(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

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

;- 



> / 



i . ) 



t 



I- \ 



* 






f 



\ , 



> ' 



V I 



I r 







, .' 




( . 



\ 




' \ / 



I '. 



|l 



I ' 



I ' 



„> 



A- 



% - 




\ 



/ 



/ 



^ ■ V _ 




■^ ^CAL 2-38C 1 ^ 


1 KOLL NO 


j 

1 
J 

1 

i 


- 


1 

4 


11 


\ 


-^^-=-' — ^^ - - - - - --..->.-- J . 


■ 


■ 


= 







■ I 



s- 



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. 








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 T O 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 

(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.; Dist.; bet. 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 







( »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 BA CK 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 T O 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 ."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\ 







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 

REFE R 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 



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 B ACK 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) 




PERSONAL AND STATISTICAL PARTICULARS 

1 < tl,» >K \ 



^yudx 



i> \ ii' < •! r. 




CxJyj 



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 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^ '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 T O 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^: 



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 C ERTIFICATE 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 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. 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 AXX^-^ X.C oci. c ' 
( Na oL ^ -^ 1 I . ' . ', St.; S" Dist.; bet. ^ W CrUKXXxl and 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( 



)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'' 

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 



^'\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 










.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 
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 












<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^ AXXavC^UlCC City of CJcu-yv ^ >^<^ 



N« 




'\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\ >^ XC 



Id 



r^ 



(\ 



V 



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 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 






! );l v> 



/Or) 



1 II!{RI'I'.N' t"i;Rril-N, Thai I atU-ii-kil .k'» i a>^e<l IniHi 



tn 



^■4 



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. 



> 

h 
^ 



c 

G 



J*^ 



''^. 



»^^. 




|i 




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 



\l!i >: 



( 







c 



^' 



Tin \H<»V1 -^T \ TI n i-KR-^MN W. l'\K 11' I ! \ K -■ XKi: i'Rri-. 
lU->r»»l MS 1. Ni »\\ I,i;i" .1. \M' 1.11,11! 



To riii; 



( I I! fi i: tllii Jit 



^d 



X'ldl t-.s 



ou 



I , ' I 



iX 



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 

G 




H,,-,^ 



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 AXX 



^ 



PLACE OF DEATH; — County ofv a^^ ^ 

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 













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^ ^' . 




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: 



w wn tpg- 



.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 

I . Ill lit 1 N 



A- 




"^^ 






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^^^ 



L 



I 





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 



) 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 




M 






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 







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 







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 (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 A/vs' 



J ^> 



Iloui <> 
M.D. 



^/tfc ^ i<,o^ (Addrews) lUH 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 Vavvcc^co City of Oa^ ;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' 



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 







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, 







V City ofv^'/<X/7XJ 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 <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 HE ALTH=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 










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 







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 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 







^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 -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 






'& 



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 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^ .\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 



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 
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 





( 



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 !) H 



^ 



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 



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 INST RUCTIONS 



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' 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 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 



^ 



-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^ 5 tj 

>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 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 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 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 





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\ \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. 




( 



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 

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 



\ 



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\> )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 

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 



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 







/\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 INS TRUCTIONS 

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 /'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 /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^^^\> 








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^ 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 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 ;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 







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 



wcrwvaj6 



xxx^ 



VllxurV 



\j Litrlu. ^cuIulI^^ 




i\ 







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 '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 








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 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 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 INSTR UCTIONS 

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) 



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 
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^^ .\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 
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' R V &>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^ \.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 T O BACK OF CERTinCATE FOR INSTRUCTIONS 



i 1 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

ofCj/avu VOL-WCUlCOCity of \J<Xmj 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) 







/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 

\ 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 

R EFER 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^ 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 

RE FER 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 








^ 



<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 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 HE ALTH-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 



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 
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 fAd dre-^^) (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 ?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 





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 

RE FER 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 



) 



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 ^X).^xculx^o Gty oiO<X/y\j J Axx^>AyC.Uiycx) 
No 1 5 5 ^ 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 BA CK 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<>^^^ X/CX/wca^i.<^ 
^ilL iWoodL St.; i 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 

(^ A ^ 



PLACE OF DEATH: — County oiOo.^ ^KCXA^^<^^ City ofOxXAV /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 » 



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 

REFE R 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 



) >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 BA CK 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^ 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. 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. ^ 







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 

RE FER 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/>^ 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 

REF ER 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: 



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 



^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 

R EFER 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^) U h^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 



^-.^— 1 1—— — ^— ^■^'^"'^^''^*'^*™"**^"*'"^ 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 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

04 m 



\,< 



t..t*^"S4-' lUSil' Cu 










,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 :, ^ ^ 






) 



FULL NAME OvAC^<XC 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 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 HE ALTH-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 










(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 CE RTIFICATE 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 plac e 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 

R EFER 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\ 



, 



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 




•. 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 










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^,'^ 



( 




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 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 

REF ER 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 \.<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 










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 



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 



'? 



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 



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 







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 BA CK 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 



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 O F 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^ 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 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 



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: £. 

















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 HE ALTH-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 



^-^ 



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. 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 




-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 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 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 ;\.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. 





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 







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 



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 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.^^ 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 F OR 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^ 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 % 



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^ 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 















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^ 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 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. 






^ 







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. 







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-; 

' 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, 
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 







' Nildie-ss 




^ 



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 ^_<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 




( 



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^ 



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 











^\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 







\ 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. 







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 



(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 xc ' 



St.; 







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 /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^ 



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 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 '^ ■ > '^ ', 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- 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 










\ 






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^ 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 







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 







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. >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 \XX WOL4/CC City of ""' CL/Vu 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 ^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 










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. 



\\ 







^ 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 



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 







\ 



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^ 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' 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 ^,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 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 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 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 







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 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 IN 3TRUCTIONa 

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 IN STRUCTIONS 

Registered J\^o, 
or 



2190 



DEPARTMENT OF PUBLIC HE ALTH=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) 







\ 



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 HE ALTH-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- 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 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 -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 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 





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 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 ».\ 



(\ 



"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.>% 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' 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 (^ 

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 '^ 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 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 







.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^^ 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 U \k4 AA.A. Cr^\^ Mace of Death ? 



Days 



PI,.\£K <)!' BfRFM. OR RIOfox XI, I nAT^-; of HrKiAL or RKMoVAI, 

n j I ( ( i 4 



(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*! 

^ 



!■ 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 B ACK 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 

(^ (? ^ , " 



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 O F 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 







^ 



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 





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>^ ^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 







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 <.- 



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 

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. ^.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 C ERTIFICATE FOR INSTRUCT IONS 






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 







(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 



-^ 



\_U^ 



J^^x 



>%. 



% 







."^ 



"X 



luR riii'i. \» 1-: 

'•!• I \ til IK 
IStnt. ..! I i.imtvv 



i 



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 LcJu Xo V >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 I NSTRUCTION S 









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 

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 







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^ ft I 



I ni)i:ktaki:k 

(Address 



!» \TI' .>; nsKiAi. >>t KHMoVAl, 

UrCt 10 190H 

vj <^vvUXi' 



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 CERTIFICAT E 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 ccov t vo. >.c.i o City of C^ 

(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 INSTRUC TIONS 

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 /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 



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 <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 "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 

\ ^ 



//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 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 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: 







*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 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 



(] \ 

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 





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- 
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 



% 



\<xv 



Certificate of E)cath 

X\. S. Stan^ar^ 

i ^ 

PLACE OF DEATH: — County of ' Ow^V J XCL'^\cuL<^DGty of ' ),<X/vv \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 IN STRUCTIONS 







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 

RE FER 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, 





,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 C ERTIFICATE FOR INSTRUCTIONS 



}•■ N' 



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 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 >^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 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 /^<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, 




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 
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 . -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 INSTRUCTI0N 3 



-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 INSTRUCT IONS 

/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 



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 ^ 



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 







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 ( 






X'Yv>^4.ul^\KTb">'v 



^■u: 



\ 



-^'y-^ 



"''I'ATKiN '^ a 



QD 



all"! tli.i' ih- ii:; 

i»rK.\Tr<»\ 
^SIGNED 

4.^ U r»oH 'A.M 



// 






xjX/'vx^ 



M.D. 



SPECIAL INTORMATION »"'> for Hnspitdls, InstityliMs. 
or Recent ReMdenfs. and person^ d)inq dv»dv froii home. 

Ho* lonq at 
. ' Plaf e ol Of jfli ? 



"S 



J Vij I 



1/ 



I "'^ ^Ho^'K sT KTI-I) I•KK>^ONAI. I'A K f li" r f,A R -^ ARK rkri; 

Jsi.^r oi- MY KN-owi,i:r)r,H AND m.i.n::- 

n 



Former or 

tsual Rfsidenre - - "^ ' 

Hhen *a<i disease ronfracfed, 
II not If N«"f •'***• 



Fransieifs. 



Dj*' 



nmt 



H) 



Addre " 






'XlH LdLdU^ 



A 



•I. A'"i; ' M 



HT KIAr, < K 



A^, 



rNlJKKT\KHK 



11^ -CX) iX 



TQoH 



IP 



Ac. 



. • I I twi t t d EXACTLY. PHYSICIA^H nhoulii 

' • ^' 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. 



I ) 



f 



i > 
1 I 



. I 



I ' 




II 





n • 






I 

H 

i 



¥ 




II 



WRITE PLAINLY WITH UNFADING INK 



H. i!lh i Vo, 1^ t'T-'aP'^ USil' 



/>///.' /v/r./, ilJ cXxrlv^X' la 



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 



rA 



'I 



!> 



\ 



PLACE OF DEATH: — County oi'-'CL'W- ' VCo vcucCity of 'a \\ J\a i 

1 Qi^; 



\ '" » , 



No. Sj cLcckXo 



\ 



St. 



- 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 ^ 

LI : '' 



'! ink in 



M.itith: 



I Dav 



MEDICAL CERTIFICATE OF DEATH 

I) \ rj' I ij- IU-: Mil "^ 

1 jij{ui:nv ^ I i< riis'. i ii . ' • ' ' '• 



\'.i- 



1 



I 



" ' ' '• '\vi;i» (»K i)t\< iRi'i-;!) 

■I -'ici:il iI. >.is_'!lati.iu) 







"'it' "! i'.illllt! V 



^ 1 in-.K 



lUR llll'i, xi'K 
-!;il< or ruuntiv 



NfMI.i;\ NAM,.- r\ 

"' M'>Tni.:k I 






\if) 



that r la^t -.iw Ii 
and that ikatli .■ 



re' • •" ♦ lit- 'latr -tati 



at 



'^ 



M. TIu- CM Sl^»l l»i;.\TI( -V 



-^ 

I K 



I. V \. <. k._^ 



VCM_^X^ 



n 



'•'K r HIM. AC J- 

«i| motiikk' 

^tati ,,r CouiitTV 




nrk.iTioN 

CONTKIIUTORV 



/» 



//. 



) V(// 



,0 ^/D\ 

(Signed )\jf\(nnjXj 



M ■nt> 



iiE.IoIlU 



/ ) r, 



>viL 



M.D. 



"UUYU 



.. t- 



iqo 



i \.\Axv^^\ LC vCnVlVfi V . 



nnl^ lor Hospifrfls Institurtohs, FranMenls, 



r 






-hXX.O. 



) 'rtJ I 



M,.„ih' 



I hi 



SPECIAL INFORMATION 

or Recent Residents, dnd persons d)ing dHdv from fiome. 

.1 I Ho* \m% at 



Former or 
Usual Residence 



Oivs 



When H3S disease contracted, 
If not at place of deatti ? 



I Hi; .\H()VF. sTAri:n i-kksonai, p\K'rrrrr,AKs arj: iKti-: to thh 
I'l'.hr oi. MY KNir^x i.i;ih;k and B};i,n:F 

fliif.irniant 




I'l.ACK OI- HrKfAi. OK Hl■^!<<\ \: 





il'at 



ai I'. \i. 






A^4,W& >v 



N. B.— Every Item o? 

•tate CAUSE OF 
sons dying^ away 



tnte.l f.X4CTI.V, PHYSIwlANH should 

,.»■ i«i^... :,.l Int'.ir-rnMt ion" tfctr D*!*- 



r , u;f.sh-H,lclheM«t..lf.X4CTI.V. PHY.S.w. a >- sno„ 

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. 



I i 







# 





If 



WRITE PLAINLY WITH UNFADING INK 



iK :.lth r Nn^ \-. ■{• 



.**.r> 



;^#j ]ISl\' Co 



/>.//.' /vAv/, tlctJ^L' 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



hj la 



IfJOH^ 



Begistf/f'r/ Xn, 



oo 



08 




'^^US 




. Deputy He 

DEPARTMENT OF PUBLIC HEALTtKitj and County of San Francisco 

Certificate of Scatb 






,) 



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 



Xc^v<rv\A' 



and 



ION 
R 







FULL NAME 



V. i 



PERSONAL AND STATISTICAL PARTICULARS 



~ I \ 



Ji 






Col.nk A 



0..t 



M..iith> 



I)av 



\<.H 



MEDICAL CERTIFICATE OF DEATH 

DA 1 ) . ill- 1)1 . %i II 



II 



u 



? 



5 .a 



^IVt^l.K MARHIKI) 

^^!it«in siK'iiti (ic^iiMiat i< 111) 



J'.IHTm-i. \cv, 

stall ,,r c, ,,,,,(, 



» \ I li i;k 



r.IHTIU'I.Ai'K 
**'■ ! ArUHR 
' "^t It' r,r ruuiitT V 



^IMI»1:n NAM}- 
•'1 MOTFIKK 



'•-IHTHI'I.ACH 
""■ MoTHKR 
state .,r Countrv 



L. ' 

A.>xci, CjyKjLt 



thnt I 



. I\V 11 



Hill I hat ilralli < Hfii ricil, nii tin ' 



C 



n 



M. Tlii- CAISI-: nl' Id \ ill s 



U/(x- ■ J y fr\ 




1)1 k ATM >N 
CONTRII'I'IOKN' 



M^'ii/i 



//>un 







3 

y 
P 




i)rk.\Ti<»N 
SIGNED) 



^ 



),w/ 



M.'Ntll 



/Kns 



M.D. 



r I jo 



fA.l.In- 




i t I ■ 



Special information ""I) '"f Hospitals. Institufions, TrdflslfBh. 
or Recent Residents, and persons dUng dWd) Iron tiome. 

Nam lonq at 

PIdif ol Ofjtii? OiH 



)>,7i 



M..>,tl, 



I '"■ >'';.>VK STATl-.r) PKKSONAl. !■ \ |< rrc I I, A H - ARi; TRfJ- To TIH- 
»i'.-I Ol- MV KNUWMCDCH aM> I'.}.;i.I l.h 



Former or 
Usual Rpsidencf 



WfiPfl »as disease rnnfraf ted, 
If not at plare of death ? 



flnfornifint 



l^f.ACi; III H' 



K ' \r, (iH K I;^tl '\ 'ii. 



m ri; 



M ; Kl Nfti\ \i. 

Ton 



A.M.. s. t) I ^ ' a <5.cH,o. -> > ^%xU I 



^' **• Rvery Item of Inform 

•tate CAUSE OF DEATH in p 



,. , niT sMo il.l be «t»te«l f.XACTLV. PHYSICIANS piHouIcI 
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. 



•on« dylnft away from home Hhoiiltl be ftiven in every instance. 



. I 




'993^'v!K^i9if 



I 



J 



' » ♦ 




II,. Ml 



'■^te nScV c 



I)ff/r Filed , 

1 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE: FOR INS TRUCTIONS 

Registered JS^), 



n 




13l 



If) OH, 



<^\A^ 



loi/ 



0059 



^w*^' 






DEPARTMENT OF PUBLIC HEALTH=Citj and County of San Francisco 



Certificate of H)eatb 



( tl. S. Standard 



%. 



PLACE OF DEATH: — County of C a 



n 



"No, 



U ^\tuu) G 



^ City of Ct IV J \ o 



and 



( " "DtATH^Orr,ll»'^n'/''l'* ^^^*'- RESIDENCE G.VE FACTS CAtLCD rOR UNDER SPECIAL INFORMATION \ 
\ IF DEATH OCCUI^RCD IN ^ HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 



FULL NAME 



-LLLlOliyv 



PERSONAL AND STATISTICAL PARTICULARS 

l.IKTII I 

iMotit !i 



MEDICAL CERTIFICATE OF DEATH 



I A 



(II ill 



' ' ''' '" -'-* ial .1. •-iiMialMii) 



I iiI':r i;i:\' cikTirN . rii 
\ip — — fi. 



It I 



"' ' ■iiMltiV 



■^ \M)-: ni 
I A III).; K 



H I k I 

'»i^ I 
■^t it, 



M > 11 
I >\ 



III'I.ACH 

N r H I-; k ■ 

' ' *^'i>iintrv 



N N\M1, 




lliat I l.f-t saw h 



ali\ i- i>ti 
and that dratll < (rciirrt'd, nii tfn 



--111 frotn 



•vv, at 



d; OF i>i; \T 



1- as (, 



\\ '- 



\ o 



'-* -, 



/^i/l s 



J li'Uf \ 



? 



^i')Tm.;K 



•■ii'i'Hi-i.Ari' 

"I \!i.T||,-k' 
' '' ' "5 * ' mtiti v) 



''■I'A'lluN 




I lotlt s 

M.D. 



'•'.^1 (U MV lvNnW!j;i,.;H AM) nHI.IJ-F 



I>1 RATION )r./;s M.'uths 

C< >NTR Il:rT( tRV 

DERATION ^ );./;v ^ ,1/ - ' 
(SIGNED) KjsVirs-sXK ' D V', 

; — 

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 

When WIS disease fontrrirted, 
If not at plare of deatli ? 



IhiVK 



A Wa 



i'i,\( 1' 1)1 i;i kiAf, <»K ki:m<»v\i, | i»\n 



J 




,>l..^AA/ 



. . . lit KIAL t H I- M( i\ \I, 



:xJkiAA^ A ' L t c < 



\.i.i.r.. blH ^Bv<h:?^ 



Lo- 



H 



<\.icireH«. lUO UWV\A/Cr>% *JAJ -a.i.ii.s^ w ^ v -. . w-^w. ^.^ 

^_^___^__ ,. Li 

-Kvery Item of Informntlon should he cwrefully nuppHed. UJB «hr.„ld Ho «tnte,l r.X4GTLY. PIIY.HICIANS should 
•tate CAUSE OF DEATH ?n pliiin X^rm%, that It m«> be properly wl.Mlfled. The '•8,,L.i„l InmrmHllun" for p.r- 
«on« dying away from home nhoutd he given In %\^ry Instance. 




I 



» .1 




t 



u\ 



1 



■I 




II 



^111 



' J III i 



i 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

• "'' '^'^' WE rSR TO BACK OF CgRTIFICATE FOR INSTRUCTIONS 






If^OH 



OQ^ 




^^70 



\,M^ 



DEPARTMENT OF PUBLIC HEALTH-City and Connfy of San Francisco 



Certificate of H)catb 



^ 



T' 



PLACE OF DEATH: — County of 



City of 



\, v-w 



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 



) 



V 



FULL NAME 



,d. 



H 



i- 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



\l I 



L^ 




Ml, I ' '. 



u 



M 



\] <V I 



' II F V J n c t I k ^<4 v_ 



~N 



I lout s 



1)1 



\ 1 . \ )V<7; 

Signed) ■ 



-\T 



KX: 



M.D. 



r\ K 



TuJUtuyvcI 



% ,li Tc^H (A(l(1rtS'4)(nSl UgJ 



L^ ,li 



tCUt At 



Special information only ''•■ Hospitals, ln<>tftutions Irdnsifnfs, 
or Recent Residents jnd persons dyinq away from home. 



na\. 



'.I. SI ui MS KNuW 1,1 iH-.).; x\i; 



Former or 
Usual Residence 

When wisdisfasp contrarfed, 
If not at ^are of death ? 



Now lonq at 
Wife of Oralh ? 



Oavs 



) lU'l I I « 



Fnf, 



iii'int 






^XXX.'^Mj ' H fVuUXA; 




i»LACR oj- niRiAi, OK ki;m«>v \ 



DML. .' H! iM \ 



cru. L 



i 



^..fiHOA. 



l& 



TOOH 



fAa.lrcs, 111 M1\4.44x^ 3i 






., . Ar»B -kr».,l«l b« atated nx^CTLY. PHYSICIANS «liould 
,...„., .h„„.,. .... .arc UM, .uppM.d *^«;J-^''„T^7'VHe S,.cl.l .„,-..,n„.,„„" r„. p.,- 

1 iH in pliiin term«, that It n%9^ "« prwR^^ij' 



N. II. Rvepy Item of In »,,,.„, 

■tate CAU8R OF Dl: 

"'»n« dying away fi-om homu Hhould be ftlven In •vary Instance 



i 




I; 



11^ 



III 




III 



* i 




1 



M 



* 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS 



l>,,.,,,i ' II, lit h I No I" *'^.'^\;''*^ n^i i 



/)(//(' I'^ilcd , 




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^ 



^u 



PLACE OF DEATH: — County of a >\ \a^^ 



f 1 



City ofU/tX'>v J ^ A '>vc^.c ^i 



% 







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 



y\ 



■\ 



FULL NAME 



\ > ■ 



PERSONAL AND STATISTICAL PARTICULARS 



^-\ 



I Ml .»K 



»r liiKiii 



^ 



k 



Month) 



MEDICAL CERTIFICATE OF DEATH 



DA IK 



!• !• i:i;\ I 



nrx 



ix 



) ,„• 



IC; 



1/. 



1 M \RI< Ii:!) 
M I> « >R H!\-nRrKI> 
' i'liatidii) 




< 1 



M;il» or I'oimt! V 



A 



H^l-^ 



A 






lukTni'i.ACK 
'•' i XrHKR 
^^M' oT I'ountrv 



<»i- M<>Tin-;k 



'■'•< I'HI'r.AOK 
"t MoTUHr' 
^tit. ,„ ronntrv 



Lcj\.' 



i< 



that I ia>,l saw ll ■ ' ntivi- on 
and that .K.ilh orrurnMl, on the 



; . \ • 

I itts'itik'fl (ll I ' 1- I <1 fi'illl 

ir.l al 



M. The CM >!■; <>!' I>i;.\'ril u I- a-^ 0)11. iws 



nrixATK >N 



}'tdr 



TU^LccUi 



c 



til 



uJx, 



i u 



.Ow^r\ '^ 



~> \ 



CoNTRIin r(»KN 
DrRATION _ ^''^''^ 



a,A.. , ...<^\ 






I lout s 



Month' 



/hiv 




CL/Vy^^vOJ 



^KlXjOuyx/L 



(XjL< 



<>Ccri'ATl()X/'0 



(SIG 






/CX 



lu 'U o 



T OO ( AiMrrss) ^^^H. ^^ "- 

.L INFORMATION ••nl^ t"r IWspildK 



iL'OA 



/fi'Ut s 

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* 

'l..fon„a„t U . \J . Kd. Clo^W 



%crUL C^^^ ^ . 



DXU-o! l!!Ni\i or KI:M<»\'XI, 

©ct a looH 



Y\,<5\J 



^ 



• **• 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. ■ "^ » 



I I 



t i 



» LI 







11 



f 






i 



WRITE PLAINLY WITH UNFADING INK 



ISi. 



:.,. 1^ -t-f;"^^^.-: l!«v 



s^v c 



I 



)<ih' nii'd, L'^WInov 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



la 



1 !)()"{ 



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 



I 






<XAA 



MEDICAL CERTIFICATE OF DEATH 



t 



^«. o 



^! 



)i 



/(jn I 



1 n im 



lf,n 



uf) i 



that I la 



J 

M \R l< III! 

1 I > < IR I I • \ , 1 I,. , )■ I, 



^^ 



\j-<x.<L<xj 



I II Ik 

' liiiliHiv 



'1 ^ N\M1 



'•• ^'"Tiii.r' 



'*" ' I'\TI()X ^ 




aihl that 



>r. Th. CM SH <)l' IM- ATI 



A 



4v<v:^K 



Aj-V^xX^ 



DIR ATION 



I (»NTR Ii;rT<)kN' ^'^■ 



/hir 



Ih 



HI s 



IM k AIM >V 



i Signed 



) •iir'i 



M< 



Hills 



Ihu 



% 



//on I s 



M.D. 



Mf) 



SPECIAL INFORMATI 

or Recent Residenls, nnd persons dvini) a^a) Urn nome 



ON fl"!'^ 'or iospifdis, Ifistifuflons, FrinsifBh, 



former or 
lisual Residence 



I 



N W- U ' • -'■■' 



NoM \m% at 
PIdff of Death .' 



Oavs 






) lUl I 



M.uiili 



I H'fien was disfasp ronf rafted, 
If not at place of deatfi ? 






n II, xk-- A Ki; TH! !■: !•» i ni-: 



I 1 1.; K 



;mi »\ \i. 



I) \ ri 



I M.i k r M 11^ 




I'l.xcj-: <•! nrKiAi 



iqc) 



N. B 



v. 



„ 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. 



r' 



P 



^ 
^ 
X 



r 



* 



r I 




J ♦ 




ii 



I 



m 



III ' 




WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I ' I \ 



■»"^ HSc I' C.) 






.<.KJS 




Deo 



JfUJ^ 



Registeipd Xo, 









DEPARTMENT Ot PUBLIC HE ALTH-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 ^ 

AME 1% 



^ and 

'ECIAL INFORMATION" N 
lEET AND NUMBER. / 



U 



FULL NAME ^V^K U 



I I 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



II 



H;iv 



liai 



at •(Miill' 



fn.t, 



M nth 



I),tv 



M..„<lr 



• ' ' i '1' -ly tia! iiiii ) 



I 



III \ 



.oJ 






that I last siiu 
and t hat (h ,1' 



Ul 



tr. UCb 

rl 



il. on the dati- slatcil 



M. Thi- CM Sl{ ni' Dl ATIf was 



iii\t-. at U 



i\\ s 



1 



so 



h 



J .cU>4AX^v.*.C^^k,d C", 



ciMrvi 



i 



K/\\ 



M ■ Is A 1 K 'A 



C < tNTRIIirToRV 



// 



>'n< riii'i.siF 
"^ ^ \riiKu' 

sill, , . 



^'\'"i N WMF 

'" ^t••^IlI,R 



'''l<TII|.|.\(i 



'^t, 



"i lll-.K 






DIRATION 

(Signed^ IX 



) (Ull 



Mouths 



n 



^cL 



I ( jO 






Ili'HI S 



M.D. 



^Jl 



' 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 



♦ ' 







m\ 




?t 



i 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



/y.//r /•: 



/A-/. O^t^W,, 



la 



/^^>H 






REFER TO BA CK OF CERTinCATC rOR (NSTPUCTI0N 3 



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 



/of) "i 



I III 



- \Kk n:j> 

i' "';■ n;ii j,,!| ) 



1', 



Mmth 



MIR 



it! S 



N AMI- 

■I IK 



'•< >ni'F. A( ]. 




<xxv^^d^ 



an, I that d.at 



li.KJ 




ite stated 



^r. The CAfSH OI 




.'U^r^a. 



i^ \a. 



<x^ 






DIKATlnN y,d}s 

i ' 'N TK IIUToRV 



.1/, 



// 



A. > V \^ O 



Vl/>%ajL 




( 



'»! N!ii 



Itl-K 



■' * "Ulltry 



on 



(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 € 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. 



I ! 



'I 

• .1 I 



r 



inif?;ir''."'V4?ff|i, 




I 

I 



I 





".■,. . - •* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^'''^''' ' 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 . 
I- 



I 



•^PS^fK* 



I 



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

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 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 



\^ 



Vix 



cxvd. 



PERSONAL AND STATISTICAL PARTICULARS 



"*^ 



y.\v. I 1 



vOl.itR * 



MEDICAL CERTIFICATE OF DEATH 



DA 



il 



•xccu 



L' 



u 



\ 



|) 



I inHi;n\ 



t t.iiii 






■ 1 < iK l>l\ I Ik ii» 
' -ikrnntioii) 



III'I, \i-K 






'0 



1 



1 *;' 



;in.l that .1. 

Jl' 



^l.HO 



\\v c'A,' "^1^ < *'■ i'i':.\rii 



U,ls ,l«- 



W '- 



KC 



ill 



\i III.K 

' ■ vriii-:K' 



^wL^ 



IMKATION 



]/ ••• 



Ihn 



//, 



' i'liiuitrv) 

■^lAIHKX NAMj- 
•" MoTHKR 

iHRrniM.ACK 

<>! MuTHHr' 

'^t:it< ,,]• rdiintty) 

iHXri'ATlON 



4 

I 

V 






^ oSXjjl 



h o 




CVUw\.v 



DlRATroN 



W r- 



SIGNED) J-^n^ dbaXl- 



/»,/rv 



Oct 



iijn 






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 





l» \ 



iL'c; 



1^ I M< i\" \I. 

ion . 



I NIil'KT 






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 



i1 



fl 
ill 



!•! 



II 




J 



I 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



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 



^ 



jU 



i'O! .( »K 



•¥r 



MEDICAL CERTIFICATE OF DEATH 

1) A'li-; 1(1 i)j-,.\ rn 



^ 



< ' I I ; ! K 1' n 



iftfoiith ' 



) >„■ 



n, 
1) 



( Day) 



M-i,'li 



■' M \R \< n:i) 

! I > < >K IMXl iKi'KI) 

Kill ili^i',' jiat ii fii) 



I'l, \r\: 




, I 



Ui.- 



I hi;r I':hv t 
Lei " . . 

that I 1.. ! 

ami that ilcatli nci ur la- 



t piiil 

(»0 *1 



1)11 



aiiiivi, ai 



I()0 
I(/0 

b 



^ M. Till' CXIM^ Ol' 1>1 ATI! u; 



as 



lUs 



/? 



wdL 



I \ I HI R 



:•'-' III I'l, \CF 

' '^ r 1 11% K 

t I'liimti V 



MAIDKX XAMJ- 
•»l MOTIIHR 



•iii< ^ln'|,\(•K 
«'^ motiikk' 

'^t;iic ,,1 Countrv) 



'>* *'ri'Ari()N 

AVwff^j/ in Siin /'litiuisrn 



CONTKinnnRV 



M,>i,th<i 



PilV 



IloHt 



1 



nr RATION 
(SIGNED) 



y, ir 



Mnulhs 



Ihiv 



in rA.l.ln-)t05^XLo 



M.D. 



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 



r 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



R..:i- 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I i 



* *. 



J .«' 



I! 



I 



I 



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'! \,-|- 



.1 



v_ 



(1 



n 



I vni Ik 



'• I K I I M • 1 , \ r F 

ot I \i*in-:K 

' "^lati , >! Count ! V 



M Mlil'N XAMl- 
<>I MoTHKR 



'•II<Tin'I.A(i.- 

'" MiiTin-;K 

' ''t;it<- or Cuunirvi 



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 

■*1 



1 



niKA rioN i ' 

CONTklHt'ToKN 



; . ,/;■ 



1/ 



/'./ 



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 



J I 



h 



^ 



? 



lii 



I f » 



I 



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 ♦ 



«>l lilKlll 



M.iiUhi 



\( 



?, 



) y.i 



(l>;iv 
1/ ..//'/ 



-•I^'.l.I- MXRRIHI) 
U ilH »\\ I |i OR I»IV«»Kr KD 
>'' 1 lal (1( >-ii'natiiin) 



• < . illllt I \ ! 



\M1 i>i- 

\ riij.R 



'" I N iin-:R 

■^t It, ,,i r.iimtrv 



MXlIiKN NAMK 

<" mothi-:r 



''•Iin'IflM.Ai'H 

'" Mn'rin-:R 



C^^nu J ."vet vx^cv,^ 



:tnf\'V^ 




V 




i>\ 



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 pla ce 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, 






J V,/ 



X?s 



i II 



I I I N 



^% 



I i 
I I 



1 i '1' -is.»ii:itiiiiii 



I'l, \K\ 

' I 'iiniti\ 




^ 



^\MI ci!' 
' VI' If IK 



- niKk 

' 'i t''iiintT\' 



"I MOTH Ik 



'•"': I lIl'i.NCF 
<»l MMTm.:K' 



'♦^'■'I'A'riON' 




V 
^ 



tlnit I In^f '^iw li , :;. 

,111(1 tha! (Ualh iH-riurt'd, dii tin- ' '*. 

M. Thr CAISH OF |)|;A 1 il u, 



I',' 



xcucb 



>^_ 



CUUL k. 



vru 



JUL<1 






1 

CONI k IIU TOR V w.\^v- ' 



/hiK 



//, 



nrRATiox 



)V<7r.s- J/i>f//// 



/hn 




(SIG 

If) 



NED) Jfth/ysj w' 



//,'!,rs 
M.D. 



w I 



ff^siiifif III Sun f'laiuif^ro 



<x. 



\ V 



• \ 



)'iin 



1/ :>f/l> 



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 

A 



that I 1h 
aild thai 'Ii I! 



'Ml 



' vn aliii\i\ a1 



M. rhv CM ^1' <'!■ 1)1 ATI! u 



•^ 



nit T \' 



M\Ilii:\ WMj. 
01 Mmiiii-k 



''nrririM.Ai'H 
'•' "^'o'i'iihr' 



'^'^■^I'Xi'lOX ^p 



? 




>vo^ 



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 — 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 







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 , \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 .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 





^ \ 







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 







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 



Ci t y 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. 



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 '^ ' 



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 O F CERTiriCATE F OR 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 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 



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 



THIS IS A PERMANENT RECORD 

REFER TO B ACK 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, 







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 



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 



>^:- - ... -. / 


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^- 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 

REF ER 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 ; — Coun t y 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^ 

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 .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 

RE FER 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 



/^ 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^ 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 

OI' M»)i"ni;k S- 



lUK rui'i.AOK 

I Siati I iv v'l miiti X 



/^^^'^^oAA 



0/Ouy\j '^ 



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- ^ . 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 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 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 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©. 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 

REFE R 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. 




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 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 







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 



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 



(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 T O 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/^^ 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 



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* 



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 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 O F 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 



^^^^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 INST RUCTION3 

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 . ; 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 CERTIFICA TE FOR INSTRUCTIONS 

Registered J^'^o. -^olo 




_^\hu Deputy HecSth Officer 

DEPARTMNT W PUBLIC HE AlTH=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 I NSTRUCTIONS 

^^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 A/>.. 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 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 CERTIFIC ATE 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 



!• 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 







^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 

, 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 

RE FER 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 

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 "^ 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 
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 

RE FER 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 



;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 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 BA CK 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 

RE FER 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 /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- ,:_-<- 



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 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 









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 

REF ER 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 Ad dress) 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 






-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 INST RUCTIONS 

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». 








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 







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 



^^ 



/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 CERTIFICAT E 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 

REF ER 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^^ 

/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: 







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 



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 

REFE R 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_ \ '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- 

... :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-^: 







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 










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 

R EFER 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 T O 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 .;^^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 

REF ER 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 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-: 

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 

REF ER 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 T O 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. ) 

/ 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 







Dft/r /'V/r^/, Uct<rW.\j I 5" 



lOOH 



THIS IS A PERMANENT RECORD 

REF ER 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) W utW^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 * 




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. 







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) 

\J i\^ 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 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 

RE FER TO BA CK 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 







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 
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>hlr e.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^ 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 BA CK OF CERTIFIC ATE 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 ^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 ROC K OF CERTir.C T. 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? 



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 d eath? _ .^ 

— ^ ^ .. ,,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 CeRTIFICA Tr 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 plac e 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 RA CK OF CERTirlCA Tr 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. ^^ 

" .^ 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,.dr e.. 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 ... ..nPCERTirlCATE rOR 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 Q A^^^- 

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.riCATr rORINSTRUCTIONa 

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' 



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.NSTR UCT.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 ^ 

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 







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 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 



' 




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 CERTIFICA TE 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 







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) 




\ 



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 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 



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 
.' 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 \ 



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 / 
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) 



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 B ACK 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 ^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 .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 FO R 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 

REFE R 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\ 



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 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 


» 

< 
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 







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 

R gFER 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/^ >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 

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 

RE FER 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 BAC K 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 CERT IFICATE 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.,., 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 FO R 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. 



*-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 
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 p lace 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 R ACK OF CERTIP.CA Tr 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^r o 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 B ACK 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 











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 

R EFER 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 



(?■ 







( 



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: 







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 <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( 




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 B ACK OF CERTIFICATE FOR INSTRUCTIONS 

2-307 



/)ii/c Filed, ly ct<ru-t\.' 

^ 



/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 /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 



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 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 








\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 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^ ;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' ^^.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 FE R 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 .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 —