State or Coiijjtrv) 




I)1'R.\TI(3X years \ Monihs 

CONTRIBUTOR V aX:vx.^L 



Days 



11 J 



^W<t,_ 



Icttt Hlatcl^ 



DUR.ATION J;,^,-^ .....Months 



(Signed) \,lj 



OCCri'ATlON 




%%c.^ 



Da vs 



fVJAX'U.tsi.h.c^:.". 



C^-^ixt7 ^ ,,oM (.Address) ii::HQ})^4.d ^j 



//ours 

//ours 
M.D. 



nrf ^9'fi'-. "^'f^'''^'^"''ION only for Hospitals, InshtuHons, Transients 
or Recent Residents, and persons dying away from liome. 'f-nsienrs, 



5 '"(".v T. Afmithy 



n,n 



(rnfoiniant 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 




l^CK OF HFKIA,, OR RHM..V.uJ nA.-F ..f H, .,.,. or R KMOVA,. 



190 



INDICRTAKKR 



^Address H)'^ .. ^l^Ui^^v A) O-tL.Ll^ 



«on, dy,„6 away from home should be feiven in every instance "*""^*'* ^^"^ •^'»*=^'«' Information" for p*r- 



I" 



ill 





i ' 'I 

'1 



t <•' 



ii 



if 






I :U. \ 



^. 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

Ilo.inl of ll.iilth- !•' No. \<. t^-f^SS^ H,«t I' Co 



!)((/(' Filed, 





REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 



10 VJO'K 

\x/s>M l^eP^ty Health Officer 



Registered JSTo, 



1 516 






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

Certificate of ©eatb 

( XX. S. Staii&ar? ) 
PLACE OF DEATH: — County ofC Cu^ >J A^:^^vc^<i^ City of C'^^t^ J A^^-wc^^eo 



No. "is \ alj;,v^aJL\.- 

(ir OtATH ( 
IF Dt*T 



^ 



OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FA 
■H OCCURRtD IN A HOSPITAL OR INSTITUTION GIV 




St.; ^ Dist.; bet. K^>^ ^nd vj .UAtrv - 

JIDENCEGIVE facts called for under "special INFORMATION •\ 
NST.TUT.ON GIVE ITS NAME INSTEAD OF STR E ET AN D NUMBER ) 

FULL NAME J./lXX/rvcu^ cCoaa^Kja; 






PERSONAL AND STATISTICAL PARTICULARS 



<i:.\ 



nlou 



COI,OR \ 






" \'\'\'. <)j- lUK rn 



a 



IP I + 



(MoiitlijT 



11 

(Day) 



/lis 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OJ- DHATH 

6xi\t T 

(Month) (,),,y) 



190 M 

(Year) 



Af'K 



bo )rius 



u n»<>\\ HI) OK nivoKCKi) 

\^ iilf 111 MH-i.-il disiiMKilioii) 



"IKTUIM.ACR 

(State or Country) 



NAMH OF 
'ATHKR 



I"l<TinM.A{'K 

f^i- i-atiikk' 

'St.itr or Country) 




■V,;;/Mi lkj\ Days 



■OJWxJu<L 




I HHRIvHV CKRTIFV, That I aUe„<le.l .Ictvasc.I from 

V-^v H upH to BoL^t 1 190 S 

tliat I last saw h /LVw alive on C)jL,lvtr X up H 

aiMl that death occurre.l, on the date stated above, at ^ 
U ^\. The <-^^l^I': OF I)|.;aTH ^vas as follows: 




C 



■/AX/CU' 



OiA? 



"^lAIDKN XAMK 

•)i- mothkk 



"nrrnpr,ACFC 

'>!• MOTMKK 
'State or CouMtrv) 



occ 




DURATION Ycar.,^ Months Days Hours 

CONTRIHrTORY C>AxflCA^vtL^rVt 



^l PATION ^ ^ \ \ f^ 



Pays 



DIRATIOX Years ^ Months 

(SIGNED). U. U . ^ J ^U'v-wA.^ 

^...JLx^L t iQo'i (Address) JI^H \tAXVtU,..OJl 



HourK 



M.D. 



f ^9'fiK"^f^'"^'^'^'0'^ ""'^ ''>^ Hospitals, Institutions, Fransients 
or Recent Residents, and persons dying away Irom home. 



Mnntll- 



na\ 



'"" ' V)ivd4v IcuatLv 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Davs 



IKIAI, OR K};M()\AI. I DA' 






^\<l.lres,s d OU^V^ 



^))Utu 






KiAi. or KKMOVAI, 



(Address .^a.'^.^KcU^^. {)cLt:. Q..^yi. 



HtHtJ'cAVfiE of DfV^Z'''7''' *'''"'''""' '"^^^^^ ACE should be stated EXACTLY. PHYSICIANS .h„..IH 



' t 



D 



'Jt 



I it 
I 

« 

J 






y 4 



I !:.f 



'*|.U 



/ 



I 



Hi 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

lic.ird of IK allli- I" No. i^ ^•?^,Ss>^^, JUtl' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Bcgistered J\''o, 



t5l7 



Dale Fih><l ,^jO^Xsuy-A)JO\j ID lOCH 

\Js\^^J^ dU/vM^ Deputy HcGith Officer 

DEPARTMENT # PUBLIC HE ALTH-Cify and County of San Francisco 

Certificate o( Scatb 



No, 



PLACE OF DEATH: — County of 



M Lccivou 



St.; 



City of MjLtrv^-'W'VV 




.Cj: 



— Dist; bet. 



and 



( " -"».°„"cc%%r.r ,rr„„"-- :i^:^5^::^iJ^^i ,;- -ip .%%%=— —-r' 



FULL NAME 



) 




.'.>a.....LL ..CrCr.cL Ax4Lt^a..... 



■):\ 



'All-: «)i- luR rn 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR ~ 

1 ■ \ II 



\oL 




I \t'.K 



(Monlli) 



(Day) 



(Veai) 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DKAIH i; 

QJLi^t % 

^(Monlh) (Day) 



(Year) 



(dH 



) fi/ ; s 



^h'tilhs 



MNT.I,}.: MAKklKI) 

\\ IDoWKD OK DiVoRiKI) 

'"iitf in stx-ial fU -^itMiation) 



Alty 



r irnRHHV CKRTIF^V, Tl.^t I attended dc(vase<l f 

—~r~ 1 90 . .-:.-:rr-r-r-to - ^ 



roiii 



that I last saw h 



•^^-'— alive in\ 






(Stair or Country) 



X/vx<y\a 



aii.l that dentil occurred, 0.1 the date stated ahove, at 
^r. The CAISK OI- J)|.;ATn was as follows- 

,1\ 




' ^^..^uuxjlA.. 



'•AllIlCR /VQ 

'!IUTin-l,\(K v^v^rwi 

'»•■ i-atmkr' ' * 

(Statf or Connfrv) 





JV<7;'j Months 



Pays 



J lours 






^An>HN xami- ,-^ 



^^-cnl^m, L> 



CONTRIIUTORV 



<na.vu. 



niKTMPf.ACF 

;•!■ mothkr' 

(State or Country) 





"Ulhj UXOA/ 



■ i-^vl' I rcjo' (A d.j rc'ss) Xl M.^.^xlvOv.1^ w. a.'. 



Hours 
M.D. 



OCCITPATION 



CixN^ 



i-toaoAJUfloa^ 



„r?''^9'fi'-."^f^'^'^'^"'''0'^ ""'' '"' ""^P'***'^' 'nstitufions, Transients, 
or Recent Residents, and persons dying away from home. 



^ 



/w- id,-,l in San //, 



rnfis^tt 



ao 



)>•(?; 



"i.»I <»I' Xn KXouij.-ix-.K AM) Jil- 
^I"f'>Miiant Co . Uj. VJ 



.^/niitfn 



Ihn. 



Former or 
Usual Residence 

When was disease ronfracted, 
If not af plat e of death ? 



HtjH long at 
Plai e of Death ? 



Days 



*"ri, AK^ AKJ'; TKi ]-; lo im-' 



CJ-VA>-t\, 



I'l.ACJ.: OF in RIAU ,,R RKM..VAI, I.ATj^o! Hr.,^,. or RHMOVAI, 






X'Mnss \'X^\ 




^ 



'^A^CaXcL/^v. 



H 



N. B. F. 



r.vDi 



:rtaki.:r U. UJ. M flxX^tAyvu ^ Co 

fAcl.lre^s 3> H ' "J ^XA'U.lt ^t 



190 



"«"aTe^CAu"sE'of dTa^^^^^^^ '"* carefully MupplJcd. AC'K nhould be su.tc.l EXACTLY. PHYSICIANS „hould 



^, 



i 1 f 




l|i^ 






i 



fl 



i.'^i 



^ixiL^km.. 




}!..;ir.! o|- HiMlUi I- No. ,^ t'-^^^^y \iSi.V r. 



WRITE^AINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BEFER TO BACK OF CERTIPICATE FOR INSTRUCTION S 

Eegistered J\''o. 




16 



10 0\ 



Dale Filed , 

3^Vu.o A.IAMJ Deputy Heallh Officer 



1518 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of H)eatb 

I tl. S. StanOar? } 



-f ^ 



No. UL, 



PLACE OF DEATH:-County ofc)<xov.!i!^<vv.^,,,, ctv nf ic^.l^, 



y\Jj\^ 



L 



i.:t,';. City of U.cXAA/ JXcl^\ 



j 

r ir DtATH occupg AWAY TRbl- USUAL RESIDENCE c.wr r-r^l** ~~" ~~~~ and — r 

^ .^ O.ATH OCC..R.O IN . HOS.TA. OR f ^T^^JVf O^." ^ / ^ ^ ^tl^i -"t ^^^^ 3;%^^^ aV D^ ^ : " '^ ' ) 



FULL NAME 





IX/lxJu-Qw.-.dL 



--I'X 



'ATI-; (Ji" iJik I'M 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR ~ 




a 




VU 



MEDICAL CERTIFICATE OF DEATH 

DATK OF r)i;.\'rn 

dxkt . 






(Month) 



6 



AGK 



h 

(Day) 



» V ) t-ats 



1.0 



Matilhs 



'-IN*'.!.!-:, MAKUIKD 
\Vn)..\yi.;i) OK DIVOKCHi) 
\^ ntf 111 social 'ksi>n;,tioii) 



vl.U3 

(Yertr) 



■ Dars 



(Day) 



(Yt-ar) 



i IHvRI-HV CKRTIFV, That I alUn.k-.l .Iccoasecf 7 
190 -to — 



roni 



til at I last saw h 



alive on 



'''l'<Tfn'I.ACR 
'>t;itf or Couiitrv) 



XAMi: OI- 



'•"-"i'in'i,Ai,-F 
<V" '■atiifk' 

(Staff or Coiiiitry) 






<>!• .M()Tnj:K ' 



'■'KTFIIM.ArK 
''!• -MoTHHR 
'Mate or Countrv) 



OCCIFATION 




and that death occurred, on the date stated above, at 
— - M. The CAISK OF i)l{ATII was as follows 

vW.tev...,. 



I90 

1 90 



V 




VL'CCcL 









/hn 



■s 



Hours 



C()\TRli;iT()l>iY 



''C-^%A-^:::i^v'ci. 




(Signed ). l^rVcrnxv 



Afouths 



Pays 



'•^ .i.. 



UfO 



A.ldresv;) UrV(rnx»u wi 



O^vwcC. 



//o/fr\ 

M.D. 






nr^.L^^'f!'-. "^f°'^'^^''''0'^ ""'> '"^ Hospitdls, Instituflons. Transients 
or Recent Residents, and persons dvina amy from homp ' """^^^^^^^ 






persons dying away from fiome. 

^*^ Place of Death ? 



M,.>ifh^ 






Wlien was disease confracfed, ' 
If not at place of deatli ? 



Days 



iyCK,>F m-R.Ar.OR RKMOVAI, | HA'^C of H, . ,. .. orRHMoVA 



^A.MiTss "Xa 





^uCA/^ ^uXcO'vw 



i- 



ei. 



rM)];KTAKI-:R 



'^>AJl<5 



\Uvof Hi KiAi. 



190 



N. B R^ 



A'l.iiUs li^ L^idv^ "' 



Htrt7Jr"sE'oF hT;^^^^^^ ^' "■"^''""^ r"'''*"^^- AGE should be «tnted fiXACTLY. PHYSICIANS . 



hould 
p«r- 



i»f ' 



■1, 



i m 




i **» 







ii. f 



WRITE PLAINLY WITH UNFADING INK 

]'uKni] wf Il.alth — I' N'o. i^ 3v^S^t) IU<t P Co 



/)(//(' Filed 





10 



7^(9S 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Segistcved JVo, 



1549 



Deputy Health Officer 

DEPARTMENT t)F PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( "U. S. StanDarC> ) 




PLACE OF DEATH:-County of ^ CL-w 3 .►vcl 

No. OS \ oU -\.C\./^A v^wv 



Avcuitto City ofOo.^. l^CLAv^v>ioo 



A 



(' 



''^^7X^^., .v.*v r«OM USUAL RES^DENC^o.v. J^j^^t- bct.O aCVO/^^^^^ andlctlatr\ 

FULL NAME Ia>cUav<x cUr^'VAi^n. 



AVV.CL ) 



PERSONAL AJNiD STATISTICAL PARTICULARS 

^'■'' 07^ [j I color; 



.t 




IL^fvCt-c 



Xf'.K 



I'Moiithl 

•4^ 



t... 

(Das') 



(Vcat) 



^MEDICAL CERTIFICATE OF DEATH 

DATK OF DK \TH > 

^^ I •4— 

^-.iaxt:..,. 

(M'.iuli) 



^ 

(Day) 



l<?o \ 

(War) 



J fU I s 



^IN<.I,H MAkKIKI). 
'vVntfiu .social ik-Kijniation) 



... .^/iit/Z/is .. 



(State or (.'niiiitrv) 



C^.o^va^ 



^ 



I y'^I^'^' CKRTIFV. That. I attcmlcl decc-ascl from 

V^^ '^^ I90H to ...cSx.|.vt. % 



f)a%i 



NAM!" OK 



D 



u 






that I last saw h .. alive on OJlI\1.. k 



190 
190 



ami that dcatli occurred, on the .late stated above, at ^3 j 
^^ M. The QAVSli OF I)I.;aTII was as follows: 



VCrOX^V^.-x^uOk.., 



*>'•■ ••atmhk' ^7. 

I state or Couiitrv) , D 




Dr RAT ION 



MAirmN XAMK 



MlKTiriT.ArK 
JH- MOTiIKk' 



iiruxx^t U'pji cUlxvcU L 



^'■'i'-y 'l^'^fi^^i'i Days 

CONTRHU'TORY SS^10^^...J0a 



Hours 



1»— iutk\»A„. 



Pars 



^LvCt^f^WwCL L 



^Vv^'i, 



•"»" II I'.K i ' 

'tt' or Country) H 

r 



1 



*>CCrFATrON 



-'£t^v\)M.I LtC 



^1 







niTRATIOX ...... ;Vi/;;y 

(Signed) l..ij...yb. 

(Ad.lress) "ibD mfr\\i;£U4 \\k 



X 



.'\fn)iths 



//ottps 
M.D. 



lc>0 



^^-¥1 



« ?^^9'f!K ''^'^^"'^'^"'''ON only tor Hospifdis, Insfilufions fransienfs 
or Recent Residents, and persons dyinq awdv from liome. 'ransients, 



/hn 



former or 
Usual Residence 

Wfien was disease contracted, 
If not at plaf e of deatli ? 



HoM long a{ 
Plare of Death ? 



Days 



J'<^>V(X 



X'Mross 



L 






N. B Kve 

son 



^VCH...- m-KIAI, ,,K KKMnVA,. I DATI-of ^Uu^.^^. orRKMuVAI, 

•ni)i:rtaki.;i< UoXcAAfc. MfVaV^.^^ VLo 



'taTe^'c^UrSE'oF dTaT^^^ l'' ^""'''""^ Huppliecl. AGK nhould be stated liXACTLY. PHYSICIANS . 



should 
p p4tr- 



••(^ 



1^ 



i -! 



I if 



III 



«■ 



m 




WRITE PLAINLY WITH UNFADING INK 

Hojik! ,,f III iltli-l" So. in *'f^^r^!S^j}&l> Co 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




190^ 



Reglsfcj'ed Xo, 



1550 



DEPARTMENT OF PUBLIC HEALTfWity and County of San Francisco 

Certificate of H)eatb 

( XX. S. Stan£>ar^ ) 
PLACE OF DEATH: — County ofCct'\^ J AQ^'.vcolcoCity of Occ-v-^ 3. V<j^^^v^^ ^^ 



No. v^U 



wt■^^\^lvc^Vi./iX St.; - 



Dist.; bet. -^:----r----.rrrrrrrr~T^^ and 



( " 'i^"^.^^::^; ::v^^^ :^^i^^j:^^-:t^ ^.Vm" ,r,.r j? :^:n-^:^'^:^n 



) 



y 



FULL NAME 



MilcuvU. 




PERSONAL AND STATISTICAL PARTICULARS 

i)\iK »)»■ itik in . 







;i)ay) 



MEDICAL CERTIFICATE OF DEATH 



C^J^t 



•Moiitlil 



\<-,K 



(Year) 



^ 



}'r'(n s 



Mnilhs f , /)„ 



(Vfjir) 



^\ii)()\y};i) OK i)[v«»RrKr) 

\\ iitc HI social flfsiyiiation) 



I)ATI<: oi- I)1:aT1I 

CW^ ...: ^ 

(MoiltJi) (Hay) 

i HIvRl'HV CIvRTlFV, That I atten.le.l .k-rcase.l from 

^^ ^^<^^ It) icp to ...C)-^jxt I i^^ 

that I last saw h .*-'« alive on Sjiivt" ^ up «^ 

ami that death occurred, on the date stated above, at \ 

tf M. The CAUSK OF Dl-ATII was as follows: 



nrRTm'i.AOH ^^ 

^tatc or Comitry^ I i/ i] 



N'AMK <)I- 

hatiii;r 






T«IRTHI>i<ACK 
'>.'• IATHKr' 
'^tatt or Contitrv') 



•"• mutuhr 



'«n<Tm.r,ACK 

<>!• MOTHHk' 
fStatf or Coniitrvl 




U ^JXxn.uUxA; X:-c*JXccajL. .&r ^ 




a^<?«Ui 



DIRATIOX J',v7;-.9 
CONTRIIU'TORV 



Months /An'V 



I/oin .'\ 



••• ••*•«» S»«^if 



IH RATION Vi-tirs 

\ ,x ff ;^ 



Mouths Davs 

(SIGNED )...LU. b. Ur>vicU>v 

Address) UJLai\A.^\JVU.v..>. 



I/oms 

M.D. 



Tqo 



(. 



?''^9'^'-. "^^^'^'^'^''"'O'^ ""'^ '•"■ "o'^P't«'ls. Institutions, Transients, 
or Recent Residents, and persons dying dway from liome. 



occri'ATiox 



cr>^v>utatA-/Q. 



Former or / ] () ,] 

Usual Residence LlX^w^ vo-va^^ 



How long at 
Place of Death? 



MniltiK 






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



Days 



(ii 



W 



^\< 



N. B 






I'l.ACK OF lUKIAr, OR RKMoVAI. DATJC o! ItrniA,. or Rl-MoVAI. 



Q-^-^^^vwvuu U xxXx 



A 



3J^vt^ r 



ini)i:rtakkr 






I90I 



^t7t7c'iuSE^of oTrVS" •^"''' "' ^""-^'""y supplied. AGE «hould be stated EXACTLY. PHYSICIANS should 







,11 



'^% 



i i 




t--i 



m 



Ml.! 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l?.>;inl ,.f llralth 1' No. i-s l^-f^^^^IKtl' Co „^„ 

""'" REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 




Dale Filed , 



4 OO J 



cM-u^u> 






10 2fJ0'{ 

^ Deputy Hozllh OfTicer 

DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 



Certificate of Hieatb 

( la. S. StanDare> ) 



PLACE OF^EATH: — County of Oo.^ ^X^V^c^^c City of O C^^ ix<X^vvcc<lac 



fNo. S^:i la VT,<vcJkVC 



_^St.; 9. Dist*; bet VJ CrVAJ-L. 



( "^ i7DrATM*'orr.fLl'^*'' "°'^ USUAL RESIDENCE GIVE facts called , 

\ IF death OCC»thRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



u 



and 



Qx 



FULL NAME 



J.^^/Cu-Wh-. 



rOR UNDER SPECIAL INFORMATION ■ N 
INSTEAD OF STREET AND NUMBER J 



Ol^LO 



) 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 COI.OR' 



iJATl'; ol- |!IK 111 



WaL 



Ai.K 



iMoiith)/' 




VW 



i(L 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII 



ux|\t 

(Moiit/i) 



O 



(Day) 



XX . 

(Day) 



(Year) 



7.S..D..M 

(Year) 



^1N«.I,K. MAKHIKD, 

^^ fiM»\yi-:i) OR nivoKnn) 

' \\ iit^- in social (U'si).ri,atioii) 



^'''"" i .!/-/»////> 1% /)ays 



MFKTm'I.AOK 

'Stall- or Ciiiiiitiv) 



NAMF Ol" 

jatiii:r 



fHKTMPl.ACK 
<"■ I" ATI IKK 
< State or Coiintrv 



"^lAini-lX XAMK 

'>i mothkk 



•'•nnniM.ACK 
ni' motiikr' 

(St;itf or CoutUrv) 



d^-v^ 



, 'oXx 



J I HEREBY CERTIFY, That I atte,„led clcccased fron, 

o.x^l»..„.x.. 190H to J -^vt E 190 H 

tlial I last saw h .A-'::*>\ ..alive on Q JL.(^vt. to 190 ^i 

and that death occurred, on the date stated above, at 5 
^^^■-^rhe CAISE OF DICATH was as follows: 

L'^L4/v^.tv.o 



n 




DFRATION y.ars Mouths - Days 

CONTkiiu'ToRY .y.l{r.>:NX 



DFRATIOX 



OCCUPATION 

hV^idnf i„ Sail /'i,,„, ;>,v 



A f 



(^IGNED ) 

OjUvI ^^ rqo 






Years Afonths Pax 



Hours 

Hours 
M.D. 



■1 



(Address) 1^ 






?''^9'^^. "^^Of^^ATION only for Hospitals, Institufions Transipnh 
or Recent Residents, and persons dying away from home. ^'"""on^. iransienFs, 



)V,7/* I Mniitll^ 



/'(/ 1 






former or 
Usual Residence 

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



flow long at 
Place of Death 



Days 



^^•I'lres.s SX^ 'l^ \J,<X.CC 



I. ^ 



i 



N. B. 



^m 



VLM^K <.>• m-RIA.. OK KKMOVAI. I D.VTiC oM. h ,. .. or R K M„v AI, 

C>XcJLwO^-^ I OX:^^!!^....].! JgQ 



^oJjOy\Xx mX<X.\a.:>vv;...''.H<.. 






«ons dy.ni away from home should he <viven in every instance ^'"**'*'^''- ^^'^ Special Information" for p«r- 



» [I 



't; 



■■f 



I 



I' 1 !• 






I if 



tM 



i: ,it' 






*/ 



I 



ih: 



I ml' 



ImI 



'■*: ^^^*- , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li.Kinl ..f irL.'iItlr I-* N'o. 1 <; ^T.^^3^~?fc Hit r Co m,...^- «^ 

-"^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r F/7r(/ ,S}jL^^\jjy^\Ajdi\; 10 IfJOH 




Be^isteved J\Po, 



1 ^^O 



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






Certificate of IDeatb 

( "a. S. standard ) 



'No. ?- 



PLACE OF DEATH:— County ofC a^ JAxinxcui.to City of Cloov Jxa-,x=.w -c 

iTt 4 ^ 

\^ \\XkkriXKjJi and ^T .^Ct>\ eu 



Id VJ 0-VvK^L.l St ♦ I Dist * bet v^ 



FULL NAME 



h\KkA. 



^i:\' 



PERSONAL AND STATISTICAL PARTICULARS 

C()I,<)R\ 



HoJLi 







V' 



..aA..C' 




i»Ai)-: oi iiiRiji 



^ 



/UJ^aax 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATJl jj 

dxkt ^ 



(M(uAh) 



oxivt T 

Moiitjl) (Day) 



(Day) 



(Vear) 



/SOH 

(Year) 



A.-K 



) V(M 



M.nttlli 



Dins 



I lUiKKRV CnRTlFY, That I atte„.le<l TUh-c;;;^.! frmn 

ojl\<!l. '1 i^ ^ to ax^. :i 

that r hist saw h ... • ahve on OjUnJfc % 



190 S 
I90 . 



^'n«.m:. makuiki) 

u idowki) ok divokckr) 

'U'litc ill s.K-i.il (Itsi^Miittioii) 



lUKTUlM, XOH 

iSt;itf 1)1 <",,ii,itr V 



NAM1-: OI- 

i"atiii;r 



Oxr, 



0^ 



1 



I 



and tliat death occurred, on the date stated above, at 
A ^^' T^lie CArSlv^OF nivATH was as follows 

C>r>A.Y'.^,^^l^tii L<>>Jj^^\^>vtx,t4.,^ pij 



'^IKTMPi.ACK 
<>'•■ I- AT F IKK 
'State or Coimtiv) 



01 .motfii;k 



MFKTMIM.ACK 
«)|- MOTIF F-:r 
'Slatf or Coiiiitrv) 



•>»<ii'A ^Io^• 
Av^/,^■,/ /„ s,ni I'l ,111, iu'it 




DCR.ATIOX Years 
CONTRIHrTORV 



Months 



Da j'.v 



Mouths 




^' y^'^ ^ .: ..0 



Pay 



nrRATlON Years 

(Signed ) 



Hours 

Hours 
M.D. 






<rVyv\.'a 



Special Information only for Hospiiais, institut 

or Kecen, Kesldents, and persons dying away from liome. 



\\m\. Transients, 



)V,M 



M.nilh- 



iKi 



■'''".?^r;;^^i):^^^;,i;'^;i^;r,?';s;;;<^;i;,;,i;^^--''^"' -^ '••' •'■•'■^ 



Former or 
Usual Residence 

Wlien was disease confracted, 
If not at place of deatli? 



How long at 
Place of Death ? 



^•" for ||l;||it 



LJfvtx^ 



(A*l<lrcss OvlC^ij 




''Ka "' '"' l^'Il'"' "" •^'■•^"•^•^'' I "AY-.MUH,... orKF.MoVAI, 



IDl 



IN. B. 



^Tj-: of HiKiAi. (H ki.:M( 
OX^..J.A T 

l-NDKRTAKKK yCJ J^cLlCXV.^» 




90 ; 



^\<l<licss 



«on. dy i„4 away from home hHouIU be ftiven in evert Instance "'"**'"•=**• ^^^'^ »»»«*='«' '"Irormation" for per- 



1 



r 



m 



m. 



■ >v I 



F 



i 



i'l 



« 



i 



4 



It 



r 



mm 



k 



'I 



f-J 



r 






^'. 



WRITEPLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






•V/rv/,,dx|^tx/vv^L£^ 1,0. 190 H 

i^Kxv^ ix\>u deputy Hesfth OfHcer 



Registered JVo. 



1553 




DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



( *a. S. StanDar^ ) 



Si 



A 0^ 



PLACE OF DEATH: — County of C<x-^ v}/v<XA^^c<i.co City of 3.a>^ 3xcX'%xtf^. 






v.. \„ 



NoAtW ^C Uu^xtv^ UimU-K^-.uXSt.; " Dist.;bet. and - 



FULL NAME 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

(Y l) I COLOR ' 




.C^OCul'V.L 



MEDICAL CERTIFICATE OF DEATH 



/cuU 



DAli: «)|- lUKTH 



'U^KaJ^ 



VIotUh) 



V 



iS- 

(Dav) 



DATE OF DKATH J? 

— .v" >v^!rSr'] Vu 

(Motilli) 



A(.K 



..../...S.'i'i I J 

'v-"^^ ...d-JL^. L 190 H 



.1. 
fDay) 



7pO 

(Year) 



(Year) 



*^IN'<'.I.K. MARKIHI) 

W n)o\yKr) OR I)i\()R{ j.;r) > 

'\\rit( ill s.K-ial (ltsi^r„;,ti,,nj 



HrkTHIM.ACH 

Strilc or (.'ountrv) 



V V Yt'at.K <3S .....Motilhs Q*..'^.. 



.Da 1 



»•■ ATIIJ'R 



'5'R'nilM.ArK 
'>'•■ I'AIHI'IR 
'Statf or Coiintrv) 



■^lAII'JlX N'AMK 
»»1- MoTMKK 




I HKRICRV CERTIFY. That f attended .leceascl from 

t" ■■<-' ' ' : 190 ' 

that r last saw h : alive on C^jLJxi t u^ 

an«l that death occurred, on the date stated above, at 3, ^ D 

y^^f- '^'^'^' ^^^ ^^'' DIvATII was as follows: 



<0^^wut^ 



HIRTHIT.ACF 
'M MoTHlCR 
fStnti- or C'oiiiitrv) 






-OlX. 



nr RATION...... JV/r;^ 

CONTRIIUJTORV 



Months > /A/)'.y 



Hours 



i] 



1 1 

/\fM,fr,f in San I'laniisro 



-i ' 



nuRATrox 
(Signed ) 



Years 



AFontlis 



X) ■ \D , wrv^LcL/>A^ 



Davs 



■V\\^..^, T()o'i (Address) LLJl^^\A.^X<v w^. t. 



Hours 
M.D. 



nr?.^„^9' M*-, "^f^"'^'^"^'^'^ ""'-' '"^ "»^P'f^'^' Insfitufions. Transients 
or Recent Residents, and persons dying away from liome. «"'»nuN, 



) 'r<t I 



M.-ut/r 



/>,!i. 







(lllfoMll.-ltlt 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatfi ? 



Days 



190 



\JJUy\\AA 



Vfr^V'^ .?. 



lyCH OF HIRIAU OR RF.MOVA,. 1 OATKof lU u,... or R FMov A,/ 

^•^*i<i'-^'*^« obios.- i>^.,^... .di. 



rNI)i;R TAKIvR 



«on, dylnft away from home should be feiven In evet-y instance ""*'"*'''''• ^^'^ »'»''*='«' Information" for p*r- 









.fl 



I 



i 



■( ♦ 



lij 



III 



Tsr35S"«-9^ 






4 













* i 



IP 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I'.uriKl of ni;i!t]i (•■ N'(V 1^ -^-^^IS^^. UScV Co 



Dfffr /vV^'^^ dxi^±X^^Jl^Vv ID 190H 



REFER TO BACK OF CERTIFICATE FOR tN3TRUCTfON3 




VCC^ 




Registered Xo, 



\ 554 



■\r\.i 



Deputy Health Ofncer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( XX. S. StallCar^ ) 

(3? 



PLACE OF DEATH:— County of CJa^^v JAyO^>v^:A^c^ City of Oo.-*^ .T .VOyv^c..^ ci 
No. ^^-W^ l*W>xtu UIrv>Vi,k^vc<Li^ St.; — Dist.; bet. and 



FULL NAME 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR > 




i 



\)\al 



t>ATlC ni- III KIM 



A < . K 







lllLt. 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 



/l.Iontli) 



30 

(I)ay) 



A'hs^ 

(Year) 



(Month) 



t 

(Day) 



bS y,u. 



MntlHl! 



\ 



I\l V, 



^IN'.I.K. MARKIKD 

w rixtUKi) OK i)iv<)R(|.;i) 

'\\iit(iii sociril <ksi>.Ni:iti<)n) 



niK'rFij'i.AOK 

'St.itr or (.'Diititrvi 



NAM!-: OI- 
"MIII-R 



'nKlllI'l.Acj.- 
OI- I-AIMIvk' 
'"^tittr or Coiintrvi 



MAII»I:n NAM}.- 

<»i mi)-i-iii.:k 



"IRTHIT.ACF 

<)i mothicr' 

(St:itr or Cotiiitry) 




I HRREBV CHRTIFV, ThatJ atten.kW (leceased from 

y^^ ^"^^ 1901 to 0^-X.S\ i<pH 

that I last saw li alive on "O-Mf^t- '. ^p . 

and that death occurred, on the date stated above, at 5. S ;* 
. '^■- A^'- 'Ij^l'^' CATSP: K)V DIvATII was as follows: 



(XLTPATION J? A 



nrRATfON Years \ Months ^ Days 
CONTRIIU'TORV 

OrRATIOX Years Mouths Pays 

f SIGNED ) U) \d . Kjr\\^,,, 

LX^X \. K^Q-. (Address) iXtwv^f \^,, •„>>. ■:, 



Hours 



A'cWiZ/v/ Z^/ SiDI /■■/ „;,, 



I \i'n 



) V<; / 



Mnntlr 



n.iv 



nrf^^^'fi'-. "^T^'^'^^^'ON nnly for Hospitals, Instifulions, Transients 
or Recent Residents, and persons dying away from home. "-nsicnjs, 



LUUwu^ 






Former or 
Usual Residence 

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



V^vy^AJl 



How lonq at 
Pla( e of Deatfi ? 



Days 



^V'Mress \AX^rv-u>a.1-V.V^.-V^^J,. 



Ij 



N. B. 



.'I..^:<>K m K,A..<>K KHMnVA,. I OAT K .. H. k .... or K KM< >VAI, 

C.N-DKKTAKHK "AxIUaa, ^■-' fc OLxCttVW 

'A.l.lress '5>ta^1^ ' I O^ XA.^± 



«on. dy.na away from home nhonld be feiven in every in8t«n!e ^'""•*'**'- ^'^'^ Special Information" for per- 



! ' .i 



\ 






|i 



11" 



»M 



K.'f 



It 

I 
I 

1:1 



k\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

!lo.tn1 .,f Health-- I" Xo. !«, f-^^Wk^ Hi«tl' Co «^^r.„«.^ _ 

' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






l)((fr /'7/r^/, dx|vtjt-^>J!h^A/ 10 lOO'i 

Xvu^<^XL\^u l^-P^t-y Health OfHcer 



Registered A^o, 



1 555 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)catb 

( XX. S. StanDarD ) 



PLACE OF DEATH: — County ofCa^^ JXO-'^^CciccCity of Oa>v in.<X >v c v^ a t 




/ „ „... St; 1 Dist.;bet. 0^ti>\A.vM^.t|^u and JLlK\t 



No. IHHt .i.CXv'^,^. ; 




FULL NAME 



si:.\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI,< )R > 



tluL 



I'AIJ-; oi- l;iKin 



ACK 




wViuC. 



'Month) 



1... 



) 'I'li i 



I 



'^'V.I.K. MARKIKI) 

\\ nMi\vi:r> or div. >Rr).t) 

'\\ rit< ill s(HJ;tl (I. vij.rt,;ai<>ii) 



■M 




IHKTMPKAOK 
(State or Oonntrj') 



lATlIHK 



lilkTili-i.ACK 
"• lAIHliR' 
iSt:itc or I'ouutrvi 



M Ml)i:\ NAMj; 
•" MOTMKK 



liiirrni'i.AfK 
«»!• .M(»ini':K' 

'State or 0)ntitivi 



i 



10 



A. > 



.1/ 



'OltllS i. ... 




V\' 



\%y..L. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(Month) 



O 

(Day) 



IQO \ 
(Year) 



I irKRFnn' CHRTrrV, That r atte,i,Ie<Meccasccl fro,,, 
LL^^x^^.'. j^-. to . gx^Jvb ^ i^q 



that r last saw h •.. ahve on 



'%■ 



1 90 



I hi r. 







atj^l that death occurred, on the date state.l aI)ove, at I SS" 
^ M. Jhe CAISlv ()!• DliATH was as follows: 





DIRATION "H^;?"' \lA,.M. 



Da vs 



\XJXX 



^)fXy\) JA^Y\^eu,e^ 






> 

nr RATION 



\ 



-cJb^^XIx. V]V(j-vv^JkjL 



'H-Ctl'.\ii,,x 






-0 •■ 

C ( ) \ T R I lU ;T() R \' L^XCjA \ wvtai. AjtLl^tU 
)N' )V<;/.s Mouths Days 

(Signed) .LLdxCoLuU vfc.h^thwvm^. 



Hours 



j\\ » 



//ours 



M.D. 

Xddre^s) llfcO Iva^lvvvxcy^^ ,. ^ ' t 

Special information only for Hosplldls, Inshfullons, Transifnts 
or Kfcfnf Residents, dnd persons dyinfj dWdy from fiome. 



14^1 ^ 



i<>o 



)V„/ 



Moulin -.- 



fhiv. 






(Aflclnss 9^H4^ ^<XK¥^^\ ^+ 



former or 
Usual Residence 

Wfien was disease fonlracfed, 
If not at plareof death? 



HoH lonq at 
Place of Death ? 



Days 



Obc^iu. Lmk^a^ I 0-^|a^ U iQo'i 

(A<hlPess....J.b.l.,M.}lA.AXLA.<riX.3t 






«rJ't7c'l'i^^U'i^'ir^"r'"" *'''"''''''■ '"''^^'"''*^ AGR Khoultl be stnted EXACTLY. PHYSICIlN^i K .. 



■ S '' » 



i'i 



I '' ■' 



I* 



;li 



1 1 



I' 



v\ 



< 'I 



as 



BBi 



'it 



^i* 



I I 

I 



t 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

!;"anl nF !l(;i!tli~ I" No. i^ T5?^^R^ nSi]' Co 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






sVv 10 



IfJO'i 



Registered J\'o, 1556 



jn ^ n ? • -^^ » I ' 1 -^ 1 1^ f.. r\ 



cer 



DEPARTMENT OF PUBLIC HEALTH-City and CoHnty of San Francisco 



Certificate of ©eatb 

( 'U. S. Stall£>ar^ ) 



PLACE OF DEATH:-County ofC^^.v J,^ua^^e.^^ City of OxXo^ "j/^ 



^vcoQ.e.c 



No. IS b 



h 



( 



' f/rrl °"='=''r= •*•" '•"O" USUAL RESrDENCEciVE r.CTS CALLto POB 
" Dt.TH OO^iuHRIO ,N . „„SP,T.L OR mSTITUTION C,»E ,tI NAME ,„s 



St.; ^ 



FULL NAME 



\\ 




and 

SPECIAL INFORMATION' 
F STREET AND NUMBER. 






.to. V. ^ 



) 



LCCVQ/CLVi. 



ct llU 



olh. 



PERSONAL AND STATISTICAL PARTICULARS 




MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 7 



•Month) 



A(;k 



(Day) 



,^H( 



(Vtar) 



Sxkt 

(Montli) 



O 

(Day) 



(Year) 



(.4 



) I' a ; .V 



Mirntli! 



MX., I,},: M\kKIi:i) 
\Ul)ou HI) OK I)IV(.Rii.[) 

'\\Mtf in MH-ia] .loivMiatinii) 



HIKTHIM.AOK 

'St;itf or C'oiiiitrvl 



Da 1 . 



I HKRrCRV CHRTIFV, That F atten.lcl decoase;! from 



LLuvQ 



r 




NAMi; oi 
^ATUlvR 







'nRTHI-l.ACK 

f>'" i-atiikk' 

'■■^tatf or Coniitrv) 



M\n)}:\ NAM).- 
<»' MOTHKR 



<>!• MoTMIvR 
(State or C<,nntrv^ 



"^■'"'■I'ATION 




\.KaJJD^ 






190- t( 

that I last' saw h f.'. alive on w-t^Y^v^ Kjo 

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



- "•"^•^ <jin.inn.-u ueieaseti in 

to C3.^).vt..J! jfp^ 



^I. The CAISlv OK DIvATH was as follows 



I)rR.\TI()X Years , Moulhs . Days /Jours 



nrR.vTiox 




Years ( Afouths % Pays 



Hours 
M.D. 



<X"v\jU{ 




(Signed ) 

ox|At> ic^ rpos f.\d«in-ss) i5::i^/ay)lc^<x>.t.. jt 

?^^9'fiK "^f^^'^'^"'''ON only for Hospitals, InstifuHons. franslenh 
or Recent Residents, and persons d>ing dH,iy from liome. 



h\-sidr,1 in Sa„ i;aii,,\,„ !^ v )',■,;/ - 



M.niths 






Former or 
Usual Residence 

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



How lonq »\ 
Place of Deatfi ? 



I'KACK OI- lUklAI. OK ki;.MoVAI. I I) 



U.l.Ir.ss ^^b 




'-v^Lcr^UxLl 



I 



'\Kf 



N. B.. 



KiAi. or KHMOVAI. 

^ isA-^^^ I ^-^^X Jl..^. ^9oS 



"rtrt7c'lu" E^of dTat^^^^^ ''^ carefully HuppHed. AGB should be stated LXACTLY. PHYSICIANS shoulH 






il 



li 



\ 



f^i 



;4 
i> 'I 



f] 



....<-, ,4.. Jg 



■ K 



f ' 1 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

}U,:i](\ of Hi;imi I* N'o. i^ '^f^^^^^DHi.V Co 



Dale Fih'<1 , QjJr^XyYrXjihj lo 7,96' 'l 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\^o, 



1 557 I 



cL<rv,A„A^ iJlxMj, Deputy Hcsfth CfTicer 



DEPARTMENT (IF PUBLIC HEALTII=Cify and County of San Francisco 



Certificate of a)eatb 

( TH. S. StanOarS ) 
J? % 



PLACE OF DEATH:-Coun.y of6c^Tx^..vv..^cGty of CC^^I^va w^^. c 



Dist.; bet. 1 A,lv 



"^ Of 



) 



FULL NAME 0.i\J^x.^<x^^, d. 

i 



sj:.\ 



" viH <»i lukin 



PERSONAL AND STATISTICAL PARTICULARS 

C()I,<)K\ 




^4XCU. 



u 



(MoiJh) 



A < . H 



a. 

(Day) 



(Vtar) 



4, 



? 



(Day) (Year) 



) ra p A 



s- 



Motillis 



b 



S|N<-.I.K. MAKUIKI). 
UIDOWKI) OK nrVoKCKi) 

'Wwu- in social .ksivii;iti<,n) 



/->./ 1 .V 



IMKTm'l.ACK 

'State <ir CotiTitrvl 



(^ 1 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- i)i.;ath P 

- ax^'xA, 

(Month) 
. i HKRICHV Cl.:RTrFV, TliMt I attcn.lcd deceased from 

...Ojqra. \ ,^o. tc, - : • ,^ 

that I last saw h ^ ^ * . alive on OXJ^vi % j^^ .^ 

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



" M. The CAISlv ()!• DIvATH was as follows: 

LOAXXA^.^xxv.'. .„ 



NAMi: Of 

""'""' Ih (Of 

•>'• l-ATHI-K* /V- 

•>>l:«tt<.r I'oiiiitrv) -V \\\\\ 

CI 



DCRATION Years Mouths Pays J/ours 

CONTRIIU'TORV 



MAIIUIN' NAM).- ^ 

<"• m<)Thi;k ' /^ 



'«nrrin'i,At-F 
oi- motiiicr' 

<Statf or Countrv) 



«>^'Cri>ATlOX 



<X'>aj ^ ^ V<X^rvowCd:i^ 



/hrvs 



Hour 




( S I G N E D ) ...to . Ll5 -U/t:ui\^K.;_ (VI , ^ 

Oxft ^ r,,o'-( (A.ldress) 11^0 fe AAV^^l^^,. CV 



?^^9'fi'- Information only for Hosplldls, Instilulions. Iransienls 
or KecenI Residents, dnd persons dying dway from fiome. 



/^'r.i.fr.f n, S„ >, l-ia,,, ifro 



) I'ii I 



^/oiil/n 



"Un n I.l'.lX.K AND !{KMI;f 



/),i\ 



Former or 
Usual Residence 

When was disease confracted, 
If not at plareof death? 



How long lA 
Place of Death? 



Days 



■|"o I'm- 



'lllf,)t,jl;Mlt 



1 





ni 



CJ-^'^ 



^A,l.l,<.ss SOl ViiW^.Vvl ±^ 








N. B 



l»l K l.-\ 1, OK 

VL^-^.^ ^ 

(Acl.hcss ^ (ob \l)Xl^iA.o->x..0.i 



""ire^Jru" E^of dT^ThI ^' '"""'"."^ applied. AGB should be ntated EXACTLY. PHYSICIANS should 



« 
w 



if I 



> ■.» 



' if;] 



I 









K' 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

!{..:ii<l i<( Hc.-ilfh-l-' No. i> ^^Si^i)HS:}' Co 



290 H 

Deputy HrrJth Cfncer 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Registered J\^o, 



1 558 



Dole File<l3.jL±ji^^J,.jij^. 10 

L i 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 









Ccvtiftcate of Death 

( 'C!. S. StanDarD ) 
PLACE OF DEATH: — County ofClcx^v v.Ka^vcvac^ City of OCV^v 3 ^cvaxcu^cc 



'No.^ACtvca lA^vv,^^v^vcvL xWv^'tfti Su- Dist-bct- A — 



FULL NAME ixo^-^x.. 



) 



) 



:k . .I,.^rtc' 



\Ajr^ 



si:.\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI,(>R. 



■y)\ 






I>A TK OF 15IRTH 



\<.H 




-rutt 



Month) f 



) v./ 



1/ » V 



an 

(Dav) 



Miinlfis 



/las . 

(Vear) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH C 

dxktr oj 

(Monih) (ijay) 



(Year) 



1 HHRKRV CHRTIFV, That I atteii.lodflcoeased from 

~ to 



ngo 



190 



A; V. 



>in<.i.f:. MARRIKF) 

\\ IDoUFI) OR l)iV()K().;n 

•«riteiii sex-ial desivriiatioii) 



^t:it< or Coinitiy) J^ iXN ij 



HIK'l*in'l,\OF 



L 



tliat I last saw h::."— alive on ' """"" "loo 

and that death occurred, on the <late stated above, at 

M.^ The CAISK OF DHATH was as follows: 






NAMJ-; 01 
I'ATlllvR 



lURTHiM.ACF 

'»'■ iatmhr' 

"^latr or c'oniitrv) 



01 mothfr ' 



lURTMl'l.ACF' 

<>i- mothfk' 

iStatf or Coiintrv) 






I)r RATION Years 
CONTRri>,i:TORV 



Mouths 



Days 



Hours 



DURATION 



} 'cars^ 



Hfout/is 



Hla- 



OCCri'ATlOx'^ : 



■? 



^Vu, 






(Signed) Li^nxiA* 




^ '?4lD.lL 



/^</ J'.V 



<X.'W<i» 



f"^^ H TQoS (Address) bA-f^U.^.A ^}l^ 



Hours 
M.D. 



'..><. 



•Vcc^xcjL 



Special in form at '^N only for Hospitals, Instffntlons, Transients 
or Recent Residents, and persons dylny away from tiome. 



Isual Residence A A N^r^-i^^yvvav ^ Place of Oeatli ? 



/y'fsi,ir<f i„ Sat, /',,tn, is,;, 



) '<\n 



M.nillf 



/hiv. 



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



... Days 



(\i\i\ 



loss . 



3.1 (J>x\>vcvv^ c^t 



'"HKST5;?Mx';;k^y;,i;?]«^^^ THH '-'^HOF nrRIAI.<,R RHMOVAiJ DVTKof MrK,.KorRKM«,VA,, 

<4^ 



Jxt ) 1 
i:ni>f:rtakkk 3 a^c, 1 ..,.\A ^^Lct^^l "^.Lo 



Ad.lr.-ss toX^. .LC.\.M\:d.vx^D..u.,U.t 



Bt^tTcru'^E'oF^DTA^H"'''^^^ AGE should be stated EXACTLY. PHYSICIANS should 

«on, dyr„/a^«r ^^^^I" r '''""; fV""«: ^'^-f '* -"^ •'^ P-^—'y -'-^^i^cd. The "Special lnWmatio„"1or p"r. 
j^ing away from home should he feiven in every instance. *^ 



I 



8 



r. 



\»j 



i; "\ 



K 







^ 1/ 



;f 



1; i;?^ 



5 




-JJI 






\k 



#i 



s 

i'i 




■,A~ i 



HomkI nf H. a nil -I* No. k T^'^^*!^) H&r Co 



/)(i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

■■ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

/(' AVAv/, .Ox|^Ajl>vJ[^ id IfJO'i 



!>fe, 



neglstered J\'o. 1 559 I 

cLma^a^ ckX\KjL DwH-^.-i ,• »' - I 

DEPARTMENT 6f PUBLIC HE ALTH-City and Cownty of San Francisco 

Certificate of 2>eatb 

{ "a. S. StnnDnrO ) 

PLACE OF DEATH: -County ^<xJl Ko..,. .,..,.. .^ Qty of ^^^^/vc^v 




vcc^i-c 



(ir DCATH OCCU 
IF DEATH OC 




Dist.; bet. — 



and 



M USUAL RESIDENCE GIVE facts called for under "special informat. on. ■ \ 
HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E eI AN p N U M " R ) 

FULL NAME ^^v..vlxli\A.t .x. 



PERSONAL AND STATISTICAL PARTICULARS 




si;\ 







I LaJjL 



COI.OR 



1>A IK ()!.• HIKTII 




>^tda. 



I. Month) 



(I>ay) 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

a4^;l ? 

(•'^f'"tli^ (I)av) 



(Year) 



Af'.K 



f. 

a iv t X 1 



)-■</- 



Mnulhs 



\WI)<>\VKI) OK I) IVOR IF I) 

'\\ntv in social (Usiviiatioii) 



IMRiniM, Ai'H 
'Statt or Country) 



NAMF <)l 
iatiii.;r 



Da r.v 



I JIIvRI-HV Ci:RTn-V, TliMt I atten.lc.l (leocasc.I fnmi 
~ " lt)0 to ' 



I(^ 



that I last saw h 



alive vtw 






"IKTin'I.Ac'F 

'>'• i-ATm.:R' 

•staff or Coiiiifrv) 






MAiDl-N NAM}. 
<»l .MOTIIFK 



mRTHlT.ACF 

<>»•■ mothfr' 

estate or Country) 




an.l that death occurred, on the date stated above, at 
<^ ^^- ''^Ivcr CAI'SIC OI-' DIvATir was as follows: 



1 90 



I)r RATION Years 
CONTRIIU'TOKV 



Months 



Pays 



I/om s 



DURATION Vt-ars Afonths Davs 

(SIGNED) .urur>\JA' J.\£).U/:,'iJl 

^^^^■^' '' --' (Address) C 



190 



Hours 
0-^vrvck M.D. 



kV 



Special Information only for Hospitdis, institufVoiis, rransients 

or Recent Residents, and persons dying away from home. 



Former or ^ i U How long at 



Plare of Deatit ? 



Days 



OCCUPATION A. ' •"'0'~ 

''''^^^'^n^'^i'7^::^^^ r- nn, l fi^^f of ih^ria.. or kfmovaf I nATFof n rH.... or rfmovai. 



Months 



Usual Residence 

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



nnfoiniant 



k (?a^ 




Jl 



IN. B. 



(A.hhcss lib IDAX^cttrvx ^H 



CNDKRTAKFR L<xLjr<r\A'XA^ tUv^cU^X<xK.U>vq Q 



I90'\ 



(Address.. ^ H C)S AJ C^A.v^ tX TII 



k'VCF 



Kvery Item o? info 



«tate CAUSE OR nTr^M . 7 *' ''' ^""^^^''^ supplied. AGE should be stated EXA 
sons dvl„A ">- DEATH ... p|«,„ terms, that it may he properly classified. The "f 
'>n« dy.„4 away from home should be given in every instance. 



ACTLY. PHYSICIANS should 
Special Information*' for per- 



i 






J -^il 






li 



n r\ 



i 

i 





WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

)!-;f'vl ,,f II,.;i!th I- Vo !=, '^'•^^^^>. Jktl' Co 



i 




REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 

Uegistered JS^o. 



\ 5G0 



ID W0\ 

^^ Deputy Health Officer 

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

Certificate of Seatb 

( tl. S. StnnC»ar^ ) 

PLACE OF DEATH:-County of O^X^ J A.x.ve^.. ■ Qty of 0,<^^ J/uo^c^,.. 

NaSOS LL^^^^ L[,.. ^,.9^ T......_. ri I ,(0-1 

^ and w,<:.:Ux^uaL 

.ur .-ro fUAUT ir-'*"- 'NfORMATION" N 

IVE ITS NAME INSTEAD OF STREET AND NUMBER, ) 



( '^ rF"DrAT°H^^C^^%rD\N"rHO^S^yTl^ o"R^fJs°T%^U^Tfo^'V./*"^V-" ^^ ^^^ ' — ' 



^ 



FULL NAME 



.LTy 





^\d^o., > 



PERSONAL AND STATISTICAL PARTICULARS 
HATK OF ItlRTM 



bi. 



AOH 



I Month) ([ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:aTH l' 



(IJav) 



Mouths 



(Year) 



(MoiitTi) 



1 



aJay) 



(Year) 



r irKRF'P.V CivRTlFV, TliMt I attended ,leccase<l from 

'^'^<^ iS:...„.„i9oH to d jLJxt: a 190 H 



^fN'.l.i:. MARklHI). 

^ innWKI) ,)K DivoRCKI) 

'\\nt.- Ill scH-ial (l(si^r„..,,i,,„) 



Do V. 



niKTflPI.AOK 

estate or Coniitrv* 



NAM)-: <)|.- 
» ATMHR 



'ilKlHpr.AOF 

<»'•• i-athkr' 

'^t'ltr or Coiintrv) 



^lAIl»|.;x XAMK 
<>!• MoTliHR 




tliat I last saw hL. , alive on OJi- ^.X 1 jf^ 

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



HlkTKPr.AC^F 

;»H motiikr' 

l^tate or Country) 







^r. The CArSK 01.^ ])1.:aT!I was as follows: 

V- ..^LoOr:\^V^w;1?v>v 



nrRATIOX Years I Montln Pays //ours 



C 







o^ 



<>^"Cri'ATlON /Q 



dL 



DURATION ;V,/r5 1 JA;;////^ 

(Signed)... J. b 4)<xJctu 

6x1 -A. 



/hivs 



U 



^ 



//ours 
M.D. 



rqo 



fA«Mress) 5 01 3^A,tljA, "^ > 



Special Information only for Hospitals, InstiluNons, fransients 
or Recent Residents, and persons dying away from liome. 



M,'„tti> 






Former or 
Isual Residence 

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



How long iX 
Place of Death? 



Days 



.tr>A. 



I 90 . 



^X.l.lrcKs 3 OS 




\.'\y-\. 



N. B. 



^''/^O^' *'-'' HIRIAI, OK KFMOVAI, I DA^^lCof I'.rHiAl, or KKMOVAI, 
^Address ^"^ .. \j .a->v 0\XA<t ..Q.av,„ 



lat^ 



""irtTcAu'sE'oF dTa^hI*^^^^^ !;' '"'''^•:."*' f"''^"^^- ^«^ «^°"'^ »>« «»«*-» EXACTLY. PHYSICIANS «houId 
«on, dyl„4 a^var?^om^nr H^'", . k "'.' * "* '' *""* ''" P-»P«Hy classified. The -Specia! Information" for p"r- 
i "K away trom home Hhould be given in every instance. ^ 



« < i 




' f ^1 



^ 



i*^ 



I 




1* 




I 







i ! 



1^- WRITE PLAINLY WITH UNFADING INK 



J!ii.ir(! of Ili-aUli-l" N'o. i', ■f"-^'!?^^^ JKt I' Co 




.1,0 



190"] 



THIS rS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR tN STRUCTIQNS 

Registered J\'*o, 



1 5G I 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Seatb 

( "U, S. StanDarO ) 



PLACE OF DEATH,-C..n,v ofd^x-.v'^.vc^^c^,, Qy .J^C^I^A-cuvx^.o. 




J! 



I 



/^ ir DEATH OCCURS AWAY FROM USUAL RF«5mFMr>C- ^. ^ ^ "="■** Vf^-l* ^flQ AO ' 



FULL NAME 



sf:x 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



1. 




Jj^ry vK.uSJ\j:t:.djLo..' 




HATK OI- lUKTU 



loJa 





MEDICAL CERTIFICATE OF DEATH 

DATP: f)F DlvATH 

(. 
(Dav) 



Jjdxi 

Moiitli) 



(Year) 



(Moiitli) 



\r,H 



oXtr Ti ,,„, 



^rVf'.l.K MAkklHI) 

U ri). MVKF) .)K DfVOKCKr) 

\\Mtr m M,ci,.,! 'l.'-ivn.Mtion) 



"IHTlir'I.ACF 
(State or Country) 



■\J 
iD.-iv 



MoMlftS 



(Year) 



J HIvRIvIJV C|.:rTIFV, ThatJ atten.kMl .Icceasc.l frun, 



that I last saw h a. >. alive on 



...?r. Day. 




N'AMI-: OI- 
I'ATllKR 



''•'KTHl'i.Aci,- 

•>'■ iaiuhk' 

'^t;ilf or l-umitrv) 






""<TMIM.ACF 
•'I- MOTHIvr' 
'^l.'itc or Coiintrv) 



F t 

I) v.. 



to ^^X^r \ j^^vt 





and that death occurred, on the date stated above, at .' 
^■^.■. M. rite CACSl.; Ol' OI-iATlI ^^■ns as foIU.ws 

DIRATION a. )V,;,,, ,yoH(/is Days 

CONTRIDrTORV LUjLvn^^ /a^nJ^lL^Lk . 



Hours 



DURATION. , Years 



w — Mouths 15 /lavs 



''M.^XX/vy^ 



occn-ATiox 



(h\vv 



UvuYv^^ 



(Signed) 

Jxl\:l > Tr.n', (Address) la L VJqwUl '.^j 



flours 
M.D. 



r 



K^O! 






^'^^9'^'- Information only for Hospitals, Insmulions, Transienls 
or Recent Residents, and persons dying away froF?i home. 



.1 A '/////> 



nn\ 






Former or 
Lsual Residence 

When was disease ii)w\uK\tA, 
If not at place of death ? 



How long at 
Place of Death ? 



Days 



I'l^ACK OF IHRIAI. OR UF.;m,,VAI. I I)ATF..,f M, ki.ai. or KFMOVAI. 



^\'l<lr«-ss 







H^ia't^c'ru'sE'oF dTa^^^^^^ \' """"^'"u"' f"'"'''*^' ^^^'^^ «^""'«' »>« «»«*-! EXACTLY. PHYSICIANS Hhould 



^'if 



' vj 



1.^ 




il » 



; m 



* 





WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



It.vird Mf ircnltli I" No !> -J'?^?'^ JiScV Cf) 



I 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIO NS 

Begisicred ^'n, f ^G-^ 



l)((lv FiUul ,^jJ^>^Xju^^ 10 7,9(9 4 

DEPARTMENT llF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Eieatb 



PLACE OF DEATH: -County ofOo^. 3ao.>^c^cc City of dcb.^ Xvo. 



Q 



>xeuLc^ 



No. S C) 5 ^h X/'>\y>-L^->Ax:),b 



( '^ ^oI^T^-cJ^r:;:-.-:: --t --?^-^-- — -LLEO .OR UNDER ■• 



St.: I 

III 

NS 



Dist.; bet. LlUit I 




FULL NAME 



\j 



^ ^^ ■ and M ^JLX'^r,-\\.<x. \\ 

XLda.>xv.c.k J. VJlu4v.e,vi, 



SK\ 



I>ATI-: Ul- I;iKTn 



PERSONAL A^D STATISTICAL PARTICULARS 




r\x. 



it 



I 






'11. .nth) 



3 

(Day) 



ACR 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF-' m: A I'M 

(Day) 




(Year) 



J t'tl t s 



a 



^ r IfHRHRV CKRTIFV, That I Mtten.lcd .Iccvased from 

^-^H "^ 190'* to - r...... * ■ i„ 

that I last saw h .L.iL.\x.alive on O-^^t 4. j 



,V^'''I<K. MARK IK I) 
U IDoWKl) f)K DIVoKi-FD 
\\nlr in social (Itsivriiatioii) 



HIKTHPr.ACK 
state f)r Oonntrvl 



'•AT1U.;r 



•5n<Tii|.i,xrF ; 

OI- I'ATHKk' ( 

'^tatrur f(„n,trv) 



MATDKX \\Mi- 
'" '^'OTIIHK 



'^n<rtIP[,ACK 
<>!•■ MoTHICr' 
'State or Countrv) 



OCCUPATION 



.1j4\ 






'^^""'^'^ ^ /^^'^ I -"^'^ ^''''^ '^^'''^t'' occiirre.l. <.ti tlu« .late stated above, at 

.^T) ''>' CArSJ{ OI; I)|.;.\T1I was as follows: 



I<}0 ' 
t)0 



ex. >%-VrWWV. 



Cti 







Dr RATION Years 

COXTRIIHTORV ......'... 



Months 3 Pays Hours 



OrRATIOX:-. Years Mouths 

(Signed) VllW" ' ^ 



Ihivs 



Hours 






Aiy>XOa.€U»j^ 



\Xv^ C\>Q^'W^. M.D. 



Oj^^ A.CL/\^'cu<it:L< 



?'^^9'f!'-."^'^0'^'^'^''"'0'^ ""'> f"^ "ospifals. Institutions, Transients 
or Recent Residents, antJ persons dyimj dwdv from home. 






Former or 
I'sual Residence 

When was disease contracted, 
If not ^\ place of death? 



HoM long a\ 
Place of Death ? 



Days 



\'l'lross So 5" V]jJ^Vu>VV/> 



(S, 



8 
5i 



VQA^- 



A 



yv 



rl. 



lUKIAI. 01^ klCMoVAI. I l)A-n:o; iMiuAi. or KKMoVAI. 

Lh.MA' I ^-^4^ II 190 n 

(Ad.his jO.S.'i 0Xt4LA..J ^Vt 






6->\j „ 



t",7cAu'sE'oHDTA°TH" ■''"■" •'• ""^ '^"'•'''""'' ""PP'ied. AGF. »ho,i.,l be state.l EXACTLY. PHYSICIANS should 



I 



i ■ 

I 



11*1^1 



:i A 



'I; 



{,1 



is: I 



. !, 









I; 



' H 



I 



n 



"C 



\f 



m i 



I 



1- * 






WRITE J.LAINLy WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

HomkI (if Health-- I" So. ic; "f^^^^ lUt I' Co 



REFER TO BACK OF CERTIFICATE FOR f NSTRUCTIQINia 

Registered JVo, 



t5(>3 



ludc Filed, Ox^^aIjia^Inw 10 IV 0^ 

X^\xui '\ju\^ Deputy Hccfth Officer 

DEPARTMENT OF PUBLIC HEALTtKfty and County of San Francisco 

Certificate of S)eatb 

( "CI. S. StanC>arC> ) 
PLACE OF DEATH:-Cou„.y oAo.^;..,^^^ Qty oi^^^K^^^^,, 



No. 





Ll.'>YV,iJ\Mt^.-. St;-- 



Dist; bet. 



and 



( " "r.".-i.t%r.r,-r„ -- o".^fj^i-for/.v^-'b^v r.— p s.%%%T.^'r.— ;r • ) 



FULL NAME 



nu 



PERSONAL AND STATISTICAL PARTICULARS 




CUul. 



I li 



^Ui.<LX^ 




coi.ok 




MEDICAL CERTIFICATE OF DEATH 

DATl-: OF-- i)i;ath 



\Xj. 



V 



L 



4 



Day) 



(Moiitli) 



(I>av) 



v.lHl 

(Vear) 



T9o\ 

(Vtar) 



^ ^ ''"'^ -O^^ Mnjiths I t 



(Moiirti) 
I HKRIvHV CKRTIFV, That I attendc.l (leccas^dfroin 

to a^UU. p. „^H 



^IV'.I.i:. MARUIKI). 
\\!I>o\Vj.:i) Ok I)[\oRiKi) 
•\^^^\<■ Ml <.HMal <ltsi^r„ati,,ii ) 



WTRTffpr.AOK 

Stati- or C'Miiitrv^ 



Da\i 




VcLtrVA^. 



f-^^^^ A^ 190H.. to QjL^Jt' S 

that I last saw h .v.V alive on dx^vl . ^^^ . 

and that <leath occurred, on the date stated ahove, at ^ Ht^ 
;;^- ^f- 'I'lH' CAl'SK OF DIjATIl was as follows: 



Cf 



VvtrwA^^i 






^"\^!^; or- 

•ATHi'R 



niRTirrLAOF 
*>'•' '•aihkr' 

"^tat.' (,r Countrv) 






"""^TFII'l.Ai'K 

'•'■■ M<>i"m-:R' 

'Male or Countrv) 



v.<my>-ui\i 



OCCUPATlox 



2) 




DTK AT ION. Years 

CONTRrRr^TORV 



Mo I! //is 



Days 



Hours 



DrRATlON..... ^''^*'' r. ^{ouths 

NED) UJ.I:)- u 



Dav 



(SiGI 



.<ryvtiXy\. 



^|a.T' I rqo'i (Address) LLi/V\x4-i(vft-V^A<. 



//<>in s 
M.D. 



?^^9'f!K"^fOf^'^'^"^'0'^ ""'^ for Hospitdls, InstifuHons, Transients 
or Recent Residents, and persons dying away from liome. 



)'ra 



Mnutlis 



f^f sided in Sau /rnn risr,, 

^'I'lress LUL^v>X^V 




/>rn,v 



Former or 
Usual Residence 

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



\^rVv4, 



How long at 
Place of Death ? 



Days 



rHK I I'LACK Ol- niRIAF, OR R}.:M()\ 



Hiif, 



'iiiiant 



'}i 






AF. I F).\Tl-;o}' FltKiAi, or R1:M()\- 



^^W/iJ^ 



•N-DHRTAKKR JVJLLUi. ^M. ^ CU^Cy^V 
(Address. 3b A- I °l .tlv V'k 



AF. 



I90'\ 



ivery ,tem of informatK 



«tate CAUSE OF DF Ax'm" "''7'*' ^^ -»''«?"">' HuppHed. AGE should be stated EXACTLY. PHYSICIANS should 



>me should be i^iven in every instance. 



11 



/ I 



■M 

- ii A 

I 

j ii 
Jill., 



' 4 



11 



**» , 




■e- 



W 



'I 



1 1 



WRITE PLAINLY WITH UNFADING INK 

U. .:m1 ..r lliiiltll 1" \o. !<; t'-f^S^Xj) JJttP Co 



/)(//e /VAv/,..dx/|^lx/n^^ 



No. O.Vt^xck' ot'CN4kA;laj 



PERSONAL AND STATISTICAL PARTICULARS 



Vi' 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfWi 



Brgistered JVo, 



^'304 



v-u Deputy Hoclth Omcer 



DEPARTMENT 6f PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 



( *C1. S. Stan^ar^ ) 






PLACE OF DEATH:-Coun.y ofO,<X-.^ kcc..xcL^,, City ofOxc^^Xcvvv 



O * <\ O ( 



St.; 



Dist.;bct. 



and 



If DEATH OCCURIS AWAY FROM USUAI R T C: I n E- lu <~ c- ^.. *'«^«-» ^110 



FULL NAME 




n^ . ,1 



:^-^ 'J,ai 




) 



■Y 



MEDICAL CERTIFICATE OF DEATH 



1. 



II 



3.^ 

(Day) 



Mnutli, 



-r^i 

(Year I 



DATK <>{'• DKATH JJ 

UxlnJl 

tMonnil 



(; 



j) 



(Day 



190 \ 
(Year) 



iO 



^^^'^••I-K MAKklHi). 

\ n)n\vi.:i) OK niV(.KCKi) 

Hut.' in >.<,cial .1. <i^Miati..ii) 



An 



i 



Vlo^ O.CU/rJb iwdOA 



I HHRKHV CKKTIFV. That I attcM„lc-.l .Iccc^ised fn.,„ 

■■~ • -190 to-:— rrr. — ,go 

that r last saw h •— nlivc on ~- j^^ 

aii.l that (loath occurred, on the date- stated above, at 
\ ^^'O^'r ^^^^^) ^*^' '^'^-^'I''I ^vas as follows: 



CX.A.^'V 



>X 



DIR.ATIOX Years 
C().\TRIJU'T()r>iV 



Mouths Days Hours 



I LcccLel. Lcprv<l{n 



DURATION 



i^ 



Years .-. Moui/is 





Da vs 



X 



>.vnox n - -'^<=Y^^ — -_- 



(§IGNED) .UXCr>>JA; J -VJi, UU, AxW .vdl 

.CJXyvl (. r()0 1 (.\d.]rc->;s) UUaU^^ ^41^^ 

SPECIAL INFORMATION only for Hospltdls, InsfituHdns, Tr, 
or Keren! Residents, and persons dying avvay from home. 



//out s 
M.D. 



Transients, 



Usual Residence I o J^o / A VXXXaJt^Vvaa^ pi^re of Death ? 

When was disease ronfrarted, ^' 

If not at place of death ? 



Days 



Xz-YK 



'"''^'"''^P "^■'<'\'''"^ KKVK.VAI. I DAT^u; 15r,uA.. or KHMOVAI. 




l^X^k LxLi-i:rX.-yvA.<x i 



^^^^... . '^^t IJ^ 



190 H 



-^^t-^ CXV^^^ oT^^XT^^^^^ 1' "'""'u'^ r"^""^''- ^^'^ «^-"'' »»° «»"*-• BXACTLY. PHYSICIANS nhoulcl 

•">", dyJnft awav wl^ ! . . u '"^' ' "' " """^ *'"' P-"Perly classified. The "Special Information" for p"r. 

J ng away trom home Nhoiild be fc'vcn in every instance. *^ 






» V-'il 



m 



., ' ' »i 












' i.-'rl 




m 






vil 



.tlffi^flEMBi^' 



i^H" 



WRITE PLAINLY WITH UNFADING INK-THIS (S A PERMANENT RECORD 



/hffr FiU>(l 




REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 



'ywXy-Vs) 



200 "i 



X^TLA^^ Xt\KA Deputy Health Officer 



Registered Xo, 



1 5G5 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of H)eatb 

( *Cl. S. StanC>arD ) 
PLACE OF DEATH:-County of Oo l>v^v>^c^c, City of ^a>v^.^ua/w<^o^c. 



No. '^ '! 1 Crlv 




I 



\joi\ 



\ ) 



St.; IC Dist,;bct) 



a«.0 ,. . HOSP.T^L OR .NST,TUt70N C-|Ve"tS nVmV I^VteVd^oP ST%%%r aVo ;°::*r„° "^ " ) 



( '^ r."o;:T°H^^C^"u%r.r .^''rHO^.^plt^.^ ""'^^^.^ --..?-! --" -« -OER -SPECAL ...OR.AT 



FULL NAME 




•€l' 



.^l^ 



\ 



HXX. U.C4 V"\"^ \J^ 



S} 



PERSONAL AND STATISTICAL PARTICULARS 

■•'^ iOT) f) I COI,<)R \ . 

jJr a.1 ,.ac,'v 

_____^ OTntith) fDav) (Year) 



JV»EDICAL CERTIFICATE OF DEATH 

DATE OF nP:ATlI 

64vb ^ 

(MonAi) (Day 



19^^ H 
(Year) 



. J 'fa > 



I 



1.1 



Miiiithi. I. V Dii\ 



^IN'.F.J-:. MAKRFKI), 

uri)<)\\i.:i) Ok nivoKci-i) 

'\\ iiti- Ml soi-ial <lrsiv:ii;ili.)ii) 



JURTIIIM, \t'H 
(State or (.'(>iiiitr\0 



N'AMI-: Ol- 



"IKTHlM.Al'F 
<"• FArnllK 
iStatf or Couiitrv) 




"I" MOTHKK 



't'KTHlM.AlF 
*\l' MoTHKr' 
(Statf or C'ouiitiA-) 



ocrrpAiiox 

Rfsidfil ill Sail /'ntini-ro 



^^VYVUL ill. S\J\J 



jl HRRHRV CKRTIFV, That J atten,Io<l (leooasc<rfrom 

^"^H ^ 190'^ to d-^Al S X90 H 

that r last saw h .'..' aHve on J-^.|\.l (. j^ | 

aiijj that (loath occurred, 01, (he date stated above, at H 
•AJ M. The CACSK nV DIvATIl was as follows: 



I'^CA.dx M )\jLy>uV^a.<i.vIa^ 



DC [RATION 



J lars 



'l/oiif/is 



/)avs 



" "^ - ' f^M' -i .u on ins / ui 



C4 



y^'iJ'-s ^ .^font/is 3) /:fays 

^\uXx, 



duration 
(Signed ) 

-•^K*-- '- 190'' (Addr.s.)H3.(.^m^^..o., i 



I lout s 

/lours 
M.D. 



o: 



nr^.^n^^'^'-, "^f°"'^^"'"'ON only for Hospitals. Insfifutions, Transients 
or Recent Residents, and persons dying away from home. ""^icnis, 



) ra I 



Mouthy 



li.n. 



''"'-^'^!ii^7i:;:^im'^-v;f::-^-^--^^r.vnr.,nu^ 



Former or 
Usual Residence 

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



How long tt\ 
Place of Death ? 



Days 



Qv. 



>\/v>^*.^t_ 



Address O <^ ^ 




% 



L-\ 



i 



190 t 












^1' »l 



i H 



t;-rf£A:i^ 



■gM 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

H'Kitd of llcaltli J" .Vo. le^ ^'^: Ar ^~£.L HSi. I' Co 



I)(f/r F/7(*f/ , 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1^ WOH 



Registered JsTo. 



1 5G6 



cL^u-A^^ i^v'-u Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 






No. 



PL-ACE 
( 




Certificate of S)eath 

( "a. S. Stan^arD ) 
OF DEATH: — County of ^'<X^>\' JA.aA\c<.4.tc Qty of ^ 



' ^ 



^vvKv^^i 



\r DEATH OCCURRED IN A 



ty of ^/CWu A/CL/>x<:oi c (. 
St; 5^ Dist.;bet. 1 9. iJL and ISiL 



" "*^" OCCURS A^WAYTROM USUAL R E S I D E N C E G I VE TACTS CALLED TOR UNDER 



) 



FULL NAME 




OJX.UX U icL-k vL 



<5:.Y\/.. 



v) . 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR \ 



MEDICAL CERTIFICATE OF DEATH 



-Jo>vta_J 

DA IK OF i;iK III 



\ 



uu. 



1 , 



\<iK 









T 



(I)av) 



M.nilh^ 



(Vear) 



DATE OF DKATH 

ujiixt. 



(Moiit^) 



^^ fpo'i 

(I>ay) (Year) 



I ]n:KI.;iJV CIvRTIFV, Thatr atten.lecl (leceased from 

'^^^^^' ''^ - -^ to Bji^ixt. X. 



190 






'\*Mtr 111 v.„-i.,l .1. vi^MK.lion) 



'Statr or I'.niiitry 



/hn 



NAM)-: (H- 

J atmi-:r 



''IHTMl'i.AOF 
'»' lArHKK' 
'St.-itr or roniitrv) 



MAIDI^N XAMK 
'»!• .M<)TH1.;k 



"fK'lIM'r.ArF 
<>!<• MoTIIHk' 
'Sintr or (.■oiuitrv) 




that I last saw h k.\ alive on dx|vt t J^^ 

and that death occurred, on the date stated above, at 1 
y^I. The CArSK OF DlvATlI was as follows: 



Kk 



Dl'RATIOX 



) 't'ajs 



Mouths 
CONTRJIU'TORV aJouqI^va/C.. 




f^ays Hours 

>\jJL'SuCi 




OCCT'PATION 



v-tta \x6^ 








nrRATIOX ^y^^^ ^rouihs nays Hours 

(SIGNED). Jt 1. <L<fUL.v.U/^-.-.. M.D. 

'^ IQOH (Address) 1 C ^1 mxlliui.tt\- di. 

nrf ^9'fi^."^r^"'^'^"''ION only for Hospitals, Institutions, Transients 
or Recent Residents, and persons dying away from fiome. 'f-nsients, 






M.nitin 



Ihi\^ 



'''"'"•■"-■- >!v-^;!M;'^;iii;:^?';^?/',^i^,:,!;^'"-'^-''^-'— ^ 



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Days 



(In r<iriiiritit 






p 



N. B. 



iQO't 



I I'l.ACH OF m-KIAF. OK KFMoVA,. I .>ATF oM. ki... or K HM<nAI, 

■..LL.v.,.v 



(Address 





F'vepy Item of information should be cnrePullv simni:^,! Aft^ u , , . ^~~'~"'"""~'~~— ————■«■ 

•to,. CAUSE OP DEATH in p.„i„ ,crm, th"^ Tt m^ hL f °", ''.'e."""'' F-^ACTLY. PHYSICIANS .hould 

-n. d„„4 aw., tr„„ h„„. lou.d be tVen ,„ .vT;t in.r.r"'" •^"■"■""'- ^hc "Special Info-mation- ,„r p.r- 



■* ,!' 



!• I,'' 






H 




««■ 



i'l 



m 



fm 



! : 



ftr- 




WRITE PLAINLY WITH UNFADING INK — 



It arrl (.f Ih.tltli- 1-* No. K **^^'^kT~«^ US: I' Co 



Dff/r Filed, 





-ChVCV^ 




\^ 1.0 WO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR t NSTRUCTIOIMS 

Registered JSTo, 



1.';G7 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 






Certificate of H)eatb 

( n. S. StanDarO ) 



No. 



^^^t r ^(>;^™=""'^°""*^ of aa>v i;vc^^xt...ct Gty of Aa^?,^vct^^,^.ec 

^t l^ku fcfr^kcLcJ St.-- Disfbet -__ ^ 

/' ir DEATH OCCURS AU/*V TROM IIQII*I o r e . « r i^ ^ ^ liU,UCU ^^(1 



( " "o;"..-Sc"c-j»;r„',^"r„„--t oVff i''J;for/,;.-^;™.° ,r. — ? :f;/.Ti 'r^li'rr ■■ ) 



) 



/ 



FULL NAME 01' a LLi.t DiJwu. 










PERSONAL AND STATISTICAL PARTICULARS 

COI.OK ^ A 



A^U^... 




^ 



' Motith^ 



■t 



(D.tv) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DEATH 



dx 

(Mont 



oX 



(Vtar) 



AC.K 



.] 

L"i (Day) 

I HKRRBV CKRtFfV, That r atten.lcd .leceasecl fro«, 



/p(9 ' i 

(Year) 



^ 

^ 



u,. 



L 



v) I )V,/;v 



10 



M.nilh> 



U n». .vyi-.i) nk iMVokCKI) 

^\ nl< 11) ...H-iid (l<-siviiati<)tj) 



Ihiv 



X 



xt 



190 'i to ...a,.^vt 1. 



(State or Country t 



»■ vrni-.K 



i!ik iiii'i, atk 
<>'•■ i-aim):k' 

"^'atc nr Country) 



MAlln-.x XAMK 
<>l" MOTHKK 



'«n< ■n^|.r,Ac^• 
*>|• Mo'l'lIKK 
(Slati- <)r Country) 







loA^VUxi 



,cV>x\.a, 







1/ LVOVLCt V 



f 



J • 190 H. 

that I last' saw h-A.\ alive on OJL^v.l ' i jgo "1 

a.i.l that (k-ath occurred, on the date stated above, at 10 3)C 

>j. M. The C.VrSH Ol' DlvATFl was as follows: 

.XL.\.vxXXAL|u-t.V:t;. UUjJ^^Lx.ax. - U^!i CK[xi^.^tJ!v 

lttjL>>j./\vl jAi>\^d>). ^, 

DIRATIOX Years Months 

COXTRIIU'TORY 




■\' 



Days I Hours 



0^ 



X 




1 



■ULttl..: 



DIRATIOX }'fars 



A/of////s 



Days 



(Sfgimed) 





('■V 



1 i I 



90''. C A (Id re 




«r?.f!„^?'M^» "^f^'^'^^T'ON ""'y ^»r "ospitals, Insmutlons. Transients, 
or Reccnl Residents, and persons dyinq away from home. 






<Xj-\A^<xXJio 



s 



Days 



OCClI'ATiox 

'lnfM;n,.,.. in II 



Mniitll^ 



/)il\. 



Former or 
Usual Residence 

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



\K}AAjl 




Cj>\ 



^-^ - 



:>] 



-5-a/>a;!i(5r^U. LoA I 3x^jat ic j^o./^ 



(Addrt'ss 



«r/crrsE'oH;TlTH"!„'''„T''' ^ '"-'"J"' r""""'""- *«B -"o-'J b. ,.a.c.l EXACTLY. PHYSICIANS .hould 



' . Mi, 



I'i 



f 



M 



* 








I 



m. 



■--sesL^, 



I 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

lt".ir<l of llciilth- »•• No. n 1^'?^^) Hitl' Co 

'"^ REFER TO BACK OF CERTIFtCATE FOR [NSTRUCTIONS 



lUi 



fr /'V/r^/, QxU^X/tWLov 



10 7.9 6>H 

^^s:\.Kj^ duL\vu Deputy Health Officer 



Registered JVo, 



15G8 



DEPARTMENT OF PUBLIC HEALTfWity and County of San Francisco 

Certificate of H)eath 

( Xa. S. Stan^ar^ ) 
^LkC:E OF DEATH:-County ofa,a^^;^,'uX.^vccc.c,. Gty of ^X^'^/vcx >x.cc.^. 



ft / IF Of*TH OCCURJB 
\J \ IF OCATH OCc|< 



Dist.; bet. ^-r— 



and 



(T) 



-) 



FULL NAME 



V 



t>- 



vq. 



.L 



>^i.\ 



PERSONAL AND STATISTICAL PARTICULARS 

C()I,«)K 

.a' 



Ol. 



i»Ai"i: oi P.IK rn 



\<.j-; 



•Month I I 



;>'V«.I.r MARK 11:1), 

\\ IDoU KI) OK DiVoKiKI) 

'^^Mt«• HI MK-ial .U^iiMiation) -V 

HFKTffi'i, \CK 
Ottttr "I ''iiiiitiy) 



NAMI-; (,i. 
^'AIii j.:r 



nikiiipi \t ,v 
'"■ lArnKk' 

'''tati' or Couiitrv 




MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 

r\ I J 

(Day) 



uxl\t 

Month) 



TQO \ 
(Year) 



Mnulh 



OF MoTMFK 



MrKi'niM.AcF 

;»' motmkr' 

'State or Countrv) 



OCCri'ATiox \fr| 
•J i 




I JfHRHBY CHRTIFY. That f attcHk-.l ^Wtse.l fr^„r 

LL|^K,a II 190 '1 to ..ix^vt .t ^^ ^ 

that r last saw h-Uv^^ alive (3ii AJjt^\.i: I j^^ j 

aii.l that (kath occurred, on the date state.l above, at \X \l 
^^ ^^^ '^»'^ CArSiM)!.' DIvATH was as follows: 



IHRATIOX Years \ Monlhs ': Days //ours 

CONTRIIU'TORV 



//ours 
IVI.D. 



'VV0^v,0. 






)'tll I A 



Mniitir 



Da 






DURATION Years Mouths Days 
(SIGNED).. U). (i. L^JLol.tv 

„rf'^^9"i'-. "^T^^'^'^'^'ON only for Hospitals, Institutions, Transients 
or Recent Residents, and persons dying away from home. 

f;"^'"" »r How long at 

Usual Residence Place of Death ? Days 

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



X'Mifss . M^\.^'VVA^rV 



I'l ACK OF lURIAI. OK RFMOVAI, I OATI-; of M,-,<,Ar. or RKMOVAI, 



A'VVA^n.(yAA,':i,A_ 




INDHRTAKFR - wv-^^ ^ y^ O^^^ 

(Address l^.hX-...l'\tK,<^i 



«';Z''c'rirSE'of dT;t^^^ 'r' ^""^t:"^ r"'""-^- AGB «ho..d be «.atccl exactly. physicians «hould 



i'l 



■t •': 



If 



j 



1]^ 



n 



K i 



i \ 



M 



■■P 



1 ■ t *^,:,-i 




■" I . '! 



f 



WRITE PLAINLY WITH UNFADING INK — 



Mo.iii! (.f ll< :ilfli I" Vo !^ '*'^Ti^Ji,i) lU^ I' Co 



/;^//r /v/rr/, dxiA^tjl^-vA^Wv 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 



10 



IfJOH 



Begisteved JVo, 



1 569 



H^ci^^s ■Xx.\.-*j^ Deputy Health OflFicer 



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

Cettificatc of Scatb 

I ^ J? (371 

PLACE OF DEATH: — County of Oxx-w JAxX/ruX4.Cc City of O/CL-rv JA.Qy>^ccA,e< 




'VVV-i,'i'..''i.'.i .St.; - i-'isi • Dei a fl . 



Dist.; bet. 






FULL NAME 





tJLmXu JCu,s^. 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



lluL 



Coi.i )K 



\l 



I' Ml-: o| lUK III 



a<;k 



'Month) 



V , 1 vOtx 



MEDICAL CERTIFICATE OF DEATH 

DATK OK I)]:ATH JU 



(Month) 



(Day 



(Year) 



^ 



DH )■,:,,■ ^ 



IS 

(iJav) 



1A. >////' 



(Vear) 



1 ■*) 



A/v.v 



^\iit.- HI Kori:.I .lr^ij.Mi:iti..ii) 



MlkTflJM.ArK 
(Stafi or Coiintrv 






^^\^tl: oi 

lAlHKK 



'••IK rni'i, \cy 
'" Jatiikk' 

"Mat.- or Coniiti v) 



M\II)KN XAMI* 
<»l -MOTJIKR 



''IKTMJ'I.ACK 

'•i- M(>'i-in;k' 

(State ..r loinitrv) 




jl IIHKI'HV CI-:RTIFV, That f aUeiulcd deceased from 

^-M^- i9o'i to ..- - •: X90 -. 

that r last saw h a. ahve on OJL\xL 1 j^^', 

and that death occurred, «>n the date stated above at 4, I 



M. The CACSlv ()!■ DICATII was as follows 



.\JUxjJj\jxi 



).juyY\.: 




tu-^2v 



IH' RAT ION }\'ars 
CONTKIUrTORV 



jV()/////S i /}(iys 



Hours 



? 







' If 



DTRATIOX 



Years 



.'\f(int/is 



/^(lys 



(SIGNED). UJ. b. LrvvLaix M.D. 

A d d ress ) vXt-VvvM Vfr 




1 



190 



( 



VVfrU.<tC 






Special Information only for Hospitals, institutions, rranslents 
or Recfnt Residents, and persons dying away froni home. 



VJWVVVAi 



) 1 if I 



Mnitth^ 



Da 



(7n '"^^"^^ '''■•"• -H AND in:i,n:F 



Former or 
Usual Residence 

When was disease contracted, 
If not ^K place of death ? 



\M<<Aa„ 



Hnw long A 

Place of Death? Days 



i In fiirniaiit 



JvA.A, 



( X'ldross 



lXAyv>\A4 



^ 



190 



V^A^^^A 



N. B. 



I'l.ACK or nrKIAI, ok RIvMoXAI, I DA-Ul-of n, RIAL or kkmovai, 
^Address Sbliv I aXLdf 



"Ilm^c'ru" f'of dTa't^^^ !:' "'"'"J'^ r"''^"''^''- -^^^^ «»^-'" »»« «*«*-• EXACTLY. PHYSICIANS should 

«on. d>l„/«w«[ f^omlome «hn , . H '":' ' ""^ ^ '"'"'""'^ classified. The "Special information" for pT- 

"jini; away »rom home should be ftiven in every instance. 



f 






J .ii 



«'iR?l 






I 






41 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



|iM:ir<l of III .iltli I" No I? •?'^'tt^5 |!.«L- }> C(, 



i\> 10 WO'i 

Deputy f^esfth Officer 



Re^istei'ed J\^o, 



1570 



DEPARTflENT 6f PUBLIC HE ALTH°C(ty and County of San Francisco 

Certificate of Seatb 

( XX, S. StanDarC> ) 
PLACE OF DEATH: — County of O/w vJ/vcxTvCUi City of ^<X^> A.<x^w^^<i 



No. cL/A; 




cy^ '.-.^<XA\ct<x\.A.\ V N V V St.; ^' 



Dist.; bet. 



a I At 



and 'X'X ' 



( " ?^^v^:^^^r:l^^ ^^^±^^z:^^itii;i ;%;.7„°s^-%-„'r£".-;r-' ) 



i 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



m:\ 



Wed, 



I' '^ I !•: '»!• i;ik i-n 



\<.K 



COLOR > ^ 




cdji/YxLuy^Ji 




y^JUxj. 




MEDICAL CERTIFICATE OF DEATH 

DATK OF I)]:.\TH 



dxivb 



(Month\ 



) V'l/ 1 



1 



iDav) 



Mntiths 



n 



(Year) 



/>« vs 



(Day) 



Tgo \ 

(Year) 



^IN«-I.K. MAKKIl'I) 
^^ iit< 111 s,K-i;il <hsi,rnati.iii) 



nikTHfi.Ai'K 

'St;itf or Cruuitrj- 



NAM1-: (»1 
FATMllK 



''IHTHl'I.ArK 

",' iaiukk' 

(State or C'outitrv) 



^' MlH-:.\ XAMl- 
OI" Moi-flKK 



"IKTm'F.ACF 
*•!• MOTH Ilk' 
'State or rouiiti vi 



i 

J? Q5f 1 

X \ 



„ I HIvRKHV ClvRTnn-, That J attendcMl dcocascil from 

Sxlojb ,s igo'i to gx^l. ^1 i,p '( 

that r last saw h i. > . . alive on 9-C|^vt I loo ' i 

antj that deatli occurred, on the date stated above, at 6 
M.. The CAl'SH OF I)I-:ATn was as follows: 



LtAxirVoJ. 



,/wo^x^a V- V 



U . 



.<X.CV >\X\' 



1)1' RAT ION Years 

CONTRIHrTORY 




Mouths 



Days 



Hours 



. vI.I.LlCXA^CK-Si, v>A.\,,v..^ 



\lk 




"'^■^''■J'ATIOX 



■^1 

X\m' V 



Dl'RATIOX 

(Signed ) 



^ 



'JX 



\xk A 



IQO 



-to 




\1 



Mouths 



Days 



\.Ku\^ 




%. 



Hours 
M.D. 



(Address) Qw^ OS. feowavd. Si 



OjyxAA 



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



ytnnftis 



m 



N. B. 



fcr- 



Former or (W+- :f j Q D "ovv lonq at 

Usual Residence ' ' >A OX , M^r U^' j piare of Deatli ? 

•^-^"A.AI. I .\K I K I I.AKS ARK TRIH TO THK I ITAr P OP niP i a r ,Mi v^.'yfr^^^ ^ r I , 
i-.i> K.>.t)\\ l,i;i)C. K AM) UK 

J P UNDliRTAKKK "^ CrVAx^V "^ /COX ll^x^i;^ 



(Ad.lres.s 1 C) X] 

"rtre^^c'lrSE^of dTatH^"^ 1" CBrefulIy supplied. AGE should be stated EXACTLY. PHYSICIANS «hould 

«an.\i • i OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for ^^ 
«on. dy.nft away from home should be ftlven in every Instance. «P«fciai intormation for psr- 



Days 




^m 



I 

ill 






i'lift 



% 



^S^r^vT-^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Officer 



REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 

Registered J\^o. 



15? 



!h 



!)((/(■ h^/Je(f ,CjJrdUi/y-^^%^ \0 

x.^^u.^ji c\X\Mj Depu^^ 

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

Ccvtiftcatc of Bcatb 



• ' 



If 



( '0. S. StalI^ar^ ; 



PLACE OF DEATH: — County of ^Jo.^. ■T,>va^\x^.c<. City of O a^ A.a/YVCv4.c (. 



No.vnit at \^l\- i 



\.)\A 



K.\r<J 



LkfYry 



St.; 



Dist.; bet. 



and 



( " rr'(ir*T!.*'«i'r*o*'*'*'' "'°^ USUAL R L o . ^ . „ w .. o, v e facts called tor under "SPEC.AL INrORMATION- N 
V iri^EATH OCCURRCD .N A ^OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STR EET AN D N UMBER ) 



--) 



FULL NAME 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



X^r\xyiUJ.OL 





\.aA,(^> 







^ 



cJU 



:• ^ I i: <»i iiik 111 



\(.n 




.\^^kXjl 




} '»v; t 



(Day) 



M.oith' 



7^54 



MEDICAL CERTIFICATE OF DEATH 

DATK <)I- I)1:aT1I U 

uxkt L 

(Monti) (Day) 



rgo \ 

(Year) 



I HHRinJV ClvRTII'V, That I MtU-n.kMl .icnvascl from 

K^^H X 190 'i t., qj^-wt 5 up 'I 



X 



Da vs 



HfVf^T.K, MARK n-D 
WllH>\VKI) OK DIVoRfj-i) 
iWrUcin wx-ial rhsiKiinti..!!) 











"IK rni'LACK 

'>>t;iti or <."oniitrv) 



'•A '11 1 Ik 



''•ii<riipi,\«K 

'*' JAIIIKk' 
"^tateor Comitrv) 



MAIDI-N NAM}- 
<'I MOTUi.-R 



"IRTIII'I.ACH 

<>i< .m<)'ihi.:h 

'St.-it. ni ronutry) 



"* *''I'\I"I()N- 







i 

tliat I last saw h i. • • alive on O-^ | vL 



190 



and that <Kath occurred, on the date staled above, at 
Ar The CAl'SI* Ol' DI'ATII was as follows: 



M. The CAT 



1)1 RATION Years Mont/iK 10 Days 

C'ONTRIIMTORV U^A-VQua:x.^XiwOr>:.. 



Hours 



DC RATION Years Mouths Pays 

(SIGNED) LlJU\Xxi.\jO^' 1<XaaXx)('v 

J..ctv.l. I. rc,o'\ (Address) .l\. J\ Oj^^aK U tiv IIaU. 



X 



//on is 
M.D. 

U 



Special information "nly for Hospitals, InsliluHons, frdnsicnts, 
or Recent Residents, and persons dying dway from fiome. 



AV>/,/'/-7 /„ Si,,, I ,,,„. , ,-n 



^ 'li, I 



"J,M (,i. Mv KNowij.ix-.K AND WVA^U'A- 

''"'"tiiiiiiit 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not i\ place of deatli? 



How long at 
Pla< e of Oeatfi ? 



Days 



'^^-^^^tx^, mYux\a^ 



190' 



N. B. 



QOOfcf t ^^^MX^ 



LX(vv\ 



(A,M„,» 'Jm- \'\ tl ^ 



INDliKTAKl' 



' <x.ct gv^x. 



{ 



Hto^t^CAirKF^Ap^nrri'C^'*"?'.'' ^^ ^--'--'^''y -"PP"««J. age «h«uld be BtHtecl EXACTLY. PHYSICIANS should 
-on. cIvhT^ r ^f^f ^'^^" '" »»'"'" •*^'''"»' «h«t It m«y be properly cla««i«ecl. The "Special Information" for p,r- 
«on« fiyinft nway from home nhoulcl be ftlven In •v^ry Instance. ^ 



i 



\u 






!.'!, 



1 'Ml 

Ilk" 



Ml 



Mi. 

i 1 '' 



ill 

til 



f H 






il 



I. 



i 



,t 




r 






}!.^n-.l > I II' .iltir I" No !«; t-?^?'3t^j I'.S: I' (*, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 

Registered JVo. 



A 



I )((/<■ Filed, QjL\<Sj^yy^{u.\j 10 



( 572 1 



.«-wv^ vvv J, Deputy l-foaJth OfTirar 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccititfcate of 2)catb 

( "U. S. 5tan^nr^ ) 
PLACE OF DEATH: — County ofO O-'yv J XQy-.\r.u.i:^ City of "CL^v I'UXaxc.si. c < 
No. Hlb Mlolft^xa. St.: 4 Dist.:bet. JT tlv. and Wklx- 

11 I ' (In ^) ^ 

FULL NAME UvtU. '(- ^ .IlLclua'Ld. J ' 



3 I n c. t. I Anu NUMBER. / 



PERSONAL AND STATISTICAL PARTICULARS 
"^'-.X A C()I,(»R 




! 



i>\ rj- <•!. liiK III 



\ • . »•: 



^u 



'M.iiitM 






MEDICAL CERTIFICATE OF DEATH 



.t 



1 

(Day) 



) 'I'lt I 



M-nilfis 



b 



/'It'l 
(Year) 



Ihn. 



i).\Ti«: oi- i>i;a'i'h \) 

flxkt 



(Month) 



(I)av) 






U IDoWFI) OK IH\<)Rri;t) 
\\r\x,- ill social tlr«*iv:natioii) 



'HH rillM.Ai'K 

'M.itc or •.'oiintrvi 



HATHKR 



niRTlli.i.ACK 
'>' IAIUHk' 
'State rir Countrv) 



MAIDKX XAM,' 

'•I M')rin;K 



lURTFTPf.ACK 
<»l" M(>Tn}.;K 

"^t.itc or Countrv* 










J I HF^Ri;i5V CIvRTIKV, That [ attemle.l (Icccased from 

^<Mr^ ^ 190 H to AjiJ^....1 r^ «t 

tliat I last saw h x. >tv alive oil ^JL^xX ^ up [ 

and that (Iratli creurred, oil the datt- stated ahove, at b "^0 

*^.Im The CAISK OF DHATil was as follows: 

I 

V'ty'CX..'.Y.\_6r:ia,;i^i 



DrRATIOX ]-cars Months T Days Hours 



.v.. 




C\' 



DlRATroX 

( Signed) 



) 'cars 

t 



Mouths 






Days 



\ 



go' ' (Address) [^"i 



^ uLu-a c 



flours 

M.D. 




\^vacLu LcvX 



Special Information only for Hospllals, institutions, Irdnslents, 
or Recfnf Residents, and persons dying away from home. 



M.niths y. /),n 






Former or 
Usual Residence 

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



How lonq ii\ 
Piu're of Death ? 



Days 



THH 



\l V.OjUrrv^x\^ 



PLACE OF HIRIAU OK R I-lMl )VAI, j DATH of \\v\k\k\. or RKMOVAI, 

.0^ iDlLv^ct I «-^Kt u ,90V 

^Ad.hoss 1 1^1 \nVv^A.^-<^-r\„. AjA. 



N. B. 



'rt7t7cl'i^r''o"J';rr"I:^^"''"^ *** corePuHy supplied. AGE should be stated EXACTLY. PHYSICIANS should 
son- ,1 • i DEATH in plain terms, that it may he properly classified. The •'Special Information" for per- 

sons clyinft away from home should be ftlven in every instance. 



l9o\ 

(Year) 



11 




<i| 



.1 ; 



i 












I 
-f 






^. 



WRITE PLArNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!, a!'! ..t" Hi :iltli I" No. !<; "*^^5»;;l-»'- HX: 1' C. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Fi/ff/, dx^vbl^JluA, ID IfJO'i 



dot 



Registered J\'*o, 



1573 



TO 



Deputy Health Officer 



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

Ccftifi'catc of 2)catb 

\ "CI. S. StanCarD ) 
PLACE OF DEATH:— County of O.CL-,\; \a^^c^^ qj^ ^f n<X.>v l>va/^x^uia<, 
^>^ U VV^xlu ' h C^ [vda I; St.; Dist.; bet. 



No. Vt 




and 



f " ,''/il'^,°'"^"J' ""*' '"°" USUAL RESIDENCE OPVE rACTs'c.LLto roR 0r.oE« ■■sPcci.L iNf?n1.Tio«--"-\' 

V ir Dt.,H OcJoRRtD ,N . HOSP.T.L OR INSTITUTION G.Vt ITS NAME INSTtAO Or ST. EET .N D N U « B t R ) 



FULL NAME \,a 



't^'Yvruu./" 



X.fv: 






\<.H 



PERSONAL AND STATISTICAL PARTICULARS 



U 



^ 




K 



lXjw 



oxlr 



Moiitli) 



11 
(Day) 



MEDICAL CERTIFICATE OF DEATH 
D.ATE or I)K.\TH _^ 

ixkt i. 



(Montii) 



(Day) 



75?0 . 

(Year) 



/^'i( 



C( 



)■-•.; 



1: 



M. nil In 



II 



(Year) 



/)./ 



IVi'.I.F MARUU K 

u iix >\\i.:i) ,,K ,,;v, (Ri j.:f) 

\\Mtc III s.K-ial rlesiKiiatioii) 



IilKTllJM..\OK 



VAMK (H 
KATMiiR 



"IKTHI'I.AiK 
oi » ATHKR 
(Statf or rc.iintiy) 



MAIDKN XAMK 



RTRTlIIM.At'F 
<>!•■ MoTIIHr' 
(Stat( (,r tN.initrv^ 




^I iri'RI-P.V CI-RTIFV, Tliat I attended deceased from 

aJLJ-^i V\ 190^ to 0x^4:-.....^ iqoH 

190 '. 



tliat I last saw li ^i. . alive on 3-^:|.\.i.. ( 

and that death occurred, on the date stated above, at 1 I ( 

" M. The CAUSK OI- DI-ATH was as follows: 



,U3UaA>Cv,^ 



-i^>.\ 






D r R A 'V I O N J 'cars Monlhs 

c .\ T R I H r T R \' Ux<Li >^A^. crt.i 




y\/y\xx 



? 



«H 




1 



DIRATIO.V ^ Years Mouths 

(Signed ) . Vjx'vcu,..UXAy%^A.'^>* -^ 

j4"^ ^. igo; (Address) 



Days 



Hours 



uALci Jb(y-<iK 



Hours 
M.O. 



^ 



v^iVca 



<^II'ATlOX p A 



lA. /////- 



/),M', 



Special information only for Ifispitals, Institutions, Transients, 
or Recent Residents, and persons dying away froni home. 

Former or CA % How long at 

Usual Residence cUX/\v\ht^ .l.^.firUAi. Place of Death ? of..'' Days 

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



' '"'''^ST 0^1;|^V^;^^;;!^«;^;^J^^^ '-K'-H TO THH PI^ACK OI^IR lAI, OK KHMOVA,. j ly K of mKi.r, or KKMOVA,, 

12^ 



(\ 






vAi/vvuxitj'u^. .. I Sx.jpJ:^ 



i.\ih 



N. R. 



tn. 



Tl^ 



n 



.1.1. 



(.Address 



JyKx^i<L^^ ^AX\.A*i/!i 



Kvery item o? information should be cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 
son. ^ • ^^^ OF DEATH in plain term., that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be ftiven in every instance. 



I !;. 



Jli 






Ml 




».'ii« 



i 



H 



H ^< 



mmttmrnt 



if 




H 




li.-anl of II.iiHli- I* No. i^ t-'^^r!!^-. n^:i> c<> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE TOR INSTRUCT IONS 

RegLtitered J\'(h 1 574 



xmj Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of E>eatb 



( "U. S. StauDarD ) 






(^ 



^a 



V 

J ;• 



^V<XavCC<i. CC 



No. 



PLACE OF DEATH: — County ofO/C-vv O^a^vCv^ ( City of 

( "^ "*;« 'occurs *W*V rnOM USUAL RESID .MCE give facts called rOR UNofeV ■special INrORMATldN- \ 
V .r DEATH occurred ,N A HOSPITAL OR .1^ ITUTION GIVE ITS NAME INSTEAD if STR E ET AN D ^ U « B E i^ ) 



and V^^VtA,t , 



L 



FULL NAMt 



,0 



(v: 



m:.\ 



PERSONAL AND STATISTICAL PARTICULARS 

Col.iiK /' 



\ 



I>AT1-: (»F l!lk 111 



LlX^. .. 




.L^■\.c 



S 



\ 




C^u 



\<.K 



sj I VU^^i 

Month) r 
5 I ,-,.„,, H 



3, 

(Uav) 



M.oilh^ 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 

DATK ()!•• DK.VTH _U 

7 ,, 

* IQO \ 

'I)ay) (Year) 

I HHRI-HV CivRTlFV, That I attended .leccase<l from 



f Month) 




c^ 



190 
tliat r last saw h rrr?:~ alive 



on 



igo 
190 



? 
U) 



Da 1 v 



■^I^'.I.K MARK I HI) 

w ii)<»\vi;i) Ok invokiKn 
\V rite in social »lcvij.r,,;itioii) 



HtK rifl'F.ACK 

State or (.'oinitrv) 



NAMI.; 01 

FATin;R 



'nkTHIM, VTK 

<V" 1 xtmkr' 

'St;itf or Coiuitry'l 



^'mi)i:n xamk 
<n MoTnHk 



'*' MoTHHk' 
(State or Country) 







I 



and that death occurred, on the date state«l above, at 
M. The or SIC OF J)I:aTII was as follows 




i.\X^Wwac>nwfc;-> 



I DC RATION Years 
CONTRIBUTOR V 



Mouths 



Oays Hours 



\jo 



L 



'H'Cri'ATlON 




Os,X>Jit-TS\JJxj 



^VW'>U'0. 



\\xx. 



^y'W.OL 



DURATION 



}'((irs 



jVo////is 



( Signed )..i/uuixv,coK Lx-waw. 



/^a ys 



1.4\jfc...^. 



TqO 



(Ad.lress) bOb aCv.tU\;. Bl 



Hours 
M.D. 



^ 



Special Information only for Hospitals, InstituHons, Transients, 
or Recent Residents, and persons dyiny away from fiome. 



Rffiilnf in SdPf /■■/,/;/,/>,•,. j,';^ }V,7/.v (. ,1/,, 



'///> 



/hi 1 A 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



''"KSTO^ Mv'';^>;;,i;^:5.;iM^ ''^^ ^""'^ I>J,ACE0F m-kIAr,OR RHMCVA,, iDATKornrK,.,. „rKHM(>VA,, 



aiifo 



unaiit 



cLlv^tvvci vJ 0-trK 



5 

^A.l.lrcss . T Id 



N. B. E 

8 

son 






/Q^^^mTuoLco Co I ax ^......i.Q j ^qvi 

:\i L:,:::::. 



(Address. .1.0 k). 




JJk:. 



t^t^r^A^" "* information should be carefully «upplled. AGE should be stated EXACTLY. PHYSICIANS , 
late CAUSE OF DEATH !n plain terms, that it may be properly classified. The "Special Information" fo 
'^ns rtyinft away from home should be feiven in every instance. 






should 
r p«r- 



f: 



1 



!,i« 



M 



i.i;, 



■> 1 1 



iHI 



Mtm 



f ( 



WRITE PLAINLY WITH UNFADING INK 



V 



v 10 



190^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Registered J\^o, 



1 ^'y^ 



>vt\,; 




V 



'H- 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



i 









PLACZ OF DEATH: — County of U/Oy-rv vJ,\^>vca.4c< City of ^cu^ OA.<X'>A/C.c^t.c 



No. 3b^ 0.\. 



CC 



(?^ 



St. 



/ ir Ot*TH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDE 
\ IF DEATH OCCURRED 



b Dist.; bet. J D'L4.tr^\/_ and OlD/Ci;L\.c^t )^ 

R "special INFORMATION" N 
IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



^i;\ 



PERSONAL AND STATISTICAL PARTICULARS 

cor.oR 



kcL 



I>\TK (U HI kit I 



\c.H 





x\y \ 



JJwol 




MEDICAL CERTIFICATE OF DEATH 

DATR OF DKA ril H 



(MontH) 



iC. 

(Day) 



(Year) 



tMotith) 



( Day) 



J Vi; > s 



.1/. 



->////.* ( t 



(War I 



Ajv.s 



\v MKtw |.:j> «.k i)i\«»K(i-:i) 

^^ lit. Ill so, i;,l .!< siKr,lati.)Il) 



"IKTMJ'I.Ai'K 
'St;it( or i.'oiiiitrv'* 



NAMK OP 

PATHKR 



<»'" i-athkr' 

(State or Country) 



^'AlhKN NAMF 
UF MOTMHK 



^ 1 



L 






p I HHRI-HV CI'RTIF-V, That I attended (leccased from 

ax^\,t ^ 190 H to 0.jJf±. LO. igoH 

that I last saw li a. ■ w alive on OJL^^Jv 1 jqo '!- 

and that death occurred, on the date stated above, at "1 IC 

A M. The CArSl<: ()!• ])I<:AT1I was as follows 

qp AAA^lxyMr\-VV\<OC . 




Mont /is Days 



I) r RAT I OX Years 
CONTRIIM'TORV 



I Jo UPS 



DTRATIOX 



RTRTTTPr.ACK 

'^tatf ,„ (.-ouiiti v) 



VJ 






cin 



)'<v//-,? 



Mouths 



Pa vs 



flouts 



( Signed ) AJlcLk Ll '^Jl\. ^ . v .., m.d. 



i 




dxu-\Xvt^JL< 






i^vt 



.(oH ( 



K^O 



Address) LcJl XovX:^ivAAV UoJLciU^ 
spJtdK, 



Special Information only tor iiospitdfi, insiituiions, iransifnts, 

or Recent Residents, and persons dying dw«ty from home. 



I .V 



former or 
Usudl Residence 

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



How long at 
Place of Death ? 



Days 



' '' li l.^ST 17,' ^Jv^ '''■•'' I'^^'X^ONAI, I'AKTU-II.XKN Mo; iKri- TO Till-: 

"i.sroi. \\\ jxNo\vij.;ih;h and in:i,ii:F 

f IiifoiniMiif 




( X'Mress 






!N. K.. 



I'Tj.XCH OF" IHKIAI, ok kF:Mo\ \I, I DATJ- of MlRiAl. or kl-:MoVAI, 

%CrVM K^Y^i^^j __ I ^-^V^ 10 190H 

rXDFiRTAKKR "^ ^<X/\Ai-/->-sJt\; ViS ^. ^-<^ 

(Address IXO^ ^ry\v4y^A,>fr-VL OX 



-F.very Item of mformntion should be cnrefully nuppliecl. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" ?op p.r- 
8v»ns dyinft away from home Hhould be ftiven in every instance. 



\ \ ' ' 



' i>l 



I 1 
it .11 



d 



\v 



'j3 



* ■ \ 






.- 



I .' 



■):•' 



' ^1 



i 






•^ <"g<f.gaiggipi 



nitfifeH*! 



I| 



:♦' 



1 






I.: 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



• II .'ih 1- Vf. !' ^?^5nj^) {i.«v!' Of 



Dff/r Filed , 6x^\le^v.i-t\. rJ()\ 

'Lf,v^^A L-x^u Deputy Health Officer 



Registered JVo. 



1576 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeath 

( in. S. StaiiDat? ) 



-D 



PLACE OF DEATH: — County of .cu^io. J /vcx^-^t^cma C( City of 'iKXrr^j J/voaxc^^co 



Ne.a.nf\t\,al ^>>xXVOt>x^o 3b(M>l • St:; Dist.;bet.- — and— - 

( " ."/y.lrt'^^r.i.'.""' 'T" "S"*l RESIDENCE OrVE r.CTS C.tLtO rOR UNDER -SPEC.. I. INroRM.TlON- -v 
\ ir Dt«TH OCCURRtO IN U MOSPlT«L OR INSTITUTION C I » E ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



If I f "^'j'. 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

C()j,<»k 




a 



L 



'WV. of lUK TM 




\aA^ 



^^ MEDICAL CERTIFICATE OF DEATH 

DATK OF I)i: ATH 



..dxlxt. , 

(Month) 



(Day) 



(Year) 



M.ititht 



\<.K 



<xU 40 ,■,..,,, 



,.-.: , SkH . 

{0«yJ (Year) 



ytimlhs * /5av.s 



I ninM':nV CI-RTIFV, That I atteiidcnl deocised from 

— to 



'■ 190 — 

that I hist saw h ": ahve 011 



WlDnWJ-.n ,,K lUV.iKfll) 

'"tit. Ill v.HK.l <ltsi^Mi;.ti.Ml) 



HIKTlir't.AOK 
fStatf or (.ouiitiy) 



N'AMK OF 

'AT I UK 



^O^ 



n'Kl'MI'I.XCF 
'»> I A 11 IF k' 
istal. 1,1 i-,„intry) 



MAtUFN' NAMF 
<»!• -MOTMFR 



""< IHl'I.Al'F* 
<>l" MoTHlCk' 
"Stilt. • or Country) 




190 



and that death occurred, 011 the (h'ltc stated ahove, at 

^r. The CAlSIv OI-^ DlvATII was as follows: 






DTK AT ION }'t'ars 
CONTRIIUTORV 



Mouths Days 



//ours 



ft<^YV<L 





( 



occupATTox 3 n 




I) i; R A T 1 N Yea rs^^ ^ J A ' // ///v /hiys 

( Signed )....UrV^>^x^; J .yb^.l. . li.i<x^xi 

.aA.l\:t loo'i (Address) UrUva\A).i! t,. -.•' 

\ —11:^: ^ — 



//ours 
M.D. 



Special information onl> for Hospitals, Institufions, Transients, 
or Recent Residents, and persons dying away from liome. 



Former or q « ^^ \\fY\ \ -^ , flow long at 

Usual Residence ^^X M \ \MA\,\J>,<>yy\. UJ Plare of Ded 



Par, 



Usual Residence 

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



o,cw\. d^ Place of Death ? 



Days 



IJFST^OK m'v u-'vv^^.^;^.^'*'^"^'• ''^'^'■'^^ ''''^ ''"^^ I I>t-\CK OF IJlKIAr. Ok kHMoVAI. I DXTl-of MtKiAi. or KKMOV\I, 

»M ..i\ KNOW 1,1.1 )C,i.; AND in%M]vF ' '^ '^ ' 



(luf 



oTJiiaiit 




V>V 



U..al 



(Add 



less 



RXX 




IX/Vu 



it 



4i 



INDKKTAKKK ,t- ^J. \J L<r>WU>^ ^<V VO 



190 '. 



^-\d<t 



/' 



■CSS . T. b.l ^rhAA,a\..<na. jSX.. 



Rvery item of inifopmation should be cnrefully supplied. AGE should be stnted BXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in pinin terms, that it miiy be properly classified. The "Special Information" for p«r- 
«on» dyin^ away from home should be given in every instance. 



lii 



V' 



'. v.. 

■••',' 
if ' 



11 



' I ^ \ 



'I 



\ 



ii 



'A 
I; 



M 






I-! 



-'■■-■miim 



14 



nil 



m 



i 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^■.-■■-'-rn,:,,th.rvo.c>.gg^H^.MV, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






l)((h> Fili'^l, 3x\vtx/>^J>^\- II 10 Wi Registered J\ro, 

^Mc\^ I \v i Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Scatb 

( Xk. S. StanDarD ) 



% 



PLACE OF DEATH: — County of Oa>\; ^ hJX.y\.'Z\A<U. City of UxX/>v J A.<X vA.Ci.<L c 



CO 



No.^1LCU^CUlUu iJXX^^ctaN-.- , St.;- - Dist.;bct. -:~::n.r:.— - and 

( " .VnllrU^J^r' *'**'' "'°"* USUAL RESIDENCE GIVE r*CTS CALLED roR UNOrR "S^tCIAL I N TO R M*T.ON" N 
V tr DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME llla^ujj..Lll Li.i)r:Ibd4Anm...... 



*.¥»•»»••«••... 



^'■•^'?!?) 



personal and STATISTICAL PARTICULARS 

; (Ol.Ok 






i>ATi; <»i liiKTn 



Di 



rXA^CC 



(M.)tithl 



iI>Myi 



(Vt-ar) 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- DKATH W 

i\t "^ 

(Day) 



- ..ux\ 

(Month) 



A 



\<.h: 



5^b JV.;' 



MoMfks *" /) 



1/ r.v 



'^^ I lt< ill V,„i;,] tlrsi}.rn;,tioM) 



»HK IMfPI.Ai'K 
'Stutf or ^"oitntrv^ 



NAVfH np 
FATlll.K 



''•IKTlll'l, \(K 
<>|- lArilKR' 
(J>tatfor Country) 



MAJDHM NAMH 
'»'■■ MoTniCR 



DURATION 



TURTJtJM.ACF 
•>»•" MoTHKr' 
(Slatf „r Conntrv) 



OCCrPATlON ^ 



■!]' 




7pO i 

^ _^ (Year) 

I IIHKIvHV CI-RTIFV, That I att<^,lc.l .IcceaseilTroin 

'^i^^ 5q 190 H to p■Jd^'^^ ^ 190 M 

tJiat I last saw li XS; alive on aJc_-pvt. 11 icp \ 

and that death occurred, on the date stated a!>ove, at 1^ H^ 
LL:SJ. The CAUSH OF DivATII was as follows: 




Years Months ^ Days 1 S Hour. 
CONT R I lU'TOR Y v.iWk/v^^^..r.^„...^r....S^:vM^ 



DURATION Years 



Mont /is Davs 



(Signed) 




^ 



h UA/YVA^^-V 






Hours 



IVI.D. 



OX|.vi 1 iQoS (Address) ^3HH CjA<d,ljLvjJi. 



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



■iXK./U^\XS 



AVynfr,f i„ S,n, ri.nr, ;s,-n 






Mnllfhf 



Pay 






Former or 

Usual Residence 

(I p 

Wlien was disease contractfd, :n 
If not at place of deatli? .' 



How lonq at , fj 
■lAnv ^"^ Place of Oeatli? iiX Days 



'"HKSTO^;^*^^'';^y;>^!^«^;;^ to THH PI.ACK m-BriyAT, or RKMOVAF, I DVPKof m-K... or RKMOVAU 

'...' .,. %xv^^(iu:_^. A(Di).%.u.w .UW_.4=.^^ 



fArl.l 



rcss 



RO^ b<:tA^..mM,LLv/ 



(Address ll?-,H....Jjl.^w':':,A<a,<U'uO...Ol 



^!ih.. 



* "'^very item 0I? infopmntion 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 feiven in every instance. 



'(. X 



i* 



«li 



^i 



w jii in m 



I 



I 



yi 



,'i,' 






I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



h((fr Filed ^ ^xK\KxjY>^^y<^ \\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^f.4..Dmcer 



Be^istered Xo. 



1 078 



DEPARTMENT OF PUBLIC HEALTtl=Cify and County of San Francisco 



No. 



PLACE 



Certificate of 5)eatb 



oi^ 



4 T ;A T 

OF DEATH: — County of ct^w /\^CL>A^ev><i^<U) City of OcX/^^ A.<x^ 



^^-^ 



( 



St, 



Dlst.; bet. 



im 



A; 



and 



tr Dr*TH OCCUBS *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. 



'D^ 



(b.tL 

) 



FULL NAME^ 



X 




\ 



PERSONAL AND STATISTICAL PARTICULARS 

^'•"^ ^ A I C(»I.«.K 



t 



skj.Cfrv.Q^.^xd^. 




rL^.C^.OL 




XXT) vcu-ruTx- 



MEDICAL CERTIFICATE OF DEATH 



!'\'ll'. OI I!IK TM 



OJLfvt 



lOlcu 



7 



(Vear) 



DATK OF I)T:aTH 



.Qjtj^. 



(MontH) 



(Day) 



I go 
(Year) 



Ar,K 



I Va w 



.!//»«/// - 



Daxi. 



I IfHKl-HV CIvRTH-V, That I attended deceased from 

^ 190 M to a-L.\-ski . lO..- ,00 4 



^-4\i7 



^JV.l.K M \kKIi:i) 
WIDOW i.:i) OK DIVoKi l-l) 
<Hrit«iii v,K.Jal flfsijriijjtif.tp 



HIKTFir'I.AOK 



p 



ate or Country) V 

6 



NAM|.; Of? 

>*'athi.:r 



''•IKTIIIM.AI'F 
Of- IATni;K' 
'Htate or Cuun(iv) 




Of 



190 

tliat r last saw h -^>v alive on C'-^jvl' K' 190 M 

and that death occurred, on the date state<l al)Ove, at 
.-..U... M. The CAISr; OI' I)I{ATir was as follows: 

>la^u^>vcU/tu.,,.. 1.. _ 



Cyyyj 



^ 



/O 



iO/>V 






<(KX 




•VIAIDKN NAMK A / 

"I MOTIIHK y y -^ 

•>!• MoTuhr' a 

istat. or Country) J 

— - UXVrrtOAX' 



'^^X-CX/>X/W^ 



C4X 




DC RAT ION ;Va;-.? Mouths "^ Days \ Hours 



r\\^. 



DIRATIOX .^.Ycars jro>/t/is 3 /^ays ^ Hours 

(SIGNED) VO/VVU. MJXAAJL>M M.D. 

DX\\ky. \h TQo': (Address) ^^'I'l V lltiv O^t 



OCCUPATION 



t 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinq away from Itome. 



h't'siilfif ii, Sun /'i ,n/, /^r<> 



)'>i!i.^ "^ yi'mth-- ^ 



/)< 



Former or 
Usual Residence 

Wfien was disease contracted, 
If not i\ place of death ? 



How long at 
Place of Deatfi ? 



Days 




' " 11 i.^J-I'Vl^^.'"'^ ''''■•" '"HRSONAI, I'ARTICri.AKS A K I- TKIH T. > 
"l.M 01 Mv KN<»\Vij.;i)C.H AM) WVA.W.V 



r 1 1 )•; 



r>^w<X^V\xw 



\-l<ltc'Ss \)\ vJJLv^^fr>\ vAa^ 



ri.ACK OF nrKiAi, OK kkmovai, I i)\ji;^)f niKiAi. or kf;m<)Vai, 



N. B. 



P'very Item oif informHtlon should be carefully Hiipplied. AGK 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- 
«nn« dyin^ away from home should be feivcn in every instance. 



'1 



t'ti 

lii? 












il A 



\ 



' \ 



: 



i 



4 L 



1*^ 



I 



'■'■A 







fcs 



i 



M^. 



i.^^ "^SKSHJSjaii^ 



>. _ri ' ^ »J. M l B ifj 



'-3-rf... 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

— ^ RgF ER TO BACK OF CERTinCAT C FOR INSTRUCTIONS 



;-^ 1 1 



7.9 6>H 



k(hU.AJi Xt 



Begisteved J\^o, 



1 579 



rt 



L 



DEPARTMENT OF PUBLIC HEALTIl=Cify and Connfy of San Francisco 



^l 



Certificate of Scatb 

( XX. S. StaiiCiarD ; 
PLACE OF DEATH: — County ofOo^ J/v(x.xcc4^c<,: City of O cuvJ tVrva. 



(?in 



'vvC-c^ <1^ 



No. .' V\.<x >va k L<ru.>x't^^^ \<XkX 1)1 



< '^. St.: 



Dist.; bet. 



r ir DCATM OCCUBS *w*V riAoM USUAL RESIDENCE GIVE facts**c- 

\ ir DEATH OCCURRtDJ InJa HOSPITAL OR INSTITUTION GIVE ITS N 



and 



ALLED FOR UNDER "SPECIAL INFORMATION" "^ 
AME INSTEAD OF STREET AND NUMBER. / 



FULL NAME L cl 



rT) 



a/,\rvo . .>J ' 




PERSONAL AND STATISTICAL PARTICULARS 



SHX 



1>ATK <»!• mkTII 




COT.f)R 




luX 



<XJL. 



y\.^r\Ayw 



M.iitlj) 



\<.K 



cdt 



b 



) .it 



'\\nf.- ui s,„-i;,i ,l,MVMi:.ti..„l 



? 



niRTm»I,A('i.; 
stjttt or Country) 



N \\TK or 
»• A rni:k 



nikTni'i.xcK 
'" iatiihk' 

'StuUor Count r\0 



(Day) 


r 


(Vear) 


Votitln 


- 


. Prtf.t 









MEDICAL CERTIFICATE OF DEATH 

DATE (tF I)i:atii y 

Qxixt 

(Month) 



...1 

(Day) 



I go - 

(Year) 



I HI:RI:HV CI-lRTir'V, That r attendcl (leceased from 

— • 190 ■ ■ t«j 



that I last saw h 



alive on 



190 



AA^tDjA^-vvrk. 



and that dcatli occurred, on the date stated a])Ove, at 
— ^ .^r. The CAl'SK 01- DI'ATII Nvas as follows; 

^7.\AAd>;.C./a./.U<±>-Ls^i 



M MI)1:n Xamp 

"I M()Tni:K * 



I'.ik riii'F.ArK 
J'.i- mothick' 

l.Staf.- ,„ Coutitrvl 




I )r RATION Years 

CONTRIIH'TORV 



Months 



Days 



Hours 



DTRATION .^ Years ^ Months -Davs Hour^ 

(SlGI 

iti T9o'i (Address) \j^\J:sy\JCt\M ^\\r'^^J., 




M.D. 



SPECIAL Information only for Hospitals, Instllikibns, Transients, 
or Recent Residents, and persons dyin.'j A'tiii) from home. 



«'« .^n KNOW 1,1, DC}.; AND HI-I.Il-F 



Former or 
L'sual Residence 

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



How long ^X 
Place of Death? 



Days 



!H lo Tin-; 




Pr.ACK ()!• nCklAI, Ok KIvMoXAI, I I)ATl.:,)f Hi lUAl, or RKMOVAI, 

^A.^^,. btx-U ' I ^-«^ li ^ ,50s 



* \<liirrss 



r.NI)l':RTAKHR 






^V 



8 



taV*^cI*ir "^ '"^"'•'"nt'o" •houlcl be cnrefully supplied. AGE should be stated KXACTLY. PHYSiCIAINS should 
on. H • ^ OF DEATH in plain terms, that it may be properly classified. The ^Special Information" for D«r- 
"» ayini away from home should be j^iven in every instance. 



•if 

. I 



! i' 






i ■■ !, 










i;( 



11 

t 



■I 



); 



ij 



■^1 



JittSK^. 



^ 







»7 
i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






/)u/r F/7('(/,6jL>f±jL^YyJiji\. II J90H 



Re^hteved J\''o. 



1 580 



{ ^ 



'^y.K.AA i.^v u Deputy Health OfTlcer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Bcatb 



PLACE OF DEATH: — County of ^Cl^' vJ rv<x>v<^v^co City of H a^'>\/ JAxx/>v^<^ct^ 



y;\ 



N 



o. H^l J-VU4^ LLo^s^ 



St.; ^. Dist.;bet. wLo^Tvo^xt and it cL< 

/ ir Dt«TH OCCURS AW*Y 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. ) 



'nU.. 



) 



I 



FULL NAME v^Kvlcl t\ 

r-tr 



PERSONAL AND STATISTICAL PARTICULARS 







l)ATK nl MIKTII 



\<.H 



Qii< 



(M..iit}t) 



JV"<r» 



io 



Day) 



.!/"»////' 



/I CM 

(Veai 



MEDICAL CERTIFICATE OF DEATH 
DATK ol- DKATH 



(M 



outH) 



..^ 

(Day) 



I go . 

(Year) 



I m-KI'RV CHRTIFV, That f attendo.l deceased from 

to -r- 



""190 " — 

that I hist saw h ~ ""iilive on 



/)<.' 



NVii><>\yi;i) OK i>rv«>mHf> 



lUkTMPT, \rK 
' Stati- or Coiiiitrj) 



N \MI- or 
1 ATM IK 



lilRTIII'I.ACK 

"t I aiukr' 

'Statr or (.'oiiiitry^ 







ami that death ocxnirred, 011 tlio ihtte stated above, at r":--. 
..r^. .. .M. The i:.\V^V^ ()!• Dl-ATH was as follows: 




\..... 



DIRATION Years Mouths 
C"() N T K 1 HI'TO R V 



Pars Hours 



MAn>i:\ N'AMF 



niRTlIPT.ArT* 
<>l' M or I IKK 
'^^tatr or Couiitrv) 




( H'Cr I' ATI OX 



\ f 1 

t?i"'t(trrf in Sail /'> ,1,1. ,\,;) ■ JV(M - C M.-xfh- 



1\ I 



Dl'RATION Years Mouths Days Hours 

axv\x 10 iqoH f, 



(Signed) L^^ri^x^ J . V£>. UJ, ckiXoAvA 

.k:t 10 iqoH (Address.) L^c.O"\\i.\^ Vii'., 



M.D. 



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



(iiif 



"*nrJ-r'\^'t''"^ '''■'* ''f^'K^ONM. I" \ »< ThM I.A KS A K I- TKIK To TMH 
"HM »)!• MV KNOW i.|.;i),;i.: AM) in'.MlIK 

UIvCuJLUn vJ ,tX.c< A-^-^rX/ 



Former or 
Isual Residence 



How long at 

Place of Deatli? Days 



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



"tniant 



rj.ACK OI- HTKIAI, OK KKM<»\"AI, I DATi; of MiKiAr. or KKMOVAI, 
^XKr^r^ A\^ l ' __.„_. I ^^^ ' ^ . I90H 

rXDHRTAKKK J^aXXJCU ^ <3^ AXXlX^YW- 



N. B. Kvery Item olf 1 .1 form Ht ion tihoulii be cnret'ully supplied. A(]F. hIiouIcI he stiitecl BXACTLY. PHYSICIANS should 
state CAUSi: OF DEATH in pliiin terms, thnt it may he properly cloHsificd. The "Special Information" for p«r- 
Ron* dyin£ away from home Hhoiild be feiven in every instance. 






\ -.1 



« u 



ill 



ill 



I ; 



I* 



•: * 



•1' 



% 



I 



! i i 






i 



.''' 

^ 



V 

I- 











M4-^*4a«_ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,|!,.,ltl, !■■ No ! = -fr^^^wj^-. HM' (\) 



Regisfered JS^o, 



1 58 1 



i<y\.A,v.A 'XtA.^'.ij Deputy Health OfTlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( 13. 5. Stan<)arC> ) 
PLACE OF DEATH: — County of CXa\; O/uCtiv^i^^co City of *^ 'CL'^v o,\.a. >v<::.lx^*:;^<:> 
Ifi JXxLaA/<X' ........... St.; ^ Dist.; bet. l^iA^Vt'u^;:^. and' hAX!u:yv^rux:;o. 

(ir DtATH OCCURS *W*y FROM USUAL RESIDENCE give facts called for U*4DER "special INFORMATION" '\ 
IF death occurred in a hospital or institution give its name instead of street and NUMBER. / 



No. 



FULL NAME 



S-.: 





( 



"^ 




^, 



O&JJL^ "^ 




C\ 




LLIllLl. 



-^KX 



DATK or liiK ru 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ A 




/.IruJti 



tMoiitlii 



^vt 






AHK 



lLJi(i\ 



(V\>^' 



} I a I . 



MiiHlh.y 



/^04 .. 

(Veai) 



Da I i 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DICATII 

Oxkt, i 

(Motltli) 



(Day) 



I(^0 i 
(Year) 



A 



I HliKUIJV CI'RTIFV, Tliat I attended .Icccased from 



wiixiUKl) ni< i»iV( .Kri:i) 

Write ill xH-ial d* sivniat i<iti) 



niRTHpr.ACK 

St;iti- or t'uiintry) 



NAM}- o|- 
KA TH J;R 



"FRTIIIM, \^•K 
'>'• KAIUHK 
IStatr or Coiuitrj') 



MAIDHN NAMl' 
OF M(>Tm:K 




..dx^.-ufc. .1.. 



190 'i 



. Cx|a1j %. 190H to 

that I last saw h -tv)! alive on ^.... *.... •* .' -.190 

and that death occurred, on the date «>tated ahove, at ^ 



^i M. The CATS I<: ()!• DIIATII was as follows 

.. atJiQ&.cvtK 



Mouths 



Davs 




HTRTlTrr.ACK 

<M" MitTlIHK 
isiMt,- nr I'oinitrv) 



i\<XVLU 







nr RATION Yxars 



f/oi{f s 



.slAiAiL^vvtoi- 



v<rw 




CLtW^tA/VYVl/vd- 




;<wfW.>>Lcv 



li 



(K-CFPATION 



c\<x,cLt> 



I )r RATION -^ Years .^Foutha Pays Hours 



M- 



M.D. 



(Signed ) av\xXA^Jk,,..u»....Aj/h.x^ 

^X|^± ^. rc)o'< (.Xddress) ^^^ U io.VvlO' ^"t 



Special information onlv for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying dv»<iy from fiome. 



Ri^'htfrf in Sntf /'nTfTri^'rn ♦ )V.7; <• •• ^f,>nf/t^ 



Da 1 



illi: M'n\F, STA T)-.!) I'KRSONAI, r \KI!(II. \K> \Ri: Ikl}-: r* > Till-: 
IlFsr OJ- .MY. KNOW 1.1:1 )C,K .\M) nFI.l I'.l- 



former or 
I'sudI Residence 

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



How lonq at 
Place of Death ? 



Days 



"iif.i-niant 



UkycxA^Lu XXjMjda,.. 



(Address (0 3 X<AJAXXxI C'R 



IM^ACH <)!• m KIAI, Ok ki;M<>VAI. 
rNI)i:RTAKKR JVIaaXu 



DATiCof niKi.Ai. or ri;movai. 



190 i 



Q^. 



u 






Address ..3vhl.-..B..tlv.Ml 



N. K. 



-Kvery item of information should be cnrefiilly supplied. AGB hHouIU 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 shoulil be 6'ven in every instance. 



,: >\ , 



■ V 



■f 



:iil 









is 



i n 



• \ 



^{ 



i\ 






)'• 





I 




^=Mku-u 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!;,,:,!■: >■{ !! 



, :,1.1l »•• Vo. !<. -^-^^S^i-ii^-I' (''• 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dfffr Fi !('<!, dxlvlcwv^MLV \'k 100\ 



BegLstered jYo, 



158a 



1 



c-wv^^ "cUavm Deputy H-Glth ORlcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

I "U. S. 5tan^arC> ) 



No." 



PLACE OF DEATH: — County of ^' CL^v ^^ Va \VCUlC^City of " CL>\ J.Va>vCU.ao 



I (^ ! r 



St.; 



D. , , , VJ A.rx g vvX 
ist.; bet. -\ 



and 



(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNOtP "SPECIAL INFORMATION" \ 
If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

\\ 11 \[^^ • ! 

FULL NAME VJ ^l\A.:ix.|i..o^^L . k VJ.) .OucUii 



I 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oK ^ . rt 



^Yn.au 



,c 






I» WV. nl lUK III 







vcU 



MEDICAL CERTIFICATE OF DEATH 



Month) 



\r.V. 

\VII)o\yia> OK I)!VnK<KI> 

• VV'ritfin '^(Ki.il (J« •.ii'ii.it i"ii ) 



lURTfirr.ArK 

'Stalf or Countrv) 



N'AMK OK 

FA TH i:k 



} ra r > 



(Day) 



!/.<»////- 



(V.-ai) 



/>(/) 



niKrujM.xcK 

'»' i AIHHK 
'State or Comitiy^ 



MAIDKN NAMH 
OK MOTHKR 



IIIK I H1M.ACK 
<)l- MdlllKR 

'State III ('omitiv'l 



t»CC 




DATl-: Ol' Kl'.ATII V 

d-iixt 

(Motilh) 



(Day) 



(Year) 



I lii;Ri;i'.V CI'RTII'V, That I attciideil deceased fn.in 

"^ *■ "■ ■■ lyO " - U) -"^ *" ■■ * ^. lip " 

that I last saw h '-^n aUve on HjL^'^ ^ 190 H 

and tliat death occurred, on the dafi- staled aliove, al D 
. v-l M. 'Ihe CArSl-; Ul" 4>ivAril was as follows: 

\c-L^AJkA^x Q cX<>uy^A^ 



1)1 RAT [ON )Vwr? 
CONTRimTORV 



Mouths Pars 



Hours 



I ) I ■ R A T I < ) \ 



Years 



Mnnths 



n<u 



'S 



Hours 






( SIGNED ).........L-.\U. ^J ^^JJUU^ M.D. 



SPECIAL Information «nly lor HospitdK, institutions, Jfdnsients, 
or Recent Residents, dnd persons dyiny .ivvdy from home. 



Rt'siihif in Sini I' I I 



rif, .■ '/■,> 



H r.,r 



, r • ^fovths * fhi 



III. Aiii ivp: sr \ ii:i) i'kusox m_ i-aki uti.aks \k }■: ikii-: to rii i", 
iu;sr oi- MN K NO \\i,K I )(•.!.; .\ N I ) in;Mi:i" 



Former or 
Usiidl Residencf 

When Has disease ronlraded. 
If not at pla(e of death? 



How long at 
PIdfeof Dedth? 



.. Odys 



' Infmnianf 



A.i.it,s.s cXlH LxLcLu ""'X 






I'l^ACJ-: Ol' lilKIAl, ok K};Mo\ \i 



^Ja'.vNjI^A '-Co^.^-vt 



DAli; 0! Hi lo.Ai. or I<i;Mo\AI, 

■\(i<h.'ss...!^l*l Lct-'^.v.^ ■/' 



M. K. hvery item oV informjition hHouIiI b.- ciircViilly Hiipplie<l. AGK should be sUiteil FiXACTLY. l»MY,SICIANS Hhould 

Htiitc CAlISi: OI' DI:A TH in phiiii terms, thiit it mjiy be pr«.perly claHniVied. The "Special InformHli >n" for p«p- 
sons dyin^ tiwny from home Hhould be ^iven in every instance. 







9 






],. 



^ 



V. 






^ \ 






•'k » 



.f' 



• ' » 



. 



'Hi 



, .1 

I 
ii> 



\ 



% 



I . 



I) 



,1... 



; 1 ^ 



• -<-«|M» r>K'9M» 



t-mt^xim^- • 




• ML 
w 



^1 »i 






II 





^^-*.^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ll,.:,lt}, (■• Vo i:; -fr-^^Jiu- I{.S:I'( 



llegLsfvrcd J\^o, 



lOoo 



cVCrccv^v^ ^v-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of IDeatb 

" a>\' o.^auccacccitv of ^^avv' \\<x^\ 



cc^cc 



'J. 



1 



No. ^J ^ c^^^ "^ ■ 'v ^ 4. 



kdr^ ^ 



St.; 



and 



Dist.; bet. 

|f DEATH OCCURS *W«V froM USUAL R E S I D C N C E C I VE FACTS CALLED rOR UNDER "SPECIAL INFORMATION' 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUWBER. 



) 



•■) 



FULL NAME dA^Lua^iv 








PERSONAL AND STATISTICAL PARTICULARS 



^i:v 



vjlWu 



COl.oK 




I>ATK Ul HIKTH 



'Muutlti 



-Ivdlc 



.11 

(Day) 



(Vear) 



\«,K 



•^ L );a,s 



M ititfis 



I go H 

(Year) 



t 



/)<;i 



^r\<-.!.K. MAKkli:!) 
U'IIK)V\K1) OK I»!\nKiKr> 
• Wiit'iii •<<Kial (k««i>j!iati<)n) 



O c^vau 



niHTHPI.ACR 
(State «>r Country) 



XAMl or 
FAIIIl-R 



lURTurr.ArK 

HK I*ATm;K 
'Strite or I'lunitrv) 



MA?T)KN NAMH 
OF MoTHKK 



lUKTHPr.ACR 

«>l- MoTHivK 
(State ur Lountrv) 




OCCUPATION .ID \ 

M*$t4^if ni S,nt /'id It 



n't \ n. 



MEDICAL CERTIFICATE OF DEATH 

DATK (I I' in; ATH i 

x^x'vt a. 

(Moiith'l (Dttr) 

I ni:Ri:i5V CI-KTII'V, That r attendtMl deceased from 

....c)x|.\.t.... '^i 190H to 10.(?QlL..cix\\.t...':^..i9oi 

that I last saw I1 :.- alive on ..Jj.-,iJ^S^^....^„ 190'. 

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

^^M. The CAl SI' ()!• DIvATII was as follows: 

Cn.'V^>"LV.5l .'Sjj^.<lt^A.:tv:5 



nr RATION «. )'t'ar.'i Mouths Days I loins 

CON T R I lU ' T O K V cl »V } \. ^V t.tv<r>AJ...Or.^^ J6.0:Ar,V^^.,... 

aiN4^....LLLc:dl:\,^U^r*'.Tt^ ., 




Vrars 



DTRATfON 
i^lGNED ) 




Months 



Day 



HXkt (0 looH (Address) ^iriCMH^^ "{ftM^ivl 



Hours 
M.D. 



- j>i?f < 



M,iiith< 



Davs 



Special information »"!> for Hospftals, Institulions, frdnsients, 
or Rfienf Residents, and persons dying away from home. 



Usual Residence 



Place of Deatli ? 



Days 



1 m; xHovj.; M- \riii i'ki<s< .\ ai, v\\< iirr i, \k> \ki: i'ki)-: to vwv. 

"l-.sr oi- MY KNOW I.KDCK AND HI.I.Il-l" 



Wlien was disease (i»ntrf»fted, 
If not at place of death ? 



hif.iMii.inf 



f \<l(hoss 



DA'li;^! Hi KIAI. ux ki:Mo\AI. 

Jjj^[vt^J.l 190H 



'I.AClvOI' HIRIAI, UK KI.MOVAI, 

{Ad.i..ss '^'^H^^s M I'Vu^^i^^.^v. :V 



N. B. livery item o^' iii?ormiition should be carefully supplietl. Adll h^iouIcI be st«te<l BXACTLY. PHYSICIANS should 

state CAUSE OP DEATH in plain terms, that it may be properly dassilficd. The "Special Information" for pwr- 
«on« dyin|l away from home should be jt'**" ■" every instance. 



~> 



.-A- 






o 






\ 









* iii, 



1' t 



% 



*i|| 



• ' ] 1i . 



Ill 



\ 



(■■ 



A\ 



t • 



"V "* ^'' 



'J 



iiv 








-*.« **"«-»»,. 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1!,,.M,1 : f }\< ;i't}l 1 



Vf, Is ■«-l^^'S~i)i5c'tr <".i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Dfffc AV7r</,GxAA.tx^^Jj-tN.' 11 



DEPARTMENT OF PUBLIC HEALTH 



Registered J\^o. 



1584 



City and County of San Francisco 



Certificate of IDeatb 

PLACE OF DEATH: — County of Ocl->X' JXCu^vc^^c<. City o{^Ouy\) o AXi./>Ayc.vA ex 
No. kll LIL^ St.: '^. Dist.;bet/. Obxv^^.^^^^^^^^^^^ and Xo. 

(IF Oe«TH OCCURS *W*V FROM USUAL R E *? I D E N C E give facts called for UrAstR "special INFORMATION" '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAO OF STREET AND NUMBER. / 




fX) !^ 



FULL NAME 



] LLt"V^XA^CL^ 




\jL 






PERSONAL AND STATISTICAL PARTICULARS 



i;\ 



[UcJL 



COI,(»R 



.llv.ix. 



:'\ri-: oi- inKTii 



MEDICAL CERTIFICATE OF DEATH 

DATK OI' Dl'.ATH 



r 

(Month) 



x.|ai: 



(Dav) 



(Year) 



« Month) 



(Day) 



vl3.4 

(Vear) 



A<'.K 



bip 



) ra > .« 



Mimlhy 



IH 



Pii I . 



--IM.l.i:. MAkKII.I). 

wriHivyKn ok ihvorckd 

\\'rifc ill >i(M-iaI (I<<!(.'iiatiiiti > 




lURTflPI.ACR 

(State Dt C'nititry) 



JTAMK OF 

FA rniK 



HIKTIII'I.Ail.: 

OI lAinKk 

'State or Coniitry) 



MAIlil-.N NAMK 

OI .mothi:k 



IlIR lUI'LAt'K 
Of MOTHHK 

(State or Conntrv) 



I 



^}(\XM 





.h^(KX^d. 







, I HEKlvlJV ClvKTIFV, That J attciKled dcccase.l fnmi 

d-X^jx-ti \^ 190H to ^jL^.At u 190M 

that I last saw h .L^v aUve on OXl^ .10 ...190^ 

and that death occurred, on the date state<l above, at -^ 
^M. The CAL'Sli OI- 1>I:AT1I Nvas as follows: 

.0AxJ(>-OvcAwL<h^A^;> 






\ 



DT'RATION '^ Year 
CONTRIIU'TORV 




//ours 



DTK AT ION Years Months 



Days 



^\) 



xfctA^ 



OCCITATION 



Ql 




( Signed ) 



cSx^xt v.. u,n fAddre>;s) 10.0^ "6 



//ours 
M.D. 




Special information onl> lor Hospitdls, institutions, frdnsicnts, 
or Recent Residents, dnd persons dyinq dWdy from tiome. 









)', ,1 1 ..A Mnilffn 



fhi \> 



THI', \MoVK ST \ ri: I) i'KKsoNAI, 1' \l< III r 1. \KS AKl. I^RIi-; 
l!i:ST OI- MV KNoWIJ-.nCK WD lU". l.Il-J" 

*'tllfo;inaiit \J . V) OU ^"! '^ ' 



To j"ni-; 



( \<l<lre?<H 



bll 




\^^% 




Former or 
Usual Residence 

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



How lonq at 
Plac e of Deatli ? 



Days 



I'l.ACK 01 lU KIAI, OK 1<1:MoVAI, 



aJvjLAA- 



„A./x 



\a^->"J 



l»\i;i;o!' Hi kiAl. (;r KICMOVAI, 




T9O 



r.NI)i;K'IAKi:K 

("Acldress 



^<xijXuL \3L Co . 



N. B. livery item oi informtition Hhould be cjirefully Hupplied. MW. hHouIU be stiitecl fiXAGTLY. PHYSICIANS should 

mate CAUSE OF Df:A TH in pliiin terms, that it may be properly tiaswiflcd. The "Special Int'ormation" 'ior p«r- 
«on» dyin^ away from home nhould be Jliven in o\cry Instance. 



I 






I 






I. ,■'■ 



^ H 






ill 



• 1 






i 
1 § 



i 







4i:'. 






i;^j 




i * 




II 



;||:i 



1 




I 







\^ 



^'^>^%^. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



II. ..(P 



-,! II. /ill > V' 



*;* 



« -,~»: li.K: i* r., 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lOO'i 



{ { 
DEPARTMENT OF PUBLIC HEALTH 



Jiegi\sfe/'efl A^o. 



1585 



City and County of San Francisco 



Certificate of Beatb 









No 



^^ bfv 



PLACE OF DEATH: — County of a^\ Xa^xCt^CO City of ' CtVt J Va^VCL^^^O 
. llHC rL>LCn^\ St.; 5^ Dist.;bet. IH Uv a 

(ir DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FC R UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



'^X 



•>i;\ 



A 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR 



UaU 



DAT)-: <»r I'.iKrii 



\<;h 



% 



Ultvtbi 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DEATH 



iM*tith) 



I'i 



)'>iti 



% 



(Day) 



M.fi'h' 



/.ill...., 

(Vcar) 



/></! 



'>l\< I.H M XKkli: I). 
uilHiWKit <»K i»i\«»Kri:i) 
|\\ri!i'iii sot-ial <U-<«i|f nation) 



niRTfllM.Ai'K 
I Statt or C'lmitrvl 



N.XMK (»r 

fathi:r 



niKTMIM.ACK 

oi- I Arni:k 

iStatf <ir c"<.uiJtry) 



MAIDKN NAMK 
Ol* MOTHHR 



D !l il 



^v 



itiRrni'i^ArH 

"I MnTIII-.K 
(State cir l"ountry> 



OCCUPATION 

^^^^ }\' hiri! Ill S'li,! / i,nii;r,i 1 ,j )V,;; 



a^^lUrVK.^- 



■Moutli) 



aJay) 



iVtar) 



I IfKRHHV Cf-RTirV, That I attended flcccascrl from 

^^^vt 10 upH t.. "dxld: I.SL. up S 

tliat I last saw h il">^ alive on .nX(\-tr . 11^ „. upH 

ami that ik-ath occurred, on the dale staled above, at \ 

■J..*4r. The CAISI-; Ol- l)i:.\TII was as follows: 

("1 i 



0. -A 



^L':^.\.VA.^i 






DT RAT ION )'t(irs .!/>>>/ ///s ^ /An.v O I lours 
CON r k I \\\ 'TO K \" "^A.Vr.'^ V ctI'C^AA.. U.l>.^WV>v(^ 

g. .^tA L^ti.. '\aa<4Xu, oxo^ 

DC RATION Years Mouths Pays Hours 

S^^XKAAjS^^^^ m.d. 



(Signed ) 



^.w'pl II IgoH 



fAiidrcss) H?.a .^r...c.^ 



Special information on'y tor Hospitals, Institutions, Iransirnts, 
or Recpnl Residents, dnd persons dyinj away from fiome. 



Ill I. SUtiVl-: S'l" \ li:i) rKKsoNAI, I'AK rifl I.AKS \ K )•". I'Kr K To III J-". 
H»:sT (H MV KNOW I.I. DC 1-: \M) UlCMKi* 



former or 
Usual Residence 

Wfien was disease lontrarted. 
If not at plare of death ? 



How long at 
Plare of Death ? 



Davs 



^ S'MrcsM 



QIV 



(^Ho J .'-* ^Vfnni M 



I'l.ACH •»! nrkiAi. Ok kj:mo\\i. 



CrW L\^^4A. 



I) Si!', ..: Ill KiAi. oi ki:Mo\Ai. 



JX|<t. . I,H 



T90H 



M.r.kTAKi-k x sDla X^.^ Ci 



fAddrcs^ 



inO)lt^i.U><ny.:Vt 



N. U. r.very item of informiitlon should be cnreVully supplied. MW. sh.nild be Htiited KXAGTLY. PHYSICIANS Hhould 

«tntc CAIJSI: Of- DIZATH in pliiin terms, that it miiy b- properly tluHsified. The "Special Informntion" ?or per- 
sons dyinil away from home Hhould be feiven in every instance. 



-3. 

t 

\ 

J 

a 



r^ 



a 



7 








» •; 



i '^^ 
■ III 



h 



I' 



k 



■ t 



i t 




. s 



I y 



* ' 



• 




! ki 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

!,,,u.l .f Ilclth I- NO i^ "^-vl^-ir^ '-"^ '' ^'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



-4 



/hi/c /■'//(''/."'•^k'to^vl'u.V [X 



TJO'i 



Registered J\''o. 



1586 



"Lci-ucCo "\JlvM_i Deputy Health OfTicer 



\. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 

( 11. S. Stnn&arC> ) 






PLACE OF DEATH: — County of V<X^\ '.Xa>\CUCcCity of ' CLlv ' KaAXCAAai 



No. 



(XU 



bl UClLL^^C^^CV St.; S' Dist.;bet. S.'^.^VcC and l5)VcL 

/ ir DEATH OCCURS *W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I IM TO R M ATI O N " \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME k ..CtX (;^. jv >1X. ^\L cL!iCt.k 






PERSONAL AND STATISTICAL PARTICULARS 

*^t:x 'Vs * , t ( )i,i »k : 



f 



dli 



vlL< 



MEDICAL CERTIFICATE OF DEATH 



T)\ TI* OK T)i:,\ 111 



rSjikk.. 



I>\ IK t»F Illk III 



\«.K 



I 



Jli 



iMiiiitli ' 



a\ 



M 



) ■.<; 



t 



M.nitfis \ 



(Vt-arJ 



Da vs 



^INf.l.K. MXkUIKl) 

\vii)<»\vHi> OK i)iv«»m i:r) ^^ 

'Writriii Notial «l» sivrnation) 



-U.ML 

'Stattor Country) I 1.' . ll « 1/ 



I ATIIKR 



I'-IR llll'l, ACK 
OI* I .\THKK 
*Stat« (,r rdiuitrv) 



Ol- MOTIIHK 



IHKTHPI.AOK 
Ol- MOTUKK 
'Statf or C<.initiyi 



OCCrpAlloN 






(Montrt) 



..1.0. 

(Day) 



TQO 
(Year) 



I lIF-iRI-nV CI-RTII-V. Thill I attended dccea.sed from 

;\\vuc^. % i^o to 'b.Ji\^. a i9ot 

that r last saw Ii-'^./v alive on OXpJt ...."ri I90'; 

and that death occnrred, on the date stated above, at I 
)^ M. The CAlSIv ()!• Dl-ATII was as follows: 
v!yX/^'U«^. .J CC^tvo A-Nxt.*L^tA^r%«C?^'W.. „ 

.Va«;S^^\*Wi]W 



^ !^ ^ ' 



,7N 



\ 



DIRATKJN Years t^ .Voni/is Days 

C" ( ) N T R I lU "!"( ) R V U.. >\^k^A.X:ft:V«^n.k 



J /ours 







DIR.XTK ).N )'t'ars Months Days Hours 

(SIGNED) wiv^V Ia- lllcLU'V M.D. 

\t 10 ic)0 H (A.hlress) 16M H 0.aLi^>:Ve^'.<^..uf. 



....c 




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






TiiK AHovi-. s'l- \ri:i» io<:ks(»na!, !■ \Kin II. \Rs ,\K 1. iKi )•; 1"' > riN-: 
Ki.sroi- Mv kn<»\\ij:i)(,k .\ni) r.i:Mi;i" 



Former or 

Usual Residence ■ • -•■ - 

When was disease rontrarted, 
If not at pla( e of death ? 



HoH lonq at 
Place of Death ? 



Days 



' Iiif«>iiii;uit 






\<Miv«s V)t 




ri.ACK OI' m'KiAi, OK ri;m(>\ai. 



.UJXZhJXy^^^j^' 



rXOliKTAKI'K 



I)ATi;<)f MrKi.vi. or RHMOVAI, 
V!^X\\± I a T90I 




'.'lAjLjkK ^^.U 



fA.lchrss h'il 



'>)tL. 



\L.<l^*<r>.'X.. 



N. K. i;vcry item otf inforrn.ition Nhould be cjirctfully supplied. .A(JK should be stilted liXACTLY. PHYSICIANS should 

state CAUSE: OF Di:ATH in pliiin terms, that it miiy be properly classified. The ''Special information" ?or par- 
son* dyin^ away from homo should be fcivcn in every instance. 



iM 



;»' 



' ► 



■ i|S 



'! 



I,' 



* fl s 



I 



\\^. 




'it 



; 

1 J t : ^ 



A 



i 



:^^ 




M 



ijfe' 




no.r. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^ II. ilth \-- Sn. :. ^■i_^*^.,nK]'r., REFER TO BACK OF" CERTIFICATE FOR INSTRUCTIONS 






ItrgLstci'cd jYo. 



1587 



.k-^rv 



w :> <X.- 



Dep'ffv K . j-^h Officer 



DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 



Ccvtiticate of IDcatb 

( XX. S. StanJarS ) 



(^ 



PLACE OF DEATH: — County ofC)<X"tX' O.'va. wai-^et City of 'J.<Xoixi 0/v<x-vv/CA^<t.c 



St.; 



Dist.; bet. 



and 



/ ir DtATM OCCUnS 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 NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME '' Ux.^X v:rw. ..X/ xt^.. 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

J COI.nk \ 



^ 



DATK OF i;iK 111 



L 



iM..iith> J 



ID.UU 



Ai.K 



Si 



) >./ 



II 

I):tv» 



M»,lh> 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATff 






i 



.1.1. 

(Day) 



TQO M 
(Year) 



Davs 



•^INi.I.K, M \K k Il-I) 
VVIDOVVKIJ t»K DIVokv KI) 
M'titfin MKMal (l(si}.'iuiti<iti) 



lUKTIfl'I.AOK 
'Htjiteor Country^ 



.C^X 







-(. 



f 



I Iir^RKRV CT:RTI1-V, riiat J atten.lcd deccascl from 

LLA>^wq,...i.'»i. 190H to S.X.|\.t> U icpH 

that I last saw h Jw.^ti.^ alive on X^^Jj. . U j^q <i 

;m<l (hat death occurred, on the date stated above, at O u vj 

.0. M. Tlie CAlSJv OF DlvATIl was as folUnvs : 



\.- 



vo. ai . . . !i^L<%M>\.' 



t 



^^^A^^^O^^VC 



N'AMF OF 
I ATI 11: R 



niRTHPI.ACH 
01 IATHKR 
iStatf or Country) 



MAIDKN NAMF 

<>I MoTHF.R 



HlRTMl'LArK 
o|' MorHFtR 
(State or Coutitry) 



? 



'\ 







\ 



DTRATION Vt-ajx Mouths 



Days 



Hours 



■'^M^^'C'^X^X'tvC 



t 



xCV^^-\-"'^-- 



^vsva^j 



I )l RATION 
( SIGNED ) 

'^\jJ^ 11. u 




'0?) 



u"J. ^^ 



Mo N I /is 



/hi vs 




'^sXA 



I /ours 

M.D. 



I 



)^ 



(Address) X^^^Ava^v M (V-\.,,\ 



OCCUPATION 



)X^1"VV€l 



-^-vA 



)'t)if's .- ,, •" , .1/.';////A 



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

Usual Residence vJ A- ^ 



Former or 7^ +- I k i .^ I' "**** '""" ^^ A A 

".raOjAAAVJ^ UXt Plare of Deatli? .O.y. „. Days 



Oil-: \M()VKSTATJ-I) I'KKsoNM. I'A K Th' I I. \ K > A K i: Tkri-. To Till- J'l.ACH OI" RfKIAI, OR KHMoVAI, 



HivST uF My knouij:i)c.h and i{i:i.m:i- 



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




O /N 



^X.Mrcss 



^ 



e. 



\C 



X'Xyy^ v<X/-»^ 



(Ml- 



Wu: 



xi- 






V 




'^ 



WYU 



Iajl^a^mxU 



DATKu!" HiKiAl. or RKMOVAI, 

^ _ aje4^ t-^ 1 90 '> 

M.l-RTAKHR fc. 0- OX^-k^ VU) 

(AcMrcss ll'il \M\^>CL"a <.^->\ . '. 



N. B.. 



-F.very item o^' information should be carefully supplied. AGE should be stated KXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinjt nway from home should be feiven in every instance. 




♦ I 



11'' 



I 'M^ 



! I 






1 1. 






i ■ 111 



!i 



. 



I 






' .1 



"I I 




f 





f 



[-Nil 



1^ I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



])nAr<\ ->r llr,,!t)i I'- Vn i-^ ^"f^-r^' n^'^I' <• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafi' /v7rv/,.C).x^^"b:.^^^N^ '21 



IfJOH 



lleglsteTed J\^o, 



1588 



' 



.(5 V. 



I « r 



Deput 



/-• f% I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eath 



( H. S. Stan^arC> ) 



PLACE OF DEATH: — County ofd.(X>^ J XcC'^"vxi,<„^ c. City of iX>\; O Xo. >vc\^co. 



No. Itb 






St.; civ Dist.; bet. 




% 



f ir DfATH OCCURS *WAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO 
V IF DEATM OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



uX<UrvX) and J .CLcL 



u 



FULL NAME 



X^U^U.. 



S50 



\Ji^\r.. 



PERSONAL AND STATISTICAL PARTICULARS 



? 



i>\'n-: i>\ luKTii 



lu 



AW. 



.U 



NJ.iiith) 



..,15" 

<I)MV) 



l.lll 

(\*ear) 



MEDICAL CERTIFICATE OF DEATH 
D.ATE OF DKATH J 



n 



DM 

(Mont 



^t: 



) 



II 

(Day) 



(Year) 



I HRRr':RV CKRTII-V, That i; attended deccnscMl from 

■LLccCL i iQoH to CJ-jei.vl. LX 



\<.K 



1 I }V,ns 



11 



M'ufhy 



\% 



Da vs 



UTDOUKD OK KIXOkrKI) 
Write ill -^iKi.-il (Usivii.itinii) 



IURTni'I,.\OK 
St;iti' or Country) 



NAM J- <)| 

I .\Tin:K 



I'.IKTIIIT.ACK 
<'l I ATHHK 
•Statf or Conntrv) 



MAIDKN NAMK 
t'l" MOTIM-.K 




f\<xwu.cl 



D/O.^I'VvxlIvcM 




C^VvJUi.' 




floo- K 




1.^4 \1) 



-CL i 190 H to 9-l^.v.L i.l icp H 

that I last saw h^^*^ alive on aJL-^t .1.0 igo'l 

ami that (U-ath «)ccurrc<l, on tlie date stated ahove, at Tl 
4-L ^r. The CATSFv ()1<^ DI-ATII was as follows: 
O Owtua ^ X.CJ^.>\JL^^X\.t.A..*rv\, &Vr..,ati.^.OAJb 




Dl-RATION yi\irs Hloui/is Days Hours 

C( )NTRII5UTUR V iX>.V. ...CuS^^N^d^fL.Cttr...lX.>:U)^a.v^. 



ink rifpT.ACK 
<»i- M(»thi.:k 

'St.itt or Country) 







? a »U\A4xt\x 








(UTt-pATlON- [J I 

VJVjttAAxdL 

. f^f"--i<!r(f iir San /'idfrrr'sm X )Vv?;<- M,<iitli< 



Ihi' 



1 UK \H()VK STA ri.-.I) PKKSONAI. PA KTICl I.A KS A K I". TKl K TO THH 
Bhsr OF MY KNo\VI.i;i)C.K AM) m;MP:F 



DTRATION Years ^'f^'^^'-^ '^^^y^ 

(SIGNED) .aJx^UV^MiI JxKAa. 

O X \ \.t: 1 ^:. i()0 ■ : ( A dd ress) C 1 .La.^V' JlAl\.Q ' .^ 

Special information only for Hospitdls, Insmulions, 
or Recent Residents, and persons dying dH«») from liome. 



Hours 



M.D. 



%u 



former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Transients, 



Days 



(Infonur.nt \J /I' 



|. Q)u.vt 










wt.\. 




i 



ri.ACK OF lUKIAU Ok kHM«>\AI. j DAXFof IMkiai. or kFMo\AI, 

llLux.lv £ca I i)x^..,„j.3, ,p„, 

(Address HX'i \i (tLcLvw dcCti .Ia.^!-^: 



'^^ **• Kvery item olt information should be cnrefully supplieil. AGFi Hhould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The ^'Special Information'* for p«r- 
*'^'" dyin^ away from home should be feiven in every instance. 



1] \\ 



I ' 






> d 



* \\\ 






\ 



*,Mi' 



I 






' 'i 



)> 






I <f< 




■*>jtLi 








^^ 



t i 




}|. •:i!'l 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I . f II. ,111. I N' i. ^^Sr^'*'*^'* " REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






RegLstered JV^o, 



1589 



\ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( 13. S. Stan^ar^ ) 



J? 



PLACE OF DEATH: — County of "a^xtcx- LlaXa' City of CJO/n/ Uo-U 




No. 



St.; 



Dist.; bet. 



and 



(IF DCATH OCCURS AW*V mOM USUAL RESIDENCE give tacts CALLtO FOR UNDER "SPCCIAt INFORMATION" N 
)F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STNEET AND NUMBER. / 



FULL NAME 



.<X\u^ .^'al^C^ 



PERSONAL AND STATISTICAL PARTICULARS 
SKX \\ ^ j COJ.oK 

OX 



I»ATH nl- III K in 



lllkoL 



I MoiitlO 



A < ■. K 



•IH 



) till .» 



tl);iv) 



y/ouths 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF l)K 



"'" A 



+ 



:UA^^. ,, 

(Monlh) 



(Day) 



(Year) 



/ht\ 



'-IV'l.r MAkRIKIt 
\yi!)< t\\ Ml) OK IH\< •!<*»••, II 
\Viil< ill MK-ial (li'xiKtiati'iii) 




a\^<^'A. 



i!iK rni'i.ACK 

^tatc or Cuiiiitry! 



^ Ml ol- 
\ rillR 



•MkTHI'I.Al'K 
'»! lATIlKK 

'Statt or Coiintiy 



MAIIlKN' NAME 

"I M<>Tm:R 



niNTHi'i.Arr, 
•»i M<trnKk' 

(State «»r Country) 



OCCIT 



i '7 

Oxx-y^ o; 



^x 



:C IT PAT ION lT\i* t 

Kfsitlfil hi Vf/i; Fl (Uli ! I ii 



( 



Al / LO^"5-^5-<XtlvtcAxtt4 



I m;RI':BV CKRTIFV, That I attended deceased from 

.'. 37r:r. :;;:.. ~~ 190 to .■rr7.:..:~":z7r.:.:.~~:.:.r:T. .190 ~ '.: 

that I last saw h ...Tn-r... alive on • igo-.-^^ 



and that death occurred, nn the dale stated ahove, at "" 
^ M. The ^\rSI<: OI' 1)I:ATII wiy^^as follows: 



...<^K^SJ^<.\^ . 



r 



or k. ATI ON Ytars 
CONTkllirTOKV 



Months 



l^ays V . Hours 



DIKATION 



Mouths 



(SlG 



iNED),..A.,t.... J 



}'i'(irs 

(Addn-ss)^a%-. l" : 



Days 



Hours 
M.D. 



J. A 



SPECIAL INFORMATION only lor HospitaJs. Institutions, Transients, 
or Rffent Residents, and persons dying away from home. 



former or 
Isual Residence 



'\\ 



) ,' 



yf.nitin 



A.' 1 



I Ml xHovi; ST \ri:i» i'kksonai, !• \k in i i. \ks aki: \r\ k vn thk 

ilJ-.sr 01 MV KN(>\\ l.llx.K AM) Hlvl.llvr 



When was disease contracted, -A ^ 1" c /% . ^ ^ 

If not at place of death ? CX. >V ^ Va^ vCvnUx^ 



{A-^^V^ ll\M. Place of Death ? 5^1 



Days 



N.l.ln 



ri^CK ()K IMRI-M, <»K RF-:M<>\\I, I DATIvof Hi hiai. or KKMOV.M, 
(AcKlrcss IDVl Q)lL^V^-(4.i,t 



N. B. 



-fivepy Item ui infrtrmiition •hould I>l- cHrefuliy Huppiied. AGF. should be stated EXACTLY. PHY8ICIAN8 nhould 
state CADSi: 01= DKATH In plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home Hhotild be ftiven in svery Instance. 






! I 



4 



' / 



i' 



1 



1 



I I 



I i> 




f'v 




H 











}',..l!. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

rn If' I ^ iy*^^<.v fu«tlMo REFER TO BACK OF CERTinCATE rOR INSTRUCTIONS 



/ 



hf/r /'V/fv/. ^xjltt^^v^vj^V 1% IfJO^ 



Begistct'ed J\^o, 



1590 



C^^VVC-0 ^ 



\y\A 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



11. S. GtnnDarc> 



PLACE OF DEATH; — County of a^\ 









XClslCOCity of 'JCt>V • ' VaA\CA.^CU^ 



No, 



.11. 



-N 




a\A^i:\jiJt(S^kJuxl St.; 



Dist.; bet.- 



and 



(\r Dr«Tw occuns •way rqoM USUAL R E S I DE NCE Gi VE facts calltd tor under "special information N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



-) 



FULL NAME 



r. 



LLtLa^Yc 




\X.^'Z 




i:\ 



.' \Ti-: or juK'iH 



\ • :. K 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OK 




CcU 



.1 



IvcU 



M.Mltfl^ 






(liiiV) 



M.,nlhs 



(V«:ul 



Da \ 



MEDICAL CERTIFICATE OF DEATH 



DATK 1)1- IM.ATli 

Bxk^ 



(Monl^i) 



(I 

(Day) 



igo\ 

(Year) 



-■IN'. 1. 1. MARRIl!n 
W IKuUKI) Ok I)(\( >K(*Kf) 
U:itrii) social <lt ".ij^naliM!!) 



HfRTfllM.ACH 
Hiate or C*Hiiitry) 



NAMI-: Of- 
I ATHKR 



niKTHPI.ACK 
Ol- lATIIHK 
'^^tatf or Cotintry 






A 



I Ffr^RlJ'.V CP:RTrFY, riiHtr atten.led deceased from 

OlVcLty n upH to k)-c[vt u icpM 

tlijit I last saw h -t>n alive on Q-c'y\'t id T90 S 

and that <katli "tcrurrcMl, on tlu' <lati' stated abuve, at ol- 1^ 
... CI M. The CATSlv Ol" DIv.XTlf was as follows: 

JAaA.VjcX'CAjc Ci- X-LC^VQ ...... 



DIR.XTION ( Years 
(.ONTkililToRV 



IMoulln 



Days 



Hours 



MAn»KN NAMK 



niRTrrri^ArK 

Of MoiUKK 
''^tatc or Coiintrv) 



OCC 




I M K .\ r |( ) N 



( Signed ) 



)\ars 




C 



Moutha Days 



'Vio.^t'frW 



Hours 



>^-^|a1: u rooH (Addrrss) M)laM-.u IcM-l 



M.D. 



:tri'ATlON J) 



Special information «nlv fur Hospitals, Institutions, Transients, 
or Rerenf Residents, dml persons dvini) nnav Irom home. 



/^/i 



' "l;,^'!!.*^ *"• '^'■'^■Il-I> I'KUSON M, I'\K lUMI, \Ks AkI-: ■\'\i.\ V. 10 Till-: 

Hhsr OF Mv KNo\\j,i:i)(.F AM) iu:i,n;K 



former or 
Usual Residence 

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



How long at 
Place of Death ? 



.. Davs 



(Itifortnr 



v4^crvv 






ri,.\ci-: oi- Ml kiAi, OR ri;movaf. 



l)\l"I-:<.f I!i Ki.Ai, or RFMOXAI, 



W 









190H 

V5 



(A<l(lr(ss 



IN. R. 



Fivcry item of Informiition shoulil bi; cnrePiilly Hupplietl. AfJR should be Htated RXACTLY. PHYSICIANS nhould 
stiite CAUSr OF' DfiATH In pliiin terms, that it mjiy lie properly classified. The "Special Informiition" for per- 
son* dyinil away from home should be (^iven in every instance. 




) i' 



f li' 



t ' 



•» 






1 1.. 



t I 



i I 



I 



I 



I 



1?^ 



I 



\ -^\ 



•iA— 



fV 



« * 

i 



ff f 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ji,,,,..!.r II :,lth IV" ; s ^?J»]?^3 JUS: 1' Co 



Begistrrcd J\^o, 



1591 



\.^K^^. dLv\-v< Bcputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



% 



PLACE OF DEATH; — County of - Cu^v J /vxXA^we4„4^c.<i. City of Cjxxa^' OA.<x\-y^ui..c.^. 



No. ^^^^)V 



-f 



LLL'w^V* St.; .: Dist.;bet. cLcXV'Vv^'>\j andU.CTUi... 

(ir DEATH OCCURS AW»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. / 

FULL NAME C-l*- \,<xiI>dJl\j Uv<it<A: 



\ 



■'^^ ^ 



PERSONAL AND STATISTICAL PARTICULARS 






^VC 



tx 



Montli) 



(Day) 



tVear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I) HATH 

3x{A:t...... (t 

(Month) (Day) 



IQO'A 

(Vfnr) 



\<.V. 



^ ^ )>»;<. I I M<mths \ 



Dii 1. 



*IN<*.I.H MAKKIKO. 
\VfI»n\VKI> <>k I)I\c>R(KI) 

iU'ritrin '.'K-i.il fl«-iv'ii;tt i-m l 




fimii 

1 < 
,♦ 



U^x:i-^o" 



MIRTHri.ACK 
(State or Country) 



\AMI-: «>i- 
HMUHR 



TUKTin'I,\iK 
<Statt or Ooimtry) 



MAir»KN' NAMK 
OF ,Mf>THKK 



UjAAXlAxt 



I 1II;ki:HV CI-RTII'V, Tlijit I attciuk-.l deceased fn.iii 



crv%' ,U\ji loUv i^ cL tw iBje4^t,^"5'^-^--*^v 190 

lliat I last saw h alive 011 , - 190 

and that death iKciirred, on the dati" stated above, at b 
Am. The CAl'SK Ol- DI'iATII was as follows: 



y^AXvyv^nvocVu, fox.->>>,*X'NJk<x<t,'.. .. ilvvCt^' 



DTRATION 



n 



^ ^vj& h^fr'-vvCAv*,^^ 



ek: 



? 



t 



BIRTHPr.ACK 
••I' MOTHHR 
'Mate or i'ountrv) 




OCCTTATTOK QJSl^ 




^-v 



Jl 



Years Mouihs ■ Days 

CONTKll?lT()RV . UJL(:yN-ut^tu. 

DURATION Years Mouths Days 

f Signed ) ...Qxouc^. M\.. MlLXli?^... 

^^1^1 ■ ^^.^ /Address) mHM)laV^:.^t. M. 



Hours 



Hours 
M.D. 



igo 



(. 



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



/^f^itlnf in Suf /'r irn, hf.r- 



) I'll I 



Mnntfn 



I\i\. 



' "l;J^-!.*^^' "^ ' '^ ''■'•■'> I'KKSONAI. 1- \K lUri, AKS A K Iv TKtK To Til)-: 
"hsriM .M;)i; KNoWIJ-.DC.K AM) WVAM'.V 



Former or 
Usual Residence 

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



How long at 
Plar e of Death ? 



Days 



finfo! 



imant 




vi.u..., s?>?> ^'^CliL*xt.v 4 



PI,ACK OF BIKIAI. OR RllMoVAI, 




n.Vn: of Hckiai. or kkmovai, 
Ox^^vt. I ij T90 V 






..'»,' 



(Addresj; 



N. B. 




Kvery item of InformHtion •hould be carefully nupplied. 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 f^iven in every instance. 



G^ 




> 









1;; 



mi 



! I 



It 

4 



1 ■ J 






K 






i i 




' il 



I ^ 




m 



<I7 



h. 








11..., 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I '1' I ^'" '^ f-^^^'.li^VCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



4 



/)(!/,■ FiJcil. dx. 



.6-\^\_a) 





10. 



l'JO\ 



BegisteTcd J\''o. 



1592 



AM- Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

(iFfptaTAoV^cuRs *w»v rROM USUAL RESIDENCE give facts called for under "special information" "N 
If OC\r^ OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITb NAME INSTEAD OF STREET AND NUMBER. ) 



PLACE OF DEATH; — County of ^0^^\j J.^o^^v^c^c^ City of O/CV-ru J >h^<x->^cevA t^o 



if^eatA^Vtc 

J' 



Dist.; bet/ 



and 



FULL NAME 



i-a>>.vL5 




' I 



.^^ 



oM.w.o.'k 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



' i 1 r. ui iJiKiii 




MEDICAL CERTIFICATE OF DEATH 



<Motith) 



\|.K 



H5 



).; 



It .« 



(Dajr) 



Mouths 



(Year) 



Jhl\.s 



DATE Ol" i)i;ath 

Bxkt 

(Mon/h) (Day) 

1 HlvklvHV CI'RTIFV, That I attended deceased from 

^ to 



I go \ 

(Year) 



'I9O 



Tqo 



WIHoWKI) OK IHVnKCKr) 

i\Vrit«-iii Mx-i;il <1» «.iir,,,.,ti,,n) 



Hik rni'i.ACK 

(State i>r Country) 




I'Aiiii;k 



\ 




TIIRTlll'I.At'K 
'" I- A niKK 

(Stale or Coimtrv") 



>fAinKN NAMl-' 
'>1- MnTIIHR 



IWR riTPf.AOK 
<>I- MorH}':K 
'State or Country^ 



/ 



^tX^^vU 



ft 

V i 



that T last saw h -rn—— alive on ••• 190 

and that death occnrred, on the date stated above, at -.••■'■' 
: : ::-:-■■. . M. The CAT SIC ()!• DICATII \Yas as follows: 




\XJ\.^A^ . 



V'A^V.a^VV/— Y%^ 



y^xtow-^xK:^^ 



DT' RAT ION Vt^ars 
CONTKIIU'TORV 



Months Days 



Hours 



DTRATrOX 



Years 



}fo}iths 



'\ 



OJvCtOLhjij 




(SIGNED ) .\JfUsy\S}\) 



\jf\Xsy\J^ . ^h. Ill MJJX/: 



Days 



/lours 
M.D. 



MAHX^Aj 



OCCllpATiox 




O^'Y'^jL,- 



lO 



^'U)<xtJ- 



VX >AA^<X^^' 



M.nifhs 



IhlV. 



' "',;,) ?!I,*^'*- ^'^IJ-I) J'KKSONAI, I'AKTUTl.AKS A K >•: TKIK TO THK 

uhsroi- Mv kno\vm:i)(-.h and !u:i.ii:k 



dxjvtj W TQo'. (A.ldress) CfrVCTyv^M vy|fvv. "■. 

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

Former or ^ \t\\ K \ '\ \ ^^"^ '<""! «* 

Usual Residence ck I U 10, Vl X\tvu V piarc of Death ? 

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



.. Days 



'Iiifottnatit 






IM.ACK ()!•* HTKIAI, OK K1';M0\A1. | DAT^-; of HtKiAl, or KIvMoVAI, 




CrVu L^uy^g 



[•\di-:rtakkk M 1 1 j <X<Ajx> > \\\ 

(Address 1 .11 1. \l lU.<L<L.v,*^\ C 



\r^^pXl 1..^. 190 



V I lU.<L<L.V,*^\ U .1 



IS. B. Kvepy item otf inforniHtion should be cnrefully supplied. AGK should be stated EXACTLY. PHYSiCfANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for pur- 
sons dyin^ away from home should be j^iven in e\ery instance. 




* 

M i 



I : i' 



'. 



I ii 



< 



% 



'I 



■k\ 







ii 



i 






m 



^mm% 




t < 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






I!JO\ 



Jicgi,stcred J\^o, 



1593 



«r»er 



Ihilr Filed, Ox^xtjc-^JUv l^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of H)eatb 

( Xl. S. StanC^arD ) 



No. 



PLACE OF DEATH: — County ofOo.-^^ JA.a/YN...C^^£^City of Jcla^ O/vO-^^ce^cc 

.; b Dist«;bct. (k^XXxXXjy^JX. andVvjA<-clv<X t 



bf5Ab.LXeK. 



St, 



o 



r ot*TM occults *WAv FROM USUAL RESIDENCE Givt facts called for un/I^er "special information- \ 



(IF DEATH Ol 
IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAOjOF STREET AND NUMBER 



FULL NAME 




yxsJJi^S 



LL...AJ..UL]b.rL\t.. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



I 



DATK OF BIRTH 




e» n,' iK 



iMuiithl f 



iLuk^LU. 



iDav) 



(Year) 



a<;k 



> I'a t s 



M-tilli^ 



S 



Pavs 



UllHiWKU UK lUVoKt i:i» n 

Wiiti ill MHJiil iN oiv'tiiaioii) \ 



Lal^l 




C3\0lCX OX/' 



n 



P.IK THPl.Al'H 
isiiitr or OMititry) 



WMI ()|- 
J ATlliiR 



HIK rni'l.xcK 

OF i-atiii;k 

(Htatf or i'Diiiitt v^ 



• H- ,M()Tin:K 



niRTlI|»l,ACK 

(St.iK or ColjUttA) 



OCCrPATlON 

tyfsidnt in Sill/ f'liiiiiisi'n 






MEDICAL CERTIFICATE OF DEATH 



DATK or DlvXTfl JP 

.6xl\t, 



(M'Hitfi) 



...LI 

(Day) 



(Year) 



^ I lfI':RI*;HV CI'IRTIFV, Tliat T atteiKlcd deceased from 

djL^AJ: U 1901. to u^^^t 1.1 190 H 

..a.x^t \i 



190 i 

that I last saw h i^> > > alive on Sw',*Ly^u f.i icp 

and tliat death occurred, on the date stated above, at l-iC) 
\f ^ M Tlie CATSIv OF Dl^ATII was as follows: 




..CrL. da.v'vx/Q^c 



Uvo-tL? 







DIRATION }'i'ars Mo)iths ^ Days Hours 

C ( ) N T R I lU" TO R V lL>Jk<::y%.<rV..sr>:^« 




DIRATION 
(SIGNED) 




Yiars Mouths 



Pavs 



Hours 
M.D. 



^ 



x|xfc u 



IC)0 



(A.Mrrss) i^vJ4^A.^.0 ..' .JJa:' 



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



) t'il I S I 



Mouths 



^ Ihiv. 



Former or 
Usual Residence 

Wfien was disease contracted. 
If not at place of deatti ? 



How long at 
Place of Death? 



Days 



Tin: Aiiovi: sr \iii) i'i<'usonai, i'\k tumi.aks aki; tkii". to tiih 

MHST 01 MV KNOW 1,1; DC. K AM) HIvl.IKK 



Informant 



f \.1(1 



ress 



biS 



'AA. 



VcA* \X^ 



1 " 



rUACH Ol' lUKIAI. <);< RKMOVAl. | DATi; of lU kiai. or KHMoXAl, 



INDHRTAKKR 



Xd.frtss . 1 bl vyric<l.ClA.t^ V Cil 



IN. U.. 



-Hvery Item «tf 1nform„tion .houid be cnrefully supplied. A(JF. «hould be stated EXACTLY PHYSICIANS should 
«ti.tc CAUSE OF DEATH in plain term., that it may be properly cla.sificd. The Special In?ormat.»n for per- 
sons dytn^ away from home should be ftiven in every instance. 



v-Jii 






iH 



o--^ 




»» 



I ' 



'I 




t ^^ 



i: t 



I' 



m ' 



> ! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



{,,.■..!.: . f II' :tit)i »•■ ^ 



No i«; ■**^^^->l'.S: 



I' Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



/^//r /'V/^v/, JA<^^|x"L^l-yvltKi^' H I^JOH 



lleglstered J^'^o, 



i 



(yvco .kx 



DEPARTMENT OF PUBLIC HEALTIi==City and County of San Francisco 



Certificate of Beatb 

( XX. S. Stan^ar^ ; 

PLACE OF DEATH: — County of C'<X->-v ^'/v(X>vcci'CfCity of 'Cv.'\v JA^X,>xC(^CO 

No. li\AAC*lval vCd' VO.Cl.,-.- "' '"St^v D;st.;bet. — -and — —=::=....:...) 



.1 



y VNwvI^wv I w<.u \^ v_ VC^- w'vtvv. j>T4v i^isi.; Dei. " and 

I / ir pr«TH occuns awAy rnoM USUAL RESI DENCE give rucTS called for under "special information- \ 

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

Cat! ^' 



FULL NAME 



;\aLVL:^u 



.OLU;. 



PERSONAL AND STATISTICAL PARTICULARS 



.1 



It\ I K «H IliKTIi 



I ("■"■"kiLu 



\i 




< Month) I Day) 



< Year) 



m:k 



Tb 



) 'li I 



M.inlhs 



Ihn 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH V 

n 



(Moirth) 



ii 

(Day) 



(Year) 



SIM.I.K, NJAKKIII). 

<\Viitcin MH.ial <U**-iKiiati<in ) ^ 



10 .■!: 



^vu" 



lUK rtIl*I.\CK 
iStateor Conntrv^ 



iathi:r 



MikTur'i. \cv 
<>|- iathi:k' 

'Stair nr Comitrv) 



MAIDKN NAM}- 
<»1 MOTUKR 




(Xc^\x 



y 



y 



in KT HI' LACK 

'M- MoTHKK N \ "^^^ 

(Slatf or Country) XJ*" 




I IIF.RI-nV CI':RTirV, That J atteniUd .Icecascd from 

civuv 5^ 190H to ^Jtixir l.l 190 H 

that I last saw h i^'V' aHve on .OX|vt l^ Igo'l 

and that death occurred, on the date stated above, at <(J -.-.. 

U, M. The CAlSIv OF DICATII was as follows: 

,. CX^V<^LL.tij 



DT RAT ION )'ears 

CONTRIIU'TORY 



Mont /is 



Days 



I Jours 



OGCt^PATlON 

/ifsufrtf in Sit II f'l ,i)ii ism \) 



DT^RATION 



(SIGNED) 



Years ^ Jfof/t/is 



/hU'S 



Hours 



lh^,n K' 



'1} 



.,J0..-.LI}. >!.XU:W"lK1 , M.D. 



^x]_\"t |1 iqoH (A .liln'ss) Iti6> 




\JJ\S.^(X..VX 



h 



)'ill I 



.1A.-////.< 



/hj \s 



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

Former or ""*''"?''/.., 

Usual Residence Place of Deatfi ? Days 

When was disease contracted, 

If not at place of deatfi ? 



1111: \novK sr \'n-,i) phksonai. rAuiicrLAKs akj-: tkik t<> tmk 

in.sT (II- MY KNOWI.lvDC.K AND lUvMi:!' 



(Iiifi)Tinant 



^Wi U. 






< A'l.lress X\\L^C^r\a.' 



.1 L XA.'Xcuiav^ ht : . 



DATK of HlKlAr. or KKMOYAl. 

%aidxi VCc 



I'LACK OI" m-RIAJ, »)K KKM<>VAI, 
rNni-:KTAKKK 

^..iL . .y.)X.U.^.^.t.i;. ii.... 



(Address 



N. B.— Kvery item of information .hould be carefully Hupplied. AGE «hould be stated EXACTLY PHYSICIANS «hould 
state CAUSE OF DEATH !n plain term*, that it may be properly classified. The Special Information for per- 



son* dyin^ away from home should be ftiven in •very instance. 



k\ 



i I 




) i f 






t' . I 



! ' . 



; t 

tl 



Hi 



Ifi 



i 





!' 



I 



11! 




ii 



III 



\l * 






4 





I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ , , ,1, ,1th I vo i..iJ"J'^5^->rAI'0.) REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



hale l-'ilcil, CX\^'tvv^v'.'-vN W 



l'J(J\ 



Registered J\f''o, 




\^vvvo"ltv^u Deputy Health Officer 



■\ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDarO ) 
PLACE OF DEATH: — County of C'CXiv J.VQ^TvCclCci City of ''O-'W J AOywC^-iCt. 
No. 15 0. W M)V llll^.. ' . ' , St.: 1: Dist.; bet. '' ,) a-vLtN. ^^j 'la, . .aa, .. 

rnoM USUAL R ES t DENCE Givt tacts called f 
OR INSTITUTION GIVE ITS NAME II 



/ ir OCATM 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. / 



-r 



FULL NAME U^|/^ 



nATi-: i>F niK rif 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.iiK 



!1 



..llUvdi. 



_je 



lunth) J 



I Day) 



/'■US 

(Year) 



At.K 



) Vi:» A 



X 



M>>nlhs 



Pa vx 



W ri>M\\j.;i) OK I)I\( iKii:!) 
■Uritciji siK-iiil clc«.iv:nalioii) 



BIR lUIM.ArK 
(State or Country) 



N\M» oi 
F-ATHl K 



WA/ixqU 



MEDICAL CERTIFICATE OF DEATH 



I).\TK «)I' DT-ATFI 



.LU/lxC U 190 

(Month) fnay) (Year) 



I III':Ri:nV CIvRTIFV, That I atten(le<l deceased front 



tlJJ(d, I I 



90 



to 



xlvt ii 190 H 



c3-l.l^ 1.0... 






RlRTun.XCK 

'H iArin;k 

'State or Countrv) 



MAlhKN' NAM!' 
(>1- MoTHKk 



niKTiII'I.ACK 

•>i- MOTMKK 

1 Stale ur CiMiutrv) 




that I last saw h i.--^ • alive on UJL'fU^ i.U 190 H 

and that death oooiirred, on the date stated above, at <k 

,U M. The CAl'SH OF Dl-ATFf was as follows: 
<^.\vC\rr"V^wvt^trvA. 



DIRATION Years I Months 



Days 



Hours 



CONTRIRUTORV 



DfRATroN 
(SIGNED) 



Years Months \ l^axs 



Qjc^JAt IX iQoH (Address) ...3'ID... 




flours 
M.D. 



I 



UwsXsjwa 



OCCITPATION 



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



former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



Ml-: MtOVK, ST X'lIU) I'KRSnNAl, I'AKTHTI. ARS A R l". IRIK TO IHH 
in.sT OJ MY KNO\Vl.i:i)«.K AM) IIHMICK 



fliifotniatit 



1 



t 



ck 



f Address 



X^bio 





\- ot 



I'I,\CK <)1- lURIAI. OR RKM<»VAI, I I)AT>; of HiKiAr, or R1<:M0VAI. 
I'M) 1-: R T A K K R V y\'\JL(y(^*'^:^ 




(Address 



^l£;'l 0">^lUU.v(ni .^t 



N. B.— Every Item of information .hould be carefully supplied. A«E Hhould be Htntcd EXACTLY PHYSICIANS should 
«tnte CAUSE OF DEATH in plain terms, that it may be properly classified. The Special information for psr- 



sons dyin^ away from home should be ^iven in every instance. 



I 



iif. 




1^ . • 
1 



H^^ ! 



1 



SI 



l^' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)!,,:,!.! ••" I!. :>lth 1-^'" 1- •^•t'S^''*''^l''"" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



RegLslerecl JVo, 



1596 



"Wtco "^v-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



PLACE OF DEATH; — County of 



I 

1 \ 



Ccvtificatc of Bcatb 

-Van i ^^ 



\a"\vcucc City of ct'^v va^vct^oc 



ffl, 




va^v^,t^^ \ vn^Ujut . .. St.; 

(ir oc*TM OCCURS *vw*v FROM USUAL RESIDENCEgi 
ir DEATH OCCURRED IN A HOSPITAL OR VISTITUTION 



Dist.; bet. — and 



IVE FACTS CALLED FOR UNDER SPECIAL INFORMATIO 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



" ) 



FULL NAME 



' fva \v 



k 







\.fX''^\.QjsJU^,. 



PERSONAL AND STATISTICAL PARTICULARS 



^KX 



DATK ni- lUKTII 



Ar.K 




COI.UK \ 

II.ivl"U 



i^ct 



'Mnnlhi 



MEDICAL CERTIFICATE OF DEATH 

r 

DATr: t)i' i)i;ath 



Llvt 



^ ,V\\ 

(Day> (Vv.ii' 



^ » y,;n< ' » M.mlhs \ 



I hi 1 . 



•^rsc.IJv MARK IK I) 
•Wrttr in social dt^MitJ^natioii) 




awc^d. 



rUKTHPI.ACK 



N \MK <)| 
HATHKR 



''•II'.TMI'I.Al-K 
«'■ 1 ATIIKK 



MAirJHN NAME 

"I mothkr 



"IHTirrM.ACF 
•»»•' MoTUKR 
(State or Country^ 



^ 







(Montli! 



(Day) 



(Year) 



-M 



that I last saw h •'-■^>^ alive oti 



to .XJ- 



J ili:i<i:i5V CI'RTirV, Tha^ I attetKUd deceased from 

ju.'jA. B 190 H 



,, I 



CL 



t 



cy an ....190 n 



and that tlcatli ocrurred, on the date stated above, at II 



^ 



i M. The CAISIC ()!• Dl'A'I'II wav as follows: 



V'OJs.A^-utryxc^^vu. .la^LoLv c.v^c^-^-v?) 



I ) r R A T I( ) N 1 J Var^ H Mouths Pays Hours 

CONTR I lii'ToR V .....'.ab.ix.w:\ax.er|^l4,^^.w: 



A\tL 



»»CCri'ATION 



L^nU^^XU- 



A*/- 



•lltt'd Ul Will /'l ,1 III !■! :> .-kv> ) 'r," 



1)1' RAT ION ^ ]'iars S Moni/is^ Days Hours 

(Signed ) ilVLtLa^n i-VtA^mvu.!^ m.d. 

c^livtlO TooH (Address) ll?DHcUa-\H.^urfr^tf--^^ 



\Jn,llU^ 



Ihn 



Special information «n'y *'>r Hospitals. Institutions, Transients, 
or Retenf Residents, and persons dying away from liome. 

Usual Residence ^^^ ' C^' 

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



tic "^cbAo^v 



How lonq at 
Plafeof Death? 



.. Days 



1 UK \Mo\K sr\r,.i, I'KKsoN \i, i-\u ruTi.xK-, AKi: rKri'. r<> cm-: 



Mnf, 



>miatit 



(\.M 



'I Ob ci -ckvcvtUv ot 



ri,\CKni- IM KiAi, OK rj:m«>vai. 

1 



IM.l.KTAKHR ^ C<XAXL<k Hi \J^ 



DATi: <)) lU HIAI. OT Kl-.MoVAI, 

Jj^lvt IX T90H 



(A(l«ln-»;s 



^.Hb 



vj)\^4.4-u5:>cx...2l.;! 



N. K. 



-I. 



-F.very item of informntlon should be cnrefully «upplied. A(]R «h«uld be stated KXACTLY. PHYSICIANS «hould 
Htnte CAUSE OF DEATH \n plHin terms, that it mjiy be properly classilfled. The "Special Informntion" ?or p«r- 
«ons dyinjl away ?rom home Hhoiild be jjiven In every instance. 




'jri 



* 1 



I ' 

i : 






^> 






»i 






ir 



K 



Mt 



••'t 



ii 






-rl 



f ! 





Wm H 




r^^r- WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ih 1 v.. ^ J-t^^Tj^^^U.tlM - REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



DEPARTMENT OIF PUBLIC HEALTH 



liO^Lsfered J\^o, 



1597 



City and County of San Francisco 



Certificate of IDeatb 

( "U. 5. t5tnuDarc> j 



,» 



PLACE OF DEATH; — County of " a^\^ " \a>\CUCc City of ' <X^\ ^'XartCc^et 



No. 1 



K\ 



St.: ? Dist.jbet. U-o^-A^.\) and lv-wlJL^^^4..... ) 



(ir Ot»tTM OCCOHS *VW*Y from usual residence give facts called for under "special INFORMATION" N 
IF DEATH OCCURRrO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 




<xU 



, 



DATK OF lilRTll 



Ai.H 






ll'.iv^U 



J t'ti » » 



<Uayi 



y/.>nihs 



iVc-ai 



+ 



FULL NAME 'wl'V^yX O^U \vvLttu N<.jIhX •vvvt.'vU \.a kaL^ 



ft 



w.v^> 



MEDICAL CERTIFICATE OF bEATH 

I)\ TK Ml- I)1;a Til J^ 

II 



(Month) 



190^ 
(Year) 



H 



ihi\. 



\VII)M\VKI> OR DIVORt'KI) 

Wiiti ill M<Kial (ifsitrnatton) 



iiiR rin-i.At'K 

iHtHti- or Country) 



NAMI-: OF 
J-ATHKR 



I'iKTHrM.VCF 
'" I A II IF. K 
■"! ii< 'ir Cr)nntry> 



"^'MlUlN N\MF 
"I MUTHKR 



"I- MOTHFK 
^? It.- or Co»ititry> 



0^^ 



MA ^\, 



va vj*^ 



j<x^v \a^\ec4c<:> 



a Kx.t<bku^ 



(IMy) 
J HI;R1:i;V CI:RTIFV, That- r atUMided dcccasecl from 

':^Xjvt 1 190 H to ...mivt: ...It. T90M 

til at I last saw li-Um alive on .dX^^t A.^ I90H-. 

and that death .u-inirrcil. 011 the <late stated above, at t 
VV M. The CAISI-: C)l- DI'ATN was as follows: 

•' ' ' ' 



'\vj^il^w" !^a^.-\x-.i^...t,4. 




1- 



DIR.XTION Years Months \ Days Hours 

C< )NTR IIJUTOR V Q.l"V.\/n.vatLV\ji. itiuX^ 






o<TrpATinx 






11 



DTRATION 



(SIG 



^,. Vcars Mouths N Hays ■..■Hours 

NED) ..Luci\..Ai; 



!:\ASiMju.. 



T'XKt 11 Ton'l (Address) C^'ib ClCcUjLhv...0.i 



iu 'A 



M.D. 



Ac a 



) 'fa r 



M, 



./////. \ 



/h!\ 



' "'i.,^'!l.*^ '"■ "^'"^ '''I) I'KKSONAU I'AKTUTI.AKS AKI! I'Kri-: T< » IHI'. 
•U'.srol. MN KN(>\Vl,i:i)C.K AND 111-; I.I l! »■ 



Special information on'y '"J^ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Fnrmpr or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



/^ 



I'l.AClv OI" BIKIAI. OK KFMoVAl. 



0)lt ii).luN^t 



DAPJvof UiKi.Ai, or K1:M()\AI. 



(Address l.l.:.6il...ml.U.4.WO^..... 



N. «.— F.very Item of infor.n..lion nhould be cnrefully nupplied. AGE «houI.I be stated RXACTLY PHYSICIANS Hhould 
«tatc CAUSE OF DEATH in pinin terms, that It mny be properly cla«8h-ied. The Special Information for per- 
sons dyln^ away from home ithotild be 6'ven In every instance. 



M 




' .! 



» 



I 



I M 






%A\ 








WRITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



rJ(A 



DEPARTMENT OF PUBLIC HEALTH 



RegLslered J\^o, 



1598 



City and County of San Francisco 



No. 



Ccvtificatc of Bcatb 

PLACE OF DEATH: — County of '^ \Va>VCU ' Gty of J a.>A .avtCL^ 

il'cN ^.LctlcV St.: 'V Dist.;bet/v^aW'>\vA-nlkandHt'l'tO 

/ ir Ot*TM OCCURS AWWHV FROM USUAL RESIDENCE GIVt FACTS CALLfD FOR UNDER "SPECIAL INFORMATION' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME LtU^ ) 1 Lavc Ivo^^xcL 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 
DATH uF I'.IRTH 

ac;k 



(Year) 



O O ).(f»A 



lA/«///' 



\% 



/\t\.^ 



\vn)«>\vKi» OR niV(»KrKi> 

• Wiiti in H«»cial (IcMiKimtioii) 



! i 




niKTHPl.ACK 
' Still «• or Countryi 



NAMK OF 
FA IHl-R 



niRTm'l.\<K 
'»' 1 ArilKR 
■Stritt or Country) 



maii»i:n' namk 

OF MUTHKR 



IlIkTrtPKACK 
«»F MitTIIKR 
'State- cr Country) 









MEDICAL CERTIFICATE OF DEATH 

DA TK <»1- Dl'.AT}! ^ 

dJ.vt a,.^. 

(Month) (Day) 



-Ipn S 

(Year) 



I ni;Ki:i'.V C1:RTIFV, That J attemlcd «leceased from 

tUta .It. 190 1 to ^i).x.^\fc u i^mA^^ "^ 

tliat I la^t saw h iA^ alive oti >?'i^^"^'^ Itp ^ 

aii.l that (Icatli ocourrcl, on the date stated above, at O.5o 
LC M 'J'he CAl'SF-: OI" Di: A Til was as follows: 

0!!iwtr>vvc .,a"LtrvvcK^t\^ 



,^c.VV .-.- 



1 



't\k 



? 



tJCCUPATWH 



lie 



/• 



8 



1)1 RATION II )'('urs; 



Months /)i7vs 



Hours 



t 



'SIGNED) iljw-cLK iL •.a.tA'Vra 



/^.n.? 



Hours 
M.D. 






^^'litvk 






' " ui}".i.*^ *'• ■^''" ^ '■' F> I'KK<,nN-\l, PAR lltTI.AK 

"hsroK Mv KNn\\M:i)(.K and hi:uii:f 

< A.l.lress t)! '^ O -I t'QjcH' d 1 
N. B. F. 



s AK1-: tkif: to thf: 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



D.ATIvof lURlAl. or R1;M0\A1. 

^4xt '3 igoH 



ri«\CH OF lU KIAIv OK KKMOX.U, 

r.sM,r:KrAKKKl)(H.<t8^^<x'UlUvd.Cy,L:. 

,.aHi.^Alll.\.^<utm at. 



(Address 



•P.very Ite. o.' in....«t;„n should h. cnneful.y supp.tecl. AGE should ^^^^^^^^^^^.^^l^^^^ .n^rn'^l^'r.'' 
«tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Spccal Intormat.on tor p 
sons dyinft away from home should be feiven in every Instance. 



kS 



n^ f 



I \ 






111 I 



M' i 



^'1 



t' 



f 



«^i 



!l 



' I 



r 



I ■ 



'\ 



Is 



' 1 



: it 



I » 



hi' 



•I 




111 







j|H| 


j 


'B 






' 


I 


. 


1 ' ■ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



nonf.l : II' 



I Vm Is ^W^^^;]\f^\'^-n 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Da/r nird. '^^\\^'^^-J>^\ I5v IO(H 



Boglstei'cd Xo, 



1599 



,V^A^^-A^ »30L 



VMJ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Beatb 

( U. S. StanDarD ) 



•^ 



PLACE OF DEATH: — County of'^ <X"vv 'viX^vcu^ct City of Oxx^v OXCtvuCM-^oo 






XA^., 



I v_\„' 



St.; 



Dist.; bet. 



and 



/ ir Ot«TM occurs aVMAY rROM USUAL R E SI DE NCE Gl Vt tacts called for under 'special INFORMATION' \ 
i, ir DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 

I'll m^ . 

FULL NAME \J^oX^:^xsL<.Ai\,<X'y^^'<X 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 



DATK OF »IK in 



u 



iVlvc-U 




I Month* 



n 

(Day) 



fVear) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH J^ 

nj(^ 1 1 

(Month) (Day) 



(Year) 



AC'.K 



iWiitfiti -'KJal lit -i^' tiat i"iii) 



»IKTHp|,ACK 
(Slate m Country' 



AD )V,n' 



M'utfi} 



\] 



14 



/></ 1 







KAMI- OF 
I" \ IMFR 



BIRTfirT.ArK 
ni- I'AIMHK 
'^tatt ur Coiuitrv) 



MAIiU.N NAMK 

01 m«»thi;k 



HIHTIin.AtK 
"•• Mi»T!lFK 
'^tatr ,,r c'uuntrv) 



v>>vCl^ 



5 Lc- ^ 



a' 



.a\u.i 



WcrpATlON 



^^ 







I HI'F-il'RV CTvRTIFV, That I attetKlod dereaserl from 

lliat I last saw h C>>a .-.live on a jJf^ H I90 S 

an.l that .K-atli ocourred, on tin- .lair statt-il above, at /!• iS 
AX. M. The CAl'Slv Ol- DI'A'III was as follows: 

. axj/^k^^^^ "^Xa*^^^ • • 



I ) r R .\ r 1 N ) 'ears Months iH , l^ay^ Hours 



hVsitirii lit Stni /'i nii, isrn^ 2, )V<m> "" Mniths 



Dl'R \T1()N Years Mouths \'\ Pays 

wttv 



KXAJsy^. 

Jl}^,\X uyo'i (Ad.lrcss) T^t ^ .x^^^.l' -^^ 



( SIGNED ) 



flours 
M.D. 



SP'^JIAL INFORMATION only for Hospitals, institutions. Transients, 
or Recent Residents, and persons dying away from fiome. 



15 



Ihn. 



IMi: AIIOVK STAIJ-.I) PKKSONAl. I' A l< f U' I " I, A K^. A K l-! TKlH To TIIH 
HhsroF MY KNOWI.HDC.K AND lU-I.HvF 



Former or 
Usual Residence 

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



\ 1 -Ki Hou long at r\ 

3uX/>v<lUrW' ^ Place of Oeatli ? cK 



1' 



Days 



fiiif. 



'Miianl 




r\.l.l 



ifi -.Cc.ect 



rcss 



UAWO^ 



PI,ACK <)I" lUKIAU <»K KHMOVAI. 



DATK of IUriai. or KFMOVAI, 

UJi^ \X IQOi 




(Address* A.IH SJJ>>.</w^^ 



w- 



I 



N. B.^B.en. iten, ot' lnfonn,atio„ .hou.d he cancfu... «upp.led. AGE should ^^^,^\^^^^^\^^l\^' .rr^on^' Vr'^:!.^- 
«tate CAUSE OF DEATH !n plain term., that It may he properly claw.f.ed. The Special information tor p*r 
"on« dyinft away from home Hhould be ftiven in every Instance. 









ti 



t" 



m 



IV ' ' 



'.'ll 



i J 



'-. 






; ( 



I 



i 



I- 



\ . 



r, 



I ■ 



*4 



k, 



)1 



.»: 



'T 





i 



( I 



>ii 



lil 




It<>:it 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,,, ,,, , vm ,. ti'fS^n.tiro RCFER TO BACK OF CERTIFICATE FOR INSTRUCTfONS 



l)„lr l-'ilol, "^^Ivt^-y^MA- !..3v I'fO'i 

.y \ _ 



Registered J\^o, 



1600 



A.5 ^..^^^-^: 



. 1 



Deputy H':^a!th Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "U. 5. Stnn^arD ) 
PLACE OF DEATH: — County of <X^\ ^ 'VCL-^xCL^Ct City of ^CL>v JXO^avCuvc^ 
,No. ' H^b CC^U^^CuCV St.; ^ Dist.;bct. 2.5 U\' and ibXH 

/ ir Dr*TH OCCURS *w»r trom USUAL R E S I DE NCE Gi VE r*CTS called roR under "special information ■ \ 
V ir death occurred in a hospital or institution give its name instead of street and number. J 



FULL NAME 




cLoo,/u s l'^'-^'-^.• 



PERSONAL AND STATISTICAL PARTICULARS 

I ^ J 






\,\ 



DATK OF niK IH 



AdK 



ll\v^\- 






,!1H 



SC ,-,,„, 



Motiths 



^Year) 



n,i\ 



WIlMiWKI) OK DIVnkt Kl) 

'Writfiii KfK'iiil <l»viv«iatioiil 



C ' i >-%> rt v< 



niRTHPI^ACK 
State or Cmmlry 



WMI MJ 

»• A iii»;r 



Hik iiipi. \( }.- 

<M- F API IKK 

'State ar C<iunti\ 



^1 ^:1'i:n NAM}.- 

••1 MOTIIKK 



''•Ik iiipj, \( 1- 
J 'I Mot I IKK 



U ^vcuvx^^n \! flu 



n<\Lla% 




MEDICAL CERTIFICATE OF DEATH 
DATE OK DHATH 




(Month) 



i 



11 

(Day) 



(Year) 



., I IIP.RRBV CF':RTrFY, That I atten«le<l jleceased from 

3-<u^:lI u 1901 to ■■— -■ - 190 " 

that I last saw h ..-^' alive on S'X^aIT 11 190M 

an.! that (k-ath orourre.l, mi the date- stated al)Ove, at lliO 
\X M. The- CAISIC Ol- DI'ATIl was as follows: 

\j cUt v^vwLo/L' liJ.,c^jc£Uiju . of Xi'uL.':t-.!L^a.^^.fc 



DIRATION )'rafs Months 



Pax a 



Hours 



CONTKir.rToRV 



sjk. 




a 



^v.voilD 



SJU- 



k4: 



'(11 



ationVi % 

h'riiifif III S,iii / 1,111, ism '^^ )'iOi- - Mmith- ' hm- 



I) r R A T H >^ , V. ^ "^''^ Months 

( SIGNED L'Id.iI U 



Days 



Ci-Cy\ 



MX 

(A.Mress) . 



flours 
M.D. 



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



nn, AiiovK sr\ rj.-i) i-kk^onai, i'\k luri. \kn aki: rKii-: r« » rni-; 
•n.sr 01 Mv kn«)\\ij:i)c,k and hi.i.ii.k 



'iiif,, 



tmaiit 



Address , IHXlp vaixAvaux fjt 



Former or 
L'sual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'l ACF Ol" lU RIAL OK KKMoVAI, 

5" 



DATIvot" lU KiAl. or KlvMdXAI. 

At|^t^ii_^ 190H 



.,.,.,..... ini ^ L^M*y^.Mi 



„,,,,.ss ini "^iLCi 



N. B. 



F-v.., i..™ „V ,„f„.„„,i„„ .h„ul.l h= cor.Ju.l, supplied. AG5 .h.uld ^e 7"- E'CACTLV P^^^j^'^*:*"^;';;',^^ 
•tat. CAUSE OF DEATH In plain t.rm.. tha. U m.., I.= properly cla.s.fKd. The Special In.ormal.on p 



«on» dying away from home should be given In every instance. 



^ 

^ 



I s 



>o 



I - 



} ! 






* t 






^' 



H 



tl 



•h 









I • 



» 






I 

I 



f. 



1- 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Re^Lstei'cd J\^o, 



1601 



■\^,.. 1 Deputy hlcatth OfTir 

DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "CI. S. StniiDnr^ i 



PLACE OF DEATH: — County 



-A 

of ^'a>\ 



x.\^ 



City of U^fV^' ■') \0. ^( *-<'-'■ 

., .11 



No. 



;nl a>VC»VA.O- St.; U- Dist.;bet. V\ Uv and 

/ ir Dr»TM OCCUHS AW4V FROM USUAL RESIDENCE give facts called for under 'special INFORMATION" \ 
V !»• DEATH OCCUBRIO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



:^v 



FULL NAME 



V 



k 



try> va Ji 



\ '1)1 



S.LLLW.:v:l. 



PERSONAL AND STATISTICAL PARTICULARS 
OATK OF niK 1 II 






MEDICAL CERTIFICATE OF DEATH 
PATH (>K DKATH 

It 

(Day) 



^xkt 



(Month' 



(Year) 



/^3^ 



M-.iUhi 



Ar*.K 



1^5 



(Dav) 



M.nilh 



I Vrai ) 



An 



Wiru>\VKI) OK I)!V..kv Kl) 
'Writrin Hficial df-ijirnali«>n) 



^\ 



Ct\^cv cL 



niK TMPI.ACH 
(Statt ur Coiintr|J 



^\^f^■ oi- 
I A III I k 



nik i 111, \( K 
OF lATHlk 

'St-it. .,f Cniiitrvl 



MAnji.:\ Nwij- 

OF MOTIniK 



HIKTHPUACK 
<».l" MOTHKR 
(Statf or Cuuntryl 



/<> 



^ 







I Hi:Ri:r.V CKRTfFV, That I attended deceased from 

...dX^xA. ijQ ..190.H to dX.}^t:....{.0. 190 h 

that I last saw h . alive on JX^\A 10. up. 

and that diath oecurred, on the datr stated above, at U 
^Lm. The CAISI-: ()!• DI'.XTil was as follows: 

OXv.tvcu.. ^X^^-u>-^v> 



Dr RAT ION Years Months Days o Hours 
coNTRiiUToRV ^\.'\Jtyy^>^'^ \LL^^^ 






tclvc 



/V\AA\ 



C^,^xL<X^vcC 

«H^"l lAllON -^ 



I ) r i^ \ T I ( ) N "^ ^ ) e^irs Mouths Pays 

f Signed ) u. A uAu:y©*u^ 

•^^ivt'ii T,oS f .Address) i.<iM U- v^' 



Hours 
M.D. 



^^ t 



SPECIAL INFORMATION onl\ tor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyin;) anay from home. 



.!/.;/////■ 



I h! \. 



(Iiifi(ni-,ani 



rUK AHOVK S|\|):i) I'KRSnx \i. |-\K ri( ri, \KS Aki: rklK TO 

in-.sroi- M\^KN<rvi.i;i)c,i.. and iti;Mi:i-- 



r 1 1 !•; 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



... Days 



VI ^CV ()!• lU klAI. nk ki:M(.VAI, D \Ti: o! MrKi.x.. ..i KlCMoVAI, 

rN.,KkTAKKk \. C. C' L^^v^v^v VU. 

rA,Uln.ss l(o1.0>U^AVirvV..0.1 



.. . ArF -houlil be stateil EXACTLY. PHYSICIANS should 
Ion should be cnrefully Hupph.cL ^^P;;^7;;'^^;,:i^'%he "Special Information" for pT- 
'H in plain tcrnm, that It may be properly ciassmcu. j 



• "• 1. very item oli informat 

Htutc CAUSE OF DEATH 

«on« dyinft away from homo should be ftiven in every instance 



M 



^ 



-rz> 



f . 



r 



?-- 



I i '' 



r'^ 



.» 



S' • 



h 



' 'i'M 



; '\ 




M t 



I * 



Mi i! 










,1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,.n!.,nK ,Mh , vn :. 1-^^^:, US.V c. REFER TO BACK OF CERTIFICATE FOR tNS TRUCTtONS 

^ l^ I^0\ Registered A'o, 



X 



Dale File(f , OjL\\Xx^rrd>A: 



160S 



cK^v.^.vo :i^<.\^u. Dep.uty ' '" ' '•'"--- 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



PLACE OF DEATH 



No. ^ni 






Certificate of Death 

( "U. S. StanOarC> ) 

J VCL->vc. . City of U-CX^v -' XCU-^vec^ c < 

^ t (1 i 

Dist.;bet. ^v^^C^lo.- V and 0.ieyA.i^>\a. > ) 



: — County of 'CX^v j 



/ ir Dt*TM OCCURS *w«v FROM LTS U A L RESIDENCE GIVE facts called for under "spccial information ■ \ 

V .r DEATH OCCURRED ,N A HOSP.TAL OR .NST.TUTION GIVE .TS NAME INSTEAD OF STR EET AN D N UMBER ) 



FULL NAME 



/y^j. 



PERSONAL AND STATISTICAL PARTICULARS 



HuL 



^l . IvlL. 



:>\TK t>i' ink IH 



Ai.K. 



Nl.'tithi K 



il 

(Day> 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK <1I* DKA TH J 

axi\t .1.1 

(Month; (Day) 



I go . 
(Year) 



J '/•<; I 



M.»iffii 



Par 



"^iN'I.K MARK IK I) 

W llMiWHl) OK DiVuKrHI) 

(Write in •ioctal (i<«ii)f nation) 



BfKTHPI.ACK 
"~t:itc or Cminf r\ 




*> 



NAMi; Mi- 
f-ATMKR 



BIRTHPLACE 
f>»- I ATHKK 
(St;ttc .ir CoiMitrvi 



WAU>KN NAMK 
or MOTHKR 



iUkini»r,A('K 
''I mothkr' 

(Hate or Country) 



OCCUPATION 



CL^xoAo^ 



I HI:ki:1'.V CI-:RTIFV. That J aUen.le.l deceased from 

V^^^-^ ^-^^ 190M. to OXlvt. -U igo ''. 

tliat I last '^aw h - • alive on OjJ^. l£i \cp 

and that diath occurred, on the date stated above, at 
M. The CAISI- Ol- I) I- ATI I was as follows: 

^...(a.;>A^..\|}XAA^w:mJL.. , 



DIRATIU.N 



Months 



} eajs 
CONTRHU'TORV aJW(^\a^c. 




Pays Hours 




DTRATIOX 
(SIGNED ) 



Years 



Pays 



IfoU) s 



Month's 
(Address) clb'ib 'ADCHX^a\.4. Cit 



*3v-oJ(>-Cr\XH> 



.\fn„l/l. 



I hi 1 



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






Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



I'LACi: Oi- lUKIAI, (»K ki;.\!nV\!, j I)A'g:..f iii KIAI. 01 kJ-;M<t\\I, 



'\.i.in-.s 'S^r- '-, 



OXA-trnv 



N. B. 



Xi-|^J\X<i.r 



d_ 0LV\,rv3*^ 



2 



5'' CSV' ft -il" oV " } P 

(Addrt-ss /^ ..^v.Cj ' . ..S.iJv ..Ht 



T9O 



Kvery Item ojf Informiitton vhould be cnrefully supplied. ACJF. should be stated RXACTLY. PHYSICIANS should 
state CAUSn OF DKATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
"ons dyinft away from home should be ^iven in avery instance. 




m 




II 



I .- 



ipir . 



il 



i! 



4i 




,1 



li ' J 



u 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

" " ' ' '' "' ' ^'" --^tg5V-"-'<^»'^''> ^ REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 





J 



IfJO^ 



Ee^Lstefed A^'o. 



1603 



^<)-\.AA^5 



V-M 



DEPARTMENT OF PUBLIC HEALTIHCity and County of San Francisco 

Certificate of Seatb 

( XI. S. i5tant>ar^ ) 
PLACE OF DEATH: — County of ^^ O-^x .a v.cuLCt City of'Ocu^-v J A.ct »xc.»-1«/ck, 



I 
^ -'-t- ' St.; ^1 Dist.;bet. 

/ tr Dr»TH occuni .w*y from USUAL RESIDENCE G.vr facts called tor UNDfR special information • \ 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 6f STREET AND NUMBER. J 



No. X^'i flb.cckc'-.., V St.; ^ Dist.;bet. J CrU,C\/L and lll^'cta VLCX ) 

/ rr DEATH OCCURi AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDfR 'SPECIAL INFORMATION • \ 



^V 



FULL NAME 



U-UXi/YA.i. V 




j^.n 



!. \ 



^4 



PERSONAL AND STATISTICAL PARTICULARS 

! COl.ok 



I>ATK OF JUH rir 



h 



,U^K^tjL 



Ai.K 



Mouth > jT 






^0 r 



V <>////.( 



-xs. 



(Year) 



Pavs 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(Monni) 



1.1 

(Day) 



(Year) 



I irr-Rr-nV CKRTIFV. That I attended «leccase<l from 
AX^/V.CU ..^b iQoH to u^^%t-. 



..CL ...Swb 190H. 



>^IN'.i.R. MAR U 11: 1) 

wnMiwKi) «»!< i>]V()Rj-Ki) 

(Write in stx'iul «ksi|rnati..ii) 



'stat<- or CountryV 



NAMI- Ml" 
FAIMKR 



''IK rni'I,\c*K 
<»■ I ATHKR 
(Slatt or (.onntrv^ 



MAIDKM ICA3IIK 
'"^ MOTHER 



;>i' motiikr' 

'State €jr Cotintrv) 






I' 




tliat I last saw h '^-' ' alive on 



• 10 190 H. 



%. 10. 



190 1 

and that death occurred, on the date stated aV»ove. at 10. 

y^ M. The CArSI<; OF I)1«:ATH was as follows: 



vx/Qa/^CoJCw d^ ' AAA,'jpjtAxAx4r fc.4A.o^v^^.a. 



a. 



i 



^ 



DURATION }'t'(7rs Moutin \^ Days //ours 



CONTRIIUT 



jJXa^ 



w 



t>CCl!l»ATlOII 






aw La^-^v vl^' 




DC RAT ION Years Months /)ays ^ '- //ours 

< Signed) ) ^^nxj^tu Axk^q^^^ m.d. 



Jj4:a..u I 



<)0 



a>^. 






'r,n - •>:..., .\f,;ifhs 



I hi 



Special information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyin'j away from home. 



JU.M ,,]. MN KNOW i,i.;,„;h .^>-,, in-UJ-.F 



in- 



Former or 
L'sual Residence 

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



HoM lonq at 
Place of Death ? 



Days 



ri,AC:K OI" IHKIAI. OK RICMOVAI, 



N. B. K, 



c4\xru.i.iXv ". 



INlJliKTAKHK 



DATK of HiHiAi. or KHMOVAI, 

n 

jxlvt L*^ 190'^ 




''Address 



9sO' Sti \ 



ery Item o¥ informjition should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 



state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for p«r- 
«'>n« dyin^ away from home should be ftiven in e\cry instance. 



t,j«f 






> 1 ^-1 



'I 



1' .*? 



I , 



t 1 i 






I 



I ; 



A"' 
I 

h 



)■■• ' 






« I 



'4t 



if 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

'^"""" """ "' -''^^"'^'■^■" n.rERTOBACKOrceRTIPICATr FOR INSTRUCTIONS 



I. Deputy Hccith CfTlcer 



JirgLslered ^'"o. 



1604 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of H>catb 

I 11. 5. 5tnn^ar^ ) 



No. 



PLACE OF DEATH: — County of 

. IfU .• 




\\ 



CV\CA\; 



City of J a >\ 



i 




ojd ynj 



St.: 



■Dist.; bet. 



"and 



( " .''/rr*l.°*'*'"'" ***'' '''°** 'JSUAL RESIDENCE Give facts calitd tor UNOtR •'sPtc.AL , n formation • \ 

V .r DEATH OCCURRtD .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E FT A N O N U M B E R ) 

FULL NAMeUxuL^cI \.V\i 







:\jL/U>v4Lxn 



PERSONAL AND STATISTICAL PARTICULARS 

> , c«>i.i>k I 

cU|vt II 

■ D.iy) 



Ckdi 



■^ 



MEDICAL CERTIFICATE OF DEATH 

DATl-; (M- I)i;\TlI 



!l. 



' Mont Hi 



r'MiH 



J 'ra t 



' v.. >////> • 



■»frirl 



/Kl 



^IN'<".L«. MARK HI. 
Wir>oWKl> OK DIVOKCK.I) 

(Wistftti Ho*-ial flf^ij^tiati.Mi) 



ii»l^!t«»r C»rtr«try^ 



c^4vt 

(MontH) 
I IU'RI-HV C1;RTI1-V, TliMt I atten.kMl .Icccasc.l from 

— .. to ■■•- : 



(Day) (Year) 



1 90 



• 190 



i 



nxmj: oi- 

f-ATIIl K 



'<II< I Ills. \c\.- 
f»' IATHKr' 



MAll.i.x NAMF 



OF MdTlll-K 
(Statf or t'.,mjtTv 



u 






that I last saw h-rrrt: alive on ■ - ..M.^^ ....J(\o 

and tliat (Kalh ocrurrcil. on the date stated ahove, at -T-. 
"^^.^M. The CAlSlv ()!• I)i;.\ril was as follows: 

c^ ±aJ. ..\&.ii''w^^^ )h;\^K^zAx- 



nrRATKlX )'rars 

CONTRllU'TORY 



Mouths 



/hivs 



Hours 



or RATION 



Ytwrs 



Mouths 



Days 



(SIGNED ) ...U}.,!^... Ua.A.t|lp^ 

^U|\t 11 T90H (Address) aaM.'VH.aiA„d ^ 



Hours 
M.D. 







Ol ( I i V 



i XTTOK 



><X^^\.<X^\A. 



I- 



Special Information only for llospildls. institutions, Transients, 
or Recent Residents, dnd persons dying awdy fro-ii home. 



h'f^ulfd in S,,,l /,,;„, 



) - ,,' 



n: 10 TMj': 



itir.,.,!i(iit 



Mil 






former or 
UsudI Residence 

When was disease contracted, 
If not a\. place of death? 



HoH long af 
Place of Death ? 



Days 



IM,ACH OI' I?l KIAI, OK KI:MoVAI< | DAl'Kdf Mikiai. or Kl-IMOVAI, 

OJl^lvt \% 



OcwLi 



( 



T90S 



INDl-K'lAKliK 



(Xt^tlci. vc L< 



Vv\ 



x.i.ir.ss ^.H.b M)U44^.-fr^a..lVt. 



N. K 



■rpry item ok" inform.ition should be cjireV'ully huppIIlmI. AdB «honlcl be stated F.XACTLY. PHYSICIANS should 
*^ ^AIJSE OF DEATH In plain terms, thnt it may be properly classified. The "Special Information" for per- 
sons dyinft nwnv i„^^ I 1 • . ... . • . 



» "yinft away from home should be liivcn in oxory instance. 




■ 


i 

' *l 




'; 1'- 

i 


1 . 




K 1 




f 


« 



,1 A 





I 1 



ni 



!k 



^4. 



■I 



lli- 



U 





I'' ill' t 



^mi 



Wi n 




'^ ~^i^ 



■ I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ito.nl. f II "'th I- Vo ir^-t^^~i^U!i,VC<, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registei'ed JS^o, 



1605 



iwCrvcvO dJLVH.« Deputy HoeJth Cmcer 

DEPARTMENT OFPyBLIC nEALTH=City and County of San Francisco 



Certificate of £)eatb 

( XX. S. Stan6at^ ) 
PLACE OF DEATH; — County of Cc>V "^ V<X>vCt^C^ City of ^^ Ct>v ^^ V<Vvy^^A^c^ 



^ 



No. 




St.; 



Dist.; bet. 



and 



AjJvc^ . . N^Ka ■ 



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

^ ■ ka . Li ^ IVlcV 



FULL NAME \\^^^^<X 



ii. 



tXM\.4a\ 



\^<L.. 






PERSONAL AND STATISTICAL PARTICULARS 

-'■■A 'V^ 

I>ATK OF lilR III , 

I MfMithi 
Ar-.K 



MEDICAL CERTIFICATE OF DEATH 



'IJav 



/hi . 

(Year) 



L-l 



r, ,; 







Mn„f/l^ 



ai 



Ihn 



^IN'I.F MAKRIi:i) 
^\n)«>UHI> OK I»!\oKri:i) 
< Write in social <l< »iv:iiati(>ii) 



ruKTIIl'I.ACK 



NAM): OF 
FATMFK 



MIRTHI'I.ACH 

OK i-ATin:k 

'Statf or C'oniiti v) 






< < 

TOO ' 



DATK OK DKATH v 

(MoiithT (Day) (Year) 

I Jll'kl'liV CI-RTII'A', That I atteiKk-d deceased from 

.....Ltvwa. . I 190 H to i!>.jJ^<k. U . K^^ 

that I hist saw h-v/\» ahve on Q-*-Y^.' 190 ■ 

and tliat death ocoiirrcd, on the date stated above, at 
M. The CAI'SI-: ()!• I)i:.\ Til was as follows: 




^AVt^ 



aOAx 

1, 



W' 



v<X\Vi^ 



u 



DC RAT ION ?^ Years 
CONTRIIUTORV 



Mouths 



Pays 



Hours 



M MOKN XAMK 



I'-IKIHI'I, \(•F 
•>1•' Moriii-:R' 
(Htatr .,r t'ountrvl 



occri'A rioN 






^ 



\ 



sJ jJ\j>fx\Jr^ 



or RATION 

(Signed) 

■A ■ 



}'t'(irs 



Mouths Days 



^.. 



LI 



(Address) ^ICi ^ Lctt^V Ot 



Hours 
M.D. 



^'f-'fif^/f /)! S,!tl /'l ,1)1, i:i-,i 



n r 



)•/„•/> 



M.nilh^ 



n,i 



' "V;,^''n*^ ^'' ^''''^■'■'•■I> »*KKS()NAI. rAK'IKTI.AKS A K l*. TKII': To TJllC 

iihsr »)i- Mv kno\\ij:i)c.h and ijhi.ihf 



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

1'' i How long at 



Former or \ 

Usual Residence 




Place of Deatli ? 



? 31 



Days 



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



Inf. 



nirnit 



Olw t.^y ilt^ljt 



('^i) 



I \ 



•Mn-ss S'bH ^H.^CU ^' 



rr.ACK Ol- HIKIAI, OK KKMOVAI. 




DATKo; HiKiAi. or RHMOVAI. 

"^X^\t )9. T90H 



N. B. 



Every item o? InformHtion 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" ?or pur- 
sons dyin^ away from home should be (^^iven in every instance. 



'1 '1 



\\ 



I 






il! 



'Hi 



iK 




i\ 







1 % 



I! 




i 




WRITE PLAINLY WITH UNFADING INK 






THIS IS A PERMANENT RECORD 



REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)i 



A.,^CC^ C 



ckx\)-L( Deputy Hcclth O^ 



Regiatet'ed J\^o, 



1606 



DEPARTMENT ()F PUBLIC HEALTH-City and County of San Francisco 



PLACE OF DEATH: — County 



h 



Certificate of Beatb 

( "U. 5. StanDarD ) 

J{ ^ 

of ' CL ^\ 



\a>V<M^CCCity of J,<X^V V<XAXC^<IC0 



1^ 



No. X:!i^C lllt^<Lcn\ St.; 5" Dist.ibet. I ^ t!u and ^0 t 

(• .r ot.TH OCCURS «w»y rnoM USUAL RESIDENCE GIVE r.CTS C.LLEO roR under "specll INFORMATION" \ 
V ir OE»TM OCCURRED IN • MOSPIT«t OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



\\ 



) 



FULL NAME 



S-o^- 



T) 



Lt-u. 







SKX 



PERSONAL AND STATISTICAL PARTICULARS 



!]laU 




Vctx 



MEDICAL CERTIFICATE OF DEATH 



HATK nl HI Kill 



\ " . y. 



Ml. nth) 



n 



(Vt-ar) 



DATK oi- I)1:aT1I Jl 



(Year) 



1 



M.;,lh 



xs 



/hn 



'^iN'f'.i.K M\kRn;i) 

\V|!_)n\\ HI) OK liIV<»K«|-|) 
'Write ill sfx'ial dcHijfiiaii. n ' 



HIKTHI'I.Ai'H 

'Htatf <ir «"'i!ititrv! 



N'\M|- ol 
»-ATIii:K 



"IKTHI'I, \i }.- 

*>' imiikk' 

'^l.ilr <.i lOimtrv) 



OK .MOTlIllK 



JiiK rin'i,ACK 
'•I- .mothkk' 

'State or Couiitix ' 



A-.. V 



Bx^xo' 



J VvcL-v«.ck \.' ' 'Veil 



II 

(MotitA) (Day) 

I IN'Rl'IJV Cl'iRTII-V, That I atteiKU'd decoased from 

. C)X|\.1 .t>. i9oi to dxl-Lt LI iQoH 

that I last "^aw h .w . . alive on "^-^..'vtr 10 190'! 

an«l that doath occurred, on the date stated above, at .'I 2jO. 
w'«- ^r. The CAISIC Ol- DIvATIl was as follows: 



VXCilrXdl^^Ai^.; 



^ 



nr RAT ION )rars 

CONTRinrTORV 



Month. 



v 4 



Days 



Hours 




DC RATION 



)\'ars 



A 



^ro)lthl 



Paxs 



flours 



M.D. 



(SIGNED) .LOA^CvM^l^UAU.^ 

r\ x.ivt la rooH (Addrls)SSSl rnlL cii. 



^\A.a 




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



"j-^'i 01 mvk.\o\vij:i)(,j.: and iu-mi-k 



Former or 
L'sual Residence 

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



How long A 

Place of Death ? Days 



nnf,,.,iiruit 



^\.M 



I«>*S 



Vh S- mXv^^vcx \ 



DA'Uliot JUkial or Kl'tMoVAl, 
^^i\t II 190^ 



I'l.ACIC OI" IHRJAI, OK K1-;M0\AI. 

(Ad.hfss ^H*l%. ..\j}\t^A^rv\...i.3i 



N. B 



s't^V^^CA '" "^ inVormiitlon shoulil !>• cnrefully Kupplie.l. AGFi should be Ktntetl F.XACTLY. PHYSICIANS should 
^on f.^^ ^^ DriATH In plnin terms, thnt it msiy he properly clossh'ied. The ''Special Information" for p«r- 
"« ilyinft away from homo should he liiven in every instance. 



\M 



i ! 



.] 






.A 



I: 



s ' 



\\ 



\ 



.1 



i 



II 



% 







■ I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



It,,,,.! ..f JI.:i1th !• No. >-^ •^'^■'rSV- ^^^ >' ^'^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dc 



IfJOH 



Registered J\^o, 



1607 



Dale Fi It'll, Bxlvtto^vl 

\ \ 

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



Certificate of S)eatb 

( "U. S. StanDar^ ) 



PLACE OF DEATH: — County of a">\' -J VaAVCt-lCc City of'"'<XA^' 0.'v<^^xCl^c,^ 



No. 



v^>i^l 



^' 



V'.U A 



i>^l\L"t 1 



St. 



Dist.; bet. 



and 



/ IF 6r»TH OCCURS *W«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. / 

FULL NAME ^luvv> O d'vLatL.V 



PERSONAL AND STATISTICAL PARTICULARS 




SI \ 



i»ATK OF HIRTH 



\".H 



(xU 



COI.OR >^ 



'-^x'vt 

'Monllfl 



1 



an ,..., 



I I)aV 



.1 A <«///> 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



'^A^ 



ic 



Day 



">IV*.|,i:. MARK I J.; I) 

W ir>o\VKI) OK I)!VoK('HI> 

' ^^ -'>, iai rk->ii)rt]ati<>ti) 



iStnf'' or r. .u!it r\- 



NAMI, ul- 
»'ATHKR 



I'lk iiiiM.ArF 

<" lAIHKK 
'St:it»- or t'ountrv) 



"I Mnriij.;K 



"IHTHpi.ArK 

'M Mt>'rin-:K' 

(State or I'ounttv) 



4 



^ 






<M')HtlU a)ay) (Year) 

I H !•: R i:i'.V C i; RT I V\\ That I attended deceased from 

Lt^cC\. iwi up: to .p^|\i. 1.1 190 H 

that I last saw h • alive on . jJLlxX. icp A 

and that (kath occurred, ^^\\ the datt.- stated above, at 1 iS" 



? 



O 



M. The CAISP: OF DICATK was as follows: 



VVO^WC 



^ua 



AWflrvvct^vv 



V 



'J. 



LL.J 



\ 



\ 



] 






DIRATION 



}'t'ars 




Hours 



.%• 



^^l^llavu 



A-Lc. 



\^^\a^v 



Mouths W Days 
(." O N T R I P. r T ( ) R V CvVh^^XCC.iD^ 

vV-vvAMA-.t^^A^- 

I) (RATION Years Jfotit/is Days flours 

(Signed) vLrv>\, vjNcLcv^Tvoo.SXtw M.D. 

r\fAAt:l1 V, / Address) m . \ ^A)L}iU\^'j^ 



cx\\^.\x 



IQO 



( 



I. 






h'f-~l,lril III Still /■; ,,,/, /. 



- ),,; 



Mniifh^ - 



I hi \> 



Special Information onl> for Hospitdls, institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 



1/r J A , \ '■ 1^ How long at 

5^ 'LX.U.WOX' Place of Death? 



14 



Days 



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



"J.sroi. \U^KN. tWlJ-DCH AM) lU-MI-F 



TH1-: I 



l'I,.\CK <>I" lUKIAI, OR RKMOXAI, 



DATIlo!" MiKiAi. or kl-;MOVAI, 

a^^ i.a I90H 



r.\'i)i;KTAK 



HR ^ 



XCUa/ 



^ 



(-•Vcldres.s 



%^ 




>..A....i^. L 



N. IJ. 



F.very item of Informiition should \r; cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 
stiitc CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" ?or per- 
sons dyinft away from home should be feivcn in every instance. 



'W 






'I 



if 



I i 



i 



J 



fii 



1} 






M i 



!;K 



i \ 



H 



ti 



I 




t 



r 

■ . i 



t 





1 



I I 





Hont.' Ill 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nil 1 N'> ,. *-r":ar:^)n.'tlC.) REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




/>.//r /v/rv/, OxK^JL^aJma^ ^X IfWH 



Registered J^o. 



1608 



VV^5 



j^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. Stan^nrD j 



4 



PLACE OF DEATH: — County ofC'o./vu fva/-.xc>^c City of Ociyw J A.<x-'»^_.c^.^ti<: 






No. 



li 



J'U^L^ 



^.JL^ 



St.? T Dist.; bet. Wck/L^rnj 



and VJ'O/CCK^, 



(ir DCATH OCCUnS AWAY FROM USUAL RESIDENCE give tacts CALLED/IfOR under "special INFORMATION" \ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME'JNSTEAO OF STREET ANC NUMBER. J 



FULL NAME ": <xV 



n 



V ^-^. 



•vJl 



A^CLaL '.'.'^IXA^J 



LL. 



PERSONAL AND STATISTICAL PARTICULARS 

J. 



I niKi'ii 



L 



d'Jivvt. 



MEDICAL CERTIFICATE OF DEATH 

I>.\TK OI- DK.ATH 



< Month > 



'I):iv) 



(Year) 



\r.F 



5S 



) .. 



10 



!/./»////< 



5, 



A; > .V 



UIDkUKDok DIVdkiKf) A 

(Write ill HiK-i.Tl flrvi^tuuioti ) l , 




I: :■ 



(St. • ,Mi,t I \ 



NAMI-; OI- 

H \ IIIl.R 



HIUIHI'I. \CK 

'»' iATin:K 

•state or Countrv) 



MA 1 1. 1 ..N NAVti-' 
"J Ml iT I IKK 



»IK rHlM^Afi- 
'H" MoTHKR 

'•^t.'it.' ,,r C<niiitrv> 



*»''<•»• PAT ION 







dxk:fc 

(MontH) 



\\ 

(Day) 



(Year) 



I HI'IKIU'.V CI'RTIFV, That I atten.lod deceased from 

i C. \LJlCX.Vv-i V. I90 - to .-..v ."T- .' .T 190 ■ 

that I last saw h '^\> alive on OX^xt. ' ! 190 . 

and that <leath occurred, on the date stated above, at » 



V.'. M. The CAISH OF DFATH was as follows 



Ll/vJLij'Vxxl' \X\ 




"U^iX^.ULVM \JL^l\j^\JU^y^...JL\xr>c>.\.. 



^ ■' 



is.fta 



ll 



■^ ' 






DTK AT ION 



}'t'(7rs 



Mouths 



Days Hours 



•< i 



C( ) NT U I lU "p ) R V ...CM-vl 



or RATION 



(, ♦ 



lO'U^aVJ &V sv>x<r'»-''. 

)\\us ^ I\fouths Pays Hours 

(Signed) m IujWu (ibx.Vvi'U^cx; M.D. 

rixtxt fl. iqo^^ (Address) t>CMC)A.vA:U'u.Ji 



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



Rffidfd IK S,ni /'i 0,1, is,-,> '^ r,-/r;v 



lA.y////- 



fh! 1 . 



" ukJ-p'^ '■• ^'"^''"'■•" »'HKSONAI, I'AK lUTI.AKS AKJ- rKlK I'o THK 

"•>« 01 Mv KNd\vi.):i)c,K AM) m-:Mi:F 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



(I 



"f"Mn..nt lAAjtivA,^^ LL. 3/V>Vvt:^lx. 



'A.ldrei 



.i 



Xso\ qXjl 



^^.^^A.Jt^ 



.ii 



PI^ACH OF IHRIAI, OK RKMoVAI, 

INDl-RTAKKR nJI" A.XXa^ /^ -C 

(Address 3.51 Oy^wvCLtV ..■jL. 



D.ATi: of IJt Ki.Ai. or RKMOVAI^ 

OMp Xf. l.a i Q o'i 

"0 



N. B.. 



Rvery item o? InformBtJon should hs corefuify 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 psr- 



-El 

«t..»^ v«'«l.j;9[l Kff UtA I H in pi _ _ 

sons dyin^ away from home should be ftiven in every instance. 



l{ J i 



I 



ii 



a, 

¥ 



Ml 



if 



•r.; 



' ft! 






S 



J ' 






.< 



■1! H' 



I ! < 




) r 



i ': 



ll ^^ 



11 • ? ; 



i 



■-** 




>i 






f 






4 j 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



„,.,,j.,ni,:iith -FNo. ,.is-rr^^u>n&i^ 



/)f(fr I'ih'd , aX^vtjL^\X4A/ IX 




100\ 



Registered J\^o. 



1609 



v-vi Deputy Health Officer 

\ 



DEPARTMENT OF PUBLIC HEALTIi==City and County of San Francisco 



Ccvtiftcate of Beatb 

( tl. S. *3taiiOarC> ) 






PLACE OF DEATH; — County of ^^/CC-yv V<x>x^v^c<) City of 0^y\j OA.ay>vc>t^co 



^ 



N^. H . U AJj U4a\jlV<X.I 




C^<L.^^,lOwl 



St. 



Dist.; bet. 



and 



(ir or«TM occurs *vw*Y rROM USUAL RESIDENCE give facts called roR UNDER "special information" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME Wn^.xw...B.mxu^ix 



PERSONAL AND STATISTICAL PARTICULARS 
SK\ A 1 COI.OR 



T 




-€C*vA 



\.\ 



DATK tU- IMRTH 



A«; H 



Il>^?^ 



iMotitlil 



ss ,,.„ 






M'Ulli^ 



( Vf-arl 



/hi\. 



MEDICAL CERTIFICATE OF DEATH 

DATH nl- Dl'.ATH 



Cixkla 1.0 /poH 

(Month) 'Daj') (Year) 



'^IN<'.!,R. V \RR IKI> 
WllMiWKI* i»K DIVoKi'KI) 
'Wrjtfiti MM'jal «kHi|rtiati Ml) 



HIk riU'l.ACK 



V \M|- MI 
KATHKR 



Kik rnpi.At'K 

'•I- I AIMKR 
<St;ite or Conntrv"! 



MAn»KN NAMK 
<)!• MOTHKR 



niKiiii'i.ArK 

J'l- MuTllHR 
(State or IViuntrv) 






c! 




^I Jn:Ki:r.V LI-RTIFV, That I attended deceased from 

i JLt^- I2j 190H. to '^JiJp^. i.0 190 H 

that I hist saw h U.>> . alive on .C)X\.vt, uyo . 

and that dtath occurred, on the date stated ahove, at I i^ 
vV M. The CAlSFv OI- DI^ATH was as follows: 

C^^^VOL.'^rv..V<tA.>(r>A. 



DTR-ATK^N )'t'ars H Mouths Days Hours 
C ( ) N T R IIU ■ T C) R Y A A^^'rJl.^.^U.xU. Aj .l.lLi.A<C.cJ^ 

vVLv^yvi:>-u„ 

DURATION . Years S .^fout/is 



f SIGNED ) 



.'. vI.OX.YU.'V aL'-JLLt:y..V' ., 



Da YS 



I()0 



H (. 



.\ddress)ll.C).lL sSjZ^U h 



Hours 
M.D. 

(K..l:..t. . 



OCCrpATlox 



f\r^i,!r,f ,11 San I'l ,t 11, i-ro 



V,„> I 






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



ll,^.^-^,f H 



former or 
Usual Residence 

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



How long at 
Place of Death? 



A ... Days 



y'ci^ 



'"l;,M!!.'^V"'^''*^ '''■■" ''»^K^<>NAI, I'VRTICrt.ARS ARi; TRri- Ti> T 
1«J,SI 01. Mv KN(>\VI.i:i)C.H AM) in-:i.ii:F 



H H 



fX.ldrcsv 



ri,ACK OF niRIAU OR RKMOVAI. I DATH ol" lUKi.Ar, or RKMOV.\l, 

8i.^.J)x^. 

k.i ct^ 



I ni)i:rtakkr 

(.Atldrrss 



N. B. 



F.vepy item of Informutlon 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 fciven In every inbtanre. 



{ W . f "ir 



'• ,m 



■V. 



h 



I) 



! ff 



» i' 



l\{ 



if'!' 






:j 



'\} 




^} 



«f k ^ ■ , 



f « 



V 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,.,ar.!..f 11. ■•"' ' '^" ■' 



acUi: H«i I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ddlr I'ilril ,^X'^^<Sjl\^>X^\ 11 



lUO'i 



liegLstered J\'*o, 



1610 



.C^^w^v-^ 



-L 






Deputy He 



< i i I W 



cr 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



ji 



I 




n 



■i 



!! 




ji • I 



Iff 

it*!* j 



Certificate of Beatb 



PLACE OF DEATH: — County 



o,4 



^ 



4 



(l^ 



f 



No. 






^ ^ 



"^ ' N > . ' St.; L Dist.; bet. 

ir Of ATM occuw* AWAY FROM USUAL R E S I D E N C E G 1 V E 



CK. - . V<X ^XCAA ex. City of d <X/YSJ. v3vMX/>Vt4.,-a^C 



V "v.vl(: ^ ■> 



and 




/ ir Of ATM OCCUH* AWAY FROM USUAL RESIDENCE Give r«CTS called for under "special I NrORMATION" 'X 
V ir DEATH OCCURRED IN A MOtPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME l^^Xou ^il>va OX^\m:A. 



PERSONAL AND STATISTICAL PARTICULARS 






WU.A 



\ 



"£ 









(Vrar) 



.<.K 



a*^ ,„,, 



^ 



\.' iif/n 



/>.t 



"N- 1,»; MAkKIJl* 
\\ t!>OWHI> (»K I»IV<iKt*KI) 
U rit«- tit Mftcinl <U»iinialioit) 



lUKTIIIM.ACK 
iStatt or Counirv 



I ^thkr 



'nkTMri,\«*F 

«>' » AIUKk 



MAIhKN NAMl 
"1 MOTHKR 



'SIK liri'I.ACI- 
''I MtJlIIKk' 
(State CM* Ci.Htitrvl 






V 



>C^XCl^^ 



MEDICAL CERTIFICATE OF DEATH 

DA ri". » >1- IH-.ATII _^ 

OX/l-vt- 11 /pO \ 

(McMjtIi) <l)ay) (Year) 

1 111:K1,IJV Cl.RTII'N', That I alleiKkMl deceased from 

^L\-\-qL-. i 190 '• to 'O.JL^AJfc ).2w ic)o H 

that I last saw h :• ahve on 3,^:\AX...-ii up 

aii-1 that iKatli occurred, oil the date ^tatetl ahove, at i- 
y^ M. The CAISE OF 1)I:A rir was as follows: 

^j AxJcW-^-^i-^^ \J^tOL%'%v^^va.Wa„ 



\A.^^r\Aj\k) 



lO ^t^ 



U-VX 






LCX J\X 



'Vvx^ 



<h:ciiwiti..n 






I ) r K A 'I' 1 N ol } Vo/ -v 
CONTKIIUTol 

diration 
(Signed ' 



A..1-.1 



It/O 



<v -J .,^L^.LrC.^^^^^wLc^.A/. 

CSw'0-\A.y%^CX.\^L\^;i 

)'iaii b Jfont/is /hiys Houra 

(Addr.ss) !0l . CbLLw-c^.a 



M.D. 



SPECIAL Information «nly tor Hospltdls, institutions, Iransifnts, 
or Reipnl Rfsidfnts, dod persons dying dHdy trom home. 



)/•</;« I !/,.,////> 



/',/ I 



1111, \||.,VKsT\TKIM'HkSONAI. J'\K 11' t I \Ks \ K i, IKI l-. T< » Till'; 
"'•^I «'| MV KN..\\|,i:i>(.i.; XM, ni.i.NI 



(Iiif,, 



MlKlllt 



U.Mr.ss ions - 3.\iiv dl 



former or 
L'sudI Residence 

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



How lonq at 
Plare of Death ? 



... Days 



I'LACK Ol- niklAI, ok kHMoVAI. 




DATKof nrwiAl, or KKMOVAI. 

.tjx^\i i.-:i 190'. 






N. B. f.vepy iie 



v.ry itern otf int'or,n„t ion .houl.l h. cnreVully «upplie<l. AGB «houlcl be «t«tccl riXACTLV PHYSICIA1N8 should 
»"te CAUSL or DIIATII in plnin term., that it m»> be properly cl««»i1rlcd. The Special InkorniHt.on for p.r- 



»on« dylnft away from home Hhould be ft'^en in •yry instance. 



^ 



'f I ' , 



'.Mil 



t i 1 



1 » 



i fii 



f ' 



H .! 



:iN 



i H . i 



1 ! 



i 



1 1 



r '■' "' 



I 



k 



it 



■I 



•te> 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/h,h AVAv/, UJ^^vt.A,y^vl'-J^\' la 



IfUJ'i 



llegistei'cd J\^o, 



1611 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of Bcatb 

PLACE OF DEATH: — County of CV ^ V vj ^a^\e^^iCCCity of <X>V X<X-^ vCXA^i> 
Nm. LCtu '''^v^• V; St.; Dist.;bet. "and -^r^^^r....... 

' / ir Dr»iM occunt •w«v rnoM USUAL R E S I D E NC E Gi vr facts calltd por under special i nformation" % 

V IF OrATM OCCVRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



ta\ 



xu.^ 



\ 



PCRSONAL AND STATISTICAL PARTICULARS 

•i:X ^"^ -i i COI.nK 

\TK OF niRTH I 



ll^ 'v.U 



MEDICAL CERTIFICATE OF DEATH 

I) A 11-: < tl I»J: A TH 

11 



.t 



\T 



1 

I ».t \ 






ax^at. 



'Month) 



(Day) 



(Year) 



11 



) -,. 



1/ .»,///. 



M 



P.! 1 



■ ' K MAKk n;ii 

AHI» OK IHVORi'KIl 
iiv in Mx-tttI ilo^ir nation) 



(■ 



ri 




\ |li H< 



I 



lilKTMFI.AOK 
'>»<Hli -.r Onuilry) 



THKR 



HtKTIlJI.XCK 
'" lATllKR 
'♦•or Country) 



MAII)r\ \AMJ 



"iiri HIM. \(i.- 

' Hint! V 



IC 






/-" 



.'111 I 



,^ I lli:ki:BV CI'.kTII-V, riiat I attcnilc<l (leccase<l from 

4\t. S 190M to ....■g-Jt|vt II upH 

Iwit I lavt saw h i^A alive on "3x1^^ 1 1 190H 

1 tliat <K'atli oc<nirrc<l, en tlu- "laic ^tatnl above, at lo 
CL M. The CAl SI' OF DliATII was as follows: 
\J\\\Jt^ -< ^ ^ CxXa/> \.C^Wv^^^^t^^A^ 



„.U\jLivi\.\,ct>ua. 



f 



tX>\\M - .cC\w- 



t 






,\CtYVCx-i Ju^UO 



' ^'WPATION 



JLCL\' 



iV. 



\ 



DIRATIOX Years Mouths Pays Hours 

N T R I i{ r 1' ( ) R \' wi\,\.jC^r\.V.1^...t A.\^.fer.^.<X*\^cLA-L«A 



<.< > 



DIRATION 



1 .. 



(SIGNED ) ..y^;.,„.L.-.uA4.Mr'^ 



Years 

e,.a 



i]/< >///// .s" 



Pax 



Hours 
M.D. 



-^ 



.^kM. 






)\ .<> 



U,./','//. 



fh!\ 



-K- , \.l 1 1 T<)0 ; f A^Mre'^^;) - 



( I 



\< \ 



r ^^^^l 



Special information ""'y '•"■ Hospltdls, institutions, Transients, 
or Recent Residents, and persons dying <iwdv froni tiome. 



former or 
UsudI Residence 

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



iDH- ;:, I., 't 



Hovv long at 
Place of Deatli ? 



Days 



I'l \CK OI" HIKIAI. OK KI:Mi»\AI. 
V "VN 



1 



I).VTi;i)f HrKiAi, or KKMOVAI, 



kl\t \%. 



' " i.rJ-r'^ '■" '^''* ^ ■'■'•■ I > I'KKSONAI, I' \ K l" h" I ' I. \ K S ARi: rKli: To Till-: 
'•'.>>r()l. Mv KN..\Vl.i:i)C.H AND |»i: 1,1 1- H 

^VMrrss Lctu '^V VX ')t' 6-i.|\£LvU.. 

N. B.— hvery item ni informntion •houlcl be cnrcV'ully KuppHed. AGB «h,.uld be stated EXACTLY PHYSICIAINS should 
•»tate CAUSE OF DEATH in ploJn terms, that it may be properly dassilfied. The Special Information ?or p«r- 



I90H 






•^"s dyinft nway from home should be ^ivcn in every instance. 



\' ^4 



\ ; 

\ 
t 

' i 
I 

-1 



Wi 



1i % 



t 1 



( 



iK, 



J. HI 



V'; 



1 1 , > .1 

r'** M' * 



' ■■! 

( . 'I 



» ;.■' I 



■1 ! ..»i 



: I 



4il|lv. 





11. .'!l, IN 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,'9.f^^^i:v.!<,\'r,> REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



]i('gi,s/rred A^o. 



1612 



,,/r ///-v/.^^lx-U^^l^V \X n'OH 

"icrvco \<\yu Deputy Health OfTiccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



Ccvtificatc of Bcatb 

' 0- vCUlCi City of .avu iJUXy^QA^- '. 
St.; Dist.; bet. J cLl ^^\^\L and UxImXcV 

/ ir o|*TM occuns *w*v rROM USUAL RESIDENCE Givt facts calltd for undip special intormation ^ 

V ir DCATM OCCUHHCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



PLACE OF DEATH: — County of 



^*ack^. 



FULL NAME 



' ■ . -'i ' 1 ^ ^ ■'V -\ 111 f ^ 



SKX 



I'Mli 1)1- IIJK 



PERSONAL AND STATISTICAL PARTICULARS 

col. 




1 






f 



'■VwV/''uL 



-^ 






10 

(Day) 






\'.h 







) Vi/i 



.^f>fMtJtS 



/)<1^ 



■..n. MARK IF !> 
^ WKII OR D!' ! n 



iRTftfLAiK 
^taif f,r Cmintryi 



1 \thi:r 



"IKTHIM.ACK 
'" I AIHKR 
^taU- or Coiintrv 



^'UrJKN NAM} 



'"K i iHM.At'K 
•'I- ^5•»TIIF,R 



4 



^ 






MEDICAL CERTIFICATE OF DEATH 

I ATK nl- Dl'. \ in 



month 



iA ZQO 

(Day) (Year) 



I HI:K!:I'.V CI.RTII'V. That I atteii(k<l <k'CtascMl from 

■^-C^vt ID ,yoH to .a^i\t....l.() up'i 

that r last saw h -^ alive on •^ ^- *" it)0 *" 

aiKJ lliat iliatli <)Conrre«l, on tlie «lalc stated above, at 
" M ilR- CAt SI'! Ol" DlvATIl was as follows: 

^tcU(Eevvv ixt |vvli,.L.:v....... 



A ' 



[■ 



KA- 



^l^ 



V 1 



r^ 



nn^XTIOX )'rar.^ 

CONTKIIUTORV 

I) r RAT I ON M»- y'l'iJrs 
iNED^ J. 



Months 



Days Hours 



(SIGNED^ JXtrXq^ 



Months Days Hours 

C ^.)VuXKtl'>\ M.D. 



i 



f 




L'tvc^i^cA. ^a^ 



1/, .■'// 



/',/. 



Special information «"'> ^"^ Hospitals, institutions, Transients 
or Reient Residents, and persons dvinij ,m.)> from home. 

former or ""^ '<>"'' ^* 

Isual Residence P'^' ^ «» ^^^^^ • 

When Has disease rontrarfed. 

If not at plare of death ? ^____ 



Days 



"'lirJ-r'^'.'^''^ '"•■■" ''^'■|<'><>^■M. i'\Kinri.\Ks \ui: TKri-; t« > rni-: 
ni'.sroi. MVKNnw i,i.:i„;h AM> in:i,n:i- 



Mnf,, .,„;,„, 



cj-Lv^ 



v 



'X-l.li 



■" ^?^n^ViH.^ 



N A 



A- 



I'l^ACK Ol lUKIALOK I<1-;M<»\M, 



I)A,ri;'»t Hi KiAi. or KliMOXAl, 




rAd.lr.ss ^51 !^.VWLU^...1M 



I NDICRTAKKR 



^. «.— hver, ,te„, of lnf.>r„,„ti„„ .houl.l he curcfully supplied. AGE nhould be stated F.XACTLY ^"Y^'^IANS should 
Htate CAUSE OF DEATH In plnin tcrm«, that it may he properly classified. The Special Information for p«r- 



Ron* dyinft away from home should he ftiven in every instance 



I 



! r 

jfii' 

I 

i ; 



Ik 

It' 1 



•I I 



I I 



i 



% 



\ 






s 



V 



I '■ "' 

! ■ ■ f 



n*- 



a^B 




I 



i 

t 

i i 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



nor-r.l -f li 



I N,. ■*-*^ « X: 1:5^ r r 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



J)nf, rih'd, :^^ivVc>^vl^\' ! ?s. 



lUO^ 



RegUteved «A7>. 



1613 



Depuiy tici-lt-h Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Ccvtificatc of IDcatb 

. 11. 5. 5tan^.ll•^ ) 
PLACE OF DEATH: — County of CX^\ \a^VCUC.( City of ' CtYv 'A.avvCA^C' 

AS ^ %' 

No. Ji \.tc^v.l: '^ \v St.: Dist.;bet. and .^ 

/ ir or*TM occuBs »w«Y rROM USUAL R E S I D E N C E Gi vc facts called »^or under "special i n formation" "N 

\ IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME UlLld ci ^.l ' \ '^t L vi£tcr\xCLll O-Crd^ 



■"" Oil 

ItM'k Ml Him ,, 



PERSONAL AND STATISTICAL PARTICULARS 



A 



Motttht 



X 



/4tH 



i.K 



J r'ff f • 



.1/..W/// ' 



t ' ;r 



/>./ 



4- 



(» »»H l>!V<IKi'KI> 



Salt </f riniiitrv> 



\\!K OF 
\TIIKR 



fHRTllPi,\OH 
"' lATMl-K 
•(♦'or rcujtitrv) 



i 1 



^!"TIIHR 



"lHTni-|.A('K 
>tc or Country) 






MEDICAL CERTIFICATE OF DEATH 

DATE OF i)i:ai n j. 

3^.1 Vt II icpo\ 

(Month) (Day) (Year) 

. I III;R1:BY CKRTIFY, That i attetuled deceased from 

^ jcivt X upH, to ,AjL^\t a i()o \ 

that I last saw h A/>»'< alive on O-^^^- U I90 H 

mikI that iK-ath ncnirrcil, mi tlu' (ImIl- ^^tatt-tl ahovc, at 

M. Tlu- CAlSIi Ol- I)I;AT1I \va<; a*^ follows: ^ 

• -, • ^ ^' 

.,..«.>'.«^M^.Vi • 




1 M k A r I n N ) '(^rs ■ Mouths \ Days. I lours 

t'nNTKllU-TUKV ' J^AKL|vO'il<XU.C . A^ 



,ca J ^ a >\ct^ 



( 




nIIkI^^' 



,i. 



. :^ 



I " \ 



it 



DlKATloN 



'^ 



)'t'ars -^■Mouths 

(Signed) ^mv'i > .wXa^HA.w... 



fhlVS 



Hours 
M.D. 



^Xlvbii 



I()0 



s 



f 



A.l.ln-ss) I 00 '3) U oXx \\ CL 'A. 



Special information ""'y f^r Hospitdls, institutions, Transients, 
or Reifnf Residents, dnd persons dying .mdv (rom fiome. 



1 './,///. 



' "lU-sTy.r^Jv^ ''*'■" »'»'*«^'>N-AI- I'AKTirri,AKS A i< I- TK 

"J'^i <>»• M\ KN<.\vi,i:i)c.K. AM) i!i:i,n;i- 



lKl^ 



\ V. 1' > III I-: 



''"f''01l;ilit 



Vi^ J\.liv^<\. 



' V-l.ltrss 



5>o J 




I 



^L^ ^' 



former or 
IsudI Residence 

When Hds disease rontrarfed, 
II not at place of death ? 



Hovv lonq at 
Place of Death ? 



.. Days 



DATl'. '>! MruiAi, or KICMOXAI, 
.-r!\^]\t \X T90H 



I'l.ACH <)»• HIRIAI, OK KlvMoVAI, 



^. K.— ,;very item o.' i„for.„,.tion .honhl h.- c.rc.'ully Hupplie.l. A(;ii «W.d bo Hti.tcl EXACTLY PHYSICIANS «ho«ld 
-tHtc CAllSfl or DIA TH In plnin term*, that it m,.y be properly cla8«llfictl. The Special Information for p.r- 
«'>n« dylnjt «w«y from home Hhould be i^iven In 9\ery instance. 



f JL 1 'if 



, r 


, ■!• 


I'r 


1 ■ .-i 


f 


1 




.J 
... 1 


H .(' 






'■ ' 


I'; 


1 '1 ■. 


*' ^ 


i 


, if! 
i 







! I 



Ml: 



(! 



I I 



1 M 



\ t 



: .1 



' I 



r 4 



I • 



■' 'n 



■M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H„ar.l..f H- '' t V,, .< 



4)1*..^ r <■ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^ 'X^, . Deputy Health CTxczr 



Rp^isfcrcd J\^o, 



1614 






.X.C'^.^wA_ 



w 



\ f 



'I !! 




DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



No. "A 



Certificate of IDeatb 

( "0. 5. 5tnnc>arO ) 
PLACE OF DEATH: — County of a:>v J.\^-^v-v<ic City of *^'<^>^' O/Vxx vvc^<i.cc 

Dist.;bet. ^^ t^K; and t 

( ir ocATH occuns «w*v rnoM USUAL RESIDENCE Givt r*cTs CALtro roR under "special intormation • "\ 

V if DtATM OCCUHMCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAC OF STREET AND NUMBER. / 

y\ Ml'* 

I 1<X W,l V(XXIa^:>..w 



ef ' 



C'vV^^ v'. .^ 




FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



ri-: OF BIRTH 



c<>i.»»k \ 



U' 



► V\^ 



u 



•Monlfi) 



1'. 



) V*(/ 1 



il>:i%) 



M'Uths 



(Year) 



Dav 



<W.K. MAKKIKI) 
WIIU'WKIi OR IHYmKiI'I) 
• Wiiit ut •Mjcial ikiiijeiiatuMi) 



•I| 



^ ttnr Cmintry' 



NX VI «»| 
HATHKR 



RTPTHl'i.ArH 

'»' I athkr' 

UStaU- or i'cuntry) 



"" MUTUKR 



niRTHPf.An- 
J'l- MMTin;R 

"^'1?' r CnintrvJ 



>Aw'^^0. 



% 








MEDICAL CERTIFICATE OF DEATH 



DATK nr i>i:\ in 



(Montfh) 



...11.... 

(Day) 



igo \ 

(Year) 



I II1:R1;BV CIvRTII'V, That I attended deceased from 

^X^ tl 190M to . .^M^^ 13. 190 S 

tliat T 1n<;t ^aw li ■*-*i alive on .S^.M(^'. Vk 190 . 

;itid lliat dialh occurred, 011 tlie date stated above, at ^ 



-M. Tlie CArSI<: ()!• DI'iATII was as follows : 



^. 






xn 



6 ^Y ' 



I » I ■ K A I* I ( ) N ) cars Mouths Days 
C( )NTR I |U"r( )R V . ..U.,>LX^v^^.^cd^Ac.'XA. 



Hours 



DTK \T ION y<ars rr^fout/is Days /fours 

NED) L:i\.a^S..H.lLl' J^^^^^ y^'^' 

(Addn-ss) l^lHxDlavLct ..'.t. 



( SlG 



i()oM 



\./^V' 



V 




dL 



r-',// - 



1/,.//,'//. 



M 



/»,n 



««J.M oi- Mv k\..\vm:i)<.k and Ml 1, 11: 1- 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Resident?, and persons dyiny av*a> from liome. 



Former or 
L'sual Residence 

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



How long at 

Place of Death? Days 



HI-: 



.-crv^j 



ri..\CK Ol" lUKlAI. OK J<H.NH>\ AI. 




nATlvof HrKiAi, or KICMOVAI, 
S.X.^'t 1.^.1 190 i 



(Address ^. 5n VB^A^^-Unx. ..l5t. 



^. H.— Bvcry ,te„, ., 1nfon.„..H„n .hould be c„r«fully supplied. AGB «houId He stated EXACTLY ,^^"7^«»^»^^^^^ 

«t«te CAUSE OF DEATH in plain term., that it m»y be properly classified. The Spec.al Informat.on for p.r- 
•on« dyinft away from home Hhould be ftiven in every instance. 






11 ; ■ 
I I 






f i ' 



«r' 



M 



IV 



( ' 

I 



Pl 






r,. 



f 



I ' 



^ 




* 



•¥ 




K 




B<KI 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

r.Iof H. itl. I V , '^ •»'ggX)lt.\r<-.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!)((/r riled, 0-L'|vtX'-v^^U^ i ?> 



rjo\ 



liegistet'cd J\^o, 



1615 



i 



V 



fy\j^'^ jlXaM.( Deputy Health Cf?lcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



No. 






Ccvtificatc of IDcatb 

' Vi. S. StanC^ar^ i 

City of 0/tX/Yu oA<X'^>acu.c:< 

^^ 1 ^ k \^ 

St.: Dist.;bet. %.A^-r-'^~.t and l^C^rvl^ 



A 



V > 



,\ _ , _.. 

r oc«TH occuns awnr rnoM USUAL RC S l DE NCC civc facts callcd tor uwdcr "spccial information 
ir ocATM occunnrtt-iN a hospital or institution civc its NAME instead or street and number. 



) 



A 
^ 



FULL NAME 



.a.d\.L>\.a \jd^J\jsj.jl:0^. 



PERSONAL AND STATISTICAL PARTICULARS 



DATK i»l 8!K| M ^ 



c ' u.« tk 



d.Kd:. 



Ntwiith 



:x5 



(Year) 



.-.i. 



> V<; > 



1 ^t.>Hlh< \ 



Da 1 s 



'>WFr» OR niVORCKI) 
;c uj mtcxnX tlftis'ntition) 



• ■- IHPJ.AOK 
(Statf nr rontitry* 



N-AMK C»f. 



BlkTMI-i.XCK 
*»• I AHIKR 
(Stntr r.r Country') 



MMIJKN NAMK 
<•!• MOTUKR 



lUk IMJM.AIF 
J»F M<.TnHk 
<Stat.- ur Cmntry^ 



i 










|d 



MEDICAL CERTIFICATE OF DEATH 

DATK » >!■ Ki: \ in 

.1.1 

(Day) 



..dxkt 

(MontW) 



(Year) 



1 Ili-Ri.I'.V Ci:RTn-V. That I altcinkMl deceased from 

IA.|\,V...IC) 190H.. to .U.J«^|:vt- b 190 S. 

that I last saw h i^-' alive on -^ QX^p^ .^.^ ......190-h 

and that death occurred, nn the «late stated above, at 



:^I, The CAl SK UV DUATH was a.s follows 










, 



u 



nrR.XTION JV<7;.? Month!! Days Hours 

(:<->NTKn;rT()KV 



I)rR.\TI(»N 



( Signed 



) J 



^^ 



'wjx: 



L O.V^>vc 





OwU^ 



t^^ 



A. A ^ 



i<>o 



}'iars Mi>uths Days Hours 

-irvi^XU- M.D. 



) cars .u ON ins 



Special information only for Hospitals, Institutions, Transirnfs, 
or Recent Residents, and persons dvinq dv»dv froni home. 



1/,./////- 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



" "it FsT'y.r';!v^ ''''■■'• ''^--K^ONAI- T \ K T FC T I,A K S A k K T k T K 

'"•^i <»i MS i:^n«)\vi,j:i)(.h AM) in-MMf- 




ro THK 







Oy>X >^XXA-nj .y .<L OwrlLA. 



^l 



V\..\£V. OF IHRIAI, OR RHMOVAI. 



DATl-of II! KIAI. or RKMOVAI, 

C)-^^ Jl T90H 



l-NDHRTAKKR V^lAvr^yWO ^<X^^V^^O^ 



N. B.-— Kvery 1,e„, of InW^Btlon .hould be carefully supplied. AGE «houId bo •fated EXACTLY PHYSICIANS should 
•tatc CAUSE OF DEATH in plain term., that it may be properly classified. The Spec.al Informat.on for p«r- 
«on« dyinft away from home should be ftiven in •yry instance. 



k ■' 



|H 



it 




i 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H,,,r,!.fH t' IN" i'-*?^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Beglstei'ed J\^o. 



1616 






Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of ©eatb 

( "Q. S. StanDarC* j 
PLACE OF DEATH: — County of vwLaV^ City of U.C^Cvt^a ..oj 



No. 



(ir DtATM occuns «w*v ri 
tr ocATH occunnco in 



St.; 



Dist.; bet. 



and 



noM USUAL RCSI OCNCE Give facts called roR undcr spec 

A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRCE 



lAL INFORMATION" \ 
T AND NUMBER. / 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



-1 \ 



n 



t t M.i ►k > 



wOwU 
I }. oi- timrit 



K 



• Month" 



lLk^U 



) '<»» 



f!)ay> 



!/.'»////> 



(Verir) 



/hn 



MEDICAL CERTIFICATE OF DEATH 

DA T}-; I »i- HI. \i Ji 



fMoiiHi^ 



(Day) 



(Year) 



I !li:Ri;r.V Ci: RTIF'V, That I attended fleceascd from 

—190 to 190 ~~ 

that I last saw h alive oil 190 ' 



NtlJ.K. MARKIKI> 
fXi\VHI» t>K nt\ c>RiKI> 

tile in Micial M« •«ii»n;if..n) 



i 




! » 



niRTH PLACE 
"• tiror C<Miitry> 



NAM J Of* 

^vrll^;R 



IHK i HII.Ai K 

'X lAIMKR 

^' iteor Country) 



MMIii:\ NAMF 






1 



Uv 



,1 



;iiid that death ru-curred, on the date stati-d above, at 
M. The CAl'SH OI- DliATH was as follows 



^v\rv^iu 




ii 



? 



BIRTH P^ACF 

'»! m<»tmi:k 



DIK.XTIO.N y'iiirs 
eONTKIHrTORV 



Months 



Days 



Hours 



DTK ATION 
( SIGNED ) 



)'rars 






r»»n 



Months Pays 

\\k ^S-^'uO^'^^' -^ 

c.\d<iress) UvA-oXva va 



Hours 
M.D. 




CC>X 



r< 






1 /..///// 



/'. 



»hST 0^ M )^^K N. lUl. 1; i„ , K AM) U 1 ■ I.I I- T 

'.nf,.n....„t *V\/J. X).< 



Special information only for HospUdls, institutions, Transients, 
or Reient Residents, dod persons dying anay from home. 



Former or 
IsudI Residence 

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



How long at 
Place of Death ? 



.. Days 



C3laj-\^> 



^<lilrc-«;s (\0 



\JL<xk.<Xj n 



i 



J'l.ACK 1)1- IH KI.\I. OK KK.M'»V,\I, | D.VTj^o! Uikiai, or KKMOVAI, 



^- 



i 



JU\\Kj. \ S 190 '1 



NDl-KTAKHK IX^VX/CtX/^ IVvxX^JLhjtxOk. 



(^.Ad<lrfss 



S^O b ,\ji\A/^u<U-<rva 0.1 



N. B. 



Hvery ,te„, o.' in^.rm«.ion .hould be carefully supplied. AGE .hould be stated EXACTLY P»Y«'C1AN8 should 
-tate CAUSE OF DEATH In plain term., that it may be properly cla.sifled. The Special Informat.on for per- 
"on« dyinft away from home nhould be tiven in my 



ivery inntance. 



I 



) 



• I 



I , if I 



I ' 



< 



Mi '. 1 



t 



I 



•r 



c 



il 



a] 



h 



n 






If 



! » i 



^ 'yl 



« 



if 



>:' 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,, ,, , V, . is-t^£>. HKIM .. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ril# 




^ 



Dafr n/rff, Sx'jA.ti.-y^x.'tMA 



-^ 



IfU}'\ 



liro^/sferrd J\^o. 



161 



r 



\ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

PLACE OF DEATH: — County of 



^ 



r^ 



\~ 






"* XCX^v: A . City of <X>X' XcVAvC^sAi^Cii 
N«. v1cu.V : -i--rJ St.: lii Dist.;bet. UoX>^\X^ and ^Ki->xtAAi 

/ ir ot«TM occults «w*v FROM USUAL RESIDENCE Givt facts called for under "special information ■• \ I 

V IF otATM occunnco in a mobpital or institution give its name instead of street and number. / ^. 






FULL NAME *^VcU.U 






.a'. 



PERSONAL AND STATISTICAL PARTICULARS 

r»ii,ok 



IK III'- ntRTH 



K 






may) 



(Year) 



) rai 



I 



If'iHtkX JL i 



An* 




; 



iMtUKU OK IHVokrKt) 



THFtACK 
teor Cmintry^ 







L 



r1 L 

' " i 



^ 



F^ 



IHKR 



'''K I ii I'l. \« }•• 

«" 1 \rin.K 

l^tttlfor Country 



MMI>1.\- WMK 
"I M'llMKk 



"IKTMlM.At'K 

• n mmthhr' 

I "^t rite or C.Mititivi 



(XCl^ c'v>xvci; 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DHATH 

Uxkt'. 



(MoiiOi) 



.11. 

(Day) 



/go 
(Year 



I HJ-Rl-riV CT-RTrrV, That I attenckMl deceased from 



to . OJu^vt . .11. 



alive oil Q.-Mf^^ ^^ 



that I last saw li 

and that death occurred, 011 the date stated ahnve, at 

'7s 
..VJ M. Tlie CAISK OI" DI'lATH was as follows 

L^'V^ix^^a- C>A^-a,.^%Xvw:.>.iv.-N. „ 



190 

t 



^ 








I 



XXUx.\>a 



UwH^t. ti 




ex 



^v^ 



DlkATlON 
CONTRIPd'TOKV 



)'t'ars Mouths 3> Days Hours 

^ksjOcsX, 



nrRATfoN 



'? 
^ 



-CAwWOL WAXWxK:yrUJ. 




^ 

)^.l^ 



(Signed 

OXiAt \X I 



Years^ 



Mont /is 



^ 



/hiys 



''0. 



()0 






Hours 
M.D. 



(Address) l^ 



SPECIAL INFORMATION only for Hospitals, institutions, Transifnts, 
or Recent Residents, and persons dyinq away from home. 



""liJJ'r'^"A\^''^''''" t'»'"K^<>\ \I, l'\K IKM l.AKs XKl- IK 
»HM OF MV KNOWI.l.Ix.H AND lU.I.Ii:!- 



/>,.' 1 . 



t )•: i<> rm: 



Former or 
Isual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'LACl-: 01 lUKI.M. «»K KKM<>\ AI 



DA'lj: i!' Ill KiAi, or KKMOVAI, 

(0} ^ C\ '^ ^ ^ 

lie. ; ^ suIa^^^uv^^.x .u^ 



(A<l<lri-ss 



.. . A/'F «ho..l»l he Ktntecl EXACTLY. PHYSICIANS should 
„.i„„ .h..„,.. ,,.. .....*u.., »upp ..... ,^^:;f;;^" 'JU",;:..? The ••Special .n»-or.„a.-.o„" fo. p..- 

^TH In pifiin tcrm», that it mji> nc |.rtM"^''J' 



«. livery Jtem o(f inform 

state CAlJSn or DMA 

«nn« clyinft away ?rom homo Mhould he ftivcn in every inHtance 



) 



i'.<i 



\: 






•Itl 

r 



♦r 



•'> 



^r 



.i'' 



M 



iki. 



W 



•1 



i'"'U 



, - li' 
1 \ 

It 

L 



mi ij 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






Ih 



\.^VC\^ 



duL' 



Deputy Health Officer 



REFER TO BACK OF CERTIFICATg FOR INSTRUC TIONS 

/»"t JtetSidfred A'a. 1618 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 







M ♦ 




PLACE OF DEATH: — County 



Certificate of IDeatb 



nty of J<X'> V J. 



K<X^\ZK.^CcGiY of vJ^'W; ^ XCvyx^ULS^i. 



'! 



St.: 



Dist.; bet. 



and — 



/ ir oraTH occun* aw«v r«oi« USUAL RESIDENCE &ivt racTs called tor undcr "spccial intormation'- N 

\ ir orATM OCCUHRCO IM A HOSPITAL OP INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



■) 



FULL NAME 



^^L^vCi.'■■_C^.^^" 3 



^t 



Ll. 



PERSONAL AND STATISTICAL PARTICULARS 

I COt.nK V 



WL 



w^vxaX^ 



HiRTH 



M.uth 



St) 



) rii I 



f|»tir> 



\f.<ttf/i% 






MEDICAL CERTIFICATE OF DEATH 
I»\TI-: ol- Di; ATM 

:n I I 

J ._ IC 

(Dav) 



/po : 

(Year) 



J)a\s 



^^ ■ ' tial tit -;k'iial!'i!i) 



^c. 



Wv<Y>-i- 






iU-.R 



IMR riii-i.vrK 
'M ! •, I iif-K 

^ 'uintry 



"• MOTMKR 



HIKTMl'|.\i-K 
«M. MiifUKR' 

<st.-,t. 



(MnntM 
I IJi:Ki;r.V ei:UTII-V, riiMt I aUeii<lc<l deceased from 

u^U*, iS - 190'i to BjL^^. ID. 190 H 

tliat I last^saw li J-^>^ alive on c)«iLyv<tr .1 & 190 '"v 

and tliat dtatli occurred, on tlic dat<> state<l al)f)ve, at ^ 

U. M. TIk- CAISI-: ()!• DI'iA'ill was as follows: 

vLCc>-VoCtc.tr\^ Crir O :kfr-v>v(X.tL^v 



D 



^w . 



V^' 



^^x^ 




DIRATION 



) V^/'j 



.Vofiihs 



favs 



Hours 



,< I ii I' T U R Y - vLt\^|\/lvu .d^.-.S 



:nt! \ 



a ouLi 






1)1' RATION •: . )V:(7rJ Months 

r SIGNED ) \..S:^.,... 0\D^\A.c- 



Pays 





I 



rixixt IX y,)oH fA.i.ir.-<s) sil ■.Ua-Vi 'Jl 



itals, InsHt 



Hours 
M.D. 



rwJ,N' 



ir, .,////. 



Special information on'y for Hospitals, InsHtuHons, Transients, 
or Recent Residents, and persons dying away from home. 

former or ■\ ^4.1 , \l ""*" 'Tn*^.o ^-^ 

Usual Residence ^ Vv'-C WifvL-*^? Plarc of Death ? v 

When was disease contracted, 

If not at place of death ? 



Days 



'''iirsT*y.r''Jv^' ' '' '•»^«^«>NM- r\K TiiTi.vks Aki:TRrK TiJ Tin-; 

lU.M n|. MS K\(.\VI,i:i)«-.K AM, |ti:i.I):K 









k. 



17 \CF Ol-' MIKIAI, OK Ki;Mn\AI. I DAli: o!" HruiAl. or KKMOV'AI, 
IM.KKTAKKR U 0\Xl\> V U)i^«j- ^ 



N. B. Kve 



•^d^-* 



-cry Item ok' Jnform„tion .houl.l be cnrcfuHy nuppliecl. AGIi mHouI.I be «totecl EXACTLY PHYSICIANS should 
•»t»tc CAUSE OP DEATH In pl«Jr, terms, that it mny be properly claBsh'ied. The Sp c.al inWmat.on for p«r- 
«'>n« dylnft away Ifrom home Hhould be H'lven in every instance. 



■< , »' 



if 



J.; ! 






!■ :li'l 



i' 



''■I i 



W 



I I'i ■ ; 



Mi 



^ I 



, \ 



I* 





I|!i 



fh,r' 



H-o 



1 , I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

r^tFE.H TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







Begistercd J^o, 



1 61 9 



■BW'"* 



Vfrv^^^ i^^^^)^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 







II il 




PLACE OF DEATH: — County of 



r 



V CL ^ V c c-i c Ci ty of O CL > V vj y\,'0^'-\ v.a V^' Co 
No. .'vits ^ A ., . St.: i Dist.;bet. Xi.ax'4'Y\U«r\tkand ArvviA. 

Cir ocath oCcums «\m«v fhom USUAL R E S i DE NCE Gi vt f*cts called roR under "special information \ 
ir DfATii OCCUHRIO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



F 



FULL NAME ^aVatv^vl C 






Z/^^ 



PERSONAL AND STATISTICAL PARTICULARS 



K OF niRTH 



lOJ 



XVAjL 



MEDICAL CERTIFICATE OF DEATH 
I) \TK OF hi: ATM P 



m 



U ]\ 



M,n,h J 



.^r.R 



>- 1 , 



•^ 
•> 



'Day) 



\r.>*iih\ 



(Veai 



ixkt 



(Month) 



(Day) 



(Year) 



1^ 



Aim 






^iT 



iit 



I'i 



I 1 



\\ 



J.ACK 



PATfUR 



•'•K , i ; , , ,, J. 

<^»' I atmfk' 

'St.,-, . 









I III'KI'.IiV C"I:kTII-\', Tliatr attended (U'ceascd from 

''^i-U-o^ 190..V. to - ..^-e-i^ti \X ....190 H 

t))Mt I la^t saw h A^U alive on OX^p-fc Iftv. igo H 

,111.1 thai death orciirred, on the date stated above, at 1 oO 
Vj M. 'ihe CM SI-: OF DKATII was as follows: 






i 






cr)^c.v 



ntryj 



or Morni-.K 



'M ^f^THKR' 






+ 






iJl RATION i Years Z 



Mouths 



Days 



Hours 



CONTRIIUTORY 



DURATION . Years Months 

^ ^^: U), 



( Signed ) cLt^cc^ 

.:\.^,' ..V ^. i«>o 



/^^7V.? /fours 

/flU-W'\XK.t M.D. 

(Address) iM0X)-iaKA< 




u 



V^C<5 



It: 






Special information only for Hospitals, Instituliens, frdnsients, 
or Rrtent Residenls, dnd persons dving dv»a) from home. 



lA./,.,'//. 



'"^' 01 MN KNnWlJ.Ix.K am, |u I.DI-- 

4 



II I 



Fnrmfr or 
LsudI Rcsidenrf 

Hhrn was dlsfdsf fontraftfd, 
If not at plare of deaffi ? 



HoH long at 

Plare of Death ? ..— • Days 



IM.ACHOI" IJIKIAI, OK K1;Mo\AI. 



DV^l'.t); HiKiAi, or KlvMO\'AI, 



N I ) 1.- R T ^ K K R Ia . tvi U /Xcvy-^^^ ^ ^^■ 



(Address 



31R\D'^3 



cL^w 



.:hL 



"• «•— ^-very Item olf lnform..ti«n .hould h. cnrcfully HuppMcd. AGB «houId be ntated F.XACTLY ^"YSICfANS should 

•H In pl„m term,, that it m»y he properly cluMBi^Med. The "Specal Information for p.r- 



"tntc CAIJSI; OF DEATI 

*"*"• *bJn4 nway from home Nhoiild be j^iven in 9\ory Instance. 



I 



■■ » 






M 



v\ 



K. 



I Jr. 



^ 



N 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

S^HSiPCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






if 

11 



H 



i% 



P I 




Deputy Health OfTicer 



Registei'cd J\''o. 



1620 




DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 

Certificate of IDcatb 

( "a. S. StanDarO j 
PLACE OF DEATH: — County of OxX^- JXCLWCUl^c City of O.-^^ v VC^vvC^UL^ :.. 



/ ,r Or.TH occurs .W.V TROM USUAL RESIDENCE G.Vt r*CTS C*LLtD ;0B UNO SPCC,,^ 'N^OBMAT.ON- ) 

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



0/<X^xCLlcr\^ 



St. 



Dist.; bet. 



and 



FULL NAME 



irk AA; \C\X.^ U-.Ci. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

i C(H.t)R > 



k. 



o^-U 




UJ^^vlU 



DA I i: Ol UIKTII 



(Monthi 



A»,K 



5?> 



)■/<;» < 



(Day) 



!/..»//// 



(Year) 



A/1 



W 1 1 )( )\y H n OK I ) I \< » k r i; I ) 

IWritt ill MMJal (l<vi^.n;iti<iii) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH } 

qx\4j. li.......-., 

(Month') ^»«r> 



(Year) 




Xojvvjt^L. 



BIRTIU'UAOK 
(Stat* or Country) 



N'AMi: Ol- 
HATUKR 



BIRTH j'l.AiK 
n|- lATMF.R 

• St.Mtr <.r Coil lit ry) 






1 



u 




U 



MAtDKN NAMK 
<»1 MoTHFR 



BikrniM.ACK 

"l- NSoTHKR 
(St;it< (,r Coiintrv) 



occrpA-noN QP) 



f\ 



) 







V A-v C" .^Mi 



/'•''^hin! ni Slip/ /'liunnrit 



I Hr\RT':P>V CI^RTIFV, Thnt I attended flcceasefl frciii 

Bx\xl; i 190H.. to ....OX\\t \:k icp ^ 

lliMt I last saw h^-.V>A. alive on O JL^xt. .1^ 190 • 

and that death occurred, oit the dal.- stated ahove, at 11 v. 0. 

LLm. The CAISI-: OI- DICATII wa^ as follows: 

\jkA^:ir>.%.^^ \l\tlviv\AX\>Ci -"...• 



1)1 RATION years Moui/is^ Days 

coNTRiHrroKV uJ^^oh^A-^-^— ^^^-^ ^^ 

Ml ^ 

Iv:\a/:y\JIL 



Hours 



6 

1)1' RATION 



^"^ar^^^^A/o^i/Z^s Days Hours 

[lUi.Qllatrw^ ^ M.D. 

(.\d<ire<s) b I SvJ/a^^.^tl^x■^ .^ 1^.. -- 



(SIGNED) 



o. iqo"-. 



)V(/; 



M.'iillr 



//,M 



"";• >'!J.»^'K ^TATl-:!) IM^RSONAK 1' \ K P IC T I.A Ks A K i: IRI K T« > TMI-: 

in.sr oj' Mv KNo\vi,i:!)c,i-: and hi:iji:i- 



(III 



formnm M l\VvU-vVi O/ 



O^ > V<xl>{5 V^-»- *v 



\.1.1r( 



SPECIAL Information only for Hospitals institutions, Translfnts, 
or Rftenf Residents, and persons dying away from fiome. 

|:«rm«r Ar -\ i ^^^ '»"<! *' 

t::,Re"de.«0^V.4ValX- Plar. .. Death ? in . Da,s 

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






I'l.ACK OF IJIRIAKOK Kl-.MoCAI 

. X^Xh '^SX\.KA.xu^...2:± 



DAi^ioi HiKiAi, ui ri:movai, 
}Jl)^. l.r. T90S 



(Address 




, .H ATF ithoiilcl be stated EXACTLY. PHYSICIANS should 
iHtion .hould be c«rcfully Hupphcd J^J;;^7;^^7^^^^^ ^y,, .^Special Information" for p-r- 
ATH In plain terms, that it may be properly ciasnincu. » 



• **• Kvery item of inform 

•tate CAUSE OF DEa rti in p 

«ons dyinft away from home should be itiven in every instance 






i ,- ,,i 



i Ir!"- 



k 



' I', 
I 



ill 



. < 



= I 



i: 



♦' 






* w. 



■f 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

«v.r,i,,fi! It!. I No i< t"^<S^)i'..tl'(*o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






I)nfr ri/('(/rX)xX\)u^^hX\^ l?^ Jf^O^ 




Re^i^tered J^'^o. 



CrcCc^i ..-Vc '\>;.i 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( "Q. S. 5tan^ar^ ) 



Q^ 



PLACE OF DEATH: — County of C'<X-^v J >sX^^^tx.4<^o City ofCva^v J /vtX/We^^^l^^ 



fD 



No 



n 



.v^Cvu ^'^ W\x>^tci U 



and 



^\K\, ■' - v^\x^'V"Lu vw^V^X-^v'w^t^-^.St.; ' -.u.-"-- Dist.; bet. '■-^•-.•- •••■ ■ 

a / IF DtATH OCCUH* «W»V FROM USUAL RESIDENCE give facts called for under "special INFORMATION" "\ 
U \ 11^ DEATH OCC^WRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



m 






i 



1 '-' 



FULL NAME 



V 




tH'VUX^ 




^i.\ 



PERSONAL AND STATISTICAL PARTICULARS 




CLAJJ. 



I' \ I 1-; nl IilKTII 



2). 



llilcU 



'JlC 
(Montki) 



VH 

(Day) 



/1h..\ 

(Year) 



m m 



a<;k 



vX y,„,s \ 



MilHihs «3S. 



'^5 



IhiM 



"^IV«*T,R. MARK inn. 
\VII»«t\vi:i) «»K IMVOKCKI) 

'\\ritc ill -..H-ijil (l<si>.MiMtioii) 



ii 



lUKTflPT.ArR 

(St.'itf (ir Coiinlry) 



VAMK OF 

f" \ihi:r 



HlkTHI'I.M'K 

'»! 1X1 hi.:r 

(State or C<.iintrv) 






IHRTHPr.APF 
J '.I' MOTUKK 









MEDICAL CERTIFICATE OF DEATH 



DATI-: OI" i»i;at!i 







Montii) 



A 

(Day) 



(Year) 



I mCRlUJV CliRTir^V. Thai I atlendcMl deceased from 

* r.lQO ^ 



...dX^ .^ 190'-, to ..^..."r. •:.. 

that I hist saw h i.-^ > ^ aHve on Cj-i/^V* 1> 



and that death occurred, on the date stated above, at 
kiw-.^I. The CAISH OI' Dl'ATII was as follows: 

Low'xcLvw;.c?^.>:.. JJ.^oJL^xlun^- 



190 :i 

5 iC 




PT^RATK^N )'ears Mi>?H/is 1 J^avs 

CONTRini'TORY 



Hours 



Mouths 



OcctLta^v<l' 



nr RATION Years 

) LI), O. LrnXouvu 



(Signed 



Days Hours 

M.D. 



cixUt' 



J 



\()n 



( 



A(Mress) UJt'^>aA.^A^\-v-.^. 



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







- M..„lln 



Day 



"'lU-J-r'y.l'.^'^ '"'■'• »'»-*KS<)NAI. I'AKTJCrLAKS ARK TRIK To Till- 
"r.sroi- MY KNo\VI.i:i)C.K AND Hl-I.IICF 



Former or 
Usual Residencf 

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



^xoiv^VV'-.v 



How long at 
Place of Death ? 



.. Days 



prACK OI- KlRIAl, OK R»<;M0\AK 



f Address 



/\W.A/>VfrA.V'S_>w 



I)ATl-:<)f HiKiAi. or KKMOVAI. 
(Address 11.01^1 ....UiOUrCA/a.<^./-v£A.vUi....dt 



■■•■:> 



^- »— Hver, tten, «. l„fon„,„tlo„ .hould be carefully supplied. AGE «houlc. »>e stated EXACTLY . ^"/«;^^;/^^^^^^^^^^ 

Htnte CAUSE OF DEATH In plain term., that it may be properly classified. The Special Information for p«r 
«on» dyinft away from home should be ftlven in cy/ory instance. 



; \^'\* 



! 



\i^ 



v! ' 



I" 






r 






a 



M 

I 



I 



!K 




Si 



n 

if 

ii 



t 




m BR ' 
w 

'a 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,. vo ,^ ^4?JgX) I5«c I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I f 



1 



hit 



'X' 



Registered J\^o. 



1622 



Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 






St.; 3v Dist.;bct. xjoaAK^\c<v.>-crV 



tUnd (ibLVrA,; 



PLACE OF DEATH: — County ofOa^xj J^VCL^^xCULao City of ^J^O^^v. O.Va'^xCc'^/C^C! 

'No, b lli U Ca\x^^ . . \ 

( \f orATH occuns *w«v rnoM USUAL RESIDENCE give facts called for under "special information" y 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION CIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME VjV.v.c!vaVcl L^>xcL M.]lvv^x.k 



MATION" \' 



i»\TK «»» luk rn 



\|.K 



PERSONAL AND STATISTICAL PARTICULARS 

I Cni.nk 



u 



X-'KaTu. 




Month) /] 






(Day) 



r\V\ 

(Year) 



b" )Vw,« S 



Mnni/i'. . . Pars 



\\ ii>t »\\ ).:i» OK i>t\'ok<i-:i) 

'^VIitr ill s.K-ial 'It -ii^MKit iuii ) 



BIRTIIPI.ACR 

(State or Comttn*) 



NAMi: n|. 

r-ATiii:K 



nikiiii'i.ACK 
«)i- i-Ariu-.k 

'State or romitrvi 



OI- MoTllllK 



Hik ^ln'^At■K 
'>|■ MoTmkk' 
istiiii or Co,nitr\'> 




MEDICAL CERTIFICATE OF DEATH 

i>\Ti-: oK r>i". \ rn 




in 



,.flV..., 

(Day) 



I go I 

(Year) 



. I m:Rin;V CIIRTII-^V, That I attendcfl deceased from 

iijiivt ...%. 190H to ..Ai\<k> u. 190 M 

tliat I last saw hA.^>A. alive on ^.rL.)(sl). \S 190 

and that death occurred, on the date stated a1)Ove, at H-.r5..V. 

jjs, M. The CArSl'! OF DIvATII was as follows: 

iXj^^i'^JLi^y^'^^^. CfrVcL^ '- 



DIRATION Years ■ Mouths Pays 



i 






I) r R \ 'I' f ON -yJ'f'^''^ Monlhs 



Days 



( SIGNED ) 



Hours 

us> 

/lours 
M.D. 



) 



H)0 



( 



Address) ^ S 3> V.' :> .- ^.' '^^- 



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



Mnltths 



]\}\ 



111. SI 01. My KNOWIJ.-.DC.H AM) HKI,IHF 



^'Mress LvV\A.^irYV 0/ 



C^/uv^<xHX 



(ibld.:^ 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



190 



n \CK OI- BURIAI, Ok RKMOVAI, I)Y':<'- ""^'•^'- '"" KHMOVAI, 



^. «— Hve.. Ue. o. ,„.o..„Uo. .Hou.c. He ca.efuH. supplied. AGB «Hou.d ^e ^te. EXACTLv^^ .rra^To'^Mof:: In- 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Intormat.o 
sons dyin^ away ?rom home should be ftiven in every instance. 



M 





\\ 



'». 





i ! 








'((*( \ 



m 



11 



I 



: I 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n 



Kegistered J^o. 



1623 



iL^uvO 3oL^^^ Deputy Health Offioer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( Ta. S. StanC»arC» ) 

((311 






G^ 



PLACE OF DEATH; — County ofCVcL^^ J-'XCLTVCviCcCity of JCt^^ J A,<xix cv^^c 



'No. 5 i^b V'^^^^ 



St.; 



M 



Dist.; bet. 



n 



and t ^L 



A;.. 



if Ot*TM OCCURS AW*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, / 



) 



I (? 



r 



i'l* 



'' »i 



r 



r*- 



tfM 



5 



r 



() 



FULL NAME 



JVvw^vLoL^L^o V LOwO^Ua.' 



PERSONAL AND STATISTICAL PARTICULARS 



<.i:\ 



lA 



XoJi 






I>\TK UF lUkTM 



A .K 



>!<.ntli> 



I Day) 



(Vcar) 



MEDICAL CERTIFICATE OF DEATH 

DATl-: OI" Dl-.ATH \* 

, UX^ot 



(^ 



(MontH) 



II... 

(Day) 



(Year) 



X% 



J V<;/ 



M>»Uis 



Da I A 



'^IN'.I.I MXKRIKD 
\VII)r»\vi;i) UK DIVokiKn 
'Hiittin MH:ia! «1. siiftKiliijij) 



«IK llll'l.Ai'H 
(State or Country) 



d^^ 



vi 




I lIlvRI-HV Ci'.RTIF'V, That I attciHled .leceasod from 

nJL^.\t U i«/j io ..OM^. l.l 190 s 

that I last saw li .U\>a alive on QXl|.%t! 1.1 190 i 

and that death occurred, on the <late stated above, at * 

". M. The CATSl': Ol- DI'ATII was as follows: 

ViVl1^L\a.'Lo ..L;v.as.V.tl 






. < 
! 



ti 



4 



NAM I <M 
'•ATlilR 



HIKTIIIM.XCF 
'"^' '(■ or C(.umrv) 



MAII>i;\ WMi-- 
OF MoTin-.K 



oi- Morin-.k' 

"^l;i!f or Cuuntiv I 



9 







'"yx' 



DC RAT ION- )'rars \ Months Days I/ours 

CONT R 1 15rT(^R Y . C>^xLor1^^0^^^.:i^iV^^. — 



I 






^<x-^\ 



Dl'R ATION )'('ars Jfon/Zts 

Q 

1 I V I I 



Pavs 



(Signed'") b 

It)0 




i 



Hours 
M.D. 



c\xia 



(Address) >> 






Special information nn'y f'"^ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



1A./////. 



111. SI ,„. ,,^ KN<.\VIJ.:i)C.H AND HHMHK 



l)o\ 



Tt) IH1-; 



(\<l(l 



ress .. 




5 1^ V^<UJL St 



Former or 
Usual Residence 

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



Now lonq at 
Place of Death ? 



Days 



DATKof Hi KIAI- or R1-:M()VAI, 



n.ACH Ol- HIRLM. OR Kl'.MOXAI 






190 



> 

lt 

r 



1:^! I 



'1 'I 




J 



pi r.; 






"tatc CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Informat.on for p.r 
«f>n« dyin^ away from home Hhould be ftivcn in ^\ery instance. 




It'! 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„,.,pi,,fii !!: 1 N' ■« i^tS?*''"^'"*'* REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 





lOO'i 



d^^j^^Ui dsJt^hu Deputy Health Officer 



Reglstei'ed A^o, 



1624 I 



if* 



DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

I XX. 5. Stan^ar^ ) 



% 



PLACE OF DEATH: — County of^^C>v ^\<X^r\.^KA cj. City of Oa>\/ J .V a, >vttv4 oc 






A n A b 






\ 



No. 'X VV^<LA' VwLL^u St.; U. Dist.;bct«Wl aUxwxKlir.. a 

FACTS CALLED FOR UNDCR "SPEClAL INFO 



(IF DCATH OCCURS J^Wav FROM USUAL R E S I D E N C E G I V r 
IF Dt ATM 



OCCURHtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET] AND NUMBERl^ 

FULL NAME ^ '^0^, J WrE Q.h\k^^. 



/tr.- and \<X.OTyurru. 

RMATIQN' N 



\m 






llffj 



I»\TK 1»H niK I II 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR > 



\\A. 



I Month) 



H r is ^, 

D.tvt (Year) 



\<.i: 



HIN'i.I.K MAKU n:i) 
WiDnU Hit OK IHVoRt j; F) 
(Write in sfnial «l»-«»i>'iiati>iii) 



IIIHTIU'I.M'K 
iStatf f)r r.unitiv^ 



)'rlll 



R 



M -tilfn 



I 



Da vs 



N WTI (.1 
1 \ III IK 



"IK IIII'l.ACK 
"1 lATMHR 
tStateor Cuimtrv) 



MAIliJlN' NAMK 
<>1 MOTHI-K 



"ll^lIll'l.ACK 
'*,'• M'»TIII-.r' 
(Statv Mr rountrvl 



CI 








I ' h 



t ' 



i^ ih 









MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

"^ ' ', IX 

(Day) 



<3xkt 

(Month^ 



T90% 

(Year) 




I HRRHBY CKRTIFV, That I attended deceased from 

190 to 190 

that I last saw h — alive on Ttp 

and that drath occurred, on the -lal^- stated ahove, at •• 

:^I The CAT SI-; Ol- DliATII was as follows: 



Ow ^\_ 



\d. 



^Z.'^X^^^^sJii CJ. JL- 



/Ixi^.tX-: 



tji/1i:y;v.v.0w. 



DIRATION Vrays Moiith<; 

CUNTRIBUTORV 



Davs 



flours 



fy''-^iifr.f ,,! S\,,i r'l nil, !.r,} f^, ; )V.mv 



\.... 



\i)0 



i 



Days Hours 

M.D. 

\d.irrss) ^^'O O-uXUs UA 



DIRXTION Ytuirs ..-^fout/is 

(Signed) J AXAih^:C^.-..^^-..V.^*^-5^-^^-^'-- 



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






^ 



.'jtO 




'''iii-sT*yA-^»T^ '"'■-'' •'^-■«^<>NAi. I'AR-rirn.AKs \Ki; tk 
^^*^AA^:r>-co 0-crH C <x^^c\ 






''nrMMiirnit 



U.Mics^ 



Former or 

Usual Residence ^ 

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



a-a 



How long at 
Place of Deatli ? 



.. Days 



I'LACH OI" IllKIAI, OK RKMt>VAI< 
INDHRTAKKR «rk. 



DA Tj; 0! Hi KiAi. or K1;M<>\'AI, 

QjJcX. .Vo. TQOS- 



^^a-^twOl, 



'^^. ^ 



\ 6o^y 



Ad.lress l^Sj. ^ O^C^-^?-. .^1:1 



^-- 









^- »— Hve., I.e. o. i„W.n„.,o„ .Hou.d he cn.e.'u... supplied. AGH «hou.a ^e -«ted BXACT^^^^^^ ,rran'ot'lf ::'r' 
«tate CAUSE OF DEATH In plain terms, that it may he properly claH«hled. The Special intorma 
«on« dyinft away from home Hhoufd he ftiven In every Instance. 



, I 



I I 

I 



1 

I! 

I' s 



n 



Mi^-' < 



^jiiii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoanlnf ll.:.lti. I No i< >-gg^ H^ 1' t'o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




1 



Registered J\^o, 



1625 



Dale l-'ilnl, "^xlxtx^-vxiMA' li I'JO'^ 

"L^vcv-5 "Llvm^ Depu'y Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 





Certificate of Beatb 



I 



"Q. 5. StanDarc> ) 



\ 



dK) 



4 



PLACE OF DEATH: — County oi C^^^' OXCLTvCU-CcCity of ^J O^-^x- OXO-Txccd/CLC 
No. S 1^0 Llv^.v.^^ '- St.; 10 Dist.;bet. 3.1 tL and ^.^ Uv , 

(ir Dt*TM OCCURS avwAY rROM USUAL RESIDENCE give facts called roR under "special information \ 
ir OtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



( 



FULL NAME 



nLcvtt 



A\i\} 



L<XCvlv2^<.^^ \J ^.4U.A..UL^..V. 



PERSONAL AND STATISTICAL PARTICULARS 

mVu L_^. ICLh 

DATK n|. UIKIll 



i> 



Month > 



(iJav) 



AGK 



I 



H 



1 'i i 



I 



W' f 



Mf 



Hi 



If 



iO 



J ■»■</ » .« 



M.iuifis 



(Year) 



/'</» 



MEDICAL CERTIFICATE OF DEATH 



datp: or dkath 



.dxi'dj 1.1... 

(MoiitH) ^Day) 



Tgo 

(Year) 



SINC.LE MARKIKT) 

(Write ill '..KJal «ii«.iKHuti«)ii) 



BIRTIIFI.ACK 
'State or Country) 



HAT 1 1 Ilk 



nik riM'i.AtF 

OF l-ATHHK 

"^tatt or (N.uiitrvl 




\ycL^U».NLcL= 



atL 



.f 



li- 
lt? 









- I HI'RI-r.V CFvkTIFV, Tliat ^ attended (leccased from 

ax^^l^ ^^i 190H.. . to QJL^-sk 11 190 H- 

that I last >M\v h alive on Q-L^xfc li) 190 H. 

and that <lcath occurred, on tlie <la(«.' stated above, at "^- 

I 

..\k ^ The CAl'Sl'. Ol- I)i:\TiI was as follows: 

K.*vtr\^v^ \i f\<wV'^-^0^*vcL^v^ 



\ 



Ur RAT ION "^^ Vcars Mont /is Days 

CONTRir.rTORV y..L{D,: 



I lours 



nrRATinN 



)'i'ars 



Months 



Days 



I fours 



'"Kl'HPr.ACK 

"i- Moth J -R 

'^tat« nr i'ouulryj 







.\r,>itfh!t 



f>a%'f 



\ \: TO THK 



fl 



"nFsT*yw'';'!"^'"' '• >•^'•H^•»^•A^ par lur l aks aki- tr 

'»»M <M MS KNOWI.HIX-.K AND Ml-IJI-F 



(SIGNED) Id. /D- J <k^^\n-^^£^u:^. ■-■ M.D. 

Oxlxt... 



■i2>:.tQQH. (.xd.ires.) 'H'lt) V.K^v.^e 



Lk^v.^eK'^1 



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



former or 

Usual Residence 

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



How long at 

Place of Deatfj ? . - - «• Days 



r\<i(i 



ress 



i&SH IjLb-^ at 






M 



I'l \CK 01- HIKIAI. OK KKMOVAI 




DATi: <jf HfKiAi. or KKMOVAI, 

....QjL^- Jj. ~.1..H IQOj- 



(A(U 



N. B 



■^^■'"■^""^■^^^"^"^■■"^■^■'■" . . 5XAGTLY. PHYSICIAINS should 

oi InformBtion should be ciirefully supplied. AGK should »e s o .•Coecial InforniHtion" for p«r- 

E OF DEATH in pluin terms, that it mi.y be properly classified. I he »pe 



F.very Item 

state CAUSE 

«in« dyinft away from home should be ftiven in every instance 



K .. 






I ' 






t 



i 





M 




I 



it 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Iinar.L.f II...I1I1 1 s„ i^^-JK^'""'^'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale I'lh'il , Oxk-\Xju^-^^~Ksfj\ 

' 



lA 290 



Registered J\''(). 



i 6'36 







X^v^^ cU.xM.| Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. Stan^arD ) 



[^ 



PLACE OF DEATH: — County 



No 









VOlI) L/y>'Vt^alAVCV'. UU^'l.!sti.ic\.(].. Dist,;bct.- and 

/ ir DEATH OCCURS AV»AY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
V IF DEATH OCCUflWiD IN A HOfePITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



i\^AL^Sk 



\\ljyy\lA.Uj\} 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



DA'I'IC ()I- lUK 111 



ll 




vuJL_ 




au 



Muiith' \ 



ACK 



. i ) .. Willi ' 



..a. 

(Dnv) 



Mouths 



Ak-'^. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

dxlxt 10 



I go 

(Year) 



(Month) (Day) 

1 ]I1';R1:I}V CI-RTII-V, That I atteiukMl ilcct-ased from 

to :■ 



IhlVS 



<IN<'.1,K. MAKklKD. 
WIDOWKD OK DIV()K('KD 

'Wtitfiii social di 'iij.'-natioii) 



I 



W^K \^' \^ \mg ■■!•'' - V_* 



MIKTHJM.AOH 
(State or Country) 



I'ATHKR 



niRTHPT.ACK 
HK l-ATHKK 

'Sl.itr or Countrv) 



MAIDKM XAMH 
01- -MOTMKK 



mirthpi.ac'p: 

<>1- MOTHKR 
(Slate or Country) 




X/Xl 



-190 



that I last saw h""" alive on 



I90 



and that death occurred, 011 the date stated above, at 

[• I) 1; AT 1 1 



rr"M. The CAlSiC OF Dl-ATII was as follows 



...v:k.!urusJLbj. 



>\ilcy5..i-5? 



(^^/)^w^ 



Dl'R ATIOX Years Months 

CONTRIIU'TORY 



Days 



Hours 



DFR ATIOX Years ^ Mouths 



Days 



CjXV^<X'>\; 



u 



CV^>xv<Lt vx 



( SIGNED ) \J:^\Jry\X>\> 



)j4xb...ia 190M. (Address) ^^X^vxJLh^ U^i^^^ 



Hours 
M.D. 






OCCUPATION C 

hVsidri! in San I'l am i:ri> ! c )iai 



yr.ntth' 



Pay 



Tin-: AHOVK STATKD PHKSONAI. I'A RT ICT I.ARS AR K TRIK To TFIK 

UHST oi' Mv KNowMaxjj': AND iu:mi;f 



Special information only for Hospitals, Inslituffohs, Transients, 
or Recent Residents, and persons dying away froii home. 



Former or 
Usual Residence 



HH^ Jb awvt 



-L -^A How long at 
^ Place of Deatli? 



. Days 



Wfien was disease contracted, 
If not iX place of death ? 




PI.ACK Ol- niRIAI, OK KKMOVAI, I DAJ^K ot Hi ki.ai. or RKMOVAI, 
INDHRTAKKR V Cr\tX\; ^'^ lU JxCtx , 



190 



(Acl<lr«-ss 



H-X?. "^alcU.^ "*;Vatt Q,-.... 






N. B. Every item o? information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that i* may be properly classitried. The "Special Information" ?or par- 
sons dyin£ away from home should be feiven in every instance. 



( 



•I'i 



I , 





\^s 






/ I 




"' w 




r n 



4^^ 




^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lofHtaltl. KNo I. *-^|k^US:I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



"«■»» 



Dff/c /v/^v/, djLLtXY>^Luv' )..3> 190' [ 



(r^co .^^u^.. Deputy Health Officer 



Begistered J\^o. 



J6?37 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( XI. S. StanDarD ) 

J — County ofOcL^v J VCL^xCAAtU) City of ^v3-(X'>^' OACL^veut^c 

St,; "^ Dist.; bet. \<X TL.t\AVn and U CM-UqAv 

TS CALLED FOR UNDCR "SPECIAL INFORMATION" \ A 

TS NAME INSTEAD OF STREET AND NUMBER. / \) 



PLACE OF DEATH 

No. AO- ti cLu^^.'cLiAX' vjL\>< 

(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FAC 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 

,-01 . ^ 




FULL NAME 



,u 



V 



. JLd. 4... sl'x.c<a^' '^■. 

1, 
— \ j 




4ALv^YxaAl.lLa\£[.. 



SK 



PERSONAL AND STATISTICAL PARTICULARS 
■:x (J?) A I COLOR 



•v 



JLA^\XX^U 




X^t 



Ar.K 



(Motith) 



} >•(/ / ^ 



IB. 

(Day) 



O [^ t- 
/- .i-V. 



MEDICAL CERTIFICATE OF DEATH 



(Year) 



Mntllhs 



Daxs 



">IN<.I,K, MAKUIKI). 

W IIM)\VKI) OK DIVoKrKI) U 

iVVritfin MH-i;il <1i vi j.r,,;it i'Ui ) 



iUKTMl'I.ACH 
(Statf or Coiuiti v) 




NAMK or- 
lATHl-.R 



HIKTHIM.ArK 
<>l' FAIMHK 
'Sl:it( or C<Miiitrv) 






DAT?: OF DKATH V 

Qxkl/ IS igo' 

(MotUW) (Day) (Year) 

I I1I^:RI:I}V CI':RTIFV, That r atteiKlcd deceased from 

'SJv JLtV%A^.i%« IQO to 



that I last saw h ::— alive on 



190- 



and that death occurred, on the date stated above, at - 
-r— M. The CAI'SP: OF DlvATII was as follows: 



.V x-VM...^ 



Ac-OA/ 




I 



\ 



(I 



MAIDKN NAMK 
Ol- MoTHKK 



HIKTHPLACK 
'»•• MoTMHK 
(St;it.' or Country) 






I)r RATION 
CONTRIHl"! 

nr RATION 
(SIGNED) 



J lours 



Yeais Months Days 
( ) R V ..\lAjX,^Ll/>.^<>^.^.J\.S>JL\}:\.m^ 



Mt))iths 



^XTv</>'y„- 



occ 






i 



X^..-..i.3 



I(>0 



Years 



I^ays 



(Address) L 



>J 



oxv-L'^'u ..!t 



Hours 
M.D. 



Special information only f»r Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away Irom home. 



Kf^iiU'd III S<ni /'i ii n< isi'ii 



) '/'ii 1 



V.-y////. 



I'ui \. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



. Days 



I" H V. A HOV K ST AT l", I) P H R SON A I. I'A K I* 10 F K A R S A K l". I" R T K T< > T H H 
U1-;ST OF MY KNOWIJ-Dr.H AND iniMlvK 



liiforinaul 







J? 



■OA^' 



ri,ACK OF lU'RIAI, OR Rl'MoVAI, j DA^l^of HiKiAr, or RICMOVAI. 

%A^, ^^v^. , I li^'ixt, IH ,9on 



UNDl-RTAKKR 0^ywX/^rJU\J vfc 



fAtldr.ss 



1X0 -^ CAx- 



A^^v 



-1 



,V.i^^\^'tr•>^^ .}t 



N. B.- 



■F.very item o*' JnformHtion Hhould be ci.refully «uppl!ed. AGF. «houlcl be stated EXACTLY. PHYSICIANS Hhould 
state CAUSn OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«p- 



state CAUSE OF DEATH In pi 

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



I ) 



y. 




> . 






\\\ 



H 



M 



a 



t- : 



ll 



t II H 



if 



I 



i 



4 



Jif 



i^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



).,,;, nl ,.f IlL-.iltli !• N'o. I^ T^-F^^acj^Ji&I'Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed , 



\.\ 




h) M • lOO'i 



Begistcred J^'^o. 



J 628 



^LLv> ,U\K^^ Deputy Health Omcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)eatb 



PLACE OF DEATH: — County of Oo->X' ACXoa.c\^c City of O <X"vv .V<x.>t.^c^^c^ 



No. b i^ 




Ch^lfc St.; '^ Dist.;bct.cLUX.AKi^\UVttVl'" and v\.^U 

(ir DEATH 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. J \. 



4 



^ 



FULL NAME 



\ 



.ju: 




m 



LOrYV vJ \L| U.^\\Aj^\.. 




•^KX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR N 



OJ 

DATK ol- lUKTW 



n\. 





iMotith) 



1'^ 
(Day) 



(Year) 



a<;k 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 








^. 



(Month) 



.....11. 

(Day) 



IQO \ 
(Year) 






I HHKI'inV CIvRTII'^V, That I attended deceased from 



it) y,a,s 



X^. 



Mnnlhs <7> V h<!\ 



SINCI.K. MAKKIKD. 
WIDoWKI) «)K I>I\«»KtKr> 

'Write ill soriul «Usi).<ii;iti<<n) 



lUk rniM, Ai*K 
(Statf nr Country) 



NAMl- OI 
FATM 



Of X 



UlI 



X^^ 





'c)Jl)^ ^ 190 H to ...3ji^f:\.t. l.L 190 S 

1 11 at I la.st saw ll /-"«-. alive on U.JJ(sXj U. 190 

and that death occnrred, on the date stated alxn-e, at ' X^ 

V . M. The CAl'Slv Ol- Div.VTIl was as follows: 

yjVftnvcJx^. .U..^>-»LVwVa->-W0^'^^V'C7w 



lUk'nii'i.ACK 
OI- i-ArHi-:K 

I statf or Countrv) 



MAIDKN NAMK 
OF MOTHKK 



,. J. VU dcfvtYv.ck 



inR'i'm'i.AOK 

o»- MOTHKK 
(State «)r Country) 






I)rR.\Tl()N Vtuir-'^ 

CONTRIIUTOF^V Vw^CvsAX AJ 



Mouths Days 




,Lui.. ,JrOci^X^uc^JL<xhJ 



.Uy»A..: 



Hours 

.<xXrM..\./C).. 



^^A^ 



P 






OCCri'ATlON 

f\f''idril ill Sdir I'l iiiu isr<) 






DURATION fi yi'<^>;^ ISfouihs 

(,SIGI 



\T10N V. Year^ J/< 



Days 



Hours 
M.D. 



Address^ Ma.\^^tt 'h..^.^. 7 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying d\*ay from tiome. 



y,ai 



n<n. 



WW. AHOVK STAT)-: I) J'KKSONAl. I'AK TlCr 1, AKS AKK rKlH TO THK 

ij;n«;K and in:i.n:F 



in:sT OF Mv k.n'o\vij;d«;k and in:i.n:F 



(iiif 



Former or 
Usual Residence 

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



How lonq at 
Place of Oeatli ? 



Days 



l'I,ACK OF HIKIAI, <)K KHMOVAI, 




>riu:int 



(\(1(1 



rrss 



Q 



t 



lC^\ V)(h4.1j dl 



?).^.i..a.L^tu>v -^.1. 



(.\d(lress 




N. B.—F.very item ai Information .hould be c«r«fully supplied. AGE should be stnted EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The Spec.al Information for pT- 
«on« dyin^ away from home should be ftivcn in every instance. 



' M 






H 



\ 1 i» 



, ... ^ 



"I 



1^ 



liK 



I 4 



n 



I 



' I 





WRITE PLAINLY WITH UNFADING INK 

,.,,;,r-l of 11. alth- F Xo. i^ -^-^^TH&l' Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i ■ 




Re^lstei'ed J\^o, 



162 



Diilr /^V/f^</,.r)jLJpXil/v>AAMA,' IS i^^H 

iVU/v-u. DepuVy Heaith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot Beatb 

( H. S. StanDarD ) 
PLACE OF DEATH: — County of ■ 'xx>X' vtA.a.m.ac<i.ci.c City of 0<x>^ J 'vo.-vvc^. c 



No. i. D. Ci. \la Oi\A..^r^.^ 



St.; c\ 



Dist.;bct. uL^C^^Ct^x- and X'.Lvjvr>:\A' ) 



(( 



IF DtATH OCCURS AW*V FROM USUAL R E S I D E N C E G I V E FACT 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



TS CALLED FOR UNDER "SPECIAL INFORMATION" N 
TS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




^^<r>\.q. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^\Ax 



COI.OR 



I>\'I'K (»I 111 RIM 




(Mo!ith> 



(Day) 



/ "S Hi 

(Year) 



AC.K 




,0 . (u )'i'iii\ 



Mi'fit/is ". Days 



'^TVf,I,K. MARKIKI) 
WIDOW HI) i>k l)I\<>K(i: I) 
Wiiti in Micial <lr>i!^n:itii)ii ) 



HlKTMPLACl-: 

iShitc or (Jounti \'i 



NAMK OK 

J- A r 1 1 }•: R 



niRTHPl.ACK 
<>l" lAlUKR 
(Strife or Comitrv) 

MAinitN NAMK 
OF MO'lUHR 


lURTHPT.ACR 

Ol- MoTHKR 

f State or Country) 




I go ~K 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DF:ATH 

m4^ H 

(Montfi) (Day) 

r III{RI':nV CKRTIFV, riiat I atUnde.l (lecoasc«l from 

190 to I90 

that I last saw h alive on • it/) 

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

M. The CAl'SI': OI- DIv.VTH was as follows: 

J. \s^..JU\.\j 



Mouths 



Days 



DrR.XTlON Yrars 



CONTRIIU'TORY 



DTRATION 



"^ 



Vcars 



Mouths 



Days 



OCCT'PATION 
A 



'fsidrif in S(ui f'niiuiyrty 15 Vfrtrs 



( SIGNED ).J./VJLdJLA-CC 



lt.C 



OJY^^'\lA.\^ 



dX_^l' - :'X T 



qo 



(.Address) i9 Ob 



3jtv.t^: 



~\ 4 



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



Mnllth^ 



/hn. 



IHI-: AHOVK STATF:!) PKRSONAl, I'A R f KT I.A RS A K l- IKlK TO TIN-; 

i«f:st of my knowi.i'.dcf: and i5i:mi;f 



Former or / -lo 

Usual Residence bo" 

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



(\ 5 J How ionq at 

N^'acR<tO>\^ dl Place of Death? 



Days 



Jnfoiniant 



(A(l»l 



rcss 



R^b 



FI.ACF <)1" lURFAI, OR RI:Mo\AI, 

) 1 •• R T A K f: r Ml Xo^^-v' vt O-^Hk U i-s^ 

%^% eu.. h 



datj: of iiiRiAi. or ri;mov.\i. 



INl 



;!!■ 



It,. 



I 




^A.ldifss 



1 




N. B.— Hvery ite.n of informntJon •houid b. cnrefully «uppl5ccl. A(]B Hhould be HtHtecl F.XACTLY PHYSICIANS «hould 
Htate CAUSE OF DEATH in plain terns, that it may be properly classilfled. The Spec.al InVormat.on for per- 
sons dyin^ away from home should be ftiven in every instance. 



ts • • - t 



i I . 



t ■ 
t 



,i'?# 




i|!= 



f 



■-«. 9« 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



p.,,n.1 ..f ll.:.l!li I'N'i- i> t^^^J^r-tl'C-o 



Ji 



l)((lr /vVrr/, C)X vtx>^vl^V IH 





tx>^vu 



100'\ 



Be^istered J\^o, 



JG30 



\>u Deputy Health ORlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. StanDarO ) 
in A.A , . 1 N A \\ n ii ct^ ru,^ ^fi 1, 



PLACE OF DEATH: — County of ^ CV>\ J Va^XCtiCt City of<3<X>\' \am.CW6 



Ne. \w.UwtL ^'^ \^^r\XVJA,{ V[\ \ Ul> i^tUA^ St.; Dist«;bet« — — and : 

( /■ IF OtATH OCCUnsrAWAV FROM USUAL R E S I D E N C E G I V E rACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N" "N 
J V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

1(^1 1-1 



1 



FULL NAME 



/ 




^i\jay\JXJ^ vAX>^^ ' ^ • ^ ' 



PERSONAL AND STATISTICAL PARTICULARS 

si:x A -^ y \ coi.oK ^ 

y\)\xxL . ' Ujjr^-L 

I'ATK Ul- IJIRTll "^ ^ 

Llkv^l %l r%X% 



(M.jiilht 



(Day) 



A(.K 



I b y.a,s 



M.»ilh> 



n 



(Vciir) 



Da 1 



T 



MEDICAL CERTIFICATE OF DEATH 

DATK <)1- DHATFI I 



(Montft) 



,11 

(Oar) 



(Year) 



^FM'.I.K. MAKklKI). 

unxiwKi) OK i>iV()Rrj:i) 

Wiittin '-•x ial (K'siv^natioii) 



niKTHl'I.ACK 
'State or Cminln'^ 



N'\MK <)J- 
I- ATI! IK 



Am. 




<XVu'vCtA\<X 



HIKTMI'I.ACK 
OI- l-APHHK 

'St.itf or I'lMititrv^ 



MAIPKN NAMK 
OP MOTIIHK 



mKTin>r,ACK 

<M- MOTHKR 
'State or (oiiDtrv) 






1 liliRI'iP.V ClvRTIFV, That I attended (Icccase*! from 

Cl\\\' W 190 H to clXJ^t. i.L....... 190^ 

tliat I last saw li .t.)» alive on O^.xtT. .11.-... 190 . 

aniitliat death occurred, on the date stated above, at 6 ' ^' 
...y M. '.The CAI'SI-: Ol- DI-IATII was as follows: 




Dl'RATION Years \ Mouths \S. Days 
CONTR I FU'TOR V • • 



Hour. 



OCCri'ATlON ' 

/\'i lihil III V,;;/ / 1,111,1^111 




DIRATION 



(SiGI 



)'faj'S Months /)ays 






.uoniiii 



Hours 
M.D. 



I()0 "' f \ddrtvs) 



Special information nn'y tor Hospitals, Insfifutions, Transients, 
or Recent Residents, and persons dving away from home. 



ULu^v^! 



Y,-,i 



Mniltln 



I 



iiii: AnovK stmm:i) i'Kksonm, i-xktkti.aks aki: tkik io inj' 



ni:ST <)I< .UV K NO \\- 1,1:1 )(-.K AM) WVAAVA- 



4 






Former or 
I'sual Residence 

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



VKa^^ 



How long at 
Place of DeatlJ ? 



Days 



I'l \ilV Ol- I?lI<I\r. OK KI-;mo\AI, I DAJI.o; Mtkiai. or Kl.MoVAI, 

7^ ■ " 



^bii-m.tt.v,M. 



'A<i.lre««« 



N. B.— Bvery item of inWmatlon .hould b. carefully Hupplied. AGB nhould be stated F.XACTLY PHYSICIANS nhould 
state CAUSE OF DEATH In plain term., that it m»y be properly clan-ified. The Special InVormat.on ?or p.r- 
sons dyin& away from home should be ftiven in every instance. 



/.'i 



. 



Mr 



I'l-. 



I^i.) 



tf 



If 



'1 







i\' 



fi 



J , 



1^ 

^1 



if 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H..Mr<l nf ii,;.ith J- No r- -T^'t^^^U^ScV C<, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






L^y 



Begisferecl J\^o. 



1631 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. 5. Stan^arO ) 



I 



PLACE OF DEATH: — County of J (X ■ v ic .'-^"M 



City of 'X^c H.Lry\' V^o^ 



k:t( 



No. 



St.; 



•Dist.; bet. 



and 



/ \F DEATH OCCURS »WAY 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 Aju^^avc^ jL .Ctvhxicna ^;uxvcv\JLa.T\A 



PERSONAL AND STATISTICAL PARTICULARS 

SKX ^^^^ - jCO. 







DVTK or I'.iK rn 



Ar,K 



<M..iith) 



<Dtty) 



r%^^ ... 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DICATII V 

c) 



(Month) 



131 

(Day) 



(Year) 



bH JVv;.> 



11 



.!/.'>////> A /hn. 



•^iSr.t.n. MARRTF.n 
WIDnVVHI) OK DIVokiKF) 

NKiittiii v.)ci;il fl< si},rii;,t iiMi ) 



nrRTiTPT.ArK 

M;itr or CumUry t 



NAM J-, oi- 
I'ATlll.K 



(\l ft 



niRT»IIM.ACH 

OI- I aiiii-:k 

•"■t.-itr or Cotintry) 



MAIIil'N NAM1-. 
OI MoTlllvK 



I'.ikinj'T.ArK 
•»i' MoTni'.k 

(Slate or Coiinlrv) 



nrrr PAT ION 



,OK 1^ 




I JlIiKJ'^HV Cl-RTII-V, That I attended deccascMl from 

.; i^-::rr:'7..::. to ■ •• up 

that I hist saw h "^ — alive on T(,o 

and that tU-ath occurred, on the (hite »^tate«l a])ove, at " 

-::-— M. The CAl'Slv Ol" DIIATII was as folI.)ws: 

'^.^s^yx.^x^ LL..Ctr\^:.\.v.cL 



DIRATION i'rars 

coNTKirirToKV ........... 



Months 



Days 



Hours 



DT'RATrON 



) 'ears 



Mi)>ith<s 



/hivs 



(SlG 



Kf^idt'il III SiDi / iiiiiint'i) 



\.^X/WJL\' 



NED) JU \). U (HAA'fVMJ-tr'vtkj .Lelfryyi 
(..\d.1rc.s) ^^^Ci^.U .' 



Hours 



M.D. 



dji^"^ '-^ »<)"' 



Special information on'y '«'■ Hospitdls, institutions, Translfnts, 
or Recent Residents, and persons dying andv from home. 



)■/•(// . 



Mmitll^ 



/>.l\ 



former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



iin-; AHox].; spa ri:r) i-kksonai, i'akii'Ti.aks .\ki; TKri-: to thh 
ni;sT Ol Mv KNo\vi,i-;i)r, K AND iu;iji:i" 



^Infoiniaiit 






PI.ACH OI MIKrAI. OK UHMo\ AI, 

c:^ l!^ "^^ ^JAAAn^^•^te^ ' ' 



Dvri: o! \uh\\\. oi ki-;mo\aj. 



\\L 



190M 



INDHRTAKl-.K 



rtrV 



1 







■^"tvat<.t!rv.\. VA-' 



.tatc CAUSE OF DEATH in pl..ln term.. th». i. m», be p-.perl, cla.».fleU. The 8pe.,»l In.orn.«t,.,n !or p.r 
• on« dylnt owajr from home »houl<l be ftiven in every inntnnce. 



f 1 



.,1 



1^1 .. 



t 



'!! 



I iin 



I SI 




I J 



■I ; • 



#1! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)'„r,!,l ,«f 



ll.altl. t-Na. \^^'^^^^.nS^l'Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



?^ 



Dfffc rUod, G^l\tci-yvlM.V IH 



Jie^istered J\''o, 



i632 






1 |!p 



%% 



'L^vc^.o ixvM^. Der.-< . ' '.. Officer 

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 

Certificate of IDeatb 

( "CI. S. StanDarD ) 



PLACE OF DEATH: — County of ^ a>\- JVCt>vC^4cc City of ^^Ct>V J V<X>vcc.i/C^ 



^ 






N 



o. 1^"^^ IV^ CULkv^vatt^V St.; X Dist.;bet. -Va^fu^v 



and 




ti 



/ IF DtATH OCCURS AWAvWrOM USUAL RESIDENCE give facts CALLED FOR UNDER SPECIAL INFORMATION • \ \ 
\ ,F nFATM orriJRBrn Jn a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / -* 



cU 



DEATH OCCURRED «N A HOSPITAL OR INSTITUTION GIVE I 

(XXCka LccL 



FULL NAME 




'f ■ DC 






COl.Ok \ 



PERSONAL AND STATISTICAL PARTICULARS 

\r\V\-\ »iF niRTM 



Lll^vvCt^ 



iM-mthl 



CLL 



\r.K 



t 



I 

(Day) 



(Vear) 



M 



i\ 






Tl ,..,,,, H 



M,»ilfn 



I O /'" 



MEDICAL CERTIFICATE OF DEATH 



DATE <)K I)1:ATH 



..sJIlI\4'. 

(Moirth) 



13 

(Day) 



790 
(Year) 



\s 



HilST.I.K MAkUIKn. 
\VII)«)\\ J.:i) OK DIVOKCKF) > 

Uiittiii sorial ih •^iJ^n:ltil)n) I 



II 



* 



I'.IKTHPI.ACl? 

'Staff or Cntintry) 



» ATIIKK 



liik iniM.AVH 

'»' lATMKK 
SfMtf or Country) 



MAtDKN NAMF 
•>1 MOTHHK 



Hlkrm'I.Al'K 
'"• MoTHKR 
(Statf or Country) 



Ll tct^v^ 



s.. • 







cu^v<^ 



I HKRin'.V CJ'IRTIP^V, That I atteiKkMl deceased frntii 

'^V^l.>AX....X.l.i:lk.ig6. to ..A-JiJfX 1..^. 190 H 

tliat I last saw h -.' alive on DX^XV J C 190 '; 

ami that <leath occurred, on the date stated alK)ve. at 1^ oC 
...U... M. The CAISI^: ()!• I) I -AT F I was as follows: ^ 

±K>.:%jLo.>± 



1) 



"CCI'PATION 



a\X>^l\) vl^xvciva^vary. 



<x > vcL^ 




DT RAT ION *^ )'cars \ Mont /is 1 1 Days Hours 
CONTRIIU'TORV UJw^:\:vULa.. W..-..iX.'.vv cL 

^^..As^'UA^, -^ 

or RATION Viius Mouths Pays Hours 

(Signed) A/civ^w/Cu'^A.^^^ M.D. 

^Jl,\X\..-' U)0 (Address) 1 A ":>'.. ...». ^ 



Special information onlv for Hospitals, Institullans, Transients, 
or Recent Residents, and persons dving away fro.-n fiome. 



h'rudr.l III Sail I'laii, !'<<i V. )>'7/v I Mmilh' 



n,i 



Itn. MIOVK STATl-.I) I'KK^ONAI, PA KTICr I.AK<. A K l'. TKI I-! T 
Hl'.Sr OI- \tV KNOWIJ.DC. H AND lU'.I.Iia' 

'Informant vX ^IV M V| l\^\KA.^^{n\) 



o IH1-: 



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Days 



' \<Mr(-^s 



^'^H^ 



(\l^a 



.^ KxA-vab. 






I-I \CK OI- IMKIM, OK KKM«>\ Al, I I)\l>:ot HrKi.M, or KHMOVAI. 

,n..i.:ktakkr 0\ ■*^^-'^<^ '^ ^« _ 



state CAUSE OF DEATH in plnin terms, that it may be properly dassmca. 1 

sons clyinft away from home «hould be given in every instance. 



i 



I 



1: 



[sf 






H 









10: 



li M 



U: 



m 



I , 


1 






' 1' 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffr Fi/rf/, OxUtXAAvW\' IH I'^OH 



Beglstcred JSTo. 



1633 



"^c 



•J? 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( "U. S. 5tani>arC> ) 



PLACE OF DEATH: — County of Ca^nj 0,Va>vCi4C< City of i^ ' (X'vv a) XCVYwtvA ' ' 



;^ 






N 



7s. 



St.; 



Dist.; bet. 



and 



/ ir orATH OCCURS AVWAV FROM USUAL R E S I D E N C F. 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 




CUfO-C 






si:\' 



PERSONAL AND STATISTICAL PARTICULARS 

CO I, 



''W 



<x\ji 



_ ...,UJ>K4.tji 



!»\l 1-; Ol lUKTll 



iMunth) 



n>ay) 



(Year) 



A«',H 



MEDICAL CERTIFICATE OF DEATH 



DATE OI- DlvVTH 



.C^jL/lAit 



(Month) 



(Day) 



(Year) 



I H1':RI':I'.V CI-RTIFV, Tliat r atteiiiU'd deceased from 

— . to 



I90 



190" 



'-iNf.i.i:. MAKi<n:i>. 

UIlK>\\i:i) nK I)l\»)Ki'l-:i> 
Uiitc in sKcial Ucsiiinatioii) 



) (•(/> .V 



1/ 



./;////> J\ \ 



/'<n 



'State or rountrv) 



NAMl-: 01 
J ATHKK 



HIK'nilM. Al'R 

Ol" iATm;K 

•state or ("<»intrv^ 



lU 






? 




1) 



<il" MoTHKR 



lUKTMI'LACK 
Ol- M()Tin:R 
'State or Country) 



^ J _ 



that I last saw h •" "^ alive on up 

and that <leath occurred, «)ii the date staled above, at "~ 
.— -M. The CAl'SIv Ol' DlvATU was as follows: 




)j^K^\^<LA--<^JL .,..,„,„„...„......„.„ 



I) r RAT ION )'('tirs 
CONTR I r.r TORY 



Mouths 



Pays 



//ours 



Mouths 



" >CCUPATlON 

Rf^idi'ii ill Sill! /'i <i III isro OO )riJi^ 



(SIGNED) L^rXOViA' 

Oxlxt 1^ TooH (Address) V.atn2\,5 I..'.;.. 




/hri'S 



/lours 
M.D. 



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



Moiifh^ 



Da 1 - 



Usual Residence 

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



Former or 1^^,^r, \^ r^\ A "^ !!r'Tn''*»K7 n 

iic.,;,i pp.irfpnri. '^ I a1 vCVtCr ^Jt Place of Deatfi? Days 



rui-: AHOVE STATKI) J-KKSONAI, rAKTUT LA KS AKl- rKfK TO THK 

iu:sT Ol' MY KN()\vi,i;i)('. H AM) i{i-:i,n:F 

f Informant C'A^V^Vv^^^X.'Ow J . wivCW'C^ V . 






f \(M 



re><s 






.(X 



I'I,ACK OK lU'KIAI, OK KKMoVAl, DAllloi Uiki.m. or RlvMOVAI. 



INDKRTAKHK .H^ -O^U tjUV ^^i ^ 



TOO 



(Address 



State CAUSE OF DEATH in pinin terms, that it miiy be properly ciassmea. i 

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



W 



V 



< I t 
I 



M 






i u 







f# 




I: 



*l 



iUk 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



**: 



,f n,;,!th »■ Vo. ^' -^-jaewi*-. I'.8:rO(. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Kegl'Strrrd JS'^o. 



1634 



^IjKxi^^ Ix ,^ J Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 



Certificate of IDeath 

( n. 5. 5tanDarc> ) 



' 



\s 



n 4 N V 

PLACE OF DEATH: — County of a^ J,VCX>xCv4c^ City of ^^<X>\- O^N^CLAvCuLOO 

No. GlC) "OXaVu St.; 1 Dist.;bet.^Ua.\K,rtWl>vtkand V^\X4. ) 



rXa\u St.; 1 Dist.;bet.i-ta.\K,rtWl>Vtla 

/ IF DEATH OCCURS AWAY TROW USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL ' ^ ^O R M AT . bJN ' ' \ 
t IF DEATH OCCURRED ^H A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME Lt^^>xU.cx^ 



vjux^ruxLc 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OK \ 






iLlvdjc 



DAIl-; <»l-" ItlK in 



iMonlli) 



A<.K 



'"I 

1 



5S 



J Vi; » . 



dJay 



M.'tillr 



rl5\ . 

(Year) 



/>f; ) 



■^IN<". I,K. M\KkIi;i>. 

u ii)i»\vi-:i) nk i)iv((k('f:t> 

U'litcin >.iK'i;il (U>iy:t''''ti'>ii) 



MIKTHI'I.ACE 
'Stiitf or Crmtitrj') 



^ 



w 



■x\/^->-cL 



NAMi: Ol 
lArHKK 



iiik rniM, Ai'H 

•>l- I'ArilHK 
'St.ttf or roiiTitrv 



.Do n ;^ 



MEDICAL CERTIFICATE OF DEATH 



DATK o}- i)i:ath 



r)xlvt 



...c 

(Montlf) 



11 

(Day) 



iVcar) 



] HIIRI'.I'.V CI'.RTII'N', That T atlcn.ltil »UM'(a"^e(1 from 
"^.JU^ i.l 190 H to ^X<^vfc iX i(>o S 

tliat I last saw li • • * alive 011 C -AL.|vt: \X up H 

and that <Ka(h orctirrc*!, on th(> <latr statr.l ahnvc, at JO I 



....yr. M. Till' CACSlv UK I) 1: A I" II was as follows: 

iLK^lr^.cOi... 




"t 



' nvcKU 



!1 



li 



maii)i;n namh 

OF MoTIIHK 



iukthi'i.ack 

Ol' MOTIIKK 
^Slatc or C()«imry) 









? 



Years 






CONTUIIU-TUKV iLcj^. S^^ 

\L.\v.i^'A)"^^i^ VxcX fri -i.Uv|\, 

DIK\T1(»N )'riirs Month's Days 

\ ^ 
NED )......4^/ V. 



//<J//;■.s 



IIou) s 




OCCUPATION (jNp 1 

I'm: AMovH sTA'n:i) i'Kksonai, i-au ih'ilaks akh rKt k 10 Tinc 
ni;>>T Ol- MY kno\vi.i;i)(;k AND in;Mi:i'' ^ 



( SIGNED ).....^3.- V. ^}Jo^'\\AJr\\.,, M.D. 



SPECIAL INFORMATION ""'y '"^ Hospifdis, InNfifufions, Jrdnsipnts, 
or Recent Residents, and persons d>inj .iwd) Iro.-n home. 



former or *t^ l /> V/ / 

Usual Residence I I ^ XM. vu. 

When was disease confrarN, V 

If not at place of deatfi ? 



k 



flow lonq at 
Pld< p of Death ? 



Days 



^ln f'MiDnnt 



^N.i.h.ss ic'l D J ^.-<^ 



4 



n ic-i.- <)!■ lii KiAr,.»K ki;m..vai. i.aii-,..! i!> hi.u. <.i ki;M(.\Ai. 



«totc CAUSE OF DEATH in pinin termH, that it m»y be properly Uiihhiiicu. 
«on« dylnft away from home nhould be ftiven in every inHtnnce. 



I 



I'll ■ 



I •( . 



M'i 



:% 



Ha 




■ ? 

1 ■ * 



I, "'f 



\v 



]t 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



|I..iltli !■ So. i"^ ■5'i!'_^'W^~«». US:!' C) 



Registered jYo. 



\ 0:35 



.1* I 



^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 







PLACE OF DEATH; — County 



No. 



55 ii ^ 1 










A' 



Ccvtificate of IDcatb 

1 11. S. StauDarO ) 

St.; ^ Dist.;bct. Oxci^^-t^-C and d^' (tL^VU 



/ 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' ^ 
i, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




rLou cU A,\h^L 



PERSONAL AND STATISTICAL PARTICULARS 






Cnl.f >k ^ 



IIATJ-: nl lUK III 



1 



--Ka^ 



MEDICAL CERTIFICATE OF DEATH 

DATP: ok Dl-.ATII P 



(Moiitht 



AC.K 






i »■ 



J ViM 



^ 



(Day) 



.1 A ->////> 



(Vear) 






/)</ : 



SIXC.I.K. MARKIi:i) 
UIl>«>\VKI) OK I)!VnKri:i) 
'Write in >iocial fUsi>fiiali"iiil 



i ll 



lUk TIII'I, \('H 
iSlatf or CMimtrv' 



\AM1-: oi-- 
lA rin.R 



luk riii'i.AcH 
<>i" I AiniiK 

•Statt or Country) 



MAIUKN' XAMK 
t>F MoTIIHR 



lUKruiM.ArH 
<>!• MOTIIKK 
'State or Country) 



J? Q]) ^ 



dxkt 

(Monlhr 



1.1.. 



(Year) 



I IirUNlTRV Cf^RTIFV, That I attended deoeased from 

Uw^w^w.CV ...l5. 190 V to d^l^t \.X uyo H 

that I last saw h ^l^- alive on 6 JL^^pX l^ 190 • 

and that diath oocurred, on the dale stated ahove, at I 
U^ M. The CArSI'! OI- Dl'i.XTII was as follows: 

KX'Zk^JLL CL\jLXr:^.:<X<S.. U ^L^T^-V^^^-^-^^ 

i.CrLLo^,c^w>x.a^.. a.^t:^>-xl^^ C<5'W'Tj.rX' 



nr RAT ION 



)'t'(jrs ' Months Pays 



Hours 



&J^ 



WOl 




X>J\J^ 



(^ 



G,<XYv o X.<X>ve-v^co 





\ OJ\X\ CX\XV cL' X U-y V' ^-^ 

Q <X ^r\) K(X >^cuL.c.o 



occri'A noN 



Rfsi'drd in Stiv ft (ni< '--" 



) Vi/ / » 



M.-i'Hi^ '■.'•' f>"' 



C ON T K 1 JJITC.) R V LlAX^^i.i'VfrtSryr^A. ........ 



DIRATION )V(/;.v Mouths .Pays Hours 

(Signed) ^^liiAJi^cL vmI ol^^ M.D. 



r^oU- 



CU^ '^ TC,0^ 



^Xddress) t)10 ^JS 



A^-<>. 



SPECIAL INFORMATION onl> lor Hospitals, Institutions, Irdnsients, 
or Rcctnl Residents, and persons dying dvva> from home. 



iMi', AHoviv sr \-n:i) i'Kks(»nai. r xur u ri. \ks .\ki' i'ki »•: r'» 'i'"'- 

m;sT <)1- MV KNOW 1.1; I)'- H .XM> Hi-,i.ii:i' 



j>i-,.->i HI- i'.i > K.>.t >\\ 1,1-, i>« I r, .\ .> 
^'"roMi.ant ck. \D ^U 



XSAJL 



(A.Mrtss '?^-'^ H \ — 11 



.d;^ 



Former or 

Usual Residence 

When was disease lontrarted, 
II not at place of death ? 



How long at 
Plare ol Death ? 



Days 



I'l .\ci': t>i in Hi.\i, <•!< i<i;m")\.\i. 



l»\l}; .1! IJiKiAi. or Ki;.M< »\'.\I, 

^^ X\^ IS 190 



,. i ll 



:31 



, s.M,,.s(J SOS" Vm.^At.i:xi^^^ V.w\U IL' .. 



N. B.. 



T^ ,. , ACP shoild be Kt.ite.l i;XACrLY. PHYSICIANS should 



-livery item of inforin 

Htiite CAlISi: OF DEAT 

Hon. clyinft uwoy from home should be ftivcn in every inHtnnce 



i ) ! 



M 



M 



I 



II 




ri 



t i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



p., ! 



H,:,!i)i I' No !- ■*-^ar^r>nS:i'ro 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A 

/III//' Fih'il . J 



1 



:^^ivLv>^vi'^vv 14 



^r\j<.\^ cLUvKi, Deputy 



190^ 



Registered J\'*o, 



le'JG 



car 



N 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

t XI. S. Stan^ar^ i * 

PLACE OF DEATH:— County of ct^v J \ancucccity of 0,a>v vivaivcu^co 

o. ilO^S )lla<LOV St.; X Dist.;bet. U.O.lLit. and JAXtri ) 

"'^PECIAL INroRMATION" \ 



USUAL REolDENCE GIVE facts called rOR UNDER 



(IF DEATH OCCURS AWAY FROM _ _ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



FULL NAME 




^Tslh. 



I 



\^^ 



)il 



A.:.iX.^ 



PERSONAL AND STATISTICAL PARTICULARS 



^I'.X 



DAIi; OF JilKTll 







„,.„,. - ^ 



^Kctx 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



( M<-iitli) 



A<-,K 



\^^ )></»> 



Uay) 



Mnilhs 



(Year) 



Am 



StN'C'.l.R. MAKUn:i). 

\\n>M\vi:i) OK i)i\(>K(*Kr> 

Uiitriii MH-iiil <U^ij:^iiati'>ii) 



niR rui'i.ACK 

i state or Country) 




awo^cL 



VAMF OI- 
lATlIKR 



Hik riiiM.ArK 

«>I" lATHKK 
'St:it« or Couiitrv 



OF MOTFIHK 



niK'nil'LACK 
<»I- MOTHKR 

(State or Cojintrv^ 




..O.-civfc 

(Month) 



(Day) 



(Year) 



I ni^RMP.V CTvRTIl'N'. Tliat I atteti(lc«l (lecoased fmni 

....^:^',:vt ?..- iQoh to .0-4^ '^ ^'P^ 

that I last saw !l L- VH alive oti 0-^^\Zr \X up 4 

ami that death orcurred, on the date stated above, at • "" 

M. The CAUSR Oh^ DIvATII was as follows: 

1), oa\^vyx>y. .ij..ULCCXU Cr^ .ti\.^..2&^a^t 



Ycay:^ Months • Pays Hours 

•ONTK I lUToKV LJbA«^^^vr\w^<^...!..J^J'.:uuX^ 



DIRATION 
C 



DURATION 



Yean Mouths .Days 



Ww>\x 






OCCUPATION 



(SIGNED) % ^»D..LU 



Hours 
M.D. 



± 



"i » V 



Special information <>"'> ^'"^ Hospltdls, Instilufions, frdnsients, 
or Recent Residents, dnd persons dying dHd> from home. 

HoH lonq dt 
__.„.._ PIdre of Oedth? Days 



Former or 
Usual Residence 



/;,n. 



TUl'. AHOVK STA Ti: I) I'KRSOVAl, I' \ K I' HI" I,A R S A R l". TRCK T« > I"!-: 
H1%ST <)!•• MY KNnWI.J'.IX". K AND IIIIIJICF 



Oiif. 



•itnatit 






When was disease contracted, 
If not at pla(cof death? 



I'l.ACK 01- HI RIAL <)K KI..M<'N\I. 



I»VI1. "! Hi KiAi til Rl-;Mn\AI. 





t 



:^4vt 



NDKRTAKKR tcU^. ^C^^txXCj^^tto ^VC U) 

rA<l.lr.-s....W!H..^ I'..CUX4A.ti ... ;3A 



N. 



^ I- .1 ACF. Hhoiild be stated BXACTLY. PHYSICIANS Hhould 

B. F.very item of information Hhould be carefully suppl.ed. A''"^ «" ,|ossiV'ied. The ''Special Int'ormHtion" ifor p-r- 

Htate CAUSK OF DEATH in plain terms, that .t may be properly class.ne 



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



fl 



. u'i ,. 



I 1 

I' 



I I 



M 



111 



i ,. 





*> 



'^p?3j0«r- 




I 



'f' If ■' 



;Ff !^ 







w 



RITE PLAINLY WITH UNFADING INK 



)>.i;:i1<\ '■! 



ii.:iin. !•■ N'> !-- t"':.:2?;>-^:''H'^'' •-■" 



/> 



.^/r /'V7.v/,^^x\vt^^>vU^V IH 7.9rA 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 



Ee^isteved Xo, 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of IDeatb 

( TX, 5. Stan^arD ) 

cm i Of 

PLACE OF DEATH:-County of ^V.v J XO^^VCUCt City of OCblV O.Va^vCv^C^C: 



No. 



11% 



XI n ( (.'Kjmi (.Y\ I-Xrvdj (a. St.; % Dist.;bet. CiLlU\X>v and 



/l) 






) 



,,<=.,.! OrSlDENCE GIVE f«CTS C.tLtD FOR U N O E B -S^ECIAI. 1 N Ton MATIO « " ^V 
( " rr"o;':T°H"oCc"u%rEV,"r„o"s^."*' o"f~SnT""o°/o,VE ,TS NA«E ,.STE.O OE STREET .-.O .U»BEP. ^ 

FULL NAME ^< 



u. 



rw: 



PERSONAL AND STATISTICAL PARTICULARS 

coi 

DATi: t»J- lUKIH 



"i^>AX(xL ! lllivcU 



'"" liv 



'lOnr 



(M.)Mtll) 



\i.K 



^i\<.i,K. MAkuii:i) 

\VJI)<»\VKI> <»K I>IV<>K< j;i) 
•Writfiii MK-ia) <UsiK"iili<>ti) 



IC 



(I):iv) 



M.-tttli. 



(Year) 



1 



/^4i 1 A 



\^V LcWvxM^cL 



niKTIIlM.AOK 
'Statf or Coiuitrs'^ 



NAMF OF 

iathi;r 



lUKTlIlM.ACH 

<>i" iArin:K 

(State «)r cOutitry* 



MAIDKN NAMK 
€>!•* MOTHER 



lUK rul'LATK 
<>!•■ MoTilKK 
fsiate «>r Country) 



OCCITPATION TfU? 












L^wa 



p.-.;,r^,f i„ s.iu ri,n,,/.u-o 5 *! )>fT»< 



M,.i,tli^ 



lhi\ 



riii; xnovK sTA'D-.i) pkksonai, p^k ihti, ak> ak 

ni;sT Ml- MY KN(^\\■IJ■:^<^^ AM) lU.lJI'.l- 



<I-. TRIK 1" ' '"■• 



Onfiiiinruit 



ll.lO^-fc-^^ 



i, 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



Sxixt. 



(MotitTi) 



.1,1... 

(Day) 



I go 

(Year) 



I HKRKHV CKRTIFV, That I atU'n.k-.l «leceascMl from 

to .-.'. '■ - -- .-.— rrr....i9o::-^t^ 
. -: .- .: :::: I 9O ."r"— 



- . : —^. ~ . .. " " -.:' :' : -■- ■ • 1 90 

that I last saw h n—- alive on 



an.l that acatli occurrcl, ..n tlu- .late statcl above, at 
— 1VI^ The,C.\> SI'. Ol- DICATH was as follows : 



Dlk-XTION Ycar^ 
CO.NTRir-rTOKV 



Months lyays 



] lours 



cars 



Months 



Pays 



(SIGNED)...^ i^. 10, liUvvdCc^rjxJv 



Hours 
M.D. 



rbiAt 1^ tm^ f.\.l(lre>;^) 



QprciAL INFORMATION onlv for Hospitals, Institutions, fransifnts. 
or R^rent Residents, and persons dyinq .may fro^ home. 

HoH lonq at 
Former or p,^^^. ^,1 ^^^^^1 Days 

Usual Residence • 

Wfien was disease contracted, 

If not at place of deatfi ? ^^^__ 



•LACK OI- m-KFAKoK KHMOVAI. 






1 , 



i»\i'j" '• Ml KiAi. or ki;m<»\ai. 







fVl.lro.,. ^"X?" vJaX'-V ; 

■■•■I— «———■— '^■"■■'^ j f XACTLY PHYSICIANS Khould 



-l.very item oi inic»rm..».".. - •- j^ properly 

state CAUSi: OF DIIATH in pl"." crms. tha '»";'; *^ InHtance. 
«on, <lylnft oway from home nhouUI be fe.ven .n every 



) 



ir^' 1 



' I 



I ' I 



I. 






WRITE PLAINLY WITH UNFADING INK 



lUO'i 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

Ec mistered A^o, » 6^8 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc of Beatb 

( "U. S. StanDarD ) 



(^ 






PLACE OF DEATH = -County of JC^^ J.Va'>xaitt City of -a'>xO.Va>xtc^Cx 



til 



4 ^"^'t 



No. 



5 5>0 Ldd 



/ 5v Dist.;bet. laVKc/\\ ^,- and 




^rVHi,. St.; A Dist.;bet. xccvr^v^w ^,- ano -^w-l 

I 1 I —' \ I . 



,Ll/cU 



FULL NAME 




tcNji^vxa 



1 

Vw^ 



> V>^u 



i 



IXCtlvK 



\ 



ii 





i: 



PERSONAL AND STATISTICAL PARTICULARS 



'OP rt 

DAI'l-: nl I;1K IH 



C<»l,«>k ' 



LivlI^ 




(Month) 



:x^ 



I 



/ 



t^^ 



a<;k 






(Day) 



Mnillr 



H. 



(Vcai 



/^</v- 



«^I\<n,K. MAKKIKI). 
UfDOWlrl) OK DIVOKCI:!) 
Wiitciij social «ltsiKii''it'''n) 



lilKTUJ'I.AOH 
*St:iti- or Country 



lATJIlCR 



LI' tcUr 



W^ 




i^ 



i\' 



lUk llM'I.AiK 
n|- l-AIIIHK 
'Statr or C()\ititry 



MAIDIvN NAM1-. 
OF M()1MI1-:k 



lUKTHIM.AOH 
<>|- MOTHHK 
(Statt or l"ounlry) 






OCCUPATION 







1 



K,->HUd III San /•<.;;,'. /V" i D 



5V 



\ /,'/////' 



/',/!. 



TU1-. AnovK sr \'n:i) pkr^onai i-ak iutlak^ 

Hi:ST Ol" MV KN<)\V!j:i)<". K AND Ml-.I<n.l- 

5^0 Lct<^^ ^^ 



AKi: TKIK TO THK 



(I 



( \<l<ln-ss 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII ^> 



(Month) 



X /p^ 

(Day) (Year) 

I IIHRKBV Ci:RTIi'V, That f attendcl .Iccoased fn.tii 

:V\3.\^. L i9o3 to ...A^Wt I X icK) H 

that I last saw h ...^. alive on cS-^|^t l^ 190^ 

an.l that .Uath occurred, on the date state.l above, at aA'^ 
T.X{iO.M, The CAIS^C OF Dl'ATII was as follows:, 

jL>vs/yvViULuXAX COxwU 1?^ d.'wXXUi " 

Dl-RATK^N years' Mo,r//is\ Pars Hours 

1 *■ 



C(iNTuii;rToKV 6-L'v(r.vvc^.o^^tui a.uti 



(SIGNED) ■y^.^i , JVa>VC^ ..,....^.... 

C^Xktll TQOS (Address) ^^3 v^caM-i '-. 



//ours 
M.D. 



SPECIAL INFORMATION only tor Hospitals, Inst.tul.ons. Transients, 

or Rerent Residents, and persons dyln,| awav from home. 

How lonq at 

Former or pjare of Death ? Days 

Usual Residence 

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






I 




av. -4- ^^ I :A^^:fc 1^ Tool 



INDI'KTAKI'.K 



^ ai.i.txd \'L C^ 



(A.M,.ss ^Hb C^Ui^^^-e.^ 




^\ ■ ^ , cvArTi V PHYSICIAINS should 

N. B._P.ve.. iten, o.' 1n.>n..,..1on «HouU. He .arc^uM. ^uppMec. ^:^:::^::^^, The "Special ,n.'o..a.1on-' .'on p-r- 

state CAUSE OF DEATH in pinin terms, *»;«•*";•;* instance. 

son, dyini away from home should be ft.ven m eery 



% 



I ( 



« . 




« 




m\ 



, > 



i, 



Hi 



m' 



Hi 



• II 




n< 



,,:,,,! ,,f II. ;ilt)l 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,. ^,, „ ^:^^^, nF.V Co REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

1 639 







N. n 



iry^n 



Registered J^'^o, 



\a/v^^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Death 

I "a. S. StanDarD ) 



Q^ 



PLACE OF DEATH:-Coun,y of ^^CU.^.lva^ve^C...Gty of Oa^^' J . VO, VAA^V^ C<) 



, ^ , , , vv- :>t.; ^ Dist.; bet. V.' cloA^^^ and CH^^Ci; -•. 

V ,r OC*TM OCCUBBCD IN * HOSPITAL OR INSTITUTION GIVE ITS ri«nn ^ 



1 

No. 150% '"^x^tU 



FULL NAME 




.LL^^LCX■^\i 




OtC^ 



si:\ 



^ 



PERSONAL AND STATISTICAL PARTIC ULARS 






CO I. OR \ 



I»ATK Ul- llIKTIi 



0*w- ' 



'XC 

• Moiilh) 



A'-.R 



11 



).•<;».< 



I 



(Day) 



M..>ilh^ 



(Year) 



IH 



A/v 



SIN«;i,K. MARKIKI). 
\V!!>o\VKI»oR DIVOKiKI) > 
U'ritt ill MR-ial <h?ii»/iiali'»n ) 



HIK IHIM.AOH ^ 
I State or roiintry^ i 



.cLcrvU" 



\\Mi-: oi' 

! ATHl-.R 



lURTHPI.AOR 
Of l-ATUHR 

istatr or (.'ovintry) 



MAim'N NAMB 
OI- MOTHKR 



HlRTHIM.Ari', 
<H- MOTHKR 
(Slatt or iNmntrj'^ 



OCCl'PATION 





ft y 

Kr-uini II, Sail /■ i ,uh /^ro ■.<. Z^ '"^'' ^ 



/',n.v 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



uxl-vt. 

(M<iiit'li) 



..11.. 

(Day) 



(Year) 



I HEREBY CURTIFV, That JattcMi.kMldccoasea from 

.UV.CU i.^ 190H to c^A^ i-^ ^^^ 

that I last saw h ./ alive on ^^^ '^ ^90^^ 

and that .kath occurre.l, on the date stated above, at I O.C)^^ 
' M. The CAl'SIC OF D^vATH was as follows: 

a^^j^\k<xix^.^^^Shf\.o,^^^^^ 

DrRATIOX rears \ ^/-M^ '^ ^><0'-^ ^^^'^ 

CCJNTRII'.rTORV iltLih^-t^^^^t^ 

4 &i(^^A).u^ii^ 

dVrATION :^ars ^lA./M.v Pays /fours 

(SIGNED) l.'i a^»^H^^>' '^•^• 



C\a\x^ 12= >r-^ TAchlress) ^5\ v-'Av. 






f 



SPECIAL INFORMATION fv lor Hospitals, lnsti.u.i.i.s. T«ns,cals, 
0, Refenl Restdeols, and persons ifm a*a, Iron, Urn. 



How long at 
PJar e ol Death ? 



Days 



Kr^idfd III Sail II aiii /"'' > -^ - ' '" 

TIIK AltOVKSTATK!) I'KRSONAI. l',\ KTI<-r I. AKS A K 1- TK 'H 1«) 
Hi:ST Ol- MY KNOWKKIX.K AND HI. Mil- 

(Infonnant VjL^UJ V V)ll<X.<^< 






5L501 O'C^tt) dt 



Former or 

Usual Residence ••• — 

Wlien was disease contracted, 

If not at place of deatti? . 

Tr^CKorm-K.M.ORKKMOVAK U^^H .f n. K..I. or KKMOVAU 



, 6xWt 1..H ■_-.J90 

C)->-pJL_Oi[^VU.<^-^--- ^ — To 



¥ 



rNDHRTAKKR ^^ ,^^ -A ^ 



__^ K * I FXACTLY. PHYSICIANS should 

«tate CAUSE OF DEATH !n P'«1" ^^T-"': l*^" /^.^o rnstance. 
«an, dyinft away from home should he fe.vcn .n evcr> 



''-? 






^ 



' I 



I . 




Ill 



I 



|ii 



!) 




ti 



;,3 



Mil 



WRITE PLAINLY WITH UNFADING INK 



H..:r 



,1 ..f H 



, ;,Hh -IN'. It 1^-^^^>1>&1'C.. 



/>^//f' /v/f'^/,6xAvtj^>^U-i>v IH 




cvXi 




7,9 (^> 4 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

16 



Registered A^o. 



Deputy rl elth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of IDeatb 

( "a. S. Stan^arD ) 

r^.CL^^' 0.\.(XYv=\A:Cc City of a^\; a,fuv-vvc.v4.tc 



fi 






No.lHC^S'^jldLv.vUat^Uxs*' St.; ^ Dist.,bet.Oa^^^^,,,: .ndVJ.Li^^<^ ) 



r?}?^^^^:-^^^ ?^?^?j^^^";^^^'5;^«^ ^^" s?;^e;-i:;=r ■ ) 



FULL NAME 




-VA^LccvAxu.. 



PERSONAL AND STATISTICAL PARTICULAR S 

vix^-vc^u. '- - 



LUJvcti^ 



\' \Ti; «»!■ iiiK in 



Month I 



/i.1,1 

(Day) (Vear) 






M'.K 






M.'iith^ 



Davs 



SrNr. 1.1- MAKKIKD 
\VII>n\VKn OK I)IV<»Rt'Kn > 
Uiitriii MH-ial <U •»!>.' n;i lion) > |\ 



!UK rm'i,AOK 

(State or Countrs") 



I A imi;r 



i'.ikthpt.aoe 

<»|- I ATMKR 
IStatr or Coutitry^ 






T-Ouy\j 




MAIDKN VAMR 
01- MoTHKK 







IURTIIPI,ACE 
<>t MOTHKK 
'Statf or t'oiiiitrv) 



CXnjJLa >%cL__. 

OCCUPATION 

kf-itlril III SiUi r'liiiiii'O VD 5 /-'M > ^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH J? 



(Month) 



ja iQo'\ 

(Day) (Year) 



I HEREBY CERTIFY, ThatJ attemlcl deceased from 



..SVt^U 



\ 



^ 



k.b 190 \ 



.jSS.. 



to ...^.X.'^-\.t' 1.3 1 

^X^^t l^. I 



that I last saw h-^^ alive on 

and that death occurred, on the date statol above, at 
XX M. The CAl'SE Ol' i)I^AT^ was as follows: 



90 



(iUvtvod 3^A^^c|^^<^^-^ex^.4^ '"''^•^ 



nr RAT ION }'rars Monl/is 

CONTRIHUTORY ' 



Days 



Hours 



■'V 



(SIGNED) 



it. 



Months 



^^X^xfc ''^ TOO ^ ( Ad.lress) 1 5 



Days 



-v-vcVtv 



Hours 



M.D. 



%HVll\avk.d ^^ 



M,,iith^ 



Pi! r> 



THK AHOVK STATK D rKRSONAI. I'AKTU- T I.A KS AKK TKrK To THK 
HKsr OK MY KNoWM-.nCK AND Hl.Mlvl- 



(li 



ifotniant LXXX^V U "L 



Q^^<^JL^'\)oJU^OJL^' 



rxddrt'^s 



ISOH 



"xinxijiAv vWti'd^^^ 



ipECIAL INFORMATION only tor Hospitals, Institutions, Transients, 

or Refent Residents, and persons dying away from home. 

How long at 
Former or ?\m ii\ Death? Days 

Usual Residence ■•"•■ 

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



"iM XCK OI- lUKIAI. OR KKMOVAI. 
U.AC*- , ,^ 




DA'UKof Hi KiAt, or RKMoVAI, 

OX^vtt.....!^.--^ T90 . 



rXDlCKTAKKR 







,._^ ^ , FVACTLY PHYSICIANS should 



,.a,e CAUSE OF DEATH In p....n «"•"»;;;; „.;;;; -.n.t.nce. 
son. dyinft away from horns shoul.l be »■>«" in . e » 



w 



1 / ; 



i. 



1 



s 



• ! 



f( i : 




#1 



it 






i;.i:i:' 



WRITE PLAINLY WITH UNFADING INK 



/lafr AV/^v/, nx|^tjL\^vlv^V 1 't 



IfnjH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTtONS 

""" " i 64 J 



Re^isteied jYo. 






"^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc of Wcnth 

I X\. 5. Jr1tan^ar^ ) 



1 n AM v)> 



PLACE OF DEATH: — County of .a>^ o^^va^X^UCc City ot 

M.K'XaL St.; 



.t:v ^ 



^LC^^Xu. 



No. '^^Ul ^^ verve ^Vt^, ^^^l ^■^^^\,fiV^cEC.Vr ^ACTS CaI *.0 .OB UNO.B 'SPrCAU .N.ORMAT.ON- ^J 



and 



FULL NAME 



CduKxxd ^huj^x 



■I'.X 



PERSONAL AND STATISTICAL PARTICULARS 
;.\ I H oi lUR I 11 



V .Vvttc 



LI»c^C 



M until' 




\C.K 



4?. 



) v.; > A 



SINT.!.!-: M\KKn:i> 
WIDOWKI) OK DIVnRi i:i> 

Wiitciti «i<Ki.il <li«.i>fn!iti<m) 



dxv 



State or ("ntijitryV 



\ \ M K OF 



lUR'llllM. \i"H 

<»i I \ nij-.K 

(Statf or foimtry) 



^ 



1 



(Day) 



A 



(Vcar) 



% 



Da v.v 



DATE OF 



MEDICAL CERTIFICATE OF DEATH 

?\d:± lA. 



IX'Vvt 

(Monni) 



(Day) 



(Year) 





MMDI-.N NAME 
<»1- M()II11:r 



I'lk'niPT.ACK 

ni- M()Tm':R 

I Stiitr or Conntrv) 




\ 

UA'V 



U\UKLU 



A 



OCCUPATION 



\ 



"AvoJo-t^'vx^' 



(r\U.KU.L 



.^0 



); ,11 



•> U,M//A> 



/),.M 



I 111: 
1 



Rfsiilfif ill Stilt /'i till, /^•■■' 

li:ST Ol' MV KNOW I.l'.lx.li AND Ml.IJl.l 



InfoMiiaiit 



? 



vJXccbo 



( \<l(li<'s*< 






Uc^ 



(V-CLh.'J.^. 



1 IIl-Rl-HV Cl'.RTIl-V. That ,1 atten.lr.l .U-cvascMl from 

i4>± H 190H to ....-la^t .. i^ looH 

,,,t Mast saw hU>. alive on ^4xt ^0 i.p\ 

an^hat.Katbocrurrc.l. ontlu-.lat.<tatc-.l above, at 
(r M TUo CAlSli. OF DKATil was as follows: 

^ -vL 



I' 



K.O^ 



"cCCr^K^V- U.rVxiAA.:^-^-^^!^"^^"- 



nr RAT ION 

CONTRllU TORV 



Years 



\ 



.CC^X^w^u<U:^^» 



I /outs 



^Months 



Days 



I lours 



f SIGNED ) >J^ J^- '^^^^ ^ >i..: 



A«l«lrr«s) >>-^*"H 



^Xi^jb 1^ TqoHj i 



SPECIAL INFORMATION »"!> I»- "o.pil.ls, I.Mi.u.ions, Iransie..s. 
fe«uiMrnts!7.< persons dying .mny Iron, hon,e. 

\ \ . y 1 Ho\t lon(| Hi / 



or 



D.IVS 






When was disease (ontraded, 

If not at place of "J^ath ? _;_. _ ,.,.^. ,..., 

dxv^v^-'^Y^ ^ .A\,) 

r N I > i: K T A K »•; p ^ ^^ f ^ 






,<^'. 




be Ktnte.l hX^CTLY. 



PHYSICIA'NS should 



N. B. I-very Jtem «f •.nf<.r.n..t.on -hoi.M b. -«. ^ ^ ^^^ properly cIoh«.»icU. 

«totc CAUSE or DEATH in •' "';,;;7;:;,;w, every in«t»nce. 

-„— ,!.,:« A „«,nv from home should l>c R>>«^ 



«on» (lytnft oway from 



f ■ •,* 



>'' 



I ■' 

■ -it 
1 



1 



i 

■■ I 



w 




tt 



'I 



i I 



' 1 



§11' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



l{,,,n,l of l!<!ilth- I" 



Vo. 1 ^ "f^^^^ HS: r Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f 



/r W^v/, dj^vtxY^vt^ 1.H If^O'i 



Begistered J\^o, 



1 VA2 



,trVA^v^ .3wit'\»-i. 



I. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanDarD ) 
PLACE OF DEATH:— County of ^' a-iv o .Vav^t-U-C : City of 0-y^ J>V(X^VC*^C-C 



(^ 



No.5*M]la 



m 



VU'^. 



Ch>lUvt<Xl. St.; — -:- Dist;bct. 



and 




III 



/ ir Dt*THV>CCU«S AW*Y UoM USUAL RESIDENCE Give facts called ton ONDtn "S^rCIAL INroRMATION- "\ 
i, IF DtA^ OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



\S 



PERSONAL AND STATISTICAL PARTICULARS 



x:)R \ 




-KX^ A I COI, 



i»\'iK <>i" lUK rn 




M.-iithl 



(Day) 



(Year) 



\<'.E 



'^ -^ )tins 



Mutiths 



Pa v.s 



'-IN'.I.K. MAKKIKI) 
\VIIH)\VKI) OK DIVORCKI) 

U'ritf- in >iiK-i;tl (l« viyiiatioii) 



luk rni'i.AOK 

state or Cotuitry^ 



FATIIKR 



IUKTHPI,ACK 
•H- J-ATHHR 
'State or Country) 



MAIDKN NAMK 
<>1 MOTHKK 



BIRTHPUACK 
<>I" MOTHKR 
(Slate or Countiy^ 



rtX/Oc- 










MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



• DKATH i 

Q.Aki 



(Moiifh) 



I.O igo" 

a)ay) (Year) 



^I JIi:Ri;nV C1';RTIFV, That J attciKkMl deceased from 

OjlI^: *i^ 190M to .....px.|^ ! .3 up ^ 

that I last saw h -iV alive oil O^X/.^ I X 190 • 

and that death occurred, on the date stated above, at V9 
CL M. The CArSI<: OV Dl'.ATII was as follows: 
i^ ^ ^\ { 

A \ ^ ^ ^ ^ 

....C>i::v.-v^.Lc^-Uury\ 



^uy:iJU^.. 




nr RATION Years Months /hiys 

C O N T R I BUTO R Y ...QA^a.t^^^rvv.ra. ../5.3 N^L.^^^ 

tL'^'W>JL:->CL-*-/C?^ •• - 



Hours 



DURATION 



^ 



Years 



J/0H//1S 



/\iys 



,1 



/lours 
M.D. 



OCCrpATlON 




t±\^l :i up (Address)dtV]aaxcg^ k^^fl 



SPECIAL INFORMATION only for Hospitals 
or Recent Residents, and persons dying away from tiome. 



litals, Instflutions, 



Residfd in Siiti /'mnciseo .m<^^ VfitrS ,, 



\r.<>n)i> 



l)a\. 



THi: AHOVK STATI-:n PKRSONAI, I' \ K lUT I.A KS ARK TRIK T<> TlIK 
HKST OI- MY KN'«)\Vl,i:i)(.K AND HKI.IKF 

<A,Wr..ss \'h\- %^^-^ O.t 



Former or ■ « o. o \ 

lisual Residence I o ' w 

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



How long at 
Place of Death ? 



^ 



Transients, 



Davs 



■% 
\ 



I'l ACK OH IMRIAI, OR RKMoVAI. 
rXDKRTAKKR v, ^ Q^Oi^^^ ^ >- - 



DAXIlof 151 KiAi. or K1:M(>\AI, 

\\k\ i.H 



190 



^Addre'ss 



SHto 



'Qu 



ULnLA-^^^A, ..Cl- 



IN. B. Every Item of information •hould be carefully supplied. AGE «''«"'** ^* * ^ "Special Information" for p.r- 

•tate CAUSE OF DEATH in plain terms, that it may be properly cla««.fied. The J»pec.a 
«on« dyinft away from home should be Jjiven in every instance. 




t! 



I li- 



t' 



' . I 



1 

1 









||3 



t 
I i 

. i 




it 



< 



)!,.,.'.l ..f II. :illll I' Ni'- I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JSI^o, 



1643 



Dale Vilvil, "^-Clv■U^-^vl'^^ IH T-fO'i 

\ i 

DEPARTMENT OF PUBLIC I1EALTH=City and County of San Francisco 



Ccvtificate of H)cath 

( XX. S. 5tan^a^D ) 
PLACE OF DEATH: — County of a>v .VCt>\.Cact City of J aw XawCuLC^ 



^ 



.t 



X^^ 



No. U^5 W\v^al^€t^^:t St.; 5. Dist.;bet;j f LCOvCct tO\xt\i| and JUa\ vx( 

/ IF DtATH OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER VsPECIAL I riFO R M ATIO N ' ^ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ^TREET ANDJNUMBER. / 



FULL NAME 






/YV J\L ' 



L JjCLj 



.^^..^tn^' 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI, 



) 



IcuU 



•"Mr 1^ j- 

ILW^L 



DATK nl III k 11 1 



\("K 






tUay) 



(Vt-ai) 



MEDICAL CERTIFICATE OF DEATH 
DATK Ol-' DKATII JL 

C^^kt 1 



Moiini) 



0,,. 

(Day) 



(Year) 



[ -\ ) III I s 

>-I\<.l,Iv MARK 1 1; I) 

W IlMtUKI) OR I)IV«)KiKl) 

W'titriii s<K-ial «l«si v'liat ion) 



}r,»il/i.^ 



/Kn.- 



lUKTHPI.AOR 
iSt:it«- or Couiitrj'^ 



1- \ I'll i;r 



J 



c 



it 



Q A^v^dx >\ 



I'.IRTHPI.AOH 

"! iArin-:R 

si.itt oi (.oiiiitrv) 



M\I!»i:\ NAMK 
"I- MOTH I-; R 



HIRCm'I.AOK ^ , 

"I- MOTHKK XN-' 

'"^tatc or Country) Xj 



OCCUPATION 'l 



W 




I m-RI'P.V CIvK'l'Il'N', That I attcii<U'(l (Iccca^od from 

^ — I90 to 190 

that I last saw h ~ ' alive on ~ ~ '""* ^^P 

and that death occurred, on the date stated above, at 
TyT M. The CArSl{ Ol" DI'lATII was as follows: 



I) r RAT ION y'-^^rs 
CONTRFIU'TORV 



Months 



Pays 



Hours 



DC RATION 



Years 



Mouths 



Pays 



( SIGNED )\J^^^^^-^ 

c)x|<t I a u,oH f. 



JJhlOldavvcl 



Hours 
M.D. 



X.l.lress) CyU> --• '-^•^i- 



KfsidfiJ i>i San /••; ./;;- /.<.yd .. .3 £.. JVtfrx... ,1A'/////a 



SPECIAL INFORMATION only for Hospitals. Insfitulianf, Transients, 
or Recent Residents, and persons dyinq anav from home. 



/'(/ 1 . 



Tin: AiiovH sT\'n-i) phrsonai. i-aktumlars ari-: trih to thh 

UKST Ol- MY KNOWUHIX'.K AND lU'Ml-.K 



r\,i,irc-ss \\% M ilr^vt c^,tn^ v^v<^ 



a 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Davs 



n.ACK OI' HI-RIAI. OK Kf:M<'V\l. 



i)Ari;<>; m kiai, n ri-:m()Vai, 

6x^vt IH 190H 



\v^ 






!N. B. Every Item of information should b;^ cnreiully supplied. ^^^ ^l""" .^,.V %hc -Speciol Informulion" for p-r- 

state CAUSE OF DEATH in plain terms, that it m:.y be properly classified. , 



«nn8 dyint away from home should be j^lven in every instance. 






■ii 



1 1 



* \ 



ii 






MfT- 







■ t 



r: 



ii ti 



1, 



III 





Ii f «| 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,,,,,„ , Nu ,-, *-tSr*"'^»'^"" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' /'V7r^/,CjXAv> 






IH 



I90H 



liegLstcred J\'*(), 



1644 



^^ Deputy Health Officer 

DEPARTMENTOF public HEALTH=City and County of San Francisco 



Certificate of Beatb 

( H. S. StauDarD ) 



(^ 



PLACE OF DEATH: — County of'O.O^^^ /L<X^fxK:-t4,Ci. City of O-O/yv Jv\XX/>v-av4/0', 
NnH^'XvAlcPvtonvf^- U^^J- St.: I Dist.; bet. U Q-lUi-O and -i\jU/>V .: .: ) 

i^\y* i V, w^ V w J V. - ,„^„ iiciiai Br<;inrNCE give facts called for under Vspecial information \ 







FULL NAME^' tCX,^'">^ v<JL'-<xa \,t.- -NJ (T 



.Jl< 



^ ;1 



i:\ 



PERSONAL AND STATISTICAL PART ICULARS 



ILo-U 

;>\TH t»l lilKTH 



lUJkJlX 






\<-.H 



I O ) ''ii » * 



(I)av) 



Mnvtliy 



/Ib.i 

fVf.-tr) 






Da 1 , 



--!N«.I.K. MARK M'.I) 

w iix >\vi-:i) OK i)i\"<»Kr}-:i) 

Uiit<iii s«Hial (1< sij.'iiatii)u) 



r.iK rni'i, AOK 

Stall- or t'i)iiiitt v^ 



N\M}' nl- 

I A I iii:k 



I'.iK rniM.ArK 

<>l" lATHKK 
Statr or Couiifrv^ 



M mi)i:n NAMK 
«'l' MoTHKK 



!UR rHI'I.AOH 
•>1- MOTHKK 
'Slate or Country) 



•KCri'ATlON j 






^L 



1 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATII J) 



aktr. 

(Motirh) 



Day) 



(Year) 



I IIRRRRY CKRTII-V, That I atten<U'<I (Icccascil from 

Ll^-^u......i.u 190S. to .... cxi^ a 190 ^. . 

that I last saw h-U^>> - alive on O.X^xt \X 19©.^- 

and that <k-ath occurred, 011 tlie date stated above, at -^ 
I M The C.Vl SIv ()!• DI'iATII was as follows: 

UXU.V\^-^^ . ^V-C^--^^^ y ..-CClrX^VvX^-CVh-V^ „ 






XCX.-U.{ 



/\/"'ii!ftl ill Sill! /'i iiiii i-^i'" 



Ik 



^xvol 'U^LoJoj^^ 



nrR.VTION 1 Years * Months 'o_J)ays Hours 
CONTRIIU'TORV ..uUf'U.X^'^^'-^^ Lk^-^r.^^v^-.^o. 

^A^^tL AL>v<:x^cu^^:0^ 

DIRATION >Va;-5 % mnths \<^ Days Hours 

(SIGNED) :wL iJxX^A-^eA^. ^ M.D. 

^.VX. .- roo fA.Mress)Hy^\lil\<^W^<\HV-- 



,|^ only lor Hospitals, institutions, Transients, 



)'r<ii s 



} foil thy 



Pa \: 



SPECIAL INFORMATIOI 

or Recent Residents, and persons dying anay from home. 

r HoH long at 

f»™f "r.„,. Place of Death? 

Usual Residence 

When was disease contracted. 

If not at place of death ? •-'•"— 



Days 



rin: AHOVKSTATl-DrKKSONAI, I'AKTUTLAKSAKl- TKlK To TUl- 
IlHST Ol- .MV KNO\VIJ-:U('.H AM) Ml-.I.Il-.H 



I>I,ACK OI- lUKIAl. <»K KKMOVAI 



DATli')!" Ht Ki.Ai. or KKMOV.M, 



I ^ >^ ^ w ^ _J[90_ 



(Address VD X^ :-b.V<y^0..t:<-V.--0- -.. ^I'.t. 



N. B. Kvery item of informBtion •houl.l b. — — -— . " properly class 

state CAUSE OF DEATH in plain term*, that .t ma> .^^ ^^ ^ 
«on« dylnii away from home Hhould be J^.ven m every mstance. 



^ * I »-VArxi Y PHYSICIANS should 
cnreSu.ly »uppM=... AGB '}"'"}*_'^^.^^^'^^'^.'^Z':ly Zo.lv.on- for p.r- 




% ■ 






, > 



I.I3HII: 




WRITE PLAINLY WITH UNFADING INK 



,i. ;,!,!,- I- Vo. !^ ^f^^^nSc\'C>. 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H M 


i 


' v^^fi 




iil 




*^b1^b 




' 9 vJrttS^^H 




B 


j 


Inj^^^^fi^^ 





m4 




M 



llcgislercd J\'*o. 



1 6 45 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 



PLACE OF DEATH: — County ofOa->V JA.Ct>\CUCC) City of JCtW 






a>vCLA.c.v 



Hd. '^Cfccv'^^ VtvL^vtu ^^ ^^^ iV^-^ ' •■ ^ St.; — . Dist.; bet. 



and 



•V ^^ »»VV( ,,cii»l DTQinrNCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION ^ 

^ ( " °"o;:,H"c"ir.*;,"°" o",","*' :"^s"t"o""v7"i name ,~s,»o cr st.„t .™o ~u»..»^ ; 



FULL NAME 



M-v 



vVv 



1 



tCCW/NX- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



liATK OF HIK IH 



iVau 



tMotith' 



AC.R 



^ <^ )>a».* O 



wiDovvKr) OK i>ivt»Kri:n 

Uiitriii -iKiui (li^i^^iijilion) 



\.Yvq 



n 

(Day) 



M.nith: 



L 



\5X 



\S 



(Vtari 



Pii I 



UIKTHPt.ACR 

(Slate or <"Miiiitry) 



NAM I'. «H- 
f MllKK 



I'.IKTmM,AcK 

oi- i-Arin;K 

'StMtf (It (.Diintry'* 



MAini'.N NAM1-: 



H!k riijM.Ari-: 

«>l- Moini'.K 
{Slat,. (,i c'ounlryi 



■Oi 



^vj '" 



\^tV^ 






\j^Lcx>vcL 





^ 



CVVu 





( 



Vo^<X 



OCCUPATION > I V 1 

lU CUV VJt^ 

kr-i,{(-i{ in San / iilii,i -n y^ U ' ' " ' 



(Day) 



190 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH C , 

cixkt. 

(Montll) 
i;V CilRTll'V, That Lattc 

^X 190^3 to .JpXyV'W. ..v:v 

tliMt I last saw h um...alive on aA..|^.........i.'4L-. i 

and that -Uatli occurred, <.n flic .late statcl above, at 1 
OL M. The CAISI- (-)F 1U':ATII was as follows : 



I HHKl'.llV CilRTll'N', That L attended (leccased fn-ni 

lI|x^- 'x 190:^^ to ^ax.^vt l..^ 



()0 ' 



nr RATION' Yean JMouths 

(.UNTKIBrTORV — " 



Days 



Hours 



Pays 



C^Xl^^t H ,.>oM (Address) UU| ^^ ^^ ^ 



Hours 
M.D. 



"<5prCIAL INFORMATION -nlv lor lfespit..ls. institutions, Frdnsirnts, 
or Rcrenl Residents, m\ persons dvin,| .m.h trom home. ,. 

How lonq at 
Former or ^^%Wv^^•.^,/ ' pjare of DeatJj ? 



/',/ 



Ml.; \HOVKSTATl-I)PHKSONAI,J'\KTIcri.AKSAKi;TKI J- T< • '•IK 
ItKST Ol" MV KN<>\VI,i;i)OH AND IJhl.ni' 



auf,„,„a„t lO-\W' "^)V. VCCcv^^V 



(0 , ci, C 




b^AA ', 



Former or t^L'a^ > ^^ . . .,,,• 

IsudI Residence ^^ ^^ ^'^ ' 

When was disease rontracfed, 

If not at place of deatli V 



b Days 



— • ^ — , ,. i.iM,,\ VI i)\ji-<>; ill KiAi- '" Ki:Mt>\-Ai. 

I'J U'K 0|- Ml KIAI,<»K R1'.M<'\ \l, i'^''- 

^cu./cu- fr^ ,, ,x Oxivt .'S' 190 H 






\ . FX4CTLY PHYSICIANS should 

..o ./cause of death in piain .en,... '•-■.-'> b« P^^^ 
»on, Hyint away from ho.no «houl<l be ft.v.n .n «ver> .n 



• , Jfl 



il 





It 
[• 

V 




' I 



iPMiii 



i^ 






j t 



•I i*k 
41} 



ll i. 



•\"\ 



! 



ll ^ f 



]1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hnan]nnir..lth--FXn. ..^^^H&PCo REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



J)(ffr Fi/e(i,AAX<LLrrrJ>^ 290 H 




(J-V^A^ 




Registered J\^o. 



i646 



I 



De 



^p^r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "Cl. S. StanOar^ ) 



PLACE OF DEATH: — County of 



City of UiCuL^"V<X\xxuiO Lrvoli' 



rNo. 



(ir Dt*TM OCCURS *w*v FROM USUAL RESIDENCE give facts called for under s 
IF DEATH OCCU 



and 



St.; Dist.; bet. 

PECIAL INFORMATION" \ 
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

7) 



FULL NAME 




^^. 



.ajI 



.^HLAJj^vJC.^.'. 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR^ 




(X 



I 



\ 1 



DATK ni- MIRTH 



\r,H 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



...dJJLC'. 

(Month) 



(Day) 



/qn \ 

(Year) 



(Moiitli 



I IIERHBY CHRTIFV, That I atten.lnl .Icrcasc.l from 

to — — — — up 

1 90 



^IN'.KK MARKIKI) 

U IDoXVKI) OR niVOKc}-:!) 

Wiit'iii soi-ial il«>iv:iiali()n) 



mKTMl'l.ACH 
(State or Couiitrj-) 



NAM J- OF 
FATMKR 



HIRTMPUAt'K 
<)!• FATHKR 
(State or Country) 



maii)i;n namk \ 

<M' MOTnF:R 



MIRTH FLACK 
o|- MOTHHR 
(State or Countrv) 




//ours 



OCCUPATION i'^ 






//ours 
IVI.D. 



vyx^rvxA.^ruDi^ 



190 



(A<Mn>ss) 



Ri'siiied in Sati I'lani isri> 



Special Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyiny away from home. 

11 J 1 i ^^^ '""•J ^* >s 

CUVv^<10j v^ Cl\ Plare of Death ? I 



Former or 
Usual Residence 




■ Days 



J ta I . 



M mil In 



/><n. 



thf: arovf: statf:i) ff.rsonai, fakticfi.aks arf: trff to tmf: 
incsr oi- MY k\o\vi,i;i)(.f: and m;MF:F 

(Informant \&'VV>'V. Q oL A,V,^w-V^ V 



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



PI.ACIEI^F ni'RIAI, or RF:MoVAI, I DATKot IUkiai- or RFtMOVAI. 

' vC 



l|' m KI.AI, OK K t^. 



,-0 



|xfc 



FNDICRTAKKR H" ^ ^ ^w^^'^ry.^'V-VV 



fAd.lless. 1^1 Q)V 



^ 290^H 





iLCi^orvv ul 



N. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for par- 
sons dyinil away from home should be ^iven in every instance. 



\*'h 



fl 



I 



I t 



ri 



.\ 



^ 



r 











:11 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H' ir.l of iKaltlr- F No. i^ ^^^^r^u^ UK^V Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




4^ i 



ifJOH 



Begisf creel 4^o. 



1647 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH; — County of Lcrtt ' , 



No. 



(IF DtAT 
IF DE 



Certificate of Death 

( "CI. S. Stan^ar^ ) 

(1 If I 

City of LiVLCO.a/t CALI 

' - and 



,U 



St.; — ■ — Dist.; bet. 

H OCCURS *WAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
EATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



Wtv 



I 



)\A\ 



UV 



^i;x 



»AT}-; ol- lilKTU 



PERSONAL AND STATISTICAL PARTICULARS 

CfU.OK > > 




aU 



'^ll 




Moiiihi 



31 

(Uay 



/IfcO 



( "j'eai 



MEDICAL CERTIFICATE OF DEATH 



DAPK ()I- nilAlH 



6xld 



\c.K 



HH 



) I III S 



\r»iih!( 



1 



PdV.s 



^INi.l.K. MAKklKl). 
WIPoWKD OR I»I\(>Rri;i) 
'Write' ill srKiitl «!fsi},'iiaf io!i) 



LiVawoccL. 



i 



Si ' 



niK rnpuACK 

(State or Country) 



NA>n-. Oi- 
l-ATI! i;r 



HIKTHIM.ArH 
OK l-ArHKK 

'Stritc or Conutrv) 



MAini;N NAMH 
OF M()Tm.:R 



lUKTmT.ACK 
OF MnT}IF:R 
(State or Coiiutrv 



OCCUPATION 



oMjJLk/kA 



T i9o'i 

(Month) (Day) (Year) 

I III'Rl'HV (.^{RTIFV, That I alteiukMl (Iccease.l from 

' ' • 190 to - \qio— 

til at I last saw hnrrrr... alive on ~" — 190" 

and that death occurred, 011 the date stated above, at 
- M. The CArSIv OF Dl-ATII was as follows: 




v^>^' 



I) r RAT I ON ]\uns .■..^.•..J\/ofii/is Days Hours 

CONTRIIU'TORV 



Dl'RATION 
(SIGNED ) 



Yeats 



Mont /is 



Days 



up 






( 






/fours 
M.D. 



Special information "nly for Hosplfals, institutions, Transirnts, 
or Recent Residents, and persons dyinq .may from liome. 



f\'-^iili'if It! Sdir l-'iiiiiiis'' 



r-.;/ 



M.nilli:- 



l>a\ 



TUF: AllOVF, STATIC) I'KRSONAI. I'A RT HT I.A K S A K l! TRFK TO TIIi; 
IIHST OF' MV KNoWM-DCF; AM) HFIJI-.F 



Former or 
Usual Residence 



L'ct; 



vA.a 



HoH lonq at 
Hcire of Deatli ? 



Davs 



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



(Iiifonnant '^X^M^^W^^VOw QjJ{\JjJL/dj!) 



f\.Mr..s ^IS^ XXCRCLOV 




i 



ri.ACF, oi- inurM, OK rf;mo\ai. 



i)\ii-, oi m in.Ai. or kf;.movai. 



C^^|a± 15- i9oi 



(A (hires 



Ibl 0)\t»Lvlc^ V^. 



N. B._F.veny iten. o.' infon„,ation should he carefully supplied. AGE should «>« ^^"^-^^^^^.^i^'^^^.^- .rr'To^n^'lr":;!." 
• tate CAUSE OF DEATH in plain terms, that It may be properly classified. The Special Intormat.on for pT- 
sons dyinft away from home should be Jiiven in every Instance. 



I 



I ii 



,1V- 



,* 



I'i 







n 



•f 

i. 



flf 



'' ri 



f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n.,:,r.l of Health !•• No. .. ^"-^f^^- ''^'^'' ^'" 



I) 




Regi.stei'cd J\^o, 



\ 618 



l)(ilt' lul('<l,'c^.K.\<^y\'Jo^\j IH lOO'X 

"^.^LtU <Jc\yu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "U. S. 5tan^ar^ ) 



PLACE OF DEATH: — County of 



XoJ 



"U 



^ 



City of l^^^ttKX^d'") i\V\^\am ^dl 



No. 



St,; 



Dist.; bet. 



and 



/ IF Dt*TH OCCUBS 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 




i 



X^vVu. ^t^^\^^\i\^ 



PERSONAL AND STATISTICAL PARTICULARS 



!>.\ ri: nl HIR in 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH i 

. .^ QJ, 



iM<nitli> 



A<*.K 



iXiifrj^)v,M. b 



<l>av) 



.1A.»////< 



(Vc.'U 



Dars 



'^IN'". I,K. MARKII'.D 

\VI1»«I\VKI> ( >K I)[\()Kri:i) 

(Writf ill MK-i:il <Usivriiati<>ii) ^ 

St.'ttt or Coiiiitry' I 4 J 



\\MI- ( Il- 
l-ATM };r 



lUR rm'i,A<K 

ni- lAPHKR 

' staff or loinitry) 



MAIDKN NAMi: 
OF MOTHJvR 






ix\\fc 

(Month') 



(Day) 



(Ytar) 



r ni:Ki:i!\' ti: FvTII'N', That I attL-ntlol dcriascd from 

— -Up to 190 

tlial I last saw h-rrr—. alive on -- i</> 

and that (kath occurred, on the dale stated above, at ~" 

rrrr.M. The CAI sic Ol- DICATII was as follows: 

.y^ xvci ivto 3-/:>.wsL^v^ 



:S..A^. 




DlRATrOX JVrf/.f 

CONTRIIU'TORV •.- 



Motitha 



Davs 



niR'ruiM.Aii', 
«M- M()Tin-:R 

(state or ('f)mitr> 1 



n 



ijl)vrA.a>vi|, 



OCCUPATION ft> 

Rf'iilfii in Siin riitih,"'.) \ f'riti 



dx|\l "-' i.>o 't r.Xd.lrcss) 



Ilourx 

/fours 
M.D. 



SPECIAL INFORMATION «nly fof Hospildls, Institutions, Trdnsienfs, 
or Recent Residents, and persons dyinj .mny Irom home. 



%\ 



\f.,,i!lr 



I hi 



Tin-. AHOVK ST \ri- D I'KRSON M, I' \ KT IT I' I. \ R s A R l- f R T J'. To 
HKST Ol- MV K.N0\V1.1-:D<". H A .\ D lU.l.Ii:!-" 

^ -tN A 
(InfotTnajit . 0. O C^AV^W^^^^ 



ITN-; 



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



'^ HoH lonq at 
Place of Death ? 



Days 



f\.Mi.vs c3 



/O.yCvXX'^ 



'-»^>jL/wX>c V.'^Ol 



l'I,.\CK Ol- JURIAI, OK K1•,M"^'AI. 



D\ri-; o! Hi Mi.Ai 01 ri-;mo\'.\i, 

isx\-±- !H 190I 



N. B. Rvery item of Information should be cnrefully HtippI.ecl. ^M. , .^..^j. The "Special Information'' for p-r- 

.tote CAUSE OF DKATH in pU.in term«, that it may he properly cla«s.^.ed. 
«on« dyinft oway from home should be feiven in every mntance. 



' . 1 ! 1 



II' % 



i' 

If • 



r < 



•I 



!^ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i.„,:.:,l ..f II<;iUh !•■ No ! «; 



?45 H5v 1' Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I )((!(' Filed , Ja^IvLL'T^vL^v 



VJO'^ 



Registered JVo, 



1649 



^^\.' * 



[^pr«iii»^V Mfnfti"' O^^/^'^f 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 






y t 



\ 



0^ 

PLACE OF DEATH: — County of ■~^'' a>\ '^ VaivCiiw; City of *<X>V 3\^avCcAC^ 



^ 



'^ 



No. Hll 



')l\^ .1 



} 



M 



V. .tq<r>>Vv\tlAl\^ S*,; 1 Dist.;betA CCtLcyo. and I^AXW 

/ ir DEATH OCCURS AW*V F Pl'b M USUAL R E S I D E N C E G I V E FACTS CALLED FOR U N D E R J S FECIAL INFORMATION ■ ' \ 

V IF DEATH Occurred in > hospital or institution give its NAME instead of street and number. / 



FULL NAME 






dtaKta 



PERSONAL AND STATISTICAL PARTICULARS 



«i;\ 



i)\ ii: (>»• iiiK III 




xu 



]]{ 






MEDICAL CERTIFICATE OF DEATH 



DATE OF Dl.ATH 



I Month) 



( Day) 



v.H.CH 

(Vear) 



Ar.K 



J '/'</ / » 



5" 



M.'Ut/i^ 



X^ 



Da 1.. 



^IM.I.K NtAKKIKI) 
U t[)( i\V»-:i) (>K I)I\t iKT j:i) 
Wiitt ill s(Kial fltsi^natioii) 



lUR'rnPI.ArK 
St;iti- or roiintry) 









NAMI-: OF 
FATm.R 



mkTiiiM.AiK 

<»|- I AIMKR 
'State or foiintry) 



^^MI)|•:^• namk 

"I MoTHHK 



iuKrin>i,A('F: 

'»!• MoTHKK 
(State or Country 1 



LaavLc^i X''. olcxi^w^ 



(Month^ 



13 

(Day) 



(Year) 



,1 HERIUJV C1:rTI1*'V, That r attended deceased from 
rO.X.y\t \X 190H to OX^-Ct 1.2>. T90 H 



that I last saw h ^--^^ ahvc on .U*<w.]pJt i ' 190 - 

aiul that death f»courred, on the date stateil abnvc, at I aC 
...U^M. The CAL'-SI-: C)l- J)lvATH was as follows: 

.Cvwti .OvLiU. -„v^.tu^ 



n 



DTR ATK^X y''<J>'S J/oi^/ZiS ^ Days Hours 

CONTRIBUTORY iLcc.vtt.. .U^.^..fe:V.^.CKi^^^ 




t 



i\xVL\\XL'Ctll 



,tx*v .. 






DURATION 



Years Moi/Iis \\ fhus 

( SIGNED ).}Xi%AJ^\ ll- J>-^ 

vt IH TooS rAddress)50^M)U^^^^vl.'^ 



flours 
M.D. 




OCCIPATION 

Rf'sith'd . Si!H /'ill )!•!/•,> *- )r(I' 



Special information onlv for Hospitals, Insfitutlons, Transients, 
or Recent Residents, and persons dying away from fiome. 



5^ ^/n,///l 



.XO 



/),n 



Tin: AHOVKSTATKI) I'KRSONAl. 1- A K IKT I.A K.S AKi; TK T K T<> THK 
IJF:ST ()1- my KNOWM-.Dt.K AND lUJ.Il-.F 



f Iiiforjiiant 



(Address 






Former or 
Isual Residence 

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



How long at 
Place of Death ? 



. Days 



I'l XCF 01/ lUKIAI, OK KKMOVAI, DXTl,.; IK inAi. 01 KKMOVAI. 



v-c 



.ti ^n\o.\v>wL' •- \.L 



,,,ares. 1 5 an ■^i^1^^i 






' pirf XGE should be «tHted EXACTLY. PHYSICIANS Hhould 

i InformBtlon .hould b. cnretully --^^^ J'^fj^ dassWicd. The "Special Information" for p*r- 
OF DEATH in plain terms, that it mii.> he progeny 



N. B. Every item of 

state CAUSE \jr ui^r" r- ^ , :„c*otir* 

«on. djinft nway from home »houl.l be ft.ven m every instance. 



!l ' 



II 

.! 

I* 

r ( 

■ ^ » 

I 



I 

1 



r' 



* i-»i 







4 


1 

t 


i 




^ < 1 


'■ ,■» 


i^' 


• 


i« 









fi' '!t| 



^:'iil^^ 



(I; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.fl|,„lll, IS. I < TS-yl^SSiillX !•(■., REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hi/c F/7(''f.\)x\\i^-)'>\,'Mhj IH 



UJOH 



llcgi.sfci'ed J\''o. 



1650 



OvCrUtt'^ \:v'i 



\H\ 



Jk. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( 11. S. StaiiDar? ) 

ity of "CL"\V '.ICL^vCl^a^ 

No. i'?:^ ^V^cLC^^' St.; ^ Dist.; bet. ^-^^'4 tX v\ 

/ IF DfATM OCCUBS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UHDER "SPEC<AL INFORMATION ' ' A 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



PLACE OF DEATH: — County 



of Cl^\ 0\cx^vCA^cc Cit ' -^ -^ ' 






voiAa«-a vaA" and J.VvOU'VWA^.a .. ) 



FULL NAME 



LI 1 viva ''J ucx\/v,cv vlv\^uliy^xa'duU\^^ 



PERSONAL AND STATISTICAL PARTICULARS 

KA'i K <>i i;iK rn L 

:,,.. axivt H ,155- 

iMonhi) (Day) (Vear) 






A OF. 



\ I y>ats 



yr.'tiiiis \ 



/>in: 



SINi.I.K. MAKKII.I) 
WlDdWKI) OK I>IV«»K<KI) 
Write in MK-ial <lf<u'iiat i'lii) 



V Vs 



LOIVvca^cL 



HIKTHPI.ACK 
(state or Cniiiitry^ 



NAMF «>l 
1 ATin-.R 



niRTMPI.ArK 
<>l lATHKK 
stittf i.r c'lHintry 



maii)i:n namr 

OF MoTUHR 



ItIK IMlM.ArK 
»»1- MOTHICR 
'Stale or Comitrvl 



OCCI'I'ATION 



jLV>^^<X>VLi, 




MEDICAL CERTIFICATE OF DEATH 

DATH OJ- I)1:aTH y 



(MoTlOl) 



* 



(Day) (Ytarl 



I HKRIiliV CI;RT1I'"V, TliMt r atteiykMl deceased fr«jm 
*|ttU.A icpX to ..-;^ dah,. uyo^ 



ly^*^ '■*' 7s '^ • ^^' V 

that I last saw hxA' alive oti C-»^i^ ^^ I«P H 

and that diath occurred, <>n the <late stated above, at 
.r. AX.^ The CAlSJv Ol" DliATII was as follows: 



DTRATK^N Vojrs .Von/fi.^ Pays 



//ours 



L 



DT RATION ^ )7<7r.v 



(Signed) 







>\l 



t 



,1A >;////.' 



Pars 




//ours 
M.D. 



<\e-^4: i?^ ronS (Address) SS fc ' H A- ' . 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying awa> from tiome. 

HoH lonq at 

Plare of Death? Days 



Former or 
Usual Residence 



"^ ,1A.;////> 



/>,M. 



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



rm- \m)VHsT\Ti-:i) pkrsonai. pAKTicri. xks aki: tkih t«> thk 

IIKST OJ- MY KNOWLl Ix.K AND lUlI.Il.f- 
Onfonuant V^-VW^VO^ JVCV.^'l-X.^-^ 



^ 



.s,,,r,-«s 3%U JXfvCVAAX 



.^ 



I'l.ACK or juRiAF. t»K ki;m'»\ai, 

Sit iL.^vv^t 

rNDl-RTAKKR UV^ ^ • ■ >- ' 



DAll! d; IUkiai, or RKMoVAI, 

■5^ 190^ 



^^JL\^ 



f 



VV 



Co 



(Addrcs'. 



li ^ . 



i)u..- 



( ^ 



■~— — — — "■"^ ; r^ 7rF KhoviUI be Htatecl BXACTLY. PHYSICIANS hHouIcJ 

N. B.— F.very item of information .hould be carefully «uppl.ed. ^^J^' ^i^^^j^.j^d. The "Special Information" for p-r- 

state CAUSE OF DEATH in plain term., tha .t may .^«= P^^^^ 

_. ,^. a i,««,^ «hnuid be ftiven m every instance. 



sons dyinft away from home should be ft 



N^:i* 



n 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„,,,.! ..f nti.]th ISO \^■^^^»^nf^VC'^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



iiii 



M 



i 



'i 






,vuv' \H 



190\ 



Registered J\^o. 



1 65 1 



K^^^kj: cL-C- V^u 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( U. 5. StanOarC* ) 
PLACE OF DEATH: — County of LlloyY>Vtd.Q. City of ^J-U.CU.<V>^.'^-^ v.. L(Xl 



No, 



St4 



r ir Dt*TH OCCURS *W*Y FROM USUAL R E S I DE NC E Gl V t facts called rOR under "SPtCIAL INFORMATION" ^ 
C ir OCATM OCCURRCD IN A HOSPITAL OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




k 



Dist.; bet. 

:ts 

ITS 

10 



and 



m 



\^.>:v. \^\.^^\) ^)JJ\j\.L\ 



r 



PERSONAL AND STATISTICAL PARTICULARS 



^ 



I»A IK <t| ItlK in 



e 




' \JjL -^^ 



(Month) 



(Day) 



/ l^s.'^ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK ol- DKATM 






M.V. 



3t )>.;/> ^ C Mn„ll,i XC> /\iy. 



«^TN'C.I,K MARKli:!) 
WIDoUKI) OK n!\'(iK(KI» 

'Wiitciii v(Kial (l««.iv'ii;»ti<in ) 



w 



\, 



•i j I 



I" 



IIP ■( 



i 


i' 




ft^^K 


1 




IB 


ILi 


L. 



lUKTMIM.Al'K 

'State- or foiintry) 



NAMK «>!• 
I ATJIKR 



lUKruiM.ArK 

()i I Arni:K 

(State or Coiintrv) 



M VIDHN NAM1-; 

«»i mothi:k 



ny MoTliKK 
(state oi c'oiintiv ' 



L 








(MontlV) ^ <I>:»y) (Vear) 

J ni':RI*:r.V CIvRTIFV, That I attemlcil deceased from 

190 to *90 

that I last saw h Trrr— alive 011 ^" '9° 



and that death occurred, 011 the date stated al)Ove, at - 
n.j...M. The CAI'SP: OF DI'lATII was as follows: 

v<ni-\A;S.A^^'^ 



DUR AT ION }'ears -.Monlhs 

CONTRinrTORY — • 



Days 



1 1 our a 



K r^ 



'^>KL 



h'f^jiifd III S,/»/ Imtii is,;i ~ " } • III - ' 

llli: AliOVKSTATJ'.I) I'KkSoNAI, I'A K lU I I. \K^ A K I. TK r K K > TIM- 
lUvST <)1- MV KNOW M-.DLU:^ AND M)-.MI-.»- 



DTRATION .^'^'^'^ 

,NED).A4. UjxLi 



(SIGI 



c)x^\t 



Mouths 



l^ays 



Hours 
M.D. 



1"^ 



\Vfi 



(A.Mress) 




r 



o^4arwtf>x' ^.a 



SPECIAL INFORMATION only for Hospitals. Insfituflons, Transifnts. 
or Recent Residents, and persons dying a>*ay from home. 

( \) -\ , How lonq at , . 

n 1 U XKKL^ C t Plar e of Oeatli ? ' ^ - Days 



f 



f IiifoTtuatit 



a.a.'v 



(Address 




former or 

Usual Residence ' ' <^ 

When was disea » contracted. 

If not at place of death ? 

I-I.ACK OF HIKIAI. OK KKMOVAI. 



V 



I)\TFof HiKiAi. or KKMOVAI, 



.tl BXACTLY. PHYSICIANS iihould 



N. B.— Kvcry Item of lnform«tion .houlcl be carefully --^^^^^ p^rp^eHr"l«l.mei?'%h; •'Speci-'i Information" for pT- 
.*<.*/rAltRF nP DFATH in plnin term*, that it may t>e propc y 



A 



Ml 



i Si' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,! .f II, ijth 1 V'. i> ■^'fp^^^.UScVr,, REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



ili 





H' 



•i' 



}'■ 




Da 



Ir ri/rfl,d 



i1 



lOOH 



Bci^isfcj'od J\'*(), 



f052 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



I M 



% 



Certificate of IDeatb 

I 11. S. 5tan^n^^ i 



PLACE OF DEATH: — C o unty of ^ 



h% 



J^JX) 



City ot ^l4 vU^ J aVa^-^wta 



No. - 



St.; 



Dist.: bet. 



and 



/ ir DC*TH OCCURS AWAY 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. J 



FULL NAME ^^^fi^^^-^^^^^ 





s 1-. \ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI. 




(xU 



t.OR \ 

U 



.1 L' I 



I) \T1-: fi! Ill Kill 



LL^vi^.^ 



ULCA^ 



^UC 



a<;k 



M.mth* 



} V(7 > 5 



J 

(Day) 



<IN<.l,Iv MAKKIi: l» 

U II)n\VKI> »»K I>!\t)RrKn "NV 

(Write in »ocial (IfsiKnalioti) ^ 



J^ 



^lAJ^ 



v-%> 



(Year* 



/'(/I 



MIRTinM.ArK 
St;it< or 'uuntry) 



NAMl-. ()|- 
FATHKK 



lURTUIM.AiK 
<>|- lATIIKK 
iStatr or Country) 



MMDl'.N NAMK 
OF MOTIIKK 



lUkTHI'LAi'l-: 
"»l- MoTill'lk 
(State or Cojuitry^ 



Ull 



(VII 



\SJ\yJX. 



WEDICAL CERTIFICATE OF DEATH 

DAT!-; «>1" nivATlI 

IL igo\ 



(Monfh) 



?; 



go 
(Day) (Year) 



I lii:Ri:UV CI-RTU'V, That I attendft! deceased from 

'190 to 190 "' 



r 



-J I 



that.! last saw h ^:r— alive on ■ • 

iiid tli.-it .hath occurred, cii tlie date stated above, at 
M. The CArSIi^Ol- Dl'.ATII was as follows: 

L<xvdlwCL.a..^A.to^^^ 



1 90 



r 



OCCrPATlOX "^ 




DIRATION Ycai\% 
CONTRIIUTORV 



Months Days 



Hours 









I 



T c 






Mouths Pays 



I lour 



(SIGNED) \AA\Ji.a4^v . .v^:V , '^•'^• 



A'f/tff,/ III Sitir /■> (!»< if-<> 



]'f-it > 



.}/,;////■ 



/'./ 



iin: XHOVKSTXTKD I'KK^ONAI. PA kT H C I.A KS A K K TK I K To TIN-; 

iu:sr (>i- MY KNOW i,i:i><".K AND nhi,n-.i' 



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



former or 
Usual Residence 

Wtien was disease (ontracted, 
If not at place of deatti ? 



How long at 
Place of Death ? 



Days 



I'l.ACH OI' urKIAU ok KKMO\ AI, 



'Info:„K.„t XjU^O.^ ^' V!xV^>V^AAlVq 



r] 






rNDi:RTAKKK 

'A(Mr<->i« 




KAll^o! MIHIAI- 01 K1:Mo\AI, 



<VC\;:^^ 









3'. 



M^^ 



N. 



mm.mmmmmmmmmmmmm^mmmmmmmmmmmmm^mmmmmmm^^'imm^tmim^'mtmmm.mmmm^mmmmmm ♦ t cl EXACTI Y. PHYSICIANS uhould 

B._Kvery item of lnform«tlon .hould be CHrc?ulIy fuPP''-'' "i^^J^.ZsJr^J^. The ^Special InVor.n.tlon" for p.r- 
•tate CAUSE OF DEATH in plain term., tha -t may .^^ ^^^^ 
-on. dylnft away from home should be ftiven m every mstance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,1.1 of He. 1th \ 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



♦ it] 




i 



!i 



If 



IfJOH 



Jleglsfe/'cd J\^o. 



1 653 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of S)catb 

( "CI. 5. StanDar^ ) 



^ 



PLACE OF DEATH: — County of ' X^V 'IVaMCUCC City of 'ctn' I VawecA-CX) 

No. '^"wUt ^LCrCCVVUl '^'v, •■ St.; Dist.; bet. — ' ^ and 

A / IF Dt*TH OCCURJ^ AWAY TROM USUAL 
I \ IF DEATH OCCURRED IN A HOSPITAL 



RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



\ 



aX^V L O^^Jl. 



IXCCCL 



>i:.\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




DATK or- HI KIM 



Ai.K 






\ iwAX 



MEDICAL CERTIFICATE OF DEATH 



(Year) 




^\X 



iHMith) 



0.^ 

(Day) 



/iHfc 

(Year) 



O i )V(i»> 



Mnuths 



\x 



/)a\s 



SIVi.l.lv M\KkIl-:i) 

\vii)t t\\ )-;i) «)K i)i\<>Kti;i) 

iWrit'in s<K'ial fUvi>.Mi;iti<)ii) 



^1 



M 






lUKTHl'LACK 

' St.itc or (,'Minitry) 



NAMK (>I 
FATin;R 



MIRTH IM.ACK 
<>l' lAIMKR 

(Stair or Country) 



MAIIH'.N NAM1-; 
n| MdlMIKR 



lURIIU'l.AfK 
<»l MOTHHR 
(Slatr or Country^ 



iA 








vC^ 



^iln^vvcn 



DATE OF Dlv\TH j) 

(^Xlvt 11 

(Moilfli) ^I>ay) 

I UliKIUiV CIvRTII'V, That, r attcMulcd deceased from 

LljLca,...:n.. i9oi to.i-^^t. M Too'1 

tliat I last saw h •'■■ alive on x.^.:„^ .'. icp 
and that death occurred, on the date stated above, at I 
(f ...M. The CAlSIv OF D^I^V^'M was as follows 



.,e, 



<XVC>V^O Vtr^^ VrO« 




\VdClu 



I) r RAT I ON 



IS 



Months 



Days 



Hours 



DURATION -yJ'i'OV^ ^Months Pays Hours 

'3' ^X. 1lD.a.Hi . M.D. 



(Signed) 






nccri'ATION A 

Rfsnifii .' I San /■'/ din /^r<> 



" );',JIS V M:<lltll> 



])a\. 



^ (^. 



^jj^<k \X TQOH (Address) ClL^MLc ' ' < > - r^ 



TIM- AHOVKSTATK.n I'KRSONAI, 1-A RTIC T I.A RS A K K TRrK T< > TUl- 
HKST OI" MY KN<)\Vl.i:i)<".K AND lUU.Il.f' 



(ill forma lit 



4' 






.^ 



\ 



SPECIAL INFORMATION onl\ for Hospitdls, Institutions, Transients, 
or Recent Residents, and persons dyinq away from home. 

Fnrmpr nr O' (VUcvX-Ul "^t ^^ How long at 

Uslal R^dence ' ^.JJUv^^lU^^t Place of Death? Days 

When was disease contracted, 

If not at place of death ? 



riACKOI" m'RIAI, (»R KKM"VAI< 






oAx 



DATlvo! MiKiAi. or RICMOVAI, 

x}^\xt iH 190 H 



rA.hlr.... licT^' IVL^.. .- 



,. .1 A(IF should be stated EXACTLY. PHYSICIANS Hhould 
IN. B. Rvery item oi informntion should be cnrcVully « » PJ^J ' *^ j' '^ proneHy classified. The ''Special Information" for pT- 

sons dyinft away from home should be &\ 



-Rvery item of informntion should be cnrcruiiy hu,„m.. - 

state CAUSE OF DEATH in plain terms, that it m:.y be properly 
„^«- ^..:-^ „.„-« «..««i home should be feiven in every instance. 



:p 




m\ 



Mr 9 



w 



,i 



' !• 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.. ,, fiL.lth , Vn t.T*'fS^.Iu«tl'(o REFER TO BACK O F CERTIFICATE FOR INSTRUCTIONS 

1 654 



I 




1 :i 

i 



/^' /vVfv/, dxKtx>>vU\, IH 



7,9^; S Registered JVo, 

XcKVcv^ "cUvKi Deputy Hecl^h OfHcer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of S)eatb 






PLACE OF DEATH:-County of '^<X^V xa^vcc^C^ City of "^C^>v Va.>vccdec 



fSo. *j^v^^\a>v vc^lv'lav 



St.; 



Dist.; bctr 



""and 



VV»w I V I WW "■'• orCinrNrP rivr FACTS CAtLED FOR UNDCR "special INFORMATION- "^ 

( '^ .7o;:TH"oCc"u%ro\;THo"s'prAt o"R'?^S°T^'J;^O^N"c.;r.;i name .NSTEAO of street ANO number. ) 



FULL NAME 





AuLv^vOL.n.tw 



PERSONAL AND STATISTICAL PARTICULARS 




■' i 



t 



lij| 



I 



t 



I 






i I 



iJ ! 



DATH <)I r.lRTll 



\ < . !•: 



Moiitli' 



^3 rVt'K 

(Day) (Year) 



'iS' )V<M> H v.,.//.- ^D /^M.v 



SI\(,I,K MAKKIHI) 

WIDOW ):i> OK Di\ t>K^ j:d 

Utitcin soiial (k-sij?'nati<>u) I 



lUKTIUM.AOK 

' Stat«- or (.'<)nntr\ ' 



NAMI-. «)!•• 
KATMl'.R 



lUKTmM.ACK 
Ol lAIIIKK 
'State tir Country) 



MAIDKN* NAMK 

nl MOTHKR 



lUkrHJM.ACK 
Ol- MoTMKK 
'Statt- or Coiinti \ 



ot'ClTATION 






MEDICAL CERTIFICATE OF DEATH 

DATK oi" i)i:aih \ 

":kKt 



fMontfi) 



a)as) 



I go 

(Year) 



I 1II':R1:HV CIIRTIP'V, That I attendol .Irccased from 

"r^xixt n 190 ; to .'^-^l^t is i<}oH 

that I last saw h • aliv. on C^^jrvt 1^ i<;oH 

and that .U-ath occurred, .m ihi- <latc stated above, at 3> 
Cl M. The CAISI-: OF ^HCATII was as follows: 



DIRATION 
CONTRIHrTORV 



Years Mouths 



Days 



Hours 



^V(XAW 



nrRATioN 

(SIGNED ) 



Years 



) cars '*i 



Months 



\x 



Days 



^y 



Hours 

M.D. 



i^xUt I? ,ooS (A.Mr,-^) \'■i^^^v<^vvA-^vi^f 



± 



)'i-iii 



M.nitin 



na\ 



TMKAm)VKSTATKDPKKS,)NALrARTlc;r|,U<SAR.;TKrKTO TDK 

iii;sT OI- AiY knowi,i:d«-.k and hi.i.h-.i- 



(Address ~ 



■sprciAL INFORMATION ""ly for Hospitals, Institutions. Transients, 
or Recent Residents, and persons dying .i^^ay from home. 

When was disease contraeted. 

If not at plare of death ? ^^_______ 



ACK Ol- JUKIAI. OK KKMOVAI, 



DATMoi itiKiAi. OI ki;movai. 



r.NDl'KTAKKKV;. • N-' > ^^^^ 



V, ', 



^^^_^^^»^ ^^— ^M^^^^^^^"^""^"*""^ , FVACTLY PHYSICIANS should 

.. «._Bv„, U.™ „. <nW....o„ .H„uUI .. .»..^r. -^-- :Z^'Si:^r%t ■•Sp.Ca- .n,<,....io„" .o. p..- 
^ -. /-AiicF r»P nFATH in plain terms, that it may -"^ v 
state CAUSE Oh Ut a 1 n m i* A:v*.n in every nstance. 

«on, dyinft away from home nhould be ft.ven in every 



:'ii 



\ ' 



tlik' 




n 



f- V i 



f. ■■ '■ 






i! 






•I 



't. 



a 






i!. :i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.l.,f Health »N.. ^.f^^^^^hf^y^-" ^______ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Erg/sfci'rd A^o. 



1 655 



IfrW^ l^j. Deputy Her!:h Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( 11. S. t5tan^ar^ ) 



J? ^^, 



No. 



PLACE OF DEATH: — County of ^ CL>^'- Va^xcc4CC City of ^ ^a'>x 

3Ad 



li 1 . '-r^ St.; ^^ Dist.;bct. O/W^ and I 

^ ^ ■" ' ' • ..^,,,, QfTCinrNrF riwr FACTS CALLED FOR UNDER "special INFORMATION" \ 



FULL NAME 



i 



CVLC 



I 



.tvn^i%jc/^ 



I 



PERSONAL AND STATISTICAL PARTICULARS 



• I . \ 



Vria 



COI.OK 



\\A.^. 



DAT I. nl lUKTII 



V 



M.,nth' 'l>:»V> 



AC.K 



Ctu-t 5"! r,-,M^ 



M.,}ilh- 



(Vt-ai) 



/Ai 1 



SINCI.i:. MARK ii:i» 
WinnWKI* <»K DlVOKiI".!) 
Wiitt ill »<m.m:i1 <Usivtiitli<ni) 



niKrniM,ArK 

fStatf (<r Coutitry) 



^ 



A 9 



- 



XV-^AXXXv 



f- ATIIHK 



niKTHIM.ArK 
<)l" I AT UK R 
(State or Country^ 



MAIDKN NAMK 
Ol- MoTHKR 




lURTHrUAcH -v \ fN 

(Slate or C()\>ntryl y^ 

occri'ATioN ;VV\ , ^ 

Ki-siiifil III SiDi I'liHh /w.. 

TMK AHOVE STATKI. .'KRSONAI. ''A X^-J^.^^"^" ' "^ ' ' ''''''' ''' '"'' 
HHST «)»• MY KN()\Vl.i:i)<".H ANI> Hl-.I.H-.l 



MEDICAL CERTIFICATE OF DEATH 
DATE OI- DlvVTH J. 



(MoiUTi) 



(Day) 



(Year) 



""""""^1 lilCRI'lHV CIvRTII'V, That I attcMidcd dercascd from 

- ^ 190 to 190 

that I last saw h t^:.-^ alive oti " — '9° 

aii.l that (k-atli ociurred, on the date stated above, at - 

M.. The CAl'Slv Ol" DI'iATH was as follows: 




,\Xvtn'\.: 



A 




DlRATrON yt'ars 
CONTRIHUTORV 



Months 



Days 



Hours 



,^ Days Hours 

^ J. (Bk.'^CL%\A M.D. 



nr RATION Years ^^ Months 

I 

( SIGNED )..l^\^^^*^ 
:^ .^Ui \% r^nH (Address) '^^V^^ 






SPECIAL INFORMATION only lor Hospitals, Instituflons, Transients, 
or Rerent Residents, and persons dying away from home. 



' Vi/ / » iTs 



Moiithf 



n,t\ 



(Informant 



( \<Mrc<'< 



4 



former or 
Usual Residence 

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



How lonq at 
Place J Death? 



Days 



DA'Cl", (Z HiKlAl, or K};M0\AI, 

T90H 






I'l.ACK (llMUKrAl. OK KliNMVA] 



(Address 



' ' '^' ^^ " ^ , pvACTLY PHYSICIANS should 

7-^ ,. „ .hould b» carefully supplied. AGB should »>« ^^^^^.^^^.^g';,,..;, ^formation" for p.r- 

N. B. Every Item of information should b. ^«^« / ^e properly classitied. The »pec a 

• tate CAUSE OF DEATH in pla.n --«;;;;« J^.^cry instance. 
«on, dyinft away from home should be fc.ven m e e y 



m 



I ' 




S^ 



a 



\ 



f'n 



J 









ri 



¥ 

,i-. 



:^' 



li 



!! 



i 



i, I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,.„ ,,,!-,f llc-alth iNo. i^-5'^l^iVH.'^.I'r, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



j; 



Dff/r /'V/r</, dx'^tx^^vlN-Uv^ IS lOO'i 



Rci^isfci'cd jYo. 



1656 




VV^VN 



Deputy Heaith Officer ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "a. S. 5tan^arc> ) 
PLACE OF DEATH: — County of Ocv^v ' Va > . ^ - 

J ( " rr"o»T°H"oci%«ro\"rHo"s^p"'' o"?:?n?u" ^'o.v. ,TS NAME ,.sTC.o o. ST«.T ... N„«e.» ; 



City of ' ' CX'>^ JA.<X vv^vA 



and 



FULL NAME 



\ 



:'^ 



ry"Y\j . VJ^CL/^\-'." 



■-i:\ 



PERSONAL AND STATISTICAL PARTK^ULARS 



COI.OR 



.OLL^ 




\\J^ 



-U 



;• \ : 1. < ii itiKTM 




l( 



i Mouth) 



\' .»•; 



(C'C J v./' 



A 



(l):iv) 



M,,>illi^ 



I ii::\ 

(Year) 



"1 '• 



.< Ai.v.' 



SINC.I.K M\RUli:n 

\V I rxtW 1" I ) n K I > 1 V( > K. (' i: I > 

Writ'.- in >.inial (lcsi^n:ilii>n) 



.li yL<i^^^-^^^^^ 



lUKTin-I, \0H 
'Statt: or Couiitry' 



h 



NAM!" <)I 

J A thi:r 



^ 



HIKTH J'l.AfK 
<>l- lAIIIKK 

'Statr or Conutry) 



MAfl>r?N NAMl- 
OF MoTllKK 







ai 






,)..5.... iqo'y 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK (»1- I)1;ATI1 J 

(Month) 
1 ill^RI'lBV CKRTIl-V. That I atteii.lcMl .IcToase.l from 

i.a 190 'I to . OX|.vt l.'i up M 

that T laJt saw h .- ■ ■■ alive <m, dJ^^t I ?^ 190^ 

a„.l that .loath occiirrcl, on the .late state.! above, at ^ -vO 
M. The CAl SIv4)l' Dl'ATIf was as follows: 




DIRATIOX Years Mouths Pars 

CONTRUU-TORV Ibx.^^^ ci..^.Uw.c 



Hour 



DIRATION 
(SIGNED) 







Mouths 



Pax. 



'C 



Hours 
M.D. 



y\Xjy\^ 



HTR'rHIM.ACH 

.)!• m.jtuhr 
(Stale or Country) 



OCCl 



X>LAA^'V<XA\Mr- 



h\-s!ilf(f ni Siiii /'ia)i.isri) 



)■,■,;; 



M.'^illn 



Ihir 



lU-SToi- MY KNOWM-IM-.H AND Bhl.H.l 



(Infoiinant 






SPECIAL I N FO B M ATION «nl, h, LfiUK Insli.utws. rra"iie"ts, 



QjLlxt' 1"^ 110'' ( 



or Rerenl ResMfoh, and persons dying away Irom homt. 

(7) I) -\ I Hon lonq al 

£V*n«b^blJa^.<^ dt P,ace..D.a,hJ 

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



Days 



c? 



(A(Mi<:"*^ ^^ ' ■ I w 



N. B.- 



''*"'''* ^ ^1 _«— — — — — ^"— """"""""""""""^ 1 FYACTLY PHYSICIANS should 

' ' ^ : H nld b^ cnreV'ully suppHed. AGE should ^'.^ ^J^'^^^j^^ ..s,,eclai ln?ormnf.on" ?or p.r- 

-Every item of information should »-;»;«;" /^ ., ^^^ he properly classified. The ^pe 

state CAUSE OF DEATH in pl«.n ^7^:;7 „ ^,,,y instance, 
sons dyinft away from home should be ft.vcn 



,:.'l': 



s 



f] 

V t 
i 



•\ ' 






■ I . 



!■#' 



If 



Hi 



W^ 



U 



1 



iw 






Mi 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1657 



H.Kinl of Ho:iUh~-F No. is '^U^S:^' ''''t'' "^ " 



lOO'K 



Registered JSi'^o. 



(e Filed , dA^vtx/Y>\,Wv \S 

■L(yw^ iuLo^M C)eputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

{ Ta. S. StauDarD ) 



PLACE OF DEATH: — County of J LaW O. 



L< 



h5^ 



St; 



Dist.;bct. 



City of VlMr^^'^v'tx^'LU VCu*. 
— and " 



^^ ^^^■'^^^^^ ^ ^^ V. v.. - . orcTnrNrF fiwr 7aCTs'cALLED rOR UNDER "special INFORMATION' \ 

( " r;o7.TH"ccc"u%;ro\"rHo".*p"*' "f^sn^Jv^"",;";! name ....... o. st-„, ... «>.««., ; 

^.. . 



FULL NAME U-^ 




iCLU^^..^. ■• 



i 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

C0I.()R\ > 1 




DATH Ol' lURTH 



,u 



y}l^ 



(Mntitli> 



AC 1-; 






(I):«v) 



Mnuths 



r%^l 

(Year) 



Purs 



SIN(.I,K. MAKKIKI). 
WIDOWKI) ()K I)IV<)Rti:n 

• Writf in *;ooi:il iK <iK":iti'>"^ 



HIk IHPUACK 
(State or Cotiiitry) 



NAMK OF 

FA'riD-.R 



HIRTHPl.ACK 
(>l- I"AI!IKR 
(State or Coiiiitrv) 






L 



1 V^ ^ 



MAIDKN NAMK 
OF MOTHHR 



HIR'rHPI.ACK 
Ol- MOTHKR 
(State or Country^ 



OCCUPATION /T) 




MEDICAL CERTIFICATE OF DEATH 

DATK oi" i)i:ath _G 

6-lkt 1 'i roo ' . 

(Motilli^ (Day) (Year) 

I H1':R1:BV CI:rTIFV, That I attended dcccasea from 

— — — IqO 



190 



to - 



that I last saw h tt— alive on 



190 



and that death occurred, on the date stated above, at - 
~ M. The CAlSIi Ol' DI'ATIl was as follows: 



R^^iii/'(1 in Siiv Fiau' ix'o 



Dr RAT ION Years 


Mouths 


Days 


Hours 


CONTRIIU'TORV 








DURATION years 
(SIGNED) > ■^- "J-'^ 


Mouths 


Pays 


Hours 




» 


M.D. 


^„.^± y^ T(io'' (Ad. I re 


^s)UjlU.V<X>xa d . 





SPECIAL INFORMATION only for Hospitals, InsfituMons, Translfnis, 
or Recent Residents, and persons dying dvvay Irom home. 



'S't'ij t . 



\f.>iit1n 



' na\. 



THK AllOVK STATKI) PHRSONAl, I'AKTKTI.ARS A R F. TRIK To TlIK 
UF:sr OF MY KNOWM-.IX.K AND in:ijl-.l' 



(InfoMuaiit Cr> 



d 



^- 



-tx^'L .-.ivJ-N.^A-^^ ■ 



( \(l(1re<s 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



PI.ACE OF JURIAI, OR RF:M<>V\I. 



rSDlCRTAKKR Ml- <) .^.a^ ^\<w 



I)\ri:ot Hi KiAi. or RFMoVAI, 

^Xlxjt lb 190H 



(Addres'' 



■""—"'^""""'"'""""'"'^ 1- A ACF should be stated EXACTLY. PHYSICIANS should 

IS. B. Every item of Information should be carefully supplied. Al,b «n -Special Information" for per- 

state CAUSE OF DEATH in plain terms, that it may be properly class.^.ed. 

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



1" 



« I 






I 



M 






' I, 



'i 



i 



I' 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'mmhI ..f Hiallli-F No. is '^•%.3>^*; HS:!' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\''o. 



Dale /v7r>^/,£3x\xtx^^^U,^.' I $: I'^O'i 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "U. 5. StanDavD ) 



PLACE OF DEATH: — County of 



City of 



6, alt \<xkx LcL, iLIqlI 



No. 



St.; 



Dist.; bet. 



-and 



-) 



iieiiAl or<:inFNCE give facts called for under "special INFORMATION' 'X 



FULL NAME 






a1 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR \ "^ 



\f\Ax 




duuu 




HAT!-: oi' niKrn 




% 



(Moiitlf) 



11 
(Day) 



./.I.6.: 

(Year) 



\(.K 



CL 



u 



HI }v,n. 



M.»il/n 



Pa \. 



•^iNci.i:. MAKKn:i). 

w iix )\\i-;i) OK Dix'oRi i-:i) 

i\Viil( ill s.iiial (Ifsij^iiation) 



IJIKTmM.AOK 
t St:ilf or (.ouiitry^ 



NAMI-: Ol-- 
I- A r I \ V. R 



lUkriiiM.ArK 

(»l I ATI IKK 

I Still <• or country) 






irUxwoLx:L 







MAIDKN NAMl*: ,'?\ 
<)1- MOTIIHR ^ 



liiu riiiM.Aoi-: 
oj- MornKR 

(StMlf or ComUry) 






OCCII'ATION (\*yv 




Ola\.'CL_ 



MEDICAL CERTIFICATE OF DEATH 

DATK OI< DKATH J/' 



( 



Montli 



) 



(Day) 



IQO 

(Year) 



I Hi:KI':nV CI-IRTIFV, That I attemled (U'Cc'iscmI from 

j : left to .,...,..,...■...""——"" i<^)0 

that I last saw h ~ alive on ■- ^'->° 

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

"~ M. The CAl'SIC Ol' DI'.ATH was as follows: 

.<3'>»('..-f'.>><'.'*~<*^-»"<»^-^*~"-^ 



DURATION Vt-ars 

CONTRIIU'TORV 



Mo II tin 



Piu 



s 



//ours 



DIRATION v> ^<!"''Vn '^""'ff' 
(SIGNED) J. ^- ^fi^^ti^U' " 



/hjys 



//ours 

M.D. 



\. 



t 



iqn 



(Ad.lress) vJaU. ^.C^toLld^. 



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



AV.v/V/^r/ /// Sail rmitiisro 



) ,„'/ 



Months 



n,l V: 



TMK AHOVK STATl-n PKKSONAI. '"A HTIO r LA RS ARK TRrK T.) TUH 
HHST Ol- MY KN()\VIj:n<".K and IDvMhb 



(In 



(Address, io'^ HI V 



A^^<i/l.vyfr\^ 



VI 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at place of deatfi 1^ 



How long at 
Place of Deatli ? 



Days 



iM.ACK Di' m uiAi< OR K^:^to^•AI, 

IN-DHRTAKKR <X/>X>^-2-\; ^^ ' ^ '^' 



DATJ". I'J llrm.M. i)t KI".Mo\AI, 

I 90 



)A TJ'. I'! HiHlAl. 



(A<l<lr< 



ss 



-i, \ O-^. 



4. 



' ' !"""! ItF Hhould be 8t«te.l BXACTLY. PHYSICIANS should 

N. B.— F.very item of in9orm«tlon •hould be cnrefully -PP '-•; ^^J^^*; clo«-UMcd. The -Special Information" for p.r- 
* * r'niisr OP DFATH in plain terms, that it may nc pi 1 
rn^dyi^Taway ^rom^home Should be .iven i > Inntance. 






? i 



I> 



'I 



h 



I i I 






^r 





WRITE PLAINLY WITH UNFADING INK — 






Ddfc hlle(l , ..QjM^'^^y^^^-^ ^5 ^^^"^ 




A^ 




THIS rS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

I 059 



Bof^istcred Xo. 



'VH. 



-»»• 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of Beatb 

^ CL -rx- , V 0. y\<iui CO City of ^ J 'Ct > v J X a/\vc^4: c *- 



u 



NO.U 



,cL\x^ 



v:^ 




v. 



C^aLjV'JLxxi 



St; •— ~ Dist.;betr 



and 






\ 



FULL NAME J ^.a''^x^U^ N f La^v. 



L<OL 



PERSONAL AND STATISTICAL PARTICULARS 

.Month) _ JUtiy) ilffi'"' 



I 



)><;/> 



t- 



SINi; I,K, M AKW ii-:i). 

uii)( iw i:i» OK i)i\< »KiKn 

'W'liti ill v.H-ial (l(si>.Mi:iti')ii) 



\ 



l^^v< 



Moul/is 



u 



Dii \s 




I Sliitf or ionntrv' 



NAM)-: «»l 
I- ATI! l.k 



mkTHlM.AlK 
<)|- lAIMl'.K 
lSt.it*- or Country) 






1 



[ii yi^AA^^ 



1 •' . 



^TAlIn••.^' NAMi: fK\ 

<»I" MOT I IKK ''I' 

AXX> vCXO 




CVvu^c^ 




lUK'llIl'KACl-: 

oi- mo'iiii-:k 

(State or C'o\nitr.v) 



OCCri'ATION 

Rrsideii in S,in /'i tiin is,<> I ' "" 




il. LcL'VvvCrYVAiX 



.CL-^v^^-N^.^-. 



'"'^ 1A.;////- \ I /'■' 



MEDICAL CERTIFICATE OF DEATH 

DATE OI- i)i:atm 

J.H.. 

(nav) 




igo \ 

(Year) 



I II1':RI:HV CI-RTH'V, That ^ atteiulo.l deceased from 

AjC^t II 190 S to dX.\.vfe l.H 190 H 

that I last saw h •. alive 011 SxVvt T90 > 

and that death occurred, <ni the date stated above, at I • ^' 
y[. The CA^"^'"' <^^* 1>'*'-^'''" ^^''^ ^^ follows: 



LiSJUrVii 



vvvTA-av 



■^' 



i 



DT RAT ION Years Mouths 1 M/|.^ 

coNTRir.rroRV LUvk.^v^^^^^^^.^-x 



Hour 



rur. Ml(.VKSTATKI>.'HKSr>NAI,PAKTirri,AKSAKl- TKIK To TIM- 

iu%sT OI-- 21a: knowm'.ix". !•; AM) nJ.i.H'.'- 



(I 



(Address 



^X^ 




A, V V. r> 



DIRATION 



(SIGNED) wX 






f 



Ad.lri-'^s) Lrui-dAJ/vV-^ J, 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals. Institutions, Transients, 
or Rccfnt Residents, and oersons dying dwd> from home. 



rs W ii 1) Hovv long at u 



Days 



When was disease contracted. ^ ,, <^ .\tL. ...t^ 3 



If not at place of death ? 



i 



DAi'l "! Hi Ki,\i. or KMMoVAI, 

OX^t lb 190S 



I'JLACK OI- IHKIAU OK K1:M'»VAI. 



..x,,an.s. ini MlW^^^AV .1' 



■"■■-■""■■-"^^■"^■^"■^■■^""■'■'■■■""'^^""^""""""""^""''"'^""""'^^^^^ I I h t t <l FXACTLY PHYSICIANS should 

N. B.— Hvery Item o^' information •houlcl be cnrefully -PP;'-'' ;;^^;r;rir"la«HWieV.' Th: "Spccia; Infor.nalion" ?or p.r- 
. * %Aii«F nc nPATH In pin n term*, that it mio t^e P"-"!' ^ 



'« f 






!!:! I 



^i 



h 









i ■ 






iSif' 



f> ill 



i^i-lt^i 




^ji 



I 




WRITE PLAINLY WITH UNFADING INK 



l,,,..n.l of Health- V No. .. ^ar^g^ Hf^l' Lo 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/h(/r F/7rd,t)j^\\Xjuy^\\>^S^ 15 ^^^"^ 




CAw^ 




Rec^istered J\'*o, 



I C)()0 



\MJ 



Deputy Health Officer 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. Stan^ar^ ) 
PLACE OF DEATH: — County of Ocmv J.-va^^cvAC^City of U-a.vv OA-Ccwc ,. 



Ilo 



and 



No. ^ »■ , „ MO,, Al nrSlDENCE GIVE FACTS CALLtD roR UNDER "SPECIAL INFORMATION \ 

( '^ rF"o;:Tr,cc^^';,ro^N''rHo"s^rT"A:: :« Tn^t^^^o^n cive .ts name .nsteao of street ano nu.ber, ; 



FULL NAME 



^.Mlt<Ja.a.£i 



^^^La'U.<i^ 



<.»:\ 



!)\ri-: <iF- lUKTM 



PERSONAL AND STATISTICAL PARTICULARS 

Col.oR \ 

' 1 \ ' 




.Li. 



I MoiUh> 



(I)av> 



(Viai) 



ACK 



^ O ),illS 



.M.»ilhs .... 



.P<ns 



<]\<.\.V. MAKRIl'.l) 
\VIl)(»\VKI> OK I)!\i>K*>:i) 
'Write in social f1e«iv:iiali<>n) 



n 




lUKTUPUACK 

Stiite <»r (,'oinitt y^ 



.\Tin-:K (Ju 






A.>^x>crU 



rURTHrUACK 

ni- i-ATin-:K 

(State or Country) 



MAII)1:N NAMi: 
ol MOTHKR 




.LA^'VqX4A 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol' Dl'.ATH V 

dxAvt 

(Month) '•>'*>' 



(Year) 



I lIICRlvHV Cl'RTirV, Tliat I iitteiKlcd (leccased from 

ijL^t. 11 . . I90'i to .^^^i '^ uyo . 

that I last saw h • alive on C .':. 1 a 190 

and that death occurred, on the date state.l above, at U 
A..I M. The CAUSIv OI* DI'ATII was as follows: 




DT RAT ION )'<'<^''^ 
CONTRinrToRV 



Mouths 



Pa ys 



Hours 



.^\jlLow''>xA 



/^ 




,tyOuOi V 



lUKI'HIM.ACK 
01 MOTHHK 
(Slate or Country) 




,<X-A/X/CL 



OCCUPATION 



0\ 



I ^ IV,;; v *" Mi>\itlr. 



/)<M. 



THKAm»VKSTAT.U>rHKS<>NALrAKT.rt^;.AKSAKKTKrKn) TMK 
IIKST OI' MV KNO\VI.i:i)C.H AND HhMl.^ 



(InfonnatU 



(A(l<lress 



31 fc ,<x.>v.cUv — - 



Hours 
M.D. 



( SIGNED ) A s) , y I.W V ^^^^- 

T^r Uih 1^ ,ooH (AddresO '0-^^ Ox^t^-' ; 

SPECIAL INFORMATION only for Hospitals, Insfitufions, Translfnts. 
or Recent Residents, and persons dylni) anav from liome. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



.. Days 



DATllof Ml KIAI. or ki;MO\AI, 

'OJLSi<k 1*0 190 H 



PI,ACK OF lUKIAI. OK KKMoVAI. 



— _^^_^^»jL i^i^— ^M— ^^^"^'^"*''***^ , pvACTLY PHYSICIANS should 

SE OF Dt ATH in plain t.rm., th- Jt -n"*^ .""J'^,. 



IN. B. Every item 

mate CAUSE OH Ut:A . n m *-■"■■, r-'-.'^-.^ ^^,py instance. 
8ons dyinft away from home «houId he ft.ven m every 







if I 

Hi I 



j 



•M 



HoMlll 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

f ,„,Uh -F vo ,-.t^f^r^».u«^lT.. REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 



Ke^isfcrcd J^'^o- 




\ 



Deputy Health Officer 

DEPARTMENT (JF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of IDcatb 

( tl. S. Stanfat? ) 



No.3v^ 



PLACE OF DEATH: -County of CV^^ ^^Vcl . -.v:.c City of O CX.-.V J.Vc.v 
\J\\XaXjUj,,Q% '<d, OCa>vVv<u>v St.: ' Dist.;bet. I 'tl^^ »"<» 



^^ ' V. 



^'t 



( 



IF Ol 

II 






DtR "special INFORMATION' 
D OF STREET AND NUMBER. 



) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

I COl.OR 



DAI" J. <tl 111 Kill 




luJ. 



I M.iiith ' 



(Day) 



(Vc.'ir) 



\<.K 







.1/,. >////,< 



/)<M. 



SINT.l.K. MAKKIl".!) 
WIIH »\Vl-:i) nK I)I\nKvi:i) 
Uiitr ill >«ocial (U-si^MKitioii) 



lUKTHI'KAOl-: 
'Statf or c'ounlrv^ 



NAMI-; OI" 

FATni:R 



niRTnri.ACK 
<)i" i-\rin':R 

( statf or Country) 



MAIDKX NAMK 
<)I MOTIIKK 



lUR'I'UlM.AC'K 
nl' MnTUHR 
(Statf or Co\inlry^ 



( )(.•(' r PAT ION Qjy 



? 



1 



L 



Ow^A^ 



cL 



9 

\JLLa.-. "■- 



I 



A'ru.frd in San I'nuuisfo 



) V(M 



M.nilh- 



/><! 1 



I 



MKST Ol' MY KNO\VM:I)OK AM) Mhl.ii.t- 



(III fonnatit 



LtrV 



co'AJL^J^ 



(Address ... 



^ 



b.L'^'v, i-L"^ 



(Vfar> 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- ni-Alll ( 

dxkt 1^ 

(Mont\i) ">''>'* 

T iTl'KI'HV CHRTII'V, That [ attciKlcd .Icccascii from 

to - — - — — — ~~ i^P 

— .'v \.:. 190 



190 
""alive oil 



that I last saw h 
atitl that (loath occurrcl, on the .late- ^tato.l abovo. at 
M. The CATSIC OI' Dii^.XTH was as follows: 



M. i I"- >^>x. .■•. -r-K 



nrR.\TK)N )Vr7/.s 
CONTRIF.rTORV 



Months 



Pays 



Hours 






}font/is 



/hjys 



(SIGNED) L^^-vX^ J.VJ^.W '^ • 



/fours 
M.D. 






('O 



dx^t 1 



H KioH 



( 



V, t ■ 



SOCIAL INFORMATION "nly tor Hospifdis. Institute, rransienls. 
or Recent Residents, and persons dying dv^dy trom home. 



Former or 
Isual Residence 

When was disease rnntrarted, 
If not at plai e of death ? 



HoH lonq at 
Place of Death ? 



Days 



PI XCK OI- MtKI.M. OK KHM.>\ \l 

r.VDl-KTAKKR -..^\XLC^L 

(Address 3>^ TX ~ 



DAji; o! in Ki.M. ot ki-:movai. 



^ 

r 






f . 



N4 



■— — — ^■■■■■■■■^■■■■■'""'■"'^'"'"""""'"^ I f VArri Y PHYSICIANS should 

ion shouU. H. c„ne.'un. suppned ^^«;:;;;7;:,,^^,:r ^Thf ''specia; ln.«..«r.on" .on p-r- 
^H in pinin terms, that it may be properly via 



N. B. F.very item of informat 

state CAUSE OF DEATH in p...... "- "j . . instance. 

son. dyinft away from home should be ft.ven 








I , 



t V 



' i V 




1 t 3 



h:\ 



t: 



u 



ti 



ft 



til 



I-. 



I 



WRITE PLAINLY WITH UNFADING INK 



l!,,;n.! of IU-.'i1th-F No. i> ^X^i.^^ H.Vir ( -. 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1^ 



Ihf/r F/7e(/ ,.nj0^tL^'^\}i-V\' VS. I'^O'i 



Registered J\^o. 



1 6G2 




A^ 




wt 



\ 



"\ « . y- 



».'- 1 ■». 



cer 



DEPARTMENT OF PUBLIC l1EALTH=City and County of San Francisco 

Ccvtiftcate of ©eatb 

PLACE OF DEATH:-County ofOot^ Va^X^l^^Gty of Ua.A. 0;l^>vCU^c.. 
Li '> Q M K ■ - 

No. i i-D \]i\XX 





, , n . jc . St.; I Dist; bet. JVLCUVtu.! and cL/xU Y<r -. xX 

•-^^^■■^-^' ' .,0.141 RFSIDENCEGIVE FACTS CALLED FOR UNDER •'S^CAL I N F O R M AT.O N • ^ I 

( " .VD;ATH"oc"u%ro\;''rHo"s^rAt OR^NSt'.t'JV'o'^O.VE .TS NAME ..STEAD OF STREET AND NUMBER. ) 



FULL NAME cUu^^^axc^^ 




'i;\' 



PERSONAL AND STATISTICAL PARTICULARS 





i).\ii-; ni- r.iKTii 



A(iK 




I Month) 



ab,.. /.iai 



5" 



) 'tUI > 



% 



(Day) 



Mntitlts 



\^. 



(Year) 



n<i\ 



siNr.i.i- MARun:i) 

WIIx lUl-: I) OK I)!VnKii:i) 
i\\'tit<in ^i»<i:ti il<—ij.' nation ) 



nikTm'i..^CK 

(Statr or (.'ounti V 



N.\MI. Ol" 

I- A r n I : R 



OS? i 



HIRrmM.ACK A 

Ol" FATHKK U f\ 

<St:il«' «)r C<)\intry) 






M \II)1:N NAM1-: /X) 

<»!■ Morm'.K I 

LcUv^Vrvt 

lURTIIT'I.ArK 
Ol NJo'lllIvR 
(Slatf or (.'onntrv"t 




(Yfar^ 



MEDICAL CERTIFICATE OF DEATH 

DATH Ol- DKATH 

dxUj I H 

(MontH) '"='>■' 

I HlvUl'HN ClvUTlFV, That I attctulvl .Uivascd from 

CLva...a5i 190H t.) c3 i.i^±. 1.5. upM 

that I last saw h ..^- ahve oil ^-^ ' -^ • 

an.l that death occurred, oti the .late stated above, at 
M. The CAISI- Ol" ^)lvATil was as follows 

'c5 ,a-:-^\xyvx. ' .^cA-iui....a .l<rY>f%^oXu-v-,. 



190 



DIRATION yesU-'^ J/<v////.9 />«/ri 



Hours 



I )r RAT ION op^ y^'<^''^ 



Mont /is \% Pays Hours 

Cu\X. IVI.D. 



A'YVOL'^^i 



0C(M'!'ATI0N 

Rf'>idf<i III San /'iiiihiu-ti 




)'iti I 



,]/,,/////• 



n,n 



/\ r .' i 1 1 r n in • ■ ^ 

rnKAHOVKSTATKn.'FK.ONA..rXKT.rrLXKSAKKTKrKTo THH 
HJ-;ST Ol- MY KN(»\VM-:iK-.H AND iiFl-' '.l 



' liifotniant 



rxddrc' 



Hl*^ bxJL(L.^v.c3.t 



(SIGNED) V. ^A.OX. 

^± 15 roo' M.Mr.ss).'^^b-viiHt. ^ 



SPECIAL INFORMATION only for Hospitdls, Instrtutions, [rdnsienfs. 
or Recent Residents, and persons dying dHdy from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of deathT 



How long at 
PIdf e of Death ? 



Days 



DAi'l'. o; I'.iKi.Ai. 01 ki-;movai, 
aXjvt I'C'. T90'' 



I'l.ACH Ol- HIKIAI. OK Kl.MoVAI, 

(Address 15.2.^ ai^^t* w '•-' ' 



IV. B.- 



^^— ^1^^ — ^i— — ^— , KVACTLY PHYSICIANS jihould 

state CAUSE OF DEATH In pln.n '^'-«: *»;» /^:^^;^ 1„b ance. 
«on. dyina away ?rom homo should be fe.ven m «very 



=.1 '!' 



^ 



f. 



r,!! 










' ? 



I' 



.•J ■ 



1 1 



WRITE PLAINLY WITH UNFADING INK 










/.9m 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

IGGS 



RciSlslei'cd J\^o. 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Ccttiticate of IDcatb 

( XX. S. StanDarD ) 

\ ^ J ^ 

PLACE OF DEATH: — County of 0<X^a. ^ .^o^y^^^^iiy of O^^ J Ao 

St; X Dist;bet. J\XO^V\w and XUU^, ■ t 

FULL NAME U'ua/^^^ .si.crtr.> , 



No, t I'X \€tC.kci.^^ 




PERSONAL AND STATISTICAL PARTICULARS 




DAII-: ol- lilK 111 




I Month) 



A' .H 






(Day) 



MoHlhf 



r%S\ 

(Year) 



Pavs 



siN«.i,K. MAKun:n. 
wiix )\vi:i) OK Divt )Kri:i) 

Wiitcin ^(Hiiil (IfSJKXi'ti""* 



IMKTinM.AOH 

iSI:it< or Oonntrv 



NAMl" Ol" 
FATin.K 



UIKTMPI.AOK 
Ol' lATMlvK 
(Statf or Country) 



MAIDHN NAMH 

Ol' M()'nn-:K 



lUR'rHlT.Ac'K 
Ol- MOTUHR 
(Statt or Country) 



7 




.<Xj 



? 



J A/aJr^ 




A^rwCU 



)'riii 



M.oifhs 



Jui\ 



OCCri'ATlON A)M 

A'rMiir,! in Son I'l n ii,i'-;) 

TMKAm)VKSTATHnPKKS.)NA..rA.nwrr|,XKSARlCTKrK TO THK 

IIF.ST Ol- MY KNoWMvIX'-H AND Hl.MJ.i 



(infoTnirint 



UJ Cr^'v.a 



a 



,W^^-^ 



(Address . 



I X LO -CX/N^-^t^^'l 






MEDICAL CERTIFICATE OF DEATH 

I)\TK ol' Dl'.AlIl J) 



(Montli) 



lYtar) 



(MontlH ">='>'^ 

I Hl-RI-HV CIIRTII'V, That I attciKkMl «lccxasc(l fn.in 

:.::::rr- ^ " Tt)0 to • ^'^ 

tliat I last saw li ~ alive on ' ~~~ """ ^'^P 

a,„l that death ..C(n.rrc<l, on the .late state.l above, at 
SI The CVrSI'! Ol' DI^ATH was as follows: 



DTK AT ION Vt-ars 
CONTRIF.rTORV 



Months 



Pays 



Hours 



I )r RAT [ON Vear^ Months Pay^ 

(SIGNED ) ..LW^^X^^ U^.U^ ^ 

Address) bH-m^^t 



Hours 
M.D. 



\jl\\}^ 11 iqoH ( 



;VO. 



SPECIAL INFORMATION only for Hospitals, Institutions. Frdnsients. 
or Rerent Residents, and persons dyin-i a»vay from home. 



Former or 
Usual Residence 

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



HoM lonq at 
Pidf e ot Death ? 



Days 



IT ACK Ol- HIKIAU Ok KKMoVAI. 



n 



DATi;')! MiKixi i>i K1;Mo\\I, 



O- 



190 



IJUU 



WJ 



,,,a,..ss Zk^lk- I'^^tk ^3t 



i 



t 



r 



t 



9> 



-J 

P 



^ ^ /-*iicf^ np nFATH in p ain terins, that it may j^ 1 
state CAUSE OH Ut^'^ ' * 1 1 k» ASven in every nstance. 
,1..:-^ o^«v ?rom home should be feiven in every 



sons dyinft away from home should be 6 



V 



" 



n 



'! 



WRITE PLAINLY WITH UNFADING INK 



/)(ffr /vVfv/, dxivtjL>^^lMA; is: ^'^O'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1 



llciHisfored J^'^o. 




-CrV-c^^ 




XKi 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 0-~> 



Certificate of Death 

( tl. S. StauDarO ) 

City of Ou-nj Xo 



^^^^^, ^^^ J UAAA^^m. and fcc-LlaUA'..; ) 

VL^ A-'CXAVLOw "« \ ^^ - ^- '-- ' - ^^** " '^^!^tt* V'i!?^X n FOR UNOrR "special INFORMATION" '\ A 

( - r4:.°"occ^%r;;N"rHo^s^rAt ?R^?^?f.?u^4rcf.;r.;i t.-^i r^s^.^o^" s.r... ano ...s... ) 5 



No. IH^ lfeA.aLla.^^-/:^.- Iv 



Dist.; bet. 



FULL NAME 




CI 



loA.^, iJ.Crlr^-^- '^ : • 



4 



PERSONAL AND STATISTICAL PARTICULARS 

i).\ri-, «»i r.iK in Q 



\\.> 




' M-.nth' 



(Day) 



(Year) 



ACR 



^ ;: 



■ ' 



(5 )>,/»> 



Moulin 



Pays 



SIM.I.K. MAKUIl'.l) 
WIDoWKD OK Diyukri: I) 






niKTui'i.ArK 

(St;iti- or O'liititrj*) 



FA rHi;K 



lUKTMI'LAOK 

Ol lAPlll-.K 

I Stall- or Coniilry) 



MMDKN NAMH 
OI- MOTHHK 



HIKTHl'LAOK 
<»I> MoTHl-.R 
(Statf or (."oiuitryi 



I 







L 







>^ 



cL 



VXK^^vXi 



.<x/vu<L 




(^ 



.a^ 



xt_kc' 



oCCri'ATIOX 



\r,>iit/i.s 



n,n- 



fill 

111 



TMKAnoVl/sTATKU.'KRSoNAl PAKIMrriAKSAKKTKrH TO THH 
IJKST OF MY KNOWIJ-IX-.H AND Mhl.n.I 

(Informant U^^X^^aJI Ur^V^-.- t' ■- 



(Address 



MEDICAL CERTIFICATE OF DEATH 

DA IK t)l- DHATH 



(Montlb 



1^ 
(Day) 



rgo 

(Vt-ai I 



4 



I III';Ki:i5v\ikTII'V, That J atk-ndcl dcceasiMl fn.ni 



'hjiJi-X i.H. 



190 H 



ax^\t '^» 190'^ to 

that I last saw li .4^.. aHvo on Cl-^^-X . icp 

an-^that .h-ath occurrcl, <.n the .late statc-.l above, at U 
M. The CAlSlv Ol' I)I:ATII %vas a^ follows: 



DTK AT ION JV'rt/--? 
CONTRlI'.rTORV 



Mouths 



Pays 



Hours 



nr RATION 

(SIGNED) 






Moutlu 



Pavx 



l 



,-\ 



I /ours 
M.D. 



ckxA. ... fA.l.lres.):^^V^ ^K^..Mk, 
— *' — ■ ' ^-.. „ni., inr Hncni»al<; ln<;tifiifions. Iransiffi 



■<5prCIAL INFORMATION only lor Hospitals, insmufions, Iransients. 
or Rcrent Residents, and persons dying dv^dy from home. 



Former or 
Usual Residence 

When was disease rontrarfed, 
If not at plare ol death ? 



How lonq at 
Pld< e ol Death ? 



Days 



D \ I1-: of III HI Ai. ol ki-:m<i\ai, 

:^_x.iJ. I*-- 190 



IM.ACK OV HI KIA!, <.K KF.MoVAI. 

(Ad.lres.s X^H\ QfYL^.^<U^^Jj^ 



N. B. 



" A -^— ^^— "^ ^ , FVACTLY PHYSICIANS should 

«»u. CAUSE OF DEATH in P'"'" "T'i.'.n „ U.ry In.t.nc 
.on. dylnt away from home should b. fv.n 



I 




( 



i? 



•I'^\ 



t : 






\l\ 



I L 
'1 



, I M 



i 



,,,! . f Hcillli »•■ No '^ 



t-^^^av^ll&l'Co 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

-f r* f^ r^ 

lu.lr l-'ih'.l. ^.^vUv,^Ima. 1? 10(n BrgLstered Xo. ^^OO 

■{jy^^-i,,-.. Deputy Hcatlh ORicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( XX. 5. StanDar^ ) 

9 ^ -^ 



(^ 



PLACE OF DEATH: — County of 'Cu^^ J V<X>xCa^co Oty ot ^ 

,M ll%0'x^K.^i.''' St.; "^ Dist.;bet. U^■U^^^-:a 

^NO. I ^OV 1^ V^-'^VAU - „„ MCHAL RESIDENCE GIVE FACTS CALLED 

( " °."o'»,°H"o^c"u%r;,"r„o"."r.^""~s.,TUT,o. o,v. ,ts nam. 



and 



,S AWAV ..O. USUAL BESTOENCE^VE^^CXS -^^^^^^ ) ^ 



) 



FULL NAME 







sKX 



PERSONAL AND STATISTICAL PARTICULARS 

C( »l,< »K 




ol' 



ic 



DAii; • '1 r.iK in 



\ ' . 1-: 






(Day) 



(Veat) 



•-IN<.1,K. MAKUIi:i> 
WIDnWKI) <>K DIVOKi KI) 
(VVritf in siK'ial drsivrniition* 



liiKrnri.x*'!-: 

I state nr fiiiitlll \' 



.!/,.»////- 



It 



Da vs 



N.WII' <)I 
I A 111 J.K 



lUKIIM'I, A^K 

()i- iaimi:k 

•St;it«- or Coiuitrv) 



M MDHN NAMH 
ol MOTllKK 



lUKTIiri^ACl-: 
til' MOTHKK 
(StMtr or Coiintrv) 




MEDICAL CERTIFICATE OF DEATH 

DATK <'l- Dl'.ATll _^ . . 

IS 



...CJxkt 

(Moiit'li) 



/QO 



lTn<:Kl-:Bv"ci:RTIFV, That_TattenacMl .ItHvasea fn.n, 

i<>oH 



lLla^cl S 190H to. ci-^tvt. 1.5 



I()0 



I 

that I last saw h A.^^-.alive 011 
a„.l that .U-ath occurre.l, .>.i the .lat. statc-.l ahnvc. at H-^O 
01' M. The CAISI' Ol- Dl'ATl!^ was as follows: 



xj^u^^-^y^ 



trr^Jtu 






h'r^i.lrd III Sun /■•/./»-/>'•" 'X--' *''^'' 



/>,/! 



JiKST ()|- MV KNOWIJ-.IX.J'. A^" lU.MJ.f 



(Infoiinriiit 




r.Vl.lress 1*1^0 la 



V 



!.-^ 



I/Oll><s 



CONTIUi'.rTdKV 

„rK.\TH.N )V,„.v .1A'«M.v Am 

( SIGNED ) Llo i.Vl7W>v^^--^, ■ •-■ 

■ SPECIAL INFORMATION «nM»'"'«P'l-^ '"^'''"'i»"^' '""^""'^' 



Hours 
M.D. 



Former or 
Usual Residencf 

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



How long at 
Pld(e ol Death 



. Days 



n.ACKor lu KiAi. OK ki:m<'Vai. 



DXn ,,: lit KIM ..I KKMOVAI, 

...B. 



r^" 



lA^vt 



11 






190H 



jDvLV^I. I ■• ' .^A _^— — — ^— — """— ■""■^""""""""'"'""^^^ 

.^_^_^.— ———^— "———"■" """"^ ,,VACTIY PJIY8ICIANS Hhouia 

rH Jn piflin terms, that .t may " ^ 



N. B. Bvery item of inVor-mnt 

«tate CAUSE OF DEATH .n ^:"'";-"°:;e„" in every instance. 
«on« dyinA away from home should be ft.ve 



•I 



m 



'^ 



i 






1 




1 1 

i 



',! 




t 



m 



jiS 



WRITE PLAINLY WITH UNFADING INK 



,..,;„.! ..f Uralth \- Sn. 1. ■^'*:.^!^^ i^^ ^' ^' ' > 



Date Filed ,L 




i^^^V 



Ux.\. \ 5 



i.96>H 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS 



J^ro^lstej'cd A^o. 



i^v^ 1tv>u Deputy Hcailh Ofificer 



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

Certificate of ©eatb 

{ n. S. StanMrD ) 
PLACE OF DEATH = -Countv of 6,^ i,>va.M:^ac Gty of 0,a.^ ^^^^^^ 

,0, (A.^ 

'No. bis v.^K.£aI. 



St.; 



("' -•;;ric:!»^- "::^^t -f ^^^^c/;;" J^J^J'^M^ ,x^r;?;^^-Jo=r" ) ^ 



Dist.; bet. M i W^^r^i ^^ 

Fl 



and J Wj^i^ - 



) 



FULL NAME 




^i^^o^y.^ .on v<ia. ()l:'.am.^t 



^);\ 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OK \ ^ ,; 

DA TH i»l lUK III 

' .t !.H 

(Day) 



QnioL 



XKAJL 




(Year) 



ACR 



!'/•<// > 



.!/->///// 5 .. 



I 



Ih! V.V 



wnuiWKi) OK i)iv«»Ki i:i> 

iWritein social ik-si>rii;»li""' 





r.iK rm'i.AiM", 

M:it( or •■oiinli \" 



NAMl <»i 
HA rill'.K 



lUkTHI'I.ACB 
<H- lAIIIKR 
<Stat«- or Cmintry) 



M \II»HV NAME 
Ml MoTMl-.K 



I'.IinillM.At'K 

111 NH)rni<;K 

(Statf or Country^ 



odll'A'noN 










J V'(7/ 



\f,„ltll' 



n<n 



ni-ST «)1 MV^N<)\Vl,i;i)<.»-. AM) 'J^''''-' 

( 111 toi lll.'lllt 




tolH 



.t ":^t 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:ATI1 P 

Dxkt 1-^^ 



TOO 

iVf:il > 



"rm[RT^nv7M:J<TIl~T^^«t r atten.U-.l <1cccasecl fmni 

X?^X^ l.M 190M to <M^ ^^- ''^ ^ 

that I last saw li-A-^n. alive o.i S^.^ '<^ 

;,n.l tliat .kalh .Kxn.rrcl, nn tin- .late statol ah-ve, at ^ ^ 

\X. M. Tlu- CAlSlv OI" KI.ATIl wa^^ a< follnns 

0..aCsSfs.C^>'>^J^^^ 



DIKATION -years 



Moulhs 






Pays 



J /ours 



/hivs 



Ihu 



r<i 



M.D. 



•>'-^'-->^ kTci '''''''^ 

(SIGNED) y "^^ \bA<A.^v^i-. 

■ SPECIAL INFORMATION onlv tor Hospitals, Institulians, [rdnsienfs. 
or Rerelu Ments^nd Persons dying away [rom homf. 



Former or 
Usual Residence 

When was disease rnntratted, 
II not at plar e ol death ? 



How lonq at 
Plare ol Death ? 



Days 







,.,,XCH..I- lilKIAI. -.K KKM.'WI. 



(A.Mnss \D<^^ ^ ^^^JLL. PHYSICIANS «hould 

■ ; . .,,„ he cnrcfully -uppUccl. AGIi ^''^/''^V^'^The'' Special Infornu.f.on" for p.r- 

N. B._|.very Item «^' inforni..t.on Hhould be c^ c y ^^ ^^^^ ^^^ ^^^^^^^^^.^ ,,3„.f,ccl. 

«tatc CAUSE OF DliATH m P'"'" J^^j;"* ;,„ ,„ every ln«tance. 
«on. tlyinft away from home should be fc.ve 



k 



I'* 






r; 



'r 






\ i 






I 



it 



WRITE PLAINLY WITH UNFADING INK 



„, ,.,1 ,,f Health J- No. 1- T^^vgg^M&PCo 



DEPARTMENT OF PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

16G7 



lle^isfct'cd J\^o. 






City and County of San Francisco 



Cevtificate of IDcatb 

( XX. S. Stan£>atP ) 



A' % 



No. 



PLACE OF DEATH:-County of 6a.avJiUX^^A:^-Gty of ^C^^ ^ AX.^^^^^ 
,,^/''r ; St. ' D.t.;bet Iti and I iL ■ 



i <^ , ' . A Sf Dist; bet. iAl^ an<^ ^. P^' 

^ '•^l *^^ .. or«TnVNCr GIVE TACTS CALLED roR UNDtR "SPrC.ALlNrORMAT,OM"> 

( - r.^r.Arocc-^RreV.rrHO^s^r.t ?r^?^?.^^^4^.'^c,v7Ts name ..s..ao o. sxRe.x a.o ...b.r. ; 

FULL NAM E UXfi-^X fc' .frU.<\ 




^ 



PERSONAL AND STATI STICA L PARTICULARS _____ 

I COI.Ok \ 

LUvK^Lii — 

^Jr %^ rm,^ 

•Month. *I>''V> __ f^-'^^ 



SKX 

DATK Ol- Hlklll 



AlVK 



I i )V< 



■•til 



M.>„i/i^ 



n 



/y.n. 



SINr.l.H. MAKUIi:i> 

wrix twi-j) OK i)!\t >Kr».:i) 

Write ill MH-ial d. >-i^'nati<>ii) 



IUKT»n'l,A(*K 
(Stat*, or (."ountryi 



VAMI-: oi- 
lA THl.K 



HIKTUIM.ArH 
n|. lAIHl-lR 
iStatr or Country) 




' MEDICAL CERTIFICATE OF DEATH 

DATE OF I) J ^ in 



..3x|^.. 



(Monfh) 



.1.5., 

(Day) 



(Year) 



Fh HRHHYCIRT IF vr'niat I attcn.lcl ilecease.! fr.,ni 

..:: -zrrr x^ —to ." ■-^^P 

that I last saw h - .'ilive on - '■■■— '"^ 

an.l that .k-atl, occurrcl, .... the .late- staUMl above, at 
rr- M. The CArSIv Ol" DI'ATH was as follows: 

aJx^-e.k iAj&'^mi.AJ^.^A^'^-^^^-^ - 



C\a"ul.o^ 



MAIDKN NAMK 
OF MOTHKK 



lUK IHl'LACK 
()|. MOTHHK 
(State or Country) 








(A KA'A \jLvctA^i? Jt 



)V'(f;.^ 



Moulin 



Ihn, 



OCCn'A'lION 

Rf^idrd ni Sav l-ra»rh,-o ^ 

IJKST Ol- MY KNOWM-.IX.H .XNl> MHl.n.f 










1)1 RATION J'<'«''.^ 
CONTRIIU-TORV 



Mouths AM•^• //<^//'>- 



( SIGNED ).Ur'unvi-v J ^£>.UO.,.A 



I^nvs 




Hours. 
M.D. 



Qxixl i(>^. 



A.i.iri-^lVvr^ 



X^A©]^ 



"c^PECIAL INFORMATION only for Hospitals, lnst,f«lions. Transients, 
orfefen^ Ments,7nd persons dying away Iron, home. 

Former or ((U lo %vClttr> 
Usual Residence > ' •- ^-^ 

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



How lonq at 
Place of Death ? 



Days 



IM^ACKOH mKIAI,0K Kl-MoVAI. 
CNDl.K I AKl-.K ^ 



I,\n;..! lit Ki.xi. t KliMoVAI. 



) I. 



"V. J I i.^V'^LM. VC i 



"^ y " r ;v/»w. ... PHYSICIANS should 
. -hould be cnrefully -uppHed. AGB should *»« "^^^'^j,; "Speciai IntforniBtion" for p.r- 
IN. B.— Every Item of !"f'>'""«i:°". ••'7'j^„ termrthat Jt may be properly cI«Hsh.ed. 
state CAUSE OF DEATH .n P'«J, J*j;'^:;J^^^ every Inst-nc 
son. dyinft away from home should be ft. 



t 



«. 



•^ 







I 



ft 



WRITE PLAINLY WITH UNFADING INK 



,.„,;,,,! .if n.-:.ltlv-l- Vo !. 1^'^^^K:^.nl(^\'Cn 



Dale I'lh'd , 



,^vLv,^ 




i^>^JUL\' ^5 io(n 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^ v^, 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Cevtiftcate of H)catb 

( Ta. 5. Stan^ar^ ) 



^ 



\ 



City of ' ^'Ou.^ o /Va-^vav^CA 



Ne. 



PLACE OF DEATH: — County ofUa.-.v J Xa>vc.^.\ 



and 



^ 



FULL NAME 




o. 



m 



o^cuezvi. 



PERSONAL AND STATISTICAL PARTICULARS 



i)\ri-. of lUK in ''(p) (] 

JXAT 

I Moiithi 
At.K 



COI.oR \ 



ILA 



WWX'- 



15 

(Day) 



/'I'i.s; 

(Year) 



5R )V,r;.v ^ ^'"''"" -^ 



/^</i> 



SINC.lJv MARKIKI). 

W IDoWKI) <»K DIVnKiKl) 

iWiitf in siH-ial ih-'-ij/^nation) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF l)i: ATII 

(Day) 



...^.il^. 

(MontTi) 



lYtar) 




ruTrKHHV CKRTIFV. ThaU atten<U<1 <lcronse.l from 
^ i.fc 190 -'-^ to "^-^^^ ^^ '^ "^ 



ax^^ 



HIRTin'I.ACK 

(Statf or C-intUi v 



NAM1-: oi- 
|- ATHl.K 



lUKTHlM.ArH 
OI- I AlllKK 
I Stale >>i Ciiunlt y 



MA!1)1:N NAMl- 
OI- MO'IIIKK 



luk rm'i.ACiv 

OI- MOTHKK 
(Statf or Country^ 










)'ia I 



M,»itlt' 



/',n 



HKST 01-- MV KNOWIJ-.IX.h -^^'^ Z 1 



(1 






that I last saw h ahve on U^A^^a. /j 

ay,l that a.ath occurrcl, on the dat. .tatcl abovo. at 5-^0 
M. The CAISHOF Dl.ATII was as follows: 






CONTIUr.lToRV 



(SIGI 




1 90 



SPECIAL INFORMATION onlv for Hospitals. Instituhons. Irans.enfs, 
orleren^^esidents! and persons dyiny a.ay from home. 

,1a I, How long at 

f"'""?'.. I JLl'VVVCi.iv^IrVV^ - Place of Death? Days 

Usual Residence VbV vvv,^i wv 

When was disease contrarled, 

If not at place of death ? 



PLACE or MKIAI.OK KI-MoVAI. 

t 



INDhRlAkKK ^- /s 

(AcMress I i ^ \) 1 >w^ 



|)A'Li:i»! MruiAi. or Kl-.MoVAI. 



N. B. 



r\,Mi.ss ^^ --' „l_ILL PHYSICIANS Hhould 



■•' ) 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n<..ir<l (if Hc.-ilth— F N'o. i =; ■J^^aifKoS:^; jut I» C< 



i^r; 



Ddic Filed , 




JS". 190 H 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begisteved JSI^o, 



1GG9 



.^rlA.^^ 



I i 



.^vu Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( XI. S. StanSarO ) 



% 



PLACE OF DEATH:-— County of Oa>^\j vj A/> 



Q^ 




City of OXX )V 



10 



f No. cl 5 I 5" \X} OjUtSJJ'x \ Q. 



St.: T D 



^f ft 
ist.; bet. J X.Ll^:\YVfiX-. 



and 



cVU'. 



(IF DEATH OCCURS AWAV 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 




\ 



A)! 



M 



V, ' 



PERSONAL AND STATISTICAL PARTICULARS 

SKX ,^ A I COLOR I ^ ;, 






DATl-; 0|- lUKTH 




(Day) 



.. t .1 1 

(Year) 



AC.K 



MEDICAL CERTIFICATE OF DEATH 

DATK OI' DKATH _V 

axkt. I ^ 



(MoiitM) 



Day) (Vt-Mf) 



% 



)'i\i I . 



?^ 



.1 A ->//// V 



/),MA 



>^IN<;i,H. MAKKIKD. 
WIDmWHD or DIVORCIW) 
(Write in social di si>.^ii;itii)ii) 




■ > 



HIK lUl'l, M'K 
(State or I'oiuitry) 



NAMI-: OI" 

iAiin;K 



HIK IHI'LAlK 
0|- }Al'!n:K 
(State or Coniilry) 



M XIDKX NAMH 
OI MOTHKK 



HIKTMI'I.Ari-: 

OI' mothi<:k 

(State (»r Country) 




"(is 



1 ni-Kl-I'.V CI'RTIFV, That^ I attended (Icccasod from 

Ll^A.»vvl...llM;.up ' t(, 3jL|\.t 13 . upH 

that I last saw li XV alive on O.^ j t » ' up . 

and that (kath oceiirred, on f he date staled ahove, at II oO 
\J: M. The CAlSI'LOl- DIvATII was as follows: 



v,V 



I Jl RATION }'('i2LS^ ^ Moulhs 



CONTRIIU'TORV \^lAA,<60r.;v^.w. ^ "^ ' 



Pays 



Hour 



,1 



lURATlOX 



(Signed) 




Months 



Pay a 



Ka^ ywX'N/'yt^i^jLu^a. 



Hours 

M.D. 



QA:^ 1H TOoM f.\ddrrss)lU -^K^ ^ ■- ^ 



occri'ATiox A 

Rf^idfil in Sirif I'l nil, i-<-,i cK\) )''-'ii^ ,lA-/////s 



/),/:. 



run AHovK sTA'n:n i'Kksonai, i-akimiti.aks aki- ikik to thi-: 

HKST OI" MV KNOWM-.IX.H AND iu:iji;j" 



Special information f»nly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying civ*<iv from tiome. 



(Iiifoiniant 



(Hd. d tjU^->^'-K!V>w^ 



Q^ 



\,l,lr,ss 0^5^^ 0.\XX/^'->\^*V-C U"^ 



Former or 
Usual Residence 

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

IM.ACK t>l- m KIAI, OK Kl,M(i\AI 



How long at 
Piaf e of Death ? 



Days 




us 



I) \ji; o! i!i HiAi or H i;mo\ai, 

.JjL'^vl' lf)0 \ 

ndi:ktak KK Ll o ', v<^ '^Ji e o ^^ ; .. 

'k - LI 'A, L' <X^-rwVU,'^t>L \,Lv 



1-^.^ 



(A(Mi. s> 



N. B. Kvery item of information should be ci.refully Hupplied. A(iB Hhould be Htntecl EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH in plain terms, that it mi.y be properly claHsified. The Special lnU>rmHtion tfor pt.r- 
«on« dylnft away from home should be feiven in every instance. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H<.:inl «.f llc.-iltli -I- N'o. i^ "^-rJ^'^'li? 15&I' Co 



l),(le File<l A^O^,!tjLrrrd>JJx, 1.5:^ 100 H 




Reginteretl J\i''n. 



1 670 



bX.'^^Js 




.^y\^y Deputy HcsJth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( "U. S. StanDarD ) 
PLACE OF DEATH : — County of ^'<X/->v J A.(XY City of C' Cu^v J A.a.-vvcv^L c 



% 






(No^vCVCUax: l!v^ 



(ax: h 



St.; 



Dist.; bet. 



and 



/\ir OeATH OCCURS away TROM usual residence give facts called for under "special INFORMATION" N 
\J IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME cLuw.^\Jio-.. . M.L^ci\..c:'.. 



SKX A 



PERSONAL AND STATISTICAL PARTICULARS 

I coi.ok 





DATl-; of ItlKTU 



\».i': 



a.. 



iM..nth> 



v\ JV,n> 



^ Am 

(Day) (Vear) 



MEDICAL CERTIFICATE OF DEATH 



MnuUn 



Pa V.- 



SINCI.K, MARRH:i) 

WIIX »\\KI) (»K I)1V< (KfKl) 

(Writf ill sfK'ial <U'si>fiiiiti<>ii) 



lUKTMlM^AOH 
' St.itc or Coiiiitrv* 



,<kjT\AS^^X^ 



NAMI-: c»i- 

FA'nn:R 



HlkTin'I.ACK 
<U' lATUKK 
( Stiitf or Coimtrv 



MAIDHN XAMH 




J JU\/^-\ v-o-'yaX 



DATE OF DKATH 

d.avt 



(Month) 



(Day) 



(Vear^ 



I iri'RKRV CI'RTIFV, That I atten.kMl dcciastMl fn.ti 

.OJl^'^xI'. 190 to (^X)fsX) 

that T last saw h • alive on 



Ji 



'..V 



up • 
190 



ami that dt-ath occurred, on the <iat(.- stated above, at l-oC 
(X M. The CAlSIv OF DI-ATII was ns follows: 



Ci^\jJLrVrcJl cfo-^Ji^^^-crY 



(3 



Y\\X^ 




LOlv 




XVY>a/rrU> 



1)1' RAT ION Years A/on //is b /^ays 

CONTRIIU'TORV LL^,L^^-^<i J - 



Ho It PS 



n 



niRTMI'l.At'K 
Ol" MOTMHK 
(Statf or Cojintry) 






OCCl I'A'IION 



Years Mont /is Pays 



DTRATION 

(SIGNED) v^'^'^^'^^ 
C\ QUI.. I ,..r. \ [ \,Mr..ss'» T C i Vj WjXKJf 



Ji\\L 



TOO \ ( 



Hours 
M.D. 



)V<? 



•\t,n,th> 



Ihn 



■\'\\r \!{()VK STV'IKJ) PKRSONAl. I'A K lUT I.A RS A R IC TRIK '1< > THl-; 

ni:sT OK Mv KNowijax'.K AM) in:i.ii:K 



(Infoittinnt 






Special information only for Hospllals, Institutions, Irdnsients, 
or Recent Residents, dnd persons dying away from liomc. 

Former or "^ f ^ K f ! -> ■ 

Usual Residence - ^^C) vA.{r> v ^^ \ t 

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



How lonq at 
Place of Oeatfi? 



Days 



:)v>r:^.- 



J'l.ACK Of- IMRIAI, OR RIlMoVAl, j DAJImI 1{i kiai or RKMO\AI, 




INDJCRTAKI'.R 

fAiMic^s 






„ .. •• 1 \rF «»,oiil.l he Htiited fiXACTLY. PHYSICIAINS Hhould 

N. B._F.very item of informHtlon should he cnreV'ully suppi.ed ^«J; ^^^Z^'^,"^^.:* •*'=;!^ ...Special InVor.nution" for p-r- 
state CAUSE OF= DEATH Jn plain terms, that it may be properly ciaHsmea. . 

sons dyinft away from homo Khould be J^iven in every instance. 



41 









' { 






it 



'I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTfFICATE FOR INSTRUCTIONS 



IfoMKl i.f Hciillh -(•■X.). n l^-^J^cT^-, ItiSil' (.V) 



RcgisfcTed J\'*o. 



1 C7I 



Ihilc Filed, d^|xtx^^Lux. IS" 7.9(9 H 

dx-^Lcvx^ Xv > ■. .^ Deputy > 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



ith ofi.cer 



Ccvtiticatc of 2)eatb 



1 "CI. S. Stan^ar^ ) 
PLACE OF DEATH: — County ofCcL vv vJ .>v<x 






City ofU'0^">\' Vo. ^ v.a^«w<i 



No. b b \ 



J I 



St; ^ Dist.;bet. ->^ L!v and • i 

(ir DtATH OCCURS AWAY FROM USUAL R E S I D E NC 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. / 



) I 



i 



FULL NAME tl>v-<^A^ 




AX^^rL^.^'vv?-, 



i'.,...- 



PERSONAL AND STATISTICAL PARTICULARS 



SI 



■■^- >?D 



1 



DAIl". nl- ItlKin 



COl.OR \j 



T 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DTvXTM J^^ 



M.iiitlil 



A(,K 



-51 



^' V JV,;,, 



(Day) 



.!/,'»////' 



(Year) 



Paxs 



•^iNc; i,K. M\Kkn;i) 
\\ii)<)\\i:i) »»K i)iv<»i<ti;i) 

'Wiitfiii N(Ki;il fU'-i^'iiatiim) 



^ '^ ^^ Q 



HFR rnj'i.Ai'H 

iStati' or foimtrx-^ 



VAM1-. <)»• 
»• ATIII-.K 



HIRTMPl.ACK 

ni- lArill'.K 

I Slate or Coinitry) 



MAIItlvN NA Mi- 
di MorHKK 



HIK ini'r.Aric 

<»1- MOTIIKK 
(State or Country) 



\ 



J.X.kt) 

(Montn) 



(I)av) 



I QO 

(Yt-ari 



I lllvRl-lJV CI:RTII-V. That I attended .Iccoased from 

It 190'! to C-^^^t l^i i(>o H 

tliat I last saw h ■■■■'■ alive 011 jXY>wt Kp 

aiiil that death oreurrcd, on the date stati-il ahove, at i 
M. The CAlSlv OF DIvATH was as follows: 




Dl'F^ATION i Years Mouths Days Hours 

C" N T K II U "!' R \' wlw^rvXA^t. LU^I" 



1)1' RATION "^ ViajJ 




jCKVCLcx 



OCCri'ATIoN 

f\f^r(fftf lit Siiii I'l ,111, i^i'ii K ) '<" 



M,, nih- 



il'! 1 



f Signed ) 

0x1 vt 15- icoH 



i\) 



Mouths 



i^uA/\<Twd..'.. :„ .." 



Ihivs 



Hours 



{ 



M.D. 



Special information »nlv for Hospitdls, institutions, Ifdnsifnts, 
or Recent Residents, dnd persons dviny dHdv Iron home. 



Tin- \HOVK ST\-n:i) I-KKsoNAI, I-\KTUII.AKS AKI-; I'Kt }•: in TIN-: 
iIKST ni- MV KN«)\Vlj;i>C.K AND \\\:\AV.\- 



(X.l.lre^s Id I:) I diA^UAN^JLt ol 



o 



Former or 
I'sudI Residence 

When Has disease ronfracfed, 
II not af place ol death ? 



How long at 
Pld( e of Death ? 



.. Days 



1-I,ACK <'l lU KI\I, <>K Ki-;M<>\AI, I HXjl.-: i:i kim. mi K )•; M < »\- a I. 
^ <3jl^..Ito I90H 



' (AD cA^ Vuft-^^i- - " vyv" 

• N I » 1: K T A K i: K 1 I l'(PrVoJvOu%AJ W fc (XKOj V, Lc 
(Ad.lr-ss l-bHl 0>V^.^.4.',^-^.. ■■ + 



IN. 15.- 



II All KhfMilcl be Btated I.XACTLY. PHY.SICIANS Hhould 
— F.very Item of informntlon .hou Id b. cnrc»ully HuppI.ed. ^^'^^^^^/^'^^^..^i^' ^he "Special Information" for p.r- 
Htate CAUSE OF DEATH in plain terms, that it may be properly cla»«itiea. me v 



Kon* dyinft away from home should be i^iven in every instance. 



¥ 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lioMi-.l „f UvAhh !•• Vo. i^ i^-t;g^lk-Ml' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafr Fi/ed, r]jL 



1 



<ru^\.'"N 




Begistered J\,'*o. 



1 67f> 



^ * I • 'v 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



(Tcvtificate of 2>catb 

( "a. S. StanDarD ) 



4 (^ 



PLACE OF DEATH: — County of^'Ccn^ 0\<X>vCAAtO City of Oy>v ,'vCX.->rv«.<X»,C< 



'No. 



(1> 






\y-\-\.0/>, •, ;l_'..vavvti'v.^ 'JV' ^ . . St.; 

/Air DEATH OCCURS AWAY FROM USUAL 
Vj IF DEATH OCOURRED iN A HOSPITAL 



Dist.; bet. and 

L RES I DENCE Gi VE facts called for under "special information \ 
OR institution give its name instead of street and number. / 



FULL NAME 



M WX/Cu \J J 



-k 



PERSONAL AND STATISTICAL PARTICULARS 



V I 



dad: <»i- hik rii 



AC. H 




COI,(>R 




MEDICAL CERTIFICATE OF DEATH 



DATR OF 



iMnllth) 



(Day) 



(Year) 



^^> 



) '»•(/ ; . 



M.nilhy 



Da 1 A 



SIN..I.I-, MAKkU-.D 

UIIx iWi:!) < )K niNdKCKI) 

l\Viit< ill ^iHJal ^l(•si^r^^ation) 



niK rni'i.ACK 

'St;it< III I'liimti \ 



NAMl- <»l 
I AT 1 1 IK 



niKTUl'I.ACK 
C)|- I AIIIKK 

'Statt or louiitrv) 



MAIDl'.N NAMK 



MikinjM.AfK 
op M(trin-:K 

(St;it<- or C"o\uitr\- 



omi'ATlON (X\p 




•^ DKATH _Q 

., Dxkt 

(Montm 



(Day) 



<Y.-Mr> 



I ITRRrCnV CIvRTfl'V. Th.it I, attoii.U-.l (kccascd fn.in 

sXuuCL L.*, up to Bx^^AjtF. J..LV ic)oH 

tliat I last saw li -.. alive on Qx^t 1? up i 

ami that (katli octiirrcMl, on tlu- date stati-tl above, at H 
.. -U^ M. The CAT SI'! OI' DilATIf was as follows: 



or RATION 



)'eats Mi'utha 



CO.NTRII'.rTORV )olh>X\J^UCXA 



Days 




I /ours 




^KlXsx/w^^ 



JwN AX'L Ow^'^^v-- 



1)1' RAT ION ^ )'t'ins Months /hiys 

fSlGNED) \Xj . O ^ 1 J: x^^.-^ V5 



Hours 
M.D. 



o-va^;iXa.^\.. 



1 '> 



h'r iilnt ill S<r» I'j uinisfo ^ '■ )''<i> 



}/.,>if/n 



/',n - 



Special information only lor Hospitdls, Institutions, Iransicnls, 
or Recent Residents, and persons dying dw,jy from home. 

How lonq at 
VX pidf e o( Dedth ? ? OJfT^ birrs 



Former or ^ 
L'sudI Residence f<0 



vJ M.ca1<Xj 11' 



Tni- xuovK sT\Ti:i) i-kk-^onai. i-AKTicn.AK^ AKi; Tkii; to tid': 

Hi:sT ()!• MV KN<>\VI,i:i)<". H AND lU'.I.II.I- 
(InfoMnai.t M rVX^ ^(X^A^''''' 



\,1,1,,.SS JnO 




When Hds disease confratfed, 
If not at plare of death ? 



/vX. 






l'I,\CI-" OI lU KI\I. •>!< K1:Mo\ \I, I HATi;<Jl m kiai or RK.MOVAI, 



'Ad.hcss 



•jJi.A'..': 



N. B.— Hvery item otf information »hou hi b. curctully supplied. ^""'''^^'^^J^^'^^, ..8p,,5„I InformHtlon" for p-r- 
Htote CAlJSn or ni:ATH in pliiin tcrmH, that it m:o be properly wlaHKinctl. i ne op 
son. clyinft away from homo nhould be feiven in every inHtfince. 



i 



V I 



I ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OR CERTIFICATE FOR INSTRUCTIONS 



Mi'Mi.! i.f ll.Mllli 1" Vo : :, ^•^^^^^; I!i"vl' Co 



i 



ii!-5. 



W ' 



l)((h> rilrflAx\-sXx^^-AyAK^. \S. V^Ci 



UA^^:) ^ic\M.« Deputy irieaUh OfTicer 



Bogi.stcred J\^o. 



\ 073 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of J(X^A) JA.a 



ff 



Certificate of 2)eatb 

( 11. S. StanDar? ) 

V City of J <X '>\i vJyVc 



^C4Ci 






( No. ) . Ct CcL ^c J s^ O^^lKl 



±ai 



St.; 



Dist.; bet. 



/i ir Dt*TH OCCUR'S »W*Y FROM USUAL R E S I D E N C E Gl Vt FACTS CALLED FOR UNOtR "SPECIAL I N FOR M AT I O N" "\ 
\\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



^j:\ 



L 



\y\\'K oi' luk 111 P 

Oxixt 

(Mouin) 



COI.OR \ 




IMX^ 



± 



(Day) 



(Year) 



ACK 



..V I ),;ns 



M.'uths. 



Davs 



SINCIJ-:, MAkKII'.I) 

\\ii)<)\vi:i) OK Dix'oRrKH 

iWiilfiii siKJal fksiitMiation) 



a, 



If 



lUKTm'I, VOK 
(Statf or ^'')lmtI v^ 



NAMl'! ol 
f' Alin.K 



HIKIliri, AiK 

^^^^ lArm-'.K 

(State- or CoMDtry^ 



MAIUHN NAMH 
<)I- MOTMHK 



lUK'nilM.AC"!-: 
(»l' MOTMlvK 
(Statr or Coiuitrvl 



OCCUPATION 



,^ 








MEDICAL CERTIFICATE OF DEATH 
DATH OH DMA TJl \ 



.Q.l/l\ij 

(Montn) 



<I)av 



(Yt-ar) 




\<rv-\>LO-^ 



, I Ifl<:Rl':HV CI'RTIFV, Thiit I attcndi'd (kocascd fn.m 

iSjupk, i;^ up to .x^ j<..>|%.fc .\.^ u^ H 

tliMt I last saw li-tt-—' alive oil C3wL.y\.\. np 

and that ilcatli orc-iirred, on the ilati- statctl above, at i O . 
....V.L....M. The CAl'SI': ()!• DI-ATIl was as follows. 

0.^:\,^%JU.:^......Ll^^J^ 

Dl R.VTION Years Mont /is ^ /hiys H Hours 
CONTKIIU'TORV « 



nr RAT ION >H Years 



■ Mouths 



/hi 



vs 



Uou 



rs 



«. 



u 



UJ- UK 



n- 



kVsi(!r(f ill Sr.ii /"/»///. /w" 



>V(M 



]n<)ith.- 



/),/! 



(Signed) ...\/yss^Wif^^^oj \jj M^.w-i'^^u^^ M . D. 

^.i.l-.t 1? TOO f Address) ^000 OU'^kX^^v -H 



— ■ 

Special information only for Hospildls. institutions, fransients, 
or Recent Residents, dnd persons dyiny dWdy from tiome. 



Former or 
UsudI Residence 



\[\ 



tu^ 



t 



HoH long at 
Place ol Death ? 



Days 



Tin- \HOVl- ST\Tl-n I'KK^ONM. I'A KTKT I.A KS A K 1- TK IK TO TUH 
lil-:sT Ol' MY KNO\VI.i:i)f.H AND lU-.Ml-.l- 



(InfoMDatit 



.,s . 



{ \(1<1rt-<s 



1 i 



v.. <X,r. 



'W 



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



l'I,.\CK Ol' lUKIAI. OK KI-;Mo\A1, 

"(^ 



DaXTi. ')!' HiKiAi. ni ki;.Mo\'.\i, 
1^ I90H 



7. 



! 



rxi.KKTAKKK Ux^X^^r ^< ^A^ClA ' .. I ). ^ 

(Address ^^ V^ O ^v ^/Vi^^, ...k.!, • . 



IN. B.- 



«tote CAUSE OF DEATH In pl«in terms, that .t mny be properly dossitiea. 
Ran. dyinft away ?rom home Hhould be ftSven in every instance. 






r 



rt 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



llo.ltd of II. ;ilf)l • I' Vo I- '^•^i!'=?~i^ l'.S.-I' (' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)a/r /••/A'./. Oxlxtx^al-Vv .15 ll^O'-[ 



Br<fi.s/f'iCfl J\''o. 



IG74 




^Uv-v_: 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "U. S. GtanJ>arC» ) 

PLACE OF DEATH: — County of Cj CUYv >ua.^vcULC< City of CUO^ 0/^^>>vCa^ 
(f^ J3 • M I LoAtt/^ ub CHlJ^VLV nj St.; -— ~Dist.; bet. and -— 

/ \r DtATJfoccuns aw*y from USUAL RESIDENCE Give facts called tor under "special intormation-' 'X 

V IP DE4TH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




si;\ 



PERSONAL AND STATISTICAL PARTICULARS 



DATi; «>!• lilKTU 






'M.mlh) 



- f.lkX.. 

(Day) (Year I 



AC.K 



I ^ )V,ns 



.*:. M.'tilhs r. 



Da 1 



SINC1I.R. MAKKIKP 
WIDOWKI) OR I)!\<>Ki'Kn 
iWiittiii >»<K-ial (irsij/natimi) 



/>, 



nrKTui'i.ACi? 

(state or i'onilt 1 v^ 



Nwti-: oi" 
FA i'ui;k 






MEDICAL CERTIFICATE OF DEATH 

T)ATK or DKATH l 

(MontH) ll)ay) 



(Ycar^ 



I IirCRnHV CI'RTIFV, That r attciKU'd <K'ii'asc'<l from 

.aji^^xti... ..a 190 H to .....o-jL.J:\:fc.....i!i... 



190 % to .....s^-*L.j:^uU.....,l..':^ up i 

iliat 1 last saw li - ali\-c on OX^^^vX ' , Tfp M 

and tliat iK-atli Dcnirred, on the date stated ahovc, at 
J. . M. TIk- CATSr: Ol" I)I:ATI1 was as follows: 



HIK IHI'I.AVK 
<)!•• J Alin-.K 

(State >ir ruutitry) 



\fAinKK NAMK 
OI" MOTIIIIK 



Hnnnri.AOH 

ol- MoTHI'.K 
(State <>i I'lmiitry^ 




DT RAT ION Yi-iTis 
CONTRIHUTUKV 



Months 



Days 



Hours 



{n>Aji^ 




0CC1 



VJ/(XA./V^A^^ 




1)1" RATION Vi-ars 

it 



Pax 



Hours 
M.D. 



Months 

( SIGNED )..,.L4^^x^''v^ JOrWx.a.'> 

e^ . . ' ' i.,o (Addn-ss) Ot viria\L|o 1^-^; ' 

Special information <»n!v tor Hosplfdls. Insliftjtions, 
or RecenI Residents, dnd persons dying away from home. 



Fransienf* 



:Ji_. 



^ f 



h'r-idr.f III ^<ni I'liitu i-ri> , .-. v JVrM 



M.oilln 



iKi 



TnKAH.)VKSTAl-lU)PKKS<)NAI.rAKTKM-LARSARKTKrKTn THK 
niCST ol" MV KNo\VI,l-:iK".H AND lil-.MJ-.l- 



(Itif')iinant 



I X.ldress I ^ O A 



^.Q> 







,/CXa^ (j.K 



Former or ''\ Ms 'in 
Usual Residence^ I ^ '-^ 

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




\, HoH lonq at 
AVOlOv Place of Deatli? 



Days 



I'l \CK ()]■ lUKiAi. ok R^•:^!t>\^I, 






l)\r]:.>(" HiKiAi. or RKMO\'AI, 

t 



190 



rXDlvKTAKHR 

(A<l(lreHs 






-'^*"-- 



—"■"—"""■""— """"^^ r^i AfiF should be Btatetl EXACTLY. PHYSICIANS «hould 

:S. B.— Hvery Item of information .hould be cnrefully -PP^- ' J'^^^^^ ,,„,.ir.ed. The "Special Information" for p.r^ 
Htate CAUSE OF DEATH in plain terms, that .t ma> be properiy i 

«on, dyinft away from home should be ftiven in every instance. 






♦ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



J 



r.o.iMl -.f ll.-.;!tli 1- N'o !-. ^•?|^j2:i)IU"tI' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(//(' riled, r\ 



0-"Vw^wVO 




IS: 



iofn 



Begi.sfrfed J\^(). 



1C75 



uepu.y Tfeaun 



-r 



DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



(Tevtificate of H)eatb 

( 'U. S. StanDarD ) 



^ 



PLACE OF DEATH: — County of J<V>V JyXai-vCu.ca.City of CVa.-vV 0.^a'%vCv^,ccL 



No. 1 1. S H 






(ir DEATH OCCURS AWAY rnOM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



A 



St.; 



Dist.;bet. b ti 



V 



and 



FULL NAME 



C' 



A. 




SK\- 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oK ^ 



.<xXx 



i).\ !»•: I >i niK III 



l^Iontli) 



AGH 



I lUi f .« 



% 



Dav) 



M. in His 









. b 

(Year) 



Day: 



slNC.IJv MAKKIl-.O 
WinoWKI) OK I)IV< iRi j: 1) 
(Writriii ^i>i-i;il (ifsifj^natioii) 



lUR ritri, \ri-: 

'Statr nr •"<niiiti V* 



NAMTv or* 
I'ATIII'R 



HiK'rmM, Ail-: 

(»!■ lAini-.K 

' Slatf <»r Coviiitrv) 



Ctiv J Vol ^v-Cc^lO'. 



'XCOAj 




U<x<:^.^.,.e IL' 4v.Aj. 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



(Month) 



I t. 
iDay) 



(Vfarl 



. I Hr':Rr':RV CI^RTrFY, That T nUcii.k-.l (|e(H'Hso«l from 

c)jiL\.:>X. k..6. 190 ':l to ^ Kp 

that I last saw h • alive on O.^^^t; 13. igjj..^. 

and tliat dcalli orcurred, on tlu- datr <tat«.-d above, at 
^r Tlio CArSlv ()!• DIvA'I'II was as follows: 

^.J^^aJL l<^....^i)r1>rtl.'Ll....|^'^^^ 



ftij 



V^c^-O 



M.\!!>J-:N namk 
<»!• MOTIll'.K 



O <x cLuL 






,»->'V,^ 



Dr RATION 
CON 

1)1 RATION 

(Signed) 



Ycfli'^ 



.Vonths f^^^^^'Pavs //oms 

T R I lU 'TO R V ^^<xl>-u. A^V-O>.0 . L<X<i!U<CVv..:5i.^^u^^ 

}'rars , Mouths 

^.X^. . AhA:^*^ 

OX\^ IH TQoH (Address) Sib jWt^v:>nA^ ji 



Pars 



Flouts 
M.D. 



HIRTUIM.ACJ-: 
(>l- M on IKK 
(State or Country) 



OCCITI'ATION 




Special information "nly tor Hospitdls, institutions, Irdosients, 
,. Recent Residents, and persons dying d^vay from liome. 



^VA/Tw-tn VCU - 



h'l-iJr,! Ill ^<ni I'l ii'h 'V«» 



);;ris I M'oilhs 'A 5 Ihi 



THK M5.)VKST\TKI)I'KUS..NA1, PAKTI;;i^I,\KSARKTKrK 

iu;sT ni- Mv KN<>\vi,i;n<".K AM) r.i'.i.ii.i- 



To TIN' 



f IiifiiMiiaiit 






i \il<lress 



lormer or 
llsudl Residence 

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



HoH long at 
Place of Death ? 



Days 



l'I,.\Cl-: Ol- ^IKIAI. OK KKMo\M. 

( 



'^jxt QLv^ 



I).\TJ-: m! Ill nim, I 'I K l.M< >\A1, 

iS 



r.N'DllRTAKF.K 

fAddvc'^s 



, ).-i.;|aXi '.%». IQO 

30 5 (y>\^A.t<^:^' ll- 



""^ r^ A(iR HhouM be «t»te.l KX4CTLY. PHYSICIANS «houlcl 

N. K._i;very item oi InformBtion Hhould be cnrotully -;;'; '"^ *, „^.;p:."y l««Hh".ed. The "SpeJal intorn,»tK>n" W p.r- 
state CAUSE OF DliATH in pli.in termfi. that it mj.> he properly 



«on»\lyinft away from home should be ftivcn in every inKtnncc. 



6^ 



i. 



: 



f 



\ 



1 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lioiiKl of II, :,!th- (■v.) !--, t-'?'^^»^', n.S:!' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/>a/r /•V/^''/,C^.x|x,Wv-n.lMA. IS" JfW\ 



EcgistPTpd J\,''o. 



1 676 




-0-\^cvo 



X 






DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



No. 



PLACE OF DEATH :- 

A ( IF DEATH OCCURS llvWAY FROM USUAL 
y \ IF DEATH OCCUR4JED IN A HOSPITAL 



Cevtiticate of H)cath 

I "U. S. StanDarD ) 






(^ 



County of- Ow^X- O-Xou^n^e^^^LCcCity of O/O.^Vu J/vCWwav^^4 



<^ ' St.; - Dist.;fc(;t. and — 

RES IDENCE GIVE facts caled for under "special in formation" \ 
OR institution give its name instead of street and number. / 



■•) 



FULL NAME 



f La\.^^Lv. 



^ 



PERSONAL AND STATISTICAL PARTICULARS 

DAIl", (>I niRlil 








Month) K 



A(.H 



V I J 'lit I s w-S. 



(I);iv) 



M.nillr 



X\ 



rVVi: 

fVear) 



Da \ A 



sinc.m:. maki<ii;i) 

WIDOW i:i) OK DIXuKil'I) 
(Wiitcin scK-ial (lf».iiMiiiti"ti) 



ni 



<XVvULcL 



lUKTIIPf.ACK 
(State or (."otiiitrv'* 



WMI' <>!■• 
I- AIM VM 



!UK III I'l. A* !•: 
Ol' lAIIIMK 

iStritr oi fouiilry) 



MAIIU.N NAMl' 
OF .MOTFIKK 



lUU rilIM,ArK 
ni- M()|H1:K 
(Stall- or Coutilry^ 



OCCUPATION Op>P 




DATK OF ni'.ATll 



MEDICAL CERTIFICATE OF DEATH 

i 







I go 

(Yeai ! 



B 



I HIUM'BV CI-F'iTrrV, Tli;il r altoiKK-.l <!c,t.Mse.l from 

UjJpX.. 



.'. .'L igoH to ...CJJL^tA. i^. up": 



tliat I l.ist s;iw h '^.' alive on 0-«^%fc ^ 3^ lyo 

ami that diath occurrcMl, oil tin- ilati- statc-<l ahovc-, at I I o 
...v-'>. M. The CAl'SK OF J)lv.\'ril was as follows: 

...VlxJCro^t . LLl'-^L c_£^:. 



I)IR ATIO.N )'rnrs 
CONTKIIUTORV 



Months 



nav.<: 



I lour ^ 



I) r RAT ION ^^J''?-/:-^ 

(Signed L ..1. 



M,>)ith^ 



fhlVS 




'y\X L(5trivt\; 



^%jLA,.y\J-\^ 






jV,7rT * v../'///- 



//,/!> 



3x1 .;. 



l()0 



( 



A.hlrrs.) LLL^^^iQ WO 



//ii/U \ 

M.D. 



4. 



I JT ; 

Special information ""ly ''"^ W*spitdls, InsHlufions. irdnsimfs. 
or Recent Residents, diid persons dyiny dHdv from home. 



TIM.' VHOVK STATi:i)rKK^«)NAI.l'\KTI(rr.\KSAKi:TKl K T<> nil- 

Hi';sr oi- .Mv KNt)\vi,i:i><'. !•; and Mi.i.n.i- 



I I n tut 111,1 lit 



c.a%^cu^ 



\.l,li.ss [.aXu^^^C 



Co 



% 



^ 



(^■Ui\jJK.€C^^ 



Former or , , ^ -4 y ;A -♦ 

Isudl Residence ' »^ 1 ' i ^'f^ ^'^' 

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



How long at { 

PIdce of Death? ^ 



Odvs 



l ft n 



^ 



w^. 



DA II, •<>. Ml HIAI. i.t KI-;.M<»\AI, 

JL\\1i i^ 190H 



(,\<lilr«.-Hn. 



r1 



INDKKTAKKK "AJuULxu CL^^.d- 'O C\,C^a/%V 



.:iu;. 



N. ». Hvery item «tf Informi.t J«n should he c.rufuHy huppIkmI. '^'•'' "I^''';''' 'I'J.j^j '*"rhc^«^8pT.^^^^^ In'Jor.m.t'lon" fol- pHr- 

•t«tc CAIJSI or DI:ATH in pli.in term., that it m».v be properly JuH«.Hcd. »pcc 

«on« dyinft uvvny from homo nhould be ftivcn in every mKtnncc. 



f 



WRITE PLAINLY WITH UNFADING INK — 



Hoar.l of lU-alth- K No. i^ t-^^^^^ UScV C . 



THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Da/c /'V/r^/,J^\jLktjL^U>X\; IS". I'^O'i 

DEPARTMENT OF PUBLIC HEALTH 



Be^i'stcrcd J\^o, 



IG 






City and County of San Francisco 



Cevtificatc of "Death 



iB 



PLACE OF DEATH: — County of ~'V >v J \XX >v<XA tc City of Ocx-W 0>UX.Wt^c 



and 






FULL NAME 




XO'\hja.....w.rU^oXl 



\ 



-^f \ 



DATl-: ol MIKTU 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




<xix 




A' 



wxJt 

Month) 



lb /ll" 

(Day) (Vear) 



Ai.K 



mMW K MARKIKH. 

\\ IIK.\V1-1» OK niVORCKI) 

(Writ*- ill social <1.. -u'li.if.MH I 



HIKTIU'I.ACK 
'St.itt ol Country' 



N-AMH OF 

1 AT III. K 



I'.iK'inri.ACK 

Ol- 1 AIJJKK 
(State or Count, y) 



MAIDKN NAMH 
<H MOTHKK 




X'X. 



I>a\ 



(31) ^) 




lUK riiPT.ACK 

nl MoTllKR 
(Statf or (."otintTv) 



« H-C 11' A rioNfT' 



/^ 



1(1) 



1 ' 7 , . 



\f.,>itJi 



r-.i 



nivy,v^iv-^-^;.ivi:iu-^^^;"^^!'--"^^^'^'"''^ '" '""^ 



f Infoi nirint 



a 






f 



3]( 



MEDICAL CERTIFICATE OF DEATH 



DATE Ol- DKATII J. 

dxAxL 

(Month) 



11 

(Day) 



I Year 



I in:Ri:nV CI:rTII-V, That I uUcii.IcmI at-oc-.Tiod from 

'AxVvt. :.i igo-A to '^M^- i-^ i<^ ■' 

llK.t I last saw h ■^;>^.alivc on OJL-^^ .l.\ .up 

an.l Uial .katli occurred, on the- .late statc-.l ahnvr. al 
K? AT Tlic CAl'SI*: Ol- Dl.ATII was as follows: 
<S.....vX^.A/L6::v^-A„tA.C) 




— • ■ "" " rt 

DIRATION y^'ors Mouths ^. PayM 

C ( ) N T K I H r T ( ) R \' . Ll4^Va/>^clL.C<d.V^i 



//ou 



rs 



Mont ha 5^1 l^ays 






(Signed ) 



'A . ^ I 



Hout' 

M.D 






SPECIAL INFORMATION «nh tor Huspitdls. Institutions. Ffdnsienls. 
or Retenf Residents, and persons dyiny mA\ froii tiome. 






Oay^ 



Wlien was disease (onlracted, 
If not at plare of death ? 






J'UACK Ol HI KIAI. OR Kl.MoVA!. 



Xix^J^ 



rS-DlvKTAKl-.R 

(AtMuss 




n\ri. ./t III KiAi- or ki:mo\ai. 

„.i.^vt IV. 190 

jUxL ^< vie , 



,^ 



o 



{S^ jIU^^^-^ 



\^^ 



.^^^.^_^^^^ ^^i^«^M^— ii^"^*^"^*^— ^^^ . I V4CXI Y PHYSICIANS Hhoultl 

state CALISl-- ur ui-^yi ^ Aiven in every instnnce. 

«on, dylnft away from home should be fe-ven m e e y 



%' 




*m^ uA^t ■_' 



C:!^ 



.«!,■■ 



LOCALITY OF 



RECORD S 



^ 



SAN FRANCISCO 

COUNTY 

S AN FRANCISCO 
CALIFORNIA 



TITLE 



RECORD 



DEATH CERTIFICATES 



» / 



M I CROP I LMED 



FOR 



THE GENEALOGICAL SOCIETY 



SALT LAKE 



C I TY 



UTAH 



C A L I FORM I A 



DATE 



APRIL 



PH OTOGR AP HER 



1975 

MAX JOHNSON 



CAMERA ■N02683B RED ] 



VOLUME 1326 



1677 



% >■ 



t I I