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■
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LOCALITY OF
RECORD S
SAN FRANCISCO
COUNTY
S AN FRANCISCO
CALIFORNIA
HEALTH DEPT
M I CROP I LMED
FOR
THE GENEALOGICAL SOCIETY
OF SALT LAKE
C A L I FORM I A
C I TY
UTAH
j^
DATE
APRIL
1
1975
PH OTOGRAP HER
CAMERA
NO ^'=;
MAX JOHNSON
RED J
I
RECORD
CERTIFICATES
VOLUME 2031
Y EAR
1904
)U
» I
♦ ..
X
'•)-.*Aj:v>^v'-,
P^i
EGIN
4
I
I
f
• •
I
..^•••••'
.^. » " • "
^ FEB8 i«0>^ ^
i»l.^f..waA. pew*' -•-•'*'•
fl/ P.
iiber H'
El)M()NI)(i()l)(^!lArX,
) I, OUDtrt
By-"
DEPury.
I
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.,1 II^;.!lh I- N.^. !. •ft.'^^^^tr 155:1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale Filed ,
hj \
100\
Be mistered J\^o,
3a3i
1
vcoo
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No. IHS
Certificate of IDeatb
{ *a. S. 5tan^ar^ )
PLACE OF DEATH: — County ofO/CLY^ J-^^O, ixo.^ci Qty ofCj-O-AT^ 0/vxx.-\-^C.^<i. Cc
/ ir DtATH OCCURS ^WAV FROM USUAL R E S I D E N C E G I V E FACTS CAILED F
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NA_M E I
FULL NAME
St.; ^ Dist.; bet. G A^^ vcJ l.Ui and ' I
-OR UNDER "SPECII^L INFORMATION ■ \
NSTEAD OF STREET iAND NUMBER. /
^ n } u
A
li A I ], ^ U lilK III
PERSONAL AND STATISTICAL PARTICULARS
Cf^
U. mil
11
(D.'iv^
/?
A' . I-
/',M
•^iM ,!,i- M \u\< n:i>
u'l In t\\ ]■ I » » iK It ;\< ii-T i: t)
iiiK rnri. st^-"
(Stat. I.; '■ .mill
A 111 Ik y I
p.iK I'll I'l.ArK
<»i I \ rin-k
a. , "
\a
M MI»KN N \M 1
m- Moilll-.K -^
cLttrwcfuX'
JUX
Jn
Jus-A.
I'.iR iiiri, \t*i:
t>i %T<»riii.K
-•• 1 1 .11 t". Ill Hi I \'
I M I I TA 1 ION .
(v..
^'
);-,i
Ar,,,'//'
/hi
Tin: M'.n\ I' ^ r ATi:n fi-KsoN m, rxKriiti, \ks ah )•; tkik m rm-
in%sTi>i 'IN KN<iui,!,i)",i'; AM) i;i'i,n,i-
MEDICAL CERTIFICATE OF DEATH
DA Tl.; nl- DMA'CH J)
U-t^UZt. 1^ /Qn\
(Mofithi 'I>;iv) (N"f,ii)
1 HlvRIUJV CIvRTll'V, That I alk-iuU-.l .U-iH-ascd from
CLl^q iS iqo , to a-dAl XH upH
4 f
> I ' f
Up
tlial I last saw li '. - alive on
and that dt-ath orciirrcMl, on tlicdalA- --t.iti'il alnivi', a
M. Tlu- C.VrSi: <)1- I)i;.\TII was as folh.ws:
Dik \ rioN
) 1 </; >
CoNTkllU'lN >RN"
Mouths
Diivs Hours
S ...i^'_'^ I
3-1^
»...,., }'(t/rs Qt Jf(>>///is
NED)C,3). ^^^xtU^
,o l f AiMrc-ss) Ss'X'ivJ
1)1 RAT ION
fSlG
/hivs
Hours
M.D.
0^'.A>-»i^U.; ^t
Special information «nlv for Hospitals, Institutions, Transients,
or Re»ent Residents, and persons dsinq awdy from home.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death ?
HoH long at
Place of DeatI) ?
Oa\s
'i,Aci': oi- nrKiAi. or kkmdvai
DATK (.1 Hi I'i \i .)! KKMOVAl,
I N I ) J : K T A K !•; K VJ ^\XX>\} ^U. LL A '. ^
T90'*
IN. B. Hvery Item of inf.,rm,tion should b.- cnfcfully Hupp!'. mI. AHr. hHouIcI be stated HWCTLY. PHYSICIANS Hhould
Htate CAlJSli OF DLA TH In plain tcrmn, that It may be properly classified. The "Sputial Information" for p«P-
«nns dyinft away from home should be d;iven in every Instance.
WRITE PLAINLY WITH UNFADING INK
;|. :,Mh
^i, l!^;:!' Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dufr' Fi/rfi, y^tc^v I
IfWi
Bniisfered J\^o.
203^
o'i
V^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
N
Certificate of IDeath
( 11. 5. StanDarD )
PLACE OF DEATH: — County ofHo.^ si JU>jy\/:AA.C^ City of H Om; ^ KOjYs^^^l
o Ul5 LlaA.1 St.; X Dist.;bet. ^ I tO-^tr^ and ^ <X^^
/ .F DtATH 0CCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ (^
V IF DEAtJh occurred in a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J
FULL NAME
lid
a^
PERSONAL AND STATISTICAL PARTICULARS
- I , X
(.<
UA 1 1-: < M lUKTIl A ^
\ < }•:
bl
M.uit
)
Davi
0s. M.,>i!li^ C\. J^
/>,!'.
U i ! M i\\ 11 1 t >R 1 'IX'i )Ri- 1 I)
\\i !!( i ti *' irial lit -i^'li.il ion)
^!.,i.. I li I '• 111 nt! \
1 A 111 l.R
luk rHi'iAiK
ni- I \iiii:r
^ t I t ■ • •'. t " \ ! 1 1 t * ■>
M \iiu;n n ami;
()]■ .Mt»riii;K
lUR rmM.AC!-:
(ii M(rriii''.R
i ^ia!i , u (.'ounlry
d
e 1
In
Aw VCU J -t\AXV)
y^^
/\'r:-;-ff'' •" Sil>r /
11 H-. AH')\'l", STA TI-: D PKR-^nXAI. I'A R Tl i " r 1 . A R S AR l*. I" K T l-l T* »
iu>riii MN' RNnwi.i.Dt'. J-; ANi> i'.i;i,ii;i
III 1-;
!liifiii inaist
lis [AjXxl 6fc
^V>Xs
X'l.h I'-s
MEDICAL CERTIFICATE OF DEATH
DATK Ol- Dl.ATH I'
(M.mtli)
(Dav)
I go
(Vt-ar)
I III'IRIU'.V C 1:RTI1'\', riial^I attoiukMl (Ucrascd fnun
axkfc
Q
1 1 1 '^ , 1 nai 1 aiU'iuuMi ii
that T la'^t ^a\v h
190
alive <Mi
JJLi ..\j
it)0 H
in<l that diath iHHurred, on t he ilatt. ^ta!t.<l almxr. at llob
AISI-; ORDi: A
^ • M. Thr CAISI'! OU, DI.A III \vt- a- tuUows:
K^^VX^fr^ VCLA V 1
Dl'R ATION \ Years ^ Mouths
CONTkllU'TORV
Day
Hon
/ s
DTK AT ION
(SIGNED)
^
)'t'ars ^ J/oi///is /^avs Hours
*^K. d^i M.D.
Special Information «nl> for Hospitals, Institufions, Transients,
or Recent Residents, and persons d^ini a^dv from home.
Former or
Usual Residence
Wlien was disease fontrarted.
If not at plareof deatfi ?
How lonq at
Place of Deatti ?
Ddvs
l'I,ACI'; 01* lURlM, <)R K!.Mii\\I,
m €.Lv>^t
>\rU.'i; I'a HiAi, <M Rl'MOXM,
I NDI R lAK i;K
(Address
W^lX I TQO'
IS. B. F.very item of infopmiition should bsr carefully supplied. AGB should ha stnted RX4CTLY. PHYSICIAiNS should
state CAUSI: Ol' DLATH in plain terms, thnt it may be properly clussified. The "Special Information" for p«ir-
Rons dyin^ owny from home should he given in every instance.
'?SjS
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'111 1 Vo :^ ti-'^>S.i: lUtP C,
l)((h' nfefl.MizkA.-
n)(r
JRo^istcred .A^o.
0
L
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( 11. S. StanDarD )
PLACE OF DEATH: — County of
\
%
CXJ.
City of
e^\)
OJ
No.
St.;
Dist.; bet.
and
/ IF nrATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V r FACTS CALLED FOR UNDER SPEC
i IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
F + n '^
lAL INFORMATION" ^
T AND NUMBER. /
FULL NAME
SKX
PERSONAL AND STATISTICAL PARTICULARS
I'l il,i >K
\)\oL
\
DAI'i: I >1- iilKI'll
\< .!•:
I7i<
1%
!l)av)
)■(■(;» t
^
M'liHi
X
/
VI
ar
I hi 1
>^I\< 1 I' MA K K II- n
wi I )i iw i- n ( iK I) :\'( )i',t' 1' I)
^ S\'i it: 1 n -SK i.il '1< -li' naliiiil'
luK rm'i. \oi-'.
>t:ili ii! I "i iiml ! \
NAM J <M
} \in IK
TUK riiri, \t'i-:
oi I' \ rii I'k
\! XIDIN XAMJ-:
(•1 MornHR
lUR rniM.An-;
(Ii Mu'nil'.K
(UHT I'A liOX
<f\^^'XKOj
A'
V,;;,' /■; ii Ihf.u'd
IV (II 5
yr,>iif//s
ih.
Tin- M'.ox'i'. STA'i'i':n i'I'-r^onai, r NKfirn.AKs ar}-: ikri-:
in;s 1' ni- Mv K.N'< •\vi,i;i)(',i<: and in;i,!i:K
i"< I I'll 1'
f liifDinirmt
^ (5? (1
'YY^^XLK.^xXj
fA(1.1rf«<«4
J AJtn^^A.^'W WO-X
MEDICAL CERTIFICATE OF DEATH
I) ATI', (M- Dl'ATH J?
Ox^aI:' 'h^ I go'
(Moirth) 'I)av> (V<-:ir)
I IIERlUiV Cl'iRTlF'V, Tlial I aU(.'iiiK<l 'lt.Hias(«l from
— — — ————up -to — ""190 "
that I last saw h - — alive nti — — —— up
and that ikalh ncnirred, on tlie <lati- stated almvr, at
M. Tlu- CAISI'Ol" DI'.ATll was a^ follows:
IH" RAT ION }V,/;s-
CONTRIIU'TORV
I )r RATION ^ Ytars
Montin
na\
Hours
.^fonths
Pav
(SIGNED)
'\
f-f
/t.
.i
«i^
Hours
M.D.
19.
oH (
Address) OXAnA?vO--^^ \jOM
Special INFORVIATION f>nly for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyini| away from home.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deafli ?
flow lonq at
Place of Death
Oavs
lil.ACH (»1' lUKIAI, OK KI'.MoVAI
in "
DAXI". of I'.IHIA
I, 01 K1-:N!( i\ A1
rSDKKTAKl-K Uk/O^ V US An^Ui-y^^^ .
T90H
(Addresf
rS. B. Rvery item of mformntion should be cnre?ully supplied. AGB should be stated KX4CTLY. PHYSICIANS should
state CAUSE OF DEATH in plHin terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ away from home should be ftiven In every instance.
WRITE PLAINLY WITH UNFADING INK —
;ii-. I
No :- t'-r^arS^: liS: 1' I
IXile Filed , U^Clt^r^MJ
K^ \
10 a
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2034
Broi,sfef'cd J\^o.
DEPART
puty Health Officer
DEATH: — County of^^a
Lie HEALTH=City and County of San Francisco
Certificate of IDeatb
( 11. 5. StanDarC> )
'Tu ' J V
City of U CX>^ J,\.CL vxxn.
No. ^ ^ X^-^
4-
St.;
Dist.; bet.
and
FULL NAME
.kXxxaJs
\JLcL
v^roKcet
■rt
4
■ 1. X
PERSONAL AND STATISTICAL PARTICULARS
fl.
i»A 11. «>i ink ill
\ " . !•;
! 1
Muiithi
D.iv)
5 ■--.,■
n
14
an
Jh!\
<!\<,1 }■' MAR ]<!)■'. I)
W\ \n >\\Ki» < >K I) ;\i i!--! i; I)
I W- il! in ■•- ' U -iL- iiatmn )
Hli
■St.
,^
1
L
MEDICAL CERTIFICATE OF DEATH
DATK <»i Dl.A'lH 0
(Moiitli)
(Vcar)
. Day!
I Ill':Ri:iiV CI'.RTII'^V, Thiit r altt. ii-U-il .krr.i^cil fniiii
190 to — — — jfp
that T last saw h — alive on icp ^
and that (k-atll iHHurreil, dii the date -taU-.l ahove. a*; -
~^~ M. The CATSI-; OI' DI-.A'PIl wi- .i- follows:
^jj^^,.^^
N V \I 1 < 1!
I A!'1!1;k
I'.iKfii I'l, An-:
()!•■ 1 Alili: K
' Stat I- 'ir I'tiluitlN
MMDKN NAMl
Ol" MuTIUtR
UTR'niPLAeK
i>I NKiTlll'lK
I Slati ..I t'oiuUl
hCLc^r
lo, a.^L
r
^
.\f,i,ll/lS
Ptn.
Tin" \!'a>vi*. sr\'n:i> phrsonai, i-akiutlaks ar>-: TRii': r< > rm
Hl-.sr ni- MV KNoWl.l I)!',)-; AND lUCUllCF
(It
Adilrfs*
%
H^^ IX ibcrWv><vN^ dt
i
^l.v.OyVU.. ■. -
DT RAT ION )V<//-.s- Moiiihs
CONTR lI'd'ToRV
Pay
//.
'//; \
DTRATION
)V«;-
Pars
(SIGNED ).L^&A\-^V . /xJb LO- iiJUx>XcL
noU-h'V^ j^oH (Ad.lress) Wurv\.iA,^ ^. ^ >
M.D.
cuycfc ^0
SPECIAL INFORMATION only fur Hospitals, InslittMi^iis, Transients,
or Recent Residents, and persons dvinj anav from home.
Former or nn r 'i F, ' Hov» lonq at , »
Usual Residence M^5 la Jt'&AA.vaK ' piare of Death? C <^ (\.:.. D»vs
When was disease contracted.
If not at place of death?
PI.ACK Ol" HTRIAI. OK Rl'.MdVAl,
I)A'n:..t" Hrui.xi. <»r RHMOVAI,
U'tLfc 3^ 190H
(Address IQl'?^ "^i C^Ldjl^^ D^Ojtx LLv^.
IS. B. Rvery Item of information should he cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for p«r-
nf>ns dyinft away from home should be £iven In every instance.
|s)RM 31
^n
ss.
m
m
1-4
M
15 O
I M
K
H
Sq
O
za
o
I— I
Eh
O
H
OQ
o
o
>
lU
CO
o:
STATE OF CALIFORNIA Local Registered No. .<'.yv.^.
3D(^p^rtlnetlt of ^lublic Henltfi
VITAL STATISTICS
Af flDAVITS rOR CORRECTION Or A RECORD
City or
Town of.
W^»
.. of.
^ r-
ll'V
22 ' ' -thj^ ^en
(Name of Affiant)
Calituriiia, bein^ tirst duly sworn, deposes and says that she is
-^ *-
J-
A.l.:rt.i<i
Coiint\ ot
Julius ...Fxad Brockwoldt " [X^f^l '"
(If relate 1. spi ■ • • It. r-— 'f frynd or gUipr>vIs<'. so &['i^ql^
the City I'i
on the.
. .V*j*.
;iN stated in a rertifieate of
wi
th flu I.ucaj Kegi-tiar loi the City of .
. f September 19 04
day or a ^^
I filed In- Porter . anjd :l;i..t.:.
/ death ) ■ (Givu name of I'hysitian or Midwife for Birth — Undertaker for Death*)
County of ■ ■ " N FF A N.GlHCiX California
r-irtifl^j
19.
04
on the ^.s. w day of
That the following tarts set forth in said certihratc are not correctly stated therein, to wit;
Pull name of decadent
w,.
:f father
li, • ;,tHai>' upon her own knowledge ^tate^ the true facts to be, and the changes necessary to make the record correct
T^nHl name of decedent- Julius .Fr^HiBockwoMt
Name of father- Jacob H. Eocfewoidt __
are. as follows;
T
y
u
h.
U.
O
( Affiant) ^^
( Address)^.C.4:...lr.¥ InjL?: ..S t
Subscribed and sworn to before me t\ih...^..y^^^ day of
»-• I
u
SiAir or C M.n oRS! \
CfMintv of
N.it.nv Public in and for the Coun^4flf.*^....ft ..'..>....SS%* <Wjalifornu
^ZZao
( .Name of Alll.iiii )
he
s Aiiait.'.-
Calif.. rnla. being first duly sworn, depos.s and says_that^ has kriowledgey,^ the facts hereinbefore alleged and that the
said tacts as stated therein are true.
(AlTiant)
(Addres|). ^.x2. C^G
Subscribed and swuii, to before me this.v^.../. day of^^^
I , . ^ ...l- , 1 93 j[;^,,rv Public in and for the County of Sr^te of California
•F.,r ,,,11,. tin,; ,,i ;i inuiia^f rntincsifp. in raic lii'itnnrrs where n.-.',.^<ai y, llic word
■justiri-," It... miy i... i,n..; J spclully t'.v way of suhstitullon througlmut this blank.
•were married." "marriage," and "minister." "priest." "judge" or
! : I:
Two
INSTRUCTIONS
iTr
inncipal artida\ir
.( ,; H'
<H1J\- Ji
niii a,
wi^ write plainly u,;,.- black ink.'^'' '''" '"' '''' ^'''"'^ '■■-'■'" M.nat
1^ ith
•*• N'o clmnu'. can .e made in a cert,T,,„. ,
maU changes that will l.-avc In,,,,,, ..,,, /^' ^; '"'"'-'•''■ ''"■ ■'■"c • > :^ :r. ■ ,K, :,, ,,,
' ]( rU ■ ■ , in,., ,n the ccrtilicat,. '
' ■ It the onjrinal certfficite to be
• '-al Reg.trar. on the <;„h of each month '■"^■""""'- ' 'n«inal cer.i.ica,,- .
ppr
ilea:-
Othe-
f'j acre-
.I'd \vi:;
affidavit
"rwardcc
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFEH TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((
tv F}h'il}ui&A>\Kj
U)0\
Fie^htcred >N*o,
'^\^*.
i /
Ow^VA^-
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTlI=City and County of San Francisco
PLACE OF DEATH:
n
No. I'XSc.
Certificate of Beatb
( 11. S. Stan^al•^ )
County ofCjCO^Yx; J /vcL-^^-e.^.^t^City of '^ -^^^"^ -J Axx^-^cv.^c^
St.; 3. Dist.; bet. ^ J^sA^ and A.<XX.Ka_,-> ^ )
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U Ad E R "SPECIAL I N FO R M AT I O N ' ' \
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIWE ITS NAME INSTEA* OF STREET AND NUMBER. J
FULL NAME >0^^^J^
H C
PERSONAL AND STATISTICAL PARTICULARS
■IS A (.Ol.OR
I
j:x)
^l,+
- TV<_^^,
n \ ii: < »i I'.iK Til
f^
M..nth>
\i
n
I>av
Moilln
M%
'X'^:
\ car
/>,
-. I \ ( 1 1 • M \ !< !< ! K I )
\\ \ I M I A I-. I » < iK 1 >;\i III ! I)
I Wi !!( Ill >-. H 1.1 1 (li -11' !ial ii in )
luimiri, \cv.
Slatt lit i". iiint I %
I \ rii ! K
• ii I \ rmtk
^' • ' • I It It ,11 nt ! \
M \ ini: N X AMI-:
isiH'cuiM, \rj-:
(If. M(.rni:K
I vta'' ' il i'l iitilll \' I
J AxLcrvAj-
MIxut
1
(1 \
1/
)i'C !
MEDICAL CERTIFICATE OF DEATH
uAi'i-; « u Di: Ai'n
axivt
igo \
Mental' I Day) (Year)
m-Rl'lJV tl.RTIl'V, That I atteii«U-.l .KcrMsc.l fn.m
tli.-it I last saw h-iA; alive on C'_L.^^xt: ^\ n>o
and th.it death tKH'urrcd, dii the datt.' stated ahove, at J
iX M. The CAI'SIv (>!• DI.ATU was ■a< foll-.wsj
C O N T k 1 1 U "1" « • k \' O/CU A \.CXVv-VA^ cLsJtt. J <>t \
Dik A'l'ION ^ Yt-ars
CONTkllU'TokV
i()0 r.Xddre^s) 13^^ uLl
Mini I /is , /^h\:jl Iloh
I Xk AT I ON' )'rv?;,v Months IH />./rA //iv/; n
(Signed) ^X A. rC.u ^^0 .. j.\ ' M.D.
Special information only for Hospitals, Insfifufions, Transients,
or Recent Residents, and persons dying away fron home.
A'C df'' III V,i;, /■
M. nil,
I I.! S
rm: \novH st \tki) pkkson m. par i iiilaks ark Tkii; to tiik
lU.S'!' nl MV KN«»\\I,J in ,}•, \N!) P.l" IJI'.F
(^
f Fn f >• inaiit
'^wAa.x:^
r
.s 1^5^
^iU.^^^v <jt
Former or
Usual Residence
When was disease fontrarted,
If not at place of deatti ?
How lonq at
Place of Deatli ?
Days
DATi; o! P.iRiAf, c)i Rj;Mi)VAI.
i;i,ACK OI" lURIAr, f)k kp:m<)\a!,
r M ) p; K i- A K V. k MX/V>vX^ i ll O-C^^-vX; ^v K,K
N. B. Every Item of inJofmntlm should b.- cnrcfully ftupplied. AGE fifiould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Sjiecial Information" for p»r-
s'lns dyin£ away from home should be A'lven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,f !!■ 111! !i F No. 1^ ^■^?^;"- li^l' ^''
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llcdistcred jYo.
i^036
HU^jLA^ dUL\KM Deputy Health OfTicer
DEPARTMENT 6f PUBLIC HEALTH==City and County of San Francisco
PLACE OF DEATH: — County
Certificate of Beatb
( 11. S. !^'tan^arD )
\ ^ . A ^
oiQ/Ouy\j vj .^vxX'^^ocAl^cc City of O.ccav 0.*
/v a, vv
No. \'^TH
r\
(^
St.; 0 Dist.; bet. 0 KAJ^
^^rrv^cAJl
and 'J
Li^c \
)
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED !^0 R UNDER "SPECIAL I N r O R M AT I O N ' ' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME ^Ivvyv
W
^.^Y^
Ibx^rvcLuui c
• J". \
PERSONAL AND STATISTICAL PARTICULARS
N
DA n. < II lilRlII
\i. K
IM.mtlit
• 1 >il s- I
^1
/>,n
\\ \\ - ' . . •:i! .!« -it' ii-il imi )
BiK in ri. Xi'K
'->t.i' ' • ■ -iii \-
.vxoo<L
k
X \M 1 ( M
1 \llil.K
HIK 111 I'l. \iH
< )! I \ ni I'.R
NI it" I i! i( lUIl! I %
M M1>1 N NAM 1-:
(ti M<triii:k
I'.ik rnrLAi'i*,
<•! %!<>riii-:R
■^I.l! Pi !'• .11 lltl \
OkV
\ f
?
A
0
( »i I ', 1' \l li >N
h'riisri! ill Still I'l i; III ntii O T. t/if/»
1/..,///
/',/i
Till ^ i'.< »\ !■• s r \i"i:i> i'KR>^< »N \i, !■ \Hrn*ci. XH'^ ARi: TRri-: to rii i%
P,l>r »>! MV KN< lUIJ'.IX.l-; AN!) iu.i,ii;i-
MEDICAL CERTIFICATE OF DEATH
DAI'H ni Di; \TH >^
'J
1
D.iv
I !II:R l-;i'.\' f i: k'll 1*V. That I aUcntU'il <kHHasc<l I'mm
a
IqO H
1»/1 \ to
tliat 1 la-^t -,i\v ll alive nti .\..y.-A. 's . t<)0
ami that <lt ath iHHUirt'il, «>ii tlu- datr >>tatiMl ahnvc, at UJt>^
' M. Tlu- tWrSl-: <)1 DI". A Til was a'^ follows:
LaJvxLv^O^i:^ J W -<^v\^-£.^^
Vf
Jy^
) '( \i I
Dik \ri()N
Motifhs
IIo
lit s
<i^'\^X4XA^
/',
i\\
I In HI s
DrkA'l'lON )'ca)s < .]f,y>i//i.s
(Signed) i /\^ix^^^^ OS ^..<r>x.,L4>'-^^. ' ' .^t v^^ M . D .
a-t^vt %C) ic,nM fA.l.lnss") 9.U DC- Lcxj
Special Information »nH for Hospitals, Insfitulions, Trdnslpnts,
or Recfnt Residents, dnd persons dyinij .may from home.
Former or
Usual Residence
When was disease contrafted,
If not at place of death ?
How lonq at
Plar e of Death ?
Days
I'l.ACK «>1- lUKIAI, OR KI-:M(>\ \I.
a
INDIRTAK 1"K
DAi'Fof Mi RiAi, or RHMoVAI,
T90
Ci,
fA.l.!
^51 oLtU/x. Vi
M. B. livery item oV inlf.iriniition should be cnrefully HuppHecl. AOB shoiihl be HtJited fiXACTl.Y. PHYSICIANS Hbould
«tntc CMISr. or DIIATH in plnln terms, that it mny be properly classified. The "Special Information" for par-
son* dyin{^ away from home Nhould be (^iven in every instance*
WRITE PLAINLY WITH UNFADING INK
I)
fffr /^y/rfI,V^z)i<Ah^>\j I
/.96>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2037
J^eo'/\s/r/'rd A'^o.
VMwO
.K^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccititicatc of ©catb
( tl. 5. 5tan^ar^
PLACE OF DEATH : — County ofO<X'>\; O-VO;
Citv of ^XX^ru g /V>cx.^^ec4 c <
. > i ry\JL<X>v Cj/0^^»^' \i^.A.>-^ -v-^< ■
No. 1 5 D ^J (VV^Uc ^.. ' ' St.; t) 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 DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
V/"Y>^vjJb (J^XX/y^JiKj
PERSONAL AND STATISTICAL PARTICULARS
l> A i i 111 ii; i<
,XX^
Ul.(.._l
a
M. Iith'
(I)av
\< .i-;
On '
--IN" 1.1 ■ MAKKll'Ii
\\ I 1 H i\\ 1- !) I iK IM\ « >Rr 1-: I)
Wi iti 111 -.iH'ia; (U -it/is.iliiiui
^ ;.»,/// '
> < ar
/>,
lUUrni'I, \r]'
\ \ M )■ < »r
1 \ 111 1,R
, ; 1 1 : K-
M MDK""^ NAMi:
or Ml I 11 1 KH
niRTin»I,\i I,
<}]• M<»'i'm:i<
' --tnt' 1 I '. Ill lit r\
I ). r r 1' A TM >N
U CXa-v O.Kcx
<"^ I. s^ f"^
1)
(\
<Xc*^^
1 1
4
L
-C'U y >
^r^j^/yy^JUuuhj
t
h'ttntfit III ^i!" /'i ilui i^fi) rA, 5'
5
^r,,„ii,^
Ihi
iM xHovi-' ^ r xrii) I'l'iRsoNAi, I'AH lu 11. \Ks xHi-. TR! J' To rni-:
lU'.'^T ni" MN KN< »\^■M'.I)«■.1^ AND FU", I, n'. I'
(Iiifoniirmt
T>
MEDICAL CERTIFICATE OF DEATH
ATi: OF DKATII _y
Dav' I Vt-ai <
I M.mtli*
I Ili:U!':n\ (I'.kTIIV, That I atUMiiUil ilt( i-ri-^i-d frnni
— — — — — -— I^ to — — ——————— Itp
that I last saw h - alive on ~ — -~ iw"
and that dt-ath ncrurred, on tlu' dati- stati-il aliovi-, at —
V M. Tlu' C\\rSI'; Ol' I)i:.\TiI was a- follows:
I )r RATION )V<7r,v
CONTUlDlTokV
DTRATION ViiU
M OH I /is
/hi]
I /on I
^/o)li/l.s
/hiv
NED ) LyurrUA^O.vfc.Uj. dulLcxAoA
/ /I'N > s
M.D.
(SIG
OxUj: so r»)oH (Addn-ss)V^ra^rraA^ , . .
Special information only for Hospitals, InsmiH^ns Trdnsipnh,
or Recent Residents, and persons dvini awav froni home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
HoH tonq at
Plare of Dedth ?
Days
ri,At'H Ol" p.iRF.xi, <>R ri:mo\ai.
r.NDi.H'iAK i:r
/€L/>'
'vL'WJlAj
fX.Mnss laOH OT
F)AI"K..f 111 KiAi. i.r K1:Mi>\'\I,
©^ X 190H
wV-nL^ U^ V"\w
IM. B. Rvepy Item of mformiition should be cnrefiilly supplied. A(JI. shoiil.l ha stateil EXACTLY. PHYSICIANS should
state CAUSE OF DI:ATH In pinin termM, that it may be properly classified. The "Special Information" for per-
sons dytnft away from home should be ftiven in every Instance.
WRITE PLAINLY WITH UNFADING INK
,1 .,r n. :i!
\ Vu 1^ t-X ^:-^^ lift I' C
Dff/c Filr>l, \L'/C.t<rlHL>v
I
V)(n
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
]i('o'/\s/ef'ed jYo,
Deputy Health Officer
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH : — County of *^ i<X-.v 0 ."va
NoiV.! VJ Lt aLO-v' ' St.; Dist.;bet.
Certificate of "0eatb
( "U. S. StanC»arC> )
Jl ^ A ^
> vJ.Mx ^ ^ City of 0/Cuy-u JXXX.^^^<^ e c
and
/ ,r 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 NAMEO'^^^^^
.vv\.>
PERSONAL AND STATISTICAL PARTICULARS
t'oi.oK \ , A
I » A ! 1(11 lU K i II
'l<
M.iiii h i
.S^H
\t .1.;
T
m\<. l.l" M \K1< I 1!)
W I ;!< -11 , : lb -ii^natioti)
luirni IM. \' 1
-?
tit )V4
SL I )
MEDICAL CERTIFICATE OF DEATH
DATK <)l- DHA TH /A
(Ml null I
I)av> iViai
I 11 i;i>J I{i'.V Ci; kTI 1"\', That T atU'!i'U-«l iltMH'.isctl ffimi
up to ' — ~~
tliat I last saw h
alivi- on
'Icp
*^ >va
N XMl- 111
I- A III IK
111 I \ : III- K
M X ! Ill- N N \Mi:
III Ml I'i i I I K
Mil' • II ri, \i' I-;
»i MMiiii: K
-!,it. -H 1 .iU!ltI\
}Ooj\X<nj<r \c
I V I \.
TTU ^>^C\
0
ami that death oinnirretl, on the dntv stated al>o\«,', at
~ M. The CMS!': Oh" DI-.ATIi wa- a^ follows:
I )!■ RATION )t(ns Miuith
Pav
IIou)
c oNiuimroRV
)'iar
:u>>>it/is
/hjv
//on,
I )re I lA I i< 'N U
l\r tjr-! I II Sill/ / I i' III i^i'i)
C4t\/A
) I ill .
V/.M/Z/r?
/),/!
!! I \ r.i i\ 1 s r \ ri i» im-k^on \ i, rAK'ricri.AKS ak i: ik r j-' I'l » rii i-
lUslo: MS K M i\\ lj;iH -K AM) Hl-iUHK
Ca"LcLL<X; >1rW\'
<Xj W'Y\r\'y^^M > V
Xi'.iIk
3l\MCi
"ti\» 0% \i)/CMOLa.vuJL vod.
Dr RATION
( Signed ) UrXCTrA^^ '.^d^Au. cixLou% M.D.
//C!t I T()nH f Address) WH.<rrXjt^^ UI|a.<^..
iT!
Special information onH for Hospltdls. Institufibn^. [r.insipnfs,
or Recent Residents, and persons (f)iiij .iwd> from home.
former or lO 5 5 P J How lonq at
Usual Residence ^ OJfiJLCij'w/dj VXJjU PJare of Deatli ?
U
Wfien was disease contracted.
If not at place of deatli?
Days
IM.AC)-; (U* m RIAI, OR K|.;MnVAI,
i>\n*..r niRivt, m ki;M(i\Ai,
r M 1 1 i< r A i; i : k NrCL/VVVXG -J 'v^c^A.^^
N. B.-
-livery item of informntlon shouhl be ciirufully 8upr»Iie<l. AGE shf»uld be stated EXACTLY. PIIYSICIAINS should
•tutc CAliSi: Ol- DIATH in plnin teriim, thiit it msi> »»e properly clussifled. The "Siiecinl Informntlon" for p«r-
Kons djln^ uwuy from homu Hhotild he given in every instance.
«m-
IU:iUh I- Vi,
WRITE PLAINLY WITH UNFADING INK
'ii; HSil' Cn
l)((h' ri/rr/,Vctj:r^-l\j
llWi
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2039
Jlro/s/r/'ed A7a
Deputy Hcallh Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Ccvtificate of IDcatb
"U. S. GtanDavC j
0 Q^ A ^
PLACE OF DEATH: — County of CJy<X^v J V<X ^ \ <- 1.^ ^ City of ^ cun^ JAa
^ A '" '
N©
m
tuLl)
\ I
HJ>\AACt
St
Dtst.; bet.
and
(
IF DEATH OCCURSUWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO
,F DEATH OCCURRED ,N A HOSP.TAL OR .NST.TUT.ON GIVE ITS NAME .NSTEAD OF STREET AND N L, M B E R .
N)
FULL NAME
xXXAJO^yy^
c
til.
1
PERSONAL AND STATISTICAL PARTICULARS
1) \ir. I >1 !,!i; I'll Y
M. Mill '
5
i i \
A t . !•;
^h
^ I
M.n:lh
An >
-^I^< l.l- M \ K l< 111'
W 1 1 n i\'i I ' 1 > < >K I 1 ' \i f '. I'D
' \\; it, '11 -11.;: .li -• na' i. .'1 I
lUK'llll'l, M"
ol^^uuL
C<r
--U
\Ml ■»;
\ 111 IK
iUKIIi li. \* K
<)i i\rm; K
M\;i)i:x NAMi:
or Mo'l'lIKH
( u- M«>riii-:R
I --, 1 , 1 1 1 lit i ■ 1 1 u n 1 1
n\Tr\iii»N r^
u
.-n
L
-I
CCrLA^O^^v
r-^
\
I \„v
V A
I < ,1
■ a>t
5
.^f..,Hh'
I hi 1
I'll I- MUiN'I-* ST \ ll-It fl-HSi i\ \I. I' UrrfiT!, \KS AR I" TK!'!'" TO I'll I-;
Hi:sl' <)l- MS K N« lU !,1.|M , 1-; AM) I'. 1 . 1, 1 1: 1-
( 111 fii' 'nanl
x.i.iK-s \X'X s^X^CkXXjO^^ry.As'^f^O^ C)X
TOO s
(Vtar)
MEDICAL CERTIFICATE OF DEATH
DATJ-; Ml- Dl'.A'I'H jJ
Oxkl
(MoiiflO l> in'
I ni<:iU-;HV CI':k ril'\', That I alU-iuk-.l .UHv.Kf.l from
a^Wt It !./.'■ to d^^xt ^ T<)oH
that I hist saw h -• < . anvc oil O-X^vV ,1. ', y<p
ami that (k-ath (ucurroil, on thi> <hitt.' statc-il ahoxL-, at «• 3v
M. Till- CAISI-; <>h' I)l{\ril \va^ a^ follows:
1).- RAT ION
CoNTkllU'TOkV
)V(7;s M on ills
Hav
Hi
out <
1) r U A T I () N
(SIG
t'iirs
NED) LU. vJ
Months I />.7r
//ours
M.D.
U/Ot I looH (Ad.lrc-ss) lllO g^CctUA. J. I
Special Information on'y for iiospiidis, institutions, Transients,
or Rt'itnt Residents, anJ persons d)inij away from fiomc.
Former or
Dsudl Residence'*.^
I y I I ^\ How lonq at
MAXCtCcL >^<-CKacL Jl»idrc ol Dcatli ?
Wlien was disease contracted,
II not at place of deatli ?
i
Days
iM.ACi-; Ol' niRiAi, OK ri;m(»\ai.
I)\Ti:-i!' I'.t HiAr, or Rl':Mti\Al,
TQO '
fAildicss
HHb Yrv
A.^4. C<^-V\
IS. B. Kvepy item c.t' inforiniition should he Ciirctully supplied. AdT. K^iould be stated EXACTLY. PHYSICIANS should
state CAlISr OP DLATII in plain terms, thnt it mny he properly classified. The "Special Information" for per-
sons dyln^ away from home should be feiven in every instance.
lir-
WRITE PLAINLY WITH UNFADING INK
\{. .' :i'. I ^<
'i;^ I'nSll' c,
Dff/r ri/r(/,h.<^)uX<>\j
■^
Dep
ino'i
k% f^ffi
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
:040
J^po^isfr/'prJ .A^o.
t3i
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of^O/^v yi K<X
Ccvtificatc of IDcatb
,, ^ ^
y]K<X , ^ City of O^Xj-ysj Jxo-^vC , ..
N
J (rlA/fvw
„ 2) 1 % - I aI St.; 2» Dist.; bet. J OXA^r'yyX' and "Vl^ CUv-v^A^m- ^
FULL NAME oL O-AvoO) 0
PERSONAL AND STATISTICAL PARTICULARS
1 < tl,» >K \
^yudx
i> \ ii' < •! r.
CxJyj
0 IvCtx
M,
3^
: >;t\')
1/, »/'//.
3L"i
S ( ; 1 !
/^,/l
-,!X. I.IV MAR I- 11 :i
W I 1 11 '\ ! I 1 1 iR I I ' . i in
Wiit
niK ' II I'l, \i 1'
-1 • . ■ ' ■ mi N
I l\<X\.>vOL<L
VXXVuCa^
MEDICAL CERTIFICATE OF DEATH
1).\ 11-, < '! I»l. v III J)
M.,nllfi 'I>:iv> (Vt-ari
I ill'Rl'lSV Ci'R'ril'N'. Tlial 1 attrinK-il <lr(Hasf,l itoin
)x^ a.0
AMI (H
\ i li I.K
lURI'lii'I, \i I-,
''' iiiiiiin %
M \I1>1%\ N \M i:
Ml Miiiin K
lUR riiiM AC1-;
111 M<»rni-: H
( >. 1 r I' \'
,o\A C
I I
J.uJL(a./\m
Krsidf.l I'l S,nl I
l',! I
K.) \runfln '. ( /'.'
Till MioVK sr\-n-I. i'FK-oN M, l'XI<ri<Tl,\KS ARK TKlH Tn THK
i5i-:>r ni- MS isNi iu i,i:i)( ,)■, AM) lu'.i.ii.i-
( lllfii; m;ml
^t
A I IqOt to aJCyVAj OU I()0
that T last ^aw ir alivron O^^ ■ s-' -^ l.p
ail. I that (k'.ith . .(•cu rred, ..ii thf <lati- stati-«l ah.ivr, at
" M. The CAl SI-; (»1" DI'.ATIl was as follows:
I )r RAT ION
)'i:ars
Moulhs
CONTRIIHTOR
^V vlAAXX>-\.<Jt -if
Pax
Hour
-o
I )r RATION ^ ,^''''^'^'^
(SIGNED)
/^//
^'s
li
H
M.D.
■ \
* t
SPECIAL Information nnly tor Hospitdls, institutions. Transient*
or Rfcent Residents, and persons dyin;) away froii home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Plareof Death?
Days
ri.^CH oi- lURiAi, «iR ki;M(»\Ai,
^^^<^^
,1
'CX
K i:m»»\ \i,
Pi. B.-
«t»t/cAUSE OF DEATH in pl,.!n terms, that it mny be properly class.t.eU. The Spe.lai Information *or pT
mnn9 dyinft away from home should be 6<ven in every instance.
i
t
Li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(//(' riicii , yA^LdjJuv> V
ino\
lla^Lstered -jVo,
*>
041
dUL/v-u Dep
/~. e*T -* ^ .J
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of ^ ^Xnt^ ■J Ax^
'♦fo. VLlU^ W^ V^tu. ill: H. Wv' . '\. \ St.;
Ccvtificate of Bcatb
( tl. S. StanDarD )
^ ^ ^ ^ City of 0/O<.^'\j 0 A.<X>\.Cla.,
■^
H)
Dist.; bet.
and
)
I w -i^.. iiciiAl or e; I nF NCE r.lUE FACTS CALLED FOR UNDER SPECIAL INFORMATION \
( '^ r/rCATH"o3c"u%r.r.;*rHo's^p"T'AL o"r fN^.'.TJV^o'^O^V.'^.Tl NAME INSTCAO OF STREET AND NUMBER. )
FULL NAME
av^
PERSONAL AND STATISTICAL PARTICULARS
n \ ri: < »r hik i ii
Vlv^
V
.vxt;
"I,
ID
1 ',,1 '//
/',/i
^ ' \i 11 M \ K K I 1
Wn'.
lUKTH J'l, VC!"
*-; • . ■ 'i uinU
N \ M i ( M
J- A 111 l.K
A
^ ^ cjbv^cJi
x<xci<.
iMK 111 ri, \t'i\
( »I i \ I 11 !• K
M \ h>i:n n wn:
(»i Miiriii-.K
lUK I'll i'l, AC I"
iH MnTlIl-.k
oi cri' A rio.x
1-
c1
o
Oa^^<x>^ ' vc
.hJLLcc yvcL
MEDICAL CERTIFICATE OF DEATH
DATH «»l I)i;Aill \
\!. Mtll)
iKivt
(Year^
4
I III-;kin'.N' CI'.kTll-N, That ! atttMiik-(l (Iccasc.l Innu
I I I % IS I . I > 1 V 1 , IN J 1 1 • ,
\ , 1 . f
T()OM
that 1 la-t vaw h .' alivi-on "" ! ^"^ ^'- ^'>«
ami that dentil omirred, <>ii tlu' datr -talfd above, at I-IO
;M. The CArSI{ Ol' I)I:A'I'II was a< follow
III I
)\vs :
-k^CrVMXV
DIRATION )'ruis
eoNTKiiurokV
DTRA'I'K >N -. )V'/'
Hours
MiUitJi
Pav
NED^ 0 'a. Ob-OXfc
rsiG
M.D.
1% H, (' %
N only lor flospitdls, Insli
SPECIAL INFORMATIO..
or Recent Residents, ami persons dvin-i dv^.iv fro;ii liome.
litutions, Transients,
J",,/
^^..,lt^n
/hi
Till- \Hnvi.- ^rxTii) rHK>-i)\ \i, r\K ruri SK-- \ki riuH to phi-
liisrm MS KNOW i.i:n<;i'; wn i;i:i,ii;i-
; Info- nianl
( \<Mr'
U^
rt
D 0-^vaX<X.I'
l-hA^llAi
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
ri.ACH Ol- lURIAI. (>K RKMoVAI.
i)\'iT:.)t lui-tiAt, (.1 k1';m(>\ai.
TOO'
■J , ,, [^ i *cp «hniilil be Rtnted F.WCTLY. PHYSICIANS should
IN. IS.— Every Item of inif.,r„.Uion «h„uhl b. cnrefully «"PP'- • „^,^f;X7laBsmei? The ^Special Information" for p,r-
•tote CAUSE OF DEATH in pliiln terms, thnt it miiy be properly ^.lassiticu.
lions tlyinft oway from home hHouIcI be given in every instance.
i
I
WRITE PLAINLY WITH UNFADING INK
(^
Dfffr hlli'd ,^"6
iXxsaMA;
in()\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llroisteird ^'o^ 2042
£crv^l^vvu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
^
^
^
PLACE OF DEATH:-County of^^<X- ^ Xc..x^..< Gty of ^^^^ 0/.C^-v.^u.
St.;
Dist.; bet
and
f4€>. ^'^^ *^WCrVC^VLU ''^ '^'^ ' "^"^ "h' „,^=?i^^lrF r,«r t^crrcArtED roR under 'special intormation' \
\
FULL NAME
tCVv
Mluv
>^i:\
PERSONAL AND STATISTICAL PARTICULARS
i < 1 1 .1 • K \
(V
1 I •
IOlU
lLi.a..
M%
\'
,1 .}-.
-:Nt ,1.1
at
\ 1 .1!
n,t
(Vt-arS
UiK I'M'" ^'-^
NAM I 'M
»• \ ri I 1 K
HiK rnri. \rH
Ml r \ rin-K
■Slut. ' i nil
Ml MMllll-K
i;m.' rni'l, MK
Ml N' I I '■ 1 1 K H
■ - • : . 1 (.'.illlitl %
ri' A timn
A',
MEDICAL CERTIFICATE OF DEATH
DATH OF DKAIH j . ^
1 lll{Ki:i'.V C!;RTII"V, That I .iUcii.UmI .UHnavcl fmin
: ; -t >*'\ ,.^nH t.) C)-^t^ ^^ T(,n K
tliat I l;i-t ^:iw h -. -Hvr Mil ^^ i '- ' ^ ^'P '
;,„.l th^.t drath ..rrurn-a, <n, llu- -Intr stated alH.ve. at IC H5
M Tin- C \r<l' Ol" Dl-A rn wa^ a^ follnsss:
j^:
0 A.vy^.^v.c •^<^-
I
■\/,.j,f/n
/>,!
T,lv\lM,VHSTAT!Un.KR.oNX, 1.AKM.M_;,XR-XKKlM<rKro THH
ni'-r Ml MY KNOW i,i,i>''. 1-: am> i.i-i.ii-t'
DrUATIi »N
SIGNED
dxMX
Mouth.
Pay
KJ
AL INFORMATION only for #nspitrtls
VU.%m4
//ours
M.D.
= 4
or RctenI Residents, and persons (l)in<| away fron home.
Instilutlons, Transients,
former or s *> f -
Usual Residence ^ ^ ^
When was disease contracted,
If not at place of death ?
Lliv
Hov^ lonq at
Place of Death ?
Day
(Infii- inant
XUlrt'^
\.
l'I,ACK 0\- lilKLM. (»K RKM«>\ AI,
datUj')*' hthiai I.I ki;m<'\ai.
' <3 ' ~^ ZTaGB ehould be «t«ted RXACTLY. PHYSICIANS should
„. B.— F.very item of information •hould b. cnretuHy f"PP«'=^- ^^ ,y ,,«,emed. The "Special Information" for p.r-
state CAUSE OP DEATH in plain terms, that -t may »»e proper y
nnnn dying away from homo should be given .n every Instance.
!l' Mil '.^ Ni
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2043
JUtIm-*
.^rx.^ 1^' Deputy Health Officer
Jlrf'is/i'j'rd J\''o.
DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco
Certificate of IDeatb
■a. S. 5tanC>arC>
J? (\,
-^ ^
PLACE OF DEATH:-County of ^ a/>^ J ^vcc^*^^* City oid<^ JA.a..vc.^....
No.
's'> ^
St.;
T
Dist.;bet. C^AJ
JLcvL^^^^ and Ax->vl^
t^
( ^ --^^i^^Jr^v. -J^i^^t :^v^f^^-i-^}^^i^^ ,;^^-: s^^EEi-No^-eEr ■ )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
lO.kd.
Mi.lltll !
'i);
)V,-
1/
■, ; \, 1 r M \ k K 111)
\\ 11,1 I iK l)'^■l ''■ 11'
\\ I n ' 1:1! 11 -.iL' n.,; ■
.^
1UK'"n 'M. N" 1
I A I II IK
lUK 111 ri, \ri-:
(»i 1 \ ni 1: K
-,• ■ ' r, .nut! \
(ii Mi»rm:K
HIR'nilM, \< 1:
<>r N^iiini". K
-^ M etc
MEDICAL CERTIFICATE OF DEATH
DATl-; 01 niA TH li \
I III'IRI'IIV CI-:rTII'V, Tliat 1 aiu-n.Ua .kcca^cl from
'^jLM. Vi upH to ^/cit: I 190 H
that I last ^;uv h ■* alive on ^ C w igO ^
an.l that death nccunvd, -ui tlu- .late stated ahnve. :-t 4
>T. The CAl'SI' Ol" nilATH %va< as loUn%vs :
V
\
Cx^oiiyw
A>Vt'
t I
DT RAT ION
)■ -/v
.l/o.'i/Zis /^tns 10 //<j///.s-
» >.-
. 1 "^
v
■T
4" ''^
coNTRir.rroRV
I)rR\ri<>N )V</r.v .Vi>>,'f/is
X.
fhivs
SIGNED)
:|
'>'>x^-^
flours
M.D.
l<»n
^t f Address) l\ H b JLtAAJ^C^kt "
SPECIAL INFORMATION only tor Hospitals, Institutions, Transients,
or Rcient Residents, and persons dying away from home.
r,'
I
1/,
.■„:^ 1
l>.'^
)K CI I'A Tit tN
Tiir xnovr-TXTini-KR.nvM.rxKTirrKXKSAKKTKrH T<> thh
lU-sT 01 MV KN«>\Vl,l-.lH'.l-; AND lU.lJl.H
(I
\iMrp«s
5X0 ' ^i
^ d
*
Former or
Usual Residence
When was disease contracted,
If not at place of deatli ?
How lonq at
Plare of Death ?
. Oavs
rLACi". »H- in KiAi, OR ri:m<>\ AI,
^
I
DA I
I.MAI 1.1 k1';m<)\ \i.
let ^
rSD.RTAKKR ^C^CcL^ WxLt^l<^k4M
IQOH
;a.i.1!. -
, TT TTf. ^sould be stated RXACTLY. PHVSICIAIN8 should
IS. B.— Every item o? inWmation should be ca.eH.lly f "PJ* "^;'- „ ' ;H>classmed. The •'Special Information" for p.r-
•tate CAUSE OF DEATH in plain terms, that .t may >^ P^"'^^*^ '
state V#^kUi5i, Kjr i#i---i 1 .. •■■ t - ■ . l«ot-»ice
sons dylnft away from home should be given in every Instance
• a of HiiUh 1- N
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2044
-t"^*'^..n^iT
H Officer
Be 'Mistered J\'*o.
\ \ ^ Deput. -^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
PLACE OF DEATH: — County of^ '<XmJO,^.<XA ^ity oi
No.
4 (1^ l' ^ 14
St; -~ Dist;bet.
and
( '^ --^^^c^uR^v -°"ti^^t -?^?^^^ .;^ .^s p. ,
..S.DENCE O.VE .ACTS CAL.XO ^^^ER ^ ^ CC • AL^ N ^R M ATK, . •■ )
K Y\
FULL NAME
XCX'
CL*
\
PERSONAL AND STATISTICAL PARTICULARS
1 1 \ i 1* til r, IK in
■>iat
Ihis
MEDICAL CERTIFICATE OF DEATH
DA XV. <>1' DKAIH JJ
iDav'
I (JO .
,Vc,U '
1 iii':ki-:r.v ci-rth-v, Thai.i auiMuK-.i .Urriisni
lolll
1 1 )1T
H'l' rni'i. \i'H
that I last saw ll ■' alivi- mi
a„.l tl.at <ivalh ..rcurrrd, .ui tlu- -1 at. .tat.-.l aln.vc, at
M. Tlu- CAT SI-; Ul" DI'ATI! was as follows:
flav^o^-cL
I
I- \ 11! l.K
!'IK rni'i.ArK
«»i 1 ArilKK
-,' i< I III I'l i\5 nt t N
M MI UN N \Mi:
Ol MKini-.H
HiH rI^'f,A^]^
(>i \;<>rin".K
! vt:itt oI riilUllI %
CONTKinrToRV
Months
DiU
'S
/lours
UJL^..<:^ ^
OkxX^ . -^
( HIT J'A'I'KtN
^5
DTRATinN
(SIGNED)
n,jv<
IJouys
M.D.
■ .i - I V
..t r^
I()n
SPECIAL INFORMATION «nly for Hospitals Institutions. Transients,
or Recent Residents, and persons dving m^s froii fiome.
K,-:Afd ill V,(>' /
■I' /...I t
)'i a ' »
M,,„!ln
I
Of)
11
I 1 Ti I . . ' t n ; I n t
\<l<lr("^H
J^J^
31
Former or y
Isnal Residence i
V^tien Has disease rontraded,
It not at pla( e ot death ?
As fi J How lonq at
VirUUv^ at Place of Deatli
Oavs
(IccL
/CL.-»-x^O.; ^ ^
nAl'lii; r.nuA!. Ill Ri:M<t\AI,
i ' 1
I'l \il-- nl- lUKIAI, OK H1;M«»VAI
TQO
■ 1 ' ■ ,. , .pp ^H,.,,tl be «tate,I F.XACTLY. PHYSICIANS should
!S. B._F.ver.v Item of Information should b. cnrofully f"n»> '^ " ^^ ;^,y '.^^^iried. The "Special Information" for p.r-
«t«ti. CAUSE OF DEATH in pinin terms, thnt it mji> nc p
if
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF r.FRTIFICATE FOR INSTRUCTIONS
10()\
DEPARTMENT OF PUBLIC HEALTH
Mes^fsfcrrd JS^o.
204
City and County of San Francisco
-^ v'^vCl
PLACE OF DEATH: — County ofOa^OA^O.
No "i QCL^^ IWUvv.- St.: Dist.;bet.
(
Gcvtificate of IDcatb
\ ^
< City of ^'^'^'^ O.h^cc^vcc^
^c
\
L^O
' '^?^^v^:^:^ — ^^^ ^^ii^^^^-^^-^^^^ :^^i: s^^-^^-r=
and J'^>-
TION" \
ER. /
)
m^
iQ\' /D
FULL NAME \my^
'lvcn'>xo.<^
\ : \ V
^_X. i\
i> \ 1 1: ' '!
PERSONAL AND STATISTICAL PARTICULARSv
mr^i. ^^--'
5.
'i; I
-.ivi I r ^'
Ji I l_ : 1 I l-I % '
N \ M 1 II
1 x lis l.R
I'.iK rui'i, A<1%
M N I I>1".X NAM 1-,
(»| MnTHl.H
iUR Tiiri, \ri-:
ni Miriin: K
oiHTl'A'rinN
1 1
MEDICAL CERTIFICATE OF DEATH
DATl-: i>l I'LATll -^ . I
I IIKRKHV CI^RTIl V, Tliat r.Ur.i U-.l .Uhh a.c.l fnm,
Vt\<t \^ iqoH to OJjJp^t ^Ci T.)oH
tliat 1 la^t -aw h • aliN^ -mi t- -*- ) >
^,,,.1 that .U-alli nrrurre.l, nn tin- .late slatcl above, at H
LU M. Tlu- C VI SK OF DKA'ill Nsas a- follow^:
1 1 ■ ^n
DIRXTION y"^rs Moulin ^ Pays
Hours
nr RAT ION y^'%^
(SIGNED) I
.][, tilths
/hw
f fours
M.D.
V.,'i' /
(. /VM
lU'.^r »)1- My KNONSl.l'.IX-''. AM) l.!.I.'l •
\
f Infii: matit
\juyvaji
o-a
.\AjJyw
fA,i.iT.-% CJ/CWw
axx/>^ IX^W^^rv^^
J
i.:)l
SPECIAL INFORMATION only for Hospitals, Institutions. Transients,
or Recent Residents, and persons dyini av^rtv from liome.
Former or
Usual Residence
Wlien was disease contracted.
It not at place of deatfi ?
HoH lonq at
Place of Deatfi ?
Days
I'l ACH OI' lUKIAI, <iK Ki:M"V \
1 S-
rNDl'.HT.
1^ X
.cv>^'
TQO'^I
1
(T>
— " ' "^ ; T"! TTr Hho.ld he «t»te.l r.XACTLY. PHYSICIANS should
^. B._Bve.. U.„, oV ......nntlon «Hcn.r.. H--^^^;^ ^^ ^^ pt L.. c.„«eWled. The "Speda. lnfo..„«t1..„" fo. p.r-
.1 ^ .-*i!«i iW- ni-\TH in pltun terms, tnni n ■•■"^
«nn, dyS„4 oway from home should he ^nen ni every
m
^
1
r.....r. .MK THIS IS A PERMANENT RECORD ^Wm
WRITE PLAINLY WITH UNFADING INK — THIS 15 M rt
"^"'^^ ..c.p TO BACK OP ^..^...r^Tr rOR .NSTRUCT.ONS
,! ,.t" III :i'tli 1 ^"'
,-^^*^'%i.i\f<vc„
REFER TO BACI
Be <^i stored J\''o.
046
l)((le /v7^>r/,L)ctM>?-A, I -^'"^^^"^
"Lxr^^-^ Ijl^xhj Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
( XX. S. GtanDarD )
PLACE OF DEATH: — County ofOcL^-vAJ
v} . VOLA'vX^^ACt) City of C )/CV>v 0 X O.
St,; \ Dist.; bet.
No. Cs6bv V,<X/>A; M WC-X^' " ^.cilill RESIDENCE GIVE FACTS CALLED ►i
- ,. DtATH OCCURS ^^^'^ ^ , ;« ° "^^ ,^3^,V,'^,i: J,^ f^! ST^.^UT.ON O.Vt .TS NAME .N
and vJ.>ULt'V\
C^IlED rOR UNDER ^SPECIAL .NroRMAT.J>N'. "J
u<:)
(
IF DEATH OCCURRED II
FULL NAME
si:x
PERSONAL AND STATISTICAL PARTICULARS
v.*»»I,(iR
STEAD Of14tREET AND NUMBE
A^ \jcrvw^>vi\
I '
j_
I) All". <»» r.IKTH
xr. 1-:
I Mi.tUhi
I Dav
/%5H
oL' y.ai^
lA
Vtarl
I hi ) V
\vii»< '\\ in OK !)!V.)Kri-:n
iWi ;t> ni -'"1.11 '1< -luMKt;.)!!'
lUR rniM.Aoi-:
f st:it<- >! i.'.i-;nli V
NAM J <•!
1 A'l li KK
lUR rin'UAri-:
nl lAPintK
M Ml U.N' NAMl-
oi' MDrni-.K
lUK rm'i.Aci*.
n! \!t lill l-'.K
(St. a. 'ii CdUtilry
f^
aur UaJ^^o-
MEDICAL CERTIFICATE OF DEATH ^
DATH «)l DEATH J ^ .
I lll-KlU'.V CI-RTIFV, That LatteiuUMl .Ucca^cMl from
Clu.q ... 190S to ijtj^^C icpH
that 1 last ^axv h ^'^ alive on t.^)^ ^' Kp'i
an.l that .U-ath oocurrcl, on the date statr-l above, at 1 1^0
OL M. The CAISI- OF l)l-:ATn was as follows:
^^(^
t
XlU^j
1)1' RAT ION )V<7/-.v ^ .Uofi/Zis
/)</r.v
//oil PS
<^\p
VVC^-Q^^^S t
t
Mt^tiths
ni'KATloN I '^^ Vi'ors
Pavs
'rw\i
(SIGNED) ^ ^- ^ a
Hours
M.D.
.trVc^s.'Lv.O.A vcx
(Kcri'A rii>N
•u
n ,
i' n
)V,.'.
M,nifJn
/).n.
ruV v,M.vrSTXTriM-KK<..NXl,PAHiU-,I,AKSAKKTRrH TO THK
' HKSt'». MV KNoWU-noH AND nHl.lKl-
(Iiif.Minant
< \Uill
SPECIAL INFORMATION only for Hospildls, Institutions, Transients,
or Reient 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
ri.ACI-: Ol- IHKI.AL OR RHMo\AI,
(Aaar.ss, bll U'CC^x. M\.U1.^ llx>
DAI To! I'.i RIAL or R1-;MoV\I,
O'ctr I 190H
I
.. , .,,F «Uould he stated RXACTLY. PHYSICIANS should
SN. B.— Every item o? Infort^Btion should he cn.cfuny -PP^-^; p^perly classified. The -Special lnfor.„Htio„" for pT-
state CAUSE OF DEATH in plain terms, that it may ne pr»p*;r ,
«on, dyinft away from home should be given in every instance.
'4fi£*-J«.c^,
i
I
.It" 11: ,::!]
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
"" . lu-vl eu REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\. ■
lie i:! isle red JS^o.
Ajl/v-u Deputy Health Officer
DEPARTMENT h PUBLIC HEALTH=City and County of San Francisco
\
No.
Certificate of Beatb
( 11. 5. i?tanJ>arD )
PLACE OF DEATH: — County oi^CK/y^ Oxcu-^vcv.; ^ C^\^J nf U<x.-rx^ J
City of *^' O^^rv vJ /UO-'W/C u^
D-'Tr^xtrWalL'Ku:'Cj/a',\Lwa\u.' .St.;
Dist.; bet.
and
(ir iJeath occurs away from USUAL R ES I DENCE give facts called for under "special information" "X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
'L>A.^^\JU
PERSONAL AND STATISTICAL PARTICULARS
iX
iMl.Ok
u^
4
i> \ri: III i;iR rii
A< . }■;
\J
I
^\
1
3.1
M.iih
I tar)
Ih
^IXt.I.l-: MAKKIl'K
U • ;;' Ml - . -ii' ' • .til, Hi
'UK T!!!'!. \(*1-:
i \'iH i:r
lURTIir!. \«K
<ii- I \ rn Ik
• '■ 111 nt \\
111 Ml tTII hi^;
niui'iii'i, \ci%
ill- ^;l•^^l•■. K
< !il' I I' \'l' It iN
v] oX,K.\^^
"VA;
(11
^ AJUL a.' X ^ ^
^
MEDICAL CERTIFICATE OF DEATH
DATK nl- 1)I:aTII
i Ml. nth)
I
igo \
fl)ay) (Year)
I ill-: k i:i'.V Cl'KTIl'^V, That I atlcii<UMl .Ktxasccl from
\^k ^.L um'i t.. APct 1
I(p
1 90 "i
that I last saw li . ahvc on ^^-^\yX; ^b ^^p '
and that death ocrurred, mi the datf -^tatt'd ahovc, at "i
•A M. The CArSF*: ()!• DI'ATII was as follows:
Jj A^Crvw-^4x,A^X ■
DC RATION
}\ar
in
t oNTkim Tory >
Hours
v^vXO„ ..
1)1 RATION
(Signed )
i\^\:
TQO
Address) b^b QxCtt.' S
Hours
M.D.
AV ,/.;'
'^fnith^
I hi
1 in. AH()\J" STAT I'!) I'KKsoNAi. i'\K ri<Tl, \RS AKI" rKri' in THK
m;sT ni Mv KNi >wi,i:i)c,}.; AND rn:i,i);i-
In!
Special Information only for Hospitals, institutions, rranslents,
or Recent Residents, and persons dyinq anay from fiome.
y r- o 1' I ! ' How lonq at
Former or
Usual Residence
Plate of Death :
Days
When was disease contracted,
If not at place of death ?
I'l.ACH <»|- lUKlAI. «iR R|.:M«i\AI
nATi-; -it I'.i RiA
I ill Ri:M(t\ Al,
•Nni:RTAKi.:R OvO. 0 OAv'i'^H/ ^''«C Lt
A<l(!ii
N. B.-
-Kvery item «V informatiofi «»houid b.- ciirefiilly supplie<l. ACJfi should be Htntecl EXACTLY. PHYSICIANS Hbotild
state CAUSE OF DEATH in pliiin terms, that it may be properly classified. The "Special Information'* for p»p-
Rons dyinft away from home should be j^iven in every Instance.
m^^
't »
II
^KR. '
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l;.>at<l
:;;th r X(,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed ,
^ctxrv>-xAj
100\
lie ii isle red jYo.
2048
Deput '■ - - - Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. 5. StanDarC* )
PLACE OF DEATH : — County o{yjiCur\j -)ao
%
^, ^ r^
" V " ■ City of VJ i0^y\j 0 AXX^-^ X.C oci. c '
( Na oL 0 ^ -^ 1 I . ' . ', St.; S" Dist.; bet. ^ W CrUKXXxl and 0 Crl^Lryrw
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I W E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME «W>VU4 \yx\/>\JvO.\cL (j/Orvy>\A.<lt
PERSONAL AND STATISTICAL PARTICULARS
roi.oR \ 5
I 1 , \ ;/
I'-
ll >:iv)
^
9. M '2
A( ,1.;
b! .■.,,,
i/,.,//A>
\ ( ari
/),;
SIM 1.1" M \U U II' I »
U I i I. >\\K1» OK li!\ I "Kv 1 I)
* I"
I
I VuXhJ
N \ M I . .'
I A 111 IK
lUR III IM. ACK
m 1 \|in-:R
■--l ;it I III < '( i\! !lt ! %■
oi- Mol'llJ.K
iMRi'mM.Aii':
' '^t:lti )1 i'ltUIitl \
h^uixL
:1 Q^
-: f
MEDICAL CERTIFICATE OF DEATH
DATIC OF DKATH
6x{^'
1
SO
(I)av)
/go
I Ill'.kl'l'.V CI'.R'ril'V, Tliat I j^tciiiU-d (IcHcasc.l frniii
dx|^
10 npH to OJL^^t; ^0 T()0
that I last saw h A/'Wx alive on QJL^^^' OC up .
and that (Uath niMnirreil, on the date <tatL'<l aliove, at O-oO
LA., M.^ Tin- CVrSIC 1)1' DI'ATII was as iollnws:
DC RATION
U jJ\jy^Xy(Xyyxx,i
Hiri'A rioN J( 0
)V<?;-.s^ .I/o/jZ/js H /.)<?r5 Hours
CON T R n u "r () R \' LlAXAr^-/oJC &. j^^-^^^axJuo^c^, .
DTRATION Yrars Jfouf/is X\ /hns IIouis
NED)|.^.Q7lCLC.U^J-
i<)oH (Addnss) "il^ LxL-du -^
(SIG
M.D.
\
SPECIAL INFORMATION only for Hospitals, InstituNons, Transifnts,
or Recent Residents, and persons dyinij away frou home.
v,/// /■/
M.nifin
/),n
iii). \i'.(»\-i': s rsii!) i'j''RS' >NAi, PAR rirn.ARS aki-; Tur j: r< >
mcsr oi- y\\ know i.i.ix.i. wd r,i:!,n:i''
0 i^ 9
[it
I j:
(Inf
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Itow lonq at
Place of Death ?
. Days
I'l.ACl-; Ol lURIAI, OR RKMtA'Ai
x)ULt
DXIT,"! J'ti roAi, .11 RlCMuVAI,
T90
Ct'.
INDl-RTAKKR UU. ^ . VJ JLLfi.^
fA.l.lross 11^ \iy\, (JJUUA-liA; Ut
N. B. Rvcpy item of infopiiintion should be cnr-efully supplied. AGB should be Htnted F.X4CTLY. PHYSICIANS should
state CAIISI: OI' DM ATI! In pinin terms, thnt it mny be properly classified. The "Special Information" for per-
sons dyinji away from home should be feiven in every instance.
I
1 1
♦I
Bonn! . f lie ,1 Itli r Vi) I -
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.^-^r^^oc.,., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
-r. !U<s:l- (',,
Megisfei^pd .jYo,
'^049
L,^^!., i:>eputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
f4©.
PLACE OF DEATH: — County of ja-yx
4-
Ccvtificate of Bcatb
' . City of ■J'Cf~'^' ^''^-'C*^'*^
J 0
^'\y\jy\JXQ <Xr\\xXxx^ St.;- Dist.;bet. and
/ ir dVath occurs away from USUAL R E S I DE NCE give facts called for under special information" "\
V inOEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
0
.fyxmAj UynX'
Xo-r
PERSONAL AND STATISTICAL PARTICULARS
'A
h
■< !l < iR
I n
Li,
fX^
C, CI
M..nt'
> tar
Ai.
1 1' M \k k ii:ii
A I !> ( »K \> '.
■ 1.1 -M -.ll .l.-K
lUK in I'l. si'j".
1)
'X >"vo,C
(
X \M1 Ml
I \ I'll IK
M \im:\ NAM I
(i! Miirill'K
ii!R rni'f, \ri-:
111 MmTIIKH
< uori'Ai'ii i.N
A
MEDICAL CERTIFICATE OF DEATH
iiAi 1-; I >i 1)i;a ill
c\
^ct
^M(.!lt1l>
Uav
(N'rrii
I II1;In1':I!V C'i:K'ril'\', That I att. n.lr.l lUcrasc.l fn>ni
uoH
U)0
I i l( )
6ct I
that T last saw h - alive nii * * ' up
ami that lUalh ocru rred, mi tlu- ilatr state-il aliovi", at 0
M. Tlu- CAISK Ol' Dl Ai'll xva-. as follows:
Q
H
^
1
W^xr
I
V, V
ktrKnA^^^Cr >v
'0
K^O. ^vo
-4 ,-.
/,/•■,/ /^' V,f„ /
yhnilln
Ihn
rni: aishvk stai'i: r> pkksiixai, v xhtuti, vk^ .\ki ikii; in in i-
JU'lSTiH'.MV K Nt »\\ 1.1 III, !•; WIi i;i ill-
flufotiiiniit vJ-X-vCXvX*
\,!,i,-,... RM"i oxa-vu
%
I )r RAT I ON Via I
CoNTkllUTORV
Dr RAT ION Ycafs
' a
J/o>///is
Da 1' ?
//
OH) V
(Signed )
Mouths
Ck
Par
A.hlri-ss) 111 '^io.n.^jl
//ours
M.D.
Special information omy (or HospifiiK, InstikiUons, Transients,
or Recent Residents, and persons dyini awav from tiome.
Former or
Lisiidl Residence
When Hds disease contracted,
It not at place of deatit ?
HoH Jonq at
Plare of Deatfi?
Oavs
Pi.ACi-: <»i I'.tRiAi, OR ki:m<«\\i,
I < , ,
UATi: >.; n
190 ,
Imiaa^o »\j
IS. B. Rvery item of informntlon shnuhr b.- cnrefully Hupplitil. AGF. should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special Information" tor per-
sons dyini away from homu should be Jiiven in every instance.
h. -Nl^;*^-
WRiTE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l>...ar.i t n :, th I N .. *^Y^~. v,:^\-(., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,(rv'-.'-o i^-' vu Deputy Heairh Officer
Itegistered vVo.
2050
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcrtificate of IDcatb
I 11. 5. 5tnn^ar^ )
^
PLACE OF DEATH: — County of
^'
1 U ^' JV '
h
City of ^ CX^^'
4
No.
nd J ^ ^^ ^^ ' '
^ ' St.; S Dist.;bet. OlDcru>a\xi
/ IF DtATH OCCURS AWAV TROM USUAL RESIDENCE GIVr FACTS CALIED FOR UNDER "SPECIAL INFORMATION ' \
V IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION dlVE ITS NAME INSTEAD OF STREET AND NUMBER. /
.^ N
FULL NAME
0
0
<X\.Kjj dj . U C^ A C
I
PERSONAL AND STATISTICAL PARTICULARS
1. \
Jl
J
r « i! i;!K rii '^
J)V
M..iith' h
D ^ y
/>,n
W I 1 >( 'W 1- I » I iK ! > 'X't >!• r i: 1)
BIK III PI, Xi'J'
iStnti i.T I ■. Hint • \
ci
Cuw
vi
s
<X
N \ M I 1)1-
1 \ I II IK
nil: I'll PL \>K
> i: I \ III i-:h
■ ■ r (.'i It! Ill I \
MEDICAL CERTIFICATE OF DEATH
ii A ri-. I >i i»i; A Til
N't Ml
M..iUli) D.iV
I lIh:Ui;r>\' l i; KTU-'N', That I att<--n'k-<l ilnx-asiMl li..iii
.. ; - 1 \i ^..„ lyo'i t«» Cvclu I I(;0*1
tlial I last "-aw h ■■' ■ ali\c nn w i^u Ti,o
and tliat lUath m mirred, on tin- dati- ^tatru alxtVf, at O. I U
...'. M. TIk' CAl SI-; Ol' I)i;.\rn was as foUnws:
1)1 RAT ION
}'itir
Miniths
Pax
I lout
CoN'Ikll'.I roRV
MAI i»i;n X w! 1
OF \!(>riij:i
^ VI A
f L(xr
^ 1 /
lUK ruiM. Ml-;
• •I Mii'rm'.K
I HAll-A riON
A'
s,;,/ /
)'
1,
/ hJ \
III 1-, AI'.OX'K ^^TATl-'.T* l'KR<()V \1. 1' \R lirr I, \RS A HI-, rkl}-:
> Till
I AT, KN'iiW
1 lllf..Mli;|!lt Sj ,\^<X^
rxd,h,.s ass a ^ S Ub lW,
nr RATION
(SIG
lV(^rs-
NED ) VL- <^. Uj.U
X
p V- «»^ 1^ I
I^ax
/fours
M.D.
I I/O
SPECIAL Information only '<»'■ Hospildls, institutions, Transients,
or Recent Residents, and persons dyinq <iway fro-n home.
Former or
Usual Residence
When was disease (ontracted.
If not n\ plare o( death ?
How long at
Place of Death ?
Davs
>.\ i L I)!" I'.iHiAl^ II' kl',Mtt\'AI,
X TQOS
PI \CH oi- mkiAi. OK ki;m(i\ \i,
w J P
r N I ) 1 •; K T A K i: K U /CX ^-AA.^x-tA.' "-J^ -N^^^o
IS. B. fivcrv item of informntion «hm.UI be cnrefuliy .supplied. AGR should he stated EXACTLY. PHYSICIANS should
state CAUSK OF DEATH in phiin terms, that it may be properly classllfled. The * Special liOormation *or per-
sons dyln^ flwny from home should be (iiven in every instance.
t
,( II. ;i'th i V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i',.-v i- I
/),f/r riJcd , U/elcrA>4J
.Hi I
lOO'i
Rrof'.sf ('/'(' f/ jYo.
O
o;>i
KJS <Xu^
'\ V-i
rv
^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of S)catb
! X\. 5. 5tnn^.u^ )
PLACE OF DEATH: — County
ofQ/CX^ 0 AXXavC^UlCC City of CJcu-yv ^ >^<^
N«
0
'\k^.)^\.\: ' St.; Dist;bet. ^3.CuH.^\< and cUwi.C'
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION'
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
A
A
FULL NAME
il
L
r
^V-w »
PERSONAL AND STATISTICAL PARTICULARS
A
1
■« >i < Ik
n
It \ IH t
Kill
C
u
:!;i\-
\". I-
to
M \ 1 ■ ! . n ■ 1 )
Ul I X t\\ 1 I > I
' \\ I Itt 111 -
[ f 1' i
X \ M 1 It
1 \ I 11 ! I<
M \ , I iix NAM i;
iUK ri! 1*1, \r I'
111 \:< t rii IK
- : ' ! i Milt I \
\
A
elv
:(T^
^U
V\ >^ 0 XC
Id
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t ll. I ', 1
"■""'(Lt.
A,<A.
V
THi' \nr»vr. SIX II. I) i'i-'Ks(»\ \i, r AK ri'i !,Ak> \in: I'kn: to tiik
H!--^r<».^^ M\" K Nt i\\ i.t i>' . I-: WD in;i,n: I-
unit V ^ C\ \ \ C^. '^ kJ A^K^KXj^Ka ,..
i 1 11 1. .> m
I 1
MEDICAL CERTIFICATE OF DEATH
1) \ri' ' l! Ill'ATII i: \
%
Miiiilh
/ 0<^
V.,.i1
I II P: 1< l.l'A' r i; k'l'I l"\', riinl I ntU-mUd dc-ciasr.l fn'iii
i*^ 4 : I
, ' i i.,(i 'i to V ^\: . i(p \
that 1 last saw h ali\f on w -. - ^ iqo
.iiul llial lUalll nciairrcMl, on tlu- ilale -tatnl above, at '
.\[. Tlu- C'Al SI', Ol' |)i; \rn was as fnllf.ws:
nik \ lit >N )V</;a H
CON Tkiiu rokv
Moiitlv
Ihiv
llou
rs
l)\'\< \rn)S
}'t'iirs
M^Nl/lS
/hiv
I
Signed )
i.U-4l^'
1 1 it lit s
M.D.
'N,-
KiO
Aa.in-.s) 5 IH \|)la4.frt
I \
Special information "iH for Hospitals, InsliliifiiHis, Transients,
or Rctrnt Rfsiilrnts, and person'* rtvin) awav fron liome.
Former or
Usual Resident e
When was disease fonfrarted,
If not at place ot death ?
How lonq at
Plare of Death ?
Oavs
IM ACl-: <)1' lUklAI, <'1C R1:M(i\\I,
) \'i'i' ..:' i;: Hi \i -1 !•: i;Mf t\ ai.
■ N I ) i: R T A K iv R H u 0 ccdLdU^>v M u ^.M. aKtt^
IQO
fAd.lti
^^as^
1
N. B._,:v..,v U..,n ,„■ ln!,..„„..l„n ,h„ul.. h. .„ne»..Uy supplied. ACE .h„„l.l b, H.a.edl fiX*CTLV PHYSrClANS ,h„„M
HtHtc CMISI- OH nriATH in plnip term,, tha. It p.,.y he properly .lo,»lfl»d. The Specnl ln!or,n,.t,..n »ur p.r-
Bt)n« dyint owny from home Bhoiild he ftiven in every inntsnce.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J )(!((' Filed . U.cl.^iMA^ 1
V,)()\
Bcillsieviul J^o,
'Wvf • ^'•'•m
M
j^^K^KA -iJ->M Deputy Health CfHcer
DEPARTMENT OF PUBLIC HEALTH =City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of IDeatb
11. ili. t?tanDav^ )
City of C' <X,^^ J /v
^r\j vj . wp
C\
A
■^
TS[o I [^iX X.^a - , — ' , St.; i Dist.;bet. JCr^C--.. • ' . and OA.v'
• iP DtA- • '.AV FHOM USUAL RESIDENCE GIVE FACTS CAtLED I^OH UNDER ' ' <^ P E C 1 ft L INFORMATION ■ \
V IF DEATH OrruRRED IN * HOSPITAL OR I^JSTlTUTtON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
^ .1) r 1, ..
FULL NAME 'X^cUv\.Cn U, Ix \ . .
PERSONAL AND STATISTICAL PARTICULARS
\ -\
ll,. ^
X
A
a^v
4
r^J: a
Ht »\ 1- SI" \ r
I'l-' U ' t >X \ I. r \ I: I
\K-, \K]: iKi 1 I "• I'll I-:
If 1,1 1,11
1 11 1| I 111, ml 1
JUs
wv-v.
cL Lc
. IIH <
\^ocM5^^iv Ot
MEDICAL CERTIFICATE OF DEATH
> \r >■ I M 111 \ ill V
■ • iI);iV
i\'.
I II1;KI.I1\' t ! Kill-N', rii;!' ■ "m.lctl <k'f<a-^fil Ipuii
ibiil I l;i-1 -.iw
1
i! ' ' till
^^Ji\rX ^H
y^
\
;v'
itioH
li;0 H
111 i lli.r '
d M.
1i I Ki'll I K-'il. I '11 1 ill t':l'
!;<• C \1 >-l: < >1 l>I- A'
• tat I'll :iiiii\t.-
\\
|( )!li i\\
M K A ri< >N
I I >N 1 K
(>i<\ '-J
// /
Mi^nths
iKix
1 A ^ 1
(Signed ) U. > ^^ '
M.D.
■J^ '^D
.,nH ^ (
gp^^l^j_ ify^FORfVIATION on'^ ''ir Hfispihils. InslittillonN. Tninsienls,
or Kt'irnt Ri'sidfnis, .mil pfrsons (Uin'i rt\*.iv from \wm.
Former or
Isudl RpsHli'nif
When was discisr <ontr.i(f('d,
If not al pldifol dpdil).'
Him Imiq .it
Pld< (• ol f)i .illi .'
Od^s
PI, \»"i: < •! IM 1^ 1 \!. '
\ Ni)l- K I'AKHK
\l.
M \'i'
- I< 1M<>\- \I,
N. II.-
' 7T ,. ., AfiF «h.» .1.1 be Btnteil HX^CTLY. PHYSICIANS bIiouIcI
-!;vcr.v item o»' inform,.t!on .houl.l h. cnre»»lly «u,»,.I.e I. ^^J' '^^ " ^^'J;", t^,,^ ••Sp.d,.! ln?ornn.f.on" for per-
HtuU- C \lISf ; OF Di: ATH In pli.m tcrmn, that !t mny be p^opcrI> U..sh,»,ccI. I
«of». tlyinft Hwny from homu nhoultl be ftiven In every inntance.
c
o
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ai REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dnh- Fi/rf/ ,\J zXy(AT<Aj 1
VJr)\
Iic^ish'fcd J\'*o,
a053
1
^
c
Deputy
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of "5)catb
PLACE OF DEATH: — County of ^^^
City of
^
No.
A
/%
(
u
St.;
Dist.; bet.
and
^•y rROM USUAL RESIDENCE give facts called por unocr " special information \
r^DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I N STCAB OF STRCCT AND NUMBER. J
f D E A T
FULL NAME
^ : \.KMJ
PERSONAL AND STATISTICAL PARTICULARS
I li.i )K
^ t \ K '' n ! t
\
N S M 1 III
I XTiil K
t! %■>
M 1 ■ ! \ 1 1 ■
. I ni 1 K
ir A rii 1
n
rin^ % !!mn*h s'r \ r K n iT K - 1 >N M. r \ K i ! 'I t \
l;| - r I n MN is Ni >\\ 1. I 1 »' . 1'^ \ \ 1 > Hi ; I.l 1 . 1-
^-^ULu XJUv\^wtrv^ 'V*^ K-
\ 1< 1 IK
V V
I i; I'n rn !•
MEDICAL CERTIFICATE OF DEATH
\ ri
M.,r
/(JO :
! lIl^KKIiV Ci:Rril'\, Til. It [ atU!itk-.l tUHxa<^LMl fmiu
— l^p to " Tip
th.it I la->l -Mw h ~~ alivv on " Kp
ail.l tliat ik-alh orrurri'd, on t he <laU- '-tatt.-il ahovr, at
- M 'riu- CAl^K Oh IM: AIM \va< a^ folh>\vs:
u
s^ ^aX^N'n- >'"''^CX.
CON ruiiir i'Hkv
'/IS
/hi
I! u,
DTK ATI ON
-->
'li
/hn
SIGNED ) JV. ^
>VO->
//ruj s
M.D.
JtnX^
,^X
\i)ry%
Special information »«'> t'»r HosplhiM, institutions, rransients.
or Rcient Rfsiilenfs, ,inil persons dsin'j .i\*.t\ fro;n liome.
Formfr or
Usual Rfsidrnre
When wns discasp contrartcd.
If not at plare of deatt) ?
How lonq at
Place of Oeatti ?
Dav*
iM \ri
I ) \ I
r /A) , ,
1, r
I QO
Ad.h.-s bH'b I a /.A. .
L
^^""^^ .. , -^c I, ,..1,1 Ko Bfnteil HX\C Tl.Y. PHYSICIANS should
,. „._nvery 1.1 n, oV inf ,.n,i.,1on should b. carefully supplied. ^^^;;^'^ ^^.:*^'^^J:>:\^,,.u.l Information" for pT-
«t«tc CVUSI or DIATH \n pl»1n terms, that .t mny be properly Uass.t..U.
IS dyin^ inviiy from home should be given m every instnncc.
nnn\
c
G
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! \..
!;\.r r.:
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n^fjH.
M
DEPARTMENT OF PUBLIC HEALTH
Jtf'(f/\s/('r('(/ 'jVfh
City and County of San Francisco
Ccvtificatc of IDcatb
■A
Q
%'
PLACE OF DEATH: — County of '' ^ City of CJ.<x-y-v 0.V.O
IVo -I ' St.; i Dist.;bet. l^U^ and l^t(
/ IF DtftTH OCCURS AWAY rROI* USUAL RESIDENCE GiVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION' \
V IF DEATH OCCiiRRjn in A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
.c
LcLa; LoJ
kJYXJL '^^ t '^K. j^-'
PERSONAL AND STATISTICAL PARTICULARS
■^
X^
~> I
• \ i r
I;
\i I
r >t \ R u ! r ! I
I \ I I 1 1 K
II r
111 M' . . ;, I K
' r II 1 K
•■ i' I r \!i( iN
A'
A
rv>x
\ >s
'w^. U
(\
\
Ll^v^^'^^.
u\lL^.l.
L>VQ
■^
in-:"-^T « ii M \ ; iM .1-: \ M> Hri.ii:!-
I". !•> i'
I II !• I- inriiit
(
H
MEDICAL CERTIFICATE OF DEATH
It
I IIKRHBV Clk riFY, That I it
1 1 1
. il I rum
'/
that I ]avt V ,w h
alive nil
iii'
I'l-
;inil I !i;it lU ilh I H-iMi rrt'd, < n t lu- i
\T
latr >>tat(.'(l al>n\"f. at
Thi.- C \I SI" Ol' Di; A'I'I L was .m folldws
A
DlkArHiN )V<//
t'(»N'rRIHl luRV
i/,.//-^
/h
I] •^
1 lom <
I M K A r 1 < ) N
I SIGNED )
Months
Par
l<)0
\
//itlll s
M.D.
h n 1 . A
SPECIAL INFORMATION ""'^ '"r Hi)S(iil.ils, Insfitufions,
or Recent Residents, anJ persons (hir.) .ih.iv tmn tiome.
former or
Usiidl Residence
Wlien Hds dise.isp ronfrarted.
If not at place of deatli ?
ffow lonq at
Pl,i( e ol Dcith ?
'ransiriits,
Days
PI. \i I I 11 I'.IKI AI. I iK M l.M< '^ '^'.
U
' ^
\
r^ «
1) x'n i' I'
Is I
AKiVAI.
TC)0
m
INDKKrAKHH
"""""""""■■"^ TTT n ,1 A(iF should be stnte.I RXACTLY. PHYSICIAINS Khould
B.—Hvery it. m o^' i„form,.t1on nhonl.! I.. c.reVuMy supplied. ^'^1'^^''':"'^^^^^ Th, "SpccU.! Infor.nHtion" tfor p.r-
stnte CAlJSi: OP DII A TH in plain term., thnt it may be properly Uoss.t.cd. I
son, dyina away ffom home Hhould he ftivcn in every instfince.
&■-
^•
i~
c
G
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
i
l)nh FHp'I , \Ji^
V. X
ll)0\
Jici^isl ci-vd v\Vy.
2055
XoA V , Deputy Hesith Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of Bcatb
11. i?. !^'tnn^al•C^
'V I
m
PLACE OF DEATH: — County of
City (A^^O^-rxj ^KO
N
().
xl
and
, v^ ^ ,■ ' , St.: 1 Dist.;bet. "^ OJ\h.y <. ' , and •■ ■'
/ ,» otATM ,, r ■ AWAY rROM USUAL RESIDENCE GIVE FACTS called for under '^--cial information \
I ,r DEATH /, MRtD IN A HOSPITAL OR INST TUTION GIVE ITS NAME INSTEAD OF STREET AND NUWBER. J
\ 'y
FULL NAME
\ /
.U\.L.V
PERSONAL AND STATISTICAL PARTICULARS
A.
o /
L
L A.'^ -
^^ik_- -^
\W\ iii
niRTIl v\. \i H
fit ! \ rin K
nA ;i
(^
' i I i I iv
L^
A, U-O
\ I I« 'N f l)
d^L
m
^ /
L
^.-^
^^
dL
Tin N I'.i »\'!.: V r \ r 1" I > ri-' i< SI t\ \
i;i:-.r»»iM\ K Ni .\\ 1. t.j " ■ ' ' ^^ ' ' '•'
j I !, \K-. AKK rKi I' ■'■<» ■l■^"■■
fi
1,1,-. 1 » il M N
OCYSJ
I \<\.
^1. <^X^,^vvX^'
MEDICAL CERTIFICATE OF DEATH
DA ri-: i
;>i: \ iH
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/Or)
1 II!{RI'I'.N' t"i;Rril-N, Thai I atU-ii-kil .k'» i a>^e<l IniHi
tn
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II,'
A
•hat I li^i ^iw h .. alivf di! '• ■
ami that df I'li < .(a-urrc<l. lui tlu- daU- -^taU-.l alxivi-, al O
' M, TIh- CAISI' or |)i: ATI! was as foll<i\vs:
111 RATION ' )■"?/
(.ONTRllU i'* >I^V
J/(-;.'//V.c
/ ></ ]
//,///
[Ir.
1)1 RATH >N
(SIGNED )
)'.'<ir
Mruth^
K.
K I
/>(i\< tk \ I Ilia s
M.D.
I < lO
Aildrt-ss)
HftH
SPECIAL INFORMATION «nb '"^ Hospitdh, InsfitufiinN Iransienfs,
or Rercnt Residents, and persons dvinq <m.iv from home.
Former or
Usual Residence
When was disease fontrarled,
If not at plareof death?
How lonq at
Plaf e of Death ?
. Davs
I'l.ACH OF lUKI \!, <»R Kl-MiiX AI,
i
1 1 ^
ni,.;rtaki.k Uw'>^.CtiU^. I^^cUUv^
^A^t
^ , u ,,,,. ....fullv Huppn -.1. AGF. HhruMcl he «tnte.l l.X ACTLY. I 1I>S!UANS should
IN. B. !.vcr.v Item otf ir.formi.t -on Hhoi.I.I b. ...fcVuHy f"t*'»"' „^„.,crlv cluW.tficd. The "SpccM.I lnform,.ti-,n" lor p«r-
«t«tc CAllSI. or DI \TH 5.1 pli.ln Icrms. that .t mny he propcrl> .Ium.
son, clyinft owoy from home should he Aivcn In every instance.
>
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ml) IS.
:'.v\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ddfr Fih'ii , \j <;^u)<t~U\j 1
iy)()\
Ih'i^ish'fcd J\^().
2056
.<^ v,^\^
Deputy
V^ i » I *_» ^. f
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of iDcatb
PLACE OF DEATH: — County of^<Xi\ ovccvvcc^ec City ofO^X^v
n\
'Sxo
No.
f
I
St.: 1 '^ Dist.;bet. " ^ ' '■^'^ ^ and cLrv^v''
USUAL RESIDENCE GIVE facts called for under
/ IF DtflTM orCURS AWAY FROM USUAL R E. Sj I U t Wt^ t G I V C FACri, i-BUi^tu ► ■-■ r. u f'. u c r,
V IF DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S
S='ECIAL INFORMATION" \
JTREET AND NUMBER. /
I
fO
FULL NAME
H
^CX...
PERSONAL AND STATISTICAL PARTICULARS
»iii.i>k ^ ^ ft
rrv
o.
M A R k :
(
hi
C> Ctx^
\ K M 1 < U
lUK I iiri.At'K
Nt \ ; 1 .} N N \M 1-:
II' Ml I III Ik
HiR I'liri Ai i:
<•'■ m<»!im:r
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To riii;
( I I! fi i: tllii Jit
^d
X'ldl t-.s
ou
I , ' I
iX
0 a.<v->->^lJ-o^^^<*-
MEDICAL CERTIFICATE OF DEATH
! Ill : 1 \Tii
Uct^ 1
I ii!;ki-;i!\' c! krir\', 'rii;r ' 'riiiU'.i .i(ri;i>..i.-«i \v>n\
i
t
A . u >
til. it I la^t -aw h -- alivi- imi
aii.l tliat •!< I- 1: Mciirr
J \I. 'Iht CM SI'" ()1" I)I';A'riI was a-- rfill.iws:
IcjO
aiiM' I'll ' i 'v*'
■cil 111) 1 1u- ilatt statt.Ml ahtni-, at S>
0--%
DTK AT ION
C<)N TKinrTORV
Dl'R A'PioN
y'tdj s
.3^
Moiii/rs H
/>ii\
Hours
(SIGNED ) dU . U. ViJ
Pays
)<x. c.^^
I lotn s
M.D.
SPECIAL INFORMATION ""b f«r Hospitals, Institutions, Transients,
or Rrrcnt Residents, dnd persons d^inq .may from home.
Former or *^"** '""^ **
Usual Residence Place of Death ? n,.vs
When was disease contracted,
If not at place of death ? __«
I ; 1 ■ in A I -
t' ^t
i'l ACK or lUKiAi, (iR ri:m< •\ M,
i:M" >\ ai,
TQO'
Atldl f'i'^
• I, I 1 h. ..r.fullv ,.n.„ii.<l. AOB »l.....l.l h« «t«t.H EXACTLY. PHY.SICIANS should
N. B. fivery item oH* ln^:»rin;it
HtntL CAUSE OF DEA . .
sons dylnft oway from home should be fe.ven .n every instance.
c
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
;th 1- V
♦ »
/}(//(' Filed , \iy /^lijyiy^K: ^
!f)n\
Bcslisfcred J\^o.
2057
^trv.c^v/i
\>^ Dep
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvttficate of ©eatb
A
11. 5. StanDarC^
City of Ucw^YV 0 AXX
^
PLACE OF DEATH; — County ofv a^^ ^
0 mo
*io ^^ Xh/ry\XXrY\) UUMi -' St.:" Dist.;bet, and
/ -r OrftTH OCCUMS AWAi FROM USUAL R E S I D E N C E G 1 V C FACTS CALLED FOR UNDER SPECIAL INFORMATION
( ir DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
> \^^-. ' ^-
)
FULL NAME
OuAaX^ .
PERSONAL AND STATISTICAL PARTICULARS
M I LclU
s^
"^
I'
M^ i-
! > < » k
HI!
' St
X \ M 1
i At II
luKr
« »l
K
M MIM Ml
I ■' Ml 1 in IK
ufK rm'i, M'K
'ii %!!iriii:H
•ill r \ri« IN
H5 .. S
0
A
A',- ,A-,^ : H S.'i; /
rin" \r.< i\'i* ^r \'ri:i>
ni> i' <)] MV KN<
, I J. \K IIi'lM. \Ks AK
! WD ni;i,ij:t-
*Kri-: TO Tin-:
(In f'i- tii'tut
MEDICAL CERTIFICATE OF DEATH
\ ri; < >i in: \ TH J/
Muihh)
I ili;i^ i:r,V C1{RT1FV, That
LLcCQ -^ iuo'3> to
t 'iO i.,oH
that I last ^a\v h '■•-' alive on ._■-,.'. I90 1
:in,| that .Icalll -.(MMirrcl. <>ii tin- date -^tatcil ahovf. at H H.
^
M 'rile CXi'^'!'" ('L^Dl.ATII was as follouv;
H^ 0 ^' .
YX-O
, i "S
A^A^WvXr^
4
nr RAT ION )'(;;
coNTRir.r'roi
Moulin
/><7)s 1 1 Oil y
n 1 K A T I < ) N
(SIGNED )
I. ■
liirs
jrnuf//.<i
IhiV
'i'
I lours
M.D.
X.l.lres.) U-4A/VV^0,A^ ftp CH^M. J„O.J
SPECIAL INFORMATION <»"') *''r H ispitais Institutions. Transients,
or Recent Residents, and persons dying away from liome.
■ IxXA/UAvt
Death
Ddvs
When was disease contracted,
If not at place of death ?
U,tl,
I'L \CV < n IMiyAI, (»K KKMi |\ M-
U l-Mt >\ AI,
INDllK TAKlsK
-^
Addit ss
IN. B.-
'*!
' TT .^p should be stated RX4CTLY. PHYSICIANS should
-Every item of information should h.- cn.otuU.v suppi.e ^J^Z^^^A, The ^Special Information" for p.r-
state CAUSE OF DIZATH in pli.in termn, thot .t m»y be properly Uass.t.ea.
sons dyinji away from home should be feiven in every instance.
s:
wwntpg-
.i%^
^
II
^%ik
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,! !l. .ilih 1- "-
luv r <•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dah' /'^ifr(/ ,\^ zk^>-^K' X
lt)0\
JiCiiisfet'cfl v\7>.
2058
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of Bcatb
PLACE OF DEATH: — County ofwCtiv
Tr\
^
City of '.OAA^ v].va.iv^
V
(\,
a
No.
f -,
^ ,. St.; -^ Dist.;bet.M t wO ^-' and^nU4.4-
/ ;r OtATH OCCUPS AWAY FROM USUAL R E S I D E N C E G . V £ FACTS CALLED FOR UNDER '■•"'" ^ <^ '* "-j;^ ''^.^^f^^ '° "' )
( .FDtATH OCCURRED .N A HOSPITAL 0« INSTITUTION GIVE ITS NAME ,N3TEA0 Or STREET AND NUMBER. J
4 r-
FULL NAME
^l [La^u
4 I ' ^^'-
PERSONAL AND STATISTICAL PARTICULARS
St 1 ! . t > K
t °% *
M Mt|< tl"!>
A
%
HVi
o
i r-k
ii • ' • 1 1
\ r in K
^.k 11 '^
ill NfOTIllR
. i Ii i:h
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A-
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Tnr MinxH htatkii im-k-hx m. pah nrt :. xk-. akh ikts: t- • ini
l;i-^r<.i MS lsN<»\\ I.l J>< .H \"^I» J^l- '••'
(Illf ,; ni;iiit
A.«.>^..
-U.
\
\ %
MEDICAL CERTIFICATE OF DEATH
\ '' \ I
ii lu: \ 1 n
f
ii.is-
! I!!:K!;1!N' t i:k'ri I'N', Tliat. l attc-ii.Uil «UHr;i-.cil frnni
il,,,t I ! . I; .ilixt nil Cn^l. -"wUviL^ a.cv
an.! that thalh ■.<. arrvMl, .ui tin- 'late -tati'.l ;,1h.vi', at
^ M. Tilt- (' \l ^l^ Ol- I)! \TII wa-. a- t"f)!l<nvs:
-!(
CONTKIIUTOKV ^
Months
Pays
1 1 1)11) <
1 1
Ur RATION'
(Signed) J C
Mo)iths
Pays
M.D.
V.Vl\,
Special information ""I^ ''••' Ho^PiMs Inslitutions. Trdnsients,
or Recent Residents, and persons dvifii) dw.iy from Ijonie.
Former or
tsudi Residence
When was disease contracted.
If not at place of death ?
HoH lonq at
f'Idce of Death ?
Dd>s
J. I \oi' ni- IHRI AI, ou ri;m«ivai
r.NI.l.KTAKKR VwO.^^C'wU- ^^ O
i»A ri; ..; Hi v.\ w <•• k!:m<>nai.
TOO
N
(Atia
H's^ <k.H. w
/0-/W'
"-* — i— ^ ,. , TTp „H„i,u| be sti.UMi liX4GTLY. PHYSICIANS stiould
N. B.— r.vcry ftc,„ o* i^V^,rm„t!on shoul.l be cnrcfuHy -r>»> '^ ;. Z]^^ f;;^ dosslfled. Th. -Speclol Information" for pT-
Htiitc CMJSF. OF DEATH In plnJn terms, that it m«> >- '* ""^'^ ^
«nn, dylnft nwoy from home should be gUen In «very .n.tnnce.
c
G
SSgiM£Z^^^
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WRITE PLAINLY WITH UNFADING INK — THTS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 N.
I'-.-v !■
Jifo/sfr/ if/ .jYo,
2059
Deputy Health Officer
DEPARTMENT ot PUBLIC HEALTH==Clty and County of San Francisco
Gcvtiticate of IDcatb
^0
PLACE OF DEATH: — County of ^^arv
J ^
\ n
< ^' City of d/Ow>\. J ;uOl > V c.cA
Ml
?4i
,j^tv l.^«^ku ob(v4>v-^"^ ^^
St.:
Dist.;bet.
and
/ , - orATH OC-URS AlWAV FROM USUAL RESIDENCE Give F«CTS called rOR under "special INroRMATION' ^
( ,r DEATH OCCURRED IN ThOSP-TAL OR INSTITUTION GIVE ITS NAME INSTEAD or .T«CT AND NUMBER. J
FULL NAME
\.(1Xm
)(rr\xSJ
u
PERSONAL AND STATISTICAL PARTICULARS
LL', '.
(\
I . li nik in
a^'
b
N \M 1 Ml
I \ rn IK
if ^
'\^y\j fllD crv\>
< »1- MmTIIHK So il
luu rniM, \( V,
(•I \;(i'nn:K
(T)' W\' >N PTn '
LtA-v
^^
uu
T!!!- \nnVI- sTXTVH I'KR-oNAl. I'XK'lUr
r.AKS AKK TRVK Tn nil-
(Iiif(.nn:i!it i '
CQ^ J C^^-^
.U.I.... 3H50 ^ inl!.^ "t
MEDICAL CERTIFICATE OF DEATH
DAlli ill- I>i; \ IH
Ni'.lit
!!:ivl
1 II I:In I". I'.V CI'.KTIIV, That T atlLMitUd ilf.r;i«>.<l Inuii
that I last -aw h . ahvc on t</'
atiil that lUalh occurred, <»ii the <hitv -tateil alu.ve, at H
\\ . The CAl'Sh; (>!■ hl'.ATII \va>- a- fn!l,.uv:
Co ■ ■
a>.
1)1 RAT ION
I 0
) N r R I r. r T <> R N' LxX^^-C^'TL^Cr^^ vO^M^\>^-<i/
//(!///'?
A C
DIRATION
(SIGNED ^
IcX.
Vrars
Mn*llll>
Pays
T«in
f AiMress) '
M.D.
>. <, A
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons d> in] av^ay from liome.
'^X.C > V V.
Former or ^
Usual Residence J
Wlien was disease contracted,
If not at place of death ?
How long at
Pldce of Deaff??
Oavs
i-i.ACi-; OF nrKiAi, « ik •; iM' 'V \i,
X ['K of ncuiAr, or Rl'Mn\\I,
% Tqo'
at
(Ada,... iHlli ^^\.^-^^^'s\.
!N. B.-
-"- ... AnB should be stated HX VCTLY. PHYSICIANS should
-livery Item of informnf.on should be ^nreVully f"nP •;^^- ^.operly classified. The "Special Information" for pT-
«tate CMJSF: OF Dl:ATH in plinn terms, that it m.«> be pr< p y
;in. dylnil oway from home should be felven In every .nstnnce.
c
G
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
1, 1 V.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
mm
'\, Depuc h O^ -
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate ot IDeath
"Cl. S. '-•tanJ.irC
PLACE OF DEATH: — County of
■X
"\
n
City of ^^CU^rv '» \0
^i.
No.
^
A
Aaaj
and Al C
(
St.; ^ Dist.; bet. M I U^^QAm^A;
^.. orrun- -^Wfty FROM USUAL RESIDENCE give facts called for under "special .NrORMATIOM' "\
.,,.M nr-uRRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBCR. J
'■^'^ A C' ^
n
FULL NAME ^ h^o^
PERSONAL AND STATISTICAL PARTICULARS
rs ;
u
%;. h\
I
'N
I
dct>v
1
u.
N \M
111 K
lUKrniM, \ii:
mt I r \ r 11 )N
(\r '^
C^y\A)
t-
] r
ml
> 1 r> S
I \. !.;!.-■
i ()\l,l^.v1 ^^
MEDICAL CERTIFICATE OF DEATH
I! XlK < >l l>i; Alii
4
I IIKki;n\ I IKlll-N. That r :ith!i.U-.l .Ilh t ,i<e<l I'r.
nil
tliat i last saw h ali\t "Ui ''
and thi* ilraili (iri-urrr.!, i.ii tlu- <latt- vtatr.l aliove. at
M *riK- C \l SI-; <»1* hi:. \ I'll was a^ foll.nss:
, J r^
ri . "
„^A
/-S - - r^
CnNTKIlUTnRV vWu>-
Mo^iths
r-v
/>^7r
i_, VA.-
Hcii^
Signed ) Lo^^toa^
Ho Ills
M.D.
SPECIAL INFORMATION wN *»r Hospitals, InNliftilionv. rr.insifnts,
or Recent Residenis, and persons dvinq dwri% frfiT, hnmp.
Former or
IKii.il Residence
Wlien was disrasr i nntrarted,
If not at plare of deatti ?
Htm lonq at
Place of Deatti ?
n.iv^
PI.A01-: >tL' r-i K 1 \i, < >K K i
c^LoJuu^:
\
DA ri
_Q^.
-s'
i:m<>vai,
'4
TOO ',
,. , >nF s'v>uld be stated I.XACTLY. PHYSICIANS should
N. B.— Hvcry Item of Inform .tlon should be cn.etully f"Pr> -d ;^;J;^,^^,^^^.,f.,d. The ^Special Information" for pT-
•tau. CAUSE OF DLATH In pli.m terms, that .t may he P^''P^'"y
"n. dylnii away from home should be felvcn in every mstance.
c
G
m^
•r*^^-
1 .
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
«« ■**»*^
uKl- c<,
{\
\_'
Ifff/
Deputy Health Officer
Ju'iji sfcrcd JVi),
2061
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of iDcatb
1 1
PLACE OF DEATH: — County of C
No. oL L v^*^Lu. ^
(IF DCATH OCqunS AWfiir FROM I,
ir DEATH dcCURRLD IN A HO
O.
4
V - 1 City of O
St.;
Dist.; bet.HllU^C
O
vXOAXand
\
i n n ' .
USUAL RE S I DENCE GIVE facts called por under special information \ \
SPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J U
FULL NAME ^ Lclt\
V I
PERSONAL AND STATISTICAL PARTICULARS
fi i ' '1.' 1^
\ I VI
/''^
>^
L
5
H
rk, -
A
r^
il W I wS.
^ IVct
MEDICAL CERTIFICATE OF DEATH
I
K.iv
/ f>( '
lint I 1
tiii| I h ■
i,,.j'v to • ^' "^t) I r.ioH
' y h alivi- nil W " V l.,n" .
h ' Hiurri-tl, on till ilatc statril ahoM-, at -
M. Tlu- t \
i<\ Dl \TII \\;.
1)1 UAl'loN )V</r
C( iNTklin I'f >KV
A/o>ii/t
fhiy
Ili'Ul
t^
Q-vcvcec
I'l \> }■
' . ^i ' 1 1 1 ( 1
;• K I II IM, \i-
» ri- \ ! h IN
V
l
^a L
\j
I HI' '>
1.!
\< i\\ 1.1 "i' <
I Pt.R^oN \I. I'XRTh I I. \H'^ NNi; TKrH k' I
i\\ I.KIii.K \ A
"-?
Cj (^V <x^<i^
\.l.ll.-.v
)^K/VVw<b'V"^-^'LjL CoJL'
Dl l< A in »N
SIGNED
J/-
'///I
LC
M.D.
! I in
f AiMn--'-) HOX
a.A_0 1 W i
Special information »"'> '"f Hnspildls, InNfitufions, Transients,
or Recent Residents, m\ iirisims dvini -i^''^ '"'" '"•"""•
Former or
Usual Residence
When was disease (ontratted,
II not rif plare of death ?
How lonq at
i'ld« r of Dcitf) ?
Days
rxnKk
aki;h Lo^OU-aX
^l
I QO
>
^
Aa.h.s^
k^ \j<xjy\j
•WNL-
N,
H._,..,,, Item nV into.m.f.on should b" cnretully MuppI.e I. '^"':;,7' '^' ^^^^^ t,,^. -SucciHl Intormr.tion" for p,r-
HtiiU CM SI OP DliATII in plain terms, that it may be properly .l»s«.t.ed.
IS <lyina i.vvay from home should be given in every inHtnnce.
noni
c
G
i^wmwip
■
1 ■;'
1
i
i
;
i
'I
1 ]
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
"v -. ! r . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
% Deputy Health Officer
Jfr<j/s/rrr(J A^o,
2062
M
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
cap
4
PLACE OF DEATH: — County oi
City ofClXX
• , 'I
No. V
.ouC
StU
Dist.; bet.
1 r ! r A T H f I
r i) ( A T H
»./,*v rHOiV' USUAL RtlSIDENCE GivF F'lrT*; «- a
(?RED IN AHOSPlTSL OR INSTITUTION C, IVE 1^ NA^/l
and
FT FOR UNDER _ _ i A L INFORMATION" \
A I NSTFAD Of STREET AND NUMBER. /
A
^
tl
FULL NAME
/U-c'
PERSONAL AND STATISTICAL PARTICULARS
h
LCUU.
X
^.
>
'V
b
1 M \k
1 ' >
1 !)
A
il ».K
>N
in
1 1
(1)
y
u^-
k n
Nf.il,;!
,„ S,ni I I
111 I \H()Vi' ^ r \'! rti vvM
HK--^ r ni MS I. Ni p\\ !,1
\ R< \ w K iH I 1-: I ' » I 'I •
^
MEDICAL CERTIFICATE OF DEATH
;i; 'i_-IliU'il (It ( < I
iN .a;
-I'll t II Mil
I (111
lie
;il|i I Ilia'
hi R A TM »N
i;(t\Ti; iiirToRV
III R \ rh 1^
\ 1 --. 1 { ( » !
Ml- (latt
lu: \ r
c &=
•i| a I )( iVf a'
a^ fnll.iu^
M^h
t
'UC'
/>./rs
Ihuys
•r^\
IhlVS
Signed • L^X-cmJ^v J ^u5.Uj JjlJUMx^
l^ in
M.D.
SPECIAL INFORMATION •►n!\ Jir Hospi
or Recent Residents, and pfisoiis dsin'i .mnv from lioftip.
als, InsfituTiohs,
tnrmer or s f ^,. . 'm' ,
I'sual Rfsidiriip ^
When w,is disp,)sr ( ontr,ufed,
|[ not at plare of deatti ?
tfrm IniKi <if
PIhi c lit flcifti ?
[idH'^icnts.
n,)vs
•1 \CJ- » Il V.\ V 1 \I, "
\X:
1 QO
I NI)IJ< I \l- 1 i;
\-Mi' s"
'^5ivy>v
SCSI-'
N. B.
, TT ;^pp Hhm.ia l»c stnte.l HX^CTLY. PliVSICIAN>i Mhotild
r> item oif inf..rmut loii shoul.l «'^ oi.-u>ull> svippli^u. • • . .. , y,,^. -SiKciH' liiformit i.ii" tor p-r-
U- CMISi: or DI ATH in pl»in terms, that It mnv he properly .Iuhs.UcU.
"fivt-r:
• tote w ,»,.,.- -,. - . . . »„„,.„
mnnm dyinft nwny iVom h«,mu should he ftivcn u, overy .n«t«nce.
c
G
t;«:
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t 1
](ri>isfr,'(ul JS^O.
mm
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
K^*U^
Ccvtificatc of IDcatb
■a. 5. t?tnn^ar^
PLACE OF DEATH:— County of av
s
CU^CC City ofw
N<,. ^\Xc\,^^ LcrWW'
St.:
Dist.; bet.
and
^ ( ir DEATH OTu^, & A' » V TROM USUAL RESIDrNCE GIVE FACTS CALtED ^OR UNDER "SPfCIAL INEORMATION \
1 V ir DEATH OCC4jRRID IN A HOSPITAL OR IN' ' ' _, n O N GIVE ITS NAME INSTEAD O? STREET AND NUMBEH^ /
FULL NAME
--^
■4-
PERSONAL AND STATISTICAL PARTICULARS
^\
n
^ u I
^
n !>
4 1 lavvct-<l
0
K
(n^^^xU ^^^
OA^cLo
MEDICAL CERTIFICATE OF DEATH
li
r
lllMl I 1;
ail'!
^\\ 1
I I ill
r 11
N , ,'I 1
:-t. ll t 1' III!
I(,0 H
1 UO i
M. Tlif C X
■ ' ' ' : ■ id a hi >\'«.', at
il l>i: ATM wa-^ a- fo!]^ u-
//.
M 1
%•' nil iJ<
IM, \r>
.1
0
I
I<.N(^'
ni>i
u! MV K Ni iW I.llttU-; \M» i;i l.:i :
ri » I'll I-
\>M'
mi'wvxsj
^
vvxs-.4x^
/>
n'v
O
//I'l/rs
M.D.
\.
SPECIAL INFORMATION ""l^ J'lr Hrispitals, Institutions Iranvirnt
or Recent Residents, and persons dvin) ,ih.iv fnvii linmr.
.U^
Former or
Usual Residence
When was disease confrafted.
If not at plare of death ?
How lonq at
Plare ol firaft) ?
I)avs
I'l \v'K or Hi U ! \i. < >i^
\ 1
Xlv. ^v^Yvcv.
ti i\ \i,
I qo
rNlU- K I'AKl- '<
(Ad.lr.sv oU'
^'J
I 'T I ' 1
'~*'"'~'"'"""~~""'~~"-~'"— """'"■ Tm IlTd \nF. shouia be stntecl KXACTLY. PHY.SICI ANH «houlcl
N. B. !;vepy Item ol" inV* >rmBtion should b." ciirctully siippii<-«i. ' L.^^ii?!^.! The "Suecial biforiii:itHHt' lor p«p-
«t«te CAllSr or DEATH !n plain tcrmn. tb„t 5t m»y he properly .lHH..t.ecl.
son. dylna nway from home should be j^iven in every instance.
s
9
■f
c
(
r
■•pa*'
^
i
« ,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RErER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hiiai ' if III Mil IN.p 1' '5--v:'3r|;^5 liS: I' r.i
^
/)/(/(' F//('f/, L/cL(rlK.^s 5>
HJfn Eeg/sfr/rd A'o, 20G4
d^\^ov_xs Xvwu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of IDeatb
( XX. S. StanDarD )
PLACE OF DEATH: — County ofU-O/^W J K<Xm/lA>U^ City of C)xXa\; O \.a tvC^UK^
No. li 51 0 (ruMrnPy\: St4 4 Dist.; bet. 1 kJX) and ^
(IF Dt»TM 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
>!.\
!i \ ri: 1 ii i. IK III
PERSONAL AND STATISTICAL PARTICULARS
^
4-
M. nth
.t
MEDICAL CERTIFICATE OF DEATH
KATI-, (•!• Dl'. \Tn
\
i nav
Ac.H
1/
/'.n
^IN«. !,l MAKHII-.I*
\\ \\n (Win I >R I»l\( iRi 11)
Wilt' ; !i -I II ' ' ' - : s.' ii.it ii ill '
■^t -• 1 I >; < '. iuntr\'
^
L>xa
t
■1
I- ATI! i:k
i; IK rii I'l, \i}',
»>i I \ rin-K
ist.i!, I.: (oiinttx
%! \II»1"N- NAM I
ni- MnlHl R
lUR llllM.Al'l-:
Ml M(»rin.;R
' St.'itr or (.'(Mint 1 \
' l\c Vq aiv i^ \x >T > \ a r
^
IL'tt
(Month)
3
'l>avi
(Year)
I IIl':ki:r.V C1;RTIFV, That I att<.Mi<k<| ilcnased from
V^X-l^t aO iQoH to ^'tt; ?>
i(p*(
T90 1
that I last saw h OYi alive on C 'ZXj 'h
and that death occurred, on the date stated altove, at \
U. :M. The CAI'SH Ol" DliATII was as follows:
nr RAT ION )'iU7rs
CoNTRIiU'Tol
A f Of ///is 3. /)(iys
11 out
\\ LLojCLl Uj \>0-"A,c4vvXtA
^i\\A^U^vl
t\^vlLa
\i<>jysJXKK^OJ
\
C/AJ^Lc-^-vd-
ot'CII'A TIDN
Kf'^niffi in Sail /'> ,i h, i ^r-t
)', ,1
.1/.
..*////' 2,
/',n
Till' \HoVH STAT1',I> I'KR-^nNAl, 1' AR PliT I.A KS AKI-: TKIK T* > 11 IK
Hl>r Ol- MV KNOW I.l.Ix.K ANDiilLn'!
(Infotiiiant
^HWq
\
niRATION
(SIGNED)
]'tars Atou//is 1 0 A/vs'
J ^>
Iloui <>
M.D.
^/tfc ^ i<,o^ (Addrews) lUH 0 Q^<Ur>Vu ot
icyt^
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
former or
Usual Residence
When was disease contracted,
If not at place of death ?
How ionq at
Place ol Death ?
Days
1M,\CH<>I HlRrAl, OR RKMoXAI,
i)ATi-;.)f lUHiAt. <»r rj-;movai.
Udarcss . 1 OS' 1. A} I'U^AUt^X .J.
N. B.— F.very item of inWmi.tlon should be cnrefully supplied. AGE should be stated EXACTLY PHYSICIAIN8 should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The S|>ecial Information for p«r-
8on« dyin^ away from home should be feiven in every instance.
i
I I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•th f V.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^
J)ff/(' Fi/f'f/, L,I^tcri.^^' ^
If^O'i
Be<^isfere(l JS^o.
2065
<^v
DEPARTMENT OF PUBLIC HEALTH-=City and County of San Francisco
Cevtificate of Bcatb
PLACE OF DEATH: — County ofJa-^v 0 Vavvcc^co City of Oa^ 0 ;v<X>\ c uix^o
jVfo 1 Ul V a CU St.: 5^ Dlst.;bet. X\.-)\A.> and 3.3^.<i
/ \r DEATH OCCURS Aw»y rpoM USUAL R E S I DE NCE give facts called por under "special information \
V IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME ^.V^ a ^v
Ka4X
PERSONAL AND STATISTICAL PARTICULARS
>
n
iR \
U^
1 1 I'^du
:^ /^■ L—
/tS5
\ t ! :
^H
]■ M \H l< I»
1 \
LI
Lr^^
V • ^ V Ca.
IlIHTIII'I.Ai 1
(St;it«' or t'om I
X \ M 1 I »!
1 \ III 1 K
lUK 1 II ri, \r )
M ^ I 1 il N N XM I
»>! Mi»SHi;i<
lURI'lII'I. Nri*.
<•!■ MMfMHR
' St.ii' 1 >i i'l Hintt \^
V>X'
.0
u ^^^
vav.A>iAX'r\)
. 5
1 , .7i
M. uth>
iHcrr A ri<»N
■\-\\r M'.<(\-i* ST \ri n iM'-!<'^nNAi, tar ricn, \k^ ari-, rRii-: r<>
1,1 --r ui MS KNDW i.i'.ix'.i'; AM' ini,ii;i'
/'.M
(Iiir<i!iii;iiit
^Qx^
JC\XX^
\.l<ll.ss
A
H,'h\ UA.CVOLA^^-fi-">^
X<5
MEDICAL CERTIFICATE OF DEATH
DA ri-; ' >i iii;aiii i \
l^'ct
(M iiitlii Davl (V.:ii>
I Ill'lKlir.V C1;RTI I'\', That I .ittrinUd «K(r.isc»l fnnn
that 1 la-t ^aw \\ -^S) ahvf on *^ ^ ' lyoH
and that lU-atli .HCiiirt'<l, on thi- <lati -tateil almvv. at H
i^^lj M. Thr cwi'si-; or hh; \rii ua^ as rnii.-ws:
V
DrkAI'loN O )'t'ins
i( )NrR I lUTORV
< ^ '
MiDiihs
Par
Hour
DT RAT ION
(SIGNED )
)'( ay$
M,>)it/is
I
/Vfr>'Vu<X^
^1 ^
/hivs
I Ivios
M.D.
l(>n
H
A.hlrLss) SIH UXX,LLvV^.a.'^"'
Special information on'y for Hospildls institutions, Transients,
or Recent Residents, and persons dyinij .m,iy fro:n home.
Former or
Usual Residence
When Has disease contracted,
II not at place of death ?
How lonq at
Place ol Death ?
D,<\>
» WW (i! Hi RIAL i>i R I Nil i\AI,
IQOH
ij^ H
.. 1 4nP =^r„,l,^ ha stilted RXACTLY. PHYSICIANS Hhould
,f 1nfo.n,.,ion should b. cnrcfully Hupph.d. ^^J' f " '^i'^,,^! /'^ ,nf<.i.nuf.un" for pT-
; OF DliATH in plnJii terms, thnt it m»y be properly cluH»i^i..il. int. , .»c
IN. B. Bvery item nV
• tnte CAlISn _ . . ^_„^^
lions dyinft iiway ?rom home Hhould be fe.ven m every instance.
^WJW_JJPUP1
mfmmmmmm
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
:,<,) iif Hi :i!ll! I
No ; ^ -f*^^^ IS.t I' O
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dftfc F//r(/, L -[rlcrAMAj 3
jorn
Jfeo^i.sferrd J\^o.
20G6
\
^
cLtv V- -.VI Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of E)catb
( XX. S, SranDarD i
PLACE OF DEATH: — County of a^^ A/X nxCUXM) City ofU>a^A; J ^X>Ct/VLCA,A/CMi
No. 3.HD
4-
-v<X^^q\fc^x St.; i Dlst.;bet. ^txXWULtm. and^KLLO^y^k )
/ IF Dt«TH OCeflWS •WAV 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. Aj
FULL NAME >ta-^-v ■■ V.lci^C\d
-•l.\
PERSONAL AND STATISTICAL PARTICULARS
1 N
HICL^..
IL'vJii
MEDICAL CERTIFICATE OF DEATH
DATl-: I >I I>I. Al'H
1
Let
!»A*I i; Ml HIK in
lU
4CS
\i .]•'
*^ IN '1.1 MAKKH 1>
WllM t'A »• It < »H Iix . r. 11)
U ! It. Ill -... !.i' ill -iy n.it i.'iO
H
L^ va^^
HIK rnri. \t"i'.
iSt;i!i 1 i! 1 '. uiil' \
N \M 1 t »1
I ■ ! in K
lUK riii'i, \»*i.:
Ill 1 A rii!:k
■->t I ' • lit (ill"!
<»1 MolllJ K
lui' I 111'!, \ii:
't| Moflil K
->taSi .! t'liuiit I \
vtVv>\ Ll^u^cl
' \ \ ^' A
iVtatl
(Month) n.tvi
1 in.RIJ'A' C IlkTII'V, That I atftn.U.l 'IcfLiiscd fn>ni
\t m 190 i tn U'ct^ 3. icpH
\
A
tlial I last saw h -^^n alivt- on V. tAi X up M
iin! that (k-atll iHi-iirrt'iI, (»ii thf datr statiil ah<ivr, at ^
U M. 'I'hi- C Arsl-; (M* l)i;.\ Til was as follow^:
LIcmJIx L^vbjVO ^^OU/^i
coNrkiiuroRV
A/o////ts \ Days //o.ns
DIRATION }'fars
(SIGNED) ;>UU>
^
Mouths
/hiv
UU^y\ uw
/
<»i'r\i' \ rioN
fsf'itifi! Ill Siiii /'ill II. ' ' ) 1.1 1
rm- .\H()\ i-: sr \ ii ii i-kksun \i. j'\k ih n. \i'> aki; tki » r< > rii>-;
llI'lS'l'tM MN K N< i\\ !,) IX'. !•. AN|) lU I.II'.I
1 M,.iitl
' lufotiiirint
10 ^1\; H. CcxXK^
\.l.!i
1%
d^<XaA^oA^^
c^t
C)<ib "X ii|o\ f.\.l.ln-ss)'t>0"l IXVO-Ah/
A
.0^
Hours
M.D.
Special information mIv tor Hospitals, Institutions, Franslents,
or Recent Residents, and persons dying anay from home.
former or
L'sual Residence
When was disease rontracted,
II not at place of death ?
HoH lonq at
Place of Death ?
Days
I'LAt,"!.: <>l- I'.l HIM, i»K Kl.MiiNAF,
INDJ.KTAKKK
DA TK lit lUHiAi. or H i;Nti i\AI,
V.' €fc 3 T90H
\(l<!i<>;s
in I
A
l\
ft >.
■\
rV
, .. 1- I AHF Khould be stated EXACTLY. PHYSICIANS should
tS. B._Kvery Item o^' Infor.nntion should b. carefully -ppl.ed ^J^^^^^lll^^^^^^ ..Sp,,j„, ^formation" W pT-
Btotc CAIJSK OF DEATH in pluln term*, that it mi.y be properly Uassmea.
son. tlylnft aw«y from home should be given in every Instance.
f !
t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!I. :!i); 1
l'.."vl' 0
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)(il(' Filed ,
V,
4
,\. 'h
l'.in\
]l('i>i,\lrri'il jYo.
2067
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Gcvtificatc of Bcatb
itv ofO<X>X. J.*\_n^ > ^ ^ ! <}
City
0
U
No, N-^^<-
^. *w >
. >K
St.;
DE
STI
Dist.; bet.
and
\ / ir DEATH OCCURS *W«Y F R O P>$ USUAL R E S I D E N C E G I V E FftCTS CAllED ion UNDER "special INFORMATION ' ' \
' V If DfATH OCauRRtD IN A HOSPITAL OR INSTITUTION GlVf ITS NAME AO OF STREET AND NUMBER. /
FULL NAME
,1
"^JXXXxh
\ I
A
PERSONAL AND STATISTICAL PARTICULARS
if H / '
\' I
: : S M \ K !. I ! t i
i\ I I H i\\ 1 1 i ( I K
I ' I
I II
ItlH I'll 1'L \"J-;
I i! 1 \ in I R
M \II>HN N\MI
<ti m<>thi;k
lUK 111 I'l, \<K
>'i MMi'iirK
I'll' \ riuN
MEDICAL CERTIFICATE OF DEATH
i» \ ri-;
r\
1 llKkl-l!\' r 1:1nT1 I'N', Tliat I attituUil «kH-iavi-.l fnuii
tllal 1 la--t ^,ii\ li * ' ' ali\«/ nil
^
r
TikT
aii'l that iltatli > h ruiri-il. <>:' 'he dati- •-tatril alioVf. at '
M. Till- (■ \i>>l-' <»1" l>i;A'i"ll \sa- a- foUnws:
<?^y
V r 1 ,
iS\ XaxX Qv
v^.
1)1 RATH iN
I < (NTH 1 lU '!<ikV
) i iN
.)/i>////lS
/I
1 lom
\
/
/
S,;,, /■
\
\
'\ T ST NTH I) I'KR-,. >X \l, l'\KT|i'ri, NR-^ \KK THI l- I' » I
111 M\' ix\< >\\ !,i;i i< . i: \ n: > hi i.ii'f
III-:
In T'l-iiinnl
y ^1 ,
, I
I ) I K A '1 I <> N
(SIGNED )
^%
Motilh.
fhiv
^
M.D.
!<,'>
Special information nnly for Hospitals, Institutions. Transients,
or Reient Residents, dnrt persons dvini m,\) from liome.
Formfr or ^ , i
Usual Residence ^
When Has disease rontrai ted,
If not at piai e of dealfi ?
How lonq at
flare of DeatI) ?
f
Dh\^
I'l \cv or in RI \i, i>i< 1^ i
Ml
I) \
k i-;Mif\ \i,
TQO'
I ni)i;ktaki:k
m
VL
Addi <ss ob li- ■ i * ' ^ > ^'
^ 7\, ,. , AHF should be stnte.l n>:4GTLY. PHYSICIANS nhould
N. B. Every item oV inV'<.rm.ition »hmil(l he cnreVully supplied. a . ,„^^\i\^A The '*.Snecia! InformatM.n" for p»r-
«tHte CAlJSi: or DI:ATII in plnln terms, thnt it m»y he properly wlus«.*.eU.
son* dyinft owny from home should be given in every instnnce.
c
G
r
h
H
m
w^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
De
IfJO'i
u •^ .«v^
Me^isfercd J\^o.
2068
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
"a. S. StanDtirD
(^
No.VC
PLACE OF DEATH: — County ofOCc^^ J/uOL-rxoUt^o Gty ofCj<X^^ J\<X >
v<"<.^ <" (
(
St.;
Dist.; bet. and
.„ -i - ---- ■• ■ ..».». ■^.-^ FACTS CALLED FOR UNDER "SPrriAL INrnRuaTin
.r DtATH AJCCURRED IN A HOSP.TAL OR INST.TUT.ON GIVE ITS NAME INSTEAD " STR EeJ AN D NUMBER
ir DEATH OCd^RS AWAY TROM USUAL RESIDENCE G.VE rACTS CALLED TOR UNDER 'SPECAL .NTORMAT-ON
FULL NAME
)
fWxA UriLL
-1 \
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
n '
• \ n ( »! i;!R rn
\<-i':
a
H^
M
\
.111! hi '
b
:):iv)
DATK ()!• I
)i;ATfI ^
ux-
%
•Dav) IViar
\r.>i'/n
x\
/>.,v
"^I^ ' ] (■ MARK F }•■.!)
\\ i IH i\\ I 1 . ( iK IMVt )!••> }:n
\\ I 1 1 ' ;n Alicia! i !t'-»i"!iat ii ill )
1 HKRHBV CHRTIFV. Thai J alien. led .Ic-rcasc-.l fm,,
^JLivl
that I last saw h •• alive on d^CVvt t< I
OX^-t
Ti)0 H.
lUKfm'I ^ ■! ^
N \ M 1 ill
I \ I II I K
HIHTHIM, Ai'i:
Of' FATHFk
M \ II>1:n NAMl
'ii m«)Th1';k
luk riM'i.Ari.;
<»r Mnrmic
iSiatf or (.Nuinli \
oi'crpATiox ^
n f
-CdcOu^^v
III
aiid that death ..ceurrcl, mi the date vtate<l al.ove, at IQ.'^O
) n *^" ^"■^' "^'v-S'^' nHATII ^^as ;,. follows:
\.\.^<A>
^J-^aX/w
K.<. > \_iX
U Uc , .^
DlkATlON )•,•,/;
C'oNTk iniTORV
Mouths
Ihn
I lOH) S
i)rk.\Tir>N
SIG
nav.<;
<ryv^rucr\)
Yeats ^ M.^)iths
NED) 10. b. C^ >X.Lo,. ,
1Xy\A ^H Tool (Address) L\Xa->%Xl4a. ^We
Hours
M.D.
Special information onlv for Hospitals, InsmuHons, Transients
or Recent Residents, mi persons dyim] aw,iv froii home.
) , ,;
M.niih^
\-\\v. WMwv. sT\-n:i> i-kksonai, i-ak irt-rt. \ks ari- tki j.- -lo i-in-
in'sTolYOJV KXdWi.l.Dr.H AM) IUI,[i;i-'
iifv.inatu OA/CL/>xJk Uw- Cj<:Jx/\'>Axta
Former or
Usual Residence
When was disease confrarted.
If not at place of death ?
How lonq at
Place of Death ?
Oavs
(III!
\'lilrr>-.s
VA-^^>VV4U■\ <i
I'LACH ()I- lUKIAF, Ok RI-tMiiX \I, I n a Tl
Ha^'W
tN"i)i:RrAKi':K *
^: .1 Ri;Nf()VAI,
T9ON
^- **• Rvery Item o»' Infcrmiitlon should be carefully supplied. AGB should be stnted liXACTI.Y. PHYSICIAINS should
state CAUSE OF DIIATH In plain tcrais. that it may bs; properly classified. The "Special Information" for per-
sons dying away from home should be feiven in every instance.
n
f^l^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
_««____^«___ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/r Filed
J DO
Ii0^isfer(ul vA7>.
2069
-^
X ^ \
Deputy Health Oflficer
DEPARTMENT OF PUBLIC HEALTB-City and Countj of San Francisco
Certificate of Beatb
tl. S. Stnn^arD
(^
PLACE OF DEATH: — County of Cl/CX^x- J a
.a.
^ ^
ly,
0
V City ofv^'/<X/7XJ 0 AXt
A
No.
r^i.
(
St.j ^ Dist.;bet. LcL4.t^..
'^'^^M ^T.j I L^ist.;bet. v^CLnlA.A,c and i^"
" f/nrl.!.^^'"' ""^"^ '^''^'^ USUAL RESIDENCE GIVE TACTS CALLED FOR UNDER 'SPECAL INTORMATION ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
/w
PERSONAL AND STATISTICAL PARTICULARS
V
> \ n < 1 !
i)
ri ii ( Ik
MEDICAL CERTIFICATE OF DEATH
;ik ill
/loH
Month
Dav
/(JO
i \'t ill
M.nth
D.iv
S*i-ar)
lURTHI'!, \C]:
10
f HJ{RP;i>,V t'i;RTII-V. That I attiiKU-.l .let > ,s< .1 f nm
If)
Jj A. cL^
UJ
V \ ^T I ill
r \ in I R
lUk III i:. \r |.;
< H I \ III IK
St.il I lit I'l in 111
M Mill- N V \M 1
Ul- Mori! Ik
lUR nil'!, \i i;
•I \'ii||(ll<
■-■1 ti . .! ('i 111 lit I \
KxXo
*^^ » 190 i to . ly^d:. [
that T last < iw h -v' alive on ^ zX: I
ami that <k'ath nrcurrc'<l, on tin- daU stated alin\r, at
M. 'llu CAl>^H Ol" DKATII was a^ follows
190 i
\iLhJLAj\^<xX.
V
I
9
c'oNTRinr'idi
I
Months
< N' N / IaAaxOu Oyyv^AA,JSr^v\.oJL'\x,'C
'//; V
n
1)1 'RAT [OX Yrars
( Signed ) dubo ^1 1
Monf/is
Ihn
'S
i -4
/^
Too
X^UT>X^CV>\.
.%
flours
M.D.
i:
< M ,•! I' Aiinx
h'f'^iilfii III Still I I ,; II
Special INFORIVIATION only for Hospitals, Institutions, Fransifnts,
or Recent Residents, and person** dvins) hwh) Iron home.
)■,,,'
v. /////«
Tin* MU)\-i' ^ r \ii;i) !'».R--nv \i, k \ k Ifr I I, \ k s A k V. TKl). T" • rili:
HKsT «)! M)»:^js X( »\\ ij'iii ,!•; AM) Hr!,n:r
'W
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
tloH long at
Place of Death ?
Days
rjL.\CK ni' nrRiAi, OR ri.:mm\\i.
f 1 1) fo- inaiil
J A4D»-^rJk L<rvuwvo
\.Mi
\V\
OX-vVvu c3 %
■X
%
\J\J^>-^iJ^
DAT!' -: n
Ni>i;kTAKi:kM il 0 <XxdLdL«/YV Hrw ^4U _,
xi ..I ki:Mi)\ \i,
•^ T 90 ' I
N. B. livery item oif informnlion should be ciiroifully »upplied. AGB shfuiltl be stntetl HXACTLY. PHYSICIANS nhould
state CAlISi: or DliATH in plnin terms, that it miiy be propi^fb wlaBsified. The "Spcciiif Information" for per-
sons dying away from home nhoiild be fe'ven in every inHtnnce*
^
^
9-
» .
^
!i 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
- REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
:f<\' r
Dulr Filr.l. ilctfrW.
liei^i.sli'ii'il J\'().
2070
.^ V A <.
Deputy Health Officer
DEPARTJIENT OF PUBLIC HEALTH=City and County of San Francfsco
Ccttificatc of E)catb
PLACE OF DEATH: — County of o^^^ vj .^.cu-*^ec4X: o City of Cj,cc^
No. I2)b Oa/>^ St.; 4 Dist.; bet. M rUAXL\.^r>% and Jb C^^^HXHA )
r .r orATH occuBs AWAY FROM USUAL RESIDENCE GIVE tacts called por under -special information \
V IF death occurred in a hospital or institution give its name instead of street and number )
Vcu >
I
FULL NAME
Cs
XooX^OL'
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
liAI'l-; I )1- DI- \ 1 H
Ll
I) \ I1-; 1
/1>SS
/(JO
(Vt'Mr)
\<^\-
\\ It-
H! K i lll'l \(' r
I \ 111 IK
sj W
V I- I.
i/nutiiin
I lIHR!;nV CHKTll V. Thit 1 atiLii.k-.l .ItHvascMl fnm,
^ - I go t<; — — — -
thai I last saw h
alivi' on
i<>o
TtjO
ati.l that .hath occurred, on tlu- .late staled aliovc-, at
" M. ThfC.\rSl{<)I [)1{\TI1 Nvas^as tullnws:
3r
i I LCL^
lUR III !■
I i 1 ] ic
<>! Mo'i'm K
lUK 1 ItlM.Ati;
«»F Mii'IIIKR
^ St,i; .iiiiili \
< H( 1 1' \ rn)N
/,v
DTK AT ION )V.//v
CoNTk IIU Tory
Mo II //is
/hiv
//<
uirs
I ) r R A r I ( ) N
iNED )L
SIGI
/^,/r
AjUV o
IL'/CAi ^ i(,n H f \, hirers) UrVfrVuiU) L ' '
flours
M.D,
SPECIAL INFORMATION »«!> for Hospitals, InstituHons, Irdnsienis,
or Recent Residents, and persons dviny awav from home.
,'(■ /
\r.,,ij,^
l>,i\
Till' \i'.« i\i' s r vn i> !'».• R-,(»\ \ i_ !• \H run \Ks xki; pri-h tc i iFii-:
lij.srtii M \- KNt >\\ i,i,i». ,!•; AM) iU':i,ii:!-
Former or
llsudi Residence
When was disease rontrarfed.
If not ^{ place of death ?
HoH lonq at
Place of Death ?
Oa>s
ri. \K'\', <i|- IM K I \I, ( >K H |.>!i i\ \
I 11 h 1- lU:i lit
\.1.1;
^.
,-vu ^ tv
-H
h \ n
O^t 1
K i;Mn\- Ai,
igoS
V I T (
\t
IN. IS. Bvery item oi' informiitlon whoulcl he cni<iifiiii>^ HupplK-il. ACT. shuilcl be «tntcil f.XACTLY. PHYSICIANS sliuuld
etnte CAUSF OP Dl A TH in phiin li-rms, thnt it irmy he properly claBRifiefl, The "Spcv'ml Informntian" for p»r-
«on« flying away from hoinu sluuilti he ftiven in every inntHiice.
♦ .
Ili 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,.__,.,^___. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
* *• ^*»'v
H^J' C
1
'C.t^yvMA;
trvoui
Dep
n)()^
Er(j/,s/r/'rfl A^o.
207i
cer
DEP4RTNENT 6F PUBLIC HEALTH=Ci> and County of San Francisco
Certificate of IDcatb
^
^T^
PLACE OF DEATH: — County ofOc
o
City oiO/(X,y-\j v .\ cx >
^-M f;
i- ^ V.t '^^ ->\.Lu, V. . ;. , ) V . \ ■ . St.; ^ -- Dist.; bet. ^ and
/ >F DfATH OCCUfIs AW4Y FROM USUAL R E S I D E N C E G I V E rACTS CALLED TOR UNDER SPECIAL INFORMATION ' ' \
V If DtATM OC^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
^n If P
FULL NAMEUj.L.Lico.>>A., Uuo --
PERSONAL AND STATISTICAL PARTICULARS
h It III Ik N
Iv
' ' \ r i: < >! i:. K 11
\(
'^
MEDICAL CERTIFICATE OF DEATH
DAi'K Ml- Di-: \i n ij'
/ (JO
1 V( ,11
I ^
^ I \ 1 , t r M
^\ 1 1 »< i\\ III'
IMK 'li i'l, Av" 1
^t;. ' . ! I . Ill n t I \
'> \
]
,cL<rtA
o
S \M I ( >I
I \ Til i;k
i
II ri, \i 1-:
\ III FR
I I i.lMll
MAII ii: V V \ M
<»i M((|-|ii.. k
inirniPi \(*!-;
'»! \;(ii'ni':k
I M:!!. ,T rt.uill 1 \
'^0
' Ml iiil li ' I ).i s i
I III-;RI:i;\- n,RTll-V, Thai I atltn.k-a (UHcascl fn.m
U;nS to 0^\X X'S up S
that I la-t saw h .. alive nn ^. . >.'\, i«p'',
and that «kafh <KHiirre<l, «iii the «lati- >>tritr.l alxivf, at 10. IS
M. Tlu- C^ArSI- ni- I)i;.\ril wa- a. folh.uv;
aiiu
\xy\j
O^vLLo.
1
y
Dlk A riON },,/;s
CONl'Kil'.r'IOKN-
nr RATION ),,/;v
Mouths 3lH Ihns Hours
Mofiths
fhivs
Signed ) u
.0
t Ml I' 1' \ r i> ».\
OA^vl
^w OJwwLu,
i
J U^|\.S %, \j Iqo'
AiMress)
IIoui s
M.D.
-Uwa^'
SPECIAL INFORMATION onl> for Hospitals, Inslitutions, rransients,
or Recent Residents, and persons dvinq dw,»y from home.
Kfsuied
ni .Siiu i i iiii
^I.nfhs
/■
'I'll I' \i'.n\!-' s r \ T) i> iM''R->(>x \i. !• \k rill I \R-, \Hi; I'krr: r« » i'lii-;
Hi>i«>i us KN« »\\ i.i;ih;i-: and iu;i,n;i-
f 111 r, 1' mniit
Former or
Usual Residence
Wlien was disease confrarted,
If not at place of deatli ?
How lonq at
Place of Death ?
Drfvs
L/Ui/vv'
A-, J
q,.\C}f. in- l!tRI\I, (ik ki;Mn\Ai,
DATI-; ,,! h
\\ .1 k i;m« (\ \ I,
IQO ;
N. B. livery Item of inforrriHtlon should be cnrclrully supplied. AGB should he stated RXACTLY. PHYSICIANS should
state CAUSE OF DEATH In pliiln terms, thnt it mny hs pr(»perly classified. The "Special lnforinntion" f»r p«r-
Ron« dyln^ away from home should be given in every instance.
f
!!■ !h IV
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
_^-^__-________ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
0
Ddlr Filed , iL ' oLcr{>JU\) 3 VJO\
Deputy Health Officer
Registered JVo,
2072
1 "^
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDcatb
11. 5. 5tnnDai*C> )
v(
-? w
PLACE OF DEATH: — County of Qa^v J \o ,
St.; Dist.; bet.
City ofOo^"v JAXXy>xt.ML<: '
Nt>. I lXcv "^ UrU/Yxl^^
and
(1, ^»., .^^.oi.*^ i^*,i« *IX1U
IF DCATM OCCU*S AWAY FROM USUAL R E S I D E N C E G 1 V t FACTS CALLCD FOR UNDER SPECrAL INFORMATION ' ' 'X
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
XX..r-
^
i;x
\t \ , \
Qic^L
i < li.i >k
u.
k IH
MEDICAL CERTIFICATE OF DEATH
i>A T1-: oh i»i: \ IH
-'X I .
So
^ 'Xixfc
{ 1*1
/ i H
I i H
M-!llll)
1>:.'
X ' . 1,
Wl
Uiit. <u
Hik iHi'i. \r 1'
(\
X/^^\XX^
•"H
% \ Ml Ol
I \ 111 i;r
in Kill I'!, \i 'I-:
< • i I \ I H 1 U:
%T \ii)i N' %• \Mi-;
<>; \;iriii! k
luk rniM. Ai'H
<»i Mti'i'm''. K
' ^!a!i I •! I'liu lit 1 \
M
\
^I HKKl'IiN' (l-RrirV, riiat J attriuk-.l .kHHasc.l fmin
that I last saw h . alj\rnii O ^ 'i^"^' ^- * up >
and that death ' n^cii rrril, <hi thi- date stated ah«i\i-. at
^ ■ M. 'Jhe CM sK nl' |)i;\ril wa- a^ foII..s\s:
DCRA ri(>.\
)'tiirs
^lonl/is . t /^fU'^
Ilom s
^v>%.
L^C^O,
C>ajlLcx yx'^^
< »i t i i- VI 1(1
N ro
e:.
c(».\ ruiinTokV
Dr RATION
( SIG
Ycuys
Months
NED) lA). t). W>OLa./v\,
/CX/^O;
V^Aj tiO KjoH
:i
f A.ldrt-ss)
/?<n.T
0
I lours
M.D.
'VV\A-^ V^ VA.AJC
Special information only for Hospitals, Insfilutions, rransients,
or Recent Residents, and persons dving away from home.
r^ r»
Rf>iilfii IH Sii II I'lOHii'iii
M..,.'h'
J hi I -
Former or
1'su.il Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
III I AHovK sr \ !'i:i) !'KK'-'>\ \i, !■ xK'rim, \Ks \H j; iHrj-: 'r<> thh
HI-,sr(H-MS KNt i\\ i.i;ii(,l-; AN!) lUl.Ii:!
f I !i fir ni/inl
^
Ui,ACi<: nj- lURiXF. OR I-' i: ^ro\ \ 1.
I N n I K r A K }•; k sAAaAXm ^^
if).
HI \r ..1 R KMOVAJ,
^ ^ T90H
\i
/CC<:\
V
c^
d.lnss 2>bTX' iq tl
,%. ji. fivepy item of informntion shoulil b.- cnre'tully siippUcil. AHR should be stated f.XACTLY. PHYSICIANS Hhould
state CAlIsr OF DKATH in pliiin terms, that it may be properly clasHified. The "Special Information" for per-
son* dyin^ away from home shoiilil be given in every instance.
V
» i
f
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)a/r rih'il , h^tAylh^ ^
lUO'i
Jfr'(f/\s/(>/-rfl JYo,
2073
Deputy Health Officer
DEPARTMEM OF PUBLIC HEALTn=Ci> and County of San Francisco
Certificate of IDcatI?
1 11. 5. *5rnn^ar^ i
PLACE OF DEATH: — County ol Cl ^\ VC City ofO<Xov 0 Vn i
. (Hi 4 n h ^ m :
No. ill \| ft.<mXatV>viN.u. lb>i St.; 1 Dist.;bet. O-XUriLCV.:; ;. andCtl
/ ir DtATM AccuRs «w«v t-ROM USUAL RESIDENCE GIVE facts called for under special information \
V, IF DEAT^ OeCUR«CO ^ A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
^ ^
FULL NAME
v-^.Lx.'>\o..
sHN (
• \ 11 ( li
PERSONAL AND STATISTICAL PARTICULARS
V I > I , I 1 1-:
g < , > , o
- \_'L
ox^fc
1^
>,i\
R01
MEDICAL CERTIFICATE OF DEATH
DA TK < ir !>i: \ rii n \
( Mnilth ) I I »;i s
•^I^.< , :.l* %f AR k II l>
BIKIfl I'l. \il*
'•^htf- .' '■ .mit'\
; k
-D
. I ni-:Ri;i;V niRTlI-V, That I attcn.U-.l ,hrr,i-~.<l In.m
tliat I la'-t '-aw h alivi- on ^-^-.^J- ' T<p H
aii<l that flcatli < h-cu rre.], cii the dati- stated ahnvc-, at '\
' >r.^Thi- CAISI-; (»1- I)i:.\Tll was as follows:
I \ 111 i;r
lUR in I'!, \i K
or I \ I II IK
'^.Llti i It I'l ilMit
M \ 1 PIX N \M1
I >i Mt I'l" 1 1 1- k
Hik ni iM, \ri:
» ir V.i ill I KK
(st.ii. ,t v'.iimti
HiM 1' \ IK )X
U 4i
I )r RAT ION }'riirs Mo>ilh^ fhiys
I lout V
DC RATION )V^/r.v
(Signed)
Months
/hi]
IIou
;v
^J
M.D.
\
€u
Cc > V V Ao. \v e ui ^ c
n»n
f A.hlnsv) Hb5
ft>\LaAi U^
SPECIAL INFORMATION only loi ll.is|Mfrtls, InstifulM, Trdnsienls,
or Recent Residents, and persons dyimj dw.iv from home.
Kr^idfil lit Situ /;,■',>;•
M.nifln
i>ii\-
Hi" \i',()\'i-: ^ r \T!'i» i'l- k--nx \i, I'AK'ri'.r !, \k'' \hi; rkti-: ii » r
HKsT «»!■ MS KN« »U 1,1.;|)<;H AX!) i!!;i.ii;i-
cLOUmj^\X^v^'^L
{ I n !i i: iiinnt
. ^
N,Mn.. 1^1 M rUnxla ^^ . > ^^^K-U L
:T1
Former or
Usual Residence
When was disease confrarted,
II not at place of death?
HoH lonq a{
Place of Death ?
Days
I'l.ACH OI* lURIAI, Ok RKM<1\ \!, | DATKo! Hiimai .,: RrNtn\-\i
0^
IS. B. Rvery Item of infornifitlon shoulfl be Ciirefully supplied. AGB shoultl be stnteil F.XACTLY. PHYSICIAIN.S should
•tote CAUSE OF DLATH in plniii terms, that it may be properly classified. The "Special Information" for per-
sons dyinft owny from home shouhl be feiven in every instance.
I ' j
I. .,'!)
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
' ^^ ••■■-^^ - '■■■ ' ' ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I
"^ Officer
Ii.eijli,sh're(l J\^o,
^074
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH: — County of' a . , City of CJxx-w V\ o ..
No, ^3jy\XKXkM L^»XJl^J:^,^ , wCu Ol Ov ^t4 ' V u • Dist.; bet. — and
(IF DEATH OCCURS A\Ay FROM USUAL RESIDENCE give facts called for under "special INFORMATION'- \
IF DEATH OCCURR^ IN A HOsjpiTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\j
k, y\A
- \
I» A
PERSONAL AND STATISTICAL PARTICULARS
HlK I
, ^V'
MEDICAL CERTIFICATE OF DEATH
DA ri-; I >i- Di.A'in
0
^to!lt^l
I);iv
(N\;il
l);iv
\< .!■;
1C3 '
/>„
i: ril PL \."l'
I fli:ki;i;\' CI;rTI1-\'. That I attLMi.k-.l .leci-ascd from
— : up to ~ —;■■■- . — -
that T last s;i\v li -~ — alivr on
■~ Kp
— Up
and that death occurred, on the dati' stated above, at —
^ M. The CAISI-. OI- I)1;ATII wa- a- tuUous:
X\M)- It)
I Sin I K
HIK in I'l, \' V
Ml- I \ III ! ■
M X :i»i:n; v \m j
111 Mill HI k
HIK 111 ri,Ai'|.:
Ml Mirnil-H
< Ki' I ■ rxi it iN
I) I k A T I ( ) N
CON TR IIU rokV
) 'I'iir
Mont ha
/hiy
I Ion I N
Is f ' .if if HI V.?)' f'l it II
M-iiilli^
t) IS
DlkATloN
( Signed >
^t 3^ iQoH
9?>
}r,niths
L^A.'<n^jl?v 0. \Jj U). dLtLoc-i.^
^ax^
fliiHI S
M.D.
(
(A(Mress) V<fUrv^JLN,^
m
Special information only for Hospitdls Instifuflolf^V Transients,
or Recent Residents, and persons dvinq away from Ijome.
Tin' \Hn\' ic ST \Ti'i> I'KKSMX XI, I' \k II. ri, \Rs aki; Tk
iu;sT of MS- KNM\vij;i>< .I-: x\i> I'.ii.ii;!-
i: r< > THI-:
Unf.itininl
Former or
Usual Residence
Wlien was disease rontrarfed,
If not at place of death?
How lonq at
Place of Deatli ?
Days
I'l.ACK <>I- ni'RIAI, OR RlSruSAI
\ ^S ft A
I>ATK .if n
Hi 4
I 1 \ ■
C^
kl'.MoSAI.
TQOH
Si1(lu-s
N. B. Hvery Item of InformntloTi should hi cnrcfully .supplied. AGE should be stated KX4CTLY. PHYSICIANS should
atntc CAUSE OF Di:ATH in plain terms, that it may he properly cfassiitied. The "Special Information" for pri-
sons dyinft away from home should be felven in every instance.
M
I r
ipi
^.\
m
all
I. : :t'. I \
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I' c
■S
7.9/9 4
Jlc^i sf rii>(l JSfo,
2075
DEPARTMENT OF PUBLIC HEALTJWity and County of San Francisco
Certificate of IDeatb
I 11. S. StnnDai'D ;
PLACE OF DEATH: — County of 0 -CU^w J ^\XX^'vc\A/Co City of Oo^-yv 0.^.<X>\^AULCo
Dist.; bet.
U%A/yu\^^>^'>^<x^\AlA^UA vv v^t.; Dist.; bet. and
f ir DC*TH OCCURS Ayw4\y from ^SUAL R E S I DE NCE gi we facts called for under special information
V IF DEATH OCCURReQ IN A HOtPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
)
FULL NAME
^^Ow^AJU
\)X\/y\j
iXx.
PERSONAL AND STATISTICAL PARTICULARS
u
r
4
•<<i,i »k ^
r-
MEDICAL CERTIFICATE OF DEATH
DA ri-; I >i PI. A in 0
'&
i N'tat )
\ I . 1
l^
ok
r>a
M \RKIKI'
HIK rtU'l \.'l
NAM! «il
FA 11! ! K
lUH lli I'l. \. }%
11' i \ I HI K
-t.it. I ,t rtmiu ! V
MXIIH^V NAM!-:
Ill M<>i"ni;R
iiM- ni I'l, \r!-;
•>i %ti ii'iiKk
••^1,1! I I i'liimt 1 \
' >'-A ri>A riuN
^0^
^ I m{Ri;i5\ ri.;kTlI-V, That I ittcipK-d ,KH,,i.r.l from
c
i,pH ti. pJOfi 'X%
that I last saw h vy-'j-v alivu on
^
^i.^xt XL
and til
■I' lUau
1 iiccurrcd, nii tlu- date '^tatl•d almvi.- at
4- M. Thu CArSK Oi- |j|;.\TH wa^ a^ follous
K^<XSjk.K.£X. c
DCR.MION )'i'ui.
CONTRIIU TORY
Mont /is
/hjys o Hours
DIR.XTIOX
)\'ars
^f<>>it/l^
NED)\!Tl. d WUx>lAi
/?rn'C
(SIG
'VC\. ',. *,
Ilout s
M.D.
.Xddn-^s) S.S0O
^A^'U.
A%> '■,//',/ /;/ V,;m /'; ,M/.
M.,„ll,^ K_ o /)„,
Special Information only for Hospitals. Insntufions, Transients,
or Recent Residents, and persons dying av»,iv from fiome.
Former or
I'sual Residence
Wlicn was disease contracted,
If not at place of death?
ftoH long at
Place of Death ?
PdVS
Tin' AH<)\'K '-r \ ri i» i'Kh^i »x \i, i- \k riiTi. \ks \r i: ih i !■■ I'o I'li i-
iiHsr ui MN' Is x< i\\i,i:!MU-: .\m> in:i,!!;i'
fA.Mnss is 0 0 0 x,\XA'ru:r\X 3a
;i,A<.'i': 1)1 iitkiAi, OR i<i;m<>\ \
XV>\AX.M ^ X','.
! ) \ !■
c ^ ^
\\ .1 RKMmXAI,
IQO't
rNi)i:KiAKi:R J^^-^JLaXli ^^
(Address ^ SblX' .H i
IS. B. Rvery item «»>' i ii form iit ion shoulil be carefully supplied. ACB should be statetl l.\ \CTLY. PHYSICIANS should
•tote C AlJSr or nriA TH in plain terms, that it may be properly classified. The "Special Information" for p«r-
Anns dyin^ away from homo should be ||iven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,.__^ I^E'^ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
s- ■^. H\ 1' (■
10 OH,
Deputy Health Officer
JlegLsteird JVo.
;2076
,d La.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Seatb
< in. 5. i?tanCnr^ )
i "^ i Of?) ■
PLACE OF DEATH: — County of OO/n^ 0 .\XX/YVCX^C0 City of w/CU^v J ;u<X.'>^ o <^ <- <
« _j'
No, W VUUWU^' :L L ^ ^ C ^ • St.; Dist.; bet. - - -^nd
/ IF OtATH OCCURS AW«Y FROM U S U A L ' R E S I D E N C E GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
V IF DEATH OCCURRED IN A HOSPITAL )0R INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
k
I \
FULL NAME
-I
d-
"^I'X
PERSONAL AND STATISTICAL PARTICULARS
Wu
> i i ( I !
(
MEDICAL CERTIFICATE OF DEATH
!) A ri; 1 !)• ni; Ai'n -A
V.zl
fMoiitlil
I
I):IV
\« . i:
■^ I ^ ' 11 ■> ' ^ '■ ' ■ F K ! '
\\\u 111 ri. \r)
'^\
K >
L!
a,
I lll{Ui:};V Ci:f<TIFY, Thai. I .ittcn.kMl (U'cia^cd frnm
tliat I la<t saw !i.?». >i\ a!i\{. on
-t,
IC)0
T<P
)vr, at D
ami that ckath nrrurrcd, nn the dati- stated ah«
^- M. The CAT SI-; ()!• Di; API! was as foIlf)wsr
LwvCo
AJ,^-kxxs4uui, IDi-
N \M I ( I!
1 All! IK
nil- riii'i.ACH
"I I \ niKk
--t.tr III r.,iinti
<n MOTH J. K
lUR'nil'I^ACH
«ti Miiriii:R
I Sl;it< u! t'ount I \
• »t V IP \ IK i\
Axxr l^^t
Uv
Cr'>\.q
Dlk.XTlO.N
CONTRIIUTORV
Mi^uiln
\
/hns
d-3
I lours
^ \
1f.>f////s
fhjv
\
/^fi,!r,
f'l itH,
'^XOL
r> I )v,,/
DTK AT ION
rSlGNED) ll) to. ^U tvU
^' '^ ■'' fA.i.iivss) s^imoxt
fliuirs
M.D.
[i)0
<■
SPECIAL Information nnn for Hospltds, institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
M.nithf
/)./!
Ill" \i'.M\'i-: '^r \ri-i) I'KRsnx \ 1. r NKTii'ti xk'^ xki jk! i: ro thi-;
iu:>i' lu MS K N*i iw i,i;iH .M and iu;i,n;i-
K 1 1! fii; ina til
.u
When was disease contracted,
If not at place of death?
\Vl ^5 1^ S HoHlonqat
f H LUaMIxXXiULC UOJu Place of Death ?
i UxJu
Oavs
i'i,Ai-i; ()i- lURiAi, OR ki:mo\ai,
A
^
OL/>'>u
\jOa
1
X^ Jt
IS. B. Bvery item of inV'.>rmnt!on should be carefully supplied. ACJE shi.uld be stated RX4CTLY. PHYSICIANS fihould
Btate CAlJSn OF DEATH in pliiin terms, thnt it msiy be prf>peply classified. The "Special Information" for pri-
sons dying «wny from home should be ftiven in every instance.
I i
"J
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
- REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
" -•■ !;^i' V-
4* -P
^
^-vcv
M
Deputy H
h Officer
liegLsfercd JS^o.
(4
DEPARTMENT Of PUBLIC HEALTH-City and County of San Francisco
Certificate of Scatb
PLACE OF DEATH: — County of a rv J Xn , „< -_ Qty ofUcv^v J Axx-^'X.c c --
No.
I I
I s
F,
^
n
St.; 3 Dist.;bet. Hi I v and 'K 0
ruRS AW*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED POR UNDER SPECIAL INFORMATION
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
FULL NAME
( J
A
Xaj^
KKJ^AAj^T^^KX)
PERSONAl AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
n ATI-; < »i !)!. \ 111
A
D.is-i
IV. al
X' K
I II!:Ri;n\- tlirni-V. riiul I alten.UMl .Uirascl fn.m
t
i',<
»K nivjii
A
i
V ■' t
Xj^
A
tl1.1l 1 la^t saw It .»-' aliNf on
aii.l thai (It .ilh » k curriil, .»n tlic dali' ^tati-d alxn-f, at l '5 0
I
M. TIk- CAISH Ol' m:Aril was as rollnw^:
Ml I »l
III IK
nik ni !'i, \( K
< »r ] \ ni HK
^' • • ' ( 111 n! I
M \ I1»HN NA^1 1
<>S MOTHHK
Hik III !M, \i i:
il Mii:ill-K
"■i.iti 1 a t'liuiit 1 N
I >v*'(p \r;< r
0
(
u
K^
>
k
DIR ATION
C<'NTRir,rT
DIR.XTIO.N
( SIGNED )
Pax
II,
tifrs
},,i
IS
n\.
M,i>!lJlS
1)0 »^
/>,
/ I s
//i^N I s
M.D.
HK'
(A.l.ln-ss) it I'l iL^O.
SPECIAL Information onI> for HospiJah, institutions, Iransients,
or Recent Residents, and persons d)in) away from home.
rm-; auovk sTAii't) im-ksonai, tak iiiii, \hs .\ki-: tki. j-. r< >
lu-sroi MS K xi )\\i,i;i)('.H A\i> i;i;i,ri:i''
!•:
Former or
Usual Residence
Wfien was disease contracted.
If not at place of deatfi?..
ftoH lonq at
Place of neatf? ?
Days
fin fiiriiiattt
'XA.^^aX^^
<X/"v^
> L, . V '
\.M
)A I'l'. ,)!' I'.rHiAr,
I'l, ACi; ol- HfRiAi, OK ki-;movai.
I ni»i-:k rAKJ':RVyyVCUi. «t' V Ja^ ,v .
I
KHMiJX AI,
TQO';
IV. B. F.very item oi inf(»rmation should be cnrefully supplied. AGR should be stated HXACTLY. PHYSICIAINS Hhould
stntc C.AlJSr OP DHATH in pliiin terms, thnt it miiy be properly classified. The "Special Information" It'or p«r-
fions ds'infe away from home shouhl be 6,iven in every instance.
«
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
t 11, ,:ili I \., .- ':■- '^ ~.^ i;^,!' r.,
Ihilr Filv,l. PctXov S
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
^mmfmrnfammnmin
I !) 0 H
0 ^
Jlr o' /,<:/(> /-r (I jYo,
J^o?8
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of IDcath
No.
PLACE OF DEATH: — County of
AtV ofC)
\<X/Vc^^«.>ax^t) City of-'<Vvu O/UX-vxCv^^r ^
4
Dist.; bet.
and
; - ^- • 1 -vw-w, j^iiju, ucu ^ ana
/ IF DFATH OCCUBSlAW«V FRO|| USUAL « E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \
V IF DEATH OCCUl^RED IN A>lf<OSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
FULL NA[V!E^<XAAKxX^\j
-^
v ^
-l.X
PERSONAL AND STATISTICAL PARTICULARS
;
V
I' \ I 1 ' il HIK 111
\< .H
WlUnw ! 1 1 Ilk : I \ I i
I: \
N \ M ! t 1 1
r \ I'm H
MEDICAL CERTIFICATE OF DEATH
DATK Dj- I)i:.\ I'll \
L*
r<}n
IV. ai!
t
/',/!,
•Ml Hit 111 I):t\i
I IIKkKBV CI;RTIFV, Thai I atU inU-.i .UH.asci fn.m
I ( )' )
that I last saw li alivt- on
ailil that (kalh mHurrfil, mi f hr A.\\v ^-tatid ahiivi- at
It/)
f\
lUK ill PI, \V
• »• 1 \ in IK
M X IDI'N" N \M
111 MMlinK
nils I'll IM. AC IC
<»i Miiilll'R
■ ■*! it 1 -A I '( mill \\
M. The CAI SK (»1' DlXlil was as follows :
.K-X^t^K^ix^^tL Orv^jLevN^-oslb lix-^-L^vVLJ%xt'a^
i-v L;
\ -<^-
Di k \ rioN
c<>.\TRinrT()k\
Dlk ATION
M,>uths
/hn
I lout \
Yra
r<
M nths
/hivs
( »iA' r r A III »N
/■
,^
MwO^Lu.
f SIG
NED )Ur\^xJl^ J Al^.U) dULL<X/vudL
//(>urs
M.D.
X
( A . 1 ( 1 r.ss ) L.tr\..crvUlM
t:
SPECIAL INFORMATION only for Hospitals, InstitufioWs^ transients,
or Recent Residents, and persons dying away fron tiome.
Former or
Usual Residence
aa
<A.XX,A,^
4 t
HoH lonq at
Place of Oeatti ?
1/, -,'//-
Pnv
Tin-; \Ho\i-: sr \ri- r» 1'i-;rs»»\ai. i- \h !"hm"i,ars a ri; rRiK to I'li i;
lusi'oi' .M\' K N< >\\ i.r.ix .1-; AM) in;i.n:i-
(Inf.Hm.nU M lUyC^VJUL WOw^A^-rxLlX^ '^
Davs
When was disease contracted^
If not at place of death ?
nxil^.tf Hi M!Ar. Ill HKMOVAI.
^ ^ ^^ TOO H
I'LAOK OI- nrRIAF, OR RHMOVAI
I N I ) i; R T A K 1.; R U ^OJJj-YVjb \ I J^^"^ ' ^ * > ^ ^
^. B. F.very item ni liiformBtion should be carefully supplied. AGB should be stnted F.XACTLY. PIIYSiCIAINS should
stutc CAUSE OF DEATH in plnin terms, that it mny be properly classilfied. The "Special Information" for p«r-
finns dyin£ away from home should be <iiven in every instance.
I
y
■uli
^i:U
1
'■*^^M
}
i
f
i
1
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'!.('!!. 'Ill I N ,
\'.S.V I
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dn/r /'V/r./, L.el(rUc\; Z
U)(n
M^cc<i
Begisfered JVo.
20?9
\Kj Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-Cit)- and County of San Francisco
Certificate of IDcatb
( 11. £. 5t^n^nr^
r>f«.
PLACE OF DEATH: — County ofd/OAv J Axxoo^cvAci City of CjOla^ o Axx^^vcc<s r« <
U>Vt\XU.^%CM. UwCVdl-M^^l Dist.;bet.
K<X.
and
/ ir DtATH occurs/Way rRoii USUAL rIESIDENCE give facts called for under "special information- \
\ if DfATH OCCURRED IN A S|<OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
I tax.c4va >v':^.
PERSONAL AND STATISTICAL PARTICULARS
^ r< »l.< iR \
<X.U
rf
MEDICAL CERTIFICATE OF DEATH
i> \ ri-; < M- !)i;a III 0
i» \ ri; ( ii i;iK 1 11
/^i'i
I>:i%-
Jjj/vt
M..:iUri
'! , ,
/ (JO ' I
\' . I,
/',
: I i>
WIIHIWI
I Wt itf ill
lU!; ;•!! ri \ 1
1 lll';ki:!;V CI':RTII-N', Thai I attLMi.U-.l ,k.,-,.asc,| frniii
I (/) t< ) 1 iff)
that I hist saw h —
alive oil
Icp
and that (h ith ( icciirrtMl, mi *J\v <la*( sfati-d aliovc at
M^. Thf CArS)-: OI* hl-.ATII was as fo]|,,ws:
CH-<L<; > ' ,\.o
VJ-\,MKX>U. vDi\A^Ay»%C)
I '
VAMl (.1
f- ^ 111 I i<
ni k I' 1 1 1'l, \i' J^
< tl 1 A 111 I- H
^1 .' ■ ;
M \ • •
N \ M 1 ,
!)!' RATION
CoN'I'KIinToRV
} 'rtir
Moutfn
Da
rv
lloi
Its
>: '.:■ 1 i II i.k
iUKriii-i,A> i:
<M M<iiin:R
I >t*it< 1 ,1 ii milt I
< »< I ! !' \ r Ii i\
1)1 'RAT ION )',iirs
(Signed ) Lox^crvw^^
6x>
%
'iriuu/is
/hiY
3-H rqoH rA.i.lriss) UA-'
XLUx >
, A
M.D.
0-yUA>6
SPECIAL INFORMATION onlv li»r Hospif,ils, InstifiKians, franslfnfs.
or Rctfnt Residents, and persons dyiti) dwdv frnm home.
f\f Itlfii III S'i'tf /'iiniilu'ii
V.>ii//n
Ih
'I'll H ^isovH s'l'M"!-;!) i'Kksov \i. 1' \ K lu r I xksaki; ik; i; r<> riii:
liu
Former or
Usudl Residence
When was disease contrarted,
If not at plar e of death ?
HoH lonq at
Pld« e of Drafh ?
Days
I'l An-: oi lu kiAi. (IR ki:M(.\Ai, I \)W^.,,\ i'.' I \i. Ml ri:m(.\ai.
I !l fill iii:i til
\j:f\Ary\jJ\M
\,l,|n.ss --
^
NDHRTAKI'K J\JLaJLX<-JL H. UC <X C^O, ^V
I
M. B. Jivcry item of inforination shouicl be cnrefuMy supplied. M\T. should be stntetl F.XACTLY. PHYSICIANS nhould
«tiitc CAllSr or ni ATH in plnln terms, that It mny i»c pr«»r>'-'»'ly clonsifled. The "Special Informiition" for per-
son* tij inji nwtiy from home Hhoiild be ftiven in every instance.
i
n<.:n,
I h I
i:K r ( ,,
/J(^/r /'VAv/, ^^
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
w
bx.K^y-^
u Deputy
h Officer
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Cevtificatc of ©catb
I XI. S. 5tan^ar^ )
4 ^ ^ ^
PLACE OF DEATH: — County of C\a>X' 0 Va,ixci4CoCity of O/Ct^YV ^KKX/yxcuic^
No.<
1U\' 'Lacaivt '^Ji...Vci St.; H
Dist.; bet.
and
( IF DEATH occJbs away FROM USUAL RESIDENCE give facts *called for under 'special information \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
FULL NAME
lai!
VC\.LlXi
i
v.v.
'<dL
(\\
oxju
PERSONAL AND STATISTICAL PARTICULARS
It \ i 1. « li
1
a'
11
\\^
n \
Dav
3.C)
L
MEDICAL CERTIFICATE OF DEATH
DATi-: . ii m; \ III _ , ^
iNfotith) I)av> (V.ai
I ni;Ri;i5\' CI:RT11-\-, riiat r att.n.k.I .kc^a^d fn.m
that I la-t saw h X>U alive on iL ctT ^1^
upH
■^i \ i; i- 1 1 [1
ri
x )
in '.' I'n ;■! n .■ k
I \ I'll t K
iuk r H iM, MI.;
')' 1 xriii'K
M A N>!:X V \Ml-
or M<>rin;K
lUKIFI I'I,AC1%
'>! M<.rHi.;i<
o.tirA 1 KIN
Ix
(X^\. J .Vet ^ VCMLCMi
1^tk>\,
<X\
kUi
ami that <li'ath occurred, on the ilatr stated above, at b
^ M.. The (*.\ISI{ OF m;.\ri! was as follows:
Mlcur J (^-wovA^ ^ d.
^
Dr RAT ION* )V.;;s- 3, J/,>„///s L Days
to N T R I n l" T <) R N- A. . .„ N ^ \Xr7vtXv^,v<i a. AVCL;
DC RATION
(^SlGNED )
//o
ID S
(1)
)'iiirs
i(»o H
\)
(A<l.lress) '^1 Vj CKtA)4,il 8t
SPECIAL INFORMATION only for Hospitals, Insmutions, Translrnls.
or Recent Residents, and persons dyinq dwdy fron fiome.
/\ri.lr,i : ii s,,)> I'l ,!ir
'\^
t
) \/-^„'//-
H
/).
(hi fi)* niiiiit
Tin: \Hn\}' ^r \rj'i) i'kkson \i, pxk rn'ri, \hs aki; TKri-; I'u iii i:
ni:sr oi M\ K \(>\\ij.;i)<,K a\i> iu:i,ii:t'
Former or
Usual Residence
When was disease ronfrarled,
If not at place of death ?
HoH lonq at
Plare of Death ?
Davs
IM.ACH OI- in R[ \I, (IK
U^
\i\)\Ji:L^-
K i:n'i >\ ai.
l)\ri.ii.' Ht KrAi, (ir KKM«»\AI,
iqoH
rxDi-KTAKi-R LolVXOU" ^^ L^xoXMi,ni
(Address '^, .U/CLO^ y\iA4
IN. B. F.very Item of information should be cni-efully supplied. AGR should be stated EXACTLY. PHYSICIANS should
stntc CAUSE OP DEATH in plnin terms, that it may be properly classified. The "Special InforniHtion" for per-
sons dyin£ away from home should he ^iven in avery Instance.
«
}•„.:, u] ,.( !i, ,11), I V
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t.£^.^^
^»:r?^;!!&l'Oo
ySXi 6
190H
Jieo'lstcred A''o.
20H i
DEPARTMENT OF PUBLIC HEALTH-=Ci> and County of San Francisco
Ceitiffcatc of Seatb
( tl. S. Stan^arD )
Am J) Q^
PLACE OF DEATH: — County of'"^CL-.v OK^^xcu^Oiy of Oxx^ J^UC^^vCc^ec
No.
a ^ D. L CU :.. L ^ V C A X St; I 0 Dist; bet. a 1 ^<i and 1?,aA
( " .■^/•;\°'^^^''^ *^»^ -"o« USUAL RESIDENCE GIVE facts called for^nder "special information N
V IF death OCCURRtD IN A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR EET AN D NUMBER )
FULL NAME '\'C^^^^JL^
L
PERSONAL AND STATISTICAL PARTICULARS
-•IX A * I COLOR
€U\XA>LL
I'Ai}-: ( ii luk I II
w.
rX>
dLsL
M..iithi
A<,K
5i
I>;iv
1/ '»/'^>
( Vear)
/OOH
/ hn.
*^IN<.IJ- MAK1<II !•
U MX >\\ l-;l» OR l»;\ I t'-M |.|,
lUkPHPI, \C}-.
^I.lti I IT I (1)1 lit t\
\ \M 1 ( U
1- A Til l.k
MIR rillM, \CV.
f»i. I \ri!|.;K
I stall ur I'liiint 1 \
mahh:n' namk
<>1 MoTIIKR
nTRTiipr.Aci-:
I Stat! i II I'ouiit I \
MEDICAL CERTIFICATE OF DEATH
DATK OF DICATH , A
(Motitli) ,i,;,y) ,Vrart
- 1 II1';RI{BV C1':RTII'V, That J atten-ld decease.! fnuii
I 190H to U/ct; I np1
that I last saw h A/A^ alive on U-^vt ^^ j^ ^
an<l that death occurred, on the dale ^ta(c<l above, at Si
yj M. The CUSI- ()!• DIvATH was as follows:
.KKJ-
Dr RAT ION 3 Years L .Voui/is Days Horns
CONTRIiUTORV LL\.aX^-c^lL ALcr . ^^J.AM)^vUi
DIRATION
">
)'rars
'^fouths Days
iytfc 3 ic)oM (Address) 153)0UUild*
(Signed) V'^J'cclx.a
Hours
M.D.
oiiTPAIK
Special Information only for Hospitals, Insmullons, Transients,
or Recent Residents, and persons d>ing away from home.
rm: \movk stai"if) i-kksonai. p\u iui i. \ks aki: ikih to tiii-;
III-;ST ol' ,MV K NOW i.iix.H AM) lu;i<I i; I'
Former or ' K . y - J , . 1 V How ionq aX ,. ^,, *a
Usual Residence iP-'UU AKJt<UAX LoJU. Place of Death? ^^ ..
When was disease contracted,
If not at place of death ?
Oiys
I'l.ACK Ol- IITKIAF, (»K KHMoVAI, I DATK ..f Hihiai, or KHMoVAI,
n
fill fonna tit V-.A./^./OU
(A-Mr«-.s
(Xaj^ C
V
I- DIKIA
f Address . .31 "^ U J /ZkKhXlX 3i
I90H
INDICKTAKK
N. B. Kvepy item of inform«t!on should be cnre?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, thiit it mny be properly classified. The "Special Information" for per-
sons dylnit away from home should be 4iven in every instance.
t
WRITE PLAINLY WITH UNFADING INK —
n.-.M^i of !i, :iiii, !■ No is t-^^*^,, i:«ti'0<,
4^ -p
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.\J 3
100\
Registered jYo,
2m2
^^■/VA^A^l.^
«l
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitiftcatc of Scatb
( XX, S. Stan^arD j
PLACE OF DEATH:— County of^ct^^ "^ \ 0L^vc^4/:cGty of ^cl^ 5x<x
^ V C K. C^ -co
No. bOT
0 ^
-V
oU^vr>Vu St; 3. Dist.; bct]aXlJ<5\/>v\X]u and d CUXXXAVLlAiKs
f .r nl'' °*=^"''^ •^•^ ^"O*- USUAL RESIDENCE GIVE facts called rOR UN^ER ■'SPECAL .NroRMAT,ON^\ ^
V IF DEATH OCCURRED IN A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEA^OF STR EET AN D NUMBER )
FULL NAME
^U^^-y^^Oj
mLcl/H
<X/rLcu)
--1 \
PERSONAL AND STATISTICAL PARTICULARS
a
i» \ ri'. <i! i;iK in
X < . »■:
•M..iithi
1
(l)av)
i
MEDICAL CERTIFICATE OF DEATH
DATK OF DEATH //A
I
Ik
rgn
(Month) (Day) (Veat
5o )-,.■;
yr,„ii)is
3
i
Vc:u
Ihn-
\^.K.
I HI:RI':HV C1.;RTIFV, That I attciKkMl <krca.sed fn.m
H t.. €\/^ I
^^.Q i \(p'
^
up\
i
» I
Ul It. !!!
lUkTiUM, xrj-:
(Stati iir t'liiiiitrx
\ \\!l' Ml
I A III I'k
lUK rillM, At K
< ti- I N I'll Ik
(Hlat« .IT r, MHiti %
M\!I>J;N NAM!-:
<>i .M()Tiii.;k
liikTni'F.Ari-;
'»! Mi>'nn:K
I stall III I'ouiit I V
.it :..ll)
.>w
<i
A
>cv. va ■>\j
I
?
that I last saw li-t.>>A alive on U/ot I icjo H LO
atid that ikalh <irciirre<l, on thi- liaU- state*! above, at S
' Uw :M. Tile CAISI-: Of- I)i;.\TII was as follows-
i
DTK AT ION 4 )'t'ars Miuiihs
C { ) \ 'J' R I lU 'T ( ) k \' ' 4\. ^.\
Days
Hi
ours
cT^
I ) r R A T I ( > x
)\'ars
V-v
.'Sfi^fiths
Days
■\
Rfsidrii ill San I iiiiiii-iit ^ ),,! i ■■ ^ '^Jinitli^
( Signed ) LI. ^-^ L uxU.
Ij/./ctj I ic)oH fA.hlress) iDDH L)Umj^ 5tj
>tifufWns7
Special information onlv for Hospitals. InstitufMns, Transients.
or Recent Residents, and persons dviny dH.j> from liome.
I hi I
Till.; AHOVI-: sr \ I'Kf) I»KKS(1NA1, I'AKTKI I.AkS AKi: I'KI !•: TO THJ-:
HKST ()!• Mv KN<)\vi,];i)c.i-; AM) ni:i,ii:t.
(Infotmaiit
^.-1.^
Former or
Usual Residence
Wlien was disease contracted,
If not i\ place of dcatli ?
How lonq h\
Place of Oeatli ?
Days
IM^ACK OI- niKIAI, (»K RHMoVAI, J DATI-of Hi hiai, ..r KI-;M(nAI,
X.l.hcs^ Ho^X si^ A.VkX/Cnv'VAj i.Jt
/D
T90*<
N. B. Kvery item of information should b- carefully supplied. AGR should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" ior par-
Hons dyin^ awny from home should be given in every instance.
t»
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board (if II ■ > \ '-' zf '-. Ik's; 1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re^j/sfcrcfl jYo,
2083
<vvcA N ' I Deputy Health Officer
DEPARTMENT OF PUBLIC llEALTH=City and Connty of San Francisco
Ccitificatc of JDeatb
PLACE OF DEATH: — County ofUCL/Tu J^-XX/^VCUl.CCiCity of 0<X^V J .^^XX ■»VC-Ci''
No. 'liH?5 >l/lc''v.v,'cL'^.. St.: b Dist.;bet. I'^'v.'^. and V\ U
r IF DtATM OCCURS AWAY FROM USUAL R E S I D E N C E G I W t FACTS CALLED FOR UNDER SPECIAL INFORMATION' \
\ IF DtATM OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME ^6^Kxyy
\)
n v
t
uavu
-(;\
i>.\
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
tTlol.
kill
fU(
.0^
Month)
\( . I-
^1
1>,I\ I
1/ ,,'1:
\ . .1! i
DA'Pl-. nl Dl'AIIl
I'ct
1
Dav)
/on I
(Viat)
-9
w riH i\\ I' I » Ilk 1 1 ^ I
u ■ •
lUK nil! ^>- )
"'^tit' . .1 1 . ,11111 ■ \
)w
OJxM^o
^4
4X/v>v<x.i
A k
iMoiitll)
I i!i-:Ri:r.\- ri;kTii\-, That i.ittcu<k..i .u«t:isi-,i f,,,iii
that I last '^aw h *>> >- . .alivf on nL C\^ X lip '\
iikI that (k-ath occurred, on the >\n\v <tatii| aliovc. at >.
^-^ M. The CAISI' i)V !)i; ATll wa^ as follows;
N \M1 ( II
I- \ ill i;k
p.iK rii i'i. \( i<:
MM i<i;n' N \M I
Ml MoTHHK
niK ruri, Ai'K
ill MtiillHR
' -' :' I -l (■( III lit! \
I >i>- IT ATIDN
nri-i\ri<)X )•,,,;. Mouths Pays
Jh)i
lis
COXTRIHrT
..\jQy-^-v\, <.
\xxk'
DURATION )\'ars
(Signed) v
Hottts
V
I<)0
J/iif/Z/is /hirs
^X^UMXt M.D.
SPECIAL Information onh for Hospitals, Insntytlons, rransienls,
or Recent Residents, dnd persons dyinq nvtay from tiome.
'^ ^ v'-vv.XK-
f\/''ii!f'i! ! II ^.;>> f ) ii III nro 1 .>
U..„//n
Former or
Usual Residence
Wfien was diseasp rontrarfed,
If not at plare of deatti ?
How lonq at
PIdf e of Deatti ?
Days
'I'n I". \!!(»\'i" ^1" \ riu I'KRsoN" M, r\K TTii t \Rs SRI rKfj.;
iU';sT <)i MN isN« iv\ i,i;i»< , J-: and lu.i.n.i
(Inf-.n,.aiit Uj Ow^K- Jl^cLcL ' fUxhJV
1) rm-;
I'l.AOK <il- IHKIAI, OR KK>tn\\i,
Qllt
^ltLAN4±
IiXri'i.f I5i PiAi iir RHMuX'Al,
T90H
r.Nur.R iaki:r Ow ■ -J 0-Ca^V\,A^
^\(l<lr< ss I I 2)1
A^'^X
Pi. B. Every item of iiiformation should be carefully Hupplieci. AGE should be stated f.X4CTLY. 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 he ^iven in every instance.
I »
%
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ll.alt!
"^. !1^1T„
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f/r Fihul ,
.0^-oU)
\
3 V)0\
Deputy Health Officer
ll('!di'^tci'('<l JVo,
2084
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of IDcatb
I in. 5. StnnDarD i
4
ni
PLACE OF DEATH: — County ofvJ/aj>%' O A.<Xi-^cu<i.e(N City of 0 CL^v JA.o ,
i[
li^
^Na.VxT^l;uxiJ L>>\X;U5uUvvCH L C^^^^UulaA Dist.;bct*
and
/ IF DEATH OCCURS aAjAV FROM liS U A L R E S j D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
\ IF DEATH OC'-'RI^Vd IN A HOaPITAL OR INSTITUTION GIVE ITS NAME INSTFAD OF STREET AND NUMBER. /
FULL NAME
t 1 fvil
UuV^
- 1 \
1 1 \ I r ' 1 1
PERSONAL AND STATISTICAL PARTICULARS
i 1
/
I M-.tlthl ll:i\ '
MEDICAL CERTIFICATE OF DEATH
iiA ri-; (ii- Di: \ rii ,
W I I 1. .w . I 1 ,
ii!K I'ni'i, \.' I-;
^\,S\I I ,• I . 11 III
X \ ^t i III
I \ ill i;r
!UK r II I'l, \' 1
< •: I \ III IK
■^t l! I I il 1 I Ml II
(ti MM'nii R
' ^! it 1 1 i! ('(Hint I \
I »t ( rp A'liox \
Cjv
V
^
i ^tl.|l'lil • . Kav)
I Ill-:ki:i!\- CI:RTII'V. That F atteu.U-.l .InHa^d fruiii
that I last s,i\s h alivt- <»ii -- jip
and thatdtath < xi ii t rt-il, cni thf <lntc statc-d ahovi', at
M. Th.- C \I -:• i>\ l»i':.\TII was as foll-.ws:
i r. *. N. '
A
{\
DIUATION }Vuis
CONTRIIUTOKV
DIRATION ^ ),,/rH
Mouths
Pa
J'V
I /oil Is
W
<X\M
I
(r
(SIG
(
NED ) \J^
m
Mrulhs
/hus
\trA\jUv
%v
dL
Hours
M.D.
'-1 0 k 1 '^■
U)n
\d<lri-ss) MrX^vuL^U Cn^
Special Information onb tor HnspiiaK insfitutfeiis, TMnsifnts,
or Recent Residents, and persons dyini] dWciy from tiome.
k,
/ ; t
II, I ,-,l TS -) )'l'll I
M.Hltln
Ihn
Tlir \Ht )\! -^1 \ I 1 n l'KR-< >XAI, 1' AKTFtTl, XR-, ARK TR t*l" '!"' » TIIH
)!i->^rni M, KNi »\\ i,i;i».;i.; AND hkijki-
( f n f()' ill
mt 0 yK^^
\J
X.Mrc.s ^XS \t
Former or
Isutil Residence
When was disease confrarted,
If nut at place of death ?
HoH lonq at
Plare of Dcalli ?
Days
I'l.ACJ" <)I- r.IR I \I, (»R RI"M()VAT, | UNll ' Ili|.'i\t
i:m<>v Ai,
I QO ' 1
INDl-.l
Ad.lit s.
^A>4. w«
IS. B. livery item of informntlon shoulfl He cnrefully Huppllecl. AGE nhoultl be stated RX4CTLY. PHYSICIANS should
• tnte CAIJSI: OF DEATH in plain terinM, that it may he properly classified. The "Specinl lnformati<m" for ptr-
nnns dyinifc away from home should be ^iven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,._,_,..,^.,________ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J)(ff(' Filed
0
Registered J^^o.
3085
l<rU^\. a 7/y^H
Deputy Hoafth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
I tl. S. Staiiear6 )
PLACE OF DEATH; — County of d\ 0 \a^\/CAulcoCity ofO<X>\; XVa>XCU^oo
No. -t \1 iWu^ liVviKciaA) St.,
(IF DtATA OCCURS *WAir FROM USUAL
IF DciTH OCCUKRCO IN A HOSPITAL
RESIDENCE GIVE fa
OR INSTITUTION GIVE
Dist.; bet.
and
FULL NAME
4
CTS CALLED FOR UNDER "SPECIAL INFORMATION • \
ITS NAME INSTEAD OF STREET AND NUMBER. /
PERSONAL AND STATISTICAL PARTICULARS
Wrf\j
l
'\
yy\XUJ>^
• \.\ y
Ha
v(»I,uK
:> \ ! I < >! luk in
c w.t.
N!o!it)i '
M.V.
Dav)
M •uth
(Year)
/hns
MEDICAL CERTIFICATE OF DEATH
DATK <)1- DI.ATH \
Day) (Vt-ar)
^IN'l.l" MAkRIi;!)
\\ [III t\\ i'i» OK i>:\i iKi i:n
' Sfnti or CiMifitry
K
I- \ III l.R
nik III I'l. \v"K
ni- I AiHHk
' StMli- or c'diinti ^
MAIIU-N NAM1-;
ni Ml en IKK
lUk I'llIM.MI':
ni M<»rm-:k
( '^tatr or I'onnt 1 v
ccL^u-vcL
(
iMoiith)
I Hl'KI'UV Cl-RTII'V. That ] attcn.k.l .kacMstMl from
U \t aa 190H to t ot 3) u)oH
tliat I last saw h A-^T^ alive on WxA X up H
and that death occurrcjl, on the date stated above, at 1
LI -.M. The CAISI^: OF DI-ATIf ^va^ as follows:
^'^'^^\yJ\JLAAA^^^>^ \Xx^<,yyJL
Dr RAT ION
)'t'ars
Mouths
L
A.
0
(
r>
Day
/lours
r
c:^
CONTRimTORV C ..|^»iMxtl.frVA. .^.^^<tatx.ot^>^x^ I
DIRATION
} 'cats
Mouths
/)av.
Hon
rs
(Signed ) t:: . o Ci-Wlva. »v
d'ct ^ iqoH (Address) otHiWvM
M.D.
L
i
uOCrPATIoN
Kt'hifif III Sati ] luitii-ti
Xj\jywXK.y\x\
) fU! I
.V,
I III f ft S I I /hi 1.
SPECIAL Information onlv for Hospitals. Instit
or Recent Residents, and persons dving away from home.
ttftlons, Transients,
i
?-
>
THl-: M5nVi: STA I'JI) I'KkSoXAl, PA KTir fl \ KS AK l". TKl' K To THI'.
nnST OI-' MY KN<)\Vl,i;i)(.K AM) HKMia-'
Iiifiii ni.iiit
X.Klr.ss I'iOO NL^^^^^'U^^V at
Former or A n ill
Isual Residence ODuYK) \^%JL
When was disease contracted^
If not at place of death?
How lonq at
Place of Death?
(I
Days
ri^ACK OK HIKIAI. OK KKMOVAI, I DVIKof Hi kial «»r KKMo\ \I
I (^ IK
I'NDHKTAKKR
cot ■ ^
t
190 "i
Athlre^^ ..Ibl. XlhAA^'U^^ . t
IN. B. F.very item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for per-
sons dyin^ away from home should be ftiven in every instance.
fn
1
~
i
f j
'*
*l '
.
1 j
■^ \
!i'
1
f
■^^
4
♦^
I
t .
' i
ri
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I. •,'!li IV..
i: \>.S^V C,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/^
Drf/c r//rf/,Kj-X..
r- , ^
r,)()
/i('<ji,s/('/-efl A^o.
2086
..V. V
Dep th Off -
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificate of IDeatb
( XX. iv. GtanDavO j
PLACE OF DEATH: — County ofOcL-rv J \a Y\/eULeO City oiOo^y^ ^ AXX \ :
N«, Ul rdxal [jmiKo^yx^ Uw (s^s^. \ stt^. (• Dist.; bet.
-~ and
(IF DEATH OCCURS A^AY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
IF DEATH OCCURM^O IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME h/OM KjA^xJ^x ) ..
^1 \
PERSONAL AND STATISTICAL PARTICULARS
M
1)^1%
\^ .1
W 1 • ! . : -
HIH I'll I'l, \.l-
'S!:if I i.T ' ". ,11 111 • \
NAM|. »»i
FATIIHR
lUI<THI'f,Al"K
i' • I'HI'H
M \ I hl.N N XMl
III M<>!"m-:K
lUR rn IM,A<H
III Miiilll'lH
I -'tilt I ,1 ' , 'U lit ■
I ■ )
MEDICAL CERTIFICATE OF DEATH
DA Ti-; < ii 1)i;ai'ii 0
J. A I
• I V.1U /Q(}
M ,!illi' iDriv'* (V< ,11 ;
I III'MU'HV Ci;UTll'\', That I attrmk-.l .IcHtiisrd fmiii
— I9O to ■ —•. 190
tliat I last saw li ~~~ alive on _______ _ ^^^
aiif] tliaf (Itatli < ucii rrtd, (iii the- datr sfatiMJ ahovr, at
M. Tlu- CAI SI' Ol- 1)I:AT1I was as f.,ll,,ws:
^C\AaJ\J_ ^uX'j oSwVaL v-vJoc^ , vj XxXvc^vwcCIa, tL
1 ) I " k A 1' I < ) N } ?<7r.v Months Days
//<>/( I N
C(>NTl<imT()RV
DTK AT ION )',,!)
.)[.>>!( /is
/hiv^
/ /on I s
/
( K r ( I'ATH >N
Kf^H>l > :,< S,,, /•
),,//
M..,.>h
/,
( SIG
(I
NED)L<r^.<n<\iA; jAd.Uj duJl
<X/v>.dL M.D.
T(»o"\ ( Ail.lr.s.) V.0 U0-"VAJLM> ^-^1^- '■ •■
L Information only l«r Hospitals, Institftfiyns, Tr,
X looH ( Ail.lr.s.) L^VCTAjeA^ L/jiv^
SPECIA
or Recent Residents, dnd persons dvintj dwdv from home
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoH lonq at
Place of Death .'
Transients,
Days
'in' .\nnVK HT \ IKI) I'KRsoN \|, :• \H IKMi, \H-. \KK fKlK i'< > 1*111';
lU-;sr nl- MS K V' »\\ l.l.Fx ,I% AND HI-l.lI.!-
„f,,.„umi L^<rX^-'YvAAA L-^ X
W ^'
f \.Mi.
T90H
I'l.ACHOI' nrRFAI, nk kI^M<.\Al, l»\l'l ,' IltiuAi, or kHMoVAI.
jS. B. Bvery item oi' informiition should b.- c.irctiilf.v siipplie«l. AGK should he «tnted HXACTLY. PHYSICIANS should
state CADSi: OP DHA TH in pinin terms, thiit it miiy be p-operly wlaHshicd. Thy '•.Specuil lnforiiiHli..n" for p.i--
fions dyinji uway from home nhould he given in every instHnce.
I 1
i
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
nu)^
Jiro^/.s/crcfl A^o,
\
DEPARTMENT OF PUBLIC HEALTH
City and County of San Francisco
Certificate of Beatb
\i 'i
PLACE OF DEATH: — County of <Xi\ J\(X^xOuic^ City of^/a/vu ^ K/X/y^'dUl^:^
No.
;^^
C^^x
s^
(ir DtATH OCCURS AW»V 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' LLLcav>%. OLt^Xl
PERSONAL AND STATISTICAL PARTICULARS
1)1
il I >K
CLl
■t^
M .mhi
.0 l.t.
1% , n 1
l>;iv
\ < . »•;
IITRIII I'!. \«' I
9
H
/•■M_
I)
.A
\ (
:i
Cl>^ J >va >a e^.^<to
FAT 1 1 1 K
;| K 1 1 1 I I \ )•■
M \ IIU-N \ \ M 1
t»l MiilIll.K
ininiiff.An-;
i»l Mit'I'III'K
";^
_u '
u
^uLLOw > \ ci.
Hill' \1I(»N I * i)
/,'. ; f,;/ 11, ^ :ii / I .1)1, ■ < ■! (k^
1/
111 f(i' matit
I'm" \isM\i* sr \ri;ii i'KRso x m. r xkih i i, \ms ar i; rKiK r» • vwH
1U>1'<»1 M» Is Ni »\\ 1,1.1m .1. AM' lU I.ll.l-
>;tv) iVc.iI>
MEDICAL CERTIFICATE OF DEATH
iMi.tltJl' !»;t
I ili;ki:i;\ tlKTIlV, rii.it I atttiKUd din a-.r<l In.iu
lliat I last saw h L-a-w alivr dii W.'CA7 I u,o H
and that ikatli (icciir rcil, <mi tin- datt- •^tattd ahow, at A^
^V M. Tlu- CAIM; Ol- ni;:.\Tn wa- a^ f^,lI,,^^s:
J -CaJCk-A^XO^ULo-^V^ err tlvX "^MwWXV^
C< )NTK!inT< >k V
1 lour
(Signed)
IhiV
ly^s
llntns
M.D.
K
CV ahj "^^ . ^&A.Lj^>Ajt
Special information nnU lor Hospltdls. InstitiiHonv Transifiits,
or Rt'ienl Rpsiiicnh, dnd persons dvinj dHdv ffum homr.
rormfr or
llsudl Residfnce
Whfn was disease confrar ted,
If not at place of death ?
Hovi lonq at
PIdf e ol Dfdlh ?
Days
I'f.Al'l^ni HIRIAI. UK Ri:M<t\AI,
DSlI'nf Hi NIAI, mi K1;M«»\AI,
IN. n.
■f
•v.rv Hem o»- 5„f,.rnu,t!on «h„uld b. cnrct'ully supplied. Adf. «'i,h,I.I he Htutcd r.X.\CTLY. PHYSICIANS should
tiitv CMISi: or Di; ATII in pljiin termm, thnt it mn> be properly clo»«hicU. The "Spccuil Inlormntiun" for p.r-
noris clyini^ nway imxn home Hhoulcl be j^lven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Huat.l • III ili!t IV,. ■ :^•' 5r — :• I'S; 1' C
Dah' FiJah aeU-l^\. ^
/^^>H
Begi.sfi'rcd J\^o.
^^\ji
ft i^
\ ■ ' I
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Gcvtificatc of IDcatb
PLACE OF DEATH: — County of
n
\. \ I
C(ty of
\ 0
y
No.
St.;
Dist.; bet.
"and
(ir DEATH OCCUR"; AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALirO t^OH UNDER "SPECIAL INFORMATION" "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
I x A T I < ij.* (k \
A
C J s.. )
^
MEDICAL CERTIFICATE OF DEATH
DA n; » »i i>i; \i 11 \
» \ : 1 III HI k
\i . 1
•^INi . ! r M \R l< iKIK
Willi -will < M< !if\-(»Ki'! f)
W' - . .
k
II
T , '/
J l^O
iV(-;ir5
/'.n
> Ml
I
lUK III
'St;it. .
N' \ M I < I'
1 \ III I I-'
liiK niPi.Ai'K
I , , 1 , 1- 1 1 I' l.
MX. Ml
III \;i I i i i 1 K
lit H III 1' I \| I'
111 Ml p : I ! ' \-
c
W> w<^l o
u
iM.infh' |);iv)
I iii;i< i;i;\' ci;i<'rn v. Thai i attcMi.u- 1 (k.ca-rd fi"ui
up til — up
lliat I la-^t ^aw h ~~~ alivf dii up
ami lliat ik-ath < iiaaiiTLal, mi tlu- dati.' stati-i] alniNi , at ~
M. Tin- CWrSf-; nl Di; ATII was as fallows:
hJv^'\A^<i '\J L^.
Dik \'rI^>^•
/ f(/; s
Months
Ihiv
Hon
rs
C(»NTkIlur(!RV
(SIGNED) U
I s
M'>ilhs
Pav
Arlilriss) ck-0-0 \j\
Hoii I \
M.D.
VA'NJOi^-
Special information nn^ for Hospitals, InstHutions, Iranslfnts,
or RcrenI Residents, and persons dving <iHiiy Iron fiomr.
I I I 1' \ I |i iN
QO\i Vci v^ -vvt
M,„,tln
l>
III I \".< i\ !■: -^ r\ i*i;ii !'»*ks«»\ m, tar iiiti xrs a hi-: tkih tu Tin-
ni>i' Ml MS" K \i »\\'i,i;r>< ,}•: and \.\ ui t
i' In I'l! fiumt
(L.
i a
rsrvxj:r'\>'^J^ Vjj^jvwwvtj
\.',i,,
Former or
I'sudI Residence
Wtien was disease rontrarted.
If not at plarc of deatli ?
How lonq at
Pfare of Oeatli 7
Days
DA'I'Riif HIKIA! 1)1 ki:M<)\AI,
\J^ 3> I90H
ii.AOi-; ni' in KiAi, OR ki;miivai.
IN. B. li
Uvrv Item of Informntlon should be corefully supplied. AOB «ho»Id He stnted EXACTLY. PHYSICIANS should
tntc CAUSE or DIIATH In pinin terms, that It mny be pr«.|>erly tiasmt'ied. The "Special Infoniuition" »op p«r-
unns fiyinft away from home should be 4iven in every instance.
■m?^
«
fi
•III
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
* J ,1
.1 t|. .;ltll I Vo I
^■— i: V.^VC
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
z)^^\>Ji\j
Ifu)^
licoish'j'cd JVo,
3089
I Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
11. 5. Stan^nr^
J? (s^
PLACE OF DEATH: — County ofOcLmjv'Axi
(^
^r\
No
, OS. ok. U '^
^_cc>
^
^ " ' ' City of CJ/CL^yv vJ AX^vxC^o. C f
St.; Dist.;bet. \ -^ and InvC^.
(ir DEATH OCCURS AWWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLTD PQR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
^CLu/'v > A^
PERSONAL AND STATISTICAL PARTICULARS
m
|i \ 11 <
1
\' . I
\\\ I H l\\ I
iW,.,. -u
luk I'll
I- \l li IR
lUK I'll ri. \t-'
•'I
I I»;ivi
1/ ,.'/
/ T' H
MEDICAL CERTIFICATE OF DEATH
DA ri-; t ii I'l. V 111
Uct
, 1
[l.is-l
/ (;i >
I Mi.llthl
I II1;RI{I'.N ri:RTIl-\'. Th.if I itti-mltMl .UHHasd fruiu
L.
/',/
! II
A
•\\\
K
.Til!
M »•
( ii >;i 1 I I i I
(l)
"U
tlml I last saw h '.. alixcoii LA^^. \ i.,
and that iltatli ocrurreil, <in tlu- ilatc stati-il a1>n\H-, at
J M. Tlu- CAI'SK OI- DhATII was as follow.
Q^..
DlkATloN )V,//s Mouths lb Days
CONTRinri'ORV -^ w^..'; U. c.i
Hours
WW 111 I'l. A*' I
ill Ml ill ! 1 ■ K
1 si, ! • 1: 111 lit 1
I HI r 1' \ I Ii tX
(X/Y\> 0 )v<X>x.c.\-si-^c
I )r RATION )V.7rs
7\
J/,.vM.'
Ihu
SIG
K)')
1 It'll is
i\/XA^^ U ^ Vv:' --■' '.^ M.D.
A.l.lnss) llOH U/Q^V^U^; a .,•.
NED) LIvO^.U U
Special Information unl> f^r Hospitals, Insntutlons, Translenfs,
or Recent Residents, and persons d)inq .iwdv from tiome.
R,ui,-,i :ii '^.;>> I
!,,;/« I !/,.»'//■
I hi 1
111' \Hi)\|.' s r \ri'i> !'KH>-.nN \\, i'\H rici'i AKs AH J-; I'Krj-;
1U>T ol- MV KNtiWIJIx.l-: AM) HKl.ti;!'
To Till':
(Inf'i! iii;nit
L-yvwA > \.o^ Q j5L^ *
n A A
former or
Lsual Residence
When was disease contracted.
If not at place of death ?
How jonq at
Place of Death ?
Days
I'LACH c)i* nrRFAf. ok ki:MM\Ai,
n (%
NI)i:RTAKi;k ^1^ \) KTYK ,
HA ri: .i m wiai ..r rkmox- \i.
T9O
N. B.-
-Rverv item of 1n?orm«tion should be CHr«fully supplied. AGE should be stated BX^CTLY. PHYSICIANS should
state CAUSK OF DEATH In pinin terms, thnt it msiy be properly classified. The "Special Intormiition ' for per-
son* dying away from home should be given in every instance.
rr
i -^
¥-
\l
1
m
I
i
I
I
,t' .
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
■<i II. lit h I- V... ,: ■?" ITSr-:-.; Hf;.}' c,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dn/r /-VAv/, i.ctcrW\' ?,
lOO'i
Iti-^l^ferrd J{().
,cvi^
Deowi
» I *. 1 ,<"^ i?^i-«
er
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitfficatc of Scatb
tl. t5. StanDarD
PLACE OF DEATH: ^--County of OxXA^ J/ua\LCv.sir ' Qty of O/Ouru oAXL^ v.CUl
Ne. V.L
It
Dist.; bet.
and
(IF DEATH OCCUR* AWAY FROW USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
(00
FULL NAME ^^
K^ i i . XX'
-■i;\
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
DATK ol- l)i:A Til
clU
u
rii
Ow
^
l).tv>
(Veai!
\< .i:
•-•M •.!' M\Kl<ir
W r I 11 • A 1 • I 1 Ilk' ! 1 V
W ; 1-
l>
III.-,
in 0
1,
luR nii'i, \«i'
N'XMl <!' ^
t A III IK
lUR 111 IM, XiK
1 »i- 1 \ ill r k
•-t;it' • \ i'. ,i;t.! ; V
^1
M \II»1;N N ANSI
i»i- M<»TFn:K
?
I'.IRI'II !M, ACi;
- ■ ■ ■; r. .\mt 1
\S
I Hl':kl':i5\- ri:KTlI-V. That I atUMi.lf.l .krtasc.l frnm
tliat T last snw h '■• ali\t.()!i nw'-*_'|v\. j^p
ailtl that lU'ilh ociurrcil, dii the ilati- --tatril ahovt- at I
to OX'JaI. a.% i()oH
M.
Tht- cwrsi-
Ol- DI-ATli was as follows
.X.
: ' t
, a.,...,v ■,:
-^
nr RAT I ON )V,//-A
CONTRIHrTOkV
Months
fhiy
Hon
rs
DTRATION
ymis
(Signed) J" ^■
J/i>////fS
vi
'■'■V
0^a\X
/hn
X) (
I lours
M.D.
1 1)0
(
X.Mn-ss) ultuU C-O Ic {SsiUt
if^ only for (To
Special Information only for ffospllals, Insmutlons. Transients,
or Recent Residents, and persons dylny dway Iroin home.
h'f : iiifi] in Silt! I
M.'rfir
Former or
Usual Residence
When was disease contrarted.
If not at place of death ?
HoH lonq at
Place of Death ? 1 I
Dav^
rm Ai'.ov!.. sr \ri t) i-kus. »\ m, rARiHTi.AK^ aki-: pRri-; to rm-:
isi'sfoi- MS- KN( >ni,];i)i ,i; and i!i:i,n:s'
III f(i- n!;nit
C.(?,%.
\.;il;
Cau V C
J
0^
K<-^<XAJ
l.A.CK ()K lU'ttlAI. «)R Ri;m«»\ \1,
A- V :v
■CWO- > Wi
'\ ri; '•' Ht HiAi or KJ^NfoVAI,
T QO \
4 j} V ^
r\ n ^
IS. B. Every item ct hifc^rniiition should be ciirufully supplied. AGR should be stnted HX^CTLY. PHYSICIANS should
state CAUSi: OP DIiATH in plnin terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ oway from home should be j^iven in every instance.
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
111 Mil !•' Xi). i -. K' -ar. i-i luS: !' r.,
Dfffc F//rf/, L otcrlMA) 5
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/fU)H
liegis/ernd J\^o.
^^.Aji 4Jb\yu Deputy Health Officer
DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco
Certificate of E)eatb
I XX. S. GtniiCarC i
PLACE OF DEATH: — County ofOoA^ ' " c Gty of C^ O. >^ U A.a >\ - v.a -^
No. vJ^'-yvtA.oJL
\iu
^-vCa-J
Stt
Dist.; bet*
and
(IF Dr«TH OCCURsOftWAY TR^M USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\J
1 i 0
j\.o..^-\ji\
« K
<^I*X
PERSONAL AND STATISTICAL PARTICULARS
^,
MEDICAL CERTIFICATE OF DEATH
I 'ATI-. I >i hi: All I
I
» \ n: < >i i;!R III
D.iv
\
.A, p. I
li
'Day^ iVcar)
cci>t be
ih
^FVi IK M \K R II'!)
"s 1 I It >-,V) \^ ^^^ | » ' ^ i i ^' i ] I )
W ; ■!. IM .,
"^! ' ; in I '■ 111 nt I \
I lIi;ki;i!V CI'kTII-V, Tliat r atUMi.le.! .lerrased from
that I last saw h a!i\A' on
Ttp
V\MI Ml
I NTH IK
lUR riiri.Ai}-:
<)! I" \'i 11 I'K
■^t ,<, , ,, (■ . unit! \
MAIi»i;x NAM1-;
<ii M<>rin:K
im< rmM,A<i:
«>i- %!<)'riii;K
'■-t >• ! t'lUHltl
and that <k'atli occurred, on tlu- ilati,- stati-d above, at
M. The CAISI-: OF I)I-:.\ 111 WIS as follows
as loiiows :
DIRA'i'roN )V</;
CONTRIIUTORV
nr RAT ION 5V<7r.r
( Signed ) LtrXxmjUu J.
Months
Pay
Hon
IS
/
< ^^'CV V XilON
\^' c.
rt
Mnnfhs
0
/\U'.
•s
I lours
M.D.
TO^'^ f Address) W^\.<rv\l^ C k s, w-^^
Mr
SPECIAL INFORMATION only for Hospildls, InsfltulWrN', Transients,
or Recent Residents, and persons ddni dwdv from home.
AV. ./(//•,/ /;; Si/ 1' / iiii. Ill
) 'ril I
Mi.iifhs
\'\\V. MUiVT-: STATl'D l'HR'^<»N M. !' \ K TIC T T A KS A K l! r R T I-! I'f » I'm"
i:i>r c)i- MY KX( iui,r;i)C, J.; wn i;i:i,n:i''
Former or How lonq at
Usual Residence -. , PJ,irp of nedtli ?
- ^ y '4-
Wlien was disease contracted, ''^ *b£n ' *^ J j n
If not at place of death ? S ti^v '^Cw-^^<C dJx^^iJ
Days
n
\ !,!'
I-^^ACK OF HI RIAI.UR RI-MoXAI. J \)\X^.l^\ Hikiai, ..i K^MmVAI,
IS, B. l-.vcry item of iriformntion should he carefully supplied. AGB should be stnted EXACTLY. PHYSICIANS should
Btate CAUSE OF Dl.ATH in plain terms, thnt it muy be properly classified. The ''Special information" for p«r<-
fion* dyin^ away from home should be given in every instance.
i i i
MHi
Mi (
H. ;ii.! ,,f irtallh I" X
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\''o.
I Idle Fi/eil, ly-ttcrlM.'v ?n
190 \
2093
^ » *
IT 6
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "D. S. StanOarD )
A
%
1
A
m
No. I bio
PLACE OF DEATH: — County oi"' Oj^^o v XOvvC w -cCity of ^aru vi^VcoNv^L^ui/C^
^fr-V^Ci lU^ St.; H Dist,bet. Stfv and btk
FULL NAME
SKX
PERSONAL AND STATISTICAL PARTICULARS
H^Xz-Y^aJL^ Oi-YNvCtA
IC kcti
MEDICAL CERTIFICATE OF DEATH
DATK UF DKATH
n A II-: »i!' Hik I II
A I . K
XX
)■
l/-.///>>
A%\
ao
» t ar
A/
fMonth)
(I)av)
(Yt-ar)
^rNr.!,!-: MAKKIKn
\\ in<»\yi-;i) ok ni\( iri f-o
•Write ill ^(H'ial iltsiiMiat i.ni )
c
h
I lU'KI-P.V CI:RTII'V, Tliat r attciKk-d deoi-ased from
.)...\\k IS' 190H t., Vzt X ,<pH
that I last saw hl.nnf\ alive on 0-£,^^ XT upH
and that death omirreil, on the date stated above, at ^HS"
'^y M. The CATSI-: ()!• DliATlI was as follows:
(?j\U
--Lrry-xyfy-N ^ ^
IURTm'I,Ai"l
( Statt I)! (.'( )ii n! ! \'
N" \MK «)!■■
I A III } K
lUKTlllM, XtK
Of- I-\rilKK
(Slat* ur t'ijiintrv
MAII>HN NAMK
OF MOTIIKR
HlkrHIM.Al'I-:
<>l" MoTHKK
(State iir (■(intittv
3'
AA
1
r^^vLCyx.
t\-
I) r RAT ION I }'t'ars Mont In Days
CONTRIinTOkV mX^a
Hours
XXAXX.XI/ »a..-uu:j
or RAT ION ^ Years b Afo/iths
(Signed) J.
&.(Jc..E
/^i7 VS
1
Hours
M.D.
(\
oi'cri' ApioNi
Rt'-iiled in San I'l atu isro #wiJk )V'(f'> 11 \t<<nHi- A 0 /'i/i
)XAAA_iA/
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
riiiv AHovK s'lA ri:i) pkksonai, parti(M'laks aki; iKri-; lo riii-;
HiCsT oj- MY KN<»\\i,i.:i)r, K AM) Hi:i,n:F
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place of Death?
Days
(Informant
(A<l(lT-e
PLACH ni- P.l klAI. OK KI;M(»VAI, I n\Ti;of Hihiat. or KICMOVAI.
'O^H^Ux^Mi^ I ^^ ^ 190 S
(A.l.liess ini \f}WL4.^-^>uI^t
IN. B. Bvery Item of inffonnatlon should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE: OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for par-
sons dyinit away from home should be jtiven in every instance.
I f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
»S*JL**'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
':"\
hair l-ih'<l, ^'.cUlvX\) 3>
/,9(9H
Registered JSi^o.
2093
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( U. S. StanOarD )
No.
4 ^ \ ^
PLACE OF DEATH: — County of OcLl\) w Va>vCv_4C{) City of C}<X>A; J >\>(X/-rvx^UU^<:)
1) A
5?) a. - \\U^, LU^
St,; ^ Dist.;bet. LLIa">'\X^
and
r ir DEATH OCCURS *W*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION ' ' \
\ ir DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
-CriKh^ )
FULL NAME
1
.I^^AXXj vl^\-AjCj(TrtCO\j
PERSONAL AND STATISTICAL PARTICULARS
SIX
Hll
4
t«»I.nR\
DATi; « i| lUK 111
\<.l-
C^.lxt
LUJviOc
M.iriihi
11
(Dav)
rl'^l
190 *1
(Year)
11
• il t
M.,rh
\\
Ih!
\V| I)( »U l.|> OK IHVi tki i:i) \
U'litf ill ■-. .cinl HeHii'iiiuii.ii i
Hiki'ni-i. \ci
Matt or ('.111 lit t \
FA I II IK
HI Kill I' I, \i ).;
'•I I \rni-:K
<H!,it« .If »\,||iiti \
M Mill's- X A Mi-
ni mmihi.k
i!ik iiii'i. An-:
••I M(»rm-;K
' ■-tat. 1.1 r.,iinii %
(]
IL LcL>^\,^^sA.<L
? 5
R)
MEDICAL CERTIFICATE OF DEATH
DATK (U- i>i;aih \
(Month) (Day)
I IIJ{kl{HV Cl-kTIFV, That I atten.kMl dcccascl from
-i--i^ iO 190H to (i//cfc ( ic^H
that I last saw h-2A) alive on 0-A^^%i 3)0 190^
and thatdiath occurred, oti the date stated above, at iQ,-50
^J M. The CAISK OK I) HATH was as follows:
px^TN^Utu ' a|xx JMx/dL h^juu^
DTRATION b Years Mouths Days Hours
CONTRIHrTOKV
yxSLOj\j!>
9 \
1 (
DIRATION
Years
iSfouth.
Ihiv
Hours
(SIGNED) dU, Mk dULOL/ru M.Q.
iy^ ( iQoH (Address) I no motdk^ dt
Special Information only for Hospitals, Institytlons, Transients
or Recent Residents, and persons dyinq away from fiomc. '
nccr PA r ION
h'f'-iitcit -11 S,;;/ f'l ti H, ni'i> OsO
) ,,;
MoDth}
/h!\^
Former or
I Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
I'm-: xHux'i-: sr \ rin i'kksi>\ \i, rAKi'iri i.aks aki-: tktk To th i-
iu;sT «n .Mv KN('»\\ i,i;i)(.i., A.M> ni:i.fi;i''
( liifotinrifit
y
Days
O)
I'l.ACH (H- HIKIAI. nk kl-MuVAI, | DATi: ,,f HiKiAf. .,t KHMOVAI,
190*1
I NDliKTAKKK
5 'CU-A.tjuL V U>
N. B. Rvery Item of information slioiild hs carefully fiupplied. A(JB should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information** for par-
sons dyin^ away from home should be feiven In 9\ory instance.
I;
bm
i
4^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I, .Mil !■ v.. i'. *•'• •«*. '--:■ ]\Si\' (
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/r F/7('(/, vJ/ttxTAM/v S
/.96>H
llegLstcj'cd J\^o,
2094
)
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of^ia .a
Certificate of Beatb
( XX. 5. GtanDarD )
m
f^ ^JKsJuyxXAx.
\X.A
L^ .VL-^v^
St.;
Dist.; bet.
City of^^Ou^Yx 0 /VCL/vx^CA^
and
(IF DEATH OCCURS AWAv FROM U S U A L ' R E S I D E N C E GIVE FACTS CALLED FOR UNDER "sPECfAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
in I
FULL NAME
(M ^\' V
PERSONAL AND STATISTICAL PARTICULARS
XUJL
) \ I i: Ml lUH in
1^
M iith
:)a\
\i . !■:
^ I NT, I, I" \! \H k n !»
-\ ■ .-^ ■ M ^ . ■ ■ :
V\M1 Ml
I- \ I II IK
FUR ill II. MK
Ml I A III i:k
-i!.'! < I ,1 i'liinU! s
M \ litis N \M 1
Ml MMIIIKK
mi- ni I'l. \i ]■',
Ml Mti'llIlK
vt 1 1 , ii i ', 111 nt I
Mm 1' \ rn »
-^l-
/).!
S^ I
A^^xXX^
n
MEDICAL CERTIFICATE OF DEATH
I).\TH Ml- Dl-.AIH
l\ \ I
1
Monllil
(Dav)
fpo 1
(Year)
1^
HI'IKIU'.V eivRTll-V, That I attcii<liMl (k-ceased from
V„ CV I KpH to
p
T90
that I last ^a\v h t. » alive- oil \w/ /cX> 1
and tliat death <ic( urrerl, on tlu' date stated above, at i
LLjVI. The C MSi-: Ol I)i;.\TH was as follows:
190M
L ">'ru ylD x^^^\>
0
DIR.XTIOX )'tijrs H Mouths Days
CONTRIIirToKV
Hours
Dr RATION
)'tuirs ^ Months
1
{\XA\JX}
(SIG
19
NED) 10. vi.MC^trU.
na\
'S
/C^ 3L I()oH (Address) ^Xl
I loui s
M.D.
Kr ;,ii<' III ^'d'/ Fl till: f-i'ii
).ai
\J, „)!),■.
I hi
Till", ^HM\i: s r \ no pkksmna!, i-nkticii, \rs, akh TRri'; ro rnK
mtsT Ml' M\ K nmw i.ijx ,1; AM) I'.i: i,n: 1-
IiiFi -in-mt V-xy
AyWX> \JXKrr\j
\ fid toss U I"
't
SPECIAL INFORMATION only lor Hospitals, InstltHflons, Transients,
or Rerent Residents, and persons dying away from home.
^ n How lonq at
J.C\^<>Cs>x V<.>WA^ Place of Death? l Days
When was disease contracted,
If not at place of death ?
Former or
Usual Residence J 'C\^<>Cs
.c.t.
l'I,.\CK OF HIKIAI. OK KK-MOVAl.
DA PK uf IUkiaf, or R1-:moVAI,
T90I
A/V\^
(..
[N. B.^— Every item o¥ information fihoulil be cnrefully supplied. ,AGB should be stated BXACTLY. PHYSICIANS shoum
state CAUSE OF DEATH in pluin terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ away from home should be given in every instance.
B
;■ \
I ;
fii
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
fil III. IV-, -t'^^^- l'^''^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
nuj'i
Regisfri'rd J\^o.
J^095
6s^\.^<j^ A H^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of S)eatb
i 11. tL\ Stani>arD )
Cj CL-Y^ 0 AXX )v<^<^,^t City ofOoy>\; OAxX^xCo:^.
C.c
No. iolSlA. ' ' St.; b Dist.;bet. 3.H tJv and 9^5 Liv )
/ 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" "S
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Lrvc
I'D'
AoiLTLn.ui.tc
%
u
JO
ft
-LMl
PERSONAL AND STATISTICAL PARTICULARS
• 1 \
ii »I,t iR
• \ 1 i: I ii 111 K III
^
t
|0„.
ac;h
--is< ij-: M AKi; n
HiH rm'!, \im:
"lint' ■>'. < I Ml 111 I \
's XM 1 < >! V U
Vt
I
ATIIIK p
hjXKA
\
1 ,
HiK Tiiri, All-;
f)i' i*\rm"H
' St;lt f ■ i! (.1 lUlit : %
M \! I UN N" \M 1
or Mttini-: k
I'.iu rnri,Ai-i-:
(Stntf I ii (.'tiitnti ■
I n {• ri'A'rii )N
^'Ct>\; ^Ks
OL
A"V^\A_.<.
/~\
\
^Ouy\j 0 H^<X>xe^<i'Cc
r,-,,-;
y/.-uf//<
J',:^^
Tin* \Hnvi' <r \rii> im* K'^onai, r \k i uti \ks ark rRiK to tiih
lyN" iW l.l.DCK AM> HI
i!i>r<)i MN lyN" |\^ i.i.iX'K AM> Hi;i.n.i
(Tuf'i'in.im
A.Mn
"ilS l)jt>v.'»AXrY\l- ].
MEDICAL CERTIFICATE OF DEATH
DAIl-: ol- Dl.ATH /
(Day) (Vtar)
] III-:KI;I'.V C1:1<TI1'V, That I attcn.k-.l den cased from
19^ 9. looH to iD.ci-
^■^ iqo H
that I last saw li a.livc on ' " ' l(p
atid that (U-ath nccurred, on tlic datr '-tatcd above, at b • J "O
>r. The CAISI-: <>l' DICATII was as foil
(1
( )\VS
^ .La„
o
itl
l,^'
.n^<xX L-c^^^a. > V
WCV.
1)1" RATION }'tiirs Months /)ays Hours
CONTRIlUroRV M\.<nr^w»L
I ) r R A T ! ( ) N
(SIGNED )
l()n
f A <ld re^.^ ) I ^ M AjlLocav VfeXd.^
I lours
M.D.
SPECIAL INFORMATION nnly for Hospitals, Institutions, Transiefits,
or Rfcent Residents, and persons dving away from liome.
Former or
Usual Residence
Wlien was disease contracted.
If not at placed deatfi?
How long at
Place of Dcatli ?
Days
ri,ACK Ol' nrRIAI, OR RHMoVAI. j DAXKof HiKiAi, or KKMOVAI,
0^ ?> TgoH
^.0-^
fAddifSs IXD^.
-unoi
N. B. Every Item of informBtion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for p«p.
sons dyin^ away from home should be ^iven in every instance.
I 11
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l'.,,;,r,l .,r Health IN- .- ?-^'5^^i) lu^ JM u x REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r /'V/^'^/, U,^t^UL>v H
/VM.
V
Deputy Health Officer
Reglsicred JS'^o.
2096
DEPARTMENT a? PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
%
PLACE OF DEATH: — County ofOxXno; ^ hXXjYx/ZKA^A. Oty of Cj CL/rw 0 ;v (X
>\ C*A. ^
No. Ho I
(ir DEATH OCCURS A
IF DtATH OCCUHf
I
1 \ *
St.;
I ,
Dist.; bet. 5 *Llx'
and
klk
WAV FROM USUAL RESIDENCE give fact
RED IN A HOSPITAL OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" \
TS NAME INSTEAD OF STREET AND NUMBER. /
)
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
iMi()k
OlJ
e
mA:
MEDICAL CERTIFICATE OF DEATH
DAI'K ()!'■ Dl'.A'l'H
i> \ 1 1 Mi- luin 11
A<.K
^IN< I.l' MAKkl!''
IlIH PHI'I, \i'l'.
N X NT 1 <»!
I A 1(1 1 R
lUR riii'i.xri:
<»! 1 A iHi: k
■^t.it?' (ir I'l Hill! t \
MAII>I%N KAMI-
(»1 MiHHHK
MIR rm'i.Ai'i-;
Ml- MnTHi:H
( Slatt ( ir t'diirit i \
A
0
M, Mill
l),l\
\r.-,i!h
/hiv
I !»
11. .n'
IaA^
^ w
(Mouth)
\
(I)av)
/go
(Year)
1 UlCkliBV CI'.RTII'V, That I attended deceased from
lD<:l '.'. T90'- to ^itL^.. .^ 190 ■'
that I last saw h C . ■ ah\e on ~~" ~ " ' 190
and that death occurred, mi the date stated above, at
UWLoi
M. The CAI'SI-: t)l- Dl^TlI \va^ as follows:
DIRATION
C()NTKlI!rT(
/></)
)'iars Months . .. , .
Hours;
xk
KJ^ K^\0.
K.c^Ou
DT RATION
iNED) ^H
(SIGI
Yi'iirs MiOitJis
T<)0 '\ (Address)
Pavsi
Hours
M.D.
\} ^ '\ Tooi ^Address) 3^ b ' H IAv ) t;
SPECIAL INFORMATION «»nly for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fjome.
I HCri'ATIC)N
l\f I'lril J II StDi / ! 1! Ill i^i'ii
rni: M'.oVK STAI'KU I'KKSONAI I'A K I' IC r I.A R^ A K l, PR f H T« » THH
iu;sT (n MV KN'<»\\ij;i)i". }•: .\Nn luii.nj-'
r,-,n
^r,.,l//l'
/),n
(In
' Xl.li.^s \ o I
,.^
\1
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death?
Days
I'LACK 01 lURIAI. OK RKM<)VAI. I DATK of Ht kial or KKMOVAI^
T90M
I ■ N I ) K R r A K K R ^ CKrwX.yyy^t \ jb >v 0- v
(AddrcHs
N. B. Bvery Item of informntion should hi carefully supplied. AfiB should be stated EXACTLY. PHYSICIANS should
state CAUSE or DEATH in plain terms, that it may be properly classiried. The "Special Information" for per-
sons dying away from home should be given in every instance.
Wit
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I'l I Vi
'-»: ?a: 1!\ !• (•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re<iistere(l jYo.
2097
Xat^*^ \ju^ Deputy Health Officer
DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco
No. ^
Certificate of IDeatb
( 11. S. Stan^arD )
PLACE OF DEATH: — County ofvCL ^^ Jk<x .w^-^'^f City o{^^^^^y\^ Jaxx/>x4v^c<
i Xl^.- -. ■ St.; "^ Dist,;bet^JJAA,C4x^CUv^XX.>% andU^-J^A^ )
(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 • \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
3
cL
n
\ n . . ,T
PERSONAL AND STATISTICAL PARTICULARS
n\'n »»! lUKi H
Molithi
r%~
\<.\:
^\
J -.ui >
1/
> I ai
/',/).
Un»i »\\!- |t < >H IM\» if" ill)
^Wliti ill -«iiia' ilf'-ii'iial ii 111 I
f.iK rm't, \i"i'
\ r 1 n R
III Kin iM. \i }■:
III ! \ rm;K
■^!a! c . il roiuit I \
\!\ii>i;n* n\mi
Ol' Mnrm.K
HiK rn i'i,Aci-:
'Stale 1 il (,'( lUIlt I \
Oi'Ori'ATlON \/
"VX^V.X3u
0 wcrwvaj6
xxx^
VllxurV
\j Litrlu. ^cuIulI^^
i\
0
n
m
Mnnth-
/),n.
rm". AHn\i--. "-.I- \i!: I) rj^-RsoxAi, i'ARri<.M-t,AKs AKi-; TRrr: to thh
iu>r oi' MS' KNOW i,i;i)<',}<; and hi:i,ii;h
(liifi)' in.'int
r \<l(lr(.-ss
MEDICAL CERTIFICATE OF DEATH
DATK OJ- I)i;ATiI
(Yf.'ir)
(Month) a>a.v)
I Hl-:kI':i5V CI{RTII'V, riuit I attcmUMl .Uh cased from
T90 1
to
<»o ^
that I last saw li ^^-w alive 0!i L' /^ I H)0 H
l<p
atiil that ileatli occurred, on the elate stated above, at • v
UL M. The CVrSI-: ()1- I)I:ATII was as follows:
DT RAT ION
}'{Uirs Mont /is
CONTkHUToRV L.<lJl/v>->./CL.
/hjv
Hours
l^a ys
nr RATI OX ~ Yi'dK "h Mouths
NED) |04^\Wm, OId
)}<^ 'h looH (A.ldress) lOl'i OX\MxA; Ot
(SIGI
CLhJu<c^
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Rficnt Residents, and persons dying away from home.
Former or
Isual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
PI,ACK OI" HIRIAI, «)R KHMOVAI,
^L-h, \i\- HI Kl\l, OK K h.
I)An;of IM KlAl. or RKMOV.^I,
N. B. Bvery Item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be ^Iven in every Instance.
\ll
♦:
J
u
Boai'l .!' II'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
w^VCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
r v<
I )((/(' riic<i ,
d^^
MwA^
Deputy Health Officer
Ite^isfet'cd A'^o.
2098
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of Bcatb
{ "U. S. Stan^ar^ )
(^
No
PLACE OF DEATH:— County of C'ay>x-^ ^o. .- '^^.c-' City ofC)KX/>A; J^va ^vc^.c
St.;
Dist,; bet.
and
(IF DEATH OCCURS A\JtAV FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL
RESI DENCE GIVE FACTS CALLCD FOR UNDER "SPtCIAL INFORMATIO
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
" )
)
\
FULL NAME ^'
SKX
MA-
A<1K
PERSONAL AND STATISTICAL PARTICULARS
V
M.>:itjr
!>,i\
M,.n'ln
fV< arl
/lay
sIN»;i.K MAKkHin
w \\n tw j:i» < »K i);\'< iRi i i»
HIKTHPI.ACl-
' Stuff or I'liimt i %
lU
OJxAaJLcL
NAMl »»l
FATllKR
itiKruri.AiK
ni- 1 AlUl'U
' Sl;i'> • il r, ,nllt ' \
A
M
I
MEDICAL CERTIFICATE OF DEATH
DATK 1)1- I)1%ATH ,A
(Month) (Day)
I HI':RI-;HV CICRTH'V, Tliat I allciKled deccasea from
O-rt > UK,H to O-Cfc 3
igo .
(Vt-ai)
[cpT tn \,/i\J\i Zi 190 H
that I last saw h l- alive oil
and that dt-ath occurred, on the date statecl above, at IC
M. The CATS I-: <)!■ DI-ATII was as follows
190
t
J<x,<iXvv.c LLtc.^'
1)1 RATION
\\
MAII>l%N NAMK /\\
111- M(>TI11';k ' l'
iuR'rmM,Ari«:
ni- Morni'.K
I S{:it<' 'ir eouiit T \'
J\
^
lO.^ I
I t ^
OCCri'A Ti
Years Miyntlis
CONTRIIU'TORV fcX'»vV\A^
nr RATION _ Years
Days /lours
Mi>nt/is
(Signed) J. TO. U<x-'v\, JiCUiA-v^l
f^avs
Hours
M.D.
00 *H
H)0
r
LuJku gyPM^ul
Special information nnly tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dyiny away from liome.
Kr- iilr<l III S'liii /'i ,111, /■> Il
M.»illi<
IhlV
TUF, AKovK si\ rin i'KRsonai, j'ak ricri.AKs aric trch t<> thh
liiisT oi- MS' KNOW 1. 1 1)1 . 1. AND in;i,n"j"
(Info-iii.int
Former or q . 1 SL Wn . . W®* •«"<• **
Usual Residence »il n Qk) '(XKhAAJTY^macc q\ dtaih
•• Days
When was disease contracted,
If not at place of death ?
PI.ACK OI" IHRIAr, OR RHNfoVAI,
(Ad.lrcHS V^^l Njr\>UiA.A,.Cnru dl
N. B.-
-Rver-y Item of jnfopmatlon should be cnrefully supplSed. AGE should be stitted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that It may be properly classified. The "Special Information" f©r per-
son* dyin^ away from home should be given in every instance.
J
lioani ,,f n. ;i!tii !■■ n;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)(fh' Filed, L'd
.tr\A,co
/L>ckM^'
H
u-u
7.9(9 M
Officer
Registered JSi^o,
2099
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. S. i?tanCar^ )
PLACE OF DEATH: — County ofU,<X-A^ 0XXX/->vCA.4f^. City of 0 'O-^'^ J A^:>-^v<i.cA. C,t
N
o. 151^ ^iyiojvk...t
I
St.; ^ Dist.; bet. \ I Xix> and I % X^\i
( \f Dt«TM OCCURS AWAY TROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N ■ \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\
\ f>^^ IaJU '^
n
)/Ou\.t^JJ
^i:\
PERSONAL AND STATISTICAL PARTICULARS
^4'
DA I ]• or !;1H ill
I
I
+
> r- I
W V.
il):tvt
\ < . J-
\>,
.car J
/>,n
sFXt.I.F MARKI!-!'
\\F in tsv)- 1 • Ilk i);\i •'■• I i;i>
' Wiit. in -..( lal '1< -it'll. iti. Ill)
lUH rui'i. \*"i-:
' stat« <>i 1 ' >■! lit ! \
N \ M 1 < • I
1 A Til j;k
mKTlll'I.Ai'K
Ml iArm:R
!Sljit«' iir ii iunt ;
NTMhlN N\M1
nj Morm.K
lUK rupi.Ari-;
nl- M4t|in;K
I'St.iti' 111 ifiuntry
L T
Is
frUJ
'(Ji^^
.>VXXa^^1X
4^
MEDICAL CERTIFICATE OF DEATH
DA'IK Ol- 1)1:ATH
(Vt-ar)
(Month) iDay
I HI':ki;r.V CI;RTII"V, Thai I atten. U-d dcccasea from
w ctj I 190M to L ctj 3> T90 H
that I last saw h J^'^"^ alive on \J t.Xj .' 190
and that ik-ath nccurrcd, 011 the date ^tatt-d above, at 1^0
V,: M. The CUSI': OF DHATII was as follows:
(^A
h
n '
i^
1
(H'cri'Ai'H)N
M.'iilh,
Ihiv.
TIM* MinVl-, SIATJ:!) I'KRSoXAI, I'A K'IF'.M- I. \ RS AH i: TRlH TO THK
lucsr (»j- MY KN" >\\i,i,i)( ,}•; ANi) Hi:i,n:5-
(111 f' I- ma lit
MYU5L^ilJd' I
I )r RAT ION )'iar
CONTRIIU'TORV
I )r RATION ^^ Years
(SIGNED)
Month's
H
Days
Hours
.}r,.)iths
/^ays
Hours
.>^.'..'wOU
M.D.
\
190
H (A.hlress) H^b a^\.tljl/v Ol
Special information only for Hospitals, institutions, Transient^,
or Recent Residents, and persons dying a^ay fro'n fiome.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
rr.ACK 01* BCRIAI, OR RI-MoVAl,
DA IK of niHiAl, 01 R}:m<)\AI,
U^CA- 'i T90H
Xwa^ ^ . sj
INDKRTAKKR yVVA-A^VA^ w. \J ^'&>.X/CKj>u^
(Address SOS \rh.4rvJL<x Lbusl..
^n
IS. B. Every item of information should be carefully nuppliecl. AOB should be stated EXACTLY. PHYSICIANS should
atote CAUSi: OH DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyinft away from home should be j^iven in every Instance.
saaass^ssnassm
1'
N
i
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
0
H
lOO'A
JRpgistcred jYo.
SlOO
TO
DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of £)eath
( 11. 5. t5tan^arC» )
PLACE OF DEATH: — County of Oo.^rv v1k<X VwC^.^ :rCity ofO/CX^rv 0 AXX^vue^^ - <.
I k n 1 fi , , ^, <;♦. ' ni^f'KoK 1dAJ\) and I
No» 5 01) \| toXo '' :>' St,; ' Dist.;bct. bA_^ and
/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
vl^-d
\ \\^ ^ T
V i WN^
■-• \
PERSONA'- AND STATISTICAL PARTICULARS
A i'<>l.<iR /^ \
D All-. I H I.IK I'll
Ucfc
Miiiilhi
Dnv
A5 5
MEDICAL CERTIFICATE OF DEATH
DAii; <>i iti'.A in jA
Month)
5
/go I
(l):tvt (Year)
\'
siM.i,}.: MAKkir;»
U IIH >\\'HI» < »K Ii \ • •• It) "\
' Yi-ar I
/hi
W I
niK riiri, xcv.
(Stiiti I i! I I illllll \
\ \ M 1 I »!
I \ III IK
lUK riiri, \^ V.
< H ! \ I I! I- k
-l' • . . ' I 1 111 t.t 1 \
M \ nii:N v \Mi.;
(»i NKiinKK
luk riiri.Ai'i:
<>l- Mn'I'lli: R
' Stati ' i! I'l 111 lit 1 \
<»i crrAi i«)-N (^
I I N
K.KT
r\^
'^xa/CL»v
\
I lll'RIvHN' C'i;kTII"V, That I attfiiiU'd «lt(xasc(l from
iL^^ X upS to Uc^ /b TtpH
tlial I last ^a\v li '* alut-on w /tL X KjO H
aii<l that (Uath > Kcurrcil, oil tlu- ilal*.' statt-d abovf, at •
0. M. Tlu- CAISI-; ()!• !)i:.\TII was as follows:
CL^-xM
-vM, VM
DT RATION )\'ars Mont /is /hns \X Hours
CONTRIHl'ToRV LO^X-iA.-^-'VYvO^ cu^vvC^
n
I )r RATION )'i'ays ^ Afouths Pays Hours
M.D.
(Signed)
/ tat > iU ."lui.s
lo. Q. ULLx
(
X
,\.l.lri-s) S3 I vbo-UJ-QL/ul
A'
1 ',.'/>,
/
TMi': MM»\K HTAri'IM'KK'^oVAl, l'\KI'I«"ri,AR-^ AHi; IKl I-. T< > Tlllv
HHsi'.iF MN Is Nt >\\ l.r Ix^l-; AND nil.tHI-
fin T'l: ninnt
Special information only for HospUdls, Insmutions, Transients,
or Recent Residents, and persons dvinq away from liome.
Former or
Isual Residence
When was disease contracted,
If not at plat e of deatli ?
How lonq at
Place of Oeatli ?
Days
0^ 5
PI.ACK OI- lURIAI, iH< HI;M<>\AI
N. B. Kvery Item «f Informntion should b,- cnrcfully KupplJecl. AGR Bhoultl be Htntecl RX4CTLY. PHYSICIANS should
•tntc CAUSr. or DKATH In pliiin tcritm, thiit it mny he properly classified. The "Special Information" for p«r-
lions cfyin^ iiwny from home Mhouid be ^iven In every instance.
»-'T-
.^^nskM.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J>„/r Fi/n/.V^X-^LK "i t!>OH Brgis/rrrd A'o.
"l^vA^ioL^ Deputy Health Officer
DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
^. 5. j5tanDarc>
4. «}
i
(^
3'
PLACE OF DEATH: — County oiUia.y\^ ^ K<^y\/:^UL^i^ City of^^<Xy>v 0 A,<WvcuU!x)
No. Ol^^ LLU.A:Atx\. ^ J A.li v^ StA' ^ Dist.;bct. and
/ IF DtATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPEC
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
lAL INFORMATION" ^
T AND NUMBER. /
FULL NAME
Cf\AX' \hxKkx^X/Yy\J
PERSONAL AND STATISTICAL PARTICULARS
ri lit »R
DA I 1. Ill I UK III
jJ(vUJ6
\!miU1i)
I):.v
\< . i'.
k
lUvC it.
4 fart
/hn
■ \\ ; it. i ti *.,, i;i 1.
iniriMii'i. \(' r;
■~.\,iU ■ ,' I '. ill III
I
Ayd-^^w^>^-XL
y
X^^^v\^^cc>v
1 AIH IH
luK I'll ri, \ij-:
i >; 1 \ ri! I R
(Htlltr iir I'ouiltf A
M Min.N N ami:
luurni'i.Aii-;
<n Moim-'.H
1
I,
? '
Cr\ou .
{J XK/YYX/X'y^
in C\]
ATION (jNp A
1
u a
hs
\f,,ntfi(
l>.
iiii; M5nvH ST ^ nil i-i- rsonai. i'\r i iri i ars ar k iKri: m riiK
i',i-:s'r oi- Mv K N< >\\ ijix.i', AND iu;i,ii:
1 11 f' I- niaiit
MEDICAL CERTIFICATE OF DEATH
DAi'i; » ii- Di'.ATn
19^
iMiiiiDi) (Day) (Vfar'
I IIICRI-IBV C'I'.kTII'N', That I atternktl <leicast'«l from
^" I(p — — tn " " ' ' ^(p
that T la«»t <a\v h alivi- on ~ — Kp
aiiil that dtalh tnH'iirrcd, on tlu- «lati- stated abovf, at b-oO
(j M. Tlic CAISI'; Ol" DI'A riLNvas as follows:
(J
1) r k A '1" I ( ) N ) Vrt;A Months
Days
/fonts
CONTkllU TORY
DTK ATION
)\'iirs Afotit/is
/hlY
SIG
NED ) Lt^.cr>\x^^ JaD.UO. oLila/ruL
iO
r^
Hours
M.D.
ii^'ct) 3^ igoH (Ad.lnss) Wx^vUA^ t/,f s
iO^
Special information only \w Hospitals, Insfitu^o^s, Transients,
or Recent Residents, and persons d\in,i .iwdv from home.
former or ^i ^ v ^
Usual Residence ^ "U^UwA^oJoc -^^Vu
When was disease contracted.
If not at place of death?
How lonq at
Place of fleafh
Days
I'l.Ari: ()l- IHRIM, '>K r!;m<»\\i.
i)Aj;i. ..f P.I Hi\i, .,1 ri:m<)\ai,
w/CAj 5~ 190H
NDKRTAKKK LIvOUO \, Ui . \JlLl
N. B.-
-livery item «.*' 'informntion uhoiil.l be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSK OP DEATH in pliiin terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be It'ven in every instance.
-J^te
m
I
■
I' r<
|i,,;ni! .'■ ll.-ilth I- N
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
"^^nlJS:! On REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
3103
n
/)i//t' Fili'il . U c.Lc-^-'
Eegisteipd J\^o.
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( xa. 5. 5tan^al•D i
No.
PLACE OF DEATH; — County of^'C:^^^ J/vXX.>xCULOo City of CVoy-vv J AXu-i^AXiAixL^M)
0 cru
St.: S Dist.;bet. S/v.'Ci
and I
Jtl
/ IF DEATH OCCURS AWfiV TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OP INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
l\
FULL NAME
A
.0
^\i
PERSONAL AND STATISTICAL PARTICULARS
!» \ 1 1' I ii i;iK 1 II A
M.. nils'
\< .1'.
\\\ I M .\\ 1 1 1 ( iK ! > ' KD
Wt-- ■■ -..',' .>. - . . .,: .,11)
-KAjtx
HOH
» I at
TyVv^iA
lUK I'M '■! \'"K
X \M1 I tl
1 \ 111 IK
lUK !H!M.\>K
<)I- 1- \ 11! Kl<
■^t i!' < I' I'l Hint! %
M MDl-.N N* XM J
<»i- .M<>rm;K
HIRTIIPLAi 1-;
<»!•■ \!tirin;K
I'^tati <>l t'i>unt1\'
niTll'A rH>N
KX/YXTs vol ^ J \AyY>^JU
MEDICAL CERTIFICATE OF DEATH
DA I'l-: < >i i»i:a Til
(Day) (Vtar)
(Month)
I Hi;Ri:r.V CI-KTII'V. That J attL-mUMl <lccLasc(l frniu
i9/C±- X i.pH to 0/ct; ^ TCP H
that I last ^a\v li -r^' alivt- «)ti V CAj 3 up H
and that (Uath ncnirrctl, on the dati- statt-d a1)<)vc-, at O- O 0
y^ M. The CAlSh: Ol' Hi: AT 1 1 was as follows:
DT RAT ION
]'('a)
Months
CONTKIIUTORV 'Wa'UL
Davs
I lours
\\X/<.'
KT
f^
N, •>■ /'llllti
'- ).,!,.
A/, III f /is '^ /hn
rni% Aii(»\|.* s r \ri:i) rKKsoxAi, v\h ii<ri. \ks mo; ikii-: to tii i-
iii>«r oi- Mv KN-< i\\i,i:i ><.)•: and iu:i,ii;!-
l!
( XiMicH^
I )r RATION ^ )'t'iirs Months Pays
(SIGNED ). 0X<^ ' ' . ^JlOvLl^V^I
il'ct '^ icoH (Addrc-ss) 46H ' 'b.V<t rit
I lour s
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinij a^ay from home.
Former or
Isual Residence
Wlien was disease contracted,
If not at place of deatfi?
How lonq at
Place of Oeatli?
Days
Ai.'}<: <)i- HiKiAi, OR ri;m<>\ \I,
DA'p: of Jit K[AI, or RKMOXAI,
Gt% H T90H
f N I ) i; R r A K I-: r \JK^\^XSL^ L LL^rocLtsjLo. ' , ' u:^
fAddrt-Hs obb \T r\AuQ>Q.A>^r>x "u^
IS. B.-
Kvery item of Information should he cnrefully supplied. A(IF. should be stated BXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it mny he properly classified. The "Special Information" for per-
sons dying away from home should be ^iven in every Instance.
•I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
„,„,.,fH. aUh IV, .^^^^^.li^VC, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r Fih'fL ^/cl^
c\> H
^
n
-H
cK^u^Ayo
\
'A
pu
Officer
Ree^isfr/'ed J\^o.
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( 11. S. 5t^nDar^ i
J? ^ ^
^
PLACE OF DEATH: — County oiOOmj J.VaA^^c<A<:<: City of ^ ' O^^ 0 .\xvvx/a^,^L/t^<)
I
"Wo.^^
XK.k C 0-vll\dloJj
^0\Xl4 -l C)-vi
St.;
Dist.; bet.
and
/ tr DEATH OCCURS AW*y Ff4oM USUAL RESIDENCE give facts called for under "special INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME ^
)
PERSONAL AND STATISTICAL PARTICULARS
!> Aii' < >' ';: K
A< ,1-
\\JI>nwKl» <»K l»
I \ nil R
u! I \rm-R
'St, it. nt
M MDi; N N \M 1
ni MOIlIl.k
I',! urn I'l. \rj-'
(stnti oi Cnuiit 1 \
oi'cri'A rioN
\!,,nth
L\_
!»..\
,1'iL
I Year)
/',/.
I --4
MEDICAL CERTIFICATE OF DEATH
DA ri-; Ol' Dl'ATH
(Dav)
k
fMotith'
(Vt-ar)
I lIMkl'r.V <.' i:kTI l-N', That I atttiuU'l dti-L-ascd from
^X^ XI upH tn JL ct ^ 190 H
that I last saw h X>V alive on V//cfc X T90 H
ami thai (K-atlt < k cii rriMl, cii tin- datt- stal^Ml ahnve, at b- I 0
OL M. Tlu' CArSI-; 01 I>I. A'l'll was as follows;
.KAf^X'
Mouths
DrKAl'ION )V./;s
^f A
CON T R 1 1 U "I' 0 R V 0 &>V,<5'*\) U4 w...
/)avs
Hours
\'
<l^
" ),,ns -^ ^r.iKtli'
I), I
Tin- \Hovi-: sr \ II r> I'H'KsoNAi, r\K lUTi.AKs AKi: iKi J-: r<> vnv:
lU-lsr ()! MY KN<>W1,HI)(UC AND HKI.IHK
( 111 fot inaiit
C(?.%.e,ic.
\<h\r
H
,<kX
nr RAT I ON
(Signed )
CM
)'raLS
A n nil /is
Pavs
o i()oH ( AiMrtss)
Special information only for HoHpllals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Usual Residence ^ w A JNXOA/Vvu
When was disease contracted,
If not at place of death ?
Hew long at
Place of Death ?
1
• Days
I'l.ACH <)1" m RIAI, OR R1:M<i\AI, j DA'lJ'.uf P.iHiAi, or KlvMnXAI,
//ctr 5" T90H
indi;r
fAddres. ISXH C
YSj
SS. B.— ^Iverv item of information nhould be carefully supplied. Adl. should be stated EXACTLY. PHYSICIANS •hould
state CAUSE OH DEATH in plain terms, that it may be properly classitied. The Special Information tor per-
son* dylnft away from home should be given in every instance.
r
i I
I
1^
_,WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
/hf/r' riled , U-ci.CrlOA; H
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
100^
Bogistei'cd J\'*o.
^i-vxx^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDeatb
( Ta. S. StanJ>acCi »
PLACE OF DEATH: — County of Vcv "ix >-■ "^Cv ,
0^
<3J D (MO
% , t * "I I
Dist.; bet.
City of "^CXA^ 0 \.CV. > ^
md
vCK- vv>4.r'' ^^ Str— Dist.;bct —and—"
/ ir DEATH OCCURS AWWAV FROM USUAL R E S I D E N C E G I V r 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 >tHLL^
PERSONAL AND STATISTICAL PARTICULARS
-■! \
j
I
a tl.oR N
I» \'i 1 III l'.' K III
\«.H
V!
^
o^u
\! ,nth
■ 1
I>..%
4l ,
i < .1!
/'■M
U I IM >\\KI> < »K 1 1!\( I ! ! ; >
' \\l itc in ^1). ;;i ! h -ii' :.
niKriii'i. \«'i'
CSlat' .>r •'■iiniii \
A
"n
o *
N \ M I < » I
I AT!! IK
lUK THI'!, \i v.
Of? FATIIKH
•■^t I'l 1 if ("mint 1 V
M MI>KN NAMI-
nl NKiTHHK
lUk 111 I'l, Ad",
m- \t«.rniK
'stati 1 1! Ciiunt!
Vt>^t|\'- It
M
()ccri'A'rn»N
UAvo
U kxXA
Kfsitifit ill Siitt /'i,in>
.Kyyx
5 V,/
1 ', nf/n
Ihs
■nil- Miovi', srxrii. i'kk-,m\ \i. p \i< rif i.ars aki-: tkcj'. 'i«' riM-
iii-.HT c)i- MV KNt »\\ 1.1!" -i-; '*^" in'i.n.i-
inf..;,„:nit OU-t^VVh-M
U 11
, I I
.1 1
,C^S_„
MEDICAL CERTIFICATE OF DEATH
i»A I'j-; <>i- Di: \in
fMomli
(Dav)
(Year)
I n I'ik i;i'.\' CI.RTII-N', That I attciukMl deccasoil from
O^^vt. Xl I90H to
tliat I last saw li W>\ alive on
X
(^
iL'c*
i{)o H
and that (U-ath uctMirred, on llu- ilate stated above, at o
\J M. The CM SI'! Ol" DI'iATlI was as follows:
I ) r I-; A IM ( > N ) 'I'iirs Mont /is 1 6 /hiys Hours
CoNTRliU TORY ''t<^<->^A^<>-^^ Vj vX^'X.O-^^Ui
DT RATION
/hi\
\ I iw.> ^^ ]'tars ^ Months
(SIGNED) i. \A. U;u^ULcu
iDcfc ^ TooH (Address) "t^b dxU^tK; dt
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyiny away from tiome.
Former or
Usual Residence -^ ^ » ^ ^
Wfjen was disease contracted,
If not at place of death ?
■ , How lonq at
/OA^UwU. .J I Place of Oeith? > ^ Days
l'J,ACH <)!■ IH KIAI, HK KI;M<»\ Al
DATllnf HiHiAi, <.i KJ%M<)V,M,
I, B — Bvcry l.cn, .i n,fo..„Ht1on .houhl be ca.ufully .uppHecl. AdI. Hh.ul.l be stated EXACTLY. PHYSICIANS »hould
.tat/cA "st: or DIIATH In pli.m terms, that it may be properly cloH-lflcd. The "Special Information" for p.r-
«on« dying away ifnm home should be a'ven in every Instance.
\i
'8S^^
WRITE PLAINLY WITH UNFADING INK
liJO\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS
i 1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
ofCj/avu 0 VOL-WCUlCOCity of \J<Xmj 0 AXL/VLyOUiyCM>
PLACE OF DEATH: — County
M
Nb
m
. JX^t^xck ubch^vd^^tx*
St.;
Dist.; bet.
"and
/ IF DCATH OCCURsUw^Y FPOM USUAL R E S t D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
( ,riE*TH —----" .- • MO«.P,TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE P
FULL NAME
TV
■-ix
PERSONAL AND STATISTICAL PARTICULARS
r< >i.t iR
'^rioL
I) A ri; • >! luK 111
,A
10 ct
A * . »•;
Hi
I > I \
V,. >////•
» carl
/>,
mS'i I.J' M \H U 111*
W! IH )\\ I 1 » » Ik 1 ) ;\ I iK . ID
I W ! ill- 1 11 ^' Ml. I i . li -U' Ii.it 1' 11 I
HIKTIII'I, \t'!
■-! iti '•: 1 ' .11 nl '
N \MK Ml-
I AT II I- K
lilK lliri. \i J".
OF 1 ArillH
i St;iti III I'lnint' A
M\ mils' N\Ml-:
(M \!<i!Hi;r
lUK I'lllM.Aij;
Ol- MO'lllI-.K
(Stnti 111 t'liuiilt V
1^ -L
\>.
I
I'
«HA'ri'.\'l'lc»N 9 ft .
Rf^titfil III So I' I 10
III. : I It
^^,,l
M.nilhi
fhl
Tin M>..)\ 1 ^r\ 111) I'KKsONAl, I'AKTUTI.XK^ \\<V. TKIK TO THH
Hl-<rt»l MS KN» >\\ I.J'.IM'.H AND iu;i,ll'.l'
i\\
( \ihlu -s
MEDICAL CERTIFICATE OF DEATH
D.\Ti-; oi- Di:.\Tii [C\
I Driv
(Year)
fMi.iitlO
I III'lRIir.V CIRTII-V, Tliat I attended tleccasc«l from
— — — — — i^o tn -■ I9O
tliat I last saw h : alivt(Mi • — -— - -^ icp
and that dcatli octurrc»l, on tlu- date stated ahos'e, at
M. Tho C.XrSI': Ol' I)1;ATI1 was as follows:
1 ) r K A r K ) N ^'^'•^ .'^/out/is /hns ' Hours
coNT k I iu"r( ) K V J.Ajuru^^v J|t>urn^ jux^:1a.^^ ^.ctr
DIRATION
( SIGNED ) LtfUn^XN?
&
Ytiii
^
Months
Pays
ct
Tt)0
H (Address)
ss) Ur^UnnJtM V\y
Hours
M.D.
Special information •>«'> 'or Hospitals, InstifutikV, Transients,
or Recent Residents, and persons dying away from home.
^ , 4. (hi pi' ««^ lonfl «»
, J 0\Aj N I lO^'CnrV. UXl Place of Death?
Former or
Usual Residence
When was disease fontrarted,
If not at place of death ?
Days
i'L.XCK OI- lURIAI, OK RHMoVAl.
Cxi
DA'!>. of IliiUAl. or KHMoVAI,
^ct H 190H
N. B.-
-Hverv Item o* Information •hould be cnrafully supplied. AGB •hould ho stated BXACTLY. PHYSICIANS should
rVatc C\U8E OF DEATH In pintn terms, that It may be properly clflsslfled. The "Special inform„tlo„- for psr-
«on« dylnft away from homo should be felven In every Instance.
I;
:N
.%\
I
m
li
t:
li
1 • . ■ I h I \
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t-.^"^?^:-, 1)5. IT
2106
Xfr^_v^ "LtyxvM Deputy Health Officer
DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco
Certificate of "2)eatb
( H. 5. StanDarD )
PLACE OF DEATH: — County of' 'CV^^ J \o avcc*- City of "'O.nv J v^O-
^-.^X
VVC.Ul^V<;
NoH^^
/-Uv-^<lOcrLt.\X) SU R Dist.;bct. U VTU^I and
ir DfTH OCCURS AWAY FROM USUAL R E S i D E N C E G I V E FACTS CALLED FOR UNDER " S^fCJ^AL J N FORM AT
(
rF'DEATH^OCcJRVED'.N'I'HoTprTA: O r" 7n ST ITU T . O N G.VE ITS NAME INSTEAD OF STREET AND NUMBE
5'
ION
R.
)
FULL NAME
LoJI k.L^A/Y^Jl i CrwA^JL
PERSONAL AND STATISTICAL PARTICULARS
4
^
Ml i;iH in
.L 7\uil
/Ibto
Miiiih
\i,j-;
al
/'„'
-iM.II MARK II It
w i iH »u i; i» UK I »;\'< iR. I i>
Wtitt ill ^iifial ill -u'l!;!!!' iM 1
^» • • ! < I 111 111 I \
Xol:
hJVA^
-v_
dL
^-hjiAxx/w^i.
I A III l.K
lURTII I'I,A('J-:
< i! 1 \ riu.. K
~.! i1 1 I It l< lUtlt I \
M \n»Hv NAMi;
(•I Moiiii; k
HiK riii'i, \i i;
<ii \tt»!iii;i<
I ^tnti I -', riiutlt I
« MAT I'A 1 I< >N
(
,/ Sitii it ii III IWii
VlLou-vxx:L
^ H )Wm^ -
M.,nll,
lh;\
Till- M'.uVl.' Sr \'n-,!) I'KHSON W , I'XRTK t! \Rs A R l-. i Rl}; To Tlli;
in;ST OI MS' KN<»\\I.I".I>(.I', AM> I'.IJ.II.I'
(III fi)i mant
MEDICAL CERTIFICATE OF DEATH
DA IF, oI- IH.ATH
III I
H
fMoiith)
iciv
IVL-ar)
I IllvKi;i'»V CI;RTI1"V, That I atleiukMl (Icroaseil fnjiu
YO^^-Xi 190 1 to ^'tlAJ H 190 H
€ot
that I last saw h '^A; alive on
and that <K-ath occnrrctl, on the date state<l above, at DoO
IX M. The CArSI- OI- DICATII was as follows:
DTk A'lloN -J Yrays \
lO
CONTKIIUTORV
Mouths
Days
Hon
r\
I )r RATION ,, )Vf/;v
|U
(SIGNED)
0
/C\
\ iryn
\.i<in-ss) o ^ U oUx^M^Q><x>dUDL^ < )t
Hours
M.D.
Special information on'y f^r Hospitals, Institutions, Transients,
or Recent Residents, and persons d>iiig away from liome.
^
Former or 1 n m "^^ >. . , ^U "•** '""' *^
L'sual Residence 'oub OMnM UX Place of Oeatti ?
When was disease contracted.
If not at place of deatfi ?
Days
I'l.ACK <)!■ lUKlAI, nk R1;MuVAI.
DAIi: ')f I'.iRiAi, or KHMoVAI,
T90^
f
<Vcx/yv
\ 0 fi
"^11
. „f l„fo.,n„f.on .hould he cnrefu.ly supplied. AGB should »>« stated RXACTLY ^"Y^'CIANS should
SE OF DEATH in plain term«. that it mny be properly classified. The Special Information for p.r-
!S. B. livery item
state CAU
«f»n» dylnft away from home should be feiven in avery Instance.
I
\
M ,
Hi
m
m*¥
!|. .!'^ I "^^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS
l^c^ ijL^ Deputy Health Officer
DEPARTMENT flfp PUBLIC HEALTH^City and County of San Francisco
Ccvtificate ot IDcatb
-No.^
PLACE
\
(
OF DEATH: -County of Oct^ 0;u^^vcv^^ City of U^C^ 0 A.<V>xc^^ - '-
(1 % ^
^^
'wCH^. wW^.<XJl
4
St.;
Dist.; bet. —
and
-XJUQ WV. %^ I ^^^--^^ or^inVNCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" ^
FULL NAME Ox^ax^^mx^
ivo c\j LLvkxa-u^
. 1 \
I \\<x.
DAI 1 . I M r.i K 1 11
PERSONAL AND STATISTICAL PARTICULARS
. \VA^'
/^
M.ituh
Dav
\ < • 1-:
i'^
) -,/'
» . ar
A/1
Wi; ). i-,\ lit « tR I I ,\t ii' ■ I' !)
X \ M I « »!
1 A III I.K
!'. I K r I n ■ I , A I F.
ni' I \ II! l-.H
M mi>i:n' nam I
{)] Mo'llli: K
lUK Tnri.ACi',
<)1' MDTIII'.R
i St;ltf I >I (.'tUllllI >
oi'Cri'A'l ION
■\^
ME
DATK «»|- DHATll i[\
tiCAL CERTIF
ICATE OF DEATH
(Year)
•Month) 'I>:«V'
I IIICRIU'.V Cl.KTII-V, That I atUMuU-d (kncastMl from
^jp
— • icp
that T last saw h
up
- aHvc oil
and that death orcurrcd, on llu- dato stat«.'<l above, at
M. The CAl SI-! Ol' niiATII was as follows:
f
" M . I 11
r\Aryy\j
nrRATloN )'rars
CONTkir.l TORY
.lA'z/Mv
/)a\s
Hours
Di; RATION
(SIGNED)
)V<?r.v Months
Davs
Hours
M.D.
fAddre
,.^yvUL^LA vJi(4
SPECIAL INFORMATION only for Hospitals, Institutidrts, Transienls,
or Recent Residents, and persons d>lng .iv*a> from home.
.aJ^'vAA.
"S'l a ,
M.HttIn
/),M
TnVM»)VKST>TKn.>KRSnXAI,l-NKIUM;i,AK^ XKHTKrHT«> TIIH
in:sT oi' M% KNowi.i.iM.i-; and iu-,i,n-.i-
(Iiifitiniant
0^X>ouu:>A\JO\M^
X.ldrf^H O'W
/(KjiAU
M
Former or
L'sual ResidenccU.\\Un'\;
Wfien was disease contracted,
If not at place of dealli?
yUOAJjb 0.0 3 Place of Deatli?
Days
IM.ACH ni lUKIAl, OR RHMoVAl.
O
i>.\ij. of p.! Ki.Ai, III ki;m()V\i.
0^ H 190H
(Ad.lnss 9s'i?>'\ QfTUAA,A„^r^ ol
N. B.-
^ .. \7 , AfiF «houId be stated EXACTLY. PHYSICIANS should
-Bvery Item of info.mntlon .hould be cnrefuHy «"PP'- • „^„^„^erir"lls^^^^^^^ The '•Special lnform»tio„" fer pr-
•tate CAUSE OF DEATH in plain terms, that it may be properly Uassmea.
son* dylnft away from home should be ftlven in every instance.
! 3
k ' |!
till
M
Il.^!th 1 ^
WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^1 A/O
t"?' -a-'.^li- luS: 1' I'
!)ff/r Fi/r</, ^/cl^rVC^u H
JOO'i
Bedisfrred ^'*o•
^'CVA.A,'
"it
Deputy Health Officer
DEPARTMENT ot PUBLIC HEALTH=City and County of San Francisco
Ccittficate of ©eatb
> 11. 3. StanOarO ;
PLACE OF DEATH: — County of
0
^
<X^^v,
txXX;
City of
v^oJo.
No.
St.?
-Dist.; bet.-
— and
-)
FULL NAME UlDOAvruxiv JXa-^uu
PERSONAL AND STATISTICAL PARTICULARS
>-!:\
^
rl ll,( >k
VX^O
ilib
I) ATI* » >t HIK 111
\< .l",
(lf>\
M , 1 111 h
1 ,,„,
aV'
H
, D.v
,U7
\ .1! i
b
1/ ,,,'/,
MEDICAL CERTIFICATE OF DEATH
DATK i>l' Dl-ATli ,p\
(Munth) 'I'=«y^ (Year)
I Hl'Rl'.l'.V C1:RTII'V, That I Mtteii.kMl ac-ccased from
- to ~ —————
190
that I last saw h — ™ alive on
T90
T90
"-.INr.l.K MAKHII'.U
\vinn\vi-i> t>K n \i>Ki*Kn
Wt it.- in -. . ial .1- '^Miatinti)
iuKrmM,Ai*K
I St:iti iir ifiiinti V
N \ M ! ( »I
I \!II1 K
niHIIMM, \«K
()l* 1 \ I'll 1-. K
(Htatt -I 1'.. nulls
M MIU-N N ami:
< »!• MO'l'lli: K
P.IK rni'i.Aii-:
Ml- Mirrill-.K
i ^tatc .1! I'ositlli V
(ucr PA rioN
an.l that death occurrcl, on the date stated above, at
M. The C.\rSI': Ol' DI^ATII was a^ follows:
yX>vvrv<XAxu
Dr RAT ION )'i'ais
CoNTRIPd'TORV
Months
Din
'S
I/out's
I)rR\TI()N )'t'iirs jr,>fi//is /hivs
//ours
K,is'-v\y^.^f"y\^ M.D.
(A. hires.) UoJuL
Kf^;.h.l :•■ -■r>' I :
) ■/•(,' )
Mn,i(/n
I-
THKAUnVKSTAT.MM.KKsnSA. PJKn.rjXK.AKHlKrK TO T H K
Hl-ST 01 MV KNoWlJ-.Di.H AM) hlKi,Il.»
^Iiifntniriiit
\.l.h
(SIGNED )
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dvinq away from liome.
r «»rnr \ ^ Howlonqat ^
Usu!l ResidenceOoAV 0 A.<X.-vx :. Pia.e of Death ? SoncXAA... ^
Wlien Has disease fontrarted.
If not at place of death'
DATj; <»t lU lUAi. 01 RI%MOVAI,
A
pr.At'H «n- lUKiAUuK ki;m»>\ai.
T90H
r , , 1^ stated EXACTLY. PHYSICIANS should
:r;."n'i -ai «-"- "cne .h.,„K. h. .'.ven 1 > InM.nc
I
I
)-'
I ' i
I r
r
It
1^ 1
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
21 09
Lrv-c^ijUK. Deputy Health Officer
DEPARTMENT (IF PUBLIC HEALTH-City and County of San Francisco
Ccvtificate of Bcatb
( XX. S. StanJatO J
PLACE OF DEATH:-County ofC^Cmv J ;v.V..xx^ Gty of C^^^ ^^^XTT"
^ I
Sf'^ Dist.; bet. U CUYV M UAA, and
FULL NAME
CUvA-trvo
PERSONAL AND STATISTICAL PARTICULARS
i» A ri; < >i niH I'll r\
5S ,„..,. '-
M'\
D.iv)
'i I a I
/>,
MEDICAL CERTIFICATE OF DEATH
DATK «)1- Dl-ATIl
Dav)
(Year)
(MniitlO
in<:Ki:r.V C1;RTII'V, That I atlciukMl .leceased from
t bO igoH to %* "^ '^"^
slN<.l,i:. M \K1< 11 !>
wil)oWHI> <>K !>;''' '''' ' ^' ^
^ \Vi itr ill '.iM iai .1< -'iMi.itiin;
ll'^d
-1 I V
I'.iK rni'i, \i"i*.
>^tat I 1 1! t'l 111 nil \
NAM I- <H
1 \ in 1 K
A
BIH miM, \«K
(U- 1 AT III: u
, St it t 1 ii i'' Hint ! \
M \I1»1%N NAMl-
()i- Mo'l'UHK
lUK rm'i.At i:
4)1 MiiTlll-K
f Stati oi I'liunti V
that I last saw li X\; alive on ^' ^ ^ ^'P
aii.l that .Uath occurred, on the .late state.l above, at 5
CX M. The CAT Si- Ol- ni^ATII was as follows:
DIRATION IV.vr.v J/ou/As H /hivs Hours
CONTkilUTORV
h^KJ\sjL \jOJ\AiA^r>^^.ArYr>,XX^
( K'rti' \ ri< »N
.', .' ,„ V.fM I'l at', isi'n I U 5 '■
M:'nt!i<
Ih
ni-ST »)!■ MV KNOWI.I.IX.H AND l.IJ-n*
I \RS AR1-; TKIK TO Till-
(SIGNED) \JYUu.^<U ^J^^^ p
/fours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, franslents,
or Recent Residents, and persons dviiK) away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
{Info- tnaul
^. i9
A.
f A<l<lr<"^'^
ioTkCs ojuuvik ^3fc
DATK .
6.
,f H! RIAI- or RKMOVAI,
/Ca> b 190H
rj,ACE OI- lURIAI, OR R1';MoVAI.
(A<
—"■"■""■■""■"■"■— """"TT T^ AfiF should be stated EXACTLY. PHYSICIANS should
:". dWnVaw«; «™". ho^-e should be llW.n y ln...nc..
I
ii^k:
w
'
V I
w
RITE PLAINLY WITH UNFADING INK
,1 i.f ih ,''i'i
>, 1- Nil
^^"^XiUS.VC
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dh/c Fih'fl , UoLcX
sJlN; H
n)o\
Jici^isfrred J\''o,
9A10
h Officer
■? i De uf H.
DEPART^ENTOI^ PUBLIC HE AITH-City and County of San Francisco
Ccvtiticatc of IDeatb
PLACE OF DEATH = -County of 6,.^^ W..^.^ Gty of Oc^ J AX^c.--o
f
!K
^c i
and
<•.
( •' r;o7..H^o^cu%r;.;^rHo^s^y.**^ r.^^^^.^^^.^o^'^o./r.! name ..s...o o. s..... ..o ...s... j
FULL NAME H K^M^d. ^
^ V ^^.O. )
PERSONAL AND STATISTICAL PARTICULARS
JO
i>A ri; t >s I'.i K rii
\i .l•:
\\ ! In i\\ i: 1 > < »K 1 > '
\\ 1 lit 1 n -. H i,i ' li' - .
, ^
( Vt-arl
!i
lUK rill'I, \rj-'
vtatt < ii I '.in lit : N
r ATII 1^K
I'.iK rniM. \<'H
Ol lAllUK
-,tatt |>I i'lilUltlN'
MAIUl'.N NXMI-:
Ml- MOTIIKK
Hiu'rmM.Aci-:
C)|- %1( I ill I'.K
oiHTl'A TioN
MEDfCAL CERTIFICATE OF DEATH
UATK UH ..KATH iCS X H
! UI:RI;15V Cl RTII-V. That I atteiKU-.l <UHcase<l from
O-^-jAt a^ .90H to 'p'^^ ^ T90H
that I last saw h Jl^ alive on ^' ^ ^ ^^P H
an.l that . loath nrcurrcl, (Ml the date statc-d above, at 5"
Ol M. The CAISP; OF DKATII was as follows
J M'< v'l' in, .A 1 I 1 ^^il> rt-^
nr RAT ION >Va;-
CONTRIIUTORV
h
Months 11 Pays Hours
V^,^'VV^"V^A.^X4Mw<5'YV0
DTRA TION
)',uirs
A'
,.' , •! S.,-'/ /
) 'r,j I s
yr,;,fii< i I /''
TH,^^1U>VKST^TK,M.KH..>NA. PAKTUM^KAKS AK,- TKfK TO
iii.>roi Mv KN«>\vi,i:n<.H AM) ni.un.h
rm-
Months \ Pays
( SIGNED )Mfl\.aAXJ 1.1-6^'
_s_'-
Hours
M.D.
Xa.lress) lloi Qaa±Uaj q1
SPECIAL INFORMATION onb tnr Hospitals, Institutions, Transients,
or Recent Residents, and persons <l)in3 away from home.
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatlt ?
HoH lonq at
Place of Oeatl«?
Days
(Iuf(>!ina!it
A.Mi
DAllIof lURlAI. or KHMOVAI,
0/Ct^ r TQOH
rNUi:HTAKi:K
— ■ TT Tgf. ,!,ouI.I ho .tat.d EXACTLY. PHYSICIANS should
,. B.-P.veO. ..en. ^n„...^,0«n .houia he_^=_a..»u,,, ,u.^p..e... ^A^.^^_^_^ ^,_^,,,,^^ ^,, ,.,^^,., ,„,„,„,,„„.. ,„ ....
:r„rd"Taw°,' from h„™, .hould b. ftW.n In .v.r, -,„,..««.
; ii
^f
iii
t!
It
I <
\
> t
H.iiu
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2111
ith r X
l',\ !' I'
Dafr Filed, ll)/cXM>--t>v H
U)0\
Be^Lstercd J\^o.
J<
if-h
'1 >-*, iOi
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( Xi. S. StanDarD )
cto
m
PLACE OF DEATH: — County of^^^^
No. His
5 A^^^CAJ^^ City of U <X/>x; J AXc/wo^^<>D
-COV
St
.; 5s Dist.;bet.
and
AVclX
. O..TH OCCUPS .WA. .ROM U S U_A L ^ ^^lO^.C^^^^^J^^^^ ^^^O .0.^..0.^. ,-,%-- 'rN^J^^ER^^' ) ^
( - r/orAT°H"o^CCU%reO IH rHOSpTTAr OR ..SnTUT.O. 0,VE .
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
I < )i,i>k
0 J
1» \ 1 1-^ I !| l.IK I II
L
_\_
.tt
Kvci.
1^
/tit)
%i.,nl
\i;i-
^H
lb
/'.
^CLX cLil/XMJ
■^I^.l ir M \K H IKI>
Writi in ^'Hi;ii di -.i^niitiiiii)
lUKTUlM. \>-»-
<XA^ 1 ^L0LyYV/C<^<^<5
I- A 1 I! l.K
<»i. I A rill- K
--' ,1 , ,• 1 ■. Milt ! \
MAIhl N N\MJ
ol- MoTIIKK
Iuua;-
1
\
fvf i.lrJ III S,ni funhi'in Q \ ,,,/< o .
lUK rillM. \ri.
Ill Miiiiii; K
t K I 11'
MEDICAL CERTIFICATE OF DEATH
DATK <>1 DEATH A
(Months 'I>=*y^ t^^'*'"^
j hi.:ki.:I5V C1':RTI1'V, That I attcii<le<l .leccasol from
C)S\X lb 190H t.> li)^ "^ I^P"^
tliatllast.aNS h-L>V alive cm ^^ ^ ^ "<
an.l that death occurred, oii the <late ^tate<l al.ove, at 0
d M. The CAl'Sl-: Ol" Dl-ATII was as follows:
I )r RATION Years
CONTRIIH roRV
Mioit/is ^l /?<n'v //6»//;
., )V<7r.? Months
DT RATION
( SIGNED ) <*wM^^-^^ UaJAA^
Uct H u,oH fAddre-^^) (s'^'3w
/?r7t'
I-
Hours
M.D.
,-„H X,MiV..sTM. l>i-KU->XX..l-XHTUrLARSAK)-TKrH To nXV.
(Inl
iLdlxA^^xH^ 'o
f A>l<lit>^'^
iXXXAAj.
SPECIAL INFORMATION only for Hospitals, InstitiKions, Transients,
or Recent Residents, and persons dying away from home.
Former or
IJsual Residence
Wlien was disease contracted,
If not at place of deatfi ?
How long at
Plar e of Death ?
. Days
n \CF OF lUKIAI, OK RKN!o\ AI
%mx. ^
DATi; (if I'.iuiAi, (>! ri:mi>vai.
(A<l<li^'^s
__ I .. ■ Trv H<.ul.l he stntecl EXACTLY. PHYSICIANS should
11
#13
S Si
1
II
!<'
If, i
11
J'
P:
i
; i
,,f H« :iUh » N'
WRITE PLAINLY WITH UNFADING INK
, *.!:,-« ,^i Its, I' t .
I>
ate Fileil , \)fdjXAhj H
V)0\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
]l(>(iisl(>rc(l JS^o.
i Xjuxhj Deputy Health Officer
DEPARTMENTS PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of Bcatb
PLACE OF DEATH: — County ofcl^<5U>^XXL
1
City of cMhC^
m
YVOA^it^
Ne-
st.;
Dist.; bet.
and
-)
.. OC..H occu.s .w.. .«o. USUAU R^S . OENC^vc^J^C.S c^;^o ^^^.« 3?:^^ri^n;M;^;;'''" )
(IF DEATH OC
IF DEATH
(CCURRED IN A HOSPI
TAt OR INSTITUTION GIVE ITS NAME II
FULL NAME
XOX.'
h \jiW\L.
PERSONAL AND STATISTICAL PARTICULARS
.-< li.tiK N
mJ
%
X
J. . .^Xjl
i>\ri '- M i.ii<
|i \ 4
M
\< .1'
u
It
lKi\ >
\l.,,ilh:
')
Vi-ar)
lhi\
IViEDICAL CERTIFICATE OF DEATH
I)\TH <)» Dl'.AlU
fMotftlO
rgo'i
1 m':Ri;P.V CI'RTII-V, That I atteiKlea (Iccoased from
__ . — — up to — —^—.190 —
that I last saw h :tr alive 011 ^ —,__:— 190
an.l that death occurred, on the date state.l above, at
-.IN'l.l- MAKKn.I>
isiK rui'i, \*'v:
^tat 1 111 ' ■ M nn \
\
L
<Lo'UJ-^d-
:\a.LO
I'S
1 A I' II ).K
lUKTiiriAiK
oi- 1 \ nil K
MMI.IX N\M1
HiK rm-i.Aii:
()i M(i'nn*,K
( state I ir ("oiuiti y
.>ccrrATH>x(yy^^^^
'LojCL^'w^^
M The CVrSIv Ol- DIvATII was as follows
n xTxK/vx/cOL
DTK AT I ON )'<'^''
CONTRU'dToRV
A/onths
/hn-
Hours
nrRATiDN
(SIGNED)
(J
TC)0 \
Yi-ats Months
(Addri'^s') cL^O
/>«n'
Hours
M.D.
\\X^.<AX<» ^CL^
M,ni(h>
lh:v
T„KAHnVKSTATKnPKH.oNXUrXK.M.M^..AKSAKKTKlKTn
l',i>T «)! MV KN«'\VI.),I)'.K AM) 'aW''*'*
THl-:
VOuvyA-
SPECIAL INFORMATION only lor Hospitals, InsHtutions, Transients,
or Recent Residents, and persons dyiny anay from liome.
Former or
Usual Residence
When was disease contracted.
If not at place of deatli ?
ttoH lonq at
Place of Deatli ?
Days
UI.ACH ol- m KI\I, OR HHM«>\^I
I NDl'.KTAKKR
DATr. > • I'.iHiAi, or RKMoVAI,
jb ^<L^ »v vl^oXit aX-^-^?^-
— """""■"""— ■"—"■^'""TT r\ IfiB should be stated EXACTLY. PHYSICIANS should
N. ».---^ ••- -• -'^TA-vs^r;.: •: r;;^::;c. rrr.r:; ."Zr^. ..«.«.»-. xne ••8..c,.. .„.o..„..,on" w p.r-
state CAUf9t: iir- ui:.« 1 ■ k ^ Sn«t«nce.
::r;d,rg aVaT Tr:™. Hon.. «h„ul.. he .iv.n 1 , .n.t.ncc
p
'I
k
[■♦-.
« >
ll
WRITE PLAINLY WITH UNFADING INK
v)(n
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Duh' /'V/r^/A^ctJjaA. H
iuyvjuOi duia><i Deputy Health Officer
DEPARTMENTOt PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( *U. 5. StanDavD j
PLACE OF DEATH:-County of C^a^^ K.X^cu.0. city of^^nrv JAXX^e^
No.
u
and ^ ^
a 0 ?5 L0L\tH.O St.; 10 Dist-bet. ..FORMATION- >J
O.-.M OCCURS -- -C. U^SU.L --^f.-,-4--;-;| N^AME -X^rO. STR.eX ..O .UMBCR. J
IRE D II
(IF DEATH OCCURS A
IF DCATH OCCURI
FULL NAME
<>o^
PERSONAL AND STATISTICAL PARTICULARS
WoXx
i» \ d: ' •! liiK in
cfc
J
5
A
\' .\-
vix. ,i,r M \H ' n '
\\ I 1)1 »'A 1 1 » < '!< 'i >
W ! itt HI -I .. n ■ '■
HiK rui'i, \i'i-:
(Stnti I ii < ' >•' II' '
N \ Ml < > I
1 \ III IK
HIK III I'l. A«'K
<»! I xrill'K
^1 ,i! I ( il ( I n\ lit T ^
s ,
11
IH
■> ' a!
Ihn
!)
MEDICAL CERTIFICATE OF DEATH
iDav) (Yt-ar")
iMoulht
(A
I I1I';RI;15V Ci:ivTlI-V, That I attcndtd <UHcascMl from
IDtt 1
M MIil'.N' X \M1
(ii M(ii"m;K
H
0
ll^
lUR'nn'i.Ari-.
(>! %!(>rm;K
I ^tat< 'it CimiUt %
OCiri'A'lK'N
that 1 la^t -aw liA^Wi alive <Mi U/CA; H icp H
..,11.1 that .kath ..rcurrcMl, on the <late ^tatc-.l above, at H
CL M. TIh- CAl'SI-: (>l* 1)1- ATI! was as follows:
DTK AT ION )V<7/-,s- Monlhs H /?<7i',s- /A>//
eoNTRiniTOkV
/.S'
DURATION
(SIGNED )
}'tars .Uon/Zis
navs
riou
rs
iiGiNtu ) nr'^'-^-'i^^-^^ »^ ^-^^^^^^^ M.D.
I<jb H 'ic)oH rxa.iress) lSOiCkL^^^ at
SPECIAL INFORMATION only ^or Hospitals, Institutions, Transients,
or Recent Residents, and persons dying dv^ay from home.
Rr::df,> in X?" /><
)/, nr-'
\ [ A/.„ff/is X'i /^'''>
THK ^.-vK-T^TKnpKR^>NA. rAKT|.r..u<. XKKTHrK TO Tin-:
P.i;sT <)l' MV KNoWl.l-.Doh AND lU.l.Il.J
(In
I'Xddrt
i"lG?i L^xaIxo ot
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
H«w lonq at
Place of Death ?
Days
I'l ACH OI- BIKIAI. OK KI;Mo\ A1.
Ii\Tl'. of HlRiAl, or KICMOVAI,
T90H
,. ■ .pp ahmild be stated EXACTLY. PHYSICIANS should
N. B.— Bvery Item «? Information should be cn.efully f^^^^^'t properly classified. The '*Spec|al Information- for p.r-
otate CAUSE OF DEATH In plain terms, that it ma> ne proper y
sons dylnft away from home should be ^iven in svery instance.
111
t ?*
h
I
4
I J'
f'
I rf"
P'
WRIT& PLAINLY WITH UNFADING INK
II. Mh \ V,
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I
Dn/r Filril, \l clt^oOA; H
l'.>0\
Jlcf^i.sli'i'cd •A''o.
2114
Deputy
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDeatb
PLACE OF DEATH: — County of
0;
No.
^ r^
• Vcv>^c^<i^ City of 0<xrr^ OXcw-vrov-^ ^
St . : Dist; bct.(XUX/v^m.uJ-Cr\.L \ and w v/ Xl C
(X\rs ^l^i\ I i(\a i\\
)
FULL NAME M-OavyuxIxj U^cx-o.
M.
PERSONAL AND STATISTICAL PARTICULARS
"^ ft V nl.t.R \ . ^
+ .,
C »-vXX
|( \ M' I 's
\^ .V.
i 1
<v.
I). I'
V, I ■/'
"\ 1 .11
/>.■
^p . I r M \k k 1 1 P
\\ I iK .\\ r 1 1 < >K i» i\"i •
HI!.' rn 1M. \i'l"
>^' • • < mil! \
I All! IK
HIKTin-l, \»i-
(II* i\rm-.K
tIiIi ..I I'liiini
M \ ! DI'N N NM I
i>l- Mnl'Hi; H
lUH rin'i.Ai'i*,
(li \!iirin",K
i Sl,(t( < il t'ouiil
ij AXJUr^>-<><^
MEDICAL CERTIFICATE OF DEATH
I llI'lKl'ir.V Cl'lRTU'V, riiat I attends. l <UH».ase<l from
- to -
til at I lavt saw h
I9O — ■
~ alive oil
T()0
up
aii.l that .Icath ..rrurrtMl, on the date stated ahove. at
- M. The CM
J\J
i)\' l)I':.\ril %va-« a^ follows:
AAJUX.4JI ci (iL ' f^ \t
^'>vO^
I
\ni^
OAXA
liX/YVOrYV
i
\
i '
1)1' RAT ION )''iJr
C(>NTR!1U-T()RV
Months
Pay
Hours
nr RAT ION
)'t'illS
( SIGNED ) Lc\Xn<\-»A'
c,
Jf(>N//lS /hiVS
^'
'\^
(0
Hours
M.D.
V 4, «V1l
SPECIAL information only '"^ Hospitdls, InslltulWiH, Transients,
or Recent Residents, and persons dying away from home.
ni'CI TA I 1< 'N
A'
,; )' ; I il III
)-,,<
M.iiith-
I hi 1
lU'srol MV KNOW I,l-.I»*.H A\I) 111,1,11.1
(Iiifii!in:int
Former or
Usual Residence
When was disease contrarfed,
If not at place of death ?
How lonq at
Place of Death ?
Days
'LACK 01- IHKIAI, «>K kl.MoXAI,
DAil, 'it IM itiAi, nr K):Mn\AI<
0^. H
(A(Mi- s^
igo
H D S ^ o-\A><,
... ~ AfiF shoulil be stated RXACTLY. PHYSICIANS Hhould
:'".' "nl «w.y «ro-n horn. -houl.. be ftiv.n i y ln...n«.
i I
J.
11
I .»
jl
' I
■•■■•maMMi
WRITE PLAINLY WITH UNFADING INK
,,.1 ..f l!.n!t!. i ^ ■
t^.t^^^,ns.v
Dttlr rih><l , \iJct<rWv' H
mo'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Ccvtificatc of Bcatb
m
PLACE OF DEATH; — County
of^C^^v 0.,^v<X/>xx^vCi/coGty ofO/CL/>v JXxvyv.^^^<ucx)
No
M
ChClK^Aj
.<xl)
St.;
Dist.;bet.
and
)
0 ft ^ iPvi -
FULL NAME
.VXX/vyj
XXX;
PERSONAL AND STATISTICAL PARTICULARS
D Ai i: or I'.i K 111
i'< M.i iK
.Uivdjb
,Cl\)
r\^^
Month
[1.1%
\« .K
ST ,
■» I ar:
/>,
siM.i.i: M \u!< n-.i> -.
Wtlx »\\!- I » I tic 1 » ;\i i!' .• !; t> ^ \
I \Vi it '■ i n ^> » ia ! lU -U' ii.i! '> ■!! '
niKPiU'iNt'j:
(Statr "'' ' ' iin! i \
Month'
,A^X<X
NAM!- <>!
FATin-.K
P.IK THlM.AiK
<>I- I Arill-.K
(Statf nr (."iMintrv'
MMin'.N NAMl-
(>1 MOTHKK
OJVX'
coK^<Y^^^^
MEDICAL CERTIFICATE OF DEATH
DArF, Ui I)1:A'1'H ,, ,
% 5 igo\
(Day) (Year^
^^ I ni;Rl-:BV CI'-KTM-V. That l atUMukMl dcciascMl fnuii
tltat I last.awh-tV alivf on ^ '^ ^ ^QO H
aiitl that .Uath nriurrcl, en the <latc stated ahm-e, at I
CX M. The CAT SI-: Ol' DI'ATII^vas as follows: ^
DIRATION Vti^ts Months H fhiys Ifoms
CoNTRIF.rToRY
I )r RATION
) 'iW'S
lUR rill'I.Ai I',
Ol- Mo'Iin'.K
(Stati i>i i<unit ! V
orci I'ATloN \{
^(Wx^\W\-
V
(M
U,.*////- ~ /'
TnKXHnV,-STATK,>1-KKSnNA, rXKT|.rj.XK.AKKTKtK TO THH
lilCST ni MY KNHWM.lx.h AND l.l-.I.H.l
\i r\jux>vou
vj CrLcur>>v
( SIGNED )U) A. ^OO^'
0^ - '^
J font/is /hirs
Hours
CoH^ r Address^ qilM^WJuJidfc
SPECIAL INFORMATION only Jor Hospitals, Institutions, Transienls,
or Recent Residents, and persons d>ing away from tiome.
c\A>cr>-
. Days
When was disease contracted,
If not at place of deatli ?
• IirRI\I<<)K KHMoVAI, I l)A'IJ-;..f liiinAi. or Kl-MOVAI.
(A.iar...s l'h'h\ QrriMMiA.-to^ Ot
N. B.-
— -"' ~. Tr.F should be state.! EXACTLY. PHYSICIANS should
-F.very Item of Information should be cBreVuHy -PP^'-'" "^^l^^tL^^.S,^. The -Special Information" fer p.r-
state CAUSE OF DEATH In pliiln terms, that it mn> be propeny
son. dyinft away from home should be felven In every .nstancc.
in
ft»-.
I
i!
m
■-.^mdittmt
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hi. mUIi
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ih
f/r Fi/rf/, UcIMjOA; H
IfJO'i
Be^i.slered J\^o,
2116
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of S)catb
( XX. 5. 5tanDnvO )
m
PLACE OF DEATH: — County of^^a-vx^ J.^^XA^cc^c^City of^l<X^a. J ^^o.m.<i^A^o
No
.at
.K^.><.¥LUs
Ch^t'VvJtxx
St.;
— Dist.;bet.
and
/ ir DEATH OCCURS AvLaY 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
PERSONAL AND STATISTICAL PARTICULARS
SKX
iiA ii; < 'I III Hill
/Us
\t.i-:
Si
M.mthi
J
1);.V
1 '
I '-
s|\» ,I.|* M \R k n.I>
W I l»< t\\'l It Ilk iMVi iKi'l-:!)
Wiitiiii -"nial ilr^iinuitinti)
lUR THl'I. \»'|.-
i Stati 111 > I ii) nt ! \
\VcxhKUL6^
I)
^
LOLW3^x:y1">-^'-<i-
J±.
N WU < »1
I- A 111 l-.K
luu rin'i. All-:
ni- I A III i; K
' Si;t( . I ii I'liilllt r\'
MAim'N NAM!-;
(U' Mol'Ul.k
luk riii'F.Aci';
(>l Mn'riii:K
( St.itt lit V'i>\Ullt \'
? p
V^C^
\ ^
«H A ri
'AIION^
/'\J'Ji^XAJ\y^
Rffittf'if in S,7ti /'i ,1 in nt i> ^ )ii!i'-
,^^X3JulA/>^-^.^«*-'>^
Af.i)if/n
/>.;
rni- \Hr>vi-: sr \ ri.!» pKk^<>N \i, i'\r ik iiaR'^ ari; TKri-: to thi-;
Hi:ST ()I- MY KNOW I.l'ix.l-. AND lU.MlJ-
dtif')- maiit
6. J. (JXdj^A-^ciycry^
XC1
MEDICAL CERTIFICATE OF DEATH
DATH ()!•■ Dl'.A'Ill
l/QAj I /goH
fMoiitht (Day) (Y«:tr>
I II1:RI:P.N' CIvRTII-'V. That J attendi-d cU-i c-asi-.l from
IJokl) CivU I90H in U-CAJ I U)0*i
that T last saw h^ < >^ alivt- (mi L <^Ai I icp H
ami that iKath omirrcd, on the date statt-il above, at u- oO
CL M. The CATSI-: ()!• Di: ATII was as follows:
(^A-Ujoctx^-vh^ UK.<rL<X.'%AXXAjtAji
DTK AT ION
}'iUt/ s
MoniliR 10 Pays Hours
1)1' RATION
(SIG
0^
)\\iys Mofiths X f^avs I lours
NED ) i . Ob. Ua,>\» J iOJ:U^JLkL
M.D.
TC)0
(A.Mn-;s) Q% ■ \kkKSLM IO0^^VLla6
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq away from liome.
Former or ^ 4 w ^ •'"^ •**"' ^* 1 a
Usual Residence U/a^>a; J -aXVMXAwA^i^ Place of Deatfi ? »U Days
Wtien was disease contracted,
If not at place of deatli?
V N I)H RTA K i: K VA • Ia) . \| fUX^cWw- \ Lc
jS. B.— Every Item of Information ,houI.l b. cnrefully supplied. AGE Bhould be stated EXACTLY PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special InVormation for p.r-
sons dylnft away from home should be feiven in every instance.
m
111
* «
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
(■- ^7.:: 115:1' I'.,
I)(f
fr riJi'<l, iD.cttrWu H
rJ0\
Ji('o^is/e/'C(i ^\7>.
21 1
\H^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
^
?ri)
PLACE OF DEATH: — County oi^CLy^u 0 ^X).^xculx^o Gty oiO<X/y\j J Axx^>AyC.Uiycx)
No 1 5 5 0 ^ 1 a t^^ itxM. St.; ^ Dist.; bet. ^ and
/ ,r DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR 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
• All; I >! iu Kin QC^
JjlXt
KaXX;
\r :i!
I
I las '
A«,F
SINi 1 i M \K I-
iWriti- ill ^
lUK rui'I. \t"K
•St.i!> ■■! ('iilIlUlS
^
'i ■ .1 !
/',/
} !>
^
» \ I II J K
b
I'.iK inri, Ari".
Ol- lATHI-R
' "^tnt«' or Ci ill n!
M \im:x NAM I
n|- MoTHHK
iiiK Tiii'i, \» i-:
Ml- Mnriii: K
' "-tatc 1)1 t'mmt I \
-<fV"r.^^XX
orvTl'A'noN
■" 1,,?;. % M.~ii!U- \
Jhn
rm- .\i?(»vi: sT\-n.r> rKR'-.)\ \i, INK IK II. \Ks xki- rKri-: t<> tiii-;
iu-;sT «n" Mv knmw i,i:i)'.i: anij in.i.ui
niifii!lll;int
\^
<XKA><A
\.l<lr.
/vxl^
MEDICAL CERTIFICATE OF DEATH
DATK 111- 1)1:aT1I h \
(M.dltll 1
I lli:Hi:r.N CI-.R'ril'V, That I atteiicU-il dtCL-ased fmm
i9^ :3k
iDavi (Year)
tliat I last saw h -^A^ alivi' oti
Tip H
and that dentb nrcurrcil, nii the datt- stati'd ahnvr, at C>
\J M. The CAT SI-: Ol" DI'.ATII was as follows:
DTK A rioN
CONTRir.ri'ORN
DTRATION )V,/;-
(SIGNED) \A. (IIdAI fU J/CxxX<x ,a m.d.
)'t\irs^ Mont In 10 /><n.H' ^^ !lour.<
Mouths
Days
Hours
Special information only Jor Hospiys, institutions, Iranslenls,
or Recent RcMilents, dnd persons dving away froin home.
Former or
L'sucil Residence
When was disease fontrarfed,
If not at place of death ?
HoH lonq at
Place of Death ?
Days
HI \I, <>K ki:M< >\ AI, I I>A I
INllllK TAKI-
..! l',t in.u III KlvMOVAI,
y-t^
N B — fivcrv i.em of information should be carefully ^uppll.cl. AHB «houl.l be stated F.XACTLY PHYSICIANS should
ItateCAlISI. OF DIdATH In plain terms, that it may be properly classified. The ^Special Information for per-
son* dyinft away from home should be a«ven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2118
Ihf/r Filed , IJJ.'tiJ.xrU-iA^ H
ii)(n
lU'!^ I sic red jYo.
KJU^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of "Seatb
H. 5. 5tanC>ari?
^
Qn^
Ne.
PLACE OF DEATH: — County of^<V>v ^ Jyoj^x/^^JU^ City of C3<>^^^ 0 X/CX/wca^i.<^
^ilL iWoodL St.; i 0 Dist.; bet. - — — and ^
F«nM USUAL RESIDENCE GIVE FACTS CALLED FOB UNDER SPECIAL INFORMATION ' ' \
" - TT AND NUMBER. J
( IF DEATH OCCURS AWAY FROM USUAL H t » I U t n. ^ IL u . » t r«v,,o ^j V« V . « =T r . n n F ^TB E E"
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION OlVt ITS NAME INSTEAD OF STREE
FULL NAME
'^TcL
JLvou ^^X/CU'
a^xoJu)
PERSONAL AND STATISTICAL PARTICULARS
1
» ' . r I ii !;: K I I
IG
\i .1-:
U i i M .W 1- I > < »K II"'
Wilt. Ml -. M i:il .1- ^
HiK'rmi. \«'i-
>--l ' . . .1 I . !l' 111 ! \
M.),'li
Ik
1)
1 Sill IK
lUK rill'l, \i !'.
< ti I \ 11! 1- H
•^1 :it t I iT ( I I'll lit I %
M \ ii>j:n n ami-;
<ii MtiTIIj; K
niRTnri.M 1
«»|. M. Ill I IK
I HI ,,: ,! »(iu lit 1 \
»HH'» r \ I It ix
1
1
AVi'./'i'i/ /!» Si.'" 1 1 it III
Y.
s
\J..iil!r
la /-
Tin XHUVl- sf MID l'KK^..V\l, !• s K I' Ft T !. A K - A R !• TKIJ-: To Till-
lii-srm Mv KN' iw 1,1 I"' J- ^^" Mi.i.ii.i'
In fn: numt
x^Ap<y<xjy\yy^^K>
VHr... Le^j[K^^J^a.<i
MEDICAL CERTIFICATE OF DEATH
DATK ol- Dl.ATH j|
(Moiitlil (Day) (Year)
I If ^;I^: !■. r.N' Ci:kTI!'\', I'hat r altet»<kMl (UtxasLMl from
that I la-t saw ll-£>^^ alivi- mi SiJ ^CA7 I i,pH
and that death -icciirretl, on tlu' <latc state<l abnvf, at o
vJ \r Tlu- CAl SI-: Ol'" dp: A Til was as follows:
UJ-UAJtA^tL.K^
I )r RATION
)'t'<l>S
."Sloulhs
Davs
Hours
CoNTKIIUTOkV C^rY\.XX^'\^^jOLK^^r>r^
DIR A'PK »N
Ycat s
Mi^iths
Ihiv
Hoi,
; V
( SIGNED ) LUUKjuL M ll XcL^A.<mX>u^^ M.D.
Special information onlv <«r Hospildls, institutions. Transients,
or Recent Residents, and persons dying ,iv*.iy Iroin liome.
Former or
Usudl Residence
Wficn was disease rontrrfcted.
If not at place of deatli ?
HoH long at
Place of Death ?
Days
I'l.ACK Ol mKlAI, nK KHMoVAI,
DATJ'.of HiHiAl, or R1:M(»VA1,
0^ H T90H
O AXxXa./CX/'-vn^
ni)i:k lAK! u vXIaaT- ^— w- -I J,
N. B.-
-Bv.ry iten. of information .hould be carefully supplied. AGF. should be «.nted F.XACTl Y ^"YSiCIANS should
•tat« CAUSE OF DEATH In plain tcrm«, thot It may be properly classified. The Special information tor p.r-
Hon* dyinft nway from home should be ftiven \n every instance.
V\
pMa0^^
I
I
I •
ill
WRITE PLAINLY WITH UNFADING INK —
Dafr /v/rv/, U^ctVinX' H
IfHJ\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered jYo. "- * * ^
DEPARTMENT Or PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of E^eatb
0 (^ A ^
PLACE OF DEATH: — County oiOo.^ ^KCXA^^<^^ City ofOxXAV 0 /v<x.^>x.c^<^o
No
JIHS VJt
J t iXtJ^ Ua>X St^ ■ Dist.;betJll^'c'.\VCV<^ ■ and 1 aJ
J JK) ^.J^^ \J \^^ ^\J ^/— ^ ,,-,,*l orcinFNCEGIWt FACTS CALLED FOR UNDER "sAeCIAL INFORMATION ' \
( " r"o;iT°„"cc"u%rcV,"r„o"s^p"Tit o%'?:?,',?u"4';'"vr,4 name ,»s...= o. st^..t .no «u«a.». ;
FULL NAME
^VJ, I
•J X
PERSONAL AND STATISTICAL PARTICULARS
DA IK I >1 lUK fH
\ t . \-
\^ I IH i\\ Hl» »»H l>i\
Wiitf in ««iciiil «1« ^1
lUK 1*111'!. \i'l-
/',/
I »
0 1 '' ' ^
NAM I <»»
FATH 1 R
lUUrm'l.ArK
• U lArill'.K
^« iff or I'ount 1 V '
III N!i (I'll 1 K
lUK riM'i.Ar »■:
(»l M«»rilKK
I ^tatc III riitiiit t \
< Hi I I'A rH)N
bwu
kriAfii III ^ii" I
I ,1 I' ' ( 'I
>» )-.;
\r.,tiHi'
Ihn
VnV MinVKKTMl I'rKK-^nNM.l-Akrirn.AKSAKKTK! K T< > THH
jij-sT ni- MV KNOW 1,1 i'*-»'. "^^i' Hi.i.n.i-
1
v-^
^ cC'-^
11
ri
1
(X/v\,4."(:
' i
i
4-
MEDICAL CERTIFICATE OF DEATH
UA 11-. « >1- lil'.A 111
(Month)
I>av
(Year)
I III'RIP.V CI-RTIl-V, That I atteiKlf.l tkHiasctl fn.iii
to . V
0.^
1
U)0 » to V^'V'L' t> 190
that I last ^aw h '. ahvcnii L'ct -^ I90 ^
and that (U-ath (uuinrccl, nii the- dati.- <tati'<l above, at 1 I oO
H
>
M The CM SI-; Ol' Dl'.ATII was as follows
V^'X^^'\..<X,w,^A.A^fr ~v V.
^.A^^LA- ^- '.' : ^-C^
DlkXrioN Yi'ais A/oiii/is Pays ^
ay (?
_,. z,^kXjl J<X.<il^^ ^>xl./..
Mo)itln /hns M) Hours
i
or RATION
(SIGNED )
)'rijrs
Afoul Ms
/hns
r
ttWKx/>x^ ^^
„u
Hours
M.D.
1
I()0
(A.ldnss) ^iol ' t Itv. Lv-a
Special information only '«r Hospitals, Institutions, Transients,
or Recent Residents, and persons dvinq away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death ?
Days
IM.\CH Ol- HrRIAl, OK RiCMnVAI.
8 /Ow^CA.4X/^«:-kNj^ . t o
fAa,i,..s. \X\ ^^AAjU-^^^
DAri'.iif in KiAl, or RliMoVAI,
U'Ci* 5^ T90H
■""■"■""■"""'^ ... ^ ,. II I APF .hnulcl bo Rtatetl fiXACTLY. PHYSICIANS should
Bon
s dying away from home should be given in every instance.
m
Hi
II
»,
WRITE PLAINLY WITH UNFADING INK —
i'di 1 ^■'•
,'U\ \ ' ■>
Ihffr Filc^l, y tLcTVt>v H
ion\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Heciisfered J\^o,
^t:^-^^
X'VA-i.
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDeatb
PLACE OF DEATH : — County of '"'rv^^J J ^ o„ . x <: tc
C ^
- '. City oiOjX.^^^ vJAXX/vx <-^-
A ac
No
m 4 1
UXhX^ JL ^ V , ^ ^ ' St.; Dist.;bet. —
RtD IN A HOSPITAL OR INSTITUTION GIVE I
and
JXLifS -'^ '^ - ' ,,c,,a, RrSIDENCE GIVE FACTS^CALLED FOR UNDER "SPECIAL . N FO R M ATIO N ■ ' \
( " rF'|;:.°"occuRr/^^-"° "--^^^^ rR'?NST'Tu';'o";"aiVE its name .nsteao of street and number. ;
)
(\
FULL NAME
N
PERSONAL AND STATISTICAL PARTICULARS
li A I !■; «»| lUK III
St .J-
uo
/ i.
ID..'
m.
\'i .^^ I
n,'
•^IN'i.I* MAHRD-.H
\\ I I K i\\l 1 » ' >K ri!N< >Ki' 1".I>
Wnti ill -'( Kii ,lt -ii-HiilMii)
ISIK 111 I'l, \iT
' Stat' 1)1 I 'i it!!)ti %■
N \Mi- « n
1- A I'll IK
C
1^ TWA -\^(K'y\xjJL
1 I ' I '^
lUK riii'i.Ai}-:
OI- (A I' I IKK
I St.il I I il i'l Mint ! N
MAII)1%N NAM)-;
(»I- MoTHF.R
lUH rniM,Ai'i-:
nl-- MnTIIKK
<Statf (il CuuiitiA
AX IXAjl
\. X )
a
(M'v:ri'A rioN 3 p
Kr hUd III X;;,' /'/ /''■ />'-'
^tcJL^
n
0 ) >r? ' >
M,<„tlr
■niK NH(,VKvTATKPi-KHS.>VX...'AKTirr!,ARSAKKTKI-KT.)
IU>r »»l MV KN»>\Vl,i;i)<'K AM) Fu-.i.n-.f-
Till-
l.x.'..\..'-x\
/90 k
♦ Year)
MEDICAL CERTIFICATE OF DEATH
DAi'i-: 111- i)ix\ Hi X
f Month) (I>:iv>
1 iniKiil'.V CI'KTIl'V, That I attcii.U.l <Uh cased from
^WXu IH up^ to vJcfc 3 TooH
that I last saw h A.>>^ alive 011 U ^ 3. up H
atnl that dt-ath orcurred, on the datt- stated alx.vo. at ol
OL M. The CAT SI-: t)l- DMA'PH was as follows:
V
DTK AT ION Years
coNTKira lOkV
Moutin
/hns
Hours
nrRATION Yt'iirs Miniths /hirs
( SIGNED ) \l\- i)- --JO^Wl^^^U^-^
Ijct ^5 r()oH (Ad. Ires.) dt
Hours
M.D.
SPECIAL INFORMATION «n'y f«r Hospitals
or Recent Residents, and persons d>ing away Iron home.
'Il\<!L^UO
ospitals. Instiiiti
Former or y S^ \^ N®** '♦♦"fl ^*
Usual Residence ^^u 1 AxX/^vMl\A.c^ ^ Plare of Death
When was disease contracted.
If not at plare of death ?
Days
l'I,ACK «>l lUKIAI, <)K KHM«)VAU
DXriliif BiRiAl. or RHMUVAI.
19^ r
1 90S
..I %.r\= oUnt.ia k«« stnted EXACTLY. PHYSICIANS should
IS, B. ^Rvery item of Informal
state CAUSE OF DEATH In p
son* dying nway from home should be ftlvcn in every instance.
I
f
It
I;
I-;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTION3
.-• f»» V
Ih I \
Dafr /'V/^v/Al^t<jX^V H
HJfj'i
Be^istercd J^o.
J?
l<^v.^ Xa^x^H DeP^^y Health OfTicer
DEPARTMENT (IF PUBLIC HEALTH=City and County of San Francisco
Gcvtiticatc of !Deatb
No.
PLACE OF DEATH:-County oi^O^ O.X<X.vc^ ' Gty of ^^CV^ 0 X<xp..A^
7l'> \trrVJU St.: ^ Dist.;b€t. if>-^ and Oa,*XU,\,
FULL NAME tO/YYvXA HL
PERSONAL AND STATISTICAL PARTICULARS
I' I 1,1 I K
^^.
W<XA4
\< ,1-;
\\ !|i< .will '
\\ T 't" ill
a
) .
H
:!!>
! »
/goH.
(Year*
MEDICAL CERTIFICATE OF DEATH
HA 11. <•! i>i;ath /A
I n i:R I'.I'.V CI:RTI1-V, rhut r attcn<UMl .Idc.i'^c.l In.m
^ ^ - ,,w-)3. in ID/Ct H IC)oH
that I la^-l ^aw h ^-WValivt- nii '^ '^'^ -' IgO ^
aii'l that -kaih icciirrcd, oti the date <tato.l a1...vt-. at ^ '^''
M
Tin- CAISI-: Ol' DI-ATIl was as follows
in' I ^.•|•
t • \
iC^yU
.<X. W
d^
N \ M 1 < > !
t \ 111 \ R
rue rni'!,A« H
<•• 1 ATIII-K
M \ IJtKN N \M!
LKcu
lUKTniM, xr I,
<»! MMTHKK
I St;(t« I If (oiitJti \
^"^uU.
(Mill'
Hf iiU'ii 111 ^>i>i
41
M,i„lh
I-
HH^T ol MV KN..WI,1-,I»«.K AM> MLiM
»\JkX T T N.-'W^
S'M!i'>-s
X5 MriA.^Q.^^^A.^i'^v^
ClouJU ^aJXk^UUl W£Uj^Xd^
lit I< AI'loN
CONTKIHlTokV oU-OCLXOJU. >t ^^ -^
u^ .
(v
t
Months Day^
K.WA^V^'w
/%
I louts
M.D.
nr RATION
(Signed )
SPECIAL INFORMATION o"''* '"^ Hospitals, Institutions, Iransient*,
or Recent Residents, and persons dvimj «*»a> froni home.
fA.i.inso iDSy/aA;u>ti.^Bx<la
Former or , a u
L'sudI Residence ' <^w ^
When v*as disease contracted,
II not at place of death ?
IRUAUiA^vl
(Vwo-^
Days
l'i,A(:K OI- HtKIA^dK KHMOVAI. nA^lK ..f Hi kiai, .a ki;M«.VAI
Tf>oH
rNI»l',KTAKl.K
iA^..^V\.» ^i ^<
A.Mn--
^1 Qfy\A.4>a---,^
.^YX
N-4
■^— — I , .(..r „^i,,uit| be stnteil F.X4CTLY. PHYSICIANS should
1^. B.— Every i.«m of Iniormnf.cn «houhl b. ^""^^^''^ uTmri e pr-.^rly clo.-lflcU. The •'Speci..! lnform»f.o„" fer pT-
•t«te CAIIHI OI 1)1 ATH in plum terms, that it mii> »w pr<.peri>
'on. .lymft «w»y from heme mHouI.I be feiven in every inntance.
y
1 1'.
i, 1
;.i
3 .
I.
i
PH ,,,
Id
i 1?^*
I! -
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
PI OQ
H5s; 1- r,
llU>-^\.'
lOO'i
Bc^istrrcd JVo,
■L^v^lc^ Deputy Health oncer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
PLACE OF DEATH:-County of^C >.^ XC..vc...oGty of ^^u.^.^VC^— <-^
' ■ A , . ( St.- ^ Dist.; bet. 0 C^^vCyW and ^ CAX^
C IF DtATt' "-""oatn IM A HOSPITAL OH I N STITUTIO '^^ Uiwt
FULL NAME
.:.^ : >>xcyvv" K \J . ^
lU !
.o.^
PERSONAL AND STATISTICAL PARTICULARS
I
1. \ 11 « >i niK 111
Mmsthi
\' .j:
5H ,.
\vii>«i\\i:ii MR ii \ 1
niK niiM XT
I \ I I I I !.•
1UK 111 I! \' M
» >l 1 N 111 i.k
■-.till 1 1 riiiinlrv
M \ 11 UN V AM I"
»»i Mt»iin:K
lUH 111 ri. xi'i".
Ill Mttiiii: u
< nrri' Ai'ION
i : »
rn
(XhK^JLC
(\
n
^
xl. ^
0
MEDICAL CERTIFICATE OF DEATH
1, A ri-: I ti I'!' \ I'H
I I
,ct,
: Month 1
a.
n:iv
(Year)
I ni:in;r.V CI{RT11"V. That I attcn.UMl .UHva^d fn»m
190
'-\
t.)
0^ ^
Ti)0 H
lip
that I la^t saw h ' .in\^- •'»
iml that .hatli nrcurrcl, on the .late "^tatr.l above, at \
Q
M. The CAl'SI-; (»1' KI-.XTIl was as follows:
^^
-xt
V J^
niK \rioN
(SIGNED^
)"( i/rT
^
Months
Pays
i.C.^Vu ^
Hours
M.D.
)
TQfl^ (
Ad.lress) ^IH%^MKL&A.^C
) ViJ /
M.„ttli<
n,i lA
TnK^,u>vK.TvrK.MM^..o^^^P^KTHM^.,^Ks^KHTK^K m Tin-
in:sT..!- MV KN.'W I.TIM,!-; \M) Hl'.M'J
IiifnMn:nit
SPECIAL INFORMATION only for Hospitals. Institutions, Transients,
or Recent Residents, and persons dving away from tiome.
Former or
Usual Residence
When was disease contracted,
If not at place of death .'
How lonq at
Place of Death ?
. Days
l'I..\CH 01 151 KIM. OK K1;M<»VA!,
A4 UVO--^ ^
INDl-KlAKl-
DA 11: of HiKiAr. <.r Kl'.MoV.XI,
iD^ H T90M
,„,Ls Ibl OlrVx^.^cr>x. t\L
.,,0 1U
^^^g^^a.t^mmmmmmm^immmmm^i^^i^ii^'''^'^'''^'^''''''''''''^''''^''^''^ ... tatcd FXACTLY PHYSICIANS fihould
,. -^-^^-;-^^;;^a^. 1: -;:^:^ ^^t :^x:^J^^^ th; ''spec,. in.o.„-uo„'' .0. ....
f
5)
i-
I
7
til
11
i'l!
,11
WRITE PLAINLY WITH UNFADING INK
Mill •-.<: II. :ilth I N"
■*•»-■«- ---i, i;\ r »'
If^O^i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Be <! isle red J\^o. 2 J -^3
Ihfte Fifed, ly^tcrUtK. H
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of ^ Cl-^^
Ccitificate of Bcatb
^
City of^3,/CL/>^ 0 AXL/VL-eoMiXi
'fi^X^
kXA
SX-VuCi
ChiAvlL
Dist.; bet.
and
L^ ^^--*'- Y VAi y V^ U-\L/( U^'N-X-A^ V/ ^"t ,.'^oV»iirn for UNDER SPECIAL INroRMATION- \
FULL NAME
A
PERSONAL AND STATISTICAL PARTICULARS
1 ( 1 1. 1 Ik
1
.a
ll
I Mi.'itll'
,qoH
» 1 ar
\t .1-;
l'^
>1\< .1.1', Nt \K 1-. II 1>
W I 1 H i\\ 1 I > I »K I »:\ ' 'I" ' ! I'
lUH I'Hl'I, \>'l-
St;it. . i! I ' ilinl I
NXMl <M
I ATH IK
lUKTHlM.ArH
ni l-ATHI-K
■ll,!!! 1 I' I'l iimt ! s
M \iin;N N \M I
(>1 Mnl'IIKK
HIH rill'I.Ai H
<>!■ MoTIII'.U
I '^tiiti lit ("oinili X
MEDICAL CERTIFICATE OF DEATH
i)\ri-: (H di.atii
n
/,f
4
(Day)
TQO
(Vt-ai
H
I ni:Ri;P.V CI-RTII-V, That I atteii.U'.l ilccciistMl fmin
cLJaIj 5 i.pH to iD^ H icpH
^d.
fKD H
ttiat I last saw h ^>ri Mlivf on ^'^-^ ^ ^^O
aii.l that death occurrc.l, on the .late ^tati-.l above, at
lJL M. The CATSK OF DHATII was as follows
Dlk Alios Years
CoN'i'KM'.l TORY
) V</; s
MoiitiK ^ I Pays J loins
Mouths
/>,/ls
I lout s
M.D.
DIRATION . ^ ^ A
(SIGNED) %. i UaX^ ^
\j/^
(HiTI'STinN
tsr uifd III Siiii I
• 11,1 • .1
)'/il I
1/,.;,'///«
/),n
T,n-A,..,VKSTVTK,.,.KK...NM rVKT.;;,;;VKSAKKrKrH To TM,.:
Dl-.M- ol MV KNOW l,i:iM,l-. AM' l.l'l.ll'.t-
,„„„..« \XXdAA/v^^ fo(SA|vdQl
Special information only tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
How lonq at a q
Plare of Death? a*^A Days
Former or
Usual Residence
?
Wtien was disease contracted,
If not at place of deatli ?
I'l \CH ot HIKIAT, OK HI.MoVAI
I)A1 Ui>} 1^' KiAl- «ii KIvMoVAI,
iD^ 5- T90H
rN!)l-:KTAKl-:K
'""■""^■"""■"^T n^ AGB should be stated EXACTLY. PHYSICIANS should
atlon .houid be CHr«*ully suppi.ecl A^pB « ^ ^^.^,.^j, ^he "Special Information" for p.r-
4TH In plain terms, that U may be properly ciassiticu.
IS. B. Every Item of Inform
*„♦. CAIISF OF DEATH In plain terms, tnai ii mi., — k- ".-•
::„. d"nl .w"^ from horn, .hould be ftlv.n y .n-.-nc.
=«
••
y
?
i I
,1 , t II. ;i M
WRITE PLAINLY WITH UNFADING INK
rj()\
DEPARTMENT ^ PUBLIC HEALTH
/VMJ
THIS IS A PERMANENT RECORD
REFER TO BACK OF CFRTIFICATE FOR INSTRUCTIONS
City and County of San Francisco
Ccvtificate of Bcatb
1 X\, 'Z\ StanDarC* ;
i
■v,
m
PLACE OF DEATH: — County of CV^wXa >xce^
Chy of C' .<X >x J A a >vc c4. <-
.9
±
1^-
\
. , nr.-^ ^ i o o I J ( .c. St.: I Dist.; bet. dJA^^-cn-vAj and
No. 1^:^ tVCOLOO ,,=,,A1 BESIDENCEGIvr r.CTS CLUED rOH u4ct. SPECIAL INrORM.TION--)
( " rr'r-X"cCU%*Pro\"r„o"s^.yTll: r"-:"Tu"o';.".,VE ,TS name ,.STE.0 ». street .»» -.UMBE,. .»
FULL NAME J U^ -^.
( I
V.
■)
PERSONAL AND STATISTICAL PARTICULARS
^KoL
:iA'ii: < ii 1.: k ill
X < . 1-;
M. nth
\-h ,.„,
C
!':
M..„'h
L
\ : A\
IhlV
• \\ 1 it. in vtit ii 1 1 .•
■^t:it . . ' I ■' 111 lit 1 \
.11 )
•^ \ \t 1 I I!
1 A III l.K
niK 111 !M, \t i-:
«>!■■ I A ill l.K
(Strlti lit Ciiilllt 1 \
MAIDKX NAMi:
ul- Mni'IlHR
lUH i in'I.ACl",
(ii- \;» till I'lK
"-; it ■ . ! idii lit 1 'v
\J
\ I
IxJLA;
( »., r 1
\ 1 I'inA ft
' MEDICAL CERTIFICATE OF DEATH
DAi'i; <)i- nr.A.'i 11
^rX
')
IQO I
( Wat-
I lillklU'.V CI'.RTIl'V, That I altcndcl (Uctasctl Iroiu
i<p to -— r— — ~ lip
tliat 1 last saw h :ilivi- <>ii ~" ~ Ttp
aii.l that <Uatli ..rrurre.l, nii the date stated above, at — "
M. The CAl'SIC ()!• DI^ATII was as follows:
0 u
I )r RAT I ON y<'^^f^
CoNTRIl'.rTORV
Mouths
Pax
Iloitrs
nr RATION
(?0
) V<7/>
}[,<)! ths
nav
(SIGNED) JAXxLiXcek 0. UXVu^ ■
I fours
M.D.
*^'WCU
M,<lltln
rnUAnnvKSTATKn.KK.nxA, pxKT.r. ; ^ ;. H s A K ,.-, r R r H r. > r n .■
HI.STOI MS K^•<)\Vl,l.l»<.^. A^M> in.I.H-.l
I Iiifot tiiaiit
f Sd.lrt'Sf'
VxJUL
'-M
.^tr-Tv'
.t
Special information *»nlv for Hospitals, Institutions, Transients,
or Recent Residents, and persons d)in:i nwdv from liome.
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli ?
How lonq at
Place of Oeatti ?
Days
PI.ACH <>1 lU KIAI. OR R^:M<»^M.
Cj/CX/'^k^o
DAl'l .>t Hi HiA!. or R1';m<)VAL
190
rXDKRTAKl'.R V • ^
XXa^^-v d 0-C V
■-■—-'■■''■•'■'•''■■'■■'■'"'''''"'■■''■■'■"'"''""'''''^ .. . A^F »ho..l,l he Rtnted EXACTLY. PHYSICIANS should
,S. B— Every Item of Information .hould be c«r«fu.ly supp .ed ^^^F;;^;" '^^^.,,.,j. y^, ..g^eclal Information" for p^r-
Ktate CAUSE OF DEATH In plain terms, that it ma.v he proper y
lnn\ dying away from home should be given in every Instance.
I
i
I
RITE PLAINLY WITH UNFADING INK
Ihilr Fil(>(l, VxLe^^y-^^ H
lOOH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
PI ^^
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
1 Xl. 5. 'I'tnuDarD )
Q^
No. V;
PLACE OF DEATH-: -County of ^CV^ix<v>-^-^-C;ty of CW.^ J /..x/Y^^^
FULL NAME
i| UIK I H
- 1 \
It \ 1 1.
\i .K
-IN. i ! M \k h i '
W 1 111 'W 1 1 I I >K I I
\\ !i!. in — ; ' '■
|;ik llll'l \i'l'
\ \ M 1 I >1
I \ ! 1 1 i H
P.!K 111 !•!, \fl'
1 >| ! \ III !• K
S!:(t ^ ■ 1 . nut '
MMltl'.X N\MI'
<>I Mnllll K
iMi; rniM, xri:
Ml Ntdriii'K
-I il . . i! 4 ( i\l!ltl %
< M rrr A'l ION
PERSONAL AND STATISTICAL PARTICULARS
rt>i,<>k ^ ^ '^
UJJkAiji
,n
i 1.1
! '. >
)
MEDICAL CERTIFICATE OF DEATH
I) A I'l-; t »i I'l: \ rn .
i 1 I -
M. .'.nil'
I Hi;i^!;i'.V CIRTIIV, That l altcmk-.l .Ucea^cd ftuiii
u,c:t^ ^ I wo . t.. " TOO -—
lliat 1 last saw h alivt nii ~ I 'P
an.l that .Uatb .KHurri-.l, m, tin- -lat.- staU-.l al.nv.-. at
M. Tin- C.\rSI-;,()l' DI'.Alil was as follow^:
M , 111
a..
i
'i (M^Mxl ' \
y
,,! R.\ri(.N Vr^irs M'^»lhs Pays Jfours
UrRATloN
(SIG
0^
)'iiirs
Months
/)avs'
K.<X^
I lours
M.D.
'1^-1 ^
I ( )'">
AV /' ^ :ii ''-><> I
) > i<
M.oilh'
n,i\
■IMIl- XHnVKHTATKlM'KK..»NAI PARTirri XK- XK
I'.l-ST (H MV KNOW 1.1. lM,h \M> I'.l, I- 1 1 • 1'
i: IK IK i<> rn H
( 1 11 f' II ni.'int
>,/W
SPECIAL INFORMATION »nl> lor Hospitals, Institutions, Transients,
or Recent Residpnts, and persons dvini) dv*,iy Irom l>ome.
Former or
Usual Residence
Wtien Has disease contracted,
it not at place of deatti ?
How lonq at
Place of Deatli ?
Days
1M,AI-K <»!• mjKIAI, OK 1<J:M«>\ Al.
I r
1 NiuK r
)ATI'. Ill Hi Hi.^l. til Kl'.MoVAI,
— — -^ T^ Itf «hnul.l be *.tate«l RXACTLY. PHYSICIANS should
state CAUSr or DIATII in p ...n erms, th« jt m»> »»; P '
;r c;;iVroU;. ;:^- -.; ;;;;ouM Hc .^en .« eve., ^n...n..
u
,111. :0th 1
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS
JfUJ^
Jiro'is/r/'('d jVo.
^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
I u. 5. StanDarD )
PLACE OF DEATH: -County of'^ O.^. 3 ^<X WCV^COCity of
I
No.
. ,,1K,
f -k
w
■St.; 1 t Dist.; bet. J
A.' ..
and -
■)
FULL NAME
h
I ^ . \w^w'UW
U I
PERSONAL AND STATISTICAL PARTICULARS
t't ii.i ik
i < I.
|);iv
%< .1-,
-^iNi . i.i" ^: *> K 1 1 n »
V\IIi< »\\ 1
Uiitt ill -• . i . .
"-.I. it.
N* \ M 1 I > I A'N
I- A I iii.k ,
luK rni'i, \»H
(H I \riii-:K
I ^t:lti n !!t I \
M Aim' N N \M 1'
<>l- NHilHJ-. K
lUK rill'LArK
I A^tril' III i'omiti N
1
K<x'Vv^'-<^
MEDICAL CERTIFICATE OF DEATH
IiAlK ()! niiAl'H
( Months
(Day)
(Vcitt)
I Ill-.RI-P.V Ci:kTil-V, Thai niUc-n.U-.l .IcTiastMl fmni
that I la<t ^aw h alivi- oil ''^ ^ • up
aii.l that <Uath ocrurre.l, en tile .late slated above, at O '-■
Xx
M The CArSI-: <>1' Dl-ATH Nva< as follows:
w^
A
\ l.T^
't i
0 ^A
'» ^
k A\ H
U
-1'
A:
t ,
4'
LoJUvVL-V^o^t ■JxJ^'^d.
]
\ .
O^u,
1A 1/.'//
/»,M
<H.'Cri'A llON
T^KA,u.vKSTATK,M.KK.ox^. rxKT.rr..xH. XKKTK.K T.. Tin-
l',i:sr «)!• MV KMiWI.l-.lx.h AM) J'.IIJ 1 I
(ITI'
DrRA'PiON H Ytars
CONTKIHITORV
Moul/is
Day
Hon
; A
1)1 RAT I ON
)V(;;a
Months
/hivs
f Signed ) \I " -cxxu -^
flours
M.D.
iiJ.<£t S iQoH (Aa.iress) 3^-^^S>u>-
" SPECIAL INFORMATION only for Hospitals, InstiluUons, Transients,
or Recent Residents, and persons dyinq dwdv from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death ?
.. Days
I'l \CK OI' lURIAI, OR UKMoVAI.
\\.\\-
1 >.\ri". (it I'.S KIAI, 111 k I'.M* »\'A1,
nxtxhlLu. "^ . :>v.w^ ,
— ^ ——4 7- ~ Tgb should be stated BXACTLY. PHYSICIANS should
.. «--Hve..J^o.^.>.^:.on .h^ ^^^^;^ ^-^t ,..,,eH. classified. The ''Specif, .n.o..«tlo„'» .0. p..-
;r;d!fn'r«wa' frL ho.e should be ,We„ In .v«r> Instance.
\!k
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
11 rr
1 vn 1^ ^;:Sir-
[u'v!- c,
Be^isfcred JS^o,
o-i o^
l^^vo Icx^ Deputy Health Officer
DEPARTMENT OF PUBLIC IiEALTH=City and County of San Francisco
PLACE OF DEATH: — County of ^ A '^ • '
Cevtificatc of IDeatb
' -^ ' ■ City of ^ iW-VNiKArO^ >v , .
No.
St.;
Dlst.; bet.
and
(
' --^:\^:- -v'^:^^^ o-?;?f,?„=4=:'o,;er4 ^-m" -svr;- ,.%%%T;:rr:.*rr' )
FULL NAME
,<r\A>^
^^rVMr '
!,\
PERSONAL AND STATISTICAL PARTICULARS
A
n\
1
K.
I li i;iK 1 li
M..!iiU>
\l .1-
u .....
>.','.
\f ■ti'h
> I ;u
/>,/!
'A I \\>. ill -.,, i;i I il. -U-!',,ti.i!l i
MEDICAL CERTIFICATE OF DEATH
I, A iK < '1 ni'.Ai n
!):i\-
(Year)
f Month)
J lll'.RI-r.V CI:RT[I-V, That I attciKltMl .k-tvasfd from
to — — ^ 'Up ""~
— 190 - —
lyo
lf\0Lh.V<^ck
' 1 , '. ' ' 1-:
at.
\ ,
X \ Ml . »l
! Alii Ik
niR riii'i.Aii-:
^' ' I ', ,ti nt 1 \
iti M<»*rm;K
r,ik in I'l. \* 1-:
' .1 \!t If 11 IK
1 Slati; .11 ».'iiniit ! ^
11
\ % . .
M
J -v..
n.Cl'l'ATION
• \r,nith^
Ih-
in-sT 01 MY KN«>\\i.!;iM->-. AM> D-.i.ni
<I-; IKIK TO THK
(Infii-inntit
that T last saw h .^- alive mi
and that doatli orcurrcMJ. on the .late stated alcove, at
M The CM Si' Ml- I)l-:ATn was as follows:
DO . I i
I )r RAT ION )'t'iirs
CONTRlIU'inRV
Months
/hivs
Hours
DT RATION
(SIGNED)
Yea
H
Months
\^
f.\,l,lrvss)N iV-OCl
I lours
vt\j M.D.
SPECIAL INFORMATION ""!> tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dvimj awav from fiome.
r », «r How lonq at
Wtien was disease contracted.
If not at place of death ? ^ ___^
ri.ACi
•: (n lu Ki.\i, Ok ri;m"Vai
I) ATJ; 'jf li! KiAi, 01 HKM'»\AI.
T90H
VJct S
M.HRTAKHK Wvv^^^ lU^-^^UKto^^
0-\.^ tX>w>
(Adi'iK H*-
b ^^ ) Wo^^tj vw ..'.L
.. , .pF should be stated KXACTLY. PHYSICIANS should
N. B.— F.very item of in?orm«f.on should be c«rafully «"PP '^ ' ^^^"^ classified. The "Special Information" for pT-
. */r AllSI- OF DEATH in pliiin terms, that it maj l»e propcny
h'
it*
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2128
„,... 11.,.!. h IV.. - -■^;^«?^ H^rcu
Ihffr Filed, 1 tlcl-es ^
100\
Re<ii^l('red JS'o.
1^^^^^^ "l^x^ Deputy Health Officer
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
Ccvtificatc of Death
( tl. 5. StanDarD )
PLACE OF DEATH: — County of '^
City of^ CX
I'.
r^
• ^ _ \ \ ^ \.^^ wC
No.
^ tk lU
I * St • Dist • bet* " — — ~" ^^^
((fri '^
FULL NAME
\ I ' I w
^1 \
PERSONAL AND STATISTICAL PARTICULARS
ri»i.<»k
^lY
, I
ill 1 U i'- I I 1
M..iith>
1».<%
\| H
I car
/',
r M\KHti;i>
\ 1 1 1 " >H I » ;\ 1
1UK I'lIl'I. \>'»*
I n
-^k
MEDICAL CERTIFICATE OF DEATH
DA ri-, t>i- ni.ATii X
M-nth
h I
(V(.-i»r)
I in-:Ki;i'.V Ci-RTII-V, That I attciuk-.l .k-rL-ascd from
— — — i(p
■ . ■- Ttp
igo
to
tliat I la<t saw h ' alive on
,,1 that .li-atli occurrc.l, <.n thi- -late stati-.l above-, at
M MMu- CAISIC OI" Dl-ATII was as follows
ai
JXH. . . wCC .
N \M 1 < »1
I \ 1 n 1 k
lui- rtiri. \i}-'
ct: t \ I'll i:k
- • It. .,» I'mllltt V
M \ii»i;n namj:
»)1- MolIlHK
nil' Till' I, \iV.
Ml N;itiiii,H
I '^tati 111 riiuiltt yt
(uHTrA'l lt)N
Rf fdri! ni S,iii I
f-,n »
1/, <•///•
l',|-,-,T i>l M-, KN..U l,i;i".F'. \Mi 1. 1.1. 11. 1
I
H^^t<Jf
Q^ ^W.
Uw-A-
U A^Ok/ctL*.
1,1 RATinN )V;//v J/on/Zis /^<n'S Hours
roNTRim TON
I )r RAT ION >*"^''^
Signed) V^ V^ a-xia*
Mouth.
l\ivs
NED ) Ux^rAXlA, J.\^--UJ. Xl' A- - '^..
Hours
M.D.
V^' ( u,"
(A.iaris^) Uh^trrAjA^ vU^^MU.
" SPECIAL INFORMATION only f«r Ho^^Pital^. InstituHok. Transients,
or Recent Residents, and persons dying dv^Hy from home.
A
\ .
Former or
Usual Residence « - »- ^
When was disease rontracted,
If not at place of deatfi ?
HoH lonq at
Place of Death ?
Days
(Inff)' tn:mt
Kj^XM^-^JlSJ^ ^ tA
%^
A-Mit-H-^ ■
I'l \CJ' <»1' mRlAI-<»H Kl.MoVAl,
D,\Tl'ii!* HiHiAi i>r R1-'M<)\'AI,
lU
ct t
190
3,.:i..-,.<kkM-*-^^'^-
(AcMi.s^ WW
Qfiv
AAA-'
-^4
^-.^— 11—— — ^— ^■^'^"'^^''^*'^*™"**^"*'"^ 1 I K f t I EXACTLY PHYSICIANS should
state CAIJM- Wr Mir.« » aj^.h !n averv instance,
son, dyini away from home should be ft.ven .n every
m
w
11
4'lf
t ■«.
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n,:,;th l^No ..-t^-f^gJtiiHM'* .
Da/c FiJ('(L L/el^cKKU\; 5"
rjo\
I{e(^isl('rc(l jYo.
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of E^eatb
"5^
m
PLACE OF DEATH: — County of Cu^^ ^
\^
City of ^'/0./>^ JJXCVrv c:^ v
No. l"^ '
V' r"l-occ%%-v,':r.o"/r.t o^"pi^^4=:";r,;!
1 Dist.;bet. LoJv'
and >JC
V„- i
TS*CALLED FOR UNDER "SPECIAL I N TO R M ATI O N ' ' \
TS NAME INSTEAD OF STREET AND NUMBER. J
n Un
FULL NAME^^^^^^^^^^^^ Ua^^a-U^CXv-v J^J^CAJ
PERSONAL AND STATISTICAL PARTICULARS
roi.ok \
. \ 1 i • il lUK I II
\i .V
•^INt.l.l* MAKHIl.l)
U I IH i\\ }:i> i»K ItlV«tKri;i)
\\! i!. ill -i.cial (1> -iL'Iiatioll*
as
(Day)
V.ar'
/>(/! *
^
NAMl Ml
I A I in: K
d.
\ [i
MEDICAL CERTIFICATE OF DEATH
DATK «»1 UHATH , A
U 1 »
1 Hf'RI'HV CIRTIFV. That I aUeii<UMl .hi ra^cl fmiii
that I last saw h -tA' alive nn "^ '*P
an.1 that <leath occurre.l, on the- .late statcl al...ve, at U-HS'
.L M. The CATSIv OF Di'ATIl %vas as foll.ms:
A
lUKTHIM.ACH
01 I AIHKK
stilt, ,,; i',.unt:\
M\n»i;N NAMl
01 MoTllKR
I'.lKTHlM.All",
oi- MoTHl-.H
iStatf i>r C.xuittA
A>•^;(/c^/ III Silil ! I •:>'.
o
A.'^^ '
n^^A lIvwCUUlOv
y
r.
yr,.,iHn
/),n
iiKST OF ^lvLK^■<|\\ i.i:i)«'.K am) i5i-i.n>
nnforinanl
\)\R.\'nos
]'tijrs Mont/n
CONTRIIUTORV \k^x)(k/^ts^
/^iivs 3b Hours
DTRATION
Yiixys Mouths
\\\ ^ t i Ci
(SIGNED) UJ.^Aj "J^^-^^^^ V^\^-v
Pars
yc
1
I()0
Hours
M.D.
'SPECIAI 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 ?
HoH long at
Place of Death ?
... Days
1M,ACK <)1- lUKIAl, Ok KKMdVAI,
iJ.A'rK of Hrni.^i. fir KKM<)V.\I,
1 90 I
^»^*
ISDI'.KTAKHR
(
QLw'.
jl
' ■ TT TTf should be stated EXACTLY. PHYSICIANS should
^, B._F.ver. Uen, of ,nfor„.ation should he carefu... supplied AGE « ^^^^^.^^^^^ ^^^ ..g^^^,^, ,„,o,^,tlo„" for p^r-
state CAUSE OF DEATH In pin.n ^;•"^^; ^JT" ;',^";% nst.nce.
son. dyinft away from home should be fe.ven .n every msta
i
i
m
it
WRITE PLAINLY WITH UNFADING INK
11. ,;ni I ^'
/)n/r Fifrrf, kJ^z^jAm-K, 5
I !)()"{
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
V-AwN^O X^OVKJ fc^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of ©eatb
PLACE OF DEATH: — County ofO O
No. *^^ I: -^
^'i'.
,-~i , s c\ '^^ '" "i.
n
m
City of ^ ' ^^^ ^ ^^^
. *>^
u>
-V
, • ^ St.* ' Dist.;bet.^^^) - ' ' ^^^ .^
)
w
FULL NAME
) I
■ ) : \ I
Ui
PERSONAL AND STATISTICAL PARTICULARS
JX'T>XO.A
11
|» x 11 III I, IK III
A< .1-
I » /~T
.%!■
5 v.;
|);iv
1/ -iif/i-
\ ' ai
-^INt.l,!'*. MAKHir.n
wiiH »\\'i-i> t »K 1 > ;\ < >i' i 1 I)
' Write in «-<>i iai ilt -ir n..!ii.n i
HiR rm'i.Ai'i",
(State <»r Ciiuiitrv
\ wii; «»I
I A 11! I'.R
niR in f'LAiK
«>i- I- A riiKK
S!:i! I f i! I'l 1)1 Ilt I %
I .CLAXi
MEDICAL CERTIFICATE OF DEATH
DA I'K <»!• I'l-. \''"
/go
(Yvar)
^4
y
.
/^
^
Nt Mill's N xMi-; A) f\
<»I Mn fHHK y
lURTIIIM.ACK
OF Mi.llll-.R
f*^t;(!i . >i Simnlr\
<H vTi'A iion(1]\P (J
kr^Hinf 1,1 San liiiii'i^'-" '-Al)'." _
T.n^XM.>VKSTXTKl..'KR...NAKrAKTICIMARSARKTKrK T. > THE
in:sT()l MY KN«)\Vl,HI)«.h AM) Hhl.H.H
fin
vJ^YnXcO^
W'\,^<X''Vv>»
ixx-tixh.-
! ll!:ki:!'.V Ci:i<Tn-V, That I attcmU-.l (leceasc-a fnmi
• ; ,^H to . iD'^ "i 190 H
that r last saw h alive o„ iD'ct H up^^
a„,l that death «h eurrcd, on the dale stated above, at U H5
M. The CAISIC Ul* DliATII was as follows:
nr RAT ION >Va;-i
CONTRIIUTORV
Months /hns 1 1 //ours
nrRA'noN
(Signed)
iqO
}Wirs .)roN//is •A fhivs //ours
4 I '-^ \uu^s^ M.D.
A.hlress) Hbl U/CUvv mLuU. Uan^
(
^SPECIAL INFORMATION only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli ?
How long at
Place of Deatli ?
■ Days
ri,ACK Ol- IHKIAI. OK RKMOVAU
HATi: of HrKiAi, or RKMOVAI,
I90H
Q
„ ^ ,PF should be stated EXACTLY. PHYSICIANS •houid
^. B.— Every Iten, oi l„fo.«,atlo„ .hould be ca..fu..y supplied- ^«J^^ ;;;-„.,„,,. The -Special lnfor„,.tlon'' for p-r-
* * r-Aii«F nF DEATH In plain terms, that it may "c p
I 111
ill
III.:'
,111 I
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
04 m
\,<
t..t*^"S4-' lUSil' Cu
0
,VA^ Deputy Health Officer
Re^isfcrcd J\^(h
fi—^ •>
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of "E)eatb
( II. 5. 5t«nn^arO j
J?
(?!
No.
^ r^ ' - - r;tv of* ' CLz-^v Oxn 1
PLACE OF DEATH: — County of ,aT ^
( 4-
' ^ St.- ^ Dist.; bet. V,l,<XCYV-ft VA.. and ;^
V IF DtlktM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE :, 0 ^ ^
)
FULL NAME OvAC^<XC 0 a^xct:
x; :
PERSONAL AND STATISTICAL PARTICULARS
! Ill lilKlll
K I I I . I I 1^
V'
• Day)
It 111
\^ .V.
■^IM , 1,1- M \ K R n'i»
\\ ; i>i iwi .1 1 I •!< I) ;\ I •!■' r Ki) "^
\\ ■ It. m - .. Ill' <1' -iL''i,il\iiii I
■t--
MEDICAL CERTIFICATE OF DEATH
DA ri", til' Df.ATH
iM.iitth)
il):iV>
I go
(Year^
V->
I HI'RM'.V CI;rTII'V, That I altcn.lol .k-tvasc.l from
M^+ t
to -^ ^
L
c.^
r^ ' 11
HiR I'uri. Si")-: Q
^Inti ')l « '• in lit ! % '
\M1 1(1
\ ill I R
»_t„^ .
lUK 111 !■!, \» l--
< ii r \ III i;r I
--' i' . \ 1 . 1, nt 1 \
MAIUKN N\MK A
ni MoTIIKH \ \^ ,
lUR ruri.Aci".
Ml- MolllI'H A
'Stat, or t'onilti \ I \
t O.^w^wtj
1,
J L' ''^-
Mirri' A rmNrVYx
•t
r?
r * I
,^_ yA„>'W
rt
■^1 » i c
Is'f I, hi! Ill Siiii I I <i
}f,,iif/i-
Ihn
Tln-^m,vKST^T.u..M^K.n.^..^•AKTU■^^AHs^KHTK^K m TUH
l!I>r <U %U. KN<>\\l,i:i)>n-. AND hl.Lll.t
.I,if..nnMnt J AXdULKA.^ ^^r
that T last saw h *■ ahve on ^ ^' ^^P
an.l that death <.0(urre<l, .... the date .tatcl above, al 1 "X^
LI M. Thf CAT SI'! Ol' ni:.\ Til was as follows:
I )r RATION >>'''^
t ONIKllUToRV ^
Mil)! I /is
/Via
J Ion I s
(SIGNED) 0.-3 JlDO/vus^'J
/hiv
Uct
T()0
f
A,l,lrrss)Tbl U O-Ua
I /ours
M.D.
X<l.*_<a-
"special information on!> for Hospitals. Institutions. Transients,
or Recent Residents, and persons dying away from liome.
Former or
Isual Residence
Wlien was disease contracted,
It not at place of death ?
How long at
Place of Death ?
. Davs
I'l.ACH «)I" lUKIAI, OK KKM<.\ Al,
DXri'.i!' I'.iHiAr 01 K i;M« )\AI,
T 90
(\
%.
(A.1.1.L HH-tJi UJJLU^ u^--^^
— ^—^-^-^^^ i^— "^T"^"^"^"'"""^''"^"'^"''"^"^^"'^^^^ ... t t I FXACTLY PHYSICIANS should
N. B.— Bve.y i..m of i„Wn.,.lo„ .houl.1 he cnreiuHy -uppl^.d ^^F;;;;";,^,.',,:;; Vh: 'S.-^i;! InSor.na.t.n" for pT-
..».. CAUSE OF DEATH In -''""""••:;;„" „.r.,y in.«nc..
■on. .lyint uwoy »'»"' h""" «''""''' ^' *'""
1^
if
I
1
'«*
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
, , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered jYo.
, f,i i,i IX.. ■ - "^^-^^^ii V'^y '-' "
l;,,;,ri1 I ■ H<:! 'I li I ^" ■ *">■■> ^
Ddfc Filed, ^'.cl.ci>-t>\j 5
IDO'i
Of *\o
i ^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDcatb
PLACE OF DEATH: — County of
V
i(
,-->
- ' .. " ' Chy of^' O. ^■^ iKCXJ^X-^
No. ^
. o
n
St* H Dist.;betAfiKa.^->vO.>^ and ^JjAM^wt )
•^1*2 t..,= V...rn rOR UNDER "SPECAL , N FO R M AT.O N • \ A
F STREET AND NUMBER. • \J
'J I
(^■^
FULL NAME 0 ivt>v o
lav.
A
i I
V I
PERSONAL AND STATISTICAL PARTICULARS
Cm.c,
roI.OR \
.. V
^l
I ! \ 1 i; < ii hi K i 11
\< J'
M
1 1 1
/'.,'
-.|\i ,|.l- \1 \K 1< 111)
U 1 I >« i\\ 1 l 1 I >K ! I ;\t il-' !
Will' : 11 -I .< 1,1 1 11' ^U' !i.i; .
lUK rin'i. \t'K
•^t;it( . ' I 1 .11 ni I \
N \ M 1 ill
I A 111 l.H
\
MEDICAL CERTIFICATE OF DEATH
DATH OF 1)1:AT11 ' ^
i Moiitli I
(Day)
igo
(Yt-ar)
I III-Rir.V ri.KTII-V. That J alUiuU-.l .loH-asc.l from
to €ct X.
that I la^l-^asv li - alive-..,, ^' - ^ ^^ I
:n,a that .Kalh occurred, o„ the- datr ^tatc-.l abnvc. at \^. 10
Q M. The CAI'SI-: (»l' m;.\'ni was as follows:
n
J?
A \
<)| » A III IK
' "^tiitt 1 1! l"iiiint 1 ^
M MDKN NAM1-" 'N
(»l MC)Tin-:K
Hiu'riii'i.Aci:
<ii Mo'rin-K
I '-t.iti iir (.'<)\niti \
<«irr\TioN
^ r
' 1
\
0^4.0,0 ^' '
.ca
k_rx'
3
DIRATION y^-ors } Months \5 /hiys
C()NTRIl''l TOKV
I Jours
i ,
I )r RAT ION
(SIGNED) UJi»^
I/ours
M.D.
^00 y ^,
h'f-„/nf in S.nt /'■'"'■"'" ^ ' "'
M.^iith
I hi
SPECIAL INFORMATION only lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dvinq away from liome.
Former or
Usual Residence
When was disease contracted,
II not at place of death ?
How lonq at
Place of Death?
Days
I'l.ACK OF nt-KI^T, OK KHM<'\ Al,
jiXll ..! lu K!Ai. ill KHMOVAI,
igon
tS. B.
^^^^.^^^^— ^^H»"i— ^''^'^*^^™'^^ . I FXACTLY PHYSICIANS should
state CAUJ»E Oh UtiA •"'"»' Ajven In every Instance,
son, dylnft away from home should be fe.ven
nTm^mm^~
RITE PLAINLY WITH UNFADING INK
l)iili' Fih'<i . CJ.cX^^»-^^ ^
lUO'A
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'^^ ^\^
Dep
1 1
f^m%^^
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccvtificatc of IDeatb
I tl. 3. StanPatC )
: (X\ Si ^^
PLACE OF DEATH: — County of ^^x^ ^ ^^ty oi
No.
V\
loi
\ ' I ^><i'\v'.»'. St.; Dist;bet. ^^^ ^^^_ ..^^.e-At .NroRWAT.oN' \
I I
FULL NAME
kjjKl^. ■
i> \ 1 1 '
PERSONAL AND STATISTICAL PARTICULARS
I UXXa ■ -
UIHIII
/ ^
M..nlh
\ I ^ !
)V..'>
W n M iN\ 1 I > t tK DINc I'- ' 1 I)
\\l ill -11 -iH i.i ' (1< *iv 'I, It i' 111 '
A Y\ q
1 »:i\ 1
T ,:ii
V k.
■» C:!!
/';
MEDICAL CERTIFICATE OF DEATH
DATH t»I' Dl'.Al'H
M.mlli)
(Day)
{V«-ari
1 iii-RlM'.V Cl-.RTirV, That I attcn.lol deceased fnmi
to '-
u>o
llIR THI'I.AiK
• state or Cuiiiitrv
1 \ I II IK
1 ii 1 \ 111 FK
■ I nntt % I
M \ ' 1 UN N \ M K
• ii M(»iin:K
iMR riiiM.Ari..
Ill MoTHl-.K
0
(J
T9O A
that I last saw h .. ■ alive on ^9©
a„d that <leath oreurre.l. on the date .tate.l above, at
M. The CATSi: OV DI'.ATil was as follows:
nr RATION
(SIG
Ycors
Months
Pavx
r
.^
NED) vO H I VCXMiA,*^^
LJ.dt. 'h TooH (Addnss) SC^SD^^v-
//ours _
M.D.
( )t rr 1
■ATloN 9 I
hCf^iiifd in Siiii I I ..
ka r
)/, ;'• ,1
n
ni-ST<il- MV KN<>N\ i.l-rx.f-. AM) I-M-'ll
flufn-matit VD M iVoA^
■ c^prCIAL INFORMATION onh for Hospildls, Institutions, Transients,
or Rercnt Residents, and persons dying away from home.
II
Former or \ \ i
Usual Residence Uw^.
Wlien was disease contracted.
If not at place of death ?
tiew lonq at
Place of Death ?
Days
)\ii: .)!' JUKI A I. 'ii K i;m< >\ Ai,
IM ACK ()!• HIKIAI, <>1< KJ:M<»\ AI,
\ilillr^>
^^^^„„^,„— — L^i— i ■— — FX4CTLY PHYSICIANS should
state CAUSt Of- UtAin h ^jv-n In every instnnce.
son. clylnft oway ?rom home should be fe.ven ^
I
I H-;<!th 1- V"
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
, 1^4^rv::^■ i!5^i'«--,
ino\
JiriSisfri'od Xo,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
11. iT'. StauDarD )
PLACE OF DEATH: — County of
h
^0,
City of ^^<^^^^ '^"^
(> .
1 I
No. S ^-
4 C* . '^ DUt • bet. l^ ' ^"^ '
^ ' ^*** UlST., Dei. SPECIAL INFORVATION- \
)
FULL NAME
^t-4XA^-K>cA-OL K\)<x/:^
f
PERSONAL AND STATISTICAL PARTICULARS
( ■ ( 1 1 • I K
■,,,■' ^ ■
1 I i! !.; K 1 11
M-, lit hi
li.c.
■»■< ;i!
\t l".
-;\« .i.i".. MARK n'i>
U IlMiWKD OR 1)1\< 'H- 1 l>
W"! iti ill -.xi;!] (h -il-IKltl' 11 '
H lloJv^A^wd.
MEDICAL CERTIFICATE OF DEATH
(Yearl
Month) "'•'>'^
I IlI-Rl'liV eivRTII-V. That I aUeiuk-.l lUTca^cd from
f, ^5ct S
lip
! H
luuriiri, \v'K
\ \ M ) ' n
1 \ III Ik
niH riMM, MK
<»I ! \ 111 KK
-• ', • (-..nnti
(>i Mi)Tm:K ^ il
lUK IHIM, Mh",
It! Miiriii: K
(Stat.- ' 'V ( oiitUi y
M
f\
1 (1
^
1
I«;0 I
that I la'^l -^aw h .£A> alivr on ^- ' ^ ^^^
,„a that -Uath nrcurrc.l, nn the date stated above, at "V I U
' M The CA^SI^ oF DKATIl was as follows;
I )r RATI ON >'''<7r.s-
CONTRIIirTORV
Months
Pavs
J Jours
or RAT I ON
(SIG
♦
)'t'ars
.iroNf/fs
Pa vs
i.
Hours
M.D.
T()0
(A. hires.) H%^vjX£_
«5PECIAL INFORMATION onlv for Hospitals, Institutions. Transients,
or Rerent Residents, and persons dying away from tiome.
r\
- •\!,<iitln
fhn
lU-sT (>! MV KNoWM-.D'.H AM) lU.I.H.l
LkxxxjLju
IS'^jS obcr^^^xX-^^-^ -^^
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatti ?
I'l \CK <)I- IMKIAI, OK Ri-MOVAI,
>^' ■ ;\ ,
tfoH lonq at
Plare of Deatli ?
Days
DXll ,,' I'.iHiM. Ill Kl%MOVAI,
T 90
\
:A(l<h(ss
— ^— — ^— — — — FVACTLY PHYSICIANS should
^
WRITE PLAINLY WITH UNFADING INK
1 . . * ' t 1 1
!)ff/r Filed , w'/cto'lMA. b
/.96>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
0| or;
^'k.'.^<M
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of Bcatb
11. jT'. St an Da rD
^
^ \
^
" a.'YX) ^
No.
PLACE OF DEATH: — County of
'-T-C ^^ooj— ^1 ■. St.; '^ Dist.;betA;/anrv
' ' /.o^TH%cp...*v.:v..o. USUAL RES.DENC^^^^^
V ,r DCATH Occurred IN A HOSPITAL OR .NsrnruTioN GIVE
i ^.O.-^ vo^ ^r City of CJ^a^ J^^^
and J^UXnoyK-
1
Kuub^
eNCE a,V. .ACTS CA.LCC, -B_ UNOER : -JC - «. J -OR M AT.^O . ■■ )
FULL NAME
)AX
PERSONAL AND STATISTICAL PARTICULARS
( i >].' 'k
A
\
a
1 I •! nik 111
fXnX
If.iv
AHH
, )■:
U.
1/
/'
--IN' , l.K %! \R m 1 !•
W'l it- 1!) -I, i.il .!■ -■:•
III !'l. \i'K
\r\ „
X v'v^^^
MEDICAL CERTIFICATE OF DEATH
DAfK nl- I)i:\Tll I p.
I'Month^
(Vrar)
I Day)
I II1:r1.1JV Cl.KTIlV. Th..t nilten.lca ikTcasea fnmi
tlmt I last <awh^..- alive nn ^^ "^ ^^P "^
a„a that drath occurred, nu the .late stated abnvc. at
ID
CL ^T- 'II"-' <^'-^^^''' **'' i>l^\'l'l^ ^vas as follows:
\ \ M 1 Ml
I Vi II IR
lUK in IM, \CK
ni 1 \. ! H 1-;H
MAIDl.N NAMl
nh MdTIIHK
mK'rmM.Aci',
OK n!uthi:k
'Htati- or Ciiunlt \
(\
<X.C<TU'
\ ^
ns
\
J^^<XMJU ^^
i ri'A'noN _9 j\
kxAAajx
\ ', ,;
1/ ,','/!
hi:-.'!' n|- MV KNuWl.l-.IK.l-. \^" H1.1<n>
(Iiitonnant \J3 ■ KKJX. - ^
DIRATION 3s )V(/;v
CONTRIl'd rokV
Mouths
Ihi\
'V
IIOHIS
DIRATION
(SIGNED )
Yrars Mouths
Pav
Hours
M.D.
Ik)^ L Tc)oM (Address) bo^UX-<X>UM - ^
SPECIAL INFORMATION only for Hospitals, Instiludons, Transients,
or Recent Residents, and persons dyinq away from fiome.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatli ?
How lonq at
Ware of Deatli ?
. Days
|i N "i
T90H
(,
N. B.
^ I FXACTLY PHYSICIANS Bhoulcl
State CAUSE OH Vi\.^ 1 n n h ^Uen in every instance,
sons dying away from home should be given .n e e y
i
I
I
I ;.:ih I N.
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t- -w i4,> I'lS:!' C'l
Be^isfered jVo.
01 *V\
\ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
I I ^
PLACE OF DEATH: — County of 1 iVoxcUcc.x^o
City of
3 C 1
No. OLcxXl
St.; -
Dist.;bet. "~
and
)
JU ^^ OVL.,V^^^CX. „ro.,^VMrrr,vr rACTS*CALLED rOR UNDER •SPECAL .NTORMATION' \
/ ,r DCATH OCCURS AV^.V TROM USUAL « ^ f ' J^^.^JV^^^^' "o", v^",;! NAME .NSTEAD OF STREET Ar.D NUMBER, )
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ^
FULL NAME ^v"ootv v.L
PERSONAL AND STATISTICAL PARTICULARS
\
, K ill
14H
M,,iithi
iiO ,
M \ K i< I J ; I »
W I 111 i\\ I i ' < Mi I>I\'< >K 1 J- l>
\\ ' in in -' I sal .li -if n,il ;> iii i
MEDICAL CERTIFICATE OF DEATH
DA 11-*. *>1- 1)1, A in
\
u
(Yt-ai )
r Month) 'l>-''y'
I lll'RlU'.V C1;kT11-V, TliMt I atU-iukMl <U'iH'ase(l frmn
r.iH rni'i, xi"i'
sfatt .It I ^ .unt 1
\ \ \n til
1 \ I II l.K
I'.iK 1 n I'l, \* K
1 ii » \ riii-.K
■^1 iti III rimnti\
, 0
1
i
^
MMlil-N NAM!'
«i| M.trilKk H
HIK rillM.Ai i:
111 MiUlll'.K
'^i:ii. Ill I'liiinlryt
^,
clA\j ^ ^ '^
r,-.,'»
yr,n,ili^
/',/!
tK iTI'A ll«)N
AV^ /<//-</ ill Sail I'l.ni. ,
Ill-.SI-or MV KNMW l.1.1>''l'. ^^1' I'l I'l'
( Infiit mini
up to - i<)0
that I last saw h " alive- (in ^'P
aii.l that <Uatlt nccurre.l, on llu- .late stat^.l al.nvi-, at
M. The CAT SI- Ol- Dl'iATIi wa^ as follows:
nr RAT ION Vans
CON ikiiH rokv
■Von f /is
Jhiy
Hours
DlRAriON
i^
Vfars
M, III I /is
J\„»w N W.J
/^avs
(SIGNED) ^ --. - , ^
iD^ ^ I.,oH ^AM.lr..HS^ IIKAXX>
flours
M.D.
y
"special INFORMATION only lor Hospitals. Institutions, Transients,
or Recent Residents, and persons dyin) dway trom home.
Forfflff ar
Usual Residence
When was disease contracted,
If not at place of death ?
HoH lonq at
Place of Death?
Days
I'l^ACK i)l- lUHFAI, nu KI-.MoVAI.
!)AT1". I)! r.i Hi.xi <ii KI'.MOV.M,
T9O
y,ct
tn2 frvu. \A.-o-\t.<i' « ^
^—^— ——— —■#■—'— ^"""^"''^''^"^'''"'^'''''^^ , , L t t I EXACTLY PHYSICIANS should
""•/.Mn^Lny "'™ hi. Should He ..v.n I y .n...nce.
I
1
w
RITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/),//(' /'V/fv/. Jct<AM^ b
LAv
IfJO'i
Bc<^istcred Xo.
Of •^^
V
-I •f-N nffi«,
No.
DEPARTMENT 0^ PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
< XX. S. 5tan^ar^ )
PLACE OF DEATH:-Coun,y of^O. .x -^ - > ■ ^cc City ofOa^ 0/^^ - -.
• "> ■ 1> s K - i , , - - , St.; 1 Dist.; bet. O-O.^X^UP'^^ and ' OJaXA-A.
(57^
)
FULL NAME
a
i .. I
PERSONAL AND STATISTICAL PARTICULARS
i
i
M n! h I
0
•. arl
U ! It- in -. I. ial il.^iufiiatitiii)
HIK S'lllM. \i'l%
^' 1 Hint t \
\ \MI* OF
I A riij.K
HIK lliri. AiK
oi 1 \ 11! I'.K
-itatt I il I'lPlUlt I \
M \I1»1'N NAM1-.
<»1 MoTIIJ'.K
i;iK 1 iii'i. \ri-:
^^t.iti .11 ('uutstry
nm I'A riUN
MEDICAL CERTIFICATE OF DEATH
DA IK ' ►! Dl'.A lil
3
Dav)
(Vtai >
iD.ct
I lll'.RIU'.V Ci:kTll-V. Tiial 1 attciidcl acH-cascl fmiii
that 1 last saw h .L.-.,xa\\\v on w.. Cw ^ I90 \
aii.l tliat <Uatli ..rrurrcl, uii the -latr -tati-.l alM.ve, at
.M. TIk- CMS!-: Ol- DI'-ATIf was as follows:
Xx^'
nrvwt<uvXu I
rVYX, ^MJ^C^w^^>^^
)Vin
M.iitli-
Ih.
TMK XHUVKS. XTKlX-KKsnXAI rXKTj.rj.AKsAK.: TKt K H. THH
lu-sr or Mv KNo\vi.i;n«.K A\n Mj-.i.n.f
(111 I'' p- ;nant
r\(i(iit-«»«
it
Ur RAT ION Viiifs
CONTRIlU'TokV
Months
/hn
I lout
nrRATioN
^
Years
M out lis
Ihiv
( SIGNED ) J . ^. ^ O-dJr^rv^
J Jours
M.D.
ID.^t
T<)n
f Address) aos-bo^g/Yxtv^JUL^
SPECIAL INFORMATION only for Hospitals, Institutions, TranslenH,
or Recent Residents, and persons dyinq away Iron home.
Former or
Usual Residence
When was disease contracted,
II not at place ol death ?
HoH lonq at
Place ol Death ?
Days
rj.ACK Ol- lUKIAI, OK RKMo'^ ^
DA ij: '.* nt HI
M ..I ki:movai.
• igo
-_————— , ^ ,, , 77p .sould be stated EXACTLY. PHYSICIANS should
.. -.---'>-'- totzr^n^:::^'' "^irr. •::'::^:t. J^U -..w... t.. ■•«,.«,., -..o..>...n-. ^ p...
state CAUSt ur ucrti" w ^Uen in every instance,
sons dy1n4 ov.oy from home should be g.ven .n every
3
I
J
(
^,:th FN
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
JJ
0
10()\
4.^, J^^l
Bp'> isle rod *jYo.
Of *>Q
' ccw
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificate of IDeatb
i
(^
No. ^uti.y "X Urury\ti.i .' V 5 ■v,', v. l- r (
^
\
(^
FULL NAME axxaa^\x v<u. UlV
c'wO..
PERSONAL AND STATISTICAL PARTICULARS
ri»l,«iK
vVio
U
}"
H
\« ,i-;
1/.
/',/
WIlHi -K ! i;\»»Ki 1*. l>
(Writ. .ii I. -ii^iuuioii)
^!;ilt . it 1 • iillit I %
w/V^.
■\ '
I \ I 111 K
lUHl 11 I'i.ACK
<u I \ihi:k
^1 '. ■ ('iilltltlX
MMDKN NXMK
<i| Mt»Tm%R
iuKiiirL.\ri.:
<»l MoIHI'-R
iSlal< •>! r<»untt \
(0
Kj<r\X^-^^^ L'^CC^,'^
( 0
nil ri'Al li»N (T)
I
ll
MEDICAL CERTIFICATE OF DEATH
DATK «»!• 1)1;A I'll (^
(Month) "»^'>-' '^'^''"^
I I1I:R1';P.V CI;RTII-V, Thai I atU'n.UMl .U-ic-asctl from
i;? ' .. 190'. t.) V/^ ^ lyoH
that I last saw h - . alivc.n ^^ 2, I90 H
aii.l that .Ualh ..rcurre.l. mi tlu- dali- stated above, at
J M. Tlu- CVMSK Ol- DKATH wa^ as follows:
DlkATION Vinrs
coNTRiin rokv
(SIGNED) J '^V
Mouths
Davs
Hours
Motiths
/><jrc
H Tc,n
H (Address) uXuV^
ORMATION only f*"^ Hispitals,
1 1 oil Is
M.D.
0\o
kf.ntff i>' '^.Z'' ^
,^ 3H
lA^i/'/;
lh!S
T,n-xHnvKsTvrK.MM.K.<.NAi.rxKT.rr|,u<.xKKrK.K m thh
liFSTol MV KN«'\VI.i:n'.F \M» MI-.lJl.I
(liifoMiiaiit VJ . V ,
,T»
n
fA.l.li.'ss VaX* M
Cv-an
SPECIAL INFORMAT
or Recent Residents, anl persons dying av^aj- from home
Former or ^qXI « a
Usual Residence 0 aJK. '>-'>rs,i^
When was disease contracted.
If not at place of death ?
Institutions, Transients,
How lonq at
Place of Death ?
Days
()\ I K Ml in iM XI ..r KKMOVAU
IM.ACK OI* HtKIAI, «»H KF,M'>VA1,
rSI>l-RTAKHK UXM^ ^ V^' '^
I90H
? 1
■■^^■■■i^B^—"^^"^"^"'^'^""*^^"''^"'"^^^^""""""^^"^""""""^^"^^^^^^ I, I I H t ted BXACTLY PHYSICIANS should
:r.''H"„?.Z from h„,no ,1.o„.d be f.v.n in .-,., in.t.nce.
r
I
J
I
R
i m
WRITE PLAINLY WITH UNFADING INK
,1 ..1, i- v., ; ; ^fi"^**^^;; HN I* I'^-
Zz^/^' Fi/n/ , L.'C^>W-^^ ^
If^O'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR tNSTRUCTIQNS
Of «^n
Me (filtered ^\o. <^ ' '
DEPARTMENT^OF PUBLIC HEALTH-=City and County of San Francisco
Certificate of Beatb
PLACE OF DEATH:
'^ - J /wCu-rV/CL4C0 City of 0/CX/>V 0 \.<Xtvx^^AXU)
-f ^
County of Cl/n^ J /V0.^V/C^C^ City
No.
oa
(
iV i st« "^ Dist.;betM^^^iuV>v<vm; and ^O^OWYVO; )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
m
1 111 K 111
0
VVJU
10
/ boJ
\t .I-
b^
?. ,,..
as
/',!
W I ; II A 111 » >K I »'\< »K(' K l>
\S ; ,:. .u ' .1 ;;il <\- -• vnatmil •
X^
vUxl
MEDICAL CERTIFICATE OF DEATH
DATK <'i' i>i:ath
1^
5
Dav)
(Year)
>. I in;Ki:i>V CI^RTII'V, riiat I atten-Uil .Icccased from
that I last saw h ^^^^ alive on ^ '^^ ^ '9° ^
an,l that death nourrcl, nu the date statr.1 above, at bAu
' M. The CAT SI* Ol* DI'ATII w.i-. a^ follows:
lUK riiri.Ai'j-:
Stntt < n t ■' .lint I \
1 \ III IK
lUK I'll I'l, \i }■;
«M I \ 1 II IK
'-^t itl I 1', I'l lllllt ! %
M \ii>i:n' n ami:
i»l .MmTIII-.K
HIK rniM.Ai'!'.
<t| MolllKK
I stall nr i'«)uutr>
1)1
IC^L^acK^^CLt
Lkkjb
\\j
«KCtl'AlH>N ( k! 4_ I
Rfiilfif ill
V,;,, //,,'/,"/•"• » \ ' "^ ^
lU-.ST ni- MY KN«>N\ 1-1 l><>li AND Ml.l.M t
(Infiit manl
e.
Adtln—*;
HOI
oJ ^^t
U J^^Xi sJ
Cj-jL'V-s-a^Aa.
DIRATION
}f.>>iihs
ill K A 1 I* '•> ' ' t'at s
CONTKMUTOKV ^^J^.^|^
nr RATION ^ )V</rv ^ -■'^^'^^^
&, U.,
/>^rv.v
//ours
nav
/loii
rs
(SIGNED) yxrrvxM
M.D.
lUd, ^
t
T()0
(
Address) \l% ^hjQ^^ U. .' .,
SPECIAL INFORMATION only for Hospitals, institutions, Transients,
or Recent Residents, dnd persons dying away from liome.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
HoM ionq at
Place of Oeatli ?
Days
IM.ACH OJ" lU KIAL, t»K K1;M(>\ M,
'Hi
r N" I > 1
KlAKl.K VV. vO
DXri.ii! I'l 1 IM i>i Kl-.MoVAl,
T90
A,
A^ Yx. '• V
.,,,,„. s %\'^ 0' T^rUvAJtUrlt,
,. , 77, ,houl<l bo .lnM.1 RXACTLY. PHYSICIANS .hould
N. B.— Rveo ...n, o* ,„,,...n„,lon .h„u..l be c...u(,.M, -UPP -I. A^f. . ^,__^,,^.,^, ^,. ..g^.,,., ,„,.„„„..I„n" lor pT-
..-.c CAlISi: or DIATH In p ...n ""••• ''"•'• "'^t .„.«„«.
""„';-.;:,»„««; *-- h„,„e »H„„... be »«v.n > .n.t.nc.
I
f
4
I
t it
WRITE PLAINLY WITH UNFADING INK
:i n
'/otxrl>-U
^. b
7-9(^A
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
p< to
Bco'i.s/crrd Xo.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of !Dcatb
( XX. 5. 5tan^al•^ )
PLACE OF DEATH:-County of^^^ iMx^x^v^Gty of Oxv^v J/v^x^c.^^
0.
T«^.4lUX\.A.-rxi Ut '
, ^^ ^ ^4 N V ^ t o \ St.: Dist.;bet. ^ ' and
*^ TX>v JV. V, , orcinrNCE GIWE FACTS CALLED FOR UNDER '■SPECIAL INFORMATION' \
( '^ ^"o7AT°H^OCCU%*Rro\;"rHo"s".rT'lt 0^'?^?f.?J;^0^'^C^7Ts NAME .NSTEAO OF STREET AND NUMBER. )
f)
FULL NAME W^
/cxxva^
-IX
PERSONAL AND STATISTICAL PARTICULARS
.1 l:,K III
V
A.'r
\t.l-;
-r,i ,1.1 \t AK l< 11" I >
Wiiti in 'iijcial lii -n'li.it i' n
Ii.\
.1/. >i'/i
i I ,1!
fhlV
MEDICAL CERTIFICATE OF DEATH
DA ij', «•! in.Ai'n
' MnlUll'
(Day)
fYciiri
I lli:Ui:r.V CI;RTII'V, TUm l .ittin.lf.l deceasetl frntii
\ ■ ^ ..^ to vJ /CA/ 5 i(p H
up
that I last ^a\v hA<'»N alive «>n
190
W .
lUK riiri. \c]-.
V • , • I '. iimt I \
I A III I.R
H I R I 11 I ' I , \ » * J-:
Ml I \ III \ H
-•\ ,' ' ' Ti 111 lit 1
%! MDl N NAMl-:
itl MmI'D) H
luk riii'i.Aii',
tMii. .1 t'onntivl
dtcKvkkcrVrN
^1 .< p '^
\v.
1)1 ri PA IION Jl
n \- ,, I 1/../////
/>,;i ^
Tin-: \H..vis sr\rKD i-kh^.-nxi, i')'^ ':|:;',!:\'^
in:-.r<»i ^^v knuw 1 i-ix.h and hi, 1,11. i-
i 1 n |. li m tut
<s \Ki, I Ki K r<> THJ-:
au.l that <U'at1i nccurred, <.n the .late state.l above, at -
J M. The CAISK or Di-yril WHS as follows:
vj
K.
LxX^.C'^^"v^^tr>"v^xx;
a i^crrvvou^J^
nr RAT I ON* r^<7/^
coNTkiiurokN'
.)/tU////S
Ihns
J Jolt I
Vctirs
A
1)1 RAT ION
(SIGNED )
0/ct L ,00 H 0
A7l'S-
Hours
M.D.
SPECIAL INFORMATION ««!> •"•■ Hospildls, Institutions, Transients,
or Recent Residents, and persons dyinq awa) from home,
i-„«»»r nr HoH lonq at
When was disease contracted,
If not at place of death ? ^ .^_^
DVTi%"' I!' HIM -I ki;m«)Vai,
CMiixA
I
rNDKKTAKKK U^>^^i^^ OQ^VCUaIo XA
190 H
'— — — — — ■"""""""""■""■"""TT r^ AOF HhouUI bo -tnte.l RXACTLY. PHYSICIANS should
N. B._,.vcr. Itcn, of I„for,„..t1on .houl.l he cn.a^ully «upp .e • A .r h ^^^^^.^,^^^ .^^^ ..^^^^^,^, ,„for„,«tlon" for pT-
. #„ r\ll«r OF DtATM in plum terms, that it vnny ne prnp»^ ^
:rn; ..>CoZ .rL hn,„. ...,.ul.. b. ftiv.n In .v,r, .-..-nc..
I
m
1
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
- c^^'^i.iKS.irn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ii i N'
I)Hlr riled, i^,ct<rt^^ b I'^O'i
l^cru./^ ioLA>u Deputy Health Officer
DEPARTMENrOF PUBLIC HEALTH-=City and County of San Francisco
Certificate of "Death
( XX. 5. 5tanC>avD )
PLACE OF DEATH: — County of
\1jUjJG-0j
City of
H pi
CkK.^
No. -
St.;
Dist.; bet.
and
M USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
M USUAL HtaiUt..^«-t K. .....r NSTEAD OF STREET AND NUMBER. /
/ IF DEATH OCCURS AWAY FROM USUAL H t a 1 U c --• «- "^ ^ • - •- ^"--^ « A M V .
( fr DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME .
FULL NAME
-;4-
'■i
V.
!> A 1 i: I 'I luk ill
PERSONAL AND STATISTICAL PARTICULARS
i(iI,<»K
>1
yvyy\yC-
,170
M.ti'h
A< , 1-,
■-1M.1 i; MAKkH !»
W I 1>' >U i;i> I »k I >IV< tK*. K I)
Will! in -1,1 I, i' !■ -iKHttli'JJJJ
1/
\ ( ;il '
Ih'.V
St, ill (ii ( 'i 111 nt ! \
N \\!1 III
lA 1 n i;k
lUk 111 ri, \^ v.
( il ! \ 111 IK
■^1 l! I 1 i! I'l lU till \
M Mill- N N WIJ;
(i| Morill'K
liik riiiM, X( 1-;
til MMTm'K
' Stati Ml Cnuiti ^
I HA I 1' xrioN
A
0 '?
A
a
\ V
^^s^
rll I <■
\J.,n!tn
/',,
THH Mi.,VKSTXTH!.I'KK^..NAI.PAKlM-I,AKSAKKTKl i: To TIIK
jil>T ()!• MV KN<>\Vl,i;i»<.K A\I> lU.I.II-.f
I I nfi )! maiit
(^vJLm y^JLJ^r\\jr\yoJ<> h^JJ^ > '
r
I \(lilr«'^"^
MEDICAL CERTIFICATE OF DEATH
DA 11', ol- DllAllI
A
\)r^
U
(Vf.u
fMonlh) ">;»y^
] 1II;K I'I'.V CI'iRTII'V, That I atteiukMl <lci cased fn>iu
— — — — ~- 1()0
~ \ip
to
that I last saw h alive on ^9°
aii.l that .Uath ocrurrcl, uii Ihe .late <tate<l above, at
^M. The CAISI-; Ol" 1)1 A I'll was as follows:
I )r RAT I ON YiUirs
CoNTRllU'TORV
Months
Pars
/Jours
DIRATION
}\'(jrs
Jfoh'/Zis
Pars
(SIGNED) oU'CL/\>V<A-
U/CXj '^ l()0 f A.Mress)
Hours
M.D.
SPECIAL INFORMATION onb tor Hospital, Institutions, fransients,
or Reient Residents, dnd persons dying away from liome.
Former or
Usual Residence
When was disease rontracted,
If not at place of dcatli ?
How lonq at
Place of Death ?
Days
J'l.ACK ol- HTKIAI. OH Kl.MoVAI,
1- UTKIAl
SO. m ^
i»\ri:.>t Ht Ki.Ai, o! Ki':Mn\-Ai,
ifA
U.t,t. b
/A) „ .-^
TQO
■n
.. . -,,f, ^u„,.i.l he stilted FiXACTLY. PHYSICIANS Bhould
N. B._r;vcr.v Item of Information •houl.l h. .a.e^u.l, .upphed ;;;f;^«^X,.jj, j. ^hc- ••Special Infor.nHtlon" for p.r-
atate CAUSE OF DEATH in plnln terms, that it may l»e pmperiy
*nn. dying away from hom« nhould be feiven \^^ «v«ry Instance.
• n.nlth i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
fir *9H,^
-- ii.S. r Cn
I !)/)'<
Bcilistcrc'l ^Vo.
Pi 10
i^rvxv^ dOAHoji Deputy Health Officer
DEPARTMENT t)F PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. 5. »3tan^ai^ )
PLACE OF DEATH: — County
of LLL Ow vwi-xi^
City of VL <X_/
Y\X^
St.;
Dist.; bet.
and
/ ,r DEATH OCCURS aWaV FROM USUAL R E S I D E N C E G . V E r ACT
( ,r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I
TS CALLED fOR UNDER "SPECIAL INFORMATION ' \
Tb NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
<
i
rl/'YXA.^./YVil CNA^ U\-a: '::
PERSONAL AND STATISTICAL PARTICULARS
1) \ ij; 111 lUK III
^.xx^
M. mil »
1 ) I \
\«.j-;
-.(
\c~
1/,,;
» I ai
r>,
sl\( . I.J' M \K l< IIP
WliM >\\ I- 1» < •'• I > ^ . 'I-' ! i»
Writ- ;n - '
liiR riii'i. \i*i-:
st;»?' ■ ■! < I 111 tit t \
Owh.^OL
A
I
NAM I ni
FATH Ik
lUk rHI'I, AtH
Ol- l-ATIIllK
'St;it»- »>r i'liuilll V
M AIIH-.X N \ Mi-
ni Mi>rm.K
lUK l'lll'I,Ai'l%
ni Mnrm-.K
(Statt m t'lniiiti %
\
• trri'AllON
"n s .
) , ./
]/,iif//'
Ih!
Tin- MM,VK^rxTKnPKK-^.)NM,i-AKnrri XK. xkv.tkvv. >•> vui:
HHST nl MV KNOWI.KIXVK ANI> I.I.IJJ-I ^
(Infotjiiaiit M I WVAwA-,AJ v. . -J ^. v-s»
^AED!CAL CERTIFICATE OF DEATH
I (JO
I Day) {Ytai>
nAl'l-: <'l I>KA I'll /' \
(MontlO
I HRRiUJN' Cl-.K'ril'V, Tliat ! attfn<U-<l (leccastMl frotii
_ u/) to —^— up
that I last saw h alivu on
190
an
,1 that <U'ath occiirre^l, on tin- .lati- .tatcl ahnvr, at
— M. The CM Sli Ol' Dl". ATI! was as follows
or RAT ION V'^i's
C'oNTRlHrTORV
MoHihs
Days
J lours
J/,>>!//lS
(Signed). Oa.\axxa^' > - . ' ' ■ -
DT RATION >'',//5
Hours
M.D.
!f)0 \ (
SPECIAL INFORMATION »nly lor Hospitals, Institutions. Transients,
or Recent Residents, and persons dvinf] <twav from home.
Former or \ 1 ^ . ^
Usual ResidenccVJXXA-A)
When was disease rontracted.
If not at place of death ?
(1J>L,
i^ How lonq at
KSXXj PIdre of Death ?
Days
IM.ACH Ol- lUKIAI, OK KI-.M'tXXI
rNi)i':RTAKi:K >^ ■ -
I) \ 11
iU.cl
M .,! m: MOV A I,
' ( T 90 ' I
0 a
^4
-o
IN. B.-
.. , Thf Khoiild be stated EXACTLY. PHYSICIANS should
.Kver.v iten, of in?.>r.n«.1«n should be cn.eH.lly -PP'-^' ^^^^.^^ ..assifled. The "Special Information" for pT-
«tate CAUSE OF DhATH in pinin terms, that it mH> be proper y
^i". d>fng away from home should be given in every instance.
-T^f
I
•hi
t
I
w
RITE PLAINLY WITH UNFADING INK
11, ,:t)i r V.
-t) H&r *.■->
I)alc Filetl ,
y^Lhj b
IfJO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^^
- jjuty Health Off^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of Bcatb
11. 5. jTitanDcnrD )
PLACE OF DEATH: — County ofCJ/a/-^^
J?
(^
X/QA^.
'. City ofCJ/CC'^^ o/N
ex.
St.; 5
and
^
RT 'I Un 4 ' ' ■ > -^ St.: ^ Dist.;bet. u^''0
No. C<b \ 1 -^-. ' ,,<=,. 1.1 RFsTdENCEG.VC FACTS CALLED rOR UNDER SPECIAL .NFORMATIOM- \
( " ^.^rE:Tt,"occ^^;To^^^Ho"s^■TlL oB'fNSn^JV'o'N^o.vE .rs name .nsteao o. street a.o .umber. ;
FULL NAME
r;J<xxL4_x
PERSONAL AND STATISTICAL PARTICULARS
!i A II. < 'I lUk I'll A ft
I
iiiilh
4
\ 1 . 1-;
•-IN".!,!'', MAKKIi: 1>
Utiti ill -..riMl (1. sJ|rnatio!i)
I'.iU THl'I, \>'I"'.
lSl;iti ii! t Dimtl N
m.iv
■»»;tr I
fiti 1 A
\
\^
I go \
(Year)
MEDICAL CERTIFICATE O^DEATH
DATi-. «»i i)i:\in I A
• Month) "='>'*
I invKl'iHV CI'RTH'V, That ! atlcn.k-.l (l..i cased from
lL)ct. -i lyo . to G^ 5 TcpH
in f '
that I last saw h . ■ alive on ^ ^^ ^' ^^P'
an.l that .Uath n.Hurrc-.l, nu the .late state.l above, at i^^
I "^, . M. The CAISI-: Ol" DI'ATH was as follows:
,A^
V
NXMI iM
FA 111 l.K
I'.ik riii'i, \» I-:
• »i 1 A III i:k
' SI. ill' ( i! I'l iimt r\-
M \1 !ii:X NAMl'.
(>l Ml ('I'll !•: K
lURI'UlM.AOK
Ml M«)!H1-:R
' -tatt lit I'dUllt 1 %
m
\ '-
.o [
U
tn rri'A riDN
!V,M
M.,iitli'
/>ii )
T,,HA,.,VKSTXTKn)-KKSnNAl.rU<TirrLAK^AKKTKrKTn THH
HKST <)1- .MV KN<»\\ 1,1 l)(.h AND l.l-.I.H'.i
In
I)lk,\'l'l«>N )V'/''\^
CDNTKnuroRV
Moulin 'i /-''/i A Hours
DTK. XT ION
(SIGNED)
Afoulhs
)'rtirs
/hiv
Hours
M.D.
Ki"
(A.hlress) X "b ^ b Vjj /VUyO>/Y\t UA
"iiRt
SPECIAL INFORMATION ^ »or Hospitals, liMUfulions, Transients,
or Recent Residents, and persons dyinq away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How ionq at
Place of Death?
Days
I'l.AOi: ol- lUKIAI, nK KI:M«»VAI<
n\r!%i)i liiHiAi. or K 1-'.M« »V.M,
190
w
' ~ ~. Tr.F. should be stated F.XACTLY. PHYSICIANS should
„ of informBtion should be cnre^uUy supplied. ^;»' '^^^ , .jj^j. The "Special InVormation" for pT-
SE OF DHATH In plain tei-ms, that it may be properly wiassm
N. B. Every Item
WRITE PLAINLY WITH UNFADING INK
1!, A-\h \ V,
^ l-i.> luSci' c
Dfffc Fih'il , Uct<r\>-iV b
100^
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
01 Id
Br<^ isle rod jYo. -^^ » f-
1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. S. StnnDarD
[\
PLACE OF DEATH: — County of
'X
4
%
o
City of 'J<xjy^ J>^'
No*
t -—-, \
\
^
Jo^yxKXO^^ ^.^ '
St.;
Dist.; bet.
and
FROM USUAL RESIDENCE GIVE fact
J/,\r DEATH OCCURS AWAY FROM U 3 W « I. nti»iww.-w.
\.\ J^d^ItVoccurrcd in a hospital or institut.on give
TS CALtED rOR UNDER SPECIAL INFORMATION ■ "N
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\JLXL
■^
PERSONAL AND STATISTICAL PARTICULARS
ftlo '
u
\w I
I
I.A : \. « •! lUK 111
\ t . »•:
1 I' \1 AK K 11- 1»
\s ijM iUKI» OK i»r ■
Wt iti i !! -iHial i\f —
lUR I'lll'l, \s'l'.
vt ,'. 1,1 ('.iHiitr^
I Alii IK
I'.IK I'll !!. \rl
I ti 1 \ I'll J'K
stall 111 I'liiintrv
MMIU.N NAMl.
<»i MolHKK
ink IHIM.ACE
»»i- M»»iin:R
(Slatr or l"< i\int ! ^
M..m^r
).,n
Dav
\'\
Star)
/','
MEDICAL CERTIFICATE OF DEATH
DAiH «»i ni'Ain
*^A_AJ
Month)
iDav)
I (^0
(Yrar)
I lIl':ki;P.V Cl'RTII'V. Thai I aUciukil «k'(xasL-a from
: , , + :^ .yoM tn ^t^t H U)0H
that I last saw h alive nii - ^ ' l^P ■
anil that .Kath .Hrurn-a, ..„ the .late stale.! al..)ve. at ^
Q^ M. The CM SI-. Oi" DI'ATII was as follows:
Ko. .
.K V ri'ATluN
h'f'litfil in San /'i u n, i^rn
)'ll! I
\r.intln
/hi
TllK.m,VKSTVrKlMM^KS.»NXl.I'AHTI;M;KAKSAKKTKri-;T.. TllK
iu;>T <»i' MY KN.»\vi,i:i)«.»-. AM> iti-.i.n-.i-
(liifoTinant
Ad.lr,.s 3l U).^^.^^.^.
DTK A riON
}'<(irs
Mon/Zis
/><n.v 13* Hours
Dr RAT ION
0
Years
Mouths
Pars-
Hours
-t, '^''
(SIGNED
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq awa> from liome.
I . (O
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatti ?
How lonq at
Place of Oeatfi ?
Days
n.ACK nl' HIKIAI, OK KKM'»V\I,
Qflfu
DA ri' o! !!i HIM or K i-:mi »\'AI.
T90
AdHrc.^ ^0 5 ^>\<nxU
5 >a\jINu.4
i
— — — — ^ — — ~T_ ,j j^ ^,„j^j EXACTLY. PHYSICIANS should
IS. B.— Every Item o? inWmetJon shouhl be cnr.tully -PP'-^. At.E « . ^^he -Special Information" for p.r-
state CAUSE OF DEATH in plain terms, that .t may be properly
^nf. dyhTft away from home should be ftiven in every .n^tance.
^
m
WRITE PLAINLY WITH UNFADING INK
! l!,a!t!i I v.> i^ •*>;*.,^;)H^ri'<»
pff/f rih'<l ,
b
100^.
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bro^/sfrrrd ^Vo.
Deputy Health Officer
DEPARTMENT (Jf PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( 11. S. 5tan^ar^^ )
PLACE OF DEATH: — County of '-■ '
Jn.O^YVC.w. Gtyof^CU^X) ^>^KXXyY^^^<^<
y\.oX
St.;
(ir DEATH OCCURS *WAV FROM U S l ^ , ., ^
IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE
Dist.; bet*
and
..Cllill RF«5IDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ ^
F DEATH OCCURS AWAY FROM USUAL "5 ^ ' ?5.;;.^,^„^J V. „ " ,^5 NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^ I
'^
A
PERSONAL AND STATISTICAL PARTICULARS
vri: I >i !UK I'H
\1. Ml h »
\< . J-.
, K t
.1
I>a%-
1/,,, '/,
» • ,il
/>,/!
HINOI.I* MAHKIKK
!UR rill'!. \tl"
"^tatt I ir <"in! n! ! %
NAM I- 01
I ATHKR
RiH rm-i, \tK
nt 1 A rm:k
St. ill i.t (.'onuti V
N!MI)1:n NAMl.
Ill .Mollli; K
lUUIMfPI.Ai'K
III MMIIIKR
(Stat. <<l CiiHUM
X
< irrri'A'rioN
■^ oJo^y^ULK' f >
/,'/■ /7f .,'■ /» Si'»' / ' '"
1/, ;•///
/>,
I'm- \!$«>vi-: SIX rri» phkn. »n \i. i-xh ii* i^i. ^^k-^ "»
lil'ST 01 .MV KN<i\VI,i:i)< .»•: A"^'' I'.I.I.II.!-
KK IK IK l«' l"'-.
f Ii)f')!iii:iiU
Ol . U) . Qnru^^vt<m>
MEDICAL CERTIFICATE OF DEATH
IiA rK 01- 1)1 ATII |'^
VZAj
I Moiitlit
Dav)
rgo
(Yea I 1
I III-:ki:i'.V ri;KTIl-V. That I atteii<UMl <kr<ase<l from
tliat T last saw h ^^ ' ■ - alivt- on
an.l that <Uath occurrcl, <.n thr .latr -^tatL-.l al.nvf. at
M. The CM SI-: Ol- Di: ATI! was as follows
190 i.
I)IR.\T1()N
CONTKIIU'TOI
) Vi// s
Mouths
/hirs
//ours
I \- wd-^-^-CxX^X^v- o ^ w
k I
DTK AT ION
( SIG
yittrs
Months
/hiy
Itouts
M.D.
NED) Uu. U)^^ ' " /D ' )%
SPECIAL INFORMATION only for Hospllals, Institutions, Translen
or Recent Residents, and persons dying away from liome
Q D * How lonq at
r
Former or
Isual Residence
-UYYVOTwd. V "1 ' Plate of Oeatli?6
kvas disease contracted,! f f ( H . « L
at place of deatli ? J A) 'V-A^OV v. . -. .. >
B«vs
Wfien was
If not at place
UI.ACK 0
I- lUKi-U, <»K i<i;m'<x Al.
Lyi-xhJlAA
DA'p". .)! I'.rwi.Ai. or Kl'.MoV.AI,
\J 190 \
.. . .^p „h„„icl be stated EXACTLY. PHYSICIANS «houl«l
IS. B.— F.very Item .S info.m«tJon should be c«re?ully f "»>n''- " ^"f^^ ,,assWled. The •'Special Information" for pT-
-tnte CAUSr OP DEATH in plain term., that it may be properly
^n". dyfnft away from home should be ^ivcn in every instance.
•w
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,, n , N„ - f.^-^S^.nu'vlC-. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ii('o-i.sfr/'erl J{o.
Of tf^
L^iwu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH:-County of^^<X^ 0 Xa.a - City of CVc^^ J.'vxvwc.^.
No ^Ol'a■ ith. St.; .^ Dist.; bet. 3 tr^U^^J-v-^' and (.b.C^^A.^.-'■ - )
INO, V ^ V. I 4^ W. '^^ r V ,,c,,., RFCSIDENCE GIVE FACTS CALtrO FOR UNDER SPECIAL INFORMATION' \
FULL NAME a ^.^^
dL
4 ^ ^
\ I
v>
I' t . ^ t
PERSONAL AND STATISTICAL PARTICULARS
i» A s H « >i lUK rn
^<X^v,
%!i.lltll'
Xt .1',
^3. ,v,...
U
' Diivi
M.oilh^
f
\ < : 1 1
/',/ 1 •
SINt.l.l' M.\kUIlI>
w I n< I \\ 1: 1 ) ( > K I » ; \ ( » k r 1- 1 )
• Writ' i n -■ .< i:i; .!■ -■ t'Hat ii ^ii >
I l\xXh./v.A
nikTHi'i, x*"!-:
' Stall (i! (*(iinit ! \
\\Mf.- Ml
1 A III KK
r.iH riiri, \y v.
<>! I \ IlII'lK
' Ni,,!. (It iDimtry
NtMDI.N NAM1-,
<»1- MOTIIHH
lUH IHI'T.Ai'l-:
<H MoTIN'K
(Stat« DT rnuuti\
A
?
(V
•HATPATION 0.0 1 t)
TllKMUn'KSTATKnPKKSONAI. rAKTUri XHsAKHTKlK JO THK
H1-;ST <»1- MV KNn\VI,j;i)<'.l% AM) r.i.i.ii.i-
MEDICAL CERTIFICATE OF DEATH
DAri-; 111- Dl'.Al'H
(Mouth) 'Day)
TOO
(Year)
I Illlkl.P.V Cl'lKTIl-V, That I atU'tKlcd dere.isi'tl from
to ®^fc ^ ^^^^
loo'i to SJ^Sj 3 IQO
: ^ <{\ ■
that I last saw h ^^^ alive on Ucl- ^. 790
and that .U-ath ocrurrcd, on the .late stated above, at i oO
' M. The CArSI'! Ol- DIlATIl was as follows:
Ur RAT ION
)V<//'X
Months
:(>NTKnU'T(>KV U/>v.k.^-^*
Days
J lours
Years Months
/)^/r,s-
nr RATION
(Signed) UJnnru ^ Aa '
l^.^ b — "^ ^A,i,ir,.<o 'lib Nlrlaiu
/fours
M.D.
Tqo
SPECIAL INFORMATION only fo"" Hospitals, Institutions, Transients,
or Recent Residents, and persons dving away from lionie.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How long at
Plareof Death?
Days
n \CK OF HI RIAL OK KKMoVAI,
DXXl!"' liiKiAi, III KlCMoVAI.
1 J \ T9OH
(Ad.li rs< iH 0 H.
.. . T^p «H«,.!,I he stnted EXACTLY. PHYSICIANS should
N. B.— Hvery Item of information .hould he CBrefuHy -PP -;«• ^^J^^^ classified. The "Special information^ for p,r-
atate CAUSE OF DEATH in plain terms, that it may be properiy
sons dying away from home should be given in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFrCATE FOR INSTRUCTIONS
)'..:ii(l t.f H.-nltli !•' N'o. te t-?' ;-:w!tti} Jl^p Co
Dale Filed, M^X
crl>~t>u '\ IdO'i
Deputy Health Omcer
Registered J^''o.
2147
cL<m.>^ Jo/v^, "''Huiy neaitn omcer
DEPARTMENT Of PUBLIC HEALTH-City and County of San Francisco
Cettitfcate of ®eatb
( "a. S. Stan5arD )
m
PLACE OF DEATH: — County ofOa.-vx J A.<x/>^/iuL<i^Gty of Haa^. JA^O/t^C^K^o
(No. Lix JLcL^X^^^ Al' ^nI KlIo..
, St; Dist.;bct. and
I "^ P/nrl.w^''"''^ ***'' '^"'"^ USUAL RESIDENCE GIVE rACTS called for under "special information- \
V ^r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR eIt AN D NUMBER )
T)
L^
FULL NAME
si;x
^
PERSONAL AND STATISTICAL PARTICULARS
! COI.OR '•
tk
i'^
%.^
VAjUj^t .. .
v^ . '^ \ > \. '"V
DATI-: OI- I!IK IH
\«;k
v^ "^ 1-,.
^
lLI
^ (
(Dav)
M>>,ilh<
-Ctx
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(M(Mith)
fDay)
igo\
(Year)
1 H
fVcar)
A: I'.s
SINC.I.H. MAKUIi:i)
\Vn)(»\yHI> OK DIVOKi'Kl)
'Write ill mnial (le-^iL^natioii)
BIKTflPr.AOK
(State or Coiiiitrvi
NAM1-: <>!••
FA'nn:k
BIKTIIIM.ACH
ni- l-ATHKR
(Stat<- or t'imiiti \^
MAIDKN' NAMl
<)»• MOTIIKK
HIKTIIlM.ArK
OF MOTIIKK
(State or Comitrv)
OCCUPATION
^UUXT
1
0 I HHRHRV C1{RTIFV, TliatJ atteii.le.l .Icccased f
.a_i4Ajt;: ai .^-m - ^
190
to
that I last saw h -A. '- alive on
roni
190 H
^t ^ 190 1
and that death occurred, on the date stated al)ovc, at 5
M. The CAUSE OI- Dl-ATH was as follows:
efc: £.
0
U
U:
^
UXA.L(, Ll
•c<rvL<X'^^dL
I) r RATION Years
CONTRIIU-TORV
DIRATION Years
Mouths
Days
Months
(SlGNED).^>i^JL/\Nil;
^ij's^AJ^'^j^^^
Pays
y.clj b iQo^i (Address) 5HD 3x.d±k
Resided in Sun I'l uin isro
Month
/hn
SPECIAL INFORMATION only for Hospitals, insHfutions, Transients
or Recent Residents, and persons dying away from liome. '
former or -s^.y^i . How long at
Residence AO i H Oo^vux/) / .
Usual
Wlien was disease contracted,
If not at place of deatti?
Place of Death?
Days
1 hf; ahovf: .STATi:n pkksonai, i'artufi.ars arf; tkff to tuf
hf;st of my kno\\ij;i)(;k and ni:i.n;F
Infoiinant VXL^VN-^w^^On^^ d^. LUUU-^
.4^-^.
(A<1<1
rcss
.10 1 H
ci
I'l^ACK OF RlRIAr. OR RKMoVAI. | DATF of U.riai. or RFMoVAI,
(Address ^sS/l ^O
190
}Jl^\^'
Jl
^' ^' Every Item oi information should be cRPafully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for per-
sons dyinft away from home should be ^iven In every instance.
I
f
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H...'ii<l ...f III lit li }• No. I- "^'f^^'^tj: H,S:1' Cn
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!)((/(' Filed ,
AyAhj 1
i'
wo\
Deputy Health Officer
RegisU't'cd JVo.
f^
No.
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitiffcatc of Scatb
' n. 5. StanDarD )
PLACE OF DEATH: — County of Ct y\; J 'LCtvvei.c^c City ofO£:L/>v JA^Cutx cl4 '^ '.
"St.; 3, Dist.;bet. V vj
^ and L
;UF*5 AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION
DCC'JRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
FULL NAME JlXuU
PERSONAL AND STATISTICAL PARTICULARS
n.\ ri; <>i iuk \ li
(■(»i.<»R ^
a
Ll
4^
mAiu
' f
MEDICAL CERTIFICATE OF DEATH
DATi-: oi- i)i:atii
Month)
< 1 );t V I
(Vtai
I);i\
\<.i.:
na-
S!\».I,I-- MARNIi;!).
'W'iitciii social lU-si^'iiat inii)
^1
\
Statt or < "i lunt r\
NAMl ni
I A Tin; K
BIKTIi 11. AC}.;
ni- i-Aiin-.R
(State or (.'niitlt! %
MAII)i;x NAM],
<)1- MdTin-R
in R TUP I, AC" i-;
•M MnTin-:K
(Stal<- i,r C<iinitr\-
< »*'(." ri'Aiiox
AV.v/(/^'f/ //' Still /'t n III i.<rii
I JIHRHHV CI^RTII-V. That I atten.k-<l .lectasc-.l fn.,,,
that I hist saw h .:. ahvc on ^' "^ \
190 ^
T90 !
ami tliat (katli (uH'urreil, on the thiti- staud aho
\'«, at
!^ M. Tlu- CAISH OF DI'ATfr was as follows
LojtcUvruVvcct U
yvx^.c t
^ rs
{Lrrrx, !
iJ^At
L
I) r RAT ION }Va/-.f
coNTRir.rToRv ^a"^
Months ^1 /;«n.v
Hon
rs
UXK^x
niRATIOX
f Signed )
y'l'ar
.V<^f////s I 'i /)ars
TOO 1 (A.Mn-sv) lOl^'lS.
mYUvl
flours
M.D.
Special Information only for Hospitdls. institutions, Transients
or Recent Residents, and persons dying awdy from home. '
) rill
Mnlth'
r>,n
I'm-: MiovK sTATi: n i'i-'rsoxai. par ri(-i-i. \ks ari' trii" 1. > rm-"
HHST t)l' MV KN'<)\\l,i:i)(.l.: AND HI". l.Ii; !••
Infonnam LU PnA^ ^ll . ' ^
Former or
L'sual Residence
When was disease contracted,
If not at place of death?
HoH long at
Plate of Death?
Days
(Address 1 I |Qs
0 ^-^
PI,\rK (II Hf-RIAUOR Ri:M()\AI. I DAT];.,; H! Ki,\r. or RHMOVAI.
1 1 '51 ^TYXa,^^,. ^i
T90H
rXDlCKTAKKR
'All{lrt's^
N. B.
-Rvery item of i.iformatlon should be carafully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be given in every Instance.
lif^
];^ ^1
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
..I llt.lltll 1' Nu^ !■: *-?^S^ li&l'Co
'^ 4 ^
.<r^oc^
XKl
1V0\
"'^*- Officer
Re^isfei'ed J\^o,
2U9
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( "U. S. Stan^arC* j
(?f^
PLACE OF DEATH: — County o{OxX/y\j OAwCA^oOLCoCity of Oct'vo J Ax»y>-i^ev4. c o
No. H n L,a.-.\ 'ib_<L-J LW-i' St.; *i Dist.; bet. 0 Ajtbr>v
/ 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^^vdxiGr J...c^
N"
1)
>j;\
PERSONAL AND STATISTICAL PARTICULARS
LillvcU
!) A ii: <»r itiK III
ACiK
i Ml. mil I
} V,.'
I»avt
M.-ut/r-
\ ta t
/'./
MEDICAL CERTIFICATE OF DEATH
DATK n|. nj:ATII
(Year
-iNi.i.i* MAKi<n:n
^tate or Cnmilrv
XAMl or
F ATI! !^k
lUk'I'HI'I.AOK
oi I \rilHR
tStati iir i'ouiiti ^■
M\II»i:V NAMI"
oi- MoTHHR
niR rill'l.Ai'K
«>i MMriii<:k
(Stati ill ^'oiintrx
Oi'CrPATION
Kt'Miir'd in San /iiinii>r
cc
(Month) (Day)
f HI'Rl-HV CI-:RTII-V, That r attemkMl deceased from
190' to WvC^ fo njoM
that I hist saw li aUve on '• .:^w J^yQ
aiid that death ocrurred, on the date stated ahtive, at ^'i -■-
-> M. The CATSIC OI- I ) I- ATI I was as follows:
is
Dr RAT ION )'rars
CONTRIIU'TORV
Mo Hi /is
rX.
/hj]
'S
I louts
Dr RATION
SIGNED )
) '('(//■
Mouths
Pavs
Vvv^O^v
b
\^
H)0
Hours
M.D.
Address) lOl^llaS
Special information onU for Hospitals, Insmutlons, Transients,
or Recent Residents, and persons dying away from home.
Y,a<
Mnnth^
/),,'
lin; \HoVH STATl'I) PKRmiNAI, l'AKTIOrf,AKS ARIC TRIK To THI-;
iu;si" 01. M\' KNo\\T,i;r)<;K ami Hi:i.n:F
(Iiifotinaiit Vl I LCXAAJ,
(Address I IT. U /Cb^rU M L L<,/
<LAj5
Former or
Usual Residence
Wljen was disease contracted.
If not at place of death ?
How lonq at
Place of Death ?
Oij's
IM.ACK OI- Hj^H|\I, OK KKMoXAI, I IJATliof ISihiai, nr RICMoVAI,
t V
I 1 90
uldifss ill. M |\a^4,A.a
l'J,.\en OJ- lil KIAI, OK K I
r.Ni)i:K iaki;r
j^^ \ \j
N. B.— — Rvery item of informntion should he cnrefulfy supplied. AGE should he xtfited BXACTLY. PHYSICIANf^ should
state CAUSE OF DEATH in plain terms, that it mny he properly classified. The "Special Information" for per-
sons dying away from home should be given in every instance.
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;. ,;ii.! .,f IIlmIHi !• \.
^••■E7.-«^, li^I' (\,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
4
IfJO'i
Bcf^Lstered J\^o,
;^150
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)catb
( XX. S. Stan&ar^ j
Ne.
PLACE OF DEATH: — County ofO a>v\C
3,t '
]
City of OXcr^L^^rvv. ^
XU^A.
V,'. . A r^
St.;
Dist.; bet.
and
f 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. /
FULL NAME
M I \cu\A.i
It
PERSONAL AND STATISTICAL PARTICULARS
'1 \ n; < •! i:ik rn
L
' Month)
\| .1-
b5
S
l),i\
M. •>,'/!
I L
MEDICAL CERTIFICATE OF DEATH
DATl-; oi- I»i:\TlI ij \
(Month)
IQO i
(W-ai i
r>,i
S!\«,l.l' MAKRIHI)
wiiM i\K i;i) ( iR i)[\( i«.'ri:r)
' W'x iti i 11 -.(ici,! I <1( -iiMi.it i'Hi)
W
I
lUKTniM, \ri-:
i St;i!c ()i I 'ini uli \
f- \ 111 i k
BIRTHI'I, \< i-:
ni- i-Ainij<
iStaii (It riiiintiA
M \ ii»i;n n ami:
III M«»riij: K
luuriii'i.Ai'i-:
<>1- MnTll!-:K
(StMtr or (.Niuntiv)
^■;
(Day)
I Hl'RI'HV CI'UTII'V, That I ittcii.lol .icTcascd fn.m
190 to
igo
that I hist saw h :t ^ ali\c' on — _ ^
and that death nccurre«l, on the date stated aljove, at
%
M. The CAISI-; OI- I)i:ATir was as follows-
<Xy>^^V^^V<3 A.U^\A Lt A,AXC„0,
i> 11
K
1 >
Dr RATION Ytars
CONTRIIHTOF^V
Months
Day:
'S
/Jours
DTRATIOX
^ Oxu
■>%
;^
)'t'ars
Month:
Ihns
(Signed) L(r*urvuA;
li'/^l^ b TooH (Address) Ot«rcki.^nv
Iloitts
M.D.
K.O.A.
SPECIAL INFORMATION only for Hospitals, Institutions, Trinslents,
or Recent Residents, and persons dying away from fio.-ne.
' H CI i'.\ri().\
-^
xjlLcx
k'f-hlt'f III ^,ni / I I
I II, I ,',i
),-,/;
Mnllth^
I hi
0
-Jf
Former or |(1 -
Usual Residence^ '^^^: i^ad.
When was disease confrarted.
If not at place of deatli?
How long at
Place of Deatli ?
Days
TH !•: AMOVl-: S,T \'l'i:i) PKUSDN \1, PAR rriTI.AKS AKl", THfK TO TUl-
IU;si' <)| MS KNnWIJ.lx', !•; AND lU'.I.Ij;!-
' III f>i! 111:1 lit
V
\.i.!re^^ cL0JvJK.A4VL^*V ^0
l;iLACKr>I-- FlUklAf, OR kllMoVAF. I DATi;,,! Hriuu, m ki:Mn\Ai.
IXDKkTAKHR O CUVXAy^xXK . I \, A v.
N. B.— — Rvery item of ln?ormntion sihoiilil h- cnrefully Hupplieti. AGIi should be stated EXACTLY. PHY$»ICIAISS should
state CAUSE OF DKATH in plnin terms, that it may be properly classified. The "Special Information'* for per-
sons dyin£ away from home Hhould be (^iven in every instance.
< M
I
4
f
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.,f Htalth !•■ N.) 1^. t«'?'->ati<-£u>iu«tl' Co
N
Deputy Health Officer
Registevefl J\^o,
2151
^ ■ 1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "a. S. StanDarO )
■r\
I
PLACE OF DEATH: — County of /CLOr^j v^^CV > vCUicoCity of ^^ ) a/>v 0 V(X vvci^i.<M)
A
">->
«?
*No.^Ja^\' v'XaX>vCl4C(.
(IF Dl
If
St.;
. OVul/^x- At . U
Dist.; bet.
and
F DEATH OCCURS AWAV FROM OSUAL R E S I D E NC E Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION"
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE
;TS CALLED FOR UNDER "SPECIAL INFORMATION" N
ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
n
%.:y\> L.a.\.^. K'
PERSONAL AND STATISTICAL PARTICULARS
nw
:»A 11 < i| lURTll
\ < . I-;
1
(
Month)
S
) V,;
1
I»av
1/ -;///-
MEDICAL CERTIFICATE OF DEATH
DATK OF I)i:ATfl // \
(Month) (Day)
I HI-KI'I'.V CI'RTH'V, That I atteiidcl «leitascMl from
— to ——r——
rgn \
(Year)
/)<? ! ,
s!N<.i,i: ^fARH^•:I)
WIIH >U 1 I» <iK I)!\(>k(. 1:1)
Wtitrin --iK-Jal tif^ii'nation)
lUKi'II I'l. \i'I-:
I Stall 1 ir i.~i iiiiit I \
.K^
N \Mi: 01
I A 11 1 ):r
BIRTH PI, AOK
Ol' FATHKK
(Stalf or Cijuntrv
MAIDi: N NAM1-:
<>l- MoTIIKR
iUR'IIIPI.ACK
<>F MOTIIKR
' Slatf or t'oiiiiti \
that I last saw Ii
190
~ alive on
190
190
and that dtath «»rciirre<l, on the date stated above, at
— M. The CAISI-: OI" DI^ATH was a^ follows
A^\\X V ^^ V s^ cv , L K.c > \,
'\.CrY>^ Oa.^'j
I tX..A.<L
O^-w.
I )r RAT ION Yvars
CONTRIinTORV
Motitin
Days
Hon
rs
B-^
DURATION
N \
HHMPAIION j^ fi
(SIGNED ) LCfUnXJL>v J Jj.ly.dU.
ILi/ci 5 uyoH (Ad.lress) WtO^XtMUM^ ^
/}iiy
Hours
M.D.
SPECIAL Information only for Hospitals, Instituttdlls, Transients,
or Recent Residents, and persons dying a^ay from fiome.
utroi
^JL'v;
Isfsitifd in Siin /'i iiHiiM',
) I'll I
Montfn
Piv.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
lays
tup; m'.ovk sta ri'.T) pkrsoxai. 1'\k rion.ARs ark trtk to thh
MI';ST Ol- MV KN«)\VI,i:i)<".H AM) HHIJllF
niiforniant
v_<^-\Xr^
^JUxj:)
V
A
U' ■'.
Addn
190
l'I,ACK t))' BIRIAI. «)R RKMnVAI, I DATHof HtKiAr. or RKMOVAI
(Address ^bll^' l^ tk il
N. B. Every Item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information*' for per-
sons dyin^ away from home should be fti^en in every instance.
•I
Id
'W
Iv'l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
liMl-l of II. ;ill1l IN'.^ : t^*"^^;, Hv'«cl' r.»
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
P
o-ivwcA^ Xtv Deputy Health Officer
lleg Ls/c I 'c (I Xo,
'*^' J. t3'^
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H>catb
PLACE OF DEATH:— County ^ ^Ouy\, J \a.i
City of 0 CUy\;
:iv..
r> - /-N
No.
^.1,1
' ' ' ' St.; Dist.;bet. : "* and \ I '
/ IF DfATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
■I fUt^L^ LI
PERSONAL AND STATISTICAL PARTICULARS
-^^■\
I'l >l.( >k
^. 1 .
i»A ri; «»i liiK 111
At.i-;
'O
iLct
MiMithi
I)MV)
/%HH
MEDICAL CERTIFICATE OF DEATH
DATl" (tl- I)i;\lII
Moiitlii
I I)av>
(Vfar>
I m-kl-BV C!;RTH<V. That I nttfii.lcMl .kcT.ised from
toD.^ ^
Ik
^IN<.I.l" MAKKIl'.U
W i 1)1 i\\ JI» ok IH\( iKi'KIJ
^\lit( in -.iKiul ili-^i(.>;i:iti.iii)
M (lev,
A
IUK!'m'I,AOI%
St.'lti- ii! < '. )M lit I %
NANTI* OI
fa'iiii:k
lURTHI'I. \«'l-:
< •' I \ in Ik
■->1 it I ( ll ii Ml lit I %••
^fMI»l•.^,■ NAMK
'•i Mill' I IKK
lURllMM, \CV.
<»i MMriii.;K
-talc 111 I'oiiiltrv)
< 's rri'A rH)N
e
lip
tlial I last saw ll -2A< alive oh ' _ wl'
aii«l that (katli .icriirrCMJ, <>m thu date stated al)()ve, at
M. The CAl SI-; Ol- DI-ATII was as follows:
I(yO
df
LLl- ^
I ^' I
K^K^^OJs^d^ ' ' ^
W
-^v
1)1 R XT ION )'cays Mouths Pavs Hours
CONTkim'TORV
1)1 'RAT I ON
Years
LU,
I I
^o lit /is /hivs
f Signed) j.xKxi^Ui'i- Ja1/\<l'. • . ■ ,
V -..'.. n,o 1 f Address) Ai . frVU C-L'
Hours
M.D.
.<X.
A
Special Information only for HospiMIs, InstUutlons, Transients,
or Recent Residents, and persons dyin:) dnay fron home.
A'' /,//(/ /;/ Silll /• I ll Hi isi'it
) I'd I
M.nilh-
/'
'1HI-; \n«)\i-; s r xn; d pkr-^on xi, r \k ruti. \k> ak i; I'Kri-: ii » rm-;
IU%sr (Hi M%" KN<»Ul,i;i)(,|-, AM) lU I.U!'
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
(I
.ifoTinant M iXm^ ^IaXa^^' \I I L
'■\(l(lll-sH O O I
Uy\,\ n
M.ACI-lol- lURfAI. OR R|;M(»\AI,
JcrnrxaXi^ ^^-'
I) \ ll; of in HI u. OI R HM( )\Ai,
\
TQO
lNI)i;kTAKK K .,w CL' J
N. B. Every item oi informntlon should bv cjirefully supplied. A(IE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per-
sons dyin(l away from home should be (^iven in every instance.
1
ftA
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H ..!!<] i.f Ifialth 1 N
Dfffr /'VV/v/, ll' ct^crlM.'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Kj 1
IOf)\
or
Begisfet'cd jYo.
2153
.Kj<A -Kx^xHj Deputy He
DEPARTMENT h PUBLIC HEALTH-=City and County of San Francisco
Certificate of H)eatb
( 'U. S. Stan&arO )
PLACE OF DEATH: — County of "^O^w ^\xX/wcUlt^o City of C) a/Tu OXxX/>xx:uik:x)
O
f'fo. V -UL-UuV^Uw'
^
k±
cl
St.;
/ IF DEATH OCCURS UwftV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVEITS NAME INSTEAD OF STREET AND NUMBER. /
! \
^
PERSONAL AND STATISTICA
I Cf>i,<>k
FULL NAME kt^noJU
L PARTICULARS
Dist.; bet.
FACTS
tZ ITS
and
^19
CrV'l<X r\.d
' \ ri; • 'I lUK Til
\< .!■;
a.
U
U Jkctt
MEDICAL CERTIFICATE OF DEATH
i>.\Ti<; OF i)i; A'lH i<"n
> h A .1
Moiitir
n.'tv
/ V
ID
'Mniitli
I
IDav)
(Vt-ar)
d.\
1 /,.;/'
P.
^IN< . I.I' M AK k i III
'Writ' in -.xial <li- ii/tiat ion )
'Stall lit < 'i HI !it I \
^ 1
XXMJ" <»I
1- A ill IK
lURTIIfl.Ari.:
<>I I'Arill'k
' Stall (It ('oiniti %■
M X IIM.N N AMI-;
'>i M(>'rm-:K
I'.iK'jiii'r.Aij-:
«»l NSoTIII'.K
( st:iti I ii i'iiniilr\
1 lli;Ri;i!\' C1{RTII-V, That I attciukMl .ItHHase.l fioni
to ... v.'cit b
TooH
that I last saw h
C^l
Tfp I
alive oti w vwv |(p
ami tliat ilcatli <i<HMirrc-(l, (m: the ilati- statid ahovr, at T ^0
^I. 'rhy CAISI^ Ol' DICATir was as folhnvs:
-f
n
LcLi-^
DIRATION }'(ars
CONTkfm TORY
J/.>,///is
Days
Fli
lit IS
C\ ^ r%
I)!* RATION )'rars
/hns
\j ^i.
M'out/is
(Signed) u. ds. Ux>v\.a
flours
M.D.
Special Information nnl> lor Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
I ti 'I 1' \ rioN
Kf-ii{rii III Sail f'l ii III i.sri} <^ I )'r(iis 'O
Former or ^
Usual Residence^
)JLu;vlL.Vi. ""*'""'"'
Plare of Dfatfi
Days
Mnillh^
n,i 1
'I'll!', Mtnxi-: SI" \ri;i) pkhsox \i, pxRiicf!, \ks .\r!-: rKiK to th )■;
lU'lsT ui MS- KN« >\\ij;i)(;i.; and Hi;i,n;F
f IllfoMllalit
Wlien Has disease contracted,
If not at place of deatli ?
ri i^cH oi-* isrKiAr. ok hi.;m(»vai, I nxq:..! ittHiAt. ..r ki-mo\\i
ro I 'I )
N. B. Every Item of itifarmntioti should be carefully Bupplivd. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for per-
sons dying away from home should be given In every instance.
1
¥ I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n,.:i!.i <>{ n. ..;'!i i s
:, ,. ! ^ t-f^r^^ nSi. v Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff
/f?OH
Registered J\^o.
airiJ.
.Cr^<-^v
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( XX. S. StanOacO )
PLACE OF DEATH: — County of a "vx- \' O ,
3,
\(
\'
:- -s. - L City of U/CXaaj 0 ;\.o. ,
No. I bib iH M l/at<rv>vC\' St.; 5" > Dist.; bet. 1 1 -tk and 1 ^ t
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
11
(I
"rX'lvL
PERSONAL AND STATISTICAL PARTICULARS
XTVXCL
ii \ ri: < >r luk rn
a
a^^r
MEDICAL CERTIFICATE OF DEATH
DAT1-: <)i' i)i:Arii
lU
(Vt-ar)
M..m!
I >a V
\< .!•:
u n)t>\\i;i» « >k !);\( »rsi;[>
\\!if( ill -iii-ial <li "-it'iiat i'lii )
i • ai
fhl 1
ll^
luR riii'i. \v'i'
'■taf f I ir • '. iiMit I \
NAMK »»l
FATHKR
HIRTHIM, Ai'H
"I" 1 \ rHKK
' Stat!' i>r C()uiitr\
M N IDi: X NAM1-;
<•! M<>rm:K
HIKI'Hl'I,ArH
<>»• M(>'rm':R
' '^tat'^ I a ( , amtT ^
(^
(Month) 'D.ay
I iii':ri:i'.v ci;rtii<v, riiat i Mttciuit-d (Uar.isrd fr..in
^ 'C^j 5 i(,o' to ...L/'/Cai tS.,_
TC)0
that I last saw h
alive oil
.^
T(p
and that <Uath occurred, on the date staled above, at I
U M. The CArSl-: ()!• J)I{ATI[ uas as follows:
ft
DlkATlOX
CONTkllU'TORV
)'ears Months
ry^J^X,
Pa
r.v
Hon
rs
C\
CLTUX-'
^Dxt
nr RATION }\<irs
'Is
(SIG
Mo tit lis,
Pavs
Hi
I()0
ft-^-
ours
M.D.
1
nClTl' \l"li »N
%
'>
vdw
yi,nith>
/J.M.
Special Information only for Hospitals, Instllutions, rransients,
or Recent Residents, dnd persons dying dnay from home.
Till". Ann\-|.: SI" \ri:!> i-i- ksi »\ \i. rAKrii'fi. ars ari-; tri'k t«> rm-:
iu%srnt- MS K Nt »\\ i.i'iH ,!■; AM) i',i.i,n;i''
{Infi>'!nruit
lu. d
V-
A-t. I
%
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatli ?
HoH long at
Place of Deaffi ?
Days
PI.ACH <)!■■ IHRIAI. OR RK^f<)VAI,
IV,'
.^
^^^ ._
fA.l.lKSS (, ;0L,A^'U<IXX_
Lt
K.
INDICRTAKKR
K/x^
\^i
r)ArKi.! H! Kivi. i.r RICMoVAI.
0
190
KJLuJ- ^^ W^^c ' v.i
fAdclrcss ^^ UyC^-YV \l UUt/^
^
■■^ VA^ ^' .-*^
N. B. Rvery Item of informntion ahouhl be cnreViilly supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pltiin terms, that It may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be ^i^cn in every instance.
^
-4o
1 1 L
1
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l!..:ml ..f 11. .iltli- 1- Nil ; >; 1^'?^?»^>> Hft I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/M/r> Fi/rf/Xj^A^>^l
IfJO'i
Registered JS'^o,
2155
^
C^^^-^ \J *— - v^ *
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "U. S. StanOarD )
PLACE OF DEATH: — County ofCxx^v J;vcu>v<:uiccCity of 'Clvu J/Vcl vxci^-ayco
^*^ UXu, ^ Mn^C'TvUi L'^(yU\A.tal St.;— Dlst.;bet
and
A / ir DC*TH OCCUR^AW*V FROM USUAL R E S I O E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
y \ IF DEATH OCCUPRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^a.d,M.tj
xx,\yoA
PERSONAL AND STATISTICAL PARTICULARS
SIX
^ i Lev
COI.OR
i ^ I
. yvL
.t^
DATl-: nr- BIRTH
A<.K
MEDICAL CERTIFICATE OF DEATH
DATK OI'- DHATH Tx
(Month)
(»av)
I go
(Year)
M.-iitli)
)■-,.■
3n
(Dav)
M.nilhf
(Year)
Da » .
SINC.I.i:. MAKKIICI).
WnxiWKJ) (>K DSVORlKIJ
(Writf in social (l<si«'nati«Jti)
lUU THPLACR
L
f Stntr (»r I'mmt! \'
I ATm;K
mkrmM.Ac'K
Of I ATIIKK
(Statt or (.'iMintrv)
^f A I r ) }•; s n a m k
«H' MoTMKR
lUKTHI'r.Ac'l.;
<>»' MnTllHK
(Statf or Countr\
OiCri' ATION 0
1
I IIICRKHV CJ;RTII-V, That r atteiiikMl <Icccase(l from
■'Ou^ iL lyoH to L/.ci H 190 H
that T last saw h C - alive on ^ '^"^. ' i igo
and that <Uatli occurred, on the date stated above, at S^ S 0
M. The CAl'Slv OF Dl-ATII was as follows
\JjuUL"0^v.,<rvvcw>VM sJ .oJCk-C^^c
A
f I
\ 1 \ M
DIRATION
'W
Mouths
CON T R I m 'T ( ) R \' ^ XJ<XsXh^<Z^^X.QJ\J
Days
Hours
vu:^.^.!
n n
\ .
OJ
A f^
I )r RATION
K^\^ ) . V
( Signed ) o
in /?
,1 KI
Months
Davs
K
IqO
f
Ad.lress) OJlu <\J:> ^
flours
M.D.
^
fl. I 4
SPECIAL INFORMATION only for Ho^itals, Institutions, Transients,
or Recent Residents, and persons dyini] away from home.
Former or tii ;4 ^ How lonq at
Usual Residence 0 56 U>a CA.Ct-r^vC^C; f* piare of Oeatfj ? i \ ' ,
Days
Kf>iiir<{ III Sail / iimii'i'o
)V,/
yfoiith'
t),i 1
THH AHOVK .STATi:i> PKKSONAl, I'A K lUl" I.A KS AKi; rKCH To TIIF,
HKsT OF MY KNo\vij:i)(iK AM) Hi:i,n:p
(liifornuuit
C.(].%.(!JUi.
When was disease contracted,
If not at piare of death?
rr.^ACK OF HI RFAI. Ok RFMoVAI, | DATl',..: p.. i.iAr, or RKMoVAI
INDFRTAKHR JuUCaJLU %L u\0/<X<X,<X N w
N. B. Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS ahould
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information'* fop per-
sons dying away from home should be given in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.f II. .ilih 1- .V
.■(1. 1 5, ■!^*c■. '3;--i.;, luS: J' Ti)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2156
t
i
trVAA^c^locxu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County of
( U. S. StanDard )
-LJ^
'..^cc City oi '0. >xj J 'VXX>vc<-<i'eo
St.
Dist.; bet.
and
/ IF PE»TH OCCUHS *W*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO H M ATION '■ \
V Up OtATH OCCURRED IN A HOSPITAL OR INSTI^TUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
-— *- /^ ^
PERSONAL AND STATISTICAL PARTICULARS
Si \
Cdl.oK
I> \ 1 i; « >! lUK in
A<,i.:
I Mouth I
-I
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATII i( \
JV,,-
il)av>
M.,vth
I "/tar)
/»./ V
1 HI'RI'HV CI'KTIFV, That I atteii.lc.l ileceascil from
to ^^ (a..
siVf.ij.: MARNtl.I>
\\ri)()\vi"i> Ok n;\-« M'i i;i)
' U't itr in -iH iai .!• ^ii' iiat iuii )
lUKTnpi.Ai'i':
•Statf or l*>itll1t! \'
^ 1
L
^ ' O^y^ v-Lv<Xix^
I9« ; to SJ f^Si te I90 S
tliat I last saw li i.' alive 011 >w ^J. j^o
an<l that death tKCurred, on the dati- stated ahovc, at b
^-L ^. The CAISF-: (»!■ DliATII was as follows:
Hi
NAMI-; n!
I'ATUHR
niRTin'i.Ai'K
OI' lAIUKK
(Statt- or Coiiiif rv
MAini X NAMl-
oi- M()Tiii;k
IUKTI!l'I,Ar|.:
Of Morm'.R
I state (ir C'ouinr\ >
IH'kATlON
CjUNTkllUToRV
YtaiR
A
.«k_'
Moytths Days
Hours
■\
v:
I )r RATION Years
(Signed) dx^
Months
Pax
•s
Hours
M.D.
Ai b iqo'l (A.Mress) 9,5 OH ubftUj-a/uci '
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
oOCri'ATION
) I'll I
.1/. .//'//.
/),)\
%
Till-; ahovr sTATi;n phrsoxai. I'AKTicfi.AKs aki", tkih to Till-;
in-:sT oi.' ?.iY KN<>\vi,i:i)<.i-; AM) in-;i,!i:i
(Informant UXC) ub '»^ ' ' - M,
x.i.ir.ss ISOH yberv.ih<L\,d. U ^
Former or
Usual Residence
When was disease rontracfed.
If not at plare of death ?
How lonq at
Plare of Death ?
Days
I'l.ACK Ol- IHKIAl, <»K KHMcHAI, | HATI-.f ISiMiAr, or KKMuVAI,
UAa, >x n vc/, L CVC'
%
K Ikjjj
INDHKTAKKK
V t
190 i
n <-»
v:\
N. B. Every Item oV in form (it ion slioiiltl be carefully supplied. AGE should be ntnted EXACTLY. PHYSICIANS nhould
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for psr-
sons dying away from home should be given in avery instance.
H.
M
i f
III .
J
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! '"1 f I', iiih ! V ^^^;j^HSci'Cn ri:fe:r to back of certificate for instructions
/)/(/(' hailed ,
■h
n)0
Deputy He '" ^
Begistcj'ed J\^o,
2157
I
t -» ''\
DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco
Certificate of 5)eatb
PLACE OF DEATH: — County of
i
^
A
."J
' City of * -"^O.-^^- J A.o
-(I
No.
' St,; 1 Dist;bct. ^UXAyv-vu,- and b '
(IF DEATH OCtUBS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPRCIAL INFORMATION" "^
IF DEATH (Occurred in a hospital or institution give its NAME instead of sTRi^T and number. /
FULL NAME
'^
.<r\_xA'
personal and statistical particulars
six or^ f\ '■ coi.ok
i
I> V\ \: « H- IMK 111 A
\
I *.db
.U
Af.j.;
r
II
i Da VI
M..,tlln
(Ttal
MEDICAL certificate OF DEATH
DAT!-: CM' Di: \TH ,. \
ilu
(Year)
a5
/',M
-!\<.i,T.: %fAKRii:n
W MX )\\ HI) (»K I»!\i il'i I, I)
iWiitfiii '■JK-ial ill vi;. 111! !■ ,ii)
C>
iMH rm-j.AOi-;
>!ati (If < (iimt 1 \
NAM I tn
lATllKR
HIH III I'l, \i H
'»! I Arill.R
' ^latt (11 r.)iiii( ! \
M \II>i;n NA Mi-
ni- MnilliOi
I U !■• T III ' I . A I ■ I ;
'M Mttrill-K
I stall .it I'laiiit I \
<)*■«■ I I'A in IN
^
O.^^ 0 VOL^'VC <^XL CO
^
b
(Month) (Day)
I in-;Ri;BV C i:RTrFV, That I attciuUMl .ktvasc-d frnm
I9O tn Ucij • Kp *
that I last saw h ali\r on joq '
and that death ocrurred, on tfu' date stated above, at 3i
U' M,
The CAISI-; ()!• DI-ATII was as follows:
nr RATION Years
CONTRriUToRV
Mouths ^ l^axs
Hours
DURATION
(Signed)
LL/^p^.>C^
h't iih.l III Siin I
I ii III I •III
) , ,1
M..>illn
xs
Years Mi > 11 ( /is
up t (Address)
/hiVS
Hours
M.D.
Jo.... I.
Special Information m\s lor Hospitals. InsmuHons, Translenh,
or Recent Residents, and persons dying dwd> Irom liome.
rhi
Former or
L'sual Residence
When Has disease contrarted,
If not at place of death ?
NoM lonq i\
Place of Death?
Days
111: Ms<i\!.: SI" \i'i:ii I'HHSDX \i, I'Xk III I I, \Ks Aki-; tkii-; to rm-;
iii>r<ii MS K Ni »\\ i.rix , i'. \>j) iu:i,ii:i'
(Dlfo'lliatlt
Vlc v-uCLo
u.
1 Nil.lii-,s
\^
^ x.^x<Ui\Xxu kXIj. I ' .
I'l.ACK ni- lil KIAI. (»R HKMoVAl, ( DXIli-' Hi him, ..i KKMOVAF,
%
I ndi;k'i'aki:r
ft
Aiiiiiiss- 3)C)5 M rW-rvLo- *■
T90
-X 4'
A,
N'. H. Every Item of informntlon shnulil h;: ciirofully supplied. ACin should be stntecl F.XACTLV. PHYSICIANS should
state CAUSE OF DEATH In plnln teriiiB, that It mny be properly tjlaselfied. The "Special inlfopmotion" for per-
sons dying away from home Khould be gi^c*^ i>i every instance*
WRITE PLAINLY WITH UNFADING INK
n-.l .>f !li-:iUh I' N'
I)(ffr Fi/e(f,\U(zk.^si>^\^ 'I
190 "i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,{^\^^v^i
\hU
cpytyHeaJthO 3r
DEPARTMENT b PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
( "U. S. StanDar? )
^
iNe.
PLACE OF DEATH:-County of '$^0^ i^xx^vc^c* City of C)/CVY^ 0 AXX>v^x^o
.Ci\A/"a1w it Cr<L\v J O..,'. St.;
Dist.; bet.
I *^ i _k.. iicii&l ore; I n^NCE Give FACTS CALLED FOR UNDER SPE
and
CIAL INFORMATION" \
ET AND NUMBER. /
- - 1
FULL NAME Ox^%\^^^
i
X,
x<A
PERSONAL AND STATISTICAL PARTICULARS
^\c
si:x
DAI i; (»i- niKTii
AT, 1-:
\
(•<>I<)K \
jj.kcbb
/ ^
%!<iiit IS
OO YiiX)
(l)av^
\!.>iifh
Ci . ar
I)ii\
> IN (,1,1.- MARHIi:!).
V.Iix >\V1-',I» OR IMVoK*' i: I)
I Write in -II. ia; <l.-ii.'n:it i. .ii)
,C^
lUKl'Ul'I.At'K
( Stat<- or I'liiiiit I \'
\A\n. <>|
I- A Til l-K
MIRIHIM.Ai!-:
Ol 1 AI'UKK
(Statf or Count rv
MAlItl-N NAMl
f)I M(»riii: K
lUKrm'UArK
ni \nii'm:k
(state I '1 Ciiuntl y
MEDICAL CERTIFICATE OF DEATH
I)\ riC Ol" Dl-.ATH ^_ ^
4
(Month)
iD.iv)
/go 1
(Vear^
I ni:i<i:i'.V CICRTII'V, That r aUcii<!<.-.l .UuHasol from
O.dt
IC,oH tn iD^A" 3>
190
3» 1 90
that 1 last saw h ^*^>^ alive on v."^' ?^ T90
and that .Ualh orcurred, oti the .late stated ahove, at I
' M. The CAl SI-; Ol" Dl^-Vril was as follows:
^^
A
ij
XXY>xa
otrti'xrioN
) ,,j,
\fnlttll-
I hi
rin* v i'.<)vi'" >-,i' \ rKi> pkkson \i, r \k ruri.xks ari: ikt i-
in-^r Ol' MS' KNo\\I,i:i)C. H AN1> lUCI.tlCF
To Till'
(I
„,,.n,.anl NIXxO fcXJ<xKL-rKX
<x^y\Jw,
(
( \flclr(>-H
DIR.XTION
CONTkllU'TORV
. 0'^
^ •' \\j.^\Jo -
Years
Months
Pav:
>s
Hour
nrR.xTioN
"^
)'('(irs
Jfoff//is
)
,<x
/hir
(SIGNED) J AJU)jlA-vdfe"u. C ^
I lours
M.D.
SPECIAL INFORMATION only for Hospitals, jnstifutions, Transients,
or Recent Residents, and persons dyiog away from tiomc. »
Former or ^^^^^Y^^'^^''^ ^* _^ « How lonq at f
Usual Residence l>-^ '2>^x^^ hX*v Place of Deatli? liM:^^
Usual Residence
Wlien was disease contracted.
If not at place of deatli?
Days
I'l \CK <H' IHKIM, OK HJ-NfoVAl, I DXi'I'.of HiHiAr. or Kl-.MoVAI,
<x.i-
, n,h;ktakkk dUXLtu V «|^^
(Address Sbl^ ^ i^ tL 0 %
190 \
N B — Kvery Item o? 1„f.r.„v.tion should b. cn...'ully Muppllcd. ACIH should ^f-^^^^ty-^'^^'^^', . ^^^"5 '^':!^, f ""'**
Ttatc CAUSL OP DEATH in ph.in term., that It may be properly classified. The "Special Information for pT-
«on» dyinft away from home should be ftiven in every Instance.
n
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
1 11
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfflr Filcif . iL /^tWv '
190\
Re^isfered JSPo.
;2158
<hV^O
Xxhu
^t6
put
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( 'CI. S. i?tanDarD )
PLACE OF DEATH: — County of C)/Ol/>v^ 0 AXX>\Cc4C<) City of U/CUW J ^^XXa-l/C^U^o
ft)
N«.
nC
CrVA/^^M vbCHLK^.t<xl St.;
(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 OcijURRED IN A HOSPITAL O R J N STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
Dist.; bet.
FACTS CALLE
GIVE ITS NAME II
and
FULL'NAME '''^ -C>\\.u, J ,L\. d
>!:\
PERSONAL AND STATISTICAL PARTICULARS
J
hi
W-^ ■ .
i). kcU
r» \ I!', t »r- r.ik in
A«.i-:
MEDICAL CERTIFICATE OF DEATH
DATi-: oi- i)i:ath //>
il^^t
iVtar)
Ml. nth
ll
I
\) ^
tuRrm-!, M*).-
i State I ir C' ni ut i \
I)av
M..,'h
Am
,0X0/^^
f Month) (Day)
^1 lli;Ri:nV CI:RTIFV, That r atlc!i.!c-,MiMcascd from
O.CX; 2> looH to iD<*" ^
^=S
I90H to \^ s^'-J O iqo
tliat I last saw h A^^^ alive on ^ ^^ ^ Kp
and that <k-ath occurred, on the dati- stated above, at I I
S
M. The CAISI-: ())• DICATII wa^ as follow
I* 1
N \Mi-: ni-
I A IlIl'.K
lURrillM. \i' I-:
01 I VIIIJK
' state i.T I'ouiltl V
maii»i-;n x a m 1
ni- MoTlu.K
liiRTniM.Ai).;
<)t- Morn I-: K
(Slate (!]• I'miiit I \-
OiTt }• Xlin.N
0
w^A\,0
DTK AT ION Years
CoNTRIIirTORV
(j-C^u -
'^■S
&
Mouths
Days
Ih
oil IS
XJ\,Y^\,CL s
\
.^Ot^^XCL'
DC RAT ION
)V<//
1
(Signed ) J;
^'/tt- IqoH (A.ldress) bOt aX^lLt.\; ^t
Mouths
P ft)
Days
I Ion
rs
1
M.D.
/\i\i\li,f in S'lin i'l ii
lit 1^1' 1 1
),.l
Moiilh^
lht\
SPECIAL Information only for llospitdls, Instilutlons, Transients,
or Recent Residents, and persons dvioq JHay froni home.
r vTVVv<Mj,A.,.tr>v c)*b „ , . ft
Former or q n Hoh lonq at f
Usual Residence hAXT '2)Ax^*^ H-Uk. piare of Oeatli? li,f^^
^^ Days
Wlien was disease contracted,
If not at place of death ?
Till-: AIIOVK STA'n-:i) t'HKSoNXl, I'AK riiM'I.ARS ARK IKI I-! T( > THK
in-;sr oi' mv kn<>\vi.i:i)<; »■; and in;Ln:t-
(n
1 f - . t ma n t M lV\4 W Vj fXsX^
/^XCl >%. ^\,
\<Mrc'
PI^ACK OK HlKrAr. (»K Ki:%T(>\AI, I D\T}-:..f II! HIAI, e.r KKM«)V\I
1 ^
,1
TQO
KNDi'.K iaki;k
N. B. Kvery item of iiifcirmatton should be cnrefully supplied. AGK should he stated RXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Informntion'* for |»«p-
Ron« dyinft away from home should be i»iven in every instance.
•■'I
1 1
'r'l
I
WRITE PLAINLY WITH UNFADING INK
I Ihallh I- No. 1"; i-fi^^^ l'.\: i" C -,
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/c nicd ,
ioLo-VM.;
K 1
100*i
Registered J\''o,
J^l59
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Ta. S. StanCar? t
PLACE OF DEATH: — County of 0-'v\. J
'1
m
i "4 ■
City of O.OLAo^ 0 XO. .
No. SsSi cLow rL<„ , . .' ' . St.; H Dist.;bct. J.^.O„''vxf.. ■. 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 ' \
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME ■ ■ > ' ■^.^:^^.?.^Jo^\oJ>\X^\^ JL. a . - . . ,v._:
PERSONAL AND STATISTICAL PARTICULARS
"' ^ I)
I) All-: or luK III
lOl.oK \
u
MEDICAL CERTIFICATE OF DEATH
DATK ()I- Dl-ATH
fl>av
(Vf.'ir)
M-iuh)
a(;h
li;iv
.^/...////^
rhiv.s
'-IN*. !,!•:. MARKn:i»
\\ iHi »\\ I'D <>K i)i\()Kii;n A
!f)i.
lUR Tiii'i, \ri-
; st:it(- 1)1 I'luiiitry
\ \M I- < >i
I NT 1 1 I.K
IURTHIM,Ail<:
<>i" I AT in: K
'Stall I •; I'mnitrv)
MAIIH-.N NAM I
t)l- MnTHHK
iuK'rmM.Ai'i-:
<'l MuTIIHR
I Statf iir t'dutiti vt
tK'Cri'A'lloN
<XhKxj
1
I HI{RI':HV CI-RTIFV, riiat I atUMi.U-.l .lercascl frnm
t. '(
I9O A
. 190 to
that I last saw h alive on 190
and that cU-ath orcurred, on the date stated above, at 'A oO
M. The CAISH OI' ni{.\TII was as follows:
LajvuK^mu^ ci
1
\Jf\h.^^r\\.^^:z a=Jw<io \
c
^X-C.\^-^
A wQ
A
^
DIRATIOX -^ )\iiis Months ' Pais
CONTRIIU TORY L-ixn^tAX a. <: JwA^vlC'
//
ours
h ^^
<Xjy
vcL
DI'RATION X\ )V<?;
(SIGNED )
[^
Mouths
Days
I lours
M.D.
HjO
(Address) 111 ^X£kJ
V.U
7^
Special Information only for Hospitals, InstlUitlons, Transients,
or Recent Residents, and persons dying away from fiome.
M.>nth'
Iht I
Tin-: A Ho VI-; sr \ nn pkksonai, tar ifitlaks aric rRii-: in
Hi;sT Ml Mv KNt)wi,i:n<.K AND in:i,n;F
Tui-:
Former or
Usual Residence
When Has disease contracted.
If not at place of deatti ?
How lonq at
Place of Death ?
Days
(Inf.irtiiant
CL/^ ^
«w I V ^^..
AM.
ri.ACl'-, OI- nrRfAI, OR RHMoVAI, I DATI -•! lu hial or RliMoVAI,
INDl'.R lAK MR
(Ad.li, s^
JUL -A
N. B. Bvefy item of Informntlon should bs cnrefuli^' supplied. AfJB should he Htuted EXACTLY. PHYSICIAiNS should
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special informntion" for psp-
sons dying away from home should be given in every instance.
t
\4
¥
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! X.)
r>i'.&i' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i
Ljl^ T
lOO'i
J^eof\s/e/'('fl jYo,
.'31 f >0
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
No.
PLACE OF DEATH: — County of
\'
city of
^^
St;
Dist.;bet.'
and
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATION \
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
/^
C" Oft
*y
FULL NAME
A
U)
PERSONAL AND STATISTICAL PARTICULARS
V. \ ii: < >i r.iK ni
,'%
11' ct
IQ
I I v
^INt.I.I-* MAKU!i:i>
U'litf ill -H-ial lit-ii-iiatiDii)
a.:
}/.»,///<
MEDICAL CERTIFICATE OF DEATH
DATK «>F DKAIH , \
I (jn
(VtMI
n,
\
lUKTfll'I.AOl-:
I stale (ir Ciiiiiiti \'
NAMJ. «)l
I' A 11 1 }.:r
FnKTHI'I.Ai'K
ni- l'\!I!KR
'Stall- (It t'ciiint ! \'
MAini'.V NAMl'
ni .m()thi-;k
HiK rm'i.Ai'K
' Stall III iduntrv^
i)*'Ol TAllON
^
( I > ""l I
I Ml lilt h- <l»ay)
, I m:Ri:HV CI:kTIF-V, That I ittrii.k-.l .Icceased fn.ui
' ■ ' • I ♦
■ ■'• I 190 . t«» - ' up .
that I last saw h - alive on <■ . j t</> S
and that (k-ath occurred, on the dati- stated ahove, at
1
■;^M. The CAr:^!^ DF DI-ATII was as follows:
\\m\^
^'^ r\
n^^-
ci
DlkAI'ION
eoNTRIl'.rTORV
Months
/hiv
I/oti rs
nr RAT ION }\'ars J/,.;/ Ms
( SIGNED ) lC>UxJuiH. J^^a-
'- Iqo (Address) ki \j
Pavs
//ours
M.D.
Si
K^K K I
C WA >.A„
Special Information oniv for HospiMs, insmutions. Transienh.
or Recent Residents, dnd persons dyinj av»d) from fiome.
AV,\/(/?',/ > >l S,;t/ /'liill,
) ,
^/,:>lf/i
/>„•
THl \I',<»\K STXTl'I) I'KKSnXM, 1- \ KTliT !, \ KS aKK TKIK To TIIH
lU'lsT oi- MS K xi »\\i,i:i»(; !•; and in:i,i];F
i, Itifii:ij»;nit
Former or
L'suai Residence
Wlien Has disease contracted.
If not at place of deatli ?
tloH long at
Place of Death ?
Da^s
(AfUlrcRS
PI.ACKoi- lURlM, Ok HIOInVAl, | IJATI*,,*- FliRiAt or Ki:mo\ai,
A, Ml
N. B. Every Item of Information should be cnrefuily Hupplied. AGE should be stated EXACTLY. PHYSICIAIN8 should
state CAUSE OF DEATH In plain terms, that it may he properly classified. The "Special Information'* for per-
sons dylnft away from home should be ^iven In every instance.
$ )i
t! Ik
I
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H 1 .1 1 1 !r I- N'o. I > t"^^-^^:, JUt I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
m
Da/r Filed, U^cIchUa; 7 10 0\
\.^\j<j<Js JlIamj Deputy Health Officer
Registered J\'*o,
a
DEPARTMENT (JF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
p
( TH. S. StanDarD )
^
PLACE OF DEATH: — County ofOxX/Vu OA.^t'-^xcUtoo City of 0<Xax» ^J /ucl/w/o^axmd
rN©XuwU^Wu^'\Xu UJl^^v^U.CU.c^St.; Dist.;bet ^ — " — and-~
A f \r DEATH OCCUfWB AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
1 \ ir DEATH OCCiLrRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
L
. (X'U 1.
PERSONAL AND STATISTICAL PARTICULARS
C<)I,<)R
K f^Uli
DAii-: ()(■ iukin
1
(
Month)
4
Ic .
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1;ATH
%
(I)av>
Month)
I Vtari
\ I . 1-;
) id I s
Dav)
Mnnlh:-
'■/.■;nJ
Da ]
^
siN(,i,K M.\Kkn:i)
iWiitcii! '-(icial di-^if Tiat i( m >
HiKrm'i.AOK
(State t>r Country
I
tCUUu/tO
I 1II:R1-;BV CIIRTII-V, That I attoiKU-d decvascd from
•^^q XL 190 'i t() ^^ ct ^ 190 H
that I last saw h . ' alive on ^' w\!; ' j^q '.
and that (loath occurred, on tlie dati- •staled ahovr, at
M. The CAlSli OI- I)I;aTII was as follows:
\ \Mj; ni
I A'l'Ill-.R
HiR'rm'i.At/K
<)(■ I Aini-:K
(Sitatt- or Coimtrv
NfAini.N XAMl-:
<>l' MOTIIHU
lUH'rniT.ACH
OF MoIHI-'R
(Stat, i-r Couiitrv
niRAriON )W7/-,9 1 Months 1 !hi\s Hours
CONTRinUTORV
DIRATION
(Signed )
Vcais
\
OCCll'ATIDN Cr^ .
Uj. \ . Wv^i
\ 190 H fA<1dre^s) Li^t
Miniths Pays
M.D.
Yy\JiLM^<:s\.
Special Information only for Hospitals, institutions, Transients,
or Rfcent Residents, and persons dying away fro.ii home.
Ni'siiiril III Sail I'l am nrn
) rai
M.nifli^
lhi\
Former or
Usual Residence
Wfien was disease contrarfed.
If not i\ place of deatli ?
How lonq at
Place of Oeatli?
. Days
rm: kmovk stati'.d t'Hrsonai, I'ARTiccr.ARs ari; rKri<; 10 tiik
r.IsST ()!■ Mi\J<N-(>\\Ij:i)C. H AM) XW.X.W.V
(Iiifiirniant
rAfl(1re<4^ V^JC'WA-Ax^^U^-W
kAM
I'l.AClC (11 IHJJIAr, OR RHM<»\ \I,
DA^jK..; H' HiAi. or Ri-IMOVAI,
I NDllKTAKKR
V
iN. B.—— Every item of informntion should be cnrefully Hupplied. AGK should be stated EXACTLY. PHY8ICiAiN8 should
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information*' for par-
son* dylnft away from home should be feiven in every Instance.
3:
%
H •'! 1' X,)
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•■^^^-' I'^^I'^''' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
A
100 \
Registered J\^o.
2±m
Dale /'y/r^/,A/etxrUt\; T
Km^k,^ Ix^ Deputy HeDfth Officer
DEPARTMENT k PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
( Ta. S. StauDnr^ )
%
0^
PLACE OF DEATH: — County of ^^OJ^fK, J \/\y-y lou-^^o City of Oa ^a. J V<Vv\.cc4 co
Ng. . .U , XLV. R-t^ ub 5-4.1 vCtaJ; St.; Dist; bet. and
(IF DEATH OCCURS A\*(AV 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. /
it
FULL NAME
CuW,».
V 1 f
^i;\
PERSONAL AND STATISTICAL PARTICULARS
L'nj.uR
(71-
.OJ
i>A ri: ni iuK rn
\\,V'
\
MEDICAL CERTIFICATE OF DEATH
DATl-: (»!■ Dl.A'lH ,. \
IL'ct
IQO H
(War)
H
5 ■,',/;
Dav
M.niii,
\ (MI
I his.
SIN<-.I,K. MAKKll-:!)
wrixnvKD or nivoRnr)
iWritfin socinl (li--i<.''!iati()!i)
HiK rm'i.AOK
'Stnti f)r CDUiitrv'
C
K.^r\j
/CUaJrCV>X^O
NAM! ni
I- AT H IK
lO^iL ^'
lUk 111 PLAr!-:
ni I \iiii:r
' ^' .\\' > < i ■, ,1111! r\-
ma!i>i;n n\\ii.;
<»1- M«)Tin,K
luirnn'f.Afi-;
<>l- Morill'.R
' Slati I ii ('i luiili \
tKAii'A'i ION-
IA a. VL^
(Mouth) (Day)
1 in;ki;nV CI;rTIFV, That I attended decvasL.l fmin
OjJfJj ^0 190H u. i)^ b r,)0 H
that I last saw h alive oti ^^ ~t t. 1,^^
and that dt-ath < HHurrcil, on thi- datv -^tatid aliove, at
V.'. M. The CAISI-: (»I" DKA Til was as follows:
Moil tin \ Pijvs IliUits
1)1 RAT I ON )'cavs
CONTRinrTOKV
L 1
I )r RATI ON
SIGI
Years
1) ^:
/Vl
'V
p
Hours
M.D.
^ b r.,oH (Ad.lnss) lol gx^tU.\; It
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, dnd persons dyinq away fron home.
-OVA-v^a
AV' '/(//./ If Sin/ / I it III f<ri> i ) ' 1/
^/.„>^/,s %% /)
Former or 1 « ^ 1
Usual Residence IclHn (J^Oj^ •
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
Tin-' Ai'.ox'i-: ST XT! i» I'l- !^s( »\- \i, i' \ k iKT !. \ ks A k ! ; Ik I )■. i'l I rn i-
HJ-.sr Ol- MV KNi )\\ l.l.lX'.H AN!) in'.Ml",!-
1' In fi I! ma tit
ih
\A
lO^j^-y^j H^^ct'ut
fAililrt'SS
3.HH
V
<XX4 " '■
I'l.Ari-: or iuriai, or ki:Mo\\i,
M LOLiv<X' La.A
r M > 1 ; K r A k i ; k uId . vT • \JJLLji\AJi/y
1>A I 1; .: lu I ' M .,T K I-.M(i\AI,
i) -I
■i
190^
N. B. Every Item of inf.»rmHt!oii sHduIcI b.- cnrefuliy nuppllecl. AGK shoiilil be Htiiteil r.XACTLY, PHYSICIAINfi iihouid
state CAUSE OF DEATH In plnin terms, that It mny be properly clasnified. The "Special Information" for per-
sons clyln^ away from home Hhould he (^Iven In every inntance*
;?i
«
M
i
N<
I
1< i;i r (1 Ml
H( ;i!t!i (■ N
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lU'vl' f
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/hf/r riJr<l, 0<±,(AM^' T
JOO'i
llciiistei'ed J\'*o,
?aiG3
•jf
,CrV,'w^:! K.A.
DEPARTMENT OF PUBLIC HEALTII-=Clty and County of San Francisco
dcvtificate of ©eatb
"U. S. StanDarD
J? iTJi)
.?
PLACE OF DEATH: — County ofU^X^ru 0 VCLAVC^^iyCoClty of C)<X/>^ vJ AXXy>^CA^<lo
^
Ne,
i^ OAirrv (fb 04..Wla IvSt.:
Dist»; bet.
and
/ IF DEATH OCCURS AWAY FROM WSUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPEC
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION
GIVE ITS NAME INSTEAD OF STREET
lAL INFORMATION' \
r AND NUMBER. /
FULL NAME
M I Lojvu V . cL<X/V> uC , '.
PERSONAL AND STATISTICAL PARTICULARS
DA il-; (»1 lUKTII
L'oi.oK ^
u
M^
I.inthl
A(.i-;
-'i^ ,. t
1A.>/M«
^l
» t-a r
I hi
WIDnWi-:!) « »K i>i\( iRi} I)
iWritrin «-i(oi.il il< '-.i<..iial i.in>
lUK rui'I.Ai^H
' St.'it f or • 'on titrv)
\kaxj5^
Crv* ^ ^
MEDICAL CERTIFICATE OF DEATH
UAl'K OK DKATH li'N
fMnlllh)
,, I in-iklU'.V CI'.RTII'V. Til It I aUeiuled (ItHH-ascd from
%
TQO ''
)a.v)
iVt-at )
ax^Al.
iPctj 3..
i</i> . to ^ v-VJ v:> i(p
that r last saw h •.. ali\i oii C 6 Kp
and that death ncrurrcd, oti thi- datt- stat(.-d al»()\X', at
M. The C.MSi; (M" l)i;.\TII was as follows:
i\XA,*^-"
I
nIVA. ix,<XA.^< ,
\- V^ > wCL
h r.
^
0
fS s
luR I'l iM.A( i:
oi- i\iin-;R
' St :it I » il k' i in Tit 1%
M\n)i:x NAM)-: a
F.iR ini'i, \i'j-:
oi- MnriliCR
(Stat',' iir Coiiiitrv
n(,'iM I'A rioN
\ '
I )r RAT ION ' )\a)s
CONTRIIUTOKV
DT RATION Ycat'S
(Signed) o, ou'
Months
Pays
/fours
Moni/is
/hrv
l^'L.
Ilonn
M.D.
u
f«)n
(A.hln-s^) \%\ ^-t<XAA.
^
SPECIAL INFORMATION only for Hospitals, InsWutions, Iranslcnts,
nr Recent Residents, and persons dviny away from home.
kD4X/>-
h'r :,!r ! ni Su >/ I
I ,1 i.'i ;mi>
}y,!
M.nii;
i>,i
I'll i: \H»)\'i'. sr \ri-:i) i-krsovai, rARricti, \rs ari-: pr r i:
iu:sr «)i Mv Kx<)\\i,).:i)r. !•; and i'.i;i,n';i'"
I'l > I'lii",
(Iiifonuant
Ktr>Ay V^ c3C<X' ^-^ V C
?l
f Afldrcss
CL/A-wtA-^O
Former or
Isual Residence
Wfien was disease contracted,
If not at place of deatfj ?
r\
How lonq at
Place of Oeatli ?
%
Days
i'Xt^CK Ol'" IHRIAI, OR R1':Mo\'\I, jl)\ru,,: Hi Ki.u, ..t Rl':.Mo\ \l,
(i
CLA'AyU.'CrA
^^
\
11
lool
! '.. K.,'
(Address sLbblo \I iVvO^ wo *
N. B. Every Item of inforitiHtion should b.- ciire»'uli> supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain term*, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be given In every Instance.
0
o*
I
"f""^
1$ I
I
^1
'1 i; 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
"/ \ i *'., REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Dff/r ri/rd ,
7
IDO'i
liro'/s/e/ed 'A^o.
2104
I
-Cruuv^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiftcate of S)eatb
( XX. S. StaiiPar& )
n
i
PLACE OF DEATH: — County of A "tAj J/UX^/vCUSyCO City of aw J AXX/wXlA^<^0
No. I o I ^ ^.y^ K^O^iijuu- ry.AJ
V
4^
^
^-a,x;
'i) K^<k.<X.Kju- Cs.AJ St.j i Dist.;bet. (laiycUl and --^-Q
(ir DEATH OCCURS AWAV FFtfoM USUAL R E S I D E N C E G I V E FACTS CALLED FOR (^NDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
cCrXax
1. h -
..K.h
PERSONAL AND STATISTICAL PARTICULARS
•Ml. nth" .l):i\i
MEDICAL CERTIFICATE OF DEATH
DATi-: oi iii;a'i'ii /
'Month t
Dav)
rgo :
) .^u^
M.>„f/i'
iWvnx
r>,t\.
\vii)M\vj-;n OK niviu'.ti I)
'NN'r.tc in •«iiii,ii fh'-i^'iiatioii )
UA '■ .
liik riiiM, A*M-:
(Statt or Ciiiititrv
N\M1- <)!
I- A rn i;k
HiK rin'i.ACK
OI" lAiin^K
' ^tat'- or t'dtuttrv)
MAIDllN' NAMi:
OI' MOTiniK
niRTiiiM, xt^i-;
Of M( (THICK
ISlatf or ('(unitrv
oi'Cri'A TION
r
I IIHRI-BV CHRTll'V, Tliat I attc-iulcl dturascl fn.iii
Ui^-CLA4 ;: 190': In ^xAni 2)0 I()0 U
tliat I last saw ]i - alive on jJU'^.. i,p
and that (Icatli orciirrtMl, on the dati- -^tatt-)! al)()ve, at 10
>
W.L M. The CAT SI- OF I) HATH was as fol!..\s^:
%
I i <
u
1
A
nr RATION
}'i;ais
Mo'i//n
fht
rv
I /out s
CONTRIIUTORV
DlRATIoN
)'cars
-\
Mi>ll(h.\ o /?r/I',V
^
i i
(Signed) nHI. U. KJ ; -» - ,
//ours
M.D.
Special Information only for Hospitals, institutions. Transients,
or Recent Residents, and persons dying away fron fiome.
Rr.siiii'if in Siiir I'iidi,
i r,a>
M. ml li-
no IV
Former or
L'sual Residence
Wlien Has disease contracted,
If not at place of death?
floH long at
Place of Deatli ?
Days
Tllf, MU)\'f: ST \l"in I'J'R^nN A !. PA K I" r< ' f I, A K - AK ]■; I' R f 1-
nf:sT of MV KNOW i,i;iH,i.: wn lujjf.i-
^
I'o TIIK
Itifonnattt \j<J
KJ
<X/^rsi\j
I
f Address
^
A
I UUl-
DAXi-: o! Hi KiAF. or Ki;mo\'AI,
T9O i
I'fACK OF BfRlAI, OH KKMo\AF
mo I:
^>St--'v*
IN. B. Rvery Item of informntioti shoultl be cnraV'ully supplied. AGR should be stilted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it msiy be properly gftissilried. The "Special Inlrormation" for pap-
sons dyintl away from home should be Jiiven in every instance.
Nlii
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ill!; l- N.)
11 Jff ^^»%^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
D^f/r FiJrd, llJctcrLux; 1
100 "{
Begisfercd J\'*o.
;52165
.<n.>Ly^w^
DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
PLACE OF DEATH: — County ofOcXy^^ I A^CL-rx^cuiXoCity of ^
i
^No.
\J
\> J.^<xrrcei V
^^^•^ '.'V. ^<l'v^.L.'A. St.; Dist.;bet. and
(IF DEATH OCCURS *WA!V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME cLc^^v V<,)0
Ic .
--I
PERSONAL AND STATISTICAL PARTICULARS
'V
I' \ I'l-: or- lUK III A
4 I LoX'
M.mtli'
\ " . !•;
^I\r, 1,1*. M \KH ij.j)
\\ \ i>i i\\ i:i) < »R iM\< M<r i:i>
i U'l it< ill V. ,( i;i ; ili^ii' n:it ii in '
:>:iN
M.nif/n
MEDICAL CERTIFICATE OF DEATH
DAii-: oi' i>i;\Tii ,| \
( Mi.lltlll
(I»av
(Year I
I m-KIU'.V CI'kTH'V, That I attcMi.le.l .Itcvav^cl In. in
/»,,
i
lUk I'HPI, Ai'l-; 0
' Mati or ('iiimti \ ' jf
Xa
»■ X III i-;r
lURTin'I.AtK
<>1 l-ArilMR
■ ^l.ltc (H I'ninif I % '
M MIM.N X \M)
()l Morill-.R
lUKTlMM.Ai'l.;
nj- M«»rii|.:K
( Slate or I'outiti % 1
i
90 \ to s-^ V,V J i,p
that T last saw h v. alive on ^ -X "T: i,jo
and that <lcat!i (KHnirrol, nn the »lati- stated al)<>ve, .at v 15
M. Thi- CArSl- Ol' I>i;.\TII was as follows:
1
>veuXo \' \^ <,\.^c^
'7
.^
IHR ATION
CONTkllHT
i''-'
Ytixrs
Month
\
( ) k \' c)
m
ix^^^^tSw.
i '"IJ.
Pay
HoiitR
DlkATION :^ Yens Mo)tths
(Signed) ^l j ^xxxx
MJx.<U.JL<xA,'
Pavs
r\JLt
Kt'^iiiiuf III S,iii t'l n III I >i'ii \
t^Cl;
1 90
Hours
^ M.D.
Special Information only for Hospitals, InsmMHoBS, Transients,
or Recent Residents, dnd persons d)in9 awdy fro.n home.
! iiu
t;, M.„lh-
IK
Former or 1 y
L'sudI Residence "^ WL<Xu,
When was disease rontrarted, 0
If not iX plare of death ?
1
How lonq at
Pldif of Death ?^ > >i.(^i.J^Oays
I" 111'. AH(»\'i', sTA'n:n i'»-i<sn\ \i, p \k ihi i, \k-, ak 1; rkii-: lo rin<:
HiCST ni M\- iyN'< >\\ 1,1.1)1, i-; \M) ni;i,ii;i
f !iifoiinaiit
0
' Nildie-ss 0
^
a
PI.ACi: Ol- lURIAI, nR R|.:m«i\aI, j l»\l!;..( lit MiAi, or RlMnVM
.O^CcC \w€
TOO
y
N. B.— — r.very item olr ittfuf million Hhould b.« ctirtifiill.v Huppliecl. ACIli whoiild ho Htnteil HXACTLY. PHYKICIAN8 nhould
HtHtc CAlISli or Dl: ATM in plain terms, thiit it miij he p?"upcrl> cluimiiiieil. The "Bpeclal Information'* for pmr-
monn dylnfi tiway from home Hhonlil ht- ^iven in evory inHtnnce.
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ddfc i^i/('(l ,
Be^isievcd JVo,
^1G6
Deputy Heclth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Crvcu) civ.
Certificate of H)eatb
PLACE OF DEATH: — County of^Ct'-rv JXOxCC^co City of'^<X/>x. J A.<X ^-..ci^^co
N^.vy ^AJl.
(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. /
.ALi .'. . V St.; — Dist.; bet.
FACT
>EATH OCCURRED IN A HOSPITAl. OR INSTITUTION GIVE 11
FULL NAME
and
\llqA.u > K,
^ \ : \
i) \ri; i'l liiKTii
PERSONAL AND STATISTICAL PARTICULARS
foLoR A
MEDICAL CERTIFICATE OF DEATH
II I
+-
■^ / ',
Ai.l-
M.Milh)
5'
Dnvl
V,.,,/^.
Monthi
I>riv1
/go ,
(Yf.ii
I in-RI'lJV i.'i:RTn'V, That I atu-iitk-.l .li-.t-ascl frnm
V ^ 5 ,.^ H
1 ..A. . 190 . til
that I last saw h ' ■ alixt- on
/>■
^l^:•.I,l■. MARklJ'I)
u nM»\v}'i> OK DixoKi i:r)
I U'l iti ill -I H i.ii ih ^i^- iiMli'iii'
"-•tilt I I ii t, 1 >niitr%* '
w (
NAM) til
I'AIH I-.K
lUK 11! I'l.At'K
ni I \ 11! i.R
MAIUKN' NAMl
ni- MOTHKK
(Stalt or I'liiinti V
A'/' ',/,'//'(/ ,'// S', /;/ / I
%^
apJ that (hath orfiirrt'd, on tht- «lati- '-latifl aftovt', at
^.--. M. The- C'AI Sli Ol" l>i;Aril was as folluws:
lc)0
1
x<k
K^O^Kk
I )r RATION y^ )'tius^ MoHlhs
CONTRNUroRV .Ct\A
Pay
%
Lb
D
rvcoxa
DIRATION
(SIGNED)
i()n
rA.hlnss) 13.1 M I
/?rt vs
Hours
- -3
re.?
': §^
//out s
M.D.
C c
^^
Special information onh for Hospitals, Inslituflons, Transients,
or Recent Residents, dnd persons dyinj dway from liome.
Former or "^ ^'l
) t'li I
1/,,.////,
fhi
vnv. \m)\'V. HTsrin pkkson \i, i- \h i iti-i.AKS ari: i'kiI'; to in i-
ju;s'r oi- ?,n* knoui,i:i)<,i^^m» inijii-
(I
"?)
f \<i(i!<"i< ( 6 ^ \J
0UCUA<..C
Ai,
:5 H ffow fong at
Usual ResidenceO/O/^rv J/uOAxCAA^t Place of Deatli? ^^Xi^x.'.... Dms
- - ' ^ '
Wfien was disease contracted, p.
If not at place of death ? ^ ' <X-y\j 0 ^_<X/>vOUl/ao
T0O*i
l'U\i"K OI- lUKIAr, OK RKMo\ AI, j n\'ll ;<,f IIihi.u, or KICMOVAI,
(Atldress . .
N. B.-^F.ver.v item o* Inlformatloti ahould be CRrefully itupplied. AGR should be stated RXACTLY. PHY8ICIAINS should
state CAUSE OF' DEATH in plnin terms, that it mny he prtipcrly classified. The "Special Information** for p«i—
nrtnm dyin^ oway from home should be given in every instance.
i
;l
\4
|;-;ii.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
f !I alih 1 No 1^, ^ ■^D'- H^^lOu REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Drf
fr FiJe<L VdiAyXA) 1
cL^CrO-^*^
Deputy Health Officer
Be^isfererl Mo,
216?
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No.
Certificate of Beatb
( U. S. StanDar^ ,)
' • -. City of Cj/Oax/ J AX>. .
\
St.; \ Dist.;bct. ^O \ H ^ , and ^
(IF DtATM OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
PLACE OF DEATH: — County of 0<xov -J Xo
C r A M,
^'
(
FULL NAME
YY
Vri
W . ! - r !
-•I-.X
PERSONAL AND STATISTICAL PARTICULARS
A i idl.oR
DA 1 i; ()i IliRTIi
'J
u
n.
.%<*. K
«IN< ,1,1' M \KI< nil
n^'IDmu i-;i» (»K i»i\ ( ikii:i)
Writfin social di -.ipn.itin!!)
lUR'nipi, Aoi-:
I St;it( I i! < 'i 111 nt ! \
i I».l V
Mxiiln
\ cai
I 'a !
Alcd
NAM I-: <H'
I AT III-; R
lukriii'i.Ai!-:
iStatf nr Count! V
MNini'.N NAMI-
<>i- Morm-R
IUR'rH!'I,Ai"K
OF M<>riii.:R
' state or ('(lunt I \
MEDICAL CERTIFICATE OF DEATH
DATl-; «)1* Dl-.A'I'II
1 1 i
' ' r
(Month) (Day)
I^m-Rl-.HV C1;RTII"V, rimt^ I at-cn.U.I 'k-irascd fi-.iii
SskXa^ \L ryo ^ to . ll'/cfc b itpM
that I last saw h •'. ' alive (ill sii/cli ^^ Icp'l
.111(1 that (Uatli (KX'tirrcd, uii tlit- dati' statc(l abnvc, at l- lO
LL 4r. The C.XrSI' Ol- |)I:.\TII was as follows:
(Vi .-ii
C
<X\/CW%'V.'0^'V>'\XX,
<A
n
1)1 RATION H }'(Uirs Mouths
C'ONTUinrTOKV \jOJ\JV ^ \ K.X.
/hns
] ) la. y VA.
I/ON
rs
H
I )r RATI OX ^ >''<^r^ U<iN//,s- /)av.s'
( Signed
OXKrrYxx^^^,
orrti'ATioN
h'l'' iiii-if III Siiir I'l i:
ID^
1 icpH (Arhlrc-^s) 15
V NflflxXAjul il
I lout s
M.D.
SPECIAL INFORMATION only for Hospitals, institutions. Transients,
or Recent Residents, and persons dying away from home.
)'rai
M.o'th,
Ihn>
VUV. Al{(»\ K ST X'I'I'.n I'KRSONAI, I' \ K r H' ( i.A K S ARl! IRtl-: To Till-:
iu:sr ui- M\ KN( »:^ i,i:i)<; K and iu:iji:i"
nnroiinnnt
Former or
Usual Residence
Wtien was disease contracted.
If not at place of deatli ?
HoH long at
Place of Death ?
Davs
I'l.ACK <)1* IHRIAI, OR RKMn\AI, | DXri:.' I!?Hr\r. or Rl-MnVXI
/Y\X<X,
n
tNH)';RIAKI-:R '^^ tx.
I Addi i-s'.;
IQO
^VkA.t ,
N. B. Bvery item of InfnrmHtlon should bj oirut'ully Nupplieii. AGB Hhnuld he i«tAtecl BX4CTLY. PHYSICIANS should
state CAUSE OF DEATH In plnm tcrm*t. that it mny he properly claasiliied. The "Special InformHtion** fop par-
sons dying away from homa Hhould he given in ev«ry instance.
^
H^
A
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!i,l of iicnUti I- No. I'; s'^ =^^^^ nsz)' r.)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
If) a
DEPARTMENT OF PUBLIC HEALTH
BegLstei^ed JS^o,
^1G8
City and County of San Francisco
Certificate of S)eatb
City of
A
9ri
\_<X/>^<:aa^c>c
PLACE OF DEATH: — County ofUO/^r^ JXa tv
Ne. J AJl/^ VC Ki (J\jCy<LKa_nu St.;—- D{st.;bet. —and
/ IF DEATH OCCUHSIAWAY 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
VVYV \
rVYv \JCrcc4CL
sj:v
PERSONAL AND STATISTICAL PARTICULARS
1(11, Ok
\<xU
II
HA ri" III i;iR Til
\ « . !•;
MEDICAL CERTIFICATE OF DEATH
DATH OF DKATH ( fX
■ct
iQo'i
(Vc:ir»
■-, h
^IM.I.I" MAKRfJ:i>.
iWritcin ■^•MJal dt -ii- ii;it u 'ii >
HI HI' HIM, \0K
' Stati i>r Ci itintrv
)V<n
Dav
M.>t,fln
f'h'i'\
t I a I
/>u\
\a ' '-^KjuL
(Mo!itls> <I)av>
I HI-:RI-;1',V CI:RTI1"V, TIimI I aUfntU-.l .Itrva^oil from
^ ..•^:, ,x. ■ •- U)0 , t<» ^^ u^' i i()0 1
lliat I List saw h ■ alivt- oti A. up
and that <U'ath Dccurrcil, on tlu tl.iti- <tatt'<l ahovi-, at ' oO
.'. M. The CAISH OF DFATH was as follows:
.1 , ,'^
LLcLA^Ajtx ^Lcri^OL^u 'J
•\yULKA
'\
N \\f)' OI-
I A I 1! i;k
HIR'lIII'l.AOK
Of- l-ArilKK
' State < ir ('i miiti %■
OI- MOT I IKK
liiRinri.At^'i-:
OJ- %i<tlIIHK
(Staff i.r CDimtrvl
0
(
v
(
Dr RAT ION
Viars
^'
.^/i>llt/lS
/\u
IIoii)
CONTkllUTORV
i • "t
y^w
iun'iT?!
J
^VCX
oriTl'A'i"ioN"y
AV,;,/,
DURATION 1 ii^/;-^ b .}r,>nt/is
Ihiys
(Signed)
U . k,-
Hours
M.D.
ll)0
(A.Mn
•s^) 15 \ j.tcLLA.S; jL
Special Information only for Hospitals, Insfltutlons, Transients,
or Recent Residents, and persons d)lnq dHdv Iron home.
Former or
Isual Residence
Ho*» lonq at -
Plareof Death? 4H Oavs
// >^! IJ I I il 11, '.-III I.
) '/il I
M nllh-
lh-S
\'\\V. AT50V1-: STATi:i) |M-R^M\ XI, I'XKTICri.AKS AK1-: TRIK '1<> Till-.
Hl-.sr Oi- MV KNOW i.j I)( .f; AM) p.i:Mi:i-
(Infn.niant U^Mr\X^'CL Vj '
Oiw\.cinX
N.Mn.s IIH^ VJcnJ^ oi
When was disease contracted.
If not at place of death ?
rijACK OF !U RIAL ok KKMoVAl/j IiAII'..* Mi imai. or RKMo\AI.
^ \ -\ "-
^NI»1^K lAKKR H. . i 1 *.
d O-CLL'^ '
(AdchcHS
S.05Jsn\>rrUxv^>v\^\i^ 'I
IN. B. Rvery Item oV inirof motion should hi cnrefully Hupplied. ACJB shouhl ba Htnted BX4CTLY. PHYSICIANS should
state CAIJSII OP DEATH In pltun terms, that it may be properly classified. The "Special Informiition*' for per-
sons dylnUt away from home shoultl he i^iven \n 'jvery instance.
i
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,f III nlth I" Vo. 1=, X"-!^ :=fv.;,>; ]>,f:^i> (_•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafr /vV^v^ U/ctX^
T
190 "i
Kc^lstercd J\^o.
O
169
'^^A^
0 n \ I
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "a. S. StanDarC* )
PLACE OF DEATH: — County oiUKXrrx) J VCu^vCUi/CoCity ofC Oa^ J Vcx. Tvc-^x^'a
o
,'0
Wo. loll LcxJl\X) St.; 'l Dist.;bet. IH.IK 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. J
FULL NAME
CL\.C'tX^
(\ D?
cuVt '..
PERSONAL AND STATISTICAL PARTICULARS
UWV. «)!■ lURTII j^
m
I go
(War)
\r.K
(Moi
\
fh>
Uav
MiOlfll!-
\ (at
A/1.
•^ IN 1. 1,1' MXkuii'n
U ! IH t\\ TI » I (K It i\'< >R.- I' I)
' \\ ! it! in ■-III i;i 1 ill >-i;' !lat •< 111 I
^'W^
L
lUK riii'i, \oj-:
"-"tit I I ii < I mill I \-
I AT in; R
I'.ik'rui'i.AcH
oi- I Arm-tK
I strife or Cijinitrv
MAtniCN NAM1-:
')! MoTriKR
inurni'i, \( !•;
<>!■ M(»tiii;k
(State iir Ouunlt
< H(. ri' \ riox
MEDICAL CERTIFICATE OF DEATH
DATl-: Oi' nivXTH
-. ± ".
(Month) I Day)
pi HRRI-l'.V fliRTII'V, That f attendtMl .UhcischI fruiu
OjJ^ T 190S to L^'Ct b TQoH
that I last saw h -thj ahvc 011 vL' ct b up H
and that dralh orciirred, on the <latc stadd above, at O
LLm. The- CAl'SIC ()!• I)I:AT1I was as follows:
n n
nr RAT ION )'i'ars
CONTRIIHTORV
Months
Ihiv
//ours
DTRATION ^ VCi^rs .^ .Vou//is
'2
^
^^-y-d^-
^^y^xX wLj. A u^
Jl
(Signed )
/)(7VS
//,
!]
CrV^
ly.cfc 1 IqoH (A. hi less) H^b^
^
(Stirs'
M.D.
p.
A'^A.A'yv
SPECIAL INFORMATION only for HospiUls, institutions, [ransients,
or Recent Residents, and persons d>in;| away from liome.
f\f,i,h'ii ni Siift /'iiiiiii^iit
.1A.„'//>
/),/
Tni'. \H<)\'K s r \ 11: 1) iM'"Ks<)N- M. I' xKiji'i I, \ks AR )■, vuvv. I" > m \'.
iji-;sT <)i- MN KN'i>\\i,j>i)(.i-: ANi' iu;i,ii:i'
(Fnfii'iiiant U
0
^\ii,ii,sH 1 3) 1 1 L/QuitA.^ c)i
Former or
Usual Residence
Wlien was disease coritrarted,
If not at place of deatli?
How lonq at
Place of Deatli?
Days
T90S
PI,A01<: ol- lU KIAI, (»K KI:M(>\AI. I liAXi;-'! HiHiAi. or KIM<»\'\I
I N 1 .i:kt \ K ) : K U <XLt.rLtX N fXoAAyvuk
N. B. Bvery Item of informRtion should be cBrulfully supplied. MW. Mhould be iitnted HXACTLY. PHY8ICIAN8 should
•tote CAUSE OF DEATH In plain tefms, that It miiy he pr<»perly wlamiified. The "Special Informtition" for p«p-
fion« AyXnf^ away from home should be given In every inntance.
3
■i'\
II
iJi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IfJO'i
DEPARTMENT OF PUBLIC HEALTH
Be^istcred jYo.
J^l7o
City and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County ofO,a/>v J.'U3^-»xc^^co City of U,(Xa^ J A ->
/ ^ _ -= W
No.
Q
0
\ N
iSu'i Mf ^CC<irvA^d St; M Dist.;bet >^^X^ and
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED ^O R UNDER "SPECIAL INFORMATION ' ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME t^STEAO OF STREET AND NUMBER. /
'-^
FULL NAME
o..
S^^s»i^
PERSONAL AND STATISTICAL PARTICULARS
iiAii; iiF HiRni
\'. iiflit
MEDICAL CERTIFICATE OF DEATH
DATl-: oi- Iil'AlU
( S"t a!
).. \
\< .!•;
SINT.I.K. MARK n:i)
wrn<>\VHi> c»K n'\ I »ki )-;i)
(Writfiii sc)ci;i' ill ■~iL'ii:it ioiO
lUK riilM, \ri"
: Stati- ..! 1'^ .init 1
lA
» i-ai
/',.' ^,^
OJxKxxA.
0
XX/rw
r>
XAMI-: OI
FA Til MR
niKTIlI'I.Ai'K
• )i- ! Arm':K
IStati (it Cdiitit I %■
maii»i-:n NA Mi-
ni M()i'ni;K
HlR'rillM.ACK
(»i' Morm-.K
1 stall lit l'( iiiiit I \
UiiTPATlON Qp
i^ % il
u
iM.mlh' (Day)
I 1I1:RI';1?V C1-:rT1I-V. That I attt-n.k'.l .Unx-ascMl frcni
^ O" '1 ■ * ^ . ■
\l 1 . .. 1 90 ti> I()0 ■
that I last saw h . aUvc on icp
1 A
and that 'Uath orciirrcil, on tlic dali- ^tatt-d ahi'vo. at \ '
^l. The
r^M. The CAlSf-; OI" I)l':ATn was as follosvs
DrRATlON )Vars
CONTkllUTORV
Mouths
Hiix
Hon
rs
\jX
YVCX<Lou
I )r RATION )■<<//,? Months
(Signed) cxaaalkak Wk^
Pil vs
T<)n
(A.hlrt-,0 llIM
U)
^ Kj
^
//out s
M.D.
Uii ...
SPECIAL INFORMATION only for Hospitals, Institutions. Transients,
or Recent Residents, and persons dvinj anav from tiome.
A'
AV.>/</i"(/ II! ^,/)/ /
^ ) '■./ '
\':,lfllS
/',>^
Till-; AnovK ST Ann i'i-ksonm, !• \r iim, \rs aki; prii-; to rii i-
in;sT oi- MY Kxt )\\ i.iix .1-, vM) iu;i,n;i'
(IiifoTiiiant
ijo, a. ^t
A '-1
( \(Mr<-ss
150^ Nf^\a^^,
Former or
Usual Residence
Wlien was disease rontracted,
If not at plare of death ?
HoH long at
Plare of Death ?
Days
&
M,AOK 01' HI RIAI, OR ki.;mi)\ai.
i>\ri;..' niin\i ..i Ri-;Mt>\Ai,
Tf)0
N. B. F.very item ok' inV'ormntlon should lie ciir«lfuliy supplied. AOB should be stHted KXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for psr-
sons dyin^ away from home should be ^iven in every instance.
t
\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!J,.anl (if II. :l!tn I' N'o. Is T^l
'.K r <■
REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Drffr F//r(/, ^//
1
loo'i
Mo<lLstcre(l J^'^o,
2171
Deputy Health OfTicer
DEPARTmENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. S. StanDarD j
C) /QWX J O KjO^'-^/X jOA^C.^ CA t V of C ) ,<X.ry\i J
No.
PLACE OF DEATH: — County of "^ J/(X/Y>J Oy\xx.^wx:i^XLC<iCity of ^ ).<X.ry\, J \.<X/v^x^LA/ao
'^ ^ ' " M Pv \^i A V. c r . St.; 5 Dist.; bet.
^ UK^ and 'IC
(ir DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
x-
> .'., \j
/O
PERSONAL AND STATISTICAL PARTICULARS
^I'X
^'
«»i.<»K ^
nx I'U or lUHi'ii
A I ■.!•■,
0.
.Ctx-
/I'lH
M.itith)
n.iv!
M,»iffi>
MEDICAL CERTIFICATE OF DEATH
I) ATI-; <»i* Di: \ in
Mi.titli)
I):tvl
(Vf.-ii)
1 iIi:Ri:i;V CI-.RTII-V, Thatl atteniUMldecease«l from
V<:X
/),
•-IXr.I.I- NJ \RUIi:f>.
Willi i\\ j: n <iK i»iv< iRri:i)
iW'iiti in ^i>i-i;il (U'viy natiiiii)
HiR rm'i,A»'i.:
i state 'It t'l HI lit I %■
r
\jO
NAM!* <)!•
HATH i;k
RIRTHPI.Ac K
nr* FATin:K
(State or Counti \-
N! \n>i:N NAM1-:
<)!■ MnTllllK
lUKTm'i.ArK
n|- Mn'rH}.;K
•Stale 1.1 ('..null \-
i
alive nil
KpH
u .
VI.
tliat I la^t ^a\v h .;> alive nti ^-' ». up
aiitl that <k-atli occurred, on the «latc statc<l above, at '^l oO
M. The CArSl' ()!• DI'ATIl wa. as follows.:
t/L.'
niR A'riON H }'rars A/on //is ^ piiys
c ( ) N T R I in ■ r( ) R \' LL\X^'c^\-Jl<x,\/ y
.vn,*>v<x.
Hour
t
^y\j vjL^^Uou
^jlLo
V
nCCri'A rioN
K'''.'{i\f III Stiti I'liiiiim'ii O O ^ I ii I
tctrs
AFonths
Davs
I/i
)HIS
DTRATIOX 10 K..
(SIGNED ) \J. vj . M / iMVi M.D.
vi'/CA! 1 inn'i rAd.lrcss)H5l UaA\.M\i4A. LI
jS>^.
Special Information onlv for Hospitals, Insmullons, Transients,
or Recent Residents, and persons dying jwdv from home.
Months
/>,n.
THl-; AHOVK STAI'i:!) I'HKSOV^I, 1' S K I' I' ' I I, A KS A K I". TRIH TO THH
BKST <)!• MV KNOW 1,1 I)(,K \NF) I'.l ' 1, 1 1", !•
(Iiifiitiuatit
^\ka
dhK^V
N'i.ii.
5.15 m H KAXUMw-^rrV dt
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How tonq at
Place of Death ?
• Days
T90
I'l.ACK OF BtKIA;,<iR R1<:M(i\ Al, I l)VTi;.,f Hf KiAi. or RKMUVAI,
I- N I > 1: R r A K i: R > Aj . U L<ry\/W«\' X L 0
(Addrtss
'XA.A^^iryx, (,
N. B. Bvery item o? Information should be carefully suppllefl. AGB ahould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain term*, that It may be properly classified. The **Special Information*' for psr-
sons dying away from home should be given in m\9ry instance.
r
r
♦li
I
tf
WRITE PLArNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H. 1:11.1 i.f H. lilh
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r n/rr/, iL'oUlj
MA;
/,9<9H
ResiLsfei'ecl J\^o,
O
173
-\
^^^Aj<^ dXvu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTI!=City and County of San Francisco
Certificate of £)eath
( "U. S. Stan^arD j
oiOCL'YXjJA.XX/yXQAJKl^ Citv of d
PLACE OF DEATH: — County
,>-u J -^xxAOX^cax^o City of u o^y\j 0 xc '
St.;
0
Dist.; bet.
and
(IF DEATH OCCURSAAWAV 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
iL
1
M
\. JV-cCtuii LAjiOj
:^,Mf I
l> »
PERSONAL AND STATISTICAL PARTICULARS
SKX
I • >I.i iK
i'ATi-: (»i lUKrii
' v^ --
M- nth)
MEDICAL CERTIFICATE OF DEATH
DAI']-: (ii F»i; \ in
/go
(VtMr>
i >a V
^1.
/(,
■-IN' .1.1" M \R U 1 I'K
'stall 11! iiiuiitrv
I N rilKR
ink riiiM, Ai-K
01 1 XlilKK
' ■"'tati or Cuuiltl V)
M\II>i:\ N\M1
t»I M<»riii;R
I'.iK riipr.Ai^K
OH MOTHKK
"^tat. .,1 roiitlttv)
< n'r\- p AI'K )N
^
Ojr\j 0 /V'O
X\
kCXA^aJ^
A.
y
(Nfontli) iDay)
I in;R!;i'.\' ri RTII'V. TIi;.t I attc-n.k-.l .k-ctasc.l fruiu
Itp to _— - _ j^^
tliat I last saw h ~ ali\(.' on ■""" — " up •
and that tU-atli <H-('urrtMl, ciii tlu' ilati' --tal».'(l alxni', at ■ "
M. Tlu- CAISI' Ol- IHIATII wa. a- follmvs:
U)\^
<10J\KkJ^^
%jS-r" ^^ sj -— - ^^ '^
u
CX'^
nr RATION
CONTRimroRN'
I >r RATION
)'tiirs
A/oNt/is
/hiv<
I Ion,
U^n^
J/,"////s
(SIG
:l
NED) o. i. \&KjajzM^<
(>)uXou>^-*,
I()0
(A(l(lrcsv)\J/
Days
(
Hours
M.D.
^OA^x-frti ^LAjq
Special information only for Hospitals, Inslitutlons, itansients,
or Recent Residents, and persons dying away from home.
Krsiiiri, III Sdti /'i (iih isiii
}'tai
M.-nth-
/)</!,
Till" AHOVH ST \ Tin I'KRSnN \l, I' XKTirn.A Ks ARi; I'Rri-; ro line
iu;sT «)!• MS KN(>\vLi:i)('. H AM) h];i.!i:f
{Infnnnant NMVxA do. ^^ U- U i) .
0 0^
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq i\
Place ol Death 7
Days
IM.ACK (U- in KIAI. OR Ri;Mn\ \I. I l»\ri;..f Hi KMI, or RlCMoXAl,
,>\
o-w->%x, ■ '
\'Mi,
rL<xLc>vvxx vJt
^'dtu^l
IL^^ %
r N I » 1
; H T \ K 1 •; R \l ri J oAjijuy^ N K yS AXCU
inLQryuv:A r
(A.Mn
X/'N^tii^'u
loo'^
I
IN. B.
-Every item of informntion should be cnrefully supplied. AGK should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pliiin termn, thnt it mny be properly classified. The "Special Information'* for per-
sona dy!n£ away from home should be ^iven in every Instance.
1, >»;
f
I'
I
,J
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/>^^/r F/^^</, l/ct^rVlAj 1
irwi
]^i^ ! sf t> i ,'/] ^Yo,
2173
^
\K^
DEPARTMENT OF PUBLIC HEALTH=Citv and County of San Francisco
Certificate of Beatb
( 11. ti'. 5tan^ar^
A
PLACE OF DEATH: — County of J <X">% J VC^^ vcvCCcCity of -^Ctw 0 VCl-yvclA^Co
;i
+ \
^kLLCLu, '^WVLO^LuU-.l"'.lvC ' • St.: Dist.;bet. and
,' / IF DEATH OCcJbS AWAV FROM USUAL R E S i D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION \
y \ If DEATH OCJCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME \a>,\^^ v^L
si;x
PERSONAL AND STATISTICAL PARTICULARS
CX
i< A ri; Ml niRTH
\r, H
.Rct^
1
MmIuIiI
MEDICAL CERTIFICATE OF DEATH
DATK of^ ni ATI! , />^
iL'ct
3
(I>av»
(War)
li.iv
t
ui ill i\\ I n ( iR i>i\'( (Ri'i'i)
' \Vi itr i u -H-ial i|. -i^iia! mu)
iuk riii'i. \('i-
^i.iti- lit ( ■. itiiit r\
.UA.<LcrVc;
I- Alii l.K
inurni'i, \cr
•>i' i-\rm-;R
'Stair .ir rutnitrv)
HrRriU'l.ACF
<H M()THI.:r
'^t ;t- MI Coiniti \
Nf.tith^
1 lI!{kHi;\' t IkTIFV. That I^attrinK<l .k-.H-ase.l from
, ' Uy tn C'tvt) ^ I()0 H
lliat I I i^t ^.iw h V. ali\t on w wv^ o joq .
and that <K- ith . xrurrt'd. on the date vtatt'd ahove, at
_ M. Tlu- C.\! SI-: OI- I)i; Al'ir was as follows-
I)I'R,\TI()N )V,/;?
CONTKIIUTORV
Months IH llavs //<
oil PS
\
-K, w r )
> ^<..
Kk
?
occr RATION rp
'-i/UT>^^<r>^X
DrR.ATKiN
( Signed )
)'<•<// 5
Afofilhs
Pa vs
S>
b . L<r >'vt-
M.D.
Ic)0
H
Addn-ss)
^"^'V^ix.ow ^,c
SPECIAL INFORMATION only for Hosplljls, Insfituflons, Transifiits,
or Recent Residents, and persons dyjny awd> from fiome.
f^r ,.lr.' ,:
I '> ,
(/ III! Ill i r il
) I'ltl
M,,l!lhs
Till- \iu)\ ].. srA'ri;i» pkrsoxai, I'SKiim. \rs aki-; tkii-: to tin-:
!iI>T ni .ajA- KNOW 1,1, lM,i; AM) Mj;i,li;i-
Former or
LsudI Residence
Wfien was disease contrar fed.
If nof at plare of deatli ?
Now lonq af
nuft of Death ?
Days
Iiifi)tm.'nit
\;,':,ss yJ6'>^*'x^
"YW^A^^V'R
I'l.ACK OI" in RIAI, OR KICMOVAI, | DAI
-4-Wunruu
lAI, OK KI'.MOVAI, I DATRof Hi KiAi. <.r KK,\H)VM
t'.M)i;RTAKi;R
fA.I.
^M *< i/U/OLXl'OL^VV
N. B. livcrv item «>»' information should be cnfefully supplied. AGE should be stated RXACTLY. PHYSICIANS should
state CAUSE OP DEATH in plain terms, that It may be prtiperly classified. The "Special Inlformation" top imp-
sons dyln4 away from home should be given in svery Instance.
P
CI
I
I
■
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIfflCATC FOR INSTRUCTIONS
)!..a!'l ..f H.alth-l- Xu. i «; ^^-^SKvJ-J) lk"v I' C. i
Dnlr Filcil, %^
1-Lhj
lf)0\
Ecgistered J\'*o.
2174
,<ru^4^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
Certificate of ©eatb
( tl. S. StanDarO )
PLACE OF DEATH: — County ofCjCX^^VJ vJAXXA-X^CxAx^cCity of C)/CX/>^^ J \XX/v\-/C>Ut>cU)
%
t
No. 1 1 0 '^ ■ > '^ ', v-L C. '. X'-^ '■ St.; Dist.; bet. V-Q-AAX<JV'^'V<„CL and Cj ,CVC\,cv -, ^
(IF DE*TM OCCURS AW*V FROM USUAL R E S I D E N C E G I V E FACTS CALl.FD FOR UNDER "SPECIAL INFORMATION" "X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD g/F STREET AND NUMBER. )
, ..V
r\
FULL NAME
' -..'...N,
-i
n
44.
PERSONAL AND STATISTICAL PARTICULARS
I'ATl-: nl- IMRTII
iV^.n
LL^rvAjbt
I Month) 1
n
;i)av)
Qr
(
A<.1-.
!V
M.,nf>l'
fS"»'ar)
Par
MEDICAL CERTIFICATE OF DEATH
DATK oj" ih;ai'h
y^t
(Year)
^\ IDitU j;ii i»K IHVoKiHI)
i\Viit«iii siK-i.il (li siwnatiim)
lUkTHl'I.Ai'l-:
'Slate or Cnunt ! v
N XM1-: ni
I ATMl-.R
H k rill'I.Ai'H
oi i'\rin-:k
'■^titt I,! (.'iniiitrv
maii»i:n' xxMi*
oi- .M()ihi;k
luR'niiM.ArH
•>» MnTlIHk
^^tat< or Count rv I
'Month I (I>av)
1 HI'IRI-I'.V Ci;RTirV, That J attcii.ltMl (lereasctl from
IqOM to '. . lyQ
tliat I last saw li '- alive oti ^- " iqq H
an<l that death occurred, on the dati' stated above, at
U^X.
.M. The CAISI': Ol' l)i:.\TH wa-^ as foll.nvs
.K,<J^-y\j o^^/KA^ CJJ^^;t^.,^ JJ^cuvhJ^
I>r RATION Vears^ Mouthx \S Days
coNTRinrToRV Ll^t4\x. \x.s,a.
»V ■">
Hours
KO
(Signed )
Pav
Ilou
f s
li'.ct. % igoS fA.ldress) llOl lJxX'ruHU^^. U
M.D.
i\xj
OAXlt
nCClI'ATlON
f\f^i,!r,i III Siill /'l ,Uh / 'i,i
SPECIAL INFORMATION only (or Hospitals. InsmuJIons, Iranslciits,
or Recent Residents, and persons dying aytay from home.
Mnllth- A 1 /''M
IHI-: A!ir)\'H S'|-\ i-|:i) I'KKSOV \i. |'\kT!i!t.AKS A k I'. TK! H r< » THK
in:sT ni MA' Kxo\\ i.i;i)..H ^xi) i'.i:i.n;(
1^ I
Former or
Usual Residence
When was disease contraf fed.
If not at plare of deatti ?
How lonq at
Rare of Deatfc ?
Diys
\.i.i
^V-ft-CLYA^CC
.1
I'KACK C»F m RrAT. «>K RI:M.>VAI, I DAIVKof HiKtAt. or KllMoVAI.
o4u. L\,t^^^: I ^^ 'i 190 4
I MiKk lAKKK
'A.l.lrcss
\..^cry\j
1
N- »• Kvery item oi ififormntion should be cnrelfully supplied. AGR should be hteted F.XACTLY. PHYSICIANS nhould
•tote CAUSE OF DEATH in pi»iin terms, thnt it mny be properly clossified. The "Special Information" fop p«p.
«on« dyitij^ away from home should be feiven in «very instance.
'"Mf^^
!!
II
11
It
If
i
11
ll
il
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
luite Filc<l\ cUWv
^am^Ewmftnm
\
wu\
]i('oi,sfi'i-e(l jYo.
2175
•\.{ Deputy Health Officer
DEPARTMENT (IF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. 5. StanDar^ )
PLACE OF DEATH: — County of OkX^Vl- 0 VCl vx-" c -cCity of ^ -Oy^^- -' A OL/^ \ c c<l^ :i
No.
^\„N^^ "l
St.; 1 Dist.; bet. ^ ' ^ ' and M H a
/ 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
0.
^1^<X
S--V.
^i.Lu.
PERSONAL AND STATISTICAL PARTICULARS
IC
XaXJj
I' \ ri-: ^i\ iUK rn
\'.K
MEDICAL CERTIFICATE OF DEATH
11 1 I
Uavt
(Year)
I I1I:RI;I:V CI;RTII-\. That I attoii.U-.l .k-ixasc-.l from
^. .1/,'!///
ihixs
NX'iUi ill -^iicial il(^i>/iiati(iii)
C
N \M1- iH
1 A I'll IK
luKriiPi.Aii-:
Nt.ii 1 111 riiiint!
M \1I>I-;X XAMl
<>! MOIMIKK
inu rm-i, \cv.
"1 Mo'I'lII'U
(Stall ,! r..uiiti\
1'
f^
190 i tn W ,UV C np^
tliat I lasf -^aw h ..» aIi\L' oii v, cl. (, ^j^
aiul that iliath < ucii rrtMJ, on thi' <lat»- staliil ahovi-, al b
-^. M. The CAISI- ()!• DKATII was as follows:
^'X,*^^^.
u.a.
lUkAIIIIN )■<■,;;
t .
-^ I
JW<LOj 'v£> AAA-CcLo
n
1/
CONTRIIH'TORV
I )r RATION )rar
s
A/i'Hths
CX > v*.l\..?^ >
/hiv
Hi
'//; V
Months
7^
Pa
\s
(\
:^:l
0
\
Hours
M.D.
(nxlAM I A
Special information only fur Huspitd
or Recent Residents, and persons dvin'j cIhjv from tiome.
s, Ins"!
itutlons, Fransients,
! V(/ ;
'^
yir„iih>
/i
I'm; AJ5()\-j.: si' \ ri:i» i't''KS(»\ \i p \r rri'ii \rs a r i: rKi i: r< > rii i-:
nj':sr o].- My know i.i.di.i-. wn ui:i,i);i-
'Iiifii.inaiit
V
'^
I
\5
\<Miv^s $11. UrXjUlt^^uct
Former or
Isiifll Residence
Wtien was disease rontrarfed,
If not at place of death ?
HoH lonq at
Place of Death ?
Days
I'i,\i-|- OF IHRFM, OR RHMoVAI. I |.\TJ.;,,! Hi|.,ai ,„ RI-MoVAI,
NlHik'l
xkkrU^XaX'^a^ nTK^XM^ao^u h I <
190
A. Mi.
$aH ll
N. B. Rvery Item of informntion should !».• ciireltully Miipplied. ACf. h'k.iiIcI b« ntntetl EXACTLY. PHYSICIANS should
state CAlIsn OP DI:A TH in pinin terms, thnt it mii> »»».• properly classilfled. The "Special Information** for p«r.
son* dying away from homo should be given in s\ery instance.
;>
Hi
i
n
;5*i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
/)a/r /'V/,'.^ iJclolK-Uv ;■
y.9^H
Jicgisfc/i'il jYo.
21 76
^1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( XX. S. StanDarD )
PLACE OF DEATH: — County of^ 'O^AO^ 0 Axx.-vv/CA.^coGty of^-<X/>v JK.<X>^xx^c^
NcS^l ^
(ir DEATH OCCU
ir DtATH OC
St.;
RS AWAv FROM USUAL R E S I D E N C E G I V r facts
CURBED IN A HOSPITAL OR INSTITUTION GIVE
Dist.; bet.
'T
0
and
l IK
:ts called for under special information" N
ITS NAME INSTEAD OF STREET AND NUMBER. J
"^ (I
FULL NAME : 'X-tvav;. -Kcu'>\,l-vU , . Au
r^-
< I'. \
PERSONAL AND STATISTICAL PARTICULARS
i>Ari; oi- luk I II
\t.i-
^XA^
u
(\
h
imomli •
);,!>
IhiV
M.int/i'
(Vear)
MEDICAL CERTIFICATE OF DEATH
DAI']-: 111- I) i:\Tn
/'„■
^IN'.I.I-: MARKIJ'.K
\vii)(»\vi:i» <iK DiVciRri;!)
lUittt in >i(K-ial <lt-ij.rnati<m)
iWKrin'i.Aoj.:
^^t^it. -n I'.mnti V
(Month) (Day) (Vt-ar)
I m:ki:P.V CIIRTII'V. riiat I attcn.UMl ,lc»HastMl from
^^ Ct; H r.pH An. V.zt.l loo S
tliMt T last saw h ■ alixc on ^ A-ccLa^i^c ct 'I j,p \
a^l that lU'ath (m rurred, im tlu' Mate statt'il above, at \
)!• DIvATII was as follows:
ami that death o( rurred, (
vi^ M. The CArSH (
I
iVja^ '
I A'nii;K
lUK'rni'UACK
<>! i\riiick
'Stiti OI CduiiIiv)
^TAII>1:N' NAMl'
"I .M()'riii.;K
lUKTm'r.Aci.:
*)>■ MOTIIKK
'^tatf ..r eciuilrv)
Ut^
CyH V^CLi
\ 1
\ r
IH UATION Vvars
CONTRIIUTORV
Mouths
/hi
/louts
,u , w \ w.L,i:wJ.
N _ ..^
J : w:
Mi^nths
/hiv
k_, '^ '
CL-^-X' nJ Xa
u-^t c
nrrrpATiox
^^^^^ A'r'iifr,f i)f Suit / i,ni,i^r,> — )><?/» •- M»iHi- *^ 1 h> \
I>r RATION- Ycius
(Signed) Jb&uKUui jlaxv^ ,
iy-^ % i.,nH (Address) Hiio mxx\.kii ^
//ours
M.D.
Special Information only for Hospitals, InslituUons, Transients
or Rftfnf Residents, and persons dyinq away from home. '
I'll !•• \iio\H srAi'in* I'KR-^oNAi, i'\R riiM-r.AKs AKi; I'Hri-; r< » riii-;
HHST OF Mi_K,N<>\\ I,i;i><;H AM) HKlJi;!-
former or
Usual Residence
Wt»en was disease ronfrarted.
If not at place of deatti ?
Now lonq at
Plar e of Death ?
Days
(\.Mri-ss 0'j,L. U^lVC'L
\-
CA.7^CL
ri^^CK OI- nrKIAT. OH RKMoVAJ, I I)Arj:..f Hiriaj, cr KHMOVAI.
M^rvy^ £. ' ' • I ^'^ \ 190 M
^- B- Bvery Item of lnlf<,rm«tion •houlcl be cnrefully «uppliecl. AOH shoulcl be stated EXACTLY. PHYSICIANS should
state CAUSE OI- DEATH In pliiin term*, that it mtiy be properly classified. The "Special Information** for p«p.
mr%n% dying away from home should be i^lven In every instance.
'■^^
n
i ■
H
ii
II
11
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IS.i.ii.l <.f Utaltlr-K No. ! :; t«^vM^^ H&i' Cu
IDCi
Registered JS^o,
2177
'
\r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( U. S. StanJiatS )
^
\\
4 (5> i ■.,,
PLACE OF DEATH: — County of CX-va; J Xa v^.cuic^City of <X>v J X/X yx<i4^xi^^
N0.HIII . >
St.
Dist.; bet.
and
/ IF OtATH OCCURS *W»V FROM USUAL R E S I O E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ 10 DEATH OCCURRED IN A ^OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
\
FULL NAME Ii
PERSONAL AND STATISTICAL PARTICULARS
^1 \
foi.ok
DA IK nr lUKTlI
A<;i;
\ 5
Alniith !'
J 'e'll I
^IN«.I,R. MARKIHn.
\\ n)»»\\i<:n or divorokd
(W'littiii social <Usi^^nati<)u)
JL'
. I)a\
^/..„//,.
^
\\Ajij
r
1 far>
Ihi \>
(Y.-ar)
'XX^Y
HlkTHPl.AOK
estate or Coiiiitrv
N\\tl' ni-
I- A I 11 i;k
mkruiM.AtK
01 I AIHKR
' Mate or I'ointfrv
maii)i:n namj-
•>!• MoTHKR
lURTHI'I.ACK
<>J" MOTUHR
(Statf or roiintrv
OCCl I'ATIOX
fy^sided III SiTH /'i a III ii'i'n
MEDICAL CERTIFICATE OF DEATH
DATK t)F I)1-:aTH , j \
(NfotUli) (Hay)
I HI':KI<:IJV CI:RT1FV, That I attemUMl .Urcascd from
• ' ' 190 to U ct \ n^ H
tlint I last saw h .■■■' alive on C Cl. j^q
and that dtath occurred, on the date stated aljove. at
^ M. The CAISH OF DKATII was as follows:
I )r RATION Years
CONTRIBUTORY
Mouths
l\n
llou
rs
DI'RATION
( Signed )
Years
'SFottths
VA.
d^xIfC l<x^^.o
190 S (Acldnss)
Davs
M t
i t. , \
//ours
M.D.
) ra I
M.nith-
Special Information only for Hospitals, insmuiioBs, Transieiits
or Recent Residents, and persons dying away from home.
Till-: AiiovK s'fAri-:i> pkrsonai, i'\u 1 umlaks aki-: tki}-: r< » iiik
IIHST Ol- MY KNi)\VI.i;i)r, K AND liKMJ:!"
(Inf.
H tii.int
\
Ao.lrc... HiUj. at >M-Ci\Jx6 lU .,
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How loRn at
f\vt of Death ?
Days
Vl^CV. nv lURIAr. OR RKMoVAI. | r)XTl- of Ht k,ai or KKMOVAI.
'\
__4 V.
^'ct
T9O
-i
INDIIRTAKHR J tL
N. B.— -Every item of fnforitifition should be cacefull>- supplied. AGE nhould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnln terms, thnt it mny be properly clasnified. The "Special Information** for p«r-
Aons dyln^ away from home should be given in every Instance.
;?
■^Mi^:^
m
«r
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFfCATE FOR INSTRUCTIONS
Hoard of II. nltli-- !■' No. is t-Si^ST^) ]',{<^V (*o
Dfffc Filed ,
290 H
Registered JSI*o,
Of ^
178
■^Kjuus dXAjHj Deputy Health Officer
DEPARTMENT (f F PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( la. S. Stan^arD )
PLACE OF DEATH: — County of Q<X>v O/b-CL^veccixo City of '<X>v J V<X/yvAM^/c<i
'No. ' :\\-,'- , ' St.; ■■■ Dist.;bet. ''■ ' " "^ * '
FACTS CALLE_ _.. _. _„
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET
and
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
IF De4tH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
)
FULL NAME
-L
1.
4
1 .
s 1-; \
PERSONAL AND STATISTICAL PARTICULARS
j COl.OR
^
nAi'i; (»!• HiKTn
A<,1',
^
MEDICAL CERTIFICATE OF DEATH
DATK Ol IM.ATH
V^
(Vt-ar)
<U4
Month) jf
r,-,.'
iliav)
M.n,tl,
(Year)
/)(,' 1
HiNc. 1,1-:. MAKRn:i»
\vn)n\yi:u (»k i)!\«)Kri;i>
(\\'ritiiii soi-ial dt — ii'iiati'in )
HIRTIIPI, \i-!-:
(State or ('mmti v
XAMI-; <>i-
I AIUKR
FURTHIM.Afl-:
Ol- lATlIKK
(Stale or Coniitrv
MAIDltN NAMl
<»l MorHKK
i
h
Dts
f Month) (Day)
I III'RI-P.V Ci;rTII'V, Thai I Mttcii.k'.l .lect-ased from
U/) : to L Ct- X up 'i
tliat I last saw h ... ■ alive mi „ ^ A. », ij^
ami that doatli nociirrcl, on the date stated alxive, at l'^ SC
>, .M. Tlie C.MSi; ()|' I)l':ATir was as follows:
^wXCu^^^XDULoJL dJA-lv,
a
Ouy^
">
fQ
^
-cc
DrR.XTION Years
CONTRIJ'.rTORV
Months H Days Hours
^.
all
1 (^A.
\
DURATION ^ Years Mouths
(Signed) \xJUoouwcL cLouci
na\
\'S
//(
'ours
M.D.
HiRTHi'r.ACi-:
<>I MnrilKR
(State or (.'oiuitry)
(HCI'I'ATION
f\'f\ui/r<f hi Sav /'i itn, i>r,} U )'iU!i> -) .1/,i//,'//>
ly/tifc ^ T<)oH (Address) llO\Mll<XA.kU 't
SPECIAL INFORMATION only for Hospitals, Insmutions. Trdnslents
or Rcceni Residents, mi persons dying andy from home. '
/',
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoH lonq at
Place of Oeatli?
Days
TIIH AHOVK STA r»;i) I' KH SON A I. I'A RTICf !,A RS A R IC TRrK T< » IF It-;
BEST <>i' MVyKN'ow 1,1 iH.H Axn isi'i. n;F
(Itifotntant
(\d<lress cS.
'^tolS
q .tl' ^H
PLACE Ol^ ^IRIAI, nR RKMnXAI. | I>ATi:.,! \Uui.m. or ki;MnVAI
r N I ) i: R T A K 1% k \j <Xkjjy\Xx ^ I Xxs^^vc >x u
(Address IS^H ^.b^^US.t<. .V
190 \
^« B.—— Every Item of information should be cnrefully supplied. AGE should be NtateU EXACTLY. PHYSICIANS Ahould
state CAUSE OF DEATH in plnin terms, that It may be properly classified. The "Special Information" for p«p.
sons dying away from home should be given in ^very instance.
f
W^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
h ]■ V,). !=^
, -fV**^-*!*,
'j-IUS:!' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Da/r Fi/rrf,.t.dixAy</x^ %
100\
RegLslcrcd JVo,
^179
.tM,o<^
/vKi Deputy Health Officer
DEPARTMENT 6F PUBLIC HEALTH==City and County of San Francisco
Certificate of "©eatb
( "a. S. Stan^arD )
PLACE OF DEATH: — County ofC'o^-^' J ^^a
f?m
^ a :^'
V
,i
■>\ciA^X) City of 'Cz-Yw J ..'vxX'vx'C^^'ao
:r
No, ULla ^ LO-W^vUi Xk SU Dist.;bet. and
/ \T DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G r V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION ' ' \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
1^
II
FULL NAME
\xXh.
->i'\
PERSONAL AND STATISTICAL PARTICULARS
\
jOCx.
^\^JJb
i> A ri-. (.! in R Til
\<.i-:
Month'
ic
! V-(/ /
I);i\»
^f >},fl,'
;i! )
MEDICAL CERTIFICATE OF DEATH
DAi'i-; ui in: \ rii A
(Months (Day)
p I IN'HICHV ti-.RTll-V. That I nttcii.lcl .Icrcascd fnuii
i\t
rcjo ^
(V«-.Mr>
to W CV b
■^ IN <!»•:. MAKKn:i>
UI IH >Ui:i) «)R I)!\( )«»•»'■ I)
'\\iiti ill viH-ial fU-ii'iiat iiiii)
luK riiiM. \i'i-:
(Stati <ii l•.,l^lt^^■
^; \ M } ( )i
1- A III IK
A
n
0
T(>0 H
that I hist saw h
1 90 1
aHvo ni! y,^^^
and that dtath ocfurreil, <>n the .hiti- stated alnn-e, at 5 S^O
^]. The- CAISI-: (U- I) i; ATI I \va> as follows:
\XAa
AXi
1)1 KAI'ION Vtuirs
C ONTK IIUTORN' '^J
M.^uf/is
/hus
Ifoitts
>
luk rn !'i. At'}-:
<>' I \ I'll i;r
stall 11! riitnitrvi
^t \iI)i;n' X \mj-
"I MoTlIHR
iHkrin'i.Aric
'•I ^;'•■|■m••.K
' st:ii. ,,t (■.Mint : \
u: V
A
A
fU
I M ■ R A T K ) N
( SIGNED )
) '<\J Is
Mo fit /is
/^avs
(^
I loui s
M.D.
jJX Y\,'>\.^
•"' ' I'ATIox ^
f\i' nit\t lit SiU! J linniM'
I'joi (A.Mriss)LCLu XLt) ibo^
%
Special Information oni> lor hospitals, insniunons, Transienh
or Retcnl Rfsldrnfs, jnd persons dvinq dHdv from home. '
M,i,i/h^
Ihi
'11 1; A!',«»\-i.: sr \'n'i) i'»''Rsi IX \!, i'\Kii('!i xr-s xri'tri i-; in » rn)-:
UJ-.sT OF MS- KXmU i,i:i)(;i.; \M) iij;i,ii;i
I'lf.i-nintit
XO
Former or , ^ ^
Usual Residence ' ^ * * ' ^
When was disease ronfracfed,
If nof at plai e of death ?
NoH lonq at
Ware of Oeatfi ?
Oa>s
■i, \( !•; < >!
A^O
(^
\'!.ln-.s \js^
h-
mo
^ ^t OL 5^*0. rA.<^V,CCt
IRIAI, OR ki'.%!(»\ \i, I ii\ir ■ n-
!NI)I:r 1 AK IK sJVJULsXu "H /I
I ^i "I R i:m< i\ \i,
' T 90 ^
IN. B.— ^f^ve^y item o? niformiitlon shnuld h.* ciiruuilly supplied. ACJK Hhoiiid be ntated EXACTLY. f*MY8ICIAN8 should
stntc CAUSn OF DEATH in pinin terms. th»t it msiy Ik- properly clu^i^ilr'ied. The "Special Inl'ormntion" fop p«f.
«ons dyin^ away from home nhouid be ^iven in ©very inntance.
>
I
m
I
1
I
k
■'I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M.iiitd (if HL.'iIth- I" No i<, ■^■t^'X.X; luti' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/c Fi7('(I,\Jjzt(A>jO\) %
JfJOH
Rcgiste/'cd J\'*o,
•2 J 80
1
^0
DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "CI. S. StanDarC* )
PLACE OF DEATH: — County of O/CU^x. 0 >MX/Y\^cuccCity of Cj/Cuyx; J VOLWOuiyco
V
^No.
^ T^
4 I
Dist.: bet.
and
/ IF DtATH OCCURS AWAV FROM U S U A L R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCUhRED IN A. HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER, /
FULL NAME
I
'^ {'^
SJ.
hxx\:A.^,.t
PERSONAL AND STATISTICAL PARTICULARS
si:x
\
DATH OF- lUKTll
A'.i-:
(*(iI,nR \ .
c
MEDICAL CERTIFICATE OF DEATH
DATK ()1- DKATH
.i^
.'^
Montlil
)•.•<;>.
lJ:i\ 1
U.'H//t>
/>,t]
^!n<.i,t:, MAKRii-;n
W II)<»\yi:i> OK I)I\'OKiKI> ^^
iU'rit<iii soiia! (It^i^/^nat ioti) I
.L
CC LC'
lUKTHl'KAOK
^Sliif« i.r (.'oiiiilr vt
NAM).; Of-
FATIIIIK
HIKTHri.AiK
<>l I ATin-:R
(St.itr or Cotititrv
MMDllN NAMl
Ol- MOTin:R
lUKTMIM.ACH
Of- MOTHKK
(fttatc or c'omitrv^
OOCri'A ru>N
(Month) (Day) (Year)
I HIvRI'HV Cl';RTn'V, That I atUMi.lol .kccasol fn»m
-■ • ■- -...,:.::::. up to
tliat I last saw h 7 alive on
lip
ami that lU-ath «)crurre«l, oti tin- (latf stattd alx.vo. at
— M. Tlu- CArSl<: OI' I)|.:aTII was as follows
I )r RATION }'(Utrs
CONTRIIU'TORV
Months
Ihn
I Jours
w
)'iars Months
nr RAT ION
(SIGNED) .. ■ ^ 1-b.ll
K/ol (A.Mrcss) .^
Ihiv
Houy%
M.O.
W,ob
\ \
Special Information only for Hospitals, InstltiHions, TraBSlenls
or Recent Residents, and persons dying away from home.
Kfsidfil 1,1 S,;i/ I 1 ,11!
) nil
M<>„lh- ', t /),/
rm-; Afun'i-: s c \ri'n i'Kksonai. pah iii-rr, ars ari' pRrK i o rin-
HKST oi' MY KNo\\i,i;i)r, }.; and Hi;i,n:[-
1 !
Former or -\ . (
Usual Residence U 'CL >vtaj
When was disease ronfracted,
If not at plareof death?
How \onq at
Plare of Death ?
Days
(InffJtmaiit
UJ. 'i)\.
(A
<lil!r<s I I O ,,i.
'\, >w ,
-r .
CX\.4,'
ly.ACK Ol III KX\r, OK RKMOVAI. I DATl-,,! lU ,< , u. or KFMoV\I
.V ^ ,v I ^ f ' ' '
CLAV.LOU ^A^vLO.' LCL^ I ^^^^ t
rSDl-RTAKHR LL . Uj . V/l UXvt \. A v
190
(Addrr
^" B«— — Rvepy Item of information should be carefully ttupplied. AGB should be stated EXACTLY. PHYSICIANS Hhould
state CAUSE OF DEATH in pinin terms, that it mn> be properly classified. The "Special Information'* for par-
sons dying away from home should be given in every instance.
^J
ia«^'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ho.ir.l ..r II. altll- 1- No. ii; -^^^{■4'Si UScV Co
790H
Begisfercd J\^o.
O
181
.-(rvM^ V\.\Ki
I «
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of S)eatb
( XX. S. StanOatP )
PLACE QF DEATH; — County oi^-Ojy>o 0 \XX WOL4/CC City of ""' CL/Vu 0 AXX.vu^u.-Ck)
No,tC
,0
^b^u^nj
0-^'
^W-H
St.
Dist.; bet.
and
(ir Dt*TH OCCUBSjUwAV FROMIUSUAL residence give pacts called for under "special INFORMATION' \
IF DEATH OCCURRED IN A HOSPITAL OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
U
aj\,K
.MJv\,i_
PERSONAL AND STATISTICAL PARTICULARS
si-:\
kXjjojJJl
MEDICAL CERTIFICATE OF DEATH
DATK OI- DKATH n \
!) AT}-: ur-- lilK 1 H
\ < , !•
K
m
Jf\r
(Motitli)
!
I I
(Dav)
1 A »>//// 1
(■^■<Tir)
n,i'
¥.t
il)av) (Year)
SfXr. i,K. MARK I I'D
\vii»o\yi-;i> t>K i)!\MK(i;t)
Writ' ill social fU'si^nat ion)
h
HIRTHI'I, \i'l-:
I Stiitt OI I'oniltl %
V \MI- ni
I \ I n i;k
niRIIll'I.AOK
OI I \riii-:K
i Sl:it» (It I'oinili v'
MAFI»K\ NAMJ-
lURT IIP LATH
'H- M<)Tin-:R
(St.iti or Coinitrv)
I uUaj
dHXJ
A
|c\.!
M
(MontJO
I IIlvHI-P.V CI'RTII'V, Tliat l^ntteu.le.l .lt( rastMl fn.iii
tliat I last saw h ■ alive on >— ^-v i j,^
and that (U-alh ncrurre<l, nii the date stated above, at
M. The CAISI': OI' DIIATII wa^ :,s follows-
n
. Y
I )r RAT [ON years
CONTUri'dTO
nr RAT ION
Months
RV V l\utMUX->\.<i,*w«jL X^X^
Pars Hours
A
(SIG
VTION ^^ )'L^rs^ ^
NED) J. VA. m
Mont /is
/CU>jfc
Davs
/lours
M.D.
K' i I te t'l
•HCri'ATlON
Re
s.'fr'if ht Sin? /'i tiiii rWtt v9 U )Vi?;v
\J/qXi % iqoH (Address) LcUN^ VO . Ibo^ivvtoa
Afldress) LCU^
ATI ON only for i)s
SPECIAL INFORMATION only for ifcspltals, Instituflons, rrmsienh.
or Rffent Residents, and persons dyiny away from liomc.
l/.M/,'//.
/ill 1,
Former or
Usual Residence
When was disease contracted,
riii'; AH<)\-i<: siaiid pkrsoxai, r\R luri. ars ari-; trik to
in;sT <)!■ xj[v KNn\vi,i;i)<;iy^^Ni) in;i,n;i'
(liifomiaiit
•m-:
3iH-hUv ']{
ontra(
If not at place of deatli ?
How long at
Place of Dcatli ?
Biys
I'UACK c)I- lURlALoR RIIMOVAI, I DATHof HiHiAi, or RHMoVAl
( \ I (0 4- • ■ -
I XDKRTAKKR 0 ^KX/C^^C^ cL'-«wCVi ..:
N. B.— Every item of infnrmntion should be cnrefully Hupplieil. ACJB should be ntnted EXACTLY. PHYSICIAiNS should
state CAUSE OF DEATH in plnin terms, that it mny be properly classified. The "Special Information'* for par-
sons dying away from home Hhould be ftJven in every instance.
5
"I
*li
til
^5
Us t I
Wt ' J
i f 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoar.! r.f n.:.ith - H Xo ;. t--r.^g;»^) H«v i' c„ RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
0
wo\
Regiatered J\''o.
^182|
cXMXXAJS
-• *i^-*,.
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of ©catb
( tl. S. StanC»arD )
PLACE OF DEATH: — Coui.ty oiOcXyy\j
^
\ o
J v_
.IM'i
-City
J? ^
No. ilCi LA.^^ st^. 2^ Dist.;bet. oC<XA^xw>-v and -^
/ IF DEATH OCCURS AWAY rROM USUAL RESIDENCE GIVE rACTS 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^d
'"v:v\AA^'>x.
d.
\\
0
^ 1 : \
PERSONAL AND STATISTICAL PARTICULARS
A I COI.uR \ q
1
DA ri-; «»F lUK I !i
\< .!•:
T
iM.itith*
13
(Hav)
'S
) >.;
M.iul/t^
Pa
MEDICAL CERTIFICATE OF DEATH
fe 7
fMcmtli) (Day)
1 HI'Kl-BV CI-RTIFV, That I atten,le<l iletvascMl from
~~ ' ~— 190 — — to ~.
tliat I last saw li alive 011
TQO 1
(Year)
190
lt)0
Sixr.ij:. >fARHIKn
WllH)\yi.:i) OK DIVnKCKf)
'W'ritt ill s(K-ial <li sijriijit iun)
BIRTHPl.ACH
' Stnt I- ' ir I'liu lit IN
lA in i;k
lUKTni'i.ArK
<H' I AT in; K
iStati or Countrv
maii)i-;n NAMi;
<»!• MOTHHK
^l
0 uSi^^dL-
<-a
il
ami that <lcath occurred, on the «lato statc<l above, at
^ M The CArSH OF I) I- AT 11 was as follows:
O-vQu^^ A„W^ ^x»
cC.c.rs^rLx ^ .L n .,L
CrUXCX 4.U/>'>vc^
Dr RAT ION Years
CONTRIIU'TORV
Mouths
Days
Hours
<xlJlJ^Xcr^-AJ-Y\. \ I
^ J
Dr RATION
(Signed)
wv^
)V</;'.s _ M,if/i/is
(TrULK*
^U^
lURriri'LAOK
«>t- MoTMHK
(Stall or Countrv
0.. a
Kf>tde<f III Siiii /'i a III i -III
Da vs
Hours
jAvt- b iQoH f Address) KjAJ^^JLKh VX\ ,. r.^.
M.D.
-Mil.
f ^^9'fl^."^f*^"'^'^^ION only for Hospitals, lnslitutrt»is, Translenls
or Recent Residents, and persons dying away from fiome.
) 1,1 1
Mnllth"
I hi
TUK AnoVK STAT1-I> I'KKSONU. TA K Ih T I. \ R s \ R i' TRl I' T< > THK
HhSroFMY K\<t\\I,|^I)i; 1.; AM) HI'Mll'
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq ^\
Ware of Death ?
Days
I Infotniaiit
wA^WO
(j
Ad'lri-ss
X\'h \J CkjCxX. V
190
^l.ACl.: ,„ niRm. OK UliMnVAI. l>ArK..! 11, «,A,, or KKMOVAI.
N. «•— f;;;/ »^7 ^^^^"/-^^^^^ H^ ....Un^ supplied. AGB «hould be .tated EXACTLY. PHYSICIANS «ho„ld
!I^1 H • ^ DEATH .n plain terms, that It may be properly classified. The "Special Information" for n^L
•on« dyinft away from home should be g^iven In every Instance. information for per-
mm
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoanl .,t HcalUi K Xo. i^ t^-^j^^V.ScV Co REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIONS
I
Da/r FiU'd, li^riJ^Aj %
lOO'i
KAJS (
Registered JSTo,
2183 I
>u Deputy Health Officer
DEPARTMENT ()F PUBLIC HEALTH-City and County of San Francisco
Cectiffcatc of Death
( tl. S. StanDard )
.1..^ ^ ^
(No.
I
J
PLACE OF DEATH: — County of ^-/CLav s3 rLCL^v<^uu:.>D City of ^'/0./vv J h^LAo^/Cx^XL^
_ 1 ii -?
/ ^ - St.; ^ Dist.;bct. A and '
/ ir DEATH OCCUBS AWAY FROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" ^
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
FULL NAME^ ' ' -■'^- ^'y^/yy\^^^■^'\Xi.d..
M,\
i
PERSONAL AND STATISTICAL PARTICULARS
j COI,()R^ .
a
MEDICAL CERTIFICATE OF DEATH
DAi'i-; or liik iji
\(.K
UJ.Iv.l.
/Kf.nith)
1/
);„
(Hav)
M<iul/is
(Year)
Da 1
Va,
(Month)
7
(Day)
19^ 1
(Year)
SfXr. r,!-:, MARKIKI)
WrDnWKI) <»K I)JV(»Rii:i)
fWiiff'in siK-ial lii^i^naliiiu)
(St.'ltf l>! (■lilllltt \
\
I lIKKI-nV CHRTIFV, That I attended deceased from
^^-^-^-^-O ...0 icjo s to \Jsi^. i TOO 1
-^ 190'^ 10 N-.V'>,^ B. IgO
that T last saw h % alive on , ).v„^ .1 ! . ^^0
and that death occurred, on the date stated above, at S
M. The CAISI': OF DKATH was as follows:
M. The CAT
I
N \M1- (»|
I \TII IK
HIKTIII'I.ArH
ni' I AIIIKK
(State- or I'oiiiitrv
mai!>1';n namk
hi motiikr
HIK rmM.ACK
01 MOT HICK
(State or I'fMHilrv)
e
ft
DURATION
JJU RATION }ean
CONTRIIUTORY Or
)'t'^s ii Mouths h Days
I /ours
%..
^
J-V>\.
<->
I
y\.
J xhjyyxxx.^^^
OCCII'ATION
h'rhlrif in S,n> i 1 ani ix-n
) rii
\
n
DURATION Years 5 Mouths \ Days
( Signed )Jir LI. GxA^vy^AvMrw
y--ct % rc>nH (Address) blX" ID tlu ^t
Hours
M.D.
f '^^'fi'-J'^r^^'^'^'^'O'^ ""'y '"f Hospitals, Insritutlons, Transients
or Recent Residents, and persons dying away from home. «"Mcni5,
M,.„lln
I hi
VWV. AH()\|-, STATi:i) I'HRSONAI, P\ KTHf I,A KS A K F TKI F To Till-
HFsT oi- ,Mv KNOW I, j; IX, J.; and I!j:i ii<:k
Former or
Usual Residence
When was dlsea«;p ronfracted,
If not at place of death?
How tonq at
Place of Deatfi?
Days
(Infotiuant
w
V \
( X'idirs.s
IH^l
:l
a4v LLxm.
T90
INDHRTAKI-K (jId . J . OA^JkA^^^Vt Cq
(A<l,l.csH^ 11 'bl
'^lA.^ry
N. B.-
"^re^Cru'sE^OF d7;th1 \' "l"J'^ T""^"';* ''''^ "''""'^ ""' •*•'*** EXACTLY. PHYSICIANS .hould
™ ^I t ^ OF DLATH in plain terms, that it may be properly clarified. The "Special Information*' for «-L
•on. dying away from home should be given in .very Instance. information for psr-
flJ
fcl
l(
I
I
I
iiii
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i;'.:jr^! J Ui.-illh t S'u ;' *-r^^;)it.'vl' IN
I)ff/r riled, SL:
I
190 "i
Registered JSTo.
184
AXJ Deputy He ~:?h Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( •a. S. StanOarO )
PLACE OF DEATH: — County of O/Ct^w OXxXa-vCUI^co City of U/Ola^v; J .>vX3LA^L<M..CL/eo
^No. ^Sb a ^ UaA- St.; 5" Dist.;bct. (ADXXh,>>wA^<p^ and J (r(A.en>^
f ir DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
)
FULL NAME
t
^<.<KX^, ri.
\JU
V»i. '>
PERSONAL AND STATISTICAL PARTICULARS
DAi'i; or- niKTii
MEDICAL CERTIFICATE OF DEATH
DATK l)J- I
t/Aluiiih)
\ « . \\
y\
5 ra
%
15
(Uav)
Minif>n
1
7 / C
fN'car)
fhi 1 ,
""" iD^
(Dav)
(Year)
siM.ij.', MAKHri-:n
(W'lilt in MM-ial (lfsi<.'ii;it ion)
niRTHlM.AOH
(Stall- «»r I'rtniiti \
NAMl- oi
fathi:k
HIK IIIl'I.ACK
OI- I APIIKK
(State i»r Onnntrv
MAIDllN NAM I'.
Oh MOTHKK
I'.iK'iin'i.Aii-;
OF m(»tiii:r
(Statf or Country i
A A
\ i I I
'Month)
I HHRlvnV Cl-RTIFV, That J attended .leceased from
^t IgoM to SJ..^. 1 i^H
that I last saw h ^ . ..alive on \J /^ T Too *1
and that death occnrred, on the date state<l nhf)ve at I
I
U; ^r. The CAISIC^F DI^ATII was as foll.ms:
(I
'-X}
Dr RATION
^
ars
\ 0
oJlyv-x/^ro
Rrsiiinl i)t San /'ihhiiu,' )'i,i>s
CONTRIin'TO
DTRATION H }\urs Mouths
1JJ(>>V J, XiDoAAMxtj
ths ^ Days Hon
<5-i^-i^. i^-t.<i.e<^^ e->:\. ...,C1.
rs
/hJYS
(Signed)
U/efc % igo*^ (Address) 1^10 J CTV
A^'Y^Xj
A
Hours
M.D.
+
„rf ^^9'fi*-, "^r°^'^?''''0'^ ""'y *«' "»^l'"«''*' 'nstitutlons, Transients
or Recent Residents, and persons dying away from home. -"^icnii,
Mii»th<
Da
Tin: AHOVK STAII-:i) PKKSOXAI, PARTICfl.ARS ark TRIF To THF
ISF'ST OF MY KX<)\VM-;n(*, f: AM) HI-.I.IllF
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
?iixt of Death ?
Days
(Infotniant
(A.l.lres^ 35"(o /a- \\ kj^j CJ.fc
^.ACKOF BlMilAr, OR RFMoVAr. | HAI^^^of n.K.A,. or RKMOVAI,
'"^ " TQOH
6ct
D
rNI)HKTAKHK\lfTr ^ 0.y6u^^JU>rS^
(AiMr.-ss
Ti muLwrv^aP
N. B. Every item o? Information should be carefully supplied. AGE should be stated EXACTLY PHVKICIAMB u .^
.t«te CAUSE OF DEATH In plain terms, that It may he properly classified. The "Sp^clai Jormat^Lt^^ for :;'
sins dy.nft away from home should be given In every Instance. information for per-
li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
nn.'il.l nf lli-altll l- No Is '&'^^*^) liS^V Co
Da/r /v7^>^/, UyetcW; I
VJO'i
Reglstei'cd JSfo,
8185
I
I
I
if
KJUS
XHJ
er
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( la. S. StanDarD )
PLACE OF DEATH: — County ofOa./v^ 0 A.<X >v>c.ulc^ City of O/CL^x^ J/VxX/>voui.<^o
No
.1)H^
, -^" St.; 1 Dist.;bct. H A.K> and S A.|v
i IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR I N STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
f^
On
SIX
DA IK n|. HIKTII
A<,!.;
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
1 COl.OR
Js.
,Cr
4-
li
Oct
M..Hthi
L^^Jii
<xX
t.
'TXw^xq
MEDICAL CERTIFICATE OF DEATH
DATK (tl- i)i:atii
o
i
\\
I
if
3 >!/ »
1/
\>vltn \
'Year)
Ihi\.
iiU
(Year)
sixc.m:. markiki).
WIDOUHI) OR IHVORiHri
i\\'ritjiii siirial tltsi^'tiiitiim)
n
lUK rni'i.ACH
(Stnti iir Country
I A 111 i;k
lUR rillM.ACK
<>l" I'ATHKR
( Statf or I'outiti v'
MAII)1;n NAMl-
ni' MOTIIKR
HIR rillM.ACK
oi' M()Th1':r
(Statf or Cotintrv)
<KCl ^ATH)N
C
OJ
u
%
(Month) (Day)
I I1I';R1:BV CI:rTIFV, That l attcii.W.l .Icccased from
^ ^^" ' 1901 to U^ ^ IQO 1
that I last saw h .. . alive on w cX t igo I
and that <leath occurred, on the «lato stated above, at io. '~< '^
V-:^^. The CAISIC OF DHATir was as follows-
( u
T
< 1
\
DC RAT I OX Years
CONTRim TORY
Months
Days H Hours
^m
I )r RATION
(Signed)
Years
Ulbo. QJlv.
'Mouths
A
Ihjvs
1 > V
\
OJlV--^^^ <->
t \ '^ * ■ • ■■•
U^ X TpoH (Address)"^ 10 0^ V) /l^^X^4^fr>X.3.1
Hours
M,D.
^^^9'^*- INFORMATION only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home.
Sin/ /■; II Hi isin
)V.n
M.nilh^
Das,
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Wire of Death?
Days
rm: ahovr stati'.d phrsonai, pAKTicri, \ks ark trck to thf
isi'.sT oi. Mv kno\vm:d(.h and HKi.ri;K
(Informant Xj'^^A^ <70t''%X^tX' uV, XX. l J
(A.l.lrcss
%H?,
-A
V^^^<^'>X'
Pj^ACK OK m-RIAI, OR RKMOVAI. I DAirKuJ Hikia,. or RKMOVAI,
KNDKRTAKKR QsD . O . \) I 1>(X<X4,<S,' V i
190 H
(Address .^.IT.JsJrLv^^V
4,
^* "*~rtaV/clT«;F^A"J nTr^M" "''?'** " ' cnre?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should
iitate CAUSE OF DEATH m plain terms, that it may be properly classltied. The "Special Information" fo- «-J^
nans dying away from home should be given In every instance. "^
' I
I!
i
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
isoard of H< iltli- 1' N'o. [^ S-^- ar^J^r. ju^cl' ("r.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^
roo'i
Registered J\'*o,
O
rw
l)(ft(' Filed ,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
186
,A.A^ CX^iAXJ
Certificate of H)eatb
( in. S. StatiDarD )
PLACE OF DEATH: — County ofOOyYV vJA^OL/vvxivCL/e^ City of C\ol/yv' 0 7UXoa.Co<L<i^
No. T . .■, St.; H Dist.;bct. M te ■ and LCLCilvi
(IF DtATH 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 te±LkK>
)
rU^^AT..
si:\
PERSONAL AND STATISTICAL PARTICULARS
\\ )
DAIl-; oi- HIKin
AC, 1.;
! \
I .Motilh)
) ,a>
• Dmv)
A /,»////'
(Vrar)
n<i 1
'^ INC. I.I", MARUn:i)
w iix »u }:i» OK i)i\( (Kti.;r)
'Wiitt in >()iial ih-^ii' iiatii)ii)
"^
MIKTHIM.ACl'
i Stati- ■ i! ( 'i iiiiit I \'
NAM}" OI-
I A I Hi: R
HIRTHT'I.ArK
ni- l-ArilHK
(Stall' or ('(iiiTitrv
MAII)1-:n NAM}-;
Ol MOTHKR
BIK'iniM.Ai'K
<►!• MoTMHK
(Sl;iti- ur C<Mintrv)
PJ l^
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATli
Month) (Day)
I ni{RIvBY CI'RTIFV, That I atteiuled deceased fruiii
■ ^- ■ 190 't to ...il//£^ ?i 190'^
that I last saw h ^. > alive on V ;tfc ' j^q i,
and that death occurred, on the <late state«l above, at
U >r. The CAISI^ OF DICATII was as follows:
~V>AZLlUll.k..% wO.,
DURATION }'ears .I/on //is
CONT R I lU TOR V vJ^.A^-^'vC-^
Davs
Hours
DT'RATIOX
(SIG
NED) -1. vJ ^jS
\JXyY\
A
ry
J/ont/is
/hiys
A.-.o^a-kx?
U/CAj i U)oH (Address) UaAM^tlifc.lria.
Hours
M.D.
Special Information only for Hospitals, institutions. Transients
or Recent Residents, and persons dying away from home. '
OCCI TATIOX
R^sitlfif in Satt /■') iiiii ism I )'iiiis
Mniiffi;
/hi
Tin-: AHOVK STATl-D I'KKSOXAI, I' \ K TKTI.A RS A R }•; TR T K To THH
UKST Ol- MY k.no\vij;i)«;h and m:Mj:K
(Informant Uk^O^C^ \X ^^KXXXJuu
Former or
Usual Residence
When was disease contracted,
If not at place of deatli?
How lonq at
Place of Oeatli? o^yj
ri.ACK OK niRIAI, OR RKMOVAI, j DATJ- of MrKtAi. or RHMoVAI,
190H
IXDKRTAKKR
(Address
Q
}:l
I'l.L 1 UA^iAWMm.. ^ K
^' ^' Every item of {nformRtion should bs carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for per-
sons dyinft away from home should be given in ^v^ry instance.
1
I tl
n
1
; I
j
i! )
(
tl
I
J
' I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I'... I!.; of H. tlth ' 1' N'O Is t'^^V^_
nf^VCn
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(//(' Filed ,
%
VJO'A
Registered J\''o.
2186
n
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtiftcatc of Beatb
( tl. S. StanOarP )
PLACE OF DEATH: — County of- ^XX'TV vj Axxyvv>CAXL/c<) City of "^^Olav 0 ^,CL/wcc<L<i^
r\
fNo.
St.; Dist.; bet.
FACTS CALLE
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE"
and V
n
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME iNSTrar, " ^-"JliND NUMBER )
FULL NAME
IK. C
i'
W 'v.
si;\
PERSONAL AND STATISTICAL PARTICULARS
\\i
DAIl-; ul- HIU i li
.\<.i<:
J I-vaJIx
M^
MEDICAL CERTIFICATE OF DEATH
DATK OF DICATH
(Year)
M-iith
) la I
Dhv!
M,mffi<~
ear)
/'■
'^IN«', IJ.:. MAKRll-JJ
\\II)<(\Vi:i» OK l)l\<»Ri i;i)
(Write ill -(Kial ili «.ij.»iiat imi)
(M.iiilli) (Day)
I IIICRI'HV CI:rTII<V, Tliut r atten<U-.l ,k"cc-ased fruni
^- i(/3 ; to U.~tj i loo "^
that I last saw h a. . alive on *^ ' ' loo'i
and that dcatli omirred, on the date stated above, at
I
y\. The CAISI- UI- DEATH was as follows
^^
v.L..,..L,. , ..
lURTIIIM.ArK
I State I ir ("i miiti \
»athi;h
niK riiiM.Ai'H
'»! lAliniK
(State or Coiniti v
oi MnTHKK
Hikrm'i.At'K
(State or Cuniitrv
f 0 d n
'\/XhJ
^
-I
1)1 RATION
V
^'t'lirs Mouths
CONTkllUTORV •:J^'Vtv>vC.
Days
n
DIRATION
(SIG
NED) J vj vJS
Mouths
/hn
'S
\
Jy/Zk) i tc)oH (Address) \J/CU\A.<^tli^i.<i.a.
Hours
I fours
M.D.
?^^9'^'- iNf'ORMATION only for Hospitals, Instltufions, Translenls
or Recent Residents, and persons dying away from home.
OCCirATloN
Kf>idf<i in Sill/ / i,iN,;^,,i I )■(■(// V
M.xilln
/hi
' "Vi.^ni^^'^'-^''"^''''" ''»'«^<>NAI, I'AK ri.ti,\KS AK1-: TKI K To THJ-'
Hhsr nl-- MV KN,,\vi.i;i),,H AM) Hia.IlCK
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Plare of Death?
Days
(Itifoiniatit
:k
,A^I.ACK OK niRIAI. OK KHMOVAI. I UAT^C of ItrR.At. or Rl-MoVAI.
190 H
(Address
11
^<X^.<i>\
IS. B. Every Item oi? iiiformntlon should be carefully supplied. AGR should be stated EXACTLY. PHYSICIANR -h« u
.tate CAUSE OF DEATH In pl„l„ terms, that It may be properly classified. The ••Specl. Informs tll^^'for^L**
son. dylnft away from home should be given in every instance. mtormation Tor per-
{ ■ J
' -wri*?^'
I
I: «
I
ft
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoatil ,if Ilialfli !■■ Xo "■. '^2T^!*K^ ^^^ j, ^.^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/hf/r r//rff,Qdj^
(\
\j I
ifujH
Registered J\^o,
.-CrAOA^
2187
I
DEPARTMENT OF PUBLIC HEALTH-City and Cconty of San Francisco
Cectiflcatc of ©eatb
( tl. S. StanC>arD )
PLACE OF DEATH:— County of^A.>v J.fUX->v0.i^M) City of H^ol/w J A..cX/>^.t,cA.c^
No.l .^.^^^^ ,^^t .., LI •■. St.: *i Dist.;bet.LC^u^vx\, and 0 cVt'>-YV(rV. >>
.,..T„ OCCURP.O ,„ . „03P„.L <,» ,Nsf,TU-T7oN -C.vV-iT; NAME .'n^T^o"" .tVe";'^'" 'n u'^B t '■,°"' " )
FULL NAMEV-tAAlAcy J^&Vq^Nvlfl^Qj^Q^^,^^^^ iv.ll.tt:
ll
SKX
PERSONAL AND STATISTICAL PARTICULARS
^ I Coi,(
X
-^
i n
K
I'A 1 i: < »i i;iK i II
A«.J-
U)lob
-rf
Miititti)
ij>^
lEDICAL CERTIFICATE OF DEATH
DAT!-; Ol-' I)I.;aTII
(I);iv
(Year)
}V,
/(
n):iv)
Mofillf
\ car)
I)ii\.
I IfHRHHV CI'RTIFV, That J^atten.lcl deceasecl from
-i\' i.i- MAKNn-:i).
\\ iiM »\vi;i» OK iH\(iR<'Kr>
'U'iit« in >H(.ri,'i] il» si^.tmti.ifi)
.^
BlkTIUM.AOl-.
NAM J. <)|
l-A rill'K
(^
^
Ac>^
0^\
J
I90 I to
alive on U/ct "I
o^^;Q'a ,
tliat I last saw h ■
iu4 that death occurre.l, on the date stated aljove, at
i) ^'-.I'l^*^-^''^'' ^^'' I>»^TII wai^as follows
190 1
90 H
Cu^ru J.\x:)uvL,c^c<ixOo
Hik riii'i.Ar!'
<»!• I A in j.;k
'St, It. Ill (.■(Mn)tr\
t »
1)1' RATH )\
^'''0 •^^'''|('^' -^^^'J'-^ ^/^'^^
^^^^ mjL^\jLAj^
M \II»I-:n NAM)-
01 MoTIIKK
HIKTiIIM.Atl.; A
«>|- M()'riii;K /TN y
I State lit t'lniiiti vl j w M
OIHTPATION
\
n-
:C'U rVAXL
DTRATIOX
(Signed)
) rars
'^ i<)oH (A.Mn-ss) Sna
5ft-<.t i
Hours
M.D.
t
nr?»'!^?'^'-. "^!r°"'^'^''''ON only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying dway from tioroe. '^ansienrs,
) V'l/ ,
.\r,>nf/i;
Ih'l
iU'.Sl 01. MS KNOW i,i:i)(;h AM) in:i,IKK
'IiifiKDiniit
Former or
Usual Residence
Wfien was disease contracts.
If not ^\ place of death?
How lonq at
Place of Death?
Days
PI^CK OF ,H = ,^AI, OR KHMnVAI. I nATK,of H, k.^,. „r RKM<,VA,.
Uu«-^^'
'©;.
rNDHRTAKHR (AO . J . Mf iLk
X
o
1 00
u
I
(Address "^ n MyVv^uu.<rv^i:).t
N. B. ';^«'*yj*e»" o» Information should be carefully supplied. AGE should be stated EXACTLY PHVAIciAMa u .^
state CAUSE OF DEATH In plain terms, that it may be properly classified. Thr'S Jclai Inwl H ^. . "^''"'*'
ion. dylnft away from home should be 4iven In svery instance. »P*clal Information" for psr-
• li
fl
■m
i '
I
M
WRITE PLAINLY WITH UNFADING INK
)','.;ir(! of ir,;ilth 1- So. i< T'>*^^^^, p,S:i' (
THrS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)ff/r AV/.v/,.,Ec1Jmju I
lOO'i
Begisteved JS^'o,
2188
C^U^
Deputy Health OfTicer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccttfffcate of Bcatb
( tl. S. StanC>arC> )
^ ^ J?
^ PLACE OF DEATH: — County ofO /CX/vu 0 Axc^nxiA^OyCX) City of Q
^
/<x>A^ o \xx/vx/<tA.^/a^
N©
. 'tii:
L \\K^^
■ K
uu
T
,\ ^
St«
/ IF deaWh occurs away from usual residence gi
\ IF C^ATH OCCURRtD IN A HOSPITAL OR INSTITUTION
Dist.; bet.
and
IVC FACTS CALLED FOR UNDER SPECIAL INFORMATION'
GI
FULL NAME
I
0
VE ITS NAME INSTEAD OF STRE
CIAL INFORMATION" X
ET AND NUMBER. J
\ ^U'-
SK\ -^
PERSONAL AND STATISTICAL PARTICULARS
COl.OR
I
DAii: (ti- niKin
ACH
\J^
)r,n
iDav)
M..Ht/,!
MEDICAL CERTIFICATE OF DEATH
DATK Ol" ni-:A'lH if
;»r)
SIXi'.I.K MARKIi;!),
WIDOUKI) OK I)fV<»KCj:i)
IWiitciii s(H-ial (U•>^iy;!lati'ltl )
HIKTm'l.ACH
'State or CiMiiitrv
I- A 11 1 },K
lUKTHIM.ArK
0|.- I AlllKK
(State in I'duntrv)
MAII)1:n- NAMi-'
OF MoTHKK
RIHTHIT.Al'H
•»f M()Tin-:R
(State or t'oimtrv
occrpATiox
iilaxvL,...^.
(Year)
I n\iRMU\ CHRTIFV. That I atUude,! deceased from
-■ • ^ T90H t.) ii' cti... t j^\
that I last saw h .. aHve on ^ zh k ,_. .,
niid thtit <U-ath occurred, on the date stated al,ove, at b. I S"
.^ ^f- '^J>^' CAISI- OF DKATII ^va. as follows:
L
^4^
( I
Ml H ?
'^^f^^
Oj^
rx-i-v
-d..- '^..'^
'^^'^^'''^^^^^ yj'-^ Mouths ] nays Hours
J( »NTR I BT-T()RV ^XiJv.alum. Jilci^^ "1 .ii.. J.l. .
DlRATroX ' Years
-^K^K
A^V^JUV
r
Mouths
Havs
(Signed)
.UJ-C>xw„L^ v-A.- iXn i,.:'.c -
Hours
M.D.
^^ ^ TQol (Address) 16^5 J.^mXH; H
orfeTpn^i'.Mif-nJ'^nrP^'^fJ'O'^ ""'^ '"^ ""^P""*'^' Insmutlons, Transients"
or Kecent KesMents, and persons dying away from home. ••-nMcnis,
/\r. Miff if hi Siiti f't ,.
f
/',,-i
'"li»?-!!ry,^'^[^i^;,---rAi;-;;i;,:,;;-^ -- ■- . - ,■„,.
(Informant
i/v-tx/^xi^ mV
esldence LL
ridii
When was disease contrar fed, ^ i 0 J
ff not af place of dcaffi ? lLli.C<xl\. 5 id
Former vi i , u
Usual Residence LLfXLa \
How long at
Place of Death ? o
D«^s
O-U.-i
4:
r\d.i
ress
.^tx-
1
I X I ) 1-; R T A K K R N^A^US^VA^yX IV K^O
yn. dylnj away from h^m. ,h„„l.l he tiv.n i„ .v.ry ln»t-n« ^'■""""'- ^he Special Information" for p.r.
■J'
\.
inncnnce.
^
^!mm!i
1
I
I
1
f.
ii'im
m I
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n^ ,f H. u,. , NO . ^mt^.n8.VCo REFER TO BACK OF CERTIFfCATg FOR IN3TRUCTIONa
Regisfered JSTo,
189
ckmjuu^ ^icVHj Deputy Health Officer
DEPARTMENT OF PUBLIC BEALTH-City and County of San Francisco
Ccttiffcate of Hieatb
( XX. S. StanC»arO )
PLAC^ OF DEATH:-County of Oa vx. J/^^vec^.^ Qty of 0^ w- JAXX^^veui^
m
^No.
St.
( "^ .°/rr*l,°*^''"''^ ***' '■''°'" USUAL RESIDENCE GIVE facts**c/
\ ir DEATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS N
Dist.: bet. \j C-LH
ALLED FOR UNDER "SPECIAL INFO
"AME INSTEAD OF STREET A
and ^^lL^xj
W
FULL NAME
J <XuJj UiAXJru,
INFORMATION" \
NO NUMBER. /
h
< I
HKX
DATl-: »>1. HI Kill
PERSONAL AND STATISTICAL PARTICULARS
i COI.OR
Ac.K
U.. kctx
J Vi/ * A
<I)ay»
V. <»////»
iVtar)
Hii vs
MEDICAL CERTIFICATE OF DEATH
V.Vl'H OK DHATH /A
(^fonth)
( Day) (Year)
I HKRHHV C|.:rT[FV, That I attemled deceasecTSoiir
>i|N<.l,l-: MARKIHD
W II)t "U i;i» (»K Dlx-nKiKr)
'Write in vorjal <Ii vis., nation )
niKPHl'I, \CV',
(Stati or I •. .iinti %
NAM!, ni
f- A I Hl-.K
:\
that I last saw h x. , . - aliv
to .
c on
0.^ H
190 H
190 H
atid that ck-ath .KHurred. on the date state.l above, at IXhO
^ %;./'"''^' ^'-^'^^^ ^'l; DHATH was as follows
1^
niKTm-i.ACF
ni- iATin;k
(Htiitc r)r t'omitrv
MAIIUIX NAMl-
OF MoTllHR
niRTHPI.At^K
Of. MOTHKK
(Statf or Countrv
r7\
u
.'w
^UL
DrRATlON Years
coNTRinrroRv
Mont /is
Pa)
'S
liou
rs
-^ >X ^V\LLV^
\J
DIRATION
Years
Mout/u
Davs
CLc-L
Hours
M.D.
JLLLr
occri'Ai i«jx
Rfsidfii ill S,n> f iiunisr,}
^^\JiJ^V\j\:'0^ ) ^<^.
) I't! I \
A/ollf/,.
/ >,! 1 .
(Signed )
^vtAj U)oH (Address) I'bS l^XOJvL
«r?''^9'fi*-."^'^0'^'^'^TI0N only for Hospitdls, Insmufjons Tmii«Ii.i.k
or Recent Residents, dnd persons dying away from home '"^'"""MS. Iransleiifs,
Former or
Usual Residence
(Informant \J fl . L^ . UCC^^.tu
When was disease contrac fed.
If nof at place of death?
Now long at
Place of Oealh?
Di^s
(A«1«lrcss b^O v'^UX^K
PI.ACH (»!■ IHRrAU OK KKM(.\ \l | i>x n- f ., ' ' ^
^ ^n.>u.\ \i, I DAI J^o! jjtKiAr. or RKMoVAI.
190 1
/I 1 M N- •
XDHKTAKKK IsD/oJUtxdL \<. Co
N. B. Every item of Informntlon •hoiild he cnrefully
•tate CAUSE OF DEATH In pl„I„ terms
«an« dying away from home should be ft
state CAimP np nf? ATM • i. ''«^"«ly supplied. AGE should be stated EXACTLY. PHVAlciANa u .^
D..TH ,„ p,„,„ ."- .H-IJ.;;.. .._^n;op.H, c,„.„.... TH. S^Jj, ,Zl^XT,::Zlt
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I
cL{^vc^A> IxoM.. Deputy H
IDO'K
h O
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o,
or
2190
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certiftcate of 2)eatb
( Ta. S. Stati&atO )
PLACE OF DEATH:— County of 3 OyYv \ .yx^<,,.^^ Qty of a<Vw. J^'UX/vvcc^^
rNo.dC-'.d.';o^Oxxl._ ,;.',. St.; — Dist.; bet. — ^ and
FULL NAME
y
mnn^CLA '
I
PERSONAL AND STATISTICAL PARTICULARS
J r
I) ATI-: OF I'.IKTii
^
)n">vA.Ll
IL . kobt
iNfcintli)
AC.K
( 1
( Da V
Month
(Year)
f)
'a v.v
SINCIJ:. NfAKklHI)
\Vn)n\vi:i) OK DIVORCKI)
iWritt in sorja] dtsi^nation)
0
\
HlkTHIM.ACK
'Statt'or t'ountrv^
NAMK o|-
FATIIKR
niKTlin.AC'K
<)l" lATHItK
(Statf or Coiiiiti V
MAII)i;n NAM!
<>|.- Mf)TllKK
HIKTUPKACH
oi MOTMHK
(Statf or Countiv)
L/VNwCl
lOu
%
S\Ji\^
MEDICAL CERTIFICATE OF DEATH
DATE OF DK.VTH
•'tt b
<I)ay)
1 ilKRKHV CivRTlFV, That I atten.l.d .Icrcascd fron,
190 — to
tliat I last saw h ^ alive on --
(Month)
T9o\
(V'ear)
and that rleath occnrre.l, on the <latc stated above, at
Di; RATION Years Mouths
190
190
(E.^
Pays
Hours
\>i
j^
CONTRIIU'TORV
duration
(Signed )
ears
J\flfN(/lS
Id
/hivs
^^ 1 igo M (Address) C(r\^^^^\^ L . s ^
Hours
M.D.
«rf.''^9'f!'-J'^f ^'^'^'^TION on'y '<"■ Hospitals, lastituiroils Traiisl#ii»r
or Recent Residents, and persons dying away from home. '"^""nMS. iranslents,
OCCri'ATl<)N(^
- i
fsfsidnl ill Sail I'lam 1 ,n
) '/'(/ J
'^r>'iith>
Da
( ♦
B
IS
I
iJKM OI- >.n k Now I,I,I)(•,^; AM) ni;i,n:F ''n.
(lu fnununl \JfVvO J. H "^
Former or ,s .
Usual Residence t^s I ^
When was disease contracted,
If not at place of death ?
Now long at
Place of Death ?
Days
fArl.1nv;s ^ : I;
*..
190 '(
,cx,c
'AcMre^sLHCI. O/CL/C/v^OU
'»^%-i4-%x.Li.. uj.t
«on« dying aw.y from home should be given In ev.py l„,t«nre *^'""'"***- ^*** «P««='«" Information- for pr-
?!
i 11
I
I
i' I
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Boar.l of IU:iltli 1- Xo. u 1^-V^^%f, iiSi.V Co
WOH
Res^l^tej^ed J\^o.
2191
Dale /■'//<■> /,t<±isi^V^ %
DEPARTMENT i)F PUBLIC HEALTH-Citj and County of San Francisco
Certificate of Beatb
( XI, S. StanC>ar^ )
'
PLACE OF DEATH: — County of ^O.^^- JX<X>v^u»Xo City ofCW-ru J KayyyjQ.UL<A>
No.
^ w
K V ft
St.
Dist.;bct. . J^A.'OT\XX/'>xaA%' and <:X.CLO
( "^ .Vl^ll."^^""^ *'*'*'' ''''°*' USUAL RESIDENCE GIVE facts called roR under "special information- \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR EET AN D NUMBER )
FULL NAME ^l^^dX^^OL^yy^ &. yAixcLt
si;\
n\rj; nr iukih
\ < . i-:
PERSONAL AND STATISTICAL PARTICULARS
r
■)\
J V(/ /
1
a>:iv)
}/.»(//,
I L
(Vt-ar!
Da
\
/go
(Year)
\Vll»<»\vi;i) »iR I»!\ »>Rv i:i»
fW'iitrin siK-ial il»Nij.'nat i. >ii )
HIKTHIM.Ai'l'
(State or C«miiiIi \
MEDICAL CERTIFICATE OF DEATH
DATH ui- i)i;\'rn / a
feci ■:
(Month) (i,„y)
^ I HHKI-HV Cl-kTIFV, That I attemUMl .lercase.l fn.m
190 ■ to sJ^ A ,go h
that I last saw li U alive on sJ cl I loo '
a;nl that .UmIIi orciirrcd, on the «late statetl al)ove, at I I
^ M. The CAISI.; Ol' DIIATH was as follows:
» A riii.K
I'.iK rm-i. \(|.'
"I I \riij;k
I St:ili ill liiillltrv)
HlkTllI'l.ACH
<>»■ M«»Tm.;R
(Slalr <ii I'nuntiv)
CdxA><x>u^
A
0.-^vd^ \nUlN.€ui (Llc^lUu^^
^\^
K^
W .4
I )r RATION }\-ars
CONTRIIU'TOkV
AfoHtfys
/)ays
//on
rs
Dr RATION
(Signed )
) car.
^
Afif)U/ts
/^avs
^-^ '■ i<)0 H ( A<Mress)U Oa^LO-ti'
//ours
M.D.
„rf ^^9' M^. "^'r*^"'^'^''''ON only for Hospitals. InsfJIutJoiis. Transients
or Recent Residents, and persons dying away from liome. 'r-nsienis,
oVtM
TATION (Op
/\fsl,lf,{ lit Will AillUil^,•,)
) (1// N t; .\/,)ii//i
I),
"'m^J-iV^','-':''*^ '''"•" ''WHSONAI, I'ARTHM-l.ARS ARi; TKl K In TIIF
ithsroi. Mv KN.»\vij;r)<;H and iii;r,ii;K
(Inf„„„a,., M., U/OJI. ri^-V^^V* •
(A.Mr.-^s bbb ^MV4 di
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death ?
Now long at
Place of Death ?
Diys
190
VJ-ACH <.F ,n K,^, .)K RKM.,VA,. I 1.^7^- -f H, H i.u, .., R HMnVA,;
r.NJ.I-.KTAKHR M L- 0 A.<Xm p ^< L (.
. . *^J/.?', '"f'"-'"*'*'"" "h""!*! ht.. ..,re?ully «upplle«l. AGR should be stated EXACTLY PHVfiiriAMe ^
•tote CAUSE OF DF: ATH In pl„l„ term., that It m„> be properly classified. The ''S Jclai l„^ •f m^. •*•**"'**
«nn. dying oway from home should be given In every Instance. »l»ewlal Information- for per-
^1^
■
I
I
I
WRITE PLAINLY WITH UNFADIIMG INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFrCATE FOR INSTRUCTIONS
Dfffc Filed ,
>v
^
lOO'-i
Regititevecl JSTo,
2191
TO
DEPARTMENT OF PUBLIC HEALTIi^City and County of San Francisco
Certificate of 2)eatb
( 'a. S. StanOatO )
PLACE OF DEATH: — County of^<V>v J V<Vyvca.<iXo City ofO-Cu-ru 0 fUX'Yy^cx-^.^:^
^ . /in V
^^* " ^ ^ ''- ^- St.; M Dist; bet; n AAyok^XAxOm; and ^\Xk.OK
f ir DE«TH OCCURS AW«V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECAL INFORMATION- \ \ '
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION G.VC ITS NAME INSTEAD OF STR EET AN D N UMBER ) 1
FULL NAME UJa11a.<Xa^ b. Qmxd '
A^i.
SKX
PERSONAL AND STATISTICAL PARTICULARS
( COI.oK
\
Mxi'i. <»r HI kin
\ < '. I-;
.^X^
<^i
)V<
// >
SINi.l.K, MAHRIIJ)
WIlMtW i;i> «>K FMVoRi Kr>
(Wiitf ill -iH-i.-il <lfs!j.Miatii)ii)
HIKTin'l,A(*H
(Htntr or I'miiilrv
3.
iD.iv
I l/<.>////
<x^vuxl
/ u
MEDICAL CERTIFICATE OF DEATH
DATK <)I- i)i;ath [C\
(Month)
*<
(I)av)
rgo
(Year)
i HIvKl-HV CI-RTirV, That I attcn«le<l .leceascd fruni
IV tar)
rhx V.
\
r\
up:. to Aw-CL i jgo\
that I last saw h .. alive on V^t. 1 loo'.
nuA that (Uath occurred, on the <late stated above, at I I
V
N" Wt 1 (>!•
I A 111 IK
MIR rill'I, \(F
or I \ rin-R
ist.ilt or Coimti V
MA^ll^N N\M1.'
<)|. MOTHKR
niRTni'i,Ati-;
'>»• M«»TIIHR
(Siat«- or Couiilrvi
:^ ^
I?
n
n
(
) ►
VA
11
aud
M. The CATSH OI-' DIvATlI was as follows
I>r RATION years
CONTRIIUITORV
Months
Days
Hours
DURATION
) ca}
Monf/is
Days
hJl^
(SIGNED) qU., i^. J. <..<XAlf: ,
U/CL '. T()0 H (Address)\J g/lAJstl
Hours
M.D.
f^^^'fi'-J'^f^^'^'^T'O'^ »"'y fo^ Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home.
)'<,iis t M,iii1h'
1 hi \
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoH lonq at
Place of Death ?
Days
'"m's^;•u'^^^^■'K!>J^l;^:laHu^ '"'^ | ;^^^»<<>'^ nrR,^,.>R KHNfcvA,, I „x;n^, .,„,,„,„, ^^^,,,.^^;
(Iiiff>i))iant
v^
'oX.
' r V
JNIiKKTAKHR M v- ^JKOUU ^'^ V,A
190
N. B. Every item o? Information •hould be cHrefully supplied. AGE .hould be stHted EXACTLY. PHYSICIAIMS 1, . .
«tate CAUSE OF DEATH In plain term., that it m„y be properly clarified. The -Special InZmJtlLt^' f'*'!"
•on. dyinft away from home should be given In every instance. mtormat.on for per-
W
^
llli
I
li
'1'
^\">-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I'.nriT.! ,,f ll.aUh I' No. 11 ^"ar-'^-J) liiS:}' Co
Ddli' Filvil, \:^
\
190 S
Registered ^'"o.
SJ92
^\^KJU^
i
i
71
T(l
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtiffcate of H)catb
( XX. S. StanDar^ }
PLACE OF DEATH: — County ofO£L>\; J A.Oyvxouix:o City of H/CX-^v OA.O^>x<m.4.x^o
No.
n /■.
^
AL'"L.C > )
St.; H Dist.;bet. '^ "klx^
and
ii
I
(IF Dr*TH OCCURS AW*V FROM USUAL R E S I D E N C E Gl VC facts CALLtD FOR UNDER "SPECIAL INFORMATION • \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
I^'LCli.
* I It.
V'^O
^n^ v5. C
PERSONAL AND STATISTICAL PARTICULARS
^i:\ ^^
n
1
I'Ai i; t)i iiiRTii
AT, H
Month)
a
SIN'C. I.1-: MARK 11. 1)
Wri>«>\yK|) (IK I»I\(»KrK|)
lUrjtrin siH-inl di -.i^»nati<iii)
(Dav
1/,,,/ /,.
.U
( Vfar)
/'<7I.
1 90^
(Year)
\
niKTHJ'I.AOH
(State- or ("ountrvi
NAMK OF
I'ATni.K
HIKTHIM.ACH
ni- lATIIHK
(Stal«' or Counti v)
MAII)1':n NAMK
lUKTlIl'l^AtK
or MOTIIKK
'statf or t'omitrv
[llcc
KKajuX.
MEDICAL CERTIFICATE OF DEATH
DATK (H- DKATH lC\
wa,
(Month) (Day)
I IIHRliBV CI'IRTII'V, That I attc-iukMl <lcHcased from
'ct7 ^ ,90'i to k).<:^ 1 icK)1
that I last saw h ^* aUve on L '^^ t> > T90'.
and that death occurred, on the date stated above, at H. IS
LL M. The CAl^H Ol- DKATII was as follows:
tX/Vx;
■^.tr^
'Xy^nuyy~\xxJ\
K, I
DTRATION A Years Mouths
Pax
'S
Hours
\\
I
I
Residrd in S,;,, /', ,int i-.n I i 5
nr RATION Viuirs Mouths Pays Hours
(SIGNED ) J . y da.\.cL . ^.Cu M.D.
lii/ct) 1 TQoH (Address) U KX^L/v^tl V J A.4.A.L<3U^ v ,
SPECIAL INFORMATION only for Hospitdls, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
\J„„tln
/h,v.
niK ^HOVK STA III) rKKSt)NAI, I'A K I" KM' I,A RS A K !•; TKt K Ic » IHJ-
HhST Ul- MV KN«>\VI.I.;i><*, K AND IU>LII:F
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli?
How lonq at
Place of Deatli ?
Days
(Informanl
Ud.lrtss So
^JjXaa.'
/VtrrvAj, jX)
PI.ACH Ol* lURIAI, OR RHMoVAT, I I)AT|;; of Hihiai. 01 RKMOVAI
INDlvRTAKHR ulf? , J OAA^
T9O •(
Ad.lrcHN liSl'X M )\\/^L^VCrvx.. ut
^' ^* Every Item o? informntlon should be cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information** for per-
sons dying away from home should be given In 9\cry Instance. \
If
•41
I
. a
p
8
1
I
II
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
_^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hoard uf Health F Xo, -; •**- 'V^^i: i;5: P Cn
/)Nfr F/7r./, ^DctXt^. %
100
Q^-J^^J^KA
Ilf'o^Lsfc/'cd J\''o.
2193
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cettiflcate of H)catb
( tl. S. StanOare )
PLACE OF DEATH: — County ofC^rLCA.<x
City of O/CucAXV-^^^Xa-aX^
fD
No.
St.;
Dist.; bet.
"and
/ IF ptATH 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
/>A.
r"\-tX.
PERSONAL AND STATISTICAL PARTICULARS
SKX
'\
A
i'< »I <)K
MEDICAL CERTIFICATE OF DEATH
DATK i)F I) HATH
M.mth)
AC. I-;
)■ ii>
l>.ivi
y/.»,ffn
( \ ear
Pit 1 .
Ml
(Dav)
iV(;ar)
SIN<.I,1* MARKIKD
I W't it( in -iK-ijil <li >«ij.'ii.i[ii.iii
lUR I'Hl'l, \rK
"^t it' ' .r ' ■..iiiitrv
i
■ Ml. nth '
1 JII';R1:BV CI-RTIJ-V, That r altcn.le.l deceased from
190 — to
tliat I last saw h ..."""" alive on ' - ^•:-.. ~
lt)0
aii<l that death occurred, 011 tlie <late stated above, at
M^The CArSK OF DI-ATIl wa^ as follows:
NAMK OF
FATHKR
lURIHI'l.AfK
Ol- I ATMKR
USlatf nr I'liimt I \
^T\^)^;^• wmi
lUKTHl'l. Xil-
<»!■ MoTHKH
(Stati- or Connltv)
oCOrpA rioN
Kfsidt'il III Siui It ,nii i>,-i>
1)1 RAT ION Years
CONTRIIU TORY
Months
Pa vs
//ours
DIRATIOX
f Signed )
\
) 'ears
Mont /is
/)avs
//ours
M.D.
iqo
(Address) CjXXy<l>uX/\%\X%\t (
}-,/
M,>nth^
I hi 1
Special Information only for Hospitals, Insmullons, rransients
or Recent Residents, and persons dying anay from liome.
'"',;, ^!IV^''^ '^''■'^ ■'■'•■'* I'HKSowi, 1>\K rrciI.AKS AKH TkrK TO THK
nh,M «)|- MV KN«>WI,I.;i)(',H AM) lU-I.n-K
flnfoMuant UuX^J^ ^M^U6 6-t^tlv
.
Formrr or
Usual Residence
Wlien was disease contracted,
If not at place of death ?
Now long at
Place of Death ?
Days
^ACK OK niRIAI, OR kKMoVAI, j DATK of HrKiAf, or Kl-MuVAI,
190
N. B.-
-Rvery Item of information should be carefully nupplled. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information** for osr-
sons dying away from home should be given in es^ry instance.
> -'
li
n
I
I
n
^ ^
I '1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
IIvaU;i 1 X.i :- -^^"^^ lUtl' I'.i
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafr FiJrfl, {.diAyJL^ %
/f)OH
Begi\s(crc(J J\^(),
2194
Deputy Health Officer
DEPARTMENT ftP PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH:— County of
Certificate of IDeath
( 11. S. StauDar^ )
y '^ City of 0a/C7uo-^>vc>vlc Lev.
I t I
No.
St.;
Dist.; bet.—
-and
(ir DEATH OCCURS AW«V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATrON ■ \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\^o.%\ ^
xo
PERSONAL AND STATISTICAL PARTICULARS
•1\ 1
It
i>A 1 1; < »i i.iK in
f\
C( >1.» iR
v^
MEDICAL CERTIFICATE OF DEATH
DAli; 111' DEATH
L
Itll
A' .!•'
I HEREBY ClvRTlFV, That I atteiKU'.l .iicrascMl fmni
(I):iv)
(Year)
\
t
\/..„ri, J^"i
/ ',1 I
N\ 11)1 lUI'D MR DlVi )K* }r>
'W'rittiti -iKial di^iiMiat ;. .11 1
J'
I'.iR rupi.Aci-;
(Htatc (It I ', ,\uUl \
NAM) ni
lATlI IK
TilU ill n, \i J.-
'»! I \ I'll I- R
iSlati .1? I'oiiTltrv
M MI)i:v NAMl-
<»i- mothi:r
inRiiri'r.Aci-:
<•! MoTIIHK
(Stale 1)1 i^^nmtrv
<KA rpATloN- ,/'
A'f'^nff'if in Siiti /■') innift'o
that I last v;aw h
T9O ~
alive on
tn
igo
and tlial (k-atli nct'urrcd, (tn llic datt- ^tatid ahovt', al
~^ M. 'V\u: CMS!" OF DFATII was as follows:
DIRA'I'ION )'car.s
CONTkim TORY
Months
Pays
J /ours
DrRATrox
(Signed)
}'cnts
.M,>Ht/lS
/hTV
rgo
( A dd rtvHs) U /a^CAXX-'VVviAvt
I lours
M.D.
SPECIAL Information only for Hospitals, Instituflons, TnnsleBts,
or Recent Residents, and persons dying away from fiome.
^'eal s
M<„it)n
l\v
THI, \HovK, SI A I If) I'KRSoNAl, PART fcr I.A RS ARIC TRIK TO THK
1U-,ST o|- MV KN«)\VI,i:i)<-,H \NI) ni:i,IKF
Former or
Usual Residence
When wiS disease contracted,
If not at place of death?
Now I0R9 at
Place of Death ?
. Days
a
yj^, \CK OF BIRIAI. OR RKMoVAr,
nAXHfft Hi KiAl, or RKMOVAI,
ii-ct I T90H
^' **• Bvery Item of information sliould be CRfefuIfy supplied. AGB sfioufd be sttited EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for psr-
«on« dyinft away from home should be given In «\%ry instance.
i
i*H
tfrni^^LiJimS;
K>:
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafr F//^>^^ OcJ>t-v^ "]
IfWH
HegLs/e/'cd J\^o,
2105
1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Wcntb
( XX. S, Stan^arD )
4 ^
^
PLACE OF DEATH: — County of ^jOuyxj o \^.Ol/>vcul>co City of '^Ol^v vJAxXywye.^-<Mio
!]'
No. ~-.
,- :\ ^
^ ^
St.;
Dist.; bet.
stl
and
(IF ocftTH OCCURS Aw«v FROM USUAL R E S I D E N C E G I V c facts called for under "special information- '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.tl
Ow.La\.C:^
"\
- L
PERSONAL AND STATISTICAL PARTICULARS
"^1 N rni,<»K ].
\
lO kdju
!>\ rj; or iuk i ii
\ I . !•:
I;
(Day
•,ai)
MEDICAL CERTIFICATE OF DEATH
DATi: (•!■ I)]:\TH
iDav)
3'' ~
U !IH )Ul.;i» » >K I)I\< »Ri I'D
I i
MUXX^Uwdw
I'.IK THHhAri'
' "^t.itt* or Ciiinil r
I A III IK
HIKTmM.Ai H
<>l" lAPHHK
'"^i ttf or roiiiif T\-
^t\Il)l■:^• nam)-
<>l MoTIIhR
niHrm-i, \ri.;
<»l M«>riii.;H
e^tatt ,,r Coimtl \
(UHTI'ATION ^ p , '
C' . t^*-\. d
I IIFUUIHY Ci:r<Tn'V, That I atteiidtMl lU'iAasod from
tli:it I l.i'^t ^.i\s li j^-^x ali\i'ni] ' T(p
aii<l that fh-ath nccu r rdt, oii tht- datr •-tatial n1u»vt', at li A'
^U M. Thi- CATSK (»!• hi; ATllNvas a-^ foll.nvs:
V^XfrAXcC M.LOtA\A^CrA^<X>MJ JAaJjuL^^'
C<.\.Cc>
DfR A riON
C'l >NTR IIU T( iRV
)'f'<ti
Months
I\u
I lout <
Mouths
l^avs
I )r RAT ION Yi-ars
(^IGNED) UJ. V^ni. W ^^ ^
11-'/CAj :t TqoH (Address) IbOl yl.<Hl*\X.^Av
//ours
M.D.
SPECIAL Information only for Hospitals, Insmutlons, Transients,
or Recent Residents, and persons dying awdy from tiome.
Rfitlfii III S,in /• I (I III I SI-,} I I. ) I'd IS
yf.nilhs
thivs
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How loHfl at
Place of Death ?
Days
THH XliOVI.' STATi:!) I'KK^OSAI. I' \ KTICri,AR8 .4RK TR T IC To THK
HHST 0|- MY KNoWI.IJX.H AND H1.:mi;K
Iiifi'iinant
X/Vw
4 5 ai\xw,€mu Bi^
N.l.llr.
PJi^ACE OF BrH,IAU OK KKMOVAI, | IJATJ^ of lli kiai, <.r RKMOVAI,
tt
If
t£tr
(AdiheH?
N. B..
-Rvepy item of {nformatton should be cnrefully supplied. AGH should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr*
sons dying away from home should be given in every Instance.
5 y
31
It
lil
i I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ofHialtJi IN.. :-- '^•^'ac^jJU'vl' t'o
REFER TO BACK OF CERTIFICATE FOR INSTRUCTION3
il
\
^
lOO'i
Dale Filed , \jfC
1
DEPARTMENT l)F PUBLIC HEALTH
Reglstrred J\^o.
106 I
Off
--O-OOUi i^JCV^M
City and County of San Francisco
Certificate of 2)eatb
( "U. 5. StaiiDar^ )
PLACE OF DEATH: — County
of ^/CX. Vu OiXxXAox^LAXx^City of ^XXav J /uOl/vuOlaxx)
No. 3S4
^
St,
inocci
»TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I
FULL NAME >jix,C->->x<XA
; ^ Dist.;bet. l^-<X>V'k.l<.-yV and J
&U.Qh.
(If DCATH^OCCURS *WAV FROM USUAL R E S I D E N C E Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "S
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
"On
\
PERSONAL AND STATISTICAL PARTICULARS
i COI.ok
M
MEDICAL CERTIFICATE OF DEATH
DATK Ol- 1)I;aTH
.1
DATi; t>I ]UK 111
A»,K
A
V
fKli.nth
K
M.ntlli^
(Vtai )
/),/
lU'iitriti "^iH-iai ih --ii.- iiat mii >
i\a.\/>^v.X<L
N'AMi: (11
HATH i;r
I'
Month)
Day) (Year)
,1 Hl'kl'I'.V Ci;kTII'V. That r attended .leccased from
j ■ . \<.p'\ to Sw^^CAl I iqo '
that I last saw h i alive on W'^A' ^ Kp '■
and that death ocenrrcd, on the date state<l above, at w
LL M. The CAISJv ()F DlvATII was as follows:
I'.IKTHPl.At'K
oi I A rill-: R
' ^t i!( ..! Cuunfrv
MAiniN' NAMH
"I Mother
I'.iKtin'i.At'K
<M- N5<)THKR
(Htatt i)r Count rv'l
I )r RAT ION ■ )'cars
CONTRIIU'TORV
Months
Pays
Hon
; V
orcri'ATiON
Resided in Sati liati, i^fn
! Ill I >
duration
(Signed)
^cars
nn ^
Mo>tths Pay's
L iqoS (Address) 3^1 '}^KKS<XA: Jt
W . sJ .
I lours
M.D.
Special information only for HosplUls, InstituHons. Iransients,
or Recent Residents, and persons dying away from home.
Mnufh^
I I J
l\i^
Former or
Usual Residence
b
f\
Lcw^
Now lonq it
Place of Death ?
Days
Wlien was disease contracted.
If not at place of deatli ?
TUK ATun'K s'rA'n:i> pkk^onai, pah iiitlars aki-: tri'H to
HKST Ol Mv kno\vm;i)<',k and iu:i,n;i-
(Informant \I lUv^^ m>X^'^--^UL v-^XX^Q/VC VA.
r\<idrcss oHH
TlIK
) <XV4,4^ Ml
D\ri;..! Ml KiAi. or ki-:movai.
1 90 1
%,
UNDHRTAKHR
(Address Aiftipb V J ' '-VQ^^^.^O^A^ J i.
N. B.-
-Kvery item of informntion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In pinin terms, that it may be properly classified. The "Special Information" for psr-
•on« dyln^ away from home should be given in every instance.
- y
§■"1
w
i
I'" '
•It
J' '
p.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I i, i M h i- V>i
rE-'.i.;, !;X; P C,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l\ \
pfffc Fi/rf/. ^ <zL(r'KxA} S
IfJO'i
Begistered JSI^o.
;2197 1
-V
-V
DEPARTMENT OF PUBLIC HEALTH
City and County of San Francisco
Certificate of E)eatb
( Ta. S. StanC>arD )
PLACE OF DEATH: — County of <^ >^ ^ Vn -.acuj City of
C'<X >v J A ex. >\ co^<ro
No.
^ i .. ^^.ixvLax Sh; Dist.;bet. and
/ IF Dt*TH OCCURS *WAv TROM USUAL RESIDENCE give facts called for under special information- N
V IF death occurred in a hospital or institution give its name instead of street and number. /
FULL NAME v.^kkcv.,U W^x^c
)
SHX
PERSONAL AND STATISTICAL PARTICULARS
L.U.
DATi: oi I'.IHTH
^]lm,
(Month
\<.H
Ha ,
^!N<.I,l MARHIRD.
WIIM )\vi:i) (»k DtVnKiKf)
iUiitfiii sdiial diHi^'iiat imi)
ii)av
\; •>!'//
> I ar
/),;
HiK'rnjM, \oi.
' "^t.ltf lit i'l.Utltl \
FATHHR
HiKTuri. \cy
ni- I \ III (. |.;
(Htali o! ii.uiit
maiiii;n nam I
«>1- MOTHKK
i5ik rin-uAi'i-
<>! MofllKK
• State- or Cmnitiy)
nccri'x riox
<XhJ^^^JL/6^
iO
'1 — —
MEDICAL CERTIFICATE OF DEATH
DATK nl- I)1:a TH U \
(Motitlii (I>ay) (Vt-ar^
I HI'RI'I'.V CIvRTII'V, That 4 atteiKled (UucMSed from
1^ ■:. 190H to W/cX 'I iqo n
that I hist saw h '^ ' ■ alive on ^ ^^ • Up '^
and that (k-ath occMirrcd, on tlie (hitt- ^tatf«1 above, at
^ M. The CArSI-: OI" Dl'lATII wa-^ as follows:
I) r RAT ION )V</r.v
CONTRMUTnRV ■
Months ^ ' Ihivs
1
Hours
,<x v'Vcvc
DT RAT ION
(SIGNED )
Yiars Mouths w f\n>s
Hours
^^^^ Kfsidfd ill San f'ldiui-in iX )V<M^ \ Months ■ I h- \
THK AKOVR ST\ ri:i) PKRSONAI, FAR IMCl-I, \RS AKl. TRIK I' > THJ
HHsT <)i' Mv kn<)\vij.;i)(;k and in.i.iin-
; Signed) \ Ki) .\XtsX\jo^^- m.d.
IP/tjt I TOO M (Aa.lress) bl^ Ij^dUyt ^K
Special information only for Hospitals, Institutions, Transients,
Recent Residents, and persons dying away from home.
Former or t^f^^X L x i How lonq at ^
Usual Residence ^ ^^\JO,JYwJuy\)^ '^Plare of Death? A Days
When was disease contracted,
If not at place of death?
or
nr.ni »M< M^ KNOW I,i;i)(,h; AND
(Infnnnruit Vl ^tv.^4'^JL'L L
KA^ > . C
f A'Idrcss
X'XH cLLcvW^ry-L.t
\
rivACK oi" nrKiAi, <»R rkmovai
i»n*I)i;ktakkk y\AAXA.A^
DAI'lio! Hi KiAl. or KKMOVAI,
QlWYvt
CV0^>nUAx4
N. B. E
»very Item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for psr-
sons dyin^ away from home should be ftiven In every instance.
=> -*
k
^l
* *l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
" ' ^ '•:.-r^ ' Vi « REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
li)0\
Regtsfered J\'*o.
2198
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. S. i5tan^ar^ >
No.
PLACE OF DEATH: — County of v <X ^x \0 %vcuioo City of ' 0^>^' J Aouwca^ <^
St.; Dist.;bet. ^^ \ ^ ^' and ^•C'v. r * >
(IF DC«TH OCCURS AW»V FROM UT JAL RESIDENCE give facts called for UNdER special INFORMATION" A
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAIVIE ^Iu^xm^LIoj yX^cLcL^*)\
PERSONAL AND STATISTICAL PARTICULARS
I) \ I i . ii
i.lK 1 li
<.
V
:.^l
'1^1.. nth) X
I )M V
> ' . v.
70
) )
\\ii><»u J n OK mvoRfi:i»
W'ntt in »..(!;,] «1« si^tuiti.iiil
lUHTHlM, \C\:
"^t.iti i: I '. .11 lit 1 \
V \M J- OF
1 VIJI KR
lUR IIIPi. \KV.
< " I A I II i;r
'^t;iti <ir r.iuiitt V
>f\ii>i.:N' Nwn-
'»! NKiTllKR
JHHTlll'i, ACi.',
'»i' Mi»iiri;R
iStatf or Viiiiiii I \
f\'f" ijn! Ill \,iii It ,!n,
^
/ Q(y \
MEDICAL CERTIFICATE OF DEATH
ilk i
(Montli) il);i\
I III:R1;1!\' CliRTII-V, That I nitrmlt-d dtri asid fnun
L -^ - .. .\ It/) i to ^.- C ^ < i()0 i
tliat I la-1 ^aw li «v-' alive nii - ^' I90 I
Hid that iK-ath ncciirred, on Hn- tlau- statiil alM.vi-, at I
c
M. The CMS!-; ()!• IH; A Til \n a- as tollous:
K^ -A^w-vtlu
C\
Dlk A rioN
) liUS
Months
Ihiv
Hours
> \. O.. \
CONTK IIU TORN
DTRATION Yi'iiis ^ M.oitJx
^.tA..C ^\,
C\..
fhiv
SIGNED ):Ja.CU J U mYI ^i)<X\Xlti
iJ/ct I TooH fA.l.lrt'ss) UH'^ :3A-aXUa; 1%
I lours,
M.D.
) ,,,-/ » 1 'I Mi^uth^
/hi I.
Special Information only for Hospitdls, institutions, Transients,
or Recent Residents, and persons dying away from liome.
rin \i!c»\K sr \ r»:i> ckksonai. I'\r i icmi.aks ark trtk to tiih
•H-.sT 01. MV KN.>i\Ij;i)p».; and mCI.IIvK
'liifotinrint
\.l.ir.s. lilD ^ Lo-yA_A at
Former or
Usual Residence
When was disease contracted.
If not at place of deatli?
How lonq at
Place of Df atN?
Days
DAT
HiKi Ai. or R i:Mi)\AI,
TQO
PI.ACH 01 nrKIAI, <»!< l:iNt(»\AI
N. B. Bvery item of Informntfon should be cnrofully nupplled. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DKATH in plain terms, that It may he properly classified. The "Special Information" for per-
sons dying away from home should be given in mvery Instance.
4-
Mt
j I
I
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD
' ll..,!h \ X
> 1-. t-S'isTT'S^; V.ScV C,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\ .1
1^)0 "i
Registered J\''o,
2199
\>
I
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
PLACE OF DEATH: — County of " O >v J \xXvvcul/CU) City of C'/avv.- 0/UX^>vc<^'CU)
Op
I
No.
\
Hi'
t}Wxkkj6 llc:<,V^t
St.;
Dist.; bet.
and
(iriDtaTH OCCURS *wtav rnoM USUAL R E S I DE NCE give facts cal'.ed roR under "special information-
it DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
^
FULL NAME
\ \
\
■\\
KxkSJkj^'\ V
PERSONAL AND STATISTICAL PARTICULARS
i C<>I,<»H ^ *
<>I lUKIll
i » I
M..!ith
A<,J-
a^
4
\ • .11
/',/!
/go 1
(Vent
^IN< I.I M \kK ii.;i»
\^!l!t•i!l v.Hial lb — ivtiatiiill)
IURTHPT..AeR
ist;i!, ,,: I ',,initt
J A III i;k
''.IRjHl'i. Ml.;
"I I \ I in;k
'stall .,i (.Dntiti \
MAIHHN NAM!
<»r MOTJIKK
I
ct
n (A-
MEDICAL CERTIFICATE OF DEATH
fM-.tithi I Day)
I Hf';kl-:P.V CI;RTII"V, Thai j atttti.li-.l .Unascil from
l()0'i t«. U ^L' i JqoH
that ! hist saw h -^ ' ahve on ^ ^^ i- Tc)n'\
and that <Uath Dcciirred, nji the dati' stated ahovi', at *« <'
M. The CAISI-: ()!• 1)1':^TII wa^ as follows;
ULcva^aJ^jL VJ iXaXoi
C^JVAJ 0 -CA^b
Cs„<w > > Vrfftr;
"t
CO^'„.j
I
\
e
Li
Aa/vucx LcU.aoA.cl ,; 4X0
HIKTIIIM.AC'H
01 Mo'nilvK
'Stall or fouiiti
\ )
) ^t'
1
DIk.ATloN }'ri7rs
CONTRIIirTOkV
Months
/hirs
Iloi
Ht S
l.CL
LI
OV.
<— VwCX/W
ci
nr RAT I ox
(Signed )
^-. Years
Afttfiths
/hus
Hours
M.D.
^/Ct i 190 H fA.1.1n-ss)3l3. %Kx|aJ^X^ JwMjU
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
<»i rri'Ariox
Former »r
Usual Rfsldence
kjG.^i
1i M^c|
. [ 1 How lonq at
4 Plare of Death ?
Days
M.nitli!
-- Da 1 .«
K
^'^^v. ahovk st a ri-.D |'kks(»n ai, i- \KTKfi, \ks akk tkik to tm
JU:ST OF MV KNONVI.i;i)C,K AND HHMJU"
f\,l,lrrssH/ UJ djb
4
When was disease contracted,
If not at place of death?
OArii^f)!' Hi Ni.Ai. or KKMOVAI,
/c^ l^ 190 H
n^ci-: OF Bi'RiAi, ok ri:movai,
d.i-cs. xx\ Ol^ CILLUju
im»i:rtaki-
N. B. Every item of infopmatton should be carefully supplied. AGB aiiould 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 m-t^ry instancs.
4-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! Ml) 1^
-sr ^wt n^l' Ci,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
%
/hf/r /'V/rv/,. tc'^
.■A^ <y'^.^^j^/i (xX XX.
s
IfJOH
Bciji^fered jYo,
2200
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of IDcatb
11. 5. SUin^ar^ ;
PLACE OF DEATH: — County of "' y\ J V'O-^vici.ccCity of ' a ^x 0 V<x>xc<^i^c
ft
No.
'
I ^ o^L *^U St.? ^ Dist.;bet O/t^VccLoj and LU^xJja^^vcg
(ir ot*TH occurs AW»v TROM USUAL RESIDENCE give facts called roR under "special information- \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
1 1^'
%
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
vjTlal,
CUl,MK
01 i veto
4—
I < 'f niK III
Let
M Miih
I>av
I
1
•-iv'.i.i' M\RHn:i>
\V I til i\V)' I» ( (k I»!\< »Ri Kl)
n
lon\
go
Vt-ni 1
^ _
MEDICAL CERTIFICATE OF DEATH
I>ATH ol- I>K ATI! i ^
'NfoiitlO 'I>av
I !II;KI:I'.V C'i;kTll'"V. That I attcn.UMl (U-rcast-d fr«»iii
C ct t 190H to ' ^ ' np 'i
that I last saw li ' alive- 011 Itp
and that d alh occurred, on the date -tated alnivc, at
- >I. The C.^rSl'; <)!• in; AT II wa^ as follo%vs:
U
<X^'>A
I ATIIJIK \
lL
,L-'^C^<^^\
,~s
HtK'IflPl, ACF
'»' » \rin:R
MA\i .11 i'.iuntrv
^t\^>^.^■ nxmi-;
<»i M«>riii;K
^
XV ^^^ n
I )!' RATION
CUNTRHU TORN
)Vtfr.v
0
A/il>i//is
/hn
Hours
V 1 A
Months
ni'RATION )V.//v
J\}r
(SIGNED)
i:
^. ^'C
/ /on I v
M.D.
v.
inKrni'UAOK
"I Moi'llKK
'StMtc- .,r CouiUiaA
I
.<x
A.V A V „
.u
r\.VrL^4
I , \ I
occri'A'noN
• "i-
,"\
{\i
UcL ^ TQoH f Address) \J<xK^^ytt iXld
Special information only for Hospitals, Institutions, Transf
or Recent Residents, and persons dving anay from fiome.
siYnts,
}v,.-
Mnllttn
I'i.lM
THi: AHOVK STA ri:i) i'KRSONXI, I'XKTIcri.AKS AKi: TKIK TO THH
H1%ST 01.* MV KNn\VI,i:i)(.l«; ANJ) Hia.IlCF
f Address
300%' ^b
-tAi cj;
i.
Former or
Usual Residence
Wlien was disease ronfrarted,
If not at place of death ?
HoH Jonq at
Place of Death ?
Days
IM \CK Of nrKIM, oK KKMOVAI, | DATKof Hi uiai. or RlCMoVAI,
C
rNI)i:KTAKKK mX). I l^*\J 1^^ H^. JC U.
(Ailrcss I 0 SI UTL^
t.r
^SL'^A-.to^ '» V
N. B.—Bvery Item oif Informntion .hould be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly classHTed. The Special Information for p«r-
«on» dylnft away from home should be ftlven In •\^r'if Instance.
/I
f
I
i^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RCFCR TO BACK OP CERTfriCATE FOR INSTRUCTIONS
/ / (ff
r> 1 Ik
Jfpo'/sfc/'rf
f^*»r^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
PLACE OF DEATH I — County of
n
4eo City of
^
T
. NCi.
NAM
St.; Dist.;bet. and
SUAL RE SIDENCE GIVE facts c«llcd roR under "spcci«l information' \
SPITAL OB INSTiTUTION r ' NAME iNSTEAr ' STREET AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
,C
MEDICAL CERTIFICATE OF DEATH
(Vtar^
\\
A-N
//<>/,
RATION
\ MI-
NI* till F K
, ,1-
npLAcr
.'n'ri! JM^
Signed ^ <.' 1 K ,m >.^ ■
M.D.
Special information only for Hospitals, Institutions, Iransients,
or Recent Residents, and persons dying away from fiome.
A'f.liitUI I It SiJtr /'iiill
til I S
H yt.iuths KX An
I'm
; A Tun H s r \ r i:n i'Ku^«>x \
tl'S'I' til M 'wJ».Xm\\1,) 1). , K
Icrr.ARS ARH TRIK TO THE
u;MHK
Former or
Usual Residence
Wfcen '^is disease rontrarted.
If not a! place of deatli ?
How toRi at
Plareof Deatfi?
Days
'"^UL
PUACH OF Bl'KIAI, OK RKMn\ AI, | DATU ..♦ !!» miai or RHMUVAI,
pi I ^ I . ^ . I - TOO
rNJ)i:RTAKKK '^-<^-^-^- VXX<IA^ Cjp^J^L
(Address kH'^SA'^oXt
N,
^ ._, ^ a „ ...„„ii-H AGE should be stated EXACTLY. PHYSICIANS should
B. ^F.vepy Item of Information should be carefully supplied. AUD snouia o .«R„^ct«l ln»rt,.,««Hft«" *«,. «-,.-
_ , . . . ^ *!._» !«. ..«nv K* nfooerl* classified. I ne opeciai inTormaiion lor* psi»-
state CAUSE OF DT ATH In plain terms, that it maj^ i>e propeny ».■••»
sons clylnft oway from home should be given In •\tirv instance.
X-
f
fi.'f,
m
WRITE PLAINLY WITH UNFADING INK
H.
I X"
^5l!5.f
THIS IS A PERIVfANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
D^ffr riled , kj otrU
J J
"kjcyvH^L
Deputy Health Officer
JRp^isirred JVo.
2202
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eath
( 11. 5. !5tanDar^ <
PLACE OF DEATH: — County of '^XXorv JXxX/>vocAX« City ofnxXvvO.'LO- . . _ .^^ . .
No.
. ' .' . , U. ' ' SU S Dist.; betMjA.CC V\.CL > va. ^ ^. and LL ^<- l^'<i
/ ir DTATrt OCCURS AWAY FROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER "SPCCIAL INFORMATION ' \
\ IF DC4TM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
xd
PERSONAL AND STATISTICAL PARTICULARS
I' \ 1 i. ' '! :.] k rii .*>PN
^
i ^- ^
V
M. nth
MEDICAL CERTIFICATE OF DEATH
DATi-: HI i>i;ath -^
I
il)av
IQoH,
:iL
"• I N « . 1 , K . M ,Jk N K I r I )
\vi III iWKD Ok 1 1:\ I >K'i 1' I)
iuk iiii'i, \t*i'
' "^!;itt I il < 'i ill 111 I \
N"AM|- (U
I AIM J k
ink in )'f. \( i-:
<•! i\iin-;k
"it. it I < i! 1 "i 111 n 1 1 %
M \ IIH: N NAM J
<il MoTin.K
lUk ruiM. xn-
' "'tntt .,1 1 imntt
< »t t r I'AIH ».\
0 (\
"N > Vv^
r
N
(i)
kXJxjXj^->\j
I t
i Month)
I HIKi;r.V C1:RTIFV, That I atteu>k-<| .U-ccasLd fnmi
H" ■ , " KjoH tn ^Ct. 1 KpH
that I last saw h ■ ah\f (Mi v, iip
ami thatck-ath (»( mnil, nn tlu- il;it<.' --ta't'l ahovc, at l I ..
>r. The C \l SI' 'M' hlMTIf \va- as follows:
^V.atXVLi^ I (X4 Iax
CoN'i KHUTORV
/hiv
//out s
)\ijr
DIRATION ....^.
(SIGNED) MiL-'Cd. M)
1
/',7r
L<X.Q ,
iqo H (Athlnss) UlOXJflOwV
M.D.
SPECIAL INFORMATION only for Hospitd.K, Instifutions, Frdnslents,
or Recent Residents, and persons dying away from liome.
//,;//,.'.,■, fiAVU )V(M* I M, tilths '^ /hns
I hi: \H0VK six til) I'HksoNAl, I'A k I* IT I" I. A KS AKK TKlK TO TIIH
lU.M'tM MS jvN< i\\ I,I-:ni .K^WD inilJIlK
anf..,,„.,„t Uj. m. \. V^.CutLi.\tc iw
\>\'\\.
51X ab<t>u-LdBt
Former or
Usual Residence
When was disease contracted.
If not rit place of deatli?
How lonq at
Plareof Oeatli?
Oavs
T90 t
1?I,\C h: ()|- in klAT, Ok klMoXAI. I DAir.i' lU riai or kl.;M<>VAI,
IN. B. F.very Item of informiitSon •hould be carefully supplied. AGB ahould be stated EXACTLY. PHYSICIANS shottld
•tate CAlJSn OF DKATH In plain terms, that it may be properly claaBh'led. The "Special Information'' for per-
son* dyln^ awny from homo ithould be given In every Infitance.
> —
^ .
I
I
I
♦I
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)fffr n/i'tl
ioo\
Be^isferpd JYo,
S203
«.,, I
f*%Cf%
ut;r
DEPARTMENT OF PUBLIC HEALTH=-City and County of San Francisco
Certificate of ©eath
tl. S. Stan^ar^
No.
PLACE OF DEATH: — County of Oa.>% 0 vo , h^cc City of ^ ^ >^' ^KX^^^ <- <-AiAto
St.; I ' Dist.;bet. ' ' and
/ ir DE*TN OCCURS AW*v moM USUAL RESIDENCE give facts CALtED rOR UNDtR SPECIAL INFORMATION \
\^ ir DEATH OCCURRED IN A HOSPITAl OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
u
FULL NAME
.c^i^xA-a
?^
PERSONAL AND STATISTICAL PARTICULARS
Ll
I
d:
i
L
MEDICAL CERTIFICATE OF DEATH
DATi-; < '1 i»); \ rii
li'cb
(Year
A,
t *, < *i
iwi ) r>
J(
(TS
< ^vc^x^t
L
V \ %t I I ,(
1 \
(Month) il>;iv>
I ni'RI-lSN' rikTITN', riiat I attt-ntUd (UHA-asoil fr. iii
L e' I«)ni tn V ^. V O
that I hi'^f saw li ■ ilivt <>n
aini lliat drafli < H-furrt'il, on tin- ii it* -,tattil alnnH-. at
%T Tlu C \rSI{ or in \ I'll \va< a-^ follnws:
TtpH
1 ( )() »
\.
L^ A.'|Vi\u \ vCVAa.
'ink
it! \
M X I I ilN N \ Ml
•'1 Mi'lin R
"'I MfillllR
■^l ill 1 ii » (iiiii( t \
«>C(tI>N'li()N
Dl R A 1 h )N
f( >\ I'ls I in I't >U N
/',
/I I.
//«
)llt V
I MR \ ri« »\
Hav
r .
L
CL^U^"
M,<iith^
fhi
Signed )
d' 0 I. HI
//ours
M.D.
!ll\
( \.
Special INFORIVIATION «>nl> («»' Hosplttrfh, lnstituflo«s, Transients,
or ReHfBt RfsMfnts, jnd pfrsws dylif vmn tnm homf.
formrr w
Usual Rfsldrnif
Whfn Wis rflspjsf ctnlrwW,
If not lit pi* I ol ^afh ?
How lonq at
Plare ol Death ?
Days
THK AH<)\|.-, sr \ IIJ) I'HUhc iX M, l'\R I l« r I \Ns XKI! VK\ I". r< » i'lllC
HKsrni- MS" K NoWI.KIx . I ', !' iMI.IHK
fill
f..rnirn)t OaJL
PI \> I I u lU K i \ I,
Ml >\ V I,
La
rsni
IK L ^\
lAiltli < -.I
i» \ 4;i: ..: iiiHiAi .11 K i:m»»\' \i,
II ' I
^ 1 90 1
N. B. Bvery It.m of inf.,rmntmn should he cwr.fully m.p|.lle.l. A«ll -•» nhl ^"f »«•;• IV^OTl.Y. PHY«ICIAN« ,houW
mate CAlJSf: 01 DIATH In plnln term.. th«l It miiy l.r proiH"!* I..n«m*«l. I »u ,s,.<,ImI |„iorin,,iio„- fop ^i*.
mtinm dy\ng, away from homa iihoiilil he ftlv«n In •very lniit»n».«.
k
«
i
'ii^-fi^slE^-
9 I
i
ll
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.uir.l ul H- Mh i V
"^: 1:5.1' C
liuff Filc<f , L ct<rlj
>^'
//^/^>H
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hegisfrrrd J^o.
i
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
^ 4
m
PLACE OF DEATH: — County ofdxX^wJ \XX ^vcc4C() City of 0<V/tv J MX^^c^^co
N«.U^U.'^L(-^u^vtu wv .^^^.',V^A.vXl St.; Dist.;bet. and
■Zls *WAv FR<iM USUAL RESIDENCE G.vt facts called for under special information" \
' IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
)
(IF DEATH OCCURS
IF DEATH OC^UI
FULL NAME
j^
Zs\y\
\ i
%, I
PERSONAL AND STATISTICAL PARTICULARS
V 1 n
I I u^
i> \ ri-: or iuk rii
\
I 4 .
MEDICAL CERTIFICATE OF DEATH
i>\ ll-; oi i»i:\T!i i \
rMoiitii>
/ go H
(Vcar'i
r\ ^ A
Moil
\'-i-:
il I
l>av
1/. . ■/
» f:ir I
siNi.I.l.:, MAKUn-.n
\Vn»n\\ I-.!) UK I)I\< >!•( Iti
'Writf ill -•iiial il-'-iu' siat i« iii >
HIK i'Ml'I, \t"l-:
St.iti I i; I f lU lit I %
FA IH IK
niKTHri.MK
OI iAriii-:K
I St;)i( iir Ciniiit t V I
MAtlUlN' X\ Mi-
ni MmI'III, K
MIR i!n'r,At'K
111 MOTHHK
■ stati ur fNiuntrvt
I III'RI-I'.N II RTIl'N'. 1'hal I atleniU'il (Urca^ed frntii
T()0 H
tliat T 1n'-;f '.aw h i- ■ alive on V^ ^^? t I90 i
an.l that .Ualli <H»urreil, on tin- <laft' ^ta1t<l al)OVi', at > » 3.
\^ \U. Tlu' CM Sl{ or l)i: ATIl was ;js follows:
U\ ^
Hi.
\^ik
,4
<)( rri'ATIoN 0 (^
Kesiiifil ill Sim /iiniii^i'i) l ^ )'iuii s
])r k \i ION )'rdrs
C< >N1 KlItrToRV
nr RAT I ON -^ X''"''Jv
^ (I
(SIGNED ) -J , vj\ (
C 0 '^ Oi-A..
MiiHths
a'd
/>.71
) V
PiU
Ih
^in \
I lout V
M.D.
N only for H^s
SPECIAL INFORMATION only for fWspltals, Institutions, Transients,
or Recent Residents, and person^^ng away from home.
^r,nilhs
Ihi
rHKAROVI-- Sl\ri!) I'KRsoNAI, PA K TICl' I,A K S A K l'. TK T H T« » THH
iiRHT OI- MV KNOW i,i;n(,r: and nKi,iKF
(1
\JCxx.^\>^
' S'ld'C'^'; \w
Pormer or
Usual Residence
Wlien was disease rontrarted,
If not at place of death ?
\J VA-,*^ ^ V tx. a_ w XT
How long at
Place of Death ? ^
Days
ri,A( K OF niKIAI, OR KKiloVAI,
iqJ'
fL^nXy^-UX
rXDKRTAKHK
(Address
I)A'i;4-:nf BiRiAi, or RKMoVM,
(m 4
^ lf)0 1
N. B.— Bvery Ite^ of Information .hould be car.full,. supplied. AGB .hould "^^.^^-^^^.f .^5[^^,^; ,„ ^"^^V^*^:!^. ••***"'*•
state CAUSE OF DEATH In plain term., that it may be properly classified. The Special Information for psr-
«nn« dylnft away from home should be given in every instance.
> ^.
>
h
^
J
f*
5 i
i i
\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n<.:".! -f !l. nMli
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffr /v7r^/, Jc^ot<riM^'
ID
IfJO\
Registered J\^o.
^
\_0\^ 0»«4/\M.
i-
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No.
Certificate of S)eatb
( xa. 5. StnnC>arD )
PLACE OF DEATH: — County of C' a. \^ -3 vVQ^w^Cvi -City of'~'.<x^v ,) Axi. vx-ci.<i,<m,
ll'X 'vJJ^,^<XcL^-V -^ St.; I Dist.; bet-U^LAA-'a^^n-Yv^ and' JJ-ClIL-'lu )
(IF OEftTH OCCURS AWAV ^R O M USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" "X i
IF DEATH OCCURRED IH A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J j
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
I
X.£kj
■-i:\
MEDICAL CERTIFICATE OF DEATH
DAT]-: 01 iii:\Tii
Vw
iL:ct
'M.ititlr
\ « . J-
ilniv)
■\f,.n'ii'
\ '■A\
/hn
Uct
IQO 'i
iMotitlO (Day) (Vtar)
I ni':Ri:i5V CI;RTIFV, That j attemlcd dcccasccl from
wA/
^ IN". I.I' M\Kkn:i»
WIIx i\\ i;i> < »K Iil\i >K>' 1"I»
U'liti ill -.(.iial ilf ^is.'!sati(iii)
lUKrin-i. AOi-:
St.tti .n < '.111 111 I \
NANfi-; nr
I- A in i:r
niR Tiifi.ArK
nf- I AillKR
(State III riiuiili V
MAIDllN' NAMK
<'I MoTHKK
nTR'nii'i.Af}-:
OF MOTHHK
(State ur C«)tintry>
D^'cri'A riox '^
190' I
alivf o!i
Tt)0
til at I last saw li ■ alivt- oti V' %,v ' joq
and that deatli occtirrcd, on the date stated above, at O
1 M. The C.MSK (M* DI'lATII was as follows:
II
dlD (CXA.LULiU
in'RATroN
)'t'ars
Mouths
CONTRIIU'TORV jX^wLa.
Day
Hour Si
^ «'
\1\
nr RATION r^ yxsJrs^
VI r It.
(Signed)
JAj;////.
'j' , a. (&
fhlVS
//ours
M.D.
IQO
. -KJ Kr\A.jx^.\. y-j M.D
(Address) lOS' (0 0 K<X/v^ ^LcLa
Special Information only for Hospitals, institutions, rrawienti,
or Recent Residents, and persons dvinq away from home.
A't\-iifrif ni San /'i aniixfn
).-.//
Mnntln
fhi
I'll I- \H()\-i.-, s I' \ii:Ft I'KRsox \i. !'\RTicr I \k> AKi; I'Rn-: t<> tiih
IJHST t)l- MY KN«)\V1J'.I)C. H AM) HHt,Ii:i'
Former or
Usual Residence
When was disease contracted.
If not at place of deatli ?
Now long at
Wace of Oeatli ?
Days
(Infoimant
'^VV
LV , V
J
\d.irc«s ^ 1 "31 ^ jj .McOwxLcu-txxt . jti
JtACH <>l- FUKIAF, <»R RllNniVAI, I DAp;..! litHi.Af. or Kl-'MoVKI
t
h..b^c:L^
\jJoJui/>r^Xx
190
1AU«
I
N. B. Every item of information should be cnrefully supplied. AGB •hmild be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly wlasslfied. The "Special Information'* for psp.
sons dyin^ away from home should be given in svery instance.
i
i*-«n>^
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
11 :»th— K No. i^ ■^5 -s '— , l;>.l'
I)
ate 'Filr^L Uct^l
0
.Hi-v^-v^
i
<x\^
v-u
IffO'i
Begisfried J\^o.
!806
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
i
^
i
y
PLACE OF DEATH: — County of CL-^v J Vcu^vCA,<i.coCity of ^<X/>v 0.\xv>x^c^^
No. :^ ^ a^
x-Nx,.. ^ St.; Dist.;bct. ^^^^^^^^ and*^^
(ir Dt»TM OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED ro R UNDER "SPECIAL INFORMATION- \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
A)
FULL NAIVIE^^^^<ici U >\tc ■ ■ • ^MtlnAj ^ LaA^\L^
^
I
4i.
PERSONAL AND STATISTICAL PARTICULARS
had; < -I liik iH ,p\
r..i.,,R \ ^ ^
liUt
M.'iitl;
Pav
MEDICAL CERTIFICATE OF DEATH
DAIK ' >I- m \'l H
Mi.titli)
) ■ \'
/ on \
( Vcarl
A <.»•■,
n,.
>1N«.I,I' MAKI<!i:H
\\ r IM i\\ I !» ( Ik |i|\< IK( |.:i»
! W't iti ill ^. H 1,11 ill -.!).> Il;t I ii 111 )
J
d
"^ t . I ! I I 1 1 1 ■ I 1 1 1 1 1 f ! \
N'\Mi: <)!
I- A 111 J-,k
niRi'ii I'l, At }•:
fn lAinj'k
I St;it( f ii I', ,ii lit! V
MAIKl'N NWfl'
oi Mn'rm:K
ruK'in IM, \( i;
'St:it'- '■! (dtnitl \
f^ !)
.wcj.
I H!kl liN ii-kTHN. That I attcn.It <1 dtHeascd from
T'iO to W,C\J \ IQO
tliat I la'"! saw h alivt- on ' icfj
ami that di-ath <icaurn'(l, (mi tht- ililv -.tati-il ahuviv at ^ ^
M. ThfCAr^l- (M IM'ATII was as foil, .us :
^,Aa.<^ ' - . . i ■
-^
X . »
a
1
n I
\ < (
La m
M^'.
IM kXTIoN }'t'ar
C'< )N'ikl i;r"l()RN'
Months
Par
Hoi
urs
(^
I ) r R A T M > N
}'i'ars
^r 'fths
Pav^
(\
h'l iifr,' in S,n' I
(Signed ) CLAAi^-cAvoo L<xJUi^/\.c -,
\lf^ Id T(,o ; (A.Mrfss) 5lH nHX/
M.D.
<X^<r>\.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
) lai s
Mnnfhs
Ihis.
Former or
I'sual Residence
When wa- disease contracted.
If not at plare of deatli ?
Now lonq at
Mare of Oeatli ?
Days
Tin.: An()\ !•' s r \ tin f i<i' son xi, !■ xini rr i sks aki% rRiK m thk
HKsr <n MN K s« >\\ t,i i»( ,i: WD iu-:i,ii;i'
Infi.tinniit V^
vvvL
\.M!
,<UL
190H
I
S-K OF mkl\r. Ok kHMoVAI, I)\T1^,,! !!. k.ai, or KKMoVAI,
jLqIa.cw'yx I ^^^ IC
INIilCRTAKl'k N-^dLuJ^.
N. B. Rvery Item of information should hi carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OP DEATH in plain terms, that It may He properly classified. The "SfMclal Information'* for psp-
nrtf\% dying away from home should be given In svsry Instance.
\\
;-v]
I
i
i
7
j\ '1
11. ., », - 1/ V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
•^■^,^1 UK V C
1
U)n\
Eegis/c/rfl JS^o,
2207
<r\<.^^
L^-xj^ Deputy Health Officer
DEPARTMENT Ol^ PUBLIC HEALTIl=City and County of San Francisco
Certificate of IDcatb
( XI. S. Stan^av^
PLACE OF DEATH: — County of "<v^^ 0 X.CL wcMic^City ofv <x >^ vJ V<x ^vc^laxl^
>
'\,
W^
">- ^
.<X\l^^
Su
Dist.; bet.
and
r .F Dt*Tfc occurs »W4V rwoM USUAL RESIDENCE GIVE facts called for under special information \
V IF OeiTM OCCURRED IN A HOSPITAL riB i ly "STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
\ \
).a l,\A_c
FULL NAME V'.a.LVv.cV. ^U»p\
n
K \
PERSONAL AND STATISTICAL PARTICULARS
DA n: «»r iur hi
A' .1'
^'
-tt
MEDICAL CERTIFICATE OF DEATH
DXTK < ij m x'l'H
Month
\\ Ml. i\\ I i> < >R i>n-i ii.'i in
\Nti!> in "-iMinl il«'«.ij.' iialHiu )
1^
%
r\
• St:i!« ( i! < "i milt t N '
0\K.
^^t.
Dav
Vi-ai
I Hinvl'.HN' «.' i: k'I'Il'N'. Tliat J attt'tliU'«l .1^ .X asrd fiDtll
tliat I Iri'-t '^nw li i- > . alive oti w '
aiiil that lU'atll (iCi'iirred, on tlic datr vtati-d ;iliini', at
lI M. Tlu- CXrSK OF hi .\TI! u : folh.ws
I ( )0
NANU'. «»|
I' A 'III i:k
^\ a.1
ix
I'.TRIHIM.ACK
• H I A rm: K
' St;il I- I i! ( "i Ml tit t %■ i
^
I k
MAIUHN NAMlA
OF motiii:r
DT RAT ION )'tays
Months
Pav
//outs
DT RAT I ON )'tars
Signed)
Month
fXMJNu
I i]
Was^.Wl<^^.c,>^
iuRrm'i,A( K
OF NfoTHKK
(State or Couiitrv)
(KariAiluN >
iij'Ct ^ iqoH (AiMress) O't \J /
1
//out S
M.D.
'>
la\M^ k ^A^
Special information ©n'v for Hospitals, InstHutlons, Translfnts,
or Recent Residents, and persons dying away from l«ome.
yfinitlis
t\j\s
I'm; \Ho\i.' sr \ I 1!) I'KRsoNAi, I' \H I hi ; \Rs AKi: I'RrK m thk
liK-^r (it MN K NOW !J;I)(;}^ AVp lUIJlF
A
In f' >' niant
\,l,li, -
ID QAAAA-^Ov
,t
Former tr , ^^ . -^ t . . M»* l«»l »!
Usual Residence
When was disease contracted,
If not at place of death ?
b 1 1 0 U \k4 AA.A. Cr^\^ Mace of Death ?
Days
PI,.\£K <)!' BfRFM. OR RIOfox XI, I nAT^-; of HrKiAL or RKMoVAI,
n j 0 I ( ( i 4
0 (Vv^c
INIHIR I AKKR M ' V _ ,
N. B. Every Item off InformHlion .hould he carefully .upplled. AGE should !*• .t«ted BXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plain term., that It may he properly classified. The Special Information'* for psr-
sons dyinft away from home should be given In svsry Instance.
B <
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoard of lk:,;!!i I- v.). i^ t-F'rssy^ jtf^ p C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihif, Fi/rf/,\)^JuLu^ (C
lf)0\
Beghfrrpd J\^o.
'^'•^ilo
^^>-e5
A^. Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-CHy and County of San Francisco
Ccttiffcate ot Death
PLACE OF DEATH: — County of OKX^^yv o >^xx/vx>CA^e<)City of C'/CL/vyj J /vcx^wcva^^m)
V A o (\
No. aOb acL>^^ V-i.i llv. St.; 'C D;st.;bet. ^H .tlw and 3.5.tL
/ IF DEATH^CCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \
V IF DEA-^tk OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD J) F STREET AND NUMBER. /
FULL NAME
\)\
^^ULA
V n
V
Cl
PERSONAL AND STATISTICAL PARTICULARS
^<xL
ll-kJU.
I 'Air. (»r liiRTii
X' .1-;
^a
(Dav)
M.ntih^
MEDICAL CERTIFICATE OF DEATH
DATH <)l' I)1-;aTH
IQO \
(Year)
%
Pa I
^ IN'. 1,1-: MARRIHl)
w MM )\\ 1:1) «»K r)i\<>KrHi)
\\ii!( ill MH'iiil ilfsijrnatioii)
lUKTHPI.ACR
(State or rnnntrv
r\
<XV\.*.X^
•\
(Month) (Day)
^I HKRI'HV CKRTn-V. That I attfii.k-.l .IcMHascd from
^^ ci t igo'i t.) licfc ^^ ic^ H
tliat I last saw h '. ■ > alive on \J "^ \ ^^ •
atKJ that <leath occurred, on tlu- «latr ^^tattMl above, at ( I
U.J ^r. The CAISI- ()r DI-ATir was as follosvs:
.<X
XANtl-: (H-
I- AlIll.R
lURTJIl'I.AOK
OI- I-ATHHR
' >it:itc or L'liuntrv)
MMDl'.N NAM1-; A
Dr RAT ION
) 'ears
Mouths
Days
J /ours
n
IHRTIIIT.ACK
Of- MoTirHR
(Htalc >)v (.'ouiitrv)
claM^iM'^
ocrri'ATioN' ('^
ruxv
K^^iilfii ID Sail /■■; ,7;/r />,',) o'l^ JV'(?;a • M,niUis
CON T R I lU 'To R V ^ <XX\n^>3^JXr'\j
DURATION j^^-.?;^ Mouths Ihiys Hours
( SIGNED ) JD. ^1 nQV X^4Jv>v Wtt M.D.
SPECIAL Information ©my for Hospitals, institutions, Transients,
or Recent Residents, and persons dying anay from home.
ihi
THK AHOVK STAI)-!) I'KRsoXAI, I'A RTIiM' r,A R S A R IC TRrH Tn
ni.si oi. MvivN«)\vi,i;i)r,H and ijhiji;!-
fliif'.onatit J. Xy^ . V^^^JLt*!
0 ^
!■ 1 1 H
Former or
Usual Residence
When Has disease contracted,
If not at place of death?
HoH long at
Place of Death ?
Days
xd.irrss AC)b d/CUVw VO^IA ^
l'I,ACK OF m-KIALOR RHM..VAI, | DMi;.,! HtHiAr. .., RFMovAf
I NDl.RTAKKR vJj-CO'X.^'^^hj \<. ^
190
N. B.-
-Every item o? information should be ctirefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" fop p«p.
son* dying away from home should be given in every instance.
^ il
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
N
-^
.'.! ,.f II. :,llh I' N.
■ ■v- -. 1U*>^ I' c
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffr F//rrf, L'ctHK
\) ID
JfJO\
Bp^isfercd A^o.
2209
^V<w^^ \^C\>
I
DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco
Certificate of S)eatb
( 11. S. GtauDarc* i
PLACE OF DEATH: — County of
01
<X/yyr\^x^u^
<x-
City of
^No.
1^05
a)
KUs
u
\^-t
St.;
Dist.; bet.
and
(ir Dt*TH OCcdRS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH O^jcURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
wJLws. ,\^ ^ JS^r\X(x.
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
JUXY\XXA
i>Ari. or r.iKrn
A < ■. !•;
iJJxeLt)
(L>
MEDICAL CERTIFICATE OF DEATH
DATK Ml- DKATII (CS
t'ct
XX
Munthii
2.q
(I>av)
M.iuths
I Vc'U
I hi:
I)av> (Veil I
I IIHRI'I'.V CliRTri'V, That I attendtMl .kccased from
— — — i^ to
"^iV" .i.i' M \K K ii: n.
W'liM AS 1.1 » ( »K i)f\< »Ki i;n
' Wi it« i 11 -I iria) 'li sijJTuiti. Ill
1UKTHPI,ACK
St;! I t I il < *( III lit ! \
NAMI-: Of*
i'atiii.:r
niR IHI'I. ACK
fH" FATni-tR
(Slatf or Coiiiitt v)
MAIi>i:N NAMJ.-
<)l- MOTUHR
HIK'I'HI'I.ACH
«)l- MOTIIKK
(St:itf or Coimtrv
<K"Cri"AII()X
that I last saw h
alive on
1^
T90
and that death occurred, on tlie date stated ahovc, at
M. 'Idle CAISI-: OI- DI'iATII was as follows
VJa-nJLcw*^
v<^ » , V
n
Dr RAT ION Ytars
CoNTRIin'TORV
Months
/hns
//(
ours
Mont /is
I )rR AT ION }'rars
(SIGNED) Xk \XX ' ■
U/Ot ^ 190 H (AddressM
/hivs
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Insmutlons, Transients,
or Recent Residents, and persons dying away from liome.
Rt'iiiril in Siiif I'l iiHcisf'ii
y'tiu .
M,»ith^
Ihiv
Tuv. Au<n-F. ST \Ti:n phksonai, parti«mi, \ks ark trtk t<» Tin
liHST oi' Mv KN()\vi,i;nr, H and hkmicf
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
(Address
I'l^CE OI" nrRJAI. (»K RKM<>\AI, I IiATKrif Bcrial or KKMOVAI,
r.N-DlCRTAKKR ^J CAAJL^j ^ LAjJk-^tlX
IN. B. Every Item of Information should be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information'* for p«p.
sons dying away from home should be given in o\'ori Instance.
i
I
I
I
|j
I.
• I >
#»fip*-
vmam
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
' . "-7" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
If^O'i
If P^j/sf (>/•('(/ v\V>.
oo
2210
I)afr /'V/r^/.UdL<rW>u ID
DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeath
PLACE OF DEATH: — County oi^ CL-s
P
^
City of ^o
n
No.
I Vw. V ^
St.;
Dist.; bet.
and w
/ IF Dt*TN OCCURS AWAv rROM USUAL RESIDENCE Give facts called for undep special information- \
V IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
V^vYv
PERSONAL AND STATISTICAL PARTICULARS
\i } I ii Hi i< r
' -1
DIR A'rroN
C( iNTkllU TORN'
WEDICAL CERTIFICATE OF DEATH
i t <)0 \
I HKI<i:i?N CI KTIIN, That J ittni.h 1 .I.hx a^i-<l frnm
that I la^t ->;.u h • alivi nn ^ it>o
1(1 tliat iKatli ixaairrt'il, !■" ''m- dalt- ^tatt'cl alniw, al »
U^ ^M. Till- CATSI-; (H J)i:.\Tn was as foII,,xss:
I
}V.;
i^av
I /ours
) '<a r
Miinth^
nav
Hon
rs
DERATION
(SIGNED) H<<nXO\> vJclAAx. M.D.
''"^ (j I' y ^ *
SPECIAL Information only for Hospitals, InsN^yfions, Transients,
or Rerenf Residents, and persons d>ing away from home.
Former or
Isual Residence
Wfien was disease contratted,
If not at place of death?
How long at
Plar c of Death ?
Days
dress i5:3lH. alMiJ^±:«->v
ry item otf inform«tion .hould be carefully supplied. AGB «houid be stated BXACTLY PHYSICIANS .hould
e CAUSH OF DEATH in plain term., that It mny be properly glawifled. The Special Information" for per-
4
I
1
- '^>.r??
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•^* -Sr.^; iiM ^■
//^//r Filed ,
l!)()H
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
JU'i^isf r(u'<( J\'*o,
flR
Deputy Health Off
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©catb
11. %, i?tnn^nr^
PLACE OF DEATH: — County of UO ^^
<i <^oCity of o./^\
'W
^ % -i^ CO
N<^
- W-C V^ ^\Am
w wrM-i
St.; Dist.;bct. and
FULL NAME ^l^^0<
1
PERSONAL AND STATISTICAL PARTICULARS
r. .1 t >k '
to.
KTn
Ll
a«;h
■-IN" . I.I M \K Iv 111
\\ I I'l i\\ I I ' « IK I ."
WTitf in •
BiK riii'i, N '1'
A
'11 nt ! \ ' I \
x-^c^ Li
NAMK «H
PATHKK
nikTHl'I,\rH
or r \ IHHK
>!,(t. , .r r(iiHitr\'
MAIDl'.N NAMi:
<)1 MoTFIHK
lURl'HTT.ACH
<»»•• NToTllFK
Stati ill ('(Mint T \
vllcxtl lo-
^
^
rv
MEDICAL CERTIFICATE OF DEATH
• F A'ill
(%t..lltlll '' ■
i IR TIFN". TliiiLj atteiKk-il «U-<H';ist'il fr<>tii
I- •■ I "\
<4
tlmt I
;ini1 1
lc,0
-1! I rpil. on tin
'ill ;iii<i\'t', ;it
M,
If c
-O^ >%.Cy~v"*'^v\-; y> J^<^
()F liKATII w.i--. a-.^ folln\ss :
Dlk A rioN
CoNTKinrToRV
DTK AT ION
1 ' 1 1
Da
vs
I lout
) \'ais
IhlVX
(Hori'A rioN
Rr^idrd in San I i ,ii
[Signed ) J . ^ A
Hours
M.D.
10 TQoH (Adclrcss)^
yfitvihs
lhi\
Tin: AllOVK STATl-n l-KR--M\Al 1-\HTI<MI,ARS AKH TRIH TO THK
BKST OF MV KNuwiji). 1 WD lUljFF
(^ (? ^ , 0 "
SPECIAL INFORMATION only 'or ^'•pttdls, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or a o. i
Usual Residence ^ J *t
Wlien was disease rontrac fed,
If not at plaec of deatli ?
Q f \^ How lonq at
XUl^'v Ja. Place of Death ?
Days
l'r,ACK OF I^l'mi'' '*•* KKMoVAI.
DATE of 111 I'lAi (>! KHMnVAI,
190'
TEof I!
Oct
\.M
(5 » .. X' A Ihr should be stated EXACTLY. PHYSICIANS sliottlil
N. B. Every Item of InformBtlon .hould be carefully «"PP''^?- ^^^.^ cla.sified. The "Special Information" for per-
•tnte CAUSE OF DEATH In plain term., that It may be properly ci«.sii 1^
•on. dyinft away from home should be given In •s^ry Instance.
J
II
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Tin ft' I'l/f'tl , ^ c
D
i!f(n
Jiroislcrcd >jY(),
f^f^ 1 ^
A
Deputy H--^'*^ Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of IDcatb
4 m
PLACE OF DEATH: — County of
City of 0<x\x; •I'vcov
Hi
No. iHC \.v^^..w; St.; 4 Dist.;bct.Hrt^<^A.06^x, and
/ .r DEATM OCCURS AW** TROM USUAL R E S I D E N C E G I V E TACTS CALLED rOR UNDER SPECIAL INFORMATION • \
( ,r"cATM IcCURRtO IN rnOSP T.: OR INSTITUTION O.VC ITS NAME INSTEAD O. STREET AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
I) \ i 1 < il lUK 111
'L' >K
L
] I la.
MEDICAL CERTIFICATE OF DEATH
DAii-; <»i'' I)i:a'iii
U^
It
!):tV
/QO \
\' .}•:
[[. .
1/ , '/
/ >,i
^IN<". I,K M \KH ll'D
' U"! it- ill (It -ii-tuitii>n> I
LL' LcC<^"LA>4<L
lui^ : iiri. \.- 1-
^t ill 1 i! I 1 illtll! \
N \ M 1 III
1 \ rii i-,H
!!IR III fl. \(J.:
«>i' I \rni:u
(Stati iir I'outitt \
MAn>i: X NAM J
<»i- M()Tin;K
HiH iin'i. \ii-:
<ii Morm-R
< ^tati or I'ouiit 1 \
-C
J^
^^ n .
(M.Hltll)
I III:R l-;i'.\' C I:KTII"\, Tli.it I :ittiii«lt<l <k'.Aasc»l frniii
t.. v.. a'^' 'f 190 H
l</^
lliMt 1 last saw li
.•ili\ f i)ti
ail<l that death .icriiiri-d, «in tin- ilati- •^tati'd ahovr. .at
lL. M Tin- C'X'^I" <>1' l>l AI'll wi-- av follcws:
T90
DrkATlnN )V</r.v
CONTUim T( »RV
Mo'ilhs
l^ax
I lout
V.
.^fnntlis
Par
(SIGNED)
Hours
M.D.
\
!()( I
(A
a,in-ss) 15'i ^3,u.^AXhj .;i
OIH'TI'ATIOX ,.
.\r,,iiih>
jhi\-
S FECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from Itome.
former or
Usual Residence
Wlif n was disease contracted.
If not at place of deatli?
How lonq at
Place of Deatli ?
Davs
Tin: AHOVI-; sTXTin PVKSOXAI, I'AKTim.AKS AKl-) TKIK TO TIU:
iu-;sT 01 iu: KNOW LiiH. !•: axd iu:iji%h'
(III fotniaiit
0^
llo.
r
ri,ACKj>Vv-Mll<!AI, (AR KHMOVAI, | DATI'.'.! liii-iM ni KKMoVAI.
((
rNI)KRTAKi:R UnJX''
(Ad.l!fS»4 W/
^ , „ ,5^,1 inB should be «t«ted EXACTLY. PHYSICIANS iilioulil
N. B. Every item of Information .hould be coretully «"PP'- " ''** ^k- cl«MH.»tecl. The -Special information*' for pT-
Mtflte CAUSE OF DEATH In plBln terms, that It mn> h. P m-
•tate CAUSE OF DEATH In pi
sons dylnft away from home should be given In •y^ry instanc*.
> l«
I
i
I
'J^at
ill
■A
WRITE PLAINLY WITH UNFADING INK
i '!h i N-
^ --u.
DS^V Ci,
I)
ftfr Fi/pf/, \L/ Alt-Hs^^v 10
JfJO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re ^i sic rod J\^o, -^-wl o
1
^r\KKJ^
\>
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
PLACE OF DEATH:-County oi^ Ck^^ ^i X^y^^^^<^ City ofC-CL^v aAxx.>^A^^
^
V^
No. ^-'Xcv ^ Iav^ >vtu. , -1 ^ ■i- 1 V ^- - -3- '
h ( ir Dr»TM OCCUR* »wav from USUAL
' V If^ Dt*TM ©CCyRRCO IN A HOSPITAL
St.;
Dist.; bet.
and
RESIDENCE GIVE FACTS called for under ■special INFORMATION' \
OR inst.tutTon give its name instead of street and number. )
\
\
FULL NAME C amX
a"!
Kj CvA.'
M
(\^
'^
(x.Ctx'
\t ■ !•;
PERSONAL AND STATISTICAL PARTICULARS
1.! lUKTll (^
!>.'V
HS
D )>./
I • ,u
Da
•-IN^.I.K, MAKHIi:!)
(Write in ftocinl flrni^iiai {•n)
ill
O.^^' ^
lukrniM.xi'H
'Stall ( ir l"i niiit ! S
1- A 111 i.;r
TURTm'I.A(H
• >i I \rni:R
' State i»i (.'kuiU I S
A
0
^
t
MEDICAL CERTIFICATE OF DEATH
DATK ul- Dl'.ATH
i
iMnlltiri
!t:i\-
(Vt-arl
^
I ni'.Ki;HV CI'.R'rn-N'. That I atUiiilL<l (lt'<ia'^f.l from
•^v«^W
\
^t
fjo H
ifp
190'^ to
that I last'saw h !•• ■' alive on ^ Tip
and that .U-atli occurrc.l, on the -lati- ^tatc.l ahcnx-. at il H5
k.L M. Tlif CAl'SH OF DI'l.XTil was as follows:
n caJjolcc^l \jTl\X<-'Ov-n.
-^
.M-,
O V.
DrK.KTION Ytars
coNTRrr.rTnkv
Months
Pays
noil
fS
XXl«:l.C^ wQ.
I U'VLC
\j
:x I
maii)i;n NAMi-: i^
01 .M«>Tin:i<
lUK'ririM.ACK
<>l- NtoTHKK
(state iir I'oniltlN
jU1/0lA>^wI'\j
,tl
^\
1 I
I)IR.\TM>N
(SIGNED)
v1 uv.
Months
/hivs
0
1 1 oil is
M.D.
L INFORMATION only f*"^ Kyspitals, Institutions, Transients,
nCrii'A'lIOX
Rf^ith'il III Siiii I iitii'i'i
M,<iilli>
lh}\
TIIH AHOVK STATKl) I'KRSONAl, !' \ K TIC C I.AKS AKl- TKlK T< » THH
UKST <)i' Mv KN()\vi,i:nc.H AM) r.i.i,n:i'
(Infottn.^nt U . v} , (aD . \jLXX.4.AH.t
e pECI AL ..». — -
or Recent Residents, and persons dying anay from home.
i:«.™.r «r f, "\ X ' How lonq at
When was disease contracted,
If not at place of death ? ^^^^ ^_
Days
DA
C
h
I'l \CK OI- ni'RIAI, OK RHMoVAI,
(AiUlrt-s.s 3vbiob \I riMlAX^«Sr>
t ISiHiAl, or RKNfoVAI.
190
rV
'J . .. 77a age should be stated EXACTLY. PHYSICIANS should
o? information should be carefully supplied. ^ ' classified. The "Special Information" for psr-
E OF DEATH In plain term., that it may be properly ciassme
N. B.— — fivery ite
State CAUSE OF DEATH In p.« , i„«t«.iice.
son. dylna away from home should be ftlven In every Instance.
+ 1
^
a
5»
I
\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT 6f PUBLIC HEALTH
Registered A^o.
22 1 ^l
f^^-^
City and County of San Francisco
Certificate of IDeatb
( "U. 5. StanOavD )
\
PLACE OF DEATHi — County of OcL>^ 0 ^xx^^.
3'
QTI
_ ^ V
City ofCJ^o^^YX' v/X<xo\^CA^^c
1 , ^^ -^ 1
No. 13 iO Ll>v.v.c St.; Dist.; bet. - Ux
/ ,r Dt.TH OCCURS .wv r«oM USUAL RE SI DENCE G.vr tacts ^^'-^/i' ;°" ,7°" ^5"^^^^^^^
V IF DEATH OCuURBED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
and VJ.U./^ c_
FULL NAME
1^.
^c'
X'>x
PERSONAL AND STATISTICAL PARTICULARS
^ i'<)I,(iK ^ -\
III
I> \ 1 !•: <»! lUk Til
» ^
jMotitli
\<^'.V.
\\ llx nVKD OK Ht\'« >Ki J i)
'U'litf- ill ^111 jal ill >-iLMKi! ii 111 I
liiK rui'i.At'i-:
I Statf or CdiiiUi V
1 )a V
M.xilh:
^3:
n
CrAjt^-^wt
MEDICAL CERTIFICATE OF DEATH
DATH OH DlvXTH |A
IQO I
(Ytar)
> > al
/'./
O-
%!. ,11th) 'Day)
I HRRFilRV C I-KTI I'"\', Thai I aUfiukMl <kTcascMl fruiii
iJ <ik: i \^p'- to wet; 1 ItjO H
that I last saw h ' alive oil ^ ^- ' Ifp
aiiil that ilcath (M'turrccl, <in the date stated almve. at u
M. The CM Si-; Ol' nivATlI was as follows:
T
\».
^ \,U_W,5
I \ III IK
P.IKTUPl.AiK
<>l I AIHKK
St III I i! I'liil lltt \'
M\ini-:N NAMl
«>i- M«»*riii,K
lUR TUlM.AnC
'•1 M<>rm':K
(Statu or Coutitrvl
U
1
I )r RATION I )'ears Months Paxs
coNTRinrToKV Ua.cU/^'^vwc s^ ^>uo
Hours
A^A-/^AA-^w^Xj
1)1 'RATION Yi-ars Months \ Pays
(SIGNED) J/V\Xr-^ iw M I Ux'vC N v-wA-
iDct X ino'l f Address) nOO.UjtUL|
Hours
M.D.
^
SPECIAL INFORMATION •>"!> ^^^ Hospitals, Institutions, Iransients.
or Recent Residents, and persons dying away from fiome.
Kt'^idrd III Sati i'loni'
,,i ' i L ) '•<? '
\/,'i/f/r^
/hn.
Tin: A!5(n'K STAil.H i'KRSnXXl, PAR lUl I. XKS ARK TRTK TO nih
ni'.sToi-' MY KNo\\i,):i)c,H ANp in:i,n:!-'
(Informant db X^"^A-M ^v • OU CKX'>-r^aAA.^V
1 \ f
A.l<1ri-.s 5v?3lO
"U
former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death?
Days
I'l \cy OF HIRIM. OK KJ.MoVAI, j nATi^ «>f HiKiAl. or RKMOVAI,
INI.KKTAKKR fojl/>Xh^ V U<JlLcX^
(Address
xo
)X
^ . .. IVH AGB should be stated EXACTLY. PHYSICIANS should
N. B. Every Item «,f Information should be CHrefuHy suppiien. classified. The "Special Information" for p«i-
state CAUSn OF DEATH In plain terms, that .t may he pro, e
sf>n« dyinft away from home should be felven .n every .nstanwe.
4
I
I
r m
r
-i
1.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
t; ,.>r.l ..f II. ;ilt!> I N<
^.y--^.^^. ,
'SF-^. l^Sil- I'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Da/r F//r^/, i'ctcl
M.\ ID
ir^OH
Megisfercd JS^'o.
'2^
IF]
o^^^vc
^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of 2)catb
PLACE OF DEATH: — County of Aa,-vv -Vex, , . . .City of C O.^ J X^-y^JZ^c^
N„ 1 LL. V- St.! ' Dist.; bet. 3 CPuUmx, and OC a\VU t , . )
/ ,r Dt.TH OCCURS .».» rROK USUAL RESIDENCE GIVE FACTS CALLED ron UNOER -SPECIAL "•'"'' ""'S"'" )
( ,roc.T„ OCCURRED .N°MCSr.r,.L OR INSTITUTION G.,E ITS NAME INSTEAD Or STREET AND NUMBER. J
FULL NAME JxJ:XcU
>i,\
PERSONAL AND STATISTICAL PARTICULARS
^
ClX-<
u
4
i» A ri- < >r i;ii^ in
\< . (
^\J
a
'IM
f%-.:i' I
I
-^
Cla^uVLKxc i \
MEDICAL CERTIFICATE OF DEATH
DA ri-; <>i nCATH fn
1
(Nfoiith)
Day)
/go I
\\ \\u i\V) I) MR DIXitKn:!)
'X^'iiti'iii ".(Mi.il (It -i>.'ii:tt idti'
v.
r
^.'^vCV
,w
HIRTIIfl.Ai'K
(Statf or Ci»imtr%'
XAMl- <)!
1- All! 1 R
p.iRiJiri.ArK
<)l' I A 11 IKK
' Sl.itf ( It V'liUllt I \'
M MDl'N N \M 1
«>l MoTHHK
inurKiM.Ac-H
«•! MoTllKR
'Statf or Codiilrv)
,c
I III':RI-:r.\' Ci;i<TIl'V, That r aUm.lr.l .U-rcasiMl from
tn UcA.' "^ Ttp *^
that r last saw h ^.' alivf on ^ ct L Tqo
an<l that di-atli occurred, on the dati- stated al)ovc, at » •.
M. The CAI'SI-; OI*' l)I{Al'n was as follows;
c
dU^L^'5.^^ >
1
«>CCri'ATION
h'rM('iif HI Sdtr /'l it II, IM n
DlkATlON )'i'ars Mon/hs Pars
C ON '1' R I I'd "1" ( ) R N* U /OJt'V-UAwLcu'v' Xkas^'
I)rR\TI()N i'tdrs .V,>>///is fhivs
( SIGNED) U^lMa^cL ' . ■
(Address) S^ioO CjX.^i.L
J/ou
rs
^
ICJO
Hours
M.D.
SPECIAL Information only for Hospitals. Institutions, Translfnts,
or Recent Residents, and persons dylnij away from home.
! V(7/
Mnilthl
Tin: AHOVKSTATl'.n I'KRSONAI, |»A KI'IC T I.A Rs A K Iv TKri- To THh
p.iisroi' Mv KNowi.i; I )(•.)•; and ni;i,n;»''
(Iiifoniiant
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
I'l.ACi-; o! lURiAi, OR ri;m<>\ai.
I>ATi:uf niHiAi. or KICMOVAI,
T90
I NDKRTAKHK U^ w k,.
(Add 1 1
-,^Co
N. B.-
"•— ^ ^ „ ..J *GB should be stated EXACTLY. PHYSICIANS vhould
-Every Item of informatmn should be cnrefully suppiiea. classified. The "Special Informallon" for psr-
state CAUSE OF DEATH In plain terms, that It may h* jjope
son. dyln4 «way from home should be ftiven .n every Instance.
4
4
I
I
I
m
r
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I N.,
»'.■« "^n*.
'A 1 I
Bo<^isfefO(l Js'^o,
-v*^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
16
,<.v^^
No.
Certificate of H)eatb
PLACE OF DEATH: — County of '<^ >^ OAxxaox^ul^cc City of ^'A. ^v J /vxx^ v^c^Axui
St.; tc Dist.;bet/ -^XCvOla' and VVA O
TS CALLED rOB UNDER SPECIAL INrORMATION' "\
TS NAME INSTEAD OF STREET AND NUMBER. /
'*N
(i F Dt
I*-
• TH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACl
DEATW OCCURRED IN A HOSPITAL OH INSTITUTION GIVE II
FULL NAME
Vjllv.
n .
PERSONAL AND STATISTICAL PARTICULARS
sj x >
- •!,< 'K
lL'. IvaJii;
I>ATK. (•! lUklil
a<;h
A
t
MEDICAL CERTIFICATE OF DEATH
DATK <>|- !)J;aTH
, tf.-iith
■OK )
■^IN'.l.K MAKHIi;!)
W|I)( i\\ 1, l> ( »R I>l\< tRt I I)
' Wt i!' i 11 -iH-ia 1 ,1. -it'iirtt ii.ti i
HfR ^HPI,ACJ;
»ATni:R
luk III rr \, 1-
< »i I \ I !i i.k
I S!;,|c (il « .jSIIUT V
M \ Iin-.N NAM J-;
"I- .M(>i-m.:K
HIKrilPI.ACI*
«>K MoTIIHK
' ^tatf or Cduiit t
'N
TOO H
' Month t 1 I >av) ( Vt-nt i
I ni{ki;nv C I:RTIIA-, Th.it I Mttiti.U-.l .krcaseU frnni
— — — — \ 1,J, , to — _______ — — J^^^J
tliat I I;i^t saw li alivt- on — ~ i«(0
aixl tliaf «liat1i < ^ , nireil, (Ui the date stated alxivi*, at
M. Tin- CAISK or DliATII was as follows:
U CCL\^V^-L<X\/
Mruj^X'
,11) .cl
Mn'ilhs
'Cfr
L
\
\^ :i
I) r RAT ION Years
CnNTRIHrTOkV
I )r RATION )\drs M-^u(hs
/>-/!s
Ih
uirs
/h
/rv
(SIG
Q<xx<x.'
?
NED ) K^tfU^^^VK, J .\b LU. XtlcAxA
Hours
M.D.
SPECIAL iNFORfVIATION only for Hospitals. InsHtotioirs, franslents.
or Recent Residents, and persons d>jng away from home.
«H CI i'.\Tir)X fQ\p
^\
M.»ilh^
Pa V.
Tin* \i!ovi.: sT \ rin i'Hrson ai, i'\r ii' ii.aks akh tki}-: to thh
HKsfcii MS" K N( »\\ 1,1 I»i ,!•; \NI) ISKI.IHK
flTifotmnnt wX/YxX-AA ' ' ' o.,.fi_
3ll NjHXcr^^
Former or
Usual Residence
When was disease contracted,
If not at plare of death ?
How lonq at
Place of Death ?
Days
\.Mi
PLACE OF BfRIAf, OK HHMoVAI. I DAXi; of Hi rial or KKMOVKI
N. B.-
-Every item of Information .hould be carefully nupplled. AGE should be stated EXACTLY. PHYSICIANS ahouid
atate CAUSE OF DEATH In plain terms, that It mny be properly claastfied. The "Special Information" for per-
son* dylnft away from home should be given In every Instance.
«
I
•f«t«»:
^mms^.
rif^W
WRITE PLAINLY WITH UNFADING INK —
IliiiUh I V,,
■Ml-
Dafr /^V/r./,Uct^Li/v
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
0
IfJO'i
]ip<^i.sfpi'Ofl jYo.
?2217
vv^ Deputy Health Officer
fF
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
1 11. i?. StanOarC^ )
PLACE OF DEATH: — County ofOCL-.^ ■''.'va
J?
City ofCcL^v JA^O_/->v
C <.- 0
No. U;uU^-vaX<xX ob.C4, \ v^ > X. ^ a \ . . St.; Dist.? bet. and
/ IF DC*TH OCCURS AWAiV FROM USUAL Ne S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL I N FO R WIATIO IN " \
V IF DEATH OCCURRED IN A HOSPITAL Oft INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
>
X > >
-- 1 \
PERSONAL AND STATISTICAL PARTICULARS
111.
XXAJL
I>A !1-; <u iUKTH
11 11
MEDICAL CERTIFICATE OF DEATH
I)\ IK ol i»i-; \TH ,, \
' Vfi.iithi
Q
iDav)
(V.-ni t
?4
\t
\ < . V.
M;
1/..I/M
^
that I h\<-{ saw h
i:Ri;nV Ci;kTn-V, That I atlt'n.U..l .UMvasd frmn ^^
1./" tl
' ah \ c' Of!
iWct
\\titiin '^■Mial 'U -ifiiatiull)
lUKTlII'I, \('H
i st.iti III r. lunlrv
NAM J- oi-
I AT in: R
niK ^m'I,A(•K
"I■ i\rnKK
I St.ttt III ('nunt ! V
MAriUtN NAMi;
«>l- MuTflKR
lUU IIIJM,\tl.:
">i- Mnrm:H
'"^talf or t'duntt \-
dJiJb
ami that (U'ath luaurrcil, nn the datr --tatrd ahnvf, at
^^. tik- catsh of i)i;.\Tif was as foii-.ws
.K^S^^-^-^j O >">\.^r
hlKA'lTuX )'tuits
CONTkllU T()RV
,7/,M/M.v
/hi\
nu>
DIRATH kN
(SIG
)',i!)s \ .^/ont/is T /hi
NED) LiJ Q?. kje^'
Uct 10 T90H (A<i,iress) qaiMKa- >
Special Information ©niv for Hospitals instituMons, rransients.
oi'cri'Aiiox
A'r\/,ffif ill Sail /■') (ini i^i'i)
or Recfnt Rcsidfnh, and persons d)lng away from liome
M.nith'
Ih
HI-: xHDvr. ST \r 1:1 > pkksoxai, ixKiii'rr.AKs akk trfk to thic
n}:> T Ol Mv KN<»\\ i,i:i)c. I-: wd ni:i,ii-:K
Farmer or t\ Oi' Hon lonq af
Dsual Residcncf UXX/AAj g A,>(X/>^,Cc4 c c pijre of Ofatli?
When was disease conf raffed. ^ '^ A^t.-^w'>^Jui, t-o ^. ;.
If not at place of death ? -uj-VnJhlxv; Xvcnoiv ^
lU.ACK Ol' UrKFAf, OR RKMOVAI, I FJATK of H
T
Oiys
-CUCL
(III flit luaiit
Address
H03.
dtr
y /> ^ I "M'->" "'HiAr. or RKMOVAI.
(W.
IQOH
(Ad.Inss 0*5 D I 1/ - *
N. B.— Hvery Item of inforitiHtion should btf cnrefully Hupplied. AOB should be stated EXACTLY. I
state CAU8E OF DEATH In plain terms, that it may be properly classified. The ''Special In
snns dying away from home should be given in every Instance.
PHYSICIANS should
formation" for psr-
t
II
!t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l; irinl , ■ !!
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ddir ri/('<l,\j
'C
^ ID
lom
Rcgis/ered JS^o,
22t8
,{ru-<^.^
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitifi'cate of IDcatb
( 11. 5. StanDarO )
No.
PLACE OF DEATH: — County of ^CLox. 1\ ex .
* "f
Lo.^
VlX^w.
St.;
(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIV
IF DCATH OCCURRED IN A HOSPITAI.OH INSTITUTION C
Dist.; bet.
City of ' /cx.^%! J A^tx.->
and J \<wV. Lc r
E FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
i'
FULL NAME
^.. \_
n
■-KX
PERSONAL AND STATISTICAL PARTICULARS
A
LclU
n A ri- t 'I 111 Kill
^
i
^1
vcL.
)l<
MEDICAL CERTIFICATE OF DEATH
DATI-; n|. Dl'.ATII
1 ,
(Year)
M.inilii r
A I , !■:
Tl
^IN<.I,I* MARRIi;n.
U li)*»Ui:i) OR I»!\'« »Rt' i; I)
\\'!it( ill vi)(j;il lit -i".'!!.!! !i itl >
FUK rifl'i. \C|.;
' St.itt or (.'(Mmli \
I I
D.iv
M.,iith-.
ir)
( Month 1 'DaN-i
I HI;RJ<:I'.V C i:kTIIV. That I attcii.U'.l (Ifccascl from
t *
1 90
to
>l.
^'^t
Ih'.X
S \ LCCw w^Jt
A
that I last saw !i .; . ^live on M-' CA,
ami that di-ath occurred, on tlic il.iti- '-tatcd above, at 0
I
M. The CAISH OF DKATII wa- as follow^:
1
fvX.<>-v-a '
V \M I- oi-
1- \i II Ik
i'.iKTHiM,\ri.:
'»! I X I'll I', K
■^1 iti 01 ri)iiiiti%
maii»i;n NAM1-;
<>i MuTHl'lR
IHRTniM.ACH
01 MoTllHR
( St;it< ol l."ouilt ? \
vj\ ft
Kfsidfii ,,i S,
4'
kCX s ! w
DTK AT ION Year Si
CoNI'klP.rToRV - '
Mnniln Days
a .
Wx<^
1)1 RATION ■ )\\irs
(SIGNED ) \
1-
Months
Pavs
C
^
\ L
rcjo t
(AfMn-ss) 51%\J rUnvLo^H S,
Special INFORIVIATION only for Hospitals, Institfltlons, TransifBts,
or Recent Resltlcnis, dnd persons dyiny away from liome.
)'itH •• .) ^fiiuflt'
Former or
Usual Residence
When Has disease contracted,
/},, M I If not at place of death ?
How lonq at
Place of Death?
Days
TH J.. AIIOVK STM'j;i> I'KRsoN \|. lARTUTr. \Rh A R I-! TKt H r< > VWV.
iu;sT Ol- Mv KX(»\\i,i.:i)( ,}.; AM) ni:Mi;i
fliifoiin.int
C<Lv.t.l -1 .
I'f.ACH <)I' HlKFAr, ciR KI:m<i\ Al, I DATHo! I!ti<i.\i, or Ri;M(>VAI
i'<x^
'W^
<k. ^<Xl'
^1
(Ad.Ii
a.51
^.
4^
m
190
I ,vih:rtaki;r
n .
AcM,,.^^ IQlU LX-
^-H
^ ccixX^cw>%d
N. B. Kvery item of infofmHtion should lu cnrefully supplied. AGE should be stated nXACTLY. PHYSICIAIMS should
state CAUSE OF DEATH In pliiin term*, that !t may be properly classified. The **S;>eci«l Information" for psi—
sons dyin^ away from home should be given In e\9ry instance.
m
^^ i.
t ?
H
I
^p
i
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
mo'i
Ilvgi^sti'icd JS^i),
22J9
^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of IDcatb
■CI. G. GtanC^arC^ )
J m
\ m
PLACE OF DEATH: — County ofHyCX/rv. 0 ^.a >vcul/co City of Ti/rvvu J A.<x >^.xva^ co
No.
St.;
Dist.;bet. .^.-^A
and
fH ti
(ir DEATH OCCURS »WAV FROM USUAL RESIDENCE Give FACTS CALLED FOR UNDfR SPECIAL INFORMATION \
IF DEATH OCCURRED IN A HOSPITAL OP INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
FULL NAME ^a
1
PERSONAL AND STATISTICAL PARTICULARS
UJ-ivdi
MEDICAL CERTIFICATE OF DEATH
it\ ri-; <>i DK ATir
I) A li; «>l IllK ! u
Ai .!•:
.Scs
^^
M.mtli
1, 1
I )a V
. I IIHRKin ri:RTII'\". 'I'll. It I ittt u.l. il .U(. iM.l fmin
1 » , .
C
to V_
I()0 1
-!"•' 1,1 MAkkllli
\\ I iM i\\ 1 i» ( ,K i»!\» >k« r ! I
\\ ; U ' ill ^c 11 i;t 1 ilt«.i J,' ti.i i '1'
n: N I fi I'l, \t'i;
strit. ,,! I ,,11 III, \
1 .\ 111 i;k
niK iHj'i.Ai i-:
<)» lATHKK
(State or Coil lit rv
M \!l»i:\- N \M},
"I MiirilJ-K
BIN rilF'I,A»l%
-lilt 1 If (till nt I
• 111 I I ' \ I ' 1 ( ( '
C'CXiv
((fp
L >
*^a \
tli;it T last saw Ii . ali\t on ^ i itjo
Mtid that (l<.'atli I iiTiirrcd, mi 'lie dati- statiil alinxr, at C oO
t 'I
M. Till- CM s|- ol 1)1 XTIf ua>~ a- follows
XCJL >\Aj M I Li. ^
Our\j
1)1 kVI'loN )'rais
TON TK 1 IUT< »RN-
JAM///'
Ihiv
Hours
0,1
?l
(
m RATION
\JC ' Ll I { )
<Xy\
V
:i'
hJX. > VCC4
SIGNED ) J V_ _^ ^
lL)/ci S TooH f Address) lt5 , Cl^xx>^t^^^
//on / V
M.D.
X
Special Information «nlv lor Hospitals, Instlfutlons, rranslenls,
or Recent Residents, dod persons dvinq a*»i»y from tiome.
Kf lillil If Sfiu / lilllil'
) III I
I M,<>,lli h />,n
iFii; Msnvi-; ST \ I I I. iM- R-M\ \i, I'SK ricri.AKs akic tkik to I' UK
HHsT (H MV KNMW 1,1 |H ,1. \N|) HHI.IKK
Former or
L'suai Residence
Wften was disease ronfrarted.
If not at place of deatti ?
NoH lonq at
Pfare of Oeatfi ?
Diys
anf,,.in,n» U >^w/V^-Cjt-'>'X^
t QoiiL'wA.
X.l.h.ss oS
";:3^'
i
ri,,ACH Ol' in KJAI, OH KKMu\Ar, I I)ATi:<'t m »iAr ..t K1'M*»VAI.
U' ic,oH
N. B.-
-Kvery item of InformntSon .hould be cnrefully supplied. AGB .hould he stated I^XACTLY. PHYSICIANS iihould
•tnte CAlISi: or Df ATH m plain term., that It may be pfopeHy classified. The "Special Information" for pmr-
nnnm dying away from home should be ftlven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i(.:iiih :■ Nil - ^^^^^- nSiV c
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
7,9/9 H
B(\^isfere(l A^o,
.(: v-oUi oULaj^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of 2)catb
( "U. S. StanDarO
i %
%
.4, "A ^'
PLACE OF DEATH; — County ofOxXAX 1 AX)L/>xcuLeo City of ^ <X/yv J ^UX > vca.<ico
No. ^ I S^; Hi iv,Ci.siL.t'>
"\
■^
Q
((
St.j b Dist.; bctAJ .\XO^a3<x. and J ^ ^ '\
(ir DE*TM OCCURS *W*V FROM USUAL R E S I DE 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
.\.<X VVLL
1^
UC "> ^ -V -*>•'
PERSONAL AND STATISTICAL PARTICULARS
DAii-: 111 liiu iH '^
Cl)l,«>R ^
MEDICAL CERTIFICATE OF DEATH
0
(Nfoiith)
7 0nH
(Year)
/ -
xr.H
31
)
1
(Day)
\l,>tiili
( V«-arl
/',;'
"^iNt.i.i' M \KK n;i>
lUiiti ill viH-jnl (Ic'-is/ii.it inH )
lURTUPI, Ai'l'.
' Slat' 1.1 I'liiiiit! \
LclX^w^ccL
y.r
I ni':RI';nV CI:RTI!-V, That I attcmled deccasea from
' ' - to ©tut.
Let' '] I./) to ^-CX- M r^o 1
that I last saw h .^^^ aUve on ^ ^^ ' up V
and that death ncciirred, on the dati' stated above, at 3
M. The CAUil': Ol- DIvATII was as fQlIows:
u
V »
FATIIHk
HIK IIIIM, \(1-:
<>i I Ai'miK
iStatt (II Coiiiiti V
mmi»i;n' na%!i;
<»!• .MoTHI'.K
\.
i
KK
t
I ) r l< A r ION ) 'rail Mouths Pays
C'ONTRIiUTOF-lV C/^Jk^O^ ^.>- w.&\:v
Hours
V\i)
lo...
^
I )r RATION )\ays Mouths /hiys Hours
(SIGNED) Aj . LL. M rl ^' \.v.^ M.D.
iy^ '\ TooH (Address) HH' '^Xd. H,
w\i
inKiiii'r,Ari.:
*St:it( (11 I'dinitl \
OCHTJ'A rioNi^ ft
()b !KX'<UU>cmJ^JI
Nfsiiirii ill Stiu I'lam i<t'o
O 5 ''(/ I V
1 A .;////<
/'.?
Special information only ^or Hospitals, Institutions, Transients,
or Recent Residents, and persons dying a»d> from home.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
... Days
'\\\v. AiW)VK sr xii'i) im-:ks()x \i, i- \k rrcri.AKS akk TRrn t<»
IlKST KW MY KXnW'MCIX.K AND lUU.IHH
Till-:
Itir-.tmiint 0>wJt h . UJ. xfriX/
f \(lclrc*^s
2)151 TTLuua^v 3t
I'J,4CK <»|. HIKI.XI, OK Ki;Mn\ AI, I DAIK.)! Ht kiai, (ji KlCMoVAI,
c<
IN. B.-
of Information .hould be cnrofu.ly -uppHed. AOH «h.u.c. »>«•»«»';;. f.^fJLY PHVS,CIAN8 .hould
E OF DEATH In plain term., that It mny he pru„erly wl«.«i«ed. The Speelal Information" for p^r-
-Every Item
•tate CAUSE _. _
«on« dying away from home iihould be given In svery instance.
i?l
m
>i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I
li.'-^i* (',.
REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
hffr /■y/('r/,x^,<ziJLt
\> 10
/^>^>H
]>('^isfrr<'f/ JYo,
QOOf I
^:^ ci^^vu Deputy Health Officer
F
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
PLACE OF DEATH: — County of
Ccitificatc of Death
City of < T
No.
Dist.; betJ llr»\tqtiiUXu ai
^ ^ '^ -^ OAi. St.; Dist.jbet.'i llfr^X^qt^iUXu and
(if DfATH OCCURS AWflV rROM USUAL RESIDENCE Give tacts called fob UNDE^ special /fNfOHMATIOlM \
ir OCATM OCCURRtJD IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OO STREET AWD NUMBER, /
FULL NAME
-.%
PERSONAL AND STATISTICAL PARTICULARS
'Vl]\.v'-
iUI .« )R
\ \ II! lUk 1 I
(Mnntli)
rg<r> .
(Vtai>
\i.-\
\<.j-:
SIN. 1 i: \1 \H|< iin>
WII)» lU I'll ( iK I»!\i »R( J-|)
'Writ* ill v.irial (|i siiJiiat -'.11 »
lUK Tlf I'l. \i-j-
(SUitt- or finitit ! V
FAT hi: K
Q
KX^X
MEDICAL CERTIFICATE OF DEATH
D \ii.' 1 >i- ni: \ III
%
I ni:Ri:H\' ci k'ni-w riiat i nttfiKU.i ,k«,asiMi from
UK) , tl I W ' . T()0
thai I last saw h alivt- ri-i itp
ainl tliat (U'atli nccmrcil, mi tlu- dali- stati<l ahovi-, at
M. Tlu- C Alsl <>l I)i;.\'ril w
1*^ ;ts f r 1] h i\\ V
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%
0
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luR riii'i. \» 1-:
'•!• I \ til IK
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niK xrinN )'rars
C<»Ni'l<ini '!'< »I<N'
^r:>l/^!s
/hi
IIv
•If V
^
MAim:x Nwti T^
OF MfiTHKK li'
lUK I'lII'I, Ml-:
<'»■■ M( rr m:i< ,,
i^t.ii.^ .,1 >',,,n)tt \ 1 U ^^
'>("C|-i'A 11, ,x
DIRATION
Years
)/,>)Ulis
SIG
' ^ f ^ f
NED) V^<X\,VO U CC > -% V I'
,eix<X,N^
d.
ly.'ct) t T(,o
H f Ad.lri'ss) loOl
U) -CLA^I
/'f?rs Hours
M.D.
US, If
Special information only for Hospitals, Institutions, transleBts,
or Recent Residents, and persons dying a»ay from home.
h'r'iittii in Siin /■'/(/»/( /'»'/>
) 'ra I
ytnttlU^
D,t\
TH].; AHOVK ST \rir> l>KR-;(>\A1. l'\K ril-fl.AKS AKi: TKIK To THK
IIHST <»!-• MA K.N'(>\Vl.i;i)(,H AM) lUU.IKK
I iTifiinn.int
\
.<X.<L/Q M-'^
\l rlvcJkjLJ
Jj
Former or
L'^ual Residence
Hhen wa<; disease rontracted,
If not at place of death ?
How long at
Plare of Death ?
Days
ri.ACK OI* BVRIAr, OK KHMOS AI, I DATK of RiRiAf, nr RKMOVAI,
V a
t
\<l.lrc!
3i% ^A--^-ix<L-A>o.u.. d;fe
4
igo
„,.„, .hould be ca..»ully .uppll.d. AGF. .hou.d b...«..d EXACTLY PHYSICIANS .hould
ATM In plain term., fh.t It may be properly clM.lfled. The Special Infoi-mallon »or p.r-
N» B.^— -Bvery Item of Inform
state CAUSE OF DEATH In p
monm clylnft owiiy from homo iihould be ftlveii In mvory instance
4
f i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ii. ,'t'. 1
' , V ; I 1 )
ii!
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)ufr Fih'il ,
3^trV>LA,^
cl^u-C
\; 10
1U0\
livgisl i'rc(1 JVo,
oooo
■•,»_.<—_■*
^^^
*enu*y Health Officer
DEPARTMENT OF PUBLIC HEALTli=City and County of San Francisco
Certificate of IDentb
"U, %. 5tanC»ar^
A
PLACE OF DEATH: — County of a^x . Xa^xO^co City of^a
PioX^V^L?^\_L">v:i .w,: * ' ' St.;'— Dist.; bet.
(ir DE«TH OCCUSS AAA< FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UN
ir DEATH OCCURBEO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAC
'^?
and
lAt INFORMATION- '^
r AND NUMBER. /
V
FULL NAME J^O-^v^vO-i
-IN
PERSONAL AND STATISTICAL PARTICULARS
• \ ri: I >! nils rn
A«.I%
vn\^
M .nth»
%
n,i\
MEDICAL CERTIFICATE OF DEATH
I Month'
U
Dav
IQO
(V«ar
I III-Ri;i;V C'l'lRTII'V, That I attt'H«lL'<l .U'.casKl from
(iO
t-)
•^INt , I F M \k K n:!)
\vr ;>< »\\ i:n tin i mv< »ki t t»
' W: ;!; in -in-ial di -ii,' n;it :-;.
lURTIIJ'l \.-i-:
X \ \f 1 I II
I \ III IK
H!K riiri, \oK
or I \ rni.-.K
MAII>j:n NAMi'
ni MUTIIKK
Ol' MnTllKK
(Statr or (.■i)iintr\-
,CL>X'
ktHLMv^\;
i()0 H
that I last -aw h • alivu on i«p i
an«1 tliat iKatli orrurrt-il, oti tlu- datr stated afMivo, at A
UL M. Tlu- (.' \r^I" ''l-" IM- ATII ua- a^ foll-nvs:
<)-<l.:ii
fQO
L^x^o i o. \ ^^cL
rv<SiA)4/ CA4x^txc4
IHRA rio.N
CoNTKIin"!
DIRATION
(SIGNED)
Mmiihs
)'ears
ORV U/L^\VoU>-iX
fhivs Hours
■<XA.^XX,4lJUi
Months
}'i\irs
■J , Lxoli^ '
/\ir
//oias
V
M.D.
A.l.lrfss)^100 LcJuXoV >VLa Jl
, InsWt
\j
I
SPECIAL Information on'v (or Hospitals, InsWutlons, Transients,
or Recent Residents, dnd persons dying dnay from home.
ot'Cl !• ATION 4
Former or V ^ ^ k 4
Usual Residence UMX^AXtO
When was disease contracted,
If not at place of death?
How Jonq at
Place of Death ?
1^
Days
"^vk>v<^
'rm-: ahovf sta'!*i-:i) ckuson m, par rirri, \k^ ari-; i'kii: r<» i'"'"
HKsT Ol' MV KNDU I,i:i)i,l-; AM) 1!KI,I1-;K
(Infiinnruit
<L
A.l.ltcs.s I't'^Ll
JcrLcLt-A. JojUlU-^
I'l \VH OI-' lURIAI, OK K1:M(>\AI. j DA I i; of Ht KiAl, or KKMtn Al,
190 n
\(I(lI t •'V
„ii.a AGB should be stated EXACTLY. PHYSICIANS should
N. B.^— Bvery Item of inform
state CAUSE OF DEATH .
•9fi« dylnft away from home should be ^Ken in every instance.
I
.1
'fl
f i
'H
I
-1^
li^i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.f H.alth (■ v., ^-^ »; ^1 I!8:I* *
/
fO + f
.\j 10
IfJO'i
Registcied jYo,
ooo
'^»5
.^r^^AJ^^
^>M--
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
"U. 5, J:>tanDarD •
J? T) -^ ^
PLACE OF DEATH: — County of Cl-^v J V<x>^Co0.coCity of JO. >v JX.<X'>vc^<> ' '.
No. V V i .. St.; '' Dist.;b€t. Uk^<AxJ\. and O.n.
/ ir DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G r V E FACTS CALLED FOR UNDCfl "SPECIAL INFORMATION \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
^
^IiIclU
V,'( ll.l »k
a
.a'v
I> A n I It !;IK 1 11
M ,11th
n.is
\< .!•;
/go .
(Year)
/),
U li)i >\\ i;ii ( »K l)!\( »i.:. 1 l>
' Wi \\, j ti -,Ki;i 1 i.-U'llat \i 111 I
-A
lui.' i'lri'i, \i'».;
^t it. ,,! r,,iint!\
I A 111 IK
HiK riiri, \rj-;
'•I I AIIIIIK
' *^t ill 1,1 riiiint I V
MAMM'N ^\^!^■
•>I M<tTHHR
lUK'llIIM.ACI.;
'•» M<»'nn;K
nCtTl'ATiux
MEDICAL CERTIFICATE OF DEATH
1) \ IK 1 >i i>i-,Ai'n , \
i\!,.!Ulii (Day)
I 1 1 l{ K I", I!N' ri:kTI!'\', Til it I ;itt«i!iU-<l .Uriasc.l from
that I I.i«.t sau li :\\\\v nil I'p ■
ami thai ihatli .H-cuncil, (»ii the <latc staltil ah<>vc, at 1
UL M The CMS!' oi" I)i;.\TII wi-- a', folinu-;:
_ /u^^'^-'J,.
[floJvci
Q
DIRATION )■'</;
CoNTKUH TORY
M, 1)1 ills
Paxs
Hon
r%
I ^
.k„ > ' t
(SIGNED )
)V,//?
^^o)lllls
IhiVs
^ii^.
IIoH) s
M.D.
rx.hlrrss) lOS-b OfUXmX' VjH^<t
n
SPECIAL INFORMATION only 'or HospiUls, Instilutions, Twnsien
or Recenl Residents, and persons dying dwav from home.
't
^ ~s-%-\ ''
Isf^iifni III S,ni I I ii n
i III I s
M.nllh^
lhl\
rill', \i5o\i.: ST \ ri.D pkr'^on \i, rsK'iicri, xK'^ aki', thii-: r«> rm-.
iu-:sT OI M\ K M »\\ i,i;i)(,i-; \M) i!ii,ii:i-
Former or
Usual Residence
When was disease confrartfd,
If not at plar e of deatti ?
HoH long at
Plareof Death?
Days
i\
iif.Hniant \J . nI M. C<X/vA„l\.M
X.l.ll.'SS Jv I
w
'ysjysjx.
\
I
I'l Xi'H (H- lUKIAl, <»K 1:i;M«»\ \I, I DVIi: .! I!i Ki.M, .11 KKMuVAF,
iL'^t u 190H
%A.
4,
N. B..
iTlACI should be Btate.l EXACTLY. PHYSICIANS should
-Rvei-y Item of Informntlofi .liould be CBPcfully supplleci. « • . ., j y,,g "Special Information" for p^r-
•t«te CAUSE OF DEATH In pl»in term., that It mny be properly U««..iie
non. dying away from home nhould be given In every Iniitante.
I
A
f t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II
If
'W^*"
II. Mil I- X.
i:.*^!'*-
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ht//' F//('ff, kJ <:^AJr{)
yJL\j 10
HJO'i
Registered JVo,
1
DEPARTMENT OF PUBLIC HEALTH
City and County of San Francisco
Certificate of IDeatb
( Xl. S, 5tan^arC^ ^
PLACE OF DEATH: — County of
City of ^J^X^^<^
No.
St.;
Dist.; bet.
_ — _ — ^^^. i>pisT.; c
/ ir DtATM OCCURS *w»v FROM USUAL RESIDENCE Give FACTS Ci
\ IF DEATH OCCUWRtD IN A HOSPITAL OR INSTITUTION GIVC ITS N
FULL NAME H Kvy U
and
ALLED FOB UNDER "SPECIAL INFORMATION \
"AME INSTCAD OF STREET AND NUMBER. /
)
LtLlXcK,\Xim
/
PERSONAL AND STATISTICAL PARTICULARS
■» "^ CKTs.
i»ii,<>k \
i I >l I; IK III
Ibc
Ml. mil
I>;iv
MEDICAL CERTIFICATE OF DEATH
n ATI-; I »r i>i: \*i n v
c
(iJav)
/go ^
tYe;u)
Ai.i.;
HfNni.i-; M \K k n:i>
w I iM »\\ III ( > K I > I \'< > i-T j: I >
'Writriu >-(i( uil di siiMial i< jii )
I'.Ik Tili'i, \t'|.;
;st;it' ..1 I mint! \ '
N \MI «»|
» ATIII.K
lUH lllli, \r |.;
<'l I \ I II IK
NJ AlliJ.N N \M|.;
<»l Miillll-.U
/>.
L
xL
I I11;RI;I'V tl kl'IFN', rii;it I alU'iuUil <U'i-i-asr,l from
' lyO t»> I<P
that I la-^t saw II :" "alivt- «>ii ^ ~~ '^ '
ail.l that .K-ath orciirreil, on the <latr statnl ahnvo. at
M. The CAISK <>!■ I)i; A Til was as follows:
I )( RATION >'''</;■?
CONTRIIUTOKV
.1/, I >///.'.<
/hjvs
HoHt V
JhtM
IHRTm'I.Ai'l-.
<'» Mnrm-.K
' St:i!.- 1)1 I'dUIlt I
in'CI I'A'riON 1
nr RATION
(SIGNED) ... - p
Ilott) S
M.D.
Lo
qI
Special information ""b '«r HospitHls, InstituHons, rran'»ifnts,
or Recent Residents, dnd persons dying av»d> from home.
h'rsiilfil III Sini I'l a III I Sill
) '/ 1/.
Monlhs
/>a'
TM)-: \M0V1' SI* \ll.:i) fKUSON \!, 1' AKIKTI, AK
i!i;sT <»i\J^iv KNnwi,|.;i){,i-; AM) m:i,i»';F
s AKi: TKIH TO TMH
X.l.lrc.^ &V . V. i \JirY^\jXx.Ku
Former or
Usual Residence
When was disease confrarted,
If not at place of death ?
How lonq at
Ware of Death ?
Da>s
yi \CV Ol m-KlAI, OK kHMiiVAI. I l»AT|.;... H. KiM ■> KKMMVAI.
N. B.
^ „ , .^F should he stntecl EXACTLY. PHYSICIANS .hould
-Rvery Item of Informiitloti •houltl he carefully supplied. « • * ^.,_,-|||ed. The "Special InformiHi.in" fof ^r-
•tote CAUSE OP DEATH In ph.in term., that it m.,> he propeHy U— mc
-on. dylna «w«y from home whoulU be ftlven In sv^ry instanee.
I
!*i
:.l
I
t
#
I
t
•I
I
t
r
w
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
/h/fr Fi/('f/ ,\^ cLcr
10
IfJO'i
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t^^o^ I.V., Deputy Health Officer
DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco
II
Certificate of IDeatb
PLACE OF DEATH: — County of '<^ ^^ ^
{\
No.
.^ V
.^.a/^xA^v4,^City of "■ ^ >^ J XO^Yve^^c^
.... . . St; b Dist.: bet. ' I iVo^dA^cL and :A^v '
/.r or.;. .M.;... r.oM USUAL « ^ S . DE NCE a, v. r*CTS c«.|^. o ro. u .^^^
V ,r Dr.TH OCCUHRtD IN * HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
1*1 ii,i »k
\
U Iv^t
:» \ 1 i: i i! 11 K ill
\ ' . I-
M.
1 '1 %
H
•-IN' i.r M \k K ii:i»
\\ 1 1 II i\\ I I » ( iK i»;\*i »'• I !■■ 1 1
I N\'i it! HI -. Kill tit -u'liat !■ .Ill
Jx^vaM
HIK rill'! \i'l-
lit I ^
0/(Xyv J AcL>-
NAM! M!
KATII J K
»'.1K nil'l, XT).-
ol I \ 111 IK
' "itatt 1)1 iiiiilit I V
maiim:n nam I
oi" .Mmi(ii;i<
I'.IH IIIIM.AI i<:
Ml- Mnrill.H
C^tati III v'lnmti \ >
/Cf's/if/'if 1)1 Siiii /'l il n, i^r,i
C V
K n
\
\\AJ^
■t'w . ^^ua
bfe
)■,,;;
%/,,., I fn 1 H /'
riii: \it()\i.: sr\ri',i> i-khsonai, i- \h rut i, xk-- aki: tkik i«> i i'
in<;s r <>i- mv kn<i\\i,i,i»(. jc and hi: iji.'
(liifoTiii.-mt
■^iXv.' ^' ^^^..u^ l^cXl.
\<h\\>
Xb
jJLaM.^
MEDICAL CERTIFICATE OF DEATH
DATH (>i iii;Arn
fi.d
(M..mlO ">''^' '^''''
1 III-RIBV i! RTII-V. Tli.t I ntlciplr.l .li< . •- -1 fn.iii
,hatlla.t.awh--- al.v.nn ^^ ^.t w IcpM
^,„a t1,;,f .U-all, ..rn.rrcMl, n„ the -lat. ^lafr.l ahnv.-, at S.BD
d M Tin- CAISH oF DHATH wa^ ..-^ ioll..us:
DIRATinN )'<.n>
CONTRII'.ITOKV
DIKATION ^ >i^^^^^^^ -'^""'^
/SIGNED) b. ^\- ^J C'.-^U'.
Months IC) A/ is
I lout s
/hiv
,C
Oob
(V.
It) ,„oi (A.l.lr.ss) Hlb':^i)Lt<Lj-
Hours
M.D.
QprCIAL INFORMATION only for Hospitals Inslifufions, fransipnfs.
or Rcreni Residents, and persons dyinQ -iv^-iv from tiome.
Former or
L'sual Residence
Wlien was disease rontrarted,
If not at plare of deatti ?
IM.ACl-: <»l in KIAI. OH
How lonq at
Plare of Oeatti ?
Oavs
,^fe-^^.
crlxf L
r N 1 ) 1 . I< I' A K V. K ^ J )-4A^'>
.A.I.I..- PsW'ol
MM\\i I iiAXK'it HiKiAi -.1 hi;m«>\\i.
ID a
190I
*^ X.CA.^A^
(K
A,ALA^A„0->>^
■ ' "■ T* ItF .HouI,! b« «t»te.l i;XACTLY. PHYSICIANS .hould
f l„»orm„tlo« .hould be cnre?ully -uppHed. ^Oh^^^ ,,.„,f,ed. The "SpccIhI InformHtlon" tor pT-
OH DEATH In pinin term-, that .t m,.y fj= [» »
N. B.-^— Kvery Item ni
state CAUSE wr- uc«in m m»">" • ; , iH.tance
«nn, dying away from homi, ahould be given In -very ln«t«n.
« r
!l
;l
• ii
I'll
■ ^)|
• ill
ifl
I
1^
'^%MC
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.nUh I
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Offfr /-V/^'^/X 'cX.trVM.^j ID
ino'i
lif'oisfrred J^o,
'^226
cc.^ "Liux-M Deputy
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of E)eath
( XX. S. StanDarC^ )
PLACE OF DEATH: — County of
City of
Wa:,-.o.
IStK
' . v ^<^KvXa_l St,; ^ Dist.jbet. and
( ,r DcaTM occults awy r«oM USUAL R E S 1 DE NCE G. vt tacts ^\'->,%^';f» " "^^^ J:,^";^^'^^^^^^
V ir DCATM OCCUHRCD IN * HOSPITAL OR INSTITUTION GIVE ITS WAME INSTEAD OF STREET AND NUMBER.
)
FULL NAME ^^t^
td-cK;.;.^.
^I-IS
PERSONAL AND STATISTICAL PARTICULARS
+
^
\jxXx
<] nil: 111
l\.
io
ion ,
(Year)
5
■-INi IF M \K k Iin
liIR rHPI,ACK
1 l»
IC)
^/.>llf/l
%
/I.
MEDICAL CERTIFICATE OF DEATH
li \ {)• t il i 1], A I'll l{ \
VL - ■ I
1 lil'kKnN' C1,UTII'\, riiat 1 aUAiuk-.l .k-(< a^r.l from
- ion'' tu L tfc %
tfiat I last ^a\v li 1 .ilivu on
an.l that <K-ath ,H-(urrr<l, . m \hv -lair statc-l ahnvr. at
■\^ 'l<),^. (^WlSl-; Ol" l)i:.\'ril ua- as follows:
Up H
I I c
_\
CL>
V'
j;va
\ \M 1 < >!
I \ 1 II IK
lUk iiil'i. \rK
«»i I \rin;K
stitt 1,1 i*i»unli y
,'^
Ujttxv ^Ick:41k
-i
Dl k.X'iloN }\-t2rs
CoNTKimToKV
.1/,';///m-
/hi]
I lout s
MMI.l \ XAMI-;
< •! M< I 111 i;k ' ^
^X > > vo
vUxUlvU\_^\
I'.iH rmM.Aci.;
<»i Nt<>'rm-:H
' Stat, c.i t'.iinit!
OiHri'ATioN 0
Ni'liii'l III Siin J iiliii:^i'i
v.t
1)1' RATH IN
(SIGNED )
M "/i/i^
Ihiv
//ours
M.D.
^.
r()0
1 1
SPECIAL INFORMATION only for Hospitals, Institutions. Transifnis,
or Recent Residents, and persons dying away from fiome.
n
1 1) \h'iiifi^% f><'^
former or i lu n
Usual Residence 1 1^ ^
When was disease contracted,
If not at place of death '
How lonq at
^^OAXnx I Place of Death?
Days
t\ r HI r i I Iff . ^ii n J f II It I . • I ' • « i . , .. ■ -
I'm-: AH(»\}.: si- xn-n pkkson \i. I'XKi'im.AKs aki-: tki"
Hi;sr «)!■ MS' KN()\\i,i.;i)r, !•, and in-;i,ii:K
H TO TIIK
( \\AAAA,^^ry\.
;, .CFOF HrKIAI,<.K KHMmVAI. I I, XM;I^ "MM k i.,. .,r KHMoVAl,
111)! Qf%V^UtA.c
fNDKK r
(Ad.li
"-^ .. ^ A<ri .hould ba .tate.l i;XACTLY. PHYSICIANS should
N. B. Every Item ol' Information .hould be carefully supplied. ^^^ c|.,.|fled. The "Special InformBtlon" for pr-
•tate CAUSE OF DEATH In plain term., that It may ^^ pr-op^-'^
-i..t_* « K««- .h«uld be ftlven In •s^r^/ Instance.
•tate CAUSE OF DEATH In plain term., tnat n .""^ ," " ' .
ann. dying away from home should be given In every In.tanc
i
f
I
i :
11
. Ml
^^
<u
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^- -3 -: 1!M' <•.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
A
0
l)<ilr Filvd , \^ C^.rl^'v IC
^t J.
U)()\
le^isl (' I (•<! ^n.
K
e^^x'
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
11. t5. StanC^arD
PLACE OF DEATH: — County of Cj<x>^ J ^c^^xc^c^City of L <X^v J xcc>
xc
Id
. c-^KC.
St.:
No. ^ • V ^ V, C^"w^ > x-1
(ir DEATH O
ir 0CATH OCCURPICD IN * HOSPITAL OR INSTITUTION GIVE I
Dist.: bet.
and
..ciiAi ore: inriMr F riwr rACTS CALLED FOR UNDER "SPECIAL INFORMATION \
r DEATH OCCURS *^*•v FROM USUAL RESIDENCE give eacts ^*^lle° ,^,stead or street and number. )
FULL NAME
^ 1 \
PERSONAL AND STATISTICAL PARTICULARS
rt
,L
11
MEDICAL CERTIFICATE OF DEATH
(V.-Mr)
CI
lit— U'li,
IK I'HPr, \C\:
lilt r \
NX Ml- ni
I AT in: R
HIKTHIM, Ai*K
"1 1 \riiKR
' ^1 it i I ,: Oinuiti V
M Xnu'.N N AMI
oi MnTllI-.K
IHR JIll'i.An.:
»u M(»riii.:K
Xj
ns
^
I
c
\
I
t
'M,.ntbi 'i'^'^'
I ni'Ki;i?V t HKTirV, I'liat J attcn<U>! .Una^it! frntii
Ii)<l'1
thai Hast ^axv h--..- alive <.n ^^^ ^ IQO «
anil that .Icatli .H-curre-l. mi thi- .laU-tati-.l ahovc. at I I -^ t
^f. Tlu- CATS I-: OI" Jil'^AI'I' wa^ as follows:
DC RATI ON r^'?'
%
^ X^OlH.
M on I lis
fhu
J /ours
)RV LLc^xix NXx-^xi
DT RATION
r-1
.1
' 'VM
A^ i^
l/,.','/^
c
/>,/!
(SIGNED
l/UXl''
ii-^ct
%i
M.D.
I < )< >
A,1.1r...s)LK^Ux^>V^ ItpQ^^t.r^
ncci'l'A riuN
A'/ /'(ftui in San /'ianii>i
a
).uil ^
M, tilth '
iKn
SPECIAL INFORMATION only for Hospitdls, Institutions, Transients,
or Reient Residents, and persons dying dnay from home.
, 11 I , ^* How lonq at ^j
Former or 5 [ j 'j-^ tj/cta,ar^^' ^ I Pla^e of Death ? A
Till- \IU)VI-. sTATin I'KRsoX M. P\R lU I I \K< AKl! TKlH TO I IH'
Iii;ST Ul- MV KNOWI.l.DCK AND lU'I,!!'.!'
(Iiiftitniant
IAxaA;
Usual Residence ^^ ^^^
When was disease contracted, \
If not at place of death ? ^
Oavs
k > xK'vxiru.r^A^
ri.ACH (
I* lUKIAT, OK KI;M"^'AI,
(^ IQ tl i . Ul/AVLoleAH
1^ 0 ft I
I ni)i:ktaki:k
(Address
!» \TI' .>; nsKiAi. >>t KHMoVAl,
UrCt 10 190H
vj <^vvUXi'
0 01 Vl3Ax4A;C}t I '
'* u ij h stated EXACTLY. PHYSICIANS should
i„?.>rm„tlon .houhl b. carefully supplied. J^^^jZasf^Micd, The "Specl.l Inform.tlon" for pr-
»F DEATH In plain terms, that It may .»>« fJl^;'*"'
N. B.^— Every Item of Inform
State CAUSE OF DEATH In p.«... - -. i„-t«Bce.
•on, dylnft away from home should be ftlven m every msta
• i
1
iMl
• I
I
WRITE PLAINLY WITH UNFADING INK —
}!-.n.!..f Hi:, It], FXo. - '-"^"^i^ ]>^]-Cn
ludv Fiioii^ y,
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
10
190\
Hegisterecl A'^o.
3328
DEPARTMENT Of PUBLIC HEALTIJ-City and County of San Francisco
Certificate of IDeatb
( 'O. S. Staii&ar£> ;
PLACE OF DEATH: -County of 0 ccov t vo. >.c.i o City of C^
0 (K M. (^
>. n ^h^
f .r DEATH OCCURS AWAv TROM USUAL R E S I D E N C E o ■ V E PACTS r!f.;^ ^ ' ^n<^ ^OJxKK^X ). )
FULL NAME AuJ
^oOx/rU^yK
-i;\
!.
PERSONAL AND STATISTICAL PARTICULARS
i>A 1 1: oi luk'ni n
.CJ..U
cl,
M ,ii!h
A<,i.:
1
1 |);l\-
yt.niUf
rgn
(Vt-ar)
< ^■<•:ll
n,l^.
iWi It. ill s,„-,,,l (It vis.-iiati..!i)
■^tati o! t'ljiinlrx
NX Ml- <>|'
I ATHIiK
''•Ik rilfl.ACF
<'i 1 Arm.;K
iSl.ilc (,i i'.miitrv)
^f\!I)l■:^' N\Mj-
'•I MoriUvK
niKTin»r,Ari.;
(Stillt 1,1 l*()Ullt!\ 1
oiiTl'A riuN ^
(^ % %
oui.
MEDICAL CERTIFICATE OF DEATH
I HHRiaiV CKRTIFV. That IalU.n.Ic..l.kHxasc.l fmm
^-^^^ K/l'^ to t'ct 1 ,,^^
that I last saw li .*..'.. alivimi W' ct 1 icjoi
.'M.i that diafh .-c-urre.l. ..„ the .late stated ahnve. at
Dl'R AIIOX
CONTRIIil'l
)iais
Months
or RATION );,//.? Months
i\u
Hours
\-XX^tKx/v^/-vxJL
CrVCu
(Signed
I
IhlVS
//<uns
M.D.
I C)0
(A.Mress) 3R b ' 1 t^
vuXcL'-rxdL
A'fMif/\f III Sun I'laiii: ,1
?^^9'fiK "^^O^'^ATION only for Hosplfdis. (nstiluNons rranslfnf.
or Recenl Residents, and persons dyln^ dway \xm home. 'ranslenfs,
.; / »
Mnlilh'
/i,n
Former or
Usual Residence
When Has disease fonfrarfed,
If nol at place of deatli ?
Now lonq at
Plareof Of ath?
Days
f \-I.lrfss
2>'i I cLxx^A^cyt^nx/
'X
-\',
TOO
I.SS I ^'\
N. B. Rvery Item of fnform«tlofi .hould be carefully «u„plle,l. Afli; hHouIJ be utate.l RXACTLY PHVAiriAMe ^ . .
•tute CAUSE OF DEATH f„ plain term., that It may he properly .i«..lfled. The •'S^,|.i |„fo"I 'T. ?^^, "**""'*'
■on. dylnft away from home •hould be given in every Instance. »Pecl.l Information for pmr-
«
;
f w i
if
t<\:
-mmf
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
A
.^n^x.KJi
100\
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Registered ^'o, ^329
l)((fe Filed ,
i
DEPARTHIENT OF PUBLIC HEALTH-City and County of San Francisco
Ccvtiffcatc of JDcatb
A ^ A %
PLACE OF DEATH: — County of^^a n» ^ \ A wcuixu) City of ^'OLOv J \a >^ ^^4 co
No. Ic^b UL.. v_ St.: > Dist.; bet. ' '^ aVh.c4.<v-^^ and ^i^ ^U^. ^ ^ t
f "^ ?yj** OCCURS *WAv FROM USUAL R E S I D E N C E G I V E facts called for under special information- \ \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) ij
FULL NAME
a
\
K.
PERSONAL AND STATISTICAL PARTICULARS
i>\ ri; «»r hik i h
\<'. I-
I
C
4-
MEDICAL CERTIFICATE OF DEATH
(0
Rdh
'ATotitlil
'IhlV^
I m-RI'in CI RTIl-N, That 1 atttn.K-.l ,K-,Hnsc,l fmni
1 if
tn
^IVrW.l^ \I \kR IJ I>
UI I M (\\ I ! ( « »k' ! 1 : \ c 1 1 in
•\\'ii?f- in -iM-i;il il» '.i r lilt ' iiil
l ^X
that T bmt saw \\
\\\\v on
t>1 (0
t .
Tt)0 *i
T()0
and jliat «Ual1i oiHiii '■'■I "ii f br ilntt- ^t.iti il alinyt' at S
V
fuRfiii-r, \ci:
■-' ,'. ,.r I ..niiti %
J A I'll IK
luk riiri, \CK
f »i I \ I irKR
'St.ir. .,T r,,,iiif\'
'i^tntf or ( •uitifrv
invT r A ri» >x
AT. Tin- C \1 s], OI DiAril ^^;,< ;,^ foI|,n\<
a
n
/O s '\ ^
niRATION )'t'ars^
^
CON'IR IIU 'r< »R\ U '
IIoui \
/ n
li
%
Co
AJ
XX. o
L
(^
I M I A
DIRATION
(SIGNED) H'tH)
7s
^frulhs % I\ns X Hours
(A (\ ^H^v M.D.
Special Information only for Hospitals, Insmutlons, TranslenN,
or Recent Residents, and persons dying away from home.
IV'iM.v ,"S Minillly
I hi
Former or
Usual Residence
When was disease contracted,
If not at place of deatli?
How loRf at
Place of Death ?
Days
THI-; \nn\K.*. STATHD I'KK'^nNAl, I'ARTIcr I,A KS .\R !•: TRTK TO THl-:
iu;sT (»!• Mv KNowi.iix ,1.; wd Hi-:i.n:F
(ho \
(Info; inriflt
fA'Mit-.^ H%\0 ^ 1.1
tli
ir.ACK Ol- IHRIAI, OK RHMOVAI, I r>.\ri<,>f lit rial nr RKMOVAI,
^.'
'^A^CL,
ft*
% u
I901
I ni)1';ktaki:k U , AajL^H^L^^
^.
N, B. Rvery Item of infofftifitlon should be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may 'e pfopeHy classified. The "Special Information** fop psi*.
sons dying away from horns should be given In svsry instance.
.11
fl
*
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board »f Hc:.Hh -KNn i. ^y--x^^:]\S.VC,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)ff/(> Fi/rff, V/zkM)Ji\> U
licgisieTpd JVo,
2330
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiftcatc of IDcath
PLACE OF DEATH: — County of ^^a
City of ^ ^^ '
' ri
(I (Ml
No. 11 11 St4 Dist.;bet. ' and
(ir DEATH OCCURS *W»V FROM USUAL R E S I D E N C E C I V F r*CTS CALtrO FOR UNDtR SPrClAL INFORMATION" "^ A
IF DEATH OCCURREt> IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / V
1 I \
FULL NAME
J \ '
•-i.x
PERSONAL AND STATISTICAL PARTICULARS
HA ri; < »F liiK 111
\ < : H
a
Miiiillii \
11 w .
%
MEDICAL CERTIFICATE OF DEATH
1) \iK <- ii !>)•; \'iii ^
\
wm»»\\ i:r» or i»i\nk( j.:f»
(Wriff
i !1 1-1 K!;i 1 ,1, .-iir ,, , t i, ,1, I
A
I'.IHTHI'r.ACH
strife or I (jii Tif r %
HAT J I Ik
FUHI'IifF, \< I'
Ol I \ in JR
I St;il ( I if ('111 lit t \'
•>i Morm.K
I'.iK rni't, At f-
'•I MornHK
' Stall i,r Coiilit rv
II 1 I i'Al' [( »N
f \
1 .1
I
\
I HRRHBV ( hRTir-V. That I ;ittc-ii.l<
t liat I ]: ' ' ' % ;ili\c on
aiiil lliat flcalh i imi rrrd. nii the da' • -
<V(:t|i
Ui rased jmni
di
U
M. 'I'Ik- V .\] <\' «»l Di ATII u.is as l"nl!,,U'
IS r ft
"^ <X<A.AA^Ol
i i
IM R A'llnN
I ( 'NTR I Id '!"( iRN
l>rR A'l'H tS
T/, n//,,
/lir
//,
tut V
) i'lir
/>,
/i^
fL
n
Kf-iili'f rit Sini I
(Signed) AJfvooi.u LL^oxi^^ . ■'
Uct) iC iqoH (Address) II OH U^>\,y U-
M.D.
Special information onlv (or Hospitals, iBstltutlofls, Transients,
or Rfcfnt Rfsldfnts, and persons dying away from tiome.
! I s .A
Sr.mth^
IC
I hi v.
Former or
Usual ResideKe
When was «ls«Be contracted.
If not at place ff deatti ?
How lonq at
Pfaceof Oeatli?
^s
Tm-; An<>\F. s ia i i i» i'KR-.t)\: \i, r \r iicri.ARS ah v. prtk t<> riiR
HKHT Ol- MV K ^••iWIJ.IX',!.; AMi I'.i: 1, 1 IC h'
dttfo; iiKint
^J O^K
(\'\.\\
Til
\
u
KXJjy\y
y\j
^
l'I,ACK OIJJl'HIAf, UK Hi;Mc»\ \|, | l)\!
A
t
ri,ACK ORBIBI
(NKKKTAKHR MW J -'VCLLa.
(A.Mmks
HiKiAi, i,r KKMnVAl,
KJJUU
-H
IS. B. Bvery item of Information should bs capefully supplied. AGH •hnuld bo ■ti.tetl nX4CTI,Y. PHYSICIANS should
state CAUSE OP DEATH in plain terms, that It mny He properl|r classified. The "Special Information" for par-
sons <fyfnft away from home should be ftiven In svory instance.
1 ;
Ii
^
r'
r
r
I
i
* #
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RrFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
f llialth- I" N'o i; t-?^^-, H*;:!' Co
Dafc Filed, ll xImmA' 11
1
Bfgisterefl X^
;233i
J2^^>u Deputy Hcr^f^^h Offin#*r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
1
.d-MwA^
\j
Certificate of IDeatb
A
PLACE OF DEATH; — County of
^No.
St.;
— Dist.; 1?et.
City of\l<xyva. y < >\x:
and
^tO'v\
(ir DC«TH OCCUnS ftWAV rWOM USUAL RES IDENCE GIVE rftCTS CAILCD row UNDKR "SPtCIAL INFORMATION "^
IF DCA7H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\N.^
PERSONAL AND STATISTICAL PARTICULARS
\\\^
\ r\ '
MEDICAL CERTIFICATE OF DEATH
HA Tl" < »r i;lk I
\<.l':
M..?.nr
iintO
1 HKRI ^ • i- RTIIA. That 1
wriK»\\ Kr» nR i>i\
i Writf i II -i^K ial ili-iiu t
(*^t;i ■ ill III ? V '
1 i»
. \ . t I
n
V
\
1 1 I
> ^
1
ruR rm-r, \( K
■ -1 1 N rii f !-•
~.t ,ii t 1 ir (i 111 III t \- 1
• «: Mf»rriKK
'''^tal.- iir (;^u^!ltr^
he rl;
M 1 he C \i <'
\X\\ w
I on
"(I lire. :i<('(| f \, \\\
- Iqn
Tc)0
1 ollows :
>th
iM
non>
c ()NTR ir;i 1 ( »m"
nr RATION Years
M
{ Signed ) ^A.\J[ /\ . jujlax>v>
M.D.
SPECIAL INFORMATION only for HosjMUH, NsllNHfl»s, Tra«le«ts.
or Recent Residents, and persons dying away from home.
>' (i i>
Rr^idr.f /,' s.:„
} r'a I
A/,»if/ts
Pa 15
Hi-;-, r I ti- M V K V( >\\ i,ri>t
mint
M. n.ARS ARKTRTK TO THK
i i I.IHF
Former or
Ikiial RfsicitBCe
H len was disease contrarfed,
If not at pixe tf deatli ?
How ioiiq at
n^-eof Death?
kys
CX.I.Ut-v
I-I.ACK OI- BrRTAT. OR RKMfn'AI. I DAD; u! BrRr^i ..r RKMOVAI,
IN'DKRTAKKR ^ ■ C3 . sJ fr-tijtOCw
^oS' Qna<rW:^tr>^uAa, iiT I
(Adcln-
IS. B. ^Bvery Urn .»f In formation •liould be carefiilly supplied. AGE .hould be .fated EXACTLY. PHYSICIANS ^Miild
•tate C M'^r: Ol" DLATH In plain terms, that It may be properly clii««lfied. The "Special Information** Im* |Mr-
mt^nm dj In4 away from home should be given in every Instance.
I
I.
il
■■'I
l)|
ill
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i{.ar,i.,f II ,itii IN. ^^^^ n.M < REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
n
Date Fih'd , \J x^
^'U^.KJ^
toAj-C
y\) \\
WO'i
Be^islered JVo.
2232 \
M
De
T r%m^^
f% w
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eath
( "a. S. StanDarD )
PLACE OF DEATH: — County of^'<X-^nj JAXC^wCWLCCity ofO,CV>">^ J AXV>TwXM^ t<.
No
.1^'^
u 'n^^'XV K s.
St.; ?^ Dist.; bet. S hAo and ' 1 LI \
(ir DEATH OCCURS *W»V FROM USUAL R C S I D E NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.CL^
W-
yj^wCLJ
V n
six
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
A
1
n »
U.Vvxt
DA'll-; <)!• lilKTII
A<.H
)■,-,/*
i
li
airiv)
yhnilln
DATl-; ol' I»1-:\TH
~\
H
(Month) (Day)
4 ilHRI-BV Cl-RTH-V, That I attc-iKlcI deceased from
TQO
(Year)
Ih!
siN<.i,i:. MAkKii;i)
wrDoUKD OK DIVokCKr)
tWritfiii "Social cU'^ii'natioii)
lUKTm'I.ACH
' st.iti 'ir <.*(J^ntr^•i
N'AMI-: iW
FATHKR
^
\
J I
li)«t
">
.«*»..
190 H
to
/ct
10 iQoH
that I last saw h ^- ' > alive on \L /ClL 1 ' jcp i
and that death occurreil, on the date stated above, at
aJ= M. The CAl'Slv OF DJ-ATH %vas as follows:
\{
HIK IHIM.ArK
Of- iATm;R
'Stall (ii Cinmttv
-Vi^d ' I'^xxvl
n
nr RAT ION
) ean
&
CONTRIIUTORV Uv*%./CX.i„^v.:Lv -r >
Months \ Days Hours
M\1I>j:n NAMh
"I .m<)Thi;k
HIRTHl'f.Al'H [\ A
OF MOTHKR 0 /T) A^ -^
(State or Country) -< | il
. Cj/cuaoxxxj Ouc«^i,L^L
OCCUPATION A
DIRATION
Mouth
IM K.Aimrs ) ears iMouins » t )ays
(Signed )..n.V). vlAAXA.C'>%Jki^.
ILi/ct; i£) rep H (Address) \5H - jlsjd^ 't
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Rrsidfd III S.ni }'i o I'l isri}
KWV, AHOVK STAPH!) I'KKSONAI. PAR P IOC LARS A K 1-: TRIK TO THK
lucsr OF MY KNn\vi,i:i)c,H AND HF;i.n;F
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
Now long at
Race of Oeatli?
Days
Informant uId . UvD
( \<ldrtss
X\\
L<:L<:Lu
AS N
PLACK OF lURFAI, OK RHMoVAI. I DATK of Hi kiai, or RKMOVAI,
rNi)F;RTAKi-:R i:w'>vUL^
N. B. Every Item of information •hould be carefully supplied. AGE should bo stated EXACTLY. PHYSICIANS •liould
state CAUSE OF DEATH In plain terms, that It m»y be properly classified. The "Special Information** for p«p*
sons dying away from home should be given in myry instance.
1
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;,.:i!.! .,f Hi ,ilth 1- X.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)a/r Fi/rff, l'.cW>^U^ II
IfJO'i
Begisterorl J\^o.
2233
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
A
( "a. S. StanC>ai*C»
PLACE OF DEATH: — County of ' <X/>v J VO^>xcuLc^City of ^^aXvu J JV<X/-nxiA^<U)
fNo.
4-
Q
IIU OLa/'>xu,o., V. St.; " Dist.; bct.VJ /OArnXL^-cu^
(If DtATH bcCUBS AW»V FROM USUAL R E S I D E N C E G I V E rACTS CAtUED roR UNDER "SPECIA
IF DEA-i>< OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET
and
X'V
Mviv-
FULL NAME
OJ\M/OJ\JJo VDKO-vui^'
3
PERSONAL AND STATISTICAL PARTICULARS
I) A n; t -I uiR III
UjJxaXk
^ V
1 Ml lit
,1
t
MEDICAL CERTIFICATE OF DEATH
I) \Ti-: oi- ni: A'lH
it, ID
Month)
(!)av)
(V.;ii»
i I):i%
\<.i-;
H
1/
U IIniUi.:i» nk Ii!\nKri;i)
'Uiitf ill Sdi'ijil (If^i^Miat ii»!i )
,U LCtot'^-^cL
lUR rni'i, \t'i.
' St;i!f 1 it ( 'i 111 lit I \
N" \M!' <)!
I- Alii IK
inKIHIM.AClC
"I I \ I' 1 1 IK
^t,l!i U! riiUIltlV
MMDJ-.N NAMH
<>»• M()TIII;k
niRriipi,A( K
<»|- Morin-tK
(Strii. or tNjiuitrvi
orrri'A Tiox
, I nf':Ri;BV CIIRTII'V, riiat lattcndcl (Ucta-d from
OX^t 15 i9nH to ^^ct. IC igoH
tliat I Inst SMSV h ■■ nlivi- nn ^ -'.. i(p \
and that lU-.ith iHriirml, kh tin- date <fati(l alimu', at U J* A,
M. Tlie CArSK Ul- I»i: ATI! was as follows:
C>v^
y
DrRA'lION
hniths «*'l /^avs
coNTRimroRV IpOjuxxX} jo. •.«
nrRATroN
//(
ours
(SIGNED)
}'t'(rrs Miniths
/yavs
IIou
rs
M.D.
15 it^i (A
^r^iifnf ni S,n> / i ,i ii, isi'it '^tj )V,;r5 ' ,1A**//'/;,v ^ /^flv.
Special Information only lor Hospitals, Insmutlons, Transients,
or RecfBt Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If noi* at plareof death?
How long at
Place of Death?
Days
Till.; AHOVK, HTA'ri'H PKRsoX Al, 1' \ R f U' I' LA KS AKi; TRrH To TflK
HHHT C)|' MV KNn\\I,i:i)<,H AND HI'.I.IKF
I A./CX.-'VXAA/a-nrv.
PLACE c)l nURIAr, OR RHMnVAI, I DATK of Hikiai. or RKMoVAI,
(0 ^ (0 t
:r LkxxNXiU AdA. J;
190^
ini)i;rtakk
(Addriss 1
N. B. Every Item of ln?ormntlon •hould be cspafully •upplled. AGB should b« stated EXACTLY. PHYSICIANS slMMlli
•tate CAUSE OF DEATH In plain terms, that It may be properly classified. The ''Special Information** for psp-
sons dying away from horns should be given In svsry Instance.
:.l
^ WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Buanlofll. ^ - _»^-- };^ I' Co REFER TO BACK OF CERTIFICATE POR INSTRUCTIONS
y^ Deputy Health OfTiccr
Regfste/'''ff A
it.
2234
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "CI. S. StanDar^ )
PLACE OF DEATH: — County of CVAx J
\\
No. b
St.: ^ Dist.;bet.
City of 'CL
.OJLMy^j
V 'X ,
and
(IF DEATH OCCURS AWAV TROM USUAL R E S I D E N C C G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION Vi
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /y
^
FULL NAME
>
ll-iYV'viJ II OA-VX^iv
1 "
PERSONAL AND STATISTICAL PARTICULARS
sJX
m<xli
r< ii ( >R
MEDICAL CERTIFICATE OF DEATH
DA TH <>i ni: \'I'H
l»A I )■; »>l lUK III
M
le
/o<>
\ « . »•:
lURTniM \.-i-
\^ , 4 ^. .
CKo^vL
N XMF OF
F A ri!i:R
4
HIK ill I'l.ACK
n»* ixriiitK
' "^lat* 1 »! k' I m lit 1
MAIDHN NAM J
<>I- MOTUHR
niKTm-LAci:
HI' MoTin.R
(Slate ur tNuuit i \
(HH'll'A'lION I C
'-%
. I
w
^-vct
1 HHRI-nV CKimrV. Ih .' I ittin.U-.l <U-«h;is«.-iI fi..!ii
that r la<t saw h i''\' in lt)0
ami that <li-at h I »C(in rcil, (iH t hi < latr ^tati'il almvi-, at '
y], Thf CAISI- {)]■ ni-ATH was as f, ILus;
T)IR ATION
C nNTRinrToRV
DIR ATK )\
Signed ) lL^-FxX
.l/,>n//;s
/ ht] 1
I/oi,
»•?
1 r
fhiv
I lout s
M.D.
C'^
IQOH (Address) lO^S^ TKoAwkd '^
La^vo^o ^ ^ •'^
Kfidril in Siiti /'ttiitt is/i> o \ J ''<" '
Special information onl> for Hospitals, Institutions, fransients,
or Recent Residents, and persons dying away from home.
.\r, tilths
ihi
Tin: \!U)vi' sr xri-n i'krs(»nai, par rici'i, xr^, \k |.; trtk to thh
HI-:ST «»1' MV KN'itw I.lix.v AND BHI.Ii;!-
Formcr or
Usual Residence
When was disease contracted.
If not iX place of death?
How lonq at
Ptare of De atli ?
Oavs
'Tiifiirmaiit
LLdULXx
A
ri^Aci; 1)1 lURFAr, MR rkm<>\ai.
DAIi;»it" ISsHlAL or R}:Mi>\ \l.
TQO
ini.ii;r'iaki;r
i
^. B. Rvery Item of Information .hould be carefully supplied. AGE should be .tated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The Special Information*' for per*
mnnm dying away from home should be given in every inatance.
rfr
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihf/r Fih><l , IL'c
^'Lo'Ima;
u
lOO'i
Eegislered J\^o.
2235
)f
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "a. S. StanDarD )
,4
PLACE OF DEATH: — County of -- O/^v J \.<X^XCU
ity of ^ <XfS\} J A,<X "rx c «.
City
0 c '.
No.
and
(
^^\.\.u^ St.; 5 Dist.;b€t. 3/vcL
IF DEATH OC^UnS AWAV mOM USUAL R E S I D E NC 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
:- )
FULL NAME
- 1. \
PERSONAL AND STATISTICAL PARTICULARS
(.■<>!, OK \ 1^
\
V{^
I;
MEDICAL CERTIFICATE OF DEATH
ni
UxU
l'\ ri; ^^\■ lUKTH
A'.K
I Mhiith
I
\\\\n »\vi.:ii ( »K nixTiKii:?)
U'litc ill -^(K jal il(>«it.'!uiliiiii )
LI.
!0
Dav
1 /,.)/,'//
Vtar)
DATK OF DlAlll (/"X
vL '.cX)
ID
(I)av)
(Year)
A
Stall ii! I'lUMUl %
NAMi: ()I
FATin.K
HIRTIII'i.AfK
Ol- lATMHK
i. Stall- or Cuiiiitrv
MA!!)}.;x XAMK
oi- N!()rni:R
HI RT HIM, Ml-:
<>i' Moim-.R
(Statf nr Country
C^CU-YX; J
I m^KI'lHV Ci;Rril-\'. That I attciKhMl (UriasL-d fmni
KpH
UOA^. IL 190H to L/'tti It
that I last saw h ^- > > alive on ^ Iqo'i
and that dt-ath omirred, on ihv dati- stati-d al)ovt', at \
M. The CA^i^Iv t)l" J)I:ATII was as follows:
rV->\; y^xc
I )r RAT ION )'tar
CoNTRira TORY
Months
/hi
IS
//on
/ s
}'i'ars
n
/h7y
DTR ATIOX
(Signed) ytrVv^r^ 0. d^ .cCc
iy.cfc 10 icK^n (Address) 3H (p ^ S ,tL ^t
I lout s
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dving away from fiome.
A^a.
,.ci
Rf^idrd ill San Fi lunisrii'' I4 )>«fit b Mi>mh^
Pa 1
TIM-: AHOVK STA ll'.I) J'KRSON Al, PA RI'mLARS ARI". TRt K T< > TIIH
ItKST Ol- MY KN(>\VI,i;i)('.K AM) BlUJlvK
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place of Death ?
kys
(lufotinaiit
C3/OJvX>^
(\.1.1
IfSS
Pr \CK Ol" ntKlAf, «)R RI;MM\ AI, I DATi: of Ht kiai. or KlCMoYAI.
INDl-RTAKHRNfTC 0 <Xd,4^YV n( ll y^AXOxL U ''
N. B.— Bvery Item of Information .hould be carefully supplied. AGB should b, stated BXACTLV. PHYSICIANS .hould
•tate CAUSE OF DEATH In plain term., that It may be properly classified. The Special information for psr-
sf>ns dying away from home should be given In m^%rir Instance.
I
I
!
n
..11
'n M
I "I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
t ii, , ,)l I V . '•••■«r.^HS:I' (■
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dnfr Filed. XJ
hj II
lOO'i
liegistcved jYo.
2236
rsr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
^
.rv\
Certificate of H)eatb
PLACE OF DEATH: — County ofC Ci^v J \a ur , City of^^'O^^ -' A "i >> CuiXt
No. ^'I'X d'C'^t'-v..-. St.; '^ Dist.;bet. I b XK' and \'\ L^^
(IF Dt*TH OCCURS »W*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ ' '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
k
r< «! I ik
olU
f
L^
i>A ri; ( >r luk rii
\< .!•;
l!
MEDICAL CERTIFICATE OF DEATH
DAT!-; «>i ni: Alll _, \ II
IC
(Year)
( Mnlltll
I HlvklClJV t IkTIl'V, That I atti'iKk'd <kTiasc«l from
i9ct It
I i;f )
tn
II . t
b
WII)« i\\ I I» UK I)!\tiRil.;n
'\\lit( ill s,»ii;il ill -.ij.'Il;iti'i!i I
/),/
e
lUR I'Ul'I.Ari"
■^t i! I 1 iT I I illllt I %
XAMI- <)|
FATin;K
JUR IH PI, ACK
<" I AIUHR
Stati ii! (.Niuntrv)
mmiu:n NAM1-;
<H' MOTIIKR
HTKIHIM.XCH
«>l- M(>Tm-;R
f Stall- or t'uunlrv
<>»rri'Arit).N
Krsiiffti III Siiu f'l i!Hi isri
tliat I last saw h ■ ali\i- <>n ^
atid that lUath occurred, on the <lat«.- stated above, at I A aO
M. The CWrSh! Oh' DI^ATII was as follows:
c
h
" i
<X,Lc
W
o
I ) r K \ ri < ) N ) 'cars X Mouths Pa \s
CoNTRIin'ToRV
Horn <■
1 ^..'
nr RAT ION . >''''"'4v^ Mouths
(Signed)
Pays
trK'Tu J UjLUXcaJHX
AV
Hours
M.D.
^-' ^ • (Address) 5Hlb' nA.k d.t
) V'(M
b
SPECIAL Information o"''* for Hospltdls, institutions, Transients,
or Recent Residents, and persons d>ing ana) from tiome.
M.,>iih \ \
/',/'
THI-. \!u»\i.: sTxi'ij) I'KK-^oNAi, r\K riiM F, \Ks AKi; Kiuv. r<» rm-
Hi;ST Ol MV KN'dW IJ.IiC, K AM) liKl.Ii;!"
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoH lonq at
Plare of Death ?
Davs
nnforinaut
f \il(lrt's»i
c
I- IHRIAL OK Kl':>f<)\AI, I DATKof Hi RIAf or Ki;M(»\ Al
lO
dLi/^Aj O^txfct bbAvcl:q U'
f.NDllRTAKIvR w
(Ad.lnss XHuO
Ul/i.MrAX
fl „ is.H ARE should be statecl EXACTLY. PHYSICIANS should
x;'s" „";t.': ";:: .h':^ rrr't n'o*;""':; c........ th. -sp..... .„»o..a..o„" .o. p...
N" B.— Every Item of inform
state CAUSE OF DE
«on« dying away from home should be fefven In every Instance.
if
(ft
ik
I
il
I *
\\
i
i
•
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n<,,:t!i I Vi, It, t"t^— ■ -., n^kp Co
l>(ih' Filed , ik^ctcAjUAj
II
U)()'\
RciiHlcveil ^^a
2237
1
in^A-^ cLc_ V 'A
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
PLACE OF DEATH: — County of a-.v - ^ :
No. ^ I C^ ^ ,<X.L L ^ V ^- St.; I Dist.; bet. L' -CcU.-Crv^ and Xux:
( ir OEATM OetUPIS AW*V FROM USUAL RESIDENCE give facts called for UNfctR SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
City of ^ ^■"•^■' ^ 'v a ^^ c ^_^ n
FULL NAME
\CL ^ V
PERSONAL AND STATISTICAL PARTICULARS
■\
■%
r« u,« iK
' \ 1 1 I 'I I.MMll
^
LI
' M..iith
\{
MEDICAL CERTIFICATE OF DEATH
1) \ II- n|.' r>i; A rii
TQO \
\< . 1
II
M,n,!h-
/»,;
■^|N< .1,1 M \k k n I)
w \ iH iU I I > t (R i»i\i »i.' I ■ I r>
|\\"ti!( ill v,„i.,i .h-ii'iiiit i.iti '
X >XQ
HiH rm-!, Ai'K
I stati III roiinti \
NA.Ntl <>l
1 All! IK
lUk rui'i.ArK
OF lArilllk
(Htatf -ir l*nuiit ! y
M XllUN NAMK,
lUK iiipi, \( i;
"I Mnriii.;K
I St.iti ,,r Count! %
(j <X>v 0 "vet ^^ ^ ^
f\f,,,ith^ 'Day)
I III-'RI'IP.V C'l-.R'ril-N', That I atten«k-.l .li.r.ist-d fmm
^., Ct I K^o'i tn ^'.ct U Kp I
lliat I last saw li '• • > alivr .iti ^ i«P
and that (Ualh < .criured, on the <lau- stafi-d abovf. at I
La M, The CAlSF-; OF hi;. \ Til was as follows:
n
5
la
a
Dlk.XTION Yans .Mi^uths ' fhiys
Ct>NTRIHrT<H<V n\txt>^^^lN.d„^AL
Iloilfi
nr RAT ION
(SIG
\TIo\' )'i'ays Mi^utlni
NED) b.W- d^<Xf^^ v\.Lo^v
Pax
M.D.
.^HLO)
(\
Lo^tL
« »» lip XT ION
t^fsiilftf ni Sii>i / I iiifi I I, I
IL^^L il TooH fA.l.lr.sO l'^3.% V<^K^C>. 3.t
Special information onl* for HospUaK Insntutions, Transients,
or Recent Residents, and persons dying dv»d> from home.
)',-,n^ i
{ M ,„Hi'.
[ J'
I III: snovK s'i\i!i> i'I';rs<inai, pakihti, \rs aki-; tkii-: to thh
Hi'.sT oi'" Mv KNOW i,i;])<',i-; ANP in:i,n;i'
Hllfii; lualit
-^
\ 1 (
Former or
Usual ResMencr
When was disease rontrarted,
If not at plare of death ?
How lonq at
Plaf e of Death ?
Davs
I'I.\CF«)F nrKFAI, OK KHMo\AI. | DA TK of Hihiu. ..t KHMnVAI,
0^ I X
^<Xy^r\.>
I go
,. ^ AnB should be stated EXACTLY. PHYSICIANS should
N. B. Fivery Item of InformBtlon should be carefully supplied. «« ^,_--|f|,d. The ^'Special Information" for p»r-
•tate CAUSE OF DEATH In plain term., that It may be properly wlas.me
•on« dylnft away from home should be ftlven In ^yry Instance.
i A
r
I ,
ill
4: i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
>tii,a;tii i \.) 1 "^T aC'^; H^tr (■(,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lU(tr Fili'il, ^d>ts^^ !!
l'.)0'\
Mr^i^tci'cd JS^o.
2238 I
(yoL>oo
VK^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cevtificate of S»catb
"CI. S. Stan^nr^ )
A QD
4?
PLACE OF DEATH: — County ofO-CUno; v1,\xwvC4^<^ City of Cixx^y^, Jx<x^/vxXvuL<v<)
\
No. I
\
St.; \ Dist.;bet N I La<,C > and J <X4.i/
r ir DE*7H OCCURS AWAV TROM USUAL R E S I D E N C E G I V t FACTS CALLtD FOR UNDER ■sPECIAL INFORMATION \ \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION r. I U r ITG NAMT nuc-rc-.r. ^ r- c.--».-,-,- J j!
IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
i>A ri; < ti luk 111
A< ,1.;
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
/^vuuvcac
II
\
rlH'i
N'ollth
MEDICAL CERTIFICATE OF DEATH
I) ATI-: III i>i:ai II nA
10
'f>nv
(Veai)
be
)
\viiH iw I- ii , »k i>[\( ti;. 1 r»
HI k run. \c\:
I^AX.^
^
:M..nth
I UI'RIUiV CliRTfl'V. That r attcnikMl <k.,-,asc-<l frmn
tliat I last saw li nWw on
icp
i(p
and that tUalh norurrt'il, (in tin- dat*.- stali-d alxnf, at 'I
LI M. The CMS!' Ol' |ii:.\ TII x^a^. as fnl|,,ws-
\ \
NX Ml- «)|-
katiii.;r
Mik I 111'!. \. J.;
' »i I \ 111 Ik
~^t.it. ,.' I , ,111)11
O&vl
L'-v
M\n>i N N\Mi: A
' »i M( (III Ik ' ^'
ink riipi, \< i-;
<»!• MMiinik
(St;it< of Coiilltl
H
KuyxJX)
•i r 11
Dlk.XTloN }r,i/
i'os'i'n liu rokv
nruATfox )',,// V
e,
Months
Ihu
//oh
fS
Months /hns
0 \ ^
//om s
M.D.
(Signed) LcrVcrva>v
ly/CAj M KjoH ^\dd riss) Lcr\^rvaA4 iL'fV--^^<.
Special Information only br HospUdls, InstifuHons. Transients,
or Recent Residents, and persons dvini] hhciv froii home.
f''f -h,'. in S^ni I' I ti
{
M.xitin
/hi
Tin; A ISO VI-: s r \ i 1. 1» i-ciusi »\m. i'\k ri<i i sk-- \ki-; rnr j-; id tiik
JU-:ST ()1 .MV KNOW I J- 1). ,1. WD m 1,11.1
niifMiniant
X'Mi. V
U. oJjt^rCrt^
Former or
Usual Residence
When was disease ronlrarled,
If not at place of death ?
NoH lonq at
Place of Death?
Davs
■^n\j
t
i'i,AOK ni- lu kiAi, Ok ki;%t(i\\i, | J)A
" ' ' .K4 ^ A ^ *> C I ^^ '\J
W: of Hi HI
Ai <.! Hi:\f<iv.\i,
'^ T90H
9,
''A.Mt. V.V
''^- B. Kvepy item o? InforitiHtion should be cnret'ully nupplied. AGR should be stated KXACTLY. PHYSICIAINS should
•tnte CAUSE OF DEiATH In pliiin terms, that !t mtiy be properly cles«ified. The "Special Information'* for per-
son* dyin^ awny from home should be 4iven In «\«ry Instance.
Ill
I
«st>
I fl
4
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'-»-^
;. n^ ]' r
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Regi^lrird v\>>.
2239
k
A Xw^-u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
I "U. S. 5tanC»ar^ )
i
(^
S
No.
PLACE OF DEATH: — County of Ouro o Ajx^vcaaco City of V/a>v 0 A>o.>vcaA,<^o
• 00 ^ ^
St.; io Dist.; bet. L^*-0 ^ >^^a; and L<l.A>vt\ala'>
/ ir DCATH OCCURS AW»V rPOM USUAL RESIDENCE GIVE facts called for urtOER SPECIAL (NroRMATION \
\ ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^^ OF STREET AND NUMBER. /
FULL NAME O^XCt 0 d/Y^x'v'^ ' '
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
DATK <>1 nKA'l'll
'! lUKTIl
rv^
u
A < . I:
il>nv
M titft^
Uob
Dav) N(M!)
"-IN '11 MARKinn
Wnt' 111 --iM-ial ili'-ij^iiat ion )
mRTHi'i, Aij-:
^t iff 1 )i (*i iniit I \
NAMH ni
FATIIIK
HlR'iii I'l. \rK
<>i I \ihi:k
' :^t.i!. ii! roiuiti \
M Mill- N NAMl-
<>i Morm-.R
IURTH!M,AiH
<H MnTiIKK
(Statf or Coniitr'*
M -ith!
I niCRi:H\ C'l.RTIFN', 'Dial I .ittrfi.ltd ikHxa-^cd fmiii
4
that I la'-t saw li ■ '■ alivi- otl Too ',
(ii.l that (Uatli (>(H-urreil, <»ii tlie daU- *.tati->l alun-c. at
M.^Thc CXI si; (>1 I>1:A'I'I1 Wa^ as 1. Mnus;
IXR XTloN
XL I C\ >^ ^
ma^o C
CoNTKIIirTORV t. '"^^
DTRATION
. SIGNED ) Uw. L • ^t
J/,
,1
rc \
fhivs
Hours
,iA'»/Mh
/^avs
OiClPATION
A'fst'itftf iv Siin /> ,nn lu'i*
^
/Ct) 11 I<>oH (A.l.lrrss) uJj. L.
'\\
//o/n s
M.D.
.A„cikx4j Jl 5^^kt
^ — . ..,- , ._ . ,
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
r,
I [ .l/,>;////.t i% /hivs
I'm'. MsnVK HTATl'D I'FR^ONAI, I' X K IliT 1,A RS A R Iv TKfK T» > THK
Hi'HT oi- My KN«>\\ij.n( ■iv.ANi) i'.i:i,n:F
(Inf. .'iii.-mt
m
R^ CiA.U..rJi
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonfl at
Place of Death?
Oavs
PI \ri- OK M RIAI. OR RHMOVAI, 1 nA'rK of Hi HiAf or RKMoX AI,
fk(0' A A I (0 4. .,.
\ IA% of II
X IQOH
% R t- .. w I c ♦!-.„ -i,«..i,i h* ^..—ffullv nuDDlletl. AGB •hould be stated EXACTLY. PHYSICIANS should
i>. B.—— livery Item ni InTopmntion •nould be cnrofuiiy suppucu. «« ,« . ™.i. .<e ,i_i ._« .. .» • _
state CAUSE Of DfATH In plain tepm.. that It m«y be properly cla.«lfl«d. The Spe.l.l Informstlon for per-
8on» dylnft away from home should be ftlvea In svsry Instance.
!
- 1 1
».
f
I
m
];■.. ■ ' . t^ H. ;i!lli (
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
II
/.V«9H
Registered J\^o.
224:0
i \
DEPARTMENT (IF PUBLIC HEALTH^City and County of San Francisco
Ccvtiftcate of IDeatb
PLACE OF DEATH: — County of Oo^-wj J,Va > vcv. City of O a/>^; J/vo . v ccAx^
No. ^^M?> - i"[.i.i- St.; S Dist.;bet. LoA-bvO and^lt-v
(ir otATH occuns aw«v rnoM USUAL RES I DENCE Give tacts callcd por under "special information" N
ir DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME J 'i\c->vs.x]la vj oJUuxq vuai
il
SKX
PERSONAL AND STATISTICAL PARTICULARS
ft r(ti«>k \ , n
UxL<
LU.^t
I wLv.^
i> \ ri; t»i lUK 1 H
\« .1'
MEDICAL CERTIFICATE OF DEATH
DAl'H nl' I)1:a'1H
\)a
I go \
(Vf.ti)
N!..!i!h>
L ,.,,
I>a%
M..u;l,
■|iai )
\\ \ IX >\\ ill ( »K r»'\i »!■■ I }■ n
' V\l itf i II •,.« i;i ; (|<^;j.'!i.it i- III I
a
BIRTHIM. \ii:
(Stfltr <iT ('.unit I \
N'AMK ni
l-ATHi:k
RIK rnlM.XCH
<>l" I ATIIlsK
'St.i'r or I'oiinti V
MAn>i:N \'\ Mi-
ni .MoTni..R
lUR rni'i.Ai'H
<n MnrnKK
( Statf or Cnuntrv
OCCri'ATlON
i
^
\ \'-r\\\\. ^
I in:Ki;HV Ci:RTri'V, That I atlcii.lc.l tU-ccastMl fron
< ^ \t 190 < to U Ct U Kp 1
that I last saw h '• > ahvc on 1 Kp i
and (hat diath occurred, on thi- date stated aliovt-. at v)
LL M. The CAISH OF DKATII was as follows:
0
*A
rrA^X^A.--'^'>"\--'Cr*\^\. o.
k A <
.ou
d.
ruTYVxcu U/CuLc^ "
I
DC RATION }Vr?/-.? Man //is /)ays
CoNTRiniToRV LxXN^ wcx, t^: ,tj v.*.A
I/ou
IS
nr RATION : w. )'i'ars
(SIGNED )
Months
Pa vs
//ours
M.D.
•\JL
KJX,
>v
cL
iJ/A 11 TcpH (Address) SC-g '^x^.tLcK; ai
Special information only lor Hospitals, Institutions, Translfits,
or Recent Residents, and persons dyinq away from home.
o
fx^^siilfti lit Satt /•'mitii^ro lU )'rii 1
\r.<,iihs
thi
Till-; \M(>\i-' s'rMi;i> i-kksonai. i'ak iirt i. \ks aki: i"kii-: t< > Tui-:
Former or
Isual Residence
When was disease ronfrar ted,
If not at place of deatli ?
How lonq at
Place of Death?
Days
(I
iifotmniil VJ . L). O.CJUL
i I
(Addn-
SiSH-i' n h
\j
1
ri.ACl". ()1- lURFAI, <iK RI:M«»\AI. I DATi: of Hiria! or klCMiiX'AI,
^%o4a4 Cu<Mt^ • ^'^ '^ T90H
r M
o* information should b. cnrut'ully HuppUcd. AGB should he stated EXACTLY PHYSICIANS .houW
E OF DEATH In pl.,m terms, that it may be properly classified. The Special Information for psr-
N. B. Every Item
state C.41JSE
8'»n« dying away from home should he tiven In every Instance.
;|
j •
I .
#
i I
1 '
»
I M
%
ft
f
n
i
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
fH.^:!ili I N .;=»■»*.,--;; I!\ i' . . REFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS
7.9(9 H
lU'gi,slei'('<l jYo.
2241
Dfffr Filed, iL'clxrWv) 1 1
\ \ ■
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDcatb
J
PLACE OF DEATH: — County of--^0,->A-' '
City of ' ct >v 0 A o > v,tA^-
I
No. 550 m
c>Lsi.^^<:
St.;
Dist.; bet.
I4t
and
(ir DEATH OCCURS fl
IF DEATH OCCURF
WAV FROM USUAL RESIDENCE GIVE faC
RED IN A HOSPITAL OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION \
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
SHX f
PERSONAL AND STATISTICAL PARTICULARS
A r( >i ,< Ik
OJvx:^ OAJiXQ) uxXX.'
^ a > V
I) w'v. or lUK 111
\(,i-.
"M
Ml, mil
MEDICAL CERTIFICATE OF DEATH
DATH Oi- DliAlH
MiiitlP
I go \
(Vi-ar)
!)..•.
)
1/
^
■-IN'.I.l MARKIKI)
Wrtti it! mieifil il.-i^.uatinu)
iiiKrm'i, \<-i
'""•tati' or i 'i .iiiit r \
XAMj; ni
I ATI IKK
niRl'll I'l.AiH
«>I" 1 Aini:K
' Mali Dt fi)nntry1
MAim:N NAM}"
OI MoTin-.K
HIRTIM'UAt'K
Of M()'i'm<:K
stall or I'dunti v)
r, 1
1 hll
iDav)
I IIHRKHV (. IkTiI-V, That I atteiKkMl .It-ceased from
that I last saw h ^ alivtnn icp
and that death occurred, on the dat<.' -tate<l above, at
M. The CAISI'! OI' Di;. \rn was .m follrms:
CL.L > X^-W-V, V.'vA X<. c > \.
DTK \TI<)N' )V.?;
t'ONTRim'ToRS'
Mouths
Pax
Hours
Is 4 ^^
Mt>Ut/lS
DIKATION ^ Vrars
( Signed ) L^\.^'>\iA'
/hivs
Hours
M.D.
i'ct \l rooS (Address) LtXoU-X^ ^ .t^
m-
OCCt'l'ATluN
fsfsi.fnf in Sint /^i inii ism
)V,,'/ . I M,>i,lh< I vJ /5<'
Special information onlv f«r Hospitals, InstltuHoBs, Translfwls,
or Recent Residents, and persons d)ing dway from home.
former or
Usual Residence
When was disease contracted,
If not at place of death ?
NoH lonq at
Piice of Death ?
Days
I m: MIOVF. STAril) I-KRS.)\ \|, I'\K iUlI.AKS AKI. I HI K l<> 1"H I *4( % ihki.ai. .i
HHST Ol' MV KN(>\VJ_,i;I)«,;H AND ISKUKI- ^Oif„ I I . I W 'C.t. \X
(IiifiiTinant
(A.l.h.-
. J. 0>UM.A<yCX./>xJ
5SD MVvA.^a^L.'C'O^ru at
« „ . . . . a ,, ..is-H AfiF iihould be utatetl liiX4CTLY. PHYSICIANS iihould
N. B._Every Item of Information .hould be c-refully f"PP'-d; p^^pe^rc •.•Ifleci. The 'Special Information- for pr-
atate CAUSE OF DEATH In plain tei«ms, that it may be proper.y ^ibmiwi^m h- •"
■on. dylnft away from home should be given In ^y/wy Instance.
\S*
■I «
i M p
WRITE PLAINLY WITH UNFADING INK— -THIS IS A PERMANENT RECORD
f "'''"' >• -" ■' 'ma^-»>HM'>-., RCPCn TO BACK OP CERTIFICATE FOR INSTRUCTIONS
A
huh' Filed , 4..^/ct<Mv-t\
190\
JReglslercd J\^o,
22^2
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
tl. S. StanDarC>
^
;i
No.
PLACE OF DEATH: — G>unty of docn^ d,>ua^rLeuL/aC(Gty of ^'/CX-/>v J Axxy>^>aUlx^o
^'^ St4 T Dist.; bet w A.a ^ Ul-l . and ' ' ' ;'
(ir DEATH occuns Aw«v rROM USUAL RESIDENCE Give facts called for undeb "special information- \ \
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J
FULL NAME ^- vClmX
I I
I) ATI. or iiik I H
PERSONAL AND STATISTICAL PARTICULARS
I
I 4
111
I Month
» rat
MEDICAL CERTIFICATE OF DEATH
DATK OF DHAIH /A
(Moiilh) (Day)
1 in-;Rl-;HV CI;RTII'V, That I atU-iukMl deceased from
'9o\
(Year)
\<.H
)V,
M •<':!!
"-^INt.I.K MAkKU:!)
u ii)o\vHi> »»K nn'okCKi)
\\ ritr in ».<Hial «J« -ivnatiiMi)
C > V-
L
HIKTHIM.AOK
(Stati or I'duntiv
N \MK oi
I XTIIllR
HIRTHPI.ArK
«>l I ATIIKK
iStafi or Coiiiiti VI
MAIhKN NAMl
t»l M«)TIIHR
HIKTHI'I.ACK
«>K MOTMKK
(Htatj- or Coiiiitry
iUii
190 to
tliat I last saw li A/>>x alive on
10
X
IqoH
190 H
and that death occurred, m\ the date stated above, at
M. The CArSIC OF DJ-ATIl was as follows:
I i_» /^.
.t
CoL>uic<]Lc nJ K<xLfrtx v^
T3
r
U/<xyx' Jacv I
.a'
^ V
o
C
u
0 (] \
I ^
DIRATION Years
CONTRIIU'TOKV
Months
Da vs
Hours
Df RATION
L
I I
(Signed)
4
Years Mouths
t^ V
C /Cb ' mo H (Address) Ibl L L
Da vs
A
Hours
M.D.
«>0Cri'ATiON
Rfsidfii III San t'l ii ih ;-iii
I \
Special information only for HospJUIs, institutions, frinsients,
or Recent Residents, and persons dying away fro^ how.
.1/,,)','//. ^ /'-?
TMI-; AIUJVH ST\Tl.;i) I'KRSOVM, J' \ K 1 Ii" r I.ARS AKH TRt H l«> I HI!
HKsr OI- MV KNOW 1,1 !)( J.; WD lUil.fllK
(Infoiniant
f \d.ll.><s
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
NoM lonii at
Ptare of Death ?
Days
lU ACF nl lURIM, OK RJ:M«>\ \I. I HATH o^ HiHiAr, or RliMoVAI,
im.i;ktakkk Ml v].^<X^^ '^^ ^< „
MM.- . a .. !• H AfiR Mhould b« staterl EXACTLY. PHYSICIANS should
IN. B.—hvery Item .W Information .hould be carefully -"PP'-^' ^^^'L^^H^^iLUlfled? The "Spccl.l Inform.tloa" for pr-
«tate CAUSE OF DEATH In plain terms, that It may be properly wiasameo.
•on* dying away from home iihould be given In myry Instance.
I
J.I
i < A
!i
1} i
r
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
It .'-< \- I N'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/),i/r /V7rv/.0<1^(.,
a
VA^
K
u
Deputy I
/!H/H
Jic ni si I' rri] ,Yn
2243
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S^eatb
PLACE OF DEATH; — County ol '^
City of^ ^^ V. ,: s n
>N
•P4€». ^LCu At ^^\.Ui\i,
St.;
Dist.; bet.
and
4, HV ^^\.W>V^,, bt.; Uist.;bct. and
n / ir or*TM OCCUCS <(w«y rWOW USUAL RESIDtNCE give facts called roR UNDER "SPECIAt INrORMATION ■ N
W\ I »■ DfATM OCT'iWpfP IN * MCSPITA! C R i N =, ' ■ ^ ' t . r, N GIVE ITS NAMT INt^TTsn nr STBfrT ft N P NUMBER J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
^l
CXiA
» A i i; or lUK in
\< .K
f\ ^
MEDICAL CERTIFICATE OF DEATH
Month)
kTIlA
M
*. I I» « iK in
t'l V
n lit '
at I '
-IV ■ *h It ,1. i;
I i t K mi
T<p H
up
he clHfi- ^tfli
31,
r \ I 't;
V \ Nt 1. , ,1
HIR Tit PI. \i-
' t' I' \ i n T (.-
i\
1/
lh-i\
I:
i\
n
: \- \ M \
■ r 1 1 : H
nfK'iifi'i.Ai 1'*
•'I MOIIIHR
■-tat, .,1 <-,,n!it
< HI" I ■ \< XX I* )X
A
MR-
i
DT RAT ION
(Signed )
I{)0
Rfiihii 1 1' Sim I 1 I.I
0
1 }V,7;< L Mntilht
I fours
M.D.
vu
-L
Special information only for Hlikpltals, institutions, Iranslents,
or Recent Residents, and persons dyinii away from liome.
Plar e of Ocatli ?
/)</r.v
\'\\V \H(»V|. >-l \ iIMj PFHSovM, I'M- IKTI.ARS AK1-; TRTK T< > THK
HT';ST ()i NV K v^^xK .j,;iH,l WD WVA.WA'
Fo.meror ^^^^ ' "^(ytil How Ion at
Usual Re^^^iiieKe LX^f <-
'if' V
Wlien was disease contrafled,
If not at place •! death 7
Davs
\<I.lr
^
'^^ u...
i'r\ci-: <)i' nrKiAi, <ik kkm<)\.\l | i>\
Hi Hi\i. or KKMnVAI,
•M.HRTAKKR^Tl' 1 OAAx^ Vuf (fej
.^ ^ , V .^-,.. . ^ ^\S^o.>sijJSCthMm*
(Ad.lreKs llll \TrU^.4.C0 >\. wA^
», „ ^J ir\ .HP lihould be stated EXACTLY. PHYSICIAf^S should
N. B.— ,.ver> Item of fnform-tlon .houM be carefully supplied ^^'^^-JX^^^^^^ ^he -'Special lnform„tloa- for psr-
•tatc g \U8E OF DEATH In plain term*, that It may he properly ciaasiiieu. h- •"
Hon* dyinft away from Noma ahould be given in •very instance.
*
i
i:
*
ii
I
■T
3l
I
! ' » !' ! Xi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
' Ijt-- -'^PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\
l}(i/i' Filvil , ^ ,^<Hj
>-C^V!
.<ru^Ui
ro
Deputy H
h Officer
Registered JS^o.
2244
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDcath
( "U. S. Stan^arC^
A
4'
J/va
n
City of^ a >\i J'
IS v^CLv
No.
PLACE OF DEATH: — County of a>\
VcLc<XA.U:L LcLUXb^^- St.; ' Dist.?bet. and
|'\ / \r oc»TM OCCURS *w*Y rwOM USUAL RESIDENCE give pacts called for under special information' \
^, V. ir death occurred in w hospital or institution give its name instead of street and number. /
FULL NAME
\
1
p
n
I .'
I
PERSONAL AND STATISTICAL PARTICULARS
i» \ I i: t '! i;ik rii
a''-+
MEDICAL CERTIFICATE OF DEATH
MotUliI
u
/ ^l-
A«.i.;
^( luii
TrMrl
Pax
1 Ifl'iRlil'.V C1;RTII'\', That I aitciukil ileceased fmiii
lyu
IqO H
^i\< .I.I' M \kk n:u
Writ* 11! v.Kiiii i|t Hii/iiat ii 111)
lUH rui'I, \i'K
N XMI «H- 0
1 X II II' K
HIK rillM.ArH
'>! I A I'll HK
MAIH1..N NAMH
«»!• MoTllKK
I'lK IMPI.ACI.*
j'l M<>rin-:k
' stall or Coinitrv
'H'lll'A iin.V
L'^
.. ^t
tliat I last saw II .. ■ .. alive on w- -^.' ' Kp
1(1 that (k-ath nccurrcd, on the (iate stated above, at li "^0
,'it
w
Kj
(jC' CiiLt 1
/>vlccc I
M The C\ISI-" OF DHATII was as follows:
f^ ' i . ' ,
I ^^v.v I ^, (S 5i.«w-A C * CC'W.1^-
1)1 RAT I ON )\iJis
CoNTklHrTORV
MoHihs
/hn-s
Hours
DTRATION
(SIGNED)
)'cav!i
}fOflth!i
Pavs
tU\X
n J KkXojo
n
%Luj\U<j\.k
I
flours
M.D.
V.
\. 1.1 1 ess) \X\ UXOAm.
SPECIAL INFORMATION only 'or Hospitals, Insfitiitlons, [ranslenls,
or Recent Residents, and persons dying andv froni home.
f\f'shit',f iti Siui / 1 ,1 III :M'it
) V,t
]/.>/!//>
/Kn
rin: ahovk si'a nn pkrsonai, i'akthti.aks xki; rRri-; t<>
"I'^sT oi'^v KNOW i,i;i)(-.i<; and in:!.!!-!'
nil';
;ii
former or
Usual Residence
When Has disease contracted.
If not at place of death ?
How lonq at
Place of Deatii?
Days
PI.ACl-; <>!
P.lk lAF, Ok kl'M<'\ \1,
f X.liltfss
I) \ 11',. if HiKiAr, or KKM<»\AI,
Ad.hfSH M u-cu^ m\xA. LI • -.
N. B.-
^^ ,, . .CP -hould be utatecl EXACTLY. PHYSICIANS should
-Every Item of !n*ormntion should be cerefully supplied, f^^^ .|.«-|#|ed The ''Speelal Informntlon" for psp-
state CAUSE OF DEATH In plain term., that It may be properly Uassifie .
«on« dylnft away from home should be given In svery Instance.
» 1
;^»-i
i
hi
^'l
I
*»«
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! V.
S^'r r,^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
nn/'i
Jh'ilisferpfl JVo.
:3245
x^\>
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
in. 5. Stan^ar^ i
PLACE OF DEATH: — County of ^Xy-u ^hMj>
City of ^ ^
No.
St.; ^ Dist.;bet. OID CrUhO^vxi and
/ ir DtATH OCCURS AVWAV rROM USUAL RESIDENCE GlVr tacts called for under "SPtCIAL INFORMATION \
\ IF DEATH OCCUWBCD IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
r , t
FULL NAME
f)
j^
H A^^ ' t-
4
jC\J^
PERSONAL AND STATISTICAL PARTICULARS
SI-; \ ■ * I « il.i iK N A
MEDICAL CERTIFICATE OF DEATH
M.iilli) (I)av
r HI'RI BN^ ( i:kTIF'V. 'ni.it l atft-n.h-.I ,1.
t,, ii ct^ :
I go
tVtai
H
;n-'i
\< ,K
^1'- ' . i.l- M \K K nil
\\ llMiWKlJ OR
< \\'r\%f in "(M'i-il , ,. - _
Ill:
I \ IH IK
lUR rill'I, \i F
«>l I XIIII-.H
M MIU'N NAMl-
"1 MOTIIKR
l''IKTHPI,A( 1-:
"I MOTHKN
<)i-rri'AT|(,^-
an.l tl
il Iriiiii
HI - '^ * lip 1
' t lit .I:i!r -f ;tf< '1 ;iIh ivi% nt ^
M. Tin- CAI si; <M hi ATll u
tllilt 1 lit-^l --.lu
I'll |! I\\ S
c<>NTRiin Tory
I )r RATION ^ )'t'qrs
Mouth
I hlXS
Hour
, . SU
Mouths /hns
kjhihj
(SIGNED )
iDctr 1^ lool (Address) '^^^ t<Liix
Hours
M.D.
4—
dlions,
/
;/ / ; a Hi . < it
) f'lJI S
\/i,>lf/l'
Pll 1 A
Tin: \HM\|.: si*\ti:i5 i-kk^hnai. i'AKTiorr,ARs aki': tkd; to thk
lu'.sr .,! Mv K NOW i,i,i)(,i.: AN!) in-:i,n;i'
SPECIAL INFORMATION ^'y 'or Hospitals, Insfitwlons, Transients,
or Recent Residents, and persons dying away from liome.
HoH lonq at
Plife of Oeatli ? Days
former or
Usual Residence
Wfien was disease contracted,
If not at ^ace of death ?
Ij'f'inii.ifit
^i^i
is
<Mi..s 3v I X ^ X/"^^^-^ ^^
i
1.,,UH()F^ IH kIM,J»K KHNK.VAI, j 1) \TI' nf HfMiAI. or KHMoVAl,
(Adill'-'*!* uIa
^
KXJ\J
.1 1 AfiB .hould be •t«Ud EXACTLY. PHYSICIANS .hould
N. B. Rvery item of Inffopmatton should be carefully auppiled. ^^" cl«.«lfled. The •'Special Information" for pep-
state CAUSE OF DEATH In plain term., that It miiy He |,r»periy
aon. dying away from home should be given In myry ln-t«nce.
J .»
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nth ! N '-•- -afi^) p.Si ;■
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
r^JyJ II
inOH,
/^'o'/.v/f'/w/ JV'n.
2246
,tru^c4
#♦•
t
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
%
0 \<xv
Certificate of E)cath
X\. S. Stan^ar^
i ^
PLACE OF DEATH: — County of ' Ow^V J XCL'^\cuL<^DGty of ' ),<X/vv 0 \o.vxccaico
^ (I I
No. iSTb w J- St.; % Dist.;bet.^<XaA.U>xCU and^JjXCC>"
/ ir DtATr- occ uRs *wAY FROM USUAL RESIDENCE give facts called for unIder "special information- N
\ ir DtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^ OF STREET AND NUMBER. /
FULL NAME ^^CL^
r>
ii
PERSONAL AND STATISTICAL PARTICULARS
11 tl.ok "S
I i N
Li>.^.t«.
i 1 I > !
11
f\ f.
M
^IN« I.K M \kls III)
wiiM»WKl» UK ;
i Wi itt- ill *;(MMa' .
A
MEDICAL CERTIFICATE OF DEATH
I) \i*i; « n' i>i: \ in /O
I in-:R \l'\' i i UTIrW
tllMl I la-t -^au li ' ■ ■"
;ui<l th;it (k-ath or«iirre.I, <.?i the dati- ^tatt-.l alMiVf. at (oO
M. The CAI SK Ol- I>K.\rn wa- a-
!at I alh-iiiUii ik'Ci-a'-cd trtnii
IcjO H
1 1 HVS
r
N \ M I I (I
I'.Ik rill-i,Ai-K
OF I ^!hi;k
">t;it- iir (."(Mint! V
MAn)l.;N NAM}-
«»}• MOTHKR
iHkTni'r.Ari-:
"> M<»Tin%K
i State or Contitrv
OUX^
LhAM
n
I
CONTRimToKV
I )r RAT I ON y^'"'^ .^
Months
Da
Iloiti^
(SIGNED
) aJvol^
Mouths
4
Davs
%>. I^lI
M.D.
ifi
Rr silt fit iti San to at'
Special information only '<"■ Hospitals, Insfirutions, TrwslfBfs,
or Recent Residents, and persons dying away from home.
), ./
M.nillv
/)(/!.
THI-: AHOVK ST\ TKI) PFRS(1XAI. iv\ k T U I I,A RS ARK TRIH To THH
HHsT <u- Mv KN'n\\ i,i: !)( ,}. AND iu;i,n:F
(Iiif..Mnrmt
X^^^
1
/^-\
fCA ^ %
rc^uoXi
Former •r
Usual Residence
When was disease contracted,
If not ^X place of death ?
How lonq at
Mace of Ikath ?
kys
lU ArK <)I HlRIAr, OR RKMoVM, I HAT^-: of H, HiAf, c,r RVMoVAU
„ . .pR _Hould be stated EXACTLY. PHYSICIANS should
N. B. Every !tem of Information ahould be carefully supplied, aud .„_.|f|ed. The "Special Informntlon" for per-
•tate CAUSE OF DEATH In plain terms, that It may be properly ^
son. dyinft ms^tmy from home should be given In every Instance.
I!
..»
i 1
.^ '»
i
ii
•i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I>fifr Filed , \^ cWu-Uxi (I
iu(n
Jic^'i si ('red JVo,
2247
. ^Vv^^ A^K^^M^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
1 11. 'Z\ Stan^ar^
4
PLACE OF DEATH: — County of
vJ \<X <ocCity of
'^a.ix,^
Kcx ^V'CA^^e>0
Nr,. ^UuU "^ V.C:r\,Oxlu \ ^v : \ St.; — Dist.;l^t.
\ ( XT DEATH OCCU
.C:r\,Oxtu \ ^v ' St.; — Dist.;l^t. and
( XT DEATH OCCURS U A AY rROM USUAL RESIDENCE GIVE FACTS CALLCO roR UNDER ' SPCCIAL iNrORMATION \
V ir DEATH OCCURRED IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
(^
FULL NAME Uvc
LL L-»vau^d' 4 1
rs
N.A
^
4-
PERSONAL AND STATISTICAL PARTICULARS
1 » \
RTn
U
MEDICAL CERTIFICATE OF DEATH
1) A TK I M I'i. XIH
iiob
M..iitl
M
\< .!■;
/),,
\
f)
!•! \.-K
LC >V
I \rni k
iHHrm'i.M'H
^t:i'i I iT l',)lintT\-
■^t MIiiN NAM)
•'1 .Mo'nn.R
HIk-|'ni'!,S(K
"I ^t'l■^lIFH
■ "^l:it' i.r Counli \
I lIKIs I'l'N' I l-RTII'N', Til it I attfiili-il <U-ciasf<l from
- — \ip to ~~~ I90 ~
llirit I 1m-1 -^aw ll ~ alivf nil — =— - i,^ —
aii.l that ilrafll <.. - • , ,1, < ,n t lir ^ I il »• -fa' - .1 a!,, ivi-, at
M. Tlu- C Ai "-!■; ' '1 I>l, \ I'll ' f'.M'i\\N :
A
.C
t^vU^^
K 8 A
IJIR A rioN
( ONTK ini T<»1<V
I ir RAT ION Yrars
Mnnih^
/)av
11 i^ lit
M^niths
/Ki\
^. ilU
SIGI
V)^"f ,(_ J ^ (A.Mr.-^s) v^Vt> w^^\^ v^ 4
1 1<U()
M.D.
L
<H A i i'ATiox
AV liU'il it' ^:!ll / lillli
r
'D
w, r \^A^%^~
SPECIAL Information onb for Hospitals, In^^tlfutlOlH, Tra«slfBts,
w Recent Residents, and persons dvini a^iv from liome.
)ril,
,1/
Former or
Usual Residence
Wfien was disease contrarted,
If not at >lare of death ?
How lonq at
Rare of Deatli?
Di>s
1 \l',n\ r: vTxT,. i> pKH»,.)\AI. 1' \ k T If T !. \ K ■> A K l', TKiK !< > Tllh
in.sf (,]■ Mv KNn\\ij;i)f, F, AM) iu;i,ri;K
inrfiMurttit
Ia. U). a<xn,^
]t\T}:<>'- Fl' HIAI. f»r KKMUVAI,
0^ I- 1901
.X.<.:k fe=^-^§
Juyx.^W' VilJX^^
(Ad(lt<-'«
i^H 0^' QJuUXiA, ji
' ,, , AGE should b. .tated EXACTLY. PHYSICIANS .hould ,
1. B. F.%ery Item of informRtlon .hould be carefully suppMed. ^^ cimmminm4. The "Sp^clut Inform«tlon** for p«p-
.tate CAUSE OF DKATH In plain te.m., that It may be proP^Hy .la..im
a-Jfi. dying away from home ahould be ftlven In -v.ry instance.
'<\
i
I
ri
I
i!
i I I
♦ i I
1
•I
J'<
iL:_
iff
WRITE PLAINLY WITH UNFADING INK
t^^-lar-^, H5;; I' Co
;j \
100 "i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Deputy HeaUh Officer
DEPARTMENT OF PIBLIC HEALTH=City and County of San Francisco
Certificate of ®eatb
11. 5. StanOarD
PLACE OF DEATH : — County of 0~.y\J o - vc^
No. Ld-tv^^^'^^'^'
Dist.; bet.
\x V l\\ I /-.-> "l I , St.; Dist.;bet. ,,„.£. "spcciAt iNronMATioN- ■»
FULL NAME
,\
Xj
PERSONAL AND STATISTICAL PARTICULARS
^l-,\ ^'
( ( ii,t »k
i>A ri-; < 'I r.iH I'll
M. Htll
\l .1-
<J
I )-,,M
' ».l \"
M,,)i'li
%'<'.ii
MEDiCAL CERTIFICATE OF DEATH
I>\ 1 !■: til- Dl'.ATII
\
I go H
(Year)
-IM.i 1 MARKIl'.l*
SVtiteln Hocifil ck's%iKi>;»i'"" -
n
,1 \ (Dav)
(Month'
, HKKHBV CI-RTIFV. That I atUn.k-.I acr.asol fnm,
. — ■ — — lip ' t"
thai I last saw h • ' aliv.' -n — ^'P ^
,„a that .U-alhutcurre.l, on the. date state! alH.ve, at
— M. The CMSK UH HKATII was as follows:
<. >
o
lUK lliri.AtM'.
: stMic I >r I '. Ill n! I \
X \MI ( U
1- ATll l-.K
BIRTH rUAOK
oi I \rni:H
I Stati oi v'minti y
m\ii>i:n nam».
I51H rni'i.AiH
(Stati 111 fotllltl N 1
s^d^dJx
i^u.^'
Ums^'oJ-j ^'
I )r RATI ON >*'''''-^
CoNTRn'.lTORV
Months
Days
I louts
^
I
OlHMl'AI'loN ^ , » 1
Uu ^ • • ■ <^
imST OF MY KNOWI.I.IX.H AM> l-M-"'
Months
Pays
DlRATinN >''"-^
(SIGNED) U^-i^-^^'^^"^^^^
SIGNED) MT^^A^ P IQ
— I. fnr Hncnit^k Instill
Hours
M.D.
(Iiifoimant
U). ^^^
1)0 Kxt^iL^^r^v^-^^^-^
-^^— y^^-j;;^^^;;;^^ omv for Hospitals, institutions. Transients,
orleren^isfdents! and persons dying a.ay from home.
r\A , (^ u How lonq at ,
f»^'""''^ M ibrYdjl^JtLi ^'^-^^ Plare of Death? > Days
Usual Residence'i' \^y\a>>^^^
When was disease contracted,
If not at place of death ?
u' -V
1,\ 11 .,; Hi HIAI, -.1 KHMOVAI,
—" .^'\i:^?au^i
190 1
,\'l/^tA >.^/v>JUU ._ , FVACTLY PHYSICIANS should
TZTuppneZ AGB should »>- ^^-'^^^^-fspLla'! information" for p..-
of Information .hould b. cn.e.uHy «upp ^^ ^^^^^^,^ ,,a««.*.ed. The Sp
E OF DEATH In plain V-*"* ' ^J^" '' ry Instance.
^' """rtatTjAu'sE OF DEATH In P'^J^J^^^-^^i^V^Jn ;ve.; InMance.
«on, dying away from home should be gi ^^^
* 1
i <
i
;j i •■•
1 i: t.i
r
■*X -jr-^i ''.'"- I ' '
WRITE PLAINLY WITH UNFADING INK-TH.S ,S A PERMANENT ReCORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J? -^ _ .^-
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Gcvtiticatc of Bcatb
IT. 3. 5tan^a^■0
s m A '.
, ' ■ - City of^ '^ ' ' ' -- ^
PLACE OF DEATHi — County ot
'Pfo. VCl
\ ,r DEATH OCCURRED IN * HOSPITAL OR ^ H%T " ^^
FULL NAME V^ -- ' ' ^^
\
PERSONAL AND STATISTICAL PARTICULARS
r\ ■
!» \ : I ' 'I
\< .!■
U
II V.
^'
MEDICAL CERTIFICATE OF DEATH
DA IK "K ni \rn
V. Ml I
I m-RKHV CI RTII V
\i.p
|>:!V'
T c)0 i
l\\
i; ,1. -is^nntntn)
llIH fl! ri, Xi'K
1 St .it 1 1 It i
\ III IK
If %
« >! I X I'll IK
St il t t ir I ii\!tlf ! ^
MMDl-.N' N\MJ
^•]: Mo'l'lll-'K
»>|.' MnpHI'.K
State . ! t'olltltl N
,1 t hat lU'at h
M. Tlu
C \i -I' <
A ril \N i-^ a-> follnu-^
UX'LLfC-^
\
JL^
nr. I r x'l'ioN
C
rs
liKST 111' MV KN.IWI.II".!'. XN^ I.I 1.11.1-
(Inf'i-maiit
-^^xX
v)l\
CSJY\y^\j
/>c7 1
I /out^
/hi
IS
.c<
M.D.
/..i,i....s^CaxUJcmv^^v
fJ
M
i
r
%;7^;^^r?^ORMATION only for Hospitals. Institutions, transients,
^rtren^isfdents' and persons dying away fro. home.
r
1^
'. f,
Former or
Usual Residence
When was disease contracted,
Ir not at m^ of death ?
How lonq at
Place of Death ?
Days
7.,.ACK01.- m-KIAl. OK KKM-VAl
lit A C<x'..
l(<
1
N,
(A.l.lif^s <^V0 *^' V M U-V^ ■■- , -^^.>.L PHYSICIANS should
' — ~ ^^^,,„„y .oppMed. AGB f ^"/^''.^^j'j^i^'Vh; "Sped.; Information" for p.r-
B._F.very Item of •'«*^»'""«»'r.', it term, that it may be properly .l..»l«ed
state CAUSE OF DEATH In P»-J"f^'"!;;e„ la .very Instance.
son, dylnft away from home ahould be ftl . —
t^'?!
i -I
h I
WRITE PLAINLY WITH UNFADING INK
^" "■*»,
.1 . i I !
t 1!
,>. 1' Cij
I)f(/<^ niriL U,i:i.<rl>x/vi 11
100
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Be <^> I sieved J\'o. ^^oO
^
DEPARTWENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of "Death
■ - - City of O/CXz-Yxtoj ^A^O-^i-XX;
N«. ^clvHoJ'S Ca^-^
St.;
Dist; bet.
and
)
FULL NAME
AXVt'^^-^^^^^
PERSONAL AND STATISTICAL PARTICULARS
u
J
; .
rV-
l>,.s
\» ,1
55 ,„,- 1
\l
\ 1 a!
/).M.
^I\. I.I* M \R K IKIl
\K ' ; 11 i\\ ! I > ( >R 1 » ;\ t II' r n
W ; ;!. ill -. H la' .|. -ik'U.it ii>n 1
1 1^
O
liik rnvi, \t"K
\ \M 1 < >I
I- Sill 1,K
p.iR'nif'i, \<!-:
ni' I XT HI" k
--! * I I ir I'l lu lit I %■
<>i M«»Tin;K
niR'nuM, Acv:
ni \i(>rni<,K
( state or Ciiuiitiy
«H Ct !■ AIK^N
LLC U, tVi^ "'I V
1^ a
W
4 ixjUJ- ^v^XCutU
^^s
h'r^iilfi! in S,m / i ii
) til
Mnllill
/',.'i
THU MU>VKSTVI'KI) PKRSoNAI, I'A RTH* ri.AKS A R H TK f K T< > I'll-
incsT <)i" >.tv KNtiw 1 iix .!•; AM» Hi:un.i'
(1
MEDICAL CERTIFICATE OF DEATH
DAi'H <»i ni;Aiii i I \ ,
I 11I-RI:HV CKRTIl'V, That I atteii.U-.l .W. easel fn.n
190 tn — — - i»p —
that I last saw li alivr on ^'P
an.l that .Uath ncciirrea, n,i the .late stated ahovc-. at
M. The- CArSI':,Ul" in; A Til was as follows:
L\.
1)1- R All' 'N
Yiars
Mouths
Pars
I /ours
rxi
lis CvixcL.u
CoNTKII'.rTORV
DTRATION )''-<Jrs
'wV..
Mouth.'
Pa
\s
//ours
M.D.
SIGNED) LU. VJ ^^'^*^ ^ • ^
iDot 10 rooH fA.Mn-ss) ^ OA^ta, UW<X. LaA
SPECIAL INFORMATION onl> for Hospitals. Institutions, Transients,
or Recent Residents, and persons dviny 6v,a) Irom home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death
Days
V\ MV «•! niRUU OK Rl'MoVAI.
INIil'HTAKKK M V-
XXxu ,
X.OLH ^^^ ^-'
IJAT};iit* I!i KiAi, or KKMOS'AI,
0
,a.iu.s ^51 m^^^xxj^ '^t
' ^ IfiE should be stated EXACTLY. PHYSICIANS should
Btlon should be carefully suppi.ed. ^''•^ *^ .^^jn^d. The "Special Information" for psr-
ATH in plain terms, that It mi.y be properly
N. B. F.very item of inform
state CAUSE OF DEATH in p.. • , instance.
sons dying away from home should be given .n ever> instance
' 1
I 2
I (
I
i
i i
i
Wi
i<*l
^
WRITE PLAINLY WITH UNFADING INK
-..V":^"*-, i.x.
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihifr /-'ifc'L ^ oLt^t^^" II
IfUJH
JlroisfrrCfl J\^o.
2251
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Gcvtificate of 2)catb
M
PLACE OF DEATH: — County oi
City of ' Cl >^'
\
>lOl ^\cc>a. CO
^
No.
. , .,,. occurs .... r.oM USUAL RES.DENCE_c..v.^ -c-rs CAUj^o .^^^^o^ st^^ J^'no^Jm B^ h' ' )
I n SU ^ Dist.;bet.
' - iiCiiAl RFSIDENCE GIVE TACTS CAUUE
f ,. , .^.. OCCUHS •..* '"^^ ^^'ilt OR^NS^TUT.ON G.VE .TS NAME .^
V if DEATH OCCUWnrD IN * MOSP..4L OR INST W
and
FULL NAME
PtRSONAL AND STATISTICAL PARTICULARS
Ua-
MEDICAL CERTIFICATE OF DEATH
■fc
Ml nth'
1 n
;\ I IRTIFV, 'I'll '• i
i' tciii Iril > i<
ti)
a^itl tioill
Kf) H
I
tlial
W\
I l-I \i' »■
V \ M 1
1- \ I ill
:!!• !';!!M \< I
I . »
u \ MM X ^ \mj:
>\ mi»i'iii;k
<•] Mtiriii-.i.'
■^1 ati I .r < I iiuit *
I i'^ T II »:
A'/' /,/f./ jc
/ ( ,;(/( ,' 1,1
) till S
Miinfti-
I III 1
r XH..VK s, X , , n ,.h....xx,,,.vktum;uarsahK tkih to thk
HKsliU MN KNOW 1,1 l»<K ^Nl> H»-.I,n-,l-
( I 11 fii- iiuiiil
^Aj
\.l
M. *riH I
i'i\ f nil
,,,1 ihf ilati- statiil .ilinvi-, at
( )!" I )i; ATI! was as lollmss :
1 1 )()
5
l h
/ 'i/M
Iloui
c
M
\ t a
Par
(SIGNED) ^- '"^ a - - ^
I Ion I s
M.D.
"^^CIAL INFORMATION only for Hospitals, Insfitullons. Transients,
or Refent Rcldents, and persons dyinq away from home.
How lonq at
former or Place of Death? Days
Usual Residence
^R was «sease contracted,
If not at place of death ? .
UAry<»f niHiAi, 1)1 ri:m<>v\i.
C
t.
L T()0
^
d EXACTLY. PHYSICIANS .hould
N. B. Bvery Item of Infopmrttlon •hould be
;py
Htattf
Item of infopmiiiion .owi.." "• — ,^g propel
CAU«r. Ot^ DEATH l» P'-'^f'^/'^:; ***"„. v^^t l„.f«c^.
c.r.luMy .uPpi.'H. *««;;;'';;.''..V,,:i?' Th. "Spcc..; .„.„r„...lon" for p.r.
won* dying away from homo •hou
I !
. <
i L *
I I
4 i.-
V
f:
I
I
I
t
u*.
. -c
m
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
tS- -.. H\ I
Pa/r /-V/r'./.yc;
hj U
inoH.
Ur <> i sh'iu'fl >.V(^
00r\0
dw^VC
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Gcvtificatc of Bcatb
•\~
PLACE OF DEATH: — County of
City of <^
> \
^.^
X.
' s$U.
Dist.; bet.
and
'%S^ \ § "V'\ ^\ A I V ^ ' • '^. Oti^. L'liil.f l^*» ,,K,nFR SPECIAL INFORMATION \
^ ^ ^"^^^--^-11^^^ --^^^ C,;^-!^^^^ ^^°0. STREET AN. N..eER. )
(
FULL NAME
\n
PERSONAL AND STATISTICAL PARTICULARS
1>
.1 i.iK I II
M
1' M \H H ir I
MEDICAL CERTIFICATE OF DEATH
i: Mil
DaV
I lIl:l<l;li^
kTli'N'. That I allcn.u-'l .U-.Ha^cd fnuii
i()n "
ti
that I !:■
;,n,l that .U-alh
aM oil
1 tjn
M. Tin- O
S • Ml- 1
hv <lat< -tat.-.l ali.ivt', ,a
1 \ I' II \\a-- H'- lollmv-
\\ ! 1 M iSV
W lit.
H!k rni'i \i' H
NAM I- <i1
F Mill K
ItlK , H I'l. Vi'l-:
< tl I \ I II l- !•
Stat I I It I'l ill lit! \-
MXini'S* S\M1
Ml Mci'riii:K
luu iin-i. Alls
<>t M<>riii;R
1%
\ '\ s
/sflitii! Ill >il>l I ''»'"'■ • ■
... , . ,, rxi'Tim \Ks AKK TKIK TO Tin'
lU-sr Ml- MS- KN«<\S l.l-H' .1 '^'^i' »M*''-f'
(llif-niiiaiit
It > OtA)
Dlk ATION
1 1 r R A r H > N
.1/,
nays
/Ion
rs
l/,u//^s
/hlV
//om s
M.D.
IM"
( A<Mn
•so LfrXe
^^\ t\A Kj\ % ■
4*4*-
" SPECIAL INFORMATION f) tor Hospitals InstilutlttAs, Transients,
orlren^lesidents! and persons dying away from home.
(V , ~\ , How lonq at
Former or Q '^ M U \ nX^>->'%0 ^ t piarc of Oeatli ? Days
Usual Residence I -* I ^ Ul^Mirr
When was disease conlracted,
If not it place of death ?
IiAlI', of m KtAi- or Ki;Mn\AI,
IX
X.l.lrr..s IHO^
i'^LAAnr^
gAJU'»
^^^""^ yLAyx^ ^ ' ._XLll I PHYSICIANS should
"~"^ vTTTTTIIefully «uppr.cd. AGB should »»« -t"'^^^ •♦Special Information" for pmr-
N. B. Kvery item of informatfon .hould be carefully ««PP ^^ properly cl»..IHed. The »pec
state CAUSri OP DEATH In «>'«'" **^/J"!;;e„ n Ury l««t.nce.
% nnnm dying away from home should be gi^en m
^1
J I I
H
I
I i i
I I I
M'
11. yi'
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
^^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
}•■ N'
0 J
Meofs/ered j\'o.
W^Wu Dep--.ty Health Officer ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No.
PLACE OF DEATH: — County of^O.
,^klM.C St.;
Certificate of Beatb
( tl. 5. StanCatC )
'%o , City ofOa/w-^^ ^.v-..^-'
and V-lau I.-
H'
"VX)
^1
K
V tr DEATH OCCURRED IN • HOSPITAL O R I n :>
■ni<:t • bet. v) 'VcOwL'WC
TS CALLED TOR UNDER •SPCCAL . N EOR ., AT.O . ■■ N
\\ NAME INSTEAD or STREET AND NUMBER. J
h
FULL NAME ^
)l,lcCl<x... V vJWlrL'>^^Lt ,
-.1 \
1 1 \\\ t •!
PERSONAL AND STATISTICAL PARTICULARS
,A
rw
II
k
^^
VcU
'f
in
\' .»■
MM ,
X
■J. I:
»! Ni , 1 r M \ H R I i;i»
w I iM »\\ I i » » iR I »i\< >Ki I'.n
W ! lt« 111 -' M ;.i: 1( -i^MlutHill '
MEDICAL CERTIFICATE OF DEATH
( MoiitlO
10
l>;iv^
(Year)
S ,,, Ki:i;V I KKTIFV. That r aUcn,U-.l .KHea..-a from
i(p
thai Iln^t^awhA. - alivL-nn ^ '^ '^ ^^
,„., that .hath .u.urre.l en the .late staua ahnv.. at
~ M. The CAl SI' Ol; I)I{ATII wa^ as follcws:
w^
a
CjCLOv 0 V<XAXCLv
1, /N /• V
rs I
I A rill-. K
HIKTllI'l.At'K
(•1 I sriiKR
M MIU-N NAMI
I'.iu rm'i.Ari',
tn- Mi»ini';K
(stall (It Country^
n
yxs
(Hcii'A'iioN Osrsf.
TnKAm>VKST\TKn.-KH<..NAi,l'ARTirt;i,XK'^AKKTK' H To Hih
HKST Ol* MY KNOW l.»;i)<-K^\Nn lU-.MI'f^
Infonnant LU mTU
rcN)- C; >
(AcMrcKs
DlkATION y^'^f^
foNTKIHrroRV ' ''
DT RATION >'"^''^
A(
(SIGNED)
Months
Months
/hiv.
'S
//ours
Pav
K.
IqO
A.hlre'.-^ ^^^^
K
//ours
M.D.
.SPECIAL INFORMATION «"!» I.r H.^pH-K In^M.ulions, I.anslrnis,
0,^" MeV', and persons d,ini a.av fro. home.
How lonq at
Former or piarc of Death? wys
Usual Residence
When was disease contracted,
If not at place of death ?
UAi'l'.i.f !l! KiAi. <it RICMoVAI,
,.LACK01^ in-RIA?. «.R HKM"VAI.
fAcMreSH
^ * 1 f^VACTLY PHYSICIANS should
E OF DEATH In plain terms, tho jt m»* ,J^^^^^
N. B.— — Kvery item
•tate CAUSE OF DEATH in p.a." ,^^' "■;';"-:„ ^^^ry instance,
son, clylnft away from home should be ftiven .« every
I I
u
»1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
11. ,-.!; ! V,, :. ••*^ti,|,s:!>(%, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)ff/c Filed, ll/ct<r\M.V. II
100 "{
Bogtsteved J\^o.
2254:
^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH: — County of Ocurv 0 >^a/>\ C'-^ y . City of Cj-Oy-y^ J X<X'/VC<^.-
No. KlC ' 10 .Uu St.; ■' Dist.;bet. fc-a>^vi-i.l' and H ' ' ' '
/ ir DEATH OCCURS *W«V rROM USUAL RESIDENCE GIVE tacts called for UNDEli SPECIAL INFORMATION*! \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J /
I 11
FULL NAME r:X^^
'jA/rru>Yvt
.-i
PERSONAL AND STATISTICAL PARTICULARS
'.I \ >"> r<<I,nK '\
a\
M mil
\| , 1-:
\:
M,:til/r
\ ' .iV
Af r^
^! M.I.I* \t\Ki<n:i>
uiixiui.n nk iuv<»K(.i-;n
(Writt in -•Mia; il. -i^natiiiii)
n
.C'^v
lUkTHI'l, \i'»'
' Stati ( ! t ■, ,11 lit t \
NAMH nl
l-ATHKR
'^
LoJLci-
H I R r 1 1 1 ■ 1 . A ( • i-:
<>i' I \rm:H
I stall (II I'outitrv)
<>1 M»>TIIHR
niRTHIM, AD-;
<>l' Md'IIII'K
'"tail I .! riiiint I \
.S'.a! t
MEDICAL CERTIFICATE OF DEATH
I).\TH »»!• I)J;ATH a
(Months (Day)
I IIIRIJ'.V Ci:kTll''N', That I attemU'l (Icicasctl fruiii
W.^1j ; 190 I to <:iX<,-A-«*.-^ir4^.. TqO
that I last ^a\v h . ' alive on U^ t V * j^pH
an«l that lU-alh (UTurreil, on the ilaU- statL-d alK)ve, at ^
" >r. The CAT SI-; OI' 1)1': ATM \v:e^ as follows:
DIKAIION
)'t'ars
.youths
C C) N T R I B r T { ) R \" LLcC4w<Lt^\Xo-v c
lloiirx
.OXu
A '
T^f
J
Mouths
Pav
(^ -tl H'
(SIGNED) V. 'I ^'
L'^> \ icnH fA.hln-s.) MC'l OAAJrijUv It
7 \A4 0 I V
HoHl s
M.D.
Special information only for Hospitdls, Institutions, Frdiiblents,
or Recent Residents, and persons dving a»ay from home.
<H'«ri'A rioN
y.ai
{■
M.niUi-
fh'
rii j: amovk sTAri-'n pkrsonai, rxn if ri, \rs aki-; rnrK ro Tni'
lUCST (H- MV KNoWLJUX'.H AND HI,IJi;i'
i\
a 9
iifotninut ^ ]\. \D .
jk/WX/^^A.^
v.<t-
r\,l,lr,-,s 5.116- ^OJU-0 .'^
xi~
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
ri,\CK<)I' lURFAI, <»K Ri;.NH>\AI, I DATi; of Hi Kl.Al. or KHMoVAI,
^^ ^ ' i!'^ U T90M
1 i
N. B.-
. ... » ,. I5..H AfiE should be stated F.XACTLY. PHYSICIANS fihouid
-Every Item of information should be ciirefully supplied. AUD snouici "« »*"^ "«a„..^s-i l„S«„.„»ti„.," f„n t^mf-
•tnte CAUSE OF DEATH in ploln terms, that it m»> be properly classified. The Special Informat.on for per-
sons dyinft away from home should be ftiven in every Instance.
I
I
I
* <
r:
■' i' .< i ' * ■
t >l :
#1
X
:f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! I '• 'i <
-ST .-. i^>x 1'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lUO'i
lU'iiis/cred J\'*o,
2255
DEPARTMENT 6f PUBLIC HEALTH=City and County of San Francisco
Ccvtificate <:X Bcatb
PLACE OF DEATH: — County of ~^a>x ' \a>xcuccGty of^ '/O/v^ Ja^X/vxc^OX^
No.
I : rs_
St.; H Dist.; bet.
5 11
V.
and
, iieiiai orCinrNrr nwr facts CALLCD rOR UNDCR "special INroRIWATION" \
( '^ r."o;:.H'^occ^%r.r.rrH "s^^.it o^".;s^^""4^."c.;.T4 name ..st.ao o. st«c.. ..o .u.bc«. j
FULL NAME wC ,
PERSONAL AND STATISTICAL PARTICULARS
(1 U « tK>
.!V
\\X^
i t ' i i 1 i K i I I
(1
\t nth •'
Ii.
-iN« .1,1" \\\\< \< ii: i»
W i i! I ill - ' :• ■ ,
1)
L %
IlIK III !'I, \i'K
'St,i!i 1 ,1 ( . iiinl I \
» ATHKR
I'.IH IHl'i. \(j.:
<>i I \rm-k
'-'lit. 1,1 riHiiit t %
MX Mil S \- \M 1
ink IHl'I, AfH
•'l- MtilllKK
"^t it( , i! i*i,nn!i \ I
L
yx^njUL M LturTTvO'Yx^
.1
MEDICAL CERTIFICATE OF DEATH
I) \ !'i-; t ii- ni; \'rii
lict
/QO H
(Yt-ar)
Month' 'I''>^'^
I Ili;KI-:nN <. l l<rn V, Thiit I alten<K-.l 'li-crase.! from
I.p'i to V up'i
llial I last saw ll
ahvt- oil
W
w
it
Icp
aii.l that diath .kh iirrcl. mi the .latr •^tati-d ahove, at
M The C \l SI- Ol' IM-ATII was as folI<.\vs
LI
in H \ rioN
} t'tlJS
\
Mouth
Par
Hour
Ci tNTIvIIUTokV ^
L>%_^>
DIR ATinN
)'r n-
Mnnths 3 PayR
()
V " t •
( SIGNED
I lour ■i
M.D.
V J A;
u^Iaux)
• •' < I 1' \ TIMN
fsf'^ldl'il III SilH /'l ll Hi I •■/'<>
)>,;;
Mnlllh^
/>,/!
IHl, AHOVK ST\TI-:i) PKKSONAI, 1' \ R lir I 1, \KS AK H TR «' K T< > THi:
in-.sr nl- MV KNnWM'.lx .J'. AND in.!, 11, 1
f
x.t.h, ss '^ H ^ J (nJUrTrx/
at
SPECIAL INFORMATION only for Hospitals, Institutions. Transients,
or Recent Residents, and persons dylni) dway from home.
former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Deatli?
Days
T; u-K.M^ m-RIM. <-•< KHMoVAI. I "Vl-j.^f nrH..u. or HHMOVAI,
tJv C* > *
I
T90
H
— — — """"^ ,. , AaB«1inuldbe •t«tc.l nXACTLY. PHYSICIANS .hould
tloti .hould be c.Mfully supplied. ^"^ » cl.«.ifled. The "Special information" for p«r-
..... W..O.. ^. a...«TH In plain term,, that It m«. He properly .I—me
■on. dylnft away from home .hould be ^iven In .very In.tanc .
N. B.— Every Item of Informn
•tate CAUSE OF DEATH In p
I : *
J ,1
4 .
i
s I
:ti
n
If
i
If
M
ri
WRITE PLAINLY WITH UNFADING INK
ih/fr Filed, ^ ,ct<r\>^\^ 'I
n)n\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR jNSTRUCTfONS
Registeird JVo, 2256
^v^»^^ Cjc/vm^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH
Certificate of Beatb
: — County of^O. >x OA„<X^ c^C^Gty of ' <Xtv 0 /^<X/>^c^<l^
m
v^\x\i^^-^ -^ " ^<. ' St.: Dist.;bct. and
i>ro. V^C^U ^ ^TCiAVwrr r.wr FftCTS -ALLEO FOP UNDER SPECIAL I N FO R M ATI O N ' \
I / ,r DtATH OC. U^.^ AAAV FROM USUAL RESIDENCE GIVE rACTS -*^^^^,^3^,„ o, s^„tET AND NUMBER. ^
V IF OC.TM OC^URBtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAML NSTK.O O
j(
FULL NAME
I
SHX
PERSONAL AND STATISTICAL PARTICULARS
1
«'! HI Kin
t'.t
M.M.ih
1
11
Willi »\VKI> ok I»:\ . ik. Jl)
\<X^x.
KK^^
! t iiml I %
N \\! I ( »)•
1 x rii Ik
'>|- I \ in \M
M \ii>»:n n \m 1
'»! Morili.H
I'.IR riMM, \( K
•'I Ntiirni'K
u
1 1
(1
Xol^^XOu ^'H
-1,1
I I ii I'l iiiiit 1 \
A)
orrrivxii,)^'
JX/>f\.o ^
\k ^
A'fMiffuf in StiH /'i ,111, i^i'i) 1 I. )f(f»*
1 A .;/,'//>
/J./l
111-. \HOVKST\THn l-KKSONM, r \ KTir 1 I, A KS AK !• TRf H TO Tllh
nj';sT oi Mv KNowi.i.iK.i-; and in;i,n:i'
ni'.M 1)1' MV KNOW l.r.lK . 1-, AM» lii'.i.ii,
JXJ
MEDICAL CERTIFICATE OF DEATH
iJAii-; »»!• i»i:\Tii ,, \
1 111 KI-HV i IRTII'V. That I atlL-iKlcl -Krca-^cl fnmi
(Yi-ai 1
i()0 H
that llaM sau h ,nix. u„ ^^. ^^^- ' I«P
an.l that .Uath nrmrrrd, .>n the date stated ahove. at ^'hi
M. The CAl^I" OF I»1-ATH ^s.
\< as
follows :
xv^
^ . f% TV --l V CS-
DrUA'PloN
CONTRir.l lOKV
\1 w^^A'w'VA^^-'^*^' •
)Vdrs MnNths
Pavs
Ho It IS
1)1 RATI* >N
(SIGNED)
) \ars
Mouths
Pavs
i\.
Hours
M.D.
OiM only for Ifispitdls, Institutions, Transients,
QprCIAL INFORMATI^.-
or ReTent Residents, and persons dy.nq away from home
Q
Former or ^ IN
Usual Residence <?^'^ v
Wlien was disease contracted,
If not at place of death ?
^it'CUv^.
How lonq at
Pjare of Death ?
Days
riACK Ol^ m KIAI, ^^R KKMOVAI
DAri". <^f lU HiAi, or KKMOVAI.
—i^—^— ^^■^■■^^■'^^■""'"''""** . EXACTLY PHYSICIANS should
.,„„ .hould b. c.r.fully .uppll.<l. Jf^^-XilL^'ci' 'xh. ■•Sp.c.ai l„for„,..lo„" for p.r-
TH In plain t.rn... that It may ."'f"''"^'*
N. B.<— Bvery Item of Infofma
state CAUSE OF DEATH In plain ierm«, *"»» - . ^..-^e
nfin. dying away from home should be ftWen In .very Inst.
» I
« t
J . I
f-
I I
'T r
hi
J i
w
RITE PLAINLY WITH UNFADING INK
■ \- I V
H/tl' <■
/////^ Fih'fl ,
'^.c'sXAj
//>'<^>H
THIS IS A PERMANENT RECORD
RCFER TO BACK OF CEBTIFICATE FOR INSTRUCTIONS
c^i s! ('I'Ofl *A^^
^^^ju<^ 3^X/\>U
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH: — County of
City of
"V.
XX/>"^ CA.'QC'C
and V
No.
St.: -^ iJiSt., Dei. ,, .. ,NroRM*TidN \
(, ,, DI.TH OCCO««t[) IN « HOSPlt.l 0» l-STnuTION S VI
FULL NAME ^^
A
PERSONAL AND STATISTICAL PARTICULARS
i'« 11.' 'K '
^^A,
r. <>! iiiK III
M.tif
A«.K
•-!N 1 I M\KKn'!»
lUK IHl'I. \CV'
MEDICAL CERTIFICATE OF DEATH
11
iDcb
M
Dav)
rgox
(V«ar>
I Hi:!
n-nV C1;RTI1N, That I allcn.k-l .Icvasd from
!<y'
alive- ni
NAMK UF
FATIIKR
niK iiiiM.ArH
«H I AIIIKK
*^t iti or I'outitrv
\T \n»J,N NAM J-
<tl MnTIIKK
i'.iRrm'r,A(!',
MF MoTHHK
(StHtt I ir I'liuut I \
' >Ci ri'ATION
AV */>//•,/ in Situ /
TMl'. AHOVK sr \ri-l) 1'HR-.'»N \I.
iu«:s'r <>i- MY K NOW 1, 1.1 >».»•: \
,-NKrirt!,AKSARKTRrK
N!> I!i:i,lHH
(Illfn
L^a-X^r-r
that I last ^au h
.,ih1 that .li-ath ..crurred, on tin ..au
M. The C.\rSH OF DHATH wa^ as follows
1<)0
I )r RAT ION J''"'
C( .N ri<ii!i r<»KV
.1/.
fhiv
J/otif s
nrRATinN ^
fhiv
I lout s
M.D.
4^
(SIGNED)
-^ii^I^TTi^^^^^-^'ON only for Hospitals, Insni.tio.. rra.,e„K
orfeTeSlesfde'-nls; and persons dying a.ay from home.
How long at
Place of Death ?
I).\JK<.t H< HSAi. ..r RI-MnVAI,
0
N. B.-
r'
r j
I t
I .
k.y
I '
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Jl<iiitc! of I?
! \
1:>V1' (*..
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/>afr /•VA'^/.UcirU-Uv 1
"^
ft
ifnj^
Be^i'S/crcfl JS^o.
S258
DEPARTMENT OF PUBLIC HEALTH=Cit) and County of San Francisco
Cevtiticate of IDcatb
PLACE OF DEATH: — County of <X^
V
City of 'J CUw ^hJXn^^^ -^
No.
^- a.L' . St.; 10 Dist.;b€t. JCL'>X<v4U-Vs and 1 '
(ir OtATH OCCURS «W»Y FROM USUAL R E S I DE NCE Gl VE facts called fOR UNDER ' SPtCI*i INFORMATION \
IF DEATH OCCURRED IN A MOSRtTAt OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\w >*_ F
1 ^
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
DATK <»F DKAl H
V
- •>- ' N . "^
v.L
DATl-; t
1 1:IK11I
I
f
Nf.
\0^,
\«,1-
^I^«,I,K MAKKIKIi
niHTm>f, \.'K
(Stn1»- ,,. I ,,ntitrv
r>
ko.
1 HHRHHV C1;RTIFV. That f .'"•-.-!..! -k. . .»,,,! fr-.m
tliat I la'-t '>aw h •■• liisf 'Ui - Kfj
aiiil that dcaUl 1 1«( u rrfl, 'iii \hv •. ■ Lafiil ahfiV«*, at b
..Mi
M. Tlic CAT^i; (»| Ii)-..\Tlf ua^ a- follnv
s ^
v^l
K O
NA\fI 1)1
I- AT in; K
lUH llll'I. \< K
in • • -ill''
»•! MdTHI-.R
JHk rHIM.ACK
'»> MoTlIKH
ll
f
iC /V^x _ _'
■u
r-s
s ■ 1
X
i\
CnNTRIIirTDKV
I)IR.\TI(»N
Signed >
fUJUxx L-
"V
wo
AJ 1 I KjO
Day
/fours
/>
\J w \Ji W W,
//nui ^
M.D.
A.Mn^~
Special information m') '^r Hos^IUIs, Insntulions, Trais»»fs,
or Recent Residenh, and persons dvini •i*^) 'fo^ home.
II'ATION />p
) I n I
I'HK ah«jvk sr xTKii PH K -ox V j, I- \ H rr f- 1, \ R - s R I iH I J. J ' » Jin;
IJKST OF MS' KNOW I.I, Ii<,K AMi i!i,i,n;i-
Former or
Isual Residewf
When ¥>i% disease (mUmM,
If not at ^i(t of death ?
Il«« lonq at
Hire of Death ?
0a*s
'I Af i; oF^ ju' R r ^f, ow
fill f. -mam
M Sin, u<x.
Ii\TK .f H'hiAi, or kKMo\ \|,
^^^-"^ '^ I90H
^^
e .. fl . , . .. , , I. s ii„ ...„»is^rl \nB «hr>uld be fftated EXACTLY. PHYSICIANS «ftoiild
Bvery item of informntion shouliJ ht- cfirefully nupplieU. ^'«o mn ,u,u -...,„ . , , a .. ,♦ #
•teU CAUSE OF DEATH In plHJn term., that it m«> be properly cl—.».ed. The Spec.l Information for pmr-
state U/%U»t: Uh IJt A I n In pi
«*>fi« dyln^ away from home nhould be ^iven in mvmry Instance.
I
S
^J?l^]
m
i!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
• ^ ' ■ HertR TO BACK OF CERTIPICATC FOR INSTRUCTIONS
fhffr Fi/rf/, L'ct^l^ ■ ^
7^(9-
Deputy Heallh Officer
//■
/ Xo,
mm
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
f
Certificate of Death
II
X\. S. 5t^n^nrO
/>
PLACE OF DEATH: — County of
City f){
ft
No. ^ H ^ ^
St.:
Dist.i het
u
f f
and
^ t /
(
ir DitTH occups •w¥*v rnom USUAL R E S I DE NCE &i vr racTS CALtro roR UNotn
tr Dt»TM OCCURnCO in * MOSPITHL or institution GlVt ITS NAME INSTrAO or «;
FULL NAME
IC Mu L
PERSONAL AND STATISTICAL PARTICULARS
i i If I iM \
<
MEDICAL CERTIFICATE OF DEATH
I r
I III R I !'
I in II s. I
K . f
A
^D\
n
II >\'i '_ 1 1
fQoH
.\ , IT I
-vi] from
I(;'i
\^\^ ^T flu I A' -I < >r hi \TII
* ■'l .^
N
I- \ III I-.K
I'lK iin'i,\t-K
>nR riii'F, \* |.'
'•t M«>'i'ni-k
nr RATION
/)
^^^
n V
/A'ur<
Xaj\
S I
A
/l7\
(V:
(Signed ^ V'u^xl.<^^^
M.D.
Special information ©"'y '"^ Hospitals, institutions, rranslfnts,
or Rfcent Residents, and persons dylnq mi) from tiome.
H'C !
! « > N
'> 6w. ' 'I"
M.nit],^
IhlVf
rni \m>VJ* ST\ i in I'KKSnSAI, PARTIOri.ARS ARi; TRIK To TIlK
'n:sT oi Mv K \< t\\i.i;i)c;K AND nHi,n:K
Pormer or
Isual Residence
When was disease rontractcd.
If not at place of deatli ?
HoK lonq at
Plate of Death ?
Dan
Unr,
>nnrni1
III KiAf If K KMi »\' Al,
TQOH
Uob IX
PLACl-: OI- niRIAI. OR RICMOVAI.
(to OLxs^
rNDKRTAKKR AD . 0^ O AjJfXf^ W. kL .
(Address
•^^ B.— Rvepy Item of Information should be car
dtnte CAUSE OF DEATH In plnln term*
nonm dying away Immii home should be given In every Instance.
,. , %nR -hould bo stated EXACTLY. PHYSICIANS ehMilrf
efully supplied. ACih •nouin "« "*" i«#«„«.»|«„»' •„,. «■>.
thflt It mi.v be ppopeHy classHied. The Special Information for prnw
h^ '
f^
^
r"
^
' I I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\b\j^^ ksu^>u Deputy H ^h Officer
Bc^istered J\'*o,
i3260
DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco
Certificate of E)eath
PLACE OF DEATH: — County of
^
No. 1 i 1 1 A^LCLVixc
1)
City ofUO^/^X- v),^CU->\.a^.4.c i
s ",^
St.; 1 Dlst.; bet.vJU\.^a.(luj<X.lL and U XX" ^
(ir DEATH occun9'«w*y rnoM USUAL RES I DENCE give facts called for under "special u nformation" \ ii
IF DEATH OCCUr^RCO IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / U
FULL NAME
\ I
I
n
PERSONAL AND STATISTICAL PARTICULARS
.i;\ (TN
ri »!,< iR
' ■'' I 1 111 IIIHIJI
\«.H
^l-.titli
MEDICAL CERTIFICATE OF DEATH
DA 11-; (tl I)1:A ill : "^
'Month) I)av)
igo .
(Year)
■^IN<.I,l-: M\RkIl.;i»
WllKiw HI, uH I»IV«)Ri Hf)
W 1 Uf ill V,,,.,;
HIRTMI'I.At'i:
' Htiitf fir I'lMi lit r \
H^li'lian. lU )
^
A
J L>\u'
I HI',ki:i:\' CIRTri'-N', That I atteii»lc<l ilercasvd from
up i fn "^ * l(p
ali\c nil V- V- \.'
tliat I last saw li ^ alive fui V. v- k; Iw I90 I
ami that <Uath .'((nrrcii, nti tlu' daii- stattd aliovc, at 1 0
M The- C \I si: Ol' I)1;ATH was as follows
J M. Tlu- C^\I SK oi- I>»--)J
N \N!r III
I NTH IK
lilKTlll'i. \(F
'•I I X ihi:k
LLrd,
'S|:l!,
<'. (.iiuntiv
<il MoTllllK
'•■IkTHiM.Al'K
oi' MoTllKR
'St.ttr ,)r Cuiiiiiry)
OClfl' \| I()\-
dto
DI'kA'i'ION }'tiirs
CONTKlin'TOKV
Miniths H Pay!s Hours
[)lou
h
.^f\XiA/>
VC
cars
7s
^^onths
Pays
(SIGNED ) A. dJ, hD
I <XC\^a a-t-^-^-k-Aj
Hours
IVI.D.
SPECIAL Information on'y for Hospitals, Instltutlotis, Transients,
or Recent Residents, and persons dying away from home.
Kr^iitfil ni Sifii /'nniiiuit | )',i!is O ^f'Hiffis I [ ^
hiv.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death ?
Days
Till.; AH0VH.STATi:i> PKKSOXAI, PXHTfOr r.AKS AKi: TKIK TO TIIH
HHST OI' MV KN(>\VIj;i)C,K AND HHI.IltK
1»I ACK DI- inKIAF. OK RKMoVAI
Si ■
,cuLco^ >v
DATi; of Ht wiAL or RKMoVAI,
(Arid
re«s
y TT ArF -hould be stated EXACTLY. PHYSICIANS should
? Inffoi*matlon .hould be cnrefully supplied. ^^^* ^l-.-ifled. The "Special Information" for pmr-
OF DEATH In plain term., that It may be properly Uassitiea. P^
N. B.— — Rvery Item of
•tate CAUSE „. _„ ^
«on» dylnft away from home should be given in every instance
I '
I *
I !
♦ « .
t»
II
si
WRITE PLAINLY WITH UNFADING INK-— THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hnat ' f II. ;ilth I- Vo. i ■: '^'^.^J^b H& P (
Ihf/r Filed , \,xXjA>^i>^ \'X
lOO'i
Bi'iiisli'rcil JS/*<),
2261
^ I
DEPARTMENT OF PUBLIC nEALTH=Citv and County of San Francisco
Certificate of IDeatb
I "a. 5. StanDarC^ i
\ v.
PLACE OF DEATH: — County of' 'Ct->v 0 . -u
fNe. VAiA^ ^L-<3\AmXu O^^AKa.' ' St.; ^ Dist.; bet
/ ir DEATH occuBd^*w*v FROM USUAL R E S I D E N C E G I V E facts CALLE
IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME
%
City of i<X'^^'^*VO
and
* / IF DEATH OCCURgJAWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER -SPECIAL INFORMATION \
' V IF DEATH OCCUR"*-" '" » MneoiT.i no INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME M LCLl
PERSONAL AND STATISTICAL PARTICULARS
--l.\
I'Aii; oi- HiRTn
CoKoK \
1
\x
MEDICAL CERTIFICATE OF DEATH
DATi; <)i i)i;\rii
M.Mltll
I ri\
TOO I
iNTotilh)
\«,K
5 b y,a,
(Day)
'^l.inth^
\ far,
/'.n.
'^IM.I.l- M.\RI<U:i)
WIDoUl.l) OR I>IV()Kij;i)
'Writtiii siKJaJ (UNi).^nalii)ii)
luK rin'i,.ACK
st.'itt or Cnuiitry
NAMK n|-
I All IK R
lUKTIirM.xrK
'^t.iti lit t'oufiti y)
maii)i:n namh
<»l .MOTIIHR
I'.IRTHIM.ACK
<'«■■ MiirilHR
'Stati' or i'i)untr\
i Hi{i<i;nN' cm;i<tii'v. That i atti-ii-Uii <ii<
190 \
. alivf on
I i i ,-^\
that I last saw h . .
and tli.at <katli orcurrcMl, mi tlie .lat.- stati <I
,1111 i\i', a
I(j<>
t b .
t f 'III
.M. Tlu- CAl'SI-; < M" IM ATII wa- as fnllou
*. ' I -\ •<
hwX ^t
.1/1 ';//// s
1)1 K.\i"i<)N y^v^ -^k:
C ( ) N T K 1 1 5 1 "f ( ) R V \J(^i^^'^^ ' <^A.k.
O-K^^W^
l)a\
11 out V
(}Ul
Dl-RATroN
rD
^4A^
(SIGNED)
>;wjy Months
/>,nv
ffoiil V
M.D.
,\.l(lrfss) CcIm gwO-^|V^^^^^
< K"
V$^X>(X^cJ'=UC. >->-A.* '
h'f.^nifil in Smi l-'i mu i-rn .*S0 5''"'
M.,„t/r
I hi
SPECIAL INFORMATION onlv lor HiftpildK InsfituHons. Translfiits,
or Recent Residents, and persons dying dv*d) trom home.
Tin-; ABOVK STA'n:i) I'KKSONAI. I'AKTHri.AK
HKsT ()i- ?,iv KN<»\vi,i:i)c. K AM) nin.ii'.i'
(Infnnnant \J . VJ. UU . ULCC^ t.
Rs Aki-; TKI !•: TO Tin-
fA.ldrtvss
A^xXu
\
^iA)r\^JjxX
or KClcni noiucnn, ohm ,»i.j"" • -/-i -• -,
Wlien was disease ronfrarted,
If not at place of death? _^
rj^ACI-; n|- lUKlAI^ nk k !■:%!< >\M
D
la^N
nAXH'if mwiM (IT RKM«nAi.
1 0<> i
S'tt 1^
/UU'i'^^
'■■^■■'^^■■■■■'^^■^■^■^^"■■■■■'■■^^■■'^"■^■'■^■^"■^^^^^*^'"^"^^^^ ... . . I r-vArTI V PHYSICIANS nhould
y !• ^ ATF should be stiiteu I.,xav*il.»' »-n 1 «^iwi
IM. B. Every Item of Information •houlcl be carefully supplied. /* * classified. The 'Speclai Informalion' for pmr-
state CAUSE OF DEATH In plain terms, that It miiy be pi-op
son. dying away from home should be i^iven in •s^ry instance.
in
I'
I.
;l
^
n,
WRITE PLAINLY WITH UNFADING INK
H.
V
^
1 I
i I I
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATC FOR INSTRUCTI0N3
-V -^
DEPARTMENT OF PUBLIC HEALTH-Citv and Countv of San Francisco
Certificate of E>catl:
13. B. 5t.1nDar^
-*-N
PLACE OF DEATH: — County of
C
No.
(
"- ' --' St.: " Di£t.;bet.
'r DE»Tw occurs «yv»v FROM USUAL RESIDENCE i .r t*-Ts c«.^
IF DCATH OCCURRED IN A MOSPitAI. 0« INS' "-' ;
FULL NAME
-s NAME
S 5 ' r i
PERSONAL AND STATISTICAL PARTICULARS
MEDiCAL CERTlFiCATE OF DEATH
i Tt
n
4 I
a
// .
i Kk
^ \
M<»T!n:k
0-\xX -
Signed
M.D.
'■!'!. \ I K
ir\
SPECIAL INFORMATION ^' • i^r H«^f*
' ^ . .1 »;
'UK AWiVK sT\ THr. i'KR-,<,v i
HK'«T OF MA KN.iU i.j.i,, ,j..
\H 1 1 1 ! r » k -•
■> lu i,;i f
'4^ K N.iW
'.■■- 5.11 J xA
Htmn m
If i«t if ^f #1 <f#ll :
«• «^f$.
M%
\XX>VuCX
N. H..
-Rvery Item of Information •hould be .«»-efully supplied. A»JR «H .jI.I b« .t.ted EXACTLY. PM^.SIwl4SS •^•Id
•tate CAUSE OP DEATH In pinin term., th.t It may be prr,pcrl> .l»««ified. Tfie "Spe.i.l Inform.i.on ' for p«r.
wn^nt dying away from home nhould be gUen In •v«ry Instance.
It
♦ .
I
f
It II
II
I
nt\
WRITE PLAINLY WITH UNFADING INK— -THIS IS A PERMANENT RECORD
ll.,illh )■ V.
■=r^ 1$& P Co
REPER TO BACK OP CERTIFICATE POR INSTRUCTIONS
i
Deputy Health Officer
RegisfrrP(( ,X(}.
J^263
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of Death
' ' ^ ^ City of C3tcrCivtt ..
o^a^\!
fNo.
St.; -
(ir DC«TH OCCURS *w«v rnoM USUAL RESIDENCE gi
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION
r
FULL NAME lc<
Dist.; l^t.
and
IVE FACTS CALLED rOR UNDER -. . t /. ^ .NroRMATION J
GIVE ITS NAME INSTEAD Or STREFT AND NUMBER. /
PERSONAL AND STATISTICAL PARTICULARS
'
ft
>1,<>R \
KAII.; (>|- HIKTU
^
I Month)
\<-i:
la
LI
i>.i\
V,.>///f.
MEDICAL CERTIFICATE OF DEATH
/^
iliayl
44/4)
I nKkKHV I
\\\. Tin-
!c(i ili-ii a'-.i M III ii;
I.
Ih
''IN'U.K MAKKIHI)
wirHnM-.i) OR inxuRCKr)
lUKTiU'r.Aci-;
sfati or !•, Militia
X
that I last saw h : alur dii
and that (U-alh nca iirrcil, 'MI the il,i' ' •. ' •' . it
M. Thf CAISI-: or |ii:\lll na-. a- f'.;! u^
It/t)
N \Ml. ni-
! AllllCR
fUkTIIPi.ACK
'»• I AlIIKk
"^tatt or Coiiiiti V
ma!i>i:n; nami.-
<>i- Morin-.K
»nk rirPLAi-K
"I MnTll|.;R'
'Mat.- or i'outiti\
L >\ ^
H
r ^
Dik A ri< >N
c(t.\ iRiinTokV
/>r/M
//,'
%
IJIR ATION
(SIGNED )
ll'ct It
Mrnths
UO LI. Jxl
n
M.D.
I()n
\(i(l i< -.- 1
iMiVXt ,.
SPECIAL Information •">'* •"'^ HiKpiyK. insiitufions, TNnsifnh,
or Rftenf Residents, dnd persons dvini) hhhv Irorn home.
) Vi7 ;
M.uitlt-
former or
llsudi Residenre
When was dKea'se ronfrafted,
II not at plaf e ol death ?
How lonq at
Plat e ol Of Jth ?
OdV'
I'm; AHuvK sTATi; I) fKRsuN \i i-\kiii I I \Ks AH i: TKi i: r<> iii»-.
'shsr oi- Mv KN<>ui,|.;iK.j., AND HI i,n;t-
I
''"•"'-nnaut CTYULu KJUY^XATV^OJj A\-tH
1
i I
I'l.AiK <>
I lit K I \!, ok kKM«»\AI. I l>V*U:"' HiKiu of KKMnVAl
f \<Mr.ss
^11
t NIiKKTAKKk W. U , U
(A.j.li. ss I I 6 I '
V^..
IQO
)A,\_
S.^*i,\-<J 'ik
1. I %rF should be «m»eJ »-^^^TLY. PHYSICIANS should
f Informntlon .houlcl H. cret'uily supplied. '^ '*':";""'. ^,,^j. The "Hp^.W IntormMiion- »'or pT-
OF DEATH In pliiln tefm., that It miiy he properly Uassmeu.
^' B.— Every Item of
•tate CAUSE or- ur,A in in p
«Ofi« dying away from home «hmild be ftlven In every Inntance.
'I
¥.
' N1
« 11
s
II. .Mtl! 1- X<
•.-- -S- ^; i;Sc\' C
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/hffr Iu/ef/,Vxtc{>-<^ 11 lf)0\ Jn'^jis/rrr,/ ^^n, 22Q4:
dvtrvcv^ 6<Xa/^ Deputy HeaJth Officer
DEPARTflENT # PUBLIC HEALTH-City and County of San Francisco
Certificate of Scatb
PLACE OF DEATH: — County of Oa^^, j\
■^
City of CV^Vi \0.
r%
No.
wCicLu St.; Dist.: bet. J a u and )
(ir ecATM OCCURS away from USUAL RESIDENCE give facts called fob u|Ioe« special iNFORMATiit
IF DC«|TM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEmI) OF STREET AND N U V B E l|
f >
" )
FULL NAME Vtldc'r
c
I \
'-KX
i»A ri; I u luRTii
xi -i:
PERSONAL AND STATISTICAL PARTICULARS
I
i
■^
MEDICAL CERTIFICATE OF DEATH
I) \
n
M'.!!th
>v,.
M.'Ulhs I dl
wu
' X\ I itc in ^-icia! <It--ivniit'.)ii)
■^tati or < .nlIltl^•
^ \ M 1 1 1 1
I VI Hi; K
li'I'THI'l.ArF
'" ! \riii.:k
>t.iii ,1 C.nintiv
^' \nn.;N' N \\\Y
<»i ^f<»TIl^;K
"iRrmM, \( |-
<>> Mt)rii,..u
' "-triti or L'liiinti v»
K.y\.
; iii'R I i;\ v'i;r rii'W Tii
tlia; [ i,
an<l tli:i1 .U If h . , . - I. on tin- ■:
M. IIk- CAI SI-; c »i hi A
r I, ,,. I
t I ( ,1NI',| f I I 1|I|
I..',
y^
Dl RATHiX )
L < >NTkimT<>kV
/',/!
n,'h
U
0 OXAXX/^^nJL''^'\Xo
1 1 r R A r I < ) N
I SIGNED )
.l^'vM
Pax
%
KjO
1 ,^
- I O 1 u
M.D.
A.lili
Special INTORMATION onl^ tor Hiispitdls, Intfitutions, ffdnsienls,
or Rcffnt Resident, and prrsons dMni J^'i^ 'f'" ^'™'"'
),,//
/),n
in; Auov!.: ST All- D I'KKsoNAi, I'XK riici \Ks AK1-: rKii* Ti> riii-;
lU'.srui' Mv KN<)\vi.i;i)(; H ANj) ini.n.t'
fliifoiniMut
iD.%
Jt/C>t<r\)
Former or
Isual Residence
When v*js disease rontrarfed.
If not i\ plare of death '
HoH lonq at
Plrire of Dfdfh ?
Da\s
f N'Micss
X\\ t
cL/cLu Q
^t,
PI \(.'F or HI KIAI, iiH KKMttVXI. I i)\T
1 M(»\ \l,
roo t
N M c . ^ .. . 4rp -hr>,il.l he stated RXACTLY. PHYSICIANS iihould
N. H._hvepy Item of Informntlon .hould be cerafully supplied. ^^^^ •;"! 'j'^.^^^s";?*^,,.. "Specl.l Inform.., i.n" ,or pT-
■tBte CAUSE OF DliATH In pinin terms, thnt It mi.> He pi-opeHy vlaiisitieu. k*
won* dying away from home nhould he given In «v«p> Instance.
« ♦
♦ «
,«
H»
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD
.rii.i'ih I- No. I', ■?*5:SK'3feH^i' c
Ih
(/(' F/7('ff,\J /zt<Aj^Jihj 11
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
—————— —^ — —
lOOH,
Bc^i.stcrrfl JVo,
h^^^
VXA^
\>U
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
XX. S. StanOarD )
N
^
PLACE OF DEATH; — County of
Op ;i
■^
A %
oav v'A a
City of ^ J CL
ft
St.; S Dist.;bet. IH th
and
l:i U'l:
(IF OCATH OCCURS AWAY rHOM USUAL RESIDENCE give facts CAUUCD roR UNDER SPECIAL INFORMATION \
IF DCATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVt ITS NAME INSTtAO CF STREfT AND NUMBER. /
FULL NAME
.tfVj
JL- )
xy\.Q.)\
PERSONAL AND STATISTICAL PARTICULARS
-IS
^
i»\ 1 1: I II- lUkTii
A'.l-
ciii.i Ik
llJrvct..
MEDICAL CERTIFICATE OF DEATH
Ii.\'l'K Ml- UK ATI!
■ +
^INi'.I.l-: MARUIKU
\V!i!,. ;,, ^,„ ,,,] ,1, >,ij.r.)ati<(n)
Iiav
^/.,ll'/,
ISIRTHPI.ACK
N\Mi-; «)i.
I'lH IHI'I.ACK
'•I I- A II IKK
'^tal. or l*.)Ulitiy
M\ll»i;\ VAMF
<M' Ml III UK
iHKrHi'r.ACH
' '^tnti 1,1 Cnunti \ !
•'*''>I'ATI()N-
I
'^'YV^
y
i
that
I II I* k Hl;\ ilk 111 \\ rii
II
'V. :lf 1
^1 ll I [I ifll
IijT) H
a^i ^:i\V ii ^
1 \ I- I III
ailil that ihatli < icciirri-il, "ii tlii
V) M. Tllr C>^ SI- <M IM \ III u
I.,.
X
O %VU
Os^i)
Wy\j
I 'i \ I
Di i< \ri'>N
tow J^ ^
.JA
/hi
l!nu,s
Ci
'oN'l'Kliii !( iKS
L
■^f^^
^ 1 V ^
;>.^ .*w
(!ijL>..k
?
"... ll^ )n
(SIGNED)
IhjV
I on
M.D.
SPECIAL Information o"'* •••'^ Hospitals, institutions, TransifBfs,
or Recent Residents, and persons dving a^»dy trom home.
Hfsiilf,f i„ Sitn /'itiHiisfn \^ )'iin <
.V.
!h.
rin-; aijovk stai'iu) phrsovai. rxK'ncr!. \rs ak j: pki i: t«> thh
Hl-.ST OI- Mv KNOWIJIDC.K AND HKi.Ii;!-
Former or
Usual Residence
When ms disease contracted.
If not at place of death ?
HoM lonq at
n«re if Jeath ?
Oav^
nnfoituant
on^ d
o-^-oi-i
£.->
A-i.ln-ss
I'^^S. Ic^l^.^^^v'^t
I-, ACK OF in KIAI. ViK KKMiiVAI. 1 Ii\TH.»f B- nial ,.i KhMnVM,
NDHKTAKKR UW- ' --^^ '
TOO I
(All.
ii 0 ^
A.A.,<iA^<i^ »u jt;
^ « ^ ,. J ArF -hnuld he -tated EXACTLY. PHY8ICIAINS •hould
N. B. Every Item of Information .hould be carefully .upplied. AUD mn i ^ ••8o«cl«l lnfopm»tlan'' for p«p-
•tate CAUSE OF DEATH In plain term., that It may be properly .laM.fled. i»e pe
•on« dying away from home should be ftlven In every Instance.
i I
.ij
I
I '
I
II
It
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IfJO'i
Ki'ois/cf'cd J\*i),
206
2"^-
DEPARTItlENT ^ PUBLIC HEALTH-City and County of San Francisco
-\^^kJs
V\yM
Certificate of Bcatb
PLACE OF DEATH: — County oi\J<X^\j -1 ^ux >vcuiX^o City of ' JOu^v J
1 ^
uCh<i4X^
•La A.
(ir DEATH OCCubtS
IP DEATH OCCU
St.; -^
Dist.; bet.
and
S AWAy FROM USUAL RESIDENCE GIVE pacts called for under special INrnRM« .
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N'IMm(u
)
FULL NAME
0
KOAXlM ul u
PERSONAL AND STATISTICAL PARTICULARS
Aft roi.ok ^
^\
MEDICAL CERTIFICATE OF DEATH
I)\
i 1 i ol lilK IH
Moiith I
I> .'
.11
I in-.Rf-;iJ\'
^•t
M
^ ( r,„,
T ,
^!"^<^I,K. MAKKIKIJ
u iDoWKij OR nrv(»Kri-.i)
Writ
t ■ 1 !
1 »;'M-i:«l >It "•ik'natiDu)
lURTHPI.ACH
State or Coinitrv
f'lKTtll'I.ArK
'•' ''ATHKR
MAIDllN NAM}
<>I- Mf)TnKR
U^>xmjL;
I'/
that I
iW II
li (
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M.D.
SPECIAL INTORMATION »"'> for Hnspitdls, InstityliMs.
or Recent ReMdenfs. and person^ d)inq dv»dv froii home.
Ho* lonq at
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Former or
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' • ^' Rvery item of information should be ciirefully supplied. ^^'f' ^ '-^ ' " ^^ •'.SjK-.ial InionnHl. .n ' i«.r p«r-
state CAUSE OF DEATH in plfiin term., that it may be properly dasume .
«on» dyinft away from home should be ^iven In «*er> Instance.
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THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS
Ifnj'i
Jf('oi.sff'f'pf7 ^\v>.
-32G7
Cruc^^i Jo^v^^i Deputy f iealth QfTicer
DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco
Gcitificate of Scatb
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PLACE OF DEATH: — County oi'-'CL'W- ' VCo vcucCity of 'a \\ J\a i
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No. Sj cLcckXo
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- Dist.; bet.
and
(ir DEATH OCCURS *WAV TROM USUAL RESIDENCE GIVF FACTS CAi i R UNDER SPECIAL INFORMATION \
IF DCATM OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STRCTT AND NUMBER. /
FULL NAME
.,., -w\
PERSONAL AND STATISTICAL PARTICULARS
l\ C<>I,i>K ^
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MEDICAL CERTIFICATE OF DEATH
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SPECIAL INFORMATION
or Recent Residents, dnd persons d)ing dHdv from fiome.
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Former or
Usual Residence
Oivs
When H3S disease contracted,
If not at place of deatti ?
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N. B.— Every Item o?
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Information should bo carclfuily Rupplieil. ^«"' ,„..u'|-d The "Spcwiiil Inl'ormatim »or p.
OF DEATH in plain term., that It m.-y He properly .l—.Hcd.
ay ?rom home should he ftlven In es^ry instance.
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THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
hj la
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Begistf/f'r/ Xn,
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08
'^^US
. Deputy He
DEPARTMENT OF PUBLIC HEALTtKitj and County of San Francisco
Certificate of Scatb
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PLACE OF DEATH: — County oiOcLrv
No. T QlH Uxxc-^^CX. , .
City of -'XX>v Ac
(
Dist.j bet.
ir DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V C FACTS CALLED TOR UnJeB "SPECIAL INFORMAT
ir OC*TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE
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MEDICAL CERTIFICATE OF DEATH
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Special information ""I) '"f Hospitals. Institufions, TrdflslfBh.
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•tate CAUSE OF DEATH in p
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Btlon should He cnrefully supplie*!- ^ ' ' i„«.ifud The "Si»tfcl«l Informal im" I'ur p»r-
4TH In plain term., that it may he properly cl»«..».cU.
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Registered JS^),
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DEPARTMENT OF PUBLIC HEALTH=Citj and County of San Francisco
Certificate of H)eatb
( tl. S. Standard
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PLACE OF DEATH: — County of C a
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"No,
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^ City of 0 Ct IV J \ o
and
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\ IF DEATH OCCUI^RCD IN ^ HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 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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Special information mI^ for HftspitdK, Instiluflinh, Frjnslfnh,
or Recent Residents, and wrsons dvinq mAs fro-n home.
former or ^ ^ r ♦ **"** '""'' *'
Isual Resldenre I UW g 5 , - PLne of Dedth? Din
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«on« dying away from home nhoutd he given In %\^ry Instance.
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DEPARTMENT OF PUBLIC HEALTH-City and Connfy of San Francisco
Certificate of H)catb
^
T'
PLACE OF DEATH: — County of
City of
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j^iXx^r St.; Dist.;bct.
r F DEATH OCCUBS AWAV FROM USUAL R E S I D E N C E G i V r FACTS CALLFD
\ ir DEATH OCCURRED IN A HOSPITAL OP INSTITUTION CltfC ITS NAME
ro A
and
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FULL NAME
,d.
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PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
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Special information only ''•■ Hospitals, ln<>tftutions Irdnsifnfs,
or Recent Residents jnd persons dyinq away from home.
na\.
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Former or
Usual Residence
When wisdisfasp contrarfed,
If not at ^are of death ?
Now lonq at
Wife of Oralh ?
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N. II. Rvepy Item of In »,,,.„,
■tate CAU8R OF Dl:
"'»n« dying away fi-om homu Hhould be ftlven In •vary Instance
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REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS
l>,,.,,,i ' II, lit h I No I" *'^.'^\;''*^ n^i i
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K.'
Deputy Health Officer
Registei rd JVo,
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
Certificate of Beatb
I XX. S. StanDar^
r^
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PLACE OF DEATH: — County of a >\ \a^^
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City ofU/tX'>v J ^ A '>vc^.c ^i
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A' 1
N«. V^Clu '^ LtrVC^^vtu ^L . St.; Dist.:bet. 'and
( / ir DEATH OCCUR^»VW*¥ FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER SPECIAL INFORMATION '\
J \ ir DEATH OCCU|<RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
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FULL NAME
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that I ia>,l saw ll ■ ' ntivi- on
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M.D.
Special —
or Rctfnt Residents, and persons d)inq dHa> from home.
Insfitutlons, Transienls.
\f,,i,tii'
Former or u a Q { f
Usual Residence ^^ ^ ^
When Has disease rontrarted.
If not at plare of deatfi ?
HoH loBfl at —
Plare of Deafli? I Days
'"I; M'.OVl-; srxii.i, I'KKSONAI, I'\KTI(t I.AKS AKI-; IRI K T< ) Till-:
i.l-.sl ul Mv KNuWil-DC K AM) III;M);i*
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• **• Rvery Item of information should be
state CAUSE OF DEATH in plain terms, that it may be properly
«on« dying away from home should be given in every Instance.
" ^ a7f should be stated EXACTLY. PHYSICIANS should
carefully supplied. Adb '*"'*,'" ,„^. ^he "Special Int'ormHli .n" tor p«r-
.. , .^ .. K- ncnnerly classitieu. ■ "^ »
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THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
la
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BPois/ci'pfl J\"r,,
2272
,<r^u<A
Deputy Health
DEPARTMENT OF PUBLIC HEALTH-City and Connty of San Francisco
Ccitificatc of Scatb
PLACE OF DEATH: — County of JOurv JAyCuwc^^ec City of Oorr^ J A^ ,
Wo. lIu "^ ^v
St.:
Dist.j bet.
/ ir DCATM OCCURS AWftV FR<>M USUAL R E S I D E N C E G I VE FACTS c,
\ ir DtATH OCCURHCD IN A HOSPITAL OR INSTITUTION GIVE ITS N
I
and
ALLFO FOR UNDER _ , . JRMATICN \
AME rNSTEAO OF STREET AND NUMBCB /
FULL NAME
I!.
PERSONAL AND STATISTICAL PARTICULARS
rni I »k
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MEDICAL CERTIFICATE OF DEATH
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M.D.
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SPECIAL INFORMATI
or Recent Residenls, nnd persons dvini) a^a) Urn nome
ON fl"!'^ 'or iospifdis, Ifistifuflons, FrinsifBh,
former or
lisual Residence
I
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NoM \m% at
PIdff of Death .'
Oavs
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M.uiili
I H'fien was disfasp ronf rafted,
If not at place of deatfi ?
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N. B
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„ A.;r. «h..uld be Mi.te.1 lAACTI.Y. PHYSICIANS .ho„ld
•t.te CAUSE OF DEATH l„ pl„i„ ,er,„.; »h«^ I. m„^ H; pr.pcH. c.«.iflccl. Th. 'S.^.i... .n^or.„...i..n" .or p..-
very Item olf informntlon should be cnrefully mippMed
"""• **>ln4 away from home Hhould be ftiven in every instance.
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.<.KJS
Deo
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Registeipd Xo,
DEPARTMENT Ot PUBLIC HEALTH-Cily and County of San Francisco
Certificate of 3catb
PL^CE OF DEATH:-County ofCc^ >x. u v , . ^ of CJct>v ^ '■ - ^. .
..II ^^ k *
XUvc^^i; (k)5-^^d
a J. St.:-
Dist.; bet
/ ir DC*TM OCCURS .WAV rRo* USUAL RESIDENCE GIVE facts'^/
\ ir DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS N
AILED f ^
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^ and
'ECIAL INFORMATION" N
lEET AND NUMBER. /
U
FULL NAME ^V^K U
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PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
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(Signed^ IX
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M.D.
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' t'oiiiitiyl
Special information ""'^ '"'' HospUdls, InsHfufions, rrdn>ienfs,
or Recent Residents, and persons dving andv from home.
/I,
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death .'
Dav*
}'■ To Till'
I-I.ACK OF m-KIAI, UK K1:M.iVAI, I I»ATl^,.f JS.Ki.Ar -r ki:M<
>\ M,
(Ad.h,.ss ^oavtcrw^AA. A
IQO
»"• dyinft away from home should be 4lven In every iiiHtance.
r
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WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
/y.//r /•:
/A-/. O^t^W,,
la
/^^>H
REFER TO BACK OF CERTinCATC rOR (NSTPUCTI0N3
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
tl. 5. Stan^ar^ ;
•<^
>"
City oi
PLACE OF DEATH: — County of "^^ a
U ^\lv<xl L V>vc^m >vCM : / ^ ^ . ,st' Dist.; bet. ~
f >f DE^TH OCCURS A%AV rROwlUSUAL R t S I D E N C E G i V r FACTS CALLro rnp UN r
\ IF DtATM OCCURfUo IN • HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAO O
J
a
and
I N FORMATIO N
N D NUMBER.
)
FULL NAME
■ I
PERSONAL AND STATISTICAL PARTICULAR!
MM
)
i< I I.I Ik'
WV- W<w
MEDICAL CERTIFICATE OF DEATH
M.iiitli
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Mmth
MIR
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(Signed ) Lc\^>^^'v ^ •
M.D.
^viX4 "^ks
''^ \'\'K'M^
OP D
'■'11, \MuvK ST\
Special Information "niv inr HospitdK. instiiufidn^, fransifnts,
or Recent Residents, and persons dvinq A't^is from hnme.
1/.
(iiif,
'nnruit
<'l MS K.\.)\vi,l.:i„-.H AND Mi;j.n;f.
N. B — r ^
Former or ^ , , \ ,
Usual ResidfRip
When Has disease contrafted.
If no( at plat e of death .'
HoH lonti at
Plate of Death ?
Oavs
I'l.ACK "1 lU KIAI. <»K RKMOVAI.
t'et
hi:mi»\' \i.
IQO
rNl>ia<TAKKKLCLLi^>V^% Ll^^aX^^k^.^ \
Ad.h..^ H 0 € V* ^vv^
;ery iten, o? I„fon.„„tlo„ should be ca.afuM. supplied. AGB «H.u.d '^^'^V'^^.f'^^^'^; .rT^iJ^ul^-lc^p;!^
•tate CAUSE OF DEATH In plain ter.ns. that it ma, be properly .lo.«itled. The Spc.al Intor.„Hlu,n p.r
sons dyinft away from home Hhould he 6i%en in every Instance.
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^'''^''' ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
U(' ill sh' I fil .S^o.
r\
\^^Aj^ IjL^Ki Deputy Health Officer
)F
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of E)catb
1:1. tT'. '?tnllDar^
X
K1
PLACE OF DEATH: — County of
City of
W .,-v. \
St.; 3 Dist; bet.
(ir otATM occuns *.v*f FPOM USUAL RESIDENCE Givr rscT«i r%
IF DC*TM OCCUBPtD IN • HOSPITAL Ol
R INSTITUTION GIVE 1 T a NAV
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
">-%
MEDICAL CERTIFICATt '^ lA , h
tijo
v^'j r
^ rs
-\
•^<.
%-,
^
- ^^^-
Signed
M.D.
SPECIAL INFORMATION
»*>
sJJ^n^jj X
J I
8.
-E*epy Item of Infopmation should He .a-sfuU* «jof>fUd. '
•l«t€ C^tSE OF DEATH \n plain term*, that M ma> ^^
•-«» d>iiig away from heme should be gl^en m e^ci-> listen. ^
* •tafe' fA%*TLV
J8«»
ifjf -/•
li
a .
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I
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I
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H..:n.1.,f H. .'rh r V - 'r^_^;^i.i)f^v r. , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
(l1
Deputy Health Offi
cL^rUA^
Ihiil si i'i ril X').
ja276
/^ Ck ••
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticntc of IDcatb
n
T^
H.ACE OF DEATH: — County of
^^C ! 'w'w\,S
City ot
NcVLlu. <\^^:XXj^\Xx\ .'v, St.; Dist.;bet. and
I f \f DEATH OCCUHfe AWAV r R 0 M USUAL RESIDENCE GIVE facts CALUtO FOR UNDER SPECIAL INFOqMAT;ON \
% V ir DEATH OCCyRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET asp ^. m m r, r a ^ /
FULL NAME
vlLCitt
y\j
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Vix
cxvd.
PERSONAL AND STATISTICAL PARTICULARS
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MEDICAL CERTIFICATE OF DEATH
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SIGNED) J-^n^ dbaXl-
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Oct
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Hi'HI s
M.D.
1
\£U>VCX
SPECIAL INFORMATION onU for H«kpitdls. Insmutions, TNnsienls.
or Recent Residents, M persons dying dwdv from liome.
' "p,!^'!!.*^''- ^^ixri' I) I'KKsoNAi, I'XKTuri \Ks AKi', rKiJ* ii • ini;
'■'■^I «»1 MS,^KNn\vl,l^M-,H AM) i;i:iji:i
\iMrcHH Lclu xUo Ad d-^i|vaA,ccI
When was disease contrarfed,
If not at plare of deatfi ?
HoH lonq at
Plare ol DfHlli 7
Da^s
IM.ACH nl lU RIAL «iK KHMoVAI.
10
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N. B. Bv
^^'^^'^"■^^^■^^^■^■■■^^^^^^^■^^^'^'■^"^^■^"^"'^"'^^*^"^^^ 1 rv*r"ri V PHYSICIAN!^ should
ery Item o¥ Information should hi cfirefully supplied. Aun sn . ^,^,. ..Spe»;lai Int'ormntion" foi* pol-
ite CAUSE OF DEATH In plain terms, that It m»y he properly wla«»me .
*y1ng away from home should be given In «vory Instance.
[ ll
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II
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tUmrt] Mil,
V„ I ; t"V-Br;-.Ti-, H5;; I' Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
100 \
Meiistercd JS^o,
2^7
Cr^AA^ dsA.\}\
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
. "U. 5. Stan^ar^ j
PLACE OF DEATH: — County of
^
(1^
,n
City of Ct^-x; ^i\XX. > v.Cv^.
No. 11 H L » ^oClL > vcv. I St.; 1 Dist.: bet. cLu n Vl; and o UX\
/ ir Ot.TH OCCURS *W«y from USUAL RESIDENCE GlWt facts CALLtD roB UI^OER • SPtCIAL INFORMATION' \
\ IF DtATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME .NSTEAD OF STREET AND NUWBER. J
FULL NAME ^
Y>V
^TAVet
PERSONAL AND STATISTICAL PARTICULARS
^
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MEDICAL CERTIFICATE OF DEATH
1) A'li-; 1(1 i)j-,.\ rn
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(SIGNED)
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in rA.l.ln-)t05^XLo
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M„„Hn A. i />'?!
HK A»(»VK STA Tl'I) I'KKSONAI, I' \ K I* ir I' I. \ KS AKI! TKrK If » I'HH
in,M- (,|. \ix KNuwi.i.ix.H AM> iu;>ji:i'
'I II I'm;
maiit
N. B.
fA'l.lr.ss 'DsTi LAIaiIaXaU! UA ^^^^__
i— — -^— --■^^«-i^--^-— -— — •— ■"'■■'■'■'■^— "'""""'^ EXACTLY PHYSICIANS iihould
o.- Information .hould b. c-refull^. supplied. ^^^^^^l^.'jU^fi.'i^'^h: -Spccla; Information" fo. pr-
E OF DEATH In plain term., that It mny he properiy
CIPECIAL INFORMATION o"!^ tf Mo'>P»«"^ "'^""••'»"^' '""^•'"'^'
or Refent R esiJenls, and persons dying hhhv froni home.
HoH lonq at
formfror pi^^^ ^f pfath? Da^s
Usual Residence
When was disease fonfrarled,
' not at place of death '
|»\ TU '■' !•' Hi\i
n.ACH <»r HIKIAI. (iH HKM'»V\
1 90
■Rvery item
•tate CAUSE _. _„ ^
•on. dying away from home should be t'^^cn in -very Inatance.
w r
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
R..:i-
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I i
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I
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Ihilc Fili'(l . \j(^XjAj^O\j IX
U)OH.
]}i'l>isfci-t'(l ^n.
278
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
A
-iTN
(^
^u^
City of O^cm; o,\.a^ , '^^4
--— and ^
PLACE OF DEATH: — County ofCJ<X>v : \<X .
CrVv\jl ItfV X.lxi. L^Q ' V St.; ^ Dist.;b€t.
X K i. iic.iAi DTQinrNCF r iwc tact^ cALteo for under special information- \
( ir DtUkTM OCCURS »W*V rRO« USUAL R E S I D E N C fe. give facts. ^'^^^ .„=Tr»n ^r crTRrrT AND NUMBER. J
\ IF BeATH occurred in AiMoSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET
r^ I
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
COl.nK \
<•!■ I.IRIH
I Month n
II
^0
J
1/.
WllH 'xV HP UK ni\t (KTl'l)
Wnt' ill >,-Ki;il lU -.is.'n;iti<iii)
nil; ■ i!l'! \,-|-
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'• I K I I M • 1 , \ r F
ot I \i*in-:K
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M Mlil'N XAMl-
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nscri'A'iioK
KX.'
Xka,^ L^'
MEDICAL CERTIFICATE OF DEATH
I 1 ■!
11!
^1
If
/o
CJX'v'
I 111 |^M;V i 1 l< ■ ir\. That Iatlc.l.k.i.kHvaM-,1 Ipuii
that I la*^! ^aw h -S-^ alive oti
a'ld that .li-ath ..rnirtvd,
(111 Uu- <l;it.
,1 ^1)0
y M The CATSI-; OF Dl- ATI! ua^ a- folL-u^:
I
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1
niKA rioN i '
CONTklHt'ToKN
; . ,/;■
1/
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1 ^
Ilniit s
jlin^JL
DTRATloN
(Signed)
jrs
Months
/Itr^
Hours
M.D.
IqO
(A(hlrts.)
Uct. u ^
"c^PECIAL INFORMATION onlv tor Hospitals. Institutions, Transients.
„r1eren^1esidrnts! dnd persons d)ing a.a. Iron, home.
/Oc^vd^
oo
f\i''i,f/-,> III Sitfi /'i iiiii iWit ^,' • ' )»i//
M.oitli
Ihn
'HI.; AHOVHSTATl-I) I'HKSONAI, PA KT UT l.A RS A K l'. TKri-. Tt » TIIK
HHST OF MY K N( )\vi,f;i)(; f; AM) in:i,n;i'
XoJkc
XjoJm-
Former or
L'sual Residence
When was disease contracted,
If not at place of death ?
n.ACKOI^ HriUAI, OK RHMi'VAl,
Death ?
Oavs
I'ct
VI or Ri;Mn\- \l,
a TooH
rNI)UKTAKHKH..U, W V^,
(A.V.ln- 111 ^
'^^ B.— Kvepy item of in?ormnt!on iihoulil
mote CAUSE OF DEATH in plnin terms, that it m»>
I I nr PHYSICIANS should
"on. dying away from home should be given In every msi
I
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II, -M 1 V<
lUS:!' Ci,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/h,fr /•V/r//,lL/c:tcrLilhj 11
liHf'i
UcLii^lci-i'il -jVfK
.^r\AJ<A
X>\A
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=C{ty and County of San Francisco
Certificate of "Dcatb
A
HTs
PLACE OF DEATH: — County of
City of ~ ^" ^^^ ^ ^^ ^
^
A
No H'it^ LU-<X,l-^.Liv St.; K Dist,;bctXlaAXC/Uc.i. and ^H^
.Xh occu.S .w.v ..OM USUAL RESIDENCE o.v^,,^CXS C^^o _^^.« ,^;S^i^?'^;-- ^^ )
/ IF DtXn occurs *W«y TROM USUAL RESIDENCE G.Vt FACTS CftLLEO
\ IF ^CATH OCCURRED IN • HOSPITAL OR INSTITUTION GIVE (TS NAME
FULL NAME
\A
Kj
( s ' >
PERSONAL AND STATISTICAL PARTICULARS
C •! .1 iR
\
II
I ♦
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M.iiUhi
\(
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U ilH »\\ I |i OR I»IV«»Kr KD
>'' 1 lal (1( >-ii'natiiin)
• < . illllt I \ !
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MXlIiKN NAMK
<" mothi-:r
''•Iin'IflM.Ai'H
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C^^nu J ."vet vx^cv,^
:tnf\'V^ 0
V
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that I
MEDICAL CERTIFICATE OF DEATH
111 |.;i i;V ( lJ<'rirN'. That ! nt!eil.U-.l .U- :i-^<l li""'
, ,, lirf) ~
,■ . - ;lu' il ill- '-ta!(<l aliovi-, at
,1 that (Kath
M. The CArsl{ or 1M.\ ni u
\\ >^
1)1 R ATK^N ^"''
CoNTRIi^rToKV
Mouths
Par
//
DlRATIoN ^ J'''^'^
/hiv
IN ED ) Ur'
-"1
'""■t It' or I'uuiUiy
nitil'ATlON
THI- AMOVF. STATl-l) PKR^ONAl, 1' \ R I' HT I, \ K^ A R I', IRlK T< » 1 " » •
HhM' oi- MY KN()\vl.i;i)C.H AND in-.I.Ii;!'
M.D.
(SIGNED ) UrV<r>-aA^
""special information »..lv f«' Hospitals. Insti.utfons. Irans.en.s
orlefen^ Ments! and persons dying away Iron, home.
NoH lonq at
plaf e ol Death ?
former or
Usual Residence
When v»as disease contracted,
If not at place of death ?
Oavs
lATi^'.f H' KiAi '•' ki:M'»vai,
i( ... ILL. PHYSICIANS Hhould
TH In plain terms, that it ma> ."« f J
'^^ ^- Every item of Informa
state CAUSE OF DEATH In p.«... - Instance.
•ons dying away from home should be given In ever*
PI
n
N ^
■i I ^
i!
H
t ir j.i- F V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD,
'"^''^ ' ' REFER TO BACK OF CERTIFtCATE FOR INSTRUCTIONS
oK^ Deputy Health Officer
lle^is/ i'i-('f/ ^\V>.
oo
Dnlr Filed, liiclMM^. \X
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
80
Certificate of Beatb
PLACE OF DEATH: — County of
City of^'a>
t. Li
St.: Dist.;bet. JtAH, -.,.- ^nd ^^-
(\f DtATH OCCURS AWAY FROM USUAL R E S I D E N C E C I V t FACTS CALLED FOR UNDtJR SPECIAL INFORWATION \
\r DtATH OCCURRED IN A HOSPITAI. OH INSTITUTION GIVE ITS NAME INSTEAD ^V S7RECT AND NUMBER )
FULL NAME
\ ii
Lk.
PERSONAL AND STATISTICAL PARTICULARS
ft <.'<>I.«iK
clU
L
MEDICAL CERTIFICATE OF DEATH
WCAj
I I
I)
iUH 111
V,
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X?s
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'•"': I lIl'i.NCF
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'♦^'■'I'A'riON'
V
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tlnit I In^f '^iw li , :;.
,111(1 tha! (Ualh iH-riurt'd, dii tin- ' '*.
M. Thr CAISH OF |)|;A 1 il u,
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JUL<1
1
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(SIG
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NED) Jfth/ysj w'
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M.D.
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ff^siiifif III Sun f'laiuif^ro
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iu.sroi. Mv K\()\vi,i;i)(,H and in-i.n-K
n-; Ti »
r 1 1 J-:
SPECIAL Information ""ly J»r Hospltdls, institutions, Transients,
or Recent Residents, and persons dying anav from home.
HoH lonq at
Place of Death? ■ Diys
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
\'l<lrc!
kix
^ u crvcLt^i^ U/cxti '' '
UATI' "' H' 1 lA'. <if KKMnV\l,
1 - t
PI \CK <)1- JU-RIAI. «>K KI:M<>\\I
ion
N. B
""^""^^"™"^'^"'^""'^"'^^^^^^^^"''"^^""*^^"""~"""'*"''"'"™"" ^ lu. f t I F.XACTLY. PHYSICIANS nhould
•Kvery Item o? Informntlon •hould be carefully supplied. AGB should • • %he 'Special liUformation" lor p«r-
•tate CAUSE OF DEATH in pl»ln terms, that it may be properly classmea.
« dying away from home should be given in every Instance.
I
I
I
i\ I
'M
H
m
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
[I. i'-li r N.) I ; 'S-F'iacvJl^ HM' Co
\. 1:1
lf)()^
]ii'oish>r> <i X(h
00 Q
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of .a
Certificate of Bcatb
I XX. S. Stan^arO 1
City of O
i
V
Nc).
f\
s.. ^
U^^ ' St.;
(tr DEATH OCCUf^S »WAY FROM USUAL RESIDENCE Gl
ir DEATH OCCiURRCO IN A HOSPITAL OR INSTITUTION
FULL NAME
A ) 1 '
DisUbct. U<X^v':. . and
IWE FACTS CALLED FOB UNDER SPECIAL INFORMATION
GIVE ITS NAME INSTEAD OF STREET AND NUMBER,
)
■i
PERSONAL AND STATISTICAL PARTICULARS
^^
i< >!.< >R
-<XU
'! I.IK in
MEDICAL CERTIFICATE OF DEATH
H IHN
I Idlll
Month
a
I
^ lit I tR iMViiK <■»•;?>
' ' I'liiti \
^'1 1. 1
''IK iiiri.srH
•" I XIIIKU
i
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that I 1h
aild thai 'Ii I!
'Ml
' vn aliii\i\ a1
M. rhv CM ^1' <'!■ 1)1 ATI! u
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nit T \'
M\Ilii:\ WMj.
01 Mmiiii-k
''nrririM.Ai'H
'•' "^'o'i'iihr'
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Sit ft I'l ti)u isro ."Su 5V(f/A
»'»,si or MY KNowijvix'.K AM) iu;i.na-
1)1 U A 1 i' 'N
DlRATtON
(Signed)
I' ^ .
( 1/
/yav
I lout s
)V/r
K.
Months
A
Ihn
M.D.
fA.Mri-^) l^u'A ' ' ^^ '- '
■ SPECIAL INFORMATION onlv for HospiWs Innfitulions. Iransienfs.
or Recent Residents, and persons dvinq dw^v fron home.
M.iiifin
I his
ARi; TKiH T<> rill-;
''"f'Mni.iiit
X
U^A
\<l<lrcsM
5Su^
Former or
Isual Residence
When was disease contracted,
If not at place of death ?
Ho>* lonq at
Place ol Death ?
Davs
PS \CF nV lUKJAI, OK KHMnVM.
1) \ rj
K i;Mti\ Al,
\C)0
m.,.:ktuL^^Ui^ \oXx iLvuUv-U^.
Ad.Ilrss OS ibo .1 ' - -^^
1 1 — — ' I fXACTLY PHYSICIAINS should
nfar,n«tlon .houlcl b. cnrefully supplied. A<;»^;;;-;;^^.^»;"%h: •Sp.cl-i InformHtion" for ^r-
►F DEATH In pl«in termR, that It m»> be properly .!»«»'»
^- **• — -Rvepy Item of I
•tate CAUSE OF ^^^ . .. ... m-"".
•on. dylnft away from home should be aivcn In every instance
,»
!
1
If
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n i!i I ^'^ •- tS-r:3^^^fi^i'C,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)u/r F/7('(/ , C
OwC^\.^«w^
hj 13
IfJ(J
Mesjisfc/cil A\).
OQQO
\.
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificatc of IDeatb
PLACE OF DEATH: — County of
i
XX, 5. StanDal•^
^
No.lH5lU..cA-v,
St.: % DhuhttSJ J/OAXXLi'
X
a
and
(ir ocATH occuns aw«v from USUAL
ir OCATH occunncD in a hospitai.
RESIDENCE give
OR INSTITUTION GIV
fACTs cailED FOB UNOtR "SPECIAL INFORMATION- \
'E ITS NAME iNSTCAD OF STHCtT AND NUMBfR /
FULL NAME
n
.L'^
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
\i \ ,
/ , /. )
1 Q
J'('.l» *
II):
l/..//'/-
MARK n; i>
i> < »K I » ^'i iRr i:i) n
- >i ;,i' ill »ii'iia(!'iii) -^
1 \
IMKTHI'I.Ai-H
"' 1 X fii i:r
MA
( )
'\lli|.\ NAMH
I II i;K i- I^V i I RTfi'V, Thai 1 attcibU-.! -1.
til at I I 1 alive !,n
aii.l thai .! '""■
M.- The CM ^K "r l)l':A'ri! u - ., ,
tillll
U)>l
R
t * i)UlltT\
'-IH |■HI'I,A(■F
1 I'niuitryi
iftLmJj UJcJLc I
DiRATinN )
C nNTRiniToRV
M.'uihs
/hn >
M'//;
DIKATKiN
)'tai
irs ~s
Mmiths
/hiVs
'^' ^'^vvvuiy,
f^'^^iti/->f in S,ni /f^,j,„ tjfo /, ) Vu i s M,.>iffi^ ^^'^' '
"",M^'!V^'*'^^'rATI.:i» I'KRSONAI, I'XRTriTI.XKN AKHTRIH T< » TIIK
'•J-.SI Ol- MY KN<J\VJ.!.:i)c-.H AND Hi:ijl,l
^Informant NlVvO t) UO \
(SIG
HZO'SjtK-^y^^ -
M.D.
iL'ct 11 TooH M.Mre^^O Ule-r.Cv^
V »
QprciAL INFORMATION ""b tor Hosp.tals, InUituffdns. Iransle.ts.
or Rerent RAfdents. dnd persons dving d.dv from home.
cua;
Ud.lr.ss iHC^Qv
l)0jU>4-t«A.'
former or
L'sual Residence
When was disease fonfrarte^,
If not at plare of death ?
HoM lonq at
plaf e of Death ?
Od*s
",.,.\,Knr m KIAI, MR KKMOVAI.
tNI)i:R'l'AKHR
I»A-ti;.>r HiHiAi, ..r KKMnVM,
'H
A,,h.s. (oiX* ^^ I U- 1
N. B
t.^^^lLL PHYSICIANS .hould
•Every ,te„, of l„for«,a,lo„ .hould be c«r«fuM. supplied. ^f^^-J^'^Umci! 'tM •Sp.cl-I Infor^-tlo"'; fo. P-r-
•tate CAUSE OF DEATH In plain term., that It may He pf-oP^
nnm Am.,\.^jL 0 — I _i I
•tate CAUSE OF DEATH In plain term., that It may be prop
«on« dying away from home should be fciven In every instan
I r
it
I
f
I,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
noardofiu.-nth FXo..,il^^H.^PCn ^^^^^ j^ ^^^^ ^p CERTIFICATE FOR INSTRUCTIONS
Dfffe Filed,
X^' \l
lOO'i
Begistei'cd J^'^o,
ja283
Deputy H
'^cr
rNo.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( tl. S. Stan^ar^ )
PLACE OF DEATH; — County ofOxX/^ru ^hJX\\.ZK.^. . City of Qxn/w JXcu\xc< ^ ^ <
St.; ^ Dist.;bet. VJ and \l<XA.k
- 5-[\
^> . w.
(IF DEATH OCCURS AWAY FROM USUAL R C S I D E NC E C I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION"
IF DEATH OCCURRED IN A HOSPITAL
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
FULL NAME
^
\.
fO
)
L(lAAeo.<lcL.,
PERSONAL AND STATISTICAL PARTICULARS
I c<)i,oR\ a
DATK <)l lUKTII
.1
kiX.
AX,'
(tvtonth) t
A(.K
) rtt I
U
\
iDav
Mnnlh.-^
MEDICAL CERTIFICATE OF DEATH
DA IK <)1- DKATH >
I' ' -^ I •;
TQO H
(Year)
( Vear)
Da 1 .
SIN«-,|,K. MAKKIi:n
WIDOWKI) OK DIVOKCKI)
iWrittin s<KMal ihsij.'ii:iti.in)
t
lUK I'm»I,AOK
(Statf «)r Coniitryl
. \ -,
XA>fK c»r(]a ft \ ly
iMoiitli) il):iv*
^I HICRHHV CI'RTIFV. That I Mttemled ilecvascd from
d.^cl U ic^'; to 0<tLt !X
that I last saw h a.. - aUvc on ^^ I \
an«l that death occurred, on the date stated above, at L 6
M. The CArSl-: Ol- DI-ATIf wa^ as follows:
190H
190 H
r^
BIRTHJM.Ai H
OF I'ATHHK
(State or Countrv
MAIDHN NAMi; ^
OF MOTllKR
0
U.t
UXavoucLd
1 %
DTK AT ION
CONTRim
a
K,
c
Yt'fi^-R Mouths /)ays //ours
TORN' ^J . ViL, -> ^ ^ a,'tc^-^wJl ^ sS J^hTt-K;
I ^
d
1)1 RATION
)
Its ^
Mont)is
/)avs
/lours
Ic!
HIKTHPI.ACK
OF MUTHKK
(Statf or Countrv)
OCCFFATION
wcLo
IVO^CVO
(Signed) vJ . U. \\\Vk m.d.
^'clj I's. rcpl (Address) blH- 1 >x,<i. Uv^s.
SPECIAL INFORMATION only for Hospitals. iBsllItttloiis, Transleiih,
or Recent Residents, and arsons dying dMd> from home.
Rfsidfii III SiiH /'null nr'ii
)'fUll .
,1/,*/////v
/i.n
run ABOVK STATi:i) PKKSOXAI, I'ARTfCfl.ARS AR1-: TRCK T< » T!I»;
HKST OF/ALV KNOWI.FDCK AND Ii!.I,N:i'
(Tiiformatit 0 , \JJ ■ V<XAy^^lXX..cLOwJL >x^
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
liys
(Afldrt'ss
IXS^x - 5tk
I'I.ACF: 01 IITRIAI, OR RF:Mm\ \r, I HATKof Hi hiai, or KKMOVAI.
AW
mJ]
v^x
r N I ) 1; K r A K t: K \| I L 0 .O-v^aj M^ ^^^
A.l.U... ^11 ^\^ (11L4'U\. Oil
190 1
N. B. Every Item o* Information ahouid be cnrefully suppHed. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly vlassifled. The "Special Initormatlon" for p«p-
sons dying away from home should be given in mvcry instance.
1
» I
. H
i
'* ^1
"f I
m
WRITE PLAfNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H..:,i-1 of H( altli — !■■ No. u "^^^^^ lUtP Co
re:fer to back of certificate for instructions
Dafe Filoil, L cl<rVvt\i i3
D
190\
.<riAA^
Rcgi,stered J\'*o,
DEPARTMENT OF PUBLIC tIEALTH-City and County of San Francisco
Certificate of ©catb
( "CI. S. Stan^arC> )
\ ^ J op
PLACE OF DEATH: — County of 0<X/ru OAxXn^c^^ci City ofO/(X>x- J;v(X^rcc<^xi.co
(No. bM i
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIV
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION <
St.; X Dist.;bet.M I UnX^at^^UYu. and JLI^Ulavm
"OR UNOERfT'SPECIAL IIM FOR M ATIO N '■ \
NSTEAD OF "STREET AN<) NUMBER. /
E FACTS CALLED FOI
GIVE ITS NAME II
FULL NAME
^UyyxL^
PERSONAL AND STATISTICAL PARTICULARS
si:x
DA ri: {)}•• luKTii
A<'. K
CDI.OR
^\\XX^K>
/Uo
Mniith)
HH
3 V,/
I)a\ )
A/.,tt//i^
\ ca r )
Pti rs
SINC.I.K. MAKKIHlJ
WIDOWKI) UK l)I\(»Ki!:i)
(Wiitfin sfK-ial <1< si^Miation)
HIRTIIl'I.ACK
(State <ir Cuiuitt \'
MEDICAL CERTIFICATE OF DEATH
DA IK ()!■ D};Arn ^
U 1 ^
(Day)
I HI'Rl-HV CI'RTff'V, That F attemk-.l ilen asi-.l from
— — — lip to
yet
(Month)
(V«-ar)
that I last saw h
alive on
I90
1 90
and that death occurred, 011 the datr stati-d above, at
w-o\/^x.cL
ft)
/Cto^<xd-0
NAMl'- oi
K ATI IKK
lUKTUFM.AOK
<)I- I'ATIIKK
(State or Country
MAIDKN NAMK
OI" MOTHKR
lUR THI'LACK
OK MoTMKK
(State or Country)
(?i
M. The CAI'SK ()!• Dl ATII wi- a^ follows
Dlk.XTloN )'t'ars
CONTRII'dTOkV
J /on //is
/hir
lion
/ s
I )r RAT I ON . }'iars ^. .l/,>n///s Days
NED) .Ur^XTYOAj J '£>. LL i.. ^
N>>^
(SIG
) I o
\xrY\XN ^ m. ^
X.ldre'^s) \w(r\,ftOViA4 W.4 ^
Hours
M.D.
iqo \ r
SPECIAL Information only for Hospitals, Instltutlo^rs; rMiislfiits.
or Recent Residents, and persons d)ing dwa> from home.
OCCt'TATION 5 A
Resided in Sati I'nnni,
■ yjn,,!),:^
fhn
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
liys
THK AROVK STATI:T) I'KKSONAI, I'A KTICr I.AKS A K K TK C K Tn THK
HEST <)1' MY KN(>\Vl,i;nc.K AND WVA.UW
(Diforniant V fl- LAj . V-<XAJk,VA A. ' ^ ' -
I'l.ACK OI" mKIAI. c»K Kl.MDVAl, I DAfK of Hi rial or RKMnVAI.
I'NDKKTAKKR U&'lxiXAXj J al ■ UAO/djAXoJvWk
(Ad.lr.Hs 3''^^ I \J rW^^t-O > t
190
N. B. Every Item of Information should be carefully supplied. AGE should He stated EXACTLY. PHYSICIANS sheulj
state CAUSE OF DEATH In plain terms, that It may he properly classified. The "Special Information" for
sons dying away from home should be given in 9\Ty instance.
■-n
P
iTKs
w
I
It I
I!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!*oM!(l of If.nlth I-
A-^ «•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!'^
XJo^^
K^ \Z
ino'i
Jfeg/sfc/'rd A'*o.
J^285
\J^\^^
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XI. S. 5tan^ar^ i
/T)
PLACE OF DEATH; — County of ^
>. V
uxa
^
I
City Or
tnv
m
No.
St.;-
Dist.; bet.
and
IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACT
OR INSTITUTION GIVE I
(IF DEATH OCCURS AWAY FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL
TS CALLED FOR UNDER "SPECIAL INFORMATION" N
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
X
PERSONAL AND STATISTICAL PARTICULARS
/rt"kVtYva/vvct t \\.
4-
\
\ n
!» \ ll. t »I I'.IK III
Miiullil
\' .1'.
-i\<.i,i-: NtAKRii'.n
\\ I IX »\\ i:i» «>K IMVt r.'
' \\ I it! ill ^iKi.-ii tji-^i^' r,.,:
lUKTIII'I.AOH
' st.itt (ir »"'niiitiy
NAMl- Of*
1- ATin:R
niK'rin'i.Ai'K
oi' I Ai'm'.K
i Sta! ' (i! v"(iuiitr\'
I>:
l/.'»,''//
(\\-.n
ID
~<y:
'/
MEDICAL CERTIFICATE OF DEATH
DATE <'l I>1". XIH
1^ 1'^°,'
(Year)
(%foiith) 'Diiy)
I H[';Ki;i'.N' f i; RTI I-N', 'rimt I atU'ii.kii »k-(ease«l from
— I.'
that I last saw h
• alive nil
■JgO— — -
190
and that <Ual1i ()rrurrc<l, 011 tin- <lafi' stntid alxn't-. at "
M. The CArSI<: Oi" I»l-;.\ril was as ff.U.iws:
. r ( '^
I )r RAT ION )'<ars
C< >NTkHU'T()RV
DI'RATION , )'r,irs
Montfn
Pax
Hours
Month}
Dav
maii)i:n NAM1-;
OI" MOTHHK
lUR'ruri.Ac'K
()i M<»rnKK
(state Df Cinintrv
ucc
CrLcLoUv;
f\r>ii{iif in Sun /'iiini/
);,i
M.oilli^
I hi
VnV MIOVK ST\'n* I) I'KKsON \1. TAR ri'TF.XKs, \KI, IKIi: r<» THH
liKST or MV KNo\VI,i;iioK AN1> HHIJKI-
(Inf-.nnant VjOCU^ \J . Ll - dJ-VVtl
AMI. LA.. Ov. <L'
f Address
<X\JA-/^
( Signed )
•4-
//ours
M.D.
fA.l.lress)Mria.-V\AX<L ') J
Special information »"!> '^f Hospitals, Institutions, Translfnts,
or Recent Residents, and persons d^inq Hv»dy from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Oavs
pi.Ac;}-: 01 luKiAi, oK hi:m<>\ai,
MUX^-^w^
r N I ) 1 . K 1 A K i: K
l»\ri;<>t 111 KiAi. or RKMoN'AI,
L'CA li T90H
'\ ^1
"^ Ti ATF -hnuld he stated KX4CTLY. PHYSICIANS should
N. B. Every item of information should he cnrefully supplied. J*''^ «^ ^assified. The "Special information" for p-r-
state CAUSE OF DEATH in plain terms, that it may he properly Uassmeo. ^
«on« dyinft away from home should be ItWen in every instance.
i
I
lA •
y
ij (
i' ^
l»ii
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i; ,'.1 ..f !T«T»1tl! }■ v.. '^ t^^S^^. lU^P Cc)
" ■- *- ■-'•- <»
nnfr FiJnl , C'/tlXxrls-Uv IS
tj5^^
V)0'i
Bo mistered JS^o,
*^^86
Vw
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
A^
PLACE OF DEATH: — County of
A.
n -
^ w I ^
No.
^
' X City of CL^x V
St.: Dist.;bet.^t^ck,te--'\' and v. va
/ ir DEATH OCCURS AVWAV FROM USUAL R E S I D E N C E G I V C rACTS CALLED FOR UNDER SPECIAL INFORMATION' "S
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
ll. ..•■
UX
cs^'.,^
PERSONAL AND STATISTICAL PARTICULARS
/\ I'OI.ilk
^! A
1) \ ri; t»i lUK I'll
A<'.H
\.
I
MEDICAL CERTIFICATE OF DEATH
DA ri-; ul DKATU I "N^
u
(M
>lUll I
• fiHi-
aa
ih
sl\» , I !■: M \KK IJ 1)
U IlMiWHI) OK I)I\»»Kt HI)
iW'ritiin siK'ial <U«-ij.'!!iitHMO
f)
/ ,
Ox>^aU
niRTIfPf.Ai'H
Stiitt I iT < iniiit 1 \
FATii i;k
niKriii'i.A*!.:
oi- I \ini:R
(St;it< D! (.'(Mint I v^
maii>i:n n\mi-:
HIK rilPLAi'K
(U MOTIIKK
(Hiatf or Countiy
0
^ \
1 N
iM.milO
liav^
(Year)
I IIi*;R lil'.N' CI-RTII'V, That I altcii«l(.il lUtxaseil from
I ijd
t., U cl.
1 I U)0 H
*
tliat I last --aw h - ,iii\i'>il ^ C^ i I90 '
aii.l that (Kath ocrurreil, nti thr dati- --tati'd above, at U
^^w M. Thf CArSI'! 01- DKATII was as follows:
niRXIloN )V</^v Mi))i(hs Qays
'I • '
//out s
DC RATION , )V<7r.v
(SIGNED ) cLo^v
Months
/hiv
L^cL
IqnH
//out s
M.D.
Special information «nl> 'n*^ Hospitals, InsfitMtlons, Tra«slenl$,
or Recent Residents, and (icrsons dying away from liome.
<)L'cri'\ 1 ION I
Ri-sitlf't! ill Sail I'l iuii isi'ii O )'>ii>^
Mniitfr
rhi\
THK AHOVK sTXTlJ) ','KK>^ON \I, I' \ K P HT I. \ KS AKl-. TKll- T< » TIIH
IlKHT IH' MV KNOW IJ-.lx.H A Nl) BMI.n'.l'
(I
Former or
Usual Residence
When Has disease contracted,
If not at place of death ?
How lonq at
Place oi Death ?
Oiys
I'l.ACK <tl lU KIAl, <»K Kl',Mo\AI.
UAIL;!': Ill hiai, iir Kl-:M(n'Al,
ii^-t
TQO
N. B. livery Item of lnformHtlo« .hould b^ carefully suppllecl. ^^^ "^"!l''',^,*,;^^ Information" for p.r-
•tatc CAUSE OF DKAT?? In plnln term., thnt It may be properly wi«««itieo.
fions dying away from home nhould be given in m^fmry Inetanee.
m
i
N I
h
I i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
»»,,:il.! t III :t"tli i V'
life!' C<
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I
I
dUrvu^ Xt'\HJ Deputy Health OP
DEPARTMENT OF PUBLIC HEALTH
Jlo^jsfej'cd JS^o.
22H7
City and County of San Francisco
Certificate of S)eatb
( ia. S. StanOarD )
PLACE OF DEATH; — County ofUCLA-v ^^
City of vJ-^^^-^^^ JX<X>\ C'.c
1 V
N(
o.UJaXdjL
t
.VULAiyn {l\^ ^<l'(\jJ^ClA: St.: ^ Dlst.;bet. and
/ IF DEATH OCCURS AWAV* FROM USUAL R E S I DE N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION \
i IF DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME Uu^xnr^xJL
PERSONAL AND STATISTICAL PARTICULARS
■^'•■^ (^
( ' ( 1 1 ' ' K
JX/YY\XkXi
DATK nl lUH 111 PN
a
.f
M-.m)
a!
A'.i:
/hi
si\. .i.i' M \KK n:i)
un)n\vi:it OR i);\i iri*i:i>
^
OJ'J
!UK rillM. \0K
stati III ('iiuiitr%
NANfl-' nl
HATH IK
lUR'nH'!, \i'K
«>i' I \iiii;r
' state i>r i'oniitt \ '
MAIDHN NAMK
ol- .NU)riIHR
HIK THrF.M'l,
()!■ MoTHHK
< Statf <jr Coiinti y
OOCITATION
cn
d,)
I w
Vv '
il
MEDICAL CERTIFICATE OF DEATH
1) \l\: I tl m-ATII
(M.imii
(Dav)
N. ai
I II I'K i;i'.\' i' !•' RTII'N', '^'tiat I ;itUMiili-(l ik-rcHsetl from
that I last saw h -.-' alivr ow W CAj 11 190 :
and that lUatli nctnirred, <,n tin- tiat.- ^tatiMl abnvt-. at ^10
M. The CAl'Slv (»!■ hllATIl was as follows:
2 /^ jktC.LfrVAA-C'-tC
,a.aX Jx^xjUwoJL \^^
DIR ATION
Years
A
Moutfv
/hl\ s
/four's
CONT!
DIR ATION
(SIGNED
RIHITORV uxKa,^-^ <X/w<^^ U w^\-<X4.<. V
)><//'
n
Mnnths
fhlVs
.^X-
Hours
M.D.
\>^
KrsitUui III S.iii li,ii', nrn <*. ^. ) '"
M.'iith'
Thj\.
THF \m)Vr STXII-.I) RKRSOWI, PARTICfl.ARS ARi: TKIK To THH
HKST Ol- MV KN()\VI,1<;Ui;K and lU'.MhH
(Infcnnanl L) . > ■ X^ CKVQ^^IaJ
(A.Mrcss
bl^ \-«AXUX Ol
0
w
'<ct ili Tl
K»
fA.hlriss) I?
c^.l
Special information "nl> lur Hospitals, Institutions, Transimts,
or Recent Residents, aU persons dyinq awdv trom tiome.
Former or r ^ a H p ^ ^ , -
Usual Residence to^6)<C^'4.A^
When was disease rontractW,
If not at place of death ?
HoM lonq at
Plaf e ol Death ?
Days
PI.ACK Ol' HrKIAI, OR RI'.MmVAI
l>\ri", .»! liiKiAL or ki;mci\\i.
TC)0
.^AX-W,
N. B.-
-Every Item of Information .hould be cnrefully supplied. ^^^ classified. The -Special Information" for p«r-
state CAUSE OF DEATH In plain terms, that It mny be properly wiass.tie
son. dying away from home should be ftlven in ^^^ry Instance.
s
^
<= t
^
I!
lift
'I i!
h ;i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
j;. -.' ■ f n<:tlth 1
V.) .- t--"™^ H.v^l' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)f(fr Fi/rf/,\Jzt(Ay<Kj 1^
If/OH
Re<9i\sfcrcd JS^o,
2288
^
^■J
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
"U. 5. StanDarD )
No.
PLACE OF DEATH; — County of
City of U ^' '
,'V\
Vj -
• Stif
Disti? bcti
and
(
ir Ot«TH OCCUBS *WAV FROM USUAL RESIDENCE GIVE FACTS CAttED FOR UNDER SPECIAL IN
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND
FORMATION" "\
NUMBER. /
I
FULL NAME
La
!-\ A
PERSONAL AND STATISTICAL PARTICULARS
A tVcuU
wk: .
DA ri: I iF lilK 1 II
A< .H
^fonthi
n-,n
M..,!fl,
\i ,t! 1
Ihn.
MEDICAL CERTIFICATE OF DEATH
SINT.I.R. MAKHIi:!)
wrnowKn or divuki*)- d
Write ill social <U-^i>f!iat'i n '
I'.IR rifPI^ACK
L\
^^
NAMI-; ni
FATn i;r
BIRTH IM.ArK
«)! lAIHHK
(Statt or Cduntrv
maii)i;n NAM1-;
iW MDTHKK
p.iKTHpr.Aci-;
III Mo'rm':K
' stall' ur Country
DAT}-: Ml- DKATH ( \r\
(Month) f 'Davl (Veart
r m';kI';nV CliRTll'V, Thai I atun-k-.l .Unascl from
tliat I Inst saw h ■ alivt- <ii) - — up
aii<l that (U-atli o(>nirre(l, oti the <lati' -talcd almve, at
^ M. Thf CAi'^i; ni' hl^ATIl was a-; follmv^:
J^U
AM^-4^w ^^^<\.
t
1)1' RAT ION )'iars M<>>if/is fhivs I/onr<;
CONTRIlirTDRV
Dr RAT I ON )V<//
,NEDlLL
^r,'ulhs
Pav
(SIGI
"Vl'A.
0 TnnH f
//ours
M.D.
Oi'Cll'A i'l'iN
^
Rfsitlril ill Sail I'laihi^m
tit i s
1 A .;////.
/),n
rill- Xnovr STATI'D PKRSONAI, I'XRTIOII, \K^ ark TRtK t<> thh
lii:sT OF MV KNo\VI,i;i)(".H AND IQ^I.H.I' ,_
(Itiforni.'int
fAddrcss
Jo^ \X- ck-
Cuvv^
H__Li__il!2
C&AL INF
A.Mri'^s)ll.U. Li. J
SPECi^AL INFORMATION onl> '"f Hospitals Instifutlons, Transicnls,
or Recent Residents, dod persons d>lnij awdv from fiome.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Now tOR4 it
Place of Death?
Days
I'l.ACK OI- BIRIAI, OR R1;Mo\ AI. IiAT^-; of Hihiai, or RHMoVAI,
t NDICRTAKKR
(AiMm'ss
l.^ ^^kt
Ll.
'H In plain terms, that It may be properly clBMitiea. h-
N. B. Bvery item of in?ormat
•tate CAUSE OF DEATH In p
monm dying away from home should be given m every Instance
ml
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'I)(f
fr n/rr/, ILlctMMA;
\^
IlJO'i
lioo'/sfrred JV^o.
'^^o9
A^ osjt^nj
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcrtificatc of H)cath
( "U. S. StanDarO )
PLACE OF DEATH: — County of
City ofv-t^'WTUL WVv<,
Nc-
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. /
^
[1
>
I
I
FULL NAME '^^
s^
.U^ <^
-'Si^ v_-
PERSONAL AND STATISTICAL PARTICULARS
^ 1 . \
n
I > >!.' ik
I t
MEDICAL CERTIFICATE OF DEATH
DATl-; ni I»i;.\ Til
\
DATi; t ij 1;1K iH
Xf.K
K
M.,iit'
^„
[>a\
.V.-»^,'^>
Wl I>( »\\ I It » »R l»l\t if.'tl r>
lUKTHlM. Ai'J-:
--! • . . i! 1 ■ 111 nt i \
\ \ \t 1 1 »1
I A I II IK
FUKriii'i. \cv:
ni- 1 Aiin;K
I state lit i'mititrs 1
^T\II)^:N N\M}-:
nl- MOTIIKR
HIk lIll'I^ACl-;
<»!•■ M(»Tin;R /
l^^tatf or 0<»unti n i.
otCll'A 1 loN
^rS!. ml
'i
UmvI iVtari
I IIi;ki:HV CI^RTII'^V. That I a1trii.U'<l ilci lasf.l ftnm
— — , . — ,,^, , — (, , — — — ,,p
that I la"-! <a\v li alivt'Ui —- — — — Kp -
anil that <U'alli oriurred, on tlu- «latf ■-takil almvc, at
M. T1j<-' CArSI', Ol' l)l',.\ Til \\.is a-^ fn!I<.ws:
I >r RAT [ON )Vc?rs-
CONTRIIHTORV
Mo)Uln
fhn.
I Ion I s
Dr RAT ION
)\ays
MiOiths
Ihn
C
u
A'f-siif/tf in Situ /'luihi:'
Months
Ih
(SIG
i,
NED) OkO.d.
a
Hours
M.D.
I
T()0
r A.Mriss) ^XjKkj
vgp^QI^L Information nnl'^ '-'f Hospitals, instifuffows, Transients,
or Recent Residents, and persons d)inq anav from home.
THH AHovr: sr \ ri:!) phrsowi. i-xr ihmi-aks ari- tkik m riU'
lilCST ni- MV KN'oWI.l'.lx'.Ji AM) iii:i.ii-.i-
(Iti fiHina
111- ,-.11 IN ,-«« f >»»,•. •'■ ■ "i ---"v A
( \<l<llfSS
<X/X?^0
former or
Usual Residence
When Has disease rontrarfed,
If not at place of death ?
HoH lonq at
Place of Death ?
Diiys
J'l.ACK iif lURIAI. OK RKMt'VAI
I)\I.j:ii! I'.i KiAi, or KKMuVAI.
190
rxniR TAKHR
I'Aiidrcss
y TT ,. . AHF Hhould be 8tote«l nXAGTLY. PHYSICIANS should
N. B. Bvery Item of Information .hould be carefully suppi.ecl. J''/' .^ clawlfled. The "Special Information- for p«r-
-— . CAUSE OF DEATH In plain terms, that it may be properly clawmea.
state CAUSE OF DEATH In pi
Hon* dying away from home should be given in every inntance.
i I :l
!i
t4l
I
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
noarfl of Hcnitli 1 N
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
il
\
Br mistered JS'^o.
Ddh' riled, t'xXAAyJLK \'h H^O'i
xtruu^ LtA^u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiflcate of S)eatb
*a. S. Standard )
^
^
^V
City of U<Xyw 0 '^ '
PLACE OF DEATH:-— County ofua
r^o. VLXC^. r ' '-^ }■ dJ.LL,..^. ... 'V St.; — — Dist;bct.
ir DEATH OCCURS «W«V fROM USUAL R E B I D E NC E G I VE FACTS CALLED FOR UNDER SPECIAL INFORMAT
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE
and
(
" )
■\
FULL NAME
14-
Nl \
PERSONAL AND STATISTICAL PARTICULARS
t ■ ( ) I . < • K
A
rVc
1» A 11 I il- lUKTII
\* .}■:
\
MEDICAL CERTIFICATE OF DEATH
DATH <>! 1>i:a 111 , \
l);i\i
iVtar)
r III'iRI'll'V CIlRTIl'V, That I aliL'ii<li'.l -liixa^t'd frniu
M.iitli)
< I):iN
■> ' .11
) r l! I
1/
siNi m: MAKun:i>
WIUOWKI) OK IHVOKi i;i>
iWiitfiii siHJal »U— i^fuatiim)
lUK TlfPLACK
(State (Il l". Ill lit I \
NAMl, «>!•■
I- AT hi; R
RIKTIII'I.MH
Ol- I APHKK
(Stall ur Cntnitrv
MAim.N NAMK
<»I MoTin-'.K
lUR THIM.ACH
<)»■ MorHKR
(Statf or L'ouiitryi
occri'A'rioN
%
(^ wQ
V.
t
I {pi t<» W i_L.' I(p
i
that I last saw h ■ alive on ' l«^
and that (hath occur red, on the date stati'd above, at J
M. The CAI SI-: Ol-" DI'lATII \va< av OjH.nvs:
J
ro
DIRATloN )'i'(Jts
CONTKIIU'l'oRV U^j
C^
Rfsidfif iif Sat I /-niin />,•>>
)
Moiilfr
Din
THK -XHOVKSTxri:!) PKRSONAI. 1' \ KTf*T F, A K s A K l- TK T K To THH
JIKST Ol- MV KNo\VI,i;i)«.H AND lU'.M' I
(Inforinaiit
CL
f'V'
K
> \. c
(Arldrcs^
lOOM.
i
kji^J^^
X^AfiU^Js'r^
DIRATION
(SIGNED)
)V<7; s
Mnnlh^
w^w
Mnnths
Ihiv
Ih
IHt s
/hns
I lour s
M.D.
KjO
f
A.idre.s) Hn^La\.M
SPECIAL INFORMATION only lor Hospitals, Institutions, Transleits,
or Recent Residents, dod persons dying i>t,A\ Irom home.
"'™"" ^]kaAj^
\
Usual Residence
When was disease contracted, I \
II not at place of death ? ^
<x
How lonq a\
Place of Death ?
Days
^ULCcLwa.
I'LACK t)I lUKIAI. OK RKMOVAI
'I
0<Xyvu
UAl'Kof ni Hi.u lit RKMOVAI,
V. ^ I H 1 90 1
INDl'.KlAKl'.K \l I W
T>
A N
A<1<lllSS
■"""■^ 73 AGE should be stRted EXACTLY. PHYSICIANS •hould
of inform«tion .hould be cnrefully supplied. ^^^^^j^^" "if led. The •'Spccinl lnform»tloi." for p«r-
E OF DEATH in plain terms, that It may be properly wl.ssitiea.
N. B. Every Item
•tate CAUSE vri w»-- ^ . 1 . „ .,
nous dying »w«y from home should be given In .v^ry Instance
WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD
REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONa
2291
. ■*.irrv^,3x. i,M t"
.tcA>
Dale AV/f'^/, L^cTcrlhXKj 1^
Deputy
'%J^^'' ^ '
h Of
Ee^ish'rcd J\'o,
I i
« k
\i I
DEPARTWENT oi= PUBLIC HEALTH-City and County of San Francisco
Ccvtiticatc of IDcatb
( •a. S. StaiiCatD ) ^^
J? © i ^
PLACE OF DEATH:-County of OC^O^ JyVa.xC. .Gty of ^^
' \
\
U ^^ ^^M ^ l^lST., DCU .-spj-cAL INFORMATION' \
FULL NAME ^
)
%
J,\,U^dw^v^''^ .
i I I
p!
p^pSONAL AND STATISTICAL PARTICULARS
DATK OF I'.iKTH
u:
\t.i-;
M..iiSh
5 , ,;»
/ ^
I i.iv
^1/ ,,,///
Af 1 A
MEDICAL CERTIFICATE OF DEATH
(Day)
( MoutlO
1'!
(Ytari
WIlH.W 1- 1) OR MIN"^' ' '»
I \Vi it<- 111 -'H-tal di-n-n .t!..ni
lUH rm'i.A^'H
stall- or CouiUiy '
llWvA^^
M^
lx\
S \Ml- «»l-
, nKKi;HV CHHTIFV. Thai 1 alU-iuU-.l .lerca^cd from
that lla^t <MW h ■ '«l>ven„ ^ ^- - ^
,,,Hhat death .>..urr..l.. -nth. aatc.tat..lahnv.. at
^ M. Ths{CA^SI^ <.l; 1 .i: ATI I was a. I0II..W.:
yuDLVx
P I'M
HlRTHI'l,Ai"K
()!• J \rm-:K
I Stat<' in rituntrv
\1 \I1)HN NAMJ"
nl MOTIIKR
HlKrHlM.Ari".
(Slati- or Countryi
Ur RATION >''(?/<
CONTRIIUTOKV
DTK ATI ON >\'<^'*-^
(SIGNED) L^ ^ ^
Months
/hns
i/iun s
M^^nlh
n<n
M.D.
Qm ^ I ^t ! -
w --*•' _! -^ • , H^.:. .1, i„.:»i»iififtn«L Tr
,3««Ue*«t ' aad pe.sons dvin, ...» f.»^ *'™'-
nrori'ArioNQp^ y ^
\r,,„tii-
/>.r;
,„,sr..,.MVKN,.^-...-.-' n .,
former or Q 1 .
Usual Residence 0 i u
When was disease contracted,
If not at place of death ^
. Hov* long at
I Place of Death ?
Days
I.Vri'"! H' KiAl. or RI%M«»VAI.
IL C. t. "-' ^ T 90 i
( \(l<lrrss
X
0 10 UJXAMA.*-.' ' ^ "" PHYSICIANS should
' 7„ ^uoDlied. A«B should »>n.'*'»'^:;.^. ..g ' Jli.*! Information" for p.r-
„, ,„fo.n,«t1o« should «;; --^^J^-^ --^;t P.OP.H. ciassir.ed. Th. 8p..
E OF DEATH In P «' "--:.' l*^"* ,,ery InBt.nce.
^- «-r:r Ja;^. op death . ;-—-:.... ....ce.
sons dying away from home »
I
WRITE PLAINLY WITH UNFADING INK
of II. :i!tll 1' N'
Dah' Fllcil , \jf^kJ\>X^ 13
/ U 0
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIP.r.ATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTli=City and County of San Francisco
Ccvtificate of 2)catb
I XX. S. 5tanC»a\:D )
f H (\tAjlXAxr 1 >
PLACE OF DEATH:-Co.ntv ofM -^-A.^-. ^ ^Uy ofM ^tic^.d^ ^
No.
wi
' Vila*-* . ' SU D'^'-'^*- .„„u.n„s»c,..,~r;\"t
I ir DEATH OCCURRCO IN A HOSFHHU un
\ 11 U]|l
)
RMATIO
MBER.
..)
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
.1'!
I) \ I K I t| lUK I'll
1 I
il
a.
/^t
\< .!■:
6 I
(Day)
M.oilli^
Vi ari
/)..•
I>\TH <>1 1>KATH [( \
L
(Day>
IQO i
(Yt-ar)
\Viit(
A
-...lal il.
I, -•
"\
i ilKkKHV CI'KTIFV. That I atU-u-k-.l <lcccasea from
-. - 190- tn __,,p —
that I last saNV li '" alive on — ''^
,„.l ,uat .U-atl, nccurre.l. .u, t1,c .lat. stated ah-.ve. at "
— M The C\rSi: Ol" 1)I)^TII wa^. as foll.ms:
-15 ' ■
^1
'^
L
(0
lUK nii'i, xr}.;
1 A I'll J K
niRTHIM.AiH
Ol- 1 AinKK
1, statt lit rodiit! y
MAini.N' N\M»
lUKTHlM^AiK
()i. M(>'i'm':K
(stall "t I'oniiiry
occrrx rioN'
1
U^/.
DU RAT I ON ^'*''^
CoNTHllU TDRV
}/,>>///ts
Pav
IIoHt S
.)r,>>itlr
Pars
Hours
M,D.
Rfidn! in S,n' /''
Il III ! I'll '
) , ,/.
fhn
n....juiiv 'y.v
(SIGNED) V(j/J^^JCwUv.,-.:
SPECIAL INFORMATION »»M"««l'i'*.l"^'''*"^' •""^'"'^'
«, Refe^ Wdenis, and persons im «■» >'«'' "»'«■
Former or
Usual Residence
When was disease contracted,
If not at place ol death ?
Hovv lonq at
Place of Death ?
Days
rXACKOl- ni-RlALOR RKMnVAI,
0
AiMtf^*^
UHvjUaaa ^^
1)\TJ •' U' KiA!. or RKM«)VAI,
T90H
*" ^ , FVACTLY PHYSICIANS should
,.„ «Hou.a H. c«.e.u,.. :^PP;^t .^hX^I:- "- --^ «"^--^'^^"" "^ "^"
m in plnin terms, that .t m»y hfj; ^
N. B. F.very Item of Informsit
state CAUSE OF DEATn m P'""" [---j^^^ ,„ ^vory instance,
son. dyinft aw»y from home should be fe.ve
« t I
h
I
wi
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2293
Registered JSi^o.
I)(,fi' /'V//>^/,(DiitA^. li lOO'i
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "a. S. Stan^ar^ )
PLACE OF DEATH: — County of O^Lox; Jxa.^CA^4c City of Oo^^ J Axx/y\/c.4.^^c
No 15^'i^ "^O ' . St.; 3s Dist.;bet.ciiXlAH.')VCU1f\ii)and WW-U
/ ir Dt*TH OCCUnS *W*Y prom USUAL RESIDENCE Give facts called rOR UNDER "special INFORMATldVl" \
V , ir DEATH OCCURRED IN A HOSPITHL OR ^STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBEF^j J
FULL NAME
>-i.\
PERSONAL AND STATISTICAL PARTICULARS
jIMotith^
W
I,;
I) \ li; It!- lUKTIl
\<*. F.
<Dav)
M.mth'
\ tar)
Ihi
SIN<,|,J-, MARKII'D
\vinn\\i;i» ok i)i\( iRk i-r)
•\\'iit«in 'sofial d' -if iiat i. m >
KhjUiA^
HIK rHIM.AOH
1 Statr or Country
I A 111 IK
HIKTIIFM.ACH
oi- lArilKK
^latc or Country
MAIDKN NAMl
(»!• MOTIIHR
niK rni'KAci-:
oj' MO'lJllvU
(State or Country)
OCCri'A TION
Tn
i
0 X ex ^ V- 1
^
V
\ I 1
n
DC^ic^ u 1 1 \.
fCf'iif/'if ill San I I ttih
)'t',n s
A/,iiif/is
/>,i
THl* AHOVK STA IKl) J'KKSoNAl, I'AR riCC l,AKS AR)' TRt K K > THK
BKsr OI" Mi' Ky<)\vi^;i)c.H and ni:un:F
(Infotniatit J . vJ
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH A
(Year)
(Month) (Itey)
I m:Rl':BV CI':RTIFV, That I attemU-.l deceased from
...... igo'i to A^ wL \X 190 H
>^:- - ... -. /
0
that I last saw h
alive on
w -ct-
1 I
190
^i
and that death occurred, on the date stated above, at i oO
'. M The CArSK OF DKATIl \va^ as foll«)ws :
Q^
c 3<X.<->L<^> ' '
d.^
DTK AT ION y'l^ars
CONTUIIUTORV
DTRATION y'mrs
Months Days
Hours
Mouths
Pass
( SIGNED ) wv^-MAX WK/O. ^ -v.. . , ,
Address) utcUxKi X
Hours
M.D.
H)o
(
4/>A^\^
Special information only lor Hospitals, instituticHis, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death?
Days
i)ATi:<if HcHiAi, or kf:movai,
OcX I'l 190H
l'I,ACH OF lURIAI. OK K1:M<>VAI,
INDKRTAKHK M^- 0 AXXU ' ^
5S1 ^dA^aijuv. 'n.t
(AtUlrcHs
State CAUSE OF DEATH In plain terms, that it may be properly ciassiTsca. 1 • «j p
«on« dying away from home should be given \t% ms^ry Instance.
I in ; I
i
t
ST
I
WRITE PLAINLY WITH UNFADING INK
2^>'6>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( XX, S. StanDarD )
PLACE OF BE ATH ; — County of
City of
\<X
(1)
/yXAAJOu
^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 I N FO R M ATIO N " \
( ,F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME Ox
•^ix
I \ 1 i: < »! lURl'Il
PERSONAL AND STATISTICAL PARTICULARS
Ji
f)
OAhjJi.'.
(.'ui.t )k
M.iitht
\<.i.;
}:•,!,
(Writ) in - •■ i il lU-^iy iiati. m >
RIRTHl'I. \tM-,
(St;it< iir I'.iniitrx'
I- AT 1 1 l.R
><
lUK 111 I'l, \< H
OF lAini-.K
(State nr Cmintiyi
M\II>i:N NAMl",
(H- MOl'lU'.U
/
p.ik rnri.At'K
ol MoTlIKK /
(Statf or iNnuitry)/
^
orci rATioN S A
rl A 8 K 1 I '
K'fsiifrif ill
Sti II I'l ti Hi 1 ■' '1
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK <>J' 1)1. \ 11 1 (V\A
(Month) K (Day)
1 illiUlUJV Cl.RTII'V, riiat I att«.ii.K-.l .kHxasctl from
• — 190 to 190
that I last saw h - — alive on — — — i^ -
and that death occurred, on the date stated ahovc, at
"-™ M T!ie CArSI<: OF DI^ATH was as follows
4 ,
),<n
MntlHl^
/),/K
Tui- \n()VKSTA'n:n pkrsowi, rARTim, \rs akk TRri- t*> thk
l!l-;S'r OF MV KNOW 1,1. Du^K AJ\I) lU.UIll-
( \<l(lr('^«;
DTK AT ION Ycais
CONTRIIU roKV
Months
Days
I lout s.
)'i'ars
Mouths
fhivs
nrK.xTioN ^
,NED ) /.. V9. a.\jL£urivc. . .
b i„oH (Ad.lress)M llo^'YV^Xa V
(SIGI
Hours
M.D.
SPECrAL INFORMATION only 'o^ 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
nart of Death ?
Days
I'l.ACK Ol" HIRIAI. OK RJ;M«i\AI
l»\ll o! Ml Ki.^i. or R1":MoVA1,
190
be stated EXACTLY. PHYSICIANS .hould
N. B._Bvery Item of l„tr.„„tion should be c«..fully -ppl.ed )^^J^;f^^^J,.^^^^^^^^ ,„for„,atlo„- for p.r-
«tate CAUSE OF DEATH in plain terms, that it may be properly classiiiea. i
state CAUSE _- . • » .^
fion« dyinft away ?rom home should be given in every instance.
J s
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Bonn! nf Ihalth !■ Vo. ;- -f-^-^ar;^ H&P Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
R
r\
Dale Filed ,
a.
190'i
Be^istered JVo.
2295
du^vco^ Ilxki Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
J!
( TH. S. StanDar^ )
Q^
PLACE OF DEATH : — County
(IF Dt*TH OCCURS Aw*V
IF DEATH OCCUrI^ED
ofU/OLA^ OA,<X.-v%CUi-'Gty ofO/CLA\; 0AXX^^v.cu4./ec
Mli
ksfea
Dist.; bet.
and
USUAL RfeSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
aSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
i I
♦
i
PERSONAL AND STATISTICAL PARTICULARS
DATH <>I lUKTH
.l).kc*
M.iiitir
AC.K
SC
r,\i>
Dav
M.nilfis
(Vear)
Dii I .
SI NT, 1,1' M \Rkn-:i>
WFI>()\Vi:i> UK !)IVnKv*i:n
lUK rniM.At*!-:
f Stiitt or (.Dimtr y
Oxj>r\jc:v\X
dxu.
-*^ V > \ \
N'AMl' ol-
I- AT III-; R
RIKTni'l,A(.K
Ol- lAIIIKK
(State <ir CiMint! V
MAI 1)1 "N N A Mi-
di" MOTIII-IK
lUHrniM^ArH
Ol' MorHKK
(stair or t'otuitiyl
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII | A
li'ct II
(Month) (Day)
I HI'iRIUJV CI:RT1I'V, That I attended ileccased from
-, to
rgo 1
(Year)
that I last saw h
I90
- alive on
190
igo
and that death oceurred, on the <late stated ahove, at
M. The CAUSH Ol" 1)!;ATH was as follows:
1)1' RAT ION Years
CONTKIIU'TORV
Months
IMvs
fS
1^
(KcrrATioN J^ 0
h'f'yi,frtf ill Sai! /'i tiiii />,•!>
) III
M,„it/i^
Din
THH AHOVKSTATKD PHKSONAK I'ARTnr I,AKS A K I
iIksT Ol'" MY KNOWIJ'JX'.K AND r.HMI-.l'
IRIK TO THH
(Informant
(A(1<lri-ss
TO- SA^d. Jt
DT RATION VciJys MwfAs ^ Days
(SIGNED) urXr^jLhj 0 .yj.U). ouX'.'. . .A
Hours
Hours
M.D.
lli^. U
I()0
(Address) WUTnO/U)
m
. .St*-; xi**-- * . ,
SPECIAL INFORMATION on'y 'or Hospitdls, Institullm, Transients,
or Recent Residents, and persons dying away from home.
51
HMa^--"^
Former or
Usual Residence
When was disease contraded,
If not at place of death ?
1
How long at
Place of Death ?
3) Days
ri.ACK OF niRIAI. OK KKMo\ AI
tNDi:RTAKF.R *■• VJ . W
DAi'l'.o! Hi KiAl, or RKMoVAI.
190' i
,. . The Hhoulcl be stated EXACTLY. PHYSICIANS should
N. B.— Every Item of mformetion .hould be caretully suppl.ed ^^^ «houhl be ^^ Information^ for p.r-
state CAUSE OF DEATH in plain terms, that it may be properly Uawitiea. h-
fton. dylnft away from home should be given in ^y^ry Instance.
~f
n-
I
\il
•A
i
if
,,f lli:<ith I- V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
•w-^^ H\.!'
Dfffc Fi/('r/\^ctA>^i>v I
rjoH
Ilc^islci'etl jYo.
,^r\xM
Vi f
! i
I) f
M
\ '
Deputy Health OfTicer
DEPARTMENt OF PUBLIC HEALTH=City and County of San Francisco
Ccttificate of H)catb
( "d. S. StanDarD )
PLACE OF DEATH: — County ofOa^x ^ \0. ^v-' < :<■ City oi^Ou^ OAxx^vvccO ' (
No. ll
Q
I V. V
^f<y
fOi
( " "^roz^^nlTcln^to ^'nl^HosPn^Z or 7nst",tut:on give its NAME instead or struct and number.
IS AWAY FROM USUAL R E S I D E N C E G I V E
tut,
FULL NAME ^VjO,
Of 4 M
St.; ■ Dist;bet.LL'<XA'tXCY\.a- . and
IIDENCEGIVE facts called for under "SPrCIAL INFORMATION"
i}
)
)
A\
OXaJ.
OJiM
-^\ \ {
.,* m
PERSONAL AND STATISTICAL PARTICULARS
A r<tl.i)K
OX
I) \ 11; til i'.i R rn
Ai ,1-
A
i^
Mnith-
r\\^
\ rar
Ihi
«^i\i ,i,i" ^T \K 1-; n'i>
1 Wri!.^ in -■ .111' !.-t"n.;ti. n)
I Stnt. 1 M I ' •nnti \
I A rn IK
Hik riii'UAt H
<)!■ I A 11 IKK
(Hlat< "ir i"(miit;\
MAIKIN \\MI,
<)1- Murm-'.K
HIRTlll'l. \K v.
»»I- Mnilll-.K
(Slate or i'lMiiitty
/^ 0 n (1
MEDICAL CERTIFICATE OF DEATH
DA 11-; i)i- ni'.A rn
M<iiith>
I I
(Day)
IQO \
(Year)
I Hl';kl';i5V C1:RTII'V, That I aUciuk-.l (ItHxascil from
— — — — — up to IQO — —
that I hist saw h :: alive mi - --- ~~ 190 ~
ami that lU-ath occiirrcil, nn the date stated al)i»ve, at
M. The CAlSh: OI" DIvATil was as foil
a
(»\VS
O^V^t » V-V NV
"^
OvTlTA TION
t V
R>-^itfr,{ ill S,;)i I'jtui. i-'-n i Ij
nojO^ Ox^C^
;i
) ,,ii
M,,Uth:
lhl\
THr An<)VKSTATH!)I>KKSnNAI,r\RTnTI.AKSAKK TKIH K • Till-
lil'STDl- MV KNO\VI.i:i)C.K AND iU-.I.n.l'
(Iiifoimant
QPrw
I
X.Ulifss 1 V J -V
Drk.XTION )'t'ars
CONTRIIUTORV
I )r RATI ON )'cars
Months
/)av
//ours
Mouths
( SIGNED ) L^r^un-vih. J m UJ-
J
Ihivs
I lours
iDct
W IqoH f
Addri'^^) W
^\j^y\XhJs
\\,^ M.D.
Special information only 'or Hospitals, InstitufioflV, Transients,
or Recent Residents, and persons dyinq away from liome.
Former or
Usual Residence
When v^as disease contracted,
If not at place of deatli ?
How lonq at
Place of Oeatli?
Days
PI \CH <»I' IirKIAI. «'K Kl.Mt'XM
i>\ri", o! lu KiAi. i>r ki-:m<)\'ai,
'^ \\ T90H
fNI)i:KTAKi;K
ir, .^^B should be Rtntecl EXACTLY. PHYSICIAINS should
^. B.— Every Item of 1nform«tlon should b. curetully «"PP'- • ^^^T;,^^";,^^ The -Special informntion" for p.r.
state CAUSE OF DEATH !n plain terms, that it may he properly Uassme
sons dylnft away from home should be gtWen In every instance.
I
* I
a:
h \
I I"
:ll
I;
1
1
'
H
4 il
1
H
]5,.:i1,l '.!' I
i I .; : ! ;i
WRITE PLAINLY WITH UNFADING INK
li)0\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lieo^isfrrcd A'o, ^^ J7
CU_
\ n. (
ue
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County
Certificate of S)eatb
( 'd. S. StanDarD )
U)
and
No %HC OcLl^vA.' St.; ^ Dist.; bet. J a.My V C
I rx c^ c
w L\„S^
FULL NAME
^ic.,
V
A
L
.a
PERSONAL AND STATISTICAL PARTICULARS
•>1.\
C< >1,< »R
J.
I) \ 11-: >»r ink 111
V\
Mutll I
/ tj it.
A». 1%
).i \
.V-.i/A//
* carl
/hn-
-I\i .!,1" M \K 1< 11 1>
W I !»t i\\ 1 I > ' -'■ ' '"- ' >*• ' 1'. I>
Writt :n
HIKTIll'I. \i")-
»• A 111 i;r
I'.iR'niri AcK
<)! lAI'Hl'H
' stii! ( iir I'tiiiiiti %
III M(»'rni K
11 »
y.
MEDICAL CERTIFICATE OF DEATH
DAll-: <»l- Iil'.ATll
u
I);iv)
(Year)
f Month >
I Ifl*;Rl!l5V el.RTII'V, That I attciulcMl (ieccasctl fiDUi
: — — — -r— — - iqo ~
: -. ;.. Up ■
li)0
~ alive oil
in
^
:l
AXLh)
(\
£L
'1)
)JLn
A
lUK'rmM.Ari-:
Ol' NtoTIIKK
( Slat' ' >'i Ctnint i \
^ I
(nCri'ATltiN
'K
) r.ii
\/. ■>■//!'
/>,M
TUKMK.VKSTXTrni.KKSnNXl.rXKTU-t-KXH- XRKTRrH To THK
HKsr Ol- .\n knmu i.i.ix,}-: and lu.i.ii.t
ill fiiniiaiit
cM-/^v^Ou
\,l,lrc>-^ u I w
OS?
M.V
1 u.
that I last saw h "^^"^
atid that (Uath occurred, on the date stated above, at
'^ M. The CAISI^OI- DIIATH was as follows :
w<.U
La
I )r RATION )'rars
CONTRIIU'TORV
Month}
Pavs
Hours
I )r RATION
f SIG
)',■,! IS -. Months
Pars
NED) UfurrWv J,mlU.llJbxA\'^
flouts
M.D.
\».
TQO
f
! SJ
SPECIAL INFORMATION on'v '"^ Hospitals, Institutions, Iransients,
or Recent Residents, and persons dving away fro:ii tiomc.
Former or
Isual Residence
Wlien Has disease contracted,
If not at place of death ?
How lonq at
Place of Oeatit?
Days
I'l.ACK <»1 lU RIAl, OR K1;M<>\M.
oX<VU^OL. rw
■Nl.l.RIAKHK b /<xLt'-r\^ J n\<YV^>'^^
nxi'i'.o: HiKiAi, or ri;moxai,
liJ/tlX .4 190 1
■"^ TT ,7 , AHF should be stated EXACTLY. PHYSICIANS should
tem of !„?orm«tion should b. cnr«»«IIy suppi.ed. '^^'* ^^^^^^^^^^ The "Special informalion" for pT-
AUSE OF DEATH In plain terms, that it may be properly classified. \
!„>. „..,-„ «««.« hnma should be ^ivcn in every instance.
N. B. Bvery I
state C
none dyinjk away from home should be A
li
r
I,
IN
I '
H
WRITE PLAINLY WITH UNFADING INK
H. at.l '.f f!< :i;'!> i V.
l;:^!' c
VJO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lie^istered J^o, ^^2 J8
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( Xk. S. StanDar^ )
PLACE OF DEATH: — County oi^^O^-f\j ^^ ex.
i
m
No. I eijacv,-v.
i
St.;
Dist.; bet.
City of ^ OwA^ 0 Axx
and
CCURS AWAY FROM USUAL R E S I D E N C E G 1 V E TACTS CALLE^D "^OR^UNOER ^ ^ PCC^At J N ro R M ATK> N ^
( ir DEATH OCCURS AWAY FROM USUAL H t i. I U t Pi ^ t u. v t .-v,,o --•-"- ,„«TrAn nr «;Tl.rrT AND NUMBtR
t IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
y
FULL NAME
\JXrs\xx.
\
^iixi.
h
^
I» A TJ' < >! iUK 1 H
PERSONAL AND STATISTICAL PARTICULARS
(■(tloR
iDav)
A I . J-
)•.■..'
Vtar!
/',/
SINT, l.I-: \IARHIl-:i»
\\'FIH >\Vi:i> <tK niXMRiKT)
: Wt w 111 ■..M-ia: ,1. -u-!Kit;i.;i '
lUK'nii'i. \i'i:
<t.i!i I .r • 'i Hint! \
N \M 1 «»l
I- Alii IK
lUKTHJ'l, Avi:
oi isriiKK
I stall III i'liuntiyl
MAini'.N NAMK 0
OI' M»)i"ni;k S-
lUK rui'i.AOK
I Siati I iv v'l miiti X
/^^^'^^oAA
0/Ouy\j 0 '^
r'>
A
-^
•v
Aj
1 (■>
LoJ
.CifrV
oCCri'ATlON
Kt-si,!f,! in Still I'l !,•
'^
) ,■,;
M ,iith
MEDICAL CERTIFICATE OF DEATH
DA 1 1-, (H Dl.A I'll
^
vi'd'
I (JO
(Yea I I
(Mi)iitlii <I)av>
I Ul':Ui;i'A CliRTII'V, That I alteiidcil dercascd from
— to — __
igO
— — — — ^^
that I la-^t <a\v h " alive on - ■ ~~— 190
and that «kath orturred, on the date stated above, at
M. The eUVrSI-: Oh* DI'lATH was as follows:
I) r RAT I ON Years
CoNTRlin'TokV
DTRATION YtQrs
(SIGNED ) %
yd; •'
Month's
Pav!
Hours
Months
Pars
Hon
rs
T<)n
\.ldress)lClk)UJaAi
'\.CTU^
M.D.
opFciAL Information on'y '^ HospiUls, lnstilutio»/s, Transients,
or Recent Residents, and persons dying dwav from tiome.
TflF M5<)VHSTATKI>l'KKS<.XM.rNKTKTI.AKSAKI- THl K To THK
lil'-ST Ol- MY KNoWI.l.lK.i: \M> Hl-.I.Uf-
(Informant \J I LOv'T^.-U-A' \! I U^
A
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoM lonq at
Plare of Death ?
Davs
ri.ACH 01 HiKiAi, OK ri:m<»vai.
mt OLv^
rSDlCKTAKKK
DATlliif BiKiAr, or KKMOVAI.
1
,. . Thf Khould be stated EXACTLY. PHYSICIANS should
N. B. Every Item of InWniHtion should be carefully fuppl'^rf. „;''^ * °,,3««;jied. The "Special information'- for p.r.
•tate CAUSE OF DEATH In plain terms, that it may be properly ciassme
•nns dying aw«y from home should be given In every instance. ^
f I
I
i
SHMi
WRITE PLAINLY WITH UNFADING INK
li, an' ..t 1I( .iith ■ !• No i^ '^-'tc^'^ "^'' ^"'^
/J.///^ /'7/fv/,U^^UWv) 13
ie9(9H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered *A^. ^^^3
^Hj Deputy Health Officer
DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of 2)catb
( Xl. S. StanDarD )
e
PLACE OF DEATH:— €t:)unty ef Ocunrv Wjl m\ b City of d^^^ ^
w ^ ■
y
No.
St.;
Dist.; bet.
and
w ,„^». IICIIAI Rr«;iDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
Wi'
FULL NAME
U
xj:xhXu
si;\
PERSONAL AND STATISTICAL PARTICULARS
i \ . .
'I »
DAii". oi- lukin
Muiithi
\«.i:
]',,,-;
Da VI
M.mihs
( Vearl
/).;i.'
H1N< ■,!.!: MAKKI!'.!)
'Write in -iM'ial ii« "-ii'tuitn'iil
lilKTHl'l. \i'l-:
(Statf I'T I'liunt I V
l\ IIU-.R
BIKTHI'l, AiK
ni* 1 A rm.K
(Stall of riiunti s
MAtUF.N NAMH
n! MoTllKK
MEDICAL CERTIFICATE OF DEATH
DATE Ol- Dl-.ATH , ^ ft
LlkxJL
(MdntlO
a)ay)
(Year>
1 in-:KHBV CICRTll'^V, That I attended deoeaseil from
, , 190 to 190 """
that 1 last saw h •^^- — alive on — '9° ~
and that death oeeiirred, <>n the date stated ahnvc, at -—
M. The CArSIC Ol' DIvATlI was as followR :
^/
V
/
lURTmM.At'l". /
()!• MoTUl-'.K /
(Stall- iir CouiitiNy'
AVsiiffif ill ">'"' /•'nii'i'^'"
) III I
1/,M/,'//.
/•
TMF AHOVF STXTF.I) «>KkS()NAI. PAKTUTI.AKs AKK TKn- Tn THH
liKST OF MY KN.»\VUKU«.H ANJ> HICUIF
c.a
(Itifo.mant N I La.yt^'
I )r RAT ION i'tars
CONTRinr TORY
Mofit/is
Days
I >r RAT I ON
Vtars
Months
!\jvs,
( SIGNED ) VA- ^ . 0 M \iO^<: \
Hours
Hours
M.D.
kx.O^ W iQoH (
Address) \)l UX/yuJUt
SPECIAL Information ©nly 'or Hospitals, institutions, Transients,
or Recent Residents, and persons dying away Irom tiomc.
Former or
Usual Residence
When was disease contracted,
If not at place of deatli ?
How lonq at
Plareof Death?
Days
ri.ACK nl' niHIAI, nk Rl-MoVAl,
DAlJi >f HiKiAl, or RKXfOVAI.
190
U-tt 15
I \ \
dv
IN!)1:RTAKKK
(AcMus'i
— ^ , .. ,. , InF should be stated EXACTLY. PHYSICIANS should
N. B.— Every Item of information .hould be caretully f"PP •-^- ^^^^ classified. The "Special Information" for p,r-
Btate CAUSE OF DEATH in plain terms, that it maj be properiy »
iton. dyinft away from home should be feiven in svery instance. A
i
P
IM
M!
•t;
•l^'l
WRITE PLAINLY WITH UNFADING INK
11.,;, 1,! .,f IKallh r Vn :^ H.H:^*' '•^'' *""
I)
((/r Filed . ycLrL^
.MA* 13
i,96>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.^cu5 Lc 'I. Deputy Health Officer
DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiftcate of Bcatb
( Ta. S. StanOarD )
PLACE OF DEATH: — County ofOctA^
1 V. ^
J (^
City of Uxxn^ J/i
No. .
Ml^dluJ
NJK V.VV....^.v St.; % Dist.; bet. cLao ' ■., . , . •. and-
/ ,r DE.TH OCCURS .w*Y TROM USUAL RESIDENCE a.vt r*CTS called ^onj^oz^ j;"'*^ '^^^J^^J'^"'* )
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTli^D OF STREET AND NUMBER. /
)
FULL NAME
a
I <
><tHCUL^
^'■^ (hn
PERSONAL AND STATISTICAL PARTICULARS
v|
c
n
1» All: ( >I UIK III
\« .1-
Ml. nth
b
ll):»vi
5,./
M ,>illn
V< at
Ihi
siN(,M- \!Akun:i>
\\ I i)t >\\ i: It < »K i>i\< ii'i !•■ I)
iWiit' in ^iiiial di -ii'iiat I'lii)
HIKTin'l,\»»
'St.lti or ('H! lit 1 \
N\MJ', nl
lA riniK
HiKiiii'i. \ri-:
«»i 1 \ rm.K
(^)t,iti <i! i"iiimtf\
\1\im.N' N\MI-
.11 MoI'Ili: K
lUK rupi, A»i",
()l- Mu'l'in K
(stall -1 *'-iinti \
occri'A rioN
K\M,If,l in San I'uix, ;
IX
\
1
\ K ^ .^
,L-'
U
r../
M.nill, V. //,/
Till- MtoVJ.ST\T1l)PKK«;«)N\l.l'AKTUri,\KSAKr. TKfH To
ni;sT«>i Mv kn(»\vi.j:i)<'.h and lu.i.n-.h
in-;
NjlLvok/CuX
r\.i.iii
"W^
v^-w \
Medical certificate of death
DATH OF I)1:aTH
,.A
(Mi.ntli>
(Dav)
I go
(Year)
I llI'lklll'A' CIRTII'V, That I atteiukMl (U-ccased fn^n
t
L 190 H to Uc^ '5.. 190 i
that I last saw h .- alive on W CX '5. 190 S
anil that death ncciirrcd, on the date stated ahove, at ! •
M. The CAl si: Ol' DI-.ATII was as follows:
M rLiryxAy-yxXlAxxX ''lbjw>^xc\
DT RATION
c oNTkim r<»KV
nr RATION
( SIGNED )
Yea
Mouths
Pax
Hours
Years
Month
Pin
'S
A 1
^\_
Hours
M.D.
(Address) 5Hb O^UXLiH.'
Special information only Jof Hospitals, Inslitutions, TraJisieiits,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
Wtien Has disease contracted,
If not at place of deatli ?
Now lonq at
Hare of Oeatli?
Days
ri.ACK oi- niKiAi. OR rj;mo\ai.
1> \I'J: .it" Hi KIM. lit RHMo\AI,
l9/ct S% 190H
^A^Xi^tV
/a. .w
. TT A,.p «hoiilil be stateil RXACTLY. PHY8ICIAISS should
„. B._Kvery Item of information should b. c„r«fulfy «UPP'- • „^^ f^,!^ ",„Uwird. The -Special lnf«r„u.ti«n" for p-r-
state CAUSE OF DKATH In pliiin terms, thot it mtiy be properly uaiiemeu.
Aon« dying away from home Hhoultl be given in .very inntnnce.
t
"'■•I>.
. • ' »
•^.Ai
.''I
t
4U
i*
i^' '
<*.♦■
'a
^v ■
; '
LOCALITY OF
RECORD S
SAN FRANCISCO
COUNTY
S AN FRANCISCO
CALIFORNIA
HEALTH DEPT
M ICROFI LMED
FOR
( ■>
T H E G EN EA LOG I CAL SOCIETY
OF SALT LAKE
C I TY
UTAH
C A L I FORN I A
DATE
APRIL
1
1975
PH OTOGRAPHER
MAX JOHNSON
CAMERA ■no2683" RED 1
I
VOLUME
RECORD
"■
300
t ^.
* ',
■- /
' ," 1
«»
k
lw>.
.,>
>•-
I '
• * I
•
mwm
LOCALITY OF
RECORD S
SAN FRANCISCO
COUNTY
S AN FRANCISCO
CALIFORNIA
DEPT
M I CRO F I LMED
FOR
T H E G EN E A LOG I CAL SOCIETY
OF SALT LAKE
C I TY
UTAH
CALIFORNIA
DATE
APRIL
1
1975
PHQTOGRAPHER
MAX J OHNSON
C AMER A MnO 2683M R ED ]
VOLUME
YEAR
RECORD
CERTIFICATES
J
301
:6
4
I
EGIN
i I
•<..»
i
^
of ^'
"
, )!)(-. \M^^'
ea
V V
Bjy
OE'"''^^'
•l
WRITE PLAINLY WITH UNFADING INK
Hnnr.l ,,( H.Mltli 1- No. i '^ ■?-'?;Scp;'A;) USc IT.,
/)((/(' Filed ,
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2301
Ec^istered J\^o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(No.
PLACE OF DEATH:— County
.a.
Certificate of 2)eatb
-i\j J ,A.a'>vCi^. C.i. City of ^ /O^'^vx;
St.;
Dist.; bet.
.{rTd.ai5.>.^xCli(. and
UNDER "nSPECIAL INJfORMAT
K.<X\.r^'\. )
( - ;;^i;i^^c:^R^v,?'- ^^t --|^?ij^^;^^;ij^m^ .^^" x:ivr\^^:z^- )
/^
f\
FULL NAME J^t
n
^l.X
PERSONAL AND STATISTICAL PARTICULARS
ftldl
r
1» AIi: » »f I'.IK Til
\ « . 1-:
(\
ipil..uth
D.iv
,'n
M,n,{ln
Iht
SI\r,l,K. MAKKIl'.n
WllXtWl'lI) <»K l)I\< X-S 1 I)
Uiit'-in ^iK'ial di -i-.Miat i< ni >
i!iR rm'i, \»'i^ \
' Statt 111 I'oiintrv s I
A
ci^C.
V
NAMK nl
FATm;R
TUKTniM,.\t.'K
«H lATIIKK
(St.ttf i>r Counti V
MAIDKN NAMl
<)!■ MOTHKK
HlKinri.ACK
«)J- M»>THKK
i Stall or Country 1
4 I I -• ■
i
I go
(Year)
MEDICAL CERTIFICATE OF DEATH
DATH OF DlvATH j ^
(Month) (Day*
I II1':RI':BV CIvRTII-V, That r attended (U-rcased from
^'.^■t: ', 190* to v.d' 11. 190 H
that Mast saw h .'■- alive on W - >^ '^ 1<P
and that death occurred, on the date stated above, at
M. The CATSlv OF DliATH was as follows:
o
^cu
4 .
l^i
ClI. ^ -^ -^ Ml
iCC^^'.^
(^.
d.xxA^o-'vC^ •
Oivtl'A rioN
KfM'di'ii i>l SiUt /'l il II, /•
rvl )v,/
M.'iitli-
I hi v.
T.lHAHOVKSTATKI>I'KHS.»NA1.rXKTirri,AK«^AHU i-Kl K To THK
HKST OF MY KNO\Vl.F:nc.H \Nn HIJ,I1.»-
(I iifoimant
Addrt-ss 1 6 I
a
Mk(X
tXA-Aj-CUx.
i
DC RATION
CONTRIIiU'
)Var5
Qflojt^
Months Days
Dl' RATION )'fV?r5 Months Pays
(SIGNED )... La • Ob. vwo. .A.A«a^V'
.ned)..LI- ob. vi
%)s:iu..X^ iqoM (Address) 5 0 a. 6^^
Hours
.), .. -....i
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death?
How lonq at
Place of Deatli?
Days
I'l.ACH «)1- nrKlAI. OR KHMOYAI.
rNI)F:RTAKKK
(Add I CSS
— ""— "■"■"■"""■"^ 77i \ II «..„«r.^d AGE should be stated EXACTLY. PHYSICIANS should
N. B. Every Item oi information should be ^"'•«^""y «"P^ ' ,y classified. The •'Special Information- for psr-
state CAUSE OF DEATH In plain terms, that it ma> he proper y
Jo^s dyini awy from home should be H^iven In every instance.
WRITE PLAINLY WITH UNFADING INK —
I'.oanl of Health -I- No. is "^"I'-^J-i^ H-'^l' t'o
I)(f
te FUe((MA-jX>^^ 13>
VJO\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered ^'o, ^-o02
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( Vl. S. StanSacS )
PLACE OF DEATH: — County ofO-OAV 'J,\XX>\ct-<i,C' City oiOo/y^j^KXK
(No.
(
an
d
and
V..acl\' St; ^^ Dist.;bct.
IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATI
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE
ON" '\
FULL NAME
:tr-CLLu^-U)
-tH-
PERSONAL AND STATISTICAL PARTICULARS
si;x r\ -» I col, OR > A
\<xXx
DA'l'l". OI' iilRfJi
A<-.i-:
(Moiuii)
) V',/
Day
M.'tith^
(Vt-ar)
Da V
\\i IX )\\ i: 1) » iK ni\'oKri:i>
(W'lit! in --iHial (U'si<.f nali m )
BIK THl'LAOl".
'Stat< or i'nmiUy
,1
>uo
Ojy\} OXx^-vx^^<La
N \Ml' Oi'
1- A Tlll-.R
niKTHPl.Ai'K
OI-- i-Arni:R
(Stall oT Couiitryi
MAIDI.N NAMK
OI- MOTIIHR
!UR rm'LAt'H
(>!• MoTHKR
( '^lat' I .t Cuttiitry
oiori'A rioN
^ r I
CMrl.^-
O^La.1^
i I
' La.\' '^ (i,<x.cc'
A'f^iil/if III Siiii /■! ,111, /',-,> I )'r(irs u .^fiintli> ^' I >,
THi' M'.ovi-: sr A ri:i> pkksonai, i'aktum'i.ars ari-: trii-; to Tin-:
lil-:sr O]- MV KNoWIJ-.lx.H AM) lU-. I,!)-",!-"
nnfoiinant
1 4^. -: \ t
MEDICAL CERTIFICATE OF DEATH
DA'n-; oi-' i)i;atii o ^
\]
Ktr
(Dav)
TQO'K
'Yearl
< Month)
I llHRKliV ClvRTlFV, That I atteii.kMl tlcixasod from
li/<db. "^ iqo'l to ©/ct U
that I last saw h !' alive on U^ i^ I90
and that death occtirred, on the (hite stated above, at ^
LL >L The CArSK (>1« DlvATH was as follows:
^X^A-XoaX^Jxa^,
I )r RAT ION
)'i'ars
Mo>it/is 1 Ihivs
r.
Hours
CONTRIBl'TORV O^wCrvxJL -O^^i A'^'^ <^
DIRATION
^'xat's
(SIG
.E.) kl%
Mouths
/htys
//on
rs
A
190
(Address) Tb^
boL/^
M.D.
V^A^<X
\t
SPECIAL INFORMATION only for Hospitals, Institullons, Transients,
or Recent Residents, and persons dying away front home.
Former or
Usual Residence
When was disease contracted,
If not at place of deatfi?
How long at
Place of Deatli?
. Days
I'UACK OF HI KIAI, OR RFMoVAI,
I)ATl-;of HiRiAL or RKMoVAr,
T90
N. B. Every item of information should be carefully Kupplied. AGE should he stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information*' for par-
sons dyin^ away from home should be &iven in every instance.
f
r
WRITE PLAINLY WITH UNFADING INK
Hoar.! of H.-mUIi-J' No. i^ **^3£:?* »*'^1' *-'"
Dufr Filed ,
IS
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\''o, 2303
,^UwA.d ckjl/U-Vi
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiftcatc of 2)catb
( "CI. S. StanC»ar^ )
PLACE OF DEATH: — County of Oc^^' O.VavvC.^r< City ofO-CV^^ O.rvov.^^4 •
(no. M "0 1
(JO
St.
(
^sL, r., -
\r dtnTM OCCURS »w«y fROM USUAL RESIDENCE oivt FACTS
rr Dt«TM OCCURRtO IN A HOSPItAL OR INSTITUTION GIVE 1
Dist.; bet. 1'3^ Ci\^ and 5.?.' V <■* )
TS CALLED FOR UNDER "SPECIAL INFORMATION" \
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^\^1A l.^\a\J
Q/Z.tJLx.':
r-
PERSONAL AND STATISTICAL PARTICULARS
si;.\
iTiowU
COI.oK
DATl': oi" lUKTH
Ar.K
l(^
4
(Day)
M. nit It'
A"-'
( Vt-ar)
Da 1 5
SIN«.l,K. MARKIl'.I)
\vinn\vi:n <»k divokckd
iWtitfin xiM-ia! <U*iLf nation)
WA.A'VC
r>i
lUKTlllM.ACK
(Stati- <ir Oountt V
NAMl-: »>l-
FATHKR
lURTHPLAOK
<)|- F ATI IKK
(Statf or Conntiv
M A 1 1 > !•: N N A M 1 1
«)1' MctTllKR
0^
i/(X/>ru 0 KXX
w _ » V-^
ii
"s
IUKTIiri,Ai.H
(M M(>rni:R
(State or Cotmti v
OCCri'A'IION
MEDICAL CERTIFICATE OF DEATH
DAl'l-; (U- DlvKTII
(Month)
( Day)
IQO 1
(Year)
I III'RI'HV CliKTIFV, That I atteiuled deceased from
iL}.ct IC) i9oH to Ut:±... I'S . 190H
that I last saw h ^. » alive on ^ ' CV i ' 190 i
and that death occurred, on the date stated above, at 0 l -
M. The CAUSIC OF I)I-:ATI1 was as follows
DT RAT ION Years
CONTRIIU'TORV
Mouths
navs
Hours
DIRATION
(SIGNED)
/)<7|,s
Krsidfd in Siiii /'i ti it, /•■t\
) 'ta » T
yfontks b DiJ I >
rin- \HOVF. ST\ III) I'KRSONAI, PARTIOri.ARS ARK TRUE TO THE
HHST Oli-^IV KN<»WIJ:I)0K AND BKUKF
(Infotmant VJ yrVC/VS^iv
f \.1.1ri-ss .1 61
Q^
Years .^ font /is
3i iQO H (Address) XVWs \|JX^■a/>vt -It
/flours
M.D.
nsfftt
SPECIAL INFORMATION only for Hospitals, Insmutlons, Transleiils,
•r Recent ResMents, and persons dying away from home.
Former Mr
Usual Residence
WkeH was disease cMtracted,
If lotatplaceof deatk?
Now loRf at
Plareof Death?
Days
LACE OF BT RIAt. OR REMOVAI,
PI, ACE C
^%)
DATKof HCRIAI. or REMOVAI^
0,^ IS looH
(.Address
110, I
IS. B. Bvery Item of lnform«tlo« •hould be carefully «ii f? '• * OWmhouW b« sta^jiXACTLY. PHYSICIANS ahwiM
state CAUSE OF DEATH In plain term*, that It r in c .p«#|y claMlfted. iHba "Special Infformatlon** foi>
•on* dying away from home should b« glvsn t« ^ui^ lastanca*
:i
4i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,,.„ „r n. .UU K No . ^-S^^ .u".!' CO REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
304
i)<t
to Fihul}jAA}^^0\j 13
190\
Registered J\^o.
cLcrvvw^-^
Deputy Health Officer
DEPARTMENT 0? PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( xa. S. StanOarD )
PLACE OF DEATH : — County of O^X^-v
JA.
o
d
f3i^
■ CA.A-r.'. City of U/CL/^-X' 0,a.<X-\a-C'.
rw©. 0 JlAA>A.a/^\J (]bChMxv.l<XL St.; — ■Dist;bct.— 7- and - -
/ ,F DEATH OCCURS AW^ FROM USUAL R E S I D E NC E G. VE TACTS CALUED ^OR "NDER Jf^'^i ' J" ^°;;*;'„° '^ ' )
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
\'yki..A
!
4
si: K
PERSONAL AND STATISTICAL PARTICULARS
COl.OR \ (j
f
M.vvy. t)r' iiiKTii
5""""M
A(',i-;
H -,
)'/■<// .
M.nilh^
(Year)
/).7 r.
siNf.l.K, MAKKIKI)
WtnnWKn OR DIVoRiKI)
(Uiitcin social (Usi^'iiatioii)
BIRTHPKACK
(State or Country
NAM}-: oi-
1- A riii;R
BIRTH ri.AcK
()|- 1 ATIIKR
(Stati- or Country)
MAnn:N NAM1-;
nl- MorilKR
niRTnri.ACK
iW MoTHHK
(Statf or I'onntry '
ID
r
U.u
Xjr\j M I. V
oi'CfrA'flON f'^
fCr-^iiffif lit Siiu /'i mil i.uti
) tUl I .
* .^f<ni//i'
Pa V.
rni- \H()VK STATJ-.I) I'KRSONAI, rAKTIClf.ARS ARK TRIH To THK
iIksT of my KNoWI.l'.IX'.K AND »HI.I1:K
IiifotTuant
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH 1 1 \
(Month)
(Yfar>
(Day)
I !I1';K1';HV CI^RTII-V, That I attended deceased fron
V, cl. H up M to L' c;t li 190',
that 1 last saw h a. . , . alive on W CA^ tl 190 ^
and that «leath occurred, on the date stated above, at 10
M. The CAlSlv OF Dl-ATII was as follows:
Dr RAT ION
}'cars
Mouthsi Pays
CONTRIIU'TORV J Axl>XN-^S<^wJL<Xhj. oi
Hours
DURATION
(SIG
Years
Mouths
NED) A.yS Ccririi/>xL.
(Ad.lress) JxK.^>
I"
Pavs
i.. \\_A
90
n
Hours
M.D.
Special information on'y ^or Hospitals, Instltulions, Transients,
or Recent Residents, and persons dying away from home.
Former or n ( /r
Usual Residence \k\D^
When was disease contracted,
If not at place of death?
How lonq at
Place of Death? -^ ... Days
OF ni'RIAU OR RHIMOVAI. 1 DATR4>f Bt RIAI, or RF:MoYA1.
(Address
ri,ACK
fNDKRTAKKR flU-^xWUJ i OO. .^
(Adclress...!lD 1' . S Xiv Bit
N. B. Every item of Information should be carefully supplied. AGE should be staked EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for per-
sons dylnft away from home should be given in uv«ry instance.
JB^
WRITE PLAINLY WITH UNFADING INK —
1)
nlo Filp(lM<^.A>^Cr\j 15
li)0\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
isos
Re^istci'-d Xo.
ll/vvu Deputy Health Omcer
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
Certificate of ©catb
{ "CI. S. StanDarD i
PLACE OF DEATH: — County of OCX^ Oxa/^VZAACt City of ^0^-^-\' ^ AXJ- -^ " v -•
Wn.
%^
aU
-Yvfcu (jb^-iwl^' St.;—- Dist.;bet.
and
- )
A / ,r DtATH occursVaway from IuSUAL residence G.vt facts "^^/-^ ';f " "^°" ^'^^"^^^^^^
11 ( ,f death OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBtR. /
Aj vJ- O Crujj<xL ixau
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
I coi.oK ^ , 1
i)A ri; «ii- iHKTii
A< .1-;
tl
f\hXj
Mottthl
5V-,
'T
i i'
I Day)
V .u'>n
Vi
/
» tar
A J 1 .V
-IN'.I.i:. MARKIKl)
\\ IlxiU HI) OK I)IVt>Kii:n N
(Write in <^ucial dt-si^'nat iim)
lU.ccl^
HIRTUri, AOK
' Statr iir t''ntntry
N \\ti-; <)i'
I A rni'.k
niK liiri.Ai'i-:
n! ! \I"HKK
^lal' I ir (.'onnt r\
MAilU'.N N'AMi:
BiR'rmn.Aci>:
»)l MorilHR
^tatf or Country)
fS
I * -^
J
cjc4^xa^<xLk
1
LU^<X,
Ilia-
KKAJrO^K
« uHl TA rioN
K^fiifeif III San f^iaiui.-m Au 5V<7;a
rb
.\r,„itii^
Par.
(InfoTnifint
VWV \noVK STXTKH I'KRSONAI. rARTIClLARS ARK TRri-: T« > TIIK
linST t>l";4V KN(>\Vl,i:n(,KANI) BHUIHF
DATH OF I
MEDICAL CERTIFICATE OF DEATH
.KATH jQ
(Year I
11^ ct IX
iMonth' <I)ay<
1 lIl'MxiniV Cl'.RTII'V, That I attcii.lcd dtH-case.l frnm
Ct ii 190M to L) ^ 11 190 H
that I hist saw h .. ahve on w Sl\j 190 1
aiul that death orcurrcil, mi the date stated above, at I 10
M. The CAT SIC Ol' I)l':ATn was as follows:
DTK AT ION )'t'i7rs
CONTRIIUTORV
J/o?t//is
/><ns-
//oios
I )r RATION }\-ars Mout/i.s
5 \A. Ob/Q->N±.
f^avs
(Signed)
Ltti \X
Tqo
1,1
(Address)
v&
Hours
M.D.
0 0b(Kk^U.l
Special information only lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away froni tiome.
Former or
Usual Residence
b I H JvLOAAAA.4 J I Place of Death? 1
When was disease contracted.
If not at place of death ?
t
Days
DA'n; of IUriai. or RKMoXAI.
PI.ACK OF niRIAI, OR RJ'.MoVAI.
l-NDHRTAKKR UtOXA \. Uj \J (Xil\U^.
(Address ^ Jp^b UJ/O.A>KA^^'>-Oyt>
190 \
N. B. F.very Item of 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 4iven In svery instance.
WRITE PLAINLY WITH UNFADING INK
}?,,nnl of Healt}v- V Sn. .-^ t-'.-^W) H&I> Co
Dff
to Filed !\U.Aj^^ \'h
190\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begistered JVo, J^oOo
* I _ ^^ I 'k.
i r
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( XX, S. StanDarD )
oi Q Cuyv 3 )^<^Jy^J<:^J^y<^o City of UjCKatv J A.cx.>a.^^ulcx)
PLACE OF DEATH: — County
N
o. ao^
n (N
St
Dist.: bet.
ib.1
t\i
and
t
,' " ' " " .„ r„«„ iie:il»l PCCIDFNCE GIVE FACTS CALLED FOR UNDER "SPtCIAt INroRMATION" \
( '^ ^F"D;ATH^OCC^%;rD^"^Ho"s^VT*AL ?« fN^'^J'^^'o.VE .TS name .NSTEAO of street and number. )
FULL NAME
.0
1
i-YV.
„L.ru^tA
s 1-: \
D.VIV. ()!• P.IKTH
A*.}-:
PERSONAL AND STATISTICAL PARTICULARS
, I C(H,(>R \
,j<w
LI.
I
.7X
jy\Jb
/i (Month)
)V,/
1^
(Dav
.1/,. >////'
(Vt-ar)
>
Prz I .
SINt'.I.I". MAKKIKI)
\\Il)t )\Vl-:i) OK I)IVnRcl-;i)
(Write- in Muial dt-sit'-iiat ioij)
I!IHTni'I,Ai*K
I State or «/ouiitrv
\ (^ (1
MEDICAL CERTIFICATE OF DEATH
DATE 1)1' DKATII
(Year)
(Month) (Day)
1 HEREBY CI:RTI1'V, That I attended deceased from
ct U icpi to U^fc IX TOOH
190 i to
that I last saw h '.. > • alive on
T90
and that death occurred, on the date stated above, at Ij.^ -3
- M. The CAl'SE t)E DICATII was as follows:
OXiUwA.
-CU.
OOu-r\j 0 A^XX^YVC C4. wO UO.'
NAMi: nl-
f- AlUlvR
. \ I
)>^ •
01* I'AI'UKK
(Statf or Country
MMIU'.N NAMK
()J- MoTIlKR {
niK'ntl'UACH
<>l' MOTIIKR
(Statr or Country
f
o
I
IK
OAXX kG rV
[^
11
OCCtTAlION
f\/'>i(iri1 III Sim 1) iiiii ni'o
Axac'
DC RAT ION Years
CONTRIIU'TORV
Months
Days ■ Hours
DTK AT ION ^V'li:-^ Mouths
(SIGNED)
0-t .
Days
TC)0 I
(Address) ^H'l" IbA-k vVt
/fours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
)>(/ / A
Vm;////.'
/),r
Tin* MtovK ST\ ri'.n pkh'sonai, par net i.aks ahh trck to Tin-;
Hi;sT ol- MV KNoWI,i;i)C. K AND lUlUIl'.K
(Itiformant
UjvlivuA; \9. \^J^\^Xx
A<l«lri'ss rfvO O ^ /
I -Jl
Former or
Usual Residence
When »*as disease contracted,
If not at place of death?
How lonq at
Place of Death?
Days
I'l.ACK OI" nrRIAI. OK RKMoVAI.
DA.ll-.o! Hi HiAi. or RKMOVAI,
(Ad<irfss Xb b.b M rtv:^'«^^Max,..uli
IS. R Every item of information •houfd be carefully Hupplied. AGB Bhould bo stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
sons dying away from home should be given in every instance.
WRITE PLAINLY WITH UNFADING INK
I'.oaul lit lit .'1th -I" N-
^•?^i«r^ ikSii* Co
Date Filed ,
ho 15
190\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Beo'ustej'ed jVo. 2307
AjyVhM
m^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
PLACE OF DEATH: — County ofOo/^v J'vo.^vcv^ccCity of vJ<X,^v J,Xa .-:•
UAxtuxl I— • - - • > ^ - ':•-> ' T^-*-' ^*- — — — — »"'*
.^A-Vl*VQ/.>XC
t >v
su
Dist.; bet. — ~
7(;:.7,;;;^ us'u.t B"ToiNCE_.,v_t,..cTs;«LL_cn ;o_-^-»cj ^^'.'^I'ijrrre"',""" )
( •' r"„r.,^^^^c■;r»^"T-o,^r.t r„^?^^%"Jv^or<f,;r,;i nam. ,;s,„o -; =,-... .«= -..-=.-.
<^
FULL NAME /^-ay>^
^
llxl
-S-.
^i:\
PERSONAL AND STATISTICAL PARTICULARS
COI.oR \
V]U
V
DAl'i: nl lUK III
A< .1-
M.-iith
I
l):.v
M.„ilh.
IS
iVtar)
/'<n
MEDICAL CERTIFICATE OF DEATH
I>ATH Ol- DKATH
»-^ ywA^
(Month'
/(JO
(Year
(Day)
I lllvklU'.V Cl'KTIl'V, That I attciukMl tlcct istd from
to __ -— i(jo
1^
•^ IN". 1,1' M\Kun;i»
WIIn )U KI» «»l< 1»!\< tki I'D p
iWritf in ••iK-ia! ih "-u'tiat i"ii ' ^l
BIRTmi. \')
^t.itf <>r t'liunt; %
lliut I last saw h ••— alive on ^™ ^^P
aiul that .k-ath nccurre«l, on the .late stated above, at
M. The CAT SIC Ol' l>i: A Til nv;>:^ a^ follows:
LAMrVC^'
V
NXMl Ml
J- A riii-.K
lUKTm'I.AiH
oi- I Aiin-.K
iStriti or t.'o>i!lt! V
MAIDKN NAMi;
OF MOTHKR
HIK'nil'LAt'l-.
(U Morm-.K
stall .11 (.'ounlry
\
K.<X/rU
u
/t)
J. lL.l
^
«Ki n
AlioNC
I
CL'N^A.'dj^
A
-^ \:
'V
h^fsiiiril III ^iti' I
JV.;,
}h<l!tlt'
/>,l^
Tni' \mn'v stxti'd i-kksonai. i-akti^ti. \ks aki: iKn-: t.» Tin-
BI-;sT nl" MV KN'nWI.l.lx'.K AND lU'.I.II.l
(Itifonuaut
,f ^^ if
■ N I • . ?.
(irrw
't
0
1)1 RAT ION Years
CONTKIIUTORV
Months
PiU
•s
No HP
Dl'RATION ^
}'tars
(SIGNED) UfUmJLh^ oAl^ UJ dJ
1f(>fif/is /hns
LKjx ,
flours
M.D.
^.^
\X TooH r
Ad.lress) LfrXO^vtA^ l^ Jr^-- C^c
SPECIAL INFORMATION only lor Hospitdls, Inslituthms, Tr«insienls,
or Retenl Residents, and persons dying a\*ay from home.
Former or
Isiidl Residence
When v^as disease contracted,
If not at place of death ?
I, -A k I i, \^Ho»» lomi at
i3)00lXUUCKI«>v Hpiaff of Death?
Days
0 fl
'OJ
I'l.ACi: «>l lUKIAl, nK K1;Mk\AI,
INIH;K lAKl-.K >'
DAIJ: o! lUKlAI. or RKMOVAU
iD/ctr I'i 190H
/^'y'wXA
i
^
V
A<i.itt^s \L'<X,kJLo^A,.^cL \^oJ^'
— ^ TT 1^ I AP.F fihoultl be stnted BXACTLY. PHYSICIANS should
N. B. Bvery lt*m of Information •hould be c.retully f"PP"«^J^- "^ ' ' , classified. The "Special Information" for pmr^
•tate CAUSE OP DEATH In plHJn term., that it miiy be properly ciassine
«on« dying away from home should be given In m^^mry Instance.
Ill,
H ;
^
uU^
WRITE PLAINLY WITH UNFADING INK —
1<, ,:,!.! ..r ll.-.dth I N''i
V c
I)((h> Filed ,
M^OO^
W
vj(n
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Eeiistcr('(l' J^'o,
^•^08
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of ©catb
r\
PLACE OF DEATH: — County of
City of ^
u
^ 1
^No.-
St.;
Dist.; bet.
and
)
( - ---^^-.-vrn^^t ii^±^^^i-:hi^i:^^^^^ -:^^ri^or::ir" )
FULL NAME
<tL
,0-'"\^-^iA^
■, h
■~ ^^
PERSONAL AND STATISTICAL PARTICULARS
(■nl,t»k
I) \ 1 1: < >i- r.iK 111
\' .1-
M
M.Hl
' I)nv
MEDICAL CERTIFICATE OF DEATH
DATK i)F DHATll (( \
(Month)
(Day
IQO
(Year)
'U
!/ ,i.
/J.M
-^1^| .1.1' M \K K I! I>
svii" i\\ i:i» »>H k: \t >Kri:n
( U'l itt 111 •"'trial lit -li-' ii.it I'lil)
lUH TIIIM. \>M'
(Ht ' 'unit I \
\
Ul) cd.^^<>-t^u
I m«;ki:BV CI-.RTII'V, That I alUu.kMl .Unascd from
up t.. — — "I<P
llial I last saxv h alive on "' ^^P
and that <Uath uiTurred, nn the .late stated alwve. at
M. Thf CAl'Si: ol- DI'ATIl was •» follows :
X
\ \M 1 < il
1 A I 11 IK
niK THI'I.Ai J%
(H 1 AlinR
~,' l1 . . • t 1 111 lit 1 %
M A ! 1 » I : N N A M J-
()l- Mt>TlIi:R
liiK rm'i.Ari:
t)i M(»riii:u
1 Slate m r>i(ititi >
ru'iri'A rioN
AVv/,//!/ in S.iH /'mm rr.i
Ol V
DTK AT ION y'rttrs
CONTRIIU'TORV
.l/o>i//is
Pays
I lout
DrUATION
(SIGNED)
YiCir^
AFi'utlis
PilV
//ours
M.D.
) r,l
M,>ii!li
Ihn
THK SHUVK ST X ,,..>. .KKSt.NAl.XKTU-i.VH.AKHTKrK T- - TM..
iu;sroi Mv KNOW 1,1, i)«.h \^" 1.1 1.1'^
D 0
(Infoimaiil
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyini away from liome.
Former or
Isiial Residence
Wlien was disease contracted.
If not at place ol deatit ?
How long at
Plareol Death?
. Days
PI \ci* or lUKjAi, t>k ki:m<»v w
lU
,., ^0.0.^ te
^ V > \.xX^
i)\Ti-<i; I'.'iuAi lit ki-;m<>vai,
190
r~
Addt fss
,,, . AGB .houlcl be stated EXACTLY. PHYSICIANS should
N. B._Bvery Item otf 1n?orm«tlon .hould b. -"-"^f^ f"^„l e properly cfslflcd. The "8pecl-l Information" for per-
statc CAUSE OF DEATH In pl«1n {'''-•j^^Jlf J*,,"^^^ rns^-nce.
sons dylnft away from home should be fttven In svery
Jiicnek
it.
WRITE PLAINLY WITH UNFADING INK
I!,,:,r.l .>f llmlth I- N". ir, ^•^.^•;
/i^//r /-V/f'^/, UctcrlMA^ IH
i^y6>4
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llei^istercd ^'o. 2309
.<H^u^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH:— County of
N«.Ot LaUvcV'.. . - . ^ ■■ St.
Ccvtificatc ot Beatb
( "U. S. StanDarD )
-^ ^ City of O/O/^^ 0 AXX >xc ^.
-^
V(X/"NvC
Dist.;bct.
and
)
(^'^^ioc^s.-- "n^r^t r-?^^j;:";^^;i'^«^ ^^°" s^^^n-^r^eir- )
FULL NAME Oa\x>.rv
0 xo, 1
\
PERSONAL AND STATISTICAL PARTICULARS
L
L
WW
Ni.iiithi
\" .i:
NiNi I.I" M NH K n
\\ 1 1 H l\\ J- 1 1 » »K 1 I
\\ • St- 111 -H-iai ■;• -
isiK rni'i. Ni'i-:
«-,t,it • ' '• < '■ .11 n 1 1 %■
1/
» .-III
/',
(Vi-:»t >
MEDICAL CERTIFICATE OF DEATH
DATH OF DHATII ; \
I Month) 'J'^'V^
I lli;UI<;iiV C1;RT11-V. That l atlcn.lca .kceasca frnni
_____ Kp t(. — ~~"190
tliat I last sa\v h ^ ' alivf on ' '^o
a„.l that dr till net ttrrc.l, .-n the .late statcl above, at
M. The CAtSI'; Ol" Dl'ATH was as follows:
n
N \M 1- ( >l
1 AI'll 1 R
15IKIIII'I,\i"K
«M I \iin:K
'-^^i'. . ,1 lllUlltl \
M \!I»i:N NAMl.
i»i M(»rm:K
niK rniM. \ti-:
(H NKillIIU
( Stiti n! eiilttltl N
uo
JJccLcrvAT
juLL*^OwT>^
.V.U.
DT RAT I ON J''"'^''''
CONTKlIUrOKV
>la--o Oc.JLc^v.c
Mouths
/hns
Hours
n
,'V.
n /cuwouTX* 0
I )r RAT ION
) V(/r
^
Mofjf/ts
r SIGNED )Lc\C ^ ^
ly^iLt I'l tnn'i (A.l.lress) llft'XC
..a
Hours
M.D.
1()0 \
I I I I
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying dwav from home.
(HATI
"'■""■UcU
fr\.C\.r.
Ri-^idrd III '^>!ii I 1 1'
M.,iifli-
Ihi
TinrXH<>VKKTA.r.MM^K.nNX,.PXKn.rKNK^AKKTKrK rnTl.H
Ml-sTol' MV KN..\VI.ri).<.l': \M' I.I.I. I' I
AJ^ U ^,
Former or
Usual Residence
Wlien was disease contracted,
If not at place of dcatli ?
How lonq at
Place of Deatfj ?
Days
I) A i',!'. ')! lit UIAI. or Hl'.MoVAI,
11* I.
1 ^ I 90 '
, xoi- <>1 lU HIAI. .•!< «1-:Mm\ AI,
(Tit tlt..vM± ^^
INI
f A.Mi. s^
.. . AHB should be stated EXACTLY. PHYSICIANS should
of informntlon should be cnrefujiy f"PP''^«; ^^„„^Hy classified. The "Special information- for pT-
E OF DEATH In plain terms, that .t may ^^^^
N. B. Rvery Item
•tote CAUSE OH UtA . n m p.«... —■"-_, ^ Instance,
•on. dylnft away from home should be ftUen In • o >
w
RITE PLAINLY WITH UNFADING INK
,! ,,f Hi iMli I" Nn
:.?^'^; M5.PCO
/)^7/r /7//'^/, Lkt<rLt>v IH
190 "{
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ee^i\sf('/'pd JSl^o.
t I
^-CM^j
Dcpt .
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
( 'XX. S. GtnnDarC^ i
fX)
PLACE OF DEATH: — County of
:\
Y\j ■' /V,C .
c\
VI
City of "^ 'ay>^ J ^^xx y vc u^
ffe LCUl "^ Wu.-rjj.J '-'^ ^V ' ■ „,^*•^^,CEa,VtHc^^C^J^D^OR UNDER 'SPEC.AL.Nr^AT.ON)
FULL NAME
4-
PERSONAL AND STATISTICAL PARTICULARS
-KX A
it il,« >R \
M iXolU
11
1» \ I i: < •! iliK IH
\i.K
^INi ,1,K M \H K i 1 1 '
\\ I |H i\\ 1 ! 1 I >!•; p ' ■
\\ ! lit ill :
lUk rH»'l.\*"K
I* A III 1 R
Hiu run. \i !•:
Ol* FATlll.K
'Htntf- nr I'iiuiit ! V
MAIIM.V N\Ml
OF Morm-.R
n:iv
1/,
V. ai)
I K_; 1
MEDICAL CERTIFICATE OF DEATH
DA I'l'; »»!■ DK A TH
iVt-at )
A 0 i
nrx^<nr^ V' '=
I UI-RKHV ClUniFV, That ^I aticn.UMl (kcA-a^cMl from
. ' . loo'l to I ' ■" i')o'^
' 1.1
that I last ^aw h '■ ahvc on ''^ '
and that .U-ath orcurre.l. nn tht- .late stated atove. at I
M. The CAlSh: ()}• ni'.ATll wa- a< follows:
nJVCTN^N-
"^ Qi\v,
-^
lUKTinM. ACl.
Ol- Molin-.K
(Slatf 1)1 ituilUi \
ocerrA'ri<>N( u 1
I )r RATI ON ^'^<^'-'
CONTRIIUTORV
.1/, '/////
'"■'^'■''""•' QK\'''n
KrsitfrJ ni Sn>i ri.iiii i^rn o > ""
Moiith-
Ihiv.
Hl.sTol MV KN()\Vl.i:i)<'.l'- AM) Hl-.l.n.l
(Inl
(SIGNED)
!____ ,
"special information only lor Hbspitals, Institutions, Transients,
or Recent Residents, andjicrsons dying away from^home.
Former or H ^ '3, n ^^« .,,
Usual Residence I'JO vJXoa r .
When was disease contracted,
If not at place of death ?
, How lonq at
" Place of Death?
\<
Days
ly \CK <>!• HIRIAI, OK Kl-.MoVAI,
"L CLlU to.
CXX
DAliiof Hi KiAi. or KKMOVAl,
MOBI
n — — — ^^—^—i ^■^— ^^— *^^^^^ * * ^ FVACTLY PHYSICIANS should
E OF DEATH In plain term., th« .t may »\* ^JJ
N. B. l.very Ite
.tate CAUSE OF DEATH In P""",."' ■":';„,„ .^ery Instance
«nnm dylnft aw«y ?rom home .hould he ftlven In every
'1
i. i
i
WRITE PLAINLY WITH UNFADING INK
]5(.;..r.1 .if lUnUli- I
.- xo I ^ -J-SS^ H&P Co
Jht
fe Wrv^.Q^cbrlo^; IH
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2311
Registered JVo.
DEPARTMENt OF PUBLIC HEALTH=City and County of San Francisco
No.
Cevtificate of 2)catb
( -a. S. StanDarD )
PLACE OF DEATH: -County ofCJOA^ J,\cx>vcv^-' City of
i/(X/>-v
0 ^^^^L'-^VC <..4
St.
and
'special informatio
( - .VorA.°"oc:u%r;.-rHo^s^r.'it o%^?^?f.?u^4ro^;r.rs ?.AM^e .;\^.7o°o? s.^... ..o .u.b..
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
/XkX
I) All-: OF r.iKTii
A<.H
ri.k.u
Uct
) ■«'(7 i
(Day)
( Vi;ir)
Pil vs
MEDICAL CERTIFICATE OF DEATH
DATK *)1- I)1':ATH
'.cfc
(Yf.-ir)
-.INT.l.K. MARRIl-'.n
\VIlM)\Vi:i) OK DIVORvl'I)
(Write in -(n-ial .l.'^iiMiation)
niKTHlM. \i'l-.
(Slate 111 i'duiUi v'
NAMl" <H
FATHl'.R
HIK TllI'l.AOK
Ol' I Ar!li:K
iStati or Country
M \II>KN NAMi: /^ /^
CJ/CLAV OiUXA vCUl^Ct
(Month) 'J>='V*
I lIIUiHHV C1:RTIFV, That I atUn.lcl .U( cased from
ifl dfc II 190 H to ii)^ '3^ 190 H
that I last saw h^^^^ alive on Iki/ct )X 190 '^
and that death occurred, on the date stated alxn-e. at
LI M. The CAI'SK OF DKA'PH was as follows:
uWv
-N
KCy\xt<^
()l- MOTHER
HIKTHPI-ACK
OF MoTHHK
(State or CotUJtry)
1
m
DV RAT ION
} 'ears
1 J I K A 111 ^ .> / c .. /^ .youths H Days
CON T R I lU'TOR V \^. <X^<^ '^VVA,-^^
Hours
4,rwW^A,0*■; '^
nu^^c c
nr RATION
(Signed)
190
Years Months Pays Hours
dA^cc^cua Llv .' M.D.
'i (Address) il5 5 U^cbxA^V<X
SPECIAL INFORMATION on'v for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq away from tiome.
)'*•(?)
I Af,,nf/n tS.J /iti\
THF- .xnoVF>.TATKni'KK-oN-Al.l'ARTUM-l.AKSAKF. TKIK TO THH
liF:ST OF iv KNoWI,i:n..F: AND HF.IJF.F
(Infoiniant
WaaXX/'^a^ VtrV'lXXX. 1
A'Mress
XX'\
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death?
Itow lonq at
I»lare of Deatli ?
Days
VI \CK «>1- lURlAI, OK RF:Mo\ AI.
D^riCof Htkiai, or K1%M<)VAI,
V^
■oX'^rwCV. 1) t
T90
^\drtrc<*s „-
IN. B.
""""""""""""""""""""^ T7. I- ,1 nr.F sSnuld be stated EXACTLY. PHYSICIANS should
-Bvery item o? in?orm»f.on should b. c«reVulIy suppi.ed J'^^J^''^^^^^^^^^ ..g^,,|«, information" for p.r-
state CAUSE OF DEATH in pinin terms, that it muy be properly classitiea. 1 nc p
sons dyinft away from home should be felven in every instance.
i ri
I
WRITE PLAINLY WITH UNFADING INK —
Jioitnl ..f Hialth- 1 N
Dale Filefl^U^td}-^ \^
190 H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTION3
Be^isterecl J^^o.
2313
S
DEPARTMENTOF PUBLIC HEALTH
City and County of San Francisco
Cevtificate of IDeatb
( XX. S. StanDar? )
PLACE OF DEATH: — County ofU<l.C\.<X>>
V L c
J , i^j
City of Q<XyQAJD^'>r\yJL'^^^
/D
No.
CHlK^t'X^
St.
-Dist.;bet.—
and
— )
A^ UUU-NLIVVV.. A.A prS^ENCEG.Vt ^CTrc^rteO roR under "SPCC.au INrORMAT|ON ■ \
( '^ fc°H"occ^%ro\"rHo"s^PrT"^^ o^"^;sf.?u"o^'^c.v. .ts name ..st.ao or STR.ex a.o numb.r. ^
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
^{\J^\jJ:JO^^
S^>\-
^
SKX
il
\<xX
COl.OK
n
uc
.OJxJU
i» \ 11-:
()!
lUKTll
'Mmitlj
\«-.K
'1 (>
5 'ra ) >
(Day)
M.niHn
{
( Voar*
A/1
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH
Id:
(Month)
(l)av)
jgo »
(Year)
I 1II":KI':BV C1:rTIFV, That I attcn.UMl .Icceased from
____ —— - igo to i^P "~~
that I last saw h r— alive on I*)0
si\<-.I.i:. MAKUIHI)
WIDOWKI) «)R n!VnK<Hn
iWiiftiii -iR'ial (l.-is-Miation)
HIKTHl'LACK
(State or t.'imiitryi
1- A iin;R
TMKruri.ACH
'Stati 1)1 I'oniitry)
MAiniN NAMl.
«)). MDl'm-.K
inKTiirLACK
ol- Mo'nil'.K
(Slalt "I C(i\intry
lUiXAAAX
u
an.l that death oceurred, on the date stated above, at
""" M The CAl'Sh: OI*' DlCA'l'll wa^ as follows:
^y~v\An,^.^
DT RAT ION Years
CONTRinrTORV
Months
Pays
Hour
DT RATION
Years
Moyiths
(SIGNED) \ l\ ^- ^ 1^ ■ ^
\K\Jt. \ I ..-„'. ^\ddress) C)
Days
11
IQO'I (
XXXIAXU^W^^
Hours
M.D.
(utMi'ArioN rx J
,\j
Resided III San /'inn, i^fo
)'i(ii
MniiUn
l),i\s
IHJ- MU.Vl- sl\Ti:nPKRS()NAI,rAKIUTI.AKS ARK TRIH To TH1<
iu;sr Ol. MY KNOWUV.IX'.K AM) lU-'.lJI'.K
(Infiirnuiiit
LIvcLhJLcrtlji
Address . J . ; 0 V
WVCL
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying a»*ay froni liome.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatti?
How long at
Place of Deatlj?
Days
PI,ACH Ol" lUHIAI, OR KJ:MoVAI.
INDHRTAKKR ^ <X L
Dyi'i; of Ht RIAL or HKMOVAI,
T90H
dress 1. 5 rXH oX^i-tJi-yLtrk'^ lit
N B —Bvery Item of i„form«t1«n should be carefully Huppllecl. AGB .hould >»• •i-t«i^^'^.^CTLY PHV^'f*^":!® •h°">;'
Ttate CAUSE OF DEATH In plain term,, that it may be properly classified. The Special information for p..--
•on* dying away from home should be given in every instance.
I
WRITE PLAINLY WITH UNFADING INK
,V,ar.l of lUaUlr l' Xo. is ^Cl^^^^i^Sl
T)((fe Filed,
IH
IDO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J^'^o. -^olo
_^\hu Deputy HecSth Officer
DEPARTMNT W PUBLIC HEAlTH=City and County of San Francisco
Cevtificate of Beatb
( XX, S. StanDar? )
\.<XAXCCVC^ City of O/Om; JX.O.^'VCC<LCC
PLACE OF DEATH: — County of
rNo
M
k^.
(IF DEATH OCCUB^ AWAY
IF DEATH OCCURRED I
St.;
Dist.;bet. - - .and^
-)
FULL NAME
si:x
PERSONAL AND STATISTICAL PARTICULARS
DATH or UlRTH
m
AC. K
b
(Day)
Motif h^
\
\%
I Vcnr)
Par
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATIl '^
(Month)
15
(Day)
igo >
(Year)
-C
mNC.LK. MARKIl'I).
\vn)<>\viu> OR nivoKtKi)
i\\iit<-in MK-ial lU-^iiirnation)
I III:RKBY CKRTIFV, That I attended deceased from
^-^ofc 15 igoH to .. tD/cl . .i.2x 190H
that I last saw h -* alive on V^ cX L.> 190'.
and that doath occnrred, on the «late stated above, at loO
* M. The CAi;SI<: OF DllATlI was as follows:
dJ JlJL</VXA.^-/>^kXJ . J
VI
^
J\JL>'^v^ vX^^'w J^
lURTm-KAOK
(Statf or "'oiuitryl
I A rill'.R
niR'nn'i.ACK
oi- lATHKR
(Statf or Cniintry)
MAIDI'.N' NAM!'.
()|- .Mo'I'in: K
niRi'in'LACH
OI' MnTin-'.R
(Stati or vNiuntry
1 1 K.
DIRATION YtiUS Months iO Days Hours
" (3 N T R IIU ' T () R V - ^ /OUfty^^A/vK^ L-O'^vx^X.fiu.^-^- &"^ ^ - ^
i'
DURATION
Years i\fontfis o Pays
Hours
yCXA^U
W
OCCl'l'ATION
Rf
siiifd in San I'l itn, is,-n Ki<i )'r,iis
(SIGNED) JjU. Id. UJ -U^V\A.e^-^ lyi-D.
Q/Ct I'l iqo (Address) ^C^5 Ua.Lt\ve\.a. A
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq away from home.
Miiiitli
/>(i\
Tin- M5(n-l.-STATKn»>KRS«>XAI. I'AKTHM-I.ARSARl-TKrK To TIIH
BK^T 01 MV KN«)\VIJ:I)<-.K AND 15KIJ1J-
(Infoiinatit
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death?
How lonq at
Place of Death?
Days
I'l.ACK OV niRIAI. OK KHMOVAI.
DA Ti: o! HrKlAi- or K1-:MoVAI,
i-ndkrtakkr'^^SA.^cLiav s3<xtx LL^vd^NLo^VU/
(Address . AH%3i M iXuLA-A-^Cnx. . J.t
-vxa W
. ~, V^. ., . AHF Bhmild be stated EXACTLY. PHYSICIANS should
N. B.— Every Item of ln?orm«tlon should be coretuHy suppl.ed ^^^^^^^/^^J^^.^i^ ^^e "Special InformBtlon" for psr-
state CAUSE OF DEATH in plain terms, that It mn> be properly classitiea. me ^p^
sons dying away from home should be ftlven in every Instance.
v.A=^
i
n
Ponrd of Ht.iUli I- N". is
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
31 4
T-^^-K^J- I'.SlP Co
Registered J\'o.
Date VneiiMAjXA>j 14 VJO'i
L^iioK. Deputy Hec^thOfn-^^r ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "d. S. StanDarD )
(^
PLACE OF DEATH:
"V
County ofOCL^ 0,.V<X vvO^r- City of ^^X/>^ JX^^V'- -J -
I?
^No.
(IF DEATH 0(
IF DEATH
.fUcLcul:
and
-^!^^^t -^J?^j;;-?^S^^^" -^riN^ -j^r ■• )
~ )
FULL NAME
\Xcc-^..
PERSONAL AND STATISTICAL PARTICULARS
SI
JX/Y\
CO I, OK
OLr,
OTntlthl
AC I-
O I T/'in
(I)av)
Mnuths
(Year)
/i.;
MEDICAL CERTIFICATE OF DEATH
DATK oi- i>i:ath
/C.
:t
(Month)
(Day)
IQO \
(Yfar>
I III':RI';BV CI':RTIFV, That I attcnde.l «leccascd from
that I last saw h
190
to
alive on
lO.ct
190 I
up '
SINOl.K. MARRIKI)
SlXt.l.r. MAKKir, 1'. «
\VIIM»\\ I-:i) OK DIVoRCKI) U fj
iWiitfiti -ooia'i (Ic-i:/ nation) -^ U
HIKTinM.AClC
(State or Country
NAMi: <>?•
FA'rm:K
1UK IHIM.ACK
oi- 1 xriiKR
(Stall of roiintry)
M\n>i:N NAM)
«(1 MorilHK
HIKlIll'LACH
i Stat I or *."onntry)
OCCVPATIOX
Rr^idrd in S,ni /'kiii,
,tJUH
*7 I -
and that death occurred, (»n the ilate stated above, at ^ ^
M. The CAl'SI-: Ol- DI'.A TH was as follows:
I )r RATI ON \ y'l-ars ■l/on//is Days I Ion
ys
?
)'i tj I
A/,,uf/t^
/),n.
iX V > V. cv.xU.0.
1)1' RAT ION Vt^irs
Mouths
Days
/fours
( SIGNED ) «sy. vi . wvcxAryva.'. M.D.
lU^. .11 too'. (Addres.)U\AJUxil/VV^ h
iNED) fo. I. OvcJlrtAX'.
a.
Special information only lor Hospitals, Institutions, Transients,
or Recent Residents, andjersons dying a^ay from home.
Fftrmpr or Ml I Now long al ^ ,
Isiral Residence 1 1) \ I dUXA>UMX <1.\^ Place of Death? ^ Days
When was disease contracted,
If not at place of death ? ■
Till- M5OVFSTATl-0l>KKSONAI<IV\KriCri.ARSAKKTKrH TO THK
liKST Ol' MV KN'OWIJ-.IX'.K AND Hl.UU-.l'
(Infotniant
)Lc^JLm lo Qn\^v^l
\^co„
r\ ^
( AiMrcss
IM.ACK Ol-;, lUKIAL OK K1-:M<)VAI
)ATl'nf HrKlAI, or RICMoVAI.
(Address Ji I ^ G' i .OL^V^VXII .A).i
N B — Bver. Uen, o* in.o.„,ntlon should b. cn.eful.y supplied. AGE should »>« ^^^^'J^^^'^.^i^^^^,^- ,rnl^jfiL^„^, Vr^'^rll
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 i^iven in every Instance.
h' ^' y
mf
1
i
H.);ir.l ..f Hi-aUl! l" N<
WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^^9 J ■ %J
t-'^'^'^^j ]i8cl' Co
190^
Bc^i'Stcrcd J^'^o.
I)((fi> Fi1r(L\Ji^:kJ^ IH
DEPARimENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of IDeatb
( tl. S. StanDar? )
PLACE OF DEATH:-County of 6o^ J ;va^.c<. c . Gty of 0 A/>.. 0 AX^ v. c ^ '^ c
(No
,.ntJ
su
Dist.; bet.
— and
)
FULL NAME
aXIa.o..
f\.^-^
PERSONAL AND STATISTICAL PARTICULARS
;i:\
i I
COI.OR
I) All' <>I- in K I'll
\».i-:
M.lmhi
J
U
5Vu-/
M.nilli^
■> I ai
/),/ 1 ^
1).
MEDICAL CERTIFICATE OF DEATH
ATK OK DKATH jP^
(Month)
1 '■^
(Day)
I lllvRlCBV Cl-RTIl-V. That I aUcn(U<l tkrcasc<l from
— — - — — — ~~~ I90 ~~~' to
that I last saw h -n— alive nii
and that (Uath nccurretl, <>n the date staled ahnve. at
IQO
(Yoar)
IC)0 ~"
190
SINT.l.l- MARKn:i»
wiotiwin OK n:\»»Kri-n
AJacLoa
I »-
HiK Tini. Aoi-:
fStatt iir «.'imnti v
NAM)- 01
FATlllR
BIRTHIM.AOK
iW lATin-tR
(Statt or t'ouiitiy^
MMlil-.N NAMl-
(tl Mi)r!ll-:K
lUKTinM.Ari-,
iW Mnrm-.K
I Statt or t'lmiili N*i
)a
,<Xt\^IA> \
M. The C.W SI-: Ol" DI'ATH was as follows:
1)1 RATION )Va/.s
CONTRll'.rToRV
Mouths
Days
//ours
XC<
LV^Clt
Ol
cLc *» "^
DTR xrioN .^^ )V(?;.v ^/out/is /hivs
(Signed)
T(jO
(Addres-;) W^
//ours
M.D.
w\4
SPECIAL INFORMATION on'v for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq av^ay from home.
( urri' \ I'm:
THl- \HOVl.-ST\Ti:t>)'HKSON\I. 1' \ R I h' r 1 \ RS A R l- TK T K To
" ,u>T (.V Mv KN..\vijn..i: AND iu:i,n-.i-
rni'.
(I
I i I ■, .-< I » ■ 1 • ■ ' ■ ' " ■
Former or
Usual Residence
When vvas disease contracted.
If not at place of death ?
run, onu pcisuns vjt"^ un«» ■•"
lays
Pi.ACl': ()I- lURIAI, OR KlMMVAl.
W\
UkX^^ cL<Xx
KxLcttX/tL
DATKof 151 RIAL 01 K1':MoVAI,
(Address
N Ttc^-A.A.-'<nrX "^1-
N. B.
""""^ ,. .. It 1 \rp ahniilil he stated EXACTLY. PHYSICIANS should
Hvery item of in*.,.m«t1on should b. cnrefully Hupplied /^^;f;^^;7/^'^^^^^^^^ ^*Sp..\Bl Information" for pT-
state CAUSE OF DEATH in plain terms, that it may be properly clossmcu. nc i
sons dying away from home should be ^iven in every instance.
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CEBTIFICATE FOR INSTRUCTIONS
Th
100^
Up mistered ^Yo,
2?A%
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of IDeatb
( tl. S. Stan^arD )
PLACE OF DEATH:— County ofO^X^v OAXu^vcc^
a'
City of Oo^y^ ^^^^
fTs
^0
No. T)^H \-' ' .^Vi^'^-vlVTVO
1
I tl
o r I
(IF DEATH
IF DE*
OCCURS AWAY F
ATH OCCURRED I
n St ♦ ^ Dist • bet ^ ^ '^ ^"" ' "
e
FULL NAME
Ld
%
Lu«^^-^-
PERSONAL AND STATISTICAL PARTICULARS
(.•()1,<)K N
si:\
1<XU
DAll". «>l- iilKTU
iMiiiith)fr
\< . !■;
)V<n
(Day)
M.nilli
\ (.'ar
/>./
MEDICAL CERTIFICATE OF DEATH
DAl'H ol Di: ATI!
(MoutlO
1 ron
iDav) (Ycari
mxi'.l 1". MAKRllvD.
\Vll)(»\Vi:i) <>H DIVORrKI)
(Writtiii •-iK-ial lU-sii^Mialioii)
IHRTin'I.XOK
(Stall or t'ouiitry
1 A 111 I'.K
HlRTHIM.AfK
OI- I AT 111- K
( stati I it I'l iimt 1 V
^^ mi)i:n namK
1)1 Morm-:K
111 Mnrni'R
. ^t ,) , , ,1 k' , uinlt y )
I in':RI':BV CIIRTIFV, That I attoiuU-.l .Urca-^cal fruni
Jcl- ,. I90*^ to iQvCt- "^ '^>o^
that I last saw h^ -. alive on - ^90^
an.] that death nccurre.l, <hi the date -tate.l above, at ^ 3Q
(B
M The CM'SROh' Dl-ATH \va< as follows:
rvO-'rv.'C^'^'wO
rs-\XA^K. A .
)rRArH)N )'rars .Months o Ihivs
I lour ^
\ju\<x^
Ytatis I Months
NED).LLma; 0.
DIRATHIN
(SIG
Days
OJx
Hour a
M.D.
^'^
Special information on'y lo^ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
5 V'((/
Mnllth>
Ihn
THI- \H()V1- STA-n:i) I'KR^ONAI. I'A H I' U' I " I A R s ARl- TRIK
HHsr ()1^ MV KNOWI.KIXU-; AND lU-I.iHK
ro rni-:
(DifoTinaut
Ol(...c.-.. ^^v
V I .
(' \iMi(,-s
TXH UU/Y>XJtA^lAy\va. '^U
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place of Death ?
Days
I'l AC1-: <>I lURIAI. OR RHMoVAI.
indicktakkrM IV 0 CUTvCaX
D\Ti:.>f Hri<iAi> or R1-:M()VA1,
T90
(AcldllSH
tu
,\J5^^,A^~'* w
, ., ,. . APF shnulil he stated EXACTLY. PHYSICIANS should
N. B.— Bvery Item of Information shoucl be crctully fuppi.ed J^^J;^^^^/^'^^^^^^^^ ..gpeclal Information- for pT-
state CAUSE OF DEATH in plain terms, that it may be properly ciassniea. i nc ^i
sons dyinft away from home should be jii%en In every instance.
t
WRITE PLAINLY WITH UNFADING INK
n.,Mt<l..f !I,:,M]> rN.> ..'^•g^^L-Hfcl'C.,
I
/>r//^' Vih'd ,
IH
2.9 6>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
<)jLa^
DEPARTMENfOF PUBLIC HEALTH=City and County of San Francisco
Ccttificatc of Beatb
( n. S. StanDatO )
PLACE OF DE ATH : — County of
8 3
I > v.'^
/"^ '-^
City oiKjaJLLo.
rN
o. S H S \Js\JJ^J^
St.
Dist.; bet*
— and
FULL NAMEQct'^-^^ ^ ^ ^'
~ )
kV- ^-l
> It"
-^i:\
U
PERSONAL AND STATISTICAL PARTICULARS
i)\ 1 r: f! iUK III 0
!• I.
8xkt
M.,inh '
A' . 1%
L^
Dav
1/., >,','//>
1
IQO
(Year
MEDICAL CERTIFICATE OF DEATH
DATK OH I)i; ATH 9 ,
(M.Jith) <I>='V'
I in-:Ri:r.V CI-RTII-V, Tliat I atlciuU-l .U-t cased from
to ..———-" — TQO
■ itp
190
na\.
HINf'.l.K. MARKIKD
wiiioxvi'.D <>K DivoKi i:n
(Writi^ in -ih i.il (h-vi^'n;iti"n '
BIRT^1•!.^^'1^ (A
'Sta'' 1 >! < "' umli y '
NAM!- <'I
F A Tli IR
BIRTH ri.ACK
(»!• } AlllKK
(St lit iir i'.iutUrv
A
Hl>
tliat I la^t saw li alive oti
aiul that .Uatli ..rcurre.l. ..11 the .late stated above, at
M The CM Si" 01- IH'.ATH was a^ follows
/13
,-^
MAIUJ-N NAMK
tH- MOTHI.R
HiurniM.AOK
oi- M»)rin-:R
I >^latl III i'liuut! '•
ovHrrA I'loN
~\>:^
DTK ATI ON )\ars
CoNTKIl'.rToRV
Monlhs
Davs
Hours
nr RAT ION Years jr<".-f/is
/?<n.s-
(SIGNED)
/fours
)V„'
Month-
/h!
ruV XBOVF STATKU .■KKS..NA1. 1' A K T IC r I. A K S ARK TRl K To TlIK
HFSTUl' MV KNM\VI,j;iH-.F. \NI> Hl-I.lhF
\ildrcss
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq av»,i> Um liome.
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place of Death ?
Days
•l.AOK Ol- lURIAl. OR R^I-'.MOVAI
n
l-NI)KRTAKKR U^Uj-0|^ \£)/U<T^
I)\T1'. of Mr RIAL or RKMt>VAl,
t \H
190H
V 'A
A_
, ,. ,. , KCF sHnuld he stated FiXACTLY. PHYSICIANS should
son. dyinft awoy ?i-om home should be feiven in every instance.
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATt FOR INSTRUCTIONS
HiCll
(1 of II. :ilth 1' N"
I
J)((h' FiJc'l ,
IH
VJO'i
llec^lslcrcd J\^o,
3318
Lt^LvKj, Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of S)eatb
1 Vi, S. StanDarO )
O/rv oVxX^cvi--' City of a,<XA^ Jxxx^CLC. •
%^
No. ^^^
e
A
FULL NAME
a.'d
<^ \.\.w^
PE
RSONAL AND STATISTICAL PARTICULARS
^l.X
^
COI.UK. \
4 I V
1) \'!'l' <»I I'.IK 111
\« .!■
n \
M..!\I'
ISA
EDICAL CERTIFICATE OF DEATH
It
(Day)
I go .
(Year I
DATE oi- i>i:ath ( ^
(Mntltll)
I ni-:Rl':r.V C1.RTII-V, That I atU-n.U-.l (Urcascl from
■" -~ 1 1)0
M,n,tln
/hn.
WIDiiWl 1> < »l< l):\(»Ki' J- 1>
l(.p to
- alive- on ~
that I hi'^t saw h ^—
and that dc-ath occurred, <.n the- <lalc .tatc-.l above, at
M. The CAlSIv OV Dl'. AT 1 1 was as follows:
up
^
C
A^^Jv/tv^«H^^A^^ ^t
"^v^Aa a,
.. .L
lUK rni'i. \^"K
N \\1 I- <»1
!\iin;K
HIKTHIM, ACK
()1- !• A TUKK
(Siatt III i"(iu!itr\'
MAinr.N NAMl-
nl- M*)THHK
ntR'rni'i.Ai 1*,
<»i MO I'm: H
I <!ati ot i oUlltt N'
« n (Tl'A rioN W
>l,v
%V
I )r RAT ION >'«<7r5
CONTRir.rTORV
DTRATION
Months
Days
Hours
(SIG
ct
,TI()N )V.;-5 ^ AI[o,tl>s Pars
NED) Lcr\^rr>JLH^ ^-^/^^ duXamL
Hour
M.D.
,n
T<)0
SPECIAL INFORMATION only Jor Hospitals, InstituTKTTFanslcnls,
or Recent Residents, and persons dying away Iron home.
I ,.
AV ;,//•/ /" S.tti / i,!H-
t )V.f<
\f,.,ttli^
n,i\
UKST «>!• MY KNoWl.J.lM.h AM) Hhl.H.l
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
. Days
l'I,ACK Ol- nrRIAU OK KKMOVAU
1) ATI'. <)! HiKlAl, or KKMOVAI.,
CtJb iH 190H
N. B.-
^ ' T' ,. H AGB should be «tated EX4CTLY. PHYSICIANS should
-Every Item of information should b. carefully supphed AG „«,,H-.cd. The ^Special information- for psr-
state CAUSE OF DEATH In P'«'" J^r-"'' ^j^" „'*,,"^;^ rnstance.
sons dylnft away from home should be ft.ven .n every m
I. t
i
Wl
R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
^^. „„, HEFER TO BACK OF C-^'^-^^r FOR INSTRUCTIONS
(>Ur^^^
Deputy hiealth Offi
lie <^ isle rod •A^'o.
DEPARTMENTOF PUBLIC HEALTH-City and County of San Francisco
Certificate ot Seatb
( la. S. StanC<arO )
PLACE OF DEATH : - County of 0<^' ^ ^<^ ' ' ^ ^.ty ot ^
r I a< ' . ^ ■ St., a Dist.; bet. '^^i^e^.ilff^u-X '
)
FULL NAME
(^
-^\. > V.\.
si:x
PERSONAL AND STATISTICAL PARTICULARS
V
I
!) \ ri: t>i- lUK I'M
L
4
axH
MEDICAL CERTIFICATE OF DEATH
i' Month)
IH
(nay)
I go \
(Yt-ar)
, M.i^ltll)
Ac^H
M
\ I )V,M
! 1 . \
M.niiln
Vi at
/^./)
--IN. ,1 I- M \HH n"i>
I \\ I it'- 1 11 ^1 11 i.i; iii''i' ii't ;• '- ■
^^[Koov
xo-'cL
"' 1 in-Kl-l!Y C1:rTI1-V, That I atUn,U..\ ,lccc.nsc-.l fron,
Cllvvd a upi to a^t 1^ upH
,„„^ nas. saw h -^ aliv...,, ^ ^^ i^ .^ ' >
„„HI,at,Uatl...ccurr..l, M„tlK..laU.stal.-.lal.,.vo, at .i
j.. M. Tlic CAISI' til'^ilvATII was as follows :
(0
0
^ru
L
11 1
V
lUKl'Hi'l.Ai'l"
I st.iti or ^'^ .iiiil! \
\ \M1 ni-
1 X'l II 1-R
(n 1 \rin-:K
«,! I- . I ir <.'iiiiiitt V
M Xini'.N NAMK
(»1 Morill'.K
HIRTHri,AiK
oi M(>rHi:K
( Stat.- Ill t'oiuitry!
ofcri'A rn>N
,yy,^jLA IvXakjyxJL
I )r RATION 1 y'-^Jf'-^
CONTRliirrnKV
MonI/is
Pax
Jlours
n
1
e
f)
DrKATlllN
(SIGNED )
jr,y>tt/is
)'ttirs
, 0 J OJvVOJx.
/)</l'5
//ours
M.D.
\H iqoHJjLlU
Is, Insltt
SPECIAL INFORMATION only for Hospital
or RefeM Residents, and persons dying away from home.
utions, Transients,
D
a . ^0
)V,n '
\r,>,iiii-
Ihn
lU-ST <)l- MV KNn\VI,l,I><.K AND lU.I.H.i
SuJ^idenccVJA/^^.^ ^^
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
(I
,„ ^'?.«c^_ -i--^
t.c^X
DATl'.o! Hi KiAi- or KKMOVAI,
IM.ACH 01-- lU KIAI, UK KKMnVAK
r.M'HR I •'^'^*''* TTs fl I) (*' 1
(9
I
I
I
I
I
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Pff
fr /u/rf/M^<:tJoJihj IH
I^O'i
i^^M//,s7r/'^^/' *^yo.
'^fji^^U
DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of 2)catb
n 'V-, J lop
'V
O.. .^^■
City ofC)xX^-'^-'C^>^-^
I
PLACE OF DEATH : — County of a. >x
n U% S 1 A St.; -^ UISTm OeU .,^„p„ ■special INFORMATION" \
FULL NAME^^ ^
PERSONAL AND STATISTICAL PARTICULARS
-^I'A
J
II il,' iR
(»i I'.iKin
4
M. nl U
^ D.iV
1
MEDICAL CERTIFICATE OF DEATH
^ .wW
(Month)
1 ' \
(Day)
tVcai >
5
I >iir
U;i1
I ^latr i.t *■' 'tin! t \
, niKi:HVCI,RTI.-V, T!,al I a.Un.U-.l .U..va.c,l fnuu
,. ,• ,„„■ to 0^ '^ "^^
thai I l;.-t >aw h alurnn ^ ^
a,„Ul,at ,U.atb -VUTCI, .„, tlu- .la,>. ..a.c.l al,..vc-. at
NAMK «H
FATIIKR
lUK rin-i, \< K
oi? J Arm-.K
iStiitr m riiuiit!
b'lx b 1
. '..w.
^1 Tlu- CMSIiOl' l)l^ATIl was a. follows
CONTKIIUTOKV
Ilotii ^
/></t'
M \n»l- N NAMl
I'.iK rinM.Ai J-:
(II Miiriii'.K
{ St ;it 1 .it il illtit 1 ^
(SIGNED) ^-TiTV^V
//ours
M.D.
Fecial information ohH lor Hospitals, Institutions. Transients,
or Re«^ Residents, and persons d)in^ a.ay Iron tiome.
Former or
Usual Residence
When Has disease contrar ted,
II not at pla« e ol death ?
How lonq at
Place ol Death ?
Days
HHsroi MV KSnWI.l.D'.l-. ^M> "r:'-" '
^M.ACKO^ lUKIM. <M< KI-^NK.VAI,
I1I%-1 » '»■ •■• ' J^ . /^N
(I„f..nnant ^ <XyyK.^^.jJ^ '
ex.. n X^
,,,a,.... IHl h<X>V^^^^'^
\\
rNitJ.HrAKi-.K-
i)\rj/'>! Hi imm i>i ki:m<»vai.
\b
TQO
(XMr.-^M ^ '^ " ■" L ,i_|L L PHYSICIANS should
■ ' ' ' , , , H^ ..rufully Huppne.l. ACf. h^ouIcI »\^..^;"'^^J; ..^..^.i^, Information" for pT-
y, B.— F.very Item n* •.nform«t1«n «houhi »^^:;"-;;7^ ,, ^;,, ,.e properly cl««s.».eU. The t»P.w
state CAUSE OF Dr.ATH In »» "'" ^^7^:;J;"|„ .very Inntance.
«an, dylnft owoy ?rom home Mhoulcl be fe.ve
WRITE PLAINLY WITH UNFADING INK
Dale /-V/r'/, ID-ctXuu IH T'^0\
S
DEPARTMENT OF PUBLIC HEALTH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ec^isterecl ^^o.
City and County of San Francisco
No.
Ccvtificate of "©eatb
( in. S. StanDarD j
PLACE OF DEATH: — County ofOo^x; OTva = City of ^/CX.>v 0
d/CLAV JXa , . ^ St.; -rDist.;bct. — -" " ' and
:v
n
i r- (
fy '
AY FROM USUAL REsTdENCE GIVE FAcVsWt^D 'OI^UNDER l^fffj^i Jq "^u M BE R^ " ' )
/ If death occurs away from usual H ta I UC i^v..^ u.»i. ",'l I,amF i^-QTFAn of stree
C 0 "^ DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
FULL NAME U<x Oo
PERSONAL AND STATISTICAL PARTICULARS
ri II, I tK \ f\
n
n
1 o y
I» \li: «)l l;IK I'll
\< .I".
iNt.nth
);■.!,
.1
!);iv
M.,>,lln
/',(
/
w iiMjivHi* <)K DtyttHrKD
Wiitcitl liticiiti ilr^it'Ilatioll)
IHK rii»'i, \'' 1
/
rgo
(Yi-ai t
MEDICAL CERTIFICATE OF DEATH
(Month) (Day)
I III-:kl':HV CI.RTII'V, That I attcJuUMl .loceascd from
— — — — — - up to 1<P "
that I last saw h .:r— alive (mi _— — ~ igo ■
ami that (Uath occurred, on the date -stated above, at —
M. The CAI'SP: Ol- Dl-ATIl was as follows:
I- A riii'.k
of 1 \ III i: k
^tati nr I iiiiiitrv)
Ul" Moini K
isiK'rm'i.Aij-:
111 Morm-.K
I >t ill . ir fiiutiti \
M
/
( »i'k r !■ \ rioN
^
RciiirJ III Si! I' I'l lUli I-, ,1
^r<niths
Ihiv
Tin \HovF si\rin i'kk-.on \i, r\R iii-ii.aks aki-: tkih To Tin-
iu;sT «>i' >.n KNOW i,i:u(.i, wd nv.x.w.v
(Itil Mtjumt
L<A'CrY%X^^ UXwUL
\A>^^A>J(xAj|^'<f^^
\ ^ A
Dl'kATloN Vi-ar
CONTkir.lTokV
M out In
Pays
//oil PS
DlkATluN
(^
) Liirs
Afoiiths
( SIGNED ) WUTAJUV J .mUJ <ixl
/hiy
C\
//ours
M.D.
^
t<)0 V (/
Xfldrcs^) WuHAJl^^ CU V
Special information onU for Hospitals, Instituttohs, Transients,
or Recent Residents, and persons dying awav from home.
Former or
Isual Residence
Wlien Has disease contracted,
If not at place of deatli ?
HoH lonq at
Place of Deatli ?
Days
I'l.ACl". nv niRIAI, OK KKMnVAI
l)ATj;..f UiRiA!, or Kl':MnVAI,
0^ IH
I \'Mrc
d^.y. y. J vulavvolUxu
INI) !•: K T A K i: K V3 CAXJ-Aj \l. LL Jr k-KAJL ^
T90
IM B. F.very Item of in format Ion ahould hi carefully supplied. AGB should be stated EXACTLY. PHY8IGIAN8 should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The ''Special Information'* for per-
sons dyin4 away from home should be &iven In every instance.
WRITE PLAINLY WITH UNFADING INK —
2^(9H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
%
Certificate of Beatb
( "a. S. StanC>arD )
PLACE OF DEATH: — County ofOaov OX^ix^a. City of ^X^^v J;u<X>vav.^
ft I
,. Ci
f4e X^'^lVvAcVLi, V St.; Dist.;bet. and
/ ,r dk.TH OCCURS AWAY FHOM USUAL RESIDENCE give facts called for under special information • \
( !V'dE*T» OccJrRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
(^ ^^ 5 ^ ^
V ' :^
FULL NAME vC v
)
I t
• ■)
SIX
PERSONAL AND STATISTICAL PARTICULARS ^
m
I) \ ri- <)! niR I'll (f\
Mwiilh
A«.l-
t:-
5
L
I 1 )a \- 1
_\; ■>,///:
/ u V.
(VciU)
/?,n
iW'iiti ill ^noial (U>«is.'n.ui<>n)
HiK rm'i, AOI-:
I Stiitc <•! '.■'Hint I \ I -
W
m-
1- A iin.R
niKini'i.ACH
ni" ! \ rm:R
i --it:!! I 11' i'l lUnt t V
M \ 11 ) 1 N \ \ M K
1)1 Mdini R
lUR rniM.Ari-:
»»i M<)riii:R
w / >
y
^^v^-o ,
KCL/TVJt
(
X.C
k'l- i,{i',l in San /'i iii'i isr,> ^Q )''ii's
A/, '11/ /is
/'<M
rill' M'.nvi* sT\ri:n j'Krsonai, iv\Riii'ri,AHS ari; trtk to tiih
in>r <>I MV KNn\Vl,l-:i)<'.H AM) Hl'.l.lKK
MEDICAL CERTIFICATE OF DEATH
DATK Ol' I)1;aTH
\/c1j
IS..
(Day)
(Year)
(Month)
1 in':Ri;P.V CI:RT1I'V, That I attended »lcccastMl from
B.x^xX ■ J : 190- to . w;cfc. - u. T90 •.
that I last saw h ■:— alive on - —"■ ^~" T90
and that death oconrred, on the date stated ahove, at
M. The CAl SI*; OF l)i:A'rn \va^ as follows:
1
-U|\<^cLo„U,^ AJ<
DIRA riON
}'i'iJ)S
Mo ft //is ^ /hivs Hours
DT RATION
^^ouths
(SIGNED) \J. J \J r-^ ^
I3i tqoH (Addrev,s) \X%i
/hiVS
//om s
M.D.
-^
Xa
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death?
-\-4-q,^ U h j ' Mow lonq at
0 h ^<L^KM k{ Place of Oeatli?
Days
ri.ACK yi" lugiAi, or rhmovai.
DAT!-; i>!' HcKiAi. or R1-;M0VA1.
Qt* IH T90H
(AdcWeas Iti"^ \mA..^^V^rA.Jjli
N. B. Every Item of Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special information" for per-
sons dying away from home should be given in every Instance.
I
1 '
I i
•III' it
WRITE PLAINLY WITH UNFADING INK —
I!. ,;,!,! 1,1' II. ,i!'h 1^ No
1' Co
Date FiJo(l /k)^<:XAyJC\) I
r
2^(9H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^
Jr^^j^"^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "a. S. StanDarC* )
ofO/CX/>A; wA.a.^xCU.CA. City of ^ <X/^yv o/uxa'^c^.>
PLACE OF DEATH: — County
"^ ubM..kLta.».. St.;
.. 'kI. i
(No. WCu. V Wuy'
^
Dist.; bet.
and
T / .F DEATH OCCURs4«AY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ ( IF DEATH OCCURfl^D IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
AAN-.^.
PERSONAL AND STATISTICAL PARTICULARS
Sl-X
ni<
COl.OR \
DA 11, ( >1 lUK lil
ID
A\J^^^
t .
M. Mil 111 K
iDiiv
\« .1-;
I \ Y,a>
lar)
/>.M.v
^1N<.I,I' MARUIKIV
\\ IIi< (Will (>K ItlVoKi »-l)
' W \ itf ill -"rial >\< -i;.'!!a! loul
lURrniM. \c J-:
1 SUltl lit I'l MUltl \
NAMl nl
FAT 1 1 J K
/^n
on 1
VJ
/YVcLcK) 4ja.
IcxU
W wJw,
HIK IIUM, \OK
III I \IIIKK
i^ititt )! roiiiittv
MA!I>I:n" NAM!
<»i M()i'm;R
I'lIK IIU'UACI-;
«n- mi»iiii.:k
J/ux .
\\jxAj
n
^AA^Jb ^Ux
'\
I K\'frA'rinx
0 ;ux>v<:ix
M.rilUn
/*,;i
xwv. \ni>\i: six i'»:i> rKK^oNAi rxk tiiti.aks aki; TKri-: Tn rin-;
lU'.sTol MV KNOW 1,1, D^K AM) Hi:i,I);j'
(Illf..:iuillt vJ-M5
MEDICAL CERTIFICATE OF DEATH
DATl-; Ol- Dl'.ATH
Uct
iDav)
TQO H
(Year)
..5,t.fc
(Month)
I 1I1':KI:15V CIIRTII'^V, That I attt'iiikMl (IciiascMl from
10 190 H to ^/otr \X T()oH
that 1 last saw h u. . . x alive on ^ ' * >- i<>o •
an«l that (Icath occurred, on the <late stated above, at 1 a aO
tl. M. The CAISH OF I) HAT 1 1 was as follows:
Dl' RAT ION Years
CONTRIIUTORV
Mouths
Da ys
Hours
DIRATION
(SIGNED)
Ycixrs
IqO H ( A<h
^fouths
Pays
Hours
M.D.
nlv for Mb
1
SPECIAL iNFORMATIOr
or Retent Residents, and persons dying andv from home
Former or i 1 1 q \ 4 j ♦
Usual Residence \\^\ UA^Cm^)
HoH lonq at
Pla( e of Deatli ?
Days
Wlien was disease contrarfed,
If not at plare of deatli ?
f \.l«ll.ss
,^ I I", <>I
0,€t
IM.ACH <»l HIKIAI, OR RKMOVAI,
r N I > V. R r A K K, R 0 xXaJULm . V -w w^^vy ^
DATKo! Hi Ki,^i. <.i KKMuVAI.
^iD
wO-
jM. B. Hvery Item of informiition should bj ciirafully supplied. AGE should be stated EXACTLY. PHYSICIANS should
stHtc CAUSE OF DEATH in plain term*, that It may be properly classified. The "Special Information" for psr-
sons dyin^ away from home should be given in every Instance.
jg^fcatfegJMifgfii:
Mte^^^i
}!.,;, nl .'f 111 rillh 1' X
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t«* x:- ?.i-. HJt r ('
Dafr /'V/rv/, U/CX<rlM>J
;,9^H
Be<!isteved JS'^o.
Deputy Health OflTicer
DEPARTMENT (ip PUBLIC HEALTH=City and County of San Francisco
Cevtificatc of 5)eatb
( tl. S. StanDar? )
PLACE OF DEATH:— County ofOxXAXi JtvCXAvCl..' City of O-Cc-w o ^XX/v^x^<^v
fsJo. v.i-^U
cru ,X'-
%^
St.;
/ ,r DEATH OCCURi AWAY TROM USUAL RESIDENCE G.VE FACTS CALtED ^OR ^V^" STR E eI^AN D 'n U M B t R^ " " )
K IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME LL ^'
Dist.; bet.
LE
Ml
and
)
ft
,<X >> V
^j„'
. VL C ! \.
-^i-.x
PERSONAL AND STATISTICAL PARTICULARS
C()i,<»R ^ ^
i»\ri-; <)t- lUK in
LL^Vwi ' f
^
i Dav
\< .!•;
I (J^ 5V,/<
M'titli
■ar)
/>.; 1
sixr. ij.-,. MAKi<i}:n
\vn)(»\vi:i) «)K i>:vnKi'i-;n
iWiit< in s(K'ial (U-«-i>.nialii)n)
lUK IIM'I, Ai'J".
'Statt iir ('■HUiti %
%
r\
NX Ml", ni
lAllll-.k
I'.!KIHl'l,\t*K
i\V I AT ill-; K
' Slati 'i! i"ii\nitrv
M \I!»1:N NAMl '
Ol MoTlll-'K
uiK rHri.,\i*i':
»>F Morm: K
fHtatf or r.iuntrv
-Y^X. ^^VjCC'
a..
Ml
LX. M
MEDICAL CERTIFICATE OF DEATH
I)
..... .. ,....., ^^
(Nfontli)
(Day)
(Year)
I I!1':R1;15V CIIRTIFV, That I attended .k'ccasetl from
\L)ct: T.^': . .to L.<ct..
I90
£)^
190*1
that I last saw h .4-<W\ alive on VLf ev ! i igo i
and that death occurred, on the date stated ahove. at
L-l M. The CArSI-: OF DI-ATll was as follows:
DT RATION
Years
Months
Days
1
Hours
>A.A^c^ ^
^^ )'i'ars Months l">avs
1)1' RATION _ Years
(SIGNED)
S.(i. It
Hours
M.D.
ID/Ctj IH TQoH (Ad.lresgUtu "'^Co.. dbo^\<>W
SPECIAL Information only for fiospltdls, institutions, Transients,
ot'Cri' \ I inN '^
h'f iihil in ^(lll flillliii'i
) V(7 » 5
M nil His
f hi 1
Till" \I!« >\l' -^'l' \ 11' I> !•». RSON \1, I'AKTICn.ARS ARK TRIE To THH
IIl>-,Tt»l MV KNOWI.I.IX.H AND HHUIKF
(
(D)fi)iiiiant N— ' .
f\d.lt•t■'^S \^'
i^
^..Lo. 0loMti\AAXxX
•r Recent Residents, and persons dying away from liome
flow lonq at
Former or ( !a
Usual Residence VD UXuTO^i^^^^
When was disease contracM,
If not at place of death?
Place of Death
Days
rj.ACK 01
M
DAlHof niKiAl. or RKMOVAl.
s'DKRTAKKR ^A , WW • M M^/OjAXv-yVr
(AddrcBs „5l^..L) J <XA.AXMj
190
IS. B. Kvery Item otf InformntJon should be carefully nuppl cil. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain term., that It may be properly classified. The "Special Information" for psi*-
ftnns dying away from home should be given in every instance.
I
n
» I
»#
WRITE PLAINLY WITH UNFADING INK
\u
,a!.lof lli:.MIi 1- No .^ ■*-?; flK^ n^ 1' Co
/>///r' /v7f></, L^cto-l^N^ IS
i^6^H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Resiisfered ^'o, ^Of45
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
{ tl. S. StanDarC* )
PLACE OF DEATH:— County of ^ 'Oaaj . Vo, ,
A
(^
City of O/CXy^v 0 /uo^^-v-c lk
No. XCC^AJI/
A
(^<S.,iA
.d
^
St.;
Dist.; bet.
and
)
/ ,r nr*TH OCcJbS »WAY from USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
( Tf DEATH OCCURrTd.N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. . J
FULL NAME ^^
. V.
4.
PERSONAL AND STATISTICAL PARTICULARS
-l.N rjPl A ! COM)R
vJX/YWO^Ll
i;i. ^ ^
i> A ii: » »!• I'.iK rn
\« .!•:
JMonlli I
!,-,.■/
(Day)
M.,»,lh:
I Vcai )
])n\.
\\ii)«»w!-:n ok ni\»iKri-:i»
l\\iit< ill ^111 i. 11 ili-.is.' iiat ii ill)
IHRI'IU'I, \i*i-:
(State I.! Cmmt r y
.dLcruj-
J A Til I'.K
lUKTIIIM.Ail-:
til I \iiii-:k
-^t it' III t'ouiitrv
M \11»1'N NAMl-
(»1 Mol'Ill-.R
lUR'IHl'I, Mi:
kW Mo'l'lll-.K
(Statr iir I ouiiti V
) I
(ll
9
XA
.0
4 I I 1
\ \
\
MEDICAL CERTIFICATE OF DEATH
DAri", <)!■' HKATM jf\
\
I go \
(Year)
(Month) (Day)
I ni:Ri;HV CIvRTII'V, That I altoiKkMl ik'icased from
LLc^.c^ \- 190'. to .^'Ct IH 190'i
that I last saw h .i..' . alive (in w cL i'\ 190 \
and that (Uath ociurred, mi the date statetl above, at Olb
J.. ^F. The CAl'SH OF I)J<A TH was as follows
'\
^rv\.<XwUi
nr RATION ^ Years
CONTRIIU'TORV
Mouths
Pax
Hon PS
niRATION
(Signed)
Years J\fonihs
Days
flours
I r
lc)0
(Address) ^^^ V/^VwAw^.'C.^u J a.
M.D.
SPECIAL Information only for Hospltdls, institutions, Transients,
or Recent Residents, and persons dying away from home.
oiCl I'A rioN
h'f'-ui^if i>i Sun I I a Hi
) ,,;/
1/. -/////.-
/»«/>
rm- MiovK sT\'n;n t'KRsoxAi. partum i.ars aki; pri i-: m Tm-:
lii'sT »)i" Mv K NOW i,i;i)(', !•; and iu;i,n;i-~
(Inftiimant
A- ,:_-<-
0 vv
uUlIaaXx^
Former or T ^ 1
Usual Residence t -J I
^^ai
1- "t . How lonq at
XkXS' Pldreof Death?
Days
When was disease contracted,
If not at place of death ?
^I.ACH Ol- HIKIAI, OR K1:Mo\ \1,
INDKRTAKKR VX>JnXUJ" ^
I»\ri<: .)! 151 uiAi. or KHMOVAI.
T9O I
(AdilreHH ..
<X/>\i
N. B.
-Every Item o? Information .hould bs carofully nuppflecl. AGB should b« stated EXACTLY. i»HY8ICIAN8 should
state CAUSE OF DEATH In plain terms, that It may be propsHjr classlflsd. Ths ''•HiiilMHMM<lon*' for psr-
sons dying away from home should be given In svsry tfi|$§j
mff.i.jA
> I
,*
WRITE PLAINLY WITH UNFADING INK
Hoanl ..f II, :iM)i 1
\-,, .- ■t-^'s^-^liScVCo
I)
lilv /'7/r>r/, LlctcrWv IS ^^O'^K
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2325
Re^i^tered JS^o,
fff cef
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( tl. S. StanDarD )
of OOmj JAxx^-vcc;.. City of O/Cl^tV 0/UX^^x<:a.-^ c.l
No.
PLACE OF DE ATH : — County
^CKKdxx-<.
St.;
Dist.; bet.
and
\^W Y VX/ ' -^ \1 >C<|I \-v^ws^v_^ . orti^nFNCK riwr facts CALLED for under "special INFORMATION" \
( '^ rF"orATH^S^:u%ro\"rH "s^rAl: o"r"n^'.?u" "^a.vr.;i name .nsteao of stre.t ano number. . )
FULL NAME
la.'. .. Lcrl In
-0.
si;x
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
./■
rc<
DAii". <»|- luurn
\C. 1'
/YV
M..iith>
5 ></ '
(l)a\ I
\/.,ii//r
r u -^' i
(Year)
/>
(7 I .\
SIN«;i,l... MAKKll'.n.
\Vn><)WKI) OK niVoKCKH
(Wtitfin •«iHial di '■it'tiatioii)
lUK'nii'i, \oi-:
iStnti- III (,'iiillit ! >
K^
dLcruj-
1 A riii'.R
lUKTniM.ACK
oi- I A I'll HK
-^Ittc III (."ouiitryi
M\!IH:V NAMl
oi m()Tiii;k
lUKTm'I.ACl'.
^^V NH»TlfKK
(Statr i>r Countrv
'i I
4^ tX^C^^AA.^.
/CXAAXJuC^ A,^^ .
\ \
OXJ^
A .
s\
XXAACCClvN^v
MEDICAL CERTIFICATE OF DEATH
DATE OI' DKATH
(Mouth)
(Day)
/po .
(Year)
I HI':R1:HV CI^RTII-V, That I attoiidcl deceased from
U. 190' J to iil^ .11 190 H
1
^ IH
that I last saw h t^ alive on S^ ^:>^.- i ^ 190
Q U C
and that death occurred, on the date stated above, at - l •>
J^- M. The CArSK OF IMvATII was as follows:
I) r RATION ^ )'t'ars
CONTRIIU'TORY
Moulin
Days
Hours
DIRATION
(Signed)
Years Jl[<^'f^^^
/Mrs
y \ s^.
X^^ '^ IQOH (Address) 3>X3»LI\AA/vdki -Jt
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
oiHTl'A I'lON
) lUl I '
.St.uith>
/hn-
THi' \H«»vi.: sr \'ri' I) pkr^onai. tak rut i.aks aki-; trik to thh
Hl'.ST Ol- MV K NOW |,):i)(.l-; AND lU.MI'.l-"
(111
f..n„ant OOVv^ ill. ^--^ '. "^ ^ '
fAd.lrtss i b I M lA
N , ,*
;v c\.L
Former or -T^iUh'^ni
Usual Residence I 0 I N U WL*
When was disease contracted,
If not at place of death?
^iHow lonq at
SA'OAflareof Death?
Days
iji.ACH OI- m'KiAi, OR ri:movai.
I)ATl-;ot HiKiAi. or Rl'.MOVAI,
{AihUvss..'^°iM<X'y\j \rUA^ Lk
N. B. Bvery Item of informHtion •hould b.- carefully «iippliecl. AGE should bo stated EXACTLY. PHYSICIANS should
state CAUSi: 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 svery instance.
te^
r^F!
•. 4
-•l!lf| i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Honrd^.f lh:,!!h- !■■ Vo ..t-X^y-i^lU^VC'-
I )((!(' Filed ,
V 15"
100 'i
Brgistered J^o,
2326
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "a. 5. StanOarD )
Q^
PLACE OF DEATH: — County of
1
"V and OwAlCL,*-
FULL NAME
^AKX.
PERSONAL AND STATISTICAL PARTICULARS
k..!
5
DAli: «»F- lUKl'll
KV.V.
CUj,
Day)
(Veur)
5-
M,.nf/l'
Pur-
\viiH»\vi:i) OR i)!v«tKri:i)
(Writt- in -iHMal lU-iL'iiat i' m >
lUR inri, A01-:
st,il< " i! I'nuiitry
»• Aiin:R
lUkTHri.Ai'K
oi- lArin.K
'Stati or v'Diinti V
MEDICAL CERTIFICATE OF DEATH
DATK «)I- DlvVTli ,r\
Day)
(Year)
fMniith)
I lii:i<!;i5V CI'KTII'V, That I atteiukMl .ItH-tasc'.l fmm
to ik/.^ I.H. Kp .
I9O
-^
ItjO
'^^ v »^
SI (fe
MMDKN NAMH /TS
nl- MOTIIHK
UKxxAJLrtLi' dOAlrc
lUK rnri.ArH
01 MnrnHK
Mat' or Country
-J (^
that I last saw h -i^^^ aHve on w '-t.1 ■ "
and that death occurred, on the <hite stated above, at 1
... M. The CAISH C)J- I) i: AT II was as follows:
1)1' RAT ION }'(ars
CONTRIIUTORY
.0
MoHi/is IH Days
Hours
0
or RATION
Years H Months
( SIGNED ) AX<LlLcu.xLi Vij.hj
iD/ct IH looH (Address) niffCUj
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
f\i'-nh\i in Siin /'i ,in, (M'li
)%,ji< O .\r>ntli> \ rhtv.<
\\\V \!!OVI-- sr\ ll'O I'KKSONAI, 1' \ K l' IC t ' I, A R S A K I- TRri-: P" » IHK
Hi;sr <)i- Mv KNOW i,i;d<.h .vnd bj:i,ii:f
,I„f,Hn,ant H>VuO wA UJ.OUUa^
\.\.^^w. L
y
^\(l<lress
1 1 lb VJCKAK.LI dl
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death ?
How lonq at
Place of Deatli?
Days
I'l.ACK ni' m RI.M. OR RKMOVAI.
DAri'.iit r>i KiAi, oi ki:m«)vai.
IQO I
INDICRTAKKR
0-<ij,X»-
AdJress 3(^5" ^VUrnXtytn^v^LxKA^^
tyts^^
j>, B Rvery item of Information should b^ cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for per-
son* dying away from home should be feiven in every instance.
f '
I I
!il
^g^_
WRITE PLAINLY WITH UNFADING INK
I.,,.i!.l . t I!> -Ith !■■ N.). !
. t"*^"^;- r.fv 1' f
n^o'i
THIS IS A PERMANENT RECORD
REFER TO BACK QF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of Bcatb
( 'U. 5. 5tanC>ar<> )
L. ■,'-'-'■'. - City of ^'^^-'^^ 3/VCV,. vVCA,4C t
c^
-Ul
No.
PLACE OF DEATH: — County ofOo.->x. Jxa ^ -
M P ^^^< --,- , , ,■ ' • St.; Dist.; bet. cUaa.
■ ' ^ ^ ,,«;i,Al RESIDENCE GiVE FACTS CALLED FOR UNbcR "SPECAL 1 N FOR M ATIO N " N
( '^ .7orAtt"oCCU%rEV,rrHOS^"*^ :r'?^?t'.T "4^/o.VE .TS NAME ..STEAO OF STREET A.O .UMBER. J
andUa„LU-\
FULL NAME
,rOC
UJvC)
f.
PERSONAL AND STATISTICAL PARTICULARS
^
^
i I \ I 1 ( if ill Kill
M .nt'
\| .1
Wl
1/ .»/,'A
I » (';ir '
/),M
! I- M \KH IJ'K
.1, ^i ..
!)
n ■■' H i,i 1
L^^C
MEDICAL CERTIFICATE OF DEATH
DATl", Ol' 1)1. ATI!
ki
13
'I);iv)
(Year)
I Month)
I HI'Rl'l'.V CI'.RTIl'V, That I atlL-iukd (kHxased fruiu
190 ~
I90
to
HiK rnri. \iM'
( Statf I iT ' "'in III 1 ''
N \M1 OI
, \ rm:K
inHTni'i,A<K
of I \ rm:R
M \11»1:n NAMl.
(>] .M»)riii%K
iuHrnri,Ari".
(>i Mtrini'. k
( Matr 1)1 i'nuntl \
?
T3n
s.
OiTll'
h'r^hh-if III SiHi il iiii- '''
)
\/ .,:'/>
/'■;i
in>r <>1' MV KNOW 1,1 IX. 1-. AM) lU-.Ull.l
K>- AK1-; TKIK TO II 11%
(Infininanl
fAd.llH■ssU^^XAJba^^^ v)
that I last saw h alivr <.ii
an.l lliat (Ualli occurred, oti tin- <latc slated above, at
LL M. Tlu' CAISH ()!• DKATII wasas follows:
190
10
DC RAT ION Vc^irs
CoNTklPdToRV
Monfhs
Days
Hours
DIRATIDN ^
( SIGNED ) C<A^C^AJl>V
Days
flours
M.D.
Years ^ Mo}iths
T.,nH r Address) L^VOAvyv^ H^ ^
ON only '"r Hospitals, InstitutiM, Transients,
SPECIAL INFORMATI
or Recent Residents, and persons dying aH.i\ from home
Former or ; ,
Usual Residence^ '
When was disease rontrarted.
If not at place of death ?
How lonq at
PIdf e of Death ?
Days
/VOUCVU\-AV
X
I'UACK 01 I'.IRIAI, nK K1:M<»VA1<
rN„HKTAKKK tk<X^ \m^. \S'^Aj^
n\l'l"i)i I'.i HiAi. or KKMOVAI,
^ ,, t ;
TC)0
V
f>^„<r>\j
State CAUSE OF DEATH In plain terms, that it may be properly Uossmea.
«on» clyinft away from home should be feiven in every mstance.
pr"
f t
WRITE PLAINLY WITH UNFADING INK —
,r,l ,.f II. I'th t- N<
1- »•<)
2,9^'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
QOQQ
Re^ititcrcd ^'o, ^o^^ci
l^^lxo^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
\
PLACE OF DEATH: — County ofOaA^ J A^
City of O/OL/YV OKXX'^x.^CAM
ILL. litAiVLcKXi'dL. U luA^i.- St; - Dist;b€t.
^fo. V^UJuL ^'^^^'^^^™^^ ;; ! ' „ USUAL RESIDENCE GIVE r*CTS called roR under
1 ( '^ r/o;rH"oct%ro\;"rHo"s^"'iL :« ?.?t..ut.o. o.ve .ts name .nstc.o or
and
ORMA-
street and number.
"special INFORMATION" '\
FULL NAME
\jOJ\1) ^. C\
-.i.\
PERSONAL AND STATISTICAL PARTICULARS
riti.iiK '
iiA n < 'I iUK i il
Pas
M,.iitli
•an
/ )./
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH , ^
(Month) ■''■'^■'
I III'Rl-BV Cl'RTII-V, Tliat I atten.le.l .lecvascl fmui
iVt-ar)
n
y
I 'A
-I\< .1,K. MAkK 11 1»
a !i>< i\VHl> <1H II '^ I I'sKH
U-M. Ml -..• i:.' ■! ^;-n.,ti.,ni
niK rm'i. \»"i"
A
\ \ M 1 < >l
\ All! 1-K
HIKTHI'l.ArK
«»i- I \ rm-.K
IStati . T I'.iimt
M \ I DIN' N \M1-
t»i Mtti'in-.K
I'.TK'niri.Aii*.
(U Mit'nil'.K
st.iti .11 I'muit t y^
T5
LoJul vJ^O.
T90 , t.. '-^ ^*^ ^
that I last saw h • ■ alivc' <m "^ -^ ' ^^^ '
and that .leath nccurrcl, on the .iatv ^tatL-.l al.ove. at »2^ ^S
M. TIk- CATSI'IOI* 1)1' ATM Nva< a< follows:
S, I %- ^rS.-*..
DTK AT ION y^-ars
COST KHUTOR V
Monlhs "^^ /^MA- /fours
n
0 -IAT) 1 xcx-'^-vu
oocrrA'i'ioN A-Y^
)V,;,'
M.u,f>'r
Ihn
THH ^m>VKSTATKl>l.KR.<>NAl rAKTl.ri AK^AKKTKrK T- > TUK
in:sr oi- nu' knowij-.ix.I". and lu.un.i
Years Arouihs I^ay.
it>o
H (
Address) \XXj
IIou) s
M.D.
1)1 RAT ION
(SIGNED)
Oct n
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
rywJ^vsJi:
Former or
Isual Residence
Wlien was disease contracted,
If not at place of deatli?
How lonq at
Place of Deatfj?
Days
(InfoMn mt
fXArX^^^
V\ \CK 01- lUKIAI. «»U U]:M»)VA1.
<0 xs.rs^'^'x.^x ^ ^yJ^J^
ini>i:rtaki',k
i)A'ri%ut HiHiAi. tit ri;m<»vai.
V^,.
A.M,-.ss SbiS-.-njJ,
,0^
'^
Si
,. . Igb should be stated EXACTLY. PHYSICIANS should
of informnf.on should b. careVully suppi.ed. ^^^^^ ^^^j^^^.y.^d. The ^Special information" for p.r-
E OF DEATH In plain terms, thot it mny be properly class.t.e
N. B. Bvery item
state CAUSE \tr L»»^rt • ■■ ■■■ f" -- — ■ , \^^^»nc-^
sons dyinft away from home should be ft.ven m every .nstance.
!. ^
a 1
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
^-^ ,„. RgFgR TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2329
t V.
/),(/(> rUetL Lc
t{KMA;
i
Deouty H
Re^i.^lcrcd ^o-
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of IDcatb
( "U. 5. StnnDar^ )
No. ^;^^C
PLACE OF DEATH: — County of J^^^ o 'va/YVCULc^v.ity oi
J ' St* — — Dist'bet ^^^
FULL NAME
V
!u^cUvL' LuA.'lV^.Y^ '^!
PERSONAL AND STATISTICAL PARTICULARS
C< ll,( iR "^
LO. kctt
> ( a!
MEDICAL CERTIFICATE OF DEATH
DATl-; OI- I'l'.ATll
■^.a
1 \! \ K K nil
III
IM!' :'ii iM, \t' I
u
Ml ill
\ . 11 1 . 1<
ink 111 ri. \i l^
til Miirill.R
HIH IHIM.Ar}:
1 IIKKKHV CI{RTIFV. That I aUciuUMl .kHva^ol from
that Hast .au h .- alive- o„ "^ ^ "^ ^V"
^„„, that a.ath .K-currol. nu the .late .tate.l ab.ive, at I 30
.1 M. The CM SK tH- DKATll was as foll..svs:
1)1 RATION
C ON T R 1 1 U T O l< V W<XX a
Years J/on//,i ^ A?,.?
Hour
\xx.c
i .-^
DTRATION )V^/r,v
( SIGNED ) L<LuJ-v>v
A (J
Months
KLk
Pav
Hours
M.D.
^o
K,-!.t,,
■., • (/ I I ll >
) , ,,'
1/ -Z//'^'
/),/)
■nn: .MovKvrsTrurKu.osu r;Kn;r.,vK-AU,,T,<rK TO Ti.K
iii-sT t»i- Mv uNiiw i,i;i)<.i-: AM) i;i,i,n,i
» n 1 ^ »
(Iiifoiinaut
c
\'Mi
•^yo^'y^^^'
"special information only tor Hospitals, Institutions, Transients,
or Reienl Residents, and persons dying away from home.
i , I \ I How lonq at
Kwdencdf^^O/yvX ll.av I Pl,„e o. Deal!,? > Days
When was disease contracted.
If not at place of death ?
l-I \CK ni- Hf KlAI, UK RI:M<»\ Al
r^ KfrV
LJaQr
saXa. K„<
rNl.l.KTAKKU Mfl.^rVCW^^
(All. his'; OO o" OO L
l)\li: ll!' 1!i lUAi. or KlvMoVAI,
wU 190
'<
JAa^
^i
/I ^— — ^M^wi— ■^'^"^— '"*"™*"*^^ r-vArxiY PHYSICIANS should
^. B._Bvcry Item of ln?.>n.««t1on Hhou.d he c.,rc.'..t.y sup,, he. ^^ ;J;.^,^;:,„^,.,.,,d. The ^Special Information" for p..-
state CAUSE OF DEATH hi ph.in terms that .t m»> ^f J ^
«on, dyinft away from home should be ^Kcn .n every instance.
'■ *^
^ml
*• i
R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
^ 15 1""'^
Uro isle red J\^o^
Deputy
th Officer
DEPARTMENT I^F PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDcatb
PLACE OF DEATH: — County of
City of U ^iXXi 1
— and
No.—
"HirS^^j'^D rOR UNDER -SPEjAt. >NrORMAT.ON ^
"*^I? ^.««r .„=TrAn OF STREET AND NUMBER. J
")
J^'
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
h-
MEDICAL CERTIFICATE OF DEATH
DA I'!-. < »1 I'l' ^'''"
I iii:i
.I:HV n I'lII^V. riiat I attcn.UMl dcrcasd from
-— - IgO
t»»
that I la-t saw li
aUt
iiis<- oil
1 I)
M. T!u CAI-i: nl- I.i:\TH %va. a. follows
ii'i \i" r
w*^
Ml ill
HIK ! II I'l. \fK
• M I \ ill J- K
>-,f : • . , ! I 1 11! nt 1 %■
III MDTm: R
luR rm-i. \cv.
(ii MMriii'u
I SI. lit 1 i! t'uunt 1 ^
in RATION )'riirs
C<>N TKlia TORY
DT RATION ^ >■'■<?/■-<
Mouths
f)av
//i)iirs
Mouths
Ihu
'S
(SIGNED ) -i^O.^ . ^'- ^_
Kp
'1 ^*N
UvClTA TioN A ^ I l*"
-Special information only f«r Hospitals,%stituUons, Transients,
or Refent Residents, and persons dvin-j av^ay from home.
How lonq at
Former or mt ii\ Death? va)s
Usual Residence
When was disease contracted,
If not at place of death ? —
R,,,ir,f ni Vc' /■■'.'".
Ki )■ I'O l'"l'
IU->.T r,l MV KN()\Vlj;i)>-.H AND lULHJ-
(InfiHtnaut
yi xci- (>!• m-KIAl. OR RKMOVAI,
rNI)i;RTAKHR
(Aiidn'ss
■"■■^ !• I \CF should he state
;very item of information should he — ^^''^ ^^f, rhe P-opeHy classified,
tate CAUSE OF DEATH in p ».n ^/•"-''J;" „'*^;;,^ instance,
ons dyinft away from home should he ^.ven m every
DATi: of r.tHi.Al. or Kl%M<)V.\I,
y^ js- 190H
v\X)^
HfeS O Cr^-^-^-Uj
N. B. 1
8
sons dyinJl
d EXACTLY. PHYSICIANS should
The "Special Informiition" for p«r-
ams
m
WRITE PLAINLY WITH UNFADING INK
I f IT... I it, • Vii I- ■?•?" SBf«"—») I'lt 1' t n
H<i.'iiii 111 II' all n . ^'> > "...^-j*
/
njot
DEPARTMENT tfF PUBLIC HEALTH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered ^''o. ^^331
r-iw^cA^
=City and County of San Francisco
PLACE OF DEATH: — County of
Cettificatc of 2)eatb
- , JAXX/>V^1^^'- City ofO/CX/>v ^h.<X ,v :c
No. ^^H Vl3(X».
0
Li I I
St.; b Dist.;bet. 3^ 1 ^^^
and '^^
^
( ,. ^.,^^cr.-; .w.v .no- osu.. -sifL",=^-".f,;.",;rN*»«7 r,c"ri? sT%%%Ti«o"r::r-°''' )
D
FULL NAME
\*
■H-
1*
>i; \
+
PERSONAL AND STATISTICAL PARTICULARS
Wet 15?
(Month)
AT.K
) V'ln
Das'
}/,„if/l:
(Vc;ir>
An
(Year>
slN.-.l.i:, MAKKIl-.n
WIDOW l'I> «»K lHVoKlKn
(Wri't ill ■^tH'ial (U xi^fualiDii)
TUKTlU'LAi'l-
I Stati or «."i)untry
SAMl- n|- ^,.
FATIIKR U\
^\xAj
^
aJja)
e
niKTin-i. AiK
r>I- lATlll-.K
( Stall- ( >r i'liiinl i v
MA'Id.N" N\M1-:
((I Mnl'in.K
lUK rill'I.Ail',
nl- M<»iin:K
(Stall Hi CiiutitiN
0
fliJUr" I\d cl-v^x^v^^ '. ^ ^-
MEDICAL CERTIFICATE OF DEATH
(Month) (Day) _
1 III-RI'HV Cl'RTIFV, That I attemlea aeceased from
lD..db -' i9o'i to.- - -....190 -
that I last saw h .— alive on — "~ "^^ ^'P "
and that death occurred, <^ii the date stated above, at 11^0
I' M The CAl'Sl': OF Dl^ATH was as follows:
^tai"(Ecyvvv Jvd^ 4^-t. I .... JyO^
DT RAT ION )'rc7rs J7ofi//is Days
CONTRIIU'TORV
I Jo UPS
n
-10
iX^UJA;
4^vu i 1 s.
DTRATION
k).l5
0 ^^
/lavs
(SIGNED) LU. U. V-.^i'VUUj.rv
^Avt II u,o'i (Address) ot^
Hours
M.D.
?
bo^dl.
SPECIAL INFORMATION only f«r Hospitdls, Instilulions, Transients,
or Recent Residents, and persons dying away from home.
(HLMjVu
a.
oCCri'ATKJN
AV.w.fA/ ill San ria>i,i^r,>
)'rU1l
M.oitln
Ihl
Tin- MU)VK ST\TKI)PKKS<)NAl.l'\RTI^TI.XRSAKi:TKrK To THH
(informant J AXxI- L. L%>xXK'-^
/I) li
( Addro'^'! O <^ I
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death? Days
IM,ACK <)1- UrRIAI, OK KKMOVAI,
i
Aj<j^>-^
):
DATlCof H' KiAi- or KKMoVAl.
0^ n T9oH
U-
State CAUSE OF DEATH in plain terms, that it may be properly classmea. i nc p
sons dyinft a%vay from home should be ftlven in every instance.
)l
WRITE PLAINLY WITH UNFADING INK
Hii.lKI I'l lli.lUll I ^"- '^ ",».,-■•
I)(ffc Filed,
• IS
190\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered ^'^o, 23o^
DEPARTMENT ^F PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
"d. S. StanDarD )
PLACE OF DEATH: — County
ffe
.A^v^
'D
,i UUrUy
AX4.^1-^^-^^'-St
♦ —
Dist.; bet.
and
- )
'Da (\ Ion
FULL NAME
II
XLC-
PERSONAL AND STATISTICAL PARTICULARS
Sl-.X
DAli: <)!• UlKTll
A<.K
coi,(»R\ n
MEDICAL CERTIFICATE OF DEATH
DATK OF 1)1;AT11
a
Ou
Momhi
I I):iv»
> M,.ulli'
T L
f Year)
D,! !
(Motith)
(Day)
I go \
(Yt-ar)
~ I HI" kl-BV Cl'RTlFV, Thai I aUcn<lc.l deceased from
QXaV It 190 H tn O^t % 190 H
wot t
•^IVC.IJ". MAKkiKI>.
\vii>o\vi:i) OK i»!V«»Kri;n
(Wiiti in -iK-iai dt >^is.'iiati' m
HIKTHPl.Ai'H
(Stall iir <'<iU!it I V
N \Mi" or
I A I in: R
lUKiin-i.ArK
01 I \riii':K
(Stat<- 1)1 riiuiHi v)
MAIPJ-.N NAMl
<H- MuTHKR
lUK rm'I,Ai'l',
statt iir Cotintt y
[90 "\ t<
tliat I last saw h • alive on wot t 190 ^
au.l that rteatti occurred, on the date staled above, at H -^
* ^ M. The CAl'SH OF DHATIl was as follows:
r^AJL\XM.
DFRATION Years 1 Miyuths ^X Days Hours
CONTRIIUTORV
\Xjy\/y\KAj
Ur RAT ION
Years
4lfl)f/f/lS
/h7VS
(Signed) UJ. ^. U^noLo/w^
k)^ ^ TQoH (Addres.) UJU^a^
//ours
M.D.
/y
"^■^■^■•"■'■'•^^%.a>x^x^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
I or Recent Residents, and persons dyiny away from home.
h'r.ii/fif III Sdii I I C.I!
M.nilh^
/),7 1
THl.-MU)VKSTXTini'KKs.>NA1.rAKTUri,\K^ AHKTKrK To THK
\A
ljT<\h}i\
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
. Days
1
(Infonnant J A./Q-/'>
i;i)<". K AM) r.i.ijj-.f
(A.Mrc
n.^A-^-'^i.
j'i,ACK oi- nriu^^u. OR ri-:m<>vai
DAI'I", i)t 111 KiAi. or Rl-MoN'AI,
U/cti ^ S 190' \
rNI)i:RTAKl'.R
f Address 'ib^^" ^^ W ^^
■ „ . .. . .^R «H«,.i,l ha Rtatetl EXACTLY. PHYSICIANS should
«on« dying away from home Hhould be felven In every Instance.
t I
m
WRITE PLAINLY WITH UNFADING INK
,,,:,T.l of H.altli !■ N" ' '- '^^.^^-'^^ ^'^^' *■'"
/)((/(' /'V/^v/,yct><MA; IS"
7.9(9 H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2333
Fie^istered JS^o.
j^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( "a. S. Stan^arD )
PLACE OF DEATH: — County ofOxiyYV JAa/>veuC(. Gtv of Oajy\j ^KOjyxj^^
0 /o n A
^No
,AUJ.J ' Wu.TUl(
^vwA.'xm-L, .St.;
Dist.; bet.
and
: ( - --^^ic3«^v.:r:: ™ r^^^^^c^i;^;^-! ^m^ .x^s; ;?;^^njo ^:;;ir )
FULL NAME ^ ^^-^^^
PERSONAL AND STATISTICAL PARTICULARS
COI.oR \ )
^
si:\
i)\ri: (>!■ lukfn C^
I
(Dav
A<.1'
M.oilh
S I
/'./>.
SIN* '.1,1:. MAKKll-:!)
\VIl><>\Vi:i) OK !>I\< »Kk'Kf)
(Wiittin Hinial dt "ii-'nnt ii nO
HIK TIU'I, \CK
' Stntr oi »'. lunti \
c^
N \M1. <U
FATHl.K y
HIKl'Hl'I.ACH
ol ! Ariii:R
(Stat»- or foniitry)
MAim'.N NAMH
OF MOTHHK
niKTHPUACl-:
«H- MOIUKK
(Stall- i)r Ooiintry)
nrcri'ATloN -P J
^1 \\L \
XxJ\
'\!
M^
Rr>ided m S,iir /'i mi, n
)',ii>
^f,„ifh'
fhivs
TIM- \noVl.'ST\l!-l) PKK^ONAl. P \ K I" IV T I, \ K S A K l- T K T H To Tl!H
iIksT 01>J4V KNo\VI,i;i)<-.K AN!) Hl-I.n.l-
(Informant JAXX/vJk LI- O/cix/Yvv',' .
UJyw^
MEDICAL CERTIFICATE OF DEATH
DATK Ol" DKATll
(Month)
(Day)
TQO
(Vt-ar^
T I IIlUxlU'.V CIIRTII'V. Thai I attc!i<k'«l (k-reased from
ox-kfc n KpH to ... A9/ct u tc^H
. alivf on ^i/ /CA^
up
that I last saw h ^ alivt- on '^ ^ZJ^ I i jyo
and that ck-ath occiirre«l, on the date stated above, at H t
M. The CAl'SIC Ol' DlvATIl was as follows:
0
f\A,<n^>^<:. C
La^va.xx^A,
u
I )r RAT ION )'iars
CONTRIBrTORV
Moni/is <>>0 /}a\s Hours
DURATION
)'i'ars
iXi
,U()/t//is
(Signed) Uj. ti). L^irrJUx^x,
liz/cij \'k xqo'\ (Ad.lress) UX'^'^v4J'
/)ays //oias
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and 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 ?
Days
rr,ACK oi- niKiAi. ok ki:mo\ ai,
/'D
UtO^JAjM !UA^
,y^ ' V.C
.NJ
I)Ali;'i; HiHiAl, or kkmovai.
190
rNl)i:RTAKKK
V%
<xxY^.
.\d.ii.-.s SbhX' l^\ Ox.
■■■■■"""'*"^ .-. .. i. I %rF fiHmilii he Rtnted BX4CTLY. PHYSICIANS should
N. B.— Every Item o? Information should b. cnrefuHy fuPP'-'- Jt^fj,lZ^'^t\^^^^^^^^^ Information" for p.r-
state CAUSE OF DEATH In plain terms, that it may be properly classitiea. me 1
sons dyinft away from home should be given in every Instance.
ii :i T I ; 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H, .1,1, , N. . t..?^.n5tPCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
])((
fc /v7^>^/, \!^£brW^ IS
lOO'i
Registered J\'*o.
2334
\J^\^
j^
Deputy Henlth OfFicer
ii
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
Certificate of 2)eatb
( Vl. S. StanDatD )
J? m A ^
PLACE OF DEATH:— County of OxXm; J AXX-^wC^ v - < City of O/O/^v J.>u<XAax^c4. -
J? n VI (^ 4
■No^jJkxWvli. L4rYXMrM^dKXyY\Ajto.^^i.Sln v^. Dist.;bet.
* \\\, ._ ' ^ ../.», r = «u IIQIIAI RTSIDENCE GIVE FACTS CALLE
and
W
.ro'EATH^occuRS a/.v FROM USUAL R E S I D E N C E G . V E FACTS S^^^^°.':°A_".'l°5rl'r.'f:*!:Jr°?^*JL°''
OFATH OCCURS A\iAV FROM USUAL R E S I U t IN i- t Giwt ^«^-l^ v-«i.i.tu, r w r. w „ ^ ^ ., -. ■ ■ " ;^-. )
°, OC.TH Ic"!hrTd IN ° "oSPn.l. OR ,NS.,TUT,ON GIVE ,TS NAME .NSTt.O Or STREET .ND NUMBER. J
FULL NAME I'^
i.
.<X4.
>i..\
PERSONAL AND STATISTICAL PARTICULARS
0^ ' ' ^"'-"^
JX^Y^XXxXl
DAI*}-: nl' I'.IKIH
A (.I-:
N!i.iith>
X
Q
)V.,-*
lU'ritciii -liiial ill -ii/iiatitiH I
L
iDav)
1 /,,?/.'//.'
.^AX^
f w<_-.-^
.^7>T
k lar
/'</ 1
iUKi"iiri,A''i:
I Statt < i: 1 ' iimt I \
NAMl.; OK
I- A Til IK
HiK mri.Aci':
ni- 1 \iin';K
(Stat< >.i i'ount! \
MMDl.N N\M1-
nl- Mt»lll}:K
r,iRTinM,Ai*i-:
nl- Mnflll-.K
I Slate 1)1 I'ollUt! X
i)(.Cri'ATION %P
0 l^
y<i
(J
MEDICAL CERTIFICATE OF DEATH
DATK Ol' DKATH
IH.
iDavl
(Month)
/go
(Vt-ai i
I IIKRI'BV Ci'.RTII'V, That I attciidtMl deceased from
■ up to - itp
that I last saw h -: — aHve on ~~"^ i<P
q uir-
aiid that <Kath orcurred, on the date stated above, at 1 ^
Ou M. The CAISF': Ol' DI-'.ATII was as follows
Dr RAT ION )'{'<trs
CONTkllUTORV
MohUis
Days
Hours.
V
Hr^uird III Sun I'lttn, i^rn
);-,u
.1/,. ;////'
n,n
•nV XHnVKSTATKI.rKKSnNAl.rAHTU-rKAKSAKKTRrK T. . TlIK
m:sT nl- MVKNOWIJ-.IHU-: AND in-.MJJ"
(Infuiinant
(A.Mn.s. ilOO LxxX4<:^Vv^.^^ ^ It
niRATION
(SIGNED )
)'iars
(^d)
Moullisi
Day
Address) Co-XXr^UX^S yil C
T<)0
{>
ST
Hours
M.D.
gp^QI^I_ Information only '»r Hospitals, InslitutioflV, Transients,
or Recent Residents, and persons dvinj away from home.
Former or If H • I ""* '*'"*' **
Usual Residence \XXAA,h-X5\)XAAJl ^^O^v place of Deatli? .. Days
Wfien was disease contracted.
If not at place of deatli ?
I>ATJ%f>f I'll HI \i. or KKMuVAl,
PI.ACK <)1" lU KIAK OR Ki:MnVAI,
State CAUSE OF DEATH In plain terms, that it may be properly ^lassmea.
sons dylnft away from home should be given In every Instance.
I
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2335
H.,a,.l of IKMltl. 1- Xn. i. t>.g^» 1)5: P C
Dad' Filed ,
IS ^^ftl
Deputy Health Officer
Ee^iiitcvcd JS'^o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate oi Death
( •a. S. StanDarD )
m
[^
PLACE OF DEATH: — County of UO/n^ -InXLA^CA.^.^ City ofOxxorAj - r^^
o ' ^
V"
and
«JL_ \ 0 'v\i"h nk \) I A'-va1\X^ ■ M db^JslJ^J. Dist.;bct. -
]Sfo. VJt^r\A.^O^V) WO^UUU^. 1_,,^; oriToENCEGtvE facts called roR under "special information- \
( '^ rrDrAT°H"0CCU%r4V/N''rH0"s^rAL o"r' ^^ S T^^^U^^^'c . V E ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
.i\rr.
^1
it
si;\
l)\ri-. <>f lUKTU
\<.i-
PERSONAL AND STATISTICAL PARTICULARS
Col.oR \ n
i - '
a.
/ -
2)5
),,..;
|):iv
!/.,»/.'//
■> tar
SINi'.l.l". M\Kkli:H
\\II)« (Will < >K DIVMki 1 |»
■Wiit* ill -oi'ial I'n-i'jiiati'iii)
(Stair iir I 'o'llltl N
NAMl <»l
F A IH I'.K
fUK rm'i.AOH
<)»■ lAI'lII-.K
' Stat I ■ ii I'l iimt t \
MAIDKN NAME
OI-- MoTIIKR
lUKIinM.AfK
OF MoTllKK
(Sl.'itr or Country
occri'A'rioN
h!,-iiir.l til ^oii I mil' ''"'"
IQO '
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH d \
(Month) '•>:'>■>
I H1':R1;BV CI-RTII-V, That I atlcii«U<l «k-rt.ased from
^x:% .'X 190 'i to ii/^ ^^ ^QO"^
that I last saw h-c alive on V^ !0 190 ^
and lliat .U-atli orcurre<l, oti the date stated above, at V
M. The CAlSIv Ol' I)I':ATII was as follows:
cr>-
^^
^
QJb > > vC^lc^.
DrRATION
CONTRIIUTORV
P %
DIRATION
Years
Mont lis Days
/hJV
Hours
'hZ
)
W M.Hllh'
n,i\ .
T„K^,U>VHS■.•^TK..PKK.<>X^. rjHTrCtMAHSAHHTKrK TO THH
SIG
NED) U-OrVOL^ A- ubx\/i,^:a-
0 ... :0JI,
//(»//
; .V
1)
M.D.
I«>o
(Address) Ub CrU-C^
t
Special information «nly for Hospitals, Institytions, Transicnls,
or Recent Residents, and persons dyina av^ay from liome.
Fnrmpr nr ^ ' Mow lonq at
S Re'wrncf isO^b k^^^- • P:a« of 0«.l,?
When was disease rontrarted,
If not at place of death ?
J
^
Days
I'l \CK Oi- lUKIAU OR KHMt'VAl.
rVDHRTAKHR OVD -tO^VAAJ,
I)Al'i:of Ht KiAi. or KHM(JVAI,
Unt. lb T90H
>^-LKi
Cx.
m.
N. B.-
B.«ii»iii^— — ii— ■^^■^■'■"■■'■■■'■■^■'^^"'^■"""""^ . , . 1^ gtated EXACTLY. PHYSICIANS should
-Every Iten, of Information should b. carefully --^^'^^^^ p^opeHy'aBsifled. The "Special information" for p.r-
-♦«te CAUSE OF DEATH In plain terms, that it may |>e propc
;in. dyfni away from home should he feWen in every Instance.
Bmnl ..f IliaUli H No. n ^-^^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2336
*'5^!:
lUS:!' ('.»
Da/c Iu/efI,VctAMJv 15"
■^ cL.C'VK.|
VJO\
OWicer
Registered J\'^o.
DEPARTMENT (JF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( H. S. StanDarC> )
J? ' om ^ ^
PLACE OF DEATH: — County ofC3.o_>> J^^vve^c. ^i Qty of ^J-O/vv -3 AXX/YVCv.^ c e
(^
'No. Tn JX'->x>vLv ■ St.; Dist.;bet.
"^
\\
and
^ IIn
/■ „ oc.t'h occurs .w.y rRO» USUAL RESIDENCE CVE F.CTS C.ULIO 'O" "N"" ^icr'iND 'nJmbJ'h""" )
( IF Dt.TH OCCURRCD IN « HOSPIT.L OR INSTITUTION GIVE ITS NAME INSTC.O OF STREET «ND NUMBER. J
FULL NAME
h
\
n '
<XhXx.L
L.'
PERSONAL AND STATISTICAL PARTICULARS
i»\i i: «»i r.iKi'ii
rol.n
>< ]
[Dkd.
iMoiflh)
Day!
\».)-;
{
)■,•,?»
M.nilh-
n
(Yt-ar*
Par.
sl\(.l,lV MARKll'I)
wiix iwi: i> (»K i>!Vt»Kii-:n
iWiiti in >-ocial <li»i',M\at i< in '
lUK THl'I. \oi-:
(Stalt (I! <■' illlltl y
FATHKR
lURTHPI^^CK
«)»■ » ATIIKK
iStaU or iinmtry
MAIIU'.N N\Mi;
()i M()rm':K
lUKTHlM.An-:
Ol' MnTHKK
(Stati or Count! >
n 1
n^cL
Tlil- \!$()VK ST\ ri'I) PKKsONAl, I'AK'rUTKAKS \Rl-;TKri-: ID TUK
(Infoiniant
MEDICAL CERTIFICATE OF DEATH
DATK in DlvATH
igo\
(Year)
(Month) (Day)
I III':KIUiV CI':RTIFV, That I attended deceased from
/>%/ .ic 190H to UcXJ I.2i 190 H
that I last saw h C aHve on v,- C.^ I ' 190
and that death occurred, on the dale stated above, at I
M. The CArSI<: Ol- Dll.XTII was as follows:
nr RAT ION Years
CONTRIIUTORV
Mouths
Days
Hours
nr RATION
(SIGNED)
Years
Mouths
Days
lnrv^A-^^A.
U-
Ucfc l?> U)o'\ (Address) llHb
^}\JLry<JjuuUe^
Hours
M.D.
-^
SPECIAL INFORMATION only for Hospitals, Institutions
or Recent Residents, and persons dying away from liome.
I, Triitsients,
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli?
How long at
Place of Deatli ?
Days
ri.ACH Ol' lUKlAI. «»K KHMoXAI,
I>An;o!" in RIAL or KHMOVAI,
0^ lb
(Address 11^ M rU.A^^-A.-<r^% uXa
T90I
„ B —Bvery Item o* in?ormHt1on •houlcl be carefully supplied. AGB .hould ba«tatcd EXACTLY PHYSICIANS .hould
.tate CAUSE OF DEATH In ph.ln term«, that It may be properly classhlcd. The -'Specal informat.on" for per-
son* dylnft away from home should be given in every instance.
i
1
.
.
"\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
iKihj
lOOH
Registered J\^o,
2337
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( U. S. Stan&arO )
PLACE OF DEATH: — County of O OAA; 0-^UX/^n.<X4.oo City ofO/CL/vu JhXXy^ ^^ .
No. tx i wLL^'>\
St.;
. 'S
Dist.; bet.
l^:
i
and ^ >
/ 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 I N FO R M ATI O N " ^
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
1 rUxa/tLo-^:
0
v^
Xlaa.cc
PERSONAL AND STATISTICAL PARTICULARS
i>A'j 1-; ni liiRin
\ ' . }•
axi^Jt
• Nt.iiitn)
10
(I)av)
,11H
MEDICAL CERTIFICATE OF DEATH
iii-ct
(Month)
15
(l)avl
(Year)
loO
J
Mmitll •
^
Star)
Ihix
1 inCRinJV CHRTrFV, That I attfii.k-.l .leceascil fro
^t\
111
1 90 ' i
to
kLlct
r:
'-'IV'. 1,1" MAKklKI).
\\ ll)»»\Vl-:i) <»K 1)!\( (KfKIl
i\Viit< ill vocial ili-«ii'natii)!i)
a
'■"^
HiurniM, \fi-:
' Stati (i! t ■.iiiiiti \
I
/ 1 ,
that I last saw Ii ... ' alivi- 011 C- 7. L
I()0
up
ami that death «KHiirro(l, on tlic date staled al)ovt', at ^ "^^
U. ^^I. The^CAISIv Ol' DKATII was as follows:
NAMi.; m
f-.\riii.K
0
V
HIK III I'l.AiH
«>l- IXini.R
'Stall Ml (■..luiti V
MAII)1:n NAM}.
Ol- .MOTHHK
I'.IRI'iri'F.ACl-:
01 MoTIII-.K
I Slate 01 i'ouiltt v)
IX RAT ION
) 'ears
Months \X nays
Hours
?
nrRATlON Years .Months X /lavs //our,
(Signed) at jl' > . . - • |y, q
^ IS' IQOH (.Address) t I'h OAAjttln.. V^
,Ph
u
?''^9'<i'- iNfORMATION only for Hospitals, Institutions, Transients
or Recent Residents, and persons d>ing away from home.
h'fsiitfff ill San /'uim tsni
) t ii .
'/--»///•
l)ii\
Tin-; M!o\i: sr \ ri:F) ckksonai. I'artuti.aks xui; trik to vwv
HICM" Ol- MV KNn\\4J.;i)r;K AND ni;Mi';F
crrsj J-
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death?
Now lonq a!
Place of Death?
Days
f Iiifiir niaiit
/^ n
XA-O^A/OiW
Acldrt-s.^ «^ I
.nr\Xj^yy\XK.
A
I^ACH t)l- IHKIAL OR Hi;MoV.\I,
1
r\K.UL4 d^jC^KAj-^
INDl-RTAKHR i'VD , -J. 'JXA^AA; ^
l>HTi;«>f III hiAi, ..r KHMoVAI,
190
<.u
N. B.-
-Bvery Item of informRtion should he ctirefully supplied. AGB should be stoted KXACTLY, PHYSICIANS should
state CAUSE OF DEATH In plnln terms, that it may he properly classh'led. The "Special Information** for par-
sons dyin^ away from home should be given in svery instance.
f I!, ^^'t'l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
3?- .3oi I!^v!' !•.,
l)(h'(' nird ,^f<ij
i '
Deputy H
inrn
hC
Registered J\^o.
2338
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of 2)catb
"U. 5. StanDarD )
PLACE OF DEATH: — County ofUCL-v\; J.Va
((T?i
No. i H
x_<^
CU..'
(I r OC*TM OCC U RS
ir DEATH OCCU
St.; ^ Dist; bet.
J? (^
City of '^ <^^-^'Vu J \x^>vc<,^
ft) J
X<xdx>v' and Lt'..-
s AWAY FROM USUAL RESIDENCE Give facts called for under "special information-
RHED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
)
•A
^>^JU
jXjxXx
V
, v. o
i» K i H «»r- iUK rn
\' i-
M..iith'
13,
/ -
\o%
M
> car'
/),/
sIN't. i.i- M \K K nil
I U'l itc ill s.M-ia'
IUK riU'l, \ri;
' Statt iif <'i luiiti \
^,ti..i!)
\xk/y
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH /P\
iMDiith) (Day>
J I in:Ri;i5V CI:RTII'V, That I atteti.lo.l ikHXascd from
Q-i.lxt XL u^o'. to li/^: i.3L
/QO I
(Year)
190 H
\\
jX'W J.\. T9O
that I last saw h ' alive on ^_ .„ u • » jgo
and that (U-ath .HH-iirrcd, on the date- stated above, at is-'h^
O^^M. The CArSl<: l)}« I)I;aTII was as follows-
r\xxA
-i^"vvwcrV\Jxa.,q
■XC .
i
N\MI «)!
FATII I.R
TUUrn I'l, AiH
<>l' 1 AIIIKK
' stall ot Couiltl \
M \ M >! \ N \M J.,
<»l .Mnilll.;K
IUK llllM.Ari-:
<>i- M()ini-R
'Stall 111 *\ 111 nt I \
Wv
-il
A
(J
'VX/
IM RATION }'t'(irs Mont /is H Days
C'oNTRimTORV W>J[v<X^\^ '*' cvx
Hours
\^
•\
sM_xa
OJxXMxx^ cUXaoaxaac -
<x-v
• Kori'A riiiN f'
u
or RAT ION Vc'ars
(Signed) LcLcu-cx.'x,<:L <^<x,o
.'IfoNt/lS
r>avs
CAj
i 1 ic)0
(Address) I^CX
Hours
M.D.
Special information only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home. '
yfitiitiu
/>a'
IHT', AHOVl*. SI" \ li:i) PKKSONAI. I'A RTICr I,A KS ARK TRI'K To
iu-:sr oi- Mv kno\vij-:d(;k and iU':mi:h
Tfn-
Former or
Usual Residence
Wlien was disease contracted,
if not at place of death ?
flow long at
Place of Death?
Days
PLACE OV nURIAl, OR rj.:mo\ai,
1.
rXDKKTAKKR KX>J\JLA..Xr ^*^
I)ATl;of I!t KMAt. or RKMo\AI,
s.^ Ww' 1 \ 190 t
(A(l<lrt-<s 7S\ U
<X'YW
IN. B.— Every item off information sliould hi careffully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for per-
sons dyin^ away from home should be given in every instance.
k^£#
^W
i 1
i It
\
I I t
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
liiiaid of Hiiilth !•■ No ;< ■&'%:»&.^HS:P Co
l)((fi' Filc(l ,\^ <:X,^A>~V\) \S
roo'i
Megisicred Js^o,
2339
.(r^M^4
/\M4
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. S. StanDarD )
PLACE OF DEATH: — County of* ' a^x ^ •
City ofQ-<X/>^ JA-<X/yX/CU4
No.
± ^^.
Ctu. ^WvLvJ.„. ^ St.; Dist.;bet. and
1 /■ rr DEATH OCCURS kw*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
J \ IF DEATH OCCUrIrED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
L")XU
J\a.aJ\..0.. >
^
sl'X
I>A 11, ( •! i;iK III
PERSONAL AND STATISTICAL PARTICULARS
ft Cni.oK
M i I c
II
M.nstl
V
Ii;r
(Vt-nr)
MEDICAL CERTIFICATE OF DEATH
DATK ol" DltATII
I* 1 -+
(Year)
\'.H
/h,
'\\iitt in xiui;il ill vi;,. ii.it 'nil)
HiK riiri. \(-i-:
(Sfati I It 1 I Miilt I s
JXAV.0.
^'\
NAM I- «U-
I ATHl'.K
niKTniM.A*, K
(H- I AIHI^K
(Stat« or t'outitrv)
MMKI'.N N\M)-;
nl- .M()THl.:k
lUK'ruI'I.ACH
«»l' MnTHI'.K
(Statt .ir riiiiiili %
<H\'ri'ATlON
^
\.^_'
0.
I Muni hi (I);iy)
I HI'RIUJV CI;rTII'V, That I attcn«k-<l deceased from
lip . t,. ^'cX 1'^ itpn
tliat I last saw li - alive on -^ ^.^ 190 '(
ami that (kath occurred, on the date stated al)Ovc, at 5^H5
G
M. The CAISI-: ()!■ DICATII was as follows
DTK AT ION
CONTRIIU'TORV
y'l'ars Months
Da ys
Hours
.ijorXju..
0.
Dl'RATlON ,-v-. J'aC'y
^ ft
(Signed)
Months Pavs
1
lU.t
^ w. I l KjO
(Address)LcU^
\
I touts
M.D.
SPECIAL Information only for iospltals, Inslltutlons, Transients,
or Recent Residents, and persons dying away from iiome.
Sj>/ /'tiiuiiarn it )'iiii^
Months
fhi\
rm: ahovi.: staii;h i'Hk^onai. I'AKTuri.AKs aki* tki'K to tiih
Ili;Si- Ol- MV KNOWl.lCIX'.H AND IJKI.lHK
f Infinniaiit
(Address
Former or iruw
Usual Residence -^ v "
When was disease contrac
If not at place of death ?
How long at
Place of Death?
Days
PI.ACH OF IHRIAI. OK RKMoVAI. I DATH of Hi kiaf. or KKMOVAI
•'YX;
(Ad<!i( ss ^ i H U J <X.hJ\jJiJ.
N. B.—— Every Item of Information •hould be cnrefully supplied. AGB should b« stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for per-
sons dyln^ away from home should be given In evsry Instance.
(S
i
i
^^b:^'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
V ■- ^■; sz:^, v,$^v Co
IS
li)OS
llci^isl ci'ed J\^<),
2340
A
M
\. "^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc ot IDcatb
I tl. S. 5tan^nr^ )
QRs
PLACE OF DEATHS — County of U<X>x xn
City of Oxx/w J /VOL
•\
T\
No.
St.; .^ Dist.;bet. . AC\<X \^\.. >\'.( and^ ' ■ " 'v ^
(ir de«t4 occurs avwav from USUAL R E S I DENCE Give f*cts CALLto for undtr "special information \
ir DEliTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / L
FULL NAME
15
LO-NiA.k.^ '^
PERSONAL AND STATISTICAL PARTICULARS
VIIICLU
\yi tir i;iKi
/JM.-iuh
DaV
\< . !:
W.
--!\' ,1 l- M \R K 11" !»
\\ I 1 H »\\ r 1 > I tk 1 1 ;\ i )- , 1 i )
->t.,i . . .; I . .11 111 1 V
i f
I X I'll IR
liiKTin-i.xtj.
oi I \rm-R
(St:iti .1(1 lUli;
ni .Mi>ini;K
luk ini'i, \\ ]■:
1 Slate iir I'uuiili \
MEDICAL CERTIFICATE OF DEATH
1) \ n; «»i- ni: A Til ;,^
I Ili;i<i;r,V ri:Rril'V, Th.H l aii.n.l. ,| ,l|.,r;isc«l fmni
(li;il I Inst saw li ali\«' mi . u^n
and that diatli <h riirroii, on tlir datt- '-tatiil ahnvc. at
J. M. Thi- CAt'SI- (M' hi; A 11 1 vnis as kill.nvs-
«H I 11' XIIMN'
DIR A'IMJN
CON ruiiu'roRV
nr RATION
^SIGNED )
)'iii/
Mo'ilh^
/hiv
IIoi,
; V
)'i(irs
JA »;//// s
/f.irs
U^.
f Adiltis^) 10 1)
//ofn s
M.D.
) {
Special information only for llos^ldls. InsHtutlons, Translenh.
or Rccrnf Residents, dnd persons dying ciHd) Irom home.
I 1
A' : i.
' >• I I :'ii
) .,11
M..1HI,
fh,x
rm: \i«>vi*. ht\ti' n pkrson m, r\Ri!i t i. \ks aki; iKri-: i' > 1*11 1-;
IU*>r «)l MS" K N< lU 1,IU»' ■••■. AM) IU:i,!l I'
1 1) ti 1; iilrint
f\l<li.-.v 1 1 Xb U\D ^Ci'C*
former or
Usual Residence
When ynis disease ronfrdded,
If not dl plare of death ?
How lonq at
Place of Death ?
Days
I'l.At'K «>l- lUKIAI, MR RIMiiXAl,
C
.nI)i;kiak}:k \4j
IJATI .)• Hi iiAi. f.t KliMuXAI,
U-rt, It, ,9„ ,
N. B. F.very Item o? inff>rmHtion should b^ cfirBiully Hupplied. AGR should be stated KXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it may be properly i,los»il?led. The "Spetlal Information" for per-
sons dying away from home should be i^iven in ^\9ry instance.
it
f
1
» t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! * 11, HI. IN.) :, t.^a?>>:. (s.ScJ'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JS^o,
2341
X(rU^U loL^. Deputy He&ilh Cfficer
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( XX. S. ir'tanc»arC> )
PLACE OF DEATH: — County of OCla^ J AXXy>vcui.coCity of 0/CU>v
L^a
No.
il
,Ouuc
u U/Ct^'x^.ta
tnv
St.;
Dist.;l)ct. *
and
f IF DtATH o|cU«S *WAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
V IF DEATmIoCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
lEATH OCCURRED I
i 1
FULL NAME cU^tuj
^Aj-crt. ^
■-i;\
PERSONAL AND STATISTICAL PARTICULARS
I» \ 1 1, 1 il i;i K I II
^
\X)r\^sjJo
• M.inlh
\| .!•
M
I
i I):iv
,v
> ■ :il
I hi
SIN. .i.i;^ M \K k ill)
\\iiM»\\ !•; i> ""K i>i\< »Kri-;i)
'W'littiii >.(Hi;i! ih^if iKit ii)n)
I'.iK III j'l. \('i-:
Slati I il I '>iimtl V
NfH
r\
A^<s\Jj\J^
N \\n 1 >i
! X I 11 IK
MIK rHI'I.XCF,
ni I Allll-K
' St:it( . i! t'diillt I y
M XIKHN NAMl-
»»l M«»Tm;K
HIKTHIM, \( i:
«»l MnrilJ'K
i '^tjllt i)T ((illllt I N
• •' rri- A riuN
/'
()
rgo
(Vfijr)
MEDICAL CERTIFICATE OF DEATH
DATK <il Di; \ III iCS
fMotilh) (Day)
I 11I';RI':IJV CIIRTII-V, That I aUcnded (IcHvascd from
— — — ■ — JyO " to ■ It)0
that I last saw h --r. alive on — 190
ainl that <Uatli octurred, on the date stated above, at — — —
^^ M. The CArSl- Oh" DliATlI was as follows:
\
h'^sidfii in S(in I 'hi II I I Silt ^ O ) rn 1 s
Miiiillis
th,
rill' \HoVK ST\T1'',I) I'KKSONAI, I'A l< IIi' r 1, \H "^ A l< I , IKIH To llll-:
HHST n|. MV KNnW'I,j;i)<".K AND nKl.llll-
: !iiriitin:iiit
%.%
e
(AcM
t('»iS
iiH LdU
I
DlkAl'loN )\ius Months Days I Jours
CoNTIUPd'TokV
I )r RATION Vtius .'Sronths Days I/our^
(Signed ) LcrX^-xM^ J. vfi.UJ.dJi^ M.D,
k)^ V\ Djo' (Ad.lriss) L(HWvUL^^ \y4iu.C..w
Special information only for Hospitals, Institutfons, Transients,
or Recent Residents, and persons dyinq away from liome.
M rUx4.<rv
Days
Wfien was disease contracted.
If not at place of death ?
DATK ()! Mi KIAI, or Ki:MnVAI,
I'l.ACKoi* in KIM. OR ri;m<»\ai.
\JuJr\KJLAAj cLcLa-U ^ x.
N. B. Bvery Item of lnf«rm«t1on .houUI be carefully nupplled. AGE .hould he •tatecl EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plnln tei-ms, that It mny be properly claaslfled. The * Special Information • for p«r-
•on« dying away from home Mhould be given !n •y/mry Inetance.
^
^^'
*A
» I
WRITE PLAINLY WITH UNFADING INK
I)((h> FfJo(L iL^cLcrW^' IS^
Deputy y 1th "
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS
Ecilsivred Xo, ^34l^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "d. 5. StanC»ar^ j
PLACE OF DEATH: — County of J^^f a^^ > > x
City of
V
Uru/n.
XCA. Y
No.
St.;
Dist.; bet.
and
/ ,r DC*TH occurs *VWY FROM USUAL RESIDENCE CVE r*CTS calutd '•O" 7"« ^rT^iNTNUMiEif*" )
( ,r Ot*TM OCCURRED IN * HOSPrTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET *ND NUMBER. /
FULL NAME
\<r>xL<^
^^ruj-v
PERSONAL AND STATISTICAL PARTICULARS
I x
( < »i ,' >k
PA
I LOw'^
i»A I i t »!■ HIK ill
no
M.iilli
LI
I».IV
\*.\:
I 1/
siN( .I,!' \t \H H n:i»
u !f»owKi» < »k iHVi »pi i:i>
Writt-iii -iMial i|ri.isf tiiil !• ill i
luirrm'i, \»*k
-'t..*- ..' ''.,11111'
<X^^.VU.dL
l\ I
\ il
\ \ M 1 1 »I
I A'l U l.R
HIHTH!' r, \t K
' »| I A I H i; K
St.lt ( iiT 1 iiU tlf t S
MAIhJ'.N' NAMi:
«»1 MuTIII.K
iUK I'HIM, \( K
lit MO'IIII'K
^t;it» or t'oiiiitr \
.^
> >i II i'A 1 ION
nf>^.
A'f/tf/'it in San /laiiiht'n
y^at i
Months
no V.
IHKABOVKsTXI HI»PHHHONAM'ARTICrLARHAKl- TKtK TO THK
UKHT OI MV KNOWI.KIX'.K AND HKIJRP
f Iiifiit iiiaiit
'\»1<Jre»ipi
MEDICAL CERTIFICATE OF DEATH
DATH i>l- KI'.A TH
4
(M.Mith)
rgo .
(Yrar)
I HI:KI;HV CIIRTII'N', Thai I attended .Icctasftl from
— • — — i^ to " 190
that 1 last saw h alive on ~ -— I90 "^^
and that death nceurred, <mi the date statetl above, at
M. The CMSI-: OI' DI'lATII was as follows
c
A^'
V'
DIRATION }'ears
CONTklHlTOHV
/IAm////?
Days
Hours
duration
(Signed)
Ycat %
C 6
Mi>fiths
/hlVS
Hours
M.D.
y^ IH i()oH (Address) ytXA"yUA.t^-L^>->^ Lxi
^. _JIAL Information oniy for Hospitals, institutions, TraBsleBls,
orlKeiit Residents, and jiersons dylnj away from home.
Former or
Usual ResMeRce
When was disease centrarted.
If notatplKeafdeatli?
Now lonq at
Plareof Death?
. Days
PI,ACE OH BURIAI, OR RKMOVAl.
iiJLA>-^
I)A'ti':of BUHIAI. or RKMOVAl.
liJ/C^ ..lb TQo't
INnHRTAKKRUAXJLtXxL \krV\AjJ\X/oJfiJ^
N. B.-
E OP DEATH In plain terms, th.t It m.y b* ifop^Hy cl«.«lfl«d. The Special Inforwatloii for par-
-Bvery Hem
•tate CAUSE _ ^ , . ^
mnnn dying away from home ahould be given In avary Inatanea
WRITE PLAINLY WITH UNFADING INK —
f ill .!ll)l
|- No 1^ t-^-T^: ]>,Si\' C
I
f t
/)ft/(' t^iJcd ,
y<K) \%
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2343
RccJisforrd J\^o.
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of IDeath
I tl. S. StanDarJ> )
PLACE OF DEATH: — County
o{0<XrY\j J.?vo^-wc v.^.-..City of O/CXyvu 0 .;^^o. Yvi^\^ o
No.
\n^
.1
%
chUv*w
tccl
St.;
Dist.; bet.
and
\ »
I ,
..:n
/ IF oc»TH OCCURS AWAY r^ o M USUAL RESIDENCE GIVE facts called for under special information \
( IF death occJrrTd in a hospital or institution give its name instead of street and number. J
FULL NAME
,0^h\.0^
u
PERSONAL AND STATISTICAL PARTICULARS
si;\
ecu. OR
\A
I> \ IT « 'F I UK III
r%
M..ttth>
\ < ; I-
t s
I);iv
M.iitli-
/ht
si NCI, I- M\RUl)!i
\\1I>« »U l.Ii « »K 1) \'« »'• in
I \Vi iti i !i -■ .< la: 'li-^ii- !i,it mn)
lUK nii'i, SOI-:
NAMI' <»f
I- A 111 IK
lUKTIiri, \CK
«>I I XIIII'.K
I >t,ll I 1(1 I'llUtlt ! \'
MAIDMN NAMI-;
«H- Mori IKK
lUK I'lIIM.At'K
<'l Mo'rilHK
< Mati nl t'lMltltl >
H-ori'A rioN f D
1
(
Y^<X
ex.
il
h'r.i\f<',f til S.nr / j,ii>. '■'■'
)V
1/-. ;;///-
/hn.
THl- AHOVK ST\Ti:n I'KRsnNAl, PAKTUT I, \ KS ARl'. TKlH TO TUF,
in<sr oi- M\' K NOW 1,1 .1 H',!-; and luii.ni-
MEDICAL CERTIFICATE OF DEATH
DATH OI' 1)1;aT11
/go
(Year
(Month) 'Day)
{ 1! lUv i;i'>V Cl'lKTIFV, That I aUciuk'd ckHcased from
— to
I90
that 1 last <a\v h -. — alive on -__ —
ami that death occurred, on the date stated a!)o\e, at
M. The CAT SIC OF DICATII was as follows:
■190
Dl' RAT ION }'fars
CONTRII'.rTORV
Mouths
Days
Hours
DIRATION
Years
^fovths
Days
SPECIAL INFORMATION only for Hospitals, Institutim, Transients,
or Recent Residents, and persons dyinij anay from jjome.
Former or
Usual Residence
When was disease contrarted.
If not at place of death?
1(DSm<l^- '-^
How lonq at
Place of Death?
Days
ri.Aci-: oi- m'KiAL ok ki-:movai,
rSDMRTAKHK IJw LU ^ ^^^
DAIHo! Ki KiAi, or K1-:Mo\AI,
S:J i<iXj 15 T90S
^rp"
Q
,0
P
Ron« dyinft away from home should be a«ven in every instance.
•! ^^
f
%
WRITE PLAINLY WITH UNFADING INK
!! .:il
,1 ,.f Health 1 N'
t.£T^t^: HSiV C,
I)
nte Filed. iL).ct<rl^^v IS"
VJO\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS
2344
llvihtered J\'*o.
\
i
^. ^v L
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
^
I »
■f!
Certificate of 2)eatb
{ 'CI. S. StanDatD )
PLACE OF DEATH: — County of 0 Orvx. J XxXAo^t o - ^ City of Ooyw J /ua/v\xxA,x^^
^^X ^ %^ , ,
Nftdt ^\^ ^Iv ...' ? St.;— Dist.;bet. and ^~~~~~
/ ,r Dt.TH OCCUBS aU*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
( Tf DEATH Ocr^RTcD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
>- 1 ■ \
PERSONAL AND STATISTICAL PARTICULARS
Col.oK \ A
UO' '
n^KXh
I>\ 11-: of lUKTII
\t .1",
Nf.iiith
t).A-
11
I).iVi
M.;,th^
x
\ trir)
/'.n.
^IN<.I.l' MAKKll-n
\\\ !»< i\\ I'll Mk I)'\'< >K I W I)
\\ ; ■!' Ml -> .. M ; il' -i^.-nat i'lll)
Ox^
luKi'inM, \ri-: 0
Mati Mf I'liuiill \ — ^f
^-vc^^ cc
N XMi: ni
1 All! i;k
!UK rHIM.AiK
()l- iAIHl'.K
(Statr 1)1 I'liiinti %
A
Kxxx: c
^s
1-^
^
(>i. M.niiHK Hill \m
lukriiiM.Aci-:
<ij- MOTHK.K
' Mate or Country)
t)rcri'ATl()N
Rf.^iifrif in Suit I'l iin, i^rn
,<x ,
5 'f'a I
}r, tilths
I hi 1
THF MU)VK STXTI'.l) I'KKSnNAI, I'AKTHM- lA KS AKl'. TRVK To THK
iJksT OF MV KNOWI.KIX'.K AND nHMlJ;
(Infonnant lo -eXAMxt NJVLUAA.^ C K
(A.l.lr.ss %C^1 ^J-LmX JX
MEDICAL CERTIFICATE OF DEATH
DATH OF I)1;ATH iCX
iL'A^.t I':
ipo S
(Year)
(Mouth) 'Day)
I IH<KI'I5V CliRTir^V, Tlial I attcMideil (kccasLMl from
iDtt 1.H
190
H
to
i()oH
t
f
tliat I last saw li ■ alive on Ifp
ami tliat cloatli ocriirred, nii the date stated al)Ove, at D
VJ ^r. The CATS I-; OF I) i: A Til was as follows:
L<r~vA^Ou^^A.'U_/0tJu LUjuul*. . ' .
Ur RAT I ON }'i'ars
CoNTRllU'TOkV
Months «*.. I^ava I A I Jours
DTRATION
)'i'ars
Mouths
l^avs
Hours
(Signed) Jyrur>^ruxA u- '.Jax > , ._x„ ,., M.D.
liJcfc 15 Tool (Address) ^ii. L aJJyvyCX^ JJl
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or H®^ lo"*) «*
Usual Residence P'a'^f of Death? Days
When was disease contracted,
If not at place of death?
I).\XKof IMKIAI, or REMOVAI,
M^ It.
Ui,ACK OF- lURFU. OK KI-MoVAI
T90H
(Ad.
N. B.-
""^^^ a ,. ,. . AHF ahniilri he Stated EXACTLY. PHYSICIANS should
•ons dying away from homo should be 4'«vcn In every Instance.
I'
;s^A
WRITE PLAINLY WITH UNFADING INK
I
I)((
l(> lu'/rti, t'ctfr^jOA' \^
n)(n
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^.dvc^.'^ ^'
DEPARTMENT Ot^ PUBLIC HEALTH=City and County of San Francisco
Cevtificate of 2)eatb
I XI. S. Stan&arP )
o;:
(1^
», ^
No.
t I
PLACE OF DEATH: — County of 0/a.i\
H ^ % I a JjsjJ^^xL.^ . > . '- \ St.; ^ Dist.; bet. cU -UX^^ >>^c
/ ir DE»TH OCCURS AWAY TROM USUAL RESIDENCE GIV
V \r Dt*TM OCCURRED IN A HOSPITAL OH INSTITUTION <
City of 0/CX/^r^j JAA^^^^C44^Ct
and qU C<^"vowCc.
)
.E FACTS CALLED FOR UNDER ' SPEC
GIVE ITS NAME INSTEAD OF STREE
FULL NAME ^ '^^
Id
1k\
MVnia-u..il)
:IAL INFORMATION" \
T AND NUMBER. J
0-
PERSONAL AND STATISTICAL PARTICULARS
si; \
vi »i < >K
It
;» \ li •>! 1:1 R I'll
\< .1-,
' Ml
1 Dav
!/,.>////'
Vtar)
/h! I
RfN< .1.1". M \KI< n I>
SVIlx t\\ i:i> < >K D'V' >K*'i:t>
iWtitriii xiHi.ii (li -iyiiati- iU)
c3xaax>''
niR riuM. \ri',
St.it I I '! ' '<nnit I \'
NAMi: <)I
I .XTllKK
lURTmM,.\OH
<)1 I APHKK
' St:it«- or Coniitiy)
M XlDl.N N AMI'.
Ml Mnrni'.K
IUKTHri,AOK
()i M<)'nii':K
I Stall' *ir Cimntry
oeciTA rioN
(^ J
I)
h'ritirif III SiUi /'i an, r-rn
) 'ill I *
y J, tilths
I hi 1
TIIK MU)VKS'r\Ti:i>I'KKSnNAI. rAKTIori.AKsAKl-TRrH To THH
liHST Ol MV l-LNOWl-EDCK ANI^Hl-.I.Il .!•
(Iiifinmaul
O'Ol.
A ,
(Address
4*^1 1 - 11 1^ '^J'^'
MEDICAL CERTIFICATE OF DEATH
DATE OF I)1..\TH \
I go \
(Year!
(Montir> (Day)
1 miKiniV CI'iRTIFV, That I attcii(k<l (k-ccascnl from
' Kp '. tn ~ ~~ T9O ~
that I last saw h — aUvc on " ^ '~ Itp
and that death occurred, on the date stated above, at
M. The CAUSH Ol- DICATH was as follows:
i aaJJL il.^^~ .. . , .
Dl'R.VTION Years Mouths Days
CONTRnU'TORV U! A,^^4:oihrL^ tl.
l/oit
ts
DT RAT ION
(SIGNED)
Years
Mouth:
iCLLUtVli.-
Pars
^\i f^ ^u (A(hlress) VJ/CUVvCKtAj vJjXd.
Hours
M.D.
y^.t
Special information only for Hospitals, Institytlons, Transients,
or Recent Residents, and persons dying dway from tiome.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death?
How long at
Place of Deatli?
Days
ri.ACK Ol- jiiRiAi, OK ki;m<»v.\i.
i).\ri/:of iji Ki.^i. or ki':movai.
Uct
rNDKKTAKKR WVVAjtjxL LL^yvdjL\A>D»^ I^JJV/i
T90
M
N. B.-
""^ iT". Ar-P ahn.ild he Rtntetl EXACTLY. PHYSICIANS should
-Every Item of Information should be c«refully -PP'-^. ^^^J^^^l^^^^^^ \^^^^^ Information" for p-r-
state CAUSE OF DEATH In plain terms, that It may be properly «.la8*mea. me 1
sons dyinft away from home should be 4lven In every Instance.
£»1
1
WRITE PLAINLY WITH UNFADING INK
M. ,;.!<! . f Hi iilllv I' N'li
N-,, ■. ■!4.**^'Sa-, iSM'O.,
Dale Fih'(l,ijizLA>-Vs. \^
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Reo^isfpvrd J\^o. 2346
s
^V^<,^'
I
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDcatb
A
XX. S. StanDarC>
PLACE OF DEATH: — County of - ^^>^
City of OcLA^
<;. ^. <.
No.
^
LC'
(ir DEATH OCCUB^ AWA
IF DEATH OCCWiRREC
'I
I
and
A^A^^^jhi Ol^^^^'L^^ ' St.; - Dist.;bct.
^rVX/Y\.MU, ^ ^ .Toi.A. orcJnFNCF GIVE FACTS CAtLED FOR UNDER "sPECIAt INFORMATION- \
U.i AWAV -OM^.U^SU^AL J„^f^°f,,^,^4-^,^;r,;| NAME INSTEAD OF STREET AND NUMBER. )
0 / A
Y
D II
FULL NAME
..L\,Q
PERSONAL AND STATISTICAL PARTICULARS
X
\Jux\mx1l
I
)
DA II-'. < >l ii K i II
\<.l".
a
Month
Dav
* I .11
s
WIlM lU I I > • >K 1 ) ;\ 1 iKi 1 |>
W'l i!' ill ---», ml .i< -11.-11,111. .11)
MEDICAL CERTIFICATE OF DEATH
i).\Ti-: oi- i)i:aiii ,, .
I lII";ki;i'A' ti;k'ril"V, That I alton.U'«l .Utxascd from
Lc^q i^ M>o'i to v^ct' it 190 H
tliat I last saw h ^- • • valive on
.^. v
u
Jip
and that .Uath ocrurreil, on the datr stated above, at b, 6C
O, M The CMS!*: Ol' DIvAlTI was as follows:
Stati 0I I'l iilti! 1 \
N \M 1 111
l.\ i II l.R
luRriii'i.Ar}-:
nf 1 AIIII'K
^t.i! I .1 Ci 111 lit ' \
maii»i:n N\Mi:
<»|. MoTlll.K
^TvC|/Li
t
1
HiR'i'iiri, \*"i-:
<il MnTlll'.K
' siatf in «.'<)Uiiti \
nrtri
A rii)N ( y
h'r>iifr<t III Sail /'nm, i^<-i>
I I .
),,i
Mnlltff
/hir
'IMIKXHMVKSTXIM<n.'KHS.>NAl rXKTU-rLXKSAKKTKrKT..
• III'
(IllfuMllIlIlt V>
(\.l<ll
Lttu^
uLoLAXt
-VL/trvv-XUvu
•hji^' \.
} lurs
DIRAIION }<^n
CONTRIIUTORV Ur:
Months Pays Hours
C/Vx/CL^
i\fi)nlJis
(SIGNED) J . ^A. OV.0^1
/hivs
J/Ci 13> i.,r,H (Address)
it)
Hours
M.D.
SPECIAL INFORMATION only for l4spltals, Institutions, Transients,
or Recent Residents, and pepons d)ina dv^ay froni liome.
Former or ( A «r i * 'l S^'T/.h, -
Usual Residence b A.^ i-^ > v.^ ^ Place of Death ? a
Wlien was disease contracted,
If not at place of death ?
Days
IT \CK <>l- IHRIAI. OK RI;M<>X AI
)cu[v>A^-'
INDI'.R I'AKHR
DATJCof HiKiAL or K1:moVAI,
190 \
V^ 15-
■■^ ATP «it,.,.ia ho Rtntetl BXACTLY. PHYSICIANS should
N. B.— Bver, Ue™ „« .„.n.™«..o„ .h.u.d h, c„r..un. .upp.--. ^^p^,';" '^'..^^.^''th: ••Sp.C.I lnSor.n...„„" for p.r.
•tate CAUSE OF DEATH In pinin term., that it mny be propeny
"n. dylnt aw., from ho,n. .hou..l be ft.v.n 1 y ln...ncc.
h;
if
ii
1
tl
WRITE PLAINLY WITH UNFADING INK
i.,n.! ..f lh:.U1i 1^ Vo. I. ^^}r^ H^P <'o
0
Dft/r /'V/r^/, Uct<rW.\j I 5"
lOOH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2347
Be^istered JVo,
d.tru^^ ^ Deputy Health ORlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of E)eatb
( -a. S. StanDar^ )
PLACE OF DEATH: — County ofO^Vw OKxX/vvX^^^ City of J<X^ ^Axv
\ / ,. orATH OCCu4.W*Vr«OM USUAL « ^ f ^ ^^^, ^^ C^^^<;-,^. /^.^S NAME -N^STtAO OP STHCET AND NUMBCR. )
( IF DtATM OCCUf*fe AWAY FROM USUAL R E S 1 U t PI V. t u . V ^ r -.,
( Tf DEATH OCCURRED IN A HOSPITAL OR , N STITUTIO N G I V E I
JCCURRtD I'M « MU»r-i "1- ""i ,.,^,.._..- ^
FULL NAME LcCtkLVo^ vi '~ lt|^^
4^
si:\
PERSONAL AND STATISTICAL PARTICULARS
ic)l OR
UkJt
kJJ^
I) \ ri' « -i HIK I H
\(.l'
IVX
\!. .iithi
)V,;)
(D;iv>
Miivlh
ar)
/),.' 1
Willi »Ui: 1» «»K I>I\ < iKT}- I»
A.) XxL
<nxr
MEDICAL CERTIFICATE OF DEATH
DATH OF I)1;aTK lC\
(Montli)
I go \
(Yt-ar)
f\
(l>av»
I HI':RI':HV Cl-iRTIl'V, Thai 1 atU-ndcd deceased frnm
\^tx,v ...;. 190H t.. . i)c± 11
that I last saw h '•' ahve on U tJu I.
and that death oeeiirred, on the date stated above, at
M. The CAISIC OF DKA Til was as follows
190 H
190 *
niK rniM, M'l",
(Stati iir <"i)iinli\
NAM)- m-
1- A 111 I.K
lUK'niiM.ArK
oi- 1 A rin:K
iStatt lit I'ottntry
MAIIM-.N N WW.
<)1- MOTUHK
lUK rHl'LAi'1%
1)1 MoriU'.K
tStatr or Coiiiili V
11
^
(\
OCCri'ATION ^
1
Kf<iiU'd in Sim I i an, r^ro
yf.utth
Ihn
THK AHUVK STATIC. .M^KSnNA.rAKTirrKAHSAKKTKtKn. THK
IJHST ()1- MV KNOWIJ'.DC.K AND lU-.Ml.f
OAXX>^>\A
.. O^^^'Y^*^^^-^^
VJJLa^wM^
\
DC RAT I ON Vi'iirs
CONTRIIUTORV
Moulin
.„. K
Days
Hours
DT RATION )'i'iJrs Months Days
(§IGNED) lU- C9. UnnJC^
,<,oH (Address) UJ-^^V^A.^^^
SIG
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from tiome.
Former or
Usual Residence
Gli^
W^^^<'
How lonq at
Place of Oeatli? Days
Wlien was disease contracted,
If not at place of deatfi ?
IM.ACH OI- HlKIAr. (IK RllMoX AI,
)QLuU'
D.yXKc'f HrnrAl, or KKMOVAI,
'^ <-!■
190
^^^^^AX.
INDKRTAKICK
/O^Ct ex. ^
(Addres
sm..S1d1.^^- la
"^
A
i
.. . -pp aHould be stated EXACTLY. PHYSICIANS should
N. B._Every Item of information should be cnre^ully «"PP'-^ AC.E s ^^^ ..^ , Information" for p.r-
stflte CAUSE OF DEATH in plain terms, that it may be properiy
•on. dying awy from home should be given in svory instance.
H. .n
WR
H. -lUh I' ^'
i t
ITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2348
^ *-!r>n»i.^i-, v.Sii' c
lU'!^isteved ^^o.
I ' '
'• I
Ifrvu.^ Uvu Deputy Health Officer
DEPARTMENT oIf PUBLIC HEALTH=City and County of San Francisco
Ccvtiftcate of IDcatb
( tl. 5. StanDarD )
PLACE OF DEATH: -County ofCcoTv JXO v - : • Gty of O^x^ J ^^tvc^ - ,
.^XlfKL^-vti ,. I SU Dist.;bet. and
^V ^^J^'^ > VV\,. .;.:., ^, orCmFNCCGIVE FACTS CALLED FOB UNDER 'SPECIAL INFORMATION" \
\ f ,r DEATH OCCURI^ AW*Y FROM USUAL f f S > ^ E N C^E^GJ V^E J A CT S C^A^L^ ^ ,^sTEAD OF STREET AND NUMBER. J
(
r-'r»T°-"cc"J.*.ro',"°:oSp" ". "n .NST.TUtToN CWC ,T. N.ME ,NST„0 or ST.C.T .NO NUMBER.
FULL NAME
^w W_'^ ^.
1 >
t »'
1
si:\
[)\ri-. «>i inurn
A< .1%
PERSONAL AND STATISTICAL PARTICULARS
I
(Kliinth
lUav)
\l,,nl'n
■> t ;i! 1
/>a
W 11)1 >\\ I'U OK !>!\ t>H«i:i)
\\!it« in *'ii ial ill -i;^iiat i"ni
lUK rHI'I, Ai'K
I SUit t lit t"i iiuU t \'
MEDICAL CERTIFICATE OF DEATH
i)\ 1 1-; tM 1)i:ath
Uct
(Month)
l>:iv
rgo
(Yi-ar)
1 HICKICBV CI'RTIFV, That I atteinUil tlcHcascd from
n^int; \H T^H to Az-ct}
tliat I last saw h '- alive on ^ -^ •• 19° ^
and that (Uath nccurrcl. nii the date stated above, at
10
\iAhx^
VAMi: OF r^)
!•ATH1^K
HIR rill'I.At J".
(>|- I AlllKK
'Staff oT Oounti V
MAIDI'.N NAM}-
01 M()Tm:R
lURTHIM.ACK
<)»■ MoIHKR
(Stale or Country
+
^^jJaXX/vu U-Co^x^uv,
OCC
ri'ATioN J) n
h'fsidfif ni Safi /'inn, i'-t-it IC ) '-■'
^r,„itln
Ihi
HKST <)1- MY KN-«)\Vl,l<;i)<.H AND Hhl.nj^
M. The CAr^>ii Ol' I>1':ATH was as follows
DT RAT ION >Var.?
CONTRllUTORV
Mofiihs
Davs
I )r RAT ION ,
(SIGNED) '
ly^ 15 11,0
) 'caj's
J f ON //is
y^ o.\. .
Days
Hours
Hours
M.D
(Ad
Iress) LaJxi^C^. d^^
ON only for Hospitals, Institutions, Transients,
SPECIAL INFORMATI
or Recent Residents, and persons dying awdv trom home.
Former or ^ . ^ 1 ^ , l ^ * "f* '"IVSk. 1 ^
Usual Residenceim dUXhJp^ >v Place of Oeatli? -
Wlien was disease contracted,
If not at place of deatfi ?
Days
I'UACK <)l* HIRJAI. OR KHMOVAI
DATlCof m-KiAl. or RKMOVAI,
0<::t IS^ 190H
(\<i(ii
^
X
INDKRTAKKR
"v%
(Address 3 (o1 X. " ^ ^
tL>
■— — y*™ .. . -^p „w„..iH he Rtntetl EXACTLY. PHYSICIANS should
N. B.— Every Item of Information •hould b. cn.efully supp .ed ^^^B «hould^^^^^^^^ ^^^ ..^^^^^^^ Information" for p.r-
■tate CAUSE OF DEATH In plain terms, that it mn> ne proper y
•on. dying away from home should be given In every .nstance.
^
1
I i
WRITE PLAINLY WITH UNFADING INK —
Bi.a; t ..( n>:.U
ui, ! V-,
IV ()\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lie i^i stored ^'o, ^o4J
l)(iti' Filed , \j <:LKj:Xs-<y>^ IS"
\ ' \
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc Q>i IDeatb
( XI. 3. StanDarO )
PLACE OF DEATH:-Countv of do... Jxa > " ^ Gtv of 0.^ Jx^x^-cc
a'
c-„^ ^ Sf 5v Dist.;bet.Cj-<XXlVXX\^\XivUand
I n
)
FULL NAME
\
-. <
,<X.Lvk.c. i.
,t > > vc ^
PERSONAL AND STATISTICAL PARTICULARS
idl.oK ^^
(\'i-:(r)
\ < . J ".
5V,/*
M,,„th
Pa v"
MEDICAL CERTIFICATE OF DEATH
(Month) '>>'ty^
I lIlCRl'iHV CI'RTIFV, That I attciuU-.l dcivasca from
(Year)
til at I last saw h
I90
to
alive on
190
T90
SIM, 1.1' M\KKii;n
WII>«i\\i:i> <>K IMVoKCl-:!)
(Wiitf in -.(H ial di '-iv Hiitioti)
HIKTin'I.Ai'K
(State '>r I'mititi v^
XxX/C. ,
HA 111 l.R
«)ct:ri'A iioN rVVY ^ ^
HIK riM'I.AlK
Oi- lAIIIKK
(Stati 1)1 I'ountrv^
MAIUKN NAMl-
Ol- MoTm;K
lUKi'mM.ArK
i)V m<>iiii.;k
(Stati- III Cotuilrv
X<X'-YV
aii.l that .U-ath occurred, on the .late stated above, at
M. The CArSIv 01' I)I':ATII was as follows
DT RAT ION >Var.v
CONTRIIU'TORV
Months
Pav
Hours
DIRATION
Years
Months
Pays
( SIGNED ) \j!i\Jr^^\X>0 ^ Vd. U). kxXojysjL
iDcfc 15- iqoH (Ad.lress) WutW^A^
Hours
M.D.
h'rnlr.'l ,n Shn /'i,ni, !•-,■,>
\r,.nfh'
Ihn
ni-ST Ol- Mi: KNOUI.IIIX.K AM) HI. 1,11. »
r 1 1 1",
(Infi)iinant
I A, > N v<''^^
fAtMrt-ss oO ck
Uut/YYvJtnoAi
SPECIAL INFORMATION only 'or Hospitals, InstitulTotis, Transients,
or Recent Residents, and persons dying away from liomc.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at /^
l»lafeof Death? )\ Days
nXJ'Hof HrRi.Ai, 01 KlvMoVAI,
>ct) lio
ri ACH OI' mKIAU OR RKMOVAI.
190H
N. B.-
i„,^„„^^^^B«M^i^«i»i— •i'^"'"'"^""^^^^"'^"""*''^"^^" I f^xACTLY PHYSICIANS should
-Every ..em o« .nformB.Ion .h„u,a be cr.ful., .uppHed *««^;/;,„.,°„:/ Th^ •SpeCa. ln«orm»..o«" Cor p.r-
» • f-AiisF OF DEATH In plain terms, that it may nc pr«M ^
:r. d^-Ji .w°, f~m hon.. Should be »,..n .„ .v.r, .n...™c..
4 #
I 1
11
» I
f Hi :i"'! I "^
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR IN9TRUCTI0N3
2350
:'•^,^ HJ^l' v"
lOO'i
Beo^istcred JS!*o,
i \
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of IDeatb
{
"Vs
J? Q!^
PLACE OF DEATH: — County of^a-^v -. ..a
City of OO-AAj OAxx->^cUi.c(.
5'
No.
I L <xLvx<x\.cx.
1
St.;
Dist.;bet. ^^
and
'"YX^w-A.'
)
c%%R"v.rrHo^s^prTit :« Tr;sT^Tu%To';'v.;r.rs name- .NSTCAo^or str" E^iN o ^N ::BrR°'* )
" ''^ ~^cinc-tu/>C-riur TACTS CALLED FOR UNDER S
/ .r (.CATH OCCURS AWAY FROM USUAL R ^ S I DE N C E^OJ VE JACTS C^^^^ .^s^EAD OF
\ IF DEATH OC
(
FULL NAME
K
w'. \-
v4
i.^ w-
ULllc.
PERSONAL AND STATISTICAL PARTICULARS
^i:\
"\
r< uj >k
wCa—^-,^
L
I . V.
I) A 1 i: <il lUK III
A«.H
V
3 ../<
Da'
1/,. »////>
War)
/'(/ 1.
TQO '
(Year)
-^!^<.I,^■. MAKun'.n
Wiiti ill -.(.lial lit «-is.'natii>n)
IIIRTm'I.MM
FATni:R
Dj
Iclt V
A^(j
lUK'rmM.Ai'K
oi- 1 ATJIKK
(Stale or Coiinti v
M \I1>1",N NAMK
ol M»)Tin;R
lURTIiri.AiF,
Ol- Mo'I'HI-.R
IStaU- or Cotinti y '
OCCrrA'lKJN
MEDICAL CERTIFICATE OF DEATH
D^k ri-; «>F DICATII
(Month) (Vi^
I m<:Ki:BV Cl'RTIFV, That I atten.lea decoased from
bCL. ni. L-'. .190. -tnj^^^'--^ -'••; 190
tliatlla.tsawh.^^- alive on W/sii.. IH '1 " . 1 > . loo ' ,
an.l that death occurre.l. on the Mate stated ab.n-e. at olX
t, :m. The CATSIC Ol- I >l'; A I'll was as foU.nvs:
^lJLvJl4L0 oXti_K^ X>v<r>^v
.A\Aii^
DTK AT ION
CON TKIIH TORY
'■'W
Months 3s /;<ij'5 //t>//r.s
OXQ-^-'lvw^^-q.
ft
0l/a7\O.
'^0lC4Aaa.<l-^
I \
duration
(Signed)
Yeat
Months
Days
C/HVx^
Hours
M.D.
^^
iqO
(Address) SO '6 ^1 1 Inni^^Ll.-
SPECIAL INFORMATION only for Hospitals, Instltullons/Translents,
or Recent Residents, and persons dying away from home.
) ra I
Mi,u1h>
Ihn
HKST Ol- MV KNOWl.lJH.H AM> Bhl.n.b
{liifoimaii
U
f Addrt'ss 0 *
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death?
Days
DATliof lU HiAt. or RKMOVAI,
^ A
VI ACK Ol- ^IRI.M. t»«< R1;M0VAU
rNDKKTAKKR mXu^^ vj Crdx
(Ad.iLs 50 5'\In^AALyrv>AXA^
-CL.^^)
._ ^uouid be stated EXACTLY. PHYSICIANS should
N. B.— Every Item of Information .hou.d H^' --^"''^^ -^^, ^^ Jtofjly classified. The "Special information'' for per-
. *- r'AiiiBF OP DEATH In plain terms, tnai n mwj "»^ m *-
:r; "n"» aZ ."L ho„., ,hould b. t.v.n I , .n..."«-
<
«
f » i
i £
IV
w
f , '•'; r V
R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2351
■iyf^^^,V.Fc)-
Ih
f/r Fi/('f/,Vc)iJj-V^
JfJOH
Medlsfered jVo.
0
cX.CrVM^^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccttificatc ot Bcatb
( n. S?. StanDarC* )
J ' Pn J <^
PLACE OF DEATH: — County of ^a^x ^^ty oi
- ^'^^ c* M n^«:f'V^t (u X. K: and
■ I f - < ^^'^ ^ UlST., DCU ..spj-cftL INFORMATION" \
)
No.
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
(•< >I,t »K
Vk^U
I» \ 11 ( >! r.iK S li
iM..iit!i*
\' ,1-
/ ^
b 3
)V
10
l>:tv
1/ ,ii'/t'
I w
Vi-art
l\t\
MEDICAL CERTIFICATE OF DEATH
DATK OF Dl'.ATll ,, ,
rMontlO
f Dav)
I90\
(Year)
I 111.-R1-;BV C1-:RT1FV, That I attcn.kMl <kocased fro
111
that I last saw h
alive on
Vi
I '^ , 4'
190 H
190 '<
>>IS«,l,K. MARK n- n
\viiMi\vi:i» OR i):\ <>K. 1 n
Wtiti in >iKial (It >.itf nati'iii'
A
f\<XXN.^xd.
ana that death occhrrc.l, on the dale stated above, at I • O U
(X M. The CAISH t)l' DHATH was as follows:
lUR riUM.AOl"
iStatr or *,*i>U!it I >
NAM I 01
I- AT II l.R
HIR'niri. \0K
(>!• I AIHI-.R
(Htatf .ir v'nuntrv
M \mi:N' NAMl".
1(1 MoTlll-.R
lURriMM^All-:
OI' MnTHl'.R
(State t)r Ci)\intry
OCCII'ATION
11
JL\,
I )r RATION
} 'ears
ruo^
Monlhs
PilYS
Hours
\ >
O. ^ \A
?
Uo-jU. nI^I^^-^
years
Month.
.\11J(UL^ Lc<J
DURATION
(SIGNED)
\Ji\^ V-
SPECIAL INFORMATION only lor Hospitals, institutions, Transients,
or Recent Residents, and persons d)ing away Irom home.
l{)n
r Address) 14 Aj v V LMAJLRa.
Days i t Hours
M.D.
/!,,M
n..;,>^-^,'^;™^ ■'■" '"'-^
(Address
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death?
Days
DATI. "t" HrKiAI, or REM<)\'AI,
J eL 11 190 H
_^^— — — ■^^■^■^*^^'^*^^^^^ 1 I K » t I EXACTLY PHYSICIANS should
State CAUSE ur Mt/* • • f . aiven In every instsnce.
sons dying aw.y from home should he ftUen m every ^^
1
> > i
: U\\
* ' i
W
RITE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2352
. ^*r:^^; :I:^.l■r,,
lf)OH
Deputy Heclth Officer
Bcili^stercd JS'o,
Dufr rih'd,}U;QX.C'c ■
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtittcate of Beatb
PLACE OF DEATH : - County of 0 Oa^ J XO . - City
-City of 0<X/YV OAXXy>VCV.<i.Ct
:\
'H
1 \
\^f4 ' ^^ ' Dist.;bct.
—and
^•"^'"1^^^^ -^c-.^",-" ^^t r^f ;^^^-;^^P"^ ^^" ^-
lAL INFORMATION- '\
T AND NUMBER. •
FULL NAME
IvLd U
PE
^i;\
RSONAL AND STATISTICAL PARTICULARS
n \ I 1 ' >i luK in
\<,i-:
M.uitl
I):.v
\l.irh'
(\. at
/),M
M
EDICAL CERTIFICATE OF DEATH
DAT}-; uF DKATII j A
igo
(Year*
(Month) 'I'^'V^
I IIl<:Ri:r.V CI:RTII'V, That l aUcn.UMl .Uccascd from
— — — — — ~~ igO ~
- .- up to
tliat I last saw h r:— alive on
190
six. ,1 J" MAKKIl'U
WIlHiU I-U OK l»!V<»Hri,0
Wi itt ni ^luiai lii-iv'":"""'
HIKTHI'l. \CV
Stat t m! I'liinit I >
a„a that .U-ath ..courrea. on the <late stated above, at
^I 'fiie CArSI':()F I)1*:ATII was as follows:
r ^
NAM J" Ml
i AlII 1*K
lURTllIM.Ai'K
«)! ! AlIIl-.K
stall 1! I'liuilt 1 \ '
M XlI'l.N N AMI,
Ml MoTHJ-.K
J'.IH rm'I.ACl",
Ml' MMTm-.H
iSiati- <ii I'Hiiiti \ '
/
I Mil TAlloN'/
x^/
L^wlw^'"^-^-^^^-^ n ^
1)1 RATION >'''^^-^
CONTRlIUToRV
Months
/hivs
Hours
■\
N
X
/
Uf RAT ION
(SIGNED) ^
Ucl IH TCP
Ytars
Months Pays
I /ours
M.D.
ipECIAL INFORMATION only lor Hospitals, Inslitutliki^, Transients,
or Recent Residents, and persons dying anay Irom home.
Kf-idrd III S,ni I'liui. iy>'
,1 1 V
\r,,iitiis
I hi v.
■ ■ ' ' . ,.,, ..xpriiTI XRs \ K 1-. r K \ ■ I". '!■' » l" " ''"
(Infoimnnt 'v.C ^-C
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
Ho\« tonq at
Plare of Death ?
Days
I'l.ACK Ol- lUKIAI, "K KI:M<>VAI.
I)\rj". o! Hi uiAl, or rkmovai.
190M
( \.lllI<•s^
N. B.-
^^^^^^^^^^^....i^^i^B^B— ■^i*-"^""'""^^"'^^^ , FV4CTLY PHYSICIANS should
Btate CAUSt ^t- UL^ • „.„,., J he Aiven in every lii«t»nce.
son. dying «w«y ffom home should be l^.ven in y ^^^^
R,TE PLAINLY WITH UNFADING ,NK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2353
» }
]00'\
llcoisterefl JS'^o.
Dale FiJv'l. y.cX<r\>JlX'
DEPARTMENT h PUBLIC HEALTH=City and County of San Francisco
Dc
cer
• ! i
*
Certificate of 2)eatb
PLACE OF DEATH: — County
ofd/OA^ J/v€u^^^^^^CUy ofC)<^^^ 3;^c^>^^--
^^
No.
St.;
Dist.; bet.
, I
and
.1
RESIDENCE GlVt FACTS CA
LtED FOR U^DER SPECIAL ' ^ "^O "^*;'° ^^ " )
r. _ «- .^TorrT AND NUMBER. •
F STREET AND NUMBEI
FULL NAME
n
PERSONAL AND STATISTICAL PARTICULARS
\.
\ IK (tl lUK 1 H
\i.i-:
SIM ,i,i- Nt AKK n:i>
uiiH i\\ 1 n < >k i>iy< "i^^ t I'
W 1 .», ill ~ K Kil 'li -ii'n.ii •< iH I
^,( ill I ll ' '. lllllt I
\ \M 1 < »:
1- A III I-.H
niR'nn'i.Ai'H
-tit. I it (.■< lllllt 1 \ I
\! Ml UN NAMl'
(U Mo'nil'.K
.1.
(Yt-ar)
M,,ut
T
/',/r^
MEDICAL CERTIFICATE OF DEATH
DATK «>»• i>KArn i, 1
(Month') '^»='y^
I IIKKHHV CI'RTiFV, That I aUc-n.U-l .leccascl fr-m,
t„ : KP
I(p
lip
tliat I last <.aw li — alivr <hi
,,„a that .Uath .uHnnrc-.l. n„ the date staU-.l ahovc. at "
— M Thf C\t SI': Oh" Dl'-ATll was as foUuNvs :
TV ■ ■' -^' •■ •
DIRATinN )Vc7;.s-
Moulhs
Pays
I /ours
lUK rm'i.Ai'i-:
'Still , III IdlUlt I \
/
DrUATION
) Var.v
/hlVS
(SIGNED) UYt>vllAj V
L' r t
,,f, 'i {A<hlnss)
i<)'
} foul lis
' IBIL
//oui \
M.D.
s^) WVO^AiAA
ftfr- —
Ukii, Trai
/
ore rr \rit>N
h'r^i,lr,f III Sail I i.nn /■>"
) V(M
M.,,illi
l>.
, ,.XK1I.-I LXK-^AHl- IHl K T" TIM'
1U> r t)I- MV KN«»\\ I.lIXii. N
"^PFriAL INFORMATION only for Hospitals. InstilutUi^*,. Transients,
or Rertnt Rfsidents, and persons dying anay from home.
Ho^ lonq at
Former or p,^,^ „j ^^^,1,1 .. pay.
Usual Residence
Wlien was disease rontracted,
If not at plare of deatli ?
!I-:n I'KKSON \1
„f.,nnant ^^JS^JTYS^-^^ ^|
f \.lili'^'^
,.1,AC1^ nr lUKIM, OK Ki;M«'\ \l.
rNI)i:KTAKl.H
li\lj 1,1 111 HIM <»i l<i:Mn\AI,
K, ■ J^ TQO'I
\
u.i.i.^^^blX
■"■"■■'"'''■'^^^■■^""^^"^^ . I FVAGTLY PHYSICIANS should
.t«»e CAUSE OF DEATH .n PJ^^ J-f^ :^^„ ,„ ,,,,y |„fnce.
RITI
, dying away from home
'il
♦.
I
h
: t 4
^
tJ
^ ♦
WRITE PLAINLY WITH UNFADING INK
^. " ^iT" "'*, livV I VI)
Pair /<'/•/(''/, y.ctA)^t^V' 1^
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Rc^islercd ^'o.
2354
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
>^^ -^ ^
( n rvv ■ \a ^ V <^c^X'. City of 3<XA^ ixxX/WCUj. ■:.
PLACE OF DEATH: — County of -J ^'
-^ ; \ i . , ''' . ^ ,1-1 St.: Dist.:bet. ^"<J
)
11 U i \ . ' - i St.; ''^'' .,„ p„» UNDER ■SPECl.L INFOBM.TION" ^
(. ,r DE.TH OCCUn-lD .N • HOSP.Tl. OR INS
FULL NAME'-O^JLuxv^^' 'J^- '^-^ ■'■
-l.\
DA 11 •
PERSONAL AND STATISTICAL PARTICULARS
riil.oK ^
n
,^"^
\j
M .mil
I:
\< . 1-:
!/.)■'//
S( .11
/',;
MEDICAL CERTIFICATE OF DEATH
DATl". Ol- Dl-.AllI
Month)
H
(Day
/ QO
I Year
t 1
190
W 1D« iWl D i>H D!\' >'•■' HH
<\Xix\> in -.. nil ,l.-i-n,iti..ii)
L
l.^c^-f^
m it 1 . 11 t I 111 lit 1 >
NAMl 01
FATHIR
lUK iiiri,\<H
• t! 1 A I'm: K
■ -,t it » ( If l' •<! "f
MMDl.N NX Mi-
ni M<»rHl-:R
!ui< rniM.ACH
(»|- MOTHKR
GyxaA-^ '
1^0-
I 111;KI;I'.V II-RTIFV, TIimI I :,1U.,i.U.1 .UT.iis.'.l fr.m,
U/J ■" — tt)
that 1 la-t V..W h " alive- oil —
a„a that .Uath nrourrcl, .-., the daU- .taU-.l al.nv., at
M. Tlu' CAISI- t)I- ni'ATli was as follows
A.A.4^J.J.
DlkATIoN
CoN'nUl'.lTOI
Vaus MonUn J^iys
Hon IS
I * (
■As.
'(
e
)Vrn.v ^ Months
nay
nrRATioN
(SIGNED) W<r^^-^ J -^A^
Hours
M.D.
4 c
1 . ,- . . 1
) ../'
^ : ..,, ,.M. ri.Ti \K- \Hi: i-Kij-. H' 11II-,
fD.r...n>ant UJ m\/ "^ '
X-l.ln-^s 11 D
IprciAL INFORMATION only for Hospitals, InstitufiW^. Transients,
o^Reielu R 'sidenfs, and persons dying away Iron home.
Former or q «
Usual Residence L »
Wljen was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
. Days
) r^
OiAtm. UaIx U.
,., KCK OF HIRI.VL OR KHMOVAI,
DAIH;. tif I51HIAI. {)r R1-;M0VAI,
^ ""A' lb 1 90' I
rNlJKRTAKl'.R
'^^'""'^ II. PHYSICIANS should
state CAUSE OF DEATH m P'»'" J'^7 ^,„ •,„ «ver> instance.
sons dylnft away from home should be give ^^ ^^^
M
1
* i
( •
'J<
WRITE PLAINLY WITH UNFADING INK
lU'vT ^'
THIS IS A PERMANENT RECORD
REFER TO ..o^.P.rATE FOR INSTRUCTIONS
Iht/i' Fih'fJ, i-'ctcri^N.'
lOCi
Bc<^>istered .A^o.
2355
1
0
OEPAmENT 0^ PUBLIC HEALTH=City and County of San Francisco
Ccitificatc of S»catb
XX, %. StanDarD )
J? (^
No.
J? On -\ '^
PLACE OF DEATH: — County of Oay>rv ov ^^ o.
' t - • St.; ' UlST., DCU _„ ,,^_,pp ■■special INFORMATION' \
V IF DEATH OCCURRCD IN A HOSPITAU ^ ^1 ^ i]
)
FULL NAME
\ N.
\jXJuu^of\^^
c^.
.j:n.
PERSONAL AND STATISTICAL PARTICULARS
i
11 \ ri: t '! 'M K I li
M.nt
> !>;i\
Vi'.M '
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH iPj i ! /^
(Month) "•^'^■^
I IIHRKBV CHRTIFV. That I alu i-k.! .Icrcase.l fnmi
/90 »
(Year)
t
\L)^t 1^
T()0
A I
Iht
^X-KiAM M \HKI! n
1 Writi ill -iHMul ill -lyti.i! -tit
I 190 H to
U,at I last saw h . alive on ^^ ' ^9°
^^^^^^ ^,^^,, .^^,,,,, „ocurre.l, o„ the .late state.l abcve, at
M. The CAl S1-: Ol- Dl'.ATll was as folUms:
H
A
lUK rin'i,\i'i"
Sl.i! ( ' )1 I ' ''1 lit 1 ^
NX Ml t»1
1 ^ ; 111 K
ItlKTlil'l, \< K
(»i' 1 Arm-'u
i st;it I' lit 1"| mil' ' v
M \I1>1-*.N NAM!
(ii M«»'i"m.K
r.iKrin'i.Nri-:
(ii Mdiin-'.H
(Statt III Cuutilry'
v
I 0
I
I
La
n n
DT RATI ON ^''"-^
CONTRIIUTORV
Moiii/is
/)ijys
SJ
^L<x^
^ i
DTRATION
, 1. 5). a
J/^ofi/Zis
Ihn'
(SIGNED) ck. cU. MlJO^^lXl.
4)ct) IS^ TqoH (A>hlre.s) hoS
Hours
Flours
M.D.
)
■,',f ; < C7^
\ IK-X.
(HOt TA IU»N
T.\, ..vuTlcll \K^ AK1-: TKfl'. l«^ '»!h
a„r.nnant (^ . Q( V\X^4^ 0 A
"special information only for Hospital
or RefeS Residents, and persons dying a.ay from l»ome.
Is, InstitulAns, Transients,
Former or
Usual Residence
When was disease contracted,
If not at place of deatli ?
How lonq at
Place of Death ?
Days
'i H 5 3j .v^v^fc^Nij
4-'
M
l-I KC}- nl HIUIAI, OK KKM..VAI
l»\l"l-i>f lUKlAt. <ir K1':M()VAI,
.^ .^ A..CW^V ^
190 I
' ^•'■''^•'^^ , . . ^^^.L. PHYSICIANS should
>f
' I
» I "
w
RITE PLAINLY WITH UNFADING INK
1
!!
*
1
i.
1
1
i
it
1
,
lii
aJ^'^'5:., i;»tl'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2356
190 "i
A., •■.
DEPARTMENT OF PUBLIC HEALTH
Bes^Lstd'ed JS^o,
tVLL'
=City and County of San Francisco
Certificate of ©eatb
, -a. 5. StanC»ati? )
J? %
PLACE OF DEATH:
^ . xiin 'Wi 0 ^n >vCv s. ^ City oi ^'^-^ ''^ ^ ^„
■County ot^- ''^vru ^- ^-- -^ ^n
No.
N
c* Dkf bet. c^U^^--*^^^^"^^^^^ ^^^ X
bt.t J_/1SI., UCl* ..„„rii "<5PECIAL INFORMATION- \
r-o;:;:^oc-.^vrn^^t^^^3^?-^
( V
FULL NAME ^^^
^OX^XUL. w
SI X
PERSONAL AND STATISTICAL PARTICULARS
i>\ 1 !•: Ml ink 111
M
/ w
M^ Mth I
Ki.I-
l»a'
V. »/'/'
Year
/>..M
MEDICAL CERTIFICAtt OF DEATH
DATK <H> I>KATK ^
k\^
sINt.l.J'. MAHKn't>
W tiH (HHl> <»K l»'^■' 'K^ ' •'
A • ' m «ociHl «lt -ifiiati-iii)
#i'> •
lUK rm'l,ACR
v,t,,|, 1,5 ('(.niitrv
NAMl <>l
I AT in; R
BiR'ruri.Aci-:
(>|- lAllIl^K
( state- i»r i"onnttA
MMDl'.N" NAMl'
ol MoTllHK
lUK rmM.Ai'i',
»U- MoTllKK
(State i>i r<mntry'
orri TA riox
nUST Ol' MY_K NOW 1.1 J >•■»•• ^^",^' {
.Month) <'^='^-^ _„^i^^^"^
I IfHRHBV CKRTIFV, That I atten.Wa ac-ccascd from
190 tc, ..— — - ^"...-190 —
that I last saw h — " ahve on — ^ ^ '9°
,^^^^^ ^^^^^t a.ath ucct.rrca, on the .late stated above, at
M. The CAISK^OF DKATII was as follows:
» I
DT RAT ION >V'^''-^
CONTRn'.l'TORV
.}fonihs
/)avs
Hoiirs
DURATION
Yt-ays
Months
Pars
Hours
^ \
(SIGNED) Cvv*>X^^ S.lD.iao^^.c' M.D.
Oa
T<)0
wiK, Trai
VpeCIAL information only tor Hospitals, lnstitutiy.k. Transients,
or Refent Residents, and persons d)ing anay Iron, home.
(Infounant
Former or
Lisual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
ri XCHOF lU-RlAI. uR RKMOVAI,
DA 1*1% of nrRiAf- or RKMOVAI,
A — — i^— — ^— ^ ^ FYACTLY PHYSICIANS should
ATH in plain term., that It may " ^
N B Rvery Item of inform
• .tate CAUSE OF DEATH .n P'"'" —;■-.;,;„,„ ,vry instance.
sons dylnft away from home should be give
WRITE PLAINLY WITH UNFADING INK
A.?-S7t,:. !lS;V'"'i
Dull' riled. I'ctoWAJ lb
THIS IS A PERMANENT RECORD
REFER TO ROCK OF CERTir.CT. FOR INSTRUCTIONS
235?
lOOH
]ii>aistcrcd Xo.
Deputy Health Orficer
DEPARTMENT ^F PUBLIC HEALTH-City and County of San Francisco
Cevtificate of 2)eatb
PLACE OF DEATH = -Countv of6^.^ J^—' ^.ty of ^^-^
A C ,F otATH OCCURRED IN A HOSPITAL OH ;,^. ^
FULL NAME
)
-^i:\
PERSONAL AND STATISTICAL PARTICULARS
(,(»1.0R
I
i>\ri: ')! HiKiii
i
h .
MEDICAL CERTIFICATE OF DEATH
,„v,..,..,...vn, 0^
(Day)
190^
(Year)
\«.i<;
S^
5
;iav
M.niHl^
Vt :i!
/'./I
1
^IN.l.l- MAK1<n-.l>
WIlMiW 1.1) »»K DIVitK* l-.I)
iWritr in -.» i;(i .l.-i!.'i\at!'iii )
^
(Month)
I HJ-KHBV Ci-RTIFV, That I attenac-a acTc-asc<l from
S ,• ^' ^^ . TOO •
that I last saw h i- • > alive on ^ ^
a„a that ckath occurrea, on the aatc state<l above, at
M. The CAISH ()^I)KATn was as follows
n L'^-v^
e^
0? 0
niRTHPI.Xi'K
'Stat' <>r «."f>niiti y
^.■^
AMI- ... (U (7Q
ATH,..K V H ^
NAM I' nl (15
1 I
t ^
DTK AT ION ^''"'^'-^
CONTRIIUTORV
Months
Pars
Hon
rs
HiKTin-LAt »■:
01 1 AlllKK
iStatc or (.■oiiiiti V
MAIDI-.N NAMi:
Ol- MO'I'IIKK
lUHrilPLAlK
m- M(»Tni'",R
fStalt" i»i i*()Hllt^^
/yavs
s1
I lours
M.D.
(SIGNED) - . V ■ c, p QTlP ,4
— — ^ _ _i- I-. u^onif >ir IncCidiHnnc Tran^ir
<Xk
"ciPFClAL INFORMATION only tor Hospitals. Institutions, Transients,
orlefent Ments, Vnd persons dying av^ay from home.
n How lonq at
Kf^idfd n, S,n, riiUi.i>rn
M,>}itli-
/hi;
(Iiifoimatit W . --J A
.<. i
Pllif c of Death ?
u »
Days
Former or sWstsAr
Isual Residence iiou J v
Wlien was disease contracted,
If not at place of death? _ .^
— ^ ^ .. ,,i-M,iv\l DVl'i;'"! IM lUAl- or KRMOVAI,
.,,ACK or HIKIAI, c.K KhMuX AK DVi •
IXA/Y
{\nru^
I
T90 i
/t)
r X-ldrt-'^s
rsDi-.RTA'^i''^
"•"^•^^ ^ , rvACTLY. PHYSICIANS should
state CAUSE OF DE^TH m P'«'" J\7 ^^„ ,„ every Instsnce.
son. dying away from home should be ft.ve
• I
I
WRITE PLAINLY WITH UNFADING INK
.,]. )■ n;.!
,. «.rr»^i.r..<tri-
l)(,/,' l-lleil, ^ ct<rlMAj
l(o
lOO'i
THIS IS A PERMANENT RECORD
REFER TO PACK OF CeRTIFICATr rOR INSTRUCTIONS
Registered A'o. 2358
^
DEPARTMENT aF PllBLlC HEALTH-City and Connty of San Francisco
PLACE OF DEATH: — County of
I'
r:\
No.
,1?S
\,<rO„ci
(
ir DEATH OCC
IF DEATH O
Cevtiticatc of Bcatb
. ( XX. S. StanParP t
1 ^
of OxXy>v ^■'^^' ■■ ■ '■
CL
(5i^
City
)
I'
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
(^/
"N
">
^Li
1 S i I '"
DA ri". < »I I'.IK 111
\«.H
ll
M..ntli^
r,».'
l»a>
M^.tilll-
\\i\
r)
/i.f 1 .
MEDICAL CERTIFICATE OF DEATH
I)\TK <>H I>HATlt \
n.onth^ .Day) JYear)^
^ I IIHRIUW CK RTIFV, That I attonae.l .leccased from
. — 190 to
that I last saw h :— alive on "
190
190
S1N».1,K. M.\K1<IKI>
\VID«nVKD OK DIVt>Ri ID
Writf in MH-ial .Usi}j:iiati.'n>
lUKTinM.X**}',
(StaU iir r>iunti v
NAM1-; ni-
I ATI 11. K
;CV'.
„,l that death occurred, on the date stated above, at
M. The CAISICUI- DHATII was as follows:
^^>^
nr RAT ION >'<''^''-^"
CONTKIIU'TORV
\
Month:
Pays
Hours
HiR rnruACK
<H- iwriiKH
(State t)r C<nniti v
MAIDKN NAMK
01 MoriIKH
lURTHlM.ACK
111. MOTIU'.K
(Slate or Oovintrv'
(S
v^r.i.v Years JfoNt/is Davs Hours
r\
occrrATioN
k f--
' ■■ itWrts,
"ciPEClAL INFORMATION only tor Hospitals. InstitutWris, Transients,
or Refelu Residents, and persons dying away from home.
Rfsiiifd III Siiii /'"I"- '■
) 'ill >
.Mnnlh'
I his
hfsiiuii III M." ■ riiK
TiiKM,ovKsTvn..,w<K:.,v^n;;;;i,^-<---'^- •
former or
Usual Residence
When was disease contracted,
If not at place of death ?
I^,ACE()F m-KIAUOH RKMOVAI,
Now long at
Place of Death? Days
DAXl'" «'■ 15' KiAl. or REMoVAI,
V//t.t' li T90H
INDICRTAKKK
.K,
^t
I (\^V\\v^-^ "^ ^1,1 LL. PHYSICIANS •hould
...U CAUSE OF DEAT" In p...n ^_^ ^^^_^ ,„.„„.
....; CAUSE OP fEATHJ^n Xul. be ftiv.n 1 , tn-.-nc
,mt dyln* away from •<»"" ""»"'" "
» • M
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
PEFER TO RACK OF CERTirlCATr FOR .r.STRUCTI0N3
lie a i ale ml •A^'^- f^'SO\y
I III 1 1' Fi /(•'/, VC
DEPARTMENT OF PUBLIC HEALTH
=City and County of San Francisco
Certificate of ©eatb
tl. S. StanDarD )
(^
PLACE OF DEATH: — County of U^Xm. ^^
" 0 .^ I ^i!* 1 4 11 T>' i. u«* — and
V
'/if DtA-TH OCCUB3
)
St.; ^'^'•' ,t„ POP UNDER -SPtCLL l~rOR«AT10»" ")
C ,f death OCCl^HRtD IN A HOSPITAL
FULL NAME
V
I
SIX
PERSONAL AND STATISTICAL PARTICULARS
/ t
1) A ii; < it lUKTIl
M,.iith>
IMO
MEDICAL CERTIFICATE OF DEATH
DATl-; OV Dl-.ATH jj |
/go H
(Year)
A<.1-;
1/
/',
\\ n»i»\vi-:n ok i)IV<»k.' id
■ • ' ■•■n.in.'Hi
\\ ! \\f ill -.ocial il< -'
lUK riU'l, MM-:
--t.i!. ..r ' "lUiili
N'\Mi-: «>i
! Aiin-.R
Q
I iiFRKBY CURTIFV, That I =Ut.uac.l .Wa.ol from
Wc^ ^^ 190 'i to ii)^^ IH 190H
, t i'l. itp ''
tlK.t 1 last saw 1, .. ^ al.vc on _^ ^
„,„, that .U.ath occurrcl, ,.„ tin- .lat. .talcl al.ovc, at .-
■ M -riK' CAVSI- (ll- lil-lAni was as lolUms:
.wC^ '
DTK AT ION ^''"'^''^
CuNTKlBrToRV
Mo)iihs
/hiys
//oitrs
B1RTH1M.A< 1:
oi- i-\riii-K
MAinilN NAM I', 1^
OF MoTHKK
lUR rm'I.ACK
()!■• MoTIlKR
' siatf or CotitUi
DIRATION
, l.'i
occrrATioN
Ow
\Xj^
n
(SIGNED
(\
- s'^ECIAL INFORMATION o.ly tor ispltals, Ins.i.uti.ns, Transients,
„1e" Mrnh,7nd Drrsons d,in, awav lr.:n home.
«
AV>/,^/-./ >>, S,i>i ria'i.i>rn_
),-,;;
— \f,,nlh'
/!,?
„„„_„„ -bx^ (jXoJt^
Former or . ^
Isual Residence * ^
When was disease contracted,
If not at place of deatti ?
, How lonq at
^C ' U Place of Oeatli?
Diys
Xj lb
CK^v^X-
\XcM
OF Hl-RIAI. OR Kl-Mj>VAU
DATl-', of ntHlAt. or RICMOVAI,
190
fAddriss ^>-^^-^. ^ PHYSICIANS should
• ■; ':
i • '•
WRITE PLAINLY WITH UNFADING INK
l)„/r /••/■//''/. ^'cLtri»-JLAj
lf)OH
— THIS IS A PERMANENT RECORD
«EPER TO n.r.K OP CERTinCAT. TOR INSTRUCTIONS
2360
Jle^jisiered -jYo,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccitificatc ot Scatb
f ^^L^^VO.^'- ■ City of OC^ l-v^Vv^C^^C
PLACE OF DEATH: -County of ^'^'^^ ^ ^^ ^ ^
, - St.; ^- DlSt.;bct. ^'„,^.spec.al information' \
V ir DEATH OCCURRED IN A HOSPIT u Aft
)
FULL NAME
A^XkX^J^
'\.\
PERSONAL AND STATISTICAL PARTICULARS
i-( 11 I »K ■
MEDICAL CERTIFICATE OF DEATH
M 1 yj.
ii \'n. »>i. lUK I II
A t , E
.1
iMniUh'
/
bH
i'.i'
T . '//
■»'i ar
DATK «»1 I'l^^'l"Jt |A
(Yt-ar^
•Dav^
(Motilh>
I ,|,;KI.:nV CI-;RTIFV, That l .tlc.loMc.va^cl fr^
i()0 — to •■• ■..■.■■—•■ ^ ''*^
' alive t>ti
luo
IM..L .
.„,Ul.at,K.al„.-co,rre.l, ...tlu. .late staU.l above, at
mN«.l.V\ MARRIKI)
WinnWJ n «»K DSVriKi HI)
Writ, in -Kial .U'siKnatu>n»
M. The CArS!< oF Dl- ATIl was as follnws:
lUK rin'i,\**i-"
N \Mi: < M-
1 ATM IK
1UKTmM,A*K
oi I Alin'.K
>-,t a! I I >i, I'l iH nt 1 y
MAn)i:N NAMK
or MOTIIKK
nr RAT I ON y<'^'"
CONTRIIUTORV
Months
I\u
\
,,, XV- I'vjj-c Months
(t)
Pays
I /outs
Hours
M.D.
r.iKi'iiri.Ari-.
(>!• MorHKK
(Htalf or Cotititi > ' y
/
/
(SIGNED) WUn^^-^
-SPECIAL iNFORMAT^f '«; J-P"-'^' '"^^'^^^"^' ^""'^"'^'
or^efeS^esfdents, and persons dying away Iron, home.
Lc\>cn^JL>
o-ts-vUk.^
(1
Former or
Usual Residence
When was disease contracted,
If not at place ot death ^
How lonq at
Place of Death ?
Days
}AA./^kCU^"^jJ /OXx,
DATl"! niRtAi. or KKMOVAI,
vni,i:ktakkk JoXW ^
N. B.-
(A.l.lress — ^ "^°~^ . . . ml. PHYSICIANS should
• •
< (
i !
N
' ;l
1
.... .... W.H ...0.0 --- ::;r=ri^
b
1D()\
Erdisfered M*o,
DEPARTWENT OF PUBLIC HEALTtKity and County of San Francisco
PLACE OF DEATH: -County ofOo.^ ^ A,0
Ccvtiticate of Beatb
J (S^
\
l^ vA K \ St • Dist.; bet.
V IF DEATH OCCUBBED IN A HOS ^
and
^e. "corrlAL INFORMATION" ^
'""^ .omVNCEG.VE FACTS CALLED FOR " 't,'^ " 3:^„"eT in D NUMBER- )
USUAL RESIDENCE GIVE NAME INSTEAD OF street *n
FULL NAME
1
d!- Ml Kin
MEDICAL CERTIFICATE OF DEATH
DA rr: oi- dv'.aih
0.t
(MontlO
il):iy^
(Year)
M. mh
\uV.
liav'i
M,,},!li
/ i. L W
(Year)
/),n
, „,.Ki;r,VCKin'IFV, Thatlat.cn.lciaov.sclfron,
190 H to
• ' 190
tlK.t 1 b.st saw 1. ^'I'vc on
.„„, ,,„, ,,„,.!, ocurrcl, -n t.K- .la.. staU-.l ahove. at
M. Tlu; CMSI. OW UlCATllwa. as follows-
WHM.WKl) OK DIVoKi l-,l>
I Writ, in -.K-ial ,l« -is^tHitiuii »
UIH rn!M,\i'i'
(Sin*- • ■ ■ nmi \
\\M1 Ol
1 \ rin.R
Of I AIUKK
MMDl-.N NAM J
<»! MoTIir.H
niUTHri.Wl".
<)! Mtirul'.K
iM;itr or Country
HHST OH MY KXOWUHUon
l)\ri ot lUKlAl. or RKMOVAI,
(Itifonnant
U,.dre.. qHi» VJX^A^^^^ ^^
, ,„,lre., 5^1 a^^^^ff^I^:;;---^^ — 7^ ...ed BXACTLV. PHYSICIANS -houid
•on. dyliift away from home » ,
190 \
>t
• »
I
I
I
, t
i
I
WRITE
PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
„EFER TO .....nPCERTirlCATErOR INSTRUCTIONS
2362
Jledisiered jVo,
Ini/c Fili'tf .
DEPARTW^NT OF PUBLIC HEALTH=City and County of San Francisco
Gcrtiticatc of S)eatb
-^\ ^K ^ .. ^ ^ ' Citv of O'O^^ \ K/yj^r^y^^^^'^
PLACE OF DEATH : - County of w^^ '^ ! . ,
No.
St.;
! I UXA.
)
~ ^ ii«5iJAL RESIDENCE Gi
/ ,. OE*TH OCCURS *^»\;''?*'„oSpVfL OR INSTITUTION
\ ,r DEATH OCCURRED IN A HOSP.T
UlSt.; OCX* ,.MDER "SPECIAL INTORMATIO
- )
(\/
^
FULL NAME
lO-^n'A '
c*
'^
K.
/"^.
SKX
-;7;;^;:;;:Tno statistical particulars
\
c
M
1) \ 1 i; ( »! niK I H
I M.iiithi
MEDICAL CERTIFICATE OF DEATH _^_
^''V.W ,.j,^^y^ (vear)
(Month)
t„ O^t w.
\<.i.:
'>^lN" I I- M \KK 11. 1>
\vn>n\VKl> OK invoK* M>
(Stati ' n ' ' 'I' '>* ' "*
l>:iv
M,,>llll
\'. ;i!
/>-/
IQO
that I last saw h - alive oti
.n.Uhataoatlw>ccurrea,n„ the aaU..tatea above, at
M. TlKCArSlCC)FI)KATIl was as follows:
X^
Vj.U^'
'V
,u<.
\
J AT 111. R
HlRTinM.AiK
»>!■ I MHHH
■^tatt 'ir Counti v
M MDl'.N NAMK
<)1- M()T1U:R
lUR'l'liri.ACK
(»1 MOTHHH
(State or 0<HJ»ilryl
OCCI'I'A riON '\
jjL^
\JLXXhj
1
\^0.^\xhX)
I }):nrs ^^ Months
DlRATloN
!.4.-
Days Hours
U^lxxXu^
HrRATiON
(SIGNED)
Years
Afonihs
'^
w<XX^>xX>w
3Jb
i ^
I
Rr,idn! n, Sun /mm', /--"^
V,("
M,<>ith>
lhi\
HHST Ol' MV KNOWl.hD* 4-
(Infortnatit
Former or
Usual Residence
When was disease contracted,
If not at place of death r
7r.ACKOKBrRIAI,nRRHM<.VA..
How long at
Place of Death?
Days
DAX'l-. of 1M HIAI. or RHMOVAI,
f Address
^10
Address '^ *- »■ ^
c^
m.ll ^ i^ (Address. »^XH QA^^^-
J aIa^-^^A^^ - ^ ^ . .FXACTLY. PHYSICIANS should
— r.H erefully supplied. AGE should ^e stated EXACT .^^ .^formation" for p-r-
rmatlon should be '^b''*'"''^ «"^'; ^^ properly classified. The
5EATH In plain term«, that, t may ^^^^
sons dying aw»y
I )
! •
* ^ i
* I
I ,'
•in
? '
«♦
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
)!,,:;r.l of n.;!lth 1
2363
,>alr Filcl, 0.d>U. It 100^ Registered Xo.
IfrvcL^ U -, Deputy Hcallh Q(Ti.cer
DEPARTMENT OlF PUBLIC HEALTH==City and County of San Francisco
Ccvtificate of 2)eatb
( XX. S. StanDarD )
J? (^ J Q!?> . •
PLACE OF DEATH:-County of Oc^^ ^^CO.a^C..- Gty of Oom. ^S/m^wc^-A^
rrN
-H
No.
and
?
(
IF DEATH OCCURS AWAY f
IF DEATH OCCURRED I
St.; -^ Dist.;bet. '- v
)
UNDER "special INFORMATION" \
\
FULL NAME
UOJLL
■^xxj'yy^
k^K.
<X^~> \XX-N.
n
PERSONAL AND STATISTICAL PARTICULARS
C\
SKX
DAl'l'. <>l- I'.IK I'll
A(.K
CDI.oK
\\jji
/Ut
M.iiith*
Dav!
Mnll/fl-
V<;)i
/hi
MEDICAL CERTIFICATE OF DEATH
DATK «»1 DlvVni ,, ,
it
(Day)
/<?n M
(V(;ar)
SIN'. 1.1* MAHKIl'.n
\\\\u i\\ i: i> < »K i)';Vi iKi »:i>
. Wi it( in -<K-ial dt >iL'iu;ti' 'ii)
BIRTH PI.ACR
(Stiitf or t'oiuit r V
aAXOL<l
I HliklCHV CliRTIl'V, That I attended deceased from
0„^ ,U^ XI igo 'i to M'Cti 1.5: 190 H
tliat I lastsawh^ .. alive on U tX ^H 190 A
and that <Uath occurred, on the date stated above, at b
LL M. The CAT'J^P: Ol' I)1:ATII was^as follows:
>
aJL\hwL<x^
(JVDX<a-
N'AMI-, «>l
iATm:R
niR'nn'i.ACK,
oi' iArHi':K
I Stat' oi (."ounti y I
MMDJ'.N NAM1-;
ol- Morm-.R
Hi H Till' LACK
ttl- MoTlIHR
(SluU- or CoiuUry)
^IX
\^
.CA^TrxXJ^V o^ J^J^<X. >-.. O
i .»
nrkATioN
CONTRIIU'TORV
}'iars Montlu,
T\..^fYS^'^
Days Hours
\ \
XK. v.\.a.A.
X V -,
j I
nccri'A rioN
Rf'^idrJ in Siiii i'l <iin i>i<>
) I'll I
.\f,,uth'
I hi
TllF MU)VKSTATKI»PKK^<»VX1. I'AKTU-ri.ARS XRHTKlKTo TIIK
IJ1-:ST OF MY KNoWl.llx.J-: AND lU-.lJl-.l'
(Ad.h.ss O H H J AAj\^
^-NX.'CX*^
DURATION 9y Years .yo>i//is
(SIGNED) \Il\ '^^ ^^ , ■
/hi VS
Hours
M.D.
\Ull
icp H fAddre-;s) 5H(:^ JaaA.^ uA.
Special information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying a»ay from Ijome.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
HoH lonq at
Place of Death?
Days
PI \CF OI' IHKIAI, OR R1-:M«»VAI,
rsni'.RTAKKR
!»\ll, of ItrNiAi, or RKMOVAI,
(Ad
-CAO/^
^-C
sH.. X\H. E<Lct
.. ■ 7^ -u„,.iH he Rtnted EXACTLY. PHYSICIANS should
N. B._Hvery Item o? Information should be cnretully suppi.ed. ^^J;^*;^^^^^^^^ ^he -Special Information- for psr-
state CAUSE OF DEATH in plnin terms, that .t may be properly class.tiea.
sons dylnft away from home should be 4ivcn in every instance.
< m
-. ....» Tum IS A PERMANENT RECORD
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERM
Xi.u.'^i- <■
190 ^i
2364
n#»nti*"'^
1
t t
t i i I
DEPARTMENT OF PUBLIC HEALTH-City and Connty of San Francisco
Certificate ot Sieatb
PLACE OF DEATH: — County of^OuVu vJ AAX/ v.
No,
\).V^^H^^'^
St • — Dist.; bet.
-)
I10>'^■^^ ' ,i.»3l*» " '^ ^^=.iwnrB"sPECiALiN formation"^
\\ IF Dt(
-4"o^.'!„r;,-°" o"/r.t ^^^-^f^^^o-^'-v-r-s .... ,~s.». . s....
p
FULL NAME
i t
-1 \
PERSONAL AND STATISTICAL PARTICULARS
i.«)l,t»K ■
*
i
It \ ri-.
«i! 1
_ 1 1
.IK in
I
\
>x^
\t.H
)V
5.
• lf;c
M •>!!li
\x
Year I
/'..'
MEDICAL CERTIFICATE OF DEATH
DA TK Ol' ni';ATH IM I
(Mouth)
Day)
(Year)
I |1I'K|-|!V CI-.KTII-V, TliMt I attcM.cW cleccascl from
•-IN* .1 J- M \\<\< 111*
\V!D< »\vi;d <»k i»- ' ''■^' '■ '•
it : I . 11 )
Wnt- in -
lUHl'lll'I. \*"J-.
N \\n- «»i
I AT in: K
HIKTMIM.AOK
(»i lA'rm-.K
I stall ui Cuiuitl N
maidi:n NAM1-:
«»|. MtiTHKK
luR'ruri.ACK
(Stati or Country
( nHirATlON
n.o-k^oJ-H
^^... ^^fi- to w^ .-^ -90^
that I last saw h-' alive on - ^- ^
a„a that <U-atli occttrre.l, on the .late stated above, at
UL M. The CAISK OF DK ATI! was as follows
r\yxxjx^ y^^'^^^^
nr RAT ION
(SIGNED) OX^ ^•
//ours
Pavs
AJ
^
iy'~i
^'^
//ours
M.D.
A.hlresi) 9.50^^^ i^HA^^^^..■ '
QPFCIAL INFORMATION onlv tor Hospitals, Institutions. Transients,
or Refe^ Residents, and persons dying away from home.
1 A, ;////'
/),/!
^^^iii^^^iw^^ '■" ■"'"■^
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
U.ltcss X^b'i 0^^^^'
^a.^vxL Bl
HI.ACK OF BfRIAI. OK KHM<>VAI,
rNDKRTAKKR ' ^
D\LM'o! HiKIAI, or K1-:M<)VA1,
T90H
<x^
,,,„„.. ib-i^- i^^
'^''"'^ '^ ^ "• , . . PHV8ICIAN8 should
,tate CAUSE OF DEATH .n ^ "'" J*^ ^^^„ ,„ ,very in.tance.
•on. dying away from home should be fe.ve ^^^
),
•4
RITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REreH TO »ACK OF cenTincATr roR instructions
l)alr Filcil. ^ct(rl^X^'
IV OH.
Reg i. sic red JVo.
2365
1 *
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
dcitificate of ©eatb
( tl. 5. StanDarJ? )
Q^^
J (3n
' !i!l^
PLACE OF DEATH: — County of
(XAX- ' XOAvCUtCoCity ot ^'^^^"^ "-
(^
fN
o»
St.; Dist.; bet- -^^v „^„„ 'specl ,Nrop».T.c,N- •)
,„ OSU.L RESIDENCE o..r;.CTS c.c^.o ;- ^7/|, 3„„, „„ NUMBER. ;
r
)
V IF DEATH OCCURRED IN A HOSPIT.L
.»
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
-I \
C()l,( »K
:, \ 1 i- .)!■ lUK ru
\(^K
n
, M..nth '
^!V»-. 1 !■ MAKKII-.n
WIDOW l-l> OK I>lVt»Ki"l-.n
W-it. in -Kial lU-is.' iiat i- >n )
lUKTiU'I. \i"i-:
M,)i'li
Vt art
Pas
' MEDICAL CERTIFICATE OF DEATH
DMH «)»• DKATH n . i
k.::^^ j^^ "^^'^
I in-RFBV C1.:RTIFV, That I attended deccasea from
to C)/€fc i.H 190 H
^ -< 19O * to
-t. ; '\ TOO ' •
that I last saw h alivc^ on - --
„,1 that death occurred, on the date stated above, at '■
M. The CMS^C OF 1)1- ATH was as follows:
lA rm-.K
T'.iK'nn'i,\i'K
Of. t Aiin-K
iStalc (ir *."inuit ! V
MAIDI-.N N\M1
01 MitTin-.K /
CONTRIBUTORY U^^^ K. .. a ••
Hours.
Years
Mouths
Pars
KxxXj
\ju
Hours
M.D.
iuR'rnri,ACH
01 M(»rin-*,K
; Sti'li' I't I'liiinti \
3x^L
(X^'wcL
Ur RATION
(SIGNED)
(0 +
■ SPECIAL INFORMATION only l.rH«p,lals, lnsll.i.t,.rs, Transients,
orlefe^ Ments. and persons dyin^ a.a, Iron, home.
CAo A.
^^.
«>rci r\T!i)N ^^
) - I."
/.',,' 1
HKSr OF N)^ KNi»\\ 1.1-.1><'I'- AM'
(Infoitiintit
IJ^./>^AA^
AtjL^
Aj^rO,/
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
■Ia
S.li,re.s .5.X%0 dXa^
mACKOF m-KlAI^ <»K KHMOVAI.
1)\T1'. I)!' ncKlAi- or RKMOVAl,
U.ct' ■ T96H
"^ 1 - PHYSICIANS should
- i.„...i„„ .H^-^ ^";=- -^-; .e;:x^.:r'Ti:: .•«...,.. .n....... w ...
F OF DEATH in plain terms that jt n,. > 5„«t««ce.
'■ '■ SSJ^r -^t^j: :z;.;^;;"^:^-" --^ ---
»
I I
' !
^ '
WRITE PLAINLY WITH UNFADING INK
■ ! Ill .iU»i
^•o,l.*?S?*»-^''
ixih- Fih''l,^.zhr(>i^ n
190 "i
THIS IS A PERMANENT RECORD
p,.„ TO ....KOrCERT.riCATrrORINSTRUCTIONa
Ueoistercd ^'o. 2366
-*_
1 ^^ Deputy Health Officer ^ _^ .
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate ot Bcatb
I ■a. 3. StanJar? )
J? (^
PL ACE OF DEATH :— County of ^ ^-v^
City ofO<x/>v a,V<x/rvc..
« r I \ St • "^ DlSt.; DCT. -"^--^ ^^o 'QPFCIAL INFORMATION- \
V ir O^TH OCCURRtD IN A HOSPITAL O • ,^
FULL NAME
vxLmjkxa-^
ti
;^
PERSO
NAL AND STATISTICAL PARTICULARS
six
^
(.oI.oR \
i)\ri. t)i lUK in ri I
M'lnthi
\<.K
I
);;n
lo
15"
i l)avi
1 /,.»/'//'
,^0?^
MCDI
DA TK i>l" I>5"-^'1"'^
CAL CERTIFICATE OF DEATH
r\
1 Day)
IQO
(W-ai)
(Vfar!
I HEHHBV CKRTIFV. That notenad dccoasea fn.n
to A!^ i^ ^')°^
K;'')
li)cfc
! (,
at
that 1 last saw h ... alive n„
,„Hl,at.U-ath.>ccurrea. on the date statca above.
M. TheCAlSH C)l^ DKATH was as follows
up
HiNr.i.l-- M XKKIll'
\V!D«>^\ »• 1> «»1< DlVoKi KD
{
I Statt 111 v'liunti V
N'AMl- <»1
FA 111 J.K
BTRTmM,\tK
oi 1 Afin-.K
i>t,iti 111 I'lnuitrv
MAUn-'.N N\MH
>i MOTIIHK
HIR riuM.Aii-:
(>i- M(»Tni':K
(Siati III I'lmntry'
0 Qsp
i \
ni RATION
CoNTRinrTORV
MoH//is ' : />iO'^ ^^''"*''
^;-\Ja„0.
)ra>^ k» .1A'»/^>>1
occri'A TION
AV' - nfr,f in S'- ' " !'> .t r, ,^.<> ^ _,
^^^^ \iit''l'UlV I'' III''
Former or
Usual Residence
When was disease contrarted,
If not at pla( e ot death?
How lonq at
Place of Death ?
Days
•I „„(„„„:,„. h-^-^ ^
,.,....AKKK JcAXxK^^ ^^^^
I, mi:,,! llruiAl. ..r KI-MllVAI.
(Vl.lr.^s b^l '^-^^^-^'^-M - . .FXACTLY. PHYSICIANS .hould
. 'r , .„„, .„ppn.d. AGB -hould Oo »'-":; ■';''.?=;,.„, ,„Wm».lon" lor p.r-
i
WRITE
PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
,,P.B TO o..xo.CeRT.nCATE.OR.NSTRUCT.ONS
236?
V
Huh' Fiii'^f^ li'cbrWv. n
It) OH
J^p^istercd JS'^o-
\ 4 1 .V4i DeDUtv Health Officer
DEPOTtIf PUBLIC HEAlJIWity and C,«nty «f San Francsco
i (
Certificate of Beatb
/ 71 ^^. i5tan^av^ )
ri ^1, 5ta^^av^
PLACE OF DEATH:-Co.ntv of a.X ^^
No.
o
^\1 <ccUv^ru
};
)X<x>
Sf cl Dist.;bet.
„TITUT10N GIVE ITS " ** '^1,^ -v
FULL NAME Kn>xCL4
and
<;♦ • ci». Dist.; bet. '''^^ ^ripciAL information- \
^ . . V . ^^ . ~ l^fxr rix/F FACTS CALLED FOR UNDER ^ffEC A gtR. /
X^ V^w S-^ I ^- "^ ' ~ .-...Ai nF«SIDENCE GIVE Fa<-i3 ^, . ^- p iwcTEAD OF STREET Anu
-^I^^^ZZn:^^^^^^^^^^'^ PARTICULARS
1) \ l■l■
\' .1
Vi I ' ii i\\ 1 1 ' ' '^^ ' '
W • ' t '
it!K rm'i, \*'i-;
st;il. k: I'.iUiUi N
1 90 \
(Yt:ii
MEDICAL CERTIFICATE OF DEATH
„,„ n„.l .;uv 1. X-V ;a.ve on ^ -^
„„,„.„ ,U..U ourrea. o,, the. ...U. SUU.,. .....v., ^.t
M. tlu. CA-SK Ol ,M.:ATn«n<.sfon„„.s:
N\M1 <>
1 A 111 i:k
r, 1 u r 1 1 r 1 , \ > * 5-"
nr I xriiKH
' stati in Cmuiti
(»1 MoTIll-.K
lURl'Ul't.ACl-.
(il. MtiTlll-'K
. • ' ", ,.\ururi \RsAKl. I HI I.
THU XIU.VK ST xTKI.rHR:^»N,'^l^^ ,;,,., KH
CoNTUHn ToHV
)V,7/^ JL. Mont In
-^
/).n.Y
J Jours
niRATIoN
) V</r.s"
Afonths
//(>iirs
(SIGNED ) V>^^CfV. 4 .
— . "":^«*i,iiTinN only lor Hospitals, Institutions,
Transients,
^CA>
lnf.,im;ml I I V V
LUAAT
formfr or
Usual Residence
When \^as disease contracted.
If not at place ot death !^
HoH lonq at
Place of Death ?
Days
.\M-
M. B.-
1
WRITE
PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
BEPER TO ^..K n. CERTinCATe .OR .NSTR0CTION3.
77n 23G8
luilv l-il('<f ' ^^
l^
DEPARTNENT OF PUBLIC HEALTlWity and County «f San Francisco
^4'"
\
Ccvtificate ol Bcatb
i ^
0 ar<\j ^ \amxA <. - ' City of
o <
PLACE OF DEATH :- County of- a>v ^ ^ ^^)
(^ ir DE»TM OCCUHRED IN « HO» ,, , ^J
FULL NAME
v,'
XA^
Tl^I^l^Iin^^^^^^^^^^^^ PARTICULARS
JuX^t.
WEDICAL CERTIFICATE OF DEATH
/
IL,
I, \ 1 1 ( il UIK lii
\i. j:
'*-4
1 1.1
/',
\ , .: I
-.IN., 1.1- MAKKn-^» .,,
C^
\Ji,
luH riu'i, \oi'
-,1 iti or t'.iunti \
N \ M 1 < »!•
1- A I Hi: K
lUKTinM.Ai'K
(.1 rxriH'.K
-,t:iti <>t r.'\nit ; V
M MDl'.N N XMl
,.i MoTHHR
lUU'l'nri.Ai'V.
,t,ttt or v'lxniti N
'\
TQO ,
,l.:,vi I War)
,,,,,,, Vci^RTirV.T.at I aU.n.W...U.,va..4r,.,.„,
■ . , up
• 190 . to ^
U.it I last ..w 1. ^'""■"" ' ' , , , -
,„„Ul,al.K:.llw«H>,m-a, ....tlu d
-' t /
r^
(\
^ w^
Co.NTUllUToKV
DTK ATION
(SIGNED^
/^av.
Hours
M.D.
thka,u>vkstai;i^i;i;^k:^>nai^i^xh«;^^„;^
(Infoiiu.'int X^ *
Former or
Usual Residence
When was disease fontracted,
If not at place ofdeath^'
Tl^ACl^OF lUKlAlV^'^ KKMOVAI
A >
How lonq at
Place of Death?
Days
,vr,-.,! n< KIAI. nr KKMOVAI.
I
N. B.-
W^ L<r\7-^-0^'^^'^'^ " ' 7 1 FXACTLY. PHYSICIANS should
, —- ,„„, .applied. AGE .l.o,.ld "• •«''"4^'=f *s%„„ ,„J„rn.Btlon" «or p.r-
E OF DEATH in P'"J". "•"'•*„ ,„ .v.ry ln..."«-
-Every Item ^. ^^ DEATH in pini" """'• •■■";_" '.v.ry In.tanc.
:l:*;dy?n. aw-y from horn, -hnuU. he »
'1
,1
I
]
,L
':' t
}
11^
\ 1
1
■
1
\ ,
1 ■
1 J
'■ ■
; ' i
m
I '
:li
■fii
I ft
^p.^e PLAINLY W.TH UNFADING INK
loo'i
THIS IS A PERMANENT RECORD
p..en --^■^■^^^^C^.^T.nCATrron INSTRUCTIONS
*>-^69
DEPARTMNT OF PIBLIC HEMJH:«y and County of San Francisco
Ccvtiticatc ot 2)catb
PLACE OF DEATH: --County of ^^ ^ | ]\\ J | ,x,
No.
AcCrAJj
St. S Dist.;bet ^^^^^^c
OU, » cV.iirn rOR UNDER SPEC
SPECIAL INFORMATION- ^
('^
^"^ M USU.L ReS.DCNCE O.VE FACTS CA.LEO -;^--; 3T;EeV;ND NUMBER.
OEATH OCCURS AWAV FROM USU^L ^^ ,^^^,^,,,^^ o.VE ITS NAM
,F DEATH OCCURRtD IN A H . 1
FULL NAME
/VX'YV LCWXH-^
■71^^^^:^:^^:^'^^^^^^^^^' particulars
-1 \ ~^
',V
f<
nx I K <>i HiH in
RTIFICATE OF DEATH
vUa
r%\^
\\
\< .1
^S
i/.i/'^n
Vi ai
/ ».M
„..,...,. o.vn. ^1^
' M..ntb
lb
(Day
iVi-arl
,. ,-,PTn--V That I attcuU-.l aoca.ol Inm.
WIIM .\\ Kl» "H It ^ ". '
lUK rin'i. MM-
NAM) <>'.■
1- \ I 11 ).H
I'.IR riM't.XiV'.
(»r 1 \rHJ-.K
MMKl-.N NAMJ"
lUUlinM.M'l'.
nl- M»t'nn-,H
I Slate lit roiuiti V
orri I'A'riuN
C\
^L'-uJUaat
^M, ■nuC.ysKn.M.Kvr.p.sfon,...
■ vc^-o-'^^
A
0
DIKATION
CON
)'iar,
ATION >'-^ •
//('/^
;'.s"
Months
Pavs
/Y\J
CX^-v^A.
IflJt/ff/.S ' "-• ■
DIRATION
:Lh-- — -^ ^r,»iiATinN onh tor Hospitdl
Rr^idn! nl Son I':
Moulin
/'.M
Ho\^ lonq at
Transients,
Oa>s
ly^ (I 190H
;r^^\,^J^
AM-
\<l«lrr
N. B.-
iq d ^l.<rtl) ^^ i ' r^v4CTLY. PHYSICIANS Hhould
. ,., ' :." . AGB should be «t"'^iJ^ .rj' ' i^, information" ?or pT-
E OF DEATH in p'b " ''r^'en in every Inst.nce.
Hon* dyinft away
fii
'1
U
) I
^^^^^^ THIS IS A PERMANENT RECORD
..... .o ..CK OP CEB— -O" .NSTRUCTIONS
7fyr>H
Registered JV^'o.
/^■wO • '
■? i 0 Deputy Health Officer .
DEPMN^ PUBLIC BEALMy and County of San Francsco
Ccrtiticatc of ©eatb
"VX'
»
No.
^. 1. . 1 i VGA A%VXX and vAl i\a.v. .. .
i » Sf DisUbct. ^ -^^-; : ,,, ,N,oRM*T.oN'\
/ IF DEATH oceans AW HOSPITAL OR INSTlTUTIU
t ,F DEATH OOCURRED IN A M , ^ .,X
PLACE OF DEATH:-County of "a
FULL NAME
COI.oli
sKX
V
au
^w^
DxlK «>I' r.lK I'H
I'
W^ >
untU
/ ^
\| .!■■.
\ I
I n:tvt
\!..iith^
iWiit. in -.H-iai .UM^natK.n)
HIK rmM.AOT"
iSlaU- iir (-'"HI 111 I y
N'wn: 111
1 A rii i.K
lUK iHri.ArH
oj- I ArilHK
I statt or rmmt rv
M\1I»1:N NAN'l'-
ol' MOTHKK
niK'niiM.ACi':
(Slate or Oounlryi
OCCl TA TION
^
1
(^ KjY^
A \ \
Vral
/)./
MEDICAL CERTIFICATE OF DEATH
DATH «>H DHATH ;\ ^ i
^ ^ (Day)
190 '^ t'^
that I last saw h ... ^>live on '^^
1 „„ ftieilatt- stall ■! aliove, al • -^
M, Tlu- CMS..; t>.--l"-Vn«- as follows.
L .'-. I -
M
DIKATION
)V</;'-?
Months
Pays
I lout.
,-,,,,, J/<,;////5 5" Pays Hours
(SIGNED) ^-^^ ,^^ .^
^ ^ • '''^ ^».u. ATIQN only tor Hospitals. Institutions, Transients.
, How lonq at
Former or \\\ ^^yy^j^^M, P'«^^ "' '^'*'' '
Usual Residence U^ -^ ^ > ^^ \
Days
AV.wV/^r/ /» >•'>" /'"'""•":
)■/■(?)
Month ^
I hi
.„. (^OW."^ Vi-o.-
WL I'v S ci«.^
.?JU
„,Vri.-,..! Ili«.AI. •>' Kl'.MOVAl.
190
N. B.-
f V l.lrrss I ^^ <Lu./^^^^^<^^ --" J. . ^FVACTLY. PHYSICIANS should
(Addn-ss -^ ^^ . 1 1 k* stated BXAwi»-»' • ,, a nmv
— ^ Sullv HuppHed. AGE should »f «»«*%he "Special Informat.on for pr
sons dying owHy
\"
.r-
' 1 1
!;li!
THIS IS A PERMANENT RECORD
Wp.TE PUA.NUV W.TH UNPAD.NG '^'^-""' . ... .....uo.,0^
,— -^. i^Op-H4
j^eo'isfci-cfl ^"^"f^-
/,,,/, /•7/r'/A'.ci>Wv n
DEPOTNtI mUC HEALlwiy and County of San Francisco
Ccvtiticatc oi tDcatb
PLACE OF DEATH: -County of
^
^
X\. '3. *3tan^av^
J (^
City ofaay>^ J^*^^ ■
V'
^
No.
and '
Cf DlSt.;bet. ..^,n^R 'special information • \
'-'^•^ . rurTS CALLED FOB UNDER ^ ^^ NUMBER. /
' „,,„„ ..., r»o» U.UAt „"„^T-f,?„^ o^^o,;.".;! NAM. ..s.c.o or s...^ •
FULL NAME ^ ' ^^ -
)
^' \'^
>^,\
\
-^
V ;;;;7^;^irirRTiFicATE of death
ct
(M.nUhi
' DaV
(V.ai >
1> \ \' 1 ' "I Ui K i 11
1
Ml, mil'
\' ,»'//
/»<
• > I . . . . ! 1 1 ! ! • 1 1
— 190 -— '
,i,.,t llasl^awh ^ alive HI,
',„„...,. u..,,..,.t.u.a„u.. ,.i-..v.-,-
.5
V \ Ml < t1
I \ in 1 R
[\
01 I \ I'lil'.K
. >,t;,t,. or iNllUlf V
M \n»KN N\MK
,,1 MOTHl-.H
I'.IKl"mM,.\ri-.
<)i Morni'.K
I
1 *
^ i
n
CONTHIBITDRV
M0>t(/l!i
navi
J lour
nruATioN ^
?
Pav^
1 1 our ^
M.D.
(\
(SIGNED) ^^
\J(0^ Ik) 122J L -— 7T„, M„c„u.k Institute
pidf c ol Death ?
\ \
oicri'Xi
■'"^%
^C
Lc •
M.ni'lr
' 0
bdLMXxA.<
iHbV^' — — ! ' ■""" TrVACTLY. PHYSICIANS «houlcl
^^■''^"-^'^ (I ^ "T. . AGB should be •^V^'^iJl^^^^ciol InVormution" for p.r-
' ■ ^ . .„„,., b. carafuHy «uppl.ed. '^ ' , ,,«s«h".ed. The Spc..o
Hon* dylnft away •> ^__^
t.
i ■
11
i
I
i : 1 1 : i
J
WRITE PLAINLY WITH UNFADING INK
I'.oMiil ■■!" lU:iHli IN.
, ^^ ia!-?^UScVC<
1
^AJL\,5 LC\>M
IDOH
nw
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Be gi sic red ^'o. ^-O^^
DEPARTMENT OF PIBLIC HEALTH=City and County of San Francisco
Ccvtificate of S)eatb
( TX. 3. 5tnnC>arD )
City of ^-/O^v J./U CU-^A.^o4 0.0
PLACE OF DEATH:-County of X^^ ^^o^-CA^^ity
No. ^^i cMaA-^wC^^
St.; \ Dist.;bct.
and CLLu^
( ' r-.;: -cc:.%r;,"r„o".^r.t --f,?.^%r.',«"r.-.^«7 ,^^»o%* s?;i^-~o-.°::«'.- )
FULL NAME
Cm^
^J.N.
PERSONAL AND STATISTICAL PARTICULARS
cm.oK
i;. iiih
\X
ar)
A«'.l-
>-.IV«. 1.1'. MARKIH!)
\\ II)t>U J 1' «>K DIVtiRt 1 I>
W : It. it) -...-ia! (U-iLfiiat n m »
r.iu rill'!, \i*i".
. «^t,it, 111 1 '. ill III 1 \
10 )v,f<> O
XS
(Yt-ar)
MEDICAL CERTIFICATE OF DEATH
DATK Ol- Dl-.ATH . ^
1 1II';R1:BV CI:RTII-V, That I attcn.UMl dcHia-^tMl from
that I last s.tw h alive on ^ '^P
an.l that tUath nccurred, nn tlu- .laic ^^tatcl above, at
M. The CAl SI-: Ol* Dl. ATH was as follows:
N \Ml' 01
1 A in 1. R
HI K 11 11' LACK
Ol- 1 Allll-.R
(Slat. < 1! Country
MAini'.N NAMi:
(»1- MuTHKK
1
\
' J ^<A/>^^ ci^-cn-Ub LL
> VOLi^'VWOCX
7
i
I )r RAT ION )>«'•?
CONTR nU TORY
Months
Days
J Jo lit
<=>^
i ■
i
nr RAT ION
(SIGNED)
J/()>////S
Davs
Vears
HiK rnri-ACK
(»1 MnriU'^K
i Slatr i>f CouiiliA
OS. cri' \ri(>:
I
KfsiiU-<J in San /i,i>!,;'r.> \ j )>i^.'-
SPECIAL INFORMATION «nly 'or Hospitals, InsUtutloWsHranslents,
or Recent Residents, and persons d>in;) md) Um\ home.
}/n,-Ol.
THKA,u>vKsTxrr:n,M.K.oSAi^AUT,rr.AK. xkhtkih n. nu,
(Infonnatit
Formfr or
Usual Residence
When Has disease contracted,
If not at place of death ?
Hew lonq at
Place of Death ?
Days
I'l.At"!' Ol' m KlAl, OK K!:M«'\A1,
oatj. (it Hi KiAi. or ki;m»)\ai.
«
\
» ^"7 13 AGR should be stated KXACTLY. PHYSICIANS should
N. B.— Every Item of Information .hould he caruVulUv -PP - " ^^^'J^;; classified. The •'Special Information" for p.r-
state CAUSE OF DEATH in ph.in terms, that ,t may be prope y
;*nl dying away from home should be ^Iven in «very instance.
i
II
!l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i.Mi.i ..r n. ,Mh !
v., ;: t"> ^Ts;.^: H8:}' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
0
ct^nMA; i
lOO'i
JRo^Lsfcj'ed J\^o,
2373
\XkM cUwVU
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of H)catb
( TH. S. StanDarD )
m
PLACE OF DEATH: — County oldcxjy\j OXavvA:
City of ^■' CL/'W J A.Ct>xCov
y
^No. H> XtwI^Jji yWCh^V-^ - St.; - Dist.;bet, and
/ IF DEATH OCCURS J»W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
\ IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME J ^tci. 1
t I
■- 1- \
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
Mf
1
) A ri; I ii iiiK 111
A<,i.;
rt
'M..iithl
1
Dav>
Q
}■
.)',,,/'/!
\ tat I
/hn
SINC, I,!' M \RR III)
wri>nui:i> OR i>:\ 1 »ki'i;i>
(Writ I- in '•inial di --ii' nat i<in)
0
\
BIRTIUM, \oi-;
'Stat' I IT I • iiiiit I \
N \M1-: ni
lA 111 i;r
d<XAX'
MEDICAL CERTIFICATE OF DEATH
DATl-; ol- DICATH
n
A
(MoiitlO
(Yi-ar^
.I)ay>
I ni;ki:r,V C1:RTII'V, That r atU-n.U-.l .Unxascd from
'' 190 to ■■■■ l90~~~
that I hist saw h ~ alive on — 190 — —
and that tlcath nccurre«l, <>!i the «hitc stated above, at
^^ M. The CArSh; OF l)i;.\TII was as follows:
dL<Mr'<^U-L
rtU
I i
lUK riiri. \i \i
<)l" 1 AT 1 11: K
(Statf »»r <'i>uMt ! %■
MAIIU-'.N NAM1-,
01 MoTIIKK
lUR rniM.AOH
( state I It t.'<aiiit 1 \
A\AX\J. oU' LC
(
• K *.
'ri'ATh)N 'op
k \
h'rsiiiril ni Sun f't inn t^i ><
/',n
Dl kXrinN )'tii/s
coNTkinrToRV
J/<>)////S
Pa \$
Hou)
nr RATION
)\ays
Months
A' \
/hlVX
( SIGNED iLCr'Unn^V J,\.B, LL
WCAj i'l iqoH (Ad.lress) L&V^nAX^ ^
//oufs
M.D.
Special Information only for Hospitals, InstitutlWB, Transients,
or Recent Residents, and persons dying away from fiome.
Former or ( lu t^J' • How long at ^
Usual Residence b I A 0 0X4_^ r »\ pfare of Death? 1 1
Days
Tin*. AHOVK STA ri:D pkrsovai, rARiini, \rs ari; trii-: to thi-;
HKsr oi- MY KN<)\vi,i;i)<".K AND rii:i,n;i
'liif'itinrmt
X.lilnss 0
CXA/VW^w^^.
tl-
Wlien Has disease contracted,
If not at place of death ?
I.ACH <»H lUKIAI. OR RI:M»»\AI,
1 ,
ni)i;ktaki:k w . «^- V
DA'p: ut Hi KiAl, fjr K1.:Mo\a1,
^^ I90I
N. B. Bvery Item of inf >rin!ition should bj ciiret'ully Kupplieii. AGE should be fittited liXACTLY. PHYSICIANS should
«totc CAUSE OF DKATH in pinin terms, thnt it mny be properly classified. The "Special Information" for pur-
sons dyin^ oway from hoitia should be i^iven In every instance.
i.
: 1
1 .
'< I
I
• U n
p:
iA
li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!,,m;,! of llcaUli !•■ N'c 1 ■; "fr^^^^^^ IKS:!' f
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)
((fe Filvd, y.ctvipt;
K n
ldO\
Be^j\sfcrcd Jfo,
O
374
D
^M^OO <J^ C \\
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of 2)eatb
( Ta. S. StanDarD )
J? QS?i ^ ^
PLACE OF DEATH: — County o{ ^^ <X/y\> ^ T\.xx.^Y\Ai\^^,j:^{\y of ^J/<X/yv JA.o >
pop % ^
^No. Lctu, V.LmjL''^y^Xu, uID(v<Ii ,.vJ a.i St; Dist*;bct.
-and
/ IF Dt«TH OCCUHi AWAY FRO** 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
^
I
1
a;
si;\
PERSONAL AND STATISTICAL PARTICULARS
I COMJR
I
I
DA 11. «tl lUKTU
Month
.\< .1-;
c^t) )V.,i
<I)av>
M.iiith
/ t i i.
(Vt-ar)
/'./ 1 .
H1N<,I,1 MARRIKH
\VII)«>\V1\H <»R I>I\t>Ki Hl>
iWiitfJn s<K'ial (lt'«i!s/nalinii)
BIRTHPI.AOK
(State or Oi)uiiti \
NAMK OI
I A rin.R
mK'i'iiiM.ArK
OI I APIIKK
(Stall or CtHintry
MMDl-.N ,VAM1<;
ni MuTiniK
fUK'rillM.AlF.
()l MOTIIKK
(Slatf or t"o\jntr\
'Month)
(Year
MEDICAL CERTIFICATE OF DEATH
DATl-; <>I- Dl". XI'II
:t II-
(Dav)
r^ I HIvRl'ir.V Cj; RTII-'V, That I attcinU-d deceased fxoiu
A^'vt? 15: 1901 to iL^tt: ife 190 M
that I last saw h'- alive on ^ ' I^ T90
and that death occurre*!, on the date stated above, at Ho 0
.' M. The CAl'SI*: OI" I)I;ATII was as follows:
:^^
"^
y.
\\]\xkKk/y\SL i jOxXr^y^.^o^'y-
Rfsitfrd in San I'latu ist'n
)'i'ij)x ^, Miiiifh<
iKn."
Tin-. AHOVK STATKU f'HRSONAI. I'AKTICr I,ARS ARK TRIK T<> THK
BUST OI- MY KN0WIJ:I)<*.K AND HKI.IHF
(I
Tifoiiuant "OX^ \jX/CxX1x)
(Address
hi
DTRATION )'ears Mouths Days
C ( ) N T R II ! r T ( ) R V Mj.J:y^f^-AS^\KM.^KA
Df RATION
Hours
(SIGNED). J
f^^ Years ^
SPECIAL INFORMATION only for Hyspitals, Institutions, Transients,
Of Recent Residents, and persons dyiny dway from home.
Former or
A
J/
How lonq at
Usual Residence HO 5^MUrUHX<UAKtu,.jlpiafe of Death?
When was disease contracted, ^
If not at place of death?
»ays
PUACK OI' niRIAI, OR RKMOVAI,
(Address .. ?)0 S^ yO^XrVX^fcoAA.
PATH of nt HiAL or RKMOVAI.
iD/ct \% 190':
Jsi^:^:^....
N. B.— Every Item of Information .hould be carefully .applied. AGE .hould b« .tated EXACTLY. PHYSICIANS •hould
•fte CAUSE OF DEATH In plain term., that It may be properly cl...lfled. The "Special Information- for p.r-
•on« dying away from horn* should be given in every instance.
',*i
4is|
I
'1
11
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
iT'i I- N<
luv !' r
REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 '
', )
f 4
790H
llegistcred jYo.
A.e^,.N Deputy Health Omcer
DEPARTMENT i)F PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
^
PLACE OF DEATH: — County of C .CXa-v' J XCX^xcUccCity ofC^ <X'>^ Z KjOuyxMU:u<U>
P % P %f if
Dist.; bet.
and
\ ( ST DEATH OCCURS AwAY FROM Al S U A L R E S I D E N C E G I V E FACTS CALtED FOR UNDER SPECIAL INFORMATION" \
J V IF DEATH OCCURrtED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRtET AND NUMBER. /
FULL NAME duUn^ \uAAX^M
PERSONAL AND STATISTICAL PARTICULARS
i)\ rr. (
l|\<xU ILkcti
>i liiKiii ^
At, I
51 s
1/
ai
/',/i.
-.|\t l.l- M \ i< H I1'.I»
U I l>« »\\ I I > < »K IM\i »K> ID
|\\'iili ill '•(H-ia; (1( vi^. nat 1" 111 i
\j
i^ .'k^cL^crvA^-i'^^
FA'l'IM.K
!!IK rill'I, \i'l-
ni- I- A 111 I'. I<
• ^tati ii! (.'iiiuil 1 \
0 Xcx^vcx
'
(ti M(»riii-;K ^ '
lUR'niiM, \«'i:
<»| MO'IIIIIR
I Slatr (It I'dinitl \
Rr uitil in Sen I i tl '
^. 1
r,w,
U,,,!f//s - /)./
111!- AUdVi-: sr\ rii> pi-rson m, i- xki'i*' i-ars ari-: rRri: nt tiik
Oil fi muaiit
ULcxo^J
f \rl.lM-.S
vCl
0^
via
MEDICAL CERTIFICATE OF DEATH
IiAll-. ul. ni'.ATH
llo
I):iv)
fMoiitli)
I m:Ri;!>V CIRTII'^V. That r alttii«UMl .UtxascMl fn.iu
C/Cfc k? lyoH tn (D/tt lb
that I last saw h Aav^ alivt'oii Vy/CXT lb
and tliat <Uath nfeurrcd, <>n the- date- ^tatoi] above, at 1 / 0
CL M^ The CAISI-: i)V l)i; Al II was as follows:
(Yt-ai I
TtpH
or RAT I ON }'r<i/s
CoNTRir.rToRV
I »r RATION — )'<r?2:.v
J/o>///is
Days
J/oiit s
'V
SIGNED) 0
M>'iths
l\
/I'V
M.D.
,1
fAaanss) Lctu fc<^V^ fe<K.AAr
1 ATI ON onlv fnr Hkpitdls, Inifitutions, Transients,
SPECIAL INFORMATI
or RfCfnt Residents, and persons d)inij dWdV from fiomf.
Former or u n a ( k /^ I T\f ""* ''""' «*
Isual Residence 1 A^ JUc^4^J )h
Wtien was disease contracted,
If not at place of deatli ?
Plate of Death? 11 . Days
I'LACl't <)I- IHRIAI, OR RI.MOVAI,
1^ €5cv^
I NDl'.R r SKJ'R
IiAT^.i! m lUAi, or KHMoVAl,
ts „ —Bvery Item o? l„foim«tlon should b. c..«fully supplied. AGR .hould be «t„t.d KXACTLY PHYSICIANS should
.t«te cluSE OF DIIATH in pl„ln term., that It m»> be properly .l««»iflcd. The ''Special Information" for p.r-
son* dyinft away from home nhould be given in every Instance.
■> • •
' \
IH
I
• r
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
376
1901
Ileglstcred JS^o,
O
Dale /v/fv^ IL ctcnU^^ 11
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
<• »•
Cevtificatc of Beatb
{ "KX. S. StanDarD )
4
PLACE OF DEATH: — County ofO<Xnru 0 ^cu
City of
r\
<3?
IJI
l^
No '^01 U.. , St.; "^ Dist.;bet. JXLL' and
*^V» - "^ '^ " '- ,. iiciiai arCinrNCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
FULL NAME
\\t-
^
PERSONAL AND STATISTICAL PARTICULARS
SKX ' \ !^ < C«iI,<)K \
I
\
I) A II', ol- ISIK III
\<.i-;
frvo
[Dav
M.tillis
(Year)
Ihi\.
->IN».1.I'. MAkUli:i»
u iix »\\ i:i) nk i)[ynRii';i>
Wiilt ill ^iK-ial ill -.i>.»^ti;ili<>n)
.oo\)\aj^6s^
luk riiiM, \cv.
' '^tati I ii " I itiiiti %'
NAM1-: TU-
FA 11 1 i:r
lilKI'III'LAiK
c>i- I- \ I'm.k
M \II»1*.N NAMI-:
III M(»rm:k
lUk iiiiM.ArH
III M(i'i'ni':k
(Stat, ii! riiillltl % i
IHHT I'ATION
I
Oa>v>
/O
O.i
jUxxaj
I
U jJ
w •
I
Kf iilfd III "^ i.'" / '
(///( / '/■(*
Yra,
M'lifli
hn
TUl' XHOVK STAri'.IJ l'KkSr)\-U, I' \ k TI»T I. \ H ■- AH I
IU%ST Ol- MV KNnWM-Jx". 1<; AND in-,I,Il-.l'
Tki }•; 1 ' I iH ••
rinfonnaiit J -^-M^^J. ' Ji-'V
r
a.i.ir.ss 5-cn uLUw/>
Wv u
(Day) (Year)
MEDICAL CERTIFICATE OF DEATH
(Month)
I III':R1:BV CICRTII-V, That I attcn<lc<l dcicasLMl from
... J ,90 to i9<:A. 190H
that I last saw h ^" alivton WC v i I90 .
and that death occurred, on the date stated above, at o
M. The CAT SI-: 01' Dl'ATII \v:is as follows:
DlkATION I )V'<?r.v IL Monlfis •' /></)'V //ours
CONTRUHTOKV
u
DT RATION i Vrar
I r.
(SIGNED)
'\Hrw
1(^1
J/of/t//s *^ /?r7V? • //oiir^
M.D.
/aA,hjJjLi kit
(A.ldress) Ta6 U vJ
Special information ©nly '"^ Hospitals, institutions. Transients,
or Recent Residents, and persons dying away from home.
Former or
I'sual Residence
Wtien was disease contracted,
II not at place of deatli ?
How lonq at
Place of Death ?
Days
nAi'ivu! Ill MiAi, III ki;M(»vAi,
1 90 ;
I'l MV ni in RIAL <»R RKMoVAI.
rNDHkTAKKk 0 .4\JL'^<L^ "V^^ .
n\_
^ ., , Kr%^ «Hr.,.l(l he Htnteii I.XACTLY, PHYSICIANS should
M. B.— Every Item n? Information .hould h. cnr«»'ully supplied. '^^J:;^^7/''^^^.;*^''^he .•Special Information- for pr-
•tate CAU8IZ OF DEATH in pli.in termn, that it m.iy He properly JpsmtieU. I He «pec »
HOfi* dying away from home hHouIcI he given in ev«ry Iniitance.
iai*
WRITE PLAINLY WITH UNFADING INK —
I'
I • 1!. alltl
^l
I •
t
' t
I
i
4 ^^v^u.
n)OH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of Beatb
^
, >
PLACE OF DEATH: — County of^a^' J \a->xCC<KX) City of CVo^OO; OA^^C^u^eo
We. '^JlX">^VOL'>^ XC^^rwtal St.;- Dist.; bet. and — —
r - °^-« occurs Aw.ir TBOM USUAL RESIDENCE give .acts calued '^ "^o" str e E^^irJ H^MBciT"
t IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION ^'VE ITS NAME INSTEAD OF STREET AND NUMBER.
FULL NAME
.. .Ct V<
»VCXav>v
-i \
1 1 \ 1 i 111 ii: K i
PERSONAL AND STATISTICAL PARTICULARS
% It i! < >k
<Xl
^
\
IvcLi
/ bii
Mont
\<.»-:
I
II
1/
> I ai
/>.
\\': 111 )\\i t > < »i< I '
W; it f' in » ii'ial ' \
OJxK^J^
■-.; it- . .' 1 lunt I s
\ \M)- <)!
I- A III 1,K
lUR IIIPI, ACK
(>i 1 \ rin- K
^>!,i! I- I ti itiiinl t \'l
M \ :1>KX NAMK
i! \!(rnn",R
I'.iH'nii'i.Aci-:
Ml Mo'llll'lU
^lati I.I CiiUiit t \
y
X.^^
ujJArAva^wu
^
- 7^
S,';' / I ii III .''■'''' O
M,.,ith
Tin xHMvr -r\Tii. i'Krsonai, i-nki h ikars akh run- t<> rm-
in;sr «>|. uv kn(i\\i,i:i><'. i'. and lU'.i.ii.i'
(Inf II niaiit
iAJuL
X^^^yVL/Ou-vu
n
r^,,,,.... S9vH UAaXVUAx^ C
:\t
(Vt-ar)
MEDICAL CERTIFICATE OF DEATH
i»A ri-: ni- i>! A 111 a\ ,
(Month* '!)avl
I Ill'.kl'iP.V CI-;R'rn*"N', That l aUciHU-.l tU-ccastMl from
w. /ct IS 190 i t.) t/ofc lb 190 H
that I last <aw h tVv^ alivf (Mi L' C-ij 1 ^ 190 H
ami that ik-atli occurred, on the ilate stated a])ove. at O
vJ" M, The CAJLSI'. Oh" DI-'ATII was as follows:
Dlk ATION
CON TKird '1
Moufin \
yt'i)rs Mouths I 4 /^<U''»"
Hours
DrkATK >N
A
Pav
Hours
M.D.
i-ars Mniiths
( SIGNED ^')l\ J. K00^|vk^V%>5
ii)^ lb »'>nS (Address) >^>v l.Q) UK^li/^
Special information '>"'> 'o^ Hospitals, Institutions, Transifius
or Recent Residrnls, dnd persons dyini) ,iway from home
Usual Residence I 111 ^^ H^Kl'
Wlien was disease contracted,
If not at place of death ?
W J -\, How lonq at
(JCH^KXhA Jtplare of Death?
Days
I'LACH oi- HIKIAU OK R1C.M'>V\I
^ ii
T90
nx'l'l'.)! Hi HtAi, or Ri;.NH>\AI,
A1M1 CHS
, .. 1-1 %rf7 .^hrttild he stnteil F.XACTLY. PHYSICIANS should
,• inf.rm.Hon .houhl be core?ully HuppI.ed. AGb nhm Id ^^.^^^ /rh. •Sneclal Information" for pT-
OP DI:ATH in plHln terms, that it m»y he properly cl««..*led. The Special Information for pT
M. B.— Rvery item of
•tate CAUSE _ . ^
son* dyinft away from home should be felven in every m8t«nce.
\
^■=yzj, '
(
9
> i
-'aii«'«R??^,
WRITE PLAINLY WITH UNFADING INK
^ ■ ! V ■ .
-^, lUSil'C
L
l)(ili' Filed ,
.(ru-^>v 11
/-9<9H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J?^rt'/,s7r/Yv/ ^\^0.
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
Ccvtificatc of 2)eatb
( 11. S. i5tanDarC> i
Si m i
v
^^
PLACE OF DEATH: — County of C CXAv JXO/^
to
City ofO'CW^ OXXX^VC
No* 3t7 1
St
Dist.; bet.
"and
/ ir nr^TH occurs AWSAY from USUAL R E S I DENCE GI VE facts called for UNDER SPECIAL INFORMATION' \
( Tf DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
^\
KKy^y\)
PERSONAL AND STATISTICAL PARTICULARS
SHX
r< )1 .< >
^\
I) ATI t >! l;IK III
\| .1-
!),.%
■> 1 .11
I'Uis
■-IM .1,1' M \KH ii: l>
\vii»« >\\ j:i( nk i>!\ I iKni)
I'.iK rni'i, \cv.
(Stat' lit r.iiiiiiiv
N\Ml <ll
I A 111 IH
lUK rUI'I.Al'K
< It 1 \ III I-"K
■ >i;i' iti! I \
M \ii»i;n n \m I
• ►1- M<»rm:R
luk iiiri.An-:
<»r Miirm: K
( ^l:iti' I It i'l Hint I
<KA ri'.x rinx
vu
\
f-
%
L
L V
J t
Ki-litni III Silir it <!ih
Mnilf/l-
l),n
TIM- AHOVI.- ST\Ti:n I'KKsOXAI, J- \ K Tir T t.A K S A K IC T K T H To THl-
lU-.ST HI. MV KNOW I.J.IX .!•; AM) l'.i;i.I l.F
f InroniKiiit
J MEDICAL CERTIFICATE OF DEATH
DAi'i-: oi' PI-: \\\\ t' ^
(Motith)
I>av)
(Vi-ar)
I llilRl'lliV CI^RTII'V, Thai I attcn.U-.l (U'<-fasi«l fr<«m
"— ICp tn — - 1()0
that T last saw h
aUvc nil
l(p
ancLthat deatlj occurrtMl, on tht- <1 ate stated above, at ''
M. The C.M'SI-: Ol" IH-'-XTII wa^ as t"oll(.\s^:
1
o_
f--. I I I
:\l->
or RAT ION )'tars
coNTKir.rTokV
.1 '-.'-• '
Moulin
Pavs
IIoii
} s
(SIG
V ;^l.: lb ,c
DrRATK'N )V./;5 Months fhivs Hours
)0 ' ; ( A.M less) Lfe^-^^xJA.^ W.U.4..^^,
SPECIAL INFORMATION "il'* '"r Hospitals, instituHdiis, Transients,
or Recent Residents, dnd persons ilvini assas from fiome.
\v\- \
Former or
Usual Residence
When was disease contracted,
If not at place of deatli ?
flow tonq at
Place of Deatli ?
Davs
•I ACK <)l in KIAUOR Ki:M(i\AI.
U.J
N I ) 1 ■; K r .\ K 1". K O /<X/> V
DAXi;..!' I'.iiixi (ii ki:mo\\i.
y.t
IL
Too'i
Ik
^
rAd.ln.s 1X0^ ^IVWxsi'.OV
TT 1. I %rF should ha stated HX4GTLY. PHYSICIANS should
N. B.— fivery item o* information should he c„..fully -PPl- • „^i:*:,'^;7,L,eifie ,!^ T^ "Special Information- for p.r-
•tate CAUSE OF DEATH in plain termii, that it may »»e properly wiassitieo.
•on« dying away from home should he ftiven In every Instance.
I
WRITE PLAINLY WITH UNFADING INK —
H.,;,-,! ..f lUaltU |- So !^ '^^r.^^^^^^' ^''
Dfffe F.
4
lOO^i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Be mistered JSfo, ^'^ < *'
<X.M.t'
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( tl. S. StanDarD )
I
PLACE OF DEATH:-County of CJct^v l^a^xc. . City of Clc^^ Jax^^Cv^c
fe? t
A ( »
u
A
rN
No.
1- -^ "^ V CLl'^i"' St.; ol. Dist.; bet. V- O.. , V and
^^^ T ,,011*1 Br«:mrNCE GIVE FACTS CALLED FOR UNDER "special INrORMATION' \
( " "r'rrlT^^cc^b-ro'.^rHO.'r.i o^f^s^u" "";"xl name ,«st..o ». st»..t .no ™u»bc». ;
)
FULL NAME
4
1 .•
,\^w^K-
i
PERSONAL AND STATISTICAL PARTICULARS
SI-\
C(>1,«>K '
1
1) \ ii: « >i I'.iuTii
/ i.
iM..nth
As.H
iM
) I ) Hi I
I)av>
l/,i.////<
/'.ft
SINt.IIV MAKkll'I*
iWnlf ill •»iHi;ii ill --ii.' nat ii>n)
A
i I '^ ->
lUR rill'I.AOK
i stilt! lit (."iiiint! V
NAM I ni-
t A riD.K
HlKTHPl.ACK
OI-- I AriIl':R
iStatt (It I'ouiiti V
maii)i:n NAMH
Ol MOTIIKR
lUR I'liruArK
Ol' MOTHKK
(State or Country)
i»>-CfJ'ATI<)N ('^
1 I
i\
0 cxXx.'^c I.
Q>
x^
MEDICAL CERTIFICATE OF DEATH
DATK Ol- DKATH ,, \
if
(l)av>
\
fMotitJi)
(Year)
1 III'RI'HV Cl-RTIl'V, That I attended .krcasod from
,...,.'. up I to ^' CX: . :j TgO H
U' ^ t 1 ►^
that I last saw h - alive on w . T90
and that death occurred, on the .late stated above, at I I
M The CAI'SI-: C)l' ])I:ATH was as follows
'ill-
}'t'ars
DIRATION - --.- . .
N T R 1 n r T 0 R V U^nrsJ^O,^
C(,)
,\JxjLc<w > \^<x.t. '.,.
t
Mouths
Days
\ A.
Hon
rs
nr RATION >^ y'i'iifs
m
Jfofit/is 15" /)(7vs Hours
(SIGNED). J. i\^o-<^ <^- ] I ua.n.0 ^ ^^u M.D.
(A.ldre.s) nCO-U)^^ iv^wolttw J.
\qo
s.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
(J^,i
rx c- [' SI t
Ne.siiifd in S,ni I 1 1
nil I'l'i)
),,i
Miintll:
I '.:
Tin- MU)VKST\TKni'HKSnNAI. I'AKTUTI.XKS AKKTKrH T(» TIU-
lii;sT 01 MV KNOWM'.IX'.K ANH Hl-.I.H.l-
(lufottnant
^\
^K\A
c
•AiMnss IbO^lX UxXaJ^'^X^
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
How lonq at
Place of Death?
.. Days
ri -^CE OF lUKIAI. «>K KHM'»VAI.
S A
DATl", of niKiAi, or RKMnVAI,
a
TQO
IN. B."
U , „ ,. . 7^, ^Houltl be stated EXACTLY. PHYSICIANS should
-Every Item o? information .hould be cnretully supplied, jur. s y^^ -Special information" for pr-
•tate CAUSE OF DEATH In plain terms, that it may be properly Ua.s.lled.
sons dying away from home should be given in every instance.
•\
^
' »
D
0
»
<
H
Q w
!«■ 1
Q M
H Si;
> H
e
1 ^
5
H
Eh
H
(Talifuruia S'tatr luarft uf ffiraltli j^^^..^, R.uistcrc.l Xn._._?327fi.„
BUREAU OF VITAL STATISTICS
AfflDAVITS fOR CORRECTION Or A RECORD C'iiy and County of San Francisco
Taomae R.Carew ; of— — -A^l^_^?.^y_.^^J ?="^ Kranci-.
k' Mw ' U>.\ \ f
ikI C'<iunt\ <>i ■ ss.
.^AN FRANCISCO S
(Nanu' (if Am.int
first flulv sworn, m
he
(Address)
• •-• 'he i. 9- frienA
" " - - — ,,f-^^,,„^,,, si^eiry dfgree-^lf frU-iid or otheiwise. so state)
Peter Keanej
l3th.Ar ,, October
k ((Jl»« iinme uf T*ti\
\ \vlTO-\mT tr«^fr* I
I who (lied
S
HI
M
• , mil CiMMi;\ of San I • ;- .- ^ a
■ ihe follnwinu facts set forth mi -^ahl
er Kane, .
.^ce of- death ^l609i California. St;.
. .,,, HiMli rihli itikcr fur lioiali**
itf are n^.t correctly stated therein, to wit: _
lir Citv and Connty of San Francisco
lo_0^. as -tatcd in a certiikatc of
with the Local Registrar
lo..0>
name of docedent
F8 ther ' s" nnTne.,J:o^rick J^ane . Jjif ormant-_ Mrs^^s
ne
hi-
„ . ,,d. c v.^ 'h. true facts to be, and the changes necessary to make the record correct
attiant upon^rPT own Knov\it '1;-A .w. ..n
Peter Keajje.
16091 California St ___. ._ ^r-— -—
Fatber'ar^me: Patrick .^eane-.^.Infoir,a^^^^
:■ iliows :
Suhscribed and sw..rn to he fore lu- tin.
XlTiant) -
Si ! • iir C AI.II'OkN I \
i II \ and C'ouiiiN of
San l-'k\NCiMo
i'
n Fran i CO, Calif<irnia
ntv oi Siin l<Yai».fim«»». HUitc «rf" Califbriila
Rev , Je r poie _ B . Hann igaa
St.PJiilipa Chujtolf
San Francisco,
(Name of Afflanl)
he
(Address)
»i n^-ht^h-m knowlcd-e of theiacts hereinbefore alleged and that the
C.lu.nni. being f^rst .hdv sworn. dcpos<y and says haj-i4>e has knowU.l^ ne^ ^^^^^^ . . n vc -
'• ^^ " . / fVy^,/ ifpf^f^^^'^^/Zr^^ ^-^^.^^J^Miu Francisco. California
sai.l facts as stated therein are true.
(Affiant)
( Address) --H
Subscribed an.l sworn to before me tin
„ thi^ords "wi-re man
M„r rnTo.tUm Of a mnrrlngp rertW*-..!-. In n-;* '"r*^':5,roSirthl» blank.
l.^," o<- . ,„ay l,e Insertt-.l sptclally l.y way of ^ulmflLitlnii tnroug
I I,, I 111,' Cliv ami Ciiiinly •'< . mi^
f,:, i.rlhco StMie i»f raUfornlii
,„,. ..,,.,.nage." and ••,»..,..,..,," ■;prtest,;; "iu^lKe" or J'lua-^
1
1
WRITE PLAINLY WITH UNFADING INK
Dale /'V/r^/, li'ctc^t-^ IT
. loa
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re^isfdred Jfo, ^380
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of 2)eatb
i XX, S. Stan^ar^ )
I
J? (^
No.
PLACE OF DEATH: — County of"^*^^
City ofOO-A^ J,h.o., ,
^^frrsJ^^fWx.
OuyxK.'. • S\
Dist.; bet.
and
-)
( " rr'o».°"occ"u%r.v,"r„o"s^prT*u r"-:"?u"o"i o-. ,t. name ,»stc.o or sT,..T .«. Nu»Bcp. ;
FULL NAME
^^
ax
PERSONAL AND STATISTICAL PARTICULARS
^! \
1) \Ti-; or HiK in
A<,1-
coi.oK ^
!
/ ij
I ^
>^IN«.I,K. MAKKIi:i)
\vn><)\vi-:i) OK i>!voKri:n
iWiilcin --."M'ial i|t «-is.' iki! u mi i
IDav
M.„ifln
Vt-ai
/Jin:
MEDICAL CERTIFICATE OF DEATH
DATK Ol- Dl-.A'PH
(Day)
(Month)
(Year)
1 Hi:Ri:nV CICRTIFV, That I attciulcd (Urcased from
^JLu n 190H to...O/ct 1.1.
tbiit I Jt saw h X^; alive on ^^ lb
T90 H
190H
\X
an.l that death occurred, on the dale stated above, at -IH5
CL M. The CATSIv C)I' 1)1:ATII was as follows:
BIKTHJM.AOK
stall- 01 I'muiti V
NAMl'. Ol-
}ATin:R
HIKTHl'l.ACK
O! I ATHKK
iStaU or Country
MAini'N NAMH
ot MoTHKR
BiKrni'i,Aci-:
01-" MoTUl-'.R
(St.-tti- iir Conntr\
III ri'A'ilMN i^
,?i
'X/rsj
0
tf
lux
>x
"vR
^KiX/C^
DIRATION Vf-'T'S Mouths />ays Hours
CQNTRIBrToKV ' . XxMI^^AaJUxX. - ^ '" ^^^ ^^
Ycays Mouths Hays Hours
nTL. LU-a. . '. M.D.
(Address) bob OkxXXjJXi ut
DIRATION
(SIGNED) J A.C
1 ■•
l(>n
R^siitfif ill ^'"1 I ' '' "' '"' ''
) , ii •
1/ .iillr
I ill 1
THK Xm>VK STAIM- n PHK^oNAl rAKTICt^I AKS AKK THrH TO
IlKST OF MV KNOW 1,1 IX. 1'. AM' lU-.l.U.l
Tin-;
(Informant
QOvv. CI
^AyYVAJ.
\.l.lr
. i/„
SPECIAL INFORMATION only 'or Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
How long at ,
Ware of Oeatli? bO Days
LU,
former or p. -. i
Usual ResidenceU^CU'
Wfien was disease contracted.
If not at place of death ?
C
n
IM.ACH OI-- HIKIAI, OR RKMoVAl, P DATK of iV. KIAI. or RKMoVAI.
(^ ft . r*^ ; U^t- '- 190':
(Addre*^?
M. B.
'> ' ,. , 7(iF should be state.! KXACTLY. PHYSICIANS should
-Every item oi Information .hould he c„retully -PP -^- ^l^X^^^-*^^^-^' T^' "^P-'"' Inform.tion" for pr-
.tflt/cAUSE OF DEATH in plain terms, that it ma> be proper y
"r. dyfn* «w.y from home nhould be given in .very .nstance.
^
')
5
I
I*-'
H
i;,,;iril of H.-allli - I- N'<>
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
,,$S^„.,.c., REFER TO BAO. OP C^RTiriCATC FOR .NSTRUCTIONS
Dafr Fih''',\J<XJ>'^ H
JUOH
Registered J^''o.
^oOA
-L
^uc^,. Ll^,. Deputy Health Officer
DEPARTMENT (JF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Beatb
( "VX, S. StanDarD )
^
fNo.
PLACE OF DEATH: — County of^/CX/^^-u
' r -■ . City of J-V-O/^
Dist.; bet. XjLOAH^inuUJ-D^U^and >.
)
FULL NAME
Cj-iML{n\)
A^CiLC.
PERSONAL AND STATISTICAL PARTICULARS
to.'
C«»I,(>R \
v.L.(
DATK or HIKTH
A (.I-
rt
Muiithi
)■,,/»
|);1V
MEDICAL CERTIFICATE OF DEATH
DATi-: i»i- i)i:A*rn
(Month)
(Day)
I go ;
(Year)
I lIlCKlUiV CIvRTIFV, That I atteiukMl deceased fnnn
igoH
that I last saw h -'■■ alive on
©e.t
190
M,»,tli-
/hn
sl\-<.I,K, MAKl<n:i> .
WIDOWHU OR I)!VoKi'Kf> ^
iWritt in s.h ial (U '•it'iiittion)
UJ ^<L^^^o-^L/X.
lUKTIin.Ai'K
I Statf III i'i»uiUr\' '
NAMl-: O!
1' ATHHR
HIKTH PI, ACH
oi- i\Tin':K
(State or Couiitrv'i
MAIDKN NAMl.
01* MOTHl'.K
HIRTIIPI.ACIC
OI- MO'I'm:R
(State or Co\nitrv
\X)xrY^'\^o
CL^^.>^.'u
\k/l)
and that deatli ..ccurre.l, on the date state.l above, at I o C
M. The CAUSE Ol" DliATll was as follows:
I )r RATION Vt-ars
CONTRIIU'TORV
J/oN^/is ^ Days Hours
I
?
orcri'ATioN
(XxlAA.i
OjUutvxo^
h',-l,fr,f III S,IH /'l-llh
U'll i
)','i; I
Moiitli^
Ihn
THKAmn'KSTATKnPKR:.>NAI PXKT.rr;.AK.AKiCTKtK TO THK
BUST Ol- MV KNOWI.l-.lX^. AND I. hi. HI
Years
^ri>nths Days Hours
nr RATION
(SIGNED) a. e). sJUi^riaYV ,M.D.
U/Ct in lOoH (Address) I^U^^Aa^^^ V. 0.1.
SPECIAL INFORMATION only for Hosjiltais, Institutions, Transients,
or Recent Residents, and persons dying a^ay from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death?
Days
PI,ACK 01* lU-RIAI. OK RKMoVAl
i(V
(Infoi niatit
(\<l(lrr
,t
D.VrHof Hi KiAl. or K1%M(»V.\I,
I go
(AtUlrt-ss
IN. B.-
^^^^^^^^^^^^^^^^.^.^^■^■iL— — ■— ■^■^"^■"'"'^■■"'"^^ t t I EXACTLY PHYSICIANS should
-Ever. Iten, o* 1„form«t1on .hou.d be cB.efu.,. supplied )^^J^;:,lJ,,ll %he "Sped.; InWaf.on" for p-.-
.tat. CAUSE OF DEATH in P'«'"f.7^:;;;« ^'.rert \n^tnZ..
•on* dyinft away from home should be fe.ven m every
'J
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
RgFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS ^
.1 .,f ii.-aiih r No 1^ -ft-^^J^) luvrou
,^^\J^jJS
Der
7.9 (yS
■ ?ca!th Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
{ "a. S. StanDarD )
(^
/ wCX, >
o^s. .. City of r I ,CL/^ 0 >vO-> ^- c^cv
PLACE OF DEATH:— County ofCJCU-yX'
L tl V
FULL NAME
u
A
y.^X.LlX"
Avc
J I
PERSONAL AND STATISTICAL PARTICULARS
sl'\
coi.ok \
\]
I
DATH nf- r.lK 111
A'.K
' J
?.M
1 Month I
)V,f*.
Dav
M.in/fn
in
fhi r.v
(Day) (Yt-ar)
ftlNC'.I.R. MAKKIl'.l)
wiunWKl) OR i)ivt>K(.Kn n
iWritf i»» siK-ial cUsijrnaliou) \
BIKTHIM.ACK
fStatf or CoiiiUty^
NAMK OI
fathj:r
BlRTHI'LAiH
(If* ! AI'IIKR
(State ur Coiuttry'
MAIDl'.N NAME
OI- MOTIIHR
lUKrniM^ACK
(II MoTllHR
(Stati- or Cottiitiy)
otCl TATION -\
W
i (
w^^
ct'^w
MEDICAL CERTIFICATE OF DEATH
DATH *n' HKATH M \
^ c. w
(Month)
I HI'kr'HV CIvRTII'V, That I attcnckMl (IcHvascMl from
.:. 190. to. ii'ct^ l.S 190'^
that I last saw h i. " alive on ^ -'-^ ' ' ^9°
and that <leath f)ccurre(l, on the date stated above, at * -
M. The CAUSr: UF DIvATH was as follows:
\^C^K.<:><y^\^^:nrs^^-''^^ Crt- Q .Qrv>v;tx/cJ(v .
nrRATioN I
CONTRIRl'TORV
)'ears Mouths
(^1 ^
Days
Hours
Days
DrRATION ^ y^^ Mouths ^
(SIGNED) ij. 1 W^^' y
n>o i (Address) ll^l^^Ko^v^
Hours
M.D.
y\jJ^
*-S i' H I
Ke>iiled in San I "J"' '-<•' -^
\ r
)>■(;'
^„ .'\f,,iif/i>
/hi y>
THH AHOVR STATKU ''HK-.NA, PARTirri-AKS ARK TRIK TO T..H
IJKST or MY KNOWIJ.IX.H AND Hl-.Ml.l
(Informant Vm^O^O^OOL VM^
^0'
!A(lilr<ss
10 o"^
V
^..i ■- . ^
SPECIAL INFORMATION only for Hospitals, 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?
How long at
Place of Death?
Days
I'l ACH OH lURlAI, OR KKMoVAI,
'V^-'^W^'X
INDHRTAKKR
(Address
DATHuf HiKlAi, or RKMOVAU
11 ■■' !•; i9o'(
RH.tJiK'^'t'
^S^sJ^-^OOX.
■-^-— —-----— —■—-—■■'■■'■■■■''■■'""■'"""^"""''"'"''"'"''""""""'^^iTf H Id be stated EXACTLY. PHYSICIANS should
N. B.— Bv.ry ...m o. ,„f„.„,..ion .hou.d b= cnr.fuU, suppH.-- J"^^.'/;,...,,,.,. Th. "SpeCI InWm.t.on" for p.r.
^ -. /-AiifiF fiP DFATH In plain terms, tnai 11 mwj' »*
::r;/,Cw^r »°- H.™. :H„u.d he t.v.„ .n .«,, in...»c..
'J
t
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
HEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,1 ..f !!.:ilib HNn i. Ir^P^ H^ »' t'-'
100%
Be^istered J\^o.
Dalo Filed }^dJ^^^ H
DEPARTMENtIf public HEALTH=City and County of San Francisco
Ccvtificate ot IDcatb
( -a. S. StanDarD )
PLACE OF DEATH: — County of
\\\
No.
Oj\j<.y^.
St.; - Dist.;bet.
City of OCunrV
and
St . - Dist.;bet. ~~" *^"" ., x
V ,r DTATH OCCURRED IN A HOSPITAL OR INSTITUTIOIM G V « A A 1
FULL NAME ^''^A^,.,cyfl v. h . -ujUfX^ku
)
'^IX
PERSONAL AND STATISTICAL PARTICULARS
• oi.oR \
\A ^
i
!)A1 1. Of JUK 111
VSrs
M.uith I
A' .H
V y
.0
n.iv
\},<Utll
\ lar
Da 1
MEDICAL CERTIFICATE OF DEATH
DATK <>1" ni-.ATH
(Month) '^^^^V^
I go .
(Yeari
1 HICRlVnV CHRTII-V. That I atten.kMl deceased from
— to
[90
^IM.I.r. MARKIKI)
\V!I)()\Vi:i> «»K 1)IVnRCi;i>
iWrittin sotial <l«-«ij.Mialion)
that I last saw h — ahveon
and that death occurre.l, nn the date stated above, at
M The CAISI'; Ol' DICATII was as follows:
" 190
190
hAAJUL
niKTHi'i.xri-:
fStnti- or ».'n\inti \
NAMH t»I
FATHHR
lURTin'I.MK
«M 1 XIHKR
'Statf or foutitry)
MAIDICN NAMH
UF MOTHKR
lUK'l'lllM.ACK
01 MOTHKR
(Stat.- Ill »,'o»uttr\
n
^ ^.
7
I )r RAT I ON >'<■<' '■«
CONTRUUTORV
Moulhs
Davs
J lout s
1
1
I
^kjIax^uwcL
nr RATION ^ >V<7r5
( SIGNED ) &. UJ- - .^^-^-^^
,ci; ^i Too'i (Address) O^O/va
Months
L.KJ
0 C),<x/vo
Pays
u
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away Iron home.
Residfd ill Sail I'lam >
5 'I'a I
Moiilh)
I)a
THKAmWHSTATKU|.KR^.NA. rAR1M.rj,AKSAKKTKrK T. > TH K
iIksT Ol- MY KNOWI.l-IH'.H AND ni-UHI
(I
KK,K.
\--^\
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
I'UACK OF lURIAI. «)K KF.MnVAI,
(Ad.lr.-s Q/<XO^ ^
a
u
o^
DXpof UiKiAl- or RF:M()VAI,
I90H
{MhU^sH V\ V<X/>^
— ^— ^— 4t— ^'■^^■^— '™— "^ ... ^ ,^ . pvACTLY. PHYSICIANS should
Btate CALlSfc U^ i^f* > " *• ,,, w* *jv»n in avory instance,
•on. dyinft away from home should be given
'J
i' X
m
:l • (
i
WRITE PLAINLY WITH UNFADrNG INK
Boi
i,9(9'l
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re^istcvecl J\'*o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
( "d. S. StanDar^ )
PLACE OF DEATH: -County ofCW^^ Jxo.. vcc.:c City of O^X^ 0,\^^^CCCLCt
i+Jo. V.L
.t^V
^ U
/TV-ttl
,^1\<,
ii
'dV*t
Dist.; bet.
and
\..AIVA/ T ^^'-^V '^^^'^* \^J^ ' " p-VlDENCE GIVE ^CTs'cALLCD FOR UNDER 'SPECIAL INFORMATION" \
^ ^ /TS ( i N I / I )
FULL NAME
e
(
^KXH
.4
^aC
PERSONAL AND STATISTICAL PARTICULARS
sr:.\
DAIH nr- HIKTH
At'.K
u
COI.OR
N ft
I i
Moiuh)
) ,.;
(Day)
Mmilh^
I Vi-ar)
/',.•
MEDICAL CERTIFICATE OF DEATH
DATK OF I)i;ATn
SIN«.I,1',, MAKKlKn.
wii><»\vi;n OR nivoKOKi)
(Wiitf in sttrial <U nii'iiatiim)
iXoAXw'. .^
niKTHJM.AOK
(Slntf or ('..iintry
NAMl-: OI
I AT in; R
niK rUIM.ACK
<)1- lAI'IIKR
(State or Country
MAIDI'.N NAMH
Ol' MOTIIHK
a-A^tta
^ f^
^nxAxcj'u
iuKrHpr,ACK
(»!•• MOTHKU
(Stall- or Coiujtt y
DCCrPATlONrVYA
AJ^L<X vxd
ft
M, tilths
" I hi
Till- \m)V».*ST\THHI'KRS<>NAl, J'A KTHf I. \ KS A R H TR l" K To THH
lil'.ST Ol- liv KNOWIJ-.IX'.K ASn UKI.ll-.I-
: 111 f.innaiit
I Ill'iKIUiY Cl'lRTIFV, That^I attciKlotl deceased In. in
'^VvUi ' . IcjoH to ^' ^ >*^ 190 "1
that I last saw h alive on ^ C v. ' ' icp .
and that death occurred, on the dale 'Stated ahnve, at ■■
.. M. The CATSH Ol" Dl'.Vni was as follows:
UhA/Cr\AA/^ LiLhJLAyVcJu J(ryu^"^^s^^^^
Dl' RATION Yeats
CONTRIIU'TORV
Months
Days
Hours
DURATION Years „ Mouths Days
LI) \d . ^^-^^^JCol/^a.'
Address) LLLvvVAi. \
(Signed)
Hours
M.D.
i9tt
190
(
W V^. \ X.ft-\,A- a_jL.
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 deatti?
How long at
Place ol Deatli? Days
PLACH 01* lURIAI, OR RKMoVAI,
\0
DATK of H» RIAL or RKMOVAl,
rNi>KKTAlKR |t5U . mTV ^Xju^xAry^^^^^^. ^^. ,
T90H
•sJi^A uCt v*w-.
(Ail.lrcsH LD.S.jL
\AA.i^-^\
^ „._r.very Item of inWmatlon .hould be cnr.i.SSy .uppIJecl. AGE should »>«»t«ted EXACTLY PM^S'^'^NS .hould
state CAUSE OF DEATH In pinin term,, that it may be properly classified. The -Specl.l Information for per-
sons dying away from home should be given in every Instance.
11
R:
11='
I
I
■
I
i
■^
l\
i
-r
!!. ,:n.
w
I
RITE PLAINLY W.TH UNFADING INK-TH.S IS A PERMANENT RECORD
REFER TO BACK OF rrPTIFICATE FOR INSTRUCTIONS
/^//r' /'V/rr/, ii'cLcl--
2385
l<n^.. W Deputy Health Officer ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cettificate of 2)eatb
( XX, S. StanDatO ) -^
PLACE OF DEATH: — County oiUO^yxj O A.<X>v -..^ity oi
("/
^
Dist.; bet. i-^ xU^^rv^"^
)
FULL NAME
/ — ^
r<\ '
^.V^O
-Ui
¥-
PERSONAL AND STATISTICAL PARTICULARS
• i:k
Mi
C()!,i»R \
L
i»A ri: i>i p.'K 111
Ai.i-;
U
A
Month
5H ,-,..„< t
■\l,,utll'
I 'I't-ai /
/ J,/ r.
MEDICAL CERTIFICATE OF DEATH
DA ri-, 01-- DKATH
(MonUi) 'I'-'V-
^^"^ I IllU^i'BV C1:rTII-V, That I alU-n.UMl .U-cvased fn.in
— — — TgO to
tliat I last saw h ..:— alive on
{Yfar>
190
^IN«,l,l* MAR K 11*. I »
\vii><>u i:i> *>K i>;v<»Ri i-.i)
(Wtitt 111 x.cial <U -'-nanMu)
(KXXKXXX^^
an<l that death oceurrcil, on the date stated above, at
■ AT TheCXrSHOl' Dl'.ATll was as follows
u
lUR riu'i.x*')'.
I Slatt or I "i iiilit i \
NAMK <>!■ ^
l-A Tlil-R
A
\.U^ou
L
-<5\-
I'.iRTm'i.ACi';
(>)■■ I Arm%K
I state iir I'liunti y
MXini'.N NAMl-
()1- Morm'.R
niRTUPKAlT-:
ol- MnTHKK
f Stall' 1)1 (.'oinitry
uOOfrAI'ION ^
lli
?
nr RAT I ON )V(7/-.s
Ci.N'rRMUTORV
.1/. •;////.?
Days
J /ours
a
( SIGNED ).WurraA^ J.vfc-^ U.Ca.^vA. M.D.
U. luoH (Address) Uv<nXilAA W V- -....
Special information onl> '"^ Hospitals, InstitutWiH, Transients,
or Recent Residents, and persons dyinq away fron home.
Rr-! ,!,■■! in ^.!'' /"'"■
);u!i
Mmifh^
/lav.
Xdilrt'^s CS ^''^
ifN^ Op n '\
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
I'l^ACK Ol' lURIAI, i»K R1:M<'VA1,
I>\J"1'"'>!* I'.' RIAL or K1':M<»VAI,
190H
<x^^J„Cl
Addre^H ioXn ^J^^<>-0.<U.^X^■
1-
,. . TnF sHould be stnted EXACTLY. PHYSICIANS should
IS B —Every Item of information should b. cnrefully supplied. ^^'^^^^^^ The "Special Information" for p.r-
state CAUSE OF DEATH in pinin terms, that it m«y be properly Uass.t.ea.
:':;. dytn/away from horn, should be 4lven in every instance.
) 't
]^:n<1 ..f lltaUh 1- N
WRITE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR IN8Tf.UCTI0N9
386
i)Hfcl' Of)
Registered J\'*o.
1 1
\j(r^jj^\x'\tM Deputy Health OfTicer
DEPARTNENT Of PUBLIC HEALTB-City and County of San Francisco
Cevtificate of Beatb
( "U. S. StanDarD ) ^
r ^ H^. lie '' - Gtv of m|\<X-vVL.Lcx
PLACE OF DEATH: — County of -^^^ ^-<^^^^ ; ^'^^ °'
No
i^L
St4
Dist; bet.
— and
■ iciiAl nF«5IDENCE GIVE FACTS CAI
,r DEATH OCCURS AWAY FROM USUAL R E S I D t. N U t U
LLED FOR UNDER "SPECIAL INFORMATION- \
( ,r DEATH OCCURS AWA. ' "" "" — pTt".: O r" . N STITUTI O N G.VE"lTi NAME INSTEAD OF STREET AND NUMBER.
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUT.y ^
FULL NAME
L
si;x
DATK OI' r.IR 111
PERSONAL AND STATISTICAL PARTICULARS
COI.OR \
M
EDICAL CERTIFICATE OF DEATH
W)
.1
li
iMoTitir
AC.H
) I'ill
Day
Mmths
(V«_-ar)
na\.
DATK Ol- DHATH J
(Moiirli)
(Dav)
I go
(Year)
1 IIKRHBV Cl-KTIFV, That I attemUMl derease,! frmn
— 190
— — — IQO
190
to
"^INi; 1 v.. MAKKIKU.
\VII)()\Vi:i) «)R DIVOKi'Kt)
(Write ill '•ocial d.vi./iiat hiIi)
BlKTMTM.ACl',
(State or Ooiintrv
rr
s^
4 <
•t
\
» 5
NAM!'. «>1-
I- A r 1 1 1; R
niRTuri.AiK
Ol- lATin-.R
(Stale or c'ountryi
MAIDl-tN NAM)-:
Ol- MOTHl-.R
RlRTHri^ACH
Ol-' MOI'llKR
(Slate or Country
that 1 last saw h ■ " ahvc on
an.l that death occurred, n„ the .late stated alxne. at D- it
M The C \rSK Ol' l)l';ATn was as follows:
DTK AT ION >V<7;-i
CONTKIIU roKV
Afonths
Days
DURATION >V<7;'5
(SIGNED) u\d
.3X1 J ^ iqo (
Jf<}fl//>S
Pars
Hours
Hours
M.D.
Address)ll^.O^ ^-J- 6%s^>^
rVX^-VX.
occri'A rioN
Rrsidrif in Sun I'lan.i.^ro
X n
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from tiomc.
How long at
Place of Death? Days
Former or
Usual Residence
.1 /,«///;.«
lhl\:
KS AKi: TRIK TO TlH-.
[Infotmaiit
Wlien was disease contracted,
If not at place of death ?
PI \CF Ol- lUKIAI. OR R1':M(>VAI,
I)\l'i:i.f HiKiAi. «»r RKMOVAI,
. AL'cL I'l 190H
(Address
iL,
V.
( Xddress
"■"""■"■^"""""^ ATF should be stated EXACTLY. PHYSICIANS •hould
:"'.%"nT.w°» frL ho... .hould he .Wen 1 > ."..-«•
M
u . Ji
WRI
TE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK O
F CERTIFICATE FOR INSTRUCTIONS
u> /v/f'^/, Lxtol)
yjo^j n
i
7.9(9 4
Off!
JRpeii.sfcrcd ■A''o.
2387
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cevtificate of Seatb
i ^
PLACE OF DEATH:-Co.ntv of^-^;.-— - CUv of 6a^ ^ Ax^™.
V^ ,F DEATH OCCURRED IN A HOSPITAL u Q i^ , H
>UUYVCXVC^
)
FULL NAME ^ f^^-
si:\
DAll-. »•! niRI'll
ACK
PERSONAL AND STATISTICAL PARTICULARS
Xtrrruno/CiuxlWt^
r\AXi'
A
iL)tt>
I M, ,11th)
II
I):iv>
Ron
5V
M.nih
5~
'I'l Mr)
/',n
MEDICAL CERTIFICATE OF DEATH
DATl': ni I>i:aT1I II 1 I . ,
(Month)
I I)MV>
(Year)
WIDOW ):i> OK I>lVoKr).l»
.Wot.- ill -», lal .1.-ii;t!nli..iit
HiR riii'i, \*"»'*
(Statf '•; < '•iiiit! \
NAM!' «»l
IS I lll.R
niRIIll'LACK
()!■ lArill'.K
I State iir t'dUiitrv
MMUl'.N NAMK
OI^ MO'nil'.K
lUKrHlM.AiV.
ol- MoTin-.K
( Statt- (»i C<i\uitry '
oCCl I'ATION
h\-.,\tr,f n, Sail ri,t>ii '■'/•''
I HKK1U5V CI-RTIFV, That ^ attcmUMl .U-rra^cl fmm
t,at I last .aw h ^ alive on ^^ » ^^ -^ H
a.i.l tltat .Uatb (ururrcl. n,. the- .late state-l above, at 5
(J M. The CAISI- ^^^M*'- VI U '""'' ''^ follows:
DIRATION
Motiihs o /)(iys
)'e(H
//ours
DTK AT ION
Vciira Months
/hn
.'S
//oh
rs
O/Ci: lio Toni f A.iaress)
SPECIAL INFORMATION only lor HospitaMnstitutionsOTranslents.
or Recent Residents, and persons dying away froii home.
),;i
yr,.i,th
/'..'I
^^.>y^;S^v^^l;^^^';^.r.^;^;.l:vl^r■^■''^'■^'■^■'■''^^
„„r.,., 0 JvOu^^'tXA/^ '\-V<i^
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Plare ol Death ?
Days
I'l.ACH Ol lU UIA!, OK KI:MoVAI.
DATi: of p.t lUAf. or ri:movai,
^du 11 190H
(A'Ulri"^^
\
, — ■ — i 7"! 77r •hould be stated EXACTLY. PHYSICIANS should
•tate CAUHi- ui ut« • • ASven In every Instfince.
none dylnft «w«y from home should be given m every
1 {
I
♦ >
M
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO PAC. OF CERTIPIC.Tr TOR INSTRUCTIONS
Dale I'll I'd , V^/'CUrVMA/ H
DEPARTMENT'OF PIBLIC HEALTH
B,p^i^tci'(^^^ >^'*o.
2388
=City and County of San Francisco
fNo.
11 ,
;
Ccvtiticate of ©catb
( -u. S. StanDarD )
PLACE OF DEATH: — County of - cxm^ \ "^
FULL NAME iKvU^A ka>vcUa ^^^Wr>---^^J^^
'hlX
)
(Vl/ylOuuVa^cc
si:\
II \ ! v: nl ];l !M 11
\i . 1-;
PERSONAL AND STATISTICAL PARTICULARS
ft roi.iik \ f]
iM.inth'
II
n:iv
10^
fV^EDICAL CERTIFICATE OF DEATH
DA ru <>i- nHA'i'ii [/ N
ob
(Months
lb
(Year)
» >S
)
5r
/>,
slNf.I.l- M\KI<li:i>
winnw 1- 1' <•« !M\ (>k^ in
:XVtit. in -.. i:n 't< ~i"i;.iti.iiii
lUKTliI'I. \r)',
I Stall > i! ' ' 'iiull N
, lIKKKirV CKRTirV. Tlu.lJ :.lten,U-.l .leccasc-.l fn-in
n.atllastsasvht^alivcon (L'^t I b 1^1
ana that .leath ..courrea. n,, the .late .tatc.! above, at 5^
T ^j. The CAISI- or DI'ATH was as foU-nvs:
,
ii
lUKTIiri.AiH
(»!•• I AlUKK
, v|:it ( i.r I'onnt vvl
MAll'KN NAMK')
lUK rnri.Aci-:
ni Mo'lin'.R
(Slat' ' i! (.'otniti >■ I
^jYva ■^'.cl\H.u>u^
I »rR AT ION
)'(ars
'^'
Months
Pays
•" M,<.i>h^ O
/'./I
y
M.D.
"<5^CIAL INFORMATION »nlv l«r Hospitals, ^nsfifutions, transients,
or Rwni Residents, and persons dvinq away from home.
^\ob Ifc H>nS (Aaaress)^jyUm,0:\tma>
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
(Inf. i; maiit
,,,,„,,. [yxX oVuxhjw
%
DAir'n! r.i KIAI <ii Kl'. M«»VAI,
iilofc tl T90H
— — ^^— ^^— 4— — — "^"^^ IFVAGTIY PHYSICIANS should
State CAUSE Oh Ut^ » " ^ AJven in every instance,
son, dyinft away from home should be g.ven .n every
' f R
I
r. p.j^ro
WRITE PLAINLY WITH UNFADING INK
DEPARTMENT OF PUBLIC HEALTH
THIS IS A PERMANENT RECORD
BEFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
j,'ro-i.stered A'o. 2389
=City and County of San Francisco
hi
Ccvtiticate of IDeatb
I ■a. S. Stan^atO )
MJi)
PLACE OF DEATH: -County ofO<:^ .1Aa-^xCx.^
%
I
City of
-"^
X CC ^x
No.
0 *-s 1
^
St.;
Dist.; bet.
5 U^
» t
/ IF DEATH OCCUBS AW«V Fl
V IF DEATH OCCURRED IN
and ' ^
^^*f ' ^„_ .lunrR "special INFORMATION" \
)
FULL NAME
\^aXjlLL<X' 'vJ
k^AA
Sl.X
PERSONAL AND STATISTICAL PARTICULARS
DA TK III- HiK 111
\<.K
l\
5 ,
(Dav^
Mntllh-
\. al
/),
MEDICAL CERTIFICATE OF DEATH
DA I'l-; t>l- Dl'.ATll
'ot
<:r>
(MontlO
(Day
I go \
^
. 1 IIKRKHV C-KKTIFV, Thai I alUMuUM .kHvased fr-m.
mM.I.K MAKI<n-D
w iD<nvi-.D OH i):\ ' •'■■' 1 i»
t
that 1 la'^l Naw h
alive oti
1 11*14- ■ ..vvv.. .-
to iDct lb
11
IC^H
up
C^
liiK riii'i \*M-:
, '-,t:itt ii! I'l Hints >■'
^
NAM I' <>!■
». Arill.K
^3
^"VO
a„,l that lU-ath nrrurrc-.l, n„ the .laU- staU-l above, at I 0
V ' M. The CAISK (>!• Dl-APlI Nva^ as foll.nvs:^
].rurA^^o-^ Ou. ^
.^0^-
Ivin^^^
X,V>A-.C5
V \ » ~».
9
I )r RATION >''«7rA
CONTRll'.rTOKV
Months
/hn
//our
UlKTinM.At'K
(>» 1 A I IIKR
iStatf or i"(HUitiv
M \idi:n NAM1-:
Ol- .MOTHI'.K
mRrmM,As.'i%
m Mnrm-'.K
tsiaii 111 i'o>uJtry^
t
OUwU
il\
h S ^
)V<rr5
or RAT I ON
iNED) WrV>^ ^
J/oh'f/lS
/hiv
(^IGI
A-Aj-O.. .
//ours
M.D.
^
Uct li -r' ^^.MresO Mlb^ n
Ik it
QPFCIAL INFORMATION onlv lor Hospitals. Institutions. Transients,
or Rerent Residents, and persons dving and) Irom home.
;,.KKSMNAl,.-NKTirrKXK-;AKH THIK T- » T
liKST C)l- Mi^KNoWl.J.lH.l. AND m.I.IL^
{Infonnant "J '' *^^ ' r w
Former w
Usual Residence
When was disease contracted,
If not at place of death ?
•LACK Ol r.l KlAl, OR RJ-.MoVAl.
How lonq at
Place ol Death ?
Days
^1
■\.^
D \ ri
IS, 1.1 M '>t ki:m()Vai,
lijot l^ T9o1
— ■— — ^■^'"■^■"'"""'^■""■'"~'''"'''''""^'"''"''''"'" ♦ I FXACTLY PHYSICIANS should
„, ,„.o.„.«tlon .Hou.a He cn^efuH. ^uppHe.. ^^,^^^;,;7;^Um:" Th;^^«^^ .„..„,„tlo„" for p-n-
E OF DEATH In pinin term«, that .t m.> ^e Pr p
N. B. Every Item
state CAUSE Ol^ "»^^ ' " "' ^T'l^L'^Wcn In every Instance,
son. dylnft aw»y from home should be given .n every
^iV
♦ I
toi
.
WRITE PLAINLY WITH UNFADING INK
^ i .,, Depu*v '-'t^a'*'^ Officer
THIS IS A PERMANENT RECORD
PEPER TO RACK OF CERTIP.CATr rOR .N3TRUCTION8
2390
lie e! i st ered ■N'o.
DEPARTIHENT OF PUBLIC HEALTH-City and County of San Francisco
Ccctlticate o£ ffieatb
( tl. S. StanOatS )
Ar^r^' J \,<X.-yxC ■ ■ ' City of ' ) <X/>^ ^ -'^'^
PLACE OF DEATH: — County ofU.CXA^, ■> '^^^ ^
0/-
Dist.; bet.
4 ^ «>/4
FULL NAME
CX/OXA
^
1^ ^
^^}••.X
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
A
COI.OR '^
DAT}-: nl- lilKlH
\«.H
• M outfit
)ru,
< I»avl
1 /.<>////<
II
(Year)
/)(/>
DATK OF Dl'ATH /^
(Vc-ar)
WIIXAVI.I) OK niVuKiJ-.I)
i\Vrit»in -'nial ilf-iu'iiation)
lUKTHJ'I.StM*,
NAMi: Ol
1 ATHHR
lURTHI'l.AOK
OI- lAPHKK
I stall- or (.'oiuitry)
MAIDKN NAMH
OF MnTHF.K
lUKTIirnACF:
Ol' M()rHF:K
(State tit Cotmli y>
(Monti,)' '«»='>'^
1 in';Ui:nV CICRTII^V, That I atten.UMl .Uucasea from
' ' I^OH tn ^^ up
1- ... )i.WAv I -' igo 'i
that I last saw h- ahvc on ^ ^I ^ ^ ^
,,n,l that doath occurrea, on the .httc statcl ahovc, at ^ ^
M The CMSIv OF HHATll %vas as follows:
\\sX^.
JONTRllUTOKN A.^..-.-«
/?av
//our
r\)^
C
DURATION ^ >'''<^''-^
Jfofii/is
Ihivs
( SIGNED ).U('^-0^
^^ci
c^>\-
.CLA
Rf>idn! in San /'iiinri^ro 10 )"''
I
^r„nff^'
Dav
.n„..HovKST.vna,^K^.sM.r.JKT,rri.K..KHTK>K to tmk
IJKST OF MY KNOWI.h»«.h AND HKi.o.t
//ours
M.D.
P- I !
■ c^PECIAL INFORMATION only for Hospildls, Institutions, Transients,
or Rerent Residents, and persons dying away Iron, home.
,llr...^1U^ h^^^^^^^
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
K,<^XA\JJ\^y>^^-^
(Adfiress
1
/CX'Wx/l^
PI ACH OF lURIAI, «»R KKMOVAl.
i)ATi%<>! niKiAi, or rf;m«>vai.
J!,!11k1^^^cuu^v %!(E.^^^^'
(AdclreHHJlll ^'^^^^AA^
^ — . . , * H FXACTLY. PHYSICIANS should
state CAUSE Ot- ocaih »" f ^i^^n In every instance,
•on. dying away from home should be ft.ven In every
).
'I
>Ji
i
I
t
r
r\
'■',
n
♦ I
i »
I I
4 11
w
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board ..f II.;. mi I N'
■?-?Si^^ U&lV C
Dff
/r AV/fv/,.li',tt^\'
dUr^<-^
n 190H
Deputy Health Officer
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2391
Registered jYo,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eath
( "U. S. StanDarD )
PLACE OF DEATH: — County of
%-
H
City of JUX-wCU-Lv' •
Xmxa
Na
St.;
Dist.; bet.-
and
(IF DC»TM 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 OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.-cn^cc'^ \
^iii
PERSONAL AND STATISTICAL PARTICULARS
>.i;\
^
cnriiR
\
A
La
li
DATi" «»r- liiH rn
AC, )•;
ai
MJ.iit
II I
} t-ii t
{y.Kv
M.'iitln
ir)
/'(/ V.
SINC.I.I.:. MAKKIi:!)
WlUnUI':!) OK DIVi iKvI-l)
\\'!it»'in "social <!< -i^'natinii)
lUH ilil'I, \C\%
(Stat( 1)1 t'DHiiti \
NAMl" Of
1- A I'll i:k
HIK rill'I.Al'K
oi" lAinKK
*Sta!( .It i'ountTvi
MAIDI'N N'AMl-:
«>!• MOTIIKR
niui'in»i,Ari-;
(Stall .)! Cnimti V
i
0
0
a^v
\<X .
^)
<xx-ucl
y^
P
Lax<Tw>xx uXju
y\jY\J(\Xx/yr\^
MEDICAL CERTIFICATE OF DEATH
DATK ()l* DlvATIl
(Day)
1 Ili:Ri;nV C1':1<TII'V, That I attciKkMl tleccasc-a from
I9O to
(Month)
(Yexn)
that I hist saw h
alive »)ti
190
ami that death oeeurred, on the dale staled above, at -
■~ M. The CAISI' Oh Dl-ATII was as follows:
\..»..
ni' RAT ION Years
CONTRIIUTORV
Months
Diivs
Hour
Ur RATION
(Signed)
Years
Months
Davs
I tours
M.D.
^
),,i
^Innth^
I hi
Tin". AHOVK STMI- I) CKKSONAl. V \K I" K I r,ARS ARK TRTK TO TUl-:
ISKST (>I* MY KNn\\Ui;i)<, K AM) l!l-:i.l l.l-'
(Infunnanl UW
(AfMrcss
1,1 /^Ov>
is
"tXa ^ %\vX^-
"X
\.
I(>0
(A.hlress)
Special Information nnly 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 loR(| at
Place of Death?
Days
JM,AC1-: 01 HI RIAI, OR RHMOVAI, I DAIl...! lU mi.^i, „r RFMoVAI
ulDCrY^'^^ wt
m
I90H
rM)i;KTAKi:K
^■"v^w/VH
*_ N
Ad.lMss kl ^TYW-y^jt/C^tOVU^Uu 11.
1
1
N. B. Every Item o? information should be cnrefully supplied. AGB whould bo ntated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plnln terms, that it may be properly classified. The "Special Information** for psr-
sfins dying away from home should be given In every Instance.
Hij
i!
I
I) t i>
'K^k-^'
I
I'l )
«t
>
h
? 1
It
[
I,
lit
WRITE PLAINLY WITH UNFADING INK —
190 "i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Be^lstcrcd J\^o.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
^CMw
Ccvtificate of ©catb
•Q. S. StanDarD )
(HT^,
No.
PLACE OF DEATH: — County of
115 ^Jo
CL'Vu
St.;
City of 0<Xnf%^ J.XCX
Dist.; hct*
C i . > w{5-'^:\.i- and
(?■
0
(
r DE^.TH OCCURS .WY FROM USUAL R E S Id i N C E GIVE FACTS CAULED ^OR "-.DER Tj "^'*;^' Jl "°;^;J'„°
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
+ -^
V \
N.)
FULL NAME
£uiA\ijy\.c
i
ii
PERSONAL AND STATISTICAL PARTICULARS
DAT!" nl- lUKlII Q,]
II
I
I Month ^
A< .1-
U
)V.i>
<l)av)
M.nitll
ALT
» tar
/;
'(/ 1 A
S!N(.i,}.: MAKKIl-'n
i\\'iit<iii --iHial (li '•is.'iiat iiiti)
IHKTMIM.Ai'H
(Statt <ir I'iMiiitt y
H I \<X.>v\.<X<L
NAM I- <)l
I'ATm.K
a\.t
V (
p.tKrupi.ArK
oi- I ai'iii;k
(Statr '>! I'diinti V
MAinKN NAMK
<>I MOTHKK
HIK'rmM.ACK
oi- MoTIlMR
(Statt' or I'DUiiti V
nCCt'i' \i'l()N
\
(
^
I iXcUvc^ ^ ' ' ^XJ ^
^hn
t\^
< n Sill/ I I ii )fi ; 'I'll
) V,i
M,,,tlli'
I hi
rnj- \H()vi- ST \ ii:ii ckrsonai, i-akiumi.ars aki-: run-: t<» tiik
lu'.sr <)i> Mv KN<»\\ i,):i»«.J-; and m:i.ii'.i'
(Iiifoi matit
MEDICAC CERTIFICATE OF DEATH
DATH Ol- DHATH
(Month)
(Day^
igo
(Year)
I m';RI';HV CI-KTU-V, That I atteiKkMl deceased from
/cfc iH 190 1 tu ...iO-ccut I.:,
190
that I last saw h
alive oti
190
ami that death .ueurrcd, cm the date stated above, at
M. The CAT SIC OF DICATII was as follows:
P .^c.<
DT RATION Years
CONTRIIU'TORV
Months
1
Days « Hours
^Ni...».
Days
Hon
nURATrOX ^'cat:s ^ Months
(SIGNED) J. U.MjUa. M.D.
/ct lb iqo'i (Address) bTH.-^^i^^^^.Lkw^,. ...
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Isual Residence
Wlien was disease contracted,
If not at place of deatli?
How Jonq at
Place ol Deatli ?
Days
DAXi: of IHkiai, or KICMOVAI,
I'l.ACHOI" IHRIAI, <»K Hl'.MoVAK
N. B. Rvery Item oV' inform«tion .hould he cnrefully supplied. AGB nhould bo stated EXACTLY. PHYSICIANS should
•talc CAUSE OF DEATH \n plnln terms, that It may be properly classified. The "Special Information" for psp-
sons dylnft away from home shoulil be &iven In •\9ry Instance.
o*,
S3
e
I
i
■
r
if I
f ! ' '
i
tl
pmir.! ..f n. ,i,i!i ' '^■'
WRITE PLAINLY WITH UNFADING INK
^^-..^-m ■
nSiV C.J
100 "i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR IN9TRUCTI0N9
2393
Be^istered JSi^o,
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of 2)catb
•U. S. StanDarD )
PLACE OF DEATH: — County
ofCJ,CL/^rt' J\XXnvC.vA'Oo City of 0/CX/^^ 3XC
?
I
I
Nn doX^^Ji^ OL ' ^ St.; Dist.;bct. and
L^iXt ^^^^^ » ''-^ ^ ,,cii»i circsinrNCE- nvE facts called for under special information' \
FULL NAME
m:.\
1) \ 1 i: I iJ !UK III
PERSONAL AND STATISTICAL PARTICULARS
coi.ok N
1' . :.
Clkv
\ I . i-:
!V./;
iUavl
M.mt/is
\ VAX
Da 1
^Ixr.I.K. MARklll)
\\ Ilx i\VI-:i> ok I>i\*t>K(KI> Cs_
11 ^o
MEDICAL CERTIFICATE OF DEATH
DATK <)!• DMATII
A
fM(.!iUi) (Dav)
I I]I*:R1;HV CI^RTII'^V, That r attended (leixased from
igo
(Year!
iQ .ct . ID
that 1 last saw h
M.
to iD^
IS.
1 ,
190
190
ahve on w '.; 190
and that <k-ath occurred, on the date stated above, at i -. 1
M. The CAISI-; OI' DlvATIl was as follows:
lUR rillM.ACK
(Stat' >»r Cmintry
NAMI-: ni
PATH IK
niRTHIM.AiK
<>!■■ lAI'llKK
I SI, it" 1)1 Coutjti y
MAiKI'.N XAMl, '*N
ol- MOTIIKK ' '
^
.1:
0
l-U
^Oj
HlKIHI'l.ACK
nl MoTHKR
( Sl.itc lit Ciiuiilt \
OCC! TATION (0
AVv/</c'(/ III Siui /'i till list-,} )ia.
/ 11 n
^f,>,ltln
r>r\.
Tin- Mi()\ K Sr\ri:i> I'HKSONAl, l'AKTHMl,AKS AR1-, IRl K 1«> 1 H h
ni-;sr ni' mv k now 1.1c ix.k and n!;iji:K
(Infonuaiit H. i
C|k;,
A.i.ir.ss. Liyvv^XnTxAj \^<X)
^
DT RAT ION }'i'iir.s
CONTRIIUTORV
I ) r R A T I ( ) N ) 'ears Monl/is
/)ays
Hours
Days
(SIGNED)
0tt
lb
lc)0
H (Address) ^'^0 3AxO_ih^ Mj.....
L
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away fro^i home. ^
Former or I -h ( ^ j ""*^ '''"*' ^*
i\jL^nt\Jjy\X} vOwV Place of Death? Days
Usual Residence
When was disease contracted,
If not at place of death?
I'l.ACK <)1' lU'RIAL OK RKMOVAI,
nA'l'i: uf HrKi.vf, or RKMoVAI,
Cn k
INDl.KTAKHK ^J V ■ ^J
(Address iS"b' /itl 3,A^U^ t
190 \
ts. B.— Bvery iten, o.' Informetlon should be cnrefully supplied. AGB should »»« stated EXACTLY PHYSICIANS •hould
state CAUSE OF DEATH \n plain terms, that it may be properly classified. The -Special InWmat.on for pT-
sons dying away from home should be given in every instance.
)'
1
i I
,! U
WRITE PLAINLY WITH UNFADING INK
II, ,i;th
h t N. ) • •, t--r -af-3;i' !U^ I' (
100
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\''o.
I)((le Fifed, k S^JrLK>\j H
DEPARTMENT (JF PUBLIC HEALTII=City and County of San Francisco
Certificate of 2)eatb
( "U. S. StanDarO )
PLACE OF DEATH: — County ofd/amj ^ City of UOj>ru J Axx .
M
» 1
No 1?^C^ St.; ^ Dist.;bet. ^^ and H *
/ ,r DEATH OCCURS *W.V FROM USUAL R E S I D E N C E G I V E FACTS CALLCD FOR UNDER "SPECIAL INFORMATION" \
( ,F DEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
Oj-rx) LUXr
D
^w*^.
PERSONAL AND STATISTICAL PARTICULARS
>I.\
(\
"I
Col.oR ^
<XXX
I
I , t
I)\ li: of lUKTH
\<,i-;
n
o
Ml. mill
)
(I)nv
MnHi^ ^
I Vtarl
/I.IX'.
SIM.l.i: M \RR IK1>
• Stutt ii! r'Htlltl \
1- A 11 IKK
HIHI'm'I.ACK
ni- lATIIKK
' "^!:itf ur (.'oillltl y
MAIDltN NAMK
()l MOTHKK
lUk'riU'KAC'i:
oi' M(n"ni':K
(Statt 1)1 Country'
OCCl'PATION
/y^sidfil I" ^ili' /l.lili
) V'l?/
Mnlltll^
!h! 1
HJ- \H()VI*, ST\r»:i> I'KKSONAI, I«A KTU' T I. A K S \\<V. TKri-
HI-:ST OI- MY KNo\VI,i;n<",K AND BKI.!!'.!'
TO fill-
I lufii! inant
OusT^^
f A(l(lif^<
[5^D
Q^/u-t
>u 0.1
MEDICAL CERTIFICATE OF DEATH
DA TK OI- Dl-.ATII
/QO
(Ytar^
(Month) (Day)
I III'IRIUJV CliRTlF^V, Tliat J MtteiiikMl (Icccased from
, .,..„^rvt i9o''. to ^^ct< lb.. uyo^
that I last saw h u .. alive on - ^^ ' ' 190
aiitl that (Uath occurre«l, on the date stated ahove, at
M. The CATSI-: Ol- DI-lATIl was as follows
DT RATI ON ^ '*'W ' Months IS Days Hours
CONTRinrTORV C:%,Kx:u.A-A-L\...C;. ,
DT RATION « Years _ Mouths
(SIGNED) UXO ^y. '^XXkLxj'\\.\
Pars
Hours
M.D.
K\ .1
190
(Address) H C) H
'\L
Special information only for Hospitals, 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?
Now long at
Place of Death?
Days
ri.ACK oi' inKiAi, ok ki<:movai.
DATi: of niKiAi. or RKMOVAI,
wet igoH
LaXXa-aXI'
N. B.— Rvery Item of information should be CHrefully Hupplied. AGE nhould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In pinin terms, that It may be properly classified. The Special Information for per-
sons dying away from home should be given in every Instance.
V
* '^
'M
i
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hoard ..f ll( altli !•' No. 1 1, -S^^W^ I!,Sl 1' Cu
7hf/(^ AVAv/,.y.cUt .:\. l.'L
190'
Registej'ed JSi^o,
i2395
,/(na.c
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( "CI. S. StanDarD )
PLACE OF DEATH: — County of
I /
^
A-CU-^XCi
No.
I
<X\.Xc4.tl^.
St.;
(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIV
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION (
Dist.; bet.
E FACTS CALLED FO
Give ITS NAME I
City ofOCL/vu Jxolavc^ca-
I XJi\i and u \Ji\)
^OR UNDER "special INFORMATION" \
NSTEAO OF STREET AND NUMBER. /
FULL NAME
lO..''.A.l oLt
I I
.Ua-'IA-C r\>
PERSONAL AND STATISTICAL PARTICULARS
SHX (
'^t
Cf>i,ok
DAi'i; or luKin
.\<.i%
I Month)
5 '»•<?#
i
iD.iv)
Mouth
u)
MEDICAL CERTIFICATE OF DEATH
Ilk li
(Month) a)ay)
I III'RHHV CKRTIFV, That I atteii.lcl deceased from
(Year)
a.^-t . L^
/',/
SINC.I.K. MARku;i)
U ll)o\\}.:i) OK l)l\ oRi i;i)
'Wiiti in "-Ofi.'il dcsi}.' nation)
IUKTmM,A("K
(State or Counti \
NAMK 4>I-
1 ATii j:r
HIKTllI'l.AOK
OI I A I'm-: R
(Stall- or I'onnti \
MAIIM'.N NAMl
Ol MormcR
FUR rni'j.Ai'H
oj. MOTIIKR
(State or Conntrv
oCCri'ATlON
Rf^idfd ni Siiii /'iiin,niii
A^Mr^
MX^CL
/
n
190 to U'Ci' lb.
Oct, ife
that I last saw h - alive on w CX ife 190 1
aiiil that death occurred, on the date stated above, at H 310
_VA M. The CArSI-: Ol- Dl-ATII was as foll.nvs :
Dr RATION Years ^ Mouths Days
Hours
DI'RATION Years Mouths 10 /p^j'?
(SIG
ii
Hours
M.D.
^^ KpH (Address) 5
^\ri
SPECIAL Information only for Hospitals, Insmutlons, Transients,
or Recent Residents, and persons dyiny away from home.
) ><M * 1 I M.,Hl/l^
I hi
'\'\\V. AHOVK STATI<:i) l'KKS<»NAI, l'\RI*I»!'I. \RS A R 1-; TRTK To TIIK
ni-;sT Ol' MY KNOW i,i;i)( ,1^: and iii:i,i]:i
( Info! mail!
aJLAX^)
( \d.hcHS
I '7 %
I !■,
!■
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Deatli?
Days
IJJ.ACK OI- niRIAr. OR RHM0VAr<
l>AlJ.;of Hi Ki.At. or KHMnVM
(Is
r NDi-.Ri'A K 1':k 0 <X^vvL^vNjt\» -^aO K,b- "i
(Ad.iiess ixoH Tru.v«t.4^<.->v .It.
190
N* B* Bvery Item of Information should be cnrefully Huppllecl. AGB should be stnted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In pinin terms, that It miiy be properly classified. The "Special Information** for psr-
sons dying away from home should be given In tisnry instance.
1
i'
t
I
1 1
1
y
Itr
it
I
I
I
A
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i)(ff(> /'VA^^/,iyoLtr4-^ n
290H
Jiegistei'ed J\^o.
S396
i
:X.d-tA,v
Deputy Heaith Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( XX. S. StanDarD )
A
os^
(No.
PLACE OF DEATH: — County of^'o^ -J^vcv ,
r^
(^
'City of ^'Ct'-YV J X/<X.'V
X. C ' C 04)
KX
St
Dist.; bet, and
(IF DEATH OCCURS AVW*^ FROM USUAL I* E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \
IF DEATH OCCURRED IN A HOSPITAL QR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
,"0
'\jn
s I ; \
PERSONAL AND STATISTICAL PARTICULARS
DATH ul- lUKTll
Mntlth)
r-
i >
u
i
iDavi
A<-,H
^
^
}'iii I
Mntll/l^
/It..
f V.Tir)
Pa
HIN<-. 1,K. MAKkll'.n
WIDDWHI) OK DIVORk HI)
iWritt'iu siKJal ili —i^'iiation)
lUKTHPLACK
(State nr Cnnntrv
NAMI-: i»J'
FATn i;k
BIRTmM.ArK
Ol" lAlllKK
(Stati' <i! i'()iiiiti\'
t-»^^
,D
'Xc
V
MAIDKN NAMK
OF MOTIIKK
HlRllll'l.Ail-:
Ol' MOTHHR
(State or Contitrv^
OCCri'ATION j( 0
r>i
Wk.
t
MEDICAL CERTIFICATE OF DEATH
DATK OF DEATH
11 \ A
(Day)
(Mouth)
igo
(Year)
I iliiKKBV CI'RTII'V, That I atteiKle.l (leixasefl from
,<wMX... 0.1 190^ to iD/cA' [h T90H
that I last saw h ahvc 011 w i^o ■
and that death occurred, on the date stated above, at 10
M. The CArSI<: Ol- I)I':aTII was as follows:
s-
Dr RATION )Vt/;.s
CONTRIHUTORV
Mont /is
Davs
Hours
e^
P
Q
6^
y\AX ^^ I
>\jy^<X^
h'f^iif/'if ill Sim /'i a>tiist'(t 07^ ) rm ^
A/,i,if/i>
/hi 1
THK AHOVK STA ri-.n PHRSONAI, I'ARTfCn.ARS AKi: TRl K To TIIH
HHsr oi" Mv:^ KNOW 1,1: IX -.H AM) iu:i,n:i"
(1
(Address
^
DTRATION
(SIGNED)
y't'ij/'s
Mouths
Tqo'i ( Address) l A I
Davs
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent ResidcoK and persons dying away from home.
Former or t 9 ^ IP ''"* ''"'A **
Usual Residence ^ KXA/T^ VXXA; pjarc of Death ?
(TfA
When was disease contracted, ^X
If not at place of death? v
Days
y\A) K,
PI.ACK OF IH RIAI, OR RF;MnVAI,
nATF;of lUkiAL or RF:M0VAI,
*'-t n
T90';
INDICRTAKHR AaJ A.'''V%.X» ^ )a '^ ,
(Ad«
N. B. Every Item of Informntion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dylnft away from home should be given in every instance.
%\
il
i
]>,.,:>'.<] ..f lltiiUll I N'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
t-t:^"^ luvclio REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
2-307
/)ii/c Filed, ly ct<ru-t\.'
0 ^
/r;6>s
Be^Lstcrcd J\^o.
Deputy Hf "hOfllcer
DEPARTMENT ijF PUBLIC HEALTH=City and County of San Francisco
Certificate of Deatb
( tl. S. Stanc»arD )
J? (^ \ ^
PLACE OF DEATH: — County olOajy\j ^ h.<>jy\.^i^!i ^'CxXy of <"''aA^J 0 /VXX.'^^'C ^-<t
wO
NoM l\ac^(Xv./-.^.u y /a^ .^.'.a^
> i
St.;
Dist.; bet.
and
/ ir DEATH oecU«S AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ^
( [/dEATh'oCCURRED in a hospital or INSTITUTION GIVE ITS hlA M E INSTEAD OF STREET AND NUMBER. J
FULL NAME
.QJJJXXXQ^ AXt^'
SIX
PERSONAL AND STATISTICAL PARTICULARS
V1T\
1) \ l!" < 1 1 1! I Kill
\i.j-;
?\\o
' Mmithl
'V
UOi
I Dav
A \ )'<-,u
\'i ari
Fhi
^i\<,i.T" M\KKn:i>
wiix »\\ ii» Ok i)i\( »R('i:ii
iWtit' in -iiciai ill -i(/ iiat i" III
I'.ik iiiiM. xt'i:
' ^talt '■! t '< unit I \'
NAMi: <»1
HA'nn:R
niRTHI'I, \<"H
<)I" lAIIIl-'.K
'Stair lit tNiUiitry
MAIIU.N NAM1-:
<H M()Tin:R
!UKTinM,At'l*,
ni- Mu'l'm'.K
'Stall 111 I'nuiltt \
uocri' \ri()N' ( ^
Nesidrd HI Sau JiiUhi-ni j^_ ^ ) luu
t, \r,.„tfi^
/hn
rim XHOVK STATl'T) PHKSOVAl, J'A KT HI' 1. A K s A K I'. rK! }-: in TIIH
liicsT oi' Mv KN()\vij-;i)«".K AM) Hi;i,n;i-
(Iiifiiiiiirmt
a
yx/y^^Aji ^Lt tr^^^-^>^-a.
I \ililr<sm
IQlI
0 a
O/CX^
vuAJt
(Yt-ar)
MEDICAL CERTIFICATE OF DEATH
DA ri". oi" I)1-;ath
„i,i
(Day)
1 H1';R1:HV C1:KTII'V, That l attend<(l dcceascMl fmni
.-- - I90...~~ to 190 —
that I last saw h ^~— alive on - - - ■■■ I90
fMoiitJi)
and that «Uath occurred, (>ti the dale stated above, at
M. The CATSIC Ol- I)1<:ATII was as follows
<>,J»^r^rsJsU^
o
or RAT ION Years
CONTRIIRTORV
Months
L , 1 v-ju
I^a vs
Hours
Ihn
DURATION )\ a rs ^^ Mj^h ths
(Signed) L^rVcrrcflX) J ■Jj-lv .>...,^.-
'S"
l()f) ( Add ri'ss) "wd U-ft >"\J^
Special information only for Hospitals, Institutl
or Recent Residents, and persons dyiny away from home.
/fours
M.D.
m
Former or . ^
Usual Residence i<^l
L
Wlien was disease contracted,
If not at place of death ?
a^CVOwnrvWu
How lonq at
Place of Death?
ranslents,
Days
nj.ACH OF IHKIAI.J)R KHMnVAI.
a
A\^\XJU^ C>w'Ol»-^» V V
ltAJj:<)f HrRiAl. or KI:M()VAI,
T90
N. B. Kvery item of information .hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may he properly classified. The "Special information" for per-
sons dyin^ away from home should be feiven in s^ery instance.
IM I
' f
i
1.4
w
WRITE PLAINLY WITH UNFADING INK
i5,,:il,l i<( Hr;;!lh
Xu - ^■^a^'S^i liS: 1' Co
I)(f
/. /vW,0^Xuv 1% i^^o^
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
" ' 2398
Registered J\^o,
i^L\ If Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Ta. S. Stan&atO )
J? (!f? \ ^
PLACE OF DEATHt-County oiOOo^ J.Va .^vca..^ e. City of Ooj>^ J;vcv>v^vA^
^^
-KXAxtu, dbchAUA
1 >
St.;
[
c
\
Dist»; bet.
and
"^ ^'-'M, ,,eiiiil DCCinrNCE GIVE FACTS CALLED rOR UNDER "SPECIAL INFORMATION ' \
( '^ ^;;:t:^4'"-^- *^^^' r^f^S^^C;::^;^ - name .NSTEAO of street AND NUMBER. )
)
FULL NAME
ftxlLA.
j\jYy\xLo.r
-0-
PERSONAL AND STATISTICAL PARTICULARS
m-\ > c<>i,«>K \ .
I) All". « »i iiiK rn
AC.!-:
i
I' '
M..iitli
I 0 5V<?,
u
a)ay)
M.mlh
r t
\ t-ari
/),/ 1 >
iW'rittiii <i»ci:il il> --is-MKitii III)
I51KTm'I,Ai"K
(Stiitc or t'ouiiti y
lATin;R
ISIRTMIM.ArK
()i- i"Ariii:K
(Statf ')! *.'ijunt!\
MAIDl'.N NAMH
(»l M()Tin;K
lURTHl'I.ACK
iSt;il( (ir t'<)\uitry)
oriTl'A'lION \
MEDICAL CERTIFICATE OF DEATH
DATH Ol- I»KATH
^Wt
(Nfonth)
(Day)
I go
(Year)
^I ni':Rh:RV C1:RTIFY, That Iattcn<UMl deceased from
190 H to v^r^ 11 190 "V
VcX.
that I last saw h
alive on
T90
and that death occurred, on the date stated above, at
nJ M. The CAI^IC Ol' DlCATII was as follows
. >-> vo^^ x.<x,t <«w
ww^
(K
0
\JXJJ'
sXjy^'
-YVOw.
i\
a^
'UJLCX. ^ ^
Rr i,li<! II! S,ni I I nil, n ,,
) lUI >
yfniltfl'
Pa
Till- MiOVK ST\Ti:!> PKK^oNAI, PA KT MT I,AKS A K K TKfK T( ) TIN-
HKST 01- MV KNoWUl'.IX". J-: AM) lU'.Ml-.F
(Infnnnant \j , Vj . Kd ■ Ul<X>cJ^
(AcMrc
t
0-4KA,toJ^
I )r RAT I ON Years
CoNTRIlUTORV
I) I ■ R A T 1 0 N ^-v^ ) Vrm?
Month Si
Days
Hours
Mouths
(SIGNED)
IC)0
(Address)
uJm
/?<7t'.? Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or -> . ^^ ^ M 1 ^> ♦ "•^ '""A ** » j
Usual Residence! n fluer:MJ-txX<l J I) Place of Deatli ? i Days
Wlicn was disease contracted,
If not at place of deatli ?
i)A'i'i:<)f HiKiAL or ri;m<>vai.
]'I \CK ()I- nrKIAI. OR RKMoVAI.
(A.Mress ^..H k?. My\A.A.^X^<nrV
190
.. B.-Bve.. Iten, of 1n^>..etlo„ .Hou.d be cn.efu,,. ^uppUed AGE «h„u,d be .tated eXACT^^^^^^ .rraHLt'^lo:';;!.!
state CAUSE OF DEATH in plain terms, that it may be properly classlHed. The Special Intormat.on tor p«r
aons dyinft away from home should he 4lven in ©very instance.
i!^
I
I
1»
»
[J
Mi •
I i
WRITE PLAINLY WITH UNFADING INK
!1.,h!!i !
Xo ,; ^•f'S^i; liSll' f')
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
luUv riled, ILlclxrWv i^l
vja
Ee^istered J\^o,
.A>u Deputy Health Officer
DEPARTMENT 6f PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( tl. S. Stan^arD )
PLACE OF DEATH: — County ofOcv^v
. 0^
'.
J ^ K^\^ „ i
( ) n /%^ J (J
City of C/CL/>x^ J /v.<X>-^w^A.A,c-c
^N©.
(IfU.^^t
rt <
n t \CHLclUUi lUulu. ^ St.; — Dist,;bet. — ^"T"" and"—-
~ / I .. JcilAI oretinFNCE GIVE FACTS CALLED FOR UNDER SPECIAL I N rOR M ATIO N" \
( " VXTH"occ*'-r.V,"r„ctpVT*t o%";^n?"<,''r.'"v""s NAME .^st^.o .. s,...t .no ..«sr., ;
vHD
FULL NAME
\XX/y\JULAj
^.1-..U
PERSONAL AND STATISTICAL PARTICULARS
^l X "VN (1)1, or \
1) A 11 111 1.1 K m
iL
M.i'itl)
\^ .v.
y.ai
L
Day
.V,->////>
ai)
Ihi 1 .
sixr.l,!.: MARHI1-;H
\vnHi\vi;i» OK i)i\< •t'l j;i>
i\S'lit«ii) ^'K'ial <!( '.IL- iiali iH)
1 1
\
' Siatf <n 1 "iiuiili _\
N \\\M o|-
lATHl.K
lURlIIPUACK
oi I AlUl-.K
I Statt iir (,'<!imt! \-
MAIDl'.N XAMl.
OJ- MOTHHR
lURTHl'KAt'H
Ol" MOTIIKR
(State or r<i\tiitry)
OiHirATKIN
Resided i)i StDi I'lmnisri}
) V<7 /
yfnillh^
lh>\.
Till-: AHoVi: STATl-I) I'KRSONAl, I'ARTIcr I.A KS ARK TRUK To Till-
HKSr OH MVrtKNoWIJClX'K ANP IJb:iJi:K
[tiif.ninant Cj J<A^AJU\}
Aildrcss
MEDICAL CERTIFICATE OF DEATH
DA 11-; OI' Dl.ATH
t\.
,1L.
(I)av)
I go
(Year)
(Month)
I HI'RI'HV Cl'lRTIFV, That I atteiKled deceased from
iD.^ \b..
190 . tu V^.^^ -l.» 190
that T last saw h-£>U alive on NL.'^:'. 190
and that death occurred, on the date stated above, at
" M. The CAI'SR Ol*' DllATIl was as follows
DTK AT ION )'tars
CONTRIIU'TORV
Months
Da]
'S
I/out s
I )r RATION
(SIGNED)
i0.ot
k.1 K
IC)0
)'rars .^fonihs /hivs //ours
duOuuOiAUuL r.. M . D.
A.ldress) (K , ^K . CK^X k U ll-
(
V w
gP£;QI^L Information only for Hospitals, InstilulJons, Transients,
or Recent Residents, and persons dying away from fiome.
Former or "ow lonq at
Isual Residence Place of Deatli ? Days
When was disease contracted,
If not at place of death?
PLACE OF lU'RlAI. OR RKNfoVAL
DATHof Hi RIAL or RlCMoVAI,
UNimRTAKKR Si SJU\^\JLA^ ^^ (Iw CM^ Pk JV
TOO ■
(Address
N. B.— Every Item of Information ihould b. carefully Applied. AGE should «»« •i-*«i^EXACTLY P"Y«'f'^J,«j;'-;»;'
state CAUSE OF DEATH In plain terms, that it may be properly classified. The -Special information for per-
•on* dying away from homo should be given In svery instance.
\*i
I
t
■p*
}■
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'Ih I- -^-'i
^ its ^*'kr^-
Dfffr Fi/rf/,{j:^:XAy^ ^%
io(r\
REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
-K
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "a. S. StanDarO )
(5^
PLACE OF DEATH:-County of Cy<X^ J/UX^^v^ c^ City of CJ ^C^ 0 ;v<Xorv^A^ c l
and
H
TM n tl\)^ '^ I L 'W^A.A SU DisUbet — —
No* I ^ '^'^ V/V^VV Y V,\ v.. . RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
( '^ r/rE:T°H^OC;u%rEV;N''rHo"s^PrAL o"r Tn^'^u'V^O^^G.VE its name INSTEAD OF STREET AND NUMBER. )
e in)
FULL NAME ^^^
SIX
DAT!-: t »r lUK IH
PERSONAL AND STATISTICAL PARTICULARS
CoI.nK \
K.
u
\
,%\
\' ,!•:
^^
1/,.,,'//.
* ' ai
/',M.
WIIH iW i: 1> t >K 1 >'• .
I Writi in -iiiKi'
.1- I'D
niKTin»nACK
iStatt or Cniitttry*
^
XXMl' t>!
1 A III IK
\ UL
niK'ni PI, ATI-;
<M 1 \ rm.:H
M \IIU:n NAMi:
Ml .M<trn)-:R
lURTHl'I.Atl-:
ni-- M(»-nn:R
(Statf or (.'ountry I
'^''
MEDICAL CERTIFICATE OF DEATH
Month)
J."
(l)av)
(Yf.-ir)
I Jli'kl-IiV CIIRTIIV, riiat I atteiKkMl <leccase«l from
*:" 190
— — — — T90 '
that I last saw h
I (p
— alive on
to
Mirn
,-Ay'W\-'<^ ^ "
Rr-iiiird in Suv /'niih "/"
Mnllfll'
Ditw
\\\V AUOVKSTXTl-Dl'HKSONAl.PAKTUri.AKs AKl-.TKIH To TIN';
IIHST <)1- MV KNn\VI,i;i)<".K AND in.l.il.l-
flnfonuatit ot O.A.>VM W i}^V>v.K.Ck
an<l that fk-alli occiirrtMl, on the «lato stated ahove, at
M. The CArSIC Ol" l>l\A'riI was as foll«nvs:
I )r RATION Ytuiis ^fotii/is Pays
CONTRinrTORV
Hours
I )!' RAT I ON ^ Yiiiys
C ft '
Mouths Pays
(SIGNED^ L<r\.trnaX' 0 ^^.UJ.AiXa ^ •
L ' ' lu- (A. hires.) U'V&^^X^ ^' vv
I fours
M.D.
SPECIAL INFORMATION on'y for Hospitals, Instltuirolfs, Transients,
or Recfnt Residents, and persons d>lng anay from home.
M I fl ^4^ How long at
OvLLa^'^ c Oh Plare of Oeatti ?
^Ol
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death?
Days
Pl.ACKOI- lU'RIAI, OK RI-.MoVAI.
iKT.KK.O[^'^CuUU^Qfn=C&.
DATl'.ot r.i vwi. or KKMOVAI,
T90 1
.\JUX^JUr
q, -^
—"■""'"'"^ TTl ^ A AHF should be stated EXACTLY. PHYSICIANS should
N. B.— Every item o* information should be corefully supplied, ^^"^^^^^/^^^"j.'i^ ^ "Special Information" for p.r-
state C\USE OF DEATH in plain terms, that it may be properly classiticu. i ne op
sons dying away from home should be given in every instance.
I
II
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
R E FER TO BACK OF CERTIFICATE FOR INSTRUCTI0N3
2401
' i ! N'
IW^<\' C,
Dnh' rih'<l,\^<:XjA>^^ Vi
100\
Re^isfercd A"o.
<.^
\
,M , Deputy Health OfTioer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. 5tan^arC» )
PLACE OF DEATH: — County of
4
n.->
^
(5r\
City of O ,<X.'Vyj 0 .Kx\ ,
Tv
(
No.
St.; Dist.;bct. i — i and
VE FACTS CALLED ^OR UNDER SPECIAL INFORMATION" \
TAND NUMBER. /
\
/ ,r oCATs occuP^s AW.Y FROM USUAL RESIDENCE O.vc f-CTs called '^°« ^^^^ ^^ ^-
( IF death occurred in a hospital or INSTITUTION GIVE ITS N A M El N STEAD OF STREE
FULL NAME LCL^U^t
'^l \
PERSONAL AND STATISTICAL PARTICULARS
-s II »!.< »k
-11
It A ri: nf i;iK 1 !l
\< ,1-:
•S\ nth
1>:)%-
1/
/'.n
^ixi.i.i-: MAKKn:i>
\\ 1 III i\\ i:n <m ni\< >i<v i:!»
-U'ti:i!i.>!l)
\\
111 -' , \A
t
MEDICAL CERTIFICATE OF DEATH
I) \ II-, < It i»!'. xrii
(Month)
I
IQO
I War
may)
I IfRRHBV C1':RTIFV, That I altciuUMl <kH L-ascd from
^ ...l. Up'i tn .r\"sX '\^\.Aa,1 _ 190
that I last saw h. alive ('ii ' Ifp '
and that «!eath nccurred, on tlie date stated above, at b 1
M The C MSI': Ol' DIIATII was as follows:
^ ' Kw P . .
lUkTIIPUAOK
(Stat I- nr Cmuit 1 >
XAMl ni
1 \ III l.R
HIK I liri. MK
<)! I All II' H
• Stttl >>1 I'iHltlt! \
M \1IU- N N AMI-
"I MuTllHR
lUk ri!ri,Ari%
<»i M(>i'ni;K
iStatf or Oniuitrv
ovcri'A'rioNf^
L
Cu
S, I
"!
.%
I
,<ru w \.{r^u>v
1^
^
K.
^
/l) II
<Xa- ,
Ki-^idrd III S.n: / ' ,! n
) ,,U-^
M,nltll-
Ihn
THK XHoVKSTATKni-KKSONAl, lM<THMI.AKSAKi:TKrK To THH
ni';sT ni- Mv KNOW 1.1; I >«•.»■: and hkkii-.i-
<W:
V
r^
fA(i<iri-^s ob \J Ow^a.-'-
^
I »r RAT ION }Va^-.?
CONTKIHrToRV
Mouths
Days
Hours
DIR ATION
(SIGNED)
^
u>o
c
/)(/
)'.?
g
(Address) bob UJ^ctixNj
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Instilutlous, 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 ?
Davs
v.A», "*^=r I i*
iM.ACi-: oi- nrkiAL or ri-:movai
TNI > l". R l" A K K R wLtXA-m.
'U
I) \ II' of r.iKiAi. or RKMOVAI,
190
■^ 1^ 1 APP aSniild ha stated EX4CTLY. PHYSICIANS should
!S. B.— Every Item of Information should be cnrafully -PP'-d. ^^^^r;;^;^,'.',,^:^! The •'Special Information" for psr-
atate CAUSE OF DEATH in plain terms, that it may he properly wiassniea. me v
Hon* dylnft away from home should be 4iven in ©very instance.
9 — to
I
9
4
' t-
f
P
,1 .,f 11. iltli I- N
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
<.TTr:^;JU^I'C
7.9(9 H
L^^v^ix^hu Deputy Health Officer
Registered JS^o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
A/^ A I ^"^
Certificate of 2)eatb
( XX. S. Stan^arD )
. City of v) <Xjy\J 0 AJX/y^^^^ ": '
u /
M Mflt ^^iAJrWj 'fc C^^i%A.t 'X' St.; Dist.;bet. ^ and
No. H I U\)- VyW. YV ^W '^'*-|^;^^ ,-_^.., residence g.ve facts called for under -specal information ■ \
( 5^ .V*D;AT°H"oc:u%;1V;N"rHo"s^PyT"At O^R^N ^ ' T U^T^O^N O.VC ^ NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
^1 \
PERSONAL AND STATISTICAL PARTICULARS
0 JL'^'^vo^'U
11
i>\ ri: « >! lUK III
\t .!•:
Lf^-
4-
M 111
I r^
l»a%
/ i-
t-ar)
Hi -
1/ ),'A
\ fa
/hi
si\( ,1,1:, M,\KKn:i)
u inowMn OK i)ivnKrj:i>
' \\ I iti ill -iK'ial ill -i;/)!;ili'iMt
lUK!" in-i, \c]-:
(stall I'l (.'"lUiitiN
\ \M1. « »1
I A III IK
lUK IHl'l. AtK
01 I \ i'm-:K
^t itt lit ^^n^!tl v
M MDi: N N \M1',
«>1 Mnl'iniK
I'.iK inri.AOK
Ml M<)rm-:K
( s(atr or i'muiti \i
nOCt TATION
MEDICAL CERTIFICATE OF DEATH
DATI-: 01 Dl-.A I'll
( Month)
(Day)
(Year)
I in':kl':HV CI'.KTII'V, That I aai-niUd «Ui-<.asc«l from
to W 'CX I'l Tip H
) iiii
.1/.. /////■
/).;
Tin- XHoVKSTATHI.PKKSMNAI.l-AKTirrUAKS NRK TKIK To TIlH
ni:sT oi- MY kno\vi,i:ik;k ani) lu-.i.n-.i-
! ■ ' ■
that Ilast saw h ■• alive oil ' ' 19° •
aiiil that (k-ath nrrurre.l, on the .late <tatc«l above, at ^' ■■ 0
M The C MSI-; Ol' Dl^ATII was as follows:
<0-V.Nw'
^'wCIa.aJC-1
i.. ,»„ >„ »■
Dl' RAT KIN
)'('ars
Monl/is
»LYV>.ArsJCA^<
Pays Hours
Xh«<i\Ui-<ow
nr RATION
(SIGNED)
Ytars
C.C^c
Afoiilfis
Da vs
I {ours
M.D.
KjO
(A<l.lress)lOl I) a-AvM\i<ia' 11.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from florae.
Former or ,, - C H ^ ^ ^ . ' ' Sf 'T/..7 H n
Usual Residence 1 \ 5 cj - ^<s^^ vo . piarc of Death ? U Days
Wlien was disease contracted.
If not at place of deatfi ?
DATHuf H! RIAL or KKMOVAI,
^K ^ " ' I go I
1*I,ACK 01- niKIAI, OK KKMoVAI.
,.0, — nui \jfTu^.cL.^A-^, - ^
N. B.-
"~~— "— ^ TT KC.¥ should be stated EXACTLY. PHYSICIANS should
-Bvery Item n? information .hould be coretully HuppI.ed ^^llr'lll^r^^^^ The "Special information- for pT-
state CAUSE OF DEATH in plain terms, that it may be properly Uass.tie
son. dyinft away from home nhould be l^iven In every inst^ince.
^>
r)
^
^
I %
iiii
It
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)
lOOH
Picc^isfct'cd JS^o.
^403
DeDu
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 5)eatb
PLACE OF DE ATH : — County of
aa^\.
*> rs
\
No.
I ? t\\
\
\
City of ''
■> \^ a ^^.
^'V\
St.;
Dist • bet ^^^
lON-
R.
)
FULL NAME
U
.m MX
PERSONAL AND STATISTICAL PARTICULARS
LX
I) \\\. < >I I'.iK IH
A « . !•:
Mi, nth ' i
1 n Y
wtixiui: n mk i)i\»»Ki HI)
iWritt in MKiiil ih -ii.'iiati(»n)
iDnv)
M ,uffi'
■»'. al
/'(/I
WEDICAL CERTIFICATE OF DEATH
DATK <)1- 1)1;ATH , \
(Month)
(Day) (Ytar)
I HRR1;BV Cl'RTII-V, That I atten<k'.l fU-rcascd from
^ -y \'^ up'; t.» . W/ci^ \% T90H
that I last saw h -S-^- alive on wcL 190^
an.l that <Uath orcurred, «>ii the date stated above, at ^ •'^ ^
lUK I'Mj'i.xri:
(Stati 1)1 r. Hint I v
NAMl<; Ol"
I A'rni:K
BlRTHI'I.AtK
OP I AlllHK
(State or Coiinti V
maii>i:n' NAMi;
oi" MO rut: H
HiK rm'i.Ari-:
oi' MoTm:K
(State or i'oiinti v
m 0
<xaK^^ ^^ '
iO
()(.A'ri'A rioN
r 1
M. The CArSI-: Ol- Dl'iATII was as follows
nr RAT ION >Var.9
CONTRllU'TORV
Months
Days
/lours
DIRATION
(SIGNED)
L-l u.
Vi-ars Months
Piu
•s
Hours
190 i
/NX<iWlo.- . ._ M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
y
KfsKtfif in Sati I'lami^rn
) < 1! •
Mnillh'
Ihn
■lM,KAm)VKSTATHIM.KRS<,XAI PAin-UMM XRSAKKTKIH TO
r 1 1 H
(Info; tnatit
n
Oc
(AddrcHS
Xj\> kLaj^
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Davs
n.ACK Ol- BIRIALOK KHMoVAI,
l)\l'i;o!' liiKtAi- or RKMOVAI,
(AiM
less
1X0^^
(y>Xv^iAA^:>A^ 11
,. . The should be stated EXACTLY. PHYSICIANS should
N. B.— Every Item of Information should be CHrefulIy -PP^'-^- JtofXclss.mcd. The ^Special Information" for p.r-
state CAUSE OF DEATH In plain terms, that .t maj »»e P^^P^"^ ^
son. dying away from home should be given .n evry Instance.
Honr.l • Ihuth
WRITE PLAINLY W.TH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATt FOR INSTRUCTIONS
2404
r^-X.-ns^vc.
100 \
Ee^istercd JS^o^
n
1 1
DEPARTMENT W PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
( H. S. StanDarD )
vor.
PLACE OF DEATH: -County of'^^aav .lv<V>vc^4C. City of
Q/CX^^ 0 AXX/'r
1^
\j
St.; H
lli
FULL NAME
)
jttW\_x.^v \^<x^\^
^ I , \
PERSONAL AND STATISTICAL PARTICULARS
M\l<xU
I
^
DAT!. ' <l 1.1 Kill
\r.]'.
L
HI
l»;is'
\',',if'l
all
/),,!
MEDICAL CERTIFICATE OF DEATH
DAl'K nl- DHATH h ^
(iniv>
(Year)
(Month)
I in-;ki:rA- Cl-UTll-V, That naUiKUa .Uccase.l frmn
.. la up H
f
0
■-IM I.i MAKHIl'l*
Ui ] )i iU }• I) « >R 1>'N'' ''•■' t" '•
\\ nti in -I >i-i;tl i|( ^i^' inl ^"'i i
I
ink rm'i. xoj"
-,t;lt( . «! ' I .imt I \
\ \M 1 « »:
1 AIM I'K
lUK niri, \v'K
111 ! \rm:K
si itf ■ >! i'ii>l!ltr\'
MAtT>TN NAMl*.
oi M()rni-;K
lUKini'LAri",
<»l- MO'nil-.K
(Siatf or iNiuntrv
J!: \
fl \
190'! tn
that I laM ^aw li .• alive- o„ V„ : ■ I up^ ■
aiul that ac-ath -HTurrcl, nti the date' statc-.l ahove, at o .LU
M. The- CAT SIC Ol' Dl'lATll was as follows:
DT RAT I ON JV<7r.s
CoNTklinTORV
M on tin
Days
flours
1Q\
XX uo^j^ ^
^Yl u ...
DIR \TIoN >''"^ ^ JA>;///'^ ,
/?<71',?
(Signed) ^
..'a. <
\
l^ ),ct
KjO
fA.hlrt'Ss) lib
V
Hours
M.D.
5,
\t
SPECIAL INFORMATION on'v for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
(HATI'ATIOnCJM ,
Ri-.nh-.f HI Sail I'l <■'" '''■"
Mnllfh-
/I-/'
lU-STol- MV KNOW 1,1. IX. 1-. AM) LUJll
(Info.inatU O. 1 ;.(; i > ' ^
Former or
Usual Residence
When Has disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Davs
I'l.ACH <>l- liTKlAI, OK Hl.MoVAl
crl
-Mr '-
I
rsDi-.K rAKi:K
( AtUlrt'ss
l)\ri,..: lirinxi. <jr R l-'.Mc >\'AI,
y,rt
t.t
190
u -Cu >aJL >
. , . ^ stated EXACTLY. PHYSICIAfNS should
f i„form»tion should be carefully supplied. ;'•••;""' .fj^j. The "Special Information" for p«P-
OF DEATH in plain terms, that it may be properly uassm
:r'iH^; »-;; w,:™'; ;hou.j .. .!«« ,« ...r, <„...««
I
I
\
m
WR.re PUA.NLV W,TH UNrAD.NG .NK-TH.S .S A PERMANENT RECORD
,111, ,'tl) I ><»• I'- - M.--^: - •
REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JS'o.
O
405
dwVU-Ui
19 fA
cLw^ cUakj Deputy Health Officer
DEPARTMENTOF PUBLIC HEALTH-City and County of San Francisco
Cettiffcate of Death
( "CI. 5. StanDarD )
PLACE OF DEATH: — County of
No. ^^^
et
City of
' .... •.■-bCO
^-N^
)
V n ' A ^ 1 C ' St.; UlSt., ^^* "^^ under "special INFORMATION" N
V IF DEATH OCCURRED IN A HOSPITAL OR I ^ ^
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
--lA
/'
r* ti,< »k
n^
DATl". <'t lUKlll
L.
I
iMonllO
\(,i.:
"7 ^
'l):iv
M.mtli*
'I'l al)
/)rT )•
MEDICAL CERTIFICATE OF DEATH
■ (Month) '^'■■'^'\ -
^ I mUU-HV CliKTlFV, That I attenacd deceased from
— to - ■
(Year)
— 190
sINi.i.l- M.\RHIKI>
W inoNVl-'.l) <»K l)l\ < >R« l-.l)
I \\ litt in -ocial (lt>.i'^Miatii>n)
n -
A
that I last saw h —- alive on
and that death occurred, ...1 the date stated above, at
[ siv OF i)I':at
-IQO
-igo
M The C\lJ^lv OF DI^ATIl %vas as follows
A,^r>\.
lUKTmM.AOl',
'St;itc or <'iiunti V
I- All! I-,R
1
J M
n
I )r RATION >"^'^"
CONTRUUTORV
Months
Days
luk riii'i.Ac K
01 I Arni.K
(Stati ii! Oo\intry)
M\1I)»"N NAM1-, /'^
<)1' MOTHKK I
1UKTHI'I,ACK
oi- M(>rni-".K
'State 111 Cutintry)
la
\
Years Months
nd ^ i\ n
Dl-RATiON
(SIGNED) X'. to. llv^^^';'
— i...,-^DiuiaxiftN only tor Hospital?,
Davs
Hours
Hours
M.D.
"Special Information only torHosM institutions, Transients,
or Rerent Residents, and persons d>ing d«ay from liome.
( K
) , ,11
yr.nit/n
n.rs
HUST OlL^tV KNOWl.l-IX.h AM) i.«.'.
vJ /<xA'N^^>-^'^
Former or
Usual Residence
Wtjen was disease contracted.
If not at place of deatti?
How long at
Plaf e of Deatli ?
Days
n.ACK OI- HVRIAI.DK RKMOVAI.
!> i
■Aa<lrt"^H T^v
)t
i> Lo.
DA ri: of UiKiAi. or RHMUVAI,
u
190
ci
lam
1 — — ^■^—n 11^^^— ^^^'^^"^"'^ J pvACTLY PHYSICIANS should
I
I
B
«<:
m
i
WR.ximv W.TH UNrAD.NO .NK-TH.S .S A P.BMAN.NT RECORD
*" TO BACK OP CERTlFICATeFORINST
,i,\ .,f llralth— t- N'-'
.. *-tJ»^n^*^''
190 ^i
h Officer
WKFER TO BACK
Re^Lstcred JS^'o,
ST RUCTIONS
2406
Dale /•V/c'/.i'^tfrtx'v 1%
Xo^'-viXt'VKi Deputy cc C Vo/i
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( ■U. S. Stan&atS )
, ^ n ^ v*^ \ - ■ City of 0<^^. i ;vo . ,
PLACE OF DEATH:— County of ^-O. ,v .
No. 5vDbb M I L
St.; I ^'"•' °^_. .„. „„„ti "SflCI.L INfO.M.T.ON ■■
t .-.
)
J Ins - St.; I L>ist.;Dei. .„: ";I".„c..l ,Nro.M.T,o«- ^
,'0
FULL NAME
kt' '^' '■ '. (jX-ctVcUj <xm.<i'
U
+
PERSONAL AND STATISTICAL PARTICULARS
« «
SKX
DATK «>I lUK III
ll:
I Ml .111
A<,H
)■,.;.
Dav)
M ,„i/,>
I
\\:i\
Ihivs
J go
(Year)
MEDICAL CERTIFICATE OF DEATH
I>ATH nl- DHATH iM i
(Month) '^^'^^-^
I m.'KI-HV CHRTIFV. That 1 aUencK-a deceased from
to ^^ -(^ "^'^■
190
slS(.l,i:, MAKKIi:!*
Wiit.in -•MUtl (U^ivrnatiiiiu
' 1
NAMK ni
FATHJCR
BIRTH ri,\iK
Ol" FAIUKK
ISlati' or 0(»\uiti y
HIKTHPI,ACK
Ol" MoTHKK
(State or Co\nitr>
^
MoTllKK J(i ^K i ,
T90
that T last saw h ••■ alive on w.'^>^ ' ' ^^p
and that death occttrred, on the date stated above, at
" M. The CArSI- t)l' DI-ATH was as follows:
G^AX'^>-<xt^^-«^^-^ ■■ ^ *-^*^^^
DIR.XTION >Var5
CONTRIIUTORV
I)IR.\TI()N >V«7;'5
On
.}/on//is
Days
.^TYy^^^y^^--^
I'
Pays
I'CX. » v-i-..
Hours
Hours
M.D.
rA.l.lr.^sliO^S d^ujiiK) d
(SIGNED)
C/Cl: i l^ H)0 — . ,
■ c;pECIAL INFORMATION only tor Hospitals. Institutions. Transients,
or Rerenl Residents, and persons dying av^ay from home.
ore I TAT ION
)', III .
Mnlllh'
/).n
(Iiiformntit
k-oo
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place ol Death ?
Days
ri.ACK Ol- lURIAI. UK KKMOVAI,
to
xs* "o^jJ^kju^ ^t.
INDKRTA'^l"
jkjlXXm.
I)ATi:oi HiKlAl- or RKMOVAI,
iqJtiXi^
^ ^'''''"^'''^ ' III III PHYSICIANS should
/
i<
w
RITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
HEFER TO n ^..^.cr^rr FOR .N3TRUCT.0NS
190\
h Officer
Jicaistcrcd •A''o.
240?
DEPARTMENT^OF'pilBLlC HEA1JH=C^^ and County of San Francisco
Cevtificate of 2)catb
<0 r. >-v^ 3 YO. >%/CA,s City of O O^-v 0 .
PLACE OF DEATH: — County of^ <X>^ J-^<^ ^^
LVve
"^l.X
PERSONAL AND STATISTICAL PARTICULARS
1 (
I
iixii-: of r.iKTn
.L,k J .
M.infhi
MEDICAL CERTIFICATE OF DEATH
DAT1-: <>I- 5>1'.A1II
ly^
\' .1-
1^
),„.)
I Dav
M.itilli
V> ai
/',
-^IN^.1,F. MARK IF I'
\vn)(>\vi.:i) <»K na "K^hi*
(Writf in -.K-ial .1. -uMnaion)
i
J HiM^FBV CKKTIFV. That 1 attended .Iccvascd from
f, Wet IH icp'i
190 . tn ^ '5-^ ^
that Ilast saw h .... alive on ^ -^ >
,„a that death occnrred. o„ the date stated above, at
•" M. The CAISI- OF IM-ATII was as follows:
( ■»
i
niKTHPLACK.
(State nr Count! v
NAMH «»l
I A rilKR
BlRTHl'I.ArK
iW I AinKR
(State or Cotinti y
M MI»»:N N'AMl-.
<»1 MoTin-.R
lURTIll'LACK
(.1- MoTHHR
(State or C<nuJtry'
oiClPATION
Oa.r\j O.^Ow^^<^^*-
CONTKllUTORV
Months IH Pays Hours
DIRATION
y lit IS
Jfot/Z/is
Davs
(SIGNED) lU_^cLWlm^'.----
IH ,00^^ (An,,n.ss)MvVulUl
Hours
M.D.
Special information only for Hospitals, Institutions. Transients,
or Refent Residents, and persons dying away from home.
) 'lUI 1
M.nitif
I'^l
:.», fXRinri NRS AKi: TRl K l«> I HI.
IHST t>l' MY KNOWI.I.IH.K AM) lU.Mi-t
(Infill ma Jit
JX^
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli ?
How lonq at
Place of Death ?
Days
I'J ACK «)!• nrRIAI. OR RHMoVAi.
(0
\.«-^
SL
DA'llKof HrRlAl- or RI''Mo\'AI,
0
/\w
tmm
(AcUlresH M I UU • f \^ ^^ * ^ fXACTLY PHYSICIANS should
l!
I
1
I
iL«
w
RITE PLAINLY WITH UNFADING INK
I'-M
,,1 ,,f !i.-:n. r So. '^ ^5^^^' n^c!' c.
lutlr /'V/r^/.ljctxjrU^ ll
2.9(^H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT W PUBLIC HEALTH=City and County of San Francisco
Cevtificate of 2)eatb
^
(^
( Ta. S. StanOarP )
PLACE OF DEATH: -County of 6 C^^ ^ ^^Cu>x^^^Gty of O Cv^ 0 A.a^v^^^
% ^ i if.
a,s ■ 1 . •■> ' St.; ^ Dist.; bet. J Crl4.Cm^ andyO<?^-
rNSTITUTION Give ITS NAME INSTEAD OF STREET .ND NUMBER. J
(
IF DEATH OCCURS AWAV FROM USUAL RE!
IF DEATH OCCURRED IN A HOSPITAL OR
r- /
t I , 1^
%
FULL NAME
wC^
X^^C
si:x
I) Nil ( >i r.ik 111
PERSONAL AND STATISTICAL PARTICULARS
U
Ix
I
wA_
/I5'i
A<1K
Month
5'
( l);iV
M.itiUl:
\ < ar
/>,n
siNc.i.i'. M\kun:i)
lU'iitt in ^iiiia! dt^ii.' rial ii ui)
niKTinM.A'i:
(stall f»r Oouuti \
MEDICAL CERTIFICATE OF DEATH
DA'II-; «)I ni'.ATH
(Month)
(I)av
IQO '•
(Vtar)
I lIlCRiUiV CICRTIFV, That I aUeiuk'.l <k-rcascMl from
lilct ' \ icpH to iQ/^ a 190H
[901 to xy/ww y i. I90
that 1 last saw h • alive on V»^^ '^ I90
a«i«l that death occiirreil, on the .hite stated ahrn'e, at
M The CMSl-; Ol" I»1';A rn was as follows
' ' u ■ '
,\_SL W I --■
W
C '
v^A-,Lix. » wd.
NAM1-: ol-
FAT II J K
niK rin'i.Ai"K
oi' 1 \riii".K
ISlatr ()! i.'<iulltl V
ma!ih:n nami-; a
(U- MO Tin: K
HlK'l'mM.AC'l-:
()!■ Mol'Ul'.K
I "^latf i>r t'otiiitry'l
ocrrrATiDN (^XP
DT RATION ^ >'«''W
CONTRUH'TORN
I >r RAT ION 3^ Yean
I/oins
- f
(SIGNED)
nrrg
Months
IhlVS
^^\A
Hours
M.D.
190 i
( Address) T 00 (fb-OA>tUlC>V dt
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
cx/vvxL
Rr.-idfii in San /'iitninrn - ! '<"
*■ Miuifhs - l'hi\
TUl- \noVK ST\TJ-I) I'KKSONA!, PA KTUT I , AKS .\RK TKl H To TIIH
linST 01 MV KNOWIJ'.IX'.K AND lU l.Il'.K
(ItifoMnant
Former or
Usual Residence
When was disease contracted.
If not at place of deatfi ?
How lonq at
Place of Oeatli?
Days
PI^CK Ol' lURIAI. OK RI:M<»VA1,
l)\ri of HrKi.A!. or ki:mo\'ai.
U^t V\ too'
(AddresM
n B —Every Iten, of Informntlon should be carefully supplied. AGE should ^•\^^-±^''^^2'^^^ \ . ^"""^ nLt^'lf n^I.**
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information for psr-
sons dying away from home should be given in svory Instance.
iv
i
1 ti
I
WR.TE PLA.NLV WITH UNFADING .NK-TH.S IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
li)0\
Re^islcrcd J\''o,
2409
1>v^j1wu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County of O-CLA-v v. /VU. >\ - A.ity oi
(Ho. ^^^
^u^^x^
LLvTV^vLlvCti- St
Dist«* bet* ^^^
)
V IF DEATH OCCUhRtD IN A HOSPITAL
m
FULL NAME
x^LcfXj Ocrw-koX-a
PERSONAL AND STATISTICAL PARTICULARS
^
DAil. <>l HIKTII
A<'.H
I I 5 v.,
siNCl,!'., MAKKIKU.
WIDOW i;i) OR IMVORi. i-:i)
(Writtin social (It-i^'natiutO
iDavi
M.nith^
W-aXi
/hn.
MEDICAL CERTIFICATE OF DEATH
DATK <>1 DKA'l'H ,i^
i
(Moiitli)
i I
(Dav)
/(?o
IVt-arl
I lll-KiaiV C1:rT1FV, That I atUu.kMl .k-ccasca from
Ax\ :- 1'^ 190H to i)^ ^^ 190 H
niKTin'i.xoi-:
(Statf or (,'ouiUi V
NAMl-: OI-
lA THKR
niRTHl'I.AOl-:
OI- I AlIllvR
(Stal« or I'onntrv
MAini'.N NAMI-:
(»l' MorilHK
HIHTIiri.AfK
OI- Morin':R
(Slate or Country^
0
that I last saw h ^ ' ^ -alive on
diet
T()0
aii.l that .loath occurred, on the .late stated above, at
M, The CMS!': OV UICATII was as follows
Kj \ O
or RAT I ON Vrars
CONTRMU roRV
Months
Days
Hours
,'y ' 1
O.
Df RAT ION
(SIG
Years
NED) Id. WP. Cc.
Months
Days
Hours
M.D.
Uct
iqo
(
Addns'.) \Xj^'
W-v.A^ >'V^> v^^^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying a*ay from liome.
OiClTAiloN
h'fsiileii h' Sill! I laihisf'i)
)rii,
Months
/hn.
run AHOVK STATKU »'HKSONAI. rARTirr KA RS ARK TRIK TO
UKST Ol-
TIIK
: ^jv KNO\vi,i:i)<'.K AND HHUi:!
^
( Xddri-ss
■\K-ii.L
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of De^th?
Days
PI \CK 01 mRI.\l, OR RKMoVAI.
cJk, J^'wN
DAXHof Ht HIAI. or RKMOVAI,
U/C^t U 190 A
l-NimRTAKKR ^JUILUX.^'^ 0^
-I
(Aclilrt«<s
N. B.— Bv.ry l..m ol t„lor„,a.lo« .hould be cr.Su.ly -"PP"«J; *°p^.Hj7l«^m'i?''Thr*8p«U< InZllfJnon-Vr pllr-
•tatc CAUSE OF DEATH In plain term., that it may be propeny ..
.on. dylnt »w.y from homo .hnuld be »Iv.n in .v.ry In.tanc
ii
B 1
H
I
HcMtn
.,f H* lUh !■' N
7R,Te PUA.NLV WITH UNrAD.NG .NK-TH.S .S A PERMANENT RECORD
-„.„ .^ ■.... nr CERTIFICATE FOR IN5TRUCTION3
J^4lo
*" j"^
;3u;U.'^i'''
Be^istcrcd J^'o.
Lv^va1-v>. Deputy Health Officer ^
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
Ccutificatc of IDeatb
i XX. S. StanDnr^ )
PLACE OF DEATH: — County of
i^^» ^ . . ...,.v t-BftM us
jLla^
A
1
City of ^-^CC
k
,a.^ V\
St.
Dist.; bet.
— and
)
V ir DEATH OCCUBRtD IN A HOSPITAL wn ^ "^ D A
FULL NAME
4
-^
jiKX
PERSONAL AND STATISTICAL PARTICULARS
n^
DATi: or 1'. IK I'll
i
flA^
I M..iUh>
\<.K
bl
^IXi'.l.l", MARKIKI).
WIDtiWKI) •>»< ni\ 'ikrHI)
iWritt ill -..iKti (I'-U'iKinon)
lUHTiiri. \t'i-:
H
lie
Day
M.,tifh
fVear)
MEDICAL CERTIFICATE OF DEATH
DATI'. oi" i)i;ath II ,
(Vr:ii
/'</
(Month) "»•'>•'
I IIHKlCnV Cl.RTlFV. That I alten.k-.l .UcxascMl fmm
t,i ..^——r-r-rrr-r-:
Itp
rep
n
i
N XM 1- ' >|
! Alll I.K
luR'nnM.ArK
(u 1 A in »•",!<
'^la1l Dt I'nimti V
MMKI.N N\M1-
nl MnTHl-.K
HlK'rni'!,A(.l-,
«)i- M(>'rni';K
(Statf or ("ouiitryi
V
0
that 1 last saw h -.7— alive on — ' ^^
.,„d that <U'atli occnrrcd. nn tin- .laU- .tatcl above, at ^-
* M. The CAISIC <)1- 1)I:ATII was as follows:
^- .^C
DT RAT I ON >V<?r.9
CoN'l'Hir.l TORY
Months
Days
Hours
<X/^^^^^
jL >AV>^AC >V^
(^
nruATioN
Yt-ars
(SIGNED) ^^v^^ U). Oi"-"^
Ar,>f/i/>s /^ays
Hours
M.D.
i'^
T{)f>
ijuxtiift
M,<n(h>
n,ty.
liKST Ol- MV KNC>Wl,i;i)l-H AMI lll-.I.U.l
^)(K<
(Address
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Rerent Residents, and persons dying away from home.
Former ©r \ u i /s ^ n Jt 1 , ( 1 -
Usual Residence \H 10 AKMKA.
Wlien m% disease contracted,
If not at place of death ? ^
How lonfl at
Place of Death ?
Days
!•! \CK OF lUKIAL OK KHMoVAI,
•LACK Ol- 1
DA 11/, of UiKiAl. Ol KI'.MOVAI,
^,
\Hlb- tXL UwV ^
INDKRTAKKH J /O.-Vvt'^nJL^
\,
i^B^^^w— ^^■•^■"■^■^■'"■"■■■"^■'^"'^"'^"'""^"~'^'^""*~"'"'^'"'^^^ w I 1 K t ted EXACTLY PHYSICIANS should
„. B— Bv.ry U.m o. ,„W,n...on .houM -;■-;•';'-'; ^^^^'^^'l ^1Z'^yZ»'^'>''^" The "Spec... lnW,n..i„„" .or p.r-
■tate CAUSE OF DEATH In plain tcpm.. that it may ™ ^ '
«n, dyint away «rom hom. .hould be »lv.n .n .v.ry In.t.nc
I
H
i
i
i
If i
RITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO RACK OF CERTIFICATE FOR INSTRUCTIONS
jUifr /'V/r^/xlcttrWv \%
lOO'i
Jlcdisfet'ed J^o^
f'-^^J — L-
Dep
DEPARTMENT (JP PUBLIC HEALTH
=City and County of San Francisco
No. ^5(]\v, ■
Ccvtificate of 2)eatb
J <n
City of O XX^.-u 0 /V<V^N
I
PLACE OF DEATH: — County of O^^a.
St.;
>ID
NS
)
«Jl«i ' *' ' ' _ ..^nra ""SPECIAL INFORMATION ' ' \
FULL NAME^ ^^"^^^
•-1 \
PERSONAL AND STATISTICAL PARTICULARS
^l
all
.IkiXt
li A 1 1 , « i! r.i K I II
A«.i';
Mi.tUli
55
\ .
Dayl
M ,>iiii'
1 Vt-av
/),/!-
MEDICAL CERTIFICATE OF DEATH
DATK nl' Dl'.ATH
1 L
iDav^
(Year)
I mU<l'BV CURTIFV, That niUonacl accvascl from
S1N<M,K MAKKIKU.
Wn>t»\Vi:i» OK 1»|\<»K* l-,I>
■\\ 1 w in -...rial dr^irnat i. >!i >
ri
I stall- oi t'ontitl V
N \M1 <•!■
1 \ III l.K
H1K riU'hAil'.
(»i 1 \ rm-.K
MAI1»»-.N NXMl
()1 MoTlll'". K
.c>^cy
\ \
<ik\jxx)
4 .
.K;.^^ i 190H to ^^ n T90H
' V „ ^'^1 •• 190''
that I last saw h ahvc o„ v. . . ^
,„a that .U-ath uccurrc.l. o„ the .late state.l ah.>ve, at
M The CAISI- OV DllATll %vas as folUms:
I )r RAT ION I ^''■'^'
CONTUIIUTOKV
I Jours
^xLo. . ^
^\. >
w
)V<,r.« J/,.;////H 10 /?^n'.s- Ifoius
lUKTinM.AeH
I Stat. Ill i'lninli N
DI'RATION
(SIGNED) V^^^^^ kO^C^a, .x.
lij.ct) \'l ion H (A.Mress)
M.D.
. NfVUA^A^>x .)i
SPECIAL INFORMATION only for Hospitals, InsUlutlons. Transients,
or Rerent Residents, and persons dying away froni home.
^r,>^^f/^'
/>,/
^^^^^in^W^^
Former or
Usual Residence
When was disease contracted,
If not at place of death?
Now lonq at
Place of Death ?
Days
(liifiitmatit
i!i.ACH in- nri^iAU or kkmiaai
!t\'n.'>S Hi HIAI. or Kr.MoVAI,
Pl^XCH in- »i H'^'
QfU^
^U^>A.
'. t "
WM
::■„'.'-""." °. .«" Hon,. :HouM b. .<v.n > -n.
itaitce*
I
I
I
WRITE PLAINLY WITH UNFADING INK
,.,] ..f 11. '.Uli I No I- ' "'••'^•*--/ II - --
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTiriCATE FOR INSTRUCTI0N9
241^
DEPARTMENT OF PUBLIC HEAlJlWity and County of San Francisco
Cevtificate of 2)eatb
( -U. 5. StanDarO )
PLACE OF DEATH : - County of ^ .^CV^ >J ^^^ - v . C.ty
(U
l1
St'
c "n'+.iv»f o ^^ y\! and v; A. »
■n ^ Q \ K /-> ^ St4 UlST., DCI. „^.„rR "SPECIAL INFORMATION- A
)
FULL NAME
,cCtKinj^x.i 0)u
1 1 '
PERSONAL AND STATISTICAL PARTICULARS
COI.oR \
-i:\ ^^"N,
1
*
n.Mi", <»!•
liiK in
"1
-Month*
-
)'r,lt
i
%
WlDoWKD nk DiViiH'in
W ; !!'^ in v...m:>' M.-U' ii:it ■■ .n i
11
.L>V<
1/,,,'//
5.(^
( V, :ii
I hi \
I go
MEDICAL CERTIFICATE OF DEATH
DATK uF 1)1- ATH ^\ , . ,,
\j^ ^ ' - - ^
;:,■ ,,x (Davl (Year)
(Month) •
1 ni'UKBV CURTIFV, ThaM atten.Wa dcccasea from
to t^ Cfc 11. TOO H
A
ICJO
lUKTinM.AfK
( Stntf or t'onntry
NAMl" <»1*
i A IH ):k
BIKTHIM.AtH
<)1- lArill'.K
•Stall or i'ounti V
MAIDI'N NAMI-:
Of. MuTIIKK
lUKTmM.ACH
()!.• MnTllKR
(Mati or I'nuntryl
I)
3
^•'
190
that 1 last saw h alive on ^ " ^'^
ana that .U-ath orcurre.l, on the .lat. statc.l above, at ^
M. The CAlSIv Ol- Dl'ATH was as follows:
(J
0
CU>^|
\
I vJ
\ 1
I I ♦
DIR A rioN
) 'ears
Months />'n'?
.ir,)?i///s IH A7V.S*
/fonts
Hours
M.D.
5V.r/. II ■^/'"■•'^'^ '
/),/!
OCOri'ATION
Kfsiiifd n, S,ni r>>nni>^.>
BKHT «»l- MV KNOWM.IX'^ ^^'' "^^ ^
(Infurmaiil
IaxI
DIRATION >^1'''^
(SIGNED) V\. ^ ' ' '^ 'M
W/ct> !t Too't (A.hlri-^M ^
■ SPECIAL INFORMATION «nlv for Hospitals, Institutions. Transients,
or Recent Residents, and persons dying a**a> from liome.
= 1
0.0 K
Former or
Usual Residence
When was disease contracted,
If not at place of deatti?
How lonq at
Place of Oeatli ?
Days
\,l,lriss 61a.
iXXAX. ut.
PKACH «)1- niKIAI. OK HHMi»VAI,
iJAlllKt HiKiAl, or KI-:M«)V\I,
'-'/cXj ' \ T90'
— ^^^^^^i— 1^— — — *— *'^'^'^***^*'^^'''^^*^ ^ I FXACTLY PHYSICIANS should
•tnte CAUSE i^r »''^'^ •" »* u u- aSv.h In avsry instance,
•on* dying -way from home .hould be given In .very
i
I'
ii
I
WRITE PLAINLY WITH UNFADING INK
I90'\
THIS IS A PERMANENT RECORD
BCFER TO n»r.K Of CERTIFICATE TOR INSTRUCTIONS
Meo'Lstcred ^'^o. -w'iXO
♦»i
I'JJ
DEPARliENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
^ "d. 5. StanDarD
Q^
PLACE OF DEATH: — County of Ca^^ o \
City of '^<^^ OX.CL *■
V
\ / ir DEATH or--
\ V IF DEATH
St.* — Dist.;bct.
and
)
OQpURREP IN A HOSf 1 I""- w y
FULL NAME
AXXTTAJ . . HAJ"*
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
\a£x
a
I
i>\ri: nf- lUK rii
I Month
l):i\
A<",K
) , ,;»
M.'iitli
(Vear)
/'..
DATH *>H ni'.ATll | \
(MontiO
(Day)
lYear'>
<IN(.1,H MARUU-.n
WinoWKD OK l)lV<.K.l-,!>
,\\n!f iti vo.ial ihslv"ali.>ti >
lUKTiirt.AOi-:
i state or rDunli y
1 ATlll-.R
HIK rUIM.ACl".
ni-- 1 AruKK
(rttatf or Oounti v
^
XXXXA
mo
I HFRFHY CKRTIFV, Tlud I atten.lca cleccased from
that I last saw h. ahvc on ^ -
a„a that .k-ath occurre.l. <.-t the .late .tate.l above, at 1
M. The CAi:SI< 01^ DHATll was as Mlnws:
DIRATION Yeats
CONTRllU TORY
Motiths
Day
Hours
[}K\.Qm yocrv
U;
MAIDJ'.N NAMJ:
OI- MOTIIKK
J!
lUK rm'J.ACK
01* MnTHlCK
(St:tti- or fouiitryl
DIRATION
(SIGNED)
\Dcfc
Month:
/yavs
3. ^. Lr^^i-o. .
//ours
M.D.
T90
(
A «ia ress)JXi221±ili
"<5PECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Refent Residents, and persons dyinq a^ay from home.
oCOtl'AIION
R^sidfii III Siiv I mil' '"'•'
Mnllth-
I his.
Tin-:
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatti?
Now lonq at
place of Death?
Days
(Informant
CLL^aa.!"
V\ \CK «)!• lUKlAI, OK KKM«»VAI,
l>Ari%<>f HTKiAi, or RKMOVAI,
^, * T9O
n
^"^'^'''^'^^ .^ . * ^ FVACTLY. PHYSICIANS should
state CAUSE Of un"'" •" aiven In •v«py Instance,
.on. dylnt .way from homo -hould be ftWen >n . . »
t
I
M
■^■^i^m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nikvc, REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
No < *
i
\%
IfJO'i
Bcgistet'cd JS^o,
r::j
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
^
{ "U. S. St^n^arO )
PLACE OF DEATH: — County of a
City of a-
(•NoAttl
L 'k Urtc -y
^tu
1
\^ > » uM.
St.;
Dist.; bet.
XO- >xct,,u
and
/ ir DEftTH occults *WW*V rROM USUAL RESI DENCE give facts called for under special I NrORMATION" \
V IF DEATN OCcklRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
^i;\
C'Ol.i »k
^
a
I».\T1-: nF- I'.IR 111
A(.H
iM.mth;
1 \
f
MEDICAL CERTIFICATE OF DEATH
DATK OI" I) HATH
ly.ct
J,
14' ar)
/hi r,s
^IN<'.I,K. MAkKlKI)
I
lUK rm'i.At'i-:
( StaU (If «'i)iiiili \
^
NAMi: «>I-
I- A III i;k
lUKTiii'i.An-;
«»|- I \rm:K
I Statf (11 iNiunt'
h
XHX ^x -ilX^C>Cr'U-^Crirx
^
MAini.N NAM1-:
<»i MoTin;K
HIUl'IUM.AC'H
• >!■ M(nHi-:K
(Statt or i'liiuittv)
A
^
I go
(Month) I Day) (Year)
I HI{R1'BV CI'IRTIFV, That I atteiulcMl .Uicascd from
"^UW.w^ 190 H tn Ji)^. 1^ IqoH
that 1 last saw h alive (in kL' t:,"u > 190 ' .
and that <Uath onurrcMl, on the date stated above, at ^
wL M. The CAISH ()F DKATII was as follows:
Q
I) r RAT I ON Years
CONTRIIU TORY
Months
/)avs
/Jours
Rr sided ill San /■> rnti t^r,) "- ) ,uj .
"^ Mntifh- ^ Ihl^
'nn; ABOVE sTA'n:i) pkhsonai. particii.aks ark trik to thk
HKSr OK MY KNOWI,i:i)(*.K AND Hin.niF
J/vCX/VsJK
VX/WA^
'Sj^
\
( A.Mri-ss
DIRATION
(SIGNED)
Ycixrs
Afoftths
X.
V.fc , s.
I()0 i (Ad<1ress)
/>avs
"W^ ) uC
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death?
Days
rr^\CH Ol' lURIAI, OR RKMOVAI,
DATJ^of Hi Ki.Ai, 01 KKMOVAl,
.\Js^\,' T90 »
(Add
_ ^CMXtX-^KV
rcH. JbXkvnjJv ^.k
N. B. Every Item of Information •houlcl 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-
s<Mi« dying away from home should be ftiven In ms^ry Instance.
I
I
\M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE POR INSTRUCTIONS
2415
Mh !■ "^
M' r
Dff/r /'V/^r/,lL'^^lKJ2A; \1)
7f)0H
Be^istercd J\^o,
dv.^
\
Xrvulo doL\K|. Deputy Health omcer
DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco
Ceitificate of IDeatb
( "U. S. StaiiDarD j
PLACE OF DEATH: — County ofC cxyv
Ji'
^
Gty of Cj/<X/ru 0 JX-Ol vvC-L^. ^ '
jvr„ l^jHC^ Ll^'^v' ' St.; "^ Dist.;bet.WO A'v -..U and LLlu
/ ,r DEATH OCCURS AWY FROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER SPECIAL INFORMATION" ^
( Tf DEATH OCCURRtD ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME^VL. ■ ;, ■. . v • UUyyxXM^MA. Va. ,
PERSONAL AND STATISTICAL PARTICULARS
r(»l.<ik '
I>.\ I1-, < >! I',! k I'll
A".!-:
£Vt
II /^OH
iM.in
H.nv
C
U(J>c
M.niflr
\ I .11
f)a 1
--IXt 1 1 MAKUIHD
\\in« >\\ J-.I» ( >H I)I\'< >!■' I'D
Write in --ik lal .Itvii.. iial i' iii )
I'.IH I"H I'l, \C\-
NAMl «M"
lAI lll-.K
HI HP 1 1 IM,A(I<:
1)1 t \ I'll !•; k
(Statr ( il iDilllt ! \
maiih-:n NAM1-:
(11- MOTIIl.k
i'.iiv riii'i,A<i%
Ml- M<>in|.;k
'Stall 1)1 Countl
j
<rV>vL.ou
M.Hlth^
Ih!
Till*. AlU)VKST\Ti:i) I'KKSONAl, I'A KTIcr I.A KS ARK TRf K T«> TIN'
Hi;sr OF .Mv KN<)\vi.i:i)»".H and hki.ii:k
nnfo-maut
f \'l<lrcss
KN<)\VI.i:i)»".H AM) HK1.I1-.
4^
MEDICAL CERTIFICATE OF" DEATH
DAl'K ol- nilATII
Muiilli
( Day)
TOO \
(Vtar)
I 1II;R1:P.V C1:RTII'V, That I attended (UTeascd from
tji)^
icp'i to Vy/CA, Q up H
that I last saw h . ■ alive on \Li^C^ ib T90 ' ^
and that (kath occurred, on the date stated above, at I 0
The CAlSli 01' dp: AT 11 was as follows
ft
\JL
\M^A^^ A^ tLvM^AXX^-d^ OA-fr^-i-'^A^d^ L » w -
nr RATION
CONTRIIUTO
DlRATlnN
(Signed)
Mofi//is 1 /hns
y'lUt' s
Hours
)'iais
ly^^ n looH (Address) R^?^ "3 -JQA^
Special information only f^r Hospitals, Instiwtlofls, Transients,
.^fotiths Days
iiutions,
//ours
M.D.
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
PLACK <)I' mRI.U, OK RKMOVAI,
n J?
■^ 4 . ' ,
DATi:*)! Ut KIAI, or RKMOVAI,
N. B.— Every Item of InformBtion .hould b. carefully supplied. AGE should »>« -toted EXACTLY ^"YSfCIANS •houid
•tate CAUSE OF DEATH In plain term., that It m„y be properly classified. The Special Information for p^r-
«f>n« dyinft away from homo should be given in every Instance.
I
i
»^^mm
i
li
I
! lIciMh - i
WRITE PLAINLY WITH UNFADING INK
ft.i.
luV 1' r
Da/r rf7rf/,\^'fzLJoJ0\j \%
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2416
Registered J\'*o,
4^
t'^tC^
DEPARTMENT bp PUBLIC HEALTH=City and County of San Francisco
i
No.
PLACE OF DEATH: — County of
Ccvtificate of "2)eatb
( XX. S. StanDarD )
St: 3^ Dist.;bct. ) .kj<KA\ and ^<Xx%^ka
n .\a vvC<.CsCf. City of O^CX/Vu 0 'xXuw
C (
/ ,r Dr-TH OCCURS .w.y from usual RESIDENCE G.vt rACTS CAtLto ^OR "n^^" sTREtT^AND 'n umbIr^"" )
\ ir DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTtAD OF STREET AND NUMBER. /
il ^
FULL NAME
;\
-\
ll ,lLL*w.D r , .. \ I loy^vclxArJLl'. i .'
-! \
PERSONAL AND STATISTICAL PARTICULARS
X\
^
1» A IJ. ti[ UIK rii
Am-
a:
si I V
Muiitl;
D.iv)
v.
k t-a r )
rhi\>
!^IN«.l,H MAKKIi:!)
WIIx »n I'D nK I)!\i»Ki i;i)
'W'litt ill MM-i.il ill '"ii.' ii.it iiiu )
i»iRTinM,A*i:
(Siiit I ii; t'l Hint I \
I A i lll.K
lUK THI'l.Ail-:
ni 1 xrin'R
( Statr or l.'()Uiilr\' i
MAII>i:n NAMl
<>l- MOTHKK
HIRTHIM^ACK
ni- MOTHHK
'Stall' or Countrv
oCCrPATIOX
AArN4.tvk
Rfsidfd III Siiv /laHii.^rn ■. ^^ ),',ii^
\r.n,!ll. \ K />IT\
THK \m)VK ST^riU) PF.RSOXAl. I'A RPICr I.AKS AKl*, IRlK To Tlll-
liKST Ol' MV KNOWUKIX.K AND HKI.UU'
(InfoMnrmt
"oXxi oto "^^JLy^
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH j,
rMotitii)
(Dav
(Vfiir)
n^ I HI'lR i;i5V ClvRTII'^V, That I attcn(U'«l «Ui cased from
-~ JIqO - to ■ -
0,
up
that I last saw h .'■. • > ^ alive on KJ .ZAf. It up H
and that <kath occurred, on the date stated above, at b
. M. The CATSli Ol' ])]':ATII was as follows:
CONTRIIUTORV V
) ears
nb..ki
V^A
Montlv.
V
Ihn
'S
Hours
I ) r R A T U ) N /v^ ) 'cars Mouths
(Signed ) J
\., ' \ i i TQO
( A. 1 dress)
■U "
Ihiv
^
I 1
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
DAT^: of Kt KlAi, or REMOVAI^
y^ JO TQOH
PI.ACK OF lURIAI, OK RHMOVAI,
A *-'
t-ndi-:rtakkr 1 *^ J\/<xa^ ^ ^<.
■^\
(Acl.
u
N. B.— Evcy Iten. oi l„W.«tlon .hou.d be ca.efu.l. supplied. AGE should •»- «*-»«^^^'^.^.^J^^^- .rrj.To^n^'lo:":;!.'!
state C.4USE OF DEATH in plain terms, that It may be properly classified. The Special Information for psr-
sons dying away from home should be givsn In svery Instance.
■
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nivA'.i] i)f !!( .iltli I- No. 1=, ■'
,.tT.^^
■^■. nN.1' (•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
«
Deputy Heaith Officer
Registcj'cd J\^o.
2417
l)„l,' Fil,'<l, VtdJoJL^j \\
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of "©eatb
( U. 5. Standard )
A
m
PLACE OF DEATH: — County of' ^a> v
't) . /O
U<X/vu J/
rNoXduV
).U
UrU. >xtu U
rwA
(vc
Ml
St.;
Dist.; bet*
City of '-'<VTU JXCLYXCCsl.
and
A ^ '^ Dt*TH OCCUilS *W«Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
ij \ IF DEATH OCDURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
t i V >
^
4
PERSONAL AND STATISTICAL PARTICULARS
SKX A
A
COI.OK 1
\l
clu.
lC.!^^^
MEDICAL CERTIFICATE OF DEATH
DATI-; n|. I)i:.\TII ^\
DA 1 i; <(!■ niK 1 11
\<.i-;
Montlit
L'
).;u.
(Dav
M.niffn
/hi v.
"-IN<.1,1,. MARRJKI)
\ViI)(»\vi;i> uR I>fVi>Ki*HI)
iWtitf ill siH'i.'il (Icsijjfiiatiuii)
lilK rui'KAOK
(Statf or I'oiiiiti V
1
t ri
W
' n
(Month)
(Day)
(Year)
^ I in:RI{HV CI'RTIFV, That J atlciKkMl -lercascd from
JjLcx>. XC iooH to SJ'^ IS. IgoH
^ck:-. xk 190H to ^^ZA) IS.
that I last saw hi. alive on wcL 1 b iqq
an<l that death ijccurred, on the dati- stated above, at I JO
M. The CArSIC ()!• l)i;.\Tll was as follows:
NAM!-: ni
J ATHl-.K
HIHIHI'I, AOK
OK I ATIIKK
(Stntr or Couiitrv
MAini;v NAMJ-:
«u Moini'.k
lUkllf IM.ACI-:
<»l- MnTIlKK
' Statr- I ir (."ouiitr%
OCCri'ATIOX ^ D
^
0 I \''^
W\,'U
■'^
1)1 R.\TI()N }'tiirs
CONTRIIH'TORV
Months
Davs
Hon
rs
(\
a1
'■V "-^
ni' RATION
( SIG
}V(/;.s Months Days
Lew- , ^^
Xddress) \aX^>^v.^Kc
NED ) UJ . ^'. \J:r'>
Flours
M.D.
SPECIAL Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
Rfisidfti ill Sati li aiu i>fit
Mnlltlu
lhl\
THK AHOV'K STATI-:i) I'KR'^ONAI, PAR rUM I.AKS A K 1-: TKIK To
HHST OF XIY KNONVI.HDCK \M) WVAAVA-
(Informant OA^tX/W^ \J^ U/ClJxi'> A.\.l. .
(Address LA^L'y>'\AyYX.<^^''w'ft-«,
TH
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
I'F.ACH ()!• in l^\I. OK KKMOVAI,
DArj;.,;" Hi KiAi, or RKMOVAI,
t
190*1
I ni>i:rtakkr -J WLA-A-X^ m^ VWO.,
*-*»MUdU_
N- B.— -Every Item of information should be ciirelrully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
sons dyin^ away from home should be ftlven In every instance.
• I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
li.ar.i.flt !!i ! No .^ t-^^[}t; fuVl r. REFER TO BACK OF CERTI FIC ATE FOR INSTRUCTIONS
Deput
if)(n
h OfTlcer
Begititered J\^o.
24 1 8
DEPARTMENT t)F PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( 11. 5. StanDarD )
i(
PLACE OF DEATH: — County of a >
%
City of
A
d^
<X/>^ 0 ;\
N©ACtu ^UVtC^\h.iAV • . ..' St.; Dist.;bet. - and
i / IF DEATH OCCURS *VW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "'SPECIAL INFORMATION" N
y V, If" DEATH OCClipRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME Vn\>^
'■^
V
<wC^^-
PERSONAL AND STATISTICAL PARTICULARS
DA 11-: t>|- i; IK 111
c
l:
MEDICAL CERTIFICATE OF DEATH
DA'rn ()!•• DlvXTll
Mllau
M..iith)
- * -
UavJ
M'.V.
%
)V...>
M.ni'h.
/hi
SIM, llv M\RKI|.:i)
w iix >u)-;i» I »R Di\"«)Kii:i)
'\\iittiii •-.iHial ill >»ii.' Mat !< ill )
UxA^qM
St: 'i ,1 1 ', ,iuit I \
N"\MI- .>l
rATii i;r
lUK riii'i. \c]-:
<>i I A III i:i<
"ital r 111 I'l lUIlt I N
MAIIUCN NAMl-;
<'l MuTIIl'.K
lUK'llllM. \(|',
oi- MnrnisK
(Siatf i»r Ciiuntrv)
I
A.V > N\ 'X >^li
(Month)
(Day) (Vtar)
0.
I lIl'RIvBV CI{RTI1-V, That I attoii.U'il dcHx-ascl fnuii
\.KJ i ,
lip
t
u . ^ - '..
I90
that I last saw h • alive- on itp
and that »Uath occurreil, «»n the date statetl abnvt-, at 'i ^
M. The CAl'Sf-: OI' DI'ATir was as follows:
/1)n . n r:s
akLlv.
( ♦
a,A^ \K\j^K >-H ^.t
ft
n
I)r RATION
)V(/;'.9 Months
CONTRiHlTORV L ^L«jL
/Mjv
'.V
I lours
l(l._, UvLut
VlULvudu
1 w ^ L , !
I JJV^> VCL
i '^V,
<)Ccii'ationQ[^ ^ ^p
h'f'iihi! Ill Siiii /'i ilHi isi'n )'i'ilt
iC. 'X:;, Lc
Months
Pavs
(SIGNED )
^ cXi Iw igoH ( Address) LLC \-n^sui\ox.s..j.
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying av^ay from home.
yjnuths
I hi
\'\\y\ AHnVK srATl-:i> I'KKSnx \l, l'\U iirri. \KS AKi; IK IK Tn
1U:ST OI- MY^iLNi»WI,i;i)(.K AM) WVAAV.X
Till-
(Infotmaiit
( Adflrcss
LAX^vut^l
Former or
Usual Residence
Wfien was disease contracted.
If not at place of death?
How loni} at
Place of Death ?
Days
PJ^ACH OK IH RIAI, (iR RHMoVAI, I DAXl.of Hihiai oi KI.MoVAI
O^ UVnL_«_
<A,i,.,..,s 3.t.73.^- IH ti -k'
190
(AD
N. B. Bvery item of information sliould be cnrelruliy supplied. AGB sliould be stated EXACTLY. PHYSICIANS should
•t«te CAUSE OF DEATH in plain terms, that it ma>' be properly classified. The "Special Information*' for per-
sons dying away from home should be given in every instance.
i
f
mmb
■^SJ?i
'«*
) i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
li,,a!.l -.f H. Otl! i V,, 1. t--<-a*j;-!-J>nS^l '(.-.,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffr Fi/(^f/, t).ct<rljL>v \%
VJO'i
Kc^iHteved Xo.
■2419
-V
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No.
PLACE OF DEATH: — County of
Certificate of 2)eatb
*U. S. StanDarD j
■ ^ " :, , City ofOxX^vu JAXXx-rct-LO. ^ <.
-^
0 A^a, ,
LCUl
MVAJ U V
lAaAju (:w Cy<l' VLLa.\ St.;
Dist«; bet.
"and
|( / ir Dt*TH OCCURsTAWAy FROM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" "j
y V IF DEATH OCCuArED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
h' II ^ 1
FULL NAME LI .Uw\,a^o. > , v N UXa^
PERSONAL AND STATISTICAL PARTICULARS
'^I'X
(TlxxL.
COI,C»R
,1-
i>Ari; (•! luKiii
A*.!-;
M'-\
I go \
(Yt-ar)
M.iiith
ST' ,,.„,
Dnv
M..„l/n
/hi 1-
^iN<,i.i'. NTAkkii: i»
WIIM i\Vi:i> (»K IUVMKri'.IJ
'U'litr ill --iHi:!] lii •>!).« iiat iiiii)
I'.IK IHI'I, AOJ-:
I Stall (ii ('iHint I \
NANfl- <»!■
I A I'll I.K
lUK rniM.ArK
'n lAiin-k
' ht lit- I IT Count 1
MAIIMN NAMl.
Of Mnl'lll'.K
nnrriii'r.Atj';
ni- \!(»rni;K
{•^tati or i'ouiltiN
()» (MI'A'lloN
MEDICAL CERTIFICATE OF DEATH
(M-.iitli) 'Dav)
I III'Kl'l'.V C'I'.KTn'V, Tliat [ aUciukMl <lcceased iron
I«/) to U't.X' 1^ IrpM
that I last saw h .^>Vv alivf on ^ I90 H
ami tliat (Uath occiirreil, on the dale stated ahovt-, at ^>
M. The CAISIC ()V DIIATII was as follows:
I )r RAT ION }'rars
CONTRIlHTOkV
Mouths
Davx
II,
III} s
Rf Hit fit lit SilH /'l illh nr'il
),,ll
M,,ii//i'
Ihi
I'm: \HOVH ST All- I) l'HI<S<»NAI, I'XHriiTI, VHs \ k ),; TKt }■" lO I'ln-
iu;s'r <»!• Mi>-KNu\u,j;i)(,j-; and hi: 1,11.1
'?. (It.-
(IiifiH inant
/^
f \.l.ll. ss
vt.
0-^^
L V,
f I K
nr RATION
( Signed )
iD^i A
f \ *
Mi'nt/is
Days
H)0
(A<l.lress)
fly for H^.
\L^
I lours
M.D.
Special Information only for HSspUals, institutions, Transients,
or Recent Residents, and persons dying anay from tiome.
Former or 's \n
Usual Residence ^ » i
When was disease confrar ted.
If not at plare of death ?
\J LoX^ . •
HoH lonq at
Plare of Death ? t
Days
I'l.ACH »>i' inHiAi. nK ki;m<>\ai
r\
DAjJloi HiKiAi, or Ki:Mn\'AI,
0^ :'\ 190 1
rA.ianss 5^1^- l^l-tL J^
IN. B. Bvery Item of Informntion •hoiihl he cnrefully muppl'iecl. AGIi should be stated EXACTLY. PHYSICIANS should
•tote CAUSE OF DEATH In pliiin term*, that it may he properly classified. The "Special Information'* for per-
sons dying away from home shctuld he given In every instance.
H..:inl «.f II' :iith \' "<
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
; Hif
1
I LA
I)
nfr Filed , \J /^iXj^^M^K> \%
lOO'i
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2420
Reglsterecl J\'*o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( XX. S. Stnn^arD )
(^
PLACE OF DEATH:— County of a.>\ V<X ,
City of '^' Ccy^ J . Vcu^irvcv
V)'l.... and O'VO-'
/ ir DCAi^M occuBS AWAV rnoM USUAL RESIDENCE give facts called for under "special information- \
V ir D»j*TM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
IVTo. \ 1 ; ' v ^Ka. St.; ^ Dist.; bct.D.O. >^^ I V..^„^. . and J \O.^X
FULL NAME
(y^,
I .n
X>H. V'.
nj.L.UL
"-l.X
PERSONAL AND STATISTICAL PARTICULARS
I) A ri-, t •! iiiK ill
M
Moiitli:
)
I
<l):ivl
M.,t,l/i
A
■t'.:ii!
Ihivs
^INi.l.I" MAKUIMl)
\vnMi\vj-;i» nK !>i\«)Rr}:i)
i\\nt<-iii vinial il»vii.'ii,it inn)
lUI' rniM. \i'l"
>t,it( . iT i 'i 111 lit ! \
Olx:^-
NAM! (M
!• ATHl.K
lURrmM.ArH
IH I AIIIHR
stall .i! roiititt V
^fA!l)l-;^' nami*:
«>h MOT I IKK V
MEDICAL CERTIFICATE OF DEATH
DAii; <>!•■ nivx'i'ii
. ^
W-C
t
Day) (Ye«r>
(Month)
I IIICRIU'.V CI';RTIFV, That I atteinkMl «k>cx'asc<l from
, . 190'! to ...L/.tX II 190 H
that I la^t saw h .^. alive on vL' cl' * ' '. 190'
aiul that death occurred, on the date slated above, at u '
M. The CAISI': OF Dl-ATII was as follows:
7} JL^ >*\-<-^-^^-u.
I )r RATION }'t'ars
CONTRIIUTORV
Months
Days
IIoii
t s
\
HlK'nil'I.Ail".
01 MOTIIKK
(Siiitf or Cuuntrv
OCCITATIUN
Krsidfd in smi I i tunisfn
} >(7 t
M.nith
Ihiv
Tin-: AiM)VK ST \ri:n i-kksonai. i'akiumi.aks aki". rKiK r< » th H
iu;sr <»i' Mv KN<»\vi,j;nc,H and hki.iiik
dress mCuuJLA ^ JjUVI ^VItM O b
4 CI, .
Dl'RATION
(Signed )
n Q!l>
qo
)>(?/-V ^ font /is
■J. -i)
IhlVS
(Address) QklH tfk)<UU,4/ J I
Hours
M.D.
SPECIAL Information only ^or Hospitals, institutions, Transients,
or Recent Residents, and persons dvinq dw<iy from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoH long at
Place of Death?
Days
I'l ACK <)I- lUKIAU OK K1:Mo\A1. I DA'J^-: of Hikiai, <.r RKMOVAI.
r.VDERTAKl
;r yb . U L^-vv^r^v- "^
N. B. F.very Item of InWmntlon .hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS •houid
state CAUSE OF DEATH In plain terme, that It m»y be properly classified. The ' Special Information for per-
sons dying away from home should be ftlven In every Instance.
• fl
i
lil ^i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H. ,!■! .,f iiinitii r V,, .^ -A^fW--^ ji&p Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Daff' Filrth V,djA>M\^ \%
100
Eeiilstcred J\^o.
2421
{
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
( "U. S. StanDarD )
PLACE OF DEATH: — County of w
L
n \
No.
t
St*;
City of
CU rwV sX '> X
cll
Dist.; bet.
and
/ ir DtATH OCCURS *W»V rROM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" ^
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
A
,Sw )
PERSONAL AND STATISTICAL PARTICULARS
SKX fX^ A I COl.ciR
IjL
DA 1 J-, of- lUK 111
,1
Mr. lit hi
A«*.H
(Day
M.>nf/>-
I Vt-ar^
/',/i -^
HlNi.i.i- \fAKKlKI).
WnioWKI) <»r' DIVORiKIJ A
iW'rilt'in ^'iK'ial df'iv'iiiilinn) \ \/A
lUK rinM.AiM-;
NAMK ()1
FATHl.K
niRTHPI.ArK
ni' I-APIIKK
(StaU- or Oouiitrv)
MAIDKN N'AMH
<>i M»)Tin-;R
lURrnpi.ACK
O!' MnTllKR
(Statf or Country
C3U\.^w. r ^ I '
•\\
MEDICAL CERTIFICATE OF DEATH
DATH Ol' I)1<,ATH lA
CSUmth)
I HivRlUiV C1:RTII'*\', That I attcnckMl tlcrcased from
— to
1^7
/QO
(Year)
I9O
"alive oil
that I last saw h •""
aii.l that death occurred, on the date stated above, at
M. The CArSICjL)!' DIvATH was as follows
190
1)1' RAT ION }'t't7fs
CONTRIBUTORY
J /on //is
Days
//ours
Dl'RATlON
)'rars
f\f-iii/-if ill Saft Fnnii f^fii
) 'lUI 1
A/,,n//i'
lhi\
Till* AHovK sr \ri-:i) pkr^onai, I'ARiim.ARs ari-; tkiv. to thh
IIHST 01 MY KN<»\VIJ<;i)<".H AND lUUJlCF
(Iiifoniiant
..Mm^
'-^-y^JL
(SIG
NED) O.S)
A/i>Ni/is
\J^
190
(Address)
il
/^ays //ours
M.D.
SPECIAL INFORMATION only for Hospitals, Instlfutlons, 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 lon(| iX
Place of Death ?
Days
ri^ACK Ol- JURIAI, OK RKMoVAl,
in'di:ri'akhr
(Addrt
DATl.ol BiKiAr. or RHMOVAI^
/ Ca ' igo'\
I
KX\^ki.
N. B.— Every Item of Information .hould be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The Special Information for psr-
sons dylnft away from home should be given In every Instance.
1IJ
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,f H< nlth I- Nn ■< t^^'^i^ H^l'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafr Filed, h xXA>AK> W
IfWi
Begi.sfcred J\'*(),
04 OQ
A^A^
, i Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
"U. S. StanDarD )
J?
rV
No. WXl
PLACE OF DEATH: — County ol^Curv^h '
Cri'dx/Vj doXo V.l\^v St.; ' Dist.; bet. CVIxo-t^A-hj
0?
City of '^'<X v\. . . A. O. > ■., C-.
\.^ o. ;
(
\T DE*TH OCCURS AWAY TROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER -SPECIAL
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A
and
INFORMATION"
ND NUMBER.
)
FULL NAME CoAxxJa; Vx^vxA.
I
wa„
PERSONAL AND STATISTICAL PARTICULARS
"L
XryyxXkJ
DA 1 J, ( ir- Hi R Til
li),ct
M-iiith)
!l
n.iv
Ai.H
5b
\ iMl
/'(/ 1
•^iN" 1,1' M \k k ii:i>
'Wiitf ill *i>iial (Ic'.iL'ii.il ii III I
lUkTHPI, A4M-:
i St:if I 1 1! I 1 III lit ! %
d.
^
vM^Lo
NAM!' <>!
FA II! IK
nikTIM'I.ArH
«»i I A I'm; K
' state (If I'onntiv
M X ini'.N NAM1-,
<»1 MDTIIKK
lUkriii'i.ArK
'ti M(iiiii:k
fSi.tlt oi I'diinttvi
nirri'ATION 'Tfvp
7
MEDICAL CERTIFICATE OF DEATH
DA 11; <>I- Dl^ATlI (Cx
^'ct
1 \. TQO
(I)av) (Vt.';ir)
(Month^
I lIl'lKlil'V Cl'lRTII'N', That I attc-!i(k<l deceased from
t
^D^ > \; A I90'; to Vw'Aj-^. ''-.. T(>o
tliHt I last saw h ^.' alive 011 C /C<^' i« 190
and that death oreiirred, on the date stated above, at i«l
M. The CAl'Sl-: OI- Di: ATII was as follows:
I )
\.L\ ^
1
f
c\
f\f'i,l,,l It' Sail /'itjihiuii \
\f,,i,Ui'
I his
rm: AiiovK sr \ 11: n pKusdNAi, i- \k 1 n n, \kn \k i: rw i-; to tiik
lil-ST OI- MY KNi>\VI,j;i><.l': AND Hl.IJl.l'
Dilii; niaiit
MS K,Ni)\\ 1,J,D<
In It + 1
\k
\.
DTK AT ION yi'_kirs Mont In » /^<n v /Jours
C ( ) N'l' R N 5 r T ( ) R y LJx^.tTA'XA.^'^ QY^xtJ.^^Li„L^„a„l.
\l\jLKKXAwtA^ , aXA^^|V\X4A4-0^v oi LaA-La\i : ^ i.,,
DIRATION I )'i'ars ^ AfoHths Days Hours
(Signed) wWyv ^"^''A'-';^ m.d.
\j^ n TQoH (Address) bOQi^ LQjLi(A.Arv<,a at
Special information only for Hospitals, InMltutlons, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of deatfi ?
How lonq at
Place of Deatli ?
Days
I'l ACK OI' lU'KIAI, ok H1-;mo\\I, I DATl%of ISirtai. or KKMoVAI,
h^
It
INDl-kTAKl-
T90
N. B. Kvery Item of Jntfornmlion .houlcl bt. cHrefuIly supplied. AGE should he stated EXACTLY. PHYSICIANS .hould
•tate CAUSE OF DEATH !n plnln terms, that It may he properly classified. The "Special Information for per-
son* dylnft away from home should he ftiven in ns^ry instance.
•
if
RITE PLAINLY WITH UNFADING INK
r-)(n
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTiriCATE FOR rNSTRUCTIONS
Ee(Sf,sfe?'cd J\^o.
M Deput
Officer
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDeatb
( tl. 5. StanDarD )
PLACE OF DEATH:-County of ^ O^ J A<X^^.4 cc City of ^^^X^ .X<X.xc..
No. w' ^- ^^ ^^- ^<^^ ^^'-^- -^ • ^-^
St.;
Dist.; bet.
and
)
VLOwl) Cr^'AA r-^^ » ^"^"^ ^ „r=T;yMrEa,vr FACTS CALLED roB UNDER •'SPECAL , N TO R M ATK> N - \
( " -- A.°H"0CCU%Rr .rrH0"s^^.lt 0%^?^?f.?U^4rcf.;Er4 NAM. ..STEAD C STREET AND .U.SER. ;
FULL NAME
\}k i
Ur->^q- ^L-C^.>
,1.
PERSONAL AND STATISTICAL PARTICULARS
•-IX
rMi.(»K ^
i; «»r !;1K I'll
\t.inth
\' .I-
) V,.- .
^ Ii 1%
Mn,l!/l'
Vtar
/)<n.
w i!m»\vi-:i> <>k i»iv<)Rri:i>
Write ill siM'iai lU ''i^'iiutiiin)
MEDICAL CERTIFICATE OF DEATH
DATl-; «»! 1>1. ^ 1 '•
S
\J
i 1
f
(Yt-ar)
x>^<
HIK I'Hl'I, X^'K
I Stati ii! I'l lUiltl %■
NX Ml-: «>F
I ATHHR
niK riii'i.ArH
ni- l-AlUKR
'St,it«' or I'onntry I
MAim'N NAMl
<>1 Mul'llKK
lUH'rniM.AOK
ol- MiJlllKK
(Slati- or Oountrvt
I
'^
1
^Cr^^q,
w,
i J . ) uwK.
(Month) /I>''y^
I 1|I.;ri;1'.V CI{KTII-V. That I atten.kMl deceased from
.^^ ,cA 190M to.J^-^ ^-^ 190''
that I hist saw h *. alive on ^'^^ ^90^
ana that .leatli occurre.l. on the <late ^tate.l ahnve. at 6
U.. M. The CAISH OF DKATIl was as follows:
Hours
Hours
M.D.
DIKATION )>-^/^ ^'<^' /^'^'^
CONTRllU-TORV Ux:^^ '
Dr RAP ION
(SIGNED)
Yi-ays
Mouths ^ Pay^
V-
U-
I c)n
(Achlress) RH
S-JU
± '
Rr^iifn! lit Sitfi / ' <
/ II, I III
r, ,M
M,,iilln
/hn
TUK A,«)VK STATK.. .-HRSON X.MVKTU-rL XKS AKH TKrK TO THH
llKHT t)l- MV KNnWI.l'IX.H )Nl> Hl.I.ilt
( Iiifotmaiit
AJ
Xdilicss
.AJU cit
SPECIAL INFORMATION only lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away Irom home.
i "^ How lonq at
When was disease contracted,
II not at place ol death?
O^^
I) \ 11 of ncKlAi. or RKMOVAl.
T90
IM.ACi: Ol- HIKIAI, OK KKM«)VAI,
rNDKRTAKHR UJ A/>^^ J^-^ 0
— — — — — "^ .. , ArF «houId iMi stated EXACTLY. PHYSICIANS should
N. B.— Bvery Item of ln?or,«„t1on •hould be c„..^u... «upp .ed. AGB « ^^^^^.^,^^^^ ^^^ .g,,,,.„, ,„,o,.„„Uo„" fo. pr-
state CAUSE OF DEATH in plain terms, tha It ma> .^« PJ ^
^on. dylnft away from home should be given ,n even> .nstance.
r^
^
9
I
^^"1^,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i i
I til
If) OH
JicH'i'sfered A''o.
^4^24
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of 2)eatb
( *U. 5. StanC>ar^ )
PLACE OF DEATH: — County oiUi<Xry\> OA.XX/r^
r»
City of W/CX/Vu JAXLAa.CM->^
A
No.
t.at
<U1}
xhA Li4.Lvi'a. ) , . St.;
Dist.; bet.
and
(ir IJTATH OqCUSS AW«V FRO^ USUAL RESIDENCE Give facts CALtrO for UNDCR "special INFORMATION"
IW DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Ol
FULL NAME
:R "special INFORMATION" \
IF STREET AND NUMBER. /
I
(XXUrrxi VIIm.
DA 11. t>J- lUK 111
.\<.i.;
PERSONAL AND STATISTICAL PARTICULARS
a
MEDICAL CERTIFICATE OF DEATH
DA TH OI' i)i:aih i
M..iitli
) ,u
: l).l\ i
M..nflis
It
fVi-ar)
/hn.
"'IN'. I. J- MAKRIKf*.
U IDoWI.I) <>K I)IVnK»J.-|) Q
'U'iit» ill vinial (l«-sii.'ii;iliiiii) ~A
IHKTHJM.ACK y
Stat< or (."iMiDt 1 \ i
NAM I-; (»I.
I ATin;K
lUKI'JM'LACH
<)I- lAIIll'.R
'State iir Coiiiitrvi
MAimiN NAM1-;
luKi'mM.Ai'i-:
<»l' MoTllI'.H
( Slatf (II roiint I \
d
(Month)
IS
(I):iv)
(Year)
, I HI-RIUiV CI-:RTrFV, That I attciKledtleccasca fruni
OX^; 9. r icpH to jQ^ 15^ TOO H
IqO
that I last saw h ;- alive oti W cL i ' j^q
and that <kath occiirre<l, on the <latc stated above, at *"
M. The CArSI-: OF DlvATlI was as follnws :
(i
W ^w-
DT RAT ION }'i'a/s
CONTRim'TORV
Months
I^a vs
Hours
(HCI rA'lloN
)",,;
yf,'iiti,.
I hi
1)1' RATION Years
( SIGNED )\X1X\xAj ^ . .
l-J/d - iQo'i (Address) Vn
/hiys
» >. w\.
Hours
M.D.
ili.U
Special information only lor Hospitals, Instituilons, Transients,
or Recent Residents, and persons dying away from home.
'I'm", \n<)vi.: sr \ ii:ii i'HK-,oNAi. r \H I UMi.AKs AKi. rkti-; t<» thh
HJ-:sr ol- .\^V KNOW l,i;i)(.K and \\V:\,\V.\-
former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of DeatJj ?
Days
'I.AC1-; «)|- lUkFAI, OR Kj;M()\AI,
n
, L'uO-^v.
TQO
DV'i'i'ii;' itt'HiAi, or Ki;m(»\\i
(Achlrcs. Obl^^* tq if. .•.
IN. B. Every Item of infnrmntion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for psr-
sons dyinjt away from home should be [fitiven In ^\^ivy instance.
I,
\
I
At
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I! 11! 1 X.
.; l:>v!' ('■
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ddfr FiIi'fl.\}xiLro-^iSj \\
JOOH,
llegi^tci'cd jYo,
1*35
2^^
DEPARTMENT oi^ PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of H)eatb
XX. S. StanDarD
J?
PLACE OF DEATH: — County of
.^VO. Yvc^ , City of ^/Ou-^v J^H-CX, > .
(No.
n
u. ^.--^^
y
%
Su
Dist.; bet.
and
/ IF DtATM OCCUBS *W«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. /
FULL NAME >^i^^ ^'*-^'<-*'^^"*^
. 0;^^XlI!.
44-
■> ! V
PERSONAL AND STATISTICAL PARTICULAR^
Y\
^
1> \ 1 i: < tf lUK I'H
\<,H
Oi
I Lctu
Mi.mh
i
U.
(Day
I f
■»'i;il I
/',M
StNr.I.K MAKKIl I»
svii>«>wHi> OK niNoKrin
(Wtitein jMK-i.ii di -i^'iiati. n
X/>i^x:krJu
lUK riUM. \C\-,
' stall iir l'( iHtit I \
NAM I' ni
lATin K
XX^*^ •
w
RIRTHPI.Ai'K
OI' l-ATIIKR
(StatJ- or Cuimti vi*^
■^
MEDICAL CERTIFICATE OF DEATH
DATK OF I)!- AIM \{\
C
■k
(Month)
(I):iv>
IQO
(Vt-ar)
.Vw'
I niiKI'liV CI;RTI1«V. That XattendtMl ilcceascd from
.rl
iip H
190
\ s 190 H to
that I la^t saw li ■ alive on V
and thai death occurred, on the date stated ahove, at l v
LL :\I. The CAlSy OF DKATH was as follows:
KJL
~s
O^XA/^X-CSJ
i
(1
DC RAT ION )\'ats
CONTRIIU'TORV
Month's
Pars
Hours
P
J -^- S.' » >
MAn>i:N NAMK H)
01 MoTIIHR V.
\jYr\jYr\jOj
^OXhyWx/CX/
OlH'tPA'noN
HiK'riipi.Aoi-:
oi" MOTHHK
iStatt 111 (.'oiintrvi
^YXA)
A V>, ■"(/<••',' //' S,}ii f'l lUh isi'it
) 'tl! »
M.nttli-
Iht I
Till-: AHOVK STA Tl- I> PKKSONAI. PAKTICI- FAKS A K !• TKIK To Till-;
HKSr OI" MV KNO\VI,i;i)(.K AM) HHI.llU'
(III
I" . .Mua n t NwK/VN-^ %J O /~S~> ^ ^ ■ '^- '' '
.X.Mri.s S 00 ^ ^^aA
0
-V
}\'ars
Months
n
DlRATluN ^
NED) LLUrVMi M f\' Xou^
Pax-
's
(SIGI
Hours
M.D.
i).t
Tc)0
Addres.)^A^K ^nO'
Liu UaM
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, dnd persons d)ing av*ay from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How long at
Place of Death?
Days
ri.ACH oi- lURIAU OR RKMoVAI,
INDHRTAKKR ^ i . \jR<X<1
I»ATi:«>f Ht HIAI. or RKMOVAI,
(0.4 ir
T90
(Ad.lrts^ ^ 11 \J rL'
A.AAA^'>V
N. B. Every item of information .houlcl be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnln terms, that it may he properly classified. The Special Information for per-
sons dying away from home should be given in ^s^ry instance.
gS
i
f
I
I
iM^':
( T
I
WRITE PLAINLY WITH UNFADING INK
— THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)a(p /'V/r^/,UcttrlML^' \%
IfWi
Eegistered jYo.
24^6
^.t'VAAAi i^LXHJ
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Bcatb
( in. 5. StanC»arC» )
PLACE OF DEATH: — County of acX-
City of U/C^C/vXXA^rLx/Tvt<i ^<X\;
No.
i W. I .s
St.;
Dist.; bet.
and
/ ir Dt.TH OCCURS AW*V FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
'M if R
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
.Kx ^
vt>I,«iK
!>.\ ri; » M i;ik I 11
A<'. !•;
M.ntli)
\ .
\x:v
i DilN I
> t a!
/hi
'Wiiti ill >iHi:il lit 'ii.' lia! i' 111 )
niRTHlM.AOK
Stntr «)r Ci>niitr\
NAMI-: OI
1 A riii;K
lUK I'll PI, ATI-:
<>i I \iin:k
•state ()i Cuuntrv
MAini'N NAMK
ni MnTHHK
HIRTHIM.ACK
nj. MoTHKK
iStatr or Country)
Ml
UX^v
^
a
LLU.
^r
I
#
MEDICAL CERTIFICATE OF DEATH
DATE OF Dl.ATM n
iMnlitll) \
15
(I>ay)
(Ytar)
I Hl'Rl'I'.V CI:RTII-V, That I attcmkMl dcctasca from
— — — — 1 90 to ■ - - I{)0
that I hist saw h r alive 011 ^ ' ___ j^ .
ami that-dtath oroiirrcMl, on the ihite stated above, at —
M. The CATSh: 0\< DICATII was as follows:
\.
XJ
nccr PAT ION
/\'n-riff(t in Siin /'i ii Hi nf"/'
) ;,i 1 >
M.nifh^
f hi 1
Till'. AHOVK ST\Ti:n I'KKSONAI. P \ K I'Ff I' I \ K S AKi; I" KIP'. l'« » mi-;
HHSr OP' MV KNOWIJ.IX. p: AM> IU 1.11 I
(lufonnrmt
( ^fUlrrsH
I )r RAT ION )'rars
CONTRIlUTokV
Monihs
/hns
Hours
DTRATiON
(SIGNED )
"^
Yiarn
Months
J . isj. Oxa^Llu,:.
Ihivs
r
at
Ilom s
M.D.
\ \ i(,n' ^ (Address) Cj <X-eV<X>>Aj. >xLo L<\ '
SPECIAL Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Isual Residence
Wlien was disease fontrarted,
If not at place of deatli ?
How lonq at
Ptare of Deatfi ?
. Days
pi.ACH OP m KiAf. OK kp:movai.
DAlJ'lcjf IJiKiAl, or KP;moVAI.
w ^ A 4 190 I
i'ni.p:ktaki-k J yiXJUrcUv V iJAX^Jk^
IS. B.— F.V...V Item of l„for„,«t1o„ .hould ».e c„..*u... supplied. AGB -houl.l »».^ «»«*«:;• ^^'^.fi^TLV . ^"^«'<i'^^^^
state CAUSE Or DflATH in plnin term., that it mny he properly .lass.tkd. The Special Information for p«r-
iion» dying away from home tihould he ^iven In avery Inatance.
1R
I
I
M
I
I li; :iUh I- Ni^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
■,\ !
Bo^istci'cd jVo,
d^^^u^^Xju^ Deputy Hoe:thOfTioor
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
Q^
PLACE OF DEATH: — County of ^'a >v ^- ~' >; Gty of Qo/^v J Xxx >vcl
( u
No,
^ A.,
St.;
Dist.; bet.
/ IF DfATH C^CURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U
V IF DrAT>« OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTE
^U
FULL NAME
O^'Y^xiU
<X/\>L > V-.XO.
4 ^
i i)
i. and o^OJ\. \
"special INFORMATION" \
STREET AND NUMBER. /
4 .■
PERSONAL AND STATISTICAL PARTICULARS
ft
I) \Ti; 1 •! lUK I'll
\< . I-
r^hJ^
r, ,;
a. , 1 V
5
M.>>if/i
^ IN' .I.I- M \R K II'D
\\'\ t)i i\\ 1 1 1 < >R I>',\< iRi i;!>
\\t il» HI -< .. '-n .1. -.ij/iiat ioii)
MEDICAL CERTIFICATE OF DEATH
DATK (M- 1)1. ATM
V^X
15 f<,o'\
(Moiitli) (Hay) (Wiu)
I in:RI':HV CIIRTIPV, That I alleutU'd lUccasecl from
■— — I9O to "" ~~~ T9O
tliat I l.i^l ^a\v li ~ alivf on ~ " l(p "
and that lU-atli orcurrcil, nn thi* ilate '-tatt-d ahovc, at
' :^ M. The CAl'Sl-; i)V I)i;.\'ril was as follows:
iCb V
NAMl- (II
I- Ai'ii j;r
HI kill I'l. \i"j',
<>! lAlllI.K
' Sl;it ( 11! I'lilllll I \
^t \ Il»l,\- NAM!
oi .Mi)Tm-:K
lUR rm'i.Ai'j-:
•>1 Morill'.K
( Slnli III Cniuit! \ '
nicTl'X I'lnN
^
I, 1 1 1! Ill I '11
}/.,„//i'
III 1: Aiu»\i.: sr \f j:i> pHK^^nx \i, i-nk ri< ri m<^ aki, iki 1:
in:sr(»i ms kn<»\\ i.iimi-; \\i» in 1,111
i }
,vi,i,,~. '^bl- \'lU. 0%
[(]
!-
\
I ) r In A T i 0 N J 'rars .l/ot/Z/is /hiys I/oiits
CONTKilU'TORV
Viuirs Months /hiys Hours
NED) Ur*Ur>Uhj sj.yb. IJL).1ulIol> ^^
nr RAT ION
fSlG
M.D.
Special information only <nr Hospltdls. Insntuti^^, Transients,
or Recent Residents, and persons dyini) a\*a> from homp.
Former or
Usual Residence
When Has disease (onfrarted.
If not at place of deatti ?
HoH lonq at
Place of Deatli ?
Days
I'UACK <ll' lUKIAf, (»H HJ:Mii\A1,
(nu ilLv^.
rNI»i;KTAKi:R
DXl'l '! Hi Ki.Ai, or KI:M<»VAI,
^^ It T90^ ,
N. «._r.ve.. t.en, of l„»or.„„t1n« .h„„lcl b. ca.un.ll> supplied. AGF. «h„ulcl H- «t"ted RXACTLY ^^f '^'^^^t^ •»'°"'*«
•tatc CAUSn OF DI.ATH In plnin ter,„«. thi.t it mi.y he properly .la«,»h'kcl. Th« Special Information for p.r-
Bont dyin^ away from home Hhoulcl be ftiven In every Instance.
■
WR'TC PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REPEC TO BftCK OF CER"^tPiCfeTr FOR fNSTRUCT'ONS
/ ■
\'..
> f
'S
S- ■ i.
Deo
DEPARTMENT OF PIBLIC HEALTH=City and Countv of San Francisco
Ccvtificntc of Pcatb
w.
FLACE OF DEATH:
SC:
t t ■; [ c - t "V i I
« r t »" '
FULL NAME
PEC£CH*w ».»<D STA* STiC*L RARTtCULAWS
t
I.-
i
%XWV%^
i d cl>
\ w -. 5> K I I K r K i < ' 1 H I
^-
^.1.
v^CCn >
Citv of
DT^t.* bet.
and
MCDiCAL CER-
OCATN
SIGNED
MP
pf Iff ml RfvWrft*. iN r ''«'»•' ^''"fl **?'
Him l^«f ^
lrw^^<.
Nm
11 V, V < n rr u 1 % I > ^ i > "^i
i *
r N 1 1 1 >■ I i » '
state CAUSE OF DEATH In plain term., that It mn, He pr„^H, .••••.f«d. TM R^...l i«f • ^- - ►•
iiofis d>int away from home Bhould be fi^en In •%er> innHintc.
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ifJO'i
DEPARTMENT k PUBLIC HEALTH
Jie^isfercd Xo.
010
4^9
City and County of San Francisco
Gertificate of IDcatb
1 '^. 5. 5tnnDar^ )
(5?)
A %
PLACE OF DEATH: — County ofCj/a'^'v 0,rva/'>l.<X4C( City ofO/O^'^'V 0 A.<Xaa. C \.<i. e (
AOV<Lk.^v . ; St.; — Dist.;bet. -^=- and
TS CALLED FOR UNDER "SPECIAL INFORMATION" \
TS NAME INSTEAD OF STREET AND NUMBER. /
(IF DEATH OCCUR^AWAY FROM USUAL R E S I D E N C E G I V E FAC
IF DEATH OCClIbRED IN A HOSPITAL OR INSTITUTION GIVE I
FULL NAME
LAjuXc
si:\
PERSONAL AND STATISTICAL PARTICULARS
(.•<il,uK \
oJjL
{L.'..d
I ■' '-_ S_-V
DAIl-; <>I IMK 111
\i.i-:
(\
iiith
L
4H
>•,■„•
(I):iV
M.,iil/i'
(W-.'ir i
/'(/ \.
si\« ,i.|- M \KRii;n
UIlx )\\ !!» OR ni\< I'Tl-r)
iW'iiti in ^itii.il (lf^i<.'iKil ii )ji)
'Statt lit I'oiintrv'
ly
'-C^^lXIAJI
I ■
I (
NAMl*. «>l
I- A 11 1 KR
?
J
L<lAAX>A.d. LLvv^xlW
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH | ( \
(Mnutli)
11:
(Dav)
I go
(Year)
, I HI^kl'HV CivRTIFV, That 1 attendod deccasctl from
Ox^\1. I'l itpi to U/et iS^ up ^
that I last saw h '■ ■ alive on w "C^U > > j^q I
and that death occurred, on the <late stated aliove. at "i- o C
xX. M. The CAISK OK DKA Til was as follows:
a
niKPii I'l.ArK
ot- lArnKK
iStatf or Comitrv)
m\ii)i;n xAMi
oi .MoTin;K
v<:.
A
HIKTHIM.ACH
OI- MoTHKK
istatf or Conntrvl
otCl'l'ATIO
Kt' sided III Sail I- 1 till
DIRATION )'car.
CONTkNUTOkV
A/ 1) tit /is
fhivs
Hon
rs
}'t'ars
I ) r R A T I ( ) N
(SIGNED) U3. Xd. Cct^aJL
Miuiths Pays
(Add ress ) LLL'"i^A.Xi.
Hours
M.D.
SPECIAL INFORMATION nnly for Hospitdls, Institutions, Transients,
or Recent Residents, and persons d>ing dw<ty from tiome.
\f,nifh:-
THl-; AliOVK STATl'n fKRHOV A 1, I' \K' rui' !,A RS ARl! I'KI'K To I'll V.
HH.sr 01-" \LV KNoWI.J-'.Ix.l-; \\I> lUJ.Il.l'
Informant
0 /vo^-»^A U- B.cJ
'W
.1
rx.l.lrcss UUL
"5
nrvvOt, i \
Former or
Usual Residence
When was disease contracted,
If not it place of death ?
How lonq at
Place of Death?
Days
^'I.ACK Ol- niKIA!. OK KHMoVAI,
V
nxri'of HJHiAr or Ki-;MovAr,
^^ ' T90 »
r.VDlIRTAKKH ytX/VV>ULft ^Iv U X^^'>%. ^i \„C
M. B. Bvery item ni information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for par-
sons dying away from home should be given in every instance.
I
1 i
■'H
I
I
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFrCATC FOR INSTRUCTIONS
B«3iir<1 1. 1" IIcmUIi- F No. i-, '^f'^'^'^rnSiV C
IDOH
Regi.slevcd ■A''o.
^430
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "Q. S. StanC>ar^ )
PLACE OF DEATH: — County oi^O^'y^ 0 Vcx.^^'C^v City ofCJ/(Xorv
3
No,
A
1
.^ \)<Xfrv M LL4.<l
St.;
Dist.; bet*
Ojfs
(IF DEATH OCCURS *W*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF
and
<^ 0
? I
A_
SPECIAL IN
STREET AND
FORMATIO
NUMBER.
N)
FULL NAME lA^^A
i
PERSONAL AND STATISTICAL PARTICULARS
■^t
SIX
^ 3
i:(>i,<>k \
a..'.-.a^
DA ri: OF' r.iKTu
.\<.K
iMoiitli
fARKIHD
U n>i»\VKI) i»K DSVnKi I'D N
i\\'iit«- ill siH'ial cU— i^'iiatii)!)) \
(Dav)
A/,>n//n
I -
'kt ar)
lhi\
MEDICAL CERTIFICATE OF DEATH
IJATK «)1" DKATH sCS
li I J
IN
(Dav
(Mnlllh)
(Year)
SlN(.!.i:. NfARKIHD
(Stati nr <."i)niU! v
NAMF (»!■
FA'nn.K
HIKTHPI.ArH
()!■• iwrnHK
(Statf or Couiiti v)
MAIDICN XAMF,
oi- MOTHF'.K
HIRrnPI.A».'K
OF m(>thf:k
(Btatf or Couiitrv)
cu
I HICRl-IiV CKRTII V, That I attended deceased from
O^t IH too' to ^KLt- IH i()o H
''-' J A 1^ ' to ^ KJ\) '1 IC)0
tliat I last saw h '• alive oti v^. -v jgo
atid that doatli occurred, on the date state<l above, at '^
-' M. The CAISH OF DKATII was as follows:
I)r RATION Yeats' Months Day^s b Hour
CC)NT R I lU'TOR V U^t<l^\Jl>\,.€rv-y\,<xL^VV<i^^....Q^^^
DTRATION 5 ):cars Months
^>^
OCCUPATION
I 0 to a 0
Rrsisfrd in San I'l ani iMn
(Signed)
Q^ II
year
Da vs
o.yyv^j^ i\)
IQO
'i (Address) 1^ U aXMa,OU\
P
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
)
Mnnlh:
J)ll\S
THF AHOVK STATHD PRKsONAI, PAR rUTl. \KS A K F", rRFH To TJIH
«KST OF MY kno\vi,f;d(;k and ni:i,n;F
«KST OF MY kno\vi,f;d(;]
(Iiifominnt \J . 0 vO
Former or
Usual Residence
When was disease contracted,
If not at place of deatfi?
How long at
Place of Death ?
Days
DATF: of HiKiAl. or RF:M()\AI,
X^
PI.ACK OF nURIAI, OR kl-MoXAI,
r.NDFIRTAKKR n£^-M.^^-wKX\^ ^^ cL^V^xt
(Address. , sLbisb AjTV'Vv^^^r^X di
T9O
N. B. Every item o? information should he carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for psr-
sons dyin^ away from home should be ftiven in every instance.
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i \-
4 -r-3L,, \',f^\' c.
((
B.('^Lsler''(l J\f''o.
2431
\j(f^^^^-,'^' Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDcatb
( 'XX. 5. StnuDavD )
PLACE OF DEATH: — County of''' o. - - " City ofOxX/^v J Axx.vx-' >i -<
ISJr^. ' llAy^VuCL^'V (AT'^ \. , ' - '' ', St.; Dist.;bet. and
l^U. - -'i^ W » » ws,^ . ..ciial nr^lDENCE GIVE PACTS C*LLED FOR UNDER "SPECIAL INFORMATION- \
( '^ r;'o;:T°H"oc:u%r/o\rrHO^S^r.t r« f^sfr^^N^O^.V. .TS name ..ST.*0 O. ST«..T .no .UMa.R. J
FULL NAME
4 } 1
0 V ' ■
4
PERSONAL AND STATISTICAL PARTICULARS
^i;\
^ 0
i'< >I,()K
I V
iiAi 1-: or lUK Til
\< I-,
,U\
M..iith»
n.iv
s%
\ tar i
Ihn
'-IN*.!,!-: M.\KHn:i»
WIlx fWKD OK I»I\t iRiKI)
X\i H< i ti -'Mi:i i .1. -•iMiati' iti >
CWvA^tl^-
i; IK nil' I, \c\{
•"-tilt, ill »"')U!lt 1 \
%■ wn-: oi-
!• A Illl-.R
HiRrnpi.ACK
Of lAPIIHR
• Stair i»r Cotmtry^
M MItJ'.N NAN!!',
oi MoTIlKK
I
kSa
i
ry.
V J JC \-_ t 1
ol- MJ)THHK
' Stati- or Cimi\ti\
H-1
Rf^i.ini in San Frainisri^ ^b ?V(7>5
Tin-: AHOVK STATKI) I»KKSONAI, r ART K* T LA RS ARK TRl'K Ti> Tin-
DKST OI- MV KNOWI.IUX'.K AND Hl-J.li:!*
(liifoTinatit
M.'iilh:
Ihi
MEDICAL CERTIFICATE OF DEATH
DATi-; ol- i)i;ATn
Dav) (Vtiir
.0
(Month)
I in':RI':!5V e'l^K'ni-V, That I atteiKU-il .Urrased from
d ' ^t )S^ I90S t.) . C)ct 1^ Tc)o"i
that I last saw a ^^ alive on I90 i
and that death (ircurred, 011 the .late stated alxn-e, at VP- « o
LL ^r The CAISI-: ()!• l)h:ATll was as follows:
oW A^CXA^
-J I
CC^
I )r RATION )><7;.?
CoNTRIl'dTORV
MoHi/is
/hirs
I lours
nr RATION
(SIGNED)
Years
Months
Pavs
I()0
r.
Hours
.^_iUu > ^ M.D.
Address) OXVwUXyW ob^^«^^
00^'
<XL
Special Information «nly for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
UsuTResidence I C) 0^1 (Ib(h.^Kt^.H
When was disease contracted.
If not at place of death ?
A
How long at
Plare of Death
Days
IM.ACH Ol- lUKIAI. OR KKMoVAl,
DAXi;"! Hi KiAr. ot K1-;mo\'AI,
.ui
(Address
QfYuA^
\-^'>Xj
T^t
N. B —Every Item of information .hould be cnrefuHy supplied. AGE .hould be stated EXACTLY PHYSICIANS should
.tatecIuSE OF DEATH in plain term., that It may be properly classified. The "Special Information" for psr-
snns dyinft away from home should be given In every Instance.
i
« 1
■M
#
til
WRITE PLAINLY WITH UNFADING INK
ih 1^
•:■ -—••3^v v.SiV c
pfffr tiled n
>Xr\j IH
100\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bo^istercd J\^o.
Deputy h :!th Officer
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
Certificate of 2)eatb
( tl. 5. 5tnn^ar^
J? %
SI
(311
No. '^-^ 1
PLACE OF DEATH: — County
(IF DtATH OCCURS AWAY FROM
ir DEATH OCCURRED IN A H
of^'^<XA^ J A<X r\ c . , City of UXX/W 0 AXX^-.x.c.
St.; i
Dist.; bet. 0 il
' ^^ si„<^YYV«
and
5H-
o
A
r^n» USUAL RESIDENCE G.VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
OSP^TAL ?R TnST.TUT.ON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
JxcL
I I *
PERSONAL AND STATISTICAL PARTICULARS
f)ul
(•( >i i»k
I
>\i\- itr- i;i!< rn
A'.i-;
As
1^
Month)
l):l%
CLO' ' .
S(N<,!.I- M\KkIi:i>
w I i>i >u I i» (»K r>!V» >kr I'D
W 1 it'- ill -Mciril ill— iv' ii.it H 111)
HiK riii'i. \ri-.
(Slatf lit ('.Mint! V
1/. <
/hi 1 .
NANt) ni
l-.\T!l )H
lURTIII'I.ArH
()l* I ArilHK
ISt:iti- ur I'oUIUl V
MAIIil N N \M 1
<»i' MMi'm-.R
lURl'mM.Ail-:
III Mnrill-.R
( "^tiil" I 1! ('oullt 1 \
< )i ill' ATloX
Re^idfi! ni Suit I'l tuh i-rn
) I'll I
M,„,Hi^
TUl- \IU.VK ST\Ti:i) I'KR^ONAI, R \ K r !* f 1 , \ R > ARl' I'Rt !•
liicsr <)i Mv KNOW i,i:ni".i-; am> r.i-.i,n-,i-
1 \
Tti lill'
(Address
MEDICAL CERTIFICATE OF DEATH
i)A 11-: oi- i)i;\ Til ipx
Icl.
W
I Ntotltlll
nay)
/ go \
(V<-ar^
I ni':RI-:HV Cl-lkTH-V, That I attfii. U'd ikHHiKL-a fmm
—^ ■ — -H/l to 190 "
that I la'^t saw h ^ — alive- on -— — ~— 190^
anil that (k-alh ocriiritMl, on the date ^tate.! above, at
M. The CAISI'; Oh* DIIATII was as fyllows:
(^^^^J^J^J^^^^ - - K V ■ ■ «^AVCb JV<. j , ., q.
or RAT ION >V77/-.¥
CONTRIin TORY
Months
Pars
Hours
^TION )'rars -^ Months /hirs
NED ) LO^CPAJIK; J Ail U) lX'..'V ■ '
//on
t s
M.D.
b
I<)0
f
m. — :
Special information only for Hospitals, Insfilutirtrts, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
Wlien Has disease contracted,
If not at place of dealli ?
HoH long at
Place of Death ?
Days
RI.ACK Ol' F.tRIAI, OR Rl-.MiiVAI,
Qna.ti DWt
I»\r^;'if HiKlAl. nr KHMOX'AI,
'Oct. i\
rxni.R TAKl'.R
■A<i<ii«ss HC'T \3 frv
1 1 I 90 1
T
I
... ... 1-1 ikCF ehniilil he «tntetl F.X4CTLY. PHYSICIANS Hhould
N. B._Bvery Item of •.„far.«atio„ should h. c„r«U.IIy -ppi.ed ^^'f^^^J"^'^',^^^^^^ ,„for.„„tlo,.- for pT-
state CAUSE OF DEATH in plain terms, that it mny be properly wiassmeu. me 1
sons dying away from homo should be feiven in every instance.
f
«n
— -— ..ac^iina
^^W^^^V.
14
If
■\
WRITE PLAINLY WITH UNFADING INK
ard.tn':'''M !
'!'! ! V,,
t-f-S^-^: lus^r
IfJO
DEPARTMENT OF PUBLIC HEALTH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
City and County of San Francisco
Certificate of S)eatb
PLACE OF DEATH: — County
ofO/
^
'V
City ofCJ/Ou^ru 0XXX.OfV<^^
No. '^'XS'N (\\j^^\r■' ^ St.: 1 Dist.;bet.
^,^^. ^.. CUvTTu^i and
( " r"o;:TH"oCCUR'Rrr.\"r«0,^p"*' o%":S,.?u"on"c,V. ,TS name ,„ST»0 or STRC^ .NO ~U»B.R. )
FULL NAME UAAXXaj
-AO^W^
1 w
L
PERSONAL AND STATISTICAL PARTICULARS
OX
s
1> ATI-: ( t| llIK I'll
llA.
.mtli) K
ll)a%-)
\t .l•
sI^■(,I,^: MAKKIJ'.li
|\\iit( in v,n-i;il tli^it- iiatiifu)
I'.iH rm'i.AOj':
•-■I, (If <ir (."'lu nt I \
VAMI' nl'
!• ATlIl-.K
niKllll'I.Ai'K
oi I A I" in: R
(State 1)1 I'lmiitry
MAIMKN NAMl-
o| MoTin-.K
lURTUlM, \CV,
Ol" Morifl'.K
(StaU- or (."ouiiti y
oocri'A rioN
!/.»/'//
n
/'.?
'
u
1
,L 'Ml
oh:x^^
MEDICAL CERTIFICATE OF DEATH
DATl-. nl- Dl-ATH pCx
1 HI-;KI':I'.V CI:RTI1'V, That I attcn.kMl aeccascd from
TQO
(Day) (Vcat)
'C .cl
1 6 t; n
up I to ^ ^^ '■
190 H
that I last saw h •" alivo (ui V. ^ v < . I90
an.l that <liath ncrurrc<l, cii the date stated above, at < -
M. Tlu- CAr.SI": 1)1' DI-iATI! was as follows:
L*
^ vj
a
A
"^UOl)
1
A'/"iifr,f ill -Vcv /■'/(,•'/( /'
) III I J-^
yfi„if//^ 1 I /''
TnKAn<)VKSTxri-l)1«KKSONAl. l'NKTU-ri,\KSAKHTK< 1- Tn T H H
HKST Ol- MS KNOW I.l-;i)<'.K A M)^1•,^N■.I•
( Iiifi 1; inatit
N ,-i
DIRATION
CoNTRllU'TOkV
)V(7r? Moulin 5 /;</}, s //<>//;-.?
DIRAI'IIIN
(SIGNED
:.t I
)U3^'S).ti
}[, Wilis f^ays
I()n
(Addres.) bH'b a^Ctl/
i
Hour<;
M.D.
\
Special information on'y '<"■ 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 ?
HoH long at
Place of Death ?
Days
I'UACK 01-' Ml KIAI. (»R k!':M()VAI
|)AII-:i>! HiKiAi. or RHMOVAI.
T go
\L^-l
I
N. B.-
•tate CAUSE OF DEATH in pl.un tei-m«. that it may He properly wlassmeu.
»ion« dylnft away from home nhmild be ftlven In every Instance.
i\
^'
U^S^^^Ubk.
I !i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
\\, ;i'l!l 1 Vo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dn/r n/rf/,XJ/zL<A>^\j l^
JfUJ'i
Eegi^sleied jYo,
^434
(X.tri^^^v^
u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( tl. S. StanDarC^
.^
J?
(5^
'4-
PLACE OF DEATH: — County of a^vx, <x
<* t '■. " '
^v<^^„:i
City of C)x^^/>x; uJvCSu>veA^/C
.--^i
^
N^Ix^vCvvOlL L'^x.^^Oa. .^.Cu (Ib5v-(iSi;'''.A Dist.;bct.
and
/ IF DC.TH OCCURS «WaY FROM USUAL R t S I D E N C E G . V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N •• \
( Tf DEATH IcCURiTeD IN A HOSR.T.L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
m
OJ\.Li
•^ r. \
PERSONAL AND STATISTICAL PARTICULARS
:'
\ri: < T liiK rn
H
/ i.
AC. I-
I O Vrai
^IN' .1.1-:. MAKHIKn
W I!h >\\ I'D OR I)IV(>Kt}.I»
'\\iit< in >.iMiai di-'-iL' tial ii m )
Dav
M.nitli
I M
(Vt-ar^
/i,n
lUR I'lll'l, \rj-:
Stall Ml ( . lunllN-
XWtl Ol
i\ riii:R
Ol I NIHl-.K
ISlati III ^.'(lUlltl v^
M\I1»j:n NAMlv
«)!•■ MoTIIHK
nikrmM.ACH
<»|- MorilKK
(Slati Ol Cnuiltrvl
nrrrr ATioN
A
\
^Wvt
MEDICAL CERTIFICATE OF DEATH
DAri-: Ol- DliATH
,■>
(Month)
w
(Dav)
I go \
I Vtal
I IIh;RI':HV CI'IRTIFV. That I attcii<lc«l (k-ccjiscd from
aX IL iQo'i to w'^ it up H
that I last saw h • • ' ahvc nii v.. C-V.- L I90
and that death occnrretl, 011 tht- dat*.- stated ahove, at n
I
1
M The CAT SI-: Oh* I H-! AT 1 1 was as follows
(? •
DTK AT ION Years Mouths
CONTRIIUTORV LLIc^X^ ..^..
Days 3s Hours
f\^feAa,s.
u
1)1" RAT ION
Years
Month.
Paxs
(SIGNED) UxMj U. \X^K^,t^\,
^/Ct) M looH (Address) lltK' "^OXci^XXM
Hours
M.D.
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from fiome.
F.™er.r a0b5-(f»^vXil U. K' ^'
Rfsiiffit in San J'mmis/'n tjx- )rais
Mioilh'
n,n
'\'\\V. AnOVK. HTATl'n PKH'^ON \1, PAR I' ICT I,A KS ARK TRllC T< ) Tin<:
I!i:ST 01 MV KXOWl.lJX.l-; AM) I?!-; 1, 1 1*. h"
(Ii
fAddrt'-^s
Usual Residence
When was disease contracted,
If not at place of death ?
Death?
Days
PLACE OF niKiAr. OR ri;movai.
DAiVKo!" Ht KiAi, or KHMo\AI,
0
190
(AiMit'ss
fS. B.— Every Item of information should be cn.efully supplied. AGE should be stated EXACTLY PHYSICIA1N8 should
state CAUSE OF DEATH In plain terms, that It may be properly classhied. The Special Intormatlon for per-
son* dying away from homo should be given In every instance.
%
i
i
i
■I- «
M
H
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JS^o,
DfUe FiJe<l,S^^d^^Osj VH ■ J^'i^l
Lcrvu^ dJUvHj Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. S. Stan&ar^ )
^
(^
PLACE OF DEATH: — County of Ocwu ^ Kcsj-r^Z\,^^<CMY of OxXnrv OAxc^^eu^Co
1,+ ^1
No, HOC) UX a J St.; 5" Dist.; bet. \l ^ tOAU\.<^a) and H
(ir DEATH OCCUPS AW*V FROM USUAL RESIDENCE give facts called for under ' SPECIAL INFORMATIO
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
i .1
+
\_ r
FULL NAME
si;\
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
oJui
, J
D.Ml. <»f" HIKTII
AC K
A'X'K
M. tilth I
'iS ,
I)av>
Mnilli-
( Vt-ar)
/),7 1
•-1\<'. l.K. MAKKll-:i>
\vn)«»\vi;i» nk niv* >Rri:r)
(Writi'iii >;(M'ial di viiinatinii)
IURTHPI,A('K ,'^
I >t.itc 1 If (."iiunlrv '
L
I- A rni;R
HIRTHPI.AOH
<1!- I'ATHKR
(Stati- or I'onntrv
VDIx-rA. 0
MEDICAL CERTIFICATE OF DEATH
DATK ni- I)1:aTH tCS
it
(Day
f Month)
(Year)
I jnCRIUJV Cl-KTII-V, Tliiit J atteii.k'd deceased from
M ! 190.:^ to qX^ 10 T90S
that I last saw h '• alive on . '-jLIvL i^q
and that deatli octnirred, on the date stated ahove, at
^ M. The CAISH OF DI^ATH was as follows:
o <xCLu. cL Jca^-rvXN.xxAA.xr>v
I) r RAT I UN
\
>! A 11 ) !•: X N A M !•;
oi- M«)rm-'.K
lUK ruiM^Ai'i-:
<)!• Mo'rUHR
(Slate or Cmnitrv*
OCOr PATIO N
a)
Hours
CONTRIIUTORV
c
I)T' RATION
)'eat-s .^fontfis Pavs
(SIGNED) y.'UrrAJt UL- nDAATLKiU/
W ^t \% ,ooH (A.ldres^.) 2)b^ UAA/tLuv Ot
f/ours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
/\r^:iir(f ni S(:ti /'i atu isrn u L )'ra>s
M^vtli-
I hi
Tin' AHOVH STAIi: F» r»KRS()N \I. 1' \ RT U" T r,A RS ARI' Ik VV
HHHT OK MY KN«)\\T,i:i)«; H AND 1!I;M};f
Ti> Tin-
^t
'\{
IN. B.
op ^ <? "
fAd.luss 3^1 UXX/^^ NjlX^^ LLu-^...
-Every item of mformntion should be cnpefiilly supplied. AGR should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DfATH in plain terms, that it may be prr.perly clansified. The "Special Information" for p«r-
«on» dying away from home should be given in every instance.
Former or
Usual Residence
Wfien was disease contracted.
If not at place of deatli?
How lonq at
Place of Oeatli ?
Days
PLACK <n' in RIAL OR ri:m<»vai
I>ATj;or Hi KiAf, or Ri;Mn\Al,
1901
^
< f
X
o>
.1
H
^'
f
, 4i^
■i!
I
i
WRITE PLAINLY WITH UNFADING INK
,••', r V
WO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ile^isfered .A^. ^436
DEPARTMENliF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( 11. 5. 5tan^ar^ )
PLACE OF DEATH: — County of
K\y^f\^
City of U/Cucw<i.
ex.
Lu f^J
i
No.
St.;
Dist.; bet. —
and
/ ,r DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G . V E FACT
V IF DEATH OCCURRED IN A HOSPITAU OR INSTITUTION GIVE I
FULL NAME
TS CALLED FOR UNDER "SPECIAL INFORMATION" N
TS NAME INSTEAD OF STREET AND NUMBER. /
■-i:\
PERSONAL AND STATISTICAL PARTICULARS
ft n
H
cuc^^
(\<xL
n
1) All; < 'r i!ik I'll
\<. 1-;
MoiUlO
V, I
i i),i\
,^^i
(A
) r,n
M,,til/i>
\ tar
lh',\
'W'litriu ^(K-ial il<-.i5.'nat i'lii)
' Slat> 'It I'l iiiiitl %
NAM1-: «>I-
1 A rin-R
Oxcl
\ a
m
r r-
! i*
llIK THI'I.Ari-:
<»!• lArm-K
I stair I )I rmillt I \
M \ll>i;\ N \ MI-
CH m<»tiii;k
lUK rniM.ArK
<>1- \inTllKK
I stall- 111 t'otlllll V
utHTJ'A'l'ION
r^
R'r-iiinl III s.,-,^ /■') ,in, i-i'"
) .-.ii
^/,,ll//l'
I hi
TIN- MiuVK ST\Ti:n l'KU^«)\ M, 1' \ K lU" T 1. \ Ks AKl- TKri-
lU-.ST <)|- MV KN'oWI.Kix'.H AM) lU-, I.l 1. 1'
r%j
TO nil-
MEDICAL CERTIFICATE OF DEATH
DATl", U1-' DHATH
Day)
I go
I Year )
(Montli)
1 III'KIU'.V C!{RTII-'V, That I atlcmUMl deceased from
- to 190
190
alive on
that I last ^aw h ^^
and that death oreurred, <»ti the date stated above, at
M. The CAlSi: ()I" DICATII was as follows:
T()0
Dr RATION )'tais
CoNTRII'd'ToKV
Mouths
Davs
Hours
niRATtON
Ytars
^^o*lths
^}{\AX,\^J'
Pays
Hours
(SIGNED) Y KS.
kJ/Z^J \% iqoH (.\.ldress)Cl
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq away from liome.
,OL.cv^<X,
M.D.
Lu CA
Former or
Usual Residence
Wlif n was disease contracted,
If not at place of death?
flow tonq at
Place of Death ?
Days
S.l.llrvs lioO
ri.ACH oi- m KiAi. nu ki;m<»vai.
^
.\ I I', 'l! Itl
0 f P ^ )
I»ATi:..f in KlAI, or KKMOVAI,
3^0 190H
(AcMn-'Js
l)nn^ C^X
ini
Ji
^ .. 1. 1 AHF .Hniilil he stated EXACTLY. PHYSICIANS fihould
N. B.— Every Item o* InformHtlnn .hnu d be c„r.*ully Huppl.ed ^"^^^^^^/^^.^^^j^i^^^^he •'Sp.clal InformBtlon" »or pr-
state CAUSE OP DEATH In plnin term., that it may be properly t.l«Mmea. 1 ne 1 «
Hon* dying away from home Hhonld be feiven in av«py Instance.
t'i
It
WRITE PLAINLY WITH UNFADING INK
,' , < ll^ ,;th t
i;>. r (•■.
Dftlc FilviL y £l,>crlM.>v. \'\
vjin
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.^rvc^^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cettificatc of H)eatb
( XX> S. StanDarO )
PLACE OF DEATH: — County ofO<^^ J.Va ^yc^ ; ' City of Uxx^^.
(?m
N
o. S'iS W<^^
Wl!v
and
^ .
St.; H Dist.;bet. .
( fr ^^v^^v::^:^ -v^o^^ ^^^:^^^^-:- ^- .^^" s?:^^-Jo T;::^r )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
'tV^A
'tX.Avo .
DATH ')! I'.IK ill
A<.i-;
d
)-,;!
iDay
MniiHi
t al
P.r V
MN<.!,1-:, MAKKIl'.n.
\\ii>t)\vi:i» OK DivoKi'i:!)
(Write in soi-ial (U«-ii.n!;itii>n)
OxA-vo
MEDICAL CERTIFICATE OF DEATH
DAII", nl Dl'.ATH
y.
(Mmith)
iQ
iDav)
rgo
(Ycar>
I IllvRI'I'.V CI'RTIFV, That I attciKlcMl .k-coascil from
oi U: TQoH to . Jii^ •' TnnH
^ ,_V. .V 190^1 to W;W*^ • > T9O
tliat I last saw li • alive on ^- -■ 190
and that death occurred, oti the date state<l alnne, at
-.i M. The CAl SIC Ol" DKATH was as follows:
(-yv^Ca^v. > N vt > u^ a.
niKTinM.Xi'K
: Stall or < '1 iitllt ! \ '
.^^'.'n'u' ^ 0 (1
•^
U ^ I
u c
A.Ou>%^d.o
niK'nii'LACH
Of- iATin-:K
(Statf or (.'otuitry I
MA 11)1*. N XAMK
OI- MOTIIKK
UIK'rHl'I.ACK
oj- MOTHHK
istatt or Country^
oCCri'ATION
KtVi
rttluW-CV i\
A'f>/iff'if ill "^ii'i /'>ini,n/-t>
)%',!!> b .■•/.»;////<
/)(/ )
rm- \novK !^t\ti:i. pkksonai, rAKTicri.AKs aki: trik to thi-
IJKST OK MV K NOW 1,1; IX ".K ANH lU.I.Il-.l'
iU'.Si 1 ill' MN K M '%> !,•.»" >»• ' *A
n
Adtlvi'ss
S-^5
A.kX
t
nr RAP ION }'iuirs
CnNTU MU'TORV
Months
Days
Hours
DIRATION
(SIGI
V,'/
A
I go
Years ^Tonths Pays
I.A 4
(Address) HuUty^^t k
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyini] av^ny from liome.
Former or
Isual Residence
Wlien was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
ri,ACK. ol" RrRIAI, OK Rl'.MoVAI.
)Ap%<>t" ncKiAi, or ri;movai.
r.NDlCRTAKKR
(Aatlrtss
DSl
flL,\Ji^ V
U , . ,. . .pF oKni.Irl he stated HWCTLY. PHYSICIANS should
N. B.— Every Item of Information should b. cn.efully suppi.ed ^^^^^^^^/^^^^^^^^^^ Information- for pr-
state CAUSE OF DEATH In plain terms, that it may be properly ^lassitica. 1
son. dying away from home should be given In every Instance.
I i
n
» j ( ■(
. II
Ii()ar<l
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOB INaTRUCTI0N3
„f Hinlth- 1- Nn 1^ ^-^^^^nSiVC^
100
Be<!isti'red JS^o.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cettificatc of IDcatb
( tl. 5. StanDarO j
0 ^
PLACE OF DEATH: — County o^~'a.^^' ^^'
%
a
City of O <Xr>r\j 0 ^0-^^v^.^c.cA,ec
0
Dist.; bet.
eric
(
and
fNo. Ob i I i l.\_.V „ no,, Al RESIDENCE GIVE FACTrCAlJcDrOR UNDER "SPECIAL INFORMATION" N
( '^ rF^*7ATH"0CCU%rcVi;''rH0^s1.rAt O^^N S 'l ^U^O^N C.VE KTS NAME INSTEAD OF STREET AND NUMBER. )
JX.'^^V.AA.Xt
FULL NAME
-^^ QD
PERSONAL AND STATISTICAL PARTICULARS
A 1 COI.oR
OutUj 0\D^UaXV\w
4
Xo I
I>AT1-: nr lUK 111
,1
S_«w w-^
it. null)
A<.K
bo 5V.,,
as
(Day)
M,<»tli>
\ i-ar
/'..'
siNCl.K MARRIRD.
\vn><»\vi:i) t)K nivoKs'Hn
Write in -iM-ial ihsis-'iiation)
lUH TMJ'I.AOH
' Slatt or l'omitr\
NAM1-: OI-
FATm;K
lURTHri.ArK
(>I- lArilKK
^Stalf or Count
MAIDKN NAM I'.
Oi- MOT 11 MR
mKTHlM.Ail",
()1* M(niIi;K
(State or Count! \
OCCll'A riON 'l5\P
vt>v.L V
MEdlCAL CERTIFICATE OF DEATH
DATE Ol- J)1:aTH /i ^
(Month) •!>:>>•
(Year)
I ill'lRICIiV Cl'lRTtl'V, riiat I atteiiikd deceased frum
Rrsidfif ill S,!H /'i tnii/'^/'i>
<x 1 wcL
that I last saw h ■ alive on ^^^4^ I 190
and that death occurred, on the date stated above, at
M. The CAISI-; Ol' DliATlI was as follows
\^isJ\.Jr^^\^^
^.
\„iUL<XJUL
^n
(^i
aJ.
Mouths
DrRATloN Years
COST RIIU TORY
niRATION Years Months
.NED) AJj. Uj. j KyAJ: .x
Pays
Hours
f^ays
Hours
(SIGI
w.
11)0
f
Address) %X.'5 S \ I LvA.^^^ vv
^l.
M.D.
\
\ i
SPECIAL INFORMATION only '•"^ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying dway Jrom home.
M.»ilh-
/',.M
Till' \HOVK STVn-.D I'KKSnNAl. 1' A K TUT I, \ RS ARl', TRIl-: l* » TIIK
HHsT Ol-' MV K NOW 1,1; IX, H AND lU'.I.n'.F
(Infoitnatit
t\<liht-s O VO I I *" I I -'Wr
I) J
\J
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
n.ACK OF HIRIAI, OR KKMoVAl,
D\T4%of iiiKiAi, or ri;movai.
FNDKRTAKKR ^S^ J<^^^V\JkjU\J ^. d^K,»^^\.t ^
T90H
N B —Every Item ot' information should be cnretfully supplied. AGE should be stated EXACTLY PHYSICIANS should
■ state CAUSE OF DEATH in ph.in terms, that it m„> be properly classit'led. The "Special Information for p.r-
Ron« dying away from home should be given in every instance.
li'l
•^^.wwi;^
f1
r
t
WRITE PLAINLY WITH UNFADING INK
.•Sf^!!S.-cH5cl'Cn
1)
(lie FiJr<!, vJclrl
yJL\j IR
vja
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
-1
XCLC<-^ :^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of IDcatb
I 1:1. 5. StanDavD >
PLACE OF DEATH:-County ofdo/^ JAX^^- Oty ofOxX/^ ^'^^^JT^'^
No. I'iSb VJ/<XC4„i
i Vine. ^' SU 1 Dist,;bet.oU.^ - • vAAKAlyftJ ^^
b \J AXI.^ t ■■ ^roTAVlsirr r.X/r TACTS CALLED FOR UNDER 'SPECIAL INFORMATION ' \
^ 0 , I AND A
FULL NAME
^ a
AX\'l> ■ '
six
i) A I 1 « M I;IK 1 H
At,!-;
PERSONAL AND STATISTICAL PARTICULARS
C< >I,<»R /'"^
UIoJli
1^
/
H
M,»if/i-
11 at
/)„■)
(Viar)
W I now 1:1 > OK DIVoRi i;i»
'Wiitiiii -iK-i;»l (li**i^ii:it inn '
1 ^t; t ' I iT I 'i (tint I \'
NANtl «>)
I- A in IK
lUK 111 I'l, \CK
«»i I \iii»:u
' Stair or C'lmlltl \
M \I!iKN N\MH (U
(il MiilIIl.K
FSlRl'mM.ACK
Ml Mo'rHHK
I Slatf or Crmiiti ^■
MEDICAL CERTIFICATE OF DEATH
I mUilU'.V Cl'.RTIl'V, That I allen.k'cl (UiHa'^cl fn.iu
(' " ( if
lliat I last saw h ■ ' :«livt' on
an<l that death .ururre.l, «.n the .hite stated alx.ve. at
- M. The CArSI-: Ol- hl'ATlk ^vas as follows
lip
I) r RAT ION y'Ciirs ^ Months Day
CONTIUIUTORV
Iloiii s
(K'cri' x'lioN
Rfiitfi! in Siiti I i< ^
THl-AHnVKSTXTK.M'HKsONA, rXKTirrKNH.AKKTKrHTM TIN^
UHHT «)1 MV KN<i\\ l.I.IX .h AND lU-.I,!!.!'
(informant \J lUXKU -<J.
\-1.1r<
1X5^
DTKATION
(SIGNED)
)'iars
/hjvs //ours
M.D.
SPECIAL INFORMATION on'y '»f Hospitals, Institutions, Translfnls,
or Recent Residents, and persons dying dv^ay froni home.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death ? ^^^^^
How long at
Place of Death?
Davs
i'i,\ri: <)!■ Ri'KiAi, <>K ki:mm\ai.
OfPJb
l.NDl.K TAKl'K V/X
Dxiivi-r lUKfAi, iir ki:mo\ AI,
(i ct : ', ,90'
/\xn LC.
VAXl
^"'^"'^ ~ -Ho,il<l he Rtfited RXACTLY. PHYSICIANS should
—Hvery Item o* in*a.m«tion .hould b. cnrefully -pphcd ^^^'l^^^^J^^^^^^^ |„formaf.o„" for p.r-
•tate CAUSE OP DEATH in plwin term«. that it may be properly wlassiiiea. 1 nc 1
non9 dying away from homy should be (|iven In tsvery Inntance.
?;i
r
t;
// ,
f.
^u.
f
l» 1
WRiTE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,1 ,.f Hinlth r N'
c-ParK^4- lUKii' r
Dale Filed , \ji€
]le<!i^ferc(l J\^o,
Deputy Hcoith Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cevtificatc ot IDeatb
( "U. 5. 5tanDatC> )
PLACE OF DEATH: — County of
City of
n
CXAAJCIV.
No.
St.:
Dist.; bet.
and
.. OCATH OCCURS AWA. .ROM USUAL ^--^^--^^^^d^^l .'^^^J s^^^E^i^ D ^^^Jsi;:^ ^ ^ )
( - -*v:;:f o^cjR^vrA:<^^L ?« t^s.;j;to; oive .
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
-■r.x
A
<xU
C(»1,<»R \ A
i» \ ij; I >F 1.1 Kill
\«U'
Mnlllll 1
^
) ,„
IC
ll);ivi
M ,<rh
ar)
MEDICAL CERTIFICATE OF DEATH
DA ri-; ni- i)i:a 111
I Year)
/),;
sivc.ijv M M< i< n'.n
WlDOWl'l) OK 1)!\ ' "■ > ''>
I W'l it<- ill MK-ial .li '!■ . ' " '
U-C^XO'Ul
/
BIKTHtM.X*!:
(Stati- or t'ouiiii s
N\M1 ni-
1 A III I.K
lUHrill'I, \^ 1'.
(»1 r \ 111 I'.K
isialt 111 I'inintt %
\! Mltl- X NAM J.
(d Mollli: K
lUK'nilM.Afl-;
oi" MnrHI«:K
(Stall- I'l Ciiuntt \
I urri'A rioN
f\'fu,lr,f III S,ni /■/!//'< /"■"
VlUu V
u
/~-,
1 inCRl'lJV CI'RTIl'V, Tliat I aUcii.kMl .KHAascd fmui
— up to '^
that I last saw h - — alivf nii — l<)0
ail.l that (Irath niHurrcl, m, llu- -late ^tatcl above, at — ^
yi Xhc CAISI-; Ol' I>i:A1 11 was as follows:
nr RATION y'crs
t nNTKIIU foKV
I )r RATION
Mont/is
/hn
Hours
(SIGNED)
I<)0
Mouth:
Pay
V
I lours
M.D.
Ri
5
M.nlfh'
Ihl
■VnV MM.VKSTAlKI)l'»'HSoXAI..-AKT!i-rKXK> XKl- TKtH T. . TIIH
lll'.sr OI MA KNOW l,l,I>r.l-. AND ISlMI I
SPECIAL INFORMATION on'v •"'^ HnspitaR, Institutions, Transients,
or Recent Residents, and persons dyinq dv^ay from liome.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
ri.Ai'K <»i>i;' Ki\i, oK ki:mo\ai.
DAIJ; 'if lii in\i. <'i K1',M<>\ \1,
II \
TQO
N. B.
. . ^, A»'i Mhoulil be stnte.l liX^CTLY. PHYSICIANS nhoiild
.r.ver.v Item ol" Information should b. cnr.full.v Huppl.cl. ^^ ;J; ;^;7,'^'.^^^^^^^^^ ...Spe.l.l In»orm„tlo„- for p-r-
mntc CAUSE OF DEATH In plum tcrm«. th»t it m.iy be pr..|.crly wlBimitieci.
nons clylnft away from home «houltl be ftiven In .very InBtnnce.
3
•r^'
•Ml
4M
H
1'f
WRITE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD
REFEP TO BACK OF CERTIFICATE FOR INSTRUCTIONS
..! ,,f n, lUli !•■ N'' i -
\ ' D e ^"^ u
Bci^islcrcd J\'o,
2441
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Ta. S. StanfatP )
Qi;^
No»
PLACE OF DEATH:-County ofdo^TV kc^oc^c^City of ^.xn^ J ;v<X..x.^.^^
Dist; bet.
)
, ^VLCLV; ..:.. XJ^\\-'- >\'K/.-.. .S^l**.-^^^. rACTS*CALLED ^OR UNDER " ' S P EC I AL I N FO R M ATI O N ' \
/ ,. DEATH OCCURS AVVaV FROM USUAL " f f ' ^^^.^JV^^^J "^', /^ItI NAME INSTEAD OF STREET AND NUMBER. )
( IF DEATH OCCURRED IN A HOSPITAL O (^ INSTITUTION GIVE
FULL NAME n I lQ
[lla, ^K
4
si;\
DATK OF- lUK 111
A<'.H
PERSONAL AND STATISTICAL PARTICULARS
s« il .< tK
\
lA.
M.nith^
HS
r
M,,„n,
■>iar
/>./
IQO
iVeai )
-IN'.I.i: NtAKKI! 1>
\\II)< lU in «iK 1M\ « •K»i;l>
iWt itc ill -..i"i;u .l.-i;.'i!at!..ii)
iuki'hjm.aim:
I Stntf <•;■ ioiititi y
NAMl". c)|-
I athi:r
fUKIin'l.A'JC
oi- lArilKK
iSlutc or roniif rv
MMIU-'X NWtJ
III MoTin: K
iiiiniii'i,ArH
' vciti , ,1 (.'(Hint I \
n rri'ATlDN -V
K
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH [A i
I'M. .nth) *J>''^'''
1 HlRl'llV Ci;RTn-V. Thai I alUMi.lcd (Icctased from
0,t.t' !'i i,o'i t„ .A?^fc n TooH
that I last saw li alive on ^^ "' ' ' ^<^P '
an.l that <k-ath occurred, on the .late stated above, at
AT The C\rSI': Ol' 1)I';AT11 was as follows:
X ' , f
'^
5^
.Cti
-5^'
DIRATION
CONTRlP.rTORV V. I
liotit s
^
DTK AT ION )?J?'*^ Months Pays Hours
(Signed) vu u.
iD^tt 1% u,oH (Address) q%-lNf>la)vL
M.D.
SPECIAL INFORMATION only 'or Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
ui^
( r)
r
M,.,itli
/>,
TUKAHoVK.TXTKnrHKSoXA. rAKTJ;;, ^. X K . A K ,. T K I V. T. ^ T. . .•
Ul'.ST oI- MV KN<>\Vl,l.I)<.h AM) 1.1 ..HI
f Infotmatil
\.Mi
1
,c
(
di
5R?^idencA3^-<^.-«^^^^^k^-^ Pll^e'roJlth ?
When was disease rontrarted, b.^f^.^^ 5l^ AnAfsK].
If not at plare of death ? l^cleXMX cM>. U>cxc4.^; ..-
Days
I'l \CK Ol- lUKIAI, OR Kl-MOVAI,
■ c
CU'^rXt
L ^ '.
IQO
!)\ri: .1 !'.<!.• I A I, or RKMOVAI,
fAcMre<*s 'Oat) wOXi
1.
^s) .. , .^^ „u„,.i,l ha fttated EXACTLY. PHYSICIANS should
*on«*d>lnft away from home should he ^Hen in every inntHnce.
51
•'I
■U'
'I
I
I
i
Is;
i'ly
1^
T^yf^irr
IPSS'^
,,f n. M'th i- N.
WRITE PLAINLY WITH UNFAD.NG .NK-THIS IS A PERMANENT RECORD
BFPER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
2,9^1
Registered ^''o.
ck.O'^^*^
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
PLACE OF DEATH: — County of
Nollu 1 mcb^xxrvM, It ^^iv da \. St.;
Certificate of IDeatb
City of jV. l ^vC v.*
Dist.; bet.
and
)
( " r"o;u"»ct%'"".:*°" ^"-.^r.t -?:?i^',^rj,;r,;iV.^«7 ,x."r^? s;%%%Ti:r.°:i"r ■ )
DC^URRED IN * HOSPITAL OR I
0
FULL NAME
-r\.Ub
cnr
•tr"^ \ \^w^.L
4 ,
sj: \
PERSONAL AND STATISTICAL PARTICULARS
0(\^.
DAi'i; tir r.iKTii
M.V.
rV
O K
M.iiith)
1\ .V,.,
(Day)
M.iii///'
/),n.
MEDICAL CERTIFICATE OF DEATH
DATE 01 i)i:ath P
64xt 11
(Montii) 'I^^'V'
/go 1
(Year)
I H1;RI:BV C1;RTIFV, That r attrn<lc.l (U-ivasod from
- TOO
— — IC)0
— — — — — —1 90 U)
that I hist saw h ■' alive on
^IN«. I.I" ^t \KKI1".I>
\\ in»»u 1 !• t>K i);\<iK»i:n
iWntr in -iH-ial ,1. -i;-- tiat Mil)
niRTin'i.x^'i"
I Stritf of i''>nnt 1 \
?
V
NAM I rtl
FATniR
lUUTm'i.MH
<»l- JAI'UHK
(Stat«- i<r v'liuiit vv
MAIDI'.N N\M1
nl" MoTIlKK
nikTIirUAOK
()»•• MOT HICK
(Suite nr cNiuntrv
au<l that <Uath occurrcl, on the date statiil above, at
M. The CArt^IC or I)i: ATII was a-^ follows
I )r RAT ION >Vt7/-.s
CONTRIIUTORV
Mi>ui/is
/hn
//()// rs
"N
\
occri'A'i'ioN -H \i
C ) 0^^ ^ ' •
Fr^idnf ni S,!ir I'l '"/i '>
I)!- RATION
y'l'jirs
■^S'
(Signed) w
T()0
^ ^fe
Months
Ctv
PiU
•s
/lours
M.D.
(Address) fCiCTr-VcWX^
SPECIAL INFORMATION on'y Jor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying a\*ay from home.
)'rii I
yr,iiit!n
(liifotmrmt
1\
ai.^a.v...
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
1'1,ACK (^l- lURIAl. OK RlCMoVAl.
I NIU-.KTAKKR Ck N I W ci^-^J
i)\:ri;.>! lu kiai, or khm<»vai<
190
Uxkt
3P DEATH \n plain terms, that it mi.y be properly UaHS.Hcd, I he »pew a
N. B. F.very Item o*
^o^.^dytn^/a^^y from home «houUI be J^Uen In every instance.
I
WRITE PLAINLY WITH UNFADING INK
ii.iMh r N'
Dafr Filrf/, U^cIvImA; H
7-9^? H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^
..trVAA^ :Kx.. ^^l!
«i
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
i
Ccttificate of 2»eatb
1 -U. S. StanDarD )
-?
(jj^
PLACE OF DEATH: — County
}(\jJ^
O^^) St.;
Dist.; bet.
and
Mn CJ JL^yW^CC'^^X' y^ <ML.']n.A/^C>-''V' J>tM t^CTS*c'itLED rOR UNDtR -'SPECAL . N TOR M AT.O N - \
FULL NAME ^
V
LccA^V*
-^i.x
i>\ ri: <>i lUK in
A<-j";
PERSONAL AND STATISTICAL PARTICULARS
n
^ W.V
1 mAiUIi)
x%
Dav
\f,<nlln
ui)
/'.M
\\
I go
\vnn»\\ i:i> <>k l>;^ ' '''■'''.'■''^
(Writf in 'filial .1. -ly nat u-ii)
^
X/^
ii
II
lUK rin'i.ACi'
"^t ;iti- I ir t'outit 1 %• '
NAMK OF
FATIll'.K
lUR I'Hl'I.ACK
i stall (ii I'onntry'
M \11H:n' NAM1-:
oi M«)Tni;K
niR rm'i.Aci-:
i)V >t<)l'nKK
(State 111- C'osuUi V
MEDICAL CERTIFICATE OF DEATH
DATK OF 1>):aTH (("\
(Month) <l>='^'^
1 III-RI-BV Cl';i<TlFV. That I atlen.kMl .leixased fn.m
Q^' i:^i<)oH to Get i% lOoH
that Mast saw h ... alive on ^^ '^ ^^''
ana that <U-ath ocmrrcl, on the date slate.l above, at il
OL M 'I'^i*-' C M'SI*: Ol" Dl-'.-Xrii was as follows:
^owkkA^^nxxX^x^ J fr->-%.^Ma„^
\.Ow4
/
1)1 RATION
> 'cars
'ar% Months '\ Pays Hours
}V<7;--V
XH
r^
Hours
m-RATIoN ^
( SIGNED )M')\ '1 : CrU^'>-^ ^ IVI.D.
Oct) 1 ! TOO (A.iaress)1:lxhyv>AXX/Vx. IdCHvVvv.Ui
t.^vv.L<x,l.
SPECIAL INFORMATION o"') '»'■ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
oCCri'ATION
)V,;/
M.nilln
In
m,sro,.>^-KN,nv,.,.....K.vN'^-'-'"
f \<lilrc»is
Former or M'^ fs
Usual Residence ^ ^^
Wlien was disease contracted,
If not at place of dcatli ?
Wi
\ . How long at
4rrA.A ' Place of Oeatli ?
. Days
I'l \CK <>1' lUKIAI, OK Kl:MoVAI,
DXTKof Hi HiAi, or Kl%MoVAI,
0^
ac
190
J'
,, . TfiE .hould be stated EXACTLY. PHYSICIANS should
^. B.— Bve.y Item of Information should h. c«r«Vul.y ^uppHed ^^«P;^^;-.^^j„,j. ^^he -Special information" fo. p.r-
-tate CAUSE OF DEATH In plain terms, that it may ne prop 9
'on. dylnft away from home should be ftlv.n In every instance.
m
!|
WRITE PLAINLY WITH UNFADING INK
Board ..f IKnltl. K No i« 1--~.-«^^. KM ■ —
190\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
He o^ist creel JS.'^o, /^444
\
11
I
«
Dale /v/r^/,y/^<rWv) 1*^
cSuji^^c^ Ajia>u. err*
DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco
Certificate of "S)eatb
( U S. Stan&atO )
PLACE OF DEATH: — County of ^'CVnrx; 0 AXX^ .tc^ .(l..ty oi
No. ICbll Mltc^.*v
... I
St^
Dist.; bet.
s
(I
1v
and
+ 1
)
^^^ A.^*.^!..^ ^-^-^ ,,wP,rB "special INFORMATION" ^
.V ,„„« OSU.L RESIDENT O.V_E/.CTJ C^.^LL.0 :°A,7o"r ST-"eT .NO NU«SC.. J
( " °,"-.r^.^=.%'-r;,':r„o"s^rt r„^?;?f,?.<=4rc^;r,;i .»m.^.s.»o o. s..^.. ..o .>.„,»
FULL NAME 0-IaX'va^Aa
A'
t (0
v\.c.
PERSONAL AND STATISTICAL PARTICULARS
'i'
i)\ri-: «)!•' luK iJi
Ai.H
aJ
H
)
iDiiv)
1 /,-;/'//'
/ R D 0
(Year)
/hiv.-
MEDICAL CERTIFICATE OF DEATH
(Month)
11
(Dav)
/go V
(Viar)
m\-«.i.i-. M \Kun:i)
NVinnUl'.K <>K I)IV«»KilJ>
iWnlt in -iK-iul ilt-i^'nati.'n)
lUKTIIlM.Ai'l".
(State i.r (,".iiuiti %
NAMJ-: <M
lATHl-.R
HIHTIMM.AiK
OI- i*atiii:h
(Stiiti- or (>'oiintrv
MAIin-'.N NAM I
()1 MoTin-.K
I HRRKHV CKRTII-V, TIkiI. I attc-n.lcl clufva-^^'l fnmi
i9^ ii 'V%. toi)-tt ii ;^;..<,oM
that I last saw h.^riK- alive on ^-' ' ^'P
a„,l that <U-ath nccurre.l, <.n the .late '.tated above, at
^^ M The CM'SICA?!' Dl^ATlI \va< as follows:
^ * ' ' V) I i 1 f . ^ .,
nrRATioN
}'ia/s
i\ font /is
CONTRIIU-TORV U^^a-^^^ nTKa.!
/)uy
J /ours
r>
•
niK'rniM.Ai)-.
OJ- MOTlll'K (\ ft
(state or CoJintryt \A U .
occri'A rioN
Rf-iiinf in San /'iiiinr',n \ ) > <' ' ^
DVRA'YIOS
(SIGNED)
}'iars Monf/is 1 /hivs
^
iD^cA. ri too'. (Achlress) 501 OAA±i£A. M
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institufions, Transients,
or Recent Residents, and persons dying away from liome.
Mnuth-
IIKST <11- MV KNllWI.I.D'-l-. AM)^I1I. 1.11.1
<,.,f n, QxtjOv 0" Urv^^^tA.'
Former or
Usual Residence
Wtien was disease contracted,
If not at place of deatli ?
How long at
Place of Deatli ?
. Days
V\ \CF i>l- lUKIAI, (»K RKMOVAI
I»\lU:;<)f Hi lUAi, or RI'"M«»V.\I,
(Address I ill ^\\AJ^\-<nX
ct \H T90H
N. B.-
-F.v.r, I.cn, ot l„«„.n,».lon .hould be cnr.Jully -""•''«;;• *;?p^.,tTl«^Wl'"'°Th^:''*8p^cW inWn,...<.n" Jr ^r-
.tate CAUSE OF DEATH In plnin term., that it mBy Be propeny
«!!. dy*n» -w., from home .hou.d he »Iv.n In .very .n.t.nce.
|1
•;•'■♦
WRITE PLAINLY WITH UNFADING INK
15' 1
',! ..f ll(.:iith'- \' N'
■r, nSil' Ci>
1!)0H
Dale riU-'l,^^cXA>^^ 1^
DEPARTMENT lOF PUBLIC HEALTH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
City and County of San Francisco
Ccvtificate of IDcatb
( 11. 5. 5tanC»arO )
A
PLACE OF DEATH = -Countyof6,CV^^- ^
.City ofO^<^^-^"^ 0/MX'%vcw-^c.\.
<,^
^ \ I 0 A»-\ lex > "^ St.; ^ ^^^^** "^'* V«o HMDER -SPtCIAL INFORMATIOH" A
V IF DEATH OCCURRtD IN A HOSPITHi. wn ^ ^.-^y^ p, ^
)
FULL NAME
,<Lv-\XXAXX'
Qn>
f
V
-J
rvOL ^ \..
si;\
DAll-: t>I- lUKTII
AC!'
PERSONAL AND STATISTICAL PARTICULARS
(.1 il.t >R
i.1
V-L
M
\\ A\h)
5V.M
Mnnlfn
\
\ 1 ai
/j|! i
MEDICAL CERTIFICATE OF DEATH
DA rH Ol' Dl'Al'H
-N
\^i
NtDiith)
(Vtar)
(Day)
I ni-Rl r.V Cl'RTlFV, That I attcii.UMl aeceased from
that I last saw h - • alivi- on ^ ^••^- ' ' ^'^^ '
a„a tliat acatli nrcurre.l, on the- .latr .tatcl ahnvr, at I W
M. The CArSh; Ol- Dl-ATll wa>^ as follows:
siN( ,i,i- M \KK n: i>
wii)t>wKD oK d:v.»r< KI>
(Uritcin --orial 1I1-.1K nali' <i>
luk rm'1. \oi'
I stall . 1! t lUiiti y
>VQ ^i
.V si.VCX
I
.M . 1 lie V .\* . ■ " -■ • --S
N \\n OF
1 All! I'R
niH rniM.Aii':
01 I \ rin:K
IStatt 'a I'mnit 1 v '
(U Morill", K
lUK'i'nruArj-:
oi- M«nin".K
(Slat*' lit Country'
J .1
> V I ' ^ >
.cL
yTVQwCO.
DT RAT ION >V.?r.9
coNTRir.rroRV
Moiil/is
Ihivs
Hours
^
^K
(\JL
JUJ^
LLC
lt\
^
I )r RATION
(SIGNED)
(I
iLloi
T<)0
)V<irs .J^fonths
(Achln-^s) liiH
/hivs
'^
//oNrs
M.D.
0 (VAACr-v
\
SPECIAL INFORMATION only lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
) .ill -
n a
I yr,<,i!fi^ js. -} /^'"'
oCCfl'A'riDN
R'-iiffil ill San I I <!"' ''< ''
T„K.HnVRSTV,H,.,..K...N«. rU<nrr;.AKS,.KirrK,H TO THK
UKSTol' Nli' KNoWI.I-.IH.h AND HJl.ni
(liif'iMuant
^^,\^ <31
rAXX/YX >A ^
Former or
Usual Residence
When was disease (onlrarte<l,
If not at place of death ?
I'l.ACJ" nl- lUKIAI, c»K Rl.MnVAl
Now long at
Place of Oeatli?
Days
,a.in..s 5 ULox-ctc^^A.^^
D\l"i<^>i! lUHiHi «ii K1':M<«\'A1.
M
-V>A/^A^ ""^ LL
I
\ I
^■^■•■■•■^-iB^ii"""^""'^'^'^"'^'''""'"'"^"^^^'^"""'^"'"""""^"'"^"'""^^^^^. I I H t t I f'X4CTLY PHYSICIANS iihould
:".%y*n» .w°I^ "on, horn- .h h. ».v.„ y ."-..nc
;i 'I
^^
I
4
I
f
M
I*
1!,,;,',1 ,.f II. .lllll 1' No. P
WRITE PLAINLY WITH UNFADING INK
liScV Cn
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re^ititercd J\f''o.
Dale FiJ('(l,\)'zkA>JLhj \'=\ l''^0'i
^r^A^ ItA^u, Deputy Health OfHcer
DEPARTMENT UP PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
{ XX. S. 5tanDarC> )
^Ui
PLACE OF DEATH:-County ofUa>v ' VO. v\ City of H <Xo^ OAXXyxCU -
ff^o. v.. k L Idn^im^ 0 to (K i xaI u.
St.;
Dist.; bet.
and
V IF DEATH OCCURS AWAY fNoM USUAL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
( Tr DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
sl'X
PERSONAL AND STATISTICAL PARTICULARS
[YlcJU
DA IJ: < >I lUK I'll
\«.i-;
At fi I
kAJ^ 1 V.
1"^
ns
):,;i
M,,>,!ll
'i lal <
/>(/ 1
si\( ,i,i" M \RR ii:n
\\ii>« >\\ i.i» OR i)!\ » »Rtj.:n
'Write in '-mial «li — i;.'!i;tlii m)
' \
c3 £^-^ 0 ^ '--
I- AT 1 1 l.K
HiR Tui'i, \*i-:
ni I \ in I-R
i St. it I 1)1 t.1 Ml lit I %
MAIDl.N NAM)
ni' .motiii:r
niR'I'Ill'I.ACl".
nl- MO'I'III'.R
(stnti I ii ^^<lult I \i
Rr^iih'd III Si! It I') ,1 til ! ••fit ^ ^rni
X. on^rc W4.-(rr^
\,Ojyr\)
" M, III I In
I his
xnv \n<)vi-: st \i*i:i) pkrsonai, pARiiniAR^ ari: iri 1; r< > i in-
iii;sT en- Mv KNoui.i'jK.H ANj) iu;i,n:i'
(Infiniiiaiit
a)
/A<l.lri'
MEDICAL CERTIFICATE OF DEATH
DATK <)!■ I>i:aT11
TOO
(War
(Mr.iitlO (Day)
I IllvklU'.V CIvRTll'V, That I ;ittcMi<k«l (Urcascd from
I9O to T(/5
that I last saw h ■ ahvt- on T90
and that «Uatli occurred, on tht- date stated above, at o- oO
(j M. The CArSIC Ol' Dl-ATIl was as follows
« ^% %\Ki
%'^^
DTK AT ION )'tiirs
CONTRIIU roRV
Mouths
Ih}\
DTK AT ION
(Signed )
i<)n
)Vr/;.s- Mo)i(ln Days Hours
\j\jO<XAjxX.s. M.D.
(Address) Ck^XdAjtAXa ybo^^kjint
Special information «n!y for Hospitals, Institutions, iMnsients,
or Recent Residents, dnd persons dying dwd> fro.ii home.
Former or
Usual Residence
When was disease contrarted,
If not iX place of death ?
How lonq at
Place of Death?
Days
IM.ACl-; <)1- m RIAI. iiU KKMCiVAI,
DAXH"! I'l KiAi, or RKMoVAI,
iS. B.-— Bvery Item <»)f inlror«mfition should be ciirufully Htipplltfcl. A<iK should ha ntiited fiXACTLY. PHYSICIANS nhould
utntc C\USr: or DHATH in pliiin terms, that it miiy be properly cluMKh'ied. The "Special inform«tion" for p«i—
Rons dying away from home nlumld be given in every instance.
')!]
V
Hi
i
■J
%
r
Ifcl i\
J.,,;,.-.] -f It^ Mllh I N
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2447
-^'^^nJS^l'O
Deputy Health Officer
lie^i\stered jYo,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Q^
Cevtificate of S)catb
( -Q. S. StanDarO )
PLACE OF DEATH: — County ofC Onrv on.o . -^.; City of
ana; tLjJUl ^ n
No. "^t^^^Wv VJHLi^X dioJA-v. St.; Dist.;bet. and
V
" ' ■•eiijii DrcinriMrr nwr facts called for under "special information" \
( " °,"„;".TH"oCCU%rc","rHo"s^."*' O^f^s'^U^'J^Vr,;! NAME ,«ST»0 O. ST«.T .» O NU-.,. J
FULL NAME
SI A
PERSONAL AND STATISTICAL PARTICULARS
IclL;.
a'
i) A li: < ii r. IK I'll
\^.\\
rlkd
MiiiiUi^
I'l
)■,,/»
Itav
M.'Uili.
S'cal I
A;
SINT. I.T' MARun:i»
WFDOW i:i) OR 1>I\ < »Rri;i)
X
ova
igo \
(Year)
MEDICAL CERTIFICATE OF DEATH
I>.\TK in- Dl.ATH
(Ml. nth) (I>ay)
1 IIICRMBV Ci;RTn''V, That I atteinkMl tkn ^ ased from
to ..•• IqO ■"
— ~— — " "" 190
190
alive oti
HiRTin'i.xoi-:
( state 1)1 CfiutUi V 1
i
Ox- ■
NAMK OI-
FATIIKR
niRTIl I'l, ATH
01 i.\iiii:R
(St.ile or Coiuitry)
maii)i;n namj;
oi- mothkr
HIR'rmM.ACK
OI- MOTHKK
(Statf or Country^
OCT f RATION \
. ^ 0"''
Kfsidfd in
Siin /'/ lUh r-rn
(1
A
\r,'nllis
/'.l^
Till" AHOVK ST\ rin> RKRSONAI, R \ R F IT f I, A RS AR1<; T K l" !•: I'o Tin-
HHST 01' MV KNOWI.ICDC.H AM) !',1:M1:i"
(\
/vv^t-^u
that I hist saw h ^^
and that death occurred, on the <hite state<l above, at
■JZT" M. The CAlSh: (>!• I)I';ATII was as follows:
W M
a..<Qj^^ en , .\ - ■ ' .
I )r RAT ION }'t'ars
CONTRir.rTORV
Mouths
navs
Hours
DTRATION
1^
Ycixrs
( SIGNED ) Lcr^unAXh^
m
MotUJis
Pavs
Hours
M.D.
^kt
\ 1
iQO
(Address) L^rXTAj^V;^ C^.U\-
uti^ns, Transients,
SPECIAL INFORMATION only lor Hospitals, Instit
or Recent Residents, and persons dying away from liome.
Former or %v^ ^
Usual Residence VI 1 ux^, »v
When was disease contracted.
If not at place of death?
o
, How lonq at
^ Place of Death ?
Days
I'l.ACJ", Ol" niRIAI. OR RHMoVAI.
V. V
.t
DATi: of Hi lOAi or K1%M«)VAI,
NI)1;R TAKKR V-
-CU
U^^^x/cLt^XaJw
&-M.>-^Jx JX...
n
Item of Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
;AUSE of death in plnln terms, that It may be properly classified. The "Special information'* for p«r-
N. B. Every W
•tote CAUSE
sons dying away from home should be given in every instance.
»
I
i I
^mm
WRITE PLAINLY WITH UNFADING INK
/>^/
/(' /v7f'</,U/tLt<rlj-Ov ao
7.9^H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS
Bo ^i tiered ^^o, ^448
Deputy Health Oflrlcer
DEPARTMENT^OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH:— County
Certificate of ©catb
( Xl. S. StanDarO )
J? QT^ "^ ^
Dist.; bet.
pro; V^WV ^ v. ^^^^ ^^^^ ^g^^j^ RESIDENCE o.vr r*cTS calued .c
( [^r DEATH OC^JRRED .N A HOSPITAL OR IN^UT.ON G.Vt ITS NAME IN
TS CALLED FOR UNDER SPEC
STEAD OF STREE
— and —
lAL INFORMATION" \
T AND NUMBER. /
FULL NAME
\] J\Xk.^^<i.<A VDcx.
Ill
MA
PERSONAL AND STATISTICAL PARTICULARS
r< >l,t >K
l>
L(XU
i).\ ri: or- iirtii
\ ' ■. !•:
(Month'
I I • <:
1
.1
Dav
Mntll/lS
liar)
/'..')
viNr.l.l.-. MARRli:!)
\vii)<>\\'i;i» < >K i>;\i •Ri.Ki) 0
Writ' in "-'"ill ih •~i).'nat imi )
niKrjn'i.Ai'K
(Stati or t:i>«uUi V
I- ATIH.K
HiK'niri,\t*K
oi- i-Arm'.K
(Htatt 111 iNnintt V
MAini'.N NA Mi-
ni- MdTHI'.K
iUKrniM,Ari-;
oi- MnlMKK
(Statf III i.'<)nntr>
MEDICAL CERTIFICATE OF DEATH
DATK ol- DllATII
W,ct
TQO \
(Year!
\S
^^-^f^
<XN^CL
*w^ruuou>^
Ofv
h',-^iifrJ III Sun /'niih ni-,i i
1/,./////.
/),n.
Tin- NHDVl- sr\Tl-'l> I'l-K<nN\I. I' A K Tl*' r 1, \ KS AKi: TKri- lo 1 HI-.
IIKST «)I" MY KNmvl.l-JX". 1-; AM) HI I. II. I-
(I
i
tifi>imaiit >J
ll
(MontJO (Day)
I in-:Ri:BV CliRTll'V, Tliat I atteiKkd (Uncased fruni
lD^.t \'i 190H to. ^^ 1% - 100 H
that I last saw h A. >. alive on \J <:X> 1' 190 .
and lliat death oeciirred, 011 the dati- stated a1)()ve, at H-OO
M. The CAl'Sl': Ol' Di'lATH was as follows:
.^.
DlR.xriON }'t\irs .l/<>)///is 1 /hjvs //o/ns
nr RAT ION
(SIGNED)
i ic)0
) 'ill IS .Vonf/i.s
PiU
'S
v^
(
\ddresK)Lctu V.Co Ob
SPECIAL INFORMATION only for
or Recent Residents, and persons dying away from home
tlbspitals,
//ours
M.D.
Institutions, Transients,
^
H?sH uxaAci^,l
Former or
Usual Residence ^ CM. UJtaA.c^
Wlien was disease contracted, ^
If not at place of deatli ?
How lonq at
Place of Death?
Bays
DATl'of HiKi.^l, or RKMOYAI,
..^^
cu^X.'
i
,S,„l„.s Llt^V \U. (fo M^'^.wLcx.
ri.ACK <)!■• lUKIAI. <»R RKMoYAI.
rM.KRTAKKRNnC j ^{icLl^ W \£^ 'tia'dH^ J
190
r~E)
5
r*
„ B — r.verv 1.e,n of info.mntion .hould be cnreffully supplied. AGR nhouhl be statecl EXAgTLY PHYSICIANS should
Itntc CAUSE OF DEATH in plain terms, that it may be properly .lo««lflcd. The •'Special information" for p«r-
nnnm dying away from home should be given in every instance.
I ■
m
i
WRITE PLAINLY WITH UNFADING INK
„.,nr.l of n. allh ■ F No. .. ^^^^UScV Co
I
Ihffc Fi/r(/,AjxXd>-V\^ AO
190 "i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^
2449
Rci^Lslered ^'^o.
I «
Officer
DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: —
('No. '^\ ^ ^-^
(
Cevtificate of "2)eatb
( la. S. StanDarD )
County of OOLA^ aK,ao..c<^- City of OO/Vu 0 A.a
St.: 9v
Dist.; bet. Wt^J^. and J
'Y .. ••CIIAI RF«5IDENCE GIVE FACTS CALLEdAfOR UNDER "special INFORMATIO
' rF"o;ArH"oc:u%rEVi;''rHOS^p?T*At OR^^Is'^JV'o^ O.VC .TS NAMe(J.STEAO of street ANO NUMBER.
FULL NAME
. y%/CA„ si C C
AA4/t
..)
^'■■•^' Q5?i
PERSONAL AND STATISTICAL PARTICULARS
\^\v\■. or r.iKin (
L
V
AC, K
t:
I Motuhl
I 5 V,7 /
SIN«-.1,K. MAKHIl'.n,
WinnWI-:!) OK I)IVoR(Kl>
fWrifciii -.(K-ial di si.,niali'>n )
(Dav
i Mnulfn
( lUuvvOL-cL
i car)
Pa 1
MEDICAL CERTIFICATE OF DEATH
DAI"}-: ol Dl'.ATH
I ' t
i I
(Dav) (Year I
niRTHPKvci.:
(Stat? or ("ountry
VWTl' ol
!• A III l.K
RIRTinM.XCl',
()t- J \rm-:K
(Stall (II (.'iiiiiitry
MAIDI'.X NAMH
OF MOTHHR
lURTHrUAlK
Ol' MOTIIKR
(Slatf or Cntjntry)
J (rLtdU
yy\)
XXJ^^~
\
(Month)
1 HIvRlCHV CI;RTIFV, That I alloii.UMl <U'ivased from
— icp to .— ^ — — — — -Tqo ~~
tliat I last saw h ••■^— alive on 19°'
and that (U-atli occurred, on the date stated above, at
M. The CAISI*: t)!" Dl-IATil was as follows:
ijLcAJtv^ '^ M\XaJjvcJI U/txWA,A.tn;
4.^..
I )r RATION Years
CONTRIIU'TORV
Months
Da vs
Hours
Years Mouths ^ Ih
^ . ujVcrnJA; J Ah-Uj AiXc
iPtt XU TooH (Address) U\^r^a->uAlk^
SPECIAL INFORMATION only for Hospitals, Institutrons, Transients,
or Recent Residents, and persons dying away from tiome.
OCCI TATION
Kfsidfil in Sim I'liiniisrn
t-
)'ra I
M.iiith'
/),i\.
THK M?OVK S'l*\Ti:n I'KKSONAl, !• \ K TI'T 1, A RS ARK IRIK TO Till-;
liKST Ol MY KNOWI.l-.lx.K WD HI-. 1,11'. F
(lllfottlJMIlt
C . a. u^^..-.
A<Mr<.ss Alb
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatfi?
How lonq at
Place of Deatli ?
. Days
I'l \CF OF' nrRIAI, OR RKMOVAI. I DATF, of HfKlAi. or RF;MoYAI,
»-ni)F.rtakf:r Lv- UJ. xH^^O^AltX^ ^ ^ Lc
(Addresjn
N. B.-
-Eve.y item of in?orm«tion should be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
^tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information- for pr-
son* dying away from home should be given in every Instance.
^
* 'I
•
H -i
WRITE PLAINLY WITH UNFADING INK
, fit '■', IX.. ^ t-*'-s^^, H&l' Co
ll
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered .Yo, «-t.>U
Dale /'V/fv/, ycl<rWv 2lO
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
{ 'd. S. StanOarD )
PLACE OF DEATH:-County of 3 c^^ i^cx.vc...^Oty of O^XAr^ ^AXX^-vc^e..
,., ILN^ A K, . ■ St.; A Dist.;bet.MU,MKUru.cJfx and
No. CKIOOO ^ > > •- ocsiDENCEOlVt r.CTS CLUED roR UNDtn "sPICI. INFORM.T, ON- \
( " r,"or.T°"oCCU%7c","r-o"s^"*.U o"?»"?u"o';''o,VC ,TS NAME ,»ST„0 O^ STRICT .NO N U « B C R . ^
c
FULL NAME
U,'va1:; \-CKo\\
V
ff,.(
L^U
PERSONAL AND STATISTICAL PARTICULARS
>-l-\
QTl
1» A 1 i: OF' lUK l"I!
A « ^ H
I Montlii
111'
1 I '
il)av>
Mo,, Hi
\ larl
/'(/I
wint i\\i-:n or nivoKii:!)
(\Vrit<iii --iHi:!! .U-si^nati'iii)
BiR'i'm'i.xoi-; \
(Statf or Cimntry I -A
■¥-
MEDICAL CERTIFICATE OF DEATH
DATE OI I)i:ATn {C\
VA> ^"
I go
(Yt-ar)
(MoiitlO (Day)
I ]I1.:rEBY CRRTIFV, That I atlciitkMl dctcascul from
lD.ct. l\ I904 tn 19^ lA IcpH
that I last saw h ^ alive on W C^-- : . T90
ami that death occurred, on the date stated above, at 10 l
UA >\ n
NX Ml* (>!•■
!■ A Til i;h
U
HIKTIiri.ACK n /I /V^
Of i-Arin-K y U \m\
I stall- or Countivi -'A X< I
!IK III I'UA^ I-, A *,^
»!• MoTHKK y (XTN
Stat*' or Couiitiy^ *A w l^
M Alius N \M1-.
()!• MOT 111". K
HlRTlirUACl-:
.rLLc
J, M. The CAISK ()F4)l';A'ril was as follows
or RAT I ON
CONTRIIUTORV >.^^C
Months
/hn
•s
Ilouts
DTRATION
Years
Months
Pavs
1
Hours
M.D.
(Signed) HtMi^
('A i' u ^uvf V J 'A
iL'ct f: IQO'; (Address) i 6 IT. (jb^^^J^X^d^Ot
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
OCCl TXTlON
Kesidfd in Stui J'l aih i^<i
)'ra I
Miiiilli'
/>,'\
Tin- AHOVK STATl-n I'KRSONAl. I'A K lU T I, A K^ ARK T R T H lo T II l-
liusr oi" MY KNo\vi,i;i)<".K AND iu:i,ii:k
S (jj) ft ^ i,
A at
A(l<lnss ^bt)b
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place of Death?
Days
DATi; of Hi HIAI, nr R1':MoVAI.
KjnJu a.0 T90n
(Address^ 5vC)vSAL Jt
N B — F.very Item of Information .hould be carefully supplied. ACJB should b^ -t«ted BXACTLY P»Y«>CIAN8 .hould
.tat/cAUSE OF DEATH In plain terms, that it may be properly .l«s«.flcd. The "Special Information for pr-
non* dying away ffom home ithould be given In every inetance.
1-
ID
i
W
RITE PLAINLY WITH UNFADING INK
Bon 11. "' Ill-all II I .>. ' 1 - H.^j^i^-
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed,
ao
190H
Registered J^'^o,
2451
DEPARTMET^ PUBLIC HEALTH-City and County of San Francisco
Certificate of ©eatb
( -Cl. S. StanDavD )
PLACE OF DEATH:-CountyofOa^0W^W City of (^ CL^ Zk^^^^...
)
V ir DCATH OCCURRED IN A HOSPITAL
OR INSTITUTION GIVE ITS NAME INSTEAD OF STRI
FULL NAME
A.C
V 1 ^^
si:x
051^
PERSONAL AND STATISTICAL PARTICULARS
A i C01,<)R
DAii: or I'.iK rn
U. *
rl-h^^
Mimth)
.\f. 1-
)'<a I
I Day
Mnnil:
(Vial
I his
MEDICAL CERTIFICATE OF DEATH
DAII-: oi- i)i;a'iii
(I)av)
(Mniitli)
I go \
(Ytar)
SI\<',1,K. MAKKll'n
WIl>n\\i:i> UK inVnRrKI)
iWiitciti ^iiiial (lisij.'iiatiiin)
HIKTmM,AcM<:
I'Statr or l,'o»u!tt > '
.V^VA^XA,
\
K ft
NAM J' <>I
iathi:k
lUR'nirLACK
ol- lAlMHK
(Slate or (.Nniiitry)
MAn)i:N NAMK
lUKTin'I.Al'K
nl- MOTIIKR
( Stall' or ConiUry
r ,
^Kx^^^o.
I lll'.Rl'BV Cl'RTII'V, That I attended <kH-cascMl fnuii
CL-^^..a . 190^ to iD/^ ^"^ T<pH
tlial I last ^awhXh. alive on ^ ^^ ^' l«P'
and that death occurred, on the <late stated above, at 3>
CP. M. The CAl'Sli Ol' DICATII was as follow^ :
or RAT ION ^X?'-- Months /hiys
CONTRIIUTORV U^
nr RATION }'iars .Uon/Zis /hn
_<
wv,-
\ I
occri'ATi<>N^\p A
A'/'ui/nf III Situ inni, n,-n i
t) )'riii V
M,:tlfll
I h! \
THK ABOVK STATHI. .•KRSnNAl. I'A KTir r I.AKS AKI- TRIH TO TUl^
IJKST {)!■ MV KN()\VI,i;i)<-.K AND HhMhl'^
« ^ p t n
(SIGNED )
T<)0
(Address) 3^50.^ " ^^^>-
Hours
Hours
M.D.
Special information on'y 'nr Hospitals, Inslitutions, Transients,
or Recent Residents, and persons dying away Irom home.
Former or
Usual Residence
Wticn was disease contracted,
If not at place of death?
How lonq at
Place of Death?
. Days
ri,\CK OF nrkiAi. OK kkmovai.
^ 0 p
I) \ 11: of in KiAi. or RKMOVAI,
T90H
X.ldris. ^^Hl QfVU^^\^V Jt I
N. B.-
"■"■""""^ „ ,. ,. . .^F eHnt.ld ha stated EXACTLY. PHYSICIANS should
—F.ver, ..em n» information .hould b, cnr.Sully ,uppl..d. _^'^^':^:'''t^'^^^'t^^.'^l„^^^^, Information" for p.r-
«a\?Cru"'sEOrDTA%"H"inprn. :;«;::. h.. r: m^rn; p.op.M, c....W.ca. n,. -Sp-ciai .nfo.matio„" for p..-
«4ns dyinft away from home should be ftWen in every instance.
I- 1
SI
%
WRITE PLAINLY WITH UNFADING INK
J!,,:,i<l .'f H.sOth )•■ Nil
t'-f^-ary-^.nSiVCo
I)
iilc luh^il S)AjXr^'^ ^0
i.96>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
no
^j^j^j^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of 2)eatb
( xa. 5. StanDatCt )
PLACE OF DEATH:-County oi^<^o. U .^* ^ City of V 1 Vuii^/>.^x
a..
No.
SU
Dist.; bet.
— and
(IF DEATH OC
IF DEATH
IF DEATH OCCURS AWAY F
OCCURRED I
"special INFORMATION" '\
STREET AND NUMBER. /
FULL NAME
U
LV<..i
PERSONAL AND STATISTICAL PARTICULARS
DAli: nl lilKl'II
\
/
Month'
AC.lv
i )Va
l):iv)
yfnfil'n
(V.-arl
I hi \\
MEDICAL CERTIFICATE OF DEATH
DATH «)I DKATII , H
(Motithl
it
(Day)
rgo \
tVf art
SIN'CI.K. NfAKkll'.n
\vn>n\vi:n ok i)!Vi»ri*i:i>
(Writfin --iKial (U ^-is-' "atMii *
lUK rni'LA''}.;
' Stat' ' ii' ' 'i itint I V
\<XKy^sJL^
I HI;R1:P»V CI'.KTII'V, That I atteiukMl .kfca^cMl fnnu
— — — — — -190 to :— 190 —
that I last saw h r— alive on — —— — r— —— - U)0
an<l that <leath occurrea, nn tlu> .late statid alx.vo. at
M. The CArSp; Ol" Di: A TH \va>^ a'^ follows:
a
OuJ<K.^'0^&J
a
a,c,^L^Ui.<v>aj
tcx'
FA I II J-.R
TUK THlM.Ai'H
«)! lATHKR
; stall 111 roiiiiirj'
MXIDJ'.N NAMH
t)I- MOTHKK
HIKTllI'LAiK
<)1' MU'rilKK
(Statv or CoMiitiy^
/CxAaaXcv J .
''^ Ml)
La,^
fXoA ^
cv Uo^c
k.
1)1 RAT ION Ytars
coNTkiinroRV
Months
Pars
J Jours
I )r RATION
(SIGNED)
II
Pars
I()0
)\'ars .Ifonths
Address) M >\'O^AtA^"^'>^-^ V-^qJlj
/fours
M.D.
^^
.Uo^Lc
OCCl TAl I<»N
1 V»r t ,
.1 /,.;.'///,>
/),n
THK MlOVKSTATKnPKRSONAI.PARTlcri.AKSARK TRIK To THH
IlKST Ol- MV KNOWM-IK-.K AND Hl.I.Il.l-
(Address
Special information only for Hospitals, Institutions. Transients,
or Recent Residents, and persons dying av^ay from liome.
Former or
Isual Residence
Wlien was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
DATl", of Hi KiAi. or RlvMOVAI,
IHOS
I'l.ACK OK lUKIAI. OR RKMoVAI.
T90
(Ad(
IS. B.
-Every item of Information .hould be carefuH. .upplleC AGE .hould »>« 7**:;^f .^^^^]^^^^^; .r^Jf^L^^' Vr'^l^
•tate CAUSE OF DEATH In plain terms, that It may be properly class.^.ed. The B^^.^m^ Information for p«r
sons dying away from home should be given in avery Instance.
, «
' K
i ;
\
I
i
I
WRITE PLAINLY W.TH UNFADING .NK-TH.S IS A PERMANENT RECORD
REFER TO «ArK OF CERTIFICATE FOR INSTRUCTIONS
,.f II. Mlth I- No :. ^5[^^ H^J' <^-"
I
Dale Fih'il,
10
lOO'i
Ite<ii.stci-ed Xo.
2^53
SI
^frA.o A ^vv^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( tl. S. StaneacO )
J? (^ ^ ^
PLACE OF DEATH: -County ofO^UYv J\xu^^c Oty ot^ ^^
'^'^,^ !i^^. Sf Dist.; bet. C .tx ^ \1 k and kcu>V^ '
No. *^ ^' -^-"^^^^ ^ ^ , .. = ,hNr.E owe r.cTS caIled for undcr "specl ,NroRM.Tio» ■ ■)
FULL NAME
'V
K:.^ ct .,
.i:\
PERSONAL AND STATISTICAL PARTICULARS
0 x»^oAj. ^
c
DAI' I". «>r- r.IRTH
At.H
^!>
IVi
^1
Iiav
M,>„!fi>
\ tar
PiJ \ s
DATK
MEDICAL CERTIFICATE OF DEATH
in- I)i:ath (p\
IIJ tt
(Month) *I'''«y^
(Vfarl
SIN*. 1.1 MARKIl.n
WIDOW I.I) OK invoke i:i)
Wiiti in -(trial ik^ijfnation >
I HICRICHV C!:RTII'V, That I atU-ii(kMl dtn umotl fn)ni
(lLo| I T9oH toi)'CX la 190 H
tliatTlast'sawh >.' alive on ^ ^t '\ T90H
ami that (U-atli occurrcl, mi tlu- .lati- state! alx.vf, at 0- O C
M. The CArSI-: Ol- Dl-.A'ni was as follows
(X "fciut x)6 N^CCC^
luK rm'i, \t"»-: f
I Slat< lit t"' 111 nt I \ ' -''
FATHKK \ \A
niR'nn'i.Ai'K
of I A II IKK
I, Slat t 111 Cunntry
M \iI»i:N NAMi:
01 Mol'UHK
P.lKl'UPKAi-H
oi MornKK
Statt 111 I'lmntrv
i
OL'VX' ^ NXX^vCA^<^<?
A
u
rva ^
DlR.X'riON I )'''ars * Months
CONTkllU'ToKV
Days
Hours
DTK AT ION
L
)'i'ars
Months
Da vs
Hon
; v
( SIGNED ) Ox^X/ClX Ch Vft I- wk. . v M.D.
%^ H)oH (Ad.lrc.s) ID IX M iUa^^^v d
t
( )rcri' A rioN
n
R^rsiifrif ill S>in /nnirir,) y> \ ) rtti>
M,>iith'
I hi
TnKAm)VKSTXTlU>.'KKS.>NAI rSKTirriAKSAKUTKIK n. THH
HFST OK ?.1\' K NOW 1,1'. IX. 1% AM) lU I.n■,t•
; Infnrinant
(AdtlrcHS
Special information only '©^ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of deatti ?
How lonq at
Place of Deatli ?
Days
I'LACK Ol" nrKIAI, OR KKMoVAI,
DAIi: iii III Ki.Ai. i»r KKMOVAI,
N. B.-
State CAUSE OF DEATH In plain terms, that it may be properly <.iassiiicu. i
sons dying away from home should be given In every Instance.
' s
H
,i
I
i
1
WRITE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 f II ,111, !■■ No 1 ; t"'«- 3Ch»:~1 Hv'^-l' *- "
I til If l'il('<l .
10
7.9(9 1
Be^ixtcred JVo.
2454
\^^^kajs do^'Vu Dei
DEPARTMENTOF PUBLIC HEALTH^City and County of San Francisco
Certificate of 2)eatb
( "Cl. 5. StanC^arD )
1 n ^-x,' J /
PLACE OF DEATH:-County of Ooax, J;v(X > v.'-. ^ Qty of -^
0
(IF DEATH
IF DE«
Su X Dist*;bet. UCrU^q^
^ * uNoe^p
and ^Ci
IxxAn.
)
- )
FULL NAME
.C.<V'Y>^ CKXA
PERSONAL AND STATISTICAL PARTICULARS
o '
<YrL.
u:
MEDICAL CERTIFICATE OF DEATH
DAT}.; (U- ni'.A'in
(Month)
(Day)
/90 I
(Year)
DATl". OF- I'.IKIII
\r.l'.
f%'k'\
• Month)
SIN", 1,1:. MARKIKI).
U 11)1 »W 1:1 » OK !)!VnKri-:i)
■ Wiitcin HiK-ial (U -is-Miat i<>n)
I'.iu'nn'i.xi'i'".
( Statt 111 t'tiUUU y
I Day
Mnnill}
ly.-a!
/»,M.
(^ «
H V
NAMl' <>1
1 A 111 i:r
lUK rnrKAiK
of I Arin:K
' stati- iif C"(>ui)t ry
M Xim N" NAMl-.
«)|- MOl'iniK
HiuruPKAn-;
(»)■ MoTHJ'.K
(SlaU- iir Counti v '
?
?
I in;i<i;P.V tl-.kril-V, That I altetuU'tl deccascl from
IX 190 . to - '- I')0
that I last saw h .i >v-alivenn ^^P '
*
and that <Uat]i occurrcl, on the .lato stati-cl ah.n'o, at -
CF M. The CAISI*: OF DI^ATH was as follows:
DTRATION X Yrars Mont/is^ Pays I/ours
CONTKIIU'TORV LLoA-^.Xi> L.SrLcIl.4^
•^" GUiooLdL On ^ ^
R,-sitiri1 III Stin /'i ,111. .'■'■'
> 'lUl I
.\f,i)if/r
THKXnoVKSTATKni-KKSONAl.l-XKTirrUXHSAKHTKrK To TlIK
IJKST «»!-■ ^iv KNOWl.l-JM'.K AND It I. Ml. l<
(Informant CctUwMI^-NxL ^J
nr RATI ON
(SIGNED)
19, ci
u
lurs
J/ott(/is I C) /yays Hours
L.
M.D.
I<)n
'1 (
Adiir^ss) %:yV ' &A.A>4ll dt
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
Wfien was disease rontrarted.
If not at place of death ?
How long at
Place of Deatii?
Days
(A-Mri-ss
^-b ^
-i
\
I'^jiTb OX.
'CVVAJ
\t
l'I,ACK Ol- lUklAU OK KHMi»VAI,
DATi;i)f HrKl.Ai. or RKMOVAI,
l9c± 3k.\ 190' i
INDKRTAKKR V ^- ^ C^^:^<^^"^^ '
. . V ~~~ !• I Arp .Hoiiia ha stated EXACTLY. PHYSICIANS should
sons dying away from home should be fttven In every instance.
I
m
\ ':
III .
1
WRITE PLAINLY WITH UNFADING INK
H,,anl ■■»■ 11., ,ilt1i I- N'
Da
/(' /'V/^v/, I'ctoAKX; ^0
IfJfA
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTJFir.ATE FOR INSTRUCTIONS
DEPARTNENtIdF public HEALT|l=City and County of San Francisco
Certificate of Scatb
i -a. S. StanDarD )
J? 05? tS ^
PLACE OF DEATH: — County ofO^V^ -'^^^ ^^ - ^^'^^ °' j ^
^T "I^l- \f\^i ^ ■ St.; ^ Dist;bet.aUx^|v
No. i <^^ >^^" ' __ „„„ ..^UAL RESIDENCE G.VE FACTS CALUto roR uAd
\.,C - V v:
- r"o»T°„=rCC%%ro\"r-o"s"pyTl^%"NSnVVTTo".-0,vr,T= N.»C ,NST..O O
R 'special INFORMATION" 'S
F STREET AND NUMBER. /
andOJbrcJ'^^^^- >
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
> I", X
ni
0<»I,<»K
oJ
DA ri". < »!• r.iK I'll
AC, H
ever
/ ^
I Month I
^S
Yrat
(Day)
1/ .»/'/'
I '^'lar
/),r
MEDICAL CERTIFICATE OF DEATH
(Month)
il)av>
(Yt-ar)
^^ li;
^INi.l.K MARKTKH
WIDOWKI) OK niVoKCKI)
iWritr in social (U'^ii^imtinn)
BIK I'Hl'I.Xi'l'.
i Slatt,' o! 1,1 HI nil >
Xa^wO^
1 '^
0
N".\Ml" ni
I- AT III, K
HlkruiM.Ai'K
oi- tArm'.K
(Stair or Country)
ma!1)i:n namk
ol- MorilKK
lUK rmM.At'i.
Ol- MoTHl'K
(Statf or ^.'onnti ^
OCOITA ri«)N
A',- ■Jr.^ :>i
v
I
I m':Ri:HV CI'-.RTII'V, TIiuL I aUcnad acixasol from
190 to-— •■ it)0 — -
Hint I last saw \\^^ alive oil ^ ^*P
an.lthat death occurre.l, on the .late stated above, at
M The CAISI'; Ol'' DIIA Til was as follows:
P
DT RAT ION Vt-ars
CONTRIIU TORY
Months
Day
/lours
Uv
V .
\,n, I
/'
HKST Ol- MV KNt)\\ I.l'.lX'l' AND Hl-.I.n.l
DIRATION
(SIGNED)
Years
Mouths Pays
an 1 (Address) loOb At<^
Hours
M.D.
U -Jr
u
^
%
SPECIAL INFORMATION only lor 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?
Itow lonq at
Place of Death?
. Days
1p
(Infotniant V.AJ.
M.ACK Ol" HIRIAI, OK HI.MoVAI
I»\J'i; o! HiKlAi, or Kl"Mt)V\I,
—"— """— "■""■"'"■^ \^% %rF ahf,..l,l he Rtftted EXACTLY. PHYSICIANS should
"ans ilyinft away from home should he feUen in every instance.
t'(
I i
ii
1
I
s^
w
R.TE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hoard of Hialtli i ■><' ■ '■ .^..^o
lfW\
2456
,.„,-, Jli'o-is/crcd ■A''o.
Lv^^^U^^ Deputy Health Officer ,^ r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate oi "©eatb
( "a. S. 5tanC»arC> )
^Itv of O /O^v J
ojy\/ o.^^/<x/>x-tM^a./cc
and
•No*
PLACE OF DEATH; — County ofOo/^^ JXa^ivCvo City
(T) p V'. 5
(^ ( - ;^-:^OCcfc,;"ni^^t J^?,;?^^^^- - .AM. .NSXEAD O. STREET AND NUMBER. )
FULL NAME tdcec-.v, JUXA a. ,
)
4-
DATl', «>I- lUKTH
PERSONAL AND STATISTICAL PARTICULARS
- I Col.oR
ll
A«.K
\\ y.-iu^
5.0
(Uav)
Mntllll^
\ t-ai
/>.n.'
MEDICAL CERTIFICATE OF DEATH
DATK OI" I)I%AT1I
.t
Day)
/QO \
(Year)
I inCRi;r.V CI-RTII'V, That I attciule.l (Icrcaseil from
-yol 190H t.) 0^t; it) 190 H
\\ ii)t>\\i:n <>K i>i^"
( Wl itf ill -iiiial il< -'.
■oRiKH N
■J nation) \ s
I90H
that 1 last sasv h .'.■ alive on ^ ^*}0
and that death occurred, nn the «late stated alx.ve, at Its,.
J M. The CAI'SI-: OF Dl'ATIl was as follows:
P.IK rinM.Aci-:
' stall I ii !'' iiinti >■
1- A III i:r
mk'rnjM.AOH
01 lATIIKK
(Stall or Country)
M XlDl'.N NAMl
Id- MoTUl-.K
niK rnn.ACK
OF MOTHI-.K
(Statf or Country
>^. r »- J..C. 1
Months
VJLAXr
,t\k
occri'A rioN
W
AVwi//-,;' /'' S,7i! /■' (.''/.
) V(7/
Mnuth-
/>tir
i5i:sT oi- Mv KN«)\vi,i:i)<-.H AND lu-.i.nj-
DT RAT ION
CONTRIIUTORV
Dl'RXTION }'iiirs Jfof/t/is
Days
I Jours
(SIGNED
!U
/)^71'
)n ^
(Address)
flours
M.D.
'HdlCo JlygK^ulal
SPECIAL Information only for rtl>spilals. institutions, Transients,
or Recent Residents, and persons dying away from lioine.
Former or r n , 4 P
Usual Residence <^ -^ t) n u
Wlien Has disease contracted.
If not at place of deatli ?
How lonq at
Place of Oeatfi ?
Days
(InfoTinant
<r'
'A.l.lrc.s CctcN^U>. dbCh^vU^l
V\ \CK ni-- lUKlAl, <>K Kl'.MoVAI,
^1 0,L..i „
DAlU'of HcRiAi. or RKMOVAl,
190 i
rsnv.RTAKKR
(Adilrc-Hs
^
J , .. .. ^ ATF «Hmilfl he Htatetl EXACTLY. PHYSICIANS should
N. B.— Bvery Item of in Wmatlon should b. CBrefuHy -ppi.ed ^^^^fLj^^T -11.. "Special Information" for pr-
Btate CAUSE OF DEATH in plain terms, that it may be properly ciassitica.
sons dyinft away from home should be given in every instance.
1 I
l«i
1
i
I
!
WRITE PLAINLY WITH UNFADING INK
5nard i'f Hcilih- I" N-
<:S^'x?^,\\S^\'C
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!)((
/(> F/V^^^/, iLlclMKXi X^
190\
Re^istrred J\'*o,
3f,
Deputy Health Officer
DEPARTMENrOF PUBLIC HEALTH=City and County of San Francisco
Cevtificatc of 2)catb
( tl. 5. Stan&at? )
PLACE OF DEATH:-County of Oxx^ J^-^' ' ' ^ty of 0^^ i/^a >^c^. •
-I 4V > St- ^ Dist-bct. 5axL and '^'
)
FULL NAME
\}sinjx^
n
da
PERSONAL AND STATISTICAL PARTICULARS
si:x
Cnl.oR \
i
I) \\'V. or lUK III
.\( .1-
I
Ctti
M. m li
C )V.,
I.
!l)av
,)/,,iif//.-
3^
( \'( at
/>,7 1.
[EDICAL CERTIFICATE OF DEATH
DATE nl' I)1:ATH
( Month 1
Dav)
/go \
(Year)
I HI*:K1-:HV CIvRTII-V, That I atten.UMl (UnH-ased fmiii
190 S t(3 ii//cl. I'l icpM
alive o„ W^ct lb Tc^H
19^
that I last saw h
mN<-.I,H, MARKli:!)
WinoWHD OK DIVORii:!)
(Writt in smial (ksiKtHititin)
that I last saw h • alive o„ ^ ^^' '^ I|>^
111(1 that <k-ath ociurred, on the date stated ahnve. at CX-X^-
' :M The CVrSh: Oh' DI^ATII was as follows
KXAxxxJ
i;iK rm-i.AO}-:
(Slati- or Connti V
NAMl' »»1
HATH l.K
lUKPni'I.ACK
OI- 1 AlllHK
IStatr or Co\intry
MAIDKN NAM)
<>l" MoTllHR
lUK Iliri.Ai'K
(H Mol'Ill-'.K
(Stale or i*ountr\
( uA! !■ A riON
O^W
CUu.
Kk.^-^^^ mul*,^4^>^^-5
-^
DIRAIION )Vr7r? T J/cm////5 M?ja //<?// rjj
CoNTRinrTORV
nr RAT ION ^ JV'?'-5
\/..llfll>
k
I hi
TnKA,M,VKSM-AT,aM>KRS.>VAI PARIM.M-LARSARKTRtKTO THH
lUvST t)l- VY KNOWI.l.Di.K AND lU-.I-IlJ-
(Signed) uX.o
11.
flours
M.D.
y^ AO looS (Address) ^Ho^mavkxt
Special information only for Hospitals, Institutions, Translfnts,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place of Death?
Days
ri,ACK Ol' lURIAI. OR KKMoVAI,
t
(Addrc s^
dt
UuCHi>^
DX'^'l'of IJruiAl, or Rl'MOVAI,
T90H
r.Ni.KRTAKHR U^ <X.^Ca.4-WC, U^vcUAjtoJ;
(Acl.lre.s I'll '^'Xva^^M.^'%- Ol
State CAUSE OF DEATH in plain terms, that it may be properly cla.sitiea. me op«=
sons dyinft away from home should be given in every Instance.
»,
I
1 ' .
II *
I*
i
l'i
I
WRITE PLAINLY WITH UNFADING INK
V. o
Ihifr FiJod.Vd^
Xb
Depuu
JW» . I
'♦U
Offi
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o, -^400
DEPARTMEnFoF public HEALTH=City and County of San Francisco
Gcttificate of 2)eatb
( ■Q.. S. StanOav? )
PLACE OF DEATH:-County of ^ Cv.- ivcx >.c..c.X:ity of d O^ ^^^^T^^
FULL NAME
\\
vmx )
K^K,
#
^l.N
I).\ I I-. <>!■ I'.IK III
AC H
PERSONAL AND STATISTICAL PARTICULARS
C()I,«>K \
I
\
b^
)'ra
(Day)
Mntiths
I Vt-av)
Pr/
MEDICAL CERTIFICATE OF DEATH
DATK Ol- DIvXTII
(Montli)
i;i.
a)av)
IQO 1
(Year)
vi\(,i I- MAKKIKIV
WlDoWKI) OR niVOHvi:!)
(Writfin Hociai d* -iuiiatii >n '
BIRTH »M,\^"J-: I
(Statf or r<.\nUi y ' ^
\ \M1" <»1
I AT II i;k
lUKTHlM.ArK
oi- I AriiKK
(State or Country)
MAn)J:N NAMH fO
OI- MoTIlKK
niR'riUM.AOK
«>).' MoTHKR
(State or Country)
I II1:KI:iVv Ci:rTIFV, That I atteiKUMl (U-ccascil from
. \ 190M to ...U^:^ it icpi
that I last saw h :.- - > ^ alive oti ^^ ^^ ^^' ^
and that <loatli oooiirrcl, on tlie <latc stated ahnve. at 1? ^L
M. The CAISI-: t)l- DI-ATII was as follows:
CJk:
."V^rv^-A./^
<Hyvvti/u^t\A^v<OC
c{r\j
c<j uLcL 1 vd.
OCCt TATION
DTK AT KIN i Yiars w Months Pay
CONTRIin'TORV
DTRATION
Years
jMxs^
AV>.f./ .. L, r,...^.r. 1 )Vwn. 1 yf"»f'>s A /^.n.
THK AHOVK STATHI) '"HRSONAI PARTJC(-LARS ARK -KRrK To TIlH
HKST «>K MV KNOWIJ-.IX.H AND Bhl.llJ-
( SIGNED )J^^ LL- sAX'^V
Months Days
/ClCL/->'V
Hours
I /ours
M.D.
I()0
(Aa.iress) % ^jVia^b^m. c
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyin(j 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).
iir.n I »M- .»i 1 i-k-- I
(Address 3>^ b\ 0 OwCNXX^n^Ji-'Vsto OX
ri.ACK OI-XWrRIAI, OR KKMOVAI
DA'XI'of BfRlAF. or RKMOVAT,
N. B.-
■""^ TT li J &rF ohmild he ittated EXACTLY. PHYSICIANS should
-Every Item o? Information .hould be cnrcfully supplied ^^^^^^^ '^^/^^^^^j^i^'^The -Special informstion" for pr-
state CAUSE OF DEATH In plain terms, that it may be properly ^lassitiea. i ne op
sons dying away from home should be given In svsry Instance.
^^^'
■\
m
h
i
WRI
TE PLAINLY WITH UNFADING INK
/){if(' Fili'il.
^0
loo'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF ^^-^.^.r ATr FOR INSTRUCTION»
2459
1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( XX. S. StanDar? j
PLACE OF DEATH:-County ofO^V^v Ja^Xoo.-.,.
0 ^
City ofC3,a/^x. 0'v<X/>^c^o<.
fNo
..b
Q.
^
\4 ^^..'j.; < _ St4
/ ,r DE*Th'oCCU«S •^^''/"^"Io^s^pVt*!: ^R^f-lsT^ITUTION GIVE ITS
V, IF DEATH OCCURRED IN A HOSPITAL u
Dist.; bet.
ind
-)
CCURS A.AV FROM USUAL « ^ S . D E NCEC. VE^ -^ ^- - ^^: 3T;^C
lAL INFORMATION" ^
T AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
si;\
<^
DA I i: <»t lUKlH
COLOR
MEDICAL CERTIFICATE OF DEATH
DATK ol- I)i;ATn
\t..iitl»
A<.H
15
)'rii I
ll)MV>
M,,)if/r
(Vear^
(Month)
(Day)
(Year)
I HlCRl-HV CJ:RTIFV, That I aUcn.kMl deccasca from
- to
that I last saw h
-~ alive oil
rgo
— igo
Pa V
SINr.l.H, MAKKIKI)
\Vn)o\Vl-:i) OR DIVoRi KIl
(WiittitJ <.«K-ial (Itsi^naHiin)
lUKTHl'UXt'K
(Slatf or Coutitiy
rn
,„.l that .hulh ..ccurrca, on the .lat. stated above, at
J M. The CAISH OF Dl^ATlI was as follows :
t /
rx
0
lAJjLC^
\AM1 ol
FATHl-.R
HlKTliri.Al'K
OJ- 1 APHHK
(Stall or Oo(iiiti v)
I) r RAT ION )'i'ars
CONTRIIUTORV
Moulin
Pays
J /ours
I
m\ii>i:n' namk
ol MOTHKR
luR'rni'i.AOt-:
«)1- MoTHI-.R
I siat< or Countryl
1
nr RAT ION ^ Vt-ats
Mouths ^_ /?<i.v-? /Ajw/t
(SIGNED) WurwiK^ ^
ft
(Address) U\.(rvUA:0 ^M^"
SPECIAL INFORMATION only for Hospitals, InstilutiolTs: Transients,
or Recent Residents, and persons dying away from home.
t) Mn„lh:
K raided /;/ Sav i;a>i,i>ro \ "^ >''T^
UrL\c a<hJJ^r\/y^ ^^
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatit?
How long at
Place of Oealli ?
Days
PI \CH or BIRIAI. OR RHMOVAl.
osj\j\y^<^ \
DAi'l", o! IJiRiAl, or KKM(»\AI,
iD^ XO 1 90' A
vni>i:ktakkk VI V. v) ■ ^ ' \ Ji
... -lated EXACTLY. PHYSICIANS should
rnrdttn*; -w"^ "r" hen.. Should be .W.n i , .n...n«.
tf; I
I;
i
■IIMMI
I
I!
N
MM
WRITE PLAINLY WITH UNFADING INK
Dii/c lu/i'il,
\j 10
THIS IS A PERMANENT RECORD
REFER TO R^CK or CERTIFIC»Tr FOR INSTRUCTIONS
Ea^i^lerod ^'^o. 2400
DEPARTMENT dF PUBLIC HEALTH=City and County of San Francisco
%
Certificate of 2>eatb
( *«. S. Stan^arD )
PLACE or BEATH.-C~« of^^l- — ' °" °' ^^^^ ^ '>^^"n"
^0 f ri'f.tv^t ^Svdb and ^HLiv
'^ ^ '^ ti -^ ^ ' -^ St; b DlSt; bet. ^^^7,^„,V^3p,c.al .nformat.on ■ >i
FULL NAME
)
KcmxCL^;
PERSONAL AND STATISTICAL PARTICULARS
SI A
nxii.; «>! HiRiii (up I
iMDiUhl
rt»L«>R
, (1
I
(Day)
MEDICAL CERTIFICATE OF DEATH
DATE ol- Dl'.ATIl
V^
"^ r
\t,K
^.H 5''"'
Moiih^
(Vfiir)
I hi '
:^.
SIN.M.I- MXRKIhn.
WlDoUM* «»K niVORi HO
i\Vt!t.- Ill -.Liiiil <U-.i!.'":itH.n)
luK rm-i.AOK
(Stall i>r t.'imiitiy
NAMl". «)!•
» ATUKR
i.^'^l'..^
igo
(Month) ^''-^'' ^^'^"^^
"TllFRrn^V C1':RTIFV, That I atUMiacd aeccasca from
\jL\<t n 190H to t).^ ^c^ 190-
■ C ) rl. ' ^ TOO H
that I last saw h .^^ ahvc- on ^^ ' ^90
an,l that .\eath occurre.l. on the date statcl ahovo. at ^
J M The CAISH OF DI-lATIl was as follows:
rvi^U
DURATION ^ >*'''^'-^
CONTHIHITORV
Months
Days
flours
HiK'niruAOK
Ol- 1 ATUKR
(State or C<miitrv*
MAn)i;N NAMK
OF MOTHHR
iiiRTiiri.Ari',
<)1' MO I'll KK
(State or Country^
\Xxajoj
«^
Years
J ,>\ju<Uk
T(,o ' I (Aadress)
CJLUJ
OCCri'ATlON
i,/i
nrRATioN
(SIGNED)
SPECIAL INFORMATION only for Hospitals, lilstilutlons. Transients.
or Recent Residents, and persons dying away from fiomc.
uCX^AX
Hours
M.D.
^Cv
I
Former ©r
Usual Residence
When v^as disease contracted,
If not at place of deatli ?
How lonq at
Place of Death?
Days
l-I \CH <>!. Bt RIAI, OR Rl-MOVAI,
(ftlt Pi
DATK of nt KiAi- or RI\MC>VAI,
(AfUlre-^s
:r„'.%y*nt— ."y .rL ho„.. .hou... b. ftW.n In .v.r, in.t.nc..
\h
{
t
WRITE PLAINLY WITH UNFADING INK
. f II ,.1,1, -- J- Vn i; 't-*:sS-^i Hftr Co
I )((/(> Filed ,
Deputy Health Officer
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS
2461
Bc^istered J\^o,
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( -a. S. StanDarD ) ^ .^
PLACE OF DEATH : — County of Ua-.v J .•ui/Yv<i^Xi. i..ty ot
)
l
FULL NAME A.
f
OwUl>a.
PERSONAL AND STATISTICAL PARTICULARS
COI,liR\
!)\ Tl, i>I I'.IK IH
\<.i-;
(Davt
M,,iif/t< 1
"v'cai )
/>//)
MEDICAL CERTIFICATE OF DEATH
DATH OK UttATH
{ Month)
in
(I):iv>
/90 1
(Year)
I HICRI-HV CI'RTIf-V, That I atlciukMl acccascd fnmi
.iDct lb 190M to O^t. i'\ 190H
that I last saw h ■- • ■ alive on
j^.i I
190
-^IM.l,!" MARU11',I>
\Vn»< »\V1-".I» oK DIVOR* i-:t>
^Wiitt in "-(Hial i1( Hii^natiKu)
an.l that <U'ath occurred, on the .late stated above, at -^
The CAISP: Ol' DIvA'I
M The CMSP: Ol' DIvATH was as follows:
C V
lURTIIt'I.Ai'H
(Statf or »*()tint! >■
NAM I- «>l"
I- A 11 11. K
IHKlUl'l.ACK
<»1 I \ rill'lR
' Sl.it« i>! rmuil ! >■
M mi)i:n namh
<)l- MorilHK
lUR I'ln'i.ACH
<>i- M«»'rm'*.K
I'StaK 'If Touiiti \ 1
f\ %
\
(\
/jC^vCJ^'V'^ '^^ U/ClAk^
DT RAT ION
CONTRinrTORV
)'fars Months ' /Mj'?
I' . ..
Hours
,.C
-a-'
L.
vt<X^
(>c(. rj'A rioN j
M,,ufli^
I hi
■VnV X,U,VKSTAT.a>PKK.oNA, rXKr,rr.,ARSAHKTH. H To T.IH
in>r ()i\Aiv KN')Wi.i,i>'.i-. AM) in, 1. 11. 1
in> r oi- JiiN K >' iN% 1.1,1" ...-. "''"'•"■ A »
Dr RATION >Vcn-5 Mouths Ihiys /fours
( SIGNED ) LoyvvxJuLo US CXTUl.C^ CLu M.D.
U^ l^ ic,oH (A.iaress)^nUr^<Yu
SPECIAL INFORMATION only for Hospitals, rJisNtutlons, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
Wlien WIS disease contracted.
If not at place of deatli ?
How lonq at
Place of Deatii?
.. Diys
Aj
IM.ACK Ol' lURIAI, OK RKMoVAI
DATJ: of li! KiAl. ur REMOVAL
U /tX ") C 190*1
'—'""''*" , . ., , Z^n .u„,,i,l ha Mtated r.XACTLY. PHYSICIANS should
^. B.— Bvery item of information should be car.fully supplied ^^*;^^ "^^/^'^^^^^^^ Information" for psr-
state C\USE OF DEATH in plain terms, that it mny be properly Uasslliea. p-
sons dyinft away from home should he feiven in evsry instance.
; I
i
I: I
:1
i
WRITE PLAINLY W,TH UNFADING INK-THIS IS . PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2^m
,.,..f n. th KN.> i.-^-t^^>H^i-c..
A Deputy Health Officer
Bcf^i^stercd -jYo,
DEPARTMENT OF PUBLIC HEAITH-City and County of San Francisco
Certificate oi 2)eatb
I ■a, S. StanCat? )
? ^ i ^
PLACE OF DEATH : —County of ' > - ^^^ ^^<^^-^ > ^'^^ °' -
No.
5 ID
(ir DEATH OCCURS
IF DEATH OCCU
St.; " D;st.!b€t::'Vv<x->x;^va
ilDEI
RRED IN'i'Ho'sPrTAL OR INSTITUTION GIVE
and
. DEAT„ OCCU -0« U_SU_.L --°,^---.^;e'7tJV.4° .'n-s-tE-.-'d-I? 3T%%'?riN 0":::= e'r" ^ ) '^
y
FULL NAME
V. ^ V
^-x
>
V
I1
/LOv. rvAAI.
Jx
i)\ 11: of- r.iR rii
PERSONAL AND STATISTICAL PARTICULARS
aJ^K
L
I
,|SM
Ml. nth'
A' . 1-
SINC.I.K. M \KKn-.i>
Wiitriti -iKia'i (Ic-iLMiatiiiii)
I D.'iv
M.nilli'
I ^ t-ar)
/).n.
MEDICAL CERTIFICATE OF DEATH
DATK 01<' 1)1:ATII
(Month) 'I>=»V*
I 111;K1:HV CI-RTII-V, That I attctHkMl <kHcaseil fnnu
rQo\
(Year)
— — I9O to
tliHt I last saw h rr."-" alive on -———--
ana that .U-ath occurred, on the .late stated above, at
M. The CATSh: OV Dl'.VTH wa^ as follows
up
up
lijL-rxlA.^xi' UAiX^A^
c' -\^ vc -J S':^
r,iK iin'i.xi'i-:
(Stati 1 >! i"| lUiill \i
X \M}' nl-
!■ Alll l.R
HiK'iniM. xri".
OI- lAllU'K
' ;->t.iti (If I'ouiiti y
M \II>i:N NAMl-
(W MUTIIKK
lUK'nn't.Aii-:
()i- M()ini;u
(statt or *,'i)untry
o(,H'11'ATI<)N(T\
ft U
?
1
?
>AxX/<X
DIR.XTION )'rars
CONTRIIUTOKV
.}fout/n
Pars
IIon) s
nrR.xTioN
)'ears
Mont In
Pav
www
0— WNjLa *^ V tt
AV.v/VMi' i>i Sail /;,/".,"' i^ ''''"'
Month;
Ih
T„KAHOVKSTVr,n..KKS,.XA. PAKTUMM AHsAK,-.-KtH TO Tin-
lU-sr 01 MV KN«)WU-,I)«.1% AM) Hll.lI.J
( SIGNED )Ur^O-vviUv J.UjUj.cMJI ' ■<_
I'D , ,
U',cL :■ ic,n'\ (Address) U^*Un\X.VO ^ -^v ,, a.
/Ion IS
M.D.
-*^^
SPECIAL INFORMATION «"•> f«r Hospitals, Institi^lttns, Translfnh,
or Recent Residents, and persons dying awd> from home.
Former or
Usual Residence
When Has disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
vJVOjtAjL
(AfUlrcf
5^10- hK.<k, '"^t
IM \CF <»1 lUKlAl, «tK KKMoVAI. 1) VTH nf Hihiai, <.r RKMoVAl,
'on* dytnft away »rom home .hoiil.1 be alv.n In .v.py Inltance.
I?.
WRITE PLAINLY WITH UNFADING INK
Boar.l of Ihaltli- »■ No
Ihtlc /v7^'^/. U^Ur^>X^ XO
2^6^H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lic('>is(ei'C<l J^'^o, ^4l>0
1+ t„ r^m%r^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate ot 2)eatb
( tl. S. StanDarD )
PLACE OF DEATH: — County ofCJCunrAJ OA.^^
^T 'iq QUv^Lli SU 5 DisUbet. iitL
No. dl M L^CrA^^vTV.^ ^,,^, RESIDENCE GIVE TACTS called ^or undcr S,
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
City of ^'^^^-^'^ vj.^ucx-kvcv
\
V.VC
and \ X X
)
r I ^ ^" RS AWA. .ROM ^U.L -fJ0E^K^^VE;^CTs'cALLED .^ U^CR ^ - C . AL . N ^ R ...K> N ■• )
V IF ^EATH OCCURRED IN A HOSPITAL OR INSTITUTION uiv
> \.l K..C \X
FULL NAME
'^h
,\-/0^/Y^
I >-
>-.i: \
PERSONAL AND STATISTICAL PARTICULARS
u
iiATi-: oi HiK in
A'.i-:
h
\ti.:ilh'
)V,n
a
l)a\ I
Mnlllln
X'h
\\a\
/hn
i)
(MontlO
(V.-ar)
siNr.i.i-. M\KUii:n
WIDoWI'.l) OK n;\«»Ki"KI>
iSViitc in -.<M ial di '-it'iial ion )
X^^ V
^
lUK rill'I, At'J'.
iS|;i!. o' t",,uiitl\'
NAMl". Ml
I- A 111 i;r
\ 1
RTR'nii'i,A< 1-:
OI' 1 xrni'.K
(Stair ol Collllll V
MAIDKN NAMI-:
<>1 MOTIII-.K
lUR rniM.Ari-:
(II- Mo'IHl'.K
I Stati o! Ci lUllt! V
i
lift" a ,
f
MEDICAL CERTIFICATE OF DEATH
DATK ol- Dl'.AllI
il):iy>
I 1II*:R1':HV CI-.KTII'V, That I attfii.kMl .U'ct a-^o.l fmm
— -— i<)0 ■" to
that 1 last saw h -r — alive on ~ "~
and that <Kath ..rrurred, on tlu- .latr ".tatc-.l ahovc, at
M. The CAISIC Ol* DliA Til was as follows
190
DC RAT ION )'i'(Jrs
CON rKii''i"i<>'<v
Mouth a
Days
I lours
Lc \ax
0
to
( )i(r!'A'n«)N
Kfbiflfd in Silll I'uifii i-iii
).,n
M,>iitln
/hr\
TI!KXH()VHS-rXTHnPKHSnNAUPAKnr.^KU<.AKKTKl K K* TIH-
(111
nrUATION >Y^ y'i;ars Mouths
/hivs
(SIGNED) 0
flouts
M.D.
Special information nnly for Hosplldls, institutions, Transients,
or Recent Residents, and persons dyinq away from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of deatti ?
HoM lonq at
Place of Death?
Days
I'l.ACK OI- lUKIAI. OH KKMo\ Al,
DAIIiof r.iKiAi. or KKMOVAI,
\j^ *XL 190'
fA(l<lltHS
"^ . rr^ AHF Mhould be stated EXACTLY. PHYSICIANS should
N. B.— Every Item of Information should be CHr^fulIy suppi.ed J^«f; "^^/^J^j.^i^* ^he -Special Information- for pT-
state CAUSE OF DEATH in plain terms, that it may l>e properly ciossmeu. m-
sfms dying away fi-om home should be given in svsry Instance.
65)
r~b
ik«'
1 ]
I
^r
1:
I
"'mmmtm
!<'
iff
I
I
WRITE PLAINLY WITH UNFADING INK
M, ,;..!. 1 ..f ii..iitii IN" :■ •5"^:,:;^^^' Hft r Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)a(e F//r^/, L'ct<rWv ^0
IVO'i
Rec^lsfci'ed J^^o,
Ja464
I
Certificate of IDeatb
XX. S. StanDarO )
J (^
PLACE OF DE ATH : — County
ofCJa.-w J .^a'-v-x.-^-^'^ ■ City of UXX/^v o
rNo. w.^JUU
.'^rCCaJj
1 M
.1.
Dist.; bet. —
"~ and
(IF DEATH OCCURS
IF DEATH OCCU
A^/yV£ V -^i_^ RESIDENCE GIVE ^CTS^c'tLED FOR UNDER ■SPECAL INFORMATION" \
RRE7.;THOs1.yT*A!: ^ ^N S '. ^U^O^'o , V . .TS NAME -NSTEAD OF STREET AND NUMBER. )
— )
S AW<
FULL NAME
W
\
L-Cii^ . V.4
si:n
!) XTl-. nl- r.lli III
Am-
PERSONAL AND STATISTICAL PARTICULARS
COJ t (R
Ml, nth
\ )'iii.
(Day)
Mmilli:
(Year)
/),.■
SIVC.I.K. MAKKIl-.n.
\vino\vi:i) OK DivoRv i.;i)
• Wiitiin viH-ial di >iy nation)
nikrinM.Ai'H
I state i>i I'lHintry)
MEDICAL CERTIFICATE OF DEATH
DATH ()!• Dl'.A'rn
(Day^
sl- . v».. U
(Month)
IQO i
(Vfar)
^0
NAM!' ni
J- A Til i;r
niK'niri.AtK
m lAini-.R
'Stall' m Onuntt y
MM1)1:N NAMl''.
ol- MUTHHK
I!IKT1IIM,AI"K
()| Mc)rill''.K
(Slat!- Ill i'i)unti\
A5
" rillUxIU'.V CI:RTII'V, That I atteinU'd (U-itased fruni
— — up to igo ~
that I last saw h .— alive on " H)0 ^
aticl that death occurred, on the date stated above, at "
M. The CArSI*: Ol' l)I':A'Pn was as follows:
or RAT ION Years
CONTRIIUTORV
MoHihs
/hiys
Mont/i:
A
{H
I
oi'i't r A rioN (^
A\"-ii/f'if III S'.ni I I, nil 1^1,1 -S ^' )r.,';>
.\r,»,th'
Ihn
\nv \HovH srxri i> i'KRsoNAi, I'AK rut!. \K'~. \Ki: iKt 1' ii » riM-;
lil'.sr ol MS KNOWMIM,!-: AM) lill.Il'.H
(Tnf.>;niatn
IU'RATION )'iiirs . . _^
(Signed )
i()oH (Address) bOb C}llI-U\
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or o • Q \ \ \ f
Usual Residence oio lUCLA,V\c
When was disease contracted,
If not at place of death?
How lonq at
' Place of Death ?
Days
fAtl<hi-*^>4
IM.ACK Ol' IHKIAI, OK RI-MoVAI.
r N I ) 1 '1 u 1" A i; I : R \i I mX
H. .
DVri', -it IJt HiAi, or RI'MOVAI,
U ct
190*^
fAd.lrtsH 0^0 sJLO-A-JL ^l
M. B. Every Item of Informntion should be cnrufully supplietl. AGE shotilil be stated BXACTLY. PHYSICIANS should
state CAUSE OF DIIATH In plain terms, that it may be properly wlassifled. The "Special Information" for par-
sons dyinft away from home should be felven in every instance.
.J^iilO&?
W
RITE Plainly WITH unfading ink
)!n,!nl .)f HiaUh
,^.,, , , t'-^-^'Siii U& I' C
I t
1)(
VJO'i
this is a permanent record
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^ A Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DE ATH : — County ofC <XTV
Certificate of S)eatb
City ofO<^>^' ^ '"^'V ' ^'
FULL NAME Ml ^/t^AXL
V)
.C > w l^
si:x
PERSONAL AND STATISTICAL PARTICULARS
i) A ri: < 'I HiR iJi
.\(.H
MEDICAL CERTIFICATE OF DEATH
DA IK OK i)i:ath '
iD.t
(Vt-art
Yr,n
(Hav)
M,,ntli<
\ I .1 t '
/'.;
■,ix< ,1 iv M \KHn:n.
\vnM»\vi;i) »»!< r>!Vi>Ri;Ki>
iWritf in MK-ial (h-ivnntion)
I", a-
I'.iK rm-i, wM-:
1 A 11! KK
lUK rin I. \' 1'.
ol 1 \ IIII'.K
I >>l,itt ' 'i I'oUlltl V
MAHUN' NAMI-,
()l Mol'in-.K
lUKTinM.AiK
ol Morill'.K
fs
It
(Month) ""=»V^
1 ni:ki:!iV CI;RTIFV, That l .Utin-Ua .Ucca^d from
tliat 1 la^l saw h - alive- m, OwA.v x Up
an.l that .k-ath ncHurrc.l, ..n tin- aat.' stated ab..vc, at l
M The CMS!'; ()!• IH.A TH was as foll..ws:
^.
,/^l
0 ^^'
~>
DrRATION >V<i/.v
c<)NTRii'.r'r()i
Months
/hiv
I lout s
nr RATION , >V</rv
(SIGNED) Jt/uJ OWUbi^
Mouths 1 .5 /^<n's
■J V -I
I lom s
M.D.
d^ujL^
SPECIAL INFORMATION only for Hospltdls. Institutions, Transients,
or Recent Residents, and persons dvinq .m^y Irom tiome.
Dicn'A'rioN
h'l-ithd III ^<ni /'iiiii, I-'''
)'.-,ii
!/,./////•
/hi
;„,- xucVKsTXTl M.-KKsnNM.rXKTUruXHSAKK TKIK D » Till-:
I'O
(lnl..:in:ii)t
Former or
Usual Residence
When was disease contrarted,
II not at place ol death ?
How tonq at
Hare of Death?
Days
ITAii: «»1 lU HI M, <»K R1.',M«>\ Al,
li\i') .,! p, 11 \i. 'It Kl'MnVA!,
u ,
luH... bi^l ' 'hK^^ 3i
%-
■■i««-i^M-i— ii— ^^^^^^■^^"^"'^■'^■■'"'■""""'""''^"'^'^'"""^"""'^^^^^ II h t t I BX4CTLY PHYSICIANS should
,. n.--", ..en. on^^^..-^.on .H....... .. .^..<u.,, .u.^.-W... ^^f;;,- •..°,:;: 'Vh. "^pcc.;, ...o™„U„„" .o, p-r-
:"';.."» ««"y «rom he™., .hou.d be *W.„ y >"..-«•
I
;il
< I
I
i!ii'
1
i
I
^
WRITE PLAINLY WITH UNFADING INK
l!(,u.! .>f lit allh 1- V,, '■■-. ?--;sc^:-i; liS:!' C
/>^//
f ri/r'f,^AA)JL\.^ x^
Dep
Ith Officer
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
24 m
Be^i^sd'fed JS'^o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccitificate of IDcatb
( "a. £. StanDarD j
C\ ;\o , City of O'O-'^'^ ^A,<x, - -
ivr„ I'^SO VI "^ -^- ' ' St.; I Dist.;bct. J.«J(X»^«Vll and J.LcV -, ■'
iNO* 1 W V, X^ ,,eii«i orCinrNTF rivr facts called for under "special INFORMATION" \
( '^ .7D;AT°H^OCCU%rEV;N"rHo's^rT':;t o7^---o';"c.;eTt1 name .NSTEAO of street AND NUMBER. )
PLACE OF DEATH: — County of C) cxata; 0 /v.
"V
I
I
"^
FULL NAME
,"^
\^ i
PERSONAL AND STATISTICAL PARTICULARS
-.i:\ t
DATl-: MI- BIR in
K'i )!,< )
M
(\
A.
^ 1 v.^-..
/ -
lM..nlhi
\«^1-
l>.i\-
M.oilh
s't-AV
Wl 1>» »\\ I'D ( >K l)l\< »Kr II)
I Wl iu- ill - "■i.il '!• -il^ii.ili'iu)
Hiu run, \''!
'Statt -• ' ■' i!n1 ■ ^
\ \ \i i: t »i
1 A III !:r
iUK rinM.Ai'H
(>!• I XI'IIl'K
■-,!:ii . I It i'iiiinlr\
%!aii)i:n n\mi:
ol Mo'ini.K
HTRrmM.Ail',
(ti M(»riii'. K
\^tiili- 111 viiunt I \
oCCriA lloN
MEDICAL CERTIFICATE OF DEATH
UAi'lC «>I I>i: AlH
w
l^X
(Vf:\r)
(MutitlO 'Davl
I HlRI'ilV (." I'lRTIl'V, That I atUinlcl deccasctl frniii
';>_lW± ' i.,'i'\ t«) wxX' \l up H
Hint I last s.iw h ..•• ' ali\<. on ^ !")'>
ami that di-ath ncrurreil, on the date statc<l ahnvc, at 1-3
M. Thf CAT SI-; Ol" l»l'.\ Til was as follows:
L
wC_JLK.'
"C\
^vrL ^IKa^,
^\^^Q
VLby^
H (in
CONTRIIU TokV U, » >.
.}/<>////rs
Pavs
I foil) <
IGNED ) LU. J
6-^_^^Ai A.
r !
/cx^-vdj
K'- !<!i,i 1)1 ^tttl /'i ilih lu-n sj \
.1 /,,),///.
/;
Tin- \nn\!- vTMI'l) PKKSON \l, I'SHTrm \R>^ ARK VRl }■■ Vn rill
lil'ST Ol MV KNt»\\ l.i:i»(.l-; A\!> IU l.^:l•
( Iiifotniaiit
rt^
\.l(ln
u ■
I )r RAT ION
(S
f Aa.iiA-ss) r
/)^n'
//ours
M.D.
SPECIAL Information only for Hospitals, Instifutions, Trdnsipnfs,
or Rftent Residents, dnd persons dving dHdv front home.
Former or
L'sudI Residence
When was disease rontrafted.
If not at plare of death ?
HoH lonq at
Plare of Death ]
Days
f^,K U
\ t
I'i, xri-: « >i luRiAi, i)R ri:m< »\- \i,
4 Id ^.' ■■',
,,,,,... 15'h- '^sn 5-. a I
DAri".!' HruiAi i.r RllMOVAI.
1^ B —F.very item of Int'ormaf.on should be cnrefully ^upplU-... AGi; s1k>uUI be «tntec!l EXACTLY PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it m»y be property clae^if.etl. The "Special Intormat.on tor p.r-
Hon* dying away from home should be felven in every instance.
n
* * J
I
i-
^.1
Ml
I
< «'
( I
«i «
:^A^A^.
]■ I
J
1
I
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n,i:iMl ..I Ili.tUli I' No !■> ^'^^s^^f^r.S:!' I
IDO'i
Be^lsfered JS'^o,
246^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(Xevtiticatc of 2)eatb
f "a. S. StanDarD )
^PLACE OF DEATH: — County ofO,<X.^. 0 \a->-CA« Gty of 0^>X' J.vct>v<M..
It
P4e. Vjl^\tAXxJu Lo^rVx.\.m Ob CHLb^jto^^ Dist;bet.
and
FULL NAME ^ ^J-d.
LL ^ ^ vC >V
sj;.\
PERSONAL AND STATISTICAL PARTICULARS
! C(>l,i>R
tUcoU
lUJvO.
DATK or lUKTU
A ( . v.
r\
I Mo lit 10
%
} V,i
1 1).\\
Mmillis
\ lal
/hi
SINC.IJ-: MAKKIl'l)
WIDOW l-:i> OK DUoRrKn
(Writr in >.(Rinl 1< ^itnuitiuti)
lURTm'l.At*!-
(Hlatf or CoiuUi \
\\Mi-: oi
I- AT in: R
ItlKrillM.ACH
(»i 1 \iiii«:k
M Mlil'X NAM I
nl MOTIIHK
HIR Iliri.Ai'K
()|- MoTHl'.K
I Statt <ii lOiititry
n I
MEDICAL CERTIFICATE OF DEATH
DATl-; Ol" DlvXl'M j/'~\
(Month) (Day)
rgo
(Year)
I lil'iRliHV C'l-RTII'V, That I attciKk'd (Uixased fmiu
^ *■ " 190H to V, c't l^ upH
K. CL 'I icjoH to V, C't l^i
that I last saw h - . - alive on n.- v up
and that di-ath <uH-urred, on the dati- ■-latcd ahovc, at ^
.' .^I. The CAISH (>!• JUKATH ua^ as follows:
u^
v\
a
Wa.
«^
\^a.Vc .
DT RATION )'ears .)/o)ff//s Days
ONTRIIUTORV LL>wC<rK.clA.4 >Nx
//oin <i
C
/s
1)1' RATION ^ ^''^/'^ , MoHtfis Pays Hon
(SIGNED) AxxaX). J- lL^^^.-- M.D.
wot It iqoH (Address) H liv V duJAhiJUJ. ll.t
luxr ^Ituk
ocrri'ATioN (
^
Nf'-idrd n< Still /■' irih /v "
) r,ii
Mnlltll^
I hi
Till- XnoVF SiTATl'n 1'KK'SnN \I, I'A K llf I' I,A KS AKl". PR IK To
HKST o!- Mv KNOW 1,1, IX. K AND in-:i^n:K
Tin-
(hifo-mriTil
\.l<li
a
A
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or ,,ur,(VVi \, How lonq at
Usual Residence hH l H 1 lt<L<iA.^ vv M Place of Oeatfi?
Wlicn was disease contracted.
If not at place of deatti?
Days
ri.Aci-: Ol luRiAi, OR ki:movai,
U 1
LLu^S
>\A^AV
c
<A
l>\ri. >' 1!( i.iAi. 1)1 Rl'.MoSAU
C^ct 9.1 T90H
rNl)i:RTAKF.R
OuA
. . X
(Ad.lresH ^blS.- l^l Lk ^.
-CXX^-IX/W
N „ — Hverv item n? information should be corcfully HuppHed. AGE should be stated EXACTLY. PHYSICIANS should
stotc CAUSE OF DEATH \n plain terms, that it may be properly classified. The Special Information ^or per-
sons dyinft away from home should be ftiven in every instance.
«!'
II
1 •
11
I* <
WRITE PLAINLY WITH UNFADING INK —
I!.i,inl of ll.altb - »■
Vo. 1- -^'^^^w^^, V.SlV Co
I)(f
fr /u/e(/,\U.^iXA>^'
hj X\
100\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2408
Re^l^tei-ed jYo,
KA^ A-C
Deputy Kealth Officer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Cevtificate of Beatb
( Ta. S. StanDarD )
PLACE OF DEATH: — County of
A ^
Or^
a
JAaX-v-^cu5.cc City ofCjO.^^ 0 Xcv-Nxc^^v
fNo IllC-d^^u S\A X Dist.;bet. Ml va^r^. and
'INO. I » w w ,„„„ iicilAI OFCimPNCC GIVE FACTS CALLED FOB UNDER SPECIAL INFORMATION \*
( " ,'',"o;'i,H"oCC.%r.",r°''„o"s^Pr," 0%'?«"?"o"'0,Vr,Tl N.«E ,»S,»0 O. S„..T ..f NUM.... J.
V. ^
if
C
/-^
FULL NAME
1 t -^
XA.^tLcL.\rvu
cl<
a ->^x4
PERSONAL AND STATISTICAL PARTICULARS
si:x
i».\'i i; or- lURTn
A< .!•;
r»>i,i)R \
a
.^5
i Ml. nth
5V,(
I>av
M.oifli-
■\'( a! I
Dii I .
SIN<,1.1- MAKRIl'.n.
\\ I I>» i\\ l'I> I )K I)1V< )R<l-:i>
\\ ! lit in -1 'li tl ili-ii^natiun
lUK ill ri. \*"}-:
' sta!' 1 il ' ■' lUiill %
VNMI OI*
lA rni;R
niR'I'HIM.ACK
(u- I ai'ukr
! State (If l*i)!11lt
M \ir>i:N' NAMl
«>I MdTHHR
HIR'IIIPI. Ail-;
(11- MoPlll-.R
1 State 1)1 CuUlltl N
occri'A rioN
'^ h
I on '"
MEDICAL CERTIFICATE OF DEATH
DATH (>»• DKATH , "^
(Miiiitht
1 H1':K1-:BV CI-:RTIFV, TImI I a-un-k-.l .kcva-d frail
— ■ ■ — ~~ 190 tt) - - —
that I last saw li -■:: — alive on
and that lU-ath ticcnrred, on the tlalc ^taUtl abtwc. at
"^T" M. The CAl'SI-: t)l* DIlATIl w a- a- foll.nv-
tqo
»\_«^
4hCu
S-
i
DT RAT I ON )'t'ars
eoNTRnU'TORV
nr RAT ION )'tars
.l/on//is
/hirs
11
I ',n
^ 4
( Signed ) Wur>\iAi j.^ U KcLa%xc<.
M.D.
ii:
A.hUc-;s) L(j\eAVL\6 \L-»\vw
Rrsidfif ill Still /'iiniiiu
M.. II tin
n,i >
Tin' \Huvi-: sr Aii.ii pkhsoxai, i-ar run, ars ari-: rRiK T«> Tin-
I!1:nT OI- MV KNOW l.l.Ix.H AM) lU'.l.li:!'
(InfiiTlH
„„ lo
rvyv
cLa,^ > \
\il,lr«j><s O 0 0
t
rvx^'tx JL
■ ■ ^t
Special information «"'* 'or Ho^^pitaK, lnMltrffl»ii<i. TrinMfBls,
or Recent Residents, and persons d>m;} awd\ from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
flow lonq at
Place of Death?
Dav
s,o:o.^.ev;»xc.t.v.
iNin'.R iaki:r
(A
nSTV.if H! KIAI m RKMOVAl.
TOO
i'ct
<
v)x>v>v ^^ u
iMns^ QlIH WcCcLcy ..\\
^, B. Bvery item of InfopniHtion should be cafefully auppUecl. A(iR should be Htnted I.X^CTLY. PHYSICIANS should
state CAUSE OF DEATH In pinin terms, that it msiy be properly classified. The "Special Information" for per-
sons dyinft away from home should be Jtiven in every instance.
MkJLii
4
' i
--1 7'-*3» >. ^
WRITE PLAINLY WITH UNFADING INK —
V,i>-Ar<] uf f!< ;iUli (•■ N'').
/)((/(' Filed ,
./ejL<r\>Uv
Qkl
190^
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2M\B
Be^Lstcred jYo,
iL'V
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of £)catb
( tl. S. StanDar^ )
PLACE OF DE ATH : — County of
(ir death' OCCUB5 AWAY PROM
IF DE<V"M OCCURRED IN A H
0^
MX^-^cu5.c^ City o{0 Q^^^ 0 Vcv^'vc.c^ ec
St.; cs.
Dist.;bet. H > LCLCl^Tv and JxXh^c'
E FACTS CALLED TOR UNDER "SPECIAL INFORMATION" "\ ^
USUAL RESIDENCE Giv
OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
lO
FULL NAME
\j
h
..\
/LaaXola)A.Ui
d
<X'y^\Aj
PERSONAL AND STATISTICAL PARTICULARS
SKN A A COI.UR \
DA 11. of- lUK rii
\«.i-:
/"Isc
Month)
(Diiv
M.'uHi'
Year)
Da 1 A
sINT, l.l-- MAKHIi: I)
( Writf ill Mfcial di situation)
lie.
4Kv*
MEDICAL CERTIFICATE OF DEATH
DATK ol- I>1-;ATH [ P\
l^'ct
I go
(Yt-ar'
fMoiith^ <Day>
1 HICRIU'.V ClUxTII'V, That I alttn-kd <kcvascMl fmin
tn
190
that I last saw h ": alive (Ml "
and that lUatli ncourrcd, on the date stated ahnve. at
" r" M. The CArSI«: 01* Di: AT 11 was as foll<nvs
190
igo
niRTuri, M"}-:
' Stat' (i! ' '1 mntl \
!• A I II IK
niKTll JM, AiK
<)!■ 1 All! KR
St.i'i 'It i'ii\nitry
N! Xini'.X NAM1-:
III MOTHKK
HiKTHri.Ari-:
oi- M()Tin:K
(State ui (.'ouiiti V
1 .
0
.^ ^
lOrrru li-da
.1 I -^A I
U
irnJU ^JTYuu
dU
(u*C 11' \ I'lON
^S-
\jix U c-v^^-> A.S, ■> ^- c^
nr RAT ION y'lUirs
CONTRIIU TORY
.l/o/i//is
Days
Hour's
I)i: RATION ^ Years ^fonths
( SIGNED ) llcfumjLhj 0 .Mj U) \iX
li'ctr 'XC TooH (Address) UrXtr^AJAA y
a
I/oui^
M.D.
».,C-'
h'f^itir(f III Siin /'i ,j>hi^r>
'J 1
.1/,M/,'//.
/hl^
Tin' xHovj*. sTA ri-:i) pkhsonai. tar iiitiak^ ari: rut i- lo rni-
IJHST Ol- MY KNOWI.l.IX.H \Nn lU'.l.IlJ-
(Iiifoiuiant vw
nnru
SPECIAL INFORMATION only for Hospitals, Institwlbns, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
HoH lonq at
Place of Death?
Days
ri,ACK OK nrRlAI. ok RKM<tVAI,
(A(l<lrf>^*
I)\XJ"'>!' ntulAl, or RKMOVAI,
. .„.^,. .i-VBllii ■••
T9O
t)
I
N. B. Every item of informntion should b.* 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 pur-
sons dying away from home should be given in every instance.
«"?5s?«*r
'^m-
St
• i '1
^.uirtbr
■
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
BfKinl .f H' iltli ]•' No i ^ *-^:;^^^' H5^ 1' C
Begistci'cd JSi^o.
4no
dUrvv^^ dxonu. Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of 5)catb
I
PLACE OF DEATH: — County of CL>% J^^oxc^ax^o City of ^O.^^ J.^.<x>xcvo cu
A
No.
St.
Dist.; bet.
and
/ IF DEa/ H OCcJnS AWAY FROM ij S U A L RESIDENCE give facts called for under "special INFORMATION'- '\
V IF D • ATM OCCURRED IN A H^JSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
,'~\
L
ft
.^1
lc>\.
PERSONAL AND STATISTICAL PARTICULARS
UAIi; nl lUKl'II
I ruxLi
.lit in
A«,|.;
)'f i/<
H
Dav
M<nillis
n
(Vear)
A? I
\\ ii>< >\\ J" It < »K i»!\« >Kri:i)
i\\!it< in -iKi.d ill -!t;nalii>n)
lUK riipi, \i'i-:
1 ! ll ' *
It: \
J?
d
CtOA.
0 .t > \oM
hJO^-ysJ^^^Ji
N WW <»1
I- A in JR
lUKinri. \t'K
O' I \ 111 l-.R
>l,U!- 1)1 ((HlHl! V
MAIDl'.N NAMK
lUK I'lll'l, \i}",
<il Mtii'lll.R
I '^InSi I ii iduiit 1 \
< H'cri'A rioN' ^'
MEDICAL CERTIFICATE OF DEATH
DATK <>l- I)1.:aTII
(Montli)
:t
^
(I)av^ (Ytar)
I Hi:Ri;r.V CI'.RTII-V. Tliat l attcnikd «leceased from
U^et \>
upM to ^ ^ l*^
icpH
that I last saw h A, - . alive on U ^t? ' ^ ,,p 'i
and tliat lUatli occurred, on llie tlulc -stated above, at
M. The CArSl-: Ol' DI'.ATM was a^ follows:
DI'RATIDN )V<7;s Months . Ihiv
C ( ) N T R 11 U r ( ) K V ^^ ^X.H/kv.O-VO'
IIoui s
L>TU
VI
J"^'
Ri'^iiifd in Siiii 1^1 atti n, n
J V(,» I
1/,M////,
lhl\
Tifi-: \M()vi': sTA'n'.n I'KR'^oNAi. 1' \K I u ri, \R-- ARi: TKn: m riii-;
iti'.sr Ol- Mv KN»»wi.i;t)»'.)-: wd Hi:i,n i-
' Info! ma til
DTRATION )'tars J/on//is /hiys'
(Signed )
ilVt ').:
M.D.
Kjo'l f
Address) ^Xo(K^.A1^>.- -^
SPECIAL Information «nly for Hosplldls, institutions, fransients,
or Recent Residents, and persons dy'nq away from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death?
Davs
IM.ACl-: Ol' lURIAI. OR RKMoVAI,
do Am ^6
-H
DXri'.uf in HiAl. iir Rl.MoVAI,
TOO
aMaX V
(AddrcHH Ul'J'X- 1^ tL^^A
N. B. Every Item of iiiformHllon should bj cnrefully supplieil. AGF. should be stnted EXACTLY. PHYSICIANS should
state CAUSi: OF DEATH in plnin terms, that it may be properly classified. Th« "Special Information" for per-
sons dyinji away from home should be feiven in every instance.
il!
» '■
I ,|
wC
1 1 1 1
i:i
J
n
f
\'t ii
III
u
'. i'
yi.,1
■
r
li
I
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Th(
le Fileil, i9/iLtJ>^\. ai ^OO'K
Begistcved J\^o.
o
4no
Deputy Health Officer
DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( XX. S. Stan^arD )
St (^
PLACE OF DEATH: — County oi^^O^-r^ Ct Axx^c^^lc^ City of Q,a>X' J A.<x^xcvo c
u
No.
e-.
MJll
\Kh
^
AuA
St.;
/ IF dea/ H occJrs *w»y from usual residence GI
V IF d :»TH OCCURRED IN A H«JSPIT»1. OR INSTITUTION
FULL NAME JiA.
Dist.; bet.
and
IVE FACTS CALLED FOR UNDER SPECIAL INFORMATIO
GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
N)
JLllWYxj
PERSONAL AND STATISTICAL PARTICULARS
•^l- \
I nxJui
1"<)1,(»R
MEDICAL CERTIFICATE OF DEATH
DATK OF Dl'.ATH
\x
AXJk
i»A'n; itf r.iRi H
A<.K
■'>^Jb
)',.n
\\I1H)\\ |.I» OR IMXoKD'H
i Wi it* in --(H'inl <U -.i^"^!!;!!'.!!!! )
Dav)
Miinlfi'
(War)
n
ha
Uav
lUR ril I'l. \»M"
I stall 1 1! I "■ in nt 1 \
NAMK oi
FAT 1 1 I.R
I!IR'niI'l,\rK
()' ) \ I 1! )•■ k
' state III riiaiil 1 \
\!\n>F;N NAM I
ol MO'I'IIF.R
ItlRIIII't, At i-:
ot Mo'rm-.R
< Statt til idiinti \
orCll'A rio.N/'
A'f^iifnf in San rmn.n.n
(Month)
(l)av^
(Yt-aD
I Hl'lRIUiV CI':RTII'V, Thai I atu-iiik'tl .UHxastMl from
.ct
0.
Hpi t(3 . L'€t i'l
that I last saw h A. aUvo on U ^Xj I I icp '^
ami that lUath <»{Hiit rcil, on the <iaU' ^tatutl iihove, at
M. Tlu- CAT SI-: Ol' IH-ATH was as follows:
n
DrkATION )'i'ars A/ofi/Zts '■ /\iv
vA.^VyJkA\,<(rVLhYU
//o/n s
CONTRIP.rTokV
}\ar
Months
Dav
niRATlON
.NED) UXk^JULN K XoL^
ly/cL x^ i,,o'i (A.iau-ss) ^^.oiKaa-LLu
(SIGI
//ours
M.D.
- 1
SPECIAL Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying anay from home.
) I it I
M..,iih
/>,;)
Tin- M5o\ F, HTATF:n I'KR--oN \I. r\R 11. 1 I \Rs \Ri: TRIH To I'IIF:
HF:sT «>!• MV KNoWM'.lM.I-: \M) lU-. IJ^;F
( Infnt tnatit
{ \<l.lt.
Former or
Usual Residence
When was disease contracted,
II not at place ol death?
HoM long at
Place of Death ?
Oavs
IM.ACK OI- lURIAI, OK R1;M<>\\I,
r N I ) V. K T A K V. K jV^ULLu ^^ (Hp CC^ytXyyv
I» \ri: o! lUi'iAl, 1.1 R I'.MoVAI,
tS. B. r.very item otf iioOrmntloti should b.- cnre?ully ^upplierl. ACIE should be stnted EXACTLY. PHYSICIANS should
state CAUSE OF Dr.ATH in pinin terms, that it miiy he properly classified. The "Special Information" for p«r-
Kons dyin^ away from home should be fei^'C in every instance.
IV'i
4
m
r^^^'.'"
!
t
i i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
no:ir<! . r lt.-:i1th- F V<
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((h' Filed ,
,MA; II
VJO\
Ee^isferecl JS,^o,
2471
A'
.Crv.^^^ ckX-x^Li
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
PLACE OF DEATH:
("SO :
{ "Q. S. StaiiDarD
rNo, H n 5 vJ uUUA„^d;
(
County oV -^0^'y\J- ^
St,; t
3;
City of '■ O. ^\; 0 A.O
IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U^DE
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O
Dist.; bet. oUAcHxmA) and ^ ^^<XX > \ '
UNDER ■'special INFORMATION" '\ |
F STREET AND NUMBER. / ^
FULL NAME J C^UlL,
iL4.
PERSONAL AND STATISTICAL PARTICULARS
i)Ali; <>! lURl'll
Moiitll^
A«,i.;
4H
It
\
il»av
\r,,fl:
J t
4 tar
P.M
si\(-, 1,1-. %!ARKn:n
wiDi »\\ i;i» « tK i»i\'t tK.i:r)
(Writr ill -ini.il il.-i;.Miat-'.iit
lUK nil'I.Ai'K
' Stall' ')!■ r, 11! lit I %
WMI- (M
1- A Til IK
lUKTHI'l.ACl-:
()l- lAIIll-.K
(State Hi rount! V
MAIKl'.N \ \M J
t)l- MttrilJ-K
lUUini'LArH
oi- Mt»i"m;u
Slate I'l Cmnit 1 %
()rt.Tl'A riON ( u
0 ^i^OLva^vx.vo
Cu\xi.
^JVch^O; Uvt
-\
»
4 -v
Re^idf,! m Sd>i I i
M,,„th^
I hi 1 >
Tn !■' \i!«)\"i* s 1" A ri'i) rt-'RsnN w. v xki'uti.ars ari: rKti-:
lu'^r 01 Mv KNOW i,i.:im;h wd in-: 1,11; i-
ro Tui-:
(Info! maiit
A^ ^JScuvV^'^
vi,i,.~> HIS JjJUhiOo 3.1
MEDICAL CERTIFICATE OF DEATH
DATi: or ni; \ ru ■'X
(Mc.iitli) (Day)
I ni':Ri:r.V CIvRTII'V, That I atteinU-.l »lcccase<l from
\ -. I90H tn iDot 1%
that I last saw h !-.' 1 alive oil \J ''^C\j 't up
and that tU-atli «>ccnrrc<l, on the dale stated above, at ' -* -
M. The CAl'SI'! Ol" I) 1: AT II wa-^ as follows:
(Year)
1
Dr RAT ION }'rars
CONTRIlU'ToRV
Montin
/hi IS
lloilt s
DT RATION
,0
)'(■(//
I7
Mouths
Pays
(SIGNED) \:JaX/:xj ^ Ov^r>\.A
Hours
M.D.
(A.ldn'4^) IfcOyj^Jfr^icc
Special information only for Hospitals, Institutions, trdnsients,
or Recent Residents, and persons dyinq away from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
HoM lonq at
Place of Death ?
Days
IM.ACK Ol- lURIAI, nR RKAtoVAl.
I NDHR lAKKR V <XX-L>aXX.
I»\i;i:.,f Hi KIM (ir KKMOVAI,
j^,,'i
TQO
Ad.lii
TsXj^ \Iq' vOJxa.^xu
IM B Every Item of inWmatmn should h. cflrefully suppHecl. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSi: OF DEATH In philn terms, that It may be properly classified. The "Special InformBtion" for p»»i«-
sons dyinji away from home should be feiven in every instance.
Ill
a^ £
r
1 i!«
i.M.
Il t
rJ
ti
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((fr FiJod, L/^W- a.1
VJO'i
llpgisfcvcd J^o.
'^17 >
Deputy Health Omcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
' tl. S. 5tan^a^^ )
\
{ I
No.
PLACE OF DEATH: — County of J ai^ vj fva . v
W "^ ~ ^l. . St.; '^ Dist.;bet.
Q^
City ofO^X^^ JyVCX^x^CA^C
and ^'
St.; bet* va7^A.*wU and ^
(IF DtaTH OCCURS AVWAV FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR U N D|t R "SPECIAL INFORMATION \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD pF STREET AND NUMBER. /
FULL NAME -J^a^ vcU H I laxccu '^ r \ ^ ^^
^! \
'■1
PERSONAL AND STATISTICAL PARTICULARS
i» \i i: (IF lUK rn
\< .)■
'^L;cv.u
M-iiilli
l>:(V
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/ 'i; 1
W [IX >U I I) • »K IMVDRCKn
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r.i-^T oi ^is' K v< >u i.i,!)'. J-. \^i> i>i;i.n i-
(T
iifuunanl J . ^<X.-% V. C-^^ ' nI K . V J L CV
\.l<ln—
(? U 'I ^
MEDICAL CERTIFICATE OF DEATH
DA'i'K < )i- niiA'ni
W,CV -'y
I lII':ki:i>V CI-.RTIl'V, Thai i alien. Ir.l <kTrasr<l {v^nn
.^X.K^K. a
A
lyO'i
In
U)0 H
tliat I last saw h .j-'v alive <>n "^ C-'. - i^o
aiiil that (k'ath tiri-urre<l, on the datt.' ^taud ahove, at i '-'
.M, The CAI'SI-: Ol- I)i;.\III \va>^ as foll<.\v<:
Ur RATION )'iais
C<)NTRIIU"T<)RV
M,'iii/i\
Ihiv
I lours
Pays
1 Inn) s
M.D.
I )r RATION ^'<'<?;a JA >///// v
(Signed ) 0 . .. clcu^
Special information onU lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying and) froni home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death?
Davs
ri,\CHni< lU'KIAI, OR KI'MoVAI,
DAIl-'of Hi H'.AI. .1 ki:M<»\AI,
ca
TOO
I NI>1:K lAKllR W
XXX^wO L<|^^t_4 \A.X3i^->^ ^ ^ ^
U 'V O "^ ' ^ ' M
1^ „ —Kverv item of Int'ormntlon should b. cnr«fully supplied. AGE should be stated KXAGTLY PHYSICIANS should
state cluSE OF DEATH In ph.m term«. that it ni„y be properly classified. The "Special Intorm.t.on- tor p-r-
sons dying away from home should be feiven in every instance.
\i
h f
I
^^««*
IM
, t
[I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lut/vA^ Deputy H th Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Crvv\^
Certificate of 2)eatb
( tl. S. Stan^arD )
PLACE OF DEATH: — County of <x-^ J.\,cl ^
i I
! r, ^ . \ 1 /">
St.;
Dist.; bet.
City of vJ tXyVAj 0 X<X ^\JQ.AM/^L^
and
(IF Dt*Trf OCCURS AWAkr FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '^
IF OEAWh OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME^ClvUL
V > »
o
Is
N_».. W 1.^
n
si:\
PERSONAL AND STATISTICAL PARTICULARS
^ r<»l,nR \
vOw-W..
DA 11. iir IIIKI II
A<". K
as
M.^ml
J
tDav
1/,
» liii
/',M.
HiN<,i,}".. M\Rkn:i»
\vii)<»\vi:n OK i>i\< »Ki 1- 1)
lUiitriii >.i»< ial lU "-it' ii.it ii 111 )
^t |1 I I ! fi illllt 1 %
NAM}* Ml
FA III i;r
niRiniM.ArK
Ol' lATHl'.K
'St:(t« iir I'omitrv
MAini'.N NAM)
<>l- .MoTlll'.K
HIU IIIIM.AIK
<»1 MnTHHK
'State iir i'ntintix'
To..
1)
?
MEDICAL CERTIFICATE OF DEATH
DAI'}-: <>1 Dl'.A'rM
Uct
JX /q(} '
(Dav) (Y<ail
(M.Hith)
I lfI{RI{!{V C'l'kTlFV, That I alU-iidcd (k-ciasiMl fn.ui
IQO '1 to ^ ^A.
in t
tliat I last saw h !- ^ alive on ^- ^ i»p
and that (kath ocunirred, on the dati- stated above, at
Os M. The CArSl\ ()!• DKATII was ;,s follows;
J _.^ , .. .
DIU A lloN
}'i(irs
Monllv
na\
llOHt S
CONTK im Tory
DIR ATMiN
Signed
)'cay$
Months
l.ti ■^Hflu
IhJV
Nout^
M.D.
L
I J
OCCll'ATION
Rf-idtii III S,nr / t ,1 III /'I'll
Miiiilli'
ihis
rill-: xHovH siATi:!) i'Kk«»nai, 1'\k rhri.xK-- aki: ii<ri'. r<> Tin-:
HKST «)1- MV KN()\VM;I)<".H AM) in.i.ii;!'
f Iiifoimatit
ck . C^" <0^
f \.l<ln
\qV\ vy ruHxxLLAKxu dt
^ ■ .. w
litdls, InsU
".5 i<,o^ (Address) gtAJlla\X{^ '^6^h^-X'
SPECIAL Information only for Hospiu
or Recent Residents, and persons dyinq awav Irom home.
tutions, Transients,
k
Former or \ a
Usual Residence C^iOCVa-YVv^wU
When Has disease contracted.
If not at place of death ?
How lonq at
N Place of Drath ?
Days
rt.XCJ'tOl- IHKIAI, <»K RKMONAI,
I>\l!of !l! KIAI in HI-.MmVSI,
-I
I no
M. B.-
». I 1 1 i; 11 «i!^.i %nF ehriulil be stated r.X4GTLY. PHYSICIANS nhould
item of 1ti?armBtlon should b.- ciire^ully supplied. A«iti sUouHl '»« »l»«eu i. %^w i u
CAUSE OF DKATH In pinin terms, that it mi.y he properly classified. The Special IntormMl.on tor p.r-
-Kvery
state Qi
sons dying away from home shouhl he feiven in every instfince.
;•
1
SUfs™^^
ir
Ir
U
\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!.,., V.I of n-tltli I- No 15 **^^^5^. H&I' Cc
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bogistered J\^o,
O f ^ f
i ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( Xl. S. Stan?arD j
^N©.LL
PLACE OF DEATH: — County of^ aix< '
City of C'CX NV
V.
^L >xtu, IX^ 1 > Vs.. , : '.514
Dist.; bet.
V* •
and
F DEATH OCCURS1AW»V FROM USUAL R E S I D E N C E G I V E FACTS CAtLED FOR UNDER SPECIAL INFORMATION
(IF DEATH OCCURSIAWAY FROM USUAL RESIDENCEGI
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION
GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
P
FULL NAME
0
PERSONAL AND STATISTICAL PARTICULARS
.aa
^1 \
A
t*<>i<»k '
aXx
Lv
I> A 11-; «»I lUK 1 11
%!..iUh
I>av
ACH
^1
1/
iW'tittin >«iMiai lic^i^'ialiiiii >
luk rin'i, Aoi'
' stall (i! t'l 111 nt I \
N \M1 «>|
I A 111 l.K
luurm'i.Ari':
i)\- 1 Arin-;R
i ?it;iti lit i'niint vy
M\!m:N NAMi-;
nik 11! I'l.At'i-:
<»1' MoTHl'.K
' State 111 Coviiili yl
a
f 1 (\
^ 1
,-> -i
I
^OJ
<>AJuLol/'>'
^'-^XK
tHCVVATinS
A'f :i/ri/ in SilPi /'i mil /^"'
ii I
M,>uth
I hi
THH AllOV!-: STATi: Ii !'K Ks( )N A I, 1' \ H lU' i I.A K-. AKi; IKrK l' > TIIK
lucsT <)^• iiy KN<)\\ i,i;i)i'.i-: \n!> i'.i:i,ii:i-
(Informant 0 XCUvJk Lv- O /ZM^TY^^^
fX.Mnss LA^V^^'^-A^
>
1 1
^\.^r^'<Aj^
MEDICAL CERTIFICATE OF DEATH
DAIH <U' DllATH
Month)
; i
(Dav
I(;i1
(\'t , 1 1
I III'lkl'HV Cl-;kTll"\', Tliat I atttu.U'.l lUctasiMl fn.in
'„jL/C :i \,fy': to U^c^b 1% i(,on
tllHl I last saw h :.. . alivr nil ^CW *. i,jn
ayd that (Uatli nccurrttl, on tin- dati,- stated almve. at J -"^
M. TIk- CAISI' Ol- DIIATII \v;is as follows:
CONTRIIUTORV
1)1" RATION Ycar^
(SIGNED)
Months
Pa
\s
//<
'out s
.V,>i/f/i.s
/hi
J.s-
/ft^tlfi
M.D.
%J^ It rooH (A.l.ln'ss) LAX^r^o^
Special information onl> for Hospilah, Insfilutions, Transients,
or Recent Residents, and persons dyinq a^as from home.
Former or
Isual Residence
Wtifn was disease contracted,
If not at place of deatli?
HoH lonq at
Place of Death ?
Davs
I-I.ACF. <)1 IHl
I>\rj: .f lU KiAi or RKMnVAI,
Uot ^^ IQO''
N. B.— Every Iten. of l„.,.n,..t1on shou... He .nne.uM. suppfeC. AGB should »>« «7'^:;^f .i^^^^^.^^; jri^lfiLt'-V'rJr'
•tate CAUSE OF DEATH In plain terms, that It mny be properly classitietl. The Spec.al ln*orm«t.on »or p,r
son* dying away from homo should be ftiven in every instance.
if
i
.1
ii
H
■^r'^A' 1
,r
1
I
-'^
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bcgisfered JS'^o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
AA^
Certificate of H)catb
( 11. S. 5tnn^ar^ )
^
PLACE OF DEATH: — County of
^
n
City of - a^ >\^ O/v
No.
6
II
(
St.:
DIst.;bct. oL XA^jxr
.vt
and
If DEATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLEID FOR UNi>ER "SPECIAL
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A
INFORMATIO
ND NUMBER.
~ )
FULL NAME
I"
> .-">
n
--lA
l» A 1 I < li
PERSONAL AND STATISTICAL PARTICULARS
u
IM'
l):i'
\ < ■. 1-;
5 ,
•^iNi.i.j' MARHn:i>
\\ lln i\\ I'll «)K 1»I\« >Ki"i:i)
'WiJti ill xKiai di — ii-nnt imi)
«^^^a
HiK I'm'!, \i"i-:
St.itt ■ i! < ■' 111 lit i \
s
Aj 'J , V
4^^
NAMl Ol
I ATll IR
®
(^
n \
\J TVCL^xCLC^
Cl.CC; V'^
HIKTIII'I. \ii-:
Of I \ III IR
I "^t;it«- ii! riiitiH! V
M\ii)i"N ^A^tK :)
Ml MciTllKR -^
HiR rmM.Aci',
ni MoTiniR
I Slatf 1 ir c'ounlJ %
n.rrrATiox
t.cx,^u.
^
MEDICAL CERTIFICATE OF DEATH
KATH of nilATH
Mmith)
) i\-
, I ifHRHHV CI'IRTIFV, That I atti-inlf.! <!< < < a^t <1 frnm
l<;n'\ to 1(^3 ■
that I last saw h • " ali\t' on l</<)
ami that <U'ath occurred, on the «lalc ^tatiil ahow, at
M. The CAi SI-; (ji- i»i;,\rii wi- as follow
,La^ tXV^i.
Aw"
,V^\
DlRArioN )'cius \ Months
CONTRIIUTORV
Pav
Iloii
t H
nrRATioN*
( SIG
)\'ars
.1fi>f///iS
Ihiv
NED ) A. dJ. ^ *XC-
ca o . .
Hours
M.D.
aaa4X4\- ' >^o^
K \
^LUCi
Kf^idrd in S,n; /'i,iih
) .ui
M, 'II til
I'
\\\V. AHOVK ST\TI- It IM-R^nXAl, I'AR I' Ii r I.A K> AKi: IR!}.; Tn 1111:
i!i;sT (>!•• M^ KNi >\\ i,i:i)''.J'; AM) !u:u.n;i'
Oil fnitnant
\,l.lri-ss lO I 'J
?^ i ' i
*.
I()0
X.l.lre^s) 1 0 3 UO^C
%
SPECIAL Information only 'w Hospitals, Insfltufions, Transifnts,
or Recent Residents, and persons d>inq dw-av from home.
Former or
I'sual Residence
When Has disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Oavs
n.Ari'.or BrKiAi.uk rhmoxai.
n \ ri: "' Hi Ki \i .1 RHM<i\Ai,
I no
(Adairss 15XS. 0 A^O vL.i^'Lt ^v
... - It I- ,1 AHF shniilti be statecl EX4CTLY. PHYSICIANS should
IN. B. Bvery item oV Information should h.^ carctully supplied. A(.R shoul.i l»e stoten n ,. ^' ,„tfop,„H.-.o„" for dt-
»tote CAUSE OF DEATH hi plain terms, thot It mny be properly class.t.cd. The Spe..n1 lnU>rmHt.o„ *or p„r
«on« dyin^ away from home should be j5;ivcn In every instance.
t »1
!•)
1.1
* *J
1^'^
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!)((
^ X\
VJO\
Bc^isiered JVo,
i'y m -^/-»
Oy^^O-^A^^ cXX'
'\Mj
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate ot S)eatb
( XX. S. Stan^ar^ i
PLACE OF DEATH: — County of^^O. >
-<-\
'No. 11^ ''-^
St.;
(IF DE
IF
ATH OCCURS AWJAV PROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORWA
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
City ofUCLT^j 0 X<Xo\c^-<
TION- \ (1
Dist.; bet. X' \ a > v rA.o. , . and i3 \c^ ^
I
)
FULL NAME
H
v.. ',
(XlVvO
PERSONAL AND STATISTICAL PARTICULARS
I»A I1-: Of lUKlll
AC. H
i !,
I Writt III -1 Hi. I
luk rui'i. \»M".
St.ltr I ir I'.MItitt \
NXMi: 111 /'^
i
lUK rui'l. Ai H
<)l I \ in IK
IStatf i>r *.'i)iiiit! \
M M 1 > 1-; N N A M } ; (^
«>1 MOTHKK l^
!l.l ! 1- ill
V K
M
\J\jrKkA^k^^-\.<x.
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH
(M.imh' il)ay»
I HI{R!{i;V CI^RTIFV. That I attt>ii.U-.l >Umh a-,,.! fmni
V. . ..... i(p . ti) V, CL' ^\ i<»oH
that I last saw h •■ ' alivt- nn ^ wl.
aiiil that iKath ocrurrcil, nn iht.- ilali- stat<.il ahnvt i'
,M. Thi- CArSI-; <>I 1»! Al'II wi- .(-. follows
A
i<('
>vl^<X ^xtv^A^
v^
1)1 R.xriON ^Ytais
CoNi Rim'lOKV
Months
Pav
Ilotlls
Df RATION
i Signed ^
Yiars
Mouth
lUK iiiiT.Ari:
«>i Mirnn'.K
(St:it»' or (.'ouilttv
(A
Ok-
nCClTATloN
f\/'^itfr{ III ^t! II I'liiii: '>»•''
1/ -,''//
I his
Tin-: AHovK sr \ n-i) iM-K^ns \i. i'\k rini. \rs aki-: iKri", r<" Tin-:
nnsT o].- NIV KNOW I.l IH.l', \M> lUI.Iljl
(1
(Address
O^^-^-xA > V
iqo
"1 (Addrfss
/hivs Hour's
M.D.
Special information "nl!" *of Hospltdls, institutions, Transients,
or Recent Residents, and persons dvinq A'f^i^s from home.
former or
Usual Residence
Wlien Has disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Oav"
I'l \fi-" m in Ki.M. «>K Ki;M<t\ u,
O'L0wL^O-/^rA/
1>A i
Mii\ \1.
I Qc^
Ad.h CSS b X^ Cr. v<hOwctcA.-ixu ...'
... .! 11 I".. I AHF sHniild he stated EXACTLY. PHYS1CIAMS should
!N. B. Every item of informHtion should be cnreVuIly supplied. AGE should '^^^.^-Y'"" ^ ^f^ |„t'„rmatmn" for D,r-
«tate CAUSE OF DEATH In plain terms, that Jt may he properly v;la«8.t.ed. The Spc.al intormat.on *or p,r
«on« dying away from home should be feiven in every instance.
Vo
i \
* Ij
[H
I
H
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HoMVl ..f llrnllh r
ti-i-^3e'.<^~j% i;<vl' ('
***Nj4r-*
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Dfffc F/Z^'r/, l^/^t{r
Brgi\sfrrp<] JVo.
*"l f -^^-^H
,(^\.KAJ>
J UV„«i
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate o£ Scatb
I "CI. S. StnnC»arl> i
PLACE OF DEATH: — County of " <XT\j ^ XCL'Y\.C\ACcCitv of ' CL I V " \ <X .V. s
No.H
t WW-
( " 7
^uM-vA. >, St.; Dist.;bet. and
rnoM^^USUAL R ES I DENCE Givt facts called for under special information'
DEATH OCCURRED IN A HIOSPITAL OR INSTITUTION GIVE ITS NAME 11
ATM OCliuRS AWVAY
FOR UNDER "SPECIAL INFORMATION" "^
INSTEAD OF STREET AND NUMBER. /
FULL NAME
I
--1 \
PERSONAL AND STATISTICAL PARTICULARS
'\
;i
It A I 1. < <l I'.IK 1 II
M .1
I).
\ I . »•:
"^INt .I.l- M \K l< I in
U llx >\\ ! 1) < »K I I X t M> ) ! »
iiiKruri.x*'!" \)
(Stntt (it I . Ill nil \ _A
r^
XjY\ ^
Oo.
NAM I <»|
I \T!I IK
HI KT IIP I, \<'K
Ol* lAlin-'K
i St^ltr 1 i! C- ,\\ lit ! \
M \iiii:n n \\t 1
<)j .MMiin.K
luurm'i.Ai i:
<>i \!<»rm;H
f Slutc ur fiitJiiti \
orrri- XlioN-
AV. /,/r,
1 /
-A
aJ n
MEDICAL CERTIFICATE OF DEATH
i» \ II-: I ii Di: ATii
1 hi-;ri;i;\- ci:rtif\\ That i ntu-iuU-.i .h. , ,
i(p tt>
thai I la--t ^a\v h alivi- oil
a?l<l that ih ath « trcii rrtal. nn tin- datr -talt.<l aliovi', at
M. 'Ilu CAl SI- i)V hi ATI! was a- tolloss-
jCL,y\j
1 II I,;;,' / / I', I
riii; MS(>\i' sr \ ri-n i'kk-.<>\ \i, r\R rin i, xks a hi; i'k! }•; ii > Tin-:
inCsT ni M\ K N< iW 1,1 IX , I-. WD iU l,li;i-
!nfi>'maij!
nrkAl'loN )V(7;v
Mmiiiis /hns
Ihuits
1
DERATION Vn^
V '>ilhs /hivs
Hours
f Signed ) ^A.liA-^cL
% ^ - _
1
M.D.
I.,', ( Aili
r«'sv 1 - '
SPECIAL INFORMATION "nlv liir Hospitals, Institutions,
or Recent Residents, and persons dving dwdv tnni liome.
Transients,
former or
lisual ResMenrp
ItoM lonq at
PIdf p ol Death ?
Days
When Has disease rontracterf,
If not at place of dcatli ?
ri.ACI- «)I in HIAI, itK RJ^Nfo
\-.u.
1 1 \ i 1 . ■ 1 ; 1 H
IMt '\ AI.
i
INI) 1-: K 1' A K i: K ' ' ^La. UL<.
IQO
A.M!.—
w 1 .,
^ ... ... I- I \vv shnulii he Rtntetl RX4CTLY. PHYSICIANS hHouIcI
B. hvery item oV hit'orm«tion «hr>ulcl be cnre»uM> suppi.ecl. A(,f. shm.Hl "e.^*"*^" J' '^^^ » |„»'....„..,„,n" tor D«r-
• tatc CAUSE or DEATH In plnln tcrm«. thpt It may be prcperly class.t.ed. The Sp...«l Inturnu.l.un tor p-r
lions dying away from home should be given in every instance.
>
>
z
/ <)l >
N . a! •
:
vx\ f'riitn
I < (O ' .
iip
^'1
* I
<1'
'.;i
v«
,\1:s^i^w
■ 1
,;'
ri
■ f H.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
•■^^i^^B&PCf
n^ffr /-V/^'^/.t ctc-l^h. 1\
1
VV^^wV'li
\^^U
Der
jfTicer
Registered A^o.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( XX. S. StanDarD j
No.
PLACE OF DEATH; — County of ^ cx-.v .
St.;
City of L cc^v V Vcv ,
Dist.; bet.
,=? 1 1.
and W
(ir Dt*TM occurs AW«¥ rnoM USUAL RESI DENCE 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
a
il
I ) X ,^ ^
^v
PERSONAL AND STATISTICAL PARTICULARS
J
H^
v_
\l 1
|j.
\< , 1
) ,,/»
S1N<,!.1-: MAKHn-.l»
WIlH .U KII t>R Ii'\-. iRiJ I»
Wtitt 111 kiiK'irii (It ^ii" iMli- Mi '
A
n
L-
stall 1 1! I '■ 111 II t : \
N\M1' III
1 x'i'ii j:k
HIRTIIIM.Avl.:
<>i i.xrm.K
■it iti (It i'ljiitit I \
M \ !i>i:n n ami-
t»l MnTin-.K
HiK riiiM.Ari.;
<>i' MornjiK
■^t.itr (It I'liimt! \
oirri'Aiiox
f\'f/il/if III S,;n I
^.
MEDICAL CERTIFICATE OF DEATH
DA TK <)I PKA rn
'Month
I>av
I Year)
! Ili'KHnV CKRTIFV, That I atlouiU-.l dii i us.-.l fr.mi
190
to V
that I last saw h
alive oil
ct
lt)0
ami that death occurred, uii the date stati-d above, at II 01^
^' M. The CAISH OF I ) I! ATI! was as follows:
'■ \ vc>
or RAT ION Years
CONTRIIU'TORV
Months
Ihiv
//oil) <
DIRATION
SIGNED ) J
)'('ins
Vout/is
/\n
»0 , i^.
U-.
^
-i)
(X^YV
^ I
D
I /
Tin-: AHOVK STA'I'l'n PI* R SOX \I, I' \KT!iMI,\KS ARl-: I'Rri-: T« > THH
lu-'.sT «)i-' MS' KN( t\\ i,i;i). . I wn hi-:i.ii:i
(Infonnaiit
OlWfc
.'V-^
m
\.i.ir,.s SlH u criA<rv>x.
-^^^^
\ i
^ . igo'l fAdilress) l o U^v
//ours
M.D.
SPECIAL Information only lor Hospitals, Institutions, transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When Has disease rontrarted,
If not at place of death ?
HoH lonq at
Plar f of Death ?
Dav
ri,A<'i:'»i luRiAi, OR ki-:mo\ai,
0'
fUt ^-L.
DAri;..:* IUkixI .11 Rl.Mo\M,
Ifiol
t N I ) I ; u i A K I-; R
In ':i
A.Mi.-ss Whl ■][ iXv^L-O^
r>x
Bvery item of infor.n.tion hHouUI be ...refully Huppliecl. AGE Hhoulcl be stutecl EXACTLY PHYSICIANS should
rtat7cAimE OF DKATH in ph.in term,, that it m».v be properly classified. The "Special l,u„rm„t.o„" *or pT-
N. B. B-
state _- -
«nn» dyinft away IrVom home should be aiven in every instance.
iri
'■ !
• I
I
J.I
r:^i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
If
i If
I
:it
! I th I- N>> 1^ '^''^y^'"''--'- -'^ '' ^''
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff
h' Filed , L'cLMj
>^o\, X\
lOO'i
s^ «
Eegi^iei^ed jYo,
^Q
tV^^<i
ENTO
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
TX. 5. Stan^arc*
PLACE OF DEATH: — County ofCJCX-^x ^ Xa ixc .
Ne.^ ' J ^ 0%V->^cL^L . • .'..^K^ .:. ■ St.; - — Dist.;bet.
A. „ ^
City of^^^''^^ 0.n.<X'>xc^.
(IF Dt«TH OCCUBS AWAV FROM U S^ U A L
IF DEATH OCCURRtO IN A HOSPITAL
WAV FROM U^UAL RESIDENCE Givr facts called for under spec
and
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
lAL INFORMATION" \
T AND NUMBER. J
FULL NAME ^ ' 0
s... U
PERSONAL AND STATISTICAL PARTICULARS
ft
!i \ n t »r i'.iK ill
^ l\i .1,!" \l \K Iv II !i
\\ ! 1 t' i\\ I !> I iK 1 I • ^ I ti- It)
HiH rin'i. \ii-
\ \ Ml 111
I \ I II 1 K
lUK III I'l, \«F.
oi I A I'm: K
I Stat ( 1 ii (.'(lunt I %
MAIIM'.N NAM I
nl MOTIIHK
HIR III I'l.At"!-:
Ol- Moiiii-K
(State o! t'luiiu 1 \
ni » I !• \ ll»»N
A'' >/i//'i
MEDICAL CERTIFICATE OF DEATH
DA IK <u Di; \Tn /('\
^/cfc
TOO
(Vrai >
I 0
J ^
!^t<>ntb■) iDavi
I HI:K!;P.V l I, RTII-^V, Thai I attt-n.lf.l •kiia'^ca from
that I hi'-t -^ INS h ■■■ alive- on l«p '•
aiitl that iliath i irrnrrcd, on the daU- slaud ahisvo, at ^
M. 'llu- CAT SI-: Ol'" IH-:.\'i'lI was as follows
vl <x V cL^^Xz-c.
rVCv^ iXCA-i
1)1 l< A'lloN
)'car
Mini i 'is
^
y
c < » N T k II s r r < > k n* w>x<y^>vaw.
/A/l'.s- T Hour
%<>Xj u.^'|v...
Mouths
Hav
DlkATinN Years
(SIGNED) ^ K. d \nU>' s '^'..
[A ^ ^
\1'/Ct IH i.,nH fAddn.s)3.S0D JxAlmx£A
1 1 tin is
M.D.
Special information nnl^ f'"^ llospildls, institutions, Fransienls,
or Rccfnt Rfsitlents, and persons dyinq hhhv from home.
/'.
in: \H(>\ I'* ST NT I- h I'KRs,. )\ \i, i'\K rue I. XK'^ \Ki; THri-:
lu^Toi. 2''v KN(t\vi.i:i»<.i-: AM) in i,n:i
Tn \\\V.
Cm
\.l.lr< S-,
r^\^t
Former or
Usual Residence
When was disease (ontraf ted,
If not at plare of death ?
HoM long at
Place of Death ?
Days
I'J \l'H «)I' HI KIAI, OR RI:M«»\ Al
I M . 1 : r t a Is 1-: R AjlLaJCU ^^
XIKoS in uiAi. or ki:m(»vai.
^/Ct Ski TQOH
... 1-1 KCr uhoulfl he stated F.XACTLY. PHYSICIANS should
N. B.— Bvery Item of Information ehouhl b. cn.cluHy suppi.e, ^J^^^^l^^^f^^^^^^^^ ..s,,,-.-..., ,„form„t1.,„" for p..-
•tote CAUSE OP DFATH in phiin terms, thiit it mn> he propLrl> c,lHS8Hieu. in*. i
iif^ti* dying BW«y from homu should be ^iven in every Instance.
«l^
1
i
m
•"^Ww*
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffr riJcfL Vl.'cl<rVO
vj X\
I9n\
Re^i.sfcfpd JVo,
so
4'
C<oO
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of IDcatb
PLACE OF DEATH: — County of
CVV\
'\
City of ^J<X>^ 0,^cx , ^4 Q ^
\
iNo.
I luxA,cgu.U.Li
\
1 1
St.;
Dist.; bet.
and
/ IF DEATH OciuRE. AVWA, .ROM USUAL R E S I D E N C E G I W E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' '\
V ir DEATH JcCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
t.v^^
)
V > V i
PERSONAL AND STATISTICAL PARTICULARS
^
.< 'k
^.
xX.^.^^
1' \ rr < •! luK rii
M-.nth
s<.i-
•-INi .1,1' M \K K UH
U I 1 »i i\\ I I > ( Ik
U iiti^ in - H ii' .,. ■
N \ M 1 i»l
1 \ I II IK
lUH rm-i, \< J'.
< U' 1 \ III J K
' -^t if ' I il • . Sillt 1
M MDl N N \M)
<>l' M< I III IK
lUKI'mM.Ai'l",
••I Mo'l-HHK
I '-t.ii I < ii I'liii lit I
1 1
-\
1 ' LcvVv^cd.
n
« >i < 11' \ rn)N
LxL^VAjto^l- ■
Till." \HOVI- STATl-l) l'KKS«»N U, r\K rin l,\K^ AKi TKl 1. T' » I'll',
in->r»>i M\ K N« lu i,i: !)< . 1', \m» inijii
f Infiirtn.-int
<X >^A- t^^v^
N.Mr.... 3s IH LcLa<
MEDICAL CERTIFICATE OF DEATH
1>AT1-; ol Dl-Ai 11 \
v
4
M.uilhl
Dav^ I Wat
I H1:R1;i;V ri'.RTII'V. 'riiat^I att«.'n<k-<l <lec-cast.Ml frniii
U'l
i«)0
that I la-l saw h .... alive on ^ CO i u T()0
and Hiat .liath uci'iirrc<l, <>ii tlu- ilats.- statnl al)<»vc, at
M. Tlu CM S1-; Ol' Dl'.XriI u.!- as fdlli.us:
mRAIMiN Years
roNTRIIUTOkV
Mouths It Dav.s
I lout
DT RAT ION
(SIGNED )
)V./r.?
Mouths
fhiv
J\jllU
M.D.
Ill
(
Aililre^s) I2»0b J ^L4,<n>v 0 ,1
SPECIAL INFORMATION on') f"!" Hospitals, Insfitutions, Transients,
or Recent Residents, and persons dvinj anav from home.
When was disease contrarted,
If not at place of death ?
Oavs
J'l.Ari.-, <»l ni KI.\I, OK Kl'.M'iVAl
^'
i>\ri;
il: ,n u
k i'M< >\ \i,
IQO
rNDKKTAKKK Y(X^^^-*U. H [^ \}a.>v^X. "
' , ,. , .pc «u„,,i,i he -mteil r.XACTl.Y, IMIYSICIANS should
N. H._Rver^ Item ni inf...„..t Ion Hh.n.hl b. c.re^ull. Ha.ppl.ed ';^^'^^^^^%^ .^,e.,„l Intonn.non" *o. p..-
•taU- CAimi: Ol Dl ATM ui phnn terms, thni it may he propcrl> wlas^meu.
Ron* dyinil away innn homu h
IiouIjI be fe'iNen In every in-stancc.
t
«r
t
m
\
i»i
: k
i
w
I
I
i
WRITE PLAINLY WITH UNFADING INK
Hnar.l -'f H- ■Ml
5, V,j ,:, ■*.S^^^HS.l'Cn
I)
dh' Filrd ,kj<::XjAj
K.K.' ^l
lOO'i
THIS IS A PERMANENT RECORD
REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
Bes^ustcred JS^'o.
cL^-CCL
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S>eatb
( X\. 5. StanC»arD
No
PLACE OF DE ATH : — County
ofCj<X^rv J Axx-rxeui^ -City of ^ <^^yy^ ^ ^'^^
XCCO cc
.. Let
.i
St.;
Dist • bet. ^^^
FULL NAME >.--... t'' J OK/^vKo. v , v-
PERSONAL AND STATISTICAL PARTICULARS
^
sj:\
ni
i«»I,< (K \
I 0 ^ i
1) \ ri: » M i;iK 111
\i .»'.
UwLM
I Motuh
si\i , IJ' M \Rk !1 1»
Wllx >U 1 I> OK I>!\t>K*. Ml)
(Writ, ill MK-ial lU "^is/nsition)
l):iv
.1/,, »////.
/hn-
MEDICAL CERTIFICATE OF DEATH
DATH t>l" Di: ATH
I'ct
1 1
(Day)
(Year)
^
ij.udc
lUK rniM, XT)-:
Ntifi ' 1! I '■ 111 nt ! \
III
n
NAMl' <U
FA Til i;k
Qir^
0
IvuXO^rru J .CL^iv' v<X
niK I'm-!, \rK
01 1 \ IHI-.K
iSt;it« . '! I I unit 1 V
M \ii»»;n n \mi 1 0
Ol- Mollll K >
A
\
a K
) ^ V
L^i'vr>\x
^ a
lUK ini'i.M 1-;
n|. MtHiiiH
(St»t« I'l Sunlit I %
« U'C I
X,iw.
M.iill,
lht\
TIIH \HoVKSTXTKn''KKsnVAI.1-AKTirri.VHS \K1, Tin K Tc TIN-
UHsTMh MV KN(.WI.i:i>.^K AM) l-J I.D 1
[ 1 11 f. 11 mafit
( Month >
I ni;Ul':HV CI^RTII-V, That I attciKkd (kccasctl from
;\L>A>. XT- igo'1 t.) ^ ct a Tcpn
tliat I last saw h .. alive «»n ^ cL 1 ■ up ^
ami that dcith «.ccurre»l, 011 the <lat.- stated above, at ^) ' '
OL M. Tl^e CAl'Sh; Ol' Dl-ATII was as follows:
DIRATION )V<?;v
CONTKIIU'TOKV
Mofit/is
Days
Ho tits
.V()Hi/tS
fhiv
DTK ATH )N
(SIGNED) UJ Xp. L-^-V^Lo- )%^
lUcfc IH ic)oH (A.hlress) UJl -y^X^L W wcc^ ■
f fours
M.D.
SPECIAL INFORMATION only 'o"* Hospitals, Institutions, Transients,
or Recent Residents, and pejcsons dyinq anav from home.
Usual Residence
Wtien was disease contracted,
If not at place of death ?
^ Place of Death ? ^
fttys
l'I,\CK «»1 HIKIAI, OR Rl MOVAI,
CfUt
V.'l'.
liATi; ot III KIAI, c.r Rl'.MoVAl,
€,ct Q.-^ T90H
( Xil.lii-^-
0O'A^.4\_.<'
IN
UVOOUDL Wc|%'
r\<l<li. s'-
Ttate CAUSE OF DEATH In ph.ln ter.n.. that it m„y he properly .la^shleU. The bpeclal lnW.n»t,o„ for pT-
«ofi« dying oway from home hHouUI be given in every Instance.
r
r-'
i
^
I
I
WRITE PLAINLY WITH UNFADING INK
1 )((!(' Filed J
n
J
\
1'
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTirrCATE FOR INSTRUCTIONS
2482
Bc(!istere(l J\'*o,
<
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
(Tettificate of H)catb
( X\. S. Stan^arD )
^ ^ + y I r
ity of "J K.^^O^'\:rO^^^ kXLX
a
a.
City
No,
St.;
Dist.; bet.
and
( ■' r."»;"..°"occ"u%*-r;,':r„„",^r.i r^^^-.^j^^";'-;.'"! 5,v^" r..".o
UNDER "SPtCIAL INFORMATION" \
OF STREET AND NUMBER.
FULL NAME
f
m
\oj\jcx. o^vxX
jU^yu^'>iA^">>'v.<n w
PERSONAL AND STATISTICAL PARTICULARS
I» \\V. « >I I'.IK I'll
C()1,<»K \
I t
/^1l
A 1.1.
Ml. ml!
J w. )'lil>
->I\< ,1 1' M,\KKIi:i>
(Write- ill -.■H-ial .h-^s/nit !■ .ii)
niKPuri. \ri
< Statf 11! I I in III! \ '
J^jy^
I):IV
M,nifh>
c^
I Vi-ari
n.n.
NAM I. <»!
I- ATI! l.K
BiRTm-i.Mi.:
oi- 1 Arm-K
I Slati <i! I'dlUlt! V
maii'i:n* namk /-^
i;k / ,)
H
<Ojyy\XM J
J aXia.^^
;x^
(»1 MoTIll';
lUK rnri.xcK
ni MoTHI'K
(Stati Hi V I ■lint I \
<)t(ri'\ riON H
\6 Kjcdxixi) d JuAaxLow-^-v
C>KJU
I
i
MEDICAL CERTIFICATE OF DEATH
dath <>i- i>i;ath n,
/go
(Month) 'I>«>'^ •''''■'''
1 lil-RIUJV CICRTH'V, That I atteiKkMl ilcif asctl from
-— — — -190 to •. igo ""~
that I last saw li alive oti '<P ^
an«l that «kath occurred, on the date stated above, at
The CArSfC t>l' DlvATII was as follows:
•4
Dl'RATION y'tuirs
CONTUIP.rToRV
Von //is
Pars
Ilotit s
I )r RAT ION
)>7r?
Months
/hlYS
(SIGNED) "3. vfc. JbO-
v. , >
//ours
M.D.
iqo
(Address) W<0^HA.CO^d- S, a.i
SPECIAL Information flnly lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying av^ay from home.
)'ii! I
yr.nith
n<i\
THH xnnvKsTViKnPHKsoNAi PAKTirri.
(I„f..n„,u,t \. ^- 3a.W</>^
\Rs AKI-; TKrK TO Tni-;
X-^/VVV/VVv-OO v^^
^ -x ^ ^ J
Former or
Usual Residence
When was disease contracted,
II not at place of death ?
HoH lonq at
Place of Death?
Days
I'l.ACl': <>!• Bl HIAI. <)K KF,M<»VAI,
DATl! tif lii KIAI. or K1%M<>VAI,
Oct ax TOOH
TQO
INl.KRTAKHK WoJjb-rCtt nTTUXA^w^^XU
(AdclresH 15 XH
Wu
'C-^¥LS-fr%%^
N. B.
state CAUSE OP DKATH \n plnin terms, that it may be pfoperly wiassmeu. c m
fiTns dyinft away ?rom home should be given in every instance.
'ft
1;
f
iM
ri'
'V
4
WRITE PLAINLY WITH UNFADING INK
^
Dfi/c ri/p(/X'AA>xK) x\
100 "i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
No.
DEPARTMENT b? PUBLIC HEALTH^City and County of San Francisco
Ccvtiticate of Beatb
( tl. S. StanDar? )
PLACE OF DEATH:-County of^CU^ l^aTvCw. .City of C^ . .V^o-c.c.ec
j«?!Dqi J no ,__
' r,".;:r°"occu%"r;,;"r„oTp"*' "fMs'Tu""; cv.^s name ,nsT..o or st„..t ... Nu«=.-. ;
(
FULL NAME
si:\
PERSONAL AND STATISTICAL PARTICULARS
nrs ft coi.«»K \ A
1. \ ! i; It! r.'iR iH D
r'\
(Day)
\».i-;
V.,,. Cclrt I M<nnh~
I 1 ai
/',.'
< St.itt III t,'inint I N
NAMl' «>l
I AT in: R
RIKTiiri, \ri-:
()! 1 \ I II »:k
i^iiatt Ml riiuntiy
MAIDHN NAMl
(tl- MoTin'.R
HIRTin'I.ACl':
«U' Mn'rilKK
i Slatr or I'muiti \
< uiTl'A ri«>x>
/s'riJrJ til S,i» I 1,111. '-'•-»
MEDICAL CERTIFICATE OF DEATH
DATH t>l-' Dl'lATH
1^1 igo'i
(Day) (Year)
ilct
(Month)
I IIICUIU'.V Cl'.RTII'V. That I atti-mU-.l (Uccascd from
lL),cfc ^^ 190' \ t.> : ' ^^p
that I last saw h-^' alive on U^^ ^^ I9O"
an.l that ck-ath orcurre.l, <»ti the .latr -tatod above, at
* M. The CAISI': Ol' DI^ATII was as follows;
I )r RAT ION Yiiirs Months
Day
J/om^
^C:
DT RATION Vi'drs .Vof///is^ /hivs //orns
NED ) Jh\. o ^ mIOxdiaaI^li m.d.
(SIG
I()0
(.'
Special information on'y '<»r Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq dway from home.
) ,,/;
M»iilli
/',/!>
THK vHnVKSTVlKI>l"KRSnNAI,rM<TUT!.AK^AHK TRIH To THH
' HHSToi' MV KNnWI.HlH^K AM. nKMHF
ni;si ni Ml K.N'iNv 1.1^" ■■•
„„r ^ 1 M^\.X^A.^VXXU-
( \<Mi< ss <7^*^ 0 V
A^-x^Vi ji
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
Mow lonq at
Place of Death?
Days
I>I \C'K (»I- IHRIAI, OR K1;M<>\ AI
r.MM.R lAKHR
nKTi: iif ijiKi.M 01 ki;m<>v\i.
\(l,li,^H obTX^ I L A^K.
"""""""^ . .. , Trv «H»..ia he fttated KXACTLY. PHYSICIANS should
son. dyln4 away from home should he j^ivcn In every instance.
n
\ 4,1
1
r>,:
^ I
n
(♦I
n
■'1
I
WRITE PLAINLY WITH UNFADING INK
!!,,ai<l ..f II^mUJi 1- Nc I" t-^^^it) V.S^VCn
I)i
(ffc /v7^'^/, UctcrU4A- X\
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.<S\.K.K '
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
PLACE OF DEATH:-County oi^^- : ^l/Va^acv^c. City ofOc^ 0 A-O-o-c...
^No.
v., C '-
, + III
^I^^lM J: '.-^ ..St.;
Dist.; bet.
and
)
V IF DEATH OCCUI
:.^r: :::ios%'f... o^ ..s..;u%To. o.vr.Ts name ..stc.o o. st«,
FULL NAME
-L
PERSONAL AND STATISTICAL PARTICULARS
DAll-; ill lUKl'll
COI.OK
ac;h
s^V
I Driv
M,,,i!li
■\r.'t 1 )
I hi
sl\. ,1 1-: MARK I1-. I)
iWiit! Ill -•Hial i|tsi(.Mi,it iim)
MEDICAL CERTIFICATE OF DEATH
DAIK «>I- Dl'.ATH
(Mi>iitli>
(Dav)
igo
(Year*
I Ill-klU'.V Cl-.kTIl-V, That I atteii.k-d (Iccrasfd from
■ ,^H to 0-t 1% icp^
Hint 1 last saw li - alive oil ^' ^ - ' ^ ^^P '
ail. I that .k-alh (KTurred, on the date state<l ahovc. at ■
'. M. The CAl'Slv Ol- Dl-ATH was as follows :
iJ AxLt ^^^>
V\i
HiK rui'!, A'M-:
St:iti "t »'' Hint 1 ^
NX Ml" Ml
1- \ I" H V. R
lUU 111 JM.ArK
(>l I A nil' K
I State (ii I'dillltl N
maiih:n nam I
ol- MOlin'.K
lUK'rniM.Ati-:
<)i- m<»tiii':k
(Slatf or Couiili ^
A
KJ
M
oaA
i^
4 ^ i
CO 'w'VCw
XX^w^^
X'"\>\aJLcxA/
'u
DC RAT ION Years
CONTRIIU'TORV
Months
Davs
Hours
nr RATION
,}fonths
(SIGNED
)'rars
/hj VS
Hours
M.D.
oCCri'ATloN
h'r^iiirJ III S,ni /ntini>t'-i ) '<'
'- .M,-,,th- " /''"
T.,KA,U,VKSTXT,U>iM^Ks.>NU J-AKTirt.XK. M< K T K r K in T,,..:
JJKST <'»;Ji'V KNOWI.I-JX.K AM) in-,l,n.l
(I„f..nnant J AX^.^^^^ ^- *^^
f \ l.lr> —^
LAJL'VyxxiJ(v<:
i<>o
f
A<l«lress) KjJ^ >
SPECIAL INFORMATION only ^"'' Hospildls, Institulions, Franslfnts,
or Rrtcnt 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 ?
Davs
ri.ACH Ol miijAi. <»H Ri-:MiiVAi,
C^'
l)\ll ,' li! uiAi. Ill KMMOVAI,
I go"
I NDHKTAKHR
(A.l,ln.s. 3b1X^ l^ V,. ^^^
■— ^ .. , 4,1 .\„.,.l.l he Htetetl I.XAGTLY. PHYSICIANS should
N. B.— F.ver, ..en. of ,„f.,r,n„.ion .h.ul.l ..-• crefuM, -.pn .e. ^ ;;_.•;;■• '^'„^°^^ ^h. "Speci.. lnWn,..ion" .or p.r-
■tate CAUSE OF DHATH in plain terms, that it mii> i»e prupwr y
"n* Hyinft away from home «hoi.ld be feUen In every mHtance.
1'.
u
ill
'■♦
I
Ml
I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REfeR TO BACK Of CERTIFICATE FOR INSTRUCTIONa
;i,:ilil 111 ll'.iiin I ->i. a^-^^-^m^^
lie^istercd J^'o,
•I •- f\ 9
j-u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
1 U. 5. StanDarD )
4
^
PLACE OF DEATH:-County of^^^ OA.a^- ^. . ^. City of O^^ J.XO, ,^<...^c
No.ot ma^u:^ A:^^.;\do
U .
St; -
Dist.; bet.
and
)
U^njJ/i A, ^>^.l WWW.^^ ; orS^ENCE GIVE ^CT^CArjcD rOR UNDER SPtCAL INrORMATION ' ^
/ ,r OzAh occurs AWY -^"O*" ^^SUAL «f SJDENCE^GJV^E ^FAC^^ ^^^^ .^STEAD of street and NUMBER. J
\ IF DfATH OCCURRED IN A HOSPITAL
OR INSTITUTION GIVE ITS NAME II
\U
FULL NAME
y
Vt iX a.
HEX
PERSONAL AND STATISTICAL PARTICULARS
« ( »1 ( )K \
a
lL^
w -^
DAl'l-. « 'I I'.IK 1 II
At. I-:
,%%\
Mmith
"kl
1 l);iv
M.-mHi
f%'t ai
])a
sIN< .l.H MAKk 11 n
\\II»< >\\ 1- I) nK ni\< »KtKI>
<\\iit« ill -'nial (1« -»vintt!'>n)
lUK nil' I. \'"»-:
<-,tat > n: • • iti n! ! \
\ \M 1 ( »r
!• A III IK
lUR I'll IM, Ail-:
oi I \ 1 11 1; K
ist.itr <ii Cnuiilry
NtVini'lN N\M1
oi Mnrnj;R
HiK'i'uri.ACi';
n|- MoTHl'.R
(Statr or Country'
MEDICAL CERTIFICATE OF DEATH
DATK OI- i>i;Arn
l^
Dav)
(Year)
I III-:UI;HV tlikTIl-V, Thai l atUndca (leci-aseil fn.ni
7^ put i' UK.. to ^^ i^. TonH
OX\vL 1. up- to "^'^^ ' ^- ^^
that I last.awh . • alive on C wU I l icp
and thai .Uath ocrurrtMl, m, the daU- staid ahovo, at 1
M. The CAl'Sh: OI- l)h:ATIl was as follows
dL^..
i Kn
XJlhJ{^f*VOL'L * *
nrk A'lioN
coNTiuinroRV
'm
^
Hours
-.j,„«
I ) r K A r M » N >3''' '"^ '^^' ' '' ^^' ''" -^^"^ '
(SIGNED) M\.1J- nIiUVv^
i^ rt, . ic,o i fA(hln>ss)qi>.^' ''--
V
I /ours
M.D.
\j xjYU<jOjy^
,d
tnJCl TATION
3<3LX,WX>
) - ,,
y/ iiffi'
THKAm)VKSTAlM.,.rKUSnNA. .AKrUMMXK.AHHTKrK To THH
HKST OI- >iy KNoWIJ-.lx.h .K>I> M-.M' t
foTtnaiit vJW,- ^-^
(In
A.M'
4XH
SI
OJ\K<A,inX'
SPECIAL INFORMATION only for Hospitdls, In^itufions, Transients,
or Recent Residents, and persons dying away from fiome.
Davs
Former or
Usual Residence
Wfien was disease contracted.
If not at place of deatli ?
AA-O
How lonq at ^ ^
Place of Death? ^
ri \CE oi- m Kl.M, «»K RKMOVAI
nxjilof I'.i KiAf, or ki;N!<»\ \1,
. - t .
c^i
T9O
A-OsA^
N. B.-
■~— "■—"■■"■"— """""""'""'^ TT^ AfiE should be stated EX4CTLY. PHYSICIANS should
-Every Item of Information should be cnretully -PP'-f* p^.^-ircla^sified. The "Special Information" for pT-
•tate CAUSE OF DEATH In pIhih terms, that it m«j bu properly
sons dyfng away from home should be feWen in every instance.
. n
•^> ; ^.
: #u
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Mil
Registered ^'o.
O 1 Qf^
Dale Filed, {).^XA>^Oso W lOOH
Ifrvo^liL^ Deputy HeGSth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( 11. 5. StanDar^ )
^
No
PLACE OF DEATH: — County of CX^% VC
City of O^CX/^^ J/u<x >A.au4
L. C L
'}c\\n'A^h:^\\d<^ ' St.t Dist.;bct.— and
LCVXU/^ a, IVv.. ^Vw oesTdeNCEg.ve rACTS called .or under •special .nformat.on • \
( '^ r/±T°H^OCC^%r;.;"rHO^s1.r*L 0^".;™0^ CVE .TS name .NSTEAO O. street A.D NUMBER. J
)
'A
FULL NAME
^l.X
PERSONAL AND STATISTICAL PARTICULARS
. r( >i,t)K ^ A
171.
1) ATK « 'I HI R I'll
L
I
I
.^^i
M-.tuh
At.K
'XO 5
(Dav
M.,)i!li
Vtai
r>a\
•^IM .! V M AK 1< 11 I>
WinnWl-.D <»K DIVoKiKI)
iWiitiin -iH-ial ilf>H''iat ii>ii )
0
i I
MEDICAL CERTIFICATE OF DEATH
DATK Ol- DKATH
(Montht (Day)
(Year)
I 11I':RI:BV CIvRTII-V, Thai I attciuUMl (IccLascMl from
\ . up ^
that I last saw h ■ alive on ^ ^^' ' ' I'P
aiul that death occurre.l, on the .late -tatc<l alx.ve. at H
I i
HiK rm-i. M'K
( Stat< ' >: ' '■ Hint ! ^
N \M1- I >l
I- A rin-.K
lUKTHIM, Ai'J-:
<>i- lAriii'K
isfatf «>t c'o'aiitry
\t \11>HN NAMl.
.11 MuTllKK
lUKIinM.Arl-;
Ol Mdl'IlHR
(State or Ccjtintryi
0 .c^xLa^ • '
t I ^^cx
or ;1
M The CMS!': Ol- hi- A Til was as follows
c'.k^■wk d.
DTRA ^I^N
Yea
Ur.l'TORV "^"H]
Mouths ^ Pavs
4 .
Hours
0
Llv^Ubt
OCCll'ATlON J I
L >A^OU
Kr.^iJe'd III S,i>i /'iiDh ,'>-*.»
5
M..„lh:
lh!\
BEST or %U' KNoWIjUx.h -V^J) l'»-.l.J''
(Informant
a. OL
>VA,' CC^
I ) r R A T I ( ) N > /'^'-^ Misfit /is /htvs
( SIGNED )..M\.dO. Mri<
.^AXA.^.<nx;
f A*Mress)C
I lours
M.D.
SPECIAL INFORMATION only for Hospitals, InMitutions, Transients,
or Recent Residents, and persons dying av*ay from liome.
Former or ^X T^^ ^^^ ««« '«"« «»
Usual Residence
Wfien was disease contracted.
If not at place of deatli?
Place of Oeatli ? ^'
Days
I'l ACK nl lUKIAU OK KHMOVAI,
pAi'i of iiiKtAi. ol ki';m(»vai.
t^^t
^ 1
TQO
J?
,„,,„.„ H XI (JO ahJvc4.irrv
; t
ua.h.ss MM ^ oJUU^v ^ oil Un.^
atate CAUSE OF DEATH in plain terms, that it maj be propeny w
»ons dyinft away from home should be ftiven in every instance.
i
I
WRITE PLAINLY WITH UNFADING INK —
H.cir.l ..f Hialth I' N
,,. ,^ '?.-?"ri?.X^l',.'vr I
■r:">^;
l)((fr Fih'(l,VfduXx.\j X\
100\
THIS IS A PERMANENT RECORD
REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
S486
Be^i'Stcrcd Xo.
Deputy H
»*^N
ORlcer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of Beatb
( 11. 5. StanDarD )
0 ' r?n
PLACE OF DEATH: — County of
r>
■ City of ^JXXA^' 0 K<X.^ \. f:
':^
%
No.
J
n , St.; Dist.; bet. ^3 CrViK- Ll'
Dt*TM OCCURS AWAY FROM USUAL RESIDE
IF DKHTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE
and
CX.^
)
. = «« IIQIIAI RrSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
( '^ ^"-^."^°"_^.r^Ar.\!.''?^.„''.lV.1|- Tp^nStitution GIVE ITS NAME instead of street and number. ;
n
FULL NAME
1
cx^o^qt - ^ .CLV4
44-
-i:\ (
PERSONAL AND STATISTICAL PARTICULARS
J
Xt>xcv
DA ri: «>i- lUK in
Ll
)
Mnnth
(I)av)
\ 1 , 1-:
Ht
'l.
1/
H
'/i;iri
/hi l.N
i\\iit» ill --.H-i.n .1. -ivn.,! .Ill
I'.iK rin'i, \i'i"
St.ltl- I IT I 'i 1(1 lit I N
N \\1 !• OI
I A rmcR
lUK 111 ri. At}':
OI I AllIKk
(St.itf III i"(»uiitrv
MAIDl-N NAM1-;
OI- MoTin-.K
HIKTIIPI.ACK
«>1' MoflllvK
(Stall- or Cuuntiv
,-U
I V I ^"w -— ^- ■
OCCri'ATloN
2)
vhv
^\.^cx ^
(Vt-arl
MEDICAL CERTIFICATE OF DEATH
I) \ ri', < )i- ni'.A rn
^ .;
1 ni:Ri:i?V CI-RTIFV, That I attcii.k.l .Uriascl fmtii
^. cA. : up'' toi^-^ '^ 190H
that I last saw li >^w alive on ^ ^^- • • ^'P '
anil that (U-alh occurred, on the date stated above, at
. L ^r. The CVrSI-: OV UKATH was as foll«>\vs:
DTK. XT ION )'('(irs
CoNTKllirTORV
Months
/hivs
I/Oltl s
DIRATION
)'iiirs
Months
Pax
I . rs
» N 1
M.D.
(SIGNED) \}\ ^ U
Oa^ at) K>o-' (Address) ^^ibMlXrvxto^M^^ ■
SPECIAL INFORMATION only for Hospitals, Institutlorfs, Transients,
or Recent Residents, and persons dying away from l>ome.
1
Kfsiilfd III Sail /'i.nhnio Ob ^ '''■
M.mth-
I hi
■nU: X..nHSTATK..l-KKS<,NA. PART.rr..XK-^AKHTKrH To TUH
liKST OI- My_KN»)WI.l-,I)<.h AM) l.l-.I.H.f
(Info.mant J ryy^<X^<^ X^X<XtrVA^O '
fx,i,irt-<s ^'^i '^y"* -^M
Q
«
4.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli?
How lonq at
Place of Oeatli ?
Days
IM \CK OI- niKlAI. OR KHM«'X AI.
TNDl'RTAKl-R U /QJLX'^>^^Xx
15 XH
DNXJ'oS ISfRiAf, of KKMoVAI,
\_
■t
<X\a. > v^
(AtMifss
<r^
ysjk
atate CAUSE OF DEATH in plain terms, that it may be propeny
son, dying away from home should be feiven in every .nstance.
ill
U
■•'il
'if
•i .
:-Hl
r^f^.
•"^•^
I lb'
WRITE PLAINLY WITH UNFADING INK
^"-'■'•^
u
..VI' r
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IfJO'i
Be^isfcred jYo,
O %c^
DEPARTMEN?OF PUBLIC HEALTH
City and County of San Francisco
Gcvtificatc of IDeatb
Vi. S. 5tanDarC>
X
PLACE OF DEATH: — County of
No.
^- i k
'':(Xy\j oAXXv^c^^eo City of
St.; ^ Dist.; bet. V-O^UA ,
U N Dt f
rV^rVca. and
or. TH OCCURS AW.Y rROM USUAL R ES I DENCE G. vt facts ^*l^," ;°" ^^^^J
ir DEATH OCCURRED .N A HOSP.TAL OR INSTITUTION GIVE ITS^NAME INSTEAD kXF
FULL NAME Xtrv^ccCLCu %0^t^
"special I
STREET AN
NFORNIAT
D NUMBE
ON' \
R. /
PERSONAL AND STATISTICAL PARTICULARS
■<ii."'k^ ^
I) \ r i: < >! HI K III ^
/ ''-
\\
A« ,i-;
W f I )• i\\ !' ! • < tls I • V' •'•' • >■ !>
■U lit. Ml ~,H :..: .!< ^:-:;.,'; .!l)
lUK rn ri. \i"i;
^' • I)! iiiimti \
ll.lV
\r,titii
I A ill i: K
^ M
La^vvl:
t 4
luk rni'i.Ai'H
r)!' 1 A IIIHK
i Stati or I'outitt \
M \I!»1:N NAMI-:
t»i M(»riii:K
lUKTIII'I, \\ V.
<M mi>iiii:k
iSlaU- III iOuutt \
occirAriuN ^i
aqt
n
/ ■» ( i
MEDICAL CERTIFICATE OF DEATH
DA ri-; t >i iii.A'i'ii
M-.nllii
i)av
iVtnri
1 ll!:Rl';r.V eiKTIi'V, riiat I altfinlcd tkHxascd from
up
, , _ t
til at I last saw h ' alivi- <iii ^
and that «U-atli (K-currcd, on tlic .latt- statcl aln.vc. at ^''^
y M. The CAISF': OF DKATII wa-- a^ follows:
Dm jviVvvc 't X
Ari
DIRATION ^ }'''<ns
CK\v
Ihiv
Hours,
RATION Jl^ r*
(//'.V
Months
I^xv
(SIGNED) vJA.<XAV
\aA,ca
<kcui
Resided m Sax I > ati. ."
^
Mntlth^
■,Mn^XI.nK.TX,M^prHR.ox^KrAKT10ri XRSARKTKrHTn
in-ST «)l- MS KN'iW !.l IX.1-, AM) lU-.l,!!.'
(I
nfnnnant U -COw^-VVA- U ' • ^^
lUd.
l()n
M.D.
SPECIAL INFORMATION ""!> *nr tlospitdls, ln\fitutions, Irdnsients,
or Recent Residents, and persons dying andv from home.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
v\ \ci-" (>i- m KiAi, <»K ki':nu»vai
■ ; 0
DA 11! of Ht HIAI or KI:M0V\I.
wet. ^a TOON
I
/>"u^
'""—"'—"■"—"'""■■— ""'"""""^ rrr^ ,. ,, ahF should be stated EXACTLY. PHYSICIANS should
J,. B.— Every item oi inWmation should b. --«- '^ ^^""^^'^t propeHy classified. The "Special Information" for pT-
state C4USE OF DEATH in plum terms, that it mn> be proper.y
so^s dyini away from home should be ^iven in every .nstance.
.^^
r
ifl
iV
■
I
I
WRITE PLAINLY WITH UNFADING INK
!)<(((' Filah CxtcA.^^' 5Ll
10()\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR tNSTRUCTIONS
Registered ^'o, 2488
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( tl. %. Stan^arC^ )
m
PLACE OF DEATH: — County of C\ >-^.
No,
' -^ , -^ ' V - City of CJ Ojy^ O XXX > \- CA^-i
St.; 3v Dist.;bet. ^ XXKM and
,.o,,«i RFCSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
■. s
)
If
0^1 i
FULL NAME J <X yv^^u^
PERSONAL AND STATISTICAL PARTICULARS
n
It \ 11-. «>i" lUK ni
\<.i-
%;
.L.
I>:t\ I
M.m'h
\v\\\ i
;i
(/ 1 .\
-.IN< . 1.1 M \K N n-l»
WIUOU I ! lit)
<Wt ill- in --» .f'lii'
ki
,t\HrVcjLcL
r.ik rm>i. \i'i'
■-t.it • ' >' ' I -n !it 1 \
NAVfH «>K
I- ATHKR
lUK I'll I'l.ACK
<)!■• I Arin;k
I St;i!r III i'liuntl V
,0. rv' J .V
LU^tc^x
lA
A
MAIDKN N\MH (iCS
«)1 NU)Tm:U U|'
I5IK rm'i.AOK
f Stntf or t'otiiiti >
\xk>: \itrvk M^
ij
0
OjJ
l^aXjtvv) C
^vdL^ilv
orcn'ATlON I
TMKA,M>VKSTXT.;.M.KRSnNA. PAKTUM^KXK.AKK TKtH •,-.> THH
HKST OF MV KX.)\V!.KI)<W% W 6^^ 0
' \.l(lrcss IHOL
MEDICAL CERTIFICATE OF DEATH
DATH ol- DHATJI , . '^
(Month) 'I>='^-^ <'^'''-''"^
I IIl'Rl'P.V C1':RTII<'V, That I altcn.lc.l <lci-t asc.l fn.ni
„ ^ ~ 1 c^o t« . — -^— TOO ■
that I last saw h ahvc on ^«P
aii.l that .U-alh ..ccurrt'd, oti tlu- <laU- statc-.l above, at
M. Tlu- CAT SI-; (»l' Dl-A'PII was as follows:
DT RATION y^-'DS Mouths Pays
CONTRIIUTORV
Hours
( SIGNED )UA.^mJtH^' J ^^ ^^ ^ M.D.
SPECIAL INFORMATION onlv lor Hospitdls. InstiMiHons, Transients,
or Recent Residents, and persons dying dwdv from home.
Former or
Usual Residence
When wa? disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
I.ACH OK niKIAl. OK KHMO\ AI,
Qui. ULLA-^XO.U^i
INDICRTAKKR M V
-H
DAXl". "S Hi HIAI <ii K1':MoVAI,
U,c.t -^ 190
(Ad
A-'-CLA^,
^\
^tl
(lit'ss Ow D^ o w t
W-4-4^
tXk^
>t
^ vx InE should be stated EXACTLY. PHYSICIANS should
N. B,— F.very Item oS information should be carefully «"PP»-^- 'I'^^J classified. The -Special Information" for pT-
state CAUSE OF DEATH in plain terms, that .t ma> be PJ^J^^J'^
;in. dyinft away from home should he given In every .nst.nce.
' J
a
1^
Hi
I
I
I
m
k
WRITE PLAINLY WITH UNFADING INK
Unanl
11. lU). ! N
i.X !' I'll
HJOH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
O f QQ
lie^isfercd J\^o. J*f
^ , ^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-^City and County of San Francisco
Cevtificate of Beatb
f XX, 5. 5tan^a^^ >
PLACE OF DEATH: — County ofU/O.^'
i
N r\
City of C' Oy^-v-
m
No. 1 b ^
(
St.; 1 Dist.; bet. U/^rvun\' and
"' P .V .o^« IJC;UAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INTORM*
" rr'dTH'ScCU%rEV.;."rHO^S^P^T*AL O "ns'tJV.O. C.VE .TS name .NSTEAO OF STREET A.O .UMB
TIO
ER.
FULL NAME
/I
— ^
>
A i
PERSONAL AND STATISTICAL PARTICULARS
'-l-X
%-
I < ii.' 'k
u
V
.. 'J
\! ,nth
A< .K
.1/
W I 1>« iW I 1 > ( t|.' I > V« iKl"!:!)
I \\i lit \n - > 1 i: •>■• -i I.' nut it 111)
MEDICAL CERTIFICATE OF DEATH
DATH OF I>i:Aril ji ^
(M..ntli) 'I>'ty^ ^^■'■•«'''
I HI:K1:1'.V CI-RTII-V, Tlmt I aUen«k'«l tU-ix-astMl fnnn
^s:X: ^ > up' to aD<:* 9^1 T«pi
tliat I last <aw li alivi- on ' ' ^<P
an.l that <U-ath occurrcl, nti the <lali- -^tatr.l abnvt-, at >- oU
.,1 M. The CAl'SI-; OF DKATH wa- as follows:
Cjx^v^
lilH 111 J'l.At"!'.
'-.tilt" iiT ',*« MHlt : %
I- A rilKK
niK inri.ArK
(M" I A iin-.K
^t.iti ii! iNiutitlv
-\ r V
^C
1
J I ■ ■ -^
maii>i:n* n\mi: (^
L
lUK'i'mM.Ari.,
'Stall 111 i'mmtiy'
.-D
-^v
^OJjJr^ tx'^a
nicri'ATioN
u
)V,;
}/.,,!///•
/):
T 1 1 1*. \ H( )V K ST \ T 1-: 1 ) »• H R -^< • N \ I . i' ^
KTI'TIXK^ ARI-; TKIK T* » THK
Hi:sr ()i< MY 5i^«>\vj,i:i)r.K an > i.mjii
(Inforinatit
n
c«w'
I) IK. XT ION
}'r<irs
1
Months
Pa
vs
I lout s
CONTKIlUTOkN
cjr^x.a
DIRATION ^ >V</^
Mtiut/is /hi\
r SIGNED )n(^- UjX\:Uic
Hours
M.D.
.a.lress) l^ia^^l<V^^
SPECIAL INFORMATION only lor Hospitals. Institulions, Transients,
or Recent Residents, and persons d>ing away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death?
Davs
I'KACK «)I- lUKIAI, OR KKMoVAl.
i)\rj- .; lUKiAi. or ri:mo\ Ai.
^'€t
vS.
T0<^
\(lilrt".s
5X1
Xolv«-VL
t
A
r N
N. B.-
— ^ "T! 77a 7\\\ should be stated RX4CTLY. PHYSICIANS «hould
„f information should b. cn.ctuHy f"r»P ^^j^" p..' erly -lasshMed. The -Special Information" ?or pT-
E OF DEATH in plain terms, that it mnj ht pr.,periy
rSin'i^'w^; «r:,;;hon;'^ ;ho«,., H. »•„.„ >., ,.=., in,.„nc..
«HIW^
■^li
M
1
•A I
-:f'
f
I t
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I V
* -^U-A'.s^Vi-
Dft!
Deputy h
IDO'X
REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'3490
Be^isfet'erl JS'^o,
,(r^^*-^
h C
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDeatb
No.
PLACE OF DEATH: — County of "\.^^ ^
St.;
^4-
City ofl'oyvv 0 ^o^
n ■ \\ ^
I rUAAA^<rY\^ and C Ctl
Dist.;bct.N I \AAAxJry\>
"■ "" i.ciiAl DTQinrNCE GIVE TACTS CALLED TOR UNDER "SPECIAL INFORMATION \
A
FULL NAME
i
CUUj Ck^t^CC<LA
A)1:CU'
o
PERSONAL AND STATISTICAL PARTICULARS
r< ii.t ik
i> A 1 i: » »r i;iK 111
^ H^
M
M
\' .i
<,INm,K. MARHU !>
\\II»()U'1'I» <iK " * ■
•- \\l it' HI ~iH'l;i;
1 ! >
MEDICAL CERTIFICATE OF DEATH
MATH '>I- I));ATH
^c
Nf.iiuhi
»av)
iYtar>
I JIKREBY CI.U'riI'N', That I atU-mlcl deicaNc.l fnmi
tliat I la-t saw li -.' alive oil V. tv s. up .
nii.l that death ncrnrrcl, on the date stated ahove. at
M. The CArSh: Ol- Dl'ATH was as follows
r.iK I'll j'l, \*'i".
S,t;ltl 1 i! t'l 111 llll ^
X \M1 < »!
I- All I )■ K
'^
i I
^fLativo.>v vbo^ldix
niR rm 1. \eK
(>! 1 \liIlK
SI
! 1 \ I' 11 IK '^i
^Vvt^v
»>i Mitrm: K
luK I'll I'l, \ci<:
(Slat*- or Count! ^ 1
t V c ^
rvTu
r
ovhtpai'ion*'^ (\
0^ 0-uuljU.o^" ■
V.0
h'fsidt'li III S.iii I ' '/' ■ i-i'"
^f ■'/;
Tin- xm,VKSTATKl.PKK...NXI.l>AKn;;rUAK^AKKTKl H Tn TIIH
in:sT ni- MY KNiiW M.Iit.l.; \Mi hl-.l.H-f
( Iiifutiuaiit
A.l.ltH-s SS^b ^ 1
oli\) U
t
DT RAT KIN
}'t'(irs
Miiiiths \ Pars
Hon
IS
CO
NTRIIHTORV ^a.N.CL^C^C
„Lk
}'r<rrs
lf,>^///is
/hiv
a.-
is
M.D.
DIRATION
r SIGNED )
^',cA^ .. i<(o
SPECIAL INFORMATION only for Hospildls, Institutions Transients,
or Reicnt Residents, dnd persons dyini) .iw.)) from home.
A. 1.1 1
es-
xo
,L'
Former or
Usual Residence
When was disease rontrarted,
If not at place of death ?
How lonq at
Place of Death ?
Dass
i'l.ACK OlJU^fHlM. "K K1:M<»\^'.
1^ f^
.,.„ ^i Xdx^ ^ ■0^ '^"*^^
i»\ii" li lii HiAi. or ki-;mi>vai,
C),ct
ir)0
,. , TaE should be stated EXACTLY. PHYSICIANS should
of hiformntlon should b. curafully fuPP''^;". ^^^'f^^^ ,„„-,fied. The "Special Information" for p.r-
F OF DEATH In plain terms, that .t may be properly ^las
HS:^r ^^^ :;;;;;.; He .Iven . .^.y instanc.
•i;
•1}
.(•:
r^
Wili*#
^J^tv
\
,,;,,.! ..f 11. :nth»- No .. *^=«J^H&P Co
R.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f/r Filed, vl'cA>i>-^Uv- ^l
Officer
Re^lsfeied J\^o,
2%ni
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(No,
PLACE OF DEATH: — Cot^ty
Cevtificate of 2)eatb
( "CI. S. StanDarO )
ofU/CXOA- J \aA^C<-t^(- City of Oo^^v 0/vcv > vc.oi.cc
Dist.; bet.
and
^iJJ^ V y V\^VUA.'>^V\j^ ..^/iTt RrsTDENCEG.vE facts called for under 'special information- \
( '^ I^^V:;:^ Ic^jfci^i't.i^^t ^^V.l^.'^^.^soV^^. .ts name .nsteao of street and number. ;
FULL NAME
lb- ^l.-A
'^
<.i:\
i)\ri-: <»! liiRiii
\l.l-.
PERSONAL AND STATISTICAL PARTICULARS
! cnl,<>Ki
xo
/ o
Mmithi
(Day)
MnUtll-
\ lari
/><n.
S1N(,1,1*. MARKIl'in
WIDoWJ: I) <»K l)i\<>Kr)-.I>
iWrittin -<K-i;iI .It-ii'tia! i< >ii )
lUK riii'i, Ai'i-:
I St;it( tit I'liuntrv
n
MEDICAL CERTIFICATE OF DEATH
DATK Ol' I)1:aT!I
I
A.
Month)
(Day)
IQO
(Year)
I Hl':RI':nV CIIKTII'V, Thai l atU-u<UMl .U-.-cascMl from
•• — — -fgo tr) "■ —————— ————r, 190
that 1 last saw h -— alive oil " 19° "
(\
\0
k
NAN! I <>!
1 A'i 11 IK
lUR IHl'l.M K
<)I- I\lin-K
Stall .11 rduntiN
MAIDl-.N N\M)
01 MmTHKK
HIK TMl'l.ACK
01 MoTIIHR
(stat< iir (.'outitiA
ovcrrA'rioN
h'r-i,{fi! til Sa>i I- 1 1!
Qj oxcy'
xo
n
(
X- V \-
?
ami that (Uath nccurrcMl, mi the date ^talid ahovc, at
" M. The CAl SIC C)l" ni^ATIl was as follows:
\
DTK AT ION )'i'ars Afontfis
CONTRir.rTORV
Davs
Hours
Dl'RATION
Years
^rontlls
Days
( SIGNED ) .L<r\.tmJA 0 Vfi. u) ^JlL
: i(,o ^ (A.l.lress) W^^^^^J^A^ ^-h4w
Wtl
•m-
Hours
M.D.
Special information only for Hospitals, Inslltutwn^, Transients,
or Recent Residents, and persons dyinq away from home.
)■,,?,
M,,>,lh'
l\i\
HKSToV MV KNOWI.KIX.K AM. lUlJll
^
informant G)^.^^rXi-^.^ L-Uw-.^.
(A<l<lt.
Former or u,/ H^ I -^ ^U ""* '"!I'J'^.,
Usual Residence " * V5 ^KaMj^>SJu \ ^i^t of Death?
When was disease contracted,
If not at place of death?
Days
ri ACK «H- lURlAl, OK KI,\1t>\AI,
Nft^xOU"nJ-<bL
I)\ri"of H' HiAi, of KHMoVAI.
ik
INniCKlAKl-.R
^'Q^
190 ^
'^ dtnv
N B —Every item o^' Int'ormnf.on •houlcl b. c„refu„y nupplled. AGE should »>,« «.«ted BXACTLY PHYSICIANS «h^ld
.tate CAUSE OF DEATH In plain terms, that it may he properly classified. The "Special information for pr-
son« dying away from home should he given in every instance.
i
1
I
1
I
i
WRITE PLAINLY WITH UNFADING INK
H, ,;.!.! ..f II.nl!!r I- No :< :^--;^*!^ BS: PCo
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
pfffc Fi/rf/,X.xXc
100
Registered JS^o,
2492
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( tl. 5. StanDarC* )
PLACE OF DEATH:-County of6xx^^^ 0;vO >. r. , r City ofO^O^ 0 Vo.^ ^
,^T h ' * - St.; ■ Dist.;bet. U ^ "^ andvrv^,.
fNO. ''^ - "- „ ,,e,,Al PrSIDENCE GIVE FACTS CALLED POR UNDER SPECIAL INTORMATION' \
( '^ r;;;ATH"oCC^%rEVi;''rHo"s^PrT"AL 0%"r;STmf4'/0.VE .TS name I.STEAO or STREET A.O NUMBER. )
)
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
m:\
111
COI,OR \
KjCkXx
UVW. of- r.lKTIl
.\ < ■. 1-:
LI. ^v
0 r,
I M()tUlt>
5',„'
( I^av
M.niths
■.tar)
Ih
SINt-.I,!- MARKli:!)
\vn)o\vi-:i) <m niv»tK«.Ki>
(Writf in -o.ial il- -'-naliDii)
HIKTMPI.AOK
'Stati' or Ciuintrv
»• A ril IK
niKTiiri.xn-:
oi' lAlHl-'R
! sta!' « '' (.'uuntl ^■
MAini'.N NAMJ'
ol MoTMHK
lUR riiri.At'K
111- MO Pin-: K
i.
Ol.
A.UL<X
\ \
MEDICAL CERTIFICATE OF DEATH
DAPH i>i-" i)i-:ath \
L'cfc I'"' I90-
(Month) <l>»y» <^'f:«'^*
I HlvKiaiV CI'.RTIFV, Thai I aUciKki! .UvchscmI from
.L^^yI; aC IQOH tn Cix^ X^ icp S
that I last saw h i- > ' alive on ■ -^. , ' 19O
and that lUath occurred, on the (late statcil above, at H
M. The CAISH OV DI'.ATII was as follows:
DT RAT ION )\ar5 Mout/is \ /)a\s
CONTRIIHTORV W.-^^^^•^t^ -Ct(xt„t <Xm .' ^
nrRATioN
Hours
1 U V 1 ^ \
Years
A
{ SIGNED )
I(>o
(Address) I5 9w^
Pars
\x^^
Hours
M.D.
ortTI'A riON
- *i)
0^vAA,y>
-\ V rt "TV
h'r.Mjfif m S,nr /'xuhnr.) .''L > f'.?
M <„!l,'
Ih!
TUr xnoVKSTXTFUrKKSONAl, FXKTIcri.XRSAKK TKIK To T!IK
lil'.S I 01- .-.1^ rv >..,..,.
flnfoonant U CU^CC lv U Ij C
0 '^
X.lilii
11% Bt vllcr^u dv
Special information onl> for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When \^as disease contracted,
If not at place of death?
How lonq at
nareof Death?
.. Days
r^ACH ol- lURIAI, OR RKMoVAI
indi-rtakhrTTI O.C1L4L<L«/>v M U vh\.
I)\rj-:.)f r,t Ki.\i, or RKMt>VAI,
Q ♦
til
'I
«'J;
■ l(
^fil
^>
(
c
. \
7-
t
■'i
3
0
'.I
N R —Fver^ Item ni information should be carefully supplied. AGE should b« stated EXACTLY PHYSICIANS should
I;at/CAUSE OF DEATH In plain term., that it may be properly classified. The "Special Information" for p.r.
sons dying away from home should be given in every Instance.
I
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hoanlnf lUalt^r ! No. ■ , T^^Wr^ii) HS: I' t o
D((fr Filed,
100 H,
Re^isto'cd J\^o,
•**^ » • / ' J
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Bcatb
( "a. S. StanDarD )
(^
PLACE OF
'N
DEATH:-County of Oc^^ i^<^-^ -^ ^c^Gty of 6 ^^ J A^-^^^cc
M ~ \'k\K St.-,? Dist.,bet. 'i^aVvti,r, andJKAC,-
O. 'I 1^^ W „ ,,.,,.1 BCSIDENCEGIVE rACTS C.LLED FOR UNDtR "SPICIAL ll-irORMATlON- -J
( " rr"o»T"oCC;R'Rr;,"rH"s^RVT'!;t o%"-:"tu"o";"o,.E ,TS name ,»ST..0 or =T...T .MO nUMB.R. >»
' 0 ,(^' ro D
FULL NAME
'1 X {
! \
JlM
m.
si:\
DAIi: r>J- ISIK Til
.\<,H
PERSONAL AND STATISTICAL PARTICULARS
UC
U
r%\!^^
M.iiithi
);\t>-
I):iy>
Mntll/l-
( Vtari
/',/).
^iN. ,i.i: MARK n:n
I \\! ill in -H ial .!< -iiMi.tli'iii)
MEDICAL CERTIFICATE OF DEATH
DATE Ol-' DKATII
X
fM(Hith)
Day)
(Y.'ai)
I III'RI'HV Cl'RTIl'V, That I iitUndf.l don asod from
.ct 9sC:
i()0 H
IX.'
iUK riMM.ACH
1 St:iti- i>r I'ltiiiit lA'
NAM J- <>l
I A III i:k
I'.IKTIiri.Ai'K
Dl- I A rui'.K
tStali III *,'iiu!!ti\'
MAII)1:N NAMl-
«tl' MO'IIIKK
lUKTlll'I.AiH
ol- MmTHHK
(State 1)1 I'duntrv
U
^\X)aX
L
lb 190 H to
tliat 1 last saw li '-^ • • alive on L ctJ ' - 190
and that death ocrurred, on the date stated above, at H
L\. M. The CAISI-; Ol' DICATll was as follows:
om I'A rioN/ u
'f'^ii1r,i III ^iiii /'iiniri^r,! Ou ^ >'•'
, f
Mnllth
I hi
rnv MM»vK sT\TKn i'KKs.,nai. iak . l , i. \k- ark tkik t-. TIIH
liKsT ni- >-iv KNowi.i ix-.K AM. irri.n.i-
(Infii'inant
II- 1?^ tk at
Ur RAT I ON Vi'iU-s M 0)1 1 /is H Davs
CONTR IHI'TORV L.<XXXM^<X/<^ UJ JLcX-i^^ v
DT RAT ION IV^j-r.? Mouths Pays
I lout s
(SIGNED )
\L',^ca^ '.^^ 190
(Address) 15'X
Hours
M.D.
„Q)
uA4.c-e-v-w J w
Special information only t«r Hospitals, Institutions, Transients,
or Recent Residents, and persons d>lng av*ay fron home.
former or
Usual Residence
Wlien Has disease contracted.
If not at place of deatli ?
Hov« lonq at
Plare of Death ?
Days
i»\Ti >; I!! KiAi «>i ki;m(»vai.
190
\.lilrt'-<
ly.ACi: nl- lURIAI, OR RKM«»\AI,
(AcMn-ss Ull \r^rUxUU..<n w tit
N. B.
""■"^ ^. .. !• -I ATF ahniilcl be iitated EXACTLY. PHYSICIANS should
-Kve.y Iten, of Information should b. cnreVully «uppl.ed ^^^^^^^'^^^^^^^^^^^^ ..gpeclal Information" for pT-
state C\USE OF DEATH in plain terms, that it may be properly wiassiiiea. • nc ^
Kons dyinft away from home should be ftiven In every instance.
^;.
1
f\
■ri
1
I
m
I
ft
■
>*».-.<.
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/<' Filed ,
n
X\
lOWi
Ko^istered ^V«.
"L^i iL^n. Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
Ccvtificate of 2)eatb
( H. S. StanDarD )
PLACE OF DEATH:-County of^Ct^^^ Oxaw - c : < City of^XX/^A. lva.vc_>
\ i
/— f
/TVi IMl %an\.«'i'^ St.; 4 Dist.;bct. bXiV. and
rMO. IV \l vV V^, V, V ..V. . „^„ uc.,,*, orSIDENCE GIVE FACTS CALLED FOR UNDER ■special INFORMATION • \
( '^ rF"o;AT°H"oCCU%';rEV.;THo's^PrAL o"r ?ns'tu"o"n"gIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
,UA ,\ . VA\(1 fCs
\.,.
)
FULL NAMEv.
^ ^CUC^VA.^.
H
si:\
PERSONAL AND STATISTICAL PARTICULARS
m ft ""•'''' ■ '
i» \ 1 i; «»i r,iK 111
A'.l-
4
) 'lii I >
fS r7s
( l>;ivi
M.,>/t/i'
\ carl
/*./
sIM.I,]-. MARkll'.n
wnx »u }:it OK nnoKij: I) y
iWiitciii -oiia! (l<-iL'n,iti"n)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKA'III ^ "^
U.cX
(Month)
(Day)
IQO
(Year)
I Hl'RlUJV CI:RTIFV, That I attciukil dcccascil from
JD/Ct' "^.f 1904 to ^ ^ ' ^ 190 ^
tliat I last saw h * alive on ^'P
and that tk-ath occurred, on the dale slatetl ahove, at
M. The CAISIC ()!•" lilvATIl \\ns as follnw:
(Statf 111 (."iiuiiti >
NAMl <H-
lATlll-.K
lUK I'HI'l.ArK
()!■ I xriii-.K
( Stati III Country
MM!»i:n NAMl,
01 Moriii'.K
nmriiri.ArK
()|- MnTMl-.H
( Statt i>r Cmillli v
\
i
.^wC^
lilvATIl \\ns as follows
DT RATION Years
CONTRIIUTORV
Moulin
/hivs
I/our
KX^"- slLvwci
^ Sjy\KKxXX^Oo
■^
^
«H rri'\ rioN
AVw,/^-.7 III ^tiii /'I'lii, .'■.('
nr RAT ION
)'t'iirs
MuHihs
/hjV<
(Signed) ^. iX ^
//ours
M.D.
I()0
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dviny avvay from liome.
) III I
\l,,„Hi
I hi
TIIK M?,n-HSTATKI)1'KR^oN\I.l'\KTirri \KsARKTKrK To THK
liKST OF MY lCNo\Vl,i;i)C.F. AND HFFIll-
(Info! inaiit
dv^'^^U-^^ ^
\.l(lH-^S 10 \\
Former or
Usual Residence
When was disease contrarled,
If not at place of deatli ?
HoH lonq at
Plareof Deatfi?
Days
J'J \CH OF ISFKIAU OR UF.MoVAI,
(A. Muss U'U ' 1 I '^^^-Uxnv Ut
i> A IF ..' I'.i Ki.\i. tit rf:movai,
V„ 1 \_ s.
TQO
'"'"'"^^ TT ,. , AHF ahniild he Rtnteil EXACTLY. PHYSICIANS nhould
Bon» dying away from home should be given in every instance.
J »
1
.%^<:^%^'
I
I
1
1
WRITE PLAINLY WITH UNFADING INK
Ji,,:n.l .,f Health \ "<'
r 1»
♦^''j-rv^.
.- I', i"?
) iuS.1' Cn
I)(f
te Fi/rffX',€tdyMsj X[
100\
THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIPtCATC FOR INSTRUCTIONS
A^
A
M<i
r^r
\ ^ ' \ K
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cettificate of H)eatb
( Ta. S. StanOarO )
4
PLACE OF
(^
DEATH:-County of^.CLAV Jxa , .c..^ -,. City of O CC'>V JAcv^vC^CO
M^
». ^
■Ki ^ I ^ n KkX r\. ^. C ^ St.; ^ Dist; bet. ' ■ -^ UsZMXXi->i^ and
FULL NAME^'^^
,WNl-
sLLU
PERSONAL AND STATISTICAL PARTICULARS
SKX A^
CDl.oR
M
,A
nATi-: «)!• luK 111
AC.K
I
^^
iMoiith
} -.(
I Dav
.U,i»////>
V.-ari
n,i V.
•%
ii— ii
«;IN»'.!,K MARKIKli
un)n\v!-'i> OK niv»>Rri:n
(Writiin -iiiial iloiiMuilinii I
HlKTHl'I. %*l-
d ^^-vCv^
(Statf ill i'iiuilll % A
o.
1 A riii'.K
^
; U
HIH rill'l.AOK
oi' 1 xriii'.u
ISlatf III *.'i>»iiit'. \
MAini-.N NAM}.
i»l- MulUKR
lUU iinM.ArK
.»i M<>'!in:K
I still ' ii I'tinuti \
m ril'ATluN
Kru/fif in Sil>l I'l ini. '-"•
wl
\[\.
MEDICAL CERTIFICATE OF DEATH
DATK OF I>i;aTH
XJ^ ^^ r9o'^
(Month) <I>:«y) (Year)
I in':Ri:HV C1:RT1FV, That I atUn<UMl actvasea from
©ct XL I90M tn ...LC*^ M
that I last saw h J-^>'^ it+ivc oti W /cv „^a.
and that tUath occurred, nn the date stattd above, at
M. The CAISIC OV I)i: ATll was as follows
1
I(>0
,V^^^<
^^%
A^CSwV.*.-.
, t
I -1
1)1" RAT ION
goNTRIl'.rTORV
Years
CM
MOHiJis
/hn
I lout
kX\-
X !<:
DT RAT ION Yiius
■V ^
(Signed ^ j.cW^-^
Months
fhlYS
VV/v Si .' ^-KJ
Mrtllll^
I hi
IMF MU.VKSTATi:ni'KI<snNXl,l-XKTU-ri XKSAKH TKlH T. > XWV
llHSTol NKV KN..NVl.i;iM,)i^AM. HI 1,11. 1-
^. i)c.^.
(\
Uigurs
M.D.
ICJO'I
(A.hlress) V\Xv 'kfc>^--^
fitffis,
SPECIAL Information «nly lor Hospitws, Inslitutions, Transjfnts,
or Recent Residents, and persons dying awrf\ from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
NoH lonq at
Place of Death ?
Days
I'LACl-: (»»•■ lUKIA!. OK R!.\!"»\ Al,
i'l, AL I*. « >r III 1^
DXIJ ■'! i'.iKiAl, <»r KKMOVAI,
t at a I 190 H
^
ISI.KKTAKHkV a I j^O X^NVV
^_ V c
AU,h..ss IS^H Ol^^klc,
state CAUSE OF DEATH In ploln terms, that it may be properly ^lo»»meu. v
nons dying away from home should be feiven in every instance.
m
> ,
'i
r
il;
'isW???*^
WRITE PLAINLY WITH UNFADING INK
1!,,:,:.! of !l.allh V V'). I' -S"-;^*^'.-* HS:^_<£^^ «^«_«-.— — — — — '
I
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)
lle^itilcicd JS'^o,
2496
DEPARTMENT^F PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
X
( Ta. S. StanDarD )
4
(?ri
PLACE OF DEATH:-County of 0,0.^0 ^^^n^^^^^* City ofCJtV>%. OAxx^ovcv^
D
fNoAAUj
I
^ru/v\AA
.1
r^\.;i.
I
St
" Dist.; bet.
and
.* r^:.: ;.om^usual resTdence_o.v^,^cts c^l^o .-^^^^^ .;;i^rij?'^::^c;::"' )
I ( '^ ^^i;:;;f^cc$«^v,r^":.i^r;;. ?« t^^;;:;t<;; o.v. .ts name .nst.^o o. .....^ .
FULL NAME
VOs^^^^-^cLov AjV.a.4. ^ ^ ^-i.^^ ^
PERSONAL AND STATISTICAL PARTICULARS
^j;v; /x ^ I COI.OK
m
<xU
i.:
DA IK <>!• HlKril
A«',H
,|\,c\r
I \)A\ I
M.nilh^
! Year I
n,n<
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH ;, -
Uct
1 . /Q(y
(Month) 'l>:»y> '^■'■•"'
I in':Ri:P.V CI:RTI!"V, That J attcncU-.l <kHxase<l frmn
QjpAAA. ci.b lOoH tn i'ct 1% IqoH
190
siNr.i.i" M \RH n;i>
NVinowKD OK i>iVMKri;n ,
iWrittiii '■ocial lU -i v tuitiim) \
lUKrnri.AOK
iStat< lit (■(iniit!\
Hlo-Y^v
that I last saw h ^. ■ - alive 011 ^^ '^^ ^ ^
and that (k-ath occurred, on the <lale 'stated above, at -l i 0
0. M. The C.\rSI<: Ol" 1) MAT 1 1 was as follows:
V" '
\
.t. > VA-
NAMK 01
FATIIIR
HlKl'Ill'LAiH
C)l- ixruHK
(State or louiit! y
MAn>l';N NAMl-
Ol- MoTin-:K
HlKTinM.AOl':
01 Morm-.K
(Slati- or Country
ovOtl'ATION
XX4 ! >^ '-\ V
-^1
0
DT RATION
CONTRIBl'TORV X C^^i >A.v.
)'tuirs 5 Months ^'^ I^ay^ Hours
Years
Months
Kisidfd III Siin /'mil, I-
) 'ra I
M,,„lhs
Ihi
HHS-r^.H^ MX^NONVUl-DoK AND IU-l.Il-.l-
DIRATION ^
(SIGNED) . lU. to. Lc^v.A..^
Pays
Hours
M.D.
IC)0
(Address)
\AXi<;L'
SPECIAL INFORMATION only 'or Hospitals, InstiluUons, Trdnslfnts,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Now long at
Place of Death ?
Days
(Iiifoni\aiit
-3
AX^
\.Mr>
k a. ^.'
(1 "^
4
PI \CK 01 lURIAI, OR KHMoVAI.
I NDICRTAKKR
DXXl'"' Hi KIAI. ot K1-:MoVA1.
0
<* 11
TOOH
state CAUSE OF DEATH in plain terms, that it niB> he propcny 1.111
sons dyinft away trom homo should he ftiv.n !n s»«ry instance.
ill
i
^
'V'Y
ill
-lii Jill
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ii.^r <:
Re^ititeicd -^o.
•3197
\ dou>u Deputy Health GfTicer
DEPARTMENTiliF PUBLIC HEALTH==City and County of San Francisco
PLACE OF DEATH: — County of Cct^
'0 I
Certificate of S)eatb
( Xk, S. GtanDarD ) ^
- Cic* City of Ci-o/^^ 0 -^-cv > '-^
A
"i
jsj^^ iH LouWCLrL- ^
I..
* ^,^ ^.,,rn FOR iAnDER 'SPECIA
and ^J ^
nvLli
c )
X^'^^v^:;^--^^- ^iv^^^^:^^^^" ■^---—' >
FULL NAME
cux DsmvLtclo.
(1^
PERSONAL AND STATISTICAL PARTICULARS
ri
I.
l)\ II" «'i' i;ik III ^
a.kLti
(Kl..nth\
(Uayi
A< ,i-;
It ,
1/,,
( Win
'\n:
MEDICAL CERTIFICATE OF DEATH
DATE Ol- DKATH l^
I Month*
(Day)
iVtari
"^I HIkl-HV Cl.RTIl-^V, That I attended decease.l fmn,
C\,.., , ,„.H to ^'ct ^0
I
up
s
>^i\< ,1 I" MARK n:i»
wiiMtwij) <)K l»:v« .!■•' I'D
i Writf ill -ocial il' -'" 'mI^'" '
lUR rm'i.ACK
(Statf or C'luiitrv
X \Mi-: oi
I A rniR
lURTHIM, \i K
oi- i\iiiI':k
I stall- 1)1 rixnitrv
niaiih:n NAMi:
t»J mdthkr
0
Lcur
^rtX-v^'vLC
190H
that I last saw h •■ alive n„ ^^ ' ^^P^
and that death occurred, <m the d.le stated ahove. at ^^0
Q M. The CAl'SI' OI' DI-A'PII \va^ a^ folh.ws
Q.l
^-yx,^^ wC
il AA^^.x-0\.OL^CC^ ^.U^
vilt<l ^
Kx.
HIR rillM.ACK
oi M<>'rin-:K
(State <»r Cotjiitry*
oCCfl'ATlON M^ 0
ft
n ),;,,. 1 v,">ffi^ 1 0 run
U /T i XX./-V^ U.-' XAv-
DURATION 5V<7;s
Ct)NTRIl'.rToKV
Mouihs
Pav
Hon
IS
.^
//ours'
M.D.
Kf^i.1r,f III Su>i I nni, / v
liHST OF MV KNO\Vl.lU)(^K AND lU.l.U-h
(Informant M ^U^
nURATION )V.7rv
( SIGNED ) I I ^^'
^ ,-. U)nH (Address)
SPECIAL IN FORM AT ION onlv for Hosplldls. Institutions. Transients,
or Recent Residents, and persons dying away Irom home.
Former or
Usual Residence
When was disease contracted,
If not at place of deatli ?
How tonq at
Place of Death?
Days
^CX/O^A^
i)\ri'. of i',i HiAi 01 Kl^^!<»^'^'.
^^^_^^^— ^B— ■— — — — , FVACTLY PHYSICIANS should
r. <
"ips"'
.1
i
M
I
I
i
I ifiH
I
WRITE PUA.NLY WITH UNFADING .NK-TH.S .S A PERMANENT RECORD
^^ p^rCR TO BACK OF CERTIFICATE FOR INSTRUCTIONS
JS.,;i!.! .if ll< ;i!tl\ ' ^'^ " -....^^
J?
/>rf
cL
t!A.tl.A
•L,
V^U
Depu
f^■ t-»
190H
1 Officer
Jf('o/\sfercd ^\^o.
2498
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccititicatc of Bcatb
( XX. 5. StanDarD )
PLACE OF DEATH:-Co.nty of^^ i /UXwc.cc Gty of ^O^^ lvc.>. .
a
n
. 5^ Dist,; bet. ^\ ^
md
■>-'. ■>
4
"' ' '' T'■'1=^■rs™^"r..•"^^^■•S?J.r
FULL NAME )(^
XL -
PE
RSONAL AND STATISTICAL PARTICULARS
IN
n^
(.« tl.oK '
IJATK OF UIKTH
L
I
/UH
M.iUtJi)
\t .1-:
x-ut HO ),
|):iVl
1/, ,»'//>
( » lar
/',/
DAIK ol- DKATH iH
MEDICAL CERTIFICATE OF DEATH
(Day) (V.aii
I III
(Month)
{KKBV fl-RTIFV. That I atU-n.U-.l .Ui casd fn.,n
— — lip "■
up
t(»
'^IX«.ii' %t\Hkll'I»
\VIH<»\S I I» «»K I>1\< •Kill)
I Wi itf 111 ^iHial '1' >u'n;it 1' m I
lUR run, \<'i'
' stati ( ii i'l iinil i \
N \M1 nl
1- A 1 II 1 R
lUK rin'L.xrH
c)|. I AIHKK
(Stall I ii i'miiiti \
MMDI'N NAM1-.
(»|- MOTIIHK
inK'niPhACl"*.
ol MoTHHK
( State 111 (.'ounti N
that 1 last sawh —^ alivi-nii
a„a that -Uath nrct,rrc<l, on the .late ntatecl ah.^vc. at
M. The C.\rSI-: Ol- I>i:.\ni was as foUnws
I9O
DTK AT ION >''''^'''''
CONTklHl'TORV
Mo fit In
Pays
Jloins
6^
Ilk.
JX
Iloiins
M.D.
-i^i^L INFORMATION onU lor Hospitals, InstitW. Transients,
or Rercnl Residents, and persons dying av^ay from home.
/
\l,.nlh
/',-■
DIHTI'ATION
in%ST ol- MV KN'»N\ l.I.!"'' ^^'
(infonnaut L<fUrY^X^^ ^i^
Former or
Usual Residence
When Has disease rontraded.
If not at place of death r
HoM lonq at
Place of Death ?
Days
,.,.ACK ni- BIKIAI. '»K KKMoVAI,
I 4 . V^
,,M1 ,; Hnuu. or K1:M»>VAI.
Q ^ .
' ^'^'^'^"'^ , M L PHYSICIANS should
1»,
, I
i!^
I
4
\
B<KI1'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
f n.MUh J No ;. ^•^f'.^.HM «• . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f
Ir /7/rv/, IiWUIrv 3.1
loo'i
Be^/.sfercd jYo.
'^ ^ 09
,<jA^A^X>Q
n
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( XI. S. 5tanDar^ i
PLACE OF DEATH: — County of JCXTV JXu .k^s..<-. City of a.>x. J AXX/i v
w
q.-
/O
Ld^u,^^ ^wCWixA
Dist.; bet.
and
No. V,C^U, ^V.CUci\.\.u - St.; , --- .
^^ / ir DCATH OCCURS iwAY TROM USUAL RESIDENCE give facts called rOR UNDER SPCC.AL . N TO R M ATIO N ' \
( "death OCC^R^TeD in a HOSP.TAt OR -NST.TUT.ON GIVE ITS NAME .NSTEAO Or STREET AND NUMBER. J
,Tr>
)
FULL NAME
I.X
PERSONAL AND STATISTICAL PARTICULARS
A
li Nil". « •! r.IK 111
M nt
\ * . ):
"•Wi.l.V. M\KHn.I>
W \\u »\\ I- l> « iH I)"''
U ! lt» 1 !1 -I n ill
I»,iv
\/. ,,:'/,
I hi 1
1 ')
I
K.
I- A in i;k
MIR rillM.AiH
Ol* I AIHKH
I Slatr i>r t'mi nt i v
MAIin'.N N\M1
HIRTIIlM.Ai'K
<u- m«)Tiii:k
(Statf lit OdUiiti \
A
c
II
^
U^j \
^
\
, iv A.
<>rcri'ATH)N X
Kf^idfd in -"<,! II / I ii III
) ,;/
M„<ih^
IhlM
Tin* \i5ovi-. sr \ ri:i> i»kks«>\ai, i'nk ru' ^ ^k
lUCSr (»!■ MV KNOWl.i:!)'.!-; AM) lu.i.ii.i-
I
-^ AKi: iKn* ro rHi<:
(In fn- iniuil
'\
JL^
m
MEDICAL CERTIFICATE OF DEATH
DAi'i-: ol i>i;atii
cA.
(MoutlO
Dav
/90
iN'cat
I HRRRP.N' CliRTlI'V, Thai I altciuli-.l <k'ccav<.'(l from
t,, A.'lLt 11 Kp't
I
:i
T90
that I last saw h
allvf nil
190
aiuLthal death ncciirrcd, on tho .late stated ahnve. at H OO
I \
J M.
The CAISI-: Ol- l)l';Aril was as follows;
Co\,v.i\.b-^'
DTK AT ION )'rars Months
C ( >NT R 1 1U'T( ) R V Wi\^*
Pars
J/oiif s
nr RATION
(^
)'i\ll
Monlhs
fhivs
(SIG
NED) 4XC<1 Vj. L^ O V
I/oni y
M.D.
!C)0
■.J i^
ON only '*"■ Bospitiils,
SPECIAL INFORMATI
or Reient Residents, and perbons dyinq dnav from home.
/^
( V HoH long at
5^^'X ^ ' PI'J'-Pof Ow^h-
Institutions, rransients,
Former or
L'sual Residence
Ddvs
When was disease ronfracted,
If not at place of death ?
ri.
0
ACK Ol- lUKIAI, OR R1;Mo\AI.
'\
J,,,.:Kru<,.:K Vv'^'%-0, ,
\) \ 1 I , ' i5i HiAi- 111 ki;movai,
'3.1 igoH
E OF DEATH In plain terms, thnt it may be properly wlassitiea.
N. B. Every Item
state CAUSE OF DE , . :„,.«„ce
son. dying away from home Hhould be g-ven m every instance.
1
, I
I:
■I
ftf
I ■•«
,|Vl
«#«l^
1
WRITE PLAINLY WITH UNFADING INK
juinni of n
Xi.v.i^v ^'-"
0
\) X{
]f)OH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT llF PUBLIC HEALTH-City and County of San Francisco
Ccvtificate of Bcatb
PLACE OF DEATH: — County
m
Nt>.
.t-
i^-
i
^
%
City of ^' ^^^"^ ^J AXi^^^'^UL.Oc
and ^
FULL NAME
-•I A
PERSONAL AND STATISTICAL PARTICULARS
^
t
a
iV
/ ^
\( .!■;
•>I\< ,1.I- M \H k 111'
WIlH t\\ lit < tK 1»'\ I I'l-'' 1 !'
Wi iff ni • t "H
1 \ ihi;h
P,1H ill I'l, \»1"
Ml- r \ I'lii-.K
stall I >; I . iii l\t ! %
M Xini-'.N N AMI
lUR rni'i.Ai. H
t)l MnlMll-.K
1 State iir i'oiititi ^
\l..„:ii
MEDICAL CERTIFICATE OF DEATH
PATK < 'i- 1)1' ATH ' \ .
11:.
I):iV>
.;r|;F.V n-.KTIl-V, Th.ii I attcn.U-a .Urca-^ol fmtn
Muiithi
1 III- ■
_- - l.,n -In - -'—up
tlial I last sasv h r: alive otl ^'>"
iNl .1!
a I
aihat.leathnrourred, n„ tlu- daU- ^tatcl abovo. at
- M The CMSI- Ol- ni'lATIl was as fo!l<.ws
nr RAT ION ^''''"^^
C< (NTkll'-rToKV
Months
Pav
Iloto <
I )r RATION . >VcJr^
lU-ST <)!■ My KN<>\VI.l.n«-l'. AM) Hll.i'.r
(SIGNED) ^^^ ' -\^-^^
Hours
M.D.
Special information onlv f«r Hospil-ls InstituH^s, iransients.
or Refent Residents, dnd persons d^inj ana) Iron, home.
Former or
Usual Residence
When was disease rontrarted.
If not at place of death ?
HoM lonq at
Place of Death ?
Oavs
J.I soF nl^ IHKIAI, OK KKM'.VAI
INI>1:K I'AKI-.K
W^^^
TQO
r\
CuAc
<\ t4v
"^""^"^ II , I |- PHYSICIANS should
' ' ^ulcl b^ carefully supplied. AGE should b« ^J-t^jJ^^.f^^^.^ |„|-orm«f.on- for pT-
„. B.— Every Iten, «* A^^-Tf^S^fpTj^ ;r^" that It muy He properly cla.s.ficd. The 8pc
state CAUSE OF DEATH m P«"«" fV^ .„ ^^^ry Inst.nce.
««n, dylnft away from home nhould he ft.ven
m
1 'P
.1 > .
i I,
If»
''it
(
^1.
H<.:ii(
] wf !I. ;iUh J- No
"wmTE PLAINLY WITH UNrAD.NG .NK-TH.S .S A PERMANENT RECORD
REFER TO BACK OF CERT.r.r.ATE FOR INSTRUCTIONS
'^50 1
••«' «r "-".
343 HS:1' Co
Re^lstcrerl J\^o,
/.././•7W,0ctX^ a.1 190^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( XX. S. StanDarO ) ^^
^ . -T^rT r .^ ^f ^ n.-fv 0 AXXA^C \,4.C City of ^ ' <^^^ ^ -^^^ ' ■
PLACE OF DEATH: — County ot C\.^^ j ^ ^^^
Tic^OXA ^ ^^^^^J^^^^ ,^,^ ,, J USUAL H"'.?5.NCE^-- -74 ^N'^A^i," Tn^s^ e7o° ^ J St%"e% ano number. ;
-)
1 ( - [;^i;:;:f ^-i^vrs^ii^^^ -f^?^?^<^^;^ .^J w^^ .^s.ea. o.^s.ree. ano n.^ser
FULL NAME
cuu.^
PERSONAL AND STATISTICAL PARTICULARS
■ 1 \
DATi: OF 111 Kill
,\<'.K.
C<>l,t>R \
iijJvsi_i'
Ai^x
I Month"
\
-\\i.\ V M AKKIl.n
\vin«Avi:i» OR nivoKCKu
.\\'iit» ill vH-ial ik-i^fiiHtmn)
,1 1
(Dnv^
M.niths
Year!
/)</i.^
MEDICAL CERTIFICATE OF DEATH
DATK oi' i)i;A'rii „ , .
(Month!
iDiiv)
igo I
(Yt-ar)
-\
niurin'i, Ai)-
(Stat* or I'onntrv
NAMK 01
lAl'in-.R
niRTIU'LAiH
OK l-ArilKH
(Statf or Country
MAIDI'.N NAMl-
,)I- MOTIIKK
HIK rili'l.ACK
oi' Morni.K
(Slatf or Con nil y
I III'RIUiV Cl'RTIl-V, Thai I Mttcn.UMl dcTcascMl from
OLI^o, IO. upH to ,)D ti^C) looH
that I last saw h i- ' . ahvc on ^ ^9"
■uu\ that .Icath orcurrol. o„ thr- -latr stakd above, at 'I-HS
M The- C VrSI* OI" DI'.A'ril was as follows
^O^^v. t 1 A^> ' ' A,^L^-^
j^Lu-o.!
(^
\\j:^\.o^
Y\j \Xj
o
I) r RAT I ON yciJis
CONTRIIH roRV
J/on//iS
/)iU.
II oil PS
<x
a.
m
/'[)
.t
.->
c>sXiL^<x>vd
OCCri'A I'lON
)',iji
M.iHth
/hn
,... -.,.,, .,-,,PKK^oNM,»-AKTIcri.AKS ARK TKIK To TlIK
'-mw^cj
(Informant \J • ^^ •
(SIGNED) i^ kjOjd:
U/t^ !(,() I fA<hlross)
SPECIAL INFORIVIATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
SV^J-iV Jvci^^"' X'Ka- ^T.D..
Wlifn was disease contracted.
If not at place of death ?
'I.ACK ni- lU'RIAI. OR H1;MoVAI.
\<l<lrt'
XcQ %CHl^^t<x'
DAT]", of lUKiAi, or KI'.MOVAI,
o
^ ' 1 90
l^ot.
www ^^-v wV^"^'^
VNDHRTAKKR iJ<XC^^.<A^
Addre.. .111 QTl^<t^Un% at
rs. B.
^ ,, . TfiF should be stated EXACTLY. PHYSICIANS .hould
-Bvery item of Information .hould be c«ref«lly -j;j>":^^; ^^J;;,^ cl«..ifled. The '•Special Information" for pr-
state CAUSE OF DEATH in pla.n term., that it ma> "^ P J
^nn, dying away from home should be given .n every instance.
t
♦;
I .
^•11
rt-rr'
I i
f^^ff
w
RITE PLAINLY WITH UNFADING INK
iv,,r.l ..r H. (Mh r V.
IfJO'i
THIS IS A PERMANENT RECORD
BPPFR TO BACK QF CERTIFICATE FOR INSTRUCTIONS
Deputy Health Officer
DEPARTMENT OF PUBLIC HEAlTH=City and County of San Francisco
Cettificate of 2>catb
( "CI. 5. StanDavD )
PLACE OF DEATH : - County of 0 c^ C /va, . , - ■ . City olOc^^ ^
FULL NAME
^
No.
i
{ ' ^
--i; \
PERSONAL AND STATISTICAL PARTICULARS
\
DA ri: <»i liiR 111
At.i;
A
~r\
M.,ulh
I 1.1 vi
M.>,'li
J I
\'.:i1
Iht^
v IN.-, 1.1- M \Kkii r>
wiiM i\\ i;ii « iK p ' *'' 1 n
, W I iti in -H : r '"
UKTiiri. X''i-
\.<UU^
(N
'-^
N\M1- or
i^\ Tin K
niKTUlM.KtK
ni- I \;in-:K
M \!1»J:N N AMI".
oi- Mt>riii:K
iiiK rni'i, \vK
(>! M<irin:K
, -^t;ii ' ■ >; Ciitintrv
nru
MEDICAL CERTIFICATE OF DEATH
I.ArH <)1- nKATH A
^si Kjn'
.Month. l'^'^' '^■^•='^'
1 in-:ki:i'.V Cl KT1I"V, That I attin.U-.l .leceascd fnmi
^ — \.p t.. itP "
that I hist saw h - alive on ^'P
an.l that .U-atl» ncrurrcl, nn thi- dat.- ^tati.l above, at
\T Thr C VrSIC Ol" ni'ATIl was as follows:
/ , ^ ^ '(in y
DIRATION Yi-ays
CONTKIIUTORV
M on tin
Pax
Hours
nrRATioN ^ )Vr?i-5
( V
/)<7l
flour's
M.D.
XjULo. vxd.
met TAl'IoN
n
•si
r. 'J>.'
s ■ , I /
5 )v<?
yr.nith
/',n
,,,,,,,VK.TVrK,>1.KK:..XU PAKT,c-rKAH.ARKTKtH To T..H
in>T ol- MV KNoWI.KIx.h AND HhKni
ilnfinuaiit
C
Ailfhi'ss
55 CoA^
c
4
( SIGNED ) ij^f\Jiry\JOv J AD \^. kXj
SPECIAL INFORMATION onJ* 'or Hospitals, InstitunbK Transients,
or Recent Residents, and persons dvinq dv».iv from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Hov« lonq at
Mace of Death?
Davs
I'l.ACI' ol' lilKIAI. OK R1;MoVA1.
rsi.i.RTAKKK W-v>-JL4 0b^<^^x
I> \ ri: ..: Hi HI Ai, i.r RHMoVAI,
190 *.
^UL ^^
■ TTZ AHE should be stated EXACTLY. PHYSICIANS should
•in/dying awy from home should be given in every instance.
it.' !
i-''i
f
1 .
V'A
I
': i
i
w
mXE PLA.NLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIflCATE FOR INSTRUCTIONS
}*(ia!il lit 111. 111!! ' ^•'- ■ K.-'v^t ■
190H
Jleo'isfrrerl jYo,
O
503
A \ . » >
^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( xa. 5. StanDar^ )
A
PLACE OF DEATH: — County of -^ ^'^
^
^No, 5'5'T uA^fr^.^
St
City of ^J.<X^
i
i
>\.C^
^ Dist.;bet.UcX<xxrv<X' and
lA-A
)
(
/\/CA>V ,,.,,., RESIDENCE OIVE "CTS CtLrO FOR UNDtB "SPCCI
AL INFORMATIO
AND NUMBER.
")
(5?
FULL NAME
m
jtOVCJj
(Jt^^-^xc^-vq/i :^
PERSONAL AND STATISTICAL PARTICULARS
^'■m
(•(>1,<)K
^>
DAri. «>I I'.IKTH
Ai.K
A
vMonth)
)■
. DmvI
M,,u'li
Vt-ar)
/'in.
MEDICAL CERTIFICATE OF DEATH
Ii\iK nl- DlvXTII
Uct
Month) 'I>='V)
"~^I HI'Rl'BV Cl-RTirV, That I atten.le<l dftcasea fnmi
u.cL 190 'i tc, 190
rgo
(Year)
SlSr.lJ-:. MAKKlK.n
WinnWK.n <»K DIVoKChl)
iWritciii •-•Kial (l.-iv'iiatinii)
that I last saw h ^^«^ alive on ^
atul that .Icath ..ccurrcl, nn the .latv stated above, at
(j M. The CAl'SF-: OV 1>1:ATH was as follows
IqO
-,|:,t I I .r < '')U1ltr%'
NAMK «H
I AT I IK R
HIR IMI'LAOK
f)l l-ATHKK
iStatf or Cotinirv
MAIIH.N NAMK
ol-- MOTHHK
nl Mt.TUHK
(Statr III i'ounti V
orrri'A i'n>N H
r^
'^
<^
n
1 I
K.^^
I )r RAT ION Ytars
CoNTRIl'.rTORV
Months
Dux
'S
Hon* a
DURATION >Vc?rjy J/<m/Mx
( SIGNED ) Ua^MVv M lUX-^V^
Pa
VA"
LI
J
li^
^cu^^^xL
c< *. I()0
( A.hlress) b 0 5 cL<xq^v^xa-
SPECIAL INFORMATION only «or Hospitals
or Rrrent Residents, and persons dying away from home.
s Insnlutlons,
flours
M.D.
it
) I'll I
Mnilfll-
/h!
TUV MU>VK ST XTKI. PKK.ONA1. I'AKTirri.XRS ARK TRIK n» Till-
(lnfo!iua!it
Former or
lisual Residence
When was disease cwtracled,
If not at place of death ?
How lonq at
Place of Death ?
Transients,
Days
PI XCK <)1' lUKIAI. OR RHM«>^ M
qkn A /^
c
rNI>i:RTAKKR
i)Kri'-.f 111 KiAi, or REMnVAI,
aJ'^X' -. : 190'.
V^<t^t^
*«n/dy1«g «w«y from home .hould be given In evry In.fnce.
! !
I
!
t
I!
t
' \
W.'
iv;
<::> '•
P%J
1^
' '1
4 <l
11
■itfU.
't»I^:
f
l»
it
w
RITE PLAINLY WITH UNFADING INK
uS:!' C
THIS IS A PERMANENT RECORD
«EFEP TC 3^C- 0-- CEPTir,CATE FOR INSTRUCTIONS
])
ute /'V/r./.L,ctcrl
,V-t\'
A t\
1U0\
rfj XO.
•3.-04
DEPARTMENT OF PUBLIC HEALTH=Citv and County of San Francisco
Ccititicatc of Bcatb
:^
PLACE OF DEATH: — County of-<x^^
No.
City of 1 <^~>^ -^ ■
and
(
IF DEATH OCCURRED IN A HOSPITAL OR IN^tmu ^
)
FULL NAME
\
X.
- 1 . X
PERSONAL AND STATISTICAL PARTICULARS
I *
> \ i j: <»i lUH rn
n-
\' .!•:
HI
M.mlh !
!V,/'
I
i > !\
MEDICAL CERTIFICATE OF DEATH
I>A 11.
i; Kill
%!
(I)av^
/0">
I V carl
1
'^
I- M \K I- 1! I>
. I I , , ,|; 1 ilN'i iKt' i: l>
I m-Rl-nV Cl RTIFV. Thii I atu-n.U-.l .Ur. a^c.l from
K, w W £- .
icp
that I la-t saw h -" a.ivc .>ti
.,„a that acatl, .H-ourro.l. nn tlu- -late .tal.-d al.nvo. at
V.W M. Tl'C CAl S1-: ^»l- ni.Alll ua- as follows:
C . . J*
-, .. M 1 "I
I A rilKK
I'.ik'nu'i.^*!-'.
(i! I \rm',H
■^t ..! I . ,T li ill lit ' S
M \ii»i:n namk
()! MOlin-.K
|;1H rill'l, \i 1,
(ii \i<rrill'.l<
I st:,!> 111 (iiUllt I S
nia ri'A ri<»N
/,V hh,l III ^^•t'l I ' ••'
.AJ^u
m K \ riON )V.ir.
^ .*> \ /hl\ S
I /oil I >
!M U \
< \ r ' I ^ "V
\
\K 1 |. 1 i ^i':
I I 11 i ,• llUIIlt Sw- . v_-
\in nu i
i SIGNED^ ^ >
/>.n
Hours
M.D.
SPECIAL INFORMATION onh lor Hospitals Institutions, Transients.
01 Rfcfnt RfvidfBts. and ^m«s rf^nj a^.^^ tr.ni homf.
Ho^ lonq at
•«^"»fV". Pla.f of Dfath? Oay^
WIlfB *i^'' disfjvf ionfi.»<t{Hl.
II m\ at Natf «»' df^^h ' >___^_ii^— ^— — —
a:is M il.x'v K .i
i< \
^\^
V
o
! KlMoXAI,
IQO
0 "xcXv. sv
S . s ',
\ M
k >. *.
N,»^^.«-^ ^ "-
II . VuU » ^ .ii«i'l'" •'
IN.
M.I.CAIIS, Ol m Mil I.. ,....!.. ,. .^- • -
I
!■ (
. (
I
I!
i
1
^
4
i
WRITE PLAINLY WITH UNFADING INK
'-. \' S'
^X-rs.^i: V.S^V C-
\
Dnh' /'V/r^/.L'ctcrt-t^ VX
]U0\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificatc of 2)eatb
0 f?^
A
(p
I PLACE OF DEATH: — County of^^^
City of C'<x/^ru o A^o^v^^^A^c
No.
I Qf ^ Dist • bet ^^ ^^ ^^^
)
FULL NAME
.{rv'N.v.
(iijd
■^v.s
PERSONAL AND STATISTICAL PARTICULARS
^ v;t»I,(>K\
i.\ 1 i "i i;!i< I'll {\r\s
IL
M.iTiih '
\« .K
m r,..,... 1
1>.1V
M..„'!,
\s
WAV
I hi 1
\vn>< »Nvi i» < 'K i»ivnRri-.n
Bik run. \>'»:
^t.iti Ml I ..'int! \
MEDICAL CERTIFICATE OF DEATH
DATH OF DlCATll |^
(M.mlh) '^*='y^
I III'KIFA- CI-RTIFV, That I attrti-k-l dcH a^eil from
tliat I last saw h --' alive on - -^ "^^ ' ^^ '
a„a that .U-ath ncrurrcl, en the .lat.' stal.-.l ahnvc. at 1>
CL ^I. The CATSIC t>F Dl^ATll was as follows:
J
1 Alii i:k
1UK IIMM. \*'J",
ni- 1 \ ni I'.H
iSlati 'II r.i\uit'A
MAn)i:N NAM!-:
<)i- M<)Tin:k
lUKTlIlM.A*!-:
oi- M<»riii-.K
I St:itf 111 CduiiIi y
tAvU^.A.A,...^
DIRATION >'';"^
CONTHIIUTORV '
, 1^ "w »- I
u I
-Uax, QkoJu-'^ '
I V
oci. riA rioN
h-r i.liil III ><i>i / I <!»• '•'" ^ V \ ■
DTK AT ION
(SIGNED)
Miuiths
Miiiillis
\ /></rs
Hour
l\}\
^\
/fi>urs
M.D.
I<>n
Special information onlv fcr HospUdls, institutions. Transients,
or Recent Residents, and persons d)ing <ih,.v from f«ofne.
How lonq at
Plare of Dcatti ?
Days
(Iiifi);inruit
\.Mv
•s>i CK (Ak "J
ii
Former or
Usual Residence
When was disease contracted,
If not at place of death ? ^ . _ —
(Ad. Ill
I
^^.^_^i^— — — — i^— ^"^^ "^^^^^^^ I pxACTLY PHYSICIANS should
state CAUbE Ol m a .^ ^^^^^ instance.
sntis dying away ^rom home snomu i.c »,
m
n i<
ii
M
WRITE PLAINLY WITH UNFADING INK
l)((fo Fi/rfl, v_
190H
THIS IS A PERMANENT RECORD
REFER TO BACK QP CERTIFICATE FOR INSTRUCTIONS
Ecs'i.stcred ^'^o. ■— '>vlO
DEPARTIIIENT OF PUBLIC BEALTH=City and County of San Francisco
Certificate of ©eatb
( XX, S. StanDarD )
i
PLACE OF DEATH: — County of O.O,
^
'S
City ofCJ/Cx^/w. O/vcv. .
rttn^V^^H , »i;= .v^.Y TROM USUA
Sf Dist.;bct. ^*^^
RESIDENCE G.WE TACTS CALLED '■°« 7^"^; st%EEt";ND NUMBE«.
OR INSTITUTION GIVE ITS NAME INSTEAU
" )
• bt.; L>^1SI.; 0%,l* u„DEB "SPECIAL INTORMATION " ^
FULL NAME
m
\j
I \
,-i
^co•.^
t
^i:\
!, \ 11. oi lUK rn
A<.H
PERSONAL AND STATISTICAL PARTICULARS
)
MnuHv
\'< ;ir)
Ha
MEDICAL CERTIFICATE OF DEATH
DATE OV DKATIl i( ] .
wet ^ ' ^
(Month) 'I'^'>-^
^Year)
" I lll-KPIiV Cl^RTll'V, Tl.at lattcmlc.l.U-cease.l fn.ni
l(p<b
\VIl)«t\Vi:i» OK I>lV.»Kv 1.1
iWtlt. ill «Hi:.l ,UMiMl;H!..ll)
IUKTIiP!.ACK
Statr or Oonnli >
NAMH <>|
KAIHlvR
RIKTHI'I.Ari-,
Ol- lAIHl-.K
(Stall- or Coniiti V
MAn»KN NAMl-r
OI MOTHKK
lUK rUlM.ACl".
ol- MOTHKH
(State or (.Nniiitt >
190 M
that I last saw h •'.- • alive on '^O
and that death .ccttrretl, .>n the .late stated above, at »
M ThQCAl'SI' Ol' I)I';ATII was as follows:
^
u
.^r^j^^
CONTRlI'.rTORV
Mouths
Pnvs
Hants
\xn^^^
Years
Montiu
Pa vs
TqO
(Address)
Hours
M.D.
Y\:
)',•(! I
DIRATION
(SIGNED)
SPECIAL INFORMATION only tor Hospitals, Institutions. Transients,
or Refenl Residents, and persons dying away Iron, home.
%v^\
/)<7 1
^^^TltlSi^^
"^m
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place ol Death ?
Days
ri.ACK<^K Bl-RIAI. i)K KKMc»VAI,
DAl'lCof Ht KIAI, or KHMoVAI,
(Aa.i.4is.n^i O'
o. . .
f ^'l*''^^^'' ^^ , " ' I I I I I I I r PHYSICIANS should
ii
I
!
H
»M
tl
' {
Ml
.-Ji.
Mi
WRITE PLAINLY WITH UNFADING INK
,M,,1 .,f 11. 'I'l 1-
VHJ\
THIS IS A PERMANENT RECORD
REFER TO BACK QF CERTIFICATE FOR INSTRUCTIONS
i \1 ,, Deputy Health Officer
DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco
Certificate of IDeatb
( u. S. StanDarD )
PLACE OF DEATH; — County of O
J
City of C ' CU-v-v.
am
m
No. j;^^^"^^
-N r -U UW L^V — ' ' St.;-— DlSt.;bCt. .spj-c.aL iNrORMATION- \
^
A
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
.1 N
*( i!.< >k
MEDICAL CERTIFICATE OF DEATH
I)\ IJ t •! iUK 1 il
^
i V\A
M-.nt'' ■
/ t
i >.l N
> ( ;i
r)
\ t . I'
/hn
DATK »>1 ni'.ATH
(Dav)
Year)
I llKRKTn- CKRTIFV, Thay atU-n.K-.l <Uo a^.a fn-n.
Vw^
liiO
' I
t„ iDct ^^.
SIM ,1 !■• M \KK HJ)
W1I>. .W ID MK I):V<»K> I- I)
\\ ■ 't
BIKTIIP1.A0I
I A 111 J K
lUK I'll iM. xri-:
Ul 1 \ IHKK
(Stati ( ir t'ouiit '. ^
MA!1»J:N NAMl.
()I- MOTHl.K
lUK'I'HIM.All'.
ni- Mn'lHJ'.K
I )t . r r \rn )N
\ ;.>ii
B\<XKK^ ■ -^
cl=
I<)0
that 1 la^t -^aw h - alivr on
,„athat.Uath.KTurre.l. nntlH-.laU^tat.a alnnv, at
M Tin- CAISK oF HKATH ^^a-, a^ folLnvs:
Hours
X
\
nr RATION ^ 5""^
(SIGNED) ^^V-^^^ J^
Months
/hrvs
KjO
fA.Mrr^-) iOD^U^giXvwCA
,-0^
Hout s
M.D.
SPECIAL INFORMATION only for Hospitals. Institution.. Transients,
or Re«nt Residents' and persons dvinq a.ay from home.
s -
Former or qqallnl. .
Usual Residence 1 i '^ V ^UA.
When was disease rontrarted, ,
If not at plare of death? 2_
How lonq at
PlHff of Death?
w.
Diys
I'l ACH OF in KIAI. «.K KKMoVAI,
/'6
I ni)1-.k'iaki;h
i)\ri . ■
!' H I H I
K l.M< i\' \I,
Ci>>C^-v
Qf>U^
.^s^^TYV
■m
'^1'^''^'^ ^ '^ " ' I I I I I I r PHYSICIANS should
m
r,
I ,
■r
I!
li
>!i.'
li
M
It
m
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF r.rRTIFICATE FOR INSTRUCTIONS
Dfffr /•V/r^/,l!J/ctM>t^' I'X
IDO'i
Be^Jslcved .A"o.
O^
07
Deputy Health Offlcer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of IDeatb
I XX. S. StanDavD )
-^ . City of
((^
xa_
J X o ,
PLACE OF DEATH: — County of
{\ I , , ■ , <:*. ■ Dist • betM il^^A^.^nv and U^OA- .
mr ^ U ^-^^ dl k I ^ * ' ' '^f'* L^lSt., DCU ■* „^„_o "special i n formation- \
FULL NAME ]"■ ' [ ^^ .
• 1 \
PERSONAL AND STATISTICAL PARTICULARS
<( »I < iR
mIIcuU
i».H ri: ' »i
\< .l•
-. I \| , 1.!- M \ K I- n i>
\\ I 1 M .\\ 1 1 • t "K I I ' ' '
lill' I'll fi x»'i"
1 \ 111 1 K
ink I'll I'l, \ii-:
oi 1 \ I'lII.U
(S(;ilt i>] I'. .11111
M \II>I.N NAMl'
111 Miil'UMK
lUH in ri, \ii'.
( >i- \!< t rn i-'H
>^ t . 1 1 I 1 I i i ' I 1 11! 1 1 I 'i
( II ( r 1' \ ri< >N >
M.intli
l»:i\
'l ■ l!
TQO
(VL'ar'
! \
A 1
C3 K^r^O^^
MEDICAL CERTIFICATE OF DEATH
DA IK t>i- i'i:\'rH I \
(Mi)nlh> ''*''^
1 HI^KKBY CKkTIFV, Thai I altnuU-M -U. .a.ol fnan
upH tn . ' J'^
that I last .axv h iliv.-.-n ^- ^'^ "
a„.lthat.Uatl,.uvun.il. ..nUu-aaU-.ta.c..lah..v., at IMS
M 'KXxK.- CMSI'-. <>l" ni'.ATll xva-^ n-, foll.ms
^
aa.%
{)
^1
Nj
i,cubU 43j^xy^>vi>vycxlA.^v c^
+^
I )r RATION
CONTRir.lTORV
, 0
i .I/<'/,'Mn
/></!'
Hours,
\j^j\J-J^^^.^t^>M.
VC' > > wCLa
^.cxq^. ■
CL^'VCm
DIRA ri"N
( SIGNED )
Yiars
I J
M tiths
Day
I/lUttS
M.D.
s. '-',. ■ ^ <
I < (1)
f A.Mr. --)
a,
^\4
<..J A..
xxaW^-^cj^'^^^
f^ru.lfl in S,iu I
,. HO ).."
1
/'
, ,, \ i> I r u' 1 1* I < • III I'
HKs'r <>i MN K^'»^^ i.J.n'.i ^ -I • -,^
SPECIAL INFORMATION «»!> I- "«?»"^. I"^'''""°"^' '""^""'^'
„, R^eM Wrms' ^"4 P"-onv d,i«, a.a, Iron. ho^r.
Nrmcr or
IsihI Residence
When was disease contrafted,
II not at plarc of dealli ?
lo\* lonq at
Plaif of Deall»?
Days
,.,.XcK OF lUKIM. ..K K»:M..VM.
(Inr(i!iiK<nt
iiff;.
^11* C!L^^
INKl.K'l' \KKK
fA.iai.
,(1
U
!
I in \i. "I K1:M«>V Al,
I
rjAxxu
S5^- ^^'^ ^^'^^-
^1'"^^ '" ^ iiYAGTLY. PHYSICIANS «hould
'ill
i
ii
r
fT*
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i' •.!
I)((lv /v/f^^/A cIctIma^ 9^^
WO'X
Jlec^Lsh'iPd JS^n.
0"-:^Q
DEPARTMENtIiF public HEALTH-City and County of San Francisco
m-
PLACE OF DEATH: — County of
Ccvtificate of Bcatb
14t). t>
'II
• ^ D'ct ♦ he^i and
,X,(rr>XCUi ■ W C>N^, VV -J^ ^J'ii^rr n.V. rACTs'cAUtrO rOR under SPCCAU ,NrORMATK,N- \
FULL NAME
L
^kLo^AX^ UXi->v\'vV
PERSONAL AND STATISTICAL PARTICULARS
I> A
(>! i;ii<ril
U +
/ 0 L I
\ < . 1 ■
WIlMiWKU «»R I>t^ '
\\!'!- ill - ■ i' ■ ''
niRTHI'l.\>'K
MEDICAL CERTIFICATE OF DEATH
v.- a I
N \\1 1 • >1
I \ I'll ) K
lURTliri.SrK
( M ! \ I'll \:\i
■-t.ltt I'! ^1.11111
M \!1)1 N N \M 1
OS Miilin'R
HIR riHM,\CK
(»| MorilKK
I ^t ii t 111 i'liuntt y
(Ki'ri'X TION
:t\
\\
I in^KKHV . KRTIFV. That I Mtt.n.U-.M-.va.cd \vnu
that I la-t -;nv h ilivmii ^ " ^''''
,„ath:.l.Ualh.KH-urrc.l. ..nth.aat.^lal.a al...vc. at
M, The CATSK OF Dl-ATll ua^ a. toll.u^;
■ :>^
<X^x
-O
' (^ ^ ■">
l»r RATION
CONTKII'ITOUV LlwU'
.1/,"////
/hiv
//our
-\
^
A
,-> V I,
^rn>///ls
CO 1)
\ *
dtk at i on >'■'''''
(Signed) ^
/?.7t
/ /outs
M.D.
CM„lL<X/'v-ucL
n f - W I < f ' < ' -— ni -^M^-»«^ '.'III'
kii^AL INFORMATION onK t«r Hosp.Ws, Institutions. Transients.
orl^M Mi;.!^ and l>ersons d.inj -h.> fro:,, home.
Formfr or i ^^ '
Usual Residence ' '- ■
When m^ disease fontrafted,
If not at place of dcatfi ?
HoM lonq at
Plar e of Death ?
Oau
J.,, UK -'K lUKlAl. OR HKMOVAI.
l>A
i;t HI \i 1.1 R1M»»V \1,
inn
CDl.K I Akl-,H H > \. s^
\(M;t<s
' \ , , pvACTLY. PHYSlCIA^iS should
%TH 'n pin-.n termn, that it may ^^ [»
N B —Every item oi int'or-m
II
• l!
Ft
i
-■
11. *?
H
I
W
R.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
;>v r !■
IWWiW^i"
Duir rih>(l \)cXaA>^^ ^3.
/^OH
Baiislerod jYo,
^\^KJ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of Bcatb
XX. 5. StanC^av^ )
PLACE OF DEATH:-County of^Ct.. J X<X-c-^- City of-C^^Axx . .
'-V„trVLixL
St.;
Dist.; bet.
and
FULL NAME >
-TS^CALLED TOR UNDtR SPECIAL . N FO R M AT . O N • ' \
;t1 name instead or street and number. J
PZ
RSONAL AND STATISTICAL PARTICULARS
--1 \
MP
1) \ 1 1, 111 i'.M< rii
\^C
v^\
.WW
\< I
•^IN. .Ij; M \KK II 1'
It 1^ r 1 1 1' I ■* 1 ■ 1-
MEDICAL CERTIFICATE OF DEATH
!>;1V
I Month >
HFkKBV CKKTII^V. Tl.at I aUcn.K-.l.kHva.cl fi-.n,
1 \ 111 1 U
luK rm'i. \i !
>r 1 N rin K
-,1 ' . , ,! I 1 in til ! >.
M \ ! HI N NAM
(tl MoTin'. I<
I'.ik'niri, \^i.
«>i' \to*rin:R
I Stiti i»r <.'(iniiti y
^0
^ »
tbal 1 la>^t saw h alive- on
,n,lthata.ath..r.ur,XMl. nntlu-.lal.^tat.a alnnv. at "
M. Tlu- CATSK OF 1 u; All l^xva. a. fuil-.u^:
ItjO
nr RAT ION >'''^^^
coNTRir.rroRV
Months
Ihix
Hour
'\ ^1
A
I )r RAT ION
(SIGNED^
}V„'/
n n/Z/lS
/hn
M.D.
f
+■
«Ki I'l- XTloN
/,>,■, ,,/,-J III "^i"' I '
Iiif.i-r.Kint
^
XU IKTl.NK-- \K
IKl 1' 11
Tin- AHOVK ^' ^' '\1' ' ' 'Vim f' \N|. ni*l,lK
<A.
VpEC.AL information o.ly .«r fepilnK Instit^li.ns I^sie.ls
or Remi Ment., and persons Mn ''■'^ I'"" I-"""'
How lonq at
former or Q i ^ I ^ n i ' Plare ol Oedth ?
Usual Residence \\o ^u^
When was disease contracted,
If not at plare of deatti ?
XCH ol^ lU RIAL MR R1:MmV\I.
Oavs
i 1 ^^^
v^Co. 'dtcv^V
-J v
Rl
1 AiMn'-^
DA 11'
i;- in At .11 R I'M' »VAI,
TOO
X.i.ln.s WV.V.M _.__— — — — — """^ ^ 1 FV4CTLY PHYSICIANS nhoultl
.tutc CAUSE Oh ^^_ATH .„ p.B.n^^ ^^ ^.^^^ .^ ^^^^^ ,„,,„„,,.
•on* dyinft aw»y
^l^i^-^^
tVom home should be ft
y^y^if..
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ii
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WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOP INSTRUCTION^
ih,fr riir<L ^ clt^l^V 1^
I'JO'i
Megisterrfl .V^.
opti n
KA -L^x
^
Deputy Health Officer
DEPART^IENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
n. 5. i?tnn^ar^
PLACE OF DEATH: — County of
No. 'I !
City of ^ CV. >
V
■ ■ ' ' ^ ■ St.; DisUbet. ,„„.. ,..;\"l,o~. >,
FULL NAIVIE JVoXOl
PERSONAL AND STATISTICAL PARTICULARS
11
); \
MEDICAL CERTIFICATE OF DEATH
], \ 11.; oi in. \ III
i Da yi
\ ■
!!!!■■ ill
M XRKIl
\'" !'
1 \ri! I K
lUH Til IM, \i!-.
->;,', , • . nnt! v
M \l 1>!'N XAMl
« u- Mi»rm: K
luiri'ni'i.xti:
urrr\ri»»N
d
I IIFKKBV CI-RTIFV, Tl.at ! alU-n-U-l .K. . as.-l Ir mu
,„.lthat.U,.h,KainT..l. ..nt1u.la'. .aU-.l ab..ve. at I I
(J^ ;^j '1-lu- fAiSI-: <»1- l»i;.\ ril ua^ as foU.ms:
ink \ TH >N )■<,//<
J/, '!////<
fhns
/fours
DIKA Ti* >N
f SIGNED 1
/),n^
I loui <
M.D.
.X IMOH
A. Mia
0
\jj^<:x.'s\^
'^ ^
,, ..,uib I = XK- \KKTHrK T-. THH
SPECIAL INFORMATION ' '- "-Pi'-'^. '"^'""«»"^' """^'"'^'
or tocnt Residenls. M person^ d^ini .i<>h> Irn, h»w.
Former or l| ,.
Isual Residence h^k^^^ > ■ , '
When Has disedsf ^nlrafted, il .
How lonq at u ,
Phireof Death? ^^ R^^^
II not at plare of deatli ?
: III fi >• ni.-mt
rM>i:K r AKi'.K
i.\ n: >' H' i-^i
^^''"'' ^r^ 7( TirWCTlY PHYSICIANS Hhould
;S. B.— F.very Item ot" '"^'^^'^^i^" f„ " j„ t,„„s. thnt it m:.> he properly .loHS.I.ed.
stote CAlJSn or DHATH .n '' " \^"^ ^^„ ,„ «very mstance.
«nn, dy-.nS away tVom home should h. ft.
( 1
,1
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ii
1 ^*PJ:
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WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1. F V
^^ :^.xK, Deputy Health Officer
Jle<sisfrrp(l >jYo,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( xi. 'l'- il'tiiiicav:
^lr^ :
PLACE OF DEATH: — County of
0
M ii
rN
I
Nu.
M
St.;
Dist.; bet.
City of O CX.^' 0 V :>-
and
^IlED rOR UNDER SPECAL INFORMATION- ^
-' a.
,MoM USUAL RESIDENCE ^^'VJ J^^^X! ^M^AmV mSTEAD of STREET AND NUMBER.
NSTITUTIO^
FULL NAME
PE
RSONAL AND STATISTICAL PARTICULARS
--i \
T^
I iK
~\
N \ M i 111
I \ ! II 1 K
A ■\
^K
MEDICAL CERTIFICATE OF DEATH
1) A ri-: t >1- IH-.A TH
, m^kl^UV Ci-RTIFV, Thai l:,tU-n.k-a.k.,:.-a fp.ni
thatl'la.t..wh-e^ aUv.nn i^^ -^ ^'>°^
,„athat.U.uh,...urrca. ..ntlu.lat.^tat.a alu.v.. at I I
lX M Tlu f AI^l^ '^1 I'l Vni vva. as loll-ms;
M,>ut/is
Ihi
// .,>
U
lit'
(U Mnriii;K
lUH riiiM, \< v.
t»l Mi»'ilU', K
«u 1 I 1' Xl'li >N
K,
TllK \n()\l* -.
f In fii- 'uatit
A
niKArioN
f SIGNED ^
Ts
^ h ,■->
lhl\
M.D.
Ki'iH
\a.iii
When H3S disprt^f Antrartfd, M o- /
II n«f .It (»I<<<P "' <!"**' ■ ^^ '
I \\, oH HJ' M'i\ '^i.
SPECIAL INFORMATION on»'«' ""^Pi'-'^ '"^l"»"""^' "-"''■"'^■
\\m lonq at g
rnrmpror 11 ,. ^ •. clkt ot Dfdth? A\ Pavs
Usual Residence M4^^<-
iu:m<i\m.
^ ''^"^ T n . IIWCTIY. PHYSICIANS Hh„uia
ftiT-*
1 !
II
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I ti
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WRITE PLAINLY WITH UNFADING INK
Honi.! .f H^a'tli t
Duff rUr'L yctcrlr^v %%
li)(n
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTI FICATE FOR I NSTRUCTiONS
]^e^>i shared J^o.
,^\wCO
Deputy Henlth Officer
DEPARTMENTOF PUBLIC nEALTH=City and County of San Francisco
Ceititicate of Bcatb
PLACE OF DEATH: — County of O.o%'
ft A -, ■ h
^'V
City of CJ Cu^v -J A
'^ ^ , St.; Dist;bet. „„ „^„.p special iNroRMAx. on- \
( ,r DEATH OCCURRCD IN A HOSPITAL OR INS^ ,^
FULL NAME
Ll^mJa.
^W
< I
>-i.x
PERSONAL AND STATISTICAL PARTICULARS
>
;»\ IJ 111 lilH 111
i< .|•
SIX. I.I' M XKK n"i>
U I IM .\\ ) I I * •!< ^
/
i)\ n; <>i- DHAiii 1,^
1 \ I
MEDICAL CERTIFICATE OF DEATH
'Oct
/on
N'.H!
:k nn'!. ■> ■ »
I \ 1 II I K
niH rni'i, \' K
ol I NTin-K
M \ii»j:n n \mi:
«)1 MoI'lll.K
lUI'iIi I'l. xi H
.11 Mollll K
I ■-( ;,t I 1.1 ti lli ill 1
{\
H.
0^
(Month) "'^'^■'
I ilKKKHV Cl-RTIFV. That I attcu.U-l -Uhh asd tmm
t L UP'^ to Let .MoH
Uial I la^t .axs h -■ alive on '^ ^ -
^,„.n|,,,t.Ualh.Kaurrc-.l. ..., tin- .laU- .taU-d abnv., at
M. Tin- fAlSK oF 1>K.\TI1 was as foll.-svs:
.Krr>
w
/hiys
Hours
Ihns
SIGNED
\^*^
Hours
M.D.
I:
i^i^T^iTl NFORM ATION onh lor Hospitals, Institutions, Transients.
\t,.,i'ii
Hnt'
or Refeln ResVdenls, and persons dvin^ a^..s Irom home.
p /7> How lonq at
former or ^x IK. ^^, d ' ■Pt«re«ol Death?
Days
When was disease rontrarted,
II not at plar e ol death ?
/Cx/v\)M w^v
vQ
M<^^A'
,., xn 01 nrK!M-"H hi m..vm.
rM>HHTAKl-K H^ ^ . ^ ^:
I, A IK,,' n-Niu ..I hi:m<>\ A
3^H
T90H
N. H.
'" ^^ ^ PHYSICIANS Hhould
' ••' "r;j'r:r;v:,;^s:':~:-:; r:;;t ,.:;:-XS:r-;;; ■- ; ■..,. .-
«tHU CAUSE Ol Dl ATM "1 Pi"'" ^ Instance.
;'n. .lying nwny from homo Hhould be ft.sen
i
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•i
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,1
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RITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO — -'- rrPT.nCATE FOR INSTRUCTIONS
nfx4 o
It \ 1 1
IffO'i
Jico'i.slei'pfl «/V7>.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDcatb
PLACE OF DEATH: — County of CJ ex.
City of
U a^'>'^
ii
No.
Sf Dist.;bet.^'cicv.^<^ and ^
)
St.; UISTm Del. ^^^ „^_„ -spt-clAL .NTORMATION \
A ftp u ^ 1
FULL NAME
l/(>4_.C,
PERSONAL AND STATISTICAL PARTICULARS
^
-M
\
vl)^>
i( il.t >K
, \ 11.; I .i HiK rn
\1 . Ml
MEDICAL CERTIFICATE OF DEATH
I, All; i>i i.KA Hi
\« .K
1 r M \KK iri»
^
I HKKI^HV CI.RTIFV, That I ,.it.n.h-.l .U. .a^..l in-n,
t1,at I laM ^au h al.vc- ..„ "''^
„„l,hat.U-all,...a-urre.l, nntlu-aaU..ta,..l ah..v., at .
' M. TlK- C.\S--K <»l I'l^ ATI! Nva^ a. UAh'^^.^:
6tdX Q>b^^d^^^<
'\X^.AA.' •
^
H ri. '<■)
^»
CJOs^^X; J )VC:
Mi < '
, ; 1 i i 1-'
I'.n.' Ill I'l, S' !■:
•,1 ll . I i! 1 1 .11 III
M \ Ml) N "-' \ '^l
Ml MolHl-.K
ink iin-i, \rK
(.1 Mnrni'.K
-,t lit' 111 r.Huiti ^
t), ,1 1' A IK tN
"I
>
\
'\
A
1)1 K \ rioN
)■/ (// s"
Monlhs
fhn
Hours
H
^xi' '^n
,^
.a.Lc%^'^
I )r RATI on-
Signed )
) ',,11 s
)r,>ni/i
I hi
\\A.\
N
M.D.
f < )"
\.l.lr
■special INFORMATION o"lv 1^' li-^'l-'^- '-»'»"»'»-• '^-"^'^"♦^'
„,1^M mJ^I^ -nd P"-"^ rt)in^ a..n Iron home.
W I
» 11
' I II fi i: mUit
rwTv
^i) .
Nrmpr or
lsu.ll RfMdpnre
WhfB w.is disrasf rnnfrdclffl,
II not Ht plat pot dpatti'
Hfm loni| at
pirfif (it Ikdih?
Oivs
i>>
I- I Ml
1 <■)' >
\.Mh -•-
aiH
y
i
, 1 1 1 1 ' r \
I
/tX/^^
N. B.
" . IIX4CTIY PHYHICIANH Hh..uld
- r,;;^;;"Svr;;;:" :;::-:: ~;:t ,;...^; i-;" -• --'
«^n« «i>-.»a »^"y *••"•" *'"""'
,t
»'
WRITE PLAINLY WITH UNFADING INK
J)
((/(' /u/rff,^.QXjXhiJ\j "XX
iva
THIS IS A PERMANENT RECORD
WEFER TO BACK OP CERTIFICATg FOR INSTRUCTIONS
Registered *A^. . i o
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( H. S. StanDarC )
^^r>
(?n
PLACE OF DEATH: — County of ■
City of C3x5^'^^ ^J.'vo ,
St
Dist.; bet#
and
-)
(
' ,Vor.TH"oc"u%ro',"r„o"s'pr.t o%"n"?u"o';"'c,.. ,T, NAME ,«ST„0 C. .T.e.T .»0 NU-«.. ^
^^
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
■ KN >^
•i >I <)K
O
1» \ 11. <»J HIKTII
Mont!-.
Ai.K
' 1 )a V
1/,, »////»
( Vcar)
Da v.w
HIN«*. 1,1-: MARUn l>
WIIX t\VKI» <»K I)i^■• (RtKI*
i\\!itf in >.iH.ial ilt^ii/nat ii lu)
BiK rm'i.Aoi-:
(Slat I- or t.'Dunti ^
MEDICAL CERTIFICATE OF DEATH
DATK 01-" 1)I:ATII I \
(Month) <I>ay^ ^^■^■^"■'
1 l!I':KHnV CI'IRTIFV, That I attcmkMl deceased from
———--190 to 100
that I last saw h :t— alive on ^*P
and that death occurred, on the dati- stated above, at
M. The CAl'SI': t)I' l>l':ATIf was as follows:
!• A rin;R
JUK IHJ'l.ArK
(M 1 A iin-'.R
iMatr oi t^ ouiit! V
MMHl'.N NAMK
01 MirniHK
niK riii'hAi !•:
«»|" MnTHHK
(Slati- ur iNiuntiA 1
(HAll'A riON
\/,>l!'h-
Ihn.
T.iK AH.>VK STXTK.. ''HRSONA, P XRTUM^J.AK. AKK TRfK To THK
in'ST ni- MY KNOWI.I.IX.H AND IShl.n.l
(Inforniant
I )r RAT ION >V.7r.?
CONTRIIU'TORV
I )r RAT ION }'i'in-s
Mont/is
/)lJ\'S
Hour
^fonths
A \
Pavs.
(SIGNED) KJ^XJry-J^^S^. Uw ^^ 'y - *
U^t ..,; looA (Address) U^^fr^v>^^^^j
M.D.
Special information only 'or Hospitals, Institutibns, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
Hov« lonq at
Place of Death?
Days
I'l \CK nl- HfKIAl, OR RKMoVAI
\
' JU^^-Vv-vvi. w .^xXJ>.
n
DAI) ot Hi KIAI ot RlCMoVAI,
I 1
^
tuA) .-s
T90
ci.
( \(l(ln'>-'<
INDICKTAKHR s/ wLA-AJUu "- -^ ^-^^
(AtUlri'Ss. OVJ L • k ^
son. dying away from home should be felven In every Instance.
U
I
1 I
i I
P I
I'
WRITE PLAINLY WITH UNFADING INK —
r H- "Uli !■ ^
, .. '*^?^^>;- IKS.!' I'u
lorn
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Eeglsivvcd jYo. -
kA ciX
.:::t,
DEPARTMENT 'of PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( TJ. S. Stan5ar6 )
: OS?
PLACE OF DEATH.- — County of . J.\.o, GtyofCJ.O-.^
No.
OAX
St.;
-Dist.; bet.
/ ir DE*TH OCCURS AWAY FROM U S U A I. « t » 1 l^ t i'. w ..«..- j---- " ~ " " " -
C ,r DE*TH OCCURRED IN • HOSPITAL OR INSTITUTION GIVt ITS NAME
-and
.«OM USUAL RESIDENCE cv. .ACTS C....O .-"^-OCR ^'-^^--,'--;3---- )
X \
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
\
^111.
roi,< iK
i)\i I, <»f' I'.IK 1 II
Nf.itith »
1):.V
\ I . I-:
J ,,/
(Vear)
/>,/!,
sisr, 1,1' MAKKn:i>
\vii>()\\ i;n < »K i)!\< iHv J J)
iWiitt iti v.Kial (It — i^MtaiMU '
HiRTini, Acr:
NAMl- «>i
FATHl-.K
HIKTH»-l,AfK
ni- l-AIIIKR
I St;itt or (."iiiititlA
MMDl-.N NAMK
<>1 MOTIIKK
HIR rUPUAOK
ni- MOTHKK
(State iir Country t /
nccri'ATioN
Rfsiilfd in Stin /■': iin,
)'rit I
\!..,,fll:
I hi
THH ^noVKSTXTl-IM'KKSnNAl.l'AKIHTI.ARS AKi; TKIK T<> THH
IlKST Ol- MV KNnWl.l.lx.H AND r.I.l.nJ-
'D
('AfMir
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1:aTH ,r
(Month)
( Dav)
(Year>
~~ I HI:RI':HV CI-:RT1FV, 'niat I alteii<UMl «lecease.l from
___ — __ _- — — igo to .- ■ 190
that I last saw h ~ alive on ^9^
and that .kath occurrecl, on the date stated al.ove. at
M The C VrSp; Ol' Di-ATH was as follows:
Dl" RAT I ON )'t'ars
CONTUllU TORV
Month's
Ihiv
flours
(SIGNED )L(rVrvxX>v o.vfi.lUcix
(Ad.lress) Ly^.^^"^-?■*^- ^- it
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, institirflens, TransienN,
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
PI.ACK Ol- lURIAI, OR R1:M"VAI.
rNi)i:RTAKi:R
(Adtlrcss
DXTKuf IM KiAi, or RKM<»VAI,
Oct -
I90H
— — — - ,. . Top ^^„„,d be stated EXACTLY. PHYSICIANS should
N. B._F.very Item of informBtlon should be cnretuHy -PP'-^' ^^^^^ ,,assi«led. The ^Special Information- for pT-
state CAUSE OF DEATH in plain terms that .t ma> ^« P^^P^*"^
sons dyin^ away from home should be g.ven .n svery instance.
>
d
1
«
i
\x:
—^ 1 '
1
? '
*i
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'
'
i ^
'
littii
#
»M
m^-
I). *
WRITE PLAINLY WITH UNFADING INK
i?,„,!>:
,i IK;tUh 1
\-o ■•> **^^i*HS:
:l' •.".)
THIS IS A PERMANENT RECORD
R^PEPI TO BACK OP CCRTiriCATg FOR INSTRUCTIONS
I)a/(' Fi/rf/X dj^M.^ 11
190H
Jicgl^fered A^o.
0^9 f^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( XX. S. StanC»arC> )
PLACE OF DEATH: — County of
J? ^
City of Oo^-N^ J A,o.
No.^
„ St.; Dist.;bet. and
ED FOR UNDER "SPECIAL INFORMATION" "\
NO NUMBER. /
FULL NAME ^
A>-UxtiA.'
A
six
KAIl-: nf. lUKTU
PERSONAL AND STATISTICAL PARTICULARS
i
1
Mi.titli
/v.
X < . H
I'll 1
sIN<.i,K, MAKHn:t)
WmnWKI* <>K IHViiKi 1 I)
|\\'iit» ill *inci:ii ilr^sk' u.il ; iH '
stat» 111 •■oimtry
MEDICAL CERTIFICATE OF DEATH
DATK OI' DHATH
il>ay
(Yfiir)
NANH ni-
!• A in IK
!UK rniM.Ai K
MAIDKN NAMK
01 MOTIIKR
HIR rulM.ACH
«»1" MorHKK
I st.itc or Countt %
/
/
<>i
CII'ATION CV\^
MR
M.'ii'li
/'.n
aiif..nnrmt V^Cj-^-^O^^' V,<^ W '«
Ks AK1-: iKiH r<> rin-.
\<\A-
(M(inth)
I H1:RI:HV CI:RTIFV, That I atten<U-.l .Uixa^tMl from
^ - 190 - tn - — Uyo '
lliat I last saw h ^ alive on ^9°
and tliat .kath occurred, on the date stated above, at
M. The CAISI^ OV DKATII \Vfis as follows:
DTK ATI ON y^'^f^
CONTRIinroRV
A/on //is
/)a\s
Hours
DT RATION
f^
Ycays
Mouths
/hws
SIG
,TOIi).1jLv,^
NED) \,^t\Jry^\.>
H)0 (Address) L-t ^
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Instityttohs, Transients,
or Recent Residents, and persons dying d^dv from home.
How lonf at
Plaff of Oeatli? Days
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
I'I,ACK MI- lUKIAI, OK KK%f«>VA!
a.
)X^'y\^'>r
Dxri: ')t I'.iHiAi, '•! ki:m<»vai.
I M ) J*. K r A K K K
■il
V'=
<i.cy-o
1X%v
fA<iaT(>,s «iW I ^^
I
TT n^ AGE should be stated EXACTLY. PHYSICIAINS should
InWm.tlon should be —;""»; «"^'' "^^ ^.^^^Hy classified. The 'NSpeclal l„»orm«f,»n" tor pT-
stote CAUSE OF DEATH in pb.ln tcrmn, that ,t m»> !»^-_ n;;;»'f ^
N. B.— Every Item o\
.on. dyin» awa^ s'ron. home »l.o„l,l he ftiv.n In .v.r, In.t-ncc.
I I
;>
iT
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
! \.
\
l)<,h> rilr'lXJAAHA} XX
jfjo'i
Jifo'/.s/c/ed J\'*o.
1/
\i^K^ XjiA.'^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
•U. 5. 5tanC>arD >
PLACE OF DEATH: — County ofCj£X^\
>3l^
(Ks
City of " '^ v^'
r-i
^i^ n
No.
St.; '< Dlst.;bet. u\D &iA/<>A_a and
iiciiHi Drcinrisirr nur facts called roR under ' special information ' \
( '^ .VrE:T°H^oc:u%ro\;''rHo"s"rAt ^^^lir.ru^'ioTl.T.ll name .nsteao of street and .umber. ;
)
((l\l?
FULL NAME
^
a.
4
PERSONAL AND STATISTICAL PARTICULARS
i I 1 1 , i • K \
u
;i Nil I ii HI
N!
■^IX' . !.J M \ k K i 11'
\\ I I )( 1 W I I 1 1 )k ! 1 ' 1 •'■ i t I
]
LU^oLcv- ^
h' I ' M IM \i' K
\ \M I ( tl
I s ! I 1 ! I'
P.I R I'll ri. All-;
oi ! \ III i: R
M \!I»i:n %■ NMl
ni- MoTlUR
lURIIll-I, \i I.
• u Morm-R
■-1 :iti ii! riiiint t \
•HTl 1' ATIoN
/^^>
\\
Vj crLcx
fl
Jlvvcv,.
,;,/ /
\f,,i^*//'
h.:
Till- \HC»V1* sTSTJ-I. IM-R^ON \I, P \ k T L' r I. \ R - ARP IRPH T« > THI-
p.i.s'i'di MS K Ni i\\ i.i;i»< . p; \^i' p.pp" '■
(Info- !ii ml
a
S-IiIh -H
1^1% \
'-yx^ r\ it
X^"\ OC
'1
MEDICAL CERTIFICATE OF DEATH
I) \ ip; t >i I'p' \ III
■ Month t
I go
(Vt-ar)
.l)..v)
1 IlKkKHN' l I-KTIFV, Tliat I • tiinU-.l .lectasea frnni
■ u^, In V. -^ Xi TOOM
that I last <a\v li ■ alive- on '^■- ' -■' I<P •
.ukI that death .u-currea, cii the .laU- statt<l almve. at '^
M. The CAT Si'! Oh* DI-^ATII wa-^ as follows:
^X?J"UC^'^-Xr
o^*.
DTK AT [ON )V<7rv
CONTUIiUTukV
DIKATION )'-"v
Months
fhn
-L
1 1 oil r^
Mnuili^
fhns
SIGNED
M.D.
-A
l<)0
A.Mress) HlH O.CC
SPECIAL INFORMATION on') J"r HospifdK Institutions, Transients,
or RfCfnt Residents, and persons dvinq dvtav Irom home.
Former or
Isual Residence
When was disease rontrarted,
If not at plare of death ?
How lonq at
Plare of Death?
Days
'!, \i'V. <»i P.PHPM* «►!* rp;m< >^ ^^-
■npi;kiaki;k Ml vi >v<XA.y
DATP'.i)!" IP HIM- "t KP:Mi>V\P
TOOH
J
(AtMusv
^sS'b- 'isn
■"— "^ 77a aGH sHuuia be stated RXACTLV. PHYSICUISS should
item «V int..rm.,tlon should b. car«tuily suppi.ed. ^t ». « ^.,„^^5,^Sed. The ^Special InformHtum" for pT-
C\USK or DI:ATH in plH'.n terms, that it may be properly wlass.tie
N. B. Rvery
state G/llJf9l- v^r «-»»--» • - , l„„#«nre.
•on. dylnft away from home should be J^.ven .n «very .nstance.
«
I
>
d
i5
0
^
■- "^ «
WRITE PLAINLY WITH UNFADING INK
riald Mil
Dnfr Fih'fl , t ct^lHL>v XX
r^o'i
DEPARTMENTS PUBLIC HEALTH
-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jirjj'i.s/e/'cd -jYo. ■ ; f
City and County of San Francisco
Ccvtiticatc of Bcatb
PLACE OF DEATH: — County of
. ■ City of Jcc>x J va >^c' c
J M
M a St.: Di5t.:bet. Vtiv and -^^^
*-^0* •-- ' ,,e..Ai orCinrNrE rlWF FACTS CALLED FOR UNDER SPECIAL INFORMATION \
( ' frorjrOCrun7.'u\r.los%'!^.': ^^':.^f^^^^Z.rJ^ name .NSTEAO of STREET AND NUMBER. )
FULL NAME ' ^
)
PERSONAL AND STATISTICAL PARTICULARS
YS^ '^ ...!...k N
I) \ ri; <u i;iR ill
C'
\».i-;
^i Ni .1,1' M \ Kl% II '
\\i Im lui.ii t »k i»;
I'.iK rn iM, \i" 1
(St:ii 1 I iT i iimi ! s
1 \ III IK
I'.ik rn iM, \. I
I M I \ I'll 1 U
A
L^^
QCLl
m
V
U lit 1 s
M \ I ill \ N \ M 1
liiR rm-i, \i r
<>1 MoTlll K
- ' '■ ' • t n lit T \
m
cv vv J Xa
I
J -vo.
r>
Lo
S,ni /■/ i!ii. '•' .-'
i^ ft
[J
) r,i
rm- MsnVKSTXT. l)PKR^..NM,I'XUrhMl.\R^AKnTKri^ TO TllK
lU'sT <)! MV KNOW 1,1. IX .K AND lU-.lJl'.!-
(\ W
YCL/Y>xiL"5
niifiiTmaiit
I
\(l<lrt— *-
51H H<^A^^^
MEDICAL CERTIFICATE OF DEATH
l> \ ri' ol- Dl'.AI'H
Dav
(Month'
/on i
War)
I ni'.RI'.r.N' C JlRTIl'V, Tliat I alUii'kMl (knca'^iMl from
i^ ^t luO I ti)
f(,n I to I^P
alivf on T^P
aiul that .U-atli occurrtMl, on tlic .li.tL- -taU-.l above, at
tliat I last saw h
M. Tlif CAr>I-; Ol' IH;.\ Til wa< a< follow
l\^.o^cw
>duuuL to £^A.^aj.<X4-CcC
1)1 k.XllON )Va/v
CONTRIIU lOkV
M<>n(hs
/>./!
1 1 oil) \
(SIGNED
Month'
Pavs
O.t . ...
Uout <
M.D.
H)0
A.Mri-O 15' I -^ '^-v C
SPECIAL INFORMATION "niv lor HospltdK Institutions. Transients,
or Recent Residents, and persons dying dwrfv from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Da\s
1» \XI" ii: Hi
!■! \CF «»i IM KI.M- OK RKMOV.M,
,snKKT.iKR lUv^X^ lUxxUni-
(Address %bb QfYWL^^^^r^V Jt
ki:mo\ .\i.
too':
il . .• I \CT should be stated EXACTLY. PHYSICIANS should
n. B.— Every item of inform;.tio« should h. cn.eVuIly f"^* -^. ^ ' ;^ ,,aH«5fied. The "Special InformBtion" *or p.r-
•tate CAUSE OF DEATH in plain terms that .t niaj '^ J J
■on. dying oway from home should be ft.ven .n every instance.
; t
J.
1 .
t^
2y
.,..*:
«i!'l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I !!■ .;il: ! N<
lOO'i
REFEiR TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jicglsferrd ^Vo,
I . -
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Gcvtificate of E)catb
( "U. S, Stan^arD i
\ O . ' V City ofO/<x/w jAX>.
f\
No.nirRj&U-- St.; ' Dist.;bet. "'t^ and ^J^
/ ,r DEATH OCCURS *WAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER SPECIAL INFORMATION' \
( ,F DEATH OCCURRED ."a HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
0
FULL NAME
4f
PERSONAL AND STATISTICAL PARTICULARS
m
a
toJUi
t»l ink III
.1
I
+
/ 3
SIN. I r M \k k nn
ri'i. \»'i-:
1
Ml < u
I li i:k
lUK I'll I'l. \ri:
<•! r \ nn-'k
■^1 it ! .1 I'l lU lit
M \ 1 lUN N \M 1-
'M MiillllH
'•I \T<)'riiKk
■I K'i llillt 1 \
-\^ ^
l1
^
< >t'* r I' x'l'loN
/s'r-n/rif m .S,;ii I'lanii
1/.
/
•in: \I5()\■l^ sT\Ti-i> I'KRs.txM. p\KTn ri \K- AkK 1 ki !■• i" I'm-
in;>>r oj. mv kx< i\\ i,i; ix.i-; am> m.iji
i"' ' iniiiil
\j 1 .
U ^ X
a?
. '1 ^
MEDICAL CERTIFICATE OF DEATH
i»A ii-: «»F i>i: \Tii ^p\
(M.,iitl,) -nayt iViai'
I II I'lk i;i'.N i. IRTIl'V. Tliat I attcii.U'il .JtHiast'.l fp.iii
,■ . , .. . iqnH to iU'^ ^^ ImoH
that I la-t -aw h ■ ■ alive nn - ' I^P
an.l that .Uatli nrrurte.l. .ai the .latr M..'<-.1 ahnvf, at <©
U M, Thf CM SI-: (>!• I)i:A'rH ua'- a- t()ii,,\v^:
IiIUATIoN )'iajs
e < »N'rK inrroKV
Mo)Ulis
Pax
Hours
DIRATION
(SIGNED)
Pav
\
Hours
M.D.
r\
ofc
^»
i()oH
A.Mn-^s) 3-lV auJH-C'
SPECIAL INFORMATION onlv for HospildK. Institutions,
or Recent Residents, and persons dying av»a> from home.
Former or
Lisuai Residence
When was disease confrafted,
If not at place of death ? ..
I ACK or nrkiAi, '•!< k!;M<'VAi.
HoH long at
Plar e of Death ?
Transients,
Davs
r.XIU'.kl'AKKR
i;
i» \ r
Mit\' \I,
IQO'
7^ ^^
Aa.ifl^s 30 5" QTV^awLc^'i
IS. B. Rvery item of informntion shauhl l»^ -••r
stole CAUSE or DF: \TH in plinn terms 5„«,„„ce
sons dyinft away from home should he ^-ven ni every instance.
"TT n MIF. .'io„I.I he stated RXACTLY. PHYSICIAINS should
afully supplied. '^'I:'^;"; ^^i^..^j. The "Special lnforniM5..n- for p^r-
. that it may »»e pr«.p'^«'"y classmeu.
I
J
1
6,;
^"'tlH,
if
1 1
^ II
<>
il
•i
il^^j^-:
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H,,.i.i •■ n^
V,, ;- *.^^ -. ;.^.i
DEPARTMENT OF PUBLIC HEALTH
REFER TO BACK OF CERTinCATE FOR (NSTRUCTiON3
licgialeft'il oVo.
City and County of San Francisco
Cevtificatc of IDcath
11. 5. t?t^n^ar^ j
PLACE OF DEATH: — County of -Ccw . \ -r^ . . City of ' ^v OAXX^
fS^,. vC a,LAx<vk '' St.: Dist.:bet. and
FULL NAME v.<r\h.L^ —
PERSONAL AND STATISTICAL PARTICULARS
^^
*( 111 >K
Xk>
Hik rn I'l. \>-i-
X \ M 1 « M-
1 All! IK
ni.'Tii ri. \i'i-:
1 » ( 111 lit ! \'
M \ I Ill's X \\11
til Mi>riii;u
i;!K riiiM. \K ];
' •' ^•| > I'll i;k
oi'iTl' \ IION ^
1 '•' ■ ! I )
. C
1
11^^
1 1
\o
,ct>v<x<L<x,'
u
\ %vn ' ■ 4
U
AV /,/,-./ /,' .s,/»/ / 1,1
^ v
- 1'
■rin% \H(»\'i-: s'l' xri: d pi.-r^^on \i, r \i< ri. ri \K'- \k i
ini'^roi Mv KNowij.D' .1'. NM> in 1. II I-
H I K I ' • t " •■'
■»:illt
S). a
f
,cu.
+ !
Xildrt-ss *i..' ,-A„J\^/
MEDICAL CERTIFICATE OF DEATH
^
^4
\'.uithl
I».'V
( Vrar
I IIIkl-l!V ClKTIl'V, That I itlcuikMl ikrrasc.l frutu
that I hi^t -aw h
I </J
,,Hven„ ^Ct 11 190 H
,11, ! thai .Ua-l! .KTUMa-.l, < m th. -latr -tati.! alx.vc. at '
M. Thi' CA' SI-: <)1' I'rlATll was as follows:
1)1 k AI'ION )V<7/.v
coNTKinr rnkv Oa
(SIGNED) > w
^ ^-.
^•v
.1/f'////'^
/>,/r
Hour
1/
/)(/!'?
I<»'
A.ian
1 1 OH Is
M.D.
f
SPECIAL INFORMATION «nlv l..r Hospitdls, InMitiitions, rrdnsienfs.
or Recrnt Residents, dod persons dvin) ,mdN Irom home.
Former or { K , ^ t . ,
tsiial Residence xiJ-^-A^/ rw*^
When was di'^ease contrarted,
If not af plare of death ?
How lonq at
Plare of Death ?
XN^'^x^^-^H ^^
Ddvs
I'l.ACl- <»l- lURIAU OH i:i;M.»\ \I-
X
1'^ ^ ' ^ vVi-^
I>\rK .-: la lU M "I RKMoV \I<
0.t:t; a^^v iqoH
Atl.ln
N,
»-" ^!^ Mlf s'ln.M be stHte.l EXACTLY. PHYSICIANS should
B. r.very item of i«for,n,.t5on Bhoul.l b. cnr^tully supphed. '^ '^ Ui.HHiticd. The "Special Int'ormHlion" »»r pT-
«t«tc CAUSE OF ni:ATH Xn pl«in terms, that .. may - ^^"^'"*
sons dylnft away from home should be a'.ven .n every mntHnce.
^ I
P
-i^'k.'*.
WRITE PLAINLY WITH UNFADING INK
I ., '. |- \',
u " — "*
f iik:' (■
I
^'^
Date /•V/r'^/,lL'£tcrl-t\; ^^^
lf)()'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jfes^is/f'rc^/ jYo,
,a:
Deputy Health Officer
DEPARTMENT W PUBLIC HEALTH=City and County of San Francisco
Gcvtificate of H)catb
i XX. S. 5tan^ar^ '
PLACE OF DEATH: — County of
^
-^
City of
<X'
V '^
No.
St.;
Dist.; bet.
and
..<^ii*i DC-e:in*FNrr nwr FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
FULL NAME
.all
X-tVCX/^-V' ;■'.
PERSONAL AND STATISTICAL PARTICULARS
\< ,
-I V. .l.K M SRR II
W ! I )< . -A r I ' I »K 1 I
r»
L
wA.
MEDICAL CERTIFICATE OF DEATH
I Vral I
I II !•' U 1:P.N' C'l.Rril'N. 'K\\.k\ I iUlmuK-.I iKnHa-,c(l Inmi
- — — — — i(,o
up I'
— alivf on
that I la^^t saw h —
ati.l thai .Uatll .Hrurrcl, on the -laic -^tatL-.l a1.<n-c. at
M. Tlu CAIM' (4^ IH;.\ ril was as follows:
\<.p
yxAx J-c<^v
i 1 r 1 \ I ' 1 •
1! I \
u >
X \ M I < > 1
i A 111 i;k
lUHTHI'I, \> 1-:
< »' I \ 111 !■ K
I SI ,1' 1 . i| I . Ill !ll ' V
Ml MdlJIlK
lUU III I'l.Aii:
'I 1! ' 1 <\ i'oniit! \
'All' \ TION
t\fsiiifd HI ^.m ! I >'■><
) , ,7)
\ f. , It'll '
\'\\v. M'.ovi*. SI' \ Ti: n i'^*Rs<>\\i, r \K II'' ' I ^'<'^ '^
mc-r 01. MS' KNnwi,i:i)< .!•; \ni> lui.ii.i
Ki: THri' r<» I'li
inntit
DTK AT ION )V,://
CON Tkii'-r roRV
M,>uu>s
Days
I/onts
DTKATloN 5V<//A
"1
SIGNED
Mont lis /hn
I lom s
M.D.
1 1 )' >
f
SPECIAL INFORMATION «"!> for Hospitdts, Institiifions. Iransirnts.
or Recfnt Residrnts, dnd pfrsons d)inq .m.iv Irom homf.
HoH lonq af
Former or p, , ^^^^, n.ns
Usihi! Residence
When was disease fontrarted,
It not at plat c of deatti ? ^ . _—
iM.ACi' 01 iu^KiAi. <•!'! ki-:m<>\ai.
u
i> \ ri
too'
' ' ■ , . ,. , Zw .'inula he Ht«te.l nXACTLY. PHYSICIANS should
N. B.— Jivcr, item »V inf„r.„„tJon nhnuhl h. ....n.lly ^^^^^^ J^ ^ .,„H«Wlecl. The S^^M lnform..t1.>n" tor p.r-
•tat. CADSI or 1)1 ATH in pinin Ur,„H thnt .t m.y ' ^^^
«nn, cfyinft «w«y from home nhould he ft.ven .n ever, .nHt»n.e.
4 i
' (
>
2)
^^J
|i
ii-
•» J,
^"
/^'
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
Hoard. . f !l.i':l' ' "-■
r >•'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale /•V/r^/Aci.C^K. VX
^
\ '^-\XXA
Deputy hi
h C
Boillsicrrd 'A^o-
riPTO
1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of a.-YX
Certificate of Beatb
J 05^
. C{ty of C) <X.^r^ J A,o
.1 s o
lU
^,u,. , ^ Sf ^ Dist.;betXt>TV'. ' and .A./j
)
ft
FULL NAME
\
I K > \..0
PERSONAL AND STATISTICAL PARTICULARS
^w W
|i \i 1. t i! !',IK I'll
M.MiSh
'I
Pas
,Rta
>,!%. ,1 I' M \K k IK!)
.< . ■, - ■ i! i. Ill >
(I)a\'
(Vtarf
.1 »
i',n>: !'H »'i. \^■^■
\ \M I- I >!
HIKTHPI, AiK
<tl I AlllKK
\t \il>l \ N \ Mi-
ni Mnrill-.R
luR riiPi, \(i:
<»i- \t(»ihi:r
I stall tir r.nilitrv
(\
Cc.
.Va.
\.
-^U
L
( )i iTl' AI'ION
V
.. X
MEDICAL CERTIFICATE OF DEATH
II \ r }■" ' 'i' I '1' A ru
iMMlltll'
1 flKRKHV CI'RTIFV. That I atU'i.-lcd dctvaso.l Inm.
that \ last saw ll ^ilivt' ^ii ^'^"
a„.l that .Ualh nrrurrcl, .mi the -lat. stal.-l al.nvc, at
M. The CAISIC Ol- I>l.\ I'll wa- a- follows:
DTK Xl'lON' Yrars
CONTRir.rToRV
S,^
^
.^fouths
Pav
Hours
DIR A rioN
)'<ars
MoutJi
'is
/>r;r
i
(SIGNED) J .'viLOJ^V^t,
Ilouts
M.D.
, r
I.' i
' ! i
' I
I
td
I<)0
f .\«Mn-ss) bub
a.
SPECIAL INFORMATION ""Iv f»r Hospitdls. Inslitutions. Transients,
or Recent Residents, and persons dvinQ d-<*dy Iron home.
/'^
)',-ai
M.oith
TnUA,M>vKSTxiMnM-KK...NA, pxktum;kxksakktk. K in
lU-sT ni- MV KN-nVl.l-.lx.l-. AM> LIL''
( Info! tnaiil
\i1(1m s*;
.OUL\
Former or
Usual Residence
Wtien was disease contracted.
If not at place of deatli ?
How lonq at
Place of Deatlj ?
Davs
IM XCH OV I'.IKIAI, <>K Kl-.MnVA
^
rNi)i;KTAK»:H N i ^
TQO
O^^ ^ ^t
CAilili' '-
3
it
^^^^— Jnm^— ^— ^■^^^^'^'^'^'*^'"*^^ , iv%rTI Y PHYSICIANS should
state CAUhfc Ot- wt'* ' " ** , , . . Aiv^n in every instance.
Hon, dyinft away from home nhouhl be ji-xen ^
4
WRITE PLAINLY WITH UNFADING INK
n-
N
Dafc Fifrf/ ,\J^<T\>-^^-^ '^'^
n)o\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
kj&\^'^-^^
DEPARTNENT ot PUBLIC HEALTH-City and County of San Francisco
Ccitificatc of ®catb
PLACE OF DEATH: — County of
^
City of ^ <^ •
\cx >
V
Sf X Dist.;betX OxX'vV^LL and
I
•1 '
)
mr f l ll I n St.; ^ UlST., DCI. '^^ ,__.„ .SPECIAL INFORMATION \ i
V IF DEATH OCCURRED IN A HOS^-M-i.
AM \
FULL NAME 0£l^<x1x; >aA-vc i^xxo.-
PERSONAL AND STATISTICAL PARTICULARS
!•, I I I
M ,i!th
I) >
■» < .11
\< i-:
b D
}
MEDICAL CERTIFICATE OF DEATH
DA Tl-; i>l DKA'l'n
1 >T.)ntti'
(Day
(Vtar^
I iiHKKBV CKRTIFV. That J atun.k-.l .Uv. a.ol fnm,
that 1 last saw h
alisr oil
<J c:l
up
- !\i ,1 1" M \KK 11' I >
\
^„,., .1,,t.Uathor.urrca, .,n tlu- .laU-tatca aln-v.. at ^
M TlK' C\rS!{ OF DKATII was as follows;
3»0
LU ccL^^^^^cL
lUK rin'i,\«'i"
I St. ill ( >! 1 1 lunt I \
lURTll I'l, \i*!"
Ml I \ nil- K
. >t ,(t I lit i'- lint • \
M XIDl.N NAM 1
oi M()'nn:K
JUK IHl'LArH
(>!• M(i'rm:K
I Stati tir Country
t )icri'A'rioN
c
L>^at c
'"n
^1
CK^v.0^^^^ Ml^Aix^ctui
IHKAI'ION Yi'iir^
CONTRllHTokV
U- A
^rontf!x
Pays
I loU} s
^
L
''>V<
e
DIRATION
C
(SIGNED) AA. ^W
l*U,t
}rnnth:
/hivs
Iqn
Hours
M.D.
SPECIAL INFORMATION «nly for Hospitals, institutions, Iransients.
or Rerent Residents, and persons dyina anav from home.
■>
) , ,;
Mnll'lf
Ih!
Till- MicVHsTATHUPKR^^nNAl^XK K 1 ,x
f ItlfoMllfUlt
U)AiXoou-^ Lc^v>^
(A'ldvess
lu
<\^"k
1
Former or
Isual Residence
Wfien was disease contracted,
If not at place of deati) ?
How lonq at
Place of Oeatli ?
Days
Uct.
,., ,\CF OI 111 KIAI. ol; k!;M<i\ Al.
TQO
^^^-^— ————'— '*'""**** , FYACTLY PHYSICIANS should
!1 1
0<
pi
hi
I
i
WRITE PLAINLY WITH UNFADING INK
'•, I N'
/ -V 0 \
l)iifi' I'iU'il \ <^':Ay^^ 3vl
DEPARTWENT OF PUBLIC HEALTH
THIS IS A PERMANENT RECORD
REFER TO ...n-r.r.CATErOR INSTRUCTIONS
=City and County of San Francisco
Ccvtificatc ^i Bcatb
i
(9rN
No. ^^
PLACE OF DEATH: — County of
City of
c\. ^ V c-
St.; Dist.; bet.
RESIDENCE GIWE FACTS CALLED r
and
( " r";»,°"ccci/.ro-,"°:c"s^r.t o%^t:s.-o. c.. .s ..«. .
.OR UNDER -SPEC.AL ' « ''O ^ "^f ^!' ° ^ ' ' )
NSTEAD or STREET AND NUMBER J
FULL NAME
>
PE
RSONAL AND STATISTICAL PARTICULARS
W\
1 1 1 i 1 K 1 1 1
L
\» ,i:
w
""" MEDICAL CERTIFICATE OF DEATH
DA IK "1 I''" "^'I " :
AS
il)ay>
i\'«;irt
111
K,:nV Ci:KTirV. That I atUn-U-l .U.va.ol rn.,u
1 1)')
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that I last -aw h ^^>w alivr ..H ^
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r -^tattd abovi', at
M. Tin- CAlSi; 111- I'l \ni ua-;,- l-n-"-
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1
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nruATioN
(SIGNED »
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M.nith
fhw
M.D.
r.\<i'ir
^
Li'^
"qpECIAL information ni> n- "-
jrlefen^ Ments Vnd persons d)inq h.„> Iron, home.
ON ""Iv tor Hospitdls, Institutions, Translenis,
li
.r.Minr.nl JA^O^%aJK
m ki»:i
Former or
Isurfl Rpsidenre
When was disense contrarted,
If not at place of df atli ?
How lont) at
pld» f ol Oedth ?
Oavs
\CI'. Ol- P.I KIAI, »)
R )<KM'»V W
::.,.„« lUK'^.
f Atl'It*'*'^ Ov Lii.
' K'l-l.c'^'^ UJ^Vu4yVV&-VC^LX. ^ ■ , , V4CTLY PHYSICIANS should
«nn, cfyinft away from h«m« ^.hnuUI bw g ™fl^^^^M
^fcta
L )
1
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RITE PLAINLY WITH UNFADING INK
f. -: -ar ,-., ;;X: 1' i
/)n/r /7/r^/,y.ctcl
1>X.^ S^^
lOf^'i
THIS IS A PERMANENT RECORD
REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccvtiticatc of ©catb
^ , f n rx ->A. o ' X o.^^e^<^c^ City of c) <^^ ^ '^ ^ > ^^
PLACE OF DEATH: — County of^cx->A. . - /
and
-^
No. .^
{ ,F OE^H OCCURRtD IN • HOSP.T.I- OF N5T
FULL NAME
St.;
0
Dist.; bet.
TS C^LED ^OB under' 'SPECAL ' ^ "^^ "^^f *^ ' ° ~ ' )
tJ name instead of street and number. J
^sj,^^ 4 I v-O-X^-
PE
RSONAL AND STATISTICAL PARTICULARS
n
^
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M.Mll !l.
M
EPICAL CERTIFICATE OF DEATH
DATK ••! I'l'ATH
(Miintli'
fun
).!'
Kl.nV ri;RTlFV. Th,.r ! m.,,,1..1 .Ut. a...l Inun
\i .i:
1 M\KI<U n
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)'i'ars
^font/is iG /><n'
IIOUK
^
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Former or
Usual Residence
•,Mn^xH,>vKSTvrrn,-KK.nsx. PNKTP^rrxK. ^KKTK^K m r.n
HKST Ol- MV KNO\VI,ri>'.l-. AND MM''
DrKATION
f SIGNED )
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IhlV
'n%'
f fours
M.D.
IijO
Aa.ln-^O i^lt)
— — ^^nriT^MATION onl^ l«r Hospiyh. Institutions, Transients,
or^efen^ isfde'-nts.nd persons dUni ...,.> Iron. home.
How lonq at
Pld< e of Death ?
< I.
„,,„„.3,.,.W«.<u.^x;$^'«"-V.
^uUi^*^^^ ' ^^
■H
^H In plain t^rms thnt it mj >
N. B. Kvepy Item o* !nV'.>rmut
1 1
)
(
WRI
,>.K.r. iMi€ THIS IS A PERMANENT RECORD
TF PLAINLY WITH UNFADING INK — THIS \^ M ri.
^^ 1 p.P.B TO BACK OP C-°-.^.^-^Tr .OR INSTRUCTIONS
^ ' Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Scath
"U. *3. Stan^ar^
J? ^
PLACE OF DEATH: — County ofCJ,<x >
J
No. HIS U
St.; 1 Dist,;bct
IDS
NST
FULL NAME ' CLc^^^^ -^
City oi^^
1 V,
n
and
)
V IF DEATH OCCURRED IN * HOSP.T
. ^
■■I
———'—~~~~ _ ^^.-ricTir Al PARTICULARS
PERSONAL AND STATISTICAL PAhii
I ( il.i >K
I
V
1 1
;^ED,CAL CERTIFICATE OF DEATH
DAIK ol- I'J ATH , '
'Mi.nth'
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U • It.
to wet ^^X I'>"^
' 190 ^
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DlRATIoN
( SIGNED)
Years ^f'^"ff''
/>,71^
Hours
M.D.
('AiMri'-'-) ^''
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— irTlN FORMATION »"ly I"' ""^''■"■"^' '"^"'"'""''' '"""''""•
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Hl-ST Ol- MV KSnWl.l-, I )«.!•. AM' i.»...
(Ill f.i- ntnnt
Former or
Usual Residence
How lonq at
PIdi e ol Death ?
Days
,,Vn{.,; iw uiAi, or KKM<>VA1,
I NI)1:H1 AKl.K ^ /Y\
<\a.ln<-. HIS" ^MaJ.AA,-W-A^ -- ^ ^_ ; , , FXACTLV. PHYSICIANS »hould
,„, .„.c.-un, -upplt.... A..B -'^"^''.'wud? TH?-'«n.c-,B. .„.-o...U..n" .0. p.n-
„au- CAUSE OF p> ATH m pl" ,^^^ ,„ .,„y ,„„.n... .__„,,
iE^::^-r;i^^^:e -=•--' —
3
)
WRITE PLAINLY WITH UNFADING INK
Xi, li^.!' ('■
THIS IS A PERMANENT RECORD
„.P.R TO c.rPT.nCATEFOR.NSTRUC^ONS
/
ii)(n
J^voislcred ^^,"0,
DEPARTMENT OF TOLOEALTH-City and County of San Francisco
t '
Ccctificate of S)catb
(7n
^
PLACE OF DEATH-. — County of
City of5.Cc/^ l\AX.>^<-^^-''
^
5 II
V
and
I t
)
No.
' St* Dist.; bet. ^ ITJ -^cpecial information '\
( ,F DEATH OCCURRED IN A HOSPITAL ^ , (\ ^ C^ f|
FULL NAME
\^
.L*.c..
^ a\
'-N
PERSONAL AND STATISTICAL PARTICULARS
^ .'^-
\ > :n
\t 'Uh)
;;;;7^,CALCERT.FICATE OF DEATH
i;iK •MUM, \v"l'
-,',•, , ,; I '1 Hint! %
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1 »l I \ 111 !• R
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MAim.N NAMl
01 MU'lMll
lURTiiri.Ari.':
up
that T last ^aw h
M TIkCAISK <n- 1.1. ATM ... n. follows:
-A
DTK AT ION ^'"'^^
lf(>>>//lS
/hn
//(i/U s
Ihiv
f fours
M.D.
L?fv - ' ^ -^
TuXoyv
6
<»r<Mi'A'n»)N
.f7T>
m;'^!' nl- MY KNi)\\ l.l-.l"-'- ^ '_
Former or . ^fe
Usual Residence ^^ o
When \^as disease contraffefl,
II not at plare of deatti ?
'J^A^K^
How lonq at
Place of Oeatti
Days
f!
\\V,^\ nl- M\ K.N«'" '.' _ ^
H
I»AT1- -M !;■ HiAi. ..I KHMUVAI.
Oct ^^ TOOH
I NUlK'l
oudxLi^^
^'(E
Aje<^^'
f AilMn
.tjon^
N. B.-
M1"-^ ^DIC Y^ ,, Y PHYSICIANS should
.t.,u- CAUSE OF DEATH .n >•!• "^' ^^^„ •„, ,,„y l„»l»ncc.
,,n. dylnft away !rom home »h....l.l he s.
I ;
i 1
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;>
<r
f
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)
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I,, ,;,h I V. , ^^^«;^ !:>vl ' REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
l>nl (' nii'fl , - "-^
/ D 0
Begh.icvcd jYo,
% •-' >
De^.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "U. S. StanDarC>
\
PLACE OF DEATH: — County of
City of
\-
"^
^
1^
No.
(
St.;
Dist.; bet.
and
IF DtATH OCCURS *W*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAI. INFORMAT
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET «ND NUMBE
N )
FULL NAME
'Ci ^^
i \
PERSONAL AND STATISTICAL PARTICULARS
' <\ !,1K III
A
H
i%\
MEDICAL CERTIFICATE OF DEATH
DAiK iu iu;a'i n
(Motith)
!l):iv)
IQO \
(Vt-arl
\^>V.
M \KK III)
i ! I 1 I K t , • , , 1.- , ) ( )
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^ ^ Ml i»!
t \ 1 1! 1-.K
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M M1>1'\ N AMI
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:1
L
<XA
I III RI;HV l i:R'rirV, Tli.it I attcn.Ucl «kH\asLa fn>iu
V up i to W wU .^^L Itp 1
that I last saw h alivi-on ^ I90 ■
aii<l tliat ik-atli occurrt'il, on the datf state*! above, at
M. The CM SI", <H" i»i:.\i'll uf- '.\^ fol!o\N<:
'^^'x^rvvQ^wv
Umh^'
, \
J
A. A i
I'f Itifii ill Sutl I litlli
I»rk\ri<>N Years Mouths
C<»N rKllJI'I'oKV
I ) r R \ r H » \ ) V</;a , ^ M, mills
( SIGNED ) Lv vl' ' ' ' -
/>./rs
I /ours
/Kn
I lours
M.D.
t
IC)f5
(Address) It JAi K'ltli.'a.a.een
Special information ^ '••'^ llosijitdls, institutions, Iransifnts.
or Recent Residents, and persons d)in;) dwdv from tiome.
I O.
\ >
iH J-: \n»»vK STAT in phrsonai, pxk riiii, \ks aki: iki j. r<> rm-
m.sTni Mv Ksnwi.i iKji". \M) iu;i,n:i-
(Iiifiitmant
Wv. i.
J r. s ->■ o
n.Mkss IbHb y
D^cycU.
I
Former or
Usual Residence
When was disease contracted,
If not at place of deatli ?
HoM lonq at
Placed Death?
Di)s
n.Afi'Oi lUKiM.oK ri;m<'\\i,
I ni)i.ktakj:k
i)\i'i:.if iHHiAi. 01 ki;mo\ai.
n
/ •
(Ad.lit Hs
'1 P, ' I
•tate CAUSE OF DEATH In plein term., that it mii> He properly wia.eiiicu.
■on* dying away from horn© nhould be given In .very Inntance.
o
s
tr
>:
J
J
! I
I
D
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
11, ,it)| IN'. J ,» ■?^ar»<-(-4) Hi*^: I' *''
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
10 0\
Bp^i^sferpfl J\^o,
* > f^ i >
,tr^cc4
/VM,
DEPARTMENT bp PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
^R
n. S. StanCar^
i
PLACE OF DEATH: — County of wG-
X a_
Vs-
I
Wo. - ^ J V t ^<
u
I v^V-
St.;
Dist.; bet.
J? QTI
City of 0<xr^\j J Ax^
and
r - , = ^« lt«IIAI Pr SIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION ' \
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
'J A
On-
I <>i,(»k
r t tf lUK 1 II
I>..v
\'.|v
w I ill >\\ i:i> « »k i»i\« iK II)
'.\ ; it ' 1 11 --I H'i.i I ill »it'ti,' t 'I ill >
(^
L
cv
HIRTIIPI.ACH
N \Mi: ni
I \ ri! iR
lUK in I'l, AtJ.:
"1 I AlllJlK
^'l.iti III rinintt V
M MIM-.N N XMl'
<>l MnTIIJ.K
I'lK niiM^Aii-:
"I Morm-.K
' "^t:ili lit I'oullt I Vl
Mi'cri'A rioN
A'r'Mi/fi/ ill Siiii /'i ail: I •! <i
Qj ,C ^'^A wi
L'.i.ci.
i»\
MEDICAL CERTIFICATE OF DEATH
III Di: A I'll
' I
I go
(Year)
I iiHRKHV C IkTiFN', That I attriiiU .1 «it . rased frotn
that I last saw li ■ alive nn ' Kp '
ail. I thai .U-ath .Kaairreil, nis the ^lale -tale.l above, at
M Thi- CM SI-; <>I' hi, ATI! wa-. as follows;
Ww^
C'oNTRll'.rToRV
I )r RAT ION >''<7/v
( SIGNED ) M I LCTvLc
Months
l)a\
Hours
Mofilhs
lhi\
/lour a
M.D.
)', ii I
M,<„lh-
lhi\
Till'. MJOVI-: STAIl-n I'f-KSMNAI. I'AKTfCt I.XH-- AKI t K I l- To TH»'.
1»KST (H-- MV KNoUl.l.lx.l-; AND 151. 1, HI
niifiiinumt
\ .AsJ^^A^Js..^^
( \fMif s).
I<K'
Address) H XO ^C
SPECIAL INFORMATION nnlv tor Hospitals, Institutions, fransients,
or Recfnt Residents, and persons 6y'm »^^y '^"^ home.
f ormff «r
Usual Residence
Wfien Has disedse contracted,
If not at place of deatli ?
HoH long at
Place of Deatli ?
Days
CJ-U^Y
i> \ ii: ..: i!( KiAi. lit ki;m< >vai.
C)-C^>^^-^'^ W /ClAJ(.
INDl-KTAKKK vULaA-M^ ^
(A.l<lr<-ss Ob iX' l". XU
IC)0 \
,. , 7j;p. „H,,uld be stated EXACTLY. PHYSICIANS should
of Information should bs corefully supplied. y^ classified. The "8|.ecial Information" for psr-
E OF DEATH In plain term., that it may be prop.rly .lass.»iea.
N. B.^— Bvery Ite
•tate CAUSE v»r E#i-« ... — f - . . ^..„,..
s'in. dyinft away from home should be given ia •vry instance
P
^
ur
5<
/
I I
ii
D
. '=.:
#
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I
I
I \'
■=c^-i.i:. n^p (■
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
L.^L/v^ Deputy Health Officer
Ee^Lslc! I'd J\y),
*"»'*' '^O
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of E)catb
"U. S. StanDar^
jt
PLACE OF DEATH: — County of Jo.
City of
r'
,0^/'^X'
h <n
k .X ^^
No.
\
(
St.;
Dist.; bet.
and
ir Dt*TH OCCURS Aw*v F p o M USUAL P E S I D E N C E G I V E facts callcd for under
IF DTATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTCAO OF
SPECIAL IN
STREET AND
FORMATION' \
NUMBER. •
/^->i
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
ii .1.1 iK
(\^
Kin
LL
^f \R k I! I»
• • ' i»Kr|.;i>
L'tUltiiHl)
X
M F 111
I 1! Ik
^V, N I N_'
li'i. \i}-
ill \u.
•I i I lU 111 I
"1 M..i'in:i<
iHR riiiM, \. 1-
'>! ^ti»•l•|ll;R
'^tat, .,1 I'tnniti
MEDICAL CERTIFICATE OF DEATH
;» \ri: t»i- i>i; \'rn "^
(Veari
I HIKl-'HN' Ci;R'ril-N', Tlial 1 alu-nli .1 .k<^ a-^cd from
tliat I la-t -aw h A^^-^a ali\<- on
aii.l that ilialli . hmii rrf-l '"> \hv dati- stntt-il a!)nve. at
^r. TIr' CM'sl, Uv IM; AIM ua-. as follow^
I<lO
DC RAT ION
Ki •NTKUUTOKV
.1/
Ihus
//•■ii^
' >* >. I !■ \ rio.N
,o
11
f^'-iiir.f III Sun I
niRATIoN
SIGNED
)'(•<//
1/-
I\Us
\
\
n
I lours
M.D.
AXjXj^i^ '-'•^^
SPECIAL INFORMATION on') f*"" Hospitals, Insmutlons,
or Recent Residents, dod persons dvim] .mdv from home.
How lonq at
Plare o( Oedtti ? \
1 / ,/ 1
lA
UK \!5
)\ I' '-r \ III) I'KK'^ON \I. l'\K lUMl, ARS AR J 1' K T 1 ' 1' • 1111';
iH'>i' <(i- MN K.Nuw i.i.ix.i-; AM) bj;i.ii:f
' III I'M iisatit
li.ia.^
1 ^,
Urld'
former or (\D
Isiial Residence ■ '
When was disease contracted, /^ ^
If not at place of death? \J ■ k^ \
Transients,
Oavs
I'l \i\' ()1 lURFAI, OR RI'MkVAI,
I) \ ri-! Ill m KiAi, f>r K
;MnVAI,
1. ^ An ,.',.,iiUI he stiite.l F.X4CTLY. PHYSICIANS should
N. B.^ Every Item of inform»t!on should h, .orctuHy supplied. ^^'''r.; T' "^n^d The ^Special Informafmn" for pT-
statc CAUSE OF DEATH In plain terms, that It m»y be properly classH.ed. He »p
sons dying away from home should be J^iven in every instance.
o
^
9£
r
r
1
I I
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C^'
m^'
! ' ', IN
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
■ - ;uv.i . . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Be ^isf ('!'<'(! jYo.
'?5.'?n
•H. ^-\ •
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of IDcatb
Xi. S. JIitnn^a^^ ■
City of O CL-yx
PLACE OF DEATH: — County ot
X.'^Xj
^feXia^.a a\Xc x '• ' SU Dist.;bet. and
/ ,r DtATM OCCURS .WAY fBOM USUAL R E S I D E N C E C I V E FACTS CAtLED roR UNDER ' ^ ^^ <= I A L I N FO R M AT I O N ' \
{ "death OCCURRCD in * HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
i 1
FULL NAME
.L^'
Uc
PERSONAL AND STATISTICAL PARTICULARS
^
I'l il.i iK
' I '! i'l i; I 1!
%\
"^ 1 Li
bS
II
i •*"■« iK I I)
' \ M I or
1 X I ill R
lUK rn I'l. \i I-
'1 \ : 1 il \ NAM 1
'•1 M'tlHilK
t'.lH rm-i.An.;
""' i'' I >! Ci mill! \ I
' » ■>■' r A rn )X
/\'' :,iril III SiUi I'l iiiii ni ,1
U ^\ . i V/^
rn
0
MEDICAL CERTIFICATE OF DEATH
DA 1 K <>1 1»K \'rif
' M.iiithi
I 11 KK V:\\\ CHkTU-V, Til 11 \ a\u\vV
thai I \A<i -;i\s li •' alivi- nil W :v .... i,p ,
and that -Kalh .hcumi'.I, mi \\\v .late statud abuve, at
\\ Tlu' C \rSI'; Ol' I'l'XXril %^:i- as fnllow^:
u
1
DiRATlnN *^ )Vr/rv
C<»NTKIi;r I't'KN'
Months
Pa
1 1 on I ^
\)\ \l\'K\ < > N
(SIGNED )
)-ra,
Mouth
Ihjvs
c
/VJ\±J
d. I
w ■>
I
n
* ■,',,■ / -
\'..,'lh
in'.sT III Mv K\o\\i,i;i)(.i-; and in:iji;i'
'Iiif.i-mrmi
n %v
■^ ■ .
I \.l.lrtv.s XO
^%^rcA.t(n^ '^^-'
^rs\) \Xf\> ■ .
-N
Hours
M.D.
Kf'i
SPECIAL INFORMATION ""'^ l'"^ Hospitals Institutions, Transients,
or Recent Residents, and persons dvin-] .ih,iv from home.
^ %^ \\m lonq at
PI,iif of Deatli? Dd)s
Former or
Usual Residence
Wlien was disease contracted, '^
If not at place of death ?
|» \ ri' ot' III KIAI, (II K KM<>\ AL
KJ :
i
IQOi
lA.Mi
N
... \r,r. s'v. .1.1 be stated KX4GTLY. PHYSICIANS should
■ B. fivery Item of information should h-- cnretully suppnf . i„„;iied. The "Special Infonniitinr' ifur pur-
stote CAUSE OF DEATH m plain terms, that it may i»^ propcrl, wlass.t
sons dyinft awoy from home should be feiven in every instance.
o
'>
1 es
' \
I
H '
g
;
'iWs&-
0"
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I , IV'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
jhf/r /•7/f'^/,Let<rUt>v XX
n^oH
JU'Lii^tcred JVo,
>-T*^|
dLX^
Ut
DEPARTMENT OF PUBLIC HEALTH
City and County of San Francisco
Certificate of Beatb
.A
i 11. S. StnnDarD
PLACE OF DEATH: — County of^ CL^^ JX<x^^^Ui.c<)C{ty of ' <x->v
1 ;
y
No
5il
\
D£«TM OCCURS AWAY
IF DEATH OCCURRED
(
I T
St.; ■. Dist.;bet. -
FROM USUAL RESIDENCE GIVE FACTS called for under
N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S
\ o
and
SPECIAL INFORMATIO
TREET AND NUMBER
N )
FULL NAME
J cn">v
n
si%x
PERSONAL AND STATISTICAL PARTICULARS
• r uiKi'ii
',*
S
\\ 1 ! 11 'A r 1 t « >K 1 ( ; \i
1 ' I 1
J(
«'♦
1 \ III IK
lUK riMM.srK
'»! I \rm.:K
"^t;lt> .1] I'ouiitrv
I'.lk lui'LACj.'
<»l Miil'UKH
I State 111 (.'ountt \
'U
MEDICAL CERTIFICATE OF DEATH
DA ri'. Oh DIATH
M,,;i;: fl)ay»
I HKi<i:i!N' Ci;KrilN'. rinl I allcn.U'.l <lr<. i-.<m1 fnnil
that I la^t saw h nlivc mi i^p
aii.l tliat .Katli nrciirrLMl, on tlir d He ^tati'd a1)..ve, at
M. The CAISK OF I>i;AriI wa-^ ;i< folL-u--:
A.e;.
C^c^c t<
-A
' I'^^-^-y^W
C_<y r..^v
DlkAlloN y''<^'
CoNTRII'.rToRV
)'i (US
M,n///f<;
Pa
IV
Hoius
M^^uth
Pav
'HHTl'ATloN i* n
A'c ■•/(/;•(,' /;/
/
/
in: M'.ovi-: srA'nuM'FRsoNAi, r\K in I ' xk> aki; ik' »' i" ''•'■
u-.s'i* oi MN KN< iwi.rix .1-; \M) lu-i.n i
iiif,
tnuant
t
%
\ \
or RATION . ^
(SIGNED ) J 'J ^<^ ^ ^ ^
iO C^ X\ looH (A.hlrrss) bOb : UaX Uh. jI
M.D.
SPECIAL INFORMATION only for Hospitdls, Institutlnns. Transients,
or Recent Residents, and persons d)inq dwdv from liome.
former or
UsudI Residence
When was disease contracted,
If not at place of deatli ?
How lonq at
Place of Deatl»?
Ddvs
I'l.xi'i: <>i I'.i KIM, OK ki;m<»v\i.
A
3 ,cc>x/ '^ i w-a
nu'i
wCX
• 1- I'M or Rl%MO\' Al,
IM)1':U r \K1%K VI
'^
Ow/^rs/ J c
A, Ml ess Civj L.JLcu
n
kJ
^n
i^r^
?
r
7
J ,. , ^.pp should he stnteil f.X \CTLY. PHYSICIANH nhcuild
IS. B. Every 'item o»' InfTm.itJon shouhl be ciirut'ully supplied. A . , ■ ^^ *'Speciol Intformrtl'ion" lor p*r-
stutc CAUSE OF DEATH in pluin term«, that !t may he pn.perly .luHH.^.ed.
«nng dyinft away ?rom home Hhculil he ft^en in every instance.
I > I
5
. -to'
CJ
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I V.
t"- w-^v USil- Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihffr Fi/fff, U/tl^-lMA' 1^
IfJOH
liei^islered JS'^o.
2532
1
^v.c<^ Cc\>t{,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of X
Certificate of ©eatb
->v J,MX\xcc<lco Gty of '^^CU>v J ^^
CL'V^^C^.^.^ 0
No.
L
St.; H Dist.; bet. I fla vklt
and
\r vn
ptATH OCCURS AWAV TROM USUAL R E S I D E N C E G I V T FACTS CAtLCD TOR UNDER 'SPECIAL INFORMATION' \
,ir DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD Qt STREET AND NUMBER. /
t
FULL NAME
Lc^q^c<r>\j )
riTUTION GIVE ITS NAME INSTEAD Qf
PERSONAL AND STATISTICAL PARTICULARS
A * ri»l,<tK >
llcul
I
UikJj.
MEDICAL CERTIFICATE OF DEATH
I) \ ri; I ii- i>i;a rn
,c,t
lilK 111
M,,'!li \
/i)^0
\i .1-:
14
\
II. I \
M. ii'li
I hi
■-l^< .1,1" M \K k 11- I>
uilHiWHIi «>K 1 1 ;\ I tpr f.' t)
'Write in •mki.,1 tli^ii'iiatii>ii J
Mit t \
lUHrnv
1 x rm-.K
Hiki'iiiM.ArH
'>i 1 xrin-.K
' St ifi (ir I'oiiiiti \-
^! \ii>i:n- n amf
<'i Mtrrm-.R
Ill Md'lIIl'.K
' '^t.itt ,,t Countryi
4 I
1
(Yt'iiri
I HI';Ui:i5\ (.l-.RTJI'V, 'i'!i:ii I atton-kd dcrcascl fr.Mii
U at' "XX 190H t.i .. :t 3>X i()oH
that I last saw h^A^x alive oil i:^ 9.:^ SO^OllNfYL iqo 1
an.l that .k-ath .xTurrcd, nii the «lalc stali-.l almvc. at 10 60
LL M. The CM "^1; <>!' l)i: A Til was as follows:
a
1 A^'
-vUvu LiA-tXrV^Li
Dl KATION )V./r
CONTRIIU TORY
)V</rj
MouthR
Pavs 1 3» Hour
X
Pax
s
//oNf.s
/yy^<ry\A>
'HC\-i'A rioN
/\r' !iilil 1)1 V,,i>; /'itlllil
AAxwvx^
cu
- )■,•,,, ^ ^ yf,.„'ln
/hn
nrRATioN
(SIGNED) U,/a,LL<3u<:^ b. ^'in^txttcr>v M.D.
SPECIAL INFORMATION (*nh lor HospitdK. Insfifutions, Transients,
or Recent Residents, and persons dying amy Uom home.
'in: Ai'.uvK sT^ri:i> i'j.:ks()\ai. r \r rur!, ars aki" ikth t«> thh
lUCST <)!• MY KNOW 1,1; IX '.I-: .\NI) Hi;!,!!'.!*
(Infotinaiit
jjU^tpw 'h. n<>«rtt
^i
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Plareof Death?
Days
Vl ACK <)l- niRIAL OH ki:M<»\AI,
n
INDHKTAKKK UW
DAIi; ,1? lu Hi.vi, or R1-;M()VAF,
IQOH
(A(l(li«.->*s
i9^ XH
^0/
l) ,. , 73,p «u„,,i,| he Rtated liXACTLY. PHYSICIANS should
IS. B.—Every Item of Information should b. carefully BuppI.ed J'^^^^^^Z^^^^^^^^^ ..gpe.lal ln»orm»tlo„" for p-r-
state CAUSE OF DEATH In pliiln terms, that it may be properly ciassmcu.
«?>ns dyinft away from home should be ^iven In every Instance.
! I
1 1
1; I
r )
WRITE PLAINLY WITH UNFADING INK-— THIS IS A PERMANENT RECORD
1
■h IN' ■■ 'r-l' ■»•■'—« 1'.^ l ''"
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'n
IXtfr ri/('f/,V^tAMXj 1%
IDOH
Uvilislered JS^o.
533
i.*.w^ \
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDcatb
11. S. StanDar^
-<
PLACE OF DEATH: — County of ^
City of' '^
V^
"%
No.
•^ J WW
f
(Q
v., u
±\
St.; ^ Dist.; bet. n Ov and
/ ir Dt*T4< OCCURS *vwiiy from USUAL RES I DE NCE gi ve rACTS called for under "special information • \
I. ir DBATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
Xi) i-k
FULL NAME
+
(H.*..
HI S
PERSONAL AND STATISTICAL PARTICULARS
» f I i , I I K
-t
\ lUK r
M
Ii:i%
\«.i-;
'11 M \ k i< n I
>| |\\ 1 I > < IK I I
^\ : it ' It) >«i M la ! ■ ,
0
It
.111)
HIH I III'!, Xi'l-
N \M1' ( i|
F \ 1 II IH
I'THI'I, Ai'H
I \ III KK
' '■ • ' i! t'tiiilltl \-
M Ximx X AMI-
'>! MolIll'.K
I'.'H III I' I. Ail-;
"I MoI'llMK
— s.
^
r^
O.'
r^xj Ji
^
ct^.^i
> ^^<1j
(Vf-ai •
MEDICAL CERTIFICATE OF DEATH
I) \ t'l: (>i i>i:a rn
\i,iiu!i> (Day)
1 IIi;Ui;P.\' Li;kTll'V. That I attiiuUa .U-«nasr.l from
tliat I last -,a\v h wH* alivf oil W.C.4J 3^3^ Kp'^
aii<l that (liath < »(riirre<l, < m thi-diitr Ntatcal ahovi-, at i
M. Thi- ( AISK or I)l'.\l'll wa--- as follow^:
I)( R.\ TK 'N
y,,,,
Months tl /hn"^ HoHts
wW >\jL
if
_ , w4.
r^
<>^ » I I'Ai ION
l\f>hlftl ill Siiii I I iiii
zx?U^<
n
CdNTRIHrTokV \/U j^wK/wlXa^ , <X , ^
^ — ^ I
1)1' RATION Yiiirs ^louths Pa
(SIGNED )vd^e-0 ■ ' ■^>
rv
/ fun IS
M.D.
SPECIAL INFORMATION "ilv fnr HospUdls. InsMtutions, friinsipnts.
or Recent Residents, and persons dyinq dv^dv Irom tiome.
> ,,/;
»-' M.iiith-
III 1 \novi sr \ ii:t) i'Hksox w, fXKTirn.ARs a hi; ikih i<» iin;
\n'.wi' ()i_Mv KN(>\vi,i:iK.i-; am> iu;i.ii;i-
(Inf.,
inatit
' \
.MrcsH Q*Db(p Jj .h.^cy1X^v\X OXI
Former or
IsudI Residence
Wlien was disease contrdfted,
If not at Blare of death ?
How lonq at
Place of Deatfi ?
Days
i'i.acj: ni luHiAi. <iK ki:m<>vai.
nsri", (it lliKiAl, or KlCMoX \F,
ni.i;ktakhk U a..U/n±l rrLoAA.-ru^ ^< V^
(A.Micss IS 3.H c\t^^
"""""""""""""""^ TrF .Hnuld be stilted EXACTLY. PHYSICIANS nhould
N. B. Bvery Item of informntfon ahould be cnrefully HuppI.ed. ^i^n s^ ,|«„if|cd The "Special Informati.m' for p«r-
•tate CAUSE OF DEATH In pli.in term*, that it mnj be properly UaMifica.
nnn% dylnft away from home Hhoiild be 0sen \n every Instance.
I'
■fell
#f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dftfc File<l ,
a?^
190H
Rp^i.slervfl A^o,
2534
I
1
Deputy Health Officer
DEPARTMENT^OF PUBLIC HEALTH^City and County of San Francisco
Ccvtificate of IDcatb
( "U. S. i5tnn^ar^ i
PLACE OF DEATH; — County of a/rv 0Xa^\.cc4Cc City of " vv J ^a^rv^^ixi^o
No. ' S ^ CLK St.; R Dist.;bet. K ■ L^ad^Ao and'/BA^cil^^ek )
(ir DEATH OCCURS AWAY rROM USUAL RESIDENCE Givr facts calltd tor under "special INTORMATION ' N
If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^1 F\c\4^ LLywtu L
PERSONAL AND STATISTICAL PARTICULARS
Ul ..Xl
3
&y
'•1 HIKIH
A
M,.mh>
(imy)
/ DO t
A ".I-;
1 1
)V.;
n
M.„i/i
I hi
-iN<.i.jv M\Ri<n:i)
\ Mm .\\ I'!) UK iJiVoRTKIi
lUNTiUM. \K'V
-n «,
X^
.4
%_ <w s.
N \M1 <)1
1 A rHi:R
"' 1 AIHKR
~-l ill ,1! I', Hint! V
".' m<iihi;r
'HR IHIM.Ari--
"i MoTllKk
Mati oi Coumr\
'^VCCL;
(Mnlltll)
(Y.ar)
MEDICAL CERTIFICATE OF DEATH
I) A l'l^ ( il ni' \ Til
il):ivi
I 1I!:RI;1!V CIIRTU'V, Th.-it I atlciidcil (Irria-tMl from
•.A 190H to iyct XX i.pH
that I la^t saw \\JJ\j alivi- on ^~ cD %,% itpH
aiiil th;it death (UHnirred, (Ui llie datr stated ahovf, a1 I oO
U. M. The CAI'SK OF DKA I'll was as follows:
^<jt\XLl ^kjtax^^c^' t - t.
rvx)
} 1,1,
i\
. i
c
^ \.>
?
vxXl
DC RATION
Mouths
/h2\
'.V
Hours
ii
< KAll
•AllUN^
r' W W U O.
L \ SJX.
Dr RATION Vt'ars
(SIGNED) U
Months
/hivs
i]X.% ^ L-vv
(0 1
I louts
M.D.
t^ %% iqoH (Address) (3 15 iaA^frtl^M<iq
Ions, Transients,
SPECIAL INFORMATION onlv for Hospitals, Instituf
or Recent Residents, and persons dylnq awdv from liomc.
Ihr,^
Former or 1 , . -1 li J
Isual Residence 1 1 0 i w^
/aVx \%
HoH long at y
Plareof Death? 1
. Oavs
When was disease contracted,
If not at place of death?
i)Ari;iif m K'lAi. or rkmowai,
iLct IH IQ0I
I 111 Aijovi-: sr \ 1) n i-kr«>nai, i'\k i rrn.ARs ari; tri k i'») thh
in-.'si'Dj. ^^^^• KN( )\\ij iM .J.; AM) in;i,n:F
^u.i.h.s. ilOL \;oJA nt
N. B._Kvery item o? i„?„rm«tlon .houlcl be carefully supplied. AGE should be stated EXACTLY PHYSICL4NS should
•tote CAUSE OF DEATH in pinin terms, that It may be properly wiosslfied. The Special Information tor p«r-
«nn» dying away from home should be ^iven in every instance.
I'l.ACK OI" lURIAI, OK K1:M<)VAI,
I i
ji !
\\
i ,
s7^
• -^
I . ij^L
•1^
»f
imi
'ii
t '
r
J
T
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,), J N-,> ^T*^-; l!M'< o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/hf/r /'VA'^/.lLet^rlMA.. a^
hjoh
Ju'oisf crrd JVo.
^585
X<r^c^ Deputy H^-^'**^ /-.«^..^..
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of IDeath
PLACE OF DEATH: — County of o. >x
r
10 City of ' O
A.
iNo. .
at
tTY^w.0.
St.: ^ Dist;bet.
i *■ .-
and
^Ol.4.C0
I t '
(IF Dt*TH OCCURS Aw«v TROM USUAL RESIDENCE give facts called for under special information \
\r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
. .{rr
PERSONAL AND STATISTICAL PARTICULARS
) ' '! i';k i 11
rlX^
1 /
N! \R Is ii:i»
1 I • I iR I> i\'UK I !
'! I'l. \i'K
1 A in IK
niR IHIM. Ai-H
' " I X I IIKK
""■'■■ • it *'i mti!! \
A' Mill N WMF
"1 MoTIII'.k
MEDICAL CERTIFICATE OF DEATH
!■ \ ij. 1 .1- III: \ I H
,-» I 11 "-J
A» • /on \
M nth' :< . > iV- !!>
I IIKKKHV t i:rTII'V, That [ attiMKh-.l .!v .-a frnni
that I la-t h;i\v h —— alive nn Kp "" —
aiiil that (Uath <Maiirre<l, nii tht- <! ati --tatcil above, at •
~ M Till- CWrSh; <)1' Dl-; ATII wa-; as foII.i\v<:
K. 'XXxn.KXaX, )b_^<x>xl> i^.^cu^CK-AJL
'•IK rillM.AOH
"1 Mot I IKK
\,tL<x-vxd
DIRATION )'riirs Months Pais
fONTKIUrTORV
DTK AT ION Years Mouths Days
llotd s
( SIG
NED)L6^^viA; J ^i^.Uj-ixLa^^
I/i'UI s
M.D.
\ ' A
__ /\f:ii/t'if in San / i ,; ii, / ,-,i ^0 ) > '" * *"
I Hi: \m)VK STATi:i) I'Kk'^oN \l. I'XKTIiri.AKS ARi: IK! !■: T
•n-.sT <u mvkn<>\vi,i;d(,i-; wd hhmi:f
'' ' " f"' '"■' nt J AX)L^Ok A rvv^.>^y-
r^d. I<)0
H (Achlre^s) L^\,e^wUxA L 4f-t.>gX
SPECIAL INFORMATION o"') for Hospitals, InstifuHtffis, Transients,
or Recent Residents, and persons dyinq av»dy from home.
M.'f'h
•JO \\\V
^\<lclrcss
Usual Residence I Ul
When was disease contracted,
If not at place of death ?
.. Days
I'LACi^ <>I^ lU KI\r, <»H RHMOVAI, | DATK of HrRi.u. m KHM<>V\I.
Uvo-^^
X'h
IQOH
/o
INDKRTAKKR
^'(Lm,VU
rAd.hvss ix:?^^ ^yutxhjkd. t
*. „ ... Af F «ho,.lH he Atated EX4CTLY. PHYSICIANS should
N. B._Eveny Iten, of Information should he CBr^fuM^ «uppl.ed ^^^f^ J^^^/^^,,^^^^^^^ .8,„,ia, Information" »o. p-r-
•tate CAUSE OF DEATH In plain terms, that It may he properly ciaasiTieu.
iion« dying away from home should be ftiven In ssnry Instance.
I I
Ii
' i I
Ii
^
rJ
^\
S
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i V. -^■-■■'v^i. ]:K]' r.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^,<
A
M
ill
DEPARTMENT OF PUBLIC HEALTH
It('gi.sl('i-C(l v\V;.
2.^
536
City and County of San Francisco
Certificate of Bcatb
( XI. S. Gtan^a^^ i
Q^
PLACE OF DEATH: — County of
a^rxcc^ec City of' ia.y\> J VcXwac-^Uio
JVa
No, KXyy^sXh^,<xX L-\>f^juxx^\-^<ii,^ fi^. St.; Dist,; l^t. and
(ir DtiiTM oc«uBS *«M>Y TROM USUAL RESIDENCE give facts called for under special information "^
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. /
rv
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
« '< »i.t Ik s
M 1 LclL^
■ iUK I Jl
i
■ '^r\KKx^ WoXXxXL
\
1\
r%X?s
I N! ARH 111)
■ 1 ' < »H 1 i;\nKi*i-:f)
• Mia ; ,1, ^i^fiatititi)
%
lA
IT
r
m
■ ^ M 1 I IF
ink iiii'i, \(K
"! I \ 111 Ik
' * I >iiiit t \
M \II>i;x N \MF
<»1 .MnTlli'k
'Hk Illl'I.MK
J'l- MuTHHk
^tsit« i>r Cotuifrv
'• ' I i'\ riox
n
^
MEDICAL CERTIFICATE OF DEATH
DA 11, t li |));ATH
\i Mill il):ivi iNVari
I H I'lR i;i'.\" (, ! RTll'V, That I .iIIi'IkIlmI .lt-<va--i'd frniii
, — -lip— to — -— — ICp —
that I la'^-t ^a\v h :-^ — - aHvt' on - — — ■ Itp
and that (k-atli iirrisrrcil, on thr datr state. 1 ahnvf, at
M. Thi- CAISI-; (>1 I)i;AriI wa^ as follows:
. 1 /n ( Kit
•„ C\ ^- > U-i-^VXX^
<xXA^a' k tA\,t
,<vA.
i
U
UjUL4jlLu aD ClLLi tt
^
jj O^^fer^x^'M ilctC4.
1)1 k.\ri<»N )v,//s
CnNTRflUToKN'
MoHlhs
fhtv
Hours
Ihn
-\ J
V<XuJ-
c
K,
(SIGNED )Le\e>\JA' 4 ^MA: J-cLo-vwci
/foia
M.D.
SPECIAL INFORMATION "nly for Hosplfa
or Recent Residents, and persons dyinq dWHv from tiome.
Ifafs, Inslinjftons, T
Former or
Usual Residence
/qX
,>CL.t:A
CJy L j HoH lonq at
IU.IKX.1 Place of Death?
Transients,
Biys
h'fhh'ff III Sun I'lnmint 5S )>'<.'<> M.oilh
Inn
nil; sijovK SIX III, ckr^onai. i»ak ikm-i. aks aki-: tki k t<> thi-:
IU;ST ()!■ M^- KNn\VM.;i)«,H AND lU'.I.Ii:!'
Wlien was disease contracted,
If not at place of deatli ?
I'I,A<'i; "1 lU KIAI, OR Ri;M<t\'M,
flnf.ifinriut
^
c
UXX-uXt
I»\ri .,'' lit KiAi, or KHMu\'AI,
VDKRT A K H K ^J t ) >VCU 1 ^ V V^
fAd.uiss ^S" ?:i - "iSl
■.),Ci_
.. , Ar-F _h«,.lrl he -tntecl EXACTLY. PHYSICIANS Hhuuld
OF DEATH In plain terms, thnt it miiy be properly wiaMiiieu.
N. B." Rvery Item of
•tate CAUSE _. ^
•on* dying away from home should be given In ©very Instance.
\
sd
f
t
{
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
P.oat.l i,f il. -Ith ! N".>^ i^ •$-T'^s^^ uScV Co
Da/c /'V/^^^/A'ct<rt-t\; li
190 H
Regi^lcred J\'*o.
2537
CV^HwCU^ dLtAj-t
\jL
\
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of 2)catb
XX. S. 5tanC»arC» )
(^
PLACE OF DEATH: — County of '^ CbY\. JXCL/WC/^CC City of^<X./y^^ J \.<X/^^'<Xxlco
Hi
Wu
, Lctc, ^ K.t\.<.rJuA. ?o CM^kAi:
CL^
St.;
Dist.; bet.
and
S AWAY FROM USUAL RESIDENCE give facts called for under "special INFORMATION" \
IF DEATH OcduRRCD IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. •
FULL NAME
H
.L±\
\}
YX VUO^^Uj
o.
PERSONAL AND STATISTICAL PARTICULARS
Hl.\
1 »!.( )K
> . r VVCVU
^Li
nAi"j-;
nl IMKllI %
IS-
M.nthl I.
(Day)
rll'l
MEDICAL CERTIFICATE OF DEATH
DATH Ul< DKATII
il'ct
A«'. J*.
•J }|■,u^ ^
M,,„th^
1
War)
Pa
SINr.ii- \!AKUIi:i»
'Uiittin -^iiiial ih --iv nalinii i
10
ccMrMj-<^
A
luK rin'i, \rj"
I St.iti- I ii * ■ III nl ! s
N \M! <»I-
I- ATI! )■ R
HIKTm'I.ACK
(H- I'AI'IIIR
istiitt' 1 .1 r. .uiit I \
<>i- Mo'nn-'.k
HiR rniM, \ci-;
<»l. Mn'inilR
(Stall' i»r loiinHy
(HHTI'A'l'lON
IL' ,et 1 D
%% /QoH.
(Month) (Day) (Year)
I lll':Ki':BV CI'RTII'V, That I alteiuUMl .krcascMl from
190'^ to w cfc 2.x ^ifO^
that 1 last saw li-\' alive 011 ii/ ct XX upH
and that (U-atli orciirre<l, 011 the <late stated al)ove, at D oO
L\ M. The CAISP: OI- !)I:.\'I"I! was as follows:
U>''Y%J„U^
s-^^
L Ol >x dc
or RAT ION )'tars
CONTRIIH'TORV
."i/oni/is
t^tK^^X^
£>m's
Hours
<xJj....^jjaA
%
xxM^o^y\j
\.L-L<xaa^
DTRATION
(SIGNED )
Yjiars
Months /hivs
//ou
rs
C.et 3.3^ iqoH (Address) UIm H Lo
fe
M.D.
^M-'
SPECIAL INFORMATION only for Hospitals, Institutions,
or Recent Residents, and persons dylny away from fiome.
xt
ransients.
Former or ,
Usual Residence I b
rt
OJvXXj ^t
How lonq at
Place of Deatli? \X Davs
A'/'Mii/'if lit Sill) /'i ii 11, /--iir \0
M.'uth^
Ih
When was disease contracted.
If not at place of deatfi ?
Tin; \ii(»\i\ sr \ I'l'D I'KRsnNAi, I'AK'iii'ri, \Rs ARi; iRi 1:
liHsT 01 MV KNnWM'JX'.H ANF) \\\'.\.\V.
!IiifM!iiiant
111 IFIK
( \(Mri-«H
Uiii '■'^ Lc fe CKA\.AjLa,l
INDliRTAKHK M/l 0 A./y\/W Jj.
TQOH
I'l.^CK OF ntKIAT. OK RKMoVAI, I DATi; of Hi rial or KKMnVAI,
(Adc
N. B. Kvery Item of Informiition mHouIcI be cnrefully Kupplied. ACJR should be atnted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In pinin tcrm», that it may be properly classified. The "Special information** for per-
sons dyin^ away from home should be i^iven in every instance.
mm
I '
)1
n
•#
m'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l; :,!,! ..f II. iiMh \ N<. i- ^'^.71:^^ i'^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r /v/^v/, ALict^rUtA-. a^
IfJO'i
Jieffis/ej'cd J[^o.
2"^
538
^
<5UCA.
.VHJ
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of a
Certificate of S)eatb
( U. 5. StanDarD )
J? ''-1 -f I P I
'^<tci^ LL<XH.<X' City of oL^<i' '-l/tCto-^ LaA)
No.
St.;
Dist.; bet.
and
/ IF Dt*TH OCCURS AW«V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME yCl'»vi<i. \D, jLiA^U5AXtr>\;
)
- 1 \
PERSONAL AND STATISTICAL PARTICULARS
(MioK
^^]
IxU
J-
'XjJjL
liAl'l-: < il lUK 111
M, iillli
JV,/
I):i\'
M„vlln
(Vt-ar)
/5./ I A
H!N«- I,K, MAKH Il'H
WinoWl.'Ii OK D'Xi iRiJJ)
(\Viit< ii! -(Ri;il iltsiviuitinii)
,L
HIK I'Hl'l. \i*K
( State ct »"' intitr\')
NAM J- ni.
J- Al H KR
HIRTU I'l.ArK
<)i i\rm:K
I Sljiti <n I'duiit! N
M Aini'.N N \\\\\
<>l MorillCK
niK'ni!M,A('K,
of- M()iiii-;k
(St:it<' or Cinintiy
MEDICAL CERTIFICATE OF DEATH
DA TH ill- 1)1;ATH .
(Month) (Day) (Year)
I HF.Ri;m' CI<:RTIFV, That I attciKkMl (U'ooased fruiii
Kp to IqO —
til at I last saw h alive on Itp
and that death ocnirrcd, <«n the dati- stated above, at
M. The CAl SI-: OF DICATII was as follows:
Q^hoJLo. .
Lcd.(
0^
\XKKjy\X
i
^A
1)1 RATION Years
CONTRIiaTORV
Motiths
Davs
Hours
DTRATION
(SIGNED
Years
Mouths
Pays
Hi
ours
,4iQrn":,..lU[l
r()0
(Address) <X,d-0/ J/OXo-^ K.<uL
M.D.
'(Xa'ucL
ov'cri'A rioN
C,
/\'f^it/fif III Stnl /■') ilHi irn
) I'll I
M,;,ll,'
fhn
THK AnovK ST \ ri-.n pkksonai. p \h rieciAKs arh trtk to tiik
H1-:ST Ol-' MS KN«»\\I,i;d<',K AND lU'IJlU-'
i\
(InrDtmant
%.
r-vciAX^rw
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or ^ M 4 if ^^^ '*'"'' **
Isual Residence '^^ J/CU^O vCtA^ piare of Death?
Days
Wfien was disease contracted,
If not at place of death?
ri.ACi: Ol* lU RIAI, t)R R1:m<i\AI, | DAri;..f nimu or rkmovai,
&^ a.H 190 H
'flU^(^iu, Ia,
INDKRTAKKR
A
V - o /cUXoc^ 'VA.il^ Co
(Addtess \J XO- S tJLL-Jl
N. B. Every Item of Information should be carefully supplied. AGB should he stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for per-
sons dylnft away from home nhould be given In every instance.
|! I
^1
)
£1
K1
J
tif
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M. !li IV'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/^' ri/rf/,VckA}<> '^.^
IfJOH
Be^istcred J\^o.
25
539
^
L^cc "". M Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of "Death
( "U. S. StanOarc* j
No
PLACE OF DEATH: — County of' a-rv J \xxJy^J:AAJ^ City of ^^ tx^^ J Xxi/vxecA/Ca
Dist.;bet. and
USUAL RESIDENCE give facts called roR under "special information ■ \
~ INSTEAD OF STREET AND NUMBER. /
St.;
/ IF DEATH OCCURS AWAt FROM USUAL R E S I D E N 1 1 G I V E FACTS CALLtu
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME
FULL NAME
.y
^
mx-
^1
{S-tkl«^K;
PERSONAL AND STATISTICAL PARTICULARS
SI- \
{w
DAii: t>i lUK ni
COI.oR 1
rvo
L
M.mth
At,H
uU>t bS"
3k^
1/,»,/,^l
M^
\ ('at
/),/l^
HINT. I, K MAKHIHD
\Vn>(>\Vi:i» OK 1>!N'»»R> }'f>
iWritfin -uial lU— is.'nat inn '
r
>v<:i/
BiR rm-i. Xi'i-:
'Sf.iti or I'lMintiy
^•\^T^• oi
1 Alii l.K
HIKIHl'I.AOH
OI* I AI'IIKK
•Statt' iir Couiili >
M \ii»i;n NAMI-
Ol' MOTHHK
lURTm-i.ArH
OK motiii;k
(state or I'luuitrv 1
MEDICAL CERTIFICATE OF DEATH
DATli Ot' DKATH 1
f Mouth) 'Day) (Vfar<
I HIUslU^V CliRTli'V, That I attcii(U«l iltMH-aseil from
L- Cb 1^ 190 H to iL^/ct -Xl \cp*i
that I last saw h-inr)r\ alive on ^ cfc X
l)0 1
Tip
and that (k-alh occiirrt-il, on the dati- stated above, at ^
'J M The CATS!' OI- DKATII wa^^ as follows:
?
'XXXrY\ju{
^
3Jk.M^^y>-
X\/YW<XA
1
DT RATION )'t'iirs J/ort/Zts Days
C ( ) N T R I BUTO R V ^Xa^lOAX^ J iXudxtuJ^
//ours
DIRATIOX
)'t'ars
(Signed) \lil J 'lfc^fvluA^
W/cJt . iqnl (Address) ^J-JA^vwam/ lljO-^utaE
//ours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Rf^iifni •>! S,;n /■> <iiii>u-i) — ) ''i?
*" M.infh^ " I
Tin- \HovK sr\'n-i) i-kksonai, pAKrurLAKs akI'; TKrK To rnH
liKST Ol' MV KN<>\VI,i;i)C.K ANI) i!i:i,tj;F
(Iiifoiinatit
h
XWWCL,
VN.
\.l<lli'
\ , now lonq at
t Place of Deatli?
Former or .A^ln f« ^J- How lonq at
Usual Residence b JLO Uja^-^Vwxi
When was disease contracted,
If not at place of death?
Days
iM \CF t)i" mi^iAi, oR ri;mo\ai, I i)\ri:<»f lUKiAt, or rkmovai.
INDl'.R TAKI-.K
■ Muss 11 5H ' mjUAA,fr>v "dt
N B —Rvery item of information should be cnrafully Mupplled. AGE should be «t„tcd RXACTLY PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly damnified. The "Special Informat.on" for p.r-
sons dylnft away from home should be j^lven in every instance.
> A
i
jn*^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Deputy Health Officer
!.»'
Re^istci'cd J\^o.
2539
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cci'tificate of H)catb
( "U. S. StanDarD j
(^
^ 4 -^ 1 c
PLACE OF DEATH: — County of Hl^^ J \.a.>vCL4cu3 City of ^ CV>v J V>ct'>vcui.cx>
No.
V\JY\\,<Xy\j
\D 0"M vCtxx^
St.;
Dist.; bet.
and
(IF DEATH OCCURS AW*1f FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
%f DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.0
(YYXj C
<KL
.Lhj
PERSONAL AND STATISTICAL PARTICULARS
I) A ri:
>i HI Kill
.Mouth)
XX
\' .1-;
^4>t (dS
) ■»•(,• t » "■
M.mlln
M'x
\ I a I
fh,
(Year)
^INf.l.l" M \KH n:i)
\v n >t I \v i; I » OR 1 ) i \'( » K I ■ i: !)
HIKTHl'I, M'l-:
'Statt- or t'l Hint i \'
NXMr: iH
I ATIIKR
luk rm-i, AtH
Of 1 A rm-.K
• st.'iii- or I'liimt 1 \' '
M MDI'.N N'AMl-;
<)1 MOTIIHK
HIKTMl't.ACK
or MoTHHK
fStatf or Conntrv)
<tCCri'Ari(JN J? ft
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATII // A
Dtt ii
(Month) (Day)
I m^RI'HV CI;kTII'V, riiat l attiiKliMl .UMvascd from
L- Cti )3> lyO H to \i.'/0t ^l loot
that I last saw h L'V*\ alive on U.CAJ 2.1 190 S
ati<l that iKatli ncciirrcd, on the date stati-d ahove, at b
'j M. The CAfSIC (>!• DKATII was as follows:
1
1
niRATION
CONTRIIU "I
) V(/;\T
Months
Days
OKV cL
X.OJ
I lout s
) cats
Kf sided ID Salt / iiitni rii *• ) lii
DTK AT ION
(SIGNED) Xjll. J. 'otc^vL
vlMlij %{ T90H (Address) O,
Mouths Pays Hours
Kjy\A M.D.
SPECIAL INFORMATION nnlv for Hospitals Institutions. Translfnts.
or Recent Residents, and persons dying away from lioine.
Former or / « . j n | « "!^x How lonq at
Usual Residence
bXO
Place of Deatli ?
Days
M.nilh^ - lui
Tin-: AHovK sr\ri;T) i'Kksowi, pxhtu ri, \rs aki-; tkih 10 rm-:
I'.Hsr oi- MY kno\vm;i)<.h and in:i,ri;F
(1 11 forma nt
h
X>wvs.^x,
y\
ulo CH^^a.,tQJb
r\(Mics« —f?
Wfien was disease contracted,
If not at place of death ?
I'I,ACR OF lU KIAI, OK KI;MoVAJ, I liXIJ of IJikiai, «.r KJCMoVAI
N. B. F.very item of information ahnuld be carefully supplied. AGE nhould he ntnted EXACTLY. PHYHiCIAINS nhould
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be given In 9\9ry instance.
( ,
t
3
•I'
w
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
if H<:ilth- !•■ No
«w^%.
I'.i^V c
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r F//('(/,h^itA)
>~t\j X%
190H
gistevecl JSTo,
2540 1
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(
F DEATH
Certificate of Beatb
( XX. S. StanOat? )
QST)
L,' 0
A R Dist: bet. 0 .Utt-
i
J
PLACE OF DEATH: — County ofUcuru Jxcxy^vc^NLCc City oi -o^^^^^ h^xx^^c^^uiycvo
No. 5 m • W q Jc St.: R Dist.: bet. 0 .Utl'YWOVi and luL WtiK^
OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO
IF DtJiTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
" )
(B
n
FULL NAME JiCXAxx.
]
,Uu^
t,
vvt^A^cnv
SIX
PERSONAL AND STATISTICAL PARTICULARS
h
i> All. ( )i liiK rii
l0Jv.i^
^A^l
(Year)
\<.i.;
bS
)•,-,/
{,
1 I):iv
M.niiln
I Vtar)
Aj i:
'-IN'. I, I". MAkHIia*
W 1 1 >« > W }•■ I > OK I > I \'« > K V ■ i; I )
iWlMiin ~iirial ^ 1. -,! v> ii:il n ill )
\(:sSK^^^^<i^
HIK rUlM.AOK
(Statf or Ciiuntrv
X\MI MI
1 A in IK
lUR'nilM.ACH
')! I ArilllK
' Stat I 1 ir l"<)uiilr%'
MAiniN NAM1-;
<»I MoTHllK
IHRTIIIM.Al'H
<)1 Moi'UKK
' Stati or I'oniiti \
oi'cri'A ri()N(7tv>'
rs
% CMjX^no. M I 1/Ol^^
MEDICAL CERTIFICATE OF DEATH
f>!imtli) (Day)
I Ill'kl-I'.V Cl'RTll'V, That I attcn<lo<l (Uocased from
ifWj C CA/ ^l upH to 190
that I last saw h-^^' alive on vLvCAj 3^,1 I90 H
ami that (U-ath ocrurred, on the clat«.' statetl above, at
S5^
M. The CAISI-: OI- DI-ATII was as follows
Jx4.k;
^
<XUu
I) r RATION }'t'(irs
CoNTRinrToRV
Mouths
Days
//on
/ \
9-
\
^
DIRATION
Wars
Mo)ith>
/hns
(Signed) ^i LAj. fltD-u^irru>u
iiicfc 13l iooH (A.hlress) X'S'l'me^Lt k
Iloni s
M.D.
J cuAJKvaAM.'>v irLcm^
0 ^^K^'UJ^.KrdUi
f\'r-itli',f III Sail /•iiiiiii'-f'n jV ) i d i
M.niths
Ihiv,
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying anay from liome.
former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli ?
How lonq at
Place of Of atli ?
Days
THI-; ABOVF. ST^Tl'Ii I'KKSONAI, I'ARTICr I,A KS AK V.
ni.:ST Ol' MV KNOW'M'.IX'.K AND iu:i,n.l
IRIK To TIIK
(I
nf...ina!il 0-^^ vj^. \j\J<XXX/S\xkX''y^'
(Arid
rcss
SOI
u (^-ULcav 0 xxXx LIaM.
Pl.ACE OF niRIAI, OR RKMOVAI. I I) ATK of niHiAi. ,.r KICMoVAl,
l-NDHRTAKKR ot Aj . " J XLUv4jbVu
(Adche... ail QfH' (]LlLu.tiA, ii
N. B.^— Every Item of Information •hould be carefully supplied. AG6 tihould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "St>ec!al Information'* for psr-
sons dylnft away from home should be given in every instance.
:>
. «i
A
V
i ■
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hnnrcl of Hcalt h I " No. \ ~ ■*T.^«ii%) I'-S: P Co
/)((/(' FiJet/ ,
(
.Cruu^
>^J X^
r.^
WO'i
Besjfis/r/'ed A^o.
2541
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "a. 5. StanDarD )
PLACE OF DEATH: — County of XUyv J AXXAA^*_<u^o City of ^^/CU^v J ,»
J( (1^
>L/<X/W<X4XU)
No. 1 ?5 5 J XXckX lU^
iL
f
'St.; 5^ Dist.;bct. 3-0 t^u
I-
and
ai^i:.
(IF Dt*TH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.try\.CL/s
%/0^'
d.
PERSONAL AND STATISTICAL PARTICULARS
CL
L
d^A^jJjL
MEDICAL CERTIFICATE OF DEATH
DATH <>i- j>i;atu
:» \ I!-: or hiki-ii
ACH
Moiilh)
bl
)%
3)
(I):ivi
M.mfh^
A\^
■:ir)
I'l
Iht
'^IN'*.!.!" MARRIl-.U
\VFH(»U i;i( r»K l»!\t»Ui HI)
IWlit' in -mial il(-tK<1l»tion)
lURrill'l, \»"1-.
'State or <.i.imti \
(Month)
la
(Dav)
(Vear^
I III':RI:i;V CI{RTI1'V, That I atteiukMl deocased from
m\\ojv 'i 190M t.. li)'C^ "kX lyoH
that I last saw h-L/Vv\ alive oil U'C-tT Xi 190 H
ami that (Uatli orcurrcil, on the date stated above, at 11 H^
Cx M. The CAISK ()!• DKATIt was as follows:
NAM I' OF
I athi:r
HIRTlM'l.AOK
«>|. lAPHKR
(Stiiti- or Coufitrv)
MAIDHN NAMH
<)!• MOTIIHR
HIRPmM.AOK
<)»• MdTHHR
(Stall- or Cotuitrvl
UCCri'ATION I U
UXi/).<x/vvc)u>u \J iV LuA.
DT RATION Years
CONTRinrTORV
DTRATION )'cars
(Signed)
Mouth}
Davs
Hours
Af()Nths
/hivs
Hours
1 Jfl Ur>v>viAX M.D.
vLkt XX rqoH (Ad.lress) lOT OAA^llicK. Ot
<xjy\Aj
Rffidftf in Sum f'l aiiii^rn O O ) '("
\rr,„th>
Ihl\^
Special information only for Hospitals, Institutions, franslfnts,
or Recent Residents, and persons dying atvay fro.n home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
THH AHOVK STATl-J) I'KRSONAI. PARTir f I, \ RS A R l', TRl K TO TIIK
hkst of m\lknowijvI)c.k and hkijf.f
(Infoitiirnit
AfUlrcMS
TiS \hJUoX
n.ACK OK RfRJAI, OR RHMoVAI. I DA IF; of Ht kiai. or KKMOVAI,
rXDKRTAKKR VJ ^WsX^yV ^ -OAX LLvwCLb Lo
(Address ^t D^ \irnAA.^U,.A^V W A
N. B. Every Item o? Information should be CHi*e?ully supplied. AGE should b« stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special information" for pri-
sons dying away from home should be given in svery instance.
< ,
t I
ffl
I
1 ;>
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoar-! f H- ilth 1 V., •- '^"^^,^J:;0i H^il' fo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
0
1^
4^ 1
190'i
Begislrrcd J\''o.
2542
DEPARTMENT OF PUBLIC liEALTH==City and County of San Francisco
Ccvtificate of Bcatb
( XX. S. StanOarD j
i
^
^No.
PLACE OF DEATH: — County of cX^a-' ^' >v<x/y^J^\A^c City of ^'O.av J \,C^->a.cuiXl^
^^^ C\ ■ % I ■ 4 i
J 1 U; • ^isA.<n^ ^10 O-Mvcto.4 St.; — — Dist.:bct.-— '- and
('\|F DEATH OCCURS /iwAV FROM USUAL RESIDENCE Give FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
y IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
A
FULL NAME
urrxAryX'
r^\
.U
CTV
PERSONAL AND STATISTICAL PARTICULARS
^^i;.\
Ol
t<»l,t>K
OJJL
i'VC
t^
1) A I}-; <»! IJIKTH
A<.i-;
.^^^
MEDICAL CERTIFICATE OF DEATH
DATE Ol' D1:aTII
X\
Vfar)
rgn
M..nth:
5-C- ,
Day
\f.>utfis
\ (MI
/J,7 1
siNr.ij.: %!AKRn:i>
w r 1 )« » u } . I ) ( » K i> [ \< > K * ' i; I )
'\\iit< in -(nial (h'><i>.Mia! i- m )
cuuucccL
lUKTHPI.ArK
' State (ir C<»iuitr%'
N" XMl", oi-
1- A'lIIKR
HIK TUl'UACK
Ol- I ATHKK
fSlatt nr Count! V
MAIDKN NAMK
OF MOTHI'.R
HIRTHPLACK
OF MornKK
(Slate or c'oiinttv
OCCri'ATION
I
(Nfonth) (Day) V
1 HfCRlCHV CI:RTII<'V, That I atteii.k-.i ikctased fmni
1
iy.ct; 1^ 190 H
to w'ct Xi
190 H
that I last saw h.*-'Vn. aUve on 'C <L\j 3^1 190'i
atid that death »)ccurrc(l, oil the Mat*,- stated above, at i(
\X >T. The CAISI'; l)F DICATII was as follows:
\t
^^A/\
h)
U/vJk'-
nr RAT ION )'ears Months S Pays Hours
CONTRIIU'TORV
DIRATKXN
(SIGNED)
Years
.'Sfouths
Days
dUU) ow . \J fLtA/vvcrv-v^
}
I
K) XK-^yy^^<x.'
Krsidnl ni Sati /'i <iH(isrit [^ )'roi.
k)j^ 1?^ 190H (Address) ^01 Qj<.Jduju J t
1
/fours
M.D.
Special information onlv for Hospitals, Institutions. TransleBts,
or Recent Residents, and persons dying away from home.
1 /,);///;>
Ihi\s
\\\V. AHOVK STATKD PFKSOXAl- PAKTUTI.AKS A K I". TKl K To TIIH
linsr oi' Mv KNo\vui:n<". K and ni-;i,ii:K
[111 forma lit
fAfldrt'ss
OiS'i. m ^ojvxxAA^YK, nt
A
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death?
How long at
Place of Death?
Days
ri.ACK 01 lUKIAI, OR RKMoVAI, I DAlllof Hi kiai. or RIC.MOVAI,
O-wvi. I ^^ ^"^ Tool
10
rj.ACr. OI- JSl K l.M, Kl
INDHRTAKKR
(Address
N. B. Every item of Information «houIcl be carefully Rupplted. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psp-
sons dying away from home should be given in svery instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hour.! . f U.-.,U1i T No ;- ■^'^■■■;af'^. uScV C
'X^s^KAj^ doiAHj Deputy Hcc:::h Officer
Registered JSFo,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No.
Certificate of Beatb
( tl. S. StanC>arD )
PLACE OF DEATH: — County of ^ CX^x' J/UX.>x>cx4.co City of Cj/Cu>% J A.<X/ryw^^c4.-cuo
\ 1^\ MU A.ULK) St.; \ Dist.; bet. Jt XycLi and
(IF Ot*TH OCCUPIS *WAY rPOM USUAL RESIDENCE give facts called for u4dEB "special INFORMATION" 'S
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAQ OF STREET AND NUMBER. /
FULL NAME
L
o^^ywj^
PERSONAL AND STATISTICAL PARTICULARS
SHX
0 ^j'rsx.oJ
IM
D.\TK OF HI Kill
A(,i-:
' C(»I,(IR \ A
MEDICAL CERTIFICATE OF DEATH
Month)
1
) 'ra >
Dav)
M.inUn
(Vtar)
na\
Ik
(Year)
SIM'.I.K, NfAKRlKl)
\\ri)o\Vi:i) Ok DIVoKiKI)
tWritt'iu MK'ial <k'>iKiiiiti<>ii)
BIRTH PI.ACK
(Statf or CcHuitrv
UArroCyVi.
■4
NAM1-: ni"
FATlIl-.K
HIRTHI'I.Ai'K
<>|.- lATIIKK
(Statt or I'ouiitry
M\I1)1-;n NAMl'.
HI MOTIIICK
HIRTHPLACK
<>l- M()THI:R
(Statt- or t'ouiiti>
rAA'
3v3v
(Month) (Day)
I HI-Rl'HV Ci:RTn<V, That I attendeil ileceased from
LL^?uJC 190S to iL/ci: aSl^ 190^
that I last saw h X^V aHvc on Uct 3^^ 190 H
uikI that death occiirrc<l, 011 tin- d;iti- slattd ahove, at I-2».U
Cr M. The CAI'SI*; Ol" l>i:.\ril was as follosvs:
%
DTK AT [O.N Years L Montha Days Hours
) N T R I in T ( ) R \' L i v<r Vt^Dj cx i^i. ^hIt^^uJLahj
DURATION Years Months Pays Hours
( Signed ) JL U). gijLAJL>urcuttr M.D.
i %% iqoH (Address) JRI UXitlxhj ot
Ou
()t'Cri'A'l"K)N
R'-yiifed in San Finn, ism ( )',iu s .^/nnf/is
/>,n
SPECIAL INFORMATION only for Hospitals, Institutions, Translfnts,
or Recent Residents, and persons dying dway from liome.
Former or
Usual Residence
Wlien was disease ronfrarfed,
If not at place of deatli ?
How long at
Ptare of Deatli ?
Days
THH AROVK STATKn F^KRHONAI, I'ARTHM' !,ARS AKH TRIK To THK
HHHT OF MY KN'OWI.KIX.KnAM) HHMHK
(liifn'iiiaut
(Addrt'ss
KN'OWI.KIX.KnA?
PI.ACK OF niRIAI. (»K KF;m«)VAI. I UATKuf Hi riai, or RKM<»VAL
n^. ...
iqoH
rNi)F:RTAKF:R V (<X^yxfc^rciA; MjA.-^k^..
(Ad.lrvss \X^^ \f)f\A.M,^\^^^\ Ut
' U'
N. B. Every Item of Information should bg 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-
•ons dyln4 away from home should be given In every Instance*
I I
\'
^
\ ■!
O,
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HoMtl . f lUulth I No i^ :$^^^-)U&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihtfr /vVrv/, lD,^tc4>XK' X\
190H
Registei'od J^'^o.
2544
,^ Deputy Health Officer
DEPARTMENT ob PUBLIC HEALTH=City and County of San Francisco
Cettificate of 2)eatb
( xa. S. StanC»arC> )
PLACE OF DEATH: — County of
City of v]l,C>-U)
ATU
^No.
(IF DEATH OCCUnS AWAY rROM USUAL
IF DEATH OCCURRtD IN A HOSPITAL
St.;
Dist.; bet.
and
RESIDENCE GIVE fac
OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" "X
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
SH\
PERSONAL AND STATISTICAL PARTICULARS
j COLOR \
-x/ys:
Lh
4)wL
u.
DATl-: nf- lUKTU
AT,!-;
(Month)i
0
t3
) ■(•(/ 1
Day
M.iulln
( \f;il
/',/:
^
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH ,/ \
^''ct 11
(Month) (Day)
I in;Ri:!5V CliRTn-V, That I atteiKkMl .Icccased from
igo .
(Yt-nr)
^IN<".I,K. MAKKFI'.D
\vin< »\\ i-:d or d!\< >w<i:i)
(Write ill sfM-ial di sivnat ikii)
B!K Till' LACK
'State or Oouiiti \
LL A ^J^
H
190
to
that I last saw h ^ — alive on
"I90
T90
and that death occurred, on the dat«.- state«l ahr)ve, at
' ■ M. The CArSl<; OF DI'iATH was as follows:
HcUv
<k.i>
'i
^^A.
Kkx
<x
NAM!-: «>I
HA I II I.K
IUklHI'I,A» K
01 lArilKK
(Htati- or t'oiiiitrv)
MAIDKN NAM1-;
Ol- MnTIIKK
HIKTIIPLACH
OF MOTHKK
(State or rotintry)
f HO r FAT ION
Resided in San Ft am ism
1)1 RATION Years
CONTRIHUTORV
Mouths
Da vs
Hours
> u
0;
)'ciiys
t
Mouths
f^avs
Ul' RATION
(SIGNED) \J . .i\D. U) O-CkU,
^/et; 3^3. Tcjo (Address) VjIxax^ MU/u
Hours
M.D.
) ea I
Mnllth-^
I>a\
SPECIAL INFORMATION only for Hospitals, institutions. Transients,
or Recent Residents, ind persons dying dway from liome.
Former or
Usual Residence
When was disease rontrar ted,
If not at plareof death?
Hoi¥ lonq at
Plareof Death?
Days
T 1 1 V. A Ii« ) V R HT \T 1: 1) P K R HON A I. PA R T KM' I. A R S A R H P R T V. T< > T H K
HHST OK MY KN'OWUHDOK AND nKMHK
(Informant
(Addresi
PJ,ACE OF niRIAI, OK RKMnVAI, | I)\TKof HtKiAl, or KKMOVAI,
T \ ^^s
INDHRTAKHR ^ i '
1 00
KJ
H
(Adilrt-sM
35 5 \i JVfr>xlci.v',
^
N. B. Bvery Item of Infopmatlon should be cspcfully aupplled. AGE should b« stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for per-
sons dying away from home should be ftivcn in svsry Instance.
I I
J
,'V'?
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
H..,,i.] .,f !I. aUh IV.. 1= ^'-VJ^Si, Hftl'C'
luUr Filcil, .. /tJ>fM>v 9^4
WO'i
Registered J\''o.
2545
n
dwd' LC-
W< /
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( tl. S. StanC»arD )
PLACE OF DEATH; — County ofO/O/^v jruX/VLCUu>0 City of Oxx.^^ o V<x ,xcUl^ '-.
1 M 1 ^
St.;
(ir DEATH OCCURS *\w*Y FROM USUAL RESIDENCE give facts
IF DEATH OCCU
IRRED IN A HOSPITAL OR INSTITUTION GIVE I
Dist.; bet. ^* and
TS CALLED FOR UNDER "SPECIAL INFORMATION" \
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
v. >«i*^ '*»
0 ^
PERSONAL AND STATISTICAL PARTICULARS
si:\ A - A '"' '!.' '^f
DAI 1-; i»!- HIK I'll A h
Kn
\xXxi
(^l.itith' i
\«.H
JV,?>.
I).,-. I
M, mills
%\
(\\:\x)
l\l\.
"^IN<'. 1,1 M\KUIi:i>
(Wiitr ill -(Hial ill --iL' natiuii
BTRTHJM.M'l-,
'State (ir I'ount i \'
NAMK <)I
FATiniR
RIRIHl'l.A* H
Of 1 AlllKK
(Statf iir (.'mititi v)
MAIUI-.V NAMK
(H- Mnrill'.K
niKTHIM.AlK
Of Mn'i'lIKK
( State or «."iiuntt y!
OCiTl'AIlON
(W-nr)
MEDICAL CERTIFICATE OF DEATH
DATK oJ- DKATH .A
(Month) <I)ay)
I IIl':RI';nV CI-:RTIFV, That I atten.kMl deceased fmtu
.- ■..^.v;— .:—.- 190 ^ to —^'.TTr up
that I last saw h ■ alive on '■-■ Ttp
and that death occurred, oti the date stated above, at
M. The CArSIC ()!■ I)i:.\TII was as follows:
Y
rvxxx- r w
J\.A^ii \ i.
n I
nr RATI ON }'t'ars
CONTRIIUTORV
Months
/\iv
Hours
/hivs
DURATION Years J/on/As
/l£fc 19. iQo'l (Address) Kj^<ry\AA^t
(SIGI
Hours
M.D.
\
*, \^\,,.^^
Special information only for Hospitals, Instlt^tyons, Transients,
or Recent Residents, and persons dving dHay from home.
Rfsidfd ill Sim /■inii,n,:> )>,ii f ^ .t/,»if/is i. 'j /Mia
r\\}- XHOVE STATHP PKRSONAl, PARTICl'I.AKS A K i; TRIK To TUH
HKST OF MY kno\vij:d<;k and nHi,ij:i'
nnfonnatil
i
i-vW Kju^^^^'^^-'
fAd.licss
Raa- lb
Xm w
r\>,ji^
Former or
Usual Residence
When was disease contracted.
If not at place ol death ?
How lonq at
Place of Death?
Days
PI,ACK OF niRIAI, OR RF:MoVAI, j DATi: of lltKlAf, f>r RF:MoVA1.
^H 1 90 H
(Address ^HS Ss M /\\AAa,^tv . )t
N. B. Every Item of Information should be c«r«ffully supplied. AGB should be stated F.XACTLY. PHYSICIANS should
state CAUSE OF DEATH m plain terms, that It may be properly classified. The "Special Information'* for psr-
sons dying away from home should be given In every instance.
1
1 f
*
t
1
'
(J*
I
D
• o'
: I
i
ill'" I
• I
r
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l!.,ar(l c.f II, alth )' V
Vii 1^ "^'f^^r^. lU^P I'o
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Da/r FiJvd, \V'^
,<rlA,^->0
K %\
U)0\
JRo^isfcvod JSTo.
S546
Deputy Health Officer
DEPARTMENT'OF PUBLIC HEALTH^City and County of San Francisco
Ccrtiticate of Beatb
{ Xa. S. StanDarD )
J? 01^ -^ <^
PLACE OF DEATH: — County ofCJoyvu ^Xxx.^>^-eUieo City of CJ/Cl^tv J ^^cl/>x.<:^..^^o
(^ n
No. oS. ^x.
xc^{m\„c
St.;
Dist.; bet.
\\-'
\}
and
K^
\
(IF DCATH OCCURS AWAY rROM USUAL R E S I D E N C E G I VE 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
\}
xrryxixo
•^%
PERSONAL AND STATiSTICAL PARTICULARS
Ml^OuU
\ ^
WkXsl
DA ri: m- lukiii
\i.|.;
MEDICAL CERTIFICATE OF DEATH
DATK <>I- DHATH // \
(Month)
as
(I):iv)
igo H
(Year)
Month'
1 v.;
^
s
(Dav)
M nl'h-
It
/'./
SIN<,|,1.: MAKklHI).
WIDi »\\ i:ii OR IMVoKrKI)
lUiitcin ^(Mial dt -.i^'nat inii)
k
,]
f
M
luR I'll I'l. \ii-:
(state or riiinitl \'
N'AMl- OI"
iatiii;r
nikTMIM.ArK
OF lArilHK
(Statt or Coiiiitrv)
MAIDKN NAMl'.
OI- MoTJIHK
FUHTHI'r.ACK
<•!•■ MOTMHK
'State or Countrv
I HI'ikliHV CIvRTH-N', That I atltii.kal ileccascd from
tcfc ia \<pH to y c;b a.3 ,goH
that I last saw h -L»-i aUve on L ' CX 33. lyo *i
and that death occurred, on the dati- statccl above, at CX\)iKvt7
11 d M. The CAlSi: (>!• Dl-ATH was as follows:
XL^ru
If uxMm)uIi
Dr RAT ION Ytars Months H^^ Days Hours
U
nr RATION 3 Years
( SIGNED ) V ll^rVuU
Mijtit/is
/)ays
Hours
M.D.
^ruLhj
di
(
3^3 i«)o'^ (Address) SH JKv^.dL
SPECIAL Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying at^ay from home.
r
OCCd'ATHIN
Residfil i» Still limit !>,■,> *" \'iilis \ ^f.niths \ ^ lhl\.
Tin-: ABOVE STATI I) PKKSONAI, I'AKTHM L\KS AKl*. TKIK T( ) TflH
nKST OH MV_K.NO\\ l.l'.Ix.K AM) WV.X.W.V
(InfoTtnaiit
-w^
\.M,,ss %\ \i) lAA/>xnrA-t Cji7
Former or
Usual Residence
When was disease rontrar ted.
If not at place of deatli ?
How lonq at
Plarcof Death?
Days
rLACi-: ni m RiAi, ok ki:M<>\ ai, | Dxri.of ni kiai. or hi;movai,
LfrUju Uu>^^L4, I ^^ ^"^ T90H
(A.Mitss in I N»\AAAA.e>\ Ut
N. B. ^»M^ry Item of Information should bs CBf*e?ully 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 dylnft away from home should be ^iven in every Instance.
( J
I
fit
\
I I
I i
:>
i I
H m1 ..f !!( -iHh - \- No
WRITE PLAINLY WITH UIMFADING INK — THIS IS A PERMANENT RECORD
]\ScVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
, ••£.
^
If)OH
Ihfh' Filed, UtiurW-N; V\
0 u
v6v„A.A. Deputy Health Officer
Registered J^'^o.
;2547
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of 2)eatb
PLACE OF DEATH: — County ofV'-<X>v
"Kc
CL )-vCU^
City of OxX/^-v dx<x>
XCa.^^
^ 3
No.^lC) \1 ll-O^xto,: . > ■ St.; ■■ Dist.;bct. Y^^-^''- ' and\J.<XC
/ ir DCATH OCCURS AWAY ^ROM USUAL RESIDENCE GIVE FACTS CALLED f** R UNDER SPECIAL I N EO R M ATI OM" \ j,
V IE DEATKJ OCCURRED \*i A HOSPITAL OR INSTITUTION GIVE ITS NAME I^^STEAD OF STREET AND NUMBER. J \J
(t
FULL NAME oru'U/^^-o
,00
-I \
PERSONAL AND STATISTICAL PARTICULARS
Cni,( )K ' ^
w .\j Y y wCX^
DATl-; OF IiIKTH
Ai.H
L.'
M.iutli'
bS
3 r
(Diivl
M.nith
\ (.'iir
/)./!<
MEDICAL CERTIFICATE OF DEATH
DATH OF I)1:aTH
(M.mlh)
(l)av)
IQO \
(Year)
I ]II-;kI':HV Ci:r<Tn'^V, That I altfn<UMl (UMvast.Ml frnui
4.. \.,\,.\,.
190
'^IN'.I,!". MARK 11!)
U I!»< tWl- I> UK li;\i iRii:[)
Uiitf ill -.Dri.il ill •'is.' iiali"i!i)
luk rm'i. \i'i-:
(Stat- i.t I .Hint 1%
Hi
OJ\)\xj
t^x
!• ATII HR
lUk flllM.XCK
01 I XIIII'R
I Stal (■ 1)1 I'lxmt t \
^T\lI)^;N na%!1-:
01 .m()Thi;k
niRriMM, \CK
n|- MoTlIKK
(State <»r Countrv)
OCITI'A TlOX *'\i?
i>x
Q^xjo^Aj
(^
to w ZXi I90 t
that I last saw h • ' alive on ' - ^ ' T90
and that tU-ath occurred, on the liatc state<l abovi'. at
M. The C ArSIv C)|<" Di; ATII was as follows
_ _t.A_^..
^
XAJo-*J\.'^i.KAj^.
Yi
DrkAlloN ' )cais
CONTRIIU'TORV uXa-^
v
&AaA-UU-^ '
Rridfd in Sijtl /'i d >n /.•>fi> J^L ) ' il i
\f.„iHl^
I),) 1 »
DIRATION
(SIGNED )
\^jCX« •*.'i 1 90
Months
Months
Ha
r.v
I lours
.<^,o
Pav
I,
rs
Hours
M.D.
Address) 15%- H 0 KxX'>\t ^£XdLc
i
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, aniJ persons dying m&s from liome.
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death?
How lonq at
Place of Death?
Davs
TIIH AIIOVK ST \'ni) l'l''RSnNAI, I'A KTUT I. \ RS A K l'. TRIK To THK
BHST Ol- MY KNO\VI,i;i)<".H AM) HI.Mi;!'
fill Tot mail!
xHVx; Lo-o-i
A.ldrts.s. %l C)
yxX
^
lU.ACK OF m RIAI, OR RFtNfoVAi, j DA IF: of HrwiAr, .u KKMOVAI,
190
(AtldKss
N. B. Every Item of informntloti •hould be cnre?ully supplied. AOB iihould be stated EXACTLY. PHYSICIANS sbould
Btote CAUSE OF DEATH In plnln terms, that It may be properly classified. The "Special Information" for per-
sons dying away from home should be given in ^s^vy instance.
I
51
• o
I
* I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H..;inl ..f il. iMh IV.. " "?'«' ^■?.- H^ P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
190 H
Re^isfevcd JSi^o.
O^
548
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( XX. S. Stanc>ari> )
*
No,
PLACE OF DEATH: — County of 'CL-yx- J .n.ou'vccULOO City of O^C^-u J /V<X/>x.C>uutU5
L O^KctoLA." St.; — Dist.; bet. - ^ .......-..-.- and-
r
,{)
(ir DEATH OCcUrS *W«Y FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL
RESIDENCE give fac
OR INSTITUTION GIVE I
FULL NAME
iXJLAj
AAA} :
TS CALLED FOR UNDER "SPECIAL INFORMATION ' N
TS NAME INSTEAD OF STREET AND NUMBER. /
'"XJ'XJLhj^MYXj
PERSONAL AND STATISTICAL PARTICULARS
COI,i»K
i'Aii-; or- liiKTH A^
1 Month I
1 rllX
1 ):l V I
A' , I-;
%!
)V
\%
(Vfarl
/),/■
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH d \
u
Month)
3.1
(Dav)
(Vrar)
U IDmUKU ok IMVoRrHI)
Wnte in social «ksiK'iation)
lUR rni'i.Ari.:
(SUiti or ' ■nuiitr\'
NAM J- Of-
I ATllllR
MlklllPI.AfH
<H- I ATHHK
Stat* or fonntrvl
mmi»i.:n namh
<»1' motiii'ir
HIKTm-i.ACH
Of Morill'.K
f Stall or i'ounl! \
1)
O^LTLn^l
I
I HI'kJvHV ri;RTlI'V, That I atleiKlcl dct tascl fn)ui
-L'tt iio T90S to 4^>ct ax
that I last saw h>C/Vn alive 011 L ct X^
UfO H
190 H
aii<l that (U-atli ()C( iirrcil, 011 the dalt' statuil ahovi-, at boO
^ M. The CAISH OF DHATH was a> follows:
.Ui
DC RATION )'cars Months I SL Days
CONTRIHI'TORV n^ — ^ d^A> VOJ Cr^ AxA^X^i)
(mo
nccrpATioN
Rrsidfif ill Si! 1,1 / i diii isrii •- )V(/i
,1 r
duration
(Signed )
)'rars Mi'n(/is
Days
)o H f Ail(lrtss)
u
o-<l
I /ours
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Instifutions, Translewts,
or Recent Residents, and persons dying away from home.
Former or
Usual ResidenceClVvCXK
K*^ VXiAJ-adow plaf e of Oeatli ? ^
yr,intii.-
IhlY,
When was disease rontracled,
If not at place of death ?
Cl|vu.A.'rx,^ N ^J^'^J^K^^u0^n»t of Death? ^ .. Days
Till-: AIU)VK STATKI) PHKSONAI, PAR P IT f 1,AK> A K l-! TKIK To THK
HKST OJ- MV KNOWI.HIX'.K AND H1;IJI:F
(Itifoimatit
^.%.^|
(Afhlrc-s
rOl^.>QyCrA^
l%l5'^ \jYLv(tiU.^ra at
I'l.ACK Ol" ni'RIAI, (IK RKMo\ AI, I DATI" of Hi kiai. or KHMoVAI,
r M ) 1 ; K r A k i: r 0 /rVwt.o^<r\> oL' AX>wvi^
(Atl.lrrsH ^$^1
ta ^X <^<r>v Q
N. B. Bvery Item of information should be cnrefuliy supplied. AGB 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 dying away from home should be given in every instance.
I I
Ir !
Hi
I
H
3
J
:>
*
«
I
i
n
f
rf*
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Unnnl (if Ilralth I' No. le, 4«^»t^H&PC»>
Reglstet'ed J\'*o,
2^
Dufe Filetl,\j/zkjXjO\j IH 1^0^
i^tc^/^lxvM Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "d. S. Stan^arD )
^
:\
PLACE OF DEATH: — County of V 'o.^ rv J A r. ,— . City of J.<X/vu JX.cx>a..c^A^.
^No. 5t ^: \ : St.; Dist.;bct. = * ^ and
(ir DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • '\
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
ji.
PERSONAL AND STATISTICAL PARTICULARS
^i:x I
!>\T1-; or lilKTII
M.V.
I'OI.nK
/ '- i
M,.iith
):-a>
(Dav)
M <n//i}
\ tar)
/hn
MEDICAL CERTIFICATE OF DEATH
DATK <)!• DlvATH
(Motitli) ri)av)
/go '
(Year)
'^IN'.l.l-: MAKNIi;i)
wiixiu'i;!) OK in\» >Kij-;i) n
'Wiifcin MMinl lit— i!.Miatii»n) I
ISIKTHIM. XCK
(Stall or Counlr vi
NAMl OF-
!• A'ni i,R
nTKTHIM.ACH
Ol" FATIIKR
(State or Cuiiiitrs
MAFDl'.N NAMH
oi MOTHHK
HIKTMIM.ACH
OK MOTHKK
(Staff or C»)uiitryi
ni-cri'ATl()N Oj\p
h'fsiiifi! in S,m /'i a III I -it
I HRRRRV CI-RTIFV, That I atteiulcd den ihscmI from
■ ■ 190 in ^....:.: nrirn:: ,." up
that I last saw h aHvc on jijo
and tliat death occurred, on tlie <latc stated above, at
M. The CATSH Oh' I) I- AT 1 1 was as follows:
DIRATION i't-ars
CONTRIIUTORV
Months
Da v V
Hours
Wars Months
nrRATioN
(Signed ).L(f\^\%jUvv^ j w*.
W ^ I<)0
Pay
Hours
M.D.
fArldrt-ss) Wv^ ,
SPECIAL INFORMATION only for MospiUls, Jnsmufions, Iransieits,
or Recent Residents, and persons dying away from home.
M.mlhs
l>,i 1..
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death?
Days
THK AnoVK sr\ TIJ) i'HKSONAI, I'A K T Kl' I,A K^ AUi: TRl K TO TH K
(I
HHST OI" MY KN0\VIJ:I)(,|.: AM) HKI,n:F
nfotmant \| iWC-JxXXjUL Q A^WxHX'
1^
'Y\i
fA.Ulrr.s 5"% V^TYXAM-AjL-ft. ^^
l'I,.\CK Ol' lUKIAI. OK RKMOYAI, I DATICof Mi kiai. or RKMOVAI,
INDICRTAKKK LC'V\aA-Ma_ IX'VV'CiXKjt.O.
(Adclr.ss ^ (0 1& ^ YXa.XMWw.'^'Vu J L
N. B. Bvery Item of Information should he carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Informstlon" for psr-
sons dying away from home should he given In svsry instance.
I I
I!
^
II
I
M #
fr
m
.ji*
«f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
It, ,..!,! of lUalth'-l-" Nn ;>; '^*;.^!S^' 1'^'' •-*"
I)(t
fr /vVrv/, yctK)-Ovi
XH.
190K
Registered Jio.
OK^
550
cLma,a^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( 'U. S. Stan^ar^ )
i^G
4 Q^
PLACE OF DEATH: — County of Ocl^a^ ^.a City of Ocx.>v ^
/ / ir DEATH OCCUWS AWAV Fl
y V ir OCATH OC^URHtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STBCET AND NUMBER
St.;
Dist.; bet.
and
ROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" N
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
SI-;\ fs^ I COl.nk ^ ,
^ I i > ■
^\ ^ ■: :
I)\Ti: nr lURTH
\*-V.
)\,n
I Day)
M.'Htll
— y.
MEDICAL CERTIFICATE OF DEATH
DA'IH Ol-' I)i;atii
's A
I I
(Year)
(Year)
Diiv
HIN«.i,K. MARUIKl)
WIDnWi:!) OK r»I\< iKi'l I)
iW'ritftii siK'ial (l(si),'iiiiti'i!i)
UA^
HlkrillM.ACK
(Statf or Country)
NA\fl-: Ol
I athi;k
HIRTHIM.AtK
Ol- I-ATIIHK
(Slat«' or C<iui)try)
MAIDKN NAMK
OI- MOTHKR
HIR'IHI'I.ACK
OH MoTHHK
(State or Country)
V^'
tJac4"
I
(Month) (Day)
I HI:KI':15V CICRTII'^V, That I attendtMl ileccased from
— -— — — - igo to iQO ~~~
that I hist saw h .: ~" aUve oti ^^ 190
and that dt-ath occurred, on the date stated ahove. at
M. The CArSI<: Ol- DIIATII was as follows:
1
^ >-^|a.>vt at dLcrttu. lu
/O. cR ,
DTRATION Years
CONTRIIJUTORV
Mouths
I hi \'s
Hours
\K,kX C^ij
%J^'\ \. r
rs
I liur ^a-tju^
Mouths
Days
Hours
M.D.
DTRATroN JC^^ars
(SIGNED) J.Vj\.. i\.
^^. ^H 190't (Address) Ulu ''' ^A.
Special information only for IJospltals, Institutions, Transleiits,
or Recent Residents, and persons dying away from home.
OCCri'ATlON
/^fsiiifd in Siiif /'i itiii isi'it
)'ftit
Mitnth:
thiv.
TIIK AHOVK STATl-.I) I'KRSONAI, I'AK riCII.AKS AKi: TRl K I«> IHh
HHST Ol' MY kno\vm;i)c,h AND ni:i,n;F
(Informant
^
-L<rX<yt
f A(lclreM««
Cdt^"^ C<H.A./V\tu hbAkKAX'^K.
.\/v\tL
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How loni] at
Place of Death ?
Days
in \(K 01 nrKIAI, or RKNfOVAI, I DATKof Hihiai, or RHMOVAI,
INLHRTAKKR KjxXaX ' NKixi^'<t<Jl U
(A<l.h
N. B.— Every .ten, of l„fo.„,atlon .hou.d b. can.fu... -upp.led. AGB .hould «-•*«*«- ^''.^f^^,^; .XTJllLll^' lof^i-t
•tate CAUSE OF DEATH In plain term., that it may be properly claaaifled. The Special Information for pmr-
(»on« dylnft away from home should be uiven In mxery instance.
I I
5
3
^m^'
-r'
,- rr
'mtfi'-m^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n .i!.l .if H,:t]th F No. !> ■*"f--7K?is:^ JiS:!' (.
m
liJO'i
Registered jYo.
2551
O^^iXKKA
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( m. S. StanDarD )
PLACE OF DEATH: — County oiOo,^^ jA^O/^cvv . City of 0,<xyr\j JX<X >x.
op
J;
i
(No. bH'-s Jc'- ' .. St.; ^ Dist.; bet. d JLC^^rx-ctj and sU
/ ir Di«TM occuns *w»v rROM USUAL RES I DENCE give facts called for under "special information" \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
A
e
%
FULL NAME Ld^^ru^y-^d^
.a.L
I I
PERSONAL AND STATISTICAL PARTICULARS
si;\
I.
C<»I,nR
I>ATi; OF IslKTH (TX
LCi^j..
Month)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH , A
(Month)
I Day)
(Year)
A<.i.;
b ^^ )>,?/>
10
(Dav)
.1/,'wM'
fVear)
A? I J
«iN«.i,i.: MAKHn:i»
\VIlJ(i\v|.;i> OK niVnKOKI)
(Wiiifin siK'ial iltsis/natiuii)
lUkTHIM, \(*1-
st.it f lit ( % Mint I %■
M rlouvvLixl
N\\t]' »»!
lA riii.K
lUKTIIIM.ArK
'»! 1 A IIIHK
< Stat* 1)1 I'ojititi V
MAn>i:N NAMH
nl MorriKR
HIRIHlM.AlH
nf- MOTIIHK
(State or Oc)tnitrv>
I
(^
■\l
)
I in{Rl-:BV CI{RTIFV, That I alteii.kMl dtcrascl from
.\J^ XD 190'i to . Ux^t X^ 190S
that I last saw h - ^ alive 011 A^- tX XX i^o ' i
and that (Uath occurred, oti the date stated above, at 5 iC
M. The CAISI-: OI- DI'lATII was as follows:
CLccCti %9 J.^voJbci\^
A
1)1 R.XTION
^'W
CONTRIIUTORV
\A^^-\.Ajfi.
^! out lis ^ Days ' •^ Hours
yfiXaXaii.^i-^^
LuAXX; W
iU\
-^(UA^ c ' ^
DURATION 2s 0 Years
(SIGNED)
,'^f out/is
d,c4 ,
fhus
M j
I /ours
M.D.
U ^0 W J
da X% 190H (Address) 1^6 OlD^t<Na>u-i
CJLAX^^Jl^
oceri'A'noN/
R/^siiffif III Satf / iiiniifi'n K, )iuji
Months
rhi 1
SPECIAL Information only for Hospitals, Institutions, TranslfBts,
or Recent Residents, and persons dying anay from home.
T{1H AIU)VK ST^ri'n PKKsoNAI, I'A KTICT I.A RS A K K TR T K TO THK
BKST OK MV KNOWLKIXIK AND m'.\AV>'
(Infonnant Mh^O-A.MjLX dv . UJ /CXA^-VlOA. dxXxuJ\^
Qfl^
(.^ddrejss
bH.^ "3 CriUu^rrru ut
Former or
Dsual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death?
Days
PLACH OI" niRIAf, OR RKMOVAI. I DA U^: of HfHlAL or KEMOVAI,
rSDlCRTAKHR
(Add
1901
N. B.— Every Item of Information .hould be carefully supplied. AGE should »^^»«-*«d EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The -Special Information for psr-
sons dyinft away from home should be given in every instance.
i
t
1
t
«
-f
1
dI
^
I
^
II
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
tT.l ..f II. :ilt!l (•
'. ■V":---sg^^ Hit!" C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/hf/r /'VAv/,yd:(rlMA;lH
190H
Regisferofl JSfo.
i^OO**^
(Mcc^ i^\ , Deputy Health Oflflcer
DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco
Certificate of H)eatb
( 'U. S. 5tnn^a^^ )
m 4
^
PLACE OF DEATH: — County of "^ <X>\; JAXX.YLCxA.coCity of CJcu^ru J TUXwcuLeo
^No. JXV^^VOu'^X' Ik 0^\xc£oJi
St.;
Dist.; bet.
and
(IF DtATH OCCURS AWAV FROM USUAL
\r DEATH OCCURRCO IN A HOSPITAL
RESIDENCE GIVE fac
OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" N
TS NAME INSTEAD OF STREET AND NUMBER. /
i !
A
FULL NAME
CrtlXuJir J L -co-rru
'-l.X
PERSONAL AND STATISTICAL PARTICULARS
I> All-: <»r lUKTH
iricLlji
\
^.
.ivcU
31
i I);iv)
,^57
\<.i-:
(d1
5 V<j *
I
.1/
\\
fVoar)
l\i
T0o\
(Year)
n
^IN«. I.J- MAHHIi:i>
wiin i\vj;i) OK i)i\< (Kr i:f)
•U'lit*' ill --m-ial ill ^lu'ii 'I'lit'
7\xXhA^CcL
lUK rui'i. \i'i-;
• '>t.lt( (II I'.iUtlll V
NAM}- ()1
I- A in i;r
lUKTHIM.Ai'K
OI' lArilKK
(Sta't or Count! V
MAn»i:N NAMK
<>l- MoTHKK
HIRTHI'UACH
OH MOTHKR
(StaU- or Couiitrv)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH 1/ \
(>!.)iitlO (Day)
I III'RI-HV Ci;kTII-V, That r atlcii.kMl .krcasc.i fn.ni
I90M to . Al C V ilS. H^H
that I last saw li ^.^m. ahve on U/CXi 9.S. T«p1
and that «U-ath <>(uiirre(l, <>ti the ilatt- stated above, at <->
CX M. The CAISI-; OI- |)i{ATII was as foil
^^ \\
ilWS
JJT^-
Dr RATION
} 'ears
Months
?
coNTRiBrTORV bLLc^cnruT-lA^
Par
^
DTRATIOX
(SIG
Years .^fouths Ihivs
iSJct
NED)MTl 0. ibft-jvk
A.\\J
5lX tqoH fA.l.In-^s) ^JIHAV\XU-A/ ^t»-4.
^
Hours
Hours
M.D.
Kr.-iilftf HI Sun /'niniiWi) \Q 5V-(7/>
occri'ATioN Q_r
M,„if/i^
/).n.
SPECIAL INFORMATION only for Hospitals, Insmytlons. Transients,
or Recent Residents, and persons dying av»ay from home.
Former .r ,^^^. | J tl, Cl ^ """'""''
Usual Residence
When was disease contracted,
If not at place of death?
^^ 0. Place ol Death?
Days
THK AHOVK srA'n:i) I'KKSONAI, I'A KTICl' f.A KS AKI-. TKIH TO THH
HKST Ol- MV.KNOWTJ-.IX'.K AND UKI.ll-.F
(Itifo-niatit
(A«Mrc>;s
'S%% - 15
^k)i\j livo^u.
PJ.ACK OJ- liTRIAI. OK RKMOVAI, | DATlio! Ill wiai, or REMOVAL
0\J w. J. v^XLi>\au^\4i
i'ofc %S
I90i
fA.lilKss
N. B. Every Item of Information should be carefully supplied. AGE should be stnted EXACTLY. PHYSICIA.NS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be j^iven in every instance.
'I
D
♦4
• Si
i
I
4
I
Iff
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ih ( V.
'-.- -art .--a, .M\ !' t"
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dull' Fih'd , li cUrW\
'^
4
190H
Jleo'l6'te/'C(l A^o.
553
.^V,i <
A
r
Deputy^ Ith Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( *a. 5. Stan&arc» )
PLACE OF DEATH; — County ofCJo^ J\.oxc^^eo City of OOyVU J XOm^CUl/ao
N«,
.1 UX- . '^^ Ui^ 1 \tu k CK. \\.d OLA.
(ir DEATH OCCUaS AWAY FROM USUAL
ir DEATH OcBuRRCO IN A HOSPITAL
St.;
Dist.; bet.
and
L RESIDENCE GIVE facts called for under spec
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET
IAL INFORMATION" "\
r AND NUMBER. /
A
FULL NAME
<!:\
PERSONAL AND STATISTICAL PARTICULARS
CLL*.
a
f
vet
X.'
DAI'}.: cil HIK III
\' -H
\\
MEDICAL CERTIFICATE OF DEATH
DATK oi- i)};ath
A
Mi)tnh>
5
Dav)
A5X
(Vt-ar)
H
■W'
I
O J* ) tii > ^
U,,Nf//<
n
Pa
"-•IN'i.lJ'. MARHIl-D
'U'litciii -..Hi;il (1. -iu* iiatiKii)
)
Ic^va'V
A-
f * . .-
HIRTItl'I.Ai'K
( Statt (ir i.'iiuiUrv
NX Ml- Oj-
JATin-.K
lUK rn I'l.AiK
<>i- I \rin:K
I st.iti' 1)1- v'ounti N >
MA I DIN N \MH
lUK riflM.ACK
•»»• Mo'I'llKK
'Stitf (11 i'ollIltlV
/"\
(Month ) fDay) (Year)
I lfl{RI{BV CI:rTIFV, That I attciKlcd dcnaso.l frmii
iL'/tltj IH 190H to ...iL/CLt 3.3L up\
that I last saw h-UV^-s.Mlivo on W Caj %'X U)oH
and that death (>ccurre<l, on the date stated above, at 0^.0
U^ M. The CAI'Sp: Ol- DI'ATII was as follows:
Lixx»xAxv
0 11
H
/
'trt'UX^va.'^VQj
^ I A
?
Dr RAT ION y't-ars
CONTRIIUTORV L.iX\.0
Months Pars Hours
1)1' RATION
(SIGNED)
fl;
M.'Hths
axXxxtvcL
occri' \rioN
Keuded 11! Sav riiuui^r,< SO Vrnt- - .Mntli^
Davs
i)/tt^ Xh TQoH (Address) Ictu HXU Ju^^ijit
ffnsi
I lout s
M.D.
SPECIAL INFORMATION only for Ifnspitals, Inslilutions, Trinsicflfs,
or Recent Residents, and persons dying away from home.
Former or ^s ts C: ^^ ^ . \->t~ ""* '""' '* 3.
Usual Residence ^ v D J ^ \ v . L Place of Death ? O
Days
/J,M>
TMK \novK sr\ ri:i> pkrsonai, i'xktismi. \k>^ aki* tkik to thi-:
Hi-isT OI- MY KN«)\vi,i;i)<*.K AM) ni:i,ii:i-
When was disease contracted.
If not at place of death ?
(Inff^nnant
PI iCF Ol" niKIAI.DR R1-:M<»\AF, J DAII ,,• IP Ki.vf, or Ki;.M«t\AI,
(Address 451 Ol V^Xi.4. ^C ) . Ot
190 H
rNDHKTAKKK 0 /ixX^^rCV-^^^ «L>.aJAH
N. B.— Every l.e^ ot <nW„.„..on .hnuld be cr.fuM, .uppl.ed. AOB .h.u.d b. .,»..d F.XACTLY PHY«,CUN8 .houW
•tat/cAUSE OF DEATH In plnin tcpn,.. that It may he properly cla..itled. The Special Information Tor per-
•on« clylnt away from homo ■hniild be ftiven In every Inetance.
\
I
J
^->
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!!■ M :
V , ., ^^rr?^:! HM' i'
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
fhifp F//r^/, K.\XAsVv SLH
IfJO'i
Regisfri'od jYo.
2554
.^^^A^A^
VV
I
No
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of H)eath
PLACE OF DEATH: — County ofO'CL/TU J A.<Xy>vCU:t>(X)City of C'/CL/^x JXxX^rU^c^cX)
. Hi \J Li\^<Xxla; LLvM. St.; k Dist.;bct.L<l/OmX\.OLXdLaJ and Ucrvctixxilt
(ir DtATM OCCURS AWAY TROM USUAL R E S I D E NC E G I VE rACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
aTb)
FULL NAME
. LcLm-^x m I Lct\xvo^5
>x.
<kK
CO
PERSONAL AND STATISTICAL PARTICULARS
"^I'N \ . C(>I.i>R
lU
^KaI^
i> All-; or i;ik 111
\ ' . 1-:
let
Mi.iilh)
!
%
(Dnv)
1/,. .////>
(Year)
Ci
IhiV
^iM.i.K, MARun;i>
\^'II><»\Vi:i» nR DIXnKi'Hn
'\\'!it' in --"H'ial ilt^ijj'natiiiiii
luk j-ni'i, \«i'
I Stall or riiuulrv
N'AMI-; (M- ,^
I'A rilKR I
MEDICAL CERTIFICATE OF DEATH
DAi'l^ <»1 IiJiAlll ||
fMiiiitht (Day) (Vear)
I KI'iRI'r.V CI-RTH-V, That I attcn<k'<l deceased from
L/otr 1% 190H to vi cfc 'xa. u^\
that T hist saw h A/^n. alive on ^ ob 2^ i^o^
and that death occurred, on the date state«l above, at I
M. Tlie C ArSI'! OI- DIvATII was as follows
lURTHIM.ACK
«)|- lArUKK
I Stat< (ft t'ounli V)
maiiii;n namk
<il' MoTHKR
Lex ^ uL
nrkATION Yrars
CONTRIIU'TORV
Months i-i Days
//ours
/h
utrs
•.IK'I'HI'I.ACH /
>l' MnTIlHR t r\ A •
Stati- or Coiiiitrvl ^ \\ U
Aj
/wdb
I )r RAT ION )Ver;-5 Mont /is /hiys
(Signed) .*AJuiJl. U. ^ic'rvvut M.D
Ucfc 3LH ino H (Address) L^Ltoj^L^VOL^rvK^nic
^
iK,a
Special information only for Hospltalsf; Institutions, TranslenH,
or Recent Residents dnd persons dying away from home.
niori'ATioN
Krsulfil It! Siiir /'iijihi^/ii
)'iiii
Miiiith^
Ihn^
THIC AIU)VK ST\ri:i) I'KRSONM, I'XRTirtl. VRS AR]-: TRTH T< >
HKST OF MV KNoWM'Dt'.K AND I{i;i,n;t"
(Informant \J fUXl^VaXi J\X/\^>clA^el?.
fA<1.1n^s \X hUaKXxLcU LLaO/
Till-;
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
I'l.ACK ol* ru RIAI, OK RKMoXAI, I DATK of HfRlAi. or RKMOVAI.
N. B.-
-Rvery item of informntion .hould b= carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may he properly classified. The "Special Information" for per-
sons dyinft away from home should be |ti>en '" "very instance.
I
I
1 ^
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Horn 1 , f II, illli i'V., ■ ■^■F'sr-'i^-inSi.l' C,
Dff/r /'77^^^/X .ct^nlj-'
t\, DvH
IfJO'i
Registered J\^o.
2555
.,■4'^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "CI. 3. StaiiDarD )
O^ 0
PLACE OF DEATH: — County ofU <X-va^ JA,a>^^' v, Qty ofO/tx^-u JX<x.>x.o
u
No.
-'^^")X ^ St.; Dist;bct. . and i
(IF DCATH OCCURS AW»Y FROM USUAL RESIDENCE GIVt FACTS CALLtD FOR UNDER "SPECIAL INFORMATION" ■\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME J A-
■>j:\
PERSONAL AND STATISTICAL PARTICULARS
\\\\
i> \ ri: or iuktu
AC-K
Mi.nih
) V „'
iri-
(Davi
.1/.;/.'/).
/ >.
(Vfitr)
Pii 1 .
SIM.ij:, MAKKIHI*
\\II)<)\Vi:i> OK I)!\i H<ri:i)
(W'litfiti siK'ial (]( ^ii'tiatioii)
luk iHPi.Ac'i-:
• Staff or Cijiuit! \
NAMI-: ()l
FATIIICK
niKTMPKACK
<>|- lATIIKK
(Statf or Ouniifrv)
MAIDHN NAMK
(>I MOTIIHR
niKTIIlM.AOK
<H- MOTIIHK
(State or Cotuitryl
OCCri'ATlON V
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH < A,
III I
V^
(Month) (Day)
I ]fF:RI':nV CI-;RTIFY, That l attcn.k><l .kicased fruin
V..-'- 190'i to y^ ».a.
that I last saw h ^-^^ >n alive on V_ ct ■ ^
/go \
(Year)
iqo
and that death occurred, nu the date state«l above, at H 3 0
^
M. The CATSK Ol- DliATII was as follows:
I
OjLc
)
xx^y^ ^' .\<x v\ c
0 ,
DIRATION Years
CONTRriUn'ORV
Months
Da ys
Hours
n
.D'ulo
3^
nrRATIOX Years ^ Mouths Days ffours
(Signed) LL. U J.ccsi.(, M.D.
ili^ ^c. iqo"; (Address) 3.X5 5 H t U4s^\.fc^v jt
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying av»ay from tiome.
Residrd in San Fiamtsi'n A?> )>ats \ M,n,th>
/hnf
Tin.; AHOVK ST\IK,I) F'KKSOXAl, r A KTIOr LA KS A K I-. TKIK Ti > THH
HHST OF MV KNOWLHDC. K AM) HHI.IKF
(Informant ^ -CO ^ U L ^ • . L
f Adilres"^
Former or
Usual Residence
When was disease contracted,
If not at place of 6(athl
How long at
Place of Death?
Days
I'I.ACF: OF BFKIAI, OK KKMoVAI, I l>n*Kof Mikiai, or KF:M0VAI,
rNDFRTAKKK (H? • J ■ U A>w4a^ '^^ W<j
(Adihf
\,4,A.A-t
N. B. Every Item of information should be carefully supolied. AGB should be stnted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for psr-
sons dyinit away from home should be given in every instance.
D
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Brvird .if HiMlth I" No. u ^?*^«^ I'.&l' C
RCPCR TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Rpgistered JSi^o,
;!3556
.^lA^Ui
.+•
dOyvMj Deputy Health Oflficer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "a. S. Stan^ar^
4
No. '
PLACE OF DEATH: — County of ex.
»\
City of '--' <x.y\j JX,o^ ,
/ l!
w u u v. I
I
t
St.;
Dist.; bet.
and
(ir DCATM OCCUMS AW»V FBOM USUAL R E S I D E NC E Gl WE TACTS CALUeO FOR UNDER "SPECIAL I N TOR M ATIO N ■ \
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
srx
PERSONAL AND STATISTICAL PARTICULARS
COI.OR N
LL^ixxt..
DATi-; (ir iiiK rii
Ai.K
Mi.iithl
(Dav)
W^ 5V.n
1/-
t V<>ar)
/'..•
SIM.I.i:. MARKIHI*
\Vri)n\VKI) OR niVoRtKI)
W'rittiii v(Kiiil ill •^i^'iialHui)
niRTniM.Ai'i:
(State i>r (."omitt v
L i^cL^^u
MEDICAL CERTIFICATE OF DEATH
DATH Oi- DKATH
(Month) (Day)
I IIHKI'HV CICRTirV, Tluit I attcuckMl <lcrcasc«l from
rgn \
(Year)
^,
I9O
to
190 H
that I last saw h -• alive on U Cs up
and that death occurred, on the date stated above, at l
M. The CAISK OF DICATH was as follows:
U-, -
A-
I
I A riii;R
HiR rm'i.ACH
<)l" lATHKR
(Stati- «)r C(nuitry
MAII>i:n NAMK
ni- MOTUHR
inRTHIM.ACH
OK MOTHKR
(Stat*- or Ci)untr\
<H cri'ATION
Ur RAT I ON
Yeai
?
Mofiihs
Day
CoNTRIin'TORV L^Vvr>AA^ ^JiA^:>\.ci
Dl'RATION Years Months Pays
(Signed) . Y- ^ ■ ^^^^^^^x
^' el
Hours
Hours
M.D.
\ \
Rf>iilfit HI ^,111 I I <: >'< I '■
) V'lf >
M,.nth'
I hi:
U'l uyo'l (Address) kX^ w CV^Cl^j^ l j
;, iRstitnlfRS,
SPECIAL INFORMATION only for Hospitals
or Receot Residents, and persons dying away from liome.
former or
Usual Residence
H'iS
) i^KA^
H«w loRf at
Plare of Oeatli ?
Transients,
Days
When was disease contracted.
If not at place of death ?
THl-: ABOVE STATi:!) I'KKsmNAI, l>\KTIi'ri. SKs ARIC TRt K l'< » I HI-
nHsroI'MA" KNOW I,}: IX, K and HIIJIJ
(Informant ^ K^^t^JUrs^ UU {HL^V.\ '
( \.l.lr. -.-
I'l.ACK 01 HI RFAf, MR RKMOVAI, I I>Ali;..t llf KIAI, nr RKMoVAI,
w S-, 190 .
rl.ACK iM HI KlAi, MK Kn.>n*v
u
f '
Utyv
N. B.— Bvery Iten, of i„f«r«.tion .hould be c.fu.ly supplied. AGE should »-..««-*«^^EXACTLY PHYSICIAN* .h^
state CAUSE OF DEATH in plain terms, that It may he properly Uassitied. The Special information for |»sr.
sons dying away from home should be given in svsry Instance.
I
2J
J
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.1 .,t Jl. aitli !■ No 1- -"t^p^lii^' HS:!' C;
Dnfc FilviL 1 .ctHOA; V\
100 H
Be^lstercd JS'^o.
2557
^
(K^u^-^Ui
Deputy Hc-fth QflFicer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( m. S. StanC>avD )
PLACE OF DEATH; — County of O/v^^ J/vcu-^vCa.
City of Uxx^x* 0 A.
4^
^
St.
Dist.; bet.
and
No. W\Ajyv\^<X^
/ ir DtATM OCCURS AWAY FROM USUAL RESIDENCE GIVE TACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\
V IF DEATH OCCURRED IN A HOSPITAiL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^1 \
PERSONAL AND STATISTICAL PARTICULARS
Qf)\^L
n ^
i> \ I »; «<i- niKTii
\ ( . I-:
viTic
1
hj
MEDICAL CERTIFICATE OF DEATH
»ATH OI- DKATIi ,r\
\
Dav)
(Year!
M.iith)
^i\< .1.1' \i \KKn-:i>,
UIIxiU l.;i» OK IHVoRTKr)
'W'rift- ill «4CM'inl <l<sit.Miat ioii)
Dav
M.nilhs
It)
l)ii\.
BiR rnj'i.Ac »•:
I Statf or t "(Ml n 1 1 \
NAMI-; <i|
lATin.K
HiRTni'i.Aci-;
OI I AIIU'R
( St;it( or roiint rv
M A I I > v. V N A M 1'.
«»| M<)Tm;K
iilkTiriM.Ai K
<)|. MnTllKR
(statf or Coiiiiti\
<HTt PA riox
Li
<LiLA LL •
I Hl';Kl':nV CI^RTII-V, That I atti-n<lf.l ilcccased frniii
— — — — — 'T igo ■" to - .-- ~ ■ lyo ■
that I last saw h ... — - aUvc on ~~ _— ___ j^ ___
and that death occurred, nii the elate stated above, at —
.^r. The CAISI-: Ol' DIIATII was as folk)ws :
/cO-^olXA IfsjfYYSj mXrrrs^'
H
\Jnj^
y\Oj
I)( RATION J'O/'^" Months Pay
C ( ) N '1' R I lU "]■ n R \' V t CAA.\,<L4_«>^ (% . ........
/ fonts
Dl' RATION
^
i'liirs
Mouths
I\i\
]
iTi^Q
\ I
~- I
(SIGNED) J \X'dXKA^ ^5. La. , ,
U/tli D.^ UfoH (Address) isOb UAA.tU^. J.t
/A Hits
M.D.
<
r^^
(
.L.
S
.
Special information only for Hospitals, Instltuflons, Transients,
or Recent Residents, and persons dying away from home.
f\r-id,',l in SilPt / iiliiii'
) ,,ii
\r.,uih^
I hi 1.
Former or
Usual Residence
When was disease contracted,
II not at place of deatli ?
Now lonq iX
Place of Death ?
Dtys
rm.; An<»vK sT\ri;i) pkksonai, i>ariicii.\ks .xri; triic to thJ';
Hl-;sT ni- MV KNoWI,i:i)c",H AND WV.X.W.V
a
(Iiifotniant
Y\AyY\J
XfMrt's'-
UI.ACK OI-' JHRIAI, OR Ri;Mo\AI, | DAIKot liiKiAt, or KIINfOVAl,
i9tt XH looH
I N I) j: R r A K K R sXJ X/y\^<X (^ A.*
fA.Mlrss % i°L
N. B. Rvery Item of Informntlon .houlcl be carefully supplied. AGB .hould b« state.l EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In pliiin terms, that it mny be properly classified. The "Spetlal Iniormation" for p«i-
softs dylnft away from home should be ^iven In every instance.
i
f
<->'
(fr.
I H
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H. arl of If. iith I No i^ 1^^J^^lutl'C^ REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
IDO^
Bogistered JS'^o,
?2558
A,. -M D. .
DEPARTMENT ^ PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "a. S. StanDarD )
i
V\
'No.
PLACE OF DEATH: — County of (Jcx^v o .^.a. ,
4 ' I ll 14
^
St.;
Dist.; bet.
City of w /CX>^X; ^ .' v<x
and
/ ir DEATH OCCURS *W*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
XA%-yX\.^
SI.X
PERSONAL AND STATISTICAL PARTICULARS
I COI.OK \
w
C\
DA TH or lilK I'll
.\(,H
MEDICAL CERTIFICATE OF DEATH
(Year)
/ t
M..iitir>
)..;
;Uav»
M,>Hlfi'
I Vrar)
J>,
SIN«.l,H MARHIl-.I)
\vn»n\vi:i» nk i)i\<»K«i-;t)
(W'litcin Hofial (li~i>.'iiat inu)
«. >
niKTm'i.ACK
fStatf ur Countrv>
A
(Month) (Day)
I HICRI'IHV CI'RTII-V, That I attoiuUMl <lecoaHe<l from
190 i
I90 't to
tliHt I last saw h ■■ alive on ^' ' icp
and that death occurred, on the datt- stated above, at i
CL M. The CAl'SI': OF DJ^ATII was as follows:
AJJY^^'UUXX^'^'^ >j .Yvv '. '
NAMK nl- A
FATMJiK ('
HIKTHIM.Al'K
Ol' lATIIHK
(Statf or (."ountry
T
DTK AT ION )'ears
CONTRIP.PTORV
Months
Day
Hours
)^,«it_
-H,
MAIDKN NAMi: A
«>!• MOTHHK I I
HIRTIIPI.ACH
OF MOTHKK
(Slatf or Country
(1)
-cx/^^x:^
occri'A'noN ? ,
ResiiUit III SiiH / I iiiii i>rn
DTRATION Vt'ars Months
( SIGNED ) UAAJ\-^w<Xi J . M ) I
/hlYS
Hours
M.D.
H>0
SPECIAL INFORMATI
or Recent Residents, and persons dying away from home.
(Address) ui; M fWuM foM.^lni
NATION only for Hospitals, iRsntntions, Transleits,
J fii I
Mimths
Ihi
TH1<: AIUn'K STATJ-.D I'HKSONAK J'AK rUT!. \KS A K !■; TK! K To TIIK
»KST OK MY kno\vi,i:d«'.k AND iti:i,ii;i-
1^
(In
fornjant H 'VvCi XXx
\
l^JUU^
Former or Uxn 1 .
Usual Residence 1 1 ^ ' i ^^
When was disease contracted,
If not at place of death ?
How tonq at
Place of Death? I Days
1*1, ACK OF ntKIAI. c>K KK%fO\ AI, i DAT f: of Ht KiAi. or KF:M<)VAI,
,T\!l
INDFIRTAKFK
}kXj
1 u
190H
N. B.— Every Item of information .hould be cnr.fuHy supplied. AGE should ^^•*«««i EXACTLY PHYSICIANS .houfd
State CAUSE OF DEATH \n pl.iin term,, that It may be properly classified. The ''Special Inform.t.on" for per-
Hons dying away from home should be given in rnvrv instance.
Dl
^-:>
I
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hoard of H.iilth l-Vo it. 1:-f-^'Z.>. i;SiV C
Dale Fili'il. y
\j IH
lOO'i
Megistcred J\''o.
!559
2r^n^
OF
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( n. S. Stan^ar^ )
-?
PLACE OF DEATHS— County ofQ<X>
V
n
J *
City of U <X/Ysj 0 huOWYXJ:^.'^
fNo»
fc
(\T Dt»TH OCCURS
ir DEATH OCCU
St.
Dist.; bet.
s 4w»v FROM USUAL RESI DENCE GIVE facts called for under ""spec
RRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
and
lAL INFORMATION" "X
T AND NUMBER. /
FULL NAME
/(X/cyi "> •
{
^1 \
PERSONAL AND STATISTICAL PARTICULARS
I rcii.oK
LtxU.
MEDICAL CERTIFICATE OF DEATH
DATH Ol' DKATII
UATK nr- lURTII
A<.1-:
ai>t /
I Moiithl
Hq )v
(Dav)
M.nilfl^
/',/i
u'n)(»\vi:ii OK n!\<»Kii:i)
'Wiitt'iii social ilrsi^fiiatioti)
lUHTIII'I.ACl',
1 Stat. .,T I '.iimti \ '
I
NAM I'. Oi'
»*atiii;k
?
HIRTIIIM.ArH
OI" KATIIKk
(Statf or Ofiunti y)
I
MAIDKN N'AMK
OI- MOTIIKK
7
HlklHIM.ACl.:
Of- M<»Tin':K
fStatf or i'oiiiilry)
I
orcri'ATiON
Rrsi,ff,t
in Smi /'i am i>»'n ,/% U )'t'<iis
(Month) (Day) (Yiar)
I m-KI'HV CKRTII'V, That 1 atUii<kMl acivased fn.iii
— — -190 tu ^ —- Tcp
thai I last saw h rrr- alive on icp
Mild that lU-ath ncciirrcil, uii the ilatt- stati-«l ahuvf, at
M. Tlu' CAISP: OI' l)i: A'ril was as follows:
DlkATfoN
JVa
'ars
CONTRJIU TORY AT V\<X->xXltl<L Ihw^ i^ y
Davs
Hours
vclC^
nr RAT ION >V<?r.? Mont /is /hiys Hours
,NED) Lcr^^-CPru^V J.'fcll ' ' . - M.D.
(SIG
' rt: %^-i
I<>0
SPECIAL Information only far Hospitals, InstUyftths, TriBsleiits,
or Recent Residents, and persons dyinq A-^xi from home.
M„iith-
lh}\
^.
Former or 1 p. ,
Usual Resldfnce^AJ,<x,^dwe^
Now long at
nare of Death?
Days
Wlien was disease ronlrarted,
If not at plareof death?
THi: AHOVK STATI'J) I'KKSONAI, I'A K T KT I.AKS AKI. I'KIH To KWV.
HKsT OF MY KNo\vi,i:i)<,K AM) hi;i.ii:f
Informant \! MwlX^VXJ. \l rW^^^
ri.ACK c)i. Ml KIAI, OR KKMnVAI, I DATltof III hiai, or KHM<»VAI,
fNDHKTAKKR > W. O <Ka.^^t '
N. B. Bvery Item of information •hould be 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-
son* dying away from home should be given in svery instance.
f
i
I
^
,5
WRITE PLAINLY WITH UNFADING INK
D<f/r /-VA"/, t|ct<Xov ^H
J90H.
THIS IS A PERMANENT RECORD
BEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\''o.
2^
560
OK. Deputy Hen.'th Oflficer
DEPARTMENT 0^ PUBLIC HEALTH^City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH:-County J<xJIx<x ._.,_,. cuy of ^,^. J^f-.o , .
( <r DtATH OCCURS AWAV TROM USUAL RESIDCNCr ^^*** ^** "• ^^'-"^^CrVi and LUX^
FULL NAME Ut..L.,v mTLc
C4 c c
V V
)
SIX
PERSONAL AND STATISTICAL PARTICULARS
■^
n
' U I
1 n \l
DATK or- lukin
x<.j':
I
i^
4.
M.iiitli )
H3 ,,.„,.
Wri)(»\\ |.;i, OR I)l\oKv-l-l>
'\\Mfr III ^.KJMi .i.-si^r,u,ti,„l)
It
'Dav
M.inth- O
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH ,^
IQO \
(Year)
K. 1
(Vear)
A? 1 ,
, Mii.:u,.:iiv c,.:rtifv, tiw„ ,„„.,„,..,, ,,„.o..,...,i f.„„
niRTHPl, AOK
(Statf- or Count! V
N'AMK Of
I-ATIIHR
lUKTHPI.ACK
Ol- l-ATni:H
'Stat, or Count! v)
o| Mo'l'llliK
T90H t.> Ut:,t ;xi ,,^.,
that r last saw h / r.livc .m iDcl -
».„ltI,,-,t,U..,lho..o,nTc,l, ..„,|,,,|atc.|Mt..,l V.-, ;,t lC>il
M. TheCArsi; or |„.:.vril was ,.. foll„„s:
y,x.>v<^ Y tiv<d Jv^ ,U^ L^ Q_^^^^
^La.l .,'„.,, ,,»| tiu %iavt ou. ^ ■ \ , ■
dir'ation
) ('lU s
Months
Ihi
Is"
Ji
(SiGI
//t>iirs
.NED) J 4v<yo 09. J^ux^cytXA^
niK rifi't.ACK
'»!■ Morinik'
"^t:it<- or Couiiti V
V
r^ P
U
-t
fcjO
/tout 'i
M.O.
.rl^en^Zu' I'^SDf f.^'^* ?l'Lr""'' '"^"•^"»"^' '"^^
1/,.,///,,
3. n.
Formfr or
Usual Residence
When was disease confrar fed,
If not af place of death '
How tonq at
Ware of Death ?
Oavs
(Informant \XX ■ .Lx-V U- I ^ ^^"^^^X Crt U-C<X-Q^ I ^^ ^H
J (1
N.Mr.s. RlX' IS lix.
TQOH
N. B.-
A.i.hv.s 3iq U"acc».'v^L
■.';;V/c'ru'"8E'oFtE;^^^^^ !:;;"^nH"^ :'"^''"^*'- '^«R «^-«i h, ,.„te.l exactly. PHY«,CIAN« H .7
* i
^
^
>,
I
t
I!. ..ml i.f Health !■■ No. k :S'$^^^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
f" :ar!-~ti> lu^ J' Co _
REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
Re^isfet'ed J\^o,
790H
ow<H.M^ L| Deputy Hecith Officer
o/x
DEPARTflENT OF PUBLIC HEALTH-Cify and County of San Francisco
Cettificate of Death
( Ta. S. Stalt£>ar^ )
PLACE OF DEATH: — County ofaay>^ d^cx_ , vacc. City of
^(1
^"(Ta
^>
-V
CX/>x.^ 0 ,\,<X > vc
CC>a
n)
U A ^,
No.
\h
St; ?. Dist;bet.V_<XLLlC^
\A..a.. and Oxxc\.a *
f "" f/rr*'..!.''*'"''^ *'*'•'' ''''°"' USUAL RESIDENCE GIVE facts called for UNAkR ■'specal inform'1t,««^^
\ IF t>EATH OCCURRrD IM A uncDi-rii «= .^c^,,-. .. • unif^H SPECIAL INFORMATION'
.T„ occu-.co ,„ . „„,,„., o„ r„s",j;v« o,;. ,Ts nVme° .'."s'Tt.",,^? srV/.Ti.'o";"::."-"'"" )
FULL NAME
ll) . ,
si;\
'4
PERSONAL AND STATISTfCAL PARTICULARS
HATl-; nr- lUklH
a.
MEDICAL CERTIFICATE OF DEATH
DATK Ol- ni;A'IH
^
il^ct
/go t
(Year)
/
A(,i-:
JV„
Q
( I)a\-
Moulin
■ 1 -
(Vrar)
I),j\s
"^IN«".l,i:. MAKUII'I*
WIDOW I.; I) OR DIXDKfi.:!)
' \\\\U- in v.M-ial d. -ii- iiat inn >
HIRTHIM.ACH
'Statf or I'unntrv^
K
^ I HHRHnV CKRTIFV. That^ [ Mttcmlcl .IccLascl from
^■^ SI. lyo , to AOt± 2.3, iQoH
that I last saw hw'A. alive on w ^L _?, .,_
and that *Uath orrurrcd, mi the date stated ahnve, at
c<
M. The CAISH i^V ni-ATH was as follows
I
{]
'<r>"w^^^-^^-4-,v<n'^-Q O <>
o
NXMi: (tl
I All! IK
lURTm'I.ACK
<>l' I AIIIHR
<Stat« or I'oiniti \
MAII»j:\ NAMl
<>l .MoTllliK
lUKTnpr.Ari.;
<H MnrilKK
(Statt or Cumittv
&ttX\/^'d
^ i
I) r RAT ION );,/
CONTRim roRV
; A
I
X\ > .
DIRATION
(SIGNED )
.^ font /is
'K fhivs
Hon
rs
/yavs
dJ ^
Uf^H rAddress) \^{i^ ob <H.U-0LKJL .. jl
f fours
M.O.
Special Information only lor Hospiiais, insmuHons. Transienis
9r Recent Residents, dnd |>ersons dying away from home.
orrrPA'iioN
J rt! .
M.oitit
I >,! 1
Till-; \Hn\H STATi:i) I'HKSoXAI, I' \ R I" KM' f. \ K-^ AK Iv TK T H To Till-'
Hi-;sr OF AiY KNou i,j;iM,K AM) Mi:i,n;i'
(liifoiinatit
Former or
Usual Residence
When was disease contracted,
If not ii place of death?
NoH lon^ i{
f\vt of Death ?
Davs
190 t
I'l.ACK Ol- FHKIAr. nK RKMoVM, I DATl-of Miniai or KliMi.VAF.
' A.I.I, .s. 112,1 OTUa
N. B,.
-Every Item of inforrtiHtion •houlii be cnrePully nuppMed. AGK •hould be iitnted BXACTLY. PHYSICIANS should
•tate CAUSE OF DKATH in plain terms, that It miiy be properly t^lasalffled. The "Special Information" for |»er-
aofie dying away from home nhould be given In my/try inntance.
^
(r-A
I
■
1
1
^^m^-
/*»V»«^*-"»
li'
11
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
■i l|.i!ih-l' Vo '■ ■f—yc_.^^.uf<}-c,. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
SLH
o^\^<.KJsdJLA>u Dei
WOH
Jfr'o'/.sfe/'ed JVo.
25^^-'
6^
DEPARTMENT OF PUBLIC HEALTH=City and Countj^ of San Francisco
Certificate of Beatb
( *CI. S. StanOarC^ )
PLACE OF DEATH: — County of ' City of
No.
St.;
Dist.; bet.
^V>/Cr>^
and
(ir Dt*TH 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
tu
<XhA.i
m
PERSONAL AND STATISTICAL PARTICULARS
DATl-: Of lilRill
I
L
I
A<,K
LI
MEDICAL CERTIFICATE OF DEATH
DATK ol* DliAIM
I>,i\ I
M^nilhs
\ car
(Month)
Dav'
rgn
(Vi-ar)
n
1 in-:RIiBV CI:RTIFV, That r atteti.k-.l <lf. rased from
!>IN«.I,i:. MAKRIi;!)
\\ II)n\\i;i) (»K ni\«iR('Kr) ^
(Wfiti'in social (lc-iv^ii;iti"in) 1
lUKTHI'l. \i'K
■state (,! < , iimtr\-
I- Ai-in,i<
lUKTUF'I.Ar}.:
<>I- 1-AIHHK
' Stale (ir Ooiintrv
MAIDI-v; NAMK
<»l Mo'lIIl-R
lURI'mM.ACi;
<»f Mo'I'lIJCK
'State ( It (.'(HI jitrv"
oCCri'ATION
A
ii'/t.t 3sO iQoS to
that I last saw h — alive on ~
^^ A
and thai <k'atli Drciirrcd, on the date '-tatid ahovi.-, at
" M. The CArSl- Of' IHi.XTII was as follows
^
I )r RAT I ON Years
CoNTRimTORV
Mouths
Ihivs
//(iiirs
DIRATIOX
(SIGNED)
)'i'ars
IT
Mnnth.^
Ihxvs
ii),ct.
/fours
M.D.
Xc T9o'l (Address)
SPECIAL INFORMATION only for Hospltab, institutions, Transients,
or Recent Residents, and persons dvinq awdv from liome.
Krsiih'd in Sitif f ! iiiii lyt'i*
)•.-,! I
M :-t)l'
l>i}\
former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli ?
HoH lonq at
Place of Death?
Days
THi-: AHox'i-: sr \-n:i) !'krs(i\ai, pARrict!, \rs ari-:
UKST Ul- MV KNoWlJ.IX'.l-: AM) liKMI!!-
(Informant ^X ^ '.'■•-. H^ lL'
TKI K TO Till-;
Acldru^H 0 C)1
i'l.ACH oi" mKrAi, OK ki:mo\\i. i i»\ri;,,t
(is i
I C)0
Ad. h CSS s^bbb y JX
-wQ^Avir*
IN. B. Every Item o? information shoulfi be cnrefully Hupplied. AGB should be stated EXACTLY. PHYSICIANS •hould
state CAUSfi OF DEATH in pinin terms, thnt It may be properly wiawslfied. The "Speglal Information** for p«r-
fiins dying away from home should be given In ovory instance.
I '
^
I
c9i
i
< k
ir
'♦■
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
Be^Lslered JSI*o.
^56;
ioo\
^Hj Deputy hiealth Officer
DEPARTMENT OF PUBLIC HEALTn=City and County of San Francisco
3
■6^\A-<i
Certificate of 2)eatb
( tl. S. StanDarC* )
PLACE OF DEATH: — County of O/Cu^^ 0 a.<x
A
n^
vc
City of
i
o
Q^-^v^
No.
St.; 0 Dist.;bet. \XX\, and ^ I
(ir DC«TM OCCURS AW«V FROM USUAL RESIDENCE GIVE rACTS called for under "special INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
%
FULL NAME 1 I
^1 X ^
PERSONAL AND STATISTICAL PARTICULARS
t:c)i,«)R \ s
J X^^^CcA„
<
DA n-; nr lUKTii
Ai.K
(Moiith>r
(W-ar)
^
0 J,-..,
I Dav
M,,Htb>
» tar)
/>,/ 1 .
■^IN'I.K MARRIHIJ.
N\ IDnUKD OK I>lV«>Kri:i) ^
iWiiti in MMMiil »l<>«ii.'iiatii»u)
lURTIII'l. Ari-: /-v
(Statt or r.niiiti \ [ y\ %
VlKJad
NAMr (H
I A 111 j;r
-I
MEDICAL CERTIFICATE OF DEATH
DATK ()!• DHATIl ,^
(Month) (Day)
^ 1 I[I:RI-:BV C1;RTII-V, That r atten.UMl ,ltHvasc<l from
' " Kp -■ tn L' C^t 3v3 IqoH
that I last saw h ■•■■ alive on L-' cJj ;i o loo i
and that dcatli occurred, m\ the datt- stated aluivc, at
_" M. The CArSl- OI' DIIATII was as foll.ms-
!,,_ .... , ,
Hik run.AiH
<n' I Arm.'K
(Slatf or i'luintrv
lUR ruPT.AOK
(Statt or Couiitrv)
t)CCri'ATU)N HjV
C\
A^-yr^JJsJ^K K
Dr RATION X )'ra/s ^i^otit/is
A
a
<XKk
CoNTRinrTORV
or RATION b Years
/)avs
I fours
(SIGNED
Mo)iths
KX.K \ X..)
fhiv
Hours
M.D.
l<>o
(Address) 113.1 JU JtA>vC. o. d. i,\ c .3t
'\jbCa^iv<x
Special information ©nly tor Hospitals. Institutions, TrinsJeBts,
or Recent Residents, dnd persons dying away from home.
^
Rfsidfd lit Sail /■ I iiHi isi'o
);.ti
M.nith'
I hi
Tm; Ai?()\'K s*i'Ari:n pkksonai, tar rirn ah-^ ari-; rKri*: rn tiih
HHSr Ol- MV KNOW I.i;i)»',K AND HHI.Ii;i"
(Informant \1 'VvO JV.o<X l
Former or
Usual Residence
When was disease contracted.
If not at place of death?
Now lonq at
l^ace of Death ?
Days
I'l-ACl-: «»l- IHRIAI, c»R RKM<i\AI, I DATJ-o' Ht kiai, or Kl-'MOVXI
I ni»i:rtakkr OcHLc^ut^rw u itXAJt UL'w.r*^
. N
T90
N. B. Every Item of Infopmatlon should be cnrefully supplied. AGE «hould be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
sons dying away from home should be given in 9vry Instance.
mm
I
I
m ■
I
s>
. -to
j c^ »
'SW-^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Sm.ii-I . f Ilinllli I- Vo : - •«'t-:^3^; WS^V Co
REFER TO BACK OF CERTIFfCATE FOR INSTRUCTIONS
Dfif,- FiJ,-<l. h.A.(X
0 V ^ A
M^h
.*. ju,
Deputy Health Officer
Ee^istcTed J\'*o,
2564
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
-?
PLACE OF DEATH: — County of cl^^ ^ ^^
h
City of u ex
.v'a:
No. I (: S C 5.L.\..^4\.
St.;
1
1
(ir OtATH 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^ /
Dist.; bet. AXO. \ " <^ > ^^^^^
FACTS CALLED FOR UNDER "SPE
GIVE ITS NAME INSTEAD OF STREE1
FULL NAME J L6\.a^
and V '
0
{
PERSONAL AND STATISTICAL PARTICULARS
"^1. \
lOl.OR ^
'1
I 'All-; ol- lURTH
At.H
/kt
Mnllth
D.i
/',/
^!N<.I.I-: MARK IID^
UF DOW 111) (»K U!\< iR> l-l)
niKTHIM, AC}-:
' stall (ii ("..iiiitl \
t
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1;A'I"II ,; \
Vi'ct It
(M(iiitli) (Day)
^ I HHRKHV CHKTIFV, That I atten.lfd dcioascd frnm
L. cL u 190H to ' t
tliat F last saw hi. alive on w '^ . * '.
TOO \
(W-ar)
190
aiiil that (U-ath nrriirred, on tlu- date state<l above, at I i
.' M. The CAISH or !)j;ATn was as foll.nvs:
.K.\^',
Kr-
f^l
•il
NAM I* 01
I'ATIUIK
HlRTmM.AOH
n|- I AIHHK
(Statr ni I'outitry
maii>i.:n' xAMi;
oj- MoTHKR
HIRTHPI.ACH
Of MoTllKK
(Slatt or Conntiyi
A
M
DIRAIION '^ }'iiirs
CONTKIIUTORV
.Vinit/is
Day
Hours
\v
N
DIRATION
(Signed
)\iiys
Jfi>n(/is
/)av
■,n
~N
Hours
M.D.
KjK
i. 'Xl I
90
( Address) i5 15 ^ihx.cCJ. I
"H'Cfl'A TIOX
\^K
Rfsidrd ill Siiii /ill
) 'lUI i
1/,,»M.
n,
Special Information only ^or Hospitals, Instifutlons, Translenls.
or Recent Residents, and persons dving away from (ion»e.
How lonq at
Plar e of Death ?
Former or fJ N ,
Usual ResidenceMDaAXv-r-w<;'u^ /
When was disease ronfracfed,
If not at plare of death ? 5 A|,4<xM ^m:^
Days
Ayw
rill.; AHOVK STATHI) t'KRSMNAl. I'A K TFC r I, \ R ^ A R ! ; TKIK To Til).; PI.ACK Ol- lURIM, OR RHMoVAI, I DATJ-'.f Hikim. nr KKMt.VAI,
liiCsT oi" ,Mv KNOW 1.1,1 ><■,}.; AM) in;i.n;i' /t) < I 1 _»
1
(infoMiianl US . U XtX^^ M K- ot)
0 J>
LuA%AX*i^
N. B. Every item of ir.form«t1on should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it may he properly classified. The "Special Information ' for per-
son* dying away from home should be given in every instance.
^
; J^\
I
I
19
II !!i 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
VJO'i
X^^^^ ; ,, Deputy Health Officer
Registered JSfo.
(^^\^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
K "a. S. Stan^arD )
PLACE OF DEATH: — County of U<X^^ JXOAUvUyC^ City cA^^Xp<\j Ja^Cuwc^l^oo
C CK. isti^tcLli Dist.; bet.
and
IF OtATH OCCURS AWAV TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDCR "SPECIAL INFORMATION'
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
FULL NAME
KUXj \
\XXX^
PERSONAL AND STATISTICAL PARTICULARS
i>A ! i; or lUR rn ^'\ a
' iuJL
t
MEDICAL CERTIFICATE OF DEATH
DATH <»1 nilATH /, \
vtcLu
Il:iv
\< . !•;
bl y
M.
\vri)ii\\Ki) OK nn'oKn I)
iNViiti in social <lt -ij.'ii.it!i i!i '
BIKTHIM. \0K
fStatf or I'uunti % '
lU^ccL
•'•ths 'X^^
^XaT
W-at)
n,n
(Uct
CMonthl
ix
(Day* iVcar)
^kolu
I HHRI'HV Ci;RTn-V, riiat.I atteiulcMl «kc-.asc.l fmm
that I last saw h-t>v alive on (L-ot %% I90H
anul that (loath occurred, on the d.iti- -.t ate.l ahove, at 10 ID
aiju;
y\. The CArSI'! OI- I)i:.\Tir was as follows
AJ^Af
ruQL<i
»A l!I }.K
HIKTHIM.Al'F
Ol- IAriIl-:R
'Slat! or Count!
m mdix x ami'
<•!■ m<)Thi;k
lURTinM.AOK
«>»• M«)Tin:R
(Slatt or Countrv)
oiATl'ATlON
c
e>ta.
I)
DTK AT ION )'t'ars
CONTRIIU'TORV
Mouths
Davs
Iloitt s
%
ic^l
DIRATION Yiars Afont/i.s Days //ours
(Signed) J L . iLoyif.xx-^vcLi^ ivi.D.
Special Information only lor Hospitals, lnsHfutl»Bs, Translciits,
or Recent Residents, and persons d>jng dHdv from home.
AV' I,!, ,f I II Si! I! i'l ,!
n , - w f »
'- 1/,. ,//;>, *" 1>,!V>
TH1-: AUOVK SIA ll'D I'KRSDN \\, 1' \ R IIC T I, A R S AKH TKt H T< > THK
HlvST C)l-' MV KNnWI,j:i)(;K AND Hi:i.n;('
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq »{
Place of Death ?
Days
lliifotnjatjt
^.Q
Oc- a^rx^y^^^ A^A.A^
(\«l.lress
5^01
oU-'UM^A^^rv
<X 6t
PI.ACKOI" ni'KIAl, <»R RKM«»\ \l, I J>\r}:..f HiKiAr, or Ki:MnVAI.
c^i^cdoc^^ I ^^ ^^ .90H
(•NDKRTAKKK U /tXJwV VS-tC \I |VoA^C/VA^ ^J-^ WO
(A.Mr.s. 15 9.H 6i<^^Jkt4>A 6t
N. B. Bvery item of informntion should b- ctirefully supplied. AGB should he stnted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for per-
sons dj-ing away from home should be given in 9\mri/ instance.
3*
k^
\l
..#••
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
7)afr Fi/r^f,^d^J,j<K^ X^
lOO'i
Begisfcj'cd J\^o.
2566
.{y\,c\^.
"^ \ * A
Deputy Hcaith Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County ofua.-v^
Certificate of S)eatb
( "U. S. StanC>arC> )
City of 0,cuw
J A,.
CA^
m
No. ^CCr>
1
and
C\ aS>.; — Dlst.;bet.
(ir t)E»TH 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
PERSONAL AND STATISTICAL PARTICULARS
SI \
?
I>X 11, .tl' lUKlH
A«,H
■<)I,nR^
LI
?Jxkt,
siNf.i.i-: MARkiKn
u iiM >\vi:n itR i)i\nKi'i:n
•Uiit'-in -.iii-i.-tl iU'^i).'?i;itii 111 )
in
I l);tN '
M,<t,lfi
/ 4 0 H
(Vt-ar)
/>,i
t
CoJx.ou \.lLx_L >
MEDICAL CERTIFICATE OF DEATH
DATH <n<' DHATIl /A
(Month)
(Dav)
/go
(%■< al )
inRriiiM.AO}-:
'Siati or (■tanitrv
N \Mi-: III'
1' A IHICR
mRTHI'I.ACK
0» lAlIll'R
(Stall or Count! v)
MAlIUvN NAM1-;
<)!• MOTIIHR
151 RTH PI, A OF,
OF MoTHJCR
(Slatt* or Coutitrv
oOCFl'A rioN
D
I HI'kl'HV CI-RTII-'V, That I atteiicltMl <lc( rased from
^ Zk up. to AJ^ti XX
that I last saw h-w.' alive nn ^ " ^
aii<l that (leatli occurred, on the date staled above, at
M. The CAI'SI': <)!• DIIATII wns as folhrns
icpi
Ttp
e
XI
"i- '1 v-O.. i
r ;l I
^^
^4vYv UVlc
I ) r R A r I ( ) N > 'cars Months Pa vs
CONTRIIU'TORV U AX-^-^^cCtv^^x.^. .:
I )r RATION Years Arniit/is /)avs
(Signed^ y%^ u '^il/N. oc .
A-ldress) ^ 6 t CJ A^-CLuw Ul,
Hours
Hours
M.D.
Kj^Xj
IQO 1 (,
Special Information only for Hospitals, institutions, Tr««sifBts,
or Recent Residents, and persons dying awiy from tiome.
Qj
u
Rrsiihii HI SiDi I'l ,-i>u i -I'll
)'rii I
M.xifh-
/hn
Tin-: Afun'K stati'I) pfr-sonai. i'AKTicti,ARs AR1-: TRtH r<> Tin-;
IlKST OP MV KNn\VIj:i)»'.K AM) HFI.Il-F
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq »i
Place of Death ?
Days
•^ \
190 I
ri \CF <)I" lUKIAr. OR Ri:M<t\AI, j I)VTF:of inHiAi. or ri;m(>\ai.
INDKRTAKFR W oX^tx^- ' ' '
N. B.— Eve.y item of information should he carefully supplied. AGE .houid he stated KXACTIY P" ^81 CIA N 8 should
state CAUSE OF DEATH In plain terms, that It may he properly classified. The S,»eci«l Information for pr-
sons dyinft away from home should he ftiven in 9\9ry instance.
, S)
: -^^
I B
>^m-
(#
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
f II. alth I' No !~ "*-^^!-'^>H5il' (■
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ditie Filed ,
9.H
100 "i
Registered Jfo.
2567
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
i "Q. S. Standard )
PLACE OF DEATH: — County of
No. ^^ IH (/LKo^-..-
City of Uc^y^^K<y.
%
St.; b Dist.; bet.
IH ii
\.
and
(
IF DEATH OCCUHS AWAY FROM USUAL B E S I D E N C E G I V E FACTS CALLED FOR UNDER SP
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STH
ECIAL INFORMATION' \
EET AND NUMBER. /
FULL NAME
a..,
'1)
xou
X V\A.'
PERSONAL AND STATISTICAL PARTICULARS
DAIl or HIRIII
k
WMonth)
Ac.H
IS ,V.,
M
(I>av)
M,.f,th>
n
\ car
Pil vs
MEDICAL CERTIFICATE OF DEATH
DATH Ol- I) MATH , \
\]^\.
(Month) (I):iv
I go 1
(Yf.Mr)
HIN<-.I,K. MAKkIKI>
\V 1 1)( )\y i: I ) o K I ) I \i > K i" H f>
tV\'ritfiii •H(>ci:il <ltsiv»iiati()ti)
LI ^.-^W^^^
BIRTH PI, M'l:
^Statf or I'diiiitry
NAMl-: ni
1 ATHKR
niRTHPI.AOK
OF l-AIHKK
(Statf or Count 1 \
maii»i:n namf
<H' m<)Thi;r
lURTHl'I.ACK
«»F MoTHKR
(Statf or Country)
I-
I III'IRICHV CIvRTfFY, That I atU-ndtMl (ktvastMl frr)m
'.: ;'' lip . i<) *c tX C\3 190H
that I last saw li •■ alive on ^ '• - I90 ',
and that death occurred, nn the date stated ahove, at i
a
:\r. The CATSJv t)!-' DIIATH was as follows:
n
%
-v^X
VV^CU
\ t'
.,.,Ah>u^<2Lt_j_L/txj-u -U^-O
1
+ ._'
DT RATION
}'raf
S
Months
Da vs
Hours
t -
ft
CONTUinrToRV
1)1' RATION Yiius
\.\
Mouths
(SIGNED)
UA
4X0 w
rD
"^%
.o/L"
OCCl'l'ATK
fsfsiitfii ill San /■ 1 iiiii i>' <'
\_ ... vi
a, ;,
(Address) "^SQ-i
/hiys Hours
M.D.
XD^tk It
Special information onh for Hospitals, Institytitns, TransieRts,
or Recent Residents, and persons dying away from liome.
) ,ai
Mnllth.
I >l! I
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death?
Days
THJ-; AHOVK STATl'l) PKRSONAI. I'ARTICC I.ARS ARl! TKIH T< > THH
MHsT oi' Mv kn'<)\vi,j:i)<;k and in:i,ii',i"
rv
(Informant C> ^ ^ Kxt-OT
PI.ACK 01 in KIAI, Ok KICMOVAI, I HATi; of lU RiAt, or RKMOVAI,
I- N I ) K R T A K K R v) (tLcLCAV ^ OJilj Ll ^ u O >
(.
Qrrw.
N. B.— Every I.em of ,„«„rm..lon .hou.d be .nr.fu.l, .uppl.c.l. AGE .W.1 "• ••'•"•',^''.*«ILV P"^''';;,*^,;;!:;.*!
.tatc CAUSE OF DEATH In ptain Urn,., that it may he properly cla...U.U. The Special Information for per-
aont dyln* away from homo should be (tiven In every Instance.
^i.
. 4=f
I
"■
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
IlrKi rd . , f H .-n 1 ! Ji V So. i% *rV[^j> 1 US: V C ,
REFER TO BACK OF CERTlFfCATE FOR INSTRUCTIONS
Iics^istcfcd J\^o,
2568
ludr Fii,ui,^.iz)zA^Jc\^ an IfiO'i
d.Ji\XAA dJL\yM Deputy m--.;.*, oflflcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH:— County of .A ^^ ■ v City oiOoyr^ -^ Ko w cc^.c
St.; : Dist.; bet. U /CULtAAyC^^XX and Jaa„Ov
/ ir DEATH OCCUnS »W«Y rnOM USUAL RESIDENCE give facts called for under "special IWrORMATION" ^
V ir DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME VA.\n^^ vUc
No. Id 11 qU-J^cxXJc : ^^
si:x
i' \ri". nr lUK Til
Ac-.K
PERSONAL AND STATISTICAL PARTICULARS
0
C\
IL^.t
M..nth'
)V
(Dav)
M.»:ih^
i'>'tar»
Ar
(Year)
•^JN'.l.K, MAKklJ.n
(NVriti- ill Sim iul clrMiKniitHtii)
C)
HIKTIIIM.AiM':
( Stat I- or i.'iinnt i y
<^^-Ma^
NAMi; (H
I'ATII1:k
KKJ.
MEDICAL CERTIFICATE OF DEATH
DATE Ol- I)1:aTH "X
Uct
(Mciitli) (Day)
I HICRIvBV CI'RTIl'V, That I atU-inkd (Urcascd from
C ct .-.f: I90i to C'tJ: Xh looH
that I last saw h a. . . nlivc on U ct^ .4cs igo "^i
and that cleath (»ccurrc<l, on t Ik- date stated above, at t iO
M. The CAISIC Ol- DllATII was as follows:
nr RAT ION
rD'\-"r\^
FURTHIM.Ai'K
<H 1 A iiii;k
fStatf 1)1 i'<ntntt V
M XIDi; N N AMI-
niRTII!M,Ai.H
of MnTllKK
(State or Comitrv)
k^Oo G
\ ''.
)V</;-.v Months H /?^7j'j
C^ 0 ,
CONTRIIU'TORV L vl\-tXA.4^^Lv^fe^ .
Hours
flu
OCCri'ATlON
Resided in San /'> int</. <■!'<>
[)r RAT ION
(SIGNED)
)'i'ars Mouths
J. CJ,4JUC'
l^avs
Th
r\/YV
<JL-C U v'
ours
M.D.
i<»o
(A.i.ircss) amio ■ n
Ik, It
Special information only for Hospitals, Institutions, TransicRts,
or Recent Residents, and persons dying away from home.
) ViM >
Mmitlo
/>,n
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How tonq at
njre of Death ?
Oavs
Tin: ABOVE STATl'I) t'KKSONAl, PA K I'li't' I,A KS AKl", TKlH T» > TIIK
HKST (H- MY KN<)\Vl,i;i)r,K AND lU-.I.n'F
(In f..i n.ant ^ SJUdULSjuZAX \K^^ K-b C \. > ^
PI \CK OF lURIAI, OK KK\foVAI, j 1)\1 l.-t Hi kiai. or KICMoVAI.
(Address
wa.,>:l^ <w^ > \.
., .. 1- A ATF .hould be stated EXACTLY. PHY8ICIAIN8 iihould
sons dylnft away from home should be given In every instance.
■
i'
y^V*»WW .««
i^
cs.
PERSONAL AND STATISTICAL PARTICULARS
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
""^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
190H
Registei'ed JSt'^o.
S5G9
Deputv H--:", Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "U. S. StanDarO )
PLACE OF DEATH: — County ofUCU-rv^ J h^aoxc . City ofvJ<Xy-^ ^ K/X-
/7\
Dist.: bet.
KXA^-^-X)
and
V.J
/ \r Dt«TM OCCURS *(^*V FROM USUAL R E S I D E N C E Gl Vt FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ !^
\ IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / I
^
FULL NAME
y%.a
n i
) \ I 1 <tr HI K Til
l.\
D.iv
4
) V</ » .4
M.,uilis 0
%
\ tar)
Da 1.
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATIl
U^Lt
IQO
(Year)
>^IN<.I,K, MARKIKIV
wiixnvKn OR ntvoRiKi)
(AVritcin -iKial di^iL'nat ion)
A.-> wO
HiR rHPi.AOi-:
IStatr or Ouuiiti V
NAMK <>I
F \thi;r
HIRTHF'UArH
OF l-ATHKR
(Statf or Country)
MAn)i:N NAMK
<>!• MOTIIKR
lURTIIl'LACK
OF MOTHKR
(State 1)1 t'nuntrv^
(Month) (I)ay
I HIvRI'BV CICRTTFY, '1 liat I attcudcd deceased from
K^tX 1 : 190 ; to Dc±. ..a.S .. 190H
that I last saw h w alive 011 ^ .^ X% lakL^Ji. i<p ;
and that death occurred, on the «late stated above, at oJ^
Ji.w.' M. The CAT'SH OF DHATII was as follows:
'>A4
iVU
<LlaJL -Lo JbQA-^-^%. Q c , j X. . . ^ ::
Oco_ V
kLcxLu
1 ^ i
0 L
DI'InATION )V</;-,? ^ Mouths Pays
CONTRim'TORV llj XoJi^rUU^ xt^
Hours
)'i'(irs.
Mouths b /Jrti'.s-
,^ •■ iH
L^tl
u
occipA rioN
DIRATION
(SIGNED)
ill-atj IH IQOM (Address) S'C?> \l KOI vt^,^
Hours
M.D.
H
SPECIAL INFORMATION only for Hospitals, Institutlotis, Transieits,
or Recent Residents, and persons dying andy from home.
sitird ill Sail /'lami^rn ^ Vrai^ 0 yr.uiths b /^<m.
rHK AMOVK STATKI) I'KRSONAI. PAR T ICF I,A KS ARF: TRIK TO THH
nnST Ol- MY KNOWl.KDOK AND HKMHF
i P
Former or
Usual Residence
When was disease contracted.
If not at place of death?
Now long at
Place of Death ?
Days
(Inf<nniant
(Acltlrc'
^%% MJ A..d<Mi^AMX4^
ri.ACE OF niRIAf, OR RKMOVAI, j DATIlof Bcrial or REMOVAI^
INDFRTAKKR
A<l<lrc<«<("
3.06" QrlV&>xI.^ U^^L.
of information .hould be carefully supplied. AGE should be stated EXACTLY P»Y8»CIAN8 .houid
E OF DEATH in plain term., th.t it may be properly classified. The "Special Information for per-
N. B.^— Every Ite
state CAUSE
•ons dying away from home should be ftlven in svsry Instance
^
1
m
I.
I
^1^
r'
.1
'it
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Honrd I'f ITealth I V
^■■, — •
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
190^
Registered J\^o.
?3570
XJ^
r\>M
DEPARTMENT of PUBLIC HEALTH=City and County of San Francisco
Ccttificate of 2)catb
( XX. S. StanC>arD )
^^
PLACE OF DEATH: — County of Jcl^x;
City of 0 ,<x.>-v
^
^
P4o. LClu X V^C ..A. ) ^ V-l- 1. ^'>-^. <i-^ v^ ■ .St,; Dist.; bet.
\ ( ir Dt*TH OCCURS AWAY FROM USUAL R E S I D E N C E G . V E FACTS CALLED f^ UNDER
* V •»■ DEATH OCCUBRrO IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF
and
SPECIAL I
STREET AN
NFORMATION' \
D NUMBER. /
FULL NAME
I '- w
-1 \
i>.\TH Ml- r.ikiii
\y.V.
PERSONAL AND STATISTICAL PARTICULARS
^
iMc.mh
I I I
RINf.I.R. MARRIKD.
Unit in «K"ial df-iy Ti;itii)nl
( Day
1/ ififh-
I Viar)
Pa 1 .
I ^tat( ■ ir I'l lunli \
N \Mi-; <»i
J A Tin: R
mR iMi ri. Aoi-:
<H I" \ 111 i-;k
i stair (If i'laujtry
MAIDKN NAMi:
ni- M«)TnKR
lURlHl'LAC-H
nj. MOTHHK
(Siatf ur Country
OCCri'A riUN
I
A )
I
'\ \ i
,ttc Cic!
A
J.
UJlA^i
ruT\AJ.
1
MEDICAL CERTIFICATE OF DEATH
DATK Ul- I)i:ATn ^
(Moulh) (Day)
(Year)
I HIUnIU'.V CI:RTIFV, Thai I atteiKkMl (kiiascd fru
HI
>^
to L zXl
1<)0
190
tfiat I last saw h alive 011
Mild that .kath omirred, 011 the .late stated abnve, at i I J
M. The CArSlC OI' l>i: ATII was as follows:
DT RAT ION ' }'<'ifs
CONTKIIH'TORV
Months
Day
I /ours
1
DT RATION
)'iays
} > ^
IXK^»vO, i
Residfii in San /'nun 1^1 n
) 't'li 1
M.nllh^
/hi 1 ,
(Signed) tU. \d . L<rYvL
Mouths
Pavs
Hours
M.D.
(Address)
rv\rsJiiM.JrKjaiJ^
SPECIAL INFORMATION ^nly 'or Hospitals, Insfilutlons, Translfiits,
or Recent Residents and persons dying d*»dy from home.
THK AHOVK ST\TJ-I) I'KKSDNAl, I'A KT ITT I.AK S AKK TKIH TO TIIK
BKST f)l' MX KN<)\Vl,i;i)<".K AND IU:i.II;H
(Informant 0 XXX-^'^ CL, O .■cJk'>->-V^i
>
(Acl^lre^s
LAX'Vruuv^o^
v,«a_-'
Former or
Isual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
V\ \CF OF in KFAI, OK KKMOVAI. I DA^-H of B. kiai, or KI-Mc»VAI.
T<)0
,<~\ '-■^ -~i
N. B, Kvery item of lnform«tlon .hould be c«i-«fully supplied. AGE . ^^ "Special Information" for p«i-
state CAUSE OF DEATH in pinin term., that It may He properly cla.sitiea.
aons dylnft away from home should be ftlven In .v.ry instance.
Isi^^
I
hi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
li.iiiirl of ll.Mlth — I- No. !^ T^^^yii^.V.fkV Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jieo'/,s/('j'('(l jYo.
2571
Dale Filed, M^<Xj^\>^0\> IH I'-^O'i
X^\AA^ dUl\Hi Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( H. S. StanDarD )
PLACE OF DEATH: — County of CJctoO/ 0 XxX/woL^ccCity of (Jxx,>^ J A>Ct>V'C^>-A.c^
(N
o. 5^1
^
St.; v) Dist.; bet.
*TH OCCURS AWA>
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE V
\\ 1
\\j
and
G
4
. r 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. /
FULL NAME
Ox
axx
v„
PERSONAL AND STATISTICAL PARTICULARS
DATi; or- lUK rii
IC ^> cU
MEDICAL CERTIFICATE OF DEATH
.. AAi
M.iinii
\«'. i-;
70
)-,,i,
(Dav
M.,>,ihs
rVh'i
13
'Vrai)
/)./!.
'Wiit'iii --mi.i! ill -i(.'niili'»ii)
MIN illl'l Xri-
IStatt 1 il » ouilt I \
\ \M I 4)1
I- A rilKR
Hiurni'i.ArK
<»! I AlUHR
(stall iir iduiili V
M MltlsN NAMl-;
()»■ MOTHKK
lUKTlIPI.Ac i:
<ii' M(»inj:K
(Stall lit i,'utinlt%
l\
DATE <)«' DllATH \
Ilk
(M.iutli)
(I>ay)
(Veai)
\ UliKI'I'.V CIlkTII'V, That I attcii.kMl .Itreasoil fruiii
,V^W ^5 u>oS to ii'llfc XX . icpH
that I Inst saw hX^' aHvc- on U/ct. ^l i«P H
and that (Uaf h IK (urred, oii the datt.' statr«l abovf, at H^O
0^ M. The CArSI-: Ol' DliATII was as follows:
ccMx^yvvtx^
C(h
'vK^^YV^
ICv^cvCo^^ya /ds
Ihn
'%
//.
out s
I) I RATION % Yeats Months
CL/>V"WO^
'V\;
I uX\,^i/va/vv'
^
nori I' A rioN
M.nilh^
Dii
DIRATION )Vf/rv S ^Tonths /hiv< Hours
i.U). iLlLtm.^ M.D.
( Signed )
L'ct
H)" 1
A.h
Special information »nly 'or Hospitals, Institutions, franslfnts,
or Recent Residents, and persons dying away Iro.n home.
Tni': \novK st^tj:i> ckusonai, i'aktkm f.ars aki; tki k r«> riuc
ni-:sT ui- ?.iv KN<»\vi,i;i)c.i-: and iuj.ii.i'
(ItifiMtiiatit
,\Arv^vva ^J ri o/oc^ yv
\,i,h,-.s 6 1 I
^3\jJ\k. C
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Now lonq at
Place of Death ?
Days
nxri.ii! I'.i KiAi. or '< i;m< i\- \i.
I'l.ACl*: Ol IHKIM, «»K ki;M<»\\I
fA.I.|t«Hs 3lH%s5
^ H
N. B.-
-Rvery Item of liiformntlon should bs cnrefully Hupplied. AGE nhould be iitnted F.XACTLY. PHYSICIANS •hoyld
state CAUSE OF DEATH In plain terms, that it mn> be properly classified. The "Special Information" for psr-
fff>ns dying away from home should be itiven In ^s^ry Instance.
• %
\
*0\
l»
>l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
jianl ..f H. alth 1 X-. i. 1*.^^^ i u'v I ' ( -. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
7)afr /'V7f'^/, \L//a:
4^
tcArV
hj c< V
UWH
Registered J\/'o.
2572
a^.Ciuuu
. ., Deputy HcaJth omcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccrtiticate of IDeatb
( XX. S. StanDarC> )
PLACE OF DEATH: — County ofO/aa^ ^J K<X/>\^<AAU> City of Ooy^V' OX<x>\ r v
A
No.
^
^V„4-.nL
St.;
Dist.; bet.
aniJ
and
.,\L
S I
; w
/ 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 ^
( .F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
■V Uw ex.'
i f
PERSONAL AND STATISTICAL PARTICULARS
si;\ A ft cui.nR ^
h
a
I>A'ri". <>l- 1;IK i 11
.\<,i.;
^xv
Mouth
} I tu
I)a%)
M'iilln
\ ! al
/).7 1.
SINi.!,!-: MAKKIKl),
WIDOW i:n «)K DIVoKv'HI)
(Wiitf-in xiH-ial ih '•i^.- uat mfi >
lUK rui'LAri-:
(Statt iir I "iiuiit I N
NAMi; <U-
FATlll.R
HIR'lHFM.ArK
OC I AI'HHK
(State or t'ountlA*
MAII)1;N NAMi:
<)I MOTIIKK
lUKTIII'I.Ai'K
(U MnrilKK
(statt- i»r Country
XoxxoucL
i
i
MEDICAL CERTIFICATE OF DEATH
DATK OI- Dl-XTll /A
\ I
(MmitlO
t
(Year)
(Day!
I II!';Ri;i'.V CI:RTI1'V, That I uttcn<k<l (kHcased fruni
that I last saw h - alive on W/ T90 ■
and that death occurred, 011 the date statid above, at -. j 0
M The CAl'SI-: Ol- DIvATII wa^ as follows:
1 \ V •'^'
kxxJ. '.
I) r RATI ON )V.//v
CONTRIIUTORV
'I
Mi>}iths O Days
Hours
Yra
rs
Months
PilYS
\
nr RATION
(SIGNED) .u L^^vtUuiL,
ilcl IH iqoH (Addre>;s) 3)^0X' ^H IJ. J
Hours
M.D.
^ >L^.<^ \AA>i-C '^ \^
vKjdj^AjuL
^
Kfsidfd in San /-i.tu^nm
) 'rti I
h'.'uf/r
Ih
Tin- \IU)VKST\Ti:i) PKKSONM, 1' \ K TU' f f, \ KS A K l, TK I K To THH
ni:ST OI-" MV KNOW! llx. H AM) in-.IJl-.l-
^W.
ij . Id. Co-^
b
A
%
i
,,1,,rcss %%X1 M I \A.^L^uA..<m, Ui
Special information nnly for Hospitals, Institutions, Transients,
or Recent Residents, and persons d>ing away from home.
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death ?
Now lonq at
Plare of Death ?
Days
190
e\CK <H in KIM. OK KI;MoVAI. I DAll ..! IUkiai. .»r KHMoVAI,
N. B.-
■"■"""""^ , ,, ,. . A,rF ahniild he Mtated EXACTLY. PHYSICIANS should
-Every Item o* I«form,tlon .hould be cnrefully supplied ^^f;^*;^,'^*,,^'^^^^ ..g";,,!., ,„formBtlo„" for p-r-
state CAUSE OF DEATH In plain terms, that it mny be properly wiassitiea. me p
sons dying away from home should be given In svery instance.
:>
ni,.ii<l i.f 111 iitli I- ^''i !«^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,s^^,.^„ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
" '^573
^
f
l)<(fr FilaL ^/ct<rls^>v ^H
VJin
lieiL^tcred J\'^o.
-?
.^r\JU^ ^^< \f-
1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
i XI. 5. StnnDai^ )
PLACE OF DEATH: — County
of -^^^xx^v 0A.a>\cc4e^ City of ^^^curu J A.xx.ym^^a c o
*
No-A^^^
tu'VV
^^L^rV
t
±
Cy-^',v\Xa(' St.:
Dist.; bet.
and
— )
L __.- iiciiAi or « I nr Nr r r.ivr facts called for under special information* \
( '^ rF^orAT^H^OCclr.r/N^rHo's^.yT*!: 0%'?n|^?U^tVn"0.VeTtI NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
hJX.y\Ji\ Lla.L^ix'Ucvv
PERSONAL AND STATISTICAL PARTICULARS
s!:\
COI.oK
au
DA ri; ni I'.iK 111
\< .!•;
^
^^
.Us
X
M ,>,'h
•Vt-ar)
/),?
\\ ii)(»\\ Ki> »»K i>iv< »Krj:n
(Write in --tK-ial (li-.i-iiatiiin)
niH riiiM, \i"i;
(Stati 111 I ■.lunti \
NAM J" "»i
PATH IK
I'.IR rill'I, \i »•;
<>!•* lA rm:K
< Statt oi I'tiiint ! V
tXCCLwU.C '\;
MEDICAL CERTIFICATE OF DEATH
DATH 01- I>i:aTH . ^
(Ml. nth) il>ay)
r Ifl':k i:i'>V CMIKTIFA', That J alUii<U<l <lt«x:ist.Ml from
(Year)
U)0
ItjO
that r last saw h i-»^ alive on vl 'CAj ^*.
ami that <U>ath occurred, on the ilalc ntntecl above, at O >^ 5^
U' M, The CAl SI-; OI' Dl'lATII was as folhnvs :
DT RAT ION )'tars
CoNTRinUTORV
Moulhs
l\iv
Hours
U-i>V^V<X>AX4
OCOVl'ATION ^ (1 , H
MAini'.N NAM1-;
<>1 M()Tni;K
luurni'i.Ai'K
(»»• MOTIIHK
(State or Counti y)
yr<»iih-
n,i\
TnFAI«>VKST\TKnPKKSnNM.rAKTIit!.AK-AKKTKl K K. TIIH
HKST «)l- MV KN<»\VI,i;i>«.l-. XM> in-.IJl.f'
(liiforniant
(\<l.lt.
4
MthjcUx.
1
Jb
DTRATION
(SIGNED)
."Sronths
/hns
Hours
M.D.
A,l<lress)LUa^^Ui .^. 0^44\A.LCVI
SPECIAL Information only forllospUdls, institutions, Transients,
or Recent Residents, and persons dying a*ay from home.
Former or , ^ , ^^ i s i
Usual Residence I C^ H LLcVwv^
When was disease contracted,
If not at place of deatli ?
> ^J Howlonflaf q
U ^cV vvv^aX Ot Place of Oeatli ? "
Days
IM.ACK c)|- m KIAL<»R Ki:M'»\Ar, I I>\TJ:..t Ml HiAi. or KHMOVAl.
lit± a^ I90S
LNJl/ry\,CLt«\Ml
'I ,. , .-,e «i„„.i,i K- .tated EXACTLY. PHYSICIANS iihould
•tate CAUSE OF DEATH In pl«ln term., that it mny be properly clawitica.
Hon. dying away from home should be given In .very instance.
D
5l
A
1!,,ar.l <,f Ht alth I V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
f^*^ 4 "dr.
lS-?^»?>*> fiSc I' ^'
f
Deputy Health Officer
Registered JSTo,
Dute Filed X
DEPARTMENT 0^ PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "a. S. StanDarD j
PLACE OF DEATH: — County of
City ofO^^-'^*^ kJ Kql -,
No.
%.
+ . ,
\\'~^r\\Oiiy !i\l' ('-■i.iV..' ~ ' St.: - Dist.;bet. ^no
1 U^ r I VAA^ . ^ V. V- I „.,,.. RESIDENCE OIVl r«CTS CLICD »OB UNOCB 'SPICIAL , N FOn M«T10 « " \
)
i',
FULL NAME
',. /w Vf\»*.. -
V
L.a
PERSONAL AND STATISTICAL PARTICULARS
M \ '>
^
COI.oK >
3xrTr\j>Xx
U
1).\T1-; nf IIIKIH
\<.I-'
<>,
M..mh
i Das
M.nilll
lhl\
sIN«.l,I-: MAKKIIJ*
WIlMtWKU OK IHVoKiKU
iW'litcin H(K-i;il "h "-is-'ilaHiili)
liiK rHPi.Ai'i-;
' st.ite or Count t y
(A
li.:->
NAMl- <)1
J A 11 1 I.K
HIK riiri.Ai K
(II' lATHHH
'- State lit I'ollllf r\
MAiliKN NAMl.
Ul MOTHKK
lUR rnI'UAt H
ui- MoTHHK
I Statt or Country
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH , r>
Day)
I mCUICl'.V CI-;RTIFV, That I atU-iukMl (ItTease.l from
(Motitli)
Kp
(V.arS
ujo'-i
that ! last saw h '-^' alive f)ti ^^^ T90
ami that cU-ath omirred, mi the (late stated al)nve, at I
^f. The CAISI-: 01' DlCAin was as follows:
DrkATIoN Years
CoNTRlHrTORV X' Q-^-sM^.
Months
Day
//our
X
C V LK.
J^A^i,
L
Jl..
oCCri'ATloN
Re s hi f if in Sun I'litii' /
) . ,fi
M.nllh
/*,,'i
TnKAm,VKSTAT.n.-K><soNA, PXKn.M-jXK.AKKTH.K To T.IK
IIHST Ol- MV KNOW l,i:iH.h AM» l-l'Ml.r
^
(Infiinii.utt
lu..^4;t
f \(l<Ir«'Hs
wLy,
J
Df RATION
(\
}V(/;'A
Mnulhs
fhiv
(SIGNED) Vwl
/lours
M.D.
(Address) iC
Special information onl> J»^ Hospitals, tnsntutions, Fransleiifs,
or Recent Rebidents, dnd persons dying away from home.
Former or
Usual Residence
'Hail
uhju^>
HoM lonq at
nm of Death ?
Days
When was disease contracted, (^ ^ \ ^ ^^^^j ["^4 ^ ^ ^
If not at place of death ? \JU.<UAHmA^ U^ ^o^^^
IM^ACK Ol" HCKIAI, <»K KKMoVAI,
DATi: <•: ntKiAr, or KIMoNAI,
U.t.1
190
n
rNl)i:KTAKKK
(Ad.lrc.sH RHb MyWL^^CT>v .1
M. B.— Bve.y Item of Information .houM be c«refull. .uppHecl ;;;;^;;,;":'4t«^n:i?''Thf '^^^^^^^ In^oTJlTon" fo" ^r-
«tate CAUSE OF DEATH In plnln terms, that it m»> ne pr m
Ion. d% .w.y from home -hou.d he giv.n In .vry InM.ncc.
^
^
J
at
♦ I
♦ I'
P
<IM#
i ■ '1 '
m \
(»
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I'.o;..!.! of HiMltb 1 Vo. 1- 'S-?'^>,T^]US:I' Cu
I)/f/r Fi/('f/X^ tX r ^^Ji:
J/
K C' \ k t
Dept-^- ; «
Jf}0
h Officer
Be^isfrrcd J\^o.
2575
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
1 H. S. StaiiDarD )
PLACE OF DEATH: — County of ' Cu^rxj - ^\. o
p
City of 0/CL>v 0 Ko
iSf,^
Dist,; bet.
and
(IF Dt»TH OCCUBS 4w*Y FRo4l USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SP
IF DEATH OCCURRED IN AJHOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRE
eClAL INFORMATION" N
EET AND NUMBER. /
FULL NAME
^ 1
lOJx.
II
L- L.W 0 > \.,
■-.iix
PERSONAL AND STATISTICAL PARTICULARS
fl
1) \ 1 j; t >r liiKTii
A«.K
n
1 Monti!)*
I»nv)
M'-nth-
/hi
i W'l ite ill ^1 Ilia 1 1 !i ■'Ii.- nat ion )
Ml
I'.iK riu'i.Aoi-:
stale ot roimti \
NAMJ-: Of-
! A rilllR
lUKTHI'UArK
ni' lAIMIKK
(Slati or t'oimti %■
M \iiu;n- nam j;
<>! m(>tiii-;k
iMR'rmM.Ari';
( Stall- or I'oinit 1 N •
MEDICAL CERTIFICATE OF DEATH
I)AT1«; u|- I>i:\TM
(Viar)
(Month) (Day)
I HF'kllBV Ci;kTII'V, That r altt'ii.kMl deceased from
— lip to — ---- ^^ — —r^ Up
that I last saw h alive on — — lyo
and that death occurred, on the date stated abovi', at
— ^ M. The CAT SI-; Ol' DI-ATI! was as follows
q^
CLA,^ ^'vCN
•^
\,
A,'_ •„
4
I
UVucJuxn^
coNTkinrToRV
Months
Days
Hours
<^
^\.KX
K UIjouO^ux,
L
\A
DT RATION
i Signed )
0
)\'iH %
n 1 m
PiU
Hours
M.D.
fA.ldress) 1<^V(^
cu
iMrri'ATioN /O ,
h'r^liit'il ni Si:ii I i iiii
KSr^,/>^^*xtx,
yf,.,itfn
/',M
rill': AMovK sTAi'i:i> i-kkson \i, i'\K rni I, \K-- aki: I'KrK m rwv
incsT Ol- MN' KN<»\\i,i;i»< .!•: and iii;i,ii i
Special information nnly for Hospitals, Instituffons, rranslents.
or Reitnt Residents, dnd persons d)ing dwd> from liome.
Former or
Usual Residence
4
How lonq at
Place ol Death ?
Days
When was disease contracted,
If not at place of death ?
(Info'inant
Ofw % C.iuA,.
:x
Vl.XCV, Ol* ni KfAI. OR K|.:m<>\\i, I OAII;..! IK kiai. ur KlCMnVAI,
190
rNIH.K'IAKKK
A^^^X
N. B. Rvery Item o? Infformntlon should b* carefully supplied. AGR iihould be utiited I.XAGTLY. PHYSICIANS should
stiitc CAUSE OF DHATH In plnin termw, thnt it mny be propeHy classified. The "Special Inl'opmution" for per-
sons dying away from home nhnuld be given in every Instance.
I 1
)
?
I •
m
P
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i!:.nl. f Htalth » No 1 T^-g^^jiiS:! I.. RE^ERTO BACK OF CERTIFICATE FOR INSTRUCTIONS
K' as
JfWH
Be^Lslered A'^o,
*yrz^.
i576
Dfffc Filed ,
DEPARTHENT OF PUBLIC HEALTH-City and County of San Francisco
1
CXM^
Certificate of S)eatb
( Ta. S. StanC>arO )
PLACE OF DEATH: — County of Cxxoa. J.*\a v^r , .Qty of C'O/yvOa.cx ,
(No. LuLc* ^Wvc'Yvt^i L\-l->-» ..v. kcv .. ..St.; Dist.;bct. and
1 / ir DEATH OCCUnS AWAY rnOM USUAL RESIDENCE GIVE facts called tor under "special INFORMATION" \
J \ IF DEATH OCCJjRRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME b
e
.1
^1 \..K.
sj;\
PERSONAL AND STATISTICAL PARTICULARS
C01,0R \
o.
I) All: «»r luKi'ii
Ai ,i:
>
M..mh>
)
b
Dav
MEDICAL CERTIFICATE OF DEATH
DATK OJ. Di; ATH \
(MotitlO
(Yt-ar)
1/m;/
n,i r.
^iN<.i,i' Nt \kk III)
WIDOW J.; I) (IK ni\MKri;u
iWtitfiti suciai <|t <.i^Mi.iliiiii)
HiKTniM.Ari.:
I State III <.'r)nntr\'
NAMK OF
FATin:R
niRTIII'l.AiH
oi- iATin:K
fStatr or t'oiintrv
MAII>i;n NAMK
<)I- MOTIIHK
ItlH llII'l^ACK
<H MOTHKK
(Slati- <>t t'liiiiitrN
f\
^
^
(Day)
, I III':K1':PA' CIvRTII-V, Thnl I MttcniUMl <U( lasc,] fmni
A))L<Xi.-^ /X::\ up. to t'ct ^2.
that I last saw Ii ^ > alive on ^.. '
Up 1
Xi)0
and that dtath ncciirrcd, on the date stati d above, at
Cf M. The CAISI- i)V I>i:.\TII was as follows:
QJktl-
rX.v./ii,wj \^-.c*„'., t , wC
,u.
n)
I )r RATION }'t'ars H Months TVl Days
t'oNTRIinTORV
Hon
rs
\A^0yO^
I
U
A
L.
(H'Cri'ATION ■
AV'/,//-)/ /II SillS / I ,!Hi I'lii
Dl'RATION
(Signed)
it t
.U,>////ts
/hiv
Hours
M.D.
(Aililress) xXXrvy^^Mt^ \.K.^
SPECIAL INFORMATION only lor Hospitals, InstitufioBs, Translenls,
or Recent Residents, and persons d>ing aMay Irom home.
) III I
M,'ii!U^
l>,l^
Till-; AHOVK STAII-D I'HKSOXAI, I'AKTUMI XHS AKi: TKIH To Till-:
in;sr oi- m\lknowi,i;fm,h and ni:i.ii:i
f InfiHinaiit
V a.
O/cl
( X-LIk"-*
former or
Usual Residence
When was disease rontracted,
Ii not at place ol death ?
How \m% at
Pl«-etf Death?
Diys
I'l.ACK ol- nrklAI, OK KHMo\ AI, ( I)\'n;..f m kiai. or KKMOVAI,
0C\_ ,,
Mm
i . W\jl/Y>UXl ''
W,
TQO
N. B. Every Item of Information .hould be carefully nupplled. AGE •houlcl be .tated EXACTLY. PHYSICIANS iihould
•tate CAUSE OF DEATH In plain terms, that It may be properly classified. The * Special Intormatloa ' for per-
sons dying away from home should be given in every instance.
I I
:>
If
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I'.m;it.1 .,f ll.nltll I" Vn : - t-'^'^S^) ]',Scl' C,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begisicrcd JVo.
;^577
4
\H| Deputy Heafth Officer
DEPARTItlENT OF PUBLIC HEALTB-City and County of San Francisco
Certificate of Scatb
( Ta. S. StnuDarD )
PLACE OF DEATH: — County ofCj/<XAv 0 Va.>xec4.ac City of C'xx^^ J AxXyvuec4.<U)
N
o. oL I "i i >. J JL k ct >^xcu
St.; S Dist.;bet. ?\<i
and
/ ir DtATH OCCURS AWAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
Ht;
FULL NAME >m'Tu LI.l.cUou>>^ ll.c^^xW
^xinjA-
PERSONAL AND STATISTICAL PARTICULARS
t
^Rcvu
i> A 11-: I ii' liiK i II
\ ' . !•:
M.iiith) t
t
I v:^
\\
Dav
rWl
V\
s
\
IK
uii)i tui. n ( >k n :\ » ii'i j n
( Writ*' i II •>!« 1.1 1 ill --iu' iiat !< ill i
XC
a.
!• A I 1 1 1 . R
nTKTni'i, ACK
<»I IXIIll K
IMtMtr Of IdUlltl S
maii>i:n XAMI-;
<>!■ MorilllK
HIR rilPF.ACH
»>» Mn'I-HI'K
(Stati- or Coiuitrvt
^
MEDICAL CERTIFICATE OF DEATH
nAi'i: ( 1 1 miAi'ii i
I III{R!:i?V CI:RTIIV, That I atlondcd .ItHvascl from
190 H tn C ZAj XX u^H
that I last saw how. alive oil l.i tX XO^ i,p H
iind that <Kath orcurreil. mi tin- diti- stati-d al)<>ve at 10
L^ R
rf
M. The C.MSI' Ol Iij;.\rn was as foil
LLccJtu.
4
d^CiiXkSj
1< >\\s
^ X^xtrvx ' V cx<i
DIR.^TION }\ars
CONTRHUTOKV
1 v-K. CO > x.e > w-CL'
Mouths A /?,/i,s- iloii
$ s
DI'R.XTION
Yiars
Mouths
i
Pavs
oceri'A riuN
tccctj
( Signed ) vlAc-Uk Lrlt^^^XL
w Caj ^-X. iqo'I (A<hlri'Hs) l5 i »- u '.sl^ >>
f font s
M.D.
\
SPECIAL INFORMATION only for Hospitdis, InslifuNons, rransients,
or Recent Residents, and persons dyinq dH<iy from home.
XA, t.4_4X'W
KfMtiiii I II '^,11! / / ,,';'i /»*'f» 1 Q J f'<
•(/; , — \f,,iit/l^
/),n
TH i; \I)« tXJ.- SI \ 11 II l'Kks< »\AI, I'XKrUT!, \KS AK1-; rKll-: 'I'l
HiCsT (»i MN Is \» iw i,i;i)«.K AM) iu:i,ii:i'
r 1 1 H
Former or
Usual Residence
When was disease ronfrar ted.
If not at plare of death ?
How lonq at
l^are of f)f ath ?
Days
IiifuTinant LoJUKJ-N.*^ VU. LL-^^VVA^Wx
(5?
X.l.lross c*.l3 '3s. J X4
t
lOAvca;
at
ri.Aci: <>|- luKiAi. (»K ki;m<>\ai, | i>\ii
.^ , sL/ct XS^
^ d
INinK TAKl'k
HI \r. i.t K i:M( i\ \i,
w v-Aj c^o T go 1
•u
'jLt .
N. B.-
-Rvery Item of Infoi'rtiHtion should he cnrefull}' MuppUed. A«B should be stntecl KXACTLY. PHY8ICIAIN8 nhould
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special lnt»riii»ition" for per-
sons dyinft away from home should be given In every Instance.
D
3 p
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hon..!..ni.;.!.h FNo .. '^'ii^'^iUikVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)a/r F//rf/, lD.ct<rU;
I
>v IS
i
d^c^v^.c-^ X.X. vq Depu*
10 OH,
Ih Officer
Be^isfcTed J^'^o.
;^578
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH: — County ofOo^^v JXa'^vCUi.'C^ City of ^^amj vJA.CLTvec4/ao
No. ^ ' loX<^^k_^ a. k^ L MivCtA.1 St.; Dist.; bet. — antJ
(ir Dt*TH OCCUBS AWAY FROM USUAL R E S I D E NC E G I V t FACTS CALLED FOR UNDtR "SPECIAL INFORMATION" "V
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
A f ^+
tXL^-VfXLU'
A
wi-tHMXX/TVV (m)
•^1 \
PERSONAL AND STATISTICAL PARTICULARS
0^
I
I) \ri or lUKTJi
A< .1-;
I
All
Ml, nth 1
as
lias i
1/ ,.;//
'i I ,'U I
(S'fiir)
SINr.lj:. MARK III)
W J r >« »\\ J.' I > ( » K I ) ; \'i I K I 1 ! I
•Wiittiii siuial lit '-uMial 1' 111 '
0
x>
L
ll
nil-' rifiM. \i-»-:
^1 !t- , -■ . ,.int I %^
NXM). (»|
I- A III IK
HIK rilPI. \( K
ni" I \rm:k
(StMtt (ir I'liunl T \
M XIUHN NAMK
til- Morill'K
lUK iiii-r. All-;
oi- Ml I'm I-: k
(Stntc or Couiitt \ '
MEDICAL CERTIFICATE OF DEATH
DA IK « »1- Dl-; AlH I j
L' ct a 3
(Muiilh) il):n>
I HJ'RIU'.V t i:kTI|-V, That I alti'U.K'.l .K-rtasiMl fnMii
lliat 1 last saw ll C^n alivf on \i' CAj 3.3 igo*^ XjD
and tliat iliatli nccurrcil, on the datf statvil ahnvf, at S» T
T M. The CAISI-: OI' I)i:.\ril was .,s folI,,us:
3
J
i^
■^
I )r RATION )'iijrs I .IA';////,s I S /;,/, v //ours
C ( ) N T R I J '. r r () K \' > > \X,ULtc-/vCut LL^4/CX4A.
»
0
AwCla^
?
//<
ONrs
A
I'll- \ rioN Qfn
^/D^^\AXjy\>
nr RATION }'rtjrs I Mn,it/is b /)^7v?
(Signed) vD n 1 LxxiAA^<j.ouvUj M.D.
Special information nnl) f«r Hospitals, Insfifullons, Transienfs,
or Rftenl Resldpnts, and persons dyini} anav from home.
Former or
AV.Wl//// //' S,;)/ /'l ll Hi ll'i) "
.»/.
././A> 4 3) i^'i
\ \.\ 4^1' y How lonfl a* g -a
Usual Residence cL.6-0 UO^vfr^ v<XV PUe of Deaf h ? I J
Wfien was disease rontrarte^, -^ \i k^ i /v »
If not at place of deatli ? rMM^ J <XM^' wQJj
Diys
rui'" AHovH ST \ ii:i» i'KK-;(>NAi. i'\K rii'ii. \K- m- r i ki »•; i " > in K
HHST oi' Mv KNOW 1,1, I)<;k \m> in;iji;i
(In fitfin.int
\.Mi. V.
5 0 S dLJ,vw^<r>vt Ot)
II \<1' iH- lUklM, iiN |.;i:M<i\ \I, I l)Ari:.it lUvwu it UHMnVAf,
\
x\
N. B. Every Item of Information .houlcl be carefully mipplicH. ACI. «h.n.UI ba «t«te.l »'XACTLY. PHYSICIA^IS .hould
State CAUSE OF DEATH In plnln term., that it mit> he properly cfomilfled. The Special Information for p«r-
iion« dytn£ away from home nhould be ftiven fn m\9ry Instance.
ijfi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!i.;ii<l ..f M. ;tUh »■' Vu :■^ t'^^-sst-J^ uSiV Cn
REFER TO BACK OP CERTIPICATE FOR INSTRUCTIONS
,^
Du/r Fi/r^/XzL^i>JJ\) ^H
790H
Bp^i^stcj'od JS'^o.
579
<X^'^_CC^J
• U L
DEPARTMENT oIf PUBLIC HEALTH==City and County of San Francisco
Certificate of Beatb
( "U. S. StandarC> )
PLACE OF DEATH: — County of
1 1
m
^No.
3 .^xx^'X'CUi/Oo City ofU-CX'-^'v J Ax>.
hIk' / ^ -^'Z , . • ■ St.; \ Dist.;bct. OAXt^m.m.CK and L^T> '
(ir Dt»TM occvBS AWAY fHom USUAL RESI DENCE GIVE facts called tor under "special information • "\
IF DEATH OtCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
.-^ ' J
f\.
A
FULL NAME
i f i
n -
ii
PERSONAL AND STATISTICAL PARTICULARS
haih (»i luk lii A ^
MM..iitli ' ICiN'
\ « ■ »■;
MEDICAL CERTIFICATE OF DEATH
DATK OI' I)}:aTH
(Month)
(I>;iv)
(Vi-arl
I I1I:KI-:P.V CIIRTII'V, That I atlen.U-.l <k-,i:i>iMl from
1/ .).
/),/
•^iSt .1,1-: M AK k 11 I»
u iiH »\\j;ii <ti< ii:\nRi'i:t»
Uiitf 111 "^iHKi; li ^ij/natii 111 1
niR riiJM, \i'i-
' *-t it I I • I I 111 nl I \
NAMl.; ni
HATni;K
nikrnpi. \cv.
fit I \ III YM
iSt.iti <ii (■( iiiiit
mmih:n nami, ,0
<»l .MoTIII'.K L
a_
rs
K^
rs
I
that I last saw h
I <>o .
alive oti
c
,, ♦
and that dcatli nccurrcd, on the date stati-d aliove, at
M. The CArSI'! Ol' I)i: ATI! was ;,s follows
I ) r R A r I < ) N
)'t'il/ s
0
t'ONTRflUToRV Lfe-i.JL<X Ovt^t l>
u
Mii)iili% I Pax < Mom \
^J^
^
cv
iivJ
DIRATION }i<irs
(Signed) > J
Months
/hi
vs
\
wY>xrYrux.
lukiiii'i.Aci-:
ol MnTHKH
' Slate tir (.'ouiiti \'
I
jy\j 0
/<X/YV o.^ucx
< H'l ri'AIIoN
fsfsiilfif ill Still I I ill), lu'if
) ■/■(?;> ^ji. Month
r>j
rilHAHi.VH sT\TKl.I-HK-oNSI.l'\kTH Ii.\k-.AKi; ll<l F To THK UlLArK..F fit klAT.ok kKNfnVAI
iqo*. (Address) HbO VirU^AlcL\.
I/oNrs
M.D.
Special information «nl> '»r Hospitals, Instilyflons, TranslfBts,
or Recent Residents, and persons dvimi a^») f^"^ h^mf-
Former or
Usual Residence
When Has disease fonfraffed,
If not at place of death ?
HoH lonq at
Place of Death?
Dtys
iIkst «)i- mv know i,i;i)«.1'; and i'.i:i,n;i
(Iiifot innnt
v.^
f \ft.!rfss
SO
>\X<X<5
> w t/x^i
I) \ ii; ..! Hi in u I.J ki-;mu\-ai.
iqo
•tate CAUSE OF DEATH in pl«in terms, that It m„y he properly cla.s.t.ed. The Spec.al Intormat.on for pr-
«r»n« dying away from home should be given In avery Instance.
:)
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hi.ar-l if It, aitli 1- N'o. i =; *'r'-^«r<«t} !kS:l' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dnfp Filed ,
oLCrvcUi
as
190\
Regisf creel JS^o.
^3580
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTII-City and County of San Francisco
PLACE OF DEATH:
Certificate of 2)eatb
( Xl. S. standard )
-f
0)^
County of QCXA-\J JAy(X/VV-<^aLCC> City ofO,a.Av J "xo
i
- <L
i-
No. V. ciu ^ u>CrL\„^
^
and
, - ' < - _CV.l St.; Dist.;bet.
/ IF Ot*TH OCCUIJS «W*V FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION \
V IF DEATH OC<jURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
FULL NAME ^ ^<x.vK
PERSONAL AND STATISTICAL PARTICULARS
"^'■^ A •, I oil >K N
1) A'n; . .r iuki ii
a
Month
\<".K
15
(Dav)
M.,uth
(Vtai
/>.;
MEDICAL CERTIFICATE OF DEATH
DATH U!- nivATIl \
(Month)
(Davl
I (^(t
(Yf.n)
u n)t)\\j:i) OR i>i\<»KtKr)
•U'lit' in *;«KHal diKi... luit i' ni >
lUa.
I in-:ki:HV Ci:RTn-V, That I attin.U.l deceasetl from
tn H'ct
lUKTMlM.AOK
i State <>r Cmuit rv
N'Wtl- OI'
F- A Tlil.K
HIKTIIl'l.ArK
oi- I Aini-:H
(State ■It I'oiuiti V
MAII»i;n NAMl
lUKTHI'LAri-:
<)i' M()'i'm:K
(State oi Coniitrv
ry
\ I LL.
WC^'fx
c^ '< 190H In v: Cb 100 i^
that I last saw h •.• i»v aUve 011 ^' ct ■ X k^q
and that death occurred, on tlic date stated aliovc, at
M. The CM SIC OI- DI-ATIf was as foIUms:
r\jrs\,*^^ W<X.>wt
u:
Dl" RATION
)'tars
Days
^
Mouths
C ( ) N T R 1 15 r T n R \- ^ V Ci^A^dvo J.a.x.u.i„ > >
/A.//
/,s
Dr RATION
Ihl
ix
r'l
UCCl'l'ATlOX QTiP a I'l
/\'f'Mif,''if in Siiii /'mi/, .' 'I ii o ) ViM
Hams
M.D.
"1
(Signed) J _ __ „.._
Ucl AS^^ iqo t (Address) UluXiVC) I) O^Ux-d-O. I
for Ifo'
Special information only for Ifospltdls, Insmutlons, Transients,
or Recent Residents, dnd persons d>ing dwdy fro.n home.
Former or
Usual Residence
'T^ '^
bSb ulo^M
How lonq at
Plif e of Death ?
Di)r$
M,>ii(h'
lhi\.-
THH AHOVK Si'Ari'.n I'KRSON AI, !• \K rim, \K-, AK1-; TK fK T< > THK
IJKST OI- MV KN'()\VI.i:i)<. I-; \M) Bll.n !■
(Infonnant VJ . V v\D . wL
When was disease contracted,
if not at place of death ?
<X^(>M
MbKwA.<\i
X,<^,'
T90
IM.ACK OI" lU KIAI. (»K KHMnVAI, I I)ATi;..r I!i hiai. or RFMOVAI
I'J
t'N
N. B. Every item of informntlon should be ciirefully supplied. AGH should be stilted BXACTLY. PHY8ICIAN8 should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "8|>ecial Information'* for p«i>-
sons dying away from home should be fti^^n In 9\9ry instance.
:>
c
w
RITE PLAINLY WITH UNFADING INK
H..aia ..f n. -.'.th ■ I- No :^^^:';^^HS:l'Co
T)((h' Filed ,
iO
15"
100\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered jYo.
2581
\A Deputy Heatth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( H. 3. Stan&atS )
PLACE OF DEATH: — County of U<x^v J /v<x .wc^^ <. Oty ot
f4o.v.^^-
U
^C^rV
Jir
11' C^^.
4
n I
St.;
Dist.; bet.
- and"
M USUAL RESIDENCE GIVE FACTS CALLED
( '^ rr"o;:T°H"oc5u%*«"cV.« r^oTpTTAr o« ..ST.TUT.O. O
FOR UNDER "SPECIA
IVE ITS NAME INSTEAD OF STREET
L INFORMATION" N
AND NUMBER. •
FULL NAME
^0 iJtcLUv^^
-4
tU'
-w-
PERSONAL AND STATISTICAL PARTICULARS
A
SHX
DAI i-; «»I lURl'll
.\t,H
C< >I,' »K N
Month
)■
n.iv
\l,„!h
I Vt ar)
lhi\
-, INC. 1,1 MARKIKl'
\\ n»<»Nvi i» OR niy»»Hv i-.i>
tWiitt ill -iK'iaS cli-sii^tial'i "ti )
MEDICAL CERTIFICATE OF DEATH
DATK t)l' DllA'i'JI
(Month)
Day)
IQO
(Y<-ai^
1 lII-kl'BV C1':RTU'V, That I altcn.l.a .leciascl from
UvX. y^
190H
that I last saw h -^ • aHvc on
ana that .Uath occurrcl, on the .late- ^tatt-a ah.m-. at
(? M The CMSlv Ol- Dl^ATII was as follows:
% _ M H^
lyO
190
i / I
BIK TIHM.AOK
'Statr or (■(Hiiiti %
NAM)-: ol
FAT II IK
id-
kXjXXi^^
HIK rHPl.Al'H
0|- 1 AIMIKK
(State or Coutitrvi
MAIDl.N N\MK
nl- MOTHI-.K
niRTin'i.Aii;
Ol' MoTHHR
(Slate or I'otititrv
\
U
U XV \ > \
IXc^Ow>v
^7s
« )(.(.- tl-ATION "w
J Xcu-v
ex.
>v.<
\.
Ur RATION Yeais
CoNTRIlU'TokV
Mouths
Day
Hour
DTRATION
(SIGNED)
Vcnt'S
T)
^r,}ut/ls
/hiv
'i\ a. %
Hours
M.D.
SPECIAL INFORMATION only lor Hospitals. Institutions, Transients,
or Recent Residents, and persons dying away from home.
.OJf^^
Rfsuff,1 n, Silti riinn,^,n \ "> ' ^"
\J,,tiih-
- /),M
ih'ST Ol- MV KNOWI.HIX.J-. AND in 1,11.1
(Iiiroiinaiit
(A<l.lr«'^s
(!du"'-<C{,/%
11':'
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
-. i
t
How lonq at
Place of Death ? o
D#ys
n.ACK Ol- lUKIAI. OR RKMoVAI,
t NDKKTAKKK JVXAAJU^ ^ -' ^ - j ^
nA'i;i!i>'' Hi Hi.Ai. 01 ki;m<ivai,
iy,c^ ^b 190M
Adai.-H ^^I'a' I I
"^^"■^^^^■'^■^'^^"^"^'''^"'"""'"'''"""'^"~'"'"^" I I h t t I FX4CTLY PHYSICIANS should
„» i„f„rni..tion .hould he cnrefull,. -PP''-^- „^„^p^:H!;7l«,-Hled? Vh^ -Special Information" for p.r-
E OF DEATH in pt»1n terms, that it m»> ^e P^^P
N. B. Every item
iif)
)
y
\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bnnrd of Heoltti— IN-. ■ - -w^^iu^ I'.Si V
l)(ih> File<h IJ/obvi-Ov XS
190\
Deput* »-J^a!th Officer
Re^isteTed JS^o,
2582
DEPARTMENT 6F PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( la. S. StanC»arC> )
A
PLACE OF DEATH: — County ofUa-r^ X<XAAXi<.-^ City of 'J<x^^ J/vo^a wc^^c<
I'D (% '"^ ^ ft
fI^.LLLu^L<^<-'l^u Ob CHlk.\1l<xl St.; Dist.;bct.— and ~
\ ( ir DC*TH OCCuAs AW«Y FRdM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" \
% V 1^ DEATH OCQURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
M Rc<J^\.oJUj L
ux
PERSONAL AND STATISTICAL PARTICULARS
S I . \
DA 11, OF- IIIKI'II
AT. !•;
ri»l,(»K
a'
f
MEDICAL CERTIFICATE OF DEATH
DATK ul- I)1:aTII
f^
n
)V,.',
(Dav)
M.I, I til
r
\'tar)
Pa
SIN«.i,K MAKKIKD
\VII)<»\\ 1:1) OR I)IVoKi'i:i>
(Writi ill -"IK i:il (it'si<.^nati«>n)
\ nxsXKuA,
niRi'm'i.ArH
fStatr or Country)
NAMK Ol-
FA rni;R
niRTni'i.ACH
Ol' I ATHHK
fStatf or Countryi
MAIDHN NAMK
OF Nf OTHER
hirthpi.acf:
OF" MOTIfF:K
(Statr or Country)
n
i."', I
(Month)
1 ^
a)av)
(Year)
I HURUBV CIvRTlFV, That I atteiuk-.I .kctasc<l from
■^c± 3s3
that I last saw h
I90'; to A^'/C;t c^N^cS 190 H
alivf nti ^. C\ liyo
and that death occurred, on the date stated above, at i- 6 0
- ■-- M. The CAlSlv iW Dl-ATH was as follows:
a
'Vh^-<rvA„w
<;l \j rlA.^>acUs^i. V
DT RATION Years
CONTRIHUTORV
Months
/hiv
Ho lit
Yi-a
rs
Mouths
I\n-
k ♦
AXAAAAXXnTX"
Resided in Sun f'iau,isrn .*sb )>(?/>■ t Months I
OCCri'ATlON Oi\ X „
IhlS
DIRATION
(SIGNED) Uj. W
i/ct X3 TQoN (Address) LcU^ 'HtL: qlDo^^xda
Hours
M.D.
SPECIAL INFORMATION only for Hbspitals, Institutions, Transients,
or Recent Residents, and persons dying dHdy from liome.
Xi^^
Tin- AnoVK ST\TF*n PKRSONAI. FARTIcn.AK^ ARF: TRTF: TO TlIK
IJKST OF' MY KNo\VI.F;DC,H AM) HHMHK
(Iiifomjant WT\,<X,« V 0 -*-* •
\(l(ln
) 6-4.'VXaX<
■1'
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death?
i How lonq at
,c^-AA-.e>\ ; ( 9\^t of Death ?
Days
T90H
PI \CF: of IURIAI, ok RKMoYAI, I da if: of IHkiai. or REMOVAL
rNDKRTAKKR\l»^ j CtdAiAV M fl y^/uLO.\lu ^ K
fA<i<inss I ill NjrrU44x-<rkv ol
N B — F.very Item of information .hould be carefully supplied. AGE «houId be stated EXACTLY PHYSICIANS •hould
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 ^s^v}/ instance.
3
:>
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I',.. «!il i)f 11- .lit!)
•?■- .•si-^ M&r Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Tht
fe Filetl,V/zLj^-\>XK^ X^
lOO'i
llegislcrcd jYo.
2583
.MA^V 5
\ (
\
'"^Icer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. S. StanDarD )
n
1^
\ .
,->'X; J;v<X>\ f^ <_<i
PLACE OF DEATH: — County ofCJcx^ ^ ^ n -<c City of Oa.->x; J/
'^No. 1H%^ .' ^ V. '. St.; 1 Dist.;bct.l£))uyd \' /. and ^ "^
(ir Dt*TH OCCURS *W*V FROM USUAL RESIDENCE give facts called for under "special INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
% +4 Fl ^ t ^
FULL NAME Jt <xrUx Li^va.A>-<..l .
^c
SI \
PERSONAL AND STATISTICAL PARTICULARS
mi, ok \
i)\ ri: or iuk rii
a; ...
K-^J
h
Mbtltll I
A< .J.;
Vv
) ,,/!
D.ivi
M.n,fll-
/',/r
srNc.i.K, MAKi<n:n
winoui-:!) OK iMN < ii'i in
i\\iit< ill viKJal ill --ii' iKit 1- 11 1
lUR rni'i. \i"]-:
' state 1 It t 1 Mint I %
,Oj\K.Kj^6^
A
MEDICAL CERTIFICATE OF DEATH
DATH <)1" DllAIH
IkX
Mmii;
(I)av)
igo
(Year)
1 ni;i<I';HV CIIRTII-'N', Tlmt I atteii(k-<l <k'tcasc«l from
tliat I last saw h •■•.' alivf on KJ -"^J^ *c l up
and lliat (U'atli occiirred, on tlu' date statetl above, at
M. Tlu- CAISIC Ol- Di-ATIl was as follows
X \MI ni'
I A in i-.K
MlkTIIPl.Ar!-,
• u- I ArHi;K
'siat( ')T i'ljuiilrv'
MAini-.N N\M1-:
<>!■ Mnrni'.K
lUk I'lll'I.AiK
Ml MOTItHk
iSlatf or t'oiinf 1 vt
\U
DCk ATION I }'tuirs
CONTkllU'TORV
Months
Pays
I /ours
orcri'A'i'ioN V
Kf silted ill Siiti Fiiiiiii'^in i
Dl'R ATION I y'turfs J/o////ts
'^ If i"^
(Signed) -j . LI
'C^ 'XS iQo'i (Afldrcss)
/hn's
m
Hours
M.D.
J XjsJiJ
'V%u0'ul O.l
S FECIAL Information only for Hospltdls, institutions, Trdnsirnts,
or Recent Residents, and persons dying away from home.
M„iith^
l).:\
Tin- AHOVK STXTHI) PKRSONAI. J' \ RT H" f r.ARS A K I- TklH TO TIIK
BHST <>1 MV KN«)\VI.i:i)C.H AM> ni.i,ii-;F
Former or
Usual Residence
Wlien was disease contracted,
tf not at place of deatfi ?
How long at
Plareof Deatli?
Days
V\ ACE OF HI RIAL OR KKMoVAI, J DATi; ..t HtKi\r, ..r RIIMOVAI,
11H i)4/vhvAOL,>cUxt J,t
< A(Mress
.tate CAUSE OF DEATH In plain term., that It may be properly cla..if.ed. The Special lo.ormalion o p.
■una dylnd away from homo should be »lven in .vory Instance.
)
i;. .:i!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,[,,,,,, , ^v, i..^£'^^-.:.]'.ScVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
du^^cu^ oLLohM t^eputy Heolth OfHcer
1\
Re^isteied J^'^o.
;2584
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of IDeath
( "a. S. StanDarD )
J on
\ 4
PLACE OF DEATH: — County of Co. >a. J^a^%^CA,a
City of Occ^r^ J Xcv
I \ CA,.
(ir DI^TH Ol
I* DEATH
"w-W
vK'^ w'^si.u,u,cc ^ ,
St
Dist*; bet.
and
■URS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
x^
CLLuQj \mc
\.
PERSONAL AND STATISTICAL PARTICULARS
m: '\
'V
i't «I • tk
DAI'l'. <»r ItlK 111
LLcM
M..iitli
\ < . V.
)'i at
V
(Dav)
M..u(/n
I . al
Pa vs
\\ ini t\vi:i» OK i)!\t>Krj;i)
Uiilf ill vinial (li'-is/nat i'ln I
lUKI'lll'l, \rv
(Statf or T' 111 iiti >
I ATM l.K
lilRIII I'I,A»1-:
<)I I AIIIKK
(Statf or Country
MAIDI'.N NAMK
OF MOTHKR
I'.IUl'IMM.At'K
ot MoTHHK
'Stall- or Coiuili vi
MEDICAL CERTIFICATE OF DEATH
DAPK (»!•■ Dl'.ATH
<^3w /go H
€t
(M.)jith) fDayl (Year)
I IIl^RIiBV LI'iRTIl'V, That I attoiukMl lUaxascd from
' -; r ,,^{ to AQ^ 2L1 190H
190 \
i<^-t;
that I htst saw h ^'\ alive on ^ " "^ ' ' I90
au«l that death occurred, on the date stated alxive, at
M. The CACSP: Ol' DIvATIl was as follows:
XV>'
nr RATION Years
\\
CONTRIIU'TORV
A/onths i X Days
Hours
Months
DTRATION Yi-ars
( SIGNED ) LLt|^J^ M fV iw
/)</
I'S
,<Xa_\,<X V ^, L\, , y
Hours
M.D.
I()0
( A.1.1 ress) (K iK . %i.^UluU^
SPECIAL Information ""'y f*"^ Hospitals, institutions. Transients,
or Recent Residents, and persons dylny awd> from liome.
oCCri'ATION
Kfsidfif itt Silt' /■></)/- /w"
)■/(/<
Mmilh-
Ihi
THK AnoVFSTATI-.DPKKsoNAl. I'A RTIi-f I.AKS AK l- TK t K To THH
HKST Ol' MV KNoWIJJX'.H AND lUlI.II-.K
(Itiformnut
Afhln-ss H I IX) Oh ■
VA-O VV'^^^VV
r\\.
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
Now long at
Place of Oeatli?
Days
DATlCof 1!' KiAt, or KKMOVAT,
f'K oi' mKiAi. OK ki:mo\ai
J f ^
ud<h.ss Hw\x^ \^xk at
190
State CAUSE OF DEATH in plain terms, that it may he properly UOMitie
•on. dying away from home should be ftUen in every inntance.
)
5t
t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
F?.,;,-.i ..f n. ,;t!i )■ S(, !c -i..^jr^; MScl' r
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)
((fc tl'li>(l X'X^J^A3<}\J X^
790H
Registered J\^o.
-^^OoO
.>CKAA^
Aj-u Deputy H -'^h Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
II
AA.^
PLACE OF DEATH:— County of ^ a
Certificate of 2)eatb
( "a. 5. StaiiDarD )
.^ City of '/Cc>v OA.cc > wcv^CLi
■^
"> \ '
*\ o
'No. H^
1
>-' * I
b+ ^^
^ f
L I A^ • Si; Dist.; bet. b A. K and
/ ir Dt»TH OCCURS AWAY FROM USUAL R E S I D E N C E G I V t r*CTS CALLCD 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
. iOI.siR \
Vl)lo '
I
X
II
I> \\\- «»F- 111 Kill
A(,l-
Q'-
11
\t..nthS
)
(n;iv>
Mm III:
\ I al
lhl\.s
SIM. 1,1:. M\KRIi:H
\VIIH>\VM) OK I)I\ « iRt 1 i»
(Wiitfiii social ili sj.j iiat t.ni >
C'X>^
lUK rUlM.ACH
stall or i'ontitry
NAMi: 01
I- A 11 1 i;k
niK TmM.M'K
01 • I\ri!HK
(Statf or I'oiinti \
MAIDI'.N NAMI
Ol' MOTIIHK
HIKTHI'I.AlH
ol- Mnr!!l-:K
( state or c'otiiili v!
^^
MEDICAL CERTIFICATE OF DEATH
DATH ()»• DHAIH \
ll 1 4
TQO \
(Year)
V5Al
(\
io.-,.d.
OiOri'ATlON
/sfMifrd /If Siiif l'i,i>iii"'>
(Month) (Day)
I HICRIUJV CI-RTII'V, That I atteniU-<l dci-cascd frnm
— ._— __^ ^ J^p -- — to :r— ric)0-
that I last saw h ■ alive on " Up
atid that death nrcurrcd, <ni the dati' -tated alxu-i-, .it
M. The CArSI'! t>l" DIlA fil \va>. as follows:
I ) r R A i" It ) N > 'e ll I X Mon ths I hns Hon rs
CoNTRim-ToRV aXv\,\.il^k "m^V-^.^k
^\!
DTRATION
l\ivs
Years Mouths
( SIGNED ) . Wurv-vXH; v . Mj LU, c
((\ p [1)0
ly/ct 5sH luoH (Addres<.)Ld\.e>xeM W I
Hours
M.D.
*
iW
Special information only l«r Hospitals, Insfitutions, Transients,
or Recent Residents, and persons dylnq dwdv from home.
) .,})
\ J, mill'
Diis
Till- \HovK sr\ ri:i) pkksonm. i'\k ihii xks aki- tkih to tmh
lil'.ST ol- MV KNt)WI,i:i)i'.H AND lUJ.HJ'
\,l,lt.sv; 1 L
kU^.d. J I
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death?
Days
I'LACK OI- mKIAI, OK KKMOVAI,
^lO^ '
DAX»'^«»f 111 lOAi. or KKMOVAI,
TQO ■
l9.ct :u
fAd.lrrss ini VnW^^fr>V '
AX<Xh,tu ^H, g.^'
■'■■■^"" TT . »np .k»..l<l he Rtatetl BXACTLY. PHYSICIANS should
N. B.— F.very I.em o( tn!or,.,».lon .houl.1 be ...r.fully .uppl,.d ^-^^Xtt^i''^^^^' "S^'-'-' ""'"-..Ion" .or p-r-
state CAUSE OF DEATH In pinin term., thnt it n.1.5 !■« P>-"l"!rly cia.sii c
.an. dylnft away from homo «houl<l be 4iven in .very in.tance.
D
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Date Filed ,
REFER TO BACK OF CERTirtCATE FOR INSTRUCTIONS
llegistered ^'o, ^586
JIA; aS^ 100 "i
; Deputy Health Oflflcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( tl. S. StanDarD )
1
PLACE OF DE ATH : — County of :x ^
si
Q
City of cUh^
r
No.
St
c
s
i
"and
I., Dist.; bet. — —
(IF DEATH OCCURS »WAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
^ ^ ,0
FULL NAME
^n^..,.n
•~v.\.u
L
CC'>'^\.
i ! \.\. \
PERSONAL AND STATISTICAL PARTICULARS
six /
loi ( >k
4-
i» \ ri; of I'.iK TH
4
MEDICAL CERTIFICATE OF DEATH
DATK C)l' DlvATII {f\
(Mouth)
I
IQO \
IDay) (Year)
\!<.nthl
\(,i.;
5 0
) '*•./ 1
(I);iv
M.itilh^
\ t-a 1
/'i? 1
\\ iix twij) OR r»i\ »>Kri.:i)
Wiitfin -iM'ial 1' - I'liat i' iiO
( 1
niKTIll'I, \('V.
(Stat* (II I'.iiinli \
namj: t)i
I ATHl'.K
niKIIIlM.ACK
<M' iaiiii:k
(Statf or i*i)uiitrv
MAini'.N* NAMK
c)I- MOTHKK
lUK inri.Aci-:
OJ- MOTHI'.K
(Statf ()! »."<)untry
^
jCYV
1 IIHREBV CliRTIF-V, That I attended (krcascd from
— ■ 190 to ~ IqO "
that 1 last saw h-:- alive on " 190
and that death occurred, on the date stated above, at
M. The CArSF-: Ol- DI^ATII was as follows
DTK AT ION Vrars
CONTKIIU'TORV
nr RAT ION rears
(SIGNED ) /X. '.^ . ^ ^
Mouths
Pay
Hours
otcrrATioN
/\f Mil fit III San I' I nil'
.'\ronihs
k Q
nivs
Hours
M.D.
l;a:1 li Kjo (Ad.iress) <L^4 U^^rucuXu La.i
Special information onl> tor HospUdls, InsHtutions, Transients,
or Recent Residents, and persons dving away from fiome.
) lii I
\r<'iitii'
Ihn
rm- AnovR stati'.d pkksonai, rAK'i'irfi.AKs ark TRrK T»» rin-:
liiCST oi'" MY KNowij.ix.H AM> iu;i,n:i"
(IiifoMiianl U
I)
J > V KA.L A£/Yw<ru- cx..'^ .
(A-ldrcss
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
How long at
Place of Deatli ?
Davs
I'I,ACK OI- lU RIAI, i)R RI;M<)VAI,
LV A.C
I)ATi;<)!" Hi HiAL Of KKMOVAI,
0.ct 15 T9o'|
^
vCc
INDJCRTAKKK Ll
of inWm«tmn should be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
E OF DEATH in plain terms, that it m»j be properly classified. The Special Information for psr-
N. B. Every Item
state CAUSE
sons dying away from home should be ftiven in every instance.
D
^Vi'^miipir
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n..,r l.f n ,;.h i n, - ^-^^i i.fclM , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Deputy Health Officer
Registered JS^o,
?358?
n
.<KAy<cX5
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
PLACE OF DEATH: — County of O a.
City of ^^'ccw JXo.
:'^
\ vCt O
No.
St.; 3^ Dist; bet J O.^'Lex,
A
and
/ IF Dt*TH OCCURS *WAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR uAfOER SPECIAL INFORMATIj^N ^
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTE/ib OF STREET AND NUMBCH^ J
)
'U
FULL NAME
u
lJ^^^^K
~>
uwL ) V, wi, , A
PERSONAL AND STATISTICAL PARTICULARS
^i:\
i<ii<»k N
Hll
i
n \Ti: or ink ru
A< .!•;
V.
L:.j
MEDICAL CERTIFICATE OF DEATH
: 4 - ' I
C^
(Yfar>
v!T
ICX
M..!i!!i'
I):ivi
I Vi-ai )
n,!
W !!•( lU KI> I iK niN'oKi KP
|\\!U« in ^(Kial .It^is-'TKitiuii)
II! ^d
OUJK.C
d
HJK 111 1*1. \i'l-".
■ Stat' "T •'■.uiitiv
NAMI-: «»J
I \ Til IR
HIKTHPI.Ai 1-:
i^\^ I AIHKK
i Statt or t'liiuit! \
MAIIM-.N NAMK
(il M»)rilI-:K
BiK iiiri.Ai i:
Ot'* MnlllHK
(Stall or Cotinti v^
f I
I I Lc
CVO
\UwLcl^v
t
ill.
w
n
(Month) I Day)
I H i;k i;i'.N' (.liKTU'V, Tlial I aUcu<U-<l (U'«xastMl from
ct
^',€t ;^H
icp to ^ tAi c^n i<>o 1
that I last saw h-' alivr on Hp
and that death orciirretl, on the date statt-d above, at it '
M. The CAUSK OF DHATII was as follows:
V- A,... v^vCX,'
1 .. (XWl
Dl' RATION }\'ijrs
CONTRIIUTORV
UJ\J
M on tin
CU5
Ihns
tiU
DURATION )V.7r5
(SIGNED ) C ^
^ft)H(/lS
/h7V
4 . S -^
Hours
I /ours
M.D.
,d
occri'A rH>N
iiifii il' Sati /ninii^i-ii OW ) - <?
fS .1/-;;///.
Ih!\>
THK \mn-F sTMi-i) PKRSONAI, PAKTirr I.AKS AR K TRIK To OH-;
linST Ol- MV KN<)\VI,i:i)<".K AM) HMJIJ-
L
(In forma nt OX.<l\/<M.
(k. LcCYV.A^^^^^<^'»^-
X-Mro'is
rYs\XK.<.<i
ii..-t
K
H)n
fA.ldress) V^'h \)->..a\.u
Special information onl> for HospifdU. Instltlrtions, Transients,
or Recent Residents, dnd persons dviny dwdy from fjome.
Former or
Usual Residence
Wfien was disease rontrarted.
If not at place of death ?
I'l.ACK (»1- HIRIXI. OR RKM«»\Af,
How lonq at
Place ol Dedtli ?
Days
1
<X vwCV-
I>Ari;of niKiAI, in RKMoVAI,
w ca- .-w
i -
rSDHRTAKKR ^R- U A^Ow^A, ^"^^^-j^
TOO .
A.lill^
a .. !• ^ AfiF -hauld be i^tateU EXACTLY. PHYSICIANS fihould
of information .hould be cnreVully supplied ^^^^^^^/^^^^^j^i^'Vh^ ..g ,., ,„formHtl.m" for pT-
E OF DEATH In plain terms, that it miiy be properly ciaHsmca. i n«s t*^
N. B.— Every Item
state CAUSE OF DEATH In p
Hons dying away from home should be given in every instance.
5
U,
WRITE PLAINLY WITH UNFADING INK —
!)(,lv F//rv/,liJ,ci:JGJ2A; %^
100\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS
2588
Re^istcrcfl JS'^o,
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of Beatb
( tl. S. 5tanC»arD )
PLACE OF DEATH: — County
ofCW-YV 0 A.O^nA^^AJiXX)Gty of
CC'-^X) 0.\.CVA-
No.
w^^
I !(■
St.;
Dist.;bet.^^
hc^tLC
V
(
ir DEATH OCCURS AW
IF DtATH OCCURR
u.Y rROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER
ED ,N A HOSR.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF
SPECIAL IN
STREET AND
and ^i^l<^
FORMATION" \
NUMBER. /
.^ ^ >
FULL NAME
'W
m
jx.i 0 l\.^^\
PERSONAL AND STATISTICAL PARTICULARS
I
i> A ri; < »r luu rii
iDct
\1..nth'
A<,H
I
^»
f^
) ■(■'(; I
(I):iV
M,.uih'.
( Viar)
/',/
MEDICAL CERTIFICATE OF DEATH
vL'cfc
i Dav
IQO \
(Year)
0\
(Month)
I III;R1:HV CI;RTII-V, That I altciidfl <lt'«<.ase.l from
1()0
SIN* .I.l-: MARK 11- 1)
WilinU i:n OK IHX' >I'i II>
\\ ! it( ill v(»,iai tit -.:s-'ii:.t i- ml
itiKrm'i.An-
I Stati- I ii C'tiuut I >
.1) CcLtr
\xr
NAMi: «>F
I A rm-.R
HIKTm'l,A*K
oi lArm-.K
(Slatr lit Oouiitrv'
M Mill N NAMi:
Ol- MOIIII.R
lUKTm't.At'K
ni- Morm'.R
(state or Country*
(H iTl'A'riON
C>aLLa >
^
AV-/</^(/ /'/ Sni! I'tatu
)'r>ii
M,,>itfr
Ihi
ni-,ST OI MV KNMUl.l.lX.I-. AM) iu-.i,n.i
(infonnant OaA^cX^-^ IUo^^C^-
that I last saw h -■■'■ aUvt- on *^ ^'P
an.l tliat <U-atli ncrurrc.l, on the date ^tatc-.l above, at li I
M. Tlic CAl'SI': Ol' Di; ATII was as follows:
CYV.,
CONTKIIU TORY
Mtnilhs Pays /fours
|>r RATION ^ >''</'v
Miiuths
PilXs
//on
IS
(Signed)
k:.\c
4
L'i i()o'
f
Vl.lrr.s) ^l^a \J|lui4.c^>A ol
M.D.
\
SPECIAL INFORMATION only for Hospitals, Insntutlons. Transients,
or Recent Residents, and persons dyintj dv*a> from home.
Former w
Usual Residence
When was disease r onfrar ted.
If not at place of death?
How tonq at
f»lareof Death?
Days
l-I.ACK <)|. HfKIAL OK KI-MoVAI.
I>AT1% 'it Hi I'IAI or Rl-tMoVAI,
(
r, .
INDHRTAKKR ^ 'tX ^"^C - ■
N. B.-
■^p.i^— i^-^"^""^"^""^^""""^"'^"'^^"'^"^*^^"^^"^^'^"'^"''"'^ I Km t t I FXACTLY PHYSICIANS nhould
-Bvcry ...n. ot l,.*o.,n-.ln„ .hou... he c-afuM, .uppl..d. ^;^;^;:^„„»J. Th; •S.-co.! i.fa.,n...o„" lor p.r-
. * r AllSF OF OrATH In pl«in terms, thot It mii* i»e Pf-"!* J'
5
t-.
f II. alth »•■ No
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2589
USlV Ci,
700 '{
Registered JS^o,
A
\A.*
! Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
^
Certificate of 2)eath
( tl. S. StanDarD )
PLACE OF DEATH:— County oi^O^-,-\j J,V<x^v<^cv City of Oa/vv
No. O.J. 0 Crvc ^ vcL L
S^Y^O^ LL^\/vCi. s
St.;
DEI
STI-
e
Dist.; bet.
and
4 »~L iiciiAi er Qinr NCE nivE facts called for under special information \
FULL NAME
i
\
L<.;
Va,';.^;
PERSONAL AND STATISTICAL PARTICULARS
Owii
u
1) \ I]-: < »! HI urn
A».i-;
li^ct
M..!ith
} ■,■,?
il):iv
Mnulllf
ov (^
(V.ar)
ATI
mNT.i,F. MAK«n:n
wiix t\\ i; i> ' »K i)'\' i!< 1 i; I)
(Wiitcin ^iKJiil di -iriiiitKiu)
niKPiir!, \0K
(Stat» or I'oiinti y
lAin ) R
niKlIllM.AOK
Ol- I AIHKK
(Slatf i»r Cniiiitry
MAiniN NAMK
Ol" M«)'lin:R
lUK'I'HIM.All-;
<»»■ M()rni':K
I state iir rinuitrv
CJ/CL^ru vjA^CU ,
e-'-"
OCCri'ATION
Rfsi,lfd III San /'inn, isr,}
)'i\i ,
Mnlltll'
Pin.
TliHAn()VHSTATHnPKK^ON^. rAHT,rr.,AHSAKKTKrH T< . THH
BEST OF MY KNO\VFi:i)<.K AND nil.n.J
(Informal
VjflfXxXXA^
(Ad.m... aSOO s^^lL^^^OlBt
MEDICAL CERTIFICATE OF DEATH
DATH Ol' Dl'.ATH
et..
(Month)
Day)
rgo i
(Year)
I II I;R I'lI'.V Ci;kTII"V, That I attcii<lcd «UH-ease«l from
IC 190'* to ^/cIj ^S. KpH
that I last saw lit.- ■» alive oti w wu A! 190 :
and that (Uath occurred, on the <late stated above, at '
M. The CAl'Sh: OJ' DI^ATfl >vas as follows:
Ccuvti,^<x.<i ^'
^v-c^y^
DTK AT I ON JVrt'-?
CONTRIBl'TORV
Months Days 1-^ Hours
Years
Mouths Pays
ft
(SIGI
flouts
M.D.
Dl'RATION ^ i\, K ^
INED) 3ll\ 3. N [WvAiA^'.
il'.tt XS upH (Address) 9.500 JAlJUweXxsJl
SPECIAL INFORMATION only '"^ Hospitals, Institutions, Transleiifs,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death?
Days
ri^ACK OK IHKIAI. OK RJlMoVAI,
i
\)axL
DATl". of ISf KiAi, «»r REMOVAIy
lytJt x^- 1901
,...„.,..,.l ikALu, V %
(Address q(p*I?^
^>\1
,, . Tpp .houid be stated EXACTLY. PHYSICIANS should
I,. B.— Bve.y Item of Information .hould be carefully euppUed. J^^^J^Z.^.m.^. The •'Special Information" for per-
.tflte CAUSE OF DEATH In plain term., that It may ne pru|,«. ,
:". d^faVaw., from hon,. .hould b. ftlv.n In .v.r, In...nc..
D
U,
!li..i'.l 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,f,,..nh rvo. i.^?i^n^>'^'.- REFER TO BACK OF CERTIPrCATE FOR INSTRUCTIONS
2590
Registered J\'*o.
^ WO
Deputy Health Qflficer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF
Certificate of "Seatb
( "U. S. StanOarO )
DEATH: — County of 0<Xax^^*^^^«-^^<^^^'»-^^ City of CJO.'Yxj J.N.O. .
Ne
^ U - vj . v'
C^^w^c^v
r»
V.\.-v^A
St4
Dist.: bet*
and
, „ liciiAi QTCinrNCE: civr facts called for under "special information" "\
( " rr".;ATH"oCc"u%r:."rHotp"T'i:: o"r"nSt'.?J;^o';"c.VE .TS name instead OF STREET AND NUMBER. )
FULL NAME
Q
crlhixt fc (X >->
\u
DAT!' < t! r.lK Til
PERSONAL AND STATISTICAL PARTICULARS
L'
axkfc
Dav
\r. 1-;
)'>'dt
WIIx i\\ I'D < >k I>'i\( tKl'KI)
(Wilt'- in ^iKial (Usi^»n:ilii)ii)
lURTIllM.XiM',
I Stntt (ir t'ountiy
NANtl" <>l'
lAIUl'.K
oi- 1'ATiii<:k
(Stair or Ciiimtry)
MAIDIIN NAMl'.
<i| Mo'lMIKK
lURTHI'l.AOl-;
f»J" Mo'l'MHK
(Stall- or t."(HiTUty
<X>-v ^
f
^S
.■■■•r)
/J,7 1,
■^VT
OCCri'ATION
Rfsiifed in >'<?»/ I'lmtiisrit
)■/■<//
M nil tin
]h!\
TnKAm,VRSTATKI>PKKSnNA, rAKTUM^.AKSAKHTKlI-r.) THH
^JTLcxXA^i^^C^Uw
1500 \^^lJyy^M^x
MEDICAL CERTIFICATE OF DEATH
DATK OI' DKAPH
(Month)
%
(Day)
!Vear>
I Ill'RI'HV (.I'.RTIl'V, That [ atteiKkil (leoease<l from
v^^rt ID 190 H to w/cl - Kp .
tliat I last saw h •■ ' '\ alive on w- Ct I90 ■
and that tlcath occurred, 011 the date stated above, at • I
Q M The CArSfv Ol-' DIIATII was as follows:
Ua.A-<i^'-<^
C C ■< rw^C
1)1' RAT ION Ycani
CoNTRIl'd'ToRV
Years
Mouths
Days
Hours
Mouths
DT RAT ION
( SIGNED ) . mII d. M lloA^
11/ ct i<)o'i r.\ddr>-^s) '. ■
Pavs
\^t\.^ - w
I lours
M.D.
t
SPECIAL INFORMATION onl> 'or Hosplldls, 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 iX
Flare of Death?
Days
I> All. m:' I'.- I'lAi, or KICMOVAI,
C ct V. 190 t
PJ,ACR f)J* niKIAI. OK KKMo\AI,
I-NIH-KTAKKR XUXUjL ^ d^l CC|yCC-v
^,„^^,^„iBi^^^^Bi^«^ii^— i^— "i^"^"^^"^^^"^"^"^^^"^"^""^" .J EXACTLY PHYSICIANS should
IN. B.— Every ...n, o« .„.„rn,«.lon .hould be c«r..uM, -upplted ^^^^^'I.^J^^J, The "Spec... Inforn....on" »or per-
state CAUSE OF DEATH In plain term., that It may ."" P' ^
«n. dyin* -w., from home .hould be given in .very .n.t.nce.
9
^
«o'
^)
RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
w
Hnanl uf Ihiilth I- Nu i . ^-^^^i) l!5c I' Co
Reiisteved JSI^o,
o^i^Y
h^K^
L,^^ 1l^)^ Deputy H..-.th Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "U. S. StanDarD )
i
PLACE OF DEATH:— County of "^ CX.^ J ■vcxv.t.a- ^Gty of ^Kx.y^ . /va.->^
^
Dist.; bet. ?b C. A ' ^^ ^ •:..c;v \. and V.* ^ Aa < --
■ •(•iiiti or c I nPMr r r ivr FACTS CALLED POR UNDER SPECIAL INroRMATlOW \ \
( " r,"o;".,°„"occ"u%;"v;."r»="»^pr.t ir:.i^r.5^.or..T^\ name ,»sr„o o- ..«.. .»» nu-.c. ; j
FULL NAME
Ql^P
\w,.^\.*AA^;
t
PERSONAL AND STATISTICAL PARTICULARS
sKx AA , v:^'i.">i^
11
LUa.C
H
\<.i-:
V.ci
M,nii/>:
'\ tar
Ih!
SINi.I.K MAKUn I>
\vin«>\vi-:i> nK i)i\< >k4 j:i)
U'litcin -(K-ial .1( -ivtiali'inl
lUKTIlTI.Xri: A /-x f\^ ('7^,
(State ..r CuimtiN ' I \a f m
\ \ Nt » < U
I- A in !:k
HiK'rm'i.Ai'K
«)l- lATHl-.R
(St:it< or iNmiiti \-
MAI!)1-:N NAM).
( » I' M ( )'r I IK K
lUK'rni'i.AOK
oj- MoTUHR
(state or Country
L o-cLc^
%,
),',;/
1/ .,/'//
//.,'
OCCri'ATION \
HHST Ol- MV KNOWM-.IM.h AM) Hl,I-il »
U J L
r^iifrd III S,nf / lUii.'-xi c^*-
v'A-q ■
MEDICAL CERTIFICATE OF DEATH
DATK Ol- I)1:a TH
A
'Month)
'Day)
(Yt-ar)
Wdu
I ni';RI':rA' CI:RTII'V, That I atUMuUa «kc eased from
s:^n:ju • . luo to w \:.u. o^r? 190S
that I last saw h A' alive on -^ - -^'^ ifpt
aii.l that death occurred, on the <late stateil ahove, at ' ■
M. The CAISE OF DI^ATH was as foll.nvs
Lft /\Ar>^OrvA.xxJL J n
\_i.
DTK AT ION >■'<?/?
CONTRirdToRV
Moulin
Pax
Hours
Ycays Mi>>iths
NED ) Ldctk ^ ■ li A„M.
Dl* RAT ION
(SIG
e
Kp I
f
Address) Wh I
l^ays lloui s
M.D.
iaL*,ix.c\,(A Jt
SPECIAL INFORMATION only fof Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from tiome.
former or
tsual Residence
When was disease rontrac ted,
If not at place of death ?
How lonq at
Place of Death ?
Days
I'l ACK ol- nCKIAI. <»R RKM<t\ AI,
c^.lD,
0 ^'
I)\Ti:uf Mt KlAl, or RKMoVAI.
T90H
^<k. ^i
r.NDl.KTAKKR
Ad.lP
UA^
UCi^i-^^ *^ *-
^„^^^^^i— «^— ^^^■^'■'^'^■'"■"■"■■"^" IH h* t ted FXACTLY PHYSICIANS nhould
of l„form«.ion •houid be carefully -PP»-f; „t?p^eHr"l -stifled! TM " Special I„for,„«tla„" for pr-
F OF DEATH In plain terms, that it ma> he proper.y
:SH"xrJ'h::::;Hou. .e ...n <
r*
f
r
WRITE PLAINLY WITH UNFADING INK —
.^,1 ,,f n.a!t]i rv.^ ,■ **^.5:^>i»^''*-"
4
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
{ tl. 5. 5tan^ar^ )
PLACE OF DEATH:-County of '^x.v " Aa .v... City of Oa.^v J\<x...c.^
CPfc. ^'C^
wi ^'^M
i\
St4
Dist.; bet.
and
— )
FROM USUAL RESIDENCE G.vt r*CTS called r
rOR UNDER "sPECI*t INFORMATION ■ N
NSTEAD OF STREET AND NUMBER. /
^ if..
FULL NAME
(^,
PERSONAL AND STATISTICAL PARTICULARS
4
H 1 LCLtX
i»Ari'. or uiKi'ii
,^WH
M.mlh'
M.v:
ipc
Day
M ,>illi
ar)
/>■/ IS
WllHtUHDcm I>!\ oKi i:i) j \
\\l !tf 111 HI KM a I
(Htate cir i<>untt\
NAM I", n|-
lAI Ill.K
{^V iai'h»:h
(Statf i>r (.'oiiiiti \
MAini'N NXMi;
(»l- MoT Ill.K
lUR IHIM.ACK
K\\: MOTIIKK
(State or i"oiiiiti \ '
ot^tVC'-
MEDICAL CERTIFICATE OF DEATH
DATE ol- 1>!:ATH '^
iVear)
(Month) ''>•'>■'
] ni';K!':BV Cl RTII'V. That I attenao.l .UitmsimI from
— — - — - — 190 — —
-~ 190
-■■■ . — I9O to
that I last saw h t:— alive 011 -
au.l that cUath occurrcl. on tin- .late -tatc-.l above, at
M. The CAI'SI-: ()1'\I)1':A ril wa^ as follows
'^c^*-^
^ ,,
\ . ,
CONTRIIUTORV
Mofi/hs
Diiy
Hants
//(>nrs
'-^/
KryiJfit III S,ni /'«'
) ,,.'<
M.<i>tli'
/i,,M
.PII^^H,>VHSTATK^PKKS..^A..^KT..^,.U<.AK^,TH^K TO TUH
HKST OF MV KNOWI.I.IH.K A^" Hl.I.IM
(Infoitu.itit
0 ),CX. c
0'?
\<Mn*'«
,,r RATION >v<^/-^ ^'^^"'^^ ^ ^'*'''
(SIGNED' J (Is UO cUX<:c%\.cL M.D.
v^ ^
^.(E.WLL.vA.
aa.
SPECIAL INFORMATION only lor Hospitals, Institutilrns. Ir.nsifRts.
or Recent Residents, and persons dyinii away trom home.
Former or f
Usual Residence
When was disease contracted,
II not at place ol death?
How lofl4 at
Place of Death ?
D<iys
pi.ACK Ol- in KiAi. <»K ki;m..vai.
I
KXl'I'if I'.'HIAI. or KHM«)VAI,
IQO
'U \.i
^ I rVACTlY PHYSICIANS nhould
I
Bonnl ..f 111 nUh I- N" ! =
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^,S-=;v^,,^,,,.„ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale Fi/<''/.\i'<:XM>^i>v 3.5"
^ i
190 H
Deputy Health Officer
PiPi^lstercd J^^o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cettificate of S)eatb
PLACE OF DEATH: — County
0 [\ !
( "a. 5. Stan^ar^ )
J? on A ^
'..-U
^Ne.
UhulWx^
a
St.;
Dist.; bet.-
and
TH OCCuIrS away F
CATH OCCURRED I
'."ri^r.t :-^?'?;^"u'=.^rj,v7"r«-«" r,.".ri: s?;^=;-.'o'r:e-;r ■ )
FULL NAME
"^l-X
PERSONAL AND STATISTICAL PARTICULARS
\ COI.OR '\ "\
h
^syxXA Ktc
a.^.
I 1
i>\ ri: tti I'lK I'H
I Mi.iitlil
A' .1-;
r.-.f
(Day)
)/ ,nt/n
% i-a!
/^<n
iWiitf in -<" 111 -i' -i/ii.HHiii)
MEDICAL CERTIFICATE OF DEATH
DA 11-: «>K DHATII j, N
i:^
n
igo .
(Ytai)
(Munth) '»'*'V>
I IlI-RI'iHV Cl'.RTIFV, That I attcii.U'.l <U-ivaHtMl from
iQct IH 190 ^t to ii^^ 3^a icpH
that I last saw li ^.>. alive on ^ ^t .^3 190 H
au.l that .It-ath occurred, on the .late stated above, at
M The CAISI- Ol- DlCATi! was as follows:
\
HIK rHJ'I. Ni'l'.
! Sf:i!t .It I*. Hint! N
N \Nf 1-; 01
I AT II i:r
lUR rniM.Ai H
( stall or i'tiunti V
maii»i;n namh
Ol- MoTHl'.R
inKTiiri.AiK
t»| MOTIII'.K
(Slate or OcHiiitryl
oiit r\ rioN
Kr^uU'd III Sun / i,nn ii<>
WCUw
N \
! V,/ /
.\/nnf/n
/ hi I
^^^ii^^y^i^^^ ""■■■
(Iiift»! tiiatit
■.:%.
.„„„.,.„ ^it
DTK Alio N >Vv//.?
CONTRinrTORV
Man tin '■^ /^tns
Hours
nr RATION
(SIGNED)
Yi'ius
Months
na\
^Vl
,<X-V.CC
1
0 .^b :X^ ,.,o-, (A,Mr...s^A^Vutivll.-
/fours
M.D.
SPECIAL INFORMATION only lor Hospitals, InsfHutions. Transients,
or Recent Residents, and persons dyinq away from home.
Former or
Usual Residence
When was disease rontrarted,
II not at place of death ?
How lonq at
Place of Death ?
Days
n.ACH <>|- in KIAI. OK KKM«.VAI,
I»)Ji:<>; UiKiAi, <»r RKMOVAI,
Y>\.
^^^^^.^__^— jj— ^^^— —— ^f^^— '^^^ . pvAcxLY PHYSICIANS nhoulfi
state CAUSE OF DfcA inn p ^^ ^^^^^ i„«t«ncc.
•f>n« dying away from home nhouiu oe gi
I
m-
\
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bonr.l ..f He;. 1th K No i; "^■f^^^O) lU<v:l* C
190H
Registered JS^o.
2594
uju^ K-. VH\ Deputy Hea!th Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( H. S. StanDarD )
Jl
m
PLACE OF DEATH: — County of '<x-*v ^ \o. ^^c^. - City of ^^ Ov 0
A.Ow >XC^^
rNo. UH ... .'_.. St.; 5 Dist.;bet. - ' ' - and JlUac^^C
(ir DCATM OCCUBS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
IF DEATH OCCURRED IN A HOSPITAL Oh INSTITUTION GIVE ITS NAME INSTEAD Sr STREET AND NUMBER. /
A
FULL NAME Ml
'1
La'^^M- ^^-
k.
\
si:\
PERSONAL AND STATISTICAL PARTICULARS
^ 1 1'
LL
DA ii; or r.iK in
0 ^
iMoiithM
M.V.
1 ^N
iDav)
\l,itilfn
car)
» ca
A/'
s!\< .1,1-: M \K l< 11 11
\\ IlXtWi: II OK IMVt iK* 1 I)
(Writfin >-<Mi:il lit -.i',> ii.it :> i", )
X
cL<rUc^
niKTHl'l. \i J-
f Stntt lit < ' unit I %
FA 111 KK
BIU I'lMM.Ai »■;
oi- 1 Arm: K
(Stall or Count!
MAn»i:N N\Mi-:
<)1- MOTHKK
lURTHlM.ACl-:
<)»• MOTHKK
(Statt or I'otuitry
'Xc^t^i\A.a >
n
\J<y\J^:^ '.VVCL
\
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATIl
m
(Day^
rgo \
(Year>
I 111":R1';P.V CI;RTII-V, That_ I atttu.K.l .Ur.ascl frf>iu
.. LL\^*wC\ L 190'J to V <Lt '-s\_ 190 '^
that I last saw li -*. alive <»ti -^ CU .-. \ i(p
an<l that death octurreil, mi the date stated aV)uve, at i^i- ^'-i
. M. The CAISI-: OI- 1)|;ATH wis as foIUnvs:
I)rR.\TI<)N 1 }V<7/v
et>NTkiiuT(>kV
Mouths
Ihxx
I lours
DTRATIoN
)\ays
(SIGNED )
^1
.Uou/Z/s
/></1S
//ours
M.D.
+
AAj^L^lX^^XX
(Hcn-A rioN
A'r^iiftif in Sill/ /'i ,; If, '>'•■<
I
1/,,;//^.
/>,.
THK AHOVK STXTI'D I'KH S( in \ I. r\K rUTI.AKS \RV. TKl H To IIIH
iIkst «)i'" MN KNOW i,i:i)( .1-; AND Hi:i,ii:i-'
(ItifoTumiit
\.l.lr.
I5ii ^
IxA-C*. k
1 1)0
r Address) 1 iq- 10 li
Special information cly for Hospitdls, Institulions, Transknts,
or Recent Residents, and persons dying d¥,i\ from home.
Former or
Usual Residence
Wlien Has disease contracted,
If not at place of death ?
HoH tonq at
Place of Death ?
Days
PI.ACH 01* niKIAI, oK HI:MoVAI, j DATK of Ht kiai or KI:MoVAI,
CrA.- VS^NA. I ^ ^' ^*^ T90^
'W Cvo-^<i.
INDKKTAKKK OCt>>^C^\^^
\
Xr
A<M,-ss IXC^l Q lf\\.^^A^ >\. H
.hould he c«r«fulUv supplied. AGB should be Mated BX4CTLY PHYSICIANS .hould
„ plain terms, that Jt may he properly wlassiiricd. The Specl la»orm»t.on for |wr-
N. B. Rvery item of Information
•tate CAUSE OF DEATH i
«Ofi« dying away from home nhould be given in every instance.
I
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
B4,.i-.l of ll.;ilth I- N.< : '^'C.Hi.^'- ''"^'' '^""
I)(f/<' F/h'f/ ,\^' ^
X5
190'i
Bcgistcfed J\^o.
2595
k^cn^A.' ' ■ ^^M Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( tl. S. StanDarC> )
J? QD ^ m
PLACE OF DEATH: — County of Oo<jyyj 0 A,<x ^m-^^^ <^' City of Cjcu>v JA^o.^ v ^.v. ^
No. ^\H - ': Xl. St.; '' Dist.;bct. ub CrwiXN^'d and JCTV^ ' .-
r IF DtATH OCCURS *WAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IP DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
11 V
LLvtru
x.u\
•^! \
^
PERSONAL AND STATISTICAL PARTICULARS
DA IT of I'.lRlll
\>.
Ll
MEDICAL CERTIFICATE OF DEATH
DATH <)!• DKATH \
^ ■ ct X\
(Moiilli)
Dav
igo \
(Vt-ar)
• Mi. ml)
M.r.
)'ra >
lUav)
M.iiiih^
fV.Tir)
I>av.s
u iix »u i:i> mk f)ivi >Ri }■:!>
iWiittiii -.(H-ial ill ><iL'ti;it :> 111)
X>^^
L
lUKTHIM.AOH
(Stntf or Coiinti V
\\Nn-: «»i
}'A riii'K
HlK'lHIM.Ari-:
<H' I Aini-'K
• St.lti III l"ol1lltl V
M \II)1:N NAM)
Ml- Morm; R
lUR'niPUAlK
«»i m(»i*hi:r
( Stati or I'ounttA
ocrri'A'iioN
<X^
\j
Xo.
i
CX-ry%^ ^^ \K.\
r
I
XJ
I HIvRHnV CI'RTII'V, That I atleiKk-.l (k-tvascd frnm
Al' at I i9o3 to W ^^ -'i up
that I last saw h alive on ' ' I90
and that death orcurred, 011 the date stated ahnve, at
.'. M. The CAISI-: Ol 1)I;ATI1 was as follows:
1)1' RAT ION .K Years
CoNTRlIU'TOKV
DIRATION ^ )\ius
A
Moulin
Pay
Hour
.'S rout /is
Pa
vs
^^^'W i
1
\
AVw,/^,/ it> Siii' r'niiiif'i,)
);„i
yj.nlth^
/',/)-
THJ- Mi.iVKSTXTJ.:nCKKS..NAl. I'XRTU't 1;^K•^AR1•:TR1 H T< > HIH
jij:ST <)1" MV KN< »\\ I.l-.IX", K AM) HhldH^
'Iiif'Hinant
(Signed) ,
il
i I t >*
Hours
M.D.
(Address) IDH'ia.' b Uv .it
Special information only for Hospitals, institutions, Transifrts,
or Recent Residents, and persons dyinq a**a> from tiome.
Former or
Usual Residence
When was disease contracted.
If not at place of deatli ?
Now lonq at
Ptareof Death?
Days
ri 4CK <>i' lURiAi, OR ri:movai, I i>\r»:<.t iti hi.^i 01 kkmov.ai.
"■■"■■"" ' , „ ,. , Ai^p ■Ho, III ha atAted EXACTLY. PHYSICIANS should
N. B.— Every Item of lnform«tlon should b. cnre^'uMy -ppi.ed ^^;^;^l^'''^l^^^X^%^^ I„form«tla„- for pr-
•tate CAUSE OF DEATH In ploln terms, thot it may he propi^rly wlassifiea. \
«on« dying ow«y from home should he given In every Instance.
6S
P-
rJ
■^
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l!.>:ir.l .,f II. nllh J- No \^ T^^^^y^^j V.ScV C',
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f
fr /v/r^/,lycfcKHl>v %S
1f)0\
Regisfcj'ed J\''o,
25^ >^^
D6
trU.^<N
S ' / s-
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
.
Certificate of H)eatb
( "a. S. Stan^ar^ )
\
No.
PLACE OF DEATH: — County ofO<X^-v. Vex >vc
-» vet ^\j ^ ^- i> v^ ' ^- v-t. a. I . St.;
,L ~L City of '^^^"^^^ J .VCL.^va^<i.ci
"and
^^^ _ _ _ . . _.., — - Dist.;bct.-
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
;n
FULL NAME
CL^\,
\\\^./'
s I-, \
PERSONAL AND STATISTICAL PARTICULARS
\\
DAIi: <»I lUKlll A
\' .!•:
\; nthi
15
inav)
l/.,./M>
k t-;
■ar)
r>a%.
SiNC.i.l- MAKKIl'.n
\\ IPi >\\ i;i» t>K I»I\(>K( HU
(\\ tit' ill ^u.ial ill -;yii.niiiii)
CCicrL<.^<.(^
lUR Illl'I. \*'l'
I Stall iiT I '.>!lllt I \
\ A 1 1 1 >• K
HIK IIIIM.AiK
«)l- I Al'in-K
(Statt 111 ri>niit!\
MAIDI-.N NAMl
CH- MOTin.K
HIK Till' I.AC H
iH MdTllHk
(State nr Codliti %
orcii'ATioN
Kf!.iiird 1)1 S,ni /'urn,
^JU^^-Y^CK
) I ii I
M.infln
l>.
THHA1M>VKSTXTKnPKK.ONAl rAKT.rtM XK.AKKTKtKTn TUK
niCST or ,MV KNoWi.I.lM.K AND l?i-,Ml.l
(liifnrniaiit
^-^ XSjXY\j'Ouy\j
\ 5-^Vh-^.
( Aililu vs
MEDICAL CERTIFICATE OF DEATH
I>ATK 01-" nHATH .. N
(M()iith>
I>:»v)
(Vcari
I Ill*'Rl''nY C1;RTII''V. riiat I iittcinU-.l deceased from
IgO 1 tn 'W'S„ V > i. up N
that I last saw It .. ' alive on - ' • up
and that dt-atli orcnrrctl, on tlic date stated alxnc. at I 0
LI M The CAl'SP; OI- DI-ATFI was as follows:
^ /^ ' '- ^
[ ^ *
nr RAT ION )'iafs
CONTRIIUTORN ^^
w<r^
J)av
Hours
">vL.^ X*^
♦ \
DIRATION
(SIGNED )
■Cfc *^'i rqo
Years M,uitln
navs
K
■+ <1 '1,
^
HoHt s
M.D.
SPECIAL Information <»nl> 'o^ Hospitals. InstltuHons, TranslfBts,
or Recent Residents, and persons dyinq Afii) from home.
former or
Usual Residence
When was disease contracted,
If not at place of death ?
im '*Um,' >'\ri.
Now lonq at
Place of Death 7
kys
D.XTHof nrKtAi, or RKMOVAI.
U-Ct %k 190H
I'l \CK 01/ lUKIAI, <>K ki;M<>VAI
— ""^ TT AnF «hould be stateil RXACTLY. PHYSICIANS should
jS. B.— Bvcry Item o? l„Vorn,«t1on shoul.l be ^"'•"^"'•y f^^^'J^t properly classified. The "Special Information" for pr-
state CAUSE OF DEATH In plain terms, that .t may be PJ«P«'-'y
««ns dying aw.y from home -hould be given In .vry instance.
il
WRITE PLAINLY WITH UNFADING INK —
it n<:iUli S- No iv -^^^-^i^JlUS:!' Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(ifi> Filed, ii'/::±.cr4-i^u V^
100\
Eegistei'ed J\i''o.
an
97
DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco
^
Certificate of Bcatb
( XX. S. StanDarD )
PLACE OF DEATH: — County of '^ cx^-v o A/cx^ > v tv^ c^ c< City of '^ vv ' vc^^x^r< o -
j(
No.
'I^ A<\-\vao..
St.; 5^ Dist.; bet.
\\tL
and
in t \
)
/ ,, OI.TH occu.s .w., fRO» USUAL BEsTdENCEGive "''"'\%%° ■■°"„7°" _f "^i'i '^'^^^^^
I IF Dt.TH OCCURBf D IN • HOSPIT.L OB INSTITUTION OlVt ITS NAME lNSTt»0 Or STRtET «ND NUMBER. /
^ t
FULL NAME ' ^^^ La x- <
L
\-4
JUJiKA.Ly\j
S I-. \
PERSONAL AND STATISTICAL PARTICULARS
I C<)I.<»R X
■i\\
LL
1) \ I'l: OF- UIK IH
A< .H
Miinth
S ,
Da VI
M,»itJi^
'1 '^ f-
1 Year)
Pa
^!N<', I.i:. MARK IK I).
W ll>o\Vi:i> Ok DlVORi):!)
\\?!t(iii ^iK'ial ill -.iLMiati'inl
lUKTIU'I. \ci:
iStati- '>! r.iiiiiti %
ns
w rv
, t V^A.V,^w
NAMV ol
lATin K
HIRTHIM.ACK
Ol 1 AIHKR
(Statf or (."ountry
MAIDKN NAMH
(»!• MOTUHR
HIK rill'UACK
OF MoTllHK
(Statt or v'imtitrv)
OCCri'ATION
^v^v
Ic
d^u^cLc/w
-CC
I
A C )
0
CjMMxLi/
•yx)
/hi\>
run AHOVK STVI-K.) '"HH-^NA, rAKT|Cr, XK. ARK TKrK To THK
HKST t)I- MV KXoWlJ.lx.K AM' HI.LH.l-
Ax.'
(Month)
(W-ar)
MEDICAL CERTIFICATE OF DEATH
DATE OF UKATII
(Day)
I Ill'lRICBV ClvRTII-V, That I alteiKlv.l dtrcased from
~.-,_::,j,.— , :-.■-■ I9O tfl * IQO "~
that r last saw h alivt- oti - T<P
ami that death Dccurretl, on the date stated above, at t^
tX M. The CAT SIC Ol" DllATll was as follows:
Ldhi^^^^^^O^ Jxy^C.Li..C. sJ,CX.vv^i^v<rvvA
DIRATION )'{ars A/o/Z/rs' Days I/outs
CONTRIIUTORV
DTRATION
Vi'ius ^ Months
^ 'is \V
( SIGNED ) ^\j^yjlx) J Ad. Uu
ly/tfc Q^H iQoi. ( Address) UX(r%>wi\^
/^(7VS
OUAVCL
flout S
M.D.
SPECIAL INFORMATION only '«r Hospitals, Instrtunons, TraRsifRts,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
Wtien was disease contracted,
If not at place of death ?
How lonq at
Rare of Death?
Days
I'l.ACK OK lU KIAI. OR RKM<»V\I. DXX!:-; H'HiAf m RKMOVAI,
■Xl.KRTAKKK ^ ^1. ^Xtx^AX^^
190 S
■^ p K I I h t itecl BXACTLY. PHYSICIANS should
of inforniHtion .hould be carefully supplSed. ^*^^ l!^"!'. .l^j" The "Special Informnfion" for p*P-
E OF DEATH In plain terms, that It may be properly Ua^.tled.
N. B.— Every Item
!•,, cl .,f n. :iltli 1- N')
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^•f'^^nfkVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Jteghte/'cd A^o,
V/M<. Deputy Health Officer
DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco
i
I
I
a
f
i
(Tevtificate of Bcatb
( XX, S. StanDarD )
PLACE OF DEATH: — County ofOa.^\. 3 Iux.^cv.n co Gty of OxX'>v. J.Va.>^.cv^ cc
n A
Na
St.;
Dist.; bet.
^nXat-nxJ^M and JLiCCviAA^
vl V, \„\^ W N^-^Y "- ,.eii«l orfSinrNCE Givr FACTS C*tLED rOH UNDtf* SPECIAL r^NFORMATION- \ A
FULL NAME
T
^YV^
La-^.'...o VJLcuac^/
d.
PERSONAL AND STATISTICAL PARTICULARS
>-J.\
1
ri»I,< >K
I» \ ! i: < >I 1! IK I'll
At .K
iDct
I M.itith
>-lNi.I,1' MAKHIl I»
WinnWKl) <»K 1)I\ i »RrKn
iWiittin -;<Hi:il ih'-is-'tiat n iii)
niRTIUM.AOK
(Statt .'T '.Miiittvi
t l>av
M,»,th>
( ^ tan
Pa vs
h\K(\\''
(^
MEDICAL CERTIFICATE OF DEATH
DATK Ol- 1)1:ATH a
(Month) • !>;«>•' ''*■«'•"■'
I lllU-iMBV C1;KT11-V, Ihat I altciKkMl <UTertsc(l from
ij^A± 1 S 190 H to ii).€t -XS TCP H
that I last saw li
alive on b d ^3
itp
an.l that «kath occurred, on the date state.l above, at \ ''
M. The CAl'SI*: OV DICAI'M was as follows:
nTv 1
X
A^C <.
Lu-
~i
N \MH t)l
lATHKR
lUKTlllM.ArK
()! lArin-.K
(Stiiti lit rniintry
MAIIU-N NAMi:
oi Morin'.K
HIKTm'l.ACl-:
ol MoTHHK
(Mali or Conntryi
/
Wi'V^v u lO^^^
(k.-v
t\
Cfw-c
U'
^
^qJ^u
()t, CI" TAT ION Qr\p
Pf. Miff if in >•''!" /
; ii If, ,''''
) , ,!
M,>i,fh'
/hi
T,,HAm>VESTATKnPHRSONAl rAKTirrLAHSAKK TKrH T-
linST Ol- MV KNc)Wl,KI><-.K AND Hl.Ml.l
IHK
f AfUlrt'ss l,Xo
V
9=
' f
nr RAT ION
CONTRIIH'TORV
) 'ears
Months
Pi
/rv
//oiu s
M
DIRATION
(SIGNED)
)V<7;-.? 3- ,)/<)>/ t//s
LAct
7)^7 1-
/OmCCIc )\:(xK,'
//ours
M.D.
iD^ XH T^^nH rA.hlr.ss) t^il L^Uiu Jt.
lilals, In^ti
SPECIAL INFORMATION only for Hospil
or Recent Residents, and persons dying a»*dy from home
titutlons, Transients,
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Deatli ?
Days
l'I,ACK Ol- lU-RIAI, <»K RKMoVAI
DATJCnf Hi KiAi. or KKM<)VAI<
Q,^ 15 T9o'i
fA«l<lrt'«^'«
^^^__^_^__^^^M^^^M^^^— A— i^M^^"^^^'^*^^^'^^*'^^^^^^^^ - FXACTLY PHYSICIANS should
jS. B.— Bvery Iten, o» i„for«,«tlon .hou.d he carefully .uPpHed J'^^'^j;iZltmVl^^^^^ "Sl-cl-'i .nfo...»f.o„- for pr-
state CAUSE OF DEATH \n plain term., that It ma> "^ P ^
•*'. dyini away from home should he ftlven In every Instance.
*
WRITE PLAINLY WITH UNFADING INK —
J?ofir
(1 .,f n. :'!H) F No ;- ■^•'T^^W^V Co
Dulo FiJcilXJi^jXAh^ V5
U)0\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2599
Re^islei'cd •A^o.
\.^K^ \jj\}M Dcpu
- alt h Officer
DEPARTMENT OF PUBLIC HEALTH=Cii) and County of San Francisco
PLACE OF DEATH: — County ofO/CVru dAXX.'>xC\
Certificate of IDeatb
{ Xk, 5. StanDarD )
^ City of U<X/"ru J /ucx. >vc\,s^ ^ ^
,c"fi
A
^fcW^^^-O^^
St.
Dist.; bet.
and
If"
FULL NAME
s.,Q^X-\0. U C.
PERSONAL AND STATISTICAL PARTICULARS
DAii: or liiRin
\r,H
C< >I.«>R
ll i.
Motini)
(Day)
M.niiri'
5.M
\ rai
Ihl^.
^INT, I 1" M \K K 111'
WIDOWJII) «)K Hl\ 1 .Kill)
(NViilf ill '^•H'ial <U->-is.'iiatioti )
^!.(t( or t'oiuit I ^
J,'
MEDICAL CERTIFICATE OF DEATH
DATK I'l' Dl.A III
lii.ct
I go \
(N\-art
UJb ^ N-C
y
1
I.' CU^f^
V O
NAMI-: <>»•'
I ATI! IK
lUKinri.ArK
<)!• 1 A II IKK
(Strit< i>r I'uviiiti V
MMDI'N VXMK
ol- MO Till. K
HIK'rmM.ACl-.
(►I- motih:k
(SlaU- or Ct)tiiitry)
XX^
">
Monlh) 'I»;iv)
I lll'kl'lHV Cl-RTII'V, Thiit I atUMi.kMl ilecca^ed fn.ni
w :;.l . . iKp'x to LL' ci, IhH. 190 H
that I la<t ^a\v h Vv alive on ' ' I<P
1,1 that (Uath ncriirrcl, 011 the <hitc stated ahove, at
" M. The CAISIC Ol- DlvATH was as follows:
at
c
I) r RATION )V(/r5
CONTRIIU roRV
.If on //is ^0 /)ays Hours
Ihiv.
nr RATION VriU's Motilhs
,,,n (A,hlress)U\Ai\- 'A.W'-
(SIGNEI
Hours
M.D.
/
OCCl'I*Al'H>N
Rr-iJrJ ni S,n! /*/ .
in, /-/■'
);;ii
\l<,l,th-
HKST Ol- MV KNoWl.J.lx.h AM) liJJ.n.l
(liifoiniaiit
(A.Mnss NlIUJ Ut)
ui
i<.S, ^ >'
SPECIAL INFORMATION only for Hospitals, Insntufions. Transients,
or Recfnt Residents, and persons dying HWdv Irom home.
Former or
Usual Residence
When \*as disease fontr.i( ted.
If not at place of death ?
HoM lonq at
Place of Death ?
Oavs
I'l ACK OF lUKIAI. OK RKMo\ Al,
DXTI'ii Hi KIM, <«i KI-;M0VAI,
(Address OAi) i, a*.
N. B.-
—^ 1— ^—— »——'—— '^^ iFVACTlY PHYSICIANS should
^ * <-Aii«P OF DEATH In plain terms, tnai n """j^ »
state CAUbti Ut- uc« ' " » ^iven in every instance,
sons dying away «rom home should be given .n eve y
P*^^ m'< 'M^ ■
^
it
WRITE PLAINLY WITH UNFADING INK
I-,,;,T.l , f 111., hi! i N.i i^ ■*'^:^r;;^H&P«.
/hf/r /u/ef/,^<:JzAhl\> X^
VJOH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2600
Jlc^isfercd J\''o.
DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of "©eatb
( 1:1. S. Stan^arD )
PLACE OF DEATH: — County ofO<:u^ J /^<x.^voui^ City of O^-v Ja^vv<^.^c.
rNo. "^^C)!^
'T>'Va. > w^ <. .
St.
Dist.; bet.
and
>^\Ji^ y t V,*^ » w^V^ . .,^,,^, DccTAVlMrE nvr FACTs'cALLED FOR UNDtR "SPECIAL INFORMATION' \
( " r.^i;iT°H"o^ru%rcV."rHO^S^VT'lt o"R'?^?f.?u"4^."o.;cT4 name .NSTEAO O. SXREET ANO NUMB.R. )
FULL NAME
^<ixv' >
I
i
g \X<x<5\\j U.u>v<it
r> ^ "
PERSONAL AND STATISTICAL PARTICULARS
1 \
r<>i,< >K
M I La V .
\^\
(lM,inth
A<.1-
r,-,/ >
H
^5
iDavi
.V,>,,/A
ai)
/'./
slM .1 1' M \KK 11-' I >
WIIH (Win « tH I'X ' >«<'»• I>
i Wi i!f 111 -.. ; i' ■!■ - -• •1" ' '■ '
J
MEDICAL CERTIFICATE OF DEATH
I go
(Vt-ni i
1UK run N^'i"
NAMI* <H
FATiniR
HI HI" 11 I'l. \<.K
(ii 1 vrin-tK
Statt 111 Country
MMUJ-.N NAMK
ol Morm'.K
lUK riiri.ACR
(Slatr .'! Ciiuntr> I
n:
<X^^
ft
.u-xLc '^
^yw
<X , ■.
O^Aj/u^'
/^
,^^X3u \J )\AJ^^<^
. t
I !1I:K1':HV C1-:RTII"V, That I aUcn«U<l «U(Ha-.«.<l from
- , . -t u^'t to ^''lP>
that I last saw h .i- ' alive on w ^A,. .. i.^o^
an. I that death occurre.l, on the date stated above, at *- 3 ^-
M. The CAISI' OV DI'lA'PIl was as follo\\s:
DT RATION Viuiis Months o /)aYS
CONTRIIUTORV M>l<UL^^^ W^ U C^-v
DTK AT I ON )V<7r.« 1 .Vo'fths /><m
(SIGNED) >ujLcv^ ^ L' ->',•:
I /ours
iL' .
KjO i
fXddress) \^^"^ ^0 i^^^
I lout \
M.D.
SPECIAL INFORMATION only (or Hospitals. Institutions. Transifnts.
or Rfcent Resldfnts. and persons dying away from homf.
oCcri'ATioN
4 \f'»ilh'
IJKST or m£knowi.i,1)..i-. and hi. Ml. I-
(Iiifonnatit
.UU>
MX
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
U ttj
n.ACH (-1 BIKIAI. "K KIMuVAl,
!)Ai;4C')!' liri'iAi. <»t KKMOVAI,
•'. TOO
^ _-^ ♦ 1 FXACTLY PHYSICIANS shoulcl
•tate CAUSE OF DtA in in i» « «vepy instance,
noti. dying away from home should be ft.vcn .n « e j
Hi
ElMD
L
/m
♦ ■^.
I..
A
y.
1.-
LOCALITY OF
RECORD S
SAN FRANCISCO
COUNTY
S AN FRANCISCO
CALIFORNIA
DEPT
T I T L E
DEATH CERTIFICATES
OF
RECORD
I
M I CROF I LMED
FOR
THE GENEALOG ICAL SOCI ETY
*
OF SALT LAKE
C I TY
UTAH
CALIFORNIA
DATE
•
APRIL
1
1975
PHOTOGRAPHER MAX J 0 H N S 0 N I
CAMERA ■n02683B f^ED 1
VOLUME
YEAR
2600
I
*. f
^^m
mmm
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