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

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LOCALITY OF 



R ECORD 



SAN FRANCISCO 
COUNTY 



S AN FRANCISCO 
CALIFORNIA 



I' 



TLE 



RE CO'RD 



CERTIFICATES 



^,' 



ICROFI LMED 



FOR 



THE GENEALOGICAL SOCIETY 



SALT LAKE 



CITY 



UTAH 



C A LI FOR N I A 



D AT-E 




APRIL 



1975 



P H OTOG RAP HER 



MAX JOHNSON 




CAMERA ■no2683B red 




VOLUME 



1678 



2030 



V-. ♦ 



f 



.1 "^" '» ■ 









\ 



EGIN 



'4 




V. 



1 



■\ 






(*! 



I 



.*^K 






c 



FEB 8 1906 ^ 
mi. i. . f . . w*»«. P<w*. .V. . . .JIf. 



•/ 



F. 



EJ)Ai()\!;(i;)i):' ! \UX, 

Rt;:;cf>DE:i-i 



. ; 



By 




'^-"<— ^rw\ 




D£P 



•^ 




■r 




^ip- WRITE PLAINOnWITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hm.ii.I ..f H< ;ilth (•v.) i^ "S-^^^irriA; MSclTo 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



J)uh' Fih'il, 3.JL^vtJUY>vLe^. lb lOO'A 



Registered J\^o, 



16T8 



.(^V>tV<^ 




/\>v, Deputy Health Officer 



M 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Vi. S. StanJ>ar& ) 



(^ 



PLACE OF DEATH: — County ofQ.a>\.' ^LOoYvCo^LCi City of 0.<X.^\) 0." 



/^ 






^No. 



n ^itlo.; St.; ' Dist.;bet. i^l -tk- and Lci'V/b-^LL 

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



FULL NAME 




^ f^ 



PERSONAL AND STATISTICAL PARTICULARS 







\ 



I).\:i: nl IlIKTH 



Month* 



A<,K 



cx,i>t 



u 



J I'll I s 



\x 



(Day) 



Motitin 






/)(/);s- 



SIXCIj:. MAKRIlvD. 

wip' lu i<:i» »»K i)i\«)KrKi) 

tW'iiti-iii social dtsiv. nation ■ 



HiK rui'i.Ad-: 

(Slatt or Couiili V 



\AMI-: oi 
I AT 111. R 



IUKTliri.A(.H 
OI- I-AIIIKK 
'St;itf or Conntrv) 



maii>}:n namk 
oi- mothkr 



lUKrmT.Ac'i-: 

o|.- MoTin-:K 
(State- or I'ovuiti V 




O^VvajLxL 



^-A^tlCv^ 



igo 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OI-' I)1-;ATH Jl'' 

Bxl.\l. i s . 

(MontW) (Day) 

I Jn{Ri:nV CI-RTIFV, That I attended deceased from 

L^Kt 190 1 to a-i.^j'^jfc LS: 190 \ 

that I last saw h - alive on C.'«Cy.*. ! j^o 

and that death occurred, on the date stated above, at Os.. I 
M. The CAISI': ()l< 1)I:AT11 was as follows: 



Dl'k.VTION 






'y\j VJjjX^ V'^cn^; 



<X'->vck 



0^VLC\. V,LL , Va_i.| 



co^cL 



Years A/ont/p X Days Hours 

CON T R IIU; T () R V LLcoJUL Xo Oh^.-.U A-V:t.U..A.iv.<r.->.kV.a.. 




duration 
(Signed ) 



I<)0 



)V<?;-.y Mouths J^ays Hours 

oU Mk o^LLuao. ... M.D. 

^i (Address) IX?, 'OC^^^U (1l 



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



OCCri'ATlON 

Rfsidfd ni Siur I'l an, im-,} 



U3.Vv,.o\<,.t<X' 



) >•<; ; > 



.^fnnf/i: 



/hn. 



THI-: AHOVKSTATl-:i) I'KRSOXAl, I'A R'lUT LARS A R I-; TRIK To THF 
H]<:ST 01-- .MY KNO\VIJ-:dC.K AM) lU'.MliK 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



(Infonnant 



fW OXcc-vv,. (S 



(Addres.s 



11 




X^vA>:t'trw^ 



Vo^'V^ ~^'^ 



ri.ACK OF BIRIAI, OR RKMOVAI, I OATH of UtiKiAL or RHMOYAL 

(^ (X)_ 




lAj^i. I ^-^i^-^ 

rXDKRTAKKRM / V <X<i.(ii^ Mfl' 

flres.s !.QL..M}.Luj.XUwfc>.v!Ol 



(Ad 




^- ^- 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 psr- 
«on« dyinft away from home should be ftiven in every instance. 



WRITE PLAIIMLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



U<y.\}.\ .,{ II,-,, nil |- v., ir •*'- 



i. 11.S.1' (• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafr Filoil, ^Jl|(A.tx^xi^\' lb V-)0\ Registered Xo, 1679 

l^vv^. \xx^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "a. S. Stauc>ari) ) 

PLACE OF DEATH: — County of Oa->v Va^A C^;i/^': City of O a>x. J.\,0. : W'ie .. 



No. 



A' . in . -x. 

and ^-CLCv 

DRMATION'" \ 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / U 

FULL NAME IjU^kAcl V^aNi^^U. 



St.; ^ Dist.;bet.^ tLa 

(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION 
IF DEATH OCCURRED IN A HOSPITAL 



PERSONAL AND STATISTICAL PARTICULARS 



si A A 



I»\ 11". t 1 1 It IK II! 




i'( U.t Ik 



M.)iit)i> 



.\(.i-: 



vS D )>.,.> 



lC 



(I).-iv> 



Moith^ 






Vcai ) 



/),;■ 



MEDICAL CERTIFICATE OF DEATH 

D.XIK OI- Dlv^TlI i 

:A . ■ 

(Montn) 



IQO 



SIM.I,)- MAkKIi: l> 

u ii)» >uj:i> « IK i»i\t ii-'i 111 

(Wiitciii ^"M i;il il< ->!;.• ii.il !> >ii ) 




lUkiMUM. \t'i" 

1 St;tt«- Df I'' .lint I \ ' 



NAM I (>1 
!• AT II Ik 



Ml k run, m i.; 
<ii I A III Ik 

I St.itt III I'ollllt I \ ' 



M \ l|)i:\ N \ M 1, 
• il MoTMI'lk 



I'.Ik IIIIM,A(|': 

<)i- M(iTm:k 

(state or fovuiti v 



I 



!l 



LCV.\\ V.^. 



i 



(I)ay^ 
1 IIHRi;i5V Ci:kTn«^V, That I iittended dcivascl fnuii 



tliat I last saw li •■ alive on 



to dX^\lj i.1. 



lc>0 . 
Up 



and that dt-atli ocfurrcd, on the date stated above, at iX 
^^M. The CAJ^SI«: Ol' I) I! AT 1 1 was as follows: 



'■^ 



\ i 



9 



i 






Dl RATION ) tojs 

CONTRIIUTORV 




Mouths ^ ^^^^y'L Hour 



< M V I 1 



•\ti(in(^ ■ ^ 



\ 



Kt'^idrd III Sair /'> aih isro <^0 )'r(H s .^font/is 



DURATION \\ Years Mouths Pays /fours 

(SIGNED) \. ' hjUy^KK^^^^^,^ M.D. 

QX.|xt 1^ U^oH (Ad.lress) ^^^l C).iJ:lcV '^ '. 



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



I hi 1 \ 




Pl.ACK OF BUKIAI, OK RKMOVAr, I I)ATJ<: of Hckiai. or KKMov^I 



Tin; Miovi* si\'n-:i) i'Krsonai, pARTirrr.ARs ark truk to tiik 

ni:sT ni MY KN()\VI,j;i)(*.K AM) BKr.IHF 

IN. B. Hvery Item of tn?opmatlon should be cnrcr'ully •upplied. AGB should b« stated EXACTLY. PHY8ICIAN8 shsuld 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information*' for psr- 
sons dying away from home should b( His :t% In svsry InstaM*. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



;ni)i<:rtakkr . J.^rU..^(MX<{A^ cL'aXN.^H..v 

(Address J 5..1 \n\A,^,/;LAxQ-:>:v. ..yl. 



I90H 



<-^ 



i \ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Honnl nf II, Mith ■ t- vo. ■ -. ^t!^"^^' '-^ '' ''" R EFER TO BACK OF CERTI FICATC FOR I N STRUCTION3 



-? 



I)a/r r//('ff ,Ax\\kx/^-vJLjL\' lb, L'JO'i 



Rogi.stci'ed J\^o, 



1680 



Cru^A^ 




^^ Deputy H<^'£\\h OfTicer 

DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco 

Certificate of ©eatb 

( XX. S. Stall6ar^ ) 
PLACE OF DEATH: — County of*^ CL^y\j O.^^a^vCAXlCO City of ^<X/y\j X<Xw,'1^v^<^< 
No/1 L 1 - ■ . ' .^L '.. St.; I Dlst.; bet. Xrn\ia\A and LmJL<lI w . " 

( " ^rnV.rWirf.u^"^ "'°'^ ^^^'^^ RESIDENCE GIVE facts CALLED rOR UNDER -SPECAL INFORMATION" \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND i^iUIWIBEH J 

FULL NAME J A.Cb:^<UACOj LlcLl^:. 



PERSONAL AND STATISTICAL PARTICULARS 



DA 1 ]•; nl ItlKTM 




I J 



(Munfli) 



AC, I.; 



HI 



)/■(;; A 



IC) 



t 

< I )a V 



Mnntlr 



1 



' V,-;ir) 



/^/M 



(Year) 



SlNT.i,!.-, MAKUIi:i). 

wiix »\yi; I) OK niV(iKrj-:i) 

'.Write ill soiial iIcsi^Miatioii) 



HIKTIIIM.AOI-; 
(Slutc or r>)uiitr\^ 



NAMl' <>l 
FATIIl.K 



Hlk'nilM.ACK 

<)i- iai'iii<:k 

I state <iT (.■niiiili \- 1 



M\II)1-;N' XAMi: 
HI' .MOTHKK 



lUKTIIlM.ACM-: 
•>|- MOTMKK 
fstiitc or ('ountr\- 



OCCll'A TION 







^Vaw\xd 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DlvATH 

^MontTi) (Day) 

I HI<:R1<:HV CI:rTI1'V, That r Mtten.U-.l .lercased from 

190. to ....c)xjrvt'. 1.5 up ^ 

tliat I last saw h .. alive on 0-t.-^vi ,1 j^o 

aujUhat (K'atli ocriirred, 011 the .lati- stated al)ove, at b 
M. The CArSH OF DI-ATII was as follows: 
^-CVotv<x)(. 






t 



:y 



1 



O K 



y\VO.X 



d- (3 



^c\rv.<r L I 



nr RATION Years 
CONTRIIJUTORY 



Months 



Days 



Hours 




JL 



cul<. 







» ' 



^OLV<^0 



duration 
(Signed) 



G 



Years 



m 



MiUiths 



,0 



Hays 



)0 



f 



Address) 3. D CJ'Ui:.K:U^..^i 



Hours 
M.D. 



nr?p^„^^'^^."^f^'^'^'^"'''0'^ •*"'y f»^ Hospitals, Institutions, Translfnts 
or Recent Residents, and persons dying away from home. '■-"Mrnis, 



h'r^iili-ii III Stni i'liiiuisrn .>,■'' ) V(? 



/ V 



Mnnllis 



fhn 



'■' ".';,>'!,? ^■'•.^7^ ■'■'•■" I'HUSONAi. l-AKTUTLAkSAKl-.TKlF To THK 

luvsroi- My K\oui,i;i)c.K and iu-:i,ihp' 

(A.l.lress 3. b ' J CMA>-JL^ HX 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



.•WCK .„. mK,A,.„K RKM.,vAi. I i-va.: .,( m,,,,,, ,„ k,.;M„VA1, 
(AcMrc-ss ISXH OU^kla-vv -.L 



«on. dyln4 away from home nhould be ftiven In .very instance. "*""*^- ^'^^ ^P*^'^'-' Information" for per- 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H<.;ii<! of Ui :i!tl) - I- N'o. ! , t"?^ W^^ M& 1' C. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Date FiJpd.O 



JL^' 



VA^V\x<i 




lb 190\ 



Depufy Health Officer 



Registered J\'*o, 



1681 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of S)eatb 

( XX. S. StaiiOarO ) 

PLACE OF DEATH: — County oi'^^Oj'YX^ 0\.a>xCV4.C City ofO/CU^Aj J.\XX/%'V/CA^d 
No.s.tUv ^ V.(rWT,Alu 'lV)(>AKaal St.; — Dist.;bet. — — -- -and 



/ IF DtATH OCCURS/UWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
\ IF DEATH OCCuk^RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




u 



jxa^u L^'-d.< 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 




oX\ 



COI.oR \ A 



DAI}- ni liIRrn 



.xcr: 



• M<>titli> 



) ril I > 



V 



(Dav) 



M.»ilJi> 



MEDICAL CERTIFICATE OF DEATH 



I).\TK oi-- DKATH 







(Vcar) 



'^- 



Bxkt 

(Montli) 



(Da 5') 



(Year) 



Ihixs 



SINf.I.K. MAKKD-.I) 

WIlx )\VI-:i) OK I)!\-<»R(}.:i) > 

•U'Tittiii soci.il (IfKi^Miatiiiii ) 



lUKTIIlM.ArK 

(Statf or Couiiti'v' 



NAMl': Oi- 
l-ATI I i;r 



mki'niM.ArH 
OI- 1 A rin-:K 

I stutf i)t ri)\intr\-) 



MAIDI-.N NAMI-: "> 

OJ- .MOTMHK ^ 






1 1I1{RHHV Cl«:RTn<V, That I atteiHkMl (lccease<l froiu 

.UvAA^....V^, 190^. to ...px|\t; 13. 

^-- {■■' 1^ 190 4 



[90 
that I hist .saw h - alive on 



190 H 



and that death occurred, on the (hite stated above, at 
^ M. The CAl\Slv OF J)1{ATII was as follows 



CA.^tA.0. 



lUKTni'F.ACK 
0|- MOTMKR 

(State or Coutitrv^ 



vXCLIvUvo^xX IIll 



Dr RATION 
CONTRimTORY .Cl^^^, 



Years Mouths 



Days 



I fours 





occri'ATiox i, 



DURATION Years ^fonths 

(SIGNED) J. vi\ "Jb/ 

\ (U 

O-tlxl. ..^ Tc)0. (Address)' 



i^\ 



f^ays Hours 

M.D. 



4. 




■\ 



„r?rj?if^K"^f°'^'^?T"ON only for hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



Moulin 



n,i\. 



1U-;ST OI- MV KX<)\Vl.l-;i)C.H AM) Hl-:i.n-:K im r. i • Jill. 



(Iiifoiinant 






Former or 
Isual Residence 



Jia. 



# 




AxOu'y^ '^ 



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



How long at 

Place of Oeatli? }. Days 



vj-Cc 



(AiMress 



L^l^.V Lc;. ^'fe (H.kvt cuJ".,. 




P^.\CE OF HURIAI, OR KKMoVAI 




I)\Tl-:oi- MrKiAi. or RHMOVAI, 

^'^W't lb igoH 

(.-Vddress 1 .i.l.L \j /lA^<iArV,tr> v. ..)...* 



.on. d,i„» .w.> fro™ ho,ne ^hou.d bTtiv.n-fn'lv,:: tZZl ' """"'• '''" *""'"' '"'-"-'-•• '"- P"" 



ff^' 



I 



i 



^ 



i 






^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H..;ti<l ..f llrahli ]■ Sn i > ^'^^^ar^t 1 U«t 1' C < ) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed , 



^vK. L^: 




bj. l^ 10 0^ 



Be^istcred J^o, 



I G8^ 



u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 



( XX. S. StaiiSar? ) 



i 



<(^ 






PLACE OF DEATH: 



County of^'<X/>v OX<X->A.CA^co City of O 



1 



Ou'y\) .\. ex \ v ci ^,Ai„ CL 



No. 



a\\'Vl)\u.VL() VU,;(V'tn.^Cu LL^...^ I Dist«;bet and 

(\r DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATIO N "• \ 
IF DEATH OCCURRED IN A HO$|PITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




1 



\^CL^v^o^Jl U Cl^^clX^.. ■ 



PERSONAL AND STATISTICAL PARTICULARS 



DATl-; OI- ItlK'lMI 



COI^OR 



Lv'l vv 






A(.K 



SH 



) itti > 



\J 



15 

(Day) 



M.>ut/i.\ 



\^- 



1 Vein ) 



/Kirs 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII 



Qxlvb 

(Month) 



^iN<.i,i:, MAKun;i). 
wnx >\v}-:i) OK i)i\-(»K{i.;i) 

iW'iitfiii social (U'^ij.'!iatii)ii) 



HIKI'Ml'I^Al'K 

iStat< or ».'oiiiitrv) 




ccwoctL 



■^\ 



i-a-|-hi;k . ^]' H i ' 



IH /9^H 

(Day) (Year) 

^I IIIvRHHY CI-:RTIFV, That I attended <k(vasc'(l from 

Jll-CLUV 1 igoM to C^.JiJfJu l.H iqo 'v 

that I hist saw h v. . : . alive on O-JLy^ ' .,v kjq '. 

and that death occnrred, on the date stated above, at 
M. The CATSK OI' 1)1-; AT 1 1 was as follows: 

.^V^V^VMi^ Vc-Ow'LfwO. 




T)r RATION 
COXTRIRUTORY 



) 'ears 



Months 



Days 



Hours 



lUKTHI'UArK 
OJ" I-ATHKK 
'State or Coiintrv) 



MAII)1':n XAMK/ 
OI' MtlTIIKR 



HIRTHPT,ACK 

()!•■ MoTinav 
Estate or Country) 








1)1 'RATION 

(Signed) 



Years 



t>xa 



OCCITATION 




Resided in Sav /'i iiiii isrii ^^4^ )Vi?;> 





j}f0)lt/lS 



CU^A IS Tc)0 . (Address) 




f^avs 



Hours 
M.D. 



k. 11 



n- 



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



Months 



/>,i\s 



Former or 
Usual Residence 

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



How long at 

Place of Deatli? Days 



THI-. AIJOVK STATl-:n PKKSONAU P A K T IiT I.A KS A k !■ TKrH To TIIK 
HHST OI" MY KXO\VIj;i)C,K AND HKMKF 

(Infonnant \^>AXXiJOCXj O 'CVAj(>-<X'Vv./^yXX) 

(Address C'/OAV ^A^KJ^Tvy^ AlUJ I^tLljUi IIls^4 



I'I,ACK OF lUKIAI, OK KFMoVAI. DATKof Hikial or KKMOVAI, 

OtoJLoL^ 1 C)^fA±, IS TcjoH 

rXDKRTAKF.R UcUU^yAiilt \f)\XXJ^J^^r^ \^ \ic^ 

(Acltlress l.^.O-H Ok^^^JUr^^.Al 



N. B.- 



^^trt7c'lTs?OF HF rxH". •*'7''* **' ^"-•'^""y «"PP«««d. AGE Should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH m pla.n terms, that It may be properly classified. The •'Special Information" for p.r- 
«on« dyint away from home should be ftiven in n^very instance. •- p-f 



m 






i 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hu.-ird of Health 1- N 



•■ No. I ;, ■^^^^?i> V>f^ r Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






I)a/(^ Filed, QjL 



^KAA^ 




lb 



lOO'X 



llegisteved J^o,. 



1683 



^. Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of S)eatb 

( Xl. S. StanDarD ) 

PLACE OF DEATH: — County ofOa^A,- VawcULCK City of Oo/^aj OXavv^UL^..<. 

'Nc^'^H llA..aJ\. St.; ^- Dist.; bet. 1 5 LL and Ibxk 

(IF DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N FOR MATI O N ■' N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



QynA.uO, 



A.K.^^J) JLCLdxiA 



PERSONAL AND STATISTICAL PARTICULARS 

SKX l\ ^ A 



^]\alx 



I COl.OR \ 



DATl-; ()!•■ HIRrH 



AC.1-: 



Lax\ 



Months ' 



4 



) Vi/ ; . 



III. 



IDiiv) 



Mnnlhs 



\ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATIl 

GxUi IS 

(Month) 



(Day) 



I go 

(Year) 



(Year) 



Da 1 . 



S1\C, 1,K. MAKKII-.I) 
\\II)()\\J<:i) OK I)I\(>Kri:i) 

(Write-in ^oiial <1< sij.Mial ion) 



lURrnri.AOH 

(Statf or e"ountrv) 



\AMI'. ol- 
»• A'nil'.K 



lUKTHI'UACK 
Ol" I-ATIIHK 
(State or Conntry) 



MAIDKN NAMH 
Ol" MOTIIHR 



lUKTirri.At K 
Ol" MOTIIKK 
(State or (.'onntr\) 



% 



'X.-^) VO L>, 



1 III<:R1;HV CI:RTIFV, That J attended deceased from 
^.i. 1.-. 190 't to OJu\^X I.S. 190 H 




tli.'tt I last saw h ;. alive on 



ej-l.l->ut.. 



190 



antLtliat death occurred, on the date stated above, at ^ 
AS M^ The CAUSIC OF DKATH was as follows: 

4^Lci%--lv.tJ.xX.\jUX 



i(X/y\ >L cl^ w a v^o 




VCtW^^vA. CO 



OCCri'ATION 

Residfd III Sun /'iiiiuisro \ )'i,ii< t Mmitlis \ \\ Days 

illl", ABOVE STA'n:i) I'HKSONAU I'AKTliT I.AKS A K l'. TKCH To TllH 

HivST OK ^nLKN()\v^^:D^•.K and mkmi:k 



duration 
contributory 

duration 
(Signed ) 

1 I()0 



)V<70 



^ 



Mouths C> Days 



Ilont s 






Yiats Months 

(Address) *^ I '^QJX.^H,1\ ^^ 



Days \-X Hours 
M.D. 



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



( In foiniant 



-Aw^C \ 



(Address .. 



a^H.iAjLc^L "cSi. 



Former or 
Usual Residence 

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



How long at 

Place of Deatfi? Days 



pi.acp: ok nrRiAi, or rkmovai. 



DA'CKof HiRiAl. or RP:M0VAI, 

'OJM^. !.^ 190'A 



CNDHRTAKKR UaD. J. C'AxAa; AC V^ 

(Address MVX QCy^N^a^U^-^x jA.t. 



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 psr- 
sons dyinft away from home should be ftiven in ^y^ry instance. 



W I 



'Vi. 



'•^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



U..;ir<l nf lli:ilth !■ No. !^ "^'-^^l"?^ H^'f ^*'> 



/)((/(' /v/^v/,ojJ^:1jl/>wcma.i 



i.b 



]90\ 



RcgLslci'cd J\^o, 



1684 




^\^o<,:\ 




vu Deputy ^•-e£|;h.OT?f^er 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "CI. 5. Stan^ar^ ) 

. — County of Q/O^^^ OA.Cc>^CU.CL City of ^-^O.'^X' OVOAVI^^^^i 



PLACE OF DEATH 






''No. 1^ \X 3^<X>\.Q;.L 



(?il 



St.; H Dist.;bet ..J.Crl>l<^. - • 



and ()b.,CJ\A^a^.:c'. 



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



FULL NAME 



^a.c^i:r- 



.o.^ 



SKX 




PERSONAL AND STATISTICAL PARTICULARS 
> I COI.OR A 



I)\ri-; n|- HIKTH 



l^ 



li 



MEDICAL CERTIFICATE OF DEATH 



DATK ()»• DKATH 



\t.l-: 




If ,v,„, ■( 



Mi»iths 



r 



l\■^.^'lI 



Day. 



(Month) 



(Day) 



(Year) 



SINC. m:. mark I HI). 

W I now I'D OK niVoKiKI) 

'Write ill ^orial <lf^i>.'iiat i<>ii ) 



lUK rnri.AOi-: i 

(Statf or Coutitry) _^ ) 



Q^\K.<^x^6^ 



\ \ < 



^l^LVX 



NAMK ol 
I' Aini-.K 



lUk'lIIIM.Al'K 
<>|- 1 ArUl'.K 

< Stalf or Coaiitry) 



MAII)I:n XAMl". 
<»l' MO'IMHR 



lUK rui'i.Ari-: 
Ol" motiii;k 

(State or t'oiiiitrv) 





I 



I III'IRI'HV CI«;RTIFV, That I attended deceased fruiii 

»a.. 190''. to BjL^rCb. l.H 190 H 

that I last saw h ■• aHve on c3-L.'^vL IX 190 ; 

and that <leath occurred, on the date stated above, at 1 1 
LL M. The CAT SIC Ul' D I* AT 1 1 was as follows: 



, ur II \-.:\ 1 II was as 



^ 



vj 



ft. 



oiTirATION 

Kfsidfd ill Sail /'i mii imd 



D r R A 'i' 1 N '1 ) 'i-ars Months Days Hon rs 

iQ.i(l..lLn.:._ 



CONTRIHUTORV 



DIRATION 
(SIG 



Ycafs 



Mouths 



Days 



- l':l.u,. 



_ . _NED ) LLli^^ U." . .. - . ... 

)jL\\k. \h u)o (A«i<iress) 10^5" MiVavki.t '\± 



Hours 
M.D. 



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



'S'ltD 



Month- 



Ihjys 



VWV. \HOVK STA'n-;i) I'KKSONAI, I'A KlMCr I.AKS AKl". TKrK TO THH 
IlKST OH MY KNOWI.lvDCK AM) HKI.IKF 

XV\x 



(lufniinanl 




(Address 




Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



PI.ACK OF m RIAI, t)R RKMOVAI. 



DXTj^Cof HiKiAl. or RlvMOVAI, 

...Lk^. 



^ 



(Address ^%\ \^^\\<^%^\,.ir>:\...Dl 



T90 



N. B. F.very Item of informntion should be cnrefully Hupplied. AGE ithould 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. 



it 



II 



1 




i'lf 



i 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.V 



I)(f/r FiJcd , .xlv" 



4- 




l..k> 1^)0\ 



Begistercd JVo, 



1685 



ck^^rV^A^ 




^-vi^ 



'"' (Cl 



er 



^No 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of H)eatb 

{ "a. S. StanDarD ) 
PLACE OF DEATH: — County ofCla^v ,Va/>v/CXAex City of O/O/TV 0;uaAAy<:w^.c 
,. Lcl^t V LcAXTvtu TO CH^kA^tcLl St,; 

A / IF DtATH OCCURSAAWAY FROM jjSUAL RCSIDEI 

y V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET 

(^ J? \ 



Dist,; bet. and 



URsVaWAY from Usual residence give facts called for UNDER "special INFORMATION- \ 

:t and number. J 



FULL NAME 



LlUnX; 



.Ui dw^OL^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I coi.ok 




oJ 



,1 



/ 



DA'ii". <>i" r.iK'ni 



AC.H 






^ 



)'i\n . 



b 



(Day: 



MnnUls 



(Vcai 



Am. 



SIN(.l,i:, MARUIKI), 

\vii)(»\vi-:i) OK i)iV()Kii-:i) 

(Wiitfiti soi'ial <h'si<.Miat idii) 



HfKTIIl'I.AriC (Vn 

(Stat«' or t'ouiitiy) J{ V(J[ ) 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATIl 5 

axl-d. ii 

(Month) (Day) 



(Year) 



1 HICRIUJV CIvRTIFV, That ^I atteiKknl deceased from 

."^JlI^aI- l.C^ 190'; to ....^jJ^t. L^ 190 H 

tliat I last saw h >^>'.' . alive on O^Y^t'. ' I90 . 

and that death occurred, on the date stated above, at ^HS 
LL,M. The CAl'SH OF DIvATH was as follows: 

.. <i.A,:>Jrr^^.\.l 




\AM1>: OI" 
FATHKR 



niRTHIM.ACK 

OI' l-ATHKK 

I Statt or Couiitrv) 



MAIItFN NAM1-: 
OI" MOTlIIvK 



in RP I IP LACK 

OI- MorilKK 
(Statf or Country) 



(H\Tl'ATION 



N 



\)^ 



/W^ 



WVv>^Ol d^XX.'k^ 



^ ? 



Dr RATION Years 
CONTRIIUTTORY V 



^lonths Days 

r\-.CXi\uLA^.ti 



Hours 



^°t 



I )r RATION 

(Signed ) 

OX^\t) lb iQo H ( 



Kfsiilfii in Siiti /'i iiik isro 



) '/'(I I s 



Months 



])a v.v 



TMI-: AHOVK ST ATI-: I) I' HR SON A I, PA R iUT I, \ RS ARl". I' R l" p: To \'\\V 

i»p:st OI' Mv knowi,p:i)c.p: and hi;mi;p- 



(liifoMiiant 



T 



(A 



(l.lrcss LaXu^ ^ \j^ 




"laXoJu 



Address) v-CU^ 
\TION only for ^ 



Hours 
M.D. 



V, L^ dVj (y<L ', \. 



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

Former or J Wv)cwcJLUvUJulaa^'%v How long at 

Usual Residence ^)f:c,.^^...^ Piarc of Death ? b Days 

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



P^, AC E O V Iil[- R I A I, O R K E M OV A I, 




,1 



DATp: of HiKiAi, or REMOVAL 
SjL^ lb ,go^ 



i; N D 1^ R T A K E K vJ OAx^Jc/VU \) (OAX IvVX 

(Address .. lH.^.'':6. \l jTUAA^V^tHV.. ...3jL. 



^' K* Rvery item of information should be cnrefully supplied. AGB sliould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The ^'Special Information" for per- 
sons dyln^ away from home should be ftiven in •yary instance. 



Pi 

II 



4 



I) 



}"■ 



m 



Ift^ 



WRITE PLAIFNLY WITH UINFADIING irNr\ — IMI5> I5» M r t K IVI M IN 1 1'* I ricv^\->riu 

i!,,:,r,l,.f H. .nil 1 No i:; i^-t*3^^!US:i'ro REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



{ 1 



Registered A^o. 



1 



Da/r /■'/7^v/,'^j^\vtov>JLov W n^O'i 

^j_^^ Deputy Health Officer 

DEPARTMENTOF PUBLIC HEALTH-=City and County of San Francisco 



Ccvtificate of S)catb 

( "CI. S. StanDarO ) 
PLACE OF DEATH: — County of J/O^^a; J>^vXX/^v^o.:i.C'City of vJ/CLTu AXX\vC\^<:uc 






'No, "^tT I'x K^Loj\.o. 



Su 



Dlst: bet* 



vS 




and 



b.t) 



(IF DtATH OCCURS *W*V rROM USUAL RESIDENCE GIVE 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 




-yux. 




i 



A^'L-.tr.v.X; . 



^ 



.KX (' 



PERSONAL AND STATISTICAL PARTICULARS 

COI.(3R \ 



MEDICAL CERTIFICATE OF DEATH 



DATl-; OF' lUKTH 




,1 I . t 




iMoiitli) 



(I)nv) 



At.K 



I L ),./(. 



i ) 



I Mnitliy 



J. 



r L X;.l... 

(Year) 



Days 




SIN(,I,lv MAKKli:i) 
\\II)()\\i:i) OR I)I\'ok*Kr) 
• WritLin SKial (U">i>.Miat imi) 



IMKIHIM. MM-: 
(Statf or Coiiiitrv> 




.LdL<r^-A>x<i^ 



.^^Oocx/^-\_^ \ 



(Montfi) 
I IIlvRIUJV CHRTIFV, That I atteiickMl deceased from 



\ 



■\J 




190 



H 



to 



;v- 




190 

that T last saw h -*-' - alive on 0-£.^V\fc ) X Kp ', 

and that «leath occurred, on the date stated al)ove, at *" 
M. The CAlSlv OF DIvATII was as follows: 



N'AMI-: ()]•■ 
I-ATHKR 



lUKTHlM.ArK 
OI- lATHKK 

(State f)r fountrv^ 



MAII)l<:x XAMH 



lURTHPLACK 
ol- MOTHHK 
(State or Co\intry) 



I 



:\ 



vuLo 



Dr RAT ION }'evjrs Months ID Days Hours 



Year, 



i\ font lis 



"V^' 



V- 



OCCri'ATION /Q u , 

Rfsidfil ill Son /'niiii isi'i) 1 . )'>(ii.^ 




/Mrs 



Hours 



DURATION 

(SIGNED) H.. V. [J\} Xj;LmJLKA.. M.D. 

cM-xt IL igo^V (Ad.lress) %T\- \ \k, 7\l . 



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



Mniilfis 



Din. 



Tin". A1U)V1<: ST AT}",!) RHKSONAI, P \ K 1' 10 f l.A RS A R IC TRIK, TO THl-' 
I5KST OI-* MY KNO\V1,i:I)(;K AM) IJHMl.l-" 



(Iiifonnatit \l fW^ N^ t^VVA^ (KjOL'^T^JCL^U^fr y 



r\(l<lrcss 



U^W 



V 



<^ 




"C^l 



Former or 
Usual Residence 

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



How long at 

Place of Death ? Days 



TLACK Ol.- lURIAI, OR RHMoVAI, 
INDl-.RTAKl^R 




I) ATj; ui niKiAi. or ri<;m()vai. 



wVLdjiNjta..kv 



(Address 



(HA>: 



'PvVS.VWa V,( 



N. 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 per- 
sons dyinft away from home should be feiven in svery instance. 



Ill 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



M..:i!<! of Hr.iltli I- N<v i^ t-?;;Ts;;-i«i-- lUt !• Co 



Ihdc FiJrd.BjJ 




AVA.\a: ' 



K, 



\ 



\.\^ lOO'i 



Deputy Health Officer 



Begistered J\'*o. 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Certificate of IDeatb 



( "a. S. StanC»arD ) 



«o 



% 



PLACE OF DEATH: — County of *CUya^ 0/\XL^xCU..e,/. City of (X.>v JXO^'-^eA.^e,C: 



TN, .^ 



(f^ 



.kXu 




,, (j\jCHl|^A.Lcx.'... St.; Dist«;bet. 



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 OCCurtHED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



oIaa^ MiLa , 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



V 




DAIi; »>I I'.IKTU 



A(.H 



iMoiith) 



AC ,..„.. 



II 



(Dav 



.V. ■.•///' 



\ 



medical certificate of death 

datp: c)i- i)i:.\th 



(Year) 



Pil vs 



SINC. I,i:, M.\KKI5:i>. 

w'lDt )\vi-:i) OR i)(\< »Kri:r) 

(Writ'iii social (li-siviiatiMii) 



HIRI'lll'I.Ari', 

• State nr t"iiuiltl \-^ 



-U .«^cL 



O-Uv^-^V 



(A 




\'\. 



190 H 

(Yi-ar) 



.■>». 

(Montlh) (Day) 

I INvkl-nV CI«:RTII<V, riiat^I mUcikKiI (lect-ascMl from 

W.>v^- .•.':^-, IgOi t.) dji..|A,t ).^ if)0'i 

that I last saw h - ■ > • alive on sJ-C-^va- k^q 

and that death occurred, on tlie date staled above, at b 
Jt^ M. The CAlSIv ()!• DIvATII was as folI.)ws: 

Ixs-cr^rxA.^ L/>:x^rLcr.'':,'<\.h^xL\«Lv« 



NAM1-. 01 
FAT 1 1 l.R 



lUkTiiri.ArK 
<)i" lAi'iii-.k 

(Stair ui Coiniti V 



MAII)1:N" NAM! 
01 M()T!11;K 




X'^V^ 







V 





I>u. ill- 



nr RATION Years 
CONTRIIU'TORY 



Mt))itlis 



Day 



Hours 



X^ 



d. 




MIR rni'i.Aci', 

Ol' MOTIIICK 
(Stair or e'ountrj) 



Kfsiiifil in Sii>i /'i i!H( isri> ^ )i(ris 



( 




duration 
(Signed ) 



6.x^ti 



)'t'ars Months 

) 'H, i()o I (.\(hlress) LU.<, '^ V..(. 



Pa ys 



Hours 
M.D. 



Li. 



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



MiniHis 



n,i\ 



riiiv Anovi.: srAri: n i-krsonai. rAKTicri.xKs aui-; tri i-: to tin-- 

ni;ST Ol-.MV KNOWM'.DC.K AM) HHMI^K 



f AdclresH 



Former or . 
Usual Residence ^0^^ 

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




i How lonq at 

v ' Place of Death ? 



Days 



DA'li; <)! m KiAi- or klvMO\Al, 



I'LACK Ol- lURIAI. OR RKMo\AI. 

(AiUlreHS 9-^,^.1. sTyXA.'a.^U.^rv^ 3t 



190 






N. ». F.very Item o? informntlon «hoij!<l be cnre?ully supplied. AGB should he stated EXACTLY. PHYSICIANS should 

state CAUSE OF DLATH !n pliiin terms, that It mny be properly classified. The "Special Information" for per- 
son* dylnft away from home Hhould be ftlven in every Instance. 



I 



•t 



ft. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMAINEINT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Unni-.l .,f Ilciltti I- .v.). ! - 1^-?^5^^. MS: I* Co 




lb ioo\ 



Date AV/r^/, GJLA\ijL/r\:> 

I) J 

(i,iLv>^u Deputy »^icalth Officer 



Registei'ed J\^o, 



1C3 



.trv<-v^ (X-i^'V^-vi 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Bcatb 

( 'U. S. StanDarD ) 



Qsn 



PLACE OF DEATH: — County of'JCL>\j .Va-n.Cvi.ccCity of vj 'CC^Aj A-CXa^^ui^-C* 



3' 



/I 



(No. ^cUv ^ Wvo^TLtvi, lb ^NL-Lk-t<xlSt.; Dist.;bct 

:URS AVVAV FROM uiSUAL 



and 



(IF DEATH OCCURS *WaV FROM UlSUAL 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 LU^^A 






PERSONAL AND STATISTICAL PARTICULARS 



^'••■^ ^'7f^ 



A 



I).\l i: ol lUKTII 



COI.OR 



II 



I 1 



MEDICAL CERTIFICATE OF DEATH 

DATE oi" I)i:ath y 



AC.H 



•5(|()iith) ,i 



(Day) (Vear) 



I - 



'> 



Month' 



Po \s 



'^iNc.i.i:. M.\Kuii:i) 

WIDnWJ'.n OK I)l\< •K():i) 
(U'litcin siKJnl »U^iv luitioii) 



I / L^V,K^\<:L^^ci^ 



ItlKTUPKACK 
iSt.'ilc or (.'oiinti v) 



F.\ 11! i;r 



lUK'i'ni'L.xrH 

Ol' l-AIHHK 

(Stat«' or r..,.iilrv) 



M.\II)1;N NAM)-: 
Ol MOTHKK 



niKTHIM.ACK 
Ol' MoTIIKK 
(Stall or Coiuitrv) 



\J 




(Month) 



^ 190 \ 

(Day) (Year) 



I UliRUBV CIvRTII'V, That J attc-ndcd (leixased fr«Jin 
,.LL|:vvJ(. X'X. 190 ^^. to ... c).wL^A.t Lb D 



[90 '"• 



that I hist saw h ■• alive on 



and that (kath occurred, on the (hde state<l above, at 
1^41, The CArSl*: C)l«' J)1{ATII was as follows 



t 





i:X-Cr-.:Ls..^.; , , .. 




<XV 



X^^\ ^ J K • \\aJj\-- 



K. 



orcTl'ATlON (J)\p :i 




nr RATION 



)'ears 



iMonUis 



Days 



CONTRIIU'TORY M.JXvaXLU v^L ^U-IjUaJx^^Lv,. 



Hours 



<Xax^ 



DURATION 



r^'cttKs Mouths 



Days 



Hours 

(SIGNED) J. VA. dV9c>.\.t M.D. 

CJXyA. lip TQoS (Ad(lress) LcIm X Lc> OK) (SA' 



IJA 



/\ru'iir(f ill Still /'i iiiii i^t-ii \J^)'rti I y "^ lA 



11/// y 



/>,n. 



rm", AMOVl': STATl'.D I'HKSONAI. !'ARTICri..\RS ARK ri<rK To Tin' 
in:sT OI- MA' KNOWIJ^DCK AND HHI.IKK 



(In fMiiiiaiit 




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

Usual Residence ^ I M J ^JL<^,t LLv % piare orDealh ? I H 1 Days 

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



Former or 



I'l^ACij: yi- lURIAI, OR RHMOVAI. 



DATI-;.)!" HiKiAi. or RKMOVAI, 



INDHRTAKKR f)^V>AJ*^X^• ^V< d<A<. i v.t. 
(Adclrcs«.....'^!o..b..\D . >J. )\UL^V.^,^r>l...,U 



IN. B.- 



-Rvery Item olf mfformiitlon shoulii be carefully nupplied. AGE i»houId be Rtateil EXACTLY. PHYSICIANS should 
mate CAUSE OF DEATH in plain term., that it may be properly classified. The "Special Information" for per- 
son* dyinft away from homo should be ftiven in 9very instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 








llogistercd Xo. 




lUtlv Fileil ,.Q.Al\kx^^^h4Jv lb l-^O ' 

1^^^ ix^vu D«P^^> ^ 'H'..2>' ==«'' 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( 'CI. S. Stan^arO ) 



SI % SI % 



PLACE OF DEATH: — County 



of ,Ol/^ V \0<j > V/a<.<L. C (City of Cj <Xj^\j J\XUy\y^Z^\jCL/(l. C 



NoAisa mIIl^, 



^Lt 



St.; 



Dist.; bet. 



n 




A\> 



and 



lit! 



\j 



( IF DEATH OCCURS *W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH orruBREO IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME II 

f\ .^ 



FULL NAME 






'1 

\ 

. \ 



\JXJy. • 



SKX (OfN, 



PERSONAL AND STATISTICAL PARTICULARS 

.:, I lot.'. 



DA I 1; nl' ItlKl'II \X^ 



AC. 1-: 



'3xAr 



iMiitith) 



O cN \'rn)s V. 



3vC) /i. 

(I):iv) (Vfai) 



M.IHl/lK 



Ihns 



SIN<,l.l-:. MARKlIvl), 

\\ii)»)\vi:i) Ok ni\(>Kri:i) 

( Write- ill sorinl (lcsij.Miat imi) 




r.iK ini'i.AiM-: 

(Statf i.r i."iiunlrv) 



NAMr: oi' 
1 Aiin.K 



lUKiii ri, \ii<: 
()!• 1 A rill-: k 

IStMlf 01 Cuuilt I v) 









IQO 

(Yt-ar) 



MEDICAL CERTIFICATE OF DEATH 

DATI-: t»l- DlvATH ^ 

Dxkfc IL 

(Month) (Day) 

J IIIvkl'HV CI-RTIl'V, Thiit I attciulod (k-ctasiMl from 

OJ..\\\. : up\ to .d.^xt IS. T(p4 

lli.'it I last saw h •• alive on O JL^v\j i o Kp •, 

aii«l that death occurred, on the date stated above, at . L 
A. M. The CAISI*' Ui- DI-ATII was as follows: 



^'^w\>.'QLAwy;i 



1 
1' 



MAIIUvN NAM)', [^ 

Ol' Morill'.K 



/> ) V 



^ \ 




^ > V-vL- 




DIRATION 
CONTRIIU'TORY 



} V<7;'j Mont ha 

:C<X-.:yx<o^:>^<>:*K.... 



M»t,ih> 



Days 



Hours 



I )r RATION . )\ars 

(SIGNED )..sJAX<^w, LL. ']k^ 



f^avs 



lUK iiii'LArr; 
Ol" M(»'i'iii;u 

(Stntf ni Countiv 



(K (."ri'A rioN 




CLV \ 



I f 



Rfyidrii in S(t)i /'i ii iit istut \ i. )')\u •< 



M.nitin 



Ihi 



riii: Mtt IV I" s'l'A'n:!) rKksoxAi, rARTirr!, \k> aki; pki m to th j-: 
iiHsT 01 Mv KNOW i.i.DCK AM) in;Mi;K 



I Infoitn.'int 



CAddri'ss 






hjL.\-\ 



I()0 



/fours 
M.D. 

(Ad.lress) llH^l M ) ^ V.M. Vt.<rvA '3l 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



IM,ACH Ol" HIKIAI. OK KliMoVAI, 



I NI)1;KI" AKKK WV 






DATi;.)! Mi KiAi, or KKMoVAl, 

O jd(<L 1.^ iQoht.. 

(Address l^ OR UT\A,^a^<.,<(r>\ .. Cjl. 




N« !*• Jivery item «>tf Inlr'ormiitlnn nhoulcl he cnrutr'ully Kupplied. Adl; Hhould bo stnted EXACTLY. PHYSICIANS should 

•tnte CAUSr OF DtATH in plnin termti, that it miiy he properly cloHsified. The "Special Information** for p«r- 
Ron« dyin^ away from home nhoiild he ^Iven in c\cry instance. 




i 



'm 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,.,,, ,,, i i,:,lih .■•Vo. :.TS'^g^-)i'.S:l'c'o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1 690 





Dale Fi/('(/,r)jiLtjU^rYJi^bj. l.W IfW^ 



Registered J\''o, 



.>Crv\.A-/) 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 

No. 0.5 \ \ -" JCV'C\,a./YYVJL'->\X(. 



Certificate of Beatb 

( U. 5. StanC>nrC> ) 

ofQ.<l^\.' J Va-wCv^.c/ City of OXX/^V 0.\.<x.'ivevXLt^c 

and J \^ 



r> 



St.; I 



Dist.;bet. ' U_^. > v_ .^ 




X^'..' ) 



Z' ir DEATH OCCURS AW*Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION • \ 
V \T DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



DA'll". ol i;il< III 



COl.OK ^ 



>i 



I \ 






il>:iv) 



A<.K 



m 



) iUl I y 



s 



Mnlllh^ 



\ \\Xi\ ) 



/^n N 



^I\(.I.K, MARK Ii:i» 
WIDOWKI) OR I)!\t)K(i:i) 

iWiitcin 'ii)ci;il <1( *<ij.';i;ittMii) 



HiK rniM.ArK 

(St;il( or C'ounti V 




(XKK<xA^ 



NAMl-: Ol' 
FA'IIIl'.K 



lUKIIII'LXrK 
Ol" lAllll'.K 
(Statf or C'oimt i \ 



MAII)i:\ NAMH 
Ol- MoTMl'.K 



lUK rHI'KACK 
Ol" MOTINvK 
(StMtc or ro\iiitrv) 



ocrri'ATioN 



I 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:ATH 



l^- 




(Day) 



(Year) 



(Moiitll) 

1 HI':R1':HV C1<;KTII'V, That I atU'ndcd (Icct-asea from 

.- ■ '^ up u, ..x)jl\sXj. 15 190'^ 

that I last saw li • alive on C)X<^\A'. !^ 190 

and that death occnrred, on the <hite stated above, at 01b 
M. The CArSlv OF 1)1-: ATI! was as follows: 

a. ^ '^ 



\ 



N V^-^^ 



DTK AT ION )'t'ars 

CONTRinrTORV 



Mouths ^ 



Davs 



Dl'RATION 

(Signed ) 



Months 
I 



/'>ays 



r()0 



)'rars 

(Ad.lress) b'^ b 'J^K^kX^J^, 



I lours 

IIoHi < 
M.D. 



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



Rrsitlrd in Sdti f'l diii /Mo 



) I'd I 



^r<„lt^ls 



/)<I\ 



THI", AHOVK STA'n-.I) I'KRSoNAl, TAR TUTI.ARS ARi; TRrH To IJIH 
HKST Ol- MY KNOWIJUXih' AM) MHI.IICF 



( In foi 111:1 tjt 




( AfMrcss 






Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'l^ACK OF lURIAI, OK U1<;MoV\I< I I)ATF:<)f IUkiai, or RICMOVAI, 



ri,Av.ii, Ol- m K 



irXDKRTAl 






T901 



(Ad«iref»s 



^.1.1. 



\^\\ 



:v..l!ll 



IN. B. Every Item oi Informntlon should be cape?ully Hupplied. 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 4iven in myry instance. 



■m 




Ml 




m 



iiil. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



]',<<-AV<\ i.{ Ileal Hi- I- Vo. Is t-^^*^^ lUtP Cd 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da/,' /■'//(■'/, dxJ^tX'y-^iyJt^ lb IfJO^ 



liegiatcred J\''o. 



1 69 1 



.^r\J<^\J^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 



V-A 



PLACE OF DEATH: — County of 



c\ ' 



City of 






-0 



No, 



St.; 



Dist.; bet. 



and 



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



FULL NAME 




.Kj 




Oj^^\j 



PERSONAL AND STATISTICAL PARTICULARS 

DA'I'K <)I IMRIMI 

III 



iM..iilhl 



AC. i<: 



}'('(// 



5~ 



(Dav) 



.1 A />////< 



C/t-ar) 



An 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol' DlvATH 




IQO 

(Year) 



^IN<".I,J-:. MAKKIl-:i) 

fW'iitiiii v.,H-j;,i clt vivriialioii) 



lUR'I'HI'I.At'l-: 

Slatr or t,"()niilry) 



NAMl" (H 
!• A III I.R 



MIR TIII'I.ArK 
Ol- l-ATIIHR 
'State (ii (.'ouiitry^ 



maii)j-:n NAM): 
Ol- Morm-iR 




(MontW) (Day) 

I III'RJ'HV Cl'lRTH^V, That I alten<lca (leccased fnuii 

■■' IC)0 



I90 to 

alive on ~-" 



that I last saw li • 
and tliat death occurred, on tlie dati- stated ahove, at 
M. The CArSl<: Ol' IH:ATII was as follows: 



v-iVojbue. 







I) r RAT ION Years 

CONTRinrTORV 



Mont /is 



/)ays 



liours 



HI Rill I' LACK 

Ol' MOTHHK ^ 

(State ol Country) \ 




ocori'A'rioN 

I\fsidf(l III Sail I'l mil isi-n 



Dw^L^VHXV'CL'i 



t 






or RATION 

(Signed) 



Mo)iths Days 



'. )X^ :.X . i ^.. rqo \ 



Years 

-— — — ^ L. 



I fours 
M.D. 



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



) ra I 



.^/nilfJix 



n,i\ 



rm-: ahovi- sta ii-;i) phrsonai. i-artrtlars ari-- trit to tiik 
in-;sT OI-- MY KNo\vi.i-:i)c.K AM) hhmi-:f ' 



(Iiifoimaiit 



^u r \y vv 



^jJLxMX, 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



9f)idl 



X 



I'LACK Ol- niRIAI, OR RHMOVAI. I I)AT>; of Hck.ai. or RKMOVAI. 



^Vddrt-^s 



i- 



"• "■~r.r/Jr"8E'o"™%H"i„*''r''' !;' """"'k'^ r"""""'- ^^-^ -••»""' "<" "-««" exactly, physicians ,h„„ld 
IZ.A-^ ? " " •*.'"'" •"■■"'• "'»' " ""'y •" properly classified. The "Special Information" for D.r. 

•on. dying away from home should be ftiven in .very instance. "iniormation tor p.r- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\\<v.\T'] ..f IU:(!th - I- No. 's **^U^^^i<&l' *^"o 



i 



M 



Dafr /'V/r./, ix^v'U.T-vJLLV \b WO^ 



Registered J\'*o. 



IP no 



(k^ 



Cv.v.<> oUL 



\ 



M^ 



Deputy Health Offscc 



DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



Certificate of Death 



A 



QSx\ 



V. 



i 



% 



PLACE OF DEATH: — County ofC ai\.. 0;v(X'>\cl^c-. City of 0,<X>v A.<X-v^w/c.w«.<;:,i 



i^ 



f^o. M '^ 



ill 



aVc Yv^ 'fo (y-<Li V ^"t CL I- 



St.; 



Dist.; bet. 



and 



(IP DCATH OCCURS AWAY FROM USUAL R E S I D E NC E Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
IF DEATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME CcLuhCLvd' v . IL <X.C^.....v/ 

;\ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



vllv 



\i 



<xu 



U 



MEDICAL CERTIFICATE OF DEATH 

DATK OH I)1;aTH 



i).\ii-; 111- liiKiH 



A(.K 



((I^lotith) 



ll I 



I'i 



)-.,! 



(Diiv) 



1 /..),■ .'/,■> 



(Veai) 



^iM.i.i-: M.\Ki<n:i) 

\\Iln>\VKI) OK ni\( tR( i;i) 
IW'iitfin "^otiiil <hxi^Miatinii) 




IM)^ 



HiR'nin.Ai'i-: 

'St;iti or t'oiint t v^ 



IAIN i;k 



lUK I'll I'I, \rH 

oi I Ai'iii:i< 



MAIItl'.N NAM I", 
oi MoTin-R 



MIKIIIlM.At'K 
OI- MOTHI'tK 
(Statr or (.'oimtrvi 










dxUt 

MontW) 



-S.j , 



(I)av) 



I go 

(Year^ 



--^-^I in^RIvHV CI'RTII'V, That I attcmlod deccascl from 

J..xXr 1^ up \ iu Q.jJf± l.S: 190H 

that I last saw h - alive on • . 190 

and that (U-alb ncciirrcd, tMi the dato staled above, at i^^ 
Us, ^M. The CArSh: 01- DI'.vTH was as follows: 



\ 



-v^ 



Xi^> 




or RAT ION ^ )'('ars 
CONTRlHrTORV 



Mouths 



Da\ 



'S 



Hours 



DURATION 



} 'ears 



Months 



/'>avs 



(SIGNED 

J! 



)...ll}.il. ^t....u 



V^l.fc^ V 



dX^ IS TQoH (A«l(lress) ynVoXv-^vJl j)b(> V 



Hours 
M.D. 



OCCrPATION \ 

Kfsidfd III Sail I'i oni isro * )><;;,? 



.'^/"ll/tlS 



"^Davs 



Till. AHOVK STATI.I) PKRSONAI. PARTICULARS ARK TRUF TO TH K 

iji-sToi- MY kn«»\vi,ki)(;k and hkmkf 



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



Former or o ^q ^ j-^ J( , How long at 

Usual Residence I on ' 1 /\^v 01 pia,e of Oeatfi? 



Days 



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



(In 



( v.i.hoss V.nVcx\A./YVJsL flb.o^l-^-Lol 



PLACK OK m-RIAI. OR RHMOVAI, I DATK of Mikiai. or RKMoVAI, 

_imtilLvU I "^M^ '-^ .90 . 

I'MDHRTAKER Ob . U . CJAAJk^j Vvlc 

(Address 1.1^.1 \nOwA,,^i<^i<V<rvv....al 



N. B.- 



'^ Ul 



-I^'ery Item onnformatlon .hould be cu efully .upplled. AGB should b« stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH tn plain term , that It may be properly classified. The "Special Information*' for psr- 
sons dyln^ away from home should be given in svsry Instance. 



i 



ri 



Mi' 



n 



!*"■ ■• 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



*^1 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




lb 2'J0^[ 



Bcgistered J\^o, 



1693 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of H)eatb 

( ■Q. S. Stan^at^ ) 



PLACE OF DEATH: — County 

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



St.; - 



Dist.; bet. 



and 



FULL NAME Ccu:^,l^vi. 'oV ItjUj. 



SKX 



\' 



PERSONAL AND STATISTICAL PARTICULARS 

I CO 1,1 Ik 



i 





I>A1I-: (>l- I!IK 111 



AC, K 



!M..iith» 



) I III 



0. 



il)av) 



M.mlln 



r ?>S.i 



15,. 

(Dav) 



(Year) 



fVcar) 



lhx\. 



un)()\yi:i) ok dixokckd 

iW'iitciii "^ori.al ilisj'.rnat ion) 




) 



lUKTIIl'l, \oi-: 
I Stat<- or ("ojintry) 



XAM1-: Ol' 

i-A'i"ni;K 



lUR'nUM.ACK 

oi" i-\!iii-:k 

( state or romiti \-' 



MAll»i;\ NAM1-: 
Ol- MO'l'HKK 



Hi k III I' LAC i-; 

Ol" MOTHKK 

(Slatf or Cotiiitiy) 






\j 




MEDICAL CERTIFICATE OF DEATH 

DATK Ol- I) HATH , 

^\ oJ.,+, 

(MoiiUiH 

I in:RI{l>,V CI'RTII'V, That f atU-ii.kMl deceased fn.iii 

~ —....190 to 190 

tliat I last saw hr-—:. alive on k^ 

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

::^I. The CAISI- ()I«' DIvATII was as follows: 

...^.../QJ\Js>. cWvAT-VN^ vCiXOwA-^V-G 



DC RAT ION Years 

CONTRIHUTURV 



Mouths 



Days 



Hours 



"^CK.- 



nr RATION 



i'tars 



(Signed) LfrV^v^A; 



© 



Afouths 



J.-.-AiXcLA- 



Days 



Hours 
M.D. 



^ > \„«. 



..Ccn-ATIONN > J Yj 



.^A^ 



cL 



,'v. 



-^- ■ ■ U)0 (Add ress ) ^ 0\Cr^\X^^^ 



r 



?^^9'S'-."^^0'"^'^'^'0N only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away fro^i home. 



) Id I V 



\t,.,i!lr 



/',/! 



iiii: AHOV1-, sj-A ri'.i) I'KKsoNAi, 1' \ u I' u" ;' i,A K s AKi- rkri- To Tin' 
m;sr Ol- ^v KNOW 1,1: DC, K AND hi;mi:k 



(111 t"i )tiiiaiit 



Former or q a r- "A \ "\ How lonq at 

Usual Residence O ^ d.>CL\Jl^v '' "f pia, e of Oeatli ? 



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



Days 



\-A. 



CvJ^^^. w 



(Address 






:DsilU iC^X^rv^.^^ I t)Jl^^V.l 190.:. 









(Adilress 



''* "*~rtr/cl7sF'oF dTat^^^ \' '"""'."^ r"''^""^- ^"""^ "'^""'^ *'*' '*"'*^ RXACTLY. PHYSICIANS nhould 

state CAUhC OF DEATH in pla.n terms, that It may be properly classified. The "Special Information" for n— 
son. dy.nft away from homo should be ftlven in ovory instance. mtormafon for pT- 






-riotiiamtw 



■^9m 






V 



1) 

t i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



liniinl .-f Mi:ilt)i I- N't) 1--, tS^^-'a^-l^-, H&l* C 



/)a/e /•'//^■r/, dx^Al^YwiUA; lb 190\ 




JtegLsle/'cd A''o. 



1 694 




^ ( 




vu 



D 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Xl. S. Stan^arD ) 
PLACE OF DEATH: — County of^CtOA; Oxa>x<x.Le '. City of JXXov u .V<X Y\.a\.o 



(^ 



No.^ 



7n 



"^l 



(\|F DEATH OCCURS AWAY FROM USUAL 
j IF DEATH OCCURRED IN A HOSPITAL 



St.; 



Dist.; bet* 



and 



RESI DENCE GIVE facts called for under 

OR INSTITUTION GIVE ITS NAME INSTEAD 



^ 



ER "special INFORMATION" "\ 
OF STREET AND NUMBER. / 



FULL NAME 



.^rf):\.aA> M h\XA 




.CO.. 



PERSONAL AND STATISTICAL PARTICULARS 

I) \1 }; ol- lilRTII 



MEDICAL CERTIFICATE OF DEATH 
DATE ()!• I)];ATH j? 



(Montli) 



1^ 

(Day) 



(Ytar) 



1 Month* 



A ( ; K 



bb )■-■„; V 



(I):i%- 



Moulhs 



(Vear) 



Ha V. 



^I\<.I,i:, MARKIi;i). 

WIIK >\yirl> «)R DIVORrKI) 

IWiitfin soi'ial <ltsij.Mi!itii>n) 



111 



CV^^ ^- 



A 



r.iR rui'i.AOK 

I Stritr or Coimtr\'^ 



N'AMI-; ol 

I' A in i:r 



HIK'rnIM.AlH 
Ol' I Aini-.R 

(State or Count I >'^ 



M\II>J<:n NAMI-: 
Ol- MOTIIKR 



lURI'lll'I.ACl'; 
Ol" MOTMKR 
IStatf or Oonntry) 



''>"u:X'VO- 



^'^^ovavv^:* 



I HRRHBV CI<;RTIFV, That I attended .leccased from 

-^t'^ 190' to ... UJL^fvt. iS igoH 

tliat I last saw h ■ alive on ^.j-X^l' i' jjp . 

and that death occnrred, 0:1 the date stated above, at WhX 
^- M. The CArSH ()I< DI^ATH was as follows: 

\^^\ .-tt 



C3 



...;. 



t. " 

DrRATIOX 3 Years 
CONTRIHl'TORV 



Mouths 



Days 



Hours 




? 
?- 



y 



i 



i 



oi'Cri'ATIO 



h't'^nh'il III Siiti /'i iiH( I'.wi) 



DTRATIOX 
(SIGNED) 



}'rars 



lihs 



■yjfofll 



iqo 



Da vs 



(Address) n.l ' ■.. a\ ' ; '^ 

-4. 



I lours 

M.D. 



) rai . 



Mmithf 



Ihn. 



III. MiOVK STA'IJ:I) PKRSOXAl, I'A R C U" f ! A R S \ R }• VKW To 

iij-.sT 01 >jv KN()\\i.}-:i)C.H AM) i!i;i,ii:k 



THK 



(Infoimaut vj 



.'A'^VO 



( \«l(lrcss 



i 



O^Tsj 




Ccc> 



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

Former or ~\ 1\ 

Usual Residence a >\y wtl V^ q. ' 



When was disease contractell, -\ 
If not at place of death ? O 



How lonq at 

Place of Death? A, Days 



a/\v %-cu. La':.. 



1'lj.ACK Ol- HIKIAI, OR RKMOVAI. t DATH of H, k.al or KKMOVAl, 

QO^ysj\^i^L K^oJ: I aX:^:vfc....J.k I, 



I • N I ) K K T A K K R Jb/CX^lAtXcL ^<^ \^ 



:90 



(Addrcs.s 



^Hb ^)\\A..^^..(^.Ai 



.N. B. 



Ttrt7cl7sE^of DFATh"-"^"''' 1" ^""''^""^ Huppliccl. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH .n plain terms, that it may be properly classi^cd. The '•Special Information" for nmr 
«on, dyinft away from home should be feiven in every instance. mtormation Ifor per- 



I I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

It. n.! ..tn ilth I NO 1^ t-5^^a8:l'C.. REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS 



1 )((/(' hl'/rd , ■ \^iU^xX>~V\, lb. 



100\ 



Registered J\^o. 



1 695 




/\>A_^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiffcate of 2)eatb 

( Vi. S. StanOarD ) 



PLACE OF DEATH: — County of 



(^ 



a\A.-rv 



City 



ity of WvU M I L(xdU\.a Levi 



^No. 



St.; 



Dist.; bet. 



and 



(IF 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 



.D. CU^^AA.uJ(j .LLLCrtV:r^ 



s};.\ 



PERSONAL AND STATISTICAL PARTICULARS 

ft I COI.OK 




<X.\, ^. 




MEDICAL CERTIFICATE OF DEATH 



I) ATI". < »!• Ill Kin 



AC.K 



'Month) 



I- 



]'(ti I . 



(Dav) 



Monl/i.^ 



( Veatl 



Da 1 . 



DATE OF DKATH 



(MonHi) 



'. 'A. 

(Day) 



/go ( 

(Year) 



SINC.l,]:, MAKKIl-;i). 
\VII»)\Vi:i) OK I)I\'<>KCKI) 
(Write in sorial 'ti'-i}/nat iuii) 




\xx: 



IUK'rHPI,AOK 

(Statf or C'ouiitrv) 



NAMl-: ol' 

I- A'rin.K 



lUK'nil'l.Ai'K 
(tl" lAIUKR 
'State or Coiiiitrv) 



M\II)1;N' XAM1-: 
()I .M()Tni-:K 



lUkllll'KAri-: 
Ol'" MOTHKK 
(Statf or C'ovnitrv! 







^vVv,^ 



i\ 



1 ]n-;RI<:RV CI<:RT[FV, riiat I atteiided deceased fn.ni 

■■~^ 190 " to v. . 190—. 

that I last saw h alive 011 ~ — ~ . ' ; - too 

and that death (jceiirred, 011 the date stated alK)ve, at 
:M. The CAT'S H ()I< I) I! A Til was as follows: 




Kj 



t\ 



DT RATION )'cars 
CONTRIIU TORY 



Mouths 



Days 



I loin s 




/CUvOl^ 



mIua.- 



? 




A 



DCOri'ATION 

Rrsidrii in Siin /'niiii i\i n 



0<XA'Y^.|AAiv»w^.L 



I )r RATION 

(Signed) 

Am- ^ 




}'ea}'s 
\ 



Davs 



IqO 



( 



I\fo}iths 

Address) 0.a^A.'vLo4-.CUl:i L 



Hours 
M.D. 



a < 



y lUn 



.y/'>ii///y 



/hn 



nil-: AHt)v^•, sTATi:i) i-kksonai, r\KTirri,AKs aki* tkif t<> rm-" 

HKsr Ol- MY KN<)\\Ij:i)C,K AND Ml'.MlvF 



(liifoiinatit 



V^AJ 



r\ (I dress 



io 



CW'w 




ouU 



L t 



<X', 



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

Former or 
Isual Residence 

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



How long at 
Place of Deatti ? 



Days 



r^^^^' ^^ m-RIAI, OR RKMOVAI, DVn-of UvHiAU or RKM()Y\I 



INDKRTAKKR 



A«l<lr«-ss .55"l D>-vtLtS; / 



190 



IN. B. 



'^'Z7 ci^T^P nf'^^2'^Z''^7^-'^ ^" carefully HuppU.cl. AGE hHouIcI be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH m plain terms, that it may be properly classified. The "Special Information- for D.r- 
son« dyinft away from home should be ftiven in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 




i 



m 




m 






)t..;.r.l ,,{ Ihaltli 1' N'o I :; T^'^'X^: U Si. I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



liegisiei'ed J^'^o, 



1 ei)6 



Dalr Fir,'<l,^_l)^L^, ....; .■ 190 

l^yv^^ ijLx-^i Deputy Health Ofricer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StaiiSarO ) 

1^ J 



ffll 



PLACE OF DEATH: — County ofOOX' vL\.a/YUlU.iC. City of O/OaA; OXa YVC.U.C 



^ No. ^ H 5 l.u a..<i- \ \. V. >-.. o ^ ^ 



L 



..WA..,^- .v'v.^-./.t'^^ St.; X Dist.;bet.0.t<Klk"t(r>X' and 1 -^ui--> ...J ) 

(IF Dr*TH OCCURS AwIaV FROM USUAL R E S I D E NC E G I V C 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 

I COI,()k 




.o^<nAj ^^jJck^ 



si;.\ 

\! I LoXv 

I) ATI". ^^V It IK 11 1 jX 



fl' 



\ 



^K^U ' 



I M(iiitli) 



A<.i-: 



) 'lUl I 



? 1 
(I):iv) 



SIN(.I,]-:. A!AKKIi:i) 

UIIX )\\1-: I) OK I)I\'< iKi).:!) 

(W'litriii social (l<si>.'n:it ion) 



I!IK I'll JM, \CV. 
I State or I'liiiiitryl 



i 



NAMl' oi' 

I'ATii i-:k 



\ 






' 1 . o 

/ 'a 

(Vfai) 



/tilVS 




MEDICAL CERTIFICATE OF DEATH 

DATK oj- i)i;ath J3 

(Moiitrt) fDay) 

I mCRl'BV CI:RT1I<V, That I Mttcn.kMl (leccasod frmn 

to 190 "v~~ 



(Vt-ar) 



[I 



iuK'rniM<AOH 

(H' IXrilKR 
(State or C'o\iiitr.v) 



MAIDlvN' NAMI-: 
OI' MOTIll'.K 



HIK rm'I,ACH 
<)!•■ MOTHKK 
(Sl;(te or CoiiiUry) 



LL fr>va 'A_<:i^>j- 



^ 



I90 

tliat I last saw li "alive on _ _ — . 

and that death occurred, on the date stated above, at 
::3: :^I. The CAISIC 01-^ DI-ATII was as follows: 

■■■LL'-.ivCLjL 



Days 






I 



.'WV- .. 



1 v^ 



c 



>^; 



I > 



DIRATIOX 
CONTKIIUTORV 




md\ 



I /ours 



( ^ 






0- 



occri'A rioN 

Rfsidfii in Si'.n I'laint^r, 

ini' AHoviv si\-n:i) i-kksonak pxuikmi.vks \ri- iKi}- Id rill' 
m;sT oi' Mv KN(>\vi,i;i)C. K and i!i-;i.n:i- 



DI^RATIOX Years Months 

(Signed) . j;uLcU>vcck 'J. La , 



Days 



A 






! TqO \ 



(Ad<lress) ICb OA.^.U^.Ai d.t 



Hours 
M.D. 



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



%"i?^ll'^ 



/),M 



(In foMiiaiit 







A 



Former or 
Usual Residence 

Wlien was disease conlrarted. 
If not at plare of deatti ? 



CLL i'-^-^ 



How long at 
Place of Death ? 



Days 






I'I.ACK OI' IHKIAI, (IK Ur.MoVAI. 

rNDKRTAKKR LU^V^VCV, v3,C< 

(Address %^^ Cli<X...^ ^± 



' 

7^ 



■e " 



,-Pi 
p t 



DA'lliioi Hi HiAi. or KlvMOVAI, 

OJL^vt lb ic)oH 



^' "*~I;«t7c'A7sF'oF'n7A"TH"-"^"''^ ^'^ cnrefully Huppliecl. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH .n pla.n terms, that it may be properly classified. The "Speclnl Information" for pT- 
sons dyinft aw«y from home should be Jtiven in every instance. maiion ror par 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



B.-«ir(1 ..f Hf.'ilth I- No '.5 •» 



U.S. I I'. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



t (>97 



W^^ I .,^ Deputy Hcnith Officer 

DEP.4RTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiflcatc of IDcntb 



PLACE OF DEATH: — County of 






No. 



City of ■ ■> > /Vex, 



v\ 



\ St.: Dist.; bet. Hi and 

(ir DtATH occuns »w«v rnoM USUAL R E S I D t NC C Gi vr r*cTs c*iirn for uwntR 'sptci*i iNro«M»TioN \ 
IF Dr»TH OCCU««ID IN * MOSPllAl OW INSTITUTION C. I V F ITS NAME INSTCAO Of STUttT *Nn NUMBtB. / 



Ql^J 



FULL NAME 







\ ^ \ \ \. 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

tt>i(»K > 



m 



1 > 



1 1 \ II'. Ml HIK I II 



\«.!-; 



MEDICAL CERTIFICATE OF DEATH 

P \ I I<: ni |>i \ I M 



^ 



\ 



I \ . MI 1 



I MMiilIit 



) 



(I»ri\ ) 



1/,..,'/, 



<\ . ril I 



/',M 



^iN«.i,i-:, MAinaii) 

U I lM»\\l.:i» nu i)i\( )i'( ) I) 

I W'l it'' ill s(i( i:i I ill --ii' n;it inn ( 



MI W rill'I.A'T". 
' St;itf ot • iiiiiit I \ I 



/ \ 



\ V ! 



'^t.<11(l|l ii).i\i 

I IM:Rin\ MRIIIN-, riiMf l ;.lf.n.lr.| .hcH'^fil ftoni 

1li.ll I l;mf miw ll !ili\rnii uy^ 

.illil lli;i( (l» Mill (!(( tifKMl, nil flic (liifc ^f:ift«l mIimvc, !|< 
M. riic ( AI'Slv.OI' 1)1- \ III Nvri^ u^ U>\\in\<: 



J' . 



,J 



o 



'I 



\ \ M I ( i! 

I \ I n I I-" 



lURIIII'l, \(l*, 
()l I AIIII'.K 

' St;if I- (>i ( ''III lit I 



vTMifi.N vwtr 
oi MdTin-k 



HIK IHI'I, \( I", 
(>}■ \tOTMi:k 

'St.'it' mt C'.uiit t ', 






I'l F.' \ I inN )W//? 

< ' ►Nik 1151 rORV 



/1/nff///^ 



Ihiy 



I/oiif < 



I MR \'f [f .\ 
^ SIGI 

r 

L 



)'/•//; <• 



JA"////s- 



/hi\"s 



NED ) UvrvvH/ ' ^^ visUj. rll.i0L^vdL 



M.D. 



(</» 



(ArMrcss) V fy'i N 1 M'\h \J \ 



SPECIAL iNrORMATION onlv fnr HnsplfaK. InstifirtfWns franslrnls. 
nr Rfffnf RfsMfnts, snrt persons tfyjnq ^wsy from homf. 



/ / /, 



) ■/■'/ 



\i ,„ii,. 



Iw 



I'll I. \ii' )^ F', si' \ r> r> i'KK-^<»\ A r, r \ k i k i i. \rs m.> r i'r ' y ro rn »• 



Ill I 1- in:i fi t 



% 



\.!.ii 



^aX^ k> jJjl ' }jiJrLkhy' 



Formrr or 
lisiwl Rfsidfnff 

Whfn was (flsfasf ronfr»»flf<l, 
If not itt pJHff of 6t»th ! 



How lonq af 
Plarf of flratli .' 



Days 



J'r,ArK f>l' Ftf KI\f, f»K Kf.'MO\-M 



^ ^.' 



r»A'rKof rjt iMAr. nr KKMOVAf, 



y. fi. 






-f.very itrm o* in?orm«tJon ahould be cnre\?ully HuppHed. AGP; «hr.uld he ntnterl RXAGTLY. PHYftlCfAlNH should 
Ktate CAIJ8F: OF DFATH in plnin term<,. thnt it mny be properly clflimifled. The "«peci«l lnform«rion" for n.r- 
non* dyinft away from homo nhould he ftiven in mvory instance. 



•■aMMf^ 



m 



>^>»tt>' 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li.K.nl , r II. Mil I V. t-!r^r^- I'-S^ir-. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' nicd , i 





n 



v)(n 



Registered J\^o. 



1 698 



.c^ 'X.V\>M D e p u t y !■; c; n i t h Om ce r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "a. 'I\ 5tan^ar^ ) 

i ^ Jj Op 

PLACE OF DEATH: — County oiOoyr^ J;\.<X.')\^<::*.'^.c^{. City of Cj/Oyw A.a > \.c.cvi - <. 
NoJtl'"-. L,a.'OvA-A.f. St.; ^ Dist.;bet. lOvt.lv and ^''Vl 

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



(1) 



FULL NAME 



\ 



^.. ^ . ) \. 



V V 



<Lcu\.d. 



PERSONAL AND STATISTICAL PARTICULARS 



si:.\ 







C(»l,(>k 




^ JvcU 



i» \ii: Ml 111 KIM 



A « . !■; 




I 



\,K) 



) I'd > v 






.1A'»////,- 



' \ 



MEDICAL CERTIFICATE OF DEATH 

DATl-; ol- DI'A'IH 

-^ I 1 

lb 



ixlxt 



(Montfi) 



(Vt-ar) 



(S-,-;lI ) 



/',/ 



>I\<.I,H N!Akl<Il-;i), 

W mow i:i) OR DIVOKCHI) 

I Write ill siH'ial flivij.riiatinii) 



luKi'nri.Ai'i': 

f state iir ruiinti v> 



NAMh ol 
!■ ATM 1;K 



HIRTH J'l.Ai}-: 
Ol" !■ ATI! HU 

' Slate <)i riiuiiti vt 



M\!I>1:n NAM!" 

or MoTiU'iK 



^ 1 



I III'Rlvl'.V ClvRTlI'V, That I iitteiidcd (Icccase.l from 

'^. l-.l' i^ 190M to O.J^vfc (b up\ 

that I hist saw h • alive on OJUy\-\j lb jcp '\ 

and tliat death occurred, on the (htte stated above, at ^ 
U^ :M. The CAlSh: Ol' DI-ATII \\as as follows: 



X(XV< 





lUK'inri.An-; 

nl- M(»'!'in-;U 

( St;it<- ut ('()\nit I v) 



nvCri'A IION 



h'rshliuf III Siiii /-'i ti III /••I'D 



I 



) VrM V "^ lA 



iillllls \ 



I) r RAT I ON Ye^s Mouths Days Hours 
CONTRim'TORV vl.C^r^Vr^ir^JChL'^ Lil.\jJlr*V^ 

)\'ars ^Mouths Pays /lours 

i 



DTRATIOX 



(Signed) 



Afoui/is 




^ 



M.D. 



K^O 



(Address) 1*3>S H (nJi.^v^^ ut 



SPECIAL INFORMATION on!v for Hospitdls, Institutions, Transients, 
or Recent Residents, and persons dyiny away from liome. 



nil\: 



■rill. \Ho\i'. sr \ ri'i) rKKsoxAi, i'\k ricii.AKs aki-; rurF To i-m-' 

lUvST 01 M,y KNOW I,i:i)C.l-. AM) IJI-.MllK 



fill foiinaiit 



Crva.\JLLo US 



f \.l<lress 



bia 







Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



pj^Aci-: Ol- luKiAi, OK ki;mo\ai. 




DAPKo!" HiKiAl, (II K1:Mo\AI, 



(Address %Ss>.So VTVuL^S-^LXrVV 



rNDl'.KTAK 



IN. B.- 



-Hvery item oV informHtlon should be carefully supplied. AGE should be stated RXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may he properly classified. The •'Special Information" for per- 
sons dymft away from home should be given in 9\cry instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoard ..f Hialtli \ 



No. n ^-f^f^) H&l' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Da/c Ju/ef/ ,.djLyixy^^Yx.Lvxj V.l /^^H 



liegLslvi'cd JVo. 



1 61)9 



O n 7^ i . *• «.> 



trh C 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

{ "U. S. StanDar^ ) 



f^ 



PLACE OF DEATH: — County ofC'xX^rv J /v<X.>vCi.Ci.-.'.-C;ty of O.CVvxi yi\^Q^\\.i.\-<^z.': 



i 



(No. ST^ v]xc\.A.^ 

(ir Dt*TH OCCURS 
IF DfATH OCCU 



S AWAY FROM USUAL RES 
RREO IN A HOSPITAL OR I 



St.; ^ Dist.;bet.^7VayTL>H.AA/>.. and J Cv^La..-Q,. 

IIDENCEGIVC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ ' 

NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / i 



FULL NAME 




<r\.L ■JjA.trTA^AJ 



PERSONAL AND STATISTICAL PARTICULARS 



SH\ 



\ 







COI,()R 



DAi'i-: oi' r.iKTn 



AC-K. 



IL 




' t 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH 



n 



(Dav) 



(Year) 



I Moll 



th) ^ 



(Dav) 



/ , i ... . . 
Ci't-ar) 



)'rai . 



Miulhs 



X\ 



Dii 1 .V 



SINC,1,K. MAKHIKI) 
WinoWKI) OK I)I\(»KrKl) 

(W'lif'-iii sofial (l«'-ij.Mialioii) 



niKTMn.ACK 

(Stall- or Country^ 



r 






^ 



(Month) 
1 HI<:RI-:HV CI:RTII<V, riiat I atteiKkMl deceased from 

B.Jl.'^AJti \h 190 H to ' : :. :..i90 • 

that I l.'ist saw h <^»a alive on CJ-^^^lI.. Lc-. k^ ; 

and that death occurred, on the date stated above, at T. oO 
A/ M. The CAl'SI': OF DIvATlI was as follows: 




NAMI-; Ol' 
I-A'IIIHR 







J! (1) 



//ours 




lUKTHI'LACH 
01" l-APHKK 
(State or Comitr\) 



maii)i:n namh 

01 MOTHHK 



lUK'l'm'I.ACF. 

(M* mothi:r 

(state or Coiititt \ I 



oCCl TATION 



f\>5 




V^*^ 



i)u J ^ ^ ^ 



V^xXu^t' 



I) r RATION }'tuirs iVoNtfi^s X\ Days 
CONTRIBUTORY ijaOLl^\<<). ..3.<^A.^vx^qJL 

DURATION Vtars AfoNt/is X[ Days Hour^ 

(SIGNED) .\ V.^. dLl.'. M.D. 

C^X^t n TQoH (Address) ^ 7. ^^j^^ W-lI^^.. i;^.. 



AV'.Wl/cV/ /// S'.n/ /'l llHi isi'it 



)'rti\ 



:/n„//iy 



1 /).n.v 



rin-: ahovk stati-d ?'Fks()nai, pak ricn^AKs .\ki-: tkik to luv 

UHsroi" MY KNOWl.llDC.H AM) HKM1-:F 



(Iiifoiiiiaiit 




CrA.A>-CV"^ 



ci X. % '^ - ■ • 



01^ 






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



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



. Days 



I'J[l^^CK Ol- lURIAI, Ok KKMOVAU DA^KoJ HiKtAl. or RKMOVAI, 

i.'X.^a ^"^LoL\iu:t M 



(Addres.' 



N. B.- 



-Every item of infopination should be cnrefuliy Huppliecl. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" ?or per- 
sons dyin^ away from home should be fciven in every instance. 



■ MB ^^ k & ■ mjf 



fpP~ WRITE. PLAIINLY WIIM UlNrMUII^IVJ 1 1'* 



r\ 



I n I «;9 I «s m r- 



ro M n e- OHJI A IVI C- M T DCT^/^Dn 



S.-JO r^>%. 



ll(.;n.l ..f 11. .illli V No 1 «. ■^■"T,.;??;^^ HM' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



II,.; 




IMt| 




Dfdc /w/r^/, OjLVjbi/Y^^^ n ^^^H 



lle^istci'cd J\^o. 



1700 




DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of Beatb 



•a. S. StanDarD ) 



^ 



PLACE OF DEATH: — County of^^^CL^V J \.a'^v<^u^t<(iCity of O CL'^^ OXCc^vca^ ^, 



'No, TH 



1 



^ I V 



t,. 



St.; 



s 



Dist«; bet. 



vt! 



V. 



and 



( 



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



) 



S% 



FULL NAME 



^iD..^^A^(Lo^ iL' xxjdt\^ 



t 



* 



PERSONAL AND STATISTICAL PARTICULARS 



Jc/>-Y\Xvl 



1) A T}". t>l I'.Ik'III 



At, H 



ll^^ 




\ 



A. 



Mi.iith' (Day) 



,VlH 



MEDICAL CERTIFICATE OF DEATH 

DATK ()!• DlvATlI 



(Montli) 



( 



(Day) (Yt-ar) 



^(i , •,.„,. 



M.oit/i^ 



'■»\ ar 



Pax. 



SIXC I.l-: MXKRIl'.D 
WIDOW i.l) (iK D!\'t»K("l-:D 

(Write in ^<nial i!< >«i}./iiiiti<>n) 



(State or (.■oiintr>-) 



oL A-cL-c^^-' 



NAM I". <>I- 

}• A rni:K 



RIKTHIM.ACK 

oi" i"A'nn:K 

(State or rmintt \- 



(^ 



h±Lo^ 




1 




U 




MAIDl'.N N \MI-; j'^) p. '\ 

(»i- M(>'iin-;i< ' ' 



HIk IHlM.AiI-: 
ol" MOIUKK 

(state or Co\intr\- 



OOCri'AIION 



^\lXxx 



''vv' 1 Crw^v 



J lU'ikl'P.V ei-lRTM'V, TliMt I altcMidt'd (lectasfd from 

VoUi 190 to OJl^ lb. upi 

that I last saw h ■■■■ alive on UJL^xk>. i t igo 

and that dt-ath (occurred, on the date stated above, at A 

' ] 
.. :M. The CArSlv()l-M)i;.\'r!I was as follows: 

U.>Jj?A..v^ Oy<:JLi-^v.^r^, . 



^ • > 



A, 



\ V 



ir. 



Rf^ldfil 111 Silii /'i<ti>i/-iii 



) '' ,1 I s 



!/.'/////> 



/),n. 



VW]-. AHOVI", S'lA'Il'.D I'KRSdNAI, I'A Kl' IC C I.A K s AKi: l"Kri-: To Tin-; 

HHST oi- \\\ kn<)wij-:dc. K AND in:!.!!: F 



f Infi iTiintit 



% 







-^ 



l)[ RATIOS 

C ( ).NT R 115 r TORY 

1)1' RATION 

(Signed) 



}'t'ars Months 

A 




Days 



Hours 



}\'ars Mouths 



.. VS'. 




Pays 



V. J .'O'l !^\.' 



g.i -l'Jt 11 icio'i' (A.1,lr,-ss) l^'^H 



'U 



Hours 
M.D. 



vJ oJUcr 



-A 



Cr^'^\' 



it 



SPECIAL Information onl^ for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyin(j away from fiome. 



Former or 
Isual Residence 

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



How lonq at 
Place of Death? 



Days 



ri^ACK Ol- HiKiAi, (»k ri;m()Vai, 




...ajL^l i.:" 



DATl^of HiRlAI, or KKMOVAI, 



(.Address 



N. B. F.very item oV information should be cjirefully supplieii. 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 given in every instance. 



I 





1 



,n I 









TU I 



A PrRMANFNT RFCORD 



Horn>l ..f IIcmUIi I N" i > '''*?,. 3^'^'*^ liftl'Oo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/c Fi/('(/, Ujl 



cL^A^cc^ 




n i'>6>H 



llei^islei'ed J\^o, 



1700 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



•Q. S. StauDatC* } 



PLACE OF DEATH: — County of^- CL'^^' ^ \.a^vac^^City of 



^ 



^ 






'^ ■.^l..<;:.l 



!^^ 



^No. I'Xlc LL^'\'^v 



*^ 1 



St.; 



5 



Dist.; bet* 



^ tl- 



v. 



and 



qt 



.\ 



( 



IF DEATH OCCURS AW*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATIO 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



N ) 



FULL NAME 



^-SD .^^V^cLolAA' ViUAA.V>v\-. 



PERSONAL AND STATISTICAL PARTICULARS 



-LavvcvU. 




4v^ 



Ii \ 11 ( >I I'.IK 111 



\' . 1-; 



ll'^^i- 



M(iiith) (l):ivi 



r%\\ 



%V 



) 'ill I 



M.'iilfi^ 



(Veil) 



IKi \. 



-.iN< .IJ-: M \ki< n;i). 

U il)«)\\l.l) OK niVUKCKl) 

iWiitr in -.iK'i:il il< v-ij/iiatioii) 



HIK flllM.Ai'l-: 
' St:it< or rciimti \^ 



\ \M1-: ni 

1 A riii.K 



I'.IK III PL \CK 

<)I" I AIIIIvR 

( St:itt or l"()iiiiti y) 



MAI|)i;\ N\MI'. 
nl' .\lt»illi;K 



HIK rillM, \*1': 
(II Mo'lllI'.K 
(St;ili oi c'oiinli \ ' 



ori. ri'ATioN 




MEDICAL CERTIFICATE OF DEATH 

DATK ol- Dl'.ATlI J? 

. dxiJC Ah 



I()0 
(Motitti) (Pay) (Year) 



I1^{RI:BV CMRTII-V, riiatl atteiKkd deceased frniii 



X) 



li^ 



190 to 

that T last saw h -:• alive on 




I()0 



...lb. 

L^.xJt. .11. up 

and that death occurred, on the date stated rd)Ove, at ^ 
M. The CATSIv Ol' DI'ATH was as follows: 



^ v. 



! LLA^'>w/C.<X.iVL 



DIRATION 
CoNTKNU'TOkV 

Dl' RATION 
( SIGNED ) 



) 'rars Months 



Days 



J lours 




Yt'ins 




A/iDiihs 



Ov.^51 



/hw 



» V'^ V • 



^ 



' .'vX^La 



/\'/'^ /if/'il III Sim /'i ii III iu'i) 



)''•(! I S 



M.nilhs 



n,n. 



Tin', AHovi-: sTATi: I) iM<: KsoNM, pAR'rFcri.AKs AKi', rRri-: ro th i-; 
iii;sT Ol" Mv KNowi,i;i)c.i'; and hi:mi-;k 



( In I'ltunnt 



rx.l.lrcvis i^b 




-^"^.^J 



G^iLIxI' 11 Tc)o'\ (A<ldrr'^s) t^-^t Crtsl 



^" if 



Hours 
M.D. 



v-.trvvv 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying «iw<iy from home. 



Former or 
Usual Residence 

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



How long at 
Place ol Death ? 



Days 



IM^ACK Ol" HrKIAI, OR K1;M(iV.\I. 

'^0 




I).\'n-^<)1 in KiAi. or KlvMOVAI, 

IaI 1.1 




OvDo-U.!! v^^.^^^^, w^^aaj I.. I... 190 

1..... ini \YV\./NA,.^. fn4 



Address Mil \1 fWULAXTA. ^ul 



N. B. Bvepy Item of in?ormntlon should be cnrefully Hupplietl. AGB should be stnted EXACTLY. PHYSICIANS shoulJ 

stntc CAUSE OF DEATH in plnin terms, that It mny be properly cloHRified. The "Special Information** fop p«r- 
«ons dy!n& away from home should be ftiven in every instance. 



M 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoar.l ..f Htrilth- I- No. i^ -f-^Mfe^ li&P Lo 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Jiegustered J\^o, 



1701 



I)((/i' /u/('</ , AjJ^<)ji/y^txK- \1 1'^OH 

a^^^loL/v^^ Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( 'd. S. StanOarD ) 



(^ 



PLACE OF DEATH: — County oi^ O^^^^ J \XV>\yCAACXi City of ^..)/<Xry\j 0AxX/\vOL^t:^c 



i/^.. 



^nd 



rNo* H rUxx^^fi-ALAjx\ 0,a/VU.fco/v A.J rr^^ . St.; " Dist.; bet*- 

/ ir Dt*TH Occurs away from USUAL RESIDENCE give facts CALLto for under •special information- \ 

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



FULL NAME 




Jb 





\,' 



M.'ti<L.^:vv LtrmA.V 



PERSONAL AND STATISTICAL PARTICULARS 



Sl.X 



i).\ii': or lUK'rn 




COI.OR 



OL' 



\^.Lj- 




lontlii 




.\(.K 



^! ,•,.„,, 1 



(I)av) 



M.inDn 



r XXh 

(Year) 



' / 



Da r. 



SIN(.I,K. MAKUIi:n 
WIDoWHI) OK I)l\(tKii:i) 
(W'littiii soiMal (|(oij.»iiatiuii) 



lUKTMPK.XOl': 
(State or Coiuitry"* 




tOAA^AjL-cL 



N.\M1-. «>l- 

I \thi-:k 



IUKTHrM..MK 
()(•• lATin^K 
(Statr or Country) 



M\II)1:n NAM}", 
ol- MOTHHK 



lUKTnrr.ACK 

()!• MoTIIHK 
(State or Couutr> ) 



y\.KX,rx\j 





MEDICAL CERTIFICATE OF DEATH 
DATH OF DKATH 



d4xt 

(Moiit!i) 



(Day) 



I go 

(Year) 



1 JIHRRRV CICRTIFV, That I attended deceased from 

— to -r: . ::7z::rr:- 



190 



190 



that I last saw h .t— r^alive on • igo 

and that death occurred, on the date stated above, at 
.•Si--- M. The CATSR OF DlvATII was as follows: 

'X.duia'^xa„^..lij.^,.o JJ lJl::v^oJt\^.a;.,.: 






vs^ 



IMonths 



Day a 



XOX/UJUAXL 



<X'> -f 




vr\lur\./ 



OClTPATION \ ^ . \ ,. I \ 

1 

Rfsidfii III Situ /'i (iiii mil J I )'riiis Mutittn 



fhivs 



lin'. AHOVI*: STATICI) I'KKSONAI. I'A K'lirr I.AKS A K l', rK!H TO TMH 

HHST oi- MY KNowi.i-'.ncH AM) hi:mi;f 

(Iiifotmant CKA^OJ \XJ ■ VtTWA.^^', 

(A.i.irc-ss H 5 t 3J.c06^ty<:ij<L sJL. 



Dr RATION 

CONTRIBUTORY 

Dl'RATION Years Months 

( SIGNED ).Lo^A^•^JL^v s) ^i)_.ljJ..XL 



Hours 



Days Hours 

M.D. 



c 



'■■.)i:^}.\i.^ ri 



Tqo 



(Address) V^fr^^jlK^ 



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



Usual Residence' 

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



Death? 



Days 



l^ACK OK m RIAI^ OK RKMOVAI, 





I'NDKR TAKKK 

(Address .<?S.. 



DAXKof HiRiAI, or RKMOVAI, 




<L>a<Vyftrw 



N. B. Every item of in?opmation ahoulfl be carefully Hupplicd. AGE should be stated EXACTLY. PHY8ICIAIN8 should 

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



1 1 ' I w in i iii i i ia ii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho:.nl of McMlth- . No >. i^^^luS:PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




4 r 




Ilegistered JVo, 



1702 



Dnlc /•V//v/,.ajLWtX'Y^OLvv. n ioo\ 

i,frv^*ix^>M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( H. S. StanDarC* j 
PLACE OF DEATH: — County of C^^ VOo^\Cv.CiCC City of JO/^a.' OAya/>vCv^-' 



vc ^tu. LU'/Y^X"l.kc-V-<;.iLSt • 



Dist^: bet. 



and 



\ ( ir Dt*TM occunW awmv from USUAL RESIDENCE give facts called for under special information* \ 
' V IF death occurred in a hospital or institution give its name instead of street and number. J 



FULL NAME 



aJ^v«^'C.k k.'.k.K^QS 




u_ 



PERSONAL AND STATISTICAL PARTICULARS 

i COl.OR 




si;\ 

\H\r\ ^ 

i).\ ri-: (»!• i!iK in 




ipnon 




A(.i-: 



1 6 'v.?/ 



W 

(Day) 



Mmilh^ 



(Year) 



XI 



Pa vs 



SI\C.I,K, MAKUn*.!) 
\\II)t)\Vi:i) OK DnORiKI) 
(Writtiii sofial di ~ .ifiiatioii) 



f) \ 





niKTUIM.AOK 

(Stat* or Co\intrv^ 



NAM1-: (>»•■ 

l-ATMl'.R 



HIRTHIM.ACH 

oi' iatiii<;k 

iSlalt or c*(mii(i\l 



MAII)1:n NAMl, 
()!• MoTIIlik 



lURTHl'I.ACK 
01- M«)THKR 
(Statf or Coinitrv 



OCCri'ATION 

Kfsitifif in Sail /'i ,i iii /.-'•,> 



t 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1;ATH 



nx^At 



(Month) 



..i..v.j5... 
(Day) 



(Year) 



I HIt;Ki:i}V CI-RTIFV, That J attended deceased from 

...LLla^C^ 't-.i 190''. to Ujlirvt. i.S 190 1 

that I last saw h'. alive on J,<t^:7jL I -' up 

and that death occurred, ou the date stated above, at ^ 



M. The CATSr: OI' DlvATH was as follows 

U^<- ' -,'wiAXu ... 



n 



X^<l<X.^\) 



Hours 



or RAT I ON Years Mouths \^ Days 
CONTRIIU'TORY LLcl<JLic ..^^Y<UL^:y\:^^ 






/X) 



\ 



^•.u<:Lo^i?' LoVX 



^ 



H 





vd- 



'S'l-tii' "" Mi>t\thf. •^ Da\ 



Tin*. AHovK sTA'n-:n phrsonai, PARru'ri.ARs ark trtk to tiii<: 
uHST oi- MVyKJsowi.i-'.Dc.K AM) iu:mi;k 



(InfoTinaiit 



1- Mvyv^ . . 



/C 



t \t1(lr(<s 





^>'\A,l'X<5-VA,^:... 



DURATION Years Mouths Days 

(Signed). ..Lb. Co, W-kOLcx^-^ 

CjX^aX ! ^. ic)o'. (Address) Lv^- \ WO Kv.-^ w^.^^.! 



Hours 
M.D. 



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



Former or l l V 1/ How long at 

Usual Residence V\A.Vi^vCUVV<KAA^ Place of Death ? 



Days 



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



ri,Aj;ji; 01* iuriai^ or rhmovai. 



DATilof IUrial or RKMOVAI, 

\^fiiAAj OJUpa: i..c> 190H 

INDltRTAKKK T • O . \j Vs<^r^^^/T\/^\j 




N. B. 



Every item olf information should be cnrefully supplied. ACJB 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 overy instance. 



\[ 



WRITE PLAINLY WITH UNFADING IN»^ — 



K<Kir(l of n<-.Mlth 1- N.). 1=; ■**?3'.'»»^ H.tl' Ci, 



. !■ I 




l»*i 



Da/r /v/rr/, .dX'^t^ry-x^^ 11 ^^^"^ 



THIS IS A PERMANENT RECORD 

REFER T O BACK OP CERTIFICATE FOR INSTRUCTIONS 

1703 



Bc^istered J\''o. 



cLtrvvA^ 




-a D c p ,w.i.>. ..{..iij..ai.lln...Q.I?..« - - ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Cettificate of Bcatb 

( Xl. S. Stan^ar? ) 
of ClcuYV' 0,Va>vcv.<i'~' City of V ),<XAAj O.Iv(X/>^C<^ C.( 



(^ 



■1 




No. I'i^.'X I) trULx'^xj O'cix II St.; 'I Dist.;bet.O>.lU%'Vo'U and J^LUYVJL'- 

/ IF DEATH OCCUBS AW*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 



FULL NAME 




^ „ „ -t 



u 



-LCLLCV^'v'Xj KlKJuu^ 



a 



PERSONAL AND STATISTICAL PARTICULARS 



SIX 



il 



DA ri: «ii' HiK III 



COl.Ok 



c, 




A V^Ljc 



/ '- 



M<.nthl 



A<.H 



i \ Ynn 



(I>:iv) 



M,»ilh.^ 



(Vt-ar) 



Da v. 



SIN(,1,K. MAI<Rn:i) 



HIKrmM.A('K 

(St.'itc or c'oiuiti V 



NAMl OI 

1- All! i:k 



lUKTMIM.AOK 
()!• I-ATIIKR 
(State <>! Couiiti yi 



M \ iI)i:N NAMl". 
()1 .Mtn'Ill'.K 



luurniM.ACi-; 
»»! M<)'rni-:K 

(Slate i>r Coiintry^ 



orrtPATioN 



I 




<x\h^uuL 



O-iV^ 



A '^ 



/^ 



MEDICAL CERTIFICATE OF DEATH 
I).\TK OK DIvATII 



(Month) 



It 

(Day) 



(Year) 



I HKRI-:HV C1;RTI1'V, riiatj attended deceased from 

190 to QX^.A^. l.b. up H 



L..C.L :\...i.L\ 

that I last saw h • alive on aj.-^'Sw^^a-v i -^. up 

and that death occurred, on the (hite stated ahove, at ^ 



d.iL^x.t IS. 



xJ.. M. The CAlSIv ()1- DIl.ATII was as follows: 

' -■ ^ 



[TliwcLli. 



< I 



^ jt 



Jv\ v\ 



, A^^- 



\>i^ 



f\'fsiifri! HI Stui /') iii/i /.■■>•') 



) 'id I 



1A. /////> 



/),/! 



rm". AMOVF, STAI'KD I'KKSONAI. J'AK rUTI, \KS A K 1- 

in;sT OI- .MY kn«)\vi,i;dc.k and h):mi:k 

( \,M,l.^s lull) V) A. , . ^ 



TKrH To THK 



•A ; 



I ) r R .\ 'r I () N ) 't\jrs ^ Months Days 
CONTR I HITOR V .Sdl.^oJsirr^Xj.^.:. 



Hours 



DURATION 



(Signed ) 



Years 



Months 




Pavs 



tVVc/:> C\OXK.'L<i:Ls,A,.-, . 



Hours 
M.D. 



^ r I., 



ic>o 



(Ad<lress)/^Ol OU-tLv^.' ^1 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



i;^,ACK oi- lUKiAi^ OK ri;mo\ai. 

in 



.uLL crv vXlWwt^ 



DA'lJ.of IJfKlAL or KKMOVAI, 

^-tUl I'l T90': 

ft) 



indi:rtaki;k 



' Q^.^iau -..U 



(Address /^ ■$ 1 .C3 jLjlLjtA.!...l).A.. 



N. B. Every Item of Informntion should be carefully Hupplied. AGFi hIiouIiI be Htated EXACTLY. PHYSICIANS Hhould 

state CAUSE OF- DEATH In pinin terms, that it mny be properly classified. The "Special Information** for per- 
sons dyin^ away from home nhould be ^Sven in every instance. 






it 

i !' 



! I 

I . 



t , 



ll<>|^ 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ii.,ar<I nt II. iiHh I" Vo i : ^'y^ssi-^^) lUS: 1» Co 



Da/c /v/rr/,.GxUlx^x.i»aA; 1.1 lOCi 





REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\''o, 



1704 



^No. 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( 'd. S. 5tan^ar^ ) 

of ^ CV>-v' Xa/%A.Ci ,. City oi'^^Oywi -J AXVvxXiAja, cc 

St.; 3. Dist.;bct. 'XU.!.^!} V and / 

r DEATH OCCURS *WAY FROM USUAL R E S I D E NC E GI V E FACTS CALLED FOR Ut^^btR "SPECIAL I N FO fl M ATION • \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD, OF STREET AND NUMBER. J 



PLACE OF DEATH: — County 



L^ 



( 



FULL NAME 








SI 



PERSONAL AND STATISTICAL PARTICULARS 



DA'ii-: Ml- itik 111 



\«.l'. 



o ', 



U 



-C 



^1 



Month* 



}■...■ 



> D.iv 



M.'uth^ 



r , [y 



/),/!> 



sini.m:. m.\ki<ii-:i> 
wiDowi: i> <»K i)i\'« )i-ti'i:i) 

iWiit<'iti siKi.'il •Ic'-ij.'ii.-it imi) \ 



lUR l"IHM< \('K 

(State or C'uililtry' 



\\MI> <»I 

i-.\'iri IK 



I!IkI"IMM,A'.K 
(»!" I A II 11-: K 
' Stati- or ronnt r% 



m\ii>i:n nam I'. 
(»1 m<>ti!j-:k 



ItlKIIII'I.ACI': 
Ol- MnllMCH 

(State or CDiiiiti V 




CCtVOAxL^L^ 



>\' 



MEDICAL CERTIFICATE OF DEATH 

DATK «>i- I)i;ath 



(Motitlli) 



1 I IQO 

(Day) (Yt-ar) 



1 m-RI'IiV CI'IRTII'V, That I atteiKkMl deceased from 



. p \(p . to ...\-^ y - V.S.. icp . 

tliat I last saw li • alive on Tyo • 

and that <leath occurred, on the date stated above, at I Xs.' 

M. The CAISI'; ()]• Di-ATH was as follows: 



(?^ 



■1 






.0X0 .. 






n 



nrU.XTION }'i-ars Monlln Days \ Hours 

CoNTKllirTORV U.\X'Vo»4.:U>w\X?w<<.. 



^CrHv^ 



ofcri'ATioN ;^ 

Rf'hUii III S.iii /'mill I'll! .-.v.. )'t'iii^ 



Miiiil/is 



/)<iv. 



Tin" \IlO\K S'lA ri I) I'KKSUNAI, I'A K T IC T I,A US .\ K l". T K T IC TO THl-: 
Hl^ST OI MY KN'«)\VI.j:I)C, K AND MKMI'.K 



(]]] foTiiiaiit 



(Address 31^5 H JxJLU>\; ol WA\M..VMj,. 



Dl'RATlON 
(SIGNED) 

CV.»lA\l' . ', i(,o 



u. 



)'<•(//', 



C '< 




Mouths 

1 h 



/)avs 



(Address) L .> I OAA.' 



X.h.r 



V 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or RfirnI Ri-siilents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Deatli? 



Days 



ri.ACH OI" lUKIAI, OK KHMoVAI, 

fXcsr^Kj^ ViVjh^^X?u VO.'^ 



.L 



DATJv ()! MfKlAl. or KllMOVAI, 



(We i ^ C 

(Address .SllH M U LLLLuL.Ll^....i.t. 






190 



IN. K. F.very ttem of informntion should be carefully itupplled. AGB nhould 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. 



"!««■ 



T-t. 



•- '•! • 



I 

1 ! 



• II 



ll'> 






I 



WRITE PLAINLY WITH UNFADING INK 

ll,,ai.l ,,f Health I- Vo :^ -*-^5^1'.S:l'<^"o 



Ddfr Filed ,Q 




THIS IS A PERMANENT RECOHU 

BEFER T O BACK OF CEBTIFICATE FOR INSTRUCTIONS 

licit! fit cred Xo. « 'Oo 



ioL^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of 2)eatb 



PLACE OF DEATH: — County of 

No. 111^ - ' - ■ 



LL t O. -> ^ aX cL rx. City of 



,<:uA-LA.<x -> 



xA VcLi's 



St.; 



Dist.; bet. ~ 



and 



/ ir Dt.TH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACT 
V, 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 vV^ Cl'^ 



I, 



.y..(X. 



u, 



PERSONAL AND STATISTICAL PARTICULARS 



si;\ 



coi.ok 



\| 1 IcxI 



Li 



DAI 1, t>l llIKlll 



.\(.I-, 



I M.mthi 



5 'lit I 



(l)av) 



Months 



(Viar) 



An 



siNt.1,1-:. MAKun:i) 
WIDOW i: I) > >K Divt»k> j:d 

iWiittiii social iltsi>.'iiat i<m ) 



(Stall- 'ii rouiit 1 \ 



1- AIII l.R 



lUK III ri, \«J". 

oi' I'xriii'.k 

I »^tatc "It ri.imlt \ I 



M \IDi: \ NAMl'. 
(»I MKllli: K 



lUR TUJM.Ari', 
ol- MoriM'.K 
(Stall' <>i t"i>\iiiti \ ' 






/ 



(Kcri'A ri«>N 



/xiMifrit ir Sdii /'iiiih/u'i 



);.! 



M.'ulti' 



l\i\ 



nil" MIOVK STATI.D 1'K U SON \ 1, I' \ K I' IT 11 , \ K s \in: IKl )! 

liivvr oi" MA' kno\vi,i:d<'.»;;.\nd iu.i,ii;i' 



ro nil-: 



(hif'itmaiit 



,N,M,.ss U<X.A^t<X>vcl„ CxX*' 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol' DlvATH 



11 



(Day) 



(Year 



^.U ..... 

1 HI>:Ki:r.V C1;KTI1'V, That I altciKk-d deceased from 

r~~ ~~ T90 



190 



to 



that I last saw h • alive 011 Tt/D 

and that <leath ocevirred, on the date stated above, at 
M. The CATSP: Ol' ])!{ATI1 was as follows: 



I )r RAT I ON )V<//.v 

CONTRIP.rToRV 



Miynl/is 



Days 



I )r RATION 



)\ais 



Month' 



/hiys 






(Signed^ ^\v.cu^ 

\..,/ . . D,o ' (Ad.hvss) ^'<^VAn ) H V.n 



//oitrs 

//o/ns 
M.D. 



SPECIAL Information only for Hospitals, institutions, Transients, 
or RnrnI Rfsidfiils, .ind persons (l)iiig .may from home. 



lormer or 
Isiiiil Rfsidenre 

Wlirn Hds disease fontrarted, 
II not at plac e of death ? 



How lonq at 
Plare of Death ? 



Days 



I'LACK Oli lUKIAl. OK Kl'MOVAl, 



DVT1-;.»1 HiKiAi, or KJ';Mo\A!< 

0X■|^.■* T 90 



rSDl'.KTAKl'.R Y^VrvA/i v) <Xc\yV.C^ 



N. B.- 



-Hvery Item o? InfornuitJon should be cjirofully Hupplietl. AdF. Hhoiild he stated RXACTLY. PHYSICIANS si 
HtHtc CAlJSn or DIIATH In plii'in terms, thnt it miiy be properly classified. The "Special Information" for 
sons dyin^ nwny from home should be ^Iven In every Instance. 



PHYSICIANS should 
pep- 



_ . .^ m •«>*-■■-• Mn A Ki c- Ki*r acr^fson 






* 



,i..^ 





I « • • • 



W 



r...;.!.! '>{ Ili ;ilth- !• 



RITE PLAINLY WITH UNFADING INK— 1MI5> lo m r-..r..,.r...^ 

^^^ REFER TO BACK OF CER TIFICATE FOR INSTRUCTIONS 

So 1=^ -i^/^-'^i; lUS:!' l. <> —————————— 




nnn 



1706 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No, 



PLACE OF DEATH: — County 



Certificate of Beatb 

( X\. 5. StanDarO ) 



esTi 



■> Q i^V (vCn Ia r^ O V St.: Dist.;bet. and 



) 



FULL NAME CVA, 




Aj 



ll. 



HI 



I A 




1 \ 



si 



PERSONAL AND STATISTICAL PARTICULARS 



^J^ 



U 



t 



li.\ ri. t )l I'.ll': I 11 



\i . I-: 



A'i''. 



M.iiuhi 



I»;iv) 



.1 A -;/'//> 



' V( ;n ) 



/'</i 



MEDICAL CERTIFICATE OF DEATH 

DATl.; (»!•• 1)I:A 111 

axWt 

(Moiitli) 
I I11;K i:!'.V ei:RTII-V, That I attended deceased from 



(I):tv) 



(Yf.-ir) 



to ...d-dut. I'l 

n ' 

.i..W. 



nyo 



sI\C, I.l-. M \K K I 1.1 > 

\\II)( )U i:i) (»K DlXtiKT i:i) 

(Wiittiii -oiiiil (U ^ij-'iKitinu) 



I'.lK'ni \'\. \'" !■ 
(St;itf or fount 1 \ 



,L x.cCc"'^^'" 



tliat I last saw h ■••. alive on O.JLfl^ l W. up 

and that <Kath (XH'urred, on the <late stated above, at i 



M. The CAISI-: Ol" Dl'^ATIl was as follows: 



M 







WMI-. <)! 

FA 111 i:u 



Itl Kill I'l, ACK 
CM" JAini'.R 

(Sl.il<- Ml i"ii\iiit rv) 



m\ii>i-:n nami', 

nl MOI'Ml'.K 



i'.I Kill IM. \t !■■. 
Ol' MoTllI'.K 
(Stjilc oi l<)\intt > 



? 






o 



I ^( 



A^L-C 



VNJ-V. I 



ry 






\.X>^^rv^<x cL o- 



OCCI I'A rioN 

AV' I,//-,/ III ^'iiii i'l ll I" ."'■" 



);-.n 



THl* MU)VH STA'n:i) PKKSONAI, I'A KT K" T I,AK S A U l-, T K T i-, lO THK 

I'livsr oi Mv !i^<)\vi,i;i'<".K AM) iu:i.n:i' 



(Iiit<iini;iiit 



'5? I Pa 



,>-4bv.c\/<iMrYX C^ 






I 




\.K. 



i . 



DT RAT ION years 

CONTUliU'roKV 



Months Pays Hours 
X...U..AxJiAu<x.Lv^... 



... > -<:./DLAo,.\J.A^JiAu<x.\. 



DIRATION 
(SIG 



Years 



Mont /is ^ /hivs 
NED) Gvvx/v>^xt VAAy>i VcJ 



OJJ^^ 



I()0 



(A.ldress) n^b VXXXUO 



CAv^^/vXX 



Hours 

M.D. 

At 









V 



SPECIAL Information only lor Hospitdls, InstiHitions, Transients, 
or Recent Residents, and persons dyinij dway from liome. 



former or 
Usual Residence 

When was disease fontrarted, 
If not at pla(eof deatli? 



A kXAJOJ\X \J^Jh Place of Dealli ? 



V Days 



LAC1-: «)!• lURlAI. OK KKM<»VAI. 



AxlxxAJL V^oJj 



I)A;41;()1 IM kiai, or RICMOX'AI, 

n TQoH 

^0 



(Addrrss 



V'Q-^^A^'n, 



di. 



, otf Information «h«uhl be cnreV'uMy Hupplied. AGE should be «tBte.. RXACTLY PHYSICIANS should 
SE OF DHATH in pinin term., that it m»y be properly classified. The Special Information for p«r- 




IN. B. livery item 

(ttate CAIJ 

«on« dyinit nway from home should be ftiven in every instance. 



awM 



)! ) 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Mo, ! : II alth I No ,. T^-f^S^ i',5^ 1' Co REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS 



W 



■\ 



Da/r /u/('</ ,AjJ^tlUy^JijLho ,11 JOO'i 



Bogistcrcd JVn. 



1707 



.^\.\AJ^ 




n^-Diitv Health Offiuer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "U. 5. StanDarD ) 

J? % 



% 



PLACE OF DEATH: — County ofO.CL-YV A.O. ^ <^^ : ^' City of O a/\^ A.CL/>^c\^ 



r ( 



m 



A / IF DEATH OCCURS A|^AV FROM USUAL 
\J \ IF DEATH OCCURlffeD IN A HOSPITAL 



Dist.; bet. and 



OCCURS Atl/AV FROM U&UAL R E S I D E NC E G I V E FACT 
H OCCURlffeD IN A HOSPITAL OR INSTITUTION GIVE 



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



FULL NAME 



Ml 



L' O. "•)'.. VIA.' 



..X- 




r\ 






PERSONAL AND STATISTICAL PARTICULARS 

si;x ' A ^ '\ I coi.oR \ 





i)\ii: ni- lUK rn 



.\(.i-; 



Mouth) 



^ 



) 'I'li I 



(I)M\ I 



M.mtlf 



t Via I I 



/)<;i 



MEDICAL CERTIFICATE OF DEATH 
D.VTK OF I)i:.\TH J? 



cUkt 

(Month') 



/go 

(Year) 



si\(.|,i:, MAKKIKI). 
'Wiitrin ".ioi-i.il <1( si<.Mi;iti' 111 ) 



lUK rill'I.Ac'K 
( Statt Df •"ouiiti \ ' 



A 



'X ^ V.O 



L 



NAM I- Ol- 
!■ All! l.K 



lUR'nil'I.ACl-; 
<)!•■ lAlIlI'.K 

( State or l'i)iiiitr\i 



MAII»j;N NAMI-, 
(>I MOTHKK 



lUKI" IIP LACK 
Ol- MOTIIKK 
(State or Co\nitr\) 



orCfl'A'iloN 









.VlvV/1\ > V iV 



S 

(Month') (Day) 

1 in{Ri:i{V CIvkTiI'V, Thiit ^ attended deocased from 

np\ to OjJ^ 1.5; 190H 

that 1 last saw h - alive on ^ ->Ly\/C ' "> \(yo 

atid that diMlh oooiiried. on the date stated above, at '. 



4' 



^ . M. The CATS!-: ()!• DllATII was as follows: 






^Vv.Xn.V^ 






^r 



x.^ 



CON rKUUTOKV 



M0U//1S 



nays 



Hour. 



niK.x rioN 



Signed ^ 



.JV.j/i ^ Mouths 



/hlVS 



h'fsidfd III Siin /'i mil i^tU) 1 )V(//» 



1/...,,'/, , 



A 



C 



Hours 
M.D. 



O.. 



i. 



loo 



1^ o, A' ^0' 

\dd, e.sAdM '^<^VC 1^0>^,I 



SPECIAL INFORMATION onU for 
o( RranI Rfvlilrnh. jrd pnson\ dvinq .mi)> Iron home 



SspiidiT 



Institutions, Translrnts, 



lotmn Of > X > \p 1 Vi HoH long at 



/',M 



rili; AHOVK STAT1",I) I'KKSONAI, I'AK rim.AKs \Kl |Ut \: ro rm 

in;sT Ol- MY KNowij.iK.K AM) m-:Mi;i- 

(lMf..tm;n.t Vj . VJ . (Aj . V.l -^ , * 



(\(l.l!ess \jXu ^M^ 



X 



OV?(y^^^vvta.i 



I 

Hhrn hjs divr,<vf tonluitrd. 
II not «it platr ol drath ' 



Pldff of Ofdtli ? 



Days 



n.\»»- 01 m KIM. OK KI-'MO\\|, 



KJk. \\J 



niu-:rtaki-:k NL 



DAXl-iot Ml Ki.Al. or KHMOV.M, 

ax^^ 1% 190H 






(;' 






Oy /D 



N. B. K.very item i>1r tnforiniition should be oirolrully Hupplied. Adti Hhoiiiti he stilted EXACTLY. PHYSICIANS should 

state CAU8I: OF Di:ATH in plain terms, that it may be properly classified. The "Special Information** for per- 
sons dyin^ away from home should be j^iven in excry instance. 




^nj. 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ddlr Filcil, dx^vtxA'^JLov n I'^O'^ 



Registered J\^o, 



1708 





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



Certificate of ©eatb 



( "U. 5. t5tan^ar^ ) 






N^ 



PLACE OF DEATH: — County of V^ 



\.<x^^^vA ^A City of^ 






Dist.; bet. 



and 



X'VL)Ow\X<P^ UU0^7\.cLa.' M.; - -^- lJist.;bet. ——— ano 

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



FULL NAME 



\Xk/:L\JLKxAX 




'uLlI' 



^'■^^ QS^ 



PERSONAL AND STATISTICAL PARTICULARS 



I) A ri; t »! I! IK 111 



.IM. 



s 



\<". i-; 



.loiith) 



,^ 



) ,„ 



I 



(I):iv) 



Moulli- 



(V. ;u^ 



IH 



/'.,■! 



Sl\C.I,i:. MAKUil'H. 

W IDiiWl'.l) <(K 1)I\(»R* I'.I) 

'Write in >«Mi;il ch si}.Miiilii)ii) 



ItlKTMI'I.ACl-: 

I Slatf or I'liiiiitrv' 



«? 




\xx^a^^:a 



N \M I'. OI 
I- ATM l-.K 



lUK'nil'I.ACl': 

di" lAfm; K 

I St.ilc ui' i'uniilT \> 



m\iih:n namf. 
OI- MormiK 



niKriiri.An-: 

OI" MOT III-: u 

I Stiitc <ii I'oillltl N^ 



oi n TATION 




J? 



JLaX\,o^^v<:L cL0L^Vrt5\/li-L\AX 



(iti 



' 



K.O 




KjXyY\.'^%, 



MEDICAL CERTIFICATE OF DEATH 

DATi-; OI' I)i:atii 



lU^ 



(I);iy) (V<;iii 



(Moiitrt) 

I III'KlvHV C I'.RTH'^V, That I atteiKk'd deceased from 

^XJaA. iH I90S to <^.^.4^fe l.a ICK)^ 

that 1 hist saw h -^ ahve 011 . ^ ^ti V\ 190 H 

and tliat deatli occurred, 011 the (hite stated ahove, at 
v' M. The CAlSh: ()!• DI-ATH was as follows: 




.^OrVW<11 \J U4^^"V:V\.^k.-*.AA^ 

DC RATION Yt-an^ Moiit/is 3> Days Hours 

CONTRIIU'TORV 



DTKATION 
(SIGNED ) 



)'t'ars ^^^^^^Mofit/is 



/Mrs 



'y\j 



f\fsiiii-il ill Siiii I'l tiiii isri) 



''■(II <■ \ y/n,///,. \S Ihn 



111 I". \HO\I". sr \ ii:i) I'KKSONAI. PAk lirn.AKs AKI' TKIH To 111 I- 

in:s'r oi- Mv KNo\vi.i:i)C.H and iu;i,n:i' 



f liifotiniiiit 



d, ^ 



CXJxA.XXyX/ 



(\.1.1 



rcss 



blX 



iJ^y^^Ji 



Oi 



64^ 



n i<,oH ( Addr.ss) 1^1 



... A 



Hours 
M.D. 



^AA.tX.^^; ul 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinq Hwny froni home. 



Former or i ^ r» V A \ | 

Usual Residence ^ lolVV ,■.-. M 

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



flow 
Plac 



H long at \ 

eof Death? XiA' .. 



Odys 



DAXl". <•!' HCKIAK or KI'.MOVAI, 

ll i9o'\ 



ri.ACK Ol' HIKIAI, OK KlCMoVAI, 

(Address . io ^.'^ .yS A..<^'C^^d,rlA/-%^/wl, 3.^. 



IN. B. F.very item olf in?ormntion should bi ciirufully supplied. AGB should bo sttited KXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special information" fop psr- 
son« dying uway from home should be given in ^v^ry Instance. 




% 






I? 



ii 



W'\ 



"> 



iii^yHBB>--- 




WRITE PLAINLY WITH UNFADING INK 








n. 



lOO'i 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1 )((((> Filed , Ojl^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



M 



Certificate of Beatb 



PLACE OF DEATH: — County 



( II. 5. StnnOatP ) 
of a -^ X' .\, o_ w c\^.C(, City of - J .<Xa V X^X vx.e^^ 



% 



N 



0.1 HOl 




Cu 



t 



St 






Dist.;bet OAX>v.^:a. 



and ' J^<:^<! 



n 



1 V. v^v^v^ ,,c,,-, oreiinFNCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \ 

( '^ rF"D;AT°H"0CC^%rD^N"rH0^S^PrAt rR^NST'lT^^O^N^O.VE .TS NAME INSTEAD OF STREET AND NUMBER. ; 



FULL NAME 




,'<X^-^kJL 




"o^ 



PERSONAL AND STATISTICAL PARTICULARS 

1) ATI". I >l- li IK I'll 

\ 



AC, K 




k ( 



)■-•</ 



% 



' l);iv) 



Mniilli' 



I Veil i) 



lhl\ ^ 



SINCI,]-:. MAKkll'.I) 

WIIX >W J-I) OK I)I\< >Kri".I) 

(W'liti ill -orial dt sij.'ii;ttiini) 



lUK Turi.Aci-: 

I StMtf 'ir *,'<)unti V 




.C 



O-tr^ 



MEDICAL CERTIFICATE OF DEATH 
I).\TE OK DICATII _^ 

■ Jt 1 b 

'Day) 




(Year) 



I lIl'kl'HV Cl'RTU'V, Tliat I atteiKlcd (lccease<l from 
(1 ' ^ 

that I last^saw h 



T90H 



Tliat I 

„ A 



\r 



(S^ 



K. CX •, ' 



i-.\'nii:K 



HI KIM I'l.ACK 
<)1- lAini-'.k 
(Sliitc or (.■iiuiiti %• 



MAI1>1:N NAMl, 
01 MoTHl-.K 



lUK'Puri.ACi-; 

(H- Morill'.K 
( St;itf 1)1 l'<iuiiti \ 



orcrr ATiox 





(371 

>L'<X>-vCJL 



\' 



^ 



(^ 



1 



A.O 



Kr^iilrii III Stin /'i (Un ' ■ 1 o 



'1 '' )-,-,n V 



Mnlllln 



lhl\ 



ini" AMovK sr\ri*,i) PKusoNAi, I'AKTUTi.AKs A k 1-; rKri' r<) Tin-: 
iii-;sT oi- Mv kn<)\vm:i)c.k and hi;i.ii;k 



\,l,lrrss 1 H b 





.U\} 



01 



...1^ 190 H 

alive- on O^^f^ ' '^ 190 

and that (loath occ-urrcd, on thc> date staled above, at O- A 
Ca. M. The CAlSlv OI-' l)i{.\ TM was as follows:^ 



a1 



DrU.XTlON y'rars '\ Months Days I /ours 

CONTRIIU'TORV 



DTR-XTION 
(SIG 



)'('(! rs 



NED )3AX<ijiAX' 



Months 




Pays 

.0 '. . 



Hours 
M.D. 



at'i-J.. ^ T9oV (.-Xd.lres^) itCrt^lJA.W^iL^^l^.-> .. 



SPECIAL INFORMATION «nly for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyiny away froii home. 



Former or 
I'sual Residence 

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



How long at 
Place of Deatli ? 



Days 



ri,ACK 01' muiAi, OK ki;m(>vai. 




DATJ'.u! liriuAi. or KKMOVAI, 



Ms - 

(A<hlr.-ss ^Hb N^'W^iAA..4y-^\ 0^ 



T9O \ 



IS. B. F.very item oif InfforniHtion should be cnrefully Kuppllecl. AGF. Hhould he stnte.l RXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it miiy he properly classified. The "Special Information" for per- 
son* dyinil away from home should be feiven in every instance. 



m^^ss 



\^- 









I . 



t , • 11' 






m 



ikytfli- 



w 



RITE PLAINLY WITH UNFADING INK 



H,,a,,l..f Hialtli I- N- > .-.l^-l'^y-^nScVCo 



190\ 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Bo^istered J^'^o, iVU J 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( 11. S. StanCiarC* ) 



9 



(W 



V 



% 



PLACE OF DEATH:-County of'Va^x. ^lvc^>vcvA.ca:ity ofO ,Cu>^ .>vcv >^c.«, c.... 



:\ i 



M I H ^t> M II' LLO' > s ' . •- St.; "i Dist.;bet. VJ.^Ov^ and iC^ 

Mo. I V (. U ^l I ^ 'v-X-.X,^ S ^- - ■ ,,_,,,, OESIDENCE OlVt f«CTS C»LLtO ron UNDER 'SPICIAL lUroRM.TION- "^ 

( " r"o»T°„'lcc"„%Tr,',"rHOS^R"*.' O^f-I^T^O^/CVE ,TS NAME .NSTE.O O. STREET .NO NUMBER, ) 



^ \ 



) 



FULL NAME 




i 



PERSONAL AND STATISTICAL PARTICULARS 



DA ri". nl i;il< 111 



At.K 




bo 



)■- 



10' 

l 

(l)avl 



\ 



( Vrar 



Ihn 



MEDICAL CERTIFICATE OF DEATH 



DATH OI- I)i;ATn 



Oxkt 



II. 

(I)av) 



(Year) 



a 



(Montn) 
I Ill'RI'HV C1':RTI1'V, That 1 attc'ii-k'(l deccascl fmiii 



b 



dX:^ 



IQO 



H 



(Write in ^oc-ial (h-sijriiation) 



I'.IK'ruiM. \C\-. 
(Statf <ir *."'iuiiti V 



NAMl 0» 

i-a'iiii;k 



lUK riM'l. ACK 
Of I AI'IM-'.K 

( Stall' iir (.'iniiitt \l 



M MIH'.N N VMi; 
ol MnjIIl.K 



i;iK riM'i.Ari-: 
<ii' Mi>rm;K 

(Slat'' 111 l'in\iitrv 



occri'A rioN 



« 



^U .CO-^r^vj- 




%; 



(57) 

X(X w-^iL 







! 






A/ni/f/r 



n,n 



rm xHovi". s'lATi: I) im'-rsonai, i'ariivti.aks ak)-: trci". to rni", 
Hi;sr oi- MY KNOW i,i-;i)C,K and iu'.mi-.k 



( In foMiiant 



that I last'saw h •• alive 011 OJc^ ' ' up 

aii<l that (loath occurred, on the <latr state<l above, at O A 
LAw M. The C.MSl': OV DI'IA TH was as follows 



DIKATION 
CONTkllUTOKV 






Mouths 



Ihu 



•s 



//o/trs 



)'C(irs 



DT RATION^ 

m 
( Signed ) g,^wL<ix^x' 



Mouths 

(0 




Pavs 



■Lcu. > 



Hours 
M.D. 



'Jl^vX; 



1()0 



( 



A.hlresK) IcCrUl Vj 



XXV^ >^v>:.i.^^\. 



SPECIAL INFORMATION ""'y *«r Hospitals, Institutions, Transients, 
or Rccfnt Residents, and persons dying awdy from home. 



Former or 
Usual Residence 

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



flow long at 
Place of Death ? 



... Days 



ri.ACK 01 lUKIAI, OK KI'.MOVAI, 





( ndi:ktaki:k 



l)A'rj;()!" Hnn.Al. or KI-lMoX'AI, 
(A.l.lrc-ss ^H^ NVLA.A.^LA^.^y-vv Ot 




N. K. F.very Item oV inforniHtlon should he cnrefully Hupplied. ACJB should be stated EXACTLY. PHYSICIANS should 

state CAUSII OF DEATH in pin'.n terms, that it may be properly classified. The "Special information for p«r- 
sons dyinil away from home should be ftiven In every Instance. 



kAL 



■Mi. 



1 

'ft ■ 




m 



:3W 




K"^ 





H 'Ml 

n I- 



^ 



WRITE PLAINLY WITH UNFADING INK 






Dfffr Ff7r(/, G xA^iJL^-vlM^ IT i'^O'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1 



Ileo^i.sirred J\^o. 





Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "CI. S. StaiiDarD ) 

PLACE OF DEATH: — County ofOoLO^' .^CL>^^v<i.C( City of^JO-^^ OXa^-vo^.^LCO 

I . i] CI \ f? 

No. S iS dL^^\-^-vvLC C\A_U. St.; . Dist.;bet. VJj.V-^^k' and I\-^. -.... 

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



) 



FULL NAME 'iCb^'^^s^'t^^ oLy.Lc^^A.xi.a> 





0(X* V. 



Ni.\ 



PERSONAL AND STATISTICAL PARTICULARS 

■ Col.oR 



fl<xL. 



-L-'iVctv. 



I) \ V]-. I •! HI K 111 



.\<.j-; 




i\. 



MoiitlP 



kf\ 



)•-.;»> 



'\ 



IS 
iDav) 



^/''ii//r 






/hn 



siNci.i" M\Kkn:i» 

\VII)()\Vj;i) OK I)I\< iRD-:!) 
( W'litf ill ■''nial <lr<irnati(iii) 



HIKTHl'I.AOK 

I Stall- <)!■ (.'Miiiitrv' 




(j/C.<yLL^. 



UXAX^A^XxL 



NAMl-: <)I' 

i-A'rin:R 



lUKIHIM, ACK 

(»!•■ iai"jii-:k 

(Statf or Country) 



MAIDI'.N NAMl". 
ol MoTIll'K 



HIK rniM,ACK 
Ol" MoTm<:R 
(Statf or Coutitry 



/-^ 




MEDICAL CERTIFICATE OF DEATH 

I) ATI-: Ol' DKATH J? 

(MontTi) 'Dav^ 



/QO 

(Year) 



I m';Ri;P.V Ci;R'fII-V, That I attt-n.U-.l diciastd frmii 
rJJiJfJo 190' to OjL^X,t; i'^ \(.p'\ 



Up 



Ibal I last saw h - alive on 

autl that death (KHMirred, on tin.- <la1r stated aliovi-. at Ia.-3>0 
vX M. The CAISP: ()!■ DI'.ATI! \va^ as follows: 



^v^ 



AX/y\/Qy0^y\) 






Moutlia 



n^s ^ Hours 



t'ONT R I in • I'D !■; \' -J o. % ^^c^.^JLAxX, crtllW^^Q/ixt, 



i' 



■4'H' 



or RAT ION ^ )V(//.v Months 5 Days I louts 



(Signed ) .() 



M.D. 



dX'|\,t IH T<,o'i (Address) ^"^i a.S^LL\> gi: 



Kf^idrJ III '^i!ii I'l it III i^i'ii V 



)'rnis *■{ lA' 



;////' 



/'r.M 



TIM", AUovi<: ST v:n-:i) i'Kksonm, tar riori.AKs \Ri-*TKri-- to Tin-* 
HHsT oi- Mv kxowi,i-:i)(;k AM) hi-:ui}-:k 

(Informant ^^^ ^^-^ ^' ' *^cULcXhj 

A n J? 



Special information onl> for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying aw«iy fron home. 

Former or How long at 

Usual Residence Place of Death ? Days 

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



DATKof HriuAi, or KHMOVAI, 



lU^ACl-; OI- HIKIAI. OK KKMOVAI, 
INDl-KTAKKK ^ <xXj{XjLA. ^< Ll. 



N. B. Rvepy item oV information should be cnrefiilly supplietl. A(JF. should be stated EXACTLY. PHYSICIANS should 

stntc CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par- 
son* dyin^ away from home should be A'ven in every instance. 






'Tl!' 1 






1,; .1.,,,.,, 



I 



"b 




n 



WRITE PLAINLY WITH UNFADING INK — 



IJoMi.l ..»• lK;t!l»i- \ N.) i-- fr-?*^^--^ !t?vlM-M 



/>^^/r nii'd,^ 



r^\ 




\j 



11 /^^H 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

17J1 



Re^lstei'ed J\^o, 




\} 



H 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( la. S. Stan^arD ) 

J? (3p \ ^ 

PLACE OF DEATH: — County of Oo^w Axx.^-.cv<i.r.-.City of CJ <Xa\; J Ax^'^.CA^^.l. 
jvT ^,^, , St.; ' Dist.;bct...&'CX.^^^-^^^ - andWh^LtO. 

/ .r DEATH OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECAL INFORMATION- \ f 
( .F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J Ij 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

Si:\ X'N ■' rnl.iiK 



\., 



^^^oJul 



^' 



I 



I) A 1 1". til i; IK 111 



AC !•; 



U.J^. 






kl 



y,-a 



M.nilh 



I S'Liir) 



/',/i. 



^IM.l.i:. MARKIl'.n 

WIIX »\\ )-:i) <IK I)!\<)Kri',I) 

'Wiitiiii >ii>ci;il (li->-i>.' iiat iuii) 




lojvvOL/d. 



liiKTni'i.Aoi-: 

'Stiitr i>r (.'oiintrv* 



FAT II IK 



lUR rin'I.ACK 

<)!•• 1 atiii-:r 

(State or I'oinitry"! 



MAIDl'.X XAMi: 
(>!• MOi'in'.R 



lUR'rurLACK 

(>!■ Mo'nncR 

(Slate or Country') 



r 



-1)11 




^^xycx."vAj 



tx . ^- d. 



J i\ 






\^OJU\r\JL\.K/>r\X dJx^^yy\/>r<j 



O. 







rM(f/-(f III SiJii !• 1 11 III isrn Oo )i-nis 



Mniiths 



na\ V 



I'm", AKovK si"Ari:i) pkrson \i, par rini.ARs ari', rKiK To Tin-; 

iu;sr Ol- MY KN«)\Vl,i;i)<'.H and HIvMHF 



^ 



fliif..'iiiant dJL^ \l iWaJVcL^ C-- i . 



( \<l(lress 



(\ 



-W\A.|>Jl>v dl 



i 



MEDICAL CERTIFICATE OF DEATH 

DA TK Ol I>1;ATII _V' 

QxM. It 

(Montlli) (Day) 

I HI':I<1:BV CI'.RTII'V, Tliat I alteii(k'<l <k'tcase(l from 

to ...S>jJ(>^ l.b icjO ""i 



I go 

(Year) 



\j.jiJ.^\X 



I Ip A 

that I last saw h ■■■■'^ alive on ..\..>L^^'k up 
and that (Uath orcurrcd, oij the thitt- stated above, at A O 
..JM. The CAlSlv Ol" l)l<;ATn was as follows: 

U) AX<vto.A-\.><^>x. ..(5^^ 



DCRATION 
CONTKIIUTORV 



Years Mouths 



/)a vs 



VwXir^Aw'CUy5rA>s,<<rv;\...Crir...^ 



DTK AT ION y'c'urs 

(SIGNED) ...H^A. 10 



Mouths 



Pays 



■'\ 



Hours 

Hours 
M.D. 



dX^^ lb TQoH (Address) S Og nA<.tl». 01: 



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 !onq at 

Place of Death? Days 



PI,ACK OF lURIAI, OK RKMoVAI. 

Led 




DATJ-: of HiKiAL or RFIMOVAI, 



rNDF:RTAKKK 



.^^axUJl.v(h'(R 



(Address I 111 



QQU 




>J/<iA/Cr.W... 



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 clossified. The "Special Information" for per- 
sons dyin^ away from home should be ^,iven in every instance. 



[f, 



i I 



(I 



^^^ 



i*. 



WRITE PLAINLY WITH UNFADING INK — 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Rc^Lstci'cd J\^o. 



1712 



I)((h' ri/r(h'':)jJr<)UU^A>^iK> 11 J'^0\ 

ou>^v\^ 30U\^u. Licpuiy J,iN..^-.i.s.?.:i...Q.fl.'- 

DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDeatb 

( tl. S. StanDar^ ) 



PLACE OF DEATH: — County of M \ ^>.0v.^> ^ 



^ 



\ 



City of '^^ Ccv^v^^Jl, 




LCLl. 



No. 



— St.; 



Dist.; bet. 



— and 



*W*y rPOM USUAL R ES I DE NCE Gl VE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \ 
_ _ . . .._ «» ...OT.TMT.OM r.iwr iTc: NAME INSTEAD OF STREET AND NUMBER. J 



( IF DEATH OCCURS AWAY FROM USUAL K t 3 I U t n V. t ^ . v t tm^.o --"— /^ '1" "I. ^Z^Zl. 
\ IF DEATH OCCURfltD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET 



\ 



FULL NAME 



nO-/'>^^ 



LV- 



PERSONAL AND STATISTICAL PARTICULARS 



SJA 



^ 



C< H,« >K ' 



vO. u 



v^ 



DATl". or lUKIM 



A • . I-: 



Month' 



) ,-a 



I):iv) 



MnuHn 



(Viar) 



/'<; 



sINC, I.l" MARK II-: I) 

\\ ii)t tw i:i> I >i< i)i\ t tKri-:i) 

iWiitiin social (hsi(.Mi:iti' m) 



(^.^ 



LOLWUxl 



iuRTin'i,\rj-: 

' s,t;iic iir ' '' >ttnl 1 \^ 



N \M I t >1 
I A 111 IK 



lUKTIiri, ATH 
Ol' lAIIIl-.K 



MAIIO'N" NAMi; 
ol Mcnill.R 



niRrnri.Aci-: 

{)!• MdTlll'.R 

( state III (.■•miilt \) 



r^tlo 



1 



\ 



cu c-.<rv> ^<maj 



V) 



^Kjo 









<H(M TAlKiN 

h'r^iiifil III '^'ciii /'i ll I'l I'l'i 



) ,,i 



\f..nnn 



/', 



Til i: \n()\'i*, s'i'A ri:i> pkrsonai, i-arih n. \rs aki: iri v. lo iim-: 
iii:sT Ol Mv kn(>\vm:i)c. i: and iii:i,ij;i'- 



(111 foMiiant 






-O 



+ 



MEDICAL CERTIFICATE OF DEATH 
i)ATH OF i)i:ath 



cSA-X 



igo 

(Year) 



(Montii) (Day) 
I Hl'ikl'iHV C1;KTII''V, That I alU'inkd .kcLascd fmiii 
I(;0 to ~~ ~ ' T(;0 



tliat 1 last saw h alive on up 

and that tloatli occurrtMl, on the date stated above, at 
M The CArSl-: Ol" DI'.ATII was as follows: 




DT RATION )Vr/;s- 

CoNTRIlU'TOkV 



Months 



PiU 



•s 



Hour 



DTRATION 



(SIGNED ) 



)'Ojys 



Miniths 



a^|xtj n i„oH (Ad.lress) <J 



Pays Hours 

-> M.D. 



Special information «nly (or Hospitals, Institulions, Transients, 
or RetenI Residents, and persons dying away from home. 



former or 

Usual Residence )<X*^^^ 

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



'CXa^aXLoJIaXo V<Ujpid(eof Death? 



'f 



'.. Days 



I'l.ArHOI" lU RIAK OR RI:Mm\AI, 

* Va a ^A 

r\I)i:RTAKi:K V.XVAwAJ^-<XA„<A. V-^ 



I).\ Ti; «)f lit uiAi. or KIvMoV.VI, 




N. K. livery Item oV inVoriiuHion Hhould b- cnroVully Hiipplieil. MIV. Mhoiild ho Htjitetl liX4CTLY. PHYSICIANS nhouid 

Htiitc CAlISr. or DKATM in pliiin ttritiH, thnt it iiuiy lie properly ciiiHNh'ieci. The "Speciiil Information" ?op p«r- 
Honc (lyin^ iiway ^Trom home hIioiiI«I he t^iven in every inHtnnce. 



I. ' \< 



•t 




WRITE PLAINLY WITH UNFADING INK 










.\1 



100\ 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be mistered J^o, 1 <4 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccrtiticate of Beatb 



( TH. S. Stan^ar^ ) 

Oft 



4 



PLACE OF DEATH: — County of 6 Ct^- C).\.CXy>x<XACC City of CJ ^^ J /\XXy >vt^. 



No. 



St.; t Dist.; bet. AJ-iAA/VXt and \i^.K.<X.a^K. 




( ,r Dt*TH OCCURS *W*Y TROM USUAL RESIDENCE GIVE FACTS CM.tED ^OR ^^^ IV^IV^'^^^VuIIbZ^'*'' ) 
\ IF Dr*TH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



^^CjaaaC/X) 




PERSONAL AND STATISTICAL PARTICULARS 






COI.OR \ 



A t . I". 



•J 



tl):iv) 



fVc'.-t! ) 



(0 5 )>„;> 



s|S<.l.lv MARK Ii:i) 

\\ I !»• >\\ 1".I» < »K IH\i )Kr i: f) 

iWiil' ill s<)ci;tl (l»si).'ii;itii>n) 




itiK'niiM.Aci-: 

( M:it<- 'II •■■luiitivl 



NAMi; <>l 
FATHl.K 



luu'nnM.ACi-: 
oi' iArni:K 

(St;itc or Couiitrv) 



MAII»i:N NAMi: 
(H- M()TII1:k 



iiiurm'i.Aciv 
(11 M()'nii:K 

(St;lU Dl roillltl \ > 



(KHTl'A'lION 



^\ 



Mntllln C*v C»s Ihl\S 



(1 



I \_ I IV. 



-o.;.. ' 



? 




'X/>v 



^ 



k 



\>-. 



/\'/U(ffl/ III '^'(111 /'l II III /'/•it ni.jL )' ll I 



\/nll//l. 



/),;. 



Till-: MIOVI". S'l" \li;ii I'I'USONAI, I'AK I KT I. \Ks \K1. IKll- 1» > rill-; 
HKST (H- MV KN<t\VI.i:i»".K AND HI, I, II, I- 



(Iiif.)imant V.V ^ N ^J - ' 



<• t * 



I 



x.i.ii.ss ll Vl Mf rV\^^.vf: > V 'Vi 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATl- t)l DKATH P 

(Month) (Day) 

1 HI:K1:HV Ci; RTII^'V, Thai I attended deceased from 

\(p to — —— :.:.;r"; 190 " ~" 

that I last saw h ' alive on ~ 190 



and that death occurred, on the date stated above, at 
^J. The CAlSIv ()!• DliATII was as follows: 



1 I 



I) r RAT ION Yrars 

CONTRinrTORV 



Mont /is 



Days 



Hours 



)l 



•RATION Years ^^ li 



loyiths 



Days 



-\' 



(SIGNED) \J^ {y^\x^' v\ . vfc. \^, XkXj(x. , vc*. 

e>J.\\t. 15 ,» o (A<ld.vss) \j^\t\\Ji\^\]U\.^^ 



Hours 
M.D. 



Special information ""'y '"f Hospitals, Instifutidns, Transients, 
or Rfcfiit Residents, and persons dyinij dv»ay Ironi home. 



Former or 
Usual Kcsidenre 

When Has disease (ontrarted. 
If not at plac e of death ? 



HoH long at 
Plare of Death? 



•• Days 



IM.ACl-: Oim KIAI. »>K ki:m()\ AI. 

^X> 



l)\T»:o! Ml KiAi. or KKMOVAI, 

^x\<k. \\ T90M 



0>u ^ Lv^ 



(,\.l.li( 'i'. 



N. B. r.very item of informHtion mIkmiUI b.- ciiroftilly Nuppllcil. AC.i; Hh.>ulcl he wtntcti hXACTLY. PHYSICIANS should 

Htutc CAlISi: or DTA TH in plnin tcrmi«, thiit it miij he properly cliiMNitMed. The "Special Information" for p«r- 
Kons <lyin^ iiway from homo hIioiiIiI he ftiven in o\ary InNtnncc. 



'■' 't^-rm-'f^i^^r, 



I i 



% 



i: 



\rm 



l"il 




1 1.1^.11 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR I NSTRUCTIONS 

A ^\ A 

Registered J\'o, »- rA^ 






l>al,- r,U:l, ,A4xU-.>JU>v VI i^o\ 

l^^W. Deputy Health Officer ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of H)eatb 

1 *a. S. 5tanC»ar^ ) ^ 



^ 



St.; 



Dist.; bet. 



and 



-) 



( 



' JiSrjB ""-i^^ --?j^;^^^;^-i'^«c ::^^ir s^^i-i^o^^-^^r - ) 



FULL NAME 




S V. \ 



PERSONAL AND STATISTICAL PARTICULARS 

rnl.ok \ \ 

DA ri'. < >! lUKlll 




Aci-: 



aW> 



S ,-a> . 



IDay) 



M.nt/h^ 



(Year) 



Hen. 



SIN<". l.lv MAKKli:!). 
\\Il)()\Vl-:i> OK l)lV<)Ki'i:i) 
(Write ill soriul (Kvii-'iiatioii) 



lliK Til ri. X*"!'. 
I StMtt DT (.■tiuntrv'l 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATII 




V 



t 



VX ipo'\ 

(Day) (Year) 

I~iTfr1TbV CKRTH'V, That I attended deceased from 

— — — — — iqo 

— ■ — T90 



(Montli') 



190 



to 



:X< 



A 







,c\ v-cci-x 



>> 



NAM I- 01 
I- A 1111 . K 



lUK Til PI, AVI', 
()!• 1 \ rill-.K 

I State Ml rminti V 



maii>i-:n nam I 

ol- MoTIll-.K 



HIKini'LAfl". 

ol- M()Tni:K 

(State or Country^ 




til at I last saw h ••-- alive on 

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

— M. The CAISIC Ol'^ DlvATII was as follows: 



1 



DIR.XTK^N )V<7/-.v 

CONTKllH' i'ORV 



Mont In 



/hiys 



DIKATION 



.e. 



Pars 






( SlGNED^LcV^^ve.^ 

g.cKt >o looH I \,l<l.v^<) Lcr\<rv^V* Vl'i(-^'t-il 



/ Jours 

Hours 
M.D. 



oCCri'AlION ^ 

/\f-u'ifr<f III Situ I'l ,nh /,w 



<x^vA, 



1 , ,; 



\.',< ,fh< 



/l.M 



Tin" MiovK sT\'n-,n I'KKSON M. i'\K rnri.AKs AKi; ik\ 1 

iIksT OI- MV KNOWI.l.IX'.H AND Hi', 1,1 1', !•' 

'0 



i.> nil' 



(Iiifoiniaiit 



Lvvcrv%ji/v/5 Wh^y 



f \.1.lre 



| \.v 

Special information only for Hospildls, Instituiions, Transients, 
or Rarnt Rrsiiirnts. .ind priMUis d>iiiq UHd> from liome. 



loimrr or 
I'mmI Rrsidrnir 

mirn \*.is dlsMsr ntntr,Htrd. 
It not .It pl.i((-ol drdtli.* 



How long at 
Plait of Deatf) ? 



Days 



ri Wl' i>l- m UlAl, t>K Kl'MoVAI, 



C3 A.^ >x. VV.W. U ^'O^L'L 



I) 



NDl-RTAKHK "i^JUULH ^V OK) 



DA TJ; .)!" UiKiAi. or KlCMOVAI, 



(Address 5^1^^^' \^ iL . d't 



N B —Rvery item o? in?orm,.tJon .houhl b. creVully suppH.Ml. AGB Hhoulcl be Htatecl RXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The -Special Informat.on" for per- 
Bon« dyinft away from home should be feiven in every instance. 



Ml 



"1 





|: 



H 














WRITE PLAINLY WITH UNFADING ir?^ 



!?..ai.l of Hr:ilth !■ 



N.) !^ ■*''SJS![^iu"tr Of) 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health Officer 



Registered Xo, 



1715 





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



PLACE OF DEATH : — County of^<X'>v 



Certificate of 2)eatb 

( XX, 5. StanDarD ) 






fNo. 



MW-l ja.^-cK..-.., St 



AXVYVCfvAC. 



^ Dist.; bet 



City of 0.<X-y^ J.Vo^-yvc 



<s.^C I 



I ilk. 



and 



1 o 



i 



occu.s .w.r r.c« USUAL H.".'.?5.-".?.^'L"^.;'7TrNV«E ,rTc7o°i^ s?."^;'.^'"";-^"';.''' ) 



FULL NAME 



m 



^<X\,A^ 



..Ux.^..' 



PERSONAL AND STATISTICAL PARTICULARS 



<•! 



DATl". <tl I'.IK 111 



COI.OK \ 



'v.L.'iv^"' 



(.Month ^ 

•J 



\(.K 



O V )><//> 



1% 

<I):iv) 



M.nilli' 



(Year) 



/'./r.v 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DHATH 

■ ■ ■ . ■■ 5 

(Day) 



fMontn) 



igo 

(Year) 



sINf.Llv MAKKIl'.n 
\VII)it\Vl-:i) OK I)I\<)Kii:i) 
IWiitciii ".iK-iiil cU -^ij/natioii) 



( [\xx^^>vOL d- 



lUK'niri, Aoj-: 

(Statf or <,"'»nili y) 



NAM J" <>! 
HATHI.K 



lURlinM.AiK 
i.^V } ATI IKK 

(State or Country^ 



MAII)1:N NAMK (,T\ ,1 
OI- M()TII1-.K ^>*"^ 






1 \ '. 



xk-Lia-v'^va \^ 







iukthim.ack 

OI- MOTllHK 
(State or CotuUry 



OCCIFATION 



^ Jt ^vVoLAXoj 



.1 









I in-:KI':nV CI-RTIFY, That I atteinU'd <lcccasc(l from 

\j^:J ■ - 190" \ to A^vb \h. 190 H 

that I hist saw h ahve on J-JL/i^x.tj . 190 

an.l that death occurred, on the (hile ".tated above, at 1 X 
:ST. The CAl'SI-: OI" DI.ATII was as follows: 



J">.U'.. 



Mouths 3> Davs 3 Hours 



nr RAT ION Years 

CONTRMU'TORV 



DrUATION 
( SIGNED^ 



Year. 



n 

,0' •. ( 




Mouths 



Days 



\)^. 



•.d-sX>v 



Hours 
M.D. 



Address) ^\\^\^X At 



Special information only for Hospitals, Institutions, Transients, 
or Rnrnt RfNidrnlN. m\ prrsons dying dHdy from tiome. 



_ vjl\.»va . ^ 



r 



Krsidfd 111 Siin /'iiUhi'-ii 



),-,i. 



y/.nif/,s 



/',; 



THl" AHOVr ST\Tl'.I> I'HKSONM, 1' \ K I' IC t I, A U S \Ki: rUl » lo 1111' 
HHST OI" MY KNOWl^l-.nCK \M> MI-l.HlI- 



(Informant 



O 



^ 






i 



,v,,,i,.,.s. ^t)?- LCuytx-) 



,LtL ^ 



i 



formrr or 
lsu.«l Rfsidrmf 

Whrn v*.!'^ dlsr.«'>f t onfr.ic tfd, 
It not Jt plat r ol dr.ilti .' 



How lonq at 
PIdi f of Deatli ? 



Days 



riVClol 111 1<I\I, OK KKMoVAI, 



V 



I)ATj:o! HtkiAl, or KKMOVAI^ 

" )x4xL ii 190'i 



(3A^^JrvNj 






(A»l(lress .. 



\f)\KjiiiA^\.^iy.) 



^ B _Hvery item o^' -.n.-ormHtlon .houhl be cnrefuUy Huppliccl. AGE •houl.l »>« «i«*«i^F,XACTLY PHYSICIANS should 
Itate CAUSE OF DEATH In plain term., that It may be properly clos.if.cd. The "Special Information" for p.r- 
«on« dyinft away from home Hhould be Jiiven in every instance. 



r^'^nm^-i 












f ^ii- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l'„,;,i.! ..f- ili:ilt!i r V<> :- *t^^^: V.Sc V C n 




Bci^isfei'cd J\''o, 



Dale Filed Q j^iU i^o — I'v ,; ^ . i'^ ninn lir^'nstPi'Pd J\ o. i-^-lO 

SI ' i 

Xt^vA^O Ijca.'.^ ".on-'^v Hf.n!-h G -r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( 11. S. 5tan^ar^ ) 
PLACE OF DEATH: — County of OxX^v VCLIxCcclCO City of OxX>\; o A-X>^^'xc<^ 



^k». 



.XL-^\L\.oX C»^JlVql>vC^ ^'b' O^JsuXx^l) Dist.;bet. 



and 



/ IF DEATH OCCURS «>/»'' »' " O M USUAL R E s[l D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
I, IF DEATH OCCURRED IN A HU^SPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



-) 



FULL NAME 





-VCri^^r^^ 



,CL 



m;\ 



PERSONAL AND STATISTICAL PARTICULARS 



n 



n 



L 



^ 



1 



I)\ ri-". nl- i;il-; III 



vjL-\'V-?v 



M..nlh) 



Ai.i-: 



a. 



. I.. 



) - 



' It.lN 



M.nilln 



■»■( ;ti ) 



Ihi 



\\ iix »\\j:i) ok i>!\< iKri:i) 

' Wi itr in ^c«i;il 'li vif ii;iii<'n) 



iSt;itf <)i I "'111 111 I \ I 



NAM I (»1 
!• A III Ik 



lUkrillM.ACK 
(»l lA llll-:k 

' St.itr u! (.'(Hint I \ 



MAIDKN NAM I", 
oi' Mo'rni'.K 



lUK'rm'i.Ai")-; 

oi- MoTIIl-'.k 
(State (II ronntiy) 



orrri'A'iioN 

Ri'siilrd III Siiii / I ini( iM'ii 




MEDICAL CERTIFICATE OF DEATH 

DATi'; i)i' i)i;ath 

-'X 1 1 



(I)av) 



/on 

(Vear^ 



(Montli^ 
I Ill-R i'l'.V CI'RTII'V. Thiit I atttiKkMl (k'OcastMl from 

— to ■ 



tliMt I last saw li 



1 90 
— alivf oil 



T()0 

1 90 



atid that (li-atli occurred, on flic date stated above, at " 
7^ M. The CAlSi- Ol- UhlATII was as follows: 

1)1" RAT ION y'cars Months Pays 

CONTRini'roRV 



Hours 



nr RAT ION )'tuxrs Afonf/ts /\u'S 



(SIGI 



Hours 
M.D. 



) /■(// 



M.'iiflr 



lhi\ 



rm: ahovi*. si'Ari'.i) i'Ivrsona!, i-ariuti \ks arj: TkiK id Tnic 

Itl'.sT OI- MV K NOW 1,1; IX ".K AND lU'.I.II.I 



\Js\jfx^y\JiJ\^ 




■V.C<- 



c 




1^ l(,oH (.\ddre'^^)W 



\j^nr\V\J^ 




^. 



! " i 



SPECIAL Information <>nly lor Hospitals, insfitutlohs, Transients, 
or Recent Residents, and persons dyinfj away fron home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'LACIC OI" lUklAI, Ok ki;Mo\Al, 

Q 



^ 



AA/W/^y\A4 



\}JUL^ 



DA'p'.of HiKiAi. or K1:Mo\AI, 
\l I90H 



V% 



( AiMffSS 



(Address 3>b'".L.V- • 1^ ^ttv J A. 



N. B.— Hvery Item of Information shonl.l be CHrcfuIly Hupplie.l. AGF. hHouIcI be stated RXACTLY PHYSICIANS «hould 
state CAUSn OF DEATH I., plain terms, that it may be properly classified. The Special Information for per- 
sons dyin^ away from liomu should be l^iven in every Instance. 



I 



![:'' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



}<<.:ii<! nf ll.iilih 1 V. 



t-^^'«!^ ]\ScVC(> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' F/7('(/, 




n i^Wi 



llegLslci'ed J\'*(). 



1717 



^-vcv^<'i 



\ 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of H)eatb 

( 11. S. StauDarD ) 
PLACE OF DEATH: — County of ' J/CL-^-v OXOuw^c^^v-. City of ^'<^^^ XCL yvc^^vsL c<. 
No. bC)0 -b.i St.; 5s Dist.;bct.^'ttr^Kl.^no.' and ^ ' ■.^-lI.L. 

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



FULL NAME 



^xL^l..( v 11. o 



PERSONAL AND STATISTICAL PARTICULARS 

.r.\ ("V^^ j c'oi.oK 



J 



I) \ 11- (t| lilK III 



.\<.i-; 



ffloiitht 



iD.-ivl 



■I'l 



)•- 



.1/,.;////' 



(\'<-:ir) 



/^,,M. 



MEDICAL CERTIFICATE OF DEATH 

DATK <)«■ Dl'ATH 



(Mont'h) 



.-'+ VVj iL 



(Day) (Year) 



siM.l.I". MAKUn: I) 

wiin >\\i-;i) <»K i>i\< »i-M i:n 

'Wiitfiii siKJal (I«si>.Miat iiiii ) 



, rlcXA/vo^ 



luuriiri.Ai'i-: 

'St:itc (ir ' "'iiiiit IV 



(\ 



\" \\t !•; ( »i 

(• A Til l.K 






I lllvRI-l'.V Ci'RTirV, That ^ atttn. led (ItMvased from 

\ip to JzhJiJ^xXj ik. \(.p . 

tliat I last saw h ■■• alive on , up 

and that (k-ath occurred, on the dat*.- stated above, at I 

'V 
\j^ .M. The CAISlv Ol" DIvATII was as follows: 



JUKlUl'I.ArH 
<M I ATMKK 

(StaU- or t'ouiiti v> 



MAIDKN NAM1-: 
<il M()TH1;k 



MiRi'niM.Aii-: 
«»i M(>Tm:K 

( St;tt<- or fun Jit I \' I 



oiHTl' \'1"H)N' 



A,. 



S{ 



I )!' RATION b )'fars Months /)ays Hours 

CONTRIIU'TORV LAvCA-^J^ \l,Lw. ; .' 




cLu. Mil Vct"Ufb 



_LcLU-k'v, 



DIRATION Years \ Months Pavs 



(Signed) 



Hours 
M.D. 



n>o 



(.\d<lress) S'a:. 



Special Information «nly for Hospitals, Instifuflons, Transients, 
or Recent Residents, and persons dying dway from fiome. 



h'l idr,i III Siin I iilihiiii 



) I ill • 



Moiit/i' 



/>„■ 



THi-: \n(»\i<: st xri: d i-kksonai. tak tk ti.aks aki: ri<r)-: ii > rii)': 

lli;ST Ol' MV KN«)\VI,i;i)C.K AM) ItllMI'.l" 



(III f'M iiiaiit 



'X.l.lr.'ss 







Former or 

Usual Residence - j 

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



How lonq at 
Place of Death ? 



' \ 



Days 



)Ai:}';.»t' III HiAf. or ki-;M<)VAi, 

I 90 . 



I'J.AC}'. <»!■ lU KlAI, OK KI:m<)\\I 



-\ 



(Address 



IN. B. F.vepy item oV informHtion should Hl- ciirefully supplied. Ad'B Hhould be Htnted F.XACTLY. PHYSICIANS nhould 

state CAlJSn Ol- DKA TH in pliiin terms, th»t it miiy be properly classified. The "Special Information" for per- 
son* dyln^ away from home Nhouid be jjtiven in every instance. 



1 



« 



)• h 



■ ••^ 




1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/c 


n/rd 


.nxUtx-rYNX- 




cLctVCA^ .iOL'V-L 


DF 


<PAR' 


rMFNTOFI 



V\, 



lleglsiet'cd jYo. 



1 71 8 



City and County of San Francisco 



Certificate of Beatb 

( Xl. S. Stanc>arD ) 



1 



<d^ 



l^ 



No. 



PLACE OF DEATH: — County oiO<Xy>^ vj \XX^vC\AC<i City oi^^<Xrr^ ^O.tvca^^q^ 

St.; H Dist.; bet. ^K^' .<XJ\)v\AJyy\^ and J Crl<^^ 

(IF DE*Vh occurs away from usual residence give facts called for under "special INFORMATION" \ 
IF QEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



V^' 



()' 



FULL NAME^^^tdc; 




^^y\JH^ 



\\ 



.^ui \X)x.\ 



A\V4Cr> 



PERSONAL AND STATISTICAL PARTICULARS 



-^l-,\ > 



V < III >k 



1 r\jx.' 



u 



II \ I i; 111 111 kin 



\' . 1-: 



M. mil 



lb 
I lav I 



. 1/.. /////- 



MEDICAL CERTIFICATE OF DEATH 

I) \ri". oi' iii; ATI! 

^Ivt; 1 k: 



fMonth 



'»t;n I 



/>,n. 



'^IM'.I.lv MARKIi:!) 

WllK »U i: I> OK I>l\«>Ki i:i) 

(Wtit< in -oii.-il (1( sij/^iiiitioti) 



I'.IU I'll I'l, \C\-. 
Mat"' iir < '■ )iiiit 1 \ 



»• All! i;k 



HIKTIiri, Mi: 

«>i' iArm:K 

( staff or l'<niiiti \- 



M \;i)i: N NAMi: 

oi Mitiiii: u 



lUkTllIM.ACI-: 

<>i M<>riij-;R 

(stall- or I'luiiit 1 \ 



(.yK^-Y^o^ 






L^ <L^ 



\ 




'tX,^\'>xJL^ 






(Month) (Day) (Year) 

I m;Ki:r,V CI-RTII-N', rii.it I ;ilti-n.kMl «lci-caso.l from 

. •. '. .' it^oH to ..aX:y\ti. '^ i(/)M 

that I last saw li - alive on UX'ji'vt lb y^p S 

ami that iKatli o(Hnirrc<l, on the ilati- stated above, at i 



^>i 



M. The CArSI" ()]• 1)1-: A Til was as follows: 



^ 



..•. •■ WOwl-^^-V^m. '.O-XA^tjk; C^ 



i>-CdL 



> X/% >-v.<A^\. 



DC RATION }'(U7rs .!/<)>/ ///s /hus 

CoNTRir-riORV 



//ours 



\J 



\. 



A'V^XOl 



Jo^IXjo 



Kj^ 



( 



j<X/y\i XCLA\xi<^sL 



DCRATION 

( Signed ) 

•'•• 1 ''•• 



)\ar 



Miyfiths 



Pays 



J 0-\)-C)-^L 



"1 



//ours 
M.D. 



r ( )0 



(Aililress) lOHi^ ' (o 



tk ii 



Special information »nly lor HuspiJdls, institutions, Transients. 

or Rcicnl Rfsidents, dnd persons dviii;) ,m.iy from home. 



I xri I'ATION 

h''''i(lf(f III Sdii / '; (?;/i ,' ><■'' 



]'i It I 



U ,,'f/i' 



n,i 



rii r. \H()\-i- ST \Ti:i) iM'"ksoNAi, pAkrirfi, \ks Aki. rki i-; n » rii i-; 
iti;sT<»i MY KNdW i,i;i)<". !•: and mI';mi-;i'' 



I II fo: niaiit 



^ 



( \.l.]l( ".S 



?s! S - f 



,. -| J 



w • " 



Former or 
Usual Residence 

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



Him Innq at 
I'lare of Death ? 



... Days 



I'l \(,1'" Ol" HlklM, nk KI;M(»\AI. ( DA'VI'"! IImmm. or kllMoWM, 
\_^ 

:0 



-♦ 






190 ' 



N. B. Kvery item of Information should be cnrcfully suppHe.l. AGF. «houM be Htntc.l RXACTLY. PHYSICIANS should 

state CAUSI: OF DLATH in plain terms, that it mny be properly cliiHsifietl. The * Spccinl Information for p«r- 
Ron« clyinj^ away from homo should be ftiven in every inHtnnce. 




-If 

I 



'•t 



f ^1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

llo^islcred ^'o. 1719 



ll.);ir<l "f lK:illli- I V.I .~ ■5-t?Er'" '*'' '■■' 



I hi If Filcil,'Ox)rsXxrx^3j-<hj ll lOO'i 

Xfr^U) IjLvw Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccvtificatc of IDeatb 

( 11. £i. 5tan^arC> ) 

J? ^^ \ ^ 

PLACE OF DEATH: — County ofOa-rA; OXa^xau^^U)City ofO/Cu^x; XXX/>vc<.a/^o 



No. 



'i l.i\' \\ SU I Dist.;bet. '^W and 

/ IF OE*TH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECAL INFORMATION" ^ 
( IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



/T)^ 



FULL NAME 




Of\ 



M^-' 



Kql 



\jrY\.^n^\jxj(k. VDAAAvd<axi..^... 






PERSONAL AND STATISTICAL PARTICULARS 




\ 



i.: 



-A^'^^ 



I) \ ri-: < 'I HI Km 



\i .1-, 






i>.i%i 



I '\ VA\ ) 



J-,<n 



y f ,. . 



<i\<'.i,i" M vKK ii-:i>. 

w iix t\\ ii» < >K i);\"< )Kii:i> 

I Wi It- • - . ..i; .l--;v'ii:ili'>ii) 



lUK I'lll'l, \t'l. 
St:iti (It I '.Hint t \ 



!• A riiF.K 



luk riii'i,.\ri-. 
oi 1 \rnHK 

fStatt 1)1 C'ovinti y) 



MAIIU'.N NAMl 
oi MuTIll'lK 



lUK'rui'i.Ari'; 
OI' Morm-.K 

(Statr Of (.N)\int! \ 



<K\T1'A|[()N 






0' 



vvocvL^-^^ J 



cL. 



-CcrvCCCLO 




Av. 



h'/'Milri/ lit Sdl' / I i! Ih !^i''i 



i 



:1 



\l,n>tll- 



I h:\ 



Tin- \u()Vi'. sr\'n:n pkkson \i, i-xkiumi. \k> aki: \-\<\v. r<> riii' 

m%ST ()!• MV KNO\\I,i:i)«'.K A N 1> J44; U l". i' 
(Inf.,:nK.nt OvOlAXtO 6 ■ ^ \^ 



Ac 



A. CL fX C 






U.Mi 



h 



1H()\ ^1 .AJv \X\.^ 



il 



MEDICAL CERTIFICATE OF DEATH 



DATK <)!•■ DICAIH 







5xkt 

(Moiilli) 



(Dav) (Yt-ar) 



I in<:RI{HN' CI'IKTII'A', That I atlfiulfd deceased from 

i i \Kp\ to O « \ ^'^■ 



TOO 



that I last saw h alive on ^-^-jW . \ up 

and that ileatli ix'eurred, oil the dati- stated above, at 
\\ The CAl SI-; Ol" DI'IATII \va^ as follows: 



'.,_<. o^X>^■ v,^vAa^>vt^ 



DlKAriON )Va/-.c Moni/is . Pays IIouvr 

• () N T R 11 ; r T () R V '^ A^t^C^^ v.'JX 



C 




■iCX^.V^'Lvtrv 



x 



I )r RATION ,v> Years 



^foritJn 



Pays 



Hours 

u. y "P \\ 

(SIGNED) J-'\uy^ V?'. 'V »V^^ > . .X^..U M.D. 

tvl ;( i.,n (A.ldres>.) ^"lO^ VXXAAjjI^QVvtva Ql 




Special information only for Hospltdls, InstiluHons, Trdnsients. 
or Reienl Residents, and persons dying .may from fiome. 



Former or 
Isuiil Residence 

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



How long at 
Place of Deatli ? 



Days 



I'KACK Ol- lURlAI, oK KI:M<i\\I. 



I) Vri'. "!' Hi HI \i. oi K i;M( W \I, 



I 



1 90 ' 






o .. 1-1 \cv ah.iiilil be stnteil r.X4CTI.Y. PHYSICIANS should 

N. B. F.very item of InformntJon should h. cnro?uIly HuppI.ed. A(.l. should "^.^ «*"*'^^ ' -Snecial ln»orm,.tion" for p-r- 

«tote CAUSE OF DKATH In plain terms, that it mny be properly clH8«.^.ed. The Specal ln»orm,.t.o„ tor p,r 
«on« dyini owny from homo should be ftiven in every instance. 



m 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,..„anl..fn...!th IN.. , t..!^;iwS:ir,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l?eo^/,stcj'cd Xo. 



1720 



/)a/r Fi/i'(L aX-kix^UMA; ll l-^O'i 

l^cc4~llA>^, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. 5tnn^ar^ ) 
PLACE OF DEATH:— County ofOcu^^ vj.\.a^vC^<LC.cGty of ^ OJYXj ^ A.<X. ^ v 







I 



No. H'i na>\' vclk^Lo-v 

OCCURS AWA> 

■M OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



St.; 5" Dist.; bet. ^ C) ) 



\\> 



and 



n tl 



/ tr DrATH OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V F FACTS CALLED FOR UNDER "SPECIAL INFORMATION • • \ 
( Tf DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




ywJb^ LCL' 



'TlL". 



,e ) .. 



^!;\ 



m. 



DAii: I '! I'.i Kin 



\<.i-; 






'0 



r, 



I Davi 



1/..//'// 



'i 1 111 ) 



•^iNc .I.I", MXkuii'.n 

\\I I)t >\\i:i> ( »K It!\'< iK^ J'. i> 
i\Vril< in '•ocial 'h>ii}^nalioti) 



iiiK ruiM.Aci': 



\ 



LL ,ccLcrv-N>^'cL 



r 



NAMl' <)1 
lA'lIIl.K 



liiK't II I'l, \>i-: 
<>i' I A nil' K 

iSli«t«- or Cmnili V 



M \ ii»i:n' n ami: 
(11 mi»iiii:k 



HIK TIM' I.AC I-: 
(»!•• VorilKK 
(Stati' Ml- ('()\nUt \ 



I >t I (I'A rioN" p. 



^^^ \jl1 

C 



{m^'^'xX. 



u 



(\ 



'V.^'v.. ^ _ .. I 





r\ ^ 



Cn'^^'w^ - 



I r 



AX.k.^ 



C r 



A'r.iJr,/ ir S,iii / 1.111,1 r.) ^^ ^ ) V'" 



Mnxtll' 



n.n 



TM1-. \H()VK sT\Ti 1. I'KusoNM, i' \ u Ticr i.A Ks A K i: rKii: T' • Tm: 
iJKST oi- .Mv K\< lui.i.ix'.i', AM) iu:iji;i'' 



(III fi)- iiiant 



ClQ) 








<b ^W •- 



MEDICAL CERTIFICATE OF DEATH 

liATl-; (H" Dl'ATll J) 

Oxixt I'i 

^ Monti)) 'I>.'iv) 



(Year) 



I lIi:Ki;r.V CI^KTII'N', That l altt-iKU-d «K'ix-;isim1 from 
: . , ' 1 iqoH to ax^^t I'l ic,oH 

that I last saw li '•■ alivr on • | \-^- ' Kjo- 

ami lliat <Kalli < xM-iirrfd, oil thi- tlatt- statttl ahovc, at *^ 

^ M. TIk- CAISl'; Ol' l)l';AriI was as follows: 







..a 



1)1 KA'IMON 
CONTRIIM'TORN 



)'tais Mont/is 

01 A J 



/)iirs 



Hours 



DIRATION 
(SIGNED ) 



Months 



Pav 



\.. ■. 



I<)0 



(A, Muss) IbSb ob&u/a\.d. J' 



Hours 
M.D. 



SPECIAL Information on'y '"^ Hospitdls, institutions, Irdnsients, 
0. Recent Residents, dnd persons dying .iwdy fro.n liome. 



Former or 
Isnal Residence 

Wlien v^.is dise.ise (ontrarted, 
If not at plai e of dedth ? 



How long dt 
Place of Oeatli ? 



Days 




in \i OI ri-:m<)vai, 

\'\ I90M 



ri.ACl', 01 HI KIAI, OK K J:M< A' AI, 



■"— — — """"""""""""""'""'""""""^ .. 1 *r'K =Ho..l.l h« «nitccl i;\ACri.Y. PHYSICIANS should 

N. B.— r.very Item of Informntion «houl.l b. c»re.ully HuppI.ed. ;\ 'f^^^^^^^^^^^ Th; -Special Information" for pT- 

•tote CAU8I: OF Df.ATH in ph.in terms, thi.t it ms.> he properly clo8«.»iea. 
finn« clylnft awiiy from home nhoul.l be feiven in every inBtance. 



f :!! 



iii 



r 



"■ ... t 



.r 



fii! 



WRITE PLAINLY WITH UNFADING INK — 



no:,r,i ..f Mcr.lth-l-- No :. -^C^'^ ^'•^^' ^'" 



/)((/(' /'V/rv/, (jJtK'tx^^^^^'^-'^-^^ ^"^ 



i9(n 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

Re ^i sic red J\'o. 1 721 




r> f» r« ^ 



I ^ i-% 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeath 



tl. S. 5tnn^ar^ 



1 



T^. 



PLACE OF DEATH:~County of ^^ O.^^ JXO.^vCU -cGty of 0-C^^^ 0.^vCL>vCL^, C 



Dist.; bet. 



.s *v.*v r.oM USUAL RESIDENCE o.vr r.CTS C....O ;-^-o.« 3;«-^-;*-----,°-- ) 



/ IF DEATH OCCURS A\A/AV TROM USUAL MtSlUti^v^t u . v .. r-v,.^ I. . mV ■ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N^ME I 



FULL NAME 



,0 



PERSONAL AND STATISTICAL PARTICULARS 



t 



six 



[ 1 UXA^< 



nu 



.or) 



LLi^a... 



DATi; 1 il IlIK I'll 



\t.l'. 



,Uot 



M..mli ' 



!):.\ 









/•■ 



^i\» .1.1" M \KU n",n 

w iix t\\ i;i) < »K i>!\« >Kr):i) 




lUK PMIM, ACl-: 

i Stiitc or ronnti \'^ 



>.\Mi; <)i- 
i-.\Tm:R 



lUKI'llI'I. \rK 

oi' lAiin-.k 

(Statf or I (diiiti \ ' 



M \!I)1:n N \M1'. 

(H M(>rm;R 



lUK Tlll'LAn-: 
(Stiil( or c'ovuitrv^ 



0/0. '>v ova > -ct 



vl ^ ' 




c\\x.\-<x 



oiji 




VCX/VAj 



ocrri'A rioN (TA 



Rr-^iili-il III S,iii I'l itfK i''-i< -^v 1' 



\r<iiih^ 



lh;\ 



TIM' \HOVl- ST\li:i) I'KK^ONAl, IV\ K II«T I. \ 1< ^ AUI'. TKri: T' > THi; 
lilvST <)!• MV KNt)\\l,i:i)<.K \M> Ml'.I.ll.l' 



( 1 tl follll.'lllt 



Q '"^"^ Co'. 



(Nd.lrcss 



nisUalk H 



J MEDICAL CERTIFICATE OF DEATH 

DA ri-: oi" DiiA'ni 



(Month') 



II):iv) 



fQO ' I 
(Yfiu) 



1 HlUxlUiV C1;RTI1-'V, That I attentUnl (k-cxaseil from 



'. ;" J-.. ,v* 



I90H to 

;iliv«.' on 



tliat I last saw 1\ . alivt- on C'X-jvt U up 


and that (K-ath occurrcil, on the <hiti' stati-(l above, at 5i 

V M Thf CVrSl-; 01 1)1:A'1II was as follows: 



: I 



I )r RAT ION ' >V(7y,v 
CONTKIIU'TORV 



Moulhs 



Pay: 



'.V 



Hours 



Ycais Month: 



DTRATION 

(SIGNED) iL. V-'- V.\\u' •-..; 

'ox|\fe n i()oH (A.i.inss)at). 



/)<7r.^ 




/fonts 
M.D. 



J6-sL^JL 



t' 



gpg.^l^l_ ||\4poRMATION onlv tor Hospildls, Institutions, Transients, 
or Recent Residents, dnd persons dying .m.iy from fiome. 



Former or '^'^Q 

L'sudl Residenff ^ °^^ 

When Has disease contracted. 
If not at place of deatfi ? 




\ 



.^v 



t 



Hov^ lonq at 
flare of Deatfi ? 



Days 



PI \CF OI- lUKlALoK K1;M«»\ \I. I)ATi-;o! Mikiai. o. KICMOVAI. 



— ~"— ■~~'''"— ■"■"■"■""""""'""''""""'""''"'^ ^ 1 Kr%^ «K,»..I,I he «tiite«l i;XAC TLY. PHYSICIANS Hhould 

N. B._Kvery item of lnV',.rm..tion should h-- c.refully HuppI.e.l. ^ •** '^;';: ''^^^^^^ The -Spcciul Information" *or pT- 

state CAIJSF. 0\ OliATH Wi plain term*, th.it .t m»y he properly classmeu. 
fion« dylnft uwny from home Hhould he ftivcn in every inHtancc. 




itti 



Ml 



■ 1 




"^1 



1^^* 



^w 



I 






i., t 




I' 



m 

m 




W 



RITE PLAINLY WITH UNFADING INK 



r„,;|!.l nf Hi:|lll 



, 1- N-,, ,-, X-^^y-^.nfkVCn 



Dfffr h'ilnl , OX 





ryj 



\l 



190\ 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1722 



Raiixicrcd JVo. 



A>V 



l^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 

PLACE OF DEATH:-County orf^Vrv J^a.xc.cc City of O.CuW J AXcox^^<t e. c 



IMST 



FULL NAME 



;lo. 






SK\ 



PERSONAL AND STATISTICAL PARTICULARS 




I 



1) \ li: nl- lilK 111 



„IJ-AxaJL.. 



/ h'X K 



Mwiitli* 



\< .!•: 



s|N( ,1,1' M \RK ll',I>. . 

U IIH )U i:i> (»K I)!V« »KvI-:i) 



( I):i\') 



.1 /,>»////. 



iVf.-ti ) 



Ihn 



MEDICAL CERTIFICATE OF DEATH 

uATi-: «>!• i)i;atii 



(Day) 



igo 

(Yt-ar) 



Ua- 



\\j-\^<y\Xni\J 



uiu I'uri, \oi'. 








(Stati or (.•oniitry^ 




1 A /C\ / 


< 


NAM1-, (H- 




V>\y^V^' 




I' AT 1 1 i:r 








IMU THri.All". 








()l- I- A I'M }•■.!< 








I Stale D] ("(lUlltl \) 








MAIItl'.N NAMI-: 
i\V MOTIU'.K 


V 
-T^ 


^^•- 




MIK rm'l.Ail". 


-^ 






<»i' M<»!in:i< 








(Slitf III I'lUllUl \ > 








1 u tll'A rioN 








Krsiilnl in 


Siiii I'l iiih m 


) , )l 1 » 



nxkt 

(Montio 

^1 Hl'Kl'l'.V C1';KT11'V, TliMt 1 alli'iuK-.l .k-ivased frniii 
^-X-|vt ' 190H to pX.\A,t I.L TC)0H 

that I last saw h .. alivr on O -H.^^ '■ ^. Icp '^ 

ami that .Katli orcurred, on tlic date stati-d ahovi-, at 
(j ^ M. Tlu- CAlSh: Ul- J)1:ATII was as follows 




C(»N TKIIH TORY 



.)/.>>/ //is 



Days 



J fours 



dt ration 
(Signed) 



Yc^-s 



I 



m 



.Ifont/is 



fhivs 



)...\\Xi \\ l(,o'l 1 



%' 



I/ours 
M.D. 



j w\ „CX-,vv ^. 
SPECIAL INFORMATION only tor Hospitals, Institutions, Transients, 



itntions. 



1A./////V 



/'./I 



TlirAH.)VKSTXTKI.PKKS«)NAM-AKTnM^I,AKSAKi:TUrK H . THK 



L 0, k)a. 



(IiifoTinatil VjJLOVCU- 



or Recent Residents, and persons d^inq away Ironi liome 

(B vow-vx^v^^v A' Place of Death ? 



Former or 
Usual Residence 

When was disease (ontracted. 
If not at place of death ? 



Ilo 



Days 



I'l ACI-: <•!• IM KI \I, OK K l,M«>\ Al, 



DAIl'.')! Ill lOAl, III K I'.MOXAI, 

Ox|n^ l**" 190M 



ni»j:ktakkk 11 V 




{A«lili<-s«^ 



:iO' $ AJv 'jt 



\ 



IN 



^^^— — ^— 11^^^^-^— ■■ fXACTl Y PIIYSICIAINS should 

. H._,;very Item o^' informHtlon •h.,ul.l b. —^""3; ""l*^' ''"•;',; p^^peHy""l«.-W1ed.' Th^ ••Hpccioi Information- for p.r- 
•tote CXlISr Ol' DKATH In plnln term*, thiit it m»> >e properiy 
«on. dyinft ..way from homo HhouUI be J^iven in «vcry inHtance. 







I 



I" 



1.1 -1 



\ 



'■W 



R^ 




WRITE PLAINLY WITH UNFADING INK 



-,] ,,f iiiaitii »•■ N<' 1'- *'t:,^;r^''"'^'* *^*" 



/hffc n/rd, Ox) 




i% 



100\ 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 



(MXA^ 




ii 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of S)eatb 

( tl. 5. StanDarD ) 
PLACE OF DEATH:-County of 0,C^^ J Xa^uCUet City ofOxVvx. .LVa.>^^Ui.Ct 



(^ 



No. OXX^Vck 'IcCi^LKLtoJ; 



IvJ, 



St.; ~ Dist.; bet. 



~~~ and 



VO^A; 'J^ ^^' ^ L MCUAL RFsTdENCEG.VE FACTs'cALLED rOR UNDER "SPECIAL . N FO R V. ATI O N - \ 

( '^ rF"orArOCc"u%'Rro\rrHo's^Pa"!: :'?NSnrJ;'o^N'o.VE .TS NAME .NSTEAO OF STREET ANO NUMBER. ^ 



c 



FULL NAME ^d^^^ 



1 1 un-vt 



q(n^\x>v.t( 



^ I". \ 



PERSONAL AND STATISTICAL PARTICULARS 




oJLi 



w. 



!• A ri". ••!• liiKTn 



\i . v. 



I Month* 



av 



l-S 



)•. ,; 






(Oay) 



M,',i'/,~ 



r I ■ '■ 



/).n A 



^iNt.1,1" M\ki<ii:i>. 
wiix »\vj-:i> OK i)iv( iK*'i:r) 

iW'iilf in social iUsi>.Miati'in) 



^cLcrV.^ 



luk riiiM, xt'H 



I- A 'I' 1 1 1: R 



HlkTIiri.ACK 

<)I" l-AI'IIKK 

' St:it( 1)1 t"<mnti >■■ 



MAIDl'.N NAM1-: 
nl- Morni':K 



lUK I"II1M.A("I": 
Ml- MOTin-.K 
' Statf <.r C'oniitt v 







Vlu^yv^/yvci. i I laA \ V.., 




? 



ft 1 



LAVAltr>% 



(urr I'ATioN 




vv 



Rfsidfif ill Still /'liiiKisro A-^ ^ '''^' ' 



}/,iiif/r 



/),M 



IHI-: AHOVKSTATl-.I) rK[<S.)NAI. I> \ Kf KM' I, A RS A K I". TK ( " K T" THK 
HHST Ol- MV KNOW l.i;i>C.K .\M) H1-.MJ'> 



( Infill niant 






(AfMrcss 



MEDICAL CERTIFICATE OF DEATH 



DATi-; Ol- i)i:.\Tn 



axWt 

(Montn) 



lb 

I Day) 



/po \ 

(Year) 



I lll-RI'il'.V CIvRTII'V, That I alien. led (IcHvasc'tl from 



up M 



1 90 1 

tliat I last saw h !- • • alive on Q)JL\^t I - up 

Mild that death occurred, en the dale stated ahovc, at 1 • 
^ M. The CATSIv Ol' DI'lATH ^vas as follows: 






--■< iV 



Cr 



\ 



<X'v\/tA.J-<<x..'i o 



DIR.XTION )'W .1A"///m- 

C N T KM I U T O R \- KJxL.fA/X^L. ■ 



/)avs 



I lours 



DIR-XTION 



Years Months 



10 



Pays 



IIOHIS 

M.D. 



(SIGNED) ,v.^.. --■ . 

Ax\At 'A ..oH (Address) 100^ U<xUA^^^A^m 



SPECIAL INFORMATION onlv tar Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyiny dwav Iroiri home. 








Former or 
Usual Residence 

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



^15 Uxjv^v 



It 



How long at 
place of Death? 



? I'lx 



Days 



IM ACK Ol- niKlAI. OK Kl-.MO\Al, 



DA TJ-; 1)! 

ox\ 






I'.i KiAi. 01 ki:movai, 
1 90S 



"~^ ^ lib toted FXACTLY. PHYSICIANS should 

f Jn?ormHtion should be cnrefully supplied. '^^^ J!^"" ' l^j. The "Special Information" for p.r- 
OF DEATH In plain terms, that it may be properly ciossitlea. 



N. B. Bvery Item o? 

state CAUSE urr i#i-« ■ ■■ ■■■ »-■- ; . S-af-nce. 

son. dylnft away from home should be ft.ven m every .nstance. 




w 



RITE PLAINLY WITH UNFADING INK — 



,,,,,.1 .i .haul, - K No .. y^-f^^-^mvco 



Dale riled, r) 




VA.^^^ 




Luv \% 



IfJO'i 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

llei^Lsicred J^^o^ 



1 ( -^4 



.^>^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of Beatb 

( "U. S. StnuDarJ? ) 



^ 



No. 



PLACE OF DEATH:-County ofO<X>v 4 >V<^>va^. City ofU^^v OA,<x ..c<^ c- 






) 



FULL NAME 




CXa V,K-\,c4iL>vO,.. VA4.v: 



" '^ 



PERSONAL AND STATISTICAL PARTICULARS 



COI.OK 



1. \ 1 J- i)\' niKTH 




\(.i-: 



\ 



)V 



(Day) 



M.nith: 



'» rai 



/>./! 



(Day) (Year) 



si\(.l,l-:, M.\KKli:i>. 

W IlxtWHD OK I)IV«)Rti:i) 

I Wi iti in v,K-ial il> »is.Miat inii ) 



(State or CnuiiHy^ 



NAM I nl- 
1 \ 111 l.K 



iMK'niri.xrK 
oi I Arm-.K 

' stall- >>r CuMntry) 



MAIDI'.N NAM1-: 
OI' MO'rni'.R 



lUKTin'i.Aii-: 

OI- MOTIll'lK 
(State or (."(ninti v 



orcl T \ TION 









a 





MEDICAL CERTIFICATE OF DEATH 

(Mnlltll) 

1 lllvRl';i'.V CI-.RTll-V, That I atten.kMl deceased fn.iii 

ijL\<h lU u)o". to .. Bxj^. ^myl"^^ 

that I last saw h ■.. alive on C) ~^\<^^ '' ^^P'^ 

aii.l that .Katli oceurie.l. m, the date stated above, at ^ 
M The CAISI- Ol" DI'.ATH \va^ as follows: 



or RATI. IN y--'r^ •'/""''" "* ^-'''^ "'""'' 



^ 



A'XcL^^v_(X<l '- 




.KX>L^ 



) V(M , 






TnKAm>VKSTATK.>l'KKSoNAI.I'XKTU;rLARSAKKTKrKT<. THH 
H1-;ST Ol' .MY KNOWUI'D'.H AND Hl.I.H.I 



(lufonnatit 






DIR.XTION 
SIGNED ) 



. 0. OuOulrV.' 



Mouths 



Davs 



Hours 
M.D. 



■j,l.|vt \'\ I()OV 



(Ad.irc-s.) U\Aidlnji.^\^ loiy^i J 



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



Former or 

Usual Residence - - -y" 

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



,\Lavvtft diaJjU'v Pl!^e of Death? 



. Days 



I>I.ACK OI' m KIAI. <"< KI:MoVA1, 




DA ir; i>f iM KiAi. or ki:mo\'ai< 

Ox^Jt I'i T90H 



INDl-RTAKKR 

^\(l<lre>'S 







N. B.- 



— — ^-^M^ ^i^— — ^■^^^■^^*^^'*'^^'^*^^**^ I pv4CTLY PHYSICIANS Hhould 

-r.v.ry -...m oS i„t.,r,n,..-,„n .houl.l ..e c.refu.I, .upplU-.l. "^^Xtl*^'^^^'. 'th: "SLecial lnf<,..-.a.l»n" «or p.r- 

. * r Aii«F nF DtATH in pin n terms, thnt it mn> t>e ppopc 3 
""';«"«» away fro™ ho^c ^ho,.,.. he .iv.n i > 1"».«"«- 



I i. 



] 



\' 



r '<f\ 



\ I 




(.»; 






,,,,.,,,! ,,f !!. :ilth 1 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 

1 725 







1^ 1!J0\ 

^(rvv^ \ioxyu Deputy Health Officer 



Raiisferecl Xo. 



DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 



(^ 



Cevtificatc of Bcatb 

i 11. S. tr>tanDavC> j 

J! QTl 

PLACE OF DEATH:-County ofOc^^ >vCV>xcv^ccCity of 



((III 






No. OXOv.' 




ww,V UVjMivcio-l St.; Dist.;bet. _:-::... ...,:^ 



SPECIAL INFORMATION" "\ 
STREET AND NUMBER. / 



FULL NAME 



vj ^^OwLOL 



1. 



CVU'^ 



PERSONAL AND STATISTICAL PARTICULARS 

■"^..ct ' 'Vol.' 



I) A 11. nl III Kill 



iMoiillO \ 



(Day 



\f. 1-: 



5 



),\ii 



M.nitln 



{.. 



I '\v\\\ I 



/),7V> 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK t.i- i)i;ath J , . , , 

(Month!) ^J'^'V^ 

1 ni;Ki:BV C1{RTIFV, Tliat I atteu.le.l deceased from 

jjL^ ■.. 190'^ to "Q^^At lb icpH 

that I last saw h -^'v alive on JJLyvi 



Tip 



SIM.l.K. MAKl-sn-.l). 

w in<>\\i:i) OK !)ivoKt'Ki> 

iW'iitfiii Muiiil »1( --ii-'nation) 




HIK TlllM.Al'K 
1 Sl.ilf or l"i)unti y* 



I- AIM i:k 



lUR'nilM.Ai'K 

oi- lAriM'.K 

( Statf oT i'omiti y) 



MAinKN NAMl". 
Ol- MOTHKK 



KIR'rin'l.At"!', 
Ol' MoTHKK 
(State or Coniitiyl 




^ /w d^ 

\ \ A 



and that death orciirred, ..11 the date stated above, at H 

Q M. The CAISI' ()!• Dl'-ATII was as follows: 



Li W IxX-A^-ct '^^^^ •• ^- ' 



DrU.xriON )V.r;-.s- .yont/is % Pars lion 

CONTRllUTORV 



rs 







IMH- An<)VK STATKI) .■KKS,>NA1. TAKTU-rKAKS AKK TKIK T(» 
HKST OT- MY KNOWUKIX.H AND Hr.M>.l 



TllK 



(Iiifonnaiit 



'^ '^ Q VJ3 ;<XAXAJLfcii O. t 



DrK.VTloN 
(SIGNED) 




)V<?;--v , Afofit/is Day 



■I t _ - . --I. t„. it/vrnit-ilc Inclitiitinnc Tr;invi 



I Ion IS 

M.D. 

A' 



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

(^ i. i x\ -"^ How lonq at r^ 

£ Residence 1^^ ^^ OxlUU O ' flare ,f Death ? ^ Days 

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



m \CK Ol- lUKlAI. OK KKM"VAI< 



X\KL^^ 



_> 



OA'U,!'". ')!' I51KIAI. or KI-;Mo\'AI, 



,i>HKTAKKR ^ ^^ ^;^ ^^^ V 
(AcMress 5-1.^^ >J r\vA.^^>v ^< 



IN. B.- 



^_— .^ MM ^■■— — ^— ^— '^— — """""""'^^ . pxACTLY PHYSICIANS should 

.Rv.r.v l.e„. „( l„to.„,».ion .h„ul.. b. cn-eJu", »upp.l=.l. ^^J;^^;;'';;;.,,',,:;: 'Vh: "Speclo; ln,-or,„a.-.<.n" for pT- 

.. * /'AiicF flP DF \TH In pinin terms, that it mny nc pri^i 
:r .^r* a^w"; fro^ llc :h„„-.. ^ .wen In ev.o ln».-nc.. 






( 






f 

i 



II 



WRITE PLAINLY WITH UNFADING INK 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



a 



io(n 



Eeo^i'Stered A'o. 



1 726 



,^^,, Deputy tiCoKJ 



d^\j<Aj:s c<xy\^u ^-*--- (• n r • 

DEPARTMENT OIF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Beatb 

( 'U. 5. StanDarO ) 



PLACE OF DEATH = -County of6^^ J.^a^^.... Gty of ^^C^' ^IxonvC^Cc 



% 



No 



nt . Ivtm^CL^ ^O^A-kd^' St.; Dist.;b€t. 

,. J *J . Vl IV^Il-V/V^O ,.„,,,, or<SIDENCE01Vt FACTS C.LH 



~ and 



\\(rr\\/>.\ "^' O'i- O.A_V.' .,r;V~rEO,VE 7.CTrc^"tO top UN^tn •SPtCL mroRM.T.ON- ) 



FULL NAME 




avi/j^A-n 



VLlJ... 



PERSONAL AND STATISTICAL PARTICULARS 

1) \ I i: t ii i;iK III V 

iMntitn^ 



„V 



)-X, , V. v 



(Day) 



\< .J-; 



) I l! I 



M.oilli 



{ 



i » tai 



M/i. 



MEDICAL CERTIFICATE OF DEATH 

DAi'i-; oi' i)i;ai'h 






'7 'I 

(Day) (Year^ 



^iNi.i.i:. MARK n:n. 

\Vn>n\VKI) OK DIVOKOl-.I) 

Wiitcin >iiK-ial <li-u'natii)n) 



iStatf or (.*r)inilrv^ -\ ^\ ^ 



/ > 




NAMl' ol- 
>■ A rii l.K 



niRTiiri.vt H 

Ol- l-AlllKK 

( Statf or Coinitry^ 



MAIDl'.N NAMK 
Ol" MoPIlKR 



HlKTHrLArK 
01 MoTlIKK 
(State' or I'ovnitryt 



oi^HTTATION 

/y.'fsi(fi-(f in Siin /'i,iih /w" 






I III'RI'I'.V C1-:kT11-V, That latlen.kMl dcceascl fruui 

■ , » up'. to qjL\\L 1.1 upH 

U,at I last sa^v h ... • alive on ^--^^ ^'^ ^90 ' ^ 

ana that .katlt .uHurrod, n„ the -lato stated above, at H ^ ^ 

M The C.MSIv Ol- I)i;.\'ni was as follows: 



l\Jv 



UXv 



I) (RATION J''"'?'-^ 

CONTRir.rTORV 



Months ' ' /><n.v 



J loin s 



DT RATI ON 



)■(■(?/' 



n 




QPrriAL INFORMATION only lor Hospitals, Institutions, Trdnsienls, 
or Rerenl Residents, and persons dying avvny from home. 



,clcA.OX«^0L 



*- )V<M 



!/,,/////> 1 '.. /''••' 



IIKST Ol' MV KNO\VIj:i)<.h AM) Ml I.H .^ 



(lufooiiatit 




dtuXi 



(SIG 



NED) U\J- ll- iVvLU-^ 



I^ivs 



Hours 
M.D. 



c'l ..\ ; ' I'K' 



( 






(^ 



ol). J-ktr 



Hota lonq aX 



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



. Days 






( \(l<lr(.-ss 



11^5 




Sj^\ 



H 



I'l.ACK en iiiKiM. "K ki.:m<.\ Al. 



190 \ 



__^_____.^i^ — — ■■^^■■^— — — ''^— """ . EXACTLY PHYSICIANS Khould 

N. B.-P.ver,. 1.e„. nV in« -ton .hou.H ..e c„.,«uM, ,upp.K-<l ^^f;;,;;";,"'',;'.:.'': 'Vh: "Specia; ,„«o.,n..-.u„" Vor p.r- 

^ . r-Aiicr OF DEATH n p nln terms, that it mny nc »» 1 
state CAUSl. t»r- uc/* 1 f a:..-« in averv inHtancc. 

«on. tlyina oway from home should be fe.vcn m e.ery 





t^l'f 



I 



t' t. 



ii i 





I - y' 



RITE PLAINLY WITH UNFADING INK 



W 









Iht/c FilrdrO. 




\l 



lOO'i 



THIS IS A PERMANENT RECOHU 

REFER TO BACK OF CERTIFIC ATE FOR INSTRUCTIONS 

lic^Lstered ^'o^ ^ ' "^^ 



\ I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County of 



City of U>-^v^^3<v ^ t^ L 



No. 



-- St.; 



Dist.; bet. 



and 



•) 



^f*» l^lSl., DC ♦ ,,K,nrB "<?PEC1AL INFORMATION ■ ^ 



^ 



FULL NAME 




tj-YVA.. uvD Cro V^vo I 




-. 1". \ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK A 



DAll". »>l' I'.IK TH 



\\. 





loiith* 




\r, 1-; 



OO 5'-/'- 



r\ 



M.n,lli> 



I V carl 



/>,n. 



MEDICAL CERTIFICATE OF DEATH 



DATH OK OK AT II V 

( Month r 



1 
il)av> 



(Yt-ar^ 



I lll.:RI«;r.V CI:RTI1-V, That I atteu.kMl .Icccascd from 

to — — — 190-" 



r 



^ 



1 90 



■^iNc.i,!-: MAKun:i). 

w nxtu i:i) «»K n!\<»Kci'.n 

Write in --orial 'li -.ij-Miat ion ) 



lUK'niri, AOH 

state or i.'onntry^ 




\oJ\}\^^-^^ 



that I last saw h .: alive on ^ ' ^ 

a„a that death occurred, <..i the date stated above, at — " 



M. The CAl"t>i: C)l- 1)1:A ril was as folU 



)ws : 



'ci 



\ 



NAM], ni' 
FATlll.K 



% 




a.\^'> ^o. 



ocrY>\; vVA^ 



YVQ. 



HlR'lMPl.ACK 
01 lAPIIKK 

(Slate or (.■oimti v) 



m\ioi:n namk 

01 MoTiniR 



luurnri.Aci-: 

i)l' MoTJU'.R 
iState or t'ovinlty^ 




or RAT ION y^'(^^'^ 

CONTRIIUTORV 

I )r RATION 



Moiitir 



Davs 






\ 



„L ^ 



O 



Minitli^ 



/hivs 



OCCII'ATIDN 

in:ST <)1- MVJsNOWM-.IX.K AM> I5'1.I»' 
(Infortnant J CTVAAJ oWv > v 

(Address 



^TION^ Tewr-s- .V"'///'^- 

NED) ^X<ix^A/J^ 'J V,a'^^-^ 



fhiys 



dxAiii./ 



(SIG 

6-4^ l'iu)oJ___J . 

c^prciAL INFORMATION only lor Hospitals, Institutions. Transients, 
or Refent Residents, and persons dyinq .may Iron, home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 




VI.ACKOF m-KIAl. OR KHMOVAI, 



.L 



INDl-RTAKKR ^^ 



^J^/^,-^ 0;Wv^ 



\.S'^. ei., i 





IN. B.- 



, cvACTLY PHYSICIANS Hhould 

. ^ /-Aii«F OF nFATH n p nin terms, that it m»> » 1 t 
Htote CAUSfc ur utirt . , I K. A-.ven in every instnnce. 

«on, dyinft away from home nhould be fe.vcn 



i.U'' 







1:^'^ -I 




I «) 



i| 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

" ' *■ " '"' ' ^" i '^■-..^';-» li^'tl'^o REFER TO BACK OR CERTIFICATE FOR INSTRUCTIONS 



Ihih' Filed , C 




1 



\^ VJO^ 



Deputy Health Officer 



Be^lstercd JVo, 



1?!38 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eath 

( XX. S. Staii&arJ ) 

SI (^ -\' 



% 



PLACE OF DEATH: — County of 



ClCLAv 0\.CX.'^<'<-<1 <^' City of OxX/^^ J.Ka>VCA, 



N«."Ot \6^U, 




^5^' 



() 



bC)-UvJ..\' St.; Dist.;bet. 

4CE GIVE 
UTION Gn 

■? ^ [ 

FULL NAME loxc^XL I V' 



and 



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



v. \ \ 



SIX 



PERSONAL AND STATISTICAL PARTICULARS 



"i.. 



i»Aii: <)|- niKTii 



u 



MEDICAL CERTIFICATE OF DEATH 

DATI-: ol' nilATH _ 



lU 



iM'.tlt)!) 



AC.H 



U < 



HH 



) ('(/ / v 



I ( 

D.iv) 



T 



I I 



I \ i\\\ ) 



I>a 



(Moiitft) 



(Day) 



I go \ 

(Vi-ar) 



1^ f 1 



I ]n:Ri:i}V CI:RT1FV, Tliat I atlciulcd dcrcascMl from 

to .ax^\fc i1> KpH 






ljl\xl 



si\<,i.i:. MAKun.i). 

'Writfiii social <lt,->ij.Miali<)ii ) 




OJUvC.OcL 



IMKTIU'I.AOK 
(Stati- <>T (.'niinti \* 



lAIIIl-K 



HIRTm'I,.\«'H 

Ol- iArm;u 

I State nr I'ouiiti v) 



MAIDI'.X NAMl-; 

<>i- mi>i"iii;k 



I'.IRIIII'I.ACI-: 
«>l' Mo'lUKK 
(State 1)1 (."oimti v) 



(HHTl'ATiox 



^X> 




? 



■ '• ! Up A. 

that I last saw li - alive on '-..i«ic/Y..v\. '. 190 1 

and that death occurred, on the date "Stated .above, at 
AF. The CAISI-: Ol- DKATH was as follows: 



v^.< 



)A\<^X.iK. *-^rULMAn/>\yq 



i\,.c 



\.<X.\..\..c. 



I )r RAT ION Years Months Pavs 

C ( ) NT I'i I Hl'Tc ) R \ NwCL^^aw^rv 



I lours 



' "yv,trrw\^.Ow....Ci 



\ 






>; 



nr RAT ION 
(Signed) 

■ y\X' 1 ', I()0 V ( 



\\irs o 



Id. JuA^ac^ 



Months 



Pavs 



Hours 



M.D. 



A d d resO b I ?j CLCL.tt.t\i <).. 



Special information nnly for Hospitals, Institufions, Transicnls, 
or Recent Residents, and persons dvin(j away from f>ome. 




Rrsiiir,^ in San /'taut ist'i) 



)rai 



Mn„lli> 



Ihn: 



I'm: Aiu)vj-; staij-.i) pkksox.m. rAK'ruri,AKs akl; tkih ro rnic 

IIHST Ol- ?.LV KN()\VIj;i)C. K_ AND lil'.I.UCK 



^ -00 

Former or i /> ^ . 4 V y ♦■ 



Usual Residence 



^11 



How lonq at 
Place of Death ? 



Days 



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



i.Aci-: oi-.inRiAi, OK ki:m()\ Ai, 



n iifoiniatit 



O^VJLcL C\^OL,lk\^ yv 



f \.l(ll 



•fSS 



1^1 



M. UAA/i. 



v(rvv 



cH 





DATIlof HiKiAl. 01 k]':M()\-Al, 



0. 'oj^y 

(Address Uyi Ml\LAA-<-<nv 01 



N. B. F.very item of inforniHtion should be cnrefully supplied. AGE should be «tnted RXACTLY. PHYSICIANS should 

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






I 



I :^ 



V » 



M 



I , »u 



n. 



"*> 



iiyULUUNtoteA.. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






it 



IfW-i 



Rcgisie/'cd JS'^o, 



1729 



Dtilc Filed , OxU^^yvxIm^ \^ 

d^^TLAA^ cL*^.r>M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( U. S. StanDarD ) 



1 






PLACE OF DEATH; — County of Oa^\; AXXa^ tMA.c. '. City of ^ ''Ct/>v ^VxXoa.c^<i ? ' 



^ 



■ 1 



No. 1) WCt'^vdxA.C OJ . ' St.; I Dist.; bet. \J CrU>-OUj and 'i H CLA-C "v: 

(ir DCATH OCCURS AVWAY FROM USUAL R E S I D E NC E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\ 
IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 




FULL NAME 



(V, 



vAJU.' 



PERSONAL AND STATISTICAL PARTICULARS 

"" kcu "■ "ll. 

I>A 11-; nj- 111 KIM 



dxlvt 



\<". I". 



H 



)V</; 



(I)jiy) 



M,'„ih.^ 



n 



\ I ;it 



/',n 



^iN< i-i". M \Ki< n:i) 

u iDow i:i) OK i)i\-(»Kri-:i) 

\\'iit< in -.()<i;il (h ^ij.Mi;iti(iii) 



HIK IHI'I, Ai'j-: 
(State or Couiitryi 



s 



NAMI. <)»■ 
1- X'nil.K 



HIR IHl'I, \(K 

<>!• lATIIKK 

< State nr Country) 



MAIDKN NAMK/ 
OI' MOT I IKK 



lUR'rnpr.ACK 

<H-" MOTIIKK 
(State or Coiiiitrv 



OCCri'ATION 

A'fy/(frif in Sii>t /'i diii isro 



dicuU|. 



(yyy\A/YvAAn^ 



MEDICAL CERTIFICATE OF DEATH 

I»A riv ol" I)i: ATM 

"^xl\tj il, 

(MontW (Day) 

I I[I:RI:I5V CIvRTII'V, That I atleiKk'.l (IcccastMl from 

190 : to CJ-t-'K^ ^^ 

that I last saw h-c-v-vA alive on ic/) 

and that death (ireiirrcd, on the date state<l ahove, at \ 
... M. Tlie CAISI- OI" DM.A'l'H \vas as follovv.s: 
JX^nw«^\^XAj iLu^Lcc . .. 

.3. >v<^^\ <ivOl "to 1haA/.->.'\^ axcx^.xmL'1:L 



I go 

(Year) 



Icp \ 




u 




DIR.VTION 



} cars 



Mi'ii(/is c< Days 

'ONTRIHrTORV (fo.cA). ...-C\>r:r' ' ' 



I lours 



'Ic ' -^ dxX'^ C' 




O^'o 




I )(• RATION ,^ Years 



SiG 



NED ) Lo^/vruJuLx 



Months 



Pays 



3x^\t 



• r.,o (A«idress) J lw>xiatr>ru^^^^'m 

L Information only for Hospitals, Jiistitutions, iVansicnts, 



I fours 
M.D. 



SPECIAI 

or Recent Residents, and persons dying away from home. 



)Vi/; . 



I 



Months •" /J,M 



I'm' \HoVK STATl'.n PKKSONAl, I'A K T UT I.A K S A K l", TKII". To llll-: 

iu;sr oi- MY KNowMvDCK AND in-:i,n:K 



Former or 
Usual Residence 

When w^s disease contracted. 
If not at place of death? 



How lonq at 
Place of Death? 



Days 



Informant CJ oJIa/-oX.<A^ LAA-A_^<AXi 



4 



(Address 



^ U /<XA'vcLjUA><xXt\j c3i^ 



I'l.ACi: Ol" lUKIAI. OK KHMOVAI, 



DATilof IliKiAi, or KHMOVAI. 



5" X\ dt^<J^tft->x. dt 



90 



(Address 



N. B. Every item o? informHtion should be carefully supplied. AGE should bo stnted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information" for psr- 
sons dyin4 away from home should be ^iven in svery instance. 








r 



f" 



■ I 



♦ I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lii. 



k*f 



'd 



.' • " 



#j 



i: 






l,,:.r<l of U.-.'ltli- I'" N.>. i> '^••^ulfEr^- 55v'=tl' Cn 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Pufi' F//rff,Qx\^Xxy^JLJU^, 14 l^O'i 



JiCgLslc/'ed A^o, 



IT'SO 




^ •.ki./vvu 



D e p u ty H e a 1 1 h O ffi c e r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of £>eatb 

( XX. S. StanC>arD ) 
PLACE OF DEATH: — County of 0/Cxy>\' J " -< c\A.ai. City of O/CX/Tu vJ Ivx^^ yvCa.^ - ' 
No* n 5 1 ,) .Wok.'t<ry\j St.; 1 Dist.; bet. G/utl''>V^U-V.:CA\. and 'J A.' 

(ir DEATH OCCURS AW*V FROM USUAL RESIDENCE GIVr FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




FULL NAME 



V- 



a,' .. . 



»A.\.4<x^ia 



PERSONAL AND STATISTICAL PARTICULARS 



^'•:x ^ j 




^Jiy^'>'VOL.Ul 




i» \ ri-: 111' 111 Kill 






1 Ivlnllt ll > 


\ < . !•; 






);■,.'»> 



(■<)i,< »K ^ 



Ll 



I I ):i V 



!/"/////> 



/ ll", 

I •/tar) 



/),n 



^IN'f.l.lv M\kKIl-:i). 

\\ iix >\\i:i> (»K i)i\(»k(j:i) 

W'litiiii sMiiitl ilf»*iv':natit)ii) 



lUK'nii'i, \ri- 

( stall- or C> Hint I \ 



.^cL(^v^>- 



\y 



1" A'lll I.K 



iukiii n, \ri-: 

<»!• lAIIII'.k 
(Statr or (■<)iiiili \ 



M \ IIH:\ NAM \. 
<>l MoTin'.K 



HiKini'i.ACi-; 
<>i' Mormck 

'stall or t."i)ii!itr\ 



MEDICAL CERTIFICATE OF DEATH 

DATK <tl' I)1;ATH 



^;l 1 

(Monl>i) 



(Yt-rir) 



.C)X/^-v', 



(Day) 
J 1M-:R1:I5V CI-RTII'V, That j attfiidcMl (U-rcasetl from 
I90M to BjL^\1; ...lb. T()o'! 

that 1 last saw h -'• alive on >J^j("SA ' up 

and that (Uath occurred, on the (hitt.- stated above, at ' '« 
1 '^ M. The CArSI- Ol- DIvATII was as follows: 



? 



«>i\ IPAl'K )N 



? 






or RAT ION 
CONTRllUTORV 

1)1" RATION 

(Signed ) 



)'r(irs Moiilhs ^ l^ays //ours 




-1 



clvl ' I<,0 



i 



)'rarj 3 Months 10 /lays 
Ad.lres.) IHOO (jV.-...'. 



//ours 

M.D. 



f 






Special information onlv for Hospitals, institutions, Transifnts, 
cr Rccfnt Residents, and persons dvinq <iw,iy from home. 



)V,M< 



M^iilh- 



/>,i\ 






I'm", AnovK sTA'n:i) i-kksonai, PAR iirn.Aus a hi; TKri-: m vu\\ 

lllCST Ol" MY KN()\V!,i;i)C.K AND lUxUl'l" 
fill for niant \| I LOJW<X_ 




former or 
DsudI Residence 

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



How lonq at 
Place of Death ? 



Davs 



PI^ACH OI' m RIAI, (»K k}:mm\\i 




:- a 



INDICRTAKKK V- N^CXAA^O- 



DA rj; ot lu uiAi, or ki-:m<>vai, 

T90 > 




'-V w(. 



N. B. Rvery Item n? informHtion should be cnrefully Hupplletl. AGE should be stated fiXACTLY. PHYSiCIAINS should 

stute CAUSE OF DEATH In pliiin terms, thnt it m«y be properly classified. The •'Special Information'' for per- 
sons dyln^ away from home should be 4lven in every instance. 






fl'''", ■ 

: 1 







! 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dafr /vAv/, djUxlxo-^xlKOv ,1^ I'^O'i 



i 






Bcglatered jYo, 



1731 




:i 



Lcputy Health 



r^r 



DEPARTMENT ap PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH: — County ofO/X^r^ XO, >vCA^c.:City o{0.<Xyy\j XVxXa^cau: 




(IF DtATH 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 



c 




c^Ax^C (Xir \JJLou 



•^v.\ 



PERSONAL AND STATISTICAL PARTICULARS 



'luL 



:> \ I1-: < •!• HiK III 



\(.i-; 



^ 






Sa 



Vj CN- )'(■(// 

>-IN«". I,K. MAKUIl".!) 
\\Il)»)\Vl-:i) OK DlVoKiHI) 
\\!it( in sorial tlivij^tiatidii) 



lUK I'llPI.AOK 

Statr or ».'i>init I \^ 



IS 

1 I):iv> 



yi.niths 



I 



MEDICAL CERTIFICATE OF DEATH 

DA IK t>l DllA'IH 



^ 



All 

' Vi:ir) 



aI /'.n 



'X 



CL^' 



MotitlO 






It 



/on ' 

(Day* (Year) 



I III:R I'il'.V ClikTII-V, That I atttMulod dccvaseil from 

OX'^^t/ 190 \ to .."QjL^.vt- i.L Kp '■. 

tliat ! last saw li . ' alive on )J^Sp^\ iip 

ami that diath occurred, on the date stated above, at •• *' ^ 
M. Tlie CArSI<: ()!': l)i:.\'IMI was as folic. ws: 



\AM1-: ()!• 
lATllliR 



niK'niri, Acic 
• >i- i-Arm-;R 

IStatf or Coiiiitrv^ 



M \ I I>i:\ NAM1-: 

<M M«>rm-;K 



IIIK IIIIM.AOK 

'•!•■ MoTiniK 

(Slate 01 ru\iiUrv) "\ N^' 



OCCITATION 



1)1" RATION Years 

CONTRimTORV 



Mont/is 



Dms 



//ours 



DT RATION 



)hn 






J/i>>///tS 



Days 




(SIGNED) ^'In i h^ 

^. ■ tU ,..^'i (Address) Ji.\^Ma>\. JL^^■ 



//ours 
M.D. 



lio u 



)" 



SPECIAL Information only for HospUdls, Institulions, Transients, 
or Reicnt Residents, and persons dying .may from liome. 



Former or 
Usual Residence 



S^?. 



'Ui^ . 



HoH long at 
Place of Oeatli ? 



Days 



Ri'sidt'd ill Sail li aiii i>i'i 



Mai < 



Moiilhs 



n<n 



rill-: AHovi-: sT\'n:D rKRs<>\Ai, rARricn. \ks ari". trik t<> vwv: 
iii:sT oi- MY kn()\vi,i:dc.h and iu-:i.n:i-" 



(In foiiuaiit 



I 'UW\'^V^X>w^>V 



~ ob (^-^^.^vaX O^V. 



(\.l(lr«- 



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



I'LACK OI' lURIAI, OR Ul^MoVM. 



DAj^liof Hrin.Vl. or RI;M0\AI, 

'^ C) 1 90 H 



»ATi; of Hi 



(Address hbl'^' RX\v -I 



N. IJ. Bvery Item of Informntion should be cnreV'uIly Hupplied. AGB shoultl be stated EXACTLY. PHYSICIANS should 

•tale CAUSE OF DEATH in plain terms, that it may be properly classified. The •'Special Information" for per- 
sons dyln^ away from home should be ftiven in every instance. 



• I.' 



tl 




fe.: 



- t 



.1 



! f 



lih 



! - 




m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Il..;.n1 ..f lh:i)lh- I- No. i> T^^^T^ nSiV C 



/)((/(' FiJrd , 



,6U.A^ 




va /^^H 



Jiegistci'cd J\'*(), 



1732 



<i Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Bcatb 

PLACE OF DEATH: — County of O/O^'VV OA/O/Yv^^^a City of OXX/YV; vJ /\XX/>^. c L v '^ ' 



No. ^"^^0 \flM. 



St.; \ Dist.; bet. 




\JL' 



i 



and 



ill 



'.V 



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



FULL NAME 



ILt: 



^J£Uw\>w 




U 



(y'^JvLUyj.i. 



PERSONAL AND STATISTICAL PARTICULARS 



ll 



OlI 



1) \ 1 1" <)i liiK in 



\< .!•; 




l-^ 



)V,; 



iL 



(1)MV) 



y/.i,if/n 



MEDICAL CERTIFICATE OF DEATH 

DATK «)I- DKATII 



'Year* 



n,n 



^iN<.i,i-:. M AKk n:i) 
\\n)(>\\i«:i> Ok i)i\( )KrKi) 

iWiitiin social <l<sij.Miatioii) 




x.^L^'VJ^cL 



'St.-iti or Cotiiitry^ 



NAMI'. <)|- 
I" A THICK 



I'.Ikllll'l, \i"H 
•>l' I Al'lll'-.k 
iStatt or Coiiiitr.v) 



MAI|)1:n NAM!', 
<»l MolIIl-.k 



lUk'inri.ACH 
t>i' M()riM':k 

(Slate or C(»iiiUr\ 






^ 



CS<A'-C- 



(Day) 



rqo 

(Year) 



(Mojitn) 
[ III:RI:BV CI:RTII<'V, TIimI I atUMi.k'<l dctvased from 

a".:". » 190. to QX^pJa U 190 H 

tliat I last saw h - alive oti QJLyvX It Kp ':. 

aii'l that (K-atli occurred, on the tlate stated above, at ; ' 
M. The CAT SI-; Ol- 1) I! ATI I was as follows: 



ll\Jl^ 



1^\.V^ 



DC RATION )'rars 

CONTRIIU TORY 



jis Months , Pays 



Hours 

:.J..^..x 



,\jUL<x . A 




.>vc 



I 



..^] 



KXX , 



omi'ATION 



UuXtVi^dL 




.OL > 



■A 



I) r RATION §, Years . Afonths 



/hiys 



Hours 
(SIGNED) \J 'JVJ 11 " • M.D. 

0x1.1'.; ruoH (.Address) V\''^\ Mn U.. ll 



Special information on'y ''"■ Hospitals, institutions, Iranslenfs, 
or Recent Residents, and persons dying .mdy from home. 



o 



f\f''it!f(! ill Sdii f'l ll lit iM'it i )'iii I 



Mnllth^ 



Ihn 



VWV. AHOVK ST\ Tl-.r) »'Kk^(>NAl< 1' A kT KT l.A KS A k l-, TklH ')•« ) 

Hi;sT oi- MY KNt)Wi,i:i)<;K AM) iu;mj;f 



r 1 1 !•; 



fll 



Qryw 



(\(M 



fcss 




•^-1 



Former or 
Usual Residence 

When was disease rontrarled, 
It not at plare of death ? 



How long at 
Place of Death ? 



Days 



L'l.ACK <)1- lUklAI. ok ki;Mo\ Al< 

, '.J 




T9O 






I)A'l"j;o! IliinAi. 01 ki:MO\'.\I, 



irNDKRTA K KK /OL/VsX^VUL>V ^>D >V6-^ 



N. B.—Rvery Item o? Information .hould be CHrefuily supplied. AGE -houid be stated F.XACTLY PHYSICIANS should 
•tate CAUSE OF DEATH In plain term., that It may be properly clarified. The "Specal Information for pT- 
non% dylnft away from homo nhould be ftlven in 9\9ry Instance. 



! 

I 






tl 



iHlW^'f.: 




hi 



' 'J 




I I 






i 



; 



IT 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Iloanl nf Ihalth I- No. :c -fr-CTi'-"* '*^*^'' *■' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nnh> AVAv/,dxJ^vtA^^>^J^ \.^ I'^O'i 

Deputy Health OnTicer 



Ees^isfe/'ed A^o. 



1738 




cUi 




•^K. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( XX. S. StanDarD ) 

PLACE OF DEATH: — County of O/Crn.' ';vX>- .- ^' ^^ ' City of O Orvx. OXxx^v^c^^c < 

No. l^XlH J\X<X\. -v'J, St,; ■ Dist.;bet. SK.U.'Ys^ and '^-' <xU 

/ ir DtATH OCCURS AV*»V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




^ 



FULL NAME 







^\ 



.UL<X.:y'^dj\.L 



PERSONAL AND STATISTICAL PARTICULARS 
l,\ A \ J COI.OR 




CL 



i 



^ 1 



1' \'li; nl I'.IKIH 



\(.i-: 







) V(M . 



10 

(Dmv) 



M.<nlli' 



\ '»'i-:t; ) 



lKt\, 



^iN<,i,i.: M\Kun:i> 

'Wiiti-iii vociiil rl« si^'iiiit i'lti ) 



iiiuTm'KArK 

M;iti- or •"oiiiiti y^ 



N WW. ()!• 

t .\imi:k 



niKTHI'I.Al'K 

<»i- jatiii:k 

(Statr or Country) 



MAIDI-'.N NAM1-; 
OI- MnTUKK 



lUklUPI.AlIv 
••1 MoilllvK 
(Slatf or I'outitry^ 




\JL/vAy>xxX' 



o '. • 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I)1:ATII 



A. 

c 



Moiitri) 



(Day) 



I go 

(Vcar) 



A 



I ni':UIvHV CI'RTII'V, That [ attcndcil (kiiascd from 



190H 



to 



r'-'-1 



J I 



i(p H 



that 1 last saw li alive on UJJ\\ kjo 

ami that death occurred, 011 the date stated above, at 1 
M. The CArSIC Ol" DI-ATIl was as follows: 



DIRATION 
C 



)'t'(irs 






/)ays Hours 



I )r RATION )V<7;-5 

iNED) ^. ^ ^^O. -<. 



J/<>>///!S t. /\/l'.V 



A 



.;»JL 



,0^-" 



1 



OCCri'AIION 

hVudt'il III S,ni I'l <nii i^i',) 

im: \llOVK STAI'I'.D I'KK^ONAI, I'AK IIClI,Al<s XKl.TKl 1-. fo 

lUvST Ol- M^ kn»»\vi,i;d<.k and hi;i,ii;k 

Oiifoniiniit 



//,/! 



Til !•; 




( \fMri"»s 




(SIGI 



/~1 ' 



l(>o 



( 



■ ' I 

Ad.lress) IblO ul^tykiU 



Hours 
M.D. 



Special information onl> '"^ Hospitdls, Instilutions, Iransienls, 
or Rf( ent Residents, and persons dyinq dway from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



ri,\ci-: (n- hi'Kiai, ok ki-;.M')V\i 






I)AT1*"1 Hi KiAi, or KHMOVAI, 

dx\vt i^ 190H 



^. „._Hvcr. Ite., o.' l„.>..„„f.on .hou.d be cn.e.^u... supplied. AGB «hou.c. »>---^^^;^.^^C;^^^^^^^^ .n^rJuir' w'::!-' 
state CAUSE OF DHATH in ph.in terms, that it may be properly claM.f.ed. The Special Intormat.on for p«r 
■on* dylnft away from home Hhotiid be ftlven in avory inntance. 



;i 




) 




.6ll';rir;i;fi" 



I 





♦ . 




r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






l)(flc Ff/('(f,C.. 





\J 



1^ 



lf)0^{ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1734 



BeiULstercd J\^(), 



\^KJ<JS 




*i 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDcatb 

( "U. S. 5tan^nrC> ) 



PLACE OF DEATH: — County of^^'CL^^ vL\.a- . a^^ecCity of J/Oy>^ J .\.0..>\^vA e. l 



N 



o. 1'^ \AX/\rO<.^ 



jr\ ' 



St.; 



h 



Dist.;bet.C3CL'>^ \th<UL and •.lUvjOvX^Cvt ) 



/ IF or.TH occ"uns AWAv FROM USUAL RESIDENCE G.vr facts called for under Jspecial information- \ 

( Tf DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ^TREET AND NUMBER. J 



FULL NAME 



L 





'^:r^\xy 



PERSONAL AND STATISTICAL PARTICULARS 







X'VWO *' ' 
I) \ 11-: < )i i;iK III 



Mctitlil 



) -./, 



D.iv 



Mmillr 



•;ii ) 



/>,n - 



Wlix »\\J-:i) ( »K |)!\< iKil-.l) 
'Wiiti ill social (l(si;.'iiat inti) 



IflKTMIM.ACl-: 

'Stall III Criunt I \ I 



\\\1I ol 
1 A III l.K 



mK'IHIM,A("H 
'>l I A I" 111': K 

' Stall ol rnilllll \ I 



M \ I i»i;\ \ \ M ). 
"1 Moiiii; K 



I'.iK riii'i.Aci': 
Ml- \ii>rm-.K 

'^I III ..I C.Mllltl \ I 



K/y\joXj< 




MEDICAL CERTIFICATE OF DEATH 

DA'ii-: «)!• ni'.ATn 

(M.)iitfi) <I)ay) (Vtar) 

I Hi;RI{r.V Ci:kTlI*\', That 1 attenik«l (Icicased from 

' . , ' 1 up- to axKt \% i,p\ 

that I last saw h • alivf oti , K/) 

anil that iK-atl) orciirred, on the dati' statnl aliovt-. at 
LL M. TIk- CAI si- ()!■ DlvATII was as follows: 




Dlk ATION 



Days J loin s, 






< •' 1 I 1- \) i< (X 

kr tdt'il in ^mi / I (I III I '■•> cAx.> ) , ,1 1 



Mmilh' 



/hi 1 



111 I", \MovK srA'n:i) i-kusonai, i-ak in ti. \ks aki. iki !■: r«> thm 
iii;sT Ol- Mv KNOW I, i; DC H AM) iu;i,n:i' 



'Inf.iiinant 



JvXXAjLvvy'vAx. Jj '^ . ' • ' 



\XXaMXax\xx^ 



, M IV . M . ^ . . > ) '' w/.v H J/oj////.? - 

C" ( ; NT l< I r. I r < ) K N' LmLc^JwI ,1 CX,^X^v^.^i\Ax :vA \.<XX.&.:. 

DC [RATION )'tins .lA'/////s H /^(/I'V //iv// v 

(SIGNED) LUir\JL^. ^.-.'...'... ^^ M.D. 



SPECIAL INFORMATION only lor llos|»ildls, Institulions, frdnsifnfs, 
or RiTP nl Rpsidenh, dfitl persons dyin;) .iwrfy from home. 



former or 
lsu.ll Rcsidenfe 

Wfipn was disedsp ronlrdrled, 
ff not df pld(P of dedtfi ? 



How lonq at 
Pld( p of OPdtli ? 



. Days 



I'J ACH Ol lUKIAI, OK KI'iMoVAl, 



L^-/0-<i^ 



l)\ri:i»! MiKiAi, 1)1 K J'iMoVAl, 



mm;ktaki:u HV/nvoJA.XX'VX' U (fe a VOj ''*^ L 



■ • ■ Kit ..Iw.iil.l lie Hti.tecl liXACTLY. PHYSICIANS Hhoiild 

!N. li. Kvery item oV inf<,rm..tlon «houl.l be c.rofully Hupphe.l. A(.l. hI.oi l.i '»« «Y'»*^^ '' ,.^^.. |„»orm»li..n" for p.r- 

«t«tc CAlISr: or OrATII in plnin term., thnt It m»y h. pr.,„crly clan^hicd. The Spcc.al ln»or.n»t..>n p 
Han» dyinft owiiy from home Hhoulcl be ^iven in every inHlnnce. 



^.*" 



li 



) 





\ 



i 






:^i 



Jf 



ill 






J 



> f 




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



H.onl..fll.;.Ul. -»• No. Is f'?S^' '^''^ »' ^■" 



nCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




^^ 






\j i.a 



/-9^;h 



/>^//r Filed y 

I^^^Ijlv^m Deputy Health Officer 



Rcglstei'cd jYo, 



1735 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtiftcate of 2)catb 

( Ta. S. Stan^arD ) 
PLA.CE OF DEATH: — County ofCjA/>A; JA.<Xa xc..,^ „.'. City ofO/<X^a; vj.Xxxn^a^cc 
I'Xl'l ^'■^)A.CKxd.^v^O.'J St.; Dist.;bet.(Uxx.'\>X^\A.iJ^,.l.: and .. ' 

/ ir DEATH OCCURS AWAvirROM USUAL R E S I D E N C E G I V E FACTS CALLED rOR UNDER "SPECIAL INFORMATION' \\ 
C IF DEATH OCCURRED ]h A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J ) 



Na 



FULL NAME 







PERSONAL AND STATISTICAL PARTICULARS 
;,.:X ^ jj I COLOR ^ , 

:> \ II'. < M iiik rn 



\t .1 



) I ll I 



Mnilli^ 



■»'t:i! I 



Ihiv. 



^iNi.ij.:, M\Kuii-;i) 
\\ii)o\vi;i) ( »K Divt tKri:i) 

Uiil» ill ^<M-i;il iUsii.':ii;ili()ii) 



lUkTIIlM.Ai-l': 

I St:it( or t'oimti y • 



NAMi: OI' 

iaiiii;k 



niRiiii'i, \c\-: 
<>i- iaiiii-:k 

(Slatf or Ccunitrv 



MAIDlvN NAM). 
<>l .Mdl'lllvk 



lUK ruiM.ACK 

<»i- M()'nii<:k 

(Statf or l'()initr> I 






V.O ^ 




I ' 1 






! i 






MEDICAL CERTIFICATE OF DEATH 



DATK ol" I)i:.\TH 



^ 



igo 

(Year) 



(Month') (Day) 

I 1II';RI;HV CIvRTII-V, Thai l attended (Iccoasctl from 

0.jd^^^.. \l 190'. to . . QX.jpJ}. i.l. T90H 

that I last saw h ■■ alive on Q.jJ(sX '. 190 

and that (U-ath occurred, on the dati- stated above, at ^ 

M. The CATSh: Ol- Dl-ATII was as follows: 



"^0 



..a.r^sJUC, .s 




ridA^>-V\. 



DT RAT ION Years 

CONTRIIUTORV 



Months 



/hns 



Hours 



DTRATION 



)\-ars 



(Signed) 0. ^.^ 



Mouths 

^ N A -1 1 ■ 



Pays 



T<)0 



f.\ddress) lllH 



VJ)^MV<^.' 



Hours 
M.D. 



Special information •►n''^ ^""^ Hospitals, institutions, fratisicnts, 
or Recent Residents, and persons dying dway from home. 



111". Aiiovi-: sr\rj:i) i-Kk^oxAi, I'Ak'iim.Aks ari: rki k r«> rni-; 

IIKST Ol'^MV KNo\\I,):i)(". H AND B1-:MI:1' 



(In 






(\<l(lrcss 



Former or 
Usual Residence 

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



How long at 
Place ol Death ? 



Days 



iM,.ACK OF nrki.\i. OR ri;mov.\i, 

^' -i 



I)A'l'.j; m!' Hiki.ai or R1-;Mo\\I. 

■-^ ; 't 



./.-A- 



INDHRTAKKR VvlvW^ ^ ^" ^ , 



'. >r 1PV . . 



N. B. Bvery Item of InformatJon ahoulcl be care 

state CAUSE OF DEATH In plain terms 

«on« dyjnjt away from home should be ftiven in every Instance. 



efully supplied. AGE should he stated BXACTLY PHYSICIANS should 
, that it may be properly classified. The "Special Information for per- 



f^\ 



r 



'Wi 



1 » 



.1 







i ! 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

., ., t n .1,1, 1 V. -.i^>^^X';I'.Sc!(.. REFER TO BACK OF CERTIFICATE FO R INSTRUCTIONS 



Dnli' ri/r(/,AjL'\ 




>JL\j \R 290 "i 



Bc^istci'cd J\''o. 



1736 



.^ru^v/0 



Lcv^M Deputy Health Officer 

r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiftcatc of £)catb 

( "a. S. 5tanc>arD ) 



:n 



PLACE OF DEATH: — County of^^ia-^A-' ' V<x^^ a^.^l.<l.LCity of ^^/O^v 



\' 



d. 



% 






No, VCLAVl iluCKlixv_A-O.V 



St.; 



r ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECAL INFORMATION • ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTyUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




Dist.; bet* 

;all 
^AA 



and 



PERSONAL AND STATISTICAL PARTICULARS 




OX' 



■ M.mthl 



\ ( . »•; 



14 



)■-■ 



[■ 






Mnith' 



' \\:i\ I 



/■>,/, ^ 



wiix i\vi-:i) OK i»i\< »Krj:[) 

\\iit( ill «^(K-i;i] dr^ij.' n.tti'i,, ) 



UIR ruiM.AiM-: 

stall or t"i>,i,it , \- i 



WMl" til 
FATll IK 



lUUTMPI.ArH 
<)i- lATMKK 
'State f>r Coiinti v^ 



M MDKN NAM1-: 
<tl M()TH1-:K 



lUKTin'l.AOK 
<>l" MOIHI'.K 
(State (H I'ovuitty^ 






MEDICAL CERTIFICATE OF DEATH 

DAl'K <»1- Dl-.ATH _9 

(Diiy) 



(Moiitfi) 



(Year) 



I III':R1':HV CI-RTH-V, That ^ atteiKltMl deceased frmii 
' • '> ! innv to . CJrL^t li Ui0"\ 



icp V to <<jJL\\Aj. A..0 up 

that I hist saw h ■ ' alive on ' ^ ' 190 

and that death oeeiirred, on the (htte stated ahove, at I 



:i}\. 



rs\. The CAISI' OF DI-ATII was as follows: 



::UlA...OL.L.^ftrrv.X. 






Hours 




\ 








KlAJ 



oCCri'ATK^N 

Kf^idfii ill Sail /'nnnni'd 



DC RAT ION )'t'(rrs S^ Mo 11 tin lt> /;</)-.? 

CONTRllU'TORV 

Di; RAT ION )'<v;/'.v Mo>ii/is Pays Hours 

(SIGNED) UX^ V^' '^-^ , . ^.- M.D. 

nX^t I'A i.)oH (Address) JgOio UxUlx^u Ji 



Special information «n'y f'"" Hospitals, Institutions, Transients, 
or Reffnf Residents, and persons dyinj away from home. 



^OHV|^.^^n i 



)■ 



■,,ns L • .^hoitfis ! '■ />'n> 



lUi: AIU)VK STATi;i) I'KKSONAl, 1' \K TUT I. A US A K l". TK T !•: To IHI-; 
1U;ST OV MY KNOWI.lvDC.K AND MI;M1;J-^ 



(InfoMiirmt 



( \(l<lri";s 



^ 1 vb /V<^tX'Clv^^ac^ 



Former or q ,- u I r\ 
Usual Residence" (J ^ ^v 

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



\ . How long at 
' Place of Death ? 



Days 



n \CV Ol- lUKIAI. OK K1:M<)VAI. l)ATi;()t Ml KIAI. (ir KI-IMOYAI, 




rNDl-.KPAKlvR 

(Addifss 






190 



305 Q^K^^t.av.^ iL-.. 



^. „._P.ver.v Hen. oi In.,. Hon •houUi b. cnrcfuHy supplied. AGF. HhouU. »>«•'»"'«;! J^^.!^,^^':,^- .rrjuLn^' Vr^p^r- 

«tate CAUSE OF DEATH In plain terms, that it may be properly clas-.^cd. The Special Information for pT 
sons dyinft away ItVom home nhould be ftiven in every Instance. 



8 



kk 



'I ■ 







I* # 



» = 



i 



I 



''• 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1737 



H„i,r.l ..f II. ;.llli I- N" i> ^iijt;^^: Hf. V V ■ 



pd/i- I'ilril, OJL 




^ 




1^ 



v)(n 



Ii('(!isicrc(l J\''o. 



^H^ Deputy Health Officer 



n 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "U. 5. StanDarD ) 
PLACE OF DEATH: — County of VcL'>%^ Acv-vv'^^^tCity of U O/^rx; OA.<x ^^.CA^ at 



No. S^5 





X<i 



(ir DfATH OCCURS AWAY f I 
IF DtATH OCCURRED IN 



St.; \ Dist.;bet. cL<Xa^v >A.^- and iSjXV 

AY FROW USUAL RESIDENCE GIVE facts called for unbER "special information' \ 

D IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



1 



FULL NAME 



v_. 



CXx' 




.■\; 



a '- ' 



PERSONAL AND STATISTICAL PARTICULARS 



si:.\ 



!i \ 11- < )I IMK 111 





(•( n,()K 



r 



f\ 



1 Month) U 



Af.K 



H- 



}.<;/ 



A A-, 



I S'l-a! ) 



Dii v.v 



>i\<.i,iv MAKu n:i). 

WlDi »\\I-;i) OK KINOKii: I) 

'Wiitiin siK'Jal ilt •-it.'n.'H iun) 



lURTMPI.XCI-: 

' Miltf or •.'nlliltl V ' 



1 i\olMv.^A^1^ 



1 A 11 1 l.K 



lUkriiJM.ACK 
oi" I Arin-.K 

'State ni Toinitrv) 



•1 



INAEDICAL CERTIFICATE OF DEATH 

DATK <tl' I>i;ATI( 



(Montti) <I>ay> . (Vtar) 



(jn 



I IIMRMHV ClvKTII'A', Th:il I attcndcMl (U-ccased from 

that I last saw h ... alive- oil O-ic^l) I "t ic^ M 

and tliat «U'alli ociurrcd, on tht- date stated above, at 



M Tlie C MSI-; Ol" DI'.A'Idl was as follows: 



■? 



v-<-V_ ^ "v-- 



DT RATION )'i'in-s J/of/J/is ^ /hiys I/oHts 

CON T R II ; r T o K \' "^^-^rvMx^v^ V 3 .^ ^-^ 



.•w.\-.<„ 






MAini'lN NAMH 
ol M()Tni.:K 



lUU riM'KAi'l', 
Ol. Morill'.K 
'St.it' ur L'oinilivi 



0( 



nn\ 



111", AliOVl-: STXri'I) I'KKSONAI. 1' \ K lU" I' I.A KS A K l". PKIK It) I'll 1'. 
m:ST Ol' MY KNOWMvDCK AND IIHMICK 



^Iiif')!iiiriiit 






1)1' RATION ^ V'"''-^ Months Ihiys 

(SIGNED) H. • 'O Wlv- Vib xxL^<x^-A. 



I lours 
M.D. 



X-|v 



1 



I()0 



CAdilress) *>P ^ ^ 



i 



Special information «nly for Hospitals, In^itutions, Transients, 
or Rcffnt Residents, and persons dying avvay from fiome. 



former or 
Usual Residence 

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



How long at 
Place of Deatfi ? 



Days 



IM \CK Ol.- JUKIAI. OK KI.:Mo\ Al 



uATj-;*)! Ill KiAi 'U ki-;mo\ai, 

190 



'^ 






'AiMk ><'< 



^^-XL t:-':z ::^t .^-;:'tL:;^.:r-;^^^^:^i ,z=^-^ 



N. B. Kvery item o9 1n?(>rmat 

stHte CAUSE OF DEAT 

«on« dyinft away from homo nhouSd be ftiven in every inHtance. 




) 



-) 

u 



yiy 




■ i 





»! 



iii'«f 



JiJ 



w 



RITE PLAINLY WITH UNFADING INK — 



U:,:th- IV.. ;.^?HD^H.S.l'r 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1738 



J^po^f\ste?'cd J\^o. 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( XX. 5. Stan^arD ) 



PLACE OF DEATH: — County of Clcv^. Ivcv .^av^ cecity ofO^Vvv. a.V<V^vCA^c.o 






No. Ul X'a„a.\- 



St.; 



Dist.;bet. Lxxtut\ \ andC3<X^^.a.Tv.^<. 



^ "^ t • ^ ' •• ..«,.-, DC-CinFNrr riVF FACTS CALLED TOR U N D e'W "SPECIAL INFORMATION ' \ 



\ 



FULL NAME 



■:i^ 







iJUc 



1)..-' 



PERSONAL AND STATISTICAL PARTICULARS 



vll\ 



lOI.i >K 



"I lUKTll 



A^^C 




MMiith^ 



\> .!■■. 



L| C- 



(I):iv) 



1 /,->////* 



\iai t 



/',/t. 



SI\<".1,K. MAKI<I}:i>. 
WIDOWKl) OK I)IVi)Kri-:t) 
(Write ill social (l('si}.'ii:iti<in) 



i;i!<i"iiri. \oi-: 

state III r<)\iiiti \' 




V(XK\^JL<L 



\AMi-: fti 

FATIIl.R 



liiK run, \»K 
or lAiiii'k 

'State oi ("(iiiiitt y> 



M \IIM:\ NAM1-: 
•»l Mit'llll-.K 



inu'rni'i,Ari', 

HI- MorillvK 
(State ul (.■(lUlltt \ ) 



(^ 




A 







ION ro 

h'f^itfrif ill Sail /'i tiin '■■'■•> i/»0 ^ '" ' ' 



\!,>iit/i^ 



lhi\ 



iin: \Mo\i-. sTxri: I) i'Kksonai, i-ak ihti. aks aki'. iKt i'. to riii'. 

11I-:ST «>l\^b' KNOWM'.IX. K AMI Hi:UI".l'" 



(II 



Cryv/O, JVAy-v^^ 



V.l.lre.s ^b^ du'X,J|X,'t5'>-vt '■ 



MEDICAL CERTIFICATE OF DEATH 

DA'llv ol- ni-.ATM ^ 



(Yenrt 



(MoiitlO (I>:iy^ 

I lli'iKl'HV Cl'iRTIl-V, Thai I attciKlcd deceased from 

, ^ t( ) -— — — 1 90 ~ 

tliat I last saw h alive 011 ' l^P 

and that death occurred, on the <late stated above, at 
M. The CM SI-; Ol' Dl^ATll was as follows: 

f . , 



DIRATION 
CONTRIIU" 



)'i'ars 



Mouths 



/hj) 



'S 



Hours 



Ol[\xL<x.o^ 



DT RATION ^ Vciifs 
(SIGNED) vJ.^JUijlA. 



Mouth! 




I\i\' 






La-. . . ' 

tc,o (Address) i^Cilo Oxa XUv -^! 



Hours 
M.D. 



SPECIAL INFORMATION ""'v '"^ Hospitals, Institutions, Irdnsicnts, 
or Recent Residents, and persons dyiny .iv^a) from liome. 



Former or 
I'sudI Residence 

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



How long at 
Place of Death ? 



. Days 



I'l.ACH t)l- lUUIAI. OK Ki:.Mo\ M 



.d<x/>^m1W^'- 



190 



(Athhess 



AAAXL 



DAIli: of HiKlAi. or KICMOXAI, 

\ 

lis Clla.,., 



1 



/"^> 



"^ 



/ 



N. B. Kvery item of informBtion should be cnre?ully HuppI.e.l. ^^'^'^ .^__;cjed. The "Special Information" for p.r- 

«tote CAUSE OF DEATH in plain term., that it mny >e properly cla8».».cti. 
Ron« dylnft oway from home Hhoul.I be ftlven in every Inntancc. 



49 



IS 



) 



. > 


r) 




11 


,0 




^o5 




C^ 






, I 



>i- 



i 



i 






I' 



■p 




J 



1 .1. 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






/)((/(' nied y 




\ \'\ 



Ci 



i9(n 



lie f^ isle red J\''o. 



Xfrccvo Xv>M Deputy Health Officer 



1739 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of 2)catb 

( 11. S. StanDarC^ ) 



^ 



PLACE OF DEATH; — County of'JcX'^v V coxcui City of ^.' CC'^x- J.\.a 



V 



rso, 






^ 



<.u/ 1 A 'v. O '" ' St.; Dist.;bet. and 

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

FULL NAME l\X<i V|).Lilc'^AXi.i oli: ^ - -> '. ' 



PERSONAL AND STATISTICAL PARTICULARS 




DAI 1 1 11 r,ik|-n 



% 



il 



.1 



\^ 



(V^. 



r\o.., 




M.>iith> 



(l):iv) 



AC. I-; 



J •,■,/;.» 



l-i 



1 M.oiih- 



■»ia! I 



I\i 



^IN'C.I.I' MAKUIHF). 

' Ut it( in s*Hi;i] ill -.ii.>ii;iliiiii) 




lUR'rni'i.ACK 

'St;iti- i»r "'oiiiiti \-^ 



iAiiii;k 



nik iiii'i.ArH 

<»•• lAIIIKK 
'Statt i.r (.'oiiutrv 



M \ll)i:\ NAM !• 
<>l Morill-. K 



ink rm'i,Ai-i-. 
Ml MoTnivk 

i St:itt (ii l"()\iiltl 






MEDICAL CERTIFICATE OF DEATH 

DATK ()!• Di: ATM 

.J..C:Wtj 1 L 

(^^Moiini) (Day) (Vi-ai i 

I HlvRl'HV CI;RTII-V, That J atten.kMl (Icotascd from 

■V^^-N >'>o^ to a_eJ^1j ]'l 



/^o 



that I last saw li alive on • ^ w. . 

and tlij'.t ik-alh ocrurrcd, on tlu- dat«.- staled above, at 
U M. The CAlSlv ()!• DI'A'I'II was as follows 



up \ 
190 



1 




DrUATlON 



}'(ari M,>n(/is ^ Days I lout 



) 






AAXL 






ocrrj'ATioN Cv\. 




f\i-^!<hif ill Siift /'ill 



CONTUIIU'TORV u Xcc .^'?..^ -.0 , 



DURATION' }\'(irs .U<'f////s Jhiys 

( S I G N E D ) LhuOAXjj \£)/C^.' 



JJLJxi^ n too' f.\ddres<) l^A J.a..Hlv '^t 



f loK) ^ 

M.D. 



^/■'llt/lS 



/>,!\.^ 



SPECIAL INFORMATION only for Hospitals, Insfifuflons, Trdnsients, 
or Recent Residents, and persons dying dHdy from fiome. 

c I5S0 Cjl^tAxJ. lU-- 



I HI. AlioVK STA'll-.D I'KKSONAI. PA KTIlT LA k S .\k l! Ikli: To 
I II. ST <)1- JdY KNOWI.JUxiK AND HKMHF 



THl-: 



(I 




(.\ddreK« . I X\ 5" ytTAJU Ul 



.OA, 



ixXl 



Former or ^ « 

Usual Residence LULou-^-vvX-H -■ 

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



fiow long at 
Place of Death ? 



Bavs 



IM.ACK Ol- lUKIAI, OK KKM()\\I. I D.VU; of Hi kiai, or K1;MoVAI, 






190 






^' ^' Rvery item o? inVormation •houl'l »..- ^ nre?ully aupplieci. AGB ■houlii be ntnteil EXACTLY. PHYSICIANS iihould 

• tate CAUSE OF DEATH in ptain terms, tiiat it mny he properly clansiflcd. Tlie "Special Information" for p«r- 
Mons dying away from homo Hhouicl be (liven in mvory inatancc. 




I I 



>r 



I I 




'is4'"' 



M 



i- 




i». 



f 



^«| 



r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

' ; > ^ ' -'t!?L?^ '''^''^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health OfHccr 



.t^CC> X.>c 



JkCgisfrrod A'^o, 



1740 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 



( U. S. 5tnn^nr^ t 



PLACE OF DEATH;~County of'0.<X/>\; vL^vavvC^cc City of 0,a.'>x. v*^ 'v-\-kvc^..vi 

,^ (7\\o ^ 



-^ 



). Lv^tu \ Wv^L^vXu ^"0^.p,.d\' St.; Dist.;bet. nnd 

1 / ir DtATH OCCURS *W»V TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION N 
J \ (F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



nnd 



FULL NAME 



"y V >\' 



V. I 



PERSONAL AND STATISTICAL PARTICULARS 



Ox 



ct )i.t Ik 



i> \ 11', <)i liik 111 



x'.i-: 



I 



Mi.iitht 



1 



) ,,M 



I I»;iv 



1 A .;////> 



/ '■ ■ 

(V.-.-r 



/><i\ 



MEDICAL CERTIFICATE OF DEATH 

I) \ II". ( »!• ni'. \ III 



(M..iitlil 



i|);iv» (V<:il' I 

I IM;R i:i',N" C i;in'!l"\'. iMiat latU-u.Ir.I -Ifccrmt-.l limii 



^iN<.l,I-: MXKKII'l) 

u'liM >\\i: I) OK i)i\( (Rii:i) 

iWiitcin social <livi>.Miali()ii) 




I H t^^ ' 



Kiirnii'i. \r)v 

' St:ilc <il (■( 111 111 I \ 



lA III i;k 



HiK riii'i.Aii-: 

<M' lATHI-.K 

'State or ("(Muiti v) 



M N ll't'.X NAM J -N 

•'I Morm-.K / ^ 
niKTin'i.Aii-: 

"I Mnrill'.K 
'State or ('o)Miti \ I 



• '((■ii'\ri()N {7^ 






a 



f lial I last saw It ■• ali\r tm 



9x\xt \% 



I()0 I 



I()0 



ami thai di-atli •icciirrc'<|, nn tin- dalr stalt'<l aliovr, at 



D 



M. rUv CAISI-; Ol" ])!•:. \1II was as follows: 



VXL: 



'VC.wvvCr^'> 



X.CV. ctUt... .. 



1)1 RAT ION 



<^XX.^A 



fl 



h ? i '-> 



Vr^rrs 



Monilni 



Pays / /(iiit V 

C"()\'!"i<J Ii'.r'i< )KN' ^Vv^^^^^ot::, Vj/(X\jL-v^C-Kxywv<xl) 



I )r RATION ,.. )'iar'i Months 



PilV 



//('III s 



cr^v^n- 




^ 



o 



f Signed) J 'J\. o^ o^aOj m.d. 

\ ' . \ ^ 'Jy 1 

} 'Ja-I i "v i(>o''. rx.i.ircKs) La^I-u '^- v< r... ^ 

L INFORMATION »nly lor Hilspifdls, Ins 



I 



i- 



Specia 

or Rerenf Rpsidrnts, jnd persons dying HH,iy Irom homf 



isliliifions, frdnsipnts, 



h'r iilrd III Siiii I 1,111,1 III 



1 . \ 



former or 
Usudl Rpsidenre 



Lvi--- 



Hon lonq n\ 
Pld(f ol DfHfh? 



Ddys 



J '■(/ ; ■ 



y/^uilln 



h,' 



III i: vHovj.: sr xri: n i-j-ksovai, pAkiFcti, \ks aki: iKri-: r- > iii i-: 

IllvST Ol' MV KNOW l,i;i)(; K AM) Hi; I.I J'.l-" 



'liifotniaiit 



' \'Mi. ss LaXu, ^ V^ . (Ai) cy ^A-v^Lo. '. 



When was disease ronlraded, 
II not al place of death ? 



I'l^ACH Ol- HIKIAI, OK K »• .Mo\ \|, 




NDl-.KTAKKK Nj^^^oX^ I U U 



i)Ai,4-;r,; iti kiAi ot ki;Mo\Ai, 

t 
-^- TQO . 



-V/W>Aj 



'Addtcs'- 



N. B. F.vcry Item of informjition should bs ctircfully Muppliccl. M\V. should he «tiited I.XACTLY. PHYSICIANS nhould 

Htntc CMJSr OF DTATH in phiin terms, thnt it mjiy he properly duNffilfied. The **8peci»l InY'ormation" for per- 
son* dyin^ nway from home Hhould be Jiiven in every inHtnnce. 



I 




I .■'4 



•'I- 



> 1 i'lW 




k '. 



lit 



.1 




, ♦ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



«^" 



I ! .:, 1 1 )l !■■ N'O. I '■ '^'K:.^-^'' l'*^ »' '''^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' FiJrd , 





XsXK' 



VH 



lf)()\ 



lici^istcrcd JS'^o. 



1741 



\XAJ^ 



^^ Deputy th Or 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

I 11. S. 5tan^al•^ ) 
PLACE OF DEATH: — County of Cja.->v JXo^^vca^co City of Oxx^v J.VCc-.v' 




W 



Dist.; bet. 



and 



CUy^<XV ^l ^-^IsU ■- ' , 

/ IF DtATH OCCURS aLaV FROM tlSUAL R E 6 I D E NC E G I VE FACTS CALLZD FOR UNDER 'SPECIAL INFORMATION" ^ 
V, IF DEATH OCCURRED IN A HOjSPITAI. OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

J 



FULL NAME 



L 



tnr\,''>A_^^t' 



PERSONAL AND STATISTICAL PARTICULARS 



••■■^ "^ 



A 



COI.oR ^ 



I'A I 1. - M niK IH 



V.V 



% 



Month) 



M.l", 



SI 



) ,it 



It 



il>:iv) 



M.nilli 



MEDICAL CERTIFICATE OF DEATH 

I) \'n-: oi- Di: \ I'H 



!l)av) (Yf.ii 



:il ) 



/',M,- 



•^INf.I.l- MARK Ii:i) 

w iiM)\\i-.i) ok i>i\()Kr>;i) 

lU'iitiiii »>(icial (U'^iv.iiati'ni) 



I'.ik run, \i'i-: 

' stall' or CouiitrN- 



r\ N ', . 






NAMl-: ()!• 
I- AT Hi: R 



lUR rillM.AlK 
OK l-ATHKK 

IStatc or Coinitrv^ 



MAID 1-. N N A M l*. 
<'!• MOT III-; K 



mRTHPI.ACK 
•>!•■ MOTMKR 
(State or I'otinlrv) 



(^ 



( \ 



N^ I'lI . ^* 





n -, 



d 



(Mutitli) 

I invRI'llJV CI'kTIl'V, 'riiat I .ittfiidcd (U'Cfascil from 
I90 t«» Kp 

lliat I last saw h alive oti up 

aiitl tliat (katli occurred, on tin- <latt' ^-tatctl abnvo. at • ^ 

M^. The CAl'SI-; Oi" Dl-ATII was a^ follows: 



I )r RAT ION )V(/;v 

CONTKir.rTOKV 



M0U//1S 



/)u\ 



'.V 



I lour 



<x:cri'AT;()N 

Kfsidrd ill Sdu f'l iiii, isi'it 1 V )»■(// ^ 




Ow ^ V. U _ 



nrRA'PloN )\'ars . Mouths Ihiys 

(Signed )...L.c'\ ' >^-. 



//OU) ^ 

M.D. 



Special information only lor llospltdls, institutions, Irdnsifnls. 
or Recent Residents, dnd persons dying dHdv Iron home. 



Q,^ 



Months 



l),i\. 



""""" is lid-, 



ril}'. AHOVl-: STAIKI) I'KKSONAI, I'ARTirr I,A RS AklC TRIK To \'\l)': 
HKST OI- MY KNOWI.KDCK AND HI'.I.IKF 







UsudI Residence 

When was disease confrdcfed, ^ , ^ f y . ^ 

If not at place of dedth ? ' »\t;>vLK^ \y 



HoH ionq at 
PIdce ol Oedth ? 



Days 



PI,ACK Ol' lU l<I\I<OK K1:Mo\ Al. 



I)\l,'i:.>; Hi KiAi, or ki:mo\ai, 

"^ ' )^\ .'- 190 





INDKRTAKKR JV) <X.<L<L^1lA \c Co 



(Address 



o? Information .hould be cnrefully •upplied. AGE .hould be .tatcci BXACTLY PHYSICIANS «hould 
E OF DEATH In pl.nn term., that it may be properly claH.ifled. The Special Information for pT- 



N. B.-^— Bvery item 
state CAllS 
mrtnm dyinft away from home should be ftiven in every instance. 



i! 



n 



* 



u 



r ' 



j.,. 



li . 



'»!?■ 



VI 




7 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ii, ,,ith !•• \.) iv ■**:,=*^»' !*^'^'' ^'" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Di 



lie /•V/r^/,.:jxlxtjL>^OlM.^u IH 



/r^r^H 



lie i^i stored J\^o, 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of ©eatb 

( XX. S. 5tanC»arC> ) 

PLACE OF DEATH: — County ofClcL^ Axx^vvc^cc City of ' J <X^^ >vCL/>^C^ c c 
No. 'jX^L'^^^XCVW ol:' Ch<Uvcl.a.L St.; Dist.;bet. and 

/ IF DtATH OCCURS AVWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \ 
( IF DEATH OCCURRED .N A HOSP.TAL OR INSTITUTION GIVE .TS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 







{^xx^ ^LkXJwxS) 



PERSONAL AND STATISTICAL PARTICULARS 




\ 



i> \ I !■ < '!' HI K I'M 



\' .I' 






)V,;; ■ 



I D.'tv 



M.,tith- 



< 'iC'ii) 



I(::>]l4i\^<n. 



^INi'.I.Iv M\KI<II-;i). 

u iix i\\i<;i) OK Divi »kri:i) 

U'lii' iti ^i)(i;i! <li'si!.Mialii>ii ) 



iMK rin'LAOi-: 

state or '.■|)lliitl \- 



\\Mi: «)I- 

!• \ Tin-.K 



HIRIIll'I, \CK 
0|- lATlIl-.K 

' State or (.■(miiti v 



MAIl)i;\ NAM}-. 
<>l- MOIMIKK 



I'.IkTlll'I.At'l-: 

'>i" M<»'nn«:R 

''Slate III (■()\nitrv) 



' '^ t I r ATION 




MEDICAL CERTIFICATE OF DEATH 

DATI-; <»1- DJ-.A'III ,' 

(Month) H):«v) (Veai ' 

1 lil'iRI'iHV f I;RTI I'V, That f alUn<k'(l dfcoasod fioiii 

u/) to JX.^\.t' I'l up ■ 

tliat I last saw h alive (Mi 

aii<l that iK-atli orcurrcd, on the date stated above, at 






M. The CAl'Sh: ())• DIlA'l'II was as follows: 



DCRATION 



) \'au 



.)/<>//i//s 



Da) 



Hours 






R , , mN 



nr RAT ION y^ 

(SIGNED) I l\. 0. Otch 



Mont /is 

1 , 



fhlVS 



Hours 

M.D. 



X 



^fX} i '.. 




i„o ; (Addre ss) UUC<i^<ii^xt ^ ''■'■f-^^- ' 



/\fsi<ir(f ill Sdii /'i (I III iS,'i) 



)V<; 



.\/,iii//n 



/),n 



I ill". \H()\'].: srATi-.i) rKksoNAi, rAKi'irn, \Ks aki-: Tkii-; lo iiii-: 
in:sr (»i- Mv KN<)\vi,i:n<".K and hhmick 



^Infoiinant 



■^ 



X\/v\^^.X^,.y>^^ 



''obo^^^A-v^i 



( \(l(l 



rcss 



SPECIAL Information <'"'> ^'"^ tlospilrfis, Insfilulions, transienls. 
or Recent Residents, and persons dyin^i dv^Hv from fiome. 

Former or ^« « ^i j' \-4 

Usual Residence ^AU g (T Ul.t 

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



How lonq at 
Place of Oeatfi ? 



Days 



I) \:4'j; o! H! iMAi. Ml K j;m< ixai, 

A , . 



ri.ACK oi" nruiAi, <»k kj;M(>\\i 

rXDHRTAKKK V9 . • N I Ut<X<lA/ ^ '. 



190 



N. B. 



— Bvery Iten, o^ •.nf.nmatJon «h„u.d he cnrefuMy supplied. AC^F. should »>« -»«^^;l^^'^.i^^^»:.^; .rZl'^I.n" Vr"::'" 
«tate CAUSE OF DEATH Jn pW.in term., that it mny he properly cla««.f.ed. The Spewlo! fnformatu.n Vor p.r 



8on« dylnft away from home should he ftiven in every instance. 



•ri.- 



ti 



8- ■' 



> fi. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ll,a!th rVn ;.^.^;^>J^M!^PC 



hih' /7/r^/, axl^iJL/T^-JL^A. 1^ 



7,9/9 4 



REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

1743 



Jird/'sfe/'ed J\''o. 




tj-VCA.O 




.^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 



( XX, S. 5tanc>avD ) 



%) 



9 (^ 



City of CJyCX/^rX' Xxx-vv-c^^v 



PLACE OF DEATH: — County ofOa.-vAj J.Vavx^ . 
No \J^'TVOi\i yUCH^LKU - ' St.; Dist.;bet. and 



FULL NAME 



•^ ' 



.CrVA.>5L 



Xo/ ' , 



'^ • 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,«)R \ 



'~i I 



■' \ n Ml l;lK I'll 



\' . J-; 




n 



( M.iiithl 



n ,v„„ L 



I I )A V ' 



M.nitli' 



1 c ;M 



/).n. 



-l\t,l,K MAKKIKl). 
WIDOW l-:i) OH DIVoKilvl) 



!Ukrm'i,.\oi*. 

St.'iti or (.'oiinli \ 



\ \M1- oi 

1 \rii i:k 



HlKIIirUACK 
OI' I \riIKR 

st.iti- 111 I'uunt I \ 



M \ii'i:\ NAMi-: 

o| MoTIIl'.K 



I'.Ik rill'LAOK 
<>1' MOTHKR 

' St.itc or t'ovmti v) 







i I' 




OVv. 



:vd. 



MEDICAL CERTIFICATE OF DEATH 

DA ll-: ol- DI'.A'I'M y 



(Moiitn) 



;t 



(Vfiii 



(Dayt 
I III'.KIO'.V CI'RTII'V, That r attcMKkd «U'(casc(l from 

: 190 to d^cCL. Kp' 

that 1 last saw h - alive on I90 

and tliat tUalh ocinirrcd, on tlif date stated above, at 
M The CM'Sl*: OI" IH'ATII was as follows: 



DIRA rioN 
CoNTUllUTORV 



)'i'ai:i ^- M tenths 



/hns 



//I'/ns 



■ \ 



\ 



'~> ' 



^L 



QSD 






' ,\^C^^^'^L 



' Hni'A'i'ioN 

Lj 

Rrsiiifif III Sail /'i tiin ix'o 1 )'in 



:/,iii//iy 



/ 1,1 1 



lill. MIOVI'-, ST\-n:i» I'KKSONAI, I'\K I UTI..\KS AKl". TKlK l' > Tin*. 

iu:sT Ol' Mv KN(»\vij;i)c. i-; and ui-i,n;i" 



.]/,'/////.< 



Pn\ 



'S 



I) r RAT I ON )''(?;-.v 

(A.ldress) ^^^ Co. '.<-••, 



(SIGNED 



If ours 
M.D. 



\. 



Special information ""'> ''"^ llospltdls, institutions, Transients, 
or Recent Residents, dnd persons dyinq dwdv from tiome. 



Former or 
Usual Residence 



s 



t 



How ionq at 
PIdf e of Deatfi ? 



Days 



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



D Vi"l-; ii!' Hi KlAI, ui ki-;m<)\'ai, 

190 



I'l.ACH <)»•■ HrKIAl, OK K1-;Mo\ AI 



im)i:rtakkr 



N 



' ' TT V A A(1F. sWilcl be stntetl r.X4CTLY. PHYSICIANS Hhould 

. B. F.very item otf in?ormfit1on should be cnretuMy supplied. Ai.r. snc^u "Snccinl Informiition" Vor p«r- 

Htote CAUSE OF DF.ATH in plnin terms, thnt it may be properly claHS.tleti. 



«on« dyinft away from home should be ftiven in every instance. 



■^ 




">1^ 



I !' 



.» 




WRITE PLAINLY WITH UNFADING INK 



,! II. ;iltli !■■ N'' 






THIS IS A PERWANENT RLUOhu ^p|^ 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)H/r riiod, Da. 





V)(}\ 



Ke^i^stcred J\^o, 



v^js d^xLvu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of ©eatb 



( XX, S. Stan^ar^ ) 

SI % 



J? (^ 



PLACE OF DEATH: — County 



No. 



II 



Vl)\f 



V CL>v' 



( 



IF DEATH OCCURS AWAY F 
IF DEATH OCCURRED I 



ofO.a.O'v A.Oo-vv^i'LAC '. City o{'^OyY\, ■^)\yO- . 
St; H Dist,;bet. '^^ OJx\.L^.t:r- and'D 

FROM USUAL RESIDENCE GIVE facts called for under "special information 

N A HOSp7tAL or institution GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



■■) 



FULL NAME 




r\ *v '■> "^ 
I 



' \\\\j 



-1 1 



I I 



PERSONAL AND STATISTICAL PARTICULARS 



- i \ 



i« tl,< »R 



!».\11' 1 >1 i:il< 111 



L 



\ ' 



•:^ \ \ 



M:.mJ\> 



);■,!>> 



I Day) 



.1/.. ;////' 



\ < ar 



/ 'il\y 



\vn)()vvi-;i) OK i)i\t •Kvi;i) 

Wiitcin --iK'ial dc-ii.' nat i'lii ) 







r'^ 



I'.IK rni'I,AOK 
'Slate or Couiiti y 



NAMI' or 

1- A III i;k 



lilKTinM, ATK 
Ol" lAIIll'.K 

iStalc ui (.'■uinti %■ 1 



MAini-.N NAMi: 
Ol' MOTIII-.R 



iUK iiii'i.Ari-; 

Ol Morill'.K 
' ^tat' ■ ii ('diiiiIi \ 



< 'lA'l 1' A'lloN 











A 



-C^-^ 



Jj % 







'•0 i] 




\\ i 



/\Vuiffif III Silil /'i iliii n<i> 



)V,/, 



M.niHi 



Ihn ■■ 



in 1-: \i5ovi". ST \ ri:i) i-kksonai, i'\k rui i. \ks a hi-; i'kii". to 

HHST or MV KNOW I, i; DC K AND iU'IJl-.l- 



rill- 



■ Infoini.'int 







MEDICAL CERTIFICATE OF DEATH 

DAT1<: Ol' Dl'.A TH 



I Moiillil^ 



i A i^n 

(Dav) (Year 



I ni'RIvHV C1-;RTII'V, That I attended (knc-asod from 

up, to aJl.\x^. l..t. 190 . 

that I last saw li alive 011 - r Kp 

and that death occurred, on the date stated ahove. at 
M. The CAl'SIv Ol- DI'.ATH was as follows: 



1)1 RATION >'''^'^ 

C(>^TRIi'd■T()R^• 



^•' ■ r 



Monlln 



Davs 



Ho 



/// s 



DC RATION 
( SIGNED ) 



I(;0 



)V,//s Mituf/is /hivs 

(Address) ?)^b ' '*.■'. 



Hours 
M.D. 



SPECIAL INFORMATION "niv lor Hospitals, Insfituflons, Transients, 
or R('( ent Residents, and persons dying away from home. 



former or 
lisiial Residence 

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



flow long at 
Place of Death ? 



Days 



I'F.ACK Ol'" HIKIAI, OK KI-lMoNAI 
INDICKTAKKR \^^ Llv^" ; ' 



)\LM-;<»; Hi KiAi. ni ki;mo\ \l. 

A . : 4- 

1 90 



^ TT ,. , Ki\\ Khoul.l be HtBte.l fiXACTLY. PHYSICIANS hHouIiI 

IN. ». Hvery Item of information should be cretully Kuppl.cil. '^"'- « . . ..'jej The 'Special InformHtJ <m" for p.r- 

«tnte CAlJSf: OF DEATH in pinin terms, that it may be properly J«hh.^.ccI. nc j 

son. Hyinft away ?rom home HhoubJ be ftiven in every inHtance. 




# 




s-'' 






H 






«^ 






^ 



WRITE PLAINLY WITH UNFADING INK — 



, • «NB m ■ « 




^ •>*'!?^v ,,c i> /• 



//.//r luteal ,C 





l-^ 



/,9i9H 



THIS IS A Kt.KIYIMI^IC.I^I I nc.\^v-rni-r 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

1745 



Bo^Lstcrcd J\'*(). 



^y\XAA 




AMJ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of "0catb 

( 11. S. Stan^arD ) 
PLACE OF DEATH: — County ofOam; J Xa.^A.^^x < City of O-O/rv. J .^uCX-^ 

I (Hl.\ \A.la. ^. St4 Dist.; bet — — — ——and — 



VC^^Cl^CI.' 



No. Ox.t'^'VCK' 



yV.7V V*^ I ^„^„ MOUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATION - \ 

( '^ rF^O^ATH^OCruRRTJ^.^rHo's'^T'L ^^V.lf.'^U.^.ol C.V. .TS NAME ..STEAD OF STREET AND NUMBER. ) 



FULL NAME 



L 






\r\ 



-i,\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR '\ '\ 




\ 



ouLl 



I \ I 1 Ml itiK rn 



\«.i-; 



I M.illt}!^ 



) III I 



r 



(l):)v) 



Mntilll^ 



\ 






r»'t;n ) 



/),n 



^iN«.i,i-: M\RKn-:i). 

WIDnWl I) OK DIVoRi}'.!) 

Wiitiiti S()ci;il (i('-i).'!i;iti<iti) 



HiKruiM.Ari-: 

St;iti- or I'oiinti \' 



r 




1 \i"iii;r 



HIKTIirUACK 

<>I" 1 ATHKR 

' State or I'onntrv^ 



maii)i-:n xamk 

Of MOTin-'.R 



lUR'nil'I.ACK 
nV MoTHHK 

(Statf or Cmnitrv) 



Va . -. 



'^v^Cl^lI' 



^h^^Xy^'V CL^. 





) III I . 



M.'iitlis 



/>,n.- 



'trcri'Ariox 

A't'Mifrif i)i Siin /'idihi^'-,) ^ 

rill-. AHOVK ST\'n:i) I-KKsONAI, P\R IHTLAKS AKl'. TRTK TO THlv 
HKSr Ol- MV KNO\VI,i:i)C. K AM) MKlJi:!-" 



^' 



i Infonnant 



.\X ^ v^JL h Cr<J|^vjt 






(Acldress 



(Dav) (Ycai 



MEDICAL CERTIFICATE OF DEATH 

DATl- Ol- Dl'.ATH 9 

(Montli) 
1 H1':K1{HV C1;RTIFV, That I aUen(U<l «li»c.isr,l h.nn 

' ', , . I go'. to ..cL.a.L. Kp 

that 1 last saw h - alive on JXJvt .< i./j 

aii.l that (loath occurred, on the date stated al.ov*-. at 
M. The CAlSh: OF DIvA'I'lI \\a^ as follows: 



DT RAT ION Years,. 

CONTRIHrTORV 



V 



Mon/hs 



Day 



DTRATION 
(SIGNED) 



) Vc/rv 



Mn)ilhA 



/hWS 



L. U 



J lout s 

Hours 
M.D. 



x\\^' 



V 



I()n 



( V,1,lrr'^s) bl^ L aj-'^x-yt 



rions, 



SPECIAL INFORMATION onlv lor Hospitals, InstituHons, Transients, 
or Recent Residents, and persons dying .iwdv from home. 

p rm« «r ^ ' V ♦ How lonq at 

SlRe%ncei^it>vcU -^ ■ Place o( Death ? Days 

When was disease contracted. 

If not at place of death ? ^ 



DAIJ'", o} lit KiAi. or Ri:Mo\Ar, 

OX^ ^0 190H 



ri ACH Ol- HIRIAI, OK KI:Mo\AI, 



N, 



B. Rvery item of information should be carefully supplied. ^^^^ « i„HH!fled The "Special Information" for p.r- 

•tate CAUSE OF DEATH in plain terms, that it may be properly .l«88.»led. 
sons dyinft away from home should be fciven in every instance. 





^^^^ 




^w 




.» 



«■' 




t 

I 




I 



WRITE PLAINLY WITH UNFADING INK 



iM), IN" l-'^^^.IU^ !•(•,, 



nnh' Filed. O X^Ujl/vA^i^Vv l^ /'^''^'H 



TMI5> 153 M Kt-MIYIMI^CI^ I ^l:.^^v•^l-r 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

1746 



liegifitcicd ^Vo. 




Deput 



iO 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ceitificate of IDcatb 

SI m i ^ 

PLACE OF DEATH:-County ofCW^ J V<X^v<lUL^Gty of U^O^ A.ay>^^^cc 



No. 'l 2) 3 



St.; Dist.;bct. UJcrV^ 



and dbcrU p.v- > ) 



'*" ' ..eiiAiorcinrNrFrivr facts called for undeiA "special informatiow \\\\ 



FULL NAME 




\^ 





'\li.. 



/ - \ 



PERSONAL AND STATISTICAL PARTICULARS 



] I IxxU 



lOI.oK , 



u 



ii\i i: oi liii-trii 



\< .1', 



Gxkt 



(Drtv) 



) Vi; I .> 



U 



:„////> 5 yK,^w/i 



(Vcai » 



/),n. 



>>1\<.M-:. MAKKIl-.n. 

W llx >\VKI> OK I)l\(>K*Kn 



HIKTIIPI,A0K 
'Stiitc or Counlry^ 



NAM)', oi' 

1 AIM i;k 



lUKTUPI.ArK 
Ol' l-ATllliR 

' Stati- or I'oniit! v"! 



MAIDKN NAMH 
<)(•• MOTHICK 



IllR lIll'UAlK 
<»1- NH)Tm:K 

I ^tatr or Oo\nUry^ 



nv'vTrATION 



Q^K.<h Mil 







L^- 







r' 



/CL^^' ,)vo^> V e\Ai z c 



fs'rMi/rJ ni S<ni /■ia>uis,n ^ ) V.w > ^ Moi>lh> 



/),/ 



rm- AHovK sTA-n-.i) i-kksonai, !>\k tuti.aks aki- tkii-: lo rin-: 

MKST Ol- MY KN<)WI.i:i)C. H AND IJl^IJl-.K 



'I 



(1, ?. ^V ^'H.O 



'Cql^v^ 



A.ldn-ss C)Abt 



cc 




0^^ 



vl 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- Dl'A'rU j 

(Montli) ">:«y^ tVrai' 

^I HI'RI'HV C1{RT1I'*V, That I atteinlcd (IcceascMl from 

J..,...,.. I '. 190. to 3-^^ A 190'. 

that I last saw h •■ alive on O-L^y T90 

ami that death ocrurred, on the date stated above, at 
y M. The CAT SI-: Ul" Dl-ATH nas as follows: 

^tAX^r^A.XX:tAAAX, ^^.i^A.vt.L -d-vv^ 1', 
[lLa/Uiy-v\L.i 



K<\...U AxO... 



DIRATION 



)'(\7is Mouths 

Ou 

coNTRir.rTouv I ^(r^v^ 



/A/I'A 



Hours 



Years 



(SIGNED ) 



xA.\X J i. i<>o 



//out s 
,<X1\a,L^ M.D. 



I )!• RATION ><'''''-^" ,^\^""^^'-^ A ''^'"■' 



^ ' ' --'U 



Special information »"Iv tor Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dyinq av»d> trorn home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



190 



n ACK OF lUKlAI. OK KliMoXM, '»^y"' ''"^'''- '" »< ••^I* •^'•^J' 



""""""""""""""""^ ,• 1 ACF .houlil be «ti.te.l F.XACTLY. PHVSICrANS «hoiild 

^. B. F.very item o! InV.irmntion should he crelully (.uppi.e.l. "'■■^ " ,|».,i8i.U The ••Rpecinl rn«ormBli..n- for p.r- 

8tote CAUSE OF DEATH in plnln term,, that it m,.> he properly .la.».«.ed. I 




sons dyin^ away from home should he liiven m every instance 




]\,y,<u\ I'l H' :illll 



J 



,1^ WRITE PLAINLY WITH UNFADING INK — THIS IS A KtKiviMi>ic.^ . ncwv^n.. 

, v.. , . t..tT^X. nS.V Co REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

1747 



Ihf/c /v7^v/,...d.X<l.Alji-^-^'l>^' l"^ 



2,9 6>H 



Jfrs^/sfc/'cd A'^o, 





Deputy Health Officer 



DEPARTMENT 0?PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)eatb 

J? (15?) ^ ^ 

PLACE OF DEATH:— County of OxX/>x; J Xcv>vc^c< City of CIax^ A-a^^^<^< 



No 



,.^t 




(I F DEATH OCCURS 
IF DEATH OCCO 



I 



r 3 



FULL NAME 



(1 



Dist.; bet. 

TS CALLI 
TS NAM 

(!^ C 



and 



%;r ,"°rkt :^v^k^J^'i^^iti^^ ,r,»ri? ;^:ii^i^-^:^- ) 



• ) 



) 



(^ 



11 



PERSONAL AND STATISTICAL PARTICULARS 

-1\ (T) I COI.OR ) 

!)\ ri: «)i' niKTii 



a 




i/Montli) 



\( .!■; 



\\ )•/•(/;- 






M,,nlli' 



i\vi\.r) 



Ihtx 



>I\(.I,i:. MAKKIl",!). 

\vii>o\vi:i) OK i)iV()K(i;i> 

'Wiitciii KMciiil <lc<i>.'^iiatii)ii) 



lU<^ 



lUkrm'i.ArK 

' St;ttc or Coimt i>' 



NAMl-: Ol 
I "A Til IK 



Hlk I IU'LAOK 
<>|- lATIIIvK 

' st.it 1- i)t r<)iiMt r\' 



M\IIH:\' NAM1-: 



I'.IK rillM.ACK 

<»!■ Mornivk 

'Stutc or Couiiti y 






^ 







n 



^ \.^.v 





r-V^?- 



•nCri'ATION 



ini'. AiiovK sTA'n:i) i'Kks<»nai, i-articii-aks akh trtk to thh 

inCsr OH MY KNOWI.KDC.K AM) HKI^lKK 






.^v^^JL 



\ 



(Month) 



I go 

(Veai 



MEDICAL CERTIFICATE OF DEATH 

IMTl-; ol' I)l", \'1H 

• I):iv^ 

1 in^Rl'iHV Cl'KTII'V, riiat I ;ittc-ii<U-<l «lt( cased fnun 
' , . • loo'i to cWjvt i I \ip \ 

X 

tlial I last saw li - alive on ^^P 

aiid that dc-atb occurrc-d, mi the dat.- stated above, at 
M The C\rSI*: Ol" DI'lATll was as follows 



.jcAX^^ 'sJ Xh^^Xv. 



.\)f^xx:^\,oj\^^ '.^.^ 



l<^ 







DC RAT I ON JVff'-^ 

CoNTKinrToKN' 



Moulhs ^ Days 



I/oiifs 



Dl'RATION 



)'i'ars , 



Monl/n 



f^ays 



\ I 



(SIGNED) 

cj.xkt ri too'. (A.idress) '. . a.uJ::U\' -n., 



//oiwi 
M.D. 



SPECIAL INFORMATION only (or Hospitals, Institutions, Iransifnts. 



or Recent Residents, and persons dying .may from home. 

When was disease ronfracfed, 

If not at place of death ? 



Days 



I'UACKOI-- nCKIAI. OK KKM'.VAI, I.AlJ;:..i H-wiM. -., KKMoVAI, 



I^^^^^HH^ 



N. B. Every Item of Informntion .h<»ul,l h. c.rofully -uppHed. ^"[|^^ "';'*" 'j*,^","^^ -Special Information" for p«r- 

•tate CAUSE OF DEATH In pLnn term., that It may be properly classmeu. »« 

sons dying away from home Hhouhl be given In svery Instance. 






r 



P 



'!> 




I 




WRITE PLAINLY WITH UNFADING INK 







I 



»(. 



M 



Ddfr tlJefl ,nJU 







c\ 



WO'i 



THIS IS A PERIVtArMtlN I ntov^ni-r 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

lle^istcrod ^'o, 1748 



u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( H. S. Stan^ar^ ) 
PLACE OF DEATH:— County of Oo^^ ^]XCX.-^-\.'^'^ 



(to 

0,^ 



No. 




'-^ Ahu^, St.-, ' D:st.,bet.'.' ■ ■ - andOLU 



City of 0'<X>\/ XCC^i^-C-vA. 
: and 



( 



IF DEATH OCCURRED IN A HOSPITAL OR II 



FULL NAME 



£.cll-^o . U^.(^' 




>i.\ 



!i \ I1-. ol- IMKI'II 



\< .!•: 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR \ V f\ 

I \ 



Month) 



t. 



)'<•(/< . 



Day) 



M,,uHi'- 



I Viiir) 



Ihn 



\\ ii)<>\\i: I) OK i)i\(»Ki i:i) 

\\"iit(in soriiil (IcsiviKil ii 111 ) 



IStati- or i,'iiiiiill \' 



\ \M1-: DI' 

iAriii:K 



liiK'niri.ACH 
*>i- i\i'm.:K 

iSt;itf or c"o(i!itrv) 




A/U<3V^"V\^ 



O 




>VUA.CL 



MAIDKN NAMl-: r\ ft 

<»1' MOTIIKK / I) 

in ur Ml' LACK \\ \ 

OF MOTHKR U A'J 

(Sl;itf or Cotititry") 

•HCri'ATlON 

h'fsiilril ill Stifi I'm Hi ism _^ 

Tin-, MIOVK STAIi: I) PKKSONAI. I>A Kl" ir C I.A K S A K l- TRTH TO Till'; 

m:sT i)i' Mv KNo\vij;i)C.K ANi),,ni-;iji"i' 




■VOu 



n 



) 'lur I s 



M.nitfis 



/),n 



'Infoimiiiit 




(Address 






(Vi-ai 



MEDICAL CERTIFICATE OF DEATH 

DATK ol" Dl'.ATII »' 

fMotitf> <!*•'>■■ 

1 III'RI'HV C^I'RTIl'V, That I Mttfii(k'«l docvased fnuii 

i^.X^ ' up to tA--^ 1'^ ^<P'^ 

that I last .aw h alive- on 3^^^^ ^^ ^90 

;m.l that .h-ath ..rcurrcl, on the- .hitr staU-d above, at ^ 
M The CAl'Sh; Ol" Dl'.A'rn \va. as follows: 



DTK AT ION y^'<J>''' 

CoNTRir.rTORV 



Mo lit /is S /^</i'v 



/Ion IS 



f^avs 



/ fonts 
M.D. 



DrR.XTION . ^'"''^ Months 

( SIGNED ) li^CV ^'^^ ^ \^^^ ^ 

SPECIAL INFORMATION ;"|y, ';|L";'P'*'*"' '"^'•'"f'""'^' ^'•'"'^''"'' 



or 



Recent Residents, and persons dying jwh\ fro:n tiome. 

HoH lonq at 
Place of Oedtli ? 



Former or 
Usual Residence 

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



Days 



IM \CK OI" lURIAI. OK K1:M<»VAI, 



DAir. ol III i<i.\i. or RI';Mo\AI, 



I NDKRTAKl'.K 

(.\d«lrfss 



m.. 



.H„u.a H, c„...u,., .uppn.H. AGP. .--' -.-"'Inf "r.".; .„r".'.-r-l":°;:'r- 
n plBln term., that It m«y l>e properly clarified. The »pe 



N. B. Every Item of Information 

state CAUSE OF DEATH In p 

Hon. dying away from home nhould be given In overy inatance. 



!i 



I rl 



pf" r f '\ 







'•» 



f 



.1 



ii 



t 



.n 



Botir'! "' II 



WRITE PLAINLY WITH UNFADING INK -THIS IS A ^EnMANENT RECORD ^ 

REFER TO BACK O F CERTIFICATE FOR INSTRUCTIONS 



■aitlv I .>•'■ '^ »..,«,« -^ 




1719 



in OH Bo^isteTcd J\i''o. 

■L-vw> 'Lo^'.^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of ©eatb 

( "U. 3. 5tanC>ar<> ) 






_P (^ 



No, 



PLACE OF DEATH:-County of '^ <>.- ^^Va.^C- ' Gty ofOom. OAx>- 

.VU l(X^>V^^ SU ^^ ^Hi^^^hk^e^ECIALI.^^^^^ 

• ^ S . OEA.H OCCURS AW.V .BOM USUAL "^^ « . D E N C E - - - ,^,^,^„ ^^^^^^^ ^^ ^^^^^^ ^^^ ^^^^^^ ; 

i, ,r DEATH OCCURRED IN A HOSPITAL OB INSTITUT.O ^^ ^ 



FULL NAME 




Ckj^ 




PERSONAL AND STATISTICAL PARTICULARS 



-i'\ 




Ci>l.<»R \ 



DATi' (ti r.iurii 






I Muiithl 



\ < . \\ 



\ C' ),,M.> 



(Diiy) 



Moil Ills 



(Vear) 



nay. 



MEDICAL CERTIFICATE OF DEATH 



TH Ol" Dl-.ATIl J} 

a^kt 

(Motith^ 



(Day) 



IQO 

(Yt-ai ' 



w iDowi-:!) OK i)i\()Rr):i) 

iWiitfiii social il>si>.'nati')ii ) 



r.iKTur'i.AOK 

' stall or C'omiti yi 



I lUxAXoixL 



'^ I iniiriuVv'cKRTIl-'V, Tliat I atlen.kMl ikcoasoa lr..ni 

OL>-a, it HP '■ to .. 04^ u up . 

t,„.t I lM.1 s„w h ,. alive o„ O-^JiV-t :■ ". ,.p 

a,„l tlint .U-atl. occnrrc.l, cm the .hite ^tale.l alx.ve, :d H 
(j M The CM Si; (il- DliATll was as follows: 



1 A'nii.K 




(JA\JLCU 

cKxxL<x/w^ 

MAIDKN NAMK A (0 OOj 

HIRriU'UACK (\ 

<'l- MoTMKR A l), 

I State or Comitiy'i l\ 



TURTHIM.ACK 
OI- lAfllKR 
(State or Country) 






I lour 



itVTkX, 




HT 




,ci- 



Rfsidfd in S.Di /'i diiri^ro ^^ ),<ii.< 



M,ui//i' 



/)./! 



Till- AHOVK STATKI) THRSONAl, PA RTU' T I. A K S AKl- TKlK To THH 
HKST OJ- MY KNOWIJvlX.K AND lU.l.H'.l' 

(.nfonnant ^'^O^.^^^-O..- 0' ^k^^ 



DrUATFON J^ >'''^''^ 
(SIGNED) IaXcIA U. 



n ■; 



I()0 




"ciprciAL INFORMATION only tor Hospitals, institutions. Transients, 
or Refent Residents, and persons dvinq dnay Iroii home. 



Former or 
Isual Residence 

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



How lonq at 
Place of Deatli ? 



Days 



>i ACK oy in- RIAL OK ki:movai. 




|)Ai;i*!o! Hi KIAI. or Rl-"MO\\I, 




V 



t xc 



T90 



(Ad.lre.. llll .Q0f^A^^<^2^^ 



vij>\XaAiu 



IS. B. 



^.^^^^^■■^■i^—^"— ■■""■■■■^■'■■"" FXACTLY PHYSICIANS should 

•Bvery Uen, o. in^o.-nBtlon .hou.d l,e ...c^uH. suppll.c. ;^^;;;;;7;;',:;^,:i? 'rui "Special .nV'o.,n-t«on" .or p-r- 
•tate CAUSE OF DEATH in plain term., tha .t may ^^^[ 
«on. dyinft away from home should be ft.ven .n every mstance 



"^ 



0, 



B 



;^^ 



*». 



ff>m 



t 



i 



■11' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



).,,,•,, , ; II Iih )■■ N". ^^ >-ti3r*''«^''^*'> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hffr rifc'i ,0. 





IH lOO'i 



Jfro^/.s/r/cfl A^o. 



1750 



V.X.U 



r It h Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



No. \ '■ 



Cevtiticate of IDcatb 

PLACE OF DEATH: — County oiO.O^^ J.MX'T-xcvacf, City of O/Cu^v J.VajvC. 

9 - ^ 

In.n.- St; n DisUbet .-^-^Ar\^.a..'.. ■ 

/ IF DEATH tcCURS AW»Y FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER •'SPECIAL INFORMATION" \ 
V IF DEAtV* OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 





and^A^^-O-d-lA-Vo! 



FULL NAME cL^rUAAJL cjj. o^CLq.... 




4J 



PERSONAL AND STATISTICAL PARTICULARS 

(■()i,( »k 



1) \ 1 1-. Ml i; I Kill 



Ul, 



. I 



Ml 



iMdiitli* 



)■ 



1 I' 



3.1 

I Da VI 



MuHlh^ 



A5l 



'Vrar) 



fhn 



^iN<'. Mv ^^.\RUIKI) 

WIDOWI'.I) (H< I)I\(>RtHI) 

W'litiii! •<i)ci;il (Usi}.'iiiiti>)ii) 




\oj 



lUKi'HIM. \("1". 
'-'late or <."iiiiiiti \-l 



\ \M1'. Ul- 
lATIlI.R 



lUIMIII'I^Ai'K 

<»i" i-.\i"m;K 

•Stntf or Coiinti vl 



M MI)i;\ NAM!-; 
<'l Morui-.R 



HIRIHPLAOK 
•>1- MOTHKR 
■St;il( or Country) 



^^ 




h; 






MEDICAL CERTIFICATE OF DEATH 

DATl-: ()!• Dl'.ATH 

r\. I. iq 

'I):iv) 



fMoiilh) 



(Wai' 



I HIvkl'J'.N' C'lvR ril'N', 'I'liiil I ;tUcM(lf«l (U-f(.;isc-<l from 

uli\^'V J-'i 190'. l<. uX^Jj. ' : i<p'\ 

tli.-it I l.ist ^aw h alivfoii ............ icp 

and that iKath (UX-urrcd, on llu- dati' stated alxivc, at 
w' M. The CM SI-; OI" I ) I", A Til was as follows: 



.^\ 



O- V CL^"V^^v^<5 <X -i-^ 



cL UjixLii/\% 






^> 



I)IR.\TI().N 



) V<7;-.? 



? 



X/Vz-vwO. >vu 



^■i-Ml'ATION l7T\p r^ 

f\f'sii!r<i ill Situ /'i a ii( isi'd 



Monl/is -J Days 
CON '1' K 1 1 5 r T ( ) K \' Oy^xlJcKAAAX^^O^^....U 



Hours, 



l)rR.\TI()N 
($IGNED ) 



I^axs 







U)0 '. 



JtVJT.? Months 

(Address) ?)bO J^>0\-\ W 



I loin '^ 

M.D. 



Special information on'y ini" Hospitals, insfilutions, Irdnsifnts, 
or Recent Residents, and persons dying away from home. 



) V(M 



Mniitin 



I hi 1 



1 HI-: \IU»VH STAT i: I) I'KRSOXAI, 1' \ R'l" K" I" I,A RS AKl': rRlK To THl-: 

iu;sT oi- Mv KNdwij.DCH AND n];i.n: I" 

'"!"')Mii.'nit 






Former or 
L'sual Residence 

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



How lonq at 
Place of Death ? 



Dd)s 



D \ ri', •<*' r.i KiAi. (-r k j;.Mt <\ \i. 



t i\ 



rUACH OI- m RIAI, OR kl-:Mu\AI, 
INDl-RTAKl-lR ^ .^y\JL^<i<L^S\j cUaJLVV-U 



190 



(Address 



N. K.--r.very Item o* information should be cnrcMully supplied. M.B should be stated nX4CTLY P" ^^'^'^^^^ "'^""'^ 
state CAUSE OF DF:ATH in plain terms, that it may be properly classified. The Special InVormat.on for p.r- 
sons dyin^ away from home should be (iiven in a\cry instance. 



■"mr 



^ 




w 



RITE PLAINLY WITH UNFADING INK — 



Hoai'l . » 



II. v.th i-N" 1' ^■^y^^-n^'^i-^'o 



.1 





Diffi' Filed , 





lOl 10()\ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Bco'is/cfrd jYo. 



^^ , Deputy Health Officer 



l- 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

PLACE OF DEATH: — County of" ^ Jxo^wc^cc City of U,<X.^^ A,- ■ 

No. IHl ' L^6^ II St,; 



Dist.;bet. l/xOvtrd. 



and 



A 



..c.Ai DrcTnrNrr riUC FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
( -^ rF"DrAT°H^OC:u%rEr IN-rHO^S^^AL «%' Tn ^nT^JV^o";' l^- v7 Ts NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 






\c 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



Xwol. 




\' \ 1I-; ' »i III K I' II 



\ "■.»•: 



(Monthi 



COl,OR\ A 

Vi ,! 



(I)ilV 



^S 



)■,■//> 



I 



M.oillr 



i Vcar^ 



l>ii\ 



^I\<.l,l-. M\KKIi;i) 

W lI>n\Vi: I) OK I)IVi)Krj:i» 

\\ lit' ill '•(n'ial (lt>.i<.' iiat i' III ) 



I'.IKTmM.AOl-; 
Siatt or (."Munti \ 




*\ 




\ \M1' (»!■ 
lA Til l-.K 



lUKTHIM.ACJ-: 
<>l" I AI-JIl'K 
'^tat. or (.■imiitry') 



MAIIn;x NAM1-; 
"I- MDTUl'.K 



l!Ik IIIPI.ACH 
<>I' MOTHKR 
'Slati- u! (.'ounttx- 






i 




h'f sill fil III S,i>i liiiihis,;i - )V(//> ^ M.oilh' 



lui 



111. \iu)v»-. sr\-n:i) i-kksonai, r\K ruri.AKS aki'. ikik r'> I'li'! 
in:sT oi' Mv KN(>\\i,i:i)<'.K Axi) in:Mi',i" 



Int'iMiiaiit 




J<^ xj^y^\jL 



( NdclrcsH 



.Lcrtrd. 



MEDICAL CERTIFICATE OF DEATH 



I 1 »a V ( Vcai 



i)\riv oi' i)i:atii ^ 

(Moiini* 

I lll'Kl'l'.V ti:RTII'V. TliMt 1 aUcii.kd <li-«rast.Ml from 
VV}:\. ' II up to J^^X}^ .^^^ iqoM 

tliat I last saw h <^vn alivr m, QX^Jj \\ Kp 

Mii.l that (Ualb ocrurrc-.l, on tlu- .lalt- stalcl alx.vi-. at Vo- O C 
C-V M TIk- C VrSI"", Ol" l)i:.\ril was as follows 



^,u^(M.vo.viL<Kav.-. ■-; A^^LuC 



KysJJ\ 



DIK.V'IION r<77/.v 

lONTRIlirTORV 



Mont In 



Days 



I loiti V 



Hon 



(SIGNED) '^ lO • CJ X.»vl[V^- tv .' M . D 



l.X^xt 



k I<)0 



SPECIAL INFORMATION onl> lor Hospitdls. Institutions, Iransirnts. 
or Recent Residents, dnd persons dyinq .mdv Irom fiome. 



Former or 
UsudI Residence 

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



tlovv long at 
Place ol Death ? 



Days 



I'l \CK Ol" IHKIAI. OK KI:M<»VAI, 



T 



(Addn 



DAi")'. ■>! Ill KIAI. <>i Ki;Mn\\l, 
' ^. I I 90 

LvwcLq \w<. 



N. B. 



-livery item of ln?ormnt5on nhould be carefully supplied. ACJB *'^""'j* ^' **" *' ' ••«„cclnl InforniHtion" for p«r- 
-tate CAlJSn OF DEATH in plain term., that it may be properly clB.«lfle.l. The „ 
•on. dylnft away from homo Hhould be ftiven in ns^ry instance. 



'^^ 




^' r 1 



-jU*^. 



■r : 



I ! 



!!*>[ 




A 




i » 




Hnanl of ll.alth I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^^r.^ „. „,. REFER TO BACK OF CERTIF ICATE FOR INSTRUCTIONS 

Tic:;! isle red jYo. 1.751 



Dale l-lh'<l/6jL\<kju>n\h~i^\°l ^'^^^ ^ 

ic^vc^ ;Uu-M D^p"^^ ^"^'''^ °^'^"'' 

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



Cevtificate ot IDeatb 

PLACE OF DEATH:— County of 0<X>a, Oxo. 



QR^ 



C]n ,^, J'.N o. City of C)<Xvv -1 .'1 o 



'. 




V0\ 



St.; 



Dist; bet. 



and 



No. <:iX^'WA (iO CVA,^XA.A,X>,^'W ^.^-^'i^CE oivr t:;cVs"cAr:;D .or under -specal .NroRMATioN'. >! 

( '^ .v-o;AT°H"o?:o%rD\;"rHo"s"prAt o^"Ns^^^"T^o^."ol;E7Tl ^na^^e .nstead o. street AND nu.ber. ; 



FULL NAME 




%^ 



u 



KAJD^'y^j 



PERSONAL AND STATISTICAL PARTICULARS 



(\ojL 



I>Ari' ( )| lUR Til 




Mi.nthi 



\ I . ) 



5S 



) .H) 



(I)av> 



M.^tillr 



, %'\ I 

^V.-ar^ 



/ hn 



-^iN'.i,!-. M.\Kun:n. 
\vii»(i\vi-: 1) OK i)iv( »Ki'i;i) 

^\ ' it' ill vociiil (l»-ii.'.ii:iti<>n) 



'M.itr III t.'DUIlll >■ 




MEDICAL CERTIFICATE OF DEATH 

i)\ Ti- <)!• Di- \ rii y' , 






(Day) (Y.ai 



1 1II;R i:rA' Ci:R'ril"V, That I attcu-U'-l dfCfa^oa fmin 

____ — ,tp to 190 

tliat I last '^aw h alive- on " "~~ ^'P 



xJLxk. 



\ \M1', ()|- 
l-A I II IK 



lilkTHI'I.AC}.: 

<'i' I Ai'in-.K 

ISlatf or ("laiiili vi 



MAIDl'.N NAMK 
"I M<)TII1-;K 



I'.ik ri!i'i,.\ri--. 

"I Mnriii.-.K 

"^t.itr .ir rnlllltt Vt 



' •' 'Tl- A rioN 











■WAX. 



D 



/\'fi,lf(l III Sun I'ranrhfo t'SV )'<<//< 



Months 



l>,t 



111 AllOVK ST\Ti:i) I-KKS()N\I, I'XKTICri.AKS A H 1 ■, IKri-; l* > TIU-: 

Hi:sr oi' Mv K N( >w I, i;i )(■.!•: and lu'.i.n'.i' 



'Inf., 



iinaiit 



O^J^J^ 



( \<1 dress 



O^^w^ 



Txo 




,>crvv dt 



an.l that .k-atli occurrcl, on tlu- .lair statcl above, at 
M. Tlu- CAISI-; Ol" Dl'.ATII uas as follows 



DC RAT ION J><//-.v 

CONTKII'.rTORV 



Monlln 



Day 



I /O !(}.'< 






Days 



DlRArinN^ Years 

{ SIGNED ) .3 hXL- H U. LaAV^x.M 



. t. I()0 



/ * 11 ^ 1"CjI n l*. H jk, A"f 

( Aflnri-^s) V. V v^ ■ -^^ v - ■ ■ 



I lom s 

M.D. 



SPECIAL INFORMATION ""Iv lor flospifdis. Institutions, Transients, 
or Recent Residents, and peisons dying away Irom tiome. 



Former or 
Usual Residence 

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



1\ J \ , How Ion 



How lonq at 
Death 



.. Days 



rNPKKTAKH 




I'J.ACK <)I-" HIKIAI, OK K1:M<>V AI 



nA,4"i-:«)! HiKiAi "I hj;m<>^ai, 
aAj IL 190 






9. c 





I 


? 


/ 


r 


r 


I. 


(^ 


1 


r" 


■^.cJ^ 


- 


r~^^ 




9 


- 


^ 


r' 


$ 



i- 



mm 



"■■■■— "————^—^-ii^—— 4i"i—"^"'"^'"'^"'"'""^'^"'^^^ ... t t cl F.XACTLY. PHYSICIANS Hhould 

N. B. Kvery item o? informBtlon •houlcl b- CHrelfully «uppl!etl. '^^''^ j!^"" .'.,*j" Vhe -SpeclBl InformHtlon" for p«r- 

state CAUSE OF DEATH in pl.iln term., that it m..y be properly claH«.t 



-Fivery itei 

state CALoE. v^. .'..^ .- . , ..„^, 

«on« dyinft away from home should be ftiven in nv^ry instance. 



I f: 



* I 




' 't«T«» 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



r 




!;).'! 






Jiro/.s/cii'il -jVo. 



1753 



f 




.^, [^ J!>0\ 

1^^^ ix^^ Deputy He^ftv O^-ner 

DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 

Certificate of ©catb 

( -a. 5. StanDar^ ) 
of^a^^O va.>vcv^oc City of J<X^^ O/vc^^vec^l- • 



PLACE OF DEATH: — County 



,\vA. I v,M'.A St.; 



Dist.; bet. 



and 



^ r - -"-^H OCCURSUWAV .ROM USUAL " " ' ^f.^J^^^^,' ^,', /^.TS NA^E INSTEAD Or STREET AND NUMBER ^ 

V IF DEATH OCCuilRED IN A HOSPITAL OR INSTITUTION G I V L 



] 



FULL NAME 



:a>'>\l.A 



,U,.,1. 



PERSONAL AND STATISTICAL PARTICULARS 

) \ n. >i 1! IK I'll 





ti. 




M 



'I:' 






iv );„,s 



T 



(I»av) 



Moufir 



I W A\ 



/)<n 



MEDICAL CERTIFICATE OF DEATH 

n A 1"K Hi" Dl. Al 11 






il);,y) (Yell 



1 iii.:r|.;HV CI-.RTII-V. That J aUciad -k-rrasca fiMU. 

OVt^r a 190': f |-^i^ ^^ '^^^' 

that I last saw h..^ aUvc- nn d-^V^ ^ ^^ ^'^ 



90 



^INf.l.K MAKUIl'.l) 

WlDnWl'.I) (>K I>I\i >Kv»:n '\ 

(Write ill sociii! clcsiv iiat ioii ) 1 



■it 




HiR rniM.AOK 

■ St.itr iir t'li'iiitr^-^ 



N \M1' O]- 
1 Al lii:R 



MIKTHIM.ACK 
OI" I AIHHR 
'Stall or Oouiitry) 



MAIDKN NAMlv 
"1 MoTIIKk 



lUKTHlM.ArK 

<>i' M<)rin':K 

Slatf or *.'()\nitry> 



iJUVo^ vlAJV<Jl^■L^l• 



a,;,.! that <lcath orc.rrcMl. o„ thr .late- statc-l ah.nv. at ^^ ^ 
Qf M. The CArSI' ()!• Dl'ATIl was as follows: 



nrKATION y^-ars i C .V..M. ' P^vs Hours 

CONTRIIU'TOKV 




Till. AIIOVK ST\'n-,I) I'KRSONAl, I'A K l UTI. \ K S AKl", TV.V'i- 1<» 
lU'ST oi- \n- KN()\VM;I)C.K AND MKMl'.K 



■|- 1 1 !•; 






►'X^to. 



Dl' RAT ION 
(^IGNED) 



)V<7r5 



J/,>>///lS 



/hJV 




t' . W^^N-O-'^' 



Hours 
M.D. 



>o 



(' AildffSs) 




Vvv^i ^'^ ^'*^^^-'^- 



'special information onK lor Hospitals, Institutions. Irdnsients. 
or Rerent Residents, and persons dvin.) .mcy from home. 



Former or 1 1 V -v >,' 

Usual Residence VA-^' ^ ^ 

When Has disease rontrarted. 
If not at place of death? 



/vky^^v^ 



.. Days 



,., XC1-- <)!• m-KIAI. OK KKMOVAl, 

\ I 







Hnn.M ni K1;NM\AI, 
TQO'i 



\xt ao 






■■■"— ■--— i~=— iii^-— ---^— — — — -^■"'"'^"^■'■^^""^"''■^^'"""'"""""'""''"'"''"'"'""'" I FX4CTLY PHYSICIANS bHouIcI 

N. B.— F.very Ue,„ „( i„!„r„...ion .h,.u.d he cn^ejully ,upp...d. J|«f^;;;':,',''..Y,,:d.'"Vh: ••8,.«.i»i .nforma.ion" tor p.r- 
..„,. CAUSE OF DEATH in pl..ln ..rm. «•■"' ■' ""^ T.Z,^.^. 



State (^ALJSti U^ UCA I n m m.« -j , 5n«t»ince. 

«on. dyinft away ?rom home nhouid be ft.ven m every .nntnnc 




't ' 



i' 



I ' 




IV.itri! 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,*""-^,.o,.,. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1754 



11. :ilth • I" No- 1 




la 



190 "{ 



llci^istrrod A7>. 



Ixih' Filed, Qj^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



.\M.i Deputy Health Officer 



■V 



Ccvtificatc of ©cath 

( 11. S. StanDarO ) 



PLACE OF DEATH:-County of ^^ - y<XO L- , City of 



ul-(KJl'Ct<rY^' 



.a. 



r^ntcdji h^\.d.<x'^. 



su 



Dist.; bet. 



"and 



FULL NAME I ll-a^\-c^AJ\.c- '. 



PERSONAL AND STATISTICAL PARTICULARS 

i:x (?pl A ! COI.IIK \ 



^3 



JO 

!>.\i i: ( >r I'.iKi'ii 



\<.i-". 








::i ^- 



) V<; / > 



II 



(l)MV) 



M,,}illi 



r 



'I'lai ) 



/',n 



-^INi.l.J". MAKKll'.I). 

W Il»< iWI'.l) Oii I>lVt»kri:i) 

Wiitciii ^i><'i;(l <!( sij.Mi;it ii 111 ) 







HIK rill'I.M'K 
^liilr or (.'ountiy^ 



\ \M1-: ni' 
lATH i:k 



Fiiuriiri.wK 
oi' I \rin-:R 

' St;it- >ii Coinitiy 



M Ml»i:\ NAMl'. 

• •I Mi>iin:R 



llik 111 1' LACK 
01-" MOTHKK 

'Slate or Coimtry^ 



^CuL«J^rtT\y>-V^LXX 



MEDICAL CERTIFICATE OF DEATH 



DATK «>i- ni.Arii l< 



.Mx.A..- 



...Q rgo 

fDav) (Vcai 



'MoiillO 

""^ I III:KI{I5V CIvRTII'V, Tlial I alU-n.U-.l .krraso.l fr<mi 

■ ■■ : 190 to ^'P 

lliat I last saw h alive on ~~" ~~ ^90 



an.l that .k-atli orrurred, en tlu- -late- -^tatr.l al.ovc. at 
'^~ M Tlu- CAISI-: Ol' Dl'A'l'll was as follows 



( i'. 







H 



Oxx,\-<^ 



OCCrPATION 

h'r-iilftl ill Sail i'l iiiii i^i'ii 



)■/•((; 



Mnnth 



run 



llli: \H0VI-. STA li:i) 1-KKS()\A1, rAKThTI.ARs A K 1 •. TKri-. T" > IHI- 
lll'.sT {)V MV KN'oWi.l.lx'.l-; AND HI'.I^-.I' 

/■'o 



< Info; iiiMllt 



( 




\. 



r\(l<lrpss 



^il 



0^ 



<y\AAr\^y\i 



r 



i 



nr RAT ION Vt^ars 

CnNTKIl'TToKV 



Mont In 



Days 



Hon 



;.v 



DTK ATM )N 
(SIGNED) 




)V(^;'..v 



Moutiv 



Pavs 



I()0 






If on PS 
M.D. 



n 



V 



SPECIAL INFORMATION onlv lor Hospifdis. Institutions, Transients, 
or Rcrenl Residents, and persons dying a^a) from home. 

<^ (s ^ ^^ HoH lonq at 



Usual Residence 

When was disease (ontraded. 
If not at plare of death ? 



Pla< e of Death ? 



Dd>s 



ri.AXK <>!• lUKFAI, "K Ki:MM\Ar, 




, ■ TQO' 



ATi:*.: 151 



^A.i.iK-H« aba.JsJ*VU4AA..>rYv M 



' — ^— ^^^i^^^^^^^—^^— — ^^^^ I liXACTLY. PHYSICIANS Hhould 

IN. B. fivcry item of informiition should I.l- carefully suppliccl. A(. •**'"''?*,' ThJ "Special Information" #or p«r- 

Htute CAIJSIZ OF DEATH in plnin term*, thnt it m»y be properly cloH«.^.ect. 
son, dyinft owny from h<.mc should be ftlvcn in every instance. 




Jv-^. , 



fM^: 



.1 






T^tg^ WRITE 



PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CEnTIFICATE FOR INSTRUCTIONS 




/.,/,. /•V/,./,.Ox^^x.w^^.^>v a Iff0\ 

■L^wc:^ loiyv^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

PLACE OF DEATH: — County of 



City of 




f^ ■^ x^CXJh 



No. 



St.; 



Dist.; bet. 



and 



( 



,r O.ATH OCCUPS AWAY TROV USUAL " ^ ^ I D E N C E O . V t F ACT 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



FULL NAME 



II' 




TsVaLLED for UNDER "SPECAL INFORMATION ' ' \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

"r 



I 



\ 



\- 



DA ri-: I ti i'.iRi"ii 



\< .1-; 



' il):.v) 



M.iillli ' 






M.»illn 



I '-.- .;...» 

fVi-ar) 



/>,/! 



\vii)« t\\i:i) «»u i>iv( iRii:i) 

'\\"iit< in v.<)(i;il (1( vii.rii:it i'lii) 



i!ik rmM.ArH 

' SI nti (IT (■( lutit rv^ 



\\\n (»r 

!•■ \l III K 



lUR rm'i.ACK 
01- 1 Arm-:K 

'St.iti or Countrv) 






MEDICAL CERTIFICATE OF DEATH 

DA'fH <>i' i>i:a'ih \ 



1 



/9" 



I 1I1:K1:I'.V CI-.KTII'V, Tlmt r atlc-n.U.l .Ifcrasc-.l fn.iii 

— to • " ~" ~"^<>o 



i^o 



thMt I ImsI saw li alivL-on 

,„„1 thMt .U-atli ..roiirrc'.l, ..,. tlic .late- stalr-l alu.vr. at 
M Tin- CM SI'", Ol" I 'i: A I'M \\a^ as foll-.ws 

C\v' ■ •• 



'\iyo 



maii)i:n NAMi.; 

<>1- MOTHKK 



luk ruiM.Aii-: 

'»l" Murill'K 

'St;itt oi Coiintrv) 




(M 111 



AT ION (^ 



/\/-^i<if<t in Sdn /'iiuin'sm " ' '■" 



.!/,-;////> 



/'-M 



•nn: xnovi- sT\'n:i) i-ku^onai, i-xktuii.aks aki: TRri-: i** ru)-. 

IU:ST OI- MY KN(>\VI<i:i)<".K AND MI'MlvH 
f I II for tun nt CTvOLu AJUvv-x^N.^-<^'C A v.t'Vy-v^ aaX 



rXiMrcM 



DlKA'l'ION y<-'i'-'^ 

CoNTRIP.rroKV 



Months 



Pays 



/fours 



DTK AT ION 



) V(/;'-s- 



I loui \ 
M.D. 



Mouths l^ins 

(SIGNED) -A. ^ vJ^lMi.cryv 

OX Ut ri i»)0 (A.l.lr.ss) 

" SPECIAL INFORMATION onlvl-rHospildls. Institutions, Irdnsients. 
or Recent Residents, and persons dyini) .iw.n (r.im t)omr. 



Former or 
Usual Residence 

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



HoH lonq at 
Pl,i( f ot Death ? 



Days 



I»AT1-, "! lii KiAi. Ill R l.Nt< "V \ I- 



I'l ACH OI- lU RIAL OR KI-,M'»VM 
rNI>HKTAKHR M^ X3 \.<XU ^^. < 



N. B. livery item o« InformHtton .houlil He .Hro?ully Hupplicl 



tote CAUSE OF DI.ATH In pIhIh tc r.n.. thnt It m..y be ^^^^'^ 
on, dying away from homo hHouI.! be ftJven In ovory inntance. 



AGB should ho M«te.l EXACTLY. PHYSICIANS «houId 
rooerly clo-W»cd. The "Special In»«rm«tion" for p.r- 



fi 
«on 




-T^ 



':^^ 



» 



^mr w 



RITE PLAINLY WITH UNFADING INK 



,.- vr. i^ •^?!^^?^^ I*'^'' *-'•' 



/^//^' Fi /('(/, 




V 



Cc^r^-vlvXA.' 



/.96>' 



...th OC 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDcatb 

( "d. 5. Stan^arC> ) 
PLACE OF DEATH : - County of * J C , . J .\ - City of U,<X^ A.O 



:] 



C: v<i. ' 



and 



Ni). 



t' Xc^Wa ^Ol? CV-^JrV J...a,l St.; ^^A^^^L roR UNDtR -SPrCAL . N ro R M AT . O . ■• >) 

/ ,r DtATH OCCURS AWAf, TROM USUAL " ^ f ' J,^,^ " ^^' ^^ . v7 .tI NAME INSTEAD Of STREET AND NUMBER. J 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVt 



FULL NAME 



C-rrvcl^. \^KkjLo^^..^ J a^j^'^c 



PERSONAL AND STATISTICAL PARTICULARS 



HAi} i)i' I'.iKTii 




nl.oK "l 



LL; /\ ^ ^ 



f ( 1 



MonthI 



\'.i: 



f> 



O (. r-v/ 



( I);iv 



\/,.n//l' 



(Vcai) 



/'<n 



SIM .1,1-: M \Ku n:i) 
\vii)t»\vi-:i) <>K i)i\t »Kri-:i) 

'Writoiii sill iiil disiy ii;iti"ii) 



liiKrmM.AiM-: 

'State iir ( 'uiiiitt \-^ 



■. v\li: (>!■ 

1 \ riM.K 



iiiu riin.ACK 

<>»•■ I \ VMV.H 

^St:ii< ni ruiiiitry) 



MAIl'l'N NAM J, 



nTRTHlM.AiK 
•'I Mn'llll'.U 
'State ,ir Codiitiv) 



0\. 



MEDICAL CERTIFICATE OF DEATH 

DAllv nl Dl'.Al H > , , 

ll 

(I).-iV^ 

I lli;Ri:r.V C1:KTI1'V. TImI I altcntU-.l .Ucc-astMl fn.„i 



(Mxiit'li' 



^ 



(Yen I 



lip 



th.it I last saw h ■•' J'livf nii 

..„h1 tltal.lcathncctirrcMl, u,i tlu-latr statr.l ahovr. at 



T(p 



(^- 



v\ M. The- CAlSlv Ol- Di: ATM wa- as follows 



^ 



OrKcv-ci-^tv^ ^- 



V'V 



ri 



\ V 







^CU-AvO-' 



K'fuilfil 'II Sou I'l itiii i^>'i> . it > '''" ' 



M.nil/r 



Ihn 



I'm: MKiVl.; ST\T1-I) I'KKSONAl, I' \ U I" M' I I. A K S A K 1-. VMVV. T< • 1 Ml-, 

iiKsT tn- MY KN()\vi,i:i)<".K AND m:i,n.i' 



(I 



nr.-ni.u.t Vj Ox). 



( X-MUS!. 




Dlk A'lloN 



) 'I'iLn 






MLt^'v^.K.Ct' 



Months t: /->,/) s 

t 



I lours 



.A,-Ci 



5l 



(SIGNED ) 



lis 

cm- 



//out < 



-^rv^jo^ . OAA/Yvux.w M.D. 



SPECIAL INFORMATION "niv lor Hosplldls. Insfifutions, F.dnsienfs. 
or Rerent Residents, and persons dyintj .mny Irom home. 



^1 



former or 
Usudl Residenc 

When was disease ronf raffed, 
It not at plare of death ? 



I !• 



flow lonq at '- ' 
1,11 e of Death ? 



^ '^il 



Da)s 



1) \TJ, >>! Ill KlAl. <<i Ki;.Mi iV Al, 

O-C^vt \^ tool 



I'LACK «)1' III KIM. "K KIM"^ ^'• 



■""""■"""■■■■"^ IK » t I fiXACTLY. PHY8ICIANS Mhoiiiti 

N. H.— livery Item o» l„form«tlon -hould be c.refully m.ppUe.l. ^;';J^;;^7,l;„rf,rd? 'tHc "SpeJl,.*! IntformHllon" W pT- 
-tHtc CAlJSn OF DI:ATH in plMln term.. th«t ft m»> >c n;"^*'">' 
«nn, clylnft »way from home -houl.l be ftiven In -very Inntance. 



I 



\ r 



t I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Da/c Fi/cd , dxlv 



.^r\,A.KA 





Mi 



l,.^ 190 



llr^isteird J\'*o, 



175 



DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



i 

o 



PLACE OF DEATH: — County of 

frI^M usual R 



( 11. 5. StanDai^ 



je ^"^ 



City ofOcC'^Ai vi; 



Dist.; bet. 



and 



/ IF DEATH OCCUni AWAY FR^M USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
V IF DEATH OCCURRED IN 4 HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



-l-wW 



\h 



vtr-v.' 



PERSONAL AND STATISTICAL PARTICULARS 

(•» il.( iK 



I I L<X/U 




U1 



ivJjL 



ul 1! IK 11 1 



,Vl 



M..tiilr 



I):ivt 



y/.n'lr 



I \\l\TI 



fun 



^r\c.i,iv M\i<un:i) 

Ml ^<i( i;il ilfsij.^iiati')ii ) 



HlKTIIl'I. \r]; 

' '■ ' ' .1 ' nllllt I \ ' 



1 AIIIl.K 



HlKTIIl'I, \r J-; 

<»i- I ,\riii;R 

'SlMti- or roiiiitrv* 




MEDICAL CERTIFICATE OF DEATH 



DATl-: Ol- Di: A 111 



1 



(I): 
I II I'. Iv i:i'.N' C" i; KTI I'\', TllMt I atti'ii.lnl ilid astd t rMiii 



(Moiilli) 



(Dav) (V.:itt 



Up 
T<p 



MV!l)i:\ NAM1-: 
"I Mdl'lli: K 



ini<riiiM,A(i-: 

" ' '■ "I *1UI11I I \ 



' '• ' ' 1 ■^'l' !')N 

A'' iiliil III '"'ill/ / iiiiiiifii 



tliat 1 list saw li alive < HI ' 

ami that dt atll i trcii rrci], (in tlic dale stattil alp<i\H-, af 
M Tlif C A I SIC Ol' hi,. \ ill was MS ffillows: 



1)1 KXTION )Vr//s- .l/>i'////s /'(/IS //(>//>s 

roNTK ii'.ri()k\' 



Motiths 



m\v: 



fhivs 



1)1 RATION y'rais 

(Signed) Lvur^^wX^ 

! ' ■• -- 



Ilom s 
M.D. 



Special information »"'> '"f Hospitals. Inslitutlons, Ifdnsicnts, 
or Retent Residents, diid persons (hinij .m.iy fro:n home. 



M,>,itli 



/". 



I III: AliOVK STxri-.I) I'KKsoNAI, PAR TIC I I, \l<s AKi: IKI}-; T" > III I 

hi;nt (ir Mv KN()\vi,i;i)<; !■: .\\i> iu;i,ii:i' 



I- 1. 



"Kint Vw-^rVCTNAjt^^ \J 






'' \.l(ll. 



Former or 
Usiidl Residenff 

When was disease (onlraded, 
II not at plare of death ? 



How long at 
Plaie ol Death.' 



Days 



) \ ] 1 m' i'.i I' I m I.I K i;m< >\ \ I, 



...... 



I'l^XL'l-; «)l lit KIM, ' •!•: I< I'M' •''' ^' 



1 90 



r .\ I 



v 




MHte C\lISr: or DflATH In plnin tcrmn. that Jt m»y he properly cluH^hkcl. The Spcci„l ln»ormHl.on W p-r- 
«in« dyin^ nway Itrom home Hhoulcl he Jt'"**" '"' «vory iiiHtiince. 



¥ 



'.w^^m- 



?"««(#•■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.Ktv! 



ih !• 



No, i.-S'^^^-H&I' 



Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1.. 

f 







Jicgisln'ed jYo. 



1758 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "U, S. StauDarC^ ) 



n 



PLACE OF DEATH: — County of Oa 



1 ♦, r 



City of 'O. 



•)\; -1 ^ O 



1* T ' 



St.; "i Dist.;bct.^C^^'Cr'roL/JlA^L4<u:t.• and 

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



) 



y ii 



FULL NAME 



A.OU 




V 






-r 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.oK > 



•! I'.IKTH 



V 



X^xt 



Mciitfi) 



J-,.;; 



15 

(Diiv) 



1 /.>/.'// 



(Vt-ari 



/ hi 1 - 



•^IN*.!,}-: MAkkll'.lt 

\vii)( >\\i:i) (»K inv« turKi* 

(Writ- !i ^, ., i;ii il.si'.MKit i'>ii ) 



lUKTUl'I. \l'l-; 
'st.itf <n r. Mint I \- 



1 \T1I i;i< 



inKlllI'l.At'K 
«>••' I \IIIKk 

'Slati r)i c'ouiitrv) 



MAIOl^.N NAM}.; A 
"I M<)Tin-:i< 



"iK'iniM.Ai'i-; 
<•! M«»iiii-;k 



O-Ola-v ^1 ' '^ 



I 




IX'C. , 



I 



1 






MEDICAL CERTIFICATE OF DEATH 

i)Ai"iv •>!• I)j;aih 



\ 



Diiy) 



(V. .,1 ! 



I I ll<: K i:i'.\' C l':R'l"li"\'. Tlial ^I atUiukd ikicasi-.l fnun 
uyo to Q-fi- , ^-'^•■' •'■■ H)0 

tliat I liisl saw h alive- oil I*>0 

ami lliat <Ualh oiciirrfil. on tin •latr statccl aliovi-. at O 
\J M, The CArSi'", <)!' hllA'I'M was as rDllows: 



DC RATION )V(/rv 

CoNTRim'IORV 



Months 



/>./)V - '■ Ihllt 



.^ronlln 



r\ ^ 



i I 






"^ >'1'I'\1"I<)N 

A'fhifif III Silii / I II III /\i'i) 



) I III > 



1 /..;////>■ 30 /'" 



I 111 AllOVI-: STAIl,!) I'KkSONAl. TAk Tlcn. \K> AKi: IK' '■■ l' * '""''• 
III, ST Ul. MY KNOWI.lvDCK AND MIU.IIJ' 



1)1 'RAT I ON )'<q\ 

( SIGNED) V| , . 

AxWt '' I(,0 (A.MtVss) 6Xt ^ 



/^nv '^ *- I lipids 
M.D. 



SPECIAL Information '•"'> •<"^ HospitdK. Instilulions, Irdnsimls, 
or Ri'fcnl Residents, .ind persons dying hh-iv Irom home. 



Former or 
Usudl Residence 

When was disease (ontraded, 
II not at place ol death ? 



HoH lonq at 
Place ol Death ? 



Davs 



IM \CI' Ol lilklAI, Ok kl.MoV \l. I'\I4.-! It-'OM ..I ki:M..\\l, 

1 Mi . J., 
r N 1 ) 1 . k r A K 1-, k JAX.L.vX'ti 

0.1 Hi' 



v1;/0l,<xcv ' 



N. K. 



state CAUSE OF DEATH In pinin term; thnt it muy be properly classiiieti. i nc i 
Ron« tlylnft away from homo «hould be itiven In every inntance. 






iv 



HoMiii .Mi 



M 



ii-.i 



J)(f/<' Ff/r(/, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„ , v.. :.*.?S^HS:rCo BEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1759 



,^.^A_.'b 




/tiL-vWiMA; XO ^'^0'\ 



Begu'tercd J^'^o. 



iAM.^ Deputy Health OPTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bcatb 

PLACE OF DEATH: — County ofQlX^iAJ 



R ^ ,, . JA.<V>^CAAC:,C;ty of Cja -A.. O/VCV \ vCV4.t.' 



^\^^ 



No. ^'1 XI C V..V. 



^5 U 



1 ^ > 1 ^ : K s^^. \o Dist.; bet. "^ -^ ^^^^ and 

.•oiiAi orcinrNr E riwE facts called roR under "special information" \ 

( IF DEATH occurs AWAY FROM USUAL "f f ' ° ^,^^f_f _^J ^_^, Z*"^,;! NAME INSTEAD OF STREET AND NUMBER. ) 

\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS n M rvi t 



l^ik^ 




FULL NAME 




k.Tsj 




'\.K.^, 



PERSONAL AND STATISTICAL PARTICULARS 



•^l-.X 



^ 



I'\ 1 I. I'l 111 Kill 




•\i.l- 



IS 



)'l ill 



R 



Mnillh 



(Vt-ai » 



/)<n 



^iN'.i.i:, MAKkii:i» 

u !i>u\vi-;n OK i)i\()i.'( »:i) 

'Uiitciii s(K-i:iI (li ^ivMiiilioii) 



HIK riil'I. \C\.\ 
isi:itt I.I <"..unlt v' 



;■ mv„.:k' 1 (TO n j 

'1,\(K A 

^F I 

\jy\x\i 

\ \ 



.<x 



IU''T|I1 

<>' lAniKK 

'State or foinitrv* 



"" MOT I IKK 





ML^AV' 



''•ll< llll'I.AfK 
"" M'flUKK 
"^tati or CoiiiUry) 



"^CrPATlON 



MEDICAL CERTIFICATE OF DEATH 

DATH OF I>i;aT1I Q 






Ivt 



IX 



(Day) (Y<'.n 



1 Ui*KI-HV C1;RTII'V, 'I'liat I alU-iitkMl (ItHcascd fn-m 

..^wLu i . 190'. t.) ^x^aI; \'\ \ip. 

that I l.'.st'sawh^*. alive (,n t^JL-\<X^ *"v up . 

r 

aii<l that tkatli (.cciirrcd, on tlu- <laU' stal«,<l ahnvo, at J - ■ 
J M. The CAl'SH OF Di: ATI! was as follows: 



1)1 RATION 
C()NTKir.rT()R\ 

1)1 -RAT ION ., 
(SIGNED^ UL< 



)'ears M,>>i//is Jhiys /Ion is 



C<t\.CX^ 



,-A„A.., 



)V(/r-V i Mouths /hir 



Hold 



v 



M.D. 






qO 



( 








/// V.J)/ 



/ '; (/;/. / w " i 1 



u 



) V(M 



c 






Till. XMOVK STA'C)-.!) I'KKSONAI. I'A U IK' I I.A KS A k I'. I'KI I". 1" 

iii;sr oi- m\m<nm)\vij:i)(-.kani) lu•■.^^■:^■ 



. » TIIIv 



SPECIAL INFORMATION "nly tor Hospitdls, Insfifulions, Irdnsients, 
or Recent Residents, diid persons dying dway from liome. 



Former or 
Usual Residencf 

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



How long at 
Place of Death ? 



Days 



I-VVCKor m KIAL<.K KKM..VA1. I DATK-.I H, ,<,,... ..r Kl-MnVAl. 



'i\ 



Lu/i 



\ I OxWt; X% 

3«w<XvAj->v • ^1 



V\XA.<L ^r^*-^^"^ ' ^''^'"'' """ 5— 



(Aildu-ss 



N. R. 



■fivery Item otf informHtlon •houl.l be carefully Huppliccl. AGB «h •Si.cclal Information" for p«r- 

*t«te CAUSK OF DEATH In ploin terms, that it m»y br properly JH««.»leci. The »p 
«on« dyinft iiway from home Hhould be ftiven in every instance. 



..JSF 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



r Fi/<>((,QjLh-djL-,-^\.Lx>\ ■•I, I'-^O 



».! 






T 



1?G0 



Bog ist creel JS'^o, 
1 (vvv.^^ Va'^.^u Deputy Health OlTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



City of 0/Olaa.' J ,^v.o^YV:CA.<i. '. L. 



No. 



PLACE OF DEATH: — County of O /a >A 

10 C Woi-u-^t ) St.; . Dist.; bet. UJ;.J|a.ryvt and lUoV 

A oo« M<;UA. REsTdENCE give facts called for UNbER 'SPECAL INFORMATION ' \ 

0' rF"o;ATH"oCC^%rEV.rrHo"s^yT'lL rR^Ns'l^u'^o'^^OIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



('^ 



FULL NAME 



1 



I' ■ 




PERSONAL AND STATISTICAL PARTICULARS 



Six 



^ 




COI.OR 



\>V\\: t)l lUKTH 




\X 



.<X\ 



(Month) 




.Q-UJ" 



/ 



A'.l. 

SlNi.l,)- MAKUIKI). 
WIDOW |.I> OK I)I\()Kil.:i) 

'Wiiti ill MK-i;il (Ksi>.Mi;iti<)n) 



)ra 



.1 A '»////' 



u 



(Vtai) 



/>,n 



lUR nn'i.\(M-: 

(St:ili (n I'riuiiti \ 



NAM!-; n|- 
I'Allll.R 



lURllli'i, Ai'K 
'"' I A III I-: R 

'St.itr ,,r Coiiiitvv) 

MAiDl-.N NAM}- 
'•• MOTIIKR 



inRTlIl'UAOI.: 
OK MoruHR 

II *.'<)mUiy) 



>^>VCLV*l 





!S|;it, , 



(KCri'ATiox 



-0| 1 




M.oitJn 



/),n 



f^'t'^idril i)i Stin /'> It III i>t'() , )'i'<jis ■" ■""" 

Till-. AUOVHSTATKI) T'KRSONAI. I'A RrUM' I.ARS AR K. TRlK To THK 
JiHST Ol- MY KNOWIJ-.DC.R AM) HlU.Il'F 

'^"f"'">:mt ok-AA,/Crv^w<:i. CrtrK 0<XA'^cl 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- Dl-.ATH j, 

'Jxkt I' 

(Moiilh) 



(Day) (Y<-:ir^ 

I Ill':Ki:r.V C1':RTII-\', That I attcinlcd dcccasL-d fmiii 

to ."^-^t:":'^^ i«/3 



190 



tliat I last saw h alivtM)ti ' ^9° 

an.l that .Uath orciirre.l, on the .late stated above, at 
M. The CATSI-: US' Dl'.XTU was as follows: 







I )r RATION y<'<J'''^ 

CONTRIIUTORV 



.Uo>//i'is 



Ihw 



UOHV^ 



DT RAT ION -VN ^'''''^ 



Months /hiys 

(SIGNED) Ij'MxLiLXA^Jk Lo^.VV > 



Hours 
M.D. 



SPECIAL INFORMATION onlv tor Hospitdls, Institutions, Transients, 
or Recent Residents, dnd persons dying av^H) from liomc. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Davs 






190H 



PKACKOK mRIAUOK KKM..VA.< I nVO:..' mK,..,. or RKMOVAI. 
(.A,l.lre.... l.tjbAl. ^^■'^^^ ^^ 






c 



■^ 



n 



n 




"""""""^ . . ... I tgj RXACTLY. PHYSICIANS should 

N. B. F.very item o? information .houlcl be carefully suppHcH. AGB 'J^"" ® ^ ." ^^ ••Special Information" for p-r- 

•tote CAUSE OF DEATH in plain term., that it may he properly clo«.lf.ed. The ^, 
won. dyinft away from home should be ftiven in every mstance. 



#9i^;4:g64^ 




I Ur. i 



III I.I r 



1,, Ml., 'til 1"< 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,--->. „5,,,. REFER TO BACK OF C ERTIFICATE fOR INSTRUCTIONS 

'^ 1761 



!)((!(' I'lh'd y 




Bc^Lstcrcd J\'o, 



^K> O.0 J^^H 

Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



C:"^VA^> 



PI. 



ACE OF DEATH: — County ofCJXX-Y\; Xa 



No. 



Ccvtificate of IDeatb 

^ ^ City of ^ CLA^' ^J ^^<^ y V CL ^ vL. C- 

and 'i-CQ' '. . 



■ r , st^. ^ Dist.; bet.HD XVcKa-r^^am and 

. .. oe.TH OCCURS AWAV PRO. USUAL « " ' ^^^.^^^J;^,- ^ ;r/xrN A m7 

V IF DE*TH OCCURRtO IN A HOSPITA. OR INSTITUTION GIVE ITS '^'^'^ 

1 1) -\ fv . 1 



FULL NAME 



.L.'w.Q. 



CH^ 



LLv^ 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



I»\ 11' ii! i;iK ril 



Ai.l. 




C(»I,nk N 



II ', ■ I 




iMotith) 



^IN'.l.l".. MARI<n:i) 
WFDnU I-:i) OK I)!V<)ki"KI) 

<\Viit( in ^iK-iiil ik-iiv iiritioii) 



HIk rill'l.XD-: 
(Stiitf (ir r.Minti V 



\ 



b 

(Diiy 



Mn>i!hs \ \ 



(Veaii 



/hl\: 







NAM]-. (»!• 
FAT 11 IK 



niR riii'i.xoH 

OK lAllIKk 

"^t;tl( or r(niiitrv) 



MAll)i:\ NAM!- 
<>1' .M()THi:k 



HIKTMl'l^AC-K 
Ol' MoTHKK 
(State or C»)\uitiy) 



^ 



X 



KJ 




\J. 



OCCUTATION 



f\fidrii in Sttti /'i iDii ifi'i) 



)'i (1 1 



\f,inf//^ 



/hn 



TH!- AMOVKSTATKI) PKR^ONAI. I'AKTlcr I.A kS ARK TRri- T<> IHK 
HKST oi' MV KN()\VIJ.;i)C,K AND in:iJi:K 

(I"f-Mn:.nt VJ . ^ . nJl^ (>-<sAAAn-'CL'K 



MEDICAL CERTIFICATE OF DEATH 

i» \ 1 1-; < >i- Di'.A'iii 

1( 






I 1 



(Moiitfi) 
I 4II;K1-:I5V CI;KTII-V, That Lattcn.kMl .k-ccascl fiMiii 

ILZ/cI' 190- to pjJpA 

11, at I last saw h- alivr on 0-X..\.vAj 

an,l that .kath occurred, .„, the .late -tate.l ahove. at O 
CL M. The CATSI^ ()!•, I )I':ATII was as follows: 



TC)0 
190 



I )r RAT ION ^ yt'<^''^ 
CONTKlI'.rToRV 



} font lis 



/hns 



Hour a 



Years ^ Moulin 
NED) S^. lO "1 ^^-^^ 



DURATION 
(SIG 



/)<n.s- 



\A 



nx 



{ 



Hoiifi 
M.D. 

<5prCIAL INFORMATION only lor Hospitdls, Institutions, Transients, 
or Rerent Residents, and persons dyin^i .mny Iron, home. 

How lonq at 
Former or mn fi\ Death? Days 

Usual Residence 

Wlien was disease (ontracted, 
If not at plare of death ? 






INDKRTAKKR U 

(Address 



ClHb 



Q(X 



vA<ice>\ 



„t\ 



f 



I pxACTLY. PHY8ICIAIN8 nhoultl 

N. B.— Every Item of Information .hould be corefully suppHed. ^^^^^^ "^""'^.^^fje^? *The "Special Informntlon- for pT- 
Htote CAUSE OF DEATH in plain term., that it may be properly 
«on« dyinft away from home «houid be ftiven in .very Inntance. 






- r 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^^.Sy-^ .^ V CO REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 



Da 



(J0\ 
} Officer 



Be^istcvecl jVo, 



tc Filed, QjL^~lx/>^^''>^^^ ^^ -^^ 

\ ■ "A ,, , Deputy i 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( H. 5. StanC»arO ) 



(?(? 



PLACE OF DEATH: -County of JCL>^' a,\.aAVCv^aGty ofO,a.>vOA- 



'■No. ' Jo . ci 




:i' 



C<,LC'VoU .Jk !y!V\\<k.O 



I 



St.; 



Dist.; bet. 



and 



) 



■ f I 



Ik 



^....VV D^if VV»\-CV »->l»t ^^o'V.i.rn rOR UNDER "SPECIAL INFORMATION ■ "V 

/ ,r oc.TH occu.s .w.. r.o« USUAL ""'""" <;'"^=;'<^;j ^.^M E .nste.c or st.ect .-.o n.mbe., >» 

1. IF Ot.TB OCCURRIO IN « HOSPn»L OR INSTITUTION GIVE^ITS "«nn 



FULL NAME 



A 



\. 



■y 



1 



\XLXU. 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 



M- 






VI i'Ul/I^. 




Lkc 



i»\ri-: 1)1 


I'.IKTU 1 

'M()iitlli> 


(Day 




\ J );;i>y 1 


MniHn 



(Year) 



/),/!, s 



'W'it' ill social fit sii.^ii;itic)ii) 



•-INi.I.i:, MAKKJKl). , 

wiixiwKi) OK niv»»Ri"Kn U A 



MEDICAL CERTIFICATE OF DEATH 



DATK 01- DKATH _y 

axkt 

(Moiitn) 



<I)ay) 



(Yi-ari 



i HHUr-BV CI'RTIFV. That .1 aUciitk-.l derc-ascl tioni 

liu^q ..X^V 190H to dJui^t. ).a uK^ 

t,,atllastsaxvh.: alive on ^^^t.. • i : 190^ 

a„,l that <Uath occurrcl, on the .latr ^taUMl ahnvc. at ^- C) 
(? M. The CAl'SI' ()!•■ DI-A'I'II ^vas as foll.-ws: 



HiK rni'i.AiM", 

'Stall or Coniitry 



XAMl-: ol- 
FATHI.K 



'nk'nil'l.Ai-F 
Ol- I' ATI IKK 

'State or roiintryl 



MAIDI'.X NAMK 
•" MOTMKK 



iilK IIII'I.ACI-, 
<>I' MnTIII-.K 
'^tatf i.r Country^ 







i 



•x^cri'Ariox 



♦ t 






'\''iiirii III .•\(i>i fiiiiniMii * ^' / r 11 . .. ^^^^^^^^^ 

THH AHovK STATKI) ^'KH^()^•AI. I'AK'rHTI.AKS ARK TRl'H 
HKST Ol- MY KNOWMCDCK AND HI-.Mi:!'" 

(Iiiforiuant VOL^ \D . oU AA./:*V'N-^':W 



TO THH 



' \fl(lrcHS 






/h7ys //oars 



)'t'ars 



.)foutfis 



/hu: 



•s 



//ours 
^,v^.^.. ^ M.D. 



DTRATION 'K"'Yo] 

( SIGNED ).U).,Aj. vJvuUt ». 

SPECIAL iNFORMATIONonlvtorHospildls, Instilutions, Transients, 

or Rerent Residents, and persons dyiny anay from home. 

I ^ How lonq at ,v ^ 

U'.* flare of Deatfj? ^<> Days 



Former or >\ ^ ,^^ 

Usual Residence U Ojy\i 

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



M iVatx^ 



PLACE <>»• mKIAI.^OR KKMOVAI, 



l)\ri; o! Hi KIAT. or RlCMoWXI. 

DX^xfc ^^ _i9o''. 



jlr..KKK^WcU^,^--^ , 



N. B. 



■"^■"^^■■"^^"'^^^■^'■""^■'■^^^'^'^■'^'^^"""''"'"^"^"^""^^ d FX4CTLY. PHYSICIANS should 

■Every Item of Information .houhl be c»refully supplied. ^;^^^ "^7,3**,^'f,ei!**The 'Spcclai Information" for pT- 
•tate CAUSE OF DEATH In plain term., that it may be P^^P^""" 
«on« dyinft away from homo should be ftiven in .very instance. 



■KM. 11 






; 



WRITE PLAINLY WITH UNFADING INK — 



])((!(' l'ih'<l , 




XO ^^^0'\ 



THIS IS A PERMANENT RECORD 

REPER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 



.Cr^- ^ ^-^ 



v^. Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of 2)catb 

i >30 



0;^ 



PI 



.ACE OF DEATH = -County ofO,a..A, OXCUYX^Ci City ofOCiv O.Va,-.vC.. 



I 



^ 



(^. 



No Hl'^) 'J)v(5:A}vL ■ St.; Dist.;b€t. 

r ■' ""H OCCURS .w.y rRO« USUAL "«:SIDENCE o.»t -. 
(, IF OC.TH OCCURHID IN . HOSPITAL OR INSTITUTION OlVt 



/YWC'Vt 



and 



JLlv^ 



r-o« USUAL HCS.OENCE CIV. ..CTs'c^.^LJ^CO ,--^-0.R ^-l-'i:---;'"" ) 



FULL NAME 




u 



Y>\i 



LlLIc 



>>! \ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



iiA ri-: i'|. r.iR rii 








iM.nith' 



Ar.H 



^iN'.i.K. M\Kkn;i), 
\viiH>ui;i) OR nivoKD-:!) 

(Writ* ill MK-iiil lit sijiriKitiijii) 



HIKrill'I.Ari': 
'St.'ilf or rmiiitry I 



(l):iv) 



.1/-. ;////> 



(Vcar) 



Ar 



N'AMK OI- 
f-'ATHl-.R 



HlkTHlM.AOK 
OF FAIHKK 

(St.'iti,' or Contitrv') 



MAIDI'.X XAMl" 
OF MOTHKR 



»IKiinM.ACK 
OF Mot I IKK 
(Stalf or CoiuUry) 




MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH jP 

QJlWJ:. 



|1 

(Day) 



I go 

(Yf:u 



I HICKI-r.V CI-;RT1I'V. That I alten.lod .lecoascl from 
190'v to c'^-i-^rOj It. 



c)jl|^ 1.^ 190'^ to ..^AJfxi li 190 H 

that 1 last saw h : alive on IjJ^^ - \^- 190 

;uul that <loath occurred, <.n the date stated above, at I 1 
(j M. The CAl'SI' Ol- DICATH wa^^ as folL.ws: 




'\x)L^XjyOL\xt J cruM-V^ 



OCCUPATION/ 




.1 A '/////.' 



Da 1 



Rfsidfd i)i Stui /'nuirisro 1'; )'''iji > ' ..m-^. ..- 

THK AMOVE STATKI) PKRSONAI, I'ARTICr I.AKS ARK TRlH Tt) TIIK 

HKST OK MY kxo\vm:ik;k and BKMKF 

(Iiifotmant Q /OLA./CLJtv 



f Address 



ci'X'3, X!>K.^^x. cH 






Hours 



CONTRir.rTORV 



DURATION 
(SIGNED) 



ox^t 



Years , 
WKWu 



MiUitha 



aO TonM (Addres.)i>gOa 




"special information only for Hospitals. Institutions, Iransicnts, 
or Rerent Residents, and persons dying dwdv froni home. 



Former or 
Usual Residence 

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



How long at 
Plare of Death ? 



Days 



IM.ACK OF m RIAL OR RKMoVAI, 



l»A'i;i:<if 151 lOAi. or RKM(»\AI. 



"' Jkr Vt ^^ ^^^^^^- 






(Address n. c^ O ^ /*-^ v^-n^ w w ^^_^.^_«_«— —————— "■"""""'"'■■'■■"^ 

'^^""""'■^^^■^■"^^^^^"■"■■^■■■^■'■■'■■■^^""""'"""^^"^"^"^"^^^"^ * i FXACTLY. PHYSICIANS should 

N. B. Every Item o? information should be carefully supplied. ^'^^^ •^^''"'''.^'Jjei! Vhe "Special Information" for pT- 

•tate CAUSE OF DEATH in plain terms, that it may be P'-«P«'-'y 
«on, dyinft away from home should be ftiven in every Instance. 



% 




1 



M 



4 



( ■ 







M • ak B • « • 



I • «■■ ■■ ■•K«»MA *^ fe M • ^Mk b ik ■ 1^ 



WRITL KLMIl^li-T wi I n ui>ir Mi^ii^va ii-^rx 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1)( 



(/(' /'V/r^/,DJLK.b^'^-OUuv..XD 1(J0\ 



Ii('gistercd jYo. 



l?Gi 



.^Cr^v^vo 



V 



■^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of IDeatb 

( "U. 5. StanDarC^ ) 



I 



City of L^^v, 



No. 



St.; 



Dist«; bet. 



— and 










1, 


o 


i 



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



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



n\< 



Col.uk \ 



DAII-: .W I',1R Til 



a. 



UjJkAjbi 



MEDICAL CERTIFICATE OF DEATH 

DAl'K ol- I)};ATH 



(Mnlltll) 



K 



TQO 
(l)av) (N'r.-iii 



At,!-: 



•A,0 

Ml. nth; T 



(l):iv) 



c< L ) V<7 / > 



I 



M.iutfi^ 



i\\-n\ ) 



n,r 



^^IN'.I.i: MARKIKI). 

wiDnw 1:1) ,,K |)iv( »Rri-:i) 

lU'tit' in >.ij<i;il (lcsij.»-nati<>n) 



HIKTHl'I.VrK 

'St:itr or <',,iintrv» 



NAMl- 111 
FATlllR 



'B 




<>' lArilKK 
(St;ih or Comitrv) 



MAII)i:\ NAMl- 

<"•■ M<>riii-:i< 



"IKiniM.ACH 

JM- M(rnn-:K' 

(Stair- or Couiilrv) 



f^CCn'ATlON 



\ 



I 1II;KI;I5V CMIKTH-'V, Tlmt I atU'ink'.l tk-ct-ast-d lioiii 

- .:. ' . ' .'...: ■ : ■ . ' . I9O to -...:...:.:.... : • :; .; .;■■:. ■ ..; ■■:'; ~Hp 

tliat I last saw h -Tr""" alive 011 — --r---r-rr-~-~r~---- ~ up 
ami that <li-ath (icriirreil, <»ii ihv datr slatr<l ahovi-, at 
M Tlic CAISIC OI'^ DI'ATII was as foil, .ws : 




■> 



-\.\- v, 



DC RATION )V(7/'.9 Mont In Pay.^ I louts 

CONTRIHrTOKV 



l'!f^iiit-i! ill Sail /'i iiin iM'ii 



);-,n 



A/,,ii//n 



n<n 



DTRATION )'t'ars J/on///s /hiys Hours 

(SIGNED) Uj. \9. ^ 



Crvs,>r>?wA„'^\-a 



M.D. 



T«>0 






Special Information only for Hospitals, Institulions, Irdnsifnts, 
or Recent Residents, and persons dyiny dw-iy from liome. 



' '",;, )'!V^'''' "^'I'A'n-.i) I'KRsoNAi, i'AKii< ri.AKs .\Ki-: i-Kii-: To TIN-: 
"i-.M ni- Mv j%>;()\vi,i:i)c,K AND m:i, n:K 



"■'("'••niMiit 



^Adilrcss 



b1>l.- 2>^cL di 



4 



Former or 
I'sual Residence 

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



flow long at 
Place of Deatti 



Dav« 



I'l ACK Ol- lUKIAl. OK K1<:Mo\AI, I DA 11^.)! IIiKiAl, -.r ki:Mo\AI, 

/i>kio. vTU^v^^rrL.uX. 



(Address 



N. B. 



Kvery Item of information .houlcl b. cnre?ully supplied. AGP. should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain term., that it m..> be properly classified. ^The * Special information for per- 
sons dyin^ away from home should be ftiven in •-wy Instance. 



Mhi- 



•*.*' 



'1 •■!ij 



ri^; * 



mi 



»■ I, 

11^ . 1. 



j».= ■ i 




I , 



H 






l« 



lawii ■ » » mt w m P^» wk.t ^* I Ikl ur 



-ruiie le a orDluiAIMrNT PFrORD 




^RUE PLAiNly Wiin ui^r/-»ufii^va ii^r\ iinw .w r^ . — 

No i^t^^J^lJ&I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

17G5 



r rili'ih 6 Jl\a±JL/v\ JLuv aO I'^O'i 



Eee^fsfrred A^o, 



^^,,;s riXA-'-vt Deputy Health Off^-^^* 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

City of H I Lt^va<X' ^ ^ ' 



PLACE OF DEATH:-— Cumity o f 



fNo. 




LavcLVv^.' 



St,; 



Dist.; bet. 



and 



I ^ ' ~~' i.eiiAi oc-CI nVlSir r riur FACTS CALLED rOR UNDER "special INFORMATION' \ 

FULL NAME V n/Y^-\K.lvL\A) vL. 0.\.CL1... 



PERSONAL AND STATISTICAL PARTICULARS 

Si:\ (\ A I Cnl.oK \ 






i>.\Ti. Ill liikTn 



AC.1-; 



Mnlllh) 



IDav) 



/\-,- 



5 V, 



Mouths 



\ till 



/).M 



^IN'W.l. MXkKIl-:!). 
WiDuW i;i) OK DIVdKCl-:!) 

IWiitciii •MH-iMl (It isivMiati'-n) 



/ 



HIKTll 



■i.\ri.: 
' '■initrv> 



NAM) (li 

I'Ariii.k 



HlKTlll'i \(K 

""■■ iaiih-.k' 

<St,itc or r,,in!trv) 



MAIlii:\- NAMl- 

"•' m<)i-iii.:k 



"IKTIII'I.AOK 
•>l- NK.TliHk' 



"^'*-"ll'ATlOX iPl 




MEDICAL CERTIFICATE OF DEATH 

I) A Ti-; «»!• 1)i;a rn ; , 

(Month) fl'-'v) (V.ait 

I HF'RJ-r.N' CI'IRTII'V, That I atU-iKlcd (Ifct-ascl hniii 



,: : ■: . ■ , ■ : . . I9O to ■-•■•• 

tliat I last saw h .—alive on —— " " 

.111(1 that iK-ath occurred, on the <lale stated above, at 
M. The CATS I-: Ol" DMA Til was as follows 



up 



1)1 RAT ION JV"''^ 

CONTRlP.riORV 



Moni/is 



Pays 



I Ion PS 



Ur RATION 



)'rars 



MiUitIn 



Paxs 






liiil 



)'riii 



.1 /,./////> 



/hi v. 



Ml, AIIOVK ST\li:i) J'KKSONAL I'AKTFiM- I.AKS AK Iv TK !' I". T<> T1H-: 
"KSl oj. Mv KN'()\VIj;i)C.K AM) in-.IJlvF 



""f'>nn;ml 



\1 RxxYtA^ V Lv. JjX/vVo 



(\. 



N. B. 




a.i^ 



<X^M.^ 



SIGNED )UV .^..^^^•^J^*-^''^>^'^^>^ „^ 



Hours 
M.D. 



4 



SPECIAL INFORMATION "nlv ior Hospitdls, InstituHons, Iransients, 
or Recent Residents, dnd persons dying .iwh\ from liome. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



T90 



n .\CK ()!•■ FUklAI, (.k kKMoVAl, LMU--! IUkiai, ... kliMoVAI, 

ll, ^. d 



rNDKRTAKKK 

(Adthfss 



E OF DEATH In plain term», that It miiy be properly cIbbsiucu. 



Rvery item 

state CAUS 

won* dyinft away from homo whoiihl be ftiven In ©very Instance. 



'! 



, 1, 





In 



» ' 



4 




f 



\/yR|TE PLMIINt.T ¥VI I n v i^ i ri w*i .^>- ..w.. 



lioindof lk-:>i!l 









Deputy i 



lOO'i 



THfS IS A PERMAIMENT RECORD 

R EFER TO BAC>^ OF CERTIFICATE FOR INSTRUCTIONS 

lirilislervd Xo, l7(>6 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)catb 



J (3i^ 



PLACE OF DEATH 



. County of Ja^'v JA.Ou^vcv<LCO City of JO^-^v J,\.o , 






HJV 



C^M.:|'\da.St.; Dist.;bet. 



and"" 






r or*TH occu^fe *w.v .i.oM USUAL RES.DENCEo.v. rACXs c^.^uu^co _-;--^J sT%".TiN'o 'n°u":b*er°"' ) 



/ ir DtATH OCCURte AWAY F«OM USUAL « ^ » I U t .-. v, .^ v- . - .. j --^ • - 
I, IF DEATH OCqURREO IN A HOSPITAL OR INSTITUTION GIVE IT. 

■J ( I I 



\ 1 



FULL NAME ^A-VlA,^ 



ii- 



PERSONAL AND STATISTICAL PARTICULARS 

1 ' :, t 

Aw',. » ^ 



DA Vi: I'l l.!k III 



AC.K 



\v^^ 



iMoiitlit 



) Vi; > . 



(I):tV) 



M.iulh^ 



(Year) 



Day: 



'^IN'.l,!: M\KKll-:i). 
WlDoWHU OR DIVnKrKI) 

'AVritf ill >.<>ii;il Mt si^.rii;it ioii) 



Hikriii'i.xn- 

(Stiito or ""Mumrv 



r 



L-^v 



t 



N'AMi; (»|. 
FATlll K 



»IKTin'|,\iK 

<>,'• J'aiiii<:k' 

(State ni Conntrv) 

Maii));n wmj- 
0^' M<)Tin:K 

"IkTHlM.XCi.- 

;»'•■ Mnrin-.u' 



(Slate- 



•" t'<nnitr> 



"^'^TI'ATION 




) V'(7 » 



M»uth^ 



f^r ^^idftl in Siin I'l an(isft) / in > ^ ....... .... 

IIIK \ii,,vF. STATKl) I'KRSONAK TAKTirr I.ARS AR K TRUK TO THH 

iu-,si ()|.- MY kn<)\vm:i)<'.k and HKMHK 




\-<CX 



^\<Ulrcss 



MEDICAL CERTIFICATE OF DEATH 

DATi-; oi- i>};\iH ( 



I Month ' 



. I /(JO 



I m-RI'r'V CI;KT11-V, That I aUcii.Uil diHcascd li.'iii 

to — ' Itp 

n^ 



up 

■ ali\r «»ii 



that I last saw h ~" 
an.l that dc-ath ocriirrcl, on the <late statcl al.nvr. at - 
;^I xhc CAISI' Ol- Dl'.ATII was as follows: 



.A. ^ 



■\ 



I )r RAT I ON y^'<^>'-^ 

CONTRir.rToRV 



Months 



/hns 



IIoiii 



1)1' RATION 



Years ^ Months 



Pays 



(SIGNED) UlV^vi^^ V 

C^xUt 1^ T9 oH (A.1.1r.ss) t^V^^^^A^ ^- W. 



I /ours 

M.D. 



SPECIAL INFORMATION onlv for Hospitdls. InstihjHons. Trdnsients, 
or Recent Residents, and persons dying av^ay from home. 



Former or Jv \t 

Usual Residence 15 VJ<xtY^ ^' 

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



HoM long at 
Pld( c of Death ? 



Days 



l.JLACKOl- lURIAUOK RKM..VAI. I nVTi:-! M-k.a,. -, KliMoVAI, 

P , -^ O-x^vb ^0 T90H 



^^^""^^"^^^^■^■"'■'■'■^■■■■■"■^"■^"■^■■^^^"^^^""""""^^ . t t d FXACTLY PHYSICIANS Hhould 

N. B F.very item o? information should be carefully supplied. AGB •^«7*' ;* f " ' ' •♦Special information" for p«r- 

•tate CAUSE OF DEATH In plain term., that It may be properly classified. The »pe 
*^r\% dylnft away from home Hhould be ftlven 'n svery instance. 



' 1 'M 



w 








I 




t 





I:' 




ia«l^i>ll II Kl 



WRITE PLMII>IUT vviin vi^. 

Itoinl of Health 1 N' 



r-A rM ivin IN 



9 9 -m ■'^09 « 



K— THIS IS A PERMANENT RECORD 



t-?^«^^ii'..'vi-r.. 



!)((/( 



' /wAv/, 6xlAljl/>-^l>-tN; 2wO V^O'i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

lie^ isle red Xo, ^ 7b7 




DEPARTMENT (JF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Beatb 

( TX. 5. StanDar^ ) 

J? (IST^ -^ ^ 

PLACE OF DEATH: — County ofU<CX/>^' JX<X/>A/^v^c Uty ot ^va. y 



'Na -^ i 






Dist; bet. U.U.^^>v ^and^;^^;^^.ci^. - 



St.; 



b 







FULL NAME 




^ 



\^a.>ulju J ^ 




O i ' . '' 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.oR \ 



DATF, oi !,':■; I II 



A(,K 






I ii I 



(Dav* 



M.oith 



(Vtai ) 



/'<;r 



^IN'.l.K. M \kl<H-:i) 
WlDoUKI) Ok DIXOKCKt) 

lU'ritr in -.ni;i; .i, vi^,,,;,ti,,n) 



lilKTMl'I.ArK 

'State or Cuinitiy I 



N'AMi: (»l 
FATlll.K 



'^'KTH('l,\rK 

^'•■' iaihi-ik' 

'Statfr,r C(.\nitrvi 

^'AinKN XAMi- 
*>!• MOTHKK 

"•KTUi'i.Ari- 
J'f" MnTni.:R 

""^XTl-ATiox ? 




\f\. 



^ 



K'f'hir d in San I'liDiiisi'o I i )>(/(> 

' '"• ^'«»VI•. srA'n:i) pkksonai, tar rirn.AK 
'" .i^v KNowi.HDc.K AND ni:i.n:i' 

1 
\<l(lresH .6^ 1 U AJl/WWCV. U 1> 



M,,>ilfis 



lhi\ 



S AKi: TKIK TO TMIC 



MEDICAL CERTIFICATE OF DEATH 

DATK »)!■ Dl'.ATH 

'I ' 

(Monti,)' ">='V> 'V.-;.r) 

I m-RIUJV ClvRTlFV, Tliat I atten.k-.l .Iccxaso.l from 

KyO to i<)0 

that I last saw li • alive- on ^'P 

MU.l that death ..rrurrc.l, on the .late- ^tate.l al,.>vv. at 
M. The CATSIC Ol' Dj'lATIl wa^ as follows: 



~J-r^K<V.W^\. "• • 



CONTRIIUTORV 



.}f0H//lS 



Pars 



( SIGNED )\Jf'^<rysJJ 



/hJVS 






Ilouts 

I lours 
M.D. 






.fc ^ 



SPECIAL INFORMATION onlv for Hospitals, InsfitiklDns. Transients, 
or Recent Residents, and persons dvinq anay from tiome. 



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- Bl-KIAI, OK K1:MoVAI. 






DVl'Ho! Hi KIAI. "I R1;Mo\A1, 

,-Jt, ^ f I no A 



190 



(Addtfis 



'^v^ 



^^U^ 



^-vv.. V. cv ', 



N. B. 



^ Ta ITf should be stated EXACTLY. PHYSICIANS should 

Kvery Item o9 information should be carefully fiui>plied. Auc. s ^^ "Special Information" for per- 

«tate CAUSE OF DEATH in plain term., that It may be properly classified. 
«on« dyinft away from home should be ftlven in -very instance. 



'Tr 






f 



t*,Di-rr PI AINI Y WITH UNFADING INK — THIS IS A PERMANENT RECORD 



RoiiriMM 11 ■111 II I .-Nw. 1-. ■'.->.«»--^^ 



])(ih' I'lled J 




./VW-' 



3.t 100\ 



REF ER TO BACK OF CERTIFICATE FOR |NSTRUCTtON3 

1?G 



lle^istcrcd J\''o. 



,trv<^^ XiAhi^ Deputy Health GfTiccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( 11. S. 5tan^al•^ ) 

City of^^CL'^^' J.^<X>\.CULCc 



PLACE OF DEATH: — County of' CL-n-vOA.'^ 






No 11^^' ^ r»^0^' . ' St.; Dist.;bet. JA.cLLi<\j 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 DBATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



) ij.Ui...L{..r:.\^ 



SIA 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.ok ' 



DAI 1. t >! l;ik I'll 



AC.K 



(Montli) 



)'i III 



^L 



(D.'iv) 



M.DllJl^ 



fV<-ai) 



Da 



^iN«,i,!:. M.\Kkn:i). 
wiDitu I.I) OK niv, >RrKi) 

(Wiiti- ill <.)ci;il (k-.ij.rn;iti<)ii) 




/cLfe 



k^^XJs\K^ 



Kik iiiiM,\rK 
(Stfitc iir <'<>iiiitrv* 



NAM)' (»r 
PATH IK 



HIKIllIM,\rF 
'>l' I All I).. K 
'^t;it' nr ("nillit! \i 



MAIDl'N NAM}.- 
<J1" MOTMKK 



JtnM-HI'I.ACK 
(Stall or (.■oiintrv) 



OCCri'ATioN \ 



II 



[^ 



^KXXsxrvxj^^ 



.<x^u 






MEDICAL CERTIFICATE OF DEATH 

DAT)-: oi- i)i;ath C' 



i<j< 



CJUxt it 

(MoiAli) tl)ay) (Year) 

I Hl'lRlvBN' CI'RTII'V, Tluit I atl«.M«U(l <l(.ixast'il liutn 



up . to k.,'^C|\.A,' . . I(^ 

alivf oti -I -*•• I ■'• - i</^ 

aiKl that death occuircil, on the tlatt- stated alxivi-, at ^ 



^./-..'-■i ' • 

that T la^t saw h 



'^M The CArSI", Ol" DI'iATH was as follows 



DlkATloN 



}V'(7;. 



Mont ha 1^ Days Iloura 

\jjZAjJ>JL . 3J..aJLoJw/.0«w1..u:s.:vv...":-, 



V 1 




<XO' 




r\ 



e. 



LCUv^ V 



y' 



X^O 




Ow'^'V'O^ 



/\f^iitr<! ill Sdii I I (iiii isri) 



) '/(I I 



Mniitir 



rin: ahovk statj:!) pkkson m, i-ak ri<ri. \ks aki-: \\<\ v. t«» tmi-; 

ItI-:sT O}- Mv KNoWMvlx-.H AM) lU. I.I l". J-' 



"nfoMuant VtKJL^viv 










x.i.irr^s Ib^C tk>cxq. 



VV V n_CL 



f 



I )r RAT ION 



Yciirs 






M(>>itJis /)(ivs '3. //o/as 



(SIGNED )UJY>"r\j j^,t>ci\. UkjL^;v,U^ 



M.D. 



Special information "n'y '«f Hospitals, institutions, Fransifnts, 
or Recfnt Residents, dnd persons dyini) dv^ciy Irom home. 



Former or 
Usual Residence 

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



How lonq at 
Pl,)( e of Death ? 



Da>' 



I'l.ACK OF lUKIAI, OK K1:M«»\AI, 



DMJ;..; Ill KiAi, or kKMO\Al. 



' iosiAllfV^,'v ^ 



'A<Mi» s>; 



/5uMrv\ 



N. B.— F.very Item of information .houlcl be cnrefully Huppllccl. AGK «houId be Htate.l liXACTLY PHYSICIANS should 
«tate CAUSE OF DEATH !n pinin term*, that it may be properly classified. The Special InWmat.on for p-r- 
Ron* dyin^ away from home Mhould be ftiven in every instance. 



Tr 




n 



'i 






I 



I 





^ 



Wf 



%*#D IT 



r PI AINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ho; 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







jRci^i^stcrcd A7>. 



17G9 



.10 ^00\ 

Deputy Health Officer 

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




Certificate of 2)catb 

( H. S. Stan&arD ) 

J? (^ 

:( in aa , . 



PLACE OF DEATH: — County of^ 'Cl>\^ Ax:).^\a./:^^cl City of U^O^v ^JX^<^v>vCA.<..<::. 



ity of O A r,\, 



(No. 



r 



,\X'cU (]b(^^K<-Lcx.*^^St 






Dist.; bet. 



and 



/ ,r Dr*TvJ\occuRS A«*v FROM USUAL RESIDENCE g.ve tacts called ;o« "-, '^^:il\')<Ho'^^Zl\T' ) 

\ ir deIVh occurred in a hospital or institution give its name instead of street and number. / 

FULL NAME 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ 



A 



I)\T1-; n| I. IK I'M 



A(,K 




H'; 



\ )V,/ 



t 



11 



( I):iv 



M.ml/r 



(V 



\ vi\ 1 



Ihn 



siN<'.i,i:. M \Ki<ii-;i), 

\VII)(»\\ J:|) ok 1K\()RI-KI) 

iW'iiti- ill sM.ini (lcsii.riiation) 




XxLcrVA>^^ 



HiKriii'i.An-: 

(Statt or Count ry'l 



NAM)-, oi 
l-ATII) R 



inKTlI|'i.\( J.- 
f\l- lATIIKk 



M\II»i;\ NAM}.- 
'•I Mnil|j.;K 



•»,'■■ MOTHKK 
•State or C"oiintrv 



OCCll-Aiiox 



\jy\jok^<Xy . 



kOLCC v.: 



(JLL 



MEDICAL CERTIFICATE OF DEATH 



DATH ol" I)J;ATH Q 



I0<^ 

(V.ai 



-A 



(Motitlil (Day) 

I ni'iKI'iHN' C1;RTI1"V, Th.il^I attciKUd <lercasc'«l from 

\... , ■ Kjo . to c)X^r\J; J '. u>o'v 

that I last saw h ■ alivr on ; u/J 

and that <Uath occurred, on the datr statrd abovi-. at t • 
M. The CAlSIv Ol- 1)I"A'I'H was as follows: 




ii^....-^^\j^oJi\L 



DC RAT ION 



}'t'(jrs 



J/()f///is 1^ /^avs I lours. 



c ( ) N '1- K 1 r. r T ( ) i^ \' ' ^-<^^ \-^. >-vA.<xlv 1 VI o 



e 



L/vAXyLxv^xxi^ 



\ 






Mnllth^ 



I 'J 



I'M!-. \ IK) VKSTA '!•}••, J) J'KKSONAI, I'A k'lir f I, \ KS A K I". TK t ' I". !< » rHl-; 
"'•.SI OI' MV K NOW M: I )(•,!-: AM) Ill'.I.IIlK 



'\.l. 



"J 



OJ\\j^'^,X I 



I )r RAT I ON 
(SIGNED ) 

6-, .t •' i.,o 



)V(//.? Months IH /;<m 



^A.^ll 





//ours 

M.D. 



fA.Mrc'^s) 



;» 



SPECIAL INFORMATION only lor Hospifdis, Institutions, fransifnts, 
Of Recent Residents, dnd persons dying Hway from home. 



Former or 
Usual Residence 

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



( Y'^V How long at ^ 

U ZO>J\^- Pla<e of Death? I . Days 




J,, ^CK OUJU-KIAI, OK KI;MoVAI, DATKo! MtKiAi. or KKMo\\I, 



«tate CAUSE OF DEATH In pinin term., that It m«y he properly cl«H«.*led. The Spccal Inform»tlon for p.r 
"ont dylnft away from home Hhould he ftiven in avory inHtance. 



-3 





1. 1^ K 

V 

\ 













i 



'i' 










rr>i-rr Dl AIN 



WW n » • 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



^^'sl^^, ns<.\' Co 



Board of Ht:iUh I N 

Date Fifr'f,OJL\< 

-\ 



±X>Wj<>v XD IfJCi 



REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

B>e^is(ered jYo. 1 TTO 



Deputy Health OfTlcer 

DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Beatb 

{ U. S. StanDarC> ) 



PLACE OF 



DEATH: — County ofO,C^-Y\. O.^c^cuicl City of 0^^^ A.0.'^ vculc c 




^ ^ -^ V^CrUu'^xtu. db ChMv\.Lo^i. St.; 

r 

(ir DEATH OCCUR9 *> 
IF DEATH OCCU«R 



Dist.; bet. 



and 



\ / .. n.... orruP, *«'*>', ^''^•-^^^^Sy^*,;: ?„^?^sT^,tu4n Cvt .TS NAME .NSTEAO or STREET AND NUMBER. ) 



kWAY 
IREO 



^ 



FULL NAME 



ijJLl 



L.O. 




^ 



L 



) \_ I 



SKX 



DATK ti! 



PERSONAL AND STATISTICAL PARTICULARS 
V - I COl.OR 



m 



li 



Ok.t. 






AC.}-: 






) ,/, 



1 



1^ 



M.nilli.^ 



J I. .; .- 
(Vcai 



/).M 



siNr,i,K. M \KKii-;i>. 

WIDoWHI) OK DIVOKrHI) 

(Write in «MMi;il <lf^i;.Mi;iti(iii) 



HIKTHlM.An-. 
(Statf or Cnnntryi 



N'AMK <)I 
FATlIi:k 



RIKTIIIM.A^K 
<^l' I'ATllIvR 

'State or rr,iintvv'> 



MA11)1-;X WMl- 

"I- MoTin;K 



iHRTin'I.ACK 
Ol- McVrHKK 
(Statt.- oi (.•()\iiiti yl 



OCCUPATION 




L< 







AXis. 



V 



I 



fyf'-iil rtf III Sail Finiuisfo olH )'i'ais " .yfoiilli 

I'Mi; AHOVK STATKI) PHRSONAI. I'ARTUM- I.ARS ARK TR 
"l-.sroi MY KN()\\I.i;i)C.K AND IJHMKK 

""foimaiit \j . 



Pii ys 



IK TO THK 







'\<M 



rens 



Lctu?V C^ OV) CKL^bcX-t 



MEDICAL CERTIFICATE OF DEATH 

DATK OF Di;Arn v 



Montll^ 



(Day) 



I go 

lYcar^ 



I ni'Kl'HV CI'RTII'V, Tluit ,1 ;ttU'H.K<l <U'iHaso.l fp-ni 
up to 3jL.\aI^' '. up 'i 



to c3jL.\a1' 

tliat I last saw h ^>>^ alive on ^^P 

an. I that doatli occurred, on the date- stated ahove. at 
M. The CAISI-: Ol- DI'iATIl was as follows: 



^.P^l^t 



.V^CX/> 



nr RATION 



Vtars 



Moni/is 



Pays 



CONTRM'd'TORV Gx^-b uv^^cii . at. M. - .. 



Hours 



„rRAT,..N ^ra.. ^ 
(SIGNED) J. ^ 



J/ti>///lS 



/hivs 



//ours 
M.D. 



Ojla-^ 



:l ri , 



90 



SPECIAL INFORMATIO 

or Recent Residents, and persons dying dway from home 



fsi only lor fWspitals, 



Institutions, Iransients, 



Former or "^ 1 f\ - 1 A !■ 

Isual Residence c^ V ^> \^^v 

When was disease contracted, 

If not at place of death ? 



Ho>« long at . 

Place of Death ? ^ Days 



n ACE OF BIRIAI, OR RKMoVAI, 




A.c^^i 



DA'^'lvof in KIAI. i)r R1:M0VA1, 



lAXiv of m 



TQO V 



UNDKRTAKKR 

(Adffresii 




(^^ ^^v 



^, 



llH. A,<:tct«^ at. 



.-^x.' ^L \. '. 



N. B Hvery Item o? information should be carefully •upplled. AGB should *JJ •*"'• "SDecial Information" for p«r- 

•tate CAUSE OF DEATH in plain term., that it may be properly classified. The »p 
«on« dylnft away from homo should be ilvsn In svory Instance. 





1 * 









! 



mi 



■i ', 



i 






I 



i 
I 



».,o.xr PIAINLY WITH UNFADING INK 

w» • • 



w» • • • • 




THIS IS A PERMANENT RECORD 

n^FER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

i771 



Registered JVn. 



Dale l-i/r<l,:^JL\\XjUxy^l>-Vv... Xb I'JO'i 

X^vvv.li.v^ Deputy Health 0-- 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( Ta. S. Stan&arD j 



PLACE OF DEATH: — County 



(No, I'l'^'^v ^JjA^yO- 



4 



F DEATH Q/tcURS AW*Y F 
ATM. OCCURRED I 



(IF DEATI 
IF DC 



ofOxx-r^j -'vcx^cviLCo City of'Jo.'-.-v O.VCWvev-J.c<. 
St.: ' Dist.:bet. '"^ ^<- and =H '" 



FULL NAME 



LZ 



( ' I "> 



C^ \^^^VlO 



PERSONAL AND STATISTICAL PARTICULARS 



SKX .X] 

DATK OF HI Kill 



COI.OR 



A : . 



a 



iMotith) 



AC.H 






\i 
(Day) 



Mntllll^ 






(Year) 



Ihn.'^ 



SINCl.E. MAKKIKI). 
\VII)o\Vl-:i) OK DIVoKt'KI) 

(Write ill ^fK-ial (lisii.'iiati<)ii) 



lUKTMl'I.ArH 

(State or Count ry 



NAMK oi 

fatiii:r 




.OL'CL 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- Dl'ATlI 



(\f()tith'> 



i^ /go 

(Day) (Year) 



I HI'RIIHV CI'RTII'V, That r iitteiuled (Icccasc'.l from 

\sj^,y ''x i9o'\ to Ax^ruU k:t> i()0 V 



that I last saw h .• alive on - ,Jl.^...- up 

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



U <xX^^wi-/Cv/v 




,o 



^IRTUlM.Ai K 
Ol- FATHKK 

(State or Oomitrv) 



MAIDKN NAMK 
OH MOTIIHR 



'nRTinM.ACl' 
J'l- MoTMKk 
(State or Country) 



OCCrPATlON 




rvcx/Tx-^xo- 



>Vw(/,^</ ill Siiti I'l am isfo \ if-^ )'i'iits 



d- 



M.nilhs 



Dins 



<) THH 




THK AnovE STATi: n PKRSONAI. I'ARTICn.ARS ARK TRl'K T 

iihsT OI- MY kno\vm:d(;k and bkmkk 

0.1 c^l VJGAAA a-TCt^ '^t- 

Tl '■ rr TT^ .Hould be utated EXACTLY. PHYSICIANS should 

W. B. F.vepy Item of Information .hould In- cnrelr'ully nuppMed. aud sno "Special information" for ^r- 

•tate CAUSE OF DEATH In pl...n term., that it may be properly cl.M.ficd. The p 
"on» dying away from home «1ioiild be given In •yry Instance. 



(\<M 



ress 



K. 



,> \ ^ 



or RAT ION 



nrRAllu.N Yt'aiJ ^- Months 

CONTRIIU'TORV AjjA.C »ue. '. 



Days 



I lours 



1)1- RATION ^^ ^'^''''r\^ '^^""^^'' ^ ^^''''' 



(SIGNED) 



A 



V>' ~X^ 1 > 



TC)0 



( 



Honyi 



M.D. 



A.l.ln.ss)^0»\jC^^^'^Ui^dv 



SPECIAL INFORMATION only lor Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dying away from tiome. 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatli ? 



Days 



I'l.ACH OF lUKlAI, OK RKMOVAI. 



DAp-;<))" MIKIAI, or R1-;M(>\'AI, 

CJXixt- '■'. 190 




1' 



•I'-;* ■ I. 



I « 



\ 



nM 



ill 



I i 



I 



...r^i-rr- Dl AINLY 
vv n I • ^ • — • - - - 









WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



PLACE OF DE ATH : — County of 



Certificate of Death 

City of /a'-uux.uXfc v.. <x ^ 




ria; 



V.L V 



^No. 



St; 



Dist.; bet. 



and 



) 



V^^v^^^'^^^^ --?^;^c;^-{^-i^^tr^ .^^" s?:^^-J?rr;r •• ) 



FULL NAME 



iXjjxjM^^... 




\ 



O^ a 



SEX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



m..x> V 



i 



DATK ()I- llIK ill 



ACH 







V) A )><;*> 



^0 

(l)ny) 



MnutllS 



(Year) 



/),; 



SINCI,!'. M.\KUIi:i), 
WIDoUKI) <>K l)IV(»RrKr) 

(Write in >^oii;il il(sij.'ii;iti()n) 



(Vcar) 




niRTMPKAOK 
(State or C'nintry^ 



A^cLc^^' 



XAMH Ol- 
FAT I IKK 



XjjJ^ 



BIRTH I'l, AC K 
OF FATin:k 

(State or 0(,\iiitrv) 



MAIDKN XAMK T\ 
OF MOTIIKR 






^a-c 



MEDICAL CERTIFICATE OF DEATH 

DATK <>1" 1)1-:ATII 

(Montll) 'I^-'y^ 

1 UliRl'iBV CI'RTII-V, Tliat I atUMi.kMl .Icivaso.l from 
- 190 —- 1., ^:::r::": -^np 

lliiit I last saw h ■ alive on ^'P 

and that <leath occurred, oti the dale stated al.ove. at ! '• ■ 
M. The CArSI-: Ol- DI'ATIl was as follows: 



t 



DT RAT ION )'i'^J'S 

CONTRIHITORV 



.!/();////." 



/hjy. 



Hour 



HIRTIIIM.A^ l- 
OF MoTHKR 
(Slate or Codiitry^ 

OCCUPATION (Q . 




V -... 






\ ! 



yfoiiHt^ 



/hn 



R fsid^d in San I'l iiii, in'o oO 'V-<7/.< '^""'"' 

THKAROVKSTATKI) I'KKSONAI, I'AK TFrr I^ARS ARK TRlH TO TIIK 
URST Ol- MY KN()\\-Ijl.:n(^,K AM) KICI.HCF 

(Informant \l PlA^^Q J XOL^^-U ^1 X> 



f\<l,l 



ress 






DT RAT I ON 
(SIGNED) 



Month> 



Pavs 



T()0 



(Address) .<XV.\.<L<X.U U V 



HoHt \ 

M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions. Transients, 
or Recent Residents, and persons dyiii-j away from tiome. 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatli ? 



Days 



I'l.ACEOF m-KIAUOR KHMoVAI 

SI 



^UCl-<!. 



Ji. 



I 



j,Av..n 






DAl'i; "t HruiAi. or R l-.M* >VA I, 



190'^ 



N N 



N I 



Mi»^^^^— — ^— ii^»^» * , EXACTLY. PHYSICIANS nhoulti 

N. B. F.very item of information should be carefully supplied. -^^^ "^**"' .*f|"d" 'xhe ••8|>cclal Information" for p«r- 

•tate CAUSE OF DEATH in plain term., that it may be properly cla8«.n 
«on« dyinft away from home should be ftiven in every instance. 







I 



' f 



il I 



I J 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Boiii 



,.■ ll>.i!tti I- No. !^ t-'^^^aan^^v-i^lU^l'Co 



]l('o'/,sf('/'('(l ^^Vo, 



1773 



Lv.^ iLv... Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( ^^. S. StanJarJ j 
V ^^ 

PLACE OF DEATH: — County of ^ 



(^ 



I 



No. 



Hi 



City of ^ '^' 0.\.CX>-v-aco 
^ Mv ^ ' ' . Sf • Dist.;bet. ^ V^Ou..*.-• andV ^ 

U ' L '^ "^ * ^„ -_D iiMnrR ' SPrCIAt INFORMATION ' \ 

/ ,, O..T- occu.s .«.v r„o» USUAL "S.DENCE -.t r.CTS c.LCO 'O-, -°^» 3=„%%% .„„ ,,„„. ^ 



FULL NAME 



\\ ' , 






[j^XXLi \1 1 Lt^v 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 








l\<xt 



.1. 



0, 



I « M IlIKTII 



Oxiv 

iMoiitli) 



vl 



\<.i-: 



ixM 



) V'<J » A 



(Day) 



M.Dllll!- 



■»\ai ) 



/><M.v 



Si\C. I.l-,. MAKKll-:!). 
WlDoWHI) OR DIVOKlKl) 

'Wiittin s(n-ial dc-ij.'nation) 




lUkpm'i.AOH 

(Stati- or Country"* 



\AM1-. oi- 
I" \i"iii;r 



Hl-itllll'l. \CK 

<»i- i-aiiii:k 

< Si.iif or Country) 



MMl)i;\ NAMl'. 

<>i M()Tiii:k 



lUKlIll'I.AClv 
<'l' MOTHKK 
(Slati- or Coimtry) 



Lol^I-CU 



.0^0.^ 




•TW 



'fV- 





i. 



n 







OL 



VLln , 



,cn'V>vc\) 



oCCri'ATloN 

k't'siiifil ill .S'liii I') inu isi'ii 



)'tii I 



yr.-ittii^ 



/hn > 



Tin: AHt)VKST\Tl.:i)I'KK^(.NAI, I' \ K lli" C I.A KS A K l. TK ' H I" '■'"■ 

HKsr oj. Mv KNo\\i,i;i)(.i-; and m:i,n.»' 










U(1<1 



ri"<s 



MEDICAL CERTIFICATE OF DEATH 

I) \'n-; t'l i>i. CI II 



V i I >- 



' M 



onth^ 



• Kavt 



1 |ll.;ki:r.V CI:KTII'V. Thai I .atcn.lol .Urtasra Inni 
up . !<• ^ * '"" 



alive oil 



tliat I last saw h 

^„,.,that.k-all,occurrc.l. on t hr Mat.-tatul al.nv, at 

(7 M Tlu- CMSI'-, Oi' 1)1 A HI ^^''^ ^'^ '"""^^^ 



IlyO 



DT RAT ION 



)'''Ul 



Mo>ilh 



Pay 



J lent 



c-oNTRinrToKV UacUwc^ -~<xV 



DTK AT ION 
(SIGNED ) 






M,utth^ 



/></!• V 



1<)0 






linns 

M.D. 



■ SPECIAL INFORMATION onM- Hospitals. Insfltulions. ir.nsirn.s. 

or Relent Mmfs, M persons dvin,^ ..hhv from home. 

lloM lonq dt 
Former or n^Kt fA Oedth? "<«^^ 

Usual Residence 

When was disease (ontraded, 

If no! dt plat e of death ? . 



IM.ACH nl IM KIAl, OK Kl.M'A \l. 



W,f:rf^J^ 



,,vn-. .' I!' I'l^i '" KJ'-M"^^'- 






•-V 



' , , I vACTLY PHYSICIANS nhoultl 

ATH In pl..in term., thn. it n.i.> I.e .r,.l.erl» 



N. B.— — Rvery item oif infor 

state CAUSE OF DEAT.. ... m- . mstnnce. 

«on. dyinft away from home should he ftUen m every mMtnnc 







0k lBk>* < 



^|:'J-M 






«» 



I 



.» 



^1 

f 

#1 




k. -^^-^, 




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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



II. . ■ ; .1" ll>.il(li !•" -Vo. i:; f'^^^^nSiV (^r, 



Ifufe Filed , 





6^^^.y\^\ 



XL lOO'X 



Deputy Health Officer 



J^of^isfci'cd A'^n, 



1774 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



11. S. 5tn^^ar^ i 



PLACE OF DEATH: — County ofU/<X/^\j ^KC 



(^) 



A ^^^ 



No. IS \i Oac\,<x>^-^. r' ^ '. 



City of '/<Xnf\/ vJ.vcL , 
St.; X Dist.;bct. ^b,lv<^ 



and 



/ \r Dt*TH OCCURS AW*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U^DER "SPECIAL rNFORMATION ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEaJ) OF STREET AND NUMBER. / 



.<x\ !■ 



FULL NAME 



trvx^A^ M ' A ^ 



PERSONAL AND STATISTICAL PARTICULARS 



l>l< 



'Alj; <>l I'.IKTU 




\ ' . !•: 



K. 



Montli) 



)>,.■; > 



LI : 

11 

(Dmv) 



.!/.<„///. 



' Vear) 



Pa 






^IN'.l.K, MAKKIl-.F) 

\vnH)\yi:i) or i)i\-.)Kii;r) 

U'l i!c in •^(K-ial 'lc>^i;M):iti.)ii ) 



IHRTHI'I.ACK 
iStMti or ronnlrv^ 



1 \tiii:k 



''•IkTUlM.ACK 
*>l I'ArilHK 




\Xy4^ 



MEDICAL CERTIFICATE OF DEATH 
DATK Ol- DI.ATJI 

iM'.nth') 'Day) 

I Hf'kl'HV ri:RTn'V, That I attcmlcd (kcrasf.l ir^nw 
Q - <-. ', \X: '.kI I ^p ■ to Q X^vt; Qls 

til at I la^t saw Ii • alive <iii , ■ icyo 

aii<l tlial (katli (icciirrcil, on tin datr >Ntattil aliovt-, at o 
\\ .M. Tlu- CAISI-: (.)!■• I) I.. \ III was ;,s follows; 



IcKlH 



0-C")Vc"»\ 



CONTKIIiCroKV V ^. O^ I ^ 



Pay 



I lOHf ^ 



MAFDKX NAMi-- 
•'I- MOTMKk 



I'-IK TMI'I.ACH 
"I" M«tTm.:k 



T> 



\^Oj 



li 




DC RATION )a<//v 

(SIGNED) \ J.-4A.\,0 






/hirs 



L L > 



L 



UoHt s 

M.D. 



u 



\<Xj "Xc t(,o H r \.Mn-.s) ^l : -V'.' '' 



? 



' " "^ 1 I'ATION 

k'f-hlf,! /,, Sim / 1,111,: ,■> ) , ,/ 



Special information onlv tor Hosplldls. Insniutions. Frdnslrnls. 
or Recent Residenfs, and persons dyinij dHdv Irom home. 



1/..//,'//. 



Former or 
t'sual Residence 

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



HoM lonq at 
Pidipot Death? 



Oa>s 



MK AMOXK ST ATI-: I) I' HK SON A I, I' \ K I' IC I ' I.A K s \Ki: IKCi; r< ) TJJK 
HhSI <»| .\jv KN()\\Ij:I)C.H AM) iJI.l.IlJ- 

L, A 



I'l.ACK ()!•■ lUkiAi. t>K ki;m<>\ \i, I i»\ii • !!(.i\r ,.t ki;m<>vai, 

^ 1 



Inf., 



Hi.-nit '^wXX/vC VC . 



Ci 



:\%-a^'-*x 



A.Mrc-ss lSl\ D-/C.\XX> >^-4/^vA^ * 



I ni)i:ktaki-;k nJ I ' . "• ., 



190 



N. B.- 



-Hvery item oV Infopmiition •houltl be cnrotrully Mupplifcl. MIV. nhoultl bo Ktiitnl f;\ACTLY. PHY8ICIAIS8 Hhould 
ntate CAUSE Or DIiATII in pliiin terms, that it may be properly clamiitr'ieti. The "Hpecial Int'ormHtiun" for p«r- 
Kons dying nway from home Hhould be given in every inntance. 







ii» 



mn' 



ra^Y" T' TIf I ^1 




f '•' 



!i 



^ 



t » 




.'- 



I 



.m 




WRITE PLAINLY WITH UNFADING INK — THIR i 
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

_^._______ REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



li. !!.:ilt)l \' So. Is-i-^^^^USi.]' i 



Ihilc Filed ^ 




AC l')0\ 

^v^ oLLAx.f Deputy Health Officer 



FiOi^isfcrcd Xo, 



i?r5 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of H)catl) 

( 11. £. Stan^ar^ i 



PLACE OF DEATH: — County 



of Ot 



,Aw<X>WCl '. ^ 



City of 



ll 



od. 



No. 



(IF DEATH OCCURS A 
IF DEATH OCCURF 



St.; 



Dist.; bet. 



and 



WAV FROM USUAL RESIDENCE GIVE facts called for under 

RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O 



% 



;/ 



FULL NAME 



\l.. 



i)'l 



. 1 



R "special INFORMATION" \ 
F STREET AND NUMBER. / 



-i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR ^ 




xxxx 

i' ^tj: <»!■■ r.iKTn Q 



Oxkt 

' Ntoiith) 



At'.K 



' 5V 



1/ 1 > 



[ 



(I):iv 



1A'»////' 



'W-ari 



/),n 



MEDICAL CERTIFICATE OF DEATH 

DATI-; ol' Di; \TU y' 

■.. I 1 I 

I m:Rl':i?V CI'KTII-N. That r atti-ii.U-.I .hcvascl from 

— t,, . . 






'I 90 



■l(>o 



^i^<.ij:. mark 11:1) 

\VII)M\\ i.:i) ,)K DiVoRCKi) 

'Wiitc in v<H-i:,l <l<-si;r„.,ti,,,i) 



HiK i"m'i,,\t'i<: 

' St:iif (,r I'ouiitiy^ 



\ WW. oi- 
• ATI11.;r 



'^IKTUI'l.AOH 
<'_••■ I'ArilHK 

(St;it< ..I r,)iiiitrv) 






tliat I last saw Ii ■■ ' alivf on ~*li/) 

aihl that di'ath occiirictl, on thr <latr >-tatr«l ahovc, ;it 
- M. The CAISH ()!• I HA Til was .■,>; follows 



DC RAT ION Yta)s 

coNTRir.r'i'okv 



Moulin 



Pax 



J/otu \ 



MAII)l.;x XAMK 

<>|- M()Tin-;K 



•'■IKTHI'KACl- 
<»l' M(»Tm1':k 
'State or Couiitix) 



"^"Orj'ATiON ^1 



\y> 



I )r RAT ION )V<//s M,'ni/i^ 

■ ^- \ ■ ^'' 
(SIGNED) \j . LI 

\ . .x^ I VA. i . I()0 



Pay 



M.D. 



(■ \.Mt.<v) -i 1 ^<>Cl....ctc 



Special information "nl> '<»r HospUdls. Invtifufions, frdnsiptifs, 
or RcfenI Residents, and persons dvini .ihhv (rrni home. 






) III I 



V-y////A 



/>../. . 



Former or n i A^ *^ 4 ] ^ , i I ""^ '""1 ''* 

Usual Residence l o J^ cJjA-CCt! Cx^ ' mr ol Oeath .' 



' "';,)""^''** STATi:i) I'Kk'^ONAI. PAR Tiril. \RS ARl! TR\ K in III I- 

iiJvsi OF Mv ivN>i()\\ij;i)c, H A,Ni) I!i:mi:i- 



Usual Residence 

When Has disease rontrarted, 
If not at plare of death ? 



Da>s 



' X.l.hrvs 



1?)1 




nL^^^-^'VA. 



.V. ii 



iM,.vi:K <>i- lUKiAi, (»K ki-;mii\ \i. I i>\ti ' I'.'iMM. ..I ki:mm\m. 



k 



-..L< . 



\ 



190 



\i)):r fAKi'.K y VI) . J O.A.^ i 



..L 



N. K.- 



-hvery Item of in (form at ion should »k- cnrelrully Hupplied. AGJi nMouhl he stilted liXACTLY. PJIYSICIANS nhould 
• tate CAUSE OP DliATH in pliiln terms, th«t It miiy he properly cluHnitned. The "Speciol InV'orniBtion" for per- 
son* ilyin^ away from home should he ^iven in every instance. 



^S.. 



' fet 



iHi 



-^i^ 



Ivl ■ I IllVllf'f 



ji'^ tn:$f>',i 




h "♦ 



t f^ 



»! 



S f 



X 



I' 



■ '7. 




WRITE PLAINLY WITH UNFADING INK — THIS I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I!,u!.!. ! llt.ilth- !•■ No. !> "J'^S^^ MS: I' Co 



REFER TO BAC»^ OF CERTIFICATE FOR INSTRUCTIONS 



/)( 



ffr /vVf'r/, 6j^^tjtv>JU.\; XO U^O^i 



liCi^isfci'cd A''(), 



ir76 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDcath 



( Ta. S. StanDarC* ) 



J on 



i 



0]^ 



No. 



PLACE OF DEATH: — County of U/ClA'\) J,Vxxavca^co City of C'XX->v Ox,<v . 
'5^" v.(.' t .,, St.; S Dist.ibet. vj ti^ltc-^v and 

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



M. 



^ 



FU LL NAME U/Cl^->'vlUlI M L<X.l!v'^ 



\ ; 



PERSONAL AND STATISTICAL PARTICULARS 

I COJ.nk 




L 



■'"^l"!: 'M l:iK Til 



xr.H 



I Month) 



.S 



J 't'lt I .\ 



(Dav) 



A/<»///n 



<^ /^ A, 

/b5 3, 



11 



fViai) 



/),/!. 



MEDICAL CERTIFICATE OF DEATH 

DATi-; ()!• ni; \ rii , 

iMoiilii) >Uuv) 

I JIl'iRI'HV Ci:kTlI"V. That I .iltni.KcI .Urr.i>.r.| Ir-.m 






^IN'.I.I-. M.\URI):i) 
\\ llXiW l-.i) ,,K DIVOKCKD 
\\ lit. Ill social flf.sivMiatioii) 



lilt-; riiiM.AOK 

<Sl,itt or (.'oiinti v) 






''•II<rni'|,\rK 

•" I \rMi.:R' 

I stale or I'oiiiiti v) 



1 




l<XAAxjL'CL 



1 

I 

(hat I last saw li 



>:U4 



vl 



I()0 



\(p (o 

aliw I 111 ■ . \Kf\ 

and tliat dcalli i xcii i iimI, nii llu' datr s(ali<l al)(i\c, at O 
Lv M. The C.MSI-; Ol' \\\: \Tli was as foil 



S 



LL^^^ c ^'X>A,.5^^Q .. . . ._,. 



|i >ws ; 




X>V/>^a.OL TVU 



^UvLc/vv • ■ - 



I . ' I 



oX\ 



.? 



va .. 



DIR.ATION Years 



M<>iit/r 



/hn 



/ /t>l(t V 



MAIDKN NAMK 

<»!• MuTlIHR 



'!'HTm'l,..\(>},' 
".'■ MOTin:K' 
'State or CoutitiA ) 



"^ ^'I'ATION-Qlfpi 




U' { 

^'rsn/,;f in .S,ni /'niihism ^\ )/■,/;> yf.nith 



DIR.ATIO.N 

( Signed ^ 



[<)') 



)'tais M<>)itlr 

I \>l(It«ss) L 






/'./l 



//out \ 

M.D. 



Special information "iI* ''"■ HospitdK, Inshlulions, Frdnslmfs, 
Of Rfffnl Rpsidenls, dnd prrsoiis dvimi .iwhv tnni homf. 



/',/ 



' " li.^J!!.'^ ''• '^''"^ll" PKKSONAI, !'AK ridl, \Ks \K j: IKI l! l<i III I- 

"hsroi.- Mv KNOW i,i.;i)(;j.; wd iii:Mi:i- 



"iif..,niaiit C 






former or 
L'sudI Rfsldfncf 

When was disMSP ronfrarfrd, 
II not dt pld(f ol drdth ? 



lioH lonq dt 
PIdif ol Ofdth? 



Odvs 



I'J.Atl-: <li-^ Ml KI \I, ( iK KIMi>\ \l, j I»\l\>;..! I»'i'i\i .,1 ki;Mit\AI. 

)/Ouy\j VC^N^X V^CV^ I ' i ^' 









'^' "• Kvepy Item ni lriformntion ahoiilil be ciirelfiiMy Nupplicil. \C,t, Hhaulil be Hliiteil I.X4CTLY. IMIYHICIANS iihoultl 

Btatc CAUSE 01= DI:A TH in pliiin terms, that it may be properly claMiih'icd. The "Special liilformHtion" for p«r- 
won* flying away from home Hhoiild be j^iven in 9\ery inntance. 



>.. 



i 



fmn" 



..iHm^M. 



'T' '•" m f 



.^ 



M i 




r, 



If 



'1 






i 




L 



/A,/,' /•V^v/,C)X' 



WRITE PLAINLY WrTH UNFADING INK -THIS •■ 
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 






Y\Xxrv>rJsjAJ' 



hj „X0 100'{ 

Xtrv cv^ Xla>u Deputy Health Officer 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiticatc of IDcntb 



s 



No 



PLACE OF DEATH: — County of 



( U. S. St.nnCavP ) 



City of O O 



St. 



Dist.; bet. 



0? 



and 



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



IRRED IN A HOSPITAL OR INSTITUTION GIVE 

FULL NAME 



o.v :.- V 



-^1 \ 




PERSONAL AND STATISTICAL PARTICULARS 



'\< 



■' '^ i I'. ' 'I It I Kill 



A(,i.; 



iL 



LLJvdu. 



MEDICAL CERTIFICATE OF DEATH 
DATH Ol- I)i:\III 



iMoiitli) 



I 



) I'll I 



(Dav) 



lAo////^ 



(Vt;ii I 



/ OO 



/>,n 



•^'^■"•i.j:. m.\rkii.;i. 

U IDnW ,.;i, n)i DIVORCKI) 
\\ 'It. in ^.H-i;il 'ifsivMialion) 



"^1 it( or C.niiitiv'i 



\ini-;R 



"IKTMlM,\rK 

•"■■ lAriii.-.u' 



<»1 Moi-in-IK 



'"•< rui'i.Aci-" 
",'•■ m<'Tiii;k' 

'Miit( or Coimtrv) 




/WOL'CL 



(Motit'lii (Day) 

I iii:Ri';r.v c"i;r Til w iimf i atu-n.ir.i .ic.r.M.i ipuh 

tliiit I last saw Ii . alivf on i(p 

and that lUath tK-tiincd, on tin- date slatt-d aliovr, at '-' 
v3 M. Tin- CAISI- OL" Di: \I"I! \va>> as follows: 



a 



'y\jxjL , ,■ V L o- 







XV r I , 



'>* "^'I'A ri,,x QC) 



V r: ) V 



i 



1, 



A 



I )r RATION )',n< Mx'ilhs 

(Signed ) LL<xvk J)ac\,>v 



/>,;i s 

PilVs 



I lOKt 



/ fiiUt \ 

M.D. 



A 



_>, j V v . . I < jo 



f Address) I 111 1.' V V»-, si Cv 



Special information <>n'v t'»r llospifaK. Instilutions, Irdnsirnfs. 
or Recpnf Residenls, dnd pfrsons dying anav from homr. 



/'(/ 1 



Former or ( V , 

Usual ResidencfO VC\' V ^ ;. 

Whfn K3S diseasp (onlriicN. 
If no! af plarf of death ? 



lloH long al 
Plare of Ofdfl) ? 



. Od>' 



"in.^J-p'y.^.^''"^'''-'* »'H«'^<>\Al, I-\KThli.\KS AKI-: TKI I- To Tlli; 

"».M Ol. Mv Kxowi.i-.Dc.K AM) iti:i,n:(. 



"•'f'.Mnant VuWi ll' J ,-C<X'^v.' 



ri.ACl<: HI- lUKI \I. MR Rl.MoNM, 

LouJt 



A«i<ir«-ss UouMj vy. 



\-<X^WO^ ^J I 1. 



A 



ni)i:ktaki-:k \I V AXXal 



I) vri-; •>'. II' i.'i \i .11 R i:m( i\- m. 



IN. fj. fivcry Item of Information ahould bf carefully «upplic«l. ACJfi Hhoiiltl be «tiiteil EXACTLY. PHYSICIANS nhould 

«tute CAUSE OF DEATH in pliiin terms, thnt it may be prf.perly ciaMKificd. The "Special Informntlon" for p«r- 
"on* flying away firom home nhould be iiiven in every instance. 



LOCAL I TY OF 



RECORD S 



SAN FRANCISCO 
COUNTY ' 



SAN FRANCISCO 
CALIFORNIA 



TITLE 



ATH 



OF 



RECORD 



CERTIFICATES 



I CROF I LMED 



FOR 



THE GENEALOGICAL 



SOC I E TY 



SALT LAKE 
CA L I FORM I A 



C I TY 



UTAH 



DATE 




APRIL 



PH OTOGRAPHER 



1975 

MAX JOHNSON 




CAMERA ■no2683 




RED 



VOLUME 



1678 



2030 



LOCALITY OF 



RECORD S 



SAN FRANCISCO 
COUNTY 
S AN FRANCISCO 



CALIFORN 



TITLE 



RECORD 



I CROP I LMED 



FOR 



THE GENEALOGICAL SOCIETY 



M 



SALT LAKE 



C I TY 



UTAH 



C A L I FORN I A 



DATE 




APRIL 



PHOTOGRAPHER 



1975 

MAX JOHNSON 



CAMERA 




NO 



26831 



RED 



VOLUME 



1^78 



2030 



^f*:ji.S!^ 




I'^iW 






H 




% 



'J^P 



ffl 



; 



WRI 



TE PLAINLY WITH UNFADING INK^THl?^ 155 1 



M 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

I lilt h- J" No. 15, ■J'--:«r^, USi.V Co 

'""^"' ^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ddfr /u7e(/,P)x, 



.Crvcv.^N 




„X0 IfJO'i 



Deputy Health Officer 



lie<^i,s/crrfl Xo, 



i i 4 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 



No. 



I tl. S. StanJav? ) 

f 

PLACE OF DEATH: — County of City of ' ^ 

' '■ St.; Dist.; bet. and 



LUjL^\,(r^\ 



( 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



■ f X 




D 



C'OI.OK 



loJU 




1 



•^ II "I IJIUTII 



iMoiitlil \ 



\Wu^JL 



MEDICAL CERTIFICATE OF DEATH 



(I):iv) 



rV 






] I'd I 



.!/,»>////' 



iVt'.'ii) 



/',M. 






i>.,\ 



I I.H > 



■ '^<-l,i:, MAKUIKI) 
U IIxiWKI) OK I)I\-«iKiFI) 
\\tllr III s-H-ial .l.^i>.Ml;iliull) 



•"!< III!'I,A0K 
'!^t;lt< or Coiiiitry'l 



■ \M1-- 01 ■ 

: \rni:K 



"IK IIII'I.ACK 

'"•" 1 Arnivk' 

"^'■'i- "t I'oiintrv) 



''' \ii'i:.\ \ \M}.- 

<>l' MOTFIKK 



'I'KTIII'LAll-- 

'"■ motiii-.k' 

'^••'1' "r t'ountrv) 




k^ulaL 










(.Monni) 
I m:Ki;i{V ti:RTI|-V. That I attni.Ir.l <lr.r.iM,l l,..ni 

that I la^t >^a\v h ■ ali\c(>ii i,^) , 

ami that drath « iccurrfd, i.n tlic ilair --talrtl alHi\f if 



a 



M. The CArSl', {){■ \)\ \TII \v,,s as folluus 



W^X^L 



II ! 



DTK A I* ION 
CON'I'k Il;ll 



) '<ai 



M.01//1S 



/hjv^ 



//, 






, M. 



); 



(US 



di'kation 

(Signed) L LolVH vj 






/-"./rv 



M.D. 



V, ^ 



±1_ 



. I<;o 



X-I.ItVss) I13vl X}.< \.'. ^ ^ 



Special information <»nh tor Hospifnls. Insfilufifins, [rdnsirnfs. 
or Recent Residents, dnd persons dyinq .rn.iy from home. 



"^*<'' I' AT K.N ((5?) A ,, 



/\'f-idf<! Ill S<ni I I nil, lu'o 



),-,ti< 



Mnnth^ 



n,l\: 



'''HFsVyu'';'!"x^''"'''''*'-'<^'''^^''I'^»<lirri.AKSAKi:TKI I^ T 
•".^I 01 MN KN<)\VM:I)C,K AND HKMI-F- 



n 111): 



former or ( v 

I'sual ResidenfcVJ M\n, ^ 

When v*fls disease rontrdrfed. 
If not at plate of deati) .' 



HoH lonq at 
Pld<e of Ofdfh? 



Dd)s 



I'^Z.OJ'Ov 



'A^<XywqA 



PLACl-: <)!• lUKIAI, <iK K' CMi i\ \ I. | DVIi;..! il 



M)i;ktaki:k M v sJ 



: la ^!^ i\ \I, 



AXXv^ 



^\<M..sv SSl a^M. ' 



' rivery item of inforindtion should be ciirefiitly Bupplied. AfJK hHouIiI b« Htntc.l I.XACTLY. IMIVSICIAINS nhould 

state CAUSE OF DKATH In pliiin terms, thnt it m»y he properly clnHKit'ied. The "Spewiiil InltormHliim" for p«r- 
«'>n« dyinjt away from home nhotild be fciven in vvcry instance. 



'V 





^^^ 



,» 



#f 



^ 



*« 




3 .1 



WRITE PLAINLY WITH UNFADING INK -THIS ,s 1 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoar.' .'■ IK.! 1th \ St) i-^ ■*"f'-»'-'4-^- USiV d) Bt-t-r-r^-.^ « . -. . 

REFER TO BACK OF CERTIFICATE FOR I fVS TRUCTtONS 



Diih' Filed ,^x}' 




,X0 VJO\ 



1777 



(rvcv^ Xov>-M Deputy Health Officer 



DEPARTflENT OF PUBLIC HEALTH-City and County of San Francisco 



No. 



Certificate of H)eatb 

I U. S. StanOatJ i 
PLACE OF DEATH: — County of City of 



n u.A 



Vfr^^- 



1 i 



. 0> 



'^ ■ ' St.; Dist.;bet. 

A IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V F FACTS Ci 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N 

FULL NAME 



and 



ALLEO FOR UNDER SPECIAL INFORMATION 
AME INSTEAD OF STREET AND NUMBER 



) 



PERSONAL AND STATISTICAL PARTICULARS 

n 1 coi.oK 




'I r.iKiii 



il 




fvdjL 



'Month) X 



(I):tv) 



/ ^. • 



I- W )>,/;> 



Mnnt/r 



( Vein 



Pa 



\V !I>"\VK1> OK DIVOKiKI) 

\\ntr in M,cial fksi^Miatinti) 



'•^\-Mv <n Countrvl 



!ATFn:R 







MEDICAL CERTIFICATE OF DEATH 

DATi-: (»!• ni:\rii 

■ , i I / ()( > 

I HlvKKlJV CI:RTII'\\ Tli.ii I iiir.i.lcl .U.,;iM ,| ti..,ii 

.U,A..Vn . u,n t,, .) tk' u,i, . 

tli:it I last ^aw 11 ■ ,ili\( <^\\ • jcp 

and that dratli (iciMinc-iI, mii the il.ii. vt.itr.l aliovt', at C» 
*0 M. The CWISh; Ol' |ii:\TII was as tV)li..u^: 



hirthpu.vck 
*"• iatiikr' 

'Stat. .,r Coniitryl 



'"' MOTIIKR 



"'•' motiikk' 

"^tatr or Countiv) 



^ -U^"Yy^^Y\X\j J <XVo 



1)1 R A I'M). \ "^ )',u/s 



s 



coNTRinri'c 



»R\- LivV^^v•^ 






I/om s 



'X\jy 



> ^ 



\\k.k 



DIR.XTIoN )',.iis Months 



/></! 



(SIG 



a . ' 



NED > L.L<X-Vk J)a*^V>\^Ko. . 



Hours 
M.D. 



1, 



:j^,t\.l. . i,,o' rX.Mit'Ss) nil ,.L' A \>'.-^. Cv':' 



X 



Special information '»"'> '"^ HospifdK, Insfitutions, Frdnsifnfs. 
or Rffpnt Residents, and persons dying away from home. 



OLl.-...l 



/^''■iifrd /// San /'i ,iih iu-.t 



)'iiu s 



M.nith^ 



/;>\^ 



Former or ( V , 

Isual ResidencfO VC\,n.O>.. . 



'.>^ 



HoM long at 
Plate of Oeaffi? 



Dd\> 



"liKj-r*y>','^^,''"^''"'-^' J'HKSOXAI, PARTKTI,ARS.\RI-: TKIJ- T< • Tlli; 
in.sroi. MV KXOWIJ.-.DCK AND HHI.II-K 



Wfien Has disease contracted. 
If not at place of deatf) ? 



(Add 



ress 



tcod. 19. 



V.Ow'WO^ 






Li,.\ci-: OI" iHRiAr, OK ki;mo\ \i, I du'i;.)' imkim .t i<i:mo\\i, 
I ni)1-:ktaki-:k M V \jAxxj^ 



r\<i(ins« o51 cVJ 



I 



N. B. Every Item of information should be carefully Hupplie.l. M.V. hHouIiI be stated KXACTLY. PHYSICIANS nhould 

state CAUSE OF DEATH in plain terms, that II may be properly claJi«ified. The "Special InforniHtion" for p«r- 
«on« dyin£ away from home should be «ii\en in every instance. 



h 




W\ 



IL'tff" 



'4 > 



¥' 








WRITE PLAINLY WITH UNFADING INK — 



1 



Ho;i' 



THifc; Id 
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



/}fi/r Fih'il , 6.JL^xtji^^^Ljj^\j l.O. 



7,9(9 'i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Boiiistcri'd ^Xo. 



\^^^K^Kj^ \sj\^x Deputy Health OfTicer 



1778 



DEPARTMENT OF PUBLIC IIEALTH-City and County of San Francisco 



(^ 



Certificate of 2)eatb 

( "U. 3. Sta^^nr^ ) 
PLACE OF DEATH: — County of J a City of ' 

^^* ' St.; Dist.;bet. and ' ' 

r 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 \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



( 



FULL NAME 



n 



n 



PERSONAL AND STATISTICAL PARTICULARS 




Ii\l'! ( .F r.lR Til 



\ I . »•; 



MEDICAL CERTIFICATE OF DEATH 

DATl-: <•! It]-: A TH 






< y 



/^ >- 



iMnlltll I 



)V,/,. 



(Dav) 



Month.' 



'Vtar) 



/)./!< 



\ni)«)\vi:i» OK DivoKn-n 

'\\'it< in siK-ia] (U'si^iiatioii) 



'•'Xl'HI'I.AOK 
^tat. .,r Cumti v» 



' M'lniK 



''>>Ki"HIM,A»,"K 
'»• I'ATHKK 
(Stat. f)r Couiitiv) 






'"HTlIl'r.ACl-" 
•»'•' MoTHl-lK 
^latc or ».-(.niitrvl 



"^'^•fl'ATlOX 




() 



iMnllttv! II, \1 

I IfI-:Ki:i'.\' C i:RTli"V. That I attin.lr.l .Icr,,,-,^! Ir.-m 

..\|. iLO... \yp to . V I ■ V rifT) ' 

that I hist saw li ■ alive on i,p 

ami that death occurrcil, on thi' liatc sijitrd alMi\r ,it 10 
vX M. '11k- CWISIv ()!•■ Di; Aid wa- as folic. us; 



Dik \ii()\ 



) f (// s 



Mof/f/i^ 



/Kn V 



//. 



o/n s 



CoNTKir.l ■]'( tk\' 



sCL ■ V o 



( 



DC RAT ION y^iirs . .)/,>>///,. /).n< ll.n 

t ' 

(Signed ' \ - ^ ivi.D. 



^ 



Special Information ""'> lor Hospitdis. inshfufions, rrdnsipnis. 

or Recent Residents, dnd persons dving dwdv from home. 



} ^ 



y.-,u V 



M.'nlh' 



/\t\ 



"livJ-r'Y.^.^'"'^ ''''■■'* ''HKSONAi, I'AKTItri. \KS AKI-; TRt I- T( » THK 
"hsroi- MV KNoWI.lvDC.K AM) iii:ijj:i- 

(Arl.lrcss i^OH \j(S^t '.)i 



former or 
L'sual Residence 

When was disease ronfrarfed, 
If no! at place of death ? 



ItoH long al 
PIdfe of Death.' 



Ddvs 



liifurni;mt 



^ 



rr.ACK ox HtKiAr, ok ki .\i<>v \i. 



TQOH 



1 1 \ I'j: m; I!' K! \i .11 K i-;m( >\- \i, 

n-I)i:rtakkk V'L LI !IVa.\ 

fA.l.lt.ss o I "^ U J ol-vnjlC^ t 



N. B. 



-Every Item of informntion should bf cjirefully supplied. \V,V. hS<miI«I bo Hinted I.XACTLY. PUVSICIANS Hhouid 
state CAUSE OF DEATH in pliiln terms, that it may l>e properly claiiffilrMed. The "Special Information" for per- 
sons dyin^ away from home should be Jii\en in overy instance. 






*«ll 



t»rt* 



,H' 



' 4 




^ 



i' 



■M 



u 



WRI 



TE PLAINLY WITH UNFADING INK--tmi« .c. 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Bo:ti<! . .r' \\, ...\\ h »■■ \o 1 1; l^aBh-iS) ){& 1' c 



REFER TO BACK OF CEWTIFICATg FOR INSTRUCTIONS 






lici^l.sfei'ed ^Yo, 



i ^70 



Deputy Health Officer 



DEPARTMENT OF PUBLIC IIEALTH-City and County of San Francisco 



Certificate of S»catb 



o 



City ofV '<X>\. ^'^ n . 



PLACE OF DEATH: — County ofvJ<X^v On r 
^o. 1.^C ,,^- St.; Dist.;bet. and 

/ IF Ot*TM OCCURS AWAY FROM USUAL R E S I D E N C E G I V C FACTS CALLtD FOR UNDER "SPtCIAL INFORMATION' \ 
\ ir DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



r^ 



FULL NAME 



.C4jL(, 



■ I \ 



PERSONAL AND STATISTICAL PARTICULARS 

A 




'1 r.IRTM 



X'.i-: 



I, Nl out hi 



M 



) r,n > 



1 






M.'itlh' 



MEDICAL CERTIFICATE OF DEATH 

DAT!-: 01 I>i: A I'll 



fM.Mlfllt 



II 



I (JO 



I iii;ri:i:\' n:uT[i\, tik.i i mcti.ic.i ,it. r,is, .i mmmi 



!(/) to 

tliat 1 last -^aw Ii ali\i' oil 



lij' i 



/'„ 



\\Mt<' IT. MH-i.ll .l.sij.Miati.)Il) 



"nn-ni'i.\(M-: 

^'•it< or '".iimtiN-i 



' \ TIlJiK 



''■IKTHI'I.ArK 
••' lAIHl-.k' 

'^>;it« or r(,iiiitrv> 



"^"'ll'I'N- XAM).- 
01 Moilii-K 



I!IRT|II'I.AC-K 
;"• ^»•>T|^■:K' 
^'•il' or romitrv^ 



'"■^■'I'ATION 



. 1 UxwoL<i 



aipltliat tUatli ixriirrcd. nii t lir «! iti' statrti almNi-, at s5 
vJ.. M. 'I III' CArSP; i)|- IH' \lll \\av ;,s f()II.,sNv: 






I )l RATION -^ )■/■<//>, „ .\/i>n//i.^ 
roNTRIIUroKN' • 



/>■/) s 



/ It'll t \ 



SLCkAx. 




\ 



(j CrTWT>xCL'L^a • 



1)1 RATH »N 
(SIG 



/\iv^ 



) ttUs Mini (/is 

NED ) -A. X). ^iDaCA^q 

( \,Mi.ss) vG-S Ld* ' • 



Ili'Hi \ 

M.D. 



I ()( I 



Special information ""'v '"f H(»spitdls, Institulions, Irdnsimls, 
or Rffent Rfsidt'nis, nnd persons d)ing Ay>A\ Irom homr. 



'sf^iitf,! ni Sail / I, I, •,!,,, j, .) ),,//. ■" 1/..-///. 



A', 



/',.'i 



formrr or 
Usual Rfsidrnrp 

When was diseasf ronlrat fed, 
It not dt pl<ii T of drrtth .' 



Hovi long ril 
PIdi r ol Drdth .' 



Odv 



'''■ )'!''^''"- "^'i'Ai'i:i) iM'-Rsi.N \i, i'\Kiii-ri,\K-« \K)- ruri: r<) tin: | i-i^ac)-: <ii iukim, ok kim"\\i, 
'ii-.M <)i-^i\- Kx,,^vi,):nt.i': AM) i'.i;mi;i' 



Inf. 



'Mii.-iiif 



■j 'i 



u 



xi^ii.^. 1 5 1^ 



.VA ^ 



A-(r~> V 



1. '\t 




i> \ 1 1 









I M 



I Ai|<!i« -.v I 



M. II. 



fivepy Item oi inV'ormiitlon •hould In- cnroltully Hiipplio.l. A^JIi Mhoiihl ho Htiitcil hX^CTI.Y. PMVSICIAN8 Nhoiild 
HtJite CAlISi: 01- DI;A TH in pliiin Icrmn. thni It mny l»c nropcrly dottuh'leil. The "HpcciHl Int'ormHl'i.in" for p«p- 
«on» <lyin|l uway ItVom home Nhoiild he ^iven in gvery inMtHnce. 



>: 




. J L. ^ . 



smm 



K 




* .1 







WmT.PC.,^„vw,THUNMO,Na,NK-rH,S..i 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 



J? 



Ihf/r /^y /('(/, a J^^tL^xAMA, 11 /f^0\ 




REFER TO BACK OF CETRTinCATE FOR INS TRUCTIONS 



i • > )i) 



<^'^ oLJlaKi 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=Citj and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County of 



-^ 



U. S. StanC>arC> 



1^ 



n 



'.\ 



f. 




City of Clo. 



V 



No. O'VcC^vxial c^.CMxXYv.4.a.V St.;— Dist.;bet. and 

( "" r/ol" OCCURS AWAV FROM USUAL ftESIDENCE give facts called rOR UNDER SPECIAL INFORMA 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMB 

^0 



TIQN 
ER. 



FULL NAME 




) 



■>\J 



PERSONAL AND STATISTICAL PARTICULARS 

COl.Ok, 




1 



'! II I KIM 




/ L 



/ o< > 



I Month) 



\' I 



J 'tin 



(I>av) 



M.oiths 



^ |i)(.\vi;r) .)k iMVoKcj.-r) 

^^"t.ui snriMl -i.sivnati,.!.) 



\\v:k\) 



lhi\ 



"IKTMlM.XtM': 



i^t-iii- .1 



I ' "iiiiti \ I 



' Vni|.;K 



'».'■ l-ATirHK' 
(Stalf ,,r (.•uuntiy) 



•»l MOTlIHk ' 







!■ 



-l 



MEDICAL CERTIFICATE OF DEATH 

i> \ I i; I M !»i: \ Til 

■ ' ., I I ' ' 

1 lli;Ki;r.\' ti:RTll"\-, rii.it I .it(cii,ir.Mrr,;.MMi In. Ml 

I */' ' " I < K' 

tli;it I lasl ^;i\v Ii ali\c on i,p 

.111(1 tli.'it death iicciirrcil, dm iIu- ii;it( st.itid .il)<>\f, at 
^r. Tlif CAISI-: ())■ l)i; A III was as follows: 



-J 

r ■ 
P 



r 

r 



1)1 RATION Yrais 

CONTR IIU TORN' 



1)1 RATION' . y,iir% 



Moiif/n 



/>,/! 



//, 



(>U> \ 



■¥j 





r 






M^'nlli 



/hiv 



"IKrillM.ACK 

•'I- mothkk' 



(Signed) J.\xd.ev 



1 1 1)11) V 

M.D. 




C 



'^0 „ 



I<)0 \ 



\,|,lr,ss) ICA. ^ 



Special information «"'> lor HospitHls, Inslilutlons, Jrdnsirnls, 
or Rerent Rfsidenis, dnd prrsons dyinfj .iv».i\ Iro home. 



I ; 



Mnnth- 



n,i\ 



formpr or 
L'surfi Rfvidfncp 

When Hds disMSP ronfrdflfd, 
If not a( pld(Pof dfdfh ? 



HoM lonq <<( 
PIdff of n<-.)th .' 



nd>< 



'"^i <>»• M\ kn<>\vij:i)(.i.; AM) h):mi:i- 



K I' iKi ]•: T«» lit !■; 



Inf.,.i„;|Ilf 






i'j..\CK<»i- m Ki\K<iK Ki;Mi'\\i. J i)\ij ..; Ill Ki.\i ..I k);M(i\ \i. 



^AC > V ) 



t 



M ) I : K TA K I-, K \1 I v<X\.^^ J O-'tr V'. 



'Ad.Iics- i 'h'X ^' C\,t.V ' 



IN. B Kvery item o? Information should h.- cnret'iilly Nuppllcd. Adfi should he stilted EXACTLY. PHYSICIANS Hhould 

"tatc CAUSE OF DEATH in pliiin tcrm-n, that it mny he properly claHnhMed. The ".Special ln»'(.rinMti«»n" for p«r- 
son* dytn^ away from home Hhoulil he j^iven In <i\9ry InHtnnce. 




i**-", 



ti 



>» 



1l 



1.; 



} 




H ,» 



-1 »■ 



/ 



./. 



WRITE PLAINLY WITH UNi 



!!( 1:11.1 ..:' !1. 



/^ 



'FADING INK ^TH/S /Si 
WRITE PLAINLY WITH UNFADING INK--- THIS IS A PERMANENT RECORD 

RgFER TQ BACK OP CERTIFICATE FQR INSTRUCTIONS 

llegf.slcrrd Xo, 1 78 1. 










^//r A/Vr^/.nx^xtx^^i^uuv ^i 100\ 



C^v\.v,<i 



(j^^ Depi?ty Health Officer 



DEPARTMENT OF PUBLIC HEALTH=Cit^ and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of Death 

-I -. 



City of 



. \ ,. 



'^A 



Dist.; bet. 



A /' IF Ot*TH OCCUPsAaWAV FROM USUAL R E S I D E N C E G . V E FACTS**Ci 
J \ IF DtATH OCCUi^RED IN A HOSPITAL OH INSTITUTION GIVE ITS N 



and 



ALLED FOR UNDER SPECIAL INFORMA 
AME INSTEAD OF STREET AND NUMB 



TION \ 
ER ) 



FULL NAME 



N 



,^\^' 



y I 



PERSONAL AND STATISTICAL PARTICULARS 




lUkTH 



A 



MEDICAL CERTIFICATE OF DEATH 

i>.\Ti-; oi- iii:.\Tii 



/<y, ' 



Miiiillil 



\' 1; 



),•<// 



I).iv> 



Months 



I in-RI-HN- CI:RTII"N'. TIi;.I J .iIIlmkIcM,. . i., ,1 t,,,ni 



\ n).)\yi.:i,,,K DIVDKcKi) 



/),; 



't"-:rMl'i,\ri.: 



''ATlliiR 



01 



•"•■ 1 athkk' 

'^'•'itf or Couiitrvl 






I'.IKiniM.AC'K 

!','■ ^i'>Tin.:R' 



u 



Axx/A 



\.U\. 



•*^"^-ri'.\Ti()x 



a 




tli;it I last saw li ,i!i\c oil 

and that ilratli i iccii rrcil, i>n the date statrd alii)\. 
M. Tlu- CAj SI'! 01 |)|. \ ril uas ,,. I- ;; 






»l . I in. V . V_l .^ I . > ' 



i\\ • 



1)1 RAT I ON )\ai 

CONTRIIMIORN' 



,1/ ''"h< 



/hn ^ 



//r.:> 



I ) I ■ R A r I ( ) X 



( SIGNED 





)'<■<//'.? 






Mi'iiths 



l\i\. 



M.D. 



"W^-voi • 



nxi\' 



!()<') 



( 









Special Information ""'> tor (hspifdis, insiitutions, ifdnsicnis, 

or Rerent Residents dnd persons dvini] dHitv from home. 

(Y . _ t' •'\ 1 HoH lomi ,»( 



former or 
Usual Re 



ir a /A I n y vi ""»♦ i""'i <»i , , 

sidenic ^^iv J.tVCv^VC 't pirfff of ne-ifh' LI ^^^^ 



1A '-''//. 



When Has disease lonlraded, 
If no! al plare of dedfh ? 






lil ST*l)r ^TxV'"'"" ''HR^ONAI, I' A k T IC C I, \ KS A K I-; TKIJ-: T 



nil' 



::^ 



rj.ACi: Of MiKiM, ok Kf;M<»\ \i, j \>\n • i; • ki;M<i\ \i, 

^ L^ >v>xL^ I' a^-v I ^-^^"^ '^^ 190H 



J. 



CCC^tX^N 






x,i,i,,... ibr:^- i^^ t< 



Kvery Item oi? inforitiHtion should b^ cnrefiill> Huppllecl. MIV. should be stiitcd liXACTLY. PHYSICIANS Hhould 

«tnte CAlJSn OI" DTATH in pliiin terms, that it iniiy be properly cliiHfi'n'icd. The "S;»cwIhI lfi>'«)rninti<»n" for p«r- 
*">n« dyin^ (iway from home should be ftiven In every instnnce. 



Hh^ 



I 



„M 



mgpi^ 



m 




.'*" 



I 



.i- 



,1 



If 



•a» 



./* 



WRITE PLAINLY WITH UNl 



f^AOlNG INK -_ THIS .s* 
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS 



M(i:ii(|. :• i; ih !■ Vrj \- "^•^^5]S^, Ii,«tl' C\, 



lh<! Filvd^ OjL 



'^X^K^KA 




X\ 



IU()\ 



lla^islcrod Xo, 



1 7S2 



DEPARTMENT OF PUBLIC IIEALTH=Citv and Conntj of San Francisco 



No. 



Certificate of IDeatb 

City of 'CV ^V 'VCL^ 

, . ihl , % 

St.; Dist.; bet/J 1 1 LlL\A\i.LkvA' and ' 

IDENCEgiwe facts cailed for under "special information • \ 

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



PLACE OF DEATH: — County of ~^ a y^ 



00 

.1 s ,-, 




( " r/oElTH'^lcrj--"-'-"" "-"""*'■ ^^^"'^"CE GIVr r.CTS CAILED «OR UNDER ' SPEC..L l»rORMATIO~ 



FULL NAME 



i.l\ 



' - cLv>(\.(? 



I \ 



PERSONAL AND STATISTICAL PARTICULARS 
1 I COI.OR 




i: (ii- liiK ru 



^' •!•. 



dxi-Jtr 



3.0 

(I)av) 



Ar[ 



MEDICAL CERTIFICATE OF DEATH 

DATK ul- I)):\TII J? 

GxKt 






J lit ; .V 



M.'>il/i> 



\\nti-Mi social .lrsitr„:„i,,„) 



(\cai) 



/>.nv 



'•iivTin'i.Arj.: 



•nI 



' '" ' "unti \- 



^ ^^t^•: oi- . 

'ATlliiK \ 



e 




C)x>^ 



Cr\ > 




iM')nt^i> (I):iv) 

I lil-;Ki;i!\- (.i;Rril-\-, riial I attin.lr.Mv, ,,,s,-.| h.-m 

that I last saw !l aliM-oii ii^ 

ami tliaf lU-atli ocriirml, mi tlic datr s(.itr<l al)i>\i-, at 
M. Tlu' CAI.SI-: OI' l»l \TII was ;,s folI.,\v^: 



HlRTHlM.ArF 

OI- i-atfikr' 

'Statr or Countrv) 






'■'ktiipf.aof 
"'.'■■ ^'otmkk' 

'"^t-itf or Comitrv) 



U^CU\; LdLL^<x\cL dL/JL^; 



\ 






DC RATION ]','iiis 

CoNTRir.rToRV 

1)1 RATION' }'rars 

(Signed )LftVc\v.-'v 



Moiitiv 



nay 



//<- 



; ■, 



Mo}itln 



\\ 



Ihix 



dX'^xfc '• . i(,o (A.Mu-^v) V.(y\^6vaK.^ 



A ^ ^ 



M.D. 



< '^"^--r PAT ION 

'"-^1 OI- M\ J<X()\vij.;i„;,.; 4N„ MIvI.ri-F 
""•""iiiiatit OOL/^VA^OU 



Special information <'"I> f"r Hospitdls. Inslilufions. Trdnsirnls. 
or Recent Residents, and persons dyimj .m.i,v Um home. 



/',/ 1, 



Former or 
I'sual Residence 

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



HoH long at 
Pl*f of Death ? 



Od>s 



A* 






VV. To TMJ-; I I'J.ACK OI' lUKIAK OK KKMo\ At, J I)\Ti:"; MikiAi ..t KliMnVAI, 



\ 




'^ 



U.l.lr.ss "T ^ H \J .cLcVVA- O. M « 



INDllK IAKI:K ^.. I' 



\ 4 I , ' ' . I » 1 



'A.l.h, .. b^^ lO /aA,t\ <. ^ ..o/. ^ ■• ''^ * 



• ^ Every Item of InPormntion should be cnreV'ully supplied. AGB should bo stnted fiXACTLY. PIIVSICIAIN8 nhould 

•tate CAUSE OF DEATH In pliiin terms, that it mjiy be properly claHsified. The "Special in»ormHtion" for p«r- 
«on« dyinU away from home shouhl be ftiven In c\cry Instance. 



N 



«n 



'M 



.'1 






», » 



•': ,/ 











N 







? 



Hd.MtvI ,,f I, 



.VRi TE PLAINLY WITH 



^NMD,NG,N«-TH,S,si 
WRITE PLAINLY WITH UNFADING INK - THIS IS A PERMANENT RECORD 

REFER TO BACF^ OF CERTIFICATE FOR INSTRUCTIONS 






Ji 



]U'Of,s/('i'(>({ Xo, 



J783 



i f 

^^^xxAj^ d.> Av., Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTIKifv and County of San Francisco 

Ccttificatc of Beat!) 



I) 



SI % 

PLACE OF DEATH: — County ofC;a->%. J Va^vcui^ao City of -'' 



V 



No. IS1JJ6 IL\- : 



i\ % 



St.; b Dist;bet. .U\X\, ,, .'. ^ and ^C 



-^1 

FULL NAME iJLCX^o 



^ PERSONAL AND STATISTICAL PARTICULARS 



X 



vi)wL 



lilKlM 



Ll 



m. 






/ V' 



)•, 



•(/; 



l.. 



I I);i\ 



!/-<;////> 1 






/',/■ 



i!ikTni-i, AT,.; 

■^'•itr or •-•oiliiitv 



' ATni.;K 



■i<'nii'i,\,K 
".' iatmkk' 



^'\")j.:n nam,.. 



'H- VKiTHKk' 



"Tin ■ . 



MEDICAL CERTIFICATE OF DEATH 

i» \ ri-. ' 'I in: \ III 

» 

I IN'.K l.l;\ ( !• RTi|-\-, Tl,,,t I .ilirinl. ,! ' m ,! i,,,,,, 

Ili;it I I;is( saw Ii ^^>a ;i1i\«' oh -^ 

.illil lll.if "Ic.ifli (iccii I red, Mil t|). ,1a), ^ta', ,1 ,i!M,\a\ at \ 

.M. The C".\l M', ()!■ |)i:.\ ill u.is as tn|I,,u. ; 






1)1 kA'I'loN ) 

(. O.NTKir.lTOkN' 






Mnjiih^ 



n<i\^ 



/ /i<!n \ 



)'i (IIS 



^^' 



(St;,| 



'' '" <.'<)UIltl \ I 



niRATfo.V 
( SIG 

Oxinjfc V\ rooH r\.l.lr.ssi 



NED ) \| ll<XVu vl ! 

1 



\f,>'l//ly 



/hn 



M.D. 



■^' <>' .vu K.\(»\vi,i;i)(.i.; A\i> iu;i,n:i- 



Special information '»nlv Inr llnspifHls. Institulions iMnsicnK. 
or Rpcpnl Wfsidenfs, dfid persons d.wng dw.i) from home. 



M..„th- 



formfr or 
L'sual Rfsidencf 

Whfn Has disease ronfrarfed, 
/;,,, I If not af pla(eof death? 



HoM ionq at 
Pla«eof Ofdtfi? 



Odvs 



S \K1' I'KI}-, To TH)-: I l'I,A(l':()| Itl RI\I, ok KI:Mii\aI, I Ii\Ti;,.' Ill I'Ia;. .a KJ..\|(.\ \| 



I0<^ 



(^iX-^X w. w ^*obuv.; 



I \i 



.1 Kr\Ki;K (fO. 0. S-CAjrvAj ^ Lo 



\(l<ll<s< 



N. B 



Kvery Item otf Information should l»- cnrct'iiily siipplied. MW. h«1(miIiI I»c stiiteil I.XACTLY. PHYSICIANS Nhoultl 
• tate CAUSE OF' DEATH in phiin terms, thjit it msiy be pr<»pcrly cluHsified. The "SpccinI Inj'ormation" ifor p«r- 
"'*"* ^ylnft nway from home should be (ii%en in Misery inHtnnce. 



;? T' 



immffiMI' 



I ' i 




y 



«!' 



i!'^ 



> '« 



T~z:: 



■* n 



M 






WR/TE PLA 



f fVf I \/ la...>. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Bo!iv>! ' '■ III ; 



,-j]\h !■ No. !s i^v^^:i{&l'C.. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)a/r luJed ,QjL 




M.V 11 



io(r\ 



Mro'i.s/('/'('f/ .^Yo. 



1 7H4 



<>\Avo dvJL^M, Depucy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH: — County ofCJo/YV JAXX/TV^UIC.(. City of Oav> " a >\<^^- 
No. Ul^rvbuxX 0>>A. ?Aq.. . . ■ ' k: ^-^ • St^ • ' Dist.; bet. and 

/ ir DE.TH OCCURS AwAY FROM* USUAL R E* S I D E N C E CVE TACTS CALLtD TOR UNDfR ^^%%%^ '*^ '^ '° " "* J '„° '^ ) 
V IF DEATH OCCO^ED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 7 



FULL NAME 






YvH 



ii 



PERSONAL AND STATISTICAL PARTICULARS 

' (•< >I,( iK \ 




MEDICAL CERTIFICATE OF DEATH 

DA 11-: < '1 i)i;a 111 



:' •■ ri: <ti HiKTii 



\<'. i-; 




[ilM.iiUh) 



b^-\ 



)'e'lt I 



I |):i\ ) 



M,mlli^ 



I Veai • 



J'.n 



SIN<'.l,i:. MAKKIi:i) 

u nM)\\i:i) (»K i)!\( >K(i;i) 

'Wiitiiii ««(n-i;ii (lisij.Mi.itioti) 



itiKi-ni'i,Ai'K 

Sl.lf ,■ r)T CMniltl V 




,vd 



I 



d 



.(r 



X^V^.^N r> 



{Moiitli) 



I li.iv) 






I 1II{RI\I!\' Ci: 1\TI I'N', I'li.it I .ittcinlfcl <lt • ra'^iii h'>ni 
___ ,,p (,, \<.f> 

tliMt I last saw h - alivr on "/' 



and that ik-atli occ-iirrcl, (m tlu- <latc ^\aW^\ alxur. at 
M. Tlu- CATS)': OI' Kl.ATII w;!'- ii-- l'"l!.ius: 



I 'A I" I IKK 



HlklUlM.ArK 
<>|- 1-ATHKK 
'Stat* (»r I'oiiiiti y) 



MMI>i:n VAMl" 
"I MOTIII-.R 



'iiK iiin.Ari-: 
ni ^^(^Tnl•;k 

(Siatt (11 I'liiint I \ 






DIR A'lIoN 
U)NTRIHrT()RN 






.)A >'//// 



/>a\ 



J loll I 



] 



DTRATION 



)V</;v Mouths 



Ihn 



(SIGNED ) LtVcn\iA' ^iVulU ^3^tlxX'VV<l 



I In at . 

M.D. 



x^ 



ot'tTl'A'lloN 






h'e'^liiid ill Siltl liilHii-ii 



) , ,1 I 



M, mills 



n,i\ 



I()M 



f A.l.livss) UAO .vA^ V 



I III-; \i$()vi<: sr\r):i) I'KKsoNAi, I'AK IK 1 I \ks aki; iki >•: in riii'. 

HHST <)!• MV KN<>\VI,i;i)<".H AM) HII.II.I- 



Mi 



it> )i m.-iiit 






Wtv<x^ 



^ Vddifss 



.K 



b 



IL 



SPECIAL INFORMATION '>nl> t^r HospitrfK, Instililllons. Irdnsicntv. 
or Rerfnl Residents, and persons dying ,iH,iy from home. 

When was disease (ontraded, 

If not at plat e of death ? 



IM XCK OI- MTKIAI. <•!< KI;M"\ M. 



• AA) 190 



'A.l.ll«s>. 



11'^'^ 



N. B. 






.. I *fi- „!,,... 1,1 Ke Htiiteil EXACTLY. PHYSICIANS nhoultl 
ivery item otf inf..rm«lion «houl.l h. o.rcfully MuppI.ecl. '^'•»- '^^T ' '^^..^j ^hc "S„cci»l l.o'ormHiion" for pT- 
tntc CAUSE or DEATH in ph.in term*, thnt it mny he properly cl..«n.*.etl. he pec h 



son. clylnft away from home Hhould he ft'ven in «very InKtance 




fe«f 



ill 



/ 'I 



WRITE PLA 



'NLV lil/IT-. 



{ 



fi 



- »• 



I 



WRITE PLAINLY WITH UNFADING INK-— THIS IS A PERMANENT RECORD 



]\i<.n< 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Depu 



!!)f) 



}i('o'i,sf ('/•('(/ .V(f. 



1 






Crv.A..^_-> 



.M\^i.( 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( U. S. StanC^arO i 
PLACE OF DEATH: — County ofOo . City of U A 

o ' ^ St.; 1 Dist.;bet. ■L-^u"^slCX<X,v''.C and - 

FULL NAME K 



^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 



^ 



i ' il I.IK I II 







?,^' 



)V,; 



•Day 



A/,,„//r 



■ail 



"■ MEDICAL CERTIFICATE OF DEATH 

DATK I '1 I'l. \ 1 II 



f 



I.l. MAR K Ii:i) 

^vjiji >\yi-;i) (Ik i)i\'«)kti:i) 
|^VIit«•ill siK'ilil (It >ij.rii;itiMi)) 



J fUx/v\AX/cL 



'nki'in'i.A '}•: 

^tiN or <''imitiv 



N'AMK Ol- 

I'A riii:R 



nik TlllM.Ari-- 
«»l" l-ATIIlvk 

'•^'^•t.- or CfMiiitrv) 



^'\llti:\ NAM}.- 
"1 MoTMHk 



•ilKTFII'F.ACK 
'•I- MOTHKK 
(St.'itt or Country I 



K^OJ 




D 








rN 



1 II \:\< ]:V,\ n KTii'N . rii.it ^i .itun.it.i >• 

I 

tliat I la-^l s;tv\ !i ;i!ivt Mil 



and that <UmIIi occii rifil, <>ii tin 
M. T1k;CAI Si 



■ ■! 1 1' 111 1 
\ 



IH'. A'i'l I \\ax as ti)ll'>\\ 



iK. 



ft 




""0rru;vcl- 




I )r RATION •■■ )"/'^ 
CONTRII'.r'iOKN- 



Dl' RATION )""^ 

(Signed) x 

■\ ■ 



Months 



Ihn 



II, 



Month 



Ihn 



II > 
M.D 



IljO 



^, ,,,,...,. a\Hi in. • 



'»''«' PAT ION I 

L> 1 1 'J ' 



.UJ I 



s 



1/ 



,.//,'//- '.. (. /''■■' 



SPECIAL INFORMATION nnU tor flospilHls. Insf.lutionv (tdOMfnls. 
or R»'(ent Rcsidfnis, dnd prrsonv d)ini| .md) fro.ii home. 



I'll", XMOVJ.; ST AT i: I) I' KK SON A I, I'A RlIC f I. A k s Akl'. Tkl !•: T< » I IH-. 
HI'.ST ()!• MV KN(>\VM:I)(; K AND HIvMIJ- 

fv.i.h.s. CjXX^vfcou A-<W,Oj L<XO 



Former or 
L'sudI Rfsidence 

Whfn was disrasf ronlr.K fed, 
If not at place ol death ? 



How long at 
Pld(e ol Death? 



nd>' 



\ 



'X^t 



I'l.ArK <)!• HI Kl \I, OK !:l-^'' '^ ^' 



( \ ri: •/: !(i CI \i "I K I'.M* i\"Ai, 



'> 



x\ 



TOOH 



iNDi; 



N. B. hvery Item of InformBtion whouhl b. cirefully HuppHe.l. A(JI. 'j'"'*"'*' **^,.*^*"**'^^J •Special lri»..r.n«ti.,n" for 

• tate CAUSE OF DEATH in plain terms, that it may I.e pr.,perly cla«H.Ucd. 



I>»1VSICI\>S Mhuuld 
per- 



sons dyinft away from home Hhoiild be ftiven in every in«tnnce 






^t^. 





M 



\ ». 



i 



• p 




aa*r^i^rr~ ■^■MiikliV#<a*i<v«ti •■»■*•» aiKaKa^ik 



vvniiu r-i-«ii^i_i ¥viin wi^rMbrimva I IM r\ iniS 1^ M KL RfVIAfVE f^T RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



f IhalHi-l- No 1^ t^^-w.^'.^i Jit's:!' (\, 



/^//r /-v/r^/, cjjU|vtx^^viMA.' x\ nfo\ 



JU'iji.sf ('(•('(( s^Vo, 



1 7Hi^ 








DEPARTMENT (IF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 



11. 5. 5tanC>arC> 



-V' '^ 



PLACE OF DEATH: — County of Oa '' ^ ulcv City of ^a^X' 






1.1 ' 



"^ 



No. A'iii'l Vi>«, -;. 



St.; 



Dist.; bet. 



and 



(ir DCATW OCCURS *WAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPtCIAL INFORMATION \ 
IF DE^TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



FULL NAME 



JxC^' 



dL'(X\.vl<.L JV' 



!' \ I'l-; • >I- l;iK I |{ 



M .I-. 



PERSONAL AND STATISTICAL PARTICULARS 




MEDICAL CERTIFICATE OF DEATH 

1) A li; « i| I»l. \ I II 



i 







)■,-,//. 



Davl 



!/.'»////- 



. 'A 



I ','1 ' 
1 1 1 \ ' \ ,11 



I < ;( I I 



WIlxtUKr) nk l)!\«tK( i.;i) 

Wi it' ill ^iM-ial lit vj^Mi.it ioii ) 



HIKTlll'l<\iM'; 
St.it( nl C'uiinti \ I 



'• \IHI.K 



HlkTlII'I. ACi-: 

'"■ I Ariiiiu 



^tAII)l.:N NAM!" 
<»!• M<>T|li;U 



i''n<iiiiM.Ari-; 
«»i- M(>Tin<;k 

'Strilf MI roiniti \ ) 



'"■""ll'A TioN 

Rf'iilfii in Sill/ I tiiiui^ti 




1 III';KI:I;\ vI K'TIIN, Th.it I ittm.U .l !( . . ..s^ ,| ti..iii 
I(>n t<i I', 

that I last saw h aii\ c "ii • i(^ 

.iihl that (katli ( x'cii i ri"«l, "Ui fhf 'I.itc --t.iti il .ilmvi . .\\ 
M, Thi- C Al si; ( »l Di \TII u.i- ' '!-u- 



U_ 



1)1 RATION )V,//v 

CONTkliHTOKN 



DTRATION )',,ns 



M,'Ullr 



/ hn X 1 1, no . 



M,nillr 



l\i\ 



uauA/> 



SIGNED) Mfl '^ 



M.D. 




Special information ""'* '•" llosplldK. Inslilutions, (idnsimls, 
or Rercnl Residents, dnrj persons dving .mnv troin home. 



) I ti I 



\I..i,!lls \. 1 1,; 



i'ln: \ it(>\'i-; s r \ri: i> i-kkson \i, r \k rii ii \ks \k i: i'ki )■: i ' » i ii v. 
Hi-.sr (t|. MN' K .\i »\\ i,i;i)(,i-: and mi. hi 



former or 
IsudI Resideme 

When Has disease ( onfrac led. 
II no! af plajeof deafh ? 



HoH lonq at 
Plaie of fleath.' 



DdN' 



InluiiiiMiit O v.-C. .. .\. 



» 



Ir 



^ 



CXy> \. 



I, w 



I'l, \rj: «>l MI klAI, <'K K IM< 'V \ !. j !• \ i I. '• !'• t i m m K IMm\ \|. 



^. Ii. i.very item o*" in^ormHt Jon hHouM he cnrcV'ully Hi.,n.lio<l. Xlf. Hh...il.l l.o Hti.te.l I.XACTLV. PHYSICIANS Hhoulcl^ 

state CAlJSIi or DFA TH In pliiin tcr.im. that it mjiy he pr.»|>crl> wliiMRitietl. The "Rpccliil InVormHilon" (for p«r^ 
Ron« clyin^ nwny Wom home Hhoiil«l he ilt*^en in every inHtnncc. 



tHIMHIti 






■t 



T r 



«r 





I '. 



14 



HMIUttlM 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Bonn! ..Ml. . 'til I- Vo. i ^ t-^^amjS^^ iu<t !' Co 



X^rvA.^ doL/v^ Deputy Health Officer 



Ji('o'/,s/('/'i'// ^Yo, 



1 7H 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bentb 

. U. S, 5ta^C»ar^ i 



n 



% 



^ 



PLACE OF DEATH:— County of 0<X/>^ 0A,( City of J<X>\. O.Va.>xc\.<ie ^ 

St.; Dist.;bet. ' ' ^v^ ' ^' and 



No. \l'^^\ 0<X )v Hl>^- 



^/^v > v re ^ - v. 5t.; Uist.; bet. . ' • V ^ ^ ' and 

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



^ 



FULL NAME 



\\ri\' 



-O^lt 



V\j 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



' m, 



l>Ml-: ol- lilKTII i\ 



AA 



\ ( . !•; 



(>Ioiit ll I 

1/ 



) Vi." ; > 



u 



tDav) 



M,>utlr 



HAII-: Ol Dl'AI II 



r<jt> 



M-Mtfl 



1».(\ ' 



' \vM ) 



/'./ 



\^ ii)t»\yHi) ou i>ivoki j;i) 

\^ I it( ill s,)( ial <1< sij.»^ii;itiini) 



r 



I'-iKrm'i.Aoi' 

'^titf M' r,,iiiiit V 



N \M1. (»|- 
lA'lllliK 



HlKTHPI.ArK 
•>' l'ATIIl-:k 
^t.ii.- or Coiiiiti V 



M \II)i;\ NAM)' 
"»1 MOTin.K 



niK riiiM.Afi'; 
"" M«»riii-;K 






I iii'ik i:i'.N' (, I InTiI'N'. Tii.it I .•itii-iiiir<i ill . I .(sr.i 1I..11I 
ii;'i ill 

t li;i( I last ^.lu Ii ali\i' <>ii it/" 

ami that <Ii'atli nccniicil, on tlu' -latr ^laU'l .iIh.\<-. :it 
.M. 'I'lic CAI SI''. ()!•■ hi; \ Til v\.r a- loII..\\s: 



,^ 



V^OL' 



ft 




A 



1)1 kA'IloN J<'<7;-.v 

coNTkinrioKN' 



M,>ntlr 



lhl\ s 



HiUii - 



kx:^ 



I )r RAT I ON Vrms 

(Signed) 



Monlhs 



/hivs 



Hi) it) ^ 
M.D. 



(.->'. 



- 'y 




c 



AV'\/(//'// /;/ S(/;,' I I, til- : lit 



Special information f*"'* '•" HospiLiK, institutions, frnnsimls, 
or Reifnt Residents, .ind persons d>ini| .ih,)) from liomf. 



);,// 



\I.n>f/,- 



/I.!, . 



Former or 
Isuiil Residencf 

When was disMse ronlrdited, 
If not at plareof death ? 



HoM loni) at 
PIrf. e ot Death .' 



Ddvs 



I'M 1', AU()vi<: sr \ri:r» pkhsonai, p \k ri«i i, \k^ \i< i. ik t i: i' • in )■: 
in:sT oi- My KNowM-. I )<.!•; AM) iu;i,n;i' 



^iiifoiiiiaiil 






1 



(t\ > > K^L'-i • < o , 



V >.0 



y.AC}-: <»i' Him \i, < •!< K i;mm\ \i. j n \ u ■ ; if im \i. ..r k i:m(i\ \i, 

I qn 






iniii;k I \ I-. n-' ' ' ' ~ 



i."^- 



N. B. Hve^v item of Information «houl.l he- cnrcfully H..pplie.l. A^Jfi hSoi.I.I be stntcl I.VACTI.Y. PHVSICIANS should 

Htutc CAllSr or DliATH in pl..in ttrniH. that it mi..% he properly dandified. The ' «pcci«l Inior.nHtion »or p.r-^ 
«on« dyin^ nway from home Khould be i^iven in e\ery inHtnnce. 



> 





i 



y 




I't: 



t 



ii# 




^- -^ 



it I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



li,.;!!.:.^; IK;iltli !■■ N,!, i^ 'tr'»:,;7r!--i, ItN. i' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)(fh' Filed, QX. 





\' 2A 



if)n\ 



JivgLstercd Xo, 



1 788 



I 



V.V'^ 



/ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of £)eath 

( 11 5. 5rant»arD ) 
PLACE OF DEATH: — County of'Ja^v Va^xc>.<i<:c. City of *^ 'a^> 



1*1' 



^„ \- ^ » > • . v 



No. M J 







St.; 



Dlst.; bet. 



and 



(ir\death occurs awav from usual res IDENCE give facts calied for under "special information \ 
^|F DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 

FULL NAME J Ix w' 



PERSONAL AND STATISTICAL PARTICULARS 




• i:\ 



\ I »•; '»r i! IK I' 1 1 



\' . »•; 




(.iiI.itR \ 



t 



,^5 



M.Mitlii 



) '/(I/ 



I):i\i 



lA"////, 



i\\:n I 



\V IlM »\\ i:i) ( »K IHX'nKrj;!) 

'' U'l itc in s(,ri:il (it>.i^rii:it inii 



I'.il; III I'l, \t"i-: 
I Stilt' «>i ri.iml I \ 



1- atiii;k 



"IK riiiM, xry. 
•>|- i-.\iHi':i< 

'StMir or CmiIiI! 



M \!I»i:\ NAM).; 

oi Morm-.K 



HiK'iin'i.Ari*, 

"I MoTlUvR 

' >l;it( MI c'l.imtiA ) 



' "'« irATloN- 




^'^^'L.'CrV.C^X^ 



MEDICAL CERTIFICATE OF DEATH 

DAT]-; <>i- i>i: \ 111 , 

'%T..||f|l' lM> 

I lll'K \i\\\ ( IKTI I \ , rii.it I .tttrii.lc! .1, 
I.,, t(. 

that [ l.'tst "^Mu Ii ~ ;ili\c Mil 
.iikI that death Mccn rn-rl. mi Ihr <iatr ■>!.ii< 1 

M. Tin- CAI SI' oi" hi ATI I : ill-w- 



/ IP < 






LL'i, V'\JrXiYy^-<\X.A-<r>v A ^-^ 



"N 






DlkATiON )V'// 



CONTkllMTOKN' 



DlkATHtN )<-/- 



. 1/t > ': : >. N 



Pas 



'\ 



I loii) 



U ' 



/'-/!> 



f SIGNED ) ^^\.(n\XV >J '^ ll ' 



OJi\\X. 



//I'/n \ 

M.D. 



!<)') 



Special information ""'> ^"^ Hospitdls, Inshlottons, Irdnsimls, 
or Rerrnf Rrsidrnls, .ind persons dvjn) dHd> froTi hmr. 



I\'' iili'il III Siiii I I iiiii I r,t 



M.nltll 



WV. Mt()\-J.: STAri',!) I'KRSONAI, !• \l< ilt'II.AK-- \K i: IN f J' 1' • 111 
Hi:sT OI- MV KN'nW |,i:i)C. )•; \\I» MI 1,11 I 



former or 
I'siiiil Rfsidcnrf 

Whfn Has disMsp (onfr.irlpd, 
If no! a\ pl<j( p of df-Hlfi .' 



HoH loni| .it 

f'I.M«' Ot iJfdtll.' 



f)rf>S 






^c 



I \<ll!n NS 



I'l, \ri-: <»i HI K I \i. ' 'I-' K iM 



I NDl.K I \K IK 

'A(|.!i 



l> \ J I 







II '\ 



O <^ '1 



. >v 



N. B. 



-livery item «.V liiformfition Hhoiilrl Ik- c.irclrully HupplJe.l. MW. Hhotiltl be stiiteil I.X \CTLY. PHYSICIANS Nhoultl 
Mtiitc CADSL or Dr:ATH in plnin tcrniH. thjit it mjiy he propcply cliiMRil'iccl. The "Spcciiil InVc.riuHli.m* Ifor pen- 
non* (iyin^ nwny from home shoulil he ftiven in c%ery innlnnce. 




ir" 



I 



jii 



wmw 



%\\i\ 



Sb^iirt 



iiUk^^- 



i^imi • 




1 



> I 



% 
¥ 



:i 



i 







4 



Hm:h.' . '■ !!• 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



r Vo : J, •?•?■ •arr-.^i US: I' (.' 



I)ff/r Filed , ax 

\ 




X{ 



Deputy He 



ll)()\ 



Begistcred X(l 



1 r.^-]9 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate ot IDeath 



u 



PLACE OF DEATH; — County of 



City of V^O O L^^^VLC \:/\*_0 C 



No. 



St.; 



~ Dist.; bet« 



and 



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

FULL NAME l^v^-ic 



f I 



1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



n 



\\ 



O^' 



u 



lUKTII 



I A- 

(M..iitht 



MEDICAL CERTIFICATE OF DEATH 

I) \i"!-: \rii 

'Moiit'h) 
I li I'kl-I'.N' ('i:KTI!\'. Tliat 1 .ittni.Ir.l ; 



/ ,"> 



\>.}-: 



a^i 



10 



iD.iy) 



M.»tlli 



i\!\. 



Ull)n\yi;i) OK l)!\t)RiKI) 
\\'iitfiii sooiiil (Ifsiv'iKitioii) 



^t.ltr ..I ri.imti y) 



N WW <)!■ 
I \ llll-K 



niuiii I'l, \K'v 
<••■ lAriii.-.k 

St, lit 1,1 I'.iutiti \- 



"1 MoTllliK 



•ilKTHI'I, AC}.- 
'>••■ Mo'lilJ.-.k 
'Stal, oi roiillliyt 



i ^ (^ 



X 

lev; 



t h.it I l.i'-t s,i\v !i .iii\ <■ ' Ml 

and that lUatli ncciii ri-ii, mi llu- «la! 

M. Tiu' ewisi-; ()!• hi; All! 



l«y<) 



;i I i( i 



,1 



I's 



r\ 



l^ 



lA. 



.'W.'>^0- i 



lie 



DIRATiON Ycdis 

CONIK Nil TORN' 

DIRAl'ION )''/yv 

( Signed ) iX/a 



M,' !tln 



/Kns 



//,.,,/ ^ 



' I. 



/hn< 



U"U 



M.D. 



ri(0 






' »' ' 1 !■ \ rioN J? 

A 



y 



'''•iilrd ni Sill/ /'ill III i^i'o 



IC 



)■-■,,■; - 



1/,.7'//- 



/',n 



Special information ""'^ '"' '•"''>pif«'i\ iiMituiionv. irdnsifnts, 

or Reif-nt Residents, dnd persons ii)'m\ ,m.n Ifnii home. 



I'm; \iiovK s'i- \'n; I) i-kksonai, i'\r rirti, aks \ki: iki i: r'» in !•; 
HKST oi- Mv KN(»\vi,i;i)('.H AND Mi';i.n:(' 



^Ilir.>;in;iiit 



C. i\S^co,sh 



Former or 
Ijsiidl Residence 

When Hds disease i oniric led, 
It not at place ot deafli .' 



Hum long >it 
f'l,i.e ol ((e.itt).' 



OrfN' 



I \<h] 



rc<s V, 



vnA„ 



^„CX^V^>^<r'^^ 




CL ix. 



i 



I'l.XCl'OI I'.IKIAI, <>K Kl.M-''. U. 



IMtr.K I'AK IK 




n V 



!-■ 1M< i\ \1, 
190 * 



A. Lis <•■,•. S^<X.' 



t-LLo-Vx-c 



N. li.— Hvery Item otf i„form,.tion .hnuU\ b. cnrcfully Mupplied. M.ii «ho.I<l he Htnte^ IX \C TL V IMIVSICIA-SS nhouhi 
«totc CAUSK OF DIIATH Jn pl..m fcrmH. that it m».v he properly .IohhI^Mc.I. The ,Spec...l Inl .rmMl.on »or p-r- 
«on« dyinfi nwny from home nhoiiM he Jiivcn in *:\cry inHtnnce. 



m\M 



fW^F^^^fll''*W^#w^w|W 



ifutt^ 




m 



1 -o 



, , I 



' > 



I iii 



r 



k'A 



f]i5~ WRITE PLAINLY 

n,. III. 1.1 !(,:.'Ul !'V.). i:, t'^'SSr^nScV Ci 



ITH UNFADING I 



1, 



THIS IS A PERMANFNT Ftrr.nan 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJfJ'i 



Jfro'/.s/rrrf/ A\/, 



iroo ' 



.<y^<^A^ 



BEPARTMENT (JF PUBLIC HEALTH-City and Countv of San Francisco 



Ccvtificatc ot S>catb 



( 11. S. jT'tan^ai^ 



(^:^ 



PLACE OF DEATH; 



N 






County of 'tx>\' 



n-o 



City of ^^a>v OA 



"^ 



r) 



Su 



Dist.; bet. 



and 



(ir DtftTH OCCURS AWAY FROM USUAL R E S I D E N C E G I V T FACTS CALLED FOP UNDfR SPECIAL INFORMATION \ 
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION G I V f ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

f\ i roi.ok 

\X\Xji 



HlaU 




"! HIKIII 



'\ 



I ■ 1 ■ 



4H 



-i^'i.i M\ki<ii;i» 
vv iiM »\yi;i) (»K i)i\t »Ki|.:r) 
\\ lilf ill soi-iiii iI<si).Mi:itit)ii) 



I'.lkTM IM. \(-l-: 

M:i|. iMli\ 



H 



'] 



( I)a\-i 



.1/ -//.'// 



.11 I 



/',/ 



n 



MEDICAL CERTIFICATE OF DEATH 

1) A I'l-: (II i>i' \ 111 

\; " i),i\i 

I II l{|>: i;i',\ I I KTll'W Th It I attril'lr.l <lc. < i. I I; II 

' ■ ■ !>, = '■ to c\xK' 1.,. 

\ li.it I last saw h i!i\<- mm ' ' i()-i 

and tli;il ik-.itli occurred, nil till- i!. I' !h.\-<-, ;it b 

M. 'I'lu- C \l ^l-: < >l" I>1': \I'II ua ■ t !• \\- : 



NAMl'- OI- 
I \ THj.-.k 



I'lK TUl'I. ATK 

'" i'\ri!i.;K 



^' Ml HA' NAMF 



"IKTIIPI.ACK 

"'■ M<»'rni.:K 

' ''' 'II Ciiiiiitr\ 



' I'ATION Qf^ 



/TUC 



^ 







y^\c i^^. 




(? n 





A 



T,c^t^ sDc . 



hi RAT ION b )V./yA 

DIRATH'N )V,/;s 

'I 4 

' SIGNED 1 LtLoCLtC^V 



Mouths 



/hn 



II 



0|V 



Mniihs H /'./ 



I'V 



!(/' ' 



f \ddn s^ 



i V»..Cl. v'-.^. i\.i,».' C'v'.. 



Special information ""'^ ''"^ llospildlv Instilulions, Irdnsimts, 
01 K«'(fril Rriilfnts, and persons dwni) d»<jv Ini.ii hnmr. 



-L,<X. -v-v-N^ "tx-AJ 

/vV' /,^i/ /// S,,.;/ /'/ ail: IM-ii . 



M,.,,ni 



lormcr or 
L'sudI Rrsidrnff 

When w.is dispdvc (onfrdffpd, 
It n»l dl |tld(r ol dt'dfh .' 



Hhu Innq dt 
fld« f ot llr'dtti .' 



|)dV> 



III I. MiovK ST \'ii-:i) im.:ks()\ai, i'\K'ii<i-i,AK-> AKi; IK ' i: I '» rill-: 

IIF.ST OJ. M\- K.\()\\i,i.:i)r, K AM) lil-M.Ii;!-" 



(h 



J\i. 






^ \.l(ll<ss 



-n 



o • 



PI, \(Y. I >l III K I \l, OK I-: l.M< '\ VI j 1' \ M 



I 



W (0 

MU.krAKI.K Vw^ 

lf jl r, f ^ ^ 



\,CX.A^qL L>^wxx>\ 



N. B. li 



^try itoiM «)V Inforiridtton 8 



»hoiil<l be CHrefiilly siipj»l!e< 



I. \i\V. Khoulil be Kliiled f.X4CTLY. I»HYSICI\NS hIioiiI.I 



stole CAlISr OF- DLATH in pliiin ttrmH, that it may be properly 
son* dyin^ iiway from homo shoiihl be ftiven in every inntHncc 



ly ^liiHHit'icd. The "Spcciul lnl'or(iinli<in" /or pi»r- 



]^, 



Mi|i;>iuui'i 



fr- 







wrr 



I 

I' 



^ 



r 



4 



I 



\i 



'f 



lA/tSfv^ _ 



WRITE PLAINLY WITH UNFADING INK — THIS IS a PFRiviAMrrjx ^rr^/^on 



*■■--** 



/)f/'r I'ilcd , ( 




(H^A^V^ 




RerER TO BACK OF certipicate: for •nstpuctions 



7-96' H 



J*r(ji.s/r/ r,/ ^]\, 



1791 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of iDcath 



PLACE OF DEATH: — County ofV'O ^a 



ci 



n. S. stanza rC> > 



I'! ! 



/>-, 



^l^'is. OclIIxvo 



/'^, 



Gty oi 



St.: Dist.; beeJ CrUL^ and 

FACTS CALLCD FOR UP 
C|:UHnED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



(IF DtATH OCcJ[rs AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION \ 
IF DEATH OCtUHRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



FULL NAME 



i 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



'1 I'.iki'ii 



M.-iilh) 



^ 



Day 



DAY}-: 



/.;'i 



1/. 



/),! 



•' ■'.!■ MAKK Ii;i) 

u ii)i»u}.;i) OK nivoKi-Hi) 

\\ ntf in «oci;iI (l.si^.natioii) 




c^ 



lilR TIII'I, Ari'. 
^1 tt> or ('< luiitrv 



^AMI- OJ- 

t- \i"h}.:r 



Cjaa;\Xi,a:_v, 



il 



I !{i{R \'.V,\ c I- RTll-N', T!i r 

tliat I last <a\\ h i 

and that ilialli ' K-riirml, ■ 






1 ! 



M. Tlif C \ 



I 1 1 



IMRTdl'I, \rK 

"• I \riiKK' n 

'^'■•i!' Mr C.miitrvl -X 



^'uj-lX 



\joJL< 



;"■ ^!«)T^^:K' a 

'i^tiitf or Country) J( M 

<»^«> TATION A \ 



IH RATK'N ) 

CONTKII'.l TORN' 

I )r RATION' }'<,i)s- 



.V. >>//// s 



1 \l 1 s 



//, 



M 



l\i\ 



Signed ) Lc^xhax^v 






M.D. 



Special information ""'> f"'' HospitdK, Instilirfmnv. Ir.msifnts 
or Reient Residents, jnd persons dvin;) dw.iy Iron home. 



1 A, */'//- 



lh•.^ 



former or 
Usudl Residence 

When was disease (ontrac(ed, 
If not at plare of deaffi ? 



ffoH long at 
PId. e ol Dratfi ' 



OdVS 



I'm; A !U)VK STATIC) PKU'^ONAI. PA k IH" T I. A KS A K l! i'K 1 !•: I" llll'! 

in-.sroi' MY K\()\vi,];i)c.K and im:i.ii;i< 



I"f";ni;mt 



O.'^^OLA 






I'l ACK <)!• HIKIAI. M|< Ki;>H >\ \i. 







15 IH OW. 



I0< » 



>^AJ '^ V^O 



^Xil.lrcs' 



N. B.— Kvery item of inf,>rm..tion should be c.ireVully H.pplic.l. \(I»; hSouI.! »>«.«t»'t«^;! «-^;\^ '''.^ j , '*'*\'''':' J^^. ,- ' 
• tote CAUSn OP DLATII in pinin terms, that It may he properly .InnHitica. The Spe....! lnU>rn.»t..,n »o 
Rons flying away VVom home Hhoulcl he Jiiven in every instnncc. 



l>inSICIAN>* Mhoultl 
r p«r- 



It 



\.i 



♦ft r,f! 



f 






f f 



#1 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M,,:i!.l ..f He 



calth I- No. <■■• *-^§^»)IU«tl' C. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!)((/(' niod , 




o 




'V 



Qvl I!f0'\ 



Deputy Health Officer 



Rc^i.slcicil jYo. 



J 7\)2 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of 2)catb 

( "a. 5. 5tan^ar^ i 



PLACE OF DEATH: — County of JXX/>a> J .\.cv. ^ v c^.^ City of ^^ <^^v v);v<x^\ <^. 



J,' 



(^ 






(No I'^S VJx:.- ■ St.; '^ Dist.;bet.VlU':l., , r ■ and I: ^ 

FULL NAMeUx''^ ■ v, . Uvo, • ^ ■ . 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.OR. \ 




I. 



DATK t)l- lUKTH 



ACK 



11 



ox \1 

iMoiitH) 



) 'ru I 



(l)av) 



Mnvth- 



(Vt-a: 



na 



SI\».!,K, MARKIKl) 
WIDOWI-:!) OK DIVOKCKt) 
(Writriii ><f)(.-ial (Uvij^iiatioii) 



lUK rnri.AOK 

(State or Country' 



\AMK (H- 

fatiii;r 



niRTnri.ACK 

OF FATHKK 

(Stale or Country I 



^ 



J 






MEDICAL CERTIFICATE OF DEATH 

daif: oi' i)i:\'rn 






MAIDF.N XAMi: /TSft (v /\ 

OF MOTHHR / W 1 1 I \\-\ 



lURTlIPLACK 
Ol- MOTHHR 
(Stale or Country) 



( 



LLVK. 



cL. 



OCCUPATION 

AV- /(j'a/ III Siiv /'i iiih !^i-,> 



!M-!lltT l'-'V> 

1 lll'ik I'il'.N' C i;R'ri 1"\', 'I'll. It I atti'inliil .U( rasf.I If .III 
. , ' i,,o . tn ^:W\^.t ■.^•1 1.^)^1 

tliat I last saw li .ilivc on " '</" 

aii'l that death <khuit«.-iI. oh tin- .l.itr -t,tt< .1 ali.i\<\ al \ 
K'- M The CArSP; ()!•■ 1)1, \TII \n i-- t-- roll. .us: 

DT RATION )V</r.s- Months Ihiys //ours 

CoNTRir.ri'oRV 



nr RAT ION .^ JV"'^ 

(SIGNED) J 



.}/(>nt/is 



/hn 



M.D. 



I<)0 



.\,Mr.ss)^lC1 Lalw 



Special information on''* '"^ Hospitrfls. InstMutions, Irdn>ifnts, 
or Reient Residents, dnd persons dying dWHv Iroii home. 



^ )•,,,.;. ^ \,',<„th' 



I'O 



■\-\\V MU)VI< ST\Ti:i) i'KKSONAI, F A K T rCf I, A KS A K F! TKIF r« • Till-; 
liF:sT Ol' .MV^NOWUHIX.F; AM) HKUIFJ" 

XXj VJXtt\A..C". .. 



(Informant 



\'l.li' 



V\ S Vj (xkmjlk^ U 



kjJ\: L/L 



Former or 
L'sua! Rfsidenre 

When was disease ronfra( fed, 
If not af place of death ? 



NoH long at 
Pla«e of Death.' 



Oa>s 



J'J.ACJ-: <)|- lUKIM, "K Ki:Mi»\\I, 

r N I . f: K T A K »•: K IL'M'l^V'n^ LLd 

^\(Miesv 1 AH L. 



1 » v II' .' IP 1' I VI. • ii K FM< '^ \ 1, 






l-\ 



state CAUSE OF DEATH in pliiin terms, that it mny be properly ciosmiiea. i 

sons dyin^ away from home should he ftiveri in every instance. 



tnift 



lk»'>-^ 



mliiti^f^^**'^!!^ 




* 



ft 



ill 



\ \ 




v> 



f«M 



11 






r-w 



WRITE PLAINLY W 



ITH UNFADING INK — THIS IS A PERMANENT RECORD 



n,.:ii.l -! II 






J)nfr I'lJcd , 



JtLo^Urv a\ /'^>^>H 



REFER TO BACK O F CERTIFICATE FOR INSTRUCTIONS 




Deputy Health Officer 

DEPARTMENT # PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County of Q<^^^ "J "^^^ 



tl. 5. StaiiJnv? ( 

VCL ■i<i<'. City of 






No. 1^11 



St.: b 



Dist.;bet/^ 



Jc and 



( 



, „„.„■ occurs .»., .-o» US..L -f-f,,"C4-- -^rs =.Vm7 :::,^To: s^:tt^^:o'^::^r ) 

IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVt 



FULL NAME 



U<L^K- 



\\: 



(" \ 



PERSONAL AND STATISTICAL PARTICULARS 



A 



\^ 



'\ 



; (iii.iiK 



III I! urn I 



[}. 



i>r(.iith) 



\' . 1- 



siN<.i,i:. M.\Kuii;i). 

WIDnWHF) OR niVOKC'KI) 

U'liti in '-ocial rli^i'.'ii.'itioii) 




(1)!IV) 



M.niHi- 



y^^^^X'<^ 






/hn 



\',\H \'\\\'\..\rv. 

' State or Cotmtry 



NAM I'. Ol 
l-A'I'll l-.K 



HIR'IMII'I, ATK 

<>i r\iiii-:u 

I State 1)1 (.■<)iiiitr\' 



MAIltlvN NAMl". 
Ol- M()TIII:R 



HI urnri.Aci". 
Ol" M()'rni:R 

'^tati- or Coiiiit I \i 







^ I 



lA 



'^ 



v-^' 



A- 



h'fnfr,! Ill Sail l-i,i>!>i r„ \^ i''^'' 



M,.,illi 



/'M' 



•I.K XHuVKVrxTKnPKRSnNA, rXRTK-lM,VK.ARK TK. K O • THK 

iii-,sr (»!■ Mv KNOW i,i:i )<•»'• ■'^^" Ml-.I.n.l 



' In f'.; maiit 



\\/^\ 



MEDICAL CERTIFICATE OF DEATH 



1) W\\ ' 'I- I'l ^'' 'I 







I 



/ i}' » 



(Mutitli* 

I |IKUI',HV ll.RTII'V. TlMt [ ,,itcM,h,l .1. . . .1 f...in 



V- 



U/i 



to 



I 



aliM- 1)11 



that I la^t -^aw h - 

an.lll.at.l...tlM-.nr.v.l, ontlu'i!.!'. -•.'--l -'"'ve. at 

T M. Thr CMS!': Ul' l»l': Mil '.^ ■ ' '\""^'-^ 






s 



DTK \ TION J'"'''" 

CON TKII"'! lo'^"^' 



Month' 



/Kn^ 



llr , 



I ) ( ■ R A T M > N 



T 



(SIGNED) t^'^*■^^^^^ ^^ ^ 



n,i\ 



// ,1 

M.D. 



I()0 



SPECIAL INFORMATION ""M»'"«^il''^- '"^'''""""' "''"^"'^' 



Former or 
Usual Rpsidencp 

When Hrts disease contrac ted, 
If nof at plare of death ? 



Huh lonij at 
Pld«e of Deatft? 



Davs 



,., xci- Ol lUKIAI, OK kKM.AM. 



|>\ I 1. ' 



;. I.. I \] ..T K IN!" '\ \I. 



INDl.K 



h 



^\(llll«S> 



"" IIVACTIY PHYSICIANS Mhoultl 

,F DEATH i. Plmn term., .h,.t .. nu. •;>;">•:; 



N. B. F.very Item of 1 

state CAUSE OF UtA i n m m.".- ;^- ■■•;: "^^^ . , ^^^^^ inntnnce. 
«on. dylnft away from home nhouhl be ft.ven .n every 



f 



0mmmmr . 











»< 



. 1^ 




I ^r^r^pff wff ff 1 I 



WRITE PLAINLY WITH UNFADING INK 



Jlcirir'i " III 'I''!' ' • ' ' ^.-.t.^-- 



^(^\.^\^ d... 




\' 11 



I90'\ 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIMCATr POR 'NSTPUCTlQNS 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 






K()i) 



PLACE OF DEATH: — County of 



UCLov 3.^.<x-v^cA-4^.. City of^-'^'^' 



«?.. 



\ n-\-\ <" (.. 



No. 



1 T>i^-'^^i:;::di^...,^±i) 

IF DEATH OCCURRED IN A HOSPITAL OR INSTITU. 



( 



St.; 



4' 



FULL NAME 



- ! : \ 



PERSONAL AND STATISTICAL PARTICULARS 




'L 



<X}J. 



U 



:> \ I 1 < •! lUR rn 






\ ( . ]■ 



1 C) 1 ,„. 






,^M 



• '/iMI I 



/ ',/ 1 



>IN<.LK. MAKKIl'.I). 



> 1 .\ < . 1 ^ I", . .\i .■\ i\ i\ i I-. I » . 
WIDOWKI) OR DIVORt-KI) N 

'Write ill <(K-i:il (It^i^Miat ion) \ 



Uvd 



vD ^v 



HIKIHIM.AOK 
StMtr or t-'onntiy^ 



J- A III i;r 



MiK'nnM.AOK 
1)1 1 Ai"in':R 

iSt;ilf or Oomitry) 



m\ii)i:n XAM1-: 

oi' MOTIIKR 



^ 




(^ 



X'' 




r\ I 



j 



■n 




HIKTHl'LACK 
<>1" MorilHR 
^Statr or routitry) 



OCCITA TION 



AVsi(h-<f III Sail I'mtn nr,i 



);■,}) 



!:■ > 



f\rsiiif(! Ill .'<<'" ' ' " " 



(lllfo! lUMIlt 



!\,\,hr.< 1^ ^ ^ 



MEDICAL CERTIFICATE OF DEATH 



DATK <>1- ni-.Al" 



iMotitli) 



, IIKRHIJV ^IKTirV. Tl,:.! jMtt.-n.l.-.l.l' 

I 

I 90 to ■• I - • 

tliat I last saw h ^^v^ alive "H 
.n.lthat.k-alhoc.urre.l, nntlu..lat..tatc..l .I-.-. .' 

M. The CAISI- Ol- I)!'. ATI! ^^- ^'-^ '"1'"^" 

-..\,l.(>'^ ,■■■■' 

■ , tail Uaw.i.'.^'-''- 

Up- 

hrRAT.nN , )■.-<„ -•/■•""" "■"• 

(SIGNED) VU3t-U^^ 

A . ,,,,„.„„ :. ;,. ov-' 

1()0 



! tP'iu 



//. '.v; ^ 



M.D. 



orlefrn^ Men. s'Vnd persons dyinq annv from home. 



Former or 
Usiicil Residenff 

When Has disease fonfrat ted, 
If not at place of deatli? 



KoM lonq at 
Plare of Oedtli ? 



riH 



\ \ 







^i> 



O^.t 



I NDI.KIAKI-K p. 



'^'^'^""" ^^^ ^ ' rTrV4CTIY. PHYSICIANS Hhnulil 

' : I, M be oTcfully supplied. M^^- h'"'"''' •^'J..'* ,"* The "SpcJial IntormHtion" Vor p.r- 

«tate CAUSE OF Dr.ATH ... »''" " ^JJ"^:;;; ,, every inHtance. 
•on, dyinft nwny fro.n ho.«c should be fe.ven 



]:• 



< #' 



^Ej^iF 




^'••f 



■if 





i i 



• 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATt FOR INSTRUCTIONS 



/)(f/r Filed, C 




^ Ovl 



IfJO'X 



llci^ish'ictl Xo. 



1795 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



,1) 



Ccvtiticatc of IDcatb 

PLACE OF DEATH: — County of^'a^v \a.vvCA,<i<- : City of Oa 



No, 



A->' 



.^/vc^ 



OCKJ 



St4 ■ 



Dist.; bet. 



and 



/ IF DEATH OCCURS fcWAV F R O A USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION \ 
V IF DEATH 0CCU(»)RED IN A^^IOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 



FULL NAME 



r\ 



->i;.\ 



PERSONAL AND STATISTICAL PARTICULARS 

f> C()I,< >K \ 



I) \ ri-: oi- inKi'ii 



\<.K 



M..iith> 



),,/, 



I ! i:i \ 



M.n,ni 



SIVi.IJv MARUn:i) 
WIDoWia) OK IHVORi}-:!) 

'Wiiti ill ^cH'iiil (It— i<jii;iti')ii) 



lUKTlll'LAiM-: 

' State or (.'oiiiitr\ 



MEDICAL CERTIFICATE OF DEATH 

I) \l'l'. 1 U ill \ I'll V 

I "1 

MiMltll' 

I II i;k i:n\' ri'K ii i \ . rhi; i ii:.'-,' 

tli.H ! i • . ' ■ ■ " 

,111.1 ! h.-it ill ,i! Ij 1 .i . HI ifil, I ni I In- ill' 
, M. Til. (■ \l -~l. I 'i i '! \ 1 I! 



\o-; 



\ WW ( )| 
I A Til I-.R 



inKTIll'I.ACK 
<)l" lAPllKK 

'Stale < ir I'ounl ;\ ' 



\IAIIh:n NAM)-: 
<)!• MOTIII-.K 



I'.iR'nii'LAn-; 

<>|- MoTlll'.R 

'^tfite or ("oniitrv^ 



< »'r|-i'A riox , 

Kf^iifiif in S,ni I'l d ii, 



\)\ K \T1< >N 

c ( >\Tl>: !i:r'r<>K\ 



Mouths 



na\ s 



Hi 



Hi I 



Dl R \ !!< »N 






/',/t 



(SIGNED) WvCr>\JA J.. ■ 



Special information "nl> '"f HospltdK. In^litutlons, Irdnsknis, 
or Rerent Rfsidenis, ,ind persons d>in| .m.i\ Iron home. 



) , .'.-. 



1A.^^'//- 



/^/l 



Former or 
lsu.il Rpsidenrp 

Whfn Hds disr.isp lontraffrd. 
It nut at pidirot dp,iffi ? 



HoH long at 
I't.ii (• lit llPdftt .' 



[Ih^< 



1H1-, \HO\-I-: STATi;!) I'HKsON \1. P \K riff I.ARS ARM I'Rri-: 1" I 

iu;sT oi-' Mv K.\t)\\i,i:i)c. )•; and lu.i.n-'.i 



' I n fuiiiiaiit 



J'^'\JL^^ U-M 



( Adilress 



1-r, \ri'; i n in rim. ' ' 



i; ;: ):%'• ■ \ 



I N I ) 1 . R I \ K v. R JXjUL/^X' \ 



' '.!''■ \ : 



d-CivL «^viv IQd 



,. , Ar-r «hrniltl be Hintnl I.WCTLY. PHYSICIANS mHouIiI 

IN. K.— r.very ite„, of inform.tu.n hH.uM h. ...rcVully supplied. ^ ' ^^^^^ 'j'^^^^^,^^^^^^^^ ..s,,,,,..! In.or.nHtl.n- ^'or pT- 

Htnte CAUSE Of DEATH in pijiin terms. tliHt it muy be prc-perly cIushukci. j 
sons tlyinft owny from home shoulil be Jiiven in every inHtnnce. 



lilP'l 



s; ^^'i 



ir 



""" 1 



•4j 



H' 



>iPt 



41 



, ^ 




I 



.1 i .j »i»»»<»l— BWBHy-MtiimMiP^TJOWWW^ ■! J. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J,,,,:,: 1 Health- (• No. l^ "S^agjl^; ISM' Co 




X{ 



lUO'i 



]i<'i>i,sli'r('<l s,V(t. 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



:i)6 



Certificate ot E)eatb 

( U. 5. StaMOnrC> i 



PLACE OF DEATH; — County of ^ C\ .v OA^ayvCA. City ofU.O.- Vcv>\.ev. 



A 



!itv ofO'^ 



(^ 



,'!}■ 



q. 








No. VxIh^"^^--^^^ ■ ' '^ Oi:)^<^,\ ■ St.; Dist.;bet. and 

\ / IF DC*TH OCCUBS,Vw*Y FROM <ilSUAL RESIDENCE GIVE FACTS CALLED roR UNDER ' S PE C . AL . N FO R M AT. O N \ 
(, ,F DEATH OCCUrtftED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ^ 



FULL NAME 



A . 



•-i-x 



PERSONAL AND STATISTICAL PARTICULARS 




\aA^^ 



lt\l !•: oi- I'.IKTH 



\' .»•; 




(Moiillil 



I)a\ 



C^». i )ViN 



1/ 



w int»\\i.:i) OK i)i\-()Kri-:i) 

'\\'iit«'iii social (Ksij.m;ttii)ii) 



1 Slate or (,"MMtlt I \ 


lAIHllK 


IURTHI'I,.\rK 
<)I- I-ArilKK 
'Stat<' or Codiitryl 


M.\ii)i-;>j NAM)-: 

Ol- MOTHHK 


H!!<'nn»i..'\rK 

»»l' MOTMl'.K 

f state or Couiilrv 1 


OCCri'ATloN 




r> ' . 1 




MEDICAL CERTIFICATE OF DEATH 

II A n. ui in; \ I'll 

'M..nttl 

I IlKRI-llV CHR'lll ' ' 

I , ,( 1 I . ' 

tli.it I Iii'-t ^;uv li ' .^ ' 

,111(1 th;it ikatli i xvii ik-.I. "M ' Ik ' • 
Tlu- CArSI{ ('! I'i \ 



Ju^vV. 



]>,< . 



I 



ill \\.i-- ;l■ 



tM:;.,^\■ 



DIR.XTION }V,//s..^ .]/,<>, //is /Kns 

(.ON TRinr TORN' ' 



I lout 




c 



X^uu 



( Ltur \U<rV 



l\f^i,!l,l III S,:>l I'i <! Hi I '>'• 



)r,,i 



M,nitll' 



(SIGNED 



-^ 



I<)M 



M.D. 



\.l.li. - 



SPECIAL INFORMATION "nU h.r HMtnls, libtifiitionv. IfHnNirnls, 

or Rprt-nl Rrsitlents, dnd peisi^ns dving <ih.i\ lro» homr. 

Whpn Hfl'; disrasp rnnlrHi ffd. 

It not at placp ot dfafli .' 



illi: An<>VK STATl-I) »'KRS()NA!, r\KTU;rL\KS.\Ki: TKIK T<' TIN': >U-^'' '" 



in;sT oi- \Lv k:^>\vli;i)(;k and Mi:i,n:F 



f Info! Tiianl 



,„,,„,.. '!,:i,,, '■• to %^•^^- 



, N 1 > 1 ; K T \ K I' K '0 O^CXa v. tie I 






'Addnsv. 10 ■< 



'■\ 



t 



,Hou.. He c...eVun. ^uppHe.. ---'>- I^^^rr^^JJ'^I".! ..Z.^"^^^ "i::" 
in plain term*, that It m»> ».e pr.M»crl> cltt8ii.»icd. i ne i 



N. B. Kvery item of information 

state CAUSE OF DEATH in p . 

<<ons dyinft away from home nhoulcl be jUiven m every mstnnce. 



1 M^^ 




»1 1 1 J 



# 



II 



1 » ». 



♦Pf 



J 




m 



I f 



^.^-iT WRITE PLAINLY WITH UNFADING INK 







THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FO R INSTRUCTIONS 



\7\)7 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot IDcath 

[ "U. S. i^'tn^^a^•^ ) 



A 

PLACE OF DEATH; — County of > 

No. IHS'b JA.O .,., . • 



V 



% 



City of Oa^ 



St.; 



Dist.; bet. 



< V 



and 



/ .r DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CAUFD FOR UNDER SPECIAL INFOHVAT ,N 
\ IE DtATH OCCURRED IN A HOSPITAL OR INSTITUTION 



GIVE ITS NAME INSTEAD OF STREET ANO NUMBER 



FULL NAME 






L Cl. 



'^'^^ '^ 



PERSONAL AND STATISTICAL PARTICULARS 



J 



i>.\ II'. <ii' i:iR rii 



«■' il,( >K 



\Y 



MEDICAL CERTIFICATE OF DEATH 

I > \ I t I 'I ! I I \ i i ( 



' Month 



' Ii;i\-i 



l! ) 



AC »•: 



7 






^IN<.I,I" M AUK li;i) 

w'lix »\\i-;i) «»u i)!\'( iK( i:i» 

' H"i iti ill social i!i -i'-iial i..ii) 



i!ii: iiiri.Aci-: 

'Statr (If CNimiti yi 



\ \ M !■ ( II 

!■ \iii i:k 



IlIK'IfMM.ACK 

"I I A rill.; k 

' SI, it. Ill Ciiunti \ ' 



M MIUvN NAM I 
"I .M«»rm.;k 



HIK III iM, \ri.; 
OI- Mt»iiii;i< 

'State ,,, Cminti \ 



• »> ' ri' \ riUN- 



I 



A.cL^y-VAJU "^ 



I II i:In \\'-\ * l.i; 1 1 i S , ih.it I .iniMi'U-i 

f!i;i( I last saw !i 

ami t hat ilrat li ■ , . 
vL-> M. 'I'll'' ^ \ I ^1. ' '1 I •! \ I I I 






11 \ c I III 



III , ! I ; ii,' , 1,1 



i' '\S s 



y » 



0-v V , . 




^XXr^ I . 



)rk ATM (N 



)V, 



I n\l'k I i;i T( 






/'./M 



//< 



'/// N 



o 

( 



1)1 i.:.\'ll( tx 

Signed ' 



(/ f/is 



/hn 



'V 



OXv>\v^ 



// 

M.D 



K/i 



\.|.! 



Special information "hIv tor H»s|.it.ils, Inshlulions. Irdnsicnlv 
or Rcifnl Krsidfnls, diiil pi-isoiis ()\iir| ,ih,)v Inni honi*". 



yf .iifin 



lormpr or 
lsii.ll Kcsidt-nir 

Whrn WHS disfdsr (onlr.idpd, 
If no( a I pl.)( «• ol dcdfh .' 



HoH liinq hI 
Plrf( r ol II. rfth .' 



Ddv« 



I'lir, \ii' »\i: s r \ii- iMM-'Ksi t\ \i. !■ \ IM n I I \ Us \ki. tki j, ik rm 
Mi;sr(»i' MS' K M i\\ i,i:i)( ,).; \\i) ni i,ii;i- 

, ^ ^ 



\. 



Mnf. I'liiaiit (' 



'\'\..<i I 



I'l, \»'l': I tl lit K I \l, I iK K I, M< '\ \l, I l< \ » 1, ••■ l; IM \! . r K I M. I'. \I 



Cr>>->^ C 



I < 



'\ii.it.-x .0 



t b 



>^ 



IM I \ I. I Is v'^ '^ ' V 



Ov 



^< 



■^^ II.— — Kvcry itt-iii <»V in lormjit ion Mhi>iil<l hj i. iirutiill.v sti|>|tl!c(l. A(il. h"ii.'.iI«I lie Htiilcil I.XACTI.Y. I')I\SICI\>S hHimiIiI 
Htiitc CAlJSi; Ol' ni;,A TH in plinn ttrnis, tliiit it mii.> Jn: propi rl> ..litMMit'icd. The "Spvciiil liiior>rtititi.in" ittr p«p- 
Ron« clyiti^ iiwny from homu nIi(»uI<I he (^iven in u\or> inHtnncc. 




#ifef 



MJ1M-. JBfe- 




HI 



WRITE PLAINLY WITH UNFADING INK — 



n.iai.i ..f iit.'iitii I' s'o. Is "^^^^^i nSi]' c, 



/hf/r F/7rf/, DjJ^k^iy\y\X}JU\' 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



..a I 



0/)M 



IfJO 



JkC^isfcf'cd A^o, 



\7UH 



A\^K^ d Xv-j Deputy Health QfTlcer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ceitiffcatc of S»eatb 

( *U. S. Stan^arO i 



PLACE OF DEATH: — County of 



r\ 



City of 



No. 



/CL^ 



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



St.; Dist.; bet. 



and 



RES I DENCE GIVE facts called for under special information 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



FULL NAME 



!!■ 



^i:.\ 



PERSONAL AND STATISTICAL PARTICULARS 




1 



^ 



"\ 1 1; III itiK 111 



\'.i-; 



I) \ 1 



MEDICAL CERTIFICATE OF DEATH 



III 



/'/ 



M..iithl 



) (■</ ( 



i>.i\ 



1/ -./'/,' 



(^l.)lll^lt I'v N 

I HI-:KI';r.\' CI'KTII'N'. TIi.u l .ittin-l. <!.!... ,i>r.| t',Mm 



1 <^' 1 



I,/) 



^iN'i.K, M.\Kkn:i) 

^\■^)(»\^ j-;i) «>k divokii-.d 

'U'litcin srx-iril ilc-^i^.Miiit ion ) 



HIk rill'I.ACK p 

(Stair or i,"()iititry^ ~\' 



NAM!-: ()!• 

1- \riM;K 



KlklMIM.ArK 
<H- l-AIHHk 
iStatf or (.'ountrv) 



MAn>i:\ NAM1-: 



itik rni«r.A(i-: 

•»!• M<)TMl-;k 
(Stall or Countrv I 



OCCri'AlloN H) 



c) 



n I 



t hat I last saw li : ali\ i 

a?iil that litatli < icciincil, mi thr ■' 

.M. 'I'lu- C.\I Si'] (»l hiATII u..> ., . kmN.vvs 

M\ , _ 



{ J (Xrr^ A/O. . 



/ 



|)rk.\ iloN 



(. ( )N'I'k Ilil'ToKN' 



l>\ k.\TI< >N 



}\ 



1 1 



1/ 



/'./I 



// 



.I/,"///m 



/' ' / 1 V 



\Xj 



SIG 



NED) J 



M.D. 



i(j'» 






Special information •»"'* '"'' HospitdU, Insfiti/fions, [rimsimts, 
or Rfffnt kVsidrnts. .ind persons dvim) dv»dy trom home. 



h'fsidrd III Sdlf / ii!. 



),,n 



M.nllh 



/■■: 



Tiir; AHovF-: ST \ ri:i» i'kk--< )\ \i, !■ xuriiTi.AkN aki; iKir n > iiH': 
iu;sT ()!• Mv KNOW i.iiK .!■; AM) iii:i.n:i' 

'liil-Miiiant C^CLaa^OJV'C^ O Q^' ' \ 



formpr or 
Usual RpsidrniP 

When HdS dispdsp fonfrnitpd, 
If mil dt pidip of dPdIh .' 



HoM liinq at 
Pld< p of Ofdffi ' 



Ddw 









l'U\CK nl- ItlKIM. ''K KI;M<i\\I, 






'A.!. 



l!.^- V. 



a'. 



V V- 



N. K.^,:ver> item ..V in^.rm..,ion «ho„l.l I.. .i.rc,-ully hup,.IKmI. M\V. hSouI.I ho h,..,c.I I.X ACTL V •JHVSICIANS hHouM 
Htate C AlJSi: or 01 \TH in pl..in term*, that It m=.> he properly .h.MKir.e.l. I he Hpecu.l hUormMl.-.n .«r p.r- 
sont flying nwny from home Khoiild he ftlven in ocr.v iriMtuncc. 




t;'^(» 



M f 



•M_A«MBadaibi 



*? 



I 



I 









1 ! 





WRITE PLAIM 



I V ««/!-•- 



la • • M . .^ 



— .,r-i tiiMfarMtsin. iiui*_ -tl...- ,^ 



WRITE PLAINLY WITH UNFADING INK — 



l!i';n.!..f U,-.iUli- I- N'o. n "fr*?^3ct-I5;»-. JUS: IM 



Drf/r /'VAv/,^X^x±JL-.>vl>^\; ;!,' 



THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTinCATE TOR INSTRUCTIONS 




/f)(n 



Jiro'/sfr/'rd ^Yo, 



J 709 ' 



AM| Depuiy Health Onricer 

DEPARTMENT (k PUBLIC HEALTH-City and Counly of San Francisco 



Certificate of IDeatb 

( 11. S. Gtan^nr^ i 



PLACE OF DEATH: — County of Lit 



<^) 



No. 



'. / 






City of ^ 



^'■.culi,L- 



St.; 



Dist.; bet. 



and 



( " ?^v^^ii::^-z^^ :^f:^^j:^^-t^^iij;^ r.-rjr .^:it-~r 



) 



FULL NAME 



.0 



lLvco.-) 



V. a 



PERSONAL AND STATISTICAL PARTICULARS 



Hi a.. 

1>AT1-: OI- lUKCIl "N 

Mi 

M'.iit li 
A<,H 



J I It I A 

'^IN'.l.lv MAKKIHI) 

W IDOWKI) OK DIVoKOKr) Q 

'U'ritfiii s<)c-i;i] d* vi^r„;,t j,,,,) ^' 



luk rniM, AOK 

I'Stiiff or (.'(.iiiitrv) 



U : U 



iDav) 



V M.,>tlf,.y \0 



I Year) 



/^n,^ 



N'AMIC ol 
FATHliK 



niKTniM.ArK 

Ol" l-ATUKK 

'Stale or Comifrv) 



MAII)|.:n NAM).- 
<>!■ MOTIIKK 



lUK riii'i. Acr; 

<•! MOTIIKK 
(Statf or roiitilr\ ) 



oCvll A lh)N 






MEDICAL CERTIFICATE OF DEATH 

I) \V\: « >l I>1 \ i II 

i I 
M.Mlfh) ;,,,, 

I lfl';Ri:i!V ri;RTlI-V, T!i,it l attm-UMi .ir,..i.>, 

U/5 t.i ,,,, 

tliMl I last saw li alivi- mi ,,^ 

iiiid (hat death oci-iirrc.i, on tht- datr ^tatr.l a!.ovi-, at 
M. The CM SI-: Ol I)|-;.\T|| u... .,. (olh.u.; 



DC RATION );■<;, V 

CONTRII'.l T()k\- 



J/, "////• 



/>./) 



//.'/, 



1)1 RATION )\ais 

( Signed 




\L<k U< 



M<yuths 

O 



/>.n 



^^^. 



± 



r ( >' ) 



- A.I.insv) UA..k.<.-» ) .'A ..• 



M.D. 



Special Information onh for Hospitals, institufions, irdnsifnts. 

or Rec'-nf Residents, and persons d\ing .mnv from home. 



I ( 



former or 



K'fsuirii III Siiii /'i ii If, n,\i 



)V,; 



i 1A-////> ( 



/ .■ 



former or i^ la ii i , 
Isudl Residencf > I I \J ClV. 

When was disease tontrarfed, 
If not af plare of death ? 



HoH lonq at 
Pla. e ol Death .' 



{i^\^ 



Till-: AiJovK s'l'A ri:n i'kkson \i. pxk i in i, \i<s \ki tkij- in 

M1-:ST 0|- MV KNo\\l,i:i)(,|.; \M) MlI.Ii:!' 



1 1 1 1". 



Oiifoniiant LAj ' ') "> V LAw -C. s 



•I \CK OI- HrKIAI,..K Ki:\lM\- W. I.VTj;..; lUuiM ■■ K1Mm\vI 



l'^ 






i^t . ai 



' rs 



•Atl.li.vs X^ U<X>A, vKlt^/O IC\^"> 



190 H 



N. B.- 



-Kvery Item olt informiition Hhouid he cjirelfiilly supplicl. A(;i. Mhoiild he Htiited I.XACTLY. PMVSICIANR nHouIiI 
mate CAUSE OF DKATH in plnin term«. thot it niii> he properly vlmiNiirieti. The 'Special Inl'ormation" for p«r- 
xon* dyin^ away from home shemld he <ii%en in c\cry instance. 



N. 



IliMiiliifilf 




♦l > 



^ 



lit 

1 « 







p 



If) 





! I 
( 



Uk. 



>i«; 



ili 



WRITE PLAlNi 



V lil#i<*>i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



J? 




5,-?, 



/.V^'H 



i -\ r. 

d^\^\^ JoyvAj Deputy Health Officer 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 



1800 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County 



o, m 



CLVctv' 



1 M - ! 



City of ^ ^Ct>v 




CV^. 



Il (^^ ^ 



St.; Dist.; bet. 



r IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS Ct 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N 



and 



FULL NAME 






'.O 



L 



AILED FOR UNDER "SPECIAL INroHMATION \ 
AME INSTEAD OF STREET AND NUMBER / 



PERSONAL AND STATISTICAL PARTICULARS 

|>A 1 1: o|- iwN rii 



COI,<»K\ -^ 

1 I " 



nM.>iiiii 



A •■.!•: 



^'N'.I.I-:. .MAKKIi;i), 

\vrr)u\vi-:i) OK DivoRi-i-:!) 

'^^■^il(• ill «'.ci:i! .!( si-iiat ion) 



i .A 



.1/,.//'// 



MEDICAL CERTIFICATE OF DEATH 

DAT)'; < 11 Di: \ in 

I iii:r i:\\\ ^ i-.k rii\, i h,,. \ i-;, ,i,ir,i ,i^ 
- j^^j — j^^ 



/' 



N . .. 
I r- ■III 



th;it I l.is! s.iw h 



;ill\r on 



I',' 




mRTiii'i.ACj-; 

'St.iU- or t'uuntiy) 




ro 


XAMi: Of- 

HA'rin;R 




Lo_ 


'UK rni'i.ACK 

f>l- I'ATIIIIK 

'Statf or fouiiti v) 






MAI 1)1. N NAM}- 

01- M()Thi;k 






'iik'iniM.Aci-: 
«>i- .M(t'nn-:K 

(Stall- or iduiili \ I 






^ 

.^ 






OCCri'A'llnN 






l\i' • Itll i! 1 II V,; ;/ 


/ / ,Uh 


/ w''/ 



:illii til, It (If.itli , .. ,|itr,'.l, on the ,1 :■ ■:•.,! ,,1,,,^ , ,' 

-- AL 'I'lu' CAI .sj' (>l i»l \ III xs ■ , 



I 



nils' \Tln\ ) ■<//,- 

CoNTk ii;i|( ik\ 



.]/,>n(h^ 



I hi I ^ 



//,', 



DikArn IN 



Signed 



Month' 



/h!\ 



I 



M.D. 



A 



\..U 



! r ,' J 



\AAr> 



. ' O. »x 



SPECIAL INFORMATION <»nlv h.r lluspilrfK. Inslitutions. IrHnsimfs. 
or Rpffnf Rfsidcnis, dnd persons dyiritj .iHdv frmi homr. 



) I'll I 



Mi.iith^ 



I hi 



formfr or 
L'sudI Rpsidence 

Wfirn *»as disMsf ronfrarffd, 
If nof «j( plaff of dfdih ? 



HoM long <il 
PUf of fifdilj.' 



Dd\« 



I'm-; AMovK ST \ri:i> f'KKsovAi, r'AKTicr I, \Ks xki- i-kij- r.» rii) 
lU'lsT oi- Mv KNOW i,i:i»c.K AM) i!i;i,rj:i- 






K 



O.'VA; ^■JVCVt.JXXA 



n 



I'l.Xri; or 1!I RIAI, «.K |.;1M..\\I. j \^\\\ .,' \v ^•^K^ ,,i K1M..\M 



I no 



I M)i.K r \kj:r 



Ol 



<\ 



\.|.!r. 






V V 



Lu,\ 



^' **• Hvery Item <»»' !n?(»rmHt!on should be cnrefiiiry Hupplird. \V,\. hSo-.iI.I hu Htutcil I.XACTLV. PHYSICIANS Hhould 

state CAUSE OF DEATH in plnin terms, thnt it miiy be properly doMsitled. The •*8;iecliil IntormMtion" tfor p«r- 
nr%n% dyinjt owny from home should be Jiiven in ^s^ry inntnnce. 



^» 








V 
•?*. 



) . 




t 



H 



#' 



WRITE PLAINLV M/ixu 



I i Ml *• * ^. 



■""'"""!S_INK — THIS IS fl p,£ 
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTITICATE FOR INSTRUCTIONS 



);-.tN! ,,f irir.ltli I-Xo ;, *-^~S?^?:j{S:l'0.) 



/>N/,' /'Y'''/ rOJLYXjUyyxLvv 1^ IfWi 





liciii.s/ci-ri/ A'o. 



1801 



t'n Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and Coontv of San Francisco 



Ccitiffcate of IDcath 



PLACE OF DEATH: — County of 



City of 



n.xU 



<X , ^ 



No. 1W\ 



St.; 



Dist.; bet. 



and 



( ■' "r»,°-e:„%;rj,rr„o"s^.y.- ^^^±^^^i:r^^^i --i: j:--~rl 



FULL NAME 



^iV 






JC\ 1 



PERSONAL AND STATISTICAL PARTICULARS 



~" (ho 

DAII.; (.!■ lilK III 



\<-. !•; 



I COI.OR > 



^ 



I 



M.jiilhi 



I):iv) 



M.^ulhs 



\ ' .11 



/>,' 



MEDICAL CERTIFICATE OF DEATH 

i» \ r\- Ml Di: \ rii , ^ 

1 IM.Ri r.\- n.RTlI-\-. !!,,! I 



II..N 



' 1 1 ■ 1 < 1 - ( 



-^IN*. I.i:. MAKKli;!) 

^\ n>n\\ KI) (»K DIV.tKii:!) 

' \\ I iti- in M>i-ial ii< ^iLMiMtimi) 



inkTill'l, Ai-).; 
' St;it( or I'oinit I \i 



\ WTI' n|- 
1 XTIII'.k 



HIK llll'i, \(F 
Ol' lAI'in-lK 

'St.itc or c'ouiiti >-^ 



<»l MorHKK 



I'-nn'in'i.Ai'K 

'M- Morn I-; R 

{Sl.'itc oi roiiutrr 



• >i"cri'A riox 

f\f>i(ffi! in Sill' /'i ii I/, /','ii 



i 



I (/) ; 1 1 

that I hist s.iw li ~ ,i!i\r nri 
and 1 hat ilrat It mccii rn-' I. "ii r lit ■] <■ , • ■ 
M. Tlu- (' \l si: (I! ! »| \ 1 i I v 



\ ■ '. 
•I tl'illl 

1 1/1 ) 



vvl 







X-'V^/YV^LuA. \* O 



lL| 



A.Ci- 



1)1 i^xrioN );v//s 

e ONTRIIirTORN 



U, •>//// s 



I hl\ s 



//, 



out s 




I ) I ■ R A T |( ) N 

( SIGNED ) ^ 

^.t\\t\'^ TOO -I 



) i\l) 



M.'Nf/;. 



/',/! 









lli'U) < 

M.D. 



' \iiiit.ssi -,.. y^ ; 



Special Information oniv i,.r fioNpif,(is. instifutions. rrdnsimis. 

or Reifnl ResiJenIs, dnd persiMs dvinij ,ih,i) trorn fmmr. 



)■.•,/. 



M. <.,'!,. 



former or 
IsudI Rfsidrncf 

When Hds disrasf ronlrd'N, 
If ncf d( plare of dfdlfi ? 



NoM lung .it 
PId. f ot l)fd(h .' 



Ddv* 






niifMini.iul 



.'\>-^' 



IQO 



\.!i|t( 



M . I ; H T A K I : K iK. j . U.A^rW . ^' 



\<l<li t «(•% 



v<i,*Jl\-0 . . 



N. B.. 



Htn't7c'ursr^ir''m^^ '"' ^"""'""-^ HuppMe.l. A*;f; h1„m.I.I be HlatC I.XACTLY. PHYSICIANS nhuulcj 

Hon. dyinft «w«y from homo NhouM be ftiven in every {n«tiince. 



?r 



^'i^liiiiMtt 





ir T^ 



* 



■I 



.M 



J I 



1 



I I 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i;,,.u.l..t li.i.ith IVo. i^.X'Sj'^^-DScVC., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)ff/r n/('^/,^x\XiyyyA-~^>^' 'XX I^Wi 



Jtro'i.sfrr('fl jVo. 



180;:? 




^- \> 



^ 



De'^?Jtv Mrr?:f*-h r^^'-^^y 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Bcath 

( 11. 5. 5tanc»avC> ) 

OA.O > City of^'O. 



.N J.VO . 



Ne. 



PLACE OF DEATH: — County of^-'<Xnx' A o 

-%VXWxlO oL^A.4.i\ ■ ^^ St.; Dist.;bet. and 

/ .F Dt*TH OCCURS AVAlAV TROM USUAL R E S I D E N C E G . V F. FACTS CAllTD POR UNDER SPECIAL INFORMATION \ 
( IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 7 

/"On 



FULL NAME 



CV^^' 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 




I 



li."- 



DAll-; ( >1 I'.IK 111 



.^HH 



I Month ) 



I):i\^ 



> ( ■ : I I 



A ( ■. H 



(i.C 



) V'(/i 



1/ 



siNc i.i:. MARi<ii:i) 

UII>n\VKI> «>K I)IVi>K»*l-;i) 

i\S'iit'-iii ';<>ci;il rlfsi}.Mi;it i- )n ) 



Miu riii'i, \oi-: 

I Stntf <>i i'dii lit r\ ' 



NAM!' <)!• 
I- \lll I,R 



HI Rill ri<AiH 
Ol* lAlin-lK 

< St;it< Ml ('i.niiti a'' 



maii>i:n NAMi: 
<)!• .Mt)Tin;R 



i:iR riii'i,Aci". 

oi' MoTMl.R 
(St:it<- or (."oiiiiti > 



nccri'A riDN 




MEDICAL CERTIFICATE OF DEATH 

DATl-. (»!• ni'.ATll 



/..-,) 



M.iiilii' ■ ■ 

1 lii; i-j i;i'.\' (,'i-:rti IN , iim* i .uiiihU.i .u. ■ < ■•! ti m 



tliiil 1 l.i'^t '^au Ii 
;i?i(l that <U at h nccui ii-'l. "ii 1 !u 
LI ,M. 'I'Ik C^I'S!'. <>i 1.1 \ 



I 1 









• J 



r 

? 

r 



r 



^j 



J.- 



cLo^« 

Ij c , • 

k'rud,-,! Ill S,!i' /i, I in no lO ' "' 



Dlk \'II( )N )',iU s M,"il'is 

c< ).\'rKir.i r< 'KN' ^^- 



DTK \'rh )N )"/v/y s Mouths 

\ 

( SIGNED ) wX ^ 



l\l\s 



I lout < 



l\n 



I loii I 

M.D 



/ \ il.l i( S-, I I "^ I 



Qn^-: 



Special information ""'^ *"r HospitdK. In^titulinns, Ifdnvirnts. 
or RfCfnf Rcsidcnls, dnd persons (l>in;| .iw.is Iron homr 



formpr or li f 

I'sudI Residence ^' CX.^' 



: x.^ 



.i 



IJOM loni) lit 
I'Idi f III Dedth 



[ld\» 



M.,>,!li 



Till- \H()Vl.-ST\TKI)rKRS<)N\l, I'A KT U' C I. \ K ^ A K l. T R I I H ' TH). 

lii'.hT oi- Mv KNOW i,i; I ><;»•; and iu-.mI'.i- 

(I M To; m:. lit \JJa.^^O. 0-^C.V^VX; 

f '0 n i? 



.' \.i.it.-< 



% ic\ Lv.a.u. Jt 



When Hds disedsc (onlrdfted. ; _ | 
It not at plate ol death.' ^ ^^^ 



1M,\CJ-: "»1- ItlR I \I, < iK !' I'.'^I' '\ '''■ 



I NIM.R r \K IK 






;, \ ![ ..: I! iM \i -! k IM' 'V \l. 



rV 



Htate CAIJSI: OP OIATH '.n pliiin tcrnin, thnt it mi.y l»e properly U.iHMmc 
Ron» c!y5ni »w«y VVom home Hhould »>c ftiven in every innlnnce. 



-x«Jf. 




rm* 




M 




I 






I ; 



, f 



it 






if: 



WRITE PLAINLY WITH UNFADIIMG INK — THIS IS A PERMANENT RECORD 



j;.-,.ii! .'I' ill :iltli 






REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dff/r Filed , 




C\ C»v 



190\ 



J^CO'/.sf ('/■!'(/ vV7>. 






CrvA^v^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beath 

( 11. 5. Stnn^ar^ i 
PLACE OF DEATH: — County of "Vn vv Vcc^c^^v City of '^ ^x^^v Oaxx ->^e w 




I 



No. HO'N H I LI.CVV.V.O. 

IF DEATH OCCIIRS AWAY F 
OtiCURRE D I 



(IF DEATH OC 
IF DEATH 



St.: S" Dist.;bet. • ' and 

FROM USUAL RESIDENCE GIVE FACTS CAILEO FQ R ONPER SPECIAL INFORMATION \ 
N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME Llui/O. Li<xvlv-. 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 




l. 



LI 



i)\ri-: ()i i;iK rii 



\<.i-; 



,%'hl 



M.iiUli) 



L \ )>,;<> 



iD.iv) 



.1/.M////S 



( w:M 



/\n 



MEDICAL CERTIFICATE OF DEATH 

i)\ ri.- 'ii hi' vni V 

-A I I 












^I\<". l,i:, MARK I!-: I). 
(Wiiti in si)fi:il ilt-xi)." nation > 




.cL^ 



X^CUrVAT 



' st:i|f ol < '( III lit I \ 



!• Aiii j;r 



liikiniM, \rH 

<>1* lAlllKK 
iStatc or Count I v) 



^^All)l'.N NAM1-; 
oi .Mi>i"ni<:K 



niK riiri,Aoi<: 

oi" MoTlll'.K 
{Statr oi Connti \ 



()(•(• ri'AT ION yVv(' 






Wt IV^^' 



I VV^ .'^■_ . ■ ' 



h t »' a 




h n I 



CUXA 



A'^vw/cL 



I II |.;r i;i'.\' C 1, K 11 I'N'. Tlif' ' i'-- "!, .! M.T. .i->t .1 fr-iu 

tlint I liist --.lu li ali\r •ui !' 

:in,l tliif -Iratll tKninc.l. < <u \hv 'l;itr ^fat.J .iIm.\i-, at 
,_ yi 'I'lu' CAl SI'! <>!' l»l' \TII Ns.i- .IV t''H..\vv- 



.J/('V///J 



c'oN'rRir.iToKN J I l^tvccl VK- 



!Kn 



II, >!(l N 



DTK \'n< »N 
(SIGNED^ > 



1 

I 



\,l,lr.-sO li"lt' 



/',/r 



H 



M.D. 



«. N\.*. V*. '■ 'r U 



SPECIAL INFORMATION '""v 1"^ Hospitdls. Institutions. IrJnsifnls. 
01 Rftenf Rcsidfiits, ,ind persons dvinj .nv.iv from hoiir. 

HoM lonq ><t 

ri,i(C ol Ocith? Dhvs 



formrr or 
I'siidl Rfsidcnff 



j C ^^ V ^i I ' ' '^ "^ • 



k\-u'(fril III ^'ini /■'' I"" 



),■,;/ 



\r 'iif/n 



When W.1S disra^p rontradfd. 
It not .il plHip ot drnth ? 



TIM- \M(>VKST\Tl-,n I'KKSONM. PA K I" I*' T I. A K N A K l! T K T K L . IIH; 
HKST Ol' MV KNoWI.l.IX.l-: AND lU.l.lI.I- 



(In f' i: iiiant 






x,,,„...s HO'^ 



> V] rLvck-^q a . 



I'l \CJ-- Ol- IlIKI \L oK !•: IM' '' 'vl 



'\ 






\i , ! K J.M< '\ M, 



,„„„.„!,„f^'^acLax>.<^)l'a,uWn . 



\.li!t<-vs 



n 



^f\. 



4-^ 



" ■ ' ,. , x(:| Kho-.l.l be Htnte.l I.WCTLY. PHYSICIANS Hhonltl 

y, B.— Hvery item oi i„f..rm,.tion «h.,ul<l b. ^'-«'""> I*;';'; "' ; ,;,.,„,Hy JuHnhkcl. Tbc "Specinl ln»or.nHt..,n" iTor p.r- 

utiitc CAliSr or DIATH in |»l»iii terms, th.it it mM> Ik proptny 

Mon. <fyinft nwoy from home HhouM be Jlivcn in every uiHtnnce. 



i' ' 



■'im'm'iJtl^: 



'le 



is 



I 



tl 



1' 



.16 f 



• t 



•i 



< In 



■f 



ii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



),..,! ..f 11. :ilili I' N'') 1=^ •&-?:W;^--»)l{S:I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ff(' Fifrd , 



ckxr\>-^-<i 




a1 



vj(n 



lie <^ isle red Xa. 



1804 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beath 

I "U. S. 5tan^al•^ ) 

9 m 



(^ 



PLACE OF DEATH: — County of 



/->, 



C >-\' Vj CU-N 



No. ^C 



St.; 



Dist.; bet. 



. City of O/CLA^O.Va >vo, 



and 



..oiiAi orCinFMrF riur FACTS CALLED FOR UNDER SPECIAL INFORMATION \ 
( '^ rF"DrAT°H"oCc"u%ro\N"rHO^s'pyT*At o"r' f^ S^^^'T^O^N ^O.vYTs NAME INSTEAD OF STREET AND NUMBER, ) 



FULL NAME 



i/<XA,M^<:i^. 



PERSONAL AND STATISTICAL PARTICULARS 

I) All. < tl i'.lK I'll 

A 



MEDICAL CERTIFICATE OF DEATH 

1) Al'l', < 'i !'l \ 1 ii 



/'.'. • 



;Monll}' 



l>:i\ 



I INK !• I'.N i I IM"liN'. 'rii.it I .itUii.lr-! .It 



\(.i-: 



/^ r 



)\-.,> 



1/ ../'//■ 



/'<! 



SI\(-.I,K. MAKUli:i>. 
Ull)n\VI-;i) «>K DINOKCJ-I) 
'Write ill 'idi-ial iltsi-.'iialiuM' 



HiuriiiM.Ari-: 

I St:il( nr •'ciUllll \ 




Xcv\-\.OLd- 

^ 



a. Lex 



\AMI-. <)l- 

|'ATiii;k 



lUKi'iiri.ArH 

<>|- l-Allll'I< 
(Still* or l"oiiiili \ 



MAIKI'.N \AM1-; 
»>!• MollIl'.K 



MU'nilM.ACI': 
»l- Mol'lll'.K 
Stall' oi I'uiuitrv^ 




•K^ 



OC'lTl' \ rioN 



I,,,, 



that I last vl^^ h •■ ''i^' "" 

.,,,,1 ,i,al .Irath oorum-.l, -.11 llif •!.''> ■^'^«t' '1 •'''"^^•- ''' ^' 
Cl M. Thr CWl si: ()!■ j'lA I'll u,, .IS fo!l..u^; 



VJv-'V.>^' 



dr\^ 



a. 



c(>NTKii'r'r'»KN' 



M,"tlh' 



/>^n 



I Ion t 



i)iir\'ri( »N 



-^ 



SIGNED ) LLLkVl^ci 



k 






/>./! s 



//it HI > 

M.D. 



I.,n ( \,Mt.sO ^'^^ ^^'^ '^ ^ 



SPECIAL INFORMATION -nMor H»s(Hldls. instihilions. 
or Rftrnt Residents, .ind (.rrsons d>in.| .iv»dv lfo;n homr. 






M,,ii!li- 



(I 



nKXlU»VHSTXTKl..MO<S<.NAI.ISKTKr. NK-^KKTK. K T<. THK 
HlvST Ol- MV KN«>\VI,i;iH-.H ANP 111 I. II. I 



( \MrcsH 



\ 



i! 



. \ 



former or 
Lsiiiii Residenre 

When was disf.isp (onlraded, 
II not ill plai e of de.)(h .' 



Hum Innq <tt 
f'i,i.e III llenth.' 



Irdnsirnfs, 



Ddvs 






.^ ; ) • !;■ 



.' 1- 



1 \1i i\ \l, 






(Ad'lti'.'. 



^ , . ♦ t I rXAOTl V l>ll\'8ICI.AINS Nhdiiltl 
N. „._Hvery .ten, cW .n.> tion .hou... h. cn.c^J-l. -rM^M^;;; ,;:;;:;'*:;1;k.W.:c.: %H:-H.>c;...i ,n. nl.on- .or p.r- 

Bon. dylnft »wny from home hHouIcI be ft.ven In every 



»"^^^ 



.jiiil^ 



; ^•I'i 



■■£' 



h' I 



mriih 



W Z-JJlf 




i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



.,, II.;, Ill, |\n. 1. t^-tJ^S^''''*^''*^'" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^,^. Deputy lleaith Ofi^ 




lU'i:! isle red J\^(k 






pfffc Filed , C 

DEPARTMENT ^F PUBLIC HEALTH^City and County of San Francisco 

Certificate of Beatb 

( "U. *!'. 5tanc>arD ) 

J? ■ ^ \ % 

PLACE OF DEATH: — County of Oorvv ■! K,(X. vvcci cc City of^^'^X^v >1 \ O^ 
No l-^H lil'O St.: '^ Dist.: b€t.lU-tWUv and ■ ' ' 

y IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAMt iN^.t 



1' 



t \ 



FULL NAME 



MU 



PERSONAL AND STATISTICAL PARTICULARS 



^' 



It \ri' I )i- I'.iK I'll 



\<.i-: 




Ix^vl 



' Moiitli 



I. 



1\ 

!l)av) 



.1 /,')////> 



■»'c :ti 



/t<n 



sINCIJ*.. M.\KUIi:i) . 

\\ii)tt\vi-"i> <)!< dixokd: I) A 

'Wiiti ill •.<)<i:it <ltsij.'n.it i'lii) 



^ 



AxLcAAT 



luu rni'i, \(M". 

'St:it. Ill •"Miint I \ 



^ J X>v^>">^0..'>^^J, 



\ Wll. oi 
I ATHliK 



I. 









I'.IK riiri. xci*: 
(»i" i-\rm:i< 

'Stritc oi (.'oniiti y) 



M \ I DIN \ AMI-: 

OI- .m(»'ihi:k 



r.iK riiiM.Aci*. 

OI' Mo'riN'.K 
'St:itc 111 I'oiml 1 \ 




TjiA/YVUX^ 



Ol/v\c/>x€u4\ 




MEDICAL CERTIFICATE OF DEATH 

DATl'. «)!• DI'.Alll , 

., .U<. . - 

I |ii;i<i;i'.\' (. I'jn'II'N. Til. it I .itwii.K.l •!• 

that I la^t saw li ali\r nii 

;,„.! that .Icalh occurrc'.l, .m tlir 'latf Matc.l ah-' 



G'l^ 



\AJA.A..^1A_4, 



IH K A I" ION 



roN'lUIIll'IOKV ^ ^ 



) , (/; 



Mnullv 



lhl\ ^ 



// 



.1/ ■','///' 



/'/I 



M.D. 



A 



< It < I I' A IK )N 



A'/' nl,-d lit Siiii I I mi. I "> * ' v; 



)■. . 



///. 



/),n 



\>,' I 



\,Mr(ss) IX^ ^ 



•,•,M^^.U,VKST^TK.MM^K^nNA. PAi<.M;MM^VK.AKi,rKrH n. ...K 
I»i:sT OI- MV KNo\M,»;i'<vh AM) m-.IJII 

flllf'KlllMIlt 






\ + 



1 ) r li A T I ( > N 
( SIGNED ' 

■ SPECIAL INFORMATION o"H tor llospiMs. Institutions, frdnsirnts. 
or Kf(enl Rfsidrnts, diid persons d>in;| hh.iv Irom hmr 

Him long hI 
UsuhI Rpsidcnrf 
Wfipn v»as diVasp (onfraftH, 
II not dl plarp ol drath ? 



|;^\(K or in KIAL UK U1.M"^ ^'. 



,,Sj |- ,,' !!• . ! \i .1 I' I Nt' •'• M. 

'^xVxt '^'^ toon 






'\'l(1ll»S VJv O ^^ -. .^1— g«^— ^■■^^— '^"—"'^ 

_^ I I VACTI V PHYHICIANH hHouIiI 

^. „._Kve., ,.e. „, in.. i-n -H.-.M .. ..;«.;;., ;^pp-- ;:,;r:;r:.-.:w,:r"TH: ••«...:...; -• .■■-•• - -'- 

* . ^AiiKF Of- Dl ATH n plum tcrmi. thiit it mii> "^ i • 
iitatc CAUhL IM "i.»>" »- ,, u. A5vi.n Jn every WiHtance. 
«on. dylnA awfly from home Hhould be ft.scn every 



i» »^ 



"i^Mmtfk^A 






ffl 







i; 



1^.1 



t 




:\ 



WRITE PLAINLY WITH UNFADING INK — THIS 15 A PL Hiv? A N t N i klCORD 



,„,.,. i,.ni.:.!ti, r v.. i^ ^-t^-i'^i'^" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jleg/sfefCfl -\V>. 



/> { ' \ f * 



\ ^ . '^'"^ V, O'jputv 1 

DEPARTMENT OF PUBLIC HEALTK=City and County of San Francisco 

Certificate of IDeath 

of C'a^ J \o.'>xcui.cc City of CL \\. J..Va ^ ' 4 c^ 

St.; 5 Dist.; bet. ' ' (rt<t(vT,>v .ind 



PLACE OF DEATH: — County 



No. 



") 



,,.,,., or = ,DENCE GIVE FACTS C.LltO FOR UNDER ■•Sl>tCI«L INtOBMATlON ) 
( " °"jE".,H"oCc"u%rE","rH "s'r.t o"f:s^""o""vE ,.S N.M. ,~STE.O O, STREET ..O ~U»RER ; 



FULL NAME 



,-~> 



-'i;\ 



PERSONAL AND STATISTICAL PARTICULARS 

I Col.oR 




:i \ll'. Ml' l;iR I'll f\ ■^^ 



u . 



Mmitln 



At.i-: 



^H 



)-,-,M 



H 



t Dav 

1/..,////. 



> < .11 



/^/i 



--IN«". 1,1-:, MARKli:!) 

U Ilx »\\ i;i) OK I)!\« tK»»;i) 

'W'ltti in >.<>oi;(l (1< -ij.'nati<iii I 




A.duC-^-^^^'V 




lUR rUlM.ACI'. 

I st.iti or (."Dtiiil I \' 



\ \M1" (»I 
1 A Til IK 



lUR'ni I'l, All-; 
Ol- lAlllJ-.R 

fStatf <»r Coiinti y! 



M \ii)i:n' nam I". 

nl- MoTIll'.K 



IUkini'I,AC'K 
o). M()T1II':R 
!Sl:it<- 1)1 ("i)iililv\ ^ 



(HHTl'AllON 



A vJ 



O 



' \ 



UQA' 




vojdj i^ .cuUu^>vc 



t. 



^\Jb 




y^' 



<L 



^i) ' 



kCLU-XX. AJJX.^^ 



/-« A I 



sKjoC 



/~1 



MEDICAL CERTIFICATE OF DEATH 

\).\r\', (ii- i>i' \ I'll 

! Mnlllhi 

I III'KI'HV (.I'UTII'N, Til ,!. I atUM.'b 
I ()( ) ■ til 

thai r last saw li ■■ ;'li\r "ii 

;ni.i that -kath (.cni i kmI. -n !hr .latr -taUMl ..!. 

- M. The CAISI-; Ol' l»i: AI'Il \\'^ ■'" Inli-u- 

>.. . , 

I. (RATION )''"^ '/""^^^ '""'^ 

t 
CON'IKIIU TOKV 

IMRATloN )V./s .IA"/M. /'-n. 



!■*■■ 



//(',V^ 1 



(SIGNED 



M.D. 



It)0 



rX-Mrcvs) 



5 : 1 ''' 



■)ON on'^ '"f Hosiiitdls. In^tiliithinv, Fr,,(i.irntv. 



Od>s 




Krsiilril in S,tn f'nniii ' 



) Vv/; 



.y/,nilh- 



l>.:s 



Till-. AHOVK STATi:i) l'»^- '<^' '^' ) '' ''. )'^ nl-S'ir- K 



\Ks AK1-; TK' I'- ■'■'• ''"'■• 



L v>- • 



A,,,,r...,. 1<^5X- 3.1 A 



t H. 



QPECIAL INFORMAT 

or Rerent Residents, dnd persons dyini a«..) from home. 

Hov* lonq a\ 
Former or ,,,j,f „| Ocdth? 

Usual Residence 

When was disease (onlracfed, 

II nol at pla(e of dedtti ? 

,., All-. «»|- ItlKIM. OK K1M"\ ^' "^^' 



lOO 



IIXACTIY PJIYSICIANS should 
«tote CAUSE Ol 1>K^ .„ ,,,^,, inHtancc. 



son. dylnft away from ho.ne hHouUI be & 



>^Jf^.^ikalmm4 



fl 



•>.U 



w 



if i^!Hii;^\i, 



ft? 



'ii 






Iv 



I •! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ii>,,:ih !•■ N" '^ "^'trS-^- n.vi-t-. 




.-^OLt^v la 



Av^n 



l)nl(' Filed , 

DEPARTMENT OF PUBLIC HEALTH 



REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 



licdisfci I'll v\V^ 



City and County of San Francisco 



Certificate of Bcatb 

( XX, 5. StnnCarD ) 
PLACE OF DEATH:-Co«nty ofO^^- 'v- -^^'^"a? '^ °' T, '-'^^ ^ 

No. OO^t' '^ • pV .. v.. ,,^,,^, ^_.Y;*'cE GIVE TACTS CALLED FOR UNDER S . t .. A t I N FO R W AT . O N \ \ 

/ ,r DEATH OCCURS AWAY FROM USUAL " ^ f ' ^f , ^J^^O ^"^ , V E ITS NAME .NST^JaD OF STREET AND NUMBER J 

( IF DEATrtJoCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



FULL NAME 






^; 



d- 



■ 1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



W 



<X, 







I ' 



iiAi i-: <>i i;iK 111 



.\ I . }■: 



• Miitith I 



,1 y... 



10 

(Diiyi 



\ln<ill 



\(;il ' 



/)(/ 1 . 



SINC.I.K. MAKRIKO 
\Vn)()\VI«:i) <)U 1)IV( (K.rKl) 
iWritfin social di si(.'ii:iti()u) 




,OLh^\AJlA 



lUKIiU'l, \i"K 
' St.itt or I ■'niiit \\ 



\AM1-: <)!• 

1- A riii.k 







,-> 



MEDICAL CERTIFICATE OF DEATH 

t 

(Motltli! '' ' 

1 iii.:kI':i;n- ci.u'niN. ih ^ 

^^ r ny) til 0^'V- 

that I last saw li • alive mi 

an.l thal.lc-atli ..ccurrcl, --ii tlu' -lat.- ~tau.l ..!.•,. 

^ M. Tiu" CAisi-: oi" i'i:\ i II N\ '- ■'- ' '''■ '^ 



i 



vXcaX" 



,<xv^ yA<i^x^'<^^'^<^^^'■ 



niRTHI'I.AlK A 

oi' i-A-nii-:K _y 

ist.'itc or (.■oimtry I "\i 




NTAIDl'.N NAM}". 
<»1- MoTin-.K 



lUR rill'KACK 
<>J MoTIlKK 
(StaU- or Co\iiitrv) 



occri'xrioN 








\ 




"1 



DIKATION 
CONTKllUTom 



ft /• X s <^ 



M.'iiths 



l\i\ 



n,un^ 



or RAT ION 
SIGNED) Vl ito^V^r ^ 



/h, 






1 ^ 



//''HI 

M.D 



C]x-yO- '->•• i«K> 



"special INFORMATION "M"'"-''"'^- '-'''"'"'"^- "■'"^''"'^■ 
o,fe«n^ Ments «d person, dvi"'! ■'-> I'-" I"'""' 



Kf.idnl ill S .in rKUiiis'-o <^ \_ > "" ' — ■ 

TMKAm.VKSTATKnPKK.nN^I rAKT|rr..AKSAKKTKlHT«. TMh 



o.>l.aJ(w 



r\fl dress 



SI fU.A.^i-'CXrvs. ut 



former or 
Usual Residfncf 

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



HoH long at 
PIdif ol Death? 



OdVS 



, , , I i.vii ,,' iti KMi "r k »■: .M< •\' XI. 



»\J 1. oi It 

INDKRTAKKR C V3 O ^ . 

1 1 -in M I\a.; 



^^a\-^. 



" ^ , FYACTLY PHY8ICI4NS nhould 

E OF DEATH i» plain «""■•••'"''"!»; Lr.nc 



N. B. Bvcry Ite 

.tate CAUSE OF DEATH ,n X'-JV^iivVn'^n .v.ry in«tBnce. 
•on« dying aw»y from home should be ft. 





sr 



w^ 



I e e 



* i 



I 



•SSm 



i I - 



WRITE PLAINLY WITH UNFADIIMG INK — THIS IS A PERMANENT RECORD 

!!.,,ii.l of lliallh 1 Vm :^ '^-z^'j^-A'.SlV K\-, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nHr\ 



liCi^isfcrctl A^n. 



f c k)8 



Dale /vVrr/.OjL^vtx^-^Ll\; ^Ci. 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Benth 



"U, t?. 5tanC>ai^ 



PLACE OF DEATH: — County ofUa > • 



^y^ 



City of CJ,<X^\' 



Wo. i' 



x< 







AaJI/YV^<X1) oUa^^^v.^.. . - V .' " St.: Dist.:bet. 

IF DEATH OCCURS AWAV FROM USUAL R t S I D E N C E G I V E FACTS CALLED FOR UNDER 



( ■ N 



and 



( 



SPECIAL I 

IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AN 

^ 

\ 



NFORWATION \ 
DNUMBER / 



FULL NAME 




\.<:\. 



^.'^\^:■ 



4- 



si; \ 



PERSONAL AND STATISTICAL PARTICULARS 

l'<i],«»R,'^ A 



vjywu 



:l 



I> \ II". < H I'.IIM 11 



\i . !■: 



uU> 



M 



Jill hi 



['' 



\l,,„:h 



/',; 



ui!)n\\i;n K\\< DiVMKri I) 

'A lite ill »>(K iai (1( sij.'iiat iiiii ) 



niK rm'i.Ad-: 

I St.itf I ii <"iinnti >■) 



^0 



KJ^\Jokx 



MEDICAL CERTIFICATE OF DEATH 

D \ I !•. « '! I'l; \ Til 

\ « 

I Molllll) 

I II IK I !:\' < \ M'W IN. Til .1 ! AWy. ii.l( .! 'l- 

I ( (I 1 til ■ '■ 

that 1 1.1^! -.IW II ni\. -M 

aii'I tiiaf <U-atIi < mcu i ri-<l, mi tli :.il a' 

vj _M. 'I"lic C" \I SI-: Ol 1,1 \ 1 II u . 



1 1' '111 






> 



I 



X/VV'^ 



Vviv/&-^ 



\\MI ni 
!•■ AllI i: K 



HIKTIMM.ACK 
Ol" 1 A lill'.K 

fst.'itc III rdiiiii I \ ■ 



maii)i:n nam I", 

(H- MOI'IIl'.K 



iilK IIIIM, \ri", 
<H' MO'nil'.K 
'Slati oi rmiiiti \> 



nrcri'AlK >N 




<r/vq 



c 



v 



X 



hi RATION 
C(»N'i"Rli'.r'r()K\' 



) I lU 



/',/! 



// 



VV^^ V- ^ 



. ^ \ <■- 






^-' 



h'f-ltllJ HI ^',t>l I'l (llh 



1 /,.„'// 



/' 



|)i KATMiN )'.//. 

' Signed ) lL v 



.1/ 



/',/) 



M.D. 



1 1 lav 



Special information ""'^ t"f llospifHls, institutions, lf,insirnts. 
01 Rnrnt Residents, dnd prrsons dvin'j rtw,iv (run home. 



Till \Ho\r" sT \ I I I) IM-K'><»\ \!, !■ \KT|il I, \Ks \ K 1 : IKI 1. T" TUl 

iii-:si" Ol' M\' K \o\\ i,i;i)( .I'. \M' nn.ii.i' 



(111 fi)! iiiaiit 



Iv^xC ^va M lVo-~Y 



V k : > 



u,,.„,.ss %X'h\x U) X3jJko^vcyU>x v't 



lormer or "A ^V \ 

Isurfl Rpsidpnip v'.\ '. 

When Has disp,isp (onfrrtded. 
II not rff pleJfP of df.ith .' 



Hou long dt 
PIdif ol Ofdth' 



I 



n.i>\ 



ri xfi-: Ol m RIM, OK ki;miiv\i. I i'\u 



':'/CL 1 V 

i ni)i:r rAKi-K 



I Mil', \1. 

190 ^ 



\ . 



It«tc CAirSF or DliATH in pinin Icr.nH. thnt it mny be property cl«H«i.iccl. The Spccnl ln»..r,„„...,n »or p.r- 
«on« clyinft nwny from home Hh«»iil«l be feiven in every instnnce. 



.Jlfe^; 



IT- 




^ 



mm 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

1!,! .,f Hi-.ilth -1- No. !<. ^'c^fsr-:^- luSii'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffr AV7^>./, CJjlWI 



I ^ . * 



Bc^is/crcil s,V<t. 






Deputy Health CfiHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



\ 



,trxw^> 



Certificate of IDeatb 

PLACE OF DEATH: — County ofC'a : City of Ocx^x "^ V<X^ v 

(I \ "^ \ ' 

No. I'S.O^ Vi)A."^<li\.a VAO St.; *^ Dist.;bet. vJa^a^xK and 

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



FULL NAME 



^1 A 



I'O 






PERSONAL AND STATISTICAL PARTICULARS 

(,<»I,(iK>( 



^ 








\«.K 



1 <• 



\ V,a> 



^1 



"> . ;ii I 



/>, 



^IN<".I.I", M \KK III) 

Wllx )\\ l-:i) » )K l>l\-nKii:i) 

'W'Titciii smial disi^^' ii:it iuti I 



iMR run,. \(*i-; 

' St.itf or L'ouiilrv 



\\M1' ();■ 
!■ Will }■.}< 



IUKTHri,.\iH 
oi- I ATIII-.R 

' St.tti or I'Diint 1 v' 



M \n>i:N N ami; 

<>!■ MoTIIl'.R 



I'.iKTiirKAri-; 

< M' MoTlIKK 

' Stiitf or rotiiit r\ ) 




MEDICAL CERTIFICATE OF DEATH 

DA ri-: • '1 !»1, Vl'H 

(Molltllt 

I iii'R i:i'.\ ci'iK'riiA', rit.i! \ ,i". n ;. 

^. . ■ Il)() ■. til 

that I last saw Ii ■■■■ ali\i' on ^*^ ' 

and that dratli i>rcnrreil, on l!ir oair -ta(< 1 .il)' ■ 






M. Tlu' CArSI<: OI 1)1 .\ Tl! \N 




7 



p t 



1)1 "RATION y<'(H:^ 

(.ONTK llil'l ORN -J-^ 



i)CR.\ rioN >■(■<// s 

(Signed) OX<>^n.^ 



■\,^^ij^ 



Qlu. 



Mr>ilh' 



Ih 



n V 



// 






/^/iv 



//',W 

M.D. 



i 



\ 



I '^ 



'"■'■"■"■"" CkJv.1..^' 



ii(. ) 



^.l.lf.ss) lit OUervtc 



vv 



Special information ••f''^ '"f HosplldK. Instifutions, Frdnsirnh. 
or Recfnt Roidents, dnd pfrsons dvin;| ,may trom homr. 



AV.v/</a/ /;/ Siiv /'i (iiiiix'i 



Monl/r 



/>. 



Till- \iu»vK sT\ri:n i-kk^onai. cxk iuii.aks ,\k i; T\<\y. t" th'': 
iJKST ()]•■ Mv K.N'«»\vi,i;i)<^J-; AM) in, MI. i- 



dm 



/^ n y p 



Former or 
Isudl Rrsidenre 

When was disMsr (onfr.Kfrd, 
If not at plare of dcatfi ? 



How long hI 
Pld( f of f>f dfh .' 



OdS 



1 > \ i I 



(Address 



1X0^ 



)XA^'C. )V<x w.n. 



n ACK <)!•■ lUK I \I, < "l^ R1M(.\\I, 

^Xddr.-ss ^bb<0 ^J7V^ s ., 



II Ml '' \1. 

ion 



IN. B.- 



■""■"■"■""■"""""^ ^ IS .1 \{\r HhcniUI be stnteil EXACTLY. PHYSICIANS should 

-F.very item ni int'ormHtion .hou Id be c,.rctull> Huppl.cd. ^^'^J ^^^^^^^..^j. ^hc "8,>cci»l Intonnntion" for p.r- 

state CAUSE OF DHATH m pliiin terms, that it miiy be properly ciaH«me«. 

sons dylnft awny from homo Hhoulil be ftiven in every in«tancc. 





Bi 



V-0F WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RtFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






/>a/,- /'y/r</,^jLLJOUYyxi>~i.\' -Xl l'><>\ Jicgi.sh'inl.Vo. 1810 

i<^^^^ "i^-M Deputy Health C^-r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bcatb 



( "U. 5. i5tn^^ar^ ) 



PLACE OF DEATH: — County ofvJCL-> 






^^ <IC.A. City of ri ^> 



\ 



No, IHll .l.a;. 



^ 



St.; ^ Dist,; bet. JXX- 



\ n N ^ o 



and vCl' '. « 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL IN^-ORMATION \ 

( IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREFT ANH NUMBER J , 



c 



\l\. 



\ 



FULL NAME 



\i 



PERSONAL AND STATISTICAL PARTICULARS 



JX 

DA Tl', ( H- lilK Til 




i,'n|,(»k \ 



M'iiiUh 



\<'. I'! 



l", 



)■' ,' 



11 
Day! 



\<..iillr 



/',.M 



SIN'C.I,]-:. MAkKIl".!) 

WIIX i\\J-:i) OK I)I\"(»Kt);!) 

' W I iti i II ^iH-ial ih -.irnalioii ) 






I '^t.iti or ( "mii lit I \ 



NAM) (H- 
FAT II ]■; K 



lUR THIM.ACK 
<)1" lATHl-.K 
'State or LNnniti V! 



MAIDI.N NAM)-: 
111- .MoTin.K 



I!IKiniM,Atl<: 

<)i- M()'nii%K 

' stall or C'ouiitrv 



<)cH:rrA iioN 

I-MKAMOVKSI-ATHDI-KK^ONA!. l-AKiI;_ri.XK-AKI- TKli: Tn VUV. 
HI-:ST <»l- .VLV KN<t\VI.i;i)<^H AND lil.I.II.I 




MEDICAL CERTIFICATE OF DEATH 

DA Ti; t!i !>i- \ in 

* 

[ ||i:i< \'A\\ (.'1;K'I'! I'N . I'h n l itu-n.U-l '!■ 

D/ ) ■ jc. r - wi , . . 

that I last <a\v ll alive oil '''' 

ainl ihat il. alli . .cc;! rrc.l, mi llir 'laU- stair. 1 a!.. \. , i' 



M. Tlu- CA' "-!■ ' '1 I M . \ i I i \v. 



'.X ^vC^s 



1)1 l< A Ti< >N ^ 5'"// 



\/.'iif/i'< 

.VCv V V. 



/»,/! ^ 



//(III I ^ 



,,, RATION 10 )■ ;■ lAvM 

;NED ^ LLx/\\.<LLcrUL.?- LL « 



/' 



^SIGI 



//•III) ^ 

M.D. 



iqo 



\,l,l,v..i IC. xS ,L,v. .\-v'^ 



SPECIAL INFORMATION "nh lor Hospifdis. Institutions. Irdnsirnts. 
or Reient Residents, and persons dyiiiii hh,iv Ironi home. 



former or 
Usual Residence 

When Has disease (onf raffed. 
If not at plaf e ol deatli ? 



Hov» long at 
f'lrfi e ol flcHth ? 



Davs 



(\\\ fo: iiiaiif 



'Aj, 



i.d ^L 



n 



S) 



^,^,,,.s lM\b X<X\Jk^'w Ol 



I'l.ACK OUFUKIAI, <'K I' 1:M' '' ^ '. 



Mio^ e., 



¥ 






I M 1 1 



„,,K,;K CvX^CV V^^'*'^-^ 






^ ' "" T^ .... X,;,. s'loi.ia bu «t,.te.l I.WCTI.Y. PHYSICIANS nhoul.l 

N. B.— F.very item of 5nt\,rm:.tion hIk.v.1.1 \u- .Mro..ll.v -''»»>'• _ ^^ J„H«ir.c<l. The "SlcJ,.! Informs. Ion" »or p-r- 

Mtnte CAlJSr OF DIIATH in pL.in terms thn .t mn> ^ '^^'^^ '' * 
son. dyinfe away from home hHouM he ,>iscn .n every mstHn.e. 



''fit 



iiuwyy«»jK 



-f *^'Wi 




\l 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lI.:iH1» ! 






REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 



/)ff/r Fi/rf/ ,(jJiX\Xj^y^^isVv' 



lf)f)\ 



/*(• (J is/ (■/'('(/ A'(f. 






DEPARTMENT OF PUBLIC HEALTH 



City and County of San Francisco 



Ccvtificatc of Bcath 

( It. S. StniiC>avt> ) 



,\ 



PLACE OF DEATH: — County of*^ a'^ 



(^ 



i^ 



^ .-^ 



n 



-\ 



No. 



City of 
St.; 1 Dist.:bct. L UO-t and 



O.Ao 



FULL NAME 



~-i; \ 



PERSONAL AND STATISTICAL PARTICULARS 



Wo^U 



I» \l I- < 1 1 ItIK Til 






MEDICAL CERTIFICATE OF DEATH 

1) \ ri'. Ol- li! \ 1 M 



Nfolitli 



\<.i-; 



1/ »/'//> 



^INC.I.lv MAKUII'.I) 
WIDoUi:!) OK I)l\'< >Ki J.!) 



I'.ik rnri, \v")': 

' St:itc 1 iT I '. Ill lit I \ 



X 



.<X.L ^l<y\ 



X 



» 

that I last sau li iIim "H 

aii.I thai <hath MCfiimwl, on lh« .l.ilr 

M. 'I'lu' CMS!; ( >1 ^i'l \ I" ^\' 



A. L, 



O-^A^Ow'Vl i 



\ 



( '•> 



NAMl-. nl' 
!• A'lll IK 



HIK III I'l, AC}-: 
<)l' lAIIIl'.K 

' St:it (■ 1)1 Ti milt I %■ * 



M\!l)i:\ NAMl. 

(>i M(t'nij;K 



HIK'rill'I.ACIv 
<»1 Mol'IlKK 
( stale iir rodiit \\ 



orcri'A rioN 






f L<XVc>\.0 



DIKATloN )V.//A- 

CON TKIHl Tolv^' 



M,>'il/r 



/Kn 



// ' 



Ll'>-v ■> V m O /CuU <xl 



tcL.1^ 



DIRATION 
(SIGNED ^ 



) Vi//V 



.)/ "////' 



/'.n 



KK' 



> tor tldspitdls. Institutions. Irdnsirnts. 



a 



)V,// 



'{ }/,.llf//' 



/>,! I 



•nKAM.)VKSTXTKI..'KKSoNA..PXKTU;rLXK.AKKTKI K in TUK 
lU<;sr Ol' MV K NOW l.l'.IX. K AM) MI.MI.l 



(In f' II mant 



^L.U.i\; 






SPECIAL INFORMATION'"' 

or Rctrnt Residi-nfs, dnd persons dyin;| dv»dy froii hnmf. 

HttH loni) lit 
Isu.il Rfsidcntf 
Wlipn H.JS (Jispiisr rnnlr.Ktrd. 
II not at pldip ol dp.itti .' ^^ 



f).n 



|ii_ \ri-: Ol i'.i Ki \i. "i 



Ml i\ \ 



i . •> 



QjL^t' 






Ni!!' 



N 



I ' ,. , irr •ihutiltMie stiiteil f A \0 I I. Y. rni.-^iwii 

. „._Hv.r, l..n, ..,• 1,.»-... .i.... .H....M .;-■ — ..'-.v -.■;;;;-•. ;;•;;,„ „.•..,. THc ••S,...i .-orinHM ...• ."' .•"- 

. ♦ rAI?<;r or ni A I'H '1 plnin terms, timt it inii> • i 
«on, .lyini ..wuy from home should be fencn n, cxer> 



^mi 










II 



fr 



1 % 



W 



i 



h ♦ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/C Fi /('(/, 





<A.<^ 



jf/fr. 



]lc£i\st('r('(/ s^Vn. 






'\ 



DEPARTMENT OF PUBLIC HEALTH =Clty and County of San Francisco 



Ccvtiticatc of IDcatb 

( X\. 5. 5tnn^nrC> ) 

'7s^ J? 



Q^ 



PLACE OF DEATH: — County of ' -^ -)^' Jxcx^xrco - City of ~'0 ^^ ■* • •-> 

and 



L 



No.UJ^U '^^LtrVA.lA.tu - ' St.; Dist.;bet. and 

Jl / I F DEATH OCCURp AWAY TROM USUAL R E S I D E N C E G I V r TACTS CALLED POR UNDER SPTCIAL INFORMATION \ 
V) \ IF DEATH OCCijRRFD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NWVnrR / 



FULL NAME iU 




a-. 



SI 



PERSONAL AND STATISTICAL PARTICULARS 

Ol) j • i i 



KA'I'i; < il III Kill 



\<,i-; 



d 



M .tit 



nt li 1 '' 



/I . 



I>;i\' 



1/.. «/,'// 



\ 1 ;ii 



/', 



MEDICAL CERTIFICATE OF DEATH 

DA 11-: <)1- Di: A Til 

I 

iM.^iitll !' 

1 l!l':Ui;r.\' ^ l-lvlIIW Tlnd l itN n.It .l -!r, . is^.l lr..iii 



/<,. ) 



SIN(,!,i:. M \KK III" 

wiDt >ui-: n ( »K iti\ « )i.' 1 I) 

U'l it ' ill -' 'I 1.1 ! 'li - i v :i:i t ' i •! I ' 



lUK rm'i.xri-: 

I StMtf or I'Miiiiti > ' 



X L<L 



.^\xr 



;} 






k- v_ - 



N \M1' ()1 
I- \ Til IK 



lUKrfii'i.Ari-: 
<»!■ I \iiii-:k 

' St. Ill III ("iiimti \- 



MMI>I:N NAMl. 

t»i M<»riii:K 



nils ini'i, ATI", 
<>!■ Moriir'.K 

(St;it< Of (.'omill V^ 



orcn-ATiox ( 




o 



tliat I l;i<l v;ivs II 
;iii<l 1 1iat <K .1' !i • 



,lil\ 1 'Ml 

I, I III 1 he I l.t; !• ->t.it«.-(l :i!u ivr. i; 
M. TIm: cm si OI- mi-, ATII w.i- ;r> foll-'W^: 



1 1 ,' 



<X^C<X^rL/0 0/CL<i.o_ 







'4)-LL 




■1 



V/iw^vt M f Lf"' 



ty^<i<i 



r\ 




.1 O 



RV'-iifrJ in Sat! /'laih/sro - )V-,/;x - M ■>ifh-- 



i)ri<\ri<>\ )■,,/y^ 

C< ».\TR ll:l 1 < 'UN' 
DIK.XTloN )'<w/\ 

( Signed • 11 

cVi-^vfa 3lO too H I \.M 



M,'>i(hs 



1 Ki 1 . 



//,'.,; , 



.U".'//ls 



/Ins 



M.D. 



... I ^ ^ . ^ 



Special information «n'^ '"^ HnspitdK, institutions, Ifdnsifnls. 
or RtMcnl Rt'slilcnfs, dm! persons dvin) .iHdV from homf. 



/'„■ 



TIM" Mjovi-; sr,\'n:i) rKKsoNA). 1' \Kii''ri.AK> .\Ki, I'Ki i-; r« » riii: 
i{i;sT oi' MV/t_j^»)\\i-i:n<'K and iu;i.n;(" 



(111 fotinaiit 



former or 
Isiidl Rcsidrnrf 

When wds dispdse tonlrdc fed, 
II not df pliK p of death ? 



HoH lonq dl 
PIdre ol [If.tth .' 



Ddv- 



'A(1.1re^< \JJL/\>V^1- . 



r M 



I)I-:R TAKI-iK JVC- 



M' ■ \ 1. 






IS. B.— hvery item ai inform,.tJ«n «.k.uI.. h. c;.rcy'ull, supplie... A(iH hHouI.I »>e.«V.ted I.XACTLY PHYSICIANS should 
«tate CAUSE OF DIIATH In ph.in terms, that it may he properly cI«H,iVied. The "Specal in»or.„Ht.,>n »or p-r- 
«ons dyinft away from homo should he feisen in every instance. 






'Hii 



-Mm^mmm^''4 





'i 



^ b 



r 




'! #1 



WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD 

M.ui.l ■ f n,-:.Hh- IVo "^'l.-C'*' 1''^''''" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS i: 



dcAVA^^ XtvvM Deputy Health Cr7]._/ 



liC^ish'i'pfl jYo. 



181.3 



M- 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

* in. 5. Stan^aiC> 



N 



PLACE OF DEATH: — County ofOcL^- " ^ . City of OcC'^^ - ^ 

oAo^l vCMrcLL\A.:r St.; ' Dist.;bet. Vlcx^q.)^ 

(IF DEATH OCCURS AWAY Fl 
IF DEATH OCCURRED IN 



and ^ 



F DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDMR SPECIAL INFORMATION \ 

A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD tJF STREET AND NUMBER. J 



^ 



FULL NAME 



il 



\\.<x.^\\"\ 



SI \ 



PERSONAL AND STATISTICAL PARTICULARS 



i> \ ii: < n i:iR rii 



V 



llnr 



Month 



MEDICAL CERTIFICATE OF DEATH 

:)A I'l' ' il' I'!- \ I'll 






N 



: i 



Af.K, 



^\ 



! ^ 



I > (.-a I J 



/)./!, 



I iii-;ki.i;\ v'l.kTii-w I'lut i .ittin.u.i .u. v i^r.i ii-m 



SFNC, i.i-: MAKun:i) 
wiDt >\\i:i) Ok i)i\"t>kr}: I) 
Wiitriii sori.il •k'-ij.^natioii ) 



iiiK rn I'l. \c\'. 

State I il I "oil lit I \ 



N wn: ni 

1- Alll l.k 



lUR 111 I'l.ACl-: 

<>i" i-Aiin-iK 

'State ur Ton nt i \' ' 



M \ i i»i;\" NAM I-; 

<)1 M nr I ll-.K 



lUKrm'i.AiH 
«»i. M<)'rm-;K 

(stall- or (."oiititiA' 



cl dv. OCr^' 




lijD til X-*^P 

thai I last saw h iHve <»n 

ami that iKatli <H-(iiiii'tl, mi the ilite ^.tatid mIkut, i 
M 'I'hc CAl'SI'] (>]•' IH ATI! \\,i- a-^ \>M>\\ 

'' , ^ * 

I)[ k \'ri< iN )■<,// 

CoNTk IIMTf 'kN' 



l(<o -A 



\/.>>lt/l^ 



/\n< 



11 



LmIjo 




iW^VLkrvk 



DTR A'IMoN 

(Signed^ L* 



(H 



.//,'////■ 



/\n 



A.. , 



K)" 



1 

, \, 1,1, vs.) U,l 



M.D. 



aw •A.v.AvaVh.L'A. 1 



Special information ^"'^ tor tlos|)i(,)K. Institutiom, frdnsifntv, 
or Rficnt Residents, dnd persons dyini .iwdv from home. 



orci'TAi'ioN 



)'l-i! I 



M.xiih 



Former or 
L'sual Residence 

When was disease ronfrarfed, 
II not at plare of death ? 



Him lonq at 
PIdieol Ofdlti.' 



Ddvs 



Tin- XMOVK ST\Tl-;i) I'KUSONAI. I'A K TKM" I. A R S ARi; TRII-: T' > Till-: 

Bi-:sr oi-- Mv KN<)\\i,L-;nt'H and hi-:i,ii-.i- 



(lufo! maul 



1 at 






I'l \ci-; oi' r.i Ri \i, "i< Ri.M' 'V \i 



il' 



I) \ i;i' .il 111 HI \i "1 R i-.M< '\' \i. 



I 



I on 



ni)1-;rt\kir ^' '- ^^..0-0- c>A-' cJJ-^ 



(A(l<lrt-<-.s 



-1 s 



CI 



51 (^Vlv-... ^, 



^. u.— rivery Item of ln?or,„,.tion hHouM h. carefully Huppl... ^^X^^^^^^^^^^, ...Spccin. Inf..r.nHti..„- Vor pT- 
Htnte CAUSE OF DHA TH in plnln terms, th.it it m,.> ho propcrl) ^r.iHHnieu. 
non* dyini «way from home HhouKI he fcivcn in exer> inHtnnce. 




'^ 



I 



•I 



II 



-*' 



M < 



ft 







mi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PER 

»!.vi,,l ,,f llr.lltll I' V,, - ■^^^'»!!5>.:]',S^]> Cu 



MANENT RECORD 

REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 



^^^t^v*-*-^ v.. , Deputy Health CfHc-r 

DEPARTMENT Of PUBLIC IIEALTII=city and Counly of San Francisco 



Certificate of Beatb 

( XX, S. StnnDnvC> i 



PLACE OF DEATH: — County oflawll 







^^U City 



ity of ^ CXX^^^js 




v< 



No. 



St.; 



Dist.; bet. - 



and 



(■'■r^'"'^">^'-'^^^^^^^^^ 



FULL NAME l^v 



■1 



si;.\ 



PERSONAL AND STATISTICAL PARTICULARS 




i> \ I )•: <M liiK 111 



M.I-: 



Wx/TY 



) 



KV^ilO 



VCCL/^\j 



MEDICAL CERTIFICATE OF DEATH 

i> \ 11, < 'I i>; \ I II 



/>^^> 



i 

• M..ntli 



li .s 



i^i\ 1 



l/..i,'A 



< > r;il ) 



/',/!. 



^ IN'. 1.1' MAKkli:!). 

uiiM tu i:i> (►K ni\( »ki'j:i) 

( U'l iff in s(ii-i;il il'vi._.;i,it i( mi) 



lUK I'lii'i, \ri-. 

( Stiltl llf (.'DUIltl \ 



I \iii i;r 



niK r II I'l, Aci-: 
<)!• I \iin:K 
(St.'iif III rMiiiiii\ ' 



MM!)i;\' \ A Mi- 
ni MOlHi; l< 



iiiK III I'l, \ti; 

or MoTIII.R 

'^tMt> III roinitj \ t 




){' ^ 



' lli;i^l l''N ^ IIM II \, Th..t I .llUlph-.l . I, ..;,... I (,:,,, 

~" ■'W" to ,,,o 

tli;it I last saw li ,il;\( nii , ,, 

and that (hafli mc( iiiic.|, ,,i, jln ,l,,n- ^f,,'. .1 .,1m.vc. at 
^I. The CAI Si; ()| iM \ I'll u , , :,. tnl|,,us: 



G, 




^'^^w:> 



V ■ 






i) 




f>I k A'I'ION )-rais 

CONTRII'.I ■K>K^■ 



.I/-^v///^ 



/>,/ls 



/A 



/// 




n 



< »i't'l'l' \TI( iN i'^^ i) 

AV^/(/?^/ /// Sr/)/ /■ I ll III I 'I <> 1 I 






^Axi- 




DiR \ri().\ 



^ Signed 



\ 



< 



) III) s 



»/ -/;,: 



/'</) 



I()n 



f \.Mi. s.ivja isj ^^<.\.^^ ll V V , 



/ /i>ii> \ 
M.D. 



Special information <'(i'> t"' Hosiiitdls, Instilulions, Iransirnts. 
or Rcu'nl Rcviilcnfs, (tml (icisons ilviii) ,iw,iv lion hum*'. 



1/-.//'// 



Fnrmpr or 
IMidl KcMdrnip 

When H.is rtisr-isi- (onfr.ii led, 
II not dt fiUr ot dedth .' 



s .-« 



llriM lonq df 
f'Id.r (ll llMth' 



Ddv 



iii-.sT uiMv KNuwi, )■;])(, !•; AM) i!i:i,ii;p n^o ft ,-0 ' I ^i"\ \i. 



' I n T' !• Ill ml 



J 






' 1 101 




a-:^ 



1 i 

■vi'f\€ V.a..' 



.M»i.ivrAKi:R ]t \- o <xaJ 



lOO^ 



rA<l.!ii-ss^^ 



ic- '' '■ 



!N. I*. livery ittm ot" iriforniiit ion hHoiiM h- cjirelfull.v stipplieil. \i\\. nlnMild he Htjiteil I.XACri.Y. PHYSICIANS Nhoiild 

stiitc CAIISI: OF- DliATH in pliiin tcruiM, thjit it miiy ho properly cliiMniVicd. The "Kpc^iiil Inioniuition" (for pen- 
nons (Ij In^ uway from hjniio Nh(nii«l he ftiven in ii\firy inHtnnce. 



Atalttflif 




I 



^'in 



iMi I 



fp . 



Iff 



!l 



I 

In 

i 



in 



WRITE PLAINLY WITH UINFADING INK — THIS IS A PERMANENT RECORD 



..in!.' II. 'til 1 \.- ■:. t"^^^ \;K\ r,, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






/.V/9H 



J'ro'i.s/rrt'f/ v\V>. 



< 1 



\ ' . 



^ 



V-Cr I. ^, v : 



f^S r-» m^ • 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticatc of Bcatb 

PLACE OF DEATH: — County of LIo City of 0,0 . 



<^ f- 







No, * '^ ^^ ' ' St.; Dist.;bet. IS'.,. and 

/ If DFATH OCCUPS AWAY FROM USUAL R E S I D E N C E G I V T TACTS CALLED FOR UNDER SPECIAL INFORMATION \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



: 1 



FULL NAME 



iN.:^ 



N] 



•-1. \ 



^ 



PERSONAL AND STATISTICAL PARTICULARS 

I 'I ii.i ik ^ 1 



1. 



l> \ 1 1. ' »!• Ill kill 



/I 



'|Hl..ntli) K 



\< .!•: 



) 



I)MV) 



1 ;,»./// 



MEDICAL CERTIFICATE OF DEATH 

!■ \ i ' >l IM \ 111 



!• .\ 



0.1 



/hi 



^ ! \< i.i M \ k k 1 1. n 
uii« tw i;i) OH i»i\i >kt}:i) 

'Uiiti- in -<» ial (1< >.i).'tiat i'<ii) 



1! Ik riM'i \(*i-: 



NAM I. <il 
I- \TII Ik 



itik 111 ri. \ti-; 

<»!• I AIMi: K 

-^t ii . . .1 Toll lit I \ 



MAIDi; \ NAMI'. 

<>i- .M()iiii;k 



lUk rii I'l, \( i; 

ol' Mo'llll'.k 

' stall' 'ti CDiiiit I \ ' 



< »i(l !■ \ rio.N 




1 II|-;i>J \.\',\ M.U 1 1 i \ , i II '■• I ■Miil'lr,! 

tlirif I la-t <;i\v ll ;ili\(,- <ni 

,i!ii| 1 Il;i( (i< .illl ' HI HI rcil, "11 1 In 1 1, I'm -;..■.. I .1 
M. 'Ilic CM ^^1' < '1 I'l \TII ■ 



( i t I'llll 
1 < ;' ) 
I<)0 



L 



iyy^O^K^^ 



J 



U 



1)1 KA'l'KtN )''■,! I ^ 



.l/,"///lS 



/hn 



I lout 



MnUlhs 



■O ' 



WioX 



vlLL^lO 



DIKATinN )<./m 

,NED ) \jA^!ry\X\ '.I v^ a 



Ihiv 



SIGI 



V. , ■: \. 



fli'H) ■ 

M.D. 



I<(0 



I N.l.lr. 



.n 



Rf^idril III Siiii / I 'III' 



),,// I I/.-'///' 



/',/! - 



Special Information ••"'!• '"f hospjihIs. institutions, iransicnts. 

01 knciif Residents, m\ persons (him) .iw.iv Im-n liomr. 

i-.r-.„r «r i\""i. "(m lung .it 

S"l.:*ncr^'^^-TMnaVK.J. ' ,.,.e,„IMh- ,.s 

When was dise.ise umlraited, 

If not .It plme ot drdth ? 



( I II I' i: nia lit 



'' \.Ml.".s 



•}.; ni- III k I \I, ' 'iv' k IN'' '^ ^ ' 

AJi ■ 






: I xTj: ..; ii' ui \i </! k i Mi <\ \ i. 



\TII in pl.iin terms, thnt it m»y he properly JuHH.tie<i. 



IN. K. livery item <>i iiiVorin: 

Htiitc CAiJsi: or di:a . . ^ 

«on. clyinft ..wny from home Hhould be ftiven in every mHtnnce. 



PJiVSICIANS Mhoiiid 
r p«r- 






Mi'< 




I.' i- 



I: I 



'* 






|i 



•I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 






mmmmmmm 



A' 



/)„/,' Filnl. OxktJU'^^-J(>v•v 3^X 



100\ 



]icg I. s/ {'/■<</ ■'\''>. 



^ - V I (> 




U_<^ 




^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( *a. S. 'i>tanc>arc> ) 
PLACE OF DEATH: — County of 



No. 



Oyiv City ofvJ<X.^\0;uO 

'^ •" d and 



St.; Dist.; bet. 



( " r"„;:,^icc!-'.r;,rr-»"s^rt „^^?:?l~.^v„".^;r,;i ^-«." r.-^^J" .%%%TiJor:e-;r ) 



FULL NAME 



M TJ 



-•r \ 



PERSONAL AND STATISTICAL PARTICULARS 



M \ v^o^u 



L 



I 



1) \ I): ( »i l; IK 11 1 



A 



M^ .iitii 



l':i\ 



\' . i: 



^. ( 



SI NT. I 1- M \KK 11, n 
\VII)»»\\ I'D < >K niVoK.il I» 

< Wi ill- i n ^1 K ial il< ^i;.'iKit ' 



itiK run. \*'i' 

^' 1 , I • I ■' 111 nti V 



N\M1" ol' 
JATin-.K 



lUK Tiiri. \« 1'. 
()!• lAlHKK 

(Stati .It t'ii\itil! \- 



MA II UN NAMi: 
Ml' Mnrill-.K 



niKTin'i.Aii'; 

<»l- Morill'.K 
(StJiti' Of (.'ouiiti \ I 




avvoLcL 







(h 



A 



.U-L^ H it 






h 



ION /I} 



"'■'-■"'"'"Hbc^^L.■^^-■■; 



) ,\n - 



: * 



/)./! 






|.^ AKK IK 11-: ro TiiH 



V ri 



(Infn: niaiil 






MEDICAL CERTIFICATE OF DEATH 

I) ATI-; (»i- i)i:\'rii _\ 



\ 



M.nHlV 



I V. It ^ 



1 |li;Ui:r.\- C IkTIl-N'. ThitV I attrll.lc.I ikrr.t-nl 1i->mi 

tlial I la-t -.iw II .iliN^' "" "'" 

;,H.lthat.lratl. or.urrca. nntluib:. Matnl a!..Nr, at . 

M Till- CAT Si-: Ol' I'l ATI! u 




,1^ lolloW^ 



a 



\.^ c > v^ 



^ ^]KuC 



DIUATION 



[■^ ));i/.^ 



Mo'ilhs 



roNTRir.rroKV K^vy^v.^^. 



ioJlA-' 



/^J\ 



//('/// N 



.]f.uith.< H ' /'(?v.s- 



.'\ 



( SIGNED ) .."i^X,^ VI . M^C>^L. ^ -M 



M.D. 



dx|xt '.;. , I»n ■ ( A'Mn- 



SPECIA L INFORMATION -K lor HospitHls. InMitutions. [r..nsi.nfs. 

or Rerent Mrnfs, nnd persons dyin., ...,. Iron homr 

How lonq iif 
Formfr or f,|^„,. ,,1 (),.^th.' Odvs 

Usu.il Residence 

When Has disedse fontrddrd. 

If not df pirfi e of death ? ^ 



P, \i-j.- .11. IMKIAl, MK ki:m"V \ 

1 



,OU<.U^-v- 



!• \T1 



.i,..KrAK^:KM^^U^'^^tLC 



111 |.M \i ..1 K I.M< >\ \I- 



'^ I I Y4CTLY PHYSICIANS HhoiiM 

^^^- ;r;?'r onVH--;:;:::: ^:^::::^;:^ -:;ri'^ -::;:™::" :^-::-^^ •--"• -••' " - - 

„t,.tc CADM: Of "» ^ ' " » , ,^^„ j„ every inHtnnce. 
.i.S«A .iwnv from home hIiouIiI l»c R'^«:' 



ion« clyinU nwny ?•'"'" 



$.&n 







K ;: 




J « 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

..,,_________ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Deputy Health Officer 



J^ro/\s/ ('/•(// ,\'o. 



.^ ^ 



i Ol r 



.OVC\^') .JOi^'\hA. 



DEPARTUIEM OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDcath 

1 X\, J?. 5tanDar^ ) 



PLACE OF DEATH: — County ofC'cL^^ Vcwv^aoj.etCity 



c City of O O. A ^ J 



TVCX.^ vc<.c 



No. bSO i^CX,^^4x. ,' . . St.; S Dist.:bet. I ilk and 

/ ir DEATH OCCU.RS 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 J 

FULL NAME r^ ^' 

__i 



^lA 



PERSONAL AND STATISTICAL PARTICULARS 

C«M,(iK \ 




■1 ^ i 



I) A ii: I >i i;iK 111 






t 



1 
I 

Ii.i\ 



MEDICAL CERTIFICATE OF DEATH 

I' \ 1): « -! hi; ATI! 



/f./'' 



\< . J-: 



' \ c.-ll 



/I,.' 



'^iM. i.i:. M\i<Kii:i) 

\\I!)n\\i:i) OK I)!\M(,>, (. I) 

i W'l iti i ti ^1 H'ial 1 1' 



^> 



MiK rnri, \C]-. 

I St itc III I •lunt t \ 



\ANT1- (i! 
1" ATI! 1-R 



I'.ik'nn-i, AD-: 
Ol" I ATm-:i< 

' St.iif <ir Coiiiiti \ 



M \l I>I:N NAM}-; 

ol Morm: K 



liiK I'll I'l, \ci-; 

Ol- Morill'.R 

I Stale <ii Con lit I \ 



Oi-cri'ATK >.\ ( *- 



\l..ni!i p.iv' y, ■ 

I m;Ri:il\- CI:RTIIN. I'l^t J attcmlc-.I .locasr,! |p,„, 

- • ■ ' - up'^ t-i JX^xb Xi i<^ ■. 

that I last saw h ■ ali\ c « ui j.^o 

.111(1 dial dcatli nil uiiL-<l, oil the d.iU ^tatril al)n\(.', at 1 Cl 
Lv ^r. 'I'lic CAISJv Ol hl,\TII wa^ a^ follow^: 



ff.fvtl 



XaJIa^ 



C)r- 



1) 



UurW\:t [\j cxd 



^ 



3/c^i ' 



DIR \ riON }'r<trs I Mn,itln 

c < IN TR nU'ToRN' •) /\ ^ ' '^ 



Pay 



//'.; , 







? 



O/t^tXoL 



DrRATlo.X 
SIG 

— -U- 



) V</;'.v 



M>ni(h\ 



N E D t ' (AD "Jlc\x:3^xJLi V 



Po 



J s 



/ /(>ia s 
M.D. 



i()0 



A.Mrt -.vj L I c^ C.'.. '.., L'. 



Rryiiffil /!.■ Sill/ I'l an, 



Special Information "n'v lor HosfHtais, insiitutions. frdnsipnis. 

or Rptcnt Rcsiderits, dnd perstinv d\;nq dM.iy from home. 



1A./////^ 



n,i 1 



former or 
L'sudI RfsidenfP 

Wfirn was disMsr (onfrdfN, 
If nof af plare of dfdth ? 



HoH long at 

PIdlf of DPHffl.' 



Ddvs 



, • ISi,. 



Tin; \iio\i-: s rx ii:i»iM-Kso.\ \!, i-\K 11(1 I, \K^ \K i; IK fi-; 1 o iin-; j i'i.ali-; oi iukim, ok i;i-m,,\\i | mvji .• •■.■-■m .i kimovm 
i!i-:sT ()!• MN' KNd\\"i,i;j><,i-; AM) m;i,ri;F- ' 



'0^6^JL 



•% 



\,Mn<- bS^O Ob O^^rVA^V'l.lwVv, -3i 



I N I *}•; H TA K i; K O O-LcLl/Vo oXjL lI > vcl-cxL a. Kl 



190 



(.A«l.!; 



>. Ii. livery itt-m ui iin'ornmtlon should h.- csiruiully supplied. \i\\. Hhrnild he Htiitcd I.XACTLY. PHYSICIANS Hhould 

Ntatc CAIISI] or DliATH in pltiin ttrniH, thjit it msiy l)e properly cluHniVicJ. The "Speciiil Intr'ormHtion" Ir'or per- 
sons dyin^ nvviiy from hnmu should be (^iven in every inHtnnce. 



f'M\^ 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



p! I' lli.ilth I'V.. ;:■. t— ■.•=?. -ci-i. liX:!' C 



lf)0\ 



Jico'is/cfi't/ A'o. 



f r 



I c>i8 



(LtjV(.^/i djLAA.| Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=Citj and County of San Francisco 

Certificate of IDeatb 



n. £'. StanOniD 



No. 



PLACE OF DEATH: 



County of 



-A 






City of <:x ^>' • ■ 



'tv A^c^ix^v:^ ^A. c 



V I ^ v_ 



A ' 



St.; 



Dist.; bet. 



and 



/ ir 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 OFATH OCCURHtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



■ TMtk 



I) \ 1 i: Ml- i;||< 1 11 



PERSONAL AND STATISTICAL PARTICULARS 

ri »i ( )K N 



1 1 



^ M.iiitli ) 



,\(.i-: 



Ltut bL 



l):iv> 



Mm III}. 



r%\\ 



MEDICAL CERTIFICATE OF DEATH 

DA'll-. t '1- I)i:.\ Til 



r^ 



J.V, , 






1 I .-II 



/',/l 



U NX i\\ I-. It « >K I)I\'< 'M < i:i) 
(Write ill <iH-iMl (l(sii.Mi:iti' 111 ) 

illlMfll-l, M'l-: 
( St;ili III I '. I'liiti \ ' 



NAM!' «»I 

I- A Til i;k 



UJ y^dl^rvA^-Od- 



1 



^M(.iitli'> l'.i\ 

I II I'lK i:i!\' C I'K'l"! I'N . That I .i! trinli il • U . r.ist.l ri,.|ii 

K^o . to >,.)-jL4iXA/ AL IijO''. 

y 

tlial I last saw li ■ :ili\i' <>n I(>0 

and t hat lUalll < iccii I It'll. < >ii 1 lu 'laU' si.itrd a!i<i\i'. at :j .."S 
V^.. M. Tllr CWrSI' (>)■ l»!:.\l"ll was as foil., us; 

I 



Vj[vfvcrv^-v<i. \l Key t 



!{|K 111 n. \* I". 

()|- I AriM'.K 

i <,lri)< I It f.iinitl ^ ' 



M \ IDi: \ NAN! I", 
Ol Mo'lIll'.K 



IlIU'iniM.ACK 

Ol' M<»rm:K 

(Statf 111 (■iiuiit I \ 



1)1 111' \ rioN 



\ 



c\\ . 



.\, 



I )rR AT ION )\ais 



Mo>ith> 



I • ( > \ 1 

IMK A I'loN 

Signed 



),,/; 



M^ulhs 



I\ns 



I li>ii> 



_JJ^JL^ 



h'r ufi-il III Si.w/ I iiiini^rn t i )>-// 



\.llln 



//(iU> -. 

M.D. 



Special information ""''• '••' Hospitdls, institutions. Fr.msicnfs, 

Of kVxcnt KV^KlrrlN. .u'l prrMUis d>in.| rtwnv Inrn hiimf. 



1 /..,/// 



rill' \ni)Vi-: sr \i'i:n i-kksonai, r\ urn ri, \kn a k i, rk i »•: r< • in i 
liivST oi- Mv KNn\\i,j;i)*; ].; and iu:i,n:i' 



fill f'l* 111,1 lit 



VouvaO^N-XX 



/oJLl I '^ • "V 



tjrnirr iH 
[\,u\ RfMdfncf 

Hhrn >»ds (lisfjNf tuntiavtfd. 
It not dt plJir ol (Jcith ? 



. s_*. 



Mom lung dt 
PIdif ol Dt'dih.' 



Odvs 



•I. \v»- Ol in KIM, t>K K I;M' >\ \ I, 



-o 



' \.lillrss 






^'l' 



It \ 11' a 111 I I \i III K I;M< i\ \ I. 



10'^ 



I.M)1,KI\KIU V_0. V-X-A^VJ 

I \,i,ll.ss ?S*'\ V. ,0 



r-\A 



^ II livery ittm o»' MiVorm-.t ion Hh-,uld Ik- c,.r.ct'ull.v Huppliecl. A(.l. hI.muIcI I.c HlHte.l I.XACTLY. PHYSICIANS „hould 

HtMtt CAlISi: or Dl ATII Ml ptiiln tcrfn««. thiit it mny I.e pr..|>^ rl> cljiMHitlcil. The "Spccinl liiior.iiHU.m*' iur |« r- 
Kons (Ijinjv iiwiiy from homo HhoiiUI he ftiveti in every inMtiincc. 



mm 



»•#!»# I 



TfWJ] 




^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i N t-^-:r^;;i:^vl I- . REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafi' /•V/r</xlo|<ix^^fea.\' 'k'k 



/fJO'[ 



licgisforrd JVo, 



J o i 9 



1 



<r^>«^A^' 



^ \ 



V 



Depu 



^ i 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of Beath 

. 11. 5. Stnn^arD j 

(?0 



PLACE OF DEATH:— County of 



^.. 



No. 



^ 



• ' and 



■'0 City of^ '^ 



. : St.; ^^ Dist.;bet. ^^ 

' ' "' ,.c.iAi orciinrNCE GIVE facts called for under special information \ 



FULL NAME 



I 




■t va 



. U, o 



^1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



^1 x^>\<^ 

I>A 1 1 ' 'I i;! K 111 



~1 



M..ntlii 



\« .l^ 



sIM', I.I" M \K k il-I) 

u iiu >\\ i; I) nk iti\< »Kv j;n 

(Ulitrill s<)ii:il (li^i^Mliitioll) 



1»:.\ 



.!/,.»////> 



i 'i'rar) 



/',M 



r^ 



IMK III ri. \>"i-: 

(Sl;iti "I ' '• mill I V 



\ WW. <>!■ 

!• A'lii i:k 



lUK III II, A«i-: 

oi- I Ariii-.K 

' sf it< or (,'"111111! \ ' 



MAlIil'.N NAM1-. 
C)l" M<)Tin;K 



lUKriUM. \(V. 
(H- NjoTlllvH 
(Sl;iU or l"oiinti > i 






/CL^'V 



^ 








MEDICAL CERTIFICATE OF DEATH 

DATK ul' I'l: \TII / 

(Moiini) ''' 

i iii:k i;i!\- (.■i;rtii-v. 'rimi i Mtti-n-K-.i ^i. 

that I last saw !i ;ili\<'' •'" 

:iii.l tliat .hatli ncni nx'.l, on tin- >latr --! itrM a! ■ '■' 
M. TIu- CAISI-; yj' I'! \ 111 \\''" •'" f«ll"^^■ 



.1 iP>tii 

I ' )' 
1 1(1 1 






CONTRII'.l Tdl^N' 



/^./i 



//,'//; 






/'./I 





lA 



Je^'^^^^stAj 



CN/a^LoLvvcL 



nrcirATioN (7J\P ^ \ , 



Mintit 



Ihn 



AI, I'AK IMTKAK-- AKi: 



TIM AHOVI- ST\TII) I'KK^nNAI, I'AK I I ' '.; 



PR \V. I' ' 1 " i: 



(Illfol 1H,-|l)t 



^'^iv<r-^v.a^ U)<xX^Jk. 



u.,.„.-.. IXM dJ^t^v^'v d,t 



^: 



I ir RATION , y''"'^ 

NED) U.X^\X1X (^. -ilVU ^ 



(SIGI 



M.D. 



e)x^ 



I«)0 



SPECIAL INFORMATION ""'^ '"f ""^P'trfl^. Institutions, Irdnsirnts. 

or Rerent Rfsidents, dnd persons dyinq HV»dv lro;n tiomp. 

. , „, H(m long at 

When Hds diseasp (ontrHrted. 

If not at pla* p of dpdth ? __^ 



I'l \(1-: <>I- HlklAI, <•!< K l-.M' '\ \l. 



% 



Lm> ^ 



1 \i 






ion 



,A.,,, H'll Oil 



Kx<K\. 



Uy H ^A.- 



V>i^<LCt>V 



,. B.-HV.., i.e™ o, i,.^..^».io„ .H,..M .. ..;c<..M. .;o...;- -;::.ir:;':Uw,:.v:'"H':''.*^,;""„. ..Z.:"- .rM-.:";:';! 

!"l'..?f-'i L^v frL ho,nc .h„ul.l be ftiv.n i„ .>.r, in-.an.e. 



ion* dylnft iiway from 



• 4ft^. 






ss^sSiaw 








fl 




; 



• a a BIB • I 



X' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



.! ..*■ t|. .I'lli I \.. t----3s:'.^-. ){X:I' C, 



"v.. 



REFER TO BAC>\ OF CERTIFICATE FOR INSTRUCTIONS 



/>///r /••/•/,'./. (^jLJjUxA^JvUv XI lUO'i 



Jii><J/.s/ ('/■('// A'lt. 



IB^O 



.<rUA.>cA 'X.S-'\>i( 



DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco 

Certificate of 2)catb 

( 11. 5. Stan^arD ) 

PLACE OF DEATH: — County of Oa-ix rULCi Cityof O. ■ 

\tI I . . . _ 4 



No. L<-UjL "^L^^Ay^xtu ^v, ' St.; Dist.;bet. .md 

A /if Dt«TH OCCURS A \AI A y FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION \ 
\) V If DEATH OCiyURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 

if i i^ ^ \ 

FULL NAME 



LcLcV-CLVd; ,C.'V' Ldo •'' • V 



^ \ 1 



i»A n. < >i nil- 



PERSONAL AND STATISTICAL PARTICULARS 

^ t.(il,« iR ' 

I'll 



MEDICAL CERTIFICATE OF DEATH 

DAii-; o\- m;\ 1 II 



Ai 



Moiilli' 



\' .1-: 



sI\( .I.I- M \U K ii:i) 

\\ii»i )\\ i;i) <»u i)iv(ti<ri-;i) 

iWiit'iii siKi.il (U-i;.Miat i'lii) 



IMiv'Tl! I'l, X*'!' 
(St;it" "! ' ■' lUiit I \' 



l/..-<///r 



/),/r,v 



\ \M )■ III 
I- \lll i; K 



HiK r II ri, \i i", 
oi" I A III i:k 



M \ i|ii;N NAM)'; 

Ml mi)Tiii;k 



i;ii< rni'K MI'", 

n\- MoTIIJlK 
(St;itf 1)1 t'oiiiiti v • 




Ox-ivt 



^TMIllfl1 






I II !•; !>: i:r.v ci;r rii-\', 'I'hat. i .ittin.U'.i .u. < .is,m1 t- .m 



tlial I la^t ^M\\ h alive (»ii 

ailil that tUatll i km uiiX'il, I'li the <la!r --tati'il alrnVf 

M. 'Hw C.\i SI', oi' hi \TII ua- a^ follou. 



I ( (< ) 



\J 






111 



<X\XL 



? 



( Signed > 



M,' til In 



iKir 



// 



. I/. '////) s 

■A. 



fhix 



I lout V 

M.D. 



i 



)cTri'A riON 



'd. 






Oa.U'- 



lt)0 



\,|,!rrss) ^L.v.u A 



1 



Special information "n'^ •'"■ ll^J^^pilrf^. In^tifutions, Iransipnls, 
or Rctcnl Residents, diid persons dyinj ,m.i\ fron home. 



/vV- uil'il I II ^111 I'l illh /,■/■'/ 



);-,n 



Mnlllll^ 



lKi\' 



iin AiiovF sT\'n:i) I'KRSoNAi, rAi<ri<ri,AKN \ki tki I I" rin-; 



f Infoi iii.tiil 



MiM^s Lulu V V.0 






former or i i " ^ 

tsiitil Residence b i ^'^ ' 



When was disease inntraded, 
If not al plate of death? 



How long af 
f'lai e ol Death .' 



Oavs 



vn 



CK.'^- 



a.J. 



I'l.AlI-: ()l l!l K I A I, ( •!< K I;M< I" \ I 



!:• ]■; \i ..I K I:M« '\ \l. 

A; 



, „ — l.very Item n^ 5nV.>rm,.t ion should I,. c,.rc,-ully supplied. ACh Hlv.uld •'««»/•*';!. ''"^.iV^^ '7; . ';"' '^'^' ':^. ' 
HtnU CAUSI or OIA TM in plnin terni«, th„t It mn, »»- properly cl..HHitlcd. The Spe.l..l ln.orn.«l...n to 
«on« dylnft iiway from home should be ftiven in every InstHnte. 



PHYSICIANS Nhoiild 
r ptir- 



'-^y 



r 



r 



r 1 1 I 'I 



\' 



■'■• L. 



i -l 



-iiiMStei^' 



ji. 




i 



lit 



I'i'. 



WRITE 



H,,n-.l of llcdth- V Sn :. ^'^^' ^^^'' "-" 



PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



— ._.»,a'^r> r'/%0 IM 



/>r^/(' /•'//(''/, C 




L9^\ 



REFER TO BA C>\ OK ct^ni ino*^- ». ■ >^ 



QTRIir.TIONS 



1821 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificate of IDcatb 

( -a. S. StanCatC i 



Qfii 



PLACE OF 



DEATH:-County ofO.O/^^ Oxcx^vc^. City 



City ofO'O-^^ -J-^<^ 



J.I- 



V' 



>«D.vJv 



yA^oJj V.K^OiXX^^ 



St.; 



Dist.; bet. 



and 



r PACTS CAtLED TOR UNDER "SPECAL .NTORMAT-ON \ 
^ '^*'^I! ^.-^iT .M^xrAH OF STREET AND NUMBER. 7 



V, IF DEATH OCCURRED IN A HOSPITAU un 



FULL NAME 



a. 



-.».x 



n\cL'" 



i).\ ri-: »>i I'.iH in 



\< .!•: 



PERSONAL AND STATISTICAL PARTICULARS 

< J 

'. . / 






SIN«.I,1- M\KKIl-.n 
\Vin«»\Vi:i) OK PlVnKi hi 

iWiitr in <'H-i:il .l.-u- n^'t" '" ' 



lUK rin'!,\*M-: 

, stilt. ■'; .•..•iiitrV 



\- WW. oj- 

J- A tin; R 



-v: 



\'t ai 



/',.■ 



MEDICAL CERTIFICATE OF DEATH 

DATl". Ol" Dl-.ATll \ 






(Pay) (Vrai 



up'. I- ' ■ ' '-- ''^' 

that I last saw h alive on 

,„athal.K.ath.uvurr.Ml. nnthr-laU-.tatol ali-.v.. at 

M. Tlio CAISI' (»!• DI.A'ni ua> as lollowv,: 



•M---^^^ 



lUR riiiM.ArH 

(>1. J-AIUKK 

I St:itc or Coiintt y) 



M \ii.»:n nam I'. 
(.1 Morni-.K 



lURrni'LACi-: 
,))• M(t'i"in-:R ^ 

( Sl.itc iir Coiititi y 



occrrATH^^^ ^ 



a. 



coNTRir.rroKV 



> 







VL 



V.O 



Krsiiifif lit S,ni /'i <ir 



I r.' 



?>C, }v.,,.^ 



1 /,,./'// 



/).n.- 



(Infonnant ^ v v , 



,vi.iu.. 'I^ib Vja.c.v>v.. 



a 



,^l 



DIRATION 
( SIGNED ) 



} Vinv 



.][,>>! I hs 



/hivs 



A 



f 






M.D. 



SPECIAL INFORMATION onlv tor llospitdK Institutions. Transients, 
or Refent Residents, dnd persons dyinq dwdy fro.n home. 

,0 A , Ou H(.y» lonq dt 



Former or 
Usual Resi 

Wfien was disease contrarted, 



If not at plare o( death ? 



Pldie ot Death 



IM.ACH ()|- lUKIAU OK K1:M"\ \I, 

(J /<X>%.' 



i> \rr. "I 1'' '■ ' ^' '" ^ ''■^'' 'N'.M, 
' ' . 190 






.X.l.hc-ss lOb'^^?O^C^ 



N. B." 



.^^^-_-^—^ ^Mii^"^^— '——'''"'"''***"'''*'''"* , rY*r:Tl Y PHYSICIANS Hhould 

stnte CAIJM "» ^" ^* ' " ' i i u^ A'.ven in every InstHnce. ^^| 

son, dyJnft away «roni home should be fe.vcn m e e y 



wMHto'^^'^^^^ 



4?-^^ 




^.} 



If 



I 



JS^l" 



WRITE 



PLAINLY WITH UNFADING INK 



I 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFiCmTe: FOR INSTRUCT!':: 



rif\t<^ 



Dale Fi/('fl , Q 




x^ i^m 

Deputy Health Officer 



liedislcrcd ^V'^- 



182J> 



DEPARTMENT OF PUBLIC HEALTlWity and County of San Francisco 



Ccvtiticate of Bcatb 

J? ^ 



PLACE OF DEATH:-Countv ofda.^ J XC.v:.. Gty ofdc.v .ixo^^vc. 



rt 



\ 



\ ; I 



V 



i . ■ 



c* Dkt • bet' 1^ ^^'" ' ^^^^ ' ^"^ ^ X 






FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



'I \ 



M J V.CL 



V 



1, \ 1 J. oi r.iK 111 



\''.K 



Mwut'h 



) . ..• 



l»;ivi 



,\f.'>if/n 



i">'i ;ii 



/>,!\ 



MEDICAL CERTIFICATE OF DEATH 

i).\ri-: <•!• in: vTH ^ 






(Day) (Y.;irl 



^1\.,1.1- M\KKM-.l' 
\MI)n\Vl-.l> nK 1>I\'»K. l-.l 
,Wnt. i.. s<Hii.l .l.-UMiation) 



[^ 



r^ 



C ^xQ■U 



, nM<i:UV Cl-RTIFV. That I:,tUn.K..l.loHM.r.l InMU 

thai 1 laM saw h alivou 

.n,lthal.Uathncau,r<-.l, nntlu-.lat..lau..lah..v..at 

M The CMSI-: Ol'- l>i:.\TII ua. as follous. 



UIK riii'i.A^"!'. 

(St;it< "' fomitiv 



WMl". Ol" 
fA'lUl.K 



A 



ua'>\ 



1) 



III vako/^^A. ^ h KsLic^yx 



DTK AT I ON J'''^'-^ 

CON rkii'.rroKV 






lUR rui'i.Ai h 



MA11>1-.N NAMl 
(>|. MoTin-.K 



]UKrnri,A<i: 

'Slat<- <ii Cotuiti V 



»Hrii'\n<»N 



I 



(Kyxd. 



\ 




^ A 



DTK xrioN 
(SIGNED ) 



)'c(ri 



\ 









lloilt s 



M.D. 




y * 






/ ': I'/" 



( A.l.lr.--) Hf.'^ 



-S^TTal information f^ '- i"'-'^' '""""^' '""^""'^• 

.,1e«^M.nl',-»d persons d)N -...» 1.™ h'™'- 



Ays/./.'./ '" ^■'"' ' """ 



Mnllth- 



I ' 



^ . ^ II I r l^ 1 !■ I ' 1 I 1 I', 

' ^...^c^'^ • ^ 

(lllfo;lH:iMt 



N-(>\Vlj:i><^'. AN.' . 



former or 
Usual Residence 

When v^HS disease fontraded, 
II not at pla( e of death ? 



lloH lonij at 
Plrf( e ol Death ? 



Dd>s 






,,M'^.. ,.! I-.t iM.M '.I KlvMnVAI, 

\i\A \'^. 190 



IS. B." 



,. ss \ ^' A O J -V ^-V : TrVACTLV PHYSICIANS mHouI.! 

item .W ••"»''>••""•»'""**''" :»:;,« thnt U may be pr..pcrly Juhh.^.cU J 

:AUSr: or DHATH .., P '- j-"::' .n every -.nHtnncc. A 



"l^CA.Sr or DHAT^ - :3.;^;:;;v;n W. every Inntnnce. 
«on« Hylnii «wny ?rom home 



iSfiK 



Hi 



1^ 




WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



- _ ..•>.'vp>ii/~'VI/^M< 



l^xir<l "\ II' 



,1,1, I- \-U. In t"?^]^H&l'C.) 



RE 



PER TO BACK OF CERTIFICAft tyjn M^o.r.w>... 



Dff/i' riled, Qx. 




%^ 



19()\ 



Jledis/ercd jVo. 



I H2:i 



\jr^K.^ iuiAhH -^^-^^'y Health Officer 

DEPARTMENTOF PUBLIC HEALTH^City and County of San Francisco 



Cevtificate of Bcatb 

PLACEOFDEATH-.-CountyofOcu^vaxc C.ty 



No. 



! V. 



Q* . 1^ Dist • bet, - J t >. e ) va -N V a. > ^ and v 

bt.; U l^lSI.t DCU ^ „^,orp 'SPECIAL INFORMATIOI 



City of O <V>v ACV ^ vc cs. 

and 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



1,M i; Ml lilK 111 



;l 



rAEDICAL CERTIFICATE OF DEATH 

DAIl'. "I- 1>1'. ^I'l* 



I 



(I)ay^ lYe;i: 



iMon'tli* 



I)av> 



\' .!•, 



\ I .11 



/'.n. 



( Moiilh ■ 

, ilKKHBV CKRTIFV. Thai I atUMulol a< .. .^ol fnun 



v|N.,l.l- MAKKlhU 
\VHM.\Vi:i» OK I»I\t)K> l-.I 
\V,it.- ill -"^i^'l MrsuMKitmni 



r\ 




that I last sawh • alive on 

,„athal.U-alh.>o-urrca, .u,nK-.lal.-lat..l above, at 

- M Tlu- C\rSl-; (>)•• Dl-.ATIl Nvas a< foll-us 



lt)0 



V' N-*-- 



.St;it< "I <'"nnlrv 



NAM)' <>1 

1- \ rm.K 






4- ' 




C^-^-v.' 



Dl RATION 
CONTRll'.l roKV 



Vrars^ .l/<'W//.s- 1 /^^m 



Ilont 



niKrillM.AvK r-\ 

OI- lATin-K / 1 

istiit. ..I i-..nntM \ V 



MA11)»:N NAM'" 
Ol- MoTin'.K 



lUR Tlll'I.ArH 
t)l- MnTHl'.K 

(Sl:it<- '>T r.>>uiti> 



orrri'Ai'ioN 



7^ 



vl 



\x 



VlLUv 



V I (sto. . 



( SIGNED ) 

dX^4. ^- ^^'^^'^ fA.M.vs. 



fhlVS 



If OK I < 

M.D. 



) 1 .^- 



1 



o,^erenUe*rnls, „n,l person, i^m -..» I-'"" "«""■ 



AV.v/./a/ /" >>'"' ^ "''''_ 



)V,M 



M.>u!li- 



l' 



(Inf'Hinunt V, '^ --- 



Former or 
Isual Residenrf 

When was disease tonfrac ted, 
It not at pldieot death? 



t{o>^ lonq at 
Plare ol Deatfi ? 



Da>s 



",y,ACKn,. lUKlAUnU KKM-XN'- 



ll:H'S 



. -e, 



rSl'l.K lAKl'.K 



I) \ ci. ■'! U' Ki Ai. "I '< i;n«"\ai. 



AcMi '■'>'> 



1 'XI 



^ -i 



N. B.' 



(\,ian-s 11:^^ ^-- - M """ TTfXAUTLY. physicians should 

" „, ,„. ......;- -rviStB;;---:-' ~ ■- -•"-. 

Htatc CAU>t sh.uihl be a<ven m e%er> ^ 

sons tlylnft «>v»y ^•'"•" ''""'^ 



liH' W; 



tfiiiiiy^ 




I 



WRITE 



PLAINLY WITH UNFADING INK 



!'...;i!.'. '.! n. ■r,\]\ ' 






Utii Officer 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTH uCTJQNS ^ 

1 8'>4 



lie i'iist ('!'('<! ^yo- 



I)((/r Filed. Vv'^vtx^^^t^tv ^3 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccttificate ot S)catb 

. ^^ r . nf ^ OA-v J \X^^vo^cc City of ^^^^>^ ^^ .^^CC>^^ ^ 
PI ACE OF DEATH: — County of ^^'^ -^ \ A ^ 



'^ I '2 ^t.; *^ i>»lSlM DCU ,,^nrR "special information \ 



1 1 



. \ 






FULL NAME 



* 1 '■ I! •' 



%, 



.vo 



PERSONAL AND STATISTICAL PARTICULARS 



-r\ 


'^1 


n 


i> \'\\' 


( 1 1 r. 1 K 1 1 1 





( il > iK 



lias 



MEDICAL CERTIFICATE OF DEATH 

!)\11-. (U- l>l.A Til \ 1 4. 



I MoiitlO 



1M\ 



I (JO 



\' 1 



^ IN., 1,1- M M< '•< I'V.'^., , M 






\ \\1 I 01 
1 ATHl-.K 



( ^A n; 



A 



tlmt I la-t sawh alivv nn ^*;^ 

:„„Uh:.t<Untb...-c-urrc.l. <.ntlu-.lat.sta,..laUnv.. :.1 

JL M TlK- CATsi: or I.l'ATll um. as |nll,,us: 



lUK IHl'I.V'J'. 

oi- lAiin-.K 

I m;,lf or Covinti V' 



M \n>i:N N AM'-: 

,,1 Morill-.K 



lUHiniM.Ari: 

Ol- M.n'IU'.K 

fStaU- "I «."'>unti \ ' 



.Hrri'Ai'i'»N 




CnN TKIIU'IOKV 



.!/<»;////? 



na\ 



■\ 



Hoiii 



/»,/! 



V \ ' T/-V ]f lint Its 

DIRAIION >""^ 



(SIGNED ^ 



M.D. 



A. Ml 



r 



^w' 



A', I.!,.' I" ^•"' ' "' 



1/.,// 



/'.■ 



-^iz^ilTW^^^i^^^^N .;"H 10, 11. K. lnMil.li»„v. I,.„sie».s. 

„,^m.^ M™Is VnJ l.n..nv d>in:| „...> !.»:" l-on-r. 



- .. . . ,. 1- -r w I 1' 1'' I'll I 



X^kj^aX^-^^ 



H(m lonq a\ 

former or pi^ie ol Onith? 

lsu.1l Rfsi(hn(p 

When v*as disease rontr.i(N, 

II not at pl .t((Mil df.itli.' 

'7^t:^v HrKivr..K K.-^unv;i. 



OrfXS 



i,vi 1:,,: K' i lAi '■' ki:m<'V\i. 
^6x>yCtj '^3» I90H 



\JN ^.<^o 



XMn--^ civl<)lcJ. ^ = . ■ TfVACTlY. PHYSICIANS should 

«on« clyinfe »w»«y >•""" '''""" 




^^^•^^^l Ji 




ll 




^'^■k^mm. 









WRITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



III .;ii 



,1 .,r 11. iitii 1- 






A 



l)((/i' Filed , nJLy\vix/>^^ 



h-Ahj 



It^ 



/.9m 



REFER TO BACK OP CERTITICATE FOR IN3THU CTiON5 






DEPARTWIENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Ccvtificatc of Bcatb 



n 



•V 



City of* '<:^>^'^T'^<^''^^'-^'^ 



\ 



^■X"^\Ao'- St.; 5, Dist^bet. ?;'v; and^ 



FULL NAME 



m 



a\>t^ 



■-I \ 



■"TI^NAL AND STATISTICAL PARTICULARS 



0,\,>^V(X/O^ 



a. 



1) \ Tl-. ' '1 r.iK Til 



M.,i,r: 



\' .!■: 



)V.M 



(I):»y 



!/.../'//■ 



'^ MEDICAL CERTIFICATE OF DEATH 

1)\ Tl-: <»1- Dl.AI'H y 






il>:tv) 






, IIKKKHV C1;RT1FV. Tlu.l 1 attr.i.U -1 .Ur. as.d fn.,,. 

t 



vlVC.l.l-. M\K1<11-.1» 

\\ IIM.W l-D <»i^ l•!^'"• ' ' 



X*>V 



.c^U 



up to 

\ ' 

tliat llastsMwh... aliv<-on ^''^^ , 

„,lthat.Katb...-umMl, nnlhcaaU-.tatc..l ahovo, at 



inK'niiM.M'i-: 



\\\n "1 



Loxu 

Av^"^'> vc 



)V(/r 



lUKI'IM'l.Ari-. 

oi- lArin-.K 

(St.itf or I'ounlvv 



M \11>1 N NA^n: 

(,1 MiilIIl'.K 



iuKinri,\ii-. 



i.,>i r\ rioN 



V- 



nr RATION 
CONTRIHI I'oKV 



Dl RATION -N ^'''"'' 





.1/, '///// V 



/hiv 



//cur 



Months 



/hn 



'.V 



SIGNED)' Ak^.^^!,-^ Ltil^^ 



.^1 



//ou/ \ 

M.D. 



or^e^S M.nl S and persons dvinq ...y fro. home. 



r 



_ W ^- ■ 



M.xillr 



/Kn- 



r,. „/.:/>. s.;'' /'■'"""_ Ll^ - ,„..,. i<rF TU TIM' 



(Illfol Mlilllt 



Former or 
Usual Residence 

When was disease ronfrarted, 
It not at plare ol death ? 



HoM lonq at 
Pld( e ol Death ? 



f)rf\' 



",., XCKOF HI KIM. -U KKNK.VAI. 






\<kj 







IQO 



( \(l(lu>'^ 



C<oS ' ^^^'- . 1 V*CTIY. IMIVSICIA^S .houl.l 

SE OP Dl.ATH in P ""•':"'"■ '„ ,„ .>,.y in.t-nce. J 






II IL 



H 





'«ii.'i^f#lijr''~' 



I 

•A 



WRITE PLAINLY WITH UNFADING IN 



^_THIS IS A PERMANENT RECORD 



,,,•,; .,! l!,:il!^ 1 '^ 



■^■tf:^.'Xi:]lS^VC<, 



REFER TO BACK OF CERTIFICATE TOR INSTRUCTIONS 



/)(ff(' rili'<l . ^xl^^-i^^^**^^^^^ ^^ 



li)0\ 



JRro'i.s/crrd A^o. 



f ' ^ %fy 



^B 




Deputy Health Officer 



DEPARTMNT^^ PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Bcatb 

( "a. 5. 5tnn^ar^ ) 



(\. 



;CJ/x i\.'.0;\ 



:\ . 



PLACE OF DEATH:-County ofOa -. XC.-C.^ City ofOa.v •v,a^^ 






^ lit. V V M I >a.U ' '^^^^ St.; Dist.;bet -spccal .NroRv^x.oN ■ \ 



FULL NAME 



\ 



.OJ\.L\^ 



-r 



^ PERSONAL AND STATISTICAL PARTICULARS 

-1 ^ n ; . 



I) \ 11. "I r.iR I 11 



M '.M, h' 



\' .!• 



( I):iv 



,1/,..////- 



V(;u I 



/',,' 



MEDICAL CERTIFICATE OF DEATH 

i)\rK *>i' ui: \'i'" ' 



/M" 



-,l\t I 1' M AKlv 11'1» 

u iiM'^vi:i) OK niv«>iui-.i) 



iMK run. \*"i' 

^(;,tf cI •'' Hint! V 



\ \M 1 ' >1 
lATM 1-,K 



HiKinn.vK 

(>!■ iMin-.K 

I >-,l;itr .11 roinitl V 



m.\ii>i:n namj- 



lUK rnri.Ari-. 

,.1 MoTin-K 
(Stall <'V rountis 



O^^Ml'VnoN 



^- 



I ria.\.\.u^- 



1 IIKRKHV CKRTIFV, That 1 atUM.U ,1 ,!.. . .^. M 1-". 

, • ■ u/) t.<> 

that 1 last saw h ■• alive- uit 

,„.l that .Iralh o.vtMre.1, „n t h. <lat. ^taU M al..., :^ 
M. The CAISK OF DFATIl Nva. a. in!lovs<: 



\ 



iC 






jv^ O- 



__ I 



DrRA'lH'N 



)V\?;v Afonlhs 

c 

roNTRUM'TORV v.»x.VCrAvv^ 



/>.nN 



//(•/ 




a\4 <Lilyra>- 

] 




DIR \T10N 
(SIGNED) 



YtiJi 



Moutir 



/hivs 



.1 



M.D. 



V 



l.,n (\,hli-c---~)V^^^ ■ 

^?^AL INFORMATION onlv tor l»i.spit.K Inst 



ifutions, Iransifnfs. 



Plat f ol Dfdlh .' 



Former or - _ , \i viu i 



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



Oa\s 







,,vTi: ..' 1!' Ki.M ■>! i<i;M"\ ^i- 



.v„, ini ^U' 



Vc<X\.^t 



1 



^Ui-'i^.^-C . 



IN. B." 






ii 



' I 



, if^Pf « 




f 



*• «k« 



w 



RITE PLAINLY WITH UNFADIN 



,.,,:, ,.!,,f ll>..l,h l^N.. ;=- •?•?«?■»• !»M'*-<> 



Q ,pj^_THIS IS-A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



-V A' 



lOO'i 



De -ly Health OfHcer 



]i(>(ji.s/('r('(l ^y<'' 






DEPARTMENT OF PIBLIC HEALTH=City and County of San Francisco 



T^. 



^H 



PLACE OF DEATH: — County ofV.<X^'\ 



Cevtiticate of 2)catb 

. .. City o{0<Xr\\< 0;\XX 



,v 



wa- 



l.v 



n St.; 

M USUAL RESIDENCE G 



( '' °;r.,H"o^c".%r;,"rHo"s=;"".. O- T.S„T.T,0. ..V,.,TS «»«. .~STC.0 



Dkt ♦ bet. '"^^^ 



OF STRtET AND NUMBER 



) 



FULL NAME ^ X)\.y\^ -^^<^<\ 



t ' n ■ 



I 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



, \ 1 1, . .1 i.li-: I'll 



\( . I- 



I).\ri-: ul- DlvXTH Jy 



/ (.'' ' 






1? 
1 I);i VI 



Mnltlh 



(■>liU ) 



/',/ 1 



1 Ill'Kl'J'.V C1:RTI1-V, That 1 altr.nlol.lo.a-.l 1 



"^-c\^t 



1 



i I</)'t 



l<> 



that I last saw h^-'v alive on 



wipMW i:i) OK i)i\»)K »-.n 

, Writ, in ■^•.' .'-it'iK.tiMU) 



„,lthat.U.atbnrcurre.l, untheaatostaU..lal,nvc.at 'l ^-. 
T M. Tlu- CAlSlv (»!•■ Dl-ATIl ua^ a^ fnll..w<: 



C) L^A^< 



luK rni'i.xfK 
i st;it«- Ml rouiitiy' 



\- \M 1 < >l 

1- \iin.K 



oi- J \riiKR 

iStaK Ml C"M\intiv' 



,,!• MOIMIKK 1 



/^. 



t\ 



* 



CL\ 




n :j\l^' cla^amxxA 



^ 



lUKl'Iiri.AC'l-. 

(Stat- ' ' CMimtrV 



(ucri'A'ii'^'' 



fn 






r-\ 




f\{rtrU 



i I 



l^ 










CONTRIIU TORV 



Months 



Days 



I lout ^ 



DrUATIoN 



(SIGNED) '^^. \)^^ 



Month' 



Dnvs 



I Imn s 
M.D. 



Ad.i -io. TooH (A.Mr.ss) lH'6b Jl^. 
^ \ _. .^..i nnk fiir HiivnilHls. Ir 



" special IN FORMATION onlv lor Hosp.l.ls. Institut.ons. Ir.ns.nls. 
or Refent Residents, nnd persons dyin., d.Hv from home. 

Usual Residencf \\^ \ ^ ^ ^ 
When was disease fonlra(fed, 
II not at plare of deatli ^ 



Ddvs 



(InfMiminit 






,.j xcr OI lUKIM. OK KKM"^ ^'- 



I)\ll "! I'a Ki M Ml k);mo\\i, 

cV 



I NDl.K' 



xVvt an 190H 

'\ i Q i i 01 WL' V 



^\(Mm -- 



f^'l'l'^'"^ '" , , , VACTLV. PHYSICIANS should 

r;::x. ..^ -^ »— - -y;:^-: -rt;;:^ r:'--^ ..e^:':;::-r'^. ...a. ......-....^" - ..^- 

..au- CAUSE Oh ptAT" m P'»" ' ^^^„ ,„ ,,.,, i„»,„„cc. 



:r ..^'^n^^^^":: - -•- =■'--- - — '""'""" 



% 



^. B\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M.Kiv.l of IKalth-K No. i«i "!^'?1?S2^ '*^^'' *■"" 



REFER TO BACK OF CERTIFICATE KUH >No t nwv i ■ v^ 



Bo^Iisfercd jVo, 



I8!28 



Dale /y/(v/, QjL'p.tjL^rn^'^MA; X2, 100\ 

Ltvw^ 1...VV. De;>-.ty Health Omcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( "U. S. Stan^ar^ ) 



PLACE OF DEATH: — County 



ofOoyiAj ivaixc^A c c City of Oa^v- Xa v\C^^ ^ c 



No. '^Ur^X'VH.V^C't alr^^'^^i^^'^'^ ^^*» ^^ Dist.;bet. 



^ ^.„.,__„ i l-'v and ' 

' ^"^ ^''^-^ '^- '^' ^ f '^ ^' ^^l\)Jx^^\ orJsTnFNCE GIVE FACTs'cALLEO FOR UNDER "SPECIAL INFORMATION ' \ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



■n 



si.\ 

DATi: Ol lUKTU 



AC.K 



COI.OK 



V 



d 






5w5 / 

(Pav* »\:ii 



), 



Moufh, 



/hl\s 



sIN(.I,l' MAKKIl'.n. 
iWiitfiii >.()ii:il iUxi).'Mati"ii) 



lUKTin'i.Ari-: 

IStatr i)r •■■miitt \ 



NAM1-: <)1- 
FATHl-.K 



HiK riiri.ArK 

OI- lATIN'.K 
(Slrilc nr Coiintryi 



M \ii)i:n namk 



lUK rill'KACH 

oj- M(»rm:K 

(stair or C'Dtititrv") 



\ 









trU^vaLcnv 






MEDICAL CERTIFICATE OF DEATH 

DATH OI- I)1:aTH 



\ 



l()0 

(Ycarl 



(Moinh^ iDay) 

I lIl-iRl'HV CI-RTII'V, That I altcii»U'(l (Itct-ascMl from 
OXl,A.t %C. U)oH to q-^vt '^^ H>oM 

that I hist s;i\v h • alive on v;. ^^ . up 

ami that dcatli ocinirrcd, on the tlate stated a1»ovo. at 
M The C MSI-; OI' Dl'.ATH was as foIl«)\vs: 

"A 



o.'>va.. \v*^L*.. 



\ ' 



I ) r k \'P I () N ) cars Months r, I >«/ vv 

.Oil 



a:, 



Hours 



CONTRIIU'TORV 



Ll\.^..tr:^rw«^ O..OL>i ^ 




JX4A) UxVav. 



. ■^ 



Xj 



DCCl TATION 

hVsiifr.l III Sail /'i iiin/sm 



\JL<X^\j 



) 'i III 



yr.oiih^ 1 ! />.M.N 



Till- \H()VK STATi:i) I'KRSONAU I'A K IHT I. \ Ks ARl'. TKIK TO 
lii:sT OI- MV KNOWI.KIXIK AM) n|:i.lHK 



Tin-: 



nr RATION Yt-ars MiUiths /><nv 

( Signed ) i- vK.<XAi.Lc/^vcL «...■. 

6V£lx_^ iqo ; ( A.hlress) \t\'^ ^^\ ' 



I lours 

M.D. 



Special information on'v lor Hospltdls, institutions, Iransicnts, 
or Recent Residents, and persons dyinq dnay from liome. 



former or 
Isual Residence 

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



HoH lonq at 
Plai e ol Death ? 



Oavs 






ri.ACK OI- lUKIAUoK K1-:MoV\1 



/VwAv.v'c'v ^- ^ 



I),VI"I*". "! II' Ki.M. t)! RI'IMOVAI, 

190 



c)x\vt X% 



,s,„.:KT.K,.:MV<i<U^QO(l'(BvL<S^t^'''M.Uu;lv-. 



N B._Bvery Item oJ InWmHtlon .houlcl b. carefully «unplle.l. AC.R «hould be Htatccl EXACTLY P»Y8ICIAN8 •hould 
rVate CAUSE OF DEATH \n plain term., that It may be properly cl»««-.«.ed. The 'Special Information for pT- 
•ont dylnji away from home should be ftiven in svory Instance. 







I 



^ 



-N « 



!i 






WRITE PLAINLY WITH UN 



FADING INK — THIS IS A PERMANENT RECORD 



I'.nar.l of Hc-ilth- V Vo. i^ *---»?;;-») !?& I' Co 



Dniv Filvd , 



REFER TO BAcrv kjy l. t. n iiriv-i 



.^.^m-^wm wr\n I A.I o-roi l/^TII^M< 



Ik i»*ii t«»"«» 



Cx^trV.A.^w^ 




n. i'Jo\ 



Me^ititcred JVo. 



1 8i^9 



"' f . * 



"^ f?l r*-f>.T 



DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of 2)eatb 

( Ta. S. Stan&ar^ ) 

Si % A ^ 

PLACE OF DEATH:-County of CW^- J^^cc^ vc^r^City of ^cx.^^. A-O. 



in 



FULL NAME 



-4- 



(l\ 



xx.:^^\•t . 



("^ 




SI A 



DATl". ol' III km 



A (■.}•; 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR \ 



L 



^Vvr^A 



A' 

i,Moi)th 



)ra 



Dav) 



M, mills 



(Vc-ar) 



/)</! 



(Year) 



SINCI.!-:, MAKUIl'I) 
WIDOW i:i) <»K I)iV()Kvi;i) 
iW'iitcin s<K-ia! df-ij-Miatinn) 



lUKTuri.Aoi-: 

( Stat< or (.''lUiitrv • 



NAMl- <M' 
FATin-.R 



lUKTHPl.AOK 
OI- l-APIIKK 
(Stall' or C<niiilry) 



\TAI1)1-:N NAM1-: 
oj M()Tm-:K 



lUR TIU't-Ari-: 
ni' MOTHHK 

(Statr or Coiuitry) 



(HCri'ATlON 

Re'^iilfil ii> Stut /'i (UK i ■■•'''> 




C>AJL 




MEDICAL CERTIFICATE OF DEATH 

DATK t)l' DlvXTH l^ 

Qxkt: 

(Moiithi) <i>"y) 

I Iir':Ri;r.V CI-RTII'N', That I attoudcl tlcrtascil from 

rY . . ' . up't to JX^'X-t.' ic/D . 

tliat I last saw h •• alivt- on ^90 

and that death orcurrcd, on thr dale stated ahove, at 
^L, The CArSI-; Ol" DI.A I'll was as follows: 



CvxivL 



tVO.' 



0, 



' >vA.O 



n 



DIRATION 

coNTKir.r'roRV 



)\ais Months H I^ays 



i.^\^CL-..:v 



DIKATION 




A. 



A'X 






n 



a 1 > 



rm- .XHOVKSTATl-nrHRSONAUrAKTICrLAKSAKl-.TRrK TO rill- 
lil-ST OF MA KN'«)\VUi:i)<'.K AND HKMKF 



)'cars I Afont/is 
( SIGNED ) ^) . Ij . M iW'i^^'v ■ 



Davs 



dxWt , : T<,o (Address) HM U D^ Vv.M U.u-v, K. 




1 



Hours 

Hours 
M.D. 



SPECIAL Information only for Hospitals, Institutions, Transients, 
or Rercnt Residents, and persons dyinq away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Dcatfi ? 



Davs 



flnfoonatit 



.Vi 



LojUl 



\XVAy\-vX. A '-^ 



(Address 



\k^\^% d;Ouw\'l^^ 



-4i 



DVTi: of Hi uiAi. or RHMoVAl, 



)xl^ 



I'l.ACl". Ol" inKlAI. OR RHMOVAI. 

l-NDl-RTAKKR ^S:^^^'^^^\^ V dXVAxt' 
(Address ....9^.b.k.!o.....\l^WL'^^^ jl 



3» 3) 1 90 ^ 



^ B __j,very item of Information should be CHrcfulIy Hupp.'.ed. AGB should »>« stated EXACTLY ^"YSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly ciassified. The Special Intormat.on for p.r- 
«ons dyinft away from home should be ftiven in every instance. 



"if 



y, 



;f 



« 



1 



V 




WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 






J)(f/(' Filed , 



,<yv<^A^ 




yyt/H 



REFER TO BACK OF CtH i ir ii^m 1 1. rv>r, .... 



II i/*-rir»M« 






i 8:>0 



Deputy Health Officer 



DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of IDeatb 

( tl. S. StanDar^ ) 

C (TC^ J? Qp 

.-County ofHcc^v J.rvCL^vC^:^oCity of ^^ <^^^ J^vCV^^c^x 



iT) 



! ^ i 



^ ^^ -iv Sf. Dist • bct.N-CLtcV^^-^^'^^- and -^cv.c.\.' 



"-> 



.X.. Y-.U' 



'^> 



FULL NAME 



\ O '' 



A 



o.\..cla^ 



si;x 



i ''1 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR 



'^Xr^^XkXs. 



DAll". «>1 lUKIIl 



.\».H 



' MnlltlO 



'ig 



(> 



r.j 



iD.-ivi 



Motillr 



\ 






/hi 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DHATII ^ 






siNc.i.H. MAKun:n 

WinoWKD OK DlVDKrHI) 
(\Viitr ill s(K'ial (U>-ivMi:itioti) 




r.iKrnri.A'M': 

(State or Co\nitr\ ' ~K 



NAM I'. OI' 
FATinCK 



lUK'nirKACK 
oi- i-Apm-.K 

(Statf or Co\iiitry) 



MA!I>i:N NAM!-; 
Ol-- MOTHHK 



lURTHrLACK 
Ol- MOTHKR 

(Slate or Country^ 



\ \\ ^ 

/ ^ 



(Mont^) '»»=«^'^ 

I ni;Ri:iJV CI-.RTII'V, That I MttotKkMl «U'riase«l fmtii 

u^o ' t.) Ax^ivti i:^v i()oH 

til at I last saw h ■ alive on • ''P 

and that <U'ath occiirrcMl, on the date state<l above, at 10 
Q M. The CAT SI-: Ol' DliATH was as follows: 



A 






nr RATION )V<7/.N- 

CONTRIIU'TORV 



Months 



Pays 



Hout s 



Months 



DURATION i )V</r^ 
( SIGNED ) m1\ . \jS(ytA.|t\.cL 
d,L*)xt. .^^. TC )0 . (A<hl ress) ITIC 




Pays 



o:x)^J. 



I lours 

M.D. 



V^VQ' 



'^ 



OCCUPATION 




Resided in Stin Fnvici^,-, 



k 



)r,ii 



\!,,}itli^ 



n,t\ 



rnv \HOVK STXTKI) I'KKSONAU I'A KT UT I.A K^ A »< l- IKri- To TH l" 
iIkSTOF MV KNO\Vl,i:i).-.K AM) \WXU-V 

5 0^ '\k.oj 



f ■Vddrt'^s 





SPECIAL INFORMATION only lor Hospildls, Institutions, Transients, 
or Recent Residents, and persons dying away Irom home. 



Former or 
Usual Residence 

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



How lonq at 
Place ol Death ? 



Oa\s 



I'l.ACK OJ' lUKIALoK K1-.M'>VAI, 



c 



•.KTAKl-R VjClr\.Lt\, 

H 1 '^ V \ 

(Address I cS 



DXT}*. of lUKiAi. or KlvMOVAI, 



, ( \ 



iNnr; 



■\ s 



State CAUSE OF DEATH In pitlin terms, that It msiy be properly classiiiea. i nc i 
sons dyinft away from home shouhl be feUen in every instance. 



k4 



w 



RITE PLAINLY WITH UNFADING INK 



l',o:ir<l "f I 



I.:,Uh ,.N„ !. t^t^«^^H&l•c.> 



^ Deputy Health Officer 



— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIONS 



18*51 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

^ ■Q. S. StanPat? ) 



-? ^ 



PLACE OF DEATH:-County of'^^^3;u^^^^..^c. Gty of ^) ^>- ^ -V<X -o... c 



'? 



iLj^u • 1 ^ St* Dist.;bet.lxv\i.\.aCi andtlLCL^C 



) 



FULL NAME 








1 V "> V! V.CXW cr 



it^i 



l\c 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



nicL 



lLvKlL.. 



MEDICAL CERTIFICATE OF DEATH 

DAIH t>l- Dl'.A'l'Jl 



I) A n: '»!■ HiK rn 



AC-H 



I M.iiithi 



(Day) 



M.iiilln 



1 \\ar 



n,i IN 



m\«,l.K. MAKklKI) 

\vii)o\vj:i) «)k i)iV()Kri-:n 

(Wiitcin Mx-ial (ksiKiiatiiiii) 



lUK rill'LAi'l* 

(Stiitf or CDuntiy' 



NAMK <)I 
r Alin-.R 




.\jJLo 



c 



MonnO 



(Day) 



(Yt-ar) 



I in:Kl';r.V CI-.RTII-V. That I iittcndocl (Icrcased from 

> 

that I last saw h -• alive- on ^'P 

aiKl that .loath ..crurrod, oti the .late stated above, at 



M. The CAISE Ol' Dl'-Afli was as follows: 




HIK TUlM.ArK 
()!• lATllKK 

(Stat<' or Countrv) 



MAIDI-'.N NAM I", 
»)1 MOTIIKK 



r.iK rnruAiK 

,)|. MOTIIKK 
(Statf or Co\intryi 



'Y^^JL^ 








il 






//ours 






DIR \TI()N )'ti7rs -o Mt»ilhs 

CCOlCX. 



(SIGNED) '^^\V,>\ 



^ 



dx\\t^^ T.,oH (Ad.lress) ISa-Aj--^'] 11 



/^OYS I loins 

M.D. 






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



I'! 



■VUV XHOVK STATl-n I'KU^..NA1, PAKTI.- T I.AKS AKK TKll- To THlC 
' HKSt'>V MV KNnWl.KIM^K ANI> HHI.lKF 



(Infoimaiit 




,ci . ll . Q1\(rt^Jl 



former or 
Usual Residence 

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



How long at 
Place of Deatli ? 



Days 



DAl'i; o! Ht wi.Ai. oi KlvMoVAI, 

c!^x\vt XH 190H 



i \i\i\xv^s 



4"1H v),<xq. 



M 



n.ACK C)l' lUKIAUOK KlvNinVAl. 




's^ 



state CAUSE OF DEATH In plHin terms, that it m»y be properly Uassmeu. 
«on« clyinft away from home Hhould be feWen in every inHtnnce. 






4 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



l?.,;,r.l <.f Health I- No. !', ■^'tH';?^' "^'^'' *-" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!)((((> FiJr(l,£)JL 




13. 



100\ 



Jico^isfercd J\^o. 



1 8'32 



i^v^ ilv^ Deputy Health Ofncer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of Beatb 

( 11. S. 5tanC»arD ) 
PLACE OF DEATH: — County ofCj/Oy^ -J;v.a.^v^v-<^C' City of O/CX-^V OXO.. ^vtcci <^ > 



Dist.; bet. 



and 



JjL/fvt^ UV.)(y<l,4\.\Aa ' St.; Dist.;bct. ano 

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



\ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



DATi; i)I' !!1K 111 



COI.OR 



MmihIi • 



AC. I-: 



)■.,// 



II' 



(Dav) 



M.nithy 



(Vi-art 



1 hi\. 



SINCM'! MAKUIl'.n 

\\ii)<»\\ i: i> OK i>i\' >'•'* i: I) 

( Write in "-oci.-il di-i;.' !iati<>n 



lUKIlll'l, \<'l", 

'Stat( 111 i.'uiiiit I % 



Iol\aaJlxL 



NAMl', Ol 
lA I'll J.K 



HIK llIl'l.ACH 

(»i" iArm-:K 

(Stale ni I'oiiiiti y) 



MAIIU'.N N\M1. 
()!■ Nio'nil'.K 



lUK rui'LAci': 
oi- Muiin-:K 

(Stair (ir I'oiiiitrv^ 




I I 1 



f^^^ 




MEDICAL CERTIFICATE OF DEATH 

DATI', (>!• Dl'.ATll J/ 



c;) dvt 

(Moiino 



•\x. 



(Dav) (Yrar^ 



T lllvKl'l'.V Ci'R'ril'N', Tliiil I atlriKkd <lc'(casi-.l Inmi 

to Ojt|.v1.' ' '' Up ■'. 



It/) 



tliat I last saw h ahvo <iii ^ • Up 

and that iKatli iHCurfCMl, on tlu> tlatr --tatt.il al)ovc, at A, 
\i M. Tlic C.XrSIv oi' l)i;.\rii was as follows: 



--CA^ -Y"V<T»A^<X 



)'rars Motil/ns Days 



DTUATION 



^ 



.,|^Lc 



DIR.XTION 
CoNTKIl'.ri'ORV U^>^' 

)'t'ars Mouths I A /^<n'.v 

(SIGNED) ^^^ V. V.,.n.uCNL{i Y\ 

1) 'XXn.oH f.\.l.lt-fss)at d„cjki^ Ot 



I Ion IS 

flours 
M.D. 




(fir- - ' ' ■ . ' -<t^J^ 



otii r.\ri<)N 

h'l ill,;) ni Sill! I I (III' isrn 



) rii I ^ 



Mnllth^ 



Ihl 



Till' \MOVl' sr\li:i) I'KKSONAI. CAKIUTKXKS A K I', PRIl-: To THJC 
lil-'ST OI MV KNOWIJUX.H .\M) lUvI.lHK 



1 11 for itiaiil 



' \il(llt ss 




cu Wa 



Special information nnlv tor llospitdK, institutions, frdnsients, 
or Retent Residents, and persons dyiny dv>,)y fron fjome. 

former or ^^^^^Vi ^ lo e Hon* lonq at 

Usual Residence ^»'^<5t^v^"^-'d^^ ^ v<:v„', Plare ol Oeatli? Days 

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



I'l^VCK OI- lURI.M. OK KKMoVAI. 



^V 



<1,JLCL Vo.j 



DAIl'. Mi lU Ki.Ai OI K 1:M(»\ \I, 

C3x^\t; ^^ T90H 



rNDKKT.\Kl<R vJ^Va^XU fc . > 



(.\tl(ll<.'SS 



\'\0H 



M 



4' 



5^ 



r 

9- 



<-J 



V^<^A.<^^\. 



N. K. 



livery Item of ln?orm»tlon HhouUI b^ carefully . .ppliMl. AGH should be statc.l F.XACTLY. PHYSICIANS Hhould 

state CAUSE OF DEATH In plnJn terms, th»i .1 miiy be properly closstfled. The "Special Information" for p«r- 



«on« dyin& oway from home should be Hiven in cNery Instance. 



* 






t 
f 



I 

< 

t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!. >:.T.I ..f 






J' Vn 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



I)(ff(' Fi /('(/, 




vWv X^ i^^H 



llcgiiitci'ed J^"')- 



1 8;53 



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



PLACE OF DEATH: — County 



Cevtificatc of E)catb 

( "d. 5. Stan^arD ) 

of^O^^' J/UX'-y^'Ct-i-c.L.City of' 'a^v J Vcx -.vcxa Cl 



No. IHOl^ Cj,a> 

(IF Dl 



f 



1 



E»TH OCCURS AWAV F 
DEATH OCCURRED I 



St.; 10 Dist;bct. 'Xl LK- and 

FROM USUAL RESIDENCE GIVE FACTS called for under 'special INFORMATION" \ 
N A HOSPrTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



xrl 



V 



FULL NAME ^ 



V)V M ) 



s v. \ 



PERSONAL AND STATISTICAL PARTICULARS 




<x.' 



.0.1. 



DATi: < '1 HIK in 



.\r.K 



' Moiitht 



J 'ra I 



• Day* 



Mntil/i.'' 



(Year) 



/hi\. 



\VII)()\Vi:i) OK niV<)R».Kl) N 
(Wiitiin social (Ksi^rnatioii) 



.1. 



nik I'liiM. AOK 

' stall or C'oiinti y I 



NAMK (M- 
FATin-.R 



lUR lUlM.AriC 

oi- i-Arm-:R 

(Statf or Country) 



M \1I>i:N NAM1-: 

()!• M()i"in:R 



HiR'rnri,ACK 

()!•■ MOTHKR 
(St:iti- or roinitry' 



L^ .L. 



,e c 



» -N 



MEDICAL CERTIFICATE OF DEATH 

DATI-: ol Dl.Alll 9 



(Year) 



(Mou^h) 'Day) 

1 in:Ki;i'.\ C IvKTH'V, rh.it l allcniUd deccasca from 

- to - ~ D)0 



190 



that I last saw h alive 011 Up 

and that (loath (UH-iirrcd, on tliL- dato ^tatt-il ahnvc, at 
M. The CM SI-: Ol" Dl-.-XTlI was as follows: 



Di; RAT ION )V<//.\- 

CONTRlIU'roRV 



Mont/is 



Da] 



'S 



I /our a 



l)rR.\TION 



«)*.\ iTA no 



^a 



Ri'sidrd ni Siui I'l ..''/, /■ 



) 'i<i I .< 



MiOiH)^ 



l\i\. 



Tin- MiovF sT\'n:n i-hrsonai. i-ARTirri.ARS ari: trik to tiih 

IJKST Ol" .MV KNOWM-.DCK AND lUa.H'.K 



(Dif'M iiiaiit 



e. 



.<r'v«^Aj?-^vci 




u- 



v_ -C, 



)\ays ^ 



Months 



/)<7l.V 



( SIGNED )L(jX^n\X*V' 



;l ^Mi ■ 



I /oil IS 

M.D. 



V } X. y I 



I()0 



(Address) \^fr\CAU.V v 



— r 



Special Information only lor Hospltdls, InstituHdns, Transients, 
or Recent Residtiits, dnd persons dying dway from fiome. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'l.ACK »)»• Ml RIAI, OR RHMoVAl, 



DAl"'-"^ Hi KiAi. 01 RlCMoVAl. 



■^X^t IH 190^ 



f \(l(lrfss 



(Address 1lS^ H ]\v^^V<r>\...>il 



N. B._Kvery Item oi ln?orm«f.on .hould be carefully •upplled. AGE should ^\^^^^^t^\'^^'^^^ \ , ^"^*'f/^':^,'l "*^""'** 
«tate CAUSE OF DEATH in plain terms, that it may be properly cla««hMed. The "Special Information for pT- 
fion« dyin^ away from home Hhoiild be iJtiven in every instance. 







w 



RITE PLAINLY WITH UNFADING INK — 






n((fr nird , c 




K^.X^ i^^H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

lie Hi stored ^'o, ■ 8o4 



Cy\ v<---> 



'No. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( la. S. StanDarC> ) 

J? 07) ^ (?^ 

PLACE OF DEATH: -County of CWtx J XCV ........ .-Gty of Oct^^v 3 Xcv->..cc^..r-C 

i . St.; ^ Dist.;b£t. "^llv and ^lilvllv' 



) 



FULL NAME 



^ m\o.' 



a 



J'.X 



PERSONAL AND STATISTICAL PARTICULARS 



\1 I IolU 



IL 



n \i'i-; <ii- iMK'iii 



.\<.i-: 









)'l\U . 



! Da VI 



M..,if/f 



(Vtar) 



/'.n 



Sl\(-.I,i:. MAKUIl'.I). 
\\II)n\Vi:i) OK n!\< iK("l'I) 
'Wiitr in '■ofial iK-^i).' nati"n 



I'.iK rni'i, \i"i' 

( Stiiti or i"i )nmi \ 



NAMl-: <>1 
I ATlll-.R 



lUKiliri, ACK 
<)1- lAlMlKK 
(State <ir Ci)\inti \ 



MAIDl'.N' NAMl. 
()1- MMlIIl-.K 



lUKTIIlM.ArK 
Ol- MnTm-:K 

(St:it'- III' ^"olllUl V 




MEDICAL CERTIFICATE OF DEATH 

DATH Ol* I)1:ATI! 



\ 






(Year) 



.(XUtUAx^vJl \I) 



M Ltur 





(Monlll) '1>:'V^ 

I III-RI'IIV CI'.R'ril- V, Tluit I atU-n.Kd 'IftcascMl fmiii 
li^o to OX'l'A.V up ", 

that I last saw h ■ alive on J ^^ vb ' up 

and that .k-atli oroiirrcl, on the <late '>tateil alxivo, at X 
'Cj M. The CAl SJ-; Ol" dp: AT II wa^ as follows: 



DT RAT ION Vrars 

CONTRinrTORV 



M,f)it/is 



/hn 



I lours 



Paxs 



I )r RATION Years Mi^)itln 

( Signed ) W' ^ i v o . ^^vcL^ > .. , . ■ '-.'.■ 

c\x')A:t XO T()oH (A«l.lrcss) iCiC)S. A^\,.0 .. 



I lours 
M.D. 



SPECIAL Information «n'y '«'■ Hospildls, institutions, fransients, 
or Recent Residents, and persons dyinq andy Iron tiome. 



Rf-idfd ni S,!ii I I ,if 



Yra 



M.uilh- 



/),n 



ruv Miovi- sT\Ti:n i-kksonai, rAUTUMi.AKS aki: TkrH TO Tin- 

liFSTorMV KNO\VI,i;i)C.K AM) MKMl'H 

v„,„.>. Til V). d-l 



fliif')! niaiit 



Former or 
L'siial Residence 

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



How lonq at 
Place of Death ? 



Davs 



ri,ACK Ol- m KIAI. OK Kl.MoVAI. 



':^ 



A-^'^^w^J.A.^ 



>wD^ 



HVl'l-.of Ui uiAi. or KKMoVAI, 




rNDKK'l'AKl-.K 

(Addrtss 



O..^. 



^ H ^ I i VV^^ 



;, « —Fvery item ai Information .hould be cnrefully supplied. AGB nhould be stated EXACTLY PHYSICIANS sbould 
Ttote CAUSn OF DEATH in plain term., that it may be properly classified. The "Special Informat.on for p-r- 
son« dyinfc away from home should be feiven in every instance. 



A0 






* 



WRITE PLAINLY WITH UNFADING INK 



,.,,.,,,,.,,• ,,.:,l,h I- No. .^ t-ggS^IUtPCo 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIQtMS 



Ddfr /v7fv/,OX 





Xh 



190\ 



Beo^Lsfercd J\''o, 



1 8.35 



./v-M Deputy Health Onicer 

DEPARTMENT OlF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bcatb 

( U. 3. StanOarO ) 






oo 



St. 



Dist.; bet. 



and 



PLACE OF DEATH:-County of 0^>^.J Vc^vv^u. City of"<v>v ' \.% .xcv^c. 

H OCCURS 'W'*^ ' 
ATM OCCURM t O I I 

FULL NAME^*-*-" 



' ...=...«. oreiriFNCF GIVE FACTS CALLED rOH UNDER "SPECIAL INFORMATION • 'X 

( " T.r..To"ii,t': ::t^o^i.\\ o%'f:^^""o*i."'o^7r4 nam. ,.s,»o or .,,... ..o .um^c-, ; 




<X v^\j 



I 



si:\ 



0^. 

i>.\ ri-: ( u itiK 111 

\(.K 



PERSONAL AND STATISTICAL PARTICULARS 



A 






ai 



)V.;/ 



(Day) 



\f,„illiy 



(Via I 



I )ii\. 



\vii)(>\vi:i> OK i)iv<»Kri:i) 

'\\tit< in ^"<-i;il 'h^if-'niitioii) 



UIK llll'I, \«M-: 
(Statr or r.,\iiitrvi 






IQO \ 

(Year) 



I- A 11 1 i;k 



I 




.O 



niK iiii'i, \ri-: 

nl- lAlirKR 

'St;it< <.i rr.diiti y I 



M\I1»i:N NAMl. 
<)l' MO'llll'.K 



HIKTIiri.ACK 
(»|- M(»TnKK 

(Stalt "1 (."ininti \ 



J? 
'-1 r ■ ■ 



(\ 



(J'C^^ 



MEDICAL CERTIFICATE OF DEATH 

HATH ol- IIHATM V 

OxUt 

1 11 I':K l-.I'.V C!;KT11'"\', riiat l atU'H.Utl <lcioasf(l from 
- - icp to itp 

that I last saw h alive on ^'P 

aii.l that «U-ath orrurrcl, mi the dati' statf<l ahovo, at 
\\ Tlu- C \l SIC t)l" DIvATll \va^ as follows: 



LKx 



C: 



Vv^CW 



.cL\-/tx-.c. XJ.. 



jw, 



Dl UATION Years 

CONTRIIU TOKV 



Months 



/)a i"f 



//ours 



DT RATION Y'-ars . Months 

,NED)LcyVcv..V i ^^^ lA 



/^i7VS 



( SIGI 



//ours 
M.D. 



I<)0 



(A<l<lri-ss) WCXfe^vXV) Ai>^i . 



SPECIAL INFORMATION only *«r Hospitdls, Instilutloits, Transients, 
or Rfcent Residents, and persons dying away from liome. 



ni'ArioN 






) 1(1 1 



\/.n,f/n 



/>,n 



.HKSONAI, 1-\K rUTl.AKS A K 1-. TKlj; T< » \'\iE 



TUl- MIOVI" STXll'I) I'HKSONAI, rM< 1 K I l..\ 
lilST oV MV KN()U1,1;^)<-.K AM) MKI.Il'F 



( Inl'ii nirmt 



( Nd.lifss 



-Uvfe.' 



'->> ' 



Former or 
Usual Residence*- 

When Has disease confrafted, 
If not at place of deatlj ? 



Hov^ long at 
Place of Death ? 



Days 



I'l.ACK OI- lUKIAI, <)!< K».M'»VAI, 



l; 




; ^; \ J-UJ 






i)\ri: m! HrwiAi, «)i ki-:m«»vai, 

. , .' 190 



state CAUSE OF DEATH in pl»-.n term*, thnt it m«y he properly clo««ifled. The Special Information top p r 
IS dyinft away ?rom home should he feiven in every instance. 



«oni 



'«». 



I 



^L> 



w 



RITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



]\,,.,u\ ..f ll> nllh I- N.i 






: WSi-V Co 



REFER TO BACK OF CERrinCAic. rvn i .^ 



^ I n w ^^ I I KT •» ** 



Bc^l^stcred JS'^o- 



1 8:]6 



6.Jr\j^^ 'Ix/v^ Deputy Health OMcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticate of Wcnth 

{ 11. S. 5tanDnrc> ) 
PLACE OF DEATH: -County of CJo.^^ J ^vCc-^^v^^? City of C)x:v>n. O.V<Xoxc • <: - 
,M I'iL)! "V'^ll • ■ St.; ^ Dist.;bet..l'X'V>V'C^.O.A. and '^ 

FULL NAME ^' 



II 



PERSONAL AND STATISTICAL PARTICULARS 



.!■ \ 



i'nl.oR 



'n_ (in. 

II \ 11-; nl- lUKTM 



At.l- 



. 1 



-v ' 



a 



Month) 



)\:n 



Day) 



.1/..;//// 



Vtar' 



/^M 



sINt.l.l' M\KkIi:i) 

\vii>« )U i:i> <>K i>iy<)Ki):i> 

iWiilriii ^oi'ial <K si).riiatiuii ) 



rUxw\jL<i. 



[It- 



(7^0 



i!iK riiri, \»M-: 

(StaN- "H '-■"Piiiiti yi 



N \M1" <>l- 

I ATI I i:k 



ItlK llll'l, \^ 1'. 
Ol 1 NIIII'.K 

i Stat I ' 't t"iiii 111 1 \ 



m\ii)i:n nami-. 
«>i Mo'rm-.K 



itiK iin'i, \ri-: 
(II M<rrm-:K 

(Stal«- or fouiiti \ 



(n i, ri'A rioN 

/^,'i,f>J II! S,ni / I 'I III I •III 



\\^ 



dx' • 



n 



MEDICAL CERTIFICATE OF DEATH 

DATlv Ol- Dl'.AI II , 



\ 



(M. 111(10 



(Day) 



,.v.A IQO 



(Yt-ar) 



I lll-KI'.HV C1;KTII"V, Tli.it 1 .iIU-ii.UmI .k(<asf,l from 

to '\A^ ''^ ^^^'^ 



■ , «9« 

tliat I last saw h alive nii ' .. -^ y Up 

aii<l tlial (Uatli o.riirri'«l, on tlu- .lair stair. 1 aliovi-, at A 
Q M. 'rill- CWISI'; Ol" l»i;\rii was as follows: 



ri" 



n 



J K.^ 



K 



' ^iHlijiA^V ' • 



\ 



DT RAT ION y'fitrs 

CONTUir.l TORY 



Miiulhs 



IhlV^ 



Ilont 



DIRATION 



(\ 



) Vf/TA' 



Months 



/hns 



(SIGNED) \ 



^ . 



A o\.^ 



Xll 



I 

I()0 



(A.l.li-css) blH 






//ours 
M.D. 



SPECIAL INFORMATION »"'> '"f HospitdK, Institutions, frdnsicnts, 
or Rpient Residents, nnd persons d)ini| .m.iy lro;n home. 



)'> ii I 



\/,„>f/i' 



/>,n 



r\lV M»()Vl* ST\-n:i) I'KKSDNAI, I'A K lie C I. A K s AKl, T K T K T. . TIM- 
lil-sr I)!'- MV KN«»\\ I.i:i><-.K AND Ml-. I.I I". I- 



(Iuf"iinaiit 



/ \(l<l!i vs 



P.^bl 



Av.t.A_i:.'s 



Former or 
Usual Residence 

When WHS disense (ontr.Hfed, 
If not at pld( e ol death ? 



Hum lonij at 
Pla< e ol Death ? 



Dd>s 



I'l.ACJ-: < U' Ml KI M, . >K K l. Nt. i\ \I, 



D V rj-. -.! Hi KIM "I K I;M< »\ AI, 

190 



\di:rtaki':k 



<XC\.Cly>v 



^ „ _,;vcry Item oV •.n*..rm..t1«n .houhl b. cruJully Huppl.e.!. Mil, Hhoultl be Ht»tcd HX ACTLY PHYSICIANS «bould 
Ht..tc CAlISr OP DI.ATIi in plain term., th«t U mny be properly clHHnir.etl. Tbc -Special In^ormnfon ?«r p.r- 
non« dyinft iiway 'irom home HhoiiKI be Jfiven in every inHtnnce. 



*«W^'. 



I 



w 



WRITE 

* 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR ini5TnvC7iCNS 



!)((/(' ?y7e(J , Aj^^^dju^^h^^ 



Be<^/sfe/'ed J\^o, 



1 83? 



100\ 
Deputy Heailh OfHccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




C; v^<^<-o '^v 



Ceitificate of ©eatb 

( XX, 5. StauOarC^ ) 
PLACE OF DEATH:-County of^^a.x- J Va.^ct^co City of ^ a.v 3 Vo^vc. - 



^No. 



k)\'h 




OL^i- 



St.; 



'^ 
N 



Dist.; bet. X.CL\.M.X'-y\^ 



andViCrVk 



V^V^-^U; ,,«siiai RESIDENCE GIVE facts callej for under 'special information • \ 

( " r^o^ATH occ^SR^eV-N'^rHO^s^PyT":: o"' ?nst'?JV'o'n cive its name insteao of street ano number. ; 



FULL NAME 







OKll U.z.\\xa>lkx 



PERSONAL AND STATISTICAL PARTICULARS 



^i:x 



DA 11. .11 lilK TM 



IL 



6xkt 



A ( ■. H 



1\ 



)•,■<;; 



(D.iv) 



.1 A ->////' 



( Vi-ar) 



/>,t\. 



SINcl.K. MAKUIi:i). 
WIDOWKD <IK DIVOKiKI) 
(Write; ill social dt si^.'natinii) 



lUK riiri, \ci: 

(Statf or ""rjiiiiti \ 




.<x.\.'^'ji<L 




x-i^c^ 



n) 



:l 






NAM I". <>1 

i-.\'nii:K 



lUKTHl'LArH 
Ol' I-AI'IIKK 

( Statf nr Couiiti V ' 



MAIDl'.N NAMi: 
(»1- MoTlll-.K 



lURTm'I.Ali: 
(»1- MOTIIICK 
(State or Cniiiitiy> 



(H ClI'ATION 




MEDICAL CERTIFICATE OF DEATH 

DATK ol' DlvATH 

1 \ 
(Day) 



(Yt-ar) 



(Monhi) 
I Hl'Rl'HV CI'RTIl'V, Tli.it I altfM(k'<l (Icixased from 

— ;,.; :". Up ' to ^^)0 

that I last saw h alivv on ^'P 

ami that death occurred, on the date -stated above, at 
M. The CAISI-; Oh' DIvA'l'H nv;>s a^ follows: 

DTRATION Yi-ars Months Days Hours 



DTRATION Vears^ Months 

(Signed) Wurw'"" 





,.ijc». 



/hiys 



Hours 

M.D. 



6x)^Ajb V^ iqoH (Address) U^^^-IM ^'j. - 



! ;■ 



) ra I 



Mnnltr 



/),;). 



TMK vHOVKSTATKDPKKSnNAI rARTlCl-LARSARKTRlK TO THH 
lil.ST OI MV KNO\VI.i:i)(.H AM) Mhl.Il-.l- 



(IiifoMUaiit 




^y\i 



4- 



SPECIAL Information only for Hospitals, Institutions, [fdnsifnts, 
or Recent Residents, and persons dying away Irom home. 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



.. Days 



PI^ACE OF HIRIAU OK RKMO\AI, 




I)\Tl". o! HcKiAL or KKMOVAI, 
(Adilrcss ...ll.1iy(.lX\Ai.<LVi.>V JL 



N B — Kvery item oJ in?orm«f.on .hould be carefully supplied. ACIl. should ^-\-^-t^\'^^'^^^\ , ^"''®\';*J'„':',VJ'n".'r'* 
state CAUSE OF DEATH in plain term., that It may he properly classified. The "Special Information for p.r- 
sons dyinft away from home should be ftiven in every instnnce. 



■i't^xkJS^ 



1 1^ 



/-//^/ 



/^ V^ ^' 



1- 



r^ 



I I 



I 



4 



\ 



WRITE PLAIN 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



}?.,:i!.! ..f ll.M'tli - l- No :s •5*!i:«i^'-^ 



D luS:!' Co 






VJO'\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1 8;58 



Rediatcied ^Vo. 




/V^-H- 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of Bcatb 

^ "a. 5. StanDarC> ) 
PLACE OF DEATH : — County of a->^ ^cv ^vc^< City of U ,<X >v J VO.^ v C ^ ^ c t 
No^2^00'l^'^'■ ■■ St.; Dist.•,bet;^V^o iv...o.v, and.A'.' ,r 



FULL NAME 



1 



I I 1 



PERSONAL AND STATISTICAL PARTICULARS 



^\\ 



OJ 






DA ri: ••!• HiKrn 



AC K 



\ 



Month) 



I 

tl)av) 



M .>.'.'//■ 



r 



(Vear) 



l\iy 



\VII)«)\VHI) OK DIVOKiKr) 

iWiitiiii <o<-i;il (U-xis-Miiitioiil 



lUK rm'i.Ari". 

I state 1)! <."omitiy 



\ \ M 1 < M 
1 A 111 IK 



lUK rillM^ACK 

<)i 1 \rm:K 

(Statf "T rmititi V 



MAini:N NAMl 



uiK'nnM.AVi'; 

Ol" MOTHKK 

(State i>r l'.)iiiiti\ 




^l) 






X^\\u, ' '.LLL^L v-O 



r 







occrcA TION 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DllATll 

i . -, , 

,M,,„tlil 'Day' (Year) 

I llI-:KI';nV CIIRTII'V, Thai I attcMKlcd <KHxaso«l from 

_^ — . up to ' ' KP 

that I last '^aw h ;ilivc on - l*P 

and that (Kath (Hcurri-il, lui tho ilatc stat«.'«l ahovr, at 
M. Tin- CAl SI"! Ol' DMA Til wa^ a^^ folI«)\vs: 

or RATION )'('(irs Months /hns Hours 

CONTRU'.rToRV 



DIRXTION J''(/;a-_ Mouths /^ns 



( ^IGNED ) lCl\CnVK.V -^P Ui^.d^v ■ M.D. 

a^\t :v. ic,o'. (A.^1rc^ss) Lc^^^vXn.^l^'tpC'l 

Special information on'y 'o'^ Hospitals, Institutrons, Transients, 
or Recent Residents, and persons d>ing av^ay from ttome. 



\) AJtCLsi- 



TMl- .vnoVKSTXT.DlM-K^nXAI. PAKTiril.ARSARKTRrK To THK 
lil-:sT Ol" MV KNuW l.l'.IX'lij ANI> nj«;Mi.J' 



(InfoTinaiit 




. 51 Vj .AJLOAXX/^aJ 



A 



Former or j^^ 

Usual Residence I 

Wt»en was disease contracted, 
If not at place of death? 



,-> . t 



HoH lonq at 
Plat e of Deatit ? 



Days 



l'I,ACK OF lU'RIAI, OR KKMOVAI, 




D.VTi: of Hi uiM. or Rl-.MOVAI, 






N B — Fvcry itcn o.' Informntlon •hould be cnrc?ully HupplL d. AGB -houhl be Htntecl EXACTLY ^"YSICIANS «h^^^ 

Itote CAUSE OF DEATH 5n plain terms, that it may be properly cl».-i«ied. The Special Informat.on for p^r- 
nons dyinft oway from home should be ^iven in every instance. 



•w 



t 



.1 



W 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFE R TO BACK OF CERTIPICATE FOR INSTHUCnunia 



Dale /v/^v/, dJLJpJa^JUx. aH ^'^^^'^ 

l^u^ L.^... Deputy Health Officer 

DEPARTMENT Oh PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( tl. S. StnnDarD ) 
PLACE OF DEATH: — County ofOa^x. .\,a.->i^v.i City ofUCfW. >! .\.a. >v<ic.J. c 



I 






Dist; tet. 



and 



• ^r.,^ «r.^,iQ« «,AiAv FROM U^UAL RESIDENCE GIVE facts called for under special informatio 

( " rF"DEATH'oCCU%reD .N rHOSpVTA!: OR .NST.TUT.ON O-VE .TS NAME INSTEAD Or STREET AND NUMBER. 



") 



FULL NAME 



SI A 



PERSONAL AND STATISTICAL PARTICULARS 




\ 



^<X.KX 



11 \i i: III- niKi'ii 



.\i.i-: 



M..i\tl\ 



) -,/ 



a ■ 



(I):ivl 



Mntllll^ 



\ I '.I I ' 



/', 



-^iM .i.i" M \Ki< n:i> 

w 11)1 »\\ i:i> «»K i>!\" »!•'< i: I) 

I \\i ill i II xixi.il <li -ivii.iti"'!) 



(-^ 



I st:itc or •'oiniti V 



\ \M I'. <»1 

!■ A III i:k 



I'.iR riiiM, \i K 

oi lAIHl-: K 

^t.lti- OI (,"iHI1lll \ 



MAIKl.N N.\M1. 
(il Mii'llli: K 



r.ik riiiM.Ari-: 
<n m()I"iii-:k 

( Stall' oi t'oiintt \ • 



.<r^A.o . 



.■_ :Kk.^ 



XV> 



ccr i'\'i"i()N[T) 

^ I ia.<y\vA o . 

AV hU'il til Siiii / I iiih i^iii 






A 



■XUV .M,.,VI--STVn.I.l'KUS<)NAI.l>\KTirri XK^AKKTKl H T' > TlH-: 
lii;sT <)I- MV KNoWl.l'.IX'H AM) IU.MI',1' 



MEDICAL CERTIFICATE OF DEATH 

DATl': ol" Dl.Alll 



( Mimhi^ 



I 1 ):i V ' 



(Vt-ar' 






I 1I1':RI':HV CI^RTII-W Tliat J attL-mU*! «U-«<;iso.1 fnmi 



i()o ; 

tlial I last saw li ■ •• ;iiiv«' mi Kp 

and that <lt atli o<riiir<.(l, nii tho <latr ^tatrd ahovc, at I 
V M. Tlic CAI SI-; Ol,'" DIvATII w-'t*^ :>^ follows: 

Li \MmX'14a jtxa/\t' J'"' ■ o^^^ ^ ' ■■>■ 



r 







nr RATION 



CONTKIIUTORV ./■ >vcA.s- v 



Moni/ia Days Hours 



vA 



UJ -CUJ (Vy\.avdv.v>xa 



DC RAT I ON JVr/r.v Mouths /'>avs //ours 

(SIGNED) W^^ '\ ' IVI.D. 



1_ 



SPECIAL INFORMATION «nly for Hospitdls, Instifutlons. Frdnsienfs. 
or Recent Residents, and persons dvinq 3wh> from fiome. 

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



Former or 
Usual Residence 



How lonq at 
Place of Deatli ? 



. Days 



f IllfMMlKlIlt 



\.Mti-^s 






I'l.ACK Ol* ni'RIAU OK KI-,M»)\AI, 



U/cJuLt^ 



^ 



^ 



DA'W-l"! Hi i<l.\l. Ol KICMoVAl. 

UX^vl 1 90 



rNi)i:RTAKi:R 



O. -J c ' 



Acianss^^ i^^ QrV\<^-V^XQ^V-\ V^ 



Htote CAUSE OF DEATH In pinin terms, that it m!i> «.e properly ciasAiTicu. • nc ^ 
nons dyinft away from homo nhould be ftiven m every inntance. 



1 1 




•m 



JIK. 



WRITE PLAINLY WITH UNFADING IN 



K — THIS IS A PERMANENT RECORD 



,l,,.„.l.^f ll-Mh IV,, - ^-S^?^' nfU^ 



REFER TO OMurv u 



- -p,^.^.^ .fc rT,a I MC3Tniir.TION3 



r v-t.niiri^»>-«i«« 



/),i/r ri/r>l, 6jlA^t)L^vt-Vv' XH l'>'"i 



.Crv^^^ 




Boi^i.stcred JVo- 



1840 



■:i, 



Deputy Health Officer 



DEPARTMENT OF PUBLIC !iEALTH=City and County of San Francisco 



Ccvtificate of IDcatb 



Q^ 



PLACE OF DEATH: — County of 



A ^^H^ -A -V 

■a, >v>V\.CLYvc<.4c.t City of 0^>^^ ^^ '^ ^ ^^^-^ 



r I 









FULL NAME AtVtTVY ^^- iB^^*-^--' 



- ) 



.i;\ 



PERSONAL AND STATISTICAL PARTICULARS 




'^ 



1) \ ri- 1 'I r.iKiii 



A (.I". 



M..nth 



il):tV' 



1/,/;////' 



4 <;il 



1 1,1 1 



MEDICAL CERTIFICATE OF DEATH 

i)Ai"i-: <>i- i>i. \''" 



1 



Moiitll 



I 



(l)ay^ (Y<-ai1 



vIN< ,1 V . MARK I I'D 
WIDOW i:i> OK I)I\'oKi )■ I) 



i;iu rm'LxrK 

' Stiltr i>I »'i)lintl \ 



\ \ M 1 < •! 
I- A 111 IK 



lUKTiiiM, \» »•: 

ol 1 Allll-.K 

(Stall >ii i'..unti ^ 



M \ii>i:n n \mi 
(ti- M(»rm'. K 



iMK'niiM.M'j': 
ol- moiiii-:k 

(Stall "I ri'Uiiti \ 



u 




d <.^vcyU 



I ni:Ki-;uv ci:rtiI'V, 'n»ai i attrn.ua .UuHa^t-.i from 

U,0 t.. • ' '*>" 

that 1 last saw h • • alive on ~h^\<^' ^^ T<)oH 

;,„.! that .Icath occurre.l. --n the- .latr slated al.ove, at 
M. Tlu- CAT SI'. Ol- hi'. ATI! was as follow^: 



GlVCb-'v. 



. , dr- C ^ 



ll 



rv a > vti. 



\ 



X^- 



or RATION Years Month:; 

CoNlKllilTOKV lU-tiAA^ J.C, ■ 



Days 



I lout 



DrUATloN -^ J'l'?'-^ 

HI 



(SIGNED ) 

4 



i 



^xK^ i' 



^ ,„oH ( 






SPECIAL INFORMATI- 

or Recent Residents, and persons dying awdv Irom tiome 



ON onl> tor llispildls, Institutions. Transients, 



iu-vri'\ IION [\\"\ 



h',',:fr,/ III S,ni Innn isro 



)'t(i • 



Mnlltll- 



I'.n 






(liifi>:iii:int 




Former or 
Usual Residence 

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



Ij 1 \ How lonq at n, 

\XXv^V^^(\ fcC>V> ^ PIdfe oi Dealt!? Cj 



Ddys 



iM.ACH Ol' muiAi, OK ki:mov\i 



MUi. 



a 



» ATJ'". of H> I'lAi. ')T Kl''.Mo\\l 

A ■, i -t 



y .' 



'^•Idrcss 



.WaAXX-Ij 






IN. B.- 



^ ^— ^-^— ^T—^^*^^"^^*^^"""^^^^^ . . , j i-XACTLY PHYSICIANS Bhould 

.Every I.em o« i„f,.r.n».lon .hould be corofuM. -unplUJ. ^^;';.;;^7,;.,w,:.,. TI.; ••8,.ecl„l ln«o.m».lo„" «or p.r- 

*„♦.. CAIIsr OF DEATH in pliiin term*, that it miiy ne pi-"!' ^ 
:". dXft^«"y f-m h.., .hould be f.ven .„ .very •.-...»««. 



*«*4.i. 



Ar 
1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,;,n! ..(■ Il.i.hh ■»• Nn. i^ "^-tS^^ ''^^^' ^''^ 



IfJO'i 



lie^i.stcred J^'^o, 



1 84 1 



Dale /■V7^v/,c3x\-LAjL>^viLov IM 

"L^^ l-^v^ D e p uty H.s a 1 1 h...Qffi c e r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( H. S. Stan^arD ) 
PLACE OF DEATH:— County ofOcL-Tv ;v0^x,c ^A.C(.City of U.CUvv 0/vco-,v ca^cl 



/\|F DEATH OCCOPS AWAY F 
V IF DEATH OCCURRED 1 




St; 



Dist; bet* 



and 



FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "X 
N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




1 



' [) 






PERSONAL AND STATISTICAL PARTICULARS 



s}:\ 



COl/tR 



! 1 



DATK «>I- I'.IK rn 



AC I". 



i 




^^(.luh) 



Ht „„,. '^ 



iDiiy) 



Mm////- 



(V«.-:n-) 



/>,/ 1> 



sINi-.I.K. MAKKIKI). 
\\"II)<)\Vi:i) *)\< I>I\'<»R(i:i) 

(Write in >i(K-i;il dfsi<.Mi;it i' >n ) 



U\cx;wuL<l 



lUUrMrKAv'K 

iStati' i>r •'■miiti \' 



NAMK OI- 
FATm;K 



IllRTHIM.ArH 

Ol" lAlUKK 

I State oi Country) 



MAIDl'.N NAMl, 
(»1- MnTIll.R 



HIK'nMM.Ari-: 

OI Nt()'rm':K 

(Stati- or Country) 



occri'A ru)N""^\, 



l^ 



]U 



UNL^l- C V. *--'uL 




k.^ 




OL/Y>\j 




I 



1. 



,o 









MEDICAL CERTIFICATE OF DEATH 



datp: of dkath 

Oxkt 

(Month) 



/^n^\ 



(Day) (Year) 

I llllRl'iHV Cl'iKTIl-A', Thai ^ ;»Uc'H(kMl (lect'iistMl from 

i9o't to c^-^|xi' ax 



IQOH 

that I last saw h .. alive on V-- t ^^ ' 190 • 

ami that <k'ath occurred, on the ilatc statc^l above, at 



M. The CAl'Slv ()!■ Dl'.ATH was as follows: 









DT RATION 



}'cays 



Monl/is 



/)lI\'S 



//onrs 



CON T R I IU;T( ) R V LOAAJL/^^OJL , AAS:L.CU^. . 



or RATION 













Mouths 



Pays /lours 



(SIGNED) 



)jLAAyrU^LjA/VN<X VV.LO. 



Kf^iilr-i! ill Sail I'l (I III ix'ii 



)V,M 



M.iiilh' 



n<i\ 



vwv \Ht)Vi* srx'n: I) i'Kksonai, par iicclaks ari; pri k to riiK 

lii;ST Ol- MV KNOWI.l.DC.K AM) lUlUl"*' 



(liifiitniaiit 



CL A w.vaJL'' 



Un^ 



|JL/tX*V 



( V.l.lrcss 






lis LI k -.v M.D. 

...Xlvl l()0 (,\«l.lrrss)V)a-CA.t<wC fo^^lVvd.O..'-, 

Special information only lor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying avvay froin tiome. 



Former or 
Usual Residence 



uxL>^ 



How lonq at 
Place of Oeatli ? 



When was disease contracted, ^ 



Days 



If not at place of deatli ? 



DATl^o! I'.iKiAi. or Rl'.MoNAl. 



ri.ACK 01 in RIAL OR Rl-.MoVAl, 

dress ^M.I^.^.M )\' 



(Aih 



^\Jiu^ 







9 



IS. B. F.very item oi iii?orm»it5on should be CBreV'ully suppIJed. 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 every instance. 



~m 



' I 



#NH* 



\^ 



M 



it 



\. 



i 



^AiilL^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



li.Kii.l (.f Hialtli I" No. IS ■^?:3r!'^ lUt l* t 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Fi/rf/,Q}jL 




X'i 



lOCi 



Registered jYo. 



f 




O A.JL'xvv-i 



"-% 



•» <^' 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "U. S. StauDarD j 
PLACE OF DEATH: — County of^)/CL^v v1\xl>xc^c,l City of ' ^'ay>^^ .VCL^vCc<ie <.. 



^No 



3t),' 




a 



St.; 



Dist.; bet. 



and 



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



FULL NAME 



'\ \ 



I 



PERSONAL AND STATISTICAL PARTICULARS 

DATi: <>l liiKTU P 






M 



,uhi> 



.\<.i': 



)■,„' 



(D;iV) 



Mnfll/l^ 



(Vfiir) 



/h 



SIN(.I.lv M\KUIi:i) 

\\\\n t\\J-:i) OK DIVoKT j:I) 

(Wiiti-iii •^'•(•iiil ilrsij.'nati')n) 



\ 



HIK IMJI'I, ATI-: , 

'Stall or rmiiiti \ ' -A 



(^ 









NAM1-: (»»•■ 
I- atin;k 



HIKIHl'LArK 

oi' I Arni-.K 

(Stall 1)1 romiti %• 



MAIDI-.X NAM1-. 
<H" Mn'lIll'.K 



inKTIIPl.ACK 
OI MOTHKK 
(Slate or OouiilT \ ' 



■ 



1 1 





'y\j J,a-<^'^ 




!| I; 



OCCITATION 



hV^iitr'tf in Situ /'i iiiii i^rn )i'tii< Mxiilh' 



Day 



VnV. AUOVK STATi:i) I'KRSONAL I'AK riiM" I.ARS A K l". TKri' To THH 
HKST Ol- MV Is.N()\Vlj;i)<".K. AND lu: MlvK 



(In fn: niaiit 






(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OI" 1)1:aTM J^ 

(MonUO (Day) 

I HlvRI'.l'.V ri;RTlI'V, That I atteii.UMl (KicascMl from 
. 1 90 to I<p 

that I last saw h ••.' alive on 190 

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

M. The CAl'SI-: ( U- I)i{ATll was as follows: 

(\ 

h5p 



"i.d.t ''y.:. 



Dlk.X'lMON )V</;-,v 

CONTRir.lToRV 



Months 



Days 



Hours 



DTRATION 



(SIGNED ) 



) liirs 



'« 



-i 



Mo)iths 



Pays 



Hours 



....V.V. .. , I()0 



f.\ddres»)^Al' 




'^/ 



M.D. 



■ 

a\(j^ ^L :^ ' 



1 



Special information only l«r llospitdls, institutions, Transients, 
or Recent Residents, dnd persons dying dway from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Davs 



i;i,ACK oi' niKiAi, OR ki:mo\ai. 



(Address lb "I M )\\,^,^A.C . 



I)ATI-:<)! lU in.M, or RKMoVAI, 
aX|vt 2.\o T90\ 



N. B. Bvery item of inform«tlon should be carefully Buppliccl. ACJH Hhoiild he stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for p«r- 
iinns dyinft away from home should he (^ixen in every instance. 



t>4 




i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IVkii.I of llealtli- I" No. 1^ '-s^'^S:?* 



■i^^eu^ nSi.1' c 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




jjL-y^A.tJc\" an 



190 



Itc^ii^icred *A^o. 



1843 




l)(f(r Fi/rdy 

l.<:^o^ X^-M Deputy Health OfHccr 

DEPARTMENT OP PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( "U. S. StanDarD ) 
PLACE OF DEATH: — County of CW-r^.- OA..CX. vvc<..^lcc City of Oxx^x- O.^ox^qa.^. ^m. 
(No HvK^^lvlA Vjla...rA St.; ■.•.. Dist.; bet.U.aA:^<XA>vX^xt^ and ULcLLy 

^^°* / .^ DtATH OCCURS AWAV FROM USUAL RESIDENCE GIVE TACTS CALLED ^O" ;^^^^°" ST%%'El*iN D 'n U M BE r" " ^ ^ ) 

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



FULL NAME 



I'C 



U 




VO" 



tVA. 



^i:x 



PERSONAL AND STATISTICAL PARTICULARS 



(V. 



i> A ri'. »•! i!iK in 



AC. K 



(\. 



.1 



idMoiith)' 



)'r(i I . 



>l. 



Davt 



M,itillr 



/'W, 



(Vtai) 



Ihi 1, 



SINT. 1.1<:. MAKKIi:i) 

\\n)i>\vj; I) « >K i)!v< iRCi';!) 

iW'iilciii social (lcsii.MiatioM) 



lUKTlUM.AOK 

(Stall- or (.'ount I \-^ 










NAM1-; ()I- 
I'A THllK 



lURTinM.Al'H 

oi' j-ArnivR 

iStatf or C'oiiiitrv 



MAIDI'.N NAMi; 
Ol- Mol'Ill-'.K 



niK rniM.Aci-. 

Ol- MoVIl l-'.U 
(Slat"' ol roiinl I v> 



occri'x ri«»N 

Rr^nltt! Ill Si!ii ! I it III ! < '' 






n 






DO 



die 



) . .r 



M,.,illn 



n,i\ 



nil- \H()\i' sr \ri-:i> i'Kkson \i, par run. \k-s aki-: iki }•: in iin-; 
iii-;sr ol" MV KNn\vi,i;i)c.K and ina.iMi" 



(In fii'inaiil 



( \.l(lr<-ss 






MEDICAL CERTIFICATE OF DEATH 

DATK OJ- DHATH 



(>!onlh) 



I go \ 

(Year) 



(Day) 
1 lli':Ui:r>V C1;RT11-'V, That I aUeiidcd deceased from 

t,) ..- — ::— — 



190 



til at I last saw h 



"T()0 
190 



alive oil 

and that death occurred, on the dale stated above, at i»- O 
CL M. The CAl'SI': UT DliATII was as follows: 




1)1 RATION Yiars 

CONTRIIU'TORV 



.]/(>////lS 



/hiys 



Hours 



DT RATION-,^ Yi-ais Afo^itfis /hiys //ourx 

(SIGNED) J\xdXKAyCjK. J V.au»v..«.i. M.D. 

Ji\\h%'\ i»)oH (Addrr.s) ioOb CltdUs. U. 



r 



Special information "nly tor Hospltdls, institutions, Transients, 
or Recent Residents, and persons dying dwdy froii home. 



Former or 
Usual Residence 

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



HoH lonq at 
Place of Deatli ? 



Days 



DAlKo! IIIKIAI. or K1-:M«)\A1, 

ox\(<k. Qlh 190H 



iM.ACK Ol' niRiAi. OR i<i:mo\ \1, 

INKl-R'l'AKlCR vUa^^XXX *^P -^ 

(A(l<lrfss . ^ \^. O <X.C/VCX ^ \->JL\\Ll 



,.^3 
- ^ 

3 



c 



!N. B. livery Item otf InJonm.ition hHouIcI be cnrefully Hupplietl. AGK nhoulil be stated liXACTLY. PHYSICIANS hHouIiI 

Htiitc CAlISr. or DEATH in plnin term«, thnt it mny be properly cluHHified. The "Special Inlformatlon" *or p«r- 
Rons dyin^ nwny from home Hhoiild be ftiven in evory Instance. 








I 



w 



RITE PLAINLY WITH UNFADING INK 



f).mv*<^^ 



) \i y. 1 f 



,1 of llialth- I- No. i^ t-?:»|-r^-. n&l'Co 



— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)((/r Fi/rf/,0 




IH 



I'JO'i 



Rci^i^slei'od J\^o. 



1844 







(No 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

{ Ta. S. StanDarD ) 
PLACE OF DEATH:-County of)oyy^ Jk<X^%^v^c City of O^v rv^cvA-xi. 
\q\\V \aA,. St.; 2. Dist.; bet. -Ux-VkviCV .md J kUn 

• ^ ' "-^ ' " - ■■■- V ..eiiai DFC;inFNCE GIVE FACTS CALLED TOR UNDER •sPEOAL I N TO R M ATI O N • A 

( '^ r/orATrOC:u%ro\rrH "s'VT'it Tr f^SnTU^T^O^'V-VE^.TS NAME I.STEAO O. STREET A.O .UMBER. ) 







FULL NAME 



^cLdw 



CClC 



f> 



\ 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 




C"<> 



I, ok \ 



DATl-. n|- lUKTII 



Month' 



AC. H 



M( 



J '(•(/ 1 



II ■ 



(D.-iy) 



M.,uiln 



( Vt-ar 



/ Ut 1 A 



siN<". i.i-:. MAKKn:n 
WIDOW I'.n OK i)ivoKti:n 

iWiitiiii sufial (IcsivMialioii) 



luK ruri.AiM-: 

(Statr or C'ounti V 



NAM! Ol" 

1 ATn i:k 



I'.IKIIiri.ArH 
Ol- 1 AIIIK.K 

(Stall i)J Count 1 y 



N! MIO'.N NAMl, 
(»| MoTIli: K 



niK'riM'I.AC-K 

i»i moiiii-:r 

(Stall- or roniitt \ ' 



orrri'AlMON ' ;' 




(I)av) 



/go 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OJ- Dl'.ATM Q 

CJxixl 

(Mont'h) 
1 inCklUiV CIvRTII'V, That I attcMi(le<l deceased fron 

A.L\.*..q ^' . icp'i to .c!^^jiJpJt" o.a \cp\ 

lliat I last saw h alive on Q-«^vL up 

and that death occurred, on the date stated above, at -^ 
LL M. The CArSl-; Ol- DKATll was as follows: 




^kLi 



■VV^iA. 



^ 



I) r k A '!" K ) .\ ) 'cars Mont In ^ ^ Days I /ours 

CONTKIIU'TORV 



1)1' RATION Yrars 

^xKi XI ,c,o'. ( Address) ?>H^l' \^' i^ O' 



(SIGNED ) 



^font/ls fhiYS 

% 



a^>v^\^ 



//ours 
M.D. 



Special information only lor Hospltdls, institutions, Transients, 
or Recent Residents, and persons dying awdy from home. 



h'f -iiir 'I I II S,ni I I till 



III)' \novi' sTAii;!) PKKsoN \i, iv\K iicn.AKs AKi. iKi i: 1 '> Til)-: 

IJKST or MY KNoWl,i;i)C.K AND lU'.I.Il'.I- 



(I nfoimant 




<X 



^^\ ^ 



^r^\.^^^ 



' < 



( \(l<lrcss 







A 



)t 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



I'l.AClv Ol- lUKlAI, OR KHMOVAI, 



1,.\V !•. « M- 11 



DVI'l'-"!" r.i KiAi. or KI:M()VAI, 



N I ) l- K T A K l- K ^ J Cr\Xx>V ^A. Uj JUa^. 






IM. K. F.very Item of information uhouici h.- cnrefully Hupplied. AGIi hHouIiI be stated EXACTLY. PHYSICIANS should 

ntntc CAUSE OF DLATH in pluin terms, that it may be properly classilfietl. The '^Spetial Information" for per- 
son* (lyin^ away from home should be (t'ven in every instance. 



—•^ 









WRITE PLAINLY WITH UNFADING INK 



Huar.l of lUalllr !•• No. i^ t-.|^a^li&PCo 



/)((/(' Filed , 




Xi 100 \ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1845 



Be^iatci'cd J^'^o, 



Deputy Hsar' Officer 



DEPARTMENT (tF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



(^ 



rN 



PLACE OF DEATH: — County o 



( Ta. S. StanDarD ) 

POL-rV vi ^VXX'A^OUICL City of 0/CX/^^ .VO.^ 



St. 



S Dist.; bet. 




X^NJL and 

'special information 



•'*-*' V' iieiiai ar Qinr NCC Give FACTS CALUED FOR UNDER 

( " rr'nrJ'Icc'J.reV.rrHo^s^PrT*' o^Tn^^u""".. ,ts name ,nstc.o or .T.»T .NO numb... 




V 



^'0 



FULL NAME 



,<XL:1 ..■: 



.t^'^''^_U;tI^w.^. 



PERSONAL AND STATISTICAL PARTICULARS 



DA'IK OI* niKTH 



L 



COI.oK ' 



aJvd 



VLA-»- 



Moiitli 



.\< .1% 



li 



) V(f ; ,>^ 



(Day) 



M.nillis 



(Vear) 



n,t \y 



mNc.i.i:. M.\KKii:i>. 
\vri)t>\vi;i) OK Divnmi-:!) 

iWiitiin '-oiial tli-sivnat ii)ii) 



uiK rnri, \*m: 

I Statr i.r I'Diiiiti N 




1 A'nii'.K I' 



lUKIHIM.ACK 

()|- I'ATHKK 

I St;itc or l'()\intrv^ 



maii)i;n namk 



lUK rUlM.AOl', 

()!■• M()Tin-:K 

(Slatr or Country 




KjUUO- 



CV .v^xx 




MEDICAL CERTIFICATE OF DEATH 



DA'PK oi" i)i;ath 







?.:^, 



(Year) 



(Moiith) <I>:'y^ 

I H1<:RI';HV CI-RTII'V, That I atttiulod dcivascd from 

OL , '. -. loot t„ ...axK-t. 5'^ 



1 90 1 to ..V-./-*«'{ ^-v. . I9O 

that I last saw h -' alive on - \ ^^P 

aiKJ that (U-ath ocrurrcd, on the date stated a»)ove, at " 
M. The CAL'SI-: C)l'' DlCATll was as follows: 



?N 



L^vOtWw^ 



DT RATION 'X i'rars A/onihs Pay's Hours 
CONTRIIiUTORV LL<r\A^^. .j\wJUD,v-N^N^^-^O^L.^-<^ 







/OXCL 




'^-V 



dL 



( )CCr I'ATION 



h'l-^iifrd III S,ni I 1 II ih I I'll 



);,n - 



,!/,;(////' 



/'(/ 1.' 



Tni- NMovKSTxri-n i'Kksonai. i-ak iumi.aus aki: ikik to riii-: 

lil-"ST <)1' MV KNOW I. J: IX' H AM> Ml'.I.ll.l' 



(Iiifojiuaiit 



Vl 



(N. 



Mouths 



DTRATION i ^ Years ^ 

NED). (JbAAXyiv cL<X.C)pw)V 

i(,n (Address) 'X<c '^b JV'^ 



Pays 



(SIG 



Hours 
M.D. 



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



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



.. Days 



I'LACK OI- I'.rKIAl. OK KlvMoX \I, 



U 



\.l<lt.sS 



SL)1. hjQX^^UUs \l 




Dvri: o! m KiAi, or ki-;movai, 

0-^|\^ '•' ' T90 



INDl' 



(Ati«lrfss 






LA^si>!uc<i '^ . 



N B.— Hvery Item of 1n?or.„Htlon .houKl be cure?uMy HuppHed. AGK should be «tatecl EXACTLY PHYSICIANS should 
.toU CAIJSK OF DEATH in plH.n term,, that it m»> be properly cla.«lfied. The "Special InWmat.on" for pT- 
Hon« dyinft away from home Hhould be ftiven in every inntance. 






■m 







\ 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



Hn;iT(l ..f Health- »•■ V«v 



fi>f^*^ 



I 



])((/(' Filed,. 




REFER TO 



BACK OF CERTIFICATE FOR INSTRUCTIONS 



lOO'i 



r^salth Giuccr 



Jie<I/s/ered A^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cettificate of 2)eatb 

( XX. S. StaiiOatC ) 

J? QT) A ^ 

^ * City of 0'CV>^ OA.^tX-lr^yC^--i.'C_ 



PLACE OF DEATH: — County ^Q<Xry^.^> ^Oyy^-^^ City 



Nt>« 




»^ ' ^ "^^ * V '^^^* St.; - Dist; bet. 



and 



OCCURR ED I 



-v^^^ o%^f:?f,?j=4ro%774 =.v^- r.»„°ir ,;%%%^rL'o-r:=*;r ■ ) 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



si.-.x T,"^ 



DATi: «ll lilRI'll 



Al.H 




COI.oR \ 



X. 



iMoiith) 



Ul 



)'rin 



I):ivl 



M.iiitfis 



11 



i '\\-A\ ' 



/^/l 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- i)i;.\Tn 



cUkt 

(MotiHi) 



(Day) 



IQO ^ 
(Year) 



I Ili:Ki:r.V C1:kTII-V, That LattciKk-.l deceased from 

J44:v1^ Xj. 190 



SIN(.!,i:. MAKUII'.I) 
WIDOW i:i) OK DIVoK'.l'.U 
(Wiitf ill ♦social lU'^iKiiitlioii' 



r.iK riiri.AiM-: 

(Statf or I'ounti v 


A '^ ^ 




^)O^JX\j J.^C, : '^ 


NAM1-: 0! 
KAIlll-.K 




1UKI1II'1,A(.1-; 
«)!•• lAlUKK 
(State or Coiiiitiy) 




MAIDl'.N NAMlv 
01 M<)Tni<;K 

HiK'nn'i,Ac'i% 

ol- MOTIIICK 
(State 111- Coiuilrv' 




(H-eiTA I'loN 




A'/'v/iA''/ /" 


S'l/)/ / '/ illli 1 ''"'> ' ' '■' ' ~ 



/ 



i()0 >^ to 

tliat I last saw h •■ alive on ^'P 

aii.l that (U-ath occurred, on the date -stated above, at »l 
CI M. The CAISIC Ul" Dl'lATII was as follows: 



DIRATION 
CONTRIHrTORV 



years .I/on //is 



/hiys 



Hours 



DTK ATM )N )V(7r-V 



(SIGNED ) 



to \ \ 



Months 



Pars 



Hours 



M.D. 



...iW . ;^ 



'^S.\^l X. TOO (Addrc-ss) 1S0\ {lb^VvXt.Vci.;n 



\1n,llh^ 



n,!\ 



Tlir NU()Vl-ST\Ti:i>lM--KSONAl. I'AKIIi-fl.AK^AKi: TKl K T« > VWV. 
lU-ST ol' MV KNO\VI,l,I)C.K .\NI> Hl-IJl.!' 



IiifoMiiant 






SPECIAL Information on'y 'or llospitdls, institutions, Transients, 
or Recent Residents, and persons dyinq away from home. 



Former or 
Usual Residence 

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



HoH lonq at 
Place of Death ? 



Days 



l%\Cl-;oi- lU RIAI, OK KI'.MoVAI. 

iNDi-.K i'.\ki:k JULA.AJCM. ^ ^ 

< T\ ' 

(Address. .^.\0 l^ ' ' "v '<.■'> 



\)\\'\.n': \\\u\.\\. or kl-:MOVAl, 



190 






N R —r.very Item o.' Information .houhl h.- cnrefully Kupplled. AGB nhouhl be «tHtecl KX ACTLY PMYS1CIAN8 «hould 
ItJu CAIISI- OF DHATH in pinin term,, that it m»y he properly classified. The "Spec.al In^ormat.on ?or p.r- 
Kon« clyinft uwoy from home should be ftiven in e%ery instance. 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



♦> . "Sf 



Hoai'l Mt" HLMltli ■ I' Vo 1^ ^"•.i:^' 



^•. IUKlI' Co 



REFER 



TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



190 "i 



]U'gisfrro<l *A7;. 



1 



ihiic i-'iir<i.^x.\<!u^-^\ist.\- an 

-I? i ^ .. . >. - 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiftcatc of IDcatb 

( 'CI. 5. StanDar^ ) 
PLACE OF DEATHr-County ofO^V^ J/^cx.>vC..cx City of CJ^v^^ J;v<X/^^c^cc 




ivT 1 ^^ ' ^ I ) o A L < ^ SU Dist»; bet. - - 

JVJO. ^ ^' ^-'^^- -'^-. _^_^ „«UAL RESIDENCE GIVE FACTS CALLED TOR UNDER "SPECAL . N TO R M ATI O N - ^ 

( '^ r.^OrATH^O^C^^RrEV.^THO^S^rT'AL O^R^N S "iT JV'o^N OIVE ITS NAME INSTEAD OFSTREET AND NUMBER. ) 



and a, >vM Va^A. 



FULL NAME 



.^'V' 




V. 



I I 



^. 



.}^:) > 



4 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



1\ 



^.\■|■^: i>i Hi Kin 



coi.nk 



u.. 




aA.( 



Muiilh' 



AC.K 



'^c> 



) V'(M 



H 



li:i\ I 



,!/,-;////• 



I ■>' . Ill I 



/'.n 



i;5 



if 



si\«.i<K. MARun-:i>. 
winowKi) OK i)iv<)kci:i) 

(Write in ^ociiil di'-i^Miat ion i 



riojv> 



MEDICAL CERTIFICATE OF DEATH 

DAl'K OI- I)1:aTH j) 



(Month) 



(Pay) 



(Year) 



lUKTJnM.ACK 

I State or (."oinitryt 



i-A rin;R 



i^iR'niri, \rK 
()!• iai'hi-:k 

(Slatf or Country* 



MMIM'.N NAM). 
ol MOlMli: K 



luu'niri.Ari'. 
Ol' Moriii; K 

(St.lte ol I'l.lllltl \ 



Oi'Cll'Al'loN 



cL^VCV^OTV^A^Ll -^ 'v 




./CXA^Ci 



A.Vav . ^--^^ 






)'iUt I 



M.nith: 



Ihn 



■\-\\v \i5()\i- sr\-n:i) im-ksonai. i-xkruri. xKr. aki: -vkv)-. i"' > rm-: 
iii-:sT «)i' >.iv KNn\vi.i:i)C.H AM) Hi:i,n:i'" 



I HI«;R1:BV CIvRTII-V, That LatteiKkMl tleccascMl from 

U^}^X' V\ i9o"i to PJL^rvtr 2.1 i<p H 

that T last saw h .;.: aUve oti ■ JJL\\ .. '\ T90 . 

and tliat death occurred, on the (httc stated al)ovo, at \ J» -^ V 
M. The CAISIC Ol' I)I{A'1"I1 was as follows: 

ol/5. Ji-\yXsJ:k^ JL''pAlJL^-V.^^.•V.V. i'.' 



f 




I) r RATION )'('(7rs 

CONTRIIU'TORV 



Months 



Days 



DURATION 



Years 



Mouths 






(SIGNED) 

aX.^ IH ic)oH (Addrc-ss) b()io 0.'..J:LlV )t 



' ^'^Hl 



Pays 



Hours 

Hours 
M.D. 



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



Former or 
lisua! Residence 

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



How lonq at 
Place of Death ? 



Days 



(InfoMu.nit 



r 



1. h 



t X'ldress 



X U 



ri.ACl'". Ol" lUKIAl. OK KI'.MOVAI, 



DAT^lo!" HiKiAl. or KI':M«»\'AI, 



T9O 



rM)i:R'rAKi:K 

(Adihess 



\K\. OA^aAA.\LC. 



N B Every item of informHtlon should he carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The ' Special Information ' for per- 
sons dyin^ away from home should be given in every instance. 



M 



h 




^'iuMi 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



I'.i.nr.l ,.f Ikaitti 1" No. i "^ 



■j"^^*^ I'.&l' Co 



REFE 



R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jhffr Filed, QJL 



,i^\.\JS 




Xi 



lOO'i 



llci^Lstered J^'^o, 



1 848 



DEPARTMENT OF PUBLIC HEALTli=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of 2)catb 

( "U. S. StanDarD ) 
Q(x^-\,i AXX/\vc^^.<:..(. City of Oxx^^ J .^<x^>veULCc 



^No. 



I ^^ l>iJti ^\t^ ^ \^\oki '< K r^ >.. St.; 1 ^. Dist.; bet. .— — •"^^^- and ^r= 

^^ UVA^V,^ V.i. L;,j: uiuAL RESIDENCE GIVE FACTS CALLED TOR UNDER "SPECIAL INFORMATION- ^ 

( '^ rF"D;AT°H"oCCU%reV;N''A VspVt- o"r"nSt'?u"o" C.VE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 






si:\ 



DATi". »)i niKin 



AC K 



PERSONAL AND STATISTICAL PARTICULARS 




a 




) Vl/; 



il):iy) 



(Year) 



n,i\. 



SINC.I.K. MARKIKH 

winowKi) OR niyt)Kri:i) 

(Writf in social lU si;.'natii)ii) 



^ 



I go 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATIl 

a4xt 3.^: 

1 lllvklUJV CI:rTII'V, That I aUcndcd dcHcased from 

'h^f^ '• - 190 '. t.. ax^"^' '>'^ icpH 

that I last saw h •• • ahve on 'JX.'^;.vL . .> up 

and that (K-ath occurred, «hi the thite stated above, at «^ 
LI M. The CArSl*: Ol'^ 1)1:ATII was as follows: 






lUKTHIM.ACl-: 
Statf or •.■miiiiIi y 



NAM!-: 01 
FATHl.R 



HIK IIIl'I.AiK 
()|- lAPllKR 

(State or c'liimti V 



maii)i:n NAM1-: 

(»!•• MOTHKR 



HIRIIU'LACK 
oj- MOTIIKR 
(Statf or Country^ 



OCCri'ATION 



J? (^ () 

%^ 



CJLAAAXV^ w A><: 




:] 







n/ 




cjk;Lo^iLi. 



t 



X 

Kr>idrd i)t San / 1 •uf/.'-f-i) ^ 



] 11! I 



y/.'irfh: 



lUn 



LLcA-Ctx dU JL.*AJ^'>r>J<^Lh^ 



\ 



Dl' RAT ION Years 

CONTRIHUTORV 



Moui/is 



Pay. 



s 



I lours 



DURATION 
(SIGNED) 



}'('(! rs 



MdhIIis 



l\\\s 




Hours 
M.D. 



TC)0 



(Address)VK.Vj\ KX-wxC. U tt\; LU' 



SPECIAL Information onlv for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyiny awav from tiome. 



PHI- XHOVK ST\T1-.I) I'KRSONAI, I'A RT UT l.A RS A K 1-. TRD: T< > I'HH 

lii'sT oi- MY RN()\vi,i;i)C.H AM) iu:i.ii:f 



(lufnnnaiit 



'\XmJi:\j 



Former or 
Usual Residence 

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



How lonq at 
Place of Dcatli ? 



... Days 



ri.ACH oi" lURiAi, OR ri:m<»vai 



DATi; o! Hi KIM. 01 RKMOVAI, 

ax.\vt IS 190H 



keel 

INDl'.R'rAKKR \- O .J O'CV 



(A(l<hi-><s 



N B — Kvery item otf mform«tion should be cnreffully HuppHed. AGF. should be Htnted RXACTLY. PHYSICIANS Hhould 
state CAUSE OF DEATH hi plain terms, that it may be properly classified. The ' Special Information for per- 
son* dyinii away from home should be jtivcn in every instance. 



mi^.^ 



^tT" 











1 



WRITE PLAINLY WITH UNFADING INK 



Ho.-ir.l nf H.Mlth !■■ N'o i"^ ^-Cf* 



■**!^5v54; lUtl' Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



-V' 



Dfffc Filed S)JL 



./MxL.^ 




IH. 



/.96>H 



Ee<^i\sf('rc(l A'^o, 



1849 



Deputy Hsalth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of ©catb 

( XX. S. StanOatP ) 



A 



^ 





PLACE OF DEATH:-County oi^<Vy^'Sj^^^<^-^^^^- City of^cv^^ J.V^>^a^-_. 

,0 I ^ h r^ 



(•No.'V.CuLclc\. 



[ C\ ,x ' r, r] c >-xj' ^ o \ nVj(>^.>A.l<X..l Dist.;bet. — — -- and-^r..^ 

K^ ^ ' ^ '■■' ..«..,«, occirtFIMCE GIWE FACTS CALLCD FOR UNDER "special INFORMATION" -V 



) 



FULL NAME LLl^/Ow^wL^ 







V<X,V^V.\.C. »' . 



si-.\ 



PERSONAL AND STATISTICAL PARTICULARS 

VN •> I C<»I,<'K 



V { 



DA 1 i: <»1 HI Kill 



A ( . H 



'^ 



Month) 



• (/' 



Djv) 



Moulli^ 



Mi 

(Vc;ir) 



D.n 



si M.I.I-, >IAKUli:i> 

wiiM »\vi:i> «>K DivoKi ):i) 

iWiitciii s(H-ial <l«-si5.Mi:itiwii) 




A^cL^ 



\J<T 



lUK riiri. \»'i-: 

( St;it<- or I'l Hint I \- 



\ \M I" « »i 

!• Ai II i;r 



liiK I iiri.Aci-. 

<»l I ArilHK 

< stati IT riMinli a' 



M \ii)i:n namk , -) 

(»| MOTMHK 



luururi.Aci', 

(»1 NJn'ni i'.K 

I Sl,il< 1)1 fotnili yt 






oX) 



-V 




V .^ 



XLO-v 




vJ aX/i/ivouO-^' 






MEDICAL CERTIFICATE OF DEATH 

DA'IK ol- Dl.ATlI ? 

Oxkt X'i 



(Year) 



I III'UIJ'.V CI;KTII'V, Tliat 1 atlfiukMl (Icic-ascd from 

,<p to JX.\^-t :)./'. Tc)oH 

tliHt 1 last saw h -^V alivi- on m ^'>° ' 

.•111(1 tli.il iltatli orriirreil, on {\\v il.itr staU-<l ;il)ovr, at 
M. TIk- CAl'Slv Ol" Dl'.A'ril was as follows: 



U 



ULvUa. 



'\ 



Df RAT ION ^ >'''rt';^ 



CON T R I I'.rTC ) R V J X>^-wv.aA.^-/^xX ■.) & tJ 



^c 



<)c"cri'ArioNOf\f 



h'r- uird III S,ni I'' tiin 



),,/(. 



M..ntli' 



/'.n 



TUF \i5ovr sT\Ti:n i-kuson \i. paktuti.xks aki: iki k r- • mi' 
Hi;sT (n- Mv KN«»\vi,i:n<ui^ AM) r.i:i,ii;i- 



(Inf'iinniit 




'^ VOU "^ XX \/|X<X ' ' 



X'ldl '"-s 




1)1' RATION 
(SIGNED) 



}'i'ar^X Mi^nths 



Davs 



ll^ ^l^-o- 



Hours 

y.'M 



Hours 
M.D. 



njc^xt q^ l()o'-l (.\<Mrr>^s) UHJD 




!lla^t, 



SPECIAL INFORMATION "nlv tor Hospitdls, InslituMons, frdnsicnts, 
or RcLent Residents, dnd persons dyiny dv*dy Irom home. 



Former or i r\ 1 1 
UsudI Residence ' v) II 

When was disease rontrac ted, 
If not at piar e of deatli ? 




' flow long at 
,^0w^ ..a ' PIdfe of Death? 



Days 



l'l,.\4;^l'. < '1 lUKlAI, oK kl-;Mi»\\l. 



rNi)i:in'AKi:K 

( 




l>A'l'j;tii" HiKiM or Ki;Mn\AI, 



TQO 






^ „ —Hvery Item of J„form..t1on •houlcl h. c.refully HupplicMl. A(;R «houM be HtHtccI ^•XACTLY. PHYSICIANS Hhould 
Htotc CAUSL or DIZATH In ph.in tcrm«. thnt it mny be properly cIa««Wied. The "Speciol Information for p-r- 
Ron« dylnft away from home nhoiild be ifiven in every instance. 



*H 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.Kir<l of lIiMlth 1" N'o p 



«• UScV C 



RCFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Iiegi6'/ere(l jYo, 






:50 



dUKA^,^ C<.v M Deputy Healtl; OfOcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

[ 11. S. Stan^ar^ ) 
PLACE OF DEATH: — County of' '(X >\; O.VCL>VCi^.lC(. City of ^>'<X'>V J AX:L^vev^<^<. 



0^' 



No, 






1 oL'C^. LO.Va..N 



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



St,* 



Dist.; bet. 



- and ~ 



L R E SI DENCE GIVE facts called for under "special information 
OR institution give its tNAME I 



FULL NAME 



,0 




.COUO-YV 



fOR UNDER "special INFORMATION" "\ 
NSTEAD OF STREET AND NUMBER. / 

i4 



PERSONAL AND STATISTICAL PARTICULARS 




l<xL>. 



IV 



I) \ ri: • >i liiK ill 






b 



2) 



I);.V 



1/ »' A 



» r;il 



/>,n. 



MEDICAL CERTIFICATE OF DEATH 

DATH (>!• I»i: \l"ll 



'- I 



fMontli^ 



Day) (Vr.ir 



>IN<.M". MXKKIKI) 
\\"ll)«)\Vi:i> OK niVoKiKI) 

Wtitt in s.«i,il ill sij.Mi.iti<»n) 



It IK I" IIP I. \CV. 
Mat' ■ .: ' 'i M tit • \ 



NA\!|- (»l 
I- A I" II I.K 



luk r iM'i, \r}-: 
<'l I AIIIKK 

' '^1:lt^ 1 ir riiUIlt ! V 



M \ IIU.N NAM i: 



lUK rnpi.Arj-: 
01- M<>Tm:k 

(Stat< or Coniiti \ 



<H\ii'Ari( ).\ 



-\ 



"r 



-S^ 



4 
U .CX/V\; J -Vol V V. r:, '. ^ ^ 



I III-R i:i'.V CliRTII'N', Tli.if I mUi-ikU-.I .Unvascl from 

It/) til \(fi 

tliat I la^f saw h ali\c'<m ^Kp 



and lliat dialli occiirreil, on tlic date st;itiil a1)ovr, at 
M. Tlic- CAISF-; Ol' l)l-..\l"ll was as follouv, : 



1)1 UA'I'ION )V(//v 



CONTK IIMTokV 



Mont ha 



Daya 



J Jo in 



I )( RATION yrurs ^ Months 

^ S I G N E D ) LCA^CrVviL\; - J 



■ ^ 



M.D. 



h' I iiifii III Sim / imiii I'll 



)',,ii 



\ I. mill 



l>n 






I(/) 



( 






Special information «nlv tor Hospitals, Institutions, frdnsicnts, 
or Recent Residents, cind persons dying dv^ay fro:n fiome. 



Ill I, \H()VK S'l" \l !■ I) I'KKsoNA I, I' \K' IP I I, \l<s Al< I'. IK I 1 1 1 ' » I'll I ; 

i!i;sr oj- \n- know i.i.dc.k wd hi i,ii;i 



(Inf..;nK.iU oUji^>XA^ ^"^ CrVtU 



^ 



U- 



Former or • ■ i ( 

lisiial Residence '^ >vb Iv 

When wds dise.ise (ontr.Kted, 
II not dl pidi e ol dedtfi .' 



'\ I Hov* long dt 

Pl,i(e ol Dedtfi? 



Odvs 



I'l^ci'', Ol lUKiAi, OK ki:mo\ai, 
^'■' '^ ■ ■ UvN,^i/s 




I) \ TJ. -.; lit lOAi, ..t k i:m<»\ Al, 



^M 



^V lI^ 



190 



rM>i:k TAKl'.k v I V. KA^^J- 

(Ad. Iks.. \'X'h^ 






IN. K. F.vepy item oV' iiiVormution Hhr>iil(l lio ciircruily Hupplled. ACIfi Hhfuihl bo Htntecl I.XACTLY. PHY.SICIANS hIiouIiJ 

state CAUSE OV DI:ATII In pliiin tcrmM, thnt it miiy be properly cluHHiried. The "Special Information*' for pur- 
Rons (lyin^ nway from homo Hhouhl be (j^iven in every inntance. 



I 



M 



'< 





s 



' It 



I \ 



iifj 



Hi 1.1 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,!.,f ll.alth I v.. !^ t-rSsp^l{S:lM'.) REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS 



Registered J\^o. 



1 H51 



ixiic /vVrv/, 6jJp±«^YYvWv an i!)0\ 

"L>-vov^ "It ^ .,, Deputy!- • - • r- -.^ 

DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( X\. S. Stan^ar^ j 
PLACE OF DEATH: — County of ^"^^a-w. ^"^ A.Ou"\vovxi.c^ City of '"^<X/^/v OAXX^>vCcsi.c 



No. lOdL ^j)Xrr\\AJ\ 



St.; ...LU 

E 
ri< 



Dist.; bet. ^^Jl^ 



Xxx^a^oaA; 



and 



.in c , 



X/:W.\.LA 



(\F DEATH OCCURS *W«Y FROM USUAL R E S I D E N CE 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. / 



OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 

FULL NAME vJ:^'^^-.<:^ " v . V ■ MILol'' U<XA.'<ix.' 



O 



PERSONAL AND STATISTICAL PARTICULARS 
^HX (7p\ A I COI.OR' 




I>.\ li: < »I- IlIKTM 



Mc.iitli> 



.A(.»-: 



) , 



I);i\ » 



.l/./>////A 



'ii ;ii I 



/)<n. 



MM. I.}-:. M.\Kuij-:i). 

WIDOWKl) OR I)[V«)kii:i) 

'Write ill ^iH'i.iI (!i — ii'iKitioii) 



(St;it« <)! •/.luiitry) 






N \\1 1 (»1 
l-.\ III l.K 



MIR rm'i,.\rK 
oi i-.xruKK 

(State <tr CNdiiitrvl 



M.AIDHN N.\MK 
OI" MoTHl-.K 



iuRrHri,\i"i<: 

Of Moplll-.R 
(Slate or Coiuitrv'l 




MEDICAL CERTIFICATE OF DEATH 

D.ATi': oi- i)i;ath 



Dxkt- 

(Moiitli) 



/go 

(Year) 



(Day) 
p I lIICRlvHV Cl'kTlI'V, That J attciidcl .IcHcascd fruin 



icpH 



to U 



f 



up 

that r last saw h alive oti 190 

and that dt-ath occurred, 011 the date stated above, at 
M. 'qie CAISI-: {)!• Dl'iATlI was as follows: 



6141 



111 ' ' 






J .OLV 



d. 







niR.X'riON }'t'(7rs 

CONTRinrTURV 



Mofiths 



Da vs 



I/onrs 



DTRATION -.^ ^'lar^ Moutha 



(SIG 



Days 



Hour a 
M.D. 




H)0 



(Address) .Ui:t'./rVLO a^V\.<i 1H1^ 



\ . 



A) 



_ \JXkxJy C V 



oCCIl'AllON 

h'f^iiifii in Sdii /'i ii )h nro 



6 



) 'ill 



\!n>,n,- 



IUl\y 



\'\\V. \HOVK SIAri;i) I'KRSONAI, I'.\ KlirC I.A RS .\ R I! IRII-: I'o llll', 

in':sT oi' Mv KNo\vi,i:i)c. !<: and iu-:mi:i' 





fl 






f Address 






Special information only tor Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away froni home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'l.ACK OI" lURIAI. OR RKMo\AI, 
fXDKRTAKKR WVX\jtXXv LlyAA, cL 



I) Ai'j'. oi Ml Ki.M. 01 ri;mo\ai. 

aje^l^ an T90H 



(AddrcHS 



N. B. F.very Item of InforniHtlon •houlcl be cnrefully 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 per- 
sons dyln^ away from home should be ^iven in every instance. 



'I 



\%. 



ii 



% 



-rr 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



♦^""""V . 



H,,:n.l mC IIt;illli 1- No. I «i ^"Z.'^^S!jr^ »«^"^'' *•'" 



RtFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



Ihffr nird, <$}iA<XjL/YYJoJU\j'X.^ 



\ 




n)(n 



BcgLstered Xo. 



-J €^ r" i.^ 



.AJ-t^ L 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

J? (cT^^ ?^ ^ 

PLACE OF DEATH: — County of Ocl/^a. .JX<x^%csacl City of Uccw /v<x^v<lv<l,c' 

No IC)1^ ..vaOA/.- >v.-. SU ^ Dist;bet. ^.'CrV^ctt^^. OaU and ^)U.VK 

/ ir Dt»TH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
\ tF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




1 I 



PERSONAL AND STATISTICAL PARTICULARS 



>>l.\ 



rn 



"S 



COI.OR \ 



clU 



i 



) - L -•- 



!) \i i; oi- lUK 1 n 



Ai. !•; 



l^)ct 



Month) 



I 



U 



(IJav 



1/.. ,////.. 



» S'far 



/>,r 



MEDICAL CERTIFICATE OF DEATH 

DATK ol- I)1-;AT11 



JX 

(Mon^i) 



U. 



(I)av) 



(Yt^•lr) 



sIM.I,]'; MAKUIl-I). 

W !I)( tWKI) OK l)I\()RrKI) 

iWiit< ill •"ocial <lt ^ij.'iiati'iii ) 



C\ 



liiKi'm'i.Aoi-: 

(Statt or Couiiti V 



NAM1-: OI 
I-A'nil.K 



I!IRTHri,ArK 

OI" lAriii'.k 

< Stat« <>i c'lmiitry^ 



MMDl'.N NAM I". 

oi- Morm;K 



liiurm'i.Aij-: 

<»»■ MOT I IKK 
(Stati- or c'ountryl 



O <\.orv^< 



;. i 



'^Ue 



o^oK.AjL>^ I ^Ve- 



CLavcV) 







\ 



orcri'ATioN" v^ 



i) 



AVs/i/rif ill Still I'linii 



)'lUI I 



M.nith; 



I'.t 



Tin-, \novi-: sta ri-.i) i'Kksonai. i-ak i uri. \ks aki: pki i. lo i iih 
in-:sr oi- my kno\vij:i)c.k and lu-.i.n.f' 



e 



(111 foiniaiit 




(A<l(li 






rt'ss 



I III;KI:1'.V C1;RTII-V, That I attciKkd «k-coase«l fruui 

190 1 lo U-^^A^ ^i icp"^ 

that I last saw h - > ■ alive ow 0-^\\X' • ' I90 

anil that death occurred, on the date stated above, at X- I 
Ll^M. The CATSIvOl' DI'.ATII was as follows: 



vLcu 







(\ \) 



■>^<:uO\j tv C, 



6l^r^ 



^ v<x.e. I \.. 



nr RAT I ON )V(/;-A- 

CoNTUnU'TORV 



DT RAT I ON , )\'in-s 



Mofii/is 



Days 



Hours 



MoNt/is 



(SIGNED) 






Davs 



Hours 
M.D. 



(Addre^-) I'Xo LlJ '..' ■* 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Oeatli ? 



. Days 



I'LACK OI- nrkiAi. OK ki:moval 
C)^.L- W. 0. \l\X»voCt(r\A 



DATI-lof HruiAi. or KlvMoVAI, 



INDKRTAKK 



fA.l.lrt-ss^ b'ib W CV<iJ 



a^\j:\> 






it , . 



N. B.— Hvery item oi informBtion hHouIcI b. cnreVuIIy Hupplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it m»y be properly classified. The Special Information for per- 
son* dyinjl away from home should be ftiven in every instance. 



h\ 



I'.-, 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



.^■T^. 



noiii 



,1 .,f iKititii- I- No i^ •**!r.;35^.'-ii nfti* c 



REFER TO BAC»^ OP CERTIFICATE FOR INSTRUCTIONS 







Dnfc /vV^v/, QjlJvWax.ImJv XH 100 H 



Jiegi^stercd' j\'o. 








DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Ccvtificatc of Bcatb 

( 11. 5. Stan^arD ) 



((^ 



^ \^CV^. C '. 



No, ^'^'^ ■V'.^.'.:' St.; ^ Dist.;betAJ.lt<-^^Kcx./^m 






L' 



FULL NAME 



XUiAX 



PERSONAL AND STATISTICAL PARTICULARS 



.1 




DATK «U-" lUK 111 



At.J- 



XvUa.L. 







)V,;/ - 



11 
iDav) 



!/.';////> 



/ !..'■. 



I Vcar) 



Pii 1 



M\«.I.I" MAKkn: I). 

WIIX tU i:i> < »K I)I\< )KrKI) 

iWiitriii vocial (l<".i).Miati'>ii) 



X' *^cLcrvo^^cL 



(Stall or (.'oiintry ' 



NAM!-. (>l- 

I- \r!ii:R 



lUR rin'i< AiK 

<>l- lATHI-.K 

(Stale <)! I'oiintfv) 



MAIDI'N NXMl". 
»>!• MOTHKK 



mKlin'I,ACK 
(Statr or Country^ 



urcrj'A'rioN 



.0 



t- "' 



L 1^. 



o 







1 rlo^vci 



Kt'siiird ill Sail I'laii.isr 



'\ 



) V'fT' < 



^roiiih- 



I>,1V.- 



TUl- \HOVK ST\Ti:i) PKKSONAl, 1' \ K T UT LA KS A K H TK f K TO THH 
linsT <)I- MV KXOWIJ.DCK AND IJKI.IHK 



f Iiifoimaiit 



\.l(lir>;s loo 




MEDICAL CERTIFICATE OF DEATH 

DATK Ol" I)1;aTH 



Moii^h 



I 



(Day) (Yt-ar^ 



I UI*H1''BV CI'RTII'^V, Tliat I ;iUfii(k<l <U'rcased fruni 

^v uv; \;^.^ ^^.^ V-- '' ^^ ■' TCP 

tint I last saw h-^V alive on \^\(\L ' ': up 

ami that <U'ath occurred, <»n the date 'stated above, at > .A..^ti... 
M. The CArSI-; Dl' I)l".A'ril wa^ as follows: 



vVv<rwoc 



DT RAT I ON Years 

CONTRIIUTORV 



J/of///is 



Days 



DURATION ^ Vcars 



(SIGNED) 



Mouths 



Days 




Sl 



Hours 

Hours 
M.D. 



i a:^ Too'i (Address) IX'IO O^e.'...' '-. \t 



SPECIAL INFORMATION on'y '^r Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinq away from tiome. 



Former or 
Usual Residence 

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



How long at 
Place of Deatli ? 



Days 



I'h^CK Ol" lURIAI. OK R1;M<»\AI. 





c 



,\.<>-<l4' 



I)A'n%of H( KlAl, or RI:M<)VAI, 



\ji)^ 



INDICRTAKKR 

(Address 



e.ot. 



,ti-WTvc\; 



IbT 



^"K^ 



Vi!. 



•v^*^^iA<<rv 



x...sSl 



«tate CAUSE OF DEATH in plam terms, that It may he properly claMiiiea. nc op 
sons dyinft away from homo should be ftWen Jn every Instance. 



^1 



If 



r 

i 
t 



I 



1!m;i! 



WRI 



,1 of ii^.iuh- »•• No. 1^ *--:^^ '«^J' *'"'J 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J/ 



Jhf/c Filed, <:] 



,^AX-V/» 




,^vUA; 1H ^'^0\ 



Jteofsfr/'cd jYo. 



4 Qr^/I 



K^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of H)catb 



I XX. S. Stan^arD } 
PLACE OF DEATH: — County ofO<X">Aj OVO-AXCui.ci. City of *-'<Xav O.VCV . . :a.4 c.<- 

I / ir nrATM OCCURS. 



\ WuAxt.^ ^"^ n \\ V.I.O I St; Dist.; bet. and 

V. v-A, N, v-A ,,cii«l DS-ciinFNCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION 



•) 



FULL NAME 



i 



/0w^.L4'U^lC'^ 




/:>^La.t..( 



A.i 



PERSONAL AND STATISTICAL PARTICULARS 



]\. ' 



.O^Uv 



DAIl-; <>1 lUKTll 



\< .}•: 



M.MUht 



b'E 



) - ,: 



(Day) 



M.;i!lr 






/hn 



•^INt.i.lv M\KUIH1>. 

W MX »\\ i;i) <»K IH\nKij:i) 

'W'litcin ^(M-ial (l«si>.Miiit ion ) 



I'.iK rniM, Aoj-: 

(Staff or <.'uunti yi 







'3 



LxX-U -'' 



NAMl', «)l" 
!• ATHl'.K 



lUkTHIM.AlH 
<)I- l-AriM>:K 

(Statr ni lountryi 



MAIDI'.N \AM1-: 
«)!• MOTIIHK 



lUKllU'LArH 
«>1- M()'nil<:K 
(StaU- or C'ountry'l 



OOCri'ATION (^ I , 



ft 



i ^ .^ 



1 



^\xX(X^\^ 



A'rsKici/ III Sitii /'nun i^>'> 



) 'rti I 



M 'lit In 



n>n 



■\nV \B()VKST\Ti:i) rHKSONAM'AKI-IiMI.ARS AKl-.TKn-: To TIIH 
lil<:sT <)1' MV KN(»\\'l,i:i)<".H AM) lU-.Ml.l' 



(IllfoilllMIlt 



\JU^ 



VJ X/Ck>tc) 



(A.l.lt 



t'KS 



'\c 




O^Ak'^ta_- 



1 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol- l)i;ATli 



3..tkt 

(MoiiHi) 



(Day 



(Yt-ar) 



1 llI<;Ki:r.V CI-RTII-V, Tlmt I atloiKkMl deceasca from 



to dX^^l 



'N *:;. 



j.jJ^xS ■ up to 4-«-i^:^ :^-^ uyo'i 

that I last saw h alive on OJl^vV • i(,o 

and tliat (U-ath occiirreil, on tlu- dale stated above, al ■' 
^L The CAISI-; Ol- Dl'.ATII was as follows: 



DIRATION )Vrtr,? 

CONTKIIU TORY 



Months 



Days 



I louts 



1)1' RATION 
(SIGNED ) 



) 'cars 






MofiiJts 



Davs 




(Address) 




Hours 
M.D. 



Hospitals, 



SPECIAL INFORMATION only for H 

or Recent Residents, and persons dyinq away from liome 

SlVsidence ISl^iOAlxxt iLv . pj^e of Veatli ? 

Wljen was disease contracted, 

If not at place of death ? 



Institutions, Transients, 



. Days 



l'I,.\i:K Ol- JUKIAI, <»K KI'.MoVAI. 



h^ III- m r>. I-'* '« 



DATl'.o! MruiAl, ->i K1-:M«»\AI, 

J«^\vb 'XS^ T90H 



M iXxXAXA^-y 



^ 



'\ 



\, / 



(Acl.lrt-ss .5> \^ U /O (O^VoXtj . ...J.t 



^ 7T. ,. , .pp «s»,ilil he Mtiiteil EXACTLY. PHYSICIANS Hhould 

N. B.— Rvery Item of 1n9.>r,n«tion «houKl be cnrefuHy -PP'- • „^,^f:H^7/:Lmcd T^^^^^ Information" for pT- 

Htflte CAUSE OF DEATH In plain terms, that it may be properly claH«itiea. 1 



Rons clylnft away from home nhoiild be feWen In every Instance 



1 '< 

I 



t 



m 

lit 



r?' 






RITE PLAINLY WITH UNFADING INK 



I5m:iJ< 



w 



1 ,,f H<;iUh--l- No. i«i ?"i;^»,W: lUSilM 



— THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



jirii t,sci'rciv ^ 



Yg. 






Da/,' r/ /<■(/, a jJ(^XjirY>-J>-lh. 3v1 ^'^'^^ 

l(n-w> i^xM^ Deputy Health OfTlccr 

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



Ccvtificate of S)catb 

( ■a. S. StmiCiatD ) 
PLACE OF DEATH: — County of'"j<^>v -lA-a-v^c^^co City 
I^vl>vtxO-l luv.J,.^-vxCH ^'(^^^U^W. Dist.;bet. 



07) 
itv of ^ 'CL/^^ ^ K.CL > •-. C V <^ • ;. ' 



and 



..<^..Ai DccinFisirF riwr facts called for under "special information '\ 

( -^ rF"D;:T°H^OCc"!rEVi;''rHo"s^rAt o"R'?:?^rT^O^"a.;r.;i ?.AME -NSTEAO of street and number. ) 



it' 



FULL NAME 



^fXOJ' 




A 



w 



x,a^J. 



PERSONAL AND STATISTICAL PARTICULARS 



DATl". «>1 UIKIM 



\(.K 



^ 



1 



'^^i. 



V' 



/ '. 



iMmitlO 



1 . ,.■/ 



; Dmvi 



1/ .»'/// - 



IV ear) 



/><i\- 



iWiitf in >-oii;il fl('<iv"''»ti')n) 



HiK rnj'i.ArK 

(State or (.'onntrx' 



Ix^A^c^Vt 



1^ 



NAMK <)1- 
I' A'lHl.R 



HlR'nin. ATH 

()i- I aimj:k 

(Staff or rodiitry'' 



MAIDKN NAMi: 
iU- MOTHKK 



HiR'rnri.Ai"!-: 
oi- M()Tni:K 

(Statf or Cotintryt 








a^acNxfc 



v.'- 




ii' 



i;l^'- 



( 



orOlTATION J( 



^Vv^ 



M..nlh^ 



PilV 



THl- \m)VKST\Ti:i.1'KKS(>NAI, I'AUTU-rLAKSAKI-.TKrK H » 

in-;sT oi' Mv KNo\\i,i:i)C.K and in.i.ii-.i' 



T 1 1 K 



MEDICAL CERTIFICATE OF DEATH 

DATK UF Dl'ATU 

I HI:KI":HV CIIKTII-V, Tliat I altciKUMl (leccasc<l from 

- to .: -— -r— — — — 



I go 

(Year^ 



I9O 



that I last saw h alive on — -~-r— — 

aii.l that <k'ath ocH-urrcl, on the .late statt-.l above, at 
M. The CATS!*: OI' Dl-ATII was as follows 



IC)0 

T90 



ix^.^.ft<yx.A..U.^ '^L..a '. , UxJvcrSLA.^ 4 1'.. . 



DlRA'noN Vtars Mouths Pays Hours 

CONTRIIUTORV 



DTK AT ION J><//--V 



^fouths 



Pays 

\ 



Hours 
( SIGNED ) ...UV^- " J \1).U), dXLO I. M.D. 

i\\}^ V^ Tc)oH (A.i.irc-ss) U^^rwt^^ W-i ^ 



SPECIAL INFORMATION only lor Hospitals, Institutkiiis, Udnslenls, 
or Recent Residents, dnd persons dyiny dvvdy from home. 

utS' Mdence I ?>1 Vj. Lla'va. vjt "Zlltm Days 

When was disease contracted, 

If not at place of death ? 



\ 

(Address I O M iQv 




(X\jOj 01 



I'UACK OI- lUKIAI. OK KKMoVAl. 




DVrilo!" HiKiAl, 01 kj-:movai. 

aj-\vt.' 11 . T90 



(Address lk?.b.. ..>ttUA/M^.lV. ..^^^ 



State CAUSE OF DEATH In pln?n terms, thftt .t may be properly claMitiea. 
«on« dylnft away from home should be ftUen In every .n«t«nce. 



I !• 



\. 



I I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



HoMV.I ..f IkMlth \- No. K *-!^^"^^ liftl' Co 






licgLstci'cd Xo, 



'^•.:i(> 



,CrVA^^ 




vq Deputy Health CfTl per 

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 



N 



Certificate of Beatb 

i 11. 5. Stan^ar^ j 
PLACE OF DEATH: — County ofQ/CL-'ru JX/a >v<:aa Ci City ofO<X'y^J .V'TX/tv.' 

■ , , St.; 5., Disf.;bet. H^ ^ '- 



o. "^"XH "^. . 



and vi' <X^txv>r G . 

/ ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED Fp R UNDER "SPECIAL INFORMATION ' \ \ 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME IJ^STEAD OF STREET AND NUMBER. / ' 



U) 



FULL NAME 



WVYV' U \! ll.>:.o..^„o... 



PERSONAL AND STATISTICAL PARTICULARS 



Nl.\ 



1 RcXLv 



COI,(»K \ 



DA 1 », » tl ItlKlH 



M..mli 



A I .»•: 



all 



) ' ■: 



D;i V 



\l..nl/i' 



'■/ciD 



/),/! 



sIMl.i: M\RKIi:i» 

u iix iw »:i) i >K i>ivt>Kri:i) 



lUK rnpi.Ai'i-: 

'Stall or t"'tiinti yl 



/ 



\AMi-: «)»■ 

I ATM KR 



HIK I H IM, \(i-: 

<ii- I \rnKK 

' stair or ("diniti y) 



MAII»i:n NAMl. 



HIK rmM,A(i<: 
<M- Morm-.K 

• Stat' 1)1 Coiniti > 



« »i«ri' \I*I()N 

A'f.uifr<f 1)1 Smi /'i iiiii ism 




MEDICAL CERTIFICATE OF DEATH 



(I)ay^ (Year) 



DATK (II- i>i;atii ; 

'Mmitn) 

I II i; K i;i'.\' (.' I{KTI l-\\ Tliiil I ;ittcii(k-.l (kciascd from 

— lyO to " i<>o 

tlial I last saw ll :■: alive oil — — ^^y^ ■ 

and that (Katll (occurred, on the date stated ahove, at 
M. The CArSI-: ()!• Dil.VTll was as follows: 



nr RATION )'cars 

CONTRMirTOKV 



Mouths 



Days 



I /ours 



}'cars 



)'i'<! I 



)/,,„///' 



/),n. 



rill-; AM<»vi<: sr \ij;i) pkksonai pxk rini, aks aki. tkii-: to tin-: 

H1-:ST Ol- MY KNOWI.l.Ix'.K AM) lil.Ml.l- 



Miifntniaiit 



\w.</vcr^ 






r\(Mrc« 



® 



Afont/is 



1)1" RATION 
(SIGNED ) : 

C)l}^ an i(,oH (Address) L 



fhivs 





dJpjt v\ 



.trVC'v^X^^ 



m 



//ours 
M.D. 



-»*r« 



Special information ""'y '"^ Hospltdls, institutions, fransients, 
or Recent Residents, and persons dyinq .ihhv from liome. 



former or 
Usual Residence 

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



HoH long at 
Place of Deatfi ? 



Days 



1'1,ACK OI- lUKIAI, <»K K1;M'>\ AI. 



DATK of Ml KIAI, or H1-:M<)VAI, 

(?jl'^ ^5 190H 



<X<T 



Ad.lr.-ss3M^^- l">.Uv 



state CAUSE OF DEATH In pl..ln term., that It may be properly class.f.ed. The Special In^ormat.on ^or p.r 
«on« dylnft away from homo Hhould be ftiven in every instance. 



» 






i 




'f 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



He i:ili 



1 .if Il.-.ilth \' No I- 



^«,?V»»^ 



'U-. ij&r Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJO'i 



licgisfci'cd J\''o, 



M % mm. 



f«oy 



X^vcu^ dUL- Deputy ^ " ^ " -^r 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of ©eatb 

J? i^o i ^ 

PLACE OF DEATH: — County of'JO-'VV JXO.>^<x<i,r City oiOo^y^ vcv^vcv^c. . 



T.o.M\t. 



) VvVCJ-^A. U V:'' 5-a;lI \xl i.^... y SU Dist.; bet. ^ and 

/ Ar DEATH OCCURS *\M«V rROM USUAL RESIDENCE GIVE FACTS CALLED TOR UNDER SPECIAL INFORMATIO 
(:T Tr DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



u 



n 



FULL NAME ^v^ ^ 



W 



ClX QA. v.. '... cL-Qj 



sIA 



PERSONAL AND STATISTICAL PARTICULARS 



t 



X »^cx '- 

h \ I 1, I >r' HI K Til 



u 



a.. 



\< .1-: 



a 



\».. nihil 



) 



'S 



I'.IV 



1/ .;/,'// 



■/(■ill I 



/hn^ 



sIM.l.i;, MARK ll'.Ii. 

\\ii)<)\vi:i) OK i)!VoKri;i) 

Wiitiiii '.ociril (lc-').'n;ili<>u I 



iliK riii'i. \oi-: 

'Sl;it< or <.'<i\ititi \ ' 



\\Mi-: oi 

!• \1 lll.K 



lUKIIMM.ACl': 
()! I \llli: K 

'St;il( '.! Cimntivi 



MAini'.N NAMl. 



HIK IIIIM.ACI-; 

<)i' M()'rm:i< 

'■^tatc or i'omit 1 \ 



nvTl I'AIION 






'-^.uUu^ 



4 



1 1 \x%cc c- 




. ) 



/\'/'!ifr(/ III Siiii I'l a>h rill 



! ,,M - 



M.nitir 



/),n. 



Till- AHOVl". Sr\Tl,I) I'KKsoNAl. I'AKTU TI.XK^ AKI'. TKri'. Tn TllK 
Iil-:ST Ol' MV KNOWM'.IX'.l-: AM) lUJ.1 1. 1' 



Oiif' >: tn.MTil 






^\(l^ln•s^ . 



XX. t 



MEDICAL CERTIFICATE OF DEATH 

DATl*. OI- Dl.ATH 






Vi 



I()0 

iV.-ar^ 



i) il):ivl 

I lli-I'J i'l'A' ClvRTIl'N'. That I altfiulrd .Icctasod from 
up: to uNji.^\' u>o'' 

tliat I last ^a\v h iilivc oil , "P 

aii.l that lUath nccurrcil, mi thr datr slatc-<l ahovc. at ► 
M. 'J'hc CAISI*; OI" DlvATII was as follows: 



DIKA'I'ION 



)'ra)':\ 



Hour 



V-VVN/V/Oi.. '..'.. I. 



"VtJ >'v\.i 



Mouths II /><n'.v 
C () N 'I" IM 1 5 r '!• () R \' p-^^ \a.J^a, vN/v<a. ' 

si .LUMA.CVV.i.^ uc .> oX<X.. \^A^ CSV H 

DC RATION Years Mont /is Pays 

(Signed) h v^i^^vu-) vjV.^-'^^ 

SPECIAL Information <»nly for tlospit.iIs, Insntutions, IrdnMrnts, 
or Rfifnt Residents, and persons dyinq .iway from home. 

Former or -X I ^ . \ 

sidencf ^ A-A.AA^vV? 



I /ours 
M.D. 



Usudl Residence ^ AAAA/^ 

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



tioM lonq at 
Place of Deatfi ? 



. Days 



I'LACK «)«•■ nruiAi. OK ki;mm\ \i, 

rNlU'.KTAKHR ^ ^'^ 



I)\'41', ot Hi in A I oi K1-;Mo\'\I, 

\tKl' ^sS 190' 






"""""^'"'""""'"'"'"""^ o ,. I- I APF ahoiild he stntetl EXACTLY. PHYSICIANS should 

IN. B.— r.very Item ui Information should he cnrefully Huppl.ecl. A(.F. « ''^"'^ J^^ "*"**^J^ -Special Information- ?or pT- 
«tnte CAUSE OF DEATH in plain term*, that it may he properly class.tled. The Special intorma 



song dyinft away from homo should be ftiven in every instance. 



^ 



r' 









' I 




i?' 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H,,:,i.l ot Ili.ilth I' No 1- f'"!ii^ie^i: US. V C < 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






.^!\JU^ 




V\ 



n)()\ 



Beg Isle /•eWJ\^o. 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©catb 

( tl. S. StanDarC> ) 



PLACE OF DEATH: — County 



of OctO^ OXOLAXCUC'City ofU/CbO^ J A.<XOfA.CLCl.C ( 



No. iHOl HKc^<i.Urrx.: St.; 5 Dist.;bet. XctL and 'M 

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

FU LL NAM E M ' l^XvL ; va; ^ J XL 1<lU. ' 



PERSONAL AND STATISTICAL PARTICULARS 



s}:\ 



1. \ 11-. ( II I'.IKIIl fVo. 

VUla/v 

iMonth^ 



rt >i.« Ik 



Li 







)'■,,, - 



(I):tv) 



.!/./»////- 



(Year 



/>iiy 



Nl\«.l.r: MAKKll",!). 

w n>«>\vi:ii «)K i)ivi)Kri:i) 

'\\iit< ill social <lf^ij.Miatii)ii • 



I'.iK Tui'i, \t'r: 

stall i>r roiiiili \ 



.0,CcUr^'^^^-C^^ 




N \M ) . ( »!• 
I- A 111 l,K 



lilKTlI I'l.An-: 

()!• I \rm:K 

< stall .,1 i'. iiiiiti \' 



m\ii)i:n na Mi- 
di' M<»ri!i:K 



lUK rUPI.ACl-. 
nl MoTMI-.K 

I State i>i riaiiit I \l 



luri I'A TlnN ^ 



I (It't d.'.! 



'r 



V 



■"y 



1 1\ a V > 



v^ 



/\'f/(!i-(f III Situ /'ntiiii^rn Xy 



Mm, III ^ 



Dav 



I 111. .\iiovi'. SI' \ii:!» i-Kus()\ \i, r\i< I i< ri. \K^ AKi". i'ki v. i' » i" i'. 

Ml'.ST ()| MN' KN«»\\ !,i:i)( .1-. .WD Hl.Ml.l' 

LoL^w^CXj v^<X'v..'..- "v 



Hn fill mail! 



viiih.ss XHlD HlWiL^iLA^^ 



\ t 



MEDICAL CERTIFICATE OF DEATH 

DAT:-: oi' Di'.ATn j} 



C.iVv 

MnlAh) 



iDav) 



(Year* 



I in':Kl';n\' t I;RTIFN', That I aUcii.k.l «lt(x;iso(l from 

tliat I last saw h -L'X- alivo on OxljO t<^ 

aii<l that (liath occurrc'(l, on the thitr stated ahovc-. at 
M. Thf CAISI". Ol' Dl'.ATII was as follows: 



^^1 






DII^.XTION 



} V(/;'.s- 



Months 



Days % I louts 






DT RAT ION 
( SIGNED) 



/fours 
M.D. 



T()n 



(.X.l.lrrss) ilil V ai-. V 



'" ( y 



SPECIAL Information o'l'y ''"^ Huspitdls, institutions, Iransients, 
or Recrnt Residents, ,ind persons dvinq dnay Jroni home. 



lormer or 
Usijcil Residentf 

When vvds disease (ontrdded. 
If not at plare ol denth ? 



HoM long dt 
PIdre ol Dedth ? 



DdNS 



I'LACl*: ()!• lUKIAI, <il< ki;Mo\ \l, 

'U 



l)\ri,:i.! Hi Ki.^i. Ol Ul'.MnVAI, 

O^... I .' ' -X TQO'. 



NDl-lKTAKl'.K M I V. 



,,. „._Hvery Ucn oi' infor,„„t1«n hH.uI.I h. ...rcfully suppliecl. AGK nhoulcl »>c«t"ted EXACTLY IMIY8ICIANS . 
HtHte CAlJSr or DnATH !n pInJn termn. thnt It may be properly cla««ineil. The Special In^ormafon ?o 
Ron» clylnft nway ?rom home Hhould be ft'ven m every instance. 



PHYSICIAINK Hhould 
r p»*r- 



,1 




yuj 

^i^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



.»r*-Zrv 



H..;,i<i ..f Hc.itii ^ »•■ No ;«. - 'i'.'*^- 



J-i: r.\:i' I- 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i8 



I)nfi> hllr^l.'^.JLY^^'^'^^-^^'^ '^H 100\ Itrglstered jYo, 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

11. 5. iT'tan^arC^ j 
PLACE OF DEATH: — County of "^^CLo^ vlvOw/^VCUC(City ofC)£L/Y\; vJ A.a/^XCC4.e(. 



No. \Hoi m..^.....^.v 



St 



.; sS Dist.; bet. '5v X.' 



and 



■^ ! , t 



F DEATH OCCURS AW/AV FROM USUAL R E S I D E N C E G I V T FAC 
RRED IN A HOSPITAL OR INSTITUTION GIVE I 



(I F DEATH OCCURS 
IF DEATH OCCU 



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



FULL NAME 



\\ 



<x\.L . .. cx- 






PERSONAL AND STATISTICAL PARTICULARS 



vtx 



I \ , 1 . .! liiK I n 



U.; dj 




' Motitht 



\' . !• 



I>MV ■ 



1/ ■lllll' 



/'./I 



-!\' , 1 1 M \K i< n:i> 

w ii»i iw i; i» OK i»:\< »kti"i) 

Wiit'iii --iiii;!! ili'-ii' tiiit i' iii I 



I'.iKiiii'i, \t"i-: 

iSt.'it' ' <r ("Dniiti V 



IVtd^^v ^C^^ 




I AT It J.K 



MIKI liri.AiH 
oi- I \IMKk 

' St;it> III iDuiit! V 



MAIDIN NAMl. 

<>i- mmiiij;k 



ItlK l'lll'I,A( !•; 
n|- MnTIUvK 

' '^l.'ltr' • ir Coiuit t \ 







\\ 



MEDICAL CERTIFICATE OF DEATH 

i»\ri-: Ml- HI. \iii 

Mciulii il):(v) IV. .(I ' 

I IN-.k i:i'.\' C I-U'll I"\'. That 1 aUcmU'.l .kirast.'.l fr.aii 

tliat I last saw ll -'-'v alivroil ' j Ii/D 

aixl that <U-atll occiirrfil, mi fhi- <latc sfalnl ahovf, at 
M. Thf CAI SI, <>!• I)i; ATM was as follows: 






'V I 






v,n.v^vv 



1)1 RATION 
CONTRIHl'TORV 



) V</y.v 






Pars %> /louts 



w. 



1 rars 



DIRA TION 

f Signed ) 



.Tf^yfTTTrs^^' " A/i'v 



Flonns 
M.D. 



\_ > 



, . A 



CX\. ^ ^<, 



< '» <■ I !• \ I'lON 



\j 



^0 



r ■. V 



f\f-iiffif III Siiii / I lllll ,' ' ' <J^ ) ' 



M'Oilh^ 



nil \H()\- J- sr \ ri: !i I'KK-." >\ \i, !• \K I III !. \K> \Ki; rRri'. ii > rii )•: 

lll.'slOl MN- K Ni >\\ |,l'i)( , J-: A\ I» m.1,11,1' 



' 1 1; t'>! iiiant 



CcL v^ 



' V'Micss 



% 



^HlO H r\A.AxiA..<r> 



V 



1()0 



(A.Mri-ss) "X\ V 'X'... ^^..■:\/^ 



Special Information »niy lor HosiiitdK, institutions, irdnsients, 

or Rerrnt Residents, .ind persons dving dHa> Ironi home. 



Former or 
Usual Residence 

When was disease (onfrarted, 
If not at plare ol death ? 



HoM long at 
Pla( e ol Death ? 



Oa\s 



I'l.AC}", <)!•■ lU KIAI, I'K KlMii\\I, 



I)\'ri;:o* I!i KIAL (»r Kl';%tt»\ \I, 



r N I ) 1 



••.KTAKl'.K \ \ \- 




N. K. 



-Hvery item of informntion hHouM b- c.refully supplied. ACI. should bo stntedl EXACTLY PHYSICIANS should 
HtHte CAUSE or DEATH in plnin termH, th»t it may ».c properly clasBitied. The Special InW.rmHt.on ior pT- 
«on« dyinit nway ?rom home should be given In every instance. 



% 



t K| 

■<.! 



} 



liM 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Xounl ..f II< tllli » No I 



»"^!;*v 






!'~4) HN: I' di 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



V,' (^ 

/>r//r /'V7(V/. Bx'^vtx-r^xUA; ^H i^6^S 



Begistci'ed J\'*o, 



1859 



(rvoui 




[0 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



PLACE OF DEATH: — County ofOa 



V 



'V 



(^ 



\a >vCAo^co City of ^ ^ cl >a_' vJ ,'\xx -aa.c u:i. c . 



3V 



p^/A M U-. %:^A.\xy\.'^ 



\ 



St.; 



Dist.; bet. 



and 



(IF DEATH OCCURS *WAV 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. / 



FULL NAME 



A 



Ct >^v^^c. 



\j ]. u/t.w.^Li^.. 



PERSONAL AND STATISTICAL PARTICULARS 

s J.; \ A A r < ) I . « • K 



"ad. 



L', 



DA ri-: «ti I'.ik ill 



\' ■ I'. 



rlX 



Month 



I);ivt 



!/..»/ ,'//■. 



MEDICAL CERTIFICATE OF DEATH 

DA II-; <)!• Dl'.A'l'II V 



'Vtimtll^ 



iDav) (Year) 



J III:RI:IIN' C'i:K'ri!'\', 'riiat I attetKU'd .Icrt-a'-Jo.l from 



» cai ) 



nti\ . 



s|\i .1,1, M \Kk I J.D 

\\iD( »\vi-:d < »K Di\t >Kr».:n 

iWiitf ill v.MJal (l«siviiali<)ii) 



l!Ik I'lMM, \i'l 

' Statt '•! •"' Hint I \ I 




NAMl- Ol 
1- Alll IK 



V 

M 1 



luk iiii'i, \ri-: / 

OI- I AT MI', k ' 

I Slatr <tT t'oiiiitt \ ' 



MAIDl.N NAM I 

«»!• Morm.k 



lUK IIIIM.Ari-: 
• >|- MoTlll'.K 
(State III lOiml I \ ' 






i^ ^ 



c I ^v 



^ 



( , 



K^O '. I,) .CJ.-^^A! '^K'^.. I()0'l 



that I last saw h - alive on d^.^ v '. 

and that drath occurred, on tlii' dati- stated above, at ^ 
M The CM Slv ( )!• I )i:.\'ll I was as follows: 






? 

1)1 U.\r ION )\ars • M on I In 

CoNTkllU'roRN' 



/></is 



I lours. 



Pay. 



'S 






t d\ ^ c\ 



J 



lA 



t\lA. 



<>m !• \ 1 ION 



\.o% 



l\r^iilr,l III Siiii I'l ii ih i^iii 



V.O0 



) Id I V 



\I,'„<ln 



I '.I 



\\\\: \u«)V)' s r \ii,D i'i-ksi)\ \i, i'\K rui I. \ks Akr: rkii-: lo in i". 

lU'lSr (»!■ MS K N()\\I,I:D< . !•. \M> l!l i.n.i' 



( 1 1 1 1 1 1 1 n 1 a n I 



LdLcv'-ojvtA^ V n cv\,a^UL<.% 



y\jj\. 



u 



^ 



-^>v 



l>r RATION )\<us Months 
(SIGNED) li). U.\ L-- > . 
CU vO IH ic,oH (Ad.lrc-ss) 'V^^ -' >- 



I lours 

M.D. 



SPECIAL Information "nly for Hospltjls. institutions, Fmnsients, 
or Reicnt Residents, and persons dying .m.iy from liome. 



former or •'y. 

Usual Residence ' 

Wfien was disease rontraded, 
If not at plare of deatft ? 



How lonq at 
Plarf of Death ? 



Days 



I'l.ACi-: «»i' lu ki \i. ttk ki.M< "V \i. 

" V, 



' V.C V. > 



V ^-.^ 



DATI-: ..! Ml KIM. ui kI''.M<>\ \I, 






N. B.— hvery item »V inVormntlon nhouhl h. c.rcVuMy huppIUmI. AlMi nhoul.! he Htale.ll fIXACTLY PHYSICIANS nhouUI 
«tutc CAIISI. or Dl:ATH in plain tcrniH, that it may he properly claHH.Vieil. The Special Information *or p-r- 
«on» (lylnft uway from homo HhouM he j]>iven in every InHtance. 



H 



7 T 



» \- 






M 



I' 






mi 



n^ 






f- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I-.. ,;,;,! uf H.-Mllh- 



M. .. ...aft 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r /'V/r^/,6x.|vU/>>^t-^ IH I'^O'i 



llpglsfcred «A^o. 



^"^(10 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( "U. 5. 5tan^nr^ ; 



A 



(^ 



PLACE OF DEATH: — County ofO'<X>"u JA-<^>^^>^ ' City of '<X>v A^o./wC-<-4.p 

No. ''^^%\ ■ * ' St.: b Dist.:bet.l..''0..i.' ■ ■ ''-^ and'^Do 'v lU-Ll 

/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G t V r FACTS CALLED FOR UNDER 'SPECIAL I N FO R M ATIO N ' \ 
V IF DFATH OCCURRID IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME ^v Jc 



PERSONAL AND STATISTICAL PARTICULARS 



I) \ii- <ti- r.iKi'ii 



<.< »I.i >K \ 



\[ 



' \!..rhth 



\< . !•; 



1; 



;i..\ 



\.' 11'/, 



!•>■. ai ' 



/'(/ 1 - 



u ii»(>\vi-:i> OK i)!\( »Kri-;i) A 



O 



HIH llll'l, X*'!'. 

<'St;it< < >i < ■< mill ! \ 



NAM!' <»I 

!• \lll IK 



lUK rilPl.AtJ-: 
Ol' I \ III I- K 

' St:it. ,,! ('. .iintl •» 



MAII)|;N NAMl'. 

ni M(>rm;K 



HiK riiri.Ari", 
<n" m<)Tiii':k 

(St;it< • ii I'liiiiili \ I 



'i 



y 



XV 



MEDICAL CERTIFICATE OF DEATH 

DAI"}-; <ii ni'A'i II 



l):i\» (V«;tl 



iMontlii 

I III'.RI'ir.N' ChlKTI I'N', 'l'li:«t 1 atti'iKlcl (lit I .I'.r.l lri>m 



1 1)0 



{< 



eU\ 



A ■ 
that I last saw h alisron ■.. - • , KyO 

and that <l(.ath uccm ml, mi tin- <lah- slati-d ahovi', at \ 

CL M Tlu- CM SI': OI" I )i; A 'I'll was as follows: 

c ■ 



K.^^cVv'^A-'- . 



I .. '. ' '. I 



nM- 



V^ 



\j 



AV'' hff'i! I II '^ii >i I I (I >' 



) , .!> 



!/,.;////> 



/),l\. 



rill'. \H()\r: st \ ri: d pi-ksi »\ \i. r \ k tkm • i, \ks aki; iki i". r«' in i'. 

IH'.sT (M- MV KNoWI.I.lx.l'. \M> I'-l , 1,1 1'.l'" 

\ . .. ( 

f Inf..; ma lit W>'W'>^ V'CV..' 






y V.I 



' \.!.li.ss 6 O i I " 3* A 



li 



M, 



1)II< \TI()N )'f(ris Monilis ^ /hivs IIoios 

. 1 > I ^ 



I )r RAT I ON 

(Signed ) 



)'('nrs 



M())llJlS ^ /hlV 




I()0 



J 



^UcO 



■A 



\J 



M.D. 



( A'Mrcss) 'o 



A.'.. 



SPECIAL Information "nly lor llospifdls, institutions, Fransients, 
or Recent Residents, and persons dyinij away froni home. 



Former or 
Usual Residence 

When was disease contracted, 
It not at pla( e ol death ? 



HoH lonq at 
Place of Death ? 



Days 



n.Ari'. ( »i lUKiAi. OK ki:m< »\ ai 



1 

INDl'.KIAKl-.K ;0 "JA.«wr 



I (All', n! I!i I'l \i 'II K 1;Mo\ AI, 



rV 



N, 



... I- I ATF uhf.iilrl he Htiited liXACTLY. PHYSICIANS Hhouhi 

K. livery item of hiV'orm.itlon should 1). cnrc.ully Huppl.e.l. A(.F. HhauKI **« ^Y 1 ..« • ., i.,tf„..,.„, ;.,„'» »nr n«r- 

HtHtc CAlISi: or DIATH in pli.iri terms, thut it m»y be properly cla«H.t.cU. The Specu.l InWmal.on for pT- 
son» Hyinft iiwHy from homo Hhoiild he ftiven In every iriHtnnce. 



I 

V 






I r 
1 ' 



I 'I 



t 



m 






w 



RITE PLAINLY WITH UNFADIIMG INK — THIS IS A PERMANENT RECORD 



H. i:ir< 



1 ,.f Ihiittli- 1 N'o. I 






**2*^N 



1)5;: 1' c 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■ I J . ^ 



Jiro^isle/'ed A^o, 



I m i 



Xc^vCi luc^. Deputy H.-3allh Cmcar 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiftcatc of IDcatb 

( "U. 5. Stan^ar^ j 



PLACE OF DEATH: — County 






(DT) 



or^OL/lX) vJ.VCX.'^vC.^vCity of' JCVW^JACC'-^vOv.^i.oL 



No. il^U- 



''U A S S 1 ^. ^ 



St. 



Dist.; bet* 



and 



/ IF DEATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION \ 
( IF DEATH OC^^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND -UMBER. J 



FULL NAME 



-LUv^c ^ [ 



^ 



\ '' 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



(\. 



1 vx\ 

It All-: ni niurn 



atonttii 



\ ' . 1-; 



! ,-,/( 



:I>:iv 



M.<„lln 



\ ( ar' 



/hi\- 



^I\| . I.l- M M-; u ii: I) 

uiix •win «iK i>!\< »Kii:i» 

Wiitiiii -diial (U'-ij.Miatioii 



(Stat< (ir '■' unit i \ 



NAMl' OI' 

!•■ All! j:k 



lUK run. AVK 

OI" l-ATIIl-.K 

' Stale 'ii C. mitt I \' I 



MAIIU'.N NAM1-: 

()i motiii:k 



IHK lIIl'LAi I". 
OI' Mo'llfi; K 

'Staff iir I'liiiiit I \ 



O't-ITATION 

A'/V'/</c(/ /// V,(;/ /'l itlh l>tO 





) ,.li 



\J niUl^ 



lh!\ 



iiii: \i'.((\i--. ST \ ri:i» i'krson \i, r\K ricii.AKs aki-: rv-vv. lo rni'. 

lli:ST OI- .VLV KNO\\I,i;i)(iK AND lU'IJl'I" 



OiifM: maul 







ccVvLXun^ 



MEDICAL CERTIFICATE OF DEATH 

DAl'l-: OI- I>1.AI'II 



(Yrarl 



(MoiitH) 'I>av^ 

I II i:iv I'I'.N CI'-KTII'V, That I atU'iiiKMl <UHiasc-.l rmm 

• J^^o to " .Trrr.7.-.— up 

that I last saw h aUvc oti ^^P 

aii<l (hat (U-ath ortnirrcil, "ii the (hitr stati^l ahovi-, at 
M. Thi- CArSl' (»!• DI'-ATIl \va>^ as follows: 






i- 



Lfly'W-t) 



Mont /is 



DT RAT ION Vt-ars 

c ( )NTR I r.rroRV 



I )r RATION )V(//-.v Jfont/is 

(SIGNED) Lfc\.Crv\X\.-^ 5> L>. . 



Pays 



Ilou) s 



\ 



gjt^t 1^ iQoM (A(Mtv-;»)uc''.-'. 



/hjVS 



.-..s.t,^ 



IIoil} s 

M.D. 



Special information <>"'> '"f Hospifdls, InstitiHfnns, Transients, 
or Recent Residents, dnd persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'LACK 01> r.lKIAI, OK KI:MoV\I, 

INDKRTAKKR ^JJ ' ' 0^ <^ 

(Adilrcss v>!o. .1 /^ * t'V v^ 



DATJ-.o! HiinAl, or K1;Mo\AI. 



IN. K. 



o ,. I- I ATF eSniild he Htiitecl EXACTLY. PHYSICIANS Hhoultl 

— I.vcry item of 5nf»rm«tion •hould b. cnrefully «uppI.e(L AGR f ""/'^ ^^..^^^^^^ Informution" ?or p.r- 

«tate CAUSE OF DEATH !n pl»5n termn. that it m»y be properly classified. The Special InVormut.on p 



«on« dyinft away from homo should he ftiven in every instance. 









■*»->.—, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



t*""^"^ 



Hnan! uf HcMltli - F No. - •t^.i'ir^- HS:l' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



f\ 

i)(ih' /•v/^^</,6x^txmO(Kt\' an i'^o\ 



llcgistci'ed A'^o. 



^\y< 



\^ 



X^KAM 




U 



LJ C;;^ P Chi C y < t w v< < 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( 'U. 5. StanDarO j 

^ J? '"if 



PLACE OF DEATH: — County of C<X^r^ v1 VCL^xoU-Co City of ^ )o^tv OA.<X>vc.^^ c 
No. ■t'^ - cl.^^^ ' " (jL*(VCi \\K \r> ^ St.t Dist.ibet. — and 



*(y^.\\v.*v^ ' St.; Dist.;bet. 

IDEI 

OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME II 



/ IF 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 -'-'-.. oorr, . k. . un«;PiT*l OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



1 

FULL NAME J 



A 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

(•<>i,<»k 



^ ll<XL< 



It A 11-. tti I '.I Kin 



\< .!■ 



I Mnlltll) 



i. 



/ 



!0 



•■ \\i it< in ^'M-i.-il (li^iv'iiatiiiii > 



iiiK 111 i-i. \»*j-: 

' St;it< lit <'imiit I >■' 



1 /, 



d'cail 



/',Mv 









<X "> V' 



"^ 



.Oc4 



wMi-: (>i 
I'A I in:R 



iMK in n.Aii-: 
I'l i\i'm:K 

I St.ll< III I'oMIlll \) 



MAIDl.N NAMi; 
• )I" M<)l'Ili:i< 



lUK'linM.AcI". 
<»!•■ NTD'I'IU'.R 
(Sliitc or rimiiti yi 



n- 



-^■V-CHL^n 



MEDICAL CERTIFICATE OF DEATH 



DA 'l-, <il I>i: A'I'll ^ 



i.., ' 



iVt-arl 



(Moiithi il):iy' 

I H IvK l''.r.\' ri;i<'ril"\', Thai I atti-ii<U'(l .UHxasc»l froni 

tliat I last saw h ■• alivi' on - ' ' I*P 

and tliat lUatli t)Ciurrf(l, on tlir ilatr "^tatcil ahovi', at >- 
M. Tlic CAISI-; (»!■ Dl'.A Til was as follows; 



1)1 RATION )'rars 

CONTRMUTORV 



Months 



Din 



'S 



Hours 



I 



--? 






I J 



/CL'>v ^' Vex 



OCCITATIOX I 

h'r^iil/'i! Ill Sit)! I'l iDii 1^1 1> 



)'iiii ■' 



M.,nllr 



111 i: \H()\1-: STATl-I) I'KKSONAI, rAK'lH'r!. \Ks \ K l"! TKIJ". To 
ni:ST Ol- MV K.N(.)\\ l.I.DC 1-; AM> lUilJl'.l" 



TH 1-; 



'IiifiM iiirml 



'^^ 



.^< 



'A 



(\<i.i,css (HI vJaJII>-^^'vA 



I )r RAT ION 



Ycays 





Months 



Paxs 



_li— 



I()0 






fA.l.lrc-ss)nt.XL^kA,'^ ^X.^<\ 



Hours 
M.D. 



SPECIAL INFORMATION only '••'' Hospifdis, Institutions, Trdnsients, 
or Rfcpnt Residents, andjersons dyin(| dwdv Irom fiome. 



^ ■, 



ISl'kiv 



former or 
Usii.il Residenrf 

Wlien was disease (ontrarted, 
If not at place of dedtfi ? 



ttow lonq at 
Pla( e of Deattt ? 



. . D«»vs 



V 



ly\ii 



I'l \CK OI" lUKIAI. OK KKMOVAI, 

hV 



DA Tl', I)!" Hi UIAI "I K I'.Mi »\AI. 

TQO 



r.VDl'RTAKHK (i^v<XCXVVAJL/V^ cL'-O-^ ' 
(Address b ^^ >^ A^'O^dxA^ ' 



9 .. !• I ATF shniiltl be stated KXACTLY. PHYSICIANS hHouIcI 

N. B.— Rvery item «tf inVWmi.tion should b. cnrcfully HuppI.ed ^^^f;;^" '^'^^^^^^^^^^^^ ..gpccial Information" ?or p.r- 

stote CAUSr: OP DHATH in plain terms, that it may be properly classmeti. i ne -»p 
«on« dyinft owny from home Hhould be i^iven in every instance. 



^ 



i 



?l 



i ! 



""f^ 



r 



*'i 



I r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,f |l,:.'!)i »■■ Vo :■> t-^|^^iHc<vl'Oo 



REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Rei^i\sf('rrd J\^o. 






l)ah> AVAv/, ^x^vtX-^^tov an 100^ 

O^^x.K^Kj) I..A'\.K.< Deputy Health CfTicer 

DEPARTMENT Ot PUBLIC HEALTH-City and County of San Francisco 



Cevtificate of Death 

( "U. S. Stan^ar^ ) 
PLACE OF DEATH: — County of 0/CL>X' 0,\.a.'\ve^<i ' City of IcVTV J AXX/^x^t^yuLcc 






No. IC'iS CjkX'Yv vI\\XL/^x<:, ' ' St.; Dist.;bet. Hovd.' and 1.2)... .^.cL 

/ ir DfATH OCCURS AWAY FROM USUAL RESIDENCE GIVE 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 



.<lCxx^ 



la> 



\kjj ( 



, r tv -'•« 



sl.\ 



PERSONAL AND STATISTICAL PARTICULARS 




\> \ri, I 'I 11 IK I'll Qc\ ^ 



^ 



i : : ' 



MEDICAL CERTIFICATE OF DEATH 



DAll'! (>1 iniATH 



fMotllh) 



(Year) 



M..iiih 



\ < . 1-: 



r 



>,i\ 



!/->;'// 



> ' .1 1 



/>,n 



''iNt.l.l" M\KKI):i) 

WIIX )\\J I) ( »K l)!\i tKiKI) 

'Wiit' in -ui.-il il'-^iv'iiat i'lii ) 



l\ 



<XVVv.t<l 



itiK rin'i.Aci-; 

Slat' or <''»nit r\- > 



NAM) (il 
lAlll IR 



I'.IR'nil'I.ArH 

oi- i Aruivk 

Stat, or Ciiiintrvl 



M \ii»i;\ N ami; 
"I -Moi-in-.R 



mRriiri.AOK 

<>l- MOTHKK 

(Statr or l"i)iiiitr\ 



ovrri'A TioN 



/CLwd^ A. 0L<X ^ 



\^ 



(Day) 
I II1;RI;P.V CI-KTIFV, That r attended deceased from 

' 190 s to aj.\xL :).J^ T90H 

(liat I last saw h • • - alive on QJu-.p k^q 

and tliat death occurred, on tlie date stated above, at 



M. The CAl'Slv OF DIvATII was as follows 



^jL^jJyv/^ 




.(J..VP Jl^"yvw<<rVui'\XX.<?^. • . 



Dlk.XTION )'i'ars 

CONTRIPiUTORV 



Months 



Da vs 



Hours 




..Ll^fdjL 



!\-C 



\ > 






,1 






■A 



Dl'RATION 

(Signed) 



}\'(irs 



Mo til lis 



c 



Pays 



^ 



IC'C'. 



Hours 
M.D. 



TC)0 



( 



.Add r..s) W ^SA-M 



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



AV'v'i/r',/ ni Si.'ii /'i(!)ii;'r,i 



)''■,!! , 



.!/,.>////> 



Pay. 



Tni-: AHovK s TAri; I) phrsonai, parthti.ars aki-: rRrn to thk 

Ul'.ST OI- MY KNOWIJ.DC K AM) lU-.I.IlCK 



Hiifo? nirmt 



(•X'l.lrcss 






.'■\> L 



N. B.. 



Former or 
(Jsual Residence 

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



How long at 
Place of Death? 



Days 



TLACK OI-' lURIAI, OR RI;MoV.M, 



vL j 



I)A'l>;of l?rKi.M. or RKMOVAI, 

,.\ll J,.b 



190 



(.\(l(lross l.XD.^. \n.\A^<lr^5.<V.«:>v.. ..J..t 



-F.vepy Item of information should be carefully supplied. AGE should be stated F.XACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ''Special Information" for par- 
sons dyin^ away from home should be i2tiven in every instance. 










c) 



^ 



f: 






I ■imftttii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,1 ,.f II. :i!th I- N'' 



r..r'^rx; 



\:ftcV C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



llci^i.stei'cd J\'*o. 



18()4 



Dah' I'ilcd, djclvLLorvJLiA, 3.H l'>0\ 

\ \ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 5)eatb 

( H. 5. StanDar^ ) 
PLACE OF DEATH: — County of <x tv J,'v<x t^Cw^v . City of CV<x->^ vT^<x vAX^vxlCt 

'^^ m 1 1 

No»J\x^vC4\) OUCj^Kv.T.o_V St.; Dist.;bet and 

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

FULL NAME ' I It^VYxUL. J/4v_cU. . 



PERSONAL AND STATISTICAL PARTICULARS 



ii A rj-: (>! i;ik i H 



M..iitri' 



\ 



I>:ivi 



I 



\< .!•; 



11 , 

^iN'.i.i-:. MAKu ii:i) 

\\ Il»< iW 1-; I) UK I>!\nKi i;i) 
\\iit< ill ^<Ki.»l (l<^ij.'!i;iti<iii ) 



I!IK llll'l. \i"l-; 

^t:i!' . .1 r. ,iint 1 \ 



.\/.'>,lln 



3.C) 



I ■»■ I : 1 1 



Am 



\ VM 1- I tl 

I- A riii;K 



I'.ik rniM.ArK 
<>|- i-Arni;K 
•Stiitf or riMiiiti V 



M MI>1".\ NAM1-: 

<)i Morni: K 



I'lKiiii'i.An-; 

<>1 MnTm-:K 
(St;il( or Comitrv 



•>i'<. ri'ATlO.N CT\ 






'^, 



O L VXC^; 



/V.S 



MEDICAL CERTIFICATE OF DEATH 

DATK «)(• Dl'.ATM y 



MoJtli 



.t 



.. I go 

(Day) (Yt-ar) 



I Ili:Ki;r.V CI:RTII'V, That I attcMuU-d dci-cascd from 

-l- . up . to ojl\\1 ;^.:v^ 190"^ 

tliat I last saw li alive oil BX^s.1 u^o 

ami thai di-ath occurred, 011 the <late stated above, at ^ 



M. The CAlSlv Ol- Dl'ATII was as follows 



em 




I 



y^v^v. ) V-' 




UJCV 



DURATION 



ll^ars 



Mivii/is 



Da vs 



CON T u I r. r T R V Lcx..\jLo.-vcJl'.A^A-^..^..:cxi 

nr RATION )\ars Months Pars 



Hours 



<V.ft.-.> • ' 
/ lours 



'\ 



fr^ 



(SIGNED ) 

0±\-^ M ic)oH ( 



M.D. 



Address) HSCN M)\t;)vU ^.l 



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



Former or (/ ,0^ h\ A\- How long at 
Isual Residence 'bio U.OCrUj U h pjdre of Oeatli ? 



"I 



A'/'.v/, //■-,/ /;/ Still / 1 ,1 II, I 'I i> J. i )i 



M.niHn 



D.tvs 



I lu', \uo\i.: sTA ri:i) pkk^onai, i-ar tumtaks aki: i-Kri-: r<» rui': 
iii;sT 01. MY KNo\vi,i:i)c.ji;:_A\i) iu-;i,n-:K 



* I" foi luaiit 






Isual Residence 

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



Days 



IVLACK 01' lU'RIAI, OR RlCMoVAI, 



DAlli; o!" MiKiAi. or RRMdVAI, 

.Q-^^vb XS I go' I 






-t. 






■^^ B« Kvery item of Infopmation should be CBrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for psr- 
8on« dyin^ away from home should be given in every instance. 



\ ■ 



1= 




? 



Ps 




ll( 




* I;'' 



!l 



I^Jlul^^^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,f 1!. .iMh I ^'' 



fi*» v»»»^ 



■W-i^) TuS^lT 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihflc /'V/^v/, Oj^IvUvvxIv-^ IH 1^)0 \ 



.^^^\^ 




Registered' J\^o, 



18G5 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of H)eatb 



<X^^^r\j V<X* City of 



No. 



St.; 



Dist.; bet. 



"and 



/ ir DEATH OCCURS *W*Y FROM USUAL R E S I D E N C E G I V E FACTS CALLCD TOR U N D E! R "SPECIAL INFORMATION" "N 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME '^jy\XA 




KjiK.^t\ I 



NlA 



PERSONAL AND STATISTICAL PARTICULARS 



a 



I) \ I 1-, 111 i:iR 1 II 






\ < . I". 






) , .: 



!>:iv 



1/ ;,'/• 



I 



i Vtai ) 



/'./!> 



^iN'.i.i-: MAki<n:i) 

w iiM t\\ ii> nk i»;\( )Ri i-i) 

\\ I 1' I iiil (I' viiMiali' >ii ) 



lilK THIM.AiM-: 

-«t (t" or I "■unit I \ 



V \ M I nt 
l"A THI-.R 



lUk THIM. All-; 

'»|- I \r!n;k 

-iliit« oi (.'uiinli y! 



M \ IIM'.N NAMl, 
"1 Mo'nil-', k 



"! Moriii'.k 

"^t;it. Ml l"i,iiiitt\ 



' " » ri'AI ION 



"^ 






MEDICAL CERTIFICATE OF DEATH 

DA ri-; <ii I)i;atii 



(Monti 






t 



(Year) 



11 

(Day) 

I II I-k i:r.\' ClvRTIFV, Thai [ atlt'iukMl (k-rtased from 

to 



1 90 

that I last saw li ": alive on 



I{)0 

1 90 



and lliat (U-ath orcurred, on tlu' daU- stated above, at 
The CAlSh: Oh" Di-A'PH vas as follows 



• 3 ,'uJL^-t^AMw\_ Lc 






^ 



^ 



DIF^ATION )'t'ars 

(.■ONTRIIUTORV 



M out In 



Days 



J /ours 



DT RAT ION ]\'ars Months 

(SIGNED) J 



/^a vs 



X 



iqo 



' . tcdl 

( A <hln-ss). JUULd-V v^'. 



Iloti) \ 

M.D. 



i-~ 



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



Ri'-ulril m \ini I \,ti<, m'li 



) 'i(i > 



Mnllllt^ 



fh: , 



1 Ml, \n<)vi<: ST \ rj.D cKksoN" \i, I'XkruMT. \ks Aki-: TRn-: ro thi-: 

lli;sT OI- MY KNOW 1,1. DC !•: AND Hl'.Mi;!-" 



liil"'>Mii;i!it 



(TvJua '^X-^.^vtnj-oX -V\J^_ 



''X'Mi.'ss 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



ri^ACH OI- HTkiAi, Ok i-;i<;mov\i. 



DATi:<)C lit uiAi. c,i ri.:m()vai, 
OjJ^ ai 190H 






(A(l<hc-ss 



IN. B. fivery Item of information should be cnrefully HUppliecl. AGR 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 ^\\cn in ^^ory instance. 



\ 



ll 



li 






Ill 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!!. :i!th I Vi 



t-" «--;■. nSaV C 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 







JU.V an Jf'o'i 



n r> 



f \ <^ 



Kei^istercd J\^(), 



tf^tm 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot Beatb 

I 11. 5. 5tanc>avC> ) 



n 



PLACE OF DEATH: — County of 




(X V>vCcl.O.; 



City of 




<x>^\xcLo„ L<x 



No. IbM 





vo-cvc 



i. V 



n 



St.; 



Dist.; bet. 



and 



/ ir DtATH OCCURS AW»V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




/ CrXa- 



• Lv. *^..A„'::. > 



r\ 



PERSONAL AND STATISTICAL PARTICULARS 



^:i' 



i ... 



.' \ 1 1: III' itiu 1 II 



\'.»-; 



^l\» . I.I- M \U l< I1-, II 

W IIH iWI- I) I »K 1)!\"< iKi }-:i) 

W'il!: .' .ll >.ij.r,|;,t i, 111 1 



I'.iK {•in'i,.\oj>: 
^t.iti III i."i)iiiit t >i 



I 




l»a\ 



l,'..//''V 



« I .11 



/',.'! 




.ccL 



t)\^v,'- 



\ \M !• Ml 
I \ I II IK 



IUUTlM'I,\iK 
ni- I AIIII.K 

' ^t.iti lit I'liunl I \ 



MMIilvN NAMl 
"I MoTin.K 



I'lR rill'I. VCH 

"I M'»iiii-:k 



Axd. 



u* 



.t\ ^^^ -^ 




MEDICAL CERTIFICATE OF DEATH 

i).\ri-; oi" 1)1 ".x Til v) 



X:.. 



TQO 
(Day) (Yt-nr) 



(MotitlA 
1 lli;i>i i:i'.V Ci:K'ril'\', That I attondod deceased fr<.)iii 

u^o to ic>o 

that I last saw h alive on ' ~~" ~~ Kp 

and (hat death (icciirred, mi the date stated ahovL-, at 
.M. The CAI SI' Ol" 1)1;ATI! was as follows: 



\ 



)JL'lvi\' 



UX^UY^VCV . 



1 



•>' ITI'A'I'ION Ml' 

l\'i fth'il ni Still / liiihi'iii ' )'i'iU 



n 



Dl k.\'l"l<)N )\'ais 

CoNTRllU'TokV 



Mo II tin 



nay. 



'S 



//oins 



!)rRATH)N 
(SIGNED) 



)'tiirs 



Ml) lit /is 



I^ays 



Hours 



Ll C ^V)! . 



I I << 



()n 



(Address) LUt-O^^^-t 



M.D. 



Special information only ''"■ Hospitals, Institutions, Iranslcnts, 
or Rctfnt Residents, dnd persons dying awdy from home. 



Month- 



/),n V 



rill", AM(')\-|.-. ST AT i: I) i'f<:K'S()\M. p\K ricii, \Ks .\K j: rKri-: to tin-: 
m;sT oi- MY K NOW i,i:i)c.i.: and m-;i,n:i' 



' Inl'i .! nirinl 







Former or 
Isiial Residence 

When was disease fonlrarted, 
If not al place of death ? 



How lonq at 
Place of Death? 



Days 



I'LACIC OF jU'KIAI, OR KKMoVAI, 



l)\'Q'. "1 Hi I'lAl, (.1 Kl'lMOV.M, 
VAj U..N) TQO' 



irNDKRTAKKK Ob - • O AaJunj ^ V^O 



N. K. 



ivery Uom oi liiforiii»tlon shoultl be carefully Hupplied. A(;B Hhould bo stated fiXAGTLY. PHYSICIANS Hhould 
tatc CAUSE OF DEATH In plain term*, that It may be properly claesWied. The "Special Information" for p«r- 



R'JnB dylnfl away from home should be ftlven In cvory instance 



ui 



% 



% 



1 



w 



fir 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



II, ;i!th I V' 



*^.^^ 



'•■i: lUVl' t" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jlrgi.s/crcd J\^o, 






li,AMi Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



.f>. LLX 5> 



Certificate of IDeatb 



(^ 



PLACE OF DEATH: — County of J.<X>^ J-V<)>y>vC^4 C.c City oi^)<X.y^ y\ K.<X.y^^<^'i 



^ 



No. l?^ 1-1 1 ' Lv,;iAA.^ 



St.; 



Dist.; bet. 



^,1 



\\: 



ind I 0.. 



/ ir DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL 1 N FO R M ATI O N •• N 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



1^,; 



FULL NAME 



h . J 



•».\ 



PERSONAL AND STATISTICAL PARTICULARS 




.O.lLL^ 



\\^^ 



\w 



I» \ I 1. < i| llIK 111 



■~\ 



\" .!•: 





M.iitli 



l);i V 



1 /.'»/,' //- 






/'<M 



si\..i.i-: MAkKii-.ii 

u iix »\\i:i) ( »K it!v< tRi j:i) 

W'lilf ill s.iii:(l ili'-i).Mi;it i' III ) 



lUK rniM. Aoi'. 

Sl;it(.- ( If roiiiitrv 



i) 



NAMI-: ()1 

iaiim;k 



I'.iki'iin, \rK 
<»i 1 \iiii-:k 

iNt.ili <ir Coinili yi 



M \II)i:\ NAM I 
<•! M<>T1IIJ< 



lUKTlU'r, \(K 

ni- Mnrm-.K 

' M:itc ( ir I'oii lit 1 \ ) 



y 



y 



MEDICAL CERTIFICATE OF DEATH 

DATl-; «)!■ Dl'.ATlI , 



.K..-L. ipo '. 

(Day) (Year) 



(Montli) 
I Ill{Kl'.r.V CI;R'II1\', That r atteii'lc'd deceased from 

— — ■ — up to 190 

tliat I last saw h ":■ alive on " 190 

and that (Kath occurred, «»ii the date stated above, at — — 

— M. The CAISK Ol- DlCATil was as follows: 



c 






DC RAT ION )'i'(irs Mo}iili% Days 

C()NTRII5l'T()RV 



DT RATION 



) Va/'i 



(SIG 



NED )LcVCrvuLK; J 



h(^ 



Months 




a. A \. 



Days 



A 



Hours 

Hours 
M.D. 



(^ 




<>(. iTl'A rioN 



) ■/ I / / 



M.nitll'^ 



lhl\. 



I'm-. \HOVl'. sr \||.;i) I'KKSONAI, I'XKlliTI.AKS A K I", PKri-: TO rii)': 
1U:ST Ol' MV KN(>\Vl,i:i)(-.K AM) UK I.I l-J-" 



f liiftii iiKinl 



Ob 



<^.,A^ 



I()0 



( Add ri'ss) Wfc^VCry^Jln^ 



%^ 



Special information only for Hospitals, Instifurtotls, Transients, 
or Reient Kcsidcnls, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



.. Days 



(\(l.lltSS 



PI \CK OI- lUKIAI, OK K1<:M()VA1, I DATHol" MrKiAi. or KHMnVAI, 
.lu-ss 3(o1^'".^..IHJLIiu.. 



iNDlvRTAKKR 

(Ad 



^OL 




W^x, 



N. B.- 



-r.very Item o? ln?.>rmatlon shoulti ht cnrefully HuppHecl. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be Jtlvcn In every instance. 



'• 






( 



i 



«!'|l|fe 




!'• 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n^ Ml- 



,f II. mM!i I ^'' 



-j.t^'5^. H8:l' (• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale rih'^l ,^x}fdj^^^^^^<l>^ ^H 



lOO'i 



lieglstered J\^o, 



18i5« 



^y\J^<J^ ^^ 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of IDeatb 

( 11. 3. 5tanC>arC» j 
of UXX^V Oa^OlyvCA^C City of *"''0.^i~ O^Cx.->A.ci_ci. c 



No. ^ 



/ ir DEATH OCCURS *W»Y 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. / 



Dist*; bet. 



and 



FULL NAME 



r 




c ^ 



PERSONAL AND STATISTICAL PARTICULARS 



o ' 






1) \ 1 1-: \M r.iK v\\ 



\!..ntli t 






\t.i-: 



) ,■, 



M.'il!ll- 



/',/ 



^IN<.I,K MAKKII".!) 
W IIX »\VI-: I> OK DlVnki i: I) 
W'litciii •sMfinl <l« vi<.'ii,itiini) 



luurinM.At'H 

<! ■'< Mf f.ninti \ 




NAM!. (»l- 

iati!i;k 



lUKi n I'l, \cv. 
«>i- 1 Arm:k 

'Slatr <ir Ciitiiiti v) 



M \l IMS NAMl. 
"! MoiHKK 



inkl'Ul'KAlI-: 
st;itr iir (.'oiiiilrvt 



^v- 



III ( I 1 ' .1 



•vr,„s (^ , , 



MEDICAL CERTIFICATE OF DEATH 

DATI'; ol Dl'.A'l'H y 



UJLkt: 

(Month) 



V) 



■v..-. /(^O 

(Day) (Year) 



I IM':RI:I'.V C1:RTIFV, TliMt r attended dccvascd from 



ii.p 



to V: 




X .XX loo H 



d.jJ^. 



that I last ^aw h - alive on -J. Ju^r^.'^ ' . . up 

and that <leath oocnrred, on the date stated above, at i i A 
. '. M. The CAISI-: Ol- l)i;.\ril was as follows: 



QAA^li-ta^CAAX^ 'CX^.A.vA ■.)... ' 



1)1' RAT I ON y'rars 

CONTRIIU'TORV 



Months 



Par: 



'S 



Hours 



DT RAT ION 



)\a>s Mouths 



Pars 



Hours 



(Signed) l.u .*^ I >Lt>x, ^ -;U fx/\y^A.c^^:.^ M . D. 



\ > 



Too 



f.\.idn-ss)lb. li"MiyvunAi :L>- 



:i\c.^.-i.V. 



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



G, .^ 



) 'iti I > 



M.nitli'- \. Ptr 



IHi: AHOVI-: SI" Xri'.I) I'KKSOVAI. I'XKIIiM'LAKS AKl". I'Kri-: T< » III !•; 
liI-:sT ()!• MV KNt)\VI,i;i)(.K AND lUlMl*.!-" 



if'nni.int \A.- Cj . \X. O 



JU^i^>JJ\^XxX 



h JU C>-^^nXt^.^ 



I \<Ml( ss 



Former or 
Usual Residence 

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



How lonq at « ^ 

Place of Deatli? ^^ Davs 



DAT^of IliKlAr. or KI'.MOVAI, 



l 



)a.\<1 XH 190H 



I'l.AClC Ol' IHKIAI, OK KHM(»\AI, 



N. B.- 



-F. 



ivery item of InformHtlon should be cnrefully Kuppliecl. ACF. Hh.nild be «tHte<l F.XACTLY. PHYSICIANS should 
tote CAUSE OF DEATH In pliiin terms, that it miiy be pr«.|>crly clasHified. The "SpecinI In\rormiition" ?op p«r- 



Rons (lyin^ away from homu Hhoiild be ftiven in every inHtnnce. 



'i\ 



m 



'J I 



H 




^"^^f 



"'I 



li ft I j 







W 



Ho.lH 



,MI. I'lh 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1 Vo . «, t-^r^.'^. ]ifk V ( 






/h(/r nicd. <CJL 



.trXAA^ 




>^LAj. 'X^. 



li)0\ 



liegisfeved J\^o, 



1 «G9 



roF 






u 



J 



/=r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 5)catb 

( n, S. StanDarC^ ) 
PLACE OF DEATH: — County ofO<V-^ J>V(X^-v<>. ^ c<. City ofOa.^^^' 0.^^cx.> 



ve<^^LCC 



h 



No. OX^^v^A.CX">x' 




'V^^^ 



iv^La.l: 



St.; 



Dist.; bet. 



and 



-) 



/ ir DEATH OCCURS *W*Y FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNDER SPECIAL INFORMATION ' \ 
V IF DEATH OCCURRfD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



lLvUiX 



PERSONAL AND STATISTICAL PARTICULARS 

ii\ ii: oi- I! I Kill 



Ll 



-i 






'^ 



\«.l'. 



44 



) lilt 



I I );»>■) 



M.;,lh^ 



\\ 



(Vt-ar) 



lhi\ 



MEDICAL CERTIFICATE OF DEATH 

DAii-: OI" i>i:.\rii ji 

(Moiitlji) 

I Ili'iK i;i'.\' tM'RTIl'V, That I attciidfd (ktxasc'd from 



(Dav) 



(Vt-ar) 



^\ 



-X 



'^IN'.LK. MARKIKH 
\Vn)o\Vl".I> (»K DIVORTKI) 
W'littiii s<H-iaI <lt •»i^'nat i<in) 



i'.IK luri.Ai'l-* 
St;i|i ( )i (I III III I \' 



Ol 



o: 




NAM): «)| 
I All! IK 



iiiK rm-i,Ari-: 

<»f I AT III-: K 

'st:it( ciT i".,\inti V 



MMIM.N NAMI- 
"1 M'tTlll'lK 



ink IMI'UACl-: 

•>i' Morm-.R 

fSliiti- or I'oniit! yi 



1^ 



> > v-L<i 



V-ii^^CL^vd 



K \ ^ r . , > r 




O-^N 



'H( ^l^\■^•IoN 
A'''•>/(/,■,(' III Siiii / liiihi^/'ii .-. 



.. ...^ .': up. to UX'^aJL, 3w2> KpH 

that I last saw h X^ alive on JjL^pX 7>.: up ■ 

Mini that ilt-ath occiirrcMl, on the ilatt- ^tati-<l alxive, at 1 -I ^^ 
M The CArSp; ())• DliATII was as follows: 



Vxx- i '\. ^kX <x/vm '^i^ '"^^ y ^'^ >^L\.^ 



} 



I ) r I< A 'I' I ( ) N ) 'cars Afonlhs \ Days Hours 

t"UN'i"lM lU'ToUN' U^A^^AX/Cu0AA^X<L <x.<nMW 

1 \ 

I ) r R A T 1( ) N ) 'iirs Months 



Pays 



SIGNED ).ii).. 



.Kj-^^sJ^. 



Or. 



flours 
M.D. 



■^yiuV) . 



A.C. I()0 



(Add 



rrss) .y 



Vl^o 



Jl1\j LMJAjyvdi. 



Special information «nly '«r Hospitdls, institutions, Transients, 
or Rerent Residents, and persons dying .iway from liome. 



) V(N 



M,,iilli- 



lUn 



I" Ml', AIIOVI.-. Sl\ ri- l> I'HKsON \|, l'\K lirri. \KS AKl-; TKll-: in 1 IH'. 

in-.sr oi Mv KNOW i,).,nc, K and i'.i;mi:i- 



M 



'N.l.lr.ss il ' I S XJf\i ^Vv' L 



Former or ^^ i k 1 ) 

Usual Residence o I " I O /U1\j ^ 

Wlien was disease rontrac ted, 
If not at place of death ? 



ftoH lonq at ^ 

Place of Deatli ? ^ 



f)ays 



I'LACH OI" lUKFAI. "K KlvMOVAl, 



V"-^ 




<L< 



DATA", o! Hi KiAl. «.i \< 1':M()VAI< 

190 . 



cjx^-a :aL 






INDI'.K lAKI-.K 



•houlil Ik- cnr«tfully MuppUed. ACiK Hhonl.1 be Htnte.l F.XACTLY. PHYSICIANS «hould 
n pliiln term*, that it m»y he |>r..|>erly cl«Hi»ificd. The "Special information" for p.r- 



N. B. livery item of informntion 

Htnte CAUSF: OF DEATH I 

«on« dyinft away from home Hhouhl be ^Iven in c\ory InHtnnce 



■A 



in 



' fl 



t 



• 11 



-f 



ij|j 



r ■ Ir 



r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS 







-.OL-e^v- 3.5 



/^V(^y^ 



llc^ltiiei'ed Xo, 



♦ ''■■TO 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( U. S. Stanc>ar^ j 



Q!^ 



PLACE OF DEATH: — County of 00.0^ VOy>vc».<i.cc City of OxX^m O.Vcc^yvci.Ai.c'. 



No. IC-^O, 



% 



t a cl4_ 1 \. ^• , St.; 3) Dist.: bet. J CrlAO^v and Oll'ttAV C4. " 

/• .. D..TH occu.s .W.Y ,RO» USUAL RESIDENCE G.vt r.CTS C.LtEO roR UNOtR "SPtC.AL .NroRM.T.ON- \ 
V .r D..T« OCCU.R.C ,N . HOSR.I.L OR ,NS„TUT,Or. G.Vt ,TS NAME .NSTt.O " STR E M . N O N U "b t R ) 

/OO ^ A. !i • 



FULL NAME v_ r 



'■> 



^C/lxcLcu 



PERSONAL AND STATISTICAL PARTICULARS 

■III.. 



K in 






MEDICAL CERTIFICATE OF DEATH 

DA ri: ( ii- Di; \iH 



1 



'MoTltlll 



I I »,-i V 



(V.;u 1 



\^.^^ 



M..„fl, 



i M \ki< ii;i» 
ix'Whi) Ok DiVnk. ( ;• 



' iillll! \ 



N \ M I .1 

' ■ ■■•il K 



I'-ik \\\\'\, Ml-- 
'"■■ I \ nil k 



^' ^n>j:\ NAM, 

'" MoTMJ-.k 



'••' ■ iii'i.An.- 

J>l< MOTMI-.K 

■ ' ' Milt I 



' I' Minx 



■A 



I lli;ki;ii\- Ci:Kril'\, Thai I ;iltc-M,Ic<Mc.rasr.I tK.iii 

4 

lli.ll I last s;iw il . '■ ' 



aliw nil 



lip 



aii'l that -hath < iccii rrci !, <mi tlir dali- stali-d ahnvt- at \ 

Ov M. Thr CWI SI'! ()!■• Dl'ATII was as follows: 



i) 



.to\-v^ 




\i)VC! 



'^C 



IHkATlMN 



CONTRIlirTom' 



til/ s 



J/oi///is 1 3 /)avs 



I lours 



\ 







tcnx' 




o 



tv 



DC RATION 

( Signed ) 

I 



}'t(ir 



Mouth 



<* 



K^O 



( 



S I 



•A 



Pavs 



//ours 

M.D. 



A.MiTss) 'XSb Ox\,LL?;v 



Special Information only tor iiospitdis, insntuiions, rrdnsimis, 

or Recent Residents, .ind persons dyimi dHiiy Irom home. 



/'■' '<lf,l ,,i \,ni r,„,i. I ,„ 



)■-•,/, 



M.>fli^ U'.. Ih 



'.-^i «>| M\ KN(.\VIj:i),,,.; AM) mj:mi.;i.- 



former or 
IKiihI Residence 

When wds disease rontrdded, 
If not dt pidi e of dedth ? 



tioH long at 
Pld( e of Death ? 



. Days 



<s Aki-; Tki}-; Id III )•; 



I'LACK Ol- HIKIAI, (»k kHM(i\ \i. 



\^\\'\'. o! I!i KIAI. oi K i:M( t\AI, 



\JC '-J A. 



im)i;ktakhu\1 R J <XxLoUyv\j\] fU Vl^xXax' 

rAd.Iicss U'U M iIaaLnLA^'Cj > V, .' 




N. tt 



•very Item oV InVormHtlon should be cirofully Hupplied. M\V, Hhoiild be Htated EXACTLY. PHYSICIANS «h 
^tiitt CAUSE OP DEATH in plnin term., that it msiy l)e properly claHHified. The "Special Iriyormation" for 
"» dyinft away from home nhould be ftiven in every instance. 



ould 
p»»r- 



i; : 






f 



<i!. 



I ! 



fc 




Ill^i ; 



■r 



k I 



■ili A'^i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Il..;i'' ■■f 



Hi' iltll I- V' 



■■ar-~i*:. iu"vl' C 



REFER TO BACK O F CERTIFICATE FOR INSTRUCTIONS 



/h(/r F//f'ff/oji\^xtjL^y^iui\ %S 



locn 



]ie<^istcrr(l Xo. 



"-7\ I 



-\ 



^^v<. 



v*- 



H 



DEPARTflENT OF PUBLIC HEALTtl=Citj and County of San Francisco 



No. 



Certificate of Beath 

11. 5. 5tan^nr^ / 
PLACE OF DEATH: — County of Ja>v •J.\.a.>vc\^ic<cCity of CX->x> ^O'^A.'li^oc 
1^^" ...-•■•.» St.: Dist.: bet.^ ^- - 



flO 



/ -r otATM occups *y***y from USUAL R E S I DE NCE g. VE facts callfd roR under special inpormat.on 

V IFOCATMOCCUHHtDINAMOSPITAL-- r^univiAiioW 



and JHu^XsLtvvd. ) 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBEH^'^ ) 

FULL NAME La 



PERSONAL AND STATISTICAL PARTICULARS 



vnl . Ik 



Kill 



vHr.tith' ^ 



V. 



!)..% 



MEDICAL CERTIFICATE OF DEATH 

1> \ IF. *•!• l»l. \TII 



lVe;ii 



M \ K k I J . I ) 
^ Kl» <>K IllVt »K. I !» 

Ml SI K't M 1 t li w i »P II , I 



\ ■ 1 



^^ 



'NTontii' (I);ivi 

I HI'.R i;i'.\- t'I-:kTII'V. That I .iMrii.if,! ,lcrcastMl from 
\ip t'« ' Kp \ 

that I la^t ^a\s Ii alixion \^^ 

.iinl tliat tlrath < >rt u rrt'<l, mi \]\v ilatr stat«.'tl above, at c. 
M. The- C\\IM': oi Itl' A Tl! was as follows: 



VucV^<c^^ 



VvL .\C 



• ' ■ ■• • I,- 



I'll-: 1 1 1 I ' I , \ t »•• 
'»' I \ nii-k 



^i mi>!;n n\m) 

'"■ MmTIIIK 



■rm-.R 

'' M 111 • \ 



" ^ ' i \ 1 K )\ 



CI 



\0 



X 



Let It a 



m^ 



\j<X^\j v:,Vo. , 



I >r RAT ION Yi'ars Mouth a 



Pa\s Hours 



\ 




I V 



-4 






i>rk.\ rioN 



( Signed 



)'( nr 



Mouths 



Diivs 



-\ 



l()0 



( > 



//ours 

M.D. 



( A.MriNs) *iil a a\\LC'? 



Special Information only lor iiospitdis, insiituiions. irdnsicnts, 

or Recent Residents, jnd persons dvinij dw<j) from home. 



A. 



' ■'.' S.M/ 



/ I il >', : 



) , ,!f , 



\'.,.'l,. 



'^' "I MN KM.w i.i;i)<;k \m, iici.ij;f 



fotmer or 
Lsiidl Resjdenre 

When wds disense ronfrdcled, 
It not dt pld( e ot dedtfi ? 



HoH long dl 
Pldre of Dedfh ? 



Dd\s 



l-l, \<'\- <•! lUKI \I, OK ki:MM\ \|, 



I M)i:KiAKi;K 



I) \ D'. o! ItiKi \i MI kl'.MdWM, 

190 . 



1 4 I . ■ ■ . Ill 



)-i'rNAM >■ J 'OXLcxJY'^-^ ^^' 



fAddiiss .. \: 



's t ' , 1 



N. It Y.y 



•very item of InV'ormiition hIiouIiI I>,- ^Mrcl'ully Hupplieil. AdI. kIi«»uIiI be Htiite»l r.XACTLY. PHYvSICIANS 
t" C\iJSE OP D|;ATH in plnin tcriiiK, that it mny bo properly cluHftifietl. The "SpecinI InforinHtion" f 
'»"• tlylnft nwny from home Hhoiild be ftiven in every inHtnnte. 



Hhould 
for p«r- 



:* 



, 



1 



4 • 



s t 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!«. .;ii< 



4 li 



I V 



,»^-r"v- 



t"- ■ s 



'aS^\' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/^//r /vAv/, dxktju%^vLL\/ as: Jf^o'i 



livi^Lsterpd J\^o. 






^o 



.,CrV,<^^-*^ 



DEPARTMENT OF PUBLIC liEALTH=City and Connfy of San Francisco 



PLACE OF DEATH: — County of 



iNt I. 



\cd. 



C^^Ka.^. • St.; 

(ir OCATH OCQUftS •W«V TROM USUAL 
IF DfATH OCCURRED IN A HOSPITAL 



Certificate of IDcatb 

• - I wo City of 



^ 






Dist.; bet. and 

R E SI DE NCE Gi VE facts called for under "special infc 
OR institution give 



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



el 







FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 

DATl-: ••!■ Dl. ATll 

\ 



I .\ruiiihi 



l):i\) 






\I .ii 



/ 

1 ' ,11 



M Vki< 11. 1» 

1 1 ilf>ii' ii.il i. .11 I 



N \ M 1 . 1 

I \ 1 I 1 I ! • 



'■"' I • 1 I I. \i !•• 

oi I \rin:i< 

■ ■ ■ ;i 111 ! \ 



M MI>J;\ NAM}.- 
<>l MoTHl.K 



lllk illi-i,A(|- 



I IIi:Ri:iiV (.•i;klll\-, riiat I altendf.l .U.,;.sc,l fi.iiii 

that I Im--! s;iu Ii .ili\<.'in k^ . 

\\\>\ that iKath net uricil. mi thi- <lati- ^^tatLMl ahovr, at ' 
M. The CAI SI-; ()l hi ATII wa- as folli.ws; 



C 



1- 1 vv w. 

V 



a 



vU-a^la. 



DTK \ Ih »\ }',ius 

C( iNTUir-I TORN' 



M on tin 



Din 



"A 



I /O It IS 



DlKATfoX 

( SIGNED ) 

\ 



)'t ars 

\ 



Mont /is 



/)a\ 



'S 



I fdUtS 

M.D. 






I(;n 



f Ad.lR'ss) v\ :\ 



Special information '»nly for Hbspitdls, Insfitufions, Trdnsienls, 
or R((('nl Residents, nnd persons dsinj (mdv from home. 



)-,/ 



V.-////'> 



(I 



'">" <>l M\ KNOW 1.1 ;!,.•,,.; aM) Hl-l.Il |.- 



i; Ti » III !•: 



ni'i' ni it)t 



■ ^ N<.A. \\J\j 



\lllll CSS 






\ ^ 



\ 



Fnrmpr or 
L'siLiI Residence 

When was disease rontrarfed, 
If no( at (ild( e of death ? 



Hovv long at 
PIdf e of Death ? 



flays 



I'l.AOl-; ()1- lUKIAI, i)K RI:M<i\\I, 



n \i:^-; u! i!i iM,\i ui K i;m( i\ \i. 






IQO 



C 



• ^^^cy item otf iniformiition ithdiiltl he cnre^'ully Hupplie.l. Mir, nhoiild be Ktiite.l liXACTLY. PHYSICIANS should 
«tntc CAUSE OF DEATH in phiin terms, that it iiuiy be properly clHHHified. The "SpecinI Inlform.ition" for p«r- 
son« tlyinft away ?rom home shimltl be ftiven in every inHtnnce. 



I- i; 



I , 



I 



1 

1»( 






i 



.JS^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.Miii.l of Hcilth I" No. li •*-?^3Kvtfc luStl* I' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







l>Ji\' 1S~ 



n)0\ 



Bo^istered jYo, 



1873 



Deputy Health OfTicar 



DEPARTMENT OF PUBLIC BEALTH-City and County of San Francisco 



Certificate of E>eatb 

( U. 5. StanJ>ar^ j 

PLACE OF DEATH: — County ofO,<X/>v OA^O/^AXX^ir' Qty ofC3/CU^^ J^Ouaa^\„a cc 



No. l^^O \X 4.^x^.^..o^^ St.; H Dist.;bet. ^ Xl. and 1>^K, 

( " ,Vnr*TM*'orr,l*J*'*.'' "'°*' ^^^'^'- RESIDENCE give tacts CALUED tor under -SPECAL .NrORMAT.ON- \ 
V IF DEATH OCCUllHED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 



) 



FULL NAME 



LkLU,.u^Mf^ 



\l 



.tHMwW 






'\aA^^\Jx\l\ I 



PERSONAL AND STATISTICAL PARTICULARS 



!• \\'\\ <»i. i;iK III 






\ < . 1-; 



Yrai < 



'Day) 



MEDICAL CERTIFICATE OF DEATH 



I go ', 

(Year) 



/ 



I Veai ) 



lb 



/) 



1/ 1 > 



-iNt.i.i" \i\kkii:n 

A ii>(i\yi-;i) OK i)i\-<)Ki"Kl) 

Wiitf in s(Ki;il (lisi^'nati'iti) 



Mlk llll'l. AiM-: 

' SI -•. ..• I'c.lintl V 



WMi; oi- 
FA I'm: R 



l'-M< rillM.ACK 
<M- l-AIIIKK 

'State or I'.miitt \ i 



MAII>J;n NAM)' 

<»!• M<)Tni;K 



Ice WojX Uk^AAi^l ^ ' 
' 



DATK <)!• 1)I:aTH C' 

(MoiAh) (Day) 

p I ill-:Ri:nV CI:RTIFV, That I atUMi.U-.l .k-ccascl from 

OX^ot ^ up 4 to l' ■ . ■ 

that I last saw li .. alive on ' j^q 

an.1 that .Katli occurred, on the date stated above, at 3 
U. M. The CAISI.; Ol- I)|-:aTU was as follows: 



ic)o M 



1)1 • RATION Yrars Months It /A/r.^ Hours 
CONTkl I'd'TOKV d^AOv.AAAX:jL^.^eA_£oAjL 






.>Viir \^ 



I'liniii'i.AvM-; / 
"I' M<>Tin:H ( 

(Stall- or c'ouiiti vi 




(?f|) 



« '^ *.l I'A TiOX 



\J^^\X J-U.v. 



CULvL^a- 



nruATioN 
(Signed ) 



ri 



^ font /is 



/)(j\ 



'S 



M« 



O.kaILJj, ,. 



//ours 
M.D. 



i.)0 (Address) lll^ (k'a,\\J^_.tV^,.'[. 



Special Information only for Hospitals, Instifutions, Transients 
or Recent Residents, and persons dyini) dway from fiome. 



)\:t> 



Mnllll,'. 



/h:\. 



Former or 
Usual Residence 

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



How long at 
Place of Deatli? 



Days 



in, SI oi'j.iN KN« >\\ ij;i)(;k AND in-;Mi:i- 



'IiifoMiiant 







I'l.ACK OI- lUKIALOK kI-;M(iV\U 



DATK of 111 KiAi. or klvMoXAI, 



rNDl-.RTAKKK VA . l^ . V I I VXXJ^^WVV ^ VO 



""' "' ^^^"^^^'^V^^:^:^'^ T ^'""'k'^ :'*"^^"^;'- ''•'• """"'" ^^'^ ^*""^'* BXACTLY. PHYSICIANS nhould 
-on. dv ni «, „ f I ^ . •'•"'*' ^^'^^ '* ""•*' •*'' P'''»P«r!y classified. The "Special ln?ormHtion" ?or dt- 

«on« djinft oiyay from home Khoiild be tiven in every Instance. mHiion tor per- 



1 



\M 



-iNMItv 



■mr 



I 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Mojinl of H.;il(»i I" No, 1^ ■?-|"''^(|^J J!& I' Cij 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jtegisfered JVo. .1 874 



/)((/r /^y/rff,CjJ^\JU^^i>JLK 15^ IfJO'i 

Xcrvu^ Xii/v-u^ Deputy Health CfHcor 

DEPARTMENT OF PUBLIC HEALTtl-Cit)' and County of San Francisco 

Certificate of 2>eatb 

PLACE OF DEATH: — County ofUo^vu X^/Ol^^vcul^I} City oiO<X/>rv .\.cv>vc^^c<: 



No. 11^. 



i^ 



LA\0..-v..'^ St.; 5 Dist.;bet. O A.cl and 

/ If DEATH OCCURS *WAY TROM USUAL R E S I D E NC E C. 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 

'1 Ci\ p 



.Hifv 



FULL NAME 



\\:...LU,.x 



0\J<.Lr\y\X^^\.^:\j. 



^l:\ 



PERSONAL AND STATISTICAL PARTICULARS 

: I COI.Ok N 



cuU 



A. 



;» \ II'. »»i i;iK I'M 



A«". H 



i 



Month) 



(Dav) 



'I>ay) (Year) 






)V. 



II 



Mntith> a 



9-1 



(W'ar) 



/'(n.s 



^IN<".I,K. MAKUn:i) 
\VII)()\\ i:i) «»R DIVdRTKI) 

VV'iilfin social <U-».ii,'iialioii ) 



-t>\.'^' 



I'.iK riii'i. An-: 

St.iti 1 ir I'oii tit I \ 



\AM1- O! 

I A riii;K 



•MR llll'I.ArK 

<>i i"ArFii.;R 

iStatc or Coiniti \ 



MAll>i:\ NAM) 
*>l' MOTIIKR 



I'lR'nilM.Al !•: 

<»!• M()Tm:R 

(State or I'omitrv) 



O XX ^ru Vex A V c '. 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATII 

(MoiAh) 

I HICRl'HV CI«;RTIFV, That I attended deceasetl from 

C^X^-vt !C ,yo . t.) , ' ' T90 

tliat I last saw h ■ alive on OX^\.t tc j^^ '• 

and that death occurred, on the date staled above, at I 
VJ M. The CAr;5l<: 01' I)1:aTH was as 



(PivLi 



' l> 



follows 



\-A.XLA^3 



vJ -MJL/^ "V V Or >\^1DJL -S^ . 




,-r 







\} 









•JJi'y . ■, _a. . 







>.HTl'\ri.)N , ?) 




f\'rsi(/r<f in \ii,f /'ia>i, i\r,> o^. )>,mv I yf.nith- 



I )r RAT ION 
CONTRIl'.rTORV 

I )r RAT ION 

(Signed ) 

^-^> . ' l(,0 



) cars 



Mofii/is 



Days 



Hours 



)'cars 



Mouths 




Days 



^ 



>'VV.. 



Hours 
M.D. 



f 



Address) 151 J CrW.{>v.\; 



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



i 



n,i 



Former or 
Usual Residence 

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



How lonq at 
Place of DeatI) ? 



Days 



Mi'.M ()!• M\ k\(>\vi,i.;i)<;h AM) i{i;i,ii:k 

I'if"'>tmant 0X0.1.1^ 4JcK>v 



I) r Hi- 



's, . , 



f\.1.1r.ss Qvl^U. JX/KO. ,>.;-. S^h 



I'l AC1-: Ol- lU'RIAL OR R1-;M()VAI, I)\.T1:o1- MiinAl. or RFMOVM 

INDHRTAKl-KN'l 0.>ctcUAV M I '^'^ ^D \X<V\iu ^<^"u\JUav 

111! Oll^^LSLA^-VV dl 



(Atldrtss 



N. B.- 



'^^lliy^XU^^ l^l'^^^T^^^ *" cnrct-ully si.pplJccl. AGH Hhould be Htate.l liXACTLY. PHYSICIANS nhould 

«ons clvlni i>' ATH ,„ pl.nn terms, thnt it m«y he properly claH«i1r'iccl. The "Special Information" for per- 

sons clyinft uway from home Hhould be ^iven in every instance. 




* 



!4 



i 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Bowdof Health I v.. i.*.tS^3M&Jc-., BEFER TO BACK OF CERTIFICATE FOR (NSTRUCTION3 



Pioii.'itered JVo, 



1874 



cL^u^5lx^>-u Deputy hk.u. '^^. -^ 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of "Seatb 



XX. S. StanC^arD ) 



i W 



^ ^ 



PLACE OF DEATH: — County ofOo/Yv J;^cx^vcaLa< City of OOyY^ .rvo/^^c^^ <r. 



No. ^ ' ' 



[I) a 
J... ', _„ . ^ St.; Dist.;bet. O A.d' and -H 

/ IF DEATH OCCURS AWAY rROM USUAL R E S I D E N C E G I VE FACTS CALLED TOR UNDER "SPECrAL INFORMATION' ^ 
(, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



Lu 



FULL NAME 



h\.UsjJ. 



u 




r^vJL 



> '. • \j 



PERSONAL AND STATISTICAL PARTICULARS 



I A 



[\\<xh 



i'( il,< »K 



i»A ii: < 'I r.;K I'll 



M..Mth> 



\f.i-; 



5b 



) 



ii 



;i.i% 



I/.,-/,- 



•1 



( Wat i 



na\. 



U'litciii siirial <1« •»iv.'n;ilii>ii) 



.C'-WO. ' 



lUKTiii'i. \t'»", r /'Vn 

(Stat* "ir routiti \ _3( Ol^ 

x \Mi-: OK 



5 



CJ/CL'Vu \,Oj\^<i 



^-v. 



I \'i II i:k 



HIKTHI'I, \(H 
<)!• lATHKK 

'St;it( nr rmiiiti \- 




\) 





Sw I I - • - ' 



MEDICAL CERTIFICATE OF DEATH 

DAI'K (>!• Dl'.A'lH J, 



1 



\ 



I: 



fl)ay) (Vt-ar^ 



(Mon'th) 
I HI';RI:I'.V CIvRTII'N', That I attfiKkMl (IccoascMl from 

..J^\.C I90 to ^(P 

tliat I last saw h ■ alive on djd(\ki iO T90'' 

and that (hath occurred, on the datt- staled above, at lO 
M. The CAi:.SI<: ()!• I) I 'ATI! was as follows: 



DT RATION Years 

CONTRIl'.rTORV 



Months 



Days 



Hours 









HIkTmM.ACH 
'•I- MOTIIKK 
'Statt- f)r Countrvi 



occ 



ri'ATION ^ 



li,i\^ 



rni-; \hovi': srA'n:i) wkksonai, rAKruri, \ks ar}". tki)'. r<> 
iu:sT oi- Mv kn()\vm:i)<;k AM) lu'.iji.i- 



TIN-; 



(I 



nfoimaiit AyCuOj oU M>COvvA^- 



r\<l.lrcss Qvl^ \X 



J.xi 



\XX/ y vxo 



A. 



}V</r-? Months 




/An.v 



Ad.lress) 1 5"! (nAJ>-. . 



Hours 
M.D. 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



.. Days 



ri.ACK Ol- lUKIAK OR RICMOVAI, 



>\.t 



Dyri". "1 !{' KiAi, or ki:m()vai, 
S^jO^ '<'X. 190 . 

rNI>HRTAKKR*^'i<XxicUAvW V^AX^w 

r.\<i<irrss lll\ Vl^VuyiyL^^.v 'J'* 



of inW.n«tlon should b. cnnefully HuppHed. AGE «houId »>««*«ted EXACTLY ^"VSiCIANS Hhould 
E OF DEATH in plain terms, thot it mny be properly classified. The "Special Information for p-r- 
i> ■ ..t._..i.i Uo AS./^n in *%/<•*•%/ inAtnnce. 



IN. B. Every item 

state CAUS _„ 

sons dyin^ away from home should be ftiven in every Instance. 



1 , 



f 



. i 



I 



^1 

I 

I. 

I 



^-^ 
^ 




r 



<<> 



i< 






'1 !' 



\r 


-h 


1 


■f 11 


^- 


* 




1 






t 
1 


1 



I 



:t 



K 



■S^j^ 




\ ■> 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



u„.,r.i .J n^w»^£^!^ '^ "^^?^ ^^^^' ^"^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hffr riled. dxKtjL^^^X^K. '^.S l^H)'\ 



CrUvc 



:. U 



Registej'ecl J\^o, 



1875 



i^ V, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

PLACE OF DEATH: — County of 0<X>vv ■ .vCvici City of 






\<X/>vc.\.^c 




[iL 



. t . 



No. K)ki \1 I laV^v'^ O'C C^ V ( ^'<.Lo...' St.; Dist.; bet. - and 

/ ir DCATHi OCCURS AVWA^ TROM USUAL RESIDENCE GlVr FACTS CALLED FOR UNDER SPECIAL INFORMATION ■ \ 
\ IF Dti^TH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME M I La-vu ^ 



4- 



PERSONAL AND STATISTICAL PARTICULARS 



^^ 



I ( il,< iK 



0^ , , 

> \ I 1. < >I 151 KTH 






4 )\cxa 



\' .!■: 



5 



) -„w 



(Day) 



1 /..»////> 



» (MI 



na\. 



^1N<.1.1 MAKKn.Ii 

W II)( •WKl) UK I>I\'t)kiKI) 

W'litfin s.M-i:il il«'-ij.Mi;tl !• >ii ) 



I'.IU I'Ml'I, AOl-; 

f St;it I- 'II t,'<iii lit rv^ 








MEDICAL CERTIFICATE OF DEATH 

DATK Oh' Dl-.ATH l' 



(Mnnlh) 



IQO 

(I)av) (Yt-ar 



I ni':Ri:i5V CI:RTII-V, That r attcMnUMl deceased from 



Kp 



tliat I last saw h ■ alive on ' ' ^ l •'• ■ '> !»/) 

and that death neciirretl, on the dale stated above, at 
M. 'I'lie CAlSlv Ol" DlvATII was as follows: 



1)1 RATION 



Years 



!UK riU'l.ACK 

«»! » \iiii:k 




MMDI'.N NAMl- 
<>l- Morill.K 



Hlk riii'KAn-: 
<>I" MoTlU'.K 

'St:itc ,,r (•(,iintr\) 





< •'•(■| \ 



•NTiox (gjn 



(iK\jlLcv>v^ 



I 



Months 



CONTRN'.rTORV '^.Quy\X>f\J^ , - 



/)ays 



Hours 



v\^. 



nr RATION Years 

(SIGNED ) b J ' 



Mouths 



Pays 



r 1 



/foNr< 

M.D. 



gjL^t 



I<)0 



(Ad.lress)0l)^^Ux^^C|6 'h^ 



Special information «nly •'^f Hospitals, Institutions, hcinsients, 
or Recent Residents, dnd persons dying .iw.iy from Jiome. 



A'/-yi,ffif ill Siiu t'l ,111, isro^ S'^C''''"' * .1Am////> 



l>,ns 



I'll. MtOVI-: STATi:!) l'KU^()NAI< I'A KTH' T I.A K S A K )•. \\<\ V. I' ) I'lN': 



^Iiif'iiin;iiit 






former or 
Isudl Residence 

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



,,, '^4' , f A How long at ^ 

\\oX IhXdJLh^j^r. ^)l Place of Deatli? o 



. . Days 



n,.^CK Ol' lUKIAf, ok ki:M«>\AI, 

A(i(ii<-ss Al....Ux;?.. > 



rNi.J-.kTAKi-K UlAXUr ^- ^"v- 



i>A r,v. "! Ml KiAi. oi ri';m()\ Ai, 

TQO 



v^a :.A. 




\wSLiv 



N. B.. 



-F. 

n 



ivery Item of InWmuf.on .houl.l b. carefully Mupplied. AGB «h«uld be HtHtc.l liXACTLY. PHYSICIANS «hould 
tate CAUSE OF DEATH In plnin term«, that it may be properly claHsifletl. The Special Information ior p«r- 



Hons ciyin^ away from homo Hhouhl be feiven In every instance. 



n 



■ 1 

I 41 
f 



H 



III! 



% ' 



I 



iiMM^^W. 






w^. 



WW 


m^lk 


IM^Wf^^^ 





U ! 




>^.iyp- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



;'.< M r 1 : < 'i r 1 1 .1 * i :i i 



1 »«.X I \ • I 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dff/c n/rf/ ,ajJpXjU^-\^l>JU\y 1 



5 



IfJO'i 



IlegLslcred J\^o. 



1 876 



,<j\.\,\„>^ vX^v *-■•, 



DEPARTMENT OF PUBLIC HEALTH=Ci> and County of San Francisco 

Certificate of Scatb 

{ (?y SI (^ 

PLACE OF DEATH: — County of^^(X'>^ XO/IVCClCv. City ofUxXTv ;v<X/'>\CC4 CC 



NeALtuK^Cr^^^-vL locKLkd • 



St.; 



Dist.; bet. 



and 



(ir DEATH OCCUNsUwAV TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ 
IF DEATH OCCUI^RID IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



IV. 



^■> 



L^V^tX 




/ c. 



4 



PERSONAL AND STATISTICAL PARTICULARS 



•^1 A 



A 



'^\J 



roi.ok \ 



A^ 



V.I 



"I I'.IK I II 



M-.iith) 



\ ' . 1-, 



"^iNt.i.K MARK n:i> 

\\\\H »u j:i> ( »K niv I iR* » I) 

Wiitiin >-<Ki;iI <lt>ii.'ii,it idii) 



I);ivi 



Munlh^ 






TQO 

(Year I 



/>^t\^ 



HIKTmM.At'l-: 

' ^t:(ti' I ir Citllllt I \ 



\ \MI- I u 
t MIII.K 



lUK IIII'I, \(K 
<»'■ I AT IN-: k 
!^tat« or *.«niiiti \- 



'" M«»Tin;K 



lilkllM'LAil-- 
(St:il< 11! louiiti \ 






MEDICAL CERTIFICATE OF DEATH 

DATH ()!• ni-.ATH '. 

A ^- t ^ ^ 

(Moiitlli) «I)av) 

I lll{ki;i5\- CI;RTI1-V, That ^ attendod .kroased from 

...d-w^xt. up \ to . q^-vt . X5 np'i 

tliat I last saw li alive on J^K-Kvl. i<p 

and that dtath occurred, on the dat*.' stated alxive, at ' ■ . 
M. '\'hv CACSI-; ())■ I)I{.\TH was as follows: 



Huci ''''' 



i\DjLS. 




DlkA'i'lON 



CUNTRIIilTORV 



) 'ears 






Moni/is 



/hivs 



Hours 



1)1' RAT ION /w)V(;;^ 



Signed ) 




)x|a1 v\ 



Months 

1^ 



l\xxs 



Hon 



rv 



i. I()0 



(Ad<lress) Ut' ^-^ \ ' ^^ 



■CLc K^' 



M.D. 



Special Information only lor Hospitals, Instilufions, Transients, 
or Rfcenf Residents, and persons dying away from home. 



"'*'l I'ATION 1^ 
.^ AVwi/a/ ill Stiu I'nttuisr,} O 1 ) V-< 



Mniilfn 



na\. 



Former or iioa lu^ j ~\4 Hon long at ^ 

Usual Residence 1 1 o A dOft-UMXVCV 01 piare of Oeatli? -) 



Usual Residence 

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



Davs 



' "',;,^J!I.'^'*^.^''"^^ ''*»•■'> '"HRSONAI, PAKTHM'I.AKS AKK TKl K To THK 
"'■.SI «)!• MV KNOWI.J'.IX'.K ANI) HHMHF 



'liifoiniatit O 



-Co-x^yL 




( \<l<lr«'ss 



LLtu\jLL{). ()V)(S^kAlaX 



ri.ACE OF BURIAI, OR RKM()\ AI, 







\J^,^U^ 



DATKo! Mi KiAi, or RKMOVAI, 
t}JU\<X kl 190 '1 



l-NDHRTAKKR \>J^ MR^ XmX/ 



'U 



U/TM^-WXu XOo . , 



fA(l(lr«'Ss . 1051 \| MAAAWM 



N. B. Bvery item of Infopmation should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It mny he properly classified. The "Special Information" for p«r- 
"ons dyin^ away from home should be ftlven In 9\^ry Inuiance. 



"I 



\ 



t 



'mI 



,|IK 



»!• 



•: 



!« 



'I 




**►, 



'jwdAKiiiiiiiJi-i 



W 



.4 

1 





fi 



lit 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!;,,,;., I,, I II. i:lM I- NO \r "~:^_.*»»> 



ll<\. I' V u 



REFER TO BACK OF CCFtTmCATE FOR INSTRUCTIONS 



IfJO'i 



DEPARTMENT OF PUBLIC HEALTH 



Bcgistcved J\''o. 



fR77 



City and County of San Francisco 



Certificate of 2)eatb 

( 11. S. s5tanC»arC> ) 
PLACE OF DEATH: — County of 0<X/Y\.> 0,\.(X>vCi^' City of CVcuv^i vJ Vo."v-vC\^ 



Ne. V.CVU, 



.O-WYVV 




St.; 



Dist.; bet. 



and 



A / IF DtATM OCCUng •WAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • ' \ 
y \ IF DEATH OCCUWRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME KS^L^vk dc) }k.L-^xA^<x.\j . 



PERSONAL AND STATISTICAL PARTICULARS 



I I 



^'_' ' 



uL. 



! I i! iWK I n 






Vvt 



a? 

(l);iv' 






MEDICAL CERTIFICATE OF DEATH 

DAT!-; til DIvATH 



(Vf.'ir 



\' . I'. 






) r,n 



1/,..,'// 



/),; 



-IN'. 1. 1- M \KU ii: I> 
\\ IIX i\\ 1- |> ( >K I)!\i iK . I : ) 
^^ ■ '*' ill ^ .>i;il 'li si).'ii;it ion I 



IWKTMJM.AOK 

' Slit f or I "oiiiit I V 



N \M 1- (>|- 

I A I 111: K 



MIRTIII'l.AiK 

' " ' \ 1" m<: K 

' ■ ' lit I'otltltt V) 



^Ml|iJ.;\ NAM). 

"1 Mt>'nii:R 



I'-iK-nii'i.Ati- 

"' M'»liiHk 



1; Lctcv<>v-d. 






d 




vlv^ w 



X 



\^: 



(Moiit'li) (I)av) 

I Ill'klir.V CI-kTiI'V. That I MtU'iuk-d .U-crasL-d from 
1. \()0 to .Q-£^x"t . 2lH i<p H 

tliat I last saw h •- alive on JJLij'N^^v T()0 '• 

.111(1 tliat (K'.itli occiirrc<l, on the date- statftl abow, at 
M. The CAISI-: Ol" DI'.ATII was as follows: 

Lljxr_ ,, 

I )r RATI ON )'tnrs Mont /is Day 

CoNTRini TORV 



'.V 



/fours 



lU 






M^ca<x 



no 



I )r RATION ^.^ )\ars MoiiIIl^ 



PiU 



'S 



(Signed) . VJ v 



,1) 



Hours 
M.D. 



V. ; -V.. . u 



I()0 



( 



A.ldre^s) Ui<j Vt Lc m O^-^l Vvlo..,. 



Special information only for IfospifHis, institutions, Transients, 
or Recent Residents, and persons dying dwdv from home. 



h'f^ldlii in S,;,/ I l,nni.u-,> » t )', ,1 



M.nitll^ 



n,!\ 



' " n.^'-!.*^ '*' '^''■'^''■'••'> I'KKsoNAi. I'AK rnrrAKs aki; vhvv. r<> rni-: 

HI.sl <)!• MV K.\()\\ij.;i)(;k AM) 111;IJI:j- 



^Illfoilll.lllt 



e.(?%. eio^.. 



Former or <> i o V \ 
Usual Residence '^ ^ ■ J ' 

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



HoH long at 
Place of Death ? 



Days 



,^ 



1 



^•MT -ss VXLu H.Cc. ^^V)Cs>:lV ' ^ 




I'^.ACK Ol' lUKiAi, Ok ki;mi»\ai. 




I)AI"l-:of Ht kiAI, or ki;MO\AI, 




lM>i;kTAKi:K 






N. B. 



Kvery Item olt Inforimitlon should he ciirefully Hiipplieil. AGK should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may he pr«»perly classified. The "Special Information" for per- 
sons dyin^ nwny from home shouhl be ftiven in every inHtance. 



I'll 
I 

■I 



t 



iM 



< I 



I '( 



:'>| 
V^ 






t Jl 



I 
I't 



iiiiiL. 


1 

i 


LJ 


■ WW-f" ' - 



.,. .^..y***,* 



h ; 



4 



Bl% 




M^milMiikiMi: 




WRITE PLAINLY WITH UNFADING IN»\ — THIS IS A PERMANENT RECORD 



ll.llltn- f >r). IS <-Z,_-^mr 



IHV I \ ' I 



HtKtH ru BACrv OF CERTIFICATE FOR INSTRUCTIONS 



If^O'i 



Kegi,sfcro(l J^'^o. 



fi, ' . 



4 ~ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

i U. S. t?tanC>ar^ ) 

A i?r,) J? Q71 

PLACE OF DEATH: — County of Ooy-yv 0/Va^vCA,A,C'. City ofO<X'>\/ OAXXVvCo(i,ct 
-L^-. . . ■ St.; ■■ Dist.jbet. JIa'-V'J .'. . V and J C'^L-i. 

(ir DCATH 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. J 



No. 



,<L.'.- I V 



A 



FULL NAME^^ 



V" 



Vka^ 



•A 



v.qo' 



PERSONAL AND STATISTICAL PARTICULARS 

■^ ("<»I.tiK 




-—^ H 

MEDICAL CERTIFICATE OF DEATH 

DATK (11' Dl'.Al II 



I'l lllKllI 



\ ' . »■; 






\ , , 



il>av> 



M.ni'h^ 



/',M 



\^ iiK ivvKi) OK r)ivi >kr}-i) 



r.Iirni \'\ \c\ 



^ 



./v. I 



NAM I <i| 
»• \ III 1 U 



I I. \t I-. I 

! ''illlltlV ' _V 



Mothli 



!I)ay) (Vf.'tr) 



I Hlvklir.V C1:RTII"V, TlmL I ;itUii.K-.l .li-ccasL-d from 



1 90 t( 

tliJit I last saw h • ' ali\f on 






aii<l that (li-ath o(M-ii tred, on tlu" tlatc statr<l ahovi'. at 
M. Tlu- C.MSI-; Ol- DI'ATil was as follows: 

<7n 



.•5...I.X 



Hlk I IIPI.All-' 

Of lATUl-.k 

(St.'i!" -I r,,uiitiv' "^ 



^!AII)|.:^• NAMI-: 
Oi .MoTllKK 



niiMni'i,Ari-- 

<>l- MOTHKK 



' '>'i 1' \ riON 




I. 






DC RAT ION Ytars Moiil/i^ Days 

e()NTRIlU"T<)RV Ua^:UUuV\-'"^-^-'- 



I Ion IS 



Xs\*;i:\. 



CUl OJ ^-... L <X KVXo 



XK. A ^ V.O 




DTRATION 
fSlGNED) H 



Years Mi>}i(Jis 



f^avs 






^ 



flours 
M.D. 






I()0 



( 



A.Mn-ss) "HSH JjUX>, 



Special information only lor llospitdls, InstitutioBs, lr.insienfs, 
or Recent Residents, dnd persons dying awdy from home. 



AVv'7, //■,/' in S,!>r /'iiiii. ' ,\i 



) I It I ' 



I/,./////' 



/i.n 



ni- \itovi- ST\ ri:i) i'Kk->()\A], par rirri. akn aki, iri »•: i" riu-; 
m.M 01 Mv KN<)\vi,i.;i)(.|^ AM) iu;i,ji;i'- 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



I'J.ACi; <>I- lURIALdR Ri;.M<>\AI, 



fliif 



iiMll.lIlt 




X.l.hrKS d^^ rj-CV/WV^VUi/V '..'1 



''i 



DA xi; .»; lit uiAi. (It ri-;m( >\ai< 
OXJ<T.. 'XL T90 i 



(Addrrss ^ i "l M YIa^-'&A^.'>^:v. ...J .1 



N. B.- 



-Hvery item of informntion should be cnrefully supplied. AGB should be stnted F.XACTLY. PHYSICIANS should 
Htiite CAUSE OF DEATH in plnin terms, thnt it may be properly clussiV'ied. The ' Special Information ^or p«r- 
«on» dyinft nway from home should be j>iven in every instance. 



1 



. ) 



I. 



,1 



< 



> I 



M i 



iJlM: i' 



M?^*. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f licHltn — t NM i; 



^f^J?^. 



|>>V I > ' < 



REFtH ru tJAcn ok ctKriFicATE for instructions 



llegistered J\''(). 



^ ^^'"^Q 



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

Certificate of IDeatb 

( XI. £. *r'tnn^ari> ) 

J? QT) \ ^ 

PLACE OF DEATH: — County of Ocuy^ i XCL'^xCAjy.CLCiiy of CjO-T^ Oy\/awCuo..c.< 



No. 



r^ 



JXl 



) F . > 



St.; 



Dist.; bet. 



Civ; .V 



and ^ 0'L««i-C 



I ^ 



(ir DEATH OCCURS *W»V 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^ 



\ > \ 



V^ 



n 



w 



..l,L 



u- 



PERSONAL AND STATISTICAL PARTICULARS 



'^iTlcxo. 



i < il,« iK 



s 



: :k ill 






iD.'iv 



I I ,(i 



■■ • 1 



—ri 

MEDICAL CERTIFICATE OF DEATH 

I) \Ti-: Ml' Di. \i II 



(MoiUli) 



(Day) (Y«-ar) 



I IIIiRl'HV ClvkTlI'V, That I attended <leccasc(l from 

to 'c).j^Lxkj. ^'.1 i< 



U/) 



,:p 



5,.;. 



v. 



■~i ' : 1 M AUIv !!• n 
\\\iu >\\ I'.lt OK I>I\nl<r»-|) 
U'litrin v(ui:il ili ■-ii.'iiitt ii in ' 






L 



iiiK III I'l. \r]-. 



■Ml (.1 
i \ III IK 



iiik I'liri. XTj.- 
oi- I \iin-:K 

"^1 ''■ '.r rnntiti V 



M\ll)|-:\ NAMK 
HI MorilivK 



ink riii'i.Mj.; 

'H MOTHI'.K 

'"'t.-lt.- .,1 r-MMltl v) 



< "TIP \ii(,x 






V 



^th<uJ'^ 



^\; 









fV 



A 



LKj 







[90 

tliat I last SMW h ' alive oil ' ' T90 

ami that di-ath occurred, nu the date- stated above, at I i.. .■')C 
yL The CMSI- Ol- DI-.A'PII was as follows: 

Dr RAT ION }\ajs M on I lis Pays I/oins 



1)1 RAT ION 



(Signed) 



)'rar5 



Mouths 



/hiys 



\ 



U I . 



« 



d 



X A. "> 1 -^.CL 



/\/-i(tr,f III S,ii! / I (I II, ' ,-,, 



) ,,i 



\l..iifh^ 



/)ii\ 



. J -Ji^ y W* ^ ■ 



I 



flours 
M.D. 



I < )0 



(Address) H 5 H vixaiu^. It 



^, 



Special information only f"r Hospildls, institutions, Trdnsients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



HoM lonq at 
Place of Death ? 



Days 



"',;,^'!V^ '■• ^ ' ^■''••■'> I'HKsoNAi, I'XK iirn. \K> \k)-; iki}-: 
'ti.si ni- Mv K.\()\vij.;i)(.i;^.\Ni) n):i.n:i- 



To •no-; 



'I'lfMMuant 



1% 



\A 



jJ^^yjy\j 






\'[,\CK ()!• IH RIAL OR R1;Mo\ AI, 



l)ATi;i>!' liruiAi. or R1-;M(i\'\I. 

C)X-'y\X ^b T90 i 



ni)i:ktaki:r o\o. J. Vl l\xX.<XNi.. 



Htion shoul.1 be cnrefully supplied. AGF. should be Htntcd F.XAGTLY. PHYSICIANS should 
^TH in plHin terms, that it may he properly classified. The * Special Information for pi*r- 



^- "• Hvery Item of inform 

state CAUSI: OF- DEA . 

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



fi i 



« 



( 



f 



'<> 



i t! 



I 

♦ id 



'III 



(h 



I I i 



i 



mjmmu' 



TWn 





:M ' 






\ m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f4f«tt*it-4*^^^SG^?- *-::: 






-i,i- uS- l> ( • 



itrcn iw i3^\v*r\ \<»p v^cn I ir iv^M I e. rvn It>i9irtw^liunist 








Deputy HeaCh Officer 



Registered J\'*o. 



-»879 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of J.a/TVvJ^v<x>-\.<;tA. 




Ccitificatc of S)eatb 

( XI. 5. StanParC ; 

OyV<x>-v<;t^ • City of 0<x>^ J.^VCx^vtrA^^i, ec 



No. iO. LVccv>A. > ^<.'\ St.; Dist.ibet. 'Ibcu,' .,C,.9,.. and C'Li.!: 



(ir DCATH OCCURS AW*V rnOM USUAL RESIDENCE give facts called tor under "special INFORMATION" "\ 
IF DrATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



\w. 



\ ' 



>'. 



i I 



^1 ■ 



\> 



PERSONAL AND STATISTICAL PARTICULARS 

f^ j CoI.'iK 



Ml 



I 



I liik I'H 



L 



I 



-\ 



-c 



M..I1I 



hi 



an 

Davt 



\' . I 



UllM»UKI)nK IHVoKtKO Q 

\\iit< in ^iK-i:il <!»^iv'ii;tti<<n) Jj( \ 

I'll-: iin-;.\i'H C] nr\ \ 

•-1 .1. or Country) y ^Uj' J 

lb A.L*^i 



\ (.:ii 



/'.,'! 






■OJ 



NAM1-: 01 



MEDICAL CERTIFICATE OF DEATH 

i).\Ti'; ()!• Divvrii I 

„ -'.. , . . /go 

(Monih) iD.'iv) (Year) 

I m<;RI':H\' CI':RTII'V, That r attended deceased from 

190 to . OX^vt 'k\ icp I 

tliat I last saw h alive on ' k/d 

and that death occurred, on the date stated alxn'e, at lA oO 



KO^^LU' 



LL,.^I. The CATSI': OFDI'.ATII was as follows: 

^..(^^LoJj LLc', 



Dlk.V'l'ION ^^'%^ Months Pays I loin 
CONTR IIU'TORV \J./\>MsjJL'}JLKXj^Qr.:,?ij.A'^.j^ 



nikTiii-i,\ii.: 
•<i" i\Tin:R 



MAini-.N NAMFf 
01 .MorilllK 



niKTun.Aci-; 
<»i- M()tm):k 

"^t.'itr ur C'oiiiitiy) 




ce- 



il 



4. 



f 



lloLUijfO ■ ' ) aruvt'^v " 



DIRATION 
(SIGNED ) 



]\-ars 

i 



Mouthy 



Pays 



i, 



I Ion is 
M.D. 



dxKt ^H TooM (.Address) HS-1 -^-XX-^x ^ 



o^^ri'ATioN- 

f^'f^ninf III S",;;/ /-'mil, i\i-(t 



1'^ 



) Vii I 



Mniitin 



/hrrs 



'" nJ!:!,*^'*' ^''*^^ ■'■»■" J'KKSONAI. VAKTICn.AK 
"h^roi- MY KNOW I,i;i)C,H A\l) MIvMHK 



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



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Days 



(l'if'>!ni:ml 



S .\K1", rRTK TO THH 



y'Vv 



fA.idrcss 3sX O AA,/\y\r\^U\j \ 



I'l.ACE OI' HIKI.\L UK KK.MOXAI 



^^\JJL^^ 



DAP-; of lu Ki.Ai, or ki;mo\'ai. 
.. OXi-vt ^.b I 



UNI)KRT.\KKR 







90 \ 



Vj lUXXXAi^ 



(.Addres.s 



\iyAAA^u-<nv. . ul 



IN. B. 



Every item oi information .hould be carefully Hupplled. AGE «houId be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information Vor per- 
sons dyinft away from home should be ftiven in every instance. 



J n 



If 

■ t 
,1 



f 



* i 

ij 

:l 



(i 



8 



i I 



I i 







' ' ! 



tumtxj^i^ 



»Ji^.'« 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PE 



li, .;.(.' Ml. Mil IV. 



•r^srsi 



RMANENT RECORD 



r.uSi]' (• 



REFER TO BACK OF CERTIFICATE FOR INST 



RUCTIONS 



,C5L^u l_..v-v; Deputy Hc^..c. Omcci' 



liegiiitered jYo, 



■' ^T^ '•> 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of SJeatb 






■i^ 



N 



\ "V -1 ^ 

PLACE OF DEATH: — County of^^^^ Vo^xc^c^ City of 'a , J/va^vcv^v 



t). 



I la<c ^ d vLtu ^ J ,a ^ \ 'A a \. i 



St.; 



f IF DtATH fccCUHS AW«V FROM USUAL RESIDENCE Gl 
V IF DE*T^ OCCURRED IN A HOSPITAL OR INSTITUTION 



Dist.; bet. 



and 



FULL NAME 




'^.^''*'^"'^ mV.'/ J" ''°" ^r,OZV^ "SPECIAL INFORMATION- \ 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 




e 



^r 



y 



LclI^. LL^a- \) lla^\A.L<xA. 



PERSONAL AND STATISTICAL PARTICULARS 



>-N, 



i'<>i.i)k ^ 



" 't I'l- "I J;|K II, 



Ll 






MEDICAL CERTIFICATE OF DEATH 

i>ATK OF i)i:.\rn '^ 



MoTltill 



(Day) (Year) 



D.iv 



M.oifl, i 



I I ,ii 



1 M \kuii-:i) 

-'K-ial <lrsiv'iialii>ii) 



n I k ! M • i \ , ■ 1 



^ 



I I1I:KI;1'.V ei;kTfI-^V, ri.at I attcn.lnl iIctc-mso.I fn.ni 
■ ■ ■ KyO 1,, Ax}^' :\'> Kp'i 

that I last saw h aliw on ' j ^ (-, 

Mini that ikath ..i-cinrc.I. mi thi- .latr ^talf.l ahovi', at 1-?lC 
^•v M. Thf C \I Sl{ Ol- |)|; ATI! was as follows: 
Vw s , - • ■ 



■I : \ 



NAMi: <)| 

I- M"in:k 



inKTtn-i.vrF 

",'■■ lAIMKk' 

'St. It, ,., Ciuii!! \ 






'MKTHI'|,\(|.> 
f\i' MoTiii-r' 
ySUiU- or C.Mintiv 



" ' ' I'ATlo.N . 









^.^Lc^t 




Si 



IH RATION )-rars Mont In T Pays Hours 

CONTRIMITORV L\.ClAlx...y.yL' ' 



I )!' RATION 



)'<■(/;.? 







i^t AL^ 






jfofit/is Days Hours 

• Signed) v. L 1 I ' ■ iLa-v m.d. 



Special Information only tor Hospitals, Instifuflons, rranslents, 
or Recent Residenls, dnd persons dvin<j dHdy froin home. 



)..'., >. 



1 A. -///,' 



'""I-: \iu)\-).- si- \ I-,-,, ,.,.,, " " 



/ >ii 1 



< > rii !•: 



former or \ \ 

IsudI Residence UOw^C a. • 

When was disease ronfracled, - '\ i i 
If not A\ place of death ? O XKl 



How long i\ 
Place of Death ? 



Days 



PI, \('i: Ol- MIKIAI, OK Ri:.\loVAI, I DXTl'"! 1! ii\i. ..! UliMoVAI, 



^'"foMiiaiit 






rvMu.ss Ucuo<XY-JXt C-... 



CCCOwOM^ 



IL 



190 



INI) !•: K r A K !•; k VwUxAA'c\.->aj LlcLovtcc-^ v J-la ti ij.i' ,. 



«tnTe*^c'AVlSF''A".^"'^'""*'"" •»'">"l<l be cirefully Kupplle.l. M\V. should be stiiteil fiXACTLY. PHYSICIANS should 
«ons d • ^ DKATH in plnin terms, thnt It mjiy be properly tloHsified. The "Speciul InformHtlon" for p«r- 

">ina away ^rom home should be ftiven hi every instnnce. 






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THIS IS A PERMANENT RECORD 

_R£FER TO BACK OF CERTIFICATE FOFl INRTB.,rT,« 






Ilcgi,slere<l A''a. 



I 



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Dep 



DEPARTflENT OF PUBLIC tlEALTH>City and County of San Francisco 



Certificate of S)eatb 

( 11. S. t5tnnC>arC> ) 



(^ 



PLACE OF DEATH:-County of 0<x.v J Vo .. ^. , Cfty of Ocu.v J A<^, 

o. 4H'l Va 



vc v^.. <?. 



^--^l.( 



St.; 



Dist.; bet. 



and <- L \ 



(0^ -o^^^^t-jR^;^- -- -- 1 r^-^^— - --I --^ .;:y;^^^: s^;^^;-.-::-r • ) 



% 



FULL NAME i\X^XA.aJ M I U 



PERSONAL AND STATISTICAL PARTICULARS 



1 illKIM 









AH 



MEDICAL CERTIFICATE OF DEATH 

DAii-; oi i)i:\rji 



JxUt 



Dav) 



I S'cMI 



^^ 



1 



i; ./'A 



11,111 



/'„• 



''>^ »l» OK |);\-nKrin 

III -"<i.l! ,1, sii'Il;,|,,,,,| 



lU!' MM V,-,.; 

'i| lit t \ 



I 111 
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' ill'l,\t-K 

■ ' ' 'll lit I \ 



OI M<iTlli:k 



HIRTHIM, \i |. 

I''- "^'"Tni-.K 



^n^ 



. I m:KIJ!V ti:RTlI-'V. TI,;,t l altc-M,l..I ,Ic.v,,m-.| Cumi 

!.>') to BjU^xt IH up . 

that I last saw Ii alivt- on . ' ,,p 

••in. I that -Irafh ociiirro.l, on tlu- -latr Matrd alx.vr. a( ' 
M. Till- C.\IS|{ OI- 1)|.:.\TII was as follnus: 



^L 






I ( 



V -A 



c(HUl 



V^\; 



m 



II 



-wo.t^j 



I )r RATION )W/y.y 

CON'I'RIIilToRV 



Mouths 



/hns 



Iloii) 



\^. 



rUA.. 



Ml . I 



'XThiN ''JW 



XK^ 



IMR.\'I"I().\ 

(Signed ) 



i7> 



.Vo'it/is 



/><n\ 



Ov il. 



• I 



u- « ' 



floiii s 

M.D. 



too (A.ldrc'ss) ^\0 U,Q.>\/ yfK.i U... 



OC^i^^^XiJtUj-U,.' 



) V ( / ; s 



M.oith^ 



lul 



Special Information »iiIv i(»r iiospifdis, instifuiions, irdnsimts, 

or Recfnt Residents, diid persons dyinij dwdv Irom home. 

former or 
llsudi Residence 

When was disease ronfrdcfed, 
If not at piare of deatli ? 



HoH lonfj at 
Plare of Deatti ? 



.. Days 



'"■•^■'■'"' ^lVy^•(^\'\V'l•^n!^?';v^'^ '.ir,'; I- >.'<^^»<»- ■'"«'■'•: 'l'» llll': I ''I.^'H <»"•• III KIAI, (IK KlvMnVAl, I DXIM:,,) H.KiAf. m ki;Mn\AI, 

~OjJ^ 3.b T90H 






•!M:il)( 



LttA; 




b&- 



(Ad.lress IXO^ \IMAXl.^CtJ . u '..U 



"twtc CAU8F OP n*^"*'**" •hould b.- ciirefully Hiippliecl. A(IB should be stiite.l HXACTLY. PHYSICIANS shoiilcl 
«ont cIvlnA ' "f^ "EATH in plain terms, thnt it may be properly claHsifieil. The "Special InlforiiiHlion" lor p«r- 
yng away from homo nhoulcl be given in every InHtnnce. 





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WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

i "EPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Mn.M- ' I !!.;iltyi -!•• No. I"; ***i:«:^' M»"tl' Co 






/;/0H 



Jf('o~i,s/t'/'e(l A''o. 



1882 



' 



.t^U^) 



DEPARTMENT OF PUBLIC HEALTtKity and County of San Francisco 

Certificate of 5)catb 

( U. 5. 5tnnc>arC> ) 
PLACE OF DEATH: — County of W^y- 1 h a -, . ~, , r Qty of Oo^vv .1 .Vex >va.^r^i 
No. s^:> CJ.Ovoivx.:' St.; ^! Dist.;bet. •' -uJ: ' and IH 1 '^^ 

( '^ ,''/nI".°''^""^ *.^*'' "°'" USUAL RESIDENCE g.ve tacts called tor under -specal iNroRMATiON ■ \ ■' 

V ir death 0CCUR|,ED .N a hospital or INSTirUTiON GIVE ,TS NAME INSTEAD Or STR EeI AN D N UMBER ) 



FULL NAME 



V 




PERSONAL AND STATISTICAL PARTICULARS 



-^^'^-xoJu 



MEDICAL CERTIFICATE OF DEATH 

DAl'l". tU Df.ATH 



KiK in 






.1^ 

I >.M\ I 



A 



J .A^ Y V, v.' 



n I. 
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itik I iipi. My 
<»!■ I \ n'n-'K ■ 

IStMi 



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MAIlHiN \\M, 
<»I MoTlli;,. 



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''.'•' ^^"■|•|lI•:k' 

''^*'"' " <"'MlIltl\ 




1 III:KI;I1\- ti;R'ril-V. That I attin.K-.Mi. ,,isc,l In-m 
lip'' to -l)JL.'|a' , u,,, ; 

tliMt I last saw li ali\<.-(iii ti/O . 

ami that ilratli MCcMiircd, on the dat*.' s(atr<l ahiivi\ at 
M. 'I' he CAISP; OI- niv ATI! was ;,>< follnus: 

^'- • ■ ■ 

I >l RATION }\i!rs Months Days 1 louts 

CONTKir.ri'dkN' 



DIRATION Years Months /hns Ilour^ 

(Signed) jL II. ■ • M.D. 



■. i I()0 



( 





Il^slC^ a.;- 



A(Mivss) 3)0 5 rJA.A..tLA' it, 



Special Information <>nly for Hosplfals, institutions, fransients, 
or Recent Residents, iinil persons dying dwdy from home. 



) , 



M.^Hilr 






IKn 



ri<: To TM !•; 



Former or 
L'suiil Residence 

When was disease (onfrnt fed, 
If not a\ plare of death ? 



How long <i( 
Plare of Death ? 



Davs 






)a^J.1x\; 



l'I,ACI': Ol' lUKlAI, OK K 1-;M< >\A1, I KAl'i;.!! Itt ui.Ai, or K i; Mt i\' A I, 

C' ■ ;loL ■, I '^M<^ ^^ 190 

'' ^1 A Ml 



J3a»-J 



1^ '-'^^^^^^^'^^^^m^^mm^^a^mm^^^^mmmmmmmm^mmmmi^^^am^im^mim^m^^^mm^^rw^m^^^mtammmmmm^^^^m^i^i^^^^mammi^^^^^^^^^^^^^^^^^^^^^ 

^very Item otf Informiition shourd be cnrofiilly Hupplied. AGB Hhould be «tiite«l HXACTLY. PHYSICIANS Nhuuid 
so ^'^rf^f ^^*^^* OP DHATH in pinin terms, that it mjiy be properly clasHilTlctl. The "Speciul iiiltormation" for p«r- 
'^n* rtylnft away from home Hhoulcl be ^iven In avcry inntance. 



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ll, ,),), 1 v,, - *-*j5^3 MX:!' (. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/y.^/r AV/r^/, GjL.Utjy>^A.LjcA- :i5 



I!JO\ 



M / 



llegisfei'ed J\^o. 



3 



•A.M^.<v.U' 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of E)catb 

( U. 55. tritnnc>arD ) 

J? Q^ -^ ^ 

PLACE OF DEATH: — County of Ja>rx. vL^.a.-rvo,^.c City of f^'<X^v •JXa.-k 



No. 



HH 



St.; 



M>1 

Dist.; bet. 1 ' ^ 



V^NLA.-Crv\,' 



and 




V. '.^- V <) 



nv' 



. 1 '■ ,^ 



(ir oe»TM OCCU»»S AW«V rPOM USUAL R E S I DE NC E Gl V t FACTS called for under "special INFORMATION" N 
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 






FULL NAME 



L 



1 



vL'XV-i/TvA C. 



PERSONAL AND STATISTICAL PARTICULARS 



I 



1 



1 1-. I 




I>.1V 



MEDICAL CERTIFICATE OF DEATH 

DAii-; <>i' i>i:.\rn 



(Motifli) 'I)a\t iN'car'l 

I III-.K i;i'.\' C"i;kTII"V. That I atteiuKd -Uccasr.l Iimhi 



I (p ; 



ll 



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' ' i.i- \i \K u n: i» 

' I ii' >\VI- I I < Ik I»!\-( |i- ID 

■ ■ . .11 I 



iii'r.M'i*. 

• It r. milt I V 




W^cd 



\ \ \! 1 ( . ! 
1 \ I II 1 \< 



I''IK1!IIM,\(}.- 

'I t'limtrvi 






til at I last saw h alive »>ii ^i^*.> 



l(;0 
!i)0 



aii-1 that <K-ath ocfiinrd, <iii tin- ilatc '-tati-ii ahovc. at <• 
-' M. 'I'Ir' CAI SI' Ol- |)i;.\'l'II was as follows; 



MM1»I \ \\M1 

"' M'iriii-:K 



HIH riii'i.ACi.: 



I i"i ^ 

LL V > 1 






.b :vi....\:\..'. ' ' ' ■ ' - 

DC RATION }'riirs 

CoNTRIUr'IOKV 



U-^Vv^vo.^ 



Mouths 



Dnv 



//ours 



DC RATION 



f SIGNED ) 



Wars 



Months 



/'>a vs 



\ 



\ 



.A, 



1_ 



I()0 , 



( 



A.Mri^sO UXcIj. ^\ K.O..y 



//ours 
M.D. 






1 



M..„ih- 



I \: 1 



SPECIAL Information ""'y f'"" Hospitals, institutions, Trdnsifnts, 
or Recent Residents, dnd persons dvin;) dwdv from fiome. 



Former or 
UsudI Residence 

When wds disease contrarfed. 
If not at place of deatfi? 



IfoH long at 
Place ol Deatli ? 



Odv> 



I '"•■ \lt''VI'. S|\I|.I» I'HUSONAI, I'AKTirrLXKS A K l", J-Kt )■ T' • riN- 

"'.^1 or Mv K.\«»\\ i.j.DCH AM) Mi:i.n:i- 



'''if')Tniaii( 






< N.I.JKss 



ll 

t 



DAT'-' •'■ I!' HiAl ni \i ):M( )\A1, 

TQO 



I'l.ACK Ol- nrKIAI, ()U Ki;%T<»\AI, 



N. H.— hvery Item of 1„for.n„tlon .houl.l be cnrefully Kupplied. ACIB «houl.l l.c «t«tcMl KXACTLY. PHYSICIANS nhould 
-tatc CAUSE OF DEATH In plain terms, th«t it m»y be properly clo8«iflcd. The Special Informat.on for p-r- 
«on« dylnft away from home Hhould be ftivcn in every InHtance. 



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-. i:\ If. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/;.//r /-V/r//, dX^UljL^A^WA; Sib 



/!/0\ 



Hegisttn-rd J\'*o, 



1884 



^VL^.• 



Deputy Health Officer 



D[PARTI^ENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcttiflcatc of iDcath 

( "CL S. i^'t^n^al•^ ■ 



c\ 



PLACE OF DEATH: — County ofV'a^v O/va^^ <^t ^ (-' City of U,a-v\ 



3 



Q^ 






N<x H I . ^ v.^*.. 



St.; Dist.; bet. 



and 



(IF DEATH OCCURS AW«V THOM USUAL RESIDENCE GIVE FACTS CALLED COR UNDER "SPECIAL INFORMATION ' \ 
ir nraTH OCCURBID IN A m. <-r. ;tb, no 'NS-'TJTION GIVE ITS NAME tN'^Trar, ->r ^TRfFT AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 









^ 



I 

i- 



MEDICAL CERTIFICATE OF DEATH 



f)h 



nj' 




a,u 



\\ 



M 






1^ 




a 






'-al-V\A.' 



tli.-it 1 ! i-t - iw li 

\i. Till I. \ ' " 



; 1 i I \ 



wi-- ,(■ 



^ 



c 



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\ 



1 1 1 U \ T 1 < > N 



) \ ars 



M(>>it/if; 



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!St. 



r 1/ 



DIk \T!( 'X 



) \ illS 



/hiv 



\C) 



\J. ^-A. ■|3JLa>b 



^.-L. 



Signed \j. .v. yvJ.^-^^- w v^^^^ 

CjJfvl .-'l rpo'i ^ \.].lnss) Ilia XO-L; 



M.D. 



'N 




h'r:i,ir-l III 



C^-^-ul^c^^Il 



ir 



Special Information ""'> f*"" Hospitdis, institutions, frdnsicnts, 

or R»-(ent Residents, dm! persons dyinj <ivv.<v froTi homp. 

Hit'.s lonq <it . . 

cue ot Dfdtli? loJ, n.i\s 



fiirmt-r or 

L'sudI Rfsidrnrr ^ 

Wfir'H WHS diseasf (ontr.irtpij, 
It not .it pLiicnf dcitfi ? 



'\XXS^ 



'''•^1 ••!• MV K\n\vi.i:i>.,i.; \m, 



I iiT!. \K-, \Ki: iKii-: 1' » I'm; 



^X'l.ln.v. H'J.'X 



VJ (Hltj 



Ot 






i> \;j • 



I Ml 1,1 



A ^1 



U^l^t I'l IQOH 



Htntc CAUSi: Oi: niZATII In pl..M, Urms. thnl it mny he property dnnnhicd. The Spc.u.! InVormut.on ^or per- 
R'>»i« tlyJnft nwny from hoin« hIiouI(1 he Jiiven in c%ery instnnce. 






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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I «!«—»W^— » ■ ■ —1. 1 M 



/^/^ ///rv/. . ) A/i-A^JL/y^ v,^^X^) Oi^t) 






i 



Deputy Heaiih Officer 



llC^i sf ''!'((/ .Yd, 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of H)eath 



r 



11. S. 5tnn^.llC> 
(to 



^^ 



>"^ 



PLACE OF DEATH: — County of ^a^v \a>,vc>LCicc City of ' 'a>v OXa\xcu.C^. 



N;. 



.-. >vea^ 




^1 



VJCy^i\A. 



Ic 



St.; 



Dlst.; bet. 



and 



/ ; rrATM occuB«iJAW*v rPOM USUAL RESIDENCE Givr facts callfd for uNotR "special information \ 

V If DfATH OrcURRlO IN A HOSPITAL OR INSTITUT'-, ■ . ■ : r t-; NAME INSTFAO OF STREET AND NUMBER. J 



FULL NAME 



4 



^WatuXa> Lu.^-.K; 



PERSONAL AND STATISTICAL PARTICULARS 



' ';.' 'K 



nvcL'U 



^ 



I 



I rioA. 



IM 



ii ^ 



MEDICAL CERTIFICATE OF DEATH 

. itl \i II 

\ INK l,l;\' '. : Kii 1 \. rii:it_ ' •• ' ' 






\! \ « u I J- ; 



WIRT! 







1 l:,i! 1 \\\^\ -:iu II 

.III'! I II ' ' ■ ■ ' il'c li I ! 



. I i i V < ■HI 



cJ-t/^-vi 'JiH 



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-l;ilr<i 



(?x.^ 



M. I !ic ('.\r^i. • »i- i ti, \ I I 



lOI |i lU s 



O.. 



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I 111- k 

< I", .,1 1 



1 l: 






IHKTHIM, \. I 
"t "MTHl.i.: 

''' *.'i>UI,t 




6V<X 



M 



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III K \ Til >N )>,?/• 



o ? "* 



)l |.: \Ti' '\' 
SIG 



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M.nilln 



r,i 



/ /.'III s 

M.D. 









NED ) > ^9. WvtoO/.-^-'-- 

,,,,, ( A.i.lns.) kj%'h I a<..U. U,- '.' 

iliilioiis, fr.insients, 



SPECIAL INFORMATION <'n!y tor lli)S|»ildls, Ins! 
or Reienf Rfsidcnls, .ind persons (l>in| .m,iv fr«:ii hom«'. 

lormeror w,^,l^l. • Hou hn.Ht 



v^ 



U;. 'r '• 



' I'l.K f ol Dcdth ? 



D,ivs 



'■' ' '" '' • 1 n:->wi,i-;i),,j, a\!> /ii:i,ij,1' 

OJJU^a \. 



-.'.■,... 4 11 




Wlicn W.1S (llscHsr (ontrdiN, 
II not at piiKcof (liHfti? 



i-i, \rj'. 1 1 



I I'.r K lAi, ' '!•: i' 1 ^^ 




DA 




A.:" 



M< )\' \ I. 



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v<X 



'-]t. 






««"te GAlISr: or- nrXTH i., ..h.in Icr.nH. that It m:.y ... ...-PLriy JusM^'icf. The Spc..a. Inio..nni..n ,or p-r 

^on* <lyin4 uway from home hIioiiI«I I»c jiivcn in every inHt.iricc. 



; 






; 

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ii 



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ii i 



M 



I! ; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANEINT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



JirjJ/.yfcfrf/ ..\"o. 



1886 



DEPARTMENT OF PUBLIC HEALTH-Clty and County of San Francisco 

Certificate of IDeatb 

4 '^ J? 



PLACE OF DEATH: — County of a>\ J VclivccsXCO City of'-'-O-^^-' \cnvaui,?o 



N 



1 ■ - '\' If 1r ' 

JX' St.; : Dist.ibct. ■-'•V.Uoxft'.'. .andvV.->.' 

/ ! Ot»TH OCCURS AVW*V FROM USUAL RESIDENCE GIVE FACTS CAIltD FOH UNDER "SPECIAL IN FORM AT ION" \ 
V It fif.TM OCCUHRtC IN A H"'^''TAL OH INSTITUTION GIVE ITS NAME > N '- ■■ t a O OF STREET AND NUMBER. / 

— ] 



K 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



I) 



.\< \ 



■> 



-Jf\l 



CX.L\ 



15 



MEDICAL CERTIFICATE OF DEATH 



1' \ 



' >! i •! \TII \ 

* 

!! ! is ! |;\ < \_:i \ l\'\ 



^ 



H 



M AK 

1 1 f > (■ 



^ 



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V. 



LoXu 



(XV^^^'v 



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Ill u \ IK ».\ ) ;•(//■>• 

ir,ir< )i^\' 



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( 1 1 \» . .1 1 • .- , , 



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SIG 



JA ".•/•; 



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NED ■ LoV^^aXV vl U). U/'. i,^ 



M.D. 



I < )' 1 



SPECIAL INFORMATION ""'^ '"^ llospil.ih. InstilirtiWv. Ininsinils, 
or Rnrnl Ri-sidcnls, .iiid prrsons dwn:| .m.iy f(o;ii hone. 



i^A. ' 




former or 
Isri.il Rcsidrnre 

When WHS discisf (onfr.rdfd, 
II no( .it lil.in" of dt'Htf) ? 



flow lonq .it 
PI,ru'ot llcifli.' 



|),is> 



Mi.f. 



Ill 111! 



\'l l"l» !■»• K' ^. .\ \ I, I' \i.; rici ; \|<s\KI I' r< i )•', I i » TIN 
\ ,1. Ni i\\ |,i;i), , i; \M , niiji 1- 






'N.M,,..s I'bHH J^Uvk Ot 



,., ■y^• |.; , ,1- lU KIM, < >K K I'M' '\ \ I. 



.AjVCUc ^<^^ 



I' \ 



-\ 



\!il' 






'. 1 



M' i\ \1, 



TQ'^ '» 



PHYSICIANS Hhoultl 
r pwr- 



Htntc CVlISi: or DLATII I,, „hn„ terms. ,h;.t H m:., •>-• P-M.oHy cU.s.h.cd. I he Spcul In^ornu.l.on 
sons flyinji iiwiiy from homo slioui<l he ai>en in e\cr> iiistniice. 



I 



I' 




.1 ! 



Yx 



i ' t. 



Ir 



!*tll 



I 






\\ 



iiiii^' 



«yjb.4 



—..rr 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



• •"^''i. 



■X ^-. H\ 1 I 



REKER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 



KK-anftMMSMHKMKaM 



/;,-■ / 



Deputy Health Officer 



7?^^i>'/.v/r/7v/ jXo, 






i 
DCi'ARTItlENT OF PUBLIC HEALTH-City and Countv of San Francisco 



I 1 



Lcvtificatc of Bcatb 

PLACE OF DEATH: — County ofO,Cf^v J/ux.'-i^-' City of ^'a/^\J J/\.a i\cu cc 

St.; D Dist.jbet. 'J ^tcaVu and W/ClCLV^^.O.. 



No. I'-^ib 



I 



/ r r>t»TM orcuRS *\A«y rpow USUAL R E S I D E NC E Cii vr facts called for undcA "special information \ 

V IF nFATM or -..CR, D ,1^ ^ H-' ' ' ". • -r- INSTITUTION GIVE ITS NAME INSTEAD oIq STREET AND NUMBER. / 

FULL NAME IiIllIc-v., 1 I'v '. 



PERSONAL AND STATISTICAL PARTICULARS 



1 1 ' ; I p Iv \ 



L' 



L,K^U. 



,n 



H 



MEDICAL CERTIFICATE OF DEATH 






' r 



1 1 r i 



^'ff 



! ( i< I \ 



U-\.V\l 



^^ 



A 



i 






r\ I 



(5*V>VUX 



1 HKk 

I l"..!inl 



M 



V 



tll.it f l;i-.! 



Ml 






It! Di-. ATM u 



h! I< \Tln\ IH }; ,//-s- 



r(i\!!xir.i r(iu\ 



.]A •;////< 



/',/! 



I loin 



hi K \ r 1 ' » \ 



u'y s 



.V'"/ 



•■/ V 



/'./l- 



"IKTlflM 

( p! 1.. , , , . 



a 



tU.: 



^"^^m^^.^ 



i 



>va'V''^ 



^ a\\xA^ 



Signed ^ ^ 



lOi 



M.D. 



cL 



\.M,v..iUi(o UJ'a.oJu.Nv^u,. ■ 



SPECIAL INFORMATION ""H tor llospit 
nr Rcicnl RcsiJenfs, .iiiil persons dying .iM,iy Inni honic. 



,ils, Institiifiiins, Transients 




IW'sT 



'•-■< i\ \ I. 1' \ K ri'-I 1, \Rs \U I. I'K! )■: I'll liil' 



'inr 



!ii:ii,i 



^ K\( l\\ 1,1:1 )( ,). \M, 1;,; I ;, j. 



\A 



''•-^ •H'^b V](sit a I 



Formrr or 
I'siidl Rcsidfnrp 

Wlipn Hds discisc fonlrdrfcd, 
if not at pl<i( e of dcntti ? 



lloH lonij .it 
f'l<)(('ol Dr.ifti* 



n.i\s 



, \,i I 1' ::> ! : \ I -' \i !■ M< '■ \ 1, 





'..I 



i'l.Ai'i' or niki \i. Ill-; ! . 



iqn 



\ iH.K I' \K M- 



N. U. 



^tnlc CAllSI. OP niAT.I 1„ ,.|,.i„ ,...„.. thnt it m:..v ... p.-M.crl.v J..sshlc.l. I he Sp.cu.l hno.iu.t .on h.r p-r- 
son* (Iji,,,^ iiwjiy from homo shotild he ftivon in c%cr> insliincc. 



-li 



■ I 



' I 



^\ 



\ 



:;!« 









1! 



'I 

If 



t ( 



M 



ilNWBiw 




■^ 



Hi 



'.i ' I 



^■ 




wrmCT 

i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



t 1! :<.U)) \- X. 



IkS: 1' (• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Be<!i\slei'ed .jYo, 



1888 



Dale /•V/'v/.OXJAXt^roJjJiA/ lb l'->0'\ 

ifrvc^ llAH^ °®P"*y Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Cci'tificatc of Beatb 

( Xl. S. StanCatJ ) 



PLACE OF DEATH: — County of 




City of "^J I Let 




Q- 



'^\ 



No. - 



St.; 



Dist.;bet. 



and 



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



V^ 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



r< »i,( ik 



\ h 



!l 



1 1 v^a... 



D.iV 



^iN«.i,i*. mauuij:i» 



!!iH rni'i. \ 'I' 

■ S< -1 • , , .. 1 



! 'Ill IK 



MEDICAL CERTIFICATE OF DEATH 

I) A riv Ml hi. \ I II 1 

MmiiHiI r 'Dmv) (V( ai ) 

I IIi:ki;r.V Cl'irril'V. TImI I attniMr.l .Icc^.i^cd fn.ni 

I9O to ..— ^ : ■ 



t!);it I last s.iw h ~ aIi\coii 



•IC)0 
1 90 



ind that (Itatli occurred, on tin- date slated a1)ovr, at 
M. 'I lie CAISI'; OI" I)i: \ril was as follows 



r'/ 



lUk Tli !'!. \. !•: 

■ • ■ \ii!i:iv' 

■ 't *'• 111 n! ! \ 



^'^ \Mi-; 

•TH I. i< 









IX K \'l"I(tN 



)'i'(ii s 



• lA '/////.' 



/>ins 



//did s 



c'o.NTR ini'iom' 



hlR Ai'h >\ 



( Signed 



) '< (IIS 



Moi!//ls 



Pa 



L 




rv 



\. 



-.J-Ci V 



I X 



[(/I 



{ 



.\ddn>;s)lA. i.Vl. d '..ViviVA 



M.D. 



Special Information only for Hospitdis, insiituiions, rrdosicnis, 

or Rcrrnt Resid'-iits, and persons dyinj .m<iy from ftnme. 






1/../'/// 



' "',,,^'!'.'^'''' "^'''\I"»-.I> I'KUSoXM, l'\k ri.TI.AKS AKI' \-\<\ V. l* ) TUl 



fliif' •iti.'iiil 






Former or 
L'siial Rfsidcnce 

Wlipn was (iispHsr ronfrricffd, 
If nol rit plare of dPrith ? 



How lonq at 
Plare of Dcdtli ? 



f)<ivs 



>. »'.. 



I'F,.\0': ()!■■ IMRI.Nr, oi; Kj;M<t\\I. i)\JI..,; l!i'i\i .,1 Kl-"M(i\\I 
A . . ,. N ' A I -K 



CWJl^.P U: 



rM)i:RT.\Ki:R 



iL J.0 



-Hvcry item oil informjition HlvMild \^^ cfiruV'uIfy supplivMl. A<;n hSoiiM he stntecl HWCTLY. PHYSICIANS Hhoiild 
«tnte CMJSh OF- DliATH in pliiin terms, th.-it It msiy he propt^i'ly cluKsh'ied. The "Special Int'orination" (for p«r- 
"onu dylnji nwny from homo should he ftiven ifi M\ery instnnce. 



! 1 



5 



' ( 



\\ 



I 



f 






'♦1 



I 



r 



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if 



< !l 



I 



.-•JN*^ 



M^fT -j|^ 1 l^^i 






W \ \ f) 







L.ili 



I 



H 



i| 



r fkr 




IS 



^.i": 



t>i 



f^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



\" 



f^t"*n^. 



"■ ~ !;.S:r r 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Xtr^cv^ xjUmj Deputy; .-...m Officer 

DEPARTItlENT OF PUBLIC HEALTtl=Cify and County of San Francisco 

Certificate of 3entb 

PLACE OF DEATH: — County oiVi(Xy\i 0,\.aA\ouicc City of O.iX'Tvj -J ;va'VvCA^•e<^ 



I 




( 




N«.H I Lt) . at NLtnU^lJi-U lU-Lllu ^ , V St.: 



Dist.; bet. 



and 



ATH OcduRS AWAV rROIVM USUAL RESIDENCE GIVE facts CALLtO FOR UNDER SPECIAL INFORMATION ' ' \ 
DEATH OCCURRED IN A MoSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 



FULL NAME 



i-uilxb 



.)\(^ 



PERSONAL A.ND STATISTICAL PARTICULARS 



-i \ 



(^ 



ri ll,< »k \ A 



ill 



u.ka 



t 



uxl\t 

\T..;it|| I 






\' ■ !•; 



! 



l^ 



-INi.I.I' M \KK HI) 

W! !>< >V\T1> < »R I);\i .1' ID 



HiuriiiM, \vM-; 

^t:itt (.1 (■.Hint r \- • 



\ \ M 1 « I! 
1 \ 111 IK 



"' I \ I'll i-:i< 



^ \ M i; 

"1 ^:> 1 1 111 K 



I'-iu rii I'l.Ati.; 

< M Ml iTl Ilk 



'" ' ' I' \ 1 N ),\ 






(h 



MEDICAL CERTIFICATE OF DEATH 

1) A ri', ( >! !>i-; \iii 

UxUt %! roo H 

'M'>nth' n):ivt 'Vc;ii ) 

n I III;K1;I:N' ti:U'ri|-\-, TlMt I altcHiK-.I .Icirasotl fp.M, 

Itp'l to O^i'^xL .%'.^^ T,,o . 

that I last v,;i\v Ii '^* aIi\T<)ii 0-C^vt X'.>. kj,, 

ami tliat 'It a!!i .KTinml, on (lu- dalr s(att.<l ahovt', at 



M.. Thr CWISK ()!■ I)i:.\'ril was as follows: 

Ccitvo t^A.U,njL.t< 



. W) 



hi kA'llON 



) '('(//• 



Months 4 PiUs Hours 



IHl^JA'IloN 

( Signed ) 



^-^ 

\j^' 



) '( 'US 

It 




Mo 'litis 



fhn 



dilvt ..... 



it)') k 



\.li!ivss)V.l\.^J\. ^^\l U.tf. U .' 



//ours 

M.D. 



SPECIAL INFORMATION "iily for llos|)if,ils, liistiJulions. iMnsients. 
or Kt'iciil Kt'siilciils. 111111 persons dyini <ih<(v from fionic. 



AV' ■ 1,1, ,i ; ,/ S',;/' / ; ,; ,,, ! •< i> 



)■-■,( 



\' 



•>ltll, I '\ lht\ V 



I III VHOVI. ST.\T|.:im'KKn()\m, i.xKii,TI.\Ks \kl TKI 1 T. > T 

'•'.^i «>i' ^l^■ KN'owij'.Dc iv AM) Hi:i,ii:i' 



'I'f ' iiiaiit 



\ l.li 



\ 



rormcr or 
UsUiil KVsidfiifp 

Wlipn w.is (lispdsp (onfr.irlcd, 
If not ,it ()i<t( (' of dcitfi ? 



lloM long <it 
f'l.Mf of ncith? 



Days 



■I, \<'V. ()!• I'.lk l.\ I, I )k I-; I'.Mt >\ .\I, 

T 




^■Cl'u.i 



It 



%.LG 



,\.'(VA'l 



,.y 



' ixl..M(i\ Al, 



■M.l.kT.lKl.-.K J^XIIXU '\L OU 



(.\.!.;i 



Oxipt XI 190' 






N. ». fivepy Item oV inlt.>rmnt loti Nhotild I)- ciirufiilly supplied. AGH Hhoul.l bo «t«te»l I.V ACTLY. PHYSICIANS Hlvmld 
Htntc C.AllSI: OP DliATH in plain terms, that it may be properly cluHMilficii. The '*Si)ecial Informalinn" iur p«#r- 
«on« (lyiniJ "way from homo should be Jiiven in every inHtance. 



( <!, 



\ 



'I 



< I 
I 

I 






I 1 



I' 



I 



I f 



till 



h-, 



{[ 



I 1 






ifci^^" 



u 





w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD -fp^ 



Hoard of Ilfiilih l \i. i 



nSi\' (• 



REFER TO BACK OF CERTIFICATE FOR INSTRurTir>lM« 



/)(//r r//rf/, e)x 





.vje/v Hd 



1!)()'\ 



Registrred .jYo, 



J890 



va^va) dJUM.| Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eath 

I 11. 5. ir>tanC>arC> j 
PLACE OF DEATH; — County of OCL>\;0x<X.->vCv4cc City of a "v^ A^Ou>xo^ c-<. 



rtr>. 






,OL\.Ln\ A) ^\i;\ L V'^, ' St.; 

AY FROM VjSUAL 



kd- 



\ 



Dist.; bet. 



and 



/ ir DEATH OCCURS AWAY FROM Vj S U A L RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \ 
V \f DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



Lck-a. lb, VbxL' 



^i-: \ 



i)\ 1 



PERSONAL AND STATISTICAL PARTICULARS 

A r()i(iK 



^x_: 



\ 



.OJLk 

•MMtitli) 



*7 
t 



MEDICAL CERTIFICATE OF DEATH 

I) \1"1'; (»!• Di: ATM 



oxkt 

■ Montli) 



(Vtiir 



\< . !•: 



It. 



a, 



i !>« 'W 1- I) « •« I»l\tiKri:i) 



i 1'!, N.-1-: 

^11 III I \- ■ 





1^ 



N"\M|- <»i 

I A I" II I.K 



'1 iv 1 ii li. \r I-- 
Ol- I-AIIIl-K 



M \!1M:N NAMl- 
"1 M<)Tni:K 



'"!■' ! ill'l.ACl- 

1 ^'Diiiiti y) 










^voL'dL 



(Day) 
j Hi;ki:i;\- C"i:irr!I'\', 'I'liat, l alUMi-U-.l <lc(x-asr.l fn.iii 

lliat I la^t saw li .:. . . alivt' on OXyxt .• i H)o'\ 

aii<l that (katli orcu rrt'il, on tlic dalr sta((.-<l ahow, af oL 

^ M. 'I'Ik- CMS!'; Ol" I)i:.\TII was a^ follows- 





ll 



KCKJUy^n^A.'Z 



V.Os. 



I )!' RATION' )',\irs 

CONTUimroR V 







i! 



ly 







% 




Miuit/is I ' Pax 



//. 



(>/()S 



I>I !>: ATION 
( SIGNED ) 



)'i'ani t 

I 



V vV. vviA.o..Ci-: 



Mivit/is 



I , 



/^<71 



'.V 



Vn^Vu! 



.tfcLi 



.i'^'ii< 



-? 



M.D. 



6X^^ :XS r„o^ I \,l,!,v.s) SM? CjAdLv 



Special INFORIVIATION only for Hospitd's, inslifiilions, Transients, 
or RfTcnt Residents, .mil persons dyini .iwdv tro:n liome. 



Former or 



Isii.il Residence blH CjXlOJA) 



it 



U,.,////. 



IM. \i;.,\l.; ST \Yi:i. 1- c: R s. )\ A I, 1'\K rirtLAK:^ A l< I ; TKl): To Tlli: 

"ivM '>i ■^^^■ k x«»\\i,i;i)( .}•; and r.i-:iji:i'" 



How lonq .it ^ ^ 

PIdreof Dedlli? i'l Ddys 



When vvds disc»ise ronfrdrted, 
if not dt pld( e of dedtli ? 



Oiif,, ,„.,,, t 






I'LAcr; n|- iifi-; fai, ok ri-'.mi >v \i. 



\ 



da;j"i' •.;" laiM \i, .11 K i;m( )\ai. 



lx\ 



\^ ^b 



I \I)i:kiaki:r 






■N. n. F.very item otf itif »rmiit ion «hr»tilil be cnrct'iilly supplied. \<H. Hhould bo Htiited I.WCTLY. PHYSICIANS should 
stntc CAUSI- Op DliATH in plain terms, tluit it msiy be pr(»pcrly classilfied. The "Spccinl Informjiti'm" for p«r- 
Ron« dyln^ uwny from homo should be jjiven in every instnnce. 



!■■ i 



II 




J 

r: 



r 



' I 



r 



' 



'i; 






'} 



ill 



I 



i ) 



hi 



t-ii 



li 



•■4. 



m^h^ 






•« w ntT 



Tfl 



I 



^1 



', t 



>l 



I *t,'i.i 



tl 




I 



r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






r I •! 



REFER TO BACK OP rFRTirir.flTr FOB I N QTDi i/--ri/Mue 



f)f 



ffr n/i'^L OJLKtlAvUMA; aio 





//y^^v'H 



lici^istcfed ^Vo. 



im\ 



Deputy Health OfTicer 



DEPARTflEM Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of 3catl) 



PLACE OF DEATH: — County 



nty of \l ' 



LQ/ 



City of A,tr 




ft 






No. 



St.: 



Dist.; bet. 



-and 



/ IF DEATH OCCURS flWAY 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 ) 

Ha. I) :7^ 



FULL NAME 




\ 



a.v 



n 



% 



A.!'., . 



PERSONAL AND STATISTICAL PARTICULARS 

!< ill 



/fc 



^ 



rihEDICAL CERTIFICATE OF DEATH 



!> \ ri' I >! I M \ 



3 x}(<kj 

V ■•••'■ 



N'; 11 



M..i!th' 



!> i\ 



b^ 



■^INt.!.!-;. MARK Il'I* 



IS!lvrMJ'I,\OK 

<!..t, .,i- (',,,Ilitt\- 



•Mi ( i: 
■- in i-.K 



niRTHI'I.M 1- 

'■'" ■ ■ riii;K 

■ i"iiiitt\ 






1 !> 



I III'RI'I'A' Cl.RiUN. That I alU'ii.U-.l .Ifrra^L-.l tn.m 

that I Ia-.t saw h aK\ i imi I(,,, 

ami that dralh (HTurreil. on the 'late ^tatnl ali<'\c, at 
M. '\'\\v CM SI-: ()!■■ I)I':.\Til was a- follows: 



ii.. 



\Xc^^\ , 






m RATION ) ■<■<;/, V 

(.'oNTKHUTnRV 



Motithi 



Pays 



Hon 



/ s 






"I- %;nTlMR 



l 



avu 



? 



DIRA'l'loN 

(Signed ) 



)'t t!rs 



M,^>nl,s 




• \ 



xX 



KlJ^O^ 



<»<^'cri A ri«)x 






1 



M.D. 



Special Information ""Iv f'" Hospiidis, institutions, ininsifnts, 

(tr Reiffil Ri'sidenfs. m^ persons ihinj awdv from tiome. 



Mutli- 



n,'\ 



'•'-^1 <>!• M^- K\u\\i,i:i)c.j.: an;) iti:i,ii:i 



former or 
Usu.ll Rrsidcnre 






■\' 



How lonq at 
PIdre of DiMth ? 



D,ivs 



When was disedsp ronlr.Kfpd, 
If not <!f pld( p of dedfh ? 



)■ TK r I-; T' I 11! }■ 



IM Mil 




\.!,;i,ss b S "J) 




1 



'a.Li,^o 



t 



. ^ 



i'l.AO': Ol' I'.lRIAt, Ok ia;M<'\ Al, 



»Ai;i. <^•' r.I l-'l Al. nl K 1M(>\M. 

aJL :<h 






190 



N. B. Hvcpy item of inV'ormTition Nhoiild |,l- cnrci'iilly sur>F>luMl. ACT. should bo stiite«l HX \CTLY. PHYSICIANS Khoiild 

state CAIISI: OP Dl:A Til in pl.iin terms, thjit it mny I»l- properly cluHsificd. The "S;)ev;iul Informulion" for per- 
sons dylnji nwjiy from home should be ftiven in every instance. 



a 



'» 



! 



i 



m 



ii 



I 
I 

i « 

■| 






1 I 



• 







H 'I 



f! i| 



m 



i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i\< ; \ . 






REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



: 'r rih'fl, Qx\<kxy^y\ljJU\j IId 




u 




mo^ 



lle^i,s(i'i'e<l jYo. 



1 892 



i Deput ' 



«-, 



Officer 



DEPARTIWCNT OF PUBLIC l1EALTH=City and County of San Francisco 



Certificate of Bcatb 

-i '^ A '^ 

PLACE OF DEATH : — County of ' (X>v J/va^\CAACo City of 0,<X >v Kxxa^cca ^ ' 
No. T vI)xX>v^v<X-y-vv V St.; ' Dist.;bet. OAjLL^v and U.^ --• • - 

(IF DEATH OCCURS AW*r TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
IF nCATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 

FULL NAME ^J.^CL^x^t4x:o va^^^wtv-cx.U 



PERSONAL AND STATISTICAL PARTICULARS 

. oXx 



)i 



I I 111 >K \ 



MEDICAL CERTIFICATE OF DEATH 

i> \ I"). 1 1! i>i: \'ri! f 



M 






' 1 



n.iv 






I I) 



i'.l! 






((D 



I lll.l<l-.l!\ n U'ri!\, That ,1 ,itlcililr.Minr;iMM| li-.m 

t l!;it I Ills! -.,i\\ h . :ili\i' (III • , . ' ■ i(,i ) 

.111.1 I'l.it iK .illi ' )i'cii 1 ml, (MI !lu' <!afr statnl aliovr, at i 

LI M. TIk' C.\1 SI-: Ol" l>i;.\ril wa- as follou^: 

U ^ i i) 0? 1] 



vJ -CL<iX\^ CU-v'Lfv J Ji 



V 



\)\ \< \il( )\ 



1 II i.k 

• ruuiitr\i 



\ 






/hi\ s ' ••'. I h^nrs 



Vyj ,\.<i'^ v.'ol \A,<vl 



L<L-1w1XNJ\-l>. 



;;"■■ i?n 



! " TMi'i.An.; 

"i \'"!'ill'.R 

' I ' ■!! Ill 1 V I 






,CL/>vULCr' c 



DIlvlA rh)\ ^^ Vi 



(Signed ) 






I loji IS 



M.D. 



« *»j_^t '^o i„r;\ 



A.i.hvss) H5oVmfr>\A^a^_U '■ 




^ i'i( iX 

Kr i.h-,' in Sail I i ,ni, 



ft 



Special Information ""'v lor Hos|iii.»is, insiifuiions, ir.insien(s, 

or RcrenI Rcsiilcnls, (iiitl persons dyiiii dWiiy Iron liom*'. 



I I 



1 ■' 



I /'•••. ' 



Tlll^ AHOVK STMI-I, I'HUSON.M, |V\ K f ir I | \ K v, xk,, n" 

<)|. MS- k\m\vm;im'.|.; \\i, i!i,i,ii;i. 



i . 1 Mi 1: 



formrr or 
L'su.tl Rcsidcnrp 

WliPn was disfdsr roiilr.Klcd, 
If not (il pl.i((' ol dcith .' 



How Jonij (il 
Pl,i(f ol Or.illi ? 



Davs 



\.Mi 



..ss 1 



7) 



Oy>'VY\><X'»\j I 



U 



' 1 •' k 



\. I-: I 11' IK I-: I \ I, < '!•; !• I '«;i 'v \ 



1 1 \ I 






I' i;m< t\ \i, 
?^ b 1 00 S 



cAyw-o 



»j*«"i»-"*» ^i« 



N. B. livery item oV iiii'.rmn ion hHouIcI Ik- ciii'o»'iiM.v s.ippIkmI. AfiK ^h >.iltl ho Htiite.! I'.WGTI.Y. PIIVSICIANS Hhoiiltl 

HtHtc CAIISi: or DliX I'll l,, ,,|„i„ umiK, thjit it mny l.o |,r.,,.cri> . laMHiiictl. The "Spcciiil liDforunili )n" Ifor p«r- 
son« (lyhm iiwny from homo Khotihl he liivcn in o\ory iiiHlnnce. 



\ 






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J! 



I ' 



'I 

i 






f f if, 



1 






ir 



ij I 



lii I 




»Jfc'^ 




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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



V o , I '. 






ijftr (• 



REFER TO BACK OF CERTIFICATE FOR lNSTRur.TinN<5 




Be(^i,sf (!•('(/ jYo. 



J893 



C-LA.^^ cLtuii Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Gcitificatc of Bcntb 

I "U. £♦. St a n On I ^ ) 

PLACE OF DEATH: — County ofQ/<Xnr\; O^XXt-vvc^OLC^ City of^J<X'>\> OAxXAacc^^i 
■ l'^*^ S .Uv St.; 1 Dist.;bet.N[ iV^'i^V.tiv and ob^VC^^ '^ 

/ ir DtATH OCCURS flWAY FROM USUAL RESIDENCE GIVE FACTS CALIED FOR UNDER "s'PECIAL INFORMATION ' ' \ 
V IF DTATH OCCURRtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 

0, A. /^ n 



V I 



A.- 



FULL NAME 



, r-' 



II U.cv. 



V 



PERSONAL AND STATISTICAL PARTICULARS 



^y\ o ' . 



MEDICAL CEI^TIFICATE OF DEATH 



/ '. 



M..l;tli^ 



1'^ 



9 



■u 







wn 






? 



I 



t li;it I l.ist ^;i\\ !i - — ,ili\ (, oil 
.iiiil ! hat dc i1 li (iccii ncii, > 'ii t In 



! I (\ ' 

1' It'll I lf(\ .|SC( I I I 111 
I ( )0 



.tat<' I a!ii:\,, ,|t 



oiv^c^-' 



M. Till C Ai <!■: (»|. |)| \ Til u 



1-- ,\'' I' .'I 1' i'.S ' 



I 



<X y\A^ 6v>\Ll\/VLa, I th Juyy\ c\ ' 




! •! ■ ;-■ \ 1 K IN )\ai\s 



Mi^nths 






I lours 



) I RATION 



!;•■■ [ 







)'t'ai 



J^ /!)■ \ 



Mouth,^ 



fhiv 



Si 



GNED > L'CrVn^JLAj ].^h. LI. 



•Jk,«^v.C^ , 



f liUDS 

IVf.D. 



., .•-*— ( ^ *• •'■ *■ 1 1 )' > 



f .\l II 1 I I -.S ) wC V-'v 



- v^ I ^-* 



'v^ 



Special Information oniv lor iiospifdis, insiituifoits, iransipnis, 

It (Jt'icnl Rcvjil'-nts, .jii'l iiffMi'K fl.i'i) ,i'^,i\ friKii ho-nr. 



AV .■,/,,/ 



'; / 






1/ .-,'/,. 



/• 



FoitiifT or 
I'sii.il Ri'sidrnif 



:ic '^i / la .. 



llo'A Innt] .if 
l'l.n (' ul Dcil 



D.is^ 



Tiir M 



' i M\ KNOW I,).; I „•,).: AM) lU-JJl . 






Whrn w.n flKp.isp rnnlr.irh'fl, 
II not lit pl.nrot dt.ith .' 



I, \ci.: I II i:t!;i \l, t II' !• ! ■^!< <\' \l. 



'» \. n-' • ■' I! 



.K. t -v-V' 



m.i;kt.\|-.ir NftX'VnJ^ M ri 



\! ■.! l; IM< >\ \l, 
roo'i 



A.YV'^A^ 



N.B. 



-I.very item of Inform.itlon Hhotild I,- cnroViilly HupplIcMl. ACV, s!i.nilcl be Htiitcl f.X ACTLY. PJIYSICIANS Hhotihl 
•*tntc CMISi: or 1)1 ATII ill piniii terms, tluit it iiuiy lie p.'opcply LhiHsilficil. The "Spccin! Iiiforiiiiili-.n" li'or p«*r- 
son« flyinj^ nwuy from home nIiouIcI be ftiven in evory instHiicc. 



♦ I 

J 

I 



II ? 



i 



1 



j! 



I 



i. 



I I 



sf 



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i< 






il I 



,B»*«(^^ 



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M t' 




f ^ 



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r 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIPICATE FOR INSTRUCTIONS 



Ii,.:,I.! -! !!' • !'■ I'^'" !' '^^i^-i' Mv^l' <■' 



Ihf/r n/rfi, d^|\lxA>JLov lb ^'^O'i 



llcgistcred J\^o, 



._^ uc^ "^ 




1894 



i I'XMj Deputy Heaith Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Bcatb 

I "U. S. StanC>arC> ) 

PLACE OF DEATH: — County ofCWx' J.\XLv_C^c. - City of Oolyv O.^uCc -. 

i) i ^ I) P 

No. 'C UXA.tCa/^'V' .d^a , St.; Dist.;bct. v_ (XUj. /. and 

/ ir Dr»TH OCCUBS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLtD FOR UNDER "fePECIAL INFORMATION \ 
V If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 






FULL NAME ^K<x.^^zxA 



H 



I ,a 



PERSONAL AND STATISTICAL PARTICULARS 

I < 111 »k 



i'.IK 111 



iMotitli' 



);■,! 



Ll 



I );i \ i 



M-ulli 



MEDICAL CERTIFICATE OF DEATH 



DATK ()!• i)i;\rn 



'Montli) 



< I ).-i V 



I()n 



<■» ' .11 



IUi\ 



■-IN' I, J". MAKKIi:!) 
WIDOW j;n (iK Divn^rci I) 

'■ i 11 MHi;|l ll« MJ.'M.tt i< >II ) 



lUK'rm'i.At'K 

' St:i(i fir *"i 111 lit ! \- 



Ml c.f 

: M ) K 



n 



A' 




1 HI-:ki;!!N- IIIRTH'W 'I'hat I atUiKkMl .IcccmscI from 

1 90 to ..QxAaA' Q^vL K/D ' 

that I last saw h -a/aj alive 011 T90 

ami that drath (iC(Mirrc<l, on the date statnl abow, a1 
M. The CAlSlv ()!• l)i:.\TII was as follow^: 



'niM II I'l. \('v 

'" I \TIM-K 

' ' "' ' I Ml 111 I \ 






'UK iiii't.Mj.; 
*'>■ ^t<>'|•n|.:H' 







r\ 



\ V 



^<la' 



<■ \ 



I)rU.\'i'ION Years 

(.■oNTRllirTokN' 



DIK.XTloN Years 

f SIGNED ) 



Motiths 



Days 



Hours 



M,ni//i' 



/hjvs 



sr 



' *'"tinii\ 



a 



-\>XqC 




{ 

lt)0 



(]■ 






//oKr's 

M.D. 



Special information «"'> '"f^ Hospitdls, Inslitutfon^, Iransienfs, 
or Recent Residents, and persons dyinij dwdv from home. 



M.nilli^ 



I ',l\ 



"i-M <)]• ^l>:.K.\<>\vIJ•;IM,l.: AM) iii:i.ii:i- 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



rijACl-; nj- lUKIAL (»K K1;M(»V\I, I DXI:^-;.)! in kiai. or KKMOVAI. 



1 90 






i\.<lh. ^M> -k-^- y ' • 



• ». Kvery Item ai InformHtion should be cfirefully Hiipi>lie«l. MW. Hhoiiltl be stiite.l KXACTLY. PHYSICIANS Hhould 
«t"te CAUSE OF DIIATH in plain terms, thnt it msiy be pr<iperly classiltlcd. The "Special Information'' for p«r- 
«on« dyin^ away from home Hhould be ftiven in 9\cry inntance. 



\\.' 



i 



.»j 



I ' 



') »• 



^ 



ii 



li 



f 

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i< 



iiibtilJ \i \ \ \ 






^'^■ T.- 






I 



I Jfcti-CL'.i* T"7"^4^^^* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nn:n,!..f M M'lti I' Vo '= t'-^'^-i: US. V ( 



/^.//r /vAv/, dx'^xtA/^-^vlJL>v lb / fWi Registered JSTo, J P05 

Uvo^ Wh^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTIl-City and County of San Francisco 

Certificate of IDeatb 

( XX, S. 5tnnc>arD ) 



PLACE OF DEATH: — County ofO CL^v 0.\a>\cuic<. City of 'J.<X>\< J;>.x^> 



vCui^CL 



N 



o. 'Xh \ 




^ > \XKl\ 



St.; 



Dist.; bet. ^XK)\. 



) , ..c ^v , . 



md \l A. v.. 



/ ir DEATH OCCURS AW«V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 

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



FULL NAME ^^ LLLl v 



V, i '\ 



PERSONAL AND STATISTICAL PARTICULARS 



\Y. xu 



i;iK I II 




ac 



ll 



/'ICH 



M..Mtll 



I):i\ ' 



'■»'<;•: I 



MEDICAL CERTIFICATE OF DEATH 

li \ 11, < •! 1)1. \ 111 



4 



")' 



Day) '^■t•;^Il 




) , 



H „,„„ ^ 



■^iNf.M-: M \KI< Il-I) 
U!!»fi\VFii OR d;',-. >k* i:i» 

:i;tt ii>ti ' 









I m-:Ki:i!\- ci-:rtii-\-, Th.it i ;itti-ii.K-<i (k■^•l^'l'^^.I fi.-m 

190H t.i • '1 ' A I icp H 

that I last saw li - ali\( (»ii I90' 

ami that (Kath orciirrod, mi the <latr stali-i] ahr)VL', at t 
I 

.M. Tin- CAISI-; <)l' Dl'ATIl was as follows; 



I! IK 



nikiiiii \y y 
"' I iii-.k 

'"'■mittv 



10 



c 

\ 




M \. 



10 



<Xy^\. 



AA.C.Cnx<lL>\' 



-^CL^^ 



1)1 K A rioN }'rars 

CON ^RIl;l"!■nl<V 



J^v////9 n /hiys 



Hon I 



. ^ ■, 



\MI. 



Ill U 







u 




'] 1 



I)IK.\TI(t.\ 



),,// 



M.>>l!lis 



/hlV^ 



mil 



l'\l!()\ 



^A^ 



uv. 



dyJXKx.'^ 



<x 



(Signed ) L^ . L. ^nI t Ur', 



M.D. 



^ ^\xl 



U 



AV. /,/,'/ /„ v,,„ /,,,„, ,,,,, 



, ,;; V 1 .\f.,„tli' L /' 



Special information "nly (or llospildls, Insfitutions, fransienh, 
or Rf(pnf R('si(I»-nts, .jnd persons dying dwdv from homf. 



"'•^» <>!• MS K\(.ui,i:i)(,i.: ANi> mi-;m);i. 

iOj 



I I-; i'< I 111 !■; 



4 \ 



former or 
Usurfl Rpsidemr 

When HdS disPdsr (onlrdded, 
II not dt pld(e of drdth? 



How long dl 
PIdf e of Dfdth ? 



Days 



|).\ Ti; m! Hi m.^r. >ii KI'.MoX' \l, 

OJllvfc 



'pX %\ 






l'l,,\CI-: Ol" lUKIAI. <»K Ki;M(t\\I, 

INI) J-: K T .\ K J •: K ■ i)x.^ > \^^\Xhj a vv<^ ^L <. v,^-> vt 



T90H 



N. B F. 



i^ 



^ery Item of •..iiform»tion •houl.l he cirefiilly Hupplic-d. A(U. Kh.n.lil be Ht.ite.l EXACTLY. PHYSICIANS Khould 
•*tiitc CAUSf: or DLATH in plain terms, that it mii> he properly claHslfied. The "Special Inltormation" for p«r- 
""ns dyinft away from home Hhould he ftiven in every inHtance. 



II 




f 



» 



I . 

*: 

I 









1 



y 






!: 



f I 



J 



il 
> It. 




1% 



jtM 





I' 



li 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lS<>;i; 



III . : I I I I 



r N. 



■fr-- -sr -^i; 15^: P Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Iipo^isfe/'ed jYo, 



1896 



lX.^<.o(-^ „'-.■.,' u Deputy Heaith Off] 

DEPARTMENT OF PUBLIC HEALTH=Cit) and County of San Francisco 



cer 



Gcvtiticatc of Bcath 

( 11. '3. t^^tan^av^ ) 



PLACE OF DEATH: — County of 'Cru Oxcx^vcc^: City of ^'<X>v J >Va/Yv.OL<i.^.c 



N.>XCtAj V L^rvc^-vtu vLl' 



\^\.M VfrVVALl St.; 



Dist.; bet. 



and 



( /if DtATH OrCuMs AW»V FROM USUAL RESI DENCE Give facts called for under "special INFORMATION" \ 

j \ IF DEATH OcquRRrn IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME ^^arvVl ^cUtKX^d-. 



PERSONAL AND STATISTICAL PARTICULARS 

.(XU 




\ 



lllva- 




M !ith» ( 



1 

il>ay> 



MEDICAL CERTIFICATE OF DEATH 



\T,,ii'th) 









i 5 ; 
' \Ki<n:i> 



I. 







I II i! !\ 1'. il\ V I-. i< i' 1 l-"\', Thai 1 aUcii'lc'l (icfi. .fx^'d ii''ni 
YD^^vA. IC u/iM to 3xi^ TsX i(,oH 

that I last s.iw h ^.Vrv aHvc (Ml OXJ^'VA." 'X^ T(;0 S 



iiiil lliat lUath iH( iirretl, <m the <lalv -taU'd aiMiw. i: 
M. 'i'lie CArSI-; ()!• I)!:.\TIF \va> a- follow. 



I I K 



! i 1 ' I . \ * ■ K 
X I iii:k 

"! t'')lUlllV 



,a V 



d^^' 



' CV^ . 






hr RATION 
roNTRinrToRN' 



1 



)\iirs b .l/<)f////s ^ J. /hn^ //(>//rs' 



L^u 



-<X vvd 






•••'iMlllM.ArK 
">i'iU, ,,r Cuniurv'i 



o^'^'t'l'ATioN/'T) 



ll 





( 



\ (0 /C 



J/, 'A'//" 






ii' 






J? 



Signed i 



a:' 




/>.71S- 



<Xj~\\J 



I h) 11 IS 

M.D. 



Ox|vt ^'^. ipnS (A.Mn-^O LLt % 




\v^l\Av,v.-iX 



Special Information "hI'- '"^ Hospitdis. instiiiiiions [ransienis. 

or Retenf Residents, and persons djinij anay Iron hnnie. 



/'/,: 



III ; ^t't> 



)', .! 



1 ' ■,'!,■ 



/',/! 



/^ KN, ,\vi.i.:i)(;h AM) ui,i,ii;i- 






(» TIN- 



Former or 
Usual Residence 

When was disease ronfrarfed, 
If not a\ place of death ? 



How lonq at 
Plare of Death ? 



I)avs 



rLACi: <1I' lURIAI, cK Ki;Nt<i\' \I. 



'^'''•'^"^'^ \}JLyv\jJnjir 



i 



\^<AJL 






IN 



l)A^ 



1) 






HrKi.M, or K1'.M< i\' \I, 

^ip rqoH 




a<M,..s 3b A- Htlx-ci;^' 



N. B Kvery 1 



ivery Item of inform„tIon should b. cMrcfuMy suppH..!. AGR should be state.l F.XACTLY. PHYSICIANS .should 
stnte CAUSE OF DlIATII i„ ph.in terms, that it mj.y be properly dnHsiVied. The ••Spcciul Information Vor p«r- 
s'>ns dyinft away from homo should be iiiven in every instance. 



• ■■ 



•\ 



t 'I 



i f 



; • S: 



«Ji 



i 'M\ 


i ; I 


i i' 


1 




11 


« 


• 


» 


1 1 


• 



iil'lV 




! 



!| 



I ' I > . .^ 



i(r*ff 




t i 



I! 




)i ii> i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

" '■"' ' "-'" ■" • ^l£ii!i_!lll_ REFER TO BACK OP CERTIFICATE FOR I Nr.TRUCTIONS 



pfffr riJrd, dxVvtx.^>vlKi>>j SLb lif()\ 



\ 



IlcLjish'f'cd ,jY(). 



1897 



V^truu^ 



Deputy Heal^H Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Bcath 

( 11. S. Stan^ai^ ) 
PLACE OF DEATH: — County ofOcx^A.' 0.>va/->\An^.c.c City ofCJAX^-v v),\,<Xa-\^Cc4.C( 



St.; ' Dist.;bet. 0<Xt*UX'rAJ.v.l: and V.''..'AA.i, 

(ir DFATH OCCUBS A W * V r R O Wl USUAL RESIDENCE dVF facts called for under "special INFORMATION ■ \ \ 

IF DEATH OCCURRtO IN A HOSPITAL OR INSTITUTION GIWE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME ■a>...: -,. LJtA.L>va./^x-i.... 



PERSONAL AND STATISTICAL PARTICULARS 



« » 1 



II 




MEDICAL CERTIFICATE OF DEATH 

i).\ IK oi- i)i;.\ III P 

nxkt 



dxvxfc 

M tAh) 



I»M 



1 • 



1 > ;(I 



n,i 



M \KRIF.t). 

■ ii.ili.iii) 



't.\(*i-: 



!| yi 



I All! Ik 



''•n-'Tiin.ArK 

I ATHKK 



^' Mi>i:\ N.wn- 
"1- M<.rin-;K 



!Si:it. .,r (."numrvi 




\!..iit!i» 



Dav 



/Oil ', 
•\ .11 < 



I II i;k !:r.\' i, i:kiii"N', rii.it .i .ntnwif.i .Ucrasci rmiii 

dx^xt x^ i,pM t.i gxJA± an i.^h 

iImI I I;i^t <;iw ll '. aliv(, <MI C)X-|VL ^\ ii,n . 

iii'l that ik.itli « iin-uiit'(l, (Ml I lie tlatc stat('<l above. a1 
J. .M. The C.\^^!•: Ol' ni'.ATI! \\a>^ as follouv,: 



DIU.XTION )<</rs 



!»r RATION 



Moiillr 



/'./I 



/A'/v; 



n 



il'NTION 

f^'f sided in Smi /'i ,i n, i^r.t 






SIGNED I vIJCav^wavC 



)/,'// ///.v 



/></!■ 



dX^At lb ic)oH (A.Mr.ss) H3>Cmr.vta 



fliUd \ 

M.D. 



) Vi; ; 



M.;,fll^ 






/',/! 



"'p,^J!!.*y^-^y^'''i'>> I't^KsMXM. r\K nri i.xRs xKi; TKii-; T(. Tin; 

••'■'^I (>I. MY K.NMUij, I),-.}.; XM) li I! 1, 1 1! I' 



■ 

Special information "nly for Haspitdls. InsliliHionv, frdnsients, 
or Rnrnf Rf>iilfnfs, dinl persons dviflfj dway fron home. 

former or ""^ '""''•'' ^ , 

t'sudi Residence P'-J'-f »f "edth . Odvs 

When wds disedse ronfrdi fed, 

It nof .it pl.ire of deatfi ? 



'Iiif.,inaiit 




^\<Mre.ss 3n U ^ 



LUjUiv^tx^v 



i).\'rT. oi' Hi i.M.\! i.r ki;m« t\' m, 

oxy^-t '^L 190 "I 

,1 



IT AC')", ol- lUK I \I. <»K !:i:M(»\' Al, 



N. B.— r.very iten, oV ln^.n.n.tu>n nhouhl b. cnrcV'ulIy supplio.l. Adf. sV.t.hl he st.-.tc. fiV^^CTLY PMYSICIANS Hhould 
Htntc CAlJSr OF DI:ATH in plnln terms, that it nu.> he p-pcrly classified. The Spcc.al Inmrm.t.on ^or p-r- 
s'>ns clyin]^ away from home Mhouid he feivcn in every instance. 



I i 



ii 



'IWBIHSWp^W' 



< 



^ 



I 




!| lii 




I!n;. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I V 






:U.;i 



Itrsj/.s/ererl A'^o, 



1 81)8 



* 



Deputy Health Officer 

DEPARTMENT Ol^ PUBLIC HEALTH-^CIty and County of San Francisco 

Gcvtificatc of IDcatb 

PLACE OF DEATH: — County ofv'a^v .1 \.(x^\.c^<lc: ' City of v (X.>X' .Vcv> 
No. Xb5s VjX\X*.u'jt St.; 4 Dist.;bet. Stk- and S l^^X 



^auj.e. '. 



V \j-CVX«-t'-.JvVj ^t.; 1 Uist.;bet. \ -v ►v and OA 

(ir DEATH OOCUFS AWAV FROM USUAL RESIDENCE GlVr FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATh4iOCC'J RRt D IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

(1 J *'^i^ A I 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



^ai 



I' 



11 



llAAVX; 



?s 



1 1. 



MEDICAL CERTIFICATE OF DEATH 



ii A ri-; ( li i»i:ai"ii 



Oxkt 



'^i 



! II i;i>: I. i;n ii rtiI'\'. Thai 



Dmv) 



3 



1 






! ' > 



M^ 




ISII 



i li i;i< 

■ '■|iniitrv> 



\!. I I'll I- )• 






lli.ll I la^l ^,i\v h '• 



aVwc oil 



.lI! 'vMliU'i 1 I Ic ■ I 11 1 I f. !l|| 

1(1" ' 



a 



\ 



,111(1 1 Ii.if 'liMtli ' H-riini.'(l, ( III ; li( . !.iw : - . . 

'J 

' -z M. 'I'lu- r.\rsi{ oi" i)i\ III w 1^ 



I :ih()\-c^ ,(! 
IN |(lll(i\\' 



X 







t( )Ni!<: I i:i T( » 



flou 




^ I Ii tN 






hi K N'l'K »\ );<//-\ 

( SIGNED J 



Mxnlh^ 



Days 



'-L- 1 



lliUtI \ 

).L0. "\)o-ti->- M.D. 



Special information "n'y '"f H!»M»i'''ls Institulionv, [r.insipnls, 
or Rerrnt Rnidents, iind persons dyin!) .)w<iy Iro n home. 



)V,; 









former or 
llsiidl Residenre 

When was disease (on(r,i(ted, 
If nof al pl.Keof deijth ? 



HoH lonq at 
Place ot Death ? 



O.ivs 



' \.l,ln-ss 



9.b?, 



N. It 1; 



XVUJL 



ll 



I'l.ACJ-; OI' I'.IKI \I, I'K Iv I'.M' >\ \1. 



CJ/CuLxy»v 

1' , ^Uv.-...'^. . 



I» \li". 'i! I!' I I \ I "! 1< I M* '\ M, 



'A.Ms'-'S 



ivery item o^' information nhould I,, .nroully supplk-.l. A«:i; s'lc.ul.l he ««"ted jiXACTLY PHYSIU A>IS , 
t"tc CAUSC Ol^ DI:ATH In pinin terms, thnl it may h. p.opcrly cluHnitficd. The Spcc.ol Intonn..t..m io 
"on* dyinft awny from home hIiouIJ be ftiven in every inHtnncc. 



PHYSICIANS Hhoiild 
r p«r- 



Ui 



I 

I 



IH 



(••?i 



I 






■ t 



% 



. jtgtm^^-''^''' 



T 









i Mi 



^1 S ? l] 



I IH 



(i 



,1 !'■ 





I J 




1 ( 



i 



"WW 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



5^ 



)!..:ir.! nf IUalth--l' No. i<; '^•--^^^n&lH^) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J)(f/r /vVr^/^dxWtx/^ lb 



100\ 



Registered J\''o, 



1 81)9 



VM. 



\ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)catb 

( "d. S. StanC>arC> ) 
PLACE OF DEATH: — County of Oa^v \avxCA.ax:o City of OxX>v OACvwct^Ci 

fNoXu^a^ WvLV.tu vlUAV^nriU.... St.; Dist,;bet. and 

1 / IF DEATH OCCURS *VWA¥ FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
\ IF DEATH oficURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



\ f m < 

FULL NAME M>X^ 



I 



BeLA. 



PERSONAL AND STATISTICAL PARTICULARS 

I) \ 1I-. « 1 1 r.iK in C 




•L 



t. 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

11 

(Day) 



(MoiStli) 



i9o\ 

(Year) 



iMoiith* 



AC. H 



b^ 



)>.M> 



il):iv> 



M.inlh^ 



^ 



(Year) 



Am 



SIN»,I,K. MAKUn:i) 
WIDOWKD OK l>IVt)Krj;i) 
iWtitf in s<H-ial dt sij.Miatioii) 




<XV\.OodL 



lilKTIU'l. \»'l': 

( StMt»- or Cnllllt I \' 



^'A^tl■: ni 
i-aiiii;k 



Mik rni'i, \»K 

<)!■• lAriU'.R 

( Statt or I'oiinti \-) 



MAIDi: N NAM1-: 
<»l' MOTIIKK 



!UK IIII'LAl'l", 
«>1- Mo'nnCK 
(Sliitf or C<)\uitryl 



1 






ill 



i . if 



y«<t 



I 



\ 



-^I in':KI';HV CI-RTII'V, That, I attended deceased from 

.cL.rtc ic ic/).'. t() .. ax.\\,t. XO 190"^ 

tliat I last saw h alive on )a. *^\X '^C i^o'l 

and that death oceurred, on the date stated above, at \ 
Ll M. The CAISI<: ()!• Dl-ATI! was as follows: 

I) Cclv^ctoA; dL'.C^JvOw^JL (TV X\\X atxOL\t 



DC RATION 
CONTKIIU'TORY 



Years \ Mouths 10 Pays Hours 



Years 



Months 






Kfsiilfil ill ^'iiii /'m ih /\ri> 



)'/ii. 



Mnutir 



n,i\ > 



Till'. \H()VK ST ATI". I > I'KKSONAI, I'AK'IUM' I. A RS A K I', VV-VV. To rill-: 
HlvST OI\M\' KNO\Vl,i:i)C.K AM) Mi;i.Ii:i- 



(In 



(A.l.liiss \sA.A/>V\Xi.'K 



C- \.K^^.J. 



1)1" RATION ^ 

,.. ,,„„„„., lU- 



Days 



(Signed) ' 



Hours 
M.D. 



''>wO^V\.^v\. -M- 



Special information only for Hospitals, Institutions, Translfnts, 
or Recent Residents, and persons dying away from l»ome. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'l.ACH OI- lUKIAl, OK RKMOVAI, 



fccckA>jL'Y>^ayw>v vo-lli 



X 






l)ATi:.)l in KiAi. or RKMONAI, 



N. B. Kvery Item otf inJormntlon should be cnre?ully nupplletl. 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 dyinft away from homo Hhould be ^iven in ovory instance. 



\mim*f^ 



I 






\ 



\ 



iti 



, '•": 



;'■< 



4 

i 

1 


1 




'1 

r 




f 


\ 


I 


t 

t 


! 


\ 


r 


• ' 1 




i 

li^ 1 


1' 



I 1 

I I! J 



llf 



t I 



1 , '.. 






*f — • 



'iiijHP^-*- 



^WW 



I i 



w 



fi>i iff 



ii 



1' I; 



Mi 
1 




u 




WRITE P 



r li' ;i'|1i i V' 



I)(ffr n/cf/, OAy' 



LAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1900 



f-.T •ar-.-ii luSiI' Ci) 



I 





rvi 'Xio 



H/OH 



Bes^isiefed ^'"o. 




Deputy Heaith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( X\. til. stan?arC> j 

\ ^ 

PLACE OF DEATH: — County of OO/irv A/Cu^vcaAXM City 






it 



\ 



p^Actvv ^^V.^ 




Dist.; bet. 



and 



vTvtc{ VA.O>nAK^aNi.>. St.; 



FULL NAME 0^»v 



PERSONAL AND STATISTICAL PARTICULARS 

3Jxc 1\ 



I 



/ 



M.mthi 



\»'. }•; 



(Driv 



\/..>il/i^ 1 



\'<\'ir) 



/',.' 



■^I\<'. I.l" MAKKIin 

\\ iix (Wi: !> < »K i)!\'nRr»:i) 

' W'l itc in ^•"■i'll '1- -ivM:iti"ti) 



lUK riu'i, \c\'. 

i St.ltc 'il ' '■ iMllt ! \ 



\ \ ^ ! I • Ml 
1 \T11 ),l< 



itikin PI. \c\\ 

^^^■ I AI'Hi: K 

■^' t I , ,1- ('. lUllt I \- ' 



MA 11)1 ".N" NAMJ; 
<)!• MoTlll'.K 



IMUril \'\..\( !■", 

()i M()'ihi-:k 




t)/OL^Uuxva>v 




Ol/V 




> ■■ 



MEDICAL CERTIFICATE OF DEATH 

i)A'ri<; «)i' I)1-:a'i'ii Q 



(Year) 



(Motitfi) n)av) 

I II 1';K i:r.\' Ci;R'riI'\', 'Plmtl altcMKlcd deceased from 
LLouCL. /^"i 190H to OX^ XX upH 

that I last saw li L . • . alive on OJtJpjtr XX i(,o H 

and that death orcurred, cm the date stated ahox-e, at I X I '^ 



M. The CArSi-: ()!• I)i:.\'ril was as follows: 



L) txX\)-uJL0L>v oL' 



XjJiXXAJL 




x<3L\t; 



I) r RATION )'rars 

coNTuir.r'ioRV 



MoiiHis 



Day 



Hour. 



Mo)ilhs 



Pav 




luj 



CX'W'^ 



( uClTAlloN Q f] 



h'f^idrii ill Sail I'l aiiii.--,-.! — )>i!i 



- 1 /.,/'//> 



/■'.'.v 



Tin-: AI'.(>\I'. sT V\-].\> l'KKs()N \I, rXKTKMI, \KS A K I-', TKfl-: To III I-'. 

i!i"sr or M s;^Nt )\\i,i: IX . 1-. and in:i<i^:!" 



n!ifi>' nriiil 






I )rR AT I ON )'('ars 

(Signed) Uu. b. Lo^-JLcx.^ 

i\i: ^3) K^o^-l (Addre^'^) uXv%vaJvM.^<i.^- 



Aw 



I lours 
M.D. 




SPECIAL INFORMATION ""'v tor Hospitals, Insfifutions, Transients, 
or Recent Residents, and persons dyint) away from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of neatti ? 



Davs 



I'j.Aci-: oi" luKiAi, OK ki:mo\ai. 



HATM:..; l!i hiai, ur Kl'iMoX'AI, 

0JL\^ Xb 190H 






INDl.K TA 



^X.l.ln-s. SlaloD- i'^ tlv. vH, 



r w. ^i * < o ' m ? w: ' i. ^w 



N. B. r.vcry item of inf.i-mtillon should he cnret'ully siippliccl. AGF. sh.uilcl he Htatetl F.XAGTLY. PHYSICIANS HhoiiUI 

state CAlJSn OP DIIA TH in plain terms, that it may he properly claHsilricd. The "Spewiiil InV'ormalion" ?or pwr- 
fion« (Ijini^ away from home shouhl he ftiven in every instance. 



m%mM^^ 



x 



A 



^1 



If-' 



It 



' 



\i 



;;w 



M: 



' ( 



-d 






,)' 



J* 



•H 



• • t 



.1 



I 



•*K/ 




III 






t* 




w 




ri 



i 



WRI 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H,.:ir.1 ..f II. .ilth I Vo i 



- ■* 



^f-^^ 



5m->I'.&.1' t'o 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




/)((/(' F//rf/ ,'d±\\Xj^^y\M^\j X^ ^« 



fJO'i 



Registered J\^o. 



1991 





th Officer 



^ Deputy K' 

DEPARTMENT 6f PUBLIC HEALTH^City and County of San Francisco 



Certificate of H)eatb 

( "a. S. StanC>ar& ) 



PLACE OF DEATH: — County of - O^Yu O.VCL->\CUtOO City 



Qfl^ 



ity ofOO-^v J\XX^>x<IA>4.C0 



1 



CCURS AWAY FROM USUAL RESIDENCE give facts called fOR UNDER "SPECIAL INFORMATION" \ \ 

~ NSTEAO OF STREET AND NUMBER. / \, 



No. t'ln d^<XV.kvn) St.; \ Dist.;bet. ><XCK;Um/ 

/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLEC 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME 



and Vl-ac^|kc 



FULL NAME 




d 



i\ 





^ 



^u\ 



PERSONAL AND STATISTICAL PARTICULARS 

SKX '^\ ^ I COI, 

DATI". <)l- r.IKI'H 



'" U.^ l.u 



I Atmitli* 



,t 



3^H 

llJav) 



(Year) 



A <■.!•: 



)'i\ii . 



M.,ulh^ [X AV\J 



Pa 1 .V 



SINC I,i:. MAKKIHI). 
\VII)(>\VI-:r) OK DIVOKCHI) 
(Write ill 'social <lt<i^natii>ii) 



n Ky^oXX 



niK ruiM.ACK 

(State or Country) 



NAMK OF 
lATHK.R 



lUK'nilM.ArK 

Of i-ArnKR 

I StMti or ^.'oniitrv) 



MAIIU'.N NAMK 
Ol MOTHHK 



lU Kin I' I, AC}-: 
Ol- MOTHKK 

(Slate or Country) 






ct>x<xcta 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DKATH J( 



(I)av) 



(Year) 



(Jxkt 

(Monthr 
I in<:KI<:nV CI-IRTIFV, That I attemled <lcccase(l from 

190 to I90 

tliat T last saw h • alive on T90 

and that death occurred, on the date stated above, at 5- O 
ll M. The CArSlv Ol- I)I<:AT1I was as follows: 



^ \ 



-,tLO.(X^^ 



Xxv 



\^-V\j 




<l^O^Cy\v^\AXXU 



occrrATioN 

Residnl ill S,ni /'i mn isi'it ^ )'rin . 



DTK AT ION }'iU2f;s Mo ft //is Days \X Hours 
CONTRIIU'TORV >jAX.:k.\\XXLv<\<NJl..y!^...V^^ 

I'jO. (^:>.\<y^ lrt>-vl^; 

nr RATION ^ Yeats 

( SIGNED )....N,U\'^>-^ cK- 







r^ 



Mouths 




Days 



Hours 



CLivC^vtu, 



M.D. 



XijXl l*^ TQoH ( Address) I bS^ ll) O^^ W\X:iX&.^.V.. A 



J 



I' 



^ .;lif! 



.1, • 

i i 

' ,1 
"» 









i 






\\.^\\/\y 



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



.yr.niths 



/hn.^ 



Tin", AHOVK STATKn I'KKSONAI, P \ RTIC T I,A RS A R 1% I'RrH TO I'UH 

nKST OF MY ivNowij-:i)(Vii. AM) HF:i.n-:F 



(Inforniatit 



(Ad.lrc^s 




l^Ob AoA^kc^ Mt 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'l.ACK OF" HIKIAI, OR RKMOVAI, 



K)^A.yv^\ 



t 



l^^ 



INDICKTAKKK JV.UL'Ul-U ^ .»V 

rAcMress.ira-l^.tiv 4t 



DATK of HrKiAl. or KF:M()VAI, 

ox^vtr x\ T90H 



J 



y. B. Kvepy Item o? hiformHtion should hi 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 par- 
sons dyin^ away from home shoulfl be ftiven In every instance. 



.mI f- 



m»***^*^-' 



I , 



,!l! 



h-if i 



.*»• 



w: 1 ' 1 



f 




nm 





m 



^ ^i^- 



i 



WRITE PLAINLY WITH UNFADING INK — 



Hoar.! of H.i.lth I- No i^ -fr-tiw^ H& P Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafr Filotl , nx<p±X^^.i^ ^ b 10 0\ 



Registered J\^(), 



loo^e 



.^oL^.j i^uvH| Dep- ■ ' ;t.h Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "CI. S. StanDarD ) 

PLACE OF DEATH: — County ofOa-A; ^a^vu^uyc^ City of OxX^^/ J A.<Vva.cva c,< 



if^: 



^% 



X'^-^K^J 



St.; 



Dist.; bet. 



and 



1 i\a\Lv/s , _. 

/ IF DE»*H OCCURS »W«V FROM USUAL R E S I D E N C E G I V E FACTS CAULtD FOR UNDER SPECIAL INFORMATION ■ \ 
V IF DgATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



- ) 



FULL NAME 



LlcLo^ vlO^U^kU. ^ . \.<^.. ^ .. 



PERSONAL AND STATISTICAL PARTICULARS 

COI.()k> 






.1'. \\aXi 



(M.iiilli) 



A < . K 



31 



),■.;; 



S 



(Dav) 



1/. <>////' 



(Vtar) 



II 



/)in 



sIM.l.lv M.\KKn:i> 
\\Fi)<>\vi';i) OK i>!\(>Kt)-:i) 

iWiiti' in social df^ivMiatioii) 



Ox. 



(Stat' or t'oiMiti v 



NAMI' (Il- 
l-ATI I i:k 



lUK'nilM.At K 
<)1" lAIIU'.k 

iSlati or I'oiinti \ ' 



MAIl)I-,\ NAM I". 
Ol M()TH1:K 



T 




A 



Kxr 






lllo^vu vj aA 



J\JS\J 

h'r- /i/rif III San I'l ,in, Isro^ [^\ )iiii- ' M^'ulli-. 



MEDICAL CERTIFICATE OF DEATH 

DATK ()«• i)i;ath J^ 

(Day) 



(M 



Jlkt 

oiilh) 



I go \ 

(Year) 



. I HI':RI<:I{V CivkTII'V, That r atU'iKUd deceased from 

Ox\\fc 1^ T90H t<) ..a^'|\t 3v5" igoH 

that I last saw h^.t\) alive on OX^C 2.5" 190 H 

and that death occurred, oti the date stated ahove, at C o 
U M. The CAl'SF-: ()1< DIvATII was as follows: 

\jlXJtVvt) d.\vv-.va.l NfyU/rtv^-ui 



x^:...: 



DT RAT ION Years 

CONTkllU'TORV 



Monl/is 



Days 



Hours 



Dr RAT ION 



y'cars 






JA '///// ,v 



lUKTUPKAC'lv 
Ol- M(>'II!I-:K 
(State or Covmtrv) 



/'.n 



Tin-: AHovi-: sixri-: o pkksonai, i'\in"u"ri,ARS ark tkii-: to iin-; 

HKST Ol-" MV KNoWIJ.IX.K AND lil-:!.!!-:!-' 



(Iiifotinant 





V.l.lrrsM 50^ Ml\^yAvtxl.A.rJ. 



Lv <^ 



(SIGNED ) l^, ^\\A\ 

Oxl\b 0.5 190 H (A.ldrc-ss) 



Pays 



Hours 




Special information only for Hospitals 
or Recent Residents, and persons dying dway from liome. 



M.D. 

, Iflsiituttons, 



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



Former or 
Usual Residence 



How long at /~t 

Place of Death? I 



Transients, 



Days 



!'I,ACK Oj^IUKIAI. OK KI':MoVAI< 



DA'^Hof in lUAl. or KI';M<»VAI, 

tlct 1 



190 



A.Mr.-ss bH:6 \)iiUui ^t 



vu 



N. B. fivery Item of tii?npmfition should be cnrefully Hupplied. AGE iihould be stated KXACTLY. 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 &iven in n\9ry instance. 



\mmm^- 



TTi 



'"i ii r 



i.f 



I 

I 






'i 



! 



1,1 



i 

X 

t 

\ 



t 






i\ 



1 1 



i 



il 



m 



■\ I 



II! 



^1 I 






ii 



Mil 



M ^ i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Il,..ii.l (;f 1I< alth • !•■ No. 



:r ■*. 



■^^i^, US: 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Be^istered J\^o. 



1903 



I)((fr AV/r^/, OjeJpjU-k^Jl>^^' ^^^0\ 

dLexMj Deputy Heaith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cr^C^^ 



(Tevtificate of Death 

( Ta. S. 5tanDarC> ) 
ofCVcLlV OACL>vCL>Ci.C>0 City of ^'<X/>"\^ A.CWU^a^'CO 
No Hll ^bcVVctt St.; H Dist.;bet.VyVM.^^ and^^a^vwwv) 

/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UlA)ER "SPECIAL INFORMATION ' \ 
(, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAOl OF STREET AND NUMBER. / 



PLACE OF DE ATH : — County 




FULL NAME 



\ 



} 



\\ av 



Urtlib 




O-UAAl. H^'tL-Yi.(LCr>\' 



PERSONAL AND STATISTICAL PARTICULARS 

SKX ^ . i COI.OK • 

MWV. <)l lUKTll 



.v^'.IvlLl 






\t.I-; 



V.\,, 



I? 

(I):iy) 
I M..„lh'- 1 






/),n 



sisr.i.i". M\KUIi:i> 

u iiM (U i:i) (»K i)i\ «u<rj:i) 

iU'iit( ill soiial (U >i;'nati«)M) 



HiK run, \i*i-; 

iSlati or I'l >mitr\ * 



NAMi: OI" 

I- A III i:k 



lUKiiiiM, An-; 
OI- iaimi;k 

iStatf (ir C'<)iiiittv> 



maii)i;n namj: 
<)i" M()Tm:K 



lUKTHrUAl'K 

(Stall or Ci)iiiitiy> 



n^ 1 



/I 



^VCLA. 




tve. 




(r>\j 






1 



MEDICAL CERTIFICATE OF DEATH 



DATK OI' DKATH \ 

ckkt 

(MoiAh) 



lb 

(Day) 



(Year) 



I inCRI'lHV Cl<;kTn'V, That I iittendcd deceased from 



\ '2 



lyo H to dxJfCt '^.b uyo H 

alive on 0^]^ 1^1 k/) H 



tliat I last saw h •■• 
aiul that (U-atli ocrurrcd, on the <hite stated al)ove, at I oC 
M. The CArSIC OI' DlvATII was as follows: 

v3 cv<iLvslcy xx.^x<L..M.VlXY\A/'vvavt 



i' 



\j^. 



DTRATION )'t'ars A/on//is\^^ /)ays Hours 
CONTR nil TORY 



Cj\w<-A.\jL LL.<XV^\X^' 




r 



(UiTl'ATION 

h'fuilrd III S,ni f'l ,111, i^r,i — )V>/;> 1 M.>„lU- 10 



r 



\) 



ih)\^ 



•nil' Miov'i-: ST \ri-:i> i-kksonai, i-ak ruri.AKs aki". iki i". 'r«> 
ni';sT OI Mv ,j<No\vi,i:i)c. K and in;i.ii:i" 



■rill". 



(I II fill ma tit 






( \(l(ll.SS 



DTRATION 
(SIG 

A. I.l J I I()oH 



}'t(irs 



Mo)iths 



Pays 



1 1 our 



N E D ) KjU>-cL<5'Xa) tp. U..<X.4^<XA.cl'i M . D. 

(Address) Till U/an.Ml-<.o..i llxKi 



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



Former or 
Usual Residence 

When was disease contrarted. 
If not at place of deatli? 



How lonq at 
Plare of Deatli? 



. Days 



ri,ACK OI" lUKIAKOK KKMOVAI< 



DAJ'liof in HiAi. or K1':VI0\'AI, 



rNDKKTAKKR dlD J. MfUv<Ul^ Lo 



(AiMrrss 



IN. B. Rvcry Item of liifopm«t1on •houltl be cnrefully nupplied. AGB nhoulil bo stated EXACTLY. PHYSICIANS should 

•tate CAUSn OF DEATH In plain terms, that It mHy be properly classified. The "Special information" for psr- 
sons dyinft away from home should be Ht'^en In •\^ry instance. 



t .' 



,*«*«^ 



.il.:Jvj«Mil .' I 



'^^^ W7\ 


•11 


■ 1 ;"^ffi] 


1 


^^^^^^1 


p 



';H Z. 




, I 



1 »ll 



H 



[1 



n 




I 



^ 



i 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H,Mni. f n. tifh 1 No .-.^C^i^l'-'tl'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihffr /v7^>r/,^xktX\>JU\, Xio 7.96>H 



Registered J\'*o. 



1904 







Deputy Heaith Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtiftcate of Beatb 

( "Ul. S. StauDarD ) 
-? ^ J? 0)7^ . 

PLACE OF DEATH: — County oiOo^n^ .Va.^^^^<:A^/c^ City ofCJxx/vu AXWvcla^l/c^ 

^f^^^iX^^^^<X'UxAlxXiOA^>%\.t<X^ Dist.;bet and 

/ ir DtATH OCCURS AW*V 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. / 



FULL NAME 




sA 



.cL....( 



\ 



PERSONAL AND STATISTICAL PARTICULARS 



SKX ^ I 

DATJ-: ()!■ lUK I'll 



cc 



"" loi, , 



■f 



iMoilth 



t 



ACH 



y,;i 



3.^ 

(I):«y) 



M..„!lis 



(Vrarl 



/) 



'</ r.s 






K\. 



\ 




\x/^ '^ 



IQO . 

(Year) 



\VII)( )\V}>;i» ()K I)!VnK(I-;i) 



1 



iiiuruj'i,\oi-; 

(Stiitf Ml (.'uiinli v^ 



N'AMIv Ol 

!• AIMli: K 



HlK'nil>I,\CK 
Ol I AillHK 

'St;iti' (»r (."oiinti \' 



maii)i:n NAMK (i 
Ol- moth1';k 



niKllIl'I.Al'K 
Ol- MoTHKK 

(State <ir C<))iiitr\l 



OCCri'AlION 

h'f-iifril III Sun / I mil /si'ii " ) V<m ^ 




MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DICATM JJ 

(Moiftli) (Day) 

1 1I1<:RI':HV LI;RTII<A', That I attciKkMl dccoased from 
Qx'pA ^^ I90H to • • • 190 

that T last saw h alive on * up 

and that death occurred, on the date state<l ahove, at 
M-, 'U»<-' CAT SI-: ()!• Die AT 11 was as follows: 




x.UU.Cv 



DTK AT ION )'('ars 

CONTRIIH'TORY 



Mouths 



J)ays 



OMj 



Dl'RATIOX 



(SIGNED ) 



a 



Yaars 



M<>>if/is ffays 



UXlAi X!^ i(,n'\ (A(ltlress)M<X^V^tL i).lLdc 



Hours 

Hours 
M.D. 



% 



SPECIAL INFORMATION only for Hospitals, institutions, transients, 
or Recent Residents, and persons dyinfj away from liome. 



M., II til- 



Ihi 



111 I', \no\i.: sr \ii:i> i-kksonai, rAKiuri. \ks aki; ri<i i-; ro {wv. 
iii;sr Ol- Mv KNOW i,i-;i)c.H and mi-;i.ii-;i- 




( Infdi iii.-iiit 



V-:^A. 



x.i.h.-ss iHHi J >Uw^l ttrvu aij 



Former or 
Usual Residence 

When >vas disease contracted. 
If not at place of deatli? 



How lonq at 
Place ol Deatli ? 



Days 



I'l.ACl'; 01 lUKIAI, OK I<I-;Mo\AI, j KAIliu! MnnAi. i.i kl-:Mo\'AI, 

OJ^^fc ^t 1 90S 



ri,.\». J', I >l lU K l.\ I, < M< 



im)1-:k rAKi-;K 



.% 



\X0 (IU-cy<V,ay, '^ 
AddVcHs n ^ 5| dJ .uJlMhlI- lL.\>-- 



N. B. Hvepy Item «>»* in?«)rmHt1on should he ciirefully Hupplietl. MW. Hhoultl be Htutetl HXACTLY. PHYSICIANS Hhould 

Btute CAIJSI: OP DEATH In pinin terms, that It miiy be properly claitfiWied. The "Special Information" for p«r- 
nona dyin^ uway from home Hhould be ^iven in every inHtnnce. 



u*»immm*^- 



\ 



I 






} 



w 



I ' 



i^♦ 



1 1 



I 



1 



^i 



i 



I !#. k 



!i* 



Iii«f#v' 



'-^j-uiiit^^*' * 






r: I 



\ 



u 



I 



/ ? 



p N 



I* 



I 

I 




WRl 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i Heiillh- I" Nt> I- 



>*'^"*-, 



I'.Sil' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



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



.^\AA^ 




5vb 



7,9i^;H 



Rvgistercd J\'*o, 



J 905 



^,^ Deputy HeaJth Officer 



H 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH: — County of' 'O/vu AxX/>vcu . c. (. City of ^ ' <X^^ Aya.>xcoa..ac 



No.cLa.ovi 




A 



ChUx^^Lo^A; 



St.; 



Dist.; bet. 



and 



/ IF DCATH OCCURS * \A/ A V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECAL INFORMATION ' ' "j 
V IF DFATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



<X^ 



ck 




II 



M 



PERSONAL AND STATISTICAL PARTICULARS 





(\ 





*^ 



\ 



V Mil 



5 5 



-^IM.l.Iv M\KKIi:i) 

W i III )\\r"!» ' •!% D'Vi tf ■ 1. 1> 



1 



tDiiy) 



.1 /.';/.'// 



I "> < ill ) 



(Vc:n) 




LdL<^v.x^-^d- 



luurmM, \r\: 

. VI .1 . , .• I ■, ,1, ,,1 ' V 



\ \ M 1 111 
1 \ III IK 



IUI-: I II n, \» 1-: 
(II I- \ III i; K 

(St!tt< < ■! ^ (Hint I \ 



M \i 111 ,X \ s M 
<'! Miri'lll.K 



niurui'LAi'i-: 





? 




C' 



? 



MEDICAL CERTIFICATE OF DEATH 

(Mi.titlil (I)av) 

I I I i:i< IJ'.N' CiiR'ri i'N', riiat I altciKUMi .Ucx-asod Irmii 

lliat I la^l <aw li '■ • alivroM O.XJ|\t %''6 np ' ■. 

ami lliat ilialli ( ktu rieil, on llir «latr stalnl aliovc, at [. o 

^.- M. Tlu- CACSI': Ol' IiJ'A'Ill was as follows: 



iLi 



cjv U X4,<r^A,iv<v.' 



1' 



DIk \'i■|<^^■ 



)'<■(7/.s' 



. lA '///// s- 



C( KN'l'U I iir'r< )i«l\' 0^ryv<X/^x-A^VA./c \ 



/hfVS 



Hon 



; v 



1) r R A r I < > N ) '<'ors Moil i ha Days 



(Signed^ OX^jVoa 



.^' 



M.D. 




Ol/AaxL 



H'lTr ■-■! lux 



iccL^N > ^ 



Oi. !' 



M. nll,^ 



Til r .M?«»VH ST \Ti:i) IM-US< »\ \I, I'AKIH I I, \KS AK 1. IK !}•. li • ill I'. 
r.lvST Ol' MV KNOW l,i:i»<.); AM) lil'.MII- 



'In f'l; iiriiil 



qxlAl 'i-'. TOO (.\.i.iiv<s)lo'^ uWu-vd j.t 



Special Information "nly l«r Hiispltdls, Institulmns Transients, 
or Recent Residents, .ind persons dvinj .iway fiom home. 

Former or r- , -. ^\. i "A i How lonq at 

I'sual Residence^ 'o (/LCrU^KXAxl JX Place ol Oeatfi? Days 

When was disease rontrarted, 
II not at plare ol death ? 



I'l^M'I' « H I'.IK I \I, I )K i; I. M' »V AI, 



DAT!', of P.I Ki AI. u\ K i;M( )\A1, 



■Nhi:i<TAKi..R VJcr\ljiA) V UJJv.Lt,^ 

r\.i.]u-.s \'\'^ uCrvdwX , o,CLtx \Ju\) -^ 




^. It. y.very Item of itiforiniition hIiodIiI I>.- cjirot'ully KvippIicMl. /Xaii h'v)'iI.I he stnte.l EXACTLY. PJI YSICI AN S hHouIiI 

Ktiitc CAlISr OF- DI ATM in pln'in tcniiH. tluit it mjiy he properly cluHHilrleti. The "Speciiil InVorniHti >n" (for par- 
sons clyln^ owny from home shoiiltl he Jiixen in every Jnstnnce. 



'.^.MWrtW^W**!^- 



liliiiHil 



m; 



'«uH 



tl 



!■:' 



i 



tl 
'i|i- 

1 



I 






t .1 



( 








'iE 




\t\ 


1. 


ill 


! R 


11 


,*, 



««nM)«Wilfc''A 




M^ 



J 



i 



1' 



•^- - i-,. 






s 



I 



■•w^ 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!.,r,t.! ..f Il< .lUli 1" N- 



•^-^'^^riS^, I'.Si. 



V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lyu6 



\ji-^Ky^ ^^^^ Deputy Health Officer 

DEPARTMENrOF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of 2)catb 

( U. 5. Stan^arD ) 

0. 



PLACE OF DEATH: — County of ^'<X>vO\^>vov<lcc City of C 






(^ 



Vo^'>v^v4.c < 



^ 



No 



, 0.^a/^xc.k' fluCh^xJlal' 



St. 



Dist»; bet. 



and 



/ IF DC*TM OCCURS *W*V FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNDER "SRECIAL INFORMATION" 'S 
I, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



1 



■V- 



PERSONAL AND STATISTICAL PARTICULARS 






cm, OR 



0.^^ 



ii 






.\(.K 



l-h 



) rii I 



% 



l):i\) 



M.nil/i> 



(Vtar) 



lht\. 



slN(.I,i:, MAKUli:i). 

\\ IDOWKI) OK DIVoRCKI) 

iWiitfiti M)ii;il (li ~i).Miiit ion) 



)x ^^.oLl 



I'.iK i*in'i, ACi-: 

( Statf oi Cmiiiti yi 



N wti-: OI 

!• A III l-.K 



HIUrill'l.ACK 

OI- I A rill-: k 

I state or Country) 



MAIDl'.N NAMi: 
OI" MOTHllK 



lUKlHI'LACK 
o|- Mo'lllKK 

(Statr or Country) 










I /a 





MEDICAL CERTIFICATE OF DEATH 

DATK OI- I)I:aTH V 



dxi\fc 

(Month) 



15" 



(Day) (Year) 



J 



I III'iKIvHV CIvRTH'^V, That I attended deceased from 



"t XX 190' to uXyvt' 'X^. np'^ 

that I last saw h - alive 011 aXl\"^ 'X5 up 

and tli;it (Uatli occurred, on the date stated above, at 10 oC 
LI M. The CAlSi*' OI- Dlv ATM was as follows: 



DC RAT I ON X )'rars ^ Months Days 

c ( IN T R I H r 'I* R \' LL>x <xX.yy\Ax:^ 



/TVCX ^ VA^ L<\-<r\ V, 



t 



Months 



I^avs 



occrrATioN 



tx wxw^o-^ viol V 

Kfsidrd in Sati /'rnitrisco 4 ) "'■'"•« ^ MniiHn 




Ihi \s 



iiiis \Hovi<: s'rA'ri:n pkrsonai. rAKTicci.ARS ari" tkch to thk 

MI, ST OI- MY KNOWI.KIX'.K AM) HHMHF 



(Informant 



T?)b V^^oulL at 



(AfMrcss 



DURATION ^ ^'^''^ 

( SIGNED )...yi. O, lLI<:U.va. 
OX^ Qs<o iQoH (Address)lS[ a>U.ttt\iOt 



I lours 

I fours 
M.D. 



SPECIAL INFORMATION only for Hospitdls, Institutions, Irdnsients, 
or Recent Residents, and persons dying away from liome. 



Former or rr o 1 \ r\ 

Usual Residence (Ob O^A^ 

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



W y -\i How long at 

O^A^iv OU Place of Death? 



.. Days 



I'l.ACK 01-" lUKIAI, OR R}-:MoVAI, 
INDKRTAKKR Ov 



D.lTKof HiHiAi- or RHMOVAI, 



(Aihlrcss 1 




I90H 






\>^. 




IN. B. 



-Kvery item of Information should be cnret'ully Hupplied. AGK iihould b« stated BXACTLY. PHY8ICIAN8 should 
state CAUSE OF DEATH In plain term*, thnt it may be properly classified. The "Special Infopmatlon'* for per- 
sons dying away from home should be (ii'ven in msmry Instance. 



^•^■S,-:*.' 



■ 



f 



!':• 



' 



U4 



\ 



\ 



ii 



' .'1 



/ 



! i i 




It. 



I 



! 



'h- 








) 



i 



'V- 



tli 



»f 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



llorir 



**L 



,1 ..f ll.alth I' N'o. K «-?'ar^^lU<tl* C( 



ar^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)((/r Filed , 





vW;. lb 



10 a 



Registered Xo. 



1907 



CCUl 



No 



1. Deputy He: .;;, Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccttificate of ©eatb 

( "d. 5. StauDarD ) 
PLACE OF DEATH: — County ofO<XA'^^ OA>a/v\Xi.oac<i City ofOo^-v 0.^.a.-^%'Cvac.c 
.SlSil b^u^vO^^Vub St.; 5 Dist.;bct. '^kAj and H Xi\) ) 

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

FULL NAME vl(rlK->Uj ^J. v J OL w^^ 



.L.|:1.<lLu- - . 



si:\ 



DATK (>»• lUKIH 



PERSONAL AND STATISTICAL PARTICULARS 

I Coi.ok 





.KaAX 




A(.K 




Month 



6 b )•,■,,, 



IS 

(Day) 



.!/"»////' 



AbS 



(Vt-ar) 



n,i 



srNc.ijv M\Kun:i» 
wiix >ui-:i> »>K i);\t>Kti:i) 

IWritrin s.M-i.iI ilfsi^'iiatinn) 



• stall ui (■' iiiiitl V' 



f ricuv\AJuL 






MEDICAL CERTIFICATE OF DEATH 

DATK <)I" DKATH 9 



f Month) 



H 



(Dav) 



IQO 

(Year) 



1 Hl'lRI'liV CI-RTII'V, That I atteiKk-d (Uci'mscmI from 

. CJjtJfvt \'l 190H to OJOf^ X^ H)0'. 

that I last saw h '- alive on ^>J XJspL 0.3 up 

and that ik-atli occurred, on the date stated above, at 1 « 'o 
M M^^ The CAISIC Ol- DIvATlI was as follows: 



NAM I'. (M- i ^ 

I A 111 i;r 




lUKIIIIM.ArK 
Ol" I Allll-.K 
(Stat'.- Ml I'miiiti vl 



M \II)|;N NA Mi- 
di- MOTIII-.K 



lUK rUlM,A(^K 
01 Ml I'll! KK 

(State or roiiiittvi 



)C<.M TAIIONMr^ 



Jx<iJUrwcl 




h'f^itlfif III Sim /'i ii ih rri> 9*.^\ )'./;> 



I) ('RATION I )Vi?/-^ Months Days 

CONTRNU'TORV ibX/Vyv^^pAAY^''^ 



nr RATION 

(SIG 



Yiars 



Mouths \ Days 

NED) J4.0 M. MAaAAX-^^lAm 



6xl\l as ,.,oS (Adiirc-^s) HtH- ^^vcLot 



Hours 

Hours 
M.D. 



SPECIAL Information only for Hospltdls, institutions, Transients, 
or Recent Residents, and persons dying dw.iy from home. 



\r.,iith- 



I hi 



Till", AHOVIv STAri',!) I'KKsoNAI, I'A K T IC T I.A K S A K l", rwiH To Tin'. 

ni:sr oi- \iv knowij.dck and iu,iji;i" 



(InfoT niMiit 



C9. \XAj^yJjLK/>r^ 



\.!.ln 



^xq'ia ■l)-wa.^>t ot 



-^ 



Former or 
Usual Residence 

WIten Has disease rontrarted, 
If not at plare of deatti ? 



How long at 
Plare of Deatfi ? 



Days 



I'l.ACl-; Ol' lUKl^M, OR RHM(»\\I, 




ni)i:rtakhk Jb<xlAAXycL VLc 



KiAi. 01 ki;mo\ai. 



I 



f Adilrcss 




IN. B. Kvery Item of tii?orinntion •hoiild btf ciiraViilly Hupplied. A(Ui «hr»ultl be ntntecl fiXACTLY. PHYSICIANS ithoulil 

mnte CAUSr OF DEATH In pliiin tcrmi«. tliiit It may be properly claHn'ificd. The "Special InformHtlon" for p«r- 
Ron« dying away from home Hhoiild be given in overy inntance. 



vumm^f^*^- 



V 



% 



:J:' 



h 



I , 






I 



1 i 



«« , 



•• 



« 



, 1 

il 




i 



I 



n 



1 




l.f: 


t . 


Aj 


<t 


1 


P' 


m 


II 


1 



fm^ 


jl 


ft 


:4iiiitew«-» 


ri 


"f^^^in vn- 


1 


!. JlU] 




^Sfif ;| 


1 


^-:'i 



I 



11! 



^; Ml 

ill 



\ ; 



it 



« 



1 



ji 



i 



1 




> 



W 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



J!.,:il.l mT H.;iUli I' V' 



^i^f*"^ 



]',S.V (• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r AV/^v/, JXJpjU.-n^l^^ If^O'i 



Re(!istcre(l J\'*o. 



1 f)08 



-V 



Dep 



i t ^ 



.icer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot H)catb 



( "U. 5. 5tan^arC> 



^ 



.,. 



No. 



PLACE OF DEATH: — County ofO/a>X' Iva >vcUioo City of'v CX/>^0/\.CV/>^c^^c^ 

Dist.;bet. (jbcwa\.CV and (TVCttrrry.' 

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



A 



).10 - 11 llv 

F DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACT 

OSPlTAL OR INSTITUTION GIVE I 



St.; ^ 



(IF DEATH OCCURS AWAY FROM 
IF DEATH OCCURRED IN A H< 



FULL NAME 



( 



V. 



CL >'V\Jw;^ 







^^. 



\- 



PERSONAL AND STATISTICAL PARTICULARS 



^ 1 . \ / 




(.(H.oR^ 



^ 



0^ ' 

I) \'ii-; t ii lUK 111 



\i.iC 



Z^Jt) 



(Vt-nr) 



M.mtli) 



(l. D )•.,/<> 



I).i\ I 



Mnutir 



(\"(:ir' 



l\l\s 



-^I\< .1,1', MAKR li:i) 

w ii>< ►\vi;i) OK i)i\<)Kt'i:i) 

'W'litciii social ili^iv'iiat i' )!i I 



I'.iK iMi'i, An: 

I stale <tl I'oimtl > I 




/v.L V<X ^ V 



NAM I- Oi- 
l-ATI 1 i;k 



I'.ik Tiiri.ACK 

oi I Ailll-.K 

I Slate or I'l >\i III 1 V 



MAIDI-N NAMi; 
OI- MoTII1':k 



itiR'nii'i.Ari-; 

nl- Mo|IM-:k 

< State I j| i".iunli \ ^ 



inn TAIION 






MEDICAL CERTIFICATE OF DEATH 

DATIC Ol" Dl-lATIl 1 

Uxkt lb 

(Moirth) (Day) 

1 III-;RI':HV CIvRTII-V. That I atteiKkd deceased from 

^^L^^vt 1^ i^oH to OX^vt lb 190H 

tlial I last saw h V. . .\ alive on ''.'V.^vt ^S k^'^ 

and that death oeeurred, on the date stated above, at <a. 
Lv M. The CAISI-; ()!• DIIATII was as follows: 



I )r RAT I ON )W//.v 

CONTRIHITORV 



Months 



Days 



I /oh PS 



k1A.V.<.OJ 



\jlL<x>vcL 



h'f^iilril III Sdii / I itih i^i'ii I I ) f,t I ^ 



y/.nilh^ 



Ihn 



III 1: \Mo\i-: s r \ ri-. D i-kksonai, pak i uti, m<s au i-; ri< 11-: 
iii;sr <>i- Mv KNowi,i-;i)oi': and in.iji'.i- 



(Infd! maul 



10 nil-: 






I \.l<licss 



Xxo ~ la 



I )r RAT ION O^'^'K ''^fo'itfis /hu's 

(SIGNED) O. J. vU^v<X<:J(^^ 

Ad<lress)Vl'<XKA,^U' ^hici H 



Hours 
M.D. 



6xi-vt ai ,00' 



\ (> 



^ 



Special information only lor Hospltdls, institutions, Transients, 
or Recent Residents, dnd persons dyinq dwdy from home. 



Former or 
Usudl Residence 

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



flow long at 
Place of Deatli ? 



Days 



1) \ ri-; m! Hi kiai (.1 KICMOVAI, 



ri, ACl-; ni lU Kl Al, iiK K l.M(»\ \l, 

im.i:utaki:k \.<X\X\/S vc L^-vC^.\.^w^v 

(A.l.lo-ss V\ UO, A\;TLLH V' V 



IN. B. livery Item otf inV'<.rmjition «houl«l h-- cnrcfully Mupplieit. Afili Hh<»»il<l bo stnteil liXACTLY. I»IIY81CIAINS Hhould 

Htiitc CAUSr or DIATH in pliiin tcpm<», tli;it it nuiy »»c properly claHah'icd. The "Hpeclul Infornifitlon" for ptir- 
nons flying nwny from homo Hhf>iil<l he driven in overy inHtance. 



Mmm4Ail^M'^'■ 






1! 



»■. - 



I 



\>.\ 



i 



t: 



: 



* < 



' 



•■•I 



jih; 



■\ 



t ' I 




I 



-JiS... 



If 



«! 



II . 



H 



I 



!l ? 



I. 



^Ib 




^ifo?^:- 



.«te JfefV"^-.. . *<^- 



) 



^Mm»\mm 



W 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoiiiil "I 



.^— !^fcv. 



II. lUli I* No. K H"*!-^' "^'^'' ^'" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




llci^Lstcrcd J\'*(), 



1 909 



Dale Filr(l,h±\f\XX'\-^\.\sl\' lb l')0\ 

It^^v^l^v., Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Beatb 

( tl. S. 5tanDar^ ) 
PLACE OF DEATH: — County ofC a^a- Va^Ct^co City of Oa >v OA.a ^^.v:c^co 
4 ^ ^ :; . > . . St.; ^ Dist.; bet. Vl cX<X WCb and Ico^Wv^X; 

/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N • \ A 
V IF DEATH OCCURRED IN A HO" PITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / ^ 



No. 



FULL NAME 



^^ 



C^'>'\/<.^VCCCV.' 



. <y K- vt^^ '^ 



PERSONAL AND STATISTICAL PARTICULARS 



>1.\ 



V 



c<)i,( >k^ 



i> \ri" oi- liiK 111 



d IvLtiL 



M..ntli' K 



MEDICAL CERTIFICATE OF DEATH 

DATlv <)»• ni'.ATII 

3.5 



(MoiitiO 



Day) (Vi-ar) 



(Dav) 



/Ul 



A' .!•; 



n 



) ,,.• 



M.'ulh^ 



9s I 



:\i-:tr) 



/),/ 



sl\(.l,]" MAKUIlIi 

U IHi »\\ i:i> nK 1M\ t 'K' J'.D 

\\\ iti- ill SIX i:i! <1' --U' na t i' ni > 



i 



Mik rtii'i, \i'i-: 

I state <)l I "'111 llti \' 






1 



1 \ III IK 



^ 



V 



j 






itikinri, \c !•; 

OI" I ATIII.K 
'Statr or C'onnti y i 




L. 



MMI)|-:N NAM! A) f\ I OT) 



I II i;k i;i5\' (.IlKTIl'V, Tliiit I ;ittt'ii(lt(l <lrri ascd finm 

, ' 190 . to ^X.yvv 'X5 KpH 

that 1 last saw h alive on OX ) nA 'XS upH 

aiul that iliath oiH'iirrtMl, on tlu' datr staU-d al)ov<.', al l\ 
U .\I. Tlu- CAi'Sl" ()!• DI'A'ni was as follows: 



-^^-^'l^CL^ V,j 



DTK AT ION )V<w-v I MiUitIn l5 l^aya //ours 

C'O.NT K 1 Hl'TC )K V V .cL<xXoLL\-<{r"\a. .{)>.XiAj. OViLahA... 



)'rars Months X /hiys 



lUK Tiiri.Aii-: 
OI- m()Tiii;r 

( Slatf or <."ount i \ ' 






orrriA rioN 

I'f 

/\'fl(h'il in \ini I iiiilii^t'ii I ' )iili 



\r.;,lln 



I ',1 \ ^ 



iiii: \Mo\i': ST \ III) pi':k^on w. tak inri. ars ak 1. lui )•: 10 in )•: 
m;sT oi- Mv KN< i\\ i,i;u<.j-; and iu:i.ii;i' 



(I iifi 1; luanl 



Ud.ln 



LI. Ko-iv\xdLo 



DTK AT ION 

(Signed) 

Q.t\xt Vo ic)oH (A.Mrcss) 1110 Hlovt-.'^ 



^1 il. (V). ^4)V<A a ^ v'...v..^ 



/ /ours 
M.D. 



Special information only '«r Hospildls, Inslitutlons, Trdnsienfs, 
(U Rerent Rpsidcnts, dnd persons dyinq .miiy from homf. 



\ ornif r or 
UsuHJ Residenrf 

When Hds disrasp rontrdftrd, 
If not dl pidtr of dfdtfi? 



How lonq dt 
Pld( f of Dfdffi ? 



Ddys 



IM.ACl'. 01 ItlKIAI, OK K |;M< i\ \1, 
I 




Cr lu, L'V^^'^^l/ 



DATi; ..( HiK 



indi:htaki:k Mil '.]>t>A>V ^iJ 



\\^ ai 



lAi or ki:M( >\ AI, 
I90H 



Mh^ 



A.M...SS \X^ ^^^ii^UAx 



IN. B. Kvery Item otf In^armiition should he cnrot'tilly Hupplied. AUK h»1(>uI«I be Htateil I.XACTLY. PHYSICIANS Hhouiti 

stnte CAlJSi: OF DI.ATH in phiin term*, thiit it miiy be pr«.perly cluHfiiiflcd. The "Special InforniHtion" ?or p«r- 
Kons (lyin^ nwny from homo Nhoiild be ^iven in e\cpy inHtnnce. 



«iiHlijM^ 



''It 




'1 ' 








ft 







saKi*i« 




1! 



II 





1 I 




UN 



i 



iA 



#1^ / 



WRITE PLA 



1 I , . ■ I 1 ; I V 



INLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OR CERTIFICATE FOR INSTRUCTIONS 



I )({!(' nird , 




at) 



rjo'i 



Re^i.stn'cd J\^o. 



1 91 



.frw^ dvCvM Deputy Health Officer 

DEPARTMENT ot PUBLIC HEALTH=City and County of San Francisco 



Gcvtiticatc of IDcntb 



PLACE OF DEATH: — County of 



No.- 



St.; 



Dist.; bet. 



City of 




/'VKXXl/OL 



and 



/ ir DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED TOR UNDER "SPECAL INFORMATION" \ 
( Tr DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

A TMl.oK 




\/Y\i 



\l ll/X/-\V 



VXV. ^ v^ 




I 



CkIX 



M ' 



\\aXx 



DA II- I li 



II 



.U^.i 



\T..iilli 



A I . 1". 



3% 



) . 



! ■ I • 



I • -.'//. 



- ; ■.. : I M \KK ll'i' 

w i ill >\vi:i> < »K Dixoi'.ri: i> 

'Wiilciii v.K-ial lit <ir'»iiti'>ii) 



III K r I in \i" )■ 

'si:it, 



dx 



) ^ w\ *>wS_ 




AxLolao^ 



N \M I 111 

I- '.ri! 1 !< 



!: !!• I'll IM, \' i: 
' >\ I \ III I u 

> I . 1 1 • ' 1 ' i ■ . u i ; ' ! 



M \ 1 !>i: \ NAMj; 
t»l Mnrill'.K 



lUKiii iM \' i: 

<>l' MnTin-.K 
( Slat( or I'liniit ] \ 





.^t 



^V\; 







MEDICAL CERTIFICATE OF DEATH 

UA Ti-: t >i urAiii 



Month') 



/QoH 



'Day) (Vfar) 

1 lli-.KI'irA' e !•: k'ril'V, That I atUMidiMl (U'cc-asiMl from 

■ 1 90 to ~~ I()0 

tliat I last <a\v li alive 011 Mp 

and tliaf death ociaini'il, (a 1 lu- dau- ^tat(.d ahovc, at 

M. Thr CWISI". (>!'' DI'.ATII was as follows: 



T 



or k A 'I' ION )V</;s 

e ON ri-j li'.r'i'ouv 



Month: 



l\i\ 



//()!! IS 



XL, 




I >i I I 1' \ 111 t.\ 



;Yn - 




./-wcL 



h't-^iih'if ill Siiu I'liiiii • III 



1/../////. 



/><n 



rni" \n<»vi'. srxri'.f) i-t- rson \i, r \k 1 i>ri. \ks ak 1: tki !• T( . 1 i: i-. 
in>r Ml MS' KN'i >\\ 1,1 i)( , I-: AM» r.i'.i.ii:!- 



' I n fi .! !n:in1 



J i ^w 



N.Mrcss 






DIRAIION 




)"((//'.S" 



Mo)illis 



SIGNED) (H^. fc v]<o|vX^\, 

(jXlvt 11 i.)o'i f Addnss) U(yt< 



I\xvs 




Special information -"i^ t"r Hns|tiWls, Insfitulions, fransienfs, 
or Rpri-nl Rfsidrnts, .mil persons dyinij <m.i\ Iror.i home. 



Former or 
L'siJdl Rcsidrnre 

Whrn Ma<; disrnsr. (onlr.irted, 
If not fli pl.Kf of <lp<)lh ? 



How lonq .it 
Pl.i( r of Oedth ? 



. Diiys 



I'lACFOl IM UI\I, OK Kl.MoXAI, 




I \JI- ..! W I'AI. ■>; !-: i:M()\' \I, 



M 






IW.« MilM < 



■ ■wii— — r^w^ 



,. ».— .,;verv item ot' •,nf„rm,.f.on nhould be cHrcfully suppliuM.. AGB Hhauhl he stnte.i l-X^VCTLY PMVSICI \>S „hould 
Htntc CAUSi; OF' OliATH ui ph.in terms, that it m:.> he properly cluKsi^icl. The Speciiil InlormutMm Vor per- 
son* tlyinji iiwny from home shoiihl he feiven in every instnnce. 



'♦dWMHMW 



Itfl 








i 




• 


r 


' 


1 


i 


i : !) 




1 




, 


.' 


! 


- 




I 


i » 


1 


1 •' 


^ 


1 


f 






■ i 





li j 


t u 

* 




' .. ' 



I'l 



I ! 



•<■ 



'■ III 



^ ! 



imuft" ' 



i^f 



^^'y-H^^.^. 



)> ( iM 





)i 



''I 






WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/>nfr n/cfi, axUtx/>-y^Lov Q.b ^'^^^"^ 



.<H-CV^O 




Bei^islci'ed Xo, 



1911 



\VM 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco 



Certificate of Beatb 



"U. 5. t?tnn^al•^ 



-{ % 



J <?i^ 



PLACE OF DEATH: — County of' 



Ua'^'0\xtAxcc<L^o City of vJ-CCv O.^^a-YvCcAc o 



No. 15 10 vijxLcKa 



> '_' 



. ^ 



\^ 



St.; Dist.; bet. 

IIDEI 
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I! 



'aAM 



ill 



and J 



ti 



/ ir DEATH OCCURS AWAY TROM USUAL R E S I D E N C E G 1 V E TACTS CALLED TOR UNDER "SPECIAL INFORMATION" ^ 
( ,P ^..,^ ^...,.. = .0 .^ » ^ocp.TA. OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



-'LA 



ItA'l 1 



\' 1-; 



PERSONAL AND STATISTICAL PARTICULARS 

r^ r < 1 1 . ' I K \ 





\r m: h 



'»\ ai I 



t.- 



u I I'l '\\ i:i> ou i>i\ ( tKri; I) 

iWiiti ill ^itiial (h Hij.' luiti.m) 



r, !!■'!■ HIM ^ \i'l' 



ni 



<XV\AX<i 



NAMI-: »>I" 
1 N'l'li (-K 



II' I \ I II 1: K 



Ml Mol'lll-.K 



1; M' ill I' I. \(' 1-: 

()!• M(tllli:K 
(Stall- ni «.'<ninti \ * 




MEDICAL CERTIFICATE OF DEATH 

DA Tl': ( M I>i; \ Til i 



1M>* 



IQO i 

iVcar) 



I'M. Hit 10 'Day 

] !ii:i<i:i'A' ri:RriI"\'. I'liat I atUMuKd tlccrascd fmiii 

' ~" Up to IC)0 

lliat I last saw li ~ — alivoiMi KjO 



aii'l thai (Uatli iktuitciI, ijii tlu' il.tti. siatr.j a1)n\T, at 



M. TliL- C.\rSl{ 01' I)i:.\ Til \sijs as follows: 



i.. 



C 



-., cU 



1)1 k ATION )',\}is 

coNiK I inrokN' 



Month: 



Days 



I /outs 



DIRATIO-N .. )\-,!)s _ Mmilh 

SIGNED )LO\Ci ' 



^.U). 







Hours 

M.D. 



( i> . I 1 



vJVcXwv^rC^CV- • 

iKi-sldrd III Sail 1; iiiii i^r,) I L) ">■•' < 



M.'iiHn 



/!.:).■ 



ri! 1: \iu)\i<: s r \ it: '> im'Kson \i. r \iv' ri*T i. \i^s ak i; i'k '!•: lo i"ii i-; 
i:i;-.i'oi' MS' KN< >\\i,i;i)' .!■: xn!> i'.i;i,n; i' 



( 1 n '"■)■ iiiai 



,t HlVv) Ll/>^AVCU \J n. v£)x/^<i^<. 




^\,Mlc-s I 5 10 



xoCL.^v<x^va 



\4 



OxIaIaH rc,oH fA.lOros.) Uv<nviMV.).U' <-v 



QxKt '.Oj 



^ 



Special Information '•n'y f'»r iiosiMidis, institutions, Trijnsienfs, 

or Keiciit RpMdfnIs, diid [tfr>(ins dvin'i (may Iron home. 



Former or 
llsuiil Residence 

When was disease fonlratfed, 
If not at plate of death ? 



How long at 
Plat e of Death ? 



. Days 



i'i,A(.")', »>i' luk I \i. Ml.; i-;i;mm\ai. 



INDl-.R TAKl.K 




1 \ ji' .1! ii 1.1 \i "1 K i-:mm\ AI, 



6Jl\<X '3^b T90H 



k^jr*^ 1 01 10 ■ 



IN. ».— r.verv Item oV Information ahould b. cMrcfuIly .supplied. AdR Hho:.hl bo «t»tecl ».X^CTLY. IMIYSICI ANS Kh<.uld 
state CAlISr: or DHATH in plain terms, thot it may be properly clussirieil. The Special ln»orm,ition ^or p«r- 
Kons clyin^ away from homo Hhotild be <tiven in every instance. 







ill 


■4 


' i - 


1' 


5 

i 





u: 



•:i 




i ; 



I .1 



« i 







r* 



'if 



(•*>*"' 




ti! 



U 



I iH 



i\ i 



i I 




M 




,^,,i.-#iiii^i. 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 . I . X' 



^•.#»-!Wn^,_ 



?-i>. i;.V ]• (• 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 



/)(f/f' nic^L 





v1jL-r^\iaA; IId 



l!i(f\ 



llei^isfci'od -jYo, 



1912 



A^ 




.^u Deputy J wealth Officer 

DEPART.^IENT OF PUBLIC HEALTH-=City and County of San Francisco 



Ccvtificate of Bcatb 



11. ti'. i?tall^al•^ j 



^ 



PLACE OF DEATH: — County of 0'Cl.>\j ;va.^^x:UiC 



City ofC)/Ct>\> AO, 



y\yZ.^-ii <:l c. 



6l 



St.; I Dist.;bet>iuA>adxA>'CXc\, and 



/ IF DTATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER S P E C I fiL INFORMAT 
(, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET JaND NUMBE 



ION" N 

R. / 



.X 



FULL NAME 

PERSONAL AND STATISTICAL PARTICULARS 




'COJ 



i 



Xrvx 

: I \ n. ' u i;!iv rii 




LI 



^ 



\ ' . I •: 



l-^ 



/',/! 



-iNt .!.i" MAR K n:i» 

\v 11)1 1\\ j:i) < •« i>i\< •'•v)'i) 

•■ Wi it'' ill -". i-i' '!< -ir li it ;• n ' 



.clWouiL 



'. StMtf ' if I "■ .unt 1 \ 



NAMl (>l 
1 \ I'll Ik 



IUi< III I'l, \' l: 

«>! I A rm:K 

--' ' ■ t'l rll lit I \ 



maii)i:n n\mi: 

()!■■ M(>T!I1:K 



niK in n. \i v, 

f '->tri(. Ill t"".ui!t1 \ 






'X'>viit<n'v 



MEDICAL CERTIFICATE OF DEATH 

I>A II'. • >!■' I'l: A Til y 



fM..iJh) 



il);ivl (Vi'lir) 



0. 



I II 1. !■; i.I'.N' Ci;U'riI'\', That I .-Uc'iiiKd (Ici'cascd fpim 



tlial I la<1 ^.i\\ h alivfon OXy^X ino i 

ami tlial death ncciirrctl, on Ihc A:\\v staU-fl a1)nvi', at CV,vV-^<,<X 
10 k; M Thr CWrSh; Ol- DI-ATII was as follows: 

a... . . 





"II I'A'l Ii 'N 



-r ol- MY KN(i\\'I,i:iH,I'; AM) jfl'.I.II'.l-' 



I III \i'.n\ r: sr \iM.i) iM'R sdx \i, !• \i-: rii'r I. \Ks A u !'■. TK I i i' 
•;n(i\\'i,i:ih, 



I MM 



n 11 f. >i inrnit 



Cl."^iAxiLL\'. 



XMi'-s loOX 



DTK A'l'loN i )',w/\ 



c(».\'i"i<ii;r'i"<>RV 



lU. 



DIRA'I'ION )'<'.(i 



Months 

f 






/hns 



I lours 



fhiys 



I loKfS 

M.D. 



I () ' I 

(SIGNED ) LaA\U\A)XOL v1 cr\A 

iolis, Trdnsicnts, 



SPECIAL INFORMATION ""ly for Hospitals, Instilulio 
or Rpirnl Rcsiilfnls, hii'I persons dyinq dHdV from l)omp. 



fOrmrr or 
ljsu.ll Rfsidfnce 

Wfirn was disease (ontrarled, 
If not fit pld( e of dr,ilfi ? 



How long at 
I'lare of Death ? 



Days 



.ATI-: Ol IMUIAI. <iK KI'.Mi iVA 1, 




I \:j'i. m! I'.i in.\i. "I K l-;\!<)\ \l, 

OJL^\t X^ 190H 






N. n. 



-r.verv Item of inV.rm^.tJon «h„ulcl he carefully supplied. A(iR shouhl be «tnte,l FiX^CTLY. PHYSICIANS hHouUI 
Htiitc CAlJSi: Of- ni^ATII ill phiin terms, thnt it rm.y be properly cInHHiltieil. The "Special In^ormiition" \or pt#r- 
son« (lyinji Hwny from hone should be feiven in every instnnce. 



i^jOMMU^i'''^^'^ 



Tw 



i 



■I 






!l 



ll 

I 

-ii 



I ' 



:' ' 






I: 



r 



1 1 







■ll 



1 1 



' ' m 



* i I 



! 



.^ 



1 ' 



f:" ■ " 



\ 



\\ 










W 



\ 



\ 



f 




i 





If*^^^ 


ni 


\ . 




1 


\ ' ' r*' • 


' \ ■: 


' v\ 


\ • ■' 


rl^iU 


' \ . \- 


\ 111] 


1 < 


1 


^MH 


^'k 


\m\ 


J 




\ 


fW 




VIVJ M 


lii 






i 


A 


i 


i 


f 


■ h 



w 



RITE PLAINLY WITH UNFADING INK 



I-, .-.1.1 ..f H. ;!lll 1 



nSiV V 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■JIMIiWilWII 



Deputy Health Officer 



llec^isfcrcd J\^o, 



913 



d^^M^A^A^O 




DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of IDeatb 

( "U. 5. Jr1tan^av^ ) 
PLACF OF DEATH: — County ofO<XA%. O.'va-^vcvXi t,. City of l) CX-^x- .VCXy-vA.cv«. <■; , 



No. II 





cX'd- 



Su 



Dist.; bet. 






and VJXV<X.l-txX-: 



/ IF DEATH OCCURA AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALIED FOR UNDER * '^P E C I A L ' ^ FORMAT I O N • " \ 
( Tf DEATH OCcUrRFD .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S-^EET AND NUMBER. J 



) 



^Di^ ^ 



FULL NAME Ur^V^id ol LULvvxA u ' •. AoXi 



\jXt>' 



PERSONAL AND STATISTICAL PARTICULARS 



-I .\ 



Ii A'l 



\ iXcxLc 



i( U.i "R 



IK I'll 




r, 



Ui 



I ! ):i\ 



.1/. /////' 



S'<;il ) 



/;,/!- 



w ii»« >\\ i: i) nk Divokr i;i) 

Wiit'in M>ci;il (i'sitjriuition) 



i 



HIK rUl'i. \v'l' 

' St, it ■ "I- t'' ilMllI \ 



\ \\n: ()i 
lATH i;k 



i!iKi"ii I'l, \ri-: 
oi I athi-'u 

' St.it I oi t,'()nmi v' 



< ii Ml I'i 11 1: K 



iMK rnri,A(M-: 
()!• Mt»rm-:K 

' Stilt' 'I', roiiiit I \- i 








» »<ri r A I ION 

l\'- ill I'll HI Si!}/ /'' tiii> i'l'ii 



)V,7 



M.^n'lr 



/'.:\' 



111!': \M«)VI<: ST xri'.I' VKKsoNAI, r AKl'Ifll.AKs ARl' TUri', TO Til I-; 
IU;sT OI- MV KNOWIJ'.IX".!-; AM) UI'.Ml'.I'" 



'I nfii: maiit 



b (J 



OA.^^"v\^ 




aiU<L Id. ff 



( \<l<lr<'s^ 



-'\N-^ 




/a^.4.^yv.• 



MEDICAL CERTIFICATE OF DEATH 

^MoAtli) 

I II i;k i; l'.\' CliRTll'V, Thai I atl<,iiilc(l (k'l^asiMl Irmn 

~ IijO to " 



X X I go \ 

(I)av) (Year) 



tliat I last saw h 



ali\C' oil 



■1()0 

T90 



and that flcatli . iccii rrcd, on thr «lato stated ahovc, at ~— ' 
M. The CArSl-; Oh" DIvATM was as follows: 

-<v d.^A. XvLl : OrvvCrl.^.....; <X' '<^k\<^v^, ^ 

l)ri<\TI<>.\ )'<ars Mo}ilhs /hns //ours 



)'(•(/;: 



I »r RATION 
(SIGNED) IIU>^ 



Mi^nths Pays 

ta ...... 



I I()0 ', 






» u ' 



I lours 
M.D. 



Special information '»"'y f'*'^ HosplLils, institutions, Transients, 
or Recent Residents, and persons dvin;) away fron liome. 



Former or 
Usual Residence 

Wlif n was disease rontrat ted, 
If not at place of death ? 



flow lonq at 
Place of Deaf 11 ? 



Days 



IIAJT: o! r.i ui \i, (m kl-:M(>\' \i, 
QXAvt >A' TQO! 



I'l.ACl", OI" lURIAI, OK Ki:Mn\AI 

r\iii-RTAKi-:R O&-V1I.C , J v) oJLt lX>AxCo \^o 

(A.i.itvs.^. Dl^^*^ vnX\A^v-c'w at. 



N. B._F.very item of InWmntlon should be c«refull.v suppIlcMl. ACiK sh.M.Id he stnted F.X JVCTLY PHYSICIANS should 
state CAlJSr OV DHATH In ph.in terms, that it may be properly classified. The Spcc.nl Information for p.r- 
sons dyini nwoy from home should be feiven in every instance. 



i^^i^j:^^^/- 






I 



I) 



11 






\<\ 



\ 



I 



i 



■| 



1.7 
( 



V 



M 






»^ 



%' 



; ^ 



:r 



j 



K.^ 



■m\ 



r 



1 1 



i > 



^if' 



» I 



t '■ 




*v.| 



me^ 



W\ 



<l 




Jlk4 



"HiT' > , 









. -jr -' T 11 'I — — — " 





II 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

1914 



Ifcmnl of Health-l- No i^ t-^^^WScV Co 



s 



Begisteved JSfo, 



lUilc FiUui ,(^j^^A^ lOO'i 

Deputy Health QfiTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 







Certificate of H)eatb 

( "CI. S. StanDarD ) 



PLACE OF DEATH: — County ofCW-^ Aa^vcu^ < City of Oxx/^ OA.a.^ 



VCCslC C 



rp^. 




■* , *-^' 



cuvOj ^1' a^v^t^A; ^v <s^. ):\ L va 



.A 



St 



Dist«; bet. 



and 



/ IF DC*TH OCCURS AWAY FROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER "SPECIAL ' ^ ^ OR M ATIO N " -V 
C IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



) 



FULL NAME 




^-CLA^^^A„Ltj 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

C()I/)R 



lU 



aU 




\ 



.w^ 



i.. 



i).\ri-; <»i- iiiKTH 



AC H 




1 



Mt.iitli) \ 






\\ ,„„. H 



(I)av) 



M, mills 



(Year; 



Dux. 



sIXC.I.K, MAKKIKI) 
WinnU KI> OK l)I\'<)K(.l-:i) 

I Writ* ill MH'ial dc'^iv'iiiition) 



lUKI'MPl.AOK 

(Statf or t."'»intrv^ 



NAMI-: «M" 
lATin-.R 



lURTUIM.ACK 
()!• lATHKK 
(State or Counti V 



MAIDI'.N NAM I". 
Ol- MOTIIKR 



HIRrill'LAl'K 
n|. MorilKR 
(Statt- or Counlrv^ 



OCCUPATION 



^ 




\ouv\AxdL 






(Year) 



/vtX^xcL 




\' 



Rfsiiirii ill San f'KJiirisrn 15" )''"* *" ^/"iil>i' 



Ihn. 



\'\\V. AHOVK STATl-:i) I'KRSONAI. PAR 1 liT I.ARS ARl", fRlH T< > rHJ-: 
HHST <)I- MV KNOWIJ-.IX.K AND PKMl-.K 



Infotmant \ \\j\A VjVOvAaJLJX 






(Address 



HlO g.K^<xaji>vO,fc 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATH v 

dxl^t 1^,, 

(Moiilh) (Day) 

I III':KI<:HV CIvRTII-V, That I attcmlcd decoascMl from 

...O.X^ %X 190I to OX^t ^5: igoH 

that I last saw li - • alive on d-L^xt,. J^^S 190 . 

and that <k'ath occurred, on the date stated above, attx\ro-vvXJ 
IjSS^M. The CArSp; Ol' DlvATII was as follows: 
OuX^vvUMJlxyCLCv^. jfV^p'vv.cyaAXK.ut. iXA^Ar. i.xvx>-cLi.avjcU'...'..i.<..L..' 

DI-RATIONI'I^ Vfars'^'^'^^y^mTfh Days I/ours 
CONTRIIU'TORY cL' u^^ij. av <U. &^^'^"t^v^^ to 

or RATION )V(7;x \ Months Davs Hours 

(Signed) \j . o . ^) av-^vu^-^-y^ M.D. 

x'pt 11 i»)oH (Address) ?)C5 vJaW..:. vj^.llcv 

nsients, 



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

Former or (j , a r \ 1 w ^ J '^ ; How lonq at 
Usual Residence I i L VJ^VV<Xa..' Place of Death? 

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



Days 



PI,ACK OF lURlAI, OR KHMo\ Ai. 
INDl'.RTAKKR >' ^J 

U a 



(Adtlrtss 



i)Ap:<)f Mt KiAi, or ri<;movai, 

2)0 S Qrnfr>vLa>u llv^ 



■^ 




Adui; 



"^^^E^^tWI* 



N. B.— F.very item o^ information .hould be carefully Hupplied. AGE «houId be stntcl EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The Special Information for per- 
sons dyln& away from home should be feiven in every instance. 



,ikm^'^^^^^'^^* 



i . \ 








' ' . 



\: 



I 



• HI I 



' 



M ; * I ! 



...Sl*^:'^'^*^^'^ 



« 




m 



a 



ii H 






WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ii.,:ii.l (.f Iliiilth I' No !■ 



■^^3S|^ MM' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed, DA. 





lb 



190'[ 



Be^istercd JS^o, 



\ 915 




Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of Beatb 

( "a. S. StanDarD ) 

P Op ^ ^ 

f XX-y V J XOL > vC L4 e L City of O/W) J ,\.<VrL CAA^^ c 



PLACE OF DEATH: — County o 






/ IF DCATM OCCURS A^VAV FROM USUAL 
\ IF DEATH OCCURRED IN A HOSPITAL 



St. 



F DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS 

OR INSTITUTION GIVE •"■ 



FULL NAME 



Dist.;bet. and 

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

(LuLLl-l y vllcrcL\A,o; . 



PERSONAL AND STATISTICAL PARTICULARS 



li-ivd,. 



i)\Ti-; »)i- lUKTn 



\<.K 




iMoiitli) 



V. s. ) 'I' I 



as 

(Diiv) 



M.->,lli^ 



('i'c:ir) 



n,ty: 



SINC. I.K, MAKKIKl) 
WIlXiWMI) OR IH\(»Kt»:n 
(Writtin >^<KM:tl il<>-i>.'ii;iti'iii) 



liA^cLc'.' ' ■ '^ 



lUK rm'i.At'i-: 

'Stiitf or <"i)iiiiti yi 



NAMl". <)I 
FATHKR 



HIR lIlIM.ArK 
«)l' lArilKR 
'State or c'ouiitry' 



maii)i;n NAM1-; 

<)1- MOTMI-.R 



JURTMl'LACK 
<)l- MuTMKR 
^Statf or Coiiiitr> 1 



OCCII'ATION 




I 



CUl-^ OuC/>'\ V.V.CL.L 



tL 



/trVX^yA; 



f 




( rLou^^<x.Qji 



OU^^<X. Q^ Vw^L-- 







AJ. 



I IcV.ClAOvOK^Ul.'l^LL^ 



h'fUilfii ill '^iltl /liDh/} 



)V„i 



M,>iilli- 



n,i\ 



TUl-: AUOVK ST\Ii:i) I'KRSONAI, J'A R r If T l.A R S A R I'. TRl H in Till*. 
HKST OF MV J»i^<)\VLi:i)<'. H AND IW'.MJ'.I- 



^Infidinaiit 



(^A'lilrc"*s 



\a.mJkJL' 



Vy-VU \.XX.. - 



190 \ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DA TK OF D1;aTM 

Uxlxl' .15... 

(Mont'Ji) (Day) 

I II1:KI':I5V CI:RTI1'V, That I attciKU-d dcccasca from 

\X}^^ '/•. 190M to ....^-t^vt "X^ 190*1 

that I last saw h ••• ahve on J-X^^x\ Kp 

and that death occurred, on the (hitc stated al)ove, at 
. M. The CATS!': Ol' DlvATII was as follows: 



LJr^Jv<rY^.<^-^ \J ' \\.\-^ocx.\.oLawL\^ 



Dl'RA'I'ION Years Months Days Hours 
CONTKIHUTORY vllv^..^fr'>:^-<v^..Al.ljLk 



DTRATION 
(SIGNED ) Lv . Vj 

dxkt 15 I 



,1. . . (-■ 
) 'ears 



Mouths 



I^ays 




rqo 



. V^1AAA-A.rvv 

(Ad.lress) UA) . d.vJkjt< 



Hours 
M.D. 



o-<i|A 



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

Former or (1 ? ' (^ f How lonq at ^ 

Usual ResidencrJ^-^f^^*^^'^'^ VwOjb Place of Oeatli? Days 

When was disease contracted, ] i 
If not at place of death ? W^r'^X.i^ 



I'l.ACK OF HIRIAI, <JR RHMoVAI. 



DA'n"o! HiKlAl, or RFIMOVAI. 

n:^' 190. 



NDl-RTAKHK O^-VX^Jl/VA. O 'tXAX Lv\ ul.Q %.( 

^.,*. (\\A . . _ ~\i 



f Address ^H 't "^ ^\\\. 



\^>^Vtn!V 



dl 



of InformetJon .houhl be c.rcfully Huppliccl. ACIB «houlcl bo stated BXACTLY. PHYSICIANS •hould 
E OF DEATH in pinin term., that it may be properly classified. The Special Information for p«r- 




N. B.— — Bvery item 

state CAUSE 

sons dyinft away from home should be <liven in every instance. 



.^4i**fi*:^-> 



Ml 



' 



i ■4" 

t 1 

1 

..1 



\ i 






. \ 
I'-i 



1 



1' 



I f. . 






*l 



. 1 



\ f 






I'. 

I 



*! I 



<l 



11)1 



g^P-^iJijMi-'i- 



1 1.^ 



\ - 



I 



11 



I ill 



'I 



Ik 



li 



IA\ 



)>^l 



WR 



ITE PLAINLY WITH UNFADING INK — TH'S IS A PERMANENT RECORD 



Hoanl of H- alth I- No. i ^ '^•-^Hlir* ^'^^' ^'' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



190\ 
OfTicer 



Beglstercd J\^o, 



1916 



Date ri/cd, dx^tt^vkcNj 9x1 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( tl. S. StanDarO ) 









(^ 



PLACE OF DEATH: — County of^ a^\. Va^vCUX^ City of OCL^V O^XXAXCUXO 



No. TH 



-'Ilk 



11 



.CA 



and 



.<LcLu 



^.. )\ St.; cL Dist.; bet. - ^ 

/ 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 ' • \ / 

V IF DEATH OCCURRID IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J \] 



X 9 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



FiCi 



4 I VajLiL 

i)\ii': 111 itiK III 



COI.OR 



-,i..t 



CV. >A 

(iMonlh) 



\' .!•; 



IrO 



) 



(Davl 



Moulin 



(V.;il) 



MEDICAL CERTIFICATE OF DEATH 

UATK OF DKATH 



(Year) 



10 



Ihix 



^IN< .I,!-:, MARK ii:i> 

u 11)1 )\vi<:i) OK i)i\ < »Ki ):i) 

iWiil' ill vi,(i;il (|(■-i^'tl.llill)|) 



UiU TIII'LM'l-: 

(Sl.itf or r.iHiiti \'^ 



\ \MI', Ol" 

!• A I II i:k 



lUK rillM.ACK 
or I-AIJIMK 

(State or *.'ouiilt \ ) 



M \I!>i:n N \M1. 
()l Mtt'l'lli: l< 



lUKI'IM'I.AdC 
Ol' MoTIII'.K 

( Sl;il( III rolllll I \ > 



orcirA iioN 






t 



L 



''t'x^■^va^vv| 



LoL^^vlvtVa 



I 



(Moilth) (Day) 

I lll'KlvHV CI-RTll'V, That I attended (Icroascd from 

.bj\\ 'h i9o3 to.UX.i:\t. .^.1 np'i 

tliat I last saw h ' alive on UX^\.V 'W npi 

and that death oeeiirred, on the date stated above, at -'-. 
^^ M. The CAlSlv ()!• DIvATII was as follows: 



V. Ol >\ ZjJ\j. CrV Xa\X. VM\, oAaa >^- Y 



I )r RATION X )'fars 
CONTKIIU'TORV 



Mo Hi/is 



/>avs 



//ours 



I ) r R A T I ( ) N' J'tdis Months 



Pays 



//ours 



(SIGI 

'^x\yX> lb t.)oH ( 



M.D. 



X.ldr.-ss) la'lO dlvtltV * it 



X\^'y\.<X^\i 



\ 



h'f^lih'il III Silll I liUlilu-i 



I )V,M> 1 



Mnnlliy 



lhi\ 



III I", AHO\I-: SIN II-: I > I' KK SON A I. I' \ K r 1*' T I.A KS AK I". TKri-: To rill-; 
\\\\XK Ol' MV KNo\VI,i:i)C.F, A\J) lUl.li:!' 



'I iifoTniant 



LLyv 



fy\.Oj ' '/C 



( \<Mn'SH 



10b 



( 



ky^vJU^^ 




Special Information only tor Hospitals, institutions, Irdnslents, 
or Recent Residents, diiil persons dying dWdy Irom home. 



Former or 
UsudI Residence 

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



flow long ^\ 
Plare of Death? 



. Days 



I'l.ACK Of" lU KIAI, OK KI;M0\AI, I I)\n:t,l Hiioxi. Ol KlvMoVAI, 



rSDllK lAK KK 



(Address ^HL M rLA.AAc<rV\j....OX 



M. B. V^y^ry Item otf Informiitlon ahoulcl be cnrefully Hupplicil. ACili should be Htntecl tiXACTLY. PHYSICIANS Hhould 

iitHtc CAIJSI: OP DIIATH in pliiin term*, thnt It miiy be properly claiinilfied. The **Spccl«l InformHUon" *or p«r- 
nnn« dyini^ owny from home Hhould be l^lven in 9\9Ty instance. 



J . 1 




i! 





t • 



II 



I I ( 



» ! 



l!li"f 





WW\W'\:W[^^^ ' 


■ fJu^Hi&'il 1 1 


1 





I 



II f 



if 



^\ l! 



II 



r 

Mi 

%!, Ji, 



, I 




y 



>l( ii mi 



^M 



75i 



WRITE PLAINLY WITH UNFADING INK 



I'.iKirdjttfJI' '''i '■ ^'^ 



li.'vr I" 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



Dn/c ri/i'd , dX 





9vb 



n)()'{ 



Jh'l^is/r/rd .yV^v. 



1917 



A-A,^ 



XiL 



v^< 



DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of Beat!) 

( 11. S. i5tanC>avC» ) 



N 



oJTl^ Oxd^ 



St.; i Dist.;bet/3jAA.^k<X>X<X^v and ^i.<XO,LA^yVwO. ) 

• ■e^iiHi DC-CinrMrr riur FarT<5 called FOR UNDER "special INFORMATION ' ' \ \ 

( '^ .v;rA.°^^:;c"u%;r;,N"rHo"s^rA:: rR'"^?nTu"4^N"oi;r.;i name .nsxead of street and nu.ber. ; i 



FULL NAME 



rU^ 



A^<X\yKjLU. 



I , \ 



PERSONAL AND STATISTICAL PARTICULARS 




ol\ 



Kill 



lliDi 



M. nl h 



H 



\' . i; 



,^'? 



^INt .1,1' M \KI; ll'.I> 

W 1 1 >. i\'. Ill Ml.; I f\'( ij.' > I 1 1 



MIKIMII'I, Ai"!-: 

' Slit' Ml I'mmt I \ 



V \ M ) 1)1 

lATii i;k 



iMiii'ii ri. \i' }•: 

nl- I A III 1. 1< 

' StMtc '.I iMlllltl \ I 



^1 \ IIM M 1. 

Ill \|i I I II 1 K 




!UK Til I'l, Ml.; 
»»!■ MnTIIl-R 

' '^ I ,■ I ' . . ! ( . . U M 1 \ ' 



CXvYoJ>Uw'k iJxclk;^ 



M ' I 






/. 



'-'/■/(//-' i>! Siiii I'l mil !'i-n ."^iV; )V' 



,f> t •• \]<<iilh- 



Day. 



1 in \uovi-. sr\'n:i) im- ushnai, paui I'TLAUS ari-, i-ri i". to tiii-; 
i!i>r <>i- Mv KNOW i,i;i)<'.i\ANn JU';i.n%H* 



(Inf'i tiKiiil 







( Xfldrcss 



t. 



IVAEDICAL CERTIFICATE OF DEATH 

DA'II'. " 'i I'l, \ III J? 



Jxl\t' 

Mi.iit'li) 



(I);iv) 



(S'fiii) 



I lli;Ul';r.\ CI.RTII'N', TIimI I .iltcipUil ilccr.i'^i-il from 

^"^X a-, 1 1./' tn cixVvt an i(,oM 



tliat Mast ^iiw 1l ..iivfon ...^.^-^ -i up 1 

aii-l that ilratli < iccii irc'il, on tlic <lat».- <taliil ahovi-, a1 l- O 
) M, 'I'lu- CM SI-; (»!•' !)!■;. \'ril w.is as follows: 
OJL-vaX^cX^vvx?. cL\.a_L X/C VO. V 



f\J^ 



n 



I)IK.\'ri()N )'inis "O Mo)i(h'< /'<nv 

CONTKIi'.r TokV 

(SIGNED ) M I Ux\iX-v'vV\X<xe^vQ.A>-x-'' /-.. • ^ 



//(>//rs 




I lipids 

M.D. 



C 



^f) T()0 *1 ( 



SPECIAL Information only Jitr llospildls, Inslilulions, frdnsifnls, 
or Rctcnt Residents, and persons dyin;| away fro n' home. 



Former or 
Usuiil Residence 

When was disease fonlr.irfed, 
If not at plare of death ? 



How lonq at 
Place of Death ? 



Days 



1J,A("H OF HIKIAI. OR R|;N!o\AI, 




KArKi)!" HrHlAl, (U R1;Mo\'AI, 



(Acltlross 



X. K.- 



-l.very item o? inWm«tlon .hould b. cn.o,' ..ly supplied. AGH nhoul.l b« «t»tcd HXACT. Y »;»^*^'C"AN 8 should 
Mtntc CAUSE OP DEATH 5n plain tern... thnt it m»y be properly classified. The Special Information for per- 
son* dylnft away from home should be Iven in every instance. 




• i 




1'ff" 

'"■•III 



•I 










, . ( ' 



il 



I I 



||S 



-•Jfc'i 



I - 



1 ti: 



lit 



>iit 



I 



! 




; 1. 



t < 



I 



lllfl 



i I 



i 



*■' 



t M'MH^Xi. ;» »iau 



WRITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J! 



Dfffr F/7rf/, Qx}^<)Ui^\ijiX; ^\o J'^^^'i 



llci^ish'rrd Xo. 



1D1S 



d^^^r^cv/^^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate ot IDcatb 

PLACE OF DEATH : — County of C \a-.A; J /uO/wtcAC c City of O O/rv J .Vo.'wc^*. ^ t 




ll 



'\J^ \X^KAh.K-\ 



Su 



Dist.; bet. 



and 



CUBS AWAY FRi)M USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \ 
^ " NSTEAO OF STREET AND NUMBER. / 



DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME II 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




VVCL/TV/^'VOj CUyvA 



-i.\ 



>\\v. »)!■ r.iK rii 



COl.' iK 



r!,. 






(l);ivt 



\ I . r. 



siN'.i.i:, M\Ki<ii:i) 



, , , 1 , 1 .,..;..,,.. I ;,, I , t 



'^^x 



HI urn j'l. \ri-: 

iStatf or <'cniiUi \ 



\ \M1 < »i 
1 A III )■ R 



HiK rn I'l. \cv. 

Ol- lATlll'.k 

I SI ' ' ■ *"i lUiiti \ ' 



NT\II)1:N NAMl', 
nl' M()'ni};R 



i;iKi'iiri,Ari-: 
<M- M(>Tm';R 

' "-triti I ll' ('< unit 1 \ 



I >i A' 1 !• \ii, i.\ 



.1 



^ 



(^ 




0^y\) ^ .^XX.^vOC^ 



MEDICAL CERTIFICATE OF DEATH 

DATl'; <>!• I)1;A III 






(I):iV» (War 



f:\t..iitli) 

I 1 I !•: K i:r.\' C" I. UTI I'W That I :itU'iiiK-<l <K-ixasfil frciii 
sA-LCQ K^nM to OXX\X.. ')n'^ u,o H 

tliat ! la<l saw li ■ " .iliM-cii QX\-^JI ' '- up 

aii'l tliat (Icatli oi^urrcil, oii the <latr sI.-iUmI above, at 
- M. '!"hi' CArSI'! ()!■ Dl'ATlI \va^ a'^ follows: 



\ •-. 



\:ij> 



'"• \r,uiii<'h[.. !■■ 



Tin, \|(i.\r. sT \ 11 I) !'i.K^( tX \1, r\KII' ri. \RS ARi- TKri- To rill- 

r.i-.sToi' My K Ni 'W i,i:i)i ,1-: and iii'i.ii"!'' 



1)1" RATION )'i-ars 

t'oNTRir.riORV 

DCRATION 
(SIGNED ^ 

UJlixL %'k roo'. 



Months 



Da vs 



Hour. 



}'i,us X .UoN^hs 



/hn-s 







I /(>!() S 



M.D. 



\,i.iiv»s)\]\.\i\. cv%^ct iit!x.u.\u.j. 



Special information o^'y f<»r Hospitals, Institutions, Triinsients, 
or Rpteni Resiirnts, and persons dvlmi anay from fiomc. 



tormer or 
Isual Rcsiiirnre 

Whrn was diseasp rontrartpd. 
If not at place of deatfi ? 



How lonq at 
PIdfc of Death ? 



Days 



I'LACKOl' HI KI\!,«>K R!;Mo\AI 



1 90S 



lA^ I-, o; lil K- I \ I 



r X I ) 



... -11 .1-^,1 \(:F. s'loiild be stilted EXACTLY. PHYSICIANS should 

>. B. Hvery itc.n of •,nf..rm..t5on should b.- CMrctuIly supplied. A(.h s.iouU. »>e suit ..„,,^. . . ,nf„^,„„t:on" for n-r- 

statc CAlISn or DIZATH in pbnn terms, that It muy be properly class.V.ed. T he Spc.u.l Information Vor pT- 
Ronst dyinft nwny from home should be <»lven in every instance. 



^11 



i 



:ii 



! 1 



H 






i 



¥ 



Ik 



"'I! 



.) 1 



11 
'1 



1 1 

\ 



If 

t:.t 



!^ 



Jiui 







: I 



I S 



\ ,.A^ 

•i 



.i 



$im-^^-' 



^I0ifi^- 



•^^^^imt^M^'^i' 






" " 




Hi 



^' 







■0. 



! m 




I:M 



1 I 



! ( 




w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



;)!1&P Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)ff/(' ri/('r/,t)X.^^\kjU\-^l>XA} X\o I'^O'i 



liPi^is/ered J\^o, 



1919 






<3v/Cy\-^^A^ 



Deputy Heajth Officer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of Beatb 



11. 5. Stnji^av^ } 



PLACE OF DEATH: — County oiOOjy\) .\.ou-yxca^cx City of Cj <xa^ ^.o^a^^vA. ^^ c 



No.1^^0^ 



4 



su \ 



DEAfH OCC 

IF DtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



Dist.; bet. UrAJ^A.'^v.Lct^ 



/ IF DEAfH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPEdAL INFORMATION" \ 
^ ir nr«TM orniRRFn IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



and JA.a.'^v.cU.c.'-. ) 



FULL NAME 





\J ^}.\\^y 



-\.\ 



! > \ ; i , ' ' ! i ; I 



PERSONAL AND STATISTICAL PARTICULARS 




CLLv 



a 



' 9 



iMMiini) 



11 



> i \ 



MEDICAL CERTIFICATE OF DEATH 

"jxlvb 15 







1^1 



; • M \ i< K 1 III 

'A 11) i\v i:i» < >K i)'\"»tKri;i) 
\\:il. in sooial (!« si>.'iiat i<m) 



_\ 



C),L. 



\,< 



r. i I I I \ 



NAMi: tH- 

i-,\ Til i:i< 



i;i I-'. rm'i.A"!-: 
1 \ rin'.K 



MAIlM'. N XAMl'; 

"I .M<)rni:K 



: I inii iM, xii.; 

oi Mdlill-.R 
(State or Couiitt > 






€Ly\j JXCX^-vCCvi 



^ 



VOl-wH 




-vJJyw'CA 



i\ 



A VO, 



( 



o 



-^ 






I II I'K I'.I'.N' CI.I'l'rilN', That I alU'ipK-'l .IciT.isid fr.«iii 

c3_L\vt i</) 1 to ox\>X xs i.,oH 

that I last s.iw h .ilivcoti O-^vt . , Kp '1 

and that ihathi occurred, oii the datr stated al>o\c, at b 
U, M. Thi- CAI SIC 1)F Dl'.A'IH was as follow- 



vXcuCLa 



• ' . / 



.<J. 



I)!!-? A '1" ION )\ars 

c< )NTR ii;r r( )R\ 



Mo)illt'< I A. Pays IIo ii i s 



DTK All ON 



)'( (US 



Mi))itli> 



(SIG 



NED ) W. O. J^^ 



Ihiv 



'wC\w-C-^C>-^'\.' 



Ill 



\ 



.VCrVV.a,C< 



')cri 1- 



A'' iilcil III S,ni I'liui. Ill i )',/; 



1,',.//'//. I 1 /',n 



Till', AMOVl': STATKI) I'KR ^ •= "■ ^ '^ ' 

I'.l-.s'l* OI' MV_KN-i»\VI.l,i)' .)• V .i' >■• ;.il.l' 



I ; iM Till-: 



'^ 



J \Xxyy^< ul^JO\ 



\.<Ui 



(\i\<]V,-S< 



noi 



--uJ/Vfr^^Jo ' 5 A. 



dX^pjt 15 igo'\ fXddr.ss) 7 S i g AA^tLt^) ot 



I lino s 

M.D. 



Special Information <»nty tor lldspifals, Instilufions, Irdnsjents. 
nr Recent Residents, .ind persons dvin-i .iwdv fro-ii home. 



Former or 
UsurtI Residenrp 

Wlien H.1S dise,ise rontr.Kted, 
If not .it plrfie ol de,itft? 



tloH lonq at 
Pldre ot fledth ? 



Davs 



I'1,A( I'. < »!• I'.l K 1 \ I, ' ii: !: r.M< '". \I, 



^"^Lj^ 



DA'IJ'; of I'.l KiAi OI K 1-. Ml iVAI, 

3x1 vl :^i i9o\ 



rM-i:KTAisi:i< UoJCXvCtjl MfL- 






C. 



i^m^w^i* 



H. r.vcry item of '.nform.itHMi hHouI.! be ciirufully siippHcl. A'ili sh^ilil be Btate.l FiWCTLY. PJIYSICIANS Khould 

Htiitc CAUSI! of: DliATII in pliiin terms, that It m:iy he properly ^hissitietl. Tbc "SptcinI Itiformiition" for p«r- 
Rons <lyln4 iiway frnm homo shmilil be i^iven in every IiiHtiince. 



I >mmcmMi^^^' 



I 






\ 



I 
I 



I. 



A 



u 



w 






• i 



t 



\\ 



M't 




l|||: 



\ 



•'f*!* 




I 



l:i Kf j 



' (» 




I 




w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f i»_^i*i, 1 



1 e *»_^i*i. 



lUtP Po 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IX 







lUO^ 



ailh Ofilcer 



Ile^Lsfcred J\^o. 



19*20 




.{rv^^^ d.iLAM^ Deputy 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County ofOa^v JVa^xCUCO City of O-Ct/^^^ O.A.XX^^VCAAC.(. 

and ^X'xcKrwl 



No.^'iSC]aa^a>)- . '^ St.; Dist.;bet.Cy:UckU tv 

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



FULL NAME CNoi^Jo 



vo. 




-0^ 

I) \ 1 1 < 'I .:;i: ' li 



PERSONAL AND STATISTICAL PARTICULARS 

r( )i.t )K 



I. 



IViEDICAL CERTIFICATE OF DEATH 

I) A I'l', t)l Dl.A'I'll 






/ on ' i 

iVcar') 



A^i 



M. 11! h 



\' . 1'. 



•■^ 



i.i \-i 



MmiDi 



\\ I 111 »\vi;i) ( »R Div ( »Ke i:i> 

Write ill sdoial ih -i5.MMt ioii) 



-~l ' ' • 1 '■ iini 1 1 \ 




\ \ Ml I >: 

!• \Tli r K 



lilK III !•!, \^'\'. 

oi- I \ rii ]■ K 



MMhl'.N \\M1-: 
It! M<»Tin':K 



niK I'll IM, \i'l-, 
l»l Mullll'.R 
(St;lt( 1)1 Couiltl \ 



CUv\,oLcL 







vj 



I ili:ki;r.\' cm: RTII^N', Tliat I atton.Kd .l(iAa><t.Ml fri.tii 

to up 



; , ^p 

tliat I last saw li -^-^ alive on 



190 



ami that ik'atli < nau ncd. <iii tlu' «latr •-lalnl alxivr. at 

M. Tlu- CMS!-: Ol" l)i; \'ril was as ("dII-.u-,: 




DlkATIOX Years 

CONTl-: HU'I'( )RV 



Months 



l\ix 



Hours 



? 




h\- ::l?il in '<iOi l'i,ni,:-in \ ) r<ii 



w 



M.^rfh 



l'.:\ 



in !••, AU(»\I', Sj- \|-|;i» IM-'.Ns. .\ \1, PAUriCII. \!-'.s \K 1: IK \V. lO III )". 

p.i'.sT ni' MN' i;n<»\\ I.I ix'.i'. A\i> in:i,i!:i-' 



( In t'l II niriiit 






(Signed) LtrVcj^viiK; 



Months 



A.\V' 



1 'V 



I I()0 \ 






/ lours 
M.D. 



o 








^y 



O 



Special Information on'y '"^ HospitdK, insfifu[h)^s, irnnsifnts, 

or RtTcnl Residents, ,iii;l iicrsons (lyiii.'i ,i'a<i> Iio;ii home. 



former or 
I'siiiil Residence 

When w.is diseH<»p (onlrarted, 
If not at plare of de<ith? * 



How lonq at 
Pld(e of Dcitli ? 



. Days 



I'l.ACI'". < li IMK I \l, ( >i; K I'.Mt »\' \I, 



I) A'^:,!-; o: iii i<i \i, <.i k 1: mux'ai, 



INDl.K r XKI.K 



I'Ui-;.): Ill 
A ■■'■■ 



190 



3 n 'J\c^AAilx ;:\i 




':i 



i 



I 



I * 

h 



M< 



Hi 




if:;ti 



i 



i 



I 



r,. B._Hverv ito.n of 1„9.>r.n,.t1on should h. . ..ct'ull. s.-ppli..!. ACIP. nSouia bo ntnte^ FiX ACTLY P"VSICI ANS kHouIcI 
«tHtc CAllSt or ni:ATII in pti.in term., thnt 5t m..y he pr^.perly .l«HK.t.o.l. The Spccu.l Iniormul.on Vor p-r- 
Rons clyina Jiwny from home should he ^iven in every inslnnce. 



.1 ii^iii'inii"*^'^- 



J""^! 






i^ 



i I 



• I 



' t 





WR 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 1 t-it 1 1 tt t .^A*^. 



K US' V r 



RrrrR to back of CERTIFICATE FOR INSTRUCTIONS 



Dff/c n/i'd , 





ab 



/.V6>H 



»:islh OfTlcer 



Bniistrrcd <jYo. 



1920 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtiticatc of S)catb 

V 11. ii'. i5tan^av^ j 



4' (^ 



PLACE OF DEATH: — County 



of u a ^v J va^vcu cc) City of 0'a/>\^ o yV<x > v<^utc < 



N 



c^^^l 



Dist.; bet.C)X^^ 



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



and 



IcMV^-*^' ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




1 



I a.' 



i> 




,lu 



MEDICAL CERTIFICATE OF DEATH 

HA II. t)l- Dl'A'l'II Q 






(Dmv^ (Vr:ir'> 



MiiiUlr 



\i 



/)-; 



-^1 ■. ' , 1 1 M \ !< !v 1 1!) 

u iiM »\\i-;i) t)U i);\< >Kii;i) 

•Wiittiti sut'i.Ml (It -iLMi.itioii) 




CUv^-<.X-d- 




\ \ \! 1 M : 
1 \ rii IK 



OI' 1 A Till- K 

' St ■• i ■ 1 "i iiint I % 



M \I DI-.N N WIl''. 



IMK ill V\ \i 1 
OI- Mo'llII'.R 
(Stiitt Of *.'..uiiti v"i 



4 

(<L^\ v^ 





I lli:Ki:i'\' civ RTI !• V. 'I'liat 1 .itU'iKkd (UcAast-d fioni 

• 1 (^f) t( ) ~ : ~~~ ~ IqO 

tliat I V\< --.iw li - — ■ alivf (111 Tc)0 

aiiil that iKatli > icmi irtMJ, (Oi the ilalr stalrtl alxtvr, at 

M. Tlu' CWrSI'! OI" Di: \'ni was as follows: 



X 




1)1 RATION Yrar^ 

CONTKIIU TokV 



Moiillr 



Hays 



1 lours 



kJ 



b 



Q 



I lour 



? 



•OlAA; 



h'r-:,h:! ill San I'l ,111. i-r,> S )'.-<n < 



1/,. ;;///. 



/',,•! 



rm: \M()\i'. sTA'n'.n pkkson \i, pak rKM'i.Aus ak j: iki !•: t«> th i: 

r.l.sr n|- MV KN(>\\I,i:!)t'. !•; AM) lUM.n'.l- 



( In r.M iiiMiil 






!)rR.\'ri<>N )V(//,v JA';////.v /^^n.v 

NED ) LtrVd^xXK^ VX) Ll). dolloL-vAxi.. M.D. 

f Address) Lc'\^'>vi,\^ U-I^.L'^r. 



(SIGI 

'A.^,\A •■ \ |()0 '. 



Special information "n'y f'lr Hospitals, Instifufrons, Tninsirnls, 
or Recent Residents, and persons dyiii!) d"Ad> from home. 



Former or How lonq ,it 
llsii.ll Residence Pl«in' of De.itfi ? 

When was disen^se contracted, 
If not at place of death? ^ 


. Days 


1M<AC1-: nl- IMKIAI. oi; K1;M<i\\I< !> A'Ui; ..!" IMkiai. .h K ]•; 

1 ni)i;rt\k].;k vX- UJ. \I iIoXIa^'A^ V \l 

(Ad.lress 5 I ^ G' i -<XAAxii C^.i 


M<)\AI, 
TQO'I 



i 



( . 



i 



' 






• ) 



I ' 



ii^li 



I I 



I 



■: i ll 
•hiJl 



IN. B.— — livepy Item of Inform 
Htiite CAUSE OF DE. 
Hon* flying awny from home shoul 1 



,t-f W.•:^*7-.^V 



..tior, Hhoul.l he ..cfutly suppne.l. AdR h'iouUI ho stnte.l r.XACTLY. PHYSICIANS nhould 
\TH \n pinin te -ms. that It m»y he properly c!oH»ified. The vSpecinl Information for p«r- 



on in ovory inHtnnce. 



1 1 



J' 



Ui,!: I l! 




*«#«^' 






'W^ 




If 



I 

11 




^ 





. ^m ^ 



WR 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



orcro TH RAr.K op CERTIFICATE FOR INSTRUCTIONS 



/hffr nii'^L hx\<kjL\^JoJljKj Vo J'^^^'i 



liPo^i.stci'Cd J^'^O. 



i im 



CX./b'V'^-'V^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

A. <^ ^ ^ 

PLACE OF DEATH: — County ofO/a>\^ JX.ayAx<tULC.c City of OxX^V J.\,ay>x<l^<i.,c<. 



N 



o. "l^^C 




<Lksi.t ^v 



St.; 2l Dist.; bet. .J 't^ Z.\\X^. > . 



and^C^ 



xv^cH 



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



n 



FULL NAME vJaVO; 



1 - » 



PERSONAL AND STATISTICAL PARTICULARS 



(>i- i;ii<i"ii 




AX 



M. 



'D.iv 



\' . !•: 



( ^ 



--'M . 1.; ■.■ \u i; ! i: i> V 

'W'litiiii -(u-i;il <!!_si}.'iKitiiiiil 



IMI-'TIir! \'"1' 




\\ . . 



V^c(. 



MEDICAL CERTIFICATE OF DEATH 



DATj': ( »i' i>i: \\'\\ 



A 






at 

'Has- 



TOO 1 

(Vi-ar) 



I II IJ'i I'il'.N' ri:k'ril'\', That J .-ittni'K-il ilcccasfd frnm 
I . ' .vV icpH to gX'^'v't Xb T(p H 

tli.it I l;ist s;i\v h ... alivron Cj^'jaX 190 1 

aii'i thai (k'atli nccuired. on the datr ^taU'tl above, at t> 
'-.} M. Tlu' CWl SI'! ()!■ I)i:.\ril wa-. as follow.^ : 



N.\MI. Ill 

)• vrii i:k 



r. I kill n,.\i'M 

<>I" f'AIIIl K 



M.\1I»1-: N NAMl': 



i;iK ; li I'!, \ri". 
Ul' MoTIM'.K 
(Stntr or i"i)\niti y> 



nTl r \ i'h iN 




hi K\l"l()\ ^''^-^ Mo'ilh^ ^ />,/|s 1 J/oin.< 






/hivs 



DIR.XTION _)Vi/;^ Mouths 

(Signed) dU 0.>vt\n, >vx 



Ilouis 
M.D. 



Special information "n'y for llospitdls, institutions, Transients, 
or Recent Residents, and persons d\inq away fron home. 



A •■-,' /r-.' /" SilU I'l dill 'iM'O 



y.at. 



M.niflK 



l'.:v 



Tii!-: xuovv: sT.\ri{ i> i'krson \i, ivxinirr!, \ks a hi; rKti; r< > rii i-: 
iii'.sr oi' ?.iv KN. »\vi.i'.i)c. !•; \Nn i!i;i,ii'.!'' 



iil-.S r Ol' MV KNi »\VI. 
[nr..:in:int XJ I LOJV 






N. !5.. 




Former or 
Usual Residence 

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



How long at 
Place of Death ? 



navs 



IM^ACIC OI' IU"KI.\I. OK 1.:i:mo\.\1 

.') 



ri,A<. 



I>ATi;«>! r.rui.M. 1)1 R1:M()\AI, 

dX|a Vl 190': 



r.NDi' 






f.Xddi.ss 



-r.verv it.m of Jnf.,r,m.tion «houI.I be cirefully supplied. AGB hHo-.M be Htate.l r.XACTLY. PHYSICIANS should 
Htntc CAUSE OF DEATH In plain term*, that it may be pr.»perly classified. The Spccnl Information for per- 
sons dylnft away from home should be ftlven in every Instance. 



•«./S6J'-*Vt 



\ ■ 



;i 



ii. 



'\r\ 





mmuiMkmdk 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



C 'iiru I.I 111 a ic n r m> i 



"■«♦» luv r V K 



( 



tii< 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)a/r /•"//(' J „djJ,x"U~r>xLLV,lL 190\ 



Regititered JVo. 



\ i)22 



I 



^^<_^:i 



"1 



Deputy Heaiih Ofncer 



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



Ccvtiffcate of Bcatb 



( tl. S. StanDar? ) 



r^ 



fJS 



VCLOC< 



UN 

PLACE OF DEATH: — County of O^^V O.Va^vCcCi cc City of Oa^v Oxcto 
No. ^'iH • o V St.; i Dist.; bet. (rl^{ry>\/ and ot-aVVUlcvru ) 

/ IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V t FACTS CALLCD FOR UNDtR 'SPECrAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME '^-<JV 




SK\ 



1) A'l'i: <)|- lilK Til 



AC i; 



PERSONAL AND STATISTICAL PARTICULARS 





,/e.\..c. 



IkcU 






<I):iv) 



(Vr;ir) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH J, 

OXlvt XS 

(Dav) 



(Monlh) 



(Year) 



, 1 IIl{ki;HV CI-;RT1I-V, That I atteiKkd (Icrcascl fro 



) Id I 



6 Mouths 



n. 



rcpH 



^INt.Ij:. MAKKIi;i). 
UIDOWI.-.I) OK DIVOKl'Kr) 

• U'liti iti >^i)ci;il (It—iViiat i(iii) 



i!ik iHi'i.ArK 

< state- or (.'oiiiiti V I 



\ \M1 oi- 

i"A'riii:K 



lUKTMlM.ACK 
OI' l-AriiKK 
<St;itc or t'omiti yi 



MAIDllX NAM}-. 
OI Morill'.k 



Mik riiiM.Ari.; 
<>»• moti!i-:k 

'state or rouiitrv) 



i 






''' up'. to ....c5-^^i? "XS^ 

that I last saw h alive on OX.^.vt '^H ^^p 

and that ilialh orcurrcd, on the tlatt- stated alxivo. at vS^ 
vA M. The CAISIC ()!• I)i; Al'U was as follows: 



ni 




V { ^ 



DIRATION Years Mo>itlis X Days IC //onrs 
CONTK I lUTOR V .C\.\,iCr\A.A.Yv... d,\^t 



or RATI ON Years 3 Mo,t 



u 



.CL^Y^Ct' 



OvTl I'A TioN 

A'fwifn/ III Sail I'l ail, ism 



6£j 



/\iys 



Hours 



( SIGNED ) \. Vi). Clc{|-C.\-C^.. M.D 



(A.Mress) ^V\\ X^ 'h\A ^\ 



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



) I'a I » 



Moiillis - Days 



rni-: xhoxi.: statkd i'Kksoxai, PAKiirrr^AKs \ki-; tkih to tin; 
iti;sT oi- My KNo\vi.i';i)c.K and in;Mi:i- 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



(Address 



3 2)1- 3);uiot 



ri.ACK OI- lUKIAI, OK K1:Mo\AI, I D.yTllot Mimiai. or KICMoVAI, 

_Q^__iJJLv^/ I '^^\^ '^T. .90H 



'^\itry item of information ahoulii he cnrefully Hupplied. AGE fihould be ntnted BXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may he properly classified. The "Special Information*' for per- 
sons dying away from home should be i^iven in 9\^ry instance. 



II :-■ 




'1 '«■> 




''^ 







*fe^'- 



»#«^r*' 



■ If? 



:'*-^.'<u* 


m^ 


piil 


km 



m 



\ 




i : 
I 



$ 




» 






Vm 1 1 i^ li^kh Ij' ^?.'ii' jf 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



, . . , : ; ; . ; : ' i n i » . 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 





n 


.MA; XI 


If/O^ Jlr^isfvrcd ,Y(>. 1.9!23 


Jv^^rU^ 


t.0 dJ>^\yu 


Deputv 


3 Officer 


HFPARTf 


HFMftF 


PIIRI If H 


PAI TH — C\i\j nn/l Catitiiv nf Q^in Frqiiricrn 



Certificate of IDeatb 

( tl. j5. Stanza rD ) 

-S ^ J? 



(3i> 



PLACE OF DEATH; — County of U/Ou^ru vJ/vOy^YXCv^cv City ofO<X/>X' J^^Cl/^v^c^cc. 
No. S^b cXll^vx^tv^^ ^ St.; ? Dist.;bet. lO liv and 3^1 aI 

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

FULL NAME \JJjyoX\x. i ■.. \ \\jxKk.{^ LL/v\xix\A. t- , v. 



PERSONAL AND STATISTICAL PARTICULARS 



i;i Kill 



ILA.1. 




MEDICAL CERTIFICATE OF DEATH 



i» \ Tj-: oi m; ATii 







Qi 



\< .1-; 



M 



) 



tltlll 



II 

il);iv 



/ 1. 



( 'i'.;!! ) 



/'./ 



6xkt. 

^Montli) 



5vb /Q0'\ 

(Day) (\\;ir) 



-IN •1.1' MAKKIIK 

w I !•< twi- 1) » >i< i»'\()i-'ii:i) 

iWiitiiii -iH-iri! 'l<^i'jn:it iiiii ) 



nil-; 11 11' 1. \i"l'; 

■^t.i',. <>\ 1 'oil nt : \ 



\ \ %T1 III 

1 \rii I i< 



I'.iK' 111 I'l, \( r: 

' '1 1 \ III IK 

-^t ll ' Ml I'l .11 lit I \ ' 



MANil'.N N\MI', 
<>!■ .MdlllJ.k 



r.i u'liiiM, \i }■, 

(Slate 1)1 r.ililil t V 



' ' 1 1' NTH i.\ 



A ' 





^\^^' 






, I IN'RIJIN Cl-;K'ril'\-. 'I'h.il I :ilUMi.lc-.l .kcrasc'd fnim 
'0±\A. ^\ ny,'t i„ . Bj^a± X^ t.^H 

lllMt I l;is( s:i\\ h ■ alivfoii QX^vt XI ,,/) 1 

aiiil tliat diatli occn rrnl, on tin- date stated ahove, at I oL 
.M. 'Idu- CA( SI-; ol' Dlv.XTlI was as follnws: 



l>l I^ATION ^'''^'A M^'>itlis S Days 



//ours 



IL^A^U. 



CJ 







1U..C 



> VCV 



1)1 K.^'n()^■ 



)'/v^^,v 



Mn)illis 



NED) \ lO- d.Vvv.N..Ll'v 





/)a\' 



//OHI \ 



M.D. 



rsiG 



Special Information ""S tor ii(isi»if,»is, institutions, irdnsients, 

or R('(enf Residents, dnd persons dyinj iiwdy fro-n home. 



'■ / 



\i,,,iii,^ 



I ' 



Former or 
L'siidl Residence 

When wds disease (onlr.irted, 
II not at pliife ol de,ifh? 



HoH long iit 
nd( e ol De.ilh ? 



Ddys 



111 \ H( t\i' s r \ I r II I'l-'Ksi )\ \i, 1' \K I irr ; \K-, \ i< |.. ri< t I-; r< » rii i: 

ni'.srnl M\ K Ni iW IJ.lM , I-, AM) l!i;i,l!:i' 



Illi'M IlKltit 







l> \'S\\ ..! l!i Ki \i. .,1 |< !•;%!( ^\ \ \ 



A^V^ ( )X 



I'l, \ri' ( »!• i',i i< lAi, I >!•; K i;m<)\ \i. 



r .\ I » I . k 



!N. K. Kvcry item olt iiilroi-miit iciri Hhoiild l> • ciirclfiilly HiipplicMl. Afjli Kh.il.l ho Hlntcl I.XACTI.Y. PHYSICIANS Hhould 

Htiitc CAIISI] Of I) r A 'I' II ill t>liiin tcntiH, tliiit il iiuiy l>^* propt-rly cltiHNil'ied. The ".Spc^iiil Int'oriniit ton" I'or p«r- 
Rons flying nwny from hftmu Hhotild he j^Iven in every iiiMtHnce. 



t \ 



i 






1 1^ 



k^ 



• ) 



I ! 




*" ' 



I I 



I « 



•PWW 



.A 






.-.f 



't! 



ii a^ 



iV 

M 




S I 



Ii 



II 



Il*» 




^ 

f' 



:iiyilii<i««ttii 



WR!TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



|!.,:,I.l ..' \\< .i!t!'. r V.i. 



-• --• liM" <•., 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1)1(1 (> /'V/r^/,dx\vtji/v>^JMA; %n 



VJO\ 



Eegi\slct'C(l jYo, 



1 9*24 





Deputy Health Omcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( 11. S. i5tanC>nvD ) 
PLACE OF DEATH: — County ofO/<X'>A^ ^ V<XavA>Ui cc City of O COv X.CLo^xyOULeo 



^k>. LlI^^ ''.lLcru<.-ia.t^, ()bch<Llv\lla.l: St.; - 

Dl 

ST 

5T 



Dtst.; bet. 



A ( If DtATH OrCUR/lf AWAV FRoWl USUAL R E S I D E N C E G I V E FACTS CALLED F 
V. IF DEATH 



and 



■OR UNDER "special INFORMATION ■ ' \ 
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



FULL NAME 



O.M^d LtU 



LOK.L(..L^\.q. 



r \ 



PERSONAL AND STATISTICAL PARTICULARS 

ft loliiK 



> \ I 1. t '1 i;:k 111 



yi 



\ 



\t.itiiiii 



f I>;t\-! 



/ ' 



MEDICAL CERTIFICATE OF DEATH 

DATi-; oi' Dl-, vrii 



I M 



olltllt 



(I):iv) 



(Vfiir 



\' . I. 



a'b 



r-,/< 



1/- 



/>■! 



~^IM . I,)" M \K i< n: i> 

unit i\\i-:i» ( n< invi »!-■( id 

'\ ■ ■• ■ • 1 - ■ 



'Sliiti' or •."diiiui V 



• "! 1 Ml 

\ I M 1 , K 



luK'i'iii'i, \(i.: 

< >i r \i 11 !•■ k 



• '1 MMiiii: k 




I m:klvH\' ri:in-|I-\'. 'riial J atlni.lL-.l .lc,-r,,sf<l fr.-ni 

"^ «'PM to y-^^t XX i,,oH 



tll.lt I \:\^{ saw ll ' ali\(.(»n v^ -^ i v.v. r>. c«» y,.Q 

ami lliat <Katli MCi-anrd, • -ii t he ilatr sf alnl al-ovr at 0X5' 



^.M. TIk' V.W SJ-: ()!•• DI'lATII was av follows: 



DIU \TloN )r(ij- 



foNTK 1 III TORY 



:!/,>>////< 



Ihiv 



Ho 



II f s 



' v<^ 






i!i i; 1 II I'l, \<- j-, 
or Mf.riij-.K 



A''' /./'''/ /" V,M/ I I I'll, I »■./ V ' ■ "' ' 



dtk ati on 
( Signed ) 



)'i'<irs J/i>/i//is 



/h,v 




I huirs 
M.D. 



L INFORIVIATION »nlv tor (WispitdK, Inslidilions, frdnsipnfs, 



Specia 

or Keiciit RcsiiJdils, diid persons duni .iw.iv fro:)i homf. 

former or 

I'sii.il Residfnrp^-OVC 



M :,■//,. 



I > 



I mi: \U(i\i.: sr \ii:[) i'»':k-.< i\ \ 1, p \ k ikt ! \ks xki.ti-'' i- in rii 
r.i.sr oi- Mv K.\o\\i,i.i)(,i-. \\i. Ill, 1,11 I 



P i- tV Howionqaf 



Odys 



When was disprisc (onfriidcd, 
If nol ill plcirr oi dfdth ? 



aiir.,;i,i:,tii vJ-5-X) 



\x^ (?icJU 



u.l-ll 



.^^ LoIm^Co abo^|\^t<x' 



l'I,(Ari<; di' l!l K I \1, ( If- !• IM< )'• \ 



Qaa/yvtu^ \J <xX.k 



i> \ I'j: 



cNDii'. r \ K i:k 




6, 



' ^ k i:M<t\ \j, 

xyul Xb iQoH 



CtCVo . 



x.i.ii.'v,^ i^b'rx- 1^1 U\; 



% 



I II fc lj l « i1 " P' I M p Hf I " ! 



N. II. livery item oV iiiVurmit ion Khoiilci h ^iirol'uMy Huppliod. Aiifi H'loiild he stjilcl I.X'ACTI.Y. PMVSICIANS nIioiiM 

Htiite CM'Sr OI' DIiATII ill |>hiin l<.rins, thiit il iiiii> he iicupcrly cliiNKilfied. The "Spccinl Infortmitioii*' ifor p«r- 
Ron« flyinji aiwny from Ikmiiu shouhi he (iiseii in cverj instniiec. 



! . 



t ' 



I ' 



I 



%"> 




• ) 



1.1 



{• 



f) ^ 



'i\ *». iX,/-. 



r-*?.'*' 







Miltlilftii 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M'Miii •; II .i;!n r >.( 



iix r < II 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J^trvouo JuL\M.( Deputy Health OfiHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( 11. S. j5tnn^uC» ) 



(^ 



PLACE OF DEATH: — County of^xX>^. O/vaAvc^cxi cr City ofO^CX^Ox^ A^OU^ v ccXi.. C c 



N^.vCtu V ^ 



A 



VU ^v V.CrVC'>^.l^>VL^-^v^r^ St.; 



Dist.; bet. 



and 



A / ir DtATH OCCURqTAWAV FROM USUAL R E S I D E N C E G I V E FACTS CAlLEn FOR UNDER "SPECIAL INFORMATION ' ' \ 
\J V IF DEATH OCC^y^RtD IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMDER. J 






FULL NAME vIoJ^NAXL/'k J vl),a.V\„iL.Ll 



PERSONAL AND STATISTICAL PARTICULARS 

^ < 1 1 . 1 I K \, '\ 



%J 



I 



Nil ' ii i;: l< I'll 



■J i L<^^\J 



W 

' I):i\' 



MEDICAL CERTIFICATE OF DEATH 

DAT)': ( II DLAlll J^ 

'»!' (I);iv) 



O-t A. 

(\h,nh 



TOO \ 

(Year) 



K\ 



1/ ..,'/, 



^IN' . 1.1' M \ Iv K M- I I 
W'l IX >U1 |i ( lU I r ' 

'Will ■ : . ■ ' 




.^^cLcrv'^^-id 




III 



1^^^ 



IMi-: III l-l. \i'l' 

' ^1 .il I III I 'mi ill I \ 



\ M 1 111 
I \ I II I.K 



IMN' III I'l, \ri-; 

•'I I Vl'IM'R 



• '1 Ml t'l'll \\< 



'in, \i 1, 

' iTII I'.K 

: »'• Ml 111 1 \ I 






i lli:i>: l-:i;\- C'I.U'1I1\-, That I^ MtU'H.Kd dccravc-.l fn, ,11 

tli.it I lasi ^;i\s li .. . alixi- on Cj-X-Yvv i ,,.,, 

.Mill that il.adi occiiiii'il, I'll tlu- ilatf -tad-tl ahow, al H 
U M. 'I"lif C\l>^i•; ()!• DI'-.ATII was as follows: 







i)rk.\'i"i()\ )',</; 



CON Tl^Ii'.l TORN' 



Month' 



Ihtv 



lion 



J \ 



■'■\-- ■ 



1)1 i^x'rioN 



Signed ) \X) ^ 



lid 



l\i 



I'V 



K (' 



qX'^\aj '^'1 i(,o 'i (A.Mi.ss) \Xk. » V X. sj ; ^ \ '. 



//(>in \ 

M.D. 



SPECIAL Information only for llospildls, InsfHutions, rmnsimts, 
or Kcicnl Ucsiilciils, •ifiil iifrsons (l)iii) ,iw,i\ Iron liome. 



< I r \ 1 1 1 1 N » 



' ' /// .S(/;/ /'; iiiii /.w ,/ 



/' 



rill V Id •\I", sr \|"1 |» iM'K^t >VM, !• \K I'li'f I, \ K-, \KI' ri.:i I'. I'll THI- 

11 I <»i Mv K \« i\\ i,i:iM .i'-, \\i) i!i,i,ii:i- 



formi'r or 
Isii.il Residrncf 

Whrn Hiis dise.is(* ( onlrdi t«'d, 
II no! .)t |)l<i(e ot drath ? 



flow lon(| <if 
VUir ot jlcdfi? 



Days 



% 



'III!., mint 









vtr^v.CLJL 



I'l, \'l" < >l \',\ \< I \I, ( »K K I'.Mi t\ \I. 

I'jriVAKru o)xUjtM V (fbi<x.<:\ 



190 



iNDi; 




'tt 



IN. H. Jivery itiin oli" inV'oriniit ion Hhotihl Ik- ciir«iiill> supplied. AfJIi kIiouIiI I»o «tiile«l i;\ AC I'LY. PHYSICIANS Hhoiiltl 

Htatf CAlISi; or DI.A Til in r>lnin tcrnis, tliiil it nuiy he pivipcrly cluNKil'icd. Tlic "SpcdHl InfoiMiuit ion" for |»«r- 
son* (lyin(l iiwny from homo sliould he- tii>en in every inHtnntc. 




ll)\ 



n 



i t 



■il 



|- 



I 



jl 



II \ 



:»l 



l( 



!, I 



) i . 



) 



i 



,™w 



■ag 







lill^^l^rifittiji 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;i 1.1 1 li ' •! Hi:i''n r"S'i). i ^ "r'- .^- .■■>■«. jux i' v'l i 



REFER TO BAC« OF CERTIFICATE FOR INSTRUCTIONS 



i 



1926 



th Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



tr'U.V-J :.U, w'U Depu 



Ccvtiticatc of IDcatb 



( 11. S. StnnDavD ) 
PLACE OF DEATH: — County ofCJ/CL^-u A^a > vOc^r ( City of Occ'^^ J.^, cX/'va./culcc 




04|v\XoLlSt.; 

ESII 



P^). V^ V.€V.\yCX; ^J <X\X-<rYV UUC^^iVAXoLlSt.; Dist.; bet. and 

(IF DETATH OCCURS AWAY FROM U SKJ A L R E S I D E N C E G I V F FACTS CALLFO FOR UNDER "SPECIAL INFORMATION' \ 
IF DEATH OCCURRED IN A HOSPITAL ORJNSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 



FULL NAME 




.Q<X,\>^) 



PERSONAL AND STATISTICAL PARTICULARS 

' \ ! I III !;l K 111 /P\ 



MEDICAL CERTIFICATE OF DEATH 

DAiic «ti i)i;.\rii 



/Q(i \ 

(I):iv) 'Vr;ir) 



^t..1ltll I 



1 M\ 



> I : ( I I 



bl 



I M \ i.' K I r I ' 



i'-l Iv III II. V \:. 
^\:\\i > iT I '• iiiiit I \ 



\ \ \ n (11 

!■ • : INK 



itlRiH I'l. \(i; 
HI- i\iiii.:i< 

' "-' ■ I ■' Mini I \- 



M\ll)i:\ N\M1 

"I Mo'rm-: K 



11 i'l,. Ml'. 

M(ithi:k 

lit' ■ -y r.,iiiit ? \ 




i 1 



K 



(Month) 

I II I:R i'JlN' CI RTII'\\ Tli.it I ;ittiii.ii-.M(«c;isc-.l fimn 
v\.q II u/jM 1.. ax^\:t 'XL i(,oM 



that I last s.iw I, ',. 



0-^^vl< .< 



iMil that (Irath Mrciirrc'(l, nii the ijatc stated ahnvr, at 
■^ M. Thr CWI Sh; Ol' I)i:.\'ni was as ff)l](.\vs: 



XL 








1)1 K AT ION )'rins Months 

CONTUlin rokV JJL^Jl^oc^-c; -^-H^i 



HiU 



'\ 



I lout s 



I ) r R A '[■ I () \ 



( ^IGNED 



Mo)iilf< 



)'<i/rs J/o/// 



/h,r 



QJ^A. J, i,),,M rA.Mr.ss) i b b ':.'aa1Aj.>v Vi. 



^ 



/hull s 

M.D. 



<v^ ^ \ \ \ 



) - ,// 



Special Information <»iiIv lor tins|(ii,jis. insiiiiitions. iransimfs, 

or Rnnil Kcsidcnis, iiml persons ilvini ,ih,i) Iron home. 



lormpr or 
I'sii.il R»'si 



'I'll I ■ \ i:. i\ |- s r \ I'l' ii iM' I,' s( i\ \ 1, !• \ uii I I. \i.!s \ K I IK I 1- I'. • 111 i^: 

' M MS I. \i i\\ 1,1 |i' . 1- \ \ I I l!l' 1,1 i:i 

'0 . , 



\'l(h.ss h'.js-'^ VAAVOAAXft ^ 



O.C 



Whrn w<is (llsr.isr (oiilr.Klnl, ^ ll \ 

11 not ,il pl,i(«' ol rjcilh .' \X VvK ^ ^ 



I'l, \i'i': < ii i;i u I \i< ( >k k I'.Mi .\ \ I, 






I 1 1 1 r ; \ I . I 




I !• I \ I (.1 k J ;m' >\ \ 1, 

^1 looH 



' \.!.l!- 




<cttiA; at 



N. H livcr.v itoiii ..V in»'.i.Mii!iti<»ti Hhdiild lij ciirctr'ully Hupplic*!. ACJI. s'loild ho sljittMl l.\ AC FLY. I'HY.SICI\NS Khotild 

Ktiitc CAllSi; (M' 1)1 A I'll in |»liiin tcriiiH, that It iniiy lie |>i'i»|»cTly ciiiHNit'icil. The "Sptciiil Int'driiiulion** V'or p«r- 
Non« (lyin^ iivMiy Vroiii lioinu HiKiiild he ii>i\cn in ovcry iiiKtnncc. 



'■■m^^ 



\ ■ 



tPil^ 



il 



:'> 




. *l m 



I .. 



*^ JS» 



i-'t A V. 



•^ " t" ••'■i»*-« • 



.^Jgl^^^}^^- 







M 


1 


mtm ^ 


iH 


W 


jj 


; 


■^-1 


■1 




F^^pI 


^^" 


nv 




n 


1 i.I *l#*t 


iitt/^iHt 



I 



d 






I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ri' I.t M i ' M J 1 I . ( : I 1 1 I 



I > IX 1 V ' ) 



MtniH ru tJAun uh utHriKiuArt kuh instructions 



J? 



Dff/c /'V/r^/, "dxWbL^r^Wv X^ 




lf)0\ 



Begi.sfcrcd J\^(). 



1 92 



:NTO 



n 



(T^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( 11. 'Ik GtnnC>nvC> ) 



J? Q^ SI Q^ 

PLACE OF DEATH: — County o^'cu-rv^ XOo^ v/ca^vcc City ofO<X/>x; JAXXy^vc^^co 



No. 2.b 1 1 L<X^Lc 

(IF DEATH 
IF DEA 




L<\j 



St,; b Dist.; bet. vI.U^A^CJl 



;5 

and C) 



/C^crtt' 



)^CCURS AWAY FROM USUAL R E S I D E N C E G t V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO 
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



- ) 



FULL NAME 



XJLV\JL 




.Ci V>aa.u-<X LI) 



PERSONAL AND STATISTICAL PARTICULARS 



SIX 



l» \ 11 ' 'I l:ll< III 







Ic^ 



M..iitli I 



a:^ 



MEDICAL CERTIFICATE OF DEATH 

I'Aii-: (>!• i>i'. \i'n 

as 

(Day) 



dxkfc 

'M-.titli) 



(Year) 



I):iv' 



\" - 1-: 



%! 



/h!\s 



^;^< ■ i,i- M - :• !< n-D 

( Wi M<- ' II V, ,<-J:,l ,1, v,'.' n;it imi^ 



lilK I'll !•!, ^^"l•■ 
'Stat' ■ ii 1 .M!it I \ 



1 \ III l.K 



liikiii I'l. \iK 
'>!■• i-\iin-:K 

' Sl.iti • < • 'ini 1 \' 



<>l- MnTllliK 



i;ii; riii"i,.\ti-, 

<'!• MnlllilK 

f St;it<' Ml run lit 1 \ i 



LU 




I lli:ki:r,\- Ci;kTn-\', That l ;iltrn.lid .Ircra'^d fi-Miii 
3jL/'|\.t' I'.i iipH to C)x\aX" 'XS' icpH 

tli;it I last saw h '.. . . aliw on OJE-^Xj 'JL5 190 '\ 

and that (Icatli orcii rftMl, on t lit- datr stated aliovi-. at lO-dC) 
^ .M. The CAISI-: ()!• 1)1' ATII was as follows: 



eL 



^.^^ 



'X 



LLL < ^ CL/T>\; V^ \A\A-AJ-CX Ll 



!l 



(^ 




lk: 



c\ 



I'I!<\TI<»\ );;irs Mouths \X l\i\s 



I Ion 



rs- 



J 4viLc-cLc'ua'\i)o.v' 



< U\ I 



fx) 



■ \ 1 1 \ ( U . _i 



A'. 



*. ,, 




I ) I ■ R A T 1 \ 

( Signed ) 






. i, 



/^(JVS 



/louts 
M.D. 



Special Information <»niy tor iiospitdis, instifutiins, irdnsients, 



t)Ji\.% 



XK u 



or Kt'H'iit Rcsidi'nts, «in<l ptTsons dyiiiij ,m,iv (roni home. 



\' -nlli- 



I'.n 



111 \ Ml i\i: ST \ I in i'i-'i< SOX \ 1, !■ vK ri.'i I, \ K-> \Kr. iKi i: ill Till'; 

Ul'.sr o!' MS' K No\\i,i;iM ,!•; \\|) lil,l,li:i- 



formrr or 
L'mi.iI Rcsiilrnrp 

When wvis disfdsf ronfrrfrft't). 
If nof a\ ((I.HP of dcdffi .' 



flow lonq af 
Pld< e ol Ocdth ? 



OdVS 



f lnr> ,• mini 






3: 



I CJJLkt 



twxojU'u.^ ( ^-^Y-^ -■^ 190't 



I N I . }•; K T \ K I', K vJLxXA^k \^ VJ^ (V (^ {_ \ ^ 



!^- '*• l.v..ry it 111 t.i' inV'.iriiHit umi Nhfxild I).- t:irc»iilly sippli-Ml. \V,\\ mIio.iIiI liu stntecl liX \CTLY. PJIYSICIAINS Hhoiild 

Htiitc CAlJSi: or DLATII in i>lirui IcriiiH, thai it miiy Ik- properly cluHNiVieU. The "SpccinI Informiitiun" fop per- 
son* (lyinjl tiwtiy from home Hhould he (^iven in every inHtnnce. 



■'Il5l: 



IJ 



, ' 



i 




I r 




t 1 

I 



■' I 




'I,-:,, 





» 


it 


......^ 




• 1 ; flLl!! 


] i 


■WMMrfg W f 




M 


' 


^1 


rfi 



.-wti'fiji """ 



«ilii.Si 



ni 



1^ 



I' 



;' ', 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•ft JB ""^in* 



i.init (I ' )i 1 1 f.i nil- 1- -M'. 



■ —— *, ;iiv 1 V ^ I 



^^t^K.l-^ lu i3Mi_r\ <jr «- cm i i m«^m i t rvjrt i rM2> i mu^^ f lurNS 



/>r//r /•V/r'^/,6x^-b^rvvW; 3vl J!W\ licgustered A'o. 1928 

iLyvc^ 'Llvu "deputy Health Officer 

DEPARTMENT (If PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeath 

( n. S. StanDarO ) 
PLACE OF DEATH: — County ofO/OuTV; J .\XX.^>^ C- ^^ c c. City ofOo./^^ OA.CU>xca,a cc 



0\^' 




OaL' 



K^Xcx^l 



St.; 



Dist.; bet. 



and 



(ir Of ATM OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCiyuHRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




si:\ 



PERSONAL AND STAT STICAL PARTICULARS 

(■< il,< iR 




cL v^\.<r"^^<lA 




<X^ 




\ 



\ < 



-♦ 



i» \ri. ( )i i;iK ni 



<)' "''t 



^1 



)•, ,; 



I).i\ 



1' .„'// 



sixt,!,}-. MAkun:i» 

WIDOW}-;!) OK n;\i )■ 1 !) 

I W: it' in -' !■ i;il •]■ -•■■.• !;,i i ;. ■ i ■ 



!iiu riii'i, \C]-. 

' Stati or Cuuiiti VI 



lA III ].]< 



IMRI'IH'!. \C}-: 

' >:■ I' \ rn i-r 

-^1 ll ' , Ml I S 



'»! >!Mriii: R 



IMKlll IM, \f ); 

'n M<»'rm-:R 

■ '~'i ' ■ • ('(III nt I \ 



Ix^TVXDlAJ. 



LoXJLc'" 



MEDICAL CERTIFICATE OF DEATH 

DAT]-; <)i- di:atii 

Oxkfc an 

iM(.nlli) 'Day) 

I lll-;Ri;r,N- Ci;k'ri[-\-, 'Ihal I alUMi-lt-l .U-ixased fn.iii 

Ll*.^a •-- ioo'i to ox^ 'XH, 



l! 



(V( ;irl 



I - T'P'^ 

that I last saw h ^ ' - alive on O-^vt' a'a j,p ^\ 

ami that <l(atli occii rrcil, on tin- datt.' stati-d ahovi-, at 0. ?> 

vL M. Tlu- CAI SI'! ()!•■ DIvATil was as follous: 



VjaaXa 



-w^rwcLh. 



1 



Q^ 



J a.vJU-Ovxia.aJL 



<y;LK. ■:■ 



Ol/yW^{ v.<l V 



N V^^CV 



> L 




DTK A'l'lON )',.n\ 

CONTRIIM'TORV 



M, mills 



Days 



//ours 



DTK AT I ON 



)'t'(jrs 



4 ^^ 

oxxX) '^ J) 



a:c\^ 



I h , I !■ \ riox 



o^xxA>truA^ 



-^x 



dL 



( SIG 



NED) JAA (JbxxA' 



Mrnilhs 



Davs 



//ours 



dtW. ...i 



11 



I')') ' 



f 



A . M rr s< ) Lclu^ V,<5 rO (K-^i ^"^ 



M.D. 



Special Information ons for if.»spifdis, institonons, iMnsients, 

or Rerfnf Resi-Jenfs, flnfl persons dvin'j ,mHy from fiome. 



Former or ^,, , UA^ il . A Hon long , if 

Isual Rcsirjcncc i^oi'XM I UXh^KU) CO. pijrc of Dciffi? 



A' 



'\'r h!r,f III Sill! f'l iiih f^ro O I 



I '■ 



Tiii: Ml' >' I' SI" \ii' D iM-'K s<»\ \i, I- \i< ricr;. \ !<-. \m' Tkr}-: I'u \'\\\-: 
is: ; ' . MV K.\n\\I,!-;D<'.K AND i!!'.lji:i 



Ddvs 



Wfien was disease fonfracfcd, 
If not af plare of deaffi ? 



I'l.At"!-; ())■■ IM RIAI, < >R l; ):M< '\' \I, 



I M • iiri !il 






r 




.Di.RTAKi'.K JVuLaJLu ^ yu<xxx<x. 



DAJi;.)l Hi KiAi. or Ri;,M(>\AI, 



v\ 



N. It. Kvery ilem otf iiifornvition Mhoiild h^- c:iroV\iMy Hupplled. \^M. Hhr.iilil be sljitecl r.XACTLY. PHYSICIANS nhould 

Htiitf CAllSr. OP DIA TM ill pljiin terms, thiit it ni:iy lur properly duKHificil. The "Special IntTorfiitition*' ?or per- 
son* <lyin^ (iway tfrom home hIiouIcI be tiven In ts\ory inHtnncct 







' » * 



I I 



i ! 



i I 



iSJ^S^' ' 



jMii 



•««- 



ltb^&> 



I I ;.i itni:< It 



it 



■!! 



ill. 



|! 



■ I 



» i 



f«l 




1 1 



II 



III 



/ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



'ffrrrfTt 



"•^^^1 



He.H;.H lU HAUrV Oh UtMMKICAIE HJH IN Si FHUCTI O N 3 



/)(f/f' F/7f'(/, 




ai 



7.9(9 M 



llegLsfri'cd jYo. 



1929 



"i^vtvA ixoH I Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH: — County ofOxxov J >u<X^vcuiyCO City o{^<Xj^\j J.\.cx./VU<X'L<l<:^'. 
No. \Xh\ WxXy^ij'^' 



St 



.; Dist.; bet. 





and \^<X<Vu 

/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • ' \ 1 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / J 

m (if 

FULL NAME ^ Ouy\/^^Ui J a^. 



-i.\ f 



PERSONAL AND STATISTICAL PARTICULARS 



X -^i^x/xLi 




1: 



L^L 



' \ I 1 ' >i r.iu 111 



lUv^ci 



MM^th> 



1^ 






MEDICAL CERTIFICATE OF DEATH 

DAri-; oi i»i:\rii 

SxKt IS 



\i . \. 



b^ 



)■■ 



M\< .1.1 M \K I- lilt 

\\'\ i)( >\\ I'D ( tk ; ):^ ( )':i i: I) 

I \Vi i*'- i II V, M-i:il (ii vi- -I ii ji Ml ) 



r.IK !;i I'l, \r\: 



\.\Mi; <)i 
I" A in i.K 



i:i !•: I'll I'l. \> !•; 
<»|- lAllli: K 
' Sl;it< i>i I'liiiiil r\- 



M \ I iti; \ ^. \M I-: 

'H MoTIIl.K 



I'.lKTIIPI.Al'l'; 
»>1 MoTlII'".!-; 

'"^tiil' I'l i'liiiiit I \ 



'^ 






CXAXaJLcL 






(Motilli) 

ThalJ 

to d 



(Dav) 



(Vcar) 



1 lli:k i:il\' Ci:R'riI'\-, Thai J atU-iuK-.l (Urra^cl fimn 

*JL iv 1 90S to Ox|\i> XS' 



T(p 



tli.it I last saw II • aiiM'oii v-'-j^-.-yv-u '^^ ],jo 

and that (lt.Mth occii ircd, on the date stated aho\-e, at l (^ 



M. 'Idu' C\\( Sh: ()!■ i)i;.\'ni was as follows 



Id U ATIO.N 
C( ).\TR ! I'd T( 




? 






Q 



)'r,n\ d .\/oit//is l^ /)a\s //ours 



or RATION 
(SIG 



} (•</; V 



NED)l)OJi^utcl J. (i^ 



Moiiths /'(/is //oi(r'< 



VI .V 






Oa\\X. ai ,.,oH ^Address) l.CL Q.cCI.Ua; ^k 



Special information "nly for llospitdls, InslJIuMons, frdnsienls, 
or Rerrnt Rcsidcnis, iiiul pprsons A\\\\\ iiwriy from hoiiip. 



A'/' I, fill III "s'd II 1 



1 ,1 II, I /',< 



M >,;l|,■ 



I .n 



Former or 
Usudl Rfsidencf 

When was disfasp r onf r»i( ted, 
If no( df pl.i( e of deafli ? 



How lonq al 
Plare of Deafli ? 



Days 



I'M I'. AM(>\ |.: ST \r!'i> i'i.-Ks()\ \i, 1' \ K r It • r I. \ K s A K I VK I 1' 11 » I'll i; 
iii;sr oi- Mv K\n\\i,j: iK.r; wd !ii;i,ii: i- 



Miif..' in:ml 









M,Ari';(»i' I'.iRiAi, (IK i'i;mm\ai 

I) 




l> \ U. >'.' Itt IMAI. OI l< i:M(t\-AI, 

dx^xt Oil i^oH 



INI 



.i.:ktaki.;k fo CluJX<^ '''^ L( 



N. B. Kvcry item nt iii?.)rmiitlnti Hhould Ivj ciircV'iilly Kuppli.cl. ACP, Hhoiild liu Mtiite.l I.XAGTLY. PJIYSICIANS hIiouI(J 

Htiitc C.AlJSn OF DI^ATH in pliiin terms, tluil it mjiy be properly cliiHNifiod. The '*Sj>c».iiil Inforiiiatinn" lor p«r- 
Rons flyinfj nwny friiin home sliuiilii he ftiven in every iiiHtfince. 



I! 



r 



' } 






• i If 










t 



t I 
'if 



"^^^ 



«»•»« 




Iliii&BHftliHilJI 






I: 







f 



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



«» i^e »» — , M^u-, — I..' V 



«*";^. 



>- «*B. i» C^^ 



ocrun iw oMx^rv v^r v, u n i i r I \^M I c r v» n i i« o i n v; Vx I I vy i'« o 



li0^i,sferc(l J\y). 



19*30 



Xcrvou> duiA>u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH: — County of "O/Oav J Axu^x/Cu.XLyc.<, City of ^^<X/vu OAxi >vx:oa..co 





St.; \ Dist.; bet. L 'CULJIXV^ and OXLtvv. 



No. It^'^H dtALd,-'-.. St.; \ Dist.; bet. U 'O.A.Ulyt) and U-- 

/ IF DHATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U N D E B] " S P E C I A L INFORMATION" "\ 
\ IF-'DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OpJsTREET AND NUMBER / 



FULL NAME 



-- 1 . \ 



PERSONAL AND STATISTICAL PARTICULARS 

(■< Hi tk 




I) \ii; <•! i;iK!ii 



f\< 



.b.lvijtjL 




vt 



1> 



' l):i\l 






4i- 



MEDICAL CERTIFICATE OF DEATH 

DA'nc i»i' i)i:a'iii 






< Dav) 



(Year) 



I \ 1 II 1 



A' . !■: 



)■. ,. 



5- 



' Wt it 1- in >.i ><-i;i 1 i\> -i ■' !l:i I i' >n 1 



i'.lKi'il IM, \r 1.; .) 

"^t.itf ( If (/■ Ml lit I \ ' _\' 



NAM): Ol' 

1 \i II i;k 



I'.IKTU I'l.AiI". 

oi- ! Arm: K 

-.' •\ ■ . i: r, .-,111(1 \ 



^ ! 



i Hi':ki:i;\' n;i<rii\-. iiiat i .ittcinkd (ic-ccascd tmni 

tliat I last >,i\\ Ii '. V x alive (in OX-jp^V ^ '' k^q '^ 

1 that iK'atli < xaiii rcil, mi t lu' dati- staU'd ahovc. at O 
LV ^I. Tlir CM si; Ol" |)i;\'ni wa^: as follows: 



aiK 



i)ri^\ri(t.\ )',<iis 

coN'iKii'.rTom' 



Mi^ntlis, .) I)a\ 



■s 



/Ion 



IS 



MAII>i:\ NAMl rN 



\j^^y\jyy^o<j 




xJUuM 



I'.IK l!| IM, \vl', 

Ol' Mt>Tm;K 

f Stall' or I'miiit i \^ 



I 111 r 1' \ r!M.\ 



1)1 RATI ON 



c 







Pavs 



SIGNED^ CoA/'v^U, \i^l,U\. 



Atlvt g'. 



I<)0 



f 






I fold s 

M.D. 



'iAA''V\0..'\ VXI 



^ Y,-,:'.- 



,1/ y/'// 



5 



SPECIAL INFORMATION "fly for Hospitals. Inslitiilions, lr,)iisinils, 
or Kficnl Residents, and iH-rmns dvinj dWdv froTi home. 



former or 
Usual Residence 

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



How long at 
Place of Death ? 



Ddvs 



I'll I- \i',i )\i- sr \Ti:i) iM'-Rs()\ \!. !■ \!<iiv-i-i, \!<-, ARi; run-; ro in !■; 
i!i;sT ()! Mv K \« )\\ij;i)i; !•; and in-: i,ii:i- 






^VO 




^ 



d,c \ 



I'i.Arr: oi iukiai, i>k i-;i-:Mi i\ \f. 



rM)i:KTAK}:K OO^CVXw vi ojtx Ll 



6x|^t XI looH 



• ATI-: .>! i;i i.'i \r. ..I R i:M( (\ \|^ 



N. B. livery item o*' informntion shniihl \y: ciircVuHy supplud. A!JH s'lo.ihl he stfite.l f]\ ACTLY. PHYSICIANS Khoultl 

«tate CAUSE OF DKATH in pltiin terms, thjit it iiuiy lie properly cluHsit'ied. The "SpccinI Inlforiiiiition" Ifor par- 
sons dyinjv nwny from homu should be i^iven in every instance. 



* 






I 






f 
i I 



I 



'^: 



1 

i 

I 1 




Ii 



' (' 



I I 



\ , 






^U>JL, 



**WTOm^w 



I 



I 



I 



?1W 






\ 



u 



fmmm 



iitmui 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!i . iiil ■ f 1 1 ■ :i 'I n >• M 



'» ■ "•» mx I <^ ' 1 



M t h LH I u MMLJfv ur i-LMiim-Mit njfi irvrsiHUcriuPia 



Dff/c /^y/rf/ ,dx\\.tl/yy\l)JU\j X^ 



IDO'i 



Jif'O'i.sfered A^o. 



1 93 J 




'^ Officer 



o^ Deputy 

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

J? ^ A ^ 

PLACE OF DEATH: — County ofO/CL^A; .^Xx.>xcUi.^(.City oiOo^y\j \Xt.y>xcc4.cc 







i>fe. V ix^. 




"yx^ ubch^ 



ixAX 



OLl 



St.; 



Dist.; bet. 



and 



(IF DEATH OCCURS AWAY f-ROW USUAL R E S I D E N C E G I V E TACTS CALLED TOR UNDER "SPECIAL I N FO R M AT I O N ' ' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 









)• \ 



PERSONAL AND STATISTICAL PARTICULARS 

r ( 1 1 . ( I K 



X-^a-xCcAJ 



\u^u 



I 'i \:IK : 






10 



MEDICAL CERTIFICATE OF DEATH 

DA ri-; Ml- i)i;.\ III 



(W^niih) 



!l):iy) 



(Year) 



A 



I III'R i;i;\' C1;RTI1"\'. That I .itlcn-lcl .Icccasr.l In. in 



\i )■: 



)■ 



■ - ' / ',' 



-i\i . i.i- ".;.\i^ Kir,!), 

w iix >\\i:i) OK invi i!-M'i:i) 

■ W: '■<:■ in ^o'---' ' • '■Mti.i'i) 



lill-iTii fi. xri. 

(stall • .: I '■ niiiti \" 



N \ M 1 < 1 ; 
i-A III IK 



r-IKTlII'I, \('K 

<>!•■ i'\rin{K 



MAHH'.N NAMi; 

<>1' MoTlll.K VI 



M I'l.Ari; 

'' « riii'.K 

'I ('. >iinti \ 



Rfsidrd in Sun 




e 



V^O^V^XXA 



that T last '^aw h-J^Aj aUvf on OJO^' "c^H i<p'l 

anil that dcalh oci'iirreil, on tin- date stated aliovc. at O 
\J M. Tlu- C\\rS!{ Oi" Dh. Xril was as fo 
^1 / UXX/1'A.AaX'\aXv<Pv 



as as I oil! )\vs : 




11. ■, 



a > V ^ 



-s 



r 



I)(k.\'l"I().\ }\ars 

C()N'i"kii;rT()RV 



) ' (/TV 



Mo>!f/lS 



/>,/1.s- 



Hours 



M>>}lths '1 l\iys 



//<)iirs 



[U 



oKX^cLcx' 



DTK ATI ()\ 

(Signed )\JjX^cl-^cIax U^o^^^ {)i:)XA.dA.>v M.D, 



Special Information only tor flospifdis, institutions. Transients, 
or RtHfnl Residents, and persons dyiny hh,i> fro:n home. 



Former or 1 1 / . ( V V \+ ""^^ '•""' *** 

lsu.il Residence \ » ^ I VJ -<X'tctv<i OX place of Oe.ifli ? 



I 



Days 



)■-,,'/ 



1/. /^'//^ 



/' 



Til r \ lit iVl'. SI" ATI"!) iM-"KS(t\ M, I' XUTMI ! AR^ AK 1' T K T }•; To Til \'. 
I!1-;ST(»I' M\ KN-« i\\ l,!;i)( .)■: AM) lU'.Ml'.l' 





I 1 . ■ ' i ■; K I 11 



CL/-\v; 




Xw>i_L>-v^ 






When W.1S diseiise fontr.icted. 
If not al pl.ire of death ? 



DATj; 111 III iMAi. '.I k 1M( »\AI, 



iM,Ac"j-:(>i nruiAi, (>!-; ki.muxai. 



N. n. !;vcr> ili-m ni Inforumtion should h.' ciirct'iilly siippli .mI. W.V. s!j )uh! be stiiteil fiWCTI.V. PMVSICIANS Hhould 

Htiitc CMISI: or nr. ATH in phiin ttrins. tlijit It miiy li>.- properly cliiKsiVied. The "Spovinl Inlforniiition" for par- 
son* clyin^ nwjiy from home shoultl bo ^iven in every instnnce. 



' i 






V 






1 
; I 



■ y 



1-4: 



jIM 



} ! 




n 









M 



.^-~"^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



:i*f! n! rtrnitn — ■ -■ 



. *^*_?" 



I'lV r V 1) 



HtHtN rU HACrV OK CtHIIHCArt KOH INSTRUCTIONS 



I)ff/r n/rf/, dx^^tvyy-^LiAj "kl l^W\ 



Iiegi.sfe/'ed vVo. 






I 



.-^^A^Ay^ ..L\./V* 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccvtificatc of IDcath 

( XX, S. 5tanc>avC> ) 

J? © i ^ 

PLACE OF DEATH: — County ofOcLOv o ,^L Cx. > vcv^i c ^. City oiOc^yx) 0.\XL/>xc^.Aic<. 

N« A Cl<..( V L^\.V>Ai^i (lb'(yU\^toa St.; Dist.;bet. and 

^ / IF DEATH OCCUwIb AWAY FROM USUAL RESIDENCI 



(IF DEATH OCCUF^ AWAY F R O 4« USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION N 
IF DEATH OCCaiRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



(^ 



m 



FULL NAME 



Cr^VLa.^ 



Id ,<x> v\^ ■ 



• l.\ 



PERSONAL AND STATISTICAL PARTICULARS 

-all llvtvLU^ 




kill 






\K. 



1 

I):iv 



MEDICAL CERTIFICATE OF DEATH 

1) All': ( »i Di; A III 

'I):iv) 






*Vf:ii • 




1 !M';Ui:r,\- Ci;KriI'V, rii.-H l atU-u.Ir.l .U-ccasd tKun 
.^^|XL o ic/)M to 9-CJ<t 'XD H,oH 

tli.-it I last s lu h ;i!i\t(in 0-^l\.tj Xi ^^,^) \. 

:\iu\ ili.it (lr;itli ( )i-(n ri('<I, cti tlu' ilatr statril al.nvi'. at Sk. 
VJ M. 'V\u- C.\ISI{ OI- l)l-:.\ril was as follows: 



1)1 RATION 

C( )N'1"!< I l:l 'ic >1 

Dr RATION 






//, 



(>n rs 



}\ai 



{ SIG 



NED^ VK. 




J/<>f!//;s 



/)(iv: 



'.V 



A.,,vv ,vi i,,n 'l (A (Mass) UXu_ U. V^ (A?(y>^p: 



//('/us 
M.D. 



1 



SPECIAL INFORMATION "iih tor fWs!»it.i!s. Instifutions. rr.insients, 
or Keient Rfsidinfs, ,iii(l. persons (Mnj ,iw,i\ frcrii homr. 



former or 
llsu<il Residence 



I Obi x) I V^^.< o>x • \ ( pu e'r'l)rl(h .' 



()d>s 



Tin: \it()\'i': SI" \i'i:i) I'KK^'^ox \i, r \u rirr I, \K-> Aki: rki i' r< > I'lii': 
Hi-:sT oiMv KNowi.ijx .]•; WD iii:i.ii:i 






When was disease (onfrarfed, 
If not at |»la( e ot death ? 



r 



w 



t<x\j 



ULAi'i':<>i I'.iKiAi, (tk i;i:M(p\\i, I I)\ 



M "1 k i'M( i\ \ 1, 
' ' 1904 



r \ I » 1 



N. ». livery item ni' inlf >rmiilinn Khoulil b.- ciircfully supplied. VUli nhmild ho stutcil liX \CTLY. PHYSICIANS Hhoultl 

Htiitc CAIISr OP DKATII in plniii terms, that it miiy he properly cluHNik'ied. The "Spev-iiil Introniiiiti'tn" t'or per- 
son* clyinjl livvny from home kIiouIiI he jii\eii in overy iriHtnnce. 




'\M 



r 



» I 



, ) 



» . 






i ■' .' ' 



^v^^'^ 




-ttC 




M 



> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!!'i r . 



iJ&PCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J^ 



/i,//r n/r,/. dx^vtlmvijUv IT /f'O'i 



Jif'o'/,\/c/-('</ .jYo. 



1933 




u Deputy Health Omcer 

DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDcatb 



(^ 



PLACE OF DEATH: — County ofCjXXnru A^O^vc-ulCc City ofO/CC'^^' J /V'CL/>^CA..<L-ao 
No. IS bo ' I'XUx; iW-v- St.; 1 Dist;bet. A. and ^^-- 

/ IF nEATH OCCURS AWAY FROV USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPtCIAL INFORMATION ' \ 
V IF DFATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N A IVI E INSTEAD OF STREET AND NUMBER. J 



I 



FULL NAME QjL^^vq 



cLul ^Ux m A./lr Irv' V v: 



PERSONAL AND STATISTICAL PARTICULARS 




\ 



\ I' I " 1 >' 



^V.CVQ 



IH 



M. -It h 



4 



MEDICAL CERTIFICATE OF DEATH 

I» ATI-, < H H! \I'II P 



Ox.' 

Mmii! 



•-vJt 



lb 



^) 



/ <Ji > 



I IN Ri;!;\ n IMII'N-. 'I'IimI I .iltrinlr,) .Iccvascl In.m 
LA.A.^'Q l</i . (.. CpX/j-vt- "Xk) Kjo '\ 



Ili.it I I;i<f s:iw h 






I'.iK 1 II I'l, \i"i-: 



\ 







\ \ \\\ 111 

I A I' 1 1 l.K 



" . 1-: 1 ! I I 

< »1 I \ 111 I.K 

I M:iti '.I iMiinti \ 




;ili\r nil OX \^ ^ 



A 



]()() 



O i : <X/0 

<v^~v<L t..<rN\rv-v_v..<s^a.v.o k v.. 



I Ufx^OJi TO aX^-V ) v^ 



\ \ \M 1 
Ml )T11 i: K 



III'TIMM \l"l-: 



u 







,K) 



II,. I ;1i.il iKatll o( cil I iiil, (III till- 'lair sl.ilcl a1i(ivt>, a1 
- ^ M. 'I"lu- CWIM. Ml l»i:\ril wa'. as |V.ll,,u^- 

A^TW'-V-vAwIL-cLa. TV ' . 

1)1 k\TI(t\ }',>f/^ J/,'////j\ ;'< /},irs //()/// s 

('< tNTK li:i T( »K\- i^vv-^^^tc*- aM.La^U.lu oU^ol to 

DI'K \1I( >.N },;ns Mo)tth^ />,,\s //nms 

D) II. jto.VjK^ iavLo ._ M.D. 



( SiGNE 



! < iO i. 



f \. Idlest) t I c^ 



v\ 



M 



Special information "nly lor HosjuLiIs. InsfiUilions, (rdnMcnls. 
or RtMrnl Hrsidcnls, iiinl iictsnns dyin) .iw.iv ffori homp. 



/\'i' ijt'.l III S, ■ II I I ,1 II, 



) . ,1 



I i/..,//A. [^ 



I'.n 



I'm: \!i()vi-: st \r):i> ri-'usov m, p \k i irr i, \i 
i!i;sr <»!• Mv knkw i.i.DC r; and r.i:i,ii:i- 



111 



(lllfi.- mini 



VA 



\.l.li 






formn or 
Imi.iI KfNidriKf 

Wlicn W.IS (lisf'.isp ( (iiilr.H Ird, 
II not dt pl<i(i- ol dc.ilh ? 



Ifnv> lon(| (it 
P(.ire ol ()e,iHi ? 



Ddvs 



ri M i; (11 I!! K I \|, 'If !■ I;\!m\ \ !, 






I mii.ktaki;k iAj. U L^Cr>V^VCr\y ^^ Lt), 



1 M< >\ \I, 



N. K. l';v«Ty Item oli' hiV'..rmiition Nhotir«l lie tiircfully «iipi>Iie<l. Adii HhouM ho Hliiteil I.XACTLY. PHYSICIANS Hhotild 

stnlc CAlISi: or ni: A Til in plnln Icrmn, thiit it may l»e pr..|)crly .. liiMHh'ie<l. The "SpccJiil liifftrmiiliotr' Ir'or par- 
dons (lyiiii^ iiuny from hdinu shoiiltl be jiJven in every inHtnnce. 



iJ 



I. 



ti; 



«' 


i 




}, 


. 




J 




■i 




1 




» 


■ ; 



I 



yj\ 



; I 

.1 



M 



fe 



ii, 



^ 



■iff^ 



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



'i I V.I, |: 



;-.~t; |5S:I' Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)ff/r nicd ,QJL 



cLa^^^.ca 




MA; XI 



loo'i 



Jlro'/s/rrrd A^o. 



1934 



Deputy Heaith Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 



[ 11. 5. i^tanDarO ; 



PLACE OF DEATH: — County ofN I Lu.lt>^o-v>va. 



City of M C V 



Xa^<X > v. fi 



A.' 



No. 



St.; 



Dist.; bet. 



and 



(IF DEATH OCCUPS 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 





5A.A^AaXu> V.Q .' . ^ ) v- 



PERSONAL AND STATISTICAL PARTICULARS 

t 



l» \ I i: I )l i;lKl"ll 



\' . 







/t 



\ cai 



MEDICAL CERTIFICATE OF DEATH 






Day) 



(Year I 



n 



1 ',,..'/,. 



V 



>^iN<. i.i:. \!AKKii:n 

WI !)< (W 1' I) I >k 1 1 -Vi <]■• i- )• i) 



Itiuiii PI. \r i: 

' ^!.M . .1' I ■. ri 111 ! \ 




^<k.^rXAj^\j 



XVv%\ ^ > 



I III:RI;!'.N- C'i;RTn-\', That r atU-n.U'.l .Icrcascl fn.in 
— ■ ,^^^ j^ii . — . 

tlial I last saw li ~ aVwv on ' • — ■ 



190 



and Ihat ilvalli nrriiiicd, on llic date stated above, al 



M. The CAISI'; OI" DI-IATII was as follows; 






lURiii I'l, \i' 1-; 
ni- i.\iiii:k 

'Stat*' ni Count t \ ' 






HI Kin !• I. \ri-: 
or ^t(t•!•m•:R 
i it' "1 country) 



DrKATlON )\,n 

c'( ).\'i'k ii;r'i( )K\ 



Month: 



PilVK 



//ours 



r 




( Signed » 



)b 



0X|\1. ..>- . [,)0 ' 






Mouths 



na\ 



'S 



\.idri-ss) VJ crVvLcxAvcl U 



//('!{ IS 

M.D. 



^ 



)',■,>> 



y!..,!tJi- 



/'„M 



Special information onlv for Hospitals, Institutions [ransienfs, 
or kerent Rrsitlrnts, and persons dvin:) ,iH,iy froni home. 



Former or 
Usual Residence 

When was fjisease (onfrarfed, 
II not at place of death ? 



HoH long at 
Plar e of Heath ? 



Days 



Till', \ui)\'ii; ST \ri:i) i'Krson \i, rxRTirci.AK'- \ki; i"k 11: r- • 11 1 ic 
iu;s'r «)i" M\' KN( >w 1,1; I )(■.!•; and iu:i,ii;i" 



I'l.ACI': ol' lilRIAI, (»!< RI:NT()\AI 



rNDl'.RPAKllR 



I) \Ti; 1' 111 Ki.Ai, 01 R i-;mu\ai. 

ax^' '^ T90H 



N. B.- 



-livery item of infosMiiiition Nhnuld be cjit'cfiilly sui>plic«l. AClfi «hnuhl be stilted fiXACTLY. PHYSICIAIMS nhould 
Htntc CAUSL Of- DlIA TH in pliiin tcrniH, that it ituiy be properly cliiKNit'ietl. The "SpecinI lnltormntion" for per- 
son* dyin^ nwny from home tihould be <ii\en in every iiistnnce. 



;i 






i 



I 



I ■ 

: t 



< • 



r 



> 



■If,. 



5 



t • 

! i 



f J 



m 



H 



1 il 



f 



* i '■ 



i> 




WMliu^ukmmil 



n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!•„ .,11,1 .,f !I. Mitli \ N.I, I % t— rsr, ^-; Ii\ I' C: 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Brg/.s/r/'pfl ./Yo. 



1 1)35 



\ i 

d^^VKAJs < •■ 1.1 Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beath 

J? or, i ^ 

PLACE OF DEATH: — County ofCjCl/VL' V<X v^c^ui^co City of O/Cl vu O.VxX/tv^axlCo 
No. ^ I 'X VJSx-O-'u. St.; ?) Dist.;bet. 0^t^tr>YV and obaX^^UiC n 

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



FULL NAME 



.L 



^ 



,v-<^<iIxo: 



:i 




A\JJ\.': 



! \ 



; ' \ 11-: < >! Ill K I'M 




PERSONAL AND STATISTICAL PARTICULARS 




i-i.'.j._ 



.^5^ 



H- 



MEDICAL CERTIFICATE OF DEATH 

DA ri-; ni' i>i: AIM 



M..ii'h' 



I );m • 



\< . l''. 



S6 



\ i-;iT 



/',,' 



- ' ^ ■ 1.1'. >' \ R K ii:i> 

WIDOW I-: I) OK D:\ oKi )■. 1) 

W- :•• ■•' ..H Ml .1. ••■■. .•.,,11) 




^or-trVcXcL 



I'.iK rii I'l. \c]-. 

i'St;a, Ml 1 (.iint I \-* 



\ \ M 1 ( 11' 
I \ 1 !l ).R 



i!iK riiri, \iH 
oi" i-\iin:K 

' t ' ' " ■iii: 1 1 



MAID1:n N.XMl'. 

oi- MoriM'.k 



iMK I'll n.Ai !•: 
<>»•■ MoTni-:K 

< stntc Mj- (*i)initrv> 



r\ 



J in';Kl';n\- Ci;Kril"\-, That I .ilk-iukMl .iLCrasc-.l In.in 
'W itpM to aX|vt, ^"i i(joH 



I I II '. 1 



tliat I last ^.iw li-U N ^ ■■ ali\f on 



dX^vt 'X'A 



T90 



and thai ikatli occu rrccl, on tlu' ilaU- stati'il aliovi-, at 
" ^r. The CAISi'; Ol- l»i:AriI was as foHows: 

^()bxOw\i JUcAXxx.<lJ. U o^t\njJUxv 



1 



r 







VfVA 



\X2 



rs ^' 



LKA,\h.^<K 



v--^^ 



DIR.X'I'ION )V.7/,s- Months /\ivs 

(."ONTK I I'.ITORV UJCoCHh^^ftAA.^: y ,\ 



//oh 



IS 



DTRATION 

( Signed ) 



)\a)S Mont /is 



/\i\ 



'A 




//ours 

M.D. 



" HTil-A I'ioN 

/\'f'>>(i/'lf 111 Sdl/ I 



a^ V,,,., 



Si\dz xhtqoH f.x.i.irrs.) 3>Hb - H"t:K cVt. 



Special information nnlv for HospildK. Insfifufions, [rdfiMfnts. 
or Reicnt Residents, diid persons dvinj a'^a) fro-n home. 



M •••nis 



Former or 
L'suiil Residence 

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



How lon<) at 
Place of Death ? 



. Days 



rn 1: \!io\-i.: sr vi'i-D I'KRsox \i, r \K iicr I, \R-^ .\Ki: IK! 1-: I'o rui'; im.aoi: 01 .imki.m, (»k ki-:mo\.\i 



Inf.. 



I'.sr OI- MV KNOWIJ'.DC. K AND Hi: 1,1 1". I-' 
'iiinl \|V. Vj A^XX^ ^^ >w^ 



X.hhx'.ss 



IM.AOi: ()I yJMKIAI, (»K I<I-:Mo\-.\I. DAI-];.,!" lirpiAi. ..i kl.;M(»V\I, 



-n 



INDl-.K TAKliK 

( 






IN. K. hvery item of informntion should be cnnoltiilly supplied. A(IR should he stnte»l hX^CTLY. PMYSICIAiNS should 

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



. . .1 



'h 






; )i 



; « 



i . 





i^ 



) ; « 



s^'»--- 



.JiU:-i 



'''' ' '^"^ 



Kmnm 



*i i 



< 



, ^r--* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



|-m:ii,1 ..r III Mlth i- \.^ 






REFER TO BACK OF CrRTI FICATE FOR INSTRUCTIONS 



/)(f 



fr File '1,6 





V\ 



IU()\ 



Registered JS^'o. 



1936 






ficer 



DEPARTMENT 6F PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Xl. 5. 5tan^al•^ ) 



PLACE OF DEATH: — County of '"'o. ^r J A.cx.'\vou.C(City of Oxx>\.i OXO. ivcc«.'^o 



(^ 



f~\ r^ r 



No, 




1) 



^ l.i-VYXAv\.AA.q' > V. St.; t Dist.; bet. ^ ^.-<XaA I a nd VJ X V^c a. 

(IF DtATH OCCURS AyiijAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
IF DEATH OCCURRBD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O^ STREET AND NUMBER. / 



FULL NAME 



— —4- 



\ ^\.o. ' 



PERSONAL AND STATISTICAL PARTICULARS 






ri il.i >R' 



) \\'\- I il 



I II 



.V 




UMiith ' ' 



[• , . 






/ ^ 



I ' ' 



MEDICAL CERTIFICATE OF DEATH 

DA ri-; ( •!• Di; x'lii 



JX 

Moiitli) 




lb 



(Day) (Yt-ar) 



\' . !•: 



1 



/Ki 



Nl \i . l.j- M \ K k I I-:i). 

w M)<i\V!-;i» n\< i»,\(>kri-:i) 



^' CAV 



ill 1< I' lie \ i"'" 



NAM) <l: 
I" A 'I" II 1 R 



Itik I II IM, ACH 

'ti" 1 ATI n:u 

' st.-it 1 I •', ("Dim' ; \- 



MAll>i:\ NAM I", 
Oj- Mnrill'.K 



i;iK Til ri, Ml.; 
OI- M(>tii1';r 

eclair ' >i rmi .1' r\-) 



'>i'i rxrioN 



C^ 



O /axi \y0^^y\Jin V t C L CUV 




. I II1;RI';HV CI{RTII'\', Thai I alttn.lr.I .k-ccascl trom 
that Mast saw h ■- ahveoii OX^vt 'AS 



T90 V 



aiid that (li'atli Dccuired, mi tlif (hilr statt'il ahuvc al O- oO 



.M. Thr CAI Sh: Ol' DI'IA'I'II was as follows: 




crVv>vA^cn\^ 



llK. djy>v 







IMRA'I'ION )','(ir^ MiXitJis IH Days Hours 



vA^ 



iNED) J. 11). L^O^ Y\,<3 CLi 



(SIGI 



h'f^lilfJ ill Sill! I 



),ai 



■ Mnillll^ 



UX^l X^ if)oM f A.Mt-rss) 5bS (/b '<XVvA,<t<rv-L 



\ 



M.D. 



k. 



Special Information only tor fiospii,iis, instituiions. rrdnsients, 

or Recrnf Rf\idrnts, diid persons dvinij .mdv fro:ii home. 



Former or 
UsurtI Rcsidencp 

When was disease fonfrarfed, 
l( not al plai e of death ? 



How lonq at 
PIdre ol Death ? 



Days 



I'll I \i!t >',!•; sr \ ri !) im.u v;, ,x \ 1, r \k rirri. xi; > ak 1; i'k r i-; r( ) 111 v. 
Hi-.sT (»i .MS K.N( t\\ i.i:i)( .)•: .\Ni) iti:i,!i;i' 





I Inf..- iii-mt 






i'],.\ci': Ml. luki.M, (iR R i;m' i\-.\i, 



D.vn; ..! ill Id Ai ..I k j.;m()\-,\i 



190 \ 



INI ) ]•, k T.\ K J-. R (j\9 . VJ . NJ xijt>U5J-/Vy^ 



N. li. livery itcin o^f inlrormHtion should h. uiircrully s-ipplied. AflK. s!n»ul«l be Ktnteii FiXACTLY. PIIYSICIAINS Hhouitl 

state CAUSE Of- DEATH in pljiin terms, ttiat it mny lie properly elasHified. The "Special Information" ifor per- 
sons Hyln^ away from homo should be jiiven In every instance. 






1 ' 



i I 




J ' I 






\ I 



; i 



wm^ 



*fe* 




ii 1 






•i 



^ 



I 



i4l 



^ 




^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•St .... r,,\ ]■ r 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



X<y^^ i^^^u Deputy Health OfHcer 



Bos^isld'Ofl jVo. 



1 93 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



I 11. 5. 5tauc>arD ) 

J? Qp 

PLACE OF DEATH: — County oi'^OJWJ ,\XX/YX CA.ACt) City of 



P 



No. 



a-, 



1 1 



St.; 



. ^ 






Dist.;bet. OuaVvv^crYu 



I /^- ■ 

and V ■■ ^^ 



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



FULL NAME 



jA.\U^<.<:^.A d\ 




AjLcn'\.<x.\.d . 



1 



PERSONAL AND STATISTICAL PARTICULARS 

ri ii.i iK 



UX^-- 



i> \ 11-: < >i r.iiMii 



\' . !•. 






It) 



S 



M 

1 I 



1 /.■;///.' O 



MEDICAL CERTIFICATE OF DEATH 

DA I1-, oi' Di: Alll j) 






(I);iv^ 



r(?n \ 

(Vfjir) 



I Ili;RI':!;\ Ci:RriI-\', 'rii.-.t J .■itU-mK-.l dccrascl fp.iii 



^ 



^ IN* ■.I.I':. MAKKIl'K 
U Fix >\\}:i) OK I'""' 

W ■ :! •• i 11 ^1 >ri;il il. 



MIH III I'l. \('l 



-A 



Q^ 



i 



'^ 



tO^'>\.' J ,^u(XAx.ec<) •:■ ( 



\ \ M (■ < M 
I All! 1,K 



I'.iK I'M ri. \ri-; 
oi- {■•AriM-:R 

I st.'itf i>r I'ouiiti \'* 



M \ I 111 x \ \M I-; 
111 M(triii:K 



itiurm'i, \i,'i': 

' -II Ml t \' 



1' \ lit )\ 



.(X 



ti! 



v.uv.'- \k 



C ;■ 



A 



w ^ 



i \ V 



AV',,.V,/ ,'// 




tli;it I last ^;i\v h .'.. ■ alivi' on '.:)-iL'|vI li, \ip\ 

riinl tli.it ihitli ocoiiried, <ui (hr <!aU' stated aliovr, a( v 
. ^.<.. M. Tlu" CAISI-: ()!■ |)!:.\TII was as follows: 

hlK.X'rioN )\ars .//,-;////>• 




OjA^Ajro LLIk^ tXCl^ .<X>vii. 

/>./) V I3v I lotos 



CON 



I) r k .\ T! ( ) .\ 










Signed) ^a v^^ \ \,a..^ . • J/^ w vxa. . > IVI . D . 

(AddtvsO ^1H UaXjc/rxcca 'v.)l 



/'./IS 



//,UI 



WJi-iV^- .^ . I<)0'', 



) . ' 



t i 'k > 



i: -! 



v^)' 



1 I 

I I 



If! 



1 



V,-) ,1/, i/,///- 



/'.M 



I'll 1. \IU »\I". ST \l"i: I) I'KKSnNAl, !• \Rrui I, XRS AK i: IK I}'. I( » iiii-: 
nivsT 111' MV KNOW I.I. IX. !•; .VND Hi;i,Ii; I" 

<Inf..-iii.tnt VAJ <XaXXAj a. CK„C^'^X''^ ■ A^ 



Special Information omv tor Hospitdis. institutions, Trdnsients, 

or Reient Residents, and persons dyin'i .m.i\ tron fiorne. 

Former or ^qou r, ^ j "^ i How lonq at . i, 

Usual Residence <A\ 01^ AA/>'v<^- ' ' llire ol Death? 

Wfien was disease rontrarted, 
II not at plare of death ? 



1 iJ. 



Davs 



I'l.ACi; Ol nrK!.\i, OI-; ki;.mii\ai, I hali ..; !!■ kiai. (.i ri:mo\\\i. 



! ^ 



^ 3v% I QOS 



it 



I 

1 1, 



I 



N. B. Kvery Item of Informntion should hi cin'eVnlly supplitfcl. A«IK sSoiilcl be stilted liXAC TLY. PHYSICIANS Hhoiild 

state CAUSE OF OriATH in plsiin terms, that it may be properly claHwitfied. The "Special Inltornintion" for p«r- 
Ron« dyin^ away from home Hhoiild be jjiven in every inHtnnce. 






mMuMhnuim 





iH 




k", 



^^1 



> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!',.,:il.l .,( I|. :, ■.[]'. 1 V.v 1- f-'[;-S-:..^i- liXil'T.. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






rJO'X 



lir^istcred J\^o. 



1938 



6C(„vo vLcvH.|, Deputy Heailh Offlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( ^1. 5. f?tan^ar^ ) 
PLACE OF DEATH: — County ofO/CU'^^ OAXXovcv^c<. City of Oci/^rv^ 0.\XX/>x^a.^ c<. 



No. 




-^'V St.; H Dist.;bet. 

(IF deatA occurs away from usual R ESIDENCE give facts called for uftoER 
IF DeUtH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEflllJ) O 

■ I' 

FULL NAME V^ 



andVlUvaoi/>\a 

R "special information • ^ 
F street and number. J 



) 



- ! \ 



^ 

PERSONAL AND STATISTICAL PARTICULARS 




\jxi 



:>\ii <>i iiiKiii 



\' . )■: 



axkl. 

M..i)tlii 




h 



VLC... 



II 



A^ 



-tt 



■syW 



U'. 



4— — 



MEDICAL CERTIFICATE OF DEATH 

I'A i"i; n\- i)i:ai"ii 



I'Mi.iit'li' 



n):iv) (Vc.Mt) 



:\\ 1 



)■, ./ 



IS" 



/),/ 



- : . : I M \|.: k 1 1, 1> 
WIDOW !• 1 1 OK It!\ I > I ; I 
' \\'; it' ill ■-• M'i;i 1 (1. -!■;■ 'i.it '.' in I 







St. (I. MI cuuiitiN Jr in) (j 



1 HI;KI';15V CI;RT1I'\-. That ^ aUou.kd .k.rasr.l In. Ml 

lliat 1 last ^a\v h L.>) . alixcon OX^vtr 3L?S np'l 

;UJ<1 that <K-atli 'XHurrcd, on tlu- ilatc slali'd alxivc, at \ 
V) M. Tlu- CAISI': Ol' I)|-:\TII was as follows; 



\ \ M 1 111 

1 '. in i-.k 



MIUrillM. \(^K 

Ol 1 \iiii:k 

" St:il ' ■ .; »'. .i"M ■ \ 



M\ii»i:\' NAM)-: 

o}- MoTlIi; K 



liikTiiri, \( 1-: 

Ol Morill'.K 



' r ri'A iK (N 








c () N T R I n r T ( ) R \' V CJ-tA; -|MM.yi.v <:xiL xitv-dU I vyy^K^^lt. 



)'(■'/;■ 







Ojlvv\- 



VCX/VUi 



c^ 



NED) Cv(B.^)A.dU M.D. 

5" ()bavy.c4^>\ nt 



1)1 RAT ION 
f SIG 



cix IaI at i(,o'i 



A.Mtvss) I'Xib aOaVv.c4^>\ n 



SPECIAL Information "niv tor llospitdls. Inslifulions. rrdnsienfs, 
or KctenI Residents, and persons dviiij ,ivv,iy [ro.n linine. 



A'- hfi'iJ III S,ni 



y,;i 



\t.n<tl,- 1 .S 



III \H( »\'i. > T \ri; i» ri'K^i i\- \ 1, I' \K rue I, \K-, AK i; tk ri-; n > I'm-; 

m'.sj- ( II' MV KNo\V|,i;i)( ,|-: AM) HI^l.M-.F 



' I n I • ) ! 1 1 ) : I n t 



■ ■IJ Mi n«. » I so n 






Former or 
L'suhI Residence 

When was disease contracted, 
If not at pifli e ot death ? 



How long at 
Pldu' ol Death ? 



Davs 



190H 



KSucxK 



I'J.ACl-: Ol- IIIKIA!, OK Ki:Mo\A1. J DATi;.,' r.iiMAr ..I KI'.Mo\\| 

1 m.i:ktaki:k Wll Lvv-Ctul. '^ Lc 



(.\(l«lress 



IN. K. fivory item of m9<.rm.itlon Hhould !>.• ciirov'iilly Hupplieil. ACFi k!io-iI(I be stnted I.X \CTLY. PHYSICIANS should 

state CAIISIZ OP DEATH in plain terms, that It may be properly cluHHifieU. The "Special Inforaiation" for p«r- 
Kons clyin^ away from home hIiouIiI be driven in every inHtance. 



n 



I . 



• i' ) 



i « 

I \ 



« ' 



t ' 



' I 



■i 



• I ; i' 



ifti #*J^u i # j 




r 




f 

f^ 



>t i> 



■ ,i 



Mlt^ll 



li 



WRITE PLAINLY WITH UNFADIMG INK — THIS IS A PERMANENT RECORD 



i:,.;ii(l of II. .ilth 1' \'w 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((h 



(' /'V/^v/, oxA'^ctuY\A.)wA/ 'XI 





V)0'{ 



Begisfefed JS^o, 



1 939 



Deputy r n Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( "a. 5. StnnDar^ ) 



i (to A ^ 

PLACE OF DEATH: — County oi ^^0^^\j<>X.O^yy.ZKj^^<^ City of 0/CX/^rv 0^<XyvOCA t:< 



I 



No. ^AHH VJc^Lk St.; 1 Dist.; bet.U 'OXltit) 2Ln6^\x.L\^ 

r ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U N D Cfe SPECIAL INFORMATION" \ 
V If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD d'p STREET AND NUMBER. ) 




PERSONAL AND STATISTICAL PARTICULARS 

' "^ (TO ' ^ ' ii.itR ^ 

1 




FULL NAME 



:■ \ 1 I-. * 'I iiiK I'll 



lui 



4^ 




M.'iit 



n 



A? 



\' . 1- 



70 



/>./! 



^1 N' I.l" MARK 1 1!! I 

U 11)1 )\\|-:i) (»k |)I\< )!■'. II) 



HiK riii'i, \ri-; 

Sl.iti oi CMUiiti \' 



ll 



\ 



MEDICAL CERTIFICATE OF DEATH 

DA ri-: oi i»i: \th p 

•Montrt) (Day) (Vt-ar) 

I lli:Ui:i!V Cl-;kTlI-V. That^I attcii.lo.l .Iccvast-a from 

that 1 la-^t sa\s h.A. a!i\con OJL-|-vt ^S np'\ 

ami {h.it (liMtli ot-currcil. ..ii tlu- »latr >.;tatf<l altovt'. at ^ 
^■. M. Tlu- C'Al SI'! ()!■ |)i:.\ri| w;,.. a^ follows: 



.\-0 




•U 



\ \ Ml- < )I 
!• A Til IK 



I'.IK rill'l, ACH 

<>i.- i\rin-K 

(Stat. ';-!tI^ 



M \ii>i:x NAM1-; 
>ii m«)1"iii-:k 



I'.IK 1 IIIM.ACl-; 
'»l Mu'rilKR 
' ^ta!( Ml COmUi \ 



i >' 'M !■ A 1 ll >N 




liY 



^y\j 




CON Tkiiu roi 



Months 



Pays 



Hours 



^. 




^AX^LOL 



Cxjv,' 



^kslLq^ .^6 



Mouths 15 Pays Ili^nis 

^ -UJV>' V VV<X N >\ IV! . D . 



nrRATlON Years 



^SlG 



NED ^ ULa.\^k 1 



Special Information only tor Hospltdls, Instilnfions, Trdnsienfs, 
or Recent Residents, .ind persons dyinj .im.iv from liofne. 



1 , 



1/ .'//// 



iin-: \H()\-i-: ST \!"i.' I) ri-R<.(>\ \ I, I' \K TUMI. \K-> \Ki; TK!}': It I Tin-: 
Hivsr<»T MS- K N( >\\i,i,i)<; !•: wn i!i:iji:i.' 



>' 



Former or 
I'sutil Residence 

When wss disease confr.)( ted, 
If not at place of deatfi ? 



HoH Innq at 
Place of Death ? 



Davs 






ri.AcM-: or lu ki\i, ok ki;Mo\Ai, I i»aj-i-;..: mikivi ,.. ktmuxm 

(^ ^, l^ } {) 

(Ad.li.s^ X\ 1)/<XAV \l\xA IIa>4. 



iN. B.—— livery item olf Infonniilion Hhoiihl b^' cnrolriilly Hup|>lie(i. A(iR kIkhiIiI he stated FiXACTLY. PHYSICI \NS Hhould 
Htfite CAlJSti OP DI:ATH in pinin terms, that it may he prri|)erly cluHNiliied. The "Siieciiil liifoniuitioir* tfor per- 
son* dyin^ uway from homo should be litiven in uvcry inittnnce. 




i 



■I" 



%} 



: t 






I y 









m»f*- 



^JiikJiA'^* 





;V' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;.i:;nl .,r 1I> .I'lli r \.. ;■, t-- V"^:.; lUScT ^^. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Si 



Dale /'V/r^/, axl|^tx-m.lMA; X-\ JfJO^ 



]i(>o^i\sf('i'(ul jYo. 



1910 




Deputy Health Officer 



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



Certificate of Beatb 

( tl. 5. GtanC»arC> ) 
PLACE OF DEATH: — County of LttcVA^^cd. o. City o{0,<x.^y\j 




cbvo vcvl 



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" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSriTUJ^ION GIVE ITS NAME INSTEAD OF STREKT AND NUMBER / 

I I U\ Xj\. y 



") 



FULL NAME 



->i,\ 



PERSONAL AND STATISTICAL PARTICULARS 



^\ 



! ' M !■ (i| I;1K ril 







rU^ 



I 



N?..!lllli 



MEDICAL CERTIFICATE OF DEATH 

DA Ti; <»i' Di; A rii 

iM'ititfii (Day) 

I III:K l{r.\- Cliin'Il'N', Thut I .ittni.lr.l .1<(< ,i^r,l fi-.m 

to : 



/QO 

(V.-;il 1 



I9O 



\ ' . 1 ■ 




I 



--INt.l !• MARK i I'll 



!!ll>' III IM, \CV. 
Sl;it( .il ( '. )Uiitl \' ' 



\ \ ^ ! 1 1(1 
I \ 1 111 K 



niK I'llPl.ACH 

01- !■ \ rm-K 

' "^l:il ■ -1 <', ,11 n; : \ 



M \ ID!, \ N \M r 
i<! .M'lllllU 



1; I kllll'I.ACl-: 
'•I Mn'llli;i< 

' "-I:i1. ■ ■■: I . ami ! 



M.n,!j,. 



.1 Vd ■ 



lli.it I l;i'.t -^.iw !i - — ;ili\C' on 



D;n 

Dp 



ami t!i:it i|- .itli iic(-in i(,-(|, on the daU- <tatr(l al)(.\-(.-, ;if 
■ ~ M. Tlu- CAl Si-; or |)i;,\TII was as fr>II.,w^ 



MIRATION )V,/ys 

c< ».\'i"ki i;r'i< )R\ 



Monf/is 



/Kns 



Hon 



IS 




1)1 RATI < ).\ 

( Signed ) 



i^//'.v Mm I lis 



Pay 



//<>in s 
M.D. 



D)0 



( A<l(lr.ss)0/CL>v ^^<X^\Ah.c K.'y}. 



<>(■(■ 1 1 



•MioN M\ 

AV :iti'<f ill Silft /'i»)li^ . • 



Special INFORIVIATION ""H lor Hospifdls. Instilulions, Irjnsinils, 
or Rt'icnl Rcsiili'iils, <in(l piTMins dviiij .iu,i\ Iron home. 



1/,.. ''/ 



riif \ II' t\-]-. s r \i'i: j) I'l' i<'.< »\ M, !■ \ u I 1.1 ! m.;^ \i.: 1, i'k r i-: I'n riii'; 
i:»':>-.i' oi' M\' K Ni iw i,i;iM , ]■, AND r,i i,:ri' 



liirmri or 
I'siidl Rcsidi'iirf 

When W.JS disp.isp (ontrrtdcrl, 
II not .If |)l.i(c ol (Ic.itfi ? 



IIOH |0I1(| .it 

Pl.Kr ot D<Mlh? 



n.ivs 



i 



• \ n: ..• i;ii;iAi .,1 u i;m( i\' \i, 

OjUpX XI T90M 



( X'Mi.Ks 



I'LAri'! ()|- IM K lAI, • >!■ !• I •^!' >\ \ I 



I \i 



N. H. Kvery item <ti iiitformnt Ion shimld Ik ^iirct'iilly sipplicd. AHH Hh.mld ho Htiilcd liVACTLY. PJI YSICI AINS Hhoiilil 

HtntL' CAIISI, or ni: A Til in pliiin terms, thjit it nuiy lie pr.iperly cliiNHiVied. The "Sjicciiil hitormiition" for par- 
son* (iytnd iiwiiy >'rom homo »>lioiild ht- jilven in every instnnce. 



'I 




i 



' ( 



,jfi^njjt^'i 




liyilnki!.ll 



I'* i I 



I < 



1 



«! 



iil 



I 



< ', 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f!--i: 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







1 Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of !Dcatb 

( tl. 5. Stanc»ar^ ) 
PLACE OF DEATH: — County of C CV^^v O Vcx^vC^^ccCity ofCWw J.\^Oo->vco ec 
No. I^S 11 cL<XV^<:iA ' St.; ' Dist.;bet. 'v iCLW-UlCA. and a-LA,<S i ; 

DEATH OCCUWS AWAY FROW USUAL RESIDENi 



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

FULL NAME UcLtv^^K 



cLwC'v^. 



A/ 




PERSONAL AND STATISTICAL PARTICULARS 



DA li-: nl- III K I'll 



r%^\ 



M.iiilh 



A' . !•; 



O 6 !Vi." > 



n;i\- 



M.n,tli' 



\ ■ :\\ 



MEDICAL CERTIFICATE OF DEATH 

DAI 1. ul Dl'.A'lII 



( I ).l V ) 






A 



- i\' . 1,1'.. M \K!v ii:d. 

w iD< •ui:i> Ok i)iV(>Rrj-;r) 

\\ • '•'.' i !i ^i).'i;i ' ' ■ ■•■ nation) 



i;iu '11 1'l. \i-i' ^^ 

'Stat. .; I'^iiTit; 



\\-\ 



\ \ M 1 ( H- 

I \i'iii; k 



Lc. JVjLVvu, 



oX' 



y^j^^T\ 




(X \ V d 



'MontfO 
I IIIKII'.N- CI'Mrril'V, 'I'li.il J .'itU'iKlt'.l .Ircr.isci frniii 

that I lavl v„.,\v Ii .. ,, ali\c oil OX-^V^. '• ^ ,,^,., ' 

ami Ihat dcatli occiirrcil, on tlu- ilati- staled abow, at I 
LL M. TIk- CAl SI'! oi' |)I';.\'I'1I \va< as foil. 

a 



)\VS 



o 



HIRTill'I. \(K 
•tl-" IXriM'R 



MAIDI'.N N'AMl-; 
ol' Mo'niI'.K 



lUKTII I'I,.\riv 
ni- MnTiIHR 

'St;itc nf Coinitrv 




cu'> vcL 




.t 



oJkX vj C'. ' 



o, r I" 1 \r ;, )\ 



\ 



,\XyLcx/^vcL 






Dlk.X'riON Ycar^ MoiiUm /)avs 1 louts 

: ( ) N T R 1 1 5 r T () k \' l^ Voji/wx^w^x ^tx-i •(^d. vL <::^. ^w:L,.. 

\jLcOLcCtX<rvv Cri- <JV' a. <"' • * 
DrK.XTloN Years ^r,>nt/,s /hiv^ /fours 

(SIGNED^ i.XXa^U<i. Oi^<xJLl6'vci M.D 

Y n^ J? ' 



■1 



SPECIAL INFORMATION "nlv for lhs|Htdls, Institutions, [ran^ients, 
or Recent Residents, and persons ilyin^j .ih,iv (ro;ii home. 



M ..■": 



I'll,- in:mt 



\>V 



T.'i i: \\u \\ v. sr \i i: D im-ks. )\- \ i. r \ k iini. \k-, ak i-: rKii-: ri > tii !•; 

HI-;sr ol' M\ KNitW l.lDi.I-; AM) l!K I,! I! I' 

\ 

c<X<X'v,M. 



Former or 
Usiidl Residence 

When was disease rontrarted, 
If not al place of death ? 



lioH font) at 
Place ol Death ? 



Days 




V\. \0\'. I )I' litK lAI, I >k K I".Mi "WM. 



'*^C 



h^J(y<L^ 



DATJ-; ..;■ I!rin.\i. oi ki:.Mn\- \] 

a. 



)x\'<Xj 'X^ 



TOO 1 



ndi.ktaki:k\JR^ 3/CLdxLt^W''^j^.^JLa\t^,'^v1j 






j»r 



N. It. !:ver> item oV int' )rin!iti«.n Hhould !>• c:irc>'iilly supplied. Adfi .s'loald be stnteil fiV ACTI.Y. PHYSICIAINS fihould 

Ht«tc CAlJSr. OF DIiA TH in pinin terms, tluit it m:i> l>e pniporly clusKified. The "Special Int'ormiition" (r'or per- 
sons dyin£ nway from homo sliould be jii\en in every iiistnnce. 



i 



\ 



I 



M 



I, ■ 



! 



if 

; V: 



»'J t 



I ■• 



I 



i 



1 J 
I ^ 



\ 



y 



j 3 



i ; 



\ ! 



:W5»' 



um 



l4-ti,.'t,*!;li» 



!l I 



w 



^ 



M 



» 



t t 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



' I , ■ I ! 



I ! ■ I ■■ V 







REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



an 



Deputy r 



i Officer 



It('o^/sfr/-rd A^o. 



VJ12 



Dff/r rifi'd , Ox 

DEPARTMENT 6F PUBLIC HEALTH-=City and County of San Francisco 



Certificate of H)eatb 



QS^ 



PLACE OF DEATH: — County ofCjA^-Y\' AxOAyCc^cc Qty ofOoy^X' ^^Cu>v<XACUi 
No. Jj^VTrvXX..A\j K:^A\\\X.(xX St.; Dist.;bet. .-md ^^ 

/ IF DfATH OCCURS AW4V 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 NUMDER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




,^^Oj 



3 



Hi. 




^i\ 



I ' \ y\ ' >i I'.iK'rii 



\< . !•: 




U;.l.i^ 






MEDICAL CERTIFICATE OF DEATH 

DAI'l-; (tl" DIIATII 

3x1 xt Xb 



< M.piitli' 



I»,ivl 






I m<:Ri:ii\- i i;R'ril'N-. rii.it l aiu-ndt.l .Ktcmsc-.I tnun 



CS.O )■,,,.,, 



S!\C. I.)- M\KKli;!i. 

WIlx >\\ i:i) ( »K I>!\t 'Kvi:i) 

'U;it< in smial disi}.' nation ) 



L 



iMki'i PI. \'M-: 

' St.l! • ' liM \ 



I A rn j.K 



HiK I'll I'l, \i ]■: 

'St,!, ,,! r.,11 I'trx • 



M \i HI \ \ ami: 

"! Mt>lill-:R 






r ( 



OX^vt' it np'i to 

tli.it I last saw Ii *..''. ali\c()ii Cj_iL.^^ 



X 






aiiil that tU-atll oi-inirred, on [hv date staUil ahovt", ;it 1 

^^ ^r. T\.c c.vrsi- oi' i)i;.\i'ii was as follows: 



K\.<r\vv^ VJ ,CL^Jt-^v<l Vvv 



\ 



-, U. . 



vU^\lvu.l^. 







^Kov 



9' Wl! 



DIUATIO.N 



)V.z.y. 




Vo 



^ 



Month} 



/'"'■ 



Hours 



c^oNTKiin'rom' v^^t<L«^>\x]o 0,1. Ax.u.va.. 




r.iK iiiiM. \ti-; 

1)1 MOTIII'.K 

' SiaU' or Coniili \- ' 






DlkATlo.X 
( SIGNE 



U-.M 



)'<(/r.v Moil lis V /),/rs- 

'^ l(>o'i ( \<Mrrss) Ol\Awa^w OUCV^U a I. 



f fours 

M.D. 



SPECIAL INFORMATION only for Hospitdls, liistifulions, rrdnsienls, 
or Rfffnt Residents, dnd persons dyintj ,iw,i> fro:ii home. 



I\:' iiitil ill Sail /',' ,,'//! /W.* vK C^ ) f <M > 1 



^ ( 



former or 
IsudI Residenre 



"Whlx 




\ , How lon(| dt 
t<i.<lco> • pid.eot Oedth? 



• Days 



When was disease conlrdf ted, 
If no( df pldre of dedfh .' 



Ill i: Mtovi-: si'ATi-:i) rHRsoxAi. r mmu i i \ks a k i, i'k vv. r« • rii v. 
in-;s'r oi' m\' k.\<)\\i,i:i)C, k and 1!i:i,i!:i' 



(Inf. 



( X.l.lrcs^ \j L 



D 



A CX>^sLC<j V<XU 



];i,ACi'; OI' lUKiAi, MR Ri;\!(.\ \i, 





.\ 1 . 1-; R T A K 1 ■■. rM 1 1 J <X{icLjl^ro M IT \J^ 



1) \Tj: u; i!i ki \i ,,t R i.;\i( >\ \|^ 



A.i.it.ss WW ^S\\K^.^<^y\ it (J 

N. B. r.vcry item oV' inV'ormiition mIkhiIiI be cjirofully siipplieil. AUli shoiilil he stjite<l f.WC TLY. PHYSICIANS Nhould 

state CAUSE OI- DliATII in phiin terniH, tlint it may he prf»perly ctuHKificd. The "Spcciul infoniintion" for per- 
sons (lyinil nwny Ir'roin home should he <ii\en in every inHtnnce. 



Ml 



< * I 






'.J 




I i 



I 

I 



I " 



I « 



•i 



; \ 



a!?**^'-*' 



UmA'"* 



'^^wm 



«i 



tif It 



w 



1 






' 



l1 



I 

I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



l'„,,ii.l -f M.ntli I' v.. :^ -«-^^; .c^V HXil'O., 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)a/r Fi/cf/, OX^tt^vLov XI 



If^O'i 



JlegLslci'cd J\^o. 



1 913 



trU^A^ dx^Mj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of E)eatb 

( 11. S. ti'tanDav^ ) 
PLACE OF DEATH: — County of ^^CLVl' vJ Vcv-nxuic^ City of O^C^ru 0/\^cxyYvC\^cuo 




No. l^ Ld^d-M St.; '•- Dist.; bet.V] CKA>ctl and M )X<X4-0>v 

(IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V T FACTS CALLPD FOR UNDER "SPECIAL INFORMATION ' \ 
IF q^ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



'^wix 



1 



4 



> \ I ) < M !;l K ril 



A5'. 



MEDICAL CERTIFICATE OF DEATH 

DAli: ()1 Dl.Arii 



ixkt 



(I):iv) 



(V<-;n) 



M-nlhl 



\| . 1 



) . .; 



; >,i \ 



1/ ■'/,'//- 



I \ . :il 



n, 



I HI;K1':1;\" l !:irni'\-. Tliat l atUMi.lr.l .U-ci.i-r.l Irnm 



•>INt . I.I- M \ Iv U 11 H 

\\\ IM »\\ 1 1 I < iK I >I\ < »!•■> 1 l> 



i!iK ri!iM,.\i'i-: 

Sl.ilr ol (■( itiiiti v^ 




A^cL. 



^^ • ^ 



tli.it I I.ist ^;i\v li t: ;ili\<.' nii 



aiicl llial "liMtli MC(-uri<.'(l, cii the date staled .iIkc.h-, at 
M. 'i'hc CArSi- Ol" in; ATI! was as lol|.,ws 



I()0 
I«)0 






-^-^Wcc\X,^Axv,ci • -t\.«r»v 



NAM I .i; 
I- A 11! IK 



MIU rill'J.AiH 

Of I \riii'u 

■ ' ■ II lit ! \ 



M \ I l»l-;\ NAM ]•■ 
«»l MitTlIi: K 



I'.ii; riii'i, \( f, 
"I MMriii-:K 

' "^t.lti ' il ( 'i.Ullll \ 



1)1 RATION )',\irs 

(.■ONTKIin'roRN' 



I )I' RATION )V,;/v 



Months 



Pay 



Hon 



r.\' 




I. j-c. r V'.. 



Mouths 

1 

/t) 



I'^ilXS 



I font x 



SIGNED) UrV^n Vil^u J. \i3LU-XuUxy>A^^^ M.D. 



1 1 )' I 1 '' A 1 



SPECIAL INFORMATI 

or Rt'ifnl Rfsidcnis, diid ppr^oiis t|yin;j <mii> frfl:n home 



ON '»nH lor llospitdls, instilinion 






It < i !• \ I 1< i.nQIT^ 

l\i- ■ ih'il I II Still /'/ il Ih 



ixxxjJi^JL\j ^'^^ 



\ , 



I'll i: \mm\i.: st \ri II ti-k son \i, r \ inirr i \ ks \i;i: tk r i-; ii » nil': 
i;i:sr oi- \\\ l^N< iw i.i.di.i-; and H);i,iri- 



lull.; mint 






lormrr or 
Isii.il Rpsidpncp 

Hhrn was disoasr fonfr.if(fd, 
II not .il plarp ol dfdth ? 



HoH lonq .if 
1'I.K e ol Dedlh ? 



ions, frdnsienfs, 



Ddys 



I'LAri', ui iMi-' I \i. (ii; i<i;m< iwm. 



• vri-; m! Hi kiai. <ii r i;m( i\a i. 



190 I 



\(i.ii<ss b'?>b UJ <XQuKa.'\ \xvl.6 > V y 



n. 



N. II. r.very Item n't inVorrmil u.fi should I»l- ciirclfiilly siipplieil. AtJIi h!v)1iIiI ho HtJite«l liXACTLY. IMIYSICIAINS Hhould 

Htntc CAlISIl Ol- DI;ATH ill plnin tcrmK, tluit it inny he pr(»pcrly claHNit'led. The "Speciwl InlPoriiuition" for p«r- 
nonv clyin^ Hway from home hIkuiIiI he ^iven in *i\cry inHtnnce. 




■ill 



I 

n ■ 

J i 



\ 



:'■) 



. I 



V 



\ ^ 




I t 



I ! 



I ii 



rt»T^»*r 



■-'•^i^^ 



wm\h 



I 



H 




'I 



fi 



I 




l. 



^^ 



.f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



]:.yr.'\ ^:f nr;''!li I-' V' 






RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

I < ' ^ ' " 1 1 - 11 11 I ———^i^^————^^^^—^^— ———»—— 



/)((/(' riled, r 

i - 




Bc^islered J\''o. 



3vi n)(n 

\ ^«P"ty Health OfHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



\ 



Ccvtiticatc of H)catb 

( 11. S. 5tan^ar^ ) 
PLACE OF DEATH: — County ofO/O-v A..(X Tvev^l C(City of Ool^a. O.VCl>x<:ica o c 



No 



Xct^iA^UwYvti ^"^ 




, / IF DfATH OCCURS VwAV 
J V IF DEATH OCCUR)F 



Dist.; bet* 



and 



TRov .USUAL RESIDENCE give tacts called for under "special information' \ 

R)RED IN A hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAMEU IvtvcccLi Vj ,a.<U' ' ' ■ ' Ua^xU UU^di \.<x:\A.a 



i . \ 



PERSONAL AND STATISTICAL PARTICULARS 



I 



:>.\ 1 1 < 'I i;; K 1 11 



M 



,%%■■ 



iMMiithl 



I);iv) 



1 ' ti'h 



si 



/J,/) 



MEDICAL CERTIFICATE OF DEATH 



DATl': (H- Dl.Al'H 







(Monhi) (Dav 



(Vt-ar^ 



siNr.l.I-:. M\KKli;i) 

wriKiu i-:!) ()u i)i\Mi.;rii) 



w 



( stall <)i (."< mull V 



X \M ) Ml 

I A iH i;k 



lUKTlIlM, \K V. 

-' ' ■ i"' .lint I \ 



M \1I)1:n namk 

t>i Moi'm:R 



I'.iRllIIM, VCl' 
<»I' MdTHl'.K 

(Stall' or l,'i>iint I vi 



M' III ' 



f1l 




OJ\)\kXJj^ 



C\y>'^^ ^ ^ 



Ic'CL'TWUi 




^ii.UvOv\-j 



I I!I;K i.l'.N" C1:RTI1"\', That I altciKk-.l .k-cia^cl from 

th;il I last saw li '.' ali\c-oii C^JL^X-t/ ^b jjp ' 

and lliat (Katli < icciini-i!, dii tlic ilatc- slalcil aboxr, at \. 

III UATION )V,;;-.s- 

C()N'l"UIl!l TORY 



I lir C.MSI-; Ol" l)i:\ril was as follows- 



■^ 




d.^ 



\J\.V.\\i 



Mouilns 



Parts 



//on IS 






DTRATION 



/hiv: 



I hTIT \!!()N 



)'ii!rs Ml) lit lis 

Special Information only lor rfc^pifdis, in>iitutions, irdnsienis, 



(Signed ) 



//(>//rs 

M.D. 



u. ■>//// ^ I H / 



or Recent Residents, dnd pmons dyiny dvvdy fron home. 

Former or j'^ a ^ ( i P \4 '^"^* '""'1 ^^ u •i 

IsiLiI Residence 'c^VjO VJ/aCMt^ . iX p|d,e of Dcdth? l6 

Wlien Hds disease contr.ii ted, ^ 

If not at place of deatfi ? 



Days 



I'll ]' \1!i (\ !•: Si" \'fi: I) IM'KSDNAI, 1' \K IKT I, \KS Al< !• I'K T }•: Ti ) III !■: 
!ii:ST (M' MV K.\(>\\Li:i)('. K AM) i!i",i,n;i- 

I In f. I' nirint 



e . Q. %. EU^v 



/D 



f \'Mi. <^ 



mmmrmmm^'f 




^wcLo '()WUvaJx5lI 



l»ATI'; Ml I!i Ki.Ai I.I k I'.Mnx Al, 



.rCt '3v'^ 



I'l.ACI-'.ol- IMRIAI, (iR KI:Mi»\\|. 

' lb Criu. L\A^ 

rNi)i;u'rAKi:K v • VJ . vj Le^v^\c\' ^^ r 



190H 



ij 



N. B. livery Item ni inf ormHtlon uhniihl !>.• cnrc'rdlly siippliejl. Adf. s!i.>tilil be stiitecl l.\ \CTI.Y. PHYSICIANS Hhoiild 

«tntc CAllSn OF- DEATH in plnin terms, thjit it mny l)e properly wluNHilrieil. The "SpccinI lrn\>rination" lor per- 
sons d^'in^ fivvay from h<»mu hIkhiUI he ^iven in every iiiHtnnce. 



S3 



c 






t m 






ill 



•I 
1 ' 

\ I 






< •! 



w 



« > 



M^: 



,^s^ 



..Ji<'« 




M^ 




I ! 



I ' 



^ 



4 



k 



\^- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



■ I .1, I vo iK^jfr- -r -. U.S. r (■ 



REFER TO BACK OF CERTIFI CATE FOR INSTRUCTIO NS 



Dii/c rih'il , 





■n 



I '.)()'{ 



lie'^i file red Xo. 



\ 1)45 



tV^ .>X'OU ^''^H^>J'*^ 



"Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

y 11. 5. 5tnn^ar^ ) 
PLACE OF DEATH: — County ofOa. , v J A.<X>-vCV-^. -(City ofa.<X'TV J .VCL.> vc,^ - < 
No"'^'^^ CcK(rXx' . St.; Dist.; bet. V^y CVXXa^a^Oo and cXXX-O.v^ . ' 

/ ir DfATH OCCURS AWAV FROM USUAL RESIDENCE Give FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ A 

(, IF DEATH ^JCCURHED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAM E ''^^'Cl vv, ^ .. (X . . .oluvxx . . 



PERSONAL AND STATISTICAL PARTICULARS 

I I '1,1 iR \ -V 



!i \ 1 1 I 'i ;;l X I II 



a 



i 



V, 






11 






\«.i-: 



LA ), . 



^ 



-IM . 1,1" M \K Ik I i: I' 

W'llM >\\l- 1) ( »K l>:\ I 'K> 1-, I» 

'Wtilciii viM-ia! il»--ivn;ili')ii) 



,U jl dLcrLA>^u:i 



d 



<t:rKYv 




r. iKTM ;•!, \cv. 

- ■ ■ ' ■■Mil ; \ 



NAMI': <)! 

1- A r 1 1 1 •: R 



liik 111 ri. \( 1-; 

«)|- lAIIM'.K 

' St l' ( < >T < ■' >n nt ! \ ' 



nl MoTlll-.K 



lURTinM.ACH 

ni- MnTin:u 

(Stiite or Cdiiiili \ ! 



I II < ri' ATiON 

/.'/■■ i,//-if n) 'silli /".' ,ti!i !■■'•> 



> V 



<^ 



MEDICAL CERTIFICATE OF DEATH 

i)Aii{ <»}• I)i;a'ih 9 

Ojixt 



(War) 



(Moiifiri 'Day) 

1 II I':k I'il'.N' C i; RTI r"\', TliMt, l aUciuK-'l ilfcrasc^,! rp.in 

Ox'ivt x'k. !(/)■'. to qx-Vvt "^^'i i<pM 

lliat I last <;i\\ li-*-' iilive on i l<jO ^ 

I tliiit <l(.-;itli orcurreil, (Hi Mic <l;it.- statrd .ihnvr. at A 
LV y\. TIk- C.\I si: nr hl.ATII \\a-> as follows: 



a 1 1 1 



UV^w<vK't vc 



'^ 



>\Xa.^"v>a.C 



I )(■ RATION 



i^ 



\,o^ e c 



\jl'L<:x ^ V <^ 



{]b,CL 



.0 





> .^ cv. 



C'ON'rUir.I TORN' 



)','(//-,? M on I lis *• /^(/rs' 



J/otn s 



(iirs 



I) I R A 'I" I < » N 

Signed ^ Vj . U . VI / urw^v^xi 



Mouths IC) /:>,n'\ 




M.D. 



U<X,'>vMIjU.4 U'^• • 



Special information '»nlv Inr flnsplfHls, Instidifions, frdnsients, 
nr Recent Residents, dnd persons dviiij .imhv Iron fiome. 



)■<■,'/ 



V,, <////> 



/^</i. 



rm; amovi*: sr \ri:i) i-kkson \i, i-sk i uti.xks aki-: rurj' r< > tin-: 
i{}:sr oi- Mv K N'owij: i)« .I', and hi: i,ii: i- 



( infi); iiiaiit 



Op i 



f \.Mi' - 



Former or 
llsu.il Residence 

When was disessf cnntr.irfed, 
If not at place of de.itfi .' 



Ho\^ Innq at 
Place of Death? 



Days 



I'l.ACJ-: Ol- \\V\< I \I, < 'K '■: '•• "*•!' '^ '^'. 




I) \\'V. m! It' !• I \\ ni K )•;%!( )\"AI, 

TQO'i 



) \ I I-, m; 1'.' 



I M 






fA<l<li<"^s 



ATH in l.l..m term,, tll.it it .....y I.-- p...,.crly cla«,i«ic.l. The ,S„c.,„l Inform,,. . on for „.r- 



N. fi.— — r.very Item of inform 
Ht.itc CAIISI: OP nil/ 
Rons dyint awny from home Hhould be feiven in every instnnce. 






■f! 



1 1 

p- 



'A 






( it 



D 



i ; 



o 



I • 

I: 



I "^1 



-^ /'f 'W' ^ 



"■••'•iw,. 



Mliiii 



WKO^r 



1 



r ' ', 



li! 



M 



, 



W'^ 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



T^^'SisiB&P 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1946 



DEPARTMENT ot PUBLIC HEALTIi=City and County of San Francisco 

Certificate of Beatb 

I ^ ^ On 

PLACE OF DEATH: — County ofCjOL^rv J.V<X/>v^c>^>ci.cc City ofOcL^rv vJ/va./>^c<^^o 

Dist.; bet, ^ .W.o^aX and vT) Axx ■^ xvv a , ) 



No, 1'i 



^ 




f^ 



X ^AlJcrt^-^-^ 



St.: ::> 



/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U N Ae R 'SPECIAL INFORMATION" \ 
i, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



- 1 ■ '■ 



PERSONAL AND STATISTICAL PARTICULARS 

(. ( iI.mK \ n 



vn\ 



I Month' 



(Day) 



MEDICAL CERTIFICATE OF DEATH 

D A ri'. ('!• in. \ Til 5 



(M..ii!lil 



lie 

(I)av) 



/QO 'i 

(Vc:ir) 



\ ' . 1 ■ 



r. 



\\ll»< »\\ HI) nk l>!\nKil-:i) 

W'liti in voiiMl (ic-i'/natiiin) 



If 



Cj ^ >-v 



na\ 



I'.ikiii iM. M'l-: 

'M:il' ' .: I '. 11:11 I \ 



,^ 




vtr<v\xxdL Ucoo- VJUx. Klv 



I'.IK I II I 1. \< V. 

<>i" I Ariii.K 

' Siai 1 . r i'. ,11 111 I \ 



M \II)i: V NAMI; 
<il' MnTIIlCK 



I'.IKIII IM, AC J-: 

" n- M(»rm;K 

( Stall <)i I'cMinti v ' 



Oi 



I lll''lvl'l!\' riJvTIl'N', 'I'hat I attiMiiK'il i1(.hx-;i-;(.m1 from 

■ \ ' ':■:. \()o'\ to oxyTl/ lt> up'H 

that I lasl saw h alive on '..'Jl\vt; AL up '1 

and that tKalli ocfurreil, on tlic> ilati' statnl ahovr, at ^ . -> 
M 'l"lu' C'MSI'; ()!• 1)1:. \ Til was a>4 follows: 



• o„ C^^\JL-<X-\v 



Dl RATIO. N 



) V<;r. 



, Months \\ /hns 



/Ii)lil s 







I ii> I |> \ TKiX 



u . 



nr RATION )V(j'/-.v Months Hays I loins 

(SIGNED) ^. IoAjTuA;. • M.D. 



dxjvt IM icn^ ( 



Special information "n'y '«"■ Hospitjis. institutions, Transirnts, 
or Recent Residents, and persons dyin:) .iw.iy from home. 



Ill I', \iio\r: sr \ rin i'i<rs(.\ai, iwktumi. ar^ ari-. trii-: r<» riii", 
I'.i.srui. \\\ K Nn\\i,i; !)<•. I-: -\Ni) I'.iMji; I' 

(lnf..:n.ant LCmAXVCL I) CTTU \jVxxKA\XL^a- 



Former or 
L'siial Residence 

Wfien was disease (onfr.ifted, 
If not at place of dealfi ? 



How lonq at 
Place of Deatli ? 



Days 



I'l.ACl-: <»!•■ HrKI.\I< t)R ki:m"\ Al, 



)A KI'^ "! I!' "1 \'- "I '•! l-^l* ^\' \'. 

xjxtr Qi^ 190H 



INDl-.KTAKl-.R OV\txt<iXccL V V. C 

(A.l.lKss SHb N lVc^a.C<) >V. 



,, ,, ... ACF tthritilil be Htiited liXACTLY. PHYSICIANS hIiouIiI 

IN. 15. hvory item <.* inf..r,nnti«n hIk.i.I.I !>-• crciully supplied. A(.h Hhoul.l b« Htiue 1 1 ..^ |„f„ri,u.t!..„" ^"or dt- 

«t«tc CAliSr or DI:ATH in pluin terms, that it mny be properly cl..KK.l.ed. I he Spcc.I lnW,rm»t...„ Vor pT 
«on« clyinlt nwiiy from homo Khoiild be fetven in every instfinee. 



1- 



i^ 



J 






'ii 



'if; 



> 




I I. 



-^SSw*'' 



yg^jJIU'l 




HHili 



i- ;-i*.t^vri*fliwr" 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



11 






i 



I 



I 



ri-.^SLt H&' P (' 



RFFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



I* 




Ihffr Fi/rf/, ' X.\AjUYy^S-l'- ^T 100 "i 



Be^L'itcrrd -jYo. 



1947 




AA^ 




Ll 



Deputy Heallh OfTic 



er 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate ot IDeatb 

( 11. jTv ir>tntiOarC> j 
PLACE OF DEATH: — County ofOcL^^ vJ XOo>XC\A.C^ity of Ocla^ .\XV>VCa<l-C o 

JLu.^Lcruy^Ail^ 'It iy<t,\vlo ' St.; 



rsfn. ^LCu 



Dist.; bet. 



and 



A / IF DEATH OCCURsiwAV TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
I V IF DEATH OCCuittED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUVOER. / 

FULL NAME K^aJoj<x\.(k kK. JL\.^. . . 



■>i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

A ('( il,i )K \ 




<xXx 



ll: 



1' \ I 1 Mi 1.1 K Til 



A' .!•; 



J Inr 



I>.i\ 



H"^ 



iC 



'<■(■:, 1 I 



/',•. ^ 






lUk I'lIl'I, \CV. 
(St.'it- ' • i: m; 1 \ 



NAM I (>l 

I- ATI! l.U 



III Kill I' I, \>i-: 
< »!■ I \ riii-.R 



MAI1)1:n NAMl-; 

<ti- M()Tiii-:k 




MEDICAL CERTIFICATE OF DEATH 

lATl-; <>!■■ DKATII _}} 

(Day) (Vrar) 

I 11 i:U I'lP.N' C'l'R'ri I'N', Tliat I alltMidt-.l dccrMseil fn.ni 



(M.int^O 



IQO 



Ojl\\^ - Kp ' to O-^^-vt- 2>.5. T()0 H 

thai I last '^aw h v.->VA alive oil OJL^t^ Kp', 

.111(1 that (loath (KH-urrcd, on the date stated above, at ^ ■ "6 

Q 



M. The CArSi*: Oi" Dl-: A'l'il wa- ;is follows 



>V<J>V'<>-' A^ ' 



v\.bLcvAvcL 



iiiKTiiri, An; 

<)l" MoTlU'.K 
(State or CouiitiA 



OCCri'ATloN 






1)1" RAT I ON )V<7/A 

C'ONTRir.rToRV 



1)1 RATION rv^>V^//-V 

on ^ ^' 

( Signed ) J 



Moutir 



Pay. 



'.S' 



lloii 



IS 



Mo)i('is Pay 

/OA-t 



Hours 
M.D. 



\ 



10 ^9 

L'v,'^^. I -.^ 



1 /,./////> 



/'.n: 



iin: Anovi: sr \'n: I) i-kksovai, paktutlars aki", rRri-: ro rin-; 

r.l':sl" oi- MV KXnwIJ'.IX". )•: AND I'.1':MJ%1' 



(I nf' i: tiiaiit 



1 is .\ 



XOc/) 



'■ X'MrcKs 



VaXu 



C^J^^aI ^^^ IQOH (Address) LAu?^tc (■IU^v^. |..v 

Special information '»n'y for frospltdls, Institufions, Transients, 
or Recent Residents, and persons dvinj awjy from home. 

Former or n , o I,, U \ i i "**^ '""^ '"'' '^ fN 

Usual Residence I b l '-< M 11 ' J v tc \ I Place of Deatli? ^S) ... Pavs 

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



I'I,ACH OF lURlAI, OK Kl-.MoX'AI. 




(tLu L\o^i.) 



DATJC (>;■ II; K!.\! 1.1 k i:M( »V \I, 



INDl-.RTAKl'.R 




/cui<LuvM ITO Ma-\tu_ :>t S. Va . . .. 







(Address \V\\ MUuI^XU^V Vjt 



N. B.—r.very itcn o.' infor.n,.tion nhouhl b. cnrc.'uMy suppl.c.!. AGB should be stated fiXACTLY •^"^^'^^■A^^ 

stnte CAUSE OF DIIATH in pinin terms, that it may he properly classified. The Special InVormat.on Vor p-r- 
son« dyinft away from homo should be jiiven in every instance. 



w 



\ 



I r 



I I; 



'.' 



. I 



' I 



< m 



. n 



1 > 



) 



( • 



j 



m 






r) 



I .i 

i I 



I ■ 



I . 



r.*! k. • 



.Ji4B»^ 



•tLJ!.^ 



Mtlii« 



Jk4 




iiiHt 



*M 






II r 



I 






r 






I I 



/ 



',1 



I i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD -^(1^ 



.yxJoi" Health I" No. 1=^ l^-; - -"-^- Hfcl' i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Filed , 




%\ 



rjo\ 



Fiegislei'cd A^o. 



-1948 



X^^v^ Uv. Deputy Health Omcer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of S)eatl) 



( 11. 5. Stan^nr^ 



PLACE OF DEATH: — County 



of(j/CL'^«Aj VCl/WCA^CC. City of U/O^^'x/ AXX A-v^cA-c \- 



No.Lt^xtval C>'rLLV>QX>vCu ()bcH;ii\sl;a,l. Di.st.;bet. 



and 



/ IF nCATH OCCURS/VWAV FROlJfuSUAL RESIDENCE GIVE FACTS CALLED roR UNDER "SPECIAL INFORMATION ' \ 
V IF DEATH OCCu|i1rED IN A HOSPITAL O R INb T I T U T I O N GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 






o^y^wA 



■IX 



PERSONAL AND STATISTICAL PARTICULARS 




!' \; ]■ < >i I'.iK ni 



jxj^ 




1 I AY 



\'.l'. 



A^ 






mRriM'i, ATK 



Cja/tvoAji 



^jUi/V\AA^^ 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol' [)i;ATn 



Sii^ 



1\ 



I9n'\ 



iM.Milfh) (I>:iy) (Year) 
I IN'.KIJ'.N' ri'.R'riI'V, Thai I attniJcI .Iccravcl from 
I ( ,r) to '. 



tliat I last v;a\v li 



alivi' on 



"[(/) 
•!(/") 



aii'l lliat iltatll ori'iirrc'il, oit tlic dati.' stak'tl abnv*.-, at 
M 



\AM1-, « »1 
FATHl-R 



I'.IKllUM. \(' J.-, 
(Stall 'ii L'oiint 1 % 



M \ !1>1.\" NAM 1-. 
«M Mi»'nil-:i< 



IUR'i"HPI,A('l-: 

<>i- MM-nii-tc 

I SlaN : r. .liiiti ^ 



AXil^v 




i\X\ 




.>i. i lU- ("AI'Slv ()!• I)i;.\ri! wa^ as follows: 
DrkATIO.N ^'<L''^ Mon//is /hivs Hours 



l()NTKim"l( >N 



( i.(T 






,W^^^' 



Dl'K.X'ritiN )\\ns Motillis Days 

(Signed^ L^Vcnxi^^ . vfe. lu. dui^Lct-kx-d 



C 



Ix^t ai 



I ( )0 ' I ( 



LorVcrvu.^ 



IIoKt s 
M.D. 



rU <1.^ 



SP 

or Ret 



PECIAL iNFORfVIATION only for flospitdls, Inslililfrons, Transienfs, 
tent Residents, Hnd persons dyini) dwdv from liome. 



h''''!i{r-i' III V,:»/ /'i ii I'l i'-iii ) i'<n 



M.'iitin 



/>,,i 



Til I', XnoVV: ST ATI- I) I'KRsUN \I, I'ARrim. \ R s, A R l-! I'Riy. To I'll l". 

in';sT" oi' MY KN<>\\i,i:i)<". !•: .anu^hi: i.ii;)' 

,t djo LA.. Q.Of^<xtt 



' Infi r m.iiil 



\i1(1m'<s 




^ 



Former or Cuafr "f ^■i- How limq ,it ^ 

UsudI Residence "^ ^ ^ \J ^ML-V 0^ Pid.e of Dedtfi? ^ 



Days 



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



ri.ACl-; Ol' lURlAI, OR RK\lo\AI. I l)\ 



\ I i: .,1 111 i.'i \i(>i Rl'iMi i\ Al, 



rNDi'RTAK i-;r 



iverv Item of information should be coruV'ulIy supplied. AdK should •-.«V"^V' ^^^..\^^^''; , ^"' '*''^"?!^, '*^""'*' 
tatc CAUSE OF DEATH in pl^In terms, that it mny be properly classified. The Spc.ul Informat.on for p^r- 
on« dyinft nwny from homo should be Jiiven in every instance. 



!N. B.— — •Rvery item of info 
«on 



m 



•■ i 



.1 



I '1 1 



) 



9' 



I 9" 



I "3 



mk' 



f0BmS 




. ■-TTTT' 



«iiiitiiiiii» 



il 





' 4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n 



IfWH 



Uegisf('/'('(J jVo. 



1 {) 19 



Dale riled . '^^UIa ywaMAj 

"Ltrvt^i Ix^vu Deputy HezWn Omcer 

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



Ccvtificatc of Bcatb 

( 11. 5. Stan^ar^ j 



PLACE OF DEATH: — County of C^CV>\ J VOAVCAA^^ City of Oa>\' Vanci4CC 



NoA^ck IxCrvvU 



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



FULL NAME 



xva 




%:dh^ I 



v^ 




->i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

i t.'»»I,()K 



'XclU 



\ 



llfvjjl 



i) \ II' ( M I'.I K lil 



(V<:il I 



/^b 



M.mt!i> 



iVfar> 



^ ■ . 1 ■; 



1% 



M.iith 



U IIMIWII) nk DIVoKrKI) 

'Wiitiin Ki.iiril <!< -'"T'lit i' mi I 



dx^ 



r.!K riiiM, AtM-: 

I St.'itf or Coiintrv' 



\\M1 (•! 
I- A I' II l.K 



lUK'nilM, ATH 
Ol- lAI'lIKK 

' St;it r 1 II I '<ninl i \' 



A 




Lv.'>\. 



MAIDl'.N N 

(>!-■ Mtvni 



S\Mi: '^ 



lURlMn'I.AOl', 
ni- MoTIIl'.R 

I "^Irit'' Ml <.\)tuitrv"i 



A A ^ 



MEDICAL CERTIFICATE OF DEATH 

DATi-: <)i' i>i-: \iii V 

fMoiltlO !I);iy) 

I Hi;iii;r.N' CI;RTI1'^\'. That I uttfn.Ud «liH\ascMl liom 

— \(p to ' "I()0 

that I last saw h ■ — ahvc on 190 



aii'l tliat <lratli ortnirroil, on thr datr statnl ahovi.-. at 
M. Thr CArSI'! Ol" I)i: A Til was as follows: 



I )r RAT ION )'rar.^ 

CONTkir.l-'i'ORN' 



M0!l//iS 



Days 



I lours 



' 11 rri'AiioN ^ , 



or RATION 



)'(iUS 



Mi' III /is 



(SIGNED ) Lc^tnviv V 



/hivs 



hs\A "Xl 



S.li)Ada^vd 

c,oH ( A.i.itvs.) lH^vav^vi'^ 



I li'U) S 

M.D. 



vti. 



Special information '>nh I'tr llospltdls, Inslitmrons, Irdnsients, 
or Recent Residents, and persons dvini) iIwhv from home. 



M.'v.tli- 



lu;\ 



rm', \H(»\-i-: st\ti- d i'i-:ks( )\ m. i'\KTirfi.\KS aki-; TKri': t<» \uv. 
i'.i;sr 01 i.w KNi iwij 'I )(■.!•; and i!i:!,ii;i' 



( Inf. ir ni;mt 





( \<l<ht-;s 



Cl S Ixvtr^A; at 



\ 



Former or 
Isudl Residence 

When Wris disense iontr,ifted, 
If not d( plare of death ? 



How lonq iit 
Pld( e of Dealh ? 



Phys 



I'l.ACK Ol-' HI RIAL 01^ K1;m<)\\! 



DAin: <>r IJiKiAi. 01 \< l.M( )\ \|, 

T90M 



i,.-\v_ r< » M- in IV I ■> I. ' ' 1^ IX 1 ...■■■ > ... ......,■- 

A,M„.-s 35-1 ^LtUv At 



INDI'.KTAKr.K 



..tlon should b. cn.cV'uM.v Huppli.cl. A(JF. should He HtHtcd CX4CTLY PHYSICIANS hHouIcI 
^TH in plain terms, that it may be properly classified. The Special Iniormat...,. for pT- 



IN. B. F.very item o^ inform 

state CAUSE OF DEA 

son* dyinft away from home should be ftiven in every instance. 



^ 






I 1 
• I 



I ' 



i 



h 






11. 



i ■}* 



') 



I i 



9 



u 



H 1 1 ^ 



"3 



I; 



I' 



t 1 



;< '•> 



w 


i 


m 


fl 



. l^tM^mm 1 • " 


! 


ll 



J^--l 



Mm 



•I 



r 



iti'iik'(«»H 



it 



WRITE PLAINLY WITH UNFADING INK-— THIS IS A PERMANENT RECORD 



n&vi' 



tarrc-D -m drcu f\c r c-Qxicir Axr tnp i IM QTOlirTini\J«« 



m I »M'M— I W~»"inW¥W»ltfT»'< 



/^//r /'y/rf/,OJLkkjLyyJi)Ji\; "Xl 



cv^^rVA^A^ 




/.VY.^H 



lle<:!(s/('i'C({ jYo. 



1950 




Deputy He: i>hOfncer 



DEPARTMENT OT PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDcatb 



11. i\ i^1tan^al•^ ; 



PLACE OF DEATH: — County ofU<Xl\) OXaAXCUlC^ City 

If 



J/VCLM/CUl'C^ City of O^^VU 0.\.<VWCl.^,C<: 




St.; 4 Dist,;bet. (jb /CL^V^UUrVu andU^A^VOAvb 

lAL INFORMATION" \ A 
T AND NUMBER. / \J 



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



FULL NAME 



(\A .-^ U 



A ^ 



PERSONAL AND STATISTICAL PARTICULARS 



1> 



\ < . I : 



I M..iith) 



I » 






!'i 



'] 



:> '.v) 



V ti'li 



1 ■ ill 



IK. 



MEDICAL CERTIFICATE OF DEATH 

1) ATI-: ci- i>i; Ai'ii Q 



MmiAi 



t 



'D.iv) (\\ar> 



I MMii'thl 

i II I'K I'lr.N' ('I':iri"l I'N', Thai I attrn-lrd (U^ccascd fnmi 
i(,o to — 



\\ I in lU i:i) OK i)i\ t»K(i: n 

Wiiti ill s()ci;il (Ic'^ii'ii.tt ii III I 



';! !■ I'll ri. ^'" I-: 

! 1 1 \ 



N\\!l «>|- 
I- A '111 Ik 



I'.ll: I II I'l. \'' !•: 
< •! I \ 111 IK 



N! \ ilU'lN NAM I-: 

<»i Moriii'.K 



i;ik riii'i \i i: 
<►!• Mo'iiii: k 

(state III riKiiil I \ 



I 11 ( ' I 




that I la^l -.aw Ii 



alKc on 



ll)0 



KjO 



ami tlia! <lratli oC( ii rrt'il, on tin- flali' <lalt(l aliovc. at 
M. Till- CWISlv OI' I)i:.\ril \\a>> as follows: 

DC RATION )'rars Mouths 



/',/r.v 



J lour a 



h'r iihul I II 



f? 1 r' 



CnXTR ! ni'Tf »kN' 

DIKATK )N ) V,// V M,niili 

(SIGNED) LtjVCi'VAJA^O Vb. UJ. dLSlXxXrv-.d. 

aX Owl i,,oH f Addfiss) \^\X:.y\3J\J> U IJa a-.'. 



M.D. 




Special Information '•'•!> for ii'tspiLtis, insiittHions, rrdnsimts, 

or Knent Rrsidcnts, dnd persons dylii') .iwdv from fioine. 



/' M 



Til 1" MtoV}-: Si" \li: I) I'KKSONAI, I'Ak 1 I' I I. \kS AKl'! Ikri-; '1< » 

iii:-,r < ti' Ms;^ K \( )\\i,i:i)'".!: wn im'ijj.I'' 



iiii-; 



' Iiitic iii.int 




w 



K)XJb 



( \.Mr.sv 




in AD<xAAAjLbb at 



Former or 
llsij<il Residence 

Wfien was disense ronfrflrfed, 
If not rif pldre of de.itli ? 



ftow lonq dt 
Pl-ire of Ot'dtli ? 



Ddys 





i.ACi-: OI' ^^iiK lAi, I Ik ki:Mi'\ \i, I nwi'i;..: i-. ri\i .,i kim<>\\i, 

^, I ojJfsXj 'Xt T90M 



r.Mii'iK'iAK i;k 




N. 



,;._,.vcrv item of inVo.m»t!on Hh.u.l.l b. cnrefully Hu„pli..l. M.V, nhoul.I h. HtMte.l liXACTLY. I'JIYSICI \NS hHouIcI 
«totc' CADSr: OJ DIIATH in pinin terms, thnt it mny he pr<M»erly clnHnhied. The .Special l.norm..t ...n ?or p.r- 
Ron« dyinji oway from home HhoiiliI be ftiven In ovory lnst«nce. 



i 



I 



I,' 






!l 



i < 



i 'Ii 



) 



' \ 



■•.':J\ 



i t 



"^ 



.1, '. 



^JBKi^ 





hj 


. 1^ 
■ i 




i 


1 , 
.1 '■' 




^ 


1 ' , 



«iliii^iiL»«)iiii 



I 






1-, •*. 

•J 




tl 



'! I, 



■^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I f .iralXi' 



ii.v !■ r 



Dc-ccis Tn oAru nr rrnTicirATP rr»o iiMc:Toiir.TinN«« 






/.9^n 



h Of 



Bei>isl('ri''f J\^o. 



1 95 1 



DEPARTMENT 6f PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of IDcatb 

PLACE OF DEATH: — County of Oa^X' 0;uX.rtCAAC{^ City of CX-^v JxCLAXCA^i.C-c 
No. 11 0,a.q,A.. St.; "■ Dist.;bct. 00U.O ')-, and 0/UX.>vk.Uv^ > 

(IF/btATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS C A I 1. E D FOR U N D W "SPECIAL INFORMATION" \ 
mr DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD £^ STREET AND NUMBER. / 

FULL NAME LLa<>.v. ; \X^:Lil/K.cil 



4- 



PERSONAL AND STATISTICAL PARTICULARS 

ft I Ct>I.<»K , 



\n\ 



o-U 



ULuxlI... 



1) \ 



MEDICAL CERTIFICATE OF DEATH 

n All-. ( ii- Di: Ai'ii 



ixlxfc 



'Diiyl (Vf;ir) 



lL),ct 



M'.iillil 



/^(^ 



\| .)■. 



oH 



11 



(Day) 



'7 



M \ K K II- (I 
W 1IM>\\ J,l» UK lM\(>Kri-"l) 
Wiiti-iii 'KiK-ial .|rsi;.'ii;ilii)ii) 




woLdL 



i;ii' I'll I'l. \''i-' 




I II i;R i:i'.\' n;i<TIl\\ That I .itUinK-.I .Un-ascd fi.)ii 

■ — 1()(1 t(i I<)0 — 

that I l.i>-t '-.■i\s- li alixc'Mi - itp 

and tliat (Ualli ocouired, nii tlic datr --fati-fl a]>i>vi-, at 

M. Tlu- CWrSI- dl' i»i;.\ril was as follows: 




\.<^>.^^0_' 



-1 



V..C , V 



c^ 



U'^ 



CC-VA^ ' V \ -^ 



vLA>N->C 



' 4. >f^V A 



NAMi; Oi- 

I \iii i:r 



I'.IK III I'l.AT »•; 

<M 1 \rin:K 

s| I' . , IT C. .11 lit I \ 



M MI'i: .\ NAMi; 
t») MOTIIlvK 



I'.i kill I'l, \ri-; 
<M- m»»iiii.:r 
( state or Citniit i > 



I 



1)1 RATION )V<//. 



(."ONTK ir.rToKN' 



.\/o>it/is 



/hi\ 



■\ 



//oiti s 



1)1" RATION 



'\>^ 



r>>'' 



< n 1 I r \ 1 ii i\ 



• ,Oi 



h't'^iiifif III StiH /'i iii/< >u(> i !',''> 

riii: \iio\-i': ST \'i i-'D I'KUsoNAi, PAR ruti, \Ks AKi; rKii-; m 'nil'; 
m-.sT Ml- MS" KN( )\\i,i;i)C.iv A\i> i'.i;i,ii:i" 



NED) WVt , ■ ' O.'^ lO.doLi 



I loll) s 

M.D. 




^ !■■>!! In 



/),M ^ 



1] t ! I'l I ; I n 1 1 1 1 



11^ \'k 



I \.l(ll<-s^ 




\^-^_ 



Signed ) v^^Vt: , ■ 'O.^LUcJJLio , ' 

^l l.loH ( \,l,ll-rss)L»\^>\XVft liluA^v 

Special INFORIVIATION "hK tor Hospitdls, InstihiFinns, frdnsifnJs, 
or Kftenl Residents, anil persons (l\iiij dwdv fro.ii home. 

Fornifr or , /n o L "i 1 ( 1 ""^ '""''''' 

UsiJdl Residence I oli i«l 'VLIaj^ fUe ot l)e.itli? .Days 

Wfien was diseasp fontr.irted, 
If not flt pl.ire of deatli ? 



'l.AC'IC OI;:^ lUK I \l, « iK k l.Mi '\ \1 

It 




I \ Ti: ><: i;i KiAT Ml k i ;Mi i\'A I, 



'L 



I NI » 1 



;kt\ki.;r Jb. J. <OAA,f\\; V Cci 



JL\^X ^S 190 1 



^\(!lh(■s^ 



1151 



(hAuj. 



o-v^^rvo <jX 



S. 15.— Kvery Item oV !nform,.tion hIiouIcI be circV'ully supplied. AdB s^ioul.l be stnteH liXACTLY. PHYSICIANS should 
Httite CAIISi: or DLATH in pl.nn terms, tbnt it m»y be pr..perly classified. The Spec...! Iniormi.t.on Vor per- 
son* dyinji tiway from home should be liiven in every instnnce. 



< . 



! , 



■'1 

i 

I 



> 



5 



9 



) 1 { i 



"9 






I 



m*^- 



Jkii 



11 



sH 



'1' 






M 



Mlili 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 »' TT^^t * *-» • 



*+ ..« J i U-_^ >Jj3 



--^/■. 



I>.<C- I> (' 



Drrro xri Darw r»c rFDTinr-flTr mo i MCTonrTinw^ 



IfJO'i 



]ie<^i\sfcrv(l J\^(). 



1953 



i { 
DEPARTMENT OF PUBLIC HEALTH=Citj and County of San Francisco 

Ccvtiticatc of IDcatb 

( 11. 'Zk Stan^av^ ) 
J? (^ J? 0^ 

PLACE OF DEATH: — County ofOo/Vu 0.'V(X'>vcA^t:i< City ofO<X>\; J VCL>vC4.<i.cc 

No. ^n LCLlA.ic\ , St.; ' Dist.;bct.^'atAiXq^ and Cjaw^ C v w. 



(ir DEATHlbcCURS 
IP DEATh OCCU 



S AWAY FROM USUAL R E S I D E N C E G I V E FAC 
RRED IN A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 




fYY\j 




TS CALLED FOR UNDER "SPECIAL INFORMATION' "\ 
TS NAME INSTEAD OF STfi^ET AND NUMBER. J 




PERSONAL AND STATISTICAL PARTICULARS 

*.'! >l.t iK \ f\ 



id. 



Li ' 



MEDICAL CERTIFICATE OF DEATH 



I) V Ir, ' >; Di: \T1I 







M.MlflO 



lb 

fDiiyl 



(Veil) 



■ M.oith 



.6'! 



(I):iV' 



' ■»'!-ai 



\' . 1-, 



t 'I 



"-iNi.!.!:. M\kkii:i) 

\\ I i>< >\\l' I) OK !>;\i >!■•> I I) 




IcUvVOLct 



lUR rin'i, \c]'. 



\ \ M 1- (I! 

1 \ rii i K 



lUKi H n. \ri-; 
t>i' i\rni:R 

I Stall- or routiti %• ' 



M \ !I)i:\ N AMI-; 



inirniri, AC}-: 

•>!■ ^5()■|•m^K 

' ^lati- . 'I riMiiit I \ t 



1 lll'lk I'JIN' CI;R'I"I I'N', TllMt I :itfrii-lrd (k-n .l^L'il ficiil 
1(^0 [d I()0 

tliat I last ^;t\v Ii - — ;ili\f()!i — — ^,j^ . 



and thai ilratli occii rrcd, mi tlu- Mau- ^tati'il aliovc', at - 
M. 'I'lir CAl si: Ol' Di: All! v^s a^ follows: 



? 

■i 



DC RAT ION )'rars 

CONTRll'.rTORV 



J /,>>///! S 



/hns 



//(>/// s 



\- 



' rci 






Dll-i ATIOX )'r,rrs^ Jf,>ii(/is /hiv 



'^ (to 



(Signed ) L.()\ArnJA; 



-OL/VnoL 



Hours 
M.D. 



i( (' ) 



f^ 



Special information '»nly for Hospitals, Institufjohs, rransifnls, 
or Recent Residents, m\ persons itvinj .m<iy troii home. 



A'/-- ,-./,. '' ,■ II \,' >■ I I ii II, 



SO ' 



\/.nitl,^ 



/),IV- 



Former or 
L!sii,)l Residen) 



eliM U-a^\MUA..NLU^vrid(eol Dedtti 



Ddys 



I'm: AJiovi-; sr\ d-.d im":r^i)nai, i'ak rirn.AKs ar i-; TRr i-: ii* in )■: 
iu;s'r ()|.- Mv KN()\vi<i;i)c.H and niuji;i-" 



I) 



\JJ\j 



x,,,in-^s IMS U J^/\JvJLaX dl 



Wfien was disease eonfraeted, 
If not at pla( e o( deatli ? 



I'LACl-; <>1 ItlklAI, (»K Ki-;Mo\\l. 

7) 



rsm-iKiAKi-.R 



\'\ 



i>A n-; ..; i!i hiai. <ii r i-;.\n »\ ai. 







190M 






N. B. 



-liverv item of information «houhl b. crofully supplied. AGB nhouhl be stntecl KVACTLY. PHYSICIANS «bould 
«t«te CAUSt: OF DliATH in pliiin terms, thnt it nuiy be properly clasHiVied. The Specml lnW>rmiition Vor p«r- 
«on« clyinft away from home should be ftiven in every instance. 



«i 






I' 



I, 






I , 



n 



m 



:> 



' i 



J> 



\ 



9 



f 

i 

' t i 
I i 

; I 



I ; 



«|i 



-«k^ 



.jife*.^* 



,V-; 



vl.i 



|i| 




r-i 



iii 



!i 



^1 



Httllli/i'ii^.Miiettlil! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






wr-r-c-r* -r-rv o r^ r* u rvp /^CBT-ip-i/^A-rr r/^D iMC"roii^"ri/\M< 



• • ^ • k. I I • ^.^ hrfrA^«t\ w( '^•^te.i 



I %# r-» • ^, I 



Megistci'cd jYo. 



1 f )53 



"l^vcu 1,^VH|^ Deputy Heaiih OflRcer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of S>eatb 

( 11. 5. 5tan^al•^ j 



PLACE OF DEATH: — County of 'a>v J XaivCUCc City of ' 'XX^V vX Va/>vC>u4 e.0 



No. 



Ul^ 



/^\ 



vj (Cuvt C-ivXa. 



St.; H Dist.;bct« 15 




\) 



and 



II 



^V) 



/ IF DEATH OCCURS AwA FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRE^IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



>\Y\' ' i)^KsVw 



■i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I \'i ! I '1 i;iK in f\ 



Cni.<iK \ ;, 




I Ni"nt 11 ' 



I I);iv' 



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WIIX »\\ I'D OR I):\i )!Mll) 
W'l iti in -.K-iri I il.^i'_' iwit i'lii ' 



I St;it( III t,'i>iintrv( 




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avvucL 



f/<-;ii) 



/>i!\ 



MEDICAL CERTIFICATE OF DEATH 

DATl'; " >!■ PI. A I" 1 1 y 

cit-kt 11 

(M(inni> (I).iv> 



(VcMl) 




\AMI' III' 

1 \iii }:r 






1 III\l<i:n\' CI-:R'I"II"\', rii.it j atlm-led dicca^o.! tiniii 

Nta>v ic^oH t.. pxjvt ,11 T,)oS 

llial r last saw li-^\) alive on OX^C 11 ^p^ 

aiKJLtliat (leatll orriirrcMl, (Hi tlu- <l,i1r ^talid ahow, at I 
i M. 'l"lu' CAlSIv Ol" l)i;.\ril was as follows: 






-tru 



HIKIHIM.ACH 
OI- fXlin'.R 
(St.'it ' (.11. >initi v' 



MAlI)i;\ NAMK 
ni" MoTIIl-.R 



HIR'nilM, \( }•: 

<)!•■ Mi»'riii;R 

f Sl:tt( dt riimili \) 



' " rri' \Tli >N 




cc 




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JuY^'^^t^^ LldmxtiAvd 




DiR A'I'ION ^'■'M''^ ^ Mo>i/hs /)(f]s Ilouts 

CON'IR MM r<)i;V J cLc*VO-A\^ dLc\v<^ 

(SIGNED) U.l^lXta>V\. Cttu>OA<io M.D. 

\l\rl X\ TooH (A.Mivvs)41 P )^^o4- 



'^ li-k 



SPECIAL Information «nlv lor llospltdls, institutions, Trdnslents, 
or Recent Residents, and persons dyin) .im.iv Irom home. 






/',/ 



111 1 \h()\t: ST ATI : I) I'KKsnx \i. r\ki'iiri,\ks ari-: rRi'}-; to rin', 
i!i;sr (){• MY KNowij: IX". !•; and mi".iji;i'' 



( I nf' >'. until 



.1) 



/LtltCt^n 



^X i)^ 



(rXxs^Ow 



v.Mn.s 9.11 o.^^^lvt'v at 



Former or 
Usual Residence 

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



Haw long at 
Place of Death ? 



Days 



rLACi; <)!• HI RIAL OK ri;mi»\ai< 



DA'n;..; Ki i.;i.\t. or Kl-:Nt(>\AI. 



4 



V ill y J -^ ^ 



N. 



„._^Hvery item of information should b. cnrefully Hupplied. AGB should be stated r.XACTLY. PHYSICIANS should 
«tnte CAUSE OF DEATH In plain terms, that it may be properly classified. The Special Information for pT- 
nons dyinft away from home should be feiven in every instance. 



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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



UiSi W f 






/y.^/r /VAv/.Ox^viUA^xX^^A; Xl J^^OH 



Bfgisterrd J\''o. 




Deputy Health Officer 



DEPARTMENT Ot PUBLIC HEALTH =City and County of San Francisco 



Certificate of Beatb 



11. £?. i5tnnC>niO 



PLACE OF DEATH: — County ofOOA^^ .^O^-xCl^Cv City ofC' Quy\j J V<X.-n^^4- c. t. 



f^o.lb.C). Uj. OiAxtV^ 





u\ 



!\ 



:Ch<LKv.lal St.; 



Dist.; bet. 



and 



(ir DEATH OCCURS «WAY FROM uiS U A L R E S I D E N C E G I V t FACTS CAILED FOR UNDER "SPECIAL INFORMATION ' '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



^^^JUL^.<x,'^^^ 



I 



JCrU»^ V.O.. 



PERSONAL AND STATISTICAL PARTICULARS 




cuU 



II 



\ 1 ! 



K 111 



lUv. 



MEDICAL CERTIFICATE OF DEATH 

1) ATI-: < ■: M \ rii 



dxlvt 

I MMl/th* 



•Vtar 



M..11II1' 



1 '.• \ 



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w ii>' 'Win OK i»i\t>ki"i':n 

W'lit' ill '-iniri! ill vij' tlal ion t 






NAM 1 

i- \ rii i i< 



I'.iK I'll I'l.At'i'; 
<>!■ i\iin:K 

-^' nnti \ 



M MDl'N \ \M1 
01 MolMll-.K 



I'.iK \\\y\. \' i: 

OF M<»T|[i:k 

( St Mil- Ml ("iin nt 1 \' I 



' • '■ I I' \ i h "N 






^ !l;i\ ' 

I III:KI:I1V CI'J^TII-N', Tliat I attomk-.l .K-ccisl-.I troni 

that I !,isl -aw h '• alivt^n OJL^t iXb T(>o ", 

aihl (liaf iK-alli i iccurit'il, on tlu- d.itr --taUil ahuvr, at 1 o C 




J. M. 'Ilic CAISI" Ol |)i;\TII \va- a- follMws: 






1)1 UA'i'loN )'rais \ Moulh^ Pi 



/I V 



J/ciirs 



CON'I'K IIH'I'ORV 



) '(■(! I< 



Mi' lit lis 



/hiv 




( SIGNED 1 LUjcJlAUm; . 6j <Xj^\.<X,^^: 



■v\ 



/ /<UI IS 

M.D. 



Special Information ""K for iiospiidis, institutions, rrdnsit-nts, 

or Rprcnt Residents, dnd persons dvinj dwdv frnn home. 



Rfiiidrd 'II ^iii! /'/ .nii 



)-,,,, 



,lA/(////.> 



/'./ 1 



Former or 
DsudI Residence 

Wlien was disease rontraded, 
If not df place of death ? 



How lonq at 
ridu- ot llPdtfi 



Ddvs 



I'll 1' \H()\ I-: si N III) 1M-:Ks.i\ \|. |'\K lliTI, AKs Wi)-] TKri-; To TJii-; 

ni>r (>!■ .M\ Kxi i\\ i,!,i)t;i-; wn I'.i i,ii:i'' 

lb. a.Uj C1x>aX\xxC (foo-^|vdaX 



' I n !'( i; liMtll 



' \ hirers 



ri.Aci': ()]■■ muiAi, OK ki:mo\ \i. 



,(pva-oJl' 



l> \ L.1' ..; I'.I !• I \i ..: K i:Mi iV AI, 

190^ 



im)i:k rAi<i';K 



I ^\S)^<^ 



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fAcMi'ss 



It t 



IN. B. 



-livery item of itiform.ition should h.- ciirct'iilly Kiipplietl. XCU Hhoiil.l be Htj.to.l HX \CTLY. PHYSICIANS Hhoulil 
«tntc CAUSr: OF DIiATM in plnin terms, tluit it miiy »>e pr(.perly cloHKifletl. The "Specinl fnlformjition" \or per- 
sons dyinji nway Prom home should be j^Iven in ovory instnnce. 



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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



.«_ _j f It „»»i v: v— .- ^ J — ^- _>- UK. U (^ 






/>^//r n/r^/, Qx' 





JRco^isfe/'ed jYo. 



t f)55 



Deputy ith Officer 

DEPARTMENT OF PUBLIC KEALTH=Cily and County of San Francisco 






Certificate of IDeatb 

( 11. 5. 5tnn^nv^ j 



PLACE OF DEATH:— County of 



/LLAyO.. 



City of 




^(XKL^AfV-O 






No. 



St.; 



Dist,; bet. 



and 



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

I 1 , 11 , P 

FULL NAME 



cLtla.>...<4.... L/r va. > vcLLt\ 




PERSONAL AND STATISTICAL PARTICULARS 



JjL/^AXCL 



\ 1 1-. < ii 



^^v 






M. 



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aa 



1 ' , '/• 



MEDICAL CERTIFICATE OF DEATH 

l).^ li-; III iii: \ I II j) 

as 



(Dmv) (Vf.'ir) 



^IN(.I,1-: MAkkll.I) 
WIln iWJ' I) < »!•{ !»'\ ' .1 ' III 
■X •. ill . 




OlWoLxI, 



lUkTinM, ACK 

Sl;it .• Ill I "mi 111 r \' 



\' ■> M I III 

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I'.iK III ri, \CH 
' '• ; ~ !1m: R 

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I'.IKIMIIM.ACI", 

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I'M'. lit ll) 

I ni;ki':i;N' n;in"ii'\'. 'i":!,!! i ;ituMi.ic.i .KrrascMi from 

I9O to — ■- I()f) 

that I last ^aw li aliw oil ' Ic^O 

aiiil that ihatli occn 1 ix-il. on [hv ilalr <ta(til aliovr. at 

M. 'I'lu- (.' \l SI'! (ll I)! \TII was ;,v jollous: 



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Mil 



MIi-N l%0 




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coN'iKir.rioKV 



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//ours 

M.D. 



Special Information ""'v J"f Ho''i»itdis, fustitufions, [rdnsimts. 

or Rfi.ent Residents, <iii!l persons dvinj dwdv from home. 






.1/..///// 



/• 



Tin: AHOVI-: ST \ CI- I» I'KK><()NA1, I' \ R T !' I ■ ! . \ '•: "^ \R I- T R 'I" T' • I'" '■■ 
I!!-;ST 01 MN' K NdW'I.I.DCH ANI> I'.l.I.H.I' 



Oiir.iM 



in. It (AD<XAAA.t II Uf' 



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XXV'^ 



f X.l.hrsv; 



2)0 




A 



Former or 
lsii<)l Residence 

When was disease ronfrarted, 
II not dt pldff of dedffi ? 



How loni| dt 
PIdre ot Dedffi ? 



lldVS 



n A 



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! II' I' ;.\i. ni K 1-',M< »\ AI, 
^ 1 



I'L \(1'' dl' IM R I \r, ok R i:Mo\ Ai, 



T90M 



rNFii: 



t 



N. B. livery item ..V infornL.tion Khoul.l b. crcfiilly supplic-.l. Af.i; «'. ...1.1 he stHte.l I.WCTI-V. PHYSICIANS shouM 

Ht.itc CAliSi: or DI:ATII in pImJh t.rms, thsit it m:i> he prupcrly J«ssificd. The "Sjiccui! ln»ormiit ...n" tor per- 
sons <lyfnii iivvay from home shoiilil he fciven In every inHtiiiice. 



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Mill ^%iiii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



^_ ,„Jh __4" -n „i+l+ _l^' VT-*-» -»^ '• -' — : - ^;- UV- I' j' 



rT«^*irfT 










Ihf/r rife^l, Ox^vtiL-r^^UA. 0.^ lOO'i 






1055 








Deputy 



H rs 



^cer 



DEPARTMENT OF PUBLIC HEALTfl-City and County of San Francisco 



Gcttiticatc of Bcath 



PLACE OF DEATH:— County of 



xx}^^ 



City of 




Lct^tjAA^^^^U' ^cv 



i 



No. 



St.; 



Dist.; bet. 



and 



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



FULL NAME 



-cL' 



.LI.CLLC 



"•I 



(VCtvv 



d.Lc 



,\.. 



PERSONAL AND STATISTICAL PARTICULARS 







\^ 



MEDICAL CERTIFICATE OF DEATH 



iii: \ r 



e1 






as 



'I):ivt (Vfiir) 



A! 



\ • . 1 ■■ 



aa 



••'M.I, I-:. MAKKii: I 

A I III »W1'"I> < »R !»M 



HIK rill'l. ATI" 

^ St;:t f I il I 'i >n ll! I \ 




(X\KU^<L 



\ \M I < II 
!■ A 111 IK 



lUK I' II I'l, \i !•: 
'»' i \II11'K 

' ' ' '1 I'l mill I \ 



MA! hi \! 1 

' '1 M< I ! li I .K 



lUK riii'i.Aris 

"I N^oTlll'.K 

' • >niil I \ 



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AV 



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a CO 

9 



I II i:i>; |-:r,N <' \ R'I'II'W Tli.it I jtUrmlr.l lU'Cra'^t-il fr,. Ill 

li/1 til \i.,o 

that I la^l "-.iw h "" ' alivr on ~ 



1 



,111(1 that iltath ' icrii rri-il, imi t lu- ilatr ^-t.itnl a!H)\-i\ .p 
M. 'I'll.- C \l ^1' ' 'i 111 \T1I \\a- ,1- 1. i'n.U' 



UC'\ ' 



hi k \TioN 



(.•()\T!^:n:i TORY 



■ 11^ 



\/,<i:l/is 



/hivs 



Hours 





OVK 



I ) I ■ R .\ TI ( ) \ 
(SIG 



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^fouths 
NED) \.'%. XtLu U' 






1 li'in s 

M.D. 



)X^ 1^1 



l<)0 



\(Mt 



SPECIAL INFORMATI 

or RcKiit Rf'sijrnis, diiil persons dvinj dw,i> Iron home 



■ I t.sv) \J I L<X\iy^A^^tLi V-0. ' 
ION ""'v 1"^ U<)S[)if,ils, rnsfittitions, fr.msicnls, 



"•>, J '/ /■'? 1.''/ 



) , , ; / 



1,' ; '/, 



I'll 1' AISOVl-: Sj- \ ri'I) I'JrKSONAI, I' \K lU T I, \K-> WiV. I"K I 

iii;sr Of .Mv KNt i\vi,i;i)<". H .\m> in;i,ii:i' 



!•: ri > rii !•; 



rnrmpr nr 
Isiidl Rcsidrnce 

Whpn Wiis (lisf.isc (onlrdfted, 
II not dt pldif of dcdth ? 



liov^ ionq dl 
Pld(f ot Dfdth .' 



Odys 



n l. >• 11! lilt 



utxxAA^t 11 Lkxx 



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.IS 



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Crvu Lvq 



IQO 



.'A.i.ii.ss Sl^ ^(XcUm/ vlcxtx Ll 



N. B. jivcrv item «>• in»'..rm..tlon «hoi.l«l h.- ...rcVully Muppliod. Atir. s', .i.l.l he st.ite.l liWCl'I.V. PHYSICIANS shoi.M 

Ht.iU CMISi; or DIATII Ml Dliiin terms, tliiil it mi.y ho |>r..pv^^rl> cliiSHW'kd. The "Spciiil liH..rm;it..iir' tor p«r- 
R^n* <l>Infi jiujiy from home shrmhl he (ii\en in every instiince. 



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1 . 1 1 _ . . u 1 1 - I . V / 1 1 



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occtra xr* oarw rsc r-roTicrrATr cno i wqtoi irTin tvjo 



/>'^//r /V/r^/, dxlvtx^vi^^ 0.^ 



Har.iMtiitr <ay*gwwni^jwg**w— n«ff.*M*w^ 




A^ cLC. \.V. 4.1 



Deputy 



h Officer 



JRc^^istci'rd J\^o. 



i 955 



DEPARTMENT Of PUBLIC KEALTH-City and County of San Francisco 



Ccvtiticatc of Bcath 

I 11. ii'. 'I1tnn^al•^ ) 



PLACE OF DEATH:— County of H.k'.X^O 



City of 




N 



o. 



St.; 



Dist.; bet. 



and 



(ir D£ATH OCCURS AWAY rROM USUAL RESIDENCE GtVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION \ 
IF DEATH oCCiiw&in im a HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



n^ 



FULL NAME 



.cU) 



.0 



y\xxw 



cLLl^-. 



PERSONAL AND STATISTICAL PARTICULARS 



V.I 



K ! li 




CV\ 



XI 



I ■ .1 1 



rx 



MEDICAL CERTIFICATE OF DEATH 



\).\ n-; I )i ni: \'v\\ 



)xKt 



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I IIl"I<l'r.\' t i.KTilN, Til, It 1 iitlnilci! .Iicrasrd Ilmii 



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HIK THI'l. \r) 

Shitr III < ',,11 li! ! 



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t]i;il I I;i-.t -.iw ll ^ ,ili\ c- i>ll ~ 

• iijil tli.it 'if. Ill) I H ( II rinl, iiM till i!,ii( -I.itcil ;iln)v«', ,it 

\|. 'I'hr C \l >!•; (Il' I>1 \ ri! w.is .t- ImMi.us; 



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M.D. 



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Special information "h'^ lnr fl'isiiif.iK, fnstiliitiunv. Fr.ii)sirnts, 
or Rcant Rcsi.linls, .mil pciAoiis d.iri'i rfw,)) Iron ho!HP. 



rm: AHovi-: s r \ ri- 1) i'i<:i-(<.i IN \i, p \K III I ' ^ '■ - \ki' rni i' id 

IU-;ST(>I' .M\' K \( lUI.I IX .1'*. \N!> I'll 1. ! 



Ill I- 



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(ormrr or 
liMial Rj'vidfnre 

Wlicn w.is (lisr.isr (on(r,i(1ed, 
It nof .ll (ilrfif ol (ItMlh ? 



How l()[ii| <it 
PIdCT ol llcilh .' 



n,ivs 



n \ I l; 'i' I'.' I- ! M I.I K j.Mi iv \i, 



Uil.h 



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NDI.KI \l.l K vA.OLAw<\ >^-^><4A/vXX^V ^\, V<J 



IQO 



!N. K._liverv Hem .W in^-rmi.t!.... nhonM h cn.H.v sv. id. AUi; k', ...M he stMtc.l ».XACri.Y miV.SICIXNS should 

Ht.itc CMISi; or ni ATII ;.. |.I..Jm Ic-ms. that it mi.y ho pr..p^rl> .hisshied. The S,,c....l ln...r.n;.t ...ii »or |,t- 
s'»n» <l.>in|i ii%Miy iVom home should he ti'iveri in ov«r> JiiHtimcc. 



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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



tfiimff nf H rn ifTt V^^f*. 



■«. ""l^rT^ . 



i I. V i ^ 'I 






If^o'i 



Bro^/sfrred jYo. 



1 1)56 



Da/r I'ilrd, at^tt\wl'-Ou Xl 

DEPARTMENT OF PUBLIC HEALTH=C{ty and County of San Francisco 



Certificate ot Beath 

( H. S. t?tanc>arD j 

PLACE OF DEATH: — County of OOw-a- Va>\Cc4C^ City of Cj^<X>V J A<X>aCuico 

4 



Co ^l CHlivLLa.^ 



Nt^. O. J V^O JV. ChIIVLIO^I' St.; Dist.; bet. and 

(IF DEATH OCCURK AW»V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATK 
IF DEATH GCC'JRRfD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 

FULL NAME ^l>V(\v,c^ HI LvlLc5 



'% 



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PERSONAL AND STATISTICAL PARTICULARS 

fl 1 " 1 1 1 . 1 1 k N 

iulu I /'IHO 



K III 



\Hintli 



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•):w 



MEDICAL CERTIFICATE OF DEATH 

I) \ li; ( »!■ !>I'. \1 II V 

Cklvt 

M.ml'li' 



at 



!V. .Ill 



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bH 



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IX 



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SIN«.!,|- MAKKIi: I) 

WIIH I 'AT' It < tR I)!''-, i;- ^ I I) 



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ItlKI'III'LAll'; 

(u- mi.!hi;k 






I Ili;m,i;\' C I.KrilA', That ,1 alU-ii<lr.l lUrra^f.l In, in 

tliat I last saw hX»\ ali\oi«ii O-^jvt; 0.1 Kp 4 

ami thai lUatli i ic* iiricl. mm Mk- tl.itc sfatcil ahovt-, at I \, 
.\L 'riu CWl^l-; OI 1)1 A I' I I was ;,s ff)IlM\vs: 



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A^V 



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II, I I 






DIKATHtN )></;-.? I J/ont/is 



//(>in s 



hi !>: ATION 



/),i\ 



(SIGNED) U). b. ' ^O.k<l>V 



//ill/Is 

M.D. 



-A>.1 



Special information ""'v tor llospiLils, Invlilutjims, Tninsipnls, 
or Rfieni Resiilcnls, .ind iifrsons (Ivln) .!w.i\ fro;ii humf. 



AV' hh(l III ^ ll >l I lllll: !■••> 



X 



1 A. ,','//. 



TIM. \i!(>\'i-: ST \Ti:i) i'i-'i<s(>\ \i, I' \ uru' I ■ F, \Ks \K i: tk ( i: i'* > rii i-: 

ni>T «)l- MS' KNnUI.I.IX.)-; ANJ) Ili'.Mi: i- 



i' 1 11 f' .■ iiritit 



n LvAjtxA 






■:x 



Formpr or (1\ ^ i, , . , ^ [ J T [ ""^ '""1 'i' l n 

Isiidl Residenre ^ *) ^ ^"^^ ^^ ^vXl^ V. a ^ f>|.„ ,- ol Oerffh .' 1 

When was disp.isr (onlrnded, v ,k 1 ,■ I ^ r 

II not Hf plH(p ol dfdlh ? A-j^OA^ AVC^hVU. 



Ddys 



IJ.ACi: <•!■ I!!' k I \ I, < iK KiM'iVXI, 

M 1 



I) \ ri' ■■! IP iM \i, ..I iv I .Ml i\ \ I, 



\<k x% 



f,\.Mt 



.s bi^^Gn bawQvti^O 



N. fi.— Hvery if.m of Information hHouI.I «,. .....funy su„pli.<i. Adfi Hh.uld bo Ktnte.l I^ACTLY PHYSICIANS nhould 

stntc CAlJSi: or DI:ATH in plain terms. th:.t it mi.> be prr.pcrly cl..H«ificd. The Spec..! In>.,rnu.. .on ior p.r- 
Rnn« riyinit nwny from hf »nc sboiibl be feixcn in every inHtnnge. 



i 



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Mi 



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iiyNVilWPHvH'^''^ 




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Mir JtMlii. 



WRITE PLAIMLY WITH UNFADING INK — THIS IS A PERMANENT RECORD -^pg 



1. I.' V«» 11 



I^ML^-^S^^Lix ItJi- I* t* 






/>^//r AVAv/. c3x 




XC5 

DEPARTMENT 




;.1 



/.VC>H 



He (^ isle red J\^<). 



I 



• V.J f^ 



Deputy Health Officer 



F PUBLIC HEALTH -City and County of San Francisco 



Ccrtiticatc ot Bcath 

PLACE OF DEATH; — County of 0<X'>v Oa.<Xt\cv4cl City ofOo.'^^ vJ7n^O^>x/>-4.c o 




No. 3v I k Vi) ^_ - - . St,; ' Dist.; bet. ^ Ul/YVt'Cr\A and LlX lv<i. I. v ^ 

(ir DtATM OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO^■ \ 
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMDEH. / 



FULL NAME 



LaLlcL 



PERSONAL AND STATISTICAL PARTICULARS 



- i \ 



'M 



,a.U 



111 ;.! I- , I ! 



CUjvt 






I 



y. 



I 



^X>LL/r'LOL' Vi<c >\.vL 






>i\r, i,K. N! \RK n I 

wi rii iwi'i' < ''•; 1 1'' 



HIIMII P!. \' 



' \rm,i< 



! i ! k I i I I ■ I '. ! 

<)|.- r\rm i< 

< state or I'niinl ' ■. 



M I 



I I 




MEDICAL CERTIFICATE OF OEATH 

I lll'KI !;\ V ! i<Tii\'. I'll, It I Mt'rii.U'.l .k'rcasod linm 
tliiit I l;i<t -^.iw h 1. . •■ ,il:-< ...| OX^^- ^'l 

,111,1 • !;,l! (1. .1' ll .M , , I. .1, . ,, Mk- <\.iU : i'.-<l -iIh-NC. :t1 '( ?)i 



l()0 
I(;0 



M. 'I'Ik- CWrSI' ( »1 l»l' \ 1 il u 



\( )]\i t\\S 



1)1 RATION 



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1 1] 



luki HIM, mt: 
"I- ^l"■|'m•:u 

■1 *.'' 'ti lit I \' I 



^O^Lo 



C5\ 



CL 



I ( >\'ri< ii;rT< >! 

Dl R \ii« ».\ 
(Signed > 









I 

%. 







I liUil \ 

M.D. 



Special Information '»nty tor iitispitjis, insiiiufiitns, iMnsienis, 

or Rfirnt Kcsiilcnts. .iiid persons dyini .iw.is turn \\wm. 



Former or 
I'Midl Resldcnre 



MoH lonq .it 
Pl.Kf ot llf,ilh .' 



n.ivs 



l\i I. III! ill Sni /;..'/'. '■' *" )'./; 



I,',.;////. ' /'./ 



When w,)S (lise.ivc (onfr.Kffd, 
II no( al pldtf ol dfdlh ? 



I II I. \U( >\i', s'l" \fi; I) i'i<"Ksi)N w, I'Ak ririi, AK^ w. w 
in;sr ()|- mv know i.i.ix.i.; and i!i;mi.i- 



I'Ki I III nil-: I I'l.xt'i'. Ill' iMinxi, 'iiv ki-.M'ix \i. 



I iif'i mint 




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igoH 



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^ran^«MMwkMMMwnb«w«pii«»iMH 



^. ».- 



-!ivcry Item of liiform.itWm Hhould ».-• .Mrcfiilly Hupplicd. Atili Khould bo HUite.l LX XCTI.Y. I»MVSICIV>S nhould 
stHtc C AlISI or DliAPH in phiin terms, that It mjiy lit properly cliiNHh'icd. The "Spc^iiil Inn'oruisiti-.n" I'r.r p-r- 
«on« (iyiiijl Hwiiy from home Hhoulil he t>sen in every inHliint.e. 



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II 






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II ' 



WRITE PLAINLY WITH UNFADING INK — THIS fS A PERrVTANEINT RECORD 



, #^**.„-vJ-* 1. =_- 4J 



r.* ';i t M * rt -I TV in t I 



,.*^.«!^r 



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/;^//r n/rf/ , 6jlIvLo^>^Ii 






.M.^^ 



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IfJOH, 



J?ro^i,sfrre(l jYo. 



1958 




> { 



1 V 4 1 



Deputy Health Office 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beath 

[ 11. S. t?tanc>arC> ) 



PLACE OF DEATH: — County of I t\c\vIiA.tu. City of 




P ll 



(nv 



,tx^a.u, LoJj 



No. 



- St.; 



Dist.; bet. 



and 



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



FULL NAME ' 




I? 



.CLVu. UW/CU'TL 



La<iu.o-i^c cL 



PERSONAL AND STATISTICAL PARTICULARS 

I \ TTN a idl.oK 




OX 



SO 



' ! lM»\\|.;ii (»!< I)' ID 



.1 1. V 






/ ^' ■ 




oav.\.ctd 



' '!<: 1 HIM, \OH 
~:.it< 111 ('oiiiitrv' 



I '. 1 I i 1 K 



itik rin-i. \(H 

' 'i" r \ I'M !■■ u 



■? 



, I ! \ 



'I Ml I ill IK 



lii k 1 iii'i, \f 1-; 
<M ^!l>^ll^•,u 

' ' 11 lit ; \ 



' ' ' ' I I ■ \ I ; n ^, 



/ .• 



f 

AX 



fSAEDICAL CERTIFICATE OF DEATH 

DA 1 1. « '1 I>1, \ 1!! P 

M.liithI n):iv) 'Vcai^ 

I li I-:K I'.r.N' C\ R'ni'W 'I'liat I .it'cn,!. .Mi-cr.isr.l fn. iii 

fli.it I I.i' 1 v.iw li .i!i\(.<Mi ■ — i()o ~ — 

ail.l lli.it iK;i!h ' pccurrcil, nii the (l;itc s(;il(.(l ;iIm)\c_ at 
M. Thr C",\I ^l; ni h!;\'l"!I \v;i^ as ff)!|..\vs: 




0. 



,<x<JLc' 



uvc^ 







ojyu^.^ 



I jr RATION )V,/r 



c()NTi>:ii:rT()RN" 



I»l"i^ ATION' ) 



Moilhs 



l\i\ 



I loitt :s 



MiiHt/lS /hiv< IJou)- 



SlGNE 



M.D. 



Special Information <»"'> t'»r ii'ts!ii(.«is, instittiiions, (rdnsjenis, 

or KcirnI Rcsiienls, .iimI prrMXis (hiii'i dw.n ff'Kii liomp. 



former or '\Q \^ f\r k ^.J U ""^ ''""H' 
IsiMl Residpnrec^" l^^ (lUcrU>^QAxX OA fldie o( Dcith.' 



DrfNS 



1/ -;///> 



//,/, 



Till. M'.i »\ I-: V r \ri I) i'K,i<-n\ \ I, I' \K 111 I I, \K-^ \i< i; ri< r )•: r<> riii: 

I'.lsToi MS K NO\\I,i:i)i'. !•; AM) !!j:i,Il.l- 



Wh»'(i Hds disPiisp ((in(r.i(lfil. 
If not at place ol death ? 



i\j VwOL<i,LcO^O-t5t^ - 




x,i,!mss ^'\{% (jK)Cr\AMX\A Vi 



HA ri' ■: I!' I'l \i '.! K i;m< i\ \i. 



ri \(i. ( »i Hiu lAi, < iR k i;mi 'X'ai. 



N. R. livcry Item oV irif .rmtition Hhoiil.l be Cfirc»'ull> supplie,!. AGIi k'imviIiI ho Htiito.l EXACTLY. PJIVSICIVNS Kh<,uld 

Htntf CMISr: or nr;\TH in pliiin terms, thiit it mjiy I»l- piM.tJcrly cliiHHh'icd. The "Sj.ccijil Intonii it ion" lor per- 
son* flying iivMiy from homo kIioiiI*! he Jii\eti in o\cry inntHncc. 



m 



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p 



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1 


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ill 



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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Tt 14 



n VliU tTt H^-.-trt ti > 



nt.rc.li I v^ DMv^A ur cc.MMM«-Mit. r-UK irvsiKuuriONS 



JRo<Jisfei'e(l ^Vo. 



1 959 



DEPARTMENT OF PUBLIC HEALTfl=Ciiy and County of San Francisco 

Certificate of E^eath 



( IT. 'I\ iT'tnnDnrO 



PLACE OF DEATH: — County of O/CLax' /ux^veu cc City ofO/CLru OAxx.'>vcv^ cm: 



p 



H^S^^xkXoX [/^-^XJLMa- •; fccHLrvdctt — Dist.;bet. 



and 



(If DFATH OCCURS A X A Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U IM D C R SPECIAL INFORMATION ' N 
If DEATH OCCURf^JD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




^\.QJL 




'\ 



vj.a. 



PERSONAL AND STATISTICAL PARTICULARS 



i' 

'i ■ 
. 1 1 



v'l )],( iK ' "I 







M 



it 



MEDICAL CERTIFICATE OF DEATH 

1 1 \ r ! : M I ! i V 1 1 1 y 

.\T..ilth) iDayt (Vi-:n 

I II i:i^ i:i'.\' ^ ' Urii"\. '!":i;it I .itlinUd .Iro-.-is.-.l tn.m 

|.i' — til 



CUvt HO 



\' !,1 \1 \K I 
' !I>< >\V 1". I) <»K 



liiii I'lii'i, \oi-: 

' Stat* (»i I'oniiti \ I 



■^ 



I \ I II 1 K 



'" ! \rm: R 

'I r< ,u;it ! \ 



M \ lIil'N \ \ M 1 

«'! MMlIM'k 



Hll: I'll I'l.An: 
<»l' MMfMl'K 




A"' 



tll.lt I lil^t s;|\v fl 



;lll\ I- < "11 



\i)0 — 



nil! tli.it iKitli I ii-riii ifil, on t In- d.ttr <t;i1<.'i| almxH', ,it 



on . 



\ I II \\a^ as h >ii. i\\ s : 



D! kAlloN Van 



t(>.\TKII!l"i<)R\' 



.7A >;//// s 



/>,/! 



/ /i>ll) S 




1^ 



DTK AT ION 

(Signed ' 



M,"!!l,.s 



111' 



\ill!r<;s) b 



M.D. 



n(mj.\/> yyxt 



Special information ""'> l'"^ llosiiildls, Inslituthns, lr,insiciitN, 
nr Rnciit RrsiJcnh, .iml |>nsoiis dviiii] ,m.i\ Iron hoinf. 



I I' \ I ji i\ 



M> 






M.,„th 



former or 
Usurfl Rcsidcntc 

When Mds disr.isp (onlr.i* ted, 
II not lit pliiff ol de.ilh .' 



Ilim loiii| .it 
l'l,i(eol Dc.ith.' 



. Dd)s 



III 1, Mil t\- I' ST \ 11 I) i'lrksi >N \|, !• AUllil 1, Xks \R i; IK II' 

iM-siMi- M\ is.\(»\\i,i;i)t'. }<: .\Ni) in"i,n:i'" 



II ' III 1' 



Iiil'.- iiriDt 



.^^^-> 



\.!ii...s 10 Igi. J -AJly>vUrv\i Ot. 



I'l.A^n; Ol liiKiM, »»K ki.Mi>\\i. 



\^ I', t 



I) \T1 .' I'a IM \i i- K IMi i\ \l, 
■ I lOO''! 



jvt 



IM 



,) KIXKl-K LixXXJb. H^, Q3. M)\itJ^ 



\.1,1h s^ b'ib UJ <XA.AXV/VA.XL/^ > 



N. ». 



Hverv Item of inVormi.tlon Hh.a.l.l b.- cnrcV'ull.v Hupplic.l. .ACJi; Hh.,i.l<l l.c Hti.tcl lAACTLY. PJIVSICIAXS sh.u.l.l 

Htiitc CAlISr or DI:A TH in philn terms, thiit It miiy he p.-opcrly cljiH«h'icd. The "Spediil lin<.r.n:il .uri ' tor per- 



sons ilyinft tiwny from home shouM he Jiiven in cvory iiiHtance. 



1 






i If 



I .^ ! 



11 



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til 
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J H 1 t 





i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n..;ir.l' t ll-.i'tli ! ^'i :■- '-■•■: —^-i- !tM I- r., 



I 



D^f/r n/rf/, JX 



.^vtx^^vlvi^ 



\' %l 



ino'i 



Ilcgisfei'rd A>>. 



\ OGO 



DEPARTMENT OF PUBLIC HEALTH 



City and County of San Francisco 



•'' 


fl 


il 

1 

1 

1 


1 


] 

i 

\ '■ 


1 



N 



Gcrtificate of H)cath 

PLACE OF DEATH: — County of '1<X^V ;va'>\CU.CO City of ' '<X>V J \<X^{\QUi/:^^ 
o. H i) OA. t^b VJXcc^lX St; I Dist.;bet. \) oJlXxvo ^ ^^n^j 0<\. ^vLtyv^vC ' 

(ir DEATH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER " Sjlp E C I A L INFORMATION" "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

(I "^ 

FULL NAME ^Uxclvt^ai JXVVa\u 



PERSONAL AND STATISTICAL PARTICULARS 

-^ i \ \ .* '. I ■ I • i . < • K 




-^ 



.1 - K&Ji 



!' \ i 1 I '! l; IK III 



i.l\t 



ai 



MX 



MEDICAL CERTIFICATE OF DEATH 

i).\ri-; ( »i mi: \ rii J^ 

Oxlvt lb 



„S 



l);ivl 






^1 



I'- 



J 



I 



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^r.r, i.i-, M \KK n.;i. 

W'lIX iWI'I) <iK Ii-\i > 1 •) 
(Writ 1 ■ ,1, . 




\<XAVUxL 



IUKri!l'I. X.'l'. 

' xt:.t,. ,,; <■ ,,.,1 , V 



\ \ M 1 ( 1 1 
lAIII IK 



I'.iK r II iM. xri-: 

<M' lAIIII-R 
'State 'Il f.)initrv 



M \ii»i:x X \\n-. 

'»; M'TiMil-K 



lUUI'MI'I, At'].; 
"I M<r!'iii:i< 

'~!.i|. .11 (■|iiiMlI\ 






I III'ki'liN I i;R'ril'\. Th.it i allciulc.I .1c(t;isc.1 fmin 
Lu-ta ?\C F./iH t.. UJ^ixt ^vS' up H 

tliat I last '^aw h t^>\ alivroit ^>X]'vt ^5 i,,oH 

ami that tlr.ilh ncru ncl, (in tlir ilatr '4at(.'(l almw, at o 
\J M. TIu' CAI SI-: Oi" l)l-;.\ ril was as follows: 






^ 



D 



C^f (fi O-t iv dueoo ivu ivcJJi 



I) 1 ■ R A T f () \ 
CONTKliU'lORV 



CLXX-0 

)V(/r.v I .JA';////v /^n' 



Hours 



P 

^ 
^ 

?- 



ii.'^ 



< < 






to^' 



I n.aVA^kx>uXic dL'Xx^vuLtnu 




/>,/! 







)V<;'/'.S" I .]/."! i /'is 



I ) r R A T I ( ) N 

f Signed ) 



I loios 

M.D. 






Special Information ""'v Im Hospitals, institutions, Irnnsients. 
or Reient Rcsidrnls, and ptrsons dyimj .iw.i\ (run home. 



'11 



miunO a 

l\>-;diul III Sitii I I ,; II, I '■''(I jO 



)■.-.■ 



M. ■Ill Ik 



/■.,■)> 



in: \iti >\-i<: sr \i"i:i) i'Kk^onai, pau iifci.AKs aki-: rKi)-: I'l > in v. 
Hi.;sr oi- Mv KNOW i,i:i)nK and in:i,n-;K 



( Iiif.i-iiiaiit 







Formfr or 
Usual Residence 

When was disease rontratted, 
If not at pldce of death ? 



lloM lonq af 
Plare ol Death 



na\s 



' X.ldicss 



s 



v]3ctvt^ vli 



xx-cX 



IM.ACi: ol' lUKlAI, OK ki:mo\\i 



1) ATI': ..: r.i RIAL .,, |< i.;m( ,\' \i^ 



IN 1)1 



,t<xiA^ 



I DO 



(Ad 



(liess Jo ^ i C, 







^t 



!N. B. Kvery Item o? inforiiiHtion should be curofully supplle.l. AGB should bo stiited EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In pliiin terms, thnt it mjiy be properly classified. The "Special InformHtion'* for por- 
son« clyinjl away ?rpm home should be jiiven in every instance. 



'M*^- 



.iiilik''l 




mmiilhmi 



t. 



h 



li 



M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ii.i .11 



!!■ I'th I- \'.> i-, ■??•': :w •-■—•■ H.VI' I 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(ffr n/rd , 'j jJfJuiAr\\l>^\} %% 



lOO'i 



Begi.stci'C(l ^Yo, 



1 96 1 



Deputy Health Officer 



DEPARTMENT OF FlIBLIC HEALTH-City and County of San Francisco 

Certificate o( 3catb 

PLACE OF DEATH: — County ofC'a>\ i Ka^vCMLCo City of CI a>v J \a vxCc*. co 

., f ■%\ 1 4 I 

Ne. 'aCLvi^ }L6-i.|XLULl St.:- DiEt.;bet. and 

/ |IF DTATH OCCUrIs 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. / 



t n 



FULL NAME 



.cLd c 



y 



PERSONAL AND STATISTICAL PARTICULARS 



lUJvCtx 



r 




^1 



m 



i/^xVu '^^MHavu JCrYci 



I \ i 1 ' M i; IK 111 



: > V 



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)V.:, > 



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/',/) V 



^iNT, i.i-: MAKun'i) 



^^^'>va 




I'.iK rii I'l. \*M-: 

<' ■(. '.; r, iiinti \ 



\ \M1' (»!■ 

i \riii:R 



IMK 111 I'l, \< ).; 
"I- lAIIIlvR 
Nt.itc (17 I'oniiti \ ) 



MA 1 hi: \ \ WW, 
'»!■ M<»riii: K 



HIKTHIM.ACH 

"I- Morm'.R 

' "^t it I Ml run lit r ' 






MEDICAL CERTIFICATE OF DEATH 

DATH ol- ni'.Alll I 

iMoiitli'' in.iv' (Year) 

I Ill{Ri;i',V C!;k'ril\-. rii.U I altni.K-.l .licrascl fi-.m 

tliat I last saw !i " \\\\\v on "" *" *" T(;o 

am] tlia( dratli < km-u rroil, on tlu' <laU' stain! ahuvc. at " 
" M. Tin.- CAISI-; Ol' l>i;.\TII wax ax follows; 



I )rR AT ION )\'ar'i Months Pays /lours 

CON'I'R Nil TORN' \v\\C\. ^'^^X^'^<.^.^X (^^\,'-U^a<^ 



1:" 



'•in i-Aiiox 

h'f'^.'ilft} III '^'illl /'l (I II' • >•!> 






DIRATION 

( Signed ) 



}'(\ns JA <;////,' 

LI '(nLvXM/ 



/hir 



! liUirs 
M.D. 



tYV 



4\t Vk> ,.,o4 



' ^a.ccjv tc ■( (v^iv^Xal. 



A.Mitsv) V'xXCc^tC .\(V4' 



Special Information <>n(y for iiospiidis. institutions, irdnsients, 

or Recent ResiiJenfs, diid persons d>ini| <m<i\ frojn fiome. 



)■',' 



Moiilh- 



h.ix 



'\'\\ v. AMoVIv SrA'fl'I) I'lrK-^ONAI. rAKI'im. \K> AK I-, I'kr)' r( ) III )•; 
HlvSr Ol" ,MV KNi )\\"I,i;i)C.K AM> MI-il.D'.F 



Former or 
Isuai Residence 

When was disensr contracted, 
It not at place of deaffi ? 



lloH lonq at 
Place of Death ? 



Davs 



\.l(l!. 



44^ 



I'l.ACI-: OI-JU K1AI< OK" ki;Mi>\\I, j DAli:.' llMou ..• K'I:Mi>\\I, 

^.lOG.^.t'u^vaW M-^^y' .901 

/A. Ml... ITXH X)X/lVUL<X(iv\/0 >\ 



N. B. Fivery Item <>V' 1n?ormntion should be cnre?ully suppliecl. AfiH «!io'.ilil bo stntecl i;\ ACTLY. PHYSICIANS Hhoul.l 

state CAlJSi: OF DEATH in pinin terms, that It mjty be properly clHssilTlccl. The "Special Informjition" fop per- 
son* flying away from home shoiilil be (iivcn in every instnnce. 



If 



I 



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n' : 



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\ . 



V 



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m 




«*ttiUJt*^-* 



ll 



I 



il 



HI 



li 



I 



i 1 Hi* 



'I 



^ 



HnHv 



»< 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;. ri-.i 



•I : I h I- N'> 



UXi r, 



REFER TO DACK OF CERTIFICATE FOR INSTRUCTIONS 







6 L.<.u^ 




xtx^-vLou a!l n)o\ 



Jlegi.stei^ed A%. 



19G9 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH- City and County of San Francisco 



Cci'tfficatc of Bcatb 



PLACE OF DEATH: — County of Av^-vc^.^^ 



City of 




Ol/>\^ 



[0 p. 



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 




o^Kjj\j^<UL j(ruciv\ 



PERSONAL AND STATISTICAL PARTICULARS 



c 




"< \ 



o^{ 



\ 



10 



M. ill 



MEDICAL CERTIFICATE OF DEATH 

I) \i"i. t li Hi; \ 1 II _i' 



axk,t 



Vf 






! . : ix i.i;\' 



i '!. 



■^IN'i.l'.. MAkKll.l 
UlUnUi i » (IK I) !\ 



I'.IKririM, \r\:, 

Sl;iti <)[ i", ,i> lit I \ 



I • 1 : 

I \ I M i K 



iMuriir!. \' !•; 

Ml' 1 y r I I 1 I . 



' 'I Ml 1 111 I. K 



i''i K 1 iiiM, \>i; 

^ ■ ■ > ■ ■ ' ; 1 ! 1 1 1 \ 



I M < ■ I I ' ,. ! 1 1 I \ 



^^1 1 



lli.it I l.i^t --.iw h 



' K T I i \ . 



!i)0 — 

~ : I i I \ 



I Il;il I .ll 1 clP U '1 < liTii-^cil t i( 111! 
{ , , - p., ^^ 



ItjO 



:l 11' 1 ! ll,l! ' 1( ..' ll ' ■!( il M 



,\ ,1 ,, 



:it 



.M. TIk i \l S|' ( )!• |)J. \ 111 u,,- ,.v !n!|..us 








A_x'l^ 1 \_'X , 



niR \TI( >N ]\\n< 

C'( »\TK I 111 !'( >kN' 



,IA'v///s- 



/>./ 



I loit) s 



L: 






I'l KATK >.\ 

Signed ) 



( :3 1 




3 4 



.(/-"■//. 



.a J 



A.l-hv^s) Jl ,0, 






! I(Uii s 
M.D. 

^„a.i.;. 



1 



A'/ 



1/. /////v 



I'll !•: \ !'.o\'i-: ST vri'. I) im-'k-^onai, i-.xKiirr i \i;s \K i: \'\< \ v. I'c » rii i 
Hi;sr (»)•■ \\\ K .vu\\i,i:i)c, 1.; and i;i i,ii:i' 



M' 






SPECIAL INFORIVIATION '»ii!v lor H(»s|(it,i!s. Inslitufions. Tr.)nsi>nfs. 

or Rt'K'iil RcMJc'ifs, .inil jtcrMHis ihlnj .lu.iv Iro'ii hniic. 

former or 
Isii.il Rcsidcnrr 

Wlifn wds disp.isr ((Kitr.idcd. 
If (lof rtt pl.Kcof d('(i(h ? 



l!oH Ittni] ril 
f'l.l( I- ot l)(Mlh .' 



D.iv- 



■I.Al'l-; " >l 111 Kl \I, < >!•■ !■ IM' >' \ I 



iVi'li"' '" 



^ T \ K I-; k ^1 L >UXAJ> ^< V. ( 



I' 1M« i\- \I, 
T QO ' 



INDl'.N 



N. li. I.vcry itom <>^* iiiformntion lihoulil h.- ciirolriilly supplk-il. AflFi shoiiltl ho stiiteil liXAOTLV. I»1IVSICI\NS mI»<uiI«I 

Htiitc CAUSi: Ol- Di: ATM ill pliiin Icnns. thnt it msiy l>o properly eliiHHiV'icd. TIk- "S;.cciiil lin'ocm.it ion" >'«)r p«r- 
Ron« ciyiiif^ iiwny VVoin lioiiic slioiilcl he ^Incii in every inMtiince. 



i:i 



t il 






1 

■I, 






il 



' 'i| => 



-J 



< 4 
I i 

) 



f^l 






1 I 



. ^vMMM* I 



i««#^y.N*^ 



u 



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(#i» 



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■; 



:!■; 



hi 



:il 




iMMUMfeM^.,, 



i 




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



I.! ..t" II. :.'tli 1- Vo ; 



^.'r'-^^r^ . 



i:\; !■ i"... 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



Dafr n/rf/, QAx 



ti/vwl)4 



,&ixt) \x l^U 



\j n 



Deo'ft- 



IfUJ'i 



Jii'ui.s/crrd .jYo. 






"^ K-' 



DEPARTMENT OF PUBLIC HBALTH=City and County of San Francisco 

Certificate of 3cath 

( U. 5. j?tanC>arC> i 
PLACE OF DEATH; — County of 'a>\ ^ \a ^\C<AZh City of C)a.^v JXO.^\ 



CC^CC 



No. 



iTO Vl.<Xq^; St.: "^1 Dist.; bet. C) lvV<Xclx\; and IrU 

(IF DEATH OciuRS 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 



LvvAjui(xl \r)V\XLLalL \ 



\i 



itviL'. J I avvu 



PERSONAL AND STATISTICAL PARTICULARS 



^)l 



I ' M.' I K 



cvJ 



!• \ : ! < 'I r.IKI'II 



'. ' ■ I-: 









'V. .1! I 



» fari 



r\! 1 



•^1N<". !.I" M\KRn:i) 

W I T>( )Wl-:i) OK i)-\-i iv , r I) 



l^A C 



MiK :iMM. \i"i-: 

'State lit I ■.iimti \-) 



FA rn i:i< 



i'.iK 1 II I'l. \i )•: 

oi" lAlIII.k 

' Sl;iti <)i linMit I \- 



M \l!n\ N \M 1. 

"i NKriii).; K 



inRTni'T. Aoi-; 

<»!• Ml. 'in MR 



< kt ri'A rioN 






Qm 




MEDICAL CERTIFICATE OF DEATH 

DA'n-; or Di; \Tn C 

M' i'ith' 1 1. IX I 

I lll';Ri-:i!V (.!•. KT1I\', I'll It I atleiiil. .M(. r.i-c.l Iimmi 
^ ^ ^ u/1 " t.) ClXivt 'X\d i.,f) \ 

that T last saw Ii "^ ali\c oil — — ^ "1,^0 ~ 

aii<l tliat iK-alli occiirml, 'Mi the datr vt.itrd al)ti\-i>. a1 *" 
^ M.^TIu- CAISJ{ Ol" l)i; ATM nas as follows: 



XAX (l^(^^>v' 



\XX>\CC4CX; 




\) 



A\,^iva^ 




;aKVu 



I 



f; 



clLl 




1)1 RAT ION 



CON'I-RII'.I Tom' 



)V, 



1 1 \ 



Mo'itln 



Pays 



Hon IS 



VLLOL 



U 






/\U'S 



//Olll'i 



DTK ATI ON )',,irs Months 

(SIGNED^ L I (XV k ' J^-LC V >v|\<X.»v M . D . 



Special information "niv (or Hirpit,ils, Inslitiifions, rransipnts, 
or Recent ResiiJcnts .ml iicrsons dyiiij ,m,)\ fron home. 



l\''-;,li\l III Still /'i ii ih ;^r<> 



]■-•(// A 



Months ^ /)i.M> 



I'lll' AltOVK ST \ri:i) F'KKSONAI, I'AR Tim.AKS AR1-; TRri-". To TH)': 
lU'lST (^I- MV IvN'o\VM:I)C.K and HKI,I1:i^ 



Oiif'.:iii;nit 



C \<l.lr< ss 






Former or 
L'sual Residenre 

When wa<. dist'iise fonfr.irled, 
II not lit pliire ol dedfh ? 



HoM lonq .it 
PIdfe ol nedth 



n,iys 



N. B.- 



IM.At,'!': Ol' ^l RIAI, OR R I-:N!()\- \l, J l)\^'i:o; liruiAi. <.i Ki:M()\\i, 



I xniCRTAKKR ()vA,L^AXcI \1 Lo 

(Address A H b \| \\.Kj^ \AJ^ VV v.lt 



-F.very item of informntlon should be carefully supplied. AGB shotild be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home should be ftiven in every Instance. 



i 



V 



.' i 



!i 



h 



ii 



z> 



J 






« r 



I . 



51 



! .-^1 



; i 



H/fti'";" 



^^ ^M^jaJk* "^ 




u ' 



u 



'I 



►;' 



'■ ^:. I 






1 11 

li 




!} 



I 



tlillitfiiji 



WRITE PLAINLY WITH UNFADIIMG INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Filed , GxivijL/VyVAMA; 



al 



7.9^; H 



iRi'i^i.sh'rrfl ^Yo. 



1 964 





C\,^ f7V-<. ^ ' ^ / 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Gcrtiticatc of Bcatb 

( 11. S. 5tnnC>.ivC> ) 

J? QQ :^ ^ 

PLACE OF DEATH: — County ofOCL-VX' 0.\.CV.Y\.<iai.c.' City of CV/CV>v /L<X->\.C^4, cc 

No. HOH VOKa^V-^ St.; Dist.;bet. SAxL- and \t}\j O.t., 

(IF DEATH OCCURS AWtV FROM USUAL R E S I D E N C E G I V F FACTS CALLTD FOR UNDER SPECIAL I N FO R M AT I O N ' •^ 
IF DEATH OCCURRED IN A HOSP;TAL OR INSTITUTION CIVF ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



.^C4vt 





i1 



•Cy V 



S' 



PERSONAL AND STATISTICAL PARTICULARS 



I 



'loJa 

I M 



I' 

50 . 




I. null ' 




II. i. 



MEDICAL CERTIFICATE OF DEATH 



1).\ 1 



:h 



i 






11 

Day* 



(Vt.ir) 



I l[I':U !:!'.\' I' ['RTM-N'. 'l"IiMl [ .itUMhlcMc-ciasr.l ("pmii 

I(/) til —Up 

lliat I \\i< ^:i\v h ~ ,t!i\r "11 i(p 



■■.i.i-:. M.xkkii.ii 
: DOWKI) OK l)i\< ' 111 



\\ 



lUKTIU'I, MM-; 
I St.'iti or (,". iimti V 



'■ ^, M ! Ill 

1 \ r 1 1 1 K 



JJIKI'IIl'I. Ai'K 

'"' ! \ III !•• R 



■^I M Dl'.X N AMI-; 
«'! M' "TI! i: l< 



l!I)M-!Il'I,Al-!-; 



(JXV^ > vex , 




.Ajt- 



A^'^V 



\X\ 



o 



o crL- 



u 



\^L^x{ 



.in«l that lUalli mHUirrciI, en tlit'iLiti- vtali-d alinvr, at 
.M. Tlu' CWrSl' (>!■ DI.XTII wa^ a^ follow^ 

DIKATIO.N }m//v .IA"////.v /)av< 

(. ( ).\TR ii:ri"()k\' 



1j 



'I 



//< 



I//; V 






nay< 



SI 



GNED ! LtrVcr>\ilV OAiO. II). dxla^vcL. 



M.D. 



y 



-CA 



(Ty-u Ct-^ '. 



i 



I. 



t)Ccrj'Ari(>\ /O , 



Special INFORIVIATION ""'y (or Ihspitdls, InslituHikv, Irdnsienls. 



or Rt'fcnt Residents, ,ind persons d>inj (Va,iv Iron ho.ne. 



rin: vp.ov}*. stai'id i'Kk-^dnai, par rirri \ks aki; i^Kriv in riii" 
iu;sr ni .\iv K\ii\\ij i)(-, !•: .wn nr:i,ii:!- 



former or 
I'sudl Residence 

When was disease fontr.irfed, 
If not at plai e of deatli ? 



tioM lonq dt 
Place of Death ? 



Days 



\.I.lrr-< 



HOH 



(d.Vx 



r 



VXXy>v>'va 



'.I 



^'- 



I. ATI-: •)!• CIKIAL OK KI-M' >v AI, 



AvU^^ 




\l'ji; "\ 1!; 1.1, \ I, oi k i;.M( i\- \i, 

dxkt XH 190', 



INDKKIAK 1:K 

(Addi. >-- 






^- L 



!N. B. Rvery item of inf-.rmi.tion shoul.l bo c.rcfully si.ppUed. \C,V. sho.l.l he state.l I.XACTLY. PHYSICIANS shoiHtl 

state CMISI: OF- Dli ATI! !ri plain terms, that it may he properly dussii'letl. The "Special ItHormiit i-.n ' lor per- 
sons dyini!' away from home shoultl he J^iven in c\ery instance. 



f 






( 



li. 




!l 






I 



! -^ 



Mt» 






')f: 




!ti 



i it^ 



' I 



'ill 




II 



» 



'4 



llHittttltE 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I- V. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lii'gistCl'Cd J\'*0, 






cWvxU) d0LiK{ Deputy Hoallh Officer 

DEPARTiflENT OF PIBLIC tlEALTH-=City and County of San Francisco 

Ccctificatc of Scatb 

PLACE OF DEATH; — County of v OUTV ^ VOU^'\CU,CC City of C)<X>V 0.\XXY\,<ic^Cc 
No. S '^v b LxX^h^ St/, S Dist.; bet. I *^ XK> and 1 R t l\i 

(IF DEATH OCCURS AW«Y rPOM USUAL RES I DENCE Gl VE FACTS CALLED FOR UNDER "SPECrAL INFORMATION \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




,cl 





'^ ^\/^'\X.^ 



PERSONAL AND STATISTICAL PARTICULARS 

(Ml,! ik 




\ 



<x. 



> \ 11. <»l I.I Kill 



'\ 



V 






5 A^S 



MEDICAL CERTIFICATE OF DEATH 

i).\Ti-: ()!■ ID \ I'll 

11 



%t<.iitlii 



' I»avl 



(V..II t 



• I>;(V» 



» car 



II 



I 



a:i 



^l\< I 1 M \ !■ I. 1 111 
\\'i it< i II - 



»Kri:i» 



niK run, \ri.: 

'Stall (ir I "oimt i >' 



N \ N! 1 < .! 
I \ I'll I K 



<>i- I xrni-K 

- ■ '' ■ I ' ill nt ! \ 



M \ ii)i:\ \ \Mi", 

oi .MoTHI.K 



Hi Kill IM,.\ri', 
ni MnTiIKK 

'Stall- MI Ciiniit t \ 



c1 . 

^ -'cL'>\i 1 va ^ V cu, c^ 



I 111 Ki:i;\ ^ l-RTIIN', Th.it I ;itl(ii.U-.M(c,Ms.Ml (um\ 

that I last vau h < ')■ ali\t on O-C |vtr %Iq ,,p H 

and that ilcatli orciiiri'd, (Ui tltc il.itr slalrd aliiivc, at lOO 
^ M. The CWrSI' ol' hl';.\l"ll uas as follows: 




AaA\JU 






Signed) 'Y^^ "^ ^ 



LoJjJUvyi 



»« I'l 1' \ I ION 



WJX 

I 1 
I I 

Rfsiilr,! in S,ni /'i<ni.r,,> 11 ).r, O U,>u'//€iX 



M<nilHs 



dx'^ri.ooS r\.hirvss)4/)b 0^ 




I hi 



) V 



//l 



//■; 



M.D. 



tUv ^t 



Special Information f»niv lor iiuspiidis, insiiiuiions, irdnsipnis, 

or Rpfent Residenfs, .ind persons dvinq awdv front ho.up. 



/',/ 



iiM \r.ovi-: s r xi'i'i) rm<s(,\ \i, !• \K IK Ti, \K^ \Ki: 'I'Ki' J-: r<» i'mj'. 

r.l'ST Ol- MV KNOW I,KI)C, l'. .\NI) 111. I, 111' 







IS' ixUot 



Formpr or 
L'sudI Rfsirfpnte 

When was (jisp.isr (onlr,i(N, 
If not df pUfol dciitli ? 



How lonq A 
Plare of f)f,ifh ? 



f),)VS 



f \rl.lr. 



i'i,.u-i;()i I!! ki.M, itu ki;M(i\ \i, j i>\j4j;..' isiimm .i ki;Mn\Ai, 
I • .v I ) 1 •: u T A K 1-: K V CV Ic (rO \ ^ \A. a- II H dA/\Xai■tc'^^a lo 



( 



N. K. j'ivcry Item of iiiJormiitlon should »>.- cnrcfully Hupplle.l. \i\\\ Hhoufil be Htnte.l EXACTLY. PHYSICIANS Hhoiilfl 

state CAlISr OF DliATH In plnin tcrin«, thnt It msiy he properly claHKilfied. The "Spcciiil InformHtion" for p«r- 
«on« dyin^ away from home should be ftivcii in *i\&r}/ InHtnnce. 



II 



Hi? 



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If 



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^ 



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iiuil 



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i« 



fi 



■ I 



!•■ 



n 



, i 




I 



«;;;&«. 



.,1.1 ..;" .1. ..;i!i r V 



WRITE PLAI.NLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



»^ -'•«. 



I'.X. [• i\ 



ihdr n/rfi, 3 xJ^Lt-^ vLov xl rj(n 



X-'CrVA^^ Xje_A>u Deputy , , 



Bf'gfs/cr^'fl ^\>y. 



1 0GG 



**—* **. J I 



ncer 



No 



DEPARTMENT OF I'L'BLIC HEALTU -City and County of San Francisco 

Certificate of E>e<itl) 

\ ^ I ^ 

PLACE OF DEATH: — County ofO<3o^\j J A,<b^\c^ Ci City ofCJ/CtVu \<X\v<r 



<-v^-ec 



V) 






V I 



St.; 



Dist.; bet. 



"and 



X ^ L^LOvlu Ju CKL _ _ 

/I / ir Df ATM occuAs AWAv frcJm USUAL RESIDENCE CiiVE facts called 'or unoer ' sptcial information • \ 

M ^ "" riE*TH OcduRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 

FULL NAME vlUo'vi -■/.'.... ■. J ., ,. 

U 



PERSONAL AND STATISTICAL PARTICULARS 



n 



'. i i< f 1 1 



I' 



/iS'; 



\« . !•; 



Ss 



ftAEDICAL CERTIFICATE OF DEATH 

n.\ ri'! I •! i'l \ 111 V 

I III:R i;r.\' CI.KTII-W Thi! I atlcirUM! ,h..HM-.c-.I fn.m 



I N\ .11 



\\ I!)')Ul-t» ( *\i Ii\ . I 









h^oi til 

t liat r l;ivl S.iw II '. ^ ■■ .ili \ r i)!l 
and 1 hat <!i'at li i u-c'ii inal, mi 1 Iir d 
M. Til 



I, 



•^^ I()0 H 

V '1 up M 



r ■ '1 alx i\H', ;it > 



J^ 1 



r (,■^■SI•; (»!■ |)i:\III \\,is a^ follows: 



x \M 1 < ,;. 
1 \i'ii Ik 



l''lk III I'l, \r].; 
"I I \Ili IK 
'St ii. ,11 run III I \ 



M \ I I>l \- \ \ M 1 

' M \ 1 , rn i-;k 



IIIK lllfi. AC)" 

Ml \T..|iii-;k 

1 'iinit I \ 



I)i !^\ri().\ )'i-ars S ./A"////v 

TON TK Ull'Ct )\i\ 



/\!\ 



Hon 



; V 



1)1 R.\TI()\ 



\. 



V 



(W 



at\ 



Mi^Utlh 



i SIG 



A' § 







M.D. 



NED) J, vA. olro\i 



ON only for l«is|iit,ils, liisfif!ilion>, frdnsirnfs, 



na\ 



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I II i: \ Hovj.; sj- \Ti.:iii'i-|<S()N M, !■ \ki'irf I. \ks \k I i k' i i i' ' iiii 
iti'.sTdi. >JN K N( i\\i,i;iK-,ic And iu,i,ii;i- 



Special Informat 

or l?tTcnl Rcsiilcnis, diid \msm\ (l\ii)(| dw<iy frnn home. 

former or u 'n u p P P ~\x ^'"^^ '""'I '•' 

L'sihil Rcsidcnfp l^^ U.<XtLL'/: < T PLia- ol Dr,ilh ? 

Wfirn W.IS (lisiMsr (onlrditrd. 
II nof <if pIeK »' ot dcitli .' 



OdVS 



L'l, Ai'i-; <ti' i;iKi\i, (»k ki,Mii\ \i. | i>\ 



• i: IMi i\ \l, 

.i.:kt\ki;k vIVJLLUm *-<- ' • ', ' ■ 



' \iiill rs» 






n« .wj m tmamm mij~r-mMmmimm^mmmmmmmm 

IN. ij. livery Horn i.V iuV'.irmiitioii whoiild hj curoViillj H\ipplie<I. AdR hHouIiI ba stiiteil I.XACTLY. PIIVSICIANS hHouM 

state CAlISi: Ol' ni;,\ Til in pliiiii terms, thsit it m^iy lio pre.perly cliiHuilfictl. The "Spcciiil Inltorinntion" for pur- 
Rons flyinjj uwiiy from homo should be jiiven in c\cry mHtnnce. 



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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1! ■'•; i \ 



Dif/r Filed, 




fc-VCA^ 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



li)0\ 



lipo^isfered JVo, 



«!)G7 



DEPARTMENT (JF PUBLIC HEALTK-City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of Beatb 

( 11. S, 5trm^arC> ) 


A... 



City of X<X' \i\.->vtoj '^C'vl 



No. 



St,: 



Dist.; bet. 



/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDE 
V IF DEATH OCCU 



and 



IRRED IN A HOSPITAL OR INSTITUTION GIVE I 



(\ 



TS CALLED FOR UNDER SPECIAL INFORMATION \ 
TS NAME INSTEAD OF STREET AND N U M C5 E R . ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



')U 



MEDICAL CERTIFICATE OF DEATH 



; i \ n . I H 



;A 



u 



i ! 



^^v.L^ 



I' \ I'l .1 !;!K l"l 



\ • • i ■, 



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V) 






I II!'.!^ !■. i;\' i'!;kTI1'\. Tint I it '.rii.K'.i .K ; > t^.d ("nun 

_ [^^(, t-> " Ii,o 

tliat r last --aw h ' .A'wv imi " — 



li)0 



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W; iti ill . •• ' '. 



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iii'l til. it iK.i'l) M(( iirrcil, iMi !lir tl.itv --tatt'il alutvc, at 
M. The C Al Si'. Ml.' |»!;\Tii \\,i. a- |nll..\\<: 



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MMDI'.N N.\M1C 

»>i Mnrin: u 



ink riiiM, \> i; 



'•■■*' I' r \ 1 i( i\ 



h'ru'ifr,' 



hlk \TI()N }\\irs .)/'////;v 

I. < »\ri< MM T()R\' 



/\iv 



I lours 



1)1 k.\Tl()N 



)\\us 



■Ills 




(Signed^ H'CU J v/V^aA. ■►;.-! 



i\ 



/I V 



Hours. 



XX 



^U_l 



iqn X 



M.D. 



SPECilAL Information ""Iv tor H.,s|iyi.iis, Institufians. Ir.insienfs. 
or ((t'ipnt Residents, diid persons dyiiii iIh.iv Iro.ii ftoijii-. 



1 



III i: Mil t\i-'. s r \Ti-i> iM-Rsi )\ \ 1. r \ K I'h r I \ k-^ \ i<i-; ru \ v. rt» rn )•; 

Ml'Sfoi- .M\ K .\» i\\ i.l.lK ,)•, \M) i;i;i,ii'i- 



lormer or 
I'sii.tl Residence 

Wfien VV.1S dispdsp (ontr.K Jed, 
If not af piare of denffi ? 



tliis> liinij <(t 
fidre ol Dcilfi .' 



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t CTVaJLu -\X.'V V V c V ■ "V ' . J v^< \ . \ \. 



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ClxA^^VO- I 3.^ ^0 ,00^ 

NDiKiAkik ML- vj Axx^A^ JVC Lc 

551'' ^A.JXt'v it. 



f.Xildi.-.'. 



i\. K. Jivcry it.iii oV iiiV'oriiiii tion Hhoiilii h- ciiroViill.v siipplieil. AUli kIid.iIiI he Htnted I.X \CTLY. PHYSICIANS hIiouI*! 

Htntc- CAlISi: Ol- DliATH in pinin tc-rins, that it iiuiy ho pi'iipLfly cliiMNiU'icd. The "Spcciiil Int'oriiiiition" Vor pur- 
son* (l> in(l iiwny from home Khould he JiiNcn in every inHtiince. 



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WRITE PLAINLY WITH UNFADING INK — THIS IS 



A PERMANENT RFCnnn 






■biu) 3a\u4 Deputy Health Officer 



REFER TO BACK OF CERTtPICATE FOR I NSTRUCTIONS 



1 968 



DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco 



Certificate of IDeatb 



( "U. 5. JTitnn^ni^ 



PLACE OF DEATH: — County of 'a>.v Va^\Cc^C^ City oi^^a^v J\a^\OUXX^c 



No. 1 







C, >v^t^V 



--^4^ . .-^ 



St.; ^5. Dist,; bet. )1>C k"U>V and Xx>L l\C >\t 



( i .''/!^l'^.°''^'"'^ *'"*'' '''°'^ USUAL RESIDENCE c.vt facts calltd tor under ■sREriAi .ntormation \ I 

V ! .r otATH OCCURRTD ,N A HOSP.TAL OR ,NST,TUT,ON GIVE .TS NAME INSTEAD " STR E e; ^N o N U ^^Bt R ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 





• 1 ( 'I i.I Kill 



IVIEDICAL CERTIFICATE OF DEATH 

I» \ I'i- 111 l>I \! II 

5LI 



A^^ 



Mon/hi 



II. i\' 







■•I.I \!.\kisii i> 



I IN'RI-liN- il.KTil W Tli it I ,,tUn,i,.,| ,|.T,asc..[ Ipm,, 

TTyO 



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HI R I" HIM. \ . !: 

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M NIL! ■ ' \M 
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"" ' ' ' ' ' • < ' ' 1 1 1 1 1 1 % 



Ct 



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• iIKJ tli.it (U.itli (i(-ciirrr>l, >'i! Mic ditf -titrij ;i!)n\T. ;it \ -^0 
^ M- The, CAL-.si.; ()|- |»!:.\TN \\, . .,s (oll,,u»: 



hik 



AT I ON );w/v 



.1/ <"////' 



Pay 



ll< 



>in 



DIR ATI()\ 



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Un/f/i,^ 



Big 



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/'■/l^ //.litis 

v^rctu M.D. 






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SPECIAL INFORMATION only [«r llospildls, Inslifiifions, [rdnsjenls, 
or Hnt-nl Residents. <ind persons dyin'j ,m.iy fnni home 

former or ^ \\ ~\ i How lomi nf 

L'sudl Residence ( U D yCtOn;^^^AAy U pUc ol f)e,ilh? D^vs 

When Ytis disease (on(r,irN, 
It nof M pl,if e of dedth ? 



Hi: \iit i\i-: s r \'n:i) I'j-'ksuN \i. 1' \K I icri. \ K> \ki: iki i-: ro iiii-: 

lUvST ()|- .MV KN»>\\lrj;i)(,l-: AM) lUil.Ii;!' 



' Inf.i' iiniit 



cL^^u V^vvi> 



vM Too 




1 



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IM, ACl-; «»1' JUKI \I, < »K ki;M(i\AI. I |)\. ! 



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\i)i;KTAKj;K \l f L<X >v 3 C^'t^U L.AV 



>. H. r.vcry Item of information Hhotild h.' cnrofully siipiiliod. Adfi Hhould bo stilted fiXAGTLY. I»M>'SICI.ANS Khould 

Htntc CMISI: OF- DfZATH in plnJn terms, thnt it mjiy he properly claxsified. The "Spccinl Infornuition" for per- 
sons flying nwoy from home should be (iiNcn in every inHtance. 



1 






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WRITi 



PLAINLY WITH UUEAQtlJm^JMM. 



Ti-IIC I Cr A r-1 f •>« ■ « M •. . 






//y^^H 



t-mviMiy t JM I Hfc.CORD 

~.^J!1L1112 .^^_9*^ Q*^ CERTIFICA TE FOR fNST RUCTtONS 



FiVglstdril Xo, 



Officer 



I DEPARTMENT OF PUBLIC HEALTIf=C% and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH: -County ofOa^^. d.Va^. -< . . City of"! a . 



No. ibs-; O^U^ 



St.: i 



A 






/ rnrATH.- . ^"^ ^ Dist.;bet; .-at\A>>\X/YC^ and 

FULL NAME L4 VaVA ■ 



Lvctt 
) 1 



IL 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 




\\ 



M.*ith 



KTllPi 



\ \ M 1 ( t' 

' y\\\ i;i< 



1 

/CL"^A/ J XCV \ > 



1 NIK 

fii.it I I;i-.t ^,i\v !; 
• IM'! t Ii.if .!r;i!!i I H-r\:] -i- 
M. Tll< (• \, 



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W.I'- as Id 



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O^VXItVA.V 



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Mo'IMll.!-: 1 



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Mii'.k 

• i'nu III I \ ) -^ 



" ' I !■ \ ih >.\ 



.O-ClO'V 



ll 



DII'JATION' 



? 



);,//- 



Months 



( Signed ) Lt5\.<rv^\' ■ ^-^ l' ' 



/I 



<f] s 






f^ 



n a c x<x/^\X/>\to I 



ux|\t 



If OK I \ 

M.D. 



I(;'^ . 



\.Mr. .., ^C'vC , ..J... ^ 



Special INFORIVIATION •>"!> I'h fhispit,iK. Inslitotffjns. frdfiMt-nls 
or Rt'tent Rtsidenfs, ,jn'l (insoiis dviiH) ,\\s,\\ fro n \wm. 



n 



/,■ 



. t 



former or 
Lsiidl Residt-nrp 

Wlien wvis disrasr ronfr<ir(pd. 
If no( .it plfiff o( dt'dfh? 



Ilou lont) lit 
f'l.lU' of f)..,ilft.' 



fl.n^ 



III ^i>'»v»': sr \ii:!) (•!■ K>ii\ \ I. !■ \K IK F I. \Rs AKr; \-\<vv xw rill" 

i:i.'-.I n;.- M \-^k \< »\\ !, i i i. , )■; wi, IM !,Ii;!' 



O 



" I' !• ni:ilil 






V 



I'l. \ci': j^i' ^ K i,\i, « )k i<!;m<.\\i. I i, 









190 



(.\«i.h.v. HOv'i "^3 o-OdUi/VK, b ^0.1 



^-x. 



N. «.- 



-liNcry item <>>' inV'oriiMit ion mIioiiIiI hj ciircl'iill.v stippli.Ml. \^\V, s'l.r.ild bo stjitc;! lA ACTI.V. IMHSICIANS shnnld 
Hiaitc CAlJSi: or Di:,ATII III pljiMi ttrmK. thjit it miiy he properly cliissh'icMl. The "S;>cviji! hn'o-Mii:! t i ..1 " tor pep- 
sins dying nvvny from homo shouhl he jii\en in ovcpy iiistiince. 




fi 



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WRITE PLAINLY WITH iiMCAn 



ll\i^^ iRIt^ av....^ 



•• r^h^ii^yj, ll^f^ 



II.MI.I. II- ;i'i IV,, - "**''"-^.: |.v. !• 






l[)()H 



ini^ 155 A PERMANENT RECORD 

^R5F£R_T 0_BACK OF CERTIFICATE FO R INSTRUCTIONS 

J^pgisfered ,Yo. i 1)70 






1 



r»r 



DEPARTMENT Of PUBLIC HEALTtWify and County of San Francisco 

Certificate of Beatb 

tl. S. StniiCiiUCi I 
PLACE OF DEAT?T:- County of ' Ct^v i Va^xcucc City of 



■;}' 



0->\' JVcl^a-Ca^ 



( ir DCAT* OCCURS Awiv FROM USUAL R F «? 1 H F N r r *'^^U 



FULL NAME avk-LV Mltcl 



V^lACnv 



PERSONAL AND STATISTICAL PARTICULARS 



jla 



'K 



a 



M 



I'ATl "I i;;K III 



II '.xct 



MEDICAL CERTIFICATE OF DEATH 









/ 



n^ 






5H 



lb 



'''N'.IJ". MVKUII '. 

-ii'iiatiuii) 



IlIKI-Ill'l. \r\: 



■^ wi)-; i»i 



IMK 1 II I'l. \. I- 

<>i I \riii;k 

'State nt CmiiiiIi \ 



^' \il'i:\ \ AMI- 

"! .M<'Tiii;k 



inu rniM, \r |. 

(St;i|. 1,1 i-.,|iiiti \ 




at- 

' Dav) 

uii':ki':i:\ n R-nrv. Th,,t ratuMnic..! w.<vm....i i,,,,,, 

that [ last saw Ii -1. >^\ alixcii 'Jxlvt ^{. ,,^,,t( 

ami that .iralh ..(Tiirrc-.I. ..i, tlic ,!,, , -;.,!,•,] .•,!„. v. •, -,( -S 
LL M. Thr CWI SH,n|' |)i:.\iii vs.is a- (,,!!, ,.ss • 



J»l k-\Tln,\ );,^/^. 

CONTR! Ill Tory Ltv\.(y^\ 



^/O'lf^'l^ /'./IS //,v//.v 






i>ik.\ ri( ).\ 



.'/. V/Z/Vs 






/^</rs 



' Signed 




M.D. 



' ' ' I ! \ 1 K ).\ 



AV- i<lr,! Ill S,!i: /'i mn i , .1 ,>0 V' ,r, 



Special Information "niv for iios 

or R('(pn( Rtsidcnis, .iiid persons dvin.j dy,,\) fro.ii ho'iit- 

Former or -A 11 ^)r 

Dsu.ll Rpsidcnre XCOR Q\jCy\JJLL 



piliils. Inilifiilions, fr,inMPnfs, 



H<m loni) Hf , 



Pld< c ol l)€.|lh 



M,'iill,^ 



When was diseflse fonfr.ir(ed, 
If no( at pl.i(e of death ? 



D,nv 



_^ ■ .... .,.,,,/,., ,/^^^ I t a I ■ U I'lll II ^ I II II"l III Jfllll I l/l UlOlll . 

I M)l.kTAKi;R V<X\JC^\r \-<. LvV.CL\.A^.QJk/ 

',\<l.!r. .. i*^ U<V>V ~J\ca.a Cl.\>-C 



I'll I 

' Illfi.: Dlailf 



^ \.l.ll( >,^ 








N. B. F. 



very Item of InPorfiiHtion nhould l»j cjirolfully sut»p!ie«l. ^d'h Hho-.ill be statc-il liXACTLY. I*M VSICIA NS Nhoulcl 
Htjitc CAUSE OF DHATH in pinin Icrins, thjit it miiy he properly clnH8ilrled. The "Special IriVormjil ion" »'or per- 
sons riytnft away from home Nhould be Jiiven in every inHtnnce. 



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tA/D I7P cat AiRii %#•*<••»•. .... ,. 

""^ ^ ir"'"""' """ """"'""'^° INK — THIS ISA PERMANENT RECORD 

■■ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



7V^ttV0 




Ji('t>i. si (>!(>(/ ^V>y. 



• 07 ! 






Deputy Keaith Officer 

DEPARTMENT^F PlIBLIC HEALTIKitj and County of San Francisco 

Certificate of £)entb 

[ 11. 5. St»inc>arC> ; 
PLACE OF DEATH:-County of -''a>V K.a>xcc4C0 G.y of Oa.v 3 ACV^xcc^o 



A- 






No. ^OS L-LcXu c, <3 i^. L -W.-.L-f H , i_ 



) 



FULL NAME 



\. V, 



PERSONAL AND STATISTICAL PARTICULARS 





».'' 'I.I »KA 





X 



I * 



II 



MEDICAL CERTIFICATE OF DEATH 

i>A It-; I . m \ III 

' ^At at 






'a. 



/?H5 






D.iv 



/Qo'i 



rj 



S^ 



} v./ 



T 



!/..;////. 



b 



^i^' I.!' M\kun"i> 

^\ lit.- Ill social (lc-.i<.Miati'>iO 



H!k !-|It 1. \ri 
^' i"' : '■■>iMllr\ 



I-ATIH-K 



Hn< 111 I'l.Ai-K 
OI- l-ATHHK 



"•' M<'i"III-.K 



inKIMll'I, \i J- 

<>i- M(>iiii.:R 

f^tatf or ^'oimtrx 



y^^^ 



^Of) 



^ 




i m;ui.n\- n:[<T[i-N-, ti,,.i i attc.i.io.hkM-e.,.c.i IP,,,, I p 
190 V. — „^,^ |j3 



that I last saw li a'.ivc oi! ,^ ^, 

•m.l that .Kath ..C(Mii rcl, (.r, thr datr -tatv-l a!...\v. at 




1 
1 1 

17 
1 



-^ .. 






yi. The CAISlv ()!•_ Dl-IATII u ,< as foIL-u.; 






VL^VCU 







1)1 RATION }• /; 

C().\TRir,rT<)i<\' 



I )!■ RATION^ );.,;y 



Mouths 



Pax 



Hon 



y V 




!■ 



1^ 



•.-:=^ 



.'/,'-'////> 



/^/I'V 



< SiG 



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f^'f^iifi',! Ill Will /'i ,/ii, /k,-,i ^'7 



VL WOL 






M.D. 



t 



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.!/,>;//// . 



Tin. AMOVK ST\'n:i) I'KKSONM 1'\k 



or Kneni Kesidcnls dnd persons dvinj ,ih,i\ fron homr. 

farmer or Q^'C I l ^ ;i4- ""** '""Q <»» 

Isiidl Residence C^ o \^ \^<XL1 QL p|,„ p (,f pf^,|, , 

When was disease ronfrarfed, ^ 

If not at plare of deatfi ? 



Odvs 



OnfirinaTit 



Hi:sT ()i- >.tv Iv|P\()\vi,j:i)(-i.: AM) iti:i,ii-;(- 



.''mKMKf"'""' '■'"■'•'■" ■'■'"■ ';'<^^-^^"'^ "'K'^'. -K KKM-VU. I ,UT,.;o; m.,.,^ .- RKM.nx, 



Cl<Xw; 



M)l<xtc{) C^ 



)_k_ 



Ivt n 



i \ili]l-r<v 



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^Ad.lress l'^ |> CIcLU It 



I90S 



^. B. F.very item ni infnriii„tion should be crciuWy sii,„.r!e.l. \r,\. s'ln.lcl be stHte.l fiWCTLY. PHYSrCI \NS -h»..l 1 
«t«te CAUSE OF DEATH In plain tcr.„s. ,h„t it nu.y b. .....pcrly cluH«ir.ecl. The 'Special In,or.„ath.„^1C pll- 

Rons dym^ nway from home should be felven in every instance. 



M^ 



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\A/RITr Dl flIMI V \nn-rL.j 



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i;-:il'! ..(■ M. ..:t!l 1-X(i '=; t-f^^^;-, It.S: [M 



' v^.^r^uiiNV. iiNrN — THIS IS A PERMANENT RECORD 

— REFER TO BACK OF CERTIFfCATE P QR INSTRUCTIONS 



41 



t . 



:4 



i» 



//v^;h 



1 



t^tu.^O 




]if'i>i.s/('rr(/ ./Vr>. 



1 97 3 



avu Deputy 



DEPARTflENT t)F PUBLIC HEALTH-Ci> and County of San Francisco 



Certificate of Scatb 

PLACE OF DEATH: — County of^' 



a>v J Aa>vOL4c« City of "'a^v Ixawcwcc 



itL 



FULL NAME 



^ll\c^u.to lL>vt 



X^TLiYCrVV^-Ov 



- 1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



|| \ 1 I ' M i;iK rii 




»L 




^fW 



%•■ :llll 



i I t;i\ ' 






MEDICAL CERTIFICATE OF DEATH 

DA ri-; (•! in; \ 111 



clxktr 

I Moiitli I 



ai 






5 . 



V 



Wi it< in ^. ,. : ' ,i,. . ... . 



5 



/',,■ 




Mil.' fw n v,'i. 



fSi 



N' \ Ml- ( il 
'■ VI II IK 



'IMit I \ 



nik III I'l, \c).- 
<>'■■ I A nil-: R 

'^' it'oi ri)Mtiti V 



^' \ii>i:N \.\Mi" 

"1 NtorniiK 



"IK IIIIM. AtJ. 

<>i" Mo'nii:u 

(Stat.- nr r<iiinti\ 



? 
? 



, I lll'kl'nV CliKTII V. T!i;,l I ,..!rn,IoI -Irrr.iM.I I,,,,,, 
^ • Ivt lb ,„o4 ,., TA ^Jxt ai ,.,oM 

tli.'it I last saw h ^\} alive on 'JX j^t ,^4 ,,^o H 

;inW tli.it (It atli MCt-iiiii'd, oil tlif <lalr '.(aU-.l alx.vi- at 10 

M. 'I'lu c.\rsi{ ()]•• i)i:\ri( u,.s ,,s loiiews: 



DTK \TI( >.\ 

c'oN'rkir.ri'oRN' 



m RATION )-,,//v 



)'<^". Mo>ttl,s 7 /^,ns Jloufs 



M."itln 



(SIGNED) 't ^\. C-a^tLlxlvA^A-v M.D 






//(UtI \ 



• I' n 



f\rsi(lri{ lit S,nt /'i uin isri) " 



Special Information onu toi nospiLiis. insiifuMons. rrdnsimfs 

or Retfnt Residcnls, dinJ persoib dyin^ ,ih,iv fio-n home. 



1A>/////. 



Inn; vMovi.: sTNTj.i) i'KKS()\xi, r\i< iirri \ks \Ki:TRri-; lo tid-; 
"^ ' M\yti>>'<>\n,i:i><.i': WI) in-i,!i:i 



Formrr or 
Usual Rfsideme 

When was dispasr ronlrai led, 
If nof at plar f of deatfi ? 



lloH lonq fif 
I'Idrp ol l)«-.i(h .' 



na\s 



Inrotiiatit 



i XiMic^s 



. VJJUvoLvdL Urru 






I'j.Acr: (>i. luRiu. UK ki:m..\ \i. J i»vri;,,! hmm u ,„ ki;M<.\ \,. 



N. ».. 



-Hvery item oif Informution should b.- cjirclttill.v supplied. ACIi m'i<.iiI<I he HtHte«l liX ACTLV. PHY8ICIAIN8 Mhould 
•tate CADSF: OF DEATH in plnin terms, that it may be pr<ipcrly cluHHilTled. The "Special Int'ormalion" for par- 
son* dytn^ away from home Hhould be ftiven In as^vy InHtnnce. 



? 71 'I 






I I 



^ 

^ 



-J 



I V 






r 



»fl!:. 



tlll'tH. 



ft 

I' 



irt 



iiWl 



i*u::>»»< 



WR.'TF PI iRIMi V lA/iTu iiMi- 



ii r*% ■ it » ,^Nk 



k K ■ • «# 



• ^ I /-nu/i IX VJ f IV r\ 






' />»fr /y/.v/, dx^vU.'v^vW. 



11 






//y^yH 




mis IS A PEBMANENT RECORD 

^EFER TO BACK OF CERTIFICAT E: FOR INSTRUCTIONS 



A>M 



DEPARTJ1ENT OF PUBLIC HEALTH=Ci(v and Counlv of San Francisco 






Certificate of Beatb 

X.\, 5. 5t^^^ar^ ) 
PLACE OF DEATH:— County oiO<Xoa, d \,<X 

No. Hit. ( ( ' 



City ofOci^-vvj J Vo. ^ 



, J , 



/ ir HEATH orrnc. ^^*' ^ I^^^t.; bct. cLlO^Vh^^xUh^ "^U nd it V V 



FULL NAME 



AME INSTEAD OF STREtT AND NUMBER, 

r, ( (? ' : 

Uj. Kj . vJ^o-vi-wl v.a. , . 



PERSONAL AND STATISTICAL PARTICULARS 



11 



^ 



i».\ 



a 



II 



•1 i-.lK I Jl 



MEDICAL CERTIFICATE OF DEATH 



/ V. 



^\ ;ii>"U-i:i) ore n'\tjK^ j;i) 
i ^nation) 



Mik riiiM. \.|- 

'<!.i!, ,,i I ■ , . 



i : ) k 



1), 



I ■ '/, 






lit I I : 



h .1 i!, 



tli;it J Irisf ^,iu h 



• I I I ' 1 1 1 1 
lt(0 • • 



.■m<i lli.il ilcilh o.-( !irrc.!, (.11 (h,. ,1 

M. 'I~!ic C \I si; ( >1 III' \| 1 I 



" |\'( , ;i1 



\\ ,i . :i -. t ( ij I' i\\ s : 







KAJiOu<U 



/ 



li'KTHPI, M}.- 
()! ' ' ■ !!1.;k 

"^' ■>iinlrv 



MAIL I M |.- 

"i M<< I II l.k 



'{!k I |ii'l,Ar|- 
'»!■ \T<>riii.|< 



y 



HI R \'J'in.\ 

c< (Nik ii;rr( »m' 

IM R AlfON 



/ < ',■/ 



JA '// 



/M 



/' 



/ 1 



II, 



II rs 



. ./A--///. 
^ -1) 



/^/l s 






! SIGNED )UrV^ve;vi J h \JU. Ij^ia. v-ul 



f li'iii \ 
M.D. 



-V. 



a 



/ 



' '■ ' rr A III )\ 



Special Information "nu lur ii.»spifdis. insiiiuihit^- \\,^^^^m^\s 

or KHcnt Rrsidcnh, .inrl prrsons dviri) HWd> frrrn homp. 



tl H I I il ,1 



1 ", 



M.uiil, 



I'irmpr or 
I'sudl Rf'Nidcnrp 

Wh((i v*,is ffisfMsr (onfr.ii led. 
It no! a\ \s\,vf ol df.)lh .' 



How loni) (it 
Pl.i« f ol flprffh ? 



I).ns 



'''n'?STy.;^A!s"^^^^^^^^^^ "" I i''-' - .MklM.okk.M.,. 



L^CTurvvXh^ 




<^/CL^ 



S-t^vt at 



' \.!.!i.-vs 






k I Ml .\ \|, 



fA.Mi. 



^- H. Jivery item o»' inVormsit Jon ithrMild Ik- cirut'iifly supplied. AflK hHoiiM be Hinted I.WCTI.N. P;nsiCI \\S Hhould 
Htntc CMJSF: or or; Xril in plai,, X^rnx>., tliMt it m.iy ho pr..pcrly cluHsiticd. The '•«pccinl Inior.niiti ..,• »„r o-r- 



«on« «lyiiij% iiuiiy frrmi home should he jiixcn in e\cr> instntue 




I? 



I 



I- 



^^-^m^' 



^je,r^^--4« 



'^j^f't' 



vw 



kiwA"'* 



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WPiTT PI A IMI V lAil-r-Lj I iKii-M »«...^ 



'■l(.:i!(!i IV.; ■'?■* "W^!- JUS.!' r., 







..... ^.^r^.^,,.,vj iiNrv— TMrs IS A PERMA/MENT RECORD 

REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 



JOO'i 







-^ \M,^ . 



DEPARTMENT ()F PUBLIC HEALTIl=Cify and County of San Francisco 



Certificate of Beatb 



PLACE OF DEATH: — C( 



'^ 



No. 



:ounty of a ^\ -) \a ^\ecac^ Cty of J a-yv J .Vcv >v ccvi CO 

^"^X:?:.^^'^^' St. .r DisMbet. nil ,nd i^iti 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



l\aU 



1' xij: ( M i;ik 111 



.0,,^' -^ 







M. .111)1 






\. , 1- 



HH 



' ">■('.')) I 



/>,: 



u iix '\\i I) (»k i»:\ I tkt j.;i) 

' \Vl It.- ill ^.K i;(; ,1, -ij.Miatl.Ml) 



C] 



liiuriii-i, \r\: 
^t;it< ..I I'.iiiiilrx 



^ \M I <)| 

'■ \'i"fii;K 



IMk'nilM. xri- 
<>•■ i-\rin;K 

'State or l"(iiiiiti \ i 



^' MI»i;\ NAM). 

''I Morin; R 



'"■ MoriiiiK 

-111' 'ii r.iiinli 



A 



i >v 



MEDICAL CERTIFICATE OF DEATH 

i>A ri-: (>!• Ml-: \i ii i 

'Mo'itfit ,,.,,.) ,v,,,, 

I 1II;RIJ:N I ! RTliN. T!,al I ;it!ci..!r.i .U , v,,s,..l lp.,li 

"^-^l^'fc \ tw"H to '^j.\'&: ai ,.,oS 

that I last saw 111 >V\ a!ivr..i) J-c'jvtrXt) i,,o H 

iiiil that <U-atli Mcriirioil. ..nth, -tatrd ah.ivr, at \ 




^"'^A^lLouvuI 



■>^\X.> V i^-CU-tVi 



Vtl.a^A-€*w 



I )r RATION ^ ),,//s 



C'ONTR lIM'I'nRN- t /lCl\, 



.)/,>ii//is 



/hivs 



Hour's 



CV^^W^^V-^ 



a\M 



a \\ji 



DIR-ATIOX - Years b .I/,v////v /J,/,. //,,,, 

■ r ^^ Hi i O 

(Signed) ^'. L ^J^avLvM 



M.D. 



"^■'I'l' \Tl(>\ [y 



o,\xLav\cL 



Special Information '»"'* lor HuspifdiN, insiituinms. irdnsienis 

or Rrifnf Rrsitlcnts. dnd persons dvimj ,m.iy fro-n homf. 



/j./i 



'",;,V!V^'''" '^''■^''"l"l> I'KU^OWl, |'\R Tlfll.AKs AKI' V\<\ ]■ T. • rill- 

iii-.si ()i- Mv Kxuw ij;i)<; ).; AM) ju:i,n:i- 



'^^Inf.,: mint 



1' Llllt^ 

N.i-i,,.s IS'SH C(yu^<xvcl at 



Former or 
I'sij.il RfsitJfnce 

When Hds dispdse (onlr.iffpd. 
If not flf piflfp o( dcilh ? 



lioH iont) dt 
PIdff of DmIIi ? 



OdVS 



lOoS 



I'LACK ()|- MIKIM.nk k|\tM\\i, 1)^11 ..! I!m , u ..: ki:MM\\j 



I M ) 1 



N. K.. 



-Kvery Item of in form tit ion Hhould be ciiruirtilly Hiipplicil. ACIi nhiMihl be Ntnteil lA'ACTLY. PHYSICIANS hIiouIcJ 
Htiite CAlJSf: OP DHATH in plain terniH, thnt it mny be properly claHHified. The "SpcwiHl InV'orni.itlon" for per- 
sons dj in^ nwny from hnmu Nhoiild be ftiven In every inNtnnctf. 



I » 



iiii 









li 



: I 




^wi*:^^^^:^ 




li 



fr. 



Hji 



i 



I'l 




write: PLAIN! V \A/ITUJ lllviirAr^iKi^% 



I!. .-Ill I \, 






-. r.^,,^^ ii^rv— inii» IS A PERMANENT RECORD 

RgPER TO BACK OF CERTIPICATE FOR INS TRUCTIONa 



\ I>75 



XteLv*.^ dUuu Deputy Health Officer 

DEPARTMENtIbF public HEALTH-City and Countv of San Francisco 



Ccvtificatc of S)catb 

I X\. S. Stan^irC i 

% Si (^ 

^. ^o*va>vcuco City of -^a^v Jva^vcuacc 

^" ^"^ ''^ kL^"^^'' St.; 3 Dist.bet. 3.vd. ,„d Hti 



PLACE OF DEATH:-County ofOxX>^ .ka>vcu co City of ^ a .v'^' 



(0 



FULL NAME 



QA^i, 



I 



tX'O-lvCtk 



( 




d 



^ 



^^ 



PERSONAL AND STATISTICAL PARTICULARS 



-J- 



X/>r\x<X 



' !• Ml 



X 'kv b 



\' .I' 




MEDICAL CERTIFICATE OF DEATH 

i> vn. (1) i.i: \i II p 



''M.piitht 




I I J.I V) 



^fcH 



Ho 



a 



ai 



I • .1 ! 



/>,! 






^'N«-i.i" M\i<kn.;i, 

w iix iw I I, , ,i< i)!\( ,1^. i: I) 



.1 lll';ki;i:\ C i:kTII-\-, TI.,.t I ;,ttr„,Ir,| ,1, .,....., I ,,..,1, 



liil-'Tii I'l. \.|.; 

' ^i i?. ,• . •.,iiiiti \ 



N \ Ml 1)1 
I ATIII.K 



nikriiii, \( I* 

<»'■' I AIIN'R 
'^l.'lti ,,i f.Mllltl \ 



■^I Mi>i;\ NAM) 

"i M'Tiii-; i< 



itik TMi'i. AC)-; 
•'I ^t<>^ln.•I< 

'^l.ll- Ml (,,,|Illl\ 



" * 'I'^Tln.N QjV- 








■■'imI tli.if .I.ath Mcciincd, .m (I,,- .!,itc stat.-<l ,-iI,.,vr. ;,i I \ 
^.^ -^f- ''■'"• ^"•^'^'■- />^' "'■•All' \\.'- as loIl.,ws: 




hi k Alio. \ 

c "N'lR IMI T( )k\ 



\XwyvCA ^<rcA> >v 



/^/l 



/ f(UH 



trvvX 




i)ik.\Ti<»\ ;;w; 



h'r^idfit in Sin, / i .i in i -,,1 3>^ 







( SIGI 



lV>\; 



M.D. 



Special information ""'v lur llosiiildls. Insfilulions, [(.msifnts 
or l?c(Tnt Rr'siilrnfs, dml prr^ons dvin| a'*,a\ troii honif. 



M.nth 



formpr or 
lsii.»l RtsiiJfnre 

Whfn WHS dispflsr (onfrridrd. 
II not at pl^rc ot (li'iflli .' 



Hon |on(| <if 
Pld(f of l»»',i(h.' 



D./VS 



' *",;,)'!V^'''" '^''' '''''''" ''»'''<^'>NAI. I'AKTU II \Ks \i<i, ) |< ( )■ y, , |)|)- I I 

Hi-.si oi MN^xnw i,i;i)(;i-; A\i> m:i,n.i' ' 



' IiiriMin.'iiii 





'I "1 \< j:.M' in \i. 



\.!,li.-,. 



I M>l,l: I \K Ik 



MR I \I. OK I; rM> i\ \l, I I) \|:i 



■N. H.- 



-livery item of informiition Hhruild I) • ciirclr'iilly Hiipiiliod. Aiili hIuhiM ho Ntiiteil fiXACTI.Y. I>»l YSftJI ANS Nhoul«i 
Htiite CAlISi: OF DI:A TH In pliiin tcrnm, tluit it mjiy he properly cliiHHiiic«l. The •*«;»eciHl InlformMlion" for p»r- 
«on« <lyin|t awny from homo Nhoiilil he Jliven in 9\nry inHtnnce. 



'! 



i! 



. I 






>-> 



iji^^ 



T^^'- 



. jiteK*^- " 



T 



..Jl^-* 






M 




I 







I 



WRITE PLAINI V lA/ITU I ii\ir>A r^.iki^ . m. .^ 

~ -.-r,^,„v;, M^rx— iMlii IS A PERMANENT RECORD 

— R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

th Officer 



Mx^ 1uam.|, Deputy 

DEPARTJIENr OF PUBLIC HEALTII=City and County of San Francisco 




No.^H5 



Certificate ot" IDeatb 

( 11. 5. J5tant>ar(> .) 
PLACEOFDEATH:-Coun.yof0a>vv ' . . City of'"' a >v -l\a 




•'^^>\' {}<x'^ 



^x{l 



FULL NAME 



C^^l\ , 



PERSONAL AND STATISTICAL PARTICULARS 





: II 



Kui^ 



\| .I-: 




MEDICAL CERTIFICATE OF DEATH 

I'A I'l-. (>!■ I '! \1 II 



lulUll ' 






A^% 



0^1 vt 



...S 



n.iv 



/r^' 

^\".-.i 



XI 



-n 
O 



1 



» t ill 



/'./ 



^'N'. I.I" MARK I I'll 

'^^ '"• i" l.-MS.'ii:,ti,,til 1 



ItlKTU!'! \ 1 



N \ M 1 ()i 
1 \1 II I.K 



'•'IKIll Pf, M-}.- 

'»'■■ I A 111 J.; R 

(State or ri.initi \- 1 



'" M«»TII1.R 



'snniii'i.Arj.' 
"I mi»!-|ii;n' 



-A ^ 



XMfYUX/\ 



that I la^f saw h L»\ .ilivf oil OX^xtT ^5~ Xun H 

ainl that .iratli ..,-,•!, ricd. ,,ii (Ik- datf statrd ah-.v.^, ,,| vl.^>fc I 



^'^(KtoykvwO ^I}x<L^.<xxU. 




I )r RATION }\,u 

I ( ).\ TR ii;i'r( )m 



. I /,"//// s- 



/hn 



//, 



'/(/ v 




vr^cv 



U-tV»V(3ynM 



I >r RATION );•</;■.? jr,uit/,s /\,y 

(SIGNED ) H ■ ii: ')t-LV^cQ,L\^dU>u 

04^ ^^ ''/""^ ' \.lWrv<si ^l 1 ^ ^JXO\f: 



ffiUI I \ 

M.D. 



Special Information oniv tor iiospiidK. iiisfi^jfiuns. irdnsimis 

or Retrnt RcMiIcnK, dnd persons dyini} .imhv lro;n fiomp. 






lormrr or 
LNiicil KcsidrfKP 

When Hds disease (onlrHfled, 
If not ,tf pl,i( e of derflfi .' 



lloH long lit 
Pld<pof Dfdfh? 



Ddvs 



'''uKSTm; Mv'u^;!;.!;^'^^^^^ m<i: .•,<.,: ,-.. ti.k |^,Ac-KnF "rKiA^^..K ukmV.vx,. I nvo,,: ,..,u. .„ n,.:m..vm. 



Oi 



lil.M (>|.- Mv KNDUI.IUX-, }•: AND I!]:i,Ii:i- 



I 



xMi.ss I lb LL'Vu^YVj 






awutda 



\I)i;k'iakj;k VV UJ i i lOACtv\i ^C Lo 



' \.|.1p 



31^0''^ 



IN. B.- 



-Jivery Item otf InformHtion fthniild he ciirofully Hiipplicd. \i\V, Hhniiltl he Htateil hX ACTl.Y. PHYSICIANS hIiouM 
«tnte CAlJSr OF DflATH in pliiin terms, thiit it miiy be properly cliiNshMed. The "Speciiil Int'onnat ion" ^.r per- 
sons clyln^ iiuny from homo Nhoiild be jjiven in ^\^v}, instnnce. 



-oil 



\\ 



j^OnaJi^* 






\ l^ 



m 



If 



i I 



ii 



t . I 



m 



.i:.' 



WRITE PLAINLY VA/ITW i imc-a m m/^ .«..^ 



V. 






ihi/r /'VAv/, jxU,ti>^vUv al 




//y^yH 



• His, IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ct.^ 




]l('gl\sl('fC(/ ^Yo, 



f 



- •' if 



u 



' f> •• 



DEPARTMENT OF PUBLIC HEALTH-Citv and County of San Francisco 



Gcrtificate of IDcath 

( n. iT'. ;^'tnn^nr^ i 



PLACE OF DEATH:--County of^^a^V J \a>lCUC<)Gty of^a >x/:i \a nCt4 CC 



N 



o. l'^'\ Lt\x^'t>vt^i 



St.; I Dist.;bet. J^LV'lCA 



( " "-^v^::^-v^^^^ ^i^±^^^z:-£'^^^ :-±v: ---^ .■-." 



and 




a;L^yu 



.^ .-v,.o .,«LutL. M.H UNDER SPECIAL INFORMATION \ 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



FULL NAME ^^aWu, O.iJji^xcuSj 



PERSONAL AND STATISTICAL PARTICULARS 



!.\ 



*.' II. ( )K 



.au 



■vt 



i 



MEDICAL CERTIFICATE OF DEATH 

DAl'l". (II IM'A III 



Ifolltll ' 



It) 

l);i\ i 



%{\ 



Mciitli 1 



11 






V' .]•: 



(^-s I iJj{Ri':i!\ ri:RTii-\-, T! 



l.l- 1 

\ 



"^l 



that I last <a\v li X'>'>A aljxr 



I"! 



17 



^■^'■i.i-:. M \uk III! 

WII). .\\|. I. ,.,-■ |>|\, ,K. (.. !) 
^^ It-^ii'iialiiiii) 



iilKTlIl' 



. M 1 



Mini I \ 



aaiL vl >\ c.^ J^ '^'xLc >vaA.v 



'■ill ,Ci| I IciClNi', I I I, i||| 

ami that iJiMtli < mcii rrcl, rui flu- dalr sf,,ii'.l ,i!M.\r, a! I- JO 

V ^\r. Th.- CM sr. (»i- j)i;.\ i-ii u.,. .,s tnii,,us- 



■\ 



\M1 <l| A 



DCkA ri( ).\ 



•^U^wt 



yVilJy ^ }/.-!:///.\ 



l\l\ 



//r 



nil 






'" M'>riii: K 



"ll<Tl| I'r.ACK 
'»!• .M'iriii.;H' 



\ 



CHlt 



^Tyj 




(.'ONTKir.ir* »K\' 



I 



aA.3 




DC RATION 



a\ic \JuaU 



w 






/>,/! s 



// 



-SIGNED) VJ J'L LV-^C>1^ M.D. 






at5 



Special Information "niv f.»r fiospitdis, instituiions. rr,insinits. 

or RetrnI Rcsidcnls, diid persons dving ,iw,(> fro.Ti home. 



Former or 
t'su.)! Rfsidcnrp 

When was disrasr (onfr.Kfrd, 
If not ()( pl,i(f of dciff) ? 



HoH long M 
PIdff of lledth.' 



Odv* 



■'■".I. \Hu\l.: STAT I- 1) I'C-RsoWl, I' \ k T [C r I. \ K n A R ) ; TRi i i, , i i,).- 
"CM OI'MV KN(»\\ ),);i)«'. K AM) i!i:Mi;i- 



Mil 










\ri: (,)|- ink! \I, MR k IM. i\ \l, I n \ L) , . |;i „, w .-: Ri.MitV \i 




y 



M)1,R r AKlk 

'AiMl.'S" 



1. ^J(vrL^aiv 
t' Jos (>>V^>.l . ,1 



roo"^ 



N. K. 



Hvery Item «.V i ii form iit Ion ithoiild h- cjircV'iilly siipriliLMl. MiV. nhnitld lie Htiiteil l.\4CTI.Y. I»IIVSICI\NS Nhoiild 
Htiitc CAllSi: or ni:A TM in philn terms*, thiit it mjiy l>o properly cliiWHllietl. The "8|)ecliil liOVirmut i-.n" for pwr- 
Rons clylnil iiway from home Nhoiild be ftiven in every inNtnnce. 




I.' 




'* f 







. I 



, I 




iim 



||:< 






1^ 



WRITF PI AINI V lA/i-ru I I air- A r^....^ ..... 



/v.//r /•y/rv/.i^^tu^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



V 



^^\j xl 



/fJOH 






Jif'gi.siercd Xo, 







DEPARTMENT OF PUBLIC HEALTH-Citj and County of San Francisco 



Gcrtiticatc of H)catb 

( n. 5. t?t^ll^ar^ j 



No. 



PLACEOF DEATH:-County of Oa^v ^1 \a.vCULcc City of^W.x ^1 \avA,cc4C^ 

r - n„,„ OCCUR. .wV, .„o« USUAL RE^.oVNrr D'S*-! bet. ^ UX< I. .IndllCVtlKlV 



FULL NAME 



.d 



a' ^ "uLyLT>\xxX> 



PERSONAL AND STATISTICAL PARTICULARS 



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mi. .Mill 



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MEDICAL CERTIFICATE OF DEATH 



DA 1) 



D.M't 



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M.'>,!h 



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!»IK' \Tin.\ )',,//v .^^niths Pays 

(SIGNED) UUWvS n 10 1'^.Laiv^ 



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Special Information "niv tor iiosimi.iIs. inv(it(ifi<»ns, rrdHMfnts, 

Of Kpfcnl Rf'sidcnis, .nifl persons dvifi'i dv»,!v fro.Ti homr. 



1/. -fii 



formrr or 
Isu.il Rcsidcnrp 

Whrii was dispijsp ronlr,i(fpd, 
II nol <i( pl.in' of dPiifh? 



lloH long .it 
PIh< p ot flcilh ? 



Drtys 



I 111 \l|n\-J.: sr \|-,.;i, |.,,;j<s,)NAI, I'AkTIcri.AKS AKi; rKI}: T<» \ll\: I l'I.ACl<: Ol lirKi\I,(»k Ki:\Iii\\i I DVIJ ..• i:-i"\i ,,i k I \t( .\ m 
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N. II. Kvery item of itifdrrniitinn Nhoiild !>.- oirtilrully KU|>plie«l. ACIR Hhoiild he stjitcd JiX \CTLY. PJIVSICIANS Hhotilti 

Htiilc CAlISt! OP DLATH in pinin terms, thnt it miiy he properly i.liiHHiritf il. The "Si)e>.i«! Inidnniition" for p«r- 
Hon« dyin^ nwny from home Hhoiild he Jiiven in G\iiry instnnce. 









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WRITE PLAINI V \A/|-ru 1 1 ivi c-a f>. i^.^ ...., 



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iHlS JS A PERMANENT RECORD -^1^ 

"^''^^ "^Q BACK OF CgRTtFICATE: FOR INSTRUCTIONS 



xM^iV) ijuvvL 



liCiJi,s((>r('(l ^Yo, 






i Deputy Health Officer 

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

Certificate of Beatb 

' tl. S, St;"iiic>iU^ I 



PLACE OF DEATH.— County of^a , Ka^vc.^Co City of ^CL^x \a 



No. 



O'-Via 



O 1 



1\ CL<i Co 



m 



FULL NAME *-UlNJ!yrL.cX v'^WXovCl 



PERSONAL AND STATISTICAL PARTICULARS 



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Mb 



M.iUlii 



I):iN- 



MEDICAL CERTIFICATE OF DEATH 

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I) r K A T ( (• \ 

Special Information ""Iv tur iidsiiii.iK. insiituiidns, ir,)nM>nfs. 

or Rpirnf Rcsidcnls, .ind persons dvinj .iwrfv fro:n home. 



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formfr or 
Usual Rcsidrnrf 

When was disp.isp (onfr,irlfd. 
If not .il plarr of drnffi ? 



lloH lung ,if 
PIdff of Of-iffi .* 



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-Kvery Item of informiition Nhmilil !>.• ciipuV'uM.v Muppli(.-<l. AfJK H^Diild be Htnted l.\ \CTI,Y. PHYSICIANS nIiimiIiI 
HtJite CAUSE OF Di;,\ TM in pliiiti tcrins. thjit it mjiy l»e pr«»pcrl> cliiNKit'icil. The "Spcciiil Ini'oriiiHti'in" »'or per- 
son* ci>'!n£ nwny from home Nhotilci be i>i*eii in ^\^ry inHtnnce. 



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WRITr PI AINI V \AnTI_J I Iivir-A r«. K.^ 

~ " "••" --'^'^^">'^ «fMr\ — THIS IS A PERMANENT RECORD 



i:\ ! 



d^>(rvoui XxYvu Deputy ■ >h 



^;£rE^R TO BACK OF CERTiriCATE: FOR { NSTRUCTIQNS 



1980 



h Officer 

DEPARTMENT of ::SLICIiEALT 



Qi^ and County of San Francisco 



Certificate of H)eatl) 



' 1:1. 5. Stnii^ar^ • 

4 (>ri 






Qd^ 



PLACE OF DEATH:--G,unty of CW>v J.^^wxc. . , City of do.^ ixa.vc. 



No. H ■^ ' H-a-c! vv. t , 



^i-i. .^ Dist.; bet. Ct/w^u-WVL .indMjXxti 



"■ nrftTH OCCURS awav from USUAL RE*.I DE ivicr -lur caz-Tc. ,... 






FULL NAME U 




vCrurru 




PERSONAL AND STATISTICAL PARTICULARS 



- 1 \ 




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Ul.4 



MEDICAL CERTIFICATE OF DEATH 



Sb'( 



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10 



tli;it I last -,i\v h ~ — alive o-i 
aiiil ! hat ik'a!]] < >r('inT( 



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Signed > UiVcnwrv. J. •■." U 



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M.D. 



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U>-Vfr>xi.»L>A V.^UvO. 



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Special Information "nJ.^ u^ ih.vM.'.;u inJ,»,fihfh, fr./(isirnfs 

nr Rerenf Residpnfs, .ind pprsoris (f)jii) ,ih,iv fro.ii ho-nf 



) . ■,'/ . 



M'H'Ik 



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formpr or 
Usual Rt'sidcnfe 

Whrn was disMsr rontr.irffd. 
If not a\ pidfe of dcilli .' 



How loni| ,i( 
PIdff of flcilfi .» 



PdV^ 



HJv.si oiyiiv K\<.\\i,i.i).-, J.; AM) iii;i,n:!' JD \ ' 1] 

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"^^ ^' Rvery item of inPormntion shoulil b;.- cnrcfully siippliL«l. AdB should ho Htnteil f'.X \(JTLY. P»I\SICI\NS Mhould 

stntc CAlJSfl or OflATH in plain terms, that it may he pr..perly cl»H.Hi»'ic»l. The "Special Inlrorniiition" for per- 
son* djinj* nway from home should be feiven In every inHtnnee. 



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write: pi AINI V ia/itu I iiiir>A p^.i..^ 

" - — „„..vv^ N'.^ — THIS IS A PERMANENT RECORD 









REFER TO B ACK OF CERTIFICATE FOR INSTRUCT IONS 

Jirg/.s/r/rf/ .,Vo. 



1 9H I 



DEPARTMENT OF PlBLiC tlEALTH^Citj and County of San Francisco 



Certificate of IDeatb 

( U. S. Stanza rC> ) 



PLACE OF DEATH:-County of "a^^ Ct .^a^xCt^ c^Cty oPV V ^ 



1^ 



S^% Jl 




^cl^UU db O^Wci-ol St.; - 

/ ir DEATH OCCURS aJsv FROM USUAL R E S I D E N ' 
V IF DEATH OCCURRED IN A HOSPITAL OR IN?;riT. 



x<xL 



\- v' \.ai ^ ^"^^^ 



"^A. 



Dist.; bet. 



and 



OS.,,.. o„^f^s^^."j;^orj,;.-;i -.T.-i ,r.e"."°^? s,\%%=;-.^-r:-rr ■ 



) 



FULL NAME 



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PERSONAL AND STATISTICAL PARTICULARS 




CLVcL 



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M"iitli I 



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MEDICAL CERTIFICATE OF DEATH 

I>\T1'; ol DI'AllI 



iMf.iih 



i 



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^I\'<'. I.|- \I \|< K II I» 

'\Vi;t< in ^. ,ci,i! <i«-si...iiati..n) 



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^ ^ mi: 1)1 
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'State .)! rmiiit ; 



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ni- M()'ini.;K 

(^talc or (."omitix 



occrc viiox 






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tli;.t I last siw IiX\; alivi ..„ OXivt ,^S ,,,^ 

.iml tliat <kMtIi oci-iirrc-d, -.11 Ihf -i.i'c M.i;< ] .,, ,■ |i30 

yj y\. Thr c.\' sh Ol' i>i;.\rii U.I. a. (■>:;,..,,.: 



'" 'NATION ^''^''-'/^ -Vonths 3> pay, jj^,.^, 

"I'-\'nn\ )V./r.v JA;;/Ms- 4 /)./i. //.,-,;, 

(Signed^ O.VxcLk LL ^^JU.vlaU. m.d. 

Special lISirORiVIATION "fiv tor (l..spifdl<^. InNlilulions. fr,tnsifn(} | 
or Reccnl RfsidPnfs, .md per'^ons dvinj dwdv fron homr. 

Formpr or 
llsii.ll Rcvidenre 

Whrn vvds disease ronfrrirfed, 
If nof fit plfii e of dedffi .' 



3 1 1 VJAX^cda; Uv»^ pi!,!*e ",?Vlith .' 



6^ 



l),)V 



1 in: \U()\K sT\'n-:i) i'kkson \i, pARrhMLAks art: thi}-: m rmc 
Hi'.si oi.- Mv Kxowi.i'Dc.}-: AM) i!i:mi:i- 



^Iiif.irni.-tiit 



V * ^ 



\<Mrt'>is 






I on 



I'LACK <tl mklAI, «»K I<i:Mm\ \i. | l»\Jj.:,,' \\■.^>^x^ ,„ ki:m,,\ \i_ 



''^* ^' Kvery item of informntion should b^- carefully supplied. AdF. should be stnted F.XACTl.Y. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, thnt it msiy be properly classified. The "Speciol Information" for per- 
sons dyin^ nway from home should be A'ven in Q\^ry instnnce. 





W^Writ^ 



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it 



\A/RITr Dl AlMi \/ \Miii-t, 



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>■-;; -is-. :,;■ ll<s;i. r., 



-.^.rHUMNU INK-THIS IS A PERMANENT RECORD 

"EFER TO BACK OF CERTIflCATE FOR INSTRUCTIONS 

^VAt^ l.v,, Deputy Health Officer 



/)',/,' riicii. lL|\tx.uxU/v XI 



1 982 



V ^>V 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate o( S>eat(i 



PLACE OF DEATH:-County Js<x^\ \a v,Cc4cc City of ^^'a m'^^cc^ 



,'V cca C-C 



No. ' a ^- 






va "■) 



FULL NAME 



A.^v^a. ^Oxttio 



PERSONAL AND STATISTICAL PARTICULARS 



i;ik 1 M 



IttYU 



\t,,,,r1 



X 



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'\\ iitt in s.H-inI .!( •,iiMi.i(i..tii ! 



1 



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"IK Til I'l. \ri- 

Of- i-Ariii:R ■ 

'Strife ,- r CmiiiIi v 



^' M!)i;n nam I, 



HlkTlllM, \r |- 
'>,!• MoTIII'Ik' 
'State or Cnmitrv 






ll)vci^ 



VKS- 




, r 



MEDICAL CERTIFICATE OF DEATH 

I>A'l)': I »1 111 \ Til !j 

Oxivt V\ 

^' "|.:ki:i;\- ri.K i li \, 11, at I .iftrnilr.Mc-.v.i.e.i |,,„i, 

i^>v ^ i^pM to ~Vl^* 'Xl ,,oi 

lli.K r l.i^t saw liJ,V alivroii IX^xtr'Al ,,^,, l| 

Mil. I Ihat .le.iMl ..crill rc'I. ..!i I l,c ■! ,t,. ..',,. ,..| ,,l.,,\e, il (: ■ '"^ ». 

^y -"^I- The CAIM. oi DiXiii vs. ,, rnMiius: 
'""''J ^'I'ON ;;v//A-. .?A';////v /;,/,, I //,,;. 



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C'ONTRIIMTON 

Dl K.\T!( )N 
( SIGNE 



(VI. D 



o 



' " 'i rAIIuN 

h'f'iilfd I II Sit n I'l ,! II. 



'x.V">^\(xn.u 



Special Information ""^ f^r H'»s|)if,iN, insfiiuHons, fr,if)sil'n(s 



or Krtcnl Rl'^iiJ('nf^, .iiid persons dM'n.) .iu,i> frtm homo. 



1/,./////. 



/',/i 



former or 
I'sii.ti Rfsidrnce 

When W.1S dispdsp rnnfr.Hfrd, 
II no! <i( pl.i(f ol drnffi .' 



HoM long .if 
Pl,i< (' ol ()r,ilh .' 



Ohvs 



' '".;,^''.V^''''- ^''"^''"''■" '■'""'^"^••^ \'- 1' \'< i'i>'''. M<^ M< i; Ik! r I'l » riu-: I i',i,\(,i: oi m Rj\r, id^ k);MM\\i, I dxji ,,; iiii.i\, ,,, ii\t,,> \r 

H1,M ()!•■ My KNOW I,i;i)C.l.; AM) ini.N'i- I jO I I 4 I 4^ '•-'•^' ' M. 



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at 




I .NDI.k r.\ K I'k 



M(K3NBWi -■>«« 



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N. B. F.very Item oV iiif<)riiuitIon Rhniild h- ^jirefiill.v «uppli>.Ml. .\V,\. s!ii)ulil he .stntcil l.\\CTI.Y. l»»n\SICI\NS Khoiiltl 

Ktate CAUSE OF DHATH in pljiin terms, tluit it m:iy he properly ciuHHified. The "SpcciHl ln><)rmHlii»n" for per- 
sons dyJn^ nway from home .should he A'^'^n in oery instnnce. 



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WRITE PLAINLY WITH iiMrnrniM 



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r-i hi^ • I n >wi 1 1 n r\ 



1 \ ••-ST— - • i>c •) ,• 



/)ff/r n/rr/ ,'^x\\^^^^^{w>J %% 



1!}()\ 




ini2, i-j A PERMANENT RECORD 

REFER TO B ACK OF CERTIFfCATE: FOR INSTRUC TIONS 

liegi.slenul .Vo. * 98-3 



^vcu axxHu. Deputy ith Officer 



DEPARTMENT ()F PUBLIC HEALTH-City and Coiintj' of San Francisco 



Certificate of SJcatb 



^ 



PLACE OF DEATH: -County of Oa>^ Ka^vcucc Gty of'U.M ^\a 



I 



^°- ^'^/f..^>„b^'^''^' St.: 3. Dist.:bct.^acVa>.Uvvtc.nd Clau 



i^ 



FULL NAME 




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PERSONAL AND STATISTICAL PARTICULARS 



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u 



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M' nth 



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MEDICAL CERTIFICATE OF DEATH 



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6x kt 

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X'.)'! 



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1 iii':ki-i:\- r!:kTir\-. That i ;--.•...'. ,i ,k> ,.s,,i i,^,„ 

I(>() 1,, i.jo — 

lll.lt I I.ivt ^;|U h - ^ ;ili\((»ii , , 




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>Vliti' ill w,n-i;, ; ,j,.^; 



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M.^ Tlir CWi Si': ni' I»i: ATil u,.-~ ,,. IwIImu.: 



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1)1 RATION );■,//>■ 

t'( »\TR I i:i'i( )k\' 



1)1' RATION'^ )\urs 



M.'tilhs 



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.Won f /is 



'■■fri 




(SIGNED) XvcrliVv.ck J. laA\.>_.. 



IVa..' 



Ho It) s L;> r' 






\'ll<).\^'^ ■ Ij 



Special Information "nK for ffosiiiMis. inviitjiionv. Fr.insirnis, I ^><^ 

• RcrrnI Rcsidrnls, dnd prrNons dyinij ,m<i> from fionie. \„^^ 



^ /', 



Former or 
I'sucil Rfsidence 

Wlipn wds disriise ronfrdt ted, 
If not .i( plaieof ArM ? 



f)d>' 






Nii: \H()\-i.: ST \'ri-:r» I'KKsoNAi, !• AKTicri, Aks Aki-; TK r i: ii I iiii'; I I'l.xt'i; t»i' imkiai.hK' ii:m(i\\i, | \)\X] .,< w-. ^ , 
in-.sT oi .Mv KNnwij.-.Dc.H AM) i!i:i,n;i-- (J "\ \ I r I -A ! 4 



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I :^bn-ivtfv,lt 



'\.!.!f. 




^' "• Kvery Item of !nfi)rm»ition nIiouIcI be cnret'ully supplied. M\\. H?ir)iil(l he stntcil liX'XCTI.V. 1*11 VSICI A'NS Nhoiild 

stntc CAUSIl Ol' DI;ATH !n pliiSn tepiiiH, that It miiy he property cliiNKit'icd. The "Spccliil Int"orinnli'in" for per- 
son* dyin^ nwny from home Nhould he H^iven fii every iriHtnnce. 



r/WMS*'. • 



. Jti>»r-W. 



!^f< 



III; '^ 



il 



.V. I 
■'t! 



Ill" 







M 






i<! 



«>••« 



mi 



WRITE PLAINIV lA/ITU t t^tt- ix r^.m,*^ ..... ^. . - . 

~ -.- r^^M^v, iiMfN— iHiii rs A PERMAIME/MT RECORD 



1 I 



i;\ !■ r 






RCPER TO BACK OF CgRTIFICATE FOR INSTRUCTION! 






lirgi.s/ci'cd A^o. 



1984 



Deputy Health Off] 

DEPARTfflENT OF PUBLIC HEALTIl-=City and County of San Francisco 



cer 



Certificate of £)eath 

( "U. i5. i^'tan^ar^ ) 
PLACE OF DEATH: — County ofO^>v vrvo..,vX^U,aGty of^l(X->v: V<X^ 



No. 361 



ti. 



I D "Ltv 



% 



\c<^<^c 



St.; y Dist.;bet. A. aWtAlCrW and JcrUcr^^v 



( '^ :^^:;:;T^^^cc;«^v.-^:^^t r^^?^;:^^o^'- -^i? -^-t^^^ -^ --. s..c,. ...opm..o. 



GIVE ITS NAIVIE INSTEAD OF STRCET AND NUMBER 



) 



FULL NAME L 






I \ 



PERSONAL AND STATISTICAL PARTICULARS 

.■(ii.tiR 



CL- 




a-L, 



! "1 r. I Kill 



\ ' . !•: 



CtV4 

M.iiitli' j 






^ 



n:i\i 



) -.; 



^ 



I 



' "t't a t 



/\) 1 . 



^i"' 1.1" M \Ku irn 

U Mm >U IM) OK I)r\-, iKiJ-M^ 
' \\ 1 iti' i 11 xoiia) ilt-.i'.-'iiatii.ii) 



HI'-;!'!) n, \.*i- 



Mt ! \ 



\ \M1- ()| 

I- AT in; k 



'tIKlill'I.Ari.' 
OI- I'ArHHK 

'"^t:it.- or Coiinti V 



maii>i-:\ N'AMJ- 



l'.!KTll'.i_ \.l. 
•M- MurilliR 
(Stiitf or C'<.\iiitt v) 






MEDICAL CERTIFICATE OF DEATH 

I'ATl. ' 'i IM:A III Q 

n I Ili{Ki:i;N ( I.RTll.-\-, Th.it I ..ii-wi.Uil -Irr., ,-,,.,! i,,,,„ 

tliat r last saw IiA U\ ;,livc on " , t 1 I t ?>6U }H i,,o H 
■ iikI that (ifiitli orciined, (MI tlic (laif <f,itiil i!u.'.,, ■■ /0-^C 
LV M. Tile CA(SI{ (»)• |)K\TII \\;i, a- (r)lj,,us: 



LLeLAjtx \crt^ 



7^ 



XaV J > Vj^. LL A M (> ^ V\^<X.J 



VCC^CX> 



(\ 



'ac 




^ 



\ 






1: -\ !.. 

t 



^ 



DC RATION 
C'ON'l'R IlMTol 

1)1 RATION 
(SIG 






Months 



/^.n^ Ifi //,,,v; . 



) •> ^ \ Ml > lit /is 



'S 



IllUt) ^ 

M.D. 



V 



t)e\:ri'Ari()x 

t\ry!(ffi/ III S,n/ /'/ a i/i /Muf 



Ka^VixiX"vvu<\' 



NED) \. ^^l^ty^tAl.| 
Special Information '>n!v for iiospiidis, in>(jiiiiionv. irdnsimis. 

or Rpcenf Residents, dnd persons dvinj dw.iy froin home. 



former or « , -I- P A 

llsud! Residence ^^07 ' lO^'L-tO 



1 HoM lon(| (it 
t Plare of Oerftfi ? 



Od\S 



I Wtien wdS'disease contrdrfed, 
!v,,,v 4 lA-y////. 3, /^"'> I If not df pidfc of deaffi ? 



I'ln: ATioVI-: srATin) i'l^KSOXAl, I'MMICII. XR-^ AK!:*TKr}: III ri!i; I ri.ACKOi' m-RIAI.OR R1;M(I\\I, I DAIKm; I!! k[,u. ,,t klMi>\\i 
lUvsT (.|.- Mv Kxowij.nc.}.; AM) ni:i,li;i-- IQ^Q r f, I',.. -X 1 -*. 



'"Info'in.-mt 



I'XdilrcKS 



»«il', AM) IW.l 

^OT ^ I oil a* 



N 1 ) }•: K T A Is 1 : R l\X^ dL^ '^ -AwX\. '(•C'G 



rx.l.lrcss 



N. B. Kvery item of informjition should be careY'ully supplietl. ACH shoiild be stJJted EXACTLY. PHVSICIXNS hHouUI 

8tnte CAUSE OF DEATH in plnin terms, thnt it msiy be properly clussiitied. The "Speciul Inlt'orni»tii»n" for p«r- 
sons dyinil away from homo Hhotild be ftiven in every inHtnnce. 





, » 



:TSMm 




!!• 




• \ ! 



) :/ 



I 



H^ 



WRITE PLAINLY WITH UNrAniivin ttau - -.-i^..^. .^ . 

"- •■"^ inio lo M f-C.KIVIMfVt!>iT RECORD 






REFER TQ BACK OF CERTIFICATE: FOR INSTRUCTION! 



1 



Jicgislcrrd A'o. 1985 

tru.v^ Ltv-u Deputy Health Officer 

DEPARTMENT OF PL'BLIC HEALTH =Ci> and County of San Francisco 



Certificate of iDcatf) 



PLACE OF DEATH: — County of Va ^v ' \a>-\CKWU) City of "'a v,^ \ a >x Cul c o 



inty of 



(^ 



No. • H ^ I 



\ ik. 



St.; 



. 'r 



Dist.; bet. 



m 



^^^.c<nv and I'aU^ 



( " ,7nr*'«.°''^'"'^ **•'' '"^'^ USUAL RESIDENCE GIVE facts called roR UNDER -SPECAL .NTORMATION \ 
V ir HEATH OCCURRED ,N A HOSPITAL OR INST.TUT.ON G.VE ,TS NAME INSTEAD OE STR E ET A N D N U "u E R ) 



vClO, 



FULL NAME 






\-v^v^ ! a>vL.^U.cr>\i 



PERSONAL AND STATISTICAL PARTICULARS 



'i i.iiv ni 



i."k \ 



1 



M-ntli 



a^kci. 



A-Cl 



'Davi 



/ 1 '1 1 



MEDICAL CERTIFICATE OF DEATH 

I 'ATI-; III Ki: \TH 

1" 






'^ 



I IIHRKHN I IRTlI-y. T!i,i;^I ..tU'iPKil .1 



\' .!■ 



L 



1 ', - 



^IN'<'. I.K M \ k K III) 
\\'v\Xt ill ..K-i.-il .U'sU'iiatioii) 



J.L ^^ 



'^' ' ' • ' ■ Hint! \ 



A„„^' 



evil 



I \riii-;K *- 



nn<Tin'i. AT}-- 
oi- I ArFii:k 

' St.Mtc or CMiinti \ 



MMIil'.X NAM).- -. 

' '! Ml I rii |.;k ^ 






^' ^ \-Aj "XX IgoS tii '^J^\<t 14 

that I l.ist vaw h tV aliw.ri V ^ !. ..t '^H 

and that (k'.tlli (K^urrcil, (Hitht -taird ili 

^L ^r. Thr CAISI'; ()|- i)j;.\TiI u.,. ;,. iv,:', .. 






a^w^^lAytrVv 



^ 



DIRA'rio.X )V.//s- 



./A •'//// .^ 



/></! 



// 



Llm^oUlav 



i 



<>!• M<»rm;R 

*S(;i!( .)! r«)iintl \ 



">'''tl' Aliox 



^1 L^^CIXVV 



■>v^ 



DIR A'I'K »\ 

(Signed ) 




" I' . . ... 

M.D, 






li 



U i' -\ 



I 



Special Information "nu fur iiospjidis. invtuutiunx, frdnsienis, 

or RnenI Residents, .ind persons d>inq away frrni home. 



AV' >.'(/'•.,' ,'// V,;;; / ; , ; ;i/ 



b 



R ,■,..-/,. 1 „. 



Former or 
L'sufll Residence 

When W3S disease ronfrarted, 
If not af plare of deatfi ? 



How lonq at 
Plare of Death ? 



Da*' 



Tin', Mtovi'. s"i"Ari-:i) pkr^^ov \i, i'\k ru'ii, \rs Aki-: rkii-: i' » ifiJ-; 

ItF.ST ()!•• >.jLy KN'(»UI,i:i)C. }•; .J^M) I!iiI,Ii:i- 



^'iif' ' tn.'iiil 







iyy\j 



s 



LACIC ol' IMkl.M, Ilk k i;Mi i\' \I. J li\Tl' ■ kl'..Miii \1 

"UWt 'bo 



I ,1 



l.\<]'l'.--^ 






190^ 



I .N-i,i;kTAKj;k ^\<XUX V.:^clyvCC'%\; \LVi 



N. B. Hvery itom of Informntion should be cnrcv'iilly supplieil. AGB rHouIiI be «tntetl KXACTLY. PinSfCI ANS Khoiiid 

state CAUSE OF DEATH in pljiln terms, thnt it mjiy be properly clossifiecl. The "Special Int'ormntiin" »\»r per- 
sons clyin^ away from home should be ftiven in every instance. 



T""^ 



f 





Mjn4vrj-u^ inuih) aku 




'?^? 





li 



i) \ 



WRITE PLAINLY WITH UNPAHiMrt iMtc 



• ■ » • • • ■ 



I (^ I C M t'tn'p-k »'«<■■•••»«>• ^ ». _ ~ _ _ _ 



li.\:!' r,, 



/.V^A 



REFER TO BACK OF" CERTIFICATE FOR INSTRUCTIONS 

Bcgiiitcrol Xo. 1986 






__ I 4. I ,-» 



huh' h^ifi''/ ,OJd^Xx.y^^h^\J X^ 

DEPARTMENT OF PUBLIC HEALTH=Ci!y and County of San Francisco 



Ccititicatc of Bcatb 



PLACE OF DEATH: — County ofOaiX' 



Nn. 




VCU^-LCUiCC City of O a/ru vj A.a > V'^A.Ci 




H ■ ( 



/Cu^v\X<x\^A^.'^ v\ 



St.; 



r ir DEATH OCCURS AWAY TROM USUAL R E S I D E N C E C I V t TACTS CALICD FOR UNDER ■SPECIAL INFORMATION 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NA 



Dist.; bet. - and 

SPECIAL INFORMATION \ 
E INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



\i 



.a-ivix-u :'l 



C' 



* '> 



PERSONAL AND STATISTICAL PARTICULARS 

.kill 

Vlolllh) I :. 



\« .I-: 




MEDICAL CERTIFICATE O? DEATH 

n \Ti-; I '! ni:.n 1! 

11 



M..rii!ii 



1 ' ■ \ 



y\ 



''^''•'' "1 Ml. , lion) 



J'.IK !-|ll'I. V ]■: 
St:! . ,1 . , .iiiitl \- 



N \M1-; . I! 

1 xTiii;k 



lilUllil'i. \' !■ 

oi" I \ihi:k 

(Sf;iti 1,1 Cnilllt I \ 



^' \iim:\ \ \Mi ,^ 



Oa-y\; J .Vex > 



I II ivK i;i:\' < I RTii \\ rii.it J ;iti.Mhicii ,!, 

t liiil I I.isl saw li • ' ,ili\i- .111 , ' 

■ iiiil lli.il (Ii.iili ( icii rrc'd, lui the .l.iir xi.|',-,| 



I liiitii 



M. The C" AISI'; oi" 1)1 \T|| 



.!•- jiilL.W 









l)(R.\T!('\ )' u/ ^ 

L ( >.\ TK ! Ml T< )K' N 



// 7///V 



/hl\ 



/!.!,> , 




niU \TI( »N 



•1 MoTin l; / 



% 






I'.iinim. An- 

. 11 1 1 1 1 \ 



-t/^VMX^VLVY\Xl; 



Pnv 



xxy- c 



SIGNED' Ll. d. oU^a-^ 

^' i-^-^ ^^^ ■ -^^ M<Mi..s) 3I9O "^X/tAu n 

ills. In\(ilii(i(ii»v, (Mnsicnfs, 



// ,7/ s 

M.D. 



.^1 n 



r<)0 I f 



' " 'I' I' \ IK i.\ 



h'riiir-,! Ill S,iii /'iiiiiiir,i'^ "^ )'i-,ii^ 



SPECIAL INFORIVIATION "'il> l"r Hifspil 
or Kcicnt Ri'sidcnls, dnd persons dyiiii .ia.iv from homp. 



lA. -////. 



/',/!. 



I'll I' XHovj; ST \ ri' I) l'KK<.n\ AI. I'AR lliMI. \K-^ \ lO ! R I I-: Ti • i'lll'; 

lii.sT OI' .\n K\<»\\i,i:i)(,K A\i» i;i;mi;|'' 



formrr or 
UsudI Residcnie 

Wlirn Wfis disPfisf ronfrrulfd, 
II no! rtf pIcKP ot dcdih .' 



How l(in(| .il 
Pl,)<p (il Dr.idi' 



Ddvs 



' Inf.iiniiiit 



GLUUt I SJ^' 



U.Mi 



^hJlL (BUc. i^ Li 



l'I,.>,il': ' 'I lUK lAI, ' 'K I- i \U i\ \ 1. I II .. J I 



I 



iMti;i'r \K i:k 









A,' 



1 \n i\ \i, 
roon 



N. B. livepy itom olf informjit Ion Khoulii bf cnrufully Huppllcd. A(ifi nhiMild he Htiitcil liX \C TLY. I»JI\ .SICI ANS Nhoiihl 

Htiitc CAlISr OF DEATH in phiin terms, thjit it inny be propcly cluHHitMccl. The "Spewiiil InVfir-nnili'in" »'<»r pen- 
nons fij-inft iiwny from hfunc shotilii lie (>iven in every inHtnnce. 








1 


H 






1 


li 


• 



Fr^TT' 



!u 



II 



J I 



\r' 



m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PEJRMANFNT arrnan 



^f^mit 



i !i..ilih IN,, i- t>-?^*-?^^H.Vl' C, 



BE-rf>< ■mmm'^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



HUJ'i 



//rr//.v/r/vv./ .y\>>. 



1987 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Bcath 

oi"^ Cl^\^ ^1 Va>\Cc4CC City of ' '<^ ^'^ ^1 va ^ 



PLACE OF DEATH: — County 

IS^. ..lIiv '^1 Lm^/^^VCu JL yy<li\Ctai St.: Dist.;bet. and 

(ir DEATH OCCURSJAWAV FROM, USUAL RESIDENCE MVF FACTS CALLED FOR UNDER SPECIAL I N FO R W AT 1 O N N 
IF DEATH OCCUBRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OT STREET AND NUMBER J 



IC>L4C0 



FULL NAME 



r 



PERSONAL AND STATISTICAL PARTICULARS 

1,1 >!,i iR 



i' \ ri ' '! IWK 111 \ 



iv^tx 






1 

I i;i\ ) 



,\r\ 



MEDICAL CERTIFICATE OF DEATH 

DATl', ( U l>I-; \ 111 






......i 



•• l);i\-> 



\i 



M 



'^ 



ai 



1 II!':R I:I;N' C I.U'rilN', That l .ilUn-Ii-.I .I<.ras,,l 
that I Ia<l saw h A.^' ah\c on ^ • ', U X 



<»" \ 






I! IK' III I'l. \'■l■ 




Ml (M 

I'll i:k 



I'.IUI HIM, M I-- 
<>> lAIIM-.K 
'Statr 111 L'liiint 



M \ II'I-.N \ \M 1 
"i| Miirili: K 



'iiKrni'LAci-; 

<•! MnTlll-;!-; 

■^1 It' 'II ('(Hint I \ I 



■^\\^\j 




a\^o.cl 



tV^vva 



^ L I A 



iihl thai ilcath < ic('ii rrf(l, (ui Ihi- Male shiitd a'li 
1 ^ M. Thi C MMi^Ol' !»i;.\ ill w.i 






hi R \TI< >,\ );•,/; 

t ( >NTI^ IIM'I OKN' 



M.>'!lh^ 



lht\ 



It ■:,> 




iW^^<^ 



a~\v>\<xi\ 




• ■ . Cl 







in RATION 

(Signed ) 



tl ,]) >u 



.I/."////V 



/',/l 



^t 



\ L O 



//•nn \ 

M.D. 



M.nillf 



/',,M 



I'M I. \M(t\|.: STXTi: !• I'l' KSONAI, r\K THll, \Ks Aki: fK I !•: T' » 11 N", 

iii;sT <)i- M\' KNOW I, i: I )(■.!•; and hi;i,ii:i'' 



Mllf Klll.lllt 



' \,i.i,.ss Ld.u \i Co - (h: <^ W ctxxx 



Special Information ""''► ''"^ Ho<i»it.iis. in>ii(iiiiiins. iNnvifnis, 

or Kcirnt Rtsidcnis, dnd persons dviiij iiw.iv from honif. 

former or /..^ V_ ^. J Ax ""^ '""'J ••' '\ u 

Usu,il ResidPOfp'^ U jx J0(y^OO\a " T f'|,,(c i.ll)»',iffi .' <:< I f),,vs 

When HVJS dlsrasr ronfr.KlPd. 
It no! dl pld(f o( dPrith ? 



it.\ r>- 



,.„,,,. Ml I'! M ■-• !■• I- \Ii .' \ I, 



ri, AC'l'. DP r.IR I \l, OK i; |M( ^\ \ I, 



'Ad.:: 



I 



IN. K.— livcrv Itc-m of Information «houl«l Ik- c.rcfully Huppl'.-I. ACJfi hHoxM he Htute.l 'AACTLY PIIVSICIANS nhouM 
•tiitc CAlJSr or I)I:ATII in pl.nn terms, thnt It mny he properly clH«Hi»*leil. The S,,c.i,.l ln»o--.,„.l ..n .or p-r- 



«on« dyin^ uwiiy from homo slioiild he ftiven in every inHlHnce. 



'» 



w 



mmsi^- 



I 



')i'i 



ti . 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






Ih 



//r /'V/rv/, ^^ lx'tx.-r>viL>w^\; %^\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJO'i 



Bpi^i.sfrii'd ,X(). 



1988 




KJS 




\M.l 



DEPARTMENT OF PUBLIC HEALTH-City and Countv of San Francisco 



No. 



Certificate of IDeath 

PLACE OF DEATH: — County of ^ a>\ ' Va>\CUC^ City of' ^ a ^\. 1 ;LCt> v<>uiCC 
\ 1 lb , aiiX^ St.; 1 Dist.; bet. U a > V M It 'lA and J ^ I k 

(ir Dr*VH occups away thom USUAL R E S I DE NCE Givt facts called for under "special information \ 
IF O^ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



FULL NAME \a>v<:LtA; 



ULq^Aa' 



PERSONAL AND STATISTICAL PARTICULARS 



t ' < 1 1 . 1 I K \ 



i» ■'. : I ' '! 1;!K I II . 

M..nlhi (T 



Ul' i^.cti 



ii 



I 1 ':i V ' 



yi..uih^ 



r 



X^s 



-i 

MEDICAL CERTIFICATE OF DEATH 

IiAll-. Ml III. \ Til 



'■\!.-!it!i) 



/ >s 



l>:!\ • 



a^ 



'■>\;il ) 



/),/ 



\\i 1)1 i\\i' !i ( ii.' ri'\-( ii-T I'D 

:• n.it ic 111 ) 



-A 



. I III;R1:1;\ CiJ<rii'\, Thai l aUniJcMc.. 

tliat I last saw liX\; alivcmi nXyvtT- '\l i.(<) H 

aiiil thai (Ii-ath > iriii i icil. nil ( lir il.iN' --l.i'ol .ilt'-.r, i^ v") 
LL )1. Thr CWrSI; (»i' DI'ATII \\a- as foll-iu-: 



MlRTiiiM. \ri; 

'^'■'.\< <ii i"iinini \- 



\ ^ M I- ( »! 



1\ ^^ 



L ci L^- avd- > , " t tt x/Q ,tv<xl d 

i'.ik III I'l. \ri- \ A 

«»'• lArilKR A I) A ^ > 



I»IR A'I'inN 



)'rjjj s '^ M<"ilhs 



fhiv 



I Ion, 



' St;ili III (.".1111111 \ 



M \ 1 1'l: \ \.\ M I 

''I M"iiii;K \. 



HiRiiii'i, Acr; 

*>y Mn|ll|.;R 
(Still- , ,1 (Diint I \ 




LU' 



(.oNTRiiM Torn V^ ^M,\-'V<j U 



/:></r.v 



M.D. 



• "A i'l'ATIi IX A 

h'ru'.lr.l III S.ni f-i,iii,i^>:, \\ ) Vw ^ ' .1A';/.V/' <M ^''^ 



Special information "hH l.ir llnspitdN, Instilulions. frdnsif-nls, 
or Rpicnl Rcsidt'iils, diid persons (|\in) .iw,)\ fro'ii homr. 



in: Aiutvi-. s'iv\ri:i) i-krsonm, rak iuti.aks ari: TRri-; i" riii': 

lilCST ()!• .\1V KM»\\I,i;iM,J<; AM) Ml". iji:i" 



fiiifii 



CxLuMX^-cJj > . ^J >ci'X cuixxv icxi- 



formrr or 
L'sudl Resident p 

When was dlseHSP (onlr,ifted, 
If not at plate of deatli ? 



HoH lonq at 
Plate ot f)eatli? 



Djv^ 



f\.Mn-,s III ^iL' cu^x.<:i 

I 




3 Oo 



k. 



PI ACJ'" Ol lilRIVI.oR Ki;M(i\\I, J Ii\li; it Ml in.Ai, ..i Ri;Mn\\|, 
.l.RTAKKR L<X\_l^CV^ VctwCvXvvL^l 



r M 



N. K. Hvery Item of JnV'ormHtlon «houl«l Wi c.reVully Huppl.ed. \U\. h lould 'V:"? ,' . *'S^,c IhI ln»',»rmHtion" for p-r- 

Mtnte CAlJSr OP DrATM in plnin terms, thnt !t m»> he properly cl«H«.He»l. The Spc.u.l ln».»rmHt.on p-r 

won* dylnft awny from home kIioiiIiI be ftiveri in every inntance. 




•* 



'^^>j^>i,*)M* ^ 



n 

1 


i 



.■,■» ■■- 



l^f^ 



It. 
If;- 




ll 



I «!ilii 



• 



'* I 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



; ! ii. ,'th IV.. ■ '-■•'■ =:■■ ~:_ U.S.;' c, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



}lei^f,sfei'p(J J\''o, 



1989 



Ihilr /7/r^/,^ixlvtx-^^-vljl>v V\ rJO'i 



MAA^ ^^H| Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of SJeatb 

I 11. S. StanOatJ' } 



-A 



^ 



PLACE OF DEATH: — County of a >\j J Va-vvtUCO City of ' a>V ) XO, ^\CiA CO 



r^ ^ 



No. Mill luXt fl Ch<i 1 \ cio-i 



1) 



St.: 



Dist.; bet* 



-itnA 



(IF DFATH OCCURS AWAt FROW 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 



(rv'^LUi\) ]KlIt^ 



' I • : ! ■ I ' ; 



PERSONAL AND STATISTICAL PARTICULARS 

t< 1 M.I ik 

:;i i< in 





WkXx 




M-!ith' 



!».■ 



\' l'. 






•^iNt.i.i'. M\Ki<n:i» 

'i.itiiiiil 



ItlkTHl'l. \*'|- 

^'■'' • I ■' 'lint 1 \ 



I 



T. 



/',,■ 



<^ >\ 



MEDICAL CERTIFICATE OF DEATH 

i>.\Ti-; < ii' i>): \ I'll V 

Moll flit lM\t 

I II i;i>; i:i;\' ^ I.RTII'N'. That I alUmK-.l .1. 

~ T9O fii - IijO' 

that I last saw !i alive on - l^fr 

aiiil that (K atli 1 K'tiii ri'il, on t lie 'l.i!r ^!,i'( 1 ■ ' • ' ■ ■' — 

.M. Tlu- C.\iSI{ OF |)i;.\TII \\a^ a- lollou^: 






% 



!■ AIM J,K 



IMK 11 ( I'l. \i !•; 

01 lA riii-.R 

' St;i(c ,)t Cdiinti v' 






J FV-€Ut'L\VVCct\.C ^J ^V^Vl Ctrv\ V.W" 



^m 



^I M I»i;\ NAM 1 

•'I .MoTlli; K *^ 



iMk ritiM.AC}-: 

'•!• MOI'in-'.R 
(Stat' (.1 c'lmiitrv) 






I )r RAT ION 

^ ( ».\'n>: 1 VA"U )R\' 



}'(tll 



.IA"////s 



/hn 



//<'.•( / \ 






iNED ) L 



(SIGI 



.b\J^^l\j 



I lo U 



CLvvA 



M.D. 



W^Ai 




Special information ""''^ ''"^ Hl»^pi^l^. Inslifiifionx, Iransjenls. 
or Ret fill Rcsiilpnis diid persons (l>in!| .iM<ty froii home. 



'>*.nTi'Ari(>\ 



I »r~ , , , , 

Krsidni in Still r'i<i>i,i^r<> v.) )'-.//v "^ i/->////< 



n.;^ 



Former or 
Usual Residenr 

When was disease fontrac ted, 
If not at pla( p of death ? 



r '^ ^ I V ^4- "*'^ '""'' *'* 

Jdenfe ^50.1 \)A\^^ 'X Plate of Death? 



Da\' 



rni', AHOVIC STAI'i: I) I'KK-^OV \1, 1' \ K I" UT I.A K S \K1" CKI I" T< > TH)'; 

iJi'isT oi' >.kiLKN()\vij:i)(.i' .\M) iu:i,ii:i' 

ntifonn;.„t J. \l/L .NjL^T\j 



i \Ai\vvss 



,M., kt.xki.:k 11 lO ^I iVonIl-vv ,\X.U 
„„.,« »,11 t' f.Cu'vVLLt "'it 






(.\i.h 



IN. K.- 



hould be carcVulIv HupplJe.l. AGfi Hho.ld be ntnte.l fiXACTLY. IMIYSICrANS .hould 
pi'n term, thnt It m^.y be properl. c.aH«it'lcd. The •'Spcci... .n.„..„Hll.>n" .or p-r- 



-rivery Item of Informntion fi 
state CAUSE OF DEATH In 
«on« dylnft away from homo should be Jilven in avery InBtance. 



f^^WlP 



n ? 



1 1 



mmimmmmm 



m'^r^' 






I . 



n 



St i 



U f 









i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 




I' II. iMli I V 



, =, '.-' tr./-: ]'.Si\' C, 



REFER TO BACK OP CERTIHCATE FOR INSTRUCTIONS 



A I A 



!{<-i>i,sf (■/■('</ v\Vy. 



1990 I 



.{r^oui 




\M.|_ Deputy Health Officer 



N 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Ccitificatc of Scat!) 

PLACE OF DEATH: — County of a >v J \a>vCiOCt Qty of 'a^V J Aa.vvcx^C-C> 



St.; 



-Dist.; bet.- 



— and 



(ir DEftTH 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 



,L' ^ t 



\.LCL^^v 



-LC \VlX\) 



±1- 



PERSONAL AND STATISTICAL PARTICULARS 

1. < 'i.( >k 



'vn\<x.u 




1 \aJ<^<- 



i;; K III 



ll 






?,1 



,YA 



'. ' . I •: 



%\o 



1 . 



X\ 



'^fN<. I.I-: M\i<i<ii;i) 

'Writ' !i -.„ in] (!' vij.Miali.iiil 



l-^V' 



-I 




luk iiii'i. \.i.- 



N \ Nt I ( I ! 
I A 11 I IK 



iiik rin-i. \<K 
"I i".\rin-:K 

st.iti' or f-.mil I \- 



>T\II>i;\ N.WIl 
"I MoTIM.K 



inu'riMT.Aci-: 
<>i M(>Tni-:K 

'Stall or C"«)uiiti V 



4 av^cL jLu^vtiAj 



MEDICAL CERTIFICATE OF DEATH 

i» \ re 1 1! Ill \T!i y 

-\. J. . , . 

I II I-:K I'.l'A' CI.KIIIW Tliat I atlcinU-il ,U-.r.isr,l h ii 

ajLlvt) ! i(/)'i to *)_L|v't S.'t i,,<)S 

lliat I la'^t s;i\v h tVv> ali\c..ii n x\^\X: a7 i,,o^ 

a III I that iK'at ll occiiiicil, mi f lit ilati- ^-tatcd ;i!,i .\-., , tr I i^U 
Li M. Till' CAISl. Ol' i)]:,\'ril was -a^. follows: 



DC RAT ION Yrar^ 

CONTRinrToKN' 



.]/,>'// /is "I'l /^/n ^S^ //r:.> 






nr RATION V'^rs 



(SIGNED 






l/nii/Zis /hn \ 



M.D. 




'^^ \xt n ,.,oH r\>M.vss) ^U ilc '1 (SNij^-tAJ 




LO^y^<rtL^A; 

• H rri'ATiox 



Special information '>"'* '"f^ Hospif.ils, Inslilufions, FrHnsjcnlv, 
or KtMpnl Rrsiilt-nls, and persons dyinj .mrfv frn;n home. 

I Vv How long <if ^ \ 

M Lc'Xr PIdre nl Drnth .' < ^ Ddvs 



ill !■, \I1(»\-1.: ST AT i: I) I'KKsONAl, I'A K'l" I«' I ' I.A K s A K !•: TK ' )•; I'l » IIII-: 

iii-;sr (»!• Mv KNOW I, i; I )(■,!<: anj) itK'Ji'.i' 



former or ( K 

I'siLtl Rpsidpnrf VJLv_ \V<j 

When Mvis disrasr rontrarfed, 
If not flf place of dedlh ? 



? 







111')' maiit 






rNi>i:iMAKi;u 



I'I,\CI-" Ol HIKIXI, "K Iv'I:M<>\ \l. I l>Vli:nl l!i i.r.\r. .,t I;i:Mm', \|, 



»tat. CAllSR OP DEATH In ,.l»m term,, that it m.,y l.e pr,.,wrl, clu»..t.eJ. Tho ,S,«....I In.ur.n..!. p. 

«-)n« djlnj awny from home «houl<l bo ftiven in every instnnce. 




t*#»>. 



JtAS>*^/Ji 



m\ 



1. 1 ■ 



I i|i 




M 



if til 



'i i 




i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PER 



MANENT RECORD 



in 



n ,:>!i I v.. 



i:.\ !■ ' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



fhf/r FiJnl , BjL^xIx^^vImLV \^ 



luo^x 



lh'<;>istc!'0(l ,jV<), 



1991 



^ < ( . •> 



- ri' 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccrtificntc of Bcath 

11. 5. i5tan^arC> > 
PLACE OF DEATH: — County olC'a-,x V<\->\cva.cc Gty 
No. ^ y\,\J^ -i\JioJ^ 6^ K\)oJLy\.^ a\(.i St.; Dist.; bet. 






/ ir DFATH OCCUBS AWAvj FBOW USUAL RtSIDFNCE GIVE FACTS Ci 
\ ir OfATH OCCURR€D IN A HOSPITAL ON IN' ON GIVE ITS N 



and 



ALLED COR UNOER SPEC 
AME INSTEAD OF STREE 



lAL INFORMATION \ 
TAND NUMBER. / 



FULL NAME 



:Vv.>va 



^ 



LCVTo u CX 






PERSONAL AND STATISTICAL PARTICULARSV 




a 



CA^ 



I 






MEDICAL CERTIFICATE OF DEATH 



C)xkt 



^' .- y 



•. I 



f 



r 



• .) 



I ! i • , K i , i 1 \ 



^5 



1 



\\"l t If )\\ II) ( IK I) ■■,•, 



MIRTHl'l. \i*i-: 



\ \M ! Ill 
I \i II I R 



'MK 111 IM \, 1 

"I I \ riM;i< 

•^tal. CI C. ,111)11 \' 



M \ II 'i:\ \ \M i- 
'•! M(»rii).:K 



Hiu riiiM. \rj-; 
'•I ^:•»■|•ln•:K 

'1 I'ciint I \ 



' " ' ' i' \ ! H NvOj^ 



I ) 






tli;it I !;i<t s,i\\ h ;ili\f >'• 

.iil'l I llat ' !' •' '■ ' '1 i .i i U'l!, Ill t I 






a 



'I' lie C'AI SI{ ( »l 



\ i II v\ 



JU\Jsj 



'U> 



XVsj 




IHR \TI()\ 

^ ( i\Tk I 111 ToKV 



Moiitin 



//, 






1)1 R.\ r!('\ 

< SIG 



' ! I \ 






NED ' JaX<%XVv/:J< L<X'>y\ 



\X<. 






M.D. 






^^ 



rf I 




Special Information ""'^ ^"' "ii*«pii<i!\ insfifutiims (r<insitnts, 

or RtMcnl Ri'siili'iih, .finl persons iMn| ,m,i\ Ifo:?! bo'w. 



*- 



K,:,!>.i',< \.l>.' /;,,•/', ,wM ,'IH '■'."- b 1/:.;,'//. H /'' 



I'lii', Miovr: sr \'fi:i) i'krson \i, i-xk ri«Ti, ak^ aki'. rKii': r<> ini: 



former or 
Lisii.ll Rrsidenfp 

W'hrn W.IS dispose (oiifr,i((rd, 
If not .if |ild( r of de.ilh .* 



floM long .it 
Pld(r ot Hcilti.' 



D.n^ 



J'l.AfI-: HI' lU K I \I, < 'K K IM' 'V \i 



!• \ I 



' liif.ii iniiil 



I \.l.!icss 



\(»1-K TAKi: K 



% 




II'KI \l ..! K IM' '\ \l, 

30 loot 






Htatc CAUSr: OF DI:ATH h, plni., terms. th..t Jt nu., Ik- pn.pcrly cluKs.V.cd. The S,k....I Into, m..t ...n ,. 



PilVSIulANS Nhoiiltl 
<i r- 



■F»w' li 



«on» clyinft nwiiy from homo should he jiiven in every mHliince. 



Stosf-'^'"^' 



(. 



Iiii 




4 Jifll^^'' 




M 



If 




■^^^^^^I^hl 


PI 




kMHW 


MHll -0.'.: 


• : n tt;n;.i 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



|. Nii ;^ •.-• ' 



ncrto i\^uir»v*r\«»»i vfc>iiiiii>*» 



cr\a I lu CT D I i<~"rt<-> lu c* 



/> 



7/f' /•y/r^/,nxWtxT>A_lv^\. XH 



/f)rn 



JU'i^ish'i'cd .Xo, 



1992 



I 



CvH^CA^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Benth 

( "U. S. t5tanC>.u^ ' 



N... 



PLACE OF DEATH: — County of^O.^^^ vJ ^ ^^ ■ ^ City of 'a.'V'A' vi v^ - 

p . ^ n (1 , 

^ C V L LO. -1 V. d . St.; b Dist.; bet. V,V V V CU' ' ' and s ^ 

, ..ciiAi oreiinirNrF nUF FACTS CALLfD FOR UNDER "SPECIAL INFORMATIC 

FULL NAME • .VtcU^v^cK JtO " 



t ^i c< 



PERSONAL AND STATISTICAL PARTICULARS 



VillccU 



' '!.' 'K \ 



I K I II 



,o.>. 



s, 



'^ 



IH 



MEDICAL CERTIFICATE OF DEATH 

,4, 



C\.i 



rii.it 



\; 



\' .1-; 



I 



I'. 



W 11)1 
WW 



lUR'l'l! !'l. \i- I' 

- ■ ■ M • \ 



NAM! (.1 
I- Vfll I U 



I'.Ik 111 I'l, A' J- 

'•I 1 xriiiK 



M MIM.N NAM 1 
<>1' MOl'Hl'.K 



IlIKIIIl'I. \C\-\ 
'>!• MciTlll'.K 
''tatf or I'oiititi \- 






tliat I Ia->t ^aw !i 

:m,l that .Kalli -iccurf 



A 



a 



'^-ni 



'iMu' c \i ^Iv <)r 



ii- \ 



wa-- a- 



CCvv 



crttlcol^ •^"•'' 




I 



JL\^ ^ v/-> 



CoNTKlliiroKV 








/A' A > 



) V,7/-.v Mi'Htns 



,'h,v. W ll.'ur 




n. 




• )m 1 









di^A-t' '^- 






M.D. 



CiPFCIAL INFORIVIATION ""!> ("^ '1-l.iN.ls. Inslitutiuns. U,.<mK 
or Kecfnt Residcnls, .ind ptrsons (j)in,! .ivwiy fro:i, homr. 

How lofMI .ll 

Usudl Residence 

When Has disease (onfrarfcd, 

If nof at plarp ot dedlh ? 



rill- AHOVl^ STATl-I) J'KKSONAL I'AK I * ' . ). 
lU'ST Of MV IvNoWI.l'IX'.K V^I' lU-.I.Il.l' 

,^A 1. i" 



\Ks AKI'. TKIJ; T(» Till- 



' I ut'if in:mt 






.0 



,., x,-j.- Ol- lUUIAI. <»K K1;M"VAI, 



i< \ p 



dx^^ '^' 



i Ml'' \ 1 . 
I90M 



INI 



„..,,,.,, % ^ 4-^- - \\ 



(Aililn'^s 



\iM 



OOVv: 



VA^VffTu 



:^t 







f^Wll 



m*^ 




I 



i 



[t 







'■ < 



' ■ H ' J J? '' 



I 



MMif 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERfVIANENT RECORD 






I 



Regisfei'Ofl JS'^o. 



1993 



X\^M 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificntc of Bcath 




X\. 'Z\ '^'rnn^;lr^ 



■ \ 



% 



PLACE OF DEATH: — County ofOcc^' O.Vcx.> 



\c<^^,< city of V/CLTu viA-O. . 



i.CC 



^i- 



iQ^ 



No vJa^^^ . '-(x'l^ ^'^<tlvc^x<. ^ M St.:- Dist.;bet. -'""^/x 

r>n. Nw'yVV^^ . . ^v^ V c:^,^>*-,W^- ,,c,,/.l''Rrc:mFNCE -tVF FACTS CALLED FOR UNDER SPECIAL INFORMATION \ 

/ .r DtATH OCCURS A^AiAY FROM USUAI^j f' ^ ^ I D E N C E ^ t V F F ACTS "^1^ , ,, c; t r A T OF STREET AND NUMBER. ) 

\ IF OFATH OrruRRtD IN A H S P T A Ij O R INSTITUTION GIVE ITS N A Vl t . ~, -■ . r ^ . O 



FULL NAME 




PCPSCNAL Ar;D STATISTICAL PARTICULARS 



V. 




,%^% 



MFDICAL CERTIFICATE OF DEATH 



5i.|'\l 



^1 

. i 



i ; 






. I 



M •■ 1- 

\\ 1 i)i i\\ i. 1) I Ms 

\\'iit( ill -■M'i.r 



!'.!'•:!" Ml- 1. \<" 1-: 



\ \ M I 1 ' ! 

r Aiii 1 K 



I'.i I- Til ri, \> !■; 

I)! I \I1I1 k 



M \II)i:\- N AMI' 
<i! MDTm'.K 



r.iKiMiri, Acr: 

<il NKfnil'R 
' ^I:it< III foiiiit! 



I »' '■ i 1 A i|(»N 

fx'rriihu} ill S^in .''nin. /w 



CL. ^ " 



that I 1.1-1 -iw h VVn .:i!i\< I'll 
,111,1 tliat <K'atli .K-ciiiTCil, ' " ;'i^ 
'J M. The CAISI-: o|- |)1' \T 






J 



^^^ 






III K.\ I'M ' 



.v^vy»v O'AV 



\ I )'(//A ri. 



//.',.'- 



^ . .NTKiin'i'om' 



}V.7/'V 



77/ A 



/ ) • 







, SIGNED > U). b. '^^'^^'■'. , '^•°' 

^x|Cb XH ,„„H ^..i, ^llMlUvk^ .J- 









d^ 



r 



Tin- AUoVKSTATl-l>.'KKS..NAI.rAKTU;rLAKSAKKTKrK n. T.IK 
Hi;sT ol- MV KNOUIJ-.IX-.K AV!) HI-.Ml-.l- 



'hi f<i:ni:iiit 






■;^tFS7i;rn7^R^^ATION «n!^ tor H.spitdls Institutions. IrHOsirnts. 
or Rrrrnt Rcsidrnfs, dnd persons d)in? anny Iron tiomr. 

(J7) (<^ HoHlonq.if 

Usii.ll Residpnrp sJ y\A/vy\vv v. 

Wlirn was disensp rontracled, 4 . . ,^^ 1^ o. ^ 
If not at piriff ot death ? -J J\J^ 



,.,,XC-,-, .'I- IM KIAI. MK KI:M..\ Ai. 






II \ 11/ 



f. ! Ml '\ ^ 1, 



U) 









IN. K. 



' " IIVICTIY PHYSICIANS «'^""'*' 

* » r'Aimr or ni-ATH n p hiin terms, tluit ii m.ij ' .^ 

8tote CAIISI. t't ui./% 1 •• "■ • , , . _ . . .„ ;„ every inHtatice. 



8t«te CAUSE: OP Dl:A 1 ti •" P.'- ^' ";' ;„ .„, ^.^ry inHtance. 
«on. <Iyina nwny from home Hhouhl bo ft.xen 



>- 



•tWPMMW 






rwnn^' 



JtU^i 




I 



I! ' 



i 



If 



iiU^fs 



*!■ <:■„ 



WRITE PLAIMLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ii...iih-FTvo ■ -^ ;•. :.^i-^.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\jL'\>u Deputy Health Officer 



Ji('!ji s/ crt'i/ .Yd 




1.91)4 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of E)eath 

11. 'Z\ i?tanC>ni^ i 
PLACE OF DEATH: — County ofCJctyx^ J\a .^ ^^^.c<. City of Ocv^v vL\xx^> vcui c c 



N^ 



ia.1 



IF DEATH OCCURS AWA>i fROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SP^ 



St.; 



Dist.; bet. 



.ind 



( 



.FORMA- J N 
IF DEATH OCCURRFD IN A HOSPITAL OM INSTITUTION GIVE ITS NAME INSTEAD OF STHELI A ,\ J NUMBER. 





) 



FULL NAME 



.0 



;r- 



PERSONAL AND STAriSTICAL PARTICULARS 




■ I 1 1 . ■ '\< 



ill 






i: !>; !' i'\ V 



P.-^ECICAL CERTIFICATE Of DEATH 



djc'/vtr 






( 



-^ 



'.' • 1-: 



s 



>^INr. I.lv MAKMl'Ii 

W'l IH i\\ I- I 1 ' li-' I 1 ■ \ I .'■ , 111 

Wrii 



p.ikriii'! ■ 1- 

"-■ ■ 1 lit ; \ 






that I la^t stw li "! 

M. 1 lu c; \ 1 :-i . ( 'i i ' 1 \ 






9 
LP 



L'Ccv^oL. 



OlUck, 



/>-L/feOOAXX, 



}v 



cck 



d' 



f. 



\ \ M ) I )i 

I All; i-,i< 



!ilk I 11 1'l, \ri.; 
'>1- lATIIHK 
^tatf f)r t'oiiiit! %■ 



M \ II >).\ \ \ M 1 
<i| M( I I'll IK 



HikiKi'i.Aci-; 
'" N">f"iii-:k 

t 'i lU lit 1 \ 








,VCLv -^ V.' 



Dl KATION Ycais. 

l,< )\TI^ ! i:i T< >l<\' 






ir ■:,. 



Dl K \ ri< IN 



' Signed ' 



U. V, 



1 1., a, . 

M.D. 



hsi\^ 



V\ ....H 



V. !,;,..,, \X\ %\.. 



\ 



9 

u J 

- (" 



r 
r 



/ 



n 



Cb 



oLf ' ' 



I'A 1 I' i.\ 



Special information ""'v i.r iii.siiiti' '•' • —■■m fr.tnsi.Mfs. 

01 Kficiil Krsiilcllts, .iMil (tri^dii^ dvini .l^^•l^ fro-ii hiimr. 



) - 



Mnith- 



Til i: \M(>vi<: •^r ATI- 1 1 i'i-:ks<»\ \i. i- >iK riiM i, \K'- \'' r tr rj- ti • \'\\)-. 
iti'.sr ()!• MN- K N< t\\i.i:i)<;i-; am» h;.i,!1i- 

' I ii f'l! luint 






'' \.!.I;. 



formn or "\ , , 1 1 ^ , . i ^ . "'"^ '"•"'"' 

When Hrts disf.isc (onlr.Ktcd, 1 . I 1 

It nol .11 plH. e ot drdHi ? CUH) LVVv O^K. ' 

I'^ACI': Ol' lU KIAl, < '" '-' ' "*" '^ \'. ''\-< 



. 15 



fl.iv 



-VvCVX.'^X-*^ 



""^^^ 






NDi.in A K i: K dLL<-fr>^a ^" <y^y\ 



n 



o. 



\ 



fAd.l,,^^ ICib 'OcLCA-- ^^^ 



:\>vC 



Htiitc CAllSI: OV ni:ATII ill Phiin tcrmn. that it m».> Ik- properly UnHHiiuti. 
«on» flying imny from home shoiil.l he Jiiven in uxcry instiuice. 



ra 



WMW"^- 



i*r^M' 



■J ^ 







I 



i* 



M^ 



*■; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

'^'"^^^' ~ ."' "flLl" REPER TO BACK OF CERTITICATE FOR INSTRUCTIONS 






/.V^yH 



Jlcifi.y/r/ r// ..V^v. 



1995 



\.o^c^^^ ^U^M.( Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcrtificatc of Bcath 



11. 5. lr1tnn^.u^ 



(^ 



J (^ 



No. ^^l > 



PLACE OF DEATH: — County ofCWl^ 0.\XL'YUXA'C<) City of 0/<XO^ ACU>xOlA^C 
L(rvLLO\.q^Otrri St.; ^ Dist.;bet. RUk and olC.Li.^ 

(IF DfATH OCCURgfAWAV FROM USUAL RESIDENCE GIVE FACTS CALiro roR UNDER "SPECIAl. INFORVATION \ 
IF DEATH OCCl^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET ANP N U M B F. R / 



FULL NAME 



PFRSONAL AND STATISTICAL PARTICULARS 

» < ' I . ' ' k \ ^ 




J ) LxxcLd 




U 



LL'J^^Jwa- 



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MEDICAL CERTIFICATE OF DEATH 

!i \ ! ! I '! Ill \| h 




->9 



\: \ ! , 



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■ \ M I I il- 
1 \ i II IK 



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Ox/vAxyU 



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tll.'lt I l:i-1 -;iA '■ 

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fir RAT ION ) ' ■''' 

NED) \l)\ LL. ^i) ' • 



liiiniiiM \ I 

ni- Mdllll.U 
(Sl:it< .»! rmiiitJ \ I 



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(SIG 



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Special information ""'^ '"' ll'ispihiK. Instilulionv. fun^irnts. 
or Rfient RcMiJi'iils, .iml pfi^ons ifvini .c* 'v tnni Im-nc. 



/ 



I IN'. MtoVI.; sr\ri:i) I'KUSONXI. rAKTKMI.AK^ \KI, TKIi: T" I' 

i!i:sr ()}■■ \\y KSi)\\\. ]■.])('.)•: .\m> i'.i:lii:i' 



former or 
IsudI Residence 

When was (lisp,)sr rnnlr-idid, 
If nof at pIfKeol dciith .' 



I||IV\ Infill rll 

f»!.i< t' ol llcitli .' 



DrfV^ 



dill. 



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I'l.NCI' <»i' HI KJAL <>U !-lM"^ VI 





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N. 15. 



■■"■'^■^''■"^''■^■■""■'^"" V -r 1 II h t t -il I X'XCTIY PJIVSIJIAN^ hIioiiI<I 

t«te CAlJSn OP DfiATH ?r, plnin UrmH, th»t It may Ik- property Juhh.^k.I. 
• dyinft imoy from home Hhouf.! be ftiven in every mHtnnce. 



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Ron 







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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

-„ ,_,_ _ PTPFR TO Rflr.K rjF rrBTIPir.ATr FOR INSTRUr,T!ON<? 









eputy * 



. Officer 



Beg I sf ere (I J\^o. 



1.996 



i 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate ot IDcath 

( 11. 5. 5?tan^avC^ 

1 ^ 



QIl 



PLACE OF DEATH: — County of("'<X^V J \a>VCX4CC City of^J a>v vJAC I 
No. b \ 'S H<X C:.k<. t St.; X Dist.;bet. AjUXVa^M. .and i-' c', vt 



1/ ir DtATH OCCURS AWAY FROV USUAL R E S I D E N C E G t V E FACTS CALLED F 
\\ ir DEATH OCCURRt D IN A HOSPITAL OR INSTITUTION GIVE ITS NAME IN 



FULL NAME 




OR UNDER "special iNfUHMATION \ 
JSTEAO OF STHE^ AND NUMBER. / 



PERSONAL AND STATISTICAL PARTICULARS 



11 




\' 1-; 



51 ,.,. 



--IXt.l.i:. MAKkll.li 

\\( n< 'W!"i> ( >K r>;\i '••'• }■ i> 



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I \ 111 i K 



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111 Mol'Ill.K 



I!IKTIIIM,AOl'. 
• U' MDl'lll-.K 

( St;it( . ii t'otilltl ^ 



^ 









MEDICAL CERTIFICATE OF DEATH 

dxAvt il 

I II i-:k i;iiv ci:i<T[r\'. rii . 

tliat [ last vaw h -• alivr on 

ail.l that i\<.-A' MTL-.I. "it ! !h ' !•■ •! -'■ 



^ 



II 






M. The C \r^! ' =' I'l: ATM u 



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/font 









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K.'^Kj QaxU- 



11 







SIGNED) 0.\^CUVCCK V.O , - 

ax\AJb "X^ r(,oH ■ \iiii n-o k)Ob oaJIx^v at 



M.D. 



SPECIAL INFORMATION ""Iv tor H.spitdK, Irhfiditions FrdnMents. 
or Recent Residents, and persons dvinj .iw,tv Iro.n ho-nr. 



,A..' 



I? ? 



1^ 



Former or L t a V\ ^ ,- r 

IsudI Residence ^^^F^^'-^- 

I i 

When v\HS dise,ise rontrdi^ied, 
If not ,it |il.)( e of de<ith ? 



Hdw Inni) .it 
PIdfe ol Oedtfi , 



il.l^s 



nr \nnvFsT\T).i.i'KK-oN\i.rAKTi»ri.vK.Aki: rkii: T" n\E 
i!i;si" Ol- MS KM »\\ i.i.i"'!-- ^^" I'.i i.n.i' 



' I lit'".; ni.int 



01 cn\ 



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31: 



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m-iwiii III! ■■m ■■»■■■— ■ ^ ~- — — ^■4^"— — ^"'*"" II u » t I f \ \<JTI ^' I'ln Slwl AN!^ should 

IN. B._Hvery item o^ l..fT,n.tlon shoul.! h. .Mrc^t.liy -"M.n-I Jl^j^^^;;';;,;^^^^^,;* 'tU^ S^^M Inw. .H.n" ^o. p.r- 

stnU- CAllSi: or nf:ATM U. plnW, terms that .t .nn> -J^^ ' ' 
Hons clyini »w«y from home shoulJ be fe-vcn m every .nHt»ncc. 



Hjl^Uiv^sJi^* 




II . '. 1 1 . I \ 



VVRITt: PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



BEFEB TO BACK OF CERTIFICATE FOB iNSTRUCTIONS 




It . 



I I 




il 







r.Kn 



]h'oisf(>i'ii/ v\V>. 



1997 



DEPARTMENT (IF PUBLIC HEALTH=City and County of San Francisco 



Gcrtiticatc of Bcatb 



PLACE OF DEATH: — G.unty of^'aYV' vjXa 



■ ( 



r 



^. 



Gty of JCl^VV; V. 



\ I 



No iXX 1\^ Q^->y\.k^l St.; -^ Diet.; bet, "A ' '.• .and 

C .F nrATH OCCURRtD IN A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBfH 



FULL NAME 




XXWJ 



\xXoj 



PERSONAL AND STATISTICAL PARTICULARS 






r< ii ' »k 



ii \' 



a 



^CO. 






I UK 111 I 




^ ^ 



a\ 



M 



MEDICAL CERTIFICATE OF DEATn 

Dl'.ATll 

C 



II!',!^ l.i'.N I I KTirN', Tb,(! ^ 



'X\y.t Tl 



lllilt I 1 I ' INN ll ' ■ • ' '" 

;iii,I (li;it ill .illi o( riiiri-.l, (111 tlu- .1.1. 



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c, 



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SIGNED) ^CL^-V-O- 



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l<»'l 



i^,X "4lla\.i -■ 



""ipi^T^NFOR.MATlOrM -">'v tor llospitrth. Inst.l.ilion^, 
or Kcd-nl Rtsidrnts, .md persons dvinj .i>..n In'ii home. 

lloH lonq dt 



''', .11 



1 '' 



THI-, \Hovi- sTA'n-:i) I'KksMN \i. '')'^ '■':', '.[..^'■^ 



\ki-; TH I i: T" 'I' ' 



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I \.Mi.-s 



a. a 1 



fnrmrr or 
IJsiirtI Rfsidente 

Whrn was disease (onlr.ided. 
II nol at plaieol dtath .' 



|»!h( (• ot Dt-atfi .' 



[tansjpnts. 



0,1 vs 



,.| \, 1. , M IMk! \I. "1 '• I ^' 



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I M,i;Kr.KKi:K UU . ^ ^ 



\IM\ V 1, 

IQOH 



PHYSICIANS should 



N. B. livery it 

Htfite CA 
Rons clylnji 



— — ^— , , v'4<-ri V l>H VSIUI A > -^ Miioun 

,„s,: or i.i:a TH m ,.h,-,n ;■;■"";;;;;' „"j: .;„„«. 

nit nwliy from homo »l.,...l,l Ik- iii>t» i" «'« > 



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lit- 






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•' .-■ / 



WR'TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,1 ..I 11. ■'' 1 V. 



liSclT 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da/r ri/r(/ ,Ox\<!tvyy^})JLK' 1' 



1 



I'^n'i 



7/r <>'/.v//'/ r^/ v\ 'if. 



11)98 




CO dLjlVMJ 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtiticatc of Bcatb 



X\. iT'. l?t^n^nl•^ 



ef^ 



PLACE OF DEATH: — County of 



a^v Jva yvcc^cc City of ' ' CL^X' \o^>xcc<L<:c 



r^. LCte 



N^Lcr^tTvtu KCSlIxJ."' St.;- Dist^bet/ - and - ^ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




^'^aX^ 



UA.O 



-i:\ 




<X 






*,(»!,< )R 





UjI 



,^H5 



\:.;th 



i ■ ;il 



\' . I-; 



WEDICAL CERTIFICATE OF DEATH 



I > \ !' 1 



A 



.t 



I II I. u 



V 



INN, Th, 



XI 



1 ',■. \ 



/^^ 



(h I \ 



5c\ 






II1I-; riM'i. \.- ! 



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I A I 11 IK 



luK Til ri. \< !■: 
(»i' I A II II-: K 

' St;it< or Oouiiti V ' 



M \ IDl'.N X AMI". 
<>)• Mo'l'lM-.R 



lUKTHiM.Ari-: 

oi" miitiii-;r 

(Stati- '>r r<mnt 1 \' • 




(Ixur 



.c^K<x 




tll.lt II ' '' 



c^jO^ V\ 



■ ,]_ MM tlu- .lat^ stati"! i' "vr, *' 
M. The C.\l SP: oi- I)I; ATll ^^■''' '■ t"n"\\'~ 



c^ 



MIR X'I'ION 



)'( (//■ 



Mo}!lh} 



Par 




>V 



d 





'7 



DCCMI'ATION 



(SIGNED) i. ^A. (Ib^OAi 






I lout -• 
■\^ 

M.D. 



C5 pre I AL INFORMATION onh tor Hl^pitdls. In.littition.. Ir.nsienls 

^ f^n.v-'ini- _ j.;_„ ... ,. from hnmp 

5 b 



nr KeifPf RfM*lents, and persons dvinj ayv from homf 



MIKXU.>VKSTATKnrKR..>NA..I'AKnrri NK.NK. rKlK n. TIN 

in;sT oi- ^Iv '>ii"y)i-'T'""''V-^ i!i,i<ii.i 

( Inl'iii 111 




INDi;] 



CxLuvxtjL virux' 



.V^XAJ 



' \(l.]rr>i'- 



iS'XH Q)l^dktc> 



vCc 



» ., « ■— .^ . j. — .. , \('F Khnvild be stated I.XAO I L> . t"i'-"w 

«tatc CADSr OF DI: ATH !n p n.n -"-j;'^; /J";^. ..„st»nce. 
son, dylnt o-»y f*-"'" '^"'"^ '*''""'*' **' *^'^ 



Former or 
Usudl Residence 

When was disease ronfrrirfed, 
II not at place of deatli ? 



lents, ann pt-ison^ u»!iij «"»■ 

"t/vA^Wi^J^vX^ 4- How Innq at 



fl.iv 



IM.ACK OF mR[AI. OK RI:M"\ Al. 



:k of m kiau "k 



i> vn 



K' iMt i\ \1, 
190 . 



■\^ 



^ 



*«Nto. 



■i)«i»iili* 



! : ' 



If?' 




r \ 



u 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



';x 






/.v^^H 



1, 



]{(■' u { .sf c; rd ,,\ V>. 



1999 



DEPARTMENT OF PUBLIC l]EALTH=Cltv and County of San Francisco 

Gcvtificatc ot IDcatb 

PLACE OF DEATH: — County of Ja>v \a^vcU.CC City of Ua a 




avu<^ (lli.(vsLkLlx< 



St.: 

ID 

NS 

A 



Dlst.: bet. 



and 



^FA-I OCCURS *w».v FroM USUAL RESIDENCE give facts called for ONDER &Pt.^. NFORMA 

r *f1tH OCc!rRFD ,N A HOSP.T.U OR INST.TUT.ON GIVE ITS NAME INSTEAD OF STREET AND NUMB. 



FULL NAME Y 



PERSONAL AND STATISTICAL PARTICULARS 




('\ 



ICLU 



LV 



/f.SS 



I i 



-<IN< 1,1-: MARkli:!) 
WIT)' >W1-1> OK T>'V' 



I.IKTill'I.Av'H 



\ \M !■ Ml 
FA I' II IK 



I'.' 
( 1 ■ 



: 1 I . K 
k'ninitrv 



V 






MEDICAL CERTIFICATE OF DEATH 

xi'li 



icl^ 



d 

1 ii!;ki;i;\ ^ m; riiW Tliat ^i 

lliat I last <a\v li "''^ ''" 

ail'! tlial (K'ath orrurri'.l. on tlu 
^' M. Tlu- CAISl-; ol' i)i;.\Ti 



! I 



t 



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' I rlcyl^c 



>->\X^ 



C'VCCL^Us.txi. 



\! . \ M 1 

<»1- .M«'|lil.K 



lUK TiirLAri': 

I) I- Md'I'HI'.K 

fSt;it> ■ •! v'' ■■■.Iltl ^ 



il (H 






DIR ATI* 'N 



\fotilfv 



Hu 



/' 



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.1/ 



/'./I ^ 






M.D. 



l.rKAIh'N ^ 

Signed ^ . 



,^ 



1 



I()0 



A 

•inKMtOVKSTATKI.rKK.oNM.I-XKTKf' VK- XKl'.TK' H P ' TM>-: 
IU:ST <)!■■ MY KN«»\VIj:i)<".l-: AN!> LI 



(Info- iiirnit 



^W^ M /l^l\.v^CX.V^.A 



f \f1<lr.-'- 



Sl^ 6<Xyvo{U.y"'^ 



SPECIAL INFORMATION "nK for tlns„it..ls. In^tliulhav. Trdnsients. 
or Reten] Residents, dnd oersons dvinj dvvny Iron how. 

_ A' ' liim htnii .il 

Former or q (^ (jn ^ LC'.w.. v' ' ' !'!''"■ •>* H.Mth ? 
LsudI Residence 1 10 WM. > ^'^«^\ 

When was disease ron(r.iffed. 

If not at plare of death ? ^ ___ 



Ddv^ 



I'l AC}' '»! r.rki Ai. ' 'K 



; ^ t , > \ I . 



l(J).,e 



XMl^ 



t MH-.KTAKKK > - V. W V-_^ 

(I nu-T Ok 



I.' 1 M' iV \ I, 



O-cVvt ^0 TOd't 






■'-■ " , .. ,. . \nF. should He stntetl F.XACTL'V. imt.-.i^i 

Stat. CADSr: OF Di: XTM ;n p a.n -'-;;» ;;^^;;; .„,r»nce. 
son« dylnft nwny from home should he jX.ven 




«*.««^ 



•y^<MttiiU-'i 



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i iilP: 



1 ■' 



u ' 



«< 



11 



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WRITE PLAINLY WITH UNFADING INK 



II., nil' ! 



y^V>*^W»Jj^^ 



ii.*v ;■ <■ 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■ awnwii — — I KIW 1— 



Hi- 'i ! sI I ! : I ' .Xi). 



>^ «>. ^V -r* I 



■^\^K.',.'. A . Deputy Health QfTiccr 

DEPARTMENT OF PUBLIC HEALTH- City and County of San Francisco 



Gcvtificatc ot Bcath 



<^ 



No. 



PLACE OF DEATH:-G,unty of'^a^' J Vawi^CO City ofUCt^^^ 0,Vay>%< 
:ir,n ■ "C> 1:1, SU 10 Dist.;bet. Uvv^JVck .ind la . 

(^U I -JV. .V,l . ,,<=.,.l PfilDENCE G.VE fACTS CALLED ron UNDER SPECIAL mroRMAT. ON \ 

( " rE'*Dr..°"ocrur D'.rrHO^s'r.t o"f^sn""o';'".E ,.S_.AM. ,~STE.D Or S.REET A^D . U . . E . ) 



FULL NAME 



- I 



PERSONAL AND STATISTICAL PARTICULARS 




lO 



ra^v 



'V 



O 1 ' ■ ■ 1 



I 



-f- 



lo.Lti 



K 111 



/ ^- 



IC 



wi I )( lUi- 1 1 I IK i»;\'' 



lUkTiiri ■ 1 



.Ocd 



C^ L^\' 



n 



^■» 



N \ M 1- < il 
I AT 111", U 



iiiK I II II. \* I-: 
<)i I \ I II i-:k 

(St;il« ii! rmmtl v'i 



M \ : 1 1;.-. ■• \M I 
ni M<rrin-. K 



MIR rmM,Aci-: 

<»!'• Mi)'|III:K 
(Sliilt ii r.miili \ 



I I'A riDN 







MEDICAL CERTIFICATE OF DEATH 

I, ATI. Ml- IM' \ 111 _V 



I 



\ 



til, It I l;i-1 -'^^ ''• ■ ' ■ ' "' 

:iIp1 ;li;it il' .!lll '"■" II"' 

" M. 'I'l^'' C- \i SI'-, ni 




"> 



vcL 



9 



cI\jLAXX. 



Y 



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ClI ,•,,, • }fn,///l- 



IHK VlUKKSTXT.^nPKRSnNAl PVKTUMM.A 



\Ks AK1-. TKl l-: T.> TllH 



1 1 lit'.' tn.itil 




( \(l.lr«'SH 



..eu.^ 



dikation )V<// 

(•(.NTKIi:i TORY IKX<:JL\J 

i)rR,\Ti<>N y'"" 

(SIGNED i IV ^^ 



Mcuilis 



/',/! 



/A'/'/ > 



M<>iilh\ 



G^ ^)\-i\ 



hi 



M.D. 



' ~ I. i.r ii,..ii;f.iU IikIi 



SPECIAL INFORMATION .".i> •- " I'"^- l"*l' '^' l'*""'^' 

or «Mnl M'liK. M V"-"^ 'l>"'l ■'••" "■"• """"■■ 



Former or 

llsu.ll R^sHfnrf 

When was dispasr (untr.idnf. 

II nol at place nl <!''''•'' • 



IIOH lollij <ll 

|»!,)(f (it lliMth.' 



PdVS 






• ,• ,,, [., „i M, ',1 K 1M< '^ \i. 



TO" . 



si' -^ 







J^ 






o 



N. B. livery Item of Inform 

state CAUSE OF Dt 
nnnm dylnft awoy from 



* .iVAi'TlY PHYSICIANS* «'"'»'<' 

„.io„ .H„ .'-.^ »-■--;:; ;,r:Hr:i':-::r •';h;''"V-.i -■ •■-•• 



MjMA'f J^^ '«iA#k) IklLA 



m-^^^ 




m 



Jr 



m.^ 



V 

i 
I 



I llv 



^ 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ntrtn lu t3Mv^ r\ vjr ^-t^«rI^l<wA^fc, njM rrv:5>Huuriun<3 



Deputy Health O^--- 



Itrgi,s'fe/'e(/ ^\>>. 



^01 



V 



DEPARTMENT OF PL'BLIC HEALTH=Citv and Countv of San Francisco 



Certificate of IDeatb 



11. t5. t5t^^l^ar^ 



No. 



PLACE OF DEATH: — County of ' a^v Va>\CU CO City of *CL^V '^\a\vac4^i 

. r % I '^? ''' 

a1? ^ IIlK' St.; O Dist.;bet. Ot^U^a^.cl and '"'^'U^^^V 

/ ir DE«TH OCCURS «W*y TROM USUAL R E S I D E N C E G I V E FACTS CALLED FO«t UNDER SPECIAL INroRMATiON \ 
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N U M F! E R / 



FULL NAME 



.ik 



auVvt^'v^'yvi' 



XC-V' 



vj 



PEniSON.'^L AND STATISTICAL PARTICULARS 

A ( I I ! . I I K \ 



> \ ■ )■ < •! i;l!< III 




M..!ltll \ 






L 



^INt.I.IV M\KUij;i» 



H 



■u 



MEDICAL CERTIFICATE OF DEATH 

IT 



Idvt 



H 



1 Ill'iUl.ilN I 



li^S 



I. 



I )\a\vucl 



HIK I'll I'l, \''»- 



I A iin:K 







'^ ^\^tt 



that I !a->t viu ll -cV a!i\r on 
aii'l tliat di-alh i k\ii iicil, nii ; lu' li a 'I ,i 

.1 M. TIu' (.' \l ^i; (H- D! \ Til \\a-~ as 



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TUKIII I'l. xri-: 
ni- I A III I- K 

'State <>r I", .lint 1 v i 



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M \ I I'i:\ NAM 1. 

Ml M>rniiK /j 

lUKTMlM, \(K 

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(Stiltc nl C'tiUUt I \ ■ 




LV^^vjO 



( 



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I i^a I 1' \ I K )N' 









C ONTKlinTON 



1 ) r R A T [( ) N 
SIGNED ^ 






/^^^ 



M.D. 



i,^0'!^A.vdi^ 



Special inforiviation *"''^ ^'" iii'^^pi'-'iv ii^titutionv. ifdnsimts. 

or Rmcnl RiAJdonfs, diid |instin> dvinj .iw.i\ fio::! home. 



1 



formfr or 
iMidl Rpsidfntp 

Whrn u.ts disense {onlMfted. 
If nfil at plrffp of dt'dth .' 



lloH lon(| <il 
Cl.iu' of llfdth' 



f),|\v 



Tin- .\iu.vKsT\TJ-n p»--KsnNAi. r\KTi<ri,\K- \Ki 1-Kii' T" ' rill- 

lU'sT ol- "UV KN(»\\I,1.1>'.): AM) Itl.l.Ill 



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'XH \\ C\>V 1 VH.. . vl 



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" !T y , a:, sMo.I.lbcHti.te.l I.WCTLY. PHYSICIANS should 

„._,:very item oV 1„form,.tlon hHouM h. cnrcuHy f;'PP '^ ; ;/ ;,„ J.,ssi,lc.l. The "SpcJal ln.'orm.,tion-' tor p-r- 

Htnte CMISn OP Df.ATH !n ph.in terms. th»t .1 mM> h. >' P^'' > 

«on, clyinft nwny ?rom home should he ai^cn n. every mstmiLC. 



3 



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WRITE PLAINLY WITH U 



NFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BAC^ OF CERTIFICATE FOR INSTRUCTIONS 



a^n'i 



};< ""/A '. i • 't ,X',. 



'^mz 



DEPARTMENT OF Pl'BLIC liEALTli -City and County of San Francisco 



T^ 



* ■ 



I! 



Ccvtiticatc of Bcath 



PLACE^OF DEATH:-County of' 'a ' VO-.XCU City of 'a.V J.VOjXCc^^. 
M ll" ^'i Vrilcv.' ' St.: ^1 Dist.:bet. LVU-VVCca' and Ix<Xvl 

;N0. I <- V, ' V ' ^^^ ,.„„ ,|c;iIAL RESIDENCE iivt TACTS CALttO ■■Ofl UNDER s <■ C r . Al . N rq, n V AT l O V 'j 

( ' .°/*;':T°"oCc"-"«r;,"rHo",^.",1' r";:"^u" ; 0,V. ,TS name ,NST„C. O. STP^.T A.O .U.,^.. ) 

FULL NAME vv -a.-^vVij, ^av..>-' ^ ^ojj^'^l- 



PERSONAL AND STATISTICAL PARTICULARS 




CLU. 



-L'lV'.-t-^ 



i ii 



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->!N<,I.l- MM 



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fUK THI'LACl-: 

(11 \» 1 1 1 1 }.■ K 

ur.tf. 



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■iH,,AH..VK^TSTKI..-KR.nNA,.rAKTi.M XK^ VK,: PK- V. Tn 1,., 



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JX 



^ 



MEDICAL CERTIFICATE OF DEATH 






^ -) 



1 lll'iKl.l'.V 

tlial I la-- 
,,!i'l 'hat ik'atli 



;■ \\ T;! it J altcndotl litit- a-^fd li'>ni 



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SIGNED J. \bL 



a 



M.D. 



V < 



o. 



\iMrt<-i ' -* 



\^; jflo.vK^t 



SPECIAL INFORMATION "nS for tlosfiifdls Institutions. Frdnsients. 
or Rerenl Residents, ani persons d^inj .iwd> from fiome. 



former or 
IsudI Residence 

V^fien was disease rontraited, 
11 not at pla«eof de-ifti .' 



tioH Innq lit 
Plare of Deatfi .' 



[),ns 



i:j. \>i-: • »i 



i;( i; 1 VJ. • iK K I'.M' ''' \ '■ 









— — " TT TZ, Z.V. KV.uld ho state.! fiX^CTLY. PHVaSICIXNS hHouI.! 

.ta.e CMISi: or DIIATH u. phnn U r.ns. th" t n. >. 



VZ^^ni «w«y from ho.nc should he ti>en in every mstnnce. 



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ft,«1 



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REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



]i('i>isf crcd 'jV<f, 



2003 



V 1 ! , 



DEPART.^ENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccvtificatc of Bcatb 

( 11. S. i?tnn^arC> ) 

PLACF OF DEATH: — County of "^CV>A Va^vCt^aCity of n^>v OAO.>VCtACO 

f ■ ^ ^^ I f tt 
W«. V^O '. v_Kt1vtu N<L i\aa.l St.; Dist.;bet. : and 

'^^ ^-\. V»^ I v^ ,,c,ifti orQinFNCE GIVF FACTS CALLED FOR UNDER SPECIAL INFORMATION t 

( " rF"„rA,°„"oCC:-tEo'.NTHofRrAL o" "n S f I "u^ I o" " V " tI NAME INSTCAO OF STREET AND NUMBER ) 



FULL NAME <-tV.>\V-v ^<^A 



^p 



PERSONAL AND STATISTICAL PARTICULARS 

:.:k:ii > 






1 '^ 



■>'c:ii ) 



\M 



M \K K 1 1 : • 

".\ i ill i\\ 1 1 > <>K 1 1 !\ < iK< 1 ; ' 

\\ I il< ill sixiiii dtsi',' tiit' 



I 



11 



Mllavvc.a. 



)MR!"!!!'I. \" I" 



NAM I Ml 
!•■ \ 111 11^ 



!'.IK I II I'l. A'l-: 
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MAini'.N N.XMi; 
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111 Mnrill-;K 

' st.iic (>i t'liuiitvy) 



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v\JlXxx/' 



MEDICAL CERTIFICATE OF DEATH 

DAll-; <'! Dl.AlIl V 

I HI'. KI'l'.N' t l-K'riiV. That i atU'inK il 'ln\aso.l fri'in 
l\fc ^1 UfA to ^-4-^ "^^^ '*'^' ^ 

tliat I last saw h -.H' alive on ~) ^jvt 'X% HyO H 

ail. I that lUatli ..rriurcl, <m tlu- ilatc stated above, at 1- I 
Jl M. The C.\ISI'M^>I' DIN'i'll was as follows; 



\[ 



I )rK.\r I ON )><?/■ 

CONTRIIU TORY 



or RAT ION ^^^)'rars 



M,uith.^ 



nay. 



■.v 



IIOHUS 



(SIGNED ) 



■^(T* 






/hn'< 



I lou) s 
M.D. 



CI 



Xkta% n,oM rv,hln.ss)Ul^Vlc WH^^^- 
SPECIAL INFORMATION only lor fJospitals, Institutions, [rdnsicnls, 



YVC^ 



• >i'tT I'A rioN 

kt'idfif ill San l'i<niii>rn A \ ^''•'^" ■^^" 



nth ■ 



/.■,;i 



THK AnMVHSTATK...'KKS()NAI,rAKTI;;rLAKSAKK TKIK T. » TMl- 



nnfuniKiiit 



(JXoto 






■n 





s 

rRi 
Former or 



or Recent Rcsidenl^nd persons dying away Irom home. 

'Tj O ^ How lonq at ^ 

Usual ResidenreH J aulovJ v\^aU Place ol O^.th? , Day^ 



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



iM<Ai:K/)i- lUKiAi, OK ki;m«»\ai. 



C (^\ 



n\i;i'. o! r.riMAi. or ricmoxal 



(Address b IR ^iWo^CV <UvKX^ ■) X> 



__Jl^»^m^ ^m ■—^^—^■^■'^■■^'^^"^^^ FYjfrcTI Y PHYSICIANS should 

state CAUSE OF DEATH in ^ «'" *;7':;^»;" /Jcry 1n«t«nce. 

snn% dyln* owoy from home nhould be ft.ven m every ^ 



s 

If 



I 



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RD 1^ 



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r— >,..M^^^^ ^^ ^^^*^ ^^ CERTIFICATE FOR INSTRUCTIONS 



7.'^r>H 



Jt('0/^f('/('f/ ^\\). 



;^004 



cLt-v ■ 



DEPARTMENT OF PUBLIC KEALTH-City and County of San Francisco 



Certificate of ^cath 






PLACE OF DEATH: — County of 



U 



City ofCJcX'^v 0-V<X>x^>s 



4 



1- 



N<^ LLUv ^^^A.C-VV>v\m. .v.^v, St.; Dist.: bet. nnd 

/ . r r*T„ OCCURS Away trow USUAL RESIDENCE c . v c facts caui ed roH uNDtR ' sp-l^.al ^formation \ 

V HOCCUWflEO ■ 'SPITAL OR INSJITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. j 



FULL NAME ---^1 



n 



PER'=;ONAL AND STATISTICAL PARTICULARS 






IL kcU 



Uo 



MEDICAL CERTIFICATE OF DEATH 



\ 111 



ci 



dxUt 



a.^ 



5^ 



•s 1 . 






I jii-, u i:i;\' c !■. KTii N , I 

■ iinl that (i. !, -: '-M 1 -• !„,v. ,) (0 30 

VI \I. Till- CA! SI'! ()\- |)i:\TII u;,s i,'. follMws: 



^niavt 



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i' ' !■ ; li I I. \. 1- 



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III k \ii' ».\ );,/; , 

hi kATh iv ,vx ^' 'i<^ 
( Signed J a. 



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//. . / . 




.)/,'v///. 



/In- 



//.,7/s 

M.D. 



|AJb an 



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ON fnly t'"" l''is|til<ils, Inslilufinns, lr,(n^i(•^l(^ 



(yvA.-AX\A>^J. 



TIM \ !;' »\ ]•■ X r \-|- )■ J I I' (. «s< i\ •>. I, !• \ i< ii'M I \ i^ > \Ki, rki !•: I't iJii-: 
-I'M MN I, ,\' >\\\.\ 1)1 . ]■: \ \A> i;r, i.in- 



MN I, ,\' i\\ i.i 1)1 . ]■: \ vi) 



Special iNFORMATi. 

(ir Rpirnt RcsiiroK, .iiid persons djlnq d\».«y froti home. 
/>. 

former or i o ^l Iv j V "14. ""^ ''"") '•' / <J 

IsudI Rrsiden.e ^ o5VD V<KUVa.C H C'X n.„p of Rcilh .' b 1^ 

When H.is disease (onlriKfcd. 
II not df pirfff of (lerfth .' 



f),ns 



rv.I.li 




Axlo*^, 



IM H I A I, '»|.: Iv'I'-, Mm' i 

^x% Qt>r dlu 




i i. i!' i.i VI Ml k i-;M(i\' \i. 



I 



ion 



.\(ii!i.-v 






N, 



It. r.vcry item oV i,i V .nmH i..ti should I).- .:.rcMiIly supplied. Mil. h'i .il.I l.c Htnl-.l lAACTLV. l»HVSlCr\NS . 

Mtntc CM'SI or r)i; A III \n |>liiiri terms, that it msiy l>c properly UiiMHiViccl. The "Spcclul Iniormiit ion" »u 
sons (lyinil jivMiy from home slioiilil be ftiven in e^cry inHtiincc. 



I»HVSICI \NS Kh<ml(i 
r p«r- 






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|f:!>.: 



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m. 



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WRITE PLAINLY WITH UNFADING fNK — THIS IS A PERMANENT RECORD 




I'.th I No 



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REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



mmflfmm^nmm 



i ' - 



jn(n 



llc^i ^-f ri ('(1 \(), 



jaoo4 



DEPARTMENT OF PUBLIC KEALTH^CIty and County of San Francisco 



'?^ 



No. 



Certificate of Beath 

PLACE OF DEATH: — County of O I vcl-n . City ofC'cx-iv J > -> . 

LLUl '^V.CvV\.>\.lu A. .^v, ^ St.; Dist.;bet. and 

\ / ir DtATH OCCURS iwAV FROM USUAL RESIDENCE GIVE FAC-rS CALIFD FOR UNDE H ., t> ,AL , r^ F O R M A T i O N \ 

V If nrATM OCCUR^fD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J 

FULL NAME "L'XUa 'f^ 



PERSONAL AND STATISTICAL PARTICULARS 






' ' 'I. 




,'.k\AJt 



l»A 1 !. ' '1 I.IK II 



Uo 



MEDICAL CERTIFICATE OF DEATH 



i I \ r 1 



ax|\t 



x% 



1 



\!..i.l!i 



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5H 



^iNt". i.i: \i\Ki<ii:i) 

Nviix >\\ i:i> (»k n;\ I •'•: I i> 

Wl it- 111 ->,.-i;|] ,], ,i;_, !|ali^ itl I 



liiK rn iM. \i' !•: 



N \M1 I H 
I A IHl-.k 



liiK III j'i. \( !■: 
oi iaiiU'R 

'St;ilr 1)1 I', HI Ml 1 \ 



M \ mi: N \ \ M i 

' H Ml till I I. 



lilinFII'I.ACK 

"I- MormcK 

(Slate ((I C"<»iiiiti\ ' 







. I ^i !• !•: i: !;v ( i. kii 1 \ . I' 
tii.ri I i.isi s,i\v h x^J .iii\f.iii - _c,^v!t !lo 

:i ii'I I !i.il iI'Mi h • Miiurcil, ( 111 ! h( ' 
Of M. 'jlir CM SI' (11 hi \ i I I • 






-t-o 



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()i u \ i i< »\ );,// N 

( < "N IK ! i:i iMiv' \- 



.;/-■///// V 



/',/! 



// 






.NjJuX 



yxA, 



! li R \ 'I' H » ,\ 

( Signed i 



•^ ■ ^1 







/',/! 



// / 

M.D. 



)ji\\X 1^ !«,oH I \,|.|r.^. ) ^^i 



[jU i '"^ Lc K o^^t 



M.C I |. 






10 



M. nth 



riii". Mjovj'", ST \ ri-:i) pkksi »%ai, pak i i'Ti, \i<^ \ k i. i'k ' 

ItKST <»l' MV- K\< iWIJlH'.F-; NNM) 111 I, III- 



' Iiifoniifiiit 






Special information "hIv lor l^(^|lil.lls, ifj^iiiutions. ii,inMViiis. 

or Keren! Rcsifjcnh, riml iicivkin iMmj ,iw,tv Iruii Ww. 

Formffor i a<r* k J . r. ^+ ""« ''""I ••' /O 

Usudi RcsldciK e ^ ->o ^^i) V^cUVvCH ' }h |'|,„ ,. „f (),,,||, .' b C> f),,vs 

When W.IS divHS'' cMilr.Mfnl. 
II not .if pUre ot dcdh .' 



\'\ AA')-". ol- It' 1^' • ■^'- "'-' ' ' ^'' '■ 




' 1 ' ! I 



^ .ct. 



■ r I M> 'X M, 





^yAJ 



iXki/sk. 



Aa^chu 

Mil KTAKIR K-. ' ' . Ll XlXV<ia^. 



'\<i.:i 



ri. 



B._r.vcry Item «f M.?.r,nHtlon .ho„l.l b. c.rcVully suppli-l. M\V. nho,.!.! »>«.hV'*%'./'^..«'"'''.^; , T" '^^''^m' r7"r' 
«tHte CAUSE OF DEATH in ^>U^\^^ tcrn.H. tli,.l it may he .....pcHy cIhhhU.c.I. The Hjkc.hI l,.»or„n.l ..n .or ...r- 

Hon* flylnjjt nwuy from homo hIiouIiI be feivcn in every inHtnnLC. 









*^r,» 




111 



s 



I 



i 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



^■" r**"*.. 



RrFFR TD RACK OF CERTIFICATE FOR INSTRUCTIONS 



/y.//r /•V/^./,,'^x\^tx^-^vivX^. V] H^n'i 



Jtro'/.^/crcf/ ./W^ 



J^oo5 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Benth 

PLACE OF DEATH:-CouotY ofOa^V d\a>XCUCO Gty of Ja>v Va >uru CC 



N 



n '1 M i\v ;iL VV (nv l^V^\t ''^ St.; .'^ Dist.; bet. ^ '^^ tk and 1 I t ', 

O. I M ' LVVL>^V V TV vv VV VV RESIDENCEG.VE facts called top under ' specal .ntormation \ 

A HOSP TAL ?R ?NST.TUT.ON 0,VE ITS NAME .NSTEAD Or STREET AND NUMBER. J 



A^WJnv V^V<^\I) '^ St.; ^'^ Dist.; bet. „..,,,„„ 

( - ---^c-Rr-,-n^^^ ^^^-f^^^^'^-^ 5;ame .^i^eTo? st;^e/: 



\' 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

. >! I;l K 1 11 I 







L 



Miiillr 






40 1 



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si\( ,i,i- M \KK n:n 

\Vi ;t' in -•' >ri.-i! ilc^r.' n.it i"ti > 






-1 



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11 



\ • .11 



/',/ 



111 KTH ri, \ri'. 



1A1)1 l.U 



I'.IK I'll I'l, \C]-. 

«)!■ lAllli: K 

' St;ilr Ml Colliltl V 



M \ Mil". \ N AMI 

111 Ml rn I i:k 



miniii'i.Aci". 
<»!• M«»riii:i< 

(stall i>r ^.iiuiiti \ 



i 

m 



oX VN oCt^AJl OA <X >\ 



Xo 



MEDICAL CERTIFICATE OF DEATH 

DATl'. nl- I>1 Alll i 



1% 



H 



I llhKl'P.V (.■|:KTII'V, 'I'll;!! I .I'.il.lr.l /|. 



si 






lli;it I last saw h L'Wi alivr i>n 
a.i.lthat .Uath ..rrun-c.l, . .„ t lu- .lal.-iatol al..vr, ,t ' I .N 
j yi Till' CAISI' Ol'' DIATII \\a> as |"oll..v\s: 



.lA';////' 



/-»,/; 



1)1 k \i ION >'<?r.s- ... .^ 



//('/// V 



C()NTKii;i"l<»l^ 



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I urn- \ iiON 



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XI 



TH,.:M.ov,:sTvrKn..K,<.oNM ^^KTK^;;^K^ vKi.rK.K To Tin-; 
iu:sri>i Mv KN<i«i.i:i"'i-. .\^" '■'■'ill' 



( 1 11 !■ I1 111.111 1 



\ !>. >< •\\ l,l'. I""- -^ -Lp. 



,^^urv\ 



/'./I 



i SIGNED ) d>VcL\X<X. '^^'^'(V ' ' ""^ 

■ SPECIAL INFORMATION oiiU tor Hospitdls. InstituViorfv, 
or Rfient R.'si.l.-n!s. ..nil persons dyin) .r.v.iN fron home. 



M.D. 



hi 

frdnsirnls. 



former or 
IsudI Residrnre 

Whrn was disedsf (ontrartfd, 
|( not ill pla' e of dpdtfi ? 



How lonq at . 
'Idfc ol Death .' 



,., ,VL-K Ol- r.l KIM. <'K Kl-M"'^' 

n 



r .M ) 1 



rxii^ii'-^" 




8tatc CMIsr «M III. ^ 111 I ,,. rt:v«>n in every inslHnte. 

«ons clylnn nwi.y from homo hHouIcI be fe.ven 



^^ 






4, -^ 



I' 



a^p**^' 






T"" 



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I 



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WR! 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



r I t .1.1. I V . 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J'l'0'/,s/('/ I'll A'o. 



o 



aoo6 



^v^cA -LiL'xvu Deputy Health Officer 

DEPARTMENT k PUBLIC 11EALTR=City and County of San Francisco 

Certificate ot IDeatb 

PLACE OF DEATH:-County of 3a.V J KauCiUK:ity c^ ^OAV XXX^C^C 

Dist.;bet. "LaX'rvl-YV. and ib^VO^^i 



No. 



mi 1'^ '-aeavc' 



St.; 



1 MCAI OFCIDENCE GIVE FACTS^CALLED rOR UNDER SPECIAL INTOnMATlON' \ ^ 

( '^ r/rEATroCC^'lrcV;.''rHo"s' alt "« "^IsnTjV'o^^O.VE .TS NAME ,NSTEAO O. STREET A.. NU.BER. J ) 



FULL NAME 






\ 



CViV^VU 



PERSONAL AND STATISTICAL PARTICULARS 



- 1 \ 




i.( If,' 'K 



flaU 




\ 



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_"U. 



1 I i| ", 1 K 1 II 



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as 



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lUH run. mm: 



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JUKIIII'I, ATH 
Ol" lAlin'K 
'St;il( or CoinitiN 



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that I last saw liC»\ ' 'ii - t^^ '^^ ' 

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\j^^^^ Deputy Health Officer 

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco 



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Certificate of IDeatb 

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DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco 



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Certificate of IDcath 

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0.\.<X> vCc;iC(City of (Xo^' o,va^ , 
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SPEcTiTTi^RMATION '.nh tor llospitdK. hM.lutions. rr.,nM.nts 
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Gcvtificate of IDcatb 



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of^Ct^^ J^a>YCUltt City of <^VXAV .1 \CWXCV4C* 



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PLACE OF DEATH: — County 

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DEPARTMENT (If PUBLIC HEALTH=City and County of San Francisco 






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Ccvtiticatc ot Bcath 

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PLACE OF DEATH: — County oi^r \a^\CU.CC City of Oax- JXCV-YV<^ 
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SPECIAL INFORMATION "iilv I,h H^.S'itHls. IrMitiitW. lr.insinits. 
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IRc'Cjisfrir'd .Xit, 



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^^^.. \^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



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MEDICAL CERTIFICATE OF DEATH 

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SPECIAL INFORMATION "n'v I't HoM'it-iK. liMitiifi.ns, Ir.m.ients. 
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^v Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

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PLACE OF DEATH: — County of Uao-Y' Va/>\X^UVCi City of .CU^a.- 



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IVAEDICAL CERTIFICATE OF DEATH 



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SPECIAL INFORMATION "nlv to. H..spit.,N. Inslituti.ms. |,.,nsirnls. 
or Recent Resi.lenis, .mil persons dyin) .iw.n Iron home. 




tUAKOXCLd' 



Fflrmer or 
Isiidl Residence 

When was diseasf (onfrarted. 
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2013 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



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Gcvtificate of IDcatb 

PLACE OF DEATH: — County ofCW^^ VX>VCaACC City of ^'^-v^J 0\aax.C<_« <^ ' 



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No l^50.'Vi5xcolvav.- St.; "i Dir.t.; bet. CWtUx' .xndVJUc^L 




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SPECIAL INFORMATION "nlv for IIos|HMIs. Instiltitioov [.ansi.-nls. 
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(low lolKI .if 

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2014 




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DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



X\. 'X\ 5tnnC>ar^ ) 






PLACE OF DEATH: — County ofCjOO^\^ ;v<X/>%Ca^co City ofC'cUYV Va/>VC 



No. IC 



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/ IF DtATH OCCUR?: AW*V FROM USUAL RESIDENCE GIVE FA-TS CALLED FOR U N ., t H SPECIAL INFORMATION • \ 
\ IF DEATH OCCURRLD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




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IVAEDICAL CERTIFICATE OF DEATH 

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SPECIAL INFORMATION "nlv lor H.ispitdK Institutions. Irdnsirnfs. 
nr Rpn'nf Rt'siil»'nls. dnd (iffsons (jvlini ,itt.i\ Intn home. 



TMKA.U,VKSTAT,.:i)rKK^oNAI,rAKTH;rLAKSAKKTKrKT.. Tin: 

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— ^^M^— ^1— ■— ^^'^— ^^'^'**^^^ i-vA.-Ti V PHNSICIANS should 

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.,aU- CAUSE OF DEATH in p.«.n -■■•»:;;^" J', ".^^ ^J„„,,. 
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prtrpR TO BACK OP C?[RTIPIC^TE FOO INSTRUCTION? 



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DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

II. 15. 5tnnC>arD i 
PLACE OF DEATH: — County ofOaTv O.Xa^^^<^<^ City of 0/CL->-u 0.\.a 
o. X\X'^'VC4\; Jc (SA.'fVvL>(X'i St.; Dist.; bet. - ^nd 

/ IF OFATH OCCURS aUaY 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 O "^ STREET AND NUMBER. J 

FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

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MEDICAL CERTIFICATE OF DEATH 

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SPECIAL Information ••nl'' ''"■ ll^^pif^ls institutions, frdnsipnts. 
or Reient Residpnls, dn^l persons (ivirii .iw.n fmii fiomr. 

When W.IS disease rontr.ii ted, 

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XcrVA.^ dUvM^ Deputy Health Offi--r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate ot IDcatb 

PLACE OF DEATH: — County ofOct^'v OA' City ofQcL^v J.\.o , 

No. It"^-. ' ^. ,.. • St.; ' Dist.;bet. 0.\jcX >V' .md Lv . ' ' 

/ IF DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS C A 1. 1 P D FOR UNDER SPECIAL INFORMATION ' \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 






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MEDICAL CERTIFICATE OF DEATH 

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SPECIAL INFORMATION "'i'^ •" H'tspilal^. In^fifutions. 
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Htntc CAlJSi: OF^ DIATM in plain terms th,.. .t mM> - P-"^ 
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201 






V.C<^^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Gcrtiticatc of IDcatb 

PLACE OF DEATH: — County of C^^^ 



I \ 



City of ^'CV 



N«. -vCL->A^!L O^Ch^Av^ 



St.; 



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and 



/ IF DFATH OCCiJRS AWAV TROM USUAL R E S I D E N C fc. & I V E FACTS CALLED FOR UNUtH ^ "^ ^ C^* l- ' ^ '''•'" '^ ^^^ " ' 
V ir DEATH OCCUaRED IN A HOSPITAL OR INSTITUTION G!\ 



!VE ITS NAME INSTEAD OF STREET AND N U M L, E (- 



FULL NAME 




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PERSONAL AND STATISTICAL PARTICULAR 



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MEDICAL CERTIFICATE OF DEATH 

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AVu.f,':f .u . ^>r '"" ' ' ___—— — 

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lU'.sr «»!.• MV KN.)\\ l,i;i)< .1'. A\l» MlJl.f 

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r.M,.... IIS VJO^v.V 



SPECIAL INFORMATION '»ii!v '"' ""M'i'.f'^ Institutions, FrHOsicnts, 
or Retent Rcsiilenls, .inrt prsoiis fl)in| 'Ih.in fr'i'i ti"'HP- 

r , „, 4 1 "^ How l(ini| .it f^ 

Formpror , ^ h ^ ■ ' ...... ..• M....h» .S 

UsudI Rfsidenre ^10 J-v.- 

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sons dyinil uwny from home should be fc.vcn .n cvcr.> 



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//.vyH 



JtC^'/.^/r/Wf/ ,A'o. 



o 



018 



3^<3H.^L.^^ duiAK4 Depu- • iealth Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Gcvtiticatc of E^cnth 

i ^ i ^ 

PLACE OF DEATH: — County of OclywO \.a^\CCA/io City of CIo^'YV. ' "' . 

I X ]^ ^1 . 

T4f>XL^\.l^^^J^Ty\.iL^<U.\x<x^ ^- 'St.: Dist.;bet. and—- 

(ir DEATH OCCufes AWAvVptOM USUAL RESIDENCE GlVf FACTS CALirO FOn UNDER "SPECIAL INroRMATION' A 
IF DEATH O^' RRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 

e .1 



FULL NAME ^c\ 



-, V, ^ 



PERSONAL AND STATISTICAL PARTICULARS 




I !.;!;i'ii 



MEDICAL CERTIFICATE OF DEATH 



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M.D. 



Special information ''nl\ l-'i llospitrfK, liMitutions. Ir-insicnts. 
or RiMcnt Rcsiitcnts, dnd persons dyin-i .iw.iv fni.n ho'iic 







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Former or M ao 
L'sihil Residenre *^ ' 

When W.IS disease (ontr.n trd. 
It nnt .it plare ol derftfi .' 



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liim Innij <it 
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* ... . . I iVAt'TI Y PHNSICIXN'^ h!u>iiI«I 

■^•- - , .. ... v<:r. Hhriuld be stilted l.XAUIi.»« » ni-^iv-i 

^. H.-_,;v.ry item o^ In^o.m.t ion shouM h_ cnrouMI. s..pp ... ^ ^ ;,.,^,.,.,,. The '•Spccud l,Wo.n..;....' .or ...r- 

♦ » r\irKl or DI \TH in phtin tcrm«, tlint it mii> i»- pr-M"- ) 
"r, ."na '.-" .vL o 's c .i.e„ in ever. Ins.nnce. 



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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






*^EFER TO EACK OP CERT.'r.'CAT^ F'^R • ^jc-tbi i/^-ri/^me. 



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DEPARTMENT OF Pl'BLIC HEALTH 



Rf'o'is/r/i'd A^n. 



2019 



,CrvAw\-^^ H^cvM^^ 



City and County of San Francisco 



Gcvtiticatc of Bcatb 

PLACE OF DEATH: — County ofOa^' VCVwcULCO City oiOOj^X' O^Va 



No. tHO.b Mrwa^vH^l St.; Sl Dist.; bet. ytnxt- 

(IF DCATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLEC 
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME 



and 



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4 



FOR UNDER SPECIAL INFORMATION 
NSTEAO OF STREET AND NUMBER 



FULL NAME 






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PERSONAL AND STATISTICAL PARTICULARS 

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MEDICAL CERTIFICATE OF DEATH 



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\ SIGNED ) U-X-Cr-VV.'. AJ). U). cLa..'..-. 

s. InsMfufiWiV. r 



M.D. 



SPECIAL INFORMATION "n!v tor llospildl 
or Rp(pnt ReMdents, ,jinl persons d.uiv| a-^a\ fron hnmp. 



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IN" XiiOVJ'". ST \11' 11 (•(•K-iiNAl, i' \K Ih I ; \K 

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f ormer or 
Usudl Rpsidfnre 

When w.)s diseasp (onfrnfted, 
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HoH lonq flt 
Pl.i.pof l)p.i(h.' 



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~- ■■ ' ~ T^. wjR «Ho...lcl be Htnte.l lAACTLV. IMIVSIulXNS sh.,ul.l 

N. B._r.very item of nWormi.tion shoul.l Ik .a.o.ully f;'PP -'^- ' ,y .u.ssh'lccl. The "S„c.u.l In.ormi.t 1 .n' fur p-r- 

«t«tc CADSf- or Df-ATH in plain torn.s t.u.t .t ni..> .^^ P^^^; ^ 
son. dyini «w«y from home shonl.l b. .i.ven m every mst»nce. 



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DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of £)eath 



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XX. 3. !5tJln^a^■^' 



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PLACE OF DEATH: — County ofV Ic 






Tri> 



Gty of^ '<X> 



No.WA^> l^tmA.<lQiv^i\ 



St.; Dist.; bet. — 



and 



/ \r oFflTH occir4 away rno^fl USUAL R E S I DE NC E Gi VE facts