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

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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hnat'l -r Il.'alth »• No. i=; "^^^^ 



-*'?•»' ^. UScV l*<) 



/)////' Filpi] 



[UA 



sjh) ^5r 



]f)0'i 



Registered A^o. 



O 



6^^ 



Deputy hlca!th Officer 



3^0 u^U^ ^t^^M '^^P"'^ r,ci:.in unicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( U, 5. Stan^ar^ ) 



PLACE OF DEATH: — County 



) 



^r^ ^ 0^ 

of O/O.^^ J .\.aAvc^.v. . <- City of 0<x>\^ J.,>vcto'vc^o.CL 



'No. 



1 1 t 



()l< 



%%'\ JlXCX..^ St.; I2 Dist.;bet. \l L\^ and M I LaW[t^v.'.> ) 

/ .r DEATH OCCURS *WAV TROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER SPECIAL INFORMATION" \ 
( ,F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




.^^.0. , .. 



PERSONAL AND STATISTICAL PARTICULARS 

^1 A A^ A (•<)I.(>K'\ 



vnuL 



ii-i. 



i).\ii-: OF lUK rii 



.\c. K 




I 



%!chilhl 



I ) ' ii I 



(l):iv) 



.1 /.»»////> 



'Vtai) 



/'./ 



SIM. 1.1' M\KUIi:i) 

wiix )\\ i:i> <>K pivoK* i:i) 

iWiitf ill >i<)ci:tl <lisii.Miiili<>ti ) 



iMK rm'i..\oH 

(Stntt <ir Count ry^ 



\ \MJ 01 

lA rni.K 



-? 



Of;) •! 



d /o^'y\) vj \ o 




IUKl'lllM..\rK 
Ol- lATHKK 
(Stall or Couiiti v> 



MXilM'.N NAMl. 
<)! MoTIIi: K 



HIK riiiM.ArK 

»»1- MolUlvR 
(Slutf or Coutitr\ I 






i . 



u,uw,Ll. 



c 








/^ 



OCCrJ'ATU)N 

A'fM.fi'if ill Sail /'mil. !>''<> 1 ' "^- 



I 



M..,itli' 



Pit v. 



Tin- AH<)VKST\Tl.:i>I'KK>^<)NAI,rAKrKTI,\KS AKI-TKIK T< > TIIK 
HKST 01 MV KNOWl.l'IX'.H ANI) lU-Ml.l- 



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( \.l.',. ss 






.^Crryj 




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^•5.^ Jx^^^<xA oi 



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MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH jA 

(Month) '":iy^ (Year) 

I IIlvRlUiV Cl'RTIl'V, That I attciukMl (k'ccasc«l from 

l9/c.t iM- 190'! to ..iD't^'t 'x.'^ Kp'i 

that I last saw hi- ^ ■ alive oil ^ ct 'V^^ Up I 

ami that drath occurred, 011 the date stated alnive, at « ^ 



M The CAl'SI-: OF DIvATll was as follows: 



X'^■vv."^^ o, 



or RAT I ON Yiars 

CONTRIIU'TORV 



Moni/is 



Days 



I /ours 



/hJVS 



Hours 



I ) r R A T I O N ) 'ca rs Mouths 

( SIGNED )..H"- ^- ^''^^^•^^^ ^'^' 



V\ IQOH (Address) I 



SPECIAL INFORMATION only (or Hospitdls 
or Recent Residents, and persons dying away from home. 



;, Institutions, Trafisients, 



Former or 
Isual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'l.ACH Ol" lUKIAI, oU Kl'.MoV.M. 





L\^<i.. 



<i. 



l)\l'i: ot MiKiAl, or KI':MoVAI, 

Oct '^?^ 1901 



rM)i;KTAKi:R 

(.- 






' ... ^ .. ... APF ahoulil be Rtiitecl KXACTLY. PHYSICIANS Hhould 

»on< clylnft nway ?rom homo Hhoiil<I be ftiven in every in8t»nce. 



WRI 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ilo.-ifl of Ilcilth !•■ No. I- 



i^'ii^^^ nfk I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



rm 



!)(,/(■ Fi7f</, \^^lXMsXhj 9.S" 100^, 



E 



nj ^^ -7 A/*^ 






ck-^KAA^ 



Deputy Health OfHcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Xl. S. Stnn^ar^ ) 

J? on \ ^ 

. County of^^'^'^^ J'^^-'^^-'^'^^^^-^^City ofQo/^^ J .^x^^-^a/ca^c. c 



'No. 



PLACE OF DEATH 

\jL/y\J>uoJj \JYY\XX 

(IF DfATH OCCURS 
IF DEATH OCCU 




FULL NAME 



mty 

% , 4 ) 

/^4. 5tl;a.v Distjbct.- " and - 

USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" A 
DSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



PERSONAL AND STATISTICAL PARTICULARS 
SI A C\ ^ h I COI.OK > \ 




DAllC or HIK rii 



JJLO 

iMoiitli) 



A<.K 



3^ 



)'i(l I A 



(Day) (Year) 



L Mntithy Pays 



SI\(.l,l-: MAKKIi:!) 

wiix »\\i-:i> <)K i)iV()Kri-:i) 

lWiit«iti social (Itsiv'iiation) 



HIKTHPLAOK 

(State or Coiintr\ 



NAMl-: Ol' 

FATin:R 



MIk rill'UAC'K 
()|- l-APUKK 

(St:it<- or (."ouiitry) 



MAI!)J;N' NAMl-: 
OF MOTIIKK 



HTKrillM.ACK 

Ol- motmi:k 

(Stat( or Country 




olA 



AL-ti'VX/ 



UyYAaXu 




<r>\j 



n 




OCCUPATION .8 . . 5 ^ ^ , 

/\'fU(ff'if III S,i)i /'i an. ' i-n ^ )V(;;^ Mmitli^ 



D.n^ 



THH ABOVE STATI'.l) I' KK SON A I, I'A U'lUr LARS AKI", TKl K To THH 

iiivsr OF MY kno\vij:i)<;k and iu:i,if:f 
(Infottuaiit utiXXxX; vD LU <X/L<L'trVAj 

f\,i.inss 11 ?i cLiLOkA/>^Cl/V<; - >. ^ ly; '.. 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH 




,!?>. 

(nay) 



/go 

(Year) 



(\fonth) 
1 in<:Rl':HV Cl<:kTn<A', That I attended deceased from 

..rTTrrr::"^-----— r— :- 190 — to ■""■■• iqo "~~ 

that I hist saw h ■'■~~ aUve on ———--——-—— 190 

and that death occurred, on tlie «hite state<l ahove, at - '^o 
' M. The CAl'Slv Ol' DI-ATII was as follows: 



DTRATION 






Mouths 



Da )'.v 



Hours 



'ONTR ir.l'TORY d /IX^La X^^^ 



Dl'RATION 



)V</rjr 



Mont /is 



Days 



(SIGNED ) Lt*.U):.Y.\x> . J- m U). <LaxX/>'ui., 
\j cfc a 5 T go ' ( A (hi ress ) l^r'vcrv^JUvo U 



Hours 
M.D. 



/C 



V 



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

Former or \ -4- I ! Mow long at ^ 

\\1 oLC/uyvxa^vi^ Uak«. 



Usual Residence 

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



Place of Oeatfi? 



.. Days 



I'I,ACK OF" UrKIAI. OK KHMoVAI. 



OATl'tot Mi KiAi. or RHMOVAl. 



lNI)F:RTAKF:R\Jk/XNX2.Xi ^\- ^ ^\AA-/»vO./>v, /^ L i. 



190 



N. B. 



-Kvery item of in9orm«tion should be carefully supplied. AGK should be stnted EXACTLY. PHYSICIANS should 
state CAUSII OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home nhould be (^iven in every instance. 






WRITE PLAINLY WITH UNFADING INK — 



}{,,:inl ..f II.;.lth-KN-<>. \ ^. 1*-\'^^,U&.l' Co 






^ U 



It/U 1 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J.lf^ iCiVV tvtv VI t-'. 



cLo-OuU) 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDar^ ) 



PLACE OF DE ATH : — County of C}o./vv jAxx/y\-<iV<i,c<; City of U-o.-^x, Jxxx.'^v^va.^.c 



J? (3? 



Qf^ 



'No. 






&\A/>Viu 



i 




\.\Li\.c^,v,.l.'.. St.; 



Dist.; bet. 



and 



Xvv^Lww^.^^^ — .. — -.^. .. . 

\ f IF DEATH OCCURS AWAY TROM USUAL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER SPECIAL INFORMATION" \ 

11 ( "death oJcIrRED in a hospital or institution give its name instead of STREET AND NUMBER. ) 



FULL NAME 




SKX 



DATi; <)!■ lUUTH 



AC.K 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




\j:xJs\) 




kXA.K,^ 



i 




AXXXJ^ 



t. 



iM«)nth) 



'W »■-•./». 



10 



1 

(Day) 



Mnvth> 



(Year) 



x1 



Pii r.v 



SINC.M'. MAKUIKI). 

wiix »\\ i-:i» OK i)iv»)Kti-:i) 

*\Vrit< ill social dt si).'iiation) 



HIK IHl'I.AOK 
(Stall' or Coiiiili y) 



JA TUl'.K 



lUR rillM.ArK 

()i- I ArnKK 

(Statf or (.'ountry^ 



maii)i:n namk 
oj- m()Thi:k 



HIRTHIM.ACH 
ol> MoTllKK 
(State or Country) 




/^xLcr\A>-Ov 




{OJ^\J-0^\^ - 



r 




OCCVPATION 



o 



Kt-^iilrd III Siiii /mill I'''" 



O-A'^ 



)'llll 



<L 



M. nit In 



IhlX- 



Tin-" Mu)VE sTA'n:i) pkksonai, par ruri.ARs ari; iRn-: lo riii-: 
in<:sT or ,Mv KNOW i,i;i)c.K and iu<:mi:f 



(Iiifoimaiit 






MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DKATH 



(M.)ntli) 



(Day) 



I go '' 

(Year) 



,'•1 



I HlvklUiV Cl'ikTIl'V, That I attciHled (U-tcased fnmi 

....\cCL/^, .-A. U/3'i to U/e^ Vh... IC)0 H 

that I last saw h i. • ahve on \J ^.^ ^o up 

and that death occiirrc<l, on the date stated ahove, at 
Q. M. The CAl'Slv ()!• DlvATII was as follows: 



Dl'RATION Ycay^ ' 

CONTRIHUTORV 



Mo fit /is . /yays 



Hours 



or RATION 

(Signed) 

Oct .v., , 



Years 



Months 



/)avs 



lO ' ^ (Address) LLL^^v.^ ? v.&V'^ 



Hours 
M.D. 



nLX. 



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



^-^^ Place of Death ? 



Former or (1 () How lonq at 

Usual Residence vAJ(xVvx^l<K.o^> 

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



Days 



I'UACK OK lURIAI. OR R1:Mo\ \I, 



DATK of Ml KiAi. or RKMOYAI, 
Qvct %Sc. 



I 90 I 



IXDKRTAKHR M I . vj A^yCy^A ^ L {. 

(A.l.lrrss 5S^ oi^AaA; "^t 



IS. B. Every Stem oif infopiiiHtion should be cnrefully Hupplietl. AGE Hhould bo stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for pur- 
son* dyin^ away from home kIiouIiI be (iJven in every instance. 



'4 



t^ 



. 'V 



WRITE PLAINLY W!TH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,.,, ..nK:.U.. .■•No.:.t^.gS^H&i'0. WRFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

.1(1 i^ [) ^^_ ^n/iu l?^^i\>io^*nr1 \^n /^OU4 



1 n /)L( 



1? rt f^-i i.*-f-o^t/ir1 \^n 

J. H ^ tut t. I \y •^■v »f«^^t 




jj^^ Deputy HeaSth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "CI. S. StanDarO ) 

i cap \ ^ 

PLACE OF DEATH: — County ofOcvr^' O/vcxovcuiCcCity of C)<^>^ J ^-^^'v^*^^ ^•^' 



'NO.HSS 




ol- 



. ^ .\.A..tT^A.' SU ^ Dist.; bet. H^ I Una>Ul<j^l\X\AJ and J.CUvaA tO'>\^. 

F DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER ]^SPECIAL I f^FO R M ATIO N ' \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ^fTREET AND NUMBER. / 



FULL NAME 




uj^Dv^'x-.c^- vVtvA^l\A/.:>rN^. 



PERSONAL AND STATISTICAL PARTICULARS 



KXjMjjLi. 



\).VV\'. Ol- IIIKIII 



/ A. 



iMnllthl 



ACK 



ok 



HS Vra,. 



(Day) 



M..>ilhs 



(Yt-ar) 



Dii 1 . 



SI NCI,}', MAKklKI) 

\vii)(>\\i:i) OK nivokrKi) 

(Wiitciii sofial (Usijj:iiali<in) 



lUR rUI'I.AOH 

'Slati or I'ltuiitrv' 



^^/ 



NAMl-: Ol- 
FATIIKR 



niKTHIM.At K 
OJ' l-AI'lIl-.K 
(Statr 01 (.Oiiiiti \ 



\I\II»i;N NAMl. 
Ol- Mol'in-.K 



iukrm'i<ACH 
Ol- Morin-:K 

(Statf or (.Oiinli \ ' / 



OCCITATION > I 4 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH CS 

lli,ct Xl 

(Month) (Day) 



(Year) 



I 1I1<:RI:BY CHRTIFY, That I attciKkd deceased from 

I9O to TTTT-.IQO ~~~ 

that 1 last saw h • ahve oil 190 — 



and that deatli occurred, on the d.ile stated above, at 
— M. The CArSI<: i)\' DlvATH was as follows: 



) I'lii 



yr.'iith^ 



lui\ 



TH1-" \aovi«: srA'n'.D i'Kksonai, tar iuti.aks aui-; tri h io rii i-; 

lii:sT 01- MY KNo\V1J;DC.K AND lUU.IlvF 



(Infif lUMiil 




C-A. 



I \(l(lrcss . —" 



or RAT ION Vvars 

CONTRIIUITORY 



Months 



Day 



or RAT ION 



)'i'ars 



Mouths 



/hiys 



(SIGNED ) LfeX-O- '. . V J . Uj. Uj \±Lo^ys^6.. 

(.\d<ln-ss) L 



ll'cfc IM Kjol (A.ldn-ss) LcV^viAA W-tk '^C..»- 



/ fours 

Hours 
M.D. 



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



Former or 
Usual Residence 

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



How long at 
Place of DeatI) ? 



Days 



ri.ACK Ol- in RIAL OR RlCMoVAI. 



DATl-;o! HiHiAi. or KKMOVAI, 

Oct 'V: 



190 I 



(Ad.lress. 3ion'>. .- 1^ -LL "5.1 



CL.CV tX.> > \. 



IN. B. livery Item of informotlon should be cnrefuliy Huppl'ied. 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 ^iven in svery instance. 



."I 

I 




WRITE PLAINLY WITH UNFADING INK — 



Hoanl of H.-Mlth-F- No. i^ -^-g^^H&l'Co 






-1 f\ r\u 



THIS IS A PERMANENT RECORD 

REFER TQ BACK QF CERTIFICATE FOR INSTRUCTIONS 

2605 



T> n t^i t..in-nor1 \'*n 



,t/C'^ VKIX. \y t V- 't^ 



L^.lu>u Deputy Hec-lth Officer 

DEPARTMENT OF PUBLIC HEALTH- City and County of San Francisco 

Certificate of 2)eatb 

( III. S. StanDarO ) 
PLACE OF DEATH:— County ofOxx/vv ;v<X^YvCu>,ccC;ty of 0^«wA^ /vCX/>-vcv<>.ca. 







^■iJD 



LU 



OCCURS AWAV 
ATM OCCURRED I 



. St.; S Dist.; bet W /CX^U^U. and 

FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDEjIp "SPECIAL INFORMATION • \ 
N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Q\ STREET AND NUMBER. / 



FULL NAME 



:LL.Li...C ir- djL^rlvcr'yu. ^-. J\aJJ\X^Xl/.yv..y)xoAuKLU 



PERSONAL AND STATISTICAL PARTICULARS 

si:\ Qr\ ^ i COLOR 



J JLO'I^XXAA 



DAri". or- HIKTII 



a<;k 




N 



b 



(Month) 



i\A.Li 



X\ /.a.Q.H 

(Day) (Year) 



) Vi/» . 



Mnulhs 



Pars 



sINC.1,1-: MAKUIl"!) 
WIDOWKI) i»K I)IV()RrH[> 
(Writtin s<K-ial (k-sivrnjition) 



HIKTinM.ACK 

* State or t'ouiitrv 



NAM1-: (tl" 
FATHl'.R 



lURTHPI.ArK 
OF- !-ATm-:R 
(State or (.'oiiiitry) 



MAinilN NAM I'. 
Ol MOTni:K 



lUK riiri.ACH 

Ol MolIlHK 
(stall- or i'ouiitry 



oCCri'ATION 







r- 




X<X>UwAj-Ow' 



cL 



QTJ) 



C'/CX/vu J XXV\xov<iyC^C 




/CxX/4'Vil^o^ xA 



lA\,\/\'-.L 



(^;^ 



\ 



'X>w/vyj Axx^\^^<wAx^L 



^'fsnfi'd III S.iii I'liuuis,-,) "^ )V-(7;f "^Months - An-, 



IH)- \HOVK STATI'.I) I'KKSOXAU PAR ricn.AKS A Ri: TR IK To THK 
HHST Ol- MV KN0\VM:I)C.H AND HIU.IHF 



( Xddrcss 



>5^0\ cmxcjaa^a^w^x Ot, 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DEATH / Pj 

V^'O 



(Month) 



:ib... 

(Day) 



(Year) 



I HEREBY CERTIFY, That I attended deceased from 

SJ.'S:^,. X!c 190H to ^../zX 9>.<o 190 H 

that I last saw h ^'- alive on 190 

and that death occurred, on the date stated above, at 
M. The CAl'Sr: OV DI^ATIl was as follows: 

(U^wIa ViSfr>v%^ % (>Vc^yo AAA-SJiX^ 



DT RATION 



Years Mouths Days Hours 

1^ 



CONTRIIU'TORY 



JL.O^^LX/^>a,L:Qu.... J.A..<XJi. 



\^..UC!w. 



niRATION 



Years 



Mouths Days 

( SIGNED ) LI A. \1 I Lo-^oJuLV 
U/cfc 9v1 Tc)oH (Address) IHI U <xJUAv.t:-v<x. H... 



Hours 
M.D. 



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 lonq at 
Place of Death? 



... Days 



PI,AOK OK lUKIAI, OK RKMoVAl, 

UNDKRTAKKR \jOj\XK\jr ^^ 

(Address %!\ U <X/>V 



DATE of HCRIAI. or REMOVAI, 

sh^. 3.5 190H 




IS. B. Kvery item of informatJon should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH J.i plain terms, that It may be properly classified. The "Special Information" for per- 
sons dyln^ away from home should be ftiven in svery instance. 



I 



li 



I 



I 




r 1 



WRI 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



-^^ISfv^ 



IJnanl of llt:ilth-»-Xo. n *'?^»;.-ini&r Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



,"^ 



h 



Ddfc Ju/rf/,\L£Lob-V>j '^^ 









2606 




<A 




.1 



Deputy Health Officer 



DEPARTMENTS PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Death 



( "CI. S. Stan^ar^ ) 



PLACE OF DEATH: 



County o{^Ojy\j J;v<X/'>axxac<.. City of O/CX^rv ;>.x>^>a.<^v^^. x 



No. 32.x 



(IF DEAT 
IF DE 




J cHL< 



H OCCURS AWAY F 
EATH OCCURRED I 



St,; 'i Dist.;bct. (/vO.<XAA^/C).<nr\j and J CK.<^^r^^W' 

FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




.JO^J. 



PERSONAL AND STATISTICAL PARTICULARS 
M.X A fK I COLOR 






DA'Ii: 01 lUKTll 



'Moiitlr 



AC. K 



ok 



2.0 



) 'iti I > 



(Day) 



M,>n///.< 



(Vt-ar) 



/h! VS 



SIN'C. I,K. MARKIKI). 
WIl)n\VI-:i) <)K DIVOKiKJ) 
(Wiitfiii s<K-ial (Usit.<natioii) 



lUKTmM.ACK 
(Statf or Country) 



NAMK OI" 
I-ATIIKR 



HlK'rHPI.ACK 
01 l-AIHHR 
(Statf or (.'ountry) 



MAIDl'.N NAMK 
ol- MOTHl'.K 



lUK'rnri.AcK 

Ol- MoTin'.K 
(State or Country I 




ION P 

f\r>i(lri! Ill S,ni /'i itiii isro "^ 



y,„i 



Months 



/hJV> 



Tin- AMOVE STATi:i) PKKSONAU TAKTUT I.AKS A K !•; TRrH To TllK 

iIhst oi" my kn«)\vm;i)C.k and in:Mi:F 

1^ 



( Iiiro!!uant 



L^rVCrv 



'^aj\j:i \JlL\yzJL 



f Address '■ 



XAjL 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

11. 



Qct 



(Year) 



(Month) (Day) 

I lIIvKr^HV ClvRTlFV, That I attended deceased from 

: to 



190 



190 



that I hist saw h — — alive on 190 '^ 

and that death occnrred, on the (hite stated above, at -— — 
::-:- M. The CAl'SIv OF DlvATII was as follows: 

l/\D Jy^-y-\.^^'>jl\^<:x.q^ 



I) (RAT ION years 

CONTRIBUTORY 



Months 



Pays 



Hours 



DURATION Years Mouths Days Hours 

(SIGNED )\.A\Xryv!lX» J Al). U) Ij^'l^AM^, 



M.D. 



/Cfc 9lM. iqoH (Address) U'Ur>V^A^ UJ 



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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



... Days 



IM.ACE Ol' lURIAI, OK KHMOVAl, 




l].tJU 



i 



DATl-:of Ml Ki.Ai, or REMOVAI, 

Oct 



xn 



T90H 



(Address ..'h^n.%- W 



I fcl. .i 



IS. B. Every item o? information should bt; carefully Huppliefl. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" ?or per- 
sons dyin^ away from home should be ^'^cn in every instance. 



'^^S^.^:^ 




WRITE PLAINLY WITH UNFADING INK 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I ^ , Id .0 



.MA„U\ 



1 (inu 



'Rflf^iafpvpfl. Mm^ 



2607 




(No. 



A>u Peputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "a. S. Stan^arO ) 
PLACE OF DEATH: -County ofOcc^ J ^v^X^x^^v^.Chy of O <X/>^ . VO^ v^a .^ c. t 

PUII NAME HYVVArvx, ». ) Jl >0\ AAyV\rf vX^J\^.\^-*v 



si;x 



DATK or r.IK III 



PERSONAL AND STATISTICAL PARTICULARS 

I COI/)R 






(Mouth) 



ACH 



lb )V<n 



(Day 



Months 



rMl 

(Year) 



lb 



Ihl vs 



SI\<,I,K, MARKIKI). 
WIDOWKD (»R DIVOKCKI) 

(Wiiltin ^oiiiil (U-sij^nation) 




<jj6^ 



lUKTHlM^ACH Q (^ ^ 

(Slatf or Conutryt _V / 11 



V 



^ 



NAM I'. <>I 
lATUHR 



LcL^vlx^' 



HIKTHlM.ArK 
OJ- I-ATHKR 

(Slate or Coiuitry) 



MAIDKN NAMK ft '\ 

()|- MOTIIKR J( \J «Y ! 

Rruifrd III Siin /'i ,nh ix'o o \ )><?;> J. Mmitlis 



()!• MorilKR 
(State or Country) 



Havs 



, MK MIOVK STA'll-I) PKRSONAl. I'ARTIOr 1,A RS ARK IRl K TO THK 
HHST OI- MY KNOWl.lCDC.K AND HKMllF 



(informant VHVv^ C , L • M\JU.^^4voXl 



-? 



\,Mress l^ 1 5 QXX^C^UX^^N-fi^^VAJt^ C?X. 



i 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 



(Month) 



IL... 

(Day) 



190 i 
(Year) 




I HEREBY CERTIFY, That I attendcMl decxascd from 

...IS 190 H. . to |y<^ Sv(d 190 H. 

that I last saw h v. > w alive on \J.'^ aS 190 M 

and that death occurred, on the date stated above, at 5" 
\JL M. The CAUliE OE DlCATII was as follows: 




DERATION }'e'ars ^ Mouths 

CONTRIIUITORY 



Hours 




Hours 



DERATION Years Mouths ^ Pays 

(Signed) djLxL-rAju^ LUj^rvlA' M.D. 

'.Xt> iQoH (Address) (q b aA.<J:iwJav...a.t 




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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 




DATlCof HfKlAl. or REMOVAL 

...y.'tJt .^.^ IQO-H' 



rUACE Ol- lURIAU t)K REMOVAI, 

INDERTAKER NI. v'/V<XAy ^a^^ a 

(Address 2),S!.'b.'^....'b.. 5 '1 CJ-4wiJiZljL>v....3A 



(•• 



U 



N. B. Every item of InfformBtion 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 dyinft away from home should be Iti^^n ■" avery instance. 



|tii;ii.l .if II. :<llli I' ^'" I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.-i!??S::s;i,ns:i'Co ref er to back op certificate for instructions 



l)<iii' rifr(f,\j(QjuAy^ ^^ 









I 



k^ilAH. Deputy Health Omper 

DEPARTMENrOF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2>eatb 

( XX. S. Stan6ati> ) 
J? ' QO ^ "^ 

PLACE OF DEATH: — County ofCJ/CV^, J-^-w^c«.crOy of O ^^a^ -'vo^ex^ e c 

(No. 55 uJ\JL^vMi<x^. ^♦^ 5" ni.t.:fcet. ibo.VvUir>--. 



and 



A ta^\ 



^'^ ..-iijii oe-eirtC-Mrrriup FACTS CALLtD FOR UNDER "SPECIAL IN FORM AT ION" \ 

FULL NAME UAxxxJL 



PERSONAL AND STATISTICAL PARTICULARS 



DATK Of" HIKTM 




COI.OR 




W^^ 



AJl. 



ACK 



(MotUlO 



IC 

(Day) 



Miiuths 



^il.,L 

(Year) 



!S 



Pa vs 



SINC.I.K. MARKIKI). 

\\ IDoWin) OR DIVoKrHO 

(Writf in social (U'si).'iialioii) 



lUKTMl'I.ACH 
(Statt or Cmmtryi 




VojNJvOL/cL 



NAMK <)l 
1 ATIIKR 



lURTMI'LACK 
Ol- l-ATHKR 
(Statr or Country) 



MAIDKN NAMK 
(U- M«)TnKR 



HIKrm'KACK 
»»|- MOTIIKK 
(State or Cimntryi 



OCCII'ATIDN Ci^ 




\V^' 



3 



A..^ 



AVsidrd III San /'i aihisri) )'i,ti 



A/ni/f/l, 



/><;r.v 



Till" MJOVH STA'n:i) I'KRSONAI. PAR TKll, ARS AKl". TRn-: TO TMIC 
lil'^ST OF MY KN0WM;I)«'.H AM) BllMlCF 



(Informant 






(Address 




MEDICAL CERTlhCATE OF DEATH 



DATE OF DHATH [A 



(Month) 



.15... 
(Day) 



(Year) 



I HKREBY CI':RTIFV, That I attended (ItHoased from 



.x\ 190I. to .J^/c;^. "^s: 190 H 

that I last saw h ■.v.'^ aUve on U/CA; '^S 190 '^ 

and that death occurred, on the date stated above, at 10 C)S 
CL M. The CArSI{ OF ])I':ATII was as follows: 

OL^jJ(yvcJo mArr^<\..<y\^J\<<^.^ cv^vcAv 



UkA<<rv)wA/<;r . 



^.V.i).... 



DURATION }'ears 

CONTRIBUTORY 




Monihs H Days n Hours 

/C\AjLcv<v/.cJhA<v^>.\.a!^vv6 





DURATION ^ Years f Mouths Days 

(Signed) J. Ad- \JvAj.y^ri<v,voHxLti 



Hours 
M.D. 



'/Cfc VS iqoH 



( 



M AAA.^k.A..-Cm. 



Special information only for Hospitals, Institutions, Transients, 
or Recfnt 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 



DATi: of HiRiAl. or RKMOYAI, 

0/C±. VX 190H. 



PI,ACE OF nURIAI, OR RFtMoVAI, 

l-NDHRTAKKR Ov) • . CJA^aJw '^ Cc. 

(Address l.,\..'^l \u\A.^l:<t.V,«r>^... ^^ 



IS. B. Rvery item o? information should be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it moy he properly classified. The ''Special Information" for per- 
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 CERTIFICATE FOR INSTRUCTIONS 






i i 












2609 



t^utUi It^ Deputy Hcailh Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)eatb 

( H. S. StanDaiD ) 
PLACE OF DEATH:— County of 0<X/>%. ^Cc-vvt^ccCity of 0<x/>v J.>v<v^x.c^cc 



No. H-XCi 




X^>'\.^.. 



St.; 1 Dist.; bet. cU UX/>vur: 




-rvv/cL 



and 



LcXA^V^ 



) 



\^\^ w 1 1 \. -Y ..eiiai BFcTnFNCE: GIVE FACTS CALLED FOR U N D E R " S P ECl AL I N FO R M ATI O N ■ \ 

( '^ .V*o;AT°H^Ocl%rEV,"rH "s'pa't o"r":St'.?u"o';'V.;e7tI name I.STEAO OF STREET A^O DUMBER. ) 



FU LL NAME \^l^L<ix:y>..- CJ.A.iA/>.^rx.a-Lt \J^X'<y^ 



^-v 




I 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.OR 



^ 



WXoJLx 

DAli; nl- HIKTIl X^ 




\ 



^VL 



u 



iMutith) 



A< .!■; 



)".•</' 



^ 



(l)av 



\/.,i///n 



(Year) 



s 1 



n<i 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DEATH ,, 



(Month) 



(Day) 



(Year) 



I HEREBY C FORTIFY, That I attemlcd deceased from 

ID-Ct XH loo'i to...iQ.^ ^^ 



190'i 
that I last saw \\^'^' alive on 



(i'rl 



'1 t. 



TQOM 

1(;0 
1 



>IN<.l.i:. MAKKIl'.n 

\\in« i\\i:i) OK nivt »kvKI) 

(Wtittiu '•iK-ial ih xi^/'Tiatioii) 



lUK rUPI.AOH 
(Statf or Country' 



I- A 11 11; K 



lUKTlU'I.All-: 

01 J Arm:R 

( stair or Country' 



MAIDI-.X NAM}*. 
(II- MdTIll.K 



lUK'ril PLACE 

(H" M(rrHi:K 

(State- or Countryi 







L>\.4aX( 



^ 




v^ M 



OCCUPATION 




KWV \noVK STATl-D PKRSONAl, I'AKTICrf.AKS A K l-'. TKrH T« > THK 
HKST OI-" MV KNnWl.l-'.lx.K AND UKLIl'.K 

(Infovnuint ''CX/'V^A- vOlX CvVtV^>r\bvM 




X.Mr.s. 'iXO?> CIV^VO \ 



1 



X 



and that death occurre.l, on the <latc statt-d above, at •::^ 
. (^ -S\. The CAl'Slv Ol' I)i\ATH was as follows: 



\. 



DT RATION Years 

CONTRIIU'TORY 



Mouths ^ />>«r-^ Hours 



DURATION 



Years 



,lfo)it/is 



Days 



(SIGNED) ...J.I'UrWAXaj Co. divwvyvX?.,^ 



NED) ...J.r 

I'cL :)l iqo'l (Address) 1101 



LoJu.i« 



/lours 
M.D. 



SPECIAL INFORMATION only for Hospitals, InstMutions, Transients, 
or Recent Residents, and persons dyinq anay from liome. 



Former or 
Usual Residence 

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



How long at 
Place of Dcatti ? 



Days 



PLACE <)I" lUKIAL OK Kl-.MnVAL 



DATlCoi IHin.M. 01 K)-:M»)VAL 






T9O I 



\A ^ 



!_^ 



.. .. !• A APF should be stated EXACTLY. PHYSICIANS should 

:S. B._F.very Item of information should b. carefully supplied ''^'^^J^^'^l^^^^^^^ ..g^^.i^, ^formation" for p.r- 

state CAUSE OF DEATH in plain term*, that it may be properly ciassmca. \ 

sons dyinft away from home should be feiven in every instance. 




1 ! 



WRITE PLAIN 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



15ii:ir» 



1 of lltiilth »•' N" I' 



'^'t'S^. Mft 1' r 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



f 1 • / / 



f 



n ». /> I- 



lom 






Re^Lstej'cd A'^o, 



o 



3(>10 



1 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( H. S. StanDarO ) 
PLACE OF DEATH: — County 



of ^Aa^v J xa.^^^cAA.<Lt City of O (X>^ o .\,a/>vc^^cc 



No. 



(XT DEATH OCCUBS *WAV 
IF dcUth occurred 




St.; I Dist.; bet. dUb<X'\r-toa>\<VM^\l and 

rooo USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATlOl 
,; A HOSPITAL ?R frlsTI^UTION GIVE ITS NAME INSTEAD OF STREET AND NUM, 



IBER. 



nu.-^.. 



FULL NAME 




.njL/Yxi LcrVwiLiA.<.L'i 



PERSONAL AND STATISTICAL PARTICULARS 



"■■•^W 



' 



DATi: «»F lilKlII 



AC.K 



L 



Coi.ok 




■\jJ 



It 



'Month) 



5 .\'. > 



(Day) 



.\f.,ufhs 



( Vt-ar) 



15 



/J,;iA 



SINC.I.H. MAKKIKI) 
WinoWKI) OK DIVOK. j:i) 
iWiittiii siK-ial il« siv'tiation) 



HIKTmM.A^^'K 

(Statf or Coimtr\ ' 



NAMl-: <>1 
FAI'm-.K 



Mik'im'i.ArK 

()»•• I AIIIKK 

(Statr oi roimtrv' 



MAn>):N NAMl. 
OI- MOTIIKK 



HIKTHIM.ACK 
nl- MoTHKK 
(Statf or Country) 



(KCri'ATION 









MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII j A 

liJx:t, .U 

(Month) '>>'>y^ 



IQO . 

(Year) 



1 invRI'UV CI:RTIFV, That r attemUd ilecoasctl from 



lt)0 H 



\\ 190 H to .^-^/^^^ J-**- 

tliat I last saw h •.- • alive 011 t/let l- I up 

and that (U-ath occurred, on the date stated above, at J^ 
M. The CArSIC OF DlvATII was hs follows: 




XX/^y^CA-A^^^' 






a 



I 



,'YV>^^^ cCwCLu 



i) 








^ M itA^i^ 



Urnffif in Sitii I'l itiii i.'i'i' 



'- )V,M 



Months lo /'"I. 



THF \noVKST\TFI) PHKSONAl, I'A K lU" T I.AKS AKl! TKlF. T'> TUl- 
IIF'ST OF* MV KNOWI.I'.DC.F: AND lU-.l.Il.l- 

f^ . .1) 



( lufoiniant 



,1V K 

i 



.. VXr\/>>JLLwvO 



f\<Mrr 



b 5 \ l* 



1^ ,Ol.^< 



^ 



0,% 



CONTRIHUTORV V<HLc*- 



1)1' RAT ION )V<f;\9 Months Pnys 

( SIGNED ) LcL'^^»AvO^ v&/O.A^<t^tA<.' 
^.'<-t 'U ,,)o'i (Address) J ll 



Hours 



-^^v 



I 



SPECIAL INFORMATION only lor Hospitals 
or Recent Residents, dnd persons dying away from home. 



C\A4-\JL)A( 
», insfitutions, 



//ours 
M.D. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



transients, 



Days 



PI,ACF: OF" lU KFM. OK kf:m(»vai. 



D.VrFlot Hi KiAi, or KF^MOVAI, 

U/ct. Vo . T90S 






(Address 



^' ITT .j^B should bo Htate.1 KXACTLY. PHYSICIANS should 

N. B. F.very Item of 5,i?orm«f.on should be cnre^ully HuppI.ed. AUn « ^^ -Special Information" ?or pT- 

state CAUSE OF DEATH in pl«in terms, that it may be properly ciassmeu. 
sons dyinfe away from home should be ftiven in every instance. 






.^ 



WRITE PLAIN 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



){(>;ir< 



Inf n-nltli l-No. ,^•*•^af^3^I5&l'C.. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



»■» • 7 / 



in 4-j 



n » 



r\ I 



/)(([(' /v/fvf , \^//CA/Crv>Jc^ c^c 



.^y\j^\^ 



innH 



Rp0^isfci'C( 



I J^o, 



5611 




^^ Deputy Health Officer 

DEPARTMENT olf PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Bcatb 

( Vi. S. StanDar^ ) 

J Off I ^ 

PLACE OF DEATH: -County ofCLa vv O^v^^^'vC^ACx City of^ O-^ Oaxl-»v^^cc 



f^^ 



fNo.<^ 



Ml 




4- 



.<X'vo St.; I Dist.;bet. 5 tk and b-U 

„^„ liciiai RFSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
( " r".»T°H"oCCuV."V,"°"-o"s^p"" 0."^S,.?"c';"'0,VE ,TS NAME ,HST„C Or S,«tCT .NP «U» = E». ^ 



V 



/^ 



FULL NAME v.<i\aaJL'Ivu^ V.'vcn^x^L/^^x; 



-i;x 



i)\ii-: <»!• lUKTn 



\<.i-: 



PERSONAL AND STATISTICAL PARTICULARS 







Mi.mh 



bc ^ 



(I):ty< 



Mnulfl 



(Vt-arl 



/'.n 



vINi.l.i: MAKKIi: l> 

\vii>i)\vj:it OK i>iV(»K*'i:i) 

■ W t it< ill •.(.( i:tl ■lt-.i>.Mi:iti«>ii) 



? 



(Day) 



(Year^ 



O.i 



lUK rm'i.An-: 

(Statr or I'omitry' 



I A T 1 1 1 . K 



lilKlIIIM.ArK 
<)l' I AlllKK 
(Stall III rmintiv 



MAIIHN NA Mi- 
di Morm.K 



lUR inri.ACK 

nl- MoTlM'.K 

(Statt or C'oinitry^ 



•"•'•"■^■'•'"•■^(?uJUajlxJL 

h'fsidfi! in Siiii I I till- r 



(>ajlL<v 







-L 



? 



( 



) 1 ,1 1 



.\r,<n!h 



I )<; . 



Till- M5()VFSTATi:i)l'KKsn\U. )• \ K 1 ini.A KS A K K TK T K T< • IHH 
Itl'.sr «)1- MY KNDWl.l'.lx.K AM) IjT.l.IM- 



( Iiifojinaiit 



(hvv. 



( Xdilri-ss ckl I 



'rvw 



tt 



(J 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATIl > 

(Month) 

1 HI:RI;HV Ci:RTn"V, That I attemled .leccased fn)ni 

lyO-l t(. Aj/tli ^.k?. TCpH 

that I last saw h -^ ^ ' alive on ^ dL ^^ up ^ 

an.l that (loath occurred, on the date state«l above, at 
M. The CAISP: (-)F DI'iATll was as follows: 

<^(--^\.,C^.y-v\.AZ\^\.Jr^.\. 



Di; RATION Vt-ars 

CONTRIIUTORV 



Months 



Days 



Hours 



DURATION )V</;-5 Months Pays 



(SIGNED) 



Hours 
M.D. 



(Address) 



SPECIAL INFORMATION only for Hospildls, Institutions, Transients, 
or Recent Residents, dnd 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 



v^ 



t 



7 

'( 






PI.ACK ol" lUKIAI, <IK Kl-MOVAI, 



DATl'.o! HiKiAl. <H KHMOVAI, 
Oct, a% I90H 



fA.l.hHss "^.W ^. QfV\^>i^v<r'^v Q.t 



"— ■■""~""'""— ■""■"""■""^ 77 TTi \r.B should be stated EXACTLY. PHYSICIANS should 

N. B. F.very item of inJorniHtJon should be carefully supplied. ^^^^ classified. The •'Special Information" for psr- 

•tate CAUSE OF DEATH in plain terms, that .t may be properly class.tieu 
son, dyinft away from home should be feiven In .very instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoar.l of Ui:.Uli-»- No. i^ ■^?:*::;^ US^VC, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




ton M 

J. %-f \./ V 






^36 1 2 



.-.•» Ill T- V.n» f\ I 

X^\x^Xil/vMj Deputy h,c^Mh Officer 

DEPARTMENT # PUBLIC HEALTH=City and County of San Francisco 

Cettificate of S>eatb 

( "a. S. StanCiarC ) 
PLACE OF DEATH: — County of cVoy^^. -^ 'vawcv^.: City of C O.^^ J.\xX/WCv.o 

,jv^o. 4S^ - ict^p. St.; ^ Dist.;bet. fo OJv^-V.<^r> v andU^AcvO. • ^ 



<:ic 



/ ir DCATH OCCURS *WAY FROM USUAL R E S I D E N C E G I V E FAC 
V, \r DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 



St.; bet. Uv'.OJV'VV.<i.«r>v andvU.^-CY^ 

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




X'V/iV-CV:^*- 



PERSONAL AND STATISTICAL PARTICULARS 



1) \ ri: t>i itiK 111 






Month I 



roi.nR \ 



^ 



\t.i'. 



n 



)'itii 



k. 



sIM.I.l- M.\KUIi:i> 

wiix >\\ J". I) •»»< i)i\< tKr);i) 

(\Viit( in MK-ial (h >i^M)ali<iii) 



iiiKrmM.MM-: 

(St.itr or (.""iniili V 



a ^ 





'A 

(I):ivl 



.1/ .»//// 

(1 



It' 



'A r 



fVt-ar) 



Pti \ .< 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 






iVt-ar) 



^^' 



I 



n^ 



NAM!. Ol 

l-A TH ):k 



lUKTHri.Ail-: 

Ol i\iiu:k 

(Statt or I'oiint r\ ' 



M Mlti:v NAM}; 
Ol MoTHllk 



lUKTHri, ACl-: 
Ol' MoTHI-.k 
'State or i'otintrv • 









DjlU. 



^VUv 






\.CA-<x-'->vd- 



orrri' \ rioN 

h'/--l,lf,i 1)1 SilH I'lllll.!^'" i^ ' "■" 



Mnlllh' 



lun 



TIM- \novi- sr\ I I I. im.:ks<.\ \i. rxKTuri.AKS \ki: TKn-: to iiii', 
Hi-:sT «)i- MS KNOW i,i: I >«■-»■: AND in:i,iij' 



' I ti f"! luanl 



Clv.vu^\vUvlAD^! 



v<\ 



< Nddrt'ss 



HH*^- IC I ' 



(Month) '1^!'V^ 

I ni'Rl'.HV Cl'RTIl'V, That 1 attended dcrcascd from 
V A up'^ to A9/t± -X^ up'\ 

that I last saw h -^ alive on '-. I up 

and that death occnrrcd, cu the .late stated above, at D ^ o 
M. The CAl'SIv Ol' DllATH Nvas as follows: 



or RAT ION 



]'tars . Months iO Days 
CONTRIBUTOR V '^^- J..r>>^^.:. 



Hours 



DTRATION 



Years 



Months 



I^avs 



f fours 



Q5J fC 

( SIGNED )AAJ/Y>^ . vJjxxV'^^'OJ^' M.D. 



,cfc ac. T( 



\ddress) 13.10 s3 (HL<i^>>\ Ul 



,o''. ( 



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



Former or 
Usual Residence 

When v^as disease contracted. 
If not at place of death ? 



How long at 
Place of Death ? 



.. Days 



DATllo! Hi lOAi, ->i Kl-.MoVAU 
\J <ZAj .-■ t T 90' 1 



111 \CK ()!• HI RIAL OK Kl'.MoX \1, 

11.11 Qfl\v^sLvt)AA.....O.l. 



(Addrt'ss 



N. B." 



'—""— """— "^ 1- 1 ATF «houltI be stntetl EXACTLY. PHYSICIANS should 

-Kvery item otf intform»tion shouhl be- cnreVully 8v.ppl.ecl. ^'^"^ « classh'iecl. The "Special Information" for pT- 

Btate CAUSE OF DEATH in plain term«. that .t may be properly classnie 

sons dyinft oway from homo should be ftiven in every instance. 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



^(vaii^i^ , 



M<.:ii 



,lof UVAhh I- No. ir1S'r;.^«;24)IU^J'V 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




1 1 • t I 



in a I 



r\ I 



,n 



l)((ii' r iir'i yS^'/s^jcts-Xh^X) okio 



cL/^^cc>o .kx 



r- 



A>M . 



■:a 



I ' 



innu 



l\\\\ Of^o-^- 



Vo(SififpTOfl JSTo. 



O 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of 5)eatb 

( "U. S. Stan^ar^ ) 

of Oo.-r^' ^.(X-^v CL<1C(. City of 0<X'^v ^ VO^-^V'C^^ec. 



N( 



o. ^H i VO.ea^<: 



St.; 3. Dist.; bet. vi Cru^^i 



ft} 



and 



iLcrckt 



(rCK^LHrv\' ) 



( ■' r,"-'-i»"-^-.'.'.-.:"?"„ -",«^ „".^?^^^"j=4'r<f,v774 ?.vi,7 r.c-rs? s^-.Ti.'o";-::.*^.'"' • ) 



de4:^m occurred in a hospital or institution give n 

.^ 



^ 



UP 



FULL NAME cL{n.AA^.MAX\A^ Oxa^-cx.-^. 



PERSONAL AND STATISTICAL PARTICULARS 



sl'X 



^l\c.U 



C(>I,t)K 



\ 'I 



DATl". or- r.lK III 



A<.H 



' Months 



) .(-Lcb. 



bH 



) V<;» 



11 



11 

(I)av» 



1 /.-»////* 



(Year) 



ri 



A/i 



sl\(.I,K. MAKklKD 

\\iiK>\vi-:n »>K DivoKij'.i) ^ 

iW'jitciti MK-ial lU si^Mialioiil 



UO ccL^rvA-' '-c^ 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 

IS 



(Day) (Year) 



(Mouth) 

1 lllikHHY Cl^RTIFV, That I attendtMl tUTtascd from 

— '--rrrrr... up to — " ~ lt)0 

that I last saw h .: — alive on — ^ :t7— — up 

and that «kath occurred, oti the date stated al)(»ve, at 
M. The CAlSlv Ol' i)l':ATII was as follows: 

cJ^v-vJUx>v ^ JUx^X iJ^\Lji^.o-AL>- 



HIKTUPKAt'K 

(Stall or roiinti V 


O^u^^lI jlvLcx -va^cL 


NA>fK OJ- 
FATIIl.R 


H 


HIKrHJ'I.AiK 
Ol" l-AIHKK 

(Statr or Couiiti yl 


d ^^AJ-Ct'TJuO ^ . ' 


MAIDKN NAMH 
Ol M()TH1:R 


h 



HIKTIirKACK 
Ol' MoTlIHK 
(Statf or Coniitry) 



'i!i:!;;y 



oCCl TATION Pi 4^ A 



AV.v/(/c(/ /// S(}}i / I an, i^f-i 



],,ii 



\f.,iith^ 



Ih!\ 



(Infoi maiit 



IX K.N 



X^TsJvu 



TIM- MJOVK ST\Ti:i) I'KKSONAI. I'AKP fCT I.AKS A K I- TKrF. To THK 
IJKST Ol" MX_KNO\\ 1,1 : 1 )<•.}•: AM) MKIJl.l- 



DURATION y^df'S 

CONTRIIJUTORV 



Months 



/)avs 



Hour 



DURATION 



Ytars 



Mouths 



Pays 



iij/et X^ TooS (Address) U-U^-^UA^VJ,^ 



(SIGNED) 



Hours 
M.D. 



SPECIAL INFORMATION only ^«r Hospitals, Institi/tlbns, fransients, 
or Recent Residents, and persons d>inj av^ay from tiome. 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatli ? 



Days 



I'l \rK Ol- mKiAi. OK ki:mo\ \i. 



l)\rj-:oJ lit Ki.M. or KKMoVAl, 






190 



(Addres* 



""■""■""""""""■— """"^ Tm is.a AGE should be stated EXACTLY. PHYSICIANS should 

IN. B. Every item of Iniformation should b.- o.reVully supplied. ^''^^ » classified. The -Special Information" for psr- 

state CAUSE OP DEATH in plain tcrm«, that it may be properly classified. . 



sons dylnft away from home should be Jliven in every instance. 



) 



tt 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„...,, ., u..UU- VSo...^-r^^-n8.VC. REFER TO BACK OP CERTIFICATE TOR INSTRUCTIONS 

2614 



f ,..7,.., lO.^J 






0^tr\.A.A>^ oJL 






in OH 
Deputy Health Officer 



Rpp^lsfered A^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( X\, S. StanDar^ ) 



A 



on 



(No. 



PLACE OF DEATH: — County of^/O^^ 



J;vCX>xCv.^ CA City of Ooyy^ J .VOw^x-Cv^ c^^ 




<^U\vvo "l^JL/TOVOLt <)V' OA-W t/Sl? — Dist.;bet. - „,.„... n 

V,-^VO V > V . .- ^ Mc,,*l' BFSIDENCE GIVE FACTS CALLED FOR UNDER "SPECAL INFORMATION • ^ 

' rF"D»T°H"oCCU%r;;N''rHO^S^pyT*A^ 0%"n?t'.?u"o "^C.VE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




djdji J ^-^^j^.. 



PERSONAL AND STATISTICAL PARTICULARS 



SHX 



^ f. 

DATi-; ill lUk 111 /> 



c<>i,<»k 



avkv.t 



^. 



Muiilh) 



\<.i-: 



VI 



) ,:n 



^ 



• iJiiy) 



1/.,;////- 



iV 



{ '7'T 
I '» I 111 



/)<m; 



S1N«,|,K, MARK I I'D 
\VIlM»\Vi:i> nK IMVoRiKI) 

i\\'iit»iii <'Hi:il il( sivMi;iti<»!i) 



m 



O. 



X J- 



MEDICAL CERTIFICATE OF DEATH 
DATK <)1- I) HATH iC\ 



(Month) 



(Day) (Year) 



1 IIJ:KI:HV CKRTIFV, That I attfiukMl <lccease<l from 
€du h .I90H to i):i:± a.C> uyo'i 

tliMt I last saw h -a-Nj alive on ^ cl ..^1> u/d ^ 

an. I that (Kath occurred, on the date stated ahove, at ^1- ' < 
vl M. The CAISI-; ()!• 1)I':AT1I Nva^ a^ follows: 



'State <»r Ooiinti \ 



NAM) <>I" 
!• A III IK 



A'N 







r.U' > ' '^ 



lUKTIiri.AlK. 
01 1 AIIIKK 

' !-.t.iti or ("oiinti v^ 



MAIDl.N NAMl 
01 MOTMKK 



luurnrLAti", 

<»»■ MOTMKK 

(State iir C'oiilltt \ 



VjX^m 




\ \. \ 



h 



r^ 




t XLLv^'.o'x 



< urrrAiioN \^ j 

K'rsitffd III S,!n I I iiii> I'l'o -^ ' ''"' 



1 



,1/ 



'„/////> I l.i /''" 



Tin- \noVKST\Ti:i>l'HKs«)NAI. l-AKTin I.XK^AKKTKri- To TIIH 
liK.ST Ol' MY KNOWI.l.IX.K AND MI. 1,11. !• 



Lkxxhjljz^ 



Cro iJ^ 



(A<l.lress 5 IS " lb 



\J/C)JIOUv>^ 



/O 



I )r RATION Yeats 

CONTRim'TORV 



Kl d^w/CXN.w>v>QL 



Mouths 



Days 



Hours. 



I )r RATION 
(SIGNED ) 



}V</r5 




Months /hiys 



up'\ (Address) It)^"^ ^.U.tbv ^i 



/ fours 
M.D. 



SPECIAL INFORMATION only lor Hospitdls. Institutions, Transients, 
or Retent Residents, and persons dying away from home. 



Former or 
Usual Residence 

When Has disease contrarted. 
If not at place of death ? 



Owi^LcuA^d ^'X 



HoH ionq at 
Place of Death ? 



Days 



I'l.ACH «)I- IHKIAI. OR R1:MoV.\I< 



DATI". '»!" HiklAi. or Kl%MoVAI, 

vD tit. 1' : 1 90 H 






IS. B. Rvery item of information •hould be c 

state CAUSE OF DEATH in plinn term 

son. dyinft away from home should be ftWen in every m«t«nce. 



-^;^ --rt .eHXrr'-^^^^l^i ,2=^-.-^' 



) 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,, ,nl .,r JU :.lth-K No ^^ i>>g ^-) I'.S: 1> Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

'3() 1 a 



I , , (().+ . D -. A, 



I 






±j^y^j<.<J^\sif\yu Deputy '-'--^Jth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of "Seatb 

( "U. S. StanDarC* ) 
PLACE OF DEATH: — County ofO<X^' -3.\XL.^v<^^*.c. City of 0<X-v^ J ^'vCu^^/^m^ tx, 

1 Jl Q . 




oJ^tiX St; ^ Dist.;bct. 1 b XiA.- 



and 



No S k VJUv->A.CU.^^ V)A.<X/CJL. St; l Uist.; bet. .iv./vyr.v. anow-v^ 

iNO. » icN ^ V- ' wv>-^^ ,,ei,«i orciinrNCE give facts called for under special information- \ 

FULL NAME OjL\A.a. 



u 



-t 



j j\.jLd. 



PERSONAL AND STATISTICAL PARTICULARS 

SIX r\ - ,\ ii>i,( »K \ 



ni< 



DAir. <»l lilKTIl 



LL 



M..1UI1 ' 



\<.l- 



la ^ 



le 






Mm ill 



\ 'III 



/).r 



^i\<.i,K. M\Ki<n:i) 
wiDt i\vj:i» < »K iiiv<>mi:i> 

Wjitfin HiK-iai «lc>.i^Miat ion I 



lUKTlll'I. \*M", 
(Stiitr <tr (.■Miiiiti \ 




{\\ 



o * 



NAMI-: 01 
!• ATIll.K 



lUK IMIM.ArH 

oi- iArm:K 

(State III (.'miiitrv 



MAIDKN NAMi: 
t>l- MOTllKK 



IlIK riiri. \K'V. 

(M- M«>Tin.:K 

'Stati' or C'ontitry 



iD.t^^i-^. 



A 



\ 



Rf^idfd III Sun /'i ,i >/< 1^,0 "^^ ) r,n ' 



\l,,ntli> 



n,r. 



•rm- MinVKST\|»:i)I'KKS.>NAl.l\UTirfI.\KS AKKTKl K T' > TMH 
IlKST <»1 MV KNOW l,);i)('.K AM) HI 1,1) I 



(I 



tifonnant ^j /VvO «L' V dXt^ 



(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII jl A 

(Month) 
1 Ill{Ki:i5V (.'I:RTIFV, ritatj atltii«k<l <U'Ccasea from 

ix.^- 1903 in €''T«.t :^fr TcpH 

t It at 1 last saw h alive on V, '^. itp 

ail. I that (U-ath ..ccurred, oti the .lato ^tatod ahovo. at '. i 
M. TIk- cat si- C)I< DI'ATII was as follows: 



I )r RATION >V'^''^ '^ Months 

CONTRIHITORV 



Days 



//o/it s 






DURATION b )V(7;-5 MotitJis 

( SIGNED ) LcL^t^rV' V' . LL^>^ '• 



/)</) 



flours 
M.D. 



iD^ 



^b 



1 



T()0 



H f.\«Mrt'ss) bO^ u.cv.LLAv.!:.va 



It 



SPECIAL INFORMATION onl> for Hospitals, Institutions, Iransients. 
or Recent Residents, and persons d>ing .may from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



. Days 



n \CK Ol" lU'KIAU OK Kl'.MOVAl. 



*yx 



cCi,t\ 



n 



D\ri'. o! lii KIAI, or KKMOVAl, 



TgoH 



NDKKTAKKK \. ^ ^ ^^ ^^'^ \ 

( Xd.lress II ^^ MTU^<».vC->V It 



IN. B.- 



' T^ 7\l AGE Hhould be stated EXACTLY. PHYSICIANS should 

-Every item of inforniHtion should be o.rcVully supplied. J classh'lcd. The "Special Information" for p«r- 

state CAUSE OF DEATH in plain terms, that .t may be P^«''^'"y 

sons dyinft oway from home should be J^Ken .n every mstance. 



D 



WRITE PLAINLY WITH UNFADING INK 



M,,:,i,l ..f !Ii:iUh-K No. i <; 5"*^: 



t>-?^!s»^H&HCo 



THIS IS A PERMANENT RECORD 

RKFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



C\ 



I 



Dafr FiM ,\J..cLthJl\ ^b I'-^O ^ 



^9 



M-U^ 



..cv-u. 



Deputy h!ealth Officer 



1 
DEPARTMENT (If PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. StanDarD ) 



Q^ 



PLACE OF 



DEATH: — County of 6xX^r\/ vJAX'^-n.O^ccGty of O Oo/>v AyCV^^<l.v<L^o 



^Ne* 




,LvWt^v^O..\.q St.; -— Dist.;bct. 



and 



1 ■•>>•>«• Ac-einr Mrr oiur facts CALLED FOR UNDER "SPECIAL INFORMATIO 

( '^ .VrEAT°H"o^c"u%r;.rrHo"s"prAt r f^^T^^'^^.'c./ETTl NA^i.E ..STEAD O. STREET AND .UMBER. 



...) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



^llcL 



COI.OR 



DATl-: or lUKTlI 



AC.K 





Month) 






(l)av) 



Mntillis 



-cruj- 



(Year) 



iO./ r.s 



SINC.1,K, MARRIKI) 
WIDOWKD OK I)IVoRil-;i) 
(Writfiii siH-iiil (lisiv:>iiiti'"i> 



lUKTUPKACK 

(Statf or Coiintryl 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Month) 



ipo 'i 




NAMK Ol 
I ATHl-.K 



mKTuruArH 
Ol- i-Arin<:K 

(Stati or Country) 



MAini'.N NAMK 
ol- M(JTnKR 



lURTUI'KArK 
Ol- MoTni:R 
(Stati- or CNmtitry) 



Ocrrva oUot; 




v^ . 





(KHirAI'lON 






AV^id^if III San I'l nin ism 



r-',?r 



Mnulh^ 



Dm. 



Tin-" AHovK srx ri:i) pkr^^onai. partrmlars ari-. TRriv to tmi- 

HHST Ol' MV KNO\VI,i;i)«".H AND inj.ll'.K 
n„fo:numt LUa/W<:^ QK)X) 

i 



(Addre-ss ^ I C) ^ OwC^w<3L/»>J^y>%XA) OXt 



a.b 

(Day) (Year) 

~ I HEREBY ClvRTIFV, That I atteiukMl deceased from 

..iQ^ ^.5^ 190M to i^<;*. 3^b 190 H 

that I last saw h .i^>VA alive on ^ '^ X5 up 'i 

and that death occurred, on the date stated above, at 
lI M. The CAISE ()F DlCATH was as follows: 



Dl'RATION )'ears Moui/is '^^ Pays Hours 

CONTRIBUTORY 



■<^- 






i- ' 



Pays 



Dl'RATION Years Jron/Z/s 

(SIGNED) 10. I9. OQTti.L.. 
iD^ifc a.b inoH (Address) ^ ^1 MlWukit^ 



Hours 
M.D. 



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



Former or ::>1 "K ^ P^ -I- ( ^ J "«^ '""' ^* 

Usual Residence ^ vCywVvV^Cryv V^/OJU piar c of Deatli ? 

When was disease contracted, ik-^- \ j^ \ \ 

If not at place of death ? <kJ ^Ji<y^KSJr>^ VtXV 



Days 



ri.ACK OF lURIAIv OR RKMoVAI. 

-0 



h 



DATi; o! niKiAL or RKMOVAI, 

£)f^ VX T90H 



Address % I Q >CL/tA-<X/>>Xje^rviU)....ut.. 



INDHRTAKHK 



^ B. Rvery item of InformHtion ■houlil be cnrelr'ully supplied. AGB hHouIcI be stated liXACTLY. 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 jlivcn in every instance. 




m 



\ « 



WRITE PLAINLY WITH UNFADING INK — 



Hoanl of IU-..lth-K No. i^ 3^«:»2.^ H«^»' ^'" 






1U0\ 



THIS IS A PERMANENT RECORD 

RCFCR TO BACK OP CgRTIFICATE FOR INSTRUCTIONS 






d^^^^AA^ 




Deputy Health Officer 



DEPARTMENT ot PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County of 



Certificate of 2)eatb 

( Ta. S. StanDarD ) 



,CX^\. ^-x 



City 



olJ 



(No. 



St 



Dist.: bet. 



and ~~ 



-w r»«^ IICSIIAI nrSIDCNCE GIVE FACTS CALLED rOR UNDER "SPECIAL INFORMATION" N 
( " r/;;".T-"oCc'u%*.*V,"rH«p"*t .""ns'tu" « ",.. ,T. name ,NSTE.0 or .T.»T .«■> NU-.t-,. ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 




i 



■^.\^/V^i'\^N-^.Cs.^Ai. 



"" *niJ 



OOJl 




^vc 



,-L 



DATK or- lUKTM 



M.P. 



/■bb'l 



(Month) 



1 ) Vti > y 



(I)av) 



.M,»ilfi> 



(Year) 



Da 1 . 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII , A 

a|?-tn.\t;. U.ct. 

(Month) 



(Day) 



(Year) 



I Hf^RHRV C1':RTIFV, That I attended deccasetl from 

:r.rrrrrr.i90 — — 

— — - — 190 



190 



to 



that I last saw h 



ahve on 



SIN(".1,K. MARKIKD. 
\VIl)()\VKI> OK I)IV«)KCKn 
iWritf in social <Usijf nation) 




V(dLcrv\>-C<:L 



HIKTMPI.AOK 
(State or (.'o\inlrv' 



NAM1-: Ol 
FATHKR 



BIRTH ri.ACH 
OK IATHHK 
(State or Conntry) 



MAIDKN NAMK 
OJ" MOTMKR 



lURTinM.ACH 
Ol- MOTIIKR 
(Slatf or Country* 



? 



VN^ 







. jAXo \X><J^^Jf^ ^ 



oCCri'ATION ^ J 3 I 

()bc)AjJUkx<uy^^-€A 

Rrsiiied ill Sav f'l iiii.i^rii [\ )'r,n s ' Months 



\ 



l)ii\> 



IMl-" AHOVK ST\'n:i) I'KRSONAl, PA K 1" U T I.A RS A K l-. TRIK TO THH 
llKST OI" MY KNOWI.KDC.K AND lU.I.lI'.K 



(Inform;int 



. i. ^^ 



^<r\.^^^cr>x/ 



( V.MifSs 



./Ouysj 




vl<X.L 



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



DURATION Yeats 

CONTRIHl'TORY 



Months 



Days 



Hours 



DURATION Years 

(SIGNED) "^ ^. ^ 



jrofit/is 



Days 



,0 



yl£t "^lo iqo H (Address) O/Qyvv 




Hours 
M.D. 



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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



ri.ACK Ol- lURIAI. OR RKMOVAI. 
INDICKTAKKK O . O. O 

i.ii.ss a 




(Atl< 



/CX./V\^ 




VCW.L 



IS B F.very item o? information .hould be cnrefully supplied. AGfi «houlcl he Htiitc.l F.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classilricd. The "Special Information'' for psr- 
sons dyin^ away from home should be ftivcn in every Instance. 



^^|r» 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



H,,:n.lMf lli:,lth-I- No. i .; t^-FTaK^ H& I' C o 






rju'i 



REFER TO BACK OF CE RTIFICATE FOR INSTRUCTIONS 

'2(\ i h\ 






duy^^^^Ui IvX/vvu Re put -^ ^ ith . Offic e r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cettiffcate of Beatb 



( "U. S. StanOarD ) 
PLACE OF DEATH: -County of CJxX^ /vc^i^cu^^ity of U<X^ JA.a^ 
fj^ S: a c: I (a , , SU 3^ Dist; bet- dJxa^..fc'>\X and 

'lNO» O^O Vw^V.VV.V. ..^.,,. ce-einrwrF ril/r FACTS CALLED FOR U|4dER "special INFORMATION 

( '^ rF"D7A^H"0CC^%;r;."rH0"s^pVT*At O^r'T^^T^^'t^O^N^O^/eTtI 5.AME INSTEAD O. STREET AND NUMBER. 



VC\^ c t 




FULL NAME 



Sl.X 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 





J iLcx. 




DATK <>!•■ r.lkl'H 



.\(*.K 







O Ci )f\n> <> 



.\l,<,illi> 



'.U 



na\s 



A/V\Xt, 



tl 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATII [C\ 

Uct IS 

(Month) <I>''>y) 



rgo 

(Year) 



mN(,l,lr. M.XRUIKI) 
\VII)()\Vi:i) ok DIVOKCKn 
(Write- ill stK-ial iltsi;Miation) 



iuK'rfn'i,.\oi<: 

(St;it< i>t Co\nUiy i 



NAM1-: «M 
FATHKK 



BIKIMI'I. AOK 
()|- I Aini':K 
(State or Coiiiiti V 



MAIDKN NAMK 
OI- MOTUKR 



HIK'rUPKAl'K 
Ol' MoTHHK 
(State or Conntryt 




iX.KT Jwyj yjXUi' 



v> \<x 



(KOrPAlMON 



cK^oJj" 




\^U) 



^\..^ V 



'1. 



h:rMili'il ni Situ /'idihiu-ii ■ /• ■ )'ili 



Months 



n,i\ 



\\W MIOVK ST\ri:i» I'KKSONAI, I'A K lUT l.AKS .\ K K TKIK TO TMH 
!tl-,ST ()!• MY kN<>\VI,i:i)(".K AND HKM1:K 



(Difiinnaiit 



3 (Dp O 



( \(l<lress 



TTlERICBY ClvRTlFV, That I alteii.U.l (Icri^ascd from 

___ — up to IQO "~~~ 

that I last saw h a'lve on ~ -~- ~ ^9° 

and that death occurred, on the (hite stated above, at 
M. The CAl'SIv Ol' JHvATIl was as follows: 




DT RATION Years 

CONTRIHUTORY 



Months 



Days 



Hours 



Dl'RATION 



^ 



Years 



Mouths 



Pays 



. . Hours 

(Signed) J.\jL/cIx\a/c.k ^ L<xa\.-)v....ai m.d. 

ilZ/cl. XI loo'i (Address) bOb U^d:UAi It 



Special information on'y ^o^ Hospitdls, institutions, frdnsicnts, 
or Recent Residents, and persons dying away from liome. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



'/ 






IM.ACK OJ" lUKIAI, OR RI«:MoV AI. 

O^vvMiLoXU) Co 

hi ■ ^ 

INDICRTAKHR vV-A^^VAXJL 0.>LV>n. 

(Ad.livss %\^i vJLo^. r\ 



DATK of Ht RIAL or RKMOVAI, 
\j CX 'X.\a 1 90 ' i 



vJCtXA^ 



IS n Bvery Item of Information .hould be cnro?ulIy «uppHed. ACIfi should be 8t«tcd KXACTLY. 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 uvry Instance. 



^^y 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HCfER TO BACK OF CERTIFICATE FOR IN3TRUCTIOW9 






I /Art 
/>r//^> Fi/e(/,SJ./zXjA>-V\) 9^b ^^^ "i 



j::.e mistered jVu. 



M.J:i. 



AfOf 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 

Certificate of S)eatb 



PLACE OF 



( "Cl. S. StanSarD ) 

DEATH: — County of 'OOyrv/ 0.,\xv^a.cui.c.i City ofCJxXA^ Jy\X)^A/C.v^c-o 



^No. 




{\\A\.\yY\X' 







iy~y\A.\\^vL^':...Su 



Dist.; bet. 



and 



/ IF DEATH OCCui^S AW*V TROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL ' " '"OR M ATIO N" '\ 
( Tr DEATH OcJIrREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 





''Y\JL'Cl' 



PERSONAL AND STATISTICAL PARTICULARS 



ih 



4- 



six 




^ 



COI.OR 



i»\ri-: <)i lUKTn 



AC.K 



? 



iM.mtlii 



7 

(Day) 



An . 

(Year) 



) Vij/ 



M.nitli! 



I hi V. 



SINC.M:. MAKKIl'.I) 
(Writf ill 'social iltvij.'nati<>ii) 



luk nn'i.Ac'i-: 

(Siatf <•! <,')uiiti v^ 




MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH [A 

VA IX 



I go ; 

(Year) 



(Month) (Day) 

I IIHRICHV C1':RTIFV, That I atteiukMl ileccased from 

LJjUUT ''•'■ 190 '1 to AiJ/d:^ X^ igot 

that I last saw h -• • alive 011 AJ-ot ii^o '; 

and that (loath occurred, on the <late stated above, at I3> ^.0 
■ M. The CArSI*: OF' DlvATII was as follows: 



NAM?", <H 
J-ATHl-.R 



^ 






.(rn^cui 




MIKTMIM.AlK 
(H I-AIIIKK 

(Stat«- 01 Country) 



MAIDKN NAMK 
nl MOTHKK 



lUK rill'I.ACl-: 
(»1- MoTHF.K 
(Slatr or (.'ouiittv 



ottri'ATlON _y 



'^V^X^UAAj, 



C^AXLo 



lo 





'^ 



r ^' 



v.\X 




X<1 



Rfsi(if(f iit Sdu f'l tuii isi'it 



),„ 



\fnntll' 



/></!. 



THi- \novK sT\ ri:n pkusonai. tak ticilak^ aki. iKri: to Tin- 

lilvST OJ- MY KN<>\\T,i;i)<".H AM) IW:!,!)!}" 



(I 



nrMiiiant JA,'CX/>v(-. LI C3,ok/>r>.^ 



i 



, . .jiL/-v^x\X.uts. 



\ 



DC RATION Years 

CONTRIHUTORV 



Months 



Days 



Hours 



1)1* RATION Years Mouths I^ays 

(SIGNED ) Li), t), L<rv-^Xcu..> v ^. 

\J ,"&> Xj. i(,o'. (Address) UJUvvvA.- 



I lours 
M.D. 



W.f^. 



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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



1'i,aj:k oi" mKiAi, ok kkmovai. 



\\ZY. Ol" lU KIAl, 



DATICoi Hi KiAi- or KKMOVAI, 



Vi^ V\ 



1 90 ' 






N. B.- 



-Kvery Item otf InfofmHtlon •hould be carefully Hupplleti. AGB should be stated EXACTLY. PHYSICIANS should 
state CADSL OP DEATH In plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be tliven in every instance. 



WRITE PLAINLY WITH UNFADING INK — 



H.,.,nlof HcaUh -FVn. u -^-g^^ IK«t »' Co 



r\ 



l)((h> Fi/rff,\}.LizLb{>V\J Xh ^^^ "* 



THIS IS A PERMANENT RECORD 

REFER TO BACK O P CERTIFICATE FOR INSTRUCTIONS 










Deputy Health Officer 



DEPARTMENT W PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "a. S. StanDarO ) 
PLACE OF DEATH: — County of C)<^^ .Wct^^xt^Cvaty of O^Xaa. a;v<v^ve^c... 



(fh>. 





:'\ 



-v^jl uu Ch^ 



kv.ta.i 



St.; — — Dist;bct. 



and 



V^^ V Vw V-V-fV, ' ,,e,,-, BFCiinFIMCE GIVE FACTS CALLCD FOR UNDER "SPECIAL I N FOR M ATIO N " \ 

( " rr"o»TH"oCc"u%*"co',"rHO.^"*t oVf^^T^u" « 3,;r^; NAME ,«ST»0 or .T«.T .-O HU-BC-,. J 



FULL NAME 




S I", \ 



u.vvi: or- lUKiMi 



AC.K 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 




'r>{y\ju (l\£)X^"vW. 



i 




.L.. 




^ 



1. 



KVAw^ 






O \ )V</»> » 



(Day) 



Mouths 



rXhi 

(Year) 







A; 1 . 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH .. . 



(Montli) 



(Day) 



(Year) 



I IIRRKBY CKRTIl-V, That I attemlcd deceased from 

to ....(D.<^;....3.3. 




siNCi.K. M.\RKn:i) 

\V:i)<>\VKD OK DIVOKCHD 
tWiitf ill social doij^natioii) 



HIKTMPI.AOK 

'State or Country'' 



NAMl-: 0|- 
FATHlvR 



lURTlUM.AOK 
OF FAI'UKR 

(State or Country) 



maii)i:n namh 

<)}• MOTHKR 



lURTHl'UACl-: 
<)|- MOTUHR 
(State or Country) 



OCCl'I'ATION J} 












.\/.,),f/l^ 4 ^ /''Mv 



rnj- M»ovK srAri'.i) i'Krsonai. par ncii.AKs ari-: rRtH to tiik 

li^ST OI- MY KNOW l,i:n<".K AND HllIJl-.F 



(Itiformnnt 



^.^:% 



"^O^ijUU^ 



I Address 




L<Xl! 



IS iQoH to ....^..<:<^....:^'^ up'^ 

that I last saw h ■'-.^'v aHve on v ^ V. 190. 

and that death occurred, on the <hite stated above, at I \ 
II. M. The CATS!': OF Dl'.ATIl was as follows: 



DURATION ^ ]'t'ars Months ^ Pays 

CONTRIBUTORY '^..JUy\XJ\.Aslj. V; 



Hours 



DURATION Years Months Days Hours 

(Signed) .OXcl^aJLlvi OXaXLwv<x. -, ■ . M . D . 

b.ct. :Xfr ,ooH (Address) ^Ol^Uvkq W 



Special information on'y 'or Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



L(r\A.>CA^rJ(>vou 



Former or 
Usual Residence 

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



Days 



Pl.ACK OF HI RIAI, OK KKMoVAI. 




D.yij'.of in lUAi. or kf:moyau 
V ^ V ^ 19 0H 

(Address ll^sH . <ijXAn.<^CV<ij^^....D.t 



N. B.- 




-Every Item of mformation .houlU be cnrefuliy supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The Special Information for psr- 
sons dyinft away from home should be ftiven in every instance. 



-IP*' 



■# 



I 



1 



i.^ 






WRITE PLAINLY WITH UNFADING INK 

|U)ar(l of McnUh-K No. i^:^^^H&I^Co 



— THIS IS A PERMANENT RECORD 



J)(( 



to FiIe(/X:./zhA>^i^ "Svb 1'^^'^ 



RCrER TO BACK OP CCWTinCATC FOR INSTRUCTIONS 

262 1 I 



JteQiiitered */Vo, 



X^O-U-A^ 




Deputy Health Officer 



DEPARTMENT (ff PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "d. S. Stan^arD ) 



PLACE OF DEATH: — County of 0<x/>x; Axx.^n.coci 



of 6. 



Axx.-/vc^.e.L. City of Oxx/^ J /vxx/\-bOua c.c 



(No. blH UJ/O.' 




Ic 



va 



SU A Dist.;bct. 







AxLand J UL.<X\, >vii.. ) 



/ ir Ot*TH OCCURS «V'*^ "0«« USUAL RfS'PJNCE CJVC J*CT5 C*^^^ iMSTEAO Or iTRCCT *n5 NUMBER. / 

\ ir DEATH OCCUt 



t 



FULL NAME 




■J 




tx^x. 



SKX ,^ 
DATK <)! IMKTII 



PERSONAL AND STATISTICAL PARTICULARS 

COI,<lR 



-#■ 



,^\xkXx 




Jl \.v 



i. 




Month) 



Ar,K 



TH ,v,„. 



11 



'iniy) 



.V,. ;////.. 



(Vt-ar) 



/l<»r. 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH f\ 

U^t 11, 

(Month) (l^«y^ 



(Year) 



SINC.I.K. MAKKIKI) 
WIDOWICI) OK DIVOKCKI) 
(Writf in 'iotial di sivnation) 




I HI^REBY C1\RTIFV, That I altciukMl (k'( cased from 

,..l9.,.ct a 190H. to ....U^ x% 190 % 

tliat I last saw h •»^";- alive on ^ "^ -^^ 



Ic/D 



lUK rm'KAOi-: 

(Statf or (.■ountry) 



NAM1-: Ol- 
FATHICK 



HiK riiri.AiK 
oi" japhkk 

(State or (."oiintry) 



MAIDHN NAMH 
()!•• MOTHKK 



niK'rnri.Ari-: 

Ol- MOTHI'.K 
(State or Country) 



i 



^\ 



!J^v 




/CkAX*-iOC^ 



'J 



Xc^ 





OCCrPATION 






I -L>v^>^'>^'0^''>^u. 



'\'r.-ii!fil III Stui I'idihrin DO )',/;< 



Mnillln 



/)</!> 



Tin- \HOVK STMKI) I'KKSONAl, 1' A K K iri' I.AKS AK i: IK T I". T' > III)- 

iii:sT OI" Mv KNowM-.DCK AND m:iji;K 



(Informant 



U.Mr.- ioXH UJ o^A.i\.v/\AX:^A^<m. :U' 




ami that death occtirred, on the date stated above, at I 30 
.... M. The CAl'Sr: OF DlCATIl was as follows: 



'\ 



DT RATION 



Years Months "I Days Hours 
CONT R I IR'TC ) R Y LxX/vycL>-^Ow^ X^:V\-<>-.v^ 



DURATION 



Years 



Mouths I Pays Hours 

( SIGNED )J^AAAXUA^5iA^ La.. cJJ A/^<i..^.A' M.D. 

iD/ctr "^^ IQOH (Address) 1^^^ vl ft Va>JLU ^ 




SPECIAL Information only for HospiU'ls, institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



. Days 



I'LACK Ol'" lUKIAI. OK KHMoVAI. 



DATJ: <>} MiKlAl. or KKMOVAI, 






190 I 



(A.l.lrfss...l2^^ N-vi Oc^^-AX/\-A^^ 



;ttl'^v 



■U 



^ B._P;very item of informHtlon .houlcl be carefully supplied. AGE •houid b««tHted EXACTLY PHYSICIANS should 
Itate CAUSE OF DEATH In plnin term., that it m»y be properly cl-«i1.led. The "Special InWmat.on" ?or pT- 
Rons dyin^ away from home Hhould be ^iven in myr}/ inntance. 



\f 




WRITE PLAIN 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoard of llt-iiUli - »' No 



-S-^^^^IUS:!' (' 



REFER TO BACK OF CERTIPICAVE FOR INSTRUCTIONS 



I 



r\ 



i\ 



/)((/(' /v7^v/,J^/cLtrl)Jl\^ "^^ 



rjo'i 



BeoLstcred jVo, 



PRP!7 




u^v^ 




-"rt^ith Officer 



vni Dcp- 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( "d. S. Stan^ar^ ) 






J? 



'N 



PLACE OF DEATH: — County ofO^yv^ ^<^>^-^^^ City of CJcc^ 



o. S U J OAAJi.^^ 






and •-' AX\^tX 



(IF DEATH 
IF DE« 



OCCURS AWAY 
ATM OCCURRED 



FROM USUAL RESIDENCE G.VE FACTS CALLED FOR UNDER "SPECIAL ' ^ "^O « *«*3'0 "^ ' ) 
,N A HOSPITAL OR TnST.TUT.ON G.VE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



s};\ 



nioL 



COI.OR 







\\^X^. 



DAIi; or IMRTM 



\ « . K 



/liMont)i> 



I' 



)'rii I 



H 



11 

(l)iiy) 



.1/. '»////.' 



\'<-;ii ) 



/)(/! 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DEATH 



(Month) 



(Day) 



(Year) 



I IIHRI';HV Cl'iKTIFV, Tliat I attendcMl (lecease<l from 

L .at ^"^ up ' to .U./^t:: X\^... 

0^. '^•^ 



<>IN<.1.1-: MARKIl-.D 
i\\'iit( ill M)oi:il il«si>.'n:ttion) 



lUKTmM.An-: 

' St:itr or Counti V ' 



NAMl" ni 
FATHl-.R 

HIRTIllM.ACK A 

(Statr or Coutilry) I \ t 



,cu^^ vcv >-vcc^. <1 1. 





.^ 



tz. 





hicx.^- 



HIRIinM.ACK z^,^ 

()i- MOTHER (n J 

(Stat«: or (.■o\intiv> -\f ^1' 
OCCri'ATION 



maiih;n namk 

«>]■ MOTHH 



Rfsiilrd ill Siiii /'i mil i^i'-' 



■,<;;> S M'>iitli- 1 ""i /'"i-^ 



THl- MIOVE STATED J'KRSONAl, PAR IIOT I.ARS AK I. TR T E Ti) THE 
HEST Ol" MV KNOWl.lUX'.E AND lU-.IJl-.l- 



(Dif<Mn.ant ^Jl-CrV^rX Jbj2^^^ IW^ 



( \(l»lrt'ss 



U)0 ' 

that I last saw h .^^' alive on W'^ilA- ^-o 190 H 

an. I that death occurred, on the date stated ahovc. at 
M The CAl'SI^ OV DIvATII was as follows: 






DURATION >Vrt'-^ ^ Months Days Hours 

CONTRIBUTORY 



Years 



Months 



Days 



Hours 



DURATION 

( SIGNED )....UJUL/V- 3. JV^'~ VV.O >v. M.D. 

i[Wt ^b TQOH (Address)^ IT M >Vavlut O.l 



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



Former or 
Usual Residence 

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



How long at 
Place of Deatti ? 



Days 



I'l \CE ()!• lU RIAL OR Kl^MoVAI. 



DATi: of HCKIAI- or REMOVAL 






190 



IN. B." 



■""—""^ ^ . »r-sT „u„..i,l hi. atflted EXACTLY. PHYSICIANS should 

-Bvery Item oV ln9or„.«tion .hould he c«rc?ully M.ppl.ccl J'^^fj^Z^^^^^^^^^^^^ Information^ for p.r- 

state CAUSE OF DEATH In plain terms, that .t mny he properly dassmca. 

sons dylnft away from home «houl»l he ftiven in every instance. 



■^ ,^ 



i 



[ .. 



n 



.-7 




:1% 



I!. 1.1 1 '1 



WRITE PLAIN 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,f ii,i.,!th I- No !^ t-ti^j:.^r.&i'C() 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lA 



A 



lUih> Fi/rfJ, \iJKXjb\y^ SLb ^'^^^ 






202^ 



(X^O^AA^ 



Deputy HecSth Officer 



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



Certificate of 2)eatb 



( U. S. StanDar^ ) 



Q7^ J er^ 

PLACE OF DEATH: — County oiO^X.^ i KxxjyxAiAAc^CiXY of CJxX/>^ J.^vcv. vc^^^ac 



No. V. t 




% 



/ ,F Dr*TH occurM*wav FROM USUAL R E S I D E N C E G. V E facts CALLE 

C .F DEATH OCC^RED IN A HOSP.TAL OR INSTITUTION GIVE ITS NAME I 



and 



- ) 



««iav«AV rpoM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION \ 
RS(\AWAV FROM U&UMU M t » I L/ 1 1-. w t i,. , „ ^ -nsTEAD OF STREET AND NUMBER. / 



FULL NAME 





y\JL, \\ \ L<X/CLcL^. . V. 



si;\ 



Q!? 



PERSONAL AND STATISTICAL PARTICULARS ^ 

COI.OK 



^Xnrw^oJLx, 



i)\i 1-. or HI Km 



\ ' . )-: 



UJ JrAAAiL 






I M.>ntli> 



4H 



) .ill 



(Day) 



M. nit In 



(Yfar) 



A;i 



sIN(.I,l-:. M.\RKn:i>. 
WIDOWKI) OK nivoKrKi) 

Write in '^(K-itil dt ».i>.'ii;aii>ii) 




XcLtrVvT 



lUR riUM.AOK 

(Statf or CoviMti y 



lA'nii'.K 



lUKTIiri, ATK 
()|- 1 AIMI-.K 
(Stat< i)r ^."ountT y 



maii)i:n NAM1-: 
oi- m()Tiii:k 



HiK rm'i.Aci-: 

OJ- MOTHHK 

(Slate or Country' 




rtr 



M . 




'>ViL 



? 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol" i)i:ath 

IDav) 



(Month) 



lf)0 I 
(Year) 



iHivKI:HV CICRTII'V, That I altcn.lcl deicased from 

...iLlct 2. 190 '1 to i):tLt XS. 

that I last saw li •■ ahve oti ^ ^ '^^ 



up ' ^ 



190 



and that dc-ath occurred, on the date stated above, at O lo 
..LL M. The CAl'SIv OI' DIvATII was as follows: 



Dl' RAT ION y^'df'S 

CONTRir.l'TORY 



Month's ^0 Days //ours 



1)1 RAT ION 



)\ars 



Mouths 



(Signed) vL' • Cs. L-c-^a^vxx-a \. 

ll'cl :s" i()o'i (A.ldress) IXt 



Pays 



»V^-\ L^'-VV..' 



Hours 
M.D. 



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



1^ y.in> 



k'rsidrif in Sittr I'l iti'< 



yj.,iitti' 



Ihn. 



Till- \!»)VKST\11-I) I'KKSONAI. l-AKTUT I.AKS A K l. TK TK To TIIK 
lil'.ST Ol- \IY KNOWI.IIDCH AND HHMl-.F 



W 



nnfoiniatil 



\X>^^y^Jk -'^ ^ 



(A<l(lres.s 




Former or u , 

Usual Residence i 

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



I xTlaXryvva. 



How lonq at 
t Place of Death? 



1 ! 



Days 



ri.ACK C)I' BIRIAI. OR RKMo^■^^ 




DA Tj; o! Ml KIAI. or RICMOVAI, 

iD'^ Altt i9o"i 



rNI)i:RTAKHl 



X'>V\A^ 



IS. B. 



DF DEATH in plain .crms, that it may be properly clB«»i(te<l. The »i.e..a 



-Every item o? 

state CAUSE OF . . ^^^^^ 

«ons dyint away from home should be ftiven m every inHtance. 



■*-rT:i^^-^^^- 



<".>«■ ^. 



Li^:!^ 



T^ 



t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•'•"T!^ . 



Una! 



,1 ,,f uv.swh 1- vo. i> ''■•"-i^i;:^^^''^^'' ^^" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



[\ 



I) 



I)(ffr /u7(^(/M<X(Aj-V\^ Xb 



190% 



Re^ I stETecv */y o. 



2624 




^v^j Deputy Hecith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of Beatb 



{ "U. S. StanDarD ) 



PLACE OF DEATH: — County ofCVcLox. J.\xXy>vcA^C! City of O O^aj /vo^v-c*-^. c c 

t,; I Dist.; bet, U/CUX.a.^^.a; 



Mo I'iSH vix<XH.u St; l Dist; bet LylctxX.V'va; and JCV^Qin 

/^ - ot*TH occV«s *w.y TROM USUAL RESIDENCE o.vc tacts callitd ^o" "N°„ :^%"^;*;;^'^^°;:J*J'„°'^" ) ^ 

C IF DEATH oLuRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



,t:>A.Oj 



HUc^'v^ 



PERSONAL AND STATISTICAL PARTICULARS 

C'(>l.( >k \ 

n \i 1, » If i;iK I'll 

Motith' (Day) 



si.;x ,5J ^ 



\< .1'. 



sIN».l,K. MAKKIi: I> 

Wllx )\VI-:i) OK 1>I\'< il""' 1 I) 

<\\rit«-iii ^<»i,il ill si;Mi;il i"ii ) 



lUK riii'i, MM-: 

I Statf or (.omilr y ' 



VAMl <>1' 

i"A Til i: K 



lUK'nii'LArH 

<H' lAIHl'.K 
'Statt III rmniti V 



MA1I)1:N' NAM! 
ol MOTIM.R 



lUKIIMM. \C1-: 
(•!• Mo'im.K 

(Sta'i- 1)1 «."i)mit I \ ' 



(HHTJ'AIION jJ , 



V Mmlh^ 



i'v'tai) 



/',/! 



^ 1 , 



/ 




l\'f hliuf ill S<nf I'l It 



M.oitln 



I hi \. 



Tin- M«)VKSI\Ti:i) I'KKsnVAl, r\KTHl I.VK-^ \Ki: TKIl-: To HI)-: 
in:sT Ol MV KNOWM'.IX.H AM) HI'.l.ll.l' 



(Iiifo! maiit 



(K. 






O OV-eyY>^A.^^ 



iJLOA^ 



^t 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- Dl'.A 111 



iiU 



') " 



\ foo'i 

l)av> (Vt'.'ir) 



(Motilh^ 

1 ni';Rl':nV CliUTII-V, That I atteiidcl .ktHasca from 
.^JL^t. Kp''. to U^t; .Xl... up 1 

that I lust saw h alivt- on v^.CA. ... up 

and that death occurred, on the (hite stated al.ove, at 
M. The CAISI'! Oh' i)iv\ Til was as follows: 

OnruivcsJc 



r, 



■'^W<L.'L-\4-.iA. C-v. ^- 



■\ 



Dlk.X'I'ION )'i'ars Mouths. Days I lout 

CONTRini'TOKV 



Yiius 



Mi'uths 



1)1' RATION 

(SIGNED) H'^X.'^^aJU Ll JUl^ > . 

I0,ct 



Dax 



M.D. 



VS M>o'l (.Xd.lress) 751 OxOXtK' "Vt 



SPECIAL INFORMATION only '"^ Hospitdls, Insliditions, Transients, 
or Recent Residents, dnd persons dying .mdy from liome. 



former or 
Usual Residence 

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



How long at 
Place of fleatfi ? 



Days 



IM.ACH <>I- lUli^lAI. OK KI;MoV.\L 



i' 







DATi; ')! Mf'KiAi, or KKMOV.M, 
UcTJ XL TQO'i 



INDl-KTAKKR UU . J . CJ AA>Vv 



V 



. ,. ,. , ./>!- ahoiilci he Htiiteil FiXACTLY. PHY.SICIANS Hhoultl 

N. „._Kvery Item of informntion «houIcl h. carefully -PP"-'- J'\:''J^;'^lt^^^^^^^^^^ •'Special lnfor.n„f.on" for p-r- 

state CAUSE OF DEATH in plnin terms, that it m»> he properly Ua«8incu. i ne cj 
«on« clyinft nway from home should he given in every inBtance. 



I 



T=" 



mmM 



1 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Mn:n<l of II.:, 1th- l- No 1^ t-fJ-^^U^f^V ( 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTION3 



f\ . 



Dafr Fi/rf/,\J^X^iyV^J 'db l'^0\ 



SI f£ I tV I r rv tv */}i u. 



J^625 



.ftccUt '.:LL'vKj Dv^r-;' ■ H.!'..-^Jth OfflRsr 

DEPARTMENT oIf PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( tl. S. StanC>arC» ) 
PLACE OF DEATH: — County ofClcm-u JAx>^Ayc.ui<c< City of O^yvv J Ay(X/>vC.vA <^ c 



No. I'XlH J.OCrL', 
( 



p p ft (^ 

^.OCrtl St.; *l Dlst.; bet. U:^-Au and LUaa 

r rr*TM OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U N D E^ "SPECIAL INFORMATION" \ 
,F DEATH OCCURRED InThOSPITAL OR INSTITUTION G.VC ITS NAME INSTEAD 4 STREET AND NUMBER. J 



^1 I i'l ^^^J 

FULL NAME ULlo^^x.I'-cX vv MfLCa;-.. 



PERSONAL AND STATISTICAL PARTICULARS 



'^"■-'^ %) 



ri 



COI.OR -^ 



I» \l I 1 il I '.IK I'll 



ilotith 



\' .)• 



O i )•,•<;/> 



11 .! V 






M, ml Its L 



/ ^ 



(Year) 



/)<; 1 v 



M\«.I.I". MAKKIl-:!). 
WIlXtWKI) OK UIVoKCi:!) 

' \\i itf in s(.<i;il .'< *i;Miali')iO 



^ 



LI <A.t'^\ 



lUK rin'i,\«'i-: 

(Slat< or Counti \ 



NAMI-: <>!• 
!• A r 1 1 1-. R 



HIKTHPI.ArK 
Of l-AIIIKK 
(State or Country^ 



maii)i;n namh 

ol' MoTin'.K 



UIR rulM.ACK 

Ol- Morm'.K 

(State or i'ouiitry"! 



^ 



JU^ 



<CVvtX/VU'Y\' 



I 



r1 



XKy"N>v<X. v\ '_\ 



? 



h 



I 






A' 



'r^idr'l III ^ii" /'i aih nrn Ob )'>'iii < 



M.oiDi' 



/),! 



Tin- \HOVKSTAT»-.I) I'KKSONAl, I'AKTUT I.AKS AKK TK IK To TIIH 
H1-:ST Ol- MY KNO\VI,i:i)«".H AM) nKMh^ 



(IiifoMnaiit 



a ^^^ 



VM.lrcss. Ib^l 6XX^' 




.\yJi 



IViEDICAL CERTIFICATE OF DEATH 



DATE Ol" DKATII ([ 



(Month) 



Vi 

(Dav) 



(Yt-ar* 



I in{Rr':HV Ci:RTn'V, That I attnKU.I .kHvascd from 
\9ot 1 190 H to ^^'Ct '^^ u^H 



1 190 H to ^'^^ -^ TCP 

that I last saw h =- aliv mi \^ /C, V • ' up 

i\w\ that death oorurre.l, on tin- .latr statt-d ahovo, at 
M. The CM SI-: Ol" Di; A 111 \v.i^ as follows: 



t 



nr RATION ^ y'l-ars 
CONTRIP.ITORV 



Mofilfis 



Days 



I /our 



DIRATION 
(SIGNED ) 



)'cars 



C.C.Qlvl 



.'l/t>fl//lS 



/hi). 



Hours 



M.D. 



Lj.ct XS U)0^ (A.hlre..) '-IM l:,a.-v..^jWo..Uv-. 



SPECIAL INFORMATION only far 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 death? 



How long at 
Place of Death ? 



Days 



1'1,ACK Ol" lU'RIAI. cm RKMOVAI, 



i)ATi;o!" HiKiAi, oi ki:m«ivai. 






190 



INDHRTAKKR 



(AcUh^ess 



0(YWl 



'^ ' ,. , .^p „u„„wi he stnted EXACTLY. PHYSICIANS should 

N. B.— F.very item oi informBtion •hould be CBreV'uMy -PPl-c • ^^^^J^^^^t^^^^^^^^^^^ Information'' for pT- 

state CAUSE OF DEATH in plain terms, that .t may he properly class.tiea. 
sons dyinft away from home should be given in every instance. 



r 




\ 



m- 



hi 




WRITE PLAINLY WITH UNFADING INK 



|-,K,..l ..f Hri.Hli I- No i^1^'^^^i>nl^VCn 



THIS IS A PERMANENT RECORD 



WCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A 



(\ 



/)((/(' FiI('(/,VcKM^Vv 9.b 



j(m^ 



Regi^tcrcti j\u. 






rK,.^!\AJ<J^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( H. S. Stan^ar^ ) 



) 



PLACE OF DEATH; — County of JIa^^ 



City of CJJL 





/CXA.I 



No. 



h.^pJ-vdjO-^rC^I W (HLi\^l<X.i.. St.; — — .. ..Dist; bet. — and — 

r IF DtATH OCCUBS »WAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER SPECIAL INFORMATION" 
( ,F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



-) 



FULL NAME 



\\j£Us. 





^C. . 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR \ N 




SKX 

\\f\\ 

i>\i"i: <n- i!iK rn "^ 



Nl'iiuh 



AT. K 



H^ 



) III I • 



\ 



1'.! 



may 



M.'iilli' 



\^ 



(Vearl 



/)./ lA 



■-IVt.I,!-: MAKKIKP 

\vii)i)\\i-:i) <»K ni\t )K(i: u 

i\\iit< ill MK'ial il«».i).Miali<'M) 



lUKTIfri.Ai'K 

iStat«- 111 Ctiuntry 




NAMI-; «)l 
FATHKR 



lUKTJiri.ACK 
(>l- lATUKK 
(State or Country) 



MAIDKN NAMi: 

()j Morm-.K 



lUK'rinM.ArH 
()i- M(irm:K 

(Statf or *.'oiuitry) 




X.AH^.XJOci 



■\^A\ 




{ 



I ULU> t > ^. 







Al, >^ > V 



OCCrPATION Jk' 5 




XXa-v 



a. 



h>M\!rtf ill San rta». n.:> " V"' ' " " ■'^f""'^" 



n.i 



Tin- \U()VKST\-n-l) I'KKSONAI. rAKTUTUAKS AKl! TKIK T< > THK 
HKST OI* MV KNnUlJ'.IX.K AND |{1:M1:i- 



'I; 



(Address 






i 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH |A 

(Month) 'I>ay' 

I Ill-RKHV CI'RTIFV, That I alteii<UMl deoiasca from 

— to 



(Year) 



190 



that I last saw h -- — alive on 

and that death occurred, on the dale stated above, at 
M. The CATSR OF I)I':ATII was as follows 



I(/3 



^ 



V 



I) r RAT ION Years 
CONTRIIJUTORV 



Months 



Pays 



Hours 



DC RAT ION 
(SIGNED ) 




(,0 



Years Mouths Days 

(A<Mress) OjL<X.tLUAlcv_ 



//ours 
M.D. 



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



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



.. Days 



IM.ACH 01 lURIAI. OR RKMOVAI, 




.Wjla>^ 



_3sOw 



v\/-vw 



DATK of niKiAi. or RKMOVAI, 
iD/CLt .'^"l 190 . 



rNI)HRTAKl-:R 

(Ad 






^ .. ,. . AHF Rhoultl be stated liXACTLY. PHYSICIANS should 

:,. B._Every Item of in9.>rm«t1on .houlcl b. cnrefully «uppl.ed J'^^J^'''^;^^^^^^ The •'Special Information" for p-r- 

state CAUSE OF DHATH in plain terms, that it may be properly dassitica. v» 

sons dyinft away from home should be fciven in every mstance. 



^•^ 



>rtNij 



I 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lioaK 



w 



l.,f H.alth l-No !^ 'S'^^t^HM'Cu 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A 



Pi 



Ihdc FiJe^l^V^zL^Ay^ '^^ 



IVO^ 










Deputy Health OfTtcer 



DEPARTMENT 6F PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate oi IDeatb 

( XI. S. Stan&atCi ) 

ofC CX>X' '-'' VCtA\.C^vl.<:(.City of 0CX/"»V OyVO^YVCv^Ct 






W 



3' 



Ne. 



it,. 





CX-\.cvO vt O^NL 



.v\^t<xl 



St.; 



Dist»; bet. 



and 



-) 



FU LL NAM E V.L^\-:^a.\.\., vlc\.v.CLu.ix.q.-^.'' 



PERSONAL AND STATISTICAL PARTICULARS 

sr.x(0 rj j COLOR ^ . 

i)\ri: i)F' r.iKTu 



cuLt / 



iMoiith) 



.\<.H 



*>.LC V 



)>./i 



'l);iv) 



M.'n/h^ 



(Yt-ar) 



/>.? 



sr\(,i,K, M\KKn:i) 

\VIIM>\VK1) <»K 1)!\< »Kri:i) 
(Wtitf in -xwial di ■.ii.'iiati'iii 1 



lUKTMI'LAiM-: 

(Stat<' nr <'i)iiiili V 



NAM I <)!• 
I-ATII l.K 



HIKTm'l.ArH 
OI- lAIIIKK 
(Slatf or r«)\niti V 



MAII)1:N NAM1-; /•!> 

(II M(>Tm:K 



lUK rni'i.Aci". 

nl- MOTHI'.K 

(stale or Con lit I vt 



OCCUPATION 0\f 




.OJyJ\Jji^v^ 



ovov > ^ 



^Jjj^ 



.^ c- '\ 







Rr^iilrd in S.ni /'i irih/^m ' ) r,! i ^ 



I. 
}r..iilhs \ /><n 



Tin- \novKST\ri:i) i-kksonai. taktu ii.aks aki: rKiK to thh 

iIksT OJ- MV knout. i:i)f.H AND lU.Ml-.l- 
( Iiifoi in:tiit J 



> Mif^s 






bS^^ 



i 



v.c:i;' 

(Month) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol' DHATH 

1 I t I 

(Day) 
I HHKICHV C1:RTIFV. That I attemlcd lU-ocased from 
up \ tn U^t X5 1()0'\ 

alive on v. CV '> up 

and that death occurred, <»m the date stated a1)ove, at ^ -^0 
M. The CAISIC Ol' DIvATII was as follows: 

..Live 



'vl 



that I last saw h 



DlKAriON years Mouths Pays IIou 

CONT U 1 lU'TOR V Lcocva,.>^:u-.V~.<-"Lc (fo.\.iAAjL\X^.U.xx: 



Hour^ 



DIRATION 



Years 



Months 



fhivs 



(SIGNED) LAJvMv^vA; 0. Vlrl Jx-^\X<. 



Hours 
M.D. 



■.;.ct V 



I()0 



( 



Address) at.HlWu y .JiL^H\.l.: 



Special information only lor Hospitals, Instilutions, [ransients, 
or Recent Residents, and persons dyinij away from fiome. 



\ Cl \ \t HoHlonqal 

C)/CUT^V)L04<U.<^ V.a»pidreol Death? 

If not at place of death ? 



Former or , 

Usual Residence UaX/Tv; . 

When was disease contracted, 




Days 



D\ii:«i! Ill KiAi. or ki-;movai. 



I'l.ACK Ol' HIKIAI. OR KI'.MoV.M, 

(Address 11. Ij /<X%V/ VllA ll/V-?w. 



190 



„ ,. , .|>,r „u„..i,| ha Htnteil KXACTLY. PHYSICIANS nhould 

N. B.— Hvery Item of lnfor.««f.on .hould be cnrefully -ppi.ed ^^ ;»;;j7;;„^;:i'''^Thc -Special InJormalion" for pT- 
state CAUSE OF DEATH in plain term., that it may be properly da.sitiea. 
«on« dyinft away from home should be ftiven in ovory instance. 



ir**^- 



T 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M,,Mt.l (.f Ih alth-!-- No. 1^ -r^^iy^l^ynSiVCn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Reol^lcr(^(v */v o. 



'S-»0^^(J I 



I)(f/^^ FiIrffX!€LM>^ '^vb IIMJ^ 

\.,.^&\^<^^j>\ju\>'^i Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of IDeatb 

( "a. S. StanDarD ) 

PLACE OF DEATH: — County ofOcL-^V >va.>^c .. City of 0.0.^ J Ka^^^A.xi.cc 
,Mo 1M^\ llJJU>'<i-'*> SU ^ Dist.; bet. V-^^^^^^^^ and MacU^ - 

(I ' \ ] ?! 

FULL NAME ViN .clA.^:1-LL /ci\^A.^cJLKX^.c.^^^^^^ 



) 



PERSONAL AND STATISTICAL PARTICULARS 



"^ 



COI.oK 



i> \ ij-: < IF' HI Km 






\i . I- 



I » ) V,/ ; ^ i 



n 



11 

'Day) 



1/ )i!/n 



s : 0, 



(V.:ir* 



l>d\- 



siN<.i.i' MARK n:i) 
\vM)»»u ):i) OK i)i\« tK* i:i) 

iWiit( ill viK-iiil il(>»iv' iKiti'iii ' 



.U .LcL^rV.0- 



UIK IMI'I, ACl'. 

< Slate <>i i"(iiintr\' 



NAM I" Ml 
FA rill.K 



niK riU'LAiK 

oi iArMi:K 

(Stiitc '>r C"i)iiiiti A ' 



m\ii>i:n' N a Mi- 
ni M()'riii-;K 



HlK'nil'I.ACK 

oj" m»)'imi;k 

(Slatt or CouiitiN I 






, ( > 



^^ 



o 



? 



M 



/CL'VKX^CCU U JlVVvX<X > VM . 



? 



I 



GL/yJOJ\^^^X>j ^ J X\/YyV<X > 



OCCITATION 



\\-^i,!r,! Ill S,ni /'laii.^x' s.A. ) /i" > 



\r.»itii- 



nav: 



Tni- Mjovi- sT\Ti:n pkksonai, i-ak ih'i i.aks aki: tkij- to tiik 

m;sT OI" MV KNO\\l,i:i)f.K and MI-.Ml.l' 



(Inf. 



X.Mu-ss Qx^CCttli LO^Jv 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DKATH iCX 



(Month) 



\ : : 

(Day) 



I go 

(Year) 



1 lII'KlvHV CIvkTII-V, That I attenik'd deceased from 

rixV^"^ • ■' 190^* to L cX. ^S' i<p ^ 

tliat I last saw h V alive on VL/ eA- • • up ■ 

and that death occurred, on the »late state«l above, at I .*^*^ 
J M. 'Plu' iWrSI-: Ol- IH'.ATII was as follows: 



DT RAT ION )\'ars Months <^^ Pays 



Hours 



Years 

( 



nr RATION 

( SIGNED ) \\J. UVJAyvA.^vvv-v 

/^ ^(o K^oH r Address) Hll O-J-O ■ J ^ 




Jfo>i///s 



Davs 



/fours 
M.D. 



SPECIAL INFORMATION only for Hospitdls, Institutions, Iransients, 
or Recent Residents, dnd persons dying awdy froni home. 



t::,v:,de»cc an ih U)xliL^it x^'Xm 



Days 



When was disease rontrarted, 
It not at place ol death ? 



JM,ACF: 01 lllKiAI, OK KFMoVAI, 






DXTF.i! Mi in\r. or KFIMOVAI, 

Ij/ct 11. 190 ^i 



(Address 



IN. B.- 



■"■^■~~ ^— — — - ^^ „u„„i,i he Htnted EXACTLY. PHYSICIANS should 

-livery item oi l„?orni«tion should be carefully supplied. ^^'^l "^^/^'^^^^^.^^^^ information" for pT- 

Btate CAUSE OF DEATH in plain term*, that it may be properly closH.f.ed. The »p 
«on« dyinft away from home should be ftiven in every instance. 




w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ui.;i1 



,1 nf IIlmIUi !•■ V" i' 



.•"^ZT* 






t. (I 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n 



n 



ludi' FiJi'(l,X)KXjs'{y^V\i ^b 



lOO^ 



Registcf'i^d J\ o. 






d^JiXAAJ^ 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

(Tertificate of S)eatb 

( U. S. Stan^a^^ ) 
PLACE OF DEATH:— County of CX^ru J VO. >vcvAC<; City ofOo-^^ J Xo^-vve^-^i-C c 
No I'^OM \n\avl-ULt' St.; " D;st.;bet. OAXC-kAi,-Llv>X and > '^^'^'> 

FULL NAME LOlXL^^rA; b. Oxa^UvU. 



^1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

i COI.OR 




llcv'v,. 



■^ 1/ 




Vv^'-' 



DATK or r.IK l"li 



\< . 1-. 



iM<mt1i> 



Ob !V,M« 



(Day) 



M.nillr 



.lb I .. 

(Year) 



Ar' 



sIN<-.I,K. MAKKIKI) 
\\II)<)\VKI> oK I)!\'()KrKI) 
W'litriii soiial <l(«.ii.'iiati<>iil 



HIKTIU'I.AOK 

I Slate or I'iniiiti V ' 



LC'^^ 



0. 




NAMl-: (M- 
FATHl-.R 



niRTHri.AOH 
<)|* J'AIMKR 

'State or I'oiiiiti \) 



MA11)1:N NAMK 
(»!• MOTUHR 



lUR'rm'i.Ari-: 

ol MorHKR 
(Slate or Country) 



'lO. 




>v 







? 



ytXA^JL 



? 



V '^ 



? 



OCCri'ATlON 0^ 



',',/ I II S,!ti /'; am isrn 



f'fMilrd in S,!t/ /'miK I 



)'r(i < 



Mnitli> 



Pa I > 



TiiH xnovHSTxri;!) i-hrsonai, i'arthti.aks ark trih to tiih 

HKST Ol- MV KNO\Vl,i:i)<>K AND Hl'.I.Ihl- 



VN\ 



medical certificate of death 
datp: of dkath S\ 

(Montli) (Day) lY^""^ 

I III':KI':HV CIIRTIF^^V, That I atten<lo«l (lecoasetl from 

l^O to 190 ~~~ 

tliat I last saw h -.:"" alive oti — — — - — 190 

and that (k-ath occurred, on the date stated above, at 
M. The CAlSlv ()!• DlvATH was as follows: 



Laa^W^ 



W\ VN- 



^V,iVV^ 






,^ " 



Olv^rWr, 



, ^^^-.CC..l... ":«-'• .. 



1)1' RAT ION Years 

CONTRIIU'TORY 



Months 



I 



Pars 



Hour 



DTRATION Years ^font/lS /hiys 

{ SIGNED )[jfUsy^JUv 0. v35. Uj .c)JLla.'^vcL 
iUtt r.'X. loo'i (Ad.lress) U^^>nXM U^j 



Hours 
M.D. 



u<;:. 



Special information on'y *or Hospitals, Institutibns, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



HoM long at 
Place of Death? 



... Days 



n.ACK Ol" niRi-V. or rhmovai. 



Lu.\-xAJL^'^ - '3^ 



DATlCof UrkiAl. or RKMoVAI, 

1.^ vx 



190 I 



(Address J9 11' blH l) .OL/^^ (y\jUL^.. 



^.*Oi. 



tmm 



"■■^ .. 1 xrr: oh»..IH he Atfltetl EXACTLY. PHYSICIANS should 

IN. B._Every Item of information nhould be CBrefuIIy fuppi.ed. ^^^ "^^Z;^^^^^^^^^ The "Special Information" for p.r- 

state CAUSE OF DEATH in plain terms, that .t may be properly class.t.ea. 

sons dyinft away from home should be ftiven in .very instance. 



Hint'" 



^ 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



]\,,:r:>] -f Mr:i;th 



!•■ S.) 1- ■*■ 



i> U8c]' C<, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



'C\ . 



Dff/r Filed, ^^oUiMA; 'c^t 



/■-V /-k M 









2fN*50 




\\.KJ^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Ccvtificate of 2)eatb 

( "U. S. StanDarC> ) 



PLACE OF DEATH: — County of U CC^-v 

CSiI\aA.olI St 



J A^CuruCAu^l^i City of ^-' <X^'^ J/vCCAV^v*! C 




Dist.; bet. — n-— —- — -and 



OS? 1 (^ 



FULL NAME 



■i.\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK \ > 



( KoXi 



DA I1-: < 'F i;iR in 



\i .!•: 






) Vi/. 



i 

1 



M.'ulh- 



I 



3. 






/),i\ 



"-INC 1,1-:. M\KKn:i) 

\\II)«)\V1-. I) OK 1)!\< iKil'I) 
'Wiitiin socKil .1< '^i'.Miatii III) 



lUK Tiiri.xrK 

' Statr or ('"tiuiti vi 



Q < 



n 




NAMl- <>1 
FATHl-.K 






niRTMIM.ACK 

01- iArm:K 

(Slatf or Coiintrv 



\\ mi)i:n n \mi: 

t)I- MoTIIllK 



lURrnri.Ariv 
oi- M<)'nn:K 

(state fir Country) 



OOCITATION 






Qp 



'It 



QjY\j -J \-(X->veui^cc 



A'rs/ifrif ill StiH /'i iiii, i>ri) 



)V,,w 



\!,'nfli' 



n,n. 



TMK \l{()VKST\Ti:n VKRS(>NAI,lV\KTUri.\KS AKl-.TKn- To TIIH 
linsT Ol- MY KN«>\VLi:i)C.K AND lU.MlJ- 



(Infonn.'iiit 



( \<Mr(,'>;s 







OLot 



MEDICAL CERTIFICATE OF DEATH 

(Month) 'I'-'V^ 



(Year) 



I in^RI'HV Cl'RTII'V, That I iittcn.k'tl «lc(vasL'(l from 

%^,.^ /hi up'^ t.i A:^t . X5 , .. i.,oH 

1 1) + 'I - ' 
that I last saw h '.. ■• • alive on v.- ci, .;, ^ ^.p 

and that death occnrred, on the <late stated aliove. at ^>. O^ 

M. The CArSI':_()l' Dl'IATIl was as follows: 



,u^Im/*vou^Loa; \1 i V^ 



■■'\ 



DIRATION 
CONTRIHUTORV 



)'rars J/of///is Pays 10 Ilouts 
.Ow-.'L::>XA-.vX*x-cLv^.Cx:.kA 




DURATION 
(SIGNED) 




)\'aLS 



' ! » 



Months 



Day 



M.D. 



(•■ 



A <1 d ress ) UhxLclM/>vA Hi ^^k. ,-.da.L 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away fro:ii fiome. 



[,!TJ!iH.nrP HI Ux^>^JL-nl^>v'x"'?iare'ro?ath? V^ 



Usual Residence ^ l^ 

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



Days 



I'UACK OI- lUKlAI. OK KI'MOVAI, 



DA riv <i! MfKiAi. or KKMOVAI, 



rNDKRTAKKK ^^ ^ d WW ^"'^ U 

(Address U'^.l (l^Uva>i.UCr^-V ^3l. 






T90 



■— "^ .. , AnF «w«..l.l he stated EXACTLY. PHYSICIANS should 
J l,.Wn.„,io™ .hou..l he cnrefuUy -^P'-;"- ^^.r:,",!,..*!^. The "Special ln!or.„a.lon" for p.r- 
OF DEATH in pfnin terms, that it mny i>e propeny 



IN. B. Kvery item of 

state CAUSE ^. . , :„„t«„ce 

sons dyinft away from home should be fe.vcn m every instance. 



T 



m 



WRITE PLAINLY WITH UNFADING INK 



H„;.v.l ..f H.:.Uh- !•- N-n. ^^■ I^^^^U^ScV Vo 






-1 r\ /^ II 

JifU 1 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CE RTIFICATE FOR INSTRUCTIONS 

2iVM I 



J.VV i^ ict( ( n^^v v»»/. 




lAA^ 



Deputy Health Officer 



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



Certiticate of 2)catb 

( XX, 5. StanDarD ) 



PLACE OF DEATH: — County of aay>^ JAxx^^x^uioCity of Ox:^ JAxc^^cv^-c 



No. ^C-'v^ l)/LK. V-^\v^. 



jt9A>c^Kv/tx^<i ^-f ^ ^ ' ^ 



xv^. SU I Dist;bet. and 

„^.- iieiiAl BTQinPNCE give: facts called for under "special INFORMATION' \ 
( '^ rF^*DrAT°H"0CCU%r;.NTH0"s"rAt o"r Tn S^t'.T^'t^o" V. V E ^S NAMEjNSTEAO OF STREET AND NUMBER. ) 



FULL NAME LO^VQ 



/O..'^ . L 






V 



PERSONAL AND STATISTICAL PARTICULARS 



J-^yywCLXl 

I)\ Tl- (»!• I!1K IH ^X^ 

J 'Oct 



ll.'- • ^ 



A'.l- 



^ft^ 



\ 



Davl 



M.,u'lr 



/I'M 

( Year I 



lKl\. 



W . •• . ■ M - .. i;il ilc-i;'ii:i1 ion I 



"-.tit' <ir T' '11 lit I \ 



NWIl- Ml 
J- ATM I. K 



I'.iK III j'l, \«'i-: 
oi- I Aiin:K 

IStalf or rcitnilt y 



M \ii»i;n NAM)-: 
<)1 MOTHKK 



HIK'lHri.ACK 
(»l- MoTMKK 
(Statf or Countryi 




(Year 



MEDICAL CERTIFICATE OF DEATH 
DATK Or I) HATH /A 

IJ.ct a? 

(MoTith) 'I>:'V) 

I Hf':Ki;iJV CI'-RTII-V, That I altcnikMl (leccased from 



I()0 H 



1(/J I 
that I last saw h ■ alive on V'Cl . . i.^o 

and that .Kath ..('Oiirrcd, on the <late stated ahove. at 1 



(X'uXv 



'"- Ua^\. 






^\J 



fN 



■^ 



V 



-r^ ^ 



h'r i,ir'. Ill Siin /'i inn >'■''" -J ^- 



);;i. 



M.iiilh^ 



n,i\ 



■nil.- XM,)VKST\Ti:i)PKKsnN-AI,l'AKTUTI,AKSAKi: TKIK in THH 
Hi:sT ol- MV KNo\VI,i:i)<".K AND HI-.LH-.I' 



(Infomiatit 




\.l.li«-,>. 







M . T he C\\i' S !*: ( ) 1 ■ 1> I •. ATJ I was as fol 1< >\vs : 







..Ux.,-.. 



I )r RAT ION T )V^;:^ Mon//}S ^ /^ays Iloiirs 



DTRATION Vi'iTrs ^ Months 



Days 



(SIGNED ) 



\J^. CJA/^'>■^J| K.<u^^ \. 



M.D. 



l\&>. X^ ,J'i (Address) Hil\jaAK.<ytX^M^^,..l 



SPECIAL INFORMATION only lor Hospitals. Institutions, Trdnsieflts, 
or Recent Residents, dnd persons dyinq away from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatli ? 



Days 



I'l.ACK OI" HIKIALOK KKMOVAI 





I)\T}-;o}' lit KlAi, or KKMOVAI. 

Oct r. 



TQO 



(Adclress S 5 ^1 OYIv<LA.^>V ^t 



ykx^o^CcA' 



N. B.- 



■ ' 77 T^ AGE should be stated F.XACTLY. PHYSICIANS should 

-F.very Item o? inform»t1on should be carefully f"PP -;^- properly classified. The ''Special Information" for pT- 

state CAUSE OF DEATH in plain terms, that it m»> be proper y 

son, dyint away from home should be liiven in every instance. 



T 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!». i.ii 



,1 of nr:tMh--»-"N<i !■; 



*-ffS^lt&l'Co 



RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihde /uleff, '\^jzt^(>-lK) 



■^b 



7(^ /^ 1 1 






7 \^. 



on^o 



n 






^jtKjif J*-^ 




Cr^^AA^ 




vu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)eatb 

( XX, S. StanDarD ) 



PLACE OF DEATH: — County 



No. 15 5 13- 



] 




11 



i 



I 



X ^. , v^^wr^-^v St.; ■^ Dist.;bet. 1 1 U\. and 

I wN \ V'N^'W >^ ,,eii»i orCinrNCr r.lVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' A 



laJLf 



V 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



mau 



aviv.! 



n A n. t •! r.iK I II 



^ 



t Miinth> 



\*.)' 



■{ 



) . .; 



10 



L 

<I):iv^ 



M 'iillr 



iVtar^ 



/'(n.v 



\vii)» »\\ i:n nk niv«)kij:i) 

(\Viit<-iii ^(K-iiil (li-.i}.'Tialii>n) 



( St;itf ui (.utiiili > ' 



N \V1 1 < M 
»• ATMl'.K 



lUKIin'I.Ai'K 
(H- lAIllKK 
(St.itf or C'Hiutrv 



MAIDHN NAMI-: (^ 
«il MOTHI". K S- 



luurnri.ACK 

(Sl.-iti- lit C'ouiiti \ ' 












AV';,,V</ /" *^''"' /•■/('>/./■>'■'» 



I>ii\." 



TMKAM..VHSTAT..inM^KsnNAI rXKTirrLAKSAKHTUrHTn 

ui;sr «)!• Mv KNt>\vi,i;i)«-.K and iu-.i.h.i- 



Till-: 



(In! 



( \(1<lrt'«s 






MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DKATH 

(Day) 



L'ct 

(Month) 



TQO V 

(Year) 



I ni:KI':nV CI-RTII'V, That I atteiulctl detcasoa from 

CjlloJ. \ip^ in ^^ ^^- Kp'i 

that I last saw h •• alive on U-CX .1 up 

aii.l that (loath occurred, on the dale statc<l above, at .*>• 6U 
^.L M. The CAI'SP: OV I)I':ATII was as follows: 



.'^ 



>">V^VA4vK VC 



DIRATION -^ Years Mouths Days Hours 
roNTRIIU'TORV LicvvU OljL\a\.\.v..ls 



DT RATION rv^ >Vr/;-:J JA;;/M.s 

(SIGNED) 0.\JLCI lI' vLlvNJj 



/^</v.s- 



X' ■^-''-' !<)" 



( Address) NnriJLL^i3uAl<:^>- 



I lours 

M.D. 






SPECIAL INFORMATION only lor Hospitals. Inslitutions, Transients, 
or Recent Residents, and persons dying away from lionie. 



Former or 
Usual Residence 

When v^as disease contracted, 
If not at place of death ? 



How long at 
Place of Death ? 



.. Days 



I'l \CK (H- lUKIAI, <>K KKMOVAI, 



X'JuJl^^ 



I)\Tl"o! lU KiAi, (.1 KKMOV.M, 



)^ x\ 



TQO 



iS-cS \x 






N. B.- 



■"— ,. , acTp „h„uui be stated EXACTLY. PHYSICIANS should 

of information .hould be cnreVuIIy HuppI.ed. A(.h s^ ,,as«h'led. The -Special Information" for pT- 
E OF DEATH In plain term., that it may be properly cla»«mea. 



-F.vcry Item 
:on*;.M„T.'«« '-m Won;; ;ho„.d bc.iv.n In .v.ry ln...nc.. 



1 



t I 



I « 



•'•^— .^l^^^i 



Tm^n^ 



WRITE PLAINLY WITH UNFADING INK 



i»< 



>ar.1 of Health- I-' Vo 15 I^^^^H&I^Co 






(H 







/^//^> Fi/rd,^AA>V\j Xb ii^^H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



- - - - \j% 







Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( 'd. S. StanOarD ) 

J? ^ 






QO 



PLACE OF DEATH: — County of OO/^v \ VCL^^cv^^ -Gty of O x:Xy>v 3 K<:^nrvc^^ c 



'^No. 



\jL^uLl^ jIjUJLVuoJ 



JIa^ > ■ 



St.; — - Dist.;bct. 



— and 



^ -„^^ iieilAI pr^lDENCE GIVE FACTS CALLED FOR UNOEH SPECIAL INFORM 
( " .Vor.rSc"-*."","":".'-"*.' o" f«"u"o""vt ,TS NAME ,NST..,> or ST.»T .«0 NU- 



SPECIAL INFORMATION" \ 
BER. / 



FULL NAME 






::\?^vaA..e>v 



si-:\ 



PERSONAL AND STATISTICAL PARTICULARS 

DATl-: OF- r.IKTII A 

llMnlltlO 




^-> 



\<.K 






(Davl 



Moulin 



ri:\ -^ 

(Year) 



Da 1 A 



SIN<.1,I" M\KKn-:i). 

\\\ l>»>\\i:it (»K I)IVnKCj:i) 

iWtitjiii »-<Hial (li •.ij.'Jialioii) 



(Stall or (.'oMiUiy 




(LoAKOLxL 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DlvATH 



(Day) 



I go 

(Year) 



(Month) 
1 ni':Ri:i5V (."I-RTII'V, That I atteiKkMl (IcTcastMl from 

that I last saw h alive on - —■-- 190 

and that death occurred, on the date stated above, at O 
^1 M. The CAI'SP: Ol' DICATli was as follows: 




NAMi-; 01 \ 

..ATHKR \. 

HIKIMIM.ACK \ 

Ol- lATHKK r\ *J 

(Stall or (."oiiiitry' 





n' 



hJi^^\^ 



^CML^Un\^ 



.t^x, t flcx^^'^ 



MAIDKN NAMi: 
01 MOTHHR 



mk'iin'KArK 

Ol- MOTHHK 
(Statf or Comitry) 





h'f>idfif ill Sail l-Kiih I '■■> iO ■ "" 




(y>X'^ 




- yfrnith' 



/),i\> 



•IHH MlovrSTXTl-Dl'KKSONAM-XKTIill.AKSARi: TKIH To TIN- 
Hi:ST OI' MV KNOWI.I'.IX'.K AND Ml. M J.I' 



(Iiifotmajit 




Addriss l?iC)'~l 



>0Ut^rvA-A>\/Orv 



I )r RAT ION JV«''^ 

CONTRIBUTORY 



Monihs 



Days 



I Ion PS 



DURATION Ytars A^''J''^'\ ^^"^'^ 

( SIGNED ) U^JnxJl^; J , v]j.. ll... ^ii^La 

Address) V^ 



Hours 
M.D. 



( 



' h i! 

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



-CX ^5" Ttp'l 



Former or 
Usual Residence 

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



jj, \. How long at 

SOI ^3^Xi'Y^-Lm^'K dtplare of Deatfi? 



Days 



I'l.ACK t)I" RIKIAI. OK RHMoVAl. 



DA'iiiof niKiAi, or ki:movau 






190 



"^ r ,1 AGE should be stated EXACTLY. PHYSICIANS should 



IN. B. Every Item of inJormat 

state CAUSE OF DEATH in p . 

«ons dyini away from home should be ftiven in every instance. 




<1 

r 



ilj«;;N 



WRITE PLAINLY WITH UNFADING INK — 



Date Fifp(l,.VjzXJ^^>~^^ ■^' I 



7P^H 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

" 2634 



Tfof^i^'iova fl. . A7> . 




CA cL.o\><.(.. 



Deputy Health Officer 



DEPARTMENT 6? PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( H. S. StanDarC^ ) 






PLACE OF DEATH: — County ofO,<Xo-v J AXV^vcv4^,(. City of 
No I'^'ll mII'U.-i. ■ St.; "^ Dist.;bet. I "^ ti 



\| and 

ORMA' 
STREET AND NUMBER. 



\^U 



\.' 



EH "special INFORMATION' \ 



FULL NAME 



/WcLiXA'. 



PERSONAL AND STATISTICAL PARTICULARS 
SHX Cjp jl I ^'^'•^>^ \ . . ^ 



DATK ol- HI k Til 



A(.K 



r.i. 



iMmithl 



) /(ii 



11 
(I):iv) 



.1/.. >////> 



(Year) 



.' \ /'*' 1 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- I)1:aTH 



y^ 



a'- 



(Month) 



(Day) 



iqo \ 
(Year) 



si\(.i,K. MARK n:i>. 

W IDoWHI) OR DIVOKi'KP 

iW'i it' in »<K-i:il ilfvi).'n;iti<>ii) 



I HICRHHV C1<:RTIFV, That I attciuled tlcHvased from 

,..t)..ct ^^ 190^ to ^f^^ ^-^ 190 '^ 

that I last saw h X.'- alive on *^ ^^j ") '.^ uyo 

and that death occurred, on the .late staled above, at .. 
M. The CAl'SIv Ol- Dlv-XTH Nvas as follows: 



\ 



\ 



A. \Jii^<^. ■'...■> 



lUKPni'I.Av'K 

iSlat< (iT (."oniitry* 






NAMI-: Ol- 

lA rni;R 



\wVW^ 




cIax-uo" vAa^cUl^v^'c i V 



HIK rUPI.ACK 
of lATMKK 
(State or Country) 



MAIDKN NAMK 
01 MOTHKR 



IMRTHI'I.ACH 
(»!-■ MorilHR 
(State or Country) 




/X) 



-vL/cLou VaX 



I L^^vcu*l' 



_ XV^XOU-YXU 



occri'ATioN y 



THK AHOVK STATKl. .'HRSONAI- !:^:^^:I7;^^•^^ ' '^ ' ' '■'"'' '"' '""^ 
HHST OF MV KNOWM-:n<.h AND Hl',I,Il',l' 



(informant "^"^ "^ - O-A^ivX' 



(Address 



11^1 \nW.<LL^-Tx. ot 



CONTRIIU'TORV . L^AlJL^^^ Alc-LdA.^ LL< 



,CA.s. '...:.. 



DURATION 



}Vw;-5 JA^/z/Z/v S I^iiys Hours 

(SIGNED) L). J- 0vV4; . . M.D. 

CL iU^ U)0 ; (.-\ddresv;) D' ^ * 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



n.ACE OK lU'RIAI. OK RKMOVAI, 



DATl-'of HiKlAl. or RK.MOVAI, 

.tJ^. ' 190'. 






(Address 



N. B.- 



""■^ Z^i ATF oHoiild be stotetl EXACTLY. PHYSICIANS should 
-F.very Item of m?orm..t!on should be crefully «uppl.cd. ^Ub « -Speclnl InformHtion" »or pT- 

«tote CAUSE OF DEATH In plain terms, that .t may be properly clas-me 

son. dyint away from home should be felven In every Instance. 



tfi 



■••■>(; 



I I 

I i 




WRITE PLAIN 



LY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H,,:ll<l nf llriiUh- »• No I' 



ij» •^.Z.i; itX:!' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\i^ ^ 



/)(f/r /u/r(f,.S^JU^\>-^: 



1 nn>. 

Lt/\J » 









3635 



Deputy hlcalth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of Beatb 

{ "a. S. StanDarD ) 
PLACE OF DEATH:-Coonty of ^C^^^ >J,VCv.ve^4C',Gty of Cjc^^ .Vc^'v^.tv.^cc 



\ ( " ,V*o»,°-'^lccl.ro',"rHo",^"*' o"?~St"" "i. C.C „S NAME ,»ST„0 C ST.CET .HO NU».». ^ 



FULL NAME 



<l.\ 



PERSONAL AND STATISTICAL PARTICULARS 




XVV.v. 




\% 



DAll-; Ol- HIU III 



AC.}'. 



A 



/ '1 M H 



Mi.nth^ 



siNr.i.i*. MARK n:n 

\\II)(t\\KI» < »K ni\ • >K^ I". I) 
(Write in sooinl ih si>.'ii;tti'm) 



I I):ivl 



M.oilh' 



(Vt-ar) 



/)<M,v 



IIIKTIIIM.XCK 

' State or Coiinti \ ' 






aAy^^cjJLt 



\AMI-. or 
lATHl.K 



u 



HiK riii'i,\rK 

oi J A II IKK 
iSt.-ttt or i"<»iintry) 



,ovavv 



-<it 



'.P 



-aL 



okir 



^^ 



MEDICAL CERTIFICATE OF DEATH 

nATK ()!• i)i:ath 



(Mi)iitli) 



(Day) 



lYfar) 



1 ni':Rl':HV C1:RTI1'V, That I attendtMl deceased frmii 

\i',c.l ...'^ 1901 t.. ^^'^fc a..s 190H 

tliat T last saw h •• alive on ^- "^t up \ 

and tliat death occurred, on the «late stated above, at ^ 
M. The CATSIv Ol- DI'lATIl was as follows: 

' • Crijr. "A^Kx >x.'.. . • ' . 



^'.Ci'iAAvt^V^C Ll"^ ■ 



DIR \T10N 



)\'ars 



M OH I /is 



Ijy-yyJb-U^^^-s.^. 



Days 



Hon 



rs 



h 



■<L^. 



DTK AT ION ,^ yc<Jrs 



Hours 



MDI'.N NAMh (^ .^ 

MoTlllvK \ j' 



luR'niruAri-: 

01 MoTIIlCK 
(Slatf or CountiN ' 



OCCri'ATlON Si 



n 



n 



h'r-u'tinf in >'"' / ' ''"' ""' 



'■, ( ) ,11 1 > 



M.nilh^ 



l),ns 



MMIK VH(>VKSTXTKn.MVKSnNAl.l-\KlMCri,AKSAKHTKlK To TIIK 
lil'ST <)l- MV KNOWl.l-.lX'.K AND lU.I.H'.l' 



(DlfotllKlUt 



C (? % tlcv. J. 



(\,l(lri 



VaXu 



O-CL. 



Awto^vj 



Mont/is />(n'A- 

(SIGNED) i (K. %OAt _^^ M.D. 

Address) IJ ^VU ^OA^VA.lv' 



'.ct '^^5 



190 



( 



SPECIAL INFORMATION only lor lW»spitals, Institutions. Transients, 
or Recent Residents, and persons dying away Irom home. 







Former or 



\ 



Usual Residence ^"il U lxwa\i ^ 

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



HoM long at 
Place ol Death? 



Days 



DV'I'lv"' m HiAl. or KHM<»VA1, 



190 



IM.ACK Ol" m KIAI, OR RKMoVAl, 



iVvC> > 



N. B._Hvery Item o^' inform«tlon .hould be cnrefully -"PP''-'; ^^^p^.^y^iaU^r.ei^^'The'^'^^^^^^ In?orm8f.on" fo" pHr- 
iitnte CAUSE OF DEATH In plain term., that It ma> be proper y 
:on.\l>ln(k nwny from home Hhoul.i be ftlvcn In -vry .n«tancc. 



•■•"■•^ 



I 




w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



^'<!fJ5*>'% ^ 



!ln:ir< 



1 .,f ll,:.ltl. I- Vo. 1^ ^•^-^'^^>H5Ll'Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 






-I n/1 I 






J^636 



ckfrvvo ixvu. Deputy Hcaith OT.cer 



DEPARTMENT OF PUBLIC HEALTK-=City and County of San Francisco 



Certificate of S)eatb 

( TH. S. Stau^arC* j 

r). 



PLACE OF DEATH: — County of Cl<W\> J 'v,<v>vC>LAC(City of 0.0^\j A.cv^-vCv^at- 



«f 



!) 



U 



(No- 



QlI Oxd_ and 



It'i t]0 Cr'w4^'>AXX/>v V^.vs^v St.; I Ci Dist; bet. ,_ 

-X "v " ■leiiiki DC-einr Mr r ri\/r r*CTS CALLED FOR UNDER SPECIAL INFORWfATION \ 



■^ -> , ,4 



(IF oe 



FULL NAME 





k^oj ^iD..-.a.v 




,^ 



PERSONAL AND STATISTICAL PARTICULARS 

,1.A ^^ 1 COI.Ok N 



n \ 1 1 <>i lUK rii 



u 



s 









\ < . I-: 



U r,..-. 



'1 



(I):(v) 



!/.;////> 



i » I ;il 



/),/!. 



-<IN<.I.lv M\KUIi:i) 
W IIM t\\ i;i> oK KIVOKv i:i) 
\\iit«iti sotiiil <1< sij.'iiMti">n I 




A.dL^^^-' ^'cL 






NAMIv Ml 
JA TIIl-.K 



IlIKrniM.AtH 

()i- I Arm-.K 

I stall or lonnti v 



m\ii>i;n namj. 

Ol' MOTMI.K 



lUR TJlI'I^ArK 
n|. M(»Tin:K 

(Statf 1)1 C*<nniti\ » 




UOCi^^ 



4' r^ 



6 



cc 



.c 



D 




rO-VvMXVCk: 



( 



A 



c Cr w v<x ^ wdj 



OCCri'ATION 



MuHtfl- 



/)it\ 



Tur M»(>VKSTATKlM'KKSoNAl,PAKTU;t;i,AKSAKKTK« K To THH 
ni-ST Ol- MY KNOWI.I.IX'H AND m.J.lI.l' 



(InfiM iiiattt 






D CJ'iv^ ^ 




(Vt-ar^ 



MEDICAL CERTIFICATE OF DEATH 
DATK <H- I)1;AT!I ,A 

Ud. 11. 

(Month) H»:'V> 

I III':R1':HV CI-RTII'V. Tlmt I atleiKU-.l .Uciased fmni 

JwLi.-'O, I ...190 I to Wv^t.- 'c^.L- upH 

that I last saw h-A-.v. alive (.ti V- - ^ ' ^- Kp 

and that <U'ath occurred, on the dale stated above, al 
M. The CArSJ-: Ol" DI'-XTl! was as follows: 



(I?- 



^ V a. 



Diu A'noN 



} 'I'lirs 



^ 

CoNTUIHrTORV O 



Months Days 



J lours 



DIRATION 
(SIGNED ) J.. 



)'<•<;;.? 



Months 



Ihivs 




CM, 



/lours 
M.D. 



^cl 



i()0 ; (. 



Address) lit Q XX.y^t,^--'-''-> '■ 



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



Former or 
Usual Residence 

When was disease contracted, 
li not at place ol death? 



How lonq at 
Place ol Death ? 



Days 



DATi: of III KiAi, 01 ki:m<)vai, 

T90 



n.\ I J', oi in Ki/\ 



IM \CF Ol- lUKIAI, OK KICMOVAI, 



N. B." 



^^ ' ~ *(;k Hhoultl be 8tatecl HXACTLY. PHYSICIANS should 

-hvery Item of informHtlon .houhl be cnrefully HuppI.e I. 'I'^l'jr^''^^^^^^ The -Special Information" for p.r- 

«tatc CAUSn OP DIIATH in plain term, tha .t may - '-'^^^'-'^ 
Ron, dylnft away from home nhould be ft.ven m every inHtance. 



'^v^'^^^^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Il(<:il 



,1 ,,f M.-.'!tli »•• No. n t"r^^«^]fe^ luSi I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A 







i- 



IV Wi 

'^'r Off' 



liegisterect J\'o. 






t r\ .r^, ^ 



Dale /v/^v/,\i'tXcrlKev X\ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "U. 5. StanC>arC> ) 
PLACE OF DEATH: — County of Ocx->^- J "vc -k^>c\,5i. <^ c City of^^^-^^ Axx^vx-^iA^CLtit 
^No. 2.tS U.tx o V -.V ;. . St.; '-' Dist.;bct. S.^cl and H Ik 

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

--kxd> 



FULL NAME 



Lc\-\\-av^-x.vv.. 



PERSONAL AND STATISTICAL PARTICULARS 



^>-.^^ 



n 



COI.oR 



1»\TK or HIKTU 



ll'. 



)}r^C 




\ ' . !•: 



5^ 



),-.: 



iDiiv) 



1/. '>/'/.■■ - 



/'„• 



s;\t,i.l" MAKKIl'".!) 

Wllx >\\ i:i) OR DIVoKt'HI) 




I'.FR rnpi, \v}-: 

St.it' iiT' I'' iimli \ 



N" \\\}' OI 

I \ in ).R 



iMR run. ACK 
(>i- 1 Aiin'.K 

(St.iti iir C'()\ititi V 



NfMlH-.N NAM1-: 

«>i M()Tni:R 



lURlMlM.ACl-: 
Ol" MOTHI'.R 

(Sl;iti or C"oimt t \ ) 








^ 



MEDICAL CERTIFICATE OF DEATH 

i).\'ri-: or diiath 



(Month) 



XL 



(Year) 



I Hi:kI';BV Clir^TII'V. That I attt'M.kd <k'rcasc»l from 
' ■ ' * ^ " ■ IqoH to W.ct • y igo'^ 



that I last saw h • alive on V-' o ^- > Up 

ami that <Kath (UH-iirred, on the date stated al»ove, at " 
Cl M. The CArSp; ()1- DI'ATII was as follows: 







fL 



iA-KT 



,C'L 



(HTIPATION 

A'/'.--i,ffif III S,ni I iiiih !>!••> I V' )iiii 



Motitti' 



lh:\. 



I'm; Auovi', .sTA ii:i) i-kksonai, i-xkiuti. \ks .\ki-: TRri-. ri> riii' 

IlKST Ol" MVKNo\VI,i;i)<*.K AND lUlJl.l- 



'Info- IlKlIlt 



(vX-d.v-a 






yuu\>^u\- 



I )(■ RATION )ViZ^.v 

CONTRIIU'TORV \i-AXvnw<:- 



Months Pax 



Hours 



»CI'^ \. .. 



DIRATION 
(SIGNED) 



Years 



Mouths S Pays 



Ilours 
M.D. 



IC)0 



H fAddreS.) 11 ^"^io X^^vl- .^Kx^^ Jf 

ions, lYansients, 



SPECIAL INFORMATION only for Hospitals, Institut 
or Recent Residents, and persons dyinq away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Deatli ? 



.. Oavs 



i<)^.t 



ri.ACH <)i" iuRL\i< OK ki;movai. 



I)\T1\<>! lU KiAi. ui RKMO\AU 



!N. K. 



• •I 4rF should be stilted HXACTLY. PHYSICIANS Hhould 
F.very item of mf>rm«t5on should he cnrefujly HuppI.ed. ^^;f:;^^7/;j5^,,^y'' ^he ^Special InWmaf.on" for pT- 
state CAUSE OF DEATH 5n plain terms, that it may be properly classified. I he »| 
«on« dying away from home should be ftivcn in every mstance. 






'sU-b 




9- 






•^^"FWI^T 



i 



i 






i-i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






llJO'i 



liegisiered jYo, 









•XjL'v^ 



V 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. Stan^ar^ ) 
PLACE OF DEATH: — County of 0<X/>v Jxo^v<M.i .City of C'cc-t^ J.Vo^>. av^ 



(^ 



C^^ 






No. 'Jib cLt<XaN^AXA_A>'C5\.L 



^^ 



c^..vv.' w-^^ T vvv. vv. ^ , V. St.; A Dist.; bet. Va^/a^VU^nx and V) <XCa^ -, 

f IF DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED/VoR UNDER "SPECIAL INFORMATION' ^ i 

( Tf DEATH OCCURRED IN . HOSPITAL OR INSTITUTION GIVE ITS N A M E j N STE AD OF STREET AND NUMBER. } \J 



) 



FULL NAME 




n 



^j\ 



PERSONAL AND STATISTICAL PARTICULARS 






\ f 



ftwu 



V 



i 



DATl". or IWKTII 



At.i-: 



VI I Ioju 

iMoiith) I 



(I):ivl 



> I M I 



' V )•,,,., 



/', 



u ii>< lU »:i) <»K nivi )K»J'. I) 

iWiitrin stH-iiil ill si^'iialiiMi) 



iiik iiiri, MM-: 

' M.itr '>i (■• mull \ 



NAMi: »)I" 
I A'lllI'.K 



n 



U <X/YV' KO . 



r> ' 



mKrni'i.At.K 

Ol- lATHKK 

I Statf <>i I'oiniti V 



MAIDl-.N NAMI. 
(»!• MOTIlKk 



I 



f t 



I 



QxWv'.o 



HIKlUl'LArH 

Ol- M()Tm-:K (\ A 

(Siatr or Country^ \\ . ! 

Rf'sidn! Ill ^iiii I I mil isro A I )>(?> ^ 










M 'titir 



n 



(I i> 



im- \noVK STATKI) PKKsoNAI. l-AKTUT I.ARS ARK TK T K To TIIH 
IIKST OI- MV KNoWlJ.IX'. K AND WV'A.UA' 

(Iiifunuanl I I ■'VTU U).oJ6-<rW^ 

,x.Mrcss \\V\ M)l^4A^.(rTV O.t 



(Yt-ar) 



MEDICAL CERTIFICATE OF DEATH 

DATK OI-' DlvATH ^ ^ 

(Month) 'I>''»v) 

1 III'IKIII'.V CI;RTIF\', Tliat I mIU'ikUmI -k-. c;isc<l frmn 

tliat I last saw li . alive on v.C.1 ' .- up . 

ajiil that (katli (HX-nrred, en tlu- date stated a1«nve. at 
M. The CAISP: Ol-" i)l{.\ Til was as follows: 



DT RATION )'eais 

CON TR I lUTORV 



Moutin 



Par: 



'S 



Hour 



nr RAT ION Years 

Ik 



Pays 



Mofitfi.s 

(SIGNED) ^-JZ^^ U.'d. 

Ct, :U too". (Ad.lress) list: "tlM- 



/fours 
M.D. 



SPECIAL Information «nly '"'^ Hospitals, institutions, Transients, 
or Recent Residents, and persons dyiiig dwny from tiome. 



Former or 
Usual Residence 

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



How long at 
Place of Oeatl» ? 



Days 



190 



I'l \CK 01-- niKIAI, OR RKMOVAI, I DATKo! Hnu.M, 01 R1-:MoVAI. 
(Address II 2)"1 ini^A.^^^.^ V J.i 



IS. B 



"■■'"'"— ■"""■"""""""""""^ 1- A ATF tthovild be stated EXACTLY. PHYSICIANS should 

,— Kvery item olr information should be carefully «uPP''<=d- "I'^^'J, classified. The "Special Information" for per- 
-.„♦. CAllSF OF DEATH In plain terms, that .t may be properly classmea. 



-Kvery il 

state CAUSE OF DEATH In pl . „,.„,e 

son. dylnft away from home should be fe.ven m svery instance. 



! I 





kri 



WRITE PLArNLYWITH UNFADING INK-TH,S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR LgSTRurT.«,uo 



((■or.! >.f n.:i!tli I" Vo ! ^ "fr-f^^ac^-. H.«v: IM'.i 

1 



7.96' 4 



.^L<.<.> 




Registered J^o, 



2639 



^, Deputy Health OfTlcer 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eath 

( XH. S. StanC>ar^ ) 
PLACE OF DEATH:~County of ^ ^^ i^^vuc.^ Cty of Cj^.V. IvxVwC^c, 




NeXtttl. "^^^Cl^. >vtu lu 



n\;LV.cnj..USt.; 



Dist.; bet. and 



f ir Dt.TM OCCUHsUwAV FROM U S U A L R E S I D E N C F r . w r Tii^l* and ■ 

FULL NAME \a.nvcN L^V 



-1 



PERSONAl ,'^ND STATISTICAL PARTICULARS 



() 



■N 



"» lilKlll "^A 



V 



I I.lI. 



ii).t\ 



4yi 



bS 



^ 



M ■'>!!/!' 



\x 



I »'fai ) 



/'./ 



MEDICAL CERTIFICATE OF DEATH 
DATK (U- I)i:.\TH / 

'^'"""" (Day) (Vear) 

I HKRHIJV e-i-RTlFV. That I atten.lcl .Icrcased fnMU 

^'/^ ^1 IcpH to . iDcfc 9.^ 

that I last saw li A. Ww alive on ^zk SkH 



n ""H-ial <ksit'n;,(i,,,,) 



' ' ' ■ 1 n t I \ 



'•ATin.K 



"ikTMi'i.Arr 
!»' I A Tin: k 



^I v:i»i:N VAM)- 
'•I MoTlli-k 



•>» MoTIIi-k' 
'^tati' ,,i (•..iiiiliv 



"*' * 1 I'A'llON 









aiMl that .k-ath ..ccurrcd, on the .late staid above, at 7 3> 
■^ M. The CATSH OF UI-ATII was as follows: 










vt 



\Ji 



^\^Ji^(X. 



1)1 RATION Viuirs 

CONTRIIirTORV 



Mouths 3 Days Hours 




"I >\1U5 



IXRATIOX 



(Signed ) 



} V</r? 



Mo)lt/L 



Vo &. Cfr>vl 



/hij'S 



<xy\> 



\Ayy\^' 



Hours 



M.D. 



/^ 



'^LioL>vdL 



Ki'-i,{r,f 1,1 S,t,/ I- 1 nil, i>r,i 



?^^9'^'- Information only for Hospitals, Instituhons, Transients 
or Retrnl Residents, and persons dying away from liome. 



) '/■(/ ; 



M.nilh' " /',, 






Former or 
Usual Residence 

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



fiow long at 
Place of Death ? 



Days 



dif.iiinant 



' X'i.llfSS 



L'lXwuilaA 



? 



\AJJL 



jjJI.ACK OF ''^W>U OK RKMOVAI, I DATK of MfKiAi. or RKMOVAI, 



f Addt fss 



'tXCV tX/yv 



3>^n:X' \q lu li 



•N. B.. 



"Itrt7c'ruSE*of dTath" ""7'*' T' "•"''':."'^ r"^''"''^^'- ^*'^' **"""'^ "^^ «*«'-• F.XACTLY. PHYSICIANS nhould 

"o„, dyWiVa^var from hn ''h"". V:.' ' "* '* """^ ^ ^""''""'^ classified. The -Special information" for pT- 
• "yinft away »rom home should be Jilven In every Instance. 



I 

t » 
I I 



"""^Sk^^ 



r 



i 




f 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMAN 



■ f Hf.ilth -I- Vo i< "fr-^^ir^cli} KS: I' Co 



ENT RECORD 



Deputy Health Officer 







Jiegls'tered JVo, 



2640 



DEPARTMENT OF PUBLIC HEALTIWity and County of San Francisco 

Certificate of IDeatb 

( XI. S. Stan^ar^ ) 

PLACE OF DEATH: — County of "V >a, "JfLa^vcv^cA r-. A^ \^ 
(^■: ;i « , I . , '>'. > V ^ '-i-i- >vuui-co City of <Xyy\j J.V.O^-^vcul/Co 



No. " )L C^xcklcu 



■!iX „,^hJ. .... Pi!t-' ^.t::%^ctcli^ax, and Uo. 







) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

j Cdl.OR 



lE^f'^ldcj. d>va' 



! ' i 



^K-^c '^^^llaM^t Lut; 



vtuc 




•H MIKTJf 




. \vk1±- 






9^b 

I) !\ 



I Vcar) 



1 



-^ ">' i.i- M.\kKn:jj 

\\ llH.WKn OR DIVOKilt) 






lilK rill'LArj.; 
'Statr or Conntiv 



I \ rill K 






^'Ail.i:\ NAM). 



i;ik riii'i, \i-|.- 



.4 






-C 



MEDICAL CERTIFICATE OF DEATH 

I>ATH OF DKATH 

ii /ct u 

(MoiUh) ,„,„,, 

. ? al"";"'!'"' ^''■••*T"-"V. n.,, I atte„,U:,I ,U.cvas..l from 

ii V^ll ^^ ,-t ac ,^ H „, i(?,(^ . i^^d^a fe , ,« H 

that I last saw h LY>\ alive on ^ ct ^b 



(Year) 



an.l that dratli occurrcl, on tin- ,lati- stated above, at 
• CAIS 



[90 



4 






^^ The CAI Slv Ol- \)li.\TU was as follows: 



J^^\h^(L XA\.^xK^ .CX^txv -(K.vtiv 



DIUA riON 
CONTRIIUTORV 



} Va; .f 




Mo)i 



-LlvAJL 



A 



r^tcLU 



Hi 



(XV^-a' 



te 



Dl'RATIOX 



)V<//'5 



'■^ ,T) 



Mo)ith<i 



XC/VVO 




(SIGNED) '1 IK. ^>Ou\.H; 

3-1 Tc)oH (A«i(iress) bS"l Uxx^Ljip nt" 




M.D. 



f ^^'f!"-. "^fOf"^^T"'ON only for Hospitals, InstitliHons, Transients 
or Recent Residents, and persons dying away from fiome. ir-nsienis, 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



... Days 






' '"foTTuarit 











190 



(AcMress ^bl b. > . lA .ti....M.. 



.ia7e*CA\rSE*OF'DT4T^^^ AfiB .h„„.d b, .lat.d EXACTLY. PHYSICIANS .hould 












:m9i 



I I 



I I 




Miu^yttl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PE 



RMANENT RECORD 



lidiinl "f Uf.iltli I" N*<) iK *'--'W--S4j ]\Si.V C 



Da/c Filed , \l^el^L1V X\ 



REFER TO BACK OF CERTIFICATE FOR INSTR 



UCTION* 



/,9r;^ 



RegLstered J\^o, 



;2641 



.MXAJ^ 




De 



V Mr 



DEPARTMENT OP PUBLIC HEALTH-City and County of San Francisco 



Certificate of 2»eatb 

J? QV\ 

PLACE OF DEATH: — County ofOCLrt JXO/^VCUL 



.1 



» 



! y 



No. ^ td ^vU^kla ^)l' &»vx 



FULL NAME 



St.; 

DEI 

>Tn 

X 



^ City of ^ ' Ct^Aj o Xcv. > VC^^AX^O 
Dist.; bet. -rrrrr 



and 



( " "•;:.:^i.":! — :-:o",^.n- r„"^?,^-forj,;/^;i ^.v^-.- :- .-rsp s.v.%T:;r«::e-jr " ) 



-LcO\( 




^ 



aVvA^ 



--i.\ 



PERSONAL AND STATISTICAL PARTICULARS 



fKcl. 



'I ill Kill 



«M..iith» 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1;aTH , \ 



iDct 



\' .!■: 



^1 . 



H 



I»:iv 



M..t,tl, 



r\XX 



(Day) (Year) 



"^IN'.I.i: \! \kKii-i> 

H IDnU i.;i, OK I>!\oKi HI) 

■ \\ I Itc ill MMiiil <ii-«.it'tl;its..li» 



i!it^ iMfi'i. \(- J-: 

I lit I \ 



li 



(Vrai I 



/'./! 



\' 



NAM}-: «U- 

• NiinK 



''•IK IMI'I. \(K 
"• lATIIl.K 
^^1 it' oi Cxilltt 



<»i- .M(>ti!i;k 



•!ii< rni'LAD- 
*»K Morm-R 

fStatr or ruiiiitiv 




X L cL^vv.ML<i. 



Uo" \Lit>vk 



(Month) 
I JN':RI;P.V CI;rT[FV, ri.at I attemld decease.! frcm. 

'P 

190 H 



'^ ^"t ^ 190I to . .^:/ct. XS'.. kkdH 

that r last saw h U»\ alive on U^/cJfc 9^5" 




? 
? 



^ aVLL':^ 



aiKl that death ocoiirre.l, mi the date state<l above, at 
^ M. Tlie CArSl«; OI- DlvATH was as follows: 

1)1 RATION ^ )',77;.? L ;]/,;;////j 



Days 



Hours 



CONTRIlirroRV 



Dl'RATION 



)'car 



Hours 



.Cr'V<i 



Mout/is Davs 

(SIGNED) i.vd/VvUi^ Uliyvtl M.D. 

^.ct U. K^oM (Ad.h-ess) Lcio d.A.(ht^h. Ji 



<H( ri'\ j-ioN 



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



1/,-;////. 



n,i\ 



Former or 
Usual Residence 

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



flow long at 
Place of Oeatli? 



Days 



"'."^1 01 MS KNOW I.1.:|)<;k AM) WVAAV.V 



^'I'lrcHH 9.5 01 Vj.VY\l "^t 



I'l^ACK OK BIRIAI, OR KKMoVAI. DVI'K of HfKiAi. or RHMOVAI 



190 H 



1 Gfco^xJi, 



Itrt^c'l^i^FUp n^rrl'r.'*'?'/' ''" -"'•«f""y supplied. AflK Hhould be stated EXACTLY. PHYSICIANS should 
Tonl H t ^ OF DEATH In plain term., that it may be properly cla.Hiflcd. Tbe "Special Information" for D,r- 
«on» cfyinft away from home Hhould be Hiven in cs^ry InHtance. *^ 



w 



^ 



I ! 



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



Ho.iicl "f II' iilli »• N'<i I' 



•fr^' 



larf-i.;} luVl' c 



RtRER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/ 






i;)0'i 



Begistererl J[''o. 



J^64 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH: — County of J\X,^>Vt City of cy\JuoJ\j 




y^ v.a_\; 



No. 



St.; 



Dist.; bet. 



and 



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



>w 



FULL NAME V^La^J^:^\ c 



Q^ 



/OJ\jLi2A.VA.Ud. 



PERSONAL AND STATISTICAL PARTICULARS 



1 \ 



^ 



^ 



Col.ok ^ 



^ 



' \ i I < ii Hik 111 



a 



* V 




\ V 



\' 



Moiitli' 



\ I . 1-. 



ao r.„, I 



3; 



Mmtli 



l\\. 



'Vcarl 



n,t\ 



sivt.i.i- \t\Kkii:ii 

WIDOWKH «)k I)i\i iKv 1 I) 



Itlk rill'I. \i'J-: 

' ^t;it' ■ • 1 . .1] nt 1 \ 



NAMi: <>I 

lA rm.K 



Itlk IIIIM. \lK 

<M- »-ATni':k 

'StMtr nr (N)>nitrv 



M \ll)l-:\ N AMI 
"1 MoTIIIik 



HlkTHlM.Ari-: 
<'!• MoTMKk 
( Slate (»r i'miiiti \ 




MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DKATH 



(Month/ 



iDav) 



I go '. 

(Year) 



1 Ill'Rl'HV CIvRTIFV, That I attended dt-ivased (mm 

190 to ■ - 190 

that I hist saw h alive on — — — — — rrrr— — ic^o 

and that d«.-ath ocrurrcd, on the chite stated above, at 
r. M. The CAT SI-: Ol' DlvATH was as folUnvs: 
\JAaJu^'>vC •" ■,: vJ.,^,^^ '.•.\X.'^.A: 



DC RATION years 

CONTRIIU'TORY 



Months 



Days 



Hours 



I )r RAT ION 



{^ 



Years 



Moiiths 



Davs 



^AA/Vv^CV 



orci rATioN 5 



A.<.^vcLv ) > 



(SIGNED) > . A. 



vj.cl'. :^:>v I 



90 



' i 



(Address) v yXXA/^\.^0 \JXlL 



Hours 
M.D. 



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



-\ 



/y'fsidfit in Sim /'i ii m !<ri> { )ViM 



yfonlli- 



I >a\ 



I'Mi: MlOVl'. STATi:!) I'KK^tiNAI, I" \ K I' U' T I, \ K S AKl, I' K T l-! TO VWV. 

iu:sr Ol' Mv kn()\vm;i)<; H and iu.i,ii;t" 



(h 



'l"'>!inan( VJ . 4 - vD . uV.' \XVtjl\.«v. V<^-> 



f \(Mress 



5.CiH ci)(rU\X^ dt 



Former or 
Usual Residence 

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



How long at 

Place of Oeatli? Days 



ILI.ACH Ol-' lU'RIAI, OR RKMOVAI. 

I 




I)AT>:of Rt'KiAK or RKMOVAI^ 

W:d.. M 



r.NDlCKTAKER VA^CXV^ MKlJk.^^ Vt.AvC' 

(Address .. HX°l^i^ AdLiA-. Jj.Xxli CL' 



190 



f\}.^ 



IN. R.- 



-Kvery Item otf inform.ition «houlil be c.ireVully supplied. AflE 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- 
nons dyin^ away from home should be tit'ven in 9\cry instance. 



I 1 



I I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•'r>. 



H..iii.l Mf Ih.ilili- I" \(). :«; "^'t^L" 



n&r Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






i Deputy Health Officer 



llegistcved JSI^o, 



2643 



DEPARTMENT OF PUBLIC HEALTtl-City and County of San Francisco 



No. 



Ccvtificate of Bcatb 

< "U. S. Sta^^ar^ ) 
PLACE OF DEATH: — County ofOcx-)^ J A<X->-vCA^<:i.Cil 



((H 



ty of U xx^vv' J AxX/'wau:ic. c 



( 



St.; ■ Dist.;bet. GC^ /CLVvUi trw and 

ir Dt*TH occurs AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED TOR UNDER "SPECIAL INFORMATION 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



FULL NAME 



v<LO^ 







I'll .aLt,-",,! 



V- 



^i:.\ 



PERSONAL AND STATISTICAL PARTICULARS 
QP) A i COI.OK '. 



1' \ 11 t 'I- I;IK 111 



i 1 



/U'> 



M.,iillii 



\' ■ !•: 



(^ 



),.,■, 



il>:i\ • 



1/ «////. 



t '■ u 



Ihi 



MEDICAL CERTIFICATE OF DEATH 

DATK OI' I>1;ATH \r\ 



(Motitli) 



(Day) 



I go H 

(Year) 






^INt.I.I- M\KUII-;i» 
\vnK»\yi:i) OR i»i\'( iki 11) 



IlIKIHl'I, \rK 
">t;it(. or <."uiinti \ 




^ ./i^cC^rVC 



-V^ 



o 



I lIl-iRi-nV CI-RTIFV, That I attended deceased from 

.*iXo.v 190.I tf) U.-C^ Sv.b i()0 '; 

tliat I last saw li -. ' alive on W/CA7 5^5 190 '. 

and that dc-ath occurred, on the date stated above, at ) i 
M. The C.ArSI': ()!• DIC.XTll was as follows: 



{ ! 



\ WW < »1 

t \ ill Ik 



lURTiii-i, \rj- 
<>i- i\rin:R 



"I M<»riii;K 



lilK lIU'l.vcj.; 
<»l MOIHICR 

"-■lit. ..I Cotniii' 



9 

? 



F)[R.\TI()N 
CO.N 



5 



Motiths 



Hours 



.\TI()N Ycaxs ■'■. Months Days //on. 



nr RATION 
i Signed ) 



)'cars Months 

1} 



«H-Cri'.\Tl()N (^ 



C/VU^L<X/\ 



-v/cL 



/\ivs //ours 

., cl '..•';. iQo'; (.Xddress) 5^01 OxjCtllV jtj 



M.D. 



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



f\'f utrif ill Sini I'l tiin i ,i> .'^i'iIVim 



Mnllth^ 



/hn> 



I" HI-. AUOVK STATl-.l) I'KRsONAl, I'A K Tir C I, A K s AKl! TKIK To 'ni)-; 
inCsT OI- >1V KNOW l,i;i)(-, K AM) HJiMMK 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



'Iiifotm.-mt 



Ow^ 



^\.l<lr.--s "10^^ R 




% 

.1 



/tX-t^-JU 



i 



I)ATl-;.»f HiKiAr, or RKMOVAI, 



ri.ACK oi- HrRiAi. OR ki:mo\ai. 



^ 



190 

Cr.Yw 



!N. B.- 



-Kvepy Item of Informjitlon shouiti be carefully HUppfied. AGB should be «tnte<i EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In pltiin terms, that it may be properly classified. The ''Special Information" for per- 
sons dyin^ away from home Nhould be 6'^*" '" every instance. 



II 



I 






• "^' 

3 




«l 



i- m^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I idle n/rd^t ,<^\>X\i Q^T 



100\ 



REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 

Registered J\^o, 



2644 



Nf). 



dc^u.A^lx\vu Deputy Health Officer 

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

Certificate of Death 

{ "Q. S. StanOarD ) 
PLACE OF DEATH: — County of Ca^Aj -.'A-aovcc^cc City of Oclaa/ J/vO-^vcuic 

>Uvx.l) U->vivo^ ^v CM Jt^-ihAStr-i. — D;st.!bet. 



I 




and 



( "" .°/y OCCURS Aw. y rRo4 USUAL RiES IDE NCE give facts called for under "special information- \ 

V .r OtATH OCCUrtktD ,N A^OSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E eI AN D N U -^BE R ) 



FULL NAME J -X>vclvc 



PERSONAL AND STATISTICAL PARTICULARS 

COlA»R 



1 1 VoJu. 



"1 iURI'lI 



Moiuli I 



N ■ . I-; 



L 



) '•; I 



.1 



H.IS 



1/ ./■-•/ 



fV.ar) 




'-^ 



MEDICAL CERTIFICATE OF DEATH 

(Month) (Day) 



IQO \ 
(Year) 



/',/' 



U li). •\yj..|» UK DIVoKDM) 
Utitriii MKJal ijc-ii'iiat k .n I 



JP 





A.^V 



''.rki'iii'i, \.*i'. 



N WW. Of 
1 XTMIK 



Hik ini'i, \ri-- 
*•'' I \rm:K 



MAII)i:\ N\M1 
<>l MOTMKK 



"'■IK llll'l. \(J.' 
'»»• MoTllHR 



(9 



I HICRI'HV CIvKTIFV, Tli.it T atteii.kMl .leceased from 

to ~ 190 

——190 -- — 



that I last saw h - 



I90 



alive oil "^ 



aii<l that (kath ornirrcd, on the date stated ahove, at 
~" M. The CAl Sl<; Ol- Dl'ATII was as follows: 



(^\^<:r\ 



.}-<^^.v..<:;..s..v1~v. 



) \ -^\^v ^ '^ ^ 



1)1 RATION Years 

CONTIUm'TORV 



Months 



Da vs 



Hours 



y^ 



Hours 
M.D. 



^^ 



• •'•Tl 



CjuL/v-^xJt- 



f\ftdri! ni S",;„ r,aii.iu-n «■ )V,// 



M..,itl,^ 



/',M 



"'ni^J-J.'^?/.^.''"^''''"'* '"HK^ONAI. l'\K lUTI.AKs AKI' T K T K l< • Till-: 
m-.sroi- MV KNOW l.iiDC.j.; AM) Hi;iji.:|. 



DTRATIOX Years . Mouths Days 

(SIGNED) UfUrVJiA; . U^ . U3. XjlLoa^A. 

L/Cl. IH too'' (A.hlress) Ltr^^rvAjLA^ L'^U-rJ 

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



former or 
Usual Residence 



How lonq at 
Plare of Oeatli ? 



Days 



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



''iiT 'Tinant 



"^-<r^AJL^^<^ 



0|| 



IM.ACK Ol' lURIAU OK KKMOVAF, 

r 



I)ATK"t HiKiAl, or KKMoVAI, 



'X.l.llCSS 



0\ . J? ^^. 

(Addrt-ss 30S \» fV^Cr^AX^ClUU. LLv^^ 



T9O I 




N. B. Kvery Item olt informntlon hHouIiI Ik- cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain tcpms. that it may be properly classified. The "Special Information*' for p»r- 
Mons dyinft away from home should be Utiven In every instance. 



i, 



>1 
1 
1 



I i 



i 



t 




t# 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M.'.'.r.l ..f Hf!tlth-K No n t^ja^^. nft^V Co 



r\ 



WgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i i 



vu 



jjuiy n 



'*'1 Officer 



lie^isfcT'ed JV*o, 



2645 



DEPARTMENT OF PUBLIC HEALTfKity and County of San Francisco 

Certificate of 2)eatb 

( "a. S. StnnC»arC> ) 

■^ ^ J en 

PLACE OF DEATH; — County ofO/CX^v vj\a^vc^ac^ City of OxX/w O.^vo.^ 



No 



3% ' 



.tS^LtlvixA 




\.<i\.^eL 



(K.Vv^i 



CLl. 



St,; 



Dist.; bet. 



and 



( " .V!ir,°*'*^'"" ***" "°** USUAL RESIDENCE GIVE r*CTS CALLED roR U N DER ■•special I NFORM*TION ■ \ 
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STR EET AN D N UMBER ) 



FULL NAME 



'.\.c 





XX->\jiJ> 



- ?^ 



PERSONAL AND STATISTICAL PARTICULARS 



1 



^ >^VCV' 



^v 



i "I i;!K III 



M. .1111)1 



\< ,j.- 



ic'^ 



) ..; 



h-( 



' I),i% ' 



^ ;■■,,>) 



t 



4 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DllATM 

,15:.. 

(Day) 



Wet 

(Month) 



(■r<;il I 



/hn 



(Year) 



■^iN'.i.i, M\kKn:i» 

W II>n\Vj:i> MR IHV»»K( I I) 

'■"' - • ' 1 1 (|< •.ii'iiMt !. in I 



lUK rui'i. \cv 

^t.Ur lit (.•.(initr \ 



OA/VXt 




I HI:K1-;MV CI-RTIFV, That I atten.lcd aeceased from 

190'A to ...w/ot xS: Kp'i 

that I last saw li alive on OyC-t AS loo ' ; 

aii»l tliat (k-ath occurred, on the date stated above, at '( 
.M.^ The <-^ArSH OF DI-ATII Mas as follows: 



-\ 



lA riii;k 



'UkTHI'l.At-K 
«'!• lATIIKK 
'>»tatr or i'ouiiti \ 



"^'MI»i:\ N\M1 
"1 M'Mlll'K 



iniMMlM.ArK 
"•■ Moj'IIKk 
• Statt III ('luiiitt \ 



? 



or RAT ION Years ^ Mouths Days I /ours 
CONTKIIU'TORV LLv-L-/ o„ ' ..'.^^.'..xJ^.^.c^.^„.,.. 



? 



;^ 



" < I 1 



•ATh.N LA 



A. 



I )r RAT ION }'rars J/ou//is Days 

(Signed ) UJ rrrv^. \Jb<XAA^^-wT>^Ov>vL., .v 

\1 Cl XL H,o"'; (Ad.lress) Ot. \i^)Ai>M\/{> 



Hours 
M.D. 

Os.?i.:|.\i. 



Special information only for HoM)itdls, institutions, Transients, 
or Recent Residents, and persons dying anay from home. 



'\lDiOJvwl 



How long at 
<^^ Place of Death? 



Days 



Months 



lhi\ 



' '",'• >!!J.»^''^. ^TATI-.I) I'KkSONAl. rAkluri.AKS NKl, TKri- To TIN-: 



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



(ii 



%J1. 



X 



\.l.l.rss '^ vJbo.A.'L^l V V 



O 



I'l.ACK OI" HlklAI, Ok kKMOVAI, 




NDl'kTAKlvK HAaXa^VVO 0. v) ^<L' 
(Address 0.0. 5^ 



DATi:.)! Hi KiAi. or kKMOVAI. 



190'i 



>LOLA.A-> 



^ ■'-^ ^ •♦ LU.L 




N. II. 



Hvery item of informntinn ahnulti in ciirelfulty Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it miiy be properly classified. The "Special Information" for psr- 
Kont dying away from homo should be given in •xcry instance. 





fi^' 



ilJI 



' ^i^jiA 




-^i****?"*! 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^g^E R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ko.it.l of Ilciltlr I-' \<i li ■**?>Mfr^i Iii«vP Co 



hah- /•VAv/, li'cl&i^, %l 



190'i 




co^ 




liegistered JVo. 



26461 



roi 



> »^ ^ esq ^ ^ ^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( XX. S. StanJ>ar5 ) 



J 



(3^ 



PLACE OF DEATH: — County of Q/<X^r^ J .'vcXtuxoco City ofOxX'-ru J/UX/vuiui.C« 



^Nc 



^al 



J .CC' 






St.; 



Dist.; bet. 




4y^rru. 



and 



/ .r DE»TH Oc4u«S *W»V FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR U N DE R "s FECIAL I N FOR MATIO N" \ 

V .r DEATH Occurred .n a hospital or institution give its NAME instead of STREE^iNo number ) 




FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



i 



!• \V\'. or 1!IK IM 







^K\r\.^y\X 



MEDICAL CERTIFICATE OF DEATH 

DATH (>»• I)i:\TH 




190 \ 

(Year) 



M..iitl\) 



\' I- 



sa 



)/•./ 



(I)av» 



M.»,fh^ 



: Vrar) 



/',M 



Uiilf ill s().i;il «li«*i)^iinti<»ij) 



lURrmM.At'K 

M.iff Mr (■<iiiii(r V 




CL\^LX.<L 



(Month) (Day) 

I in-KI-HV CI'RTIFV, That I attendcMl (leccased from 

^ ^t ^l 190M to ii'/ct a.fc 190H 

that I last saw h .XV aHve on l^ ofc 9^6" icp 'X 

aii.l tliat death occurred, on the date stated above, at 3 
AL M. The CAISK OF HKATII was as follows: 




NAM)-. (»| 

|"athi;r 



HIKTIIlM.AfH 
OI- I AIHKK 
(Stafi or I'ouiitryi 



^^MI»l.^• nami- 



JnKllllM.ACK 

'»• MnTllKK 

• St.itr or Country) 




-VTX' 



I )r RAT ION i ]'ears 
CONTRinrTORV 



Mo>iihs 




Days 



Hours 



DIRATION 



Years 



7) 



.^fonl/is 



Days 



/Fours 



(SIGNED) >.. 'M. ^h J.Aj\^iJ^jjUi M.D. 

li^tt Xl iqoM (A.Mress) UCMla.Xml/a,M ULa.uL 



OCCri'ATlON ^ I 

h'f-^htt-J 1,1 S,in /nuh/uo I'X )/.//v "^ lA 



/////s 



'"''',;,M'?y»\^:T,^ ■'■>•■'' J'KKSOXAI, I'AKTICII.AKS ARi; TKIH TO 
Jihsl 01. MS KN()\VI,i;i)<-,H AM) m:i,IHK 



T 1 1 K 



('llf'lMUflUt 



^ 



■J •-'VvCk^ CiAjLAjUk 



/tX-^v-wv 



f\.M 



rrss 



iioa 



aivtrtuKii d 



t 



N. B. 




Special Information only for Hospitals, institutilni 

or Recent Residents, and persons dying away from Jiome. 

former or 
Usual Residence 

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



Kvery Item olf InforniHtlon should bs cnrefully supplied. AGE should be stated EXACTLY. PHY8ICIAN8 should 
state CAUSE OF DEATH in pliiin term., that It may be properly classified. The •'Special in?ormatlon" for p.r- 
«on« dylnft away from home should be ftiven In every instance. 




s 



"•^^ 




te«i-'^i 




iiii 



.1 



>Mmj|yJ^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



£EFER TO BACK OP CERTIPICATE FOR INSTRUCTIONS 



Dafr /v7r</, (ilct^rls-i^ Xl 



100\ 



Begistered JVo, 



.KsXXK^^ 




2647 



^^t 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



i 



"CI. S. StanDarC> ) 



(^ 



PLACE OF DEATH: — County of aOAJ vJ;vai\Ct4.C: City ofO;a/rv; JAXX/Yvo-Xixvo 



t.^^\i.kH...USt.;- Dist.;bet. ^ and - 



\ f ir DtATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDTR "SPFCIAL I IS. P^p I.1-r.« '-". \ 

\] V IF DEATH OCC^RRtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E eI AN D ^ u M B^;,^ '^ ) 



FULL NAME 



^\.y\Xl.\L'^\.y\.K. ^\.O^f^ 



'^ 



PERSONAL AND STATISTICAL PARTICULARS 



aU 



COI.OK \ 



1> A 11 < T ItIK I 1( 



A'.I-: 



iC Sx .t 



L' 



I Mouth I ' 



C 



),,; 



5 



10 

• Dav) 



M.iiffn 



(Vt-ar) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF r>KATH 

(Dav) 



(Year) 



n 



fhns 



^IN<'.I.K. MARKIKI) 

U MM»\yKI» t»K DiVokrKI) 

Wiitcin MH-ial (itsivnaliwii) 



I'lK riMM.Ari-: 

^tatc or «."oiint I \ 



I atui:r 



lUKTm'I.ACK 
'»»■ KATHKR 

I State or rouiitrv' 



MAIDKN NAM}.- 
<»1' MoTHKK 



"Ik rupI.ACK 
•>»• MoTMKK 
'Stat«- or C'oiiiiti v> 






LIU ■lev ^- 



I '.ct 

(Month) 
,^ I HI-KHBV C1:rTIFV, That r attemlcMl deceased from 

Aict. 'XO 190 H uy J^ <± .0.1 T90M 

til at I last saw hXK. alive on Li^cjfc X\ jf^H 

and that death ()cciirre«l, on the date stated above, at ^ 3S^ 
^l M. The CAISK OF Dl-ATII was as follows: 



W.o^xy'^ 



■\ 




Dr RATION Years Mouths X Days Hours 

CONTRIBUTORY 



>\Xa. 



DURATION 



Years 



Mouths 



Days 







Hours 

(SIGNED) .11 Cd. C^Tv^Clo^ M.D. 

^ ^ ^l i()oH (Address) LLtvvV<J(^ 



'\.^r\jUUi 



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



hW^idr,} in Sa}i I'l iun i.u-<> " )',-,n 



Mouths 



/'(/I, 



"'nKJ!r*y.l'^J.V'"'''" '•f<«^<>NA». I'AKTKTI.AKS AK1-: TKIH To TlIK 
Hhsroj. MNKNOWl.HDC.K AM) MHMKF 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



(Address .. 




vx^VvcrVA^M^ 



n.ACK OF nrKIAI, ok KKMOVAI, I OATHof HiKiAl. or REMOVAI, 

(Address 3(p1 a- 1^ i^V ^..Bt 



IN. B.. 



-Every Item of information •hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it m«y be properly classified. The "Special Information" for per- 
sons dying away from home should be given in m\evy instance. 




n 



M 



-y 




1 ) 



iiii 



mil 



««iij(. 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TQ BA CK OF CERTIFICATE FOR INSTRUCTIONS 



J) 4 



l'JO\ 



Registered ^7>. 



;2648 



cLcrvcA^ >^vu Deputy Health OfTicer 






DEPARTflEM OF PUBLIC HEALTH-Cify and County of San Francisco 

Ccvtificate of ©eatb 

( XX. s. st■1n^at^ j 

PLACE OF DEATH: — County of Oa-^.. J Va.>xcvA-co City of C3,cv.^ J axc 

FULL NAME '^'-t^m. oL/cn-.o ',,>.._ 



'WAl^^>J^VL^'^ 



) 



^t A 



PERSONAL AND STATISTICAL PARTICULARS 



w. 



^ 



!• \ I 1 or r,ii< III 



A<.i.; 






M. iilli 



^IN'.r.K MAKUli:!) 

N\ riK >\vi:i) OK i)!\« tK» }:i) 

\\\\\< ill v.H-iiil <l« vivriiation) 



MIKTMl'I. \t-|.; 

'■ •■ '•Hint I \ 



I)MV 



M nit/r 



MEDICAL CERTIFICATE OF DEATH 

DATH oi DKATH A 

'Dav) 



IQO I 
(Year) 



(Month) 
I IIHRI'IHV CI-RTIFV, That I atUMi.lcl .Iccvased from 

- to 



I90 



/',/ 



i 



Uv 



NAM I 01 
lA I Ml-.R 



HIK riH'l.MK 
'»•• lAllll-.K 

'Stiiti- ..r (•i.uiiti 



\I \ll)i:\ NAM|- 
01 MoTiniK 



HIKTIIPi^ArK 
"I MoTHKR 
'St.itc (,r (.VniiitM i 



'>^ ll'ATKJN 



'V^\XX' 




T90 
tliMt I last saw h ~ alive on ^^q 

an<l that (Katli occurred, 011 the date stated above, at " 

M. The C.\(SI<; Ol- I)I«:ATn was as follows: 

1)1 RATION JV'rt/-.? 

CO.NTRIHUTORV 



Mouths 



Days 



Hours 



DI'RATIOX 
(SIGNED) 



Years 



\j;(\<rv\JO\j 



Mouths 



Havs 



vA. 



d- 



Hours 
M.D. 



i()o'. fA«lilri-ss) LtrVcn-vJt^(» liJ|i..v. -',., 

Special Information only for Hospitals, InstltuA, Translfnts, 
or Recent Residents, and persons dying away from fiome. 



),,/ 



\t.<„tii' 



/>.! 



'"nrJ-r'!?,-';'!".^''''"'' '"^^'^ ^' >N- \ "• I'A t< lie r i. \ Ks a K !•; Tkl 1-: Tu THJ- 
•iJ.M OI- y\\ KNOW i,);i)«,K .\m, itj.iji.; j.- 



former or 
Usual Residencf 

When was disease confracfed, 
If not at plareof death? 



How tonq at 

Place of Death? Days 




( \<ui 



ri.ACi: (»I- HIKIAI, OK KHMOVAI. DA-ri; o!" MiuiAl. or KKM()V\I 



Oaa/vwvu^AJ /txXjL 



ress 



(Acl<lress....3W'j^- IC\ .tL ^1,. 



T90H 



N. It.- 



-I. very Item of informHtion shoulcl be ciirefully Mupplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classilTied. The "Special Information" for par- 
dons dylnft away from home should be ftiven in ovcry instance. 



Ill 







I I 

1 

t i 



i.r 



-»■•* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lUfh' Filed, \l\/^j:M^yv V\ 



RgFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 



cMrVAx/i 



100 \ 

Deputy Health Of^'^'^'' 



Re^ititcved JVo, 



2649 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 

( "U. 5. Stan^arD j 



No. 



PLACE OF DEATH: — County of6<x,^v i,Vcx.TvaA.Ci.cLGty of 3 Cu^ -^ .Vc^%x.t:i.v^.CLc 

SU I Dist.; bet. -at C C KUi.v and ' ' 'H.^.H. Ll 



IcXS ^V>U?^v. 



( " f/rr",° *'''"'" *'**'' ^"^"^ USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION- \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E ET A N N U M B E R° " ) 



FULL NAME 



RESIDENCE GIVE facts called for under "special INFORMATION' 

INSTE 



'S' 



.<.Z<L\\JA..... 



PERSONAL AND STATISTICAL PARTICULARS 

f 



a 



i ' ' ! I ; I !<■ I 1 1 






3.S 

(I)av» 



MEDICAL CERTIFICATE OF DEATH 
DATH oi- DKATH /A 

f Month) 



( Day) 



(Year) 



\' .1 



) ..I 



i't-ar) 



/',n 



^IN<.I,K M\Rkli:i) 

Uiittiii ^(K-ial <h *ij.'ii;iti.iMl 



I 



HI km I' I, \<'i-: 

"■' ■' ' 'i ' "Milt I \ 



X 



NAMI- OF 

» atiii;k 



^ 






iMk riii'i.xcF 
«»'• !-Arm:k 

'Slati- ,,r Ciinitr \ 



^'AlI»l:^• NAMi 



•nkiin'i,\(i- 
•'1 M<>rHi-:k' 

(Stat* or (\>iuiti \ 



cLv^ 



I m'RI'iHV CI-RTIFV, That I attcn.Ie.l <leceased from 

L''c;t up. to j9'Ct '^h icjoM 

tliat I last saw ll . alive on ^ ^l / loo . 

and that .U-ath occurred, (.11 the date 'staled aljovc, at i 1. 
^ .M. The CAlSf' ()I< I)i;ATn was as follows: 



'1'\jL\)... .K^-y^v ■'.? . 



\ "X/^ X c^vi- e. clxv e. c 






nr RAT ION }rars 

lONTRIlU'TORV 



Mouths 



Pays 



//ours 



'•* * I I'A rioN 



A. 



ex 




U 



I ) r R A T I ( ) N ) 'ears .^font/is /)ays //ours 

(SIGNED) Lv, JID. '0A^Ov•>^.-^•v . M.D. 

ly.C.t 11 ,<,o I (Ad.lress) 501 3x^.U„LV Jl 



Special Information only for Hospitals, institutions, Transients, 

or Recent Residents, dnd persons dying away from home. 



) v./ / 



1A'/////v 1 /;,;!> 



""lir<-r'y.'/^J^'*'" ''>-■'< ^•>NAI. rXKTKlI.AkS Aki: Tk 

"j-.si oij M\ KN(»\vij.;i)('.K AM) iu:iji;i- 



n-; To \\\v 



Former or 
Usual Residence 

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



How lonq at 

Place of Death ? Days 



ri.ACH Ol- MTKIAI, OR RKMoVAI, 



I)Ari;.)f MnuAL or RKMOVAI, 

i).^ .^i. 190H 



f Athlrt'ss 2) S" VinX<r>xtxVM LL.A*:.'. 



1 



Kvery item of informntion should be cnrefully Hupplied. AGK should be stated EXACTLY. PHYSICIANS should 
state CAUSE OP DEATH In plain terms, that it may be properly classified. The "Special Information" for psr- 
«on» dylnft away from home should be i^ivcn In every instance. 







•***>■ — 



T^^ 



I 



l! 



V ^^- 



!*: 



I ( 



™ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

__-—«________ REFER TO BACK OF CERTIFICATE FOR INSTRiirTinw. 



I'..,.!i<l '.f H. .(Itli i-' Vo i=; "^-f]^^ lU^r ( 



Ihf/c /v/fv/, Jvx 



,^VM^ 



ttrWL>v 



^1 



IfJO'i 




Re^isteied J\^(), 



2650 



itw • ; 



' u r\i=f. 



O 



No. 



ak^ Depu 

DEPARTNENT OF PUBLIC HE ALTH-Cify and County of San Francisco 

Certificate of Scatb 

' 11. S. Stan^arC» ; 
PLACE OF DEATH: — County of '^O.^rxj JKO-vxcx^LCOGty of ' Cu'W; J Xctox^cXAAi^ 

/ ,. „^,^^ ^^■^'^^1 S*" ' Dist.;bet.m{-^vt<l,OvU'iUandXt<X^TVu 

( ° y," """" ••'" "<P" "SU»L RESIDENCE =,«t r.CTS C.LLCO rOR UNOr»lsPirC..U INXnM.TlON" \ V 

^ ir DC.TH OCCU.«tO .» I HOSf.T.L OR ,NST,TUT.ON CVE ,TS N«ME .NSTE.D o" J^REET .NofuMBjR ) j 



FULL NAME 



in\^\,. 



^)L 



<o\,(i 



PERSONAL AND STATISTICAL PARTICULARS 



\ 



UaU 



ri >i,t >k 



I-.: kin 



IMx.L 



M-iitli 



/in 



11 



I DaV 



>/ '»,,'//« 



MEDICAL CERTIFICATE OF DEATH 
DATK 01- DlvXTH 



(Day) (Year) 



'>'i-ar) 



Pa 



^IN'.I.I- M\kUli:i> 

n *<Nial ilcxij^'iiatifiii) 



ill' nil' I. \i'|.- 

'tnt t \ 



N\%fl Ml 

I- ATlll.k 



''•!k llll'LAiH 

"" » athkr 

'^t itr .,r (.'omit! V 



"I- MnTHHK 



ItlKTUJ'i.Ari-: 
'"•' Morilllk 



•" - ' i'\ 1 1<>.\ S( {) 



X^L^^'X.CX >X(. i 



( 



(Momli) 
I IIIvRI-IJV Cl'RTirV. That I attende.l deceased from 

wet %\ T90H to cLoii. 190 H 

tli.d r last saw h .<^ »\alive on vk ^ 9.H T90 H 

and that death occurred, on the <late stated above, at 
^ ^ -M. The CATSI-: OF DI-ATII was .as follows: 





DC RAT [ON Years Mouths Days 
CONTRIIU'TORV UL\j^^y\luCCL 



Hours 



dtratiox 
(Signed) 



Years 



\ \_). \XaX\^^^'^ 



Mouths Days 





//ours 



M.D. 



'/ct ai 190 H (Ad.iress) bX?> llatlLiU/r> clt 



■ '^V'>>\.ot-rLc 



/\'f-ii/r,f ni S,ni /'mm ism 



)'i'(t I 



1 A. /////> 



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



/),n. 



'''ltl.^<T'y>V';!:^ '"'■■'' •'f^'K^'iNM. »'\KTICri,\RS AKi; TkrK To TIN.; 
"'•^I 01 MN KN(.\VM:I)C^ and HKI.Il-K 



former or 
Usual Residence 

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



How lonq at 

Place of Deatli? Days 






(x<i.i,,.ss 2)C^S^ N(f\>r>\t 



o.'cn'^'v.^u 



d 



^j4.. 



I'l.ACK OI- lUKIAI. OK RKMOVAI, I DATlv of Hi rial or KKMOVAI, 

3.0..S: . .QXtr^LQ:M....L^^^^ 



rxnivRTAKKR 

(Address 




F.very 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 per- 
sons dyinit away from home should be ftiven in every instance. 



! 



I M 






1 

i 






I' 




I I 

I i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f n. llth— »■" Vo. P 






)H.S:PCo 



/>^///' /v//v/, ii).ct<i4HL>v xn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lOO'X 



Becsi,stcj'e(l J\^o, 



2651 



1, 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Seatb 

( U. S. StanOarC> ) 

PLACE OF DEATH: — County of C cv-v^ J /v,tx.>^cvac .c City of u o^>^ J /vtju 



^'V-'CA-<il.C^ 



No. 



'A\!} 



nil V.CXL^f^OV-)v^cx. St.; 3s Dist.; bet. ^^CLV.kA.^'VA. and Otai-cU, 

/ .r Dr»TM^occu».s .way from USUAL RESIDENCE give facts called tor under special information • \ 1 

\ IF DEAtX OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )j 



FULL NAME 




xlx/y\) 'CNA, Cc(-C^v.O„ M I i' 



LLv 



PERSONAL AND STATISTICAL PARTICULARS 



i iK 1 li 






) >.i 



'X 



■^i^-I.K M \kk IM) 
W[I)n\\i.;j) ( »K in\» »K, II) 

•\ ' ■'» i II ^iMi:iI il'-'-i v'liat ii 111 > 



'! 



' '^t;i»< or I'Miititi \-^ 



V 



il):iv' 



1/ ..////. 



f- 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DICATll 



'Motitli) 



AL\.. 
(Dav) 



(Year) 



II 



Am 



(V 



NWTl Ml 

! \ 111 Ik 



I 



niK IHIM.ArK 

•>i- lArm-.R 

'State- nr l*oimti\ i 



1 \n 



1 I1I:RI:I5V Ci:RTirV, That l attended deceased from 
i9oi tn ..iy-^t^ 3s.b 



,'^ 



IQO % 



tliat I last saw li - alive 



on 



v^^ ct- ;u 



190 



and that <k'ath occurred, on the date stated above, at 

,^ yi. The CAr^i<: of di-a'j 



,^M. The CAr^I<: OF DIvATII was as follows: 



^S^ 




^^\, 



\! 



DTK AT ION )'i'ars 

CONTKIIUTORV 



Months 



Days 



Hours 



DIRATION 



"I MoTHI-K ( ^ ll / 1) 



»MK rm'i.A("H 
"!• Mnrin-.k 

'>\-M< ..r Coiiiitrx ) 



li 



"1 




ID,/CL\AAA.C>\; 



)'i'ars 



Mi>nths 



Havs 



(SIGNED) Jj. Uj. M I WxLviYAJUx^t 



Hours 
M.D. 



Jri 



-t; I()0 



(A.hlress) (o b JViu aX 'v \,M -'^.. 



I; 



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



' " ' I'I'A I'KtN- 



Vt^^'Ci 



]',■,<> 



\i,.„th- \ 



/',,• 



' "',;,\!!!,'^^'''''''^ ''''•■" ''HKSONAI. I'AKTkTI.AKS A K !•; TKIK To 1II1-: 

Hi-.si oi- Mv KN()\\ij.;i)c.K AM) iti:i.n:i- 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



l'I,ACK OI'JU'KIAI, OK RKMOVAI, | DATi; ot Hi kial or RKMOVAI, 

A9^" 7^% iQoH 



\(Mn 



LoJuJL^ 



N. B. 



Hii Vw<x^^r<J^wmJux, 



\ 



Qnu iDJLvoit 



I NDERTAKKR 




, K9.<x 



f Ail.lress . 1 *! 0^ ■ B-<^-^^^aJry^vlI^:>.\.LQ....Ql 



^ ' ■ 



Kvery item otf in?(>rm>ition should be oipefuily Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in piiiin terms, that it mjiy be properly classified. The "Special Information" for psr- 
"ons dyin^ away from home should be l^iven In 9\9ry instance. 



! 






I » 




g^ 



J"fl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



U.,.l!, 



f II. ..nil I- N.I l-^ -^-^^^n^) i'.Si.\' ( 



't*P^ ^r\ ■^*^%L# ^m^ W ^^ mm wm^^m wm* 40^ m ^^ >»am-. 






-■*-■' « w o»nv.r\ \yr v^CwPi I ir l^rfM I b P«jn ini9 I liU<^ riUNS 



7.0'(9S 



Registered J^''o. 



2652 






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



Certificate of E)eatb 

( XX. S. Stan^ar^ ) 



ofO 



(?^ 



PLACE OF DEATH: — County ofvA.~)V JVn, > v-,_i Qty of ' 'O^-vv J X cx^^kv t<-A ^ 



en 



No. 



- M 



V. 







St.; A Dist.;bct. LcldLL and Lilv.. 

[/ ir DL^TM OCCURS AWAY TBOM USUAL R E S I D E N C E G . V E FACTS CALLED FOR U N D E 1^ SPECIAL INFORMATION" \ 
A IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O^ STREET AND NUMBER. J 



t 



l! 1 ^1 



FULL NAME ^civ^.MXvd \1 K 



1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



:• \ n: < n luk i m n » 

u 

'JM..iitii 



^ 



l^ 



I).t\ 



I/..-,'/,' 



MEDICAL CERTIFICATE OF DEATH 
DATK OF I)i:.\'JH I \ 

(Month) I Day) 



/go 

'Year) 



■»car» 



^IMl.K MAKI<n:i) 

'^^ ' ■ -i^'iiati'iti 1 



■i 



I'.ikTni'i. AOK 

' Siat( or ^.'omitrv 



t" A I lll.K 



iUkTm'i,\rH 

'>'■ FATMKK 
->t at' nr Contitrv 



MMDKN NAM J 
'•1 MOTin.K 



ItlKTm'I.Ari-: 

<»i M(>rni.:K 

^lati .,1 C()\llltr\ 







0(> 



I III-klvHV CrCRTIFV, That I attcMided deceascMl from 

~~ ■ :--:—-. 190 to 190 

that I last saw h • alive on — — jjp 

and that deatli occurred, on the date stated a])ove, at 
M. The CAISK OF J,)1<:ATII was as follows: 



f "lOf - 



■A 



nr RAT ION Years 

CONTRIIU'TORV 



.a. 



Mouths 



Days 



Hours 



(\ 



■j\ 



U'V^C ecu. 



^tJ-^JL^v 

Kfsiiirt^ ill Sa>i I'l.uui-i 




Dl'RATION 



,0 



Years 



Months 



Days 



.-V' 



( Signed ) LcI\^n^Jl^; o.vJt),tll.AL:la.v 

'^^ "' " ---' (Address) L»\.fr-> \„<.\C) ll'^V^-^.^ 



Hours 
M.D. 



V. Al 



IQO 



I/,.-,'// 



/'„■ 



' "l;;M!V^ ''* STAT i: I) pfrsonai, I'ak ircn.AKs ak}; tkik to thh 
in-.si oi- Mv kn<»\vm:i)(.h and iihmi:f 



Special information onl) for Hospitals, instilufidns, Transients, 
or Recent Residents, and persons dying d^dv from tiome. 



Former or 
Usual Residence 

When was disease contracted, 
If not h\ place of death? 



How long at 
Place of Death ? 



Days 



niif.)Mn;nit 




lOx4.-L\U 



V(XL' 



'X'l.luss I I A. dll- ■O^A.i^icA^ -.,' e 



PI<ACK OI' RrRIAI. OK RKMoVAI. 



I)ATi;of HiRiAl. or KKMOVAI, 



^''tl 2:1 



190 



<Ad.ha-ss W^ U.ChLAJC/VV J /C\JLl...LL.VV.-^ 



• ^* Kvery item of infnrmHtion should \m cnreV'ully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in pliiin terms, that It may be properly classified. The "Special information*' for par- 
dons dyin^ away from home should be jiiven In every instance. 



I 



^ 



^^ 



'( 



J 



_,^j,^^jU|J^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



< A ^« lA «^ I 



K^rcn iw oA^^^rx vr v^cn i i r i v^m i k. rv*n li'v a I nuv^ riuiMa 



Ihffr n/r(/,V.<:XA>Vv 



XI 



ifjfj'i 



Begistcird J\^(), 



S653 



.^\^<,KJ^ 




.vu Depiity rlcaith Ofri!:er 

DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



No. 



dcrtificatc of Beatb 

( 11. 5. Stnn^ar^ ) 
PLACE OF DEATH: — County of 0/CL^\; J ,\xc>xculc v City o{^<Xjwj 0.\XX/Yveui,ac 
ll n ^Wvv..O > s St.; T Dist.; bet. \j iZA.<X'\^.<^. and 0^<X.Oj^^'^^O.. 

(If oc*TM OCCURS AWAY rnoM USUAL RE S I DENCE give: facts CAULto roH under "special i n formation" N A 
IF OCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / \j 

FULL NAME JX\.cL\.^va . . ^ VJ.<xcjlLLv;' 



^ "^ 



PERSONAL AND STATISTICAL PARTICULARS 



^n\. 



XXAx 
: 1 \ 1 1 < 'I I'.ik rn 



\ 



JUv 



Mdithi 



V . I-; 



r\ 



) ,,; 



i ; 



' I);i\ i 



!/.■»'// 



MEDICAL CERTIFICATE OF DEATH 

i»ATH or i)i;.\rii 



*•-. I I go 

(D.iy) (War) 



a 



/',,• 



-^i\« i.i' M \k \< ii-;i) 

\V tin >\\l-:i» nU |iIV< »K» 1' I) 

\\i if<- i II 'siK i:il rli vj^Mlat l"ii * 



\ 



•^tMl" or i". piiiid \ 



N \MI III 
\ \ III IK 



lUK'iiii'i, \t }•: 
'•I I \i'iii;k 

(St.it» ol luiiiltl V 






b. 



I 







r4 



f Month I 
I IllvklUn* CI'RTII'V, That 1 attciuk.l (Ircrascd from 

)jJl\X .' up. to ^. "-t :ii 



KP 'i 



that I last saw h '• alive cm W -cX ^b I90 '1 

ami that diath <»cturro«i, oil the date ^^tated ahovc, at ^ 
'■' M. The C.MSI- Ol- Dl-.A'PII was as follows: 



M \II)i:\ N \M) 

"I m<>tiii;k 



iiiK i-ni'i, \(i. 

■"'1'' "I e>)iiiiti 







DI'R.ATION }'rars 

CONTk 1151 TOR V 



Montin 



Days 



Hours 



iY 



II' \ I lO.N' 

AV /.//i' /n Si/;/ I 1,1)1,! Ill 



DIRATION 



(SIGNED ) 



C 



i 







r()0 



Yeats Months 



Paxs 



Flours 



M.D. 



Ad.lrc-ss)100('.D 



MKO->(iu.' a. u .■!. 



SPECIAL INFORMATION only for Hospitals, institutions, Trinsients, 
or Recent Residents, and persons dying away Irom home. 



)v,M- 5 \t,'iiiii- 



l>,!\ 



I'll I'. \Mo\K ST \ri:i) I'KKSOVM, l'\Kliri-I, \KS AKi: r K T l-! To I" III", 

iu;sr<)i. Mv KN<»\\ij:n<,j-; and in;i.n:i- 



'lllf')!IU.IIlt 



^JAA.A.^-^jL.i'Jpjl ^J /O^c^xJCi' 




X'lrit,.^^ \\ 11 U^^x^^.,/(r^v uAj 



Former or 
I'sual Residence 

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



How long at 
Plare of Death? 



Days 



I'l.ACK <>i" niRiAr. (»k ki:m(>\ai. 



HAllCof MiKiAl, or KI:M(»VA1, 



:x!\ 



190 t 






1^' B. livery item of informHtion vhould Sn cnrefully supplied. AGE Hhoiild be stnted EXACTLY. PHYSICIANS should 

• tatc CAUSE OF DEATH In pinin terms, that It mny be x*ropcr\y classified. The "Special Informntion'* for psr- 
son« dyln^ away from home should be jlivcn in every instance. 



•Ml 



4' 



i 



II 



^"•'— ^- 






I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f 11 



, .Itli- !•■ No. !<; ■^•t^sav^Mitr C.) 



REFER TO BACK OP CERTIFir.ATF FOR I NCiTPiirxiniuci 



i)(ih> /v/fv/,li\et^lU^; X\ 



IfWI 



Bcgisfered J\'*o. 



2654 



M.^A.^ cLv,\»^t 



\ 



Deputy 'ricntth OfTmer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( XX, S. Stan^a^^ ) 
PLACE OF DEATH: — County ofC a.^\; ^V^C\ >vCUiCoCity of Oo^vv AxX/vv/ci.a^^1x^o 
No. ^ ^''taVK St.; I DisMbet. vUX<KX<iA.u^au and vTac^Lc 

(IF orATH occurs Ay*(*v from usual R E S I OE NCE gi vc facts called for under "special information" \ ^ 

IF OCATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET ANO'nUMBER. / U 



FULL NAME 






■\ 



; \ 



PERSONAL AND STATISTICAL PARTICULARS 




1. 1\ I 



V. 




k^tc 



DA ri: < ir uik iii 



l)v. 






lb 

il);ivl 



r%\^ 



X 



1 



Miiitlf 



II 



(VtMI I 



/!,/ 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH l\ 



^Nfontli) 



a.1 

(Dav) 



(Year) 



1 -<Miii I <l< •«iviiati<>n) 



•IK linM.AOK 

^' '*' '>! ' ■'>ll!lt v\ I 



'Ml (t|- 

^ i hi:r 



''■IRI !in. \cy 

•'I I MiniK 

'Sl;it«' or ('.unit I V 



M Mill' \ N \M). 
M' >TIIJ K 



I'lK IMI'LAlH 
"( MniiiKK 

' '•• "t <."-tumi\ I 



1 

I 

' >\' J Cr^-v 



I in':RKHV ClikTlI-V, That I atten. led decvased from 

^ ct. 10 i9on to ..ii'^'ct XI up 4 

that I last-saw h 't^n aHvc on ^ ^ ^H 190 H 

and that <U'atli occurred, on tlie date statcfl above, at i 
UL M. The CAlSf-: ()!• I>J'<-)slJf was as follows: 




'^k^ 



J.XCL -\^' cx 



».' \ 



1)1" RAT ION )V(7/.? 

CONTRllU rokv 



u 



Month: 



Davs 



Hours 



DT RATION 



) I'ars 



AfoHlhs 



"^AXrAla 



Days 






1 \ 1 ION 

l\' uiiil III Siiii / I iiiii lu ,) lU )V'(M> ^f'liilfi' 



(Signed ) 

iDdt 0^1 lc)oH (Address) li^C Olcllxh/ ^J 



Hours 
M.D. 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



THI<: AMOVK Sr \Ti:i) I'KKSoNAI, I'VKIUTI, aks aki-: TKIK To thh 

Hi-.sroi Mv KNo\vij;i)i,K \\i) iti:i,ii;K 



"'if'itniaiit 



^Nd.lrt-ss 






PI,ACK OF lU'RIAI. OK RKMOVAI, 



DAXKot HiKiAl. or KKMOVAI, 



INDHRTAKKK 



L cX 2>o T90 

fA.Mrrss 2)0 5 \I)\^>xWu. '^Lv-S-. 




•Uv^'O 



lition .hould be cnrefully supplied. A(JR nhoiild be stated EXACTLY. PHYSICIANS should 
ATH in plnin terms, that it mny be properly classified. The "Special Information" for p«r- 



'^' •*• livery Item of inform 

state CAUSE OF DEATH in p 

«on» dyin^ away from home should be 4iven In 9\^ry Instance 



II 



I ■ 






I 



& 



li 



III' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^^=^ ~"^ — BEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

la/,- ri/,;l. lixttr-W 5.1 



W0\ 



Regisiered J\''o. 



'^655 



MLU Itwu Deputy H 



er 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

dcvtfficatc of 2»eath 

( "U. S. StanDarD j 
PLACE OF DEATH: -County of^^^^^V Ka ^xCuyco City of 3^^ JxcVwcc^ o 








FULL NAME 




■I oi\Q_ti 



?> 



^.o 



PERSONAL AND STATISTICAL PARTICULARS 



ill 



n 



I'M lilk I M 



\r..nlli 






1 



•D.ivt 



\«.»-; 



^^ 



\ ,.-, 



I SC.ii ) 



/'./I 



LMojith) 



W ! it«- ill s. ,. l;,l tl( Slvrl|;,tj,,,,) 



iiikrm-i.ACK 

"^tlltc I ll ( '(Mint f 



\M1 (.1 

\ iin.K 



ClWj^K.d^ 



i^iK rni'i. \c\: 

^' lI- XX Volllltf \- 






"ii<inpi..\(F 
•" "^'<'i*in<:K 




MEDICAL CERTIFICATE OF DEATH 

i> \ri-; nj- uKAi n , , 

I Day) (Year) 

I lU'RI-HV Ci;RTn-V, That X attemkvl clecc^ii^ f roin 

li-.d: 15^ 190H to i!^d: XL Tcp^ 

that I last saw h OVi alive on (L'^ Xb up H 

auil^that .Iiath occurred, on tlu- <latc- stated above, at % 
M. The CAISK Ol- Dj-ATH was as follows: 



DIRATION 



)'fais Monl/is Days X'i Hours 






Mouths 



Pavs 



ah.u Uai^(^' 



1 1 






I )!• RATION Ycius 

(Signed) * LL L^vv'rtMXu 

li/ct 5-1 igol (Address) 5bS (fc <Xh,VL4*M dt 



Hours 
M.D. 



Special information only for Hospitals, Institutions, Transients, 
or Rerrnt Residents, end persons dying dway from home. 



I ia\ 



Former or 
Usual Residence 



W 



-^j How lonq at 
VVX JV Place of Deatfi? 



Days 



When was disease confrar ted. 
If not at place of death ? 



"••^1 <»!• MS kN(>\VIj:iK,H AM) HI-I.MJ 

(i pj 3 J 



■: 'n > THH 



ri^XCH ()!• lUKlAI, OK KKM(»\AI, 



DATlvuf Ml KiAi. or KKMOVAI, 



(Adclress L.^ '^ ^^ (yCUvJU. ['It 



TQOH 



N. B 



Kvepy Item o^ Information should be ciirelrully Mupplied. AGB should be stated KXACTLY. PHYSICIANS should 
•tate CAUSE OF DEATH in plain term., that it may be properly classified. The "Special Information" for p«r- 
"""8 dylnft away ?pom home should be given in svory instance. 



r 



\\ 



' 






! I 



^ 



.:- - sr.-res 



« ' 




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

'^"^ ■— ^ "gP'gR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



6^1 



.trV.L<^ .is^k. iH^ 



/.v^;** 



^^ cy~ 



Registered J^^o, 



8656 



DEPARTflENT OF PUBLIC HEALTII-City and County of San Francisco 



Certificate of S)eatb 

' 11. S. Stanza rC^ ) 



PLACE OF DEATH:-Co.n.. of ^ C...'lka>vc..cc Gty of ^^.^Vo^^., 



INo. 



X.t.,.VL 



Mi "v^Uj 



I VlVtiv^tCi.^ St.! 



Dist.; bet. 



FULL NAME >'^avLK W^»x(r>vd 



and 



( ■' -^J^vt^::^: -vj^;:^- o%^^^%— -.--^v^v :;a -°i- s.%%%Ti:ri?^;'°^ 



^i;\ 



PERSONAL AND STATISTICAL PARTICULARS 



i^ 



J'A ! i; Of i:iK in 



U'ivcL 



M..Iltll! 






n 



r, .; 






1^ 



' »'i-,' ; ' 



/',.' 



'YfMr» 



( 



MEDICAL CERTIFICATE OF DEATH 

I'ATK <»!• I)):aTH , 

, 1 HI-:KI;I5V CI:RTIFV. That J attc-nde.l .k.casc.l from 

tliat I last saw h <-rv\ alive on Vi at AH iqo4 

.'iM;! that .li-ath ocourrerl, on the .latr stated af)ove. at I I 
'■' M. The CAISlv Ol- I,|.;.\Tn was as follmv.: 



' St. If, .,r I". Mint r \ 



V\M1 Ml 



'ilKTin-l.ACK 

",'•■ »-atmi:r' 

iStiitf or I'oiintrv 



MMI»K\ N\Mi 
' MoTllKk 



"»• NtM.'HI'k' 



/^ 



'^-^4>U 



1^ k 



1 



CO.NTRIIU'TORV 



Honn; 







I M RATION 



\ 



Years .^foui/is 



Days 



^SIGNED) a C9. L0^JLcL.>V^ M.D. 




)-■./, 



^ 1/.../'// 



nr?.^n^?"!i'-, "^r^"'^^''"'^'^ ''"'> '"^ "^^P'f^^ Institutions, Transients 
or Recent Residents, dnd persons d>ing avvav from home. "-nsients, 






Former or 
LsudI Residence 

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



HoH long at 
Place of Death ? 



Davs 



N'Mr.vs LLt'^>vCu'rv(r^ 



J 



••c.<lX 









INDKRTAKKK 



«t"t7cMr8E'ofD^^^^^ AGF. should be «t„tcd KXACTLY. PHYSICIANS «h« IH 

.,,«r '-^IJSt OF DliATH in pluin terms, that it mny be properly classified Th. ••« • • . ^"^^^'^'^NS should 
«'>". dy.nft away from home should be ftiven in evert instance ' "*""'*^- ^'^^ '^^='«' '"formation- for per- 







It 



f 





. t ..f tTf^tnii r Nu ir i-!-aw?««i) j[,\:i' c, 



WRITE m.A,NLy W.TH UNPAD.NG .NK-TH,S ,S A PERMANENT RECORD 

"g^g'^ TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

^'^^^ ^ RegLsteved ^^o, 2656 



\ 



'^wv 'U 



^ 



<•' ♦* 



DEPARTflENT OF PUBLIC HEALTH-City and County «f San Francisco 



Certificate of Beatb 

( tl. S. StanC»ar^ ) 
PLACE OF DEATH : - County of ^' C^>^ h ►va^cc4cc G "^ 



(^ 






No/^Ltt'. '-^L 



^U^^U^ 



, f 

^ i>u.fua4v St. 



ty of ^W'>\i J Xa/vx<^ui. 



C>0 



r "■ f/*;»^ occuis AWAY FHOM USUAL REsTd 

V IF DEATH OCCURRED IN A MO^o.t.. «= . " 



Dist.; bet. 



and 






) 



FULL NAME ^\aa\ 



--i \ 



PERSONAL AND STATISTICAL PARTICULARS 



jxk\ »x{rrcdL 



1)1 



aL 



<. 



' ' 'I i;iK 1 n 



lllvLbc 






^ 



[ I 



r,,.r, 






M.i>illn 



/Ub 



/p<9 I 

(Vt-ar) 



"»■«■; II I 



"^' iJ-. M \ku n-!» 
' ii>«'\v».:i> (.k i.i\mk:. i,r) 



IS 



/' 



'(/ 1 



Si.itt- ,,r Ciiiurx 






"f ' mmi-k' 

fStnf, ,,r roimtrv) 



"! M<»Tni.;R 



"1- MnrilKk' 



"* »'i r\i-i().v 



( 

\ 



MEDICAL CERTIFICATE OF DEATH 
I>ATK (►F I)I-:\TH ( > 

(Month) ,,,.,^.) 

I HKRHIiV CKRTIFV, That ^atteMdc..l.lcccase<r from 

ajrvn^a ^3) ,,^s to (i'/ct 1^ i,^L( 

that r last saw \\Kjyy\ ahve on (i at PvH ioqH 

■•«U.l that death occurred, on the date stated ahove, at 1 1 
M. The CAISH OF DFATM was as follows 



:j-X,>: 




I '1- RAT ION )Var. b Mouths I /A^,, /y^,,,., 

CONTRIIUTORV 




I I )r RATION Years Mouths Days 



ft 



Hours 

^^ M.D. 

rvv<^k e'L^<Ll 

nr^p^.n^^'^'-. "^f*^"'^^"'"'ON only for Hospitals. Institutions, Transients 
or Recent Residents, and persons dying away from home. "-nsienis, 



( Signed ) 

_^t IH ,,,oH (Address) 










former or 
Usual Residence 

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



How long at 
Pla( e of Death ? 



Days 



"'ifoitll.'lMt 



' X'Mi.'ss 



'ML4x 



^rUACK OF m-KIAI UK KKMOVA,. I F.ATK of H, ku,. or K KMOVAl. 





C^i^^lX 



.<yi' aUli^ W./etr AS J00I 

N-DHRTAKKR JVLLLtU ^1 



.1 



/<X 



(Address ... 5.b.l^ X - \ \ t JL. "rii 




"Wi 



"X^c'r^SE OF DF ATh" "'7''' "" ^"-''""^ »"-P'-"- AGE should be stated BXACTLV. PHYSICIANS should 



ill 



^ ti 

' 'I 

•I 



i ^ 



i I 



S i 



'^LLiS'^' 






■iissm. 



I i ' 



I 
» 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

f llijillJi IV.. 1^ t-^'^^Sv^iuS:!' Co 

RCFER TO BACK OP CERTinCATE rOR INSTRUCTIONS 



cA/y^c^> <,..v. Deputy Health Officer 



Registerecl Xo, 



3657 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( "a. S. StnnC»ar^ ) 



PLACE^OF DEATH:-County of d<X^ Jx^^c^c. Cty of io^v^XC. voc^ c. 




\ 



No. IbbS" HfLc>:LNL^. ' St* 5 n- f t^ i"^ M i' I' 

( >r otATH OCCURS AWV FROM USUAL R E S I D E N C E r , w r I.J. * ^'* ' ^^^^^ Li .t. 



) 



FULL NAME 




1} 



o.\Qa;^.-...'., 



■<^ 






PERSONAL AND STATISTICAL PARTICULARS 



'■»'f;ir) 



(Year) 



V 1 , ., 

-^ ^'I.K M\KKI);i> 

A i:»ii\VKi> Ok l);\ ( >h-, J. I, 

H ;M'- ill •;.K-!;i; .l.-.ij,MK,i;.,n ' 



v^ 



1 ' 



HlkTMPI.XC).; 
Sl.itc «>i Ciiitili \ 



\ \MI ()| 
»• 'THl-k 



"it< rniM.ACK 

<" lATMI-K 
'>>tatc or liiiiiiti \ 



""^ VH'i:\ NAM).- 

"I MoTHKk 



"Ik'lUl'i.ACl* 

• >i NjMTHHk 

'Stat. Mf rouiittA I 







MEDICAL CERTIFICATE OF DEATH 

DATK (»}. DKATM ^ 

^ Month) ,i),,y) 

I IIHRKHV C1:RTIFV, That f atte...U<l (Icceasedlroin 

'^^^ up u> ...iQct. 5s5: 190 H 

tliat I last saw li •■^^ alive on ^ ^ ' '• j.^ ; 

.111.1 tliat <lcatli occurred, on the date stated above, at '.-. ' '. 



yi. The CAl'SK 01.' DivATH was as follows: 



vxv.'vd.' 




OxA,..*Nji;xA.>x^', 



ni RATION 



CONTRIIH'TORV \h 



/.uc, 



Monlhs Days /Jours 

....(^.V-<X,' LLiLL.ixv>.,.v..O. 




DIRATIOX ^ Years 



.'ifofit/is 



(Signed ) 



JAJUL LI vS>V,cx 



/A/ vs 



I /ours 
Y M.D. 

(Address) XV'V\ vhA.<iA.L^'>v ;' 



'" ' 'I'ATION '^ 



?^^9'^*- INFORMATION only for Hospitals, Institutions, Transients, 
01 Recent Residents, and persons dying away from home. 



) V 1/ / . 



M..iith^ 



lhi\ 



• .Ti iji .M\ KNOW 1,1.1),, J.- xvj, ({|:iji;i. 



CoU 




Former or 
Usual Residence 

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



How ionq at 
Place of Death? 



Days 




f\'"^r\^' !I^ Cr\'*'/^'' *"^ '<HMnVAI. DATi-:,,) HrRiAi. or KKMOVAI, 






(Address . 



•^trtTc'l'TsF^oP m^^^ '*' ^"-«*'""> «"PP"«^''- A(iK should be stated EXACTLY. PHYSICIANS .hould 

«on. dvlnl Oh DLATH m pliun term*, that it mny be properly classified. The "Special InformHtion" for per- 
son. d^Inft away from home should be i^iven in every instance. ^ 



~1 



< I 



I 



I 



I 



i li 



\'.ii:\u] 



tt^-^' "'''» I' 



i 



WR.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

\ \-, [^ ^'f'Sr^-^L;:. i*.v. 1'.' 

REfEH TO BA CK OF CERTIFICATe FOR INSTR UCTIONS 

658 



/»,/,■ I'll,', I, tcti^t. 



6-U.O 



I Deputy Health Officer 



Regiatered J\''o. 



2(^^ 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



Certificate of Bcatb 

I tl. S. StaiiD.irO ) 



PLACE OF DEATH: — County of 



iX 



(^^ 



City of M I LCL\\.ce I 



No. 



St.; 



Dist.; bet. 



/ ir orATM occuBs *w*Y rnoM USUAL RCSinrNrr .. r 'and 

c .. DEATH OCC....D ,N A .o,%fA[ Tr^ fj s^^^j^fo^-ji.v 7t1 5,Vm7 ^.w^.To' j:!!^^-^::^:," 



) 



FULL NAME 



■tVO-dx*!. 



PERSONAL AND STATISTICAL PARTICULARS 




a.1 



iK 



MEDICAL CERTIFICATE OF DEATH 

DATi-: t.i- i)j:\-im 



"I Hik III 



.v<x^H 



M :n 



Dav 



0,d 



» ' ; 1 ! I 



/l/i 



i"'U i:i> OK I)IV,)K. J 1) 



'^tiitf or c'otiiiti \ 



Ml I 1 1 



luk rui'i, \vy 
*'i rvriii-k' 

'Staf, , ,„,„,, 






I'll' iill'i.Xi-i.- 

''I '^?«>rin;k 

«^talf ,11 Cnuiitiv 




I 



\ 






^^'""^'•^ <I>ay) __^ ^(Year) 

1 HHkHIiV CI-RTIFV, Tliat I attemlcl (lcccas^<rfrmii 
- ■— 190 -to ,^ 

lliMt [ last saw h r — alive 011 — j^^ 

.111.1 that (Irath nccurrcd, <m the .late state.! alM)ve. at 

M. The CAISI- or I)i;ATn was as foll.nvs- 



. w. ^ 



X- 



\J^K> ^ ^ -^ ' 



r 











L\.<r V \. 



DIRAIION }'rars 

C'oN'lRir.lTojn' 



Dr RATION }-rtirs 



Months 



/)iJVS 



Hon 



; V 



(Signed) 



V. 



iL\t 



Mouths 



Pays 



Hours 



\ \r^^ ~ 



^'i loo H ( 



Address) . IfWvtW^vOu ll ) 



M.D. 




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



)',.,. 



^J..;tli^ 



•" MN KNOW ij.iH.K AM) iij:i,ii:i- 



' ' " '"itiiaiit 






former or 
Usual Residenre 

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



How lonq at 
Place of Death ? 



Days 



I'l.ACK Ol- m-RIAI, OK RlvMoVAI, I I) ATi: o! U( kiai. or KFMOV-M 






vOLavVAwO (J. Jo-d • -< V 
Ad.lrt-ss SOS" ^n\^rrj^1^ Vt.U^ 



rM)i;KTAKi-;K 



•iaVe'^cl'imFU"ATri^'C^ '''""''' ''^^ ACIF. Hhoflcl be «t.,te.l liXACTLY. PHYSICIANS should 

»«on. dvln^ <P T" '" »*'"'" **''•'"•' "''" '' '""> '»'^ Pr-operly cla8i.h-|cd. The ••S„cclal Information" ?or p^r- 

"n« cii.n^ away from home Nhoiild be Jiivcn in .very instance. 



1 \ 









1 ^ ^ ' 



' li 



.f 11, ilfh )■ V(, I : "^'Sr-Tr-ii'. iix- p r-.- 



WRITE PLAINLY WITH UNFADING INK-THIS ,S A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

lUgLsteved J\'o, 2659 






\ 



D'^ni.'* 



10 0\ 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Scatb 

"U. S. StnnC>arC> ) 
PLACE OF DEATH: -County of '^' a .x. + Va.v^t^cCity of dcu-VA. i 



vV, 



7^rf>» 



riVMVctt'&c^iK.tal 



ty of Q^.O^y\j J .Vo^/VL/CuiC 



St.; 



Dist; bet. 



and 



( " .vr.:.:^^c"r„%;r„',"r.".-i^ :i^±^^:::i:-- ^.r.'i ,x — ? s?.%%T.^'r.— ir- ) 



) 



FULL NAME 



1 i 

I 



V LLCrV<i 



VlV^... CIA: 



PERSONAL AND STATISTICAL PARTICULARS 






J ' 

''I I.IKIH 



.1 



IC k.t. 






lb 



/IbH 



MEDICAL CERTIFICATE OF DEATH 



DA ri-; < >!■ hi: A'l-JI , ^^ 

(NfoiitJi) 



'■»'<ar) 



\ I • !•: 



^C 



A 



1 



'i.i:. M\KKii;i) 
'""Hi-:i> MR i.;\okri;i) 
1' >''.Ktiati«»!i) 



riii'LACi. 

'■ or <'.Mnitr \ 



')■: 



la^^' ^ 



(Day) (Year) 

I UKRJ-HV CI;rTII'V. That I atU'M.kMl .leceasedfrom 

-' -^t 13^ K^oH t.. e ?.t Xb i^^ 

that I hist saw h Lv>N alivr n„ 11.. ct ^l jf^oH 

aiiij^that (It-atli ..(>oiirrc.I. mi the .latr statol abuve. at 1^0 



^ 



NAN! I Ml 

'•■ \Tiii:k 






" M"Tii);k 



HIRTHlM.Ari- 

"I mmthi.:k 



^ 












•M. The- CMSh: ()!■ |)|:aTII was as follows: 

I>r RATION I )V</yv 1 Monlln Days Hours 

(. O.NTkllU TORV 



I >r RATION 



) 'ears 



I\[o}iths 



Days 



Hours 

(SIGNED) \m.M^ OiAL\.rw M.D. 

' C) ' 

ll Ct 11 ,c)oH (A.hlross) t'^a lLaM.A ^.t 






L 






1 

SPECIAL INFORMATION only for Hospitals, Instituflons, Transients, 
or Rpcent Residents, and persons dying dnay from home. 

Former or 



rormeror .^ , \~\ {] *^ How long at 

L'siial Residence lot ^Ab " b \J\, \X\>\^ o Plare of Death ? 



\I,>,lflls 



Ihl 



'''nKsVorl'lvVv^u'^'^^'*^^'- '•^x'lrii.AK^AKKTKi K n. Tin-: 

"1 -IN KNn\\l,j..i„;K AM) MHI.n:F 



When was disease contracted, 
If not a( place of death? 



Days 



' '"f'i'lllMIll 



■ N'ldress 



••-.•..'■.1, .I.-.!/ i>i-. i.ii', r 

la.'xb -(«,ti. d ... 'y 



ri^\CK ()i> nruiAi, ok rkmovai, I datkoj" ntKiAr, or kkmovai. 






T90 



N. ». 



8t V^CA*^"* ^^ '"*o»''"»tlon should be cnrefully Huppliecl. AGE should be stated EXACTLY. PHYSICIANS should 
son I • ^^ ^^ DEATH in plain terms, that it may be properly classiltied. The "Special Information" for p«r- 
n« clyini away from home should be ^\\er. in every instance. 



■I 



i 






I 



> 



WRITE PLAINLY WITH UNFADING INK — THIS 



H..c.',II! 'Ill iV.. :- ^-t^-JT^lj, n.^^ |. ,-,, 



Ih 






K n 




100\ 



»S A PERMANENT RECORD 

^^^n Tu BACK or CERT.nCATE FOR INSTRUCTrONS 

Registered A'o, ^660 




^'^'^A 



^ 



DEPARTflENT OF PUBLIC HEALTIl=City and County «f San Francisco 



Certificate of H)cath 

( "Q. S. St^n^arC> ) 



PLACE OF DEATH: -County of 3 ^.v i Xa vxco., City of 3<....'^. 



Nf). b \ 



1^ 






C - or.TM occurs .w.y rp,OM USUAL R E sTde Ncf. ..r ^^^^-^ ^^'^^-^ "^^"^ V^n^XXm, and ■ ^^ <' . . . 



xvv.'.) 



^ 



FULL NAME ^VA.-^vd 



^A-C'VCVO, > 



1 " "^ "^^N 



PERSONAL AND STATISTICAL PARTICULARS 



i ' \ ; 



V V 



a » 

lulltll 



»,l \ 



.1/ ., 



M \ k k I J . 1 1 

<: 'I' si^'tiat i.,Ti » 



iti \ 



^ 



Lcy'. 



MEDICAL CERTIFICATE OF DEATH 

I ^J^kl•HV CI;rTIFV, That I aUen.lc-.l deceased fn. 
190'. to ...kL/'^. 9>.5, 

that I last saw h aUvc 011 Vl c (. \, . 



• Day) 



I go 

(Year) 



III 



aii-i that death ...vurred, .1,, the date stated above, at 
^^ M. The CAISr: Ol- Di-ATH was as follows: 



190 
190 



'> V-'. '^. 



v\\ri or 



'•■■- . Mil. A. l-- 



\IMI.|;\- NAM,. 
01 MuTtlKK 



'>lit.- ,,r (^M^u,^ 



<X^\ 



(? 



va. 



"V. 



cv.tv^^-k 




ucv 




I>f NATION Ycai-^ 

CON ^RIll^T()RV 



.I/(>;////.? 



Day 



I lours 



)\ius I Months 



l\ivs 



DIRATIOX 

(■ Signed ) \. . d ctWvlLcx^j 

^'<^ ^'> 190 H (A.ldress) ICHia'tllv, JA 



Hours 
M.D. 



Special Information only tor Hospitals, institutions, Transients 
or Recent Residents, and persons dying away lro;n liome. 






Former or 
Usual Residence 



HoH lonq at 
Place of Death ? 



Days 



'■' '•itiaiit 



^X'l.lrcss 



U)0 \ 






^'very item o? lnform«tion .h 



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

J'LACK <)I- fUKIAL OK RKMOVAI. I DATi; of lU rial or KKMOVAI, 

^crlu 1^<HU-. I ^' ^t.^^M 190 'I 



rXDKKTAKKR > ■ V' , U V^^''''*^>"^<f\: .'>.V...L..<1 

(Address 1. i».l \I/\a^4AA^>Tl....^.1 



state CAUSE OP Hf riu" "*'**"'*' **" carefully «upplled. AGE should be stated EXACTLY. PHYSICIANS should 
«'>n« dvJnrt „ "f- OEATH In plain terms, that It may be properly classified. The "Special Information" for p«r- 
^•ng away from home should be ftlven In every instance. 



i % 



I 





n 



w. 



ii L 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



«» 



pHjiTtt trf w^Hit#==^^ ^J'~» 



...*je*r>.- 



us. U I ' 



nrppR TO RACK OP CFRTIPICATE FOR INSTRUCTIONS 



D^fr /v/r</,W/ci>Wv 3.1 



190 H 



Registered JSTo. 



2661 




\-A <\jlj\>\A 



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



Cevtificate of H)catb 

( "a. S. Stan^arD ) 



^ ^ 



PLACE OF DEATH: — County ofO/avu O/VOavculc City of Oo/w J A^VA^^e i^i:^, <?. c 



No. 




L 



\ Lave \xiu ' i^ ^^ i vv t a. ^' 



St.; 



Dist.; bet. 



and 



/ ir DtATH OCCUtvfe AW»V FROM USUAL R E S I D E N C E G I V t facts called fob under "special INFORMATION" N 
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



^K.Oj 




JV>X*i-C)v 




NJ.X 



DATi: tir iMKTn 



.\<.K 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.OR 



.V .) uL^'^ 



')U: 



^ 



MunthI 



IM 

(Day) 






5b 



J 'i-ii I - 



M.nifh- 



L 



(Year) 



/'./ 



SIN(.1,K. MAKKIKI), 
WinoWKI* OK niVoKCKI) 
'Write in suiial iK >ivMiati<)ti) 



niK IMU'LATK 

(Stall- or (."otnitiv 



x) .c-cL 



CrL.o^\; 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH 

(Day) 



(M<»iith) 



(Year) 



I in^RHHV CICRTII'V, That I atteiKlcd deceased from 

/<XciL li^p^i to \y..^^. S».b iQoH. 

that 1 last saw li •'^- • alive on vJ-^' ^>b iqq 1 

and that death occurred, on the <late stated above, at T o .':^ 

M. The CArSl*: C)l< Dl'ATH was as follows: 



i 



CA &A_\>'0 



NAMK oi 
FAIMI R 



lUR'I'HI'I.AOK 
OI" l-ATIIKK 
IStatf or I'omitrv' 



MAn>i:N NAMK 
Ol' MOTHKR 



lUK'rni'KAil-, 
OI- MOTIU-.k 
(Statf or Country) 




.^Av<i ^ .V 



1) 



1 . ? 



I) (RAT ION 1 Yeats 
CONTRIIUrrORV 



Mont /is 



Days 



I /ours 




f\rsiJfi{ ill St:>i f'l am i>i'n " ]',tu •. " Minifli.'' 



OCCITI'ATION Wt 



DTRATION ^'tars Mouths 

VA., .at.oA^t 



Pavs 



(SIGNED) J 




:i 



1.1 U)0'i ( 



Address) LaIu Xc Lq . lb (V^^y^ut^ 



Hours 
M.D. 

a.1 



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



Former or 
Usual Residence 



MliwlLiida^^.li. 



, „ How long at 
fXy.(^< 01 !> Ware of Death? It. I... Days 



na\. 



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



Iiifonnant 



TMK: AHOVK STATl.I) I'KRSONAl, PA R lUT I.ARS ARl*. TRKK TO THK 

nK:sT OK MY knowm;i)('. K .\M) iu:mk:k 




0-<i-' 



U.A..V.KX. 



rNDKRTAKKK 



i).\'n;of utui.Ai. or rk:m()vai. 



IM^ACK OI" niRIAI, OR KKMOVAI. 



I9OM 




N. B. Rvepy Item of Infopmation should be carefully Hupplieil. AGK flhould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information** ?or psr- 
sons dyln^ away from home Hhould be ttiven in every instance. 



< ■ 



1I 









(1 ° 



V-\ 



\: 



w ♦ 



^rif|l 



# 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

itoataof ihMiih » No 1' '*4^^^)ii.<tl'C.i REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da/c /v7r^/,iL'.<:l^V^ 5.1 



190 H 



Registered J\^o, 



2662 



cL^A^AA^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificatc of Bcatb 

( in. S. StanDarC> ) 



PLACE OF DEATH: — County of OxX'■v^J J A-<X/ vvoi^c'City of Oay\^> O/v-cxv^cvo-Ci, 






No. 





<.<Xk) ()b(yA\vv.ia.'(- 



St.; 



Dist.; bet. 



and 



IF DEATH OCCURS AWAjT FROM USUAL R E S I D E N C E G I V E FACTS 



(IF DEATH 0( 
IF DEATH 



OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



TS CALLED FOR UNDER "SPECIAL I N FOR M ATI O N '• \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




/ ^ 




yVY\AJL .\jL0:sl4,\j 



PERSONAL AND STATISTICAL PARTICULARS 
DATl. <»l It I Kill 



i.iitij) 



•\(.H 






J v.; 



I I);i\ ' 



M'fi'ln 



' V<-;»r) 



MEDICAL CERTIFICATE OF DEATH 

DATK (>»•• DKATII 



CI 

(Month) 



(Day) 



(Year) 



/'./I 



•^i\«". i.i:. MARK ii;i) 

\\II)(»\\KI) OK I)I\< »Ki i: I) 
I Write- ill s<M'iitl drsij^iiiitioii) 



lUK riliM.Ar).; 

I Statr (il (."1111111 I \- 1 






I ATI! i;k 



HiRrnri.ACK 

<)!• I ATIIHK 

• Sl.iti- i»r I'luiiitrvi 



MA1I)J;n NAMl-: 
<»l- MOTHHK 



r.TKiinM.Ari<: 

ni- MoTMHR 
(StJitf or Countr\ * 



oiCri'ATION 




VOVVCL^ 



&.\ 



I mCKl'il'.V CICF^TIFV, That I atU'iKlcd dcocased from 

■LuL.Li^ 



N^ >>w 



d. 



I 







<x 



\Ax 




0^j\\.^LX.'y\} 





f\rsi,lrif ill Sun /'i ,n/, /\ri> O^ )'c'rM.v '\ .\f,int/i.\ \\ /)(iys 



... ..<L^)Xi ] 190 ') to A^O-VJi. 190 'l 

that I last saw h •: alive on ^ T90 '< 
and that diath occurred, oil the date '>tated above, at 
M. The CAI'SIC ()1< I)I-:ATH was as follows: 
.„Lca-s,.La- >3yr>^X^^LtA, v^v ^/^c^-tXc^A^, . • 

>^k L^.l.^.^^ 

Dl'RATION )'tars ' Mouths Days Hours 

..\..\ a....at.j^/>AjjL<aA5..n\.;. 




CONTRIPd'TOF'lV 



DURATION 



Aw:w.c 






\n 



Years Mouths 4 Days 



(SIG 



NED) H,.,/&). LUiA>O.La 



Hours 



iqo \ (Address) 



M.D. 

b:x?s WUx^vt oit 



»fls. 



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



Former or .a , . 
Usual Residence c^ I i)l> 



\\ "Ax How long at 

LV/WaAvx 'i~ Place of Dea 



Place of Deatli? Days 



Tin-: MIOVK S'I'A'n.I) I'KKSoNAI. rAKII(*ri,AKS AKT: TRIK To TIIK 
l«i;sT OI- MY KNOWIJIDC.K A NI ) HKIJICH 



(Iiifoi iiiant 







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



(Aflclress 



ri.ACK OF niRIAI, OR KICXfoXAI, I DATlC of HfKiAl. or RKMOVAI, 

%J^Qu^^ I ^'^ ^'j .90H 

UNDKRTAKKR U <xJjlA^ctL M lV'CX7Uw/>^^! ^'^ Ll 

CHS 1..5"XH 0±^KtJ*Ctcx.^....di: 



(Addro 



!N. B. Bvery Item of information should be cnrefully nupplied. AG6 should be stated BXACTLY. PHY8ICIAN8 should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "8pecial Information*' for per- 
sons dyin^ away from home should be ftiven in 9\ory instance. 




|i 



i 



■;i 






WRITE PLAINLY WITH UNFADING INK 



»',,,.,!.! .J H'llfli I" N.. 1= f^'^sr^-^^WKV C 



THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I) 



a/r /'V7r^/,i:^UVt\; IT 



190 H 



Registered J\^o. 



2663 





X4 -sJlAj^ Deputy Health Cfflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( U. S. 5tan^ar^ j 



A 



Q^ 



^ 



PLACE OF DEATH: — County ofOcX'^v J,x,cx-»'v.cc^.e.<.City of 6 /cv^-v.' J /vcv^ vc e<:i ^. < 
cL'Avl'- . St.i Dist.!bct.H I tOCt<LV.<n\; and ^^O^V. 



No. \ I oL'xcO 



St*; Dist.; bet* 

SIDENCEGivt rt 

OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE 



/ ir DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \ 
V IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



L/wMK^a,) 



FULL NAME 




c\ 



JL 




si.\ ."Vn 



PERSONAL AND STATISTICAL PARTICULARS 



I).\ri: ni Hik in 



l 



)X- 



Q'\<rv^ 



Month) 



(Oay) 



AC. I-; 



3 



)>,n 



\ \ 



M.'iilli^ 1 X 



(Year* 



/)./r,v 



SINCI.K. M \RK W.U. 
WIIX »\\ }:i) (tk I)IVnK(Kr> 
Write ill s(H-ial ih-sivrnriti<iii) 



HIk riUM. AOK 

' Stati or I'oiinti > 






NAMl-; »)l 
I- AT Hi: K 



(^ 



/^Cr»\,<X'i ^L\.^'L4\X^tc'VcL 



IUKTIIIM,At.K 

<U' I-ATHKK 

t Slate or C«)iiiitrv^ 



MAIDHN NAMIC 
<»I MDTIIKK 



I'.IRTMIM.ACK 
<»l- MOTIIKR 
(Statr or Country! 



(^ 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ; \ 

(Month) (Day) (Year) 

I HFTRKRY CKRTIFY, That I attended deceased from 

v. / 190 t to •• vJ^cA^. ^.$ 190 H 

that I last saw h ■• alive on W/CAl %.^ 190 

and that death nctiirred, on the date stated above, at i oO 
M. The CATSIv OF DI-IATII was as follows: 

Dl'RATION Years Mo>i(/is "^l Days Hours 
CONTRIIU'TORV Lo^\XXJLXXLL^ft:>:u 






\\<XKl\ ^ 



OCCri'ATlON 

• Kesidrii III Sill' /iiiii.;\^i-i) v. 5 )'ri!is \ \ .'\/i>ii///< \ i. /^tiv. 



DTRATION 



}\ars Jf()fi//is I Days Hours 

V^vCL.I'LL^'.. M.D. 



(SIGNED) Ai. V \j)\' 
W.el! 0.1 iQo't (A<ldress) VJ |\aAAut^.e\ibJLA^t£i^:l^. 



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



% 



Tin-: AUOVK STAll",!) I'KkSONAI, PAR TUri.ARS ARK TRIK T( ► THK 
UKST OF MV KX()WI,i:DC. K AND IJICMKF 

(Infunnant Vj rixXX>L4 \jVAAjUkjL>J[trS^ 

(A.hlrcss U dJ-uJLMj'^JL VXaM. 



Former or 
Isual Residence 

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



How long at 
Place of Death? 



Days 



ri.ACE OI<* BlRl.\r, OR KKMOVAI, 

/ 




DATKof BlRiAi, or RKMOVAI, 

ly.tLt '}^^ 






(AddreM 13L.0 H. \l)l\./aa,x,4r:vv.... J.i 



I9-.M. 



!N. B. F.very item of InformBtlon should be carefully supplied. AGE should be stated EXACTLY. PHY8ICIAN8 should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for per- 
sons dyin^ away from home should be driven in «\9ry Instance. 



%% 






m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



);.,.,n! ..f It. itH) I" v.) n ^'^^:?ijr'' 



liNil' Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff 



h' /7/rr/AUt>Wv X\ 



.^y\jJ^^ 



Dep 



100 \ 
Officer 



Registered J\''o. 



2664 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "U. 5. Stan&arD ) 



PLACE OF DEATH: — County ofOo^^^^ vLV<Xa\.cuicc City of 0/O^-w Axx/>v^Ui^,i) 
NoXlXu VL(rUw>xtu. X^^:llvvlcLl St.; Dist.;bet 

\ ( IF Dt*TH OCCURS *W*V FROM USUAL R E S I D E N C E G I V E TACTS CALLE 



J \ IF DEAT 



H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 

FULL NAME dLji-Lqo O.eku>i.qj,o 



ED FOR UNDER "SPECIAL INFORMATION" N 
NSTEAD OF STREET AND NUMBER. / 



^ 



"i 

4i 



•i;\ 



PERSONAL AND STATISTICAL PARTICULARS 
VNj ^ I COI.OR ^ 



i» All', oi" lUK rn M N 



iM()!ith> 



1 



I go 

(Year) 



A(,K 



?>^ 



)V<Mv 



MnuHl' 



fVtar) 



/^/i> 



Sl\<,l,lv M\KUIi:i). 
\VH)n\Vi:i) (»K DIVoKrKI) 

• W'litrin «^ii(i:il (l«-^i^'ii;iti'iii) 



HIK rmM.Ai'K 
(Slatf or C'oiiiiti \ 



V 



I 



■-,C_^L<X--VN-'C^.. 



lA rm-.K 



L 




MEDICAL CERTIFICATE OF DEATH 

DATE oi" ni:ATn , A 

\)A Ik. 

(Month) (Day) 

I Hl'lRl'HV ClvkTirV, That I atteiKk-d deceased from 

,|\aU^ i:^ K^o'. to AD^t. a.b 190H 

that I last saw h •- alive on ^ ^ '- -^^ ic/)', 

and that <leath occurred, on the date stated above, at C) o 
Cb^M. The CAlSlv OI' DlvATll was as follows: 

A,jL{r>-VJ^\^i^Jx.^'^L'.. ■> 



lUKl'lIll.ArK A 

<)I I'ArilKR - V 

(State (II l'<)initr\' ' 




cX'^AwO- 



MAIDKN NAMH 
Ol MOTHKK 



IUKTHI'LAlK 
<)»•■ MOTMKK 
(Statf or C'oiiiiti vi 







X>7 




Ol/"'! 



'\j^Y\AJS^\j 



A 



^.*x.»..v,,. Years Months Days Hours 
:ONTRIIU'T()RV O.^AJ..,.^I.|.\K^.Dr..^;::..0iJ.)u.d.^.l.^v.{i 



DURATION 



DURATION Years Months Days Hours 

(SIGNED) \X. U. V)^L.Vv^^. t- 

W/CJ). .Xlo TQO ' i (Address) LCt^^'^VC VXl .. .fe 

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



M.D. 



DCCIPATION ^ 1 Ova 



Kfsiif/'d In Siiii J't am i.^ro 



) Vv/ ; .' 



MmitU^ 



Day. 



THK ABOVE STATi:i) rKRSONAI, I'A K TU* f LA KS A K Iv TKIK TO THK 
HEST OE MY KNOWLEDGE AND »EM1:K 



(IiifiiMiiaiil 



LXxx,^ 



(A(l«l 



ress 



\SXkx 




Former or ^^ ^ o 4 1 ^Jr- ^^^ '""^ ^* > c 

Usual Residence I I ^ H AtK; jX Place of Death ? ' \>... 



Days 



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



ri^CE OE HIKIAI, «IR REMoVAE I DATE of Hikiai. or REMOVAI, 
I'NDERTAKER ^^■ . UU H v Axx/Vv>.XX/-v^ M \^ 



(Address . 



ia.0..a Of>\A.xui.o<rvx dl. 



N. B. F.very item o? Information should be carefully supplied. AGE should he stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
sons dyinft away from home should be &iven in %\9ry instance. 



! ( 



|H 



I i 



WRITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lf)OH 



JiegLstered A^o. 



2665 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanC>atC> ) 






No ^"^^^ U St.; T Dist.; bet. U->^v.trw and •.' X\-(>^AL 

/ ir DEATH OCCURS *W*V FROM USUAL R E S I D E N C E G I V E facts CAtLED FOR UNDER "SPECIAt INFORMATION • \ 
( IF DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



PLACE OF DEATH: — County of Jcu^v J.^.cov^.cv^c<.City of c3/cxav; J .\.cx^^e,^ c,<. 



FULL NAME 






Ji 



•\, O . ^ V , \.. 



44- 



^i:.\ 



PERSONAL AND STATISTICAL PARTICULARS 



nla^ 



I>A I i: <•! lUKIII 



\<. J-: 



i> ! ^i 



M..iith) 



! 'Ill 



V. \. I 



«1)MV) 



M.iuth 



190 . 
(Year) 



fVtar> 



/hi vs 



SIN*. I,lv MAkKll.I) 
WIDOW 1. 1) <>K 1)I\< •»■!(}•: I) 

'Wtitfiii v(Mi;il dcsi}.' nal i' "11 ) 



Q^'j^y\.cJji 



I Sl.itt or «.'i»iiiiti s 



NAMI' Ol- 
FATIII.K 



lUKTIIIM.ArK 

Ol' 1 AIUKK 

' State or t'oimtrv' 



maii)i:n NAM1-: 

01 MOTMHK 



lUK rnrLACK 

Ol- MOTHKR 

(State or ("oil lit r> I 







^ny^L 




\"v<x/y\/>^'t \ \^ 






MEDICAL CERTIFICATE OF DEATH 

DATH OF I)I;aTH ,f\ 

iD,d ?i 

(Month) (Day) 

I III'lKl-HV CIvRTIFV, Tliat I atten<k'(l dcocasetl from 

Oct "X^ upH to ...i0..cl ,A 190 A. 

tliat I last saw h -^>'>>^ alive 011 ^-' ^-* ■' ^ T90 '\ 

■,iiu\ that death occurred, on the date stated above, at i 1 
M The CATSIv Ol" DIvATll was as follows: 

\.<y'y\. v.r \„V.A..<L.' .'■ . . 



DC RATION }'ears Mouths I^ays ' Hours 

CONTRIHUTORY C7^/:>^^1 V'uw. •> ^ ....'....•...... ..cLIlLl 



,.Uvi;A.i, 



X^A..A.'^^J^lL^...lJl^xi^^.xxx. ^bx^wx-o-vJi 



t' 



DURATION ^ Years 



\,<X.( 




n 






oiUf J- \l"ION 

Kf^idrd in Snii /'luni ism 



) 'f'li I 



M.nilh^ 



/hns 



THI-: \HovH sT\ii:i) i'kksonai, pAKriciLAKs aki; TKIK To tiih 

MKST Ol- MY KNoWI,l-;i)C.K -XND MKMHF 



(Illfoi ni;itll 



\\XX/'W/>'V^tPv ^ • 






(Address 



Monl/is Pays flours 

(SIGNED ) J-A^XX^wk v). ..JA/<Xm^ M.D. 



iQct 



Xb 190 'I ( 




«^i 



.^\;^JLUl. 



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

Former or How long at 

Usual Residence Place of Death? Days 

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



ri.ACK <)l' UrRIAI, OR KKMOVAI, 



DATKof IHMiAi. or RKMOVAI, 

M^<^. V\ 190H. 



NDKRTAKKRU'txXXnnJti ^jfyVcMW^^r^ V Lc 

(Address. .1.5 0.1 ai.Jir1M^l(r>:V . .'.J.l 



IN. B.- 



-Every Item of inPormatlon should be carefully Hupplied. AGB 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 dyinit away from home should be ^iven In svsry instance. 






At 



I 






I 






i i 



rk 




I 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



_J r 11 ..It I. — I.' V, . ir "•«■ 



i!.^ J' r.-i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/r /v7f'</,iL:.^lMA^ XI 



lOO'^i 



Be^istered J\^o. 



2666 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( tl. S. StanDarD ) 



PLACE OF DEATH: — County 



of O/Ol-^v Xva/wti^UictCity of 0'<X/>v vj Xa/> vc\-4^ <; 



No. ^ H 3v ,<x.L'\j 



A 



St.; iC Dist.;bct. 3.1 



x\V' 



and 5.S U\\ ) 



/ IF DEATH OCCURS *W«Y FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNDER "SPECAL . N FO R M ATIO N'" \ 
( ,F DEATH OCCURRED .N A HOSP.TAL OR .N^T.TUT.ON G.VE ITS NAME .NSTEAO OF STREET AND NUMBER. J 



FULL NAME 



1' xXxxxx/yy^ 



PERSONAL AND STATISTICAL PARTICULARS 

^I A A f\ j COI.OR ^ , I 




\<x'u. 



I> A IJ'. Ml i;iK III 



NtMlltlll 



Li 

(Day) 



X*^ 



/ i^ 



A < . !•; 



^iNt'.i.i.: MAKuii:i> 

\\l I><>\\i:i) nK I)l\nKv): I) 
'Wiitrin '^iH'i.'il (li.-iv'iKilioii) 



lUkTIIIM.ADv n 

' St;itr 1)1 «'')nnti >• -^ 




1/.,;////.' 



kkJj6^ 



(Vt-ar) 



/).M . 



Q^ 



\ \ 



I ATIM.R 



IURTHIM..\rK 
OI- l- ATI IKK 

iStiitc or Ooiinti V 







^\-^\X4,^M- 



MEDICAL CERTIFICATE OF DEATH 

DATK <»J- I)i;ATn I A 






(Year) 



(Month) 
I m':Ki:HV CI:RTIFV, That I attetided deceased from 

.^lJL. ic. 190H to JO^ u 190^ 

that I last saw \\<- > alive on ^ ' ■ ' ^ Itp - 

and that death occurred, on the date stated above, at I 30 
M. The CArSIC OF DICATH was as follows: 



\/vxiaA/c\^* 



Days 



Hours 



DTR-XTION ^ Years H Months 



MAIDI'.N NAMi: f\\ 

01- MOTIIKR ' 



lUKIHI'I.ArH 

<>!■ MormcK 

' Slate 111 LN.dtili \ I 








oJ\ 



^ \ ' 



A" 



rsidni 11, Salt r>,uui,,o '^'~[ YfOts 6 Mouths \\ /'<n.« 



Tin-; AlinVH STA'r»-,l) I'KKsONAI, l'\KiUMI,ARS A K I". rKlH To TUl-: 

ni-:sT ()!• MY knowm; I )(".)': .\ni> mi;i.ii-;i-' 



(In 






r\fl(lrt'ss 



?)MX 



"i 



n • V 



It- 



DURATION )V<//-5 Mouths *1 /^rtv.? 



(Signed ) 

-Ov ^ I 1 Qo H 



Hours 
M.D. 



(Address) 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



i:i<ACK Of" lU KIAI, OR KKMOVAI, I DATi; of niKiAl- or RKMOVAI, 



ini)1-:rtakkr O crOcLx^vv Cj <xtX L\AvCi^D VC 

^.'^Vh ^^^^t(^^ 



(Address . 



N. B. J.vepy Item oV InformHtlon shoultl be cnreifully supplied. AGE should bo stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH \n plain terms, that it may be properly classWIed. The "Special Information" for per- 
son* dyinft away from home should be ftiven in every instance. 




■! ^ 



W 






iu ;< 



I ^',r 



li 



:( ♦ 



r 

. t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Mn.-,r.l of IKaltli |- N" i '^ -t- W;^ !US: 1' ( . 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dnfr ryn'f/X'<dA>Vyj Xl 



JfW'i 



Registered J\^o, 



2667 



cLorvu^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)catb 



( TH. S. StanDarD ) 



PLACE OF DEATH- — County of O/Cl^tv vJ,\XL>vcx<irv City oi^/0./y^ ^^ .\xx/>AyCA^<i<. 
No 0:ia OXxMLVv^LK. St.; 5 Dist.; bet. ^^mv and (lt^a^A,vA.rlv.) 

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



FULL NAME 



OXXXx 



L d. ai<rdul-' ^ 



PERSONAL AND STATISTICAL PARTICULARS 






COl.nK ^ 



IL.k^t., 



DAi'i". or- III u in 



\< .!•: 







14 



JV,.w 



i iciy' 



i 

r I 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DKATH 

lb 
(Day) 



/p(9 i 

(Year) 



( Vtai) 



Tht 1 



^i\« i.iv M \KKn:i) 
wiix t\\ i:i) (»K i>i\<)Ki i;i) 

'Wiitcin vDi'ial ili*iiv'iiatiini) 



lUK I'Ml'I.AOK 
' State or (.'ounti \ 



X) .^C^Cr 



a 



CV ^ 



\AMi-: (II 

lATHI-.R 



HlKTin'I.ACK 

<)i iatiii:k 

(Stat«' or C'()iiiitr\ 



M\II)1;N NAMl", 
<H MOTHHK 



lUK'rm'i.At'K 

(►!• MOTIIHK 
(Staff or Cotuitry 




\j^yK.z 



A 



V 







\} kk.^\k)\\jJ^ 



A 



(Month) 
I IIlCKlvHV C1{RTII''V, Tliiit I alteiKlcMl (leccaseil from 

190'?' to ..AL'.GX "XSa Tc)o'i 

tliat I last saw h ^*^ alive on W ^.\ ^b 190 v 

and that (U-ath occurred, on the date stated above, at ^-■'h.^.... 
M. The CAr^Sl*: t)l' DICATII was as follows: 



r-h^ 



:X\^&-YNA<5^^.. 



DIRATKJX 3^ Years 
CONTRIiaTORV 



MoutJn 



I}a\s 



Hours 



OCCUPATION 



\'r.''l\lf(l ill Siirr I'l iiih i^i'it CN V) ) idi < 



Mnlltll^ 



Ihn. 



Tin: AUOVH STATi:i) PKKSONAI, I'A KilcT I.A KS A K I'. IKri': TO TIIH 
HKS T Ol" MY KN()\VI,i;i)<",K AM) lU'.I.lHl'" 



(I 



II forma lit WAKA/W ^ .L^WCL^^A^CV 
(Address 533.^ T iJv O ^ 



I)i; RATION 

(Signed) 




)'cars 



^fo}lt/lS 



Days 



//ours 



UL. J^oXt M.D. 

Tc)o'> (Address) I ^ 5 ^JM^ XvxJ^Jlt d t 



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 deatti? 



How long at 
Place of Death ? 



Days 



ri.ACK <)!• lUKIAr. OR KKMOVAI, 




DATK of HiKiAi, or KKMOYAI, 

Qxi x"] 



190 H 



r N I ) 1: R I* A K 1-: R vX>^.AAX/cL IW^'cLsaX "^RlV '^ 
(Addrt-ss %[d\) \U\AAA.\.irk\, uiL 



IN. B.- 



-Bvery Item of information should bs cnrefuily supplletl. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it mny be properly classified. The "Special Information" for per- 
sons dyinft away from home should be [^iven in «very instance. 



^'t' 



I 



i 



i 



m 



ni.^ 



il 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f !i. il'li I" Vo 






\\Si.\' 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Registered J{o, 



2668 



Dulv 1-'Ui'iIXSjA>A^' X\ V.)()\ 

\^K.As^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate <^i £)eatb 

( *Cl. S. Standard ) 

\ ^ \ ^ 

of 0/0^-1%; J /V<X-^xc^vi r. ( City of '-^ <^-^^ J X'O^v/^'-^t i. 
No. ai \] l\v.>^t '. ' iu" Dist.; bet. M I IoaJ^ and ^ I U^vo > 



PLACE OF DEATH; — County 



FULL NAME 




K.^-^- 



PERSONAL AND STATISTICAL PARTICULARS 
-I A A ,, ! COI.OR \ ^ 1^ 



1 \\oJjL 



LL-1vo^^. 



i> \ ri: or r.iK iii 




\' .I'. 



e" 






Dav) 



/ V 



^^ 



)■,■,/- 



2> 



M.'nlh 



' \'<;ii * 



/)iM 



\\ IIH »\\ l.I» t»K I>l\t >K' i: I) 
Wiitcjn <iKiiil (Usivn.iti.iti) 



lUk IfUM, Vv'K 



vo^ 



NAMI, t>l 

»atm):r 



niKTHri.AOK 
<>l" lArHKK 
(Stall or t'()\iiitrv^ 



MAll)i;X NAMI". 
OI- MOTIIHR 






d- 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH \\\ 

(Month) (Day) 



I go , 

(Year) 



1 IH';RlUiV CI;RTII'^V, That I attciuled deceased from 

Uct ^H iqoS to ..Uxi; ^5: 190 H 

that I last saw h j^. - alive on Vctj XS Kp H 

and tliat <leath occurred, on the date stated above, at 1 
A.L .M. The CAl'Sl*: OF l)Iv.\TI^was as follows: 

I) r RAT ION Years Months ^ Days Hours 
CO.NTRinrTOR V wyAA^«c:>A^^^.s:. LJJLllxO'ixxO'LA..^-v:^r. 



lUKTHIM^ACK 
<)|" MOTMKK 
(Statr or Cottntrv) 




OCOrrATlON JJ I 



.^fanths 



/h!\. 



Tin" AHOVK STA'n.I) I'KkSONAl, PAKIFiT l.AKS A R 1' TRl" !•: TO rHK 
HHST Ol- MV KN<)\Vl.i;i)('.K AND IU;M1;K 

(Itiforninnt C) CTU . CvX'VA./^'V^finrNj 



'A<MrcsH 



^- ? 



Ai. 



1)1' RATION Vraf 



(SIGNED) 



Jfo>i//is 



/)ays 



( 



■\d<lress) vA.XX'wt \vA 



Hours 

M.D. 



ons.ir 



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



Former or 
Usual Residence 

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



How long at 
Place 0'. Death ? 



Days 



ri,ACK Ol^IURIAI, OK KKMOVAI. 



'U 



imXL...^.^^ ^-t .^v^ ,_,,oH 



\ 



l)AXi:ol JU KIAI. or RIvMOVAI, 



INI 



)i-:rtakkr ^X/y\y\jjL. \. U /oJULolxvW. v 

-.3^0+^. 1; '' 



(.\d<lress 



N. B. 



-F.very item of Information •hould be carefully «up|>l!ecl. ACJB iihould be Htatecl EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain term*, that It may be properly classified. The "Special Information** for per- 
sons dyin^ oway from home should be ^iven in every instance. 




,^. 



i 



i . 



1/ I 




lilB 



Nif 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;. ,,1 



1 Mf He :ilth t" N'o 1 



.; -fr-^ar-Ta) US: V Ca 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



•^ 



Registered J\l*o, 



ibtty 



dLiLv u Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



.c-uv-v.^ 



Certificate of Death 

( Ta. 5. StanDarO ) 









-4 ^ 

PLACE OF DEATH: — County of ) <X-iV Jv\xx.-.vCA^o(.Gty of ^ Cu>^ J \. cv^^^c^^:e.c 



V w ,Cl\.^.^L k, St.; H Dist.; bet. flb .OA/VUlC-ya,' and i^^^i-ya^Ai ) 

/ IF DfATH OCCURS *W«Y FROM USUAL RESIDENCE GIVE FACTS CALLED rOR UNDER "SPECIAL INFORMATION" \ A 
( ,F DtATHlcC^RRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J J 



No. Sni fe. ^" 



^ 



FULL NAME mxu-va/C.v^ 






si;\ 



PERSONAL AND STATISTICAL PARTICULARS 




<xXa 




\ 



1 



I) \i ); 1)1- 111 urn 



A CI-; 



Mnllt))> I 



5. 



J III > 



^ 



(Day) 



Mnutfr 



MEDICAL CERTIFICATE OF DEATH 
DATE 01< DHATH 



Uci 



(Year) 



/ I 



.W.. .^.•. 



(Year) 



l>ii\. 



SINCI.K. MAKKIi;i) 
UII)n\\l.;i> OK I)I\<)Kri-:i) 

'U'lilriii VIM i;il clisijf nation) 



fX) ft 



L 



HiK rm'i.AOK 

fStati <>l (."nniltl > ' 



NX Ml <tl 
!• Allll.K 



HIRTllI'l.ArK 
<)l- I API IKK 
(Slat*- or t'ouiitry 



MAIDKN NAM1-; 
Ol- M()TIM:K 



lURTMPI.ArK 
«)|' MoTMKK 
'Slate or Country) 



(HCrrATION 

Resiilrd III Situ I'l ami I'll 



^'V^^C';i^CX• 




rv\ 




(Month) (Day) 

I in^KlUJY CI:RTIFV, That I Mttendt'd jleccased from 



\i . 



^..^ 



vL; cl XL i9oH to ....Vy.'^ 5^ic 190H 

that I last saw h • alive oil W r..^ ' ^ 190 ' 

and that death occurred, on the «latc stated above, at ^ 
L M. The CAl'SH OF DKATII was as follows: 

^ ^ -. . ■.^^.■: ^ ■■ 



1)1 RAT ION years A/on //is Days Hours 
CONTRIIUITORY \.AjJsJf\^.:>c^C\ 



^'ini 



\ 



.\h>iiHn 



Pm 



THl', AliOVK STA'ri:i) I'KKSONAI. I'A K r IC l" I,A K S A K Iv rklK lO THK 
HHST OF MY KNOWMCDC.K AND HKI.Il*:!" 



(Iiifornjant 






( Addrt-KH 



DURATION Years Mont/is Days Hours 

^ % 'H 

(Signed) •). o nocc.rv M.D. 

l)/cl.Vl i(,o'i (Address) 3 C "i - bXL .... J.I 



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



Former or 
Usual Residence 

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



How long at 
Place of Deatli? 



Days 



I'l.ACK OF lUKIAI, OK Kli.MoVAl, 




DATlvof III KIAI. or KKM(JVAI, 



190 



l-NDHRTAKKK VO . i- UAA_Av\/ ^\1. La. 

(AtMreHH 1 .1 .'b.l^ \](l^l\AAA->crr>.:L....x)l... 



IN. B.- 



-Bvcpy Item otf Informiitlon shoultl be cnre?ully Mupplied. AGE HhouIti bo stated EXACTLY. PHYSICIANS should 
state CAU8K OH Df:ATH In plain terms, that it may be properly classified. The "Special information** for per- 
sons dying away from home should be given in svsry instance. 




m 



^ 

^ 
^ 










o 



I 






h\ 



WRI 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



nnAV'\ .<f n.-..it»i- »•■ N'.). 



♦^^»v^>lUS:l»C 



o 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihffr Filed, (L tl."UA'-t\, a!li 



100\ 



Registered J\''o. 



^670 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( •Q. S. StaiiDarO ) 



^^ 



PLACE OF DEATH: — County of dcc^-v J .>vO. Yv.av^tcCity of CJx^^^ JX<X.>^cv<i.c.t 

, 1 



No- "4^0U'^->wt.' db t-<l.'.x^' ri..'. St.; Dist.;bct. and 

mo. ~'^'-'V^ ' "-^ JV^l,!-...^ .,_,,., occinrNCE Ciur FACTS C«LLID »0« UNOIB SPECIAL INFORMATION" \ 

( " ,V'.rAT°-"o?c'!.rC.\N"r-o".'pr.t 0%'fNS°,',?>fT%';"',f,;r,;i «»«. ,NST»0 of ST..CT .NO NUMB... ) 



FULL NAME 



sj:\ 



PERSONAL AND STATISTICAL PARTICULAR 

»\ i COl.OK 




\\.^r\} 




LcvLcn^' 



Cv\.^. 



.^'X'..; 



J. 



!% 



i)\ I K «>i i!iK in 



\« .K 



Vl 






} Vi*i 



lo 



'P.-tv) 



.l/./M/// 



/l^i 

(Year) 



/'</! 



siNt'.i.i:. M\kun:i» 

WIDnUKI) OR I)IVnKri:i) 

iWiitf ill •.(K-iiil (Ic^ii'iiiiti'iii) 




.u 



lUK riiiM, \cv. 

'Stiif <• or r<iMiiti V 



NAMl- <»l 
\- A r 1 1 1 . K 



niKTIMM, \t*K 
oi I AlUKK 
(St!it< or CeHinti v^ 



MA1I>i:N NAM): 
nj- MOTIIHK 



lUKTnruArK 
OI- MoTm:K 

(Slatf or Countrvi 



oc'("ri'A'rioN*\rp 



I UyY\^ 




X. 







MEDICAL CERTIFICATE OF DEATH 

DATK OF PKATII 



(Month) 



(Day) 



I go 

(Year) 



s:. 



I III'"I<I*RV CI';RTIFV, That I attenilf.I deceased from 

Ms± XX. 



190 1 to Ni/ CU ds\ 190 i 

that I last saw h •- ahve 011 ^- ^^' 19O - 

and that <leath occurred, on the date stated above, at W 
M. The CAl'SIv Ol' Dl'ATII was as follows: 



c 



CrL D-LXLCjAa.^ 



CC ^ -^^^UL\j Crl- L-'jL^Cj-'^ v.:\ v.a.c\. ' . ' ■ ■ 



\ V,«-^J 



I I LOAXL 




Rrsidfii lit Sail I'liiiiiisrd 



) I'll 1 



V-'/////' 



/>./!> 



riii-: AMOVE sT\'n:i) pkksonai, i-ak ricn.AKs aki: ikih to thk 

HlvST Ol" MY KNOWI.i:i)(".K AM) UKI.II.I" 

(Iiifotninnt UJ '^TVAJ cU Vvr\ VV. ^ \.q 



(A.Mrcss -^b 'b?^ 



i 



.CA^' 



, '\ 



tU'- n 



I)rK.\TI()N )'fars Mouths Days 

,...a,L.i:5w'\.:N,':rC\»L.s..A> 



Hours 



CONTRinrTORY 



DURATION Years Months Days 

NED ),..at<X."^OLLu_ Q:i.JLL'- 



/'YWS>^> V. 



Hours 
M.D. 



\^A> ai rno, ^^ddr.ss^10'^\^la^,klt; \ 



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






Former or a . 1 'i A h ) , w A t ""^ '""' ** , 
Usual ResidencecJvb 00 yXA^Uw.t\ ' <. Plare of Death? 



Days 



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



iM.ACK OF niRiAi. oi< rf:movai. 







I>ATF, of »( RiAr, or RKMOVAI, 

fict . V\ 190M 



A.l.lress 1 ISlS. dU-t^V>-\.^^i/tX^.^V.Vi....J± 



N. B.— hvcry Item oi in?<,rm»tion .hould be CHrufully Hupplled. AGE nhoulcl »>«»tated EXACTLY PHYSICIANS .houid 
fitatc CAUSE OF DEATH In pliiln term., that It may be properly clarified. The Special Information ?or p«r- 
Kont dyin^ away from home Hhoiild be It'ven In every Instance. 



I, 
I 



I 

i 



WRI 



H..:it.l i.f II. iMh I- V< 



TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



*'rTw.^jH&.p Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



2671 



/>af,' FiM,i)zt<rL.>^- X<i lOOH Registered Xo. 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDarC* ) 



01? 



PLACE OF DEATH: — County of (^ CU^ l^U3.Avcc^coGty of ^c^^^ J.Va.^vcv^co 



No. 



^^CLU Cl "^o, , 1 



.\.<X/ WC\-'sl c. c St. 



Dist.: bet. 



"and 



' r __^„ iieiiki nrcinrNCE civr facts called fob under "special information-- "V 

( \ rF"DrAT°H"oCc"Rr;.NTHO^.^pVT*t o"r":St'?u"o';"o.VE%I NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



.UUQ.N-V. 



S-' 



I 






s !•: \ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




\o.U 



v^ 



L 



DA'll-: (»l- lUKTM 



\(,i.: 



( Monllil 



) Vl» I A 



(I)av) 



Months 



(Year) 



Pit v. 



SIN<-.1,K. MAKUIKI) 
WIDOW!-:!) nU I)IV« )Kr J'l) 

iWtittiii MH-ial (It "-i^'iiatioii) 



HIRTMlM.Ai'K 

'Statt or Country > 



NAMJ-: Ol 

FATin:R 



HlKTHPl.ACK 
Ol' l-ATHKK 

(Statf or Country 



MAIDICN NAMi: 
()!• MOTHlvK 



IMKTHn.ACK 
Ol- MOTMKR 
(Statf or Country'' 





occri'ATioN r^' 1 



Ihiv: 



Tin- AHOVH STATKI) I'KKSONAI. I'AK'IK T I. A KS \ K i; TR C K To THH 
HKST OK MV KNOWl.i:i)<".K AND ni:Ml-:F 



(lufoinuint 






( Afldrt-ss 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



IQO 

(Year) 



(Month) <I'ay> 

I in^Rl'BV CI-:RTirV, That I attended (leoeaseil from 

.— 190 to 190—:"— 

that I last saw h • — alive on ■ — — -^ — 190 

aiiil that death occurred, on the date stated above, at Trrrrn 
M. The CAl'SB OF DIvATlI was as follows: 




\/uC^ 



>->V\.\-^iw.c; 



\ 



i)i:r.\tion 
contributory 



.^..>w.d...>.. 
)'ears Months 



Days Hours 



Months 



Pays Hours 



DURATION Years _ 

LcrV<rpJl\^ v), O...U^..\jLLa^\vo M.D. 

.iQlj.^ 

Transients, 



( Signed )...Lcr\-^cr>^x^^ 



ILlc^l. IM T9o'i (Address) L(r\^-vJL^^. .UXj-v 

SPECIAL INFORMATION only for Hospitals, Institutlok 



or Recent Residents, and persons dying away from home. 
Former or - ^^ 



Usual Residence 

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




\d 



How long at 
' Place of Death? Days 



PI^ACH OH BIRIAI, OR RKMOVAI, 



%A^^ 






DATK of niKiAi. or REMt)VAI, 

^:\^. QJl. 190H 



I NDKRTAKHR VOvAJw>-\/ ^^ VV 

(AcUlres.s %^.\j.<X.y\J. .. JfVXA,^ LL.V.-', 




N. B._Hvery Item of 1nform„tlon .hould be carefully nuppMcd. AGB should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH !n plain term., that It may be properly classified. The Special Information'* for psr- 
sons dylnft away from home should be ftlven In every Instance. 



I 



u 




>^'. 



■lUI 



I 



^1 M 



WRITE PLAINLY WITH UNFADING INK — 



!ifSi«t ttl lleiiU'' - »•■ ^'" 1 "^ **tl^*l:?*" '"'^ '' *''* 



!)„/,■ Fi/c'',VdLttW\j 3,1 



7.9(9 H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2672 



Registered J^o, 



.^-VA-v^•:i -.v.. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



^ 



A 



(?n 



PLACE OF DEATH: — County 



of '"^CL ^-v'^^Vva.vvc^Ci.e.LCity of ucx^^ ^va.>^c^^^c.A. 



^No. 



•^ 



^xl 



C) WOi^ U i ' St.; '1 Dist.; bet. '^ ^^^ and 

^.rVV, -V.A..A. ,,-,,*• OFCSIDENCE GIVE FACTS CALLED FOR UNDER "special INFORMATION" A 



..b.<Ob 



) 



FULL NAME ^l^*- 




»:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR \ 




A 



i>\ I f 1)1 r.iK 1 II 



\ t . !•: 



L 



Moiitlil 



)•..;, 



(!):iv) 



Mntllll 



(Vcar) 



/'(/I. 



\vin»)\vi:i) OK i)iv< >KiKi) 

iWiittiii s<K.i:ii tU-xij-'iiatixn) 



V.< 



lURTHIM.XOK 
(Stall or C'ountrv 



\ \M)-: <)I 
I- A r I \ }•; K 



HIRTHlM.AcK 
Ol* lATIIKK 

'Statf or Coutiti v' 



MAIDl.N NAM1-; /-y>^ 



(■^ 






GL 



A,^CL v„ r 



J JLoJtx 



..<^ c. : 



HiK'rnri.ACK 
()i- M<)Tm-:R 

(State or Countiy 



OCCUPATION 

AVsiiff(f III Sitii /'iiiniisrn 




iiWCC 



)></ 



■ yfoiith^ 



lKi\ 



Tin" \HOVK STA'n.n PKRSONAK I'AK'lIcri.ARS ARl". TRIK TO IHH 
iIksT Ol' MY KNOW I.i:i)<".K AM) HKMllK 



(Infoiniaiit 



a. (nocrLwv^^ 



^\(l(lir 



q^M 



OLA/vA.xixrw dt: 



* 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH ,, , 



(Month) 



(Day) 



I go 

(Year) 



I Hl^RHBY CI':RTIFV, That I attciKkMl (leccase<l from 
i^<^.l' y. ton'. to .....^.^:c't. 



190 'i 



I90' to 

that I last saw h ■ alive on IQO 

and that death occurred, on the <latc stated above, at ^ 
M The CArSp; OF DlvATll was as follows: 



ci.vJLdL. aaj-o-^. xrUL-.U^A.sJl.NX.c'w 



DERATION 



Years 



Months 



Pa vs 



Hours 



CON T R 1 lU - T O R Y "IJxJLouL^d.. . .i/vtV'..^-<l-::v>^^..xA. f v^c^tvUft^ 



c 



. AA^vtjL . .A./Tv-vLcA^.V - '■' 



) 'ca rs ^Vou (hs Days Hon rs 

ijlct' J.1 iQo'i (Address) i^XS j:3jKXh^v J.A 

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

Former or How long at 

Usual Residence Plare of Deatli? Days 

When was disease contracted, 

If not at place of death? 



Dl^RATION 

(SIGNED) m- ^4.N-^'^^. M.D 

5.1 iQo'i (Address) \'hXS "^JKXh^ 



I'l.ACK Ol' HIRIALOR KKMOVAI, 




DAl'lvo! 151 KiAl. or KKMOVAI. 

..Q..^ .^1 igo'l 



(Address 



as.! QOa.^ui^> 



N. B.— F.veny Iten, o." infon..Btlon .hou.cl he CHnefu... supplied. AGB should »»• •*-*':;^f .f.^J^^^,^^^ ,„Zm^a'ul>^„^' Vr'^r'r" 
•tate CAUSE OF DEATH in plain term., that it may he properly clarified. The Special Information ?or p.r- 
Kons dyinft away from home should be ftiven in every instance. 



^' "" \l 



11" 



m 



f- 






!■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ ,„ ,. , v., ,= ^r.?i.,,...^.c„ RCreR TO BACK OF CERTiriCATe FOR IN3TRUCTIONa ^ 

Registered JVo. 



I>a/,' /-V/.-Z.^.c-UUv X% l^^O^ 

t(.c^i-«- Deputy Health Officer 



2673 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 

( XX. 5. Stan^arD ) 
PLACE OF DEATH:-County of 0(X->v ).Vct.vac^c.Gty of ' Icc^^. J A.<V.vCc^c. 



Pfc.L!v^idv->v.^ 'db 0A.Iv\.Iq-1 St 



fn L >\.i ui, i>-Mjrvv.v.ui.v L».i Dist.; bet. ^^r:--:^— -^^--^^- ~ and 

X<. \J. t VJ VVJ \.->J-'I ^_*-^\^ RESIDENCE OIVC r.CTS CILEO fOU UNOtX "SfCCIAl INFORM.TION " "V 

FULL NAME ^^-"UX-^vcX-s Jxvlx^'^a..^ Ovu 



) 






PERSONAL AND STATISTICAL PARTICULARS 



l) 



I)\ I K ol lUK 111 



'Moiit'h) 



\i .»•: 



) 



i\i I 



r 

(Day) 



Minlli ' 



I 



' f 



10 



(W-ar) 



I hi 



\\ll)«)\Vl-:i) OR l)I\'<)Kv I'D 
iWritfin stK-ial <!« si^natiou) 



'X\vQ 



lUKTm'I.AOK 

(Stutr or C'ouiitrv' 



NAMT-: «)l 
FAIIIKR 



BIRTHIM.AOK 
(>l- lATHKK 
(Stall' or i.ouiiti y 



MAini;N NAMK 
(U- MOTIIKR 



lUK rilPLACK 
Ol" MOTIIKK 
(Statf or C«)untry^ 






OCCUPATION 

Kfsitlfi! ill Still J'l tiiii !.u'<i 



0.. 



Till- \noVKST\THI) I'HKSONAI. I'AKTUr L \KS AK l- TKl K To J^^ 
HKST OF MY KNo\VM;I)C.H AND HHIJi:!' 



(Infornmnt H^<LA,\Jl J -^wC'X^t:J 



( \(l<lress 



MEDICAL CERTIFICATE ©FJ^EATH 

DATK Ol- i)i:ath 



(Month) 



(Day) 



I go 

(Year) 



I IlICKlUiV ClvUTII-V, That I attendetl «lecoased from 
l^ - 1. - '. "^'^ to V^'Ct...3.b.. 



190'V 



190 *t 

that I last saw h =• alive oti ' * ^9° 

and that (U-ath occurred, on the date stated al)ove, at 
M. The CAlSlv Ol' DIvATIl was as follows: 

\ ' ' . • 




DI'RATION Years 

CONTIUIU'TORV 



Mouths 



Days 



Hours 



DTRATION 



Years Months 

( SIGNED ) &. . Cvai>-tv>...'.. 



I\iys 



^^. 



xw> 



T()0 



( Ad<lress) \J\<xA\X\x.x MtHJfs 



Hours 

M.D. 

1 



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



Usual Residence 

Wlien was disease ronlracted, 
If not at plare of deatli ? 



<rvx )l Place of Deatli? 



Pays 



J'I,ACK OH IHRIAI, OK RllMOVAI, 



DATllof HiRiAi, or KKMOVAI, 

iiJ..e.t %l 190'., 






(Address 



""""""""^ !• I ATF shniild be Htntetl KXACTLY. PHYSICIANS should 

N. B.— F.very Item of information .hould be cnrcfully MuppI.ed ^f^l^l^^^f^^^^^^^^^ InformHllon" for pT- 

•tate CAUSE OF DEATH In plain terms, that It m«> be properly ciaasmea. 1 nc op » 

sons dylnft away from home should be 4iven in ^y^^ry instance. 



If. 



( , 




m 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,^ ,..,„ s..,.^-^^§^myr. BEFER TO BACK O F CERTIFICATE FOR INSTRUCTIONS 

/,atr lu7.'</M,diXv^ 1% 1^^0'i Registered JVo. ^674 

X^v . V I . M. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 






No. 



Ccitificate of Beatb 

( "a. S. StanDarD ) 
PLACE OF DEATH:-County oi^CK.^^ J;vcx.^A.C..OxX:ity ofOcxy^^ ^T;vcx.^^Wc.c 
'^^ t. Vln -j^tv^C St.; ■ Dist.;bet.d_Joa\>^ox^U:<5\.l'Kand 

I 0:> O V> /LV^<-^VV^^ ,,oi,*L RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 

( '^ .V;rATH^oSru%r;.NTHO^S^PyT:L O^R^NSt'.TU^o'n'o.VC ITS NAME INSTEAD OF STREET AND NUMBER. ; 




^'-'"^ 'Ol:..u/:cU. 



FULL NAME 



I 



ill 






PERSONAL AND STATISTICAL PARTICULARS 

^i:\ r\ A j coi.oR 




a< 




I 



i)\ IF. «»!• uiu rn 



AC, K 



^1 



Lcv.^■ 

Moiithi 



1% f t. 

(Diiv) 



^1 



)V,/. 



^ \I,»illi' 



(Year) 



/^; 



SI\(.l,K. MAKKIl".!) 
\\II>«»\VK1) (»K I>I\«»Ki l-:i) 
(Write ill MK'ial lUsij^iiatioii) 




VcxwvXcL 



HIK rHIM.XOK 

' Statr or I'miiit r> 



NAM1-: Ol- 

I A Tin: R 



lURTUIM.ArK 
<)l 1 XIHKK 

(St;i(i- iir Coiiiiti y 



MAIUKN NAMK 
<»1 MOTHKK 



HlR'nil'I.ACl-: 
Ol- MOTHKR 
(Statt- or Coujitry^ 



,-> 







r. . ^U ;^e; 





occrrATiON 



o^yOuL}-^' 








(^^ 



AVMifr,/ ill S,in /'nnn lyr.i h )'fi)'< Months 



/)./!. 



Tin- MIOVK ST\ THI) PHRSONAI, I'A K lUT I<A KS AKH IRrK !< » 
HKST ())• MY KN()\Vl,i:i)C.K AND HKMHK 



TIIH 



Informant ulvY>J>-^^-^ %AX3|1mjI 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DFATH ^,\ 



(Month) 



(nay) (Year) 



1 in^RIvHV CI{KTIFV, That I attended (lec^-ased from 



that I hist saw h - alive on — 

and that death oceurred, on the date stated above, at 
M. The CAl'Slv Ol' DlvATIl was as follows 



190 



s 



j ■•}. 



:s 



'-^ 
^ 



nrR.xTioN 



10 '»W»i.,'5 

Days - Hours 



Years Monllis 



nr RATION Years Mouths Pays 

(SIGNED) A-,yj. N(rivaxJ[^\^^ 

0/ti n iQoH (Address) Hia 




Hours 



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

Former or (? ] ^4 "^^ '«"<! ^* 

Usual Residence l^S ^o\) -O-C^V^i Jl. piarc of Death? Days 

When was disease contracted. 

If not at place of death ? 




% 



^^ 



« 



r^ 



im.acf: <)!• m-RiAi, or rf;movai. 

r N I) 1: R r A K f: r v<XMvX-^f^^>vv o.. \Xf\ 




.... I- e II «..»»i:^<l AdE should be stated EXACTLY. PHYSICIANS should 

" "-r^aV/Jiu^E r dTa"Vh" n't-n" 1:;;:::^^ rr^t't p*o;;.i, c.....i.d. th. "specie, .„.or™...o„-. ,on p.^. 

fions dyinft away from home should be ftiven in overy instance. 



' 1 



WRITE PLAINLY WITH UNFADING INK — 



r • •• »•- .. tkf^SJi:^ liX I' I'll 

IttOTTIlTlI in-.iilii 1 •'•' •- - «..,»-c- 



THIS IS A PERMANENT RECORD 

RCFER TO BACK OF CE RTIFICATE FOR INSTRUCTIONS 



Registered J\''o, 



2675 



\ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( XX. S. StanC>arC> ) 



/T) 



PLACE OF DEATH: — County of 



(v->,-N <v--y \A ri 



City of ^ 'O^^^ oj V)L(y<L<X V- a. 



No. 



St.; 



Dist.; bet. 



— and 



..oilAI PPSIDENCEGIVE FACTS*C*LLED TOR UNDER "SPECIAL INFORMATION • \ 



,^1 1 



FULL NAME 



SI- \ 



DA ri". OF HIK 111 



PERSONAL AND STATISTICAL PARTICULARS 




(Month) 



Ai.l' 






(Dayi 



M.nitfis 



1 Vtar) 



/'./I A 



SIN«.I>:. MARKIKI) 
\VII)o\Vi:i) OK IMVoRri"!) 
(Wiili in sooiiil <1« sijriiation) 



\\\o.: 



U 



,U AA 



HIRlMiri.ArK 
(St:«t«- or Cimnti v> 



NAM1-: oi" 

!• atmi:r 



lURTHI'l.AC'K 
Ol' I A I'll KR 

(Stiitf or Vountry 



maii)i:n NAM1-: 

()l* MOTIIKR 



lUR rm'LACK 

ol' MOTHKK 
(Stalf or Coiuitry) 



OCCITATION 

A'fuifrif III Sim I'niiK i^'ii 



vie 



.v>x' 



xv^ 



) >(// 



Mniitln 



/),n. 



Tin-* MU)VKST\Ti:i)i'KRso\Ai,rARTirri.ARs AKi; TRiH TO riii: 

iIhsT <)l" MV KNOW l.i;i)«.H AND Hl.I.nJ- 



(Infoiinatit 









MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



l( 



Day) 



(Year) 



(Month) 
I 1II:R1':HV CICRTII^^V, That I attended deceased from 

V .IQO ~~" 

— ll)0 ' 



I90 



ttj 



that I last saw h ' — alive on 
and that death occurred, on the date stated above, at - 
M The CAT SIC Ol' DM AT 11 was as follows: 






DT RATION VnJfS 

CONTRIIU'TORV 



y'tars 



Mouths 



Days 



Hours 



Months 



Days 



nr RATION 

(SIGNED) L,- ,^ 

Ct X' I 100 ■ ' ( Address) CP^vvJ^.W 



vJ^aaaJu- 



I lours 
M.D. 



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.ACK OI" IU'RIAI, OR RKMOVAI. 



,„dkXX<-A,>-vA 



DATK of HiKiAl. or RHMOVAI, 
Ot.t '^X . IQO.'A. 



INDHRTAKKR ^'^ O A.CCVA ^ V. t 



„ ,. ,7 , ./'p «hniil.l he Htutetl EXACTLY. PHYSICIANS should 

N. B.— Every Hem otf information .hould be cnrcfully -"PP"-'- '"'^^^.^''tl^^^^ ''Spccl-I IntormHtlon" for pT- 

state CAUSE OF DEATH in pluln term., that It m»y be properly classltieu. 1 ne p 
sons dylnft nway from home nhoiild be ftiven In svory Instance. 



4i4i 



f i 



I 



% 

% 

i 



|ii 



f t 



1| ; 



lioari . .1 III .1 II 1 



WRITE PLAINLY WITH UNFADING INK 



I 1 ■ »' 



I) 



((((' /'7/f'^/,iLlct>lMA' '^'^ 



190 \ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered Xo, '^^* \ ^ 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( '01. S. StanDar^ i 



07^ 



i 



> 



PLACE OF DEATH:-County of O.Cu^ J.Vc^.ve^cc City of "^^^ J V^^^^v^co 

FULL NAME ^-t'^ v\.^-Luv,*.,;. M i L<XVV-v.. . ... 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK \ 



Wo. 



o. 



u 



i).\i}-: <»i- uiK in 



.\i.H 



. M.iiith) 



lb y.itfs 



!0 



Dav 



M.oilli' 



I Vt:ii 



/),/!. 



^IN<". 1,K. M.XKRll'.n 

\\ IIX >\Vi;i» OK DIVOKTHn 

IWiitfin 'xuial <l<sij,'nation) 



lUK rMri,.\CK 

(Statf or t'omitrv^ 



i\Tm:R 



niKTiiri.ACK 

Ol' I-AIIIKR 
(Stair or Country I 



MAIDKN NAMK 
<»!• MOTHKR 



lUK'ruri.ACK 

()!• mothkr 

(Stiitf or Country) 




'V^TS^ 






MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH , ^ ^ 



(Month) 



(Day) 



(Year) 



I mCKlvDV CICRTII'V, That I attended <leceasea front 

. ' i^'. to....^..ct :^k>. 190 'I. 

tliat I last saw h .c. .-alive on '^. ^-^ •'>'- 19° 

and that death occurred, on the date stated ahove, at H 
G^ M. The CAl'SR OF DliATII was as follows 



^t 



Ky^\J 




< 




/-O 



\wCr\AA-.Ci 



o 



OCCll'ATION 

Kesiifrd in Sun I'minixn O X )><»' v 



Mniiths 



Ihn. 



•rilK AHOVK STATHI) PKKSONAl, I'AKTlcr I.AKS AKK TKIK TO TllH 
IlKST ()!• MY KN«nVl.i:i)<'.K AND HHMKF 



(Informant 



^VvAy 







rxdilress 






nr RATION 



Hours 



CONTRinrTORY ^tLj.yJ..X<<Y^i:vX^ 0|: 



DURATION ^^ Years Moul/is Pays 



( SIGNED ) VAi'VrA^ VJj <XAl>r.0..fc.. 

^^' e5?) p 4 

Xl TOO .. ( Address) 1^10 J &l-^-<:r^->- -li 



Hours 
M.D. 



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



Former or 
Usual Residence 

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



How long at 

Place of Deatli? Days 



I'l.ACK OF lU'RIAI. OR RKMOVAI, 



Ovo-^^-^ 



DATE of niKiAL or REMOVAL 

....l9.^t M 190' i 

l-NDERTAKER i)^Cr\t-Uv ^^C lX'.kv.U 

(Address ...."i "5-^...."^ 0-^-<^^>>^^ | 



, .. ,. . ..>rr „ur...ia he Rtfltetl EXACTLY. PHYSICIANS should 

N. B.— Bvery Item of inVor.„«tion .houlcl be CBrcfully -PP'-^' ''^^'^l^.^tt^J,,^^^^^ Information" for pT- 

state CAUSE OF DEATH in plain terms, that it may be properly vlassitiea. p 

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



^m 



I 



II ' ^1 



1^ 



Sr 






W 



• I .\,\, »• v.> ic -^-J^^S^* HSlI' <^'o 



I) 



RITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

267? 



ff/r /v/^^/XVtKsOv X% 



VJ()\ 



Registered J^o> 



\ ....lo.M, Deputy Health Officer 



,^sWJ^'^ cLLoMi 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate ot Bcatb 

•Q. S. StanC»arC> ) 



PLACE OF DEATH: — County 



of "^ O.^' -' .XOL^vcciLCO City of ^' -O-^^' ^ '"^^ ^ ^■^^''^- "^ ' 



|:i^ 






(iWv 



ikJe,dt).dLLj\jLA 'll; M.iV^lcLl 



St. 



Dist.; bet. 



and 



J^h-XXJ^ 'w\^ l>^|V^^Va.L or^TnVNCra.vE facts caTled roR under •special .nformation- \ 

( '^ .VorAT^^OCC-^Rr^.^THO^.^rAt :R^?^?f.?J;^0^.'^C.;ETs ^NAME ..S.EAO C STREET A.O NU.SER. ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



s I-: \ 



CO I, OR 



^1 I ^<X\^' 

DATl. <>l !IIK I'M 



1 



\ 



^ 



iMoiith* 



A<.H 



C: ^ ),,?;• 



( Dmv 



M.>n//i- 



/ C. J. . 
(Year) 



/)</ 1 



<.IN<.1,K. MAKKIK.I) 

winowKi) OK nivoRrHi) 

(Writf in >-<K'ial ili-i^rti.itioii) 



.0 ^c- ^ 



MEDICAL CERTIFICATE OF DEATH 

DATK l)F DHATII 



(Month) 



(Day) 



(Year) 



I IIHRUHV C1':rTIFV, That I attended <lcccasetl from 

190 to 190— ^- 

that 1 hist saw h "— aUve on — — — 190 

aiKl that death occurred, on the (hite stated above, at 

M. The CArSI*: C)I' DIvATlI was as follows: 



lUK'ruri.AOK C 

(Statf or Comitrv^ 



,13 



LcrV' 



NAMK (>l- 
FATIIKR 



HIKIMIM,A».K 
01 I-ATIIKK 

(Stat*- or Country) 



MAIDKN NAMK 
oi- MOTIIKR 



lUK'riiri.ACH 
OI- MOTHKK 
(State or Country) 



OCCrPATlON 



.0. Ov\JL 

? 




'AjlLo 



A 



( 




AjJL 



hVsiiinf lit Sdir I iiinii^i'i) 



)V,n. 



MA,ith> 



Pays 



THK AHOVK STATKI) PKKSONAK rAKTICrLAKS AKK TKlK To TlIK 
IJKST (W MY KNOW 1,1; DC. H AND HhUhh 



Informant V-A^X-* oC 






(Address 5n I ' fo <XU'^-> H. 




,0 



DIRATION Years Months Pays Hours 



CONTRinrTORV 



nr RATION 



/t) 



Years 



Months 



Davs 



(SIGNED )Ja!Vcr^\Jl^' ^i . ^A. UJ...3juLa.<\.vci. 



iD.^ ^a. 



iqo 



( 



Address) ^ 



) V,^XC^aXH.<5 . 



5 



Hours 
M.D. 

..'v./^-? 



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



Former or u '^ 

Usual Residence ^^ 

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




A 



i 



How long at 
Piare of Deatli ? 



Days 



n.ACK OK HVRIAI, OR KEMOVAI, 



i: 




DATJ^of BlKiAl. or REMOVAI, 

0^ 



?.^ 



INDHRTAKKR 



(Address 1 lo 1 Qfl'V^^J^^Xia'u ..dl.... 



IgoH 



•tate CAUSE OF DEATH In plain term., that .t may be properly Ua»8l»iea. 
«on. dyinft away from homo should be ftWen in .very instance. 



f 



\'i 



•' .» 



* 4H 1 1 

m 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOB INSTRUCTIONS 




Pu'iideved Xo. 



2678 



\^^^,s\^ Deputy Health Omcer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Beatb 

A ^ \ "H 

PLACE OF DEATH:-Coun.y of JcL , JXa^xe^c C.^^^ %.. ^U- ■ 






BER. 



FULL NAME 




Y AJ cr>xxx.L.d» 



PERSONAL AND STATISTICAL PARTICULARS 

I»\ll". oi' r.IK Til 



a 






\(.K 



\D 



.* ) V-.» • > 



.^ 



ll 

(I)JIV> 



M.mlh' 



I'l 



(Vear) 



/'</ 



\\ nx >\\ i;i> OK i>!\< (Klin 




MEDICAL CERTIFICATE OF DEATH 
D\TK OK nKATH f\ 

(MontlO <I^'t>'^ 



igfo 

(Year) 



rnnKl-BV CI:kTII-V, That I attenaed .leceasca from 

.^,cX I '"o • t(. ....£^..<;wfc xb. 



190 



C ' ^ ....9.^. 



190 1 

ll,at I last saw h-x- ^ alive- on ^-^ ' • «^^ l*>o 

M„.l that .loath occurred, on the <latc statoil above, at IX I 5 
M. The CAISP: Ol' DivATII was as follows: 



IcClX^^CV- 



frli 



I 



lUKrHI'I.At'K 
f Stiitf «iT Coimtry 



NAMJ-: (H 

I A rnKK 



HIRTIUM.ACK 
()|- I-AIUICR 
(St.ite or Coiuitry) 



MAIDKN NAMK 

()!• M(vrni'.R 



niR Till' LACK 
nl- MoTHKK 
(Statf or Country^ 



(? 



.clLl^W' 



^ 



CdLc<.-cvvc^ L«.^silcve^- 




d\.^.^^^.A^ 



J v<i,aJU-xa.a>-\-.L' 



,C-<J.\.^ 



\ 



r\A^'LO.':vrv^O >• .>w^tX'v\.Y 



DT RATION 



Mouths 



A ' ^ i 

CONTRIHl'TORV A.^>\^r>:s^.<^^^^^ 



Pays Hours 

;1LC)wLo.>i..S..\'. 



Years Months Pays 

CO 



CL. AA-<i- 



OCCUPATION (Jy 



Ursittrd i>> Siitt /'lanrt'srn 



4r 



) Vif ' 



^ Month: 



lh!V 



TMH ABOVE STATKI) I'KKSONAl. I'AK IIC T 1. \ Ks AKK T K T K TO TMK 

iu:sT oi' Mv kn«>\vm:i)C.k anp in.i.Mi- 

(A.l.h-ess ^H I Q .A^U/VVI^ ".it 



1)1- RATION ^ ^00 

( SIGNED )2j OwATVXL ^^ Oi-^V 



Hours 
M.D. 



rt., -;! iQo'l (A.hlress) ^C)b OA.aX^ ■)! 



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



Former or 
Usual Residence 

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



How long at 
Place of Deatli? 



... Days 



n \CK OH lU'RiAi. OK ri:movai, 

arvp r 




DVri'.of m Ki.M. or RKMOV.XI, 

Q.ri:da xia 190 V 



±1 



rSDHRTAKKR >>^-^ C^-VV->^«rV ^U 
, . , Vl 1 lo n M7lA^^siA^>X < 



N. B._F.very item of Information .hou d be cnretuHy «;PP -^; p^rp;rly clossWied. The "Special Information" for pT- 
8tate CAUSE OF DEATH in plain terms, that it mnj be P'-^P" > 
8on« dyinft away from home should be i^lven m every mstance. 



1 c 

^1 



I 






II 






i 



.[ if 



M 



• t 



I p4' ^^"4 



m i 



f1 



tRw 



I 



II. .iMh I- N" 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

.*-^. „.,.,• TFEF. T O BACK OF CERTIFICAT E FOR INSTRUCTIONS 

2679 



190'i 
• ^ ^ t » h or 



Begisteied J^'^o. 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtificatc of S)catb 

( "U. S. Stan^ar^ ) 



^PLACE OF DEATH:-County of^C.v J Va..cc.e. Cty of O.CX...^ J Ax..>-a^o 



-) 



FULL NAME 



1 t ^1 t 



PERSONAL AND STATISTICAL PARTICULARS 

KAIJ-. nl- KIKTII ^'\ f\ 



IM(.iith)* 



At.l", 



Mt 



} V.fi 



(l);ivl 



1/,.)/,'//' 



! ^ 



/ 16 

(Vfiir) 



/',/! 



"^iM .i,i".. \t\Kun",n 

U IIX »\Vi:i» OK I>I\< »K< I". i» 
\\ I it' in »<« ial (l<si).Miati'iii) 



MEDICAL CERTIFICATE OF DEATH 

uATK ()»■ i)i:ath 



(Month) 



(Day) 



/go 



(Year) 



(Stall ..I Cinnitry) <^ | 



-U-> V^IAO/ 



/A . 



NAMK ni 

lATu i:k 



lUK run, \rK 
oi I \i'm:u 

( Malf <ii CiMinti V 



M \I1»i:N nam I". /-v 
(li MOTIII'.K ' 






I \ 



I III-RIIIV ClCRTll-Y, That I attemUMl <lcnase<l from 

, j; xa ,^-^ „, Oct:. 'U K^'v 

^ t 'I 

tliat I last saw li :»live on ^ " "^90 

an.l that .U-ath ..ccurrcl, on the .late- statc-.l above, at UHi 
lL M. The CAlSlv Ol' DlvATII was as follows: 



63 




or RAT ION 
CONTKIIU" 



>Vrt/'.f 



A/on //is 



Pays 



Hours 



u^^OCX/V'^^.'V/'^^^ 



X"> V 



HI H 11 MM. AT K 
«)l MoPlIKK 
(Stall' ol C"i)iiiiti \ t 




-•X^ ^ ' ' ^- 



O-Zv. 



(•rcri'A r .(»N , 



K,XXA>-tr' 



VjLA^ 

h'esidftl in Sun I'liiiiii r,i 



) III I 



M.inllr 



lhi\ 



TMK xn.,VKSTArKI..'KKS«>NAl.rAKTH;rLAKSAKK TKIK l* • THH 

iii-.sroi' MY kn()\vm;i)<'.k and iii.Mhi- 



(111 






(\<l«lrfss 





% 



\ Jl- n «, ',. M.D. 

(..\<l.lress) LJx^VU ib(><>.WtJb 



(SIGNED) ' ^^ -^ "^ • •• 

lL)<:t 0.i iqo' . 

■ SPECIAL iNFORMATIONonlyforHospitdls, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 

Wlien was disease fontracted, ' 

If not at place of deatli? 



r 



r ^ 

c 



Former or , r>. 

Usual Residence cOVo 



How lonq at 
Place of Death ? 



Days 



I'J.ACK Ol- lURIAI. <>K K1;Mi)VAI. 



>^yvwu- 



IAI< < 'K K I', .VI' I 



\).\'\'Eo{ UrinAi, or RKMOVAI, 

Oct ^H . T90H 



' Cm:lW\A,ol.''C 



(A<ldresH...2>.b.X3^- 1^ tL -' 



^ . . . ., I InF Hhoultl be stated F.XACTLY. PHYSICIANS nhould 

N. „._r.very Item of InJormntlon .hould be cnreMly «;;»P"«'^; J^;;*;; do-siflcd. Tbe •Special Information" for p-r- 
state CAUSE OF DEATH In plain term., that .t m..> »\« P^ ' 
son. dylnft away from home should be ftiven m .very Instance. 



11 






I 



-«r 



mm 




WRITE PLAINLY WITH UNFADING INK 



H 'M, t 






f 



/.,/. AV/../,iiclcl.^^ n I^^OH 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



(rv\.v^ 




? »■► t. 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of Beatb 

( H. S. 5tan^ar^ i 

J? ^ i ^ 

PLACE OF DEATH: — County of J <X•^x ■ ^vcc'-^ vcwc uty ot 



%\..At 



FULL NAME 










Ic 



\. 



-ij. 



PERSONAL AND STATISTICAL PARTICULARS 



DAii ni- luK rn 



\ < . v. 




( M..iith> 



s 

I);iv' 



(Year) 



\ 



\ )rai 






s!\..l,l-. M\KUIi:i> 
\VII)<»\VJ:i» nR DIVoR^KI) 

Wiitcin viK-iiil ilisiviiiili'iii) 



lUK IHl'l, Av'K 
IStiitf or foiintiN ' 



[ (Xoc^^vuxi 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

(Month) '»='V^ ^^'*^''"'' 

1 1!I:RI:HV C1;kTIFV, That I atten.UMl .k-ccased from 

-^ : 190'^ to IL' ^^ i^p • 



that I last saw h iHvc on 



190 i 



("^ 



\AMi-: «n- 
jatm):k 



lUKTHl'I.ArH 
(H lAIMllK 
(St;it( >ir Coiintry) 



MAIDKN NAMK 
<)1- MOTIIKR 



nik IMl'KAll-: 
OK MorUHR 
(St:it«- or Country^ 




^ 






XXX/>^<lX 



M ''II tin 



n,i\. 



orrri'ATioNf^ x i 

Krsidni in S<iu /'i,i>hi>r» O.*. )'■<"' 
TMK AU.>VK STATK I) I'KRSONAI, ''A KTUM'I.AKS AKK TRlK To TlIK 
HKST OI- MY KNOWM-IX.K AND Hl-.I.n.H 



(Iiifoitnaiit 



VJCLA.aJC 



V^ V<X. \ 



aiKl that (U-ath (.ccurre.l, on the ilatc stated above, at ' ' 
M. The CAlSlv OF Dl-ATII was as follows: 



DTK AT ION - J''^?''^ 
CONTRIBUTORV 



I\/onths 



Days 



Hours 



DURATION 



Years 



(SIGNED) 

liV^t '.U TQo''. (A(hlres s)HOb dx 



AFoHths Pays Hours 

JxjJJLoc M.D. 



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



Former or 
Usual Residence 

Wlien was disease contracted. 
If not at place of deati) ? 



How long at 
Place of Oeatfj? 



. Days 



(A,„1re»» 3?^S 0<VVV V<XK.L>^' LU>- 



I'l.ACK OI" lU'RIAl. OK KKMOVAl, 
rNI)i:RTAKKK 



DAlHof HiKiAl. or RHMOVAI, 

D'tt x^. 



190 1 



C><AwJcxxaa^ 



(Adilress. 



\.i.^ , 



' ~ TfiE should be stated EXACTLY. PHYSICIANS should 

oi information should be carefully f^PP ^d- AGb s ^^^^ ..^^^^^^^ Information" for p.r- 

E OF DEATH in plain terms, that it m»> be proper y 



IN. B.^— Rvery Item 



; ! 



i 

I 



il 



% 



^ 



:asl' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

Registered A'o. ^Ool 



,f lUi'.iti! I- No. \y '^^^■^^v-n^y^'" 



hah- Fii('<iMfdA>x^' rl ^^^'"^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( XX. S. Stan^a^^ ) 



PLACE OF DEATH: — County 

,'0 \ (-0 (^o 



of '^a^ ^^AL->A.^CAA^<^ City of U/O.^ J .^^^'^AX.v^^:^. 






^ 



\q>^.su'.' 



Dist.; bet. 



— and 



( '' rroZ.ToT..To\r.''.os%'!.\' :^iisf.':.%^oTi.. .s name ..sTe*o o. s..... ANo .u.Bc. ; 



FULL NAME 






V. .J 



,_L. 



^ I : \ 



PERSONAL AND STATISTICAL PARTICULARS 



Ha 



1 

I 



DAI i: nl lilK III 



\».i-: 



a 



M..iitli' 



sl\«.|.)-: MAKKIl'.l) 

WIIX »\Vi: I> <»K I>I\t »K*1"I) 

Wiitt in v(>fi;il lit •.i^Miiitioii) 



IV 
(l)av) 



1 /,->////' 



I \«a! 



/^n 



(Stiitr r»r CfMMitry^ 



\AM1-: (»! 
I-ATIIl-.R 



HIKTUIM.ArK 
oi- » AlUKK 
(Stilt* i)r I'Dniitry' 



MAinivN NAM1-: 
nl MOTHKK 



UIKTMJ'KACK 
OI- MOTin-.K 
(Slatf or t"<)untiy) 



r 

(? ^ ^ 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



^A 



igo 

(Year) 



AL 






Keaidfd in Siui I'l om i.-rx 



) I ii I 



Moiitlf^ 



fhn. 



HHST OF MY kn«)\vi.i:i)<".f: and IU-.I,n.l' 



nnfui inaiit 



m0v<x. 



(•\(Mrcss .3-Mb 




-CL'>^.. 



U 




'Ou'W' 



.<^. 



(Month) 'l>"y^ 

I Hl-IKI'BV CIvRTirV, That I alkMidcd deceased from 

- up -lo ^ '90 

that I last saw h alive on rrrnrrr- 190 — 

and that death occurred, on the date stated above, at 
Af The C\^SI^ ()!• 1)1:ATI1 was as follows: 



1 



DT RATION Vc'TS 

CONTRIHl'TORY 



Months 



Days 



Hours 



^e 



Yeats ^ Months 



Days 



l^rt ai ,nnH r Address) Co\.<nxiL\^ U^ly^: 



Hours 
M.D. 

:^A 



DURATION 

( SIGNED )..W\^«3^^''^ 

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

How long at 

Place of Deatii? Days 



Former or 
Usual Residence 

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



uJt\\ 1 v.llj'OL/Lk.. 



ri,ACK Ol- HfRIAU OK KKM«>VAI, 
rSDlCRTAKF 



DATiCo! Hi KIAI- or RFIMOYAI. 
U'cfc '^. 190' i 






—————— -- — ~^ ^^ ^j^j^j EXACTLY. PHYSICIANS should 

IN. B.— Hvcry Item o? Information .hould be c»re?ully «"PP ';^J; properly classi^ed. The "SpeciBl information" for pT- 
•tate CAUSE OF DEATH in plain terms, that .t may be properly 
:on. dyfnVaway ^rom home should he ^iven in every instance. 



'< I 



"!ri: 



\ 



I J 



I'- 



1 



< i 

TT 







'i 



i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






100 H 



Registered JSI^o. 



2682 



iorvcu ^tvu. Deputy Health Omcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 

U. S. StanDnr^ ) 



PLACE OF DEATH:-County ofC)a/^ iw^^^^^ City ofCl^>- OAx^^^^^eo 

,0 l"A\,) (1 



^?T7» 






\ CtoX St; 






FULL NAME 



.0 



CYYX} 



Aa/wcjl 




SIX 



H \ I 1 »»| lUKTM 



\ ' . )•'. 



PERSONAL AND STATISTICAL PARTICULARS 

i col.ok 




a 



u 



k\Lt. 



^^ 



I Month) 






,^5-^ 



H? >,,,, 



II 



M..>if/n (A, O 



(Vtar) 



/>in 



\\ II)o\\ I.I) OK DIVol^il'!!) 

: \Vi it'- in >-.)4i,il il<-iv'iiMti')ii) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF l)E 



"" iVt 



7.1 

(Day) 



(Year) 



(Month) 
I 111{RI:BV Cl'RTIl-V. That I attende.l (lercase<l from 

JX^xt 11 I90"i to ..^/C* ^1 190^^ 

tlKit I last saw ht. . . . alive- on U/ct Xl T90 

au.l that .Uath occtirrc.l, on the <latc statc.l above, at S-Hb 



'Stiitt or Connli yi 



WMI, ni- 
!• AI'II I-.K 



I'.Ik rillM.ACK 
<»l I APIIKK 

(Slatr 01 l"o\intrv' 



MAII)1:N NAMI-, 
01- MOTIIKK 



HIK II!IM.A('1% 
OF MoTHKk 

(State or t'onntr\ ' 



c 









AO/JL VJ^jLxx 








"X^ 



,'// " /''" 



lMKAM.,VKS•!•^•n^I.WKl*S..NA^l•^KTI^^I.AKSAKKTK^K T' » THK 
hl-ST OP MY KNOUIJ'.DCK AND MI.Ml.f- 



M The CVrSIv OF Fti-^ATll was as follows 




(y.sLA^ 



DTK AT I ON Vt-ars 

CONTRIIUTORY 



^/()>l//lS 



Days 



Hours 



DT RAT ION 



ATION p^ ^'X'-^o 
(SIGNED) >•■'- 'V 




Mouths 



I^ays 



I /ours 
M.D. 



I<)0 



( 



SPECIAL INFORMAT 

or Retfnl Residents, and persons dying away from home. 



A.Mu-ss) ^^IkSk.. U fc^^-jvAial 
IXTION only for Hospitals, Institutions, Fransients, 



Former or ['Xr\ H 

Usual Residence I 3U' l 

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



X.\\j o 



. How long at ^, ^ 

X) Place of Death? " ^ Days 



'Infinnjaiit 



\\ r\ .>« » >» I, I . 1 '■ > • 



I'l ACK OI- lU RIAW OK I<i:M«>VAI. 




DATKof HtiMAi, f)r KlvMOVAI, 



X^(i^^:J/LXMy\...s!it. 



(Address 



'I 77 7^ A(^ 8houltl be HtBtecl RXACTLY. PHYSICIANS should 
IN. B.—Every Item .W lnWm»t1on .hould be cnrcfully «"PP'-^- properly cl»««i«ed. The •'Spcclol Information" for p.r- 
state CAUSE OF DEATH In plain terms, that it may be proper y 
:or. dyfng away from home Hhou.d be l^iven i y Instance. 



? 






HJ 



.f^s^i^t^ 




■ t 



v*;*- 



W 



.1 ,^ t?*=s-H*t^F?i&j«.*^^«r 



RITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 



^oHSiV C>, 



REFER 



TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lom 



Registered JS'^o, 



2683 



l^atr Filed \^^dAA.K^ X\ 

6^<^v^v^ AjLv4 Dep Jty -Icalth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of ©eatb 

( Vi. S. StaitJar? ) 
FLACE OF DEATH = -Coon.y of ^ CV.., ^ Vt.xCu.C.Gty of ^^ ^ VawCU,^. 



-M 



'LL'>\ 



h ^ U l>>^^- kcru.«4i: Dist/, bet- 

^Vi ^"^ „-- .r>r-M»-r r-.iur PACTS CALLE 



V '-^ WV^ i.eiiAi RESIDENCE give facts called F 



roR UNDER "SPECIAL INFORMATION" N 
NSTEAD OF STREET AND NUMBER. / 



FULL NAME 




(r )XCLT\J 






PERSONAL AND STATISTICAL PARTICULARS 



1^ 



11 



<X,L«L 



C I ^ 



IvLlX 



M\ II" <»r" !UK in 



\«.l". 



N!..iith> 



I'X 



) till . 



li;IV> 



!/..»//// 



(Year) 



A/ r 



slN«.l.l-: M\KKIi:i) 
\\'iit»iii vcK'ial (Ifxii'iiiili'iii) 



lURTIH'I.Xi'H 
iSti(t«' «ir Oovintry'' 



N\Mi<: ()i 

1 XTIIVR 



I'.IKTIUM.At'K 

• >i I \rnKK 

(Stat* or CcMiutry) 






MEDICAL CERTIFICATE OF DEATH 



(Month) (I^^y) iX^L 

1 in:RI«:BY CKRTIFV, That I atteude.l aeccased from 

£^^xc. 1 up^ to .1..^ 3.5:. 190 ^ 

that I last saw h-*->^ alive on ^ ct 9^ 190^ 

a.uJ that .leath occurrcl, o.i the date stated above, at t) 
Cl M. The CArSI- OF DIvATH was as follows: 

.cW^^^'^ 




xXxV<X''>v<:^ 



MAIIUvN N.\M): 
»»1- MOTIIKR 



ItlK rm'i,.\fK 

OF MoTHHK 
(State or Coimtry 



<>ccrr.\TioN 



J^^ixW' 




"h 



or RATION )><irs 10 M<w//,s iS- Days //ours 

coNTiunrToKV 



DURATION 



)'i'ars 



Hours 

(SIGNED) U. '^^- Lfr^<X.W...^^ M.D. 

i^ lifc ^S iqo'i (Address) UXvvaA.-tx.(>-v^.A^.. 



M0N//1S Pays 



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



Rfsidfd in S,iti I'liiniisrn *^ ^ ''''' 



•- M,»ifh> 



Dm. 



TlIK AHOVK STATK 1. PHK^ONAI. »'AKTICrKAKS AKK TRlH To 
HHS'1M)K MVJ<N()\VI,K1>(.K AND HhUIhF 

A.Ulre.^H UXvAAWvcAX 



r 1 1 }-: 



(liifoTinant 



►LAJLv^^j^-^^^-M^ 



Days 



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



I'LACK OV lURIAI. OR RKMOVAI. 



DATlv o!" m lUAi. or RKMOVAI, 

Qjdc a.a 190H 



,Ad,.,..», 2,U3-^ -. w tk ...ai ." 



N. B. 



— ^ vZ AGE should be stated EXACTLY. PHYSICIANS should 



1 f 

f 

I 



■r^ 






I I 









U . 1 Jl- - " I I I M 




|a ^i 



( t^ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ih 



' p (i 



J90H 



Bes^lstej'cd J\'o, 



2684 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of Beatb 

( n. 5. 5tanOa^^ ) 



PLACE OF DEATH = -County oi^C^ :^K<X>vC^coGty ofOlc^^v J A.a...-.Ax:- 



Q'u 



( •-/-ATrocc^^ro^-^.o-pV^^^^ ^ 



) 



FULL NAME 



CJAilJkAAJuLo^ 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 




''\(xU 




\v<tii 



\> \ li: ol' III RIM 



\' .1'. 



Month) 



)'i ii I 



% 



11 

(Day) 



!/,.»//// V 



(Year) 



/'./lA 



MEDICAL CERTIFICATE OF DEATH 
DATK 0\- Dl-.ATM u ; . »x w 

(Day) 



(Month) 



fpo\ 

(Year) 



-^ixt.l.l". MAKKIl-.I) 

W ll)<»\Vi:i> »>K DlVnKvKD 

iWjitriii s<K.Mal tUsi^'iiatioii) 




r.ik rmM.AOi-: 

tStatf »)r Country' 



NAM J- ol- 
» Alin.R 



lURTHIM.ACK 
OF I-ATIIKR 
(Statf or Comitry^ 



maii)i:n NAMI-: 

Ol MoTIlJvR 



lURTJlPI.ACK 

<»>• m(>thj:r 

(State or Country) 







i 



kVYVCi 



f Ill.'RFliV CI-KTIl-V, That I attended deceasea from 

act' iL .90H to Jf^^ la 190 H 

that I last saw h ^>. alive on U^ ^^ ^90^ 

and that death occurred, on the date stated above, at M- ^0 
(? M The CAISH OF DlvATIT was as follows: 



OJ 




DrRATION y^^ars "^ A/o,i//iS Pays 

C(^NTKI1U:T()RV Siy\sJ^Ci^^AJ^Ax^ 



Hours 



ni'RATION 
(SIGNED) 



Years % Months Days 



i\j^^^sy\) 



Hours 
M.D. 



lO/ct 0^ TooH (Add^.>c<vCDlX>^tll-Ot.- 



^ 



icy\^ J.ivCX/>vC^^c^ 



OCCri'ATION 

. - )V.//v 1A''///'a'0 nays 

RfMdfif III Si lll I Kill' l^'-fl ' "" ^ ■ 

T.n^Am)VKSM-VlM^l>l'KR^.»NAl.rAKTIcri,ARSAKKTRrHTn THH 

ni-sT Ol- Mv KN()\vi.i:nc.H and im-.i.h.h 



.tf? 



(Informant 



f \(l<lr»-ss 






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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



n.ACK Ol- lURIAU OR RHMOVAI. 




(Address 



..1.3L.l^..^..i!^^ 



N. B.- 



' ' ' T'l ItF should be stated EXACTLY. PHYSICIANS should 

-Bvery Iten, of in^ormetlon should be carefu-.y «uppl ed- JJ^^^^^^.'^^.,,,,. The 'Special lnfor„,atlo„" for p.r- 
* * r'Aii«F nP DFATH in plain terms, that it ma> oc pr h 



' I 



I 






% i 



II 



if'! 



4" 



el 



p^ 



*« 



'l4'^ 





'■\ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1*1. I." 



v.. , : H-f^-STJU: luK: P i*o 



IffOH 



K(' mistered vVo. 



2685 



\ \ -^. 

DEPARimENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanC»arD ) 
PLACE OF DE ATH : — County oiOo^-VM ^ 



IvOyvxCA^iCity of ^<Xa-v J X/CC->a_Ca_^c^. 



No. liS"! LLctu 



Sf '^ 



Dist.; bet. 



O-vR'^l-Urtj' 



x'1 




Jc\ 



/dli. 



( 



V \ C\ ^K ^\.»f C\ ^^^^ *♦ * ,«_ iiKinrR "special INFORMATION ■ '\ 



FULL NAME 



\cLhuJj.... t- ^-c^v^C>v 




PERSONAL AND STATISTICAL PARTICULARS 

^Uc ^0 /US 

, Month) <"»v' _ j^"-"" 



H)l, ' 






AC.K 



i 



1) ,v.. 10 



M.>i,l/is 



1- 



/'.; 1 



\VH>(>\VKI> «>K I)IV»>KtKl) 
Write iti s<Kial (hsiirnatioii) 



MEDICAL CERTIFICATE OF DEATH 



(Month) 



<Uay) 



(Year) 



()\<XKKkX<^ 




HIKTIU'l.AOl- >\ A (\ 

(Stall or CcMintryi \|\K J \ 4" J J 



lA IIIKK 



HIK'niri, ATK 
<)l" lAIHKK 

' State '>t (."iiUlltl v) 



M \I1)1;N NAM1-; 

(»!• M()Tm:K 







1 llFKl-HVCI-RTHV, That T atten.kMl deceased from 

a..va' I 190^ to.l^ ^ 190 H 

thatllaLawhiA^aliveon ^ <* ^^ 190 J 

a„d that doath occurre.l, on the date state.l above, at t, \0 
LI M. The CArSJv OF DHATII was as follows: 

^y^/xnrvOiY^r^ rj 



.\--'. 



-f)-.- 



T)rRATION )^.i,^^^^^';??^^^ /^«>- 

CONTRIIU'TORV 



Hours 



DIRATION 



Years 



Mo Hi /is 



Days 



Hours 



lURTnri.ArK 

()!• MOTMKK 
(State or Country) 



LOJvu 

occrrATioN / L? i_ j 

Rrsidri! in Suri /t ,j>h fs>:> Q^Q ) ,./< 



/)(M.v 







THK AHOVK STATKD PHRSONAl. J-AKTIcrLAKS AKH TKlH TO THH 
HKST or MY KN«»\\M:n<''H AM) Hhl.ll.l p 

c\Jttv 



(Informant 




( \<l(lress 



CLuJt 



(SIGNED) Q U). Wl^. 5 '^^• 

to Oi TOO 1 ( Addrefs) \SI%\clJ^^^^^^M 



SPECIAL INFORMATION only for Hosp^kals, Institutions, Transients, 
or Recent Residents, and persons dying away from Ijome. 



former or 
Usual Residence 

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



Now lonq at 

Rare of Deatli? Days 



ri \CE ov nuRiAi, or kkmoyai. 



DATK of lURiAi- or RKMOVAI, 

i}/ct Xa 190H 



IHSI 



„,„,.„» .35-^- °^S1 n.^^bU'v .at I 



N. B.- 



— — ] „ . .pF should be stated EXACTLY. PHYSICIANS should 

-Every item oi in?orm«tion should be c«re?ully HuppUed AGE « ^^^^^.^^^^ ^^^ ..g^^^,^, Information^ for pT- 

-. * /-*iieF ftp nFATH in plain terms, that it may ne pri*H ^ 
:or;d""/awt °"I1. "hou,- ^c *lv.„ m .v.., ln«.n«. 




I i 



• ( 



:■: if 



\ 




'i 1 




41 




WRITE PLAINLY WITH UNrAD.NG .NK-TH.S IS A PERMANENT RECORD 

RrFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS ^ 

■U^.^l.^v., Deputy Health Officer 

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

Ccvtificate of IDcatb 

( tl. S. Stan^arD ) r. r^ 

DEATH : - County of dc- ■^ ^C -c. .X Gty of ^ <^. . .V a ..^c . 



PLACE OF 



^ 



No.l.b>V-^^^' CAK.cn V 



I c. 



St.; 



Dist.; bet. 



and 



-) 



FULL NAME '^ ' 







s»;\ 



PERSONAL AND STATISTICAL PARTICULARS 



l)\<xU 



i)\ii'. (tl- lUK rn 



\t.H 






^\ ),.;»> 



^l '. 



(Day) 



Miitilhs 



r ■ 



(Vrar) 



Pa V. 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DHATH 



I go 

(Year) 



(Ivionth) _^^^"''^ 

fnKUHBY CHRTIKY, That I attended deccasea from 

--. : I90 " — '"^ to ■ 



xiNc. i.K makkij:i> 
winowKi) OK nivoKrj-i) 

;\Viit<iii >i<Ki:»l tl< -U'lKitioti) 



J iVoLrUv-v.C'CL 



tliat I last saw h-T:— alive on 

and that <loath ocrv.rred, on the dat. staled ahove, at 

-..:.■ -M. The CAUSJC C)I' Dl-ATIl was as follows 



riQO' 
190 



lUKTMl'J.Al'K 

' St.'itt <ir <".)untry) 







NAM1-. 01 
FA TUlvR 



mR'PHJ'I.Al'K 
0|- JAIUKK 

(State <»r Coil 111 IV 



MAIDKN NAMK 
ol MOTIIHK 



lUk riMM.AC'K 
Ol" MOTHKK 
(State or Country) 




1)1' RAT ION >''''''-^ 

CONTRNU'TORV 



Mouths 



Days 



Hours 



in- RATION 



(0 



Years rrJ^'^"^''' , ^^'^^'^ ^^^^"'^ 

( SIGNED )..U:\^--^ l(SU}.lii<XvvH. M.D. 
llu-t 0^' ..^ ^A.ldress) UrV<r>'- 



l)d: ')''\ TQO ( 



N'Axyy^-lv^^ 






Kfsidfd ill S,7ii riiiihisrn 



[; )',tll 



.■\f,»ltll> 



n,iv. 



T.n. Am>vK STATKO rHKs.,NA. PAK.McM^;.AKs AKirrnrH -n^ 

HHST ()I« MY KNOWI.KIX.K AND HhMJ.H 



(Address 



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



( \\. \ How long at 

usual Re*nc, 5-^ ^'^ M lU^^^v^ 'Place .1 hath? 



Former or 



Days 



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



V\ ACK Ol- HIRIAI. OK KHMOVAI. 
INDKKTAKKR ^ 



I)ATI%o! HiKiAi, or RKMOVAI, 

..sJ.^tJw 25-Cj 190'i 



oJLcAjj^cL 



(Address n.-^Vo Q00.V^3^^<nrV 3.1... 



^^^^i^iB—^^^^^^^'^'"^"^""^"^"^^"^^^^^"^^^^ . I FXACTLY PHYSICIANS should 

of InformBtion .hould be cnrofuliy •"PP''-*; p^,^':;,!;";,a,,Wlci? Vhc "Spccl.'l Information" for pT- 
E OF DEATH In pl»1n term, tha It m»y ^e P-P 



■i*^. 



N. B. Every Item 

state CAUSE Oh uc/* . " •" '':"" ''."-: .„ ,„ ,very mHtance. 
son. dylnft away from home should be H.ven 



B 



4 1 
^' I 



- % 



u 



I 



•I 



II 



'll 




.? 



4 It 



w 



mXE PLA.NLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD 

REFER TO '-•' "" r.gRTIFICATE FOR INSTRUCTIONS 



.1 ,,f H' il'li ' ^" ' >.-S«»^ 

4^ 



UJO'i 



Ec^islcred Xo, 






^frvcvAli^. Deputy Kealth QfT^cer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Ccitificate ot Beatb 

( "a. 5. StanDarD ) 



J? 



CT) -^ ^ 

PLACE OF DEATH: — County of C CXaa; v/^t^ ^ 



.c 



No. ^S H 



\KUi^:'^'y^-^-^^- and n-'CV-'^. 



^ -i Q* . 1 Dist • bet. cU A.:\^^"^"^'^^- ^^° 'rx 



,...l 



) 



FULL NAME 



■'\ 



i.'X.O 



.c 



.1^..:.^. 



PERSONAL AND STATISTICAL PARTICULARS 

, col, ok , \ 




r 



DAI)-: < >i I'.iK rn 



\ •.»•■. 






) - ,;. 






M.»illi' 



\ 



( V«iir> 



/'<n 



MEDICAL CERTIFICATE OF DEATH 

DATK <>l- i)i:ATn 



(MoiitlO 



(Day) 



(Year) 



, iii.:ki:HV C1:uT1FV, That I atten.lcd deceased from 



,...^.dL :u 190 



^IN«.I,l*. MAKKIHIi 
\VIlMt\Vi:i> <>K DIVoKCKl) 

(\Vrit<in s.Ki;il .|<«»iv'»i:tti"ti) 



lUKTHIM.ACK 
' Stiitf or (."ounlrv ' 



o^w^^xcL 



NAMI-: 01 
I AT HI". R 



MlkTMIM.ACK 
(Statf or Co\iiiti V 



MAIDKN NAMl. 
()|- Morill'.K 



lUkTHri.AiK 
<)1- MoTlll'.k 
(Statf or Coimtry' 




.<_l ctV'>^v <x 



X ,o<t c<r>vv^ 






"vCXa^^^Co 



Wx) 




that 1 last saw h X. , alive 011 

,,,1 tl^at .Uath occurred. <.m the date stated above, at 

M. The CAISK ^1'' DI^AHl was as follows 



up 



., n 



urRATH.N rears 3> Mo.Uks Pays 

CdNTKlltUTORY 1aa>A?v U.-v-xi 



Hours 



'.X-^.vLv^ 



DIRATION 
(SIGNED) 



Years 



Months 



Days 



Hours 
M.D. 



Oa 



Cpru 




I()0 









'> "^ 






t„kahovkstatk,.,.kk:^.na, r;KT|rr,xK>AK,< rnrK r.. 

MKST OF MY^KNOWM-.DOh AND m.I.n.i 



„:::.: %...^ u; \o^k^ 



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

4 .How lonq at 

Wtien was disease contracted, 

If not at place of death? ^ 



^ 



:l,ACH01- lUkl.M. OK KKMOVAI. 



DA TH of HfRlAl. or RKMOVAI, 

t,t M 



i \<Mrcss 




A 



T^ 1 d^ OAKA^^^rrA.' 



\i 






T90 




INDKHTAKKR 

(Address 



^— ^^-^— ■ . » 1 rvACTLY PHYSICIANS iihould 
-~ .j„„ .h„„1.l h.- .„r.SuMy -uppli..!. A«B .hould "• "•""':;j;''.i's';„,,, ,„t„,„.,i„„" tor pT- 

nr/d^T-w^. .ro^ H„.c »H„u..l He »lv.„ i y '"-..nc.. 



(. 



ll-» 
t 



m t^ 






J**—. 



WRITE PLAINLY W.TH UNPADING .NK-TH.S ,S A PERMANENT HECORD 

,».o -rn B»r.K or CERTIFICATE FO R INSTRUCTIONS 



1. \. i; V.> t 



^ -^uf^T?:^ lu^r I') 



IfUJ^i 



Registered JVo. 



DEPARTkEN?OF PUBLIC HEALTH=City and County of San Francisco 



No. 



Cevtificate of IDcatb 

, -a. S. 5tanMrC» > 
PLACE OF DEATH: — County of .CX> ^..v/ 



-Dist.; bet. 



— and 



— ) 



.4 Ji'^i^.-r^.^-V -,v. ^■lriStivi■^x.rlP .K~;r=^ 

V ,F DEATH OCCURRt:> 'N * ►^°«*"^*'- °" v^ X 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



>l\ 







Ct)I.*>K '\ 



MEDICAL CERTIFICATE OF DEATH 

DAIH «'l- DlvATlI 



i.\ ij; «»i 111 Kill ^ N 

'v| Lev 



a ' V ■ 



<- 



\c.v. 



iH .„,.. il 



(Day) 



M'utli' 



X^ 



i Nfiu ) 



/)</! 



(Month) 



%1 



(Day) 



7poH 

(Year) 



I HHF^TurTcHRTrFV, That I attcMKlol .leccased from 
— — r.190 • to 



SINC.l.K. M\KKIl*l> 
\VII)n\VKI> UK DIVoKi ».!> 
iWiitciii MM-ial <l« -itnialixn) 



lllK riU'l. \rK 
(Slatf or l"oMnlrv 



NAMl- 01 
l<A 1 H l.R 



HIK ruri. AOH 
()|- lAlllKK 



MAIin'.N NAMi: 
01 MOTMKK 



lUK inri.Ari': 
i\\- m(»tiu-:k 

(Slatf ox Cuuiilvy 



llU 



ft 




that I last saw h ^r. alive oti 

,n,l that death occurrea, on the .lalo stated above, at " 

M. The CAl-SK C)l- Dl'ATll was as follows: 



ri90 
190 



C^. Jx^^-K J:w:^vt;^.%.wi.>:v>.<<?^^^^^^^^ 



rv^^tx ^ ' ' ^'^ ^ 



^ 







\,\jnys^. 



tH^itATft>N 















Yf^f i M r^nHt^— — --Bttyr^- 

C, .NTH lH.n-. .R V (L^k .;.i^^.^r^..., -. 

( SIGNED )LciVcnoX'^ 



Nrrrrry 




//ours 
M.D. 



SPECIAL INFORMATION «"ty l«' "'^Pi*. '»^«"'"»»^- '»»^"""' 
«r ReTtJi RtsWtnts, and persons dyiiij a*ay from Home. 



JV'iM 



(Iiifoimant 



.>V 



.•„Ka,.>vkstatk.>.'KK:.>na, rAKnrr;,xKSAK.-TKrK 

Hl-ST Ol- ^Y KNoWl.l.Di.h ^^'> lU.l.n.i 



IH1-: 




Former or ' 
Usual Residence*^ 

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



\i.^zA\X.^y^ . ^-"^ ' 



How lonq at 
Place of Death? 



Days 



DATl'.of IMKiAi. or KKMOVAI. 

vD<* '^% 190H 



I'l.ACK OH nrRI.M.()K KKMOVAI. 

I'NimRTAKKR /t " ^ " ^ TnT J. 

(X,l.lr..s.. ^^'^ M)XvA.^W^ys. J± 



N. B. 



^— ^M^w^^"^— PYACTLY PHYSICIANS «houla 



^ 



Il 



1 i 



I > 



t < 



"^ 



WRITE PLAINLY WITH UNFADING INK 




li)0\ 



THIS IS A PERMANENT RECORD 

BCrER TO B «CK OF CERTIMC ATr TOR IN3TRUCTI0Na 

Registered JVo. 



luilr Fi/c'l ,-i..<:.tb\>Ji*v 'X^ 



Deputy Hcr.;:"-» OfTicer 

DEPARTWENT OF PUBLIC HEALTH-City and Coanty of San Francisco 

Certificate of ©eatb 

PLACEOFDEATH: — County of JCt>^ J ^- ^^ ' q^^ 



No. 



^ 



\ - \\ 



tfv 



St.; ^ Dist;bct. 



■■..V. 



) 



t K St.: - UlSU;Dei. '^V^ro 'special information- A 

-^^^ r«OM USUAL RESIDENCE O.VE FACTS CALLED -" UNO.B SPEC.AL^^ ^^^^^^ ) 

( ,r or.TH OCCURS ^^^^^.''^^'^o.pVt.l or .nst.tut.on give its name instead o 

V ,r DEATH OCCURRtO IN A hospital u ^ ^ I > 



FULL NAME 




OjyxjJu 



\jJx.Of.M- 



PERSONAL AND STATISTICAL PARTICULARS 




I.ivd 



/ i 



• Muiith) 



(I):ivt 



\t.» 



5% ...... I 



si\(.I,K, MARKIKn 
\VII)«>\VKI> OR DIVoKi ll> 
WiiK- ill MK-iiil (Ifsijftiati'in) 



lUK rm-l.At'K 
(Stat< or Country' 



M,. Ill In 

0^ ,c ^A.a'^* 



(Year) 



Ihn 



(Year) 



.^ 



MEDICAL CERTIFICATE OF DEATH 

DATK ol- DKATII > 

(Montn) _ 

^firRRlVFY^CKRTIFY, That I atlen.lcl .kocase.l fron, 

--, to .-.--.::=:r=:^..-I90- -: 

tl,at 1 last saw h - alive on "^"^^^^^ """ ''^ 

,„„, ,„a, ,U.a<h ..ccurred, o.. tbc ,la,e stat.-l al,ove, at 
::. M. The CAUSi; Ol' I>i;AT11 wasas^follows: 



-I 



fcV>A.>' 



-■j^V^>* 




NAMK <>1 
FA in l.K 



HIKTMIM.ACH 
Of lAIMKK 

(Stat«- or t"o\intry) 



MAIDKN NAM1-: 
Ol MOTHKK 




CC^ vOL.^' 



I ili.-. 



HIRTlUM.ArK 
o|- MOTHKK 
(State or Country) 



OCCUPATION 



\^i 




A 






4 

DIRATION 
CONTIUnrTORY 



} 'ears 




MoN//iS^ Pays Hours 



DIRATION 



'\^KJ\J 



Years Months 

,t) w 

( SIGNED ) .LQ^L^^AX^. 





Days 



/ay.y.v.^i" 



Hours 
M.D. 



iO^t 



'\'\ 



iqO 



( 



Aatlrcss) t^\-^>xi-^^i4- 



.W<.»4>< 



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






/),;i. 



iii'ii 



IlKST Ol- MV KNI1W1.1-.I)''1-- ^J^" '"•'■"■'^ 



(Il 









Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



DATKof HiKiAl- or KKMOVAI. 

v^ :hL^.....,,j9o:± 



an..- vH.. 




I'UACK Ol- BIRIAU OK KKMOVAU 



'^''^'^''""' I I II II I PHYSICIANS should 

; . .houUI be cHrofully HuppHed. AGB should »»• "'»'*:Jh7..8p^,|al information- for p^r- 

N. B.— Every Item o? •nf^-^^i,'"" •^'^Vl ^'"^that it m»y be properly cla.«.«ed. The »pc 

.tate CAUSE OF DEATH in P'-J;,^*^;;';:;;;,^ .very instance. 

sons dylnft away from home should be ft.ve 



4 



1^ 



1? 



I 1 



w. 



Il 



' I 



! ? " 



' 



I I 




9« 






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

REFER TO BACK OF CERTIMCATE FO R INSTRUCTIONS 

So90 






, *.rv.i:4i lu^i' *" 



lfH)\ 



Registered ^'*o. 






\ \jUK4 Deputy He 

DEPAmENTOF PUBLIC HEALTH=City and County of San Francisco 



^ 



Ccititicatc of IDcatb 

PLACE OF DE ATH:- County of ^'O,^' /T) H (V\^ 

V ir DEATH OCCURRED IN A HOSPITAL OR >. 



FULL NAME 



41 r, 



JOxAAj llAK>c.'>^*-^>^ 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

i)\ n. oi- lUK 1 11 







\' .1-: 



) r,ti 



s 



(Day* 



\!.,ntli' 



(^■t■:lr) 



5lS 



/'i/ 1 



MEDICAL CERTIFICAT^OF DEATH 

DATK OF HHATM 



(L'ct; 



190 H 



<.1\. .1 I- M \KK 11: 1) 
\VIlM>\Vi:ii «)H I)IV<»Kv Kl> 

(\Viit»in »i»>«ial ili siv-ualioii) 




ItlK rill'l, AvM- 
(Slati or C'i\niti v 



NAMl <H" 

KA riii-.R 



HIKIHIM.AOK 
01 lATHKK 
(Stall- <>t rovititi V 



MAini-.N NAMi: 
01 MOTUKK 



I'.IR rm'LACK 
Oh MOTUKK 
(Statf or Co\>nti y> 







<x\y^ 



d. 



{L 



NOL^ VCL ^ YVO 



(Month) ^^^='y^ 

I m.-RrirV Cl-.RTirV. That I attouU-a .leccasd from 

that I last saw h A, ahve on ^^ ^ 

,„.l that .l.ath occurred, on the date stated above, at 
-^ M The CAl-SK ^^^' ^'""^V' "'" ^" T'""'"'' 



DIRATION >Va^ 3 A/ouf^ 

CONTRIHl'TORV 



Day 



Hours 




* 



Q^^-Sj A.<X^^CvA-00 



c 






DURATION 



)V(7r5 



Months X l^ay^ 



( SIGNED ) ...>^ryv^ ^).C^^U-o4a^ 




l^ ^' 



Hours 
M.D. 



■ .SPECIAL INFORMATION ««ly f»' "»■.»"■"*. I"**""' •""^""'^• 
or RereS ResMenls. and ptrsons dyin, avtdy Iron. homf. 




,„KM,OVKsrV,-K..,.KK...NA,PfKTKr,.U<.AK,,rKr. T, . ,1.K 
MHST «)1- MV KN»)\VM;i)<.h AND HM.n.i 



*vn\rV3 



Former or 
Usual Residence 

When was disease rontracfed, 
If not at place of death ? -^ 



How long at 
Place of Death ? 



. Days 



1'UAC:K Ol" lUKlAI. OK KKMOVAI. 



DATi: o! lUKiAl- or KKMOVAI. 

t)^ 2>0. 190 1 






( \.1«htss 



^^— — ■— — — ^— — """"""^ ^ , FVACTLY PHYSICIANS should 

; OF DEATH In pl».» •""!;•'•- J' ""t ^n-^nc.. 



IN. B. Kvery Item o 

state CAUSE OF DEA in .n p.«... J^' •■■-: ;„ j„ ,^,^y instance 
son. clylnft away from home should be ft.ven 



i^ 






I I 



I ) 




m 



I J* 



i0iii^ 



WRITE PLAINLY WITH UNFADING INK 




iKi/c Filed, 



^ 1°, 



VJO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTir.CATE T OR INSTBUCTI0N9 

lie di sieved •A'''). «<50«H 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of ©catb 






1 



PLACE OF DEATH: — County of 0.->x J v. 



\ 






Nolo oXA^^Ofi. 




i: ' .XV 



.t..t 



Dist.; bet. 



and — ■ 



) 



St.; '-"^'" "'^'■„ ,„. UNDtR "SHCIAL INFOBMATION • ") 

( r. DE.T" OCCU-»tO .~ . HO.P.t.L 



> 1 



FULL NAME 



:\ 



' VI vva' VjJ oxv^^vo- ^a-^^) 



PERSONAL AND STATISTICAL PARTICULARS 



^^- 

JX 



i»\ ri: or uir iji 



\ < . 1% 




r< »!,' >K 



LL \-vvtx> 



(M.)iith) 



\ , 



II 



tl)ay^ 



\t..,illi- 



I 



(V< al 



/»,/). 



(Year) 



w inn\vj:i> «»K i)iv< »Kvi:n 

Wiitf ill ^<H ial (lt>.iv'iiati<'n) 



(St.-itf or I'otiiiti V* 



J\Tm:R 



lUK TMIM, Ai'H 
01 1 AIUHK 
(Stat<- iir Cotintvv) 



maii))-:n namh 

(>l- MoTIlHR 



lUR IHri.At 1', 
()J- MoTm-'.K 
(Staff or e'ountry' 






MEDICAL CERTIFICATE OF DEATH 

uATHo.nKArn Q^ ^ 

.1 ^ (Day) 
(Miiiilh) Ji 

I HKKiniV Cl-RTIFV, That I attcntlctl aeceasecl from 

li^ct ^H u^4 to.CD.^ ^^- ^^)°^ 

that I last saw h ...^' ahvc o„ \. ^ ^ /^ 

.„a that .U-alh..ccurre.l. on the .lat.statcl above, at 

aM, The CAISH OF DKATll was as follows: 

?^lrvo^.^.cvvXoJU.L Kp.^^vw.^ 



d^^^Y^^^^''^^ 



<XU^^'VV<X ^ V-A^ 




DIRATION J>«'-^ 

CONTRIIU'TORV 



JA>;/M-^ 4 /^^r-^ ^^^'^''^ 



DI'RATION 



.wJaXo^^aJL'O/'v^^ 



Pays 



(HIM TAI'ION OpVJ) 

Rfshird in Siju Inn'' '"■•' ^ . ^ 

HKST Ol- MY KNDWI.l-.lx.h ANl^U.I.n.f- 



\V(irs J/ont/is i^uy.> Hours 

.^ ) lliivuL W ^ O^vJJAm. M.D. 
(SIGNED )...VwM4^^-Vtv iiv /r^ JT> ,-> 

0^ %^ ...S fA.hUess)l^ ^^^.K. lKa.>>. 

-SPECIAL INFORMATION only for Hospitals, Insflulions, Transients, 

or Rerel^ Residents, and persons dying away from fiome. 

J( (T) How long a* n 

Former or 1^7 ciSi, r) r)k/vv\ijAA>t^/U) Plare of OeatI) ? ^ Days 

Usual Residence > I O D u a^ 

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



n \CK OI- IH-KIAI. OR RKMOVAl. 



DA'Ll'o! IMKIAI. or Rl^MOVAl, 

iD^ %Sl ^9°'^ 



«.n^l 






N. B.- 



^ ^''"^'^'"'"' ^ |_M L PHYSICIANS should 



^» 



\) 



I ) 

i 




'«, 




I I 



r 

[5' « 

1' 



t3ia.jt*^:T?Iir^ 



t'-^::^^ ws^v c 



li)0\ 



..^ ^LJicr le; A PFRMANENT RECORD 

DEPAmENT^FTuTur and County of San Francisco 

Certificate of Beatb 

( XX. S. StanCatC> ) . 

-r-.T /- »„ «f CL>A.- 3 )v,cvAv<i*^'^<- City ot - '^'-^ ^ - 
PLACE OF DEATH: — County of ^-L>a.v; (|^, 



No. 



,y o H D;sfbet.ll^^<^^ and ytfrW^XnA 



FULL NAME 



tSSJ^OA.'i^f!^^ 



PERSONAL AND STATISTICAL PARTICULARS 

si:\ 




MEDICAL CERTIFICATE OF DEATH 



i»\ 1 1-. oi i!iR rn 



\<.i". 




.L-'tvCfci. 



31 



)■<•(/' > 



n 



n 

(Day) 



M.mlh 



/%1S 







I Vt-an 



/'.; 1 > 



DATE OF DKATH jQ . 



(Month) 



(Day) 



(Ytar) 



^cL 



\vii)o\vi:d »>R DIVoKrKD 

•Writ, ill s<ni:il iN-vivrnation) 







'Statt.' or Cuiuiti y* 



I- ATM i:k 



HIK TMIM, AfK 
oi lAlllKK 
(Statr or Cuuntiy^ 



MMDI'.N NAMl. 
OI' MOTHKK 



lUK THIM.ACH 
()J- MoTUHR 
(Statf or Couiitryi 



■J .>VOUOrV^CJl 

lO. \--.ic - .\fnnths 
NrsnM in Snu /> »n. i.^fo \ O "" . 



T-HHRlil^CKRTIFV. That I attended aeceased ^on, 

iq .90 ■ to ^^ ^^ ^90^ 

that I last saw h^^ ' aliNCon 

,„, ,,,t death occttrred. on the <late stated alx.ve, at ^ 



(? M. The CArSlM)Fl)lvATlI was ^s follows: 



^.x-wv^A-^v^axy^ 









DIRATION ^'''■^ 

CONTRIIU-TORY J^ 

:XAXti >unXiv Mil 




DIRATION 



>Vrt;.J 






A^Cl.^yv/ClX 



o ;^i Co^-c - ^v^^^ ~'-''- 



(SIGNED) J M.A^-vv^^ - — 1., , 

■^i^^^L INFORMATION -I, ..r HospiMs, liiUiUlloii. liansWs. 
or to^ Re*drnts. anJ persons dying a*ay Iron. home. 






Tin. ABOVE STAT.U.T.HHSONA.rAKrjcn;ARS ARK l-HrK ■ 



(liifoiinant 



y<vyv-\^ 



iJL a: 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days I 



IOC) • s 



"place oi- BIRIAI, OR REMt)VAI. 

UNDERTAKER <^CV-.^1j^ 
(Address . © rfs^ A*-^ 



DATE of HtKlAl. or REMOVAL 




IN. B. 



^^'^'^'^^^"^ ' ^ . _,_.LL PHYSICIANS should 



ij 



I ) 




f 



i 



I i>, 



( 



T 



I I 



?i 



» I 



t^i 






.U 






WRITE 



PLAINLY WITH UNFADING INK 



/.96'H 



^ dUL-"' Deputy Health Officer 



THIS IS A PERMANENT RECORD 

„rER TO « .CK OF CERTiriCAT rrOR INSTRUCTIONS 



DEPAmEN?OF PDBLIC HEALMy and County of San Francisco 

Certificate of Beatb 

PLACEOFDEATH:— County of Cv^ 

I IF ei«lH OCCORRCO IN « H»SP1T 

c . , J (Q 



FULL NAME ^ 



cLjUa/ Mj'v^n^v/^^^ 






PERSONAL AND STATISTICAL PARTICULARS 



\<.K 




axxXj^ 



) lUl I 



% 






M.infli^ 



(Year) 



(I)av^ 



(Year) 



Ptx \s 



•-.INi.l.l-., MAKUn-.l) 
\VIl)t»\Vi:i) <»K DIVnRv'Hn 

1 Wiitr ill s<Hi:il .l(siv'n:(ti<iti' 




MEDICAL CERTIFICATE OF DEATH 

DATH <>»• I»HATll /r>^ 

, „,K,.;„V C,'"nKV, T.,at l.atte,.ae,. ac-cascl fro.n 

that Hast saw h ^^' ^^^'vc on ^^ 

.,,,,,,,aeathoccurre.l...nU,caatcstaU.l above, at 

- M. ThcCAlSlC OF DHATll was as follows : 



i!ik rinM.AiM-: 

stiitf or Oi)\intrv^ 



NAM1-: o» 
FATllKR 



HiR ruri.ACK 

of I AlllKK 

(Stiitf or Co\intryt 



MAIDl'.N NAM I". 
Ml' MO'nU'.R 



lURIinM.ArK, 

(»»• M«»riii:R 

(Statt- or i'(<(ititrv) 



(KC I TAT ION 







CONTUIIUTORV 



Mouths 10 />«M'.s- //^"'-^ 




^^^■^^^ _— — ■ .„ u„.»ii.ic institiitnns. Trans 



Hours 
M.D. 



...VJ...V 



.rlefeM Wdents, Vnd persons dying awa, (..m home. 



•nn.AnoVKSTATK,.rKKM.SA,rAKTU;n;VKSXKKTK.... . 
UHST OK MY KNOWl.KIX.H ^^'^ l.Jl.o.r 



i/^aAJ^ 






(A.l.lresHH mX Ut^ ' 



Former or 
Usual Residence 

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



JvMiA 



How long at 
Place of Death? 



Days 



DATK"!' n'KiAi. or RKMOVAl. 



)ATi'. <>: 1 

A9ot 



lUA\'\' 






(Addri'ss 



N. B." 



(Ad.lress.H I Vjj UA; . Y^ 1 ) - ■ ■ 11 I PHYSICIANS should 

' -4) r.K nrefully iuppUed. AGB should »^,VH"''The ''Special Information" for p«r- 

-F.very Item of Information .hou.cl ^^ --^^J'^ «, ^^..^ He properly cla.shlcd. The Spec 

.tate CAUSE OF DEATH m ^ "•" J^^7^:;,„ •.„ ,very Instance. 

son. dying away from home should he <l.v 



'i 



k 




i 



I 

• ! 



4 



r . 






\ 




THIS IS A PERMANENT RECORD 



REFER TO 



BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihifr /•V7rr/,'lL'ctA-^- IH 



lOO'i 



Jlro^istered J\'o. 



2694 



\ 

I 




Deputy Health Officer 



DEPARTNENT W PUBLIC HEALTH-City and County of San Francisco 



Certificate ot Scatb 

( XX. 5. 5tanC»arC> ' 



V 



PLACE OF DEATH:-Coun.y of '. 'C. Jxc..v.^,e. Gty of cVc.>. Wp^.e. 



I ,r Dt*TM OCCORRtO IN A HOSPITAL OR INST. lU 



r^Js.4 



) 



FULL NAME 



>'v.^"kv 



^■ 



u 



<^..s:.. ^v. 



-! \ 



DA'n: <»i lUK 111 



PERSONAL AND STATISTICAL PARTICULARS 

r(»i.<»K 




M..iUh> 



AC.K 



5,5 



5 •,•,;>, 



V 



(I)av 



!/,.>////' 



V.'^AX 



b 



fVcar) 



/',M 



MEDICAL CERTIFICATE OF DEATH 

DATK <)i- ni.ATH j("\ 



(Month) 



(Day) 



(Year) 



1 ill 



.Ki:nV Cl'RTn^vTTliat T atteiKlcd .Icceased from 



190 



to 



SINr.l.K. M\KUIKI> 
WIlXtWHIl OK I)IVt»K* in 
(Writfin mmmmI McvuMialioii) 



,<^>^^<X v.^ 



r.iK ini'i.Av'i-. 

' Sljtti lit t.'inmtr\ 



NAMl- 01 
FA III j;k 



Hlk lliri, MK 
Ol" lATIM-.R 

< Sl.ilr or rouiitrv) 



M \ 1 1 ) I-. N N A M 1 •; 
ni- MOTIIKR 



IMKIUPLACK 
Ol- MoTHKR 
(Stale or Contitry) 



i\^ 



^LKJ^L.^O-^y ^ 




,l,..,t I la^t SMW h alive on 

,,,,, ,,,,., ,K-,tl, <.rcurrca. on tlie .late .tate.l above, at 
M. The CArSE OF I)h:ATIl was as follows: 



190 
T90 



CONTRIBUTORY 



Months 



Days 



I /outs 



Years 



DURATION 
(SIG 

%^.V\ TQO ' ^ ( 



I^avs 



Hours 

A.l.lress) L^ VC^ ^^ "^ ^ if- ^-^-^ 



occrrATiON 

Rrsidrii in Sa» I'l nin i>r<< 



b )V.Mv 



\/,,i/f/i> 



Ihns 



HKST Ol'" MY KNOWl.KDCK AND Ml.I.Il-.l- 



(Infovnuuit 



V^^CA.'Crv^wfi^V^ 



f \'l(lri'ss 



"■^^ECIAL INFORMATION only for Hospitdls. Instituhons. Transients, 

or Rcrcnt Residents, and persons dying away from liome. 

How lonq at 
former or p, | Dc^th? Days 

Usual Residence 

Wlien was disease contracted, 

If not at place of death? 



i)ATi%<)t m KiAi. or ki:movai, 
VcXj ^"i I90H 



I'UACK OK BrRIAI. <m RKMOVAl. 



N. B.- 



^^-^^■— ^— ^^— "*^^"™^^™^ * » I f=v*CTI Y PHYSICIANS should 

.tote CAUSE OF DEATH In P'«'" ^^T-^^;;; J'^rc^^ r„stance. 
«on, dymft away from home should be fc.ven .n every 



1li:i 



4 




Ill 



p^^ 


'^r 


' 1 




$ 




( 1 




;iNi 

1 


1 • 
1 



WRITE PLAINLY WITH UNFADING INK 



I V . 1 \'"^ 



■\ 



:■( 



VJO'\ 



THIS IS A PERMANENT RECORD 

REFER TO BACK Of CgRTIFICATE FOR INSTRUCTIONS 

Registered ^'o, So95 



A /'U^,, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtificatc of 2)eatb 

( XX. S. StanPatD ) 



N 



o. 



PLACE OF DEATH: — County of ^C^->- ^ o.^.<:ca Uty ot 



.^ Uv 






w ^ ^f. ^ ' Disfbct 0LO'aAN.vXl.<nA. and J C^^<LC^>■^-^- 

lU '^ Vi ^ > ^^'^ ^ 1>»1SIm DCU ^,„ot- "SPECIAL INrORMATION- \ 

FULL NAME tL^^tcti U' - ^ 



) 



PERSONAL AND STATISTICAL PARTICULARS 

cm.* iK 



HATK nl- lUKlH 



V 



M..ntli> 



A I ". K 



\ , 



I I):iv 



M.nilli' 



( Vfiir) 



n,i \s 



SIN<.I,K. MARklKI) 
WIDoWKn OR DIVoKrKI) 
Wiittiii MK'ial lit siviialioij) 



HIKTm'I.AOK 
(Stiitf or Country 1 



NAMl- or 
V \TMKR 



HIKTMI'KACK 
0|- FATHKR 

iStaU- or c*(Miiiti v^ 



MAIDKN NAMK 
Ol- MOTUKR 




MEDICAL CERTIFICATE OF DEATH 

DATK <>K DKATH 



i)„ct 

(Month) 



(Da J') 



(Year) 



I HlvKI-HV CI:RTIFV, That I atteii(Ud <leccase(l from 

.^ ' I loo-. to...^.^ '^'^ '9oH 

that I last saw h alive on ' ^^ ^"P 

a„a that .leath occurred, on the date stated above, at 1 1 
OL M. The CAUSK OF DJ-ATH was as follows: 




^AX.'Lo 



r\ 



IMK rilPI.ACK 
o|- MOTHKR 
(Statf or Country) 




) w I 



'xxi* 



<)ccri»ATiON igvp ij , 

Mrsitfrd Iti San /■uiinisfo \K' > '''^ > ' 



\rnnth: 



Ihi y." 



TUK ABOVE STATKI) PHRSONAK l'AK'>*'S7, V^-'^'' ^ ' 
HKST OK MY KNOWM-JXVK AND Hhl.n.l- 

(Informant 



f Address . 






DURATION ^ years 



Months 



Days 



C(,NTRim'TORY^..i^^^^^^-^^-^t" 



nr RAT ION 1^ Vt-ars, 



J^ONt/lS 



Days 



'?I^ 



( SIGNED ). -U) ^^\^ 'y- ^ CL^.U.ai...^ 



\^cti Xl iQoH (Address) 1?> 



C^^v 



Hours 

(DV 

Hours 
M.D. 



SPECIAL IN FORM AT ION only for Hospitals. Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



PI \CK OF niRIAI. OR RKMOVAI. 



DATKof IHKIAL or REMOVAI* 
iD/tjt :3^A TQO'i 






(Ad(lre.s.s....l.l11 



^4.^fr>^ 



■— — i— ^^^^— ■^-■■^"^■^■^'■■^■■■'^"""'""'""""""""""'""""'""^"""""^ IH K t ted EXACTLY. PHYSICIANS should 

N. B.— Every U.n, o« InSorn...!.- .hould be c«r.«-l.> .-PP"«-^ p*„';^eH^Tl...m'd! Th. "Specl.! lnt.rn....on" .or p.r- 
.*•*» CAIIRF OF DEATH In plain terms, that it may oc \» 



r^vi 



i 



i 



I 




tj rt 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„.,„. , s„ ,>^.S*H&PCo RtPER TO BACK OF CERTIFICATt F OB INSTRUCTIONS 



Ddic Filed , 



•zXjX-v^ 5a 



190 "i 



Begisterecl Xo. 



3696 



Drn 



' A • >-S 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "a. 5. 5tanDar^ ) 



(^ 



PLACE OF DEATH: — County of 



'acv<x^\JL-i\/ti:)..City of vio^c^.o^Y>^X'v^L£ LcL.^: 



: .1 ii iifjt,. 



— ) 



FULL NAME 



'1 

i 



-'" (^1 



PERSONAL AND STATISTICAL PARTICULARS 

COl.DK 



> 



datj: ok lUK rn 



\ \ 



s 






Ar.K 



-i.^ )■/•</;> 



(Day) 



M.>nt/i' 



J V 



(Year) 



lhi\. 



SIM.I.K. MAKklKI) ^ 

\VIl)(»\VKI) (»K DIVoKrKI) Q 

'\\iil« ill '•luial (h»>i^'iiatioii) w\ 



lUKTHl'I.ACK 
( St;»t«- or (.•Minti \ 



\AMI-: ni 
I" A in l-.K 



HIk rin'l.AiK 
ni I AIIIKK 
(State «>r Coiiiiti \ ' 



MAIDHN NAMH 
<)l- MOTMKK 



HIKTIIIM.AlK 
<»l- MOTIIKK 
(Stati' or Country) 






c. ^^^CrV>X\. 



d. ult 



L 





1 



cc^V'cL 



^\^iX/' 





\ 



kJOsT ^nLi t' 



'i- I - 



OCCUPATION 

h'fsidf,i in S,n, I ,,iii,is,-<> XS )>.M> r> .U>./<///' 



l><i 



Tin: AHOVHSTATl.'.I) rKKSONAl. l-AKTUT I.AKS A K l. TK t l'- T' > 
IIKST Ol' MY KN<)WI,i:i)<VK AND MHUhf- 



11 IK 



Informant Vjxtj_\) CmLLo 



"V^^3 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII ,A 

VA li 

(Montli) 



(Day) 



M 
(Year) 



I IIHRKlTv CivRTIFV, That I atten<lo<l tlcccasfd from 

-. . ..up - to ..: ■^■' ~ i<)0 

that I last saw h aUve on ' ^9° 

and that death ()ccurre<l, on the date stated above, at 
M. The CATSK Ol- I)I<:ATII was as follows: 



DIRATION Years 

CONTRIIU'TORV 



Months 



Days 



Hours 



I )r RAT ION 



Hours 



Years Months Pays 

( SIGNED ) ..Li). ^ "^ &V%vvXXAa. LVU>U^' M.D. 

\i/'.ci XI TOO ' 1 ( A.ldress) dxX crvo^-y vxi.'\\l>0 L^ 



.QA. 



SPECIAL INFORMATION only for Hospitals, Institutions, Translcnls, 
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'l.ACK OI- IMRIAI. OR RKMOVAI. 





( • 



L*u^A<L> 



DATK of m-RiAi. or RKMOVAl« 



..iD'ci :6i 



IQO'l 






„ . TfiE should be stotetl EXACTLY. PHYSICIANS should 
N. B.— Every Item oi Information .houlcl be cnrefuMy «"nP ''^'^- .,.operIy cl— WIed. The "Specl.l Inform.tlon" for pr- 
•tate CAUSE OF DEATH In pinln term., that it m»y be properly 
•on. dying away ?rom home -hould be gWen In every Instance. 



I'l 



► 




)• 



li 
0:t 



li< a- 



f II. illti »• N'" 



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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

53697 



. •«>.% •'x' —'' r.iN; r » • ' 



Ddlr Fili'^IX^^^\>^^^^ ^^ 



VJO'i 



Be^Lstcred JS'^o. 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



J «v 



PLACE OF DEATH,-C„„.,V .1 ^c.> J^^.--»0,v o.3-- ^ VX.-..C.. 



No. 1-^H \l\<xt(r>VA-/a; 



Dist.;betMli-taMK*nW 



Mini ^■^V\X3U St.; DlSt.;bet. ^^^^ •special Information- "\ 



) 



FULL NAME 




'\0lKU L^^^-C<XAX-rL.C^: 



^ 



PERSONAL AND STATISTICAL PARTICULARS 



U : ^cU 



n: <.i I'.iK ill 



' M..1HI1' 



.\r.K 



)V.» 



H 



M.»illi 



n r 



i ^' 



I ■»■'•, ii I 



/),/!. 



sl\.,l,|-. MVKUIl'.n 

wiiM lUii) «»K i)i\t)i ri;i> 

Wiitrin MH-ial (h-urtuitiou) 





I 



f 



I'.iK riiri. \>"i<: 



NAM!' «»I- 
I- A 111 J-.K 



I'.IK I'll I'l, \ri-: 

<)1" lArill-.K 
iStait iir Ciiuiitrv 



M\II»i;N NAMl", 
<il- MOTIIKK 



r.iK rinM.Ai'H 

t)|- MorilKK 

< Stale (II i."ounliyi 



OCCII'ATION 

A'f-^n/r,f III '^tiii I'l tiih /w. 






(Year) 



^ 



,\ 






MEDICAL CERTIFICATE OF DEATH 

DATH Ol- DMATII 

fMunth^ '^'-''''^ 

, m-RICnV CI-KTIFV. Tliat I aUon.k-.l dcccasea from 

lO^ctr ' '. 190^^ to AU'cfc ^^a T90H ■ 

n.allast.iwh..- al.vcon ^^^ - ^'|^ ' 

^,,,, ^,^^^ ,l,,t„ .„,,,,e.l. on the .late statol ahovc, at cO^^^vL 
6 '. M. The- CAISI- Ol" ni'ATII was as foll.nvs: 



(Hn ^^ Oc\ -v-.vX^<r>^- 



niRATION )VH^-^ 



e' 



Months ''> Ada- 



Hours 




^\,Cw 



T/'rf ' 



.!/-.,////> 9L.^ ''".'••* 



n.K AUOVK STXTKP '"^^X^-'NA, rXKTUM^I.VKS AKK TKl K H > 'HK 
lU-ST Ol- MV KNOWl.l.lX.K AND IM.l.U.i 

„„f „ Qf)VclvC^ C^.v<^O^v^^^^ 



.HRA-noN ^. 

(SIGNED) .LL- CK WL 

ID^ A.a too' 



}V(7;v Months ^5 /)<m 





Hours 






M.D. 



"c^prciAL INFORMATION only for Hospitals, Institutions, Transients. 
Of Rercnt Residents, and persons dying away from liome. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



•l.ACH OF IHRIAU OK RKM<>\ Al. 



nA;i;i; <>!' iukiai. «>i khmovau 






IN. B.- 



^^— ^— — FVACTLY PHYSICIANS should 

state CAUSE Ol ULA i n inHtance. 



state CAUSE OF Dt A l n m p..- , " "- ' .„ ^,^^y inntance. 
«on. dyinft away from home should be ^'ven evcr> 



1 



w 



RITE PLAINLY WITH UNFADING INK 



«, r*^— ' ■ . lit J > 1,1 



r 




Dufr AV7f'//,iy. 



.\; 'XH 



7,9(9 H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIONS ^ 

Uc^isfcrcd J\'o, 



2698 




Deputy Health Offtcor 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



No. 



Ccvtificatc of 2)catb 

PLACEOFDEATH: — County of 'O,oy>-v^ ^ y „ . 



J I V X rV <:VV«^ 5t,; ' UlSI.; DCU "^ '''~ I "special INFORMATION" \ 



FULL NAME 




X^xx; cL'Jl.^'vOJvXAy^^u. 



PERSONAL AND STATISTICAL PARTICULARS 



"3 



!>\Ti: ol- I'.IKTU 




l.k^U 



iMoiitlil 



\ * . »•: 



)V,n 






M.,uth' 



(Vrav> 



I 



/*,? 



MEDICAL CERTIFICATE OF DEATH 

I.ATKOl.nKATH „ , ^^ 



(Year) 



siv<.l.l" MAKUn'.n 
U IlM>\\ l-;i> OR niVoKv I'D 
\\ 1 ill- ill 'iixial (h •«u'ii;ili"n) 



i 



\ 




lUkTnri.xcH 

' Slatr or *.'oiinti V 



NAMl-: (H- 
FATin-.R 



lUKTIlIM, \(K 

HI- jArm>.K 

(St.ttt ur Country 



M AIDl'.N N \M1-. 
(»l- MO'lMl-.K 



1URTH!'LAC"H 
Ol' MorHl'.K 
(Statr or Count ryl 



DCCll'A TION 

AVMiifJ 11/ Salt /Kill, isrn 



. ^ ->^qAjl 



X/^'W<X. 






.^X*w-k 



^u 



(Month) 'J^=»y^_ 

I n!.:ki:i'.V CI-KTII-V, That I atten.UMl acccase.l from 

^ — icp — tn -— "~^^ -" 

tJKit I last saw h -— alive on " ,^:-r.r~—— up 

,„., that .l.ath occurred, on the .late statol ahnvc. at — — ~ 
- " M. The CAISIC Ol' DI'iATH was as follows: 



I )r RAT I ON >''''''•''" 

CONTUIIUTOKV 



Moni/is 



Pays 



Hour 




'Os^L 



1 



) Vfi; 






HHST OI- MY KNOWIJ-.IX.KAM) m-.I.H.l 



DTkATION )'''<"■■''" 

(SIGNED) Wur^-^^ 



JA);/M.s- 



Pavs 



^ ^.Q>Vo.lda.>va_ 



flour s 
M.D. 



(J 



) Ct -VA ,.,o'l M.l.ln-^'^) UvtA^-C-M 



Oil 



.^wX.. 



Special information only for Hospitals, Inst.tufc, Transients, 
or Rerent 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 



(1 






\yy\jo 



ri.ACK OF lURIAI. OK Rl-MOVAI, 



r 






DAIlio! lUuiAi. or RlvMOVAI, 

0-€t 2.0 jgo\ 



(A(l«lress 



( \<l(ln 



N. B. 



— ^^ — — ^— — ' '" , FVAGTLY PHYSICIANS hHouIcI 

* • rAii»4F OF DEATH in plain terms, tfiat it m»y nc p » 
Htute CAUot ur l»l« »- , , . „ ASv*n in every inHtnnce. 

«on, dyinft away from home nhould be fe.ven 




Ill 



l« 



*l 






¥ 



1 1 




w 






p,TE PLAINLY WITH UNFAD.NG .NK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 



.^llSil'l'o 



Jierfi.sfrred J\''o. 



, ,^A?-, Deputy HeaJth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Bcatb 



* rM J? ^ 

PLACE OF DEATH:-County of^-.. .^.^<x.....-Gty of - -> 



No. bbH * X-\ Ux. 



— and 



n^ \ K, St.; DlSt.;beU -spj-cial information" "v 

(^ ,r DEATH OCCUBHID IN A HOSPITAL OR INST 



) 



FULL NAME 



\:^A.i)( 



{\y^\ 



^ 



JU.: 




PERSONAL AND STATISTICAL PARTICULARS 

I) ATI". «•! r.iK in 




,C 



U 






\ ' . ]■: 



%H 



)V,;. 



I».i\ • 



M.nilll^ 



a 



(Year) 



/),fi 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol- 1)1:aTH 



tl.t 



(Day) 



(Year) 



W IDOWKP iiK |)I\t>K» !• I> 
I \Vi itr in v(K-i:il W -i',- iKit loii ) 



lUKTin'I.Ai'K 

si.il( 'ir t'liuiili V' 



.L .»s.<Ccrvo-<L ci- 



<:jo 



■i. 



NAM)- <•!■ 
FATIII.K 



HiKinri.ArK 

OI- I-AIUKK 
(Stale or Country) 



M MltJ-'.N NAMK 
(»!■ MoTMHR 



lURTHl'I.AOK 
ni- MoTHKK 
(St:it< or Country t 



? 



(Moiitli) 

I HFRKIJV CKKTIFV, That 1 attcmU-a aeccase.l fnm, 

.... -■ . — — - TOO 

that I last saw h •• - alive on "^ 

,„.,that.Uath..cH-urrca, ontheaat.statclabovcat 

"T- M. Tlu- CArSl- ()|- ni;A Til was as follows: 

QA:U^.v<^X <^.aJU.^^<^^^ 



nr RAT ION >'''^'-^ 

CONTRIIU'TORY 



Months 



Days 



Hours 







JlonlZ/s 



DIKATION . )V<?r.? 
(SIGNED) .JX^ kW^i-.s^- 



Pavs 



flours 
M.D. 



/\>-'iiiri: II' ■"' " ' ■III* 

T.n^XH.)VKSTATK.n.KK..>NA. rAR.Mrr..AKSAKl-lKl H -n 

HK.ST 1)1- MV KNOWI.I.P'.K AND HKM».»* 



(Ii 



V^^rwxlx.^ 



i^Ltn^f . ..o'-. (Aa<lnsO ^^^^> JAXX^^CA^-.^ 

"special information only tor Hospitals, Institutions, Transients, 
or Refent Residents, and persons dying a.ay from home. 



Former or 
Usual Residence 

When v^as disease contracted, 
If not at place of death? 



How long at 
Place of Death ? 



Days 



( \(l<lrcss 



,v 



^'^wa JA.: 



liJ.ACK OV lUKIAT. OK KKMOVAI. 
INDKKTAKKR V_-3_hJLW- 



DATI". ot UiKiAi. or KKMOVAI, 

,0.^1 '^\ 190 H 



^<L y^-vxyL 



\_>l-..Vv:. 



(AcMross M OOw/V^ 



'\jLc^...vL 



A^.-f^^. 



^ ^— ^— ^^— li— — — , pvACTLY PHYSICIANS should 

' : ^ .Houhl b^ carefully supplied. AGE should »>« «t«te^ "^ ..Special Information" ?or pT- 

IS. B.— Every item of informat.on .hould b. cb y ^^ properly clas^.t.ed. The Sp 

state CAUSE OF DEATH .n »»'»'" '.7' j^J^^j^ every instance, 
son, dyinft away from home should be i^.ven 



J 




¥,-. 



ili 



t 



I; 



) • 



WRITE PLAINLY WITH UNFADING INK- 




1U()\ 



-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Jie (Mustered Xo, SrOO 



luilr AV/f'</X£tcrWv ^^ 



\iA>u '^^P^^y ^''calth Officer 

DEPAmerrtF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate oi S)catb 

^ . inn ^>. .' U<X~iVCVmA City 01 -""^^^ ^-^^ 
PLACE OF DEATH:— County ofUCV^x - -^^ 

'■^ I) % If 







St.; 



Dist.; bet. 



and 



-^ 



Zit.! X^iil** i-^" •cprriAL INFORMATION" \ 

(^ ,r DC*TH OCCURRtO IN A HOSPITAL 



rR^T^^T^^^T^O^.'^O.vYTs .Am£ ..ST.AO C STR. 



FULL NAME 



Ulo\lc^A^^-C OX^^c^^-^ 



PERSONAL AND STATISTICAL PARTICULARS 

, COI.«>K \ "t, 



1U< 



I) \ 1 1 I •! r.iK in 






■ M..nth ' 



\| . I'. 



i^ i )'' 



<;> > 



tUay> 



M,.uth' 






/>,M 



MEDICAL CERTIFICATE OF DEATH 

DATK OI I»1;aTH ,j , , 

JLb. 

(Day) 



(Month) 



79^ '- 
(Year) 



C- 



^. 



sixr.l.lv MAKkll-J* 
WIDOW l-:i) nK DlVttK* I- I> 
Write ill xiR-ial <l«'stv:nati<ni) 



IMK inri.xri-: 

I St;it' "t t'liimtry^ 



La^a^qC^ 




N'\M1-: OI" 

I- A rill 



Leu 



ThFrT^^^'^K''""'^' ri-i I attc.n.U..! .loccBscMl from 

,li„l llMsl saw 1. ..— I'vo on ^^ /" 

.,,.1 ...at ,K-at1, ncurrC. u„ tin- .la,, sta.v.l ab..vo, at 
a, M. The CAI-Sl. Ol'- ni.:.Vri. «as as follows: 



^ 
^ 




I |J.l»wv^. Utt^ >-^-^ 







Hfli 



HiK riiri.AiK 

OI' lArill'.K 

(St:it<- "11 I'miiit I y) 



MA1I)1-:N NAM)". 
Ol- MOTIIHK 



HIK rni'LACK 
OI- MOTUKR 
(Stall- or Cotmtry^ 




nl^riON y^^ars Months /^ays 

CONTKll'.rTORV iX--'^- ' '-^ 



^ 

c. 



Hours 



'A 



^ (^-viX/^ N-^X-^-^a^ ^ 






I )r RAT ION 
(SIGNED) 



)Va/.s '^ Mouths Pays 




:1, I't- 1.10 M (■ 



A,l,lr..s) T5iij±hyidii^ 



/fours 
M.D. 



J" 






_ L<XA^U. 
OCCll'ATION -P D \ 

h',-^!\lnf III S,ni I- HI If />'•'' ^' ^ '''" ' 

TnKvm,vKSTVrK,M-KH.oNA, r.;KT,r,..vK s A K ,ri- K . .■: . o 
m-,sTi.i- Mv KN-o\vi,i:i"-.i'. ^Xi! '"■'• 

(„,f ,. CLwoxL) J .c^fr^-^ 



ipECIAU INFORMATION «"ly >«' «»^P»^I^- '"*'"«»"^' '™^'"'^- 
orl^e^ Residents, Vnd persons d,in, d.., (.«». Home. 



Q \ How lonq at 



Whf n was disease contracted, 
If not at place of deatli ? 



/CLmjKMa,' 



Deatli? 



Days 



i.i.Acr. oi-- m-KiAi. OK i<i-:movai. 



.^./CVV^^ 



l)Ari':«)f lUKiAi. or KHMOVAI, 

,.Q^Xj i.^ 



190 






IN. B. 



fVlln^'^ 1 A<b Vi^ j , pvACTlY PHYSICIANS should 

^ ; :, „ .„„„ ,, ...refuny suppHcd. AP.B f "^IsWUc'r^Th: ^SpeclB; Information" for p.r- 

F.vcry item of information .houici he o ^^^ properly claHS.fictl. 

.tate CAUSE OF DEATH in P^-^.^^^^'j^^'^l^ ^^cry inHtance. 
«on, dyinft away from home should be &• 



} 



'^W 



m 



'i 



i^fi 





RITE PLAINLY WITH UNFADING INK 



^brW 



^ J^ --' Depu*:y Health Officer 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFIC ATE FOR INSTRUCTIONS 

llcc^istcred J\'o. 






DEPARTMN^OF PUBLIC HEALTH-City and County of San Francisco 

Gcvtificatc ot Bcatb 

, -a. 5. 5tan^lr^ ) 

^ cnn /-w J h^cx. ^ vC'^^ c, i. City ot . J ^a- > ^ -^ 

PLACE OF DEATH: — County oiL'^^^ - ^^^ 



c. 



FULL NAME CL.^^vL>x.- l^WvAtU... ^_ 



^ 

^^4' 



PERSONAL AND STATISTICAL PARTICULARS 



av-.'-^ 



Ii \ I 1 ol I.IK 111 



\ 




liM.iiitht 



r> )v 



il)ay> 



M.mlli^ 



15 



Vt:iT) 



Pay. 



MEDICAL CERTIFICATE OF DEATH 

DATE Ol' DKATH ^ , . 

.■A..X- 
(Day) 



fMontlii 



rgo 

(Yfarl 



, HI-UIUIV Ci;:<TIIV, That l atten.U..l .Iccvas.,! from 



,- t 



^ -V 



-;hL 



.190't 



to ...<U..^S^^- 



Will' )\\ I'.l» < "K l>l^■' •'■!'■ !• " 



lUKTMl'LACl-: 

' siiitf or ("oiititi V 



NANH •»! 
lATIl l-.R 



JUK rinM,A(."K 

01 lAIMKR 
'Stale or foiuitry) 



M \ii)i:n n ami, 

nl MoTIIi: K 





lURTin'UNCl". 

«ii' M(>rui":K 

(Sljitc or Country i 



8 x^y-^oXX 



that I last saw h •• alive on 

.„., that .Uath oocurrcl. on the .late statcl above, at 

M TheCMSK OF DHATll was as folloNVS : 

0' 



M. The LAV ^'"' ^" " 



DIRATION J>'7''^ 

CONTRIIHTORV 



)Vti'r^ 



Monllis 



Pars 



1 1 our ^ 







Mouths 



/^avs 



Dl-RATION ,^ J 

l9^ M !U (A.Mrcss^M'ljWtLo^ 



//ours 
M.D. 



SPECIAL INFORMATION «»ly •- "-P"* '"^'""*^' '"•^""'^• 
„^e«^ Ment'Vnd persons dyN away fr.^ home. 



IIKST 01 MV KNcl\Vl.i:i)<.K AMI lll.l.n.l 



(llir')ini:iTlt 



VA/rLhv'^-^cx^ 



0-vaA^^ 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



"I'l^ACKOF lUKlAU OK RKMnVAI 



Ov< 



190' 



[^ 



^O' VM.X 



rNDKRTAKKR w— ^W 
(Address 




DATi: of Ht KIAI. or RKMOVAl, 



(X,l,lre^s I c^VD \ ]^> I I II II I PHYSICIANS should 



J 



\m 



mi 






-.-ulc: ic a PERMANENT RECORD 
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANt 

WRITE PLAINL ^^^^^ ^^ ..c. OP CERT.r.CATCrOR INSTRUCTIONS 



Rpgi.slercd Xo. 



'f4702 



•V ^ Deputy Hca'th Officer 

DEPARTMENT OF PIBLIC HEALTH-City and County of San Francisco 

Ccitificatc of 3catb 

. . ,;5cv,^v^.VC.->^C^^ctGtyofdc^'^'^<^^-^,^^^' 
PLACE OF DEATH: -County of ^ a. >^ /? ^ , 



I 



No. :>» 



) 



St,; I l^lST.; D^^* ^^r^^'oER 'SPECAL INrORMAT.ON \ 

^ ir deatW occurred in a hospit.l n 



J .*^ v^^-'- 



^ 



FULL NAME 



I V, 



■\ 



PERSONAL AND STATISTICAL PARTICULARS 



'1-^ 



<XL. 



lL 



I)\ IJ t >1 lilK I II 



f 1 



M.iiit^i' 






\' . 1". 



«t 






I I/,.;////' 



MEDICAL CERTIFICATE OF DEATH 



Xi. 



(Year> 



a 



/'..■ 



-IM.l.l' MARK 11-. I) 
'Write ill ^'"inl .I'-'-u-'uitioii ) 






, „,:R.;r.V Ci'kTI.-V. TL.t l atu„.K-.l .U-.^.-l from 
.___— up- to 

ti,at I last S..W h - alive ot, ^^o 

.^,,, ^,,, ,,,Ut occurred, ot, the. late .latca above, at 

M The CVrSP; ()!•' I>nATH wa. asfoll.uvs: 









^ 






!•■' 



iiiurinM.ArK 
Stiitf or ContUrv' 



NAM I- n! 

1 \ rm.K 



niKTHPI.AiK 

oi i\iin:K 

(Stall "1 r<)vnUr\ 



MAini-.N NAM1-. 
(H MDTIIHK 



inRTnrLAfK 
or MornHK 

(state <ir Country 



oCCll'A TION 



O/CL-NV d-^v<x-^'^^ 




CONTRinUTORV LL.^^^-^^ 



//oitrs 



)'rars 



Months 



/^(ivs 



^Lv^^^'- 



v-Uid\\u 



M.D. 



DIRATION 

(SIGNED ) AJ 

'■~\ 

■^^ClAL INFORMATION o.l, l». H-M-i- l".!"""""^ *"»^«"'^> 
^^efe^^'sideM s,7.d persons «>i«q .»^y !ron, h«me. 



( 



[ions, Tn 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



- Ti. 1- T W I ' !•' T' ' 1 111'- 

IIKST.)!- MY KNOWI.KIM.K AND 151.1.11-' 



>o 



"^^JuU 



l.j.ACKOF m-KIAI. OR R1;M«'VAI. 



DATHo!" Hi KIAI. OI R1;M0VAU 






V V,c^ 



N. B 



(Address ^ I ^ ) ' ^^"^'^V. 11 II II I PHYSICIANS should 

,.a.c CAUSE OF DEATH in P ■"" ^:„'":' 'Ti^ ,,„, l„«,.n«. 



T«.7cAUSE OF DEATH In P""".";;'-:;.„ in ,v.r, ln«t.n«. 
»on. Hyin* awoy Sron. ho-..c xhnul.1 be ft. 



? 




!'**! 



RITE PLAINLY WITH UNFADING INK 



W 



M,aPl..f ITenlth- 1 V- i - t-^sij^^ 1US:1> Co 



i»»^>i-iii/»^i/Ni 



100\ 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIPiCaTE FOR i N3TN ww . .^.^^ 

Registered ^'o, ^=5^IK5 















Dale /'V/r^/X ci^Wv ^"^ 

d^.<rVAx^ dULA>u Deputy HeaJth OfTlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( XI. 5. StanC»arC> ) 
PLACE OF DEATH: -County of d(^<rr^<^ City of 3 Cr>^.C>>^^' ^0,1. 






) ? 



Ill 



'No. 



St.; 



Dist.; bet. 



— and 



( 



\r DEATH OCCURS *W*Y F 
IF DEATH OCCURRED I 



„ ,,Qi,*, RESIDENCE GIVE FACTS CALLED FOR UNDER "'SPECIAL INFORMATION • \ 

rrnosPaAL OR ?nst.?u4n'c.ve its NAME instead of street and number. ; 

_. %.Ji) 

FULL NAME 





CK^^^y: 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 



-4 



DAii: «>i- HI Kin 



Month' 



A».K 



'iS 



r.-,/» 



LL 



(l):iy) 



M,,nthy 



Am 



(Vtar) 



Pa \ A 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH /p. 




.s.. i. . . 
'Day) 



IQO > 

(Year) 



(Month) 
I 11I;KI:BV C1:RTIFV, That I attended deceased from 

TQO 

— -— ■ T (/) 



— — — — - 1 90 to 

that I last saw h aHvc on 



1 

I 




I! 



A\ 



w 



Nl\..I,K. MARKIKO 

\vii)t »\\ i:i> OK i)iv«iKri:i> 

(Wiitfin siicial <lt si^'iiatioii) 



lUKTHlM, \CV. 
(Statr or roiiiiti y^ 



N WW <>»■ 

!• A 111 i:k 



HiK rHri.Ary-: 

()!•• I-AIIIKH 

'Staff or ro\niti ^ 



m\ii)i:n xAMi; 
oi- Morm-.K 



'X 



O 




Kxr OvL) rcu^rv^vv^4 



s. 



luK riiri.ACK 

oi- MOTHKK 
(State or Cotuitry) 






p. 



oCCri'ATION 



) 'ra ■ 



}/,>,i//r 



/)<!) 



Tuv \iu>vi' sr\'n:n i-kusonai. i'akiuti.aks aki: tkik to rnH 
r.KsT oi' Mv KNn\vi,i:i)<".H AND iu:mi:i" 



< \(l(lrcs^ 



ati.l that death occurred, on the date stated above, at 
M. /rhe CATSI-: Oh' DlvATIl was as follows 



1)1 RATI ON >V(//--9 

CONTRIBUTORY 



DURATION }'i'(irs 



Months 



Days 



I/oiiys 



}ronths 



/hrvs 



(SIG 



NED) to. 







I lours 
M.D. 



1 1 



IL'.cCt. ',}X iqo'i ^ (Address) "^ tr>-c^V-v^.-<^ LtX-L 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



ri.ACK Ol" lURIAI. OK RKMOVAI, 

(5 iL il) '^^ ba/>%xaltvu 

INDKRTAKKR NJ . OVD • >. 



i)\p\ oi uiKiAi. or ui:movai, 

iVt 3c, 



TQO'I 



(Athhess 






7^^ !• 1 \cv ehoiild he stated EXACTLY. PHYSICIANS should 

N. B._Bvery Item of informBtion •houl.l h. cnrcfully -nP'-'- ^^'^^..t "lossmei! The ^Sp^ Information" for p.r- 

state CAUSE OP DEATH in plain terms, that it mjiy be properly classitiea. me j 

sons dyin4 nwny from home should be feiven in every instance. 



I i' 



H r • 



4:, 



[ « 



I i 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 



I-,', nf Ill-lth I N" i^ 



X-tTvs.^, 1J^:I'C() 






nr r.FRTIFICATE FOR INSTRUCTIONS 



7)r//^Wv7rv/,ii).tlxA^N^ X^ 



I00'\ 



Registered JS'^o, 



2704 



icr .v^ il^V ''"''"'' ''''"'' '''^'''' r . 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of ©eatb 



^ 



No. 



, XX. S. StanPatO ) 
PLACE OF DEATH: — County ofO/X/vv- ..xaovCwcc C.ty otv, tv >v 




^CL.^:M..<y^ and OL.Crv^>av..c^,. ) 




FULL NAME 



cuuv.^w^:^^^^ 




"•f 



^i-"\ 



PERCONAL AND STATISTICAL PARTICULARS 

DATi: <ii r.ii^ r.i '-""I 




.LL^h^A-vx' 



A(.i-; 



lo'^ 



:> r„; 



I 



(Day* 



M.-H'h 



( Vfiii) 



/',n 



M.l,]" MAKKIl'.I* 
.. 1I)( »\\i;i) i>K l)I\< 1 
Wiitf iti MR-ial (U-ij-'iiati'iii) 



DATE 



MEDICAL CERTIFICATE OF DEATH 
2 0F~I)KAT1I [A 



(MontlO 



Day^ 



I go 

(Year) 



W ll)(»\vi;i) iiK 1>IV< »Kvi:i) A 



MXcl/V'^ulA 



irf 



( » 



i!iK riiri.Ai'j-: 

(Slate or Coimtty 



NAMK nl' 
FA rn l-.R 



luR rmM,Aoi<: 
^^\■ i-\rin:K 

'Slati- c)r Cimiitry) 



MAIDl'.N NAMl". 
OI- MOTIIHK 



lURTUPKArf. 
(Slate ur C«mnlry) 



Ux^vo^^cx 




1 in'RI':BV CI'RTIl-V, That I attended dcrcascl from 

tTLt ' ^ 190M t., i)A^t. ^\ H)oH 

that I last saw li -^-^ • > alive on ^^ ^^ ^'P ' 

and that deatli occurred, on the date stated above, at 
CL M. The CAl'SI' OI' Dl^ATIl was as follows: 



I ) r R A T 1 N ) V<7r.v Months 

coNTRiurTORV CL\JU>vaX) ^.sJU^Ka^s^j:^. 




Mouths 






OCCUPATION 

RfiifrJ III S,ni I 



I illll !''■'> V ' ' '■'" " 



- M.'iilh- 



~- / III \ 



m 



TMK AHOVK STATl-.n l'*^" «:^,">,V'' )'*,'; 1^', I;. ,\ 
HKST Ol- MV KNOWI.l.Di.h AM) Ml-.I.n.l 



KS AKi: TKIK TO 11 U'. 



I )r RATION IC) )\\n-s 



(SIGNED) 



-ct- :Vi- 






T()0 



(A.ldress) ^M^ 



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



Former or . 

Usual Residence > 

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



1 lLvJLoU^X^^'v^" Place of Death ? 



i 






^ 





. Days 



(Iiifoi matil 



oil 



f V.Mk-w 




Oo'YwA^ ^ 



X, 



DXTl'of MruiAi. or RKMOVAI, 



t u 



PI \CK ol lURIAI. OR R1;Mo\ Al, 

11 ^-l M>U><t>a^^^r>v 01 



190 



A 



(Adthcss 



N. „.— fivery Item ot* information •houlcJ be cnrefully ""nn''-'; ^^^;fe;y7lal«i^'lei?''Th^^^^ Information^ fo"r p"r- 

«tntc CAUSE OF DEATH in pinin terms, that .t m»> be properly 
«on, dyin^ away from home Hhould be feiven in every mstancc. 



■^^^m^ 



»i 



^ 



i I 



V 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



1 rii ,it)i 1 Vo - t'*?" t»-^^ I'iSlI" Co 

1',. iiinl "I 1 1< :i It n I ^'' . > i.,* ^ 



nPTFR TO BACK 



OF CERTIFICATE FOR I NSTRUCTIONS 



/> 



,iii' Fih'^l, ILIoUa>-1\^ a^ 



rJ()'-\ 



Rco^isfered A^o. 



2705 



^. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of IDcatb 

i Ta. 5. StanDarC> ) 
PLACE OF DEATH:-Coun.y oi^<xJ\t^^y^^^- ■ City of 1 1^ Ue v. 




No. 



,4^ . -^^ '/ll' xaL . \ n V 



CJtccU 0v:,cs4\v^.la. 



St.; 



Dist.; bet. 



and 



.«OM USUAL RESIDENCE cvt tacts c-.lu.o ro_P^--« ^^%%%-;- ^rr^eR^"" ) 






FULL NAME 



U,-t 



\L\A^cLi 



0\ 



PERSONAL AND STATISTICAL PARTICULARS 



slA 



T 






ft 



C( »I,« >K 



^^ 



DAll-; »>!• r.lKTM 



\' .1-: 



V 



.L 



t. 



MonllO 



(l):iv^ 



M.ni'h^ 



I \' i-a r I 



/^, 



MEDICAL CERTIFICATE OF DEATH 



UATK oi- i)i;ath 



IL'cl- 






I go 

(Year) 



W IDoW j:1> ok IilVttKrj-.I) 

.\VMt«- ill ><Hi;(l (k-.i>.'iuiti»)ll> 



liiu riiri, A^M-: 

(Stati- or rouutry' 



NAM1-: <>l 



lUR IHIM. \rK 

<)»•• I A rill-: K 

fSlatf or c'ount! V 



MAn)i:N NAM): 

Ml- MOTIU'.K 



1UK rillM-ACK 

«»i- M()ini:K 

(Statf or I'oiiiUtA ' 




s ' I 



._CV ^ v.X 



(Month) *I'='>'^ 

I in:ki:r.V CI-RTII'V, That I atU-ndcnl .U-ceasdl from 

up to .■.^— - - - ''^ 

that I last saw h . alive on ^'P 

an.l that .Icath occiirrcl, on the .late state.l ah<ne. at 
M. The CArSl-: Ol' DIvATIl was as follows 

nr RATION y<-ij's 

CONTRllU TORY 




dL.cLi'v. 



Mouths 



Pars 



I /ours 



Mo fit lis 



Pars 



i 






t 



«^v-^<- 




-CV 



o 



^ 



-oX 



k 



»KCl I'A JinN 




-\ 



J N > VCi - 



Achlress) C)t-< 






//(>Nrs 

M.D. 



Dl'RATlON >V(7r.v 

(SIGNED) Mill' 

H^ct; :^b two' ( 

SPECIAL INFORMATION only for Hospitals, Institutions. Transients, 
or Retent Residents, and persons dying away from f>ome. 



M.nilll' 



/',; 



TMKVMOV,:STV,KnPHKS,,NA, rSKTU-r|AKS,SUKTK,,- T. . THK 
m:sT ni MV KN«)\VI,M><-H ^^" Hl-.MIJ 



(in 



(\<l.lw 



v>h J? v., |-U.X«: 



,. 1. 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at placed deatli? 



How long at 
Place ot Death ? 



Days 



IM.ACK Ol' lUKIAl.oK KI-:Mo\AI, 



U^\ 



\hSAA 



l)\n:of HruiAi. or KlsMOVAl, 

9. 



IN )J'.R I'AKl'.K 

(Ad 






190 



,„..„ qn^.'^ "^^' 



V 



' ' ' T! T^ AGB «haulcl be Ht«tc.l l.XACTLY. PHYSICIANS should 

:S. »._i;very Item oV in*orm..f.on -houlcl b. c..r«tully -'«>»>-;• ^^^'J daH^iVtccl. The •'Speclol InformHtion" ?or p-r- 
Htate CAUSl: OF DEATH !n pl.iin terniH. that .t m»> be pr«.per y 
«on. dyinft nwny ?rom home Khould be ftivcn in every mntance. 



I 



'\ 



M 



^i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

1 .11 ..It-., r"V() n t-1^^^~^ MM' 0.) ___^_^_ 



. ^^ ^t-o-ripir-ft-rr POR INSTRUCTIONS 



LA.' 




Deputy 



io(n 



Registered J\'*o. 



2706 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certiticate of S)eatb 

( -U. S. StanC»arD ) 



-P ^ 



PLACE OF DEATH: — County of UOyY\/0.\yO./>axyLA^:^ity oi 

-+ '^^ 1 4- 1 I y . . . j' . . ^ (1 O. . r»!„4.»k^+ - ": and .^rrrrrrr7r-r-r:rrr. 



rrO 



.'udu^^ UnA^ 




/ \T DEATH OCC»/«S *W*V rRO 

V IF OtATM 0<fy:UHRED IN A MOSP 



.t)^:::^s^^.c. ... ?S^^^ ---i^^-;::;r" ) 



FULL NAME 



TAL OR TnST.TUtToN GIVE ITS NAMEjNSTEAD OF STREEl 



r-'V 







SKX 



i>.\ri*. ni- i;iu rn 



At, K 



PERSONAL AND STATISTICAL PARTICULARS 





kjd^ 



51 

(Day) 



(Year) 



11 



)■/■(/ i 



sINt.l.K. MAKKll'.I) 
WIDOWKI) OK DIVDHtl-.I) 
(Wvit'-iii MH-ial il< •.i'/iiati' >ii ) 



lUKI'm'I.ACK 
(St;it» i>r (."Dunlry' 



Mntlth^ (A.O 



UOxxL^nxMAj 



/><n 





\AM1-. OI 
FATHKR 



HIKTMIM.AiK 

OI- I Arin:K 

(State or I'oimti v 



MAIDKN NAMJ-; 

OI- MoTni-:K 



lUK'rniM.Aci-: 

OI" MOTHKK 
(Statf or Country) 



oeCVi'ATlON 







YV<i 



MEDICAL CERTIFICATE OF DEATH 

(Month) <I>^^V^ ^^"'■^ 

I llJ'Rl-HV ri'RTIFV, That^ I attoii.kMl deceased from 

.v^vxi b 190H to .''■■■^' ^^ ^90^ 

that I last saw liA^v^ alive on U CX- 1<P 

and that death occurred, ..n the date stated above, at \lSCi 
M. The CAISP: OI* DIIATH was as follows: 



CL[ 



DIRATION 



)'tars Mouthsi Days 

1 



J lours 



IM IS. .-V I 1^ '•'' ' • "; "^ 

CONTK ir.rTORV oU.<Uu<iLJL.^V>XL\- 




Oj<A\l 





kjJLKJX/y\\M 




DURATION 



) 'ca rs 



J/(;;////.v 



Days 



(SIGNED) UJ^ Vl^- U^-vOUxyVVv 

0C1 . ::^'.'-i TOO n (Address) L 




Hours 
M.D. 



Vcu^'^vaJI 




Rfyiifrd in Stiu /'nni, />' 



)'/•(?; 



M.mth' 



n,n 



TI.K AHOVK STATK .. ''H^I^-NA. VAKTirrKAKS AKH TRrK TO TM..: 
in%S'r (>!•• MYKNtlNVI.HIX.h AM) lU.Ml-.l- 



(Itifiiiniant 



( \<l<lri'ss 






c 



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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



DATIC o! Ml KlAi. or RKM<»VAI, 



(^'^ a.% T90H 



I'l ACK 111' IHKIAl, CIK KKMnVAl, 

.■n....:ktakkk Xilixu V%-a^cv^ 

(A.l..re„ , iblt -.l-aKv "dt 



!N. B.- 



,.,.,^^^.i««ii««^^— ^— ^^^"^■■^^^^■"""^^"^'^"^ t t d EXACTLY PHYSICIANS should 

-r.very item of ln?<,r.n..t«on .hould be c»refully --^^l^^^^ p^rp^cHyTlo-'"^'"^- ^he "Specia'. Information^ for pT- 

•tate CAUSE OP DEATH in plain term., tfiat it mi.y be p r P 

^on, dyinft aw.y from home nhouid be ftiven in .very Instance. 



i!"' 



• I 



WRITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



^M^*»^ 



n 



•r-j.-af' 



!Lv r.s^rc. 



REFER TO 




Dn/r /w/^>^/Xot<s\>t^' 1^. 



lOCi 



Registered JVo. 



^r%M€ 




^ 



^vu Deputy Health Officer 



DEPARTMENT 6f PUBLIC HEALTH=City and County of San Francisco 



I' * 



Cevtificate of Scatb 



% 






PLACE OF DEATH : - County of 3 C^ -- - ^c^^ v cv*_.Uty J( | , 

f \ *1 <;,. \ Disfbet.i)-^Uv.^^t and jic^^U. 



\ ) 



FULL NAME 



1 



X 



L^": i- 



PERSONAL AND STATISTICAL PARTICULARS 



-«r.\ 



C(>I.<»K 




a,L< 



^ 



i,\ n: i>! iUK in 



\| . !•■. 



/ I ^ 



M. nth 



\\ 



\vn)o\vi-:i) UK i>:v.tK> 1 i> 

(Write ill s<x'ial (l.«.;>.Mi.iH"n ) 



lUKTuri.NO)-: 

. Stiitr i)T <"o«\1\tl vl 



iD.ivi 



War I 



/Kiv. 



MEDICAL CERTIFICATE OF DEATH 

i.\ I'K OI- ni. \'i"'i 



(Day) 



(Year) 



C'A ^vq 



, <^. N V 



I' ' 



NAM I t>I 
FATIU'R 



lURTlirLACK 
Ol- lATHF.K 
(State- or Coutiti y' 



NTAIDl.N NAMl 
Ol MOTHKK 



lUR rnri.At'K 

Ol MOTUHR 
(State or Country^ 




I 



(Month) 
I HKKI'BV Cl-RTIFV. That I atUn.k-.l (lecease«l from 

_ — 190 to ..r~- — 1')0 

that I last saw h — alive on — ' " ^'^ 

,„a that aoath occurred, on tl,e .late stated above, at 
M Tlu- CArSIv ()!• Dl'ATIl Nvas a<; follows: 

s„Lcc.\-.cL.'.- ^ 



V. s\. 



o-v^tr>"v^w'vv-o 



-« ' 



I )r RAT I ON >Var5 

CONTRIHrTOKV 



Months 



Da ys 



Hours 



VCU'lVCX ^ 



S. mW^^ • 







\_- v^L; 



( SIGNED ) UA^^^ 0. -.D lL.ALK./^„. '^ 



.r- 



iqO \ 1 



Hours 
M.D. 



>«*■ 



OCCri'ATION Si . 




<X\^ "^ 






);ti> 



M,.,:lln 



'lu\ 



m\ 



HKST «)l- MV KN«)\\l-J-.l><-»- AND Ml. 1,11.1 



SPECIAL INFORMATION only for Hospitals, Instilutibrt^, Iransienls, 
or Recent Residents, and persons dying dv^ay from liome. 

Former or \\ ) 

Usual Residence VCL/^XXX. ^ v 

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



How lonq at 
Place of Deatli ? 



. Days 



(Infi>Mii:int 



(A<1ilrt"«'< 










■">! 




DAfKof in KiAi. or RKMOVAI. 
0^t .^C; 190 M 



I'l.ACK OF fURIAU OR RJ:M«>\AI, 



^v^ 



vC. 



(.Xdihess 




^_^_^__.^^— MM^^— ^f"^^"^— ^— ^^^"'^ t t I EXACTLY PHYSICIANS should 

state CAlJS^. Ul- uu-^i" 1 ^jven in every in8t«nce. 

son. dyina away from home nhould be fcoen m e ery 



i I 



:il 



t . 



h 



I 



i I 



W 



RITE PLAINLY WITH UNFADING INK 



^ ' 



. i 



I ' 



Una 1(1 '>f lh :iUh » >" '"^ ^-.;!;::g__^_— ^ 




190'i 



THIS IS A PERMANENT RECORD 

p >.i.BTi rir.ATE rOH INSTRUCTIONa 

Registered JVo. '^•••v« 



Ifrv^ UuH Deputy HcaJlh Officer 

DEPARTMENT OF PUBLIC HEAUWty and County of San Francisco 

Certificate of 2)eatb 

( •Q. S. Stan^ar^ ) 
PLACE OF DE ATH : — County ofU^-fV '-^ 






No, 



St,; 



Dist.; bet. 



— and 



'-'"t - _^ ,^- MMorR "SPECIAL INFORMATION" ^ 



FULL NAME 




si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COi.oR 



nfwu 



lo 1^ . 



X 



DATK «)!- HIKTJl 



Af.K 



(Month* 



)V-i;» 



(Uay) 



M.>nl/is 



(Year) 



Pa V. 



MEDICAL^ERTIFICATE OF DEATH 

„.v,.K o... ..H.-^r-Q-^ . ^^ 

/-, ' .»,\ (Day) 

(Month) 






J 



ipo 

(Year) 



I in.:Rb:BY CIC RtTfV, That I atteiuUul deceased from 
that I last saw h •. ahve on - •^^■^"^^- ^9° 



SIM. UK. MAKUn-I). 
WIDOWHI) OK DIVOKi l.J 
(Wijttin scK-ial Mtsivtialion) 



IMKTMIM.ACK 

(State or foinitrv* 



NAM1-: or 
KArm-.K 



niRTlUM.ACK 
OV lAIMIKR 
(Statf or Connliy' 



maii>i:n namk 

i)J- MOTHKR 






and that death occurred, c, the <hite stated above, at 
M. 



>V^ 



M The C\rSP: OV I)1':ATII was as follows 

5 r\„ 



DIRATION 
CONTKIIU TORY 



)'ears Months 



Pays 



Hout 



s 





V 

occupation /ii, »^ ^ ' * 



lUKTHri.ACK 
Dl' MOTIIKR 
(State or Country' 



Years 



Mouths 



Hours 
M.D. 



( SIGNED )L\^viV ^.^.U)^i^^^^^^ 

tt 5a rno' i ( Address) ln^^^^Uii-^-^> 

SPECIAL INFORMATION only for Hospitals, insthotions, Transients, 



M,»illn 



Ihn 



T„KAH(>VRSTATKI>.KRSONA.rART.crKAR.AKi-.iRlK T<> TMK 
HKST OK MY KNOWI.KIX.K AND m-MU 



or RcfeS Residents, and persons dying away from home. 



Former or *\'\'\u 
Usual Resldence^^'''^ »> 

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




How long at 

Place of Death? Days 



" l>I XCH OK m-RlA l. OR RKMOVAK DAH^ of »rK..K or KKMOVAI, 








^-^^■^ —i — ^^"i— — — , cv*cTLY PHYSICIANS Bhould 

.. .^^^.^^^-XL ^:^::^:^ '^:r ^^- --- - ••— • ■"'"-"°- '"' -- 

state CAUSE Oh UtA i n m r ^Sv^n In •very instnnce. 

son. dyini away from home should be ft.ven In .very 



■^ k 



;* . 



li 



,1^ 



! . 



f 



t I* 



WRITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



„„„.i ..r ii,:.i.i.- FN.. i^->-!!Sr»"'-'^''^'" 



I l_ I Wl > < "V 



-rr\ BArK OP CE 



RTIFICATE FOR INSTRU CTIONS 



/)a/i' /v7(v/,.i.vctJj^^ X^ ^^^^'^ 



lie^iatcrcd ^'o, 




1 



^\XA^ 




Deputy Health Officer 



DEPARTWENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDcatb 

( XX. S. Stan&at£> ) 
PLACE OF DEATH: — County of ^.- 0.^^' ^ -^ ' » 



ii\ji I'l :'! 



lo 



n 



U *! fll'^ ^l ' \ ( \Ki> St.; ^ * r«o .IMDEH "SPECIAL INFORMATION" \ 

V IF ^E^H OCCURRED IN A HOSPITAL OH 



Crvj 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 
nrx ft ' cni.oK 





^\L 



'-wXrtrV^ 



^i:n 



K.xri: «>!■ r.iKin 



Af.K 



loi.u 



A en 



I MMiith) 



qi , 



% 



I I):iv» 



.M.,ti'/i' 



' Vc-iii 



/•,/! 



MEDICAL CERTIFICATE OF DEATH 

DAIH OF DltATH 



SINC.l.K. MAKUIKI) 
WinoWHI) <»K I)IVt»Ki KI) 
i\Vrit<' in >*iMJiil <ltsiv;tiati')n» 



lUKI'm'UAOK 

( Stiitt i>r fotiiUryi 



NAMK ni- 

FAT 11 »:k 



lUK rm'l.A* H 
OF lATIlKK 
iStiitc or Cottiitry 



MAIDI'.N NAMl- 
dl' M<)Tin-:K 



HIR rm'I.ACl'", 
()»• MOTIII'.K 
(State- or Coiititry" 







''\^ji^crvv/ 



I inrRl.-BV CKRTII-A-, That I attendcl .leceased from 

,,,, nasi saw h .Xru alive on ^C* ^^^ -/>^ 

,n.l that cU.ath occttrre.l, on th. Jat. statc.l above, at ^ 
d M. The CAl'SK C)l< Dl-A'PlI was as follows: 




Dl-RATION JVrtr-? 

CONTRIBrTORV 



Months 



Days 



Hours 



DURATION 





Pays 



Years Moutns i 'ny-^ /lours 

^ ^ ; VV>\^o - ■ ii M.D. 

(SIGNED) ^...M IV. .^^j 

\^^t 0^ .nn'l fAa,lress^ H(^DdA.t■U^. ^t. 
"c^PECIAL INFORMATION only for Hospitals, Institutions. Transients, 
or Rerent Residents, and persons dying away from home. 







I5F;ST <)1- MV KNOWI.KIX.F AM) lU-.I.n.t^ 



(Iiif(iini!int \AJ 



( XrMrtss 




Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



ri.ACEOF lURlM. OK KF.MOVAI, 





a^ HI ^ 



zz:"iiLu,.^u c. 



)vii-l^>-V ^-^ 



^^ *^'' ML PHYSICIANS should 



1114 



'I 



I' 



! t 



1 i 

> 



•Ml 



WRITE PLAINLY WITH UNFADING INK 



100^ 



THIS IS A PERMANENT RECORD 

R^FER TO BACK OF ^r»T.P.C.ATE FOR INSTRUCTIONS 

Be^istcred JS'o- 




X^^<A^ doLvHJ. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Ccvtificatc ct Scatb 

I XX. S. StanOatS ) 
PLACE OF DEATH: — County ofOC^->v o va^ . . 

FULL NAME ^^ aa V 



\ 




CXA-V*^<X. 



PERSONAL AND STATISTICAL PARTICULARS 



• 1 \ 



Dvn-: " 'I r.!K TM 



Coi.oR 



^^{^'^Y\X.^^ 






%!..iit1ii 



\ '■.!•: 



O^ )V.ii- 



diav^ 



M.Dllfl 






(Year) 



/',;i 



->|N..I,1-.. MAKKIl'.n 

\\ Il>n\Vi:i) «>K niVnl-MlI) 

iWritciii -■H-i:tl .l«-si».'ii;ili"n ) 



lUK rnn.At'i-: 

'St:it« or (.'Dtinlry I 



NAMl nl 
lATni".R 



IllK'rHlM,ACK 
(>|- 1 ATIIKR 
iStaU lit Country^ 



MAllU-.N NAM1-, 
(.1 MOTIII-.K 



lUKIIiri.ArK 
(»1- MoTllKK 
(Stiitf or Country' 







MEDICAL CERTIFICATE OF DEATH 

..VrHO.UKATH ^. ^^ 

(Month) '^'='^'^ 

1 iiHKKHV CiarriFV, Thai I aUcn.lc<l .Icccascd fr-Mu 

__^ __-— 190 -- to - — rr-r TCP ^ 

tliat 1 last saw h •.— aHvc 011 ^'^ 

,„.l that .Uath ..cc-urrcMl. ..u the aato statc-a above, at 

„__ ^j 'piH- CAISI': Ol- DlvA'ni Nvas as follows: 



c 



(XvLVwA^O^ 




DTRATION y<^ars 

CONTRir.l TOKV 



Mouths . Pays Hours 



Months n<n'< f^''^"'' 

) a. X% too". (A.l.lr.ss)U\.CrVvitX^^U^^ 



DIRATION ^ >V<^''^ 

( SIGNED )Ltr'unviin; 



OCCTI'A rioN Ji O I . 

CJ ^- vet: \ ' MP.r^- ' ■ • 

Rrsiifni III S.ni I nun i^<-'> ' ' "" ^ 



.}/,,ii//r 



lhi\ 



in:ST i)l- MV KN*>\V1J'.I)<.K AM) ni,I,li-r 



(Inroi nutnt 






■ SPECIAL INFORMATION only ««'«»sPitals.l«shl»uUV, transients, 

or Reteni Resldtnis, and persons dying away Irom home- 
How long al 1 _ 
Place ol Dealli? '- Hays 



V' 



former or \ \^ 1^ ^ ^^ 

Usual Residence 1^ (^-^^^^ 

When was disease coiw-acted, 

If not at place of deatti? 



I'l.A^K Ol- Ht KIAI, OR KMMOVAI, 




DATl^ol' lUKiAi. or KHMOVAI. 

^,^X- ■i>l 190'; 



L.!,.!. 3^^^ ^l<k.d^.Ai 



N. B.- 



'^'^'^"''^ ^-"^ A "^ , 1 FVACTLY PHYSICIANS should 

:.„,, ue„ . i....„».io„ .h1. .. c^.^. ^;..-; ;- -rrr^- — - ■— - - -- 

Htate CAUSE OF DEATH In P'"'" ^.T^j;.*;"; every InHtancc. 
«on, dylnft aw«y from home hHouI.I he fe.ven 



V i I 



"I »i 



r 



!• 



t' II. ;ilili ' 



WR.TE PLA.NtV W.TH UNPAD.NO .NK-TH,S .S A PERMANENT RECORD 

I T ....x.r.r.T. rOR INSTRUCTIONS ^ 

Reiistcred Xo. fiiXA. 



^.,^ i, -*.T^/;"?-l)!tS.r<.".' 



? ^- Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALT!i=City and County of San Francisco 



1^ 



Certificate ot 2)catb 

. tl. 5. StanMrC* ) 
PLACE OF DEATH: — County oi^>^^^ j ^ 



^ 



eu. 



.^ 



i, IF DtATMiOCCURREO IN A HOSPITAL O '0 ^ 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 








O^Cv. 



'^ 



U.Ml. nl UlKin 



At.i-: 







Otv 



(Day) 



\l>ntln 



(V<-:iT 



MEDICAL CERTIFICATE OF DEATH 
DATK OI- DKATII ,, \ ^ ^ q 

(Day) 



iii^^; 

(Moutli) 



I I 

rgo \ 

(Ytar) 



Ihi 



VINT. 1 V . MARK 11" I> 
WinnWl-.D nk DIVi>Kri-:i) 
iWrit'in ^.I'ial (U'^iv'iiatinn) 



lUKTUlM, \^"1'. 
'StMtr or ronuli \ 



\AMi-: <»i 
i- \ rni: R 



HIKTin'l.AiK 
Ol »• All IKK 

iStatr ..I i"i .\inti 



MMIH-.N NAM1-. 
OP MOTHHK 



niRTHPI,ACK 

<)i- mothi:r 

<St:iU- or Country^ 




1 in.;KKHV ClUrm-'V, That I aUcn.lo.l aeceased froir 

. ^ — - ^90--—- to 

that I last saw h alive oti ^"^ 

,„,! that death occurrea, on the date .tate.l above, at 
- - M. The CAVSH C)lM)l'ATH Nvas as follows: 




DTRATION years 

CONTRIIU'TORV 



Months, 



Pars 



IKRATION 



Years 



Mouths 



Days 



( SIGNED ) ..i?>aALVvti^. J 



(O^t-.. .,.. ...^r.^k^^^^y-^ 





I 



".SPECIAL INFORMATION only !«' Hospitals, l^slitutLns, Iransie»ts. 
or teenl Reskirnls, and ptrsons dyinj away from home. 



How lonq at 
Place of Death ? 



Days 



, ^C) )V<nv ^ .1/../////. 

T„KAm>VKSTATKD,.HR^>N..^AKn;-;.AK^AK...TRrKT.> iU. 



(I 



' \<Mrcss V V.' V ■-' ^^ 



Former or 
Usual Residence 

Wlien was disease contracted, 

If not at place of dea th? . . ■ 

-.cK o. mK,M. OK .KM,n^- ...jw-:; »>-»■;■•■■■■ ««-"^-^'; 



i. 



(>-trk. Oj 



Aci.h-.ss..^L6K.U^eA^^c....^ 



^^'^'^'^"''^ i , . Ml PHYSICIANS should 



hi 







1 1 



!■ 



Hm;i 



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

r^reiTB -rr^ HiirK OP CERTIFICATE FOR INSTRUCTI ONS 



Registered M'o. 



27ia 



l^cvoA Deputy Hcn'rhOfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

{ U. 5. StanC»arC» ) 



-V 



'^. 



(^ 



No. 



PLACE OF DEATH; — County of lOz-^x 



Ct^vCvAC City of^":^^^v-'>v.a/^v<^t<iC(. 

and 



I/MJL-Yv 



■) 



FULL NAME 



.v.. \..^„\; ^ 



Jl 



PERSONAL AND STATISTICAL PARTICULARS 

I)\TF, or HIRIU 



SKX 








AC.K 



) '» i( I 



(I)ayl 



MnUlfl' 



A. 



(Year) 



n.t \s 



MEDICAL CERTIFICATE OF DEATH 
DATE OH DKATH 



(Month) 



'■L 

(Day) 



190 
(Year) 



m 



siN(.|.K MAKKIKD, 
WIDoWKI) OK DIVOKrKI) 
iWritf ill s<K-i;il (It-ivMuttioii) 



HIKTIiri.AOK 

Stiitf or Country) 



liLcuuX^^ccC 



1 ni'RKBY CKRTIFY, Tliat I attciKlcl ilcccased from 

..i^.-... \ 190't to '^^■■■■■■^ ^^'^ 

that I last saw h - alive on ^ * ' ^'P_ 

an.l that .U-ath occurred, on the date statc<l above, at t I^ 
G^ M. The CAISH OF Dl-ATH was as follows: 



JJ\j^'y^O^^\^ 



NAMl- «>I 
FATHKR 



lUR Tnri.Ai'K 

OI- IATHKR 

(Statf or Country) 



MAIDKN NAMK 
OF MOTHKR 



JUK riiri.ACH 

oi' MO'IMIKR 
(State or Co\intry) 




n 



L'W 



JL> VTV' 



? 



,, (RATION " Years .yont/n Days 

CONTRIBUTORY VAr.^-.Ow.'L..VA v.-L.-Ci.. 



Hours 



y'l'iirs 



I 



\.- 



( \^^'^■^o■^ > ^^ 



OCCl'I'ATION 

A'r.-i,inf ni San /-lOiinsro \ V- > ''" ' ' 



Mnilth: 



l)(i\ 



nn.A»OVKSrAT,n.,.KK^.NA,r;KTHH|,AK>AK,.TKrK TO TMK 
IIKST OV MV KN()\Vl,KD«-.h AND HKI.Il.^ 



DURATION ^ 

(SIGNED) \-^ \JC\Xk. 



J /oh //is Pays 

\)i^\Jk.^^- 



I fours 
M.D. 



( A,1,lr.< .-> .k)l?>" U^LUyG -H. 



"special information only for Hospitals. Instilutttons, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



,„r,„„.,„ Q^f\^« M>\Lt. 



(Address 



1^0'^ 



/CbVAX\ 



PI \CF OV lURIAL OR RKMOVAI, 



l)Vri%<>f HiKlAi- or REMOVAI, 






190 



(Address . 



.p.,^.^— ■— — A-^""-""""" , FXACTLY PHYSICIANS should 

on .hou.c. he ca^efuH. suppl'.cd fj^^^^;,^;;;.^,,^,,:^ •♦Spcci.i I„fon„,»tio„" »or p-r- 

H In plom term., that It may he properly 



IN. B. Every item of Informati 

state CAUSE OF :>EATn m h..— ;-"-;. .,„ ,,.^^y instance, 
son. dyinft away «^om home should he il-ven 



1 ' 



I t \ 

I 



1 ( 



«l 



! 14 



w 



R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



,f IUmU 



h »• V'l : ■^■^^'SSi^^]lK\'('|> 



nrrrn TD BACK 



OF CERTIFICATE FOR INST RUCTIONS 






o 



HJO'i 



Registered JVo. 



2713 



Deputy Hca'th Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( tl. S. StanOacS ) 



J? ^ 



PLACE OF DEATH:-Coun.y of6cv..ixo , c..ccGty of ^ C- Jk<x,.^.C..c c 



No. 



1 1) . Xc V^k.U J C' ^vL \ \. ^- 1 O, ^ 



St.; 



Dkt • bet. ■ •"• ^^^ 



■) 



M.; L-'lSt.; DCl. ^^^' ,„_„_ "gprciAL INFORMATION" \ 



^' 



FULL NAME 



V. 



'-> ' 1 'Hj, 







'V\/Y> V<X'> 



>A.. 



PERSONAL AND STATISTICAL PARTICULARS 



l.\ I 1 «•!■ lUK I'll 



10 

I Day 



(Vt-ar) 



\< .»•: 



) til > 



Mnitli^ 



/hn. 



MEDICAL CERTIFICATE OF DEATH 
DATH OK DKATH H 1 1 r. .->, 



/go ^ 

(Yt-ar) 



-i\..I,l" MAkKII-.n 

W IDnWl'.l) 1>R IHVOKtKI) 

Utit'- in MK-ial (l« ■^ii'iiat ion) 



'Stat« or (.oiiiiti V 



NAMJ". «>I 

I AT mi; R 




(Month) <''»>'' 

1 ni;Ki:HV CI;RTIFV, That I atten.kMl dcceasea from 

UtX 15 190'; to 0^ ^"^ '^P'^ 

that I last saw h -^ alive on ^ '^"^ ^^ ^90 " 

and that .Uath ocrurrcl. on the .late stat.<l above, at ICl L 
iL M The CAT SI-: OV DICATIl was as follows: 



x.kJL- 



<L 



v^cx 



Kin\y>v 



,>A^cLo 



H, 




HIKTlMM.AiK 
(>1- I AlUKK 
ist:it< i.r Coiintvyl 



MMDl-.N NAM1-. 
01 MOTMKK 



UIK IMl'KACK 
oi" MO'lMIKK 
(Statf or CiMUitryl 



OCCri'ATION ^'' 



,iLA:.«^cc 




'J ft-toJu 0,A^; 



/;L^\.xr>\. 



\i 



U'> 



v 



iVojiths -^ Oays 



A. V \J \.X.^.' 






M.iiilln 



/),;i ■ 



TMK^Hov.<s•rv^aM.KK...^A..P^HTu;.;^^K^AK.,K^.< to tmk 

HHST OF MY KNnWI.J-.lH.!'. AND lU.l.U.i 



DfRATION )«.« 'I/'W/'" •' '^"^'^ '""'" 

COST K I mn-( .R Y IftrWv U''^^^^^-*^^*- 

DURATION )V."-. <'A"''^" t /),v. //."".v 

( SIGNED )..iU3,.0Xb.>v M.D. 



"special information only lor HospiUls, Inslilullons. Ifansknls, 
or Rtcent Residents, dod persons dyinj a*ay Irom home. 



^ 



Former or "^ s T> '^ 
Usual Residence v< l C) O 

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



How lonq at 
.t^CL-^-^Ty. Ul Place of Deatli ? 



Days 



(Inf'>iniant 



Y KNnWI.J-.lx.l'. ^>" niM,.... 



PIACKOI' lUKIAI. OK K^monm. 



I)Ari;<»f HiKlAr, or KKMOVAI, 

QlcAT 1 T90'. 



(^>. \vy_ ^ o . VAJL/ I r v^vvAj ^ . 




( \«i(ir«'ss (•-»-- — — ^— ^^^^— 

.^^^_^.— — ^^.i— — — ■— t t I EXACTLY PHYSICIANS nhoulcl 






It 



l» 



i « 




w 



RITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



,,,r.,\ .,! l!<;iiili I "<' 



1!.M 



,'. ■*'?oar'2ii) ii,<t}' I'.i 



•rro -rnt C»Ar>K rt 



fltl^l kail t 



F r.F-RTIFICATE FOR INSTRUCTIONS 



!h,fr Fi/r^/M^tU^^' ''*-'. 



lOO'i 



llc<^ustcTed J\''o. 



3714 



M\^K.\^^ d..-c^^vt 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificatc of IDeatb 

1 U. 5. 5tanC»ar^ ) 



^ 



PLACE OF DEATH: — County 



ofcScx^^^ i xa^vcv^oCity o^d^^^^ Jxcc-^v^vAC^ 



pto» 




I 



vcl^X-^ ^llOA vCtaV> 



St.; 



Dist.; bet. 



and 



- ) 



__ -^r, iiiunrR "«iPrCIAL INFORMATION" | 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

I \ 1 i; I )I lUKTU 




V 






cU\jA) 



M.iiilhi 



\< .!• 



VXVVC' ^ 'b ) r,ii - 



(Dav) 



- M.,„tlr 



(V<:iit 



IhJV 



WIDoWKI) OK niVOKfl'.I) 

\\iit<- iti voriat il' '>i'/ iiat i- iii) 



Itlin'Ul'l.ACK 
' state i>i C'oMiltiy ! 




NAMI' Ml- 
!• AIM IK 



lUKIMIM.AtK 
(»I I AIMl'.K 
(Stat' or «."onnlry) 



MAIDJ'.N NAM1-: 
oi MOTMl'.K 



lilK'nilM.ACI". 
<)»• Mo'nil'.K 
istatr III iDiinti \ ' 



nCCr I'ATION 

h'riit'-ii III San I'liiiHisro 






MEDICAL CERTIFICATE OF DEATH 

rMo„th) 'i>»v^ :^^l 

"" I lIlKi:i'.V C1:RTI!-V. That I MtUMi.UMl .Icceased frnn. 

\0 ^ 0.C up^ to ^-^ ^^ ^^p H 

tlii.t I last saw h A.A^ ahve on ' ^ ^ '^ ^'P 

a„a that <U'ath oocurml. o„ the .laic- statc-.I aboNV, at SHS 
CI M. The CAISI' Ol- I>i:AT11 was as follows: 




y.^AAyW^f 



I )r RATION 



Years 



Mo til lis 



n 



CoNTRiin-ToRV L^^J^X^ ^ 




i.v Hours 

xjJi^ 



Days 



Dl-RATION rV7/r5 ^ 



Hours 
M.D. 



(SIGNED).J. ^'^ '^'^'^.^ -^" ~j"Qjy 

(^0 .t 9^ ,,,H (A.hln-ss) dt lw<U^ nPivA^tAl 



» ,,N 



Mn>llh- 



Ihn 



IIKST m-- MV KN<i\vi,:^i".i-. AN'> '•! '-IW, 



(Iiifoiinant 





XAAnJlt 



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

When was disease rontracted, ( 

If not at place of death ? ' 



h(. How long at o 

CM Plarcof Death? ^ 



Days 



I'LACK Ol" lUKIALoU K1;M«)VAI, 



DA'I'liol HiKiAi. or KlCMOVAI, 

iD/^ ^0 190H 



\ajJaAA 



0-Vl 






cv-^Ajtr 



^^—^— 11——^———'——^*'"* I 1 h t t I nXACTLY PHYSICIANS hHouIiI 

:rn';..y?n?aw"; fron. h.„nc »h, He t>v.n •,„ .v.n, .......nc.. 






ill 



it. 



w 



>\ 



■ 



V 



\ : 



" ^mf 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



,{,,:, r.l . f II. alth 1' N' 



,, It J-TlaC'^H.tlT. 






OF r.FRTIFICATE FOR INSTRUCTIONS 



>(> 4- r. 



/>.,/. FiM, iditU^ X'\ J^^"! 



Registered JV*o. 



3715 




^Cr^^Oi ckx.\>u 



D 



o 



! -^ c e r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2>eatb 

( "U. S. 5tan^ar^ ) 



-? 



((\;^ 



Na 



i <o?> A ''V 

PLACE OF DEATH: — County ofOxx^ J^v^'^^^v<l« Qty ot J^ 
1 VJxt^v. 



TS NAME INSTEAD OfUtREET AND NUMBER. J 




X -^ - — OC-R-V -A^^^t?^?:^^^- - 



FULL NAME 



.<X^X\.OJ dJ CkL' 




^ 




KA 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OK 






u 







\ « . J-; 



Rl 



);.( 



Iwi 



(Davl 



M.nitllS 



vlIx 



(Yt-ar) 



3 



/)<M, 



MEDICAL CERTIFICATE OF DEATH 

(Month) 'I>='>'^ 



(Year^ 



>n 



717[7^T?RY~C1': RTIFV, That I alteii»kMl .leocasoil from 



sIN(,l.K. M.\KKn:i» 
\vii)(»\vi:i) (»K inv< •un: I) 

' \Viit<- ill >^(Kial (1« "-ij-Miation) 



lUK rin'i.AOK 

' stall iir O'unitiy ' 



FATin:R 



lUKTlllM.ACK 
OI" lATHKR 
(Statr or Country' 



MAIDI-.N NAMH 
<>!• MOTHKK 








,oa.,yA; ^'C^tlnX 



AA^^ 



^<A .1 KpH toL.^ '^ ^ooH 

,,,,, , l,,t .aw h^ alive on ^ ^t X% i<pH 

an.l that death occurre.l, on the date stated above, at >5 




rSli C)l< 1) I'! ATI I was as follows: 



l^ 



) JtorvvcA.^J^'V'<xxx-^ 



DT RAT ION >Vrt'-^ 

CONTUIIU'TORV 




n/ouths Jl Days Hours 




HIKTIII'I.ACK 
(•»• MOTHKK 
(State or CojMitrv) 





(SIGNED) CLclJU^oU(^>^^^ M.D.^ 



■ SPECIAL IN FORM AT ION only for Hospitals, Institutions. Traiisients. 
or Recent Residents, and persons dying away from home. 



(X^yl^ 



OCCUPATION 

AVw(. ' //' >'"' / nf^^. isrn t U ' "" ^ 

TMHAHOVKST rK.) PKKS,>N A . rA U T.cr , AKS AK K TK I K TO T.«K 
Ill'.ST Ol- M\ KNOWM-lX.h ANI) m.i.n.i ^ . 




(Addrt- 



ss 



IUxXaaxLvo LI.VX 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'l.ACK Ol- lURIAI, OR KlCMOVAI. 



DATl". o!" IHkiai- or RKMOVAI, 

iDct 3.0 190S 

INDKRTAKKR VV- V --->-*. j- - u 

,Aa.>,c,.551>-?>'l51. D.A^tllA,,B,.t 



■iflK..' 



wmmm^mmmmm.m^^mmmm^im^'mmmmmmmmmm^mmmmmi^^»mmmm,mm^mmm,mmmmmmm,mmmm^^^~—— » ♦ ,1 EXACTLY PHYSICIANS should 

^ » i-Aii«F nF DFATH in plmn terms, that ii mii> "^ ,» i 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2716 



.,f ihi.ith i-N". 1' -^^^sir^'' 



cvr \-«i 



Diifr /•'//('</, AI'cLo-'LkvV 5^"^ 



i<»' 



1 



\' 



,(vv,x.Ui 



cLl. 



lOO'i 



f^.fi^' 



Ee^istered J\''o. 



/v-u 



DEPARTMENT OF PUBLIC HEAlTH=City and County of San Francisco 

Cevtificate of 2)eatb 

( tl. 5. StanDar^ ) 

PLACE OF DEATH:-Co.ntv of^^t^X.^-^-CUv oii^^^^-^-^ 

^ , ^ U c, . ^ Dist • bet/ ^XXslM^yxo.:.^ and VS^jl"^- ^ ■ '" 



) 



FULL NAME 






six 



PERSONAL AND STATISTICAL PARTICULARS 



♦ i 






A ' . 



^l 



DATi: ul- HI KIM 



\<',K 



iMoiitli) 



! ■/■<; i 



(Uav> 



M.'Vtln 



'Vt-arl 



Ihn: 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATIl 



(Month) 



(Day) 



I go 

(Year) 



SIN.. 1,1". MAKKIKD ,-. 

WIDDWKI) OK UIVoKiKJ) U 



Wiittiii s<Ki;il <l.->-iv'":>ti>>ii) 



HIK TMTM.AOF 
(Sliitc or Country t 



FATllI'.K 








V 



I llHKi:nV CI<:RTIFV, That I atten.kMl decoased from 

__, igo to ...TnT-rr-rrrrrrrr:^ ' " 

that I last saw h -" aUve on — -—190 

an<l that death occurred, on the date stated above, at 
:M. The CAI'SI^^OK DUATll was as follows: 






''•i 



II 



niRTHl'l.ACK 

01 i-ArnHK 

(Statf or «.N)UTitry) 



MXIDl'.N NAMK 
<)1- MOTHER 



lURTUri.AlE 
oi" MOTHER 
(Stutf or Country) 






? 



i, 



DTK AT I ON >V'<2;.y 

CONTRIlil'TORV 



Months 



Days 



Hours 



Days 






Hours 



(SIGI 



M.D. 



iqo ' t ( 



Address) L^A^Xi^><) 1)14 ->.-:■■ -••■ 



"special information only for Hospitals. InstltutW Transients, 
or Recent Residents, and persons dying away from home. 



OCCri'ATION(Y^^^C^^^,V^>vCAvt • . J 



AV.wV/r</ /// Sati liti>i> /*"' 



) V/f ; 



MniiUn 



htn 



IlEST OF MY KNOWl.l-.IX.E AND Hl.I.N-f^ 



(1 



Lvv^rvvJA-^ .. . , 



(AfMrcss 



Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



l'I,ACE OF lURFM. OK KEMoVAI, 



DATE of nt-RiAi. or REMOVAI. 

..^/cl 2.0 190 H 



R J_,.LjU-d-^^AJLNJ^ . 



(Address 



N. B.- 



i^ J K t t d EXACTLY PHYSICIANS should 

-Every ...m «« i„»or.-.!«n .hou.d be c....uM, .uppncd ^'^^^^^''ll^Z'.T, 'thc "Spec..'. .«.or™..lon" lor pr- 
«a« CAUSE OF DEATH In ■>'»'■•, »'7':;J';„".r.ry TnZZ<. 



,J 






hi ; 



1 



I 

I I 
1) 



^ 



I1 



\\i 



u 



! 



Hti 



WRI 



|!,,Mr.1 of HfJlltll r Nm 



TE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



■tje^y*'^^ 



h&¥^& 



REFER TO 



BACK OF CERT IFICATE FOR INSTRUCTIONS 



I'JO'i 



Mc^i^s'tered J\^o. 



271? 



l^v^ U.H, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco 

Certificate of IDeatb 

M1\x^X'cL^^v>xc City of iLk^o.'^v vai 



No. 



PLACE OF DEATH : — County of 

/ ir DEATH OCOUPS »W*Y FROM USUAL 
V ir OE»TH OCCURRED IN A HOSP'TAL 



St.; 



Dist.; bet. 



and 



) 



RESIDENCE GIVE 

OR INSTITUTION GIV 



7*CTS CALLED TOR UNDER -SPECIAL , N ro R M ATI O N ' ' \ 

'e itI name instead or street and number. J 



FULL NAME VoSJxT^-^ 



I. 



v\ 




PERSONAL AND STATISTICAL PARTICULARS 



«»:\ 



JL^^^cv^ 



C«)I,<>K \ 



l^ 



t ' 



!» A Ij; t)l lUKTll 



AC.K 




L-5> 



) 






\;,,nffn 



( Vtart 



/i./i. 



MEDICAL CERTIFICATE OF DEATH 

DATE OV I)i;\TII '^ 



(M<mlh> 



.:VL 

<Uay) 



LI 

/Q(y \ 

(Year) 



\VI1>< )\\ l-.l> «»K IHVoK^KH 
'Wiit'iu *<iii;il ill -i;.'iiiili'>ii) 



lUki'in'i.Ari-. 

(Stat'- or Country! 



NAMl*. (»l- 
J- A 1111 "R 



HTRTIirT.ArK 
Of 1 AIHHK 
(StMt«- or Country) 



MAIDV.N N'AMl- 
<)1 MOTHI'-K 



lURrHT'LACK 
(U* MoTIll'.R 
'^t;itf or (."ountryl 








1 |11.;ki:I'.V CI:RT1FV. Th.-.t I attondc.l .Icrcascl fron, 

— up to " ^'^ 

th.Hl I last saw h - — alive on — ^'P 

ana that <leatli occurred, o,i the date stated above, at - " 
— M. Tlie CAISI- ()!• Dl'ATH was as follows: 



I )r RATION >V'?''^ 

coNTiunrToRV 



Months 



Days 



Hours 



DURATION 



e 



)'t\irs 



Mo tit /is 



Day 







orct TA rioN 

hVMifrd ill V.o; /'i ,1)1, I"-. 



)>•,!, 



\f,o/f/r 



/>.!). 






liO.^i^ 



(SIGNED) Ad UJ. ^JVA^^-q. 



'^Icl Xl IOO'> rvMn-s-l LLk^-Jx U. 



/lours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Instiliilions, Transients, 
or Recent Residents, and persons dyinq away from liome. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



(Info! iu;mt 



^\^<^^<^ 



( \.l(llC*«^ 



PI XCH Ol HIRIAI, OR RKMt'VAl 



t 






i)\ri;ot inuiAi. or ri-:m()vau 



^a. 



TQO'V 






rNDl-.R TAKKR 



(Address sJ. A^Cue^A V.-COL' 



:±i 



^_^^— ^^, ^M^^— i^^^i*^^'^-^^^ f t I FXACTLY PHYSICIANS should 

state CAUSt Ut- ul«iii »- , i k . AUen in every inHtance. 
«ons dyinft away from home should be Ji-Ncn m every 



r 



R,TE PLAINLY W.TH UNFADING INK-THIS IS A PERMANENT RECORD 

„.rrn x« BAr.K OF CERTIFICATE FOB INSTRU CTIONS 



\;Si\' *'" 



w 
Ifr^odx-v.. Deputy Heaith Officer 



7.96'H 



Bcs^i.sfered JVo. 



2718 



DEPARTMENT bf PUBLIC HEALTH^City and County of San Francisco 



Ccvtificate of IDeatb 

( tl. 5. Stan^arD ) 



J? (5? :\ T 

PLACE OF DEATH:-County ofUfV>^' Jxa.>vc.^.^Uty 






and Cllxv-n^^^ 



V IF DEATH OCCURRED IN A HOSPITAL OR IN^ST.TU ^ ^ 



) 



FULL NAME a.v.vA.o^ 



PERSONAL AND STATISTICAL PARTICULARS 



:i 



: I 



L 






I>\ I K nj- ItlKIll ^T\ 

iM..ntir> 



wiDowj-D OK niyoKn-.i) 

iWiitfin ^-Mcial (U-ii>.'n:iti<'iil 



luu rin'K.M'i-: 

Stiilc or Coiiiitl V' 



NAMl" <)l 
l- ATin.K 



HlKIMlM.ArK 
OI- l-APHHK 
(Statf or (.'ouiitiv' 



MAIDl-.N NAMK 
oi- MOTHKK 



lUK rm'KACl", 

()i- M(»rin:K 

(Sl:itf or I'uunlvv* 



a 



( l»av) 



y/.,„//r 



(Vt-ar) 



/),n> 



MEDICAL CERTIFICATE OF DEATH 
DATE OF Dl-ATU 



[iWuvv. 




/go 

(Month) *^>-'^V^ 

I Hl.Rl-HV Cl-RTIFV, That I altenacMl .Icocasca fmn. 

IP.,- I 190'^ to P-^ ^^ -P^^ 

tl,at I last saw h .... ^^ alive on ^--^ ^'^ '^P ' 

a,„l that .U-ath occurred, on the .late state.l above, at 
^ M. The CAl'SIv C)l- DliATll was as follows: 

T)rR.XTI(>N y^ars Months Days Hours 

.J.X.'vr\-^W..' 






CONTRIIUTORV 



.A^ 



DlRATloN 
(SIGNED) 



Ho HI 



■s 



i 



occi I'A rioN C 










.1//-'////- 



/),M> 



BKST Ol- \J^' KNOWM'.IX.K ANI) Hl^i.u-' 

(InfiiinKint 




^;ol g. n>o'i (A<ici.>ss^^:x-a A-a^x>vt <.U 

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



Former or 
Isual Residence 

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



How lonq at 
Place of Death? 



Days 



IM \CK 01- lUKlAU OK KKMOVAI, 

,-v.,.,,.ur.vwKK JnJUy wCr 



D.VT'. "' H' in.Al, or KlvMOV.M, 

U/tt. 30 T90'\ 



.o<. ' 



(Ad.lrcss 11 I H 



(Address 



C| 5 ^ M YUA^<.-cr\A.. at 



_^____^^_^^^ — — ,— ^— ^■^■^—— — — t t I EXACTLY PHYSICIANS should 

:rnr."Taw«y ^ro^hle Should He .Iven i .r, .n-.-nce. 



:t| 



^ 



h 



M 






( 



WRITE PLAINLY WITH UNFADING INn-THIS IS A PERMANENT RECORD 



■ " I'- **^3i^' "''^'' 



-.r> /sr-B-ririr-ftTF FOR INSTRUCTIONS 



REKfcH IW OM^n 



f r x^fc««»>«» 



i;,,:,t,l..t li.Mlth IN 



/>/ 



Crv.\.x^ s>-.v .' vt 



Deputy 



OfTlcer 



Registered J\'*o, 



3?19 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



PLACE OF DEATH:-County of 6 C.^ ^ Xc^.c^oGty of Oo.^ ^S.^ 



^wCc-<i. CO 



No. l*^^"^ 







i\. 



FULL nAMEH^^^^^^'^-'^'^^^^^^^'^ dft^CUv 



) 



PERSONAL AND STATISTICAL PARTICULARS 

li\ll nr lllK 111 Oy Q ^ u I 



U'k^U 



V 






il):tv I 



\(.K 



^^ ,v.,. H ■''■"■"- 5v| 



(Year) 



/).n. 



MEDICAL CERTIFICATE OF^EATH 

(Hay) (Year) 



'i'A 



(Month) 



lc>0 H 



vlNC. |,K MARK I I'D 
\Vil)(>\Vi:i) »)K nivoKrKi) 
Wiitf ill >.<Hial ihsivMiatioii) 




lURTHlM.ACK 
i st;itf or (.■oiitUrv 



NAMl". Ol 
FATHKR 



lURTMI'l.ACK 
()|- lATMKK 

(State or Country) 



MAIDKN NAMK 
ttl- MOTHKR 






1 m;RKRV CKRTIFV, That T attende.l <lcccastMl from 

lU^o, 190^^ to Ajl^o:!^--^ TCP - 

that I last saw h .^-'v' alive on ^ ^"^ ^^ 
ait.l that (U-ath occiirre.l. on the .late stated above, at 
Q M. The CArSI<:C)l- Dl'ATII was as follows 




V\.wv\. 






Hours 



lURrm'i.ArK 

Ol- MOIMI-.R 
(fttati- or Couiitryi 



DIRATION 



Year's ?> Mouths Pays /fours 



(SIGNED) L Cl *^Jm1.^ J, ^'^• 

(O^.t X^. TOO H ( A.hlress) b C b O.utt g K^ ■^V^- 

--I.. t>.^ Hnri^;f3ic Incfitiitinn^. Triinsie 



i 



OCCI TATIONW 



k'rsidfil III S,ni /'ni m /sni 31 ^ ''•" ' 



/>,!} 



r\rsnlrii III .'"" ■ ' — - 

rMKM.0VKSTATK,,,.KK:.;NA,r;KTK,r;;XK>A,O.,K..< I- THK 
HKST Ol- MV KNOWMUX.h AND Ml. I. II. t^ 



flufoimatit 



(Address I O I 




c 



.Ou^^^ydL OX 



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



Former or 
Usual Residence 

When v^as disease contracted, 
If not at place of deatli? 



How long at 
Place of Death ? 



.... Days 




n \QV Ol- lURIAI. OR RKMoVAI. 

(Address U^l V>U.^i^l^<n^ 0.1. 



IS. B." 



— ^^^- TT ITf Hhould be «totetl EXACTLY. PHYSICIANS should 

-F.vcry item of inforn.ntion should be cnrefully -pp hed. AOr « ^ ^^.^^^^ ^^^ ..g^,^^,„, ,„f„,^„t-.on" for pT- 
* ;/r AimF OF DFATH !n pliiin terms, that it ma> be proper y 






n 



■\\ 




i) 



til! 

T 

r\ 



' I 



w 



;,.n.! ..: !l. -^'1' ' 



RITE PLAINLY WITH UNFADING INK 



r-V ar^^l'.S:!' Co 



THIS IS A PERMANENT RECORD 

r,.r..* ^D rroTiFlCATE FOR INSTRUC TIONS 

rv, rtn iw ur^^ •> ■«»• — — - ■ - i^ — _ ^-^— i^^^m^— — ^ 



I/,./. /.VA./.l0.cfc^Uv'o.q 7,9^ H 



Ee^Lstered J\^o. 



2720 



DEPARTMENT OF PUBLIC HEALTH 



=City and County of San Francisco 



Ccvtificate of 2>eatb 



PLACE OF DEATH : — County of J ^VUl^-vX) 



City of ^J XJlA'>a.o 



ej 



No. 



St.; 



-Dist.;bct. 



-and 



-) 



^U ~~^ \\:,rn FOR UNDER -SPECAL . N TOR MATIO N • \ 

FULL NAME (iKX^'^^^ 



•COvXc-^^ 



■'■■^ 



PERSONAL AND STATISTICAL PARTICULARS 

I Cnl.nK 



V 



1) \ 1 1 ()| r.lKTH 



\< .»•■. 



..'. 



M.inth) 



y{ ,v.,.. 



si.N<.i,i:. M\KKn:i» 
\vii>o\vi:i) OK i)ivt»Kri:i) 

Write in «^<>ci:il .U'^i>.'ii;iti')n) 



liiK rni'i.AOj*. 

'Si;itf or Couiitiy' 



(I>:iy) 



(Year) 



Pars 



MEDICAL CERTIFICATE OF DEATH 
DA TH Ol- DKATH 



(Month) 



(Day) 



(Year) 



r 



lU 







"' 1 lli:ki:BV ClvRTIFV, That I alU-iMcMl .k-coasea from 

that 1 last saw li " • alive on ^- - "'■'^ "'^ 

an.l that .Icath occurrcl, o,i tin- <latc stated above, at —r:^r,. 
M. T^ie CAV^Iv <>!• I>l'.A'l''l was as follows: 



\ wii' or 

1 A 11! I-.K 



HIRIinM.AtK 

(M i\iin-:K 

iSt:it« or f«)>iutry) 



MMIil'.N NAMl- 
ol MOTIM-.K 



HIK llll'LAri-: 
()!•• MorilKK 
(Stiiti or Country) 



OCCri'ATIoN 






0' 



DTK AT ION >'''^''-^ 

(.'oNTKir.r'roKV 



Months 



Days 



Iloitr^ 




<X<^^^OLL.U 



^< 



Rfidfil ni S,ni I I >ni, i^r.i 



) ',<i I 



}/.,ii//i^ 



!>,! 



nn-Xn<.VKSTXT.U.lM^KS..NA. rAKT.CriAKS AK.: TKCK TO 
HKST Ol- MV KNo\VIJ-;i)C.h AM) Hl-.I.H.l 

nfoiinant v I ^ ^^ ^^ *• 



111 1- 



DIRATION 
(SIG 



Years 



Jf(tnt/is 



/)(7VS 



..o.ivy(^^^^<%^ 



Hours 
M.D. 



il.,'<r.t D,S Too'i (A.l.lress) J AXXLAV^OA^-^ 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Deatli? 



Days 



I)A'rj% o! Ml uiM. or KI'^MOVAI, 



(1 



<t'>\ 



(Address 



<^ MVl.a,v<.v^ v]x^K.<^.<t>- 



IM.ACH OI- lUKIAl, OK KKMoVAI, 

rNni-.KTAKKK ^ /^i ^^'Kcca^aU 

(AcMres. .^,0. M Uv^a^^^vV ^ 



IN. K. 



— ^ — — 4#i^^— — — '^— — — '^"""^ ^ » .1 FVArxi Y PHYSICIANS hHouIcI 

«t«te CADSi: OP DI:ATH in „l..m term*, tha .t m»> J^ »;"'^;'^'^ 
:on, cl^lnft ..w«y Vro.„ home Khould he ftKen In every .n«t»nce. 



. I 



t 



WHITE PL.,NLV W,TH UNF.O.NG INK-THIS .S . PERMANENT RECORD 

. ,^ =«/^u ne rPRTIPICATE FOR INSTRUCTIONS 



I Dafr /v7r./,y(cl<KHJx; 'hij ^'^^-^'^ 



Bc^Lstcred J\^o, 



2721 



.CrVA.\.c^ 



Deputy ^ !ca|th Officer 

DEPARliENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County of 



No. 



City of J C-> V^ 1"^^- ' J ^"^^■' 



and 



( 



_____ ■ St.; Dist.;bet. ^^^ ^^^__ ..sp^c.al information- ^ 



- ) 



FULL NAME 



kt-UiU 



.C:br.>A-^^.- 



PERSONAL AND STATISTICAL PARTICULARS 






\«.i". 



iMoiitli) 



U i )r,n 



LL 



iDavi 



M,,iitli^ 



K^ 



,U?., 



(Vi-ar) 



I hi i> 



MEDICAL CERTIFICATE OF DEATH 
DATE Ol- DKATH ,, \ . 

(Day) 



(Month) 



/ go K 

(Year) 



ThF.RI'BV Cl'KTIl-V, Tlu.t I attciukMl .lercascMl from 

__---— -r-rrrr^ to r. - HP "~ 

that I iMst saw h r" alive on -— " " ^'^ 



sI\t.l,J',. MAKKIl-.n. 
WIDOWKI* OK I)I\i»K« >'.l> 



lUKTHl'LAOK 
( Stall- fir Connlrv 



^ 



LI -a 



.M-C 



\Jh crK-^'VwA- 



a. 



NAMl- nl 
!• AllI I'.K 



HIKTHri.MK 
()!• I MIII-.K 
(State 1)1 Countt \) 



MAIDJ'.N NAM1-: 
»)I- MoTHHK 



HIRlUlM.ArK 
«)|- MOTHKK 
(Statf or Country I 




a„.l that .U-ath orc-urrc.l, o„ the -late .taud above, at ' 
^I 'I'l,^. CArSI". Ol" l)i:Aril was as follows: 

%X-cuvtj 0..<x.^-.'...<.-c... 



CONTRIIU'TORY 



Months 



Pays 



I Jours 



DIRATION 
(SIGNED ) 



/ 



)'riii 



Mnllfll- 



/»,M 



OCCri'ATU)N 

R^i^iiirii III S,ni /'xni. nro 
■inr vm)VKSTVTri)PKKS.>NAl .l-AK-n>ri.\KSAKK TKrKTM Tm: 



]'rars .Uon/Zis /hrys 



//ours 



M.D. 



^ 



iLrt « too'/ rA.l.lress VJ tr>VO-\vCX^/- '^■••-• 



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



(Informant 



Juy 




d»^d> . 



( Vfldrr'^s 






Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'UACP: nl- lU KIAI. OK K1-:M«>\ A!, 




Cr^^^-A^ 



4^ 



JwO-AL-^- 



DATKof m KIAI. or K1-:M0VAI, 



290 ' 



a 










«« ^ ^ ' 7"] 77p „^,ould be Htnte.l F.XACTLY. PHYSICIANS Hhould 



11: 






n 



.1 : 



» 



tl 



>' 



i I 



WRITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



.^..-..r* r-^D I •OCTDIir'.TIONS 



,.: 1!. -I'.h !■■ N"'' ' 



*.^ jJTz^, lutr cn 



REFER TO BACK OF Ccn i iriv^><< w ■ >^ -' 



Dff/c /w7^v/,L/d.crWv' '^ 



h 



A' 



x.ty^^~^'^' '-<y^-'M 



'60 



Deputy 



VJO'i 
vMh Officer 



Ee^lstered J\^o, 



27m 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of IDcatb 

( "U. S. 5tanDarC> j 



PLACE OF DEATH : - County of J O.',^ ^ >^(X vx^ va c.c Gty ot 



^ 



No. b^\ 'vl!>Xc 



St.; 



-^^ -^^V ^ ■ RESIDENCE GIVE FACTS CALLED 

( '^ r.T.".Tr^oc:u%r;,;''rHo^s"prAt :iv.i^.u^^o. o.ve .s name 



r);«;t-bet H "Llx' and '^X-lv 

UlSt., OeU ^^^ ^^^^^ -SPEC.AL .NFORMAT.ON- \ 

INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



oXnj^o 



. % %x k^a: 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1) \ 1 1 < >1 lUK I'll \ , 




iM..nth> 



1 Dmv^ 



I'di'l 



\<.i-; 



'10 



) V((» 



\!.„itlr 



11 



(Vtail 



/'./I 



MEDICAL CERTIFICATE OF DEATH 

DAT!-: Ol I)lv\lH 



t),ct 



(M.mth) 'l>"y^ 

I |li:ki;nV CI:kTIFV. That I atten«kMl «k-coaso.l from 



(Year) 



W./:cL.. 



J.A 



\(p 



4 



to 



:^.£L. rt. 



s|N(,l I M \RK1KI> 

W Il>n\VJ:H «»K DIVuKil-.l) 

(Wiitc in -ocmm! <U--i;.Mi;iti"ii) 




iiiKi'in'i.Ai'i'. 

(St:itr or CoiiiUi v' 



NAMl" •>! 
lAIIU-.K 



lUK riiri, wK 
of I A rm:K 

iSt;it< ot I'oniit vv'' 



MAIDI'.V NAMl". 
()!• Molin'.K 



lUK riM'I, A^J". 
ol- Mnllll'.K 
(Stiilf or I'outitry) 











lt)0 '. 

tbatllastsawh... alive on ^'t± ^ 190'^ 

ana that .U-ath .uHurrc.l, on ll,c .lair stalnl above, at ^ C-^O 
v^'v M. The CAl SIv Ol- Dl'-ATIl was as follows: 



DTK AT ION '* JVay.v .1A'//M.? /><m 

CONTUllUTORY L.bvCLjLA>v^.ci.v 



^',Ov.^..'..v 



Ho lira 










lA'/////' 



/'</ 1 



TMKVm>VKSTATK...KK...NA..rAKT.rrUAKS Mn:TKrK To THK 
UKST <)»• MY KNOWl.KIX.I-. AND Ml-.Ml.l 






/></i.v 



I/out's 
M.D. 



I )r RAT I ON 
( SIGNED) 

SPECIAL INFORMATION only for Hospitdls, Institutions. Transients, 
or Recent Residents, dnd persons dying awa) from liome. 



I()0 \ 



(A.iaresv.) HOS- 'h 



- 'iM-^. C) 



i. 



former or 
Usual Residence 



i. 



, , How lonq at 

When was disease contrartcd, 
It not at plaf e ol death ? 



UKST oj^^Mv KN()\\i.»M""-. --' ••• , 



f \<Mr«"-.s 



^oS/vi^^V^aI ^^ 



i)\'n:oi' m KiAi. or k1':m<)VAi, 

i9^ 'ic. 



ri.ACH <)!• MIKIAI. <>i< K1:M<'\ Al< 



190 I 



— — ■— — — ^ . , I . I tg,| I XAGTl Y PHYSICIANS hHouIcI 

N. „._Kvery ...n. o« .„W,n..,i«n .h,.u..l b. ...refuH, »...ml-l. *;;';;;"';^..u,:a" Th: ••8,..c'ib. ln«or,n».l..n" »or p.r- 
.tote CAUSr or- DI:ATH In l>lii!n «criii«. Hint H n>i.> >e l'-" I 
:,". dy.nft »w,y from home 1.1 he »•...« i ry .n,.oncc. 



J 



t-, t 






, 



w 



RITE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



/r /v/r^/,(!L)cl<rLov) 2>0 



REFtR ru b 



:j back of CE^TJf'C 



▼ r cr»R INSTRUCTIONS 



i|t 



/)'' 



,tr\AA^ dULAMJ P'^'P 



10 0\ 



Be^istei'efl Xo. 



2723 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeath 






•Q. 5. 5tan^arC» ) 



^ 



A 



PLACE OF DEATH: — County o{J(C^^\^o.^ 



City of '^^'^*' 



AA^ 



Xo 




(mo ■) J 

^H \ \ ci. - Dist • bet ^~~ ^^" 



) 



FULL NAME A^o 



L.U A 



'y 



^^AX^-'-"'• 



PERSONAL AND STATISTICAL PARTICULARS 



v1 



1)\1 !•: <>I I'.IKTM 



C<>I,t)K \ 



i , t 

( 



bI' 







\^M 



il);iy) 



I (. 



\(". 1- 



3s 3> y>a,^ t .v...//n M 



Year) 



/>(M. 



MEDICAL CERTIFICATE OF DEATH 
DATK nl-' DKATII 



T()0 t 

(Year) 



Li ' ' 



si\(.i,i-: M.\Ki<ii:i>. 

\VII)()\VKl> <>K DIYmKI Kl) 
iWritrin MK-i:il dt -iviiaticn) 



lUKTinM.xrK 
(State or Country) 




'I 



I- A rm-.R 



iMK'nn'i,ArH 
(ii- i\rm-.K 

(State or I'oimti \ ' 



MAIDI'N NAMl". 
ol M(»Tin:K 



UIKrm'KACl-: 
(state or Coiuitryt 



DCCri'AilON 









let 

(Month) "^^'^-^ 

1 nivKI'HV CI'RTIFV, That I atten.UMl .lc(-casc<l from 

that I last saw h .^:— alive on " ^^^ 

a.i.l that .loath occurrcl, i.n the <h.tc stated above, at 
M. The CMSI^Ol" 1)1«:ATI 



M. The CMS!-; Ol" 1)1-:ATI1 was as follows: 



nrkATION Years Mouths Pays Hours 

CONTRIIU'TORV 



A 



Qj? 



-\ n 



)'i'ars 



Mi)>illis 



Pays 



I /ours 



DTRATION 

(SIGNED) ■^.^ ^t! „ «?-°- 

i^Jcfc 5.a l.,n , r>.l.lr,..;.ld/XC\,<X-wOi.^4-<.A,t..' 



%kjX 



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



tx/y^'O^ 



l^\-si,lr,! ni Sail I'ntiu i^rn .' I > '<" ^ 



yrniilh^ 



n,i\. 



,MKMU)VKSTATKI)rKRS<)NM,l'AKTirri,AKSARKTKrK To 



rm-: 



(Iiifoiniant 






Former or 
Usual Residence 

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



How long at 
Place ol Death? 



Days 



I'l VCIC Ol' lURIAI, OR KI-:moVAI, 




■^Sj\<i^^^' 



DAli; of IliKlAl. or Ri:MnVAU 

hytX. '^.l TOO . 






(AthlreHS 



IN. K. 



^^— ^^^n^— — — "^^ — — — ^^^j rXACTLY PHYSICIANS uhould 

livery Item of ln?or.n«t5on »honM he crefully -Pj;''-;; „^^;':;,;7laH«hlcd.' Th; ••Special Information" for p.r- 
» ♦ rAllSF OF- DFATH in p nin terms, that it mn> i>e PJ-'M ' 



J 






Ill 



M; 



IM 



$ 



ll 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

«^^^« -P^ o*^« ne r.rRTIFlCATE FOR INSTRUCTIONS 



!!. Ill I 



V_^ ;. *-?'~-ir;'S^ HM' (N 






Registered JS'^o. 



2724 



Pair /••//.'./, UcUWv 2.0 1'f0\ 

l^.v^l.v<^ Deputy P.ea!th Officer ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No.H ( 



PLACE OF DEATH: — County of 




Certificate of E>catb 

( n. 5. 5tan^arD j 

. "^ Dist.,bet. rU^'tV^MXVd and JC^^C^-v^ 



^' l'>\ \.'J-.I7^-.a. .' Q L<.0-.-Vi. St.; 



„o- usu.L RESIDENCE cvr r^^{^':is .-".r„°^: :;.%%'ri:rr:a"'.''"' ) 



FULL NAME 




P.. 



,Ol^l-U^ UXL. 



-<i.\ 



PERSONAL AND STATISTICAL PARTICULARS 
VN ^ ! COI.OR 

JL >^->-X?J 




.L'o.^' 



i)\ri". «'i' iiiK 111 



AC.H 



M.nitlH 



(I)itv) 



, 1 l^'^ 

(Vear) 



%■• 



) V'(7» 



M,>}itli' 



Pa 1 .V 



(Year> 



MEDICAL CERTIFICATE OF DEATH 

DATK OH I)1:aTH j( N 

(Month) 'I^''>'^ 

I in':RlTnV CKRTIFV, That I attcn.k-.l .Icceasccl from 

i£^fe X^ 190 H to 

that I hist saw h •: ahvc on 






190 
190 



SlNC.l.i:. MAKUIl-.T). 
WinnWHI) OK DIVOKThl) 
iWritrin xiuial dt- sij/'iiati'tn) 





BFK I'll ri, ATI-: 
fSt:it<- or (.■ouiitry^ 



NAM1-: 01 
FA I" 111; R 



lUKIH rUATH 

()!•• JATIIl-:k 

I Sl.'itr or i"ouiitry1 



ma!I)i:n nam I", 
nl MOTHKK 



lUK rnrLACK 

oi- MO'IIIKK 
(Stall- or t'lmntryi 



i)Ccri'A rioN 







Xyy\/^r\^^'^J^ 






^h 



A^a^X^aj 



an.l that .Icath occurred, t>n the date stated above, at H ?)C) 
M, The CAISI*: Ol« DICATIl was as follows: 






DT RAT ION Years 

CONTRIIU'TORY 



Mouths Pays ^H Hours 





^/uUUo-^ 



-vX^w 



[ |\x^hX)AX>v.U3 




I 



Cv"<^^-> 



( n 



axJCcuvvOw 



DTRATION ^ y^ii'S ^^ M^i^nths 



Pays 



(SIGNED ) >JyVV^^ 



[qn 



(A.Mress) 'C)'\ 






Hours 
M.D. 

1 



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




RrM,ff(f ill Sail l'in>i< i'"i> -^C ^ ''^' ' 




Month- 



/)in. 



TMKN,.>VKSTATK.>.'KKS.,NA. rAUTUMMAKSAKKTRlK TO THH 
HKSr OF MV KNOWIJ-.IX.K AM) HhMl.I' 



(InfoMiiaiit 






Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



FI.ACK OF ni'RIAI. oK RFMoVAl. 







l)ATF:of HrRiAK or RF:MoVAI, 



1 90 1 



iAin-^s 10 SI. ^yuji^^.^4^ Dt 



— ' ' ,. , Tne should he 8tate.l EXACTLY. PHYSICIANS should 

N. B._Every Item o? inJormBtion should he crefully ^-^^J^ J'^^^J^ dasshMcd. The ^Special Information" for pT- 
state CAUSE OF DEATH Jn pinm terms, that it mH> t>e prop 
"on. dyinfc away from home should he fiivcn In every mstance. 



I 

-t 

II 



I 



I 



li 



I 



111 



I 



t I 

ii 



\h 



\'\ 



♦ 



< 



» 



RITE PLAINLY WITH UNFADING INK — 



W 



,,,,,1 .,f n, :.ith !•• V... .^ '^C:fe^'»^^'^'' *^'" 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICAfrroPTmiTWU^riOnia 



I',..: 11 



Ihffr /v7^'^/,\L)ciMKA; iO 



ifJO'i 



Jfe^/.sfcf'cd A'^o. 





Deputy I ^c""?*!^ Officer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Q^ 



Ccvtificate of IDeatb 

( "a. S. StanDarD ) 
PLACE OF DEATH: — County ofO^A^. J.Vo. ,- 'ACiCity of<"''a.>v 3 



VtXAVC^-^C. <- 



1 v^ 



(E4o. J .'vAy^^C- ''^ OV: (Vi, A'-Lo..'.' 



,i 



St.; - 



Dist; bet. 



and 



- ) 



V.O ' V J^ ^^""^ ' "^ ..OM*. BTQinrNCEGIVE FACTs'cALLEO TOR UNDER •SPECAL . N FOR M AT.O N - ^ 

( '^ ^F"o7A.°H"ccc^^;ro^^^Ho"s"prTlt :^^:.if.':o%%rLT:.% name ..steao of street a.o .u«ber. ; 



JJiX 



FULL NAME J^^^ [\jx.y^jLo^^ 



PERSONAL AND STATISTICAL PARTICULARS 






u 



I M.mthi 



At .K 



.'^^ 



) V(i. 



'I 



1 



M.oilli^ 



r % 5 

'Year) 



/h!\ 



siN«".i,K. MARK n:i) 
\vii)<)\vi:u OR i)!V(>K»>i;i) 

iWiitriii "^otial (W-sij-'uatioii) 



lUKTHIM. \r}-. 
(Statr or C"niintrv' 



(Year) 




''VojvVOLcL 



MEDICAL CERTIFICATE OF DEATH 

DATic oi" i)i:ath ^ 

(Month) <J>:»y^ 

1 Hl'lRIU'.V Ci:RTn'V, That I atton«U'<l dccvascd from 

, -1. . '.. looH to JD:^ %"". .I90M 

that 1 last saw h - ahvc on V " tqo 

au.l that <k-ath ooourre.l, on the <latc stated ahove, at » 
M The CAISIC Ol" Dl-ATII was as follows: 



dj .'L/^-^ftJL/^^^-'*-^ \^.CXAX.cL ^^XX 



NAM1-: <)?• 
!■ ATMl'.K 



lUkl'MJM.AlH 
()!■ I ATI IKK 
(Stale i)t Coiiiitrv* 



maii>i;n namh 

01 MOTIIKK 



luK'rniM.ACK 
ni- M<)'nn<:R 

(stale «)r Ooiiiitry^ 



• n'lTl'ATlON QjSj) 




L<Xova.'^ 



.vcy 



Lo^ V , cod^ 




\v 



h\-^i,fr,l ill Sail /'imhisr.i ^ )V<ma 



yrmilli- 



Ihn 



Tin- \H0Vl.-ST\Ti:i)l'KRS<)NAI, I'A R K UT I.A RS A R l. TR T K To Till- 
lilvSr »)!• MY KNOWM.IX.K AND m-.IJl.l- 



Infiiiniant '<-' 






( \(l(lress 



DlRA'riON Years 

CONTRIIU'TORV 



DTRATION p^ Vi-ars 



Months 



Pays 



I lours 



Months 



Pays 



I I I 



(SIGNCD) J^V K.:. 

Uct 'k: 100' I (A«l<lress) "^ H O^U^i^Ll 



V 



Hours 
M.D. 



SPECIAL I INFORMATION only for Hospitdls, Institutions, Transients, 
or Recent Residents, and persons dying anay from tjome. 



Former or i r ^ /^ 

Usual Residence i v U c** 

When Has disease contracted. 
If not at piare of death ? 



QXl A 



t 



HoH long at 
Place of Death ? 



f 



Days 



l'I.\CK <)I- lURIAI. OR Rl'.MOVAI, 

c^. © '^. f^-Vw.^^ '- 

INI)1;R TAKKR 

(Addrt'ss 



DAW of HiKiAi. or KKMOVAI, 

JDcX ^>! 190S 








N. B.- 



. . |r\ »f>li shouhl be Htatecl EXACTLY. PHYSICIANS nhould 

-Hvery item of information .hould be cnretully «"PP«-d- „'^';H;7,3UTficd. The "Special Information" for pT- 
»tnte CAUSE OF DEATH in plain terms, that .t may he properly claBSineu. 
«on« dyinft away from home should be ftiven in every inHtancc. 



/ 



;.::* 






I' 

1)1 



lii 



/ 



i 



i 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERft 



IN3THUCI luno 




/)(ff(' Filed , 



^0 



^ 






10 ()\ 
IfTlcer 



Registered J\'*o, 



2726 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( ■a. S. SlaiiPatS ) 



J,' 



ds^ 



PLACE OF DEATH : — County of C^ C^-^^. J.V<x>^^^ c<. City of ^^^ ^ .V<v->%.^^-<i^c. 



;0 




IF DEATH OCCURgflAWAy FROM USUAL 



and 



OF«;iDFNCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 

( " r."o»TH"occ"r.rr,',rr«o"s°rT".^ o",^?,:^^^"';'.",^ „s name ....»o o, .....^ .no ....... ; 



FULL NAME 




cLtui...yy Li' ■+- 



PERSONAL AND STATISTICAL PARTICULARS 



It \ri-: < >i- r,iK 1 II 



\(.i'; 



M.mth) \ 









) '<\n . 



(I):t\ I 



M.,>ith> 



. k 



'(I at ' 



l)il\ 



Sixr.1,1' MARKIl"!) 

\\ii)t i\vi-:i) < tK DiNoKri: I) 

(Write in ».(>i-i;il dt. '-ivMiatioii) 



lUKTmM.AOK 
(Statf or <."i)untt v^ 



NAMi: OI 

FA'rm'.R 



HIRTHIM.ArK 
<)1' I-AIMIKK 
iSt.'iU' or rouiitryl 



MAIDI'.N NAMK 
()!■ MOTHl'.K 




MEDICAL CERTIFICATE OF DEATH 

DATK (>»• DKAIH // "\ 

(Month) n)ay) (Year) 
I Ml'iRlir.V CI'RTIFV, That I^ attended deceased from 

lyO'. to U'^A). ^'; 190 't 

that I last saw li ' alive 011 ^- - icp 

and that death occurred, on the date stated ahove, at l^- lo 



a. 







■^^Or 



lUR'nnM.ACK 

ol' MoTHKK 
(Sliilf or Voiiutry) 



orcri'ATioN 

RfyidfUf m S<in I'l mi, ist-,i 



) r,i I V 



.!/,./////> 



/)./l.v 



Tin- MIOVK STATl-.n I'KKSONAI, I'A K TUT l.A KS ARl- TRfl'. T*' IHK 
IJHST ()!• MY KN()\VI,i;i)C.K AN!) HKI.li:!' 



f Itifonnaiit 



^. .. ( i- > 



O 



\ 







to 



( \(l(lri-ss 



ciLo 




r'. 



^al\v.\Xxx.J. 



\J ,0, • 



rhe CAT SIC OF DICATIl was as follows 



Di; RATION }'i'ars Months Days Hours 
CONTRIIU'TORV LLL.<;ktrl.\..CrL.S^.sL 



DURATION y.)'tW5 
(SIGNED) 



'^ ii 




J/()/lt/lS 



Pays 



Hours 
M.D. 



lU.ct 



I()0 



(Address) VU-M sV- ^ jV(K.W' 



iSl 



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



^'^H' 



Former or 
Usual Residence 

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



a .. 



r^ 



How long at 
Place of Death ? 



Days 



e 



I'l.ACK OV nrRIAI, OR RHMOVAI. 



QJi}=yX}^U±±^ X . - 



,. ' K ._/> . 



DATICof IUkiai. or Rl^MOVAI, 



lii 



(Ad.ln.ss HbTX' l^li('V 



190'i 




^ ^ , , ^ 8 ,, .,.„„,;e,i AGB 8houhl be stated F.XACTLY. PHYSICIANS should 

of information should be carefully HuPP'-<'' '^'„;;,7,,a««iyied. The "Special Information" for per- 
F OF DEATH in plain terms, that it may be properly ciassmcu. 1 



M. B. Rvery item 

Htate CAUSE OF DEATH in p 

IS dyinft away from home should be feiven in every instance. 



soni 



' i 






I 



■m0SiA. 



WRITE PLAINLY WITH UNFADING INK — THIR !«; A PFRMAMFNT Rrrnon 



ii 



r »' 



i 



H.>;ii<l •<{ HcMitli-t- Vn i; "^'^^^ hf^V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begisfeved J\^o, 



2727 



I)<(lr hlJoflMz^A^A^ ^.\. 100\ 

\ji\.Kj<,>^^ . Deputy Health omcer 

DEPARTNENT 6f PUBLIC HEALTH=City and County of San Francisco 



Certificate of ®eatb 



Nd. 



PLACE OF DEATH; — County of 








St.; Dist.;bct. 



City of LiL>x,tx\.^uLL^ 



. \ 



and 



1/ IF Dt»TH OCCURS *W*V FROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "s PEC I AL I N FOR M ATIO N ••\ 
LA IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME X)<X/^\a 







-AVcLi/ 




si:\ 



DAII-: OI- I'.IKl'M 



A ( ■. 1-: 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR \ 



li 



'M.inth 



I ^.' 

SlNT.i.K. MAKKli-.l) 
\\II)()\yi;i) OK DIVOKtKI) 
(Uritriii social flesiKiKitioit) 



lUKTin'I.AOK 

(St:it( <>T (.'onutrv^ 



) I'll ) 



( D.'i V » 



Mnith^ 



z^iH 

(Vt-ar) 



Pa r.v 



NAMl, (H 

FA Til i;k 



HlRTHri.ACK 
ni- lATllKK 

(Statt or Countrv) 



MAII)J:n NAMH 
Ol- MOTUHR 



HIR'niPl.ACK 
<»!•■ M(»THHK 
(St.'iti or Conntrvl 






lyAEDICAL CERTIFICATE OF DEATH 
DATK OF I)F;aTH 

(Month) (Day) 

I ni'RJCHV CI:rTIF<V, That r atteiKlcMl (leocased from 
"I90 to ~ - iqo 



IQO I 
(Year) 



that I last saw h 



alive oti 



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



T(/D 



M. The CAISI-: ()I< Dl-iATH was as follows: 



I )r RATION Years 

CONTRIIU'TORV 



Mont /is 



/hiys 



'.V4i . 



I /ours 






I ) r R A T ' < > ^' j^ ^ '''"••y Mom /is /}ays Hours 

( SIGNED )....|9, (i) Q^U.L\,v.yvo. > . " M.D. 

IQO 4 (Ad«lress) Vy<xfeX<Xy^vf^~ K.O.. 



?^^9'f^*- 'N FORM AT ION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 



VA r<-<v-. ^ ; », 



Former or x^ .J^ A '^,. How long at 

I Usual Residence 1 o A (rv^O'Y>v Cu. p|^,f Qf pf^ji, 7 



) I'll I > 



M,<„ll,^ 



/),,■!- 



''""V;,>'!!.'^''' ^'■^'■'•■I' t'HRSONAl, I'ARTUMI.ARS ARK TRIK To THF 
MF.sT Ol- MV KNOWI.KDCK AM) IJHMKF i^i'- lo iiik 



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



Days 



( Address 



I'^C^a i C^l^Cr^-v^, -3t, 



n.ACKOF niRiAr, OR rhmovai. | i)vn.:,,f mimia,. or rj-movai 

rXDKRTAKHR fc . J U^J(v^^ V.Lo 



""* "'"Ilrc^'l^SF'of dT^TH^^ ^ ^""•''k'^ :*"^''"^*'' ^'''''' ''^""" ^'^ «*"*^" r.XACTLY. PHYSICIANS should 

state ^AUhL OF DEATH m plnm terms, that it may he properly classified. The "Special Information" for n-r 
«on« dyinft away from home should he ftiven in every instance. information torpor- 



in 



Si 



2:f 



I 



p 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lioMI.l of n< ;i!tll ■)'S(> !■:. t-fT^^, lUtP c. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r riJ(></,\Ji 




-^\ "1 



190 \ 



Registered JVo, 



2728 



(^l.<.v^ Xju\^i Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and Count}- of San Francisco 

Ccvtificate of Hicatb 



( "a. S. StanDarC* ) 



(^ 



PLACE OF DEATH: — County of J/CX^-v O A.ouo-^ui c c Qty of ^' ' a , J 



/Vo^we V.' 



;\ 



No. itV'. MfT 




) 



A.v^vi.'U^.;\ St.; : Dist.; bct.VyJ^AX.ixXX^^^^.C. . and -. _ 

/ 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. / 



VJ jJsaXx\: 



FULL NAME 



(Lcl 



n.cx.^wcL 








SI "A' 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ok 



DAT!-; oi- IJIKTII p\ 

•MMlltllt 



.o! 



AGK 



.^^ 



) t ii I 



10 



(Day) 



.!/.'>////> 



10 



( Tea I 



/^/i > 



MEDICAL CERTIFICATE OF DEATH 

DAT!-; Ol' i)i;ath 

•Day) (Year) 



SI\(.I,K. MAKKIKI) 
\VllM)\yi:i) OK I)IV«»Kri:i) 
'Wiitiiii MK-ial (Ksi;.';iiati<)n) 




HIK !III'l,\ri'. 

'Slate 11! Cinint I \' 



NAM)' Of- 
I- A 11 1 I. k 



MIK 111 I'l, All-; 

Ol" I \iiii:k 

'Statt oi I'liuiiti \ ) 



M\!I>!:\ NAM I'. 
Ol MOTMllK 



lUK'rni'i.Ariv 

Ol MOT III-; R 
(state- or Coiiiitrx 




X) xXXj^<X -n'-> v ^JS^v ci ! ■ 



fM(.ntli) 
,i in-Rl-nV CICRTIFV, TliMt I altLii,lc<l .IcHvascMl from 

t'dij H i^o'-i t., AD/cvt ^Ci 

tliat I last saw h ■:■■ ■ > alive on vL C. L 



T<)0 H 



Kp 



and that (Uatli occurred, on the dati- slate«l above, at b 
XL M The CAl'SI' ()!« DI-ATII was as follows: 



IS 



4 . 



CHli 



in 



-<y^\ 



ilo 



r^ 




V-^'VA^ \ V '_ 







or(i-i'ATl<)N^ 



V \- 



C<- 



nr RAT I ON y-rars Months 15. Days Hours 
COST u I lUiTOR Y Ovv^rrv\A.ra ^h^yxXju^^'^A^X^.^v^ 

I )r RAT ION i Ycavs Months Pays Hours 

( Signed ).\J\ (jS Jj ^ ■■; jvi.D. 

'M. Tcjo'i (Address) !:).b J\JtCX.\y>v^.< . ) l 



?^^9''ft'- INFORMATION only for Hospitdls, Institutions, tVansients. 
or Recent Residents, and persons dying away from liome. 



h'f'-ttlri! Ill SiDi I ) a III I ~,-n ,') ) )',(/;> 



Mnlllll^ 



/hi 



■rni-; \itovi<: stati:i) i-krsonai, par rion.AKs aki; tkih to tin-- 
n!-:sT Ol- Mv KNo\\!,i:i)c.H AND in;i.ii;i- 



Former or 
Usual Residence 

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



How long af 
Place of Deatfi ? 



Days 




I>ATi: n! Hi NiAi. 1)1 KJCMOVAi, 

190'i 



\ 1 1'. 11! Hi N 



i'i,ACH OF nrRiAi. OR ri;movai, 

INI) )•: R T A K 1-; R g ^A^AjLn, \j cj .oJtjL LL/^ ^cL q I. c 



N. li.- 



^''to't^crirSF^of n7rTH^'*'T','^ '"■ ^"""'""^ H".»pli-I. ACK Hhoul.l be HtaU.I fiXACTLY. PHYSICIANS nhould 
Htotc CAUSfc OF DEATH in pl..in term*, that it m»y be properly cl«H«.illcU. The "Special Information" for o«r 
«nn« <lyinft away from home nhouM be ftiven in every InHtance. ■niormalion for p.r- 



i. 

II 



I 



fr 



f' 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANPNT RmOPn 



}!<iriM! of Ilialtli- \'Si). i<.1^'^<yr^-j]iSi.\' Co 



Ihi 



!,■ /•V/^''/.y-ttxrWv 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



31 



190\ 




Kcgi,sf('i'p(l JYo, 



729 



U^ XjL\y\A. Deputy Health O^ner 



a^To. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "CI. S. 5ta^^arC> ) 
PLACE OF DEATH: — County ofO/CL-'>-v OAxx-wcv^i City oiOo-y^r^ -J/^,x>--^^.a^.\i c.<. 

^ ': ^ \ ^ 

115, J:a.u' •■■ St.; 2, Dist.;bet. JAA^V-'k and C' 

/" ir deaVh occurs away trom USUAL R ES I DENCE Gi VE facts called tor under "special information" \ 

V IF Di^ATH occurred IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME ^^^ " v. ' -..vl; ^fc \i)AjL^LLc '.. 



M, 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

j c<)i,<)k\ 



nij. 



II ', >t. 



DATl-: <)!■ IIIKTII 



AC.K 



I Month) 



'ia 



) v.; ( 



<I>:iv) 



M..,,ili 



MEDICAL CERTIFICATE OF DEATH 

DATK ()»• I)];aTH 



(Day) 



(Month) 



>iai ) 



/'(/I. 



SINC.I.H. MARklKI) 

\vrn<>\vi:i) ok nixoRrKi) 

<\\"iitc in social (ksij^natioii) 



mKTHr'UAOH 

(State or Country) 



NAMK ()I- 
I'ATIIKR 



niKTHFM.AC'K 
<)l" lAI'IIKK 
(Stiitf or Con lit rv 



MAII)1.;n NAM}" 
(»I- MOTHKK 



lURTHl'I.AC]-: 
OF MOTHKR 
(State or (.■(Hintrv) 



()la-w 



\.^t 



td. 



(War) 

I JH'RKRV C1':RTIFV, That I .ittL'n.lc-.l .k-.-vascI fn.m 

—190- — to ~ 190 

that I la.st saw h : alive oti u^q 

and that (U-ath occurred, on the datf statt-.l ahovt-, at ' 

M. The CAUSI^ Ol- Dl'i.XTII was as follows: 



LcLAJLHinrv' 



i. 






\ 



> 



i> W^'CrY^^iu:\.A-A.. 




? 



'X 



v^t 



I)rR.\TIOX Years 

COXTRIIU'TORV 



MofUhs 



Days 







.a^* 




It .^ 



'^ 



DURATIOX Yrars .^foNf/is Pays 



(^ " '^~^ /T^' 



( Signed ) Wvcr^^siv 



U/£t: C^-C. i<)o ' (Ad<lress)L&VCl>^J-M^U 



Hours 

Hours 
M.D. 



OCCri'ATlOX C^ , (? 



h'f'^hiiui III Sii n f'l a ii( i.^fn 






/\n. 



TMK AHOVK STA'n;i) PHKSONAl. PAKTICri.AKS ARK TRri'! To TlIK 
HKST OI- MV KNOWI.KDC.K AND HHMKF 



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

Former or (Yu . ] How lonq at 

Usual Residence^i iU5Vv.-»v.to.... >. I. Place of Death ? Days 

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



(In foiniant 






I'l.ACK OF m-RIAI. OR R1.;MoVAI. I DATK of Hikiai. ur KFMOV\J 



r.\D 



I'RTAKKR (AO<xXA.tc^ ^M. Lo 

(Address ^..HL ^n^\A;^^'rrVriDr3.\:...dl.... 



190 I 



rs. B.- 



-Hvery Uem olf information should be carefully supplied. AGF. should he stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for D«r- 
«on« dyini away Vrom home should be jiiven in every instance. 






I 



it 



Iv * 



n 



''! 



il 



!! 



I. 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li<.:n.l of II. :ilth !•• NV) i^ t««^ ■^'~iij JUS:!' Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



l)nh> riJ('(l!i)(djyiyV\j 



31 



loa 




Registered J\^o, 



2730 




1 1 \^ 



DEPARTMENT OF PUBLIC HEALTfl-City and County of San Francisco 



Ccvtificatc of H»catb 

( xa. S. StanC)arO ) 



PLACE OF DEATH: — County of C'.cv.^pu Jx^cxoo^^iA-a^ciCity of 0/O^>^ J \.o^>v<:.\^cc 



No. IC)5^ 



av.'c •^'... 



St.; 3. 



^ 



ic. 



p f) 



Dist.; betUo'/OA^iVo-^xa^C >< and \A. O.u 

/ ir Dt*TH occurs *w*v FROM USUAL RESIDENCE GIVE facts called for under "special information- \ 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE^ AND NUMBER / 

FULL NAMELkAwlAc', \Jclo,'\^Ji. 



\A 



uXA.qAA...;ui. '.... 



'S' 



X.CUL^.Ox.ji* 



PERSONAL AND STATISTICAL PARTICULARS 



-^i-:\ 'T^ . 

DAT) < •! I'.IK ill 



.\<. K 



-4- 



:1. 



Mimthi 



J v.;/ 



(Day) 



M.'ulfi^ 



i\\-i\r) 



Da vs 



WEDICAL CERTIFICATE OF DEATH 

DATK OI' I)1<:A'IH 

(I)av) 



0.ct 



igo \ 

(Year) 



SINCI.l-: MARRIl-;i). 
\VIIM)\\KI> OK IHVOKrj:!) 
(Writt'in social (itsij^uatioii) 



5 



HIRI'MPI.AOK 

<St;it< or rouiitrv^ 



I A Tin; K 



HIKTMIM.AiK 

()i- i-ATm<;K 

'St.-iti- or Coiinti v^ 



maii)i:n namk, 



lUKTFII'I.ACH 
<>I MOTIIHR 
(State or Country^ 






(Month) 
I HKRI'HV CIvRTlFV, That I atten.lc.l (lecoased from 

W/^. .^0 190H to ...iU^t h^. I 

that I last saw h : - alive on — — — 



[90 
T90 



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

:^r^..^^i:tS.^..A J.^kaJLI J—^ 




/tL CX./W V6LJW. . . A/< . 



zL 



iZ}^<Xj\>-^ 



or RAT I ON Years 

CONTRinrTORV 



Mouths 



Days 



Hours 



^ 



^ o 




xc 

i" 



<x^L cL 



c 



A^Ol.iV'C->l 



di'ratiox 
(Signed) 




Years Mouths 



Days 



.^ 



V 



Hours 
M.D. 



I go 



(Address) I2)b JiUx^u ^ 



% 



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



OCCri'ATlON 

Rfsidrd in Sail f'l 1! ih i^in 



)V„' 



.y/<»ff//.y 



fhn. 



rnV. \nOVE STA'n%I) PKRSOXAl, I'ARIU'ri.ARS ARi; TRIK TO THF 
HHST OF Nn- KNOWI.HDC.H AND lUiMKH 

(Iiifoimant W/CAyCUA>X V^VCL^Q^'-OLC . ., 

(Address ICS^i MCK^..A>4JU ]t 



Former or 
Usual Residence 

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



flow long at 
Place of Death? 



Days 



ri,ACH OF Bl-RIAI, OR RKMOVAI. DATKof ^\vm^^. or RFMOVM 

.Q)U. Qi^^t I Oct :m „,s 






(Address 



XhTV..... 



N. B. Every item of inVormHtion should be carefully «uppliecl. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Speciol Information" for D«r- 
sons dymft away from home nhould be feiven in every instance. 



'; i 






• Il 






■ t 

f 



\v 



i^ 




W'^'^ 



! f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






d^^CrV/U^ 



Deputy Health Officer 



Registered J\^o. 



S731 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of H)catb 

( "a. S. StanDarC> j 






© 



PLACE OF DEATH: — County of C) CXy>^ J.^xx/Yv^-c^^ciCity of C)<X/v\; /v<X/-*^tLoa 



ec 



^■^1^ D 



No. 1 4 1 S i^i. J cr 



J cr 



L 



St.; '^^ Dist.;bet. 



iOi 



k^j 



and 



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



11 ll\ 



FULL NAME 



a 



.^y\jY\jUb 



c 




I»\rj". nr- HIKTH 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.(lR \ 




1 - *> 



t 






MEDICAL CERTIFICATE OF DEATH 
DATE OF I)i:.\TH 



"^.r 



Month) 



A". J-: 



a'l 



J ■,•,/<> 



'I);i\) 



, !/./»////« 



(Vt-ar) 



/>,; 



W IDoU i:i) OK F>IV»)Kri:i) 

'Wtitriii social ili-sii^'iiat ii m ) 



lUK I'MIM.ACl-: 

I St.'itt- or ri)iiiit I \' I 



\ \M !•• ( >!• 
I A 111 IK 



inKTilI'I.ACK 
<»I I AIIIKK 
'St,ii« ( ji (■(iniitrv) 



MA1I)1:n NAMI-; 

<»i M()Tni-:K 



liiR'rm'i.ArH 
<•! M(>Tin:R 

(State or Comifrvl 



ofcri'A'riox 



^ 




I go 1 

rMonth^ (Day) (Year) 

I HI'iRJ'IiV CI:RTII'V, That I attoiidn! <locc'aso(l from 
LA^A^*x.^l ic/)'i to \LyoL. 9^2 i(p H 

that I last saw \\X,\. alive on U/cX 2,6 xtp ■ 

ami tliat lU-ath orriirrcd, on the date stated a])ove, at ?) LS 
M. The CAlSlv ()!• DI-ATII was as follows: 



a_a.-'«l<Vj6. 



O^/^t-Xi >oCc\A,.e<.sj 



V i f nt 




DIRATION ; Years 
CONTRIHrTORV 




Mouths Days Hours 



L 



'V.Oo^ 



V vj^-iL > 




-A^cL' 



DURATION iia. )Vrtrj JA;/////.9 Days 

(SIGNED) Q. J. OXi-ctl 

Hi T(,oH (Address) ^5^ :X Uaa. L l...'>. 



//ours 

M.D. 



i^).^fc 



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



AV%/(/r,/ /// Siiii I I mil i'-ii) K [ )'.(/;> 



!/-./////> 



/>,r\ 



Former or 
Usual Residence 

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



How long at 
Place of Oeatli ? 



Days 



rill". \MOVH STAII-.I) I'KKSONAI, PAR rUTI.AKS AKI'. IKII-; To TMl-; 
IIKST (}}• MY KNOWI.HDC.K AM) MI«:i.Ii:i- 



Htifor maiit 



Qf^vv^U) (2), d^J... 



(Address 



lIlS iZ J (rU.<rv>v O.i. 



''^^^^H OF HIKIAI, OK KI;moVAI, I DATHo} Hi KMr. or KKMOVAI, 




(J (Ke^ 

(A(l.lr.-ss in I NyU>0.^iA.,<rYV Jt 



Oo<ixU./>v. NmI'^ \^ \.ux\Xu. V ) \ . 



N. B.- 



-Kvery item ni infortTnition shoulil be ctirefully supplied. AfJR should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DHATH in plnin terms, that it may be properly classified. The "Special Information" for p«r- 
son« dylnjl away from home should be ftiven in every instance. 






! 



I 






I 



f 



I 

•I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!l.,:ii.! ..f II( :iUli !•' Vu < •-. '^"''S-r-'^) HS^ ]' C n 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



D^ffr ri/rr/,UdLXv^^ 3l 



290 "i 



Jteglste/'ed A'^o, 



O- 






Crv»c^^ cLivu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDcatb 

( XX. S. StanJar? ) 

A ^ 4 0^ 

PLACE OF DEATH: — County of Oo^'wj .V<x>\.c^.si.cv City of C)/<X/-w O^Vol^v^ca^^loc^ 

No. 11 5 'i \ij/u^<xcL.vj-cx-A.< St.; 1 Dist.; bet.cxJl0Lxv4i^>xcetr\l h. and ^A.\. 6^j. 

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



) 



FULL NAME 



cLLC:.t'.Qa. ) MA 



s}:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI/)R\ 



Wol: 



I» A 11, I )!• HI Kill 



\< .1- 



IC 



I 



,»VI 



Moiitlit 



i: 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol- I)i:.\TlI 



lilct 



(Yf.-ir) 



)•'■.// 



(I):iv) 



Mn„lln 



I Year) 



Pa 



MN«.|,i:. NJAKK li;i), 
WIDoWKl) OK DlVoKiKI) 
|\\iit<iti s(K'i;il ili-'.ij.Miati.iii) 



lUKrm'i.AC}-: 

'Stiiti' or C'DUiitrv* 



NAM}' ill 
1 Allll-.K 



HIKrillM.ArK 
<>i- I ArMJ<:K 
(Stale ()j I'omitt v^ 



MAII)i:\' NAMl' 
Ol- M()T1I1-;k 



1'. I K rill' I.AC H 
<>|- MOTIIKR 
(State or (."ouiitiA^ 



*>v"n I'Aliox 

Kfsidrd III Siiii /'i (in< iM'i) 












(Montli) (Day) 

I HI:RI:IIV CI':RTIFV. That I attended .k-rcascd from 

c^l ''X'\ 190 H to ..Ai//t±: .^,a u)o'i 

til at I last saw h L- > , . alive on A-'^cX 'X [ up ^l 

.111(1 that death occurred, on the <late stated above, at t ?)C. 
^..A. M. The CAI'SIC Ol- l)l{ATll was as follows: 






f 



O'VVJ-V.v'^A.^l 



VV.0-0 






DTK AT I ox )'tuirs Mont /is Days Hours 

CONTRIHrTORV 




/D 




h^v^^ 



1 i\xx\l^ 



Dl'RATIOX 



(Signed ) 



)\a)s 



Mo Hi /is 



a,(j.^)Yki[. 



/^a vs 



'^t-C'VYXA-CL' 



Wet 



i<>o' 1 



( 



Address) R H 1 ^1 ^ si, t " Vi 



Hours 
M.D. 



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



) Vin 



M.'xllr 



n,iv 



'\'\\\'. \H()\I.: ST \ Ii;i) t'KKsONAI, I'A K rKTI.A K S .\ K I". TKII-; To Til Iv 

in;sT Ol' Mv k.\o\vi,i:i)(;h and iihi. n;K 



'Iiif..iiiiaiit 



(E 



M 



f \fl«lri-ss 



1X5^ 



KAyX\JX^.Aj-<]LJu ..)t. 



Former or 
IsudI Residence 

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



How long at 
Plareof Death? 



Days 



n,ACH Ol' IUKIAI, OK KKMOVAI, 



DAri;.)!" MiKiAi, ill ki<;mo\ai. 



4 






'^^ "• Kvery item of inV'orm«t!on shoultl be ciirefully Hupplied. AGF. «hould be stated KXACTLY. PHY8ICIANS should 

state CAUSE OP DEATH in plnin terms, that it may be properly classified. The "Special InformHtlon" »or p«r- 
Ron« dyin^ away from home should be Hiven in every instance. 



,. %• 



u 



h I 






.i; 



■ft. 



»7 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RPGORD 

HmmiiI .if Hciilth I' No 1 1 ■B'^^S?^!*^ US:!* Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(f/r F/7pfI,^A 




ii 




wo H 



Registered J\^o. 






V-.cc^ dLi\i 



M^, 



Deputy He?Jth Offir-pr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( XI. S. StaiiOatS ) 



PLACE OF DEATH: — County of <x-va/ J/^<X'v^-oui^co City of C'<v\^ J A,<v->-vcui.-c« 



'Na 






<^''^'^^Xm SXa 1 Dist.; bet. cLL.<X-^>^-^\^^^tAi^J!^nd 1%-.W 



(\r DtATH OCCURS AWAV FR^M USUAL 
IF DEATH OCCURRCO IN 4 HOSPITAL 



RESIDENCE give fa 
OR INSTITUTION GIV 



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



FULL NAME 



SKX 



'■^ 



PERSONAL AND STATISTICAL PARTICULARS 

J COI.ORn 

DAii: or- lUKTii V 




lCJv^u 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH /A 



(Year) 



A«.H 



(Month) 



(Day) 



190^ 

(Year) 



J ra 



I s 



t 



M.»itfi^ 



n,t 



vs 



'^\\i'.\.V.. MAKklKD. 
WIIJOUKD OR DIVoKCKD 

'Uritfiii MH-inl «ltvj;.r,,;itioii) 




ItlKTHIM.ACK 
iSt.ttc or Country) 



JATHllK 



JMKTIII'I.ACK 
oi" I-AI"m<:K 
(St.itr or I'otmtrv' 



MAIDKN NAM1-; 
Ol- M«)TlIhR 



ItlRTFIPLACK 
OF MOTIIHR 

(Htiitf or Country) 



CUV\A^<^ 



I niCRIvBY CKRTIFV, That I attended deceased from 

^ --^ 3^^ I90S to ...AL:^ M igol 

that I hist saw h -* 'v alive on ti' t^^ "^ >. k^ '-j 

ami that death occurred, on the date stated above, at \X 
nJ ^'- '^l'^' ^rSF- OF DI'ATII was as foUows : 







c^ 




OCCri'ATlON 

A'f'Mti^if in Siiii /'i ii/n /M't) " )',,!i 






CONTkllU'TORV 




Mouths t >9rt;'.y 

l!L-\^\,i(^ 



Hours 




DIRATION Years Mouths lo Days 

( SIGNED ). 11. (E, ^'ij.cU 
1^),-Ct ?>[ 100 M (Address) ^Vig Cl^ol fst 



Hours 
M.D. 



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



Moil fir 



/>, 



Tin: AHOVK STATHI) I'HKSONAl, I'A KTKI- I.ARS AKi; TRl l- To TlIF 
MhSI OJ. MY KNOWM-DCK AND M1:I.I1':f 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



'Iiifoini.iiit 



c< 



(Address IX^ ^ 




(B 



MHX cL<A^ Oux C jt) 



o^ 



W.ACK OF IHRI.AJ. OR RKMOVAI. DATI- of Hikiai. or KKMOVAI, 

XJUL<l_3vaA^->v I ^^r^ '^ 1 90S 




cr\r a 



(Address .... 



"■ ^'~^tlt^ CXVSr nfuri'-^"^^^^^ """ cur.iuUy supplied. AGB should be «t«ted EXACTLY. PHYSICIANS should 

!o«l 11^ .PI **!"'" **"''"*'' •''"* '* '""* ''•= n''»Pe''«y cla-Hlficd. The "Special Information" for p,r- 

«on« dyinft away irom home Hhouid be Hivcn in every instance. ^ 



til 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT J^FCORD 



I^Kinl of lUalth ]• N'o. K ■f'J'vSr;'*^;^ I5&P Co 



V 



I 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed , 




%\ 



19Q\ 




Registered J\^o. 



O 



734 I 






iwii v>ri« 



DEPARTMENT OF PUBLIC HEALTH 



=City and County of San Francisco 



(^ 



Certificate of H)eatb 

PLACE OF DEATH: — County of O /O^^^ J X<X^»a.c\A ccCity of O '^X^v O A^Cl^^a. 1^ ul oc 
^o- "^ll '^i->Vv..t:^A.: St.; I Dist.; bctM lV>^i.q.tr>^^u^ and JUL^^ 

( " .7DrlT«^orru»»rn\"°** ^^^'^'- "EVIDENCE G.VE FACTS CALLED TOR UNDER VsPEC.AL . Jfro R M ATI O N - N ^ 

\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF «TREET AN^ NUMBER. ) 



FULL NAME 




CrVcL 



OUYVO 



si:\ 



I) \li; <)I' MIKTU 



\( .!•: 



PERSONAL AND STATISTICAL PARTICULARS 



iMoiitli) 



lb 
ll);iv) 



/IH ; 



O O J ><?/ > 



.1A»;////A 



I H 



(■/.■;ir) 



/hn> 



MEDICAL CERTIFICATE OF DEATH 

DATK OI" DllATII 

a)av) 



(Month) 



(Year) 



>iN"<.i,i-:. M\KKn:i) 
\\ii)M\yi:i) < »K i)(\(>Kr};i) 
' \\ I itc ill scciiil ilc^i^Miation) 



lURTHIM.ArK 
! St,it( or <,"i)uiiti \ I 



NAMIs t>I 
FATIU-K 




I m-lRl'IiV CI-RTH'V, That I attende.l .leceased from 

....djL|^"t i 190H to Qi.-ixtA. iQoH 

that I last saw h L. N>\ alive on vV 'tlAj 3^^ joo \ 

an.l that death occurred, on the date stated above, at ^. H5 
U- M. The CArSlv ORDivATII was as follows: 



-Ch(Lv^ 






<X>XO 



Of- lATin^K 
(St;it« or Country) 



MAIDHN NAMH 

<>I" MoTHl'.K 



iwR'nn'f.ACH 
•'I- mothi<:r 

fStatf or C'oimtrv) 



ri 



kt 



CL>L^{ 



CLVa.' 



? 



DI-RATION Years ' .lAv////.y Days 
CONTKIIU'TORY Oax^Cu-vXaJU^^vv 

DTK AT ION Years \ .}ro?it/is Days 

(SIGNED) \ <D. LuXuqA^^X^ 

'/CX. ?>l Kjo*-! (Address) bi?N U.OC- 



vCoJLm 



Special Information only for Hospitdis, institutions, irdnsients 

or Recent Residents, and persons dying anay from liome. 




Hours 

Hours 
M.D. 

fit 



* 



^^^^^ f\f>idri1 ill Sail I 1 ail, i sen O C/ )V(M> 



M.nilh^ 



Da 



Tin-: AMovi': stati:i) i'kksonai, par ikm-f, aks \r i i-ki}-- 

HhST ()!• MV KN()UIj;i)C.H AM) HKMHI- 



To Tin- 



(Iiif')iinant 



jtrk/w L/(yV'cL 



CX^^AX) 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



... Days 



l'I.\CK OK HI RIAL OR RHMOVAI. DATlvnf Hir.ai. or KKMOVAI, 



I90H 



(\.l.lrrss ?i I I Ll/WyMTYVCrt 






N. B. 



^ir7 r^^^s^f )^lZTJi''J^r*^''f"^ ''' CHrefully Huppllecl. AGK Mhould bo stated EXACTLY. PHYSICIANS should 
state CAUSE Oh DEATH In plain terms, that it may be properly claHBlfled. The "Special Information" for D«r- 
Bon« dymft away from home should be Jiiven in every instance. 



81 

S' 



\\ 



it; Ij 

1/ 



I 









I 






I 




H 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RPCORn 



Ild.iid of Hcilth h" No. 1- t'-?^»r!S,;) ]!5;^j> e',, 



lUde File<l,^,AjX^Kj 5 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lOO'i 



Registered J\^o, 



2735 



.CrVLA^ 




AM| Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Xl. S. StaiiSarCi > 

i ^ ^ ^ ■ 

PLACE OF DEATH: — County of C Xb^^^j Axx/>a.c^\^<i.e<) City of^ o^^^ Ax\.Avcc<i.ao 



No. oSiVU' I til 



0)1^ 



St.; M Dist.;bet.O.<X'>\.c.^vta and M flan^R-Lt 

/^ ir OE*TH OCCURS *W*Y FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "sPEOIaL INFORMATION- \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREeV AND NUMBER. ) 

FULL NAME •^A.cc4\x]L^ui J .ivcrvYvcu 




i<X/\T^JUS 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

(■<>i,(»k 



U 



OL^ 



I>A I}-; ol- lilR TH 



\<.I. 



X fvCtx 



I'Moiitli) 



}V,; 



^ 



lb 

(Dav 



M,mlli 



n 






lhi\. 



MEDICAL CERTIFICATE OF DEATH 

DATK <)!• 1)1-;aTH tr\ 

(Month) (Day) 



(Year) 



\\ii)r)\\|.;i> (>« i»i\< »Krj;i) 

' \\\ itf ill ^orial di ■<i).'ii:it ioii ) 



lUK'rmM.Ai'i". 

( state- or Coiiiiti \' 



NWtl 1)1 
I A III I.K 



lUKTUP!, At'H 
Ol I AI'm:K 
iStatf or (.oiiiiti \ ' 



MAII)).:\ NAMl- 
Ol' .MnTIIi:K 



Itlk riM'hAl'K 
Ol Moriil'lR 

' Stall oi I'oniltl >■> 



orcri'A'i'iox 







. I m;F<i;HV CI-RTII'V, That I attende.l deceased from 

w'/ci 10 190 H to ...iilirLt ^.0 icp'^ 

that I last saw h.^-^nA alive on KJ <^ '^0 T90 H 

and tliat death orrurred, on tlie date stated above, at 5^ 
^ M. The CATSlv ()!• DI-ATH was as follows 



.. -'uJj-aaxl^aJLo.^^ -H^vX-^A^^^aAjts 










CI 



/'a_-LnX^ 




nrkATION )Vrt;--? 1 Moulin Days Hours 

CONT R [ in -TOR V C>n^4-iX/-^l.\^Li. .Unr.v.v^wf.^ 




0- 



OL>vdl 



DTRATION 



}7'r?/'jr 



( Signed ) 




Mouths 



Days \ Hours 



3^1 looM (Address) fOO?5 1)CLC1> 



M.D. 



190 



UC^yCLut' 



h'f-^iilr,! Ill S,ni /'i (III, rfii *" ),,ii^ ^ Mmifh^ \\ l>ii\> 



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



Former or 
Usual Residence 

Wfien was disease rontrarfed, 
If not ^\ place of death ? 



How lonq at 
Place of Deaf Ij ? 



Days 



rin: AHovK sTA'n-,1) i'kksonai. pak tumi.aks ari; tki k to vwv 
HhsT Ol.- Mv k.\owm;i)c, K AM) Mi:i,n;K 



(I 






PI,ACK OI- m-KIAI, UK KH\f«)VAI. DATK ..f Hikiai. or RI'M<)V\I 



IN. B.. 



-Hvery Item otf Information Hhouhl b;; cnreltully Hupplied. ACJK HhoulJ be stated EXACTLY. PHY8ICIAIN8 should 
«t«te CAUSi: OF DKATH in pl..in terms, that It may be properly claHHh'led. The "Special Information" for nmv 
«on« dylnft away from home Hhouhl be ifciven in every inntancc. 



...i. 



t' 



\ u. 



t 1 



r "vii 



I 



. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!l,..i.' ..f n<:iltli I'N'o \-^'^-r-^'SC-^i.nSi.VC 



RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



fhf/r /v7/v/, y ctcrlMA- I 



[ 190^ 

3^^^^c<^ Aji/v u Deputy Health Officer 



BegLstei'ed J\^o, 






DEPARTMENT loF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX. S. StanCarS ) 






PLACE OF DEATH: — County of ' J <X/>aj .\.<X/v^ovac^o City of ^<X-rx' -),h.xx , ^cv^ cc 



NoAlolH 11 cLa 



dL< 




uorv.' 



St.; 



(ir DEATH OCCURS *WAY TROM USUAL 
\r DCATH OCCURRED IN A HOSPITAL 



RESIDENCE GIVE fac 
OR INSTITUTION GIVE 



Dist; bet. cLcs YYvlh Ol^^.cL and vIaXsI 

TS CALLED rOR UNDER "SPECIAL I N TO R M ATIO N " "\ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



t .A 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

1> \ II. <t|- lUkTII 



\ 



At .»•: 



xkt 



n ,.■„,. I 



I 

(I)MV 



.)/,»lf/l< 



r L '.. 

fVr:ii) 



lhl\^ 




HXd\--; 



I 



MEDICAL CERTIFICATE OF DEATH 

DATi-: (II' i)i;ath /A 



rgo 

Day) (Year) 



^IN<.I,i:, M.\KUIi;i) 

u ii)(»\\ j:i) »)k ni\( iKi 1.1) 

iWiitciii <^i)fial ill si^Miiit i'lti) 



luk riu'i. At'K 



mi< 1 iii'i. MK p T^->. A 

St:.t«- or rouiitiy) Jf V(J.l \) 

NX MI' <»l- \ 

I A 11 1 i;k V 



(Mnlltll) 

I I1I<:RI-:HV CI;RTIFV, Thai I atteiulcd deceased from 

- to — -- 



190 

tliat I last saw h alive on 



190 
T90 



and that death occurred, on the dati* stated above, at -rrrrrr. 
M. The CAISI': Ol- DIlATIl was as follows: 



lUK ri!IM,A(K 
<H lAIHl'K 

(StMti III (."Dimt I ^ 



MAII)I:n NAM1-; 
•11 MO r I IKK 



HiK rni'i.Ai'K 

<)1- MOTHER 

'StMtc or Coiitif ry) 




nr RATI ON Yrara 

coNTuinrTokv 



Mouths 



Days 



Hours 



DURATION 



Years 



Mouths 



) C r\ » > ^ ' cLt 



« I 



ore r PAT ION J . 

Kfsidfii III Soil /'i iiiii isi'i) I 1 )'rti I ^ \ MnnZ/i- 



( SIGNED ) LV^jn^jin) 



m.uj. 




/)ays 



//ou 



rs 



kJ<:% '- : I (,o ' t ( A d < 1 ress ) t v\,fr-^xx^y^ Vti ^c^. 



M.D. 



V I > i 

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



/>,i\ 



ITIi; AIK)\'I*. ST \li;i> I'KKSONAI. I'A K I" H" l" I, \ K S AKlv IK IK To Til 1% 
H1-:ST <)I MV KN<>\VI,i;nC.K AM) HIlMia- 



f InfMini;inl 



f \iMn-ss 






1^10 



-V^X-^V 



'i 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



■• Days 



I'l.ACK OI- mKIAI, OK KHMOVAI, I DATl-ot Mikiai. or KKMOVM 

(Address 1 1 'ill \J^\,v/a.^aA.<ryrv...dt 



N. B. Kvery Item otf inforniHtion should be cnpeFully Hupplied. AGP. Hhould be ntuted EXACTLY. PHY8ICIAN8 should 

Mtate CAUSE OF DIIATH in pliiin terms, that it may be properly classified. The "Special Information" for psr- 
sons dyinft away from home Hhould be i^iven in svery instance. 






ft 



■ii 



m^ W RITE PLAiNiXIftaXMJUN FADING INK — XMJS IS A PERMANENT RECORD 



! 



1' 



I 






'Ss 



KoarM ..f Hialtli J- No. i «; "^^^'w-i:) H&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Lcr^o^ "Ll^mj Deputy HeaUn Officer 



Bes^istered J^'^o, 









DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

I U. 5. StanDarO j 
PLACE OF DEATH: — County of C)<X/>v; J-^^x:wy^OLA<:o City of C'/CUwj Axx^^^tiA-A^ec 
No. lb 14 \'X X<XVRl r .,. St.; I Dist.;bet. X^n^A^lKlAxl and 

(\r DCATH OCCURS AWAY rROM USUAL R E S I D E NC E Gl V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION" 'S 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME .'.L^^^.... cJ.uiU iah<x.-. ' 



L/kjUut-WLut 



PERSONAL AND STATISTICAL PARTICULARS 

DATi: ol' niKTU 




4- 



'<T ' 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATM 



I Month) 



Af.K 



I ^ ) lit I - 



(I)i»V> 



V.»if/i^ 



' Vear) 



/hn 



SIXC.I.K, MARK 11:1) 

\\n)()\vi:i) OK inxokrKi) 

'Wiitfiii social (Usij.Miatioii) 



lUKI'm'I.AOK 
(Stat«- or Country^ 



NAMi: Ol" 
FATMKR 



lUR'rm'I.ACK 
Ol" I- A 11 IKK 

'Stat« or l'ouiitr\'^ 



MA11)1:n NAM!': 
01 MOTIIKR 



HlkTHI'l.AOK 

oi> mothi-:k 

(Stall* or Oountrv) 



% 




(Month) 



(Uay) 



(Year) 



I HICKIvBV Cl-:kTII-V, TliMt I attended dcoeascd from 
190 to ■■ ■ igo~— : 



that I last saw h 



alive on 



190 ^ 



and that death occurred, on the date stated above, at 
^ M. The CAlSri; Ol' DIvATlI was as follows 

L^<:<.VwdUL::kx.;Lcx-.L 



or RAT ION }'t'ars 

CONTRIBUTORY 



Months 



DiU 



•s 



Hours 



I I 



DT RAT ION Years Mont /is /Mys 

(Signed ) ...L<r\.<r->AJLAj ^i>. LI- kxLcL,r, .^ 

cX 't\ ino'\ (Address) V^'UCrvOA^ 



Hours 
M.D. 



igo 



W 



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



orcri'ATfON ^j^ 

h'rsiiifif 111 .S,ni I'l ,t ih iM'it iL .^ ).(// 



M.uilh' 



/Kn:^ 



rill': -MJovK sTATi:i) pkksoxai, i'aktuti.aks aki; rKii-: to riiH 

1U:ST OI' MV KNO\Vl,i;i)C. K AND lU'IJlvK 



(Infoiiuaut 






'>^.0..'V^.' 



former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'l.ACK OF Bl'RIAI, OR RKMOVAl, 



I)A'i;^Kof HfKiAi, or RKMOVAI, 

AJ^ a,i 



I • N i> f: R r A K f: r (J vD . J . aa^A'V' ''^. w 
(AcMrcss. IC^l Vl y\*^<^<;tU(:r>.v 



190 \ 



IN. B. Every Item ot information should hi CBrefully supplied. AGG should be stated EXACTLY. PHYSICIANS should 

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



■ V- 



i 



! 







ilr w 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

II. .i!.l Mf Hi;, nil I' Vo i; -^-^^^iiilK^cr (*., 



REFER TO BPCK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc Filed ^ 




il 



2>1 



190\ 




Registered J\''(). 



2738 



-^ ■ ...u.ith...cirj-. . 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( tl. S. Stan&atJ) ) 



PLACE OF DEATH: — County ofCJ/CL-y^ JXcc^A^cO/t^City ofOcL/w J A.o^'wco^iyco 



No« 1 1 II 




I 



>A.^tr^, VIA.<X-<1>1 St.; \ Dist.;bet. OAIX^A/ and 

/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL I N FO RM ATI O N '■ ^ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




) 



FULL NAME 




KkJXj 




PERSONAL AND STATISTICAL PARTICULARS 

1 COI,()R 



i> A 11-: ( >r niRTii 



Uj.rujtx 






\<.i-; 




) 'r,n 



(D.-iy) 



M.itilli' 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATH lf\ 

(Month) (Day) 



(Year) 



5 



(Vi-ar) 



fhtv.- 



MM. 1,1-: MAKl<Ii;i), 

\vn)n\vi;i> OR DivokcKi) 

•Wlit'ill '.■H-i;il (l(si;.'ii;(ti>>ll) 



lUK riUM, A^K 
' St,it< or Ci)niitr\ * 



P\ 



^0>V 



\ \Mi-: oi 



JUk rni'i.Ai'K I 



I HF.RKBY CrmTIFV, That I ..tteiKlcd decefised from 

\1 /^t ^.H 190 H to.. AjuQlLs... igo - 

that I last saw h ' alive oil " ' ' Kp - 

and that death occurred, 011 the date stated above, at 



/O 



M, 



The CAI'SIC OI- Di-ATH was^s follows: 
L:\\XrU\.\XA^^ L'U,Aij./ix.c Co-Lv; U 



XjOJ 




LOU 



D 



v^Oj \^Ar^^ 



Uvto 



01 i'atmi-;k 

' Statt or Coiintrv) 



MAini.N' XAM1-: 
<>!• MOTMKK 



P. I KT HI' LACK 
OF MOTUHR 

fStiitf or Conntrv) 



/\t'sitlrii in Sim /kiik/.u-i) \ ]',-iiis O .lA/;////-)0 /'</i> 



Dl'RATION ]'rars 

CONTRIBUTORY 



Mo)itlis 



Days \ Hours 



nr RATION 



)'cars 




Months Days 





(SIGNED) \J IL LI . vJi 

jy.^t g)l TQoH (Address) 5^ 1 1 Njlltm lQ/U. Ll-.^ 

iOTs.JTransicnts, 



Hours 
M.D. 



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



Till-; AHovK srAri-;i> phrsonai, far ihtlars ari-; rRii-: 10 vwv. 
HHST *>i\M^' kn<)wm:i)(;.k and ui-:i.n:F 



(Address I 1 LvTV 



Ky^rW) 




■a.-cjL 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



FI.ACK OI- HIRIAI, OR RlvMoVAI, 



XjdJL^-^ 



(Ad 



DATliof III KiAi, or RKMOVAI, 

^^r^ 1 190^1 

dress. bH^ \j <xX,lu^. 4t 



XXjsAi. 



^' ^- livery item of information should be carefully Hupplied. AGE should be stated F.XACTLY. PHYSICIANS should 

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



I m 






I 



i 

i 

4 



pi ! 



I 




I! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



}?...ir'1 of 11. ;i:th I- No ! =, ">-.|^«^~fc I'.S: P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




I 



<rl-CV ^l 



WO'i 



RegLsfered J\^o. 



2?39 



l)(((r Filed , 

i 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "a. S. StanOar^ ) 



QO 



PLACE OF DEATH: — County of^ CX^ v 



vo 



'No.M I Lo^o^dA^Li^t d/CV>XA^LaV^.. 



St 



'W- I v.. w .V-V« 



Dist.; bet. 



City of U/CX/^v J/^cx >A,c<.vc.c 



3. 



and 



E FACTS CALLED FOR UNDER SPEC 
GIVE ITS NAME INSTEAD OF STREE 



(IF DEATH OCCURS AWAY FROM USUAL RESIDENCEGIV 
IF DEATH (jsCCURRtD IN A HOSPITAL OR INSTITUTION < 

FULL NAME UJxvO- ■ J...,V L 



lAL INFORMATION" A 
T AND NUMBER. J 



PERSONAL AND STATISTICAL PARTICULARS 
SKX f\ ^ I COI.OR \ 



DAIJ: nj lilKTU 



\<.K 



cu 



u 



I 



£ 



M(>iitli) 



*1S J,.,, 



1 1).l\ 



1 A. >////> 



«\a! I 



/>.n 



Sl\(,l,l-; MAKUIi;!), 

\\ II)<)\Vl-:i) OR DIVOKCKI) 

'Wiitrin <<<Ki;il (lt^ivriiatii>ii ) 




uuL 



HIi< IMU'LACK 

' Statf or Coiinti v> 



XAMK Ol- 

t'atiii:k 



lUk IHl'LACK 
Ol J APHHK 
I Stair Df Couiitrv 



MAiniCN NAM I". 
Ol- MOTHl'.K 



mU iniM.AClv 
Ol- MoTHKR 
'Statf or Coiititry^ 



r^ 



4 




1 






I Ua.MX' d C'cl 



MEDICAL CERTIFICATE OF DEATH 
DA TK OF DKATH /P\ 

(Nfonth) (Day) 

I in';Ri:HY Ci:RTn>V, That I attended deccasca from 

— — — I90 to 



(Year) 



til at I last saw h ~ 



alive on 



190 

1 90 



._ \^ V- 



and that death occurred, on the date stated ahove, at 
-^ZIT- M. The CAISI- Ol- DI-iATII was as follows 

J ,VCVctA.A/>JU., i^k... _ 
.... LLLv\..Ow.<..\^.C: y:^.:..xVr....y^. .ChL.i>v . sLl.C, 

DIK.XTION )'t'ars Months Days 
CONTRIIU'TORV 



Hours 




3Jx>L^vfc Vl'^.^Cl/>^-><^J^ 



Dr RAT ION 

( SIGNED ) Lcr\X^>^Jl^' 



Years Months Days Hours 

Lcr\x^>^Jl^' 3 vjj. U). LiL.La/>.-v.-^ M.D. 
(.\ddrr<s) L^V<r\\ji\A v'v^ ......... 



I()0 



SPECIAL Information only for Hospitals, InstltiHtens, Translfnts, 
or Recent Residents, dnd persons dying av^ay fro.n home. 



b5^ 



Kf'^idrd III Situ /'i iiih i^iU) ^\ )'i'iiis 



.y/onths 



lht\. 



iin-: Auovi.: sr\ii:i) pkrsonai, r\K iuti. \ks akj; ikik to tii »■; 
iii-;sT Ol' Mv k\o\\i,i;d<'.k .\ni> iu-;iji-;i-' 



\ 



1 1 11 f(i; maiit 



v. lO«Jlv,r'^ 



Ad.lrc^v, 3 I b ' aJ/\> KX. V • . 



Former or 

IsudI Residence I bO ^t >\jLC) 

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



k 



HoH lonq at 
Place of Death ? 



. Days 



•I.ACK Ol' MIKIAI. OK K1-;mo\ AI. 



rNi)i-;RTAKHK vU^v >"vK^^-' ^^ c)saa,^\JL 



DATl'o! Hi Ki.Ai. or KKMOVAI, 



(Ad 



idress .^lob.io. Nj IX; 



.\^,<i-*..-<n(V 



N. B.- 



-Rvery item oV intiormiition should b.- cnrulrully Nupplied. ACiB should ho stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it miiy he properly classit'icd. The "Special Information'* for psp- 
sons dyin^ away from home should he i^iven in every instance. 






i 



% 
k' 

.f 




lA/RITr PI AIIMI V lAllTM IIMrAniM/^ i lU ic -ri-i ■ 



"•»•»• » » ■» • • « ^M I • « I « 



}Ui:iifl of HcuIth"F No. !c, i-f^^U&F Co 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/(' Fi/e(f fsJ./z^.^>Jl\j ^\ 



100\ 



XtrccvCi Xcvi| Deputy Health Officer 



Registered J\'*o. 



2710 



'No 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( H. S. StanOarD ) 
PLACE OF DEATH: — County of <X^ru J A.cc^'vCiAXLCoCity of H/CX/^v J /vcXax^^uvc^ 



(ir DCATH OCCURS AWAY FROiM USUAL 
IF OCATH OCCURRtD IN A HOSPITAL 



Dist.; bet. 



— and 



RESIDENCE GIVE facts called for UNDER "special INFORMATION 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



lAL INFORMATION" '\ 
T AND NUMBER. / 



FULL NAME CNA^O. 



\j^L,KX 





m.^X 



PERSONAL AND STATISTICAL PARTICULARS 



SK\ 



10^ 



COI.OR / 
\ 



%l 



vCLC 



I> A 11. nr lUKTU 



A<". K 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



fMr)llth) 



Mdiith^ 



2)0 r,.,,. 



II 



(Day) 



Mnllfhs 



{Vear> 



(Day) 



(Year) 



3.^ 



Pity 



HiN<',i.K, \!ARun;i) 

WIDOWHD Ok I)I\OKrKI) 
'U'ritciii siK-ial <ksij.'nati<m) 



lUKTHPI.ACH 

'State or Country) 



NAMi; ()|- 

kathi:r 



TUKTHIM.ACK 
Of I'AIMKK 
(Statf or Coiiiifrv) 






I lIlvRlvHV ClvRTIFV, That I attended deceased from 

Ai.:.<dj. XL 190't to ll^/t^ iq 190H 

tliat I last saw h-iu^>' aliveon \J fzk %^ icp H 

and that death occurred, on the <late stated above, at o 5 
W... M. The CAl'SK C)l- I)l':ATn was as follows: 



M.. M. The CAl'SK 



















lUKTHlM.ACl-: 
«>l MOTHHK 
(Statf or C()tintr\ ) 



cMjvm^wa^ cx ML) cx^^JUiy 




MAIDKN NAMK A ^^ A 

<»!•• M()Tin-:R J/ (^ I) D . 



DTRATION Vears Mouths Days 




Hours 






M ULAA^ UvtAJk 



^ 



(JONTRIIU'TORV 

DURATION )Vrtrj Mont /is Pays Hours 

( SIGNED ).VJ, Ij . UJlx%<X^^'CUa; M.D. 

U t^t' X\ iQo^( (.Address) 9>i 1% O/0t^C\XX/>fVJ?/^\X^ Jt 



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



nccrpATioN J/ /\ 

AVsiif^if lit Still t'l tiii4 isiU) ~>l T/i/zv 



M.oiths 



lht\ 




iiir; \Hovi.: stati;!) i'Kksoxai, i-AKriciL \ks .xki-: iKri-; r«» rnK 
iti;sT oi- MY kn()\vm:d('.k .vnd iu:i,ii:i- 



(1 



"f<"">.'>iit VJOcXA.yOo' M I V \' 1^ tV\,cy^DLAA. 



(A.i.iross T-'i OX^crvvjL 01 



?t, 



former or 
Usual Residence 

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



c^\x dt) 



How long at ^ 
Place of Death? > 



Days 



ri.ACK OF HIRIAI, OK RKMOVAI. 



DATHof IUkial or RKMOVAI., 



NDKRTAKKR U CUuL'^kAXx M y\.OJV\^^VVAj 



(.Addrcs.s 



IN. B.- 



-Kvery Item of informntion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special information" for per- 
sons dyinft away from home should be ftiven In every instance. 



-# 
^ 

cs 




r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



K#> 






l!.i;iT<l "f H* .ilth- !•' 



• No !«, -^-I^^ar^ n8i.V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff 



ti> Fnoi{X)^^^\i 31 



lOO'A 



Registered J\^o, 



2711 




£^,^1 Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( TH. S. Stan&ar^ ) 



PLACE OF DEATH: — County ofO/Ou^vA; OA/CXy-naiuiccCity of O.CL/>xy A.<XywcA.<i.c^c 
No. 0-SlS LO JLt-NLL^.'\.. St.; 1 Dist;bct.MO.cJLvc and MX.OK^ t . 

(IF DCATH OCCURS JkWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDeU "SPECIAL INFORMATION" '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD oWsTREET AND NUMBEHJ / 



FULL NAME 




\A>:- 




PERSONAL AND STATISTICAL PARTICULARS 

DA TIC Ol- niKTM r-. '\ 

iMAmh) (Day) (Vearl 



\r.v. 






M.nillf 



Purs 



^IN(.I,K. MARKIKI) 
UIlM»\VI-:i) OK divokd:!) 

tWiitciii s(K-iMl <li''i).Mi;itioii) 



HIKTMI'l.Ai'K 
(StMt«- i)r Country^ 



N'AMK (M' 
I- AT II HK 



P.IRTHPI.AlK 
Ol* l-ATMHK 
'St;it<' or Crmntrv 






MEDICAL CERTIFICATE OF DEATH 
DATE Ol" DKATH 

(Day) 



LU 



(Year) 



(Month) 
I Hl'RIUJV CI-KTIFV, That I atteiKkd dcccascil from 

- — — — — — —— — ic)0 to 190 "~ 

that I last saw h ~ ~ alive on ~~ T90 



and that death occurretl, on the date stated above, at ~~ 
M. The CAlSIv OF DICATII was as follows: 

-M>HrvxAJt\X^w AA^,A.A./ZA.xkji &>j...OL<C.-C^.<ijL/>\X.. 





/X>d. 




juxJL i V 




M \ 1 1 » I'. .^ .> \ M h, A r> --^ . (» » A 



a 



MAIDIlN NAMK 



DT RAT ION )'dars 

CONTRIBUTORY 



MoNi/is 



Days 



Hours 



DTRATIOX 



Years 



."^font/is 



Days 



niKTHPI,ACK X 

Ol" MoTMiCK r\ \) 

(State or t'ouiitrvl 




V">" 



> ^ c rt'cL V ^. 



OCCrPATlON /T)' 

AV\i,/r<f III San /'i mil isrtt 



£iLii>vk 



(SiGNED).Ur\xrAJiA; J Afi.uJ..XLLa/■vLd- 



Hours 
M.D. 



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



)'rtii . 



Months 



Ihn 



THK AHOVK STATl-I) I'KRSt)NAI, I'AKlIi T KAKS A K l", TRIH TO TIIH 
DKST Ol- MY KNOWMIDCK AND MICMHK 



[Informant \] jI/OA^ V^ fcjLXX.Ox 

(A,l<lress Xl IH Uj JLWIjIAj QI 



Former or 
Isual Residence 

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



How lonq at 
Place of Death? 



Days 



PI^ACK OF lURIAI, OR RKMOVAI, I DVPHof HfRiAl. or REMOVAI, 

.©4lLxW. lol I ^-t -6.,. 



r.NDKRTAKKR ML- v3 AXXX4 ^«^ L<i 

(Address 2>5'i.^ TbS 1 U-O-ty 



igo'i 



0-o-0wl,\.' 



i < 



IN. B. Every item of Information should be carefully Hupplied. AG6 should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for p«p- 
*on« dyinft away from home should be ftiven in every instance. 



mS 



, - 5 



lAf D i*rc* Di A I M I V tA/inrui I iM CA rM Ki/^ I Ki i# nri_i I 



A EsnaniiAivic-Ki-r Dc/^/Non 



wwitiik. • ^r-«t>«^> ••■••• ^^•^•f-« %^ 11^ ^1 ••«■% ■••• ^ I ^# r^ I hia«iwif~«ivh>t'«i 11^ «^>^ I ■ *^ 



li«iar<l ..i" lU.ilth l- No. w 1t-v^'^^^\\^V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I'.' 



1 




Registered J\^o. 



2713 



luilr /-V/rr/, li)£tcrl>Ji>v 31 1'JO'i 

duyvu^ loL/vviji Deputy Health Officer 

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

Certificate of S)eatb 

( U. S. StanCat? ) 
PLACE OF DEATH: — County ofO<x^y^ o >ucx-va.cv.a.<i<j City of C)/0^^r\j J >L^ou-vx/a^u^^c 
(Ne. V,t^-\XNXuLi L'WUL/'vQi;. -i\,ci.i (fl? ^<iV\A5t,?i..A Dist.; bet. ^ and ■ 

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



FULL NAME 



s};\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OK \ 



^ 



IVYv ODjU.L'-v;. 



Ol 



CO 



\X 



-'r^^Lc 



DATi: oi- III k Til 



A(.lv 



MEDICAL CERTIFICATE OF DEATH 

i).\TK OF I) i: AT 1 1 ,r\ 

0,c.t 



(Month) 



(Day) 



(Year) 



! MolltlO 



(Day) 



sinc.i.j:, m \ku iki>. 
winou i.;i> OK i)iV( )K(i:d 

'Wiitfiii social iltsi).'iiali<)ii) 



lUK rnpi,AOH 

'State or I'oimtiy^ 



NAM J- OI 

F.ATin:R 



lUKTMIM.Al'K 
<'|- l-ATHKR 
(State or Countrv) 



MAIDHN NAMK 



HIKTm'KAC'K 

<>i Morm:K 

(Slatf or Countrv) 



OCCri'ATION 




I HI-:RICRV CI'RTIFV, That I attoiukMl deceased from 

190 to 190 

tliat I last saw h ^rr- — alive on " — ————————— igo "" — 

and that death occurred, (^11 the date stated ahove, at — : 

M. The CAl'SH Ol- DlvATII was as follows: 








^\.'>L.i<rrY\j^r>,.\. 



1 



DT RATION Yi'ars 
CONTRn?UT()RV 



Months 



Days 



Hours 



DURATION Years Mouths Days 

( SIGNED )Uy^^r>XJL^;0.\fcUJ.L^ , '^ 

wet- ai T()o'\ (Address) C&Vr-yAX>vQ Vl^^^^ 

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



Hours 
M.D. 

>L.C..S, 



AV'W(/((/ /// .S'(;;/ I'l (lHi l^iUt 



) lUU 



M..>ith^ 



I hi I, 



IMJ". XHOVK STATi:n »'K KSONAI, I'A KTIC C I.A KS A K l". TKCH TO TIIK 

HJvST oi" Mv KNowi.i:n<. H AND ukmj:k 



i \(l(lrt'ss 



Former or 
Usual Residence 

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



How long »{ 

Place of Death? Days 



l'I,ACK OF niKIAI. OK RKMoVAI, I DATK of HfKIAL or RKMOVAI. 

-* K ^ I I Q^ 5^^ 



I'NDKRTAKKR v'\fcA-\ 



(Address 3)^1^- kR .tJk, Ot' 



kjLu. "^^ m 









I90H 



N. B. F.vepy item of InformHtion ahould be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

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




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



m 



I 



I?n:,r.l of Ikiiltli- !•• No. ic 'S>F;wr;^ H^I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r riJc^L t^ctXov 31 



WO'i 



Begistered J\^o. 



8743 




,rt 



Deputy Health OfrJc 



er 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( H. S. StaiiOat? ) 



Qi^ 



PLACE OF DEATH: — County ofCj/Oy^^ Jaxx/^xcc^c.c City ofOcu^^ O^Ou^n^coCL'ac 



^N©» 



VOL^^vOCL^^ 




,C<tYV.L^VNLO_\v! St.: 



Dist.; bet. 



and 



(IF DEATH OCCURS *W»V FROM USUAL R ^ S I O E NC E Gl VC FACTS CALLED FOR UNDtR "SPECIAL INFORMATION" "X 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




^ 



/'\ \ 



crrv- 



INI 





1j 




DATi; or lUKTlI 



-u. •. ' 



Mi.iithl 



ACH 



.^^ 



V' 'w ) '(■(// - 



(D.iv) 



Mouthy 



( Vt-ar) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DHATII 



(Month) 



SJ^ ipo^i 

(Day) (Year) 



Ihn 



^IN<".I,K. MAKUIKI) 
\\II)()\VKI> OK I)IV<>K.i:i) 
iWritriu social ilcsiviiali" pii 



I'.IKTHl'I.An-: 
(Statr or C'oiiiiti v> 



NAMl' nl- 
IATin;K 



lUKriii'i, \rK 

OI- lAIIIKK 

'State i>r Count I y) 



MAIDICN NAMi; 
OI- MOTIIHK 



lURTm'LAl'l-: 
oi' MOTHKK 
(Slate or Country) 



y 



OCCUPATION 



""'I.. 




I IN'RIiBV CIvRTirV, That I attetKled deceased froni 

iD.ct :• ! loo'^ to .....O/^t .a.o 



190 H 



'^ o 



1 90 to 

that I last saw li -'•• . alive oil sJ/CT.' • . iqq 

and that death occurred, on the date stated above, at i 
lL M. The CArSiC OI- DIvATII was as follows: 

A J ^ ^ 



Dl'RATION 
CONTRlUrTORV 



)'ears -., Months Days 



I Jours 




.Q) 



J 



f\Vs/ifrif in San I'l ,nii isiu) \ )'iin ^ v Mii)illi\ J^ Pin- 



Dl'RATION )\uiys Months Days rfours 

(Signed) ..UJ . t?.- vj o-tHL-.. m.d. 

iD-ct) 2>l ic,oH (Address) ^aiVn^OAJ^jlt.d^ 



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

Former or -A r ^ How long at 

Usual Residence O (J-^^^.-^rvv^X; vc place of Death? ! Days 






^ 



I 



r 



TJIH AHOVK STA'n:i) I'KKSONAI, I'AKTlcr I.A KS A K l". TKIK To TMH 

HKsr ()i< Mv KNo\vij;i)(*.H AM) luajia-" 



(I 



/Ol 



nff)nnaiit O'cA.A-.'fr'VV/Cl- ^ (y^TrK. c3 , 

(? I i '^ 



Wlien was disease contracted, ~A (^ i^^ 

If not at place of death ? (ir'>^0> % v oj V V. 



1 



a I 



IM.ACK OI-^ nrRIAI, OK KKMOVAI, 

1 

.0 



C)xx.'^v \J yXoJuLO L< 



I 



NDIIRTAKKR okAA.x<r\-y^<l. j CMTK 0.0^ 



I)ATKf)f HiHiAi, or RFIMOVAI, 

V-^t ^1 igo'. 



(A. Id 



less 





M« B. Kvepy Item of informiition should be cnrefuily supplied. AGB Hhould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information*' for p«r- 
snns dyin^ away from home should be ^iven in every instance. 



WRirr PLAINLY WITH UNFAniNr; INK — TMIC^ |c; A PTRMANETNT RETCORD 






I 



1 ? 

H I 



I 



J{(,;ir.l nf llialth 1- Vo i •' t'-v^.^g^:, ]lSi\' ( 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






lOO'i 



RegLslet'cd JS'^o, 



2744 



! «■ !, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 



( "a. S. StnnOnrC> ) 



PLACE OF DEATH: — County 



of (j/Cu^^ ^-^OL ) uC^v '~ '.. City of CJ/O./^^' Axvyvxc-VAix: <.. 



No. ^^ 





vwl^ 




w 



(^\lK\XclI St.; Dist.;bct. 



and 



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



It' 



FULL NAME v)a^AA.L 





s};\ 



DATl-: ol' IMKTU 



\<". H 



Cv^'ol 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.OR 




)A\Ky^'^ 



/ 



iMoiitJi ' 



)>.;( 



IDay; 



M.nith 



(Vt-art 



/)r/l,v 



■4 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH I C\ 

Met Ik 

(Month) 



I go 

(Day) (Year) 



si\<.i,i:, ^tAKUI^:^. 
\vin< iwia) OK iM\'t>Kv i;i) 

'\\'iit»iii social ilt'si'.riiatioii) 



lUKTinM.ArH 
iStatt or Coiintrv) 



? 




\AM1-: ol- 

I' A 11 1 i:r 



MIK'nilM.AC'H 
<)!• lAlIlKR 
• Stati- or C"i)niitrv 



MAn)i:N NAMK 
ol- MOTIIKR 



HIKrHJM.ACH 
OI- MoTlIKK 
'StriU- or Countrv) 



OCCri'ATION 






I IfHRI'BY CivRTIFV, That I attciulcd dertased from 

— — — — —————— 190 " to ■ •■ I90 — — 

that I last saw h • - alive on :■ ■ :■;■-. ' .. ..; icp 

atid that dvatli occurred, on the dale stated above, at -. •"." 
M. The CAT SI*: Ol- DI-ATII was as follows: 
(>-<3L,\,'..VJ.a.'^UlA<-w.':>>:"v,<^r:>.v' - \A^l\.t */ 




Dr RATION Years 
CONTRIBUTORY 



Months 



Days 



Hours 




f\f\<ii{r<1 ill Snti I'l nin isro 



DURATION 
(SIGNED) 



Years ^^^ Months Days 



TC)0 ' \ (Address) LfrV^TAJl^.^ uii ; . . ... 



Hours 



M.D. 



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



)V,/; 



Months 



l\i 



■nil". AUOVH STATI'I) PKKSONAI. I>.\ KriC T I.AK S A K IC TKll". TO THH 
HKST OH MV KN<)\V1J;D0K and HKMlvl" 



(111 






(Add re 



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Days 



ri,ACE Ol' lURIAI. OR RKMOVAI, I DATK of Hi kial or RKMOVAI, 
rNDKRTAKKR 



K9 /oJLjtxxi^ 



(Addres.s 



N. B. Rvepy item of infnrmntion 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 p«p- 
Aons dyin^ away from home should be ^iven in every instance. 



m\ 




WRITE PLAINLY WITH UNFADING \Nt\ — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,;it<l of Hi-Mlih »• S>j. m t-r^aif;^*) JtS:!' Co 




IfJO'i 



Registered J\'*o, 



O 



745 






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

Cevtiffcatc of 2)eatb 

PLACE OF DEATH: — County ofO CXa-v OAyCL/>\.CA.<L<:(City of C) <X/>Aj ^V<x/>a.<^\.<LCC. 



No. 




1C)T M.lA.-yvX'f^ St.; 5" Dist.; bet. M r lvA,NLC<nA.. and OtOvo-^/ 

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

FULL NAME :^ JU.Ax 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

' C<»I,ok \ \ 




I>\ ri; ni' HlkTII 



a<;h 



a 






) - ,; 



(Day) 



M,mlli^ 



'Year) 



/'./I 



MEDICAL CERTIFICATE OF DEATH 

DATlv OF I)i;.\TH |P\ 

(Month) (Day) (Year) 



SINCI.K. m,\rkm:i) 

WIDOWKI) OK I)IVOKii:i) 
• Wiitfin scKJiil <l<sij.'n:iti<)n) 



MKriUM.ACI-; Q (V>. 

Statr or Cotintix I Jr Hjll 



^ ^ 



NAM!-: OI 
l-ATin-.K 



v rx 



HIKTHI'I.ArK 
OI- lATHKR 

iSt.itf or Coiiiitrv) j ^ i 



MM1)J:n NAM)". 
o| MOTin:K 



HI k TUP I, AC H / 

o|' MOTHKK [r\ 

(Statr or C(MitUry) ^ U 



OCCIPATION 




. I HI<:kI':i5V CI-RTIFV, That I attended (leccascil from 

.Aii..!ct. :;: 1 190H to ...(il^ 3.a 

that 1 last saw li i- ^ > alive on li/ /tXv 



.T90M 
190 . 



and that death occurred, on the date stated above, at ' I 30 
'J M. The CArSI*: ()!• DI'ATH was as follows: 



L<n»^>A,ou LA-L<;Mn- 



\-^' 



I )l RATION 



} 'ears 



Months 



Da r? 



c" ( ) N'i" R ii{rT( ) R V C^xh.^cr>'vAyc: ...LLLc..e.^^ ' 



Hours 



vca -JX^oy^ 



1)1' RATION 



(Signed) 



Months 



<L 



t U I 





Days 



Hours 



Years 

Address) n ti*^ UOAxkajiL 



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



\ 

RfliU'd III .Silfl /■ I ilili l^i'il ' ■x'' 



)V,n 



.lA 






THI-: AHOVK STAT i: I) PKKSONAI, TAK rUTI.AKS ARK TRTH TO THH 
UKST Ol- MV KNOWM.IX'.K AM) Ui;iji:i" 



(h 



if'M Ilia lit >^/Y\/WaJ2, 

r 





Ci- 



■\' 



x.i.in.s (On ^9 "tl^.. <^t 



Former or 
Usual Residence 

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



How long at 
Place of Deatfi ? 



Days 



l'I,ACK OI" niRIAI, OK RHMOVAl, I DATH of I?i kiai. or RJiMOVAI, 

0^ QL^ I ^^-- . 



190 H 



INDICKTAKKR WVCLA^ V^^^lJk/VllX^VA^ \?L C' 






N. B. Bvery Item o? information should be cnrefully «upplied. AGR should be stated F.XACTLY. 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 l^iven in every instance. 









C| 



X 



^~^ 



<^ 




mm 

m 







JSiT" 



WRITF PLAINLY WITH UNFADINC^ INK — THIS IS A PERMANENT RECORD 



if 



* » 



I 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(( 



f(> Wrv/,lL)<^tXt^ 



31 



190H 



Registered JVo. 



2716 




DF 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( X\. S. Stan^ar^ ) 



■A Qi? 



PLACE OF DEATH: — County of a . J axx^ . c . . : u City of O.o^/-v^ JA.<X/\ayi^A,^e. 




No. I C) M H (jb ■O.'^-Y-Ux^/Vv.'. ■ . 

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



St. 



Dist.; bet. 



^ 



>;vv 



:d..' and .12)A/^. 



RESIDENCE GIVE FACTS 
OR INSTITUTION GIVE I 



FULL NAME 



-U 






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



/'TL-trW: 



I) All! nl* 151 KTH 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR \ 




.O.lv.l.. 




\<'. !•: 



a;^ 



J 't-ii I > 



L 



(I>:iv) 



.1 /-;»//// - 



I 



fVear) 



/*,M. 



■+^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH ,r\ 

iD.ct IH., 

(Month) (Day) 



/pot 

(Year) 



^IN'.I.i;. MAKKIl'.I) 
\Vn)«)\Vi:i) (»K DIVOKrKI) 

\\iit»in s(K-i:il <l<«si(.'n;iti<m) 



ItlRCUlM, AOK 
(Statf or (."oiinti y^ 



NAMl-: <)I 
I" AT Hi: K 



MIKrnPl.ACH 

<ii- i-Arin-:K 

(State or t'oiiiitrv) 



M \ 1 1 ) !•: N N A M H 
<)!• MOTHKK 



mRTlIlM.ACl': 
<>l" MOTMKK 
Kt;it»." or (."ountrvt 



ocori'ATioN ,^5^r) 








I IN'iKIUiV CI'iRTII'V, That I atteiulcd deceased from 

vL'/.-Lt X'^i. 190'; to iD./X±" ^R 190 H.. 

that I last saw h :-" alive on U vCLi; .=f-. i 190 'i 

and that death occurred, on the date stated above, at i 
..Ul M. The CAl'Sl^: Ol' DI'^VTII was as follows: 

0, 



ry^JLcv/orvA-'trvA.A^txi 




Dl'RATION }'('ars 
CONTRIIU'TORV 



Mouths -^> Days 



/fours 



^ 



A A^L 






&A„V^> ^ 






DTRATIOX }'(ars ^Mouths Days Hours 

% (^ . , ■ 

(Signed) ub /aJvAA^ M aj>X!xA.cLc|..... M.D. 

ILi/cl. r.vl 190 H (Address) /i OS- C* XXc^xA, ji. 



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



Resitirii ill Sutt I'laiiiism X'^ )Vii 1 s k. MiHiths \.. Davy 

I'lU'. AHOVl": STATl'I) PKKSONAI, TA Kl" HM' I,A K S A K l", TRll-: TO TIIH 

in;sT oi' MY KNowi.Hnr.K and hkmi:f 



( Ad dress 



OHH 




1. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



190 I 



ri.ACK Ol- lU'RIAI, OK KKMOVAI, I DATi: of Mikiai. or KKMoVAI, 
NDICRTAKKR ^ • C3 . X3 £X\JLCVa < 



(Address .. 




..d.y:::^. 



N. B. F.very item of iiiformHtion should be cnre?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

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







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



|t,,;,t.! ..f n<.ilt)i - 1- No. P, "J'-t^w-j^^JlUtP Co 



REFER TO BAC»^ OF CERTIFICATE FOR INSTRUCTIONS 



i 



Deputy Health Officer 



llegistered J\''o. 



2717 



DEPARTMENT <IF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)cath 



i XX. S. Stan^arD } 



PLACE OF DEATH: 



^ 






Q? 






'No. LCtu,^^ V-CtLvwIv 



i 



County ofO-CC^^ vJX<X/^xC^^a.c<City ofO^O-^>^ J /l.0.^ vc^a.^ e ( 
CK.\ \.v.l a. ' St.; Dist.; bet. r— r ::..— .:rrr-.:r and — - 

\ _ _ _________ -^ •• _ . _ _ . 



/I / IF DtATH OCCURS 'away TROM USUAL R E S I D E N C E C.I VE FACTS CALLED FOR UNOCR "SPECIAL INFORMATION 
y V IF DEATH OCCUrtREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAWE INSTEAD OF STREET AND NUMBER. 



") 



FULL NAME 




c 



^L") V: rk.C r 



PERSONAL AND STATISTICAL PARTICULARS 



"\ 




SKX 



DATl-; »)l- MIKIII 



COI.OK \ 



\< .!•; 






HS 



5V.; 



'^ixr. I,K. MAKKJKI). 
WIDOW i:i) OK I)I\'<)Kij:i) 
iWiitfiii s<Ki;i! ik-sijni;iti')ii) 



HIHTIiri, AOl'. 
(Stall- or c'ounti >'^ 



a.; 

X 

(Day) 



.-'_L. 



r%'o 



(Year) 



/', 



'X ,-<;. 



if 

I 




^ 
f 



XAMr: ui 
i-A riii;K 



lUR rm'i.AOK 
oi- iArui:K 

'Stiitt or r()\iiitiAi 



^TAIl)l•:^• namk 
<)!• .M()Tm:K 



iuK'rni'i,ACK 

*)1- MOTHKK 
(Stall' or Country^ 







\j c^(L >V ■>'^v-C > 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH d^ 

(Month) (Day) (Year) 

J HF'iRlvHV C1:RT;FV, That I atteiKk-d (U-ccased from 

L' ct '^^O.. 190H to .. .ct 3)C 190 \ 

that I last saw li-- ahve on v.'-CX r..." nyo ' 

and that death occurred, on the date stated above, at \ 
Cl^I. The CAlSIv OF I)I{AT1I was as follows: 



190 H 



xa}cJa\^^\< cL si ' 






DTRATION 



Months 



Hours 




W 






Rfsldfd it} Satt /'i atui.^ro l "^ )Vif;.v O ^fln!th.^ h:^, /)<m.> 



OCCUPATION ^ . 



>N ^/i>'-^ Months Days Ho 



CONTRIHl 

DTRATION )Vr7;-5 ^fonths Days 

( SIGNED ) ...,UJ..:,....[:.) y ..K.L.'O-tl 

\w cl/ ^C iQo" (A(l(lress) Vlcto ^d> N^ lb. 0-^.|.V.Cta( 



Hours 
M.D. 



i^ 



SPECIAL INFORMATION only for H^pitals, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 

Former or Q, 1 n 11 ^ f How long at , ^ 

Usual Residence ^ ' ^ \j:U'i\.\ . ^ 



THK ABOVE STAIi: I) PKKSONAI, PAKIiriKAKS ARK TRIE T<> TIIK 
UEST Ol- MV KNOWlJvDC.E AND MKI.Ii:!-" 



[Informant \J . \J ^. vJL<X>^X>M 



I 



U.l.lress LCtoL^^ Lo ()x)^<i.'|^\..to..'. 



Usual Residence 

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



n 



Place of Oeatli ? 



Days 



ri.ACE OF nrRiAi. ok removal 






DATi: of Hi lu.Ai. or KEMOVAI, 
A/UrJ- I 190H 



indertakerVI R ^ 'CulxLv. u \J Ia VDajuxaIu, ^"^^ vAjl^ 

cy>vv4^^^x 5r 



(Ad(li( 



lai 



N. B. Every Item of Information shouhl 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 p«p- 
sons dyin^ away from home should be (i^iven in every instance. 



I 




m 



lit 



f I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.'i'i.l ..f !l. :iltli I' v., 1^ ^tya-f'^: Ufk]' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da/r r//rf/,\^\ztJijL\^ il 



IfJO H 



Re^istei'cd A'^o. 






748 




v.<^ 




u 



Deputy Health Officer 



DEPARTMENT 6f PUBLIC HEALTIl=City and County of San Francisco 

Certificate of 5)eatb 

( "U. 5. StanOarO ) 

PLACE OF DEATH: — County of U Ol^Aj JXo^-v.c^<i,ei:. City of Q (Xjy\j o/vOc^x^Ui C 



No. ilci 




lt^Y>l.qf tTYYVich^J vl \»- • St.; 1 Dist.; bet, vU -MhX OXO-CLu and U /O. 

(IF DEATH OCCURS *W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED I N JA HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET ANN NUMBER. / 




'A. 



h 



FULL NAME 



^4JL- 




^ 




PERSONAL AND STATISTICAL PARTICULARS ^ 




■^lA 



1> \ I i: «»l' 1;IK ill 



\ < . »•; 



COI.OR 



^xu 




. \\^ 



Xji 




1% 



) .,/ 



1 



M.'iil/i. 



,\h^ 



3>3 



( \\-„{\ 



/),l\s 



MEDICAL CERTIFICATE OF DEATH 

DATl-; ol- i)i:ath iCS 

btt 30 

(Month) (Day) 

J HIvRJ'HV Cl'UTirV, That I altciKk'.l <leocasc(l from 

z% 11 H^oH to il/cLt .3>c iQo'i 



(Year) 



vl. 



'-iN'.i !■: M\ki<n;i) 

'Wiit' in Sofia! <l» si).'iiat ion ) 




iiiK run, \cv. 

'Statr or Connt i \ 



NAM I ol 
I- ATI! Ik 



HIK 1 H I'l.AiH 

Ol- I AlIM'k 

' Stale or CotintrN' 



MAIDJ.N NAM}; 
<»I- MoTMHk 



111 kr IIP LATH 

<>»•• M()Tiii:k 

(State or r<jMiiti \ I 



C, 



(X- 




1 



\ OA. \, uxL 



-CrV^x^Oj 



? 



(>0 

that I last saw h - ali\f on \^ .•^..\j v; w igo 

and that death ocriirrc<l, on tlic dati' stated above at 

(? 



(E. 



M. Tile CAI SI*; Ol- I)|;aTII was as follows 



KJyw, O^A^ \J ('Y\JU^4./-rV'\,.0^ \Ay-C 




\ 



K. VvvA/vo.. 



^Ov^X.'Wj 



DIRATION 
(.ONTRriUTORV 



)'i'ais ^ Months 3.0 Payfi^ Hours 




.^...}U.\X....\jU\y^>\:. 





■)i 







DIRATION -. Yi'ars 



/hivs 



Hours 



Rr^idi'ii III Sim /'iiuhiM'" OO )'■</; > J Mnulli^ cA O /'(/i 



Months 
(SIGNED^ J . \Jj Crvvv/Y^t M.D. 

iy,'C.t ?)l l(,o '; (Address) 1^0 Ni)UYV.L<V4 lLv>. 



iuSoUT 



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



riir, \it(»\i.: si- \fi: d i-kksonai, pxk iim.Aks Aki: Tkii". 'n> \'\\v. 

Ill'.sr (H- MS- KNOW I, I -.DC, H AND IlKI.Ii; K 



' Infoiniaiit 



fXddrcss OX?) 




LLv^ 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'l.Afi-: Ol' nrkiAi, Ok ki-;mo\ai. 



DAir, o) IltKiAi. or ki-:m(ivai, 





t T9o4 




va. 



N. B. r.very item of Information should b.- cjirefully niipplied. AGE should be stnted FiXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pliiin terms, thnt it may be properly classified. The "Special Information'* for psr- 
Rons dyin^ away from home should he (Iti^en in every instance. 



if 



y ^ 



^i'i 






■fjl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Iin:!l'! ..f lli;iltll }■ 



No it, ■J'Sl^rii-. i;;;^!. c, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafr F//rf/, (D/ct<A^^ i\ lOO^ RcgLstered ^'o, ^7 1\) 

i^v^c^ljlA^u Deputy Health OfTlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( xa. S. Stan^ar^ ) 
PLACE OF DEATH: — County of C)<X>v ^O. \ . cut ^ (.City of O (X'v^ Vo. > vcca 'i(. 



l^fO. 



M 



i^r^Oi\}\^ 




(V^V<-t.<X> 



St.; 



Dist.; bet. 



and 



F DEATH OCCURS AWAY F 



(IF DEATH 0< 
IF DEATH 



OCCU RRt D I 



FROM USUAL RESIDENCE GIVE facts called for under "special information- \ 

N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 







FULL NAME tO 



lLvC<X'ty\ 



k.^\.L 



'>\. 



\ 



PERSONAL AND STATISTICAL PARTICULARS 
^1 \ ,A ^ I COI.OR 




■^ 




It \ I'l-: »)i' luk fn 



lL>vk 



\<.i': 



alt S'^ 



Month) 



),,;; 



iI>:iV» 



M.,„i/,s 






(Year) 



/>,i\ 



^IN<.I,I-: MAKKIKI* 

w n)n\vi:i> OK i>i\-«)Rr):i) ) 

iWiittin MH'i;il disij.' nat ion) -A 



nx/> 



lUKTm'I.Xi'K 
stall or fuiiiilrvl 



NAM I- oi 

I- AT in: K 



lUK'nii'i, \rK 
OI- iAriii<:K 

^i:it« or t'ountrv 



maii)i:n namk 

<>I Mo'rill'.R 



ItlK 1111' I.AC !•: 
•>!• MOTMKK 

I State or ^^)^uItr^•) 




'X\/^r>v<x > --'vi. 



'J 



X 



MEDICAL CERTIFICATE OF DEATH 

DATK OI' DKATH \ 

(Month) (Day) 

I III'IRI'HV ClvRTIl'V, That I attoiKkMl deceased from 
c' <l,t> it .190''. to AV.^'^' ^"^ U)oH 

tliat I last saw h '^r^^ alive on v_ C' %^ up . 

and that di-ath occurrcil, on tlu' date stated above, at ''Mo 
J.. M. The CAl'Sh: Ol" DIvATII was as follows: 



DT RATION I }'t'ars ^ .1/(w///s 

C ( ) N T R 1 1 U ' T ( ) R \' L LcA-^TLi . s3 0- >.<XXa.:v 



/)ays Hours 



o% 




Dl'RATlON 
(SIGNED ) 



Years 



Mouths 



\d<lress)C3t) 



/\ivs 



//our 



I()0 I ( 




M.D. 



SPECIAL INFORMATION only for HttspUals, Institutions, Transients, 
or Recent Residents, and persons dyiny dwdy from liome. 



crrrATioN 4 A 

Kesiilftf ill Son /'i iiih isrn 1 \j )'riiis 



Former or 
IsudI Residence 



>ii. 



50^ Wj O^iL VvA,'Vcat*> v)4 Place of Dedtfj ? 10 Day s 



Months 



Ihn. 



Till-; AHOVK STA ri:i) I'KKSONAI, I'AK lIiMI.AKS AKl', IKri-; TO TM1-; 
HKST Ol'- MY KN(>\VM;I)C.K AND FlKI.IlvK 



(111 fiinntitit 



(Address ,iv - j.j ■r.j. - .i.L:.j:..j:v;uJ.. ......» : .„ 



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






I'UACK ()!• HIKIAI, OK KKMoVAI, 



DATi; ot Hi KiAl, or KKMOVAl, 
W/Ob Z\ T90I 



(Address ^ ^OSG^(^^A>iLU ^ dt 



N. B.- 



-Hvery Item o^' informtition ahould l>* cnrefully nupplied. AGE nhould be stotetl EXACTLY. PHY8ICIAN8 iihouid 
• tote CAUSE OF DEATH in pliiin term*, that It mny be properly classi^ed. The "Special InfopmHtiun'* for p«r- 
Rins dyin^ away from home Hhould be ^Iven in m\mry instance. 



(i1 





m 




WRITE PLAINLY WITH UliFADING^LNA— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H..;ip1 ..r 11. .ilth \' No. I' '^^^'^^-^' nfcT C"() 



IDO'i 



Registered J\'*(), 



^750 



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




Cevtificate of S)catb 



( "CI. S. StanDarD ) 



i ^ 



i % 



PLACE OF DEATH: — County 



ofC)'(X/-rv AXX/-rvc*JlC<. City of CJ<XyW JAXXywxrii^c. 



(No. lC)H'-'>. K ij,-^_. 

( 



11 

St.; . Dist.; bet. \..L>^'^t-i\ 



os^ 



and ^ -^^ 

IF DEATH ^OCCURS *W«V FROM USUAL R E S I D E NC E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" A 

fE ITS NAME INSTEAD OF STREET AND NUMBER. / 



IF DEa'I^H OCCURRED IN A HOSPITAL OR INSTITUTION GIVI 



FULL NAME 




VyCU 



.L.xJy V. 



PERSONAL AND STATISTICAL PARTICULARS 

I)\l I. nl lUKTII 




,-.4\aXx< 




\".i-. 



Ml. nth) 



^ I !,,//. 



s 



(Day) 



.V.-„///v 



* » 



(Vi'ar) 



n,i\ 



S1\(.1,K. MAKHIHI) 
WIDOW !• I) OR DIVnKi i: J) 
(W'lilriii social (l<si>.'iiati<)n) 



HIk TMI'U.XOl-: 
(Stati- or ComiD y) 






CXy^^^o A^XXA^cxiA^ C c 



MEDICAL CERTIFICATE OF DEATH 

D.\TK Ol- Di;.\TH n\ 

,J^ 1", 



(Day) (Year) 



(Month) 
1 inCRIvHV CI'IRTII'V, That I attended dcivased frotn 

MdL.. Xk^ IQO'I to .iO'^t 3^^ T(>oM 

tliat I last saw h^^'v alive on v. cL up' > 

and that (Kath occnrred, on the date state<l above, at > 
CL .M. The CAlSlv OI- DICATH was as follows: 

o^Jy\>-<xJ\>^J(y^JLK^^r... ' 



N.XMi: Ol- 

I'A'iii i;r 






!l 



I , 



lUklHI'I, ACK 
OI" I ATIIKK 

(Stat( III (.'mint I y) 



M \ID1:n NAMK /7\ 
OI MOTHlvK ' ^ 








HIK IIM'l.ACl-: 

OI" MoTni.;k 

(state or Country) 








DIK.XTION Years 

CONTRIIUTORV 



Months 



Days 



Hours 



DFRATIOX 



( Signed) 



)'cars 



Mouths 



Da vs 




^"^ >" TOO : (.Address) IOM'I^- L l^ '^\ 



Hour. 



M.D. 



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



occ 



:ri'.\Ti()N J 

O /OULX^A^A-^tr'V^A^t^^n \ • 

A'f'Mifnf III .Sin/ / I iiih I sii) ,K [ ) iii > < 



M.nith- 



/),rr> 



Till-: AIIOVK STAII-.D I'KUS»)NAI< I'A K lirr I.A KS A R I". TRt H I'o Till-: 
HHST OI- MV K.No\VI,HD<'.H AND I51-:IJ1-:K 



(Infornianl 




CUUx 3JvJi 



, p 



( \<l(hcss 



lOH^. (h^^x^ : yi 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



ii 



•I,ACK OI-' m-RIAI, OR RKMOVAI. 



DATHof Hi KiAi, or RKMOVAI, 

Q.^^ 2..).. 



rXDHRTAKKR Vj (yvtxhj ^-V UJJvAAi. 



190 



v-c 



IN. B. F.very Item o? Informntlon shouhi be cnrefully Hupplied. AGE «hould be Btntetl 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 homo should be i^iven in every instance. 



wn 



imm 



u ' 



y 



n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IlJO'i 



llegliitei'ed J\'*o. 



2751 



i i 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Wcatb 

{ U. 5. StanDarD ) 



l*rO» 



PLACE OF DEATH: — County 



(Sa ^ ^ 

ofCl<X'"r^ J A,'OL/^\yC<<w^c^. City of O /C^-^^ J .\XX/>A^o^-<Lac 



' \:- ^-<l 



k^.1.0.. 



St.; 



Dist.; bet. 



and 



) 



/ ir DEATH OCCURsiwAV FROM USUAL RESIDENCE GIVE rACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \ 
V IF DEATH OCCUIiIrED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



(^1 
I 



S J • \ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.t »K 



ra 



o 1 



k} 



IiAl'K nl UIK III 



\ ' . !•; 



.1 



(Month) 



(l)av) 



M.,v!ln 



(Vrar) 



/hiv 



^IN'.l.i: MARKI}-:!) 
\\'II)<»\Vl-;i) OK I)IV< iRCKI) 
'Wiitrin «R'i;il <1* •^ij.'Tiatii'iO 



HlkTlIl',, \C\-. 
(State or Coiititiv^ 



FATlll.R 



JURTIIlM.ArK 

oi" iai'hi:k 

'St:it«' or (."(miitrvi 



MAIKKN NAM1-: 
Ol" MOTHKK 



lUk'inrr.Aci-: 

<>|- MornKR 
(Statf oi i"ountrv> 







\.o. 



<)*.crrA rioN 

h'f'-litrif III Silll / IdlhlMii 



)V,M> ■" M.oilh^ 



1)a\ 



\'\\\\ AMOVK STATKI) I'KKSOXAI, I'AKTUTLARS AKl! TKrK To THK 
nUST OI- MV KNOWI.I'.IX.H AM) lU-I.Il'F 



(Iiif 






f Addrrss 



f 




^•vJuLV^.<xv-a-.._:'WtcL.i- 



MEDICAL CERTIFICATE OF DEATH 
DATl-: ol- I)]-:a TH ,1 \ 



I go 

(Year) 



fMnntlO <I)av) 

1 lII'iKI'HV Ci;RTri-V. That I alttMiik'il iU-ixase<l from 

tr) . 



-190 



\(p 



tliat I last saw h ■ alive on 190 

and that death ocrurrcd, oti the date stated al)()ve, at 0- oO 
■ M. The CAI'SP: ()!• 1)1':ATI1 was as follows: 



DC RATION Years 

CONTRIIUTORV 



Mouths 



Pars 



1)1' RAT ION Years ,}fonths Pays 



(^ ' (w 



(SIGNED ) Lcr\.crYAjt\, 



Hours 

Hours 
M.D. 



)ct 'V 



^ . 



IQO '. (Address) V^YOVPA 



.,J,h 



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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



ri,ACK OF iuriai, or rkmovai. 



DATHof niKiAl. or RKMOVAI, 

. iDct^ .^.1 



(Address 1 XO^ NT%A..^i^Q.A,^ryiL...lj± 



T9O 



N. B.- 



-Kvery item of information should be carefully «upplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home Hhould be feiven in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



B 



f II. a'.'li I \'< 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/ 



)(Ur /'V/r^/, IL'/cLcrW 



Kj 51 



l^O^i 



licgLs/rrcd jYo, 



f^ f O-^ 



,6l.c-^^ 




w Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot Beatb 

{ 'U. 5. 5tnnC>aiC> ; 



PLACE OF DEATH: — County of CI cx.'^^ JAXcrtcuiccCity of CJ/CX/yv o )v<x^vCUi,cc 



N< 



>.Li 



I / IF OtATM 



\ 



a...v St.; 



Dist.; bet. 



and 



/■ IF OtATM OCCUrtS AWAY F R O 1^ USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
\ IF DEATH OCCMRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



.CLVq/a.vL'lj h/uIc! ■ ■ 




-1 



PERSONAL AND STATISTICAL PARTICULARS 






MEDICAL CERTIFICATE OF DEATH 

i> \ Ti'. « )]• Di. \i'n 



1 ' '! Illk 111 



'Month) 






A^n. 



\ 1 . 1-. 



Si 



/',.M 



>iN<.i.i' M\KKn:i) 

wiix i\\ i.:i> t>K i>!\t)kii-:i) 

Wiit'iii sociiil <U>i^Mi:ili«»ii) 



St:it< or roiiiKi V ^ \Q| \ 

. ^ '^ II ; 



NAMr: ni 
lATII I.K 



HIK I'M I'l.Ari-: 
<H I AlllllK 

'*^tat<- ot iNiiiiiIrs ) 



(I);iv» (Vf!trl 



(Mont lit 

1 1I!:KI;HV tl.RTII-V, Tliat I :iltcn(h-.l (k-.^asi-<l from 

I(>n Id up 

tli.tt I last saw li alixion 



atiil that <k'alli < xiii rrc-tl, oii tlu- <lati' statrtl al)Ov<.', at 
U.. M. Thf CAISI-: Ol" Dl'.ATll was as follows: 
(Xc-a^aXji Vj ,CX_N.X >VC'. ..,.|. , . X.l<>v,N^ vVtlw 



-190 






i 

hr RAT ION )V</;-.v 

t( >NTK ir.l"i( )RN' 

DIR ATlo.N 



yO 



Months 



Pavs 



//out 



MAIDi: \ NAMi: , 

01 M()Tin:k ^1 



itik rirPKAn-: 
or Morm-'R 

(Statf ..I I'oiinli \ 



ori'll'ATIoN i>y> 






.sA 




k'ri.h,! Ill S'liii / 1,111, :-,-,i 4 J 



(SIG 



NED ) C<rXfr>vJL>\j O.vh tU.dxlx? 



/hus 



I lours 
M.D. 



Dr:l 3 : 



OJ 



|C)0 



( 



A.l.ltiss) W' 



•'UJ-AVJUV^ 



SPECIAL INFORMATION only for Hospitdls, lnslihirtt)hs, fransipnls, 
or Kecrnt Rrsidcnls. and persons d)in(i <mdy from home. 



1/.. //,'// 



/',.M 



I'll !•: \r.o\-i': sr \ri: n phk^^mnai, i-akihti, aks ak i; ik i i-. r< > rii i-; 
Mi;sr <)!• MS- KN(>\\i,i;i)«",K and i{i-:i,n:i" 



'Iiifoimaiit 






\.1.1p ss 



former or 
Usual Rfsidenrf 

When was disease rnntra( ted, 
If not al plare of deattt ? 



How long at 
Plare of Deatfi ? 



Days 



ri^Cl-: 01 IMKIAI, OK Ki;.M(»\AI, I l)\l'i:ol m in,\l 01 KI'MOVAI, 



1904 



r\.Mi. ss 






N. K. livery item otf Infi.rmntion should be ^iircltutly supplietl. AJIli Hhoultl be Htiiteil liXACTLY. I»JI YSICIAINS Hbould 

state CAlISIi OT DI:A TH in pliiin Icrms. thiit it iiuiy be properly cliiHHiti'ied. The "Special liiVormiition** for p«r- 
Hon« <lyin(^ uwny from homo should be ftiveii in every inHtnnce. 



li'f 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Moar.l of II. ..!th- I* No i '*-^'?*i;^'' HSi I' Co 



Ihdr /•V/rr/.t',ctJc 



i 




^, Deputy Health Officer 



Registered jYo. 



2753 



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



Certificate of 2)eatb 

( "U. S. Stan^ar^ ) 
PLACE OF DEATH: — County of C)<x-va.< 0/vxx/>vi^\ai<:< City of O <Xy^^ J 



oc 



No. Il5 l:x ctIa.C; > 

(\r DEATH OCCUBS 
ir DEATH OCCU 



St.; 



Dist 



.;bct. 7 .tJ 



V 



and 



I 



li. 



\r DEATH OCCUBS AWAV FROM USUAL R E S I D E N C E Gl VE FAC 
RREO IN A HOSPITAL OR INSTITUTION GIVE I 



TS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N •' "X 
TS NAME INSTEAD OF STREET AND NUMBER. • 



FULL NAME 



■w ^- 1 



, .. ..,e 







n V.O. 



PERSONAL AND STATISTICAL PARTICULARS 

1» \ I 1 ' '1 lUlv I'll 



iMinith) 



\« .l''. 






):■,(- 



I»:i\> 



M.,vtli' 



>■« ;it I 



/'.;i 



MEDICAL CERTIFICATE OF DEATH 

DATl-; ol- Dl-'.ATH n'A 



t 



'(ZX^ 



:ic 



IQO \ 
(Day) (Year) 



\Vll>n\VKi> OK ni\ • )Kri:i) 
• Write in social iU>-i}.'iiati<tii) 



HIKTMIM, \*-|", 
( State or roiiiit I \ ' 







O^ 





NAMi: Ml 

lATii j:k 



itiK 111 i'i,A« J-: 
<»i I A rill' K 

( St:il I Ml ('iiiillt I V 



MA 11(1 :n \ami-. 

ni M()Tm:K 



luKrni'i.Aci-: 

•»l MoTHKK 
(Slatf or (Nmiiti vl 



occri'A TION 









(Month) 
I 11I':R I'I'.V CI'RTII'V, That I atUiidcd dcccascil from 

U...ct ' i(/3'' t(t vL'/c^"t 2.% up'i 

that I last saw h L' . alive on W cl ' i<p 

an<l that diath incurred, on the date stati-d ahnvi', at ^ 

ili JS\. Tlie CArSlv (>!• I) I-: AT II was as follows: 

"^ f 



...J..LA_tr>>x.(Xj C'». 



..K.J^ 



V- 



i" 



or RATION 1 )'t'ars 
CON'IRir.rTORV 



Months 



Days 



I 



LIcv.<lI' 



CV.<L^VCOU 



DIRATION 
(SIG 



)\'ars 



Mofitlis 



!^:. :^1 iqo'l (Address) ' ^^ ' 



Paysi 



Hours 

flours 
M.D. 



Ss 



Special information onlv for Hospildls, Instituti^hs, Transients, 
or Recent Residents, and persons dying dway from liome. 



AV>/(^(/ /// S',/)/ /'iiiihni,! 



',■,1 I V O Mnlllll > 



||.l^• 



III I". AU<>V1<: STAIi:!) I'KKSONAI, I'AK rii'|- I.AKS AK 1'. IK \ V. 1< > I'll 1<; 

Mi-isT ni- MS kn()wm;i)C.k AM) in;i,n:i" 



Oiifoiniant O 



\. a, >A 






^ \.).lless 



Former or 
Usual Residence 

Wlien was disease ronlrarfed. 
If not at plare of death ? 



How long at 
Plare of Deatti ? 



Days 



i)\ii;o! Ill KiAi, <jr i<i;m()\ai, 
V. -^ '^i ,90, 



ri.ACK (►!• lUklAI, OK KI:Mo\ VI, 

(A.i.hess ^51 ^Yi\aa.v^^O'>v j^ 



N. B. F.very Item of !nf«»rimillon shoulil be CBrofully Nupplietl. AGIi hHouUI be HtHlcil fiXACTLY. PHY8ICIANK nhould 

state CAlJSn OF DI.ATH in pliiin Icrmtj. that it mny be properly cInMnified. The "Special InformHtlon" for p«r- 
«on« dylnft away from homo Hhould be ftiven in every InBtnnce. 




■Ml 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



..! ll-aUli- »•■ No. ]'■ 'S•*•fl^>^){S:I' t*o 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



r| 



Ihf/i' AV/rr/.i/ctMs^\; 31 



(X^^KXA^ 




Deputy Health Officer 



Registered JSi'^o, 



2754 



DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco 



Certificate of H)eatb 



( 11. S. StanOarD j 



A ^ 



^^ 



PLACE OF DEATH: — County of ^xx/w Xxcx-v^c^c :City ofClcx^-V' J /vo^>vc.oci.a. 



No. 1'^5'i V.' vj ,clVu^.'. ' -..o^ St.; "^ Dist.;bet. '.:.<^J?'. :. .. andOvCCrUj 



/ ir orATM OCCURS AWAY FROM USUAL 
v. ir DCATM OCCURReO IN A HOSPITAL 



RE SIDE NCE GIVE facts called for under special informatio 
OR institution give its name instead of street and number. 



" ) 



FULL NAME 



(O^y-^xJLd 



M 



Q'll^v... 



PERSONAL AND STATISTICAL PARTICULARS 

•"^ (h-L ' ' " 

I' ^ i 1 "I r.iK rii 




a M ' t . 



MEDICAL CERTIFICATE OF DEATH 
DATl-; <)1- DKATH 



QlL 



/ . 



I Motitli > 



\' 'l: 



I 



w'lix »wi:i) OK niN'oKo; I) 

'^^'Iil» in MK-iiil iUsi<.'iiati<iti I 



• Dny) 



M."!''; 



I Ve.-;irl 



/><n. 



itikriii'i. MM-; 

fst.itt or Country^ 



I'ATIIl-k [~ 






Uzt 



A. 4 /QO 

(Day) (Year) 



(MontlO 

I lIIlRI-r.V Cl'RTIFV, That I attcii.lcd .Icccased from 
' Kp to '~~T~r7r::7rrr7TrT:rrTT:: icp 

tliat I last saw li ~ alive (in ~ it)0 

aii<l that (k-atli occurred, on tlie date stated ahove, at 
M. Tile CAlSlv ()!• Dil.rni was as follows: 



-^ k 



HiK riii'i.Ati-; 
<>i" I aiiii:r 

'State i,\ Ci)\\u\] \ ' 



MAII)|;n NAMl' 
Ol- MO'IMII-.R 



I'.iR rniM.Aci'. 
•>i' M(>thi:k 

lSlat»- or Couiili \) 




l) 



I )r RAT ION }\\irs 

CONTRIIUTORV 



Motttha 



Days 



Dl'RATlON 



Years 



•^ 







.^y\rwj vC" Vv V v.^. c- \ .• 



OCCl IATH)N(^ ^ 




^-X- 



dL 



( SIGNED ) LcYcr^vJUv 



Monl/is 




Days 



liJct 



?>C I()o'\ ( 



A . 1 . 1 iTss ) L{fU) >>ji\.o ly .1 u. - 



J lours 

/lours 
M.D. 



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



k'r^idri! Ill Siiit /'i ,nit i.^t'i) C^\> ) >tn ■■ 



M,i,illi^ 



h.i\^ 



\'\\V. AHOVK STA ri:i) rKRSON \I, I'A K IKM' I, \ Ks AKl", PKri': T<> 

Jn;sT oi- Mv KX()wi,i:n(,i-; and iu;i,ii:r 



TIN': 



(Inf 



1)1 



'"^".t N I Vv<i C . \1 \\x.' 



U'l.l 



rts« 







Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



ri^\CK OI" HIKIAI, Ok RKMOVAI 



DATi;of MiKiAl- or KI<:M0VAI, 



U.ct 8. 



\ 



ofeoXcu buy 

(A.l.lifss X\ \J/Ow-v>' m\v .!U3 Li V '^. 



TQO 



N. B. F.very item of information should be cnrefully supplied. AGR should he Rtnted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pliiin terms, that it may he properly classified. The "Special information" for p»p- 
Ron« dyinfl away from home hIiouIiI be (Itiven in every instance. 



^^m 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






,,1 ,,(• II.:i!tli • J- No Is ■^^■^'X^nS^VVo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\^o. 



2755 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( 11. S. StanDarD ) 
PLACE OF DEATH: — County of OCX^A; ^CXyvv.c^.C'City ofC)/<X.^r^ o Jvxx/^-vai^^l a '. 
No. "iOH ^CyV^^OL^.C^.. St.; ^ Dist.;bet. ?^V<'^^ and \A 

/ ir DEATH OCCURS *w*Y FROM USUAL RESIDENCE Givr facts called for under "special information- ^ 
V IF death occurred in a hospital or institution give its name instead of street and number. J 



''\^> 



^'Sp 



FULL NAME 



'j'- . ■ llV VJU^<ilLL^ 



PERSONAL AND STATISTICAL PARTICULARS 



w 



XXa^ 



'l.i 



ii.\ 1 1: (11 r, IK III 



Ai.K. 



! M..ntli> 



) I a I 



l):ivl 



\!,>it/r' 



/ «>. ^.. 

(Vfur) 



Ihns 



^IN'.l.K. M.\KUIi;i) 

\\ IDnWKl) OR nivcmcKi) 

Writ' in soiial <lt>.ii.'ii;it inn ) 



I a ' 



t , 



uiK riipi, \cv. 

I St;itr ui (."(innti \ • 



NAMlv n|. 

I- A'rni'K 



MIKIIll'I.ACK 

<)i iArMi:k 

' St.itt 1)1 Country) 



MAIDl'.N NAMi; 
<)1- MOIUHK 



lUK rni'i.ArK 

iSt;it«' (ir ('oiuitry) 






'\ 



y^:- 



MEDICAL CERTIFICATE OF DEATH 

DATK OH DKATIl 



(Month) 



(Day) 



(Year) 



I JflvKl'iHV Cl'lRTIFY, That I attcn«lcMl deceased from 

— — — 190 to • IQO ~"~ 

tliat I last saw li :" — alive on I'P 

and that diath oeciirrcil, on the date stated above, at 
,^I. The CAl'Sr: OF DlvATII nv^is as follows: 



i 






I) (RATION }'ci7rs 

CONTRIIUTORV 



Mouths 



Days 



I Ion IS 



DC RAT ION 



)'cars 



Mouths 



t(E.U)U 



Days 



Hours 



^ ,-N 



V 



\>p 



Rrf.i<ir(i in Suv l-iaiuisro ) 'rn > s Mniifhs Ihi\.^ 

'VWV. AMOVK. STATl-.I) I'KKSONAI, J' A Kl' ir f LA KS ARl". TKrK TO THK 

iiKsT oi- Mv KNo\vL}:i)c.K AM) m:i.n:i-* 



rVfl.lrc 



i 



JCK/JL\yzx./^rr\JU\^!X^ 



CJ^ 



(Signed) Lc'ut ■ J • '\C). U) iviXou^vd^ M . D. 

ti %.L iqo'' (Address) \.J^^J:.~)\lA:^\JX:Us.j^.. 



C' 



4**^ 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



PLACE OK lURLXLOR KKMoVAI, 

t) 



DA'D:*)!' Ui kiai, or RHMOVAI, 
iQtll> h.\ . TOO". 






IN. B._Kvery item of in?orm„t!on .hould be carefully Hupplicd. 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- 
soni dyinft away from home should be given in every instance. 



li 



a 



■ ;( 



^-' -"' 



-•r 5- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H..:.r.l uf lltiilth- I- No. i«i J"*^»^n8Ll' Cr) 



RCFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 






19 0\ 



Rvgititeved JsCo, 



2756 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^ 



Certificate of H)eatb 

( "CI. S. StanDarO ) 
PLACE OF DEATH: — County ofC<X\\; OA,<x>vc^^co City of (J/CX-^^ >vo^^v^eui.c.o 



No, XL >vcKv oL M.; vlIccI 



St.; 



" Dist.; bet. and 



(ir OCATH OCCUnS IaWAV from USUAL RESIDENCE GIVE facts CALLCD for UNDER "special INFORMATION" N 
IF DEATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME ^^'^ 



It 



-y>/ 



sj 



x<X'>\xlXA^ 




^C^.: 



V^V^1 




PERSONAL AND STATISTICAL PARTICULARS 
SHX v>'> [\ I COl.ok 

1>.\TK OK MIRTH 



lllltti 



A(.K 



S 



) (■(/ » 



(I):iv) 



M,mlhs 



(Vt-ar) 



/'<n 



SlXr. |,|.:, MAKUIKI) 
WllHiWi:!) nK DIVnkfHIl 
tUiittiii scH'ial <l«'^iv'nati<>ii) 



lUk IMIM.ACH 
' State or c"iiiititr>> 



NAMI-; 01 

»"A rnKK 



IHKTHIM.ArH 
0|- I-ArMKK 

lStat«- or fouiitry) 



MAIDKN NAMK 

oi- M(vrni;K 



HIKIIIPI.AiK, 
<>»•■ MOTIIKK 
(Statr or CouJitrv) 






MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 



(Month) (Day) 



(Yt-nr) 



I 1II':KI':BV CI;RTIFV, That I atUMuUMl deccaseil from 

.•...'. I90H to •U'tXi. dS\ \vp\ 

that I last saw h L\).. alive on li'/tAT 3.H n/jH 

and that diatli orcurred, on the date state<l ahove, at 
M. The CAUSR OF DICATII was as follows: 

vXciaXX AjVLlvVv\.^^tu^ 



DT RAT ION Yeats Mont lis S Days Hours 
CONTR I lU'TOR Y L.L?V<rv%.A>iCL M. )l)A.a^.CUv..d^uU.w 



'\ 



Yeats 



Mo tit lis 



/\iys 




J > 



OCCri'ATlON (?JW ■- 

h'rsidrii In Stni /> iini ism — )/<//> "^ l/"/////^ - l>ii\ 



DIRATION - 

{ SIGNED ) VMA^^ \S^<X^Aj 

iLvcl'^l it)o'; (Address) ^O'l J-iC^u Jt 



Hours 
M.D. 



4 

tuiii 



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



^ .L< 



T!1I<: AHOVK STATl-I) I'KKSox \l, I'AKIH t I. \Ks A K J-; rKCH T<) TIM-; 
HKST OI' MY KN«)\\lj;i)«,K AND lUlI.Il'.K 



t Informant 






^ 



Former or \u [\ 

Usual Residence \\\^ \.O^O^^r\.CK. 

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



A J How long at 
Jl Place of Deatli? 



Days 



I'l.ACK OI" HIKIAI, OR RKMOVAI, 
I NDKRTAKl'lR NtVOL 



DATi: of niRiAi. or RKMOVAI, 

0\rvr I 



(Address S "^ \TtW>aXOL^ LL\' 



I90S 



\. 



N. B. F.very item otf int'orniHtion should be cnre?ully Huppliecl. 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. 




Ill 



' 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



■rr -« . V . 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J? i 



11W\ 



J^eo'istered v\''>. 



^T57 



v^^. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



ro 



PLACE OF DEATH: — County of ^CnvlXO; V_^^V.a City of 



txCL V_^^t.' 



Vlllaxt. >•. 



<: 



No. 



St.; 



Dist.; bet. 



and 



»vw.y FROM USUAL RESIDENCE GIVE fact 



/ r CE»TH OCCUKS AVW** FROM U S> U A L « e. O i L/ t .■.%,.- ^ -. 

(, r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 1 



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



V- 



FULL NAME 



\, \ 



v.. ■ .. 



PERSONAL AND STATISTICAL PARTICULARS 



v^V, 



V,\ 



LO. 



1 ■ , 



- i \ « . 1 . 1-. M A k k 1 K I » 

u fi>i lu i:i» OR i»i\"t iR }-:t) 



^ 







Q x >^ci/^ 



IMkTUPKAOK 
' St.itr or C'limitrv 



I \ 11! };k 



HIkTHl'I.ArK 
<" 1 ATIIKR 
" '• or Ci)vnit! V 



I'l MoTHKk 



lllk IHri.ACH 

<>i- Mi>rm:k 

' ^t:i!i 1 .1 (i III lit I \ 






s: 



V^clvYV^^^vd ^ Mj.V^' 




,^'^V<k. 



.l/,,/////^ 



An 



/',M 



ovCIl'ATlON S "■ 

Pr^iifr'f it> S,ni ft (in- i>i'<> ) , iti 

1111, \li.)VKSI\r|-l. CKksONAl, I'XklU ri.\k> AKi; ikl K TO IHF, 

MHST <)1- MV K\*o\Vl.»:i><".K ^^''> HKI.IMI^ 

"" ( 



(IiifoMiiant 




\.lclu-S.H 3v'^l * 1 'h KJt\i ^^ 







' -Vol 



V \J 



V 



MEDICAL CERTIFICATE OF DEATH 

I>\rK OI- lU-ATH 

L ct. -"^^ /^<' 

I !II:R1:1'.V CIIRTIFV. That I .itton.Icl Icvx-.i^Jca U' 111 

• \qo to 'TiK^ 

tliiit I la-t -aw h alivf on l^)0 

ail. I that aoath ncciirrca. on the .late -laid a'^no. at 
M. The CAISI-: Ol" l>i:Aril \>a- a< follns^: 



( 



"^ \_<„L^ ■>> VCr ^ v'^ :\ 



I ir RAT ION )Vj;a- 

CONTRIHITORV 



I )r RAT ION 



Mouths 



Pav 



Hours 



J/Olllf 



/\2\S 



LCL-Cu 



)\\jis .^foiit/is 

(SIGNED) A-^-Ur^.Cl'^ ^ 

SPECIAL INFORMATION onlv lor Hospitals. InslltuUons. Trdnsirnts. 
or Recent Residents, dnd persons d>inq d>»rf> Irom home. 



M.D. 



Former or 
I'sual Residence 

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



HoH long at 
Place of Death 



.. Dd\! 



I'UACK OF lURIAI. *>k kKMo\ AI, 



l)An;.i! lUKIM >>i kllMOXAl, 

Q\^v^ Ji. 190'. 






. .. TT. », ir „hoiilil be stiite.l fiXACTLY. PHYSICIANS «hould 

N. B.— F.very Item ai InformHtJon .houM b. cHretuMy nupphed ^^J* ^^^^^^^^^ ^be "Specl..! lnf«rm«lion" ?or p.r- 

stntc CAUSE or DI: ATM in plnin term., tbat .t may be properly claM.tleu. 
«nn, dyinft away from b«.,.e Hhould be ftiven in every instance. 



ia*r« i^pp> r-^i 



I' B< 



I 



^^w .woLc r-.-Mii>ii.T wiin UINPAOIING INK — THIS IS A PERMANENT RECORD 

Ho;tr<l (.f 11, ;il(h !■• N'o. u ■^'^S^Su^ I'.ScV Co 



7)(ffr Filed 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



3.1 19 0\ 



Registered J\'*o, 



2757 



^-^-A^ A-i/v>u. 



i 

DEPARTflENT hf PUBLIC HEALTB-Cify and County of San Francisco 



Certificate of Beatb 



( Xl. S. StanDarJv ) 
PLACE OF DEATH: — County ofL{mX\,ou L^^Iol, City of 



'TU 



Wo. 



St 



( '^ "o;:^^^?j.^r .-- — t r^^?^?;?^fc^^;^^;i ^tr^ .^ — r ;^;^?r;:^=r ' ) 



FULL NAME 



Dist.; bet. 

S ( 
S I 

1 (^ 



and 



/?) 



-4- 



IA.V... 



s !•: X 



DA TIC <»I' lilKTU 



AC.K 



PERSONAL AND STATISTICAL PARTICULARS 




Ill, 



'Month) 



••\ 



.H 



)'i<n 



1 



1^ 



M.oith; 



•VJEDICAL CERTIFICATE OF DEATH 
DATE OF UKATH 



(Month) 



(Day) 



TQO 
(Year) 



O 



(Vtar) 



Pax 



^IN'<".l,i:. MAkklKI) 

\\n)(>\yi-:i) OK invoRrKi) 

'Write in social (ksi>.Miati()n) 



lUKTMlM.ArK P Opv I 

(Slate or Country) -^ V(J ) [ 



I llHRlvHV CI-:rTIFV, That I atU-tulol .leccaseiffronr 

^90 to ....- : ^ ^, _ 

that I last saw h TT— alive on -rr-rrrTrrrrr- t^ 

and that death occurred, on the date state.l above, at ^ - 
^I. The CAlSlv OI- DIvATlI was as follows: 



NAMK OF 
FATII);r 



lUKTMI'I.ACK 
0|- J-AfllKK 
(Stale or Country) 



maii)):n namh 

Oh MorilKK 



ItlRIFn'I.ACK 
OI- MOTHHR 
(State or Country) 



cJojOu. 




DTRATIOX 
CONTRIIJUTORY 



) I'ars 



Months 



Days 



J /outs 



DI'RATION 



y'ears 



Mo Lit /is 



/>a\'s 



(SIGNED ).AJXfr\/qX 



axk-O-Xax? 



■y-X.Kk. 



^-^^l ic)oH fAd.lress)^^W\iA. 



VJ 



Hours 
M.D. 



«?^^9'fiK"^''Of''^ATION only for Hospital 
or Recent Residents, and persons dying away from home. 



s, Instituiions, 



Iransients, 



Kesidrd ill San I'loii, ism )>,,, 



M.niths 



I hi 



'""r.i^'^^^^.p;^^!^^]^-^- ^-V. TK,K r„ TMH 



Former or 
Usual Residence 

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



How long ?X 
Place of Death ? 



Days 



A,l,lrcss.3v'^T - i^ 



^tlv 4, 



••^CK or lUK^.U, OK KKMOVAI, | .,A|-K of Mr, <,.,... K HMOVAl/ 

Vlfr\/;_A 190'; 



Wu^. 



(Achlrcss.. .111.1 TTUxU^MT^X 




^ UAjO/vi 



.o„. .I„n4 aw., f.„„ h„„.. 'ho,,,.. :.»;.;„ ?„.r.:j tZZ." "■"••""'• T"' ■•«"«"" ■"f<.r,„a.ion" »„. p.,. 



.t 




WHlTt PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lUKirtl iif HiMllli I N.) It T"« -K&^i^ j{& I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)<(fi' FUi'd , 




51 



100 \ 




Registered J\^o, 



•^TSS 



f^ 



DEPARTMENT OF PUBLIC HEALTH-City and Connfy of San Francisco 

Certificate of IDeath 

PLACE OF DEATH: — County ofC'<X/'>\; ^l\CL/>xciA'CC City o{0 /0<J>r^ \) Kjck^y\jci'^<lz<k 
f^. C'l) . \| I LolVm,>5 OlS ^^K\.tcL(. St.; - 



/ IF DtATHloCCURS AWAf FROM USUAL RESIDENCE Gl 
V. IP OCAIH OCCURRED IN A HOSPITAL OR INSTITUTION 



FULL NAME 



Dist.; bet. 



and 



IVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' 




lAL INFORMATION" N 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




PERSONAL AND STATISTICAL PARTICULARS 



KoXi 



)k 



MEDICAL CERTIFICATE OF DEATH 



!>\ri; OF- niKTn 



AC.K 



:t 



Mnllth) 



)■- 



(Day) 



Motilh.s 



(Vear) 



ll^ot 



(Year) 



Afi 



^IN<".I,!-: MARKIKI) 
\VII)()\yi-:i) OK DIVOKCKI) 
•U'littiii s(K-i;tl <U--i<.Miatioii) 



nikTni'i. AOK 

(St:itt' or Couiiti v' 



^■\^!l•: oi 

FATIIKR 



HIKTHI'I.ArK 
<>|- lAIIIKK 
(Statt. or Contitrv' 



MAiniiN NAMI-: 
<>1- MoTHKR 




DATK (»F DKATH 

II 1 a 

___ (Month) (Day) 

^ I lII-:Ri:nV CI-:RTIFV, That I attendd deceased from 

lV'.cL 11 np\ to .i)./t± Ska. 

tliat I last saw h <.- ^ . alive on iL' tJt 5s^ 



190 H 



190 \ 



atid that death occurred, on the date stated al)ove, at S.3>0 
^ ^I- I'l'l^^' Y^(1\ii' ^^'' '^''--^I'J' ^vas as follows: 



^\Jt-L<X/-> v,d. 



DIRATION Years Mouths Days Hours 

CONTRIIU'TOKV LIa!Ll\>c^ 3/cXjL^L.;ChSli 



.^v/A 



Years 




CUuDyOAXX 




niRTiirKAOK 

Ol" MOIUKR 
(Statf or Conntrv) 



\Xj 



Dl'RATION 



(SIG 



Mouths Pavs 



^t :•. : rnn'l ^ Address) ot M)\a.^ 



//ours 

M.D. 



iqo'l ( 



SPECIAL INFORMATION only for Hospitals, InsHtutlons, Transients 
or Recent Residents, and persons dyinq anay from home. ' 



Rfsidfd ill S(i)i /'i aiii isr.) 



) 'rti I < 



'\l.>ntfi> .:K L />tn 



THK AHOVK STATi;i) PKK>>( )\AI, I'A R TlCr l.AKS A K l-) TKIF To 

Hhsr oi.- MY KNo\vi.i:i)<,K AND iu:mi;k 



TDK 



Former or 
Isual Residence 

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




Now long at 
Place of Death? 



Days 






fAd.lre.v 



;1 



^'^'0^0 "*■ BIRIAI, OR RKMOVAI, DAT}- 0} IJtRiAl. or R^MOVAI, 

KDCHL^^Jjx^Ht^i^ I Ay c.t :i) TOO'. 

i-NDHRTAKKR vJ .cMZu^J^c LL^wv<Lt\X<x^kxrw:i 



IN. B.- 



-Every Item of Infonnntion should be carelfully Aupplied. AGE should be stated EXACTLY. PHYSICIANS •hould 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" ?or Dsr- 
fions dyin4 away from home should be ftiven in ©very Instance. 



HggUggi 



u 



H 












ffll'fe't 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Mwiid ,.i' Il.:i!(li \- \o 1- ■J-^'*!^; I>5tl' Co 



190'i 



Deputy Health Officer 



liegiHtered J^''o. 



2759 






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



(Tevtificate of Bcatb 

( "a. S. StanDar^ ) 



PLACE OF DEATH: — County ofUrv-yv Xvo v- ^ v o r City ofc)/CL/>x; J.Va. >vev.c^ - 



^ 



No 



M 




^->A.aVLd..> dbcKLWv.L<x.l St.; Dist.;bct. 



and 



( " °r'D?iTH''orru»*«*/n'' •^''^"-^SUAL RESIDENCE GIVE facts CALLtO rOR under ••sPECAt .NTORMAT.ON ■ \ 
V IF DE^TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 

FULL NAME '.. , . .v.'.... cLcj^c^:^ J ixX^cLco.. M 



V 



^»:\ 



PERSONAL AND STATISTICAL PARTICULARS 
A I COI.OR 




I 



<xXx 



DATi'; oi- 1:1 urn 



AT, Iv 




mI)iui») 



5S 



y,a. 



I 



ll.l 

(I):iv) 



M.,>ifli> 



fV.-ar) 



Di 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATH C\ 

I'd IH 



(McMith) 



190' K 

(I>ay) (Year) 



^IN<". I,K. MARK li;i) 
UIDoWKI) OK I>I\-oK().:i) 
iWiitfin sooial dtsij^Miat i<>ii) 




HIinMM'I.ACH 

' State or t'onnt I \) 



K.) 



-Vv^trVCJLcL 



I 1II-:UI<:HV CI-:RTI1'V, That 1 atUMulcd deceased frnni 

t- ^t ^ 190S to .^^ M. 

lliat I last saw h a. ... alive on ^,ot '• \ 



190 n 



190 



and that death occurred, on the date state<l above, at ^.H 6 
^ M. The CAISIC OI' DI-ATII was as follows: 



J 



^ . 



(XJsSi.!^ 



.ote-....d>w^~.v?r-:^,.^.•.... 



^v(X 



NAM I- oi- 

iAriii;K 



^ 



y 




nik rni'i,.\rK 

OI- I AT I IKK 

'Statr or Ooimtrv 



MAIDKN NAMK 
OI- MOTMKK 






-^ -. 



I )r RATION 3v >Vrf;.y 

C (a>- 'i' k IIU ' T t) R Y cU7L^'|x.<l.^ 



Mouf/is 



Days 



Hours 



•^ 




lilK rillM.ACH 

OI MoTjn:K 

(Sl.itc or CcMiiitrv) 






^ry,^ C>r->xiji..c.lA. 



t >w 



Months 



f)r RATION Vrars 

( Signed )cU A; Loo'>v-<X/C/ 




Davi 



'S 



Hours 



' >' > ri'A rioN 







li).tfc ■ 



A 



I()0 



') (Address) I I 01 U/OUW 



<UvX) |^A.A^ M.D. 



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

Former or 

Usual Residence I H 



M h U.Uv(l1jlN;.J.<piafeo"Veatfi? 



Months 



Dit 



I UK \HovK sTA'n:i) pkksonai, I'ARTim.ARs aki; TKIK To Till- 
iti-.si o|. MY kno\\m;i)<;i.; and ni:Mi:K 



(hi 



f'.iniatit Vw^VCUO ^ 



\(!.!i(-;s 'Si 'JX, 



"^ 



( 1 



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



Days 



I'KACH OI- IH RIAL OK KKMoVAI. I DATi; r,t Mi kiai. „r RKMOVAI. 



a 



% 



X 



'V^V>VOU 



1^ 

INDliK TAKl'K O"- 



T9O i 




cUA.V/oXvv'i ^< M) 



(A.iciifss b^^ vij A..<yt\ycLAwv>-ax>\ 31: 



^ 



N. B. Kvery Item olr iiiformiitlon shoulti be cnreirully supplied. AGK shoiird be stated KX4CTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for D«r- 
son« dyind away *rom home should be Utiven in every instance. 



H 






tt 







VAfmt^t^r- v^ I «»& 



■ to *. » 



£S^ wwr,..!^ r-uMM^iLT wim UINFADING INK — THIS IS A PERMANENT RECORD 



Ihffr Filvd 




K 2) 



J 



IfJO'i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\^o, 






760 



tLcu x.^ .u Deputy Health Officer 

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

Ceitificate of Scatb 

PLACE JDF DEATH; — County of U<X>x; J.Va-^xc^c^City of ^Ic^^^ J/u<X^xcv<Lac 



No. i C) 1 S VD^.c^k 






/ .c nr.. St.; V Dist.; bet.c)olO^\M.>a^^>tr\tl(\nnd \'ty^\;^ 

/ IF DEATH OCCURS AWAY rPOM IIQIIAI D r c i n r- kj <> e- -^ v. v V, iw- ♦ VitllO y, vj I V-A,.Xi 

FULL NAME Axrl^iL\X OaX^ 



f\- 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

C<H,<)R 




'\ 



CV,u< 



i>A ri-: oi- liiKTii 



.Uv^h 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATM .A 



MMiithl 



\< .!•; 



^juo-t. 



H^ 



)V,; 



^IN« .1.1" M \kK 11-: I) 

i\\'l itc ill v,,ci;il il«si>.rt|;iti.)Il) 



IMKTUl'I.AC}-: ,A,,, 
'St.-itr or Coiintryt \|1| 




il);iv) 



M.niil,^ 



\.\JJL^ 



I Villi ) 



(Month) 



(Day) 



(Year) 



1 II HRKIJV Ci- RTIFV, Tl.atJ atton.lol .leccascl from 



C^ 



/',/lA 



I, 






190 H 

190 '; 



WMi-: 111- 
iArni:k 



IUR|-1I1'I,A(K 
•>l J AIHKK 

'*^t,it< Ml i"()\nitrv'l 



<»l MOTHKK 



'■•iR'nri'i.Aci-; 

'St;iti- 1)1 I'oiiiitrv 



OCCrj'ATlON 



/a>o^vl>i\A.o OX\/>'>va>vu 



tliat r last saw h i.>)\ alivt- 011 \J^zX. 
a^ul that (loath orourrcd, on the dato stated above, at H-^jO 
^^ M. The CACSI-: OF I)l.:ATn was as follows: 



4i,:^.■^v 




■-^ 



o 



r 



I) r RATION Years 5, JA;;///;., 

CONTRIIHTORV LJvuOavcc 







-u^. 



'\yri 



,J^ 



>^ 



\) 



/?</ \s 



Kr^idid III Sail I lait.i^in | Q ),,,; 



I)rRATI()N^5^ Years Months 

( SIGNED )l^.tcU^A.c4 ^. La„vv>vxx| m.d. 

T()oM. (A.Mre^v) bob OxA^tliA^ J' 



ii)^* • 



M 



Hours 



It 



nr?^^?'^"-. "^f^^'^'^'^'ON only for Hospitals. Institutions. Transients 
or Recent Residents, and persons dvinq dHdv from fjomp. o">«:nii. 



)/.'///// N 



n,i\ 



'""V;,^'!,?^''^' ^''■^■'■'■'" I'HKSOWl, !>\K Ticri AKS SKI' TKtF To TH 
lll-.sroi- MV K.VmVI.JilX.H AM) in-l.IJF 

Infuiin.itit '^ vj 



Former or 
Usual Residence 



HoH long at 
Place of Deatli ? 



Days 




X.lrlr.-ss I0"l^ U^vUuCLiv at 



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

INDl-KTAKKK ML A/CCla H(?L L(.. 

(Address. 55-^- 'bS^t dvcttOA, rjt 



I90H 



I 



N. B. 



IVaTe^c'rUSE'of dTathV'T^ I"* "''"^^"u' «"Ppr.e.l. AGE nhould be «»ate.l F.XACTLY. PHYSICIANS «hould 
!o^- 1 : ^ .P^'^T" '" '*'"'" *^'''"«' ^''"^ 't •"»> •''^ pr<.„erly cIo«8il?lcd. The •Special Information" for n^L 

««nns dylnft away from home should be ftiven in •very instance. lormai.on Vor p,r- 



JfeM&^>f 



1 1 

• I 



it 



ta> r« ■ 1^ *• 



^,^ v.n..,^ r-i.MiiNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

liisiri] of Uta'Hi »•■ No. i r -^-fi^Sa^^i^. Hv«t I' Co 



1 



.C^tA^C/i 




7.9 6>^ 
Deputy H'aalth Officer 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Begistered JVo, 



S5761 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



"U. S. Stan^nrD ) 






PLACE OF DEATH:-County of d,c^^ i-V^^A^c^^cOty of <3c^^'"J ,^v^^xev<. --c 



(^ 



No. Ill 



(?r,^ 






iii 



3 .- i ^ 

/ .^n~r.Vu o. ^^*' ^ Dist.; bet J:a.A.i/L<r\^ and \^ 



V f 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



si;\ 



n ATI': <'r- imk rn 



coi^ok 



^ 



LLikdj. 




MEDICAL CERTIFICATE OF DEATH 
DATE Ol" I)}-; AT If 



Montht 



(Day I 



AC. I-: 



.'^ 



Oc*» )''(/; 



II 



M.itillis 



11 



(Vt-ar) 



A/ 1. 



ID<1 



(Month) 



^INC.I.K MARKIKI) 

u ii><»\\i:d or Dr\'()Kt};i) 
'\\ rite in sorial dc'^ij.Miation I 



lUkTFIJM.Ai'K 
'^tnli- of c'.MiMtrvl 



i 




uuL 



I \'rii i;k 



MIRTH I'l.ACK 
<>l" l-ATHKR 
•state or Countrv* 






^^ rgo\ 

'nay) (Year) 

J invF<HBV CIvRTlFV, That I atlcukd .Icvascl fron, 

u^t ^'^ T90M to ly.^ .^.'A ,,o^ 

tliMt I last saw h .-...'U alive — ^ ' " ' 



on 



K/D i 



aii.l that (U'ath occurred, .-ii the .late stated above, at 1 

^l^I. The CAlSh: OF DIvATII was as follows: 



G^ 



o-J^,, 



iXRATIOX 



CONTRrm'TORN 

VJAX/0 




MAlDl.X NAMK 
<»1- MOTIIKR 



I'.IRrill'I.ACl-; 
oi" MOTMKR 
(State or c'oniitrv) 





y\jy\xx) 



'^xx/Vva.' 







V^'"fJ''^ '^ ^^^^y Hours 

I -- UioAAyvUi, 

f SIGNED ) ^. Tl\xX.<jLe<iL.-. ^^.D. 

Udj 3G K^'l (Ad.lress) inO M^W^J^Ot. ^5^ 





( 



O 






■^ 

-^ 
^ 



^^ 



oCCri'ATlON 



W 



orfeTe.^^.^e'-n.s'l^^r^oJ^S::?*':', SS. 'iT""''^' '"^"•""-' "-'"''• 



Former or 
Isual Residence 



V, -////< \{ />., 



lihsl 01. M\ K.\<)WIJ:I)C.K AND li!:MI-;F 



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



... Days 



/CX'-tJ.wt) 



'X'l.lnss 5 1ft J.>jLA>4A,t (ji. 



M.ACK OF Hl-RIAI. <.R RKMoVAI. | DATj:of Urui^u or RKMcVAI, 




CL. -VA. 



.VDHRTAKKRU/oXc-rJjl nTUxA^A^VVj ^^ (Jo 






N. K. 



Tt«t7c'MrSE'of dTIthV'7'-' 1' ""'''•;"^ r"'"^"'^''- ^^'•'^ «'^-"'' •»« «»"»-' EXACTLY. PHYSICIANS «houId 
Ho^. dvfnl^ OF DEATH m pl«,„ ermn, that it m,.y be properly cla»«iflcd. The -Special in^'ormation" for p.r- 
8on« dyinft awny from homo should be ftiven in every InHtance. '^ 



iir 



XAil^frtr mi m i i^i ■ \# ittci^i 









?;w 



h ^1# 



r 'M 



....L- rL.«.,^,.T vviin wiNi-AuiNG INK — THIS IS A PERMANENT RECORD 

Hoard of Ilciiltli \' So. k ^-pvS^^^} M&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JsTo, 






DEPARTMENT OF PUBLIC HEALTH-CKy and County of San Francisco 



Certificate of 2>catb 

( 'CI. S. Stan&arC> ) 



PLACE OF DEATH: — County ofOcu^^ J.V(X/>^e^<icoCity of Oa.>x. J/^cx>voUL^ 



Wo. 






3:\S1 ^^4XcV<XY>A^.>xt:o St.; 7 Dist.; l)et.VI,^X^uydU^ Uv^ and Xu,ty>\^ 

f 0"1" OCCURS *WAV TROM USUAL R E S I D E NC E G . VE FACTS CALLED TOR UNDER "SPEC.AL . N TOR MAT.ON^ Jt^ 

V .r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR EeI AN D NUMBER ) 



FULL NAME 



.u 



PERSONAL AND STATISTICAL PARTICULARS 




C'/Cyi\yC\Xt 





DATI-; oi-- lilKfH 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 



(D,€b 




IH 

(Day) 



(Vear) 



AC.K 



Ta 



) '•(/ ) 



M.niths 



15" 



Da 1 ,v 



(Month) (i,j,y) (Year) 

I mnuvnv CliRTir'V, That I attcn.kMl .leccasedlrom 

^<^ ^"^ I90S t0...iL)vcl, 2S.D TCK)M 

that I last saw \\Xhj alive 011 ^' ot 3^S 



190 H 



siN'.I.Iv MAKklKI). 

'Write in Mu-ial (l<>-i>.'!i;ttioii) 




lUkTHIM. \(*K 
'St.iti' or ("oiiiitrv 



NAM1-: ()!• 
FATHKR 



lUK'IMI'I.ACK 
Of lATIIFK 
(Stat<' or Comitrv) 



MAIDl.N NAMl- 
<>1" MoTllKR 



I'.IKTHIM,ACH 
•>»•' MoT|II':K 
(Statf or iNmiitr\ ) 



A/vVvQ^i:L 



I 



CJ Ji;v^»^\.<x/>vu, 



ami that (U-ath <KHurre(l, on the date stated above, at 1 H 
^1 ^I- The^CArSlv OI' DICATII was as follows: 




U /C^VVV\,tt 






DIRATION )W7/.y 
COXTRIP.rTORV 



A/ont/is *i />>rt'i,? 



Hours 



? 



1 



(Signed) \j. Vo J 



Days 



Hours 



'CX/WX.A.A./WV 



^ 



<)CCri'ATl()X(^r\ . A 

A'fMifrif ill Siiv /'i ,111, i\,',> "X^ )'>in ^ 



Wot 'h I n,oS (Ad.lress) ?50S ^IaAA^U Q>I 



M.D. 



i^l 



?''^9'^'- Information only for Hospitals, institutions, Transients 
or Recent Residents, and persons dyinq away from home. 



^/nll///^ 



/>,/ 



"",';,^!!I.*^'^' ^'''^''■'•■l» I'HKSONAI, I'AKTICn.AKS ARK TRIK TO TMK 

in.sroi- Mv k\<)\\ij;i)(;h and in;i.n;F 

frnformruit LJJLv^^ M ll^ CVOUI 



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Days 



Jl 



A<lrlress 5 ^ S I U /CX^CAXX^WaJI/WU) <jt) 



i. 



lMw\CK OK HIRIAI. OR RKMOVAI. DATK of H, kiai, or RFMOV\I 

mt-Dlw-d I ^^^ I ,QoH 



IXDKRTAKKR U/CJU/VvtC N /V/CX/LA/VUJ V. Q 

(A.Mrcss I^XH uJt4y^<t<rk\,..^ 



N. B. F.very item ot Information should be carefully Hupplied. AGE should be ntated KXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for dsp- 
sons dym4 away from home should be ftiven in every instance. 



Ml 



. 



J* 



■^M! 1 liW k 



\A/RITP Dl AINIV lAiinrUI IIIVICArMKl/^ iivii# -v-uie^ le* m w*r- r-tmm n wkt w^ m.M'w M>>^.M.m*« 



• •II ^ri«i«-«h^ii^%4 ii^i\ iiii^^ i*s m i-^r» ivi ^ni '« c I ^ 



Hoaril Mf Hcaltli }-'.Vo. K '5"^3^^r. M&P Co 



REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




2>l 



i^(9H 



Jicgliitered J\^o. 



2763 



u_v.c 




■vu 






l)((fe Ft Jed, 

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

Ccvtifkate of IDcatb 

( tl. S. Staiii>nrJ> ) 



p 



PLACE OF DEATH: — County of OxXoaj o \xxy\..CA^<:.c City of Ocx/ysj ^ 
^No. 3.1)0 Ja-^V?'. St.; ■■ Dist.;bet.<ijUXaKy>^A.e<?\:L'p.and V ' 

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



C„ O 



FULL NAME 




I 



^ 



.'C'l'A^v.. 



'v 



■^'■^■^ (^ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR \ 



^ 



DA ri': oi" lUKi'H A 



I 



Mciiith) 






V. 



AC. H 



HI 



)■.;, 



1/ '/'// 



(Vi-ar) 



/>in. 



MN'.I.K. MAKUIHI). 
\\II)()\yi':i) <»K I)IV()Ri|-:i) 

(Wiitiiii "-ocial (li><i).''iiatii>ii) 



lUKTIIlM.AOH 
(State or Country^ 



FAIHl'R 



mRrill'I.AOK 

'Stale III Coiinti \> 



MAIDI-.N NAMi; 
<»!•• M(tTlIi;K 



HIK lin'I.ACl-: 

OI- Morni:u 

(State or rmititi \ • 




^\J\.^<JLd^ 



.CVQ/\. \V ^ ^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- I)1-;aTII 

(Month) (I>av) 

1 HlvRlvHV ClvRTlI'V. That 1 ..ttiii.U-.l .UivasLMl from 



(Vfar) 



^, 



Utl ?.(. 



that I last saw li •... alive on v^ v.-'v. ^m. ijp 

and that death occurred, on the date stated above, at S o (. 
I '. M. The CAT SI- ( )I-^I )1{ATI f was as follows- 






A 



? 



1)1 RATION }\u7rs 

CONTRIIUTORV 



Months 



Days 



Hour. 



OCCII'AIION 

h'fsiiif.i III Sixv I'l iiih ist-(} ,■l,i^ )tuii 



DC RATION Wars Moni/is Days 

(SIGNED) '']\. V ^ ! ^><JJLo_cLa..\. 

Vi^cl Ow T«>o'i (Ad.lress) Eb^ CJaaAIx^.- "^ t 



Hours 
M.D. 



SPECIAL Information only for Hospitals, Institutions, Transients 
or Retfnt Residents, .inil persons dvin;) .inay from home. ' 



M.' It til.' 



/),n 



rm- \uovi-: sTAri-:n pkrsonai, i'ariuti.ars ari-- trik to tih-- 
iu-;sr (H-- Mv knowm-jx-.h and iu-;mi:j- 



Former or 
Usual Residence 

Wtipn was disease fonfrarted, 
If not at pla( e of death ? 



HoH long at 
Place of Death ? 



• Days 



(In foiniant 



\P ■>\^<^.*^y\^^ U /C-/t \.<3A. • 



'^ 



^ 



\.l.lr<-ss XhO vjA.AA_^k Ot 



I'l.ACl': OI- lURIAI. OR R1-:M(»VAI, 



DATK of liCKiAi. OI K1<;M()V\I 



rNDKRTAKKR 




^. • ^^ 



TQO 






— - -'V ^ <>-vw\A. 

Ad.lress. .. ^b W. V. \j(\\/LA^\w^<r>V jJl 



'^- "• fivery item otf information should be cnreV'iilly supplied. A(JR should he stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in pinin terms, that it may he properly classified. The "Special Information" for per- 
son* dyinft away from home should he feiven in ©very instance. 



[ 



R 



I. 




\ 



Mi 



WW I 1 • I i« r I 



■ ■ » ik B Vi* A 



ii^fc-i vviin cn^rMUiiNU I IN r\ IMI& Ifii A KLRMANENT RECORD 

F'.oMid -if n.'.iltti )■ Si,. \r '^'^'■Sil^^V.ScVCn 



Ihf/r Filed 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



} -St^ .' 



ai 



VJO\ 




c)oiAMJ 



lleglstered JSl^o, 



O 



?64 



DEPARTMENT h\ PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( TO. S. StaiiOar? ) 
PLACE OF DEATH: — County ofC'cL/^rXi ■J>\XX--»vc.<.'^ Ct City of O-CX^v^ J A_<X/>vc..c^<i t 



'No. UlUAl Ur 



V^„ 1 I 
\J^\j\xx v0(M4v\.L0Li St.; 



Dist; bet. 



and 



f " .°/nrl.M^«i^''^r**'' '^"OM USUAL RESIDENCE GIVE tacts called for under •special information- \ 

V IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



(^ 



FULL NAME 




.O.^UJ..^. 



XXAA.K.-. 



1 

I, 



Si.X 



I»AI}-: <)!• lURTH 



PERSONAL AND STATISTICAL PARTICULARS 

[\ I COI,<»R '\ 




L^ 



% 



Uw. Kct_L 



(Month) 



.AC. K 



'\\ 



) V(/ ; .* 



(Dav) 



MnuHf 



\.\v\\x) 



Days 



SIM.I.K. MAURFHI), 
WIDoUHI) OK I)I\'< »R(i:i) 
I Write.- ill social (lcsij.'iia(iuii) 



MIR IHI'1,ACH 
(State or Countrv) 




NAMl" OI 
I-A riD-.R 



\. 






MEDICAL CERTIFICATE OF DEATH 
DATH Ol- DKATIl 

(Month) (i).,y) (Year) 

I HHRIUiV CI':RTn<V, That I atten.k'.l rlcroase.l Yr^r 

.W^nX \:\ 190 4 to . Dt:it 'XSX. 



that I htst saw h '• -> alive 



on 



^■%X. 



.%'\ 



Ic)oS 

190 * 



and tliat death occurred, on the date stated above, at 1 1 
QpM. The CAISP: OI' li^CATlI was as follows: 




S U-<X<LClL-. 



lURTHI'I.At'H 
Ol- I- A I'll HR 

'Statt or roinitrv) 



I 



])!• RATION Years 

CONTRIIU'TORV 



Mouths 



Days 



Hours 



OI-- .MOT UK 



MAII)1-:>J NAMH /V-\ 



^ (i 



DTRATIOX ^ Years Mouths 

(SIGNED) J . VJ\. 



Pays 



niRTHPUACK 
Ol' MOTMKR 
(state or Count 'v) 






OCCUPATION 

Resided III San /'i hin ist-i) \ )'i'iiis 



■j,cl IM. 



T()0 



(Address) UXmNtcQ*. 



Hours 
M.D. 



4xu. 



(^^ku..aL 



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



.1A/;////,v 



Days 



THH AHOV^K STATKD PKRSONAI, PARTHTI, ARS A R I-' TRIK To 
HKST OI- MY KNO\VIJ<;i)C.K AM) IlKMl^F 

(Informant V . Vj . (JVO . UuXAAHj 



1" 1 1 1-; 



Former or / « c- 
Usual Residence V9Ao 

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



LvCtu. 



jl 



How long at 
Place of Death ? 



Days 



PI.ACK OF m-RIAI, OR RKMoVAI. D.AJHuf Hikiai. or RFMOYAI 
INDHRTAKKR ^ ^^./CLc^Tu "^ Ojtjt UyWdlb VC) 



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 "Specinl Information" for Dsr- 
sons dymft away from home should be feiven in every instance. 



\A/Dr 



AIKII \y tMI l^' ■( liikii^aia^sai^ik .Ksa^ 



til 






I' 



«i 



Hi .:i r.! .)f Health I" No i s "J-^-sS^!^^ Hft I' Co 



inid Id M KtHMAINLIN I HLC;ORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafr /v7^v/,ytJ:(rlaA; Si lOO^i 

oa^^cui kjj\>\j Deputy Health Officer 



Registered JSi'^o, 



2^ 



res 



DEPARTMENTlOF PUBLIC HEALTH-Cify and County of San Francisco 



,) 



( No. V^^OJVO.' Vjj cs.hLt > ■,. OHl) (>A/lvvi<X.A:St.: 



% 



Certificate of IDeatb 

( la. S. StaiiDarD J 



PLACE OF DEATH: — County of O.cx^^ J.\.cc-> veuicCity of 0<X^^ J>\xx^ 



V a v^ c, <- 



Dist.; bet. 



IVE FACTS CALLED FOR UNDER "SPECIAL INFORMATIO 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



(IF DEATH OCCURS AVWAV FROM USUAL RESIDENCE Gl 
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION 

FULL NAME lhJ^<Llh.Kj:i.k. dmAjLi.^ .. 



and 



" ) 



PERSONAL AND STATISTICAL PARTICULARS 




s};\ 



DAll". «)I- I'.IK rii 



AC.K 



I 



COI.OR 




1 Month) 



S 



) I'll I 



(I)av) 



.1/../////.. 



^ 



(Vcar) 



/>,n 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII 



iU 



IQO , 

(Year) 



SIN(.I,K. MAKkUMi 

\\ ri)n\\ i.:i) OK ni\< >kii:i) 

tWiitfiii MH'ial (It sivnatioii) 



lUk IHI'LAOK 
(Statf or Countrv* 



FA 11 1 i;r 



lUKTllI'I.AiH 
<»(•• |-ATm:K 

(Stall' or c'oiintrv^ 



MAII)F:\ NAM1-; 

ni- .M()Tni:K 



lURTIIPI.ACK 
OF MoTMIvK 
(Stati- i>r CotitUiv 



1' 






(Month) (l)av) 

I mvUI.IHV CIvRTIl-V. That I attcii.kMl <UHvase<l from 

up ■ to ^.SlL :^H KpH 

that I last saw h ' > ' aUvc on vJ ct.- > ; up . 

atitl tliat (k-ath occurred, on the date statiil above, at S ? (.. 
^^ M. The CAlSlv OF DIvATII was as follows: 







OwOV /oOu V 



"UC 



UI^utaaaIxu Uj. 0/Ofv.^< 



C()NTRnU'T()RYv5r^L<L^: 



"W<OrVA^ 



c'/,', 



DC RATION 
(SIGNED) 



CXA-C4, 



%x. 



(jWt 






}'('<! rs Months 

NL/.cC >-> C^ i<)o''. fA(l.lres^) li 1 ?, ' < v < 




/^rfj'.v % Hours 



M.D. 



SPECIAL Information only for Hospitals, Instifufions, Transifnts 
or Recent Residents, and persons dying away Irom liome. 

former or /^r. 
Usual Residence 0^ <^ 1 



lI 



UVV 



) -■,; 



I M.oitir 



/hi 



Tin-: AIIOVK STATF.I) I'KKSONAI, 1' A KTir r I. \ kS AKi; IKt I" To TUF 
HHST OI- My KNOWIJ.DC.K AM) m-Mi;!- 



(111 forma nt ^ -^\.<XX 



\ . How long at 

^ -' A Plat e of Deatlj ? 

Wl»en was disease contracted, i i \ ■ ^ 

If not at place of deatfi ? VlZ/CX '^'\ il ', 



Days 




't 



pi..u:i! oj- inKni. Ilk ui:miivai, I ii.\Ti;„f in uiai. ..i ki!miiv.\i, 

(Ad.lrrss I I Vl xAXvAi^^CT Y\. ^.3 1 



'^' **• ^'very Item of InformHtlon shouUI be cHretfuliy nupplied. Afifi Hhoiild be Htateci RXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pliiin terms, that it mny be properly classittietl. The "Special Int'ormation" for p«r- 
Ron« dyinft away from home Nhotild be j^iven in every inHtance. 







n 



p 



M 






%At tr% t ^ r* r^ i m m wk.» » \m ■*«■ ^ 



B m B b ^ . 



jlj^l^ w.n.it. i-uAMi^uT wiin uiNrMUliNVi IFMrv — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nJOH 



<x^ru^^ XjLT^u Deputy HeaJth OfTlcer 



Registered jYo, 






?G6 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Vi. S. Stan&at£> ) 



J f\J^j^J~Xy\y-(xXj. 1 



PLACE OF DEATH: — County of U 



K,^. ,'i 



CX/^ V V V.-'- a^ jCX.!... City 



ity of Ua^aOC- 






^Na 



St.; 



Dist.; bet. 



and 



( " r/n^.TM^^i^^^***'' "'"'^ ^®^*'- RESIDENCE GIVE FACTS CALLeo FOR U N DE R "S PtC AL . N TO R M ATIO N • N 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 

FULL NAME UyLuL,J.xi ali.\^<) 



PERSONAL AND STATISTICAL PARTICULARS 



IiVaXA.,, 



\ 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DKATII r\ 



1) A ri" • >l l:iKTM 



\ « ". I-; 



1 Muiitli) 



b 



J V (/ ( 



II);iv) 



V. •>,!/, ^ 






n)Mv) (Year) 



(Month) 
i INvkl-BV CI-KTIF-V, That I attoii.Kd .U-ivascdYnmi 

to 



I90 



T90 



/)ii\ 



^\\<.\.\'.. M.\Ki<i};[) 
wiiMiu I'll) i>K i)i\'()i<ri:i) 

'Write ill "-cH-inl di '.i^'ii;itioii) 



■1 



iJiK rii PI, \c\'. 

'Stiiti- or (."onulry 



NAM!-: or 
i-atmi;r 



Ml Kill i'i,.\(i<: 
<»!•■ I \iiii:k 

(St.lti (II ('oiillt !\- 






tliat I last saw h alive on — '^^^ 

and that (Ualli occurred, 011 the date statid above, at '^ 
M. The CA(SI<: ()l- DI'ATII was as follows: 

.Ly'^'V-i V^V.cL J 







.A^y<i^ 



/"Lo uXx\.<^1j 



I 



^xJULAUL 
( 

OCCIPATION 



DC RAT ION Yiars 

CONTRIIU'TORV 



Mouths 



Hays 



MAII)i;\' NAMl, 

«)|- .M()Tiii;k 



niK THI'LACH 

Ol- mothi:r 

(Sl;itf or foiintrvi 



duration 
(Signed ) 




Years 



(iOfVid 



Mouths /)in"i 
\JVvwo 



Hours 

Hours 
M.D. 



l()o'^ (Address) La 'r..>. -1. 



I 



Special Information only for Hospitals, Instllulions, Transients 
or Retenl Residents, and persons dying away from fiome. 



Tni'; AUovK ST\ ri;i) )'KKso\ai< paktut i.ars aki; ikii- 10 \\\\- 

ni-'.ST op MV KNOW 1.1, DCH AM) MI'.IJl'.l-' 



Former or 
Usual Residence 

When was disease rontrarfed, 
If not at plare of deatfi ? 



HoK long at 
Plare of Deaf li ? 



Days 



' iiiroiiuitiii 



U^V>u^<l.tC' 'J J 



AjCv 



<^Kj 



OP 



Kx.xj3<j\rojK.jL 



.0...' 



IM ACK ()!• HIKIAI. OK Ki;.Mo\AI, 



I)Al>:o! ItrwiAi. or klCMoVAI, 

^- '^^ -i 190 ■•. 



^Addrt-ss kVo LO 'CVCtl^^^A^o.^t^vv .^1 



N. B.- 



-F.very Item of mform.itlon slioulJ Ik- ciireltully HupplJeU. Ai.'B should be Htnted HXACTLY. PHYSICIANS should 
stiite CAUSE Of- DIZATH in plnin terms, thnt it may he properly clHSsiified. The "Speciul Information'* for per- 
son* dyinft away from homo nhoiild be Jiiven in 9\9ry instance. 



I 



;LiitAF7. 



•f 



---f 



f 



II 






laf r« I •■'•^ BK • • . • • . 



v.r,..c r-uMiiNLT wim UINFADING INK — THIS IS A PERMANENT RECORD 

H.>;ir.1 of He, 111, |- Vo. It; ■^^l^^^hSi.l'Ci, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)a/r F/MM^. 




>-^ ^i 190 "i 



Hes^lstered A^o, 



S767 



D 






^Jlh.am.c.er 



DEPARTMENT OF PUBLIC HEALTIWity and County of San Francisco 

Certificate of Beatb 

( XI. S. StanCarO ) 

J? (V ^ ^ 

PLACE OF DEATH: — County ofO,a^^. J,'vaA^C'L<i<:« City ofOc^^x. J n. cu w c va c^ 



(No. 11\ y ^^^^. su 1 Dist., betA..ft.a.tL._'^u and^Jtfr^Ob 

FULL NAME iuA^Cia.. J Cl^tyJLlIXl-,^ 



PERSONAL AND STATISTICAL PARTICULARS 



i)A'i-i-; in- itiKrii 



V-vaJIX 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



ou< 



Ac.i-: 



^ 



(MoiithM 



) I'd I .- 



a 



11 

(l)av) 



M.'uihs 



Ml . 

(Vear) 



(Month) 



50 

(Day) 



(Year) 



Pa y. 



SIN<.I,K. MAKklHI). 

WTDowi:!) OK nrvoRrKi) H 

< Write ill s(K-i;il (ltsi^Mt;iti<iii) 



HiKrm'i.ArK .1 

'State or Conntryi -A 



NAMI-: »)!■ 
FA I" 1 1 );k 



IUKTIIIM,A(K 

IStatr or Coiinti \-1 



MAII)i:\ XAMK 
<)1 MOTHKR 



HiRrm»r,ArK 

OK MOTHHK 
(State or C()niitr\ ) 






I HHRKRV CivRTIFV, That I attende.l <leccasea from 

O u ((V4- .. ^ 



190 

190 H. 



• •^ct 1^] ,90 N to ...iDct -h.b... 

that I last saw hX\; ahvc on iD/^ 5)0 

aud that death occurred, on tlic date stated above, at b 
^ M. The CArSH OI-^ DIvATII was as follows 




DC RATION 




rs 




AV^/(frif ill Sail /'i tiiii i.-'i'o 






CONTRinUTORV J ^^^Jij^VC^s^L.CLhj 

( SIGNED ) .1' 0? . CS .C^c.v.^vJL^^ M.D. 

^ ^^ 190 n (Address) UIC OA^C.i^"U^^; dt 



' I'ii I s O 



„ f ^^'ft*-* "^f ^""^^"T'ON only for Hospitals. Insmufions, Transients 
or Recent Residents, and persons dying anay from home. "-nMcnii, 



Mouth- 



n,i\ 



''""m-Jv)".\^';'!*^>''J-!' i;?''^:^'*^^'' '"AKTI^'I.AKS AKK TKIH TO TIIK 



MKST Ol- MY KNOWIJ-.IX-.K^AM) lU-MliF 



Former or 
I'sual Residence 

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



How long at 
Place of Death? 



Days 



' Iiifoniiant 



c>^VwA./V. cy\j O A^^.V^ >xX.Vy^Wj 



rxddress 



N. B.- 



VJ CkAi/^X^\ 



PI.\CK OF IHRIAI, OK KKMoVAF. I ''VH^of H, k,m. or KFMOVAI, 
--^1.qJL 12^^. I l^-^^V^ I jc)0l^ 






(Ad 



dress IpQs^ \J6 >\^(yCV<i^V'-CUA OtT 



^';rt7c'A7sE OF dTatH^^ !;' '"''''':."^ r"'*""'^^- ^^-^^ •»'^-'^' »»« «^«*-^ exactly. PHY8ICIAIN8 should 

«inl .Ku!i f OF DEATH ,„ pin.n terms, that it m„y be properly cla8Hll?led. The "Special Information" for n^r- 
Rons dymft away from home Hhould be ftiven in .very inHtance. ^ 






!M 



« 



\A/D ITC Dl A I Kl I \/ t*f i-r-LJr ••■^•»>jk*^«»i««, >•.■•« ....> . ^ 









■m '-'« 



niinr<l of irtrillli I- No. \k t^^^s^llSii !>;;; I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da/r F/M,QcL<LjOxj Z\ 



^ 






r . 



IfJOH 



Jieglste/'cd J\^o, 



?68 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of S)eatb 

( "a. S. StanDarD ) 
PLACE OF DEATH:-- County ofO/tx-^A.- J V<x>ves.<j.co City of CJo.^^ J A^cv-^x^ 



r^ 



'No. 



'. Lctu, ^ WuyTvtL^ 




C '•^Ki. C i 



Ty'V^i\.^ru<i,-St.; 



Dist»: bet. 



and 



( " .Vy OCCUR* AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
y V .r DEATH OCci^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E ET A N D N U M B E R ) 



FULL NAME 




.a.q/O.A.;„ J -UVv-u 



ti. 



PERSONAL AND STATISTICAL PARTICULARS 



J 



DATI-: OI- lUKTM 



UU>.t; 



\r,}'. 




b^ );■„.. 



H 
(Dav) 



M.>u(/is 



ign^. 



J - 



(Vtar) 



Da 1 



Srvc-.I.K. MARUIKI) 
\Vri)<>Vy»:i) OK DIVoRi'KI) 

(Uiitt in sorial disiiMiatioii) 



lilKrniM.AOH 
(State or Country^ 







MEDICAL CERTIFICATE OF DEATH 
DATK OK DIvVTH (A 

(Montli) (Day) (Year) 

I IIHRI'HV Cl-:RTn«V, That I atUMKk'd (U'coascl from 

^A^t IS 190 ^ to .Mel k.L ,^ . 

that I last saw h -'.". aHve on Ai' et Xt n^ , 

and that (kalh occurred, on the date state«l alxn-e at ^ 
A.>.-, M. The CAISH OI' DliATII was as follows: 



■1 



*-AZVX!^^U. 



NAM I- (H 
FATin:R 



niKTiin.AiK 

OI" lATHKK 

(State or roiiiitrv) 



cL 



i'»'v_C'. 




i 



nr RATION )W;/-.? 

CONTRIIUTTORV 



Yearn 



Mouths \X Days Hours 



MAIDKN NAMl-.A 
OF MOTHHK ( \A 

HIRTm-KACH I 

Ml- MOTIIKK r\ % 

(State or Conntry) U " ,] 

_ C>AjJL<X/> v-d 

:cri'ATioN (j\ 



KoX) 



occ 



DURATION 

(SIGNED) .10. \d. K^^-y-Jba.^ 

L<:t j;: t(»o' . (Ad.iresv;) \\A.■\'^\.:^^\t \.<. 



Motiths Days 



Hours 
M.D. 



?''^9'<iK"^fO'^ "NATION only for Hospifdis, Institutions, Transients 
or Recent Residents, and persons dying away from liome. 



0'V>xiL>CLA^< C 

/\f\llfrif lit SiDI I'l illK i'm-iI 



)•-■,;; < 



."^rmit/i- 



/),n.< 






TM1-: AUOVK STATl-.I) I'KKSOXAI, I'A KTU-f LA KS .XKIC TKl l- To Tin- 

i!i<,sT <>''\-liv kno\\!j;i)(;k ,\Nn mi;i.ii-;k 



Former or 
Usual Residence 

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



How long at 
Plat e of Death ? 



Days 



T90 \ 



^^Qi\D^' *'a "''•^'^^'"'^ KKMOVAI. 1>ATK„} IJrui.Ai. or Kl-MoVAI. 



^' "'~rt'r/clT«rU'p n^ri-'r •^?'*' ^' ^"'•^^'""y «uPPn-l. A<;B should be statc.l EXACTLY. PHYSICIANS •hould 
mate CAUSE OF DEATH ..1 plain terms, that it may be properly classified. The "Special Information" for onr- 
«on« dyinft away from home nhoiild be i^iiven in ovcry instance. 









fti 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PFRMAIMFNT RFrORn 



Jioard of I!i:i)i}i }■ Sn \-^ -S-t^^S^^ nSi 



]• Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



]90\ 



Registei'ed J\^o. 



2769 



DEPARTMENTOF PUBLIC HEALTH-City and County of San Francisco 



Certificate of 3>eath 



( TH. S. Stan^ar^ ) 



(^ 



PLACE OF DEATH: — County of U<X/>x' J.^.CCA^.rL<l':<..Citv of O/Cu^rv o.>vo^^v/c\^ 




^V,\,7"vli^ LLL ^ > vd\M..tSt;'. 



Dist.; bet. 



and 



\ ( IF DtATH OCCUBS 4WAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
'J \ IF DEATH OCCUrt^ED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



^0.,/yyxiA Uj /cuucL 



PERSONAL AND STATISTICAL PARTICULARS 

si;.\ / \ i^ I COLORE 



% 9 



/iMoiith) 



u.r. 



go 

(Day) (Vtiir) 



\ < . !•; 



b'j. 



) ,,// 



n 



(I)MV 



Months 



(Year) 



/>a 1 ,v 



SINT, I.l-, M\KUIl-:i). 
WIDOW i:i) nl< DIVoRCKI) 

(Wiitfii! sociiil <!< •.ij.^natiuii) 



HiKiiii'i, \ri-; 

'Stiitc or t."i)Mnti \ 



.Ilea 



NX mi: «)|- 
»A riii;R 



^ 






MEDICAL CERTIFICATE OF DEATH 
DATK ()»•' DKATH - Pv 

(Month) 
, I 111<:RJ;1{V CIvRTII'V, That I attended (Icfcascl from 

dxlvt.. 1'., ,90 M to....Q/cl ^^ npH 

that I last saw h - ■ alive oti W,/.1^ Xt Kp 1 

and that death occurred, 011 the <late slated above, at '1 -C. 

yi. The CAISH ()!• Dl-ATII was as follows: 



'J^<UL<\jUL 



^ 'tlx-i. .jfcjLa.^t. 




lUKIIII'LAiH 

<)|- i-Arm;u 

' Stiiti or roniitt \) 



MAIDI.N NAMl-: 

OF Morm-.K 



niK rm'i.Aii-: 
oi- .\iotiii;k 

(St.iti- or roiiiiti \ I 






I 



<XJ\^' 



s^ 



I) I k A ri N ) -rars I .l/<>,j//,s * ' . /)tiys 

CONTRNU'TORV 



Hours 







XA< 



,V'_- 




o^H•^•l•ATIC)N 






DIRATION 

(Signed) 



) Vtf/'.? 



iMoyiths 



Pa vs 



I()0 



■ . ( t 

Address) VA>V.>^\^>Vx() V-V-A 



//ours 
M.D. 



Special Information only lor Hospitals, institutions, Iranslcnts, 
or Rfffnt Residents, and persons dying away from home. 



/\f'Milttt III Siin /'mill lull 



),,n > 



,!/,-/////> 



/',n 



Former or 
Usual Residence 

When Has disease contrarfed, 
If not at plare of death ? 



How lonq at 
Plare of Death ? 



Days 



TMl- AIIOVK STATl'D PKKSONM, PAR P KT I.AKS A K Iv TRIK TO THH 

mcsT oi- \Ly KNo\\i,i;i)<.i.: and i5i:mi:i- 



( \.l(lt. s^ 



01..- 



.\ 



^"YX./iiuA ^o<M.A.>Q^X 



PLACK OI' lUKIAI. OK RHMoVAl. I DATlio) IJi kiai. or Kl-MoVAI. 




N. B.- 



-F.very item of {nformntion should be carefully nupplied. AGE nhoulil be stated EXACTLY. PHY8ICIAIN8 should 
•tote CAUSE OF DEATH In plain terms, that It may he properly classified. The "Special Information" for par- 
dons dyinft away from home Hhould be 4iven in every inHtance. 



ui 



I 

! 






itf' 






I 






WRIT^ PLAINI V \A/ITM lINrAniMr* iMir -ri-iie i 



« w^ • • » ^«t t • w f « 



Mm:!!'! of II. -all}! !•■ Vo. i^ t'-F^i-ar:'^ USiV Co 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Si 



WOH 




Jteg/sfered A^o, 



2770 



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



Certificate of H)eatb 

( "a. S. SUnSar? ) 

4 Q^ 






(^ 



PLACE OF DEATH: — County ofOcvru OA.<x >\ c ^^ '^. City oiO.o--,^ JAxvvvcvo'- 

No. UX\.-»-V<XO\j (fbCHLkCtcLl St.; - Dist.;bet. rrrrr::rr::r::rr^^ and " 

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

FULL NAME JAJLdjiA.cc.K..:i. LU. 



O 




PERSONAL AND STATISTICAL PARTICULARS 



DATl-; <)I lUKTll (TpV n 



Li 






•Montli) 



Ar.K 



bb 



JV, 



1. 



(I)!iV) 



Moiit/is 



/ C l.i 

(Vear) 



Pa vs 



SINC.I.K. MARKIHI), 
WIDOVVKI) «)K I)I\t)I<ri:t) 
(Wiitf in s(K-i;il di si^'iiatioii) 



lUKTMPI.Ai'l-; » 
(State or Coiinti yt | 



.O.rt 



r* 1. 1 » 



UuX>dLlJ(\xv 



i) 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH r\ 

Uci ?>c. 

(Day) 



(Month) 



igo 

(Year) 



.<) 



I lilvRlUiV CivRTlFV, That I attciidcMl deceased from 

^■•^^ ^ 190H to .. .lD.dLj :i.Ci 100 '; 

that I last saw h - ' alive 011 ' 1'.. joq 

and that death occurred, 011 the date stated alxn-e, at ^ 

U^ M The CAl'Slv OF Dl'iATII was as folUnvs : 




NX Ml-: OF- 

j-A'riii:K 



luk inn.ArK 

<)|- lATMKK 
(State or Countryi 



maipi:n namj; 
ni- .M<)Tni;K 



lUKTHI'I.Al'K 
Ol' MoTMHK 
(State or Conntrj') 



OCCUPATION 

h'rsiiird III SiiH /'iihiiimii 



.•y 



1)1 RATION Years 

CONTRIIU'TORV 



Mouths 



/hjvs 



Hours 



^'^ 




nr RATION' 
(Signed) 

iy.^...';i..o TOO 




Years .^foni/is 

J. ,()b(y iv.r..^. 



/)avs 



( 



Address) 



% 



Hours 
M.D. 



-fiXA^kA^jLoo. ()x) (Vi.Vv,Lta.i. 



y,ais 



yr,<niji^ 



1\; 



Special information only for Hospitals, Institudons, Transients, 
or Recent Residents, and persons (jylng away from fjome. 



Former or 
Usual 



Residence '^*-^ \ 



ffoH long at 
Place of Deatli ? 



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



Days 






u.l.l 



less 



INDHRTAKKK OlO • \| WxXyTXJ^^' Lo 

(Address. Rl'^ M /L\.XUU^£l>x...fli* 



^' **• Kvery Item oi? tnformHtion should b.- cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be ppoperly classified. The "Special Information** ?or psr- 
«on« dyinft away from home should be jtiven In svery instance. 



il 



^Jii 













lat r% I 'V fR- r^ • oaaiix •«• (aiBa 



wwmiu r-uMii^iuT wiin <J 1^ h M U I IN <ji I IN 1% THIS 15 A PERMANENT RECORD 



Ito.-ird of Mc.-ilth !■• V... ; - t-y-^y.T^i, y.ft^ ]> c, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/c Filed, 



1 




2)1 lOO'i 



Regi,steic(l J\''o. 



2771 



^\^,^^ (Ljl/\^u Deputy Heaith Officer 



uv-'V v_A«A.A) cvJiL/Xrvi i-^v^p«^*j ■iv/c^ii.ti v^iiiv.^«;;;r 

DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( XI. S. StanSatO ) 
PLACE OF DEATH: — County ofO,OwA\) J'Voyvvc<^&.ct City of Od/vu J,'v<»v>^c^A.tc 




'No. ^5.H LL;cUlI\a^-v«/1-: , St.; X Dist.;bet.OlWk.tt-i.. and 

/■ ir otATH OCCURsJ>W«V moM USUAL RESIDENCE GIVE KCTS C«LLtD TOR UNDER "SPECIAL INFORMATION" \ 
V tr DEATH OCCUlW*CD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



<^A^|\C^\t 



FULL NAME 




SKX 



DATr; (»I HIK TH 



AC. l- 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 





X.^ ) \yO. 



Ijjj 




iMotith) \ fl)av) 



O L )V,;;. 



5 



.1 A '»////.' 



I Vcar) 



/)(/ 1 .s 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DK.^Tli (A 

(Month) (Day) 



/go ', 
(Year) 



SlVdlj-: MAKKIi:i), 
\Vn)0\Vl-:i) OK DIVORCKI) 
• U'ritcin social ilf.ij.-iKitioii 



HIKTHl'I.ACK 
(Stittt- or C«Mintry) 



NAMi: OI- 
J'ATHI'K 



HIK'nil'I.AOK 
(^\^^ lATIlMK 
'Statr or (."oiiiitrv) 



maii)i:n' XAM1-: 

0|- MOTHKK 



HIRTHl'LAlH 
<>1 MorilKK 
(Stall- or i'ouiitrvt 




1 in';kI':HV CI-ikTII-V, That I attended deceasctl from 

190 *" to ••■• .■::rr::7:r.T:7::r7r7ri9o — :- 

that T last saw h.T™ alive on ' :.: ■- ^.q 

and that death occurred, on the date stated above, at 
-. M. The CAUSK UK DI-ATII was as follows: 

L^cuv-cLa-x^^c JO..rAwJLoJCix'L<_.- ) . 







\.<i 



Dr RATION )'i'ars Mouths 

CONTRIlR'TOkV 



Days 



Hours 



i 






Dl'RATION . )>;-5 JA>;/M.9 

( 



Days 




■\\JJj 



V. ^ * V. a.' 



OCCITATION (^^^^ 

f\'fsi(Ifii ill Sail I'l tini istui c/vO )'riiis 



Signed). J, '^) Lp^^"v;v^.uLH. 

U/CAj ^. \ u)0 (Address) bOb 0Avt.O„\^ ^"^ 



Hours 



M.D. 



Special Information only for Hospitals, Insntutlons, Translfnts, 
or Recent Residents, dnd persons dying away from home. 



MoHt/l! 



n.n. 



TMK AHOVK STA'n:i) I'KKSONAI, PA K'ricr I,A RS A K K TKIH TO TMK 

iiivST OI- Mv k.vo\vi.i;i)<;k and iu;i,n-*.F 



(Infonnaiit 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



i\ 




I'LACH OI- BIKFAI, OK K1:mo\AI, 



DATKof lHHiAi. or RKMOVAI, 



IQOi 



ixi)i-:rtakkr 

(Address 




^' ^' Rvepy item of Information should be carefully oupplied. AGB should be stated RXACTLY. PHYSICIANS 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 ftiven in «\9ry instance. 









I 



i 



I 



^ 



r. 



I 



jstr 



\A/DITir Dl /\ I Kl I W Mkii'rt 



.r-« • • ^ k I VV I I 



I • t » • ■» m 



I!.., -in! ,,f !h:iUli-|- N'o. i^ "^^^p^i, U&I'C, 




v^i>irMuii>iu mr\ — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 




IDO'i 



^v>c 




Registered Jfo, 



2772 



■v»' 



Deputy HeaUh Officer 






DEPARTMENT OF PUBLIC HEALTH-Citj and County of San Francisco 



Certificate of Seati? 

( XI. S. StanCarO ) 



\ 



(?^ 



^No 



PLACE OF DEATH:~County ofC),CL>x, J/u ccwcv^ccCity of c3.cu>-v 3.;^>xe^cc 



. mdb \]ju-{ 



St. 



Dist.; bet. 



/" ir DEATfiH OCCURS *w*v FROM USUAL R r c= i n r iM r« r ^.. •^'^^•» '^'^* and 



FULL NAME Llx/V 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 






Dl. 




wL 



vJ X^^rv'A.Oc-^ 



DAT}-: (»r iMurii 



AC, K 



L 



L.. 



I ■ V 



|^^)tllh» 



O T) 



) :,: 



iDav) 



M.nilh^ 



Wa\ ) 



/>(/). 



•VIEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH , A 



(Vi-:tr) 



^iN<". i.i:. M\kKii:F» 

\\II)(»\Vl.;i) OR I)I\«»KiK[) 
(Write ill s<)i-i;il <1< si;..ii;itioii) 



HIKTIU'LAri- 

'Stiitc III (,■( iiiiit I \ ' \ \ \ 



NAM}'! «)!•• 

fathi;r 



LI' K A • 

' I \ '1 



< Month) ,i).,y) 

,, 1 IIHRKHV C1;RTI1^V. Thai I attcu.U.I -ic-ro:,^,! fr..„ 

it)o . to cLaL.ii, 






\ 



1 I 



that I last saw h .. ahvt- on .. .. , ,,q 

atiil that .K-ath occurrcl. ..„ the- .lak- ^tatol al.ovc. at I 
^'^ M. The CAISIC ()1- I)i:,\TII wa. a. follows: 



Dr RATION '; i )Va;-.? b Mouths 
CONTRIHUTORV 



A/1 



'JT 



//t;// 



/'.V 






niRTHIM.ACK 
0|- l-AIUKK 

(Stat I- or Coll lit rv^ 



MAIDI-IV NAMH 
<)I MorHHK 



I'.IK'nil'LAC")-: 
(Slate 111 CouiitrN-) 



OCCII'ATION 



V. 



DIRATIOX Years 

(SIGNED) .^ri, L, .^^vrrV^,^.^-cU 



Mouths Pays 



Hours 
M.D. 



. f P^^'fi*-. "^f°"'^^''"'ON only for Hospitals. Institutions, [ransients 
or Recent Residents, and persons dying anay from home. 'r-nsienrs. 



f\l>illt'd ill Si 



'<! 1/ I'l illh /v<-(> V ' V ' ) •,.,,, , 



U. /////. 



/i. 



THK \HOVKSTATl-:i) I'KKSONXM.AKTiofi.AKs \KI TklK Tm Till- 



(In fni inaiit 



v^VCVaJLu 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



\ii.iii 



(? 



P 



-C 



^^'^^ • .go'. 






'^^ ^' Kvery item of informntion should be cnrefullv mmni:..,! \nt^ u , i^ ^^"""""""""""'"""■■"""^ 

statt CAUSE OP DEATH m pl„m terms, that It may be properly clu«HiVied Th. ..vT • . V^^^^'V^ ^ should 
«on« dyina away from home should he Jiiven in every JnsrHn'c ''"*'*"*'**'- ^^"^ ^'»'^'^'«" l"Vormution" for pT- 



i 









ii^ 



ii 
W " 



If! 

if) 



1 i •1 



ilk 



l«» 






*#^' 



mm vVRi. t PLAmLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



''•"■•'"' ^'^ llc:.!tli 1- N'n. K -^'t^^g^ |)<t 1' Co 



a„. 




fc Vv_^ > , u(>^i. 1 



/,9^;h 



k^^K^A^ UvA/ Deputy Heafth Offii^er 



Jiogisfcrcd v^r;. 



0^^'^«^ 



^ ^ 4 



DEPARTMENT OF PUBLIC IIE ALTH=Cit> and County of San Francisco 

Ccitificate of 3)catb 

( *Cl. S. StanC>arO j 
^l.KCE OF DEATH:-County of dxv^ ivcta^c.,,,cay ofC)<U>^ i .'vcl^xcc^ c. 






^ 



No. i i. '■ ■ 110^ «:, '^ ^^. . i ^, P 

C - „„,„ occu.s .„.v r-o„ USU.L RESIDENCE o,vt JIc'tsV^*- ^^ '^^^ "'X C VOj and ^ / tV.<y. 



k. 



FULL NAME U) 



-V 



r\^ 



r, , 



■^ i: \ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.Ok 



-0. 




c^L.:. 



i>Ari': Of- HiRTii 



Mi.tilhi 



\<.i-: 



\: • 



! 



I ),l V I 



M.Dlt/l^ 



IVt-ai) 



Hay 



tYf.ir) 



^IN'<".I.I-:. M.\KKi|.;i) 

wiix lU I'll OK i)i\t >kri:n 

I \Viit< ill MHi;il <1< si>.-.ii:iti(iii) 



(Sl;it< 1)1 C.iinit I v) 



A 



la'vx^. 



MEDICAL CERTIFICATE OF DEATH 

i).\-n<; oi- i>);ath ,, , 

'Month) f,,.,y) 

I nKKKHV CI-RTIFV. That I altc-n-U-.I .k-x-ascl fn.n. 

^•^^•'- ■" 190^^ to D'^t -a 

tliMt [ last saw h '.. - . alivc" mi iL' ^~ I 6i ,,^ 

aii.l tl.at (Katl. ..rein rc-.l. ,>i, tlir ,latc- stated al..nv. at 
'^n ''''''■ ^"■^'"^'' <>'\'»'-:ATn was as folh.ws 



I(>0 S 






!• ATM j:R 



lUK llin.AfK 

oi" iAiin:u 

' state <)! I'oiiiiti v) 



MAiIn:\ XAMl" 
<»l' MOTIIKK 



lUR'riFF'r.Al H 

<»!• M<)Tin:R 

(Statf t)i I'ouiili \ ) 



'X 111' A TID.N n A^ 




...Ll.^llt.0\.tJ,3 






1 



1)1 RAT ION )Vv^/■.^• 

C<)N'i'RIl{iT()R\- 



Mouth: 



Day 



I lour 



K) ,'Ccuvr' /^ 




L ^vL 



I )r RATION 

(Signed ) 



)Hn s 



k 



4^1 on til} 



Pay 



<^Jt^ 



(X ^ . . .ac 



'^1 



1' 



td 



M.D. 



I()0 



f A.MivsO >'^^5 ■ 1.1 c1 



\i 



vva 



I I -A 



'J . 



t 



h', •:,!,■,! ni S',nt /iiUhi^ro ^( ),,ii 



^,.M.n^i'.ML"^r°"'^^^'0'^ ""'^ '"^ ""^l'^' Insfifufions. Irdnsients 
.{funt ResKJffits, .jnd pfisons dying dWdv frofn home. •«»>«•"|^, 

Oavs 



or 

former or 
Isiidl Residenif 



HoM lonq at 
PlHf e of fleatli ? 



1 A ./////. 



/'./ 



'''n,"T';;^'^i;^^^:,;;'i'i^',;-\?\!'f:'^;;;,:,ii;^''^ --'•"' '^ '■• ">- 



^ 



v\wC 






Wfien was disease (ontratfed, 
If not al plare of deatli ? 



l'I.A(.'i; 01 IM klAI, »»R KI'M(>\\I I i.vif TT ' " 

LI (^^ ^ 



IN 



N. K.- 



^•1)i;ktaki.;r [X lO ^1 (\a>v^l: 



• V ^ .. 



«on, dy.nft aw«y irom home Hhoul.l be ftlvcn in «vry inHtanic. ''"****'*'''*'• ^^"^ ^l**^^'"' Informntion" W p«r- 



iC:^. 



m 



\ii 



it 



nr 



vvn I I 



t r-LAiNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of Hi.ilth ! V,,. .. "^-^tsr^p nScV Cn 



Bate /vAv/, Vltx^-n-vLov 



C\>^-\^CCi 



i 



De 



?»th Offic^er 



REFER TO BACK OF CERTIFICATC FOR INS TRUCTIONS 

Registered J\^(), 









DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



deitificate of ®catb 

( la. S. Stan^ar^ ) 



.-^ 



(?!l^ 



PLACE OF DEATH:-Countyof6a^.i^^.vc^^c^ City of '1o.^ J.Vcv-^xo., 



\ 



FULL NAME 




/o 



AX-'>XAJL ^^^Q/vt 



^ 



«Kx(jn 



PERSONAL AND STATISTICAL PARTICULARS 



1 p y 



\ 



\^\\'V. or- IMKTII 



AC. K 



I 
Mhnthi 



)■- 



i|):iv 



M.nill, 



.01 

<'/i-;iri 



/',7lA 



>^FN«,i,i:. M \Ku n;i). 
\VM)(»u i:i. OK i)iV(>Kti:r) 

( \Vi itf ill v,„ i;,l (l.-i(.-iiatiMii i 



HiK riiri, \ri: 

(Stale M- rMiinti v 



\ 



MEDICAL CERTIFICATE OF DEATH 

D ATK <)}■• I)].; \Tn ; \ 

I IIKRKHV CKRTIFV. That [ aUcn.U-.l .Wc-ascMl fn,„, 
that I last s;iw li .. ali 



(Year) 



I(^0 I 
alive- o„ ' ' ' ^^^ 

■■m.l that .hath ..crurrcl, ,„, the .late s(ak'.i ahnvr. at 10 '60 



-i--^ .M. Ill 



^- \ 




\ 



NAM)' oi 

!• A'lii j:r 



MIR IIIIM. \('K 
<)[■• 1 AI'FIKK 

'Stall (ii (■(iiiiiti \ I 



MAIDI'X X\Ml 
OI .Mt>TIIi;k 



HIK';"!IIM,A()' 

OI" M(>rin:i< 

(Stat<- iir Caiiiitv 







CL. 



1 \ 



I I 

1)1 RATION .. Years 'i Mouths ' /V.v 
C n N TF^ 1 1 '. I • T () R \- \J\\ c -> N . K^jn, . (Jb. 



Iloil) s 



? 



DIRATION 

f Signed ) 



)'i\us '. Mmiths 



%\. ^ ^ 



/',/ls 



Hours 



r')o'' (A(Mrc.ss) ^"1 2. '• 



M.D. 






h'r^iifrd III Suit I'l ,i i 



A 



■ V 



,\t 



?^^9'^^. "^'^O^'^ATION onlv lor ll<.s|,ifdls, Inslitulions FrdnsienK 
or Rnent Residents, and persons dvinii dwdv from home. Tdnsienls, 



1/,./////, 



/■, 1 ■ 



Till- Miovj.; sT\ri:i. i-i.-rs. .\ v i. i^xr i nr: \rs \ri. trii- T( . t.m- 



(^ 



former or 

I'siidl Residence . . 

When wds disease ronfrdcted, 
II no! d( place of death ? 



'XClc ' V 



How Innq af 
f la« e ol Oeath ' 



Odvs 



' In fill 111 lilt 



' \.],h( <s 



(I 



••l^C^Kor M, R.At.oR R,.,M..VAI, | UAT K ..I M. „.,.,„,< K MnV M 



-MXC' 






TOO 



«on. <l3 mft „w«y from homo sl,..ul,l be ftivcn i„ every inslnnle ''"'"*'*"^*'- ^'^^' '*»'>^'-'"' lnVorm..li.,n" for p.r- 



•ifeii 









f'-i 



!;■• 



1^, 



l^i 



I 



1 



I?nMr-| ■ f ]{, 



I- V 






/>^//r /-'//(V/, Y\ 



wRiTE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 



ca^^-v 




1. 



\ 



Den»jtv ^ 



100 \ 
'. I QfTicer 



Q^^ J 

^^^4 



DEPARTMENT OF PUBLIC HEAlTlf-Cify and County of San Francisco 



No. 



Certificate of H>eatb 

( "Q. S. StanDarC^ ) 
PLACE OF DEATH: — County ofOcu^. v \^.\ r . ; . Qty of J-a 

St.; Dist.; bet. V^L^rvC ci.» \.v r ^ 



") '\ 



r '^ 




1 



VCV-vVC 



V 



Ow.r 



( '^ ^'o^^v:^i:--v:^^^.^^^-:^h^^^y^:^ 



and 



.O IN A HOSP,.-AL OR INSTITUTION O.VE lls NAME I^^^T.^n^nr .' " " ^:*^J ^ ^° " "J^ "^ 



^^DcV.v 



->J\ 



FULL NAME 




(0 



INSTEAD OF STREET AND NUMBER. 



' ) 



'A^A^.N^i ^^^Q.Vt 



SI 



PERSONAL AND STATISTICAL PARTICULARS 
■^^'^ (] j COLOR \ 

10' ' 

DATJ- or- llIRTii , 



I 



I ^ 



Mhiith) 



\(.i-: 



siv<-.i.i-: MAKun;i) 

WIDoU i:i) OK DIVoKiKI) 
' Wilt'' ill '-n ial ilrsi;r„;,ti,,„) 



?»0 

(l);iv^ 



Mnufh 



Bl 



» I ;ir 



/'.; 



MEDICAL CERTIFICATE OF DEATH 

DAI'}-: Ol- I)1-,ATH 






(D.tv) 






lUR rm-i, \r»-: 



NAMl oi 

i'ATin:K 



lUK run, \ry 
»>i- lArni-.R 

(St;it( or Couiitrv 



MAII)i:\ N A Mi- 
tt !■ MoTHHK 



iuK'rm'i,.\('i-: 
<>i Morin-:K 

(State i>r (.'oimtt \^ 







? 



1 NKRI^MV CKKTII^V. That ^ aUcM,.K..Mccva.ol fn.,., 
tliat I last saw h alive nn 

I (JO 

-ni.l that .K-ath o<-(inrc.I. on the -late vtatol al-o^. „1 1 ■ ' ^ 
(^O" ^^' ""' ^^^"^'' ^'''' "'■•■^'''" ^^'"^ '-'^ «"oll<'ws: 






Signed ) VJl. o. ' 



Hotit 



s 



//'>;</ \ 



Vlo.. 



u^ 






M.D. 



I()n ^ 



(AM.ltvs.) . \0a U. . V-V.OVV '^t 



orcri'ATiox 



M.'iith^ 



/',,M > 



n f ^^9'fS^. "^r^^'^A''''ON on!v for Hospifdis. Institutions TrdnsipnK 
or Recent Residents, dnd persons dvinq d^av Iroin home. 'rdnsienfs. 

Former or '^^ 

iJsiidl Residence 



lU-.sr Ol- MV KNoWi^i:!),-.!.; aM) Iti-i wv ' "^ ' '• '" ""• 



On foTTii.itit 



When Hds disease confrdcfed, 
If not at place of death ? 



I i\ , - , ', , HoH lonq at 
X.)-^CLCV ^ p|j,eof Death? ^: v 



Ddv 



V'Mu-.s \'X^ ^ vhx-rx.c?- '^ 



t 



iKsr, .^ ' '^'.MON \i- I u\n, of I?. KIM. ,,t ki:m.)\ai. 

rNi)i:KTAKi:K V^<X^JLA.AJ- '^<^ CwaA ' 



Hons clymft away from homo should be ^ivcn in every InsIaJ^ce. * ^^"^ '^''*=*''"' lntorm.,lion" ?or pT- 



. .-..-a. .-t . ' K 






m 



1^ 



■■■ 



lA/ts i-r r- »ni Mini 



v^r^ii^ — .i.iu. i-u«iN'LY Wi I H UNFADING INK 



i 



\ ) v. y> ^ 



100 H 



^-VA^A^ 




-THIS IS A PERMANENT RECORD 

Rg'^ER TO BACK or certificate: for instruc tions 






L\' ■( 



DEPARTMENT OF PUBLIC HEALTII=Cit^ and Countv of San Francisco 



Ceitificatc of Sicatb 

( "U. S. Staiic>nrC> ) 



PLACE OF DEATH:-Coun,y ofCl^.v l^VCV.vCU^cGty of^,CV>v Jxa^ 

No.ia Ja..,^v,c , ' . ^ ■> ^. , (If (% , 

St.: D,st.,bet.aUx(.M^>VH andLlauif. 



Z' ir DTATH OCCURS AWAY FROM USUAL RESIDENCE r.vr T.lVy ^*''* ' ~ " "^ ^^ 'I^Cl V„\-\ 

V .F DEATH OCCURRED ,N A HO^o,..: T^ ..' P.^ _ .^A^ ' ^ ^ '^•^^^ CALLED rQR UNDER ' SPEClJ INFORMATION ' ■ \ 

INSTEAD OF STREET 'iND NUMBER. ) 



«R.O ,N A HOSPITAL OR . N ST .T U tTo N O I V E lil N A M E^ 1^ 



^ 



FULL NAME 



OV ' n 



> ^ 




-to- 



1 



s}:\ 



PERSONAL AND STATISTICAL PARTICULARS 



'lUxl. 



i>A I'j-: <ii niK rn 




U.'i\AjL 



MEDICAL CERTIFICATE OF DEATH 



MmiUIi I 



l» All'! til' I)i:aiii , \ 






V<.ir) 



I)., VI 



\< .!•; 



Li 



):■, 



■i/ / 



1/.. 



u iix •\vj:i» (»i{ r>!V()i'. i:i) 



' '\ r:\\ 



IK 



lUK I'Ml'l, \C\:, 
'St.-lfr .11 I '-miitt \ 



\\M1 (11 



lUKI II IM.ACI-; 

oi- i \i"iii;k 

' St.-iti ..I Oiiunli \ 



M \M»i;\ X WW 



MIK TIII'I, Ml-; 

(St.'itt III Coiiiitt \ 



' »*''"ri' \ I i()\ 



m .... 



'Month) 

' "|.R,.:,;V r,.,UT,Kv. TlK.t lat,.n,...I.l....,.,., ,,.„.. 



\\XX^J 




rs 



tli.it I last saw Ii ali\( mi 

1 1/) 

""«1 tli^'t '1^'atli ...TiiMcl. on lb, ■.1,1,. Stat. •,! aln-w. at 
M. Tlu- C.USI-; (,K I.I. ATI! „.,. a. r,,l|.,sNs: 



•^ ) ' , \ 



IH R \TI()\ 



) 'r(7/s 



JL'. ' ' 



( 



^ONTKiin Tom- V. 






/Av/ 



; V 



'v. 



DI'K.XTION 

(Signed) o 



.,' ; s 



liWt 



'•^1 



» I( 



Uut.- ■ 



,o'( 



A.I.I rrss)U< 



J/."////s 



v.. > t..^. V„ 



/^n 



'V 



//o/n \ 
M.D. 



OJvA..^ tl < 



„r?»^^?"^.^. "^f^^'^'^'TION only lor HnspiMs, lns(i!ii|jons ■Fraiisii-nf. 
or RecenI Residenls, and persons dyini dH^y fro.n hom.-. irrf"si<nfs. 



W. ■>//// ~ 



I'll I \|{()\I- sr \ 1 III ITKs.iNxi I'MMiiTl \I'< M.i- -.•o,-,- •,- " 

Iti:sT..l >IV KX..UI.|.:Im;h \NI) HKUKK '^ '" ' " '' 



nnt'i- mini 



Ll'>'v^Aja i Jux^ol^Wx^v^ 



former or 
Usudl Residence 

When was disease (onlraefed, 
If no( a( plare ol death ? 



HoH lonq al 
PIdre ol Dedlh ? 






Days 



^ 



V r 



I'l.ACKoi. MrRIAI,.,K KKMMVAI, | IMTK.f M,.,.,,- -a KKMoVAi; 



■X~-' ■ ■'" ■■^111, 'F IV K I', 

s Dl- RTA K I.:k Ia . LU VnV'OA.XA.^X 



190 \ 



"n, ,..,,.» „„„, ,,„„ h„„, Should Vrtlvlnln'ev,": in^rrr: " ^ ""'• '''" "''-■■^'"' ""—■"'"•"•• «or p:!-. 



sr vr, 



»'1 



It 



r 

I 



I 



a* 



t#i 



i^ 



-• l; 



^ 



vvn,... PLAllMLYWITH UNFADtNG INK-THIS IS A PER 



MANENT RECORD 







/)(f/r Filed 

i 




I 






"^'^gPt T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

^'^^t Rcgustcred jYo, "^ ^ ^^^ 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=Cify and County «f San Francisco 



Certificate of IDeath 

' 11. S. StanOnrC^ ) 



A 



PLACE OF DEATH:-Cou„ty ofdcc.^ 3a.<x..,c... Cty of Jcv^^ Ixa 



f(t,^ 



-? 



d^ 



No, Uvu^AvioX L' 



.CO./VV 



\ > ' 



I ^ V 



St.j 



Dist.; bet. 



/ ir DEATH OCCURS AWAy FROM USUAL R r <; I nV M r- ir ^^^y 

V - DEATH OCCUBREO.. . HO^S^pyTll: O «^ f N S t' ^JVf O n".'. w^ ". ! l\''J.^ -R^ U.O.P 'SPECA. ..FOP; 



and 



y 



GIVE ITS NAmV . """"^ SPECIAL INFORMATION ■ • \ 

GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



'A 



V V. V, > \ 



J 



sj;\ 



PERSONAL AND STATISTICAL PARTICULARS 




ojU 



" \ 1 !■: < 'f i;ik ri! 



\(.i- 




M..utli) 



1 



M.U.U 



' I);i\) 



.11 I 






{r( 



}■■ 



/>., 



^iN'.i.i" M\kkii:i> 

u n)<i\vi;n ok imvi »kt|-j) 

'^^■"•' 'I' -■> i.il (l<-i).'n;iti..ii) 



Mik i"ni'i,.\n-: 

'Stjitf or (.'oiiiiti v) 



!■ A I ni;k 

nik'nii'i, Acj- 
«>i I \riii:k 

'St.iti ,,\ ruiiiitl \i 




,.„f 



a. 



MEDICAL CERTIFICATE OF DEATH 

i)ATi>; (u- Di'ATn ,r\ 

(Month) ,,),,^., 

^^ I UKRHnV CKKTIFV. Thai I atUn.K.I ,k..va...l in 

tliat I last saw h ' alive on 

.ni.l that .Irath orcnrcl, <.., tlu- -latr statr.l al.ovr. at 
M. Thc^MSI-: (H- l.i:.\TII was ..s lollcw.: 






111 



It/) 



C^v\.^v-vv 



q- U-|vx.s^.^^v 0<-, 



1 






r>^ 




M\ll>i;\ NAMl- 

<»' .Mniin;k 



HikTHIM.AiIv 

<>i' M()i"ni;k 

fSlal. Ml fniintrv) 



/\'f /(//■(/ f II \,: II I I ,1 II , 







CONTRIIilTOkV UwC^Vt^vC, dl . 



//t>i(yi 



( dij 



VXJlX. 



I > I ■ R .\ 'f r () \ 
( Signed ) Iv 

l<)0 



)'<(ll- 



M<^>iths 



Paxi 



'S 



M.D. 



^ 



r 



A.Mivss) ^;;'lVIii ^'. 



or Keren! Residents and persons dving dwdv from home. Tdnsienrs. 

Former or 
Usual Residence' 



m^ aiiu i^rnuiiN a>mg away irom home. 



);■! 



■ill 



Mnllll,-. 



/^■|> 



When was disease ronfrar Jed, 
If not af place of death.' 



hi 



\^' 



Days 



CCi^i 



''''m'sT'o^^l^^^;!^l;'i;;;;;;^.VAl;^^/,;;^ ■- n,,.; | ..^acku. ,.,.<, ^..k k..:MovM. 



flllfnim.lllt 



\.|.|,.ss DlH 




/a. 



M 






l> \ll' ■■• I'.l KM VI .,1 ki:.M(.\- \I, 

TQO . 



"' ""lurJVl'sr of dTvph" •"';''•' "■ """"''"'" "'""■"'"• '''•'• ""■""•' '»' ""•«'" ••XACT..V. |.HV.S1CU>S »h,.„.., 



•'i^^ri 



1 






t a* r« • -iv ^ 



^-^ vwriLs. r-LMirjLY WITH UNFADING INK — THIS IS 



/>/'// r Filed 





lyJO\j 



Deputy Health Officer 



A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTI ONS 

Bogisfcred jYo, 



^^ 4 { 



^^-^n^^M^ 0U6\HJ. i-r^^HMty ncuivH ^^nicef 

DEPARTMENT OF PUBLIC tlEALTH=Cify and County of San Francisco 






Certificate of 2»eatb 

PLACE OF DEATH = -County oA^ K^^^^.^,^^^ of ^.C^^;vcx >vc,..c 



Ne. 



L ^L^^^.'.V^ db^^kdal St.; Disfbet 

1 ( IF DEATH OCCUBsl i»«/.v rn«„ ..o.... _* -L'lSI., OCT. 



/ IF DEATH occurs' AWAV FnOMluSUAL 
V rF DEATH OCCI^j^RED IN A HOSPITAL 



RESIDENCE give fa 

OR INSTITUTION GIVE 

"0 



and 



FULL NAME 




.' Ob €Ln v.nj .. , . 



•'•^^;?fp 



PERSONAL AND STATISTICAL PARTICULARS 



I> \'ri: « M l;iK i ii 



\'.l-. 




M.'fl !; 






MEDICAL CERTIFICATE OF DEATH 



i>\Ti<: «•! i>i:.\'in ,/\ 



(Dav) 






?N 



I 

1 1 



M..,ith. 



lb 



^IN'.I.i: MAkKIl I) 
MIDnWi.;!) OK I)I\(ii' i- () 

' W'f Itr ill s,„-ial rl, >i;'!l,lf.>n I 



1;1K ill I'i. \CV. 
( State f (I T' 111 iiti V ! 



t Ct 



'>f(iiitli) 
I iII-RlU;VCI-RTlFV. Th.t I atU-„.k-.l ilocvMs..! f,.,,,. 



i \ 



!(/) '. 






It/) 



X .L( 



'^ ^ 



NAM I- til 

I" A I' 1 1 Ik 



inkiiti'i. \<i- 

<>'■" I ATlIl-k 

'St. If. . • Cnmt! \ 



MAinilX N \Mj.- 
<U" M<»TlIi;k 



iiikTniM,\(i; 
III Mo'rnirk 

' St, III . ,r ('Miiiiti \ 




C^V'^> • ' .'^ 



lli.il I l;ist s.iw h ■.. alive tin <L' C"t 

.1.1.1 (hat. Ir.itlt.K-cirrc.l. ...i t he .latf .taU-.i al.-.vr. at 'l '-\G 
■ M. ;rhc CAI-SK OF I)1;aT|[ was as foll.iws: 





<»''<"rpAii(i.\ 



% 



e 



vv/d. 



I "1^ ATI ON )-,,;;,. 

(-■ONTRIIirTORV 




Months /hiys 



//(>ll> \ 



Mini //is 







I liUil \ 

M.D. 






I>1 KATION )Vay-,? . 

(Signed ) J VA ()\9 ,;. 

or Recent Residents, and persons dvinq dw,iv from fiome 

Pldtf of nedfti .' 



Sue*,,.Sl'?xcU^^iT^t """'"""-' 



Tin: \u..vK ST \ii;i) ri-kstix \i. r \ kti.-(i. \ks a ki-- Tk i j- r. , im.' 
III. SI .11 ••<v K\()ui,ij)t.K WD Hi-i,n:i- 



'In )'..• juaiit 



CO 1, (lea. 



Wfien was disease rontrarfed, 
If not at plare of deatti ? 



Odvs 



' \'l.ln ss 



N. 




'r\AAx\_ 



'"'''i^P*"^ i"''"!^''"" '^'•""''■^'' I nXTJK.,.- M, ,MM. n, R,.,M,iVM. 

^^''" J^ T90I 



^\-C ^ 












"■"Itni^c'uiSr'oFDTvT^^^^ '"' '""'^u'^ """'*'"''• ^^^ ^'^-'t^' be «tHte.l EXACTLY. PHYSICIANS nhould 






.»a&%. 



ij' 



«■ 





MHI^ 



WRITE PLAINI V lA/iTu 



liKir-Mi>%>Ki.^ 



l!'>:inl ,if n. ■■nil 1-V,,. K t-'^':??^ H^i 1' iV. 



lh(li> Fi/rfL Ml^My^'vvlK.v^, 



r„^M>,u .i>irv~-THIS ISA PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRU 



CTIONS 



lOOH 



Beg/.s/r/'fw/ Ay). 






(k^K.\.\A <:kiviL Deputy Health Officer 

DEPARTMENT i»F PUBLIC HEALTMy and County of San Francisco 

Certificate of IDeatb 






PLACE OF DEATH.-County of^^>.1'.vc..>vc..c.Gty of ^-.v^/vc.vcc. .. 



No, 




\ 



^ ^ 



St.; 



Dist.; bet. 



/ ir DtATH OCCURS AWAY TROM USUAL R F «; I nV M r- c- 

^ - OtATH OCCUR«.0 .r. A HOSPITAL O R fr. SnTU 4 r- -' .'*"!" S*^^^^ ^"^ ^NOrR -SPECA. 



and 



FULL NAME 



GIVr ITS NAME INSTEAD Or STREET AND NUMBER. ) 



) 




OLo^ 



-^lA 



PERSONAL AND STATISTICAL PARTICULARS 

I' \'i i: « »!■ iiiK 111 



1 



MEDICAL CERTIFICATE OF DEATH 

i> A I'l-; Ml- i>i; A I'll ,\ 



Mmil h I 



X ' . 1 . 



I I):i\l 



!/■.;/'//> 






'Mf.titlO 



M;ivt 






/). 



^IN'.I,!-:. MAkKIli. 

umm»\vi-:i> or I)'\(»i.'(i;i) 

' \Vi itc ill s.H'ial di si}.'n,i| i-ni ) 



I ■■* 



iSt;il( or i- 



NAMI-: (II 

iA'im;R 



Mik III I'l, \ii.- 
••' I vrin-k 

' -'t.it. or (iiiiiiti \- 



M \II.i:\ N \M1. 

"I MoTin;k 



iiik ill I'l.Ar I-; 

<'l M«)|-|n.;R 
'St:itc or I'ouull \ 



" ' 1 I'Al I().\ 



V^ 



I in:Ki:i;v ri:KTii-v, ti,;,i i „ii,.,m,.,i ,i,.,,..,.,i ,,.„„ 

that I last saw Ii -. ' alivi-oii ^ ' 

•'""' "'^'' •'^■■''>1' "<v„ric<I. <Mi tlir ,Ialr .latrd al.ovr. at i '.. 
rs ^'- '''''^' ^'\';SI': (M l)i:.\Tli was as follows: 

CL^xci-i VJ. { _,.u'..'. .. , 







^CAw > > 



'1X 



^ 



I 




''/ / / ,///, / , ,, \^ ) ' III • 



r 

'J 



C <).\TRli;rT()k\ U/Cct.; • ■ .. 
•>II<.\Tn).N Yrars ^' M,n,ihs 



fhns 



//i>nt s 



fhn 



'S 




SIGNED )U\>>,.U\ItU la' 



M.D. 



I()0 



(\k ^ , 



I 



f^^^'fi*-. "^f^"'^^"'"'^'^ ""'' '••' HospiWs. Iihliliiiions. rr..nsicn(s 
or Recent Residents, dnd persons <fyjn:| ,m.iy Iron home. 



1 A '/,.///, 



/>,!■ 



Jll.SI (If- M\ K Now 1,1 Df.i; AM) Itlllll' 



' liif'Mi m.iiil 






Former or 
lisiidl Residence 

When Has disease ronfrarted, 
If not d\ pld(eol death? 



HoH lonq at 
Pla<eol Death.' 



f)a>s 



'^^n '■'*-!'' "'■';;'^ ''•""= KKMOVAI. | |.\iTm! It, ,o m .„ kl.M.iN U, 



1 u. 



1 



} 



'%Au Ca^ 



^:> 



INDI'.KTAKIIK 



1 n (0^ Q. (0 



vj- '0. 



I QO 



>X/-y-w(^\.> ''.<. l^ 



r^„ I • i f I ' " *'"''"*• *''"* '* '""> '"^ properly cloHshicd. Tht: •'SpccJul ln>'..rm.,ti<,„" for n-r 

«on, dy.nft awoy from homu Hhould be ^Iven In every ln»t«nce. m..t,<,„ for p,r- 



i 



m 



• ^ I «-« ii^i 1^ va 



li'..!!'! of lUiiIth !•• N'o. !' t-fr-xT!^, p,<;tPC<) 



/>^'/^' /•>■^^'^^ Qlcn^ 



>\AM.>V' ! 



iiNK — THTB IS A PERMANENT RECORD 

"^"^^^ TO BAC K OF CERTtnCATE FOR INSTRU CTIONS 

JtegLstcrcd jYo, 



nJO'i 



2 



--0 \^ *w.\^ \ jUo \.> \.i ■*• 




DEPARTMENT OF PIBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( 11. S. StanOarD ) 
PLACE OF DEATH:-County ofL^I^^^^e.Gty of ^^-v.^c^ 



'No. 



^'" I i ^^ 



V'C^vi o <. 



St.; 



Dist.; bet. 



f ir DfATH OCCURS AWAY^rpoM USUAL R F Q 1 nV M r r ^ 1ST., Det. and 

FULL NAME ta\.l 




-LMvc^ ■ 




i \ 



I' A ri-: (»!• l;ik 111 



A' .!■; 



PERSONAL AND STATISTICAL PARTICULARS 



U}.L^ r 



illct 



iMonth) 



.^a 






.V.-/','//v 



MEDICAL CERTIFICATE OF DEATH 

DA'l'H oi- DlvA'llI ir\ 

•Month) 



M):iv 



(Vt-ai) 



L 



Tiiiri 



/',. 



^'N'l.l. MAKkIi;i) 

WUu .\VI-:i) OK DIVttRi i:i) 

' U'lilc ill .S(ui;,l iI«-:i!.Ml;Uiiill) 



'State r)r (.'imiitrvi 



NAM}.; OI- 
lA'liniK 



IHKTHI'I.ACF 

ni' i-athi:r 

'St;it( or (".iMIltl \ 






' '"^'<'^I5V CHRTIFV. Tha, I aHc-n.U..I .icrcasol fn 

I(lO • to ^ r I , 

that I last saw h -. . alive on VkX- '^ C , '^ 

.in.l tliat (K-atli occurred, on the .jatr statr-l alu.vr. at '^' '* '' 
M. The CAISIC OI- J)!-.\TH was as foljou.: 



>tii 



^'V>sX^v>-wtr^V'^.ytX>vM. ^l^J, ■ 






rv^4/ci 









\Lkry..^^A.^ ^\A\x.',: 



■ • ^^ 



V\-V^LVwA» 



DIRATION }\'ars Mouth, /;„, s 

coNTRinrroRv LLca^^JUl CLlco ; - 



//, 



',7/ \ 



lilRTHIM, ACl-: 
OI" MoTHKR 
(State or t'fuintiv) 



MAii)i:\ NAMi-: ,r\ - a 

'>! MOTIII-R i^- ! y |\ 






DIRATIOX 



(Signed ) 



y'rars 



J/<>/////s 



Oil i,(|. 



/',/! 



-•1 






I()0 



( 



\<l(lr.ss) Ox.\.')>\..a. >v, Jl: ;> v\\xla.(. 



M.D. 



?^^9'^K"^''*^^'^^"'"'ON only lor Hospildls. inslJtutions. Frdnsients 
or Keccnl Residents, and persons d\inq dvvrfv [ro-n home. 



Rr>idr,1 ni Sun /-'niiir i^rn IX C )>,7/^ 



M.n'.th^ 



Ihn^ 



IllvSI (»i- M\ KN. )\VI.i:i)(;i.: AM) |!I{M):i-- 

(Address - " „. 



Usual Residence V^^ QXX\>< ^^ . • , 

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



How long at 
' Pld(f ot Death .' 



Davs 



rXDlCRTAKHR 



TQO i 






IN. B. Hvery item ui i n form Ht ion should be carefully sui 



state CAIISF OP nr-ATH • .• * 'eVuHy supplied. AGB should be stated RXACTLY. PHYSICIANS should 

sonl dvfnA ^^^^^^^ •" "'"■"Jl'''"*' '^«* '* »"«> •- properly classiUMed. The "Special Information" for per- 
sons d>in4 away from home should be ftiven in every instance. 






V 



m 



WRITE PLAINLY WITW 



IIIVICAr\iivi^K •» 



• » • ri 1^ I m VI 



.".'i;tn! ..( n.:;li!i • l' \o. 






I )((!(> FiJrd 








• •^K — THIS rs A PERMANENT RECORD 

REFER TO BACK OF CERTinCATE FOR IN STRUrrmMo 



liegi\slcrc(l A^o, 



27H0 



DEPARTMENT OF PEBLIC HEALTH=Ci(y and County »f San Francisco 



Ccvtificntc of E)catb 

( XX. 5. i5taMc>aiC> ; 



PLACE OF DEATH.— County ofOc^^x. v/v^ >^c4oGtv ofO 



((Jl 



ty of * '<Xjy\j J ,n.^ay-i v t 



<-o. T c 



No. ho U,CXO^ 

e«Vh 



(- .' O..V„ occu-s .... r„o„ USUAL RESIDENCE o,». f^^',1'' ''*'• ^ '^'^^^f^' and iLxtoL X>^« ) 



FULL nameUxU'H.o; 



r ^ I f-n-va.fi 



\ a 







.X. 



^-^ Q^ 



PERSONAL AND STATISTICAL PARTICULARS 



-^ 



r 



A 



COI.ilR 



i>A'! i: t.r- i;iki-n 



A(,i-; 



i I 




/ V" 



1 Nl'iithl 

■^ t,. 



I I):i\' 



^CH 



■^ IN". 1.1" MXKkllD 
UIDoW l-;i> <»U DfVOKt I- F) 

' U'litc ill ^..fi:,! .l.-.i^.,i.iti-ii» 



^^. 



MEDICAL CERTIFICATE OF bEATH 

i>Ari{ oi i.i;ath |'\ 

'^T'"'"'' U.,-.v) 

I lil-KKHV C'hRTlFV, That I aU.n-lol ,Iovas.,l |n„„ 

I'y') " til 

Miat I last saw h alivr (ui 



I</0 



n>o 



aii-i tliat .Katli ..rrurrc-.l. .mi the- .late ^tatr.l al..vr, al 'i.'^Q 
>'• TIx' CAISi; ni^ DK.XTII was as follows- 



Hik riii'i. Al-)-: 

'State .(I I'liiint I \- 



\ \^T1■ (d- 
I A ill IR 



'UK III PI, \(h: 

'»' I \rm>:R 

"-'t.it. ,,1 Cuiilltl \- 



MAMii:\ WMl' 

'H' .M<)i-in-:K 



liN-; TlU'I.A.'l-- 
"I- MnrilKK 

'Slat.- nv l^HIIllt V) 



^ 







I: 



J 



i^- y^^'- ) 



1" KATION }rajs 

C().\ TP. IIUTORN- 



Months 



Ihiy. 



//( 



'///'V 



)x. 



•>»AI TATIO.V 

f^fsifftif in Sdir I'l ,;ii, ;-,-,> 






DrRATloN .^ Years .^ Months /),/,. 

f SIGNED ) UNV(r>\lX; J. ' y^Ln . 



Cu 



<-^ I 



i^ 



Hours 

M.D. 



KjO 



X.l.il-rsx) LftVCAV^\0 V. , \ 



Special Information only for Hospitals, institutiohs'. iNnsifnts 

or Keren! Residents, dnd persons dyintj dH.iv from home. 



I/,..'/// 



ih, 



TlIK \H<.VKS-r\Ti:i) IM.ksowi, l-AkTUri.XkS \k)-TKrj.- T,. nil' 

iti.M <>!• Mv k.\.)\\i.i.ih;j.: AM) i{i:i,ii;i- 



former or 
Isiidl Residenre 

Wfien was dise.ise (onfrdcfed, 
If not d( pldre of dedtfi ? 



How lonq dt 
Pld( e of Dedffi ? 



nd>' 



niif.i-in.iiii 






i> A 11^: .,: la Ki Ai Ml k i;m. )\ \i. 

^*'^<^^"" 1 i9o'1 



I'I,.\C"1': <t|- lUKIAI, Ok kIMi i\ \ I 

r x I ) 1 ■; K T . \ K I-: K '<X/> vL'> ^L>v V J^^ ' ■ 



IN. B. livery item olr i.H'.,rm.,tion nhoulcl b.- cnrciuHy supplied. XCF. should be stated F.XACTl.Y. PHYSICI.ANS should 
«tiite CAIJSI or ni:ATH i.i pinin terms, thnt it mny he pr..perly cinssilfied. The "SpecinI Information" for D«r- 
Ron« clyinii jiwny irom home should be fiiven in every instance. 



11^ 




• til N/i^ri^uii>iV4 iNi\ 



'^"■•■"'-f "■■■''"' '• Vo :- ^4:^^S^tI.^l-(N, 



J)((f(> FiJrd, r 



i 




ii^/9'i 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTfON ft 

Registered A^o. 



2781 



DEPARTMNT OF PUBLIC HEALMy and County of San Francisco 

Certificate of ©eatb 

( "CI. S. Stan^ar^ j 
OF DEATH:-County ofO^^v J.\C^ vxcu^oGty of c).C^'>v i^VCL^vC^^c c 



PLACE 



No. 



\\\^ 



\ 

(■ 




^ V.C. 



St.; 



v^ 



Dist.; bet. 



. ^.d. 



and 



r DtATH OCCURS AWAV FROM USUAL R T <! I r> r M /~ .r A-'l^l** DC I. 



PERSONAL AND STATISTICAL PARTICULAR^ 



FULL NAME wK-^ oU <Xa 




".-C . '^ '' 



si;.\ 




COI.OK \ 



I'ATI-: t)i- j;iu 111 



A(,i-; 



cvU 



\\ 



'M..iith) 



MEDICAL CERTIFICATE OF DEATH 

DAi'K <)i' i)i:.\rii 



^.)ic 



(M.)!ith) 






I'.iV 



» t ;ti 



X\ 



'Day) 

1 IIKkl'MV CIIRTIFV. That I aUc-n.K.1 .Icvasc.l fpuu 

to OXta: ( 



I (/ ) I 



I(>0 i 



tli;it I last saw li 



;ili\c on 



Ullx.wi.;!) Ok DlXMM^Kr) 
■ U'l ilf in MK-ial -It sij,Miati(.n) 



j 



.L'^'\.>( 



lUKTHl'I.ArK />s 

(State or (Muiittv' -A ^ ()i J I j 



IijO 



ami that .Katli ocrurrcl, ..ii the date stated above, at b 



CI 



^:^r. The CAISK OI- I)i:.\Tlf uas as follows: 



i^ 



w\^ V/Ajl^-^voJLc'' 



NAMl- OI- 

iAriii;K 



iHk ^m>I,,\^•F 
<>I i"Arm-:R 

'State Ml ("(nititrvi 




Dr RATION Years 

coNTRinrTokv v ^ . 



Month's X \ Days 



//ours 



MAH)I.;\ NAM). 

OI- MornKR 



i''iR rin-i.Arj.; 
'»!• M«>Tm-;K 

(State or Coniitrvi 







' »*'el I'A Tiox 

Kr^ultd III Wni /'i inh i^m 



\ I 
<XAAX<rV 'y\.C'0.' 



^^R.\TI()^■ 
( SiG 



)'c'ars Months X /)avs 



NED) HC^^^^^^ LL CLCy 



//on 



; s 



I()0 



rX.Mtvss) 'tl?^ I A.(_v 



M.D. 

\ 



r ' ^ 



?''^9'^'- Information nnlv for llospitdls, Insntiitions, rrdnsicnts 
or KecenI Residents, dnd persons djini) .mdv (ro;i) home. 



)■-■ 



''// 



i 



/■ 



""iM^J-r'^w^'iy^ '"'•'• ''^''^^''NAI. I'VKTI*-! I.VKsAK)'. TKIJ-: To -nil. 

Hi'.sroi- MN KNOW ij.;i)<".K A\j) iu:i,m:i- 



Former or 
Usual Residence 

When was disease tonfrarfed, 
It not at place of death ? 



HoH long at 
Place of Death ? 



Davs 



.1. „ts U 




. V . \ 



•>X/CA.XX, 



nUACi: oi lilUIAL Ok kl.Mo'.Al, I).\T|.;o: Hi KIAI. u, kl-Mox XI 



C^L.i \j\.<>-<L, 



(h.cv :, 



IQO 



N. B. Hvery item ni informntion should be cnret'ully supplieil. AGK shrniltl be stilted F.XACTLY. PHYSICIAINS should 
state CAUSE OF DLATH in plnln terms, that it may be properly classilried. The "Special Information" for o.r- 
Rons dyinft away from home should be ^iven in every instance. 



sn 




) 



WRITE PLAINI V iA/i-ri_i 



i 1^ > V- a 



-THu.riU INK — THIS IS A PERMANENT RECORD 




I 



cxCMwU^ ix\Hj Deputy Health Officer 



7,9(9 4 



^EFERTOBACKOFCERTinCATEI FOR INSTRUCTIONS 

Rogisfcrcd A'o, 27S2 



,a 



DEPARTNENT'OF PUBLIC HEALTIKity and County of San Francisco 

Certificate of Death 

' "U. S. 5ta^^nr^ ) 

PLACE OF DEATH = -Co.n.v ofcW'j'^.^^,, cay oi^c.^^ 

o. .llO 



<XvLiVL WO. '• c.. -p.. ^ 1 .Mi ♦ "U 

f .^ or.TH OCCURS .W*v TROM U S U A L R E sTd E N C r . . . . '^^^^ ^^^ ^ ' ^^^^ ^ and ^ » 

^ .^ o... OCCUR.. . . ..3..,.. oR-j-T-forc^.;;-! ^Jii^i - — ? sT%%%TA^rN-r r •■ ) ' 



FULL NAME 



A. C. i 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

! (■<•!. (Ik A 




/> 



"•■k 1 I "I I'.IK Til (V-N 



KtLc 



■^ 



M.iiiiht 



\< .!• 



) . ;. 



I', 



, !/..»/ 7/ 



I '>r;ii ) 



/',/ 



^iN'ij-: M.\Ki<n:i) 

UII><»\\|.:i, OK DIVokv I [) 

'\\ Mt' 111 voriMl il.-.ivii;,|i.,ii) 



I'-lk IHIM. Ai'l-: 
I St.itc or Cuiiilrv* 



(X) 



Hi 



<XV'\.OLcL 



MEDICAL CERTIFICATE OF DEATH 

i> \'\'h: oi i)i:.\Tn 

f Mo II till 

' '"^'<':I'VCHRTIFV. Th.il I at.cM,.I...i .lc.vaM.,I fnu, 
1 90 til 

that I last saw li 



r 
^7 



-f- 



61 

I);iv) 



(Vcai) 



alive on 



•■'•'.I t!ial .Katli ucciirrc.l, .„, the- .latf statt-.l ah.uf. at 
M. Thr CACSK OF I)|.:.\TII ua. as toll.-u.: 



ft/) 



J 



r 

r 



"^ -CV 



I \ III I X 



'UK rill'l. \CF 

•»' I \Tin-K 



M \II)»:\ NAM) 

'" >t'»rMi;k 



Hn< riii'i.Aci-; 
01 M(>Tin.:R 

'^l.lt.' 01 CollIltlNl 



-^ 



i 



) 



WCX.'u-C-\>/^A V r. 



m RATION )V, 

CONTRim TokV 






/V, 



/I V 



Hours 






c 






VUL. 



IXR \'l I<).\ 

( Signed ) 



■J. V n -^ 



Mniiths 



Ih 



/rv 



Hours 
M.D. 



I 



i(j') 



(Address I LC' 



/N 'N 



'•^■< ri'ATiox ^ 

____^ ^V' ^/iA-7 /// s,,„ fi .1 II, i^ni J ' \ )',,,/ 



?^^9'^^. "^'^^"'^'^''■'ON "n!y lorHospitdls, Institutions, frdnsienfs 
or Kecrnt ResitJpnfs. dnd persons d)inq nwdv fro:n homp. 



lA.„///~ 



/' /I 



HI, SI (»i- MS K.N(>ui,i.;i)(,i.; AM) in;i,ii:i. 

4- 



formrr or 
llsu.ll Residenre 

Whrn was disPHsp (onfrartpd, 
If not at pla( p of dPdfli ? 



Ho\> long <it 
Pld«f of Dpdlfi? 



Ddys 



l'I,ACH «)l- ni-KIAl. (M< KK.M..\ \J, | I.\Ti;,,| \u ur^u o, Ri.Mnv \i. 



m)i:ktaki:k LU 



11,0; 1 i I I 



190 



A^'^ 



X.lili.ss 6 >^ 




^' "' Ii«i7Jrirsr'nr m"rV^^^ ''' cnrcfully Hupplicl. A.;i; «h...M be H.ntc.l EXACTLY. PHYSICIANS „honhl 

lr!l, , . i 01 DLAIH !n pl„u, terms, that it m,.y be pr.,„erly cluHHiticil. The "SpeclHl l..i-.,rm„ti,m" for p-r- 
son* clyinft uway from home hHouIcI be ftiven in every inHtiincc. 



wtm 





I 






11* 




.offil 



lAf ft i IP ^ r% I M • B I 



..r-* ...... - r-,.«,„u, wiiM UIMFADING INK — THIS ISA PERMANENT RECORD 



d^tvu Jjwvu Deputy Health Officer 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Bcgi.sfci'cd J\^o. 



O'^Q*: 



783 



vv^^\.A^v-o cna,\Hj 1-ftp-ui.j ncijicii v/iiiuer 

DEPARTMENT OF PUBLIC HEALTII-Ci> and County of San Francisco 



Certificate of Beatb 



J? 



^0 



J? (3^ 



PLACE OF DEATH:-County ofS^^v i..V^>.c...,.Gty of d^>Jkcc. 



'No. 



l'i^lR^LL>v., 



St.; t) Dist.;bet. JCsVa. 



V1^V.<1. c c 



andL'xla 



f iro^.tH occu.s .».. rpoM USUAL RES, DENCE c,v. V}^}^}^^- -'^^'•'\' and L'xl 



\' V. 



FULL NAME 'cx^yiyl 



^ 



n.. 



X.^..'.. , 



PERSONAL AND STATISTICAL PARTICULARS 

'''■•'' "^ - j cor.oR \ 

nAii-; <»!• itiK I'll 



0\< 



' M<itit}i> 



Af.i-: 



bS )v.,,.. 



(Day) 



M'Oitlis 



SINCI.!-:. MAKKII-I) 

\vii)(»\yi:i) im i)iv(>K(j-:i) 

(Wiitr ill s<M-ial i!( si^'iiatii'ii) 



I'.iK I'lii-i, \r »•; 

' St:il<- <>I i'oMIlt I \l 



(VCMI) 



l\l \s 



MEDICAL CERTIFICATE OF DEATH 

^^^""*''' (Day) (v,.,r) 

I ni.:Ki:i>.V CI:rTIFV, That I attemUMl .Iccvascl fn.m 

■ to :; 



• 3 



itp 



A, 



WMI- oi 

I' A in i:k 



liik rni-i, ACK 
OI- iArm.:R 

(State or fount! y) 



MAIl)i:\ NA\J}; -N 
Ol MoTIIJ-iK / 1 ) 



IIIKTMI'UAC]: 
Ol- MoTinvK 
(Slate or l'uuiili.\ I 






i<>o 




L 



\-yA.. 



that I last saw h aHvc on 

and^that .Irath nrriirrcl, on the .lat.- stati-.l al.ovo, at 5" 
M. The- CAISH OF DFATil was as foll.nvs 



r 



S^- 






Months 



■\ ' 



C^ Vl^'Lcv >a.'cL 



DIRATIO.N Yrars 



Day 



//on I V 







CtLOL' 



^\, 







c^ 



I ♦ 




,C CL/>YV> 



/hi\ 



//oUfs 



.^/ont/is 



I«)0 , 



omi' A'l ION p , 

''"'".;.>?!,V^''-*^''"^ ''■'■" '•"-K'^ONAl. 1'\KTI.I I.\Ks \\<V VKVV T. . Tl.r 

jti:sT(»i- Mv K\-()wi,i:i)c,i.; AM) iii:i.ii:f ' 



«rf ^9'^'-. "^f^^^'^'^'T'O'^ ""'> '"^ Hospitals, Instifiitions, [rdnsicnh 
or RtienI Residents, dnd persons dying dwdy fro.Ti home. '^-nsifnts. 



h.:\ 



(Info; iiKiiit 






former or 
I'sudl Residencf 

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



ffoH long at 
Plare of Death ? 



Days 



f X-Mi, 






^IJ^I.ACKOI.- in K,AI...R RKMOVAI. | I.ATK of H, k,.v,. o, KHMcVM 






VAjlAx/vX.^ '^ >\ <\ V,^ > , - 
r.NF.J-.KTAKl-.k 0<UsX-^\X,t MYL0LK,a.,>v<j 



Tf)0 



'A<i<iless 






,■!' 



>l 




f 



,^ 



WRITF PI AINI V %Aii-ri_i 



• •tklr»Jk w^ . m. t .^m. 



• --till \^i^rMUii>iVji IININ 



H''.iu\ ,,} HialHi !•• Vo. I ^ '^•-._"K^]5i,-) li.S: !• C, 



/.V//r /vAv/ 








L, 



7.96/ H 



v.cv'> 




—THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIPICATE FOR IN3 TRUCTIQNf% 

llogistcrcd jYo, 






?84 



vr.Lj^ Deputy 

DEPARTflENT OF PUBLIC HEALMy and County of San Francisco 

Certificate of Death 

( "U. S. Stan^arO ) 
PLACE OF DEATH:-County of C^^ J?..<x,.e..c... Gty of ^.V.v^Aa ,vc..c - 



No.^lU".dJ 



-ca , 



St.; 



(\'(^ 










■i' 



/' ir DCATH OCCURS AW.Y TROM USUAL R E S r D E N C F r . w r r.iti'V 



\ 



FULL NAME 



Dist.;bct/0 JaN.'LA. ',.' and 

AME rNSTEAD OF STRCET AND NUMBER. ) 



K.. 






^1 



:->^ (To 



PERSONAL AND STATISTICAL PARTICULARS 



t'< >I,I)R 



l»A IK OF- ItlKril 



ACI: 



Month I 



) 



I l);i\- 



M.inHn 



Of - 



/>./!, 



<I>:<V> (\V:.r) 



^iN'-i.i:. MAKun:i) 

WIDOW KI) OK I)IVOR*K() 
lUiitriii s.K'i.-il <!( si>rii;iti«)ti ) 



MiK rm-i.ACK 

iStiitf or Coiinti v) 



NAMJ-: oi 

iatmi:k 



MIKTMIM^Ai-H 
<)(■ I" A 11 IKK 

i St,it« or c'oiiiitrv^ 



maii>i:n wmj- 

<)!• MOTMK.K 



HiKTni'r.AiK; 

<>»• MOTMKK 
tSliiti- or Country) 



tK'Cll'ATloX 




\t 



(J 



m 






MEDICAL CERTIFICATE OF DEATH 

DA'IK ni. I)i;aiU 

• - 'h\ 

(Moiiih) 

I HHRHMV Cl-RTIFV, That I attc.McMl .Ic.vaso.l 7ro,„ 

^90 to .— ,^^ 

Uiat r last saw h ^rr- — alive on , ^ 

I ( K ' 

ail. I that .kafh occnrrcl, on \hv .lato statr.l ah..vc. at 
M. The- CAISFv OI' DlvATH was as follows: 



I >r RATI ON }\'ars 

CONTRIlU'I'OkV 



.1/t)f///lS 



/)ays 



I/on 



t s 



Dl ■ RATION 



,'t' 



)'tijrs 



'-^ • 










^^1^ 



M<'>if/is 



/hj\< 



( Signed )i^r • ','' j^, [\; 

^' ' ■ r()o' (A(Mn-.s) Lc\.C>v.'A>L.i , 



//ours 



M.D. 



A'rMifr<f ;/i S,n, /', ,1,1, is.n ^"X.^ )>,,■; v 



?''^9' mK "^f^"'^^"^'0'^ ""'^ '"^ Hospitals. Instifulions, Iransienls 
or Recent Residents, and persons dying away fro.-n fiome. 



M.'otli- 



IK 



I 1 



Tin: AM()VKST\Tl.;i) IKRSONM. 1' \ KTh" C I. \ R s VRJ- TKl K 
MhSI (^|.• MV KNO\Vl,i:i)C.K AM) HKMl-K 



io I'm-; 



(hifoiiii.int 



x^- 



J O-VV o A 



' Xddress 






former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'l^H OK lUKIAI. OR RKMOVAI. I „.vrK of MrH,.,. or KKXK.VAI, 



rxnKRTA K KR M U J ad<ix/vv Vjll^ Ob 

(Address 1 ill OfKA^l.^i. C(5^\ S"^ 






N. B. 



8t 



ivery item olf information should b. carefully supplied. AGE should be stated EXACTLY PHYSICIANS K 1 . 
>tate CAUSE OF DEATH in p,„i„ tcnm«. that it m„y be properly cl»H«i«cd. The 'S.Iciai In^orZt^ m^' Jr p^ 
on. dyinft away from home should be kiven in everi. instnnce. iniormaiion »or p«r- 



^ 

1 




;ir 



III' 



WPITr Dl A I Kl I M lAfi-v. 



Horir.l cf UciUb - \- S 






'^. -...n u,>.^Mmi>IG INK-. THIS IS A PERMANENT RECORD 

A T— "EFER TO BACK or CERTIFICATE rO R INSTRUCTIONS 



Ovcv^ci dJC\y^t. Deputy Health Omcer 



A d. 



Be^i\sirre(l J\^o, 



2785 



^-^v^vvvo 'jv^v\Hr •-''-jjwty ricciiin umcer 

DEPARTflENT OF PUBLIC HEALTH=C,> and County of San Francisco 






^' 



Certificate of IDeatb 

( 11. S. Stnnc>arC> j 

■W-C -v<i r . City of C) KX^v 



PLACE OF DEATH:-Coun,y of6cv.^"Jxc^^^,,„ p,„ ^^S^,,?^ 



1 



CL ">\.<r <.v> r 



n (^ .r DEATH OCCURS aW . V FROM USUAL R E S mV M r r . ^^St.; t)et. ^^^ 



TION' \ 
ER y 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

si;\ , , . 

I'Ai J-; or- I'.ik'ni 



MEDICAL CERTIFICATE OF DEATH 

i> \ TH <)i 1)1 :. veil "^ 



V 



1 



MKltii 



\< .1-: 






1 /-;/;// 



Mouth; 



' / 9( » 

I);iv) iN-.:ni 

I IN;ki;i;V CKRTIFV. Tl,Ht J ,,tU-M.lr,l ,Ir.va...l 
I(>n ' to 

tliMt 1 last saw Ii . 



0\ 



l"III 



I()n 



ali\ I' ( )ii 



^'N< 1.1 M\KkIj:i>, 

\vn>< "Will (»K i»rv()K(ii) 

'Wiit. in -..<i:,' -l.-i-iiatiMui 



iJiK rm-i. \r»-: 

'Stati or r.Miiitt v) 



X \M l- i »!■ 
IN 111 1 K 



nik III I'l, \rii; 
<>i" I ATin-.K 
Siati- iir I'ounli \ 



MMi)i:\ swwryrs 
<'!• M«>riii;K ' ' 1 



^ ^ vaLi 






I(yO 



■in.l Ihat .IcMtli orciirrcl, .mi tlir .latr staU-.l ahovr, at 1 H C 
V, ^'- ''"''^ t\\ISh..()I- hi \TI| u:,- a. tr.I|..us: 




v^' 



I'lK rni'i, Acr: 

"!■ MoTMMk 

'"^tafc .11 Coiiiiti \ 



' " < 11' \ riUN 



^)\JL<k:': 



v'^ <^ 






I M RATION ) ,//. 

C( »\Tlv' ll;i !• iR\ : 



I>"l< \TI<>.\ )V<//-.s- 

( Signed ) 



KjO 



Mouths 



/><M V 



//, 



//; s 



/>, 



/is- 



/fans 
M.D. 



^1 



• 'M" ■ ^ Adilrcss) Vyl \..^ s\. \^. (^ (It ^v 

ECIAL INFORMATION "niv for HMspitdls, Inslitutionv 



SP 

or Recent Residents, dnii persons d)inq dH,)y from fiome. 



ffdnsients, 



A'fy/ffrJ III S,ni I'l, II,, ■•.,■,, 



M..,illi. 



Ihi 



"ni-V-r*y.','"-^Jv^''"'" '•^'-«^'»^AI. l-AKTrcri.AKsAKl-.TKI]-: To THJ- 

lUvM <)j M\ kn()\vi.j;f)c.k AND iii;i,ni. 



former or '( 

Isiial Residence 

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



HoH long at 
Place of Death ? 



Oavs 



'Iiir.ii mnnt 



^ \.|.lr<-.v 



IN. B. Hv 

son 




^^^ 




fi 



3^<^j\\.t^i. 



I'I,ACK Ol' lUKIM, OK K|.;Mo\ \i 



KNTI-; ..; lit i/iA! .,1 UKMov \i 



rof ) 



INI 



)KKTAKKK U oJLt/>vtLX N^ V.<X>V.V-'> V 



fAd.l 



n-ss 



5 an 



51 



U 



■m.L 



<>CL.i-». I -^ , V. 



r''cl'ir«r''nr^nTri^«" "''7''' ''' ^"''«"f"">' ""PPH-t. AGC •houlcl bo Ktntc.I F.XACTLY. PHYSICIANS hHouIcI 
tc ^AUSn OF Dt ATH m pinm terms, thnt it mi,y l.c pr.,„erly cloHHilfled. The "Special ln»or„u,tion" for p«r- 
»» Uyinft away from home Hhoultl be Jliven in every inHtnnce. 




Iii< 




i«« r^ I ^ M. 



wwniit. r-uMiiMLY WITH UNFADING IIMK — 



n.r.iV.]..^ H<:t!th -F \o. !- -5..rsT^„^,.^.,^ 



/>^//^^ /'VAv/, 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'T^ 



\jUv\^. 



190\ 



(y vcvi 




Regi.s(ered J\^o. 



2786 



>M. 



Deputy Heaith Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Death 

( "CI. S. StanDarD ) 



PLACE OF DEATH: -County oiO^x^y^ i^Ux.vc..c< Qty of i<:^^r^o. 



(No. 



\\.Q.\A C O 



.. d t A RcLVmiL' ^<lU„v;i a.l 



St.; - 



Dist.; bet. 



and 



( " -v^^vi:;^ --^^ o^":^%--'/,;•=;r.— :-^-- .%^^;-„r— r ■ ) 



FULL NAME 



^mo,;..Li li 



Ch.a.c; 



PERSONAL AND STATISTICAL PARTICULARS 



DATH KM-- IJIRTll 



COI.OR 




\jJUi 



MEDICAL CERTIFICATE OF DEATH 

DATK (>I- I)i:a111 



iMiiiilh) 



r V: 



AC.K 



) '•</» .V 



(Day 



M.niUis 



' W-ai ) 



/\i 



^Motith) 



5i 

'Dav) 



(Yt-ar) 



I m.KHliV ri;RTlI^V. That I attcKUMl ac.vasv,l fn.m 



^iN<". M-:. MARi<n:i). 

WIIM >\VKI) i»K 1)I\( iRCi:!) 
'Wiitfiti social iKsi>.ri,ati.)ii) 



luurni'i. \i-i-: 

' State <il l,"niillt I \- 



I- A Til i:r 



lUkl'lIlM, AtK 
<>!• lArilKR 

(State or rniinii \-i 



M \II)l-;\ N A Mi- 
ni' MOTIIKR 



HIRIHI'I,Avl-; 
<)1- %!(>ri!J.;R 

'Stale . ii Couiltlx ) 



vl' v.cL^^v'" 



o^>^ycL 




that I last saw h '.'v alive on l!./ ct. 3; f. 

ami that .k-ath Mrcurrcd. n„ the .\aW statr.I aln.vo. at ^ 

LL^M. Tin- CAISI-: 



1(/D 



.a 



!•: C'l- l)i;.\T|l ua^ as follows: 



oi 




1 



'^^'XX/s cL'XK/^^ V 0- 







DC RAT ION )V,//-.v 

CONTRIBUTORY 



Months 



l\}\s 



//ours 



,K. \ v_ 



• I 



,1 , 



)\; 



ot'di'A rioN 

/\l' h/f'f III Sill! / ' i! II, ;\,,l 



1 



1)1 RATION 

iNED)llv.Li 



! I V 



(SIG! 



Months 



/>r/r 



yi 



//om < 
M.D. 



n 



Ucl; ^1 u)r^ r A.i.itvss) dt AJ/lah..^./^ (]C.<s^;vu a. 

f ^?'^'-. "^'^Of^'^^'^'O'^ ""'' '"^ HospiMs, InsJtulions. Irdnsienls 
or Recent Residents, and persons dying ,iwh> iro.n ftoine. 'rdnsienis, 

Former or 
Isual Residence 






)V,,, 



.!/,./////> 



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



Days 



Tin-; AH<)\KsT\Ti;i) i-hrsonm, i- xrtumi. \rs \ki- tri i- t, , v^s- 
iii-sT oi.- Mv kx.)\vi,i:i)(;k AM) miii.iiVk ' 

(Informant H^trK/>A.( VjV^O-O 






1 



^V.O-SL^ 



r \ n 1 






190 






I 



r.-j 



I 



^^1 



ijif ■-* fi^tf" 



i^ .,^,,^ r-..HMNUT wilM UNFADING INK — THIS IS A PERMANENT RECORD 



/)a/r Filed 




^^\kkj^ 




>y \ 1[J0\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Eci^isferod J\^o, 



2787 



'\yu 



"fth Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of BeatI) 

( tl. S. 5tanC>arD ) 
PLACT OF DEATH=-County oA.<x^ i Vo,>vccAcCity of 3-a.>^Ixcv.wcv<.cc 

Ncsoi ''Ja^JJ^ St. <^ n..^..^rn)! I ^\ 'I 






FULL NAMe'JJ 



\l.z.,t\.. 



t 1 



) 




'frCrLv.u crc d. 



SK\ 






DAT]-. Of- lUKTM 



AC.K 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



Ilio^L 






It 



) 



(I):.v) 



.1A'»////A 



rli: 

(Vfiiri 



/hl^ 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DHATII ,i 

1 HKKI^HV CKRTIFV. That I allcMol .Iccvasnl fn,,,, 



I (JO 
(Vt;n) 



1 90' 



tn Aij'ct :6.i 



SIN<.I,i:. MAKKDID 
\\|Do\yi-:i) OK DI\MKiKr) 
' Write ill social ili-<iv'iiatioii) 



MlKTFn'I.AtM-: 

^Stat<' or Coiinti vt 



_P 



NAM}-: ()!■ 
I ATI 11: k 



HrkTiii'i, \ri.; 
Of lAIIIKR 

'St.if <■ or (."oiinti V I 



M\II)|:N XAMi; 
01 .MoTIIliK 



lilKTUI'r.ACl-: 
01 MoTMI'.k 
(State or Coinitrvl 




tliat I last saw h .. alive- mi C. - I ^ : 

and that .U-ath orcurrcl, on tin- .late <;talol ahovr, at ? 
- -M. The CAISI.; 01- m-:.\Tll was as follnws: 



I ) I ■ R A I" ION J 'ears 

coNTkimroRv 



Moftlhs 



Pays 



//ours 



\ 






OCni'ATION „V , 



1 



•C'l V \.\„o 



dtration 
(^ Signed) v 



)'i'iirs 





.^/duIIis 



A-O, 



Days 



//on 



rs 



U)n 



( 



M.D. 



or Recent Residents, and persons dving dwdv fro-n tiome. 



/\fsi(frif III Siiii /'i ,1 ih i',',i 



)>■/ 



Mnllth 



/>,/. 



Former or 
IsudI Residence 

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



tloH loni] at 
Place of Death ? 



Days 



rm; AHOVK Sr \Tin I'KU^OXAI, l'\KTh'tl \kS \i;|- rwij.- r. . riii- I ,,, ,,.., " " 1 . 

nivST ni. MV KN..\VI.I.;I).;k And HKi'iKF '' "" '' '" ""• i.'"^^^- '*' ""^':^'' '"< KKMoVAJ. DVT. ■■ M, .m, ,„ ,<,.;Mnv\I, 



nivST ni- MV KNoWI.IlDC,}.: AM) lui.Il'l 



Ux^VvJL^ 



I NDl-kTAKKk 



.O^K^K)\\j 



J^tv* :jl 




(Address ^Ht Ha^^-4^VX. "ck. 



I 90' I 



"■ "■"r.r/cA^SE'orDnATH"'''"."''' ^" ""■'"'""" """'"•^■'- '*••'• "'■'"■'" '■' """-' EXACTLY. PHYSICIANS .hould 



i 



m> 



I 



lA/RtTr* Dl A I IVI I \/ i««i-«-i 



1 • • v k I *w I I 



i •••»■■•> 



H. .;,!•.! ,,f n,;,iih- !•■ No. :. t-^"'"^:':Si- 



: nSc]' Cn 



n(ffr Filr^l ,\[\js-,^.so^y^^ 




v^.^rMuiiNU inifv — THISTSTA PERMANENT RECORD 

^ RCFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 



2788 



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

Certiticatc of IDeatb 

( 'U. S. StaiiJarO ) 
PLACE OF DEATH: -County ofO^^^, .1 Kcvwcv^c.Gty of Ocu^x, i^^^x^^^c,. 

No. a I ?^^ vf ctvcA St • 1 n' . K. J cuTK . 1 n 



FULL NAME 



e. 



.^.AHXh^ 




(n\-Lu,. 



PERSONAL AND STATISTICAL PARTICULARS 




SJA 



1>AI) . 11 !;1K 111 



A<.i': 



<xXi 



coj,()k\ 



MEDICAL CERTIFICATE OF DEATH 

nATlv «'!• I>i:.\Tll ((\ 



Mr mil) 



bS )•,•.,/. 



•^IN*. ij-:. ^TAl<R ii;r), 

\\II)( i\\i: 1) <>K i»i\-( )R( ).;[) 
• W'l it< i II v,„i,.,; ,|,.si._. ii;iti,,ii ) 



' s!;it< dt (■< III nil \- 1 



N \ Ml- (»| 

I AT in; K 



lUKTII !'l..\»}-: 

<>l I \ 11 IKK 

I state (II t"c III III ! \- 



M \ IDi; \ \ \M| 
••I' MoTlll.K 



HIK'IIII'I, \( i; 
• >i M<>iiii;u 

'Statt i>r rcimiti \ i 



k 




(I);.v) 



M.»:!l,y 



>v^.■,. 



(Vrai 



'Day) IN,.,, 



(Month) 
I IN-kKHV CKkTirV. Thai Iat(c-,„K-.I,U..v:.M..I f. 



^ 



% yx 



/'., 






M;0 t 
tliat r last saw li . ■ -, alive- on 

I (yO 

an.l tliat .kadi . .(•ciirrcMl. ,.i, tin- .lat.- st.,i.-,| ,,!„,vc, at 



M. TIu- C\rsi{ ()|.- I)].;. Mil ,,,. ;,. tollnuv: 



'v > \/ ^.» V c 



':) 






<X 



Iv.. 




"]■ ' 



J 





1)1 RATION );.,;, 

roNTRIlilTom- V 



J/<'/////.^^■ • /></)■ V 



//<>// ><( 



<X^ vd. 



I X ■ R .\ T [ ( ) \ 



) '(ifJ-S 



lO 



.wm. 



(SIGNED) (/(JJiyvWu '^ 



.'A'/////' 



'dlOX/Wvu M^Xi 



-Cr>v. 



f 

\ 






M.D 



nrciJ' \ rioN 



^r 




?^^9'fiK "^'^*^^'^^T"'ON only for Hospitdls. Insfitutions, frdnsipnts 
or Recent Residents, and persons dying away fro.Ti home. 'ransienrs. 



h'f'iiir.l III S.ni /'i ,1 II, I .,•.> ^^ )',,ii^ 



M.'iith- 



/>,n. 



Tin \M7Vi: ST\Ti:i) IMvusoNAI. l'\kTrr»-|.\KN XKl-Tkll- To TIIK 

iu>T or Mv k\.)\\i,i.;i)(;k and ukuhk '' 



Former or 
Usiidl Residence 

When was disease conlra<fed, 
If not at place of death ? 



HoH lonq at 
Plare of Death ? 



Oa>s 



Mil li II nil III 






KIAI. OR K1;Mo\-.\I, I DATi;.,: liriMAi, .„ Kl'.MoVAI, 

190'' 



M . i: K T A K I.; uW i o.daU^Xm^ V)\XW.< A< ^s) >vJU/ . 
A.l.inss in\ MVt\A.>\>M>>v At 



N. li.- 






.It 

1 



'} 



•5 



WRITE PLAINLY WITH 






UIMTADING INK 



TMICS IC A r^*-».. 






RiViANeNT RtCORD 






10 ()\ 



l 



Certificate of iDeath 



,»Cr» TO ,.CK or C.RT.r.CAT. ...... , 

CitjandCount) of San Francisco 



11. S. Stanfnr? 

PLACE OF DE A TH r . r (i ^ '^ 

i-'trtin: — County of UCL'>\ 



'^-^ 



No. !(■ ' ; ; 



si 



5*1.1 d;s,., bet)]> 



City of OxL ,v >' Vcv>x.t.v4. 



>"\,. 



1 



1 n. "'^'''•fTANDNUVIBtR J 



1 



FULL NAME V 



-l* ^ 






\'.l 



PERSONAL AND STATISTICAL PARTICULARS 



^ 



' '!,( )R \ 



MEDICAL CERTIFICATE OF DEATH 






^JMH.Ui.i, OR I.tVMKCFf) 



/',/ 



lUR riii'i V,- ,.• 



I-ATUl.R 



'>i' lA riiKR / 






'«IRT}II'r.A('F 
<»^' MoTirKR 
(State «»i Count tv 



A'- ,■:/.,/ 




I 



la^^^^vxci 



'Moiiihi 

<'i-it r las; .;,,\ I, ,. , ^^ 

"1.1 tiK.f -le.'it!, .,(,! , . , , , 

-\ ' .lira ; ill, 

1 . 



Il IV 



/ ()n 



<•' ■ 1 vr, 



<>o 



:'- as |r)il,,\^^ . 









1/ 



/hi 



(^ \ 



^ JJ 



1 



11 





DTK \Tf()\ );^ 

^'< 'NTRIHCTom- L'^ 

(Signed) lL^>v- •' <,.' ■ 

^ ^-^^ -' ">^ (A.l.lrcss) 'U i U (ri , 



I v 



//-'.' 



,7; » 



JA'v/// 



/^,;t 



'V 



M.D. 



'•t^^f<^»iz,!z^z^fx> t:::r"" '"" »- - ^^ 



) fill 



\r nil til. 



/>,! 



'" '■■'■-''■■'■ "vi^^^lM^Sa,;?,)'.^;,"^.!^^^^'^-"^ -■'■'- 



Former or 
I'.ual Rfsidenrr 

When was disease ronfraefed, 
If not af piare of dedfh ? 



HoH long al 
Plaieof Oeafh.> 



Oavs 



'^Iiif'iTin.iiit 



¥ 




r 



->■"■- ^'\'x b^Jj^ 



190 



VXl^wOL Ul 



N. B.. 



I'WKOF FHRIAr, OR RKM()V\I I i.vr,.- , ,„." ^ 



'Address 



"'r.? Ju;;n'o;''DT;;Hi' pti' J: ^"""k"^ r--"'-'- ^-.-^ '••.„„„. h. .,„,ed exactly p„vs,cu^k . ." 



I 



M 



mm 



MM 



■H 



^ 



-3 



WR IT£^-PI AlMiviAfiT-u iiRi.>.»...^ 

- " -•^'■^^••^^ ii>l»\ — THIS IS A PERMANEIMT RECORD 

RrFER TO BACK OF CERTinCATE FOR INSTRUCTIONS 




/>a/<' /'V/^v/All^r^ML-^-^-aKiN; I 



"XASV 



If)OH 



lie^i.sfored Xo. 



O^C 



790 



Deputy Health OfTiccr 



1 ^ 
DEPARTMENT OF PUBLIC HEALTH»Ci()' and County of San Francisco 



I 






I; I > 



\V\v 



1: ' y. 



V '• 



lit 



\S 



Certificate of Death 

( "Q. S. StnnDai^ ) 
PLACE OF DEATH.— County of Ocx. Jtlx.x >vev... , G.y of c5 a .v'^Vcx.vc , 



No. 



i^iH b 



CLVa- 



/ If DtATH OCCURS 
V ir DfATH OCCU 



St.; 



S AWAY TRCM USUAL RESIDENCE 



Dist.; bet. 



i 



»v 



and 



i( V. 



RRED IN A HO 



' . ^ «t*lUtr>ICE GIVE FACTS CALLED rOR UNDER SPECIAL INrORMATION \ 
SPITAL OR INSTITUTION GIVE ,TS NAME INSTEAD Or ST R E E I A N o N u m " " ^ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



T .L 



' ' 'I.ORv ^ 

U 



• \ i I I M I; IK Til 



A' .)•, 




tontlil 



' I):i\- 



IC 



w iiMtuKi) (»K i»i\i»Ki i:r) 

'Wiitriii s(Mi;t| (ltsii.'ti;iti.(ii) 



l!IK llll'l. \ci-: 
I St:ifc or (■..lint t vi 






\.\M} ()I- 

i".\i ni;K 



nikiii II, \( }•• 

Of lAIHI.K 

I '^f.it.- ,u «-.,tuitt \ 



M \ I I>1'\ \ \ \J 1 

''. M<»rm; K 



lUR l'iriT.A( !•: 

<>i' M(>'i"m:K 

(St:i(f or t'diiiil! \ ! 



' '■ ' I i' \ r 1' IN 



V/C-V..<i Cl 






TN 



r 



r> 



i 



/i'-' /.A'..' I II \,i II I 1 ,1 ,1, 




V \ 



\x . 



I> 



I'm". \IK)VK STATII) I'HR^ONAI, f \ K I !»• K I. A K s ARl., iKri-: To Till- 

in-:sT<>|- \n- K N'( iwi.i f)(',i- \s\; i;ii,n:i'' 



^ .Xy}. v^vt^ vj) 



'X.Mlrss IH 



'i yoccvixcdj ii 



u.4.^clcL 



o 



MEDICAL CERTIFICATE OF DEATH 

I m-Ri-nv c I kTi!\- 






U/! 



that I la^t -^au li 



V ( ' ' ! ! 



'■'' 1 ■■'ttcii.lr.I ,|(i I I'^i .! t |, ,111 

l()0 I 

- T()0 . 



in.l that <U>atli oooHrre<l. <•!> !])<« .],it.- <tatf.] i!m,\.-, .i I 
(A M, '1!^. (■ \i < 



'1 1 ' i . \ , I ! 



\\ ,1- 



V' 



IH Ix \Tln\ 

^ < '\'!Rn;rT(>k\' 

I»! k \'J K >N 

' Signed 



l/.-7,'//.V 



/),/: 



//,.,v, 



I ■ 



.U"ulhs 



na\ 



M.D. 



A.l.ln^s) iH^^oJ^AvLtLtl 



Special information «nl\ loi llospitdls. InstituMons. Trdnsipnis 
Of Re(pnl Residents, and persons dying .m,j\ Irom home. 



former or 
UsUfil Residence 

When Has disease rontraded, 
If not dt plare of death ? 



How Ion*) at 
Place ol Deaffi ? 



Dh*" 



I'l^ACI-: OI- IM K I AI, (_)k i< i:\I( A AI 

(XAXJ 




I M)l KTAKl'.K 






I > \ri:^M! Ui y I Al .,t k 1:M( i\ \ I 



loo 



•F.very item oV inlforiiiiilion fthoulcl be cure»\illy Mupplied. \(l\. hSioiiIiI bo Ktntc.l EXACTLY. PHYSICIANS Mbould 
state CAIJSIZ or ni; ATM ill pliiin tcrmM, that it miiy be pr<.|>cply wliiSMSificti. The "Spccliil InVormatJon" *«.r per- 
son* tlylnft away from home should be ftiven in every iiifttnnce. 



I 



1 



% 



«^?5?qiB? 



iif 



<pi< 



»t)i 




Hit 



WRITE PLAINLY WIIj 



I IM K TLJIC tC« n r.— H.. 



M' ■,■.!.) ..f H,;i!i!i--|- Vn. IS ^t^^^ 



.•mtllftl'O) 



Df^fr /'VAv/, Qlru^, 







O^VVtM„\; 1 



njo H 



,t\.A^\J 



^ 



• ...w ,<, i«» I'cniviMlNt.lN 1 RECORD 

_ REFER TO B/iCK OF CERTIFICATE TOR INSTRUCTIONS 

Begistci'od Xo. 



27[)\ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTtWity and County of San Francisco 

Certificate ot E)eatb 



vc^<5 ec 



/ IF DCATH OCCURS AWAY FROM U S UlA L RESIDENCEGI 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION 

FULL NAME 10 A^ 



Dist.; bet. 



IVE FACTS CALLED FOR UND 

: I 



riur .Tc MAHiiir ^ " SPECIAL INFORMATION 

GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 




) 



"V^X- 



.1.1,..+ 



■- 1 . \ 



PERSONAL AND STATISTICAL PARTICULARS 




<xU 



/ 



1' xri: <tf. i;ik 111 



A<.i-; 






M..nth 



1 



l);i\ > 



r^^' 



^IN'.I.K. M\KI<1)-I» 

WIIX »\\|-:!) (»K |i:\nRit II 

i\V:::' •:! - ;, 



• Stale (ii foil nt I \ 



MEDICAL CERTIFICATE OF DEATH 

DATl; (»1. nilATH .f\ 

I in-:Ri.;nv ci:ktiiv. ru.a \ attr„.i..i .lovasoi in. 

tli.it I last saw h '. .ili\f ,,„ ' ^ t 



(V.-;ir> 



til 



i(>oM 








v,\ 



\ip 



aiiij that .iralli occurrcl. oti tlu- .latr st.ili'd al..>vr, a1 S- lO 
M. 'ihr (WISI-; <>[;^1'1;ATI! was ;,. follows: 



\ \ M I < .1 
I A 111 1- 1< 



MIK IHI'I.AC'K 
«>|- I AIIIIIK 

'State 'ii rniinti \-; 



MAIIIIV \\M1 
<»1' .Morill.K 



iMk rm'F..\cK 
"I- >j«»i"iii:k 

'State ,,i r,,initi \ ) 



^' 







/ 



I»l K A'ilo.X >''//A 

c'( )\Tkir,rT()kv ' • 'v,^,c 



(Signed i ' vjojvVo • 

ill -1 .. , 






/h;y^ 



■^ 



//(>!/rs 

M.D. 



I()0 



( A.I.llTSs) \JX 



Special Information <»n!\ lor HuspiiaN. institutions, irdnsients. 

or Recent Residents, dnd persons d>inij ,m.iy Iron fiome. 



former or 
t'sii.il Residence 



Q. .^. 



HoM long dt 
PIdc e ol Dfdth .' 



n,i 



vs 



//'■-/(/,,/ i,/ ,\,, r I I ,1 1:. : r.i 



lA. /,'///- 



/',/! . 



IIN-: Mtovi*: ST \'n:i) i't<-Ks<)\ ai, i-\r rini vks aki- i-kiI' to tiii- 
lU'.sT oi'Mv KNOW i,i:i)(;i.; AM) iii;!,ii;i- 



lU'.Sl ()!• MV KNOW l,i:i)(; !■; AND I 

fn;ni;tllt LV . LAi. ■ ^1 



When Has disease rontraded, 
It not ,it pliire of dedtfi ? 



1.^ 




IM.ACl-: Ol HI kl\I, OK K};Mo\\i, 



I i,.\v. r, > I r 111 K I 



IQO I 



I ni»i:rtaki:k 

r\(i(ii( s. 



daij: .>■ i:i i;i \i ..I k)-;mo\ Ai 

vKtv ; 



^' ^' 'ivery Item olt infopinntlon Hhoiild h.- cjircV'ully Niippliod. AGR should ho stilted r.XACTLY. PHYSICIANS Hhould 

state CAlJSi: or DLATH in pl«in terms, that it mny be properly cliiHNh'led. The "SpecinI Int'ormtiliun" V'or p«r- 
Hont dyini^ nwny from home Hhould be ftiven In every instiince. 



■•^^, 



! 



I) 



I 



I 



I 



^i 



III 



m 




4 






1 1 
V 



WRITE PLAINLY WITH UNFADING INK — TH 



IS IS A PmiWIAMrMnr Di 



II. :;!(!! !■ No 






■ ■ I h» V/X^ I 




(yxM^v^-v 



Wv' o 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



..Iaa.-i 



a ifJOH 



!)((/(' Filed 

d^vu.^ Iaa-u Depucy rieoi,.h Officer 



Fiegistercd JVo. 



^793 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of ®eatb 

( "U. 5. StnnC>arC> ) 



PLACE OF DEATH: -County ofCW^v J.xc^yvC^^: City of Oc^^^ J A..;v . 



No. J.'UL^vCiv "^ 



cvxi.t t. 



0-<i.iA-vlai St- Dist-bet 



FULL NAME ^ 






PERSONAL AND STATISTICAL PARTICULARS 



O'l 



O 



1 

V 



;• ^ ; !' < If I'.iu I ii 



MEDICAL CERTIFICATE OF DEATH 

DATj-: di' i)i: \'rii 






M :itlp 



I'. IS I 



(Year) 



0^t 



/',M 



--'N' l.l' M \KI< I)- |» 

W llx iWl 1. < »K !»;\(ii.T I n 




lilkTMI'LACi: 

'St,it( or "/iiiMiti \ 



V VM I . I! 
I A III IK 



«? 



V<XVVA^(L<L 



Momli^ (Day) 

I HI'RliliV CIvRTlI'V. Thai I atk-n.U.i dccvased frmi 

1 90 M t(i ^rur^^- ^. 



9" * I" ,;'^^ ■' T(>o 1 

tliat I last s.iw h '.. . alive on 

■ in.l that (K-ath ocrnrrt-.l, .,,1 ihc .latr ^tatr.l aln.vo. at 



9. 



fh '''''■ ^^-^'■'^'^O'" "I':ATII wa. as foILnvs 



,^\ : 



Vo , 






I'-ik niiM.xcj- / 

<" 1 MHKU (j np, 

l.Stii. ..i f(,iiiiii.\ HM ' 



"t l< A'l'loN Yrars Mouths 



Pav^ 



Hours 



CONTN 



M \ IIM-V \ \Mi. 
"" M'»||||.;k 



i!n<'ini'j.\,-,.- 
<>i' Morin-R 

(St,-: , ..iiiiti \ 






I )!■ RATION' 

(Signed ) 



)'rars M.niths 



KjO 



r\(l.lns^) ': .■• 



/^avs 



a to J 



\ 



//oil IS 

M.D. 

;1 



f^'''-iil'-,l f„ Sail l'),ui,,-,., 



Special INFORIVIATION only for Hospilals, InsNtutlons, fransienfs 
or Keren! Residents, and persons dying away fro?n home. 



),,// 



Mnllllr 



/ hi \. 



"».^1 ni. MS K.\(>\VIJ:I)C,i.: AM) iii.:i,ii.;f.- 



''xf.rniant LLLvtL,C Lva 



former or -^ hI 

Usual Residenre •^ 'o v.nji./<x>vAv<.i 

When was disease ronfrarfed, ^ 

If nof at piare of death ? 



Days 



' \'l.lr<'ss 



^i5 



JUUXA. 



■-^vu CjlA 



I'l.ACHoi nrklAI. ..K RlvMMVAI, I DATi: ,.! 11-kial ,„ RKMOVM 



190 



r N I ) 1 






"^Iw^X^^^^V^r^ ""7'." •; • — '""^ supplied. A(;n Hh,n.l.l bo stHte.l EXACTLY. PHYSICIANS should 
» "jinft awny *rom homo should be ftiven in every instHnce. 



< 



i^ 



i I 



I 



i 



11 



liii 



li 



iir 



m) 



ppt 



J 



iiiSil 




WRITE PLAINLY WITH UNFADING INK — THIS I 



'ERMANPMT Drr*nBr% 



> • • I 



li ,'-1, 1 %•■ 



-'..•^-. H,«vl' (• 



cLo-vv^^.^ > M Deputy Health Office*' 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 



279,3 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( *a. S. StanDarD 



^■^^ 






PLACE OF DEATH: — County ofOxX^x'ix<XaA.cc^c<. City of 0^^ ^^VOlv.o^^^ 



i^ 






.^<. 



^LL>\.t.'J 



L>^\A^ ^' •..St.; 



Dist.; bet. 



and 



( " "•„;:.-^c"c-„v»r„',^"r„o"s^py/.t ^^^:^f::^^-,:rd\:i^i ,x.r^p s.%7i;-ij„"=r ■ ) 



FULL NAME ^l- C^Lv.avv j 




^i.\ 



I) 



PERSONAL AND STATISTICAL PARTICULARS 



' I i:iK I n 



ic?n '\ 






r \.-. 



M..inli 



I'av 



> '■.•II 



Ihl 



^^ ' ■ -il'iiatitMi) 



liiK i-in 1. \. i 

' St.rfr (>j ( oiiiili v 



NAMl- n! 

I'A'i ni:K 



IWk riM'I, xri- 
'H- I AIIIKK 



M Mill \ \ AMI- 
"1 Mi>rili:K 



HIKTHl'l, \(l.; 

<>i M(»ihi.:k 

'Statf oi iniinli\ 






MEDICAL CERTIFICATE OF DEATH 

I> \ I I" ' '!■ I>1' AIM , A 

(Mouth) (i,.,y) (v,..,r) 

I lN:kI-:i'.V CI{RTII.-V, That IatttMi.k.l.lc(vase.l frnn, 

'^.Ct 15 T,pM to ^'Ct SO icpS 

tliat I last saw h •'... ., . alive- on ^ ct SO ^^ i 

aji.l that (h-ath ocoiirrcl. on tlu- .hitt- statf.l ahow, at L ' 
M. The CAISI-: ()!• |)i;.\TII was as follows: 



,is 



1 



C ONTUir.rTORN" 



Mouths It) Anv 



Hours 







1 1 






nrRATioN 
i Signed ) 



)'/'(! rs 





.Uof////S 



/hu 



•s 



I()M 



v.. W I 

(A.l.lrvss) \XX ^^ 



I lours 
M.D. 



VM. : ;..<) '.'„-■,. 



/ 



-1' 



V 



1,.. 



' '11' XTloN ;) 

c ^ 

A'/' ith'd I II S,i ti / 1 ,1 ,1 



V^\,(X > .M 



Special information only for Hospitdls, Inslitufions, Transients 
or Rcrcnt Residents, dnd persons dying dwdy fro:n fiome. 



M.'iitl,^ 



l)a\s 



^•U^'^N'»u'i.i:i)<.i-: AM) hi:mi;i- 



Formrr or 
lsu.ll Residence 

Wlien Mas disease contrarted, 
If not at plare of death ? 



How long at 
Plare of Death ? 



Days 



^ \'Mifss \J^3^J~Y\\A)f\J^\J<, 



a 



«-t 



I'l^ACl-; Ol- H 



U>11jUU. 



K KJvM()\AI, I I)\'n^>!' MiHiAt. or R1-:M()VAI 






V ^}S!d fxa cv . 

(A<l<lress ibl^a- \'\ \Xk, O.t 



TQO'i 



-N. ».- 






.very Item oV !nV'orm«tlon shoulil be cnrefully Hiipplied. A(;r. nhould be stiite.I HXACTLY. PHYSICIANS Hhould 
o!!- I . i^' ^' piIATM in plain tcrmH. thtit it iiiHy be properly clamiilfied. The •Special Informntion" for p.r- 
on* clyinft awuy from home nhould be ftlven In every Instance. 



\ 



i 



i 



jIBBJ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PER 



i:...'i.; , f II. .ilth l-Vo : ^ t-^>15r:.:?Li; I{,<^ } 



* n 



l)((h' Filcil, \K 



,L 



nN^^>>xiML.\, a ii)o\ 







IVIANENTl^ECORn 

REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 



794 1 



VA^Vo 



-i Deput; r^ealth Officer 

DEPARTMENT OF PIBLIC HEALTIl=City and County of San Francisco 



Ccttificate of H)eatb 

1 11. S. 5tn^^ar^ ) 



PLACE OF DEATH: — County of Ml\jyWcU^C. 



^J 



City of 




V V.<\, \: 



No 



:. Ot<xtx~()l:)^-^lvdaJ( 



St.: 



Dist.; bet. — 



'and 



FULL NAME -'>-'<- -' , '^^ ^-^ '.^ I. ', . oU-C^oK^^xxl "■ 



? 



PERSONAL AND STATISTICAL PARTICULARS 



J- 



V ' • > I . I • k ., 



' ^ 1 1 or i;iK ni 






/ 1 ^l 



M..nlh 



I»;is I 



\' 



l-x 



> I ;ii 



/',; 



MEDICAL CERTIFICATE OF DEATH 
DATH oi- DHATII 



lL),a; 



2,( 



(Year) 



(Month' (Day) 

I m-RI'HV CI:RTII-V, That I alUn.lo«l .leooased from 

that I last saw li .. alive on 



M 



1()0 M 



-^IN".!,!". MAKRII'.I) 

\\{\n ^\\■\■\^ ,)K I ) IV( > K >, i: | ) v 

^^ ' ''' '!! -■ ■< i.tl <h-siviiati<)ii) 



IIIKTKIM. \r)- 

*"' '< or (."uuiit I 



I AT hi; k 



"IK I'M I'LATF 

Of I Arin-:K 

'St.itc or rnniiti V 



^MII•|•;\• NAM! 

''i M<»i"in-. K 



HIIMlll'I.Al'K 
<>l MoTMI-k' 
(Sta(f ui i'lMiiiti \ 



' '> * fi'A riox 



<Aj .ccL^^u- 




1 90 



aii.l that (k-ath orciirrcMJ, on 11k> date stated above, at XH 
_ M. The CAl'SF'; OI-' I)J.:aTI1 was as follows: 



/VOUOVC* 



I )r RATION }'cars 

CONTRinrTORV 



Monlh.^ 



/hi 



IV 



> / 



"^^: 
y 



OrKATIdN 
(SIGNED ) 



)'t'ars 



.^ft)>lf/lS 



TOO . f Addtiss) vJ OwV 



/Mrs 



I lour a 

Hours 
M.D. 



''VvA.O„O..V \. '^..'j 



■^ 



Kl ,',/,-,/ /;/ S,,„ / ; ,,^,, ^ ,,.,, 



Special Information only for Hospltdls, Insfifutlons, Transients 
or Recent Residents, and persons diing uwdy from home. 



former or 
Usual Residenc 



fdt L<x.'tl[uvA.'>\xic ()b 



) , ,.'; - 



M.niflr 



/>il\ 



"'hFsT nr'i'Iv'i'v!' '''^'^^"XM. r\K inilVKs ARK T K T K In Till. 



(Ill 






►'V^rV<Ju 



Wfien Has disease contracted, 
ft not at ptace of deatli ? 



, H floH long at -. 
^^'yxSU (/bo^>a. Place of Death.' 1 6 Days 



' \.]<lu-ss 






'"> 



N. B. 



hvery item olf Info matlon shoiihi be cirefully supplied. AGF. should be stated EXACTLY. PHYSICIANS should 
«tote CAUSE OF DEATH in pli.in terms, that it may be properly classilfied. The "Special Information'' for p.r- 
«ons clyin^ away trom homu should be ^iven in every instance. 



"1 



I 



im\ 



P 




I 

r 

4 



m 



■.t 



WRITE PLAINLY WITH UNFADINGJLWK — THIS IS 



A PrPlUiAivir M*r 131 



I5..,!!.! ..f llcltli !•■ No :-• -^'^ r>'.^, j-^^i- 



Ci, 



Ihtic I'ilvil , 



.^\A.u:5 




^V 



-l 



Deputy Health Officer 



_ REFER TO BACK OF CERTIFICATE FOR INSTRU CTIONS 



Be^isfeved JVo, 



DEPARTMENT OF PIBLIC HEALTH-City and County of San Francisco 



Certificate of H)catb 

1 "U. S. StanC^aiO ) 



PLACE OF DEATHr-County ofO<X^, J 'vcv^^^^cc City of C3 Cu>v 0/vcL^ec^ c, 



No. 12.^'t LdA. 




FULL NAME ^ (Xaa^Lc^ ax J cui -^ 




wa ) 



I 



PERSONAL AND STATISTICAL PARTICULARS 



•''^ I i: <»f i;iK 1 II 



,1 



*'< »i.< Ik 



U:?\>t 



/ L ■.-• 



Mont h 



\' .i; 



>.i\ 



1/ .'.■.'// 



N\ n><»\yj-;i> ok nixoKOKr) 

'Aiitriii soii.il <!i sii'n.ition I 



Oi 



IMR rill'l. \i|.; 
i St;it<' or <,'muii| i \ 



I 



MEDICAL CERTIFICATE OF DEATH 

DA it: oi- i)i;\Tn A 

(Month) ,i)j,y) (y^,.,,, 

I III-:R1-:HV C1';RTII-V, That l atU-M.U-.l .lerea"^l from 

'- — 1 90 to 

that I hist saw h ."— alive 011 

aii.I tliat .Irath (x-ciirrt'.l, on t hi- .hitr <talc.l ahovr, ;,t ^ 50 
•M. TIu' CAISI-; OI' l)i:.\i-|| was as follows: 



~.I()0 

. ,u..jii.ii'Ai'tlii..Uiianiuiin. ;r--r ■• .. | qq 



NAM I- ()! 
lAI HIK 



1 



C'<Xa^OA 



HIK I Hl'l, \KV 
'>!■ I ATUKU 

"^'■M< ,^X C.UIltl V 



IM mi>);n n\mi-; /^ 



ItlK rilPI.Afl- 
'H- M<)Tiii.;k 
'St:itf 01 (•(niiitiA 






\jc 



I >r RATION );wr.v 

CoNTRIIil roR\- 



Mouih^ 



Day 



'S 



//ours 



i 



X>W>x<X/>'vo 



63 









5 



I, 



VJ 



f)r RATION 



( Signed ) 




}'t(ini 



Q\^ 




Mo)ilhs 



Days 



»>iT| 



•ATI(»N<(J\l'? 



vvlccaxu 






r 



I iqoS (A.Mriss) i;^3 







Hours 
M.D. 



Special Information only for Hospltdls, Institulions, Transients, 
or Recent Residents, dnd^ersons dyin;) awjy from tiome. 



f^''"'''<fr<f ni S,i„ /,,ni, !,„ GlH )>.?/» ' \r..,:fl,. 



n„ 



I 



"J.^l <)!• MS kN(»\\Ij;i)C.H AM) Hi-IJl-F 

6. Q>\JLoX>v. 

(A.l.lnss 13, ST VXLcLu Ol 



Former or 
Ifsual Residence 



/ V-> 



l<Ob \w<X<Xu JT Place of Death? 

Wtien was disease contracted, ' 
If not at place of deafli ? 



Days 



niif":in:iiit 



!N. B.- 



8 



1 90 i 



I'l.XrK OI- I!( klAI, Ok RKMoVAl, DATHof IUkiai. or KKMOVAI, 
(Atl.lrrss ^ SI VH W<i^V^<r->A. ')t 



.very Item oV Inform.ition should b;r cnrolrully supplied. AGE should be stated RXACTLY. PHYSICIANS should 
tatc GAUSn or DflATH in pinin terms, that it mny be properly classilfied. The "Special Information" for per- 
f»n» tlyin^ away iVom homo should be ftivcn in every instance. 



^.; 



n 




m 




m 



I 




I 



Mf 



Health- F No ! «. J"-'^^**^; H& 1' Co 




REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS 



if^fn 



J?r(^/.sfered J\'^o. 



O 



796 



^SvuLAd<Ji\>\i Deputy Health Officer 

DEPARTllENT OF PUBLIC HEALTIMity and County of San Francisco 

Certificate of Seati) 

PLACE OF DEATH: — County of O^a^^ 0.^a>xtcic ■_ City of U^V^v A.C^ . vC w. t c 
No. I^aq OxxLLc^' St.: 1 DisuUt.Io.a.xLi and lxv\,L 



FULL NAME 




ceco '.].( 



PERSONAL AND STATISTICAL PARTICULARS 
Qfj^ ft i tol.ok 



I» \ ! I. nf lUK 111 



\' ■)•; 









I, i 



(Vr:iri 



^1 






3.a 



/'. 



'^IN" I.l M \K l< 11; I. 

u fix >\vi;i» MK i>i\<tk»Ki) 

' Ui iff ill -, H ial 1!. ^isMri(i..it> 



I'lK rm-i, \r».: 

'St.itt i>r (', ,i|)it I 



V 



I \ III IK 



iMk III n. \( |.- 
•»'• I \rm-K 



^' \ii>i:\ \ AMI- 
«>i M<»rm;i< 



i!ik iiii'i. At-).- 

<»l- M<fni|.;K 



\- 



icp H 



a \ f I '. n 




.lXx\) o 



V<x\a,Xo 



MEDICAL CERTIFICATE OF DEATH 

i)\ri-; (II- Di-ATii , v 

^i d So 

'Molltll^ ll);iv) 

I m;Ri:i;\ ri.KTII-V. That^I alU-iKk-tl .U-t-cased fn.m 

-- u^V«0^ r.. N- u^)'' to U..ci. dC 

that I last ^,i\v !i alivt- on U-'C--"^- 3' up 

aii.l that <Ifatli . u'cii rrt'd, on tlu- <lati- statt-d aliovc. at 'i 
"'^D ^^' *'" ^-^ '•''''• <'!•■ '"^ATII Nvas as follows: 




Dl'RAriO.N ]'tiijs 

CON TKIIM TOKV 



.lA ';////.' 



/A/j 



'.V 



/lour. 




CL>VOU 



( 



I)rR.\TI()N }V</r.s- 

{ SIGNED ) J Jvo-^ Ij. xjlt 



MoHtJlS 



/:>t/)'.v 



1 1 oil)- s 




■\^.• 



i()n 



VO-^ VJ. \J IL oUCrvvixLO, M.D. 



( 



Hill 






Special Information only for Hospitdls, institutions, Transients, 
or l^ecfnt Residents, and persons dying away from home. 



!/,./////> 



/>,! 



"Hr<-i-*y.V'',.0 '"'■'" ''^"K^'^NAI. fXKTh-ri.XUS AKI'l TKIK To Till; 

"'•^1 «>i- M\ KN<)\\i,i.:i),-,H AM) iu;i.ii;h 



Former or 
Usual Residence 

When was disease ronlrarled. 
If not at plare of deatli ? 



HoH long af 
Plare of Deatfi ? 



Davs 



' \-l.llr^s 



N. K. 



^g^ l)<xLLi|t ^-t 



ri.Af}-: <)!• m KiAi. i»K ki:m«i\ai, 
rM)i:RT.\Ki:K v^'t\(X.<5 >- nJj 



I)ATl-:()! Ill Ki\i. 01 KlvMOVAI, 

mYctlT. a too' I 



A.l.Inss l-^'iloVVO <X.^l 




A.A^-lA.-fi,^ i ■ 



'X 



Hvery Item o»r informiit ion Hhoiild be cnrct'uMy Hiipplicd. A(;ti fthoultl be Btnteil F.XACTLY. PI1Y8ICIAN8 sboulil 
Btiitc CADSi: OF- Df:A Til in piiiin tcrniH, thnt it mjiy be properly clnsHiltlcd. The "Special Infornuition" ?or p«r- 
«on« ilyinft nwny from hfuno Nhoiild be ftiven in every inHtnnce. 



II 



, 



J 



M 



I 



Ml 



•ii 




m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PE 



RMANFNT Jafrnnan 



JJ.iiU'l ..f lltri'tli !• \<) I <; ^^' ar%ii H/t 1' Co 



Du/r I^y/r^/ ,\l\^r^y^'yy^JoJir}j 



cLtrvAA^ 



De. 



I) o ~ 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

llei^lstered ^7>. 






797 



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

Certificate of Beatb 

' 11. 5. i?tnll^nrO ) 
,.PLACE OF DEATH:-Coun,y of 'a >v J ^a. , ..w.cCity of O^v Jxc^xeuMit 



N«, 



M.I 



-C'^fLti ObO-l 



kd 



a I) 



St.; 

>ID 

NS1 

1% 



Dist.; bet 



tnd 



( " "-.r.-i^.-j.-r.-r-o-- :^^:^^^^^i:-- s,v^7 -^ -;? j;,%T;.'r=;r ■ ) 



FULL NAME 



.OAX/TVCJl Jl.C^YX 



•^1 \ 



It \ I I 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



•'F 1:1KIH 



M 



I);iv 



DA ri-; (II- Ki VIM 



\ 



•J I C \, 

'Moiiilii 



I):iv» 



(Year) 



\' .1- 



^1 ■' I.I \t \K iv ) I I 
' Wiil.- ill . 



r.ik in I'l. \('|.. 

'Sl;il. I.J r,,uu(,^ 



\ \ M 1 (II 

! ■ III 1 k 



1/ 



• "»'f;ii I 



/>,. 



I 1II;KI i:\ ( I klllN. ThalJ atU'n.k.l .Itocase.l from 

190 H 








tli.it I last s.iw h ..... alive on Vl\-C 



1 90 '. 



aiiil thai (h.itli .•((■iirrod. on the .jali- slatrd ahovo. at U.SO 
Uj M. Tlu' CMS!-: ()!• I)i;ATn was as follows: 



IIIKTIII'I, \CV 

"I I \ rin.K 

^' ■ ' imitiv 



^' MIMN \ AMI 
"I M'tl'Ili:K 



I!II<TI11M.\,H 

«ii M(»rin-:R 



' ' ' rp.xTiox 




Mrvrui 



i O \J^ ■>-) v.. 



nik ATioN 






J/(>f///LS' A /)iJ\'S 



Hours: 



(.( ).\'i"i>: I lU TORN' ^ ^\ >... , , ..\ 



n 



\ 



.a 



OJf\i 




t\jJkj^<X 



LU 



n 



I )r RATI ON 



)\'a) 



. - . ■ - M'^nt/is X /)ays 

(SIGNED) to. Ll LaJXk^. 



IIoius 

M.O. 



\x 



XXji\) 



/\i-.i,f,if 1,1 Si!>i / idih' r.i ' I 



)'i,} I • 



M.'i:lll 



r>o 



""liKJVy.K^JV^ '■'•'' ••'^■«^'>NM< 1"\KTI(II.\KS Aki; Tkll- TO THH 

m.^roi- M\ KNOW ),i-;n.-.i.; AM) }n:Lii:i- 



Special Information only for Hospitals, institutions, rrdnsients, 
I or Recent Residents, and persons dying away from fiome. 

Former or n o Q ( 1 / "t 1 How lonq at 

Usual Residence c^OD cMvU.t Place of Death ? 1 

When was disease contracted, [f] 4 

If not at place of death ? ^..<J^.3 '' 



. Days 



Xddicss <?L O ^ 



■ . .t i. i 



t. 



I'l.ACK OI- lUKIALoR KKMOVAI. I J) \ Ti.; ,,f IJikiai. or KFMOVM 

fAd.iuss H 11. nO'\v4KLv^v....sJ1 



INDKRTAKKR 



IN. B. 



-F.very Item of inforitmtlon should be cnrc9ully supplied. AGE should be stnted EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
Rons dyinft away from home should be ftiven in every instance. 



i 



! 



I 



'I 



! 



m 



fWi 



WRITE PLAINLY WITH UNFADING INK — THI?? i«; 






lioan! ..f II< ilth T N. 



•-■-x.-ij- i{.vt J' c, 



i., "• 




Deputy Health Officer 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIO NS 

Registered A'o. ^798 



DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 



Certificate of Scatb 



in. 5. Staii^arD 



No. 1 ^. S 



PLACE OF DEATH: — County of 'J<X>^ J,va^xc*.<i.oo Ci 




j,< 



O-vv <:J,<X.l- 



St.; b 



( " :'V".,T.'iii.7::::°''.^^^^[ r»'f:°,^"j;^c^:'/..'--=i^ i'>.-° -- --" "-■" —— 



ty of O/CX^^^ J/uX'Vve*^ o c 

n '^n ! 1 ^-1 \ 

Dist.; bet.O K<X^y\^YLK.u^\) and J C^lC-O/ u 

FACTS CALLtD FOR UNDER "SPECIAL INFORMATION" \ 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



'\ 



FULL NAME 0<xvai\^ 



PERSONAL AND STATISTICAL PARTICULARS 



■*f ' 



I' U i: ' i! I;: !•• 1 11 

Ml.iitht 



u 



Il.:\ 



MEDICAL CERTIFICATE OF DEATH 

I) \'v\i oi- i)i-:.\-j-n 



^i\.. 



I ()0 
(Vtar) 



I IM;ki:F'.V CIIRTII'V. That I atte.i<]c.l .lovasc.l fnm, 



; (;r) 



to 



U\tL- i. 



5 a 



! , 



i; 



■^'■^'■11' MARK 11 
\V llH tU ID OK d: 

I Writ, ill ^.,,- ,■ '^ . 



lUK ril II. \c\:_ 
I S(;it, MI t."<mtiti V 



1 1 



a.: 



I(;0 



iifot.. 



that f \\\^\ <..K\\ li ... jihve on w -^^. j, q 

.111-1 thai -Uatli ocrurred, on the date statid ahovo, at ' ' O 
M. Thc-C.XrSI' Ol I)i;.\ril was as follows: 



^^^^-'vvcL ^X'-^ >v« ' 



N \MI 111 

I- \ i II Ik 



IlIKTIII-l.ACJ- 

'•'■ !• V link 

' •■!!i|;\ 



N' Ml)i:\ N\Ml- 

<>! MDriu'.k 



'■'IK iiii'i.,\ij.: 

OH Mo'lFIJlk 

'^'■'' "t t.'..iiiili\ I 



.1 



J .-■.^.,..:i^,.v..au o^^v'dj N r\i^,t>'t.Q^cU^oJL ^-<U:iX-»u.\.a.l>u;).; 




\^\^ ' I ^ r > A 



- a c It \X d^^ 



IMR.XTIO.N 7 JV<;/-.s- Mouths 

c ■ < ) \ T k 11 ; I ■ T (> R N" l.'..\. ^... •.. -\ '^ V-C O..' 4 \ - V 



/><71'V 



I louts 



iKSJ- 









' . n 



u 



Dik.x rioN 
(Signed) 

\1 tC. V. , r()0 






/><?i'. 



'.V 



^ - *'^i^ i 



I Il>Ut\ 

M.D. 



LC 









AV'v/,//',/ /,/ S",;;/ /'i ,!!•, .•',■ 



Special information onl\ for Hospitdls, institutions, Transients, 
or Recent Residents, dnd persons d>in(] awdv from fiome. 



\'.r,f)f 



/',M 






m.sroi .^I^ k.N<.\\i i.:i)<-.H and m;i.M;F 



Former or ^ 
UsudI Residence 1.^3 



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



LoLcljL^V ..J 



at. 



How lonq at 
Place of Death ? 



Oavs 



I'JL^.ACK or lUKIAr. nk KIC.MOVAI, I DATK of Ht ki.ai. oi kKMoVAI, 

T 90 ', 



r.\I)KRTAKi:K V. 




(A(l(li( ^s .. 






Kvery item olf information should be carefully Hupplieil. AGE «ho;ild be stated EXACTLY. PHYSICIANS should 
stnte CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special InformHtlon" for per- 
sons dyinft nwny from home should be ftiven In every instance. 



1 



I! 



', 



[H I! 



II! 



mi 



fli 

til 
ill 



iif> 



td 



g™* 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANE 



NT RECORD 



..i:-! ■•! 11. .;ili I Vm : ^*'^■3^"5:;■. );X; 1- ^^, 



i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.^^A^CA^a 




\Ki Deputy Health Officer 



lte<f/\s/e/'ed J\^o. 



t^ 



?799 



1; 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

I 11. j5. Stnn^arC> i 
PLACE OF DEATH: — County ofOo/v^^ ,va,",xcv^co City of CJ.Q.-.A. i'voyyv-cv^ <ic 
No. ^10qlpC^I.v.>-.;;^,^.^. St.:^^ Dist.bet.dU^lUx. ^ndV 



ukI 



(^ 



FULL NAME 



.iw-^ ..vLi_C 



PERSONAL AND STATISTICAL PARTICULARS 

• < '1.' >k / U M 







lu. 



^ 



I) 



111 Kill 



MEDICAL CERTIFICATE OF DEATH 

I»\TK (>!• DllAiH /A 



M-i ,li 



(Year) 



\< .1 



^^■M " '^> ! ! > < iK , . 
'\^ .1 .1. 



I! Ik I'll 1'). \.- 1 

'St;,t(-- ..IIS 



N \M 1 (»| 

1 \tiii;k 



I'.ikrii fi \( J. 

oi- I Alin-R 

"^l '*' '•! CMlltlf! 



^' \ii)i;\ \ \M 
"I m<>i-|ii;k 



iniM 11 i-i. \i 1- 

••I- Moiin.K 
'State nr roiinti \ i 




cw^vu^d. 



.M.mtli 1 ( i).,y) 

I Hi:ki;i'.\- Cl,kTII-\-, TIih I attin.lr,! .Ifctasd rn-m 

that I last s.ivs h ali\(«)ii r.-,:-— |,p 

aii'l that death i xiii i n-.l, mi thi- date ^tati-d ahovo. at 
.M. Thi- CWI Sr: Ol' i)l-;.\TII was as foll.nvs: 






I V^ I X' 






n V,' 







^""■^- la 



cru^r 



u 



C<>.\TI<: [I'd'IOK V 

r SIGNED ) J • 0. \ ' 



Mouths 



na\ 



'S 



Hours 






' ^ 



^ 



J 



t 



Mn>itli: 



l)a\ 



'S 



> 



I lout s 

M.D. 



,CV 



> i()i I 



'1 f \ 



i|i| less 



I G I:. .\- 



f\l' •■ hllUi I II \,l II I I ,; II . 



* ■> 



' \ , .,, 



Special information «nl> tor Hospitdls, Institulions, fransients, 
or Rf(fnt Rfsidenis, diid prrsons dyiiiij .m,iy Itoin honif. 









1' ./////. 



/', 



"I. MinVl-: sr\T|. I, l'|. k^. .\ M, pxK iiri l,\|<s AK].; TKI 1-; T<» T Ill- 
Ill, SI (,i Mv KNOW |,i;i».,l.: AM) Hi: 1,1 1'.l' 



Former or 
lsii.ll Rcsldenje 

Whrn W.IS disfdsp ( onfrrK fed, 
II nol (it plare ol denth ? 



How long <if 
Pld<eol Oedlh? 



Days 



'lllf..;iii.illt 



f X.l.llcss 



^0^ 



Uj CuJrv<./> 



'^uoXjtiy\j 



\ 



I'L A' !•: Ol' HIKIAI, <»k Iv I'Mi i\ \ I, 



IJA 1^-; u! Hi KIM, <>i k i;m( )\ ai. 



I M ) 1 k T A K I- K Ml IXXA/>X/ J CMHk ^^ ' .,1, 



' ''Very item «,V inf -rmiHion should !>.• cnroltiilly Hupplied. \i\\\ slioiild be Hinted EXACTLY. PHYSICIANS Hhould 

Htatc CADSi: OF- DflATH In pliiin terum, thnt It miiy l>e properly claHHllfied. The "SpecinI InfonnHtion" *or p«r- 
Hons dylnjl ««way iVoin home Hhould be jfciven in every instance. 



riifi 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMA 



NFNT RrrriDPi 



ho-Al'l it' !1' 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



< 



J?rgisfe/'cd .A^o. 



S800 



/^^/^W'V/r^/, \l\(p^>JLo->^ba.\; X JfJO'i 

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

Certificate of Seatb 

A ^ J? (^ 

PLACE OF DEATH: — County o{C).<X'>^; J^.<x-vxc\..v. ^City of C)/aA^. aA.a..v^^o( 



ity oi V-' '^v T V V' / VA^ >xc\..vj '. City 
No.'l^S dcvcV<X.>v. , ' St.:' Dist.;bet}oOx^; • ' andOl^C^Vft 

r ir Dr*TH OCCURS AWAY TROM USUAL RESIDENCE GIVr facts called for under SPEC.AL INFORMATION' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR EET AN D N UMBER ) 




FULL NAME 



-'~..V 



PERSONAL AND STATISTICAL PARTICULARS 



■i 



Iv I . \ q 



si:\ 



'>\ I ) "I Hiurii 



''«'!. «ik -^ 



\ 



L' 



-I Li 



n;.,im !i 



: 1 ,s 



MEDICAL CERTIFICATE OF DEATH 

i>\ I1-: {>\- i)i-;A'rn / • 






/QO 

(V<';ir) 



■^IN' ■ 1 ! M \K k 1|-I» 

u ii><»ui:i» nk iii\ < tKii:i) 

Wi it- ill >..., : ,^ ,1. .;.,,,.,,,.,,,, 



H!i-: I'll I'l, \r|.; 

' St.itr (,i C-Miuli \ 



A 



(J 



*M-)litl|l (I);iv) 

I III;KI:!'.\- i I.K'III'W rU.a l Mttcn.kMl .U-,t;,sc.I from 

"" " I'*" i" Tip 

lll.it [ I;ist ^;i\\ Ii .ili\( Mil [ — yqq 

.iinl tli.it <K'atli iicfiincil, i >n tlp-datr sfati-d uhovo, at — 
M. Tlic- CAISI-; oi' I)i:.\'lMl \va-> ms follnw^: 






O 






MTW 



,'<X/VU. 



J ■A-clK.L' 



Kv 



\ \M 1 III 
I \ III 1 K 



i;iK III I'l, \ci-' 

"1 1 XIMIrR 



MAini;\ NAMl- 
OI" Mo'liu-K 



iinriii iM, \t 1 
oi M..rin:K 

' ■ < "II lit I s 



. * 







DIKATION )'r,ns 

^.ONTR nil TORN' 



Monlla; 



Days 



Hours 






[ iLoA' ' 



IH- RAT I ON 



<5? 



) '('(/;■ V 



Mont In 



I^avs 



f Signed) iAJtcUxA. 



Hours 
M.D. 



I()0 



Special Information only for Hospitdis, insiitufions, [rdnsients, 

or Rpcrnl Residents, dnd persons dyimi dw.iy from tioine. 






\^ 



\ K 



Rf I,!,- ' : ,, >,,,,, I , ,11,, , , ,, 



'\ ^. "^ 



) , 



M^^filli- 



h.i 



' "n.^!!.V^ '■ ^■'■^■''>'i> I'KksoN \i, I'Ak rifi i, \kv \Ki: rkt i.; ro tiii. 
in'.si oi- Mv K\(>\\i.i:i)c.K AM) iu-;i.ii;i- 



former or 
I'sudl Residence 

Wfien wds disedse lonfrdt fed, 
If nol at pidre of dedffi ? 



flow lonq d( 
PIdfe of Oedfl) ? 



Days 



' III f'M IllMllt 



1 ^ '^^1' 



] 



' \'i.ii. vs b i C) C. 




. t 



DA^l^J'! .)!' Hi RIAL or kl'IMOWM. 
•^ T90H 




I'l.ACl-; ()!• HIRIAI, OK K|;M<i\AI, 

r.NDi-.krAKi-.k vV''A.'\'va ' 



• 1 



-^- I 



1 



■ *** '-very Item otf !n)ii>riii;it ion should Ijj cjiret'iilly Hiipplieil. Adfi should be stnted HX4CTLY. PHYSICIANS should 
Htiitc CAlISn OP DIATIf In plnin terms, thnt it miiy be properly cinssiltlcd. The "Special Information'* for p««r- 
«on« <lyinji nwny from homo should be Utiven in every instance. 



I 




h 





wWr* 



fW* . 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PFR 



MAfMFNT atrnr\ark 



Moiinl of llenlih— F No : . ?•-> -»;■ ~^;-, n.^p c 



IfWi 



DEPARTMENT OF PUBLIC HEALTH 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



280 1 I 



=City and County of San Francisco 



Certificate of 2)eatb 

( U. S. i?tau^arC» ) 
PLACE OF DEATH: — County ofOo/^v J.^a,oVCVA ..(City of UO/^vx, Jn.Q.'> 



VC (^Ci. C '. 



No. ; M 1 



% 



, St.; i Dist.;bet.^A.<XT\/T\XWu and J ^U>\^j(L/>\.c( ^ 

/ .r DCArn occurs away trom USUAL R E S I D E NC E G. vr tacts called pop undtr •special . n roRMATiON' \ """^-^ ' ^^^ >* 

V -r orATH OCCURRED . N A HOSPITAL OR .NSTITUT.ON O.VE ,TS NAME INSTEAD Or STR EeI AN D N UMBER ) 

FULL NAMELL .lILc. , I A. vLI\X/^o \x.o.tx;v 



PERSONAL AND STATISTICAL PARTICULARS 

\\ \ , • 




1 



I» \ I i: I >I l:lK I II 



i.dvt 



o 



M.-iMhi 



\' -h 



I ( 



MEDICAL CERTIFICATE OF DEATH 

i»\ri-: (>i- n];.\Tn A 



^^ 



' '-• . I r M \R k n: ii 

u iiM >u );i> OK i)i\( »Rri:i) 

' \\ I i!< ill soti.il (li sit-ti;i!i..iil 



I! IK Itn-I. \i'l-. 
< St;itt III foiiiit I 



^ 



L/^^y^< 



L 



N XMI' ol- \ 

1- \ Til Y\i ' 






t> t' 



I Hf{Ki:!',V CI-;RTI|-V, Tluit I atlcn-UMl .Ucoas,-.l fmni 

i9o'( to ..A.' Wu I i<;o'-i 

that I la>^t saw li .. alive on ' '^C v i ,,,o 

an.] that <Kath occiirrcd. on thr .lati- statr.l ahovi-, at 5^ 
M The CM SK^OI' DI'ATII was as foll.nvs : 



CMiX.'^^ C -v-v-'Li.'xjC t ..„ 



I5IK 111 I'l, \\ V 

OI- I \iiii:k 

' St.lt. . .! r. Ml t!t r \- 1 



M\n>i;\ \\M|- 

•'I' Moiin.;K A 



I'lk.xrioN Years Mouths Days Hours 

CONTRIIU'TORV LL'iXix. . , -.;m 



I''IK1HI«I,AC1-, 
o!' M<CI-||1.;k 
'StMlr MI Coiilltl \ 



' ' 'I TXI'ION 






DlkATlOX }V(//-,v 








(Signed ) 



Mouths Pays 



•'--<. 

^ 



Hours 
M.D. 



(A.Mrc-.) ^?\Pk Ot^^^<.<,^>v 'W 



Special Information only for llospitdls, Inslifutions, Transients 
or Recent Residents, jnd persons dyint) HH.iy fro.-n fiome. 



fx'f'tiird III Siti! /-'i ,1 Hi i\,-,i 



)'r,i; - \ M.nitli. 



/:: 



I "•; \";.'\1' ST\ ri.i, !.(.KS..\ \i. l-\KTh-||.\K^ AK).; TUI )■; To Till" 
"•I.>I (»!• MV K\d\\|.i:i)(-.i.; wd miiji;!- 



former or 
L'sudl Residence 

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



How long at 
Place of Death ? 



Rays 






\.i.i„.s HHH 'K'<xy\KAX 



,t f\x. 



I'l.Aci': ()!• lUKiAT, OR ki:m<»\\i. 



I) AI'J'; ..! in Ki.\i. ut KlvMOVAI, 






IN. B. livery Item oir" Jnform.ition Nh.>ul(i I,.- ciroltiilly supplied. AfiG should be stntecl KXACTLY. PHYSICIANS should 
state CAIJSL OF Di:ATH in pini., terms, that it may lie properly classilfled. The "Special InVormation" for D«r- 
Ron« dyinft uwny from home should he ftiven in every instance. 



1 1 



i 



KV » 






I 



I 






WRITE PLAINLY WITH yjNlFADlNG !NK 



■•••#^ •«•. • i_ — 



/>^^/^^ Fi/i'd 





W0\ 



Deputy Health Officer 



ii-iio lo M Kt-HiviArMENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTION S 

Ev£i\sfcrcd J\^). 






DEPARTMNT'OF PUBLIC HEALTH-City and County of San Francisco 






Certificate of H)eatb 

• "U. S. Stnn^arC» j 



PLACE OF DEATH = -County oi^^Uj^^.^,, c,y of da.Xa........ 



No. V.Uu 






' -^^' ''^ "■' V. , •..>J..O.J.. St.; 



Dist.; bet. 



and 



A /' IF DEATH OCCunIs AWAY TROM USUAL R F c; i n f M <~ c ' anO 

F STREET AND NUMBER. / 



OR INSTITUTION GIVE ITS NAME INSTEAD Ol 



) 



FULL NAME 



Plo '' 




i) 



"^^ ^ 



-MLt.l>C\VC 



PERSONAL AND STATISTICAL PARTICULARS 



I 



*"• '1,1 )k 



i»A ii: < 'f I.IK in ^ 



\!--nli» 



\' .i: 



ff-^ 



1 



I .!/-»///, 



\VII). t\yi:j) »(K I»!\( (RD r) 
\^ I It'- ill ^<Mi:i; iN -^ii'ii.-iti,,!! ) 



nn<riiiM,\('j.- 

' St. if- ( I (•.Mint! V 



k ( ;ii I 



/>,;i 




NAMI-: III 

FA'nn.K 



niKTni'i. Aij.- 
oi' I Arifi:K 

'State (.1 l.Miiiti \ 



M \ II»i:\ NAM) 
'" MoTIIt; U 



''•'Krni'F.Al i- 
ni Mi.riM.U 

^' ' ■ "' ' '"tUIlt 1 \ 



I 



,\_ 



MEDICAL CERTIFICATE OF DEATH 

DATl-; Ol' DI-.AIII \ 

I iIM<KnV ClvRTlFV. That I attc.k-.l .lecvasecl front 

•••■•' 190 . to Lai.L .^i „^o'^ 

tliall last saw h .. alive on iU'd .. ,^ 

an.l that .hath nccnrml, .„, the <late stated above, at ' i 'j '^ 



M ,| ( 



.•n„s.^ 




IX RAT I ON }\>,j,,, 

fONTkllirTORV 



Monlhs 



/>avs 



Hours 



nCRATlON 



)'/■■(//- 






.Von t /is 



/hivs 



Uigurs 
M.D. 



0"^ 






A''- /./,■./ ,,, s,,„ ,,,,„,. ,., 10^ 



) , .!, 



-^ 



1A.;////. 



(SIGNED) J . l)\ ')t 

^T I O N only for Hospitdls, institutions, Transjents, 



I(;o'l { 



Special Informat.win -'...» ..,. m 

or Rerenf Residents, dnd persons dyinij dWdy Iroin ftome 



n.:\ . 



( 



'''"."T;;i^il^^;,;;'^sr,^'Ai;f;',^i;,:,i;^---^ '- -'- 'HK 



fhif.,Miiaiit 






former or 
UsudI Residence 

When was disease rontrarted, 
if not at piare of deatfi ? 



How long at 
Plare of Dedtfi ? 



Days 



^'' ''<- LaJIu AcLc. 




0- 



Mvwx^ 



l^l'I.ACK OJ- ISfRJAr, OR KI-Mo\vi | iTTrT TT 
rXDl-RTAKI-K JuXLUi X dl^OLao.. , 






1 



/ 



fM( 






WRITE PLAINLY WITH UNFADING I 



NK TUIC ICr 



t k ^ m • k 



\h ,'i!i I- \. 



~-^^ nscv Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Regi.sfcfrd J\^o, 



380,3 






cLcTLoui (Lt^Hj, Deputy Health Officer 

DEPARTMENT OF PUBLIC HE ALTH-C.ty and County of San Francisco 

Certificate of 5)catb 

PLACE OF DEATH:-Coun,y ofd CV^.'^.^a.^a.^cCy of .L>.\^.v... . c 
iNo. ill I 'Jb.Vt •. c,. r,.* L.tl . '^ f 'J t 

C T nr.,„\occ..s .w.v ,„o„ USU.L RESIDENCE o,v. HctI'V*^'- ^ ^^V-OT-lV .^^J J , »_ ^ . - ^ . 

(. - otv„ OCCUR-, o ,„ . „o,P,T.. "fN^nxurmJc'/^n ^Vi,'." .'"A.".'".''" ■■"""^ .N.„„„.T,ON.. ■> -" 

OF STREET AND NUMBER. J 



FULL NAMeUvUcI.:'^ U, 



^ 






I iVX. I ^,. J 



'^ 



si:\ 



I' \ M. . .r i;iK 111 



X' • I-: 



PERSONAL AND STATISTICAL PARTICULARS 




-r 



XO 




L 



.L.^\. 



Oct 

■ M-.ntli' 



,1 



I 



MEDICAL CERTIFICATE OF DEATH 

i)Ai-]-: or i)i:\Tn /A 



ID.iv) 



il);iv) 



) ,-,t 



1/ , 



\ ■ 1 1 



Ihn 



11, 

1 nnRKHV CKRTirV. Th.., I.m.u.K.likcvMso.l from 



/ QO 

(Year) 



unit (Wiin UK i)i\-. , II) 

'VVtitt JM .,„|;,1 .!rsi-n.itl..;i) 



I'.IIM'ni'l.XCI' 
'Strilt iij r.niiiii \ 



\ I II Ik 



Mr kill I- 1, \(|.- 
<>' I xrin-.k 
'^1 'tf -II r.iiuiti \ 



"*' \n>i:\ N \M 1 



I'-IK III I'l. \< !•• 

"I' Mo'nii'k' 



n 






••-> 



tll;if I List ^;i\v h 



tn U --J 



all\ (• nil 



.•>n.| thai .Kail, ocr.irrcMl. ,,„ tlu- .lati- statcMl .,l„,vr, at 

M. TIu- CAl SI-: OI- |)|.;.\Tn wa. as follnus: 

t . 



I()0 

1 90 



: \ 






\ >.. > ^ \ y^ 






n 




^ ^VK^Cl 



1 

/ I 



OX\^^U ...si) r. 



IXk \TI()N 



)'rars Mo)ithx 



Pars 






/louts 



*? 









t I 



I)tR.\'II()\ 
SiG 



)'cV7;-.v 



"I r xrinx 



*)w 



NED. Qn^iJ.^i 



Mtuit/i: 



/\n'} 



'S 



//i^iirs 



^0^-sLl. \. , 



M.D. 

iQoM fA(Mivss) IXXO BA*.tU.V ''H. 



?^^9'^'-."^f^'^'^'^"'"'ON only for IJospitjIs, Institutions Frdnsienfs 
or Recent Residents, .ind persons dying away fro.Ti home. 'ransienrs, 



)V,// > 



M,n,!lr 



/■ 



'■''n.;v;.';,^;^i;^;;--:[--'Ai;;/<^;;i!,i;^- --^ ■'<" ■- ■■'- 



^I'ifi);in.iiit 



a 



C 



-LtlxJk 



former or 
Usual Residence 

Wfien was disease rontrarted, 
if not at piare of deatfi ? 



How lonq at 
Plare ot Death ? 



. Days 



'V'M..^^ 3.1 10 ()l"^^V'A.A a1 



T90' 



jF.XCK OF lU km. <.k^K..:M^,VAI. I ...^i:,.| IMULM. .„ kKMov.M. 

A<i.i..-ss 3>.i*^.h..^..- \ajji di 



(.■ 



""' "' ''Zl! l'^:::^sv o':'^^^^^ '"^ "•"*'''""- -"'P"-'- '^''f-^ '''^-''' •- HtHted RXACTLY. PHYSICIANS «houlH 

»i«ic v*/%lJ.>i, 01 OLATH in plnln term*. tliHt it mny be nroncrlv cln».«ik*{eJ Xh . ••« • 1 ■ "'*»'^'^'^'* should 
-on, <|,.i„4 „^„y ,Vom ho.„c Hhouhl be ftivcn in every iaHlnTe ''"""'"^*'- ^^"^ ®'»"^'«' l"*orm«tio„" for p.r- 



II t 



I 




WRITE PLAINLY WITH UNFADING INK _ 



HPI 



IC iCr n trtr'i'^Mmmt^.m^m.. «m^ 



) i 






Ihth' l'lli',1 , xrUrLMy^-^viM.^; ^ 



:l 



^ 



rJO\ 



nmMi>ici>j I RECORD 

RgFER TO BACK OF CERTIFICATE FOR I NS TRUCTIQNJit 

Itegistered J\^o. 



28041 



n^; 



t ?« f^y or 



DEPARTMENT OF PUBLIC HEALTJKfty and County of San Francisco 

Certificate of IDeatb 

< tl. 5. Stanza rC^ ; 
PLACE OF DEATH:-County oiL.3.>.c..^^^, chy of C^^.>.^^.V<x .. o. , .. 

• w.La..'-^ 



) 



FULL NAME 



M : \ 



PERSONAL AND STATISTICAL PARTICULARS 

\ ^ ' ' ' I . ' I k 



fiv. 



O^'^K 



I* \ ; J ' 'f i!ik I'll 



\' i; 



(^ 



U^ 



Moiitli 



MEDICAL CERTIFICATE OF DEATH 

i>ATH oi- ni-: \ 111 



Moiitlit 



(Dmv) 



(Vt-ar 



I FIKRHnV CHF^TfFV. That I attendcMl .l.cv.s..! f,-.,,,, 



to . vlT-C^^ 



"'IN'.I.i:, M \kK Hit 



State or (."..uiai \ i 



\\M1 (M 
I- A 111 l.R 



HFK rm-i, An-' 
•" I \ rin:K 



^'\II•J•:^ \\mi 
'" M'»'i-in;i< 



Hll<TinM,,\c,.' 

'»'• m<iThi;k 
''';it< M, r<.iinti\ 






/>C^'"^0/ 



t 



'Ii'it I laxt saw l! '..■■. alive on w .. .. , ^ 

Ml. I that .Uatli nccurrcMl. o„ the .late stated ah<,vr, ,,t 
W ''"' ^•^''^'- ''^'\ '>1;ATII was a. fr-H.^vs; 



t 



v<?t:.i^,A^Vw- 



C.^t 



V(i 



C. 



\L'vL 






O O 



l) 



Di'RATloN ),,/, 

^■< >NTKii:rT<)in' 



. JA '///// . V 



/>»<nv 



Il0U)S 







' la. 




hlR \TI()^• 



)'(•(//v 



Vj 



Signed) ^9 m\ J ^VL 



^'1 i'fii/i.\ 



/\iv.s 



'uar 



.:*». 



I()0 



//oius 

M.D. 

(Address) M 1 1 S M, t U. ^ 4x.^x 'Jt 



' '' < I !• A riox 



f ^9' fiK"^rO'^ "NATION only for Hospitals, Institutions Transients 
or Recent Residents, and persons dying away from home. 'ransients, 



M.nith^ 



% 



I hl\ 






Former or 
Usual Residence 

When was disease contracted. 
If not at plareof death? 



How long at 
Place of Death ? 



Days 



\.i.]i, 



(%?. 






V' ' c 



4 



:<y<Ll 




ri.ACy.:()F IU^KIAI. ,,R KKMoVAI. | DATKof MnoA,. .MKKMnVAI, 

QXcrvr 1 



s b..H.^....l)'<xilt^<,...£ 



TQO'l 



iire^'jAirSEof d7;V^^^^ ''7'*' ":' '""^'^ :• '^ ""'"'"*^'- ^^^ ^^^"'^ •^^ «*"^-' exactly, physicians should 
ic s*^u:>L Ul Df.ATH in plum terms, that it may he Dronerly claaHWIerl Th» "c • • ■ "'*'"^"*'^» should 

«-", .|,|„4 „,„y ,Vom home should he ftivcn !n every instance ''""'^'•^- ^'^^ ^'»'^^'«' information" for p^r- 



' I 



mm 



ammmm 



! I 



"^ 



t 



. l-^JU 



WRITE PLAINLY WITH UNr/in 



« av t > 



I Ni r^ I Ki i# 



•»* I ■ « t% 



!■..•■': II. .''li r v., ■' ■*'V^;^~^.i:{<c\' C 



lUdr AV/r./AjV\M^-.^x,!>Ov 



cMr^wA.v<i 




ll)()\ 



— ^TriiS iS A f-tKiviArNEfVT RECbRb 

REFER TO BACK OF CERTIFICATE FOR I N STRUCTIQNc^ 

llegLstered JSTo. 



2805 






DEPARTMENT 6f PUBLIC HEALTH-Citj and County of San Francisco 



Ccitificatc of 2)catb 

( "U. S. Stan Da rO ) 
PLACE OF.DEATH:-County ofCW.^. JAa,>..a..ccGty of Occ^Ta..^<^., 

No. iiHia 



St.; I Dist.; bet. J a.\.yl.>&\i 

_ FACTS CALLED 
OR INSTITUTION GIVE ITS NAME I 



INSTE^p OF STREET AND NUMBErL / 



i^ist.; bet. vJ CVWL>& \i and ^ .t > .> 

^^'il! ^V«r '°" 4°" "SPECIAL INFORMATIc/tc 



FULL NAME 



I-Uj 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 




(1 



D 



yx\X' 



nu ? . 



•i i.iKIII 



u 



MEDICAL CERTIFICATE OF DEATH 



i».\ ri-; (n- di: vxw r\ 



(MoJitli) 



' ^t.,Ilt}l> 



/'^S'-i 



Af.i-: 



I);i\ 



1 /•'.,//,. 



1 
1. . 

(I)av) 



I go \ 

(Yrar) 



/'.M. 



•^.'N'.I.J- M \1<|< 111) 

\\ii)<»\\i.:i) ok i)'\-, .Rn- 1, 



Uiit. i 



n '■^ 



■ nai i, ,11) 



A 






HIKTHIM, Xr}-; 
'Slat,, or riiiiiiti \ 



lAI II IK 



lURTIIlM, \CK 

<>|- 1 \ riri-R 

"'lit. ..I ('.,llllll\ 



^'Mi)i;\ \\Mi 
"I M'>tiii;k 



iiiKriii'i, \ri- 

'" ^t^•|•||l.;K' 
' ^t.iti Ml r..miti V 



)! 



I Hl-;Ri;nV ri-RTlPV, That I atlen.k-.l .kvcasd from 
'VO to Q\f^.-- I ,,,oH 

that I last saw h . alive on ^ ' ^ ', 

and that .Icatli occurred, .ui the .late stated above, at ^ 
CI M. The CAISI.; (»!•• UI-:.\Tlf was a. follows: 






l^ 






T . , , 



^■' 



( (, 



'' ■ '^^V'...L<ysiA. 



"1 KATION );•(//-.- 

t^'oS'lRiniTORV 



Monfhs 



Pars 



//ours 



DC RATION );v//-.v 

A 



.'\fouths 



( Signed ) 

a- ,, , t 

I()0 




■^ : 



nay 

< -! 



( 



\v-^ 



' "TI'l 



■\TloN pp 






//ours 
M.D. 



f ^9'fi'"."^f°^'^^"'"'0'^ ""'^ ^"' "n^Pi'-JK Institutions, Transients 
or Recent Residents, dnd persons dying .iwdy Ironi home. 



O , '• 



AV'w,/,-,/ ,.„ s,;„ / , ,,,,, ,.,,,, 1 i 



1 A -////,. 



/', 



I I 



'"'m^^Tor M"v'rv'i;^''^''^^'''^'^'''''-^«^-^«HTKIK T. » TIN-- 
'w.M oi- M\ KNOW i,i;i)(;k AM) I!j:mi:i-- 



Former or 
Isudl Residence 

Wfien Has disease contracted, 
II not at place of death ? 



How lonq at 
Place of Death ? 



• Days 



^Illf.);i)laill 









T90 



n,ACK OF lUKUI. OR RHM..V.AI, I ')Vn.:.,f llriMM ,„ RKMOVAI, 
(A<l(lr^■^s Q,.l H XyC^-<i^( 



i;re^c'urSE'oF'D7;T^^^ ';^' """''';;'" r"'*''"^'"- ^^^^^ «'^-"" »- «»«»-• P.XACTLY. physicians nhouUI 



: 'i 
♦ 



if ^j 



r 



I 




WRITE PLAINLY WITH UNFADING INK — 



C I cr A nr- r-k I 



M..Mnl < f Tr..'ilth !■• V.) ■-• -srw-;- nSc \' C 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



C^V^W/^ 




IfJO^ 



Jiegi.stei'pd J\^o. 



'2806 I 






DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Gcvtiticatc of H)catb 

J? ^ 










PLACE OF DEATHr-County ofCW.vta. ^Lcw Gty of 0^^, >,^e. LaJ 



No. 



(1 " .''/nl*'..°*'^'""' •**'' '"°'' USUAL REsTdVnCEg.ve ^cts*c- 

V .r DEATH OCCURRED IN A HOSPITAL OR .NST.TUTION GIVE ItI N 



/' 



St.; 



Dist.; bet. 



and — 



FULL NAME ll0Litx\) A 



■Vi'/i' ''°" UNDER 'SPECIAL INFORMATION" N 
AME INSTEAD OF STREET AND NUMBER ) 



^-'.. ) 



PERSONAL AND STAT!STIC/>L PARTICULARS 



■^IIX 



> 



! coi.ok \ 



I' \ i r ( »f i;ii< ill 



V 



D.iv 



\' . I 



^ IN' 1,1 M \ kU \\ \ 



I.Ik i iifi, \('j.; 
' stiitf itr C'uiiui \ 



I \ I'll i;k 



HIKrni'I.\o- 

OI- I \ rm--R 



MEDICAL CERTIFICATE OF DEATH 

'Ml. mill 
I UKRKIJV CI-RTIFV, That I atu-n.lr.l .Ic-rc-ascl trn„ 

\kO tn 



'I);iv> 



/ (JO 



i 



O. 



' V, ^ 



ali\c on 



that [ hist saw li .. 
■ m.l that .katli occurrd, on the <lati- stated ahovc, at 
M. Thr CAISlv ()!• I)|;.\TII was as 



I90 
1 90 



foil 



ows 



v-L.L->->-v , 



i ♦ 



I ' : \ 



M MI>i;\ \ \M1 

•" M"'ni}:K 



'■'!'< I' HIM, AC K 

"" M«»Tm.;K 






Cr>v Cp 



. ^.L '. 



^ _ I _ 



DC RAT I ON Years 

C(>.\TRli;r'i-()RV 



Man f /is 



/hiys 




\oj 



% ^ 



,ait 



Ai 



<"'^Tp\i-i().\ 



'JL^UA 






DC RATION )V.7;-.v JAv/M.v 

(Signed) lL .. ^k 

\l\t\r 



/^ays 



<^ I()0 , 



d 



v^a 



v.. V 



Hours 
I /ours 

M.D. 



(A(Mr-ss) dxx,>jH'?^-<u I 



?„?!S?ifii:..''^_f9.^'^^T'0'^ ^"'^ l""^ Hospif^ls, insfitufions, Irdnsients, 



■■ *-s 



' o 



■~i > 



''^' '''''■ '" ^':n.' /',,'//,•.,,, ',. (, IV,. 



or Recent Residents, and persons dying av\ay frorn home 

Former or l ' p 

-CUV' 



Usual Residence 



.U\..<mj \.. ■ 



M.'titli' 



'U.M 01. M\ KN0WI,);i)(.K AM) ni:i.I I-l- 



/h; 



When was disease fontrarfed, 
,; ; , If not at place of death ? 



HoH lonq at 
Place of Death ? 



Days 



IIII: 



AX \ V d-^../'.... 






<:c^k.eA<L tAjL Ltl I. a.i 



W ACKOK m-RIAI. OK KKMOVAI. I DATi:.,;- \U^u.^^. ,„ KKMoVAI, 



(Atltl 



less 



ini 0^\ 



^vCiAA^/CrvA; iJ n:t 



IN. K. 



"rtX^C^USE of dTathV'^T T ^^'"^^'""'^ -ppli.,1. AGE «hoa..l be stated EXACTLY. PHYSICIANS should 
Hnl..\'^ OF DEATH In pl«,n terms. th«t it m«y he properly classified. The "Special Information" for D^r- 
Hon, dy.nft oway from home should be feiven in every instance. Tormaiion »or per- 



1 ' 






i . 




WRITE PLAINLY WITH UNFADING INK 



TMic: icr A tac-ckH 



m H tki r- Ikt-r- r*r>.«..«.a._ 



H..;(!.' . r H. i!!!. 1 \. - -t-*- •sT^i.;. J>,5^ ). ,\, 




Dff/r Fih'd , \lltpu<^/>>0([MLV 3. 



>JcmL' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



vjn\ 



Keo^isfrrod J\^o. 



O 



807 



:^C^VA<.^ -<^ 



Deputy Health OfTiccr 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Ccrtifk-atc of Scatb 

( "CI. S. j5tnnc>arC> ) 



PLACE OF DEATH; — County of 



City of 



\' VjIckl *-> 



No. 



St.; 



/ ir DFATH OCCURS AWAv r R o VI USUAL RESIDENCEgiv 

\ IF Dt*TH OCCURRED IN A HOSPITAL OR INSTITUTION C 



Dist.; bet. 



and 



■ 'r^ 



e FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 



1^1 



■\ 



\^-^i 



h 



PERSONAL AND STATISTICAL PARTICULARS 



hPlcxu 



I-: r 1 1 



MEDICAL CERTIFICATE OF DEATH 

i> A ri-; 111 iir \ru 






LUVuJL-' 



n 



I IM^UIJIN- r|.;kri!-V. TIi,.t I attcn.lc-.i .lev. ;i....l h,„ 

j^p ^^^ ~— — 

tlwit I l.isf s;iu ], alive oii 



II 



I()0 

I90 



\\ IDnWKD <>K I' 



'St;it( .>r i.'cMiiiti \ ' 



\ \ M I I .! 
I '. I II I l< 



) I) 




o 



■ iM.i that .Kalh ..ccurrcd, 011 tlu- .lat.- stated abovr, at 
^'- ','"Ji^- CAISH 01" DICATII vva. a^ follows: 



'UKTIIPI.ACI- 






I'iKriN'I, Ai'l-- 
<»1 NT.tTlII-.R 
^' ■ t"'>inil I \ 



•I' 'T !• \ riox 

'''''■'</'(/ III \,i>i r< ij }•, i^i'ii 



1>I RATION y,ars 

K < >NTk I ill T( )K\- 



M()}illn 



l\x\ 



'.V 



Iloiit s 



( Signed ) 



)'i'(irK 



C^ ^ 



.Ui >/////: 



/I 



v/rv 



^^ 



I 



\()() 



( 



A<l(lrfss) -'/C' 



M.D. 



K<^^^Ou ^^ 



Special Information only for hospKhk, institutions, rransicnts 

or Recent Residents, and persons d>inq dw,iy from home. 



) rifi 



Mini thy 



/>< 



III. SI 01 \\\ K\.»u i,i:iM-.H .\M> I!i;mi-:i-- 



Former or 
Isual Residence 

When was disease contracted, 
If not d[ place of death ? 



lloH fonq at 
Place of Death ? 



Days 



./>• 



State 





H Ol-^CKIAI, OR KICMOVAI. 



i)Ari;.it lit i4i.\i, ..1 ki-:m(ivai. 

^Wvr h 



I'NDliR lAKliR 




(Adtlrcss ....Q)./0^y\ 






T9O ! 






rry item oif information should b? ctirefully supplied. A 'IB sh.nild he stated EXACTLY. PHYSICIANS should 
te CAUSE OF DEATH In pinin terms, that it may he properly classified. The "Special Information" for D«r- 
« tiyinjl owoy from home should be f^iven in every instance. 






ll 






hp,. 



i 



:ii 




i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M..,r.l ■■( !I. :ilir I- V' 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i|' 

.1, 











190 "i 



llegl^fercd J\^o. 



O 



808 



xyvcv^ -LcvH, Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDcatb 

J? (^ J? (^ 

PLACE OF DEATH: — County of C'Cb^^- J VCL^x -^NLicCity of 0<X.>v J.V<X, ^ .cuCL^i 



■' r 



No. 



ti 



nt J XVvO^O-rvO.' St.; Dist.;bet. 5 .U\' and I ■ 

(ir OCATH OCCURS AW/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. / 



> ; 



FULL NAME 



I 



PERSONAL AND STATISTICAL PARTICULARS 

^1. . ■ . 



0\ 



MEDICAL CERTIFICATE OF DEATH 

DA ri-; oi-- i)i:.\TH 



: ' \ IT. (If- !; IK I'll 



c 



,t 



\i. !•; 



0. I 



at 

' D.tvi 



Mnvtln 



n. 



siNc.i.i^ M.\kKn:i). 
\\ii)i )\\i:i> (»u i.\-, .i-T II) 



\\; itt in -,„ 



HlkTHl'I.AOK 

'Stiitc or Count I \ ' 



;tloIl) 



Vi\ 






(Moiitlil 



I 



IQO A 



I lll-:Ui;r.V CI:RTI1'V, That I atlcii.k-.l .It-rc-a^od from 
. :.\. 190' to Al^^jv*- ?> iqo 1 

til at I last saw li alive t)n I wCV "2^ icp 1 

and that dralh < >o(.-inrcd, on the date stated above, at I \K 
M. The CAT Si' Ol" DIIATH was as follows: 



NAM J- OI 

FA rm-.R 



Hik riii'i, \<K 

<>!■ I'AIMl-.k 
(Statr or I'ount! \ 



MMIU'N NXMI', 
<>! Mo'nn.K 



lukTni'LAci-: 

III- MnTm-:k 

i Sl;i|i or roiiiit r\ ' 



orrri'AiioN 




\^JL^ 



^ 




Wl 



\xkx- '\Lv l 




") 



•wf •. 



DTK AT ION Yiarx 

CONTRir.rTORV 



I )r RATION^ Years 



Months 



Pax 



Hours 



(SIGNED) Mi Lt( 



Mo}iths Pays 



Hours 
M.D. 






cWl 



,0l ^ ^cv 



^\.„ : 



I()0 



(Address) 111 V.1 > Nil ... \ 



Special Information onlv for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyin;) .iway from home. 



k'l'^ulrd ill S,?;/ / 



; ,; I', / ',,■.) 



)■.-,.•; 



yi.'iiHn 



/>,ir 



ill I'. MJOVl'. ST \ri:!) I'KkSON \I. I'AKlIiTl.AKS A K l-. PKri-: I'D 11 ll' 

iii'isT «)i Mv KNi)\\i,i;i)(-.K AND in;i,ii:F 



(Inf. 



>i niaiit 






Former or 
I'sual Residence 

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



How long at 
Place of Death ? 



Days 



ri,AClv Ol" HIKIAI, OR R];M()\'.\I, 



D.Vri'.of IJiKiAi. or kl':Mn\-.\I. 
^V L IQO 



ini»i:ktaki:r IX^n^AXl^ LLvvciX'xLa^ ' 

(A.Mivss %{ok) \l/\AAA^UrY\ .. ' 



N. B. Every Item oif infi.rm.ition should b.' cnrefully supplied. ACF. should be stilted KX4CTLY. PHYSICIANS should 

state CAUSE OF DEATH in pliiin terms, that it mny be properly classified. The "Spcciiil Information" for par- 
sons dyin^ nway from home shouhl be feiven in every instnnce. 



I 



11^ 



■H 



<■ 



)} 



'I 



1 



It 



< 



t ! 



n', 






^1 




.«. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ho.inl of MLHlth--}" No. !- "J'v*??^ UK:!' I'o 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







rJO'i 



BegLsfered J\^(). 



2809 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



[ X\. S. Stnn^ar^ ) 





No 



PLACE OF DEATH: — County of LLLcL , . ^^xLa City of 
iVJlX<l<.c\.U.>xq ')'0&<i.i\'.l.x\ St.; — Dist.;bet: — and — 

/ ir Dt*Tfc OCCURS aWv»v rnoM USUAL R E S I DE NCE Gi ve tacts called roR under "special ineormation 
V IF deS^th occurred in a hospital or institution give its name instead of street and number. 

FULL NAME V^^-nJU uId. CoatJU^ • ' 



>vA LoJ- 



) 



si:\ 



li.\'V\ > ir ill kill 



\ ' I : 



PERSONAL AND STATISTICAL PARTICULARS 



IL^ct 



'Moiithl 



vV 



i)..\ 



^ r 
•^iN' i.i' M \Kk n;i» 

U IIK lU i;i> < tK IH\'< »Hr JM) 

' U't it<- ill >.ii,i:|] ill viiMI.-lt'i '!l) 



^ 



I'.IK rill'I. \y'V. 
'St.iti' or (.'oMiilr V I 



I- A II! r:k 



111 kill IM, All-; 
•»!■ i'\riii:k 

' >t:i!t lit ("i )ilill t \- ' 



M MDJ-N V AMI 
Of .MoTMI.k 



llIkl'm'I.ACJ-: 
oi' MOTHKK 

'Strit" or foiintf \ 



<^x>xqLe.. 



I) 



(1 



MEDICAL CERTIFICATE OF DEATH 

1) \ 1'!. I >!' DlvXTII 

{Month) (Day) 

I IM'lUlvP.V Ci:RTn*V, riiat I attcMi-k-.l .kccased from 
^^^^ _ ^^j _,_ ___^^^ ^ 

(liat I last saw li ~ alive on 



/go 1 

(Yfiir) 



I(>0 



and that <katli n(Mnirr<.-(l, on tlu' ilatr statc'il ahovc. .it 
M. Tlir CAISI-: Ol" Dl-ATII was ms follows 



-\ 



/ 



<D^->AJL^ LOLY^V 



K ,1 



ULVO 



CL ) V > ..' 



DIRAIION ]\'ars 

I < tNTKIinroRV 



MofU/is 



/)(}] 



•s 



Hours 



(^ 



<>' <^ 11' \ I'loN ,'0 1 



J- 'uX^LxXv >xcL 



1)1' RAT ION Years Moufhs ^ /htvs 

( SIGNED ) lb . Vih. \I/IlLv.Y>V<X. , , 



Hours 
M.D. 



Special information only for Hospitals, Institutions, Transients, 
or Recrnt Residents, (ind persons dyinj away fron liome. 

Former or , ^ , J OO j \ How long at 

Isual Residence I uH hXlkkrw 3X 



Piare of Death ? 



Days 



/\'"iilri{ III 's.ni I'l ,111, i-i-,< '^ ^, JV(7, 



yfoiiiin 



/■.I 



'111 I. \u<>\ i: -, r \ III) I'l- ksoNAi, I'Akrit'ii.Aks Aki". Tkt !■: rn rii !•: 

lilsIiM MS K.\( »\\ ij.jx; K AND nKMi:i-" 



(Inf.,! 



nImA^ ^ Ouy\/>/></xkj L<X^v\\ivLL) 



UiMi.ss 



OH AXJUU 



Tu 



When was disease rontracted, 
II not at plac e of death ? 



190 . 



I'l^Cl-: Ol- lUklAI. Ok klCMOVAI, I DATI-of Mikiai. or kllMoVAI, 
....0 'U.'A (V 



(Ad( 



N^YtuiAA.-^m. 



IN. B,. 



-livery Item otf Informntion •hould be carefully Hupplled. AGE should he Htated EXACTLY. PHY8ICIAN8 nhould 
«tntc CAIISK OF DEATH In pintn terms, that It may be properly classiltied. The "Special Information'' for p«r- 
«in« dyinit away from home iihould be ftiven in c\cry Instance* 



u 



;■' 



31 I 



Ih' 



rr 



.11 



i::- 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ii.i.ir.! ..f 111 ill)i I' No 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Xtrccv^ ^. ', Deputy Health Officer 



liegLstered J\^o. 



2S\0 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of H)eatb 

( "a. S. Stan^arC^ j 
PLACE OF DEATH: — County ofOxX/^^, J \XX . -;lc<: City of Cj/OyVuvJ/vcC'^A.CA^iLC 



No. 



1 ^l Ha^^-<^ ^~ -^ St.; Dist.; bet. ^' 'i^C'P. '.. .. . and l'l.\.lv<r > v). 

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



^ii 



\A 



FULL NAME 



lb o-t ) ■- • 



-^^\ 



PERSONAL AND STATISTICAL PARTICULARS 



V I 



l> A 11 I 'F MR 1 II 



as : 



MEDICAL CERTIFICATE OF DEATH 



..^::> 



ll^v^ 



M..I111P 



\' . 1-: 



>.i \ 



1 ' ».'/, 



'^IN'.l.r: MAKKII !i 

\\ II)( lUIW) OK It;\ I 'Kv I-. I) 

W:!!' in "-((I'liil ili-^i^' ti.it iiiti ) 



I'.IR rill'i, \r\-, 
^\:\\v or •-■'niiiti y) 



O ' 



(Month) (Day) (Year) 

I m:Ri;i'.V C'I:RTII'V, Tliat I atton.k-.l .UiviistMl from 

_. j^^^ ^^^ : .;:r r7. " - . - i(p 

ihat I la^l <a\v li alive oil " T()0 

iinl tliaf (Katli ocrurrcil, on tlic dati- ^tati-d aliovr, at 
M. Tin- CAl'Sf- ()!• I)1-:A'1I1 was as follows: 



6> 



^ ^>v' 



lv-W\<iji' 



<iJl'Vv\. O ■ ' .. 



I- A 111 j;k 



i'-ii< ill II, \. r: 

OI- l-ATHHK 

iSt.if*- or l"iiuiit r \ 



M \ii'i:\ N \Mr 

OI MOTIII.K 



IMK I lll'I, \» 1. 
«>l- MoTllJ'U 
(Stat*- or t'ouiitt \ • 



I' » 11' \l ION 



? 



'D 



I )r RAT ION )'<ais MoulJus Days //oms 






I)rRATI<)N\_^ )',ars }ro)iths Pars Ilour^ 

I SIGNED ) J .^JuLl^A.<:A vJ ^s a. . ^ 



M.D. 



,A^VO 



\l Ua 



rcjo 



(A(l«lrcss)Aa.Cb . 



I \ 

I ..ujuXL.. 



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



ly'r^nlril in Sidi // c,/ .i \\i 



) ,,/; 



.■\r.iitfi'^ ' /hn> 



I" III-; \|{()VI-: Si" \lll) !'1-|.'s. >\ \l, !• XKTIcri. \Ks AKI-; rKIH TO TIIK 

iu-:sT oi- Mv ivN(»\\i,i: !)(,!-; WD nri,ii-;i-' 



?^ 



(lllfo'llKllU 



L.rw/v\^ LO 



CkAJ 



(\Mrrs^ TX^ HfO^/cJk^^L-irr^ at 



Former or 
Isuat Residence 

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



How lonq at 
Place of Death ? 



Days 



I'l^ACK Ol-' lU'RIAI, OR KHMOXAI, 



INDl-.RIAKKR \) I vCXA/Y\; « w . » p.. 

(Address 1 ^ X...NJ.<a^C^Vll ' /^ 



DA'ri-;o!' iJiKiAi. or ki-:movai. 



TQO'I 



(1 



^' B. F.very Item otf irif .rm.itiori should be cnrefully (iuppl{ecl. AGB should be stHtecl RXACTLY. PHYSICIANS Hhoultl 

•tnte CAUSf: OF- DKA TH In pIhI4 terms, that it may be properly classified. The "Special Informntton" *or p«r- 
nons dyin^ nwny from home should be Hiven in every instance. 



I' 



l' * 






\l 



•it 






I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJO'i 



Dale Fi/('f/\\\f\>^yY\.h^J ' 

X^^v^ Lc . u Deputy Health Officer 



llei^isfri'cd J\^o, 



2811 



DEPARTMENT OF PUBLIC HEALTn=City and County of San Francisco 

Certificate of Beatb 

{ 11. 5. iytan^ar^ ) 
PLACE OF DEATH; — County of CX^rv Ja.o^>a.Culc<. City of Cj/a/v^OAx^AAx:uicc 



(Oil 



No. 



St.; 5 Dist.;bct« O VC 

(ir DtATH OCCUBS *WAV FROM USUAL RESIDENCEgi 
IF DtATH OCCURRED IN A HOSPITAL OR INSTITUTION 



A 



and 



\ t 



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



FULL NAME 



tviv 







\ 



-•(r^a^o/*..:^\. 



->) \ 



PERSONAL AND STATISTICAL PARTICULARS 



1» \ 11 < T IllK III 



a 



MEDICAL CERTIFICATE OF DEATH 

DAT!-: Ol* PICA Til 



■\t..L.(5.>.:- 

(Month) 



IDav) 



(Year) 



iMoiltl 



■>■(•. II ) 



\' . I- 



SIM. I, J.:. M \Ku ii:i> 

WIlMiW HI) OK I>l\»»Rr JJ) 
iWiitfin MKi;iI ilrsiv Hat i<iii) 




lUK iiii'i. \ri: 

I St:itf 1)1 i.oiiiili \ 



NAM[-: (»1 

lA riu.K 



MIRTH I'LAi}-; 

•>!■ I A nil-: K 

'^t;it» (,i Couiiti V 



M \il>l-:N NAM1-; 

"I M<)'rm;K 



i;iK liii'i, \ri-. 
"I MDiiniK 

'M;it( or I ..iiiili\ i 







— V~' 



I in-;Ki;i5V Ci:kTlI"V, That r attcn-KMl .Icct-ased from 

AL/'CL li>l u/^', to .ArXfi[\r X upM 

that I last saw h • ,\\\\v on \l *-^ i(_)0 

ami that ikalh t»c(nirreil, on the date stati'd above, at \ >') • 
i.i M. The CArSI-: ()!• DI'ATll \vas as follows: 



IXo^vXjL ^ J I \ \j, -Cr CXUvcWt 



a^.' ■:. 



% 



A^-Ci 



"^ <JO^KJ^' ^ 





<XKx,K \J I 1>CLHC 



C . 



'HTll'ATioNljNn ft 

/\>- iilfil III SiHi /■> iiih /"■■> .* ■ \ )V'i//> 



Id RATION )'i'ars 

CoNTKIIUTOkV 



DTK ATI ON }'((irs 

^ In r' 

iNED ).J \Xj. \^t 






J lours 



,}fonl/ts i /Ml'.? 



(SIGI 



IqO 



(Address) 5 Id 5 



'k KX.K 



Hours 
M.D. 



1 



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



Months 



DiW 



\'\\V. AUOVI-: Si' \li: I) I'KKSONAl, l'\K III"! I. \KS .\Ki; IK 11-: TO Til)-; 

Hi:sr oi' Mv K.\()\\i,i;i)c. !•; AM) m:i,n:i' 

form.-mt UJXX^IlXX\) \^ VV^4 V't-O., > V 

'\<i.in^s \o\ \JLoJvxx 01 



(In 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatli ? 



Days 



I'l.ACK Ol- mRIAI, (»K RMMOVAI, 




DATKof HCKI.AI. or R1;M()VAI. 
vrV-A3V. ^ I go 



r.\i)i:KTAK 



(Aii.hcss 1 11 1 \1 Kuuu^(ryv.,..at 



hXkA 



IN. li. Kvery item otf iiiV'ormntlon should hi cnrclfully HuppHed. AOFi Khould be stated I.XACTLY. PHYSICIANS nhould 

Htutc CAUSE OF DLATH in pinin teriii», that it may be properly classified. The "Special Information" for per- 
sons dyin^ uway from home should be ^iven in every instance. 



I 



/!' 



' .J 



% 



1 
H 



\h 



w 

It '1 



\i }'■ 



I 



fl 



pi* 



li! 



■ Iwf 






- 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




i \ 



Ij-Ov '- 



^ ' , 1 



V.'.. I 



DepUL , 



IfJO'i 



) Officer 



lici^i'Slcred jYo. 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

I 11. 5. Stan^arC* ) 



PLACE OF DEATH: — County ofOOyvv i \<XJYKCK.ii.<ZL City of C'/CC-ru OKxx.-wtui.c.c 



No. 'X?> S 






St.; b Dist; bet 1 1 ^-"^ ' 



and 



(1 r Dt ATM ipCCURS AW/AY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECrAL INFORMATION" "\ 
IF DEAtlH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 



FULL NAME =L' <X^^d 1 



PERSONAL AND STATISTICAL PARTICULARS 

(.1 >!,< ik 




:i \ I 1 I 'f I'.iK in 



a 



/i^' 



M.iiitli 



I I 



4 ■■.II 



\l . I 



i'. 



sr\<. !,)■ M \k u ii:i> 

\vii)( lu i:i) ( (K n:\< )\'.( i;i) 

i\V!it(iti ^(H-i;tl il< — ii'iiiif ioii) 




\ 



o 



lUR llll'I. \C\-. 
' St:itc 1)1 I'liiintr >• ' 



N \MI' III 
I- A III Ik 



liiK riii'i.xrj-: 
<»i I \riii:k 



M MI'i: N \ AMI 
•>!• .MmT1ii.;k 



MIK rillM.Ai J., 

«>1 MorilJ'.K 

' Statt <.i (MUiiti V' 



<>m I'AiK ).\ 



-<^ 



MEDICAL CERTIFICATE OF DEATH 

DATK (»!" DJ.A'lll 



( Muiuli • 



'Dav) 



IQO 

(Yiar> 



I 1II-:K i;i?\' n-.KTH'N'. That I atU'ii.U'.l .k-cr.'i'^LMl from 
>.'.\. , . up' to ■■■■ \j\.CX^ up '1 

tlial I la-'f saw li '.. alixc on ' '^ ^ ■ • I90 "" 

ami that ikalh occurred, on the date stated above, at 
• M. Tlie CAISP: Oi- DIvA'PlI was as follows: 



.-'>-vv :, 



AXLO 



(t) k W Y\j 







-^ 



I 

^4 



Dr RAT ION A )'rujs Mouths 

R I r, r T ( ) R \' Xj.-<^.oJ:\)\,. \ 



Davs 



I fours 



CONTR 



VC 



k 



% 



^^C-^o. . 



DIRATION Vi-ars Mouths 10 Pays 

(Signed) .Ut^-CL' UJ . Q\ 
1'/; ,.K. 



V 



I lours 
M.D. 



( 



Add ress ) vS" (1 1 '}■ A. S. 1 1. J\) " ^ 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyintj rm.iy from tiome. 



Kl'hli'lf in Sil >t / 1(1)1, I'lii 



•(I I 



M.nilh^ 



lui\ 



'\'\\v. \uo\i.: s r \ ii: I) i'»-KS( »\ \i. i'\in[ci I \Ks \ki-: rkri-: r< > '\'\\\\ 

Hi;sr OI MS KNnwlJ'.DC 1-; \M) lU.lJl.P 



niifi)! iiiatit 






former Of 
Usual Residence 

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



How long at 
Place of Death ? 



.. Days 



l'J,ACH <»I- lUklAI. OK R1:M(»VAI, 



\. rV.^. 



DATr; .)! Hi KiAi <.i klCMoVAI, 

0\^ 



\ 



T90M 



r N I ) 1 



•KTAKI-'.k ^ .\J ■ \J 






!\. K. Kvery item oV iiif )rm.ition KhourtI h.- ciircV'ully supplied. A(IF. should be stnted KXACTLY. PHYSICIA^JS Hhould 

Hlate CAUSE OH DLATH in pliiin terms, thiit it miiy he properly clasHilfied. The "Special Information" for pwr- 
«on« dyin^ away from home should be fe'vcn in every instance. 



;. i 






SI ' 



f!»; 



fi 



■ k 

V 

It 

r 



U 

M 






m\ 



\ 



^ ' -J ' 



» 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ii,.:ir.l .if H :ilfll I V' 



•-4- life I' C. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ddh' /7/fv//Jl(rV)JL'r>x(Kt\; 'i 



7.9(9 H 




RegLstci'od J\^o. 






trU^A.": 



Deputy Health Officer 



DEPARTMENT OF PLBLIC HEALTH-City and County of San Francisco 



Ccitificatc of Eicatb 



PLACE OF DEATH: — County of <X-> 



r 



cv^aC'. City of ' CX-^v o ^\xxy>vcA.<i,<::\/ 



09 
J/ 



1 



'^ 



No.LLWVL(r^cY\iu V'.'. , > ..^. St.; Dist.;bet. and 

^ ^ "^ DCATM OCCVRS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 

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



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 

^ I \ i"< '1,1 »K 



> ' ; 1. • If IlIK III 



U 



' Moiitti 'I 



!), 



\' . 1- 



- : ■ • ! I M \K i< 11: 1 1 

u iiM )U i;i) OK DivuKri-.i) 

\\'!it« ill •■iK-iiii <lrsii'ii;iti<iii I 



X 



I 1 r 



HIK rillM. \ 1 
Sliitf <ii (."iniiit I \ 



N \ M 1 III 
1 \'l IM.K 



IlIK III n. \»i-: 
"I 1 \ III i:u 



^! \ II>1 \ \ \Mi- 
'•I Morm'.K 



iMu ritiM. \ri: 
'>»•• Mnini:u 

ist.ii,- ,,t r..nnti \ 



^ 



MEDICAL CERTIFICATE OF DEATH 

DATlv 01 nr.ATH 

' I ' . . 

IQO 

'M-Hitht (I);iv) (Vfiii) 

I m:Ri:i{V CI;RTII'V, TUaX I atlcMi.UMl .Ifocasfd fnmi 
i()0 ' ti> v' V . , i(;o : 

tll.it I l.l^t s.tw li . ;ili\inii " ,. K^ 

aiij that ilL-atli nccurrccl, <mi tlu- ilati- statiil above, at O 



'H 



M. Tlu- CATSI-: Ol" J)I:aTI1 was as follows: 







\[ 



' V^Lcx/->- 



.^'x v -' • '^ 






niR ATION 



CONTRIIU roRV 



) '('(irs 



Mouths 



PilYi 



Hours 



1)1 RATION Yray^ 

I Signed) Ix . fc . 



M,>u(/i.< 



fhus 



/fours 
M.D. 



""'»'»• I' \ri ON '^ 

h'f^liif'if III Sim III! 



u^/olCo 



I 

\ 



U-\r 



l<)n 



( 



A(l.lrrs^) U^.'. 



Special information only for llospltdls, institutions, Ir.insifnts, 
or Recent Residents, and persons dying away from home. 

Former or *\ xr. n 4 » ^ ^ ^''^^ '""1 ''' 

Isual Residencf Aid' M CK. flare of Deatli .' ' ,' 



fMvs 



)■-,; 



1/. ;////. 



/;./! 



■i"ll V M!o\l' sr \|-i:i) I'l-KSON M. I' \K IHT I, \K>. A U 1: IK I l! 1' « I'lU'! 

Mi:sT oj.- Mv KNOW 1,1: 1 )(.!•: AND iii;mi:i- 



' liilii- m;iiit 



' \il(lr<-.s 



\v\.>0^^ V 



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



ri.ACl-: Ol" lUKIAL OR KI;Mo\AI, I I) \ri; .)!' IMkiai. m KliMoVAI, 



■1 



\.S ^ 



Vj 



\ K^ - ^l 



TOO 



NDIK TAK 1:R M I I. vL' 



lAiidicss 






1 ( 




.( , 



-OLA^if-L.ctj .: '.. 



IN. H. r.very item ^^i 'itit\>rinii t ion Nhoiild \r; ciirefiilly Kiipplie<l. ACHi should l»c Htiiteil I'.XACTLY. PHYSICIANS should 

state CAlISr. OI' DI:A Til in pinin terms, thnt it miiy he- properly clusHified. The "Special Inlformation" for p«r- 
Kons dyin^ away from homu should he given in every infttance. 



I 






W^^ 



i 



Hi 

I 



I: 



I' 

I 

t 



M 



1' 



'' 








i' 


i 




II 


i ^ 


11 


■ 


m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;. ,:il.! . • 1 I i :: :i II I 



.. " — "w 



<>■■ » Ui; \:Si I' c 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







Deputy H'^rt^th OfTiner 



lle^isicrcd A'^o. 



281 4 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



-*c 



Certificate ot IDcatb 

( 11. 5. StanC^ai^ > 



^ 



JP ^ 



PLACE OF DEATH:~County of J OLrvv JXo. , - 



City of U,<:X/v\; J Kcx.' 



No. Sib V\.*..vvi.-; 



St 



.; iO Dist.;bet. 15 Xj-^y 



and 



Yv CA-4^ C 



JX.L\v 



(ir DC«h-H bccuRS *wav fpom USUAL RESIDENCE give facts called for under "special information" "\ 
IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME A^^rVLUL^c J :OJwv^./.-'. 



PERSONAL AND STATISTICAL PARTICULARS 



■1 \ 



>r> 



r( M,< >k • 



' V ri: < 'I i;iK III X 



^ 



ii 



IV<-:n 



X'.i-: 



! 



-• I M \ K K ii; I» 

\V 1 i)< i\V l-.I) <»K I)I\"nR*l-;t) 
Wiiti ill '^otial dt *ii'ii;ili<(ii) 



Illk IIII'I. \ri: 
' St;it< 111 i/iiutitlV 



U -^ ' 



. cr VA^\, Ci.. ^jo^^ > V a^ 



\ \M)-: 1)1 
1 vni IK 



);IK iiii'!. \(i-: 

• >1 I \ IIIl-.K 

^!.ll I e It ('. m 111 ' \' 



M \iih;n n amj 
'»i M()Thi;k 



inK'niiM.Aci- 

<»1 MOTIIHK 

'Sl:iff m ri)\nUi \ 




MEDICAL CERTIFICATE OF DEATH 

DAIl-; nl- id: ATM 

J It ,. 

(Moiitlii 'D.iyl 

I mvRIUJV C1-;RTII'V, Thai I .itti'ii-KMl .kccasoil Inmi 

that I last saw li . aHvcoii WtV [ up" 

and that (Uath ix'currcd, <mi tlic "latv statnl ahnvo, at *" 



M. The CAlSh: ()!• DI'A'lil was as follows 



'^^ 



~\. 



">"> VU 



XKc\\ 



DT RAT ION }'(tirs 

CONTKIIII'TORV 



Months 

t 



Day^ 



X 



K 



t ^^' 



1 
I 



"* < t I'A ru)N 

/\>'>llh\l in '<,! >r / I I) Hi l^l'i) 



I)rRATI(»N' )',v/-v Months /hiys 

(SIGNED) Vj, \} MtV '-ULl 



ViWr ?> i.,oH (A.hlress) ICi^ ■UuM.LA Jt 



I /ours 
Hours 

M.D. 



Special Information only for Hospitdls, institutions, Transients, 
or Recent Residents, ,ind persons dyini] dway fro.ii fiome. 



)V,M 



M,tiith> 



/'„M - 



THl': \IU)\-].. SI' ATi: 1) I'KKSDN \l. rAKriiMI,\Rs AKi: TKll-; T') Til !•: 

in-;sT<M- Mv KNu\\i,i.:i)c, 1-: AM) iti;i.n;i" 



'IiilM'in.-iiit 






Former or 
Usual Residence 

When was (!isease rontrarted, 
If not at place of deatfi ? 



HoH lonq at 
Place of Death ? 



. Days 



I'l.ACI-: ()!■ IMRIAI, OR Rl-.MOVAI, 



t 



DATKu!" HtKiAi. or RlvMOVAI, 

C^lrM • 



190 



(.\<1.1 



rcss 



.v^-vt^X^ 



.tr.>^.\i.^^l..v. 



Address 'i .5 VjTUrrywLcLI 



N. B. F.very item of inforniHtion «hould b.- carefully supplied. AGE H^ould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pUiin terms, that it mii> be properly classified. Tjie "Special Information" \ov p«r- 
Rons dyin^ away from home should be given in every instance. 



I 



3 



t- 



D 






.H 



I 



♦ 



h 



I' 



V ) 






fk 



U 



« 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



iSip.dc! .if n> :il 



1 li I- Nm i ^ t-'^TS^Ili-, i;^: 1- (.• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Du/c /'V/r^/,\J\cv<XA^oJ[aA; ?i 



//y<^>H 



Re^i.stcrrd J\^o. 






815 





v^Ui M.\Kj D^P 



» ••■» o 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of E)cat() 



4 '3ri A ^ 

PLACE OF DEATH: — County of CL^w vT.\cx.''vxouLC'.City of C'^CWu O.^^xX'V^LX^A.^ei. 



No. 



^1 Ua-Ci... v.- , 



St.; 



Dist.; bet. 



A \ 



and 



b ^Li.Aj 



(ir DC*TM OCCURS *WAV rROM USUAL RE SI DENCE GIVE facts called for under "special INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 







\\ y^. 



FULL NAME 



.t 



) ^ I K 



r- 



■4- 



t 



-L 



PERSONAL AND STATISTICAL PARTICULARS 

I I il,< Ik 



I' A r»; < It r.iK 111 



vni 



N!..iit 



o 



0.^ 



MEDICAL CERTIFICATE OF DEATH 

DATl-; «)!• DliATII 



1.1 \ 



A<.i-; 



i; 



- : ^ • I ! M \K k ii:i» 

\v ii« »\\ i:i» ( >K ii;\t »Krj-:n 

U'l It'- ill s.H-i.ii .!( sit'n:tli(i!i) 



!;iK in I'l. \c J-: 
M.ii< oi I'lUTitrv' 



\ \MI- <>| 

1 A rm,R 



HIKTIIl'l. \()-: 

<'i- I \ riM.-R 



M\II)i:\ NAM! 

<»i m«>tiii:k 



I'.iRini'i. \(]-\ 

<>»• MOTMKK 
(Stati- .ir i'r))nitr\ 







I go 

I V<-:iI ) 



(M<)titli> (Day) 

I I[l-:k i;i{\' CliRTll-V, Thai I atU-ii.k'.l (lecra^ed fiMm 
» I90 ' i to ;' .. '.. '- 'i it)o'i 

tliat I last saw h alive ^^\\ \i ' Tc/D . 

ami tliat di-atli (incurred, <>n the date- stated al)ovo, at T 
', M. Till- CAI'SI-; Ol' l)l'..\ril was as follows: 



CI- 



■^ 



Wo~>vcc VJ a.\x » V. e . uv^ « > ^ 



^r 



Years It) Mouths 
■< )NTk 1 lU'TORV U,cJ(a)-UwLcl?v. 



DIR A'I'IO.N 




1 » 






nr RATION 

(SIGNED ) 



)'cars 



Mou(h> 




%^ 







Pars 



IQO 



Hours 
. UA.(J.^ts.\j .}... , . M.D. 

(Address) 'h'in.\o ' nX^^. 'IL 



SPECIAL Information ohK tor Hospltdls, institutions, Transients, 
or Recent Residents, and persons dying anay from fiome. 



/\''Miii'if III Sim /-'i It III I u'lt 



) r\ll 



\hni>ll^ 



Ihn 



Till-: \H()vi-: s TAri-:!) i'kks( »\ m, i- \k run, \rs aki-; rRii-: t«> thh 
in-;sT Ol-- Mv KNOW I,)-: 1)1.1-: and in:Mi-:i-" 



f Itif"Miiant 



' .:j^\^^ \^L V- \. C*s-OL- ^.- 



(A.l.hcss It)"! i ', 



^ 



\A.yQ^'X-*-<<rv"^>' 



Former or 
I'sual Residence 

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



How lonq at 
Place of Death ? 



Days 



I)ATlC<jf Hi Ki.Al. iir RimoVAI, 



IM.AC1-: 01 lURi.M. OR ri:mov.\i. 

rNl.l-RTAKKK Aa vX) • Aj )\^\l^>v .^^ 

{Adclross....S.l.^ ..G! d.K:X-^vAJLU.....a^^ 



T90 



IN. B. r.very item of information should be cnrefully supplied. AGE should be stnted EXACTLY. PHYSICIANS should 

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



li 



t-j ' i 



\ 



-^■■^■5P»'"Wi 



I 



u 

n 'I 



t'l 



1^ 






m 



m 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H'.lT' 



-.' ]:ScV (•■, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Re<^i\sfci(ul A^o. 



2816 



\^yju^^\ 1 . Deputy Health Officer 

DEPARTItlENT OF PUBLIC HEALTH-Ci> and County of San Francisco 

Certificate of Scati? 

PLACE OF DEATH: — County of OcX'^Aj .VCL rvcv^ City of OxX/l-v; o^ucX/yvC^^ e^ 



7 



No. lists |a v^, ,.,._^ St.; I Dist.;bet.V3")n.(vO,d.tv:'.u and '(aCL). 

/ ir r)t*TH OCCURS AW*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "S PEC I Alj t N FO R M ATIO N '• "^ 
V ir OtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER / 

FULL NAME 1 I Oa . < 



PERSONAL AND STATISTICAL PARTICULARS 

I I ii.i »k 



nvxL. 



;%:^:x 



M..111I11 



1'.. 



» t ;ir '' 



%'X 



M A K Iv I r I ) 

\V ill'- ill >«iM'i;il <lr>'iL' ii;itiMii) 



,1 ■ -^ - 



-•t.ttc or Coiiiilr \ 



\ \MJ- 01 
»■ A lill K 



'■'!■; run. vri-- 
' I \iin;K 

--lit' . >: 1 .,iii!ti 



^' M!)i:\ \- Wli' 



ink riii'i, \< V 
;»!• Mnrin:R 



^ 



vcL<x/>^'cL 



MEDICAL CERTIFICATE OF DEATH 

I' w'v. Ml i>i;.\Tii .-•, 

(Month) Day^ 

I lll'lUl'jn- CI-:RTII-V. 'i'lial I attcii.lf.l .ItHxascMl fnnu 

'.. 0ct .^l 



(Vo'ir^ 



.- V 



I()0 



lyO I to 

t 

that I last saw h i.. . . . alivf oil _ ' i^p 

1.1 that (Katli ncoiirred, on tlu- datr "-tatotl ahow, at O, oO 



at 



>!. Tlu' CArSl«: ()!• 1)1 {A Til was as folKnvs 



M^, .. ,. 



r^^ 



'' . wvo^-i 



1 ( 




^ 



A. 



nr RATION 

CoNTKir.l'TOKV 



{ 




Mt>>if/is Pays 



I loii> \ 



\ .KX; 



I 










\ n 



nrU.XTlON I Years r^JIonths /\i\s 

(SIGNED ) Lu>J(XuX'T>\j J . (iL . ^ -V. . ; o..'. . 
Vl lev • 1 00 ' '. i A .1.1 ri-ss ) Hd 1 X.iiay\Ml/^VCt^ntki,)l 



I lour \ 

M.D. 



Special information «nly lur llospitdls, institutions, Transients, 
or Rf(ent Residents, and persons dying avvdy troni liome. 



R*stt1rif ill Sti>i /'mil./',,! \ ' r,//;> 



Moiifh^ 



/',/! > 



rin-: xnovi.; sr \ 11 n i-i-ksonai, p \k 1 ui i. ars .\ki'. rui i-; it* riii-: 
in;sT (.«. Mv KNi »\vi,i;i)c,H and nL;i.ii-:i" 

lb(55ii Hr^AX4 ^i^ 



former or 
L'sudl Residence 

When was disease (onfrarted, 
If not at place of deatfi ? 



How lonq at 
Place of Death ? 



Days 



(A. Id! 



IT.ACi; •)!• lUKI.M.nU ki;.M(»\AU | D.All-, o! Hikiai. or k^MoXAl. 



■\T H 



N I ) !•: R •!• A K H K wvvAaJ./cL lX^yA./(Lu>Jt.XX.>TL£ 



TQO 



(.\cl(l 



less %(0.b \ry\A>^. 



<i,\^-<J>X 



^- B. Kvery item of inforniHtion should bs cnrefiilly Hiipplied. AGE shoulil be stated EXACTLY. PHYSICIANS Hhoiild 

stHte CAUSn OF DEATH in pliiin terms, that it may be properly closnified. The "Special inlformation" ?or p«r- 
Rf>n8 dyinjl away from home should be diven in every instance. 



If 



i 



'i 



I 



5 



•••^j 



^ 



rei 









iil' 



w' 



r|! 



•t 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PER 



MANENT RECORD 



Jt.M!il <'\ H' ;iitli I \'o 



-sr ••^;. U.S. !• ('.) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



If/0\ 



cLcr^ccn A.X Deputy Health Officer 



liei^is/ri'pd ^Yo. 






DEPARTMENT OF PUBLIC ilEALTH=Ci> and County of San Francisco 



Certificate of Scatb 



11. 5. Ji'tnnDar^ 



PLACE OF DEATH: — County ofOa , 



^ 



No.^^U^ ^^^Ci.c^v^ 'K^v,.v".. . St.; Dir.t.:bet. 

\ r ir Dr*TH occuAs «w*v rn6*t> USUAL R E S I DE NCE gi vr facts called for und 

V ir DfATH OCOUHRfO IN A HOSPITAL OR INSTITUTION G I V F I T fi NAMT iNCTran 



City of ^'<X>v 3 X<X'%^Cc<i 



and 



I^L RESIDENCE GIVf FACTS CALLED FOR UNDER "SPECIAL I N FO R W ATI O N ' ' \ 
AL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



\w I 



PERSONAL AND STATISTICAL PARTICULARS 




•I IMK 111 



I) AT I 



MEDICAL CERTIFICATE OF DEATH 

.j:\th ||> 



I go 

(Vf.-ir) 



I 'i \ I 



\' . 1-; 



^\ III?' i II >i>t'i;i ! iliv-'.. n it I. ,ti ') 



fiTRriii'i.Aci.; 

or roimlrv' 



' ■ I .' i I K 



!■ I III'!. \t }. 

I \ n 1 1- K 







^CiVAT 



'Moiitli> (I)av> 

I ni{RI-:HN- CI-R'ni-N', That I atteii.k-a (IcctascMl fn.ui 

- . *- ur- tn V. J. M TooM 

1 hat I la<t '-.lu h ■ aliw on 

and that fk-ath ■ )rcurrcMl, on tlicdatr statt'<1 aho\'c. at : 'i' 

. M. Thr C".\I Sl<: OI- l)!:.\ril was a< fallow • 



Too 
T9O 



*^ ^\yx\xy<^ 



kx On 



lOl 



A^>CX>LU. 



^a 



LA^i' 



I>I K \I1( tN 



CONTF^II'-I'TORN 



)V// ^ 



Mouths />(}]■< 

\l l.LLiy.ISr.lLO 



I lours 



' 1 MoTlIKk 



ink iiii'i.Ai 1- 
<>»• m<»tii):k 



I)rk.\ ri().\ f^^ Yvars 
(SIGNED^ 



Mouths 



fhivs 



lIour-< 
M.D. 



A.v^^. -^ 



r 



W,rt 



I(;r) 



f 



mispitals, 



i ATI'»N .T,> 



k'r ..I, / „ 



/^i 



1/ ' » i 



M,<„ll,> 



1 >a\ 



'"',':,) '!*'^''- "^'"^ ■'■'■'» i'Kk--<»NAi. i>AK rrrri,ARS Akj; TkrH to riii: 

Ml.sroj- MV KNM\\I,j;i)C.H AM) HICLM:!-' 



SPECIAL INFORMATION only for 

or Recent Resii|ents, and persons dying away froii home. 

Former or t^^v^^'Ol Vb <*y^<^ How long af 

Usual Residence U'<xcA.-<<^nrvobvNXc 01 Place of Death ? o 

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



nstitutions, Transients, 



Days 



I'l^ACK ()!• lUKIy^I, OK ki;.M()\AI 



i'llonnrint 






' X'l.lrrv;^ 



DATl^u!' Hrui.Ai. oi ki;M()\Al, 



\.^X\ 0L(y^Li^l^:^A. J.t 






(Address I./ 



'.very Item of iiiformntion should be carefully supplk-il. AGE shoiilil be stated EXACTLY. PHYSICIANS should 
tHtc CAUSE OF DEATH In pinin terms, that It may be properly cluHsified. The "Special Information" ?or p«r- 



N. B. F.< 

stmc *^Aii»i: UF DEATH In pi 

son* dyinjt nway from home should be ftiven in every instance. 



I 



- l. 



-fe 



\\ 




\ 



']•' 



•ft 

I 






I '' 



rii 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMA 



NENT RECORD 



i:,.;.i.! .-f 11. ..Itll } V 



I I , - " 









IfJO'i 



REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

Jie^istei'pd ^7>. 



2818 



--• k 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Gcvtificatc o( Scatb 



U. 5, ir*tanDarC> 



^,) 



t 



No. 



PLACE OF DEATH: — County of Oj-yxj !i KO. , City of JA^va; J r^o , -^v^/-/ 

^ • , ^V^\--^ r.ll St.; S Dist.:bet. ' " and ^ ' * 

/ ir Dr«TM occurs AWAY TROM USUAL R E S I D E N C E G 1 V E TACTS CALLED .^OR UNDER SPECIAL INTORMATION \ ' 
\ IF DEATH OCCUBRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER J 

A ^ .1 



FULL NAME 



W. 



l.\ 



PERSONAL AND STATISTICAL PARTICULARS 



)) 



: ! : I K r 1 1 



I> • 



MEDICAL CERTIFICATE OF DEATH 

I-ATII 






\1. !,; 



\' I-. 



^' ■! r M KK K !!■ n 
U IIxiW J-I) (,K j,p , 



■^t.itt or i'miijiI? >' 



1 ■ • 



1 n 



rticL^ 



V VOL ex. 



r\Nv ' 



(Month' !),i\' 

i lli:ki:r.\ ri'irni'W That I altcinU-.l .lo-asc-.l fn.m 

thai I last s,iw h '■ . alive on ' *"■ icjo 

aihl ihatiU-atli nrcurrcil. on the (hitc statt'd ahovo, at 
M^ Thf CAI SI-; OI I»l, ATII was a>^ follows: 



O 



\K<r^\ 



\ \ M I (11 
I V 111 Ik 



ItlKTlU'I. \C)' 
'•' ! \ IlU-k 

'iiintt\ 



^tv^»J•.^• \\mi 

"I MoTm.K 



IIIK IIIIM, \, J- 



f AT ION 







.6:^.^Kj_ 



i\ 



i) 



1)1 RA'i'loN 



coNTRir-rroRV 



)'(\Jf ^ 



,!/(•;//// \ 



/hn 



Hours 



'AwOLc<X' 



7 



^.hJLVCV . 



nrRATloN _^ Years Mo) ths /hiys Hour^ 

^ (? ^i. 

i Signed m.d. 



I()0 



(A. 1.1 ass; 



Special information onlv for Hospitnls, Institutions, Transient';, 
or Recent Residents, and persons d>in(j dwdv from liome. 



AV- .'.//,/ :,, S,.,f /irii.i'.,! O S )■-,."> 



\t.',illi^ 



n,i\^ 



' " u.--.^*^ *'" ^'" '^ '''■■" f'-KS,nNAI, J'AKTHTI.AKS A K !■: TKIH TO Till-: 
««».SI ()!• MV KNOW I,|.:i)C, K AM) H^IJlvK 



Former or 
Usual Residence 

When was disease contracted, 
If not at pidceof death? 



How lonq at 
Place of Death ? 



. Days 



•Iiifiinnant 



U.I, !,,<»; 



.^:i.\ 



'I .ti i 



D^THof HlKiAl. or KK.M(»VAI, 

\r '■: 190': 




ri.ACK OF HlKIAI, OR KKMoVAI, 



(Address . . 



N. ». hvery item of information .hould b.* cnrefull.v supplied. A(iB should be stated EXACTLY. PHYSICIANS should 

"tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for pmv 
Rons dyinii away from home should be Jliven in every instance. 



I 



: I 



i 



I 



— I- 






''c) 



I 



i 



:i I 



4 



l-f! 



(I 



n' 

I' ' 
(ft 



) 



1 



t ■ 



Il'l 



in 



!■ 









, 





WRITE PLAINLY WITH iiMrAn 



• '-« a» I I ' 



IIVI^^ IKIt# t^i . , ^m. .__ 






•1 



^(k.^ 



:i AjcuM Deputy Health Officer 



i^rx — imo i:> M KLRIVIANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 

Begisfrrrd J\'*o. 



^81 9 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

I "CI. 5. •^'tnn^ar^ j 



PLACE OF DEATH: — County of JCv(x>a... 



i 



City of 0,c^^v.^^\^Vv^^-s^; L<Xl 



,c 



No.— 



/' ir DEATH OCCURS AWAV FROM USUAL 
\ \r DCATH OCCURRED IN A HOSPITAL 



St.; 



RESIDENCE Givt fac 
OR INSTITUTION GIVE I 



Dist.; bet. 



~ and 



l^i 



T! ^^'■.^^J' ''°'' UNDER SPECIAL INFORMATION \ 
TS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



LIv... 



((SiM 



1 



Hill, 



^ 



PERSONAL AND STATISTICAL PARTICULARS 



• i-:\ A 



• \ : i. . '! i;lk Tii 



)■: 



COI.OR \ 



NJ..mh 



/ 



Day) ( Year I 



iDav) 



• War) 



/'■/ 1 



uiiM)\vi:i) OK i»:v(iRi.)[) 



IWRI'MI'I.Ari.: 
• Stati- or Cumiii \ 



J^->^Qj\X 



I \ nil F< 



niKTIII'l.Ai-K 



MMI<KN N\Ml 

<'l' .M<»Trn-.K _^ 



JtIK THI'I, ACK 
"I- MoTin-.R 

'^tatc .ir (."uinitiA 



' HXTl' \V\( IN- 




MEDICAL CERTIFICATE OF DEATH 

DATi-: di" ni: \iii 

i HKRHHV CHRTIFV, Th.i I ..ttcu.le.! ileccascl from 

"" ' '^>^ '~ t" up 

that I last saw h alive on ^^^ 

aii.l that .k-ath occurre.l, ..n the .late stated above, at 

M. The CACSH OF DFATII na. as foll.nv.; 



■V— ■ I v„ 



'—'-"v^ L 



DlkATlON 
CoNTRir.CToRN- 



)\a> s 



.1/,'V///.s- 



/\iv 



//oup-s 



'^'■'^•^''■'^'^' ^'■-''■^- -V-'.//;. nays /fours 

( SIGNED )..UJ.A5. IcLeVv^ , -: 

i ' 

_Lr:___:: "''^ • ( A d . 1 ress ) d X-C a^nj^^c-^a.- 



M.D. 



nrf ^^^'^^''^f^'^'^'^TION only for Hospitals. Institutions, Transifnts 
or Recent Residents, and persons dving d>f>d) from home. "ransienis. 



h'iM.I,-,! 1,1 S,if /'/ III/, :■,■,, 



):,;, 



M^.nths 



l\! 



^Iiir'irniniit 



Former or 
Isiiai Residence 

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



How lonq at 
Place of Death ? 



Odvs 




X-llAMuLth^ ) -^ 







rxi)i:RTAKi-:K 






«on, .,,J„^ «^ay iron, ho.c sHo:,c, rA^;e':[:;re;: insZc'e ' "'*'• ""'^ "^'*^^'«' '-'o-«''-" ^or p.n- 






ir; 






Is 
I,' 



l':| 



L'li 



^ 



* 



,i. ! 



( 1 ^ 

'■Ml 



■Ml; 



!!#< 



I 



: 



WRITE PLAINI V \A/ITU l iivir a rNii...^ 



■ m •« 



}{<■:, 1. 1 ,,f If.rilth !•■ No .•, tV-Vis 



w^"?-*; USi]' Ou 



/^../.^ AVAv/, Qfl(n)^/>^> 



.-^..^vj ii^rx— ini5> IS A PERMANENT RECORD 

"gP'ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



y-Vxj 'h 



IfJO'i 



lieglstered J\^o. 



28J9 



b^K,U!i dJ.^>u Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccitiffcatc of Beath 

( X\. 5. StiiiiSarO ) 



PLACE OF DEATH: — County of 6^^ , 



City of O .K^K^K^^LA.Kyy^ L-O^V 



No. 



Su 



Dist; bet* 



~ and 



f tr DEATH OCCURS AWAY FROM USUAL R E S I D E N C F r i u p r«<--ro.*V- 



FULL NAME 



x.\^\.'.<: 



1 i^i' ) 



■\' 



1(1^ 

i 

.'.^' J.va. 



I . \ 



PERSONAL AND STATISTICAL PARTICULARS 

' COI.OK \ 



nie. 



■ • vn: . .1 i:ii<'i-n 



\' . f: 



M.Mith 



i 



ll» 



n .\ 



MEDICAL CERTIFICATE OF DEATH 



i»\ i"i-: ( >i- Id-: \Tn i 



CMontli^ 



(I):iv) 



) I It I > 



' Wilt) 



/',/^,^ 



(Year) 



I ni-RK15V CKRTIFV. Tl.at I attended .leccascrf 



roiu 



190 



to 



"^ IV'. 1.1:. MAkKIl I» 

uiiM)\\ i.;i) ,)K i)r\-Mi^ 1 [) 
' \Vi it.- ill ^(,ci;il . lesion. III. )ii I 



HiKTin'i,.\rK 
(Stall- or Country^ 



\\M}- 01 
I ATM Ik 



MIk IIII'I, At-).- 

•»' r\rni;k 



maii>i;n- namj- 

<>l' MuTFIi;k 



itik riiiM.Ai}-; 
<»!• M<»i'ni:K 

Estate 01 r<.niitr\) 



f\''Mi!r,f III S,ni /'i ,111, r^,-,) 




iuive on 



that I last saw h . 
and that death occurred, on the (hite stated ahove. at 
M, The CAISK OF Dl-ATll was as follows: 



T90 
T90 



'" 'NATION Years 

c'o.N'ri^iniToRv 

nr RATION )yars 

( SIGNED ).Ll),.^^, 1) 



Months 



/h 



7VS 



Hours 



Mont /is 



Day 



n 
t^)^ ' (A.ldress) '. 1..LA-V.'^4,^^v^., 



Hours 
M.D. 



CJV>'VA>Oj 



?^^9'fl^."^f^^'^^'^'0'^ only for Hospitaisjnstitulions, Trdnsienfs 
or Recent Residents, and persons dyina a^^ay from home. ""nsienis, 



)V 



(,' ' 



Mnnths 



/'.I 



Former or 
Usual Residence 

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



How lonq at 
Place of Oeafli ? 



Days 






(Illf, 



)Muaiit 




( \'l(!i, 



it 



S^i V^x.itA>>odUAje )1. 



190 






son. clyJni „way from home should be ^ivcn in every instance ''"''"""''* ^'^'' '**'»'^^'"' Information" V'or p,r- 



m 



f <! 



II 



jil! 



;i i: 



I 



I * 



i 



l> 




WRITE PLAINLY WITH UNFADINH INK 



TI-IIC: ic A atr aum /iii.%tr 



• ^i^> 



r~t • ^ • I 1*1 rt i « h_ I « I 



KIT- r« r~ «^ «H ip^ ■* 



l!. .,,;.! . f 1!. ;i!lh f V. 



f.,*^—**"* 



• • IKS; 1' ('., 



I)((h' Filed , \i\<po^^-rT-J!MA; 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






VJO'X 



.TS^^VA- ^ •' 



lle^isiei'OAl JVo, 



OQOO 



Dep Health OfTicer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtificate of H)catb 



a. 



«i 



PLACE OF DEATH: — County of Cj/(X^-w J Vcxov^^^ City of ^^ O/vu o,.W-y-^CA,^.e.O 
No. 15 01 I I U > cV.a'1^^-v , .,. . ' - St.; 1 Dlst.; bet. ' ' *' -Xry u.<.> .-^ '. . and Xts V>x(- ^ ' ^ 

/ ir ntATM occuRsfWwAY rpoM USUAL RESIDENCE give tacts called por under "special information- \ 

V IF DEATH OCCLf^RED IN A H O S PJl T A L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



) 



A 



FULL NAME ><^^ - 




'<XUXv 



t\XfY \.^X. 



PERSONAL AND STATISTICAL PARTICULARS 



' \ II t'l r.iK 111 



U ; ■ ■ 




(r)iivi 



■;tr> 



\^ .1 



^IN' . I I- M \K K" ll-Ii 
\\']\u .\\ 1 I) OK l>i\ < ikt 111 
Ui it ill x.K-i;il <l< s!;,'!!;!! iiiii) 



lURiMIlM \r\.\ 
IStat. •iiili\ 



MEDICAL CERTIFICATE OF DEATH 

i»\Ti<; oi- i)i: ATii f\ 



fM.)nth> 



D.iv) 



(Vi-iir) 



^ 



\: 



'X 



^? 



I m-RllHV Ci;kTll-V, Tlmt I atU-iidiMl .liTrasi'd (n.m 
^ ^t !(/) . to Wcl M upH 

that I last -^aw li ... alive on \.. ' S. ' T(io'' 

and tlial dcatli orcurrcd, nn tlic dati.- state(l ahovi-, at U '' 

M. TIu- CAl Si' Ol- DIvATII was as follows: 

P ' ... . i ,. . t. 



N"\M1 OI. 
!• A IH J,K 



I'.iK run, \,).; 
"I lAini-.k 

^l:il'- (If ("( 111 nt I \ 



^^ \ iim:n x \mi 

«>I' Mdl'lll-.R 



I'.ik TiiiM, \(}-; 
• H- Moriiiik 

(Stale or iNiuilti V I 



Cl^\. Vou >"v-^c<-^axj 



li . 



L 






<x/y\} J^\.CL' 



1)1 RATION 
CONTRIHlTom' 

DIRATIOX 

(Signed^ 



) V<//'\ 



i'fars 




Uo/z/Z/s . /)iiys 



Hours 



Mouths 



Davs 



MUv ;. 



I()0 



Ik i(i-i . 



(A.idits^) S Sb 'JXA^U.x; 



J 



//ours 

M.D. 



Special information <»nly f<»r llospitdls, institutions, Iransients, 
or Recent Residents, and persons dying .iwav froni fiome. 



OviTl' \i K )N 

f\i\^idf(1 III Still I i.:ii, /.,' 



)V,,w 



' \l..„fh. 



Ihn 



'I'll i: A!!t)\ r; SI" A IP I) ^I'■R-^o^Al. i- vki'ii r i \ks Ak i-: rkii-: To rii !•; 
iu;m'(m mv knowij.ix.}.; and iti:i,ii;i- 



former or 
Usual Residence 

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



How lonij at 
Place of Death? 



.. Days 



(InfnMiiaiit 



12) 



f \'1.1 



I (■k<S 



SOI 




4 



'>xiA.C4 ol 



l^^.AC'l': Ol' lU klAI. ok ki;Mo\ AI, 



^^ 



^U^-^^ 



Din: <■!" Ill KiAi. <.i k j;m« >\ai. 



T90H 



r.N 






Q 'I' 



\A/Y\A. 



.<■(', 



!^. ». JivL-ry item ni iiiV'ornmt ion Nhould be ciirc»*ully supplied. .\V,V. Khoiild be Htiited liXACTLY. PHYSICIANS Hhoiild 

Htiitc CAUSI: OF Dl; ATH in pliiin terms, tbnt it msiy be properly cluHHilfied. The "Spccinl Informsiticm" for par- 
sons dyinj^ uwfly from homo should be ^iven in every ioHtance. 



I y 



■?5SW5C 



.1! 

r 






1^; 



i 



li 







\h 



1'^ 



I 
It ' 



l< 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PFRMAlNrPMT prrn 



on 



Hoftr.l ..f H.'i'th I" V') !•: ■^^"-x*^<..-; !US:IM\, 



/>^</f' /'VVr^/, vX^jvut^rraOA; H 



RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IfJO^ 



Bo^i\sfcrc(l J\^o. 



.^^uu) 




r-wO^w 1 



^ 



Deputy Health OfTlcer 



DEPARTflENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Scatb 



( 11. S. J?tan^al•^ ; 



:'^ 



PLACE OF DEATH:— County of 0<X^ . 



^v 'City of^'/CU^X' J .VCu>vc^<i^o 



N(x 



h 



1 "n ^ ^ ' - St.; Dist.;betH.) U 'vlc\t .. 

r IF Dr*TH OC40PS *WAV FROM USUAL RESIDENCE GIVE facts'called for unideb •special iNro*RM^TiON""A 

V IF DEATH (^CCURRID IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET ANb NUMBER. ) 



FULL NAME XbVa.!v.o 



at 



VCL/KOL . 



PERSONAL AND STATISTICAL PARTICULARS 

" , I"' '1,1 ,K 'i 



A 



u 



: ' \ 1 I < )i 



I • . I- III 



\;..i;li, 



1/ .;,'/; 



/'./' 



■^1 ^' .1.1 \i \ k i< 1)1) 

Ullx >\\ III OK li!\n!.' lit 



w 



' st,it< III ri.ii lit I v^ 



V \ M I . . 1 
1- \ III 1 K 



iMk rm-i, ACK 
"I I \riii-;R 



M \ ; I il', \ N \ M 1 
Ml MdilD-.K 



I'.iKriijM.Aci-; 

<»| Mm|||i;u 

^1 il .1 ('(Mint I \ 



■' I 1' \ 1 h ».\ 



!i:it iMll ) 



r\ 



'i I 



lO. 



A 



■ ^^^-^^^ o 



I 



cxe<5\^ I'- 



'x.\./T\VO 



MEDICAL CERTIFICATE OF DEATH 

DA'ij-. (»!• i)i:\rn 

^Moiith) (Dav' 

1 1II-;R1:HV CI:RTIF-V. That I attrn.K-.l .lc,rasc<1 frniii 

-!--' I90H l() M\ C ■. 

Ill at I last saw Ii .. 



(Vc.-tr) 



1 90 



ali\c oil 



lyo 



and that -K itli occu rrfd, 011 (Ik- date stati-d ahovo, al M 
^V ^M^ Tlu- CACSh: (l^ DKATII was as follcws: 



v.0^1 .. .L , . V 



I 'Ik AT ION )\cirs 

CONTR IIHTORN' 



Moil lis 



Days 




JJ\. 



IL 



DIRAI'lON 



}\'ar. 



Months 



Days 



Hours 

Hours 
M.D. 



i 



UX^/T>\.0 . 



SIGNED )...LUUr\j^cl UJ. JXV' , 

(A.ldnss) 10^5 \[VuUuk(i .it 



Y\ 



rqo , 



SPECIAL INFORMATION only for Hospitals, Instiiulions, Transients, 
or Recent Resittents, and persons dying away from fiome. 



AV iiii.i III \,ir / iiiiiii '■! ' [ )'iii I 



M.'iilh^ 



n,i 






I III'. \M(>\'i.: sr \ri'i> i-kkson \i, i-aktiiti, aks aki; tkii- id fii i' 
IW-,M' 01. Mv k\<>\\i,i;i)(;k wd |{j:mi;i- 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



.. Days 



f^CH OI- nCKIAI, (»K KKMOVAI, | DATK oi Mi i<i.\i, ,.1 KJCMoVAl, 



t 



Q'W^ H T90H 

r N 1 ) !•; K T A K 1.; K \J\Oj^ • V ^ \J YUicL-yL^^v 



(.\(lflrfs.«» 



J-rw .wL 



iN. K. Hvery Item oif information nhotild lu ciirefully Hiipplied. ACK should be stated KXACTLY. PHYSICIANS should 
state CAUSi: Of- DEATH In pliiin terms, that it m,i> be properly classified. The "Speclnl Information" for p«r- 
^ong dylnj* away from homo should be ftiven in every instance. 



I'. r» 



n 



J 



I! 



f 




H 



« 



''If' 
I 






'"I 



«|! 



M 



■J V 

r •- 



ri 




ft^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PER 



MANENT RECORD 



lloanl of Health- J" No - ^''l.^^-^ UScV Co 



Dff/c Ff7r(/, rLcxMi^Axl^\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



^v^. 



^ 



Deputy Health OfTicer 



Registered jYo. 



OttOO 



I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beath 

( U. 5. Stan^nrC* ) 

-^ OS? A ^ 

PLACE OF DEATH; — County of ' • .• v;A.<x^-ocX^VvlC'~City of 0/CX/>^ ^^ .^ouoo/CVAi- ^::^ 






^CXV ^ . - V^VO A ^ VC^U ()b ^SLk^la(:Dist.; bet. and 

f .r or*TH OCCURS *w*> TROM Us6al RESIDENCEGivr facts called for under "sPEcrAL information 

\ ir OtATM OCCURRCQ IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



FULL NAME*^^-^^^<-a-o^ 



) 




'iJU-W 



PERSONAL AND STATISTICAL PARTICULARS 



--i:\ 



a. 



^^■\ 



•> 



O- ' . 



>>, 



ri)!,i iR \ N 

\ 1 ' ' 



1' \ i 1 < 'I i;iK Til 



.\*.K 



MEDICAL CERTIFICATE OF DEATH 

DATK <>»•• I)1;ATH 





-V,. 




'Month) 



■Dav) 



(Year) 



/ 



M..!i!:i 



I IMN 



» < :ii 



/',; 



I Hi:Ri;nV Ci;KTn-V, riial r aUe.i.k.l .U-ceased from 
- -— up to 



that I last saw li 



alive on 



^■N'.l.i;. MAkKlllt 
WIIHIUKI) OK Iil\-t )ki 1 I) 

^^■T it'- in <o(: : ' '.-■■• 



HIKTMl'l. XTK 
'State iir (.'Miititi V' 



"■■'Ml Ml 
1 \TI! IK 



Mik riiiM. \.H 
•"" r \ iiii.:k 



MAII)1:n namh 
Ml mmtiii;r 



lilK IIIIM.ACl-, 

<>» m<>thi;k 

'stall or roniiti \ 



oCCfl'Aliox C 



n 



^^^KT ■ 



] 

J 



■ 190 
190 



and that (k-ath occurred, oti thr dat*.- stated ahove. at • 
^ M. The CAT SI-; ()!■ l)i:.\Tll wa^ as follows 



VVCv^U^Lv. ccL . ^ rUL.^\i.1u\A!i.\^. 



DC RATION }\uns 

CoNTkll'd roRV 



Months 



I^axs 



Hours 



r^ 



DTRATIOX Years _ Months ^ Days 



(S 



iGNED ) .Lcr\<mjl\; J ^^3 Id A^tia , . 



.^fonths 

I 



% 



Hours 
M.D. 

uce 



^i 'i-'V '' rqo"' (Address) \M^^i^Su\JS 

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



Former or 
Usual Residence 



Ur \) . i b Ua; v*^ v) U >vv - >' ,p|af c of Oeatti ? 



.;'/ / 



' ,; )i. : ■»■.) 



) rat . 



M..,illi^ 



iKi 



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



Days 



rin-, A MOV].; sta ri:i) kkkson \i, i'\Kiriii. \ks aki- I'Kt}" ro riiK 
iiivsr oi- Mv KN()\\i,).:i)<.H AND hi:lii:i-- 



nnloMii.-nit 



vvr> , 



,^ 



ri.ACE OI" IHRIAI. OK RKMOXAI 



I)A'l"i:o!" MiKiAi, or KKMOVAI, 

190"^ 



0\(ar.....S 



'A.hlross bO^ \>^\^KjM:y~ , ) t 



fAddross mi ^yi..Ul.<i..UC->X ^ii 



N. M.. 



-F.very item oif infurmiition shouiti be cnret'ully supplied. A(IF. should be stnted RXACTLY. PlIYSICIAINS should 
state CAUSE OF DIIATH in pliiin terms, thnt it mny be properly classified. The "Special Information** ?or par- 
sons dyin^ away (tVom home should be ftivcn in every instance. 



if H 



i 



f- \ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i''; 



!l. 

:f 






t 



'hsi 



I 

|i 



It'} 



fllcttltl. I" V 



^i^nScVCn 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 






u 



If/O'i 



Bi^^Lsfci'od A'*o, 






2f^'^ 



-\ 



cLtrV^^.- 



Deputy fr' \ri\ Officer 



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



Certificate of Beatb 



[ XX. S. StanOarO ) 



No. 



PLACE OF DEATH: — County of 0<X>v J,\.<X^^XCA.A.C City of CJ/CV^ .'uOywcUi 



^v ; 



St.; 



Dist.; bet. 



Tind 



(ir Dr*TH occurs awav from usual residence give: facts called for under "special information" N 
IF DEATH OCC'JRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



I'O 



FULL NAME 



v.<. 



o 



I I 



PERSONAL AND STATISTICAL PARTICULARS 

( 1 11,1 )k ' 



I' \ I! < ^r lUK III 



MEDICAL CERTIFICATE OF DEATH 



I) ATI'! (H- Di: \ Til / 






I go 

(Year) 



> c ,11 



\' .1. 



'C 



-^IN' . I.l M \K Iv iri> 

U IIK i\\ 1 I» UK It:' . .' 1 |i 



itik inpi.MM-: 

'St.ttr or ("miiiti v' 



(Month) fl)ay) 

I 1II;KI;I5V CI;rTI1<V, That r atteniU'.l (leceasea from 

.w'..-' loo'. to .....yLca^ X --'- 

tliMt I last saw h alive on I \.-t 

ami tliat (katli oci'ii rrcd, on the <!a(r stated above, at I 



T90 1 

190 



M. The CAlSlv Ol- DIvATII was as follows: 
>>\A^\A-L.'Q..N.. ' ' 




\\M1 <>| 

1 \ I II Ik 



mK'nii'i.xr!-; 
oi' 1 \rin:K 

(State 01 (". ,111)1 ! \ 



M \ I iii:\ \ \M I. 

01 .Mnllli: K 



I'.iKini'i.Ari-. 

Ol- Mfil'HJ-.K 

(Stat- 01 foil nil \ X 



/ 



I ) r R .\ T K ) N ) 'i-ars Mouths 

C()NTRIi;rT()RV 



Days 



Hours 



^y 



/ 



y 



flours 

M.D. 



/ 



<H(M T \Th)N 



) III I 



M.iiilh^ 



lhi\. 



DTRATION -v-v y^'(k}-^ .^rotifhs Pays 

(Signed) ] . vj\ :'0.ojCv 

'vllr. .- ■ i.)0 . ( Aihlress) Lctu UCC - ^^M^f '.'^ ' 

N only for liDspifals, Institutions, Transients, 



SPECIAL IIMFORMATIO 

or Recfnf Residents, and persons dying away from tiome. 



Tin: Mtnxi-: sr \ ri: d i-kusonai, i- \u rirn. \ks aki; rKci-: to rm-: 
i«i';sT oi' ^iv KNOW 1,1, 1 )(■.!•; .\M) iu:iji:i'' 



nnfoi niant 



. oto. Llcv^L 







Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'I,ACK «)I' lURIAI. OR Kl•:^toVA^ 




D.XTIvof niHi.Ai. or KHMOV.M, 

. Ol^ar.....^^ 



T90 



(A.l.lrcss.aUir- l^>bk. M.t. 



N. K.- 



■F.very Item at in1forinntion should be cnreV'ully supplied. AGB Hhould be stated EXACTLY. PHYSICIANS should 
state CAUSEi OF DEATH in pinin terms, that it may be pr«»perly classified. The "Special information" for per- 
sons dyin^ away from home should be f^iven in every instance. • 









r»'. 



w 



It • V 



f 



ttt 



•' I 



V 



■ 



ill 



ii 



jH/ 



mtT' WRITF Pi AIIMI V WITH UNFiiniMn IMK — TH'<=^ '«= '^ dc-oiui amc- w-r oir/-»r*on 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hof.r.l of II.-Mllh -I- Vo :« t'^Tar^^i- MS:!' Co 



ReQ^istered J\^o. 



^^O's^^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccrtiticate of H)eatb 

( 11. S. StanDarC* ; 
PLACE OF DEATH: — County of C'/CLo-v JXcl^-vcvAC.^. City of ^-<^>\' VcL-yva^aec 

No. •/" i • v,v..v„.... St.; Dist.;bet. J Liv and b-Li\ 

(]lF DEATH OCCURS AW«Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL IN TO R M ATI O N " "N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME Lll:,^^oJ; 



/O 



...C ' S. r ^v,.. >...'.• 



-'i \ 



PERSONAL AND STATISTICAL PARTICULARS 

Coi.i >R 



DA ll'. (>l I! Ik 111 



•MoiiUi) 



AC.H 



\ 



JV.M. 



LL^ 



'Diiv 



MottlUs 



I Vt-art 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DKATH 




(Moiitli) 



/go \ 
(Yenr) 



n,! 1 . 



^iN'<". I.I- MAKi<n-;i) 
\\iiM>\\ i-;i> UK i)i\'()Kri;[) 
'W'litfiii social <ltsiv'iiati<)n) 



lUkTiiri, \ri-; 

'Slate 'ir Comili v • 




>v^^OoC^ 



] 



(Day) 
I HJ':RI;HV CIIRTIFV, That I attfiKk'.l (Unvased from 

)JL^\y.l. .. up'\ to Ly^t. n k/d'. 

tliat I last saw h -u-' alive on 'v. ' » j^q ' \, 

ati<l that (loath occurred, on the (hite state»l above, at 
M. The CArSl<: ()!• i) I- AT 1 1 was as follows: 



X.. I 



-\ 



'^'^-.\..;. 



NAMi; DP 
I ATI II -.K 



lUK Til I'l, ACH 
<)1- I Arill-.K 
istatf or ronnti \ ) 



M \l III \ \ AM »•; 
<»l- Morill.K 



lUK riM'I. ACl-: 

<>i' Morm'.K 

(stall ■)! Coutitiv I 



r 






(^ 



^ ^- ' 



OCCrj'ATlON 



%, 






I)r RATION )Vrm9 Months 

c () N T i< 1 1; r I" () R \- vLrJuLoA^ v^ 



na\ 



•V 



//t'// 



/.v 



.1 



f\i'i({r(f ill SiDi I 111 Hi I Wit 



DIRATION 

(Signed ) 




Mini til' 



/J(/1V 



'.V 



r(,o'. (A.hiress) at) Villauvo Jlo 



I Iou> <i 

M.D. 



Special Information only for Hospital 

or Recent Residents, and persons dying iiwdv from home. 



s, Inslmitions, 






Former or 
Usual Residence 



1 . . V<A.^t^ • Pld.eof Death? 



Transients, 



Days 



Mouths 



Ihi 



TMIC AM()\-K ST XTK D I' KK son A I, 1' \ K I" If T I,A KS A I< !•; IKri-: To III I-! 

i!i;s'r oi .Mv kno\\i,i;d<". H .wd i{i;i.n;i-" 



J-^A. \\^« 



I I 



.-V 



\-l(lirss > 



.-t/CL<lVX. 



w 



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



ly.ACK Ol' lUKlAI, OK K);Mo\\i 




r: 



D.vrj-;.>i MnnAi. OI ki-:mo\\i, 
L^U5-V^ ^'^ ' 190 . 

fA.l.li.vs ini OVuVy.vlA.-, , . • 



■^ 



'^^ K- fivery Item of liiforniHtion should be ciirclfully Hupplicd. WW. Hhoulii he HtHted liXACTLY. PHYSICIAINS nhould 

state cause: of death in plnin lerniM. thnt It miiy hr properly cluHHh'icd. The "HpecinI InVoriiiHtiun" for p«r- 
mons dylnjl away from homo Khonld be ftiven in OK^ry inHtnnce. 



(I 




w^ 



m^ 



' 



' 



WRITE PL AIN LY WITH UIVFAPINQ INK — THIS IS A PFRMANENT RFCORD 

: ! ,,nic .nil- K No 1^ ^■?J^^r..S:l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Rei^is(('i'P(l J\F(), 






.<5' 



^ i.eAv<.^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of S>catb 

1 "U. S. 5tan^ar^ ) 
PLACE OF DEATH; — County ofC'CL^^ A.<x-^^e<><LC(. City of C'xx^^j v' a^clovcaw-cl^c 
.LltvXvcxI L\"^^^V0J„^'^- -U ('l^^^^VS♦4t '"■■■' Dist.;bct» and 

f IF Dt*TH OCCURS AWAV FROM USUAL R E fe I D E N C E Gl V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURilED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

% e % 

FULL NAME ^^ a.\Vu. Uiuj<x\-cl. vl 



tHo 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 



DA 1J-; OI lUK 111 



a 



MEDICAL CERTIFICATE OF DEATH 

DAi'i-: (>!• Hi: \ III 



I MtiiUliI 



\' - !■; 



H 



(Day) 



»' ' h 



I ■»■< arl 



/',;i 



•^iN' .i.i: M \Ku ii:i>, 

\\ MX lUj;!) OK i)i\» )Kr j:i) 

iW'iitf ill •^oi-iii'i (1< ".ij.'iiiiti«)ii) 



MikTiiri. \ti-: 

' state Of I'nmit rv ' 




U^vOA-*^ 



(Moiitli) 



1 



(Vtar 



XAMl- Ml 

I \'ni i;k 



nik in I'l, \ri-: 
oi- I A nil-: K 

' St-itf or rdunti \' 



M \iiu:\ NAM)-; 

"I Mo'l'llliK 



HiR'i'ni'T.Aci': 
<>!■ MormiK 

'stall' 1)1 I'oiiiiti \ ) 



^\ 



Lvw. ^ 






\ 



KAJ^ 




^' 



(Day) 
1 III'.UI'HV CI:KTII'V, riiat I mIU'ikU-.I .lorcasotl fn.m 

It/) tn \()0 

lliat I last saw ll ~ al'iM' tm up 

ami that (Katli ocfiiircMl, mi the dati- statt-<l above, at 
M. Tin- CAISI'! Ol- DiiATII was as follows: 

1)( RATION Years ^ Months Days 



CONTkllUTORV 



Hours 



DIR ATION 



)'rars Months 



Days 



I'O 






OCCUPATION 



"^ 



a. 



Vlc r- x 






(SIG 



N ED ) Lc\.CrAJl\; 3 . Vft . UO. XlL; 
jlC'. ' (CO ! (A.l.lr,ss) V<rvr\vtV:i CitU. ^^ 



I/iUirs 

M.D. 



Special information «nlv t<'r Hnspltdls, Institiltrons, Transients, 
or Recent Residents, and persons dying away from fiome. 

former or ( k \) |) " i ' Mow long at 

Usual ResidenceVljXX/VWV-CLiA- ' < " Phue o» Oeatli? 



J' 



lA ■-///.■ 



/'./I 



rm: AHovK STA ri'i) i'kksonai. i-xk ri»ri.\KS aki: ikih r<» rm-: 
iu;sT oi- Mv KNOW i.i:i)(. J. \Ni> iu;mi;k 



X.Mnss 5 I LU JvvX 



VV^L"v\Je.Ci \- 



Isual Residence 

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



[) 



Days 



ri,A('}: Ol' lUKlAI, OK kl-IMoVAI, 



DA ri-; n! lii Wi \l, oi KMMOX' Al, 






T90 



N. K. Hvcry Item «>f information hIiouM h j ciirefiilly Hiipplieci. Adh Hhoviltl be Htnted RXACTLY. PHYSICIANS hHouUI 

Htate CAUSE OF DTATH in plitin terms, thnt it miiy hs properly cluHsified. Tlie "SpecinI Informntion" for pen- 
nons (lylnil away from homu Nhoiitd he driven in every inHtnnce. 



f 






I 



I- i'' 



m ■ 



r; 






WR!TE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ll,:iUh"J- No. i^ l^-?^^*'!^^ ll&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nnh' Filed , \iX^^Lw\l)^\> M 

i 



.^ccv^ 




I!) OH 
Deputy Health Officer 



Registered J\^o. 



•■^ o^^-<.3 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



i 



J? 



PLACE OF DEATH: — County of OC.a^.co^^Jtor^JL^ City of ^^^OwC\^0^>^AX>v1a) Lcv^'. 



Na 



St.; 



Dist,; bet. 



and 



(IF Dt*TH OCCUBS AW«Y FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



a 



FULL NAME 



' -...'w 



/ 



1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 

i).\ri-; oi- Di; \Tn 



I'ATl ' >I i'.lR III 



\' . 1. 



r%^\ 



iMoiith) 



) 



I):.v 



1/.'"'// 



'V<;ii ' 



/),M - 



SINt.l.lV MAkKli:i) 

iWiitt ill »,(K-iiil (1< '•ij.'.natioii) 




,A,/:L<rL\M>v 



lUK IIIIM, AC}-: 
' st;it< or I'.iiintrv^ 



NAM}' ol 
I'AIHi: K 



ItIK IHIM, \ri.; 
«>l" 1 Ari!i;K 

"^t.iti or t'oiiiiti \ 



MA!i)i;\ NAM)". 

«'i M«trin;K 



HIKTHI'LAi'l-; 

'»i M<»riii:k 

'Slatf (ir I'oiiiiti \ 



< >i 111 ATION 



I 



(M(nith) 



Day) (Vfar) 



I II1':RI;P.V C"|;RTII'V, TIi.iI I attoiKk-il (Uh-cmsciI frnin 

— to 



that I last saw h 



1 90 

alive- <iii 



T()0 
190 



and tliat <l(atli ocnirrcMl, on (bo dali- statt-d abovo, at 
• .M. Tin- CArSI<; ()!■ I)i;.\'rn was as follows 



:) 



JLK. 



'A 



Dlk.XTION )'rars 

CONTRllU'TOUV 



Mouths 



/></).' 



'.V 



Hours 



^^' 



I)rK.\TI()\ )V(//;s Mouths 

(Signed ) % 

-\dd tvss) O O.C 



/hiy 



'S 



Hours 
M.D. 



I()0 



( 



^<Xr\ 



Special Information flnly for Hospltdls, Inslitutions, Transients, 
or Recent Residents, and persons dyinq away from fiome. 



h'f nliuf ill Sim I'l ()Hi i^i'i) 



)'r ,n 



\f.,,if/i- 



n.n 



I"!!!', AUOVK STAT K I) PHKsONAI, r.VRTHTl, \KS A K l-! TKri-: TO VWV. 

ni:sr <)i- my knowi.iux'.k and hkiji:i' 



Former or 
Usual Residence 

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



How long at 
Plare of Deatli ? 



. Days 



I'l.ACK OK lilRIAI, OK Rl-.MOXAI. 



D.KTlCo!' I!i i<i..\i, or kI<:M()\\I, 



^^^ 



INDICKTAKKR UCoJs ^ ' V ^^(HytVv 

^\,i,irrss bl%- (alH bcL^^j MViV) Ll .' 



190 



N. B. Kvery item of information Hhould hi cnrefully Hupplied. AGB should be stnted F.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for par- 
sons dyinil away from home should be ftiven in every instance. 






i 



I 



}' ' 






)\ 



I' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 

III 



J.^ 



[4 



l;,,,.!.i .1 He: !l!i I V"- : '^'l'^^' 1'^^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ihf/r n/cf/, vK 



<ro-iyr>\,M^ H 



I 



.tr\A.cA 




190 "i 



OfTir^er 



JiP<:>/\sterrfl A^o. 



282? 



i Deputy He 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( XX. S. i?tanc>nvc> ) 



J 



("V^ 



^ 



vX, 



X 



((V^ 



v. i_V ' «. V. — *j. 



City of "^ CV ^ V XCL ) \. c^. 



PLACE OF DEATH: — County of 

No. I ^'^5 (ADOiw' St.; Dist.;bet. 1 H A^K> and 

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



FULL NAME 



JLC\ 



PERSONAL AND STATISTICAL PARTICULARS 
\ "Vn ' cni,(ik\ 



'h 



'Nil-: <>[• I'.iK rn 



U 



LLcv.n 



\! 



I l>;\\i 



\' ■ v. 



/\ 



'"..■' 



1/ 



-IN'.l.K. M\kKIi:i» 

w ii>« t\vi:i) ok i>i\"< iR^ }:i» 

W'liti ill '.iicial lU •«i).^iiati')u) 



l!IKT!H'I,Ai'K 




\ \Mi; oi 

1 ATHKR 



d<XT> 




I'.iK'niiM.ArH 

•»l lAIHKK 
State or Coimtrv^ 



MN1I)1;n \\M1' 

"I Murm.K 



i!iK riiiM.An-; 

<>|- MnTHKK 
'Statr ni Coiintrv) 



" n V I PA riox 






MEDICAL CERTIFICATE OF DEATH 

DA I'l' *»!• I)i; AllI 



Vf 



(MoTltlO 



Davl (Year) 



I Ill'k !:i',\' I. I'kTil'V, Thiil I alU'iKKil (IcccasL'd fnuii 

I(^f) tn ■' V. ^ s. .'. Tip 

tliat I last saw h •• alive on ' li>0 

ami that <Kath occiirrcil, on the 'late- stated al)()ve, at 
.M. Tlic CAISI^ Ol' Di: ATII ua- a>^ follows: 



or RAT ION •• Years 
CONTKIIU TORY 



Moiilhs 



Pays 



//out s 




\ i 



/CU>\, '^X-CL ! .^^-^4^ 



U.Us^^VCXO ' 




1)1' RAT ION 
(SIG 



y'l'ars 



MoNi/is 



Ihns 



Hon 



rs' 



N E D ) . J.-^OXOL^c CV, !■'...' .. M.D. 

( Address) Ul'^.^llv-v-v.V-rvL .''I 

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



I()0 



A'/" '/(A',/ /// Sti)/ /'iiiitiiu'ii * V )i'iii 



1 A . (////.- 



/),n. 



I III", AHOVK STAIi:n PKRSONAI, I'A K'rUT I,AKS AKI' TKrK TO TlIK 

nivsT Ol- M\- KN()\vij;i)c.i.: AM) in;Mi:F 



flnf, 



>;niaiit 



^ . Q) w, 






Te -5 



Former or 
Usual Residence 

Wfien was disease contracted, 
If not at place of deati) ? 



How lonq at 
Place of Deatli ? 



Days 



IM.ACK OK lUKIAU oK RIvMoVAI, 



%iLi^w^.i 



1 



i)A'n:Mf ui in.M. or ri-;m<i\ai. 

■'I ' ' i TC)0''. 



• XDK RTA K K R sJ 4'VLCriXfr\. ^ oL ' O, 



(Address 



^.5.1, a) iUAXiA^-vv^ ui 



. o? information should be carefully supplied. AGF. should be stated BXACTLY PHYSICIANS «hould 
SE OF DEATH in plain terms, that it may be properly dassitled. The Special Information for pi.r- 



N. B. Kvery item 

state CAU 

sons dyin]2; away from home should be ftiven in every instance. 



I 



1 



/-^ 



f 






I 



H,,ai(l • f Hialtli \ No. i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



-•:■■ i;M' <•■ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







IsA,^ 






7.9(9^ 



Jtrgistcred J^'^o, 



2828 



DEPARTMENT OF PUBLIC HEALTfi=City and County of San Francisco 

Certificate of IDcatb 

I XX. S. t?tan(>arC> ) 
PLACE OF DEATH; — County of^C-^AXXCL ^^^Lo,. City of VyJXOwCK oL'x<X/>%xc-.\(l V,al 



No. 



St.; 



Dist.; bet. 



and 



^ 



/ IF DEATH OCCURS AWAY FROM USUAL 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 NAME t^Q 



1 



PERSONAL AND STATISTICAL PARTICULARS 



\ 




KATJ: It!. lilKTII 



\X.\\^X. 



MEDICAL CERTIFICATE OF DEATH 



DATK OF HKA IH 



'Lu 






. i'. 



I). 



1/ •u;l, 



\ < III 



P.: 




^IN'.I.K MAkKH.Ii 




!Uk I'lli'I. \i-)" 
' St;itc iir (.'iiimt: y • 



N \Mi- or 

1 A'lIII.K 



liiKiiipi.xii.: 
oi- i-ATm:i< 



"^'M1>1:n NAMl- 
"1 MUTIII-.K 



inuriiiM.Ari. 

'•»■ MnTllllK 
'St;itc or <uuilt I VI 



I iW^V^td 









(I):tv 



(Vi-ar) 



I lli;ivl{l{\' I ]•■. RTII'N', That I attLiitlcd (loccasetl from 

to SK^^^.X looM 



J(;0 



1()0 

tliat 1 last saw h -'L>^^ alive ()n \jV.^\; i yep 

and that (U-atli occurred, on the dale statc-d above, at 
^L. The CAlSIv OF 1)I:ATII was as follows: 



'JVi 



> . ^(XV* 




nr RAT ION )'t'ars Moulin /hrv 



Hour 



CONTRir.rToKV vA^avA, 



C V Q^: \ : 



?) 



i) 



"> «'i rxTioN 



f\''Mcir(f III Siiii /'i till, .'M'fi >.k ) V(M * 



Mniilh' 



/',M 



1)1" R A'!' ION )',/rs- 

( SIGNED ^ A. ^A. 



MoNt/lS 



/hlV 



//ours 
M.D. 



loo 



( 



Xddn'soU^Xac. iN Jv,0„^.^': 



SPECIAL Information «nly for Hospitdls, InslituHons, Trdnsients, 
or Recent Residents, and persons dying .iwdv from liome. 



TiiK Aii()\K s'r.\'n-:i) r^KsoNAi, par iicn.AKs aki; tkii-: ro «■"»•; 

H1-,ST ()}•• MV KN(>\VI,J-;i)C. K AND Kl-IJl'J- 
(Achlrcss 1 I UJ-^ Uj 



N^-JL,*. ^ 



^V 



(XrvYvr C)X) 



former or 
Usual Residence 

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



How long at 
Place of Oeath ? 



. Days 



I'I.ACP: OF inKIALOK RKMOVAI 



D.VI'Flof MiuiAl, or KF:M()VAI, 
' l\0%' 5 TQOH 

119. X^ crt<ijiAv.. i:5.'<^k..U;' 



IN. B.. 



f . ? ♦• K 1 1 K. nrefallv suDpUcd. AGE should be stated F.XACTLY. PHYSICIANS should 

of mfnpmntion should be caretully suppnen. ^vi •»c„,.ri«il Infnrmntion*' ?or D«r- 

E OF DEATH In ph.in terms, that it m«y he properly classified. The Special Information tor p«r 



-Rvery item 
state CAUSt OF DEATH In p 
son* dyinft away from home should be ^iven in every instance 



I I 



i 






4 






It 



::r -. i.M' T. 



^-^. ^.^ M-r^r- i'/NB I MCTBI irTION^ 

REFER TO BAt.»\ ur <>.cn i i r ix^>^ . i- ■ w.. • - - 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

J)(tf(' Filed , 




^JP^^t/^-y'vl>-v^■ H 



7,9(9 H 



Ke^ustcrcd A'^o. 



2829 



i"^ 



.X^V^v 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH:-County ofdc.v i ,^.^>xc..c.- Gty ofOc^ .Uo.xc. 

( '^^^S^H-occ^^^ o^":?f.r.^T^oro.r.;i -i^l -s"teao O. STR.T a.. ...SER. ) 



FULL NAME 



V. 



PERSONAL AND STATISTICAL PARTICULARS 

I C()I,<»K N 




> 



1 



LCVL'^ 



I.\ 1 : . 'I !'.II< 111 



At.i-: 




M..ull^ 



t) 



1 1' 



MEDICAL CERTIFICATE OF DEATH 

1) \ r»-. <'i- i»i ^1" 



\!..!'t1l'l 






, MKRKIIV U.KTl! V. That 1 .nt.,.^K-Mov...cM tP-u. 



1 , ,o ' . t ' 




^IX'I.l' MAKHll'.n 

A ! ; M v\\ I I 1 t Ik li'\'< iK*" !•■. I> 



HlKTm-KXri, 

-^f .•' ui i'"nmli \ 



CJ c^^OX^ 



•05? 



I 



\ \M 1 < »l 

1- ATI! i:r 



I'.lKTIl V\. \v)-: 

<>i i-\rin:K 

' >l.itt iir Coiiiiti \ 



M \ii>i:n n \mi. 

Ml MoTin-'.R 



lUK'l'mM.AC'K 
nl MoTlIKR 
(Stntr or OimntiN I 







CPr"V<XVOv -.v^LLr. 



(\ 




r\ 



:^t5U\-^. 



occri'ArioNPv-N , , . . /] 

K'fdr.l III S„n /i.nni'" H ' \ )V.M' 



(1)0 

that I lii-^t s.iu h :i)i\'"ii 

:.n.lthat.Uath.KVunv.l. .unK.l....^taU.lahov..at 

M. Tlu- CMSK <»r lU.A'lll Nvas as tollnw'^: 

v. '. ' ' ' ■-• - 









DIRATION 
(SIGNED) L-V-^ V 




//ours 
M.D. 



I > 



I()0 i 



-L; 



Mrnllh' 



n\v. MiovK sT\-n:i) i'Kk^onm. rxKTUT i.aks aki: ik' »• 
iu-:sT or MY KNo\vi,i:i)<'. !•: an'i> ni'.iji.i' 

'x,M,.ss %%K Uvv. -v,ta' V.l • 



or^eren^ Ments, Vnd persons dyin,, .m..v (,on, home. 

. Days 



Former or r 1 ^K ., , , , , ', 

Usual Residence -^ J 0:^-4-1 ^ ' • ^^^ 

When Has disease ronfrarfed, 
It not at place ol deatli > 

\'\ \('V. Ol' in KIA.. 



Hov* long at 
I'lar e ol Deatti ? 



DA ri-. '>! Hi !<i.\i. <" Kl■■^^"^ ai, 



)\rv 



TOO 






.SKTtm' 



^'"""^^ ^^ ^- ' ^ . — ^ TTrXACTlY. PHYSICIANS Hhoulcl 

Btntc CMISn OF DEATH In pIhIh tcrm«. t»^» '» '"'/^ inHtancc. 



-F.I 

state CAllSn OF DEATH in pl.t... .- ."^'j - - inHtancc. 

sons dyinft nwny from home should be ft.ven .n every 



Tf 



t i. fe 




r i;i 



■%^' 



m 



■ 1 

III 



N- 



I 
If 






*4 



* 



-,uic= ic a PERMANENT RECORD 
WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMAN 

REFER TO BACK OF CEFmnCATEFOR_INST 




REFER TO BACK OF CERT IFICATE FOR INSTRUCTIONS 

— 









DEPARTMENT OF PUBLIC HE AJJIWity and County of San Francisco 



PLACE OF DEATH 



Ccvtittcatc ot Bcatb 

. rf n-i^'vVcvTxcv-^' City ot ^'^^^^ 
: — County ot^^^^^^"-' 



<-> • 



fO . i'^ ^? . I ^^ T.. L . and 

! J H- 4 H<^^*^'>^' '"^ ^ St* Uist.; bet. „,„ '.iprciAL intormation' \ 

V IF OCATH OCCUJ^BED >N A HOSPITAL 



) 






FULL NAME ^ 



i 



PERSONAL AND STATISTICAL PARTICULARS 

i( il.' 'K 



J i 

III r. 1 K 1 i i 



. «^ 



LL 



MEDICAL CERTIFICATE OF DEATH 



i.vri- ..!• nv.ATH I Y^ 



I Mniitlr 



1 

(I)ay^ 



IV. ■ 



M.uttlO 



I' 



!. 






/ 



-iNi.l.l" MAKKli: 1' 



n 

it ■• .11 ' 



i)\ 



CLV'v^" 



,„i.ui:,..vo.:KTn.-v.T„.,.^..u.„.u....u— ••If 



p 



, VW/^^ V Ow'v^\ 



vt ,1, (ir ^""lmllI^ 



> \ 111 I'U 



o! 1 A 11 IKK 

Statr or Country 



^ 



UvccvLu 



nr RAT I ON ^'■'^'•^ 



.Vof/Z/is 



Days 



//oiif:< 



M \11»1"\ N AMI 

• ;i MM-nn;i< 



luk Tiiri.Ari-", 

nj- M(»l'm-",K 
(Stall (It rounlrv 



only lor H^ 



(Signed) 



IH'iMl^^i-' 



V) 



q 



VLo ^ «'»*T' 






How long at o „ 

Place ol Dedth? W 







rSDl'.K TAKl-'^ 



(Atldrt'SS 






QW^^utt. ^1 



OuX^ U (JVl' ^< l^>>A,V-0... ■ _ , . rPXACTLY. PHYSICIANS nhould 

, , j,.....on «H,n..a .. ^..^^^y;;;^ --l-t pt.peH, c.a.«-...ea. THe Spc.a. 
OF DEATH In plnin J*^/"'";; * „ •„ «,cry m«tance. 



M. B. r.very item otf t,.rmH. i«"" ' 

.tote CAUSE OF DEATH In P'"'" ';;'",.., in every in»l«">=«- 
.on. dylnft »w.y «ron. home »h.."l.l •" t 




i 



I' I 



I 






fii 



r 



m 



h 



\i\ 



,</, 






In" 



W 



WRl 



, , ,, .1,1, 1 \n --, ^* ^•'i?":3n&i*Co 

;>,,;.l(!i;t ll<:iHll I ■^'' "- .-■<-« ___^^ 



TE PLAINLY WITH UNFADING INK 



— THIS IS A PERMANENT RECORD 



_-« m^ m ^ Lt fy.r- r»C"DTICI 






rATr FOR INSTRUCTIONS 



/>r//^' /•7/r>^/,ILr^Nt^v!>t>v H 



/,Vr>>H 



Be^^l^'^^cred jVo, 






.O^^wA-^ 




o^^r^^ .^A,v^t Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( 11. 5. Standard ) 

PLACE OF DEATH : — County of U XXa^ vJ ■ ^ -^ . 

, -t "' c. R Dkt • bet U 'CV_-U./T\.C^J andH'\^'4--i-'^-'''' 



■) 



No. 



o 




FULL NAME 




■^ 



LOJvao. 



W .ULc 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 



VI W 



(XU 



i» \ rr < 'I i; I Kill 



\<.K 






1 1 . 1 \ 



MEDICAL CERTIFICATE OF DEATH 

D \ II' I il' I'l. \ I'll 



J .. ... . 

(Month) 



(I)av) 



IQO 

iVcar) 



, ,i,.;ri.:I^V ri:uTIl^\. Thai I aUcn.U-.l .Icceased from 



tJV.. 



)<•./» 



M.^ulh 



iKi 




Ni\<.i.r M\KK!i-:i) 

\Vi il' in -.rtia! (l<->.i!.'nat k >ii) 



iMK rin'i.Ai'iv 

' htatf <>t (.■'niiitrv^ 



!• A'lUl-.R 



HlKTinM.ACK 
• ll- lATHKR 

(State or Cotuitryt 



MAIDl'.N NAMH 
<>1 MOTHKR 




t(, M vwv C.S.. IQO ^ 

^^,^^,,,,„,,,,„„,.rru.rc.l. oM the .late staUMl above, at 
M. The CAISI-: ()!• Dl'-ATII xvas as foHows: 



'i)jUv^o.-\J-^.o.- 



c^ . .... 



0^^vr\Xl^- 



fs 



1)1 RATION ■' y^-ars 
CoNTUliU'TORV 



M out ha 



Days 



Hours 




^ 



fl 

ocrLLcv > 



lUK rin'LACH 
(H- Morm'.K 

'State or OoiintTy'l 



DTRATION 
(SIGNED) 



Yi'ars 



Monlhs 



Pays 



%Xv \\ . 



M.D. 




CAT?, ....M >.,,,i..ssnnVs5,v.c^'.w 



IS 



v:)l 



"c^PECIAL INFORMATION onh for Hospitnls, Institutions, Transients, 
or Rerenl Residents, and persons dying away from home. 



vC 



afefti I 



Re^idrd m S,i>i /'nnh 



)',(i I 



1/ i/.'/i 



/K!\ 



^r:,HOVKSTAT,a..-KKSnNA. rXKn;^-,;;^K>AKKTKrKTO THH 



(Iiifortuant 



A--(5"y . 






Former or 
Usual Residence 

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



How long at 
Place ol Death ? 



Days 



I)\rr of lU Ki.Al, or KKMOVAl, 



TQO 



pi,\CH«)i' muiAi, t)R ri:m<»vai. 

V P i^^ ; ^^Lo 

.-,.^,•«T^KKR VA^O^^ ^<!>'^^^-^'>; ^ . ,'. 



1 1^ 



(Addv 



Hl'^ 



- , FVACTLY PHYSICIANS should 



-Every item o^ mtormoii"" ».■>'- proper 

i.vcry nF\TH in plain terms, that it ma> nc i 

state CAUSE OF Ut:A i n m »^ ^U^n in every instance, 

son. dyinjl away from home should be fe.ven 



t 






{I 



[ 



•ti. 



« J.,, 



tW 



41 



.11 



I 



k, 
\\'^ 





WRITE PLAINLY WITH UN 



FADING INK — THIS IS A PERMANENT RECORD 



>«te«»p^ii^^^>l^iklO 



..,!■■!' H< "'''i ' '•" 



-A.v'^I^IlS:!' Vn 



Dale A'/7r^/,\l LrvN^^/v>A^ 




.04A.' 



H 



VJO'A 



REFER TO BACK OF CE HTiPiCAit Fvn i i^o i nw>^ . . w.-^ 

llecJistcred jYo. ^-Oo^^ 



.t\.KAj^\jssy^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)catb 



PLACE OF DEATH: — County 



No. 10 1 i 



Ta. S. StanC>at£i ) 

\ ^ 

of OCL^^ J VO. v-vC 

St.; t) Dist.; bet. 



(!f^ 



City of '-J 'CC'>^' A^<X > vc,^. C i 



U/C^Ov ^.o'^nrMrr r.xyc ^CTS 'c A^u't D^O R Vn DE R "sPtCIAL . N rOR M AT.O N • A 



FULL NAME '^<^^, 



{ 



i 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 




f\(xU 

H \ I i. t Pi i; IK I' 1 1 



Month '/V 



I 



/ '■ 



\ < . !■: 



\H 



i I)av» 



M.^iitln 



I S'r.ll 



Pi! 



MEDICAL CERTIFICATE OF DEATH 

DATI-: ()1 IM'.Alll 

(Mnnth) 'I>^'>-^ 

I IlKRKnV ei.kTll^V. Tliat lalteiulc.l.lcTcaseil fn.,,, 

liiO t 



(V> ,11 



\ 



1 iiai I ai 



i\<.I,lv M\KKIi:i) 

u 



\VII)<>\V1-:i> <»R I)IV« (Kt I'D \ 



that I last saw li-^>A alive oil sj l.C i'»o > 

a,M that .Ivath nccurre.l, on the .lale state-l above, al ^ '> ^- 
M. The CArSl^Ol" DIATII NNa«; as follow^: 



1 -1 



a ^ -1 - 



lUKTIIl'LAOK 
I Sl;it<- or e'outilry ' 



\\M1. <)I 

I \'nn-;R 



luurin'i.Ac'K 

t»|. lArilKK 
'Stiitf or rouiit 1 \ 



M \ii)i:n nam 1 

1)1 MoTIIl-.R 




lUR'i'inM.ArK 

Ol' MoTIIHK 
( StaU- or CoiiJilrx 






U^j^' 



,^fY\/^^ V.fcA, C 



DIRATION 1 
CONTKIIUTOKV 






/)(/r.v 



Hour 



\J\\^-^ 



Moudi. 



/hiVS 





'^ 






//ours 
M.D. 



SIGNED ^ 

]\(r\r3 u)oH ^ . , 

SPECIAL INFORMATION onlv lor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away (ron home. 



(A.hlre..) RTH ^1\XX/V^ ^^ 



f\i-sijri{ in Siiii I'l (i>h ;.'<■■' 



) ,,;/ 



.'[/.'>///'/• 



/'<(\, 



THKAIU>VHSTATKl)l'KK^«)NAl,!VXKTirri.\KSAKi;TKrK l'> 

iu:sr oi' .MY KN()\vi,i:i)c.K and invLii-.i- 



I'ln 



f„„ Q(]\.^,Wtu>v 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



. Days 



PI \CF Ol- in-RIAL (»K KKMOVAL 




DATI-: '>!' HiinAi. oi K1-:M<'VAI. 



.m,..:ktak,.:k \3 ^\U^ ^]^^^'- ' ^^^^ 



(^\/d^'y\' Oo-Lv.AwVv 



N. B 



(\<l(hvss. c:*w^ CP^'^^r\JLA;^'^^ V - '• ^^^^^_«— — — — — — — ""—^ „ . ,, 

■ ^ iFVACTlY PHYSICIANS Hhould 

..ate CAUSE OF DEATH in pl..in ..rm,, thnl -t ""> . [ 



-Rvery li 

state CAUSE OF Dt A in m p...". -■■•■-; - - instance, 

son, dyinft away from home should be fe.ven m every 



I 




iii 




M 




ITH UN 



FADING INK — THIS IS A PERMANENT RECORD 



>«».■«-*«• I^^BI^KII 



Dale /v7^>^/, \^Uv^^y>>^JU^^ H ^^^'^ 



REFER TO BACK OF CERTIFICAit. rv^n i i^io ■ nwv. . .v/.^ w 

*)QOO 



LV^'UwA/i ckx^.^ 



Dcpu.y Heal'^' ^M?^^'' 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate ot Bcatb 

( 11. 5. StauDarD ) 



No. 



PLACE OF DEATH: — County of -Cl 



Q^ 



-> 



> ,OLA.Ci City of C'CLA^ ^^cx.->vcc<^ 



Dist.; bet. 



_y\J ^- ' /\J ■ ^-' / VVX-' ' V, V, WJ r _,,,rr> rriR UNDER SPECIAL iwnjn 



and 



"special INFORMATION" '\ 
MBER. / 



FULL NAME 




UX' 



K\ 



cr' 



v-' 



r 



^^ ^^^ 



PERSONAL AND STATISTICAL PARTICULARS 



\ 



i»\ ri-: III KiK 1 II 



V 






\i .!•: 



,^ 



I l):i\ 



.!/.'»//// 



/',M 



MEDICAL CERTIFICATE OF DEATH 

DATK *>1' l)i;.\TIl 



I>;,v^ (Yoart 



(Month) 
I11;r1.:1>.V C1;RTII-V, That I alir.i.U.l .IcrcascMl In.ni 

■ P *: ^ • '-■ i()0 1 



si\(,i,i-: M\kuii:i» 

^\ I iti- ill ^iK-ial <li -i'/n;ili"n> 




IMKTMIM.ACl'. 

.'>;t it. i.r I'oimlt v 



N \\11 <>1 
KATIIIK 



lUKTiii'i. \ri-; 

Ol- lACm-.K 
'State cir roiintJ v> 



MAIDl.N NAMT; 
<>!• MD'rilKR 



J^ 










V<X< 











190; t.^ 

tit, it I last saw h alivfon 

,,M that .K-atl...-nm-.l.o„ the. lat.statc.a above, at ■ 

M. Thf CAISI' ()!• I)1:AT1I wa- as 

V 



n/j 



follow 



]'t'(7rs 



DTK AT ION 
CONTKll'.rTOKV -'-^ 



Moil tin Pay_s 



I lours 



\\ 



lUKTHri^Al'K 
nl MOTHHK 
(st.iti- <ir C"i)\intr\^ 



U/OO-^tJOoo' 



A 



aXV 



nrrri'ATION 



M.niih 



Tin: MIOVK STATi:i) PKKSONAl. 1' ^ •< ''^■.Sl- r*^^ ^ '^ ' 

i»i:s'r <n- mv knowi.j.ix.k ani' mi-.mim' 



IK I J. I" '■'"■ 



DTK AT ION )<'"'^" 

SIGNED 



Months 1 /^a.rv 



OunL^V AyWQ /VC^ ^^ 



•1 ■' A- ■\ - 



r^ 



KiO 



f \.l(lrcs<) '-'^P ' ■-' 



t^^ 



I loHl^ 

M.D. 



ilM only lor llospitdls, Institufiuns, Irdnsients, 



SPECIAL INFORMATION "my m .m 
or Relrnf Residfnfs, .nd persons dyin:j d.H) tro;n home. 

How lonq .it 
former or nm ^\ Di'dlh? 

Isual Residence 

When was disease contracted, 

II not at place ol death ? 



Odvs 



(Iiif'iimritit 






( X.l.hcss 














"Jf 






—,^^^^—^-^— . 1 1-X4CTLV P1IY8ICIA1NS iihaulcl 

N. B. P.».ry Item ot information .houl.1 h.- ^•"-">;">; ,. 'J .^ ^^ orooerly >;lB«.i«lcd. Th» »p«cioi 



..a.c" CAUSE OH DEATH In plnln Urm.. «;-|;'^-;> ';:ZZ" ' 
.on. dytnft awB, «rom homo -houlU be fv.n .n .very 



t 



i 



i 






WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,,f ll.'MltTi— I 






X' 1 



rjoH 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2831 



Jlr(^i\stercd A^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



,<VAw\-*^<i 



M- 









Certificate of Beatb 

PLACE OF DEATH: — County ofOct^A. J-^cx^vc^iccCity of -a. v, Vo . -c^ct 

FULL NAME Ov a. J o ^cx w 



) 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



^\ 







u 



n 



i)\ ri-. «»i- i;iK I'M 



; f M.Mllh 



\< . !•; 



XI 



) ' .: 



\):\\) 



M.'uth 



\'i ;ii I 



Pa 



IQO \ 
(Year) 



MEDICAL CERTIFICATE OF DEATH 

i).\ri'. «»i. i»i;a TH \ 

(Month) . O^-'V' 

I lli:Ki:r.V 1"1;RTI1-V. That l alU-iKU-.l .Ircva^cd from 



lliMt I la^t Nuw li t . . alivf on 



I ' '-' 



->!%•, I. Iv MAKU IJ.l). 



a„.l that .Uath uccau.v.l. <.m tlir -latr statol above, at - . r. . 
M. TIk" CArSM ()!• Dl'.ATll was as follows: 



^^, 



lURTinM.vri" 

^t:i!i or CoUtlll \' 



\ \M 1- ()!• 
!■ ATIII'.K 



^ 






H' 




0.^ax^^ V)V<xcaj;lc i v 




lUK THl'I.ArK 
ni- lAllIHK 

'Stall or CoiiTiti y) 



MAlI(i:\ NAM1-: 

<>l Morill'.K ^ 



^J 



1' ., . . 



Ov^\X\lLv\xa 



v,^ 



r.iiniii'i.Ari". 

«»1' Mi>|||l.,K 

"^iiiti- oi t'l unit 1 \ I 



Xhj^'WCL'^'v^ 



1/../////- 



/'.^ 



Ki--idr,{ in San li,ni. :<•' > '"' 

HI<;ST <)1' MS" KN()\\l.i;i)f.H ANI) in.1,11.1- 



(I1 



Crrw 



.<XA^^.>a,<'^vA; 



O.. ; V V-.C . '.o; 



1 



..^dyiK^^y 



I )r RAT ION ^''""'K^ .l/<"'///.s- /^'^''^" 

CoNTKiniToRV V^\a^,aA.:.:..- 



Hours 



DIRA'PION 



)V(//-.v 



^ 



:^ 



( SIGNED ).Ll 



\ 



\ ' 



jron//is An'-^ 



'o"i 



Hours 
M.D. 



\-^ 



\ Lt ■ . 



I(>0 ■ 



.........^nt y^^fi^ ^W^luu 



"Special information «nlv i»r Ho^ifxK institutions. Transients, 
or Rerent Residents, and persons dyinq awdy fron tiome. 

J,' Hnv\ iontj dt 

S«e««abbl^^v,va. I, Pl« «(««...■ 

WIten was disease f onf rafted, ( 1 , , ^ ' , 
If notatplaceofdeatti? \X\.^i.\ 



.. Oavs 



iM.ACK «)i- in KiAi- <'!< ri:m<.vai 



uA'i'H of in KiAi. "I ki;m()\ Ai, 

1 90 ' ' 



^Ti'; of in K1.1 



( \<l(llC^S 










b^ia (JVD.OA.i ^ 

^_^.J^ — —■———'— '^"'™*'''^ . EXACTLY PHYSICIANS Hhoultl 

N. ...-Rv.r, Uc™ of ,..« Oon .hou... H. c.roV.,.., -upp..e... XiLt'T.a.'K-.:!.': 'th; ••Sl^cI..'. .,..o..,.».i..n" «... P- 

..„.c CAUSE or DEATH in pl..in ;-•"»;;;;' „".r,'-; JJ.^. 
.on. .lying away from horn. »lioul.l b.: »i>«n in ov.ry 



I 11 



I'l! 



i : ( 

1 . \ 



!! 



i 



li i 



^- 



• t 









J 



i 



LOCALITY OF 



R ECORD S 



SAN FRANCISCO 



COU NT Y 

^ \^ ^J I H i • 



S AN FRANCISCO 
CALIFORNIA 



TITLE 



DEATH 



RECORD 



CERTIFICATES 



I CROP I LMED 



FOR 



THE GEN EALOG I CAL 



SOC I E TY 



SALT LAKE 



C I TY 



UTAH 



CALIFORNIA 



DATE 




APRIL 



1975 



PH OTOGR AP HER 



MAX JOHNSON 



5 "^t 




CAMERA ■no2683 




RED 



VOLUME 2601 — 2900 



904 



> 



T 



LOCALITY OF 



RECORD S 



SAN FRANCISCO 
COUNTY 



*# 



S AN FRANCISCO 
CALIFORNIA 



TITLE 



RECORD 



CERTIFICATES 



/ 



I CROP I LMED 



FOR 



c 



THE GENEALOGICAL 



SOC I E TY 



SALT LAKE 



C I TY 



UTAH 



C A L I FORM I A 



DATE 




APRIL 



1975 



PH OTOGRAPHER 



MAX JOHNSON 




CAMERA ■N0 2683B RED 




VOLUME 2601 — 2900 



904 



h h 



K^ 



,1, 

'I 



If ^ ; 



I 






1'! 



li:, 



.i 






I ■;■ 



I' 






U- f 



. 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I!();il.l of lie riltll I' N'o. ! «i "^XH-'^'' ''^^' ^" 






IfJO'i 



]iCgi>s!crc(l J\^o. 



<38o4 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDcatb 

( Xl. S. Stan^arC> ) 



J? 



PLACE OF DEATH:— County of CVcu-w. J /*va. , .,-•...-,■ City ofOo. 



P 



'No.Ot).Ho-^vl\A JId &-Ua-V^o..I 



ll 



St.; 



/ IF D^ATH OCCURS AWAyIfROM 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 



D 



CL 




Dist.; bet. 

S Ci 

s N 



and 



\) 



kuXUw 



Ui.C. 



si:\ 



DATi-: Ml r,iRi-n 



PERSONAL AND STATISTICAL PARTICULARS 

! COI,(>R \ 







]!|,,t- 



(IM.-ntlp 



AC.H 



ll 



JV.// > 



!' ■ 

ID.-iy) 



(Vtai 



n,i\s 



TOO 

(Yfiir) 



SI\(,1,};. MAKK li;i). 

WIlx >\\ i:i> (»K I)IV()K<.'HI) 

'Wiitciii s.uiiil (It si<.rtiati<)ii) 



HIK llll'l, \01', 
! SlMtt IT L'otuitry^ 






HIK'niFM.ACK 
Ol" F-AIin-;K 

(Stnl( or C'Duntiv 



vtaii>i:n NAM1-: f^ 

(H- MOTin.K 




o^. 



OiAyTYVCXwu . 



"'■"'"'■■^(J^cvvkj,. . fl 



MEDICAL CERTIFICATE OF DEATH 
DATK ol' DllATlI 

Mlcv- 

(MonUi) . I Day) 

1 in':RI<;F.V CI<:RTIFV, riiMt I aUfu.k-.l .Icccased from 

'- ...t : .:. T9o'i to 0\x^\" '^- T()oS 

that I last saw h A. . > alive on ' ' ^-l up \ 

ami that (U-ath ocnirred, on the date stated above, at . <i ?> c 
■. M. The CAISI' ()!• DIvATII was as follows: 



DIRATION yt'dis X Motitin Pays 

CONTRIIU'TORV J rUx/VO.A > , 



Hours 



IUKIin>I,At.l". 

()»• m()Tmi<:k 

(Sttitf or Coiintrx^ 



or RAT ION Years 

( SIGNED ) LL -Y>V. L»b ^ ' 



Months 



/hus 



Hours 
M.D. 



\ I U 



igo ' \ (A dd ress) Q t . H-1^t^\i\^ ^^ ^A}^A \ 



Special information only for HoM>itals, Inslifutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual 



y/nuth- 



Dms 



VWV, \II<)\'1-: S TAl'l-.I) I'KKSONAI, 1' \ K r IC T I. \ 1< S ARl". l^Kl}". It » 1 

iiKST oi- Mv KN()\vi,);i)c.K AM) i5i;i,n:i" 



II 1- 



(I 






Residence 3(^b>v<xavwwa' Jt piare of Oeatli? 1 H Days 

LIa<co 



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



HoH long at 
ce of Oe 



ri.ACK <)!■ RfKUI, OK RKMoVAI, 

LuA\hX^ .:A.xxyrYX/ 



DATI'luf HrkiAi. or K1;M()\AI, 




5:.. 



TQO'' 



•NM)i:KTAKKK\nl ocuiaieAv ^DVlb/oavlu ''v<"^:)^•^ 



Ad.ln-Ks . U1.L . \l)\vXiAv<r>\ J'^. 



:! 



!N. K. Hvery item cWinf<jkS»rtT3tion should b.' careifully supplietl. AGB should be stated KXACTLY. PHYSICIANS should 

■•"— "••-!, Hi 'iw Cft'tl.v4L TTfDE:ATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home should be given in every instance. 



I 



I 



4 









5' 
It- 



\if. 



I: S^ 

If 



mi 



IP 



it 



I i 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

)i..M.l ..f ihMlili t No !. t-^iT^, H.<vPc'.. REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS 




Dff/c Filed, \\ L(:V-t-\> vlMLA- ^ 



100'{ 



Roi^istcrcd jYo, 






,^V*V.Aw^ 




\.^ I. 



Deputy Health Officer 



DEPARTMENT bp PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "a. S. Stanc>ni^ ) 
PLACE OF DEATH: — County ofC'CX/^v ' X>xca.^ City of ' ^ J ;v<x ^vca^/c^c 



^No. SvCi Ll.>L^v '.J, St.; ' Dlst.;bet.L a/^\.' i and 3 A.XX'Y\/KU v.. ) 

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



FULL NAME 



CT', 



:.\\ 



^l.\ 



PERSONAL AND STATISTICAL PARTICULARS 
« j COI.OR \ A 




\ 



DAI 1, nl r.IKl'H 



\ « . }•; 






\ ' , , 



t 



(Monthl 



S'' 



) l-ilt 



(Day) 



M,»il>n 



'•»\-:ir) 



/'(/: 



MEDICAL CERTIFICATE OF DEATH 
DATK OI' DIIATH 






(Dav) 



(Voiiil 



WIDOW I-:i) OK D!VoRri:i) 

(Wiit<-iii '<«K-ial <l«-i^'iiati<)ii) 



n ' > 



luk ini'i.AO}-: 

(Stall III Ciniiitiyi 



\ XMl' ol 
!• Alii i:k 



itiK III ri.Ari-: 
oi" I Aiiii-;i< 

< stall- III t'nunti V 



MAIDl'N NAMi: 
(U- MoTlIIiK 



IlIK IIIIM.ACK 

oi- motiii:k 

( State Ml r<mtiti \i 



occri'Aiiox {^ 



LcclJ t 





-OL 



u. 



I lll':UI':i5N' fl'RTM'V, That I attoinkMl .lotasid from 



LLL\^C^ 



It/) 



to 



(*> 



upH 



\) V.'C^ 



that I last saw h ' alivr on •' ^XV r. up i 

aiitl that tlt-ath (icciirrci!, mi the <la1f statt-il alutvi-, at ^ 10 
M. The CAlSlv Ol' DliATII was as follows: 



Ouy\j6^ 



v^'^ 



^ 




aXX 



1)1 RAT ION Years M,uillis Days '■< \ Hours 

nr RATION ^ Years Months Days Hours 



(SIGNED) 




I{)0 



f 



Arhlrt-sO ^1) H Ij <XAJL/VUt 



r>A^»xxx > M.D. 



SPECIAL iNFORMATiON onlv tor Hospifdis, Institutions, Transients, 
or Rfienf Residents, dnd persons dyinq dWH> from tiome. 



h'fsidrd ill Siin ft iiii( /•'I'll \ •' )''-<ns ' ' Month 



1 hi 1 



rni", \i?()vi': sr \ ii.d i-kksonai, r\Kii<*ri,AKs aki-; TKri: ro rii i-; 
iiKST or Mv knowi,j:d<".k and r.i".iji;K 



fin fill matit 



former or 
L'siidl Residence 

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



HoH long at 
Place of Death ? 



Days 



DATlCo! Ill KiAi. I.I KMMOVAI, 



ri.ACK OI" lUKIAI. OR KKMOVAI, 



[S. B. r.very item of informntion should be ctirefully Hupplieci. A^il. should bo ntnted PiXACTLY. PHYSICIANS Hhould 

state CAUSE OF DEATH In pin'in terms, that it m»iy he properly classified. The "Special Information" for per- 
sons dyin^ away from home should be (^iven in every instance. 



li 



\m 









»' 



i; 



'>. ■< 



'*! 



W 



If 



X 



i 






J- 

I*' 

pi' 



ti 
It ' J' 



I 



I'U!^ 



it*; 



P 



If 



ir 



u 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




/)((/r /v/rr/, .\j(l0\^>oA.tvJLv H I'^O H 

i^^c..Al^.M. Deputy Health Offtcer 



Registered J\^o. 



:8;i8 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of E)catb 

( Xl. 5. Stan^ar^ ) 



PLACE OF DEATH: — County ofd<XA\, J .\v<x^vc^c. City of cv>v J A^<x.>^t,v 



and -' ^ ^■ 



a 



No. H'^^ LU.rv.. , ^ St.; % Dist.;bet. 1^ l^v 

FULL NAME - ■ ■ - • - ^ • mxa^ax^ LL \J\yOj VJlO'Si.-: 



4i 




si:\ 



i).\ 1 1, «ii lUK rii 



.\(-i-: 



PERSONAL AND STATISTICAL PARTICULARS 

I coi,i)k 







}'^<Xj. 



t^^ 



iMnllthl 



(Day) 



)V,n 



M.,>it/n I 



fV.-ar) 



/)./! 



siN<.i.i" m\kk:i;i). 

WIlx »\\ i:i) OK DIVOKi I'!!) 

'Wiitriii '-orial (Ksiyiialioii ) 



1 



'^ . -a 



I'.iK riii'i, \i")-: 

'stale of r<)illlt I \ ' 



NWtl-, «)1 

lATii i:k 



Hik in ri.Aci". 
()i- iwrm-.K 

' stall oi ('i.uTiti \ 



M \m»i:n n ami. 

(II MOTHI'.K 



i:ii< III ri.Aci-; 

I »!■ MitTIII-.K 

( Malt Ml louiitt yl 






/tly^^AX^ 



docrLLo s 





V\KX; 




orcri'ATioN 

Rr^idfil in Sui' /idini^r.) 



\jy\yOA~^o^ » \yCL 



)•,,;/. 



.lA'/////> 



/),/ 1 



THK M»)VK sTA'n: I) i'Kksonai, par ricn.AKs aki: Tkn-: to rm-: 
in:sT OI-" Mv kn<>\vm:i)c.k and ni;i.ii;F 



\<lflrc«s l?)^^^ 



^i)lx:^A.ful. at U/oJilaA- 



MEDICAL CERTIFICATE OF DEATH 



DA ri-; OI- Di-:ATn i"\ 

MLcrv 

(Moiilli) 



5,. 



(\):\v) (Vcart 



."\ 



I II I'il-J i:i!V C'l'R'ril'N', That I attc-n.Ud (k'crasfd from 



t., 0X( 



i^o'i to \}vz\y .'6 



KpM 



that I last saw li ■ ■ alivt- on ' VXJ\r ^, up 

and that (Ualh orciirrctl, on the- <lat«.' staltil ahovi". at . <^ 6 C 
Ul. M. TIk- CArSI- ()!• DI'ATII was as follows: 



■T' 






1)1 RAT ION )'rnr.'{ 

L'()ST\<\V>\"\'()\iy 



.)/(>)/ //is 



Pen- 



's 



I lours 



DC RATION 
(SIGNED) 



Years Mo tit lis Pays 

t 



E. CI %. 






(.\<l.lrt->v) Vi'hS 



CI,. 



V-'W 



Hours 
M.D. 

1 ^)\ 



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



Former or 
Usual Residence 

When was disease contracted, 
l( not at place of death ? 



How Innq at 
Plac e of Death ? 



Davs 



TQO 



V\ \CV OI-" IMKLM. OK KKM<»\AI, DATlj. ul M- ui.ai. <.t K 1-;M( )V.\ I, 



N B — Bvery Item of InforniHtion •hould be cnreVully HuppHe.l. AGB nhould be Mnte.l EXACTLY. PHYSICIANS hHouIcI 
•tote CAUSE OF DEATH In plain terms, thnt 5t may be properly claiisWIetl. The Special Information for p«r- 
«on« dytni^ oway from home Hhoultl be ftiven in every 'instance. 



'T 



< 1 



. 1.1 



M 



ll 



h]:l 



ii^l 



m 

i 



r .- 



n 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.v,r<l of Health- J- No. i. '^C^^ '^^^' ^'^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




sJL\ H WO'i 



Rci^Lslei'Ccl jYo. 



2837 



Deputy He-"-'-^ '^'^•-^er 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of Bcatb 

( 11. S. Stan^arO ) 

J? qn .^ 

ofOcu^x/ J.\XX^vcv.M.e<.. City of'^^X.'V^ J.V-cx-»va^^ c..t. 



\ 



^ • 



No. VV.V. 



St.; 



Dist«; bet. 



and 



/ If death occurs avway frow USUAL RESIDENCE give facts called for under "special information • A 
V, IF death occurred in a hospital or institution give its name instead of street and nuwber. J 



FULL NAME 



PERSONAl AND STATISTICAL PARTICULARS 



si:\ 




CL 



COI.OR 



LL'-Vv-^l.^- 



i)\ ri-: t)i- r.iK 111 



\ ( ". 1'", 



V- 



/ . 



Moiitlil 



JViM 



(I)av) 



.1 A '/////.' 



(Vt-arl 



/),M 



sIN't.IJ* MARK IK I). 

WIDOW i;i) Ok DiN'oK* i:n 

iWiitriii social lUsi^Miat ion) 



r 



x.^yy^a, 



u 



itiKrmM.AOK 

( Stati' or (.'ouiitr\ ' 



N'AMi: Ol 
I- ATHlvR 



HIKTMJ'l.ArK 
Ol' I-ATHKR 
tSlatf or Country' 



MAIDIIN NAMl- 
Ol MorilJ'.R 










Xi 



\X 



I go 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OV DlvXTH , ^ ^ 

(Month) (Day) 

I HI'iKI'HV CI-RTII'V, That I attetulcd (k'ecasc'd from 
l\^> 2> iqoH to O^'^' '^ I<p ■■ 

that I last saw li ■: alive on ' I90 — 

ami that deatli occurred, on tin- datt.- stated above, at ' 

M. The CAl'SJ*; ()!• DIvATH was as follows: 



DIRATION Years Mi>n(/is /}ays I/oitts 

C ( ) N T U 1 151" TO R V ' }\c\t^^v^\^aA. LL.Cl\.'L^. 

ILL ^r •■.,.. 

Mi^nth v / ^a \ .v Ih > // ; .v 



IMU TinM.MM-: 



oi-"' MO TiVI'Ir' (^ (^ 

(Slatf or (."oiintiy) I 



Kr^- ' 



\ l\.'A^ 






oocii'A'nox 



/\'rM\ft(f III Si! It I I llll, I 



) 'ra I s 



\hcx r 



Moiith- 



./'■" 



'nil-* \Hovi'* srJi'n'.D i'Kkson \i, i-xu run. \k> ari; \'\<\ v. 

linsT Ol" MV KNOWI.l'.DC.K .\ N I )l5i; I.l H I' 



\'^^ 111 !•; 



(Iiifoiniatit 



( \(1(lrfss 



3H3.'('^ J-Moa dl 



Dr RATION 

(Signed ) 



)V</r 



iXO- ^'^ vV' '.J^', 



T()0 



M.D. 



(Ad.lress) ^5^H .ni:' frA^V<X\^s C'i 



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



Former or 
llsiial Residence 

Wfien H.1S disease contracted. 
If not at place of death ? 



How lonq at 
Place of Death ? 



Days 



IM.ACl-: 01 IURI.M, or Rl-'.MoV.M. 




DATI'.o! Mi wiAi. or R l-:.MOV.\I, 



(Adclrrss IHl I l\ui4.VC> ^ "^ ^ 



NO 



IN. B 



. F.very item otf iiiformntion should h- c.irultiilly HiippMe.l. ACT. should ho stilted f.XACTLY. PHYSICIANS , 

stotJ CAUSt OF DKATH mi plnin terms, thnt it mny he properly clussilfied. The "Special inV'orinMtion" fo 



PHYSICIANS should 
r per- 



son* dyinft away from home should he ^iven in every Instance. 



P 



,i 



}',,,:, t.l ..f II. :i!lll I- No. 1- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

-.^?S?^r n&P Co REFER TO BAC>^ OF CERTIFICATE FOR INSTRUCTIONS 



l\> 



!)((!(' Filed , \l..ucrvs-«^ 

\ \ 



Eei^istcvcd -jYo^ 



28;58 



,^J>^H l'-)0^\ 

r\£i ■'-'■ ' ■'■if i' ^ HTl -^ ■:'^ *> 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^No. 



Cevtificate of IDcatb 

PLACE OF DEATH : - County of " "^ ' VC^Tv au.c Gty of O <X..^ y^..^^ c <; 
\^C\ L , ,-. , -. St.; ^ Dist.;bet. la^. and 

' ' ^ -"w ! - - - ,._,,., orCinrNrC riVE FACTS CALLED FOR UNDER "SPrCIAL INFORMATION' \ 



FULL NAME 




{ 



A\JL> 



lYi 



/CV 




■O'YU 



PERSONAL AND STATISTICAL PARTICULARS 






1 



1) \ 1 1. t >!• r.iK I'll 



\« .1-; 






M-Mith) 



S^ 



)' 



(Davi 



Mnillr 



^ C 



(Year 



/),M. 



SI\(,I,I",. M\KKIl-:i) 

wiiM )\vi:i) «)K Divouri-*.!) 

iWiilciii Mxial (ltsij.Miati<)ii) 



^w 



I 



HIKTHri.AOl', 
(Statf or I'oniit! \ 



WMl". oi 
I- A r 1 1 1'. K 



lUK'niri.ArK 
(>»• iwriiKR 

(State or Comitry) 



MAIDl'.N N'AMl", 



15IR'nnM,ACK 

»)!• M<)'nn':K 

(Statf or Country) 



OCCri'A ilON 



-P (^ (J 










XL! 



(V.art 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATII f. 

fM.)iith) <l>ny* 

I lll-.Kl'l'.V CI-RTII'V, That I alUMi<U'.l <UHcasLMl from 
190 t to £)<cX ^^ up"i 

that T last saw h alive on U^t SC up 'l 

aii.l that death ornirrcd, on the date statrd ahovo, a1 io- 3 
^I. 'PIk- CArSlv <)!• DIvATH was as follows: 

DT RAT ION )V'/'-? .^fonjhs Ihiys 

CONTRIIU'TORV LLca^Ix Si).A^^:S:^ix.v.L 



I lout s 



Dr RATION 
(SIGNED) 






/?(?r.v 




o 



Hours 
M.D. 



I()0 



• 1 

rAddri-sQ^^^ UXOA^^ jl 



Special information on'y '»^ Hospitdls, Institlilions, Transients, 
or Recent Residents, and persons d)ing away from liome. 



AVw-,/.7 n, S,n. Funnn,:, 1 , v^m^!^_WA_J_' ■ /v, 



TinvAHOVKSTATKI..'K.<S,»NAI rAKT.;M_JAKSAKI-rK.K-n TMH 
ni'ST OI- MV KNOWM.IX.h AM) Ul-.M l".'' 



(Inf<)iin:itit 



2) 



<X^^ 



) /CA,A^ LA.A^/Wi 






<J^ 



( Address 



I5R 



-^ XAx/Duy-y^^oj Cjt 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatfi ? 



Days 



ri.Aci-: oi" lUKiAi, <»K ri-;m<>\ai. 






i)Ari:o! r.i KiAi. 01 ri;m<)\'ai, 



Tf)0 



'Address 






„ .. ,. , 7,'F .Soiilil he stilted FiXACTLY. PHYSICIANS Hhould 

N. B._Kvery item o^ information should be CBrefuIly «upp1.ed ^^''^^^^/^'^^Vfiei t'»'« •*«•>-'»' Information" for pT- 
Atate CAUSE OF DEATH in pli.in terms, that it may be properly cIohhhicu. 
sons dyin4 away from home Hhould be ftiven in every instance. 



k \ 



t 



['■^ 



I 



J 




••«•> 



^ 



Sl> 



'*.'' 

•i[\ 



j i |i} 




WRITE PLAINLY WITH UNFADING INK 




HJOH 



THIS IS A PERMANENT RECORD 

BEPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



x^d.L^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( tl. S. StanOarCi j 
PLACE OF DEATH: -County of :\ cc^- J^cv ,vo^cv City of C'cc.^ .V'vo.-^ ^e.^ c . 
rM ^fCV ^ . , .. ' • St.: Dist.;bet. J.c^-^^K and Lcld- 

FULL NAME ^- - ova -J.; 



) 



personal and statistical particulars 



DAIK or- HIKTll 



\< .1'. 



Month) 



)■■.!> 



I I);iv 



Mmith:- 



All 

fYear) 



A; ' - 



>>I\<,1,1". MARK 11". I> 
\\Il)<)\Vi:i) OK I)!VOKi'i:i) 
'Writtiti ^iK-iiil <hsi>^ii;itii)i\) 



.0 LcL^^.v.• 



HIK riU'LAiM-: 
tStatr or <'m\iiiIi y 



NAMi: Oi 

ja'ihi:r 



Mik'rui'i.ArK 
<)i- iArin%R 

ISt;itr or (.'oiiittrv' 



MAIDl'.N NAMl. 
«)I- M()Tni:R 



r,iKriiri,ACK 

ni MOTHl'.K 
(Stiiti- or (.'oiintiyi 



il 



^^ 



X 



^ f 



I 



\.^^ \k.^KXt'\^<}- 



A) 




(Ic 






,t0L ^X > VCU I ' 



.1 



II 



>. \\\^K\/^ 



MEDICAL CERTIFICATE OF DEATH 

DAI' I". <>1' Dl'.ATM 



(Day) (Year) 



(Month) 
1 III;KI';HV Cl RTII-V, Tliat 1 :iltt-ii.U<l «Utx-asiMl from 

that I last saw h alivv on \.^.'' Hp 

and that (loath ()rcurrt.Ml, 011 tht- date stati-d ahovo, at A 

:\T TIk- cm sic Ol'^ DI'.A'ril was as follows: 



Dl'RATION Yt-ars \ Montin 

C( )NTU I lU TOR V ^'■:^'J^/:s'>Jit^': 



/hns 



//(i/tf s 



DTRATION yrtff's 



J/,>//f/is 



/hivs 



//<>/// V 



(SIGNED) L^-'ot!} Vl'l'Vo.^' . _ M.D. 

^h ' . TOO ( AiMr..s.) ioOl <X.>V^lU0ll.'- 



I()0 



Special information o"I> '"f Hospitdls, institutions, Irdnsienls, 
or Recent Residents, dnd persons tlving dwdv from home. 



(JCCIJ'A rioN 



1 



ly'r^i,/r,f III S,ni I'miunro 1 ) ''.ma 



A' 



Mnilfh^ 



lUi\' 



THK AHOVK STATHI) ''HK'^ONAI TAKTU-rL VRS ARK TRrK TO THK 
in- ST OI" MV KNOWM-IX'H \M> m-.I.Il'.»- 

,^. J? 



,nf..:„tant ^1 VV^ ^ A\.^X X.<X.^XX>Ji^-^' 

b <Xy>\J NJUA/O LI 



fAiMrcss TOO \)<Xjy\i 



xt-K 



Former or 
Usual Residence 

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



How long at 
PIdf e of Death ? 



Da>s 



I'l.ACK OI" lUKIM. OK K1;Mo\A1, 
IVDI-KTAKKR \J0O-^wA\ ^ 



l)\l"I"o! Ht KiAi. or RKMo\'AI, 



IQO 



^\ 



(Address 



bliL^ i: i'i ^'CCvv- ^ w. s V 



N. B.- 



state CAUSE OF DEATH In plain terms, that it may be properly cia«8meu. 
sons dylnft away from home Hhoiild be ftUen in every Instance. 



{ ' 



! 1 






> nv 



^-i' ■= ->. !',S:l'On 




RITE PLAINLY WITH UNFADING INK 




1 



!)((!(' ri/('</,\il^r^jJL^'\^L^\j H 



IIJOH 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.^vcu^ (K>j\yi 



Deputy hieailh Officer 



DEPART.^ENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County ofC<X>- 



Certificate of IDeatb 

( XX, 5. i5tanC>av^ j 



ity 



f^ 



«o. 



h a\lr 



1^' 1 '^ 

^v ,\.'..L.- . St.; 



( " rr"o;:TH'lcCU%R"V,N A HOSP.T.. OB .NST.TUT.O. CV. . 



- Dist.; bet. 



and 



..cm nr«;iDENCE - ivr facts called for under "special in for w ation" \ 

CCURS AVWAV FROM. USUAL RESIDENCE.^ /.„V .Ts NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



,1 < 



OXxa^. ' 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

A Ct»I,()K \ 



n 



( 



i)\ ri", (»i lUK rii 



\t .»•: 



'L 



iMontli' 



I):iV 



i; >/'// 



A/1 



WIDOW I'D ()K DIVoKCKI) 

' W't itc ill -«i>(i:il .1. -.k'natioiil 



lliKTIiri. AOK 
lSt;it<- <ir (.'ountrv 



NAMl': <)1 

I- AT in: R 



lilK'lin'I.ACK 

()i- I A I'm-: K 

I Stritf lit I'liiint I \' 



maii)j:n namj 

{)\- MoTIIl-.R 




/^cL<rvA>-CcL 



MEDICAL CERTIFICATE OF DEATH 

DATi-; t»i- DiCA'rn 



(I):iv) (Year) 



I lil.Kl.l'.V r l-Uril'V, That I altonai.l -k-coasea fruiii 



up 

that I la^t saw h - alive on ' ^^P 

an.l that (Ua'h (.roiirrtMl. ..ii \hv .late- stated abcvc, at il H5 
...J M. The CArSI'! ()!• DI-ATM Nvas as follows: 




i. 



? 



lUK I'liri.ACl', 
()»■• MoTlll'.K 

(St;itf >>v Cl<\\^^^^ \ 



AVs/(lr<f III . S'./>/ / "!"■ ■"•''• ■ V ' "'' 

T,m; N.I..VK <rxT|.n PHKr^nNA. PAKTUMM AK> AKi: T 



■ M,,iilli^ 



/),.M 



TO Till-: 



(III fipriniiiit 




V,Mro.. iHOO 




'\kOV 



'\^.v^ 



DlKAllON -> 
CoNTKir.rTORV 



)V<7/-.s- J/. > ft //is Pays 



I lout s 



DlRATloN Yi-ars 



Months 



Pars 



(SIGNED^ 



l()n 



Hours 
M.D. 



SPECIAL Information ""'^ '"f Hospitals, institutions, [rdnsicnls, 
or Refcnl Residents, dnij oersons dvin-) .m.i\ Irom tiome. 

When was dlsM<sf contracted, f 

If not at place of death ? 



Days 



I'l.ACi'. oi r.rKi\i<oK ri;mo\ai, 

rNI.lCRTAKKR U <X^.U^>aJ2^ M^-V^-i 



I)\n-'. "! H'HIAI ui RI'IMOX'AI. 

mVc^^ ^ 190 , 



-C^^ L 
c^^ 



f AdchrHS 



l^Ci^ 



^Xw^Lc^m. )i 



—— """~— ~"— ■"— """""""""^ 1^ .1 Ar.F Hhould be stBte.l l-XAGTLY. PHYSICIANS Hhould 

■ tate CAUSE OF DFiATH in plain terms. th«t it m»> r>e proper y 
•on. dyinft away from home nhould be ftSvcn in ev.ry inHtancc. 






4i^ 



W' 



I 



i^i 



r 



} 



•K 
li^ 



u ' 



i. 



iittl> 





o!dd 



..■." . I' II' ilth I N"') 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

- ir,^ ^ ns. 1' Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

2m t 



i^v^c^^ll. uiy Heclth O.ffiper 



llc^Lslcretl A'o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

I 'd. 5. Gtan^arD ) 
PLACE OF DEATH: — County of^^a^a- ^)^0.. . .av4:Gty of ^ 0.>v . 



No. 



otAX/xr^-^ 






( 



St.; Dist.; bet. ^ cUw-vxX' .ind ' '^' ' 

' ,,_,,., orCinFNCC f iwr FACTS CALt-CD ^OH UNDER "SPECrAU INFORMATION- \ 1 



FULL NAME 



%XX/YY\X^ 



ii- 



PERSONAL AND STATISTICAL PARTICULARS 

I) \ 1 I. < >I lUK I'll 




Mi. mil) 1 



A' .1-. 



11 



i I ).iv 



Mnlllh 



>\ A, 



■ 1 F, ' 

'V. ai) 



/',n. 



sfNCi.K. MAKkn;i) 

\VII)n\Vi:n <>K I>IV(tK<l..I) \ 

i\\rit<iii MH-ial dc-irn-itioii) ' 



MEDICAL CERTIFICATE OF DEATH 

DA I)-; <•! Dl.A'ill 



I 



(Muntli) 



:.) I go 

iDav* (Yf.'irl 



\X) K cLcrV,\^-OcA. 



itiK ruri, xri-: 

'State or louiiti \ 



NAM I" Ol 
I- A rill-, K 



HIK lliri, ACl', 
OI' lAim-.K 

'Stat( or roinitryi 



MAIltJ-.N NAMl- 
Ol" MOTHl-.K 



uiKTmM.Ari-; 
Ol' M<»'ini':K 

(Slalv or (.'ouiiti VI 






1 I ■. u \^' 



D 



oocri'A I'loN ^1 







AV- idf,f III Vj>' /■/.;;/' /•"' 



)'/■</ / 



Mniitir 



/>,! 



ruV. AHOVK STXTK .. -•HK-ONAI rAKT.Cri.AKS AKK TRrK To IMH 
lU-ST Ol' MV KNO\VI,i;n<.h .\M> HlvIJl.l 

' n. 



(In fo: tuaiit 






I lll.Rl'ir.V C" !•: KTII'N', rii.it I .itltH'U.l «K-c(.-usc(1 from 

t • 

that I last saw li alivt- on ^'P 

aii.l that (Ualli (.ccuircMl, on tin- datr stated ahovo, at 
M. The C.\rSI-: Ol' l)i:.\ril was as follows: 



{^^\Aj\xXA.^y^-^'0^' \u 



DIRATION • y^'d's 

CONTRir.l TORY 



Mouths 



/hiv 



/lours 



1)1' R \TI< )N )'car!s M>^>i(h 

(' ^ 1 

(Signed) v. •.' x.-'.-^j' 



na\ 



,'.V 



1 



J Iour<, 
M.D. 



I()0 



(A.Mn-^s) .:-. C -r .oM^C^^S. 



SPECIAL INFORMATION only for Hospitdls, Institulions, Fransicnts, 
or Recfnf Residents, and persons dying away from home. 



Former or 
Usiial Residence 

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



How long at 
Place of Death? 



Days 



IM.ACK OI' lUKIM, OK Kl-.MoVAl, 



l)\rK<.! Ml lo.vi. OI KlvMOVAI, 

T b 190 




) l,.\V_ I. " "• 111 IX 1 1 1, • ■ ■■> " ■ -• 

(^. y. Vy. i • Uv-LTWClU^im^ 



-"""""""— """■■"— —""""""""""""""""""""^T v\ AdF should be Htiite.l f.XACTLY. PHYSICIANS should 

N. B._F.very Iten, o* 1nfor.„Ht1on «h,.uUI h. caretuMy «up,> -ec.. ^,^f; "„,,,,,,. ^^Hc -'Specie. lnf«r.naf.o„" for p-r- 
state CAUSE OF DF:ATH in plum terms, that it mJi> ne proper y 
son. <lyinft away from home should be ftiven in every mBtance. 




f 



If) 



i 



I ' 




' \ • 



« « 



t . 



It.' 



V" 



?«;! 






H 




write: plainly with unfading ink 



I'.,,!.l -f Jl.aUlK !■ V'. :■ *-V.,'=!::;'^>»<S:l'C(, 



THIS is a permanent RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Re^istcicd J^'^o, 



4^Q * O 



I 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




Certificate of Beatb 



•a. 5. i?tnnDarD ) 






PLACE OF DEATH: — County of 0<X^a 

^s1'VU-^aX<X\) cL-.Ln..- t '..«-. ■ >. St.; 



City of <:^ 






Dist.; bet. 



and 



..CIIAt RF*;iDENCE GIVE FACTS^CALLtD FOR UNDER SPrCIAL INrORMATION \ 

( '^ rF"o;:roccu%ro\rrHO^s"^Ti:: ?R'tN?T'.TJvU"a,ve .ts name ..st.ao of strcct a.o .umb.b. ; 



FULL NAME ^Ucn^q 



^ 



s }■: \ 



PERSONAL AND STATISTICAL PARTICULARS 



llccia 






DAl'l-: 111 I;1K I'll 



\r.V. 



'M..nth 



1»,(V 



'^iN^ ,i.i:. MARK ii:i> 

WIlx i\Vi:i) OK I)!Vt >K^ I'. I> 
iWritf in MK'iiil dt -i;.'n;itiiin) 



,^ 



Lc^v^ 



liiK riii'i. vr)'! 

(St;itc or "".innli \ 



NAMl'". Ol" 

I- ATI! i:r 



niKTiii'LAC)-: 

Ol- lATIM'.K 

( St.'ltf 1)1 ('nlllltl V 



MA11)1:N NAMl' 
Ol' MOTlll'.K 



lUK iiiri.Arj'. 

(il- Morill-'.K 
(Sl:ilc- ol Cownlrv^ 







• 



u 



c 



V V. ^ X ex 







i7\ 




Xl 




om TATION 






^^r<mfhs 



hu- 



MEDICAL CERTIFICATE OF DEATH 

DAD-: ol- Dl'.A'lH 

Ml:. "^^ ^90'^ 

I H1:R!:1'.V C1:RTI1-V. That 1 atti-n'Ud <U-i\'ase(l from 

^ , : u)o'^ to ^ i^n-' > up '\ 

thai I last saw h ahvo on ^ ^- ■ ^'f> ^ 

,111.1 that .Uath occurro<l, on the date stati-.l above, at » 
Ol M. The CAT SI- Ol" Dl'.ATH was as foUosvs : 




niRATK^N 
CONT 



TKllU roRV ^''\ 



\ )'tars Months /hns Hours 

:XLA«^ \ > V ;lmA^.rLv..>- 



*^-<^ 



Montfv 



1)1' RATION H Years .-■■ 



/hivs 



(SIGI 



QfW H TcoH (AcMress)MXiV]o^^U Ot 



Hours 
M.D. 



SPECIAL INFORMATION "nly f»r Hospitals, Institudons, Trdnsicnts, 
or Recent Residents, and persons dying dwdv from tiome. 



Usual Residence^ 

When was disease contracted 
If notat r'jrcof de;»*»-: 



,0 \. Place of Death ? 



Days 




TMK XHOVKSTM. nrKKSONAl.rAKTKn-LARSARKTRrK lO TM H 
" lil.-STOl' MV KNOWI.KDCK ANM) BKI.IKK 

A 



(Infill ni.'int 







PJ.ACH ()!• Bl'RlAI, OR R1;M<»VAI. 



)>Oyvw 



i 



DATK of IUhiai. or KHMoVAI. 






(Address 



^. „.__,.vcry Item of Information .hould b. cBnefuMy .applied^ p^^p^enX^^^^^^^^ In^o^m'l^Ton^'Vr^'p.'rl 

ntBte CAUSE OF DEATH In plain terit., that It may be propeny ci« 
«on. dylnft away from home should be ^Ivc" In .vary Instance. 



N 



!li 












\i 



if!) 





H..,u.|..f ll.;>llli-'l-'No. 1< ■S-'^lSa 



/)(t/(' Fih'il, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. ,.Sr,S5* „<. .■ e,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2813 




Y> 




h. 5: loo'i 



llesiistcred Xo, 




v^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ceitificatc of 2)eatb 

( 'CI. S. StanDavO ) 
PLACh OF DEATH:-County of ^ Cu>v J Ka >.cv^.c. City of ^ ^cuv.^ J A.cx v^e^^cc 




No. lOXH LllcuA.>a.vv->..-> 



>T 



Dist; bet. X'X ^> vd 



i^i. .^_ . and -' 

^^.^ BFS?DENCE GIVE ^ACTS^c'lItLED FO^ UNDER "SPECIAL INFORMATION • \ 

f ,r DEATH OCCURS AWAY FROM USUAL "f f j D,^. ^ ^ ^^°J ^^^, J * %| ^f^^^ INSTEAD OF STREET AND NUMBER. J 

\ IF DEATH OCCURRED IN A HOSPITAL 



OR TrlsT.TUTToN OIVe" .;; NAME INSTEAD OF STREE" 

FULL NAME 'U\^ U.^vd 



trM' >-L" 



'4^. 



X 



jIA. . 



PERSONAL AND STATISTICAL PARTICULARS 



^^Y. 



^ 



o 



DAll-; «»l- lURTM 



.\(.H 



Month* 



J V</; > 



(Day) 



Mntllll^ 



(Vt-ar) 



n,i 



siNi.i.iv M\Kun:i> 
\vii)o\\i-:i) tiK Divoun;!) 

( Wi itc in '-oiial (W'^ivnation) 






luu rin'i, Aov: 

(Stall- or CoMiiti y 



NAM1-: <)I- 

!'atiii;r 



i 






MEDICAL CERTIFICATE OF DEATH 
I)ATK OF DKATIl (\ 

(Month) <''"y> 

I HI';KI;1?V CI.KTII-V, Thai I atttMi<UMl (U-roastMl from 

^... ' * 190M to . Al\.^ .. 



I go 

(Year) 



I()o'i 



-CC'VCl.' 




HIK'rmM.AC'K 
()|- I AIHKK 
(State or Coiintry) 



MAII)I:N NAMl. '; 
OF MOTUHR A 



'I 



,--4 I i 




rl 



Crvc^, 



lUKTliri.ACK 
»)1- MoTm-'.R 
(State or CtMintry> 



ll 



■5 



OCCI'PATION 

f^\s,jrtl III S,ni /'Kill, /^'■" 



1 

)V,M « O Mouth: 



that I last saw h ■■■ alive on ' ^'P 

ami that .loath occurred, on the date state.l above, at 
..iw M. The CArSI-: Ol" DIvATIl was as follows: 
., M.l.Ua.'rx^Q-si- 



DrRATlON 



]'t'ars Mont /is Pays 



Hours 



DURATION >'lW5 

(SIGNED)^-'. 



VKr 



rr 



I()0 



Mouths H Pays Hours 

(A.l(lrc-ss) .■'' '" Ibij.b dt 



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



/'.t 



T,IKAm.VKSTATK..PKKS.>NM l:U<T,rr..AKS VKKTKrK T. , TMK 
IJHST OI- MY KNoWI.I.lx.h 3lN " HI, 1,11. 1 



(I 



,,,„„,„t \)JUy\/Y^ ^^-^ 



f 



^ 



( Xdilrc^s 



b%'\ 



III 



-O-ImX/^-yvO. ^^t 



:^ 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



.. Days 



ri.ACK Ol" lUKIAI. nK KKM"V.\I, 



DAlj: ol HiKiAi- or KKMOVAI, 



190 



T^ 






^. B._Bvery item of InformBtlon should be -«"«*;">; "";;f;;;t pX'^Hrctl«rr.ri?''TJ;''*^87eciai InformaUon" fo" p^r- 
fttate CAUSE OF DEATH in pliiin terms, that it m«> he proper.y 
Vonu dyinft nway from home Hhonld be ftiven in every Instance. 



r 



fi 






' M 



t , 



' I 



I, 
I 



I 



JI5 



,,„ ^ 



< 



\< 



i f ' 



li 



K 



I; 

: r 



I 



I 






t'Vi 



w 



RITE PLAINLY WITH UNFADING INK — 



I!,,:i!.l . f H' :ilt'i 



(■ V,, It ts-?*^*?:.?) Hi*t I 



' Cn 



pffff AV/^'^/,.M..L(rL^^^-vvv^v 5" 



lf)0 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Re^Lsfcred ^'o. *->H44 





!'\^-\J, 



Deputy Health OfTtcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( Ta. S. 5tan^arC» ) 
PLACE OF DEATH:-County of 6<X..^ JAXc^xa^c- City of O.C^.^ J/vcx^.v^c^^.c 
^, Ihr^. H^ St.; ^ Dist.;bctXcul<.^^V^^-^. V and 

No. ^^'^'^ 1 ^.... o.c.A;NCCn.VE FACTS C*LLrD rOR UNOtR -SPtC.AL .NrORM*V.ON-\ 

ITS NAME INSTEAD OF STREET AND NUMBER. J 



( i* OEATH OCCURS AWAY FROM USUAL " ^ f ' ° ^.^C^^J^^^,;*^,;! 
t 7 IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE IT. 



u 



^^ 



FULL NAME 



IIol^ll v. vjWs.^.A.:K...., 



PERSONAL AND STATISTICAL PARTICULARS 



S!;\ 

1) \ I 1. til HI Kill 



vXL^ 



II 



.1^ 



M-.tith) 



\y.\- 



) V.M 



siNCI.i:. ^!\RK^^I). 
WFDOWKI) <»K DIVoKiKI) 
iWiitr ill M)i-ial (lt-i}.rtKtli('ii) 



C'^^ 




'Stiitf or (.'oiintiy 



vj OL/^^ 



^ 



(Diiyt 



M.,>ilh^ 



f 



iVcar) 



/)<f I \ 



MEDICAL CERTIFICATE OF DEATH 

DATK (»!• Dl'ATH A 

(Month) 'I^-'y^ 

I in-:Ki:i'.V ClU^TU-V, That I aUtn<k<l <lcccase<l from 

t,, W^' ^V 'I Tno 'l 



(Year) 



190 



! \ r 



T90 

that I last saw h aUve on '■ ' ■ ^*)0 

and that (U-ath occurred, on the date stated above, at M 
U M The CAISP: Ol- DlCATIl was as follows: 

■■•'? ' \ -\ . 



NAMK OF \ 

i-ATin:R \ 



/O 



10 .^lUcx^^'^ ^^^^^^ 



HlK'rHIM.ArK 
iW J-AIIIKK 

(State or Country) 



MAini-;N NAME f7\ 

OI- MOTUHR ' ^ 



C 



lURTHPLACK 
OJ- MOTHKK 
(Statf or Conntry* 



I 




DIRATION >W?'-.? 

CONTRIIUTTORV 



Months 



Days 



noHt s 



Years 



DURATION _ ^^''^^ 
(SIGNED) . JJ/O-C. : 



M())il/is 



Pays 



Hours 
M.D. 



OCCrPATION 

Rf silled ill >"" I'lmm"'" 



)'riii > 



M.nith^ 



/hi 



TMKXm>VKS-.VNTKI)rKKS<>NAl rARTlClMAKSAKHTKrK Tn THK 
liUST OI- MY KNoWI.KUr.h AM) Bl-.Mhl- 






. 



\)\ t ..,. 



I()0 



(Address) ' 



^A.avvb^^fcAd 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



I'jLACK Ol' lURIAI. l»K RKMoVAI, 




DATi^ot" muiAi. 01 ki;m<)Vai. 

( I C)0 ' i 



;ko;" Mr I 



I-NDKRTAKKR ^ • Ij . U Cr> V ^ ^. t'- 

(AchLslbl Ql\v<i^'^fc>A.' .3.1 



N. B._F.very item of informatJon should be carefully f^PP'*-;^; p^oTerC"l»««'«ei?'*Th^e^ Information" Jr p-r- 

statc CAUSE OF DEATH in plain terms, that .t ma .^^ P-Pf'''^' 



Ton\ dylnft away from home nhoulcl be feiven in every inHtance. 




I 



I : 






I 



" 1 



m 



w 



RITE PLAINLY WITH UNFADING INK 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/ )/(/(' /''///'^/.Vl 




\> 6 



Jf^OH 



]lro'/,sfr/'ed vAV>. 



2845 



i^,,,-Lv^^ Deputy Her -HO^^oer 

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

Certificate ot Beatb 



X\. S. Stan^avC^ ) 



PLACE OF DEATH: — County of O 0.'>x. 0,^CL->^CA^CcGty of 



^ 



■5^ 



4 



■:\ %-vC 



No. • ^ 



^P 



^^•^..w.. 



and 



St.; Dist.;bet. . 

r.,^« l|C;.JAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATiON \ 
( • ;V;EATH^OCCU%ro\;,'^rHO^S^pVT"L ^^^US^.ru^O. O.VE .TS NAME ..STEAD OF STREET A.O ^UMBER ^ 



FULL NAME 




^j:\ 



I. \ r I < '1 iUK I'll 



\< ,]•: 



PERSONAL AND STATISTICAL PARTICULARS 

L< il,< 'l< , 



u 



) f\o 



\ 



\! 



^I\. .1 IV M \K 1< III' 

W II)t>\Vi:i> nK I)lVnKtJ:n 

Wiit< ill s.n'i;il ilr^ii'n;iti"n) 



MEDICAL CCRTIFICATE OF DEATH 

D \ T)' 111 in, \ 111 



iM.uitli^ 



'. <. .\ 



1 lll-K! r,\' *. ' KM IN, I'll. It I altfii K'l 'K . V .'.-i-.l : ! m' 



uiu riiri, \>'i", 

tStnlf oi ('"iiiiti ^ 



N A M I < I ' 
!■ \ 111 IK 



IMK TlllM. \* !•; 

(.1 1 \rin-K 



MAIDl'.N N\Mi: 
OI' MOTIII'.K 



r.iKriiri, All-: 

ol' MoTin-.U 

{St:it'- "1 rmmlT ^ 



[ 



^ 



< y \ 



\ 



Jed 



^ 



Lcx.Uvx^v.'V^^ L^'C:.k^ ^ 



^^ 



1 



nvXirAlMiN 



M.'Hth- 



/■',:,' 



niKXIU.VKSTATKnrKRSONA. PAKT.M^IVK.AKKTKr,.; in T.I.-: 
H1-:«,T (II- MV KN«»W1,1 I'f.h AND HI- I, HI 



V 



I 111 f. 1- limit 



( \Mrrv. 









that I la-t <a\v li ■ .i'i\^ "!' 

.,,,,! thai .1. atli .u-nirri-.l. on the .lalv >^tatv-.l . i^ 

M. The C'AT'^l'. <>1' ''!■ ^l" ^^''^ •■'"■ f""'l"\^^ 

..Lie.-- ■ ■ 



t»/0 



D! I>1 ATION 



c()N'n^!r.i'r< 'KV '^ 

1)1 RAT I ON )' "'^^ 

I SIGNED 



.1/. "////v" /■'./rv 



//<'// 1 






' \ 



i(i'> 



(' X-Mri -■ 



l\ix 






M.D. 



SPECIAL INFORMATION -i'^ '"^ ""M'it.ilv li'^tihlions. Ii.Hisients, 
or Rc.rnt RcsiJcnls, .iihl |»rrM)iis (l;.in| aw,iv trn:ii home, 
r „, "*! ^ How lonq at 

Wfirn was diMMsr riiiilr.iifcd. 

II not at plaip ol dtath .' ^^^^ 



iM,\ii-: oi- 1" i'!' ^'- "'•^ '•' ' "^'' ''■'''• 



c^,ii) 



(iY> 



I)\I);i.! 1'.' i<i\!. <ir U1-*,M« >\A1, 
\- T QO H 



0\r.: 



I NDru lAK i:k 









-^— — ^— «— ■■! I ^mt^^mm ^ ill. 1 l"l I \\CTl Y Pll >'SI wl A!N !^ Khoiild 

«tnto CMlsr or ni;.\TH \n pl.im terms, thnt it mn> l>- •."^•' * 
«on, «I:>ln4 ">vny from homo shouM he ftlven In every .nslnnce. 



f. 



Mi 



• *^ 



'■?i 



I* 






I i 






f 



I 




w 



RITE PLAINLY WITH UNFADING INK 



t^i-"-'\ 



);, ,:.;.! ..r II. ;i;tli- !■' '^•^ - ''^'l "., 



-: V.^V Co 



IDO'i 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 



crvcvoLv^u Deputy Heaith Officer 

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 

Certificate of S)eatb 

( 11. 5. 5tan^avC> ) 
PLACE OF DEATH: -County of O CL^. ^t^vO-^cA^^ Gty otO<X^^' ^^n 



r > ^ n i 



No. A 



\ . ■ . St/, Dist.; bet. ^^d 

„ ..c.iai RFSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ^ 
( '^ rF^orATroCCURrEVl^rHo's^Py.^L O r' Tn S n ^JV'o^ C.VE ITS NAME INSTEAD OF STREET ANO NU.BER. ; 

FULL NAME ^ 



! \ 



PERSONAL AND STATISTICAL PARTICULARS 

r(il,<ik\ 



Ml 



u 



i».\'i 1 < >! i'.i i< ri! 



\<.i-; 



M..iitli 



"^' )V,n 



si\. .i.j-:. M \Ki< I j;i> 

I Wril< ill -.'.li ■ ' ■•■,'■•••' 



(Day) 



M.,iil'i' 



» < :ii 



/;,/! 







liiKTni'i. \ri-: 

iSt;itr Ml Ooiiiitrv) 



\ ', M 1 ' >!•■ 
1 \ 111 I'.K 



HIK'nil'l.AfK 

Of 1 \rm;K 

I St.it I 'IV I'l .initi s ' 



M\I!)1;N NAMi: 

()i- Md'riii'.K 



iMui'iiri,.\ri", 

(Slatr 1)1 (.'<iiinli> 




n 



A.V -tit V I 

^ I 






MEDICAL CERTIFICATE OF DEATH 



i),\ri-; ()!• 1 



IQO 

(Vt-ar) 



>i:.\rH i\ 
■l^l'.r.N' C"!;i^'I"I 1"N', '\\\'\\ I ;iniii'U<l 'ItHHiisod from 



I III 

190 1 til 

that rlast sawh ^. ■ alivr on ^H.^ v ' Kp 

;m.l that <Uatli (uH-urrr.l. ..11 the <lalr stati-d alxtVL-, at 
M. Thr C ArSi'". (>!'■ l)i;.\ril wa^ as follows: 

I 



DCRATION )',</v Moulhs Pavs Hours 



DT RAT I ON 




f° 



1) 



OOtTl'A liON 



Xn. 



I 



^' ec^l. ^ 



^ r^ 



1 



. -4 



A 



W'.MifrJ in S.iu /'!:!>!( '>ro A-"* J'-vr' 



.1 /..;//// 



/;,M 



I In fi)' inriiit 



<TH'ri.\KS AK1-: VKVK To rill'; 

r.i. I 



n\}- \H0VK STATIK IM-.KSONAI l-A! 

1!)-:>I' *>1" ."'•IV KNOWM'.IM.I', AM) l.I-.l-ll-.l- 



u 



^,H,...s V^- e U\. M 



G 



SIGNED > V 

i Lt\.' •' l()0 



)'<.//v Mo)iths Pars 



!0 



flours 
M.D. 



iMfions, Transients, 



SPECIAL INFORMATION onh for Hospitals, Insti 
or R('( fnt Hcsiilents, and persons dyin j away from fiome. 



Former or 

llsiiai Residence^*- '>v 



I 



k:>^^A.^'^" 



How lonq at 
Plare of Deatfi ? 



.. Davs 



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







DA'I'lvof HiRlAi. or Kl'.MoXAI, 






Bnar?«w««fcx^«^^*'w*' 



N. B. 



--- ~ , „ ,. . *nF sSoild be stnte.I f.XACTLY. PHYSICIANS should 

r.very item o? l.V'.rnv.f.on should h. cronjlly -PpLe . '^ /.f;;^;^^^^^^^^^ The "Special Information" for pT- 

stnte CMJSF OF DKATH in pinin terms, thnt it mny Iv.- properI> cIohhiiicu. 
sons dyini owny from home should be feiven in every instance. 



TTW 






IB 



i- 



> 



5| 



i ' J • 
1. ^ 



I r 



! 



I 



i:i 






3 



ii'» 



II 



WRITE PLAINLY WITH UNFADING INK 



l?.,:,r.'. of IhMlth- I- No. i> t-^^x^ HS^ 1' Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



pff/r Filed , \)\/r^^^^^-^i^-tX' S 



VJO'[ 



Registered »A7;. 



.2846 




Sin. 



cr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( H. S. 5tanC»avD ) 

ofO/Cu^Y^;^'!AXX^xcA^..<:.l City of O/CV-^-v J A^co^ v^A^^i, cl^ 



PLACE OF DEATH; — County 



^ 



No \\'^ 3'v^v.oJ. > >.•..< St.; ■■ Dist.;bet.Vl a.^l-^v.^vQi^ . and VtX/ 

/ ir DEATH OCCURS'AWAY FROM USUAL R E S I D E N C E GI V E FACTS CALLED FOR UNDER 'SPECiVl INFORMATION • ^ 
C ,F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREETJAND N U M B E f^ J 

ft. .M 

FULL NAME 




<J A 



I 



{O^jrwsu^. 



.OJ\J 




PERSONAL AND STATISTICAL PARTICULARS 



'X 



DA 1). n! Ill K in 



/ 



Month 



!i t 



\< .!•; 



be 



5 'rd I 



il):tvi 



M.,iilln 



(War) 



An. 



RIXC.I.K. MARUn:i) 
WIDnWi: I) (>U IM\t»krj-I) 
iWiitrin »'Kial (ii*«ir'iation ) 



HIK ril I'l. AvM-: 
(Statf or (."oinilry^ 



N.\M1-: <)I 
FA Til l.R 



niK rni'LAOH 

0\' V.VVUVM 

(State or t'ounti v) 



maiih:n namk 

Ol' MDTHHK 



lURTHPi.ArK 

()»•• MOTIIKK 
(State or Country) 



OCCri'ATlON 

fCrsiiffi/ III S.n/ f'> ani :^i<> 



MEDICAL CERTIFICATE OF DEATH 

n \TK OF DlvATll 



fMonth^ 



I 



(Year) 



(I)av) 
1 IIICRl'iHV (.'1. RTl lA', That I aUfii.KMl <leroasc«l from 

-. ; - I90 — to .——:-—:. 190 " 

that I last saw li rrlivc oil ^trrrrtrrrrrrr:^- up :— 



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



v.: 



M The CAl'Sl- Ol' Dl-ATll was as follows: 



'>'v<r>'vtx.'\A.v. Ar\J(,^rrlL^s^.'c<vc-.L<y.>^.«v. 



t 



DURATION Years 

CONTRIIU'TORV 



Moni/is 



Days 



Hours 




) Vi; ; 



M,n,th^ 



/i,n 



Tni< \HOVK ST \TKn I'KKSONAl, I'A KTICl" I,ARS AKl- TRrK TO TllK 
HF:sT OF' MV KNO\VI<i:r)C.K ANI> Hl'MltF 



\Js\/rv\SL' 



,'A 








(AiUlrcss 



nr RATION -^ Years ^^ Mouths 
( SIGNED ) .Wv<rVAjl\j J 



Pa vs 




1 



Hours 
M.D. 



^JU,: :;. 



I()0 



( .Address) V,fc\,C/-> ^^Wa V. .; k 



Special information only for Hospitals, Instltutrons, Transients, 
or Recent Residents, and persons dying av^ay Iron home. 



Forrrer or 
Isual Residence 

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



How long at 
Place of Oeatfi ? 



Days 



I'I.ACF: OF' lURFM, OR RF'.MoX.U, 



DATIlo! MiKiAi. or RHMOVAl, 



\J..U[:sj^ .:;S: T90' 



1^ 



(Address 2.^ V 4X^X! M\LuLO ,iXx:>^ 



I 



N B —F.very Item of informntion •hould be cnrct'uMy supplied. AGE should be stated EXACTLY PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p.r- 
sons dyinft away from home should be J^ivcn in every instance. 



f^ 






I ' 



( 



I 



ii : 



^\ 



■f 



1} 



\ 



\ 




tl^. 







w 



r,. ar.l '■*' 11' :iMh t 



RITE PLAINLY WITH UNFADING INK — 






/)(ffr l-^il('(l , \i\c V-v >-> V 'o V ^ ' S 



li)0'i 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

nr^isfcred jYo. 2847 



iaBHM^i*<i"< 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



Certificate of H)eatb 

J? ■ (^ ^ ^ 

, \ St.; '■ ^ Dist.;bet. J^<-' ' ^ ^ and 

"^ "^ „ iienai orSIDENCE GlVt FACTS CALLED roR UNDER SPECIAL INFORWATION' ^ 

( " r/'r.ric"!-'".",":" o"s'",*.t r":s"ru" =-. =... .xs name ,.=,». o. s.-^t .^o n.«=e». ; 



PLACE OF DEATH: — County 






FULL NAME 




.M. 



-.t 



H 



jw 



c 



>i;\ 



!t \ n: ' 



PERSONAL AND STATISTICAL PARTICULARS 

I Ml, I iK 




(xXi 




\ V 



\vCLi' 



11 



V 






rW 



\' ,1 



il 



) ■- ,; 



.S" 



M \KU 111'. 

w ] 1)1 1\\ I'. n <>!< i);v<)Kri:i) 

Wiit'i'i s(Ki:ii (1< -iL'iiat inn) 



'Stat' 



'^ 



/CL\.VOLCv 



MEDICAL CERTIFICATE OF DEATH 

i> \ Ti''. • n ni'.A'rn 



\W- 



iDav^ 



(Ve-arl 



(Mnlltli^ 

I lIi:ki{I'N' t" !.K'ri!'\', 'l"Ii;it I altciflcil clcceasc'd tr<«iu 



I()0 



that I last -^aw h-i- '>v alive on I V.t > Mp 

.•ii),l tliat .Kalli (.(-ciirrcd, ":i the (I'ltc >-ta1e«l al.ovc, at 
M. TIk' C' VrSI*; Ol- ni-iATII w.-i^ as follows: 



ivj2j\jijyv^ oivv%^x3uV V fVX'rs.^/vA-.a 



V 



N \ M I ' > : 
I \l 11 IK 



i)V I'xini'K 

(Slat- '! '■• i'.'"' ^ 



MAIKl'.N NAMl 
()1-* MoTIll-: K 



lilK II! I'KN*)'", 

oi- m()Tmi;k 

' Statf 'M (iHMltl V ' 



ill: 






L 



Crt ("x 



iX'^Xp^ 




'\ 1 



\. \X 



I '< 



< »v I ll'A 



Rffiiifil itt San I'ltni-r-m ?* i >' 



M,^iifli' 



I\i\ 



I11>1- <»1' MV KNOW 1,1. IX.}-. AM> Hl'.I.n'.l 



' 1 II f>)' iiiaiil 



f \'l.lirv:s 






C( iNTRlill ToKV 



Mo II //is ^ C^ />,nv I Ion in 



\... 



orK.x'rioN 



)■, ,// 



.]r<nit/is ^ ^ />./rv 



i r 



SIGNED ) 



//ours 
M.D. 



SPECIAL INFORMATION '•"'• '"^ Hospildis, Instifutians, Trdnsients, 

or Rptcnt Residents, and persons dyin-) dw-iy Irom home. 



lormcr or 
Isudi Residence 

When was disease rontrarfed, 
It not at place ot deatli ? 



iioH lonq at 
Pld« e of Deatfi ? 



. Days 



IT.AC1-; Ol- nrKIAI, OK RIMo\ \I, 



INll'.KTAKl-K J-AviUrll-^n-' ^-^JC■v.-,.; ,, 



I > \i r .,1 I',' ri \i, <ji k i-;.M< )\' A \, 



*'^ """" ,. , .^,r „u„..i,i K,. Rtfited r.XACTLY. PHYSICIANS hIiouIiI 

^- "--r^r j'u,;ropnT;TH^:r.:" '::.™:r".c. rr.tt ntM^-H: :...--... tk.. ••s,..c,., .„«o .•,„,'• .'o,. p... 

*-.n.\l>ln» nwny from home should he ftlvcn in «vory instance. 



* 






,t 



I 

■ 






! 

! 



':! 



i.' 



I 



I 



WRITE PLAINLY WITH UNFADING INK 



,..,,:,r,! .,f »l.:.lth I' V.'- i^ "?-^;^34:. lU^TO, 



Date AV/r^/, HLcru-tYW 




ijL^B lOO^i 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

^?848 



Registered J\i''o. 



i 



N 



,K.voL^ Deputy F.eulth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)catb 

( "U. S. 5tan^ar^ ) 
PLACE OF DEATH:-County ofda^^ J/vCL>vC.: -^Gty of Oxv>v J.Xcx.>^c^. 
o 5.0 0% C Wv St.; I DisUbet.XU-V-,oo.. V 

/ ,r OE*TH OCCURS AWAY TROM USUAL " ^ S I D E N C E G. VE r ACTS C AL.E D I 
( °F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



and .. .c^L■ 



..<!^...• DCCinrNrr nvr FACTS CALLED FOR UNDER "SPECIAL INFORMATION • "V 
,F DEATH OCCURS AWAY FROM USUAL ^^^}^f_^'r,^J'^\,J^'',ll NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




\/L.ixtru<x^'i 



.^ LloJ: ': 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 

i>\'n. t »!• r.iR'ni 







! I? 

i 



\<". »■; 



(M.iiith^ 

%H r.,„. 



rl 

(Duv) 



M, 1)1 1 In 



( V«';ii 



I >il\: 



si\('.i,K. M\Kun:i) 

WIDOW i:i) OK lM\nKr Kl) 

( Writ'- in >><K-i;il .!< >>i>.Mi;itii>ii) 



I St;il< or I'liuiili > 




NAMi: Ol 
FATIIKR 



lUKlIll'I.AtK 
oi' lAIHKK 

(Statf i)r CiMiiitiV 



MAIIH^N NAMK 
<>1 MoTllKK 



lUKrm'i.Ac'i-: 

ol- MoTin'.K 
(Stiitf or Couiitiv' 




MEDICAL CERTIFICATE OF DEATH 

DATK OK 1)1:ATH 



Vlltv 




L^w^AJv^^CX' 



1 




h'fsidfd III S,iii I'liiihisr,} O C. )>■«?/> 



Moiilli' 



/'</>. 



TnKAHOVKSTATKnPKKS<>NA. rAK.MjM^jAK^AKKTKlK TO THH 
HKST ()!• MY KNOWI.KIX'.K AND HhMhH 



(IiiroimaTit 




!-vjt-w \s>- i-'CVU-OV-i-clv 



'<3;^ 



( 



,aA\xJu; 



I go \ 

(Montli) 'J>"V^ ''^'*''"'^ 

I m^RlCHV CI'iRTIl'V. Thai I altciKkMl <krcasc(l frniu 

^> :.t i9o4 to \]^.CPv.^ '^- icp"^ 

that I last saw h ■• alive on i*P 

aiiclthat (loath occurred, on the .late ^^tatcl above, at ^ 
J M. Tlui CAl'Slv Ol" 1)I{.\'I'1I was as follows: 



nrkXTloN Years Moutin ^ Days /lours 



I )r RAT ION )'rars 

(SIGNED ) ... b. ^^. '-- 



Mouths 



Pays 



I fours 
M.D. 



iW- 



I()0 



(.\(Mress) 






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 deatli? 



How long at 
Place of Death ? 



Days 



1M,ACK Ol- MIKIAI. OK UKMOVAI. 



i)Aiu:o! Hi KiAi. «)i ki;mo\ai, 
M^U- K. 190'. 






N. B." 



■tate CAUSE OF DEATH In pl»ln term., that it may be properly ^la..iiica. 
■on* dylnft away «rom horn. »hould be ftlven In .»«ry In.tance. 



^ 



!• 



( 



I'. 



II 



ifN 



i 



I 



n 




WRITE PLAINLY WITH UNFADING INK 



,•.1 .1 !l. :.'lll !■ '^■ 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc /•V/r^/A(Vtv^"v> 



,0[>X\' -^" 



n^oH 



Boi^islcred J\^o> 



?849 



\ A, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc oi Bcatb 



( XL 5. Stan^av^ 



J 



^ 



PLACE OF DEATH: 



County of C) a.>\' «'V<X^^C\A c c City of ^' ^ "^ ^ 



'v^'OA VCA^-^C 1 



I ^■■ 



No. 



( 



ir or ATM OCCURS AW 

IF fi r A T M o c c: ',) R R 



St.; i^ Dist,;bet. ' j\^ '- - '/ and 

MCIIAI RFCilDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION' \ 
rD\NTHc''s^p?T''AU o' Ns't^^V^'n G,ve .TS NAME .NSTEAO OF STREET AND NUMBER. ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



' 1' I '1 1.: i; Ni 



\i i; 



^IM.l.lV M AKN li:i> 
\VII«>\Vi:i) «»K I>!\«M.'. 1 ID 
, w, it,, in -.. ■.•n.ili.mi 



lUK'niPI. \'M" 



M>\ 



"^ 



A 



(\ 




N \ M I 111 

I- A'ln IK 



I'.iKiMi ri. \i !•: 
<)!• i.\rm:R 

(Shilf or Ci'\inti \ 



>! \ IDl-.N NAM 1 

i'\ Morni; K 



luin'mM.ACi': 

dl' MoM'lIl'K 



I . , ■ 1 I 1 • ^ 1 1 1 1 N 



0, 



V 



Ld > ■ 



TQO \ 



MEDICAL CERTIFICATE OF DEATH 

I) \\'\'. <M' i»i;a III 

i ^ > 

I 

iM,,titli' '1>;'^' 

1 lli:Ki:rA' ri'.R'ril'W 'riiat I atU-n.Ud <Uti;isc(l from 

tlKit I last <.i\\ h ' alivf <>n ' ' lo^ 

aii.l that .Irath < .coil itimI, mi the «laU- ^tatrd abnvo. al t 
M. 'I'lu- CWrSI'', Ol' Dl'.Al'II wa^ as follows: 



DIKA riON 

c"c)N'i"Kii;r'r()kv 



A. 






Hiix^ 



Hours 




>^ 



"< ^ 



.\)^ 



-4 



) 



1,' :-•.'/, 



IU>T «.|- MV KNOWI.I-K'.l': AM' lil.I.H.I- 



(Inf')Miriii 




>V 



a 



(v 



( \iMrr^>; 



bl^ 







\X's 



\ 



DIU ATION 



)'('<! rs 



(SIGNED 

J 






(\. 



1/ .,,,'//• 



/hirs 



I<)0 



( 



A.Mn'^O'J.U^^-"^^ " ^ 



//(un s 
M.D. 



I \ 



Special information "n'y f"r Hospitals, Inslitufloiis, [fdnsients, 
nrRfffnt Rosidpnis, ,iiii persons dyini] aw.iy froii home. 



Former or 
I'sudI Residence 

When was disease contraded, 
II not af place ol death ? 



lloH lonq at 
Plare of Death ? 



Days 



I'l \cy Ol lUK I M, '>K ki-;m( >\ \i. 






0\r 



TQO 



"> 



a 



^t. 



(A.i.iir^^ \ru 



Q) ..V. 



— — ^^•''-*-'""" .. . ,, ,. , xci s'.i.ul.M.o hI.iUmI r.XACTLY. PHYSICIANS shoulil 

utato CMIsr or ni. ATII in piniii terms, tluit it iiuiy !>• properly cIhhhoicii. 
sons rlvlnft i.>v».y Vrom home s!,onl.l ho ^'ven l.i every insti.nce. 



T 



1. 1 



: r 



] 
i 



% ll 



; I 



(i 



I" 



m 



"^ii?*'' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

2850 



„,,:,,.!. f II. ..nil 1^^'" '--^r.^iU^-"-^''^" 







II 



JOO'i 



Registered JS'^o, 



/)((/(' Fifed, 

Lv.^Aev,j Deputy Heairh OfTlccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 0<X",v -J A-Cu^xc 



Ccvtificate of Beatb 

( -a. S. StanDarD ) 

, Jn a.^^ c City of O/CL-vv J.^.O- , 



(?n 



A. 



i 



and 



KT Ml 1 ; ^ - o St.: ^ Dist.; bet. . 

No. I I ^' '^ ' ^-^ „ ,,o,,.l RFSIDENCE GlVt FACTS CALLED FOR UNDER "SPECIAL . N FO R M ATI O N ' • ^ 

IF DEATH OCCURS AWAY FROM USUAL "f » I p_E N C E^GJ VC J A C ^ INSTEAD OF STREET AND NUMBER. / 



(IF DEATH OCCURS AWAY FROM «J =» U « I. n t c . i^ .- .- « ^ 
,F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 




I or 



OA^v<i<<:^. 



PERSONAL AND STATISTICAL PARTICULARS 



I iWaa 



.L. f V'- ' 




DA ri". of UIK'l'II 



AC K 



I 



'^■' 



I ! 



a).ivi (Vtar) 



.\h»it/is 



/>,n 



sixt.i.i:. M\Kun:i>. 
\vii)«>\vi:i> <>K nivoKiKi) 






ft I 



cLc^CCX' -).LfcV'' 



1 



-i 



O-'-- 



lUKTmM.AOK, 



NAMl-; <H' 

I- A'rni'.R 



HlkTMPI.ArK 
()|- I AIHKK 

(Stilt"' or Ciiunti V 



MAIDl'.N NAMK 

ol ^tnTll^;K 



Hik Turi.ACi-: 

nl' M()'nil-:K 
(St;iti .11 rmuitry^ 



oecrrATioN 



4' 



ll 






MEDICAL CERTIFICATE OF DEATH 

DATH ()I 1)1;aTH 



(Month) 



(Day) 



(Year) 



I ni<:KJ:HV (.'!•: RTIFV, That I atten. led deceased from 

CL^ xt 190'' to Q.\<^'-....A i()o 'I 

that I last saw h • alive on lVc:v i up 

and that death occurred, on the date stated ahove, at o 



r-> 



M The CAUSIv Ol'' I)I'U>'I'1I ^vas as follows: 

■ ■ (0 






DIRATION }\uirs^)'X Monihs Pays I/ours 

coNTkinrToRV LA^ovaXX ULL^V.\.;kA.^jL^ 



DC RAT ION 



)V<//'.s- 



J/'i)/l//lS 



/rv'> 



. V . ^, 'v. ^. 



^ 



^ 



_ Ca.L'€U''^U 



M,,,ith> 



n,n 



T.n^Am.VKSTATK.>»-KK^>NA. rAK.McM^I.AKSAKl-rU TO THH 

HKST OF MY F<:NO\Vl.lvI)<.h AM) MhMl,! 



(Informiitit 







xJk/Cv 



(SIGNED) 



l\^Ml.^\x'. 



Days 



Hours 
M.D. 



()0 



(Address) bW^^U£_n 



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



Former or 
Usual Residence 

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



How jonq at 

Place of Death? Days 



I'l.ACK OI" lURIAI, OK RKMOVAK 

/ "0 




DATKof HiKlAi. or KKMOVAI. 



190 






IN. B. 



•tnte CAUSE OF DEATH in pinin terms, that .t m..y be properly claHH.t.ca. 
son. dyint away from home should be ftiven in every mHtance. 






t • 



,4. 



I 



! 



■1^ 



s. 



»i 



if! 



ill 




WRITE PLAINLY WITH UNFADING INK 



I )((!(' Fili'il. \Rcr^>X/v^JLMA^ 5: lOO'X 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\^(h 



.^vco^ 




u Deputy Health O^^c^r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate ot 2)catb 



( XX. 5. 5tan^ar^ ) 



PLACE OF DEATH: — County of 



Jiaov ^yux/y\^u\M^ City of Of0^^y\} J;va/>AyeA>a..oo 



NoXcIa/^^ V.CrV^^\iH Ub CKLk^t<x.l. St,; — — Dist.;bet. 



and 



/ .r nrATH occuls .WAV FRbM USUAL RESIDENCE GIVE facts called for under "special information- \ 

( ,F DEATH OcS^RrTd.N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 






FULL NAME 



"^h 



KAj 





VY\! 



^^••■^ CJ^ 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR ^ 



'i 



n 



n \ I 1. t >i r.iiMii 



ACl- 



a 



Month* 



).,,■' 



D.iv) 



M.nilln 



(Vt'ar) 



Ihi 



«.IN«.I,»'" MAKKli:i> 

\vn)o\\i-:i) OK i)i\t»K« 1 I) 

iWiitfiii >-<H-i:il ili>-i>.'nati"ii) 



r ■ ^ 



HIHIUl'I.AOH 

I St.itr til r.iUIltl V' 



\\M1 <>1- 
!■ A 111 IK 



HiK riiri.AiK 
oi' lAini'.K 

(State or L'livint i \ 



maii)i:n nami- 
oi' Mo'rm-.K 



lUKlHri^ACl', 
oi' Mol'm-.K 
(Statr nr I'Dimtryi 



\ 



X 



COl^CL^ 



dl 



1. ' 






t . 




OO 






M.iini- 



n.i 



Till- \HoVHST\Ti:iM'KKs<)NAl.r\Kri'ri.AKSAKi: TK( 1-. T« • TIIK 
lilCST OI" MV KNO\VI,i:i)C.K AM) lU.l.lll' 



(Inf<i;inatit 



X^XA) ^-J XxxX.\ 



( 



LJL.\c Lo . ob (y>ciA\AXxuL 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- DKATII A^ 

(Month) (Day) (Vi-ai) 

.1 IllvKICHV CI'iRTII'V, That I attended (U'tvasei I from 

Oct ll ioo'i to ClTrc- M ic)oM 



Q.c... 



tliat I last saw h •-' alive on Vl :_C - l(>o 

and that diath oceiirred, on the date stateil ahove, at 
UL M. The CAl'Si': (>!• DI-ATll was as follows: 



.O. ■- > 1 



DIRATION Yrars A font /is Pays 



I lours 



DIRATION 



^"x 



)'rnrs 







Moiiths 



K rv. 



Pars 



I lour 



(SIGNED) 

iXcAr,.'! i()o'. 



\ 



(A.ldress) 



b^\„t. ^^ M.D 



XI 



Special information «n!y for IWspltals, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 

Former or , ^ -. .r.-\] A , ""^ '»"«'„«' ., , , - ■ 

Usual Residence ' » ^ ' 1 A A-' ' Place of Deatli? Days 

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



ri \CK oi' niRiM, OK ri;m<»\a!, n\ri:M; mikiai, ux kkmovai. 



IN. B. 



TT . .. .. I- I \cv uhr.iilil ho Htiited RXACTLY. PHYSICIANS HhouitI 

-Hvery Item otf ln?orni..f.on «houI«l be cnreVully HuppI.e.l. A(.f. KhouM •»•» '*Y^*=.j;/: ..^ . , ,„f„^,„„tion" for p.r- 
«tHtc CAUSE OF DEATH in plnin terms, that 5t m,.y he properly cIoii«i?ied. The bpecu.1 In^ormHt.on for p«r 
won* clyinil nway from home Hhoiiltl be ftivcn in every InHtnnce. 



'1' 






^m^ 



II 



4^ 






WRITE PLAINLY WITH UNFADING INK — 



HmmkI iif Ili:ilth !■■ N'" 







/^r/Zr FiJrd f M L^v 




.\; 



7.9(91 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Re^Lslci'rd J\^o^ 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "U. S. Stnn^arD ) 
PLACE OF DEATH: — County of 0.-^^ y\.a.o \.cui^. (City of U/Cl>v 0. 
No 1 1^1 " ' St.; '^. DIst.;bet. 0.-4 / and v!^ 



KyO 



\^^..^ 



FULL NAME 




I. \. .,..'. u 



■XiTM 



V . » _ I ' -. 




I 








:i: 






si;\ 




I? 



I) AIJ". < il 1. IKIMl 



\< .I". 



PERSONAL AND STATISTICAL PARTICULARS 

-> CO!. OK 



'^ 



M.iMthI 



)■. 



I);i\ I 



M.„ii/i' 



\ i:ii 



n,!\. 



<.i\(.i,i-:. MAKuii:i> 

UID' >\Vi:i> OK I)I\ oKi i;i) 
' W'l itc ill MK'iiil ilr>-ii'ii;ili"n) 








lUK'rm'i.M'i.: 

' St.iti- ')! <"iiniiti v ' 



NAMl'. Ol 

1- A Til i:k 



lUK llll'l.AfH 
0|- lAIHKK 
(Stiitf or Covititry^ 



MA1!»i;N' NAMH 
Ol MoTin'.K 



lUK lIMMvACH 

Ol- M(»rin':K 

(Stati- ol rmiiitry* 



OCCIPATION 

h'r.Mdr'if III San / I itiii isf,) 






ii 



Q)/o^^^ J.\,cv '>\.cv^c 






'W-JUv '■-''' ' 





)'l II I 



.\/,'ll//l' 



/),l\. 



TUl.- MlOVKSTATKI.l'KKSONAM'AKIirri.XK^AKl-.TKrK To TIIK 

iii:sT Ol" Mv kno\vij:i)<.k and ni'.Mi-.i- 



fliiri)!in.'iiit 







i: 



t 



MEDICAL CERTIFICATE OF DEATH 

DATH Ol- nivvni r'Y^ 



(Month) 



(Day) 



IQO 

(Yfiii I 



I III'IRIUJV CI'RTII'V, That I atton-K .1 <U'r«.-ascMl from 

to Ah.^ 



that I last saw h 



1 90 . 
alivt' nil 



I()0 
lip 



ail. I that <U-ath orrutreil, on the date stated above, at 
M. Thf CAI'SP: Ol' DICATH was as follows 




\ 



DT RAT ION Years 

CONTRIIU'TORV 




v\JL<L<LL.<ry>u 



Mouths 



Days 



Hon 



rs 



DTRATION 
SIGNED) \ 

LC '. H)o' 



Years 




Mi'ut/is 



/hiys 



Hours 
M.D. 



( 



,\.Mus<) IM U.CL >vMUa-o I'.. 



Special information «nly '<" Hospitals, institutions, Iransicnts, 
or Recent Residents, jnd persons d>in;| dway froni home. 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



r;^\ci': Ol" niRiAi, ok ki:movai. 




DA'I'l-'o! lii KiAl, or KKMo\AI, 



ISDHKTAKiK W^V.^ ^' ^ ^ > . , V Co 



190 




state CAUSE OF DEATH in pInJn terms, that it mjiy l>e properly ciasHiiicu. » 

«ons clyinft away from homo Hhould be ftiven in every Instance. 



r' 



• if 



• »• 



\ 



I. 



M 



^'' 



^ . I 



tlJ'!J 



i i 



■ «. 



> 



.•■I 



I- 



i 






WRITE PLAINLY WITH UNFADING INK — 



f II. -th I- Vo 1-^ -*-^^^^MS:!'Co 



J)ff/r nii'd , VlLcpJ-^^^ 




,^^\JU^ 




"•><. 



W S: i^^H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFtCATE FOR INSTRUCTIONS 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gevtificate of IDcatb 



"a. 5. Stan^arC^ ) 



-? 



(^ 






No. 



PLACE OF DEATH: — County of -^ ■'CV^^' -X<X 

I ClV^ ( - ' O-LLc^v . V . \. I -,^'.. ^-. St.; Dist.; bet. 

V,V.<, VM - VN^^^v iv. ysUAL RESIDENCE G.VE tacts called for under ' SPECAL .nformation \ 

•ROM U»W«I- ntoiu'tii'- ^. . .. r ,^.r, «c cTBrrT AND NUMBER. / 



( ' °"o;:,°.=occ-„%r;,"rHo"s^r.t o%^?^^^"Jvtorc,;r,;s «.«. ,.^». o. sf.» 



/^ < \ r> ( 



and 



FULL NAME 




^^'\1A ck^^rVcL ylc Cnx 



PERSONAL AND STATISTICAL PARTICULARS 



SHX 



^ 



\ 



C01.< >k 



LCV.U 
1) Nil-: I w r.iiv rn 



VlRo 



IN!. null) 



— - I 



Day! 



\<". 1", 



n,t\ 



si\<.i.i-: M.\KKn-:i> 

u iixtwKi) «)R niv<)kvi:n 

I Wt itf ill <'>ci;il (l>-ii.'-n;it i' >ii ) 



r^ 



.--^ 




nik inpi, \^"i-: 

(St;itf or Conntrv' 



N \M1 • H- 
J- All! IK 



TUK'IMI IM. \CK 

())• I \ rm-:K 

(Slate "1 rounti \ 



maii)i:n NVMi: 

ol" MOTIIl'.K 



HIKTm'LAtl-: 
Of- M<>rHl",K 

fStiitc or Coiuilryl 



OCCITA rioN 




LO^^CCO'i 






I \ 




CX-'vL/*^ 




VV^a^aU^ 



-? 



.KJ^^<X. > V 



^•, r*. 



IW...I 



Rrsidrd in S,ni /'i an, ism O >-.' > "' ^ ' 



M,<,>lh~ 



/'. 



I,AKS AKH TKIK T' > rili: 



Tin. AH()VKST\Ti:i> IM.-KsONAl. '' ) '^''j!;'; I.^. 
in':sT OK MY KN«>\V'l.i:i)t''H -^^^l* Hl.I.ll-.b 



(Iiiforinaiit 




>^tO 



cr>X'>\J-N.' 



-^A^' . . 



(Address 



.9lS1 O/CL^a; 




n 



MEDICAL CERTIFICATE OF DEATH 

DATK t>l- ni-.A'IH lA -,. 



MotitlO 



l^ 



\ 
I Day) 



TQO \ 
(Year) 



I lll'Ulvr.V C1:RTI1-V, That I atteii<k'<l 'UiLasc.l from 
1 l. u)o'1 to yX.Q^- '. ic)0 M 

that I last saw h .. alive on '^<^ T90 

aii.l that (K-ath orcvirrcil, on the date statnl above, at 1 •'>' 
M. Tiic CArSlv Oh' DllATII was as follows: 



I v 



.1.,--vt..cri 



(^' 



U- 



::^.i.>. 



A ' ^ r- 



nr RATION 



)V<7/'.? 



Months 



Da \s 



I louts 



CONTRIIUTORV LLcy^ 



I )r RATION ^ Years 





(Signed) Sw^vaJ^w 



^ : 



1 ()n . 



L 

f A.Mress) 



Mouths 



/)rt v.v 



//ours 
M.D. 



lXa^.id ^1 



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



Former or ^^ ctn A ^ \k 
Usual Residence <^o { U Ay vv vr^ v.'. 

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



How lonq at 
^ Place of Death? Days 



I'LXCK Ol" lUKIAL-OK RI-:Mo\AI 

' _V 



DATllof HiKiAi. or K!-:Mo\AI, 



(Ad.lress M^^. M cAAJL^ CvXl LL.VM. 



-tote CAUSE OF DEATH in plum terms, that it mn» ne propcny 



state CAUSE OF . . . « 

«on, dyinft away from home should be jS-Jvcn m every mstance. 



i ! 



• I 
s : 



' I 



i 









t 1 



' • V 



! 



' : {:' 



;»■ 



: 'i 



{ 

t ! 



' iMjir-'^ 



tH 



n.Kir.l -f II. .'-Ah 1- ^' 



WRITE PLAINLY WITH UNFADING INK 



Dale Fi/i''L .lltrvM.^'Ols-Uv' 5 



rj()\ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFI CATE FOR INSTRUCTIONS 



■rVWGiWMKMBi 



4r' 



Icvvv:^ Uvv^ Deputy Health Oflncer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 






PLACE OF DEATH: — County of O CV^O; K.O^VCC^C( uty ot^ 



No. '^"^^ 



-\ 



u V^av<.^<i. 



.,1 



St.; 



Dist.; bet. 



if*' 



and 



I'l t 



) 



.J VCX.X^^^'^ ' ' '^^** ^^ Y,lV^*r\^ilr, FOR UNDER "special INFORMATION" A 



^^ \ n 



FULL NAME 






^ !^ '1 



\i 



•>A' ^^ 



,1 



r\ >A \ 



yAi ubx^vic. 



PERSONAL AND STATISTICAL PARTICULARS 



I 



DA n: ( )| \:\K I II 



I V'^- 



Lrc 



\' ■ !•; 



\ 



1 • .11 



/'.( 



m\<.ij' M\ui<nn 

wiix twi.n < »K i»i^ ' "' ' ' " 

iWi itc in s.H-i;iI (lt'><ii.MKili>'M) 



A ) 



(Vc:ir) 



lUK I'llfl, V'' I 



NAMl t>! 
I AT III '.K 



'^ 



0^ 



Ocv^v 



'\ -1 



Ci f I 



.o.« 



u \ v^^ 



HIK 111 IM. \> »■ 



«>i" i-Aiin'-.K" (?(?\ 



.L\^>^ 



l( 



MEDICAL CERTIFICATE OF DEATH 

1)\11', nl" ni'.ATH ■ 

I lll'KI-r.V CI'.RTII'V. riiat I aUciidcl (k(rasc-.l l"i..m 
IC)0 to K/O 

tli;,t I list ^aw U alive on '*>*^ 

,.,n,l that AvAih occurrtMl. on the .late stat.M above, at 
M. 'I'lie CAT SI". Ol" DI'ATII was ;is follow-^: 

CU-l0..ck.N>vil.^>\.ti...C:r '^. ^.^ ^UXC.^>Xt^ 

VD t'v \ \) • ' 
DIRATION 






coNTi-iir.r'roRV 



I 



Months Pitys 






MAIl'l'.N NAMJ' 
(»l MOTHlvK 



lUKruri.Ai'l", 

«>1- M<»Tni-:K 

(St;it' or rmitUry^ 



orct rATH »N 







L >'A, tV.> 



) , .V 



- \!,.i'fli^ 






lii;sT Ol MV KN.IU i,i:i".K A^l' I"'-"' 



(hi 






urKATK.N^ (V^'" 



J/,>/!///S 



/hJVS 



(SIGNED ) 



/JLC > V v,c^. 



t. 



f SIGNED ) vj ^>^^v > > ^-^ »--^- n 

\|' ' icoS rA.Mre.s)l1[C)cU 



,«La\NA. >viv 



Hours 

Hours 
M.D. 



SPECIAL INFORMATION only lor Hospitals, Inslitutinns, Trjnsipnts, 
or Rercnf Residents, and persons dvini) .iw.i) Iron home. 



Former or 
Isuci! Residence 

When WHS disease contr^rled, 
If not at plare of death ? 



How lonq at 
Plare of Death ? 



Oavs 



DATI", "f Hi KIM. <ii K i:M< )\ \I, 

190' i 



>A ri", '>\ liiKi 



n \oi-: Ol- nrRiAi, ok ui.mo\ ai, 



r M 1 1 



,,M,><— ■■im !■■ 



-—- ""■"""■■ ' 77 IZ vTf. sh >uia be stnte.I F.WCTLY. I>HYSICIA!NS should 

t,. B._Rvery Item of inJormBlion should be — ^"'^v -»^;> ; ' ;, .i,^ J«.„-.VicU. The "Spc.U.l Inforn^.tion" Vor p-r- 
^ . . -^viisF OF Dl A TH n plain terms, that it niji> i><. I"- »»^ * 
:". .bin* Lny fron, ho,„c .l.ouM be fcHen In «v,r> !n«t«nce. 



1 



■ \ 



\ 



1 

l! 



f 









1 fii 



1 

i 


< 


1 
1' 




\ 




1 < 

1 


^ 


■\' 


i;! 


1 


i' 



\ \ 



I hi 



■ fc' 






l^i 



WRITE PLAINLY WITH UNFADING INK 



p.. .!•.; ' il 









ji)fn 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of Bcatb 



PLACE OF DEATH: — County of ' ^^ ^ 






City of 



i 



C-cx ■ ^ 



•nji 



it'.djtvu 



a 






St.; 



D 



ist.;bet.cL X VV>La.cL. a and^-^^clx^^' 



n-;! 



)C»^/VO ^^J- ' pp^TdENCEG.VE rACTS*CALlfD roR UNDER '•special .NTORMATION ^ 

( ^ "/r.rocruVRro\;"rHo"s'py.i^ o^'?:?.^"u'4^.'^o.v. .s name ..srcAo o. str^t a., number. ; 

FULL NAIVIeUvlIcLc. ^ dcv Vjfl .aV^ X^x^(Ux>x. 



PERSONAL AND STATISTICAL PARTICULARS 



J X »\CuU 




k^tx' 



1) \ I 



n 



Lrvr 



/SOH 



) 



S!\i, l.K M \KK il'.n 
'\Vnl<'in vufiul di '-i}.'iuiH"ii « 



(^ 






+ 






lUK ril !'i \'" I' 

- • • • :\],\t \ 



1\ III l.K 



itiK Tiiri. \r i<; 

of I A I" II l.K 

iStrUr nr »."imiit! v 



111 Ml riii i; i< 



lUK run,. \^"i-: 
< u- m«>i!!i:k 



c) 







. ^ w^^cL^*^ 



\\^ 






ilocv.a.dcsVf- > 



\ ■'■■ ' 



MEDICAL CERTIFICATE OF DEATH 

i>\rr, «•! i>r ^I'n A^ 

1 lli;Kl-;r,N' e'i'.RTli-N. 'rii.it l mt^MiM^a .U>rcasc<l li-'in 

frff tt» ' .^» ^ '"" 

that I !m-1 -.(w li '-.'\.' a-H-vtron '^ ^- ^*)0'^ 

ana tliat >Ualli .KTuncl. .ui tlu' .laic •>tatr.l aln.vr, al 
M. Tlu' C.\I SI- OI" l)i:.\ril was as ff)lln\\-;: 



\)\ i; \'rH »N )V<//x 



Mouths 



l\iy 



Hours 



( SIGNED > 



1 



Mouths 



/\iv< 



Hours 
M.D. 



I 1)0 



( A'l 



,ltV<s) I (^ 



A.L'v...... 




( 1 






\'. <'lh 



in-STOI- .MV KNoWI.I.lX.h AND lU.l.H.i 



(111 fi: m.iiit 



yxt- '^ 



V 



( \.Mm-'^s 



\Va'>. 



.11 



cl\.Ll»v 



M 



i 



SPECIAL INFORMATION only lor Hospitals. Institutions, frdnsipnts. 
or Rerent Residents, dnd persons dvin| a^a) from home. 



Former or 
Usual Residence 

Wfien was disease contrdcted, 
If not at plare of deatli ? 



How lomi at 
Pl,i. c of Deatli ? 



Days 



I'l \CK OF rUKIAI. OK K1,M«'N' •>! 



l> \ I 




If TOOH 



I NIil.K 






V.l.il 



-^Mlfk 



^ 



I 



^ --^ — TTT r I Ml s'v. .Id l.c HtMte.l F.X \CTLY. PIIVSIOI ANS nhouM 

;S. B.— -r.vcry Uom o»' MformMtlon Hhoul.I Uc cnroU.lly -'PP -' • ' ; ^i.^.ir.cd. The "Spc.-M.! ln^-orm,.f...n" *or p«r- 

iitate CMIsr. OF Dl ATM \n pinm Urms. tlint .t m,.y ». pr...,c > 
^on. dyinft nwny from ho.nc sl..nh. he ftivcn in every .nstnn.e. 



T 



1* 



I 



I 

! 

I 
ft 



4 tA 

i ■ 



' i 



! ll 



i 



N 



r^ .' 






\ 



i 



1 

1 1 



i u 



m 



I 



ill 



I't 



m 



]'.,Kw\ "f !!( i.lth IN 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^ 



pfffc /v7fv/,\J ^tpj^^^x. 



\jJi\ S 



W()\ 



Registered J\'*o. 



^856 



Ia^^/..^ "LiLv^ Deputy Health Officer 

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of S)catb 

\ 'U. S. Stan^ar^ ) 



PLACE OF DEATH: — County 
No. ^M^ 



ofOxx/^' Jxc^'^vc^C'.Gty of Oxx->x' ■ ^ <^ 

A) 



CV.>VC^-<i. ^' 






II,- , Sf ■ Dlst.;bet. VttU^ and -VCrk 



<^ 



FULL NAME - - ^H ^ ^ - '" 



-^l■\ 



PERSONAL AND STATISTICAL PARTICULARS 




I) \ ri-: <»i- I'.iKTH 



iL'cl 



I \ 

M..ntlO 



\(.j': 



):./' 



Mnllfll- 



\k 



O 



(Vfiir) 



/'(MA 



SINt.1,1" MAKKIKl) 
\VlI)o\VI-.I> OK IMVoKt l-.l) 
(Wiiti-iii >-<><i:il (l>-i•^'Il;lli"n' 



MEDICAL CERTIFICATE OF DEATH 



DATK (U- Dl'.AIH 






(Vt-ar) 



(Day) 
I lU'KI'HV CI-KTM-V, That I utttMi.k-.l .lic-^asctl from 

— — ——190 to .t:-------^^^^^^^^ i^P 

til. -It I last saw h alive on ^'P 

aii.l that <U-ath ocourrcl, on the .late state.l above, at 



M. The CAl'Sh: Ol' DI'lATIl was as follows: 



'^ . 



HIKTHri.ArK 

1 Sl:it( or ruilllll V 



NAM I*. «>!• 
FATIM.K 



HIKTIIIM.AOK 
of I Allll'.K 

(Stlltt III (."ouiiti \ 



MAllO.N NAMl 
01 M<)Tm:K 



lUK'nirKAl'K 
Ol- MOIHKK 
(Statf or C()unlr\ 1 



C' O. VX' vJ .^-CL . 




-^^ 



t 



^jVV 






O^V^TVCV^VV.^ 




vaIaXx 



I'O 



^vvf-^w*- 



JLcla^. 



1)1' RATION >Va;.? 

CONTKIIU'TOKV 



Afotiths 



Days 



Hours 



nr RAT ION 



,C.^ 




1 1 



UnJ-^ Cl^ 



Jj X<X/V^-CO^^<X.' 



OCCri'ATlON 

fy'r^idr,! Ill 'xni / i'i>i. /w.> 



)>((' 



U.'iif/i^ it) /'"'> 



T.n.XHOVKSTATKI.rKKSONUrAKT|rr,.XK.AKKTK.K To THH 
HHSTOl- MV KNoWI.I.Doh AM) Hl.LIl.I 

(infotinant (jbx^-WU 






)V«;'5 Afouths Pay; 

{ SIGNED ) LC[\.^r>\JlX^ vJ. 



a. , 



Hours 
M.D. 



Qfi^v- 



IC)0 ( 



X,l,la-ss) U^O^£^AU4^ 



SPECIAL IN FORM AT ION only for Hospitals, Insthullons. IransJcnts, 
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 a( 
Place of Death? 



Days 



IM.ACK Ol- HIKIAI, OK KKNtoXAI, 



i)\Ti;o! in KiAi. or ki:movai, 

O'V ■■ ' 190. 






f Addo'ss 



■^-^-^— ^^■^■^^^— ^"™"^'*^"** ... » * I fVArTI Y PHY8ICIAN8 Hhould 

N. „._F.v.ry ..e„. oV „.«o.m,...on .HouM ... .....«uMx -u,M. .-I- A ' ^ - ^,^.,,„„,. Th. "8,«ci.. l„W.n,..lo„" W p.r- 

*„.« rAIISF OF DIATH In pinin term*, that it mii* nc p 1 
:or. ..yfnt aw^' «rL h. < > b. «iv.„ in .v,r. -.n-.-nc 



I 



t 

:) 

♦ I 



\ 



I 



* « 



1 ^ 



If 



' ^. 



fee 



m 



ii 



II,,;, 1. 1 '>f 11. ;iHh 1- V') 1-- 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'^•t'^S'Xt) WSiV Ci> 



l)((h> AVV/v/, •;l.r\My^ 



-rJcM.^' 5" 



loa 



Re^istet'cd J\''o. 



LlcoIlvu Deputy Hes'uhOmccr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. StauDarO ) 
PLACE OF DEATH;-Coun.y of^C.v .W.x.^cc City of Ocv^x. J ;vcv..c.^.o. 
, , ■'^ , 1 ^. Sf % DisUbeJjt IfrU^' andCLv ■ , . ) 

FULL NAME t^^^U ^' '^^^^■^'■ 



-V " 



4- 



PERSONAL AND STATISTICAL PARTICULARS 



-i-x >^ 



COl.oK 



v J 



X 



'CvLa 



LO.Llt. 



DAI 1. «»! I'.IK 111 



\< .!•; 







ri 



) ,.,> 






< I):iN I 



1/..I////' 



'V.-;n) 



/),iv 



TQO V 

(Year) 



SINt.I.K MAHKIi:i> 

\vn>o\vi;i) <iK iiivoK* I I) 

(\Viit«iii •>')« i:»l <1« siv'tiiitioii) 



( Sl:if > "I I "■unit I \ 






N\MI- OI 
FA I II IK 



vr, 






' ^^ cv 



i!iKrni'i,\("H 

Ol- lArilKK 

' Stiitf ui «"«)initrv' 



MAIDl.N NAMl. 
<»l MOTIIl-.K 



HIKIinM.ACl", 
nl MnTJIl'.K 
'Slatf or fotiiiti \ ' 



L 



MEDICAL CERTIFICATE OF DEATH 

I III«:R1vHV C1;RTM-V, TIkU I atteti.U-d.lcccase.l from 

■,...,..1 ■. u,o'i U. ..^^--'^ 

tliiit I last saw h ' alive on 
an.l that .leath ucrurrcMl, on tlu- .laU- statc.l above-, at " " '^ 
-^ M Tlu' CAlSIv Ol' I)I*:ATII was as follows: 

; 1 ^ '...■.. ' 






DIKATION 



.MK.M.W., y^s Mouthy navs 



Hour 



LC-t.'- 




T 



n 



-Vox ^ vOw 




(nn I'A rioN 

h'f'ulr,! Ill ^iin /'i mil i^rn 



^ 



t'' 



a 1 



),,f. 



\f,.,i//i^ 



1 1,1 1 



n.KAm>VKSTV.K...M^K.<.NA. rAKTUMM.AKsAKKrK.K To THK 
ni.sTol- MV KNOWI.I.IX.K AM) lU.I.Il.l 



(I 






DTK AT ION >V'/;-.v ;)A';////v 



Ihiys 



( SIGNED ) 



^v-t-'wC 



V/ltV ^1 H,o'\ (A.l.ln-ss) XC?^ ^t,^ '>■• ' 



//out a 
M.D. 



SPECIAL INFORMATION only (or Hospitals. Institulions, Transients, 
or Rfcent Residents, and persons dying away (rom home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



X,l.l,..ss IW (K)CK.^<\ 



PI \C1- Ol' nrRI.M, <»K Kl-MOVM. 
fAd.lr.ss OO I 



HAIi: of Hi KiAr. or KliMoVAI, 

Q\^' y 1 90 'I 



N. „._F.v.ry ...n. o« I„» ...Ion .ho"l<l h.- .„r.«ully -upp ..... A<. . " ^^^^^^^^^^ ^^^ „^^,^^,„ ,„,„„„„.„.„.. ,.. p.r. 

. * r AilRF OF DEATH n plain term*, that U miiy nc pr 1 
:rn. /Z -w^r »-". Ho™., -h he tlv.n » ."...nc 



f 



■ .! 



! 

i 

( 






!• 



I t 



I I. i 



WRITE PLAINLY WITH UNFADING .NK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Himrilut H«.-;iUn i ■>■" > -^ '^ ■ ..-..,^ ^ 



100H 



Jies^isfered J\^o, 



I 
l^^^o Ixvv^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 0.>^' 



Certificate of S)eatb 

( X\. S. 5tan?arD ) 

' -^.cc City of C)o.>x. V<x ixccAc ^ 



A 



J \.cv. 



No. 



St.; Dist.;bet. 

3ID£NCE GIVE FAC 

( '^ ?ro\''.ri%t:u:.ro\rr.os^:.r. o-r-.nst.tut.on g.ve . 



|\a.vIm V.C-. ) 



\. 



and 



%f 



. OCATH OCCU.S AWA. FROM U^UA . - ^ O . N C^^ VE ^^CTS^CALLE O ^ ^^^^^ J^ ^ r^Ill^'*" ) 



FULL NAME 



.oJUax^-'... ' 




a.^;>\,o.;v. 



PERSONAL AND STATISTICAL PARTICULARS 






i 



\ 



i)\ ri*. oi uiK III 



Molith' 



\i.\: 



)'i i! I ^ 



il);iv) 



V '»////' 



!^"<■;lI ) 



/'.7I 



MEDICAL CERTIFICATE OF DEATH 



DATK C)l' DKATH 



V1.W 



(Month) 



; 
(Day) 



' \ 



I go 

(Yt-ar) 



it! 



SlNT.l.K. MAKUIl'.n 

\vi:)(>\vKi) <»K ln^ ' »K> J I) 

iWiit* ill HCK-ial iU-iv'iiati'>iil 



'State or t'>iiniti \ 



^ 



S . 






\ \ 



NAM)' <)1 
FATHl-.K 



lUK rnri.ArH 

OI lAIHKK 
(Stalt or C'oatitry • 



MAn)i:N NAM1-: 
(>i .mutiii';k 



lUKTHri.AOK 

OI MoTm:K 

(State or Country 1 



1\ 




,rsy\j (j^j^Ll<./V-Ola^v 









\ invKlCHV CI'RTII'V, That I attemkMl .leocascd from 

J£).CC 190 'X t.. OX^TV-. ...S TCP '^ 

I V"\ 
that I last saw h .^^^ alive on '^' ^ ^'P 

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

- M The CAUSH OF 1)1':AT1I was as follows: 






DrRATION ^ y^^an Mouths Pays 

CONTIUIUTTOKV U^lx^e^ .3.C.Ll^a^ 



Hours 



^J,A^O. 



Month: 



DT RAT ION >>'''''^ 

(SIGNED )\Lo^ V y^-^V^ 

'Address) lig^ iJxvv^^a^^Vc At 



Days 
ivOuAW 



Hours 
M.D. 



Ciltv .'. 



I go 



( 



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



OCCl tation 

I '^ 



\r,,llfll:^ 



/'<;i. 



•,MHAm,vnS-rATKt,,.KKSONA,r.JKT,or,,,VKS.KKrKrK TO Tin; 
lUvST OH MY KNOWI.l-.IX.h AM) I hl.ni 



(J p 



<M^ 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



DATIiof Hi KiAi, or KKMOVAI, 

' ri<5\^ ' I 1901 



PI.ACK OF HIKIAI.OR RKMoVAI, 



^^^^^_^^^^^^^,^_^^^,^,^«^^^—^— —■-'■"■""""" » t I FXACTLY PHYSICIANS should 

N. B._F.v.ry ...„. o. ,„S...n....on .houM he c,...un, .-ppl.e-. ^^^^^'^^.'^..^.^d! 'th; "SpcCal .n»or„...1on" .or p-r- 
* — rAilftF OF DEATH In pinin tepm», that it mny "c i 

:™ if., .™ <™ —• ■>-"'•' -•'-'■ •••" '•""••• 



I 






\ 



\ . 



')i^ 



! 



( « 



1 ^ 



I I 



I 



i 




m 



^bB 



m 



w 



RITE PLAINLY WITH UNFADING INK — 



IV r.i ■>: n 



I > , ) v . . 






I 




/>c//r /7/rr/. NJVtrV-^VV^Wv S 



U 



/ /y (^> s 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Roo^i stored Xo, <?00 J 



5th O 



^\ V o "^ ^^ "^^^ ' Deputy ■' 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of IDeatb 

I "U. 'Z'. *I'tnu^avc> » 
of C' CL^X; A^a^^CUCC City of ^^'Ct->^' ^J\^0. ^- 






P 



Dist.; bet. 

,CT' 
IT 



>. i S. V' 



and -^ 



N'>- ' '^ ^,. .;;-,^e.-,_^^ ..o. OS... :4?-L;;^,H'^^^ ^r'" ;?;^i^i:"=r ■ ) 



FULL NAME 



^'\C.' 



,'> 



v'm 



PERSONAL AND STATISTICAL PARTICULARS 



V 



\l..!i!h 



),„■» 



M 



EDICAL CERTIFICATE OF DEATH 



f\ 



I (JO 

(V.':n I 



I)\ IT. < il I'l A Til , 

(Month) ''^•■'^■' 

I I1I;KI:I'.V n.KTIIV, riiat I attcu.U'.l .Uc.asr.l tP.in 



i ' < 



"^iNc.i.i:. M \KH!i:n 

\\T!)t>\VKI) iH< I)IV<»!-- 1 I' 
\\:\\r in -.M-i.-il (k-iviKilixii • 



r.iK iin'i. \*' I 

^ ■ • ' ■. )H nl I \ 



!■ \rii 1 u 



lUK I II I'!. \i j; 
(ti I \ iin- u 






w vv 



?^( 



1 



I()0 • 

that I last saw h - • • -ilive on 
;,„,! that .Iratli orrurrcl. uu the .lal- ->taU'.l ah..vr. at 
M. Thi- CAlSh: (»!• Dl'.ATH was as follows: 



Ti;0 
M)0 



IdkA'noN 



(.•oNTKIili roKV ^• 



Mo lit /is 



/hn< 



1 1 out S 



c^.o. 



M \ i 111 . ■ \ M 1-. 
<)1 MoTlll.K 



lUKiin'i.Ari", 
oi' M()Tin:u 

(Slate i>r C"i)\uili n 




^' 



,3 






rL >,^ vJX/CU YvC' 



I ncl 1' \ IK >N 



) r,-ii 



y'..iifii 



1- l:r 



rm: \m<»vk stvtkd i'KK<;0Nai PAUTirri u<s 

Itl-.ST 01- MV KNuWIJ^IX.K AM) lU-.MJ.i 



<S AKl'. TKl]-: T" I" '•'- 



(Iuf"-ni.iiit 






DIR ATK »N 



(SIGNED) ^ 



)'•-//■>. 



Mont lis 



/hiVS 



VI U. 



I ( )' > 






//oi/i s 

M.D. 



SPECIAL INFORMATION onlv (or llosmtdls, Insfilufions, Transients, 
or Rorent Residents, dni persons dvini] dwcy IroTi home. 

How lonq at 

f'"''".V., Pldreol Death? Days 

Usual Residence 

When was disease cnntrarted, 

It not at plare of death ? „______ 



,.,,ArK Ol' m-RIAI. OK KI-.M'»\ \i 



DATi'. '<: i;t iMAi. <>i ri-:m<)\ \i< 



^ 



I NI'l'. 



„.:,....i ^r iX 



fAtl.Ii'>^>- 






^— — — —^—i ii^— — — — — pw^Tl Y PHYSICIANS Hhoulcl 

!!"r..'^^t'r'L»r fro,. ho,.,« »...,u1.i be ftiven i ory •.n.tnnc. 



ion« clyinft nway from 



I 



i 






I 






^4 

•♦ 

.t 



^' 



L*^--- ^'**" 



m 
4 



«■ 



write: plainly with unfading ink 



f..l. — Z-;, I'.S: I' ' 



!)((/(' /•V//'^/,M\^^o^Jt-»->v^CML^' 5 



!!)0'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.^vxv:' "^^ ^^ ' 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtiticatc oi IDcatb 






'V 



(^ 



City of C3.tx>v .\. a. A 



PLACE OF DEATH : — County of ^^^^ tX>V' X Cv . 

--r'i' > Sf " Dlst.:bet. V. I A > . . and->;^\ 



V. • * 



FULL NAME 



) 



i^A 



[lak.o. uac' I 



I 



PERSONAL AND STATISTICAL PARTICULARS 

^ ' ' I . I ' »• 

i 1 . 0. V ^ 

I. \ 11 < •; !1!K 111 



M 



\' .1 



IViEDICAL CERTIFICATE OF DEATH 

1>A Tl-; ol- I'l'.A'lIl ( ' 



\ 



V^ 



Li 

\ 



(Vi-;ir) 



1 



I 



r 



W l[nt\Vl-.l» OK I)I\ < ''<•'!• 
(\Vi itc ill >-<)<-i;il .l.-ivMiatK'iit 



lUKTIiri. \''l' 
-■ ■. ■ .unt I V 



A 






\ 



~\ ^yj vj \ C\ ' 
\MI'. <>1 . A y 





ex 



r.iK riii'i. \^ !•: 
oi- 1 Arin-:K 

■ St.lt' ■ ■! t""\lllt IV 



A ( V .\ 



I Hl'Rl-inV CI;kTIIV. Tliat I alK-n.UMl .IcHX-a^o.l fn.in 

that I la<l .aw h alu. o,, ^^t-^r H upS 

.,,,,1 that -U-ath occurrc.K nn the .late -tatol above, at U -^ C 
M. The C.\I S1-: (>!•■ DIAXTM was as follows: 

^j,-NA.n. \'\.A,A 






H 






r 






! : 
II 



r^ 



CoNTKll'.l'l'Ol^V 



^ % ^, ^ 



\ , ' 



'. ^ ', 



Monf/is 1 /^ns 



Hoars 



Monihs 



Pays 



IIOHl s 

M.D. 



MAini.N NAMi: (Vn 

oi- m<)Thi;k ^(Ji^ 



% 



xO\\j^ 



[\ 



tX.\vO 



r.iKiMiiM, \i I". 

OI- MoTlllvK 
(Sl;ite i>i iDiintiN^ 



olTITATION 




VC^ . - 



,T / <■ 



M,.>i!lis 



l\-\ 



.^n^^HovKSTAT,a>.■KK^>NMV.^uTu;r..^Ks.u.rr.:K r„ ,„..: 

HI-:ST OI-- MV KNOWM'.IX.H AND HI. Ml, 1 



(Info; lliailt 




/1\ r. 



CC"\'>s/0. 



f X.l.lrc'is \) M. V. 




i)rR.\'ri(»N )''<'''^" 

( SIGNED ) I. M'I^ClUl^.AClI-. 



c;pECIAL INFORMATION only for Hospifdis. Instifiitians, Transients, 
or Rcrent Residents, and persons dyinij away from Irnme. 



<,'.• 



J 



• 'ii 



{'•: 



i 
Ii 



Former or 
Isiial Residence 

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



How long at 
Place of Deatfi ? 



Days 



IM.ACK OF HIKIAI. oK Kl'MoVAI 




) A ri; of lUKiAi <n K 1".M()\' \i< 



^L 

(A.uh-.ss 5H0'^^\aAAxa..Bt 



T90 . 



^__^^_— — , pvACTLY PHYSICIANS should 

state CAUSE Oh Vti^ in ^Jven in every nstonce. 

«on. dy-.nft oway ?rom ho,nc shouhl be ft.ven every 









!'.m!'1 n! I|. .i'-M I 



WRITE PLAINLY WITH UNFADING INK 



V. 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Duir ri/rf/S\\T\sl^'rr^Wv S 



I!) OH 



Bo(^islct'e<l J\'*(>' 



*^8^' 




V.V.O jkji_Vi- 



Deputy Heolch Officer 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



PLACE OF DEATH: — County ofCJ.<X->^ ^A 



Ccvtificate of IDcatb 

City of ^'CU\v J/v€L-y vCA„<i 



^<T{^ 



No. 



, ■ ' Sf 'I Dist.;bet. ^^ACI\4 and V,-U. 

( ,r DCATH OCCURRED .N A HOSPITAL 0« -NST, TUT, ON G.VE fX ^^ fM/Oi 



) 



FULL NAME^KA.U4^<VT.vcvd ■^^Mldlo, I 

^ ^ ~ I r7_-».>-.«i /~ c- DTI ri r flTT OF [ 



PERSONAI. AMD STATISTICAL PARTICULARS 



I . \ I 1 . >1 I'.IK III 



r« »i.' ii< 



^ 




n- 



h. V 



,^ 



IViEDICAL CERTIFICATE OF DEATH 



nA'pi-: (»!' pi'x'rii 



\' 



"^ 



/',,M 



-.. ■ , 1 ! \t\KU H-.il 
U I l.i .W !• 1) «)K 1>'^ ' 
> \\i it» in ^<>ci;il d 



)!1H riiri, \''V 



NAMl- <»1 
r ATIII.K 



^ 






lUK iiiri, \^ 1-: 
m- J A nil-: K 








la^fl) 



^K\A. 



I lll-Rl'-.l'.V CI:KT11'V. That ! :.!U-n.k'.l .Unvascd fnun 
I .. ^ U)o\ t.. ^^ ^-^V '■ up'- 
tliat I la^l>..wh-.~ alive ..n ^'P 
an.l Ihat .Uath occurrcMl. nu \hv date ^tatcl a1..vr. at • 
^ ;^j 'I'lu CAISI'. ()!■■ ni-.ATIl was as follows: 



111 i^\Tl<»N JVa/-.s- 

CoNTRir.1'1"'^!^'^' 



Mnn/hs 



Pav^ 



IltUH s 






MAini-.N NAM1-: 

oi- Mo'i'm-.K 



lUKiiiiM.x^ i: 

<)1- Mo'nil'.K 
(Stiiti- i>l C'oit'.itt \ I 



(Hv't T AflON 




DIRATION 



)','<rs 



.][,'>! t Ik 



/\iv 



Hon 



rs 



(SIGNED^ ^ 



iC- . 



M.D. 



QVtAT 



I()0 



f.li.hvs.) ^%i ^IflUvkA -.^t 



"c;prciAL INFORMATION only lor Hospitals, Institutions, Transients, 
or Rercnt Rrsidrnts, ani persons dying away from fioiie. 



t^V^V'^.a.' 



- )-,VNC - .lA"////- 



/),;:- 



(II 






\sX. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place ol dcatli ? 



How lonq at 
Place ol Death ? 



... Davs 



I'l.ACH Ol- lUKIAI, OK KKMOVAI. 



VA/ft-^' 



DATl'ot HrKi.vi. '>i K1;M(»\AI, 






^ ^^^ . pvACTLY PHYSICIANS should 



f 



■' 



I 
I 

1 

1 



i;' 






I 'i i 



I I 



1 ! 



t • 






WRITE PLAINLY WITH UNFADING INK 



Hoard of II' :i!il» ' ^' ' •■••-•» ^ 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




pff/r Filed, rLti\M.^TvU<A.' 5:. 



lOO'i 



lle^istered JSi'^o, 






.^V-^Ui .ki-v<.^ 



OEPARTNENT OF PUBLIC HEALTH-City and County of San Francisco 



Cevtificate of 2)catb 

( XX. S. StaiiOarCi ) 

J? ^I5?i ^ 



(^ 



X.. ^ TH r ntv of ^ c^ J^X<x,-wc^.c-c City of 3 <^- ^ .VO, .X., vc . . 
PLACE OF DEATH: — County ot v. t^,>^J aj 

1^ ■^ '\ 



f t ^'"- 



u 






4 



W 



\ 



Dist.; bet. 



and 



ij ( " Tr or.TH ocSuRRto .n * hosp.t*l 



-) 



-f^^^^^c;;:^- - -- — ^°" — *^° ^"^"^ 



FULL NAME 




v-U\. 



SI A 



PERSONAL AND STATISTICAL PARTICULARS 




l\ 



<xk.i 



a 



DAll". «>I ItlKlH 



M..iithi 



\<.l-. 



)■ .;' 



(l):iv) 



M.mllr 



•/. ai 



/).; 



MEDICAL CERTIFICATE OF DEATH 

(Month) 



(Year) 



Tm^KKHV CKRtIfV, That latteuacl aecease.l from 



..y/cA. 



SINT.I,!-. MAKl<n-.l> 
\VM)<»NVi:i) OR T)I\«»Ki hi) 
f\\ tit-- in '^oiiiil .l.-itrnation) 



iiiK rin'i.Ari-: 

'Sl;it. <)1 (.■illlltlV 



N\M». <>I 

» A rm-.K 



lURTHIM.ArK 
Ol- lATMKR 

'Slatr ui ('o\nitrv 



MAIDI-.N NAMK 
«)j. MoTIlKK 



HiK'rnri.ACK 

()»• MOTMKK 
(Slatf or ConntvN 




tliat I last saw h - • aluc on ^ 

,„a that death occurred, on the .late stated above, at 10 ^^ 
M. The CArSl<: Ol' Dl'ATIl was as follows: 

(Xk^^^^^^^^^-^^^ , . , 

DIRATION Years Months Pays Hours 

CONTRIin'TORV 






Hours 
M.D. 



1.1 ,'r\J^ 

CITATION i^ i) 




CX/>v 



cL^ 



Krsi,ir,f i>i >'•■" ^ "'"""•"_ 



;^ )■',;- 



M,,iitli- 



/),n. 



„„f ^-^ VJIaJ..A, 



(SIGNED) -J ^-^ '^-^ ■ p ^Tjv,, 

-SPECIAL INFORMATION »"lv l»r f pl.als, In.m.Hm. Transients, 
orlefen^ teside«ls,Vnd ;|ers.ns d>ing a»a, Urn Home. 

formn or 1 '5 A /> rva 1 1 v.. ^i, ( -Cf ol Dealh? 3.H. Days 

Usual Besidencf -^^ VJA\a.v^^. 

Whfn was disfasf contracW, 
II not al plarfol death? 



■7I7«T;riIwAi..iKK.;M.>vAi 



l)A'i;i. ot lUKiAl. or KKMOVAI, 



rNDKRTAKKR ^ CrX^-^^v n n IT 



( All (Ire 



'SS 



1. 



I , PVArri Y PHYSICIANS should 

rH in pin.n term., thot 5„-t»nce. 



M R Fverv item of in?ormat 



( 



ii 



1 

I: 



\ 



! t 






i1^ 



I 

1 



^•*l 



K 



< I 



i f 



I » 









■) 









•> 



II 



I 



t.. 



<£ 



jf 



WRITE PLAINLY WITH UNFADING INK 



H.,,T.! .r n<:.lHi »■ No. l=;'^^»^-^H&POo 



/>r//r F/7r(/f 




5: 2'^ OH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIF ICATE FOR INSTRUCTIONS 

G3 



Begistered J\'*o. 







l^^v^ ii/v^V Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 



•Q. S. Stan^ar^ ) 



J? Qo -*^ ^^ 

PLACE OF DEATH:-County of C'x^v Jxa/^rxx;<AC.(. Gty of Oa-^ ^]Xa,^v 
w S V^X\yk,lL Vl IccCt. St.; 1 Dist.;bet.0AJ<Jl->^^m.:Oiu andJvC 

No. I ^-^ \yT\~K - V-Vl. ^V. ,,-u.L RESIDENCE SIVE TACTS CULtO FOR UNDER -SRtCl.l. 1 N ro R M.TIO t. ' 

" "^"or.ricc'uV.ro',"""".'-"*!: r."-"?^"'; O.VC ,TS NAME ,NST». Or STREET .»0 NUMBER. 



( 



) 







FULL NAME 'A.{^tU VJxrx^^^a.o 



M 



SKN 



PERSONAL AND STATISTICAL PARTICULARS 



nwL 



DATK «>I- HIKIII 



A<.H 



, 1 
<Mniith),l 



)>(*/ 



lb 
(l)avl 



1 //»;////' 



ll 



(Year) 



iH.; 1. 



SINCl.K. MAKUIF.n 
\\n)n\Vi:i> <>K IM\< »Kri;i) 
(Wiitt in s(Kial tli'><iv'iiati<)ii) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH C\,^ 

mW 

(M(MiUi) 



v.V. 
( Day) 



IQO'X 

(Year) 



I IlFvRICHV ClvRTlFV, That I attenckMl (ieccased from 

,"; . rrr~~r: -190 io "igo "" 

that I hist saw h .v:-— alive on -— — — ' - "^9° ~ 



(Statr nr tDntitrv 



La,l J c: 






iXyvv '-> 



NAVF nj 
K Alll J.K 



^"11 



luk I iiri.AiK (A 

oi r\rm-:K fV ft 

IStatf «ii r.mnti v^ \\ . ;] 



maii>i;n NAM}-; 

OI MO'ini.K 



lUK riiiM.Ac 1-: 

<»1 MnTHl'.K 
(State i>r Country) 



^cXcr Vccu H I V 



O^^^Oj 



_ atctU 



(H CI TAT ION 



)><;;> O Mi'iillis i 



; ) 



/',/i ^ 



TMl' AHOVKSTAri-DPKRSONAI.l'AKTIcrLAKSAKKTRrK T< > TJlH 
BEST 01<' MV KN()\Vl,i:n<".E AND in-.Ml.H 



(Infoniiant 



(Address 



H 



^xvL (?1 



■-ccX 



and that death occurred, «)ii the date stated above, at 
The CArSi: Ol' 1 



M. The CAISI*: Ol* DI^ATH was as follows: 



Dr RATION }'t'ars 

CONTRIHrTORV 

DURATION ViiJrs 

( SIGNED )UA^rvvM 



Months 



Days 



,} font /is 



,t> 



/hivs 



Hours 

Hours 
M.D. 



M"^ C\^ .^ iqo' i ( Ad.lres>.) lfrVtr>\X\^ ^.U-^^^- 



SPECIAL Information ^nly fo"" Hospitals, Instituttolls, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



DAIi:<): 151 KIAI. or REMOVAI, 



PLACE OF lUKIAI, OR RHMOVAI, 

l•NDFRTAKERtAAA^. CO/^tcCI^ ^^J2.tt<) "^^ V 



190H 



(.\d(lress 



i9...^,'i)..l)...< 



N. B." 



""■—""""""■— "—^ VK AfiE should be stated EXACTLY. PHYSICIANS should 

-Every item o? information should b. CBreVully supplied. J^^^ * classified. The "Special Information" for pT- 

state C\USE OF DEATH in plain terms, that it may be properly class.t 

«on« dyinft away from home should be ftiven in e%ery Instance. 






^> 









* 




Si! 



RITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^1^* w 



Jlro'i,s/crcd jVo> 



28()4 



/;/^/r /'V/r^/.MXirx^A^^Wv 5 i^Vf^y^ 

"^ A^ Dep'-^' ^^^^-^ Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Bcatb 

(^ 



-V ex "V 



J? (?7l 



No. 



PLACE OF DEATH:-County ofC]/CX>^ -VCXvvcv^coGty of '^ - 

-,, St.; ;0 Dist.;bet> •.A,''.CU.< .ind 



FULL NAME LUa.QX.Io. 



w 



r r [ 



PERSONAL AND STATISTICAL PARTICULARS 



■l.\ '" ^ 



\ 



^l 



1 1 ■ . 1 



\^ ■]■: 



\v 



) ^n 



MEDICAL CERTIFICATE OF DEATH 



DA I'l-, ' '1 



m-.A'i'ii , \ 



''Wv 



(Yi:ir) 



1 |II:k1,1;V Cl'.Kril'V, That I .atr.plr.l .lc(t;.sr,l In-ui 

that I last saw h • alive on ^'P 

a„,l that .Irath ..rcurrcl, on thr .latr ^tat..l al...vr. at > 
.' M. Thv CAI SI'. <»1' l)i;.\Tll \va< as folloNvs: 



>.i\< .1,1-:. M \K t- I) 1' 



I'.iH riiri.Aci". 

I St;it< or «,"<>uiiti \ 







N V M 1 ' > ■; 
1- \1 li IK 



lUK'nnM.M'K 

<>]■ I .\rni:K 

IStiiti Ml- i'(i\mti V I 



M \ im;N N \Mi: /'^ 
<.r MoTiii: K 






M.>uLtvo^ VL^Lannoj 



11 






niK rmM,Ai"i-: 

iSlatr or (OutUvv' 



O^oJixL 






^ J,vn> 1 I-'""'''' '^^ ^' 



^Ty^^i-^s;,^^i;^^;^.r^i'^^.i^.:.K^''^^'''^^ 



(Inf.i: niriiit 






C()NTKH:rT<>-I<V 

I )r RAT ION J'"''^" 

/SIGNED) L i ^ 



.]/,>!///( S 



/hus 



//cars 



Mouths 



I hj VS 



A.ians.) '1^^ -HIUav-' 



I lours 

M.D. 



"special INFORMATION only tor Hospit-.K ln,lit.itions. Irdnsicnts. 
or Recent Residents, ond persons d)ini .'^cv Iron honie. 



Former or 
Usual Residence 

When WAS disease rontrarted, 
If not at place of death ? 



HoH long at 
Place of Death ? 



Oavs 



IM.ACl- OI lU KIAl, OK K1-:M"\ AI 



I) A T}'. ('! Ill Ki \I "I Iv l-'.M< >\ \ I, 
'^""lA ^ ^' ''• TOO . 






I ^ ^ iivvrriY PHYSICIANS should 

.. * r'AiisF riF DFATH in pliim terms, mai n "«"0' 
state CAlIbfc U^ iJt.^ii> » AUi-n in every inslonce. 

Hon* dyinft away from home should be fe.ven .n e e > 



I 



mr 



h 14-; 



I 



m 



m\ 



WRITE PLAINLY WITH UNFADING INK 



,;,,;,,,! , r ii.M'th »■ vo !^ ^T3-: 



MM' Co 



/>.,/<• /•V/r'r/.ViVcx-^•v^^.t.-^■^ " -^^^-^'^ 

DEPARTMENT OF PUBLIC HEALTH 



THIS. IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Re^htcred Xo. 



'V6'^ 



City and County of San Francisco 



Certificate of Beatb 

, "U. 5. Stan^arC ) 



'7n 



No. 



PLACE OF DEATH:-County ofO cv^^ .' .V^^vcvAcGty ot 



...a."»va.^^'"-.^.'-'-'> 



St. 



( ,. „..,- „c::-s^..://-cVosu.. ^"--,f--;r,;r«VM^° r,e"r" sT%".Ti:„"'r:^i'r • ) 



r."or.T- 0C"«."V,H .«oVp.T..O« ,~ST,TUT,0N 0,V. .' 



1 



FULL NAME 



Icu 



d 



CVvv. . 



,clv^«^'^' 






PERSONAL AND STATISTICAL PARTICULARS 



1)\ I I. «»l- lUK TM 



A t . K 






<nav) 



M.^ullr 



Pit ys 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 




(Year) 



mvt.T.i:, MAKklKI). 

W II)<»\VHl> OK I)lV<>RiJ-.l> 

(Writfin s.nial .U^ivMKitiuii) 



nvcx.v\.^e(i 



(M.,ntio '^^»y^ 

I m.;Ki;HV C1:RTIFV, TIkU I aUendcl deooased from 

that I last saw h alive on J v..C.v .: icp • 

and that .Uath occurred, on the date stated above, at O 
_M. The CAISI-: OV Dl-ATH was as follows: 



iSt;it«- or l"«)Uiiti V 



N\M1 Ol 
FATMKR 



niRTlIPKAiH 
Ol- I AIHKK 
(Stat«- or Ooiniti V 



.Ov 




f^"^ 







jLX.>>-^<x^V' \dJ 1 ^ 



'J^lv\.Ci:^.vv.t^ 



I )r RAT ION >Vr7r.9 

CONTRinrTORV 




.}/()n//is /^tn'S Hours 



0'^"N-V-C 



\ 






MAIDKN NAMK Q 

Ol-- MoTlllvK -V ~\ y i 



^ 



lUK rmM,.\«.H A 

(U- MO riii'.K _ y 

X V>TVOyYVLl 



(Slati i>i c"o\inlry) 



Dl'RATION 
(SIGNED) 



I- 



)'C<J>'S 






/hivs 



//ours 
M.D. 




H)0 



(KXTI'ATIOnQJVP 



:i 






a 



!/,./////< 



/'<7V 



■-'i^i^^Mr^^^^tiM^^ "■ '"'^ 



(Itifotmatit 



[\i^C\. > ^^ 






A 



M.ldr..s):.S-tAlilaA.Kxt ll 

"Special information onlv for Hospitals, Institutions. Transients, 
or Rerent Residents, and persons dyiny away from home. 

, i . , 1 How long at 

Former or 5,1 1 \^^ fSlt LV Place of Death ? Days 

Usual Residence ^^ 1 1 P ^^^' ^' 

When was disease rontracted, 

If not at place of death ? 



ri.ACK OF HIKIAU OK KJ.MoVAI. 







I)\n"ot" Ml KiAi, or KHMOVAI. 

M^C>- L 



j9oH 






/ " ^ , KVACTLY PHYSICIANS nhould 

E OF DEATH In pinin term, tH«t U m«, ^f ^^^ 



IN. B. Every Item 

.tate CAUSE OF DEA rti m P'"";^' " -"j^^^ .,„ „ery in«t»nce. 
«on. cfylni aw.y from home nhould be jk-ven 



r^ 



f 



Mil 



■^ 



I 



i. 



h 



i 



'*' 



'fl 



WRITE PLAINLY WITH UNFADING INK 



r-l^i. 15\r (".) 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hf/r /v7fv/,Ml{PJ-^'>'>'vlvL\j "^ 



190 ^ 



lie^Lstered J\'*o, 



2sm 



d^fr^o ^v.| Deoutv Health Ofncc- 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of TDeatb 

I •a. S. StanPar? ) 

1^ -^ 



PLACE OF DEATH: — County 



of JXX^v^' A^Yvcuici City of CJ^xao. O-'vcu* 



VO^a:, '-' 



r. ( 



No. "^ '^ " ^ <^ 



/^ V 



1 .. 



St.; 



Dist.; bet. 



.cLowu 



and 




) 



( '--^^^v^:::--^-^ -d::^:^-^^^"^^^ ^^i^?:nn^^=r' ) 



FULL NAME 



I 



-\ 



xa 



A 



] 



PERSONAL AND STATISTICAL PARTICULARS 

I) XT}-, nr ItlKTII - 

in.v) (Vt'iir) 



\' .]■ 



i -J ) ■ 



M.nitir 



/\i\ 



SIN<-.I,1' MAKUn-.l) 

W I1K>\VKI> t>K l)IV»»K»KI) 

i\Vtit» ill --tKiiil (U*iv;"ati"n) 




luk rm'i.M'K 

(St;iti- >•! r.mnti v 



NAMi: OI 
I A Tin. K 



HIKTHIM. A^l-: 

(St;it«- or I'ninitt v 



MAn>i:N NAM!-: 

oi- Mo'rin:K 



lUK'rmM.ACK 

(»!• MOTIIKK 
(StMtf or Country! 



OCCI I'ATION 






MEDICAL CERTIFICATE OF DEATH 

MW\r ^ /go- 

(Month) <I>^'V) (Vear) 

1 m':Ri:r.V CKRTIFV, That I atten.UMl dect-asea from 

L-U^q 190' ■ to.J^ri^ ^ ic>o'l 

that 1 last saw U alive o,t M\^ ^ up ^ 

an.l that <loath occurred, on the date stated ahove, at 
Q. M. The CAl'SH OF l)i<:ATIl was as follows: 



DIRATION 
CONTRIIU" 



)'t'ars Moftt/is Days Hours 



/ 



Y 



-v^' 



Dl'RATION . Years .^Months '^- Pays 



(SIGNED) 



i) , 3. ^ 



\^\.r . 



Hours 
M.D. 



iqO 



( Address) \y^ ^JLO^^t/ y 



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




^j-V^^Ui^C 




Rrsidfd in Satf /'ic:>h'^r,> -' ^ '<" 



Month- 



Ihiv^ 



rMKM,„VKSrVrK>,.HK.nNA..VAKTU,r;v^HSAK,CTK,-H TO TMH 
IlHST or MY KNOWl.l.lX.h.A^^' lU.I.ll.^ 

,„„„„ W^vJU -iSx^^AhJ^^ 



(A 



Former or 
Usual Residence 

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



How long at 

Place of Deatli? Days 



ri aCK t)l- m rvi ^i* ^"^ 



ULccJk 



It^ ^ 



I'l.ACK or lURIAU OR KKMOVAI< 

(AclclreHS..kl5k."^^^^'^'^^^^ 



I)\TKof lliKiAL or RKMOVAI, 



I9(> \ 




.a.> 



,..v,Sr?v. 



_^-^^^ —i ^— — — — — ' t t I EXACTLY PHYSICIANS should 

,. „._P..„, ,.e™ o. ,nV,..„.»..on .H„uM H. c^...uM, .■.PP...-. *^'; •^/r..,",,:.? 'tH. ••Sp.cla. .„fo.n.«..o„" ,.r p.r- 
* * r>AiKF OF DFATH in plain term», tnai 11 mnj' f 

•tate CAUisfc Ut- uc«iii k , , k- A:v*.n tn every instance, 
•on. dylnft away Vrom home should be fe.ven In every 



f 



I 



f«!. 



I : 



<• 



. » i\ 



{ t 



w 



rite: plainly with unfading ink-this is a permanent record 

REFER TO BACK OF r.FRTIFICATE FOR INSTRUCTIONg 



t.^i^-^'X.i; HJtl' O'l 



g ^ ■ H W M»L»J»J I 



riC^lsfercd J\'o. 



2867 



DEPARTMENT OF PDBLIC HEALTH-City and County of San Francisco 



Ccvtificate of Bcatb 

. 11. '3. iritnnDavC> ) 



i) ^ 



No. 



PLACE OF DEATH = -County of ^C..^ ^ ' a.v^^ CUy of cV^.v J VO... c. 



) 



(\ 



FULL NAME U^ -^^ 



V\ 



A 



..tvV.Aj^," 



PERSONAL AND STATISTICAL PARTICULARS 



'^ 



^ 



I 



!> -v 



MEDICAL CERTIFICATE OF DEATH 

I) \ 11-. * 11 Dl. \ 1 II ^ _^ 






D.iv) (Vcarl 



\vii)i)\\i;i) OK invourrn 

i Wtitc in »'>«i-il il> viv.ii:iti"iii 






V^\ .'• 



I |I1-:ki:I>.V Ci:KTliV. That I ,,tt<M,.l.M .U-ooasea from 

tli.il I l:.-^t saw h ... alive on ' ' ' ^'P • 

,„„, ,,,,t .Uath orrurrc.l, nn llu' .late ^tal.d alnnv. at T 
''. M. Tlu- CAT SI' C)l" Dl'-ATil \va^ as follows: 



I'.iK riiri, \ : 

, <.,t I*' 'I ' '■ "<"'■ ^ 







N.\>n »•! 
»■ \'ihi:r 



'N 



viv 



vv<l' 'ocd 



m 




lUk I'll IM. \''l', 

<)»• I- A I'm: K 

i S(:,(i. 1 ,1 Ci unit 1 \ ' 



maii>i;n n\mi. 

<>r MOTIII'.K 



lUK I'lIl'l.Ai l", 
in- MnTHl'.K 
(suite or Ot)\inli yt 



1,1 RATION yt'(i[-^ 

CONTRHirTORV ' 



Month: 



Pays 



Hours 



nVu.t^..e..a.*ucL'. 



t 



N A ' f^ 



XtAXci M A^OXL 



(III ^T ^ V «g V AAJ"'^-'^^ 



M,:,:'Il' 



.„KXHovKSTATKn,.KKsovurun;|;^r,.AK.AKKrKrKT.> TMK 

ni-ST OK MY KNoWl.l-.Ix.h AM) lU.IJI.l 



DIRXTION )V'''-^- ^ Mout/is 

(SIGNED) VV . '^>: 



Pavs 



//ours 
M.D. 



(<)0 



f X.Mrc-ss) C^I i.At^l.»v,..^ - 



cprciAL INFORMATION only for Hospitals, Institutions, Transimts, 
or Ren'nt Rcsiilfnts, and persons dyin;) away from home. 



Aa^ 1 How lonq at 

Former or ocii,\J| 



Usual R^sidence^Sl^MlWu^vi- I Place of Death? 

When was disease rontractcd, 

If not at place of death ? ^____„ 



.. Days 



( Iiirui niMtit 







r ! 



D.Vri", '>! i'aui.M- (11 K1'-M<>\A1, 



ri ACK ()!• nruLM. <'1< KI-MoVAI, 



rv^ 



^— — ^— ^ ——^»'—'^-— —"''—*' PYACTI Y PHYSICIAISS should 

•tntc CAUSf. OH UK.* • n ■" !> -v.r-v instance. 



Btotc CAUSE Oh uc.»i.. ■" I-—" , . .: _ ,„ ,^„y instance 
.on. .lyinft »«ny «r»tn home «h..ul.l b, An.n 



r 



I; 



* 

4 



t 



I 



■1 



m 



1 



TA 



w 



RITE PLAINLY WITH UNFADING INK 



,,, ,-,,1 -}• v.. It ''^'^y^^us^vi^o 



^tPvMw Y> V 



ls^\j s 



JfWH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CER TIFICATE FOR {NSTRUCTION3 

rip<>isteie(i ^^o. 28G8 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( X\. S. 'I'tanDarC> ) 



% 



PLACE OF DEATH: — County of X>^. .'/vavvCvc " City of ^X w OA.C 



/V<\ ->, ^. '^ < ^^ r^ ^ 



No. 



St,; 5^ Dist.; bet. 1 b 1-' 



and 



,, I 



MC../1. RFmOENCEGlVt FACTS CALLED TOR UNDER -SPECAL INPORNIATION \ 
( ,r DEATH OCCURS AAAY FROM USUAL RESipENC^E-^GlV^E^^^..^^ NAME INSTEAD or STREET AND NUMBER. J 

\ IF DEATH OCCURRED IN A HOSPITAL 



) 



FULL NAME ^^^ 



PERSONAL AND STATISTICAL PARTICULARS 



vi i|,< >K 



:> \ ! 1 



\' 



\ ' . ! 



six. .1.1-: M \K k 11 .1' 

\\ I i»t iw 1 1 > « »K I > ' \i 'iv ' i';i> 



MEDICAL CERTIFICATE OF DEATH 

'J lev 

I lii;k I'-.l'.V C'l'.U ril N'. 'rii''t I iitlfinlv.l .U'casr.l fp.ni 

^ i \ t 



I()0 . 
(Year> 



I9O . ti) 

alivc' 1)11 



^ ': \ 



\\\\\ 



,. , ., 



•iiitii'ii) 



A 



Vi>, 



IMK TMI'I.AiM-: 

<^i . 1 . . ,t I ". 11 1 lit I \ 



i-ATu i:k 



niRTHlM.ArH 

(>»•• I aihi:k 

(Stall- or r<i;inti %■ 



M \ 11 )!•■%" N \M1 
I.I \1()III1-:K 



HiR'nn'i,Ai'i% 

()J- MOTIU'.R 
(Slatf or CovimUa 



^L^.^'iV vl:\tai 




c 



w^ 



tliMt I l;ist saw 1\ -■ 
,.,,1.1 thai -Iralli .uTUire.l. on Mu- .l.itr st;itr.l al.cVL-. at 
M. TIk' cat si- ()!■ I)i;.\'ril was as fDllow-^: 



I()0 
lt)0 



'i b 



DlKATlnN 



)'<jr 



Mouths S Pays 



Hon 



rs 



CoNTKim TORY oA^-.^^ (trllo 
,,,KATI(>N )V.//.s- .[fon/hs^ I nays 



iSlG 



^W \ rooV (A.Mu.^) in^ JH...... :< 



Hours 
M.D. 



OCCUPATION ^^^^^ .P,...le 



Kr^itlrd in S,:)/ I i ■•' 



I ' I ,•■(.' 



! ,-,-M 



1 yfnlltllS 



/).M' 



TMHA,...VKSTAT,Mn.K„.OVU PAKT,.M|K.K-AKK,K.K To .UK 
in;sT OF MY KNn\VIj:i)'.h AND nhl.U.l 



i;i)i.h AM) IS r. 1.1 I.I- ^ 

„M,..ss ^Mic J^ &'LA>-a/v^cL .1^ 



"special INFORMATION "nly l<»r Hospitals, insfitiitions, Transients, 
or Recent Residents, and persons dyin) away from home. 

How lonq at 

Plare of Deafli? ^ ■ Days 



,^U 



Former or Vy\ i i s ^ % ' 
Usual Residence n <-^^ V'CV^- 

When was disease contr.icfed, 
II not at place of death? 



{•i.ACi-. <»i- lUKi M, «>i< ki:m"V\i. 



DATI*..)! HrKi.M. < n Kl'.MnXAL 






'^ 



,> ' 









■^^„ 






z' 



5 



I 



■ti 



¥\ 



1^^— 1^— ^■^^^■— '^— — ""* '"^^'*™*** ^ ^ 1 FVArTl Y PHYSICIAINS should 

N. B._Bvery Ue™ o« in*,.. on -houl.l he c„.eSuny ,upj. ... A^K » ^^_^^_^.^,.^^_ ^^^ ..g^,^^,„, ,„,„,„„,•„.„.. ,„r p.r- 

* *. /-Aiisr nP nr^TH in pln5n terms, thnt it m.i> nt. p. » 
"r.'dt'n'i Jlwa, fro,. ho,n. ^houU. he *lv.n .n ever. In».nnc.. 



I 




\l ,«-tli - I- V' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



t'-'-rr*^; Uf^V Co 



/)<(/(■ AV//v/,M\dx^^Vvv1v4L\i 



V 



lUOH 



Picgisict'cd -jVO' 



t?R()9 



^ I 

\ ^ , Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTK-City and County of San Francisco 



Gcvtificatc of Bcatb 



PLACP. OF DEATH:— County of CJ Cr->v-CO"^ 



City of 






No. 



St.; 



Dist.; bet. 



and 



FULL NAME 



m U] 



c 



n \ r; 



PERSONAL AND STATISTICAL PARTICULARS 



1 1 



1 '. 



MEDICAL CERTIFICATE OF DEATH 

\ 1 I, < •! M. \ I II 



1^, 

i ^ C. V- 



il»;iv> 



(VtMl) 



\\ 1 i 1 1 • ■ 



.-I ., I . ... I , ,,1 .1 1 1 \ 



1 ! > 



:M1 



%:i 



I'.Ik I'll I'l. \ ! 
•■' I Allll-.K 

- ' i' . 1 ii r< Ml lit I s' 



■ I \ i ! >1 N N \ M 1- 
1)1 M'tillKK 



lUR'nU'l.M'l". 

(>i- Mftriii-.K 

iSl;it( ")i Ciinntvvi 









I lIi:!<i:r.V Cl.inil'V, Tliat I .itUn.lr.l .Ucrascl frniu 

tliat I Insl ^aw h -^ alive Oil ^'f' 

.1 that .Kalli nrruri-f.l, on llir ilalc staU-.l alw.ve, at 
M. 'Ihr CAISI' oi" l)l'.. \rn ^vi»s as follows: 

1,1 I> \'ri< >N )V^?/ s- Mi>n//is 



/>(n.v 



//out '< 



Dru.x'rinN 

f SIGNED ) 

..He. ', 






Months 



I >(? r.v 



) 



l(,o 



( 



^.,u...A.-vCv>-\daJU. VA.V 



i. 



IIoui'^ 
M.D. 



K . ri'ATIoN 

..1 I • ' - 



-M.'iith^ 



TnKXHoVKsTVTF,.rKRSONX,.PSKT>rri,NK-NK>-'HrK Tu T.lK 



HI SI* Ol. MV KN.»\Vlj:i)'.h AM) Ul-.Ml.l 



(lufu-manl 



f \.M'i -s •. 



^.R 



( 



"special information "nlv lor lloM.if.ils, Institulions, Transients, 
or Rerenf Residents, diid persons dylnj .mnv Iro.ii home. 

HoH ionq at 

f"'^"'f "■■., Place of Deatli? Hays 

L'sii,il Reside me 

Wlien was disease ronl rafted, 

It not at plare ol deatfi ? 



J. I \(V (»i.- HI RIAL «»« kj:m«»v m 
1 Ni)!: 



1 



|)\ri", '»! lirwi.Ai. fi! R I". M( )\'.\I, 



Pc 



TQO 



,Kr..M<K,< ll U) ^ K\<9^^^ <- >v 



1> 



,,.,„„..,. jic^ 0' ^U^^ii a.t 



—^^^i^mmim^^m^^mim^ rv*r"ri V PHYSICIANS shoiild 

— iwi>^ -i» »ii. \rr a'vvilil be sttiteit FiX ACT I. T. fnioiwi* 

!!r;..':>!i L"r tin, h„,„« .h„ulcl h= eiv.„ m ever, ln».ancc. 



Ron« dylnjl owny ?rom 



H. 



I 



■II 



'4. 

'I ^4 



I 



r 



« 



I 



( 



i, ! 
1 



{ 



(. 



w 



RITE PLAINLY WITH UNFADING INK 






l),lfi' /■V/r^/. ^1 LcrvM_/\^^ 




.tx\' 5 



I!) OH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFI CATE FOR INSTRUCTIONS 



^v.vvo 



U^M. Deputy Health OfT.rer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Ccvtiticatc ot IDcatb 

PLACE OF DEATH = -Coun,y of^,a>v -1 ^va.vo^^. City of ^- - -^ ^ - - ^^^ ^ 



I L '\ 






) 



I 



FULL NAME 



.^<"* 



PERSONAL AND STATISTICAL PARTICULARS 



,%' 



\' 1 



-^ISt.l.l" M \K K 111' 



MEDICAL CERTIFICATE OF DEATH 

1> ATI. < '1" Dl'.AI 11 



u.. 



I I):i\-> 



(Vc.'irl 



\\i ilc i 



-it^nalixiil 



I P '^ V ^ ^ V '^^ 



J ,,|. ,.,.•,. ^- ^ i Kill \, r'ltt I atlcu>k-<l <kH-c-;iso(l fnun 

^,,,.1 ,h;,t .Uath oc.uinMl, ...1 Ihr .l;iU' sl;,!.-.l aLoVf, a1 
M. The CAl SI". OI" Dl'.ATII wa^^ a^ follows: 






\v. vC.^^^''•• 



-<A.l.^^. 



ft 




I' ATI! IK 



r.iK iHiM. \>i". 
01 1 xini'.K 

(St:ttr III rmilltl \ ' 



M \ 1 1 ' 1 N N \ M 1 . 
(il MMllll K 



iMR rin't.A*'!". 

I H- MMrill'",K 



a 










\< 



] 



~1 



k 



rs 



DTK XTinN )>.?; v 

CoNTRir.l roRV 



1)1 KATK'N' ^^''"'' 

(SIGNED ^ ^ ^A,(X 



Mouths 



/)<?). s- 



Hours 



Month 



s "y^ Pays 



/fours 
M.D. 



KjO 



(A.Mrc^^) v' vA.' 



.A .^ \ 



TAIION 

h',-'i,t>;! II' ^•ni ri <>ii, I '•> 



'\ 



) . ,11 



!•■'// 



n,i 



m-.STOl' MV KN<»\VI,I,lK.h \\!» M.-.Ul.t 



( Inf.i; ni.itil 



( \,l,li. -• 






"special INFORIVIATION "niv lor Hospitdis. Instihitions, Trdnsients. 
or Rp.rnt RpsiJrnts. and persons dvhm .r>v,i> Iron home. 



I (irmpr or 
Us11.1l Rpsidenre 



/ !^ 






\v 



^ ^ 



l!ow Innq .it ^ 

Pl.ircol Dp.ith? ^^ Days 



When was dise.isc(ontrHrted. , ^ i ^ ; ^ f> ?,^a.clv v^i., 
If not at plarp of deatti I ' ' ^ ___' 



DA'I'I.; ,,!' I!i Ni.Ai. or K1:M<»VAI, 






TOO 



C^ 



'Ailtlii-^^ 



-^— — ■ I ■ *""" "" i-vA.-Tl V PHYSICIANS Hhotild 

■■■-.I ii-i.» I ,. , *,>|: H'louhl be stnted f.XAUTLY. 1 iiioiwi » 

^. „._H.erv ...... ,.« •,„«,..,n...!o„ .h.„l.. ..- ..-*M^. --M. - • j^' |;. ^ ^„.,,..,,,.,. T„c ••«...>»< .nfor.n >- p.r- 

. . r\ii»il- OP I)r ATII n plum Urni'*. th.it it •"••> ' » 
state OAIIM. »M "'•'* ' • • 1 1. . rtivfii in every instance. 

«on, .lylnjl awny from home shoul.l be ft.xen m e^ery 



V 

■ 



\ 



1 < 



-■ < & 



ii'. I 



1 



1; 



' !< • 



I t 



I* 



WRITE PLAINLY WITH UNFADING INK 



IfJOH 



THIS IS A PERMANENT RECORD 

REFER TO SACK OF CERTIFICATE FOR INSTRUCTIONS 



S87J_ 



J -^ ,^ f * J-v /~\^*1 



l^^..^ Den • 

DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco 



Ccitificatc of IDcatb 

PLACE OF DEATH = -Coun,y ofOa^v 3 ^<v>vcv..c. Gty of^Vo >v Jxa w -.■ c . 



Nr). ..^Ut "^"^ 



an< 



■ " St/ Dist.; bet. . . 



FULL NAME 



1 1 Lavo,o-V^,l 



iV \A'' -" 



PERSONAL AND STATISTICAL PARTICULARS 



"S 



111.' 



ill 



IViEDICAL CERTIFICATE OF DEATH 

I, A I'l-: <'i- i»i.A 111 



MontlO 



DaV^ 



(Year) 



III-.K i:i;\- n:K'i-|l'V. That l alU-mlrM di-rrascd fn.m 

to i ' 190 '' 



Wl Ii< >\v i: !• • »K 
W • !• • a •social <it— ir 



IMK 111 ri \'' 1 



NA M 1 ' 'I 
!• ATI! IK 



I'.IK I Ml 

Ml 1 AriiJK 

I stall- III Coiintt V 



MAI Di: \ ^ \ ^i I , 
<»!■ MfiTlil-K ' 



lUKiiiiM, \> r: 

<»1- M()THI-.K 




,^ 



■> ' 



1 1/ ) 

that I 1 t^t saw li iilivr '>n 

,.,,,,1 that -Irath McriirrcMl. .ai Hu- <latc stalcl al.-.vc-. at 
UU M. Thi- C.U'^l' *^'" '^'''•'^''"" ^^■■'" ='^ follows: 



190 ■ 

13.0 



^ 



> ' 




m'i 



K 



k/lA\(X- ^ 



a 




'VCL'^iv >■ '\ 



( K I ri'ATlON 



n 




^A. 



CX^v 



d 



o, 






\!,.iifli< 



/)<!V^ 



lli:ST Oh NIV l<NO\Vl,i;i».l-. AM) lUvl.M.I 

„„,„„,„„ (j.ulto.Llcu 



, s„„„.-s UtuV Ca %^^kda.l 




DiKATlON 



) Vi/r< 



Moitlhs 






* '^ 



/)</r.v f/oiits 






.]/,■<!! lis 



'X J^ 



/>(n\ /fours 

SIGNED) ■. JV ''■^■O^l .^^ M.D. 

SPECIAL INFORMATION «"!> for WiiMiitals, hstilulion^, Transii-nh, 



SPECIAL I iNr wnivi>^ « iv-"-* / . 

or Rerent Residrnts, and persons dyini aw,iy from home 






Former or 
Usual Residence 

When was disea-ve cnnlrarted, 
II not at place of death ? 



How lonq at ^ ^ 

Plare of Death? "^ i Days 



I-I \ri: OI- lUKIM, OK Kl'-.MuVXl. 



DA'll". "I Hi lOAi. cr K 1\ M< )\AI. 

Ci\CPu^ b T90S 






1 






V I 



_____A -_— — ^— ^1— — — ^— ^^— ''*^^™'*'"*' , r-vACTLY PHYSICIANS sh«»iil<l 

utaU- CAllbfc "1- ur.«iii ' ^Jven in every in»t»nce. 

.-n. dylnt nwoy from home shoul.l he fe.ven in every 



I 



I 



. , 



r» : 



» 






Ft * 
liill:! 



it,j 



f 






I'.. .Ml 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2H72 



.,,,ni.:,ith rv'. 1' ^tH?^^-»»^''^''^ 




wo\ 



Registered JS'^o, 



Ddh' riled, M Lrv^Ay>-wl^\' ? 

\,^\ju,^:\^^. Deputy Health cricer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)catb 



1 H. 5. Stan^arD ) 



QS^ 



No. 



PLACE OF DEATH:-County of^^v i rvC^>xC^c.Gty ofO.CUTv .J^v^.v^u^a<. 

"" '^al St; Dist.;bct. ———and 



n 



^ i. 



^^^■^^^^^^ '^' ^^^^ ".,e.,., orctinPNCE GIVE FACTS CALLED FOR UNDER 



ER "special INFORMATION" \ 



FULL NAME ^'^v xv 



,thNl/V VV. K>OUwA.^O... 



STREET AND NUMBER. 



...:^ ^> 



PERSONAL AND STATISTICAL PARTICULARS 



l>^aU 



1 1 \ii- t >! r.iK 111 



\< .J-; 



M.pinlr 



aio 



),.!> 



Day 



1/ ■,,:h^ 



>\ a! • 



/).M 



M 



EDICAL CERTIFICATE OF DEATH 



DATK nl- I) i:\TM 



\ 



'^L 



.(r\r 



I Day) (Year) 



I m<:Ri:r.V C'1:RTII<V, That I .ittondc.l deceased from 



. \ 



1 90 



to .. .M\<r>jr-. 3.. 



OXtx^ 



190 



M 



'5 



Wi itf ill ^' 'lial tltvi^MKitioii) 



HIH rill'I, An- 

I Sta!<' 'ii ("Dnnt I \ 



NAM I", ttl 

FAT II i;h 



I 



i 



X 



L->^^q. 



/■ 



that I last saw h i- alive on MA^v o T90 

and that (Uath (Hunirred, on the date statc-d above, at C 
M The CAI'SP: K)V DIvATIl was as follows: 



CONTRllU-TOKV^^fc^^^^^-^^^^^ LLc-^dx 



^3 



i ' 



i 



'■ ) 



iMK'nnM.ACH 

or lAIHKK 

(Statf or Coimtrv 



MAIIH.N NAMK 
«il MOlin-.K 



lUR'lHlM.AtK 
ol- MOTHKK 
(Statf or Country^ 



occii'A rioN ^Jr 



-^' 



"i' 



/O 'v -^' 



."> K I 



R^siifrJ in San /■ 1,111, /'■r,> 



] 'I'li I 



Mniitln 



Day. 



IJKST Ol- MY KNOWl.l-IX.h AND lU-.MlH 



(I1 






)Vr7r5 Af out lis Pays 



Hours 




DrRATION 

(SIGNED )...&). 

I Ltar/6. iqo . 

SPECIAL IN FORM AT ION only lor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying a>vay from home. 






rv.i.ir.ss) :■ C^- -. .u.^rv\t :. 



Former or \ \ 
Usual ResidenceU^ 

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



l/UrVXATLLLl 



Days 



I'l.ACK OK lU'KIAI, OK RKMoVAI. 



,.„. ^m mojsxjSX 



DA'rj'of Hi KIAI. or KKMOVAl, 

\i\j^xr ^ T90 '. 



1 ; 



\A, 



It 



__^^^__^_^_^^_^__ ^■— — — — ■■■■■■■■■■■■^■"■"'^■■""''"""^ ttl EX4CTLY PHYSICIANS should 

N. B.-Bve.. U.™ „/,„.o..».lon .hou... he c.r.fu... -upp.>.d. ;«^^„';J'>r..',:a! 'Vhc" Special .„.on„...ion" »or p.r- 
-. ^ r>Aii«i= OP DFATH In pinin terms. tn»i 11 miij ^'^ »* 
:"rH":t'aw^' .r^ h1. :Hou.d be .lv.n in .v.r, in...ncc. 



■1 



jj 



w 



RITE PLAINLY WITH UNFADING INK 



•■ n ,'t!i 1 '^■' 



^-^^rarTISi-, nfc)' v'o 



l)ff/(' Fi/c^L Tccv^^'>vL^v 



lOO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

!8?a 



liaiislci'ed J\^o. 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc of IDcatb 

f 11. 'Ik 5tanc>arC» ) 



k)0 



_P 



PLACE OF DEATH: — County of J'Cc^ 



■'!• 



No. 



^V-^LUi^^ 



St.; 



V<X \ V City of 
— Dist.;bet. 



^ 






V (X^x c '..>:i. c ■ 



and 



■OR UNDER "special INFORMATION" \ 
NSTEAO OF STREET AND NUMBER. J 



FULL NAME 



v^ V. I ^V.'-.. V 



> 



->i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



li 



» \ II- t >l l:IU I II 



A t . 1-: 



dxvvi 



1 ' ,ii 



! ■ .; 



MEDICAL CERTIFICATE OF DEATH 

i)\ Tj-; oi' i));.\i II 



'.) ». c ■. 

(MutitlO 



1 

-i, - 

(Day) 



(Yi-ar^ 



>-I\i.l.l" MAKKIJ l> 

\\ii»t >u i: i» « >K i);\« tivi ) i» 

Wiiti in menial di^ij-'nat i"n ) 



\ 



HiK run. \«M" 



I A rill. K 



HIK rnri.Afi". 
of I- A rm:K 

' stall or c'ouiiii y 



M \1 KIN N WW. 

Ml Ml rnn;u 



nik riiri, \ri'. 
«)»• Mii'iJU.K 

(Stall- or Cuuiiti N 1 



:\ 



QT^ 



C'/Ol>v xc\ 



-^ 



> V, 






I lIl'Ul'inN' CI'.KTll'V, That I altctukMl .Icix-ascd from 

\JcAj ^ 190'; to M.U\:: '^ I90H 

tl,allla>l.awh V alive- on ^Wr 1 I90 'i 

an.l that .K-ath .xHurrcl, on the- .late- stated ahovc, at 
LV M. Thf CATS!'; Ol" DI'lATIl was as follows: 

Vl iVo^v/CL^. ^'> vv^.•.■ 



I)^•RA•n(>^■ >'''^'-^" ^ Monlhs Piiys 

CONTkll'.lToRV 



Hours 



DIRATION 
SIGNED ) 



)'i'iU'S 



Mi)>il/is 



/hns 




Hours 



M.D. 



vj" 



i)t.cri'A rioN 



),.n 



M..,ith' 



IU!\ 



TMKAU,,VKSTVT,.:,.rHKs,,NX, ru<nrr. VKS nki:tk. k t- rm: 
iii'sr 111- >.o Ksoui i;i)i.i-. AMI 111.1. 11. 1 



I I nfo' iiiaiil 



N,l.lH-.. ^'>O0 



'^Ji 



YYV-Cr\X 



l.C 



1 V. 



S „ 



)0 



,A.Mr.ss) a5oc idi.>^v^v.'^t 



SPECIAL INFORMATION only (or Hospitals, Institutions, Transients, 
or Recent Residents, dnd persons dyin(| dWHv from fiome. 

How long dt 

''^'"""^.. ,, Pldreot Oedtli? Days 

UsudI Residence 

When was disease contracted. 

It not at place of deatli ? ^^^ _ 



n \cH c)i- I'-ruiAi. OK ki-:movai. 



uAji-; '>! Hi KiAi. "I ki-;mo\ai. 



OU<XtX..> ' 



■■««■»■*■— i^^B—^""^^^^"'"^^"^""""^^"^^^^"^^""'""^"^'"'"^^^^^^^^ I FVACTl Y PHYSICIANS Hhoiild 

N. ,..— livery i.o™ .„• .„«,.rm,..ion .h„uM he cnr.VuHy «up,.n.... *^»; "^X.^i.^: 'yt.^ 'n^.^i^l l,.«„r„.„.i..n" ..r p.r- 
* * r-Aiier nP nFATH in p »in terms, tnnt it ni.i> "<- !»■ 1 
""*;."„« nw^, fr" hlo -H„„M H. »<ve„ i , •."-"«• 



f 



n 






I 






■'i 



i 



' »!f 1 



f 



H 



I! 



^ 



i. 



ii 



1 


t 


^•i' 


!■ 




\ 




f 



I 



u 



i^ 






w 



RITE PLAINLY WITH UNFADING INK 



ll.,,!th I- V-' i' -^'l, ^j^-^-i'.S.]' C>> 



/)(f/i' Ffli'il , 



\ 



^'-v. > ^ ^~ *^^ 



y.96^M 



THIS IS A PERMANENT RECORD 

REFE R TO BACK QF CERTIFICATE FOR INSTRUCTIONS 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of £)catb 



PLACE OF DEATH: — County of 



•~),<xn\> J A.a. > vr .A City of ^'<X-"i^ J .»v<x/> vcv-i r ^ 



.\ 



No. 



-PC 



y-N r 



Dist.; bet. 



and 



^^^li.e\,^ai' UsiDENCE G.VE ^0X5**0111^0 rOR UNDER 'SPECAL . N FO R M AT. O N ' ^ 

.WAV FHOM>JSUAL RESIDENCt GIVE FA^^^s ^^^^ instead or street and number. J 



( '^ :7o;:t^^occ:r^v,n A H;v;:v:ro;rNST.TUT.oN cve -ts name ., 



FULL NAME 




c 




OJ 




X 



c^. 



■^l.\ 



PERSONAL AND STATISTICAL PARTICULARS 



vO ' 



U. 



\ 1 1 1 1 1 1 , 1 i< r 1 1 



\; 



\i . I 



!0 
I'..-, 



:> /''M 



SIN. .1.1' MAKMl.I* 

WIIK iWI-'.H < "K IUVtt!- 1 P 



' St:it '■ <it t "• 111 nt ! V 



\ wn- « •! 
I A I II j:k 



lUK 1 II II, \' 1-: 

()( lAllUK 

i siiit lit iniint I V 



N! \11>I \ V \Mi: 
<i| M<»l'in,K 



I'.ik riiri.vrj", 

• I I- MnTMI'.K 
fSt.'itt nr tOllIlt 1 \ 



on 



MEDICAL CERTIFICATE OF DEATH 

DA 11-. oi Dl'.ATJI r\ 



'Month) 



(l):i\0 (Vt-ar) 



- z.\ 



n 



^ > .. •- k^Cl 



1 lll.Ul'P.V CI-.KTll'V, That 1 alien. k-d (k-icascd from 

til at I last <a\v ll '■ alive- ..n ^ ■ ^•- - ' ^'P 

and that (Kath ..rcurrcl, <.it llu' -laU- ^tak-.l above, at b 
OL M. TIk- CArSli <)!• I>i:.\ I'll was as follows: 



DIU \ rioN 
roN'n^ir.r'foKV 



)'<ars 



.]/,>>t//is 1^ /^ays //onrs 



DT RAT ION 
( SIGNED ) 

.1 Lc'v v' M)o 



) V</r.v 



J/()f////S 



r\ 



I 






//ours 



( 



\.Mn-ss) ^^C 



Ol\.M A<£^^ '■ "^ • ^ • 

J J(iyrvA.(rM at 



< H riTA rioN 



).,n 



lA/(////- 



/'^/ 1 



■MKxm.VKSrATKnPKK^.NUrjKT,.,MA,<..KKTl<.l^ T. . TMK 



' I'lfiii m.uit 



\,l,lu v,^ <^0 



SPECIAL INFORMATION only lor Hospitals, institutions, Transients, 
or Recent Residents, and persons dyinq dway from fiome. 

How lonq at 
Usual Residence 

Wlien was disease contracted, 

If not at place of deatli ? ^ 



1? ^ 



i>\:ri-:<)r h. uiai. or kkmowm, 



S' 



i W; 






TQO i 






Htatecl I.X4CrLY. PHYSICIANS Hhould 



state CAUSE OF DEATH in pl"«n tcrm«, thnt it may [>« « » 



«on« dylnft oway 



from home Hhoul.l he ftiven in every instnnce. 



u '. 



I I 



! 



1 i 



t^ 



U 



h 



I- 



i 



n 

1 






l.l 



\% 



ll 



WRITE PLAINLY WITH UNFADING INK 



H..;ir«l of M 



i-alth »• No i'^ -"-r "«J^-^ i'^^ 



!• C 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffr I'ilol . M^ta^^^vl^'^'^- 



li)0'[ 



I^e^isfcred J^'^o, 






{ 



1. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County of -'a>\ 



Ccvtiticatc of £)cath 

( "a. 5. 5tan^ar^ i 



A ^ 



vccv City of 'J ^'^^' -' -^ <^^ ^^ ^^ ^ ^ 



No. 



H.t 



(ir DEATH OCCURS »W«* I 
ir DEATH OCCUBR t H 



St.: ^ Dist.;bet. ^ .^.^'.v and 

USUAL RESIDENCE O.VF tacts called roR UNDER SPECIAL . N TO R M AT 1 O N • \ 
OSP T.L OR NSTITUT.ON G-VE ITS NAME INSTEAD OF STREET AND NUN.BER. J 



4- 



FULL NAME 



\!} £t>>V-r^^XX<l-C.iV^^XLa. 



!■ 



sf 



1 \ 



i» \ n 



PERSONAL AND STATISTICAL PARTICULARS 



M ll 



n 



: II 



M. 



\< .i: 



n!\. .1.1. \t \Ki< n-.i» 

I Wi ill- ill >■->,■!;(' ' •■•••»! • -'^ 



HIK rillM, \C\ 
st.itc or Cmitilr v 



Jy 



\ \M 1- « tl 
!• ATM IK 



FUKIIIJ'l.XCK 

(>|- 1 \rm-K 

(Stati ■>^ ( i.initi \ 



Ml Mitriii: i< 



lUKrnpi.Aci-: 

(II- Molin'.H 



1 1> > ir A rin\ 

fy'f-i.frif III Sun I'l iiiiiisri) 



/ 




V 



J 'fa I 



}f,>}iths 



/hns 



TMK ^^.,vKs|•^TKn^KKs.>NA^^ART[c^^AKSAKKrRUK to tiik 
HKST (»!• Mv j;;n()\vij:i)<*.k and HhMh^ 



(Infoini.mt 




f \<l(lrcH» 



MEDICAL CERTIFICATE OF DEATH 






ly.Kv) 



IQO \ 
(Year) 



I 11 !;R I. I'A CtlvTH-N', That I altcMukil .K inasi-d from 

- T90 tt^ ■ "^»)0 

that I Ia<t <a\v h alive on — ^ ftp 

Mini llial (Ualh (.iciirrt-.l, on the daU' stated al.ovo, at 
M. Tin- C\rSI'. Ol' Dl'.A ril was as follows: 






l»l RATION J''"'?'-^ 

C()^TKIl'.^T<>K^■ 



Mouths 



Days 



Hours 



DT RATION 



)\'ar<, 



Mouths 



IhJYS 



P ^rD^.> -v ) 



(SIGNED) Wv-cn^^JiA' 



'^Io.IlL^ ^-l 



Hours 
M.D. 



VlUv" 



A KlO '. ( 



^ 






SPECIAL INFORMATION ""'^ ^''f Hftspitals, InstitbtfOns, Transients, 
or Recfnt Residents, and persons dying away from home. 



Former or 
Usual Residence 

When was disease rontrar fed, 
If not at place of death ? 



How long at 
Place of Death ? 



Days 



n.iTi:<if Hi KiAi. or KKMoVAl, 



PLACE OK nURIAI, OK KKMOX AI 

(Aa.hc.,s?)Lo-r:)?' iq,U. d.£ 



190 \ 



,, , ^F .Hould bo stated F.XACTLY. PHYSICIANS .hould 
of Information .hould he carefully auppMed J^G^^^J^.^^,,,.,. The "Specl-I information" for per- 
E OF DEATH In plain terms, that It may ne prw^w 9 



vEB^iz .-"11. .ho„.,. b. »>v.n , .«..."«. 



I ^ i 



H 



I ilj 



Kl 



•■ 3 



V 

i 



I 






I ! 



< 



I 



li 



t 



WRITE PLAINLY WITH UNFADING INK 



I i 



M..:.r.l ..f lI.MMh I- No ! '- •*-^'«'?>^ I'^*^!' ^" 



/.v/^y^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i ^ Deputy Health Officer 

DEPARTMENT OE PUBLIC HEALTH-City and County of San Francisco 

Certificate of Beatb 

, 11. 5. 55tanDar^ ) 
of O.a.^A.0x<x.-vxccCi,cc. City of U co>v O.V<x.>v.- . 



PLACE OF DEATH: — County 



Vw 



^ 



No. 



St; 



Dist.; bet. 



( 



rVx^LV^.V > ...\.^ ..^..-I'DrcinrNCr GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \ 



«L RESIDENCE GIVE facts calle 

»i na institution GIVE ITS NAM 

FULL NAME /V^J^^. ^'>^cl'Vu OCclVul^ 



— and 



<^i 



PERSONAL AND STATISTICAL PARTICULARS 

D \ i J t •! r. IK III 



/ ; 



\! 



\« .1-: 



I • \ 



M.,iilli 



^iN< i.i: M AKK I i:i» 

W IIH )\\ l-n OK I»!\< »!•■> 1 I> 
I Writ' m '."1 i; il.>.;).'n:in'>nl 



I'.iK rniM.AOK 

st:iJ« I a " 'iiililt I V ' 



.^: 



\ \\t I I >i 

I \lll l.K 



HiK ill 11. \i »■: 

Ol- I Allll'K 
<Sl;it< or Country 



M \iIH-:N N \M1, 
Ol MoTlll-.K 



inu'iiij'i.Ai'i-: 

ni Mdini'.K 
(Slate or Count t> > 




CL'OL^^ 



^ 



V 



•nJ 






h'fsiifrJ ill Sav I'l aiii i"''> 






Mouth' ^ /'-' 



TnKA...vKSTATK.>.-KKsnsA. rxKT.rr..xKSAKKTKrr: TO Tin.; 

1»HST Ol MV KN«)\Vl.i;i)<.h AM) HI. I. II. 1 



V-VXXX^^^J 



(Info:m.nt O . ^ ^TK^' 



MEDICAL CERTIFICATE OF DEATH 

DAii", or in; A 11 1 > 

\l Lev H.. IQO'- 

(Mnnth^ (Day) (Vrar) 

I III':KI;1'.V CIvKTM-V. Tliat 1 ;iltcii.K-<l (looL-ascd fmin 

190 to 190 "" 

tlial I iM-t s;i\v h alive oil "— ^'P 

and that .U-atli ..rcmrf.l, oil the- «latr stated alxivc, at 
M. TIk- C.\rSI<: Ol' 1)I:ATI1 was as follows: 

Ox, ^f^..,-. 



DlR.X'noN >V(7;-.? 

CoNTKir.r'i'ORV 



Months 



Days Hours 



DTR-XTION 
(SIGNED 



)'i'ijrs Months Pciys 



n>o 



( 






I louts 
M.D. 



SPECIAL INFORMATION «nly lor liospltdls, InstituttoU^i, Transients, 
or Recent Residents, and persons dyinij .iH,iy from Imme. 



X . How long at 



... Days 



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



PI.AC1-. OV lUKIAI. OK R1-:Mo\ \l. 



6 oJji >>■> 



DATl'". o! lUKiAi. or KIvMoXAI, 



190 \ 



I .Nni-;K TAKl'.K 

(Adilrcss 






IN. B.- 



— i— i"— ""■■"""■"^■■■^■■^'"'"^^'""'^'"'^""'^'^^'"'"'"^"^"""^^^ Ik t t I FXACTLY PHYSICIANS should 

■Kv.., ...m o» .nf.r,n».!on .houl.l he c».«<ull, ""Pn""^- .^rplrC'l^-.W'"''" Tl.: '•Spcclai l„f„r,..a.l..n" for p.- 
* * r'AiniF OF DFATH In plnin terms, thnt it mji> ne pr i 

:r„rH^Z ow^, »"" hL. :ho„,., ^. »w.„ » , .«..."«• 



■ 1 < 



tf 



I 



1 1 1 



■ 



»• 



I 



% 



[ 

If 



If 
I 



WRITE PLAINLY WITH UNFADING INK — 



M.,...i,.f H. /tl, IV,, ;. ^.t^:^>i:.|'..'vl•Co 



li)0^ 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

lie i: isle red ^'o, ^o^T 



l^v^^^iaovM D^p^^> '■^"'^' ^^^^'' 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc of Bcatb 



rl 



'? 



PLACE OF DEATH: — County of J/CU^-v a.>vcui.e(<^ity oi 



No. ^ 



XvtXv 



&6--. 



St.; 



Dist.; bet. 



— and 



— ) 



RESIDENCE GIVE FACTS called f 



( ■■ r,'r.:,°'occ^%r.'o\"°" "s'r.to»r.I,-,Vu-TTo-. c,ve ,ts name , 



rOR UNDER "special INFORMATION" \ 
NSTEAD OF STREET AND NUMBER / 







V)\y 



FULL NAME 



1 ^..^., 



-^! \ 



n 



PERSONAL AND STATISTICAL PARTICULARS 

rill. I 'K n 



JiVclo: 



, 1 1 ; r 1 1 



; I ■ \ 



\< . 1. 



>.I\(.l,l" M\KI<1I-.1> 

\\ I l)t )\\ i: I) OK I»I\ < »i- • ! 1 ' 



ttIK iiiri. \r l- 

■ st:if 1 "'. ' ' unt i \' 



V- ^ ^- 



MEDICAL CERTIFICATE OF DEATH 



rgn 



J CO L- 

I 11I;R i:i'.V CI'.RTM'V, That 1 attcn.U'tl <Unx-asc(l fi.uii 

— — icp — — 



— !(/) In 

tliat I last s;,\v h alive- nti 



-190 



L->vo'v- ^ 



\ \Nt I nl 
I \ I H J.K 



lUK 111 I'l. \» )•: 
<)»•■ I A rm- K 

' Stutt <iv v"i Hint 1 V 



MAil>l,N NAMl'. 
<)1- MOTin-.K 



lUK rm'KAii-: 
()i Moriii-.K 

(Stal( or cOiniti % 



f- 

-^ 



\ 



''y 



X 



)i\ri'ATION '(V 









)■,-,;/ 



M.niHi^ 



Pin. 



m>T i)l- MY KN<)\VI,i:i)<-.h AM) IM.MU 



(I iifi'i tniiut 






aii.l that (kath occurred, <>n the .late stated ahnve. at" 
M. The CAVSh: ()!• PI'iATII was as follows 



I)Ii;\TI()N )'t'ius 

CONTRir.rTORV 



Months 



Pays 



DIRATION 



) V(//'.v 



Months Pay 

( SIGNED )L^3Vrv^JiA' J-^-U^ 

M\<J^r .ooH (Address^ L(fv<nvm 



7 A / ''" 



aA 



Hours 

/lours 
M.D. 



\..C,'. 



i()n 



SPECIAL INFORMATION onl> for Hospitals. InstituliW?, Transients, 
or Recent Residents, and persons dying away from fiome. 



lOn no^ 'onq at 



Isual Residence 

Wlien was disease contracted, 

If not at place of death ? 



Days 



Address Sbl^a- l^A Uv Ot 



i)A'n;of m KiAi- or kkmoval 



CV \Aj 



( Adtlress 



N. ».- 



I— ^— ^i— ^M— ^■^■^^"'^^^■"'^^"'^^^^^"""""""'"""^^^^^^ h t I EXACTLY PHYSICIANS should 

-Every -.ten, of ,„.>rn,«tion should he cnrefuH. supplied ^^^^^^^l ^^he •'Special lnfon„,atio„" for p.r- 

state CAUSE OF DEATH in pin.n ;;7^:;J;" „'*J/,* \L\nZ., 

sons dyln4 away from homo Hhm.Id he li.ven .n every 



•I i 



^ . ■ 



. J 



\ I 



I, 



< I 



. if 



1 '. 



• I 



^\ 



"•I 



i 



m, 



\. 



I 



WRITE PLAINLY WITH UNFADING INK — 



J,,.-..,' ..f If. ilt1i 1 



f..r, -arl^j; ];S^\' I'o 



p(f/r Fih'tl , nXcx*^ ^^vb^V 



7.9 /9H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

lleiisfeved jYo, '-'L>/0 






A. 



•^^n ^ iT- 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County pf ^ 



Ccvtificate of Beatb 

t U. 5. i5tan^ar^ ) 



No. 



. , ' Xa/-> vcv: City of O Oj'y\) J Xcx. vv ceo. r c 

Sf Dist.;b€tA^^'-^^^'" and M I lo^- • 

,.e,.»l Rr«?iDENCE GIVE FACTS*CALLEO FOR UNDER •special INFORMATION' \ 

( '^ r/rr:T°H^^oc:u%rV.rrHo's'pa*t o^'?:s.'.Tu'T^o^"o.vE .s name insteao of street ano number. ; 



) 



FULL NAME 



I v. 






PERSONAL AND STATISTICAL PARTICULARS 



s| \ 



c<>i.<>k ' 



J. 



\\ 



i)\ri; ••! lUK 1 ii 



I 



M..iith 



\« .»■ 



5 ,-,; 



P.iv 



M.,)tl/is 



\ Sfai ) 



/'.; 



<.iN"<". 1,1' M \KK n:i>. 

iWiitfiu •^<Hi:il -1. xiv'niitioti I 



p 



1 



MEDICAL CERTIFICATE OF DEATH 



DATH OF nK ATM 



(Momh) 



(Day) 



(Year) 



I lll'RI-r.V CI'RTH-V, That I atteiuled .kHoasod from 

llt^ . 190'^ t., ...ArUrv:....H 



lUR 111 ri.AOi: 

'St;iti "T •'■lunli \ 



1 



CjA.'^^Oy^ 



NAMl- 01 
J- A iHl.K 



BIK 111 ri. \rK 
or- i-aiim:k 

' si:ni' or r>)uiiti \ ' 









nyyjc^' 



\ 



'.,L: 



n V - ' 



MAIDI-.N NAMl. ,'-\ 






itiu riii'i.Aii", 

«)!• MoTIIHK 
(Statf or Country I 



OiClTATION 



Up 1 
that 1 last saw h ^.^v alive on M A,^- S up' 

and that death occurre<l, on the date stated above, at 
U M. The CArSr: 01* DliATIl was as follows: 



r V) 



DiR.x'rinN 



I,rR\nn> VfiUS Mouths ^ Pavs 'i Hour, 
CONTRIIU'TORV ^A..A^^.^OvsXx:^^J U\.v > v^^vq^v^ 



DIRATION „^ Ycors \ Mouths Pays 

( SIGNED ) 1^ . ^..^ a.-CAX|j^lu^k^.' M-D. 

^j\..rv 4 TOO'. (.AddressHLiO OUck.t.>v 61 




u 



X<x.L^i 



h'r^iiird >>i S,;n /'i,i>h /w.. 



)•,-,// 



•- yfiiiitin 



/\ns 



nn- AHOVK STATKP ''HH-'NA'. l^AKTIO r;. XKS AKK TKlK .0 TMK 
HKST Ol- MV-^NOWl.l-.lX'.K AM) in-.l.H.l 



j 

1 



(\fl(lres« 



l\b 



.-(rw 



yY\JJ 



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



Former or 
Usual Residence 

When K3S disease contracted, 
If not at place of death ? 



How long at 
Place of Death ? 



. Days 



I'l.ACH Ol- m-KIAI. OR RKMOVAl. 









I).\TK<)f lUKi.^i. or RHMOVAI, 



190 



_^^__^__— — ^— — — *V"^—— — '^T"™ t t I FXACTLY PHYSICIANS should 

N. B.-F.vcry U.™ o. 1„.„r™..ion .hou... he c,r««uU, ...ppMed A«^^ •^;;;.„,'„:,: 'k; •Sp-ci .„»or™,..on" So, p.r- 

* * Vaiirf of death n plBin terms, that it may "c i» 
state CAU»t ut- uci« ■ ■• • *" a :^.- « Jn avery instance. 

«on. dylnft away from home should be ft.ven .n .very 



h * 



I 









S I ' 

1 
1 



I, 



j« 



..: 



i' 



hi 



i< 



[ 



u 



I 



./."■ 

R i 



I 



. 



WRITE PLAINLY WITH UNFADING INK 












/.v/^;^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 

llci^istcred v\^o. -o / .) 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of IDcatb 

, tl. 5. 5tanC>arC> j 



PLACE OF DEATH: — County of O/CV>A;0 \o.^vCl4.C(., City of ^ O..^ 



\.(X^'^Q.^<^.<>.t 



No. 



V. V. 



St.: ^ Dist.;bet. v. v.- and ^ -^- 



V 



) 



*.M 



FULL NAME 



'. :; lIm^v "^ U^ 



'? 



O'^ 



vX^. •' 



-1 \ 



1» \ 1 1. ' '! 



PERSONAL AND STATISTICAL PARTICULARS 



) 



; li 



li 



H 



\' . i: 



--IN' .1.1-: M \K i< n.i» 

\\ 1 iM »\N i: i» < »K i>i\< »!•'> ' i> 

\\ . -iKi.il ill sij.-ii;il;.>ii) 



I'.IK I'lU'I, \>'l-. 



N \ \1 1 til \ 

lA 111 J K ^ 



HiK rii 11. \i !■; 

()! lATHJ-.U 

' St.itr or ColUltl \ 



M \ I i 1 1. N N \ M 1 

(ii mmihi: K 



itiK riu'i, \i'\) 

o»- MMjlII'.K 
(Stiitf ot tiiunti V ' 




MEDICAL CERTIFICATE OF DEATH 

i)\ri-; tti nr.Arn i^ 



(Motitli) 



iDav) 



(Year) 



.uicVVLUX) 



I < 1 r \ iioN \\ 

A', ulrJ III S,ni I'ldin '•■'■. I "i "II 



M..iilh^ 



n,!V 



TMK^HovKSTAT..:lM.KKs,.^^, i-u<nrr..AKSAK.:TKrK TO Tin: 

lU'sT <»!■ MY KNOWl.l.D'.lv A ND Ul-.M 1 • I 



(Inf. 






I Ill'.Ul'r.N' Cl'.K'ril'N', Tliat I alU-ii.U'.l (liHiaNcl from 
OUjV" : i9o'l t<. MX^y ■. up'^ 

111. It I last saw li -.. •> alive oti ' '■■ T90 . 

;m.l that .Uatli (.(MMirred, on tlir <l:it.' statid above, at 
M. The CAISI-: ()!• DIvATH was as follows: 

DlKArioN )V</;.s- 

CONTKllilTORN' ♦•' 



Months I Pav^ /Ion is 



Mi)HlllS 





,,Lu V^^''^>■\^■^'■^■ 



/?<7^ 



'.V 



fS 



IGNED ) LKoJv' 



Hours 



M.D. 



U\r 5 ,< 



»" 



1 L.^ 7aC) <')b^M-^,^...■^. 'jl 



(A.Mri'Ss) TOvC) 



SPECIAL INFORMATION <»nlv tor Hospitals, institulionv, [rdnsients, 
or Reifnt Residents, and persons dyinq away Irom home. 



Former or 
Usual Residence 

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



How lonq at 
Plai e of Death ? 



Days 



1M«\<^'H 01 lUKFAI, OK KI.MOVXI, 




DA II' I)! Hi KIAI. 01 KI';M<»\A1, 



INDl'.K TAKl'.K 






;V^ 



^ .1 I VAPTI V PHYSICIANS Khoulii 

N. „._,. ...v ..en, „« ln*..r .Ion .h,.u... b. crCuMy »upp .e. A..F. « ^^^^^^^^^^ ^^^ ,.^_,^^,^, ,„,,„„„.„„„.. ,„. p.r. 

. r^AilSF OP Dl ATH n pl""" termH, that It inny '"^ i' » 
::;•:. dtlnr»w"x ^1 n c -. .a be *iv.„ , in».."- 



Ih 



i , 






: i 



' » 



I r 



1 



I 



I' ,, 



WRITE PLAINLY WITH UNFADING INK 



J,,..,., , • ii . \'r. 



rs -^i: ni^V Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)/ffi' /'V/r^/, 




C\>-v^n"vv-'^', 



Ifnj\ 



liei^isiered J\^o, 



?8^^() 




/\Kj 



DEPARTMENT OF PUBLIC HEALTH 



City and County of San Francisco 



Certificate of Beatb 

"CI. 5. *3tan^arC» ) 



I- 



PLACE OF DEATH:-Coun,y or'a.v -1 Va , -^,c.,Gty of O.CU^ ^a . -^VC 



L 



1 ^ ^^1 ']^i 

,, - - St.; -^ Dist.;bet, v -M^^ . and -i^OK-U 

FULL NAME Cla.^ \J I Uol 



) 



PERSONAL AND STATISTICAL PARTICULARS 



sl.\ 



w 



( I ll .< 'k 



i \ 1 1 ' ' 1 1 . i !• . ; . 



m 






1>, 



» cii : 



\' . I 



Hi \< .!,»■ M \K In I 1- 1> 

\\ I I>< 'Wl" 1 > < »K 1 »I\ 1 I' I 1 I • 



itiu rni'i. \i"»' 



,'^ 



'■-C 



I 



l\ 



\ V M I I >! 

I \ I II i;k 



III k I'll I'l. \i 1-, 
(ll I \ii!i:k 

(St;it< III (.oiiiiti V 



M \ !1)|.\ N \Ml-. 

Ill M<ti"in;K 



niK riiri,.\ri': 
t»i M(trin:K 

(St:it' i>r Country* 






OwV^ 



Jxo 



05? 



^i 



XJ^^ 



IQO 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

I) \\'v. ni' 1) i:\rn 

(MontiO ^I>'iy^ 

1 Ili;Ki:r.V CI.UTII'V, That I attended (leccascMl from 

x,p\ t.. M.V^:%-': a Tcp'l 

tb;,t I la.t ^aw h . alive on h1^\ !»/)'• 

and that deatli ..ccnrred, nn tlie date stated ahove, at 3. 
lI M. The CArSl*: ()!• DlvATIl was as follows: 



.-.<ry.\ 



1)1 Ii ATloN 



Months 



Years 



^</).v 



Hours 



DIRATIOX ^ )V(/r.v 



Mouths Ptiys 

(.SIGNED). fa.. 0. m U^^ -■ U' 
C.V, ...>5 T()o 



I lours 
M.D. 




(Address) 7CS "J.<A.tU.V 



-A 



\i 



SPECIAL INFORMATION only lor HospiMIs, Institutions, Transients, 
or Recent Residents, and persons dying away Irom home. 



'V 



J Axx-A^vcji 



oceil-ATION 



Vw<>-cr>^ 



Kf:uh-d in Sun /'nin. /w.» 



^( 



):uii 



Moiitir 



lhi\. 



IlKST «)I' MV KN«)\Vl.i:n«'.h AM) lU.I.n.l 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



•1 .\CK OF BrRIAK «)K KK.MoVAI 



DU'lCof IHkiai, or KICMOVAI, 

0"u- 



-vr: 7 






IQO \ 



^^^^_^^^^^^^__^__«««i«i^——"^i^"^— ■■■■"■■'■■"''"■ t t I FiXACTl Y PHYSICIANS should 

N. B.— F.ver.v Uem of l„*n.™,..ion .h„„... b- c„.,!uM. .uppMed. *;;;';;;^7,^„i^.i:,': 'j^l ..Specl.. .„.-or.n„.io„" for p.r- 
... * r-Aii«K nP DFATH in i> nin terms, that it may in. »» i^ 
"r/cl'fnTawa' fromLme Uo... he .Uen In every Instance. 



|: 



: 3 ' 



t r 



. ( 



M 



.1 



( ' 



H^^ 



w 



n 






I 






lin, 



ill 



I 



WRITE PLAINLY WITH UNFADING INK 



/^///' AV/r'/. -J U\.^-C>^VV^~v^.- '. 



/.V^y^ 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

lie o'i si err (I JS^o^ ^^-Oo I 



ck ^L^. v>^ 



A^x,v Deputy ileculli OfTicer 

DEPARTMENT OF PIJBLIC HEALTH-City and County of San Francisco 

Ccitificatc of IDcatb 

PI ACE OF DEATH:-Co.n,y of'^c^iv^--^- City ofO.a.v .1 ^vc.a.-C.c. 



No. 



( 



,fltM ..t, .J OS AAA* TROM USUA 
I OEATH OCCURBED IN A HOSP 



FULL NAME ^^ 



St.- \ Dist.;betcLa.Vyv.v^ andVJCr 

, orsTDrNCEGivr tacts called roR UNDER -special ^^'OH^^IJOU- \ 

' rlsTITUT^ON GIVE .TS NAME .NSTEAD OE STREET AND N U r. B E R . J 



PERSONAL AND STATISTICAL PARTICULARS 



an 

(l)a\ I 






MEDICAL CERTIFICATE OF DEATH 






I);iv 



tV.-:ii-l 



I III. Ui:i'.\' c l.uril ^^ That I aUeniUMl .UTra^tMl from 



lluit I last saw li 



I90H 
alivf on 



iU^ ' 



T()0 \ 
190 '1 



Mu' that -katli .uaurr.M, on llu< ilat. .latril above, at I 
M. Tlic- CArSlC <>!• l)i;.\rH wa- as follow^: 



<p \r\K K ii.i » 

\\1 ; , ! . ( tk |>'\'i •l-■ 



N 



HIK riH'!. \'l' 



\ -. ^ 1 1 « > , i">N 

1- \ I II i k \'\. 



'\ 






i •^^- 



(i)^ 



i: ^vo. 






Xllll.K 







n 






M 



M 1 



U 



r.iK I iir; 

« »!• M« >'r o i , 1- 

(Stat«- «it tounti ^ 



\J^\.'\JC^i> 



A ' M, . 



l^. 



. 1. ' I r 



\rii»N(?r\P ' ^ 



1' ,-'// 



HKsr OF MV KNo\VlJ-,I)«.l'. ^^"rvi";/' 



x,M,.... l'^^^^ o.\.LiL^v6t 



•( 



^ ONTKll;! 'I'OI^V ■ ' ' ' 

(SIGNED) '^J'^-<- ^^^ 

\J L ^V '1 TOO ' ' . 

""ciprCIAL INFORMATION "niv lor llospitdls, Institutions, Transients, 
or Recent Residents, and persons riyini awav Irom home. 



Months 



/\us 



o 



I lours. 
M.D. 






former or 
Usual Residence 

Wtien was disease contracted, 
|( not at placed death? 



How Innq at 
Pl,ice ol Death .' 



... Days 



i-i \cK <)!• in-RiAT, <'K ki:m'»vai. 






I) A IT, '»: il' :<1AI- "I 1< l-M* >\' Al< 



IN. ». 



''' . p\;\cxi Y PHYSICIANS hHouIiI 

8t«tc CAUhl. Oh Ul.Ain I instiince. 



son, dyinft owny ?rom home hHouLI be a-Nen -ry 



\ 



% I 



! '.. 



;■•• ? 



I r 



i i 



\ 

% 

I* 



\ 11 



i. 



i 




w 



RITE PLAINLY WITH UNFADING INK 



v , 



^4r*-S>i;iuSii'0 



/ht/t' /-V/r'/. Nl\t\^^->vV 



t\»-^ ^■>vVA,\^ I 



H^O'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTION3 



\ i Deouty Hon'jth OfTicer 

DEPARTMENT OF PUBLIC HEALTll=City and County of San Francisco 



Ccvtificatc ot Bcatb 



PLACE OF DEATH:— County of "io^^^O 



^ 



of J<x>^'0 • -- - - ■ -<- City of '<3^T~ J.VCX.>A.C^^C.t 



No. 



St.: ' Dist.;bet.. '.-V^X-.-U'v) and v ).L<X->^-H,- 

HOSPITAL OR INSTITUTION GIVE ITS NAME H 



. , .... . c.«s .... .«o« USUAL -s.oe.c.^v.;.cTs c^;^o --^^-—i -—---' ) 

V ir DEATH OCCURRED IN A 



FULL NAME -^ <x^^^ "^^^ 



M,\ 



\ 



PERSONAL AND STATISTICAL PARTICULARS 




V 



: 1-; I 1 1 




XVC '^ 



I: 



,^A5 



\: 



rl 



MEDICAL CERTIFICATE OF DEATH 



i.A ri- •)!■ Di: \ni />, 



va< .: 



5 



--!%«.! J" M \KKH.1» 

u III! .urn < •« i>:v. I' 1 i> 



mu 




\<xx^c^cL 



N \ M 1 ' •! 
J- A 111 IK 



IUK111II.\ ! 

ni- lArm-.K 



M \ ; 111 N N \M 1, 

( li Ml I rii 1-. !•: 



IllK I IIIM. \> )■ 

oi- Ml rr lu.K 

(Slatf ui fniiiili \ 






(A 



Month' '"='>■' ^'^''"' 

I II! Ki:i'.V CI:KT11V, riial I atU'u.k-.l .Unvascd inun 

,],;,t I la-t -^aw h^->^^ alive on ' ' ' ^'P 

,„a that .Ualb ..(vurn a. on llu- ^latc .tatol almvo. at 5 50 
(? M. Tlic CAISM ()!• DI'.A'ni was a- fnllows: 

/)(nv Hours 



\ 



\ \ 



r 




.A.\r 




.» 



\h£i 






1)1 u\ri<'\ 



) V(/;'.v 

V.., .v. » v^^d.*.( 



Months 

\ 



1)1 R.\'ri«)N 

( SIGNED ) 



Years 



Mouths 



Crv^ 



mo 



fAildt-f^s) 11 VI 



1 



naxs 



luL 



I JiU(}S 

M.D. 



in I i 



'■^""^' LLtltrV.v.u ot ia..- 



, \ ex 



A" 



) '/■(■! I 



M.>ii>h^ 



I 



I,i:ST OI MV KNOWI.I-.D'.K A^^' ''J. ''''•' 



Hii hmiKiiil 



u.i.in.s 3v%l M^^n^^l 



"cipFCIAL INFORMATION only lor Hospitals, Institutions, Transients, 
or Kcrent Residents, and persons dyin:) .m.iy from tiome. 



Former or 
Usual Residence 

Wlien was disease (ontraefed, 
II not at pla( e o! death ? 



How lonq at 
Plar e ot Death ? 



.. Days 



,., ^^•I,• ol- lUKIAl. OK KI-MnVAI, 

,.,„.:kt..m.:k^.^^h''''^ H 
,,.,,,„.- 55^- '?'5~ ^■■^^ 



i)\X'""' I'-'i^''^'- "' ki;m<>\ai, 
Vn.^x^ \ 190H 



KXx\< '^' 



« . M 



I 



A " " ^ , f-YACTI Y PHYSICIANS Hhould 

HtHte CMISt: CM ui- ^ . , , , i... rtiven in ovory mntance. 

«on, dyinfc nwi.y from homo hIiouIcI »»e ft.^en .n o c y 



M 



H' I 



vr-i 



1^ 



w 



RITE PLAINLY WITH UNFADING INK 



... ,,.1 .,f I!< :iMh- »•■ ^'^ 



^^^JTS^: HS: I* Co 



l)(,h' Filc^l AXv^^^-^^i^"^ 



IfUJ'i 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

'^883 



Jtro^/sfcfed J\'*o, 



Uv p 



1 OfTicer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

^ "U. S. StauMr^ ) 



i QO 



PLACE OF DEATH:-County of ~^a-. l^<^>x.c..c,.Gty ofd^.v -1 A.a..vC...c. 

^00 



'V 



r A 




No. 



( 



r or aTrt OCCURS *W 

ir OE^TM OCCURR 



D FOR UNDER "SPECIAL INFORMATION ' \ 

T AND NUMBER. / 



St.; Dist.; bet. v' X.<X/^ 

• iciiAi cir«;iDENCE GIVE facts called for und 
ro\;TH's^pVT*At o"r"nst.tJ;'on oive its name instead of stree 



A^'^v and U lVL^O/i V' 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

._ inl.nk \ 



! 



1. \ IJ-, nl I'. IK 111 



\ < . 1-: 



-CxU 






1 ,,i 



VI I 



ll.!\ 



!/,..////> 



■>■<■. 11 



Ihn 



SIN. .l.J* M \KU n.l> 

w 11)1 (U I'll <>K in\ <»Krin 
\\\\ itf ill >.<K i;(l ill xiriialioiO 



lUKTMlM.Xt'l-. 

I st.itt <ir •".Mint I \ 



\\MI Ml 

I A I iii;k 



.0 xa 




V 



lUKTIiri.ArK 
()|- I \ III IK 

iSt:»1»' "I riiiinti \ 



maii)i:n NAMJ". 

Ol MOTIIKK 



lURTHI'I.ArK 
nl* MorHKK 
(Stall- or Country^ 



I 




yv 





I 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- I)i;a'ih a 

(Month) '!>••'>') (Vear) 

I H|.;ki;1'.V C1;RTI1-V, That l atUMi.k-d .U'ccascl from 

up. to yXtrv.- H upH 

t,,,, I iM.t .:.w h >. alive- on ^XCD- up ^ 

,,n,l ihal .kath oourrcMl, on the .laic slatcl above, at ^ ^ 

M. The CAISIC (H< Dlv.XTH Nvas as follows: 



^^^ ^^ ^ l^jrs Months ^ Days Hours 

ci>N'n<iiu'T()RvM;v^ttwvi-l..tU.^kL^^.^ 



Dlk.XTION 



nrR.xTioN 



Years Months ^"^ Days Hours 






Rrsidfit in Sun /'idiKisro 



Month ' 



Ihivs 



V„KM,..VKSrvrH,n.KK.,SA,V.KT,r,;KAK>.K,..KM. To TMH 
1U%ST Ol- MY KN«)\Vl,l,l><-h .\NJ> HI''"' 



(I 






fA.Mu'S'i 



(SIGNED) Ob/a.^Jvu 





■ c;prciAL INFORMATION only for Hospitals, institutions. Transients, 
or Rerent Residents, and persons dyln« away Irom iiome. 



r 



I 
I St 



<1^J^. 






c ' 






• « 



.-V . How long at 

— « .J ^nij uO<X.vt,w^ ' *^ Place of Death ? 
Usual Residence OoC J yu m^v ^^ 



Former or 



,5a5 






Days 



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



IM.ACK OK m-RI.M.OR KKM<)VA1. 
fNDKKTAKKR \j:X.\Jj^ '"^ 



DATlCo! lU KlAt. or RICMOVAI. 

Q>\^ "I T9OI 




I •* 



< ( 



\< 



\ 



. i. 



A . , FVACTLY PHYSICIANS lihould 

■ ~~; ;,„„ .houW b. c-r.fully .uppll.<l. *«« •"""''' "^t-'i The ••S...ci.'l ln«or.n».io™" «or p.r- 

;,. B.— F-v';y <«- "' '"'--^Vh ." urn,., .h.. U n..., b. P-P"'^ ''—'""'• ^'" 
State CAUSE OF Dt a in m m .very Instance, 

•on. dylnft away from home should be ft.ven in . • y 






It , 



I 



\u 



HI' 



i y 



* 



.^•{ 



IC. 



m 






f < 



4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRU CTIONS 

QQ 



Ee^istercd J\^o, 



O.Q.Q4 



/>r^/r /v/rv/,.,Mlru^>^^\:MA^..:; i.9^>H 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiftcate of IDeatb 

( Xl. 5. StanDarO ) 



i 

PLACE OF DEATH: — County of Vex 



■V 



No. 






^ .a. ^vc\.^. «^ ^ City 01 

^ ^ ?! 



^' City of ^Jcu^"^ OXo->xc<^ 



Ci 



St.; ^ Dist.;bct. 0,A^^U'v->-v^>_-. and J-Lt 

/ ir DE.TM OCCURS AW*V TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER •SPECIAL INFORMATION" \ 
V, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



<^ 



FULL NAME 



1 LC^CyO, 

u J. 





. H. 



PERSONAL AND STATISTICAL PARTICULARS 



SI A ( 



r< n.ok ', 




t 



XVA^ 



DAIl". OF" IlIK IM 



iMi.ntli> 



\».K 



(Day) 

1/..,,///. 



(Year) 



/)</!,< 



SINr.l.l-: MAKUn'.D 

UIIM >\\i:i» (»K I)I\« »Kti;i> 

(Wiit« ill ^<M i;il lit xiviialimi) 




CXWoLC^ 



lUK rm'i.An: 

(State or Coiii'ti \ 



NAMl" 01 
FAT II IK 



HIKIHIM.ArH 

(>i- I AT in: K 

(State or Coiiiit I V 



maii)i:n NAM1-: 

01 MoTHI'.K 



iUKlHl'KAlH 
<)|- MOTIIKK 

(Slate or I'omitry^ 



OCCri'ATION 



(\jLsj<r 




c'C r V^v ckJ Jb'y^y^h vslx.u 



C7Jv.cLa„'> vC^ 



i 



Kfsitf^tf ill Sun /'i aih m'" 



) It! I •• 



Months 



/)<n> 



THl" \HOVK SrATi:!) I'HKSONAl. I'AK lUT l,A KS AK !•: IKIK T() THI-; 
HHST or MY KNOWl.KIX.K AND lU:!.!!:!' 

(iiir..riiiant \l Wxxm *"3J^w^-/^'vo v..'-'vj 



(Address 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH f' 



Vlrv- 



^ J. irv" 

(Month) 



(I)av) 



I go 

(Year) 



I in^RI'HV CI'RTIFV, That I atteiwlcd (U-coased from 

a.x!pjt' 190-^'- to \rUv".....S. 190 1 

that I last saw h - alive on MLrv^ ^ nyo 

and tliat dcatli occurrcil, mi the date stated ahove. at I 1 
,lL M. The CAlSIv ()!• I) I- ATI! was as follows: 




coNTR I r.r TO I 



DIRATH^N ^ Years A/oni/is^ Days /lours 



.Dr.'Sr^3u^:\A.ry. :\.a 



Months 



I )r RAT ION _^ Years 

(SIGNED) LJxOaS ^. \S<xy\^-\\.h 



Days 



kXcx- 



lc)0 



(Address) ^"l^ 






Hours 
M.D. 



t 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



DATKot Ht KlAl. or RKMOVAI, 



n.ACH OF nrRiAi. OK kkmovai, 

rNDKKTAKKR hI /VCW. ^^3. 

(Address. 3 5".?)' ^5 7 <3-C^tU>V dt 



190 



.0 



N. B.- 



_P.v.., >.e. „< ■„,„..-..on .h„„... he c„..,„M, -uppH.... AOB »-.""•<• ^•!'-"l!''.^"hl; .rrj-^i'^.w-^'r- 



-Rvery Item oV Information should l>e CHreruiiy «upp..ct.. — - „..,..- ••s„ecl«l Information" for p«r- 

Ktate CAUSE OF DEATH In pinin term., that It m«y be properly cla««.Hed. The Special Information p 

monn dying away from home nhould be (liven in avory Instance. 



K 
I 



-• ' 



{ I 



')« 



, J 



M 



. < 



* \' 



I 






\- 






I I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I',,:,!.! ..(' II. •' :i ! ■-■' 



^..^r'rrv. 



i: l'.\ !■ «■., 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihih' Fi/rff ,\i\^\>JLy^v.'.>^ '; 



IfJO'i 



Rc^lstci'cd jYo, 



2885 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



Certificate of 2)eath 

( U. 5. £itanc>arC> ) 
PLACE OF DEATH : — County of ""^ -^ > ' Va > lc « - City of C a.-.v J/v.cx w ava e 

St.; Dist.; bet. 



and 



/ ,r t.A^M OCCURS .W-v rnOM USUAL RESIDENCE GIVE FACTS called roR UNDER -SPECIAL INFORMATION ^ 
C ,F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



On 



FULL NAME 



I I 



Uv^ 



Oj\^o. 



^ I \ 



PERSONAL AND STATISTICAL PARTICULARS 

I I 1 1.' iK 



\ HCLU 



a- LlU 



I> \ 1 1. < •! UIK III 



\' .!•, 






I»av 



1 /..»/'/.' 



' "/taft 



/',/ 



(\\iit( ill s.K-ial .!«-irii.«ti"n) 



r 



«. ■^ • a' 



iiiK rm'i. \i' »•: 

(Statr <•! i"'iiMiti % 



-, \ M 1 < >! 
I \ I li I K 



HIK rill'I, MK 

->! it , - It I'l iTint! \- 



M\Il»i:X NAMJ- 
ol MnTm;K 



liiR ii!ri,.\(.i-; 

<»»•■ MoTin-.K 

(State or Coiinti \ 



L 



/ 



" X- 



nrciTA II<> 



^' 'vitt, 



vxA 



f\ru(!,-.f III Siin /'i It III ism 



] r<r I V 



Moiilli 



I >,i \. 



Till- XH(.Vl.-ST\Ti:i) I'KKSONAI. l'\KThM I.AK^ ARi; TKl 1. i«) I H I- 
HKST ()1\,MY KNOWI.KIX.K AND in-I.Il.l- 



ckAwXi 



f \(l(lress "Trr:? 



MEDICAL CERTIFICATE OF DEATH 

DATI-; <>l' Pl-.ATIi > 



M I C. ■.. 

'Mnlltll^ 



(nay) (Yt-ar) 



I Ill'.m.liV ti:R'riI'\', Thai r attfink'il dciiased from 

up'! tn /\.c\r ^' 190 '"X 

that I last saw li alive on 1 ^ <"■ '■ T90 

and that diath orcnrrcMl, on thr date stated above, at T>, I o 
M. 'Idle CArSl-: Ol- DK.XTU was as follows: 
Sy^^^-v C-^XA> nJa^ £.jl\^ \ . v./O^'WA-^.O. JwAj^IOvv 



S 






t 



! , 



Dl'R.VTK^N Years .)/<>>////s^ Pays Hours 
C" < ) N T U I Ul 'TO R N' Uf"^^'^'^ \.v.Al. Xoowd.<^.C.- D^\.a^ 

DT RAT ION , )V<rr^ Mouths 

( SIGNED ) >- . J I C^V". 

^ ^'^ *" 'Addn-ss) JJtV-a\.tX>v 'fb^ V , A 



Pav. 



5- n 



)0 



(, 



Hours 
M.D. 



H^ 



SPECIAL Information »nly for Hospitals, Institutions, Transients, 
or Recent Residents, dnd persons dying away from fiome. 



Former or ns V A, , . , a 

Isual Residence ''-< v .J- -XA k. , ^ 

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



\\ 



HoM long at ^ 

Place of Deatli? A Days 



DAllvol Hi Kl.Al. or ki;M()\'.\K 






190 



* 

U 



■"■"■"""""■""— "■"■■"■^ rTvGE shoulil be stntetl RXACTLY. PHYSICIANS should 

N. B.— Every Item of intform«tion should be careVuIly «"PP'-'^ ' /;^;^;^^^ classified. The •'Special Information" for p.r- 
state CAUSE OF DEATH in plain terms, that .t may be properly classme 



-Every Itei 

state CALrji- vi .^.-r, ^ . _..„-, 

son. dylnft away from home should be given m every instance. 



i 



I 

t I 



■ if 



. i 



I 1 



d 



. i. 



1 



■^^ 



.'^♦■. 



1\ 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho..r.l<.fn.:.l.h • V,, :- -^:-»r>PArr, REFEP TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 



/)(f/r Filed , 




il 



»^^^vlvX\/ 



i 



]f)OH 



Rci^i.stcrod J\^(>. 



<0Ct 



i. 



(yvcc^ c\JLvu Deputy Heaiih Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



U. S. Stati^ar^ ) 



-V (^ 



J too i ^(^i^ 

PLACF OF DEATH: — County of O^^v "^ - - .vc<.c ■ City of )<X>v Jxc^wcc^ct 
ivj„ ' > -^ , • ^. ,^<i'sU<^-A Dist.;bet. and 

i^^'* ^ . .. iicM&i Rr<tinrNCE give facts called for under "special information" \ 

.( '^ rF^-DrAT^H^^OC^^RrcV.N'THo's'rAt o"r' f^.ST^'u" " ^O I V E ^S NAME INSTEAD OF STREET AND NUMBER. ) 



) 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 




' I \ 11, < ii r.iK rn 



/^' 



\!..iilhi 



l>.i\ 



\< . I- 



^ IN'. 1,1 MAKKIJ l> 
W 



u ii>i lU i:i> nK i)i\oRrj:i) 

'<vi;r|l.lliM!l* 



lUK 111 »•!, \>"»". 
M;it' 'iJ <"'>Miiti \ 



\ \ M 1 III 
I \ 1 II Ik 



lUK III I'l, \ri-: 

(If I \ VWVM 

St:il< til ("lint I V 



M MKICN NAMl'. 
(Il MoTIM-.R 



lUR inri.MK 
oi- M()III!-:k 

I St. ill ' .1 r<miiti \ 



( (rnpATH )N 






^ 



I) 



K,\_. 



s^N-A-.*^ 






U 




-4 



h'f III'-,! Ill s.:v I I .//'. 



) III I 



M.nilh- \ ' /'<" ' 



llll- XH()VKST\T!:i)l'HK^.»N\l.l'\Kn|ri \Ks AKI, IKI 
lll-sToI MV KN(>\VI,i:m.H AM) Ill.l.Il.l' 



!•. ro Till-; 



(I 






MEDICAL CERTIFICATE OF DEATH 

1)\11-: ( •! 111. A Til 



V..C\. 

Month) 



(Day) 



(Yfur) 



I II !■ K I'l'.N' C I'.RTIl'N', That I allfiuU<I .U'ti>;is(.-(l from 



tliat I last saw 11 \- :>livc on f UV" up 

;m,l tlial death orciirrcd, on tin- .latr stat^-.l ahovf, al I -) 
.CL M. The CAl'Sl*: ()!• I)l'..\'ril was as follows: 



DT RAT I ON )'tar 

C ON TKii'-r-roRN' 



Months 



Pays 



Hours 






Df RAT ION ^^ )V<//-5 



(SIGNED) 0> 






\ 



Hours 
M.D. 



f Address) SX'l MKOVi^^ 



SPECIAL INFORMATION only lor Hospitdls, Institutions, Transients, 
or Recent Residents, .ind persons dyini ,m.iy irom tiome. 




former or 
UsudI Residence 

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



-4 o . I 



o -^ o, 



How long at 
Place of Dedtfi ? 



Days 



I'l.ACl'. Ol' niKIAI, OK KI:M0\ Al 






1) \'l-i'' <)! IMiMAl. <ii KI'iMOVAI, 



IQO 



N. B." 



^^.^■.^■^■•■^^■^■^■— — ■-^■■^^■^■"^^""^^■■■'■"""^'"^ ,11, t t i FXACTLY PHYSICIANS nhould 

-livery Item of intformntion .houUI b. cnrct'ully H^pplie.!. j^;^;^^ •jj^.^^^.^^j^j" 'Vhe -Spcclai InformHtion" for p-r- 

state CAUSE OF Df.ATH in plnin terms, thnt .t m..> be proper y 

«on. dylnft «way from home hHouIU be iliven In «very mHtance. 



I 



<r=> \ 



< I 



^ 



I 



i»r 



?- 



\ 






' r « 



. »• 



it*'* 

,1 '^ 
lip 1 1 

if/ 



I; 






i;i 



d 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



, n"^.». 



i'.M' '• 



Ihffr AV/'''/. MVt^vXY^JLi 



If^OH 



'-i.t^.j^:^ ixVA^ Deputy Hacnth Officer 



]?f'o'is//'/'('(I A^f). 



i288' 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County of^O. ^v o v<x-^xcuiooCity of '<^^-/^^' J ^^^X/'>vcu:i.eo 






N 



(). 



St.; ^ Dist.;bet. ' and 

ktl f D FOR UNDER SPECIAL INTORMATION ■ \ 
AME INSTEAD OF STREET AND NUMBER. J 



/ - .ATM OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V E FACTS CAtlED FOR UNDER SPECIAL INFORMATION 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N " " «■ ■—'--- - - --=--- . k, r, k, . ■ « c r o 



) 



FULL NAME ^^^ 



^^ M \ 



U 



PERSONAL AND STATISTICAL PARTICULARS 

r , 1.'' li.l Ik \ 



F 



-U-L- 



1 1 '•, I i 



\' . I 



'^l^■t,l.I• MAKUIK1>. 



/h 



W !li 



IU1-: nil" ' 1 



N \M 1' <>1 
1- XTIl IK 



!'.ii; Til !'l. \ T. 

oi" I \ 1 II j;r 



M MlilN N \ Mi- 
ni- MOTIII.K 



lUK III I'l, \* I. 
<)!■ MoTlIl-.K 

(Sl.lti 'i! l'iillllll\ 



I )( 1 ri'AiK i\ 

A'. 



-i}.'".iti"i>' 



\ 



^ 



-L'>V^ 



'v<X >vc 




> ■ I 



a r\ 



1 ' 



■■\'^ 



I ^ 



'' n , 



/^ \ 



(\ 



MEDICAL CERTIFICATE OF DEATH 

1» \ II'. < 'I 1»1. A 111 

!M(intlO I Pay) (Vf:ir> 

I lIl.Kl.i'.N riKTIl-N", Thai I alteiKk'tl drci Mvrd (v 
\i.)n \ to . i()0 « 

tliat 1 last s.iw h • alivi' "11 \l VtV 



nil 



\^)0 ' 



ami that <Katli > xcurrcd, en tlif tlati- statc"! alxivr, at Il-oO 
^ M. Tlu- CAlSi', Ol' I)i:\ril was as follows : 



>vt^- >\A.v.'... > > .. 



1)1 RATION )V</rs 

C ( > N T U II '. I 1 o R \' 



.lA'/////\ 



/>(/rv 



I/iUi) < 



/\ivs 



V I _ I 



do, >v • 



n 



)■, ,; 



t !/,■.////■ 



n,i 



( SIGNED )L0 O ' ^'-^^ ^. ^ ■• 



M.D. 



Special Information "!i'> ''t Hospitals, institutions, Tr.msirnts, 

or Rnent Ri'siJents, jnd persons dyini) dWH\ fro.n home. 



Till' \!'.«i\|-. SI \ ri' I) I'K1<S(»NAI. I'XKThTI.AKS AKi: rKli: Ti • I' Hi: 

iw>T Ki- Mv KM iwij'.ix'. !•; AM) in:i,ii:i- 



' I n f' iMiiMiit 






Formrr or 
l'su.)l Rfsidcncf 

Wlipn Wcjs (lispflsp fonfrarted, 
If not .it plarr of dfatfi ? 



How lonfj at 
Plare of Dp.itfi ? 



.. Day* 



ri.ACi-: "1 liiki^M, OK n!:m(i\ai, 
V^uAv^Vt^^- ^-c\* 



-V^"W/ 



i» A ri; <>:" iuimai. <>\ \< i'..m< >\' \i. 






TQOH 



^ „ __v,,,,. ;,em on:W,.rn„.t5on shoul.l h. c..ofnIly supplleC. ^dH sVv.l.l be stHte.l EXACTLY PHYSICIANS should 
HtaU- CAl'si: or DIIATH in pl:nn terms, that it may be properly cloHKificcl. The •\Spcc1nl InW.rnu.t.on Vor p«r- 
sons (lyini uwny from home shoiiltl be Jiiven in overy inntunce. 



't 



I 



!•■ 



, i 



;( 



f 



l! 



'Jil 



I t 



1!. •!'■. IV 



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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






!)((/,' /•V7fv/.M\r . r^vl 



,>-il\' 1 



lOO'i 



Jiro'is/cj'ed A^o, 



2888 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^■/■/T' y // s^^:.^^ 



/J?. 



PLACE OF DEA-Tff; 




Certificate ot Beatb 

P QTi^ J? (5^ 

ountv ofCj/0^^>^' JXOu^vCV^:lC^City of U/<X/^^ J /VOy^o^^.^ OC 



No. 



?n';- 



b t-K. 



St.; Dist.; bet. 

lOEl 

OCCURflED IN A HOSPITAL OR INSTITUTION GM 




U^AtV^^n^' and 




Cruu-'CX' 



/ ir DfATH OCCURS AUVAV TROW USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • ' "X 
V IF DEATH orruRRFD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



il 



FULL NAME 



; I 



PERSONAL AND STATISTICAL PARTICULARS 



I ]\<X,\.K 



s , 



/ 



( J I i ^ ' 



:tt=? 



iJO 



1 • 



' \Vl !l( i 11 -' » : 



I ILoJVvaX^L 



IMK I'HIM \'' 1' 
(Stilt. . • ■ ■■■■'t: 



NAM}' (H 

|- \ in i:k 



iiiK III ri. A* }•; 

<U- lAIIUlK 

'•<t:it( I A rminl I \' 



n!aii»i:n NAMi; 



KIR! illM. \ I 
Ol- MoTlll-.R 
' Sl;it»- 1)1 I'diltlt I s 



I 



MEDICAL CERTIFICATE OF DEATH 

DATi-: ol i)i:Ain A^ 

va 



I Month t 



TQO . 

'Day) (Vtar) 



I li I'lv i:il\' Ci;u'lll V, That I atU'ii.kMl (IcHcast'd from 

~ I (p 1 1 1 ■ T (p 

tliat I last saw h ■' — alive oti — — — — — — Kp 



x>; 



ami that (Irath nccuircil, mi the' dale stated above, at 
— 'r M. The CAT SI": ()!• DI-lATll was as follows: 

LoJ\-U-cr> V. V 1' \\^r\^j^ ^/cC*L . \J ^\<^MrYv^>.'vq.. 

LLc^C<a^ ci^t. -v-vi..•CX,L 



I)(■R ATION Years Monl/is Days Hours 

CoN'ruirdToRV 



Years .]/<>>! I /is 



/htVS 



Hours 
M.D. 



I i^m-A 1 ION 






Rf sided in Stm I > lUi 



)■-,.;; 



\'..,!t!i 



IK; 



111 I Mil »\l- -^T \ri:i> I'KRSONAl, l-AKTb't!. \R> AR I'. PR l)- 

iu-;sr «)i' Mv KNOW i,i'.i)«'i': \^''> Hi:i,n:i' 



o i-ni-: 



Mill"- 111 lilt 




AX-X 



( \(l(lrts'< 



1)1 RATION 

(Signed ^ 

-J : ^ ■ (jr 

SPECIAL INFORMATION on'v for Hospifdis, InstittiTiftns, Transifnts, 
or Recent Residents, dnd persons dyin;| .iwdv from fiome. 



.^^^\JAJ) \'\\ K. -..v 



Former or 
lsu,il Residence 

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



5^^H' IL ii. 



How lonq at T 

Place of OeatI) ? * 



Days 



I'l.ACK OI' HIKIAI, OR RI:Mo\ AI. 



DATlvof MiHiAl, 1)1 RI-;M<)\'AI, 



IN 



I)1-;k'i"aki:k v)CrL<XX' 



y-^ O/oAx. 



fA.M,.-.. 'X\^^ ^)\ 



at'' 



A.Xb^-A^<rrvj C J 



IN. B." 



... s ,t I- A AHF Khfiiilil be 8tnte<l r.\4CTLY. PHYSICIA'NS Hhoiil<1 

•livcrv item oV iiiformiit ion should be cnroViilly suppliwd. \U\. snovilil "« J*""*^';/' ^..^^ ' • , , e « .:,,„" tf«n n-r- 
«t«U CAlJSr. OP DIIATH in plnin terms, that it mny be properly cl«««iVlccl. The Spccnl InformHt.on ^or p-r- 
nons dyinft nwiiy from home should be ftiven in every instance. 



:.(■ 



I 



IS 



I It 



m 



t 



. s 



jblic Health 




was 



of 





,e\- 



an<i 



t . . .; . 



I foM ('ROSny, Clerk of the County of Hudson, and 

• : . •ir'^^^,-^ "rrMW"''^' hcil(l''ii tly^cin, Iffic sj^c Vjcjncr CourJ^j''fT' 

re whom the ioxii%o\nf>r-!<rnrJJ 

., ,,^ ,, J , ,,, ;...,,, ;m in ..n.i for said Colinty and state, commissioned 

iithonzod to take the s.un<'. An^i. further that I am well 
; . ,th the handwritiiv^ ' ary Public, and verily believe the signature purporting 

IX\VrrXI<:SS\Vni-:i<F:()i;rI>#^hereunto siil mi/h:uid and affixed the seal of said Courts 

'J'^x^ ,* , u^xir/t-.-'^*-^*-''^—^^ A. D., lyi.':^ 

(o\uit\' 'hi-- ^ ' 'i'^' ■'* • ^^ /w' ' ' .^' ' ' ' '.y^' ' '/9' ' ' /O 

^ ' ' * ' ' nerk 




ii 



ii ) 



i-*i. 



* ( 




c 




•a 

0) 



I 

O 



1^r» 



ubiic } iralth Birth and Morf . Div. F NO 7 



DEPARTMENT OF PUBLIC HEALTH 

City and County of San Francisco, State of Calif6rnia 

• FFIDAVIT FOR CORRECTION OF A RECORD 



B&P 



■r^r:^.^ <P i 



^ 




of y^L: V . ^^^V ^ 



W V^ v.. A .-::.^..i^V(2^^^ 





V^. being first duly svvorn dep^oses and says l/,.,^^Ax.[^ ^^ 

C ' ^ ^"^i-^LAyl ^ '^X^'^^^J (state Relationship, if any) ■ 

-vas born rA^^ ^/^^X^ -- /U. i ^ / ^ ^.^Wt^^. .^ w^ i 

^ .>v iM.d ruuunly ^f , Sqh VvnuCm^ on the/ ^ day of . £^^^^ 

_ Department of P.bi.c I ..itb of the c.ty and c:::;;7:r^:i- :^:-; ^;t:;tr r ^"^ 







•4f?I 



■n a crrtifieateof 



^r'^r^:^. i^^/y^^ 



191 

nt further deposes and says that 



'^lA^Z^Ss" 



\ 



an error or errors w <?L<I made m refer^ce to the 



[u.^ 



-t<^C 



..ere,„before^men„oned. and for the purpose of correct.n. the 3an,e n.al^s this affida 
-...ti^te.ot (,J^^) should be corrected to read as follows: ^C'-^ '^ .^Z" <t^ 



/■ 



vit and states tliat the 



'^-f t,-7> 



-< * » 



/ / ^ 



I / 















< ^ 



V / -i C^ 

y / 



.^»„.<L. <. 



/ 



!^ 



SIGNED 

Sx^bdtribed and svyorn to l>elore me thi 

■if ^ - 



day of 
The facts'rontaiaed in the ab 







and further affiant saith not. 



// / ^ NOTARY PUBLIC 



:s; 
191 ,) 
ove affidavit are true to tl^e best of my knowledge and WxM't.^-n^^^ 
'SIGNED n. ^. * - \i Ai . ^ 






iiiiflnir~^T~*i 



J 
i. 






iii 



1I«W1^»HU! iWlil4M n m» 



a I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,,;,,,;, M ,h , V , t-^"^'-. ii.u . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







Jiro'/.s/erefl J\^o. 



If) OH 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County ofO/tX^A 



No. 



Certificate of IDeath 

( 11. t5. J^'t^n^nvC> ) 

O/Cl-^a' « ' ^ '^ , .. — . City of O/Oyrv -Vcv, » \.<^ ^ si ':^ f 
St.; ^ Dist.; bet J .^ixLi\A^ok and Dj^O-Lluv 

;IDENCEgive facts called f 

HCCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME II 

FULL NAME^A.lXv.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 DEAT- ^-"/-..Borr. i k. a u r. c: P , T A I OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 







PERSONAL AND STATiSTICAL PARTICULARS 

, • I 1 1 . ' I R ■ , 



Vj I ^o. 



r.iivTii 



J 



>?n 



\!i !■! ll 



3 



\ ' . I : 



/'ii 1 



SIN*', i,K, M\Kkn;i» 
\vii»<>\vKi» «>K i)iV(»Kri:n 

W'Titriii H<K-i;il (l« sij^iiationl 




iMK rn I'l. \'M' 



\ \Mi-; (»i 
\- \Tii i: K 



i;iu iiiri. A* 1-: 

<>|- I All! I" R 

> Stati ' I ('(.11111 1 \ 



MAIM'.N N\M1. 
Ol- .M(jTni:K 






MEDICAL CERTIFICATE OF DEATH 

DA I}-; ()!• Di': \'\'u 




(M..ntli) 



a)av) (Vt-ar) 



I in; I-J I'ir.N' (~ !•: R'l'l 1" V, That I atUn<K(l (!(.•(•( a^fil from 

. , ' \i.)() . to ^rv-tv L up I 

that I last saw !i ilivr on | Uj \J~ b T90 

aii'l that (Kath ocuurriMl, on [Uv Mate statt-il ahow, at * 
.M. TIk- CAI'SI- ()!■ DI-ATII was a^ follow^: 










rvXAAjJe^Y^yZAj^y 



vcu OV VrhAX\XxJj f<X^\A^ LLtvlvC 



Months 



/hus 



//ours 




V.<X/VVO 



.4 ., 



I > 



(0 I 



lUKlli 11, \' I. 

(»(• Mi»riii;K 

fSlatt' iir C'oiiiitiA 



DC RATION 5.C) }'riirs 

C ( )NT U I r.I 'TORY U^U^'LiAAjb X-^fiA-^^w^^ , <'i,W\A<tlHV..s,t: 

I )r RATION )V</r,v 

(Signed) Cd. cioa; TV ^ jj v^y tx.>-vt 



/hJVS 



//i)/ns 
M.D. 



Special information ""ly '"^ Hospltdls, Instltiilions, rransimfs, 
or Rerenl Residents, dii'l persons dyini) ,VA,i) Iroiii home. 



h'r-iili-i! Ill S'./" /'/ ('"■ ' '■" 



),,■;/ 



!',.-////> 



/'.■I . 



Ill \i!i(\-j- s'i\'n:i) PKK^<»N\i, i'AKi"n"«'i-^»<^ \Ki;i-Krj-. i-n 

lM>r HI- MS" KNnWIJ'.I)''. !•: AM) I'.l ' I, ! I '. I- 



III !•; 



(1 11 f. r ni:illl 






(\<1<lrt-<s 



former or 
Usudl Residence 

When was disease (onfrdcfed, 
It not at plare ol deatti ? 



Hov\ lonq at 
Plare ol Death ? 



Days 



I'J.ACI'; Ol' HI Kl W. < "K 1: IM' ''. M. 



I) \'VV. <it" H' It \i 01 N i;M( )\' \ I, 
V^ i TQO'l 



M I', <i! 



r\I)l-:RTAKi;K lA)-ULLv,V>\i LLcLcL\Xc>C>v 0-U/\\iA/CX„\j aL/A^ 



IN. ».- 



«tHtc CADSI or DEATH In pl..in term«, that it m,.y be properly cl«H«h.cd. The Spe.ml InW.rniHt.on Yor p-r 
nons dyinft iiwiiy from home Hhoiihl be ftiven In every InHtnnce. 



I* 



I 

I r 
I 



M 







¥>i 



!».M1. 



WR'TE PLAINLY WITH UMFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



«^w^ ^'*%. 



r- ■ s 



i'.\ I- 




t\^'\^rV 






bJOyj 7 



If)OH 



Begi\sfei^p(l Xo, 



2S'dO 



'^ r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeath 



(^ 



PLACE OF DEATH: — County ofC/0.>A. 



VCL> 



xcUi cxCity of '^ 



xa/^vcvAcc 



(1^ 



list.; bet. 3.H -L 



ivj,, .Ml iL^v^• ' - St.; V Dist.;bet. A"\ A^>\J and ■• ' 



FULL NAME 



a..vyKo '1 



v' . \\Ji.^ 



- f 



vK7\ 



PERSONAL AND STATISTICAL PARTICULARS 



A 



\i 



i 



I 



N! .llth> 



1" 



, )■ 



vi\. ,1 1- \5 \K \i il'.l' 

W I1)(>V\ 1.1> OK I)!Vi >kri- I) Q 

iWiit'iti social ili-siviiat i"ii ' -A 1 

cVLAvaU 



iMK iiiri \''y 

(Stat' 


V.<xlc| 


N\M1 <>l 
1 \lll IK 


"Mi 


lUK III I'l, \> J-: 

()i- 1 xini'.K 


"^ . - . H . 


MAIDJ'.N NAMl 
(II- M(»'nii;K 




HiK riii'i, \ri-. 

<»! Mft'l-HJ-'.K 
1 st.it'- "I r.i\mti \- 


SI 



n 



MEDICAL CERTIFICATE OF DEATH 



.All', (»!• Dl-.ATH A 



nr 

Moiitli^ 



il)av> 



(Ytiirl 



I lli:ki:r.\' li;iv'ril'\', 'I'liat I attcmlvl «U(H-asc.l tnmi 
1 ' up' \ to Vl\c \; K. U)o'i 

tli.it I last saw h : alive on ^J ^- ' T'P 

an.! that ilralli orciiMC'l. on t lu' <l,ilr ^talrd a!)ovt', at lal'oL 
M. TIu _C.\rSI': l»l' l)l\.\ri! wa-. as follows: 



.>-V!. '- 



M,n r \ Til >N 

/yfsil/fif III Sillt I'l (lIKI'^fil ck i ) '■«/ A 



v-.^'///« 1 D /'" 



T,n Mi,>VFST\Tl IM-KKsnNAl.l'AKTUM-I.AKSAKKrKl !•: T< . Tni' 
!!i;sr (•)• MV KNCWIJUX'.K AM) lU-.IJI.I' 



Itifo'inaiit 






*\ 






Dlk ATION 
(•oNTRll'.r'roRV 

i ) r K A 'I" K ) N 



'. ^ V .■,,. U'V Ao 



)'rars Mottlhs s Hays 
cjJv< 



Hours 



}'(•(! rs 



M on til 



V i 



Days 



ll.> ■ .••> 



(SIGNED ) ytSVVYV 
^ %M ' i o,o". f A.Mn-ss) a:C 1^ M)Vv^4^.C ■, 



i I<)0 



11 ours 
M.D. 

\. . V. 



Special information only for llospitaK, Instituliuns, Iransients, 
or Rnent Residents, diid persons dyini) ,m,iy from home. 



Former or 
Usual Residence 

Wfien was disease ronlrac ted, 
If not at place of death? 



HoH lonq at 
Plare ol Orath 



... Days 



IM \CIv Ol' mUlAI, (»K Kl.Mo\A! 
INDl'.K' 



DA Tl', >i! ill i;i Al. ui k j;M()\'A1, 






IN. I*.- 



tatc CMISn OP DI:ATH !.. plnin tcrniH. that It m»y be properly claM«.»icU. P 

s tlyina uway from home Mhoiihl be ftiven In every iiiHlnnce. 



-r. 



/ 



^1 





^ ' 


5' 


■ * 




i' 



tl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Dufr I'ih'il , l|\t\^vnrTvlvJi.V T 



lU(n 



Jlrgislrred J\^o. 



•^891 



o^.C»v<.A^ 6j^ 



c^vc^dc^vv^ Deputy Health OfTlcer 

DEPART,^1ENT OF PUBLIC HEALTH=City and County of San Francisco 

Gcvtificatc of Bcatb 

PLACE OF DEATP-I: — County oi^O^'y^' J ^CLwc^^oo City of O/CU^^ k^ Kxx^^>r^^Q.^A/:^o 



Da 



H.tl 



Sti 



No. ^HH ^ICJVCV St,; H Dist.;bet. n vUK. and 

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

FULL NAME \l RoXULcLoj J .hjUy^^Yx<x yv 



"^ CV) 



PERSONAL AND STATISTICAL PARTICULARS 



^.^ 



\ I 






iX-lvA^lX) 



,\\'\ 



^, . 1 



^{^ 



1,'. iilh 



\\ . .., ; ,, ••. II .1^ .n' 



hIK lii >'! ' I 



% 



.C"N\ 



^, 



u 



!> 



MEDICAL CERTIFICATE OF DEATH 

D \ii. III i>i \ 111 r\ 

■M,,iUlil il);iv> (VfatI 

1 Hi;i'Ji;P.V C !'.K'riI'\', TliMt I altc-U'li-.l ik-craso.l from 

^>^ ^s upS to VrUnr S" \ifo\ 

that I last s;i\v h X\) alive nii VlUrvr- 5" Kp i 

aii'l tliat (Uatli ( ici'urrfil, uti tlu- ilatc stalnl alxivc, at 
M. The CAl'Sh; ()l' l)i:\'l*II \va^ as follows: 



B 



at: 



1 \ i 1 1 1 K 



( »i I \ ri! I i-; 



MMIii: \ NAM I. 
ni Miti'lli: K 



IslK I ii I'l.AT !•: 

<)!■ \i(>Tin-:K 

' ^titr ot (Mlllllt V 



oiTfrATinN 



^ 



.^VC 




\XAjyy\'Ojy\j 



/WOj 



v<xrrsj 



Dik ATION 
C'ON'IK ilMTOi 

1)1 R \'il< )N' 



/hlV 






I louts 



) \ ,IIS 



Mo Hi /is 



/hJV 



//oil 



r\ 



) 



Or 



( SIGNED I .^N. - d 



\' 



\ <. »\\.... 



M.D. 



Vtv 



Kio'i f 



A. 1,1,....) SC'i Ai.v.Ua.V (.)t 



Special information "nly lor Hospitdls, Institulions, Transients, 
or Rcrent Residents, and persons d>in,j away froni home. 



) , rl I 



l/.^(////> 



/',!\ 



Till' \Hovi- sr\ri:i) i'Kk-.(.nai, i-ak ihiiak^ arj-, Tkii-: in rni-; 

lil'ST (H MV IsN(>\VM:I)<'.H AM) MIvI.Il.l 

AJUywv<v-t^ 



Miifiriu.'itit 




fAfVlross 



IMH 



UCoAXX* dt) 



former or 
Usual Residence 

Wfien was disease rontra(ted, 
If not at plare of death ? 



How long at 
Plare of Death ? 



Days 




i>i \ci" <»i' inuiAi, (iR kI■•.^t<lV.^I. J D.vn: ..i ic i;i.\r, m ri.mox.m. 



I NKl'.KTAKI". 



- .. ,. , .pp ««,n,,ld be Htnte«l F.X4CTLY. PHYSICIANS «houltl 

^. „._Hvery Item of informntion -houl.l be cnro.uMy -PP'- • J^^V^'^^^^^'tu. "Special lnfo..n«tion" for pT- 

utiite CAlJSn OF DFATH In plain terms, that it may be pr<,perly ciassmcu. 

Rons clylnft away from homo should be ftiven In every Instance. 






f 



I 



I i 



fT^f?' 



■' f- 



f^.i 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



j:-.i!.| • I II< a:th I" No i;, *■* "s-o^;. !!.Vr I-., 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffr rili-(L 



^^Mrvc^ ■ 




^P^^-^0\y\XA>o T 



lUO'i 



lle^Ulered jYo. 






t^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc ot IDcatb 

PLACE OF DEATH: — County of C XX^^' o ;v<X^a^\^cc City of ^'.Cu vv; A.a. ', ^^ r^ t 



No« ^ ^ 



V^ V- . ■ . . wL , *^ St.; i Dist.;bet. 1 -^1' and .1 Ovd.* 

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

FULL NAME ' * 'al^A ^ ' I a\.LLo^-> ^ '^ 



PERSONAL AND STATISTICAL PARTICULARS 

11 il,( )R 



fh^.al 



ll ' 



MEDICAL CERTIFICATE OF DEATH 



\ 



\ !■; Ill 



,?Ml 



\r liDii 



1 ■ 



lhi\ 



~^i\< ii-: M \K i< ii:n 

\\ iiM i\\i-:n (»K iii\"<>Kri;i) 

Wilt' in "iuriiil <i« si^'iutt ioii) 



m 



r\ 



v.W' X \\y\ , \ ' \ 



1 A III IR 



iiiK r II I'l. \> !•; 

ni I \ III IK 

I S!.i' < . .1 I 'i .iiiit ! \ 



M \I1>i:n \ \M1 
til MnriIi:K 



ItIK Til ri, \' i; 
()| Miillll.U 

' St.ili- ( ii k\ iinit 1 \ 



nrrr PA IK I. \ 



(\. 



^tnIlll^) 



I 



^ I l!i:Rl{r.V CI'lKTIi'V, riial I .iltL'ii.UMl .Irciiisrd frniii 

vTUnr S i„oH t(. Cn•^\^ i i^oH 

fliat I last saw h'L^jV alivt- on M*^ • i j,^^^ 

and that <kalli 'icc-unx'tl, on tlir ilatc si.itcil almvi-. at \ 
'. M. Till' CAISIv ()!• I)i:.\'l'll uas as follows: 



.Vw^i. 



^ 



u 'tX-VL. L ex -^ \. cL 





? 



'^^Axl<x>vd 



DIkATlON )\\n:% 



C'ON'I'kllH 'I'OKV 



M on I ha 



na\ 



Hon 



/ V 



DlkATK >\ 
( SIGNED ) 




Kr...k. r(,o'i (A(Mrfss) lOC) (lbcLKhA.4c>v 11 



Hours 
M.D. 



SPECIAL INFORMATION ""ly tor IliispiJdis, Institutions, Trdnsients, 
or Rerent Residents, ,tnd persons dyinij dw<iy fro;n fiome. 



AV* '/(//■(/ //' S'(/// /'iitih 



) Id I .- 



Mnnth, 



lh>\:^ 



I'm: \iin\i-: st xri: d im'-rs* i\ m, r \ fc iiir i, \ks au i; rki}''. n > rii i- 

Hl'>r(>l' MS' KN< )\\ l.l'.IX . I'. AM) i!i:i,i):i- 



Former or 
L'sual Residence 

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



How lonq at 
Place of Deatti ? 



Odvs 



( In !• >: m:iMl 



(Address I J^ ^ 



'W<X/>v 




\ 



\. 



V\.\QV. (>!•■ HCKIAI, «»K K1:M()\'AI, | I)\TI:<)! liiKiM. (.1 ki;M()\\I, 

' ' '' ' (hi 






INDI'.K rAKl":K 

(A.lLssTbl Oil 






V.'iLQ. L C > V 



■jl 



[\, K. ILvcr.v itom ni iiiVormntion should be cnroltiill.v Miipplied. A<ir. Khoiild l>c Htnted KXACTLY. PMYSICIAINS nhoiild 

Htiitc CAlJSn or Df- ATH in pliiln terms. th«t it miiy Ik- properly cluHHiliicil. The "Special lnformHtit»n" Ir'or pur- 
Honv dyin^ nwoy from home should be Ji'ven in every instance. 



-^ 



y 



-J 
c 



V 






I 



; ) 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANETNT RECORD 

,;.„. 1 ,; II. vn. !v .-''■r*-...^^v,i., ,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




IfJO'i 



]le<:> I stored Xo. 



2893 



l^vv^XtxK^ Deputy ^'-'.tth Officer 

DEPARTi^lENT OF PL'BLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

I "U. 5. StnnC»arC> ) 

oo A ^ 

^^ -^ ■ :^ -' City of 0/CX->v J 'V a > ^C \ 



PLACE OF DEATH: — Couniy ofC'-Cu^^ '.cl 



No. 



V s. 



St.; \ Dist.; bet. 




(X^CHAj 



^. '". o 



and ^J .'Ct-ii/LC\ 



(^ 



/ ,r DtATH OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




'<X)\.<X cxMlX) 



\^ Ct > V4X/>\^ 



PERSONAL AND STATISTICAL PARTICULARS 



I ; . I-; 1 1 i 






TQO \ 

(War) 



/I HI 



L? 



A 



w III. ' \\ i:i> <>K i>i\"< >k>"i"i> 

\\ - :t : 11 -■ « i.il ilc-i'.Miatiiiii) 




\ 



\a\\.^.^cL 



C^-/^< 



\ \ M 

!■ \ I IN l< 



luK I'll I'l, \» 1-: 
. I! 1 \ III Ik 

'- • • . ■ i ! 1 1 : n V 



M \! Hi; N N \M1 
111 MoTIM'.K 



HIK I II I'l. \ri: 
n|- M<>Tm-".K 

( State III Couiitl \ 



oVlL^u 



0. 



a A.U '^- 



\ 



? 



MEDICAL CERTIFICATE OF DEATH 

DA Tl-; (•!•' I'1;a ill ■' 

Vjlnr L 

(M-iiillO (Day) 

p,^ I iii:Ri;r.v c'i:R'rii"\'. rii-n i .iiii.ii.ir.i .u-ciascd frcm 

tll.-il 1 \a< saw ll •■ ali\fnii VlA-XTL* -^ Kp'l 

ami lliat ik-atli < •cviirn-il. nii the date staled al)ovc, at 1 oO 
^l M. 'llu' CArSlv Ol' hI'A'PII was as follows: 



wAA-VC 



DC RAT ION 

C( iN'i'RMU'roi 



yt'xirs Minilhs b Pays , Hours 



DIRX'CION >•' Years'^- Mouths 



Diu 



'S 



S I G N E D > 0\L' MutX^cL- Ot- -IW L > VCyt fc >\ 



Hours 



M.D. 



'A^t-VCL 



t< 



( i> rri' \ 11 






^ \l. ,'lh- " P^! 



•nil- \uovi. ^T\Ti:i> i"i:kso\ \i. p aktuti, \k> aki; rKiK r.) tin- 
iii;sr ni' MS KM •\\i,i;i)(;k and iu-.i,ii.1' 



( 111 fi)' mint 



^^yuJUm; 




f'^ 



\fV L i(,o'i 



fAd<i.v.s) Sib mav-k.t \ 



Special information "nl) for Hospitals, Institutions, Irdnsienfs, 
or Reient Residents, aniJ per'sons dyinf] <m,i\ fro n home. 



Former or 
Usual Residence 

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



ffow long at 
Place of Death ? 



Days 



I'I.ACH OJ- IIIRIAI, ok KIMKXAl, 



.b^<^ 



I) \ IT. i>! Id KiAi. ui RI';M(»\ AI< 

Q^Vu- ^ 190H 

iM . 1.; K T A Iv. K U <X^Ut'> vli6 \^ U 
(A.Mu.ssiSlH O.i^t.fcUn.J'lt 



' ^ ^^^^ , .. ... .,>r «l,,...l.l he Ktiiteil F>X\CTLY. PHYSICIANS nhould 

N. B.— r.very !tc.„ o.' •.„.-.>,M„»t1on Hhouhl h. cnrcV'ully suppi.ecl '^;^'^;^'^^'^l ..gpcciBl Infor.notlon" for p.r- 
Btntc CAlISr. or DEATH in pliiin terms, thnt it miiy be properly wiat»smeu. j 

son* dyinft nway from homo shoiilil be ftiven In every JnBtnncc. 



I 



* 



I 



1^ 



i \ 



t. 












!|i 



m 



Y '1*',' 






ft',; 



WRITE PLAINLY WITH UNFADING INK 



f.'"-^>. 



t JI. I'tll 1 V'. *:••' -T '-i- !:."^ 1' Cm 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Dafr nii'd, ilca)^o^A.(M^ 7 100 M 



\M^ 



JicgLsfered A^o, 



2894 







^u,A,c^ vcv^ Deputy Health OfHccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( X\. S. Stan^ar^ ) 
PLACE OF DEATH : — County of ^ >v 1 .\xx . ^ City of vj a. >v J ,\x>^ > . 



q 



and 



No. ^ctu ' ^C\... iwV.L ',. ' . . . I ' St.; Dist.;bet. -..v* 

,( / IF Dt*TM OCCUHfe AVW*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION \ 

Ij V, IF DEATH OCC^IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 






lA 



PERSONAL AND STATISTICAL PARTICULARS 




1 



n 



\ 



ii • 



; (•■. r 1 1 



^7^ 



\' .1-, 



%!■ i;tll' 



)■ 



^ 



I),,v 



.v...,'// 



MEDICAL CERTIFICATE OF DEATH 



DATl-; •)!• I)i;.\TII A 



n^ . 



I go 

(Vfrir) 



fMoiitli) fl):iy) 

I II I'lK i:r.\' CivRTlI'V, That I ,tUfii<K-.l »k'CHaso(l from 



\(p 



to 



\ 



^/ 



I\l\s 



-I\< .1.1" M \K \< II-'.I> 

\\ ii»( i\\ i:ii OK i)!\< iKci: I) 

Wiitciii MH ia! <U><i>.Mi;it ioii I 



ItlK iniM \i 
(St.it- 



NAMl- <U 

I- A I! I i:k 



X 



\ 



O .o-v-vo/U 



I'.IKTIIIM.Ai }•: 

<»i i\rm:i< 



MAIIU'N NA\!1. 
(II MoTIM-.K 



lUIMlll'I. \t 1-, 
Ol' Mn'IIN'.K 

' stritf III I'diiiit I > 



I 1 ''^>' 





lt)0'i 

that I last ^a\v h -'vf'v-VA aHvc on nI Wv up 

ami that drath occurred, on the date stati'd aliove, at I'i ' '. 



M. The CArSh: ()!• DliAYH. ^V''^s as follows: 



DC RAT ION y<',n\ 

C"()\TRII!rT()RN' 



Mofillv 



l\i\s 



Hours 



? 



nCCri'A ri')N 







Ki-^itlfii in San /'i ii ih irn 



'^ 



) > ri 



DC RAT ION 



( Signed ) 



/)(7ys 



Qacx- 



}'i'(irs MiDiths 

'10 1 

(,n ^\ (Address) L^-L^~\^-^^ ^ ' * '■ 



Hours 
M.D. 



n^) * 



Special information ^nly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying awdy from fiome. 



1/ '/'// 



/', 



THI- MioVJ- sT\Tl I) I'I'KSONAI, 1-\K IK 1 I.NKs XKl-.TKIH TO TIIH 
HKST OF WS KNOW 1,1, IX. H AND WVAAV.V 



KSTOF^ 
niifi(iin:iiit 






t 



Former or 
llsuaf Residence 

Wtien was disease contracted, 
If not at place of deaft) ? 



HoH long at 
Place of Deatli ? 



. Days 



I'F.ACK Ol" Hrk4,\I. OK KKM«»VAI. 






I).VI"l'"f Hi KIAI, or KIvMOXAI, 

7 




190 



State CAUSE OF DEATH in pliiin terms, th.it it miiy he properly classhled. The Special iruorniHii p 



•Kvery itei 

state CAI 

son* dyinft away from home should be ft'ven in every Instance. 






i 






I 



It 

If I 

'I 



I ' 



I t 



WR'TE PLAINLY WITH UNFADING INK — THIS IS A PERM A NT \T RlCC^^D 



»=; E '" C «? "^ O F t ." s v^ •" J 



^- A - r fV^ «^ N 5 - <^ . / ' .' N 5 



.> 



WO 



.4 



.-v^ 



K.W 



Dep'it^ ^'-^'th Oniccr 



DEPARTMENT OF PI BLIC liEALTH-Ciiv and Counn of San Eran:is;o 



Ccvtificatc of il^cath 



u. ^ t•I;l!l^;u^ 



PLACE OF DEATH: — County ot 



L-.f 



A 



N 



S' • 



n-. 






^ ^ . ^ 



FULL NAME ^ 



^ V V. 



J^-EPSONAL AND STATISTICAL PARTICULARS 



MEDCAL CERTlfii'ATE OF DEATH 



_»w 



V < 



i. , 



\ o 



nf- 



N V 






1". Ti . \\ 



V '^ C ^ V 



t 



V v\ ^ a 



^ >\ ^ 



Ow-^v 



%^ 



A u a 






■ ' • : !»i:n n ami; 
<<i .\i<»iin:K 



III ri.A' »-. 
M<>rni:K 

: '''Mint t \- ' 



I !■ A'lK tX 



1 ' ' 



^Y>"v^A^ 




(X^ 



UHi 



-L 



'\ C. 



^ ') V, '^^ 



1 '1 u \ ri(>\ 

c'» »\ ru 1 1'i I'l 'KN 

I M RATION 



;"'.•! s 



SIGNED I ^. \) I I V.i. ' • - M.D. 

' - ( x.l.hr.O i.''X'A ^U^ l^vAxl .'t 



l()i> \ 



^P£C\fKL Information '"''^ '•" Hi'*>t»ii«iN. insiiintions, hanNiniiN, 

or Rnciil Rrsidnits. ,iii.l pi-isons ilvin!| .m.n ho'ii home. 



ly't- 'Jill : II Siiii /■'/ ,/'/. • '<•'» 



m \ I '.'.'> !•■ sT xTii) t'i.:Ks(>\ \i, r xu M'T I Ms-' \K I', i-Rri-: !■"> TIN-; 

lil.srdi MN K\< >\\ l^HUr.H AM) i:i l.ll'l- 



dti f' I'll) iiti 






Fornirr nr 
I'siiiil Krsidrnrr 

When wds disrdsf (orili.K fnl. 
II nol <il plfnc nl fliMll' • 



llnu hini| ,it 
ri.iM- ol Hc.iIIi ' 



n.i>N 



PI \^ 1 , ,1 !u K I \i, < li: K 1M< >\ VI. I I' \ 11 ..' IM 11 V n Mi .\ \ i 



I M 



IS. H. 



I»JINSICI\NS Nh«uil<l 



Itnto CXllSi: or DI XTH W. ph.ln terms, tlu.t it mu, I.. P-pcHy cluHsitficd. Th. Spcc.nl IntonnMtion ... 
Hr>n« flyiim iiwny liVom homo slioultl be ftivcn in every instHnce. 



t 



I 



i 
{ < 



i 



\u 






[i 



\ ' ' } 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



-> -. !;\ !■ >■ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hf/r ri/r^l, M\ 



f) 



X>C'\'- 



M 



Deo 






]i('i;>islr!0(J Xo, 



2896 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate ot Beath 



( n. 5. 'I'tan^aiC> ) 



^ 



PLACE OF DEATH: — County of 




CV. > > V. 



«w- 



City of 




,CV ^>V-»^C 



i.a' L<x.' 



> I 



No. 



St,; 



Dist.; bet. 



and 



/ ir DfATH OCCURS AJVAV r R o M USUAL RESIDENCE give tacts CALIFD roR UNDFR "special information \ 

V aTH OCCURHED IN A HOSPITAL OR INSTITUTION CIVE ITS NAME INSTEAD Of STREET AND NUMHER. / 



FULL NAME 




a^acuu.Uv-' db.cltLLu'vo 



\\ 



PERSONAL AND STATISTICAL PARTICULARS 

MA ^7f) \ '"'."K 

.1 



I i-; 1 1 1 



I' 



I 



MEDICAL CERTIFICATE OF DEATH 



l» \ II. t >1 I H \t'li 



A 



Xi. 



\I r,ll>) 



/ 



1 >.'\ 



\ ' I ■' 



I r 



'<INi ■ I.J' M V U !< n I 

w iiic ''\ i:i) ( >K i':\ ' "•> i-:i> 

\V I ;• : u v(i( i.i ; .|i-.ivti;il i'ln) 



(^ 



fVojvA.\_Ld 



I '.I!.: nil' 



1X1111 K 




CV 

fMoiilh) 



'1 



'l>;iv) {\v:\\^ 



I li i: i< i:r.N' ('i.k'i'ii-n, iimi i .iitcnit -i <ir.t;ist(i 11..111 

' ! 1^0 111 I(/<) 

t li.it I I;isl '-.iw li .i!i\ <■ on ic;() 

;ill(| tll.if ill atll ixcii t icil, <Mi tlif il;i1i' staled ;iliii\( , ;it 
M. 'Ilir r.\l SI'; iH' pi:.\'!"ll w^s .is lollnws: 



Cav\J 



V^^IA.'^ C^ 






ux^Vy 



JXVA 



lUKTII II. \' l''. 
1)1 1 \ 1 II 1 K 



M \!Iti:\ N AMI 
(i| MnTHl'.K 



lUK Til I'l V' 1. 
(II' MoTHHK 



? 



JU\/r\\XXj'y^^ 



I )1 k \TloN 



(. ( )\Tk I i;r'i'< >R\' 



I ) 1 R .\ Ti .\ 



) V(// N 



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//on I 



? 



( n iTl' \ I'll »N 
A ■ 



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OXA. 



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Vc \.*.^^ 



ix 




}'r(fr^ }/i>)illis /^avs //outs 

NED) IL. ll 'j1<xM&X<A. M.D. 



SIG 

O f (,f) { f \<I<1 I( s 



.<x/\v\X.^(x,> L ex I' 



Special Information "niy tor (ios|iif,iis, insijiuijons, Fr.insirn(s, 

or Kcfcnf Rrsidrnfs, .jrid persons dvimi ciw,iy Iron fiouif. 



/'. 



Formfr or 
IsUfil Rpsidpnce 

Whrn was diseasp rontrarfed, 
If not af plaip of dpatti? 



lloH lonij fif 
flarf of Ofafh .' 



Days 



nil- Ml' A I' siXTl I) ^M- K-(>\ \l. l'\KTICt'I,\K-- AK]' THli; T- ) Till-: 
I'.I'.sTdl' MN' K \< 'U I.KlH.i; AN!) 1! I '. 1. 11 ■ I- 



I 1 1 1 ! . . ■ 1 i r 1 1 1 1 



r\,inr.-^. iO'X'^ MK^vL<r>\. 



% 



PI.-XCJ-: '») IMKiAI, OK I-" r.\Ii >V \l, I I'X 





, 1 )! Ill I' I \ I 




r 'I 



^} ^ i I. 



!■ l.Mf »\ \I, 



rQol 



^i ,j —rverv U.m o,' i.^.rm.t i.n shouM h- ..rc'u.ly suppU-.M.. AOr. nhould be HtHtc.l f^XACTr Y PUVSICIANS should 
:;„t7c UlSr or OrATM in plaln tcr.ns. thnt it n... bo properly Ja««ir.ed. The •'Spcch.l lntornn.t.on Vor p.r- 
son* dyinft iiwoy from homo hHouM be <tiven in every inHtnncc. 



f 



< 



{ ^ 



I' 



]\.<AiA ..' II. I'; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

■"—7":. !;\i REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



L 






lf)0'{ 



Jiro'/\s/r/'Pfl ^Vrv. 



'^897 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

I 11. 5. 5tnnc>arC> ) 



■X 



PLACE OF DEATH: — County oi'JO^-t\j' ^^- v^Ci^^c^. Gty of ^<^ "^v .Va>vcv4<- ' 

^ 1 [\ 



No. 



,.., St.; 3. Dist.;bet. •' <X<.^.A.^• and i^)^-v.^ 

> rATH OCCURS AWAV TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U N *) E R 'SPECIAL INFORMATIO^' "V 



(( r ATM ( 

IF or AT 



H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA0|OF STREET AND NUMBER. 



FULL NAME 



JJ -CvL^i^wAj V/*^ 



L 




PERSONAL AND STATISTICAL PARTICULARS 






^ 

o <.^< 



' 'K 



'1 



,iH( 



\' 1 



I'-' 



1/. 



-si\t i.iv M \ Ki< n;i) 

wiiH tw i:i> <»K' !HVt»KM'i;i) 



\\-. ;i. .' 1, 



|. 1 ; II 



1- Alii 1 K 



i' .!( •'■.'iKiti'Ml) 



iiiK rui'i. \v 1-: 

(»l 1 \III1K 



MAIDl-.V V\M1 
..! \!<»Tm K 



I,! K i II IM. \K i: 
..|- MmTIM'.K 

:■-'.. I ^ .11 Ml I \ 




MEDICAL CERTIFICATE OF DEATH 

p \ riv I '1 in; A I'll 






1 

' I):iv^ 



/Qo'i 



I i I i;is i:i'\' C'l.k'l'IlN'. That 1 attiii-lrd iKvr.istMl tiian 

\]Ka..u '1 upS to Q\ov ". up\ 

that I last ^a\v h ?•' .iliwntj VlVrL'' up^ 

ami that <Kath ( iri-iirit.'il, I'li tlic ilalt.- ''tal(.-<l ahoxx', at II oo 



C:. M. Tlu- CAT SI-: ()1- Di: ATM was as follows: 

-VQ, OXa nJA-CUU 






\jX 



.c\"L\aVlUv 



CUlA.(XOn,i.t\Lc 



' I M N 



1 I 



n C 









( K''l 1 






DIRATION )'('iirs 

C()NTU!!;l"i"<»I 



I Monlhs io Pars Hours 



..aov ■.. 



I ) r R A T K > N 
( SIGNED > 



)'/7/r\ ^- Minilhs 



I hi vs 



6 1 



C3I-^\-^J- 



il 



<x)LLa\ 



I Ion in 
M.D. 



T(,n \ (A.Mnsv) ^' ^ C' A. U^tVv ..A 



Special information <»n'^ '"f Hospildl*!, institutions, Tidnsients, 
or Rerenf Rfsidents, dnd persons dyinj dwdv from hoinp. 



A • 



'11 )-<v< 



1- -'Ir 



1)11. \!{(.VI- sr\Tl-I) rFKs,.\ \1, l'\K Ih l! \Ks AKi: TKii: T" THK 
l';l>rM| MN KNOW 1. 1.1 ><".»•'. AM) MI-.Ml.l' 



( In f.r ni:nit 



i— — » — -IJfT i. l i J ' I ' Wi' 






Formfr or 
Usual Residf-nre 

Wfirn Hcjs dlspflsf fonfrrirted, 
II not .it pl.i( f of dPdth ? 



HoH lonq at 
PIdff of Dfdth ? 



Odys 



I'l \CK Ol" nCRlAI, OK KI-.MnVAI. 

On M ^ " 



n vi'i- >' 1'.' i!.\i, I.I u i-;m«>\'ai< 

T90H 



\ I I- >• I. r!.\i 



,„,,,„.. iS^-Hsn diAXU^u .).t 



p,. „._j;very Item oV Infor.n.f.on should b. ...u^'uH.v sm>,.lK-.l. ^^; /J;;^ '^/^'^^^'^^..^i^^^ ..SpecinI Inforn.H.ion" for p-r- 

«tiitc CMISr OF Di: A TH in pliiin terms, thnt it mny he- pn.pcrl> clOHsmtu. c , 

Ron« tlylnft nw«y from home should he ftiven 5ti every inntfince. 



: f 



li 






! 



WRITE PLAINLY WITH UNFADING INK 



Ito.ird of lit alt 1i 



., V.SiV I"' 



/hf/c /•V7r^/.ML<r\^^"» 




1 



.\' 



If^O'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFI CATE FOR INSTRUCTIONS 



]iro^/,^/rred J\^o. 



'■'. , \ 




TjI/v-u Deputy Health OfTicer 



djvvo^:^ SJl/V-u Uepuiy ncLiiin ^^niuur 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of Bcath 



i 



^ 



N,yri.; 



PLACE OF 

A 



. ^0 



DEATHr-County ofCW.^ XQ. wCc.. - City of O C^iA. O/^C^wev^c^O 



St.; 



Dist.; bet. 



y ^ V . ^! ^^ ^^^--V^^^;' , pfsTdENCEG.VC FACTS^CALtrD rOR under ■sPr-.-AL .NroRWAT.ON • \ 

.'cu%*Rrc:,rt".c^s^pVT''A!: :« ?ns'?J;'o'n"c'.v. .ts name .nst.ao o. street a.o nu^.er. ; 

^ ^ ^ l\ \ 



/ l».jC. fcATH 6CCOI 
V. ir DEATH OC< 



FULL NAME 



L 



LI 




.v( 



UX^^\^ \^l'WY\y^^^\^ 



L 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I 1 i!.' 'K 



1)1 



■^ 



clO- 



\ v^L<- 



\] 



;1. 

1 1);iv 



\' 1 






■>■( ;irl 



/' 



lUK rm-i 



I \ I 1 1 1 K 




I'.iK I ni'i,\»"i-: 



\1 \ I I '1 \ ^ ^ M 
» (1- M< '111 '■ ^< 



HIK iiMM.Arr: 

-III, . ,; (■, Ml 111 1 \ 




MEDICAL CERTIFICATE OF DEATH 

1. \ ri', < )i i»i" \ I'll 



vyic. 



(Year) 



< Month > (J''»y^ 

I lIi:ki;rA' *. i; K ril'V, That l it t. mi. Ud deceased from 



H)0 



to 'I uc.v. L 190 H 

that I last saw Ii • • ahveoii • ^'P 

,.,,1.1 that death nreurre<l. m, the date statf.l al.nve, at 
M. The CAISI': ()!• Kl. ATM was as follow^ 



o < 



dUhNi l.lwqcOL^ V^CU 




XxkhM^ ' '^ <- 




^ C^ 



ll 



o^'> vcL 






)V 



M.'iitlr 



^n^In^W^il^^ '■" ■'■■"■■ 



nnf'i- in ml 







1)1 k AidoN 






Mo II I /is ^ /'<ns 



//o/n < 



J/<>!////S 



)<iiis Moih 



/\iv 



//ours 



M.D. 



DIK \ rioN 
( SIGNED ^ 

Vlltv; ' : i()n'> 

"special information oi.lv (or Hospitals, Institiitions, rrdnsienfs, 
or Rpffnt Residents, and persons dyimj .m.i\ fro;ii home. 



M.i,i,..ssmti^^^^WU...v<vJ - 



former or 
Usual Residence 

When was disease fonfrarted, 
If not at place of deatfi? 



Ilov^ lonq at 
Pia* c of Deatli ? 



Days 



)C 



I) \ri" o! It! "'VI •" i< i--^'' )\ \\. 




I'l \C1" <)1- IH KIAI, OK R|;M(>\ Al 

r.xii,. ss 1 f>S 'I QnriAA.<^-v<r>A- .01 



190 



PHVSICIAMS Hhould 



__^-------«B«^ ♦ I fWCTI Y Pin'SICIAMS kI 

.on. .lylnft ■.«..> *Va,n h.....c «h,.ul.l be »»... ... »>.r> .n 



I 

I « 






w 



RITE PLAINLY WITH UNFADING INK 



|!,,.,r,l .,. !!■ .'I'' 



■-•^"^■H^IT.. 



CA>4yY>vlvt\' "I 



liiO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Rr^ii sirred X<>. ^899 



I III I, n/ri/AX 

l^v^<-^ Wu Deputy Hr-M, ORlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDcatb 

PLACE OF DEATH:-County ofOcu^.. J>^ ou....Gty of da.^.- ^ ^a.. ..^c. 

\\ ^ 

r^^^ V,^^^-' V. ,,ciiai l*r«;iDEi 



Dist.; bet. 



and 



-) 



_ - ^\,<XV OL X-^ \\^^ .V\L.A\. .' ' Ol.t VJV.7. rn roB UNDER "SPECIAL . N FO R M ATI O N ' ' N 

. . OE..H OCCURS *w.v .ROM USUAL J^^f^^^^.J'J;^,--;* ;i n"aME ^^^r^^oT. street .no .u.oer. J 

V r death OCCURRtD IN A HOSPITAL CjR I N ST IT U T I u ■>. 

FULL NAME 




\ 



! I \ 



PERSONAL AND STATISTICAL PARTICULARS 




!• Ml 






\ ■ . 1 • 



5 >..■ 



•^I\( .1 I" M AK l< III* 

\\ MX tU I I' '•'< I>:\'>l'*'l-I» 



iiiK;iM'i,\ri-. 
^1;,', , ,' r.,.uiiti\ 






(i 



\ \ M 1 < '1 
I \ 111 IK 



Xjub hJVcx->v. 




lUR IIIIM, \^ ]■'. 
(»| 1 AIUI.K 
St:it< 'It Count IV 



M MDIN" N \MI 
dl' M(»rill'!< 



IMK iHIM.M'K 

Ml \i<>rm-:K 

I Stat' ' '1 I'll! lit I V 




MEDICAL CERTIFICATE OF DEATH 

i> \ ii: Ml- i)i;a Til 1 ^ A 

fMunth> '"^'V^ '^'^''""^ 

I ll!-:KI-:r.V njrniN, riiat l atlcii.k-d dcvcascMl tnmi 

HP ■ to — T()0 

that I last saw li alive- on ^ '90 ~" 

an,) that .K-ath ..(ouried, on tlu- date stated ahovf, at 
- - M. TlK- CArSI- ()liJ)l'..\TII Nvas as follows : 



,:::> 

< 



r' 



V 

-^ 










1)1 RATION )',//-.s- 

CONTKirdTOKV 



Months 



/hus 



I lout 






V 



1)1 RAT ION, 



)V./rv 



Monlhs. 



Days 



Hours 
M.D. 



(SIGNED) OAX<Ll^A^K 0. LCLO^-V-YViAj. 

'1 H,oH fAddn-s.) b(^b dc^tlxA. Ol 




(i\r 



SPECIAL INFORMATION onlv for Hospitals, Institutions, Transients, 
or Rfffnt Residents, and persons dyini] away lro:n fionie. 



). (ITAIION J? 

,■,■ .V,,i/ / ;<7//. •■>'•-- vjL' ' ' •■" ' 



A'^- /./'■■■' 



1/,.)/'//. 



/»,M 






Former or 
Usual Residence 

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



How lonq at 
Place of Dealli ? 



Days 



iM.ACH ()i-\i'.rKiAi, OK ki;m«>v\i. 






liXU!"; Ill KIAI. <'i K I'.MOVAIv 




mate CAIJ>»L Ut !"-» '.._...,, u.. ^:v^n In ever* instnnce. 



«tatc CAUSE Ul- in:,^. r. ... „ .... — " instnnce. 

«on, clylnil ..wny from homo shouhl be fe.>en «>er> 



» 






I 




w 



R,TE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD 

BtF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2900 



1. i;\|-'-.. 



• Officer 



Jic(>is/cf'ed *^Yo. 



OEPARL^IENT OF PUBLIC HEALTH=Cit) and County of San Francisco 



Ccvtiticatc of Bcatb 



PLACE OF DEATH:-C„™., of3 a ^^?>.cu^..«o G,y .,3^- J/^^^-"> 



,^ 



JIO^ ' V\ A i ^aVI I' cL C^'rVX'^'^^^'^M S^** ^ DlSt.;bet. •specAL information 



) 



FULL NAME 



MV ^' 




xJb 



PERSONAL AND STATISTICAL PARTICULARS 



J (\<X^^ 



1; IK 111 




A-il 



■» . Ill 



MEDICAL CERTIFICATE OF DEATH 

p \ 1 1 » i|' 111. \in 










b?^ 



ck 



1/ ;,/// 



,1 V M \KU n:i> 
..»\\ i-:i) «>K i)iy«»' ! I) 

.,• ill o«Hia'i (U*'«iv'i 



C^c^^cv^^ 



S A M I "I 
I \1 li IK 



4 



)\^^'1\XX) 



e 1 



LOI' Livtr->v 



11! 



M \ 1 I'l. N N.\M 1. 
.,1 M..T11HR 



UIH i li !'I. \' 1. 

tiV Morin",i< 

f^t:it< "I- t">Hlllll •. 



V.' 

f^f.id.-.! Ill ^o''/ / /-■' 




I m.;ui-.i;V rikTil'V, Th..t ^ atU-n.U.l .kTra-,c-.l fpun 

t1,;,l I la.t vawh'- . alivvo!, -I -' ^'P 

,,„.ni,al.U.all, ncvurrcil. . ., th. .laU^tat.-l above, at I 
lL M. TlK- CATS!-: ()r l)i:.\ ril was as foll.>ws: 



O.NTKir.l TORY LKx^>^^ ^4^^^^ 
f SIGNED ) 



<H- 



? 

r 
r 

■■>! 

^4 



)', iUS 




Moiitin 



M.D. 



i(»n 






"\ 



2^'i ^ 



M.~vlh< 



I\r. 






1 n I' 11 tiKinl 






., ci- 



DdV' 



■"Fecial information ""'^ l'^ llospilnls, institutions, Transients, 
or Rerent Residents, and persons dyin^ j^^hs Irm, h.,me. 

f\ \ ] How long at 

Former or 11 jJ ^^, p, „j pe^n,? 

Usual Residence ^^"^ ^"-^ ^ ^^ 

When was disease r ontraded, ^ . , ^ ,o o ; 
If notatplaieofdeath? >^ ■ y ^; j^ ■ 

Auu I ' ''> > 



)\ii- ..! I! KiAK i.r ki-;m«>\ai, 

a' 



r 
r 



jWc I 



190H 



!S. 15. 



I 
^^'^"•"'" ^ r ^ --^ ~7 , y^.nyt Y PHYSICIANS Hhoulcl 



LOCALITY OF 



RECORD S 



SAN FRANCISGO 

« 

COUNTY 



S AN FRANCISCO 
CALIFORNIA 



I CROP I LMED 



FOR 



THE GENEALOGICAL SOCIETY 



OF SALT LAKE 



C I TY 



UTAH 



CALIFORNIA 



DATE 




APRIL 



PH OTOGR AP HER 



1975 

MAX J OHNSON 




CAMERA ■N026831 ^^^ 




TITLE 



RECORD 



VOLUME 2601 -2900 



^* 



f^ 



Jm JL. 



n 



*» 




ROLL 



\ 



LOCAL I T Y OF 



<. 



R EC0R4) S 



T I T L E 



RECORD 



SAN FRANCISCO 
COUNTY 



S AN FRANC I 
CALIFORNIA 



/ 



DEATH CERTIFICATES 



-.». 



I CROP I LMED 



FOR 



T H E G EN EA LOG I CAL SOCIETY 



VOLUME 2901 — 3200 



OF SALT LAKE 



CITY 



UTAH 



C A L I FORM I A 



DATE 




APRIL 



PH OTOGR AP HER 




CAMERA BnoPSSS 




1975 



MAX JOHNSON 



RED 



* . ■ '■ 






• ♦• 



f , 



4 'a. 



EGIN 



» 




^ 



V, 



I 




'^'*'^^« 



••••^XfrTi 



t^ 



HB 



•-• 



<>f J, 




• *» 



TTi 



write: plainly with unfading ink — THIS IS A PERMANENT RECORD 



a»-. 



}!..:. 1<1 ..f IK.-r.tli 






REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



l)((h' Filr(l ,\[\jr^j</r^\l>-L\, 



iu(n 



lie<:ihte}'C(l jYiK 



901 



.M-<^vo ^ <. ^ ■ ■ 



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



PLACE OF DEATH: — County of 



Certificate of IDeath 

city of ^ ^ > v-v^ ^ ''- v.crlx5\.a.a. 



No. 



St.; 



Dist.; bet. ^ 



and 



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



FULL NAME 



4- 



A^K. ) ^.C 



-u- 



-):\ 



i» \ 



PERSONAL AND STATISTICAL PARTICULARS 



^]\cli 







_CO^c 



I . . !\ I ] 1 



/%HH 



I I);i\) 



I » r;ir 



\' . i: 



l^r 



^ INC. I.I' \T\Kkn: I' 

w . , ) 



? 



lUR ill ri 



I I ,11 )!I I \ 



MEDICAL CERTIFICATE OF DEATH 

i).\ri-; oi in;.\ 111 \ 

I'd 1 (■ 

'Month* (Day) (Yt-ar) 

I IlI'lRl'lJV C1:rTI1-\-, Tliat I attcinkMl «U-coase(l from 



TQO' ■ 



190 



to 



lliat I la^t saw \\— alixc nii 



——190 



aiil that di'atli 1 icfuneil, on tlu- (late sta(«.'<l alxn'c". at ' 

M. The CAl'J^I' Ol" l)i: ATII was as follows: 



\ \ M 1 (H 
I .\ 111 ! K 



Ml kill r: \> 1.; 
Ol" I A 111 i: K 

'State Ml i"i)iinl 



M \ liii:N N \Mi; 
01 MoTlll-; R 



inKIIIIM.Atl-: 

01 \:<ri*in'.K 

' Sl;it. 1,1 rollllt I \ 



'• ' I I'A TK (N 



? 



L 



I V 



DIU A'PION 
CON'l'kllM'roKV 



) 'car 



Mouths 



Pax: 



s 



I/oiirs 



1) 1" I^ A T K » N 



)\cirs 



J /',>>////. s- 



(T) 



/h7VS 



? 







fVU 



' w v_ ^ 



^ 1 



( Signed ) LC* . v3 >)L ^x■o.. , v Uvc , • ■ ' 
^''d i,,o', (Address) SJ-e/vw-ov vl^U' 



Hours 

M.D. 



Special information only for Hospitals, Institutions, Transients, 
or Rprcnt Rrsidents, and persons dvin;] away fron liome. 



AV ,.,'/■./ //' Si!)' / I tllli />('/' 



V..//,'//~ 



IK 



111 1: \ii()vi<: ST vn: D j'krsonai, tar run, \ks \k 1; i-ri i". in 11 1 !•; 
in:-.r (>i- .Mv KM »\\ij:i)<'.i% and lu i.ir.i- 



(Infii'in.-inl 



liv C 'uA-t.[ 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 




\,M 



...s i5l Cj-c^^JJoa. Ot) 



I ni)i;r r \i; I'.r 

r\(l(lrcss 




1) ATi; o!" liruiAi, 01 ri<;m«)\ai. 



l'I,ACl<: Ol- FMRIM.OR R1.;M(»\ \1 



N. B. hvcry item (ti itif.irniiition kHoiiIiI he cnrot'iilly suppliotl. A(ili shrmhl |>e Htntt.-d EXACTLY. PHYSICIANS Hhould 

Htiite CAlISi: or DI:A Til in plnin terms, thiit it mjiy l»o properly cliiHsiricil. The "Special informntion'* for hmk 



ROTis clyinji iiwny from hnmu HhoiiUi be ^iven in overy itiHtniicc. 




^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H();ii.l ..f IK:i!th I- V 






REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 







J-^ 



V 



I!/ OH 



Iirgi.str/'cd A^o. 



'^902 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccctificatc of E>catb 

( TX, S. S?tanC>arD ) 



No» 



PLACE OF DEATH: — County of 



/ClA-vL<X^-\. c^. M W^Lk 




-v^ 



vcd 



City of UKX.I•CL<X.'^'vC^- L-cxt 



v_ 



St.; 



Dist.; bet. 



and 



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



FULL NAME 






<rvvAX) L/Li- M I l<x.\Xc > V 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



i^ 



i\J 



A 




\ . 



\.c 



u 



DAir: oi iiiKiii 



\t .!•; 




MEDICAL CERTIFICATE OF DEATH 

DATl". nl I)1;ATH 




.tar 

(Month) 



X 



(Day) (Year) 



Motiihl 



L^\ 



)'»<// > 



i( 



1 
(n.-i\ ) 



^!n„tl,. 



r 



{Why) 



/',M 



^;n«". I.1-: MAKuii:i) 

\\Ii>()\\i:i) OK I»I\<)Ri.l' I) 
Wiitiiii ^<n-i:il (|(--i'_'ii:il i' 111 ) 



I'.IR IMII'I, \0K 

I St.if 1- i>r r>iunti \' 



\ \M 1 I »1 
I AIM IK 



lUKTHIM. A^'K 
<)!•• I-Arill-.K 

( St;(t(' <>!■ (.'dUIiI ; \ 



M\!i»i; \ \\M1 
III- Mi'TilI.K 



lUK iiiri, \t~i", 

ni- Mnl'IlllK 

I Slat' .11 r>iinit I \-) 




1 Il!';kI-:P.V CI-RTIF'^V, That r atten.kMl (U-reased from 

—"TyO ~ to iqo 

that I last saw h ^alivc on "" icp ~ — 

and that death ixMnirred, on tlic datr statid al)()vt\ at " 
fy^ :\T. Thij CAIS1-: Ol- I)i;.\Tli was as follows: 



J ^oXIm oUjUy£ v\X^v.O^L\..^ fc 



JLo.: 



DC RATION Years 

CONTklinToRV 



Mouths 



J\iys 



Hours 



-t\ 



) » u . I ^ 



tV> 



KX^'^- . 



1 J 



t 



'^ 



Jl>v/> . • >vl 



ocrri-ATiox i' 



M^ . 



DIRATION 
(SIGNED ) 




)'ra 



IS 



.Vou///s 




.'^ mVlUvvvvvou^ 



I louis 



Da vs 
vwsu UjYcvaX^ M . D. 



AV 



->,',: ! 



I .: 'h ''.' 



) -■<•?/ . 



M.nfh< 



n.t 



rill-: \M()vi-: stami-.o i'i<:k<.()nai, v \\<y\cv i.aks ak j: i'k ii- T( • rii j- 

Ill'.ST Ol' MV K\o\\I,r.I)C.l-: AND lil'.l.Il'.K 



'■ 1 II f'l; m;mt 



OlUvb (E 



''VtKAr^v 



/cCtvLo. 



x.i.iicss \U,oj(<..LcX''N\x:i^ L<x.\ 



I; 



Special Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyin:] away fron home. 

Former or 
L'sual Residence 

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



How long at 
Place of Oeatfi? 



Days 



DA'nv of HiKiAi. or RKM<)\AI. 



ri^ACK Ol- I'.ruiAi, OK ri;mo\ai, 
AlLal^tTYVOu^ 
rxDi-.RTAKi.R UJ(JlM>J7 vJj \j^\j<rY>u 



""' "'"rtnT/c'^rSF^of nrXTH" '''T-' ^' ^"-^^'""^ Huppne... AGE «houIcl be stated F.XACTLY. PHYSICIANS «hould 
«inl 1 -^ ^ .1 '" ''i"'". 1""': **'"' " •""* ""^ P->«>«^Hy cloHsified. The "Special Information" for per- 

sons dyinft away from iiomo should he (iiven in every inHtnnce. *^ 



9i 
I 



WR!TE PLAINLY WITH UNFADING INK 



H..:ir.l nf ll.iilth- 1- No. !«. ■^"t'^'.'r*" ''"'^'' ^" 



/hf/c F/7('(/ MuroJi/Yy\JMy\} 



lf)0\ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jlro^i.sfr/rd .Yo. 



^L^o ll\H^ Deputy Health Officer 



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



Cevtificatc of 2)eatb 

( H. S. 5tan^avD ) 



PLACE OF DEATH: — County of C\cl^^J-VCu>^.xi^A/cc City of Q /O^^^ /vcx/^xx^^ax^o 



) 






£ 



No. 3^5 ^ '^^ ^J CLCvi^A^c V.I ' St.; ^1 Dist.; bet. CJ .tjL^AxJL\. and VJ.aJL^vo^:, 

)it:uRS AWAV FROM USUAL RESIDENCE GIVE facts called f 

H\pCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME II 



/ ir DEATH oit:URS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \ 
V IF DEAThT'>'-'-"«»0( n IN A wnciPlTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



lIvlI ■ kvWtrv^ 



PERSONAL AND STATISTICAL PARTICULARS 




a 



I) \ II', <H I'.lKIll 



A*,!-: 



'OfW 



Moiitli ' 



55 



),.!, 



^1 



.1/. «/'// 



/IH"^ 



(Vriir) 



/',. 



S INC I.I*, \t.\RUIi:i» 

wiix >\\ i-:i> <>u jiixi It;. 1,1) 

'W'lilc in --ocial ili'.'-i^'iii! t '■ >n ) 



I Stat I or <'<iiuitr\ ' [ i ) 




ojuvoidL . 




!■ ,\'ni IK 



It I urn iM, Ad- 
oi' iATm':K 

iStatf or Country) 



M AIl)i:\ X \M I', 











Ill- Mtiriii: i< V. u 



^V^LA 



\A\' 



)KX">wK>^rv< \ . 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- i>i;ath /> 




(Moiitlit 



(I)av) 



/QO t 

(Year) 



I Hl'lRl'J'.V CI.R'ril'V, That I atteiiikd (IcrL-ascd from 
ii)./cl. 11 icoH in JK^ .b 



190"^ In \l*-\iV «W iqo'^i 

that I last saw h l.< alive on n* vc v icjo 

an<l that ikath occurred, (»ii the ilatc stated above, at O^ivX S '^( 



M. The CAISI' OI' DllATll was as follows: 



niRATlON 



lOi 




L 






wd.1 J -V ' • 



alt 
nr RATION . Years Moulin 



( SIGNED ) 



\Jr\t\VU^ }bx\ v^AjU'^Xj 



/^ays 



■ . \ 



nik'niri.Aci-: 

nl M(>'nil-:K 

(Stat' 1 II Count I \ I 



I )v Til 



^7^ 




a^^viL 



AV-, ,/.-./ ■/' V,;,,' / ; ,',7, '■/-. -^'^J ) V,;; v 



M.^n'h^ 



/',n. 



■nil-: AitoNi-: siai'd:i) i'kksonai, r.\K net i,aks ,\ki; rRri: ro iin' 
iM-:sT oi' Mv k,n(i\\m: I )(.!•: and i'.i:i,n;i-" 



( I n fo; mant 






r 



0^.ctU.^ ^k 



I lours 

Hours 
M.D. 



Special Information only for Hospitals, institutions, Transients, 
or Rftenl Residents, and persons dyin.} away from fiome. 



Former or 
Usual Residence 

When was disease rontrae ted. 
If not at plareof death? 



How lonq at 
Plareof Death? 



Days 



IM.ACK ()!• JU-KLM, OR R1.:M(»V,\I, DVn.of ISikiai. or RKMOVAI. 

^, Oil? C>vt>^od.^^ ^^ _jooH 

fAd.ln-ss ,i$'^','?>S'^ QA\..tU^J it 



IN. B. Rvery Item o¥ Informiition should Wt carefully supplied. AGF. Bhould he stated EXACTLY. PHYSICIANS should 

state CAlISn OF- DIIATH In plain terms, that It may he properly clossifled. The "Special Information" ?or per- 
sons dyinft away from home should be feiven in every instance. 




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

H..ar.l ..t HcMlth F No. r- '>-?^~ H.«vP Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lUt 



fc File(l ,\[\xsj^Xrr>\X} 



)JL\} 1 



100\ 



Re(!fstercd J\^o. 



8904 



\ 



li 



XM,cvc ■ v><i Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificate of Bcatb 

PLACE OF DEATH: — County ofU/CU^r^ J J\.<X^^cui.c^ City ofC)/0^^>^ A.<xn,^Cv>i<^c 
No. 3.11^ CricLC ) ' St.; :\ Dist.;bet. ^0 .U\. and Xl Al 

(IF DEATH OCCURS AWAY FBOW 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 NAWE INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



\\.o 



^\x::. 



PERSONAL AND STATISTICAL PARTICULARS 



'^ 



!> \ll I '! r.IK I'M 



Oct 



M.nith' 



Ul.U 



'^ 



4 



I lav' 



)■, ,;; 



Mouth- 



1 



l\i\ 



si\(.i.i- MAKkii;i), 

iWiili in ^'n'ial di-if ii:it !• m ) 



niK'nu'i, Ai'K 

iSt:it< or I'oniitrv' 



NAM I OI' 

!• A Til i;k 



lUK riIIM,\rK 

<)i" J aiiii:k 

I state lit (.■(illlltl \' 



MMDl'N NAMF. 
<)1" M()lin:K 



HIKTIIIM.AOI-: 

<)i- Mt»rm:K 

(State- or ConiitVN > 




r 

\ _ 5 




MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

b 

'Dav) 



a, 



Month) 



rgo "I 

(Year) 



1 in:Ri:nV C1:RTI1-V, Tlmt r attciukMl (Ucvased from 
U.ct 'i-L' u,o'-. to VrVtPJ^.. b 



I90 '■ to VI V^tPJ^. A?. l()0 H 

tliat I last saw h >. • alivt- on VlUtfX'" L Kp 

and lliat «k-atli occiirrt'il, mi tlic date statcal above, at 
M. The CArSl' OF Di-ATI! was as follows: 
O^.V\.XX.>\.vJ ^. t: . .. cWsJl ;i^ .■|.'XN..ct.jJx(X-l ■J.. 



\ ^ > > \ ^. 







/VO^ 



a 




I) r RAT ION Years 

CONTRIIU'TORV 



Motiths 



Da vs 



Hours 



deration 
(Signed ) 



) 'cars 



Pays 



> cars ^ font /is 

\l W^ ^ i()0^l (Address) X'lC) I JCr-l<i.(n>A, ^1 



Hours 
M.D. 



J -iA/»\-'^ 



1 .'.i 



'UATPATIOX 

Is- ■.:,-.; Ill S.\<l I : .in, ! ,-,> 



) Vfl ; . 



M.oi'fi^- [ />,! 



THl-: MIoVF: Sl'A'I FI) i'KKSoxAl, I'AK I'UMl.ARS WiV VKVV To 

mf;st oi" Mv KNo\\Fi;i)«. f: and mf;i,if'.f 



Til l' 



i In loi inaitt 



»v 



fAiMrt'^s 






Special Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons d>lnij .may fron fiome. 

Former or 
Usual Residence 

Wfien was disease contracted, 

If not at place of deatti? 



How long at 
Place of Oeatti ? 



Days 



I'I^VCF: of »^KIAI, or RHMoVAI, I DATFo!" IM Ki.u. or RKMOVAI, 

M\<i\r 1 






TC)0 ' 



IN. B. 



-Rvery Item of 5n?ormntlon should be coreVully supplied. AGR should be stated EXACTLY. PHYSICIANS -h«..l^ 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The 'Splclal inZ^at^L^- J " ' 
sons dyinft away from homo should be ftiven in every Instance. ^Peciai intormation tor p«r- 






I 









jj.Kii.i of Hiaiiii »•• No. !- "^-c?^::.^^ i^^^' <■*'■ 



/)(f/r /'V/r^r/,...\]l.CaK^TYxiN^.a lOO'i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




t\AXA 



4^ 



\ 



Dep «'" Hpair.!'! OflRcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of S)catb 

( X\. S. Stanc>arC» ) 
PLACE OF DEATH: — County of C'Ayvu 0.\Xl,-t^c ....:'. City ofO/CU->^ OA.<x~.-v.<:.v.->. - . 



'No 



. ut 



\ 



M 



/ / IF DEATH 0( 

V IF DEATH 




^r^'X^.iltrUA.K.St.: 



Dist;bet> and 



F DEATH OCCUWfe AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
OCdtlRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



(DL/^y:\lA. 



SHX 



DATl': Ol- HIKTH 



PERSONAL AND STATISTICAL PARTICULARS 



(iJ 



xtu^. 



a 




ivvL-.. 



Moiitlyj 



A<". !•: 



bo 



) III > 






v. <!////. 



/ '. 



(Year) 



/hivs 



SINr.I,}-. M \F-{kIl-:i), 

wiixiw i:i> OK i(iv(»K():i) 



lUKTin'I.AOK 
(Stiitf or I'oMtilrv' 




,L'CL(VVAJ^\' 



V \M J". <)I 

1 A in }:r 



niKTHIM, AOK 
Of lAlllKK 
(State or Toutitry) 



MAn>i:\' NAMK 
1- MoTHl'.K 



lUKl'm'I,AtH 
OF MoTlIKK 
(Statt- or C'ouiitry^ 



Oi'Cri'ATloX 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



\ 



(Month) 



(Day) 



(Year) 



I HI:RI;HV C1;RTIFV, That r attended aeceased from 

tlal- .C looH to SXWr:. X loo "1 



iqoH to \i.us\r:. d^ iqo 

that 1 last saw h ~ alive on \l L4"\J~ .'X. 190 H 

and that death occurred, on the date stated above, at 2. ^ C 

M. The CATSIC ()l< DlvATII was as follows 

,0 " - - 



Cv\-^w^r>^^uc Ljihjjb-' 




V.y\.i^y.:)U^. 



Y\. 



<k 



Dl'RATION Vt^ars Mouths X^ Days Hours 
CONTRIIJUTORV 



nrRATION 



(SIG 

r 




rnON Yap-s 

ned)..^1jO. t. '° 

(Address) vL'{/vv\/C.A . 



Mouths 

\ 



Days 



Hours 
M.D. 



V-^- '. TQO 



^\.^ 



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



yfnnlln 



Ihn 



\'\\v. \iu>\'i-: s r \i j:i> i'kksonai. I'akihti. aks \ki' tk ij-- -w » i-ji \- 
HHST 01 NLyKN()wi,i;n(;H and in:i.ii;i- 



f Iiifoimaiit 






\AUj^„1 



Former or 
Usual Residence 

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



Now long at 
Place of Deatfi ? 



Days 



IM^CH or lUKIAI, Ok KHM(>VAI, DATl-of IUkiai. or RKMOVAI, 




INDICRTAKKR 




(Adflri-ss A I H, /LcC<!L<..^ 






^>yvwu. 



IN. »•— f^-'^;^ JtY" "'' '"J'^j;;""^^^^^ •'* cnr«fully Hupplied. AGE should be 8toted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH .n plain terms, that It may he properly classified. The "Special Information" ?or per- 
sons dyinft away from home should be ftiven in every instance. 




I 



t 



i 




M.x.nl ..f JIi:ilth I" No. i> ''-n.Hir^ "^"^ '' *-*" 



DEPARTMENT OF PUBLIC HEALTH 



REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

5906 



Ro^isfei'cd J\^o, 



City and County of San Francisco 



Certificate of Beatb 



11. S. StanC^arJ) 






'No. 



PLACE OF DEATH: — County ofO,CL-r^ 0.\.a. , _ a^<.e < City ofU.Oy^^ A.<X/>^^CA.<t-aO 

I n i' "n^cf . v.^* and 





VCXA; K/TYxXKaJL >X/C. ^J 0^3 ChStLvV-Lo^l. Dist.; bet. 

/ ir DEATH OCCURS AWlftv FROM USUAL R E S I DE N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \ 
V IF DEATH OCCURREpI IN A HOSfilTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




ClXuL 




UU-a: 



PERSONAL AND STATISTICAL PARTICULARS 

v:<»i,t>K 




DA ri: < >: r,iK rn 



M. !•; 



M..mli> 



ai . 



,L' 



I Dav 



M.otUr 



!\,ctj6 






Ihi 



sINt.l,]- MAKKIl-.n 

wiiti »\\'i: i> <>u n!\(tK> i:i» 



lURTHPI.ACK 

( Stati i>r r<)ii lit I \ 



NAM J" <•! 
FA 11 1 J.K 



lUK rm'i,.\c-H 

n|- 1 ATIIKK 

f Statf or L'oiuit r\ 



M \ !I>i;N' N 
nl MdlMll 




CV.<^nIL 






MEDICAL CERTIFICATE OF DEATH 

DATK Ol- Dl'iATIl C\f\ 

Vl l<Kr H rgo M 

(Month) (Day) (Year) 

1 lli;k I'I'.V CI-RTri'V, That I altcndcMl deceased from 



190 



to 



tliat T last saw h t:~ — alive on 



■ I90 
190 



and that death occurred, on the date stated above, at 
J. The CySI' OF I) I! AT 1 1 was as follows 



&-V'<My>A^ V^A vc 



J,*^^.v..:e'^rLjiL 



1 



DC RATION Years Moiilfn Days J loins 
CONTRIIUTORY 



Dr RATION : Years 

(SIG 



Mouth 



lilK riMM.ACl-: 

Ol' M<»Tin-:K p. 

(Stat< Ml Cmnlrv) \.\ Ij 



Wo, If /is 



/)., 



DATK of HiRiAL or RKMOVAI, 

VX^^X 190^ 



■)H1'. \1U)\ !•: STATi: I) i'KKSONAI. PAK'ncn.AkS AKi: TKn-: lO TIIK 
lUvST Ol' MY K\t >\VI,i;i)C.lC AND lUCMKK 

(Inf .•tn.nl yOivVV \I |\AA^^^ 

IN. B. livery Item o? Information ahould be caro?ully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

«tnte CAUSE OF DEATH In plain terms, that It may be properly classified. The ''Special Information" f«r per- 
sons dyinft away from home should be given in 9vry Instance. 



NED ) Wur>^J^' J . VD. W. ^MX.<x.^\.d 

M Lev- S' iqoM (Address) L<yVC>v«A^Vl'tv "■■:.•. 




Days 



Hours 
M.D. 



Special information only for Hospildls Institil^ilns, Trdnsients, 
or Recent Kesidents, and persons dying away front home. 



Former 
Usual 



^"^ lu^QQ^ 1 4 -^H How long at 
Residence 1 1 0^ oL/A,v/^v<!r>\Aj ol' Place of Deatli ? 



Days 



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



Pr,.\CK OF HI' RIAL OR RKMOVAI, 

-_Jl2^A^<xJLv^43Lryv 

lNnKRTAKKRV<Uue^T\AX N iW,^^^ ^ Lt 
(Address. i.JriHotcf-cJct^ 



I 



K 



,3 



I 



I 



^j_^; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!;..:ii,! . !' II ,.!t)i IV.,, ^ '^•:- V A; HXlT C.) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



[r\. 



L 






' r 



If)OH 



Jfro^/\s/e/'C(l A^o. 



2907 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of 2)eatb 

( U. S. 5?taiiDarJ> ) 

PLACE OF DEATH: — County of OxX^^ /v<X/yvc<^co City ofO-CL/^^ J Axx^a^ovalc-, 



No. 5^^ .Jc-vk,q.Lr 



St.; 



Dist.; bet. U .LojtXv^ 



and 



tl. 



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



M) 



FULL NAME Sba^^wfL 







PC 







I 1 



•-1 \ 



> \ I1-: < )!■ iiiKi'ii 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 





.kvt.- 



Mnfilh^ 



\< . I'. 



) . ... 



?> 



15 

I I)ii\t 



|'> 



^ 1 ail 



/>..!\. 



MEDICAL CERTIFICATE OF DEATH 

DATK ol* I)1:AT1I 

(I);iv) 




^Montli) 



/QO 1 
(Year) 



^iN'.i.i:. M\ki<ii;i), 

u ii)<>ui<:i) <»K n!\oKri:n 

W'l it>- i 11 ^' "'']:•] (|(^i'.Mi:it i >ii^ 



\\Arry\Ax^ 



Stair 111 I 'i Mint I \ 



\ \M 1 111 
!■ \lll !■ K 



lUKl'll PI. MI-: 
(»l" I AIHI'.K 
'St;itc • ■! rmitil I \- 1 



M \IIH:X NAMl'. 

<»i M()'riii;K 



iiik rniM.Ai)-; 

<>l MOTlIl'.N 

(Strtlf or riiiiiii 1 \ 



' " ''I !■ \||( )N 






1 ni-;Ri;i',V CI.KTII-V, That I attc-iKkd .k-cc-ascl from 
MLtrU 6 up^ to vTUpLr 5" npN 

that I last saw h •^- ■ • alivt- on VlL^Cxr- 5" 190 H 

aii<l that <kat]i ortnirrod, on the (hit*.' stated above, at H 

v-.., M. The CAl SI{ Ol- I)1:ATII was as follows: 




Y 




I)(R.\'I"1()N ]'t'(7rs 
CONTRIIU'TORV 



J/(>f////s Days H /louts 

.A-t^i 





CL'^x^a; 



V. >!'!,. i \ /),, 



DIRATION 
(SIGNED ) 



)\ars Mouths Days K. /lours 



^^^^'^'-."^'^^^'^'^"'''O'^ ""'y *"^ Hospitals, Institutions, Transients, 
or Kerrnt Residents, and persons dyinij away Iroin home. 



Tin: Ai!o\i", ST \ii:iM-Kks(»\ \i, 1' \u iht I. \Ks \k) !-Ki ]•• -j-o riM. 
iti'.sr Ol- Mv KN< •\\i,i:i)( ,)•: w I) iii:iji:i- 



1 1 II f. ■■ 111:1 111 



(A.1(lii-.s 



t n 



Cr-uvQ\.<Xw/<LA vjt) 




former or 
Usual Residence 

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



tfow long at 
Place ol Death ? 



Days 




MA'nCr,) IJriMAi. or KlCMOVAI, 



I'l.ACH Ol- lUKIAI, OR kl-:Mn\.\i 

Uclcln-ss Nil Vl'lXuL^^v^C-k^ O.t ^ 



IN. li. !.vcry ,t.m o> mV.mnj.t.on hHouI.! I>. oirefully h»p„IKmI. AUK should be Htnted B\ACTI Y PHV«iriA,Ni« u .. 
Htnu CAIISr or DLATH in ph.in terms, tlu.t it m„y I,, properly cla8«mrd The ••«?:, . ^"^^^'^'^NS «hould 
«on. d.inft nw«y from home Hhould be ^iven in ev«rt ins « ce ''""'"^"^^- ^'^"^ «»--»"' '"Vormatlon" for p.r- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H..:itil Ml' lit ;iltll !•■ No. ! ". ^'"L:.^;^«' l*'*^'' <■''> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Da/r r//rf/, M V^yv<Jim\X>Jihj 1 ^'^O'i 





llro^i.s'fered J\^o. 



^^908 





DEPARTMENf OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of Beatb 

^ *a. S. StanC>arC> ) 
PLACE OF DEATH: — County ofClcLOAj J-^^Oo-^^CAACLCity ofO/O^or^ J ;v<x/-y^xi.^aCL 
UY>'AJL^.a-. , :- / ()t'^<i.Wi-.aA Dist,;bet» and 

/ IF DEATH OCCURS A\MAY FROM OSUAL R E B I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRldD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



No. vj\D a.' 




FULL NAME 



(X/cq u.. 



1 



cr 




A-Lh\ 



-, 1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



111. 



<xXx 



ll 



Iv-J 



I) All I 11 HIK I'll 



A", i: 



M.iiitli) 



bH 



)V, 



i>.i\- 



1/.../'//^ 



i S'ciir) 



/', 



^ I M.I.I-: MAKH ii:i». 
wiD' )\\i-:i) OK Dixokri: I) 

iW'iiliin >-'HiMl <1( si'Miat ii 111 ) 



IMKTIiPI.ACl-: 
' st:it< or (.'oitnti \) 




->L/VVOAJj 



n 



^ V 



n ' 



MEDICAL CERTIFICATE OF DEATH 

DA II'; oi- i>i:\rn A 

mIov- 5: roo'i 

(Month) (Day) (Year) 

I III'I^^ l-;r.V CI:RTII-V, TliMt r atteiKk-d (locoased from 

~~~~ ^ ' 190 to "190 ' " 

that I last saw li •" alive on ————————— — icp - — 

ami that dcatli occnirred, on tlu- dati- stated ahovc, at 

.M. Tlu- CAISI- OF DIvATH was as follows: 

VJ ^-\,>a.r<r-V'V\, V \. n 




i! 



li 



'( f 



i' ! 



NA\tl' 01 

iai'hi:r 



iiiK rn iM, All-: 

Ol- lAIHl-.K 

I State or (."oiiutrv) 



M \ ii»i:n namj: 
1)1- M(ii'iii;k 



lUKinri.Ari-: 
<•!•■ Mo'riii:K 

(Stale 1)1 rouiiti y) 







1)1 RATION }'t^ars 

CONTRIIUTORV 



Months 



Days 



I lours 



X 



-^ 



c^y 



» htci'a rioN 



Qk... 



IX'RATIOX Years .^fouths 



(Signed ) .Lc5"Urv>ji\; 

^^ ^' -' T on' , ( . \ . 1 d r f s s ) UA^-^^JLV^ 




Pars 



T()0 , 






Hours 
M.D. 



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

Former or - "^ 



( n 



Krsidi-if III ^\iu I liiiiii III V. ) If' I ^ 



M.iiilh^ 



n,i 



TIM'. AM<)\'i-: s'iA'n:n i-kks. inai, parthti^aks a hi: tki f to thi-' 
i{i':.sr 01' .Mv kno\\ij:dc. H .\nd 111:1, n;i-* 



(In foiniant 




n 



' \<l.ln-Ks UjavXJkjOj Vi) 






:> 3 (kiuIa^ 



lormeror ^^^ A i How lonq at 

t«ual Residence ^<^ I U/OXAJ:L/Yy^Jl"^aAx piare of Oeatli? 



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



■ Days 



J'I..\^K OF m-RlAI, OK K1:moVAI, 






DATE of MtKiAl. or KF:\H)VAI, 

VKtrx- 1 




T90 1 






N. 1$. Every Item oif infoniiHtion should ho ciirefiilly supplied. AGE should be stated EXACTLY PHYSICIANS sh 

stiitc CAlJSr OP DEATH in pl«in terms, that it may he properly clossilFicd. The "Special information" ?or 
son« dyinft away from home should be feiven in every instance. 



oulcl 
per- 



ill 



! 



w 



f 



N 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



K<y,\r<] '<( H-. ;tllli • ^ 



iS^'^'K, 



»^ ^. -■* 



lu^r I.'.) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ie9ai!B*aRvi 



]le(^it;tei'cd J\^o. 



2909 



l)(i/r /•VA''/.M\r>M.A-rJb-Ov 1 l'.)()\ 

(L^VA.^^ \j. ^ Deputy Health OfHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beath 

{ "U. 5. StnuDavD ) 

J? (^ A ^ 

PLACE OF DEATH: — County ofC'/O/^rX' J A.<Xy'>AX^u:)X:(. City ofOxX/>^ J Axx/y v ti^ui.^^-0 



I, 

No. 1^^ i:x 



VJxva 



(ir DEATH OCcA^fS AWAY FROM 
IF DEATH (JbCURRED IN A HOS 



St.; 3> Dist.;bet. 3;vcl' and l-jl't. 

USUAL RESIDENCE GIVE facts called for under "special information" \ 

DSPITAL OR institution GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 




r\jJUjo 



1 




a 



CUv-C^/Ck. Vl A dCo\.Ay>x. :y\! . 



-ij- 



PERSONAL AND STATISTICAL PARTICULARS 






DA 1"}; •)!■■ I'.IKTII 




' M..ntli' 



\< . I- 



iDavl 



M.nttir 



n 



/ I V. 



(» <:n I 



/'./ 1 



si\(. i.i". M\KRn:i) 

(Write in "Mnial il« -iiMi.tt i' 'ii * 



i 



JURTIIIM, ACK 

' St:it' "•■ ' '>'nilt 1 \- 



!• A in i;r 



inu III ri \ri-: 
<>i' lAini'K 

(St, 111- III I'riuiitry) 



M \i I 'i;\ N \M 1-; 
<)i- Miiiiii: K 



I'.nvnnM.Ari", 
oi- M<)iin-:R 

( StMtf iir I'oimtT \-l 






MEDICAL CERTIFICATE OF DEATH 

DATK Ol' DKA'l'H 



V 






b 



(Year') 



I ni'kl'r.V C1:RTII-V, That I atU'H.UMl (UHi-ascd from 



0\^. 



oXv 



'^Cl 



,k,A.V. > 



v^ 




^ 







AlXtv--' L upH to \i v^OAT vj Tfjo'n 

til at I last saw h alive oti ii^ 

aiiil that (k-alh occurred, on t1n> <latr stated above, at 
M. The CAISI' ()!• DI.ATIl was as follows: 

DIR \TI()N Years 

CoNTRIUrTOKV 



Moutlis 



Pays 



Hours 



DT RATION Years }roitlhs Pays 

(SIGNED) O.JU) '0 Vj,^^JLc-,-^, 



Hours 



Muc 



^ Tqn I 



(Ad.lress) 'hJ\, 



M.D. 



oocri'A rmx 



■'r; ; 



M,»i!li- 



/).;v. 



Till". AHONl': STA ri'n I'KKSONAI, I'AKIUTI.AKS ARl', TRri' To rill-' 
HlvST <)1' .MY KN()Wl,i;i)<;i.: AND r.l'.I.IKl'" 



i In f.); niant 







SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons d>in«] awdv froni liome. 



Former or 
Usual Residence 

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



How lonq at 
Place of Oeatti ? 



Davs 



PL.\CH Ol' lURIAI. OR KKMoVAl, 



DATl%or niHiAi. or RlvMOVAI, 



KR dV9. i 6ax1xA. "^vCo 



^- *^- ^'very item of inform.ition should be cnrefully suppIIlmI. ACifi shmild be stated KX4CTLY. PHYSICIANS should 

stnte C AUSr: OP DEATH in pinin term«, thnt it may be properly classified. The "Special Information" for per- 
sons dyinft away *rom home should be f^iven In every instance. 



I»l 



■•J'NL'' iV'T"^ 



A? IMG ^» * 






■^r-'-^-i 



•Z TrtC V :> 



' I. t 



^ 



D t . .. '. 



DEP\RPU-M OF riBLi: HFUJii :::: xfdimstk} i?f 5-r -- -. 5.-^ 






I 

I 



.? 



ft _^ 



! T - 



% 



9 

■^ 






^ . - - - 




.-■.■«■-- w. 


5 . A . 

' ■ 4 . 




--. 





*^ ^ 



FULL NAME 



= :«»-. i'. z s~x~ S" :a. -i 



-A = 5 



J 



". /^ 



^ / ;. 






1 



VI £ r :.4 



'.*' 



».r •^ 



:rd4' - 



/ / 



S oNe:: 



v^ . 



h^ 



\. ■. . 






SPECIAL IN'O^'VA'^ ON "»•' "»'• 1»»NHtii\ u>rr.iam>> ' iriNiM 

!'■ *■"■"}■ r":,tft"?'v i\i nr-i.t- i'. i ; ■,*,;, •■•(rt ^nmr 



Firnn-" It' 






t.; 



A'^ 



' > 



.* .C^'\S.\ ■•\ X N\ >v 



V \ V ^ 



. C <- ^ ? ^ 



.- . . » '■ I r: I ' , i \,i 111' 

!"-.'i1 -i '''il M rr ti ^ f r ' , t rt ii'i*r 



• li ,jM S t-iiuMy Kuppiied. -XGE »S ^ald b< sttttetl l.WCTl.V. PM^SICl%NS ^VmiUI 
ttttttn Icrrnw, thnt it m.-i> ^>« p«'of>«rl> clasnifWd. The "Sivccin! I'^f\>~i«sic«.»«** f,»r |*«r- 
e«h'<iilf1 ht iiiven in e^c^v in<«tanc<. 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no.,.l.i 11. ,!tl. 1 N.. ; ^■^-; luVl-O. REFER TO BACK OF CERTIFICATE FOR INSTmjCTTONS 

29 J 



1 /)(//r /'V/c'v/, 




Bo^istercd JS^'o. 






1 ■^' 



Deputy HeDith Officer 

DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH: — County of O/CV^^ v'^.Vcx.-.A.^^A^coCity of C'/O^^ta; Axx^wcv^oo 
No 5?>iL. - ^^ Li St.; b Dist.;bet. ^(>^^A)-O.V<k and V I VsL^i. L c. ) 

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



\J 



FULL NAME ^^'^^'-<ij^<- h LuLX-:^ 




(? 



./CuL 



v\.<.a> 




T'YLV.Ul^^.iV 



PERSONAL AND STATISTICAL PARTICULARS 

.! \ A A ' ' 'I.' 'K 



X 



ft 



i» \ ; ! 



'A 



i /So- 



\1-Mthi 



) 



I 



•V : i '" |\\ I ,11 tiK I»l\ < »Ki i:i) 
Wiiti-in vMiial iK— i'/iiat u ill) 



I'.Il^ riM'l. ^''1 
^t,il< (.1 ('>]inili \- 



\ \M1' (11 
1 All! J.K 



lUK run, Ari-: 

(II !AiIll-:K 

'^tM' < I It ("i )ii nil \ 



"«' Mill-, \ \ \M1- 
■ MnTlli:K 



IllKriI I'l, All'. 
<>1 MnTm-:i< 
(Htiitf or linnili \ I 



-OAxXl 



.ULU 




.<X^.<L )^V^<--C 



MEDICAL CERTIFICATE OF DEATH 

n \'n-: oi- diiath A 

Ml 



(Month) 



1 

(Day) 



(Year) 



I II !:U I'J'A' C i;R'ril'\', That I alU-iKlf.l ilc-irascMl from 

— — ^^190 to K/5 

that I last saw h alivt- (Ml ■ I90 

ami that (U-ath (icrurix-d, mi flu- ilatr staU-d alxivi', at 
M. Tlu- CArSI'. oi" Di; A'i'Il was as follows: 



IMKATION }V</;-.s- 

CON'rUllU'roKV 



Montin 



Paxa 



Hours 







(KATl'AI ION 

A'C' l,!r-ll I II V,; II I'l :l II. ' < 1' 



) f rt 



M.n'tin 



n,i 



riii: \Hn\-i.: siAri-n ri-'u^oNAi, rAKinTi \ks aki v\<\ \'. T" > I'li i-: 

Hi;si(»I- .M\ KN( i\\l,i:i)C, K AM) I'.l.l.ll 1 



' I nfoi mai 



(\.l.1n-ss 00 lb ^ 3L(o X>Ki ' )1 



Dl' RAT I ON )\'ars Mouth. 



Signed ) .Lt^J^v\i.^; J . 




AxJL' 



Wr 



"I T()oH ( 



AildtTSs) L^ 



/hns 



I lours 

M.D. 



/CrX(nvi\>Ci 



' -<*. 



SPECIAL INFORMATION only for llospitdls, lnstituno\is, Transients, 
or Rcfpnt Residents, and persons dvinf) away from home. 



Former or 
Usual Residence 

Wfien was disease rontrarted, 
II not at pla( e of deatli ? 



How long at 
Plare of Deatti ? 



Days 



ri^ACi'; oi' i»t;^KiAi, (IK ki;mii\ai. 




DA ij; of I'.tKiAi 01 ki:m( »\ai. 



T90 



INDl' 






IS. 15. r.vcpy item olf inV'ormiit ion Hhould he cnruV'ully supplied. Adf". shinilcl be Htiiteil i;\ACTLY. PHYSICIANS should 

Htatc CAlISi: OI" Dli ATI! in plnin tcrinM, thnt it iiui^ he pi*<>|)crly cluMNificd. The "Spcciii! Inlforinution'* for par- 
sons d^ilniii liwiiy from liomu hIiouIiI he (i,iven in every iiiHtnnce. 




■f' '''a 









^ 



I 




WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



•■— _. 'f^ 



,; II ,.ith— FXo. i^ '^-^ 3::,;-^^ 1'^ 1* *•' 



REFER TO BACrV UK i^tMiirn^Mic rw 






/)((/<' ri/('f/ ,\i\<p<>JL^ryJo<V\> T 



/,9i9H 



]ir<!f'Stejrd A^o. 



9911 



1. 



i 



.,trv<^' " • • ■-.( Deputy >•' ■ <■ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County ofOo. 



No. 



Certificate of ©eatb 

(la. ' J Axxovc v>Ci.C(.City of^/CLorv J >U>. > vc^ •:^ ' 
^ 01jL^-'>\X\ Su Dist.;bet. JAX.*^y\ and llona.^^\ 

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

FULL NAME 



<X'\.' , c]/o'['\/rULi.cl..jL'\ 



PERSONAL AND STATISTICAL PARTICULARS 




<xU 



Ll.kcta. 



1) A , ; "1 i;iK 1 II 



DATl'; ol- DKATH 



MEDICAL CERTIFICATE OF DEATH 



L 

(Day) 



(Vt-ar) 



r i- 



t'^^ 



) '. \ 



i; 



b(. 



/'„' 



Wiit' in -.(R-ial ilt — it'iialioii) 



lUkiiiiM. vt'i-; 

(Stat< or t,'iiiiitry) 



\ \M1- Ol' 
I- \ III i: K 



r.iKiiii'1, \ri-: 

<M lATIIl-: K 

I stall 1 ii rotiiit I \ ' 



M \iiii:\ N \Mi-: 

<)I- MOTIN'.R 



i!iK rniM.Ari", 
<)i' m()Tiii:r 

' State III l"iiiiiit T v) 



? 




vtAxlx^^J 






t >irti 






c\ 



/\r' iilrii ill Siiii f'l itiit ix'ii ov ) I ft I s 



M >nl/i< 



/i,n 



y\\]- \H()\r: sr \ ii; d i'I'Ksonai, r \kiuti.ars aki', rRD': Tti rin-: 
m;sr oi- m\ know i.iix'.i-: wd r.i.Mi'.i" 



(Infi.iinaiit \S) . \Jj 




V 



\\jL^<\-)c'\ 



\ililrrss X4 3> L O XX^VA^UL/V 



1i 



(Month) 
I 11 i;U i:!'.\' C1;RT1I"'V, Tliat I attcmUMl dcccasc-d fiom 

- — \ — "190 to 190 

that I last saw ll •■: — - alive on — —————— T90 

ami that (U'atli oci-iirred, on the dale stated above, at — - 
M. The CAl'Slv Ol" DlvATH was as follows: 



or RATION )'rars 

CONTRIIM'TORV 



Moulin 



Pay 



1 lout 



1)1 RATION ^'<''?''^^ 

( Signed )L(3-Xr^^a\; J, 




Afont/r 



Ihn 



•s 



I lours 
M.D. 



J UV- n 



I()0 



f 









Special Information '>niv lor iiospit.iis, instituiions, iransicnts, 

or Recent Residents, dnd persons dying dwd) (ro;n home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatlj? 



Days 



ri.ACH OI-' lUKIAI. OR Ri;Mn\AI, 



DATi;')!' HiuiAi. or RKM()\A], 



rXDl-.RTAKHK (AO J Cj AaJI V>V ^^ , 

(Address. 11 'in Q[l\l>i.<i.^:«n.\...J..! 



190 ^ 



!N. K. Jivcpy item of inlrornuition Hhoiild he cnrcfully supplied. AGK shoulii be stntetl FiXAGTLY. PHYSICIANS should 

Btntc CAUvSE OF DI:ATH in plain terms, that it m:iy he properly classiVled. The "Special Information" for per- 
sons dyin^ away from home shoultl be given in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



',\ 1 



MC.^t.r^ i vj dmopv wr v^u.i« 



llfl'V^'f^l^i • 



er\o I M OTDMrTirklM<^ 



Pi 



Sk^^AAA '^'^.- L>., 

DEPARTMENT OF PIBLIC HEALTH 



Beci/.sfr/'ed J\^o. 






City and County of San Francisco 



Ccvtificatc of Bcatb 

. 11. S. tr'tanC>arC^ ) 



4 






^ 



PLACE OF DEATH: — County of Jxx-^ J.\xx.vvC\-<i< City ofUC/^^v. J X>cx^^x.c^-^o<. 

bX.Kj and IX 



No. I () 5 ^^ Ob ^vv>KXV^:^ 



St.: Dist; bet* 

5IDEI 

A HOSPITAL OR INSTITUTION GIVE ITS NAME II 



/ ,r orATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER 'SPECIAL INFORMATION" ^ 
( ,r DEATH OCoJrRCD IN A HOSPITAL OR INSTITUTION GIVE .TS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 0X0.0. 



/ V..S„C\ 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



"i 



<1 



> \il < M i:!!: ril 



II 



V -JI 



4f| 

1 *^Um 



M..m!i» 



Diivi 



/'.M 



^IMI.f MAKKIl II 

wim >uKi) OK i):\ ( >Kri;i) 

' Writ. i!i -iH-i:(! <l.-->M-.t '•"! ' 



Ll\a.\.vuLcL 



HIK ;M i'l. \'' 1' 



1 \ I II 1 ,i; 



liiKiii ri, \ii-: 
«)i r\iin:K 



M MIU'.N NAM}-: 
<)| M..I1I).:r 



lUk lUl'I.A*.!-: 
<»l MoTlIKK 

iSt;it. . .1 r. iiuiti \ > 



HHTl- AI'Ii »N QTNn 



d'LcroWtt^^v U)^t 



L 



C' 



*. t 



c 



'J^Crokl 



^y\) 



n 




Rtsiitfif i)i Smr I'lani isrn 



)', ,n 



\f..,ith^ 



IKi\ 



I'll I. Ai'.( »\i': sr a'i'j: I) !••.•"K-^( >\ai, i-ak rn r i. \ k> a k !■; tri i-: td I'li i', 

in>r oi- MV KNOW l.llx.K AM) IU,Mi:i-" 



' Inf.i; r.iajil 



Mrv-vw 



r\-... 



- I V.-'... 



(X.ldrcss 



'> c 




^\KyoJ\u\: 



A. dl 



MEDICAL CERTIFICATE OF DEATH 

DATl-; ()!• I) 1 ".All I I 







I 

I):iv> 






I HI'RI'IIV ClJv'riI'V. Thai I attrii.kMl (k'ct'asc-.l fmin 
' clj ' ^ I c)0 ' ; tn . VfVtrx'^ A. loo 1 



thai I last saw !l v alive nti ' I Virvr . Ti up 

ami that dialh occurred, nii tlu- dak- stated above, at 



M The CMSIv ()!• DICATH was as follows: 



M A.*^ 



\- ' 



ION ^ ) \'a 



Mouths^ 



C" () N T K 11 U "I" < ) R \' v<X\. cL^tX Cr 




dt rat ion 
(Signed) L 






Months 



Days 



S^ 



/lours 
M.D. 



up 



(Address) 



0.^0% :i(^U<5-nv .") 



Special information <»n'v for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyiny away from home. 



Former or 
llsu.il Residence 

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



How long at 
Place of Death ? 



Da\s 



DA'n;.)!' HiKiAl. or KHMoVAl, 

XlLtra %. T90 



I'l.ACi-: oi' lUKiAi, OR ri;mo\ai, 

INDl'.RI-AKl-K HtX^>^rUbO Mil OA/VV^A.' ^ vC 



N. B. Jivery item of information shoiiltl be cjircfully supplied. A(iF. should be stated RXACTLY. PHYSICIANS fthould 

state CAlISi: or DI:A TH in plain terms, that it may he properly classinMed. The "Special Information" for pur- 
sons dyin^ away from homo should be feivcn in every instance. 



m 



WRITE PLAINLY WITH UN 



FADING INK — THIS IS A PERMANENT RECORD 



I /)(ffr /-V/fv/. Vj\(poJLO>^lv^^.' "I 



IfUJ'i 



REFER TO BACK OF CERTI FICATE FQh JNS i nUC i iONo 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Bcatb 

; 11. 'Z\ jT'tan^avC^ j 
PLACE OF DEATH: — County of3<X"ix JAxxa City ofCJ^-»^ J.Vclt^- < ^ - ' 

No 10^--^ dltc'.^lc, St.: Dist.:bet.mt,K^ . : andU.'a^^KvAvqA^-) 

' / ,r DC«T» OCCOOS A*.Y rBOW USUAL B E 3 1 O E N C E C , V t r.CTS CAtUCOi'OR UNDER ■•s»EClAL . N ro R M ATIO N • ") 
( "ot.T" OCcJr.Vo ,N ° -OSP.T.U or .NST.TOT.ON 0,.C .TS NAMEJnSTE.O or STREET AND NUMBER. J 



1 



FULL NAME 0.'^^-)\' 



^^^ 

i 



PERSONAL AND STATISTICAL PARTICULARS 



-'l.X 



11 > I . ' I K 



< (^ 



i> 



A 



\' . I-. 



U l!»n\\ i:i> MK 

w •••.■ 



I'.iK 1 n i'i.\»"i-: 



\ \M1 . H 

1 \ 1 !l IK 



r.iK riipi. \ti-: 



M \!I>i:N N \M 1- 
I'l MoIMilK 



lUK I'll IM, \« »•; 
"I MOTIII'K 

"-'::■ • ' I r . . ', 1 1 I t I \ 



9 



1, 



\} 



M 



K L ^ \; 



V. 



QVs 



J .KJi 



I 1, i' i I 



•VI... N J A 




i\JLX 



>vaj 



/''f 'Jr;f ill s',ni F^iniiit 



riii \U()\i-: > r \ri:i> iM'"K^()\ \i, r \ K ri> T I. \Ks \ki i"ki >•: r< » rni'. 

1!1>1'(»1. MV KNOW !,i:i)C.H AN!) I'.l-l.lll 



KNOW !,i:i)(.H AN!) 

cLvA^/CrVXX5. J 



^ 



MEDICAL CERTIFICATE OF DEATH 

1) ATI'. ' )1- ni'.A 1 11 




(M.)Hthi 



IQO \ 
(Ytar) 



r 

I I1I:In1 r.N' riK'rilN'. Tlnl I iillcii<Kil «KHrasc(l from 

t,, : 



Up 



lll.ll I \:\< s.iw h - 



ali\c oil 

aii.l that iliatli occurred, on the date staled a1»ovo. at 
M The C M S1-. Ol' DI-IATII was as follows: 



■I()0 



.J 



^ 



DC RAT I ON )V(7;--v 

CONTkllU'TORV 



Mo lit /is 



Dius 



Hours 



/\us 



1)1' ILLATION )\'ars .V,>>i//is 

(Signed) v . v.o^ . v. ^ v.v'..\ 

MUr\r 'i T(,o'\ (\<l.lress) ioCib 0,A.v.tl..'. 



Hours 
M.D. 



Special information «n!y l.»r llospildls, Inslitulions, Ir,insirnts, 
or Rerrnt Residents, tind persons dvinq im,»y from home. 



Former or 
Isiial Residence 

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



llov> long at 
Place of Death? 



. Days 



IM.ACi: Ol' I'.tKIAI, <>K l<l',Mo\\I. 



J/CX/W 

\i)i;i< T. 



I)Al"K. of IM UIAI, oi K1:M»)\'AI, 

X 



1 I', o! 

0\' 



TQO 



(Ad.hrss i.OA-. . 



W 



'Q. 



yCX/tl vi V^ 



:it 



r 



IS. B. Kvery item oV in?<.rm,.t5on shoiihl be cnroYully supplied. W.V, shaul.! be Kt«tecl EXACTLY. PHYSICIANS should 

Btntc CMlSr. or DTATH in pbiin terms, thsst it m:iy be properly chissified. The "Special Informiition" for p»r- 
Rons <iyin(^ nwny from home should be feiven in every instance. 






r 



i 






,« 
I 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,.f ir 



\.. ;. *-'^-s'V H.Sc 



r «• 



/.9i9H 



i, 

DEPARTMENT OF PUBLIC HEALTH 



.fc-^lwV^ 




REFER TO BACK OF C ERfirrCATE rOBTfreTWUCTIONS 

Bcdi sieved A'o. --./I-* 



City and County of San Francisco 



Certificate of S)eatb 

PLACE OF DEATH: — County ofO/a>v J /vex >xxc^. c City ofOo^^, O^vOy^xC^xlc 
No 2.5ix'VV>voi^. , - .' St.; ■ Dist.;bet/JM/Ca_'YT\.tN,... and iVtk 

* ^ ,r pr*TioccuRS aw»y r«OM USUAL RESIDENCE give tacts called roM under special iNroRMATiON • \ 

( ^.*.ATHOCc!«RTo^^ A HOSPITAL OR INSTITUTION GIVE ITS NAME IN^EAD OF STREET AND N U N, B E R . J 



( 



FULL NAME 




\\ 



a^Jtv>v Mcactir U cy-^q. 



PERSONAL AND STATISTICAL PARTICULARS 



VI n 



n. 1^. 



a',1 



AHL 



. ' . 1 . 



^1 



»w' 



-• ; i M \K k IJ.H 

\\ I l»«>\\ I 1» (»K 1»(N« »Rr j;!) 




'\cv.'K_^,v^d. 



f.ik 1(1 1'l. \ri: 

>':ilt III I ". iiitlll \ ' 



\ \ M 1 . . ' 
1 \ I'll I U 



r.ik iiii'i. \tK 
"I 1 \ 111 }\i 



^t \!i.i;\ N AMI-; 

"I MoriM'k 



I'.ik rti ri, \ri.: 
|>i MMiin K 

' ^t:i'." . .1 ('. niiit 1 \ 



i 



? 



s '. 



? 






'^)a\^\^ CO •. .V . , *■ • ' 



/ // '-'III' / I ,1 III : ■■I'o 



I I 



) , ,•/ 



/Kn 



I'll I \11M\1- s|- \|| I) l'»-'k-M i\ M, !■ \ Kl I' T !M-'. >- \k I. I 1< ' '•■ '' ' ' " '■"• 

111 -^1 111' MS' i< Ni iwi.r.ix , |.; AM) i;i:!,ii'.i' 



^ 



^ 






f 




0>\' 



)i 



4 



-ii 



MEDICAL CERTIFICATE OF DEATH 

iiATi". <'!• i>i". \'rii 









(Vt-ar) 



tli.it I last saw h alive on 



1 lli.klJ'A' Cl'.K'rUV. That I attriuKnl .Krrascd from 

: 190 ■ 

: ^ ;. : — 190 



iiiil that ilrath oi-ciiiri'tl, on tlu- 'iati' stati-d above, at 
M. i'hr CWrSI-; ()l- l)i;.\'ril was as follows: 

- : -4 



\ 



, ., o 



« 1 



coN'rRir.i'rokv 



M ON I /is 



/hivs 



//i)/n s 



iXRA TloN 



( SIGNED ) 



) 'i\n\s 



Mi)>iths 



Pays 



" v\jl^) \ \b. LU. dJLlO/YvcL. 



M.D. 



A 



A.Mrc-ss) vJ 



H 



Ua: '. i(,o'i (A.Mrc-ss) V,^\t5>\>LV^V;.Uv-„*. 

Special information ""ly fw Hospitals, Instinilions, Transients, 
or Recent Residents, and persons dyimi away from home. 



Former or 
Usual Residence 

Wlien was disease ronfrarted, 
If not at plare of deatli ? 



How lonq at 
Plare of Deatli ? 



Days 



ri \CI", ••!• lUklAI, OR ki:M'»\ \I, 



rNDl.K TAKl-.R 







I) Ai'p; .)!' I'.i KiAi, ..1 ri-:mo\' \i. 



TOO ; 



A.l.Iosv M'51 \n\A.^^\^C-^ V, ^"^ 



N. H. r.vcry Ucm 01 Ini'o.MMMtion nhouUI be crcVully HuppHe.l. Adli «h,u.l.l he sta.to.l i;X ACTLY. PMYSICIAtSS Hhoultl 

Htatc CMISi: or I>I;A III in pljiin terms, that it may be properly cluHhitfietl. The "Special InVoraiation" Vor per- 
sons iljinfi uwny Ir'roai home hIuhiM be i^iven in every inHtniice. 



'^i 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



*^ -T"^.. 



HM.ird of H.alth 1 ^ C-:; ;w--4; lUS:!' l'-, 



/)ff/(' Fi/cfi, 




\) 1 



UJO'i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2915 



Br^isfercd J\^o. 



.CrXAA^ 




Vi 



Deputy ; leS'/.h OfTlcor 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH : — County 



Gcvtificate of ©catb 

( "U. 5. Stan^ar^ ) 



No. 



(IF DEATH OCCURS AWAY Fl 
IF DtATH OCCURRED IN 



St.; 



"Dist.; bet. 



and 



-) 



FROM USUAL RESIDENCE GIVE FACT 
A HOSPITAL OR INSTITUTION GIVE I 



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



FULL NAME 



'^ 



N, 



r 



CTv 



clxhj 




''WAJVL\.0, 



PERSONAL AND STATISTICAL PARTICULARS 




•ol.oK \ 



■t 



1) \ I 1 t 'I lURI'll 



a 



\i 



^v 



I \!i.nth ' 



r 



^ 



UuJ 



(I):iV» 



1, '../,/// 



MEDICAL CERTIFICATE OF DEAT 

DA IK (>!• I>1;AT11 



t 




/ c c 



( Veal ) 



Hu 



SIN(.1,1- MAR km: I) 
WIDOW i;i> OK DI\ORri'D 

Wiittin M)ii;il (Ic^iviiat inn ) 



S) 



r 



lURrni'i.Ari-: 

(StMt<- lit I'lnniti v' 



I 



] 



^ 



^ >"VO 



i 



UX^^-^^. o.. 



» V 'J 



NAMl' or ,^ 

FAT 1 1 i:k / l' 



Lh 



\y 



(P*\) 



d.eA. MlieYvlvA 



i!iR iiiiM. \ri-: 

O!- I AIIIHR 

(Stati- (ir Ciiiuitrv) 



M \; 1 'l,X NAMl', 
ol MolIM'.K 



HIR'IIIIM, Ml", 
«»1 Mollli; R 
{Sl:r ■ I I'unlix 



(H\'l 1' Al'loN 



.'\.q. 



X\, ,> .■?.. 



. I 



/^ 



5 






c- )■ 



//(■ .S"iM/ /'i it III iMi' .'' )Vrt 



f\fMiii\! in Siiit r'l ii III iMi' 



}ro,iffi< 



I),! 



Ill)-; AHo\i<: SI" \i'i: D i-frsonai, i- \r rirr i.ars ar i-: CKrH r*) I'li ]•; 
lU'isT »)!•■ Mv KNOW i,i;d('. f: and ni:ijF;i'" 



N.Ulr.ss I LCXA^IrOV'^v^a- 01,. 



i^ 



(Month) 



3, 

a)ay) 



(Year) 



I H!:Ri:r.V CI':RTI1'V, Thai I aUon.kd deceased from 

~— — — I90 to •■ 190 ~'~^- 

that T last saw h -^^ alive on • T90 — 

an<l that (Uath occurred, on the date stated above, at 
M. ,The CAI'SI' Ol- i)l-:.\Tll was as follows: 

O^A.A.A^K^S^cL^. 



1)1' RAT ION Years 

CONTRIIUroRV 



Months 



Days 



Hours 



DTRATION 
(SIGNED ) 




)V(/;- 



J/of///is 



. ff.^tt 



I^ 



Day. 



Hours 



c 



>^^x/OUY>j Ld\(rv\x^^\ M.D. 



T()0 \ 



(Address) dyOLAV VD 



XXAv vDX\y>vaVclvvv<U 



SPECIAL INFORMATION only lor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyin-j anay from home. 



Former or 
Usual Residence 

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



Hovv lonq at 
Place of Death ? 



Days 



im.acf: of btriai, or rf;mo\ai. 



^mii. 



to^rtcttc'v^, 



rNDF;UTAKF:R 

(Atldi (■'is 




^ 



\ 



^.^U 



DATF:.)! IMkiai, or RKMOVAI. 






!^' K. Fivery item of inlformHtion should be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DF.ATH in plain terms, that it may be properly classified. The "Special Information" for p«p- 
Rons dyinl^ away from home should be ^iven in every instance. 




I 



m 



I! 




WRITE PLAINLY WITH UN 






/}(//)' /'V/r//, mLcv-C'V>xImLA; 1 



FADING INK — THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lOO'i 



1 



^AAA/i C<X'\M.^ 



\x\y\.\ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

{ "VX. S. 5tanC»arC> ) 
PLACE OF DEATH: — County ofJO-'^^ -J A rvwccorcCity 

No. ')XKrr>r\.O^y\^ Ob C-A rxvlCLV 



;itv of 'J/a.>X) 



St.; 



Dist.; bet. 



/l<X/wx?<^^ ti c 



and 



M USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION • \ 
m «^w I. __ ^ ^1^1^ NUMBER. / 



/ ir DEATH OCCURS AWAYIFROM USUAL H L S> i U t PI ^, r. u . « t r«v,,o X,V« r ■ JJ-r r - r, «r c-r* r r 
t IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ST« E E 



FULL NAME OX^V 



PERSONAL AND STATISTICAL PARTICULARS 

t < iI.' iK \ ^ 



si:\ 

i» \'i i; 1 >i r.iK rn 




I A 



I 



y^t 



M,.tith' 



.\r,v. 



4^ 



^IN'i.I.K MAKkn".I> 

wiix >\\'i: i» OK i)!\uK>i: I) 

iWtitiin s(iri;il ilt-i'^Miatioii) 







M,n!tli> 



KK^JU'^ 



t Vein ) 



l(o 



/'M.v 



luk riii'i. \oi-: 

'St;il- '■ ''"Miitryl 



I 



^\ 



NAM i: <•!■ 

!• ATii i;k 



1',1R1"1I1M.A<-1-: 

<)i- 1 Ai'ni'.R 

(Slalf or Count 1 y 



X>V/Y\ X <X^V^v 



MAIDl'.N \\M1. 

<»!•• Morni'.K 



HIRTIIIM.ACl', 

<)i" Mi>Tin:K 

(Stiitf or rountry) 



occri'A'i'iDXj lJ^ 






( \ ' » 



\ 



l\/''\!i:! ni S,;:.' / i ,! i>, ;-r> lO )',-,'n < 



,1/- .,////- 



/),.M 



rill* AHovT-: s'l" \ri-:i) i-kksonai, i'\Kri*"ri,\Ks aki: rKn-: ro I'ln-: 

lii:sT Ol" MY K.\«)\\I,i;i)C.H AND HKI,!!",!- 



(In 








7<?o 'i 



MEDICAL CERTIFICATE OF DEATH 

DATH Ol- Dl.ATH (\^ 

Mlev b 

(MouUO (Day) (Yt-ar) 

I llI'.Kl'P.V ClvKTIi'N', That I attou. U-d dc-rra^c-d from 

tliat I last saw h . alive on \|\^\' L icpi 

and that death occurred, on the date stated a])()ve, at ^.i i 5 
• I. M. The CAISK OF Dl-ATll was as follows: 

I) 



1)1 "RAT ION )'mrs 

CONTRim'TORV 



Mouthsi 



Pavs 



Hours 



DC RATION lVa/--v jro^/Z/is /hiys 

(SIGNED ) M ,R ^((Lo-k.|k.V<^v>^ 
M\t^" C Too^l (Address) ^X\A^VO..\V 'St^-i.,lCl 



Hours 
M.D. 



i 



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



Former or ^ ^ , > i 4 y ^4- ^^^^ 'o"*! a* 

Usual Residence A .4. L * I 6 t VV (J I. pjace of Death ? 

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



Days 



rj, ACK 0\- iU'RIAI, OR RKMOVAI. 



ri.ACK (^F JURIAI, < 



DATKof HcKiAr. or Rl-iMOVAl, 

Tgo'i 



\ I J-. O! JUKIAr 



n 



%. 



c 



rNin:RTAKi;R f'-' o ^aa-4\A' ^ v^(.. 



N. B. Kvery item of informtition should hi cnrefully supplied. AGE Hhould be stated F.XACTLY. PHYSICIANS should 

«tnte CAUSE OF DEATH in plnin terms, that it mny be properly classified. The "Special Information" for per- 
sons dyinfe away from home should be t^iven in every instance. 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 



Itoai.l ,,f III ;!!lh I" No. 1 =, "^'"[-.r^:^^ J'-'"^'" ^'' 



!)ff/r ri/cd , 




T 



lOO'i 



REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 



Eei^istered J\^(). 



.^\^\^v^ 




\ 



Deputy ; ^-^^t^h Officer 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( "U. 5. Stan^arD ) 



PLACE OF DEATH: — County of 



City of 




J 



u 



LtX' 



No, — 



St.; 



Dist.; bet. 



and 



■^ 



/ ir OEATH 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 DfATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



LLcU.. ' 




XaJ. 



J 



PERSONAL AND STATISTICAL PARTICULARS 



^ 




(.< tl,« )R 



HATl I 'I l;l!<ri[ 



.\<.i-: 



Months 



)■ 



.1 



I):(V> 



.1/.//,///. 



(■/(.■at 



/hn 



SIXC I.l- MM<UIi:i) 

wiix >ui:i> < »K i)i\i iKT i:i) 

!\\iitiiii M)ri:i! ih si;- ii.i I i' ui ) 



Slatt or Count \y 



XAMl. <»! 
I- A Til IK 



I'.IK'IIIIM.AfH 
1)1 1' AT I IKK 
'State oi Coniilry) 



M \ I i)i;\ NAM J-: 

(ii .M( rr II i-.K 



lUKrmM.Afi-: 
oi" M" )'iii i:k 

I Slati I < '' .lint 1 \ 



1 <''K I TATI' IN 







AJi 





111 



I 



7 




jey^WUttXxV' -LC V 






u 



AV' '/(//'// /'/ S:t>t I I III',: 'I •> 



) 'l-t I 



.y/.;if//^ 



Ihr 



WW. MIOVI", STAIi: I) l'»<. R»( >N \I. I' A K T [C f I.A K S AK l', TKIl.; To Til V 
J{i;sT (»!• MY KN(»\V,Ij: I )<.!•: AND Itl'.Mi;!' 

(\ \ %^ 

'Inf.. niaiit \- CK . (JsSX^ 



X.Mrc^s ^J^O^IsJL^aJUjL'OcL 



'■ 






MEDICAL CERTIFICATE OF DEATH 

DATH OI' i)i;atii (\^ 

\\js\: L /po'i 

(MotitlO (Day) (Year) 

1 HI'iRl-JiV CI:rTII'V, That I atteii. led deceased from 

— to 1 90 -'— ~: 



— — — — — ic/D — 

that I last saw h ~ alive on :—— — — 

ami that death f)ccurred, on the date stated above, at 
M. The CArSI<: ()!• DICATIl was as follows 



190 




DT RAT ION JV(/;-.v 

coN'rRir.rTokv 



Moulha 



Days 



I lours 



1)1 RATION 

(Signed) 



Years 



Afofit/is 



/Mvs 




rc)0 



tj 



( 



\ (h 1 ressf OXX l\XhJL.tvli.X A 



Hours 



M.D. 



Special Information «nly for HospUals.'institutions, Transients, 
or Keren! Residents, and persons dying awny from liome. 



former or 
Usual Residence 

Wtien was disease conlrarted. 
If not at plat e of death ? 



How long at 
Plare of Deatli ? 



Days 



ri^ACH OI" lu KiAi, OK kj;mo\ai. 




DATi; of I'.iKiAi, or KlCMoVAI. 

OX<ar 'i 



(TrnJl cry '^''Xo. _.. 



T9O 



I^- '<• Kvery Item of Informntion should be cnrcfully supplied. ACJK hHouIcI ho Htntetl F.XACTLY. PHYSlCIAtNS Hhoiiltl 

Ktnte CAlJSr OP DEATH in pliiin terms, thnt it vnwy he pr«)perly cluHRified. The "Special rnformtition'* for pi#r- 
Ron« dyinft nwny from home Hhoulil he (^iven in every InHtnnce. 










i 



'*M^ 



W 



RITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



n,,M,i,.f ih.iUh 1--NO ;-^ •*-«'w>^H&PCo 



rJOH 



REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale /'V7rr/,^lrvM.n.jU^..' 1 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Wl* »-vJ 



PLACE OF DEATH: — County of 

No. ila?)! '-V i -■.."^ . . vo._ \- St.; 



Ccvtiticatc of IDcatb 

( la. S. Stan^ar^ ) 



''>^xJLwCf City of 





ou L<x.' 



Dist.; bet. 



and 



— ) 



/ 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" \ 
( ,F DEATH OCCURrTd IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



^V 



FULL NAME 



K. 



.A-- I 



'. i. 



y^xx}. 




-i',\ 



1) \i i' lit I'.ik III 



.\i.i-: 



PERSONAL AND STATISTICAL PARTICULARS 



<xu 



lOJv^u 






I \ Yrai 



b 



as 

I Dav) 



M-ull- 



/13C 



(\\-ar) 



/I,/ 1 



siNt.1,1",. MAKkn:i) 

WIDOW I'D <»K IM\'« tKri:i) 
\ Writi ill -"liiil lit -ii'iLitiiiii) 




iiiK I'll I'l, \r)-: 

stall or l"' 'imt I \' 



NAMV (M 
I A 'I" II IK 



I'.iK'i'iii'i, \> ]•; 
(ti' I'Aiiii-;k 

I Statf or iNiuntrv 



M Aini'.N N VMl". 
(»f M()'l'li»;K 



\oj\Kxjl6. 



r 



y 



? 



iuKrmM,\('K 

ol Mn'llll.;K 



K'f llh'd III Sdll /-'l ll III / ^I'll \ {. )''!•! I. y 



M.-iiths 



Pa vs 



iiii'. \nt)VK si'\'n:i) thrsonai, rAuiirn.AKS aki-: TKri-; t«> thi-; 

lti;sT(.|' MY KNoWI.l'.IX'.H AM) lU-.I.^l-lK 



LUo<X^orv\Jt<Loj 



(^ 



MEDICAL CERTIFICATE OF DEATH 

D.ATl-; Ob DHATH 

5 



^W 



(Year) 



(Ntoiith) (Day) 

1 II IvR I'.r.N' Cl'iK'ril'V, That I attcMKk'd dcccaseil from 

— rr-r— — ~ ~~~ 190 to ••••"• 190 

that I hist saw li ;iHvc' on T90 - - 

and tliat (U-alh (xuMirred, on the (hitc stated aljovc, at 
M. The C.MSl': ()!• DI-i.XTH was as follows: 



.VC 



I )r RATION )'rar 

(.ONTRIIU'TORV 



Moni/is 



Days 



flours 



DURATION )'iur)s Afofiths Days 

(SIGNED) LI- LI O.toJU-C^'VX:^. 




Hours 
M.D. 



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



Former or 
Usual Residence 

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



flow long at 
Place of Death? 



.. Days 



I'L.'VCK OF niRI.M. ()R KKMOVAI. 



CtyynX 

UNDKRTAKKR 

(.Address 



\ X<x.eC 








N. B. F.vepy Item of infopmation should be cnrofully Hupplietl. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSU OH DEATH in pinin terms, that It may he properly classified. The "Special Information*' for par- 
sons dyin^ away from homu should be l^Iven in every instance. 



^■MW 



w 



R.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 







J) 



k' 



i£y6^*i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered JSfo. i^-^\.'<7.. 




I 






1 1 



i Si 



4 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Bcatb 

( "U. S. 5tanDarc> ) 
PLACE OF DEATH: — County ofCJ^^v J.-vo, > ..Cv^^Gty of C)xv>x. J Axv->a.ca,^c •, 






^ 




. O..TH OCCURS AWAV .ROM USUAL R ^ B • O E N C E_C . V^E ^ACTS C^A^LL^EO ^^ --R ;---,'--:---• ) 



CI -LmX'VOjj 0'^' ^ V ' ^Va.l Dist.; bet. 

iV IF DEATH OCCURS AWAY FROM USUAL RESIDENCE Gl 
A IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION 

FULL NAME J AJUL LLc^t A. 



'and 



) 




Sl.X 



PERSONAL AND STATISTICAL PARTICULARS 

I C<)I,(»R \ 



nwL 



ii.k. 



\ 



DA'li: <>| lUKTU 



\(.l- 




(Day) 



(Vfar) 





t » 



15- 



)'i(i I 



Mnuth: 



Pa r 



SINf.l.I*. MAKKlI-;i), 
WIDOW i;i) OK DIVok^KD 

'Write ill sociiil (li>«i^'ii;it ioti) 




xx^,VL.l■^ 



(State or (.'oTintiyt 



N \M1". oi 

I- A I" 11 i:k 



KJixkxKK.<: 



\^,.^ 



HIRTlM'I.ArK 
OI' lArill'.K 
(State or «,"oiiiitrv) 



) I 



MAIDl'.V NAMH 
Ol- MoTIIl'.R 



lilKlUPLACI-: 
Ol' Mo'nil'.R 

(State or (."ouiitryt 




ori'l 1' \ TK )X 



'■> . 

A'fsiiff'if n; Smi /'i iiui i>rii .' i v, ) rd > ^ 



. ,-^ 



hfnl/f/lK 



l>ll\ 



■\nV. AHOVK STATl'lD I'KRSONAl, PA RT IC f 1, AK S A R i; TR T K TO TI!1<; 
in<:ST Ol- MV KNoWM.Di'.K AND Hl'MJI-.l- 

r\-Mrc'.s T 1 S \)jsJLK<JL at. 



MEDICAL CERTIFICATE OF DEATH 

DATK OI" DKATJI 




(Month) 



(Day) 



igo 

(Year) 



I IllvUICliV CI:RTIFV, That I atteudtMl deceased from 



:sj- I. 



1 90 i 



to 



til at I last saw h .*-... alive on 



*^"W;- 



T b. 



T90 H 
190 . 



and that death occurred, on the date stated above, at 
Uw M. TJie CAl'SH OF DlvATII was as follows: 

^L\Ja„a..{ 



I) r R A 1' 1 N ) 'cars J/ofi/Jis Days lion rs 

CONTk IIU'TORY ...Us^.Vw\Xl c^^ 



t:\.i>^jc<:x.. 



nr RATION Years Months ^ Pays 

.UJ , Vj . Vjj XX^kJ^^J^XjO^^s^ 

Iress) ll^bteOllLU 



(Signed) 



Hours 
M.D. 




(.^ 



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



Former or 
Usual Residence 

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



Place of Deatlj ? ^^ Days 



ri.ACK Ol' HIRIAI, OR RKMOVAI. 



DATI':<)}" ISiKiAi. or KlvMoVAI, 

T9O > 






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

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



1 



— S ~ \A/RITr DIAIMIVIA/ITUJ llfVIC*ArMKir> iNiirf ._^ t-Lj 



>-« r~ r^ ka M iki^-i^i -^r- ••& *~ .«« . 



H<>:ii<l of H(.:iltli F Ni 



^«»!»*i,^ 



^■»:-"-*: nScI' C( 



1 )((/(' /v/r^/.Mlcrv-t/rnloA^ ^ 



ifii^j i<;9 r\ r-criivi^^i^^i^i m^V^V^rni^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



100\ 



Registered jYo, 



ooo 






^^\^\.:; 



DEPARTMENT OP PUBLIC HEALTH-City and County of San Francisco 



Ccvtificate of S>catb 

J? (^ -P 



Qy 



PLACE OF DEATH: — County of --/CX-i J^V<XAVCva.C' City of^J.CX-YX J A^Xy^ v^\,^co 



(5^ 



No. S 05b JrUt.,. 



St.; te 



Dist.; bet. I'ld. IlcIv 



tVi.( and 




V rr OCATM OCCUBRID IN • MOSPlT«L OR INSTITUTION CIVE ITS NAME INSTEAD OF STREET AND n U U B E R / 



xtir^X' 



I Jr\ k I 



FULL NAME lW^ c'^XaV'.. "^ vfilaVA-... lUvcU\A.c . 



- i \ 



I» A 



PERSONAL AND STATISTICAL PARTICULARS 





UjJ- ' 



VCLl- 



11 




-t^ 



MEDICAL CERTIFICATE OF DEATH 

DAT]-; oj- DHATH 



(MntUh) 



iDav) 



Mi.titli' 



1 



[).(\ 






A« .!•: 



V.ar) 



/^ 



(Vcai-» 



SINi.IJ. MARK 1 1: 1 > 
Wrr 



HiK'rnjM.Aoi-: 

'Stall' or <.'imiiirv' 



1- A Til i:k 



l:iK III !'l. \i}.; 

<)i- lAiiniK 

'Statr oi Cmntrv' 



M \1 I»i:\ N XM!' 

"I MMi"in:K 



IURTin'I,A("K 

()i- Mi)'rin-:K 

(Statr or Country' 






-CiM. 



OP ^ 



1 III'RI'P.V CI'RTII-V. That I altcn.k.l -Icvtasol from 



that I last saw li 



190^ to 

- alivf oil - 



icp 



and that (k-ath occurred, nu the datr stated ahove. at 
- M. The CAlSh: in- l)i-;.\TII was as follows- 



I >l RATION );,;,. V 

CONTRIHITORV 



.J/("////.V 



/hn 



s 



/lours 



t V 



(\ 









nr RAT ion- 



Signed ) 



)\i 




n:s 



^ 



Moil tin 



Pavs 



MTWa^ Va^-A.'AX.^N 



oiHTi'A'l'ION 



\ilc^r.....i Tool fAd,iress) H 1^ l^cvLLa>xd. vl 



/fours 



M.D. 



f'^^^'^'-J'^f^'^'^AT'lON only for tlospitdis, Institutions, Transients 
or Recent Residents, and persons dying away fronj home. "dnsienis, 



) 'rfi ! 



M^n,!!, 



/\!X. 



iMi' \i!ovK sr\-n:n iM':KsoNAi, i'AKi-irri,\Ks aki- vki]- id rnu 
Mi;sr oi' .Mv K.Nou i,i:i)<-, H AM) i!!:i,n:i.' 

QIT^ A J 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



n.ACHoi. n'WAI. ,,K KKMoVAI, I DAT,.;... lU.u.,. or KHMnVA, 

ktaki;k 0\D. 0. CJxaJLk; ^'C L(. 



I ■ M ) 1 : K 1 



^' "• ^'^'"'* '*•"" "*' i ■•' form »t ion should h,- c.rofnlly supplied. AtJF. should be stilted F.XACTI Y Pll Y^ilt^I AN« u . . 

rl^l I -1 c I '^i"'" •''"*'• *''"* '' """' ''^' properly classitfied. The "Special InformHtio,," ?or dt- 

Ron« dyinft nwny from homu should be Aiven in every instnnce. 'oprnHMon »or p«r- 










\ 



*%* 



vv ri I I t^ r-L.i^ii^L.T vv I I H w IN r M L^l l>l Va I IN r\ 






I ma la m r^ c. mivi m in c in i KHOUKLr ^P|^ 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



cLcrouL^ Deputy MecSth OfHccr 



llro^/.s/r/'ed Xo, 



ooo 



I 



DEPARTjyiENT OF PUBLIC HEALTH-=City and County of San Francisco 



Certificate of Beatb 



^ 



PLACE OF DEATH: — County ofCjA^^^ Jx.<XAX^.AACt City of CJ/CL/>a; J /V/CLO^Ca^C.< 



No. . 



; \ U-''cClx 



UCOAh.S^a." Dlst.;bet. 



/ IF DEATH OCCURS iwAY FRON^ USUAL RESIDENCEgi 
v. ir DEATH OCCUI^PED IN A HOSPITAL OR INSTITUTION 



and 



/ 



n 



IVE FACTS CALLED TOR UNDER "SPECIAL INFORMATION 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME V,L 



/ 



O V V. V. '.. 




N ' ^ 



C ' 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

i n ii.< "k \ \ 



i'S 



ll.l 



\.L'^. 



DA 1 1. 1 ■! i;ii< ril 



X' . 1'. 



M..I1I11* 



I)i(\ ) 



'V<:ir) 



MEDICAL CERTIFICATE OF DEATH 

DATi-; oi" i»i:ai n A^ 

VI U,^ 



I M.>iitli> 



^Day) (Vrar) 



1 lli;KJ-;nV Cl-:kril\-, riial r attcibU.l deceased from 

— to .- : 



ivi > w 




-I \' :.l- M \K K III! 

wi i>o\\i:i) o>v ' i > KM 1:1) 

' \\ \ it<- in srn-ia . ■ ii;ili' 11 ) 



niki II ri. \'' I, 

'State oi C. Hint I v' 



\ \ Ml ( >! 
1 \!ll Ik 



r.ik III ki.Aci-; 
01 lAriii'.k 

' ^1 .it I ■ I '■ U II t I \ 



MAIIU.N x\Mi; 
OI' MOTIII'.K 



lUkTii I'l.Ar !•; 

or MoTlll-'.k 
Cytale 111 rmiiit 1 \ 



n rtk \\ loxHTp 



1 

0\, » .0,.' 
I 

I) 






I()0 — 
lliat T last saw li : ali\e oil 



IQO 



T90 



ami that dratli occurred, on tlie dale dilated aliove, at — — . 

■;_ M. The CAlSlv ()!• I)i:.\TIl was a^ follows : 




DCR.ATION 



^'cars 



Moulhs 



/hns 



J/ottJ s 



.^ 



CONTRIHrTORV 



^^<^. 



/ Signed )Lc^'C^AX^• OAib. a..c 






Ri'tih'i' III Still / iilihl'ii) [ )'irl I ■^ 



\\^- 






//of/rs 

M.D. 



^vt'X^ 



OH 



A ^ k' 



Special Information only for Hospif,ils, InslitWitns, Transients 
or Recent Residents, and persons dvin] dway from liome. 



U:.„//,, 



Former or g ^ , 4 J ^"^ i 

Usual Residence " o I ^ x> M\) J ? 

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



How lonq at 
Place of Death ? 



Davs 



rii ) Mil »\-i', sr \ri; n rt.iksoxM, i-AkrnT!. \ks ak i; rkij-: r< » rii r; 
iii;-.r OI .MN k.vo\\ij:i)c, !•; .wd iu';mi;i-' 



'1 11 f' >' mini 



(Xd.lrr^s 






ri.ACK OI- HI 



»K kK.MoVAI, I I)An;<jf Hi Ki.Ai, or k i: .\f 0\-.\ i, 

.o^wMv I -J t'^\•^ t 1 90' I 

ixdivKTaki-rHiI 0/CXxixii/ru n[|V Q) \jUX\tei. ' n ., , 




(^.AcMres 



s ini 0)vv^^ 



^\^<r*\ s 



t 



I 



N. K. F.very Item o? iriformntion shoulti bs carefully Hupplictl. AGB fthoiild be stated KXACTLY. PHYSICIANS Hhotild 

state CAUSn OI- DHATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyini^ nway from home shouM be £iven in every instance. 



I 



f 



*\ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoat.l .,f II..;ilth »• \ 






S:!M\ 



REFER TO BACK OF CERTI FICAT'=: FOR INSTRUCTIONS 




/)((/r /v7r^/, MlnML^'vl'a, 



V,' 



WOH 



RegLstei'ed J\^o. 



OQOO 



ec;:::i omccr 



No. 



ACrvvu ckxv-M Deputy r ,v 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 5)eatb 

( U. S. StanDar^ ) 

J? ^ ^ % 

PLACE OF DEATH: — County ofCJ/CUVX' J Vclax^^a^^cc City of Oojyyj J Axl >\.caaoo 
^W "'O-C'v, ?. <,._.., ' ' St.: cs Dist.;bct. X.OJ\^¥s^'y\: and 0A.\.O,' 

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

\ 



FULL NAME 



A! 



.cL 



^^^ ^ W <X "WC^'CL- \J\^^\.<X^^ \ 



G- 



a 



PERSONAL AND STATISTICAL PARTICULARS 

li \ 11 ' 'I I.IK I'll 



iMoiiihi 



\| .1-. 



6n 



)■,,/' 



( I>:i\ 



1 Mi>jfh> 



r\\-AX) 



/>,t\ 



MEDICAL CERTIFICATE OF DEATH 

DAll-: Ol- Dl.A'iM 



■vile. 






(Vrar) 



(M<nith> (Day) 

I II I:K1:1'.V ti:RTlI-V. That I atteiulcMl «lc(xasc<l from 



v.. 



-NT. I, I". MARK li: I) 

A ii)«)\vKi> < >K i»i\i »Ki i: l> 

Aritfin -'M'ial dtsij^Tiatiun) 



lUk'nnM.Acj-: 

^!.iti or •■'iiititi \ 



N'ANt!-: ol 
FA 1 II I'.k 



Mik III I'l, \i I-: 

Ol I A III I'.K 

'S|:it> I It I'nil lit I V 



M \ I |)i: N \ \M I, 

Ol .moiiii:k 



I'.tKTMI'LAtK 
Ol Morili:K 
(Slatf or I'niuiti \ ' 



oic! r.\ rioN 



I 1 ^ . 



> 



' •- ' 



I . > 1 



n , 



I I 






I()0 ti I V.V.t?>^.^w.*.. igo 

tliat I last saw li ' alive on ' *^^' ^ n^o 

and that <katli nciurreil, on tlu' dati- '-tatt'il above, at ' •^ 
M. The C.\rSl<: Ol- DI'IATIl was as follows: 



.^ 



V 



I )r RAT I ON )'f(jrs Mont /is Days 

DTK AT I ON , )\'iirs I Mo)it/is /\iys 

(SIGNED) ^KOlxLu b \J\J^^- 



Hours 




I I()U} s 

M.D. 



o\: 1 ic,o'. (A.i.itv.s) Til Mrlavk..! "^ 



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



t <.» \ , V 



h'f hlfl! Ill ^iDI / IlllhlWll 



) Vt! I 



.\/,>,l//l' 



r>,irs 



Former or 
Usual Residence 

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



HoH lonq at 
Plare of Oeatli ? 



Days 



rm: M'.OVK STATIJ) I'KRSONAI, J' A KT HT I,A KS .\ K I •: TKl K To IMH 

iii.sr Ol- Mv KNOW i,»:i)c. H AM) i'.i-:mi;f 



'IiifM; in;iiit 



'jX\1>-V\Xj 






\ 



DATl-; o!" Ill KiAr. or KKMOXAI, 



ri.ACK OI' niRIAI, OR KKMoVAI. 



N. B. fivery Item o? infopmation shouiti nctully nupplietl. AGE should be ntated EXACTLY. PHY8ICIAN8 should 

stole CAUSE OF DEATH In pln'n terms, thnt It miiy be properly classified. The "Special Informntlon** for psr- 
sons dyin^ away from home sli«>uid be ti\\en In 9\mry Instance. 



'I 



I 



i^ir.-J-^^n 







i 



^J 



p 



* I mu 



■VI^MrsiKIA* I Kl L# 



-L-iic: ic A DCDiuiAiMrrMT RmnRn 



■ ^M • • • • • • 



VV h( I I C P'L.Ml INU.T vviin \j m r rM^tftyjt ii^i\ i • i • ^* • '^ 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






B(*<:>ist('rc(l J\^o. 



pqoo 



cKxru^v^ -LioM Depu* '. 'J j. Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Gcvtificatc of Bcatb 

( 11. 5. 2>tanc>arD ) •• 

PLACE OF DEATH: — County of Oa^-x \t5 CXC^L ^^^^v- City of oltr^kX^-^-u VoJk 

J 1 



No. 



St.; - 



Dist.; bet* 



and 



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

FULL NAME yCLA-oju \J\.^r^\y^ ^ J Kxcj .>.. 



PERSONAL AND STATISTICAL PARTICULARS 

^ r > 1 1 .1 I 1< 



1 



A- 



.1^.1 > ii i; ;k I'll 



i . ! uclt 



vl 






1^ 



\ ■ . ! I 



l>.: 



SIMM \r\Ki<i):i> 
i\\ I■ 



HIK I'liri Vl' I- 
' St;i'< '• ' ■mill \ 



(l 




A^xr 







MEDICAL CERTIFICATE OF DEATH 

DAT!-: OF Dl'.ATM 

I M \ 

iD.'iv 
I ni{Ki':i{\' (' I'.K'l'I I"\', TliMt I attoiiiUi; .krcasc-d rnnii 

I()0 to 



iMoiith) 



(Y.-:.i 



tli.'it I last saw h 



alive on 






MHil that (K-atli occii riCMJ, on tlu' <latc- stated almve. at 
M. Tlu- CAl'SI'; Ol" l)i;\'l'II was as follows 



I 



tj 



\A>n' <»!• 
i< A III i;k 



HiK I II ri, \ti% 
t)i I \rm;K 

SI .!. .1! r.iiiiit! \ 



M \ iiu .\ NAM i: 
<ti M( till i: li 



lUK I11IM,A<."K 

Ml' M()rii!:K 

(Slate <>i t,N)iinti \ 



AV- /,//',.' /// Siui /'i .III. ."'■" 



o c 



o^x. 



DCUATION )\'ars 

CON'lKIIirroRV 



Moulin 



Pavs 



IIoiii 




Yin I 



M.<„lh^ 



l\i\ 



I 111- \i!(ivi<: siwn:i> pkkson \i, iv\i< ihti.aks aki-; iKric lo riii; 
i!i;si' (>!• Mv KNOW 1,1 ; DO H AND iu-:i,ii;i' 



( I lif'i: iil.illl 



Ob Jb . \.ckkXx 



J\s^.. 



Dr RATION 
(SIG 



Years 



Da vs 




Mo)itlis 

NED) VA. '^. XaA-VX^V..! 

y ^ Tqo*^! (A.l.lrrss) Utft-Ck.t^nx. *^ a V' 



I loui'^ 
M.D 



Special information only lor llospitdls. Instilutions, Irdnsicnts, 
or Recent Residents, and persons dying dwdy Irom home. 



Former or 
Usual Residence 

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



How long at 
Place of Deatli ? 



Oavs 



ri.ACK OI' lUKIAU OK KKMoVAI, 

A"t,> - 



0-, U. U. vJ . L\JLy-rrvO.U\'- 



DATlvof HiKiM, or KI';M0\AI, 

VTlrsJ: ft ^^qlj 



I ni)i;rtakkk 

(Acldir-ss . 







i 



^^ K, Kvery Item of Inforiimtion hHouIiI »>o carefully Hupplied. AGB should be Btated BXACTLY. PHYSICIANS Hhould 

HtHte CAUSE OP DIZATH In pliiin term*, that It miiy he properly duHsified. The "Special InforniHtion" for pur- 
son* dylnft awoy from homo Hhould lie ftiven \t\ o\^ry Instance. 



II 



:i' 



H 





• ': us' 






i 



WRITE PLAIfNLY W I I n U IN I" MUl iNVj 1 1"* r\ 



ini<;9 to r^ r^f»i»ir-«t^ 



r*irr»»iiAMtrMT' DCr*r»DP» 



I « • ■ 



lfr.;ir<l wf li. .litli !•■ N'o 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)a/( /•y/r^//\ri'rvN'i/v>AX-^^' I 



IfJO'i 



Jfe£i,s/r/'r(l A'^o. 



"^f: t'^y^ 



d^Jx 



WC^ 



DEPARTMENT OF PUBLIC nEALTH=-City and County of San Francisco 

Certificate of 3eatb 

PLACE OF DEATH: — County ofC)/<X^Yv .V(X>vevAi/CX)City ofO/CLA\; J /^O. yv.Q^si^.A.. 

f ir Dt»TH OCOURS AW»V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER ' SPECIAL INFORMATION" \ 
V !F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME yiHLJL'(\i\; 0)ut5^^q^> 



Dist.; bet. 



and 



ii 



PERSONAL AND STATISTICAL PARTICULARS 




HA 1 I 



\<.l-. 



; 1 1< r 1 1 



•J 



! !■ 



1/ ).'// 



\ liir 



/'.M 



\Vil)« iWi:!) t'K l»i^< I'-". > f i> 



lUK 11! ri, \r]-: 
I Statr III •-■'lunl t \ 



1 



.vwcy 



u 



N \Mi: <)!• 
lATII IK 



C(l 



1 I 



'~\ 



lUK riii'i.Ari-: 

ol 1 Aflll-'.k 



M \ I IH.N \ \Nt 1 
<i| Molll i: K 



r.lR III I'l. MM 
Ol- Mn'nil.K 
(St;ili' >>v roinili V 



7\A^ "^^ 'A^ h ^' ' 



d-Nxlcx.>vcl 



MEDICAL CERTIFICATE OF DEATH 



DAT)-; Ol- Dl.ATH \, 



IQO 
(Yt-ai-l 



fMontli) (Day) 

I II i;U I:P.\' CI:RTII'\'. Thai I alten<U'<l .Icccascd from 



til at 1 last saw 1iXa>\ alive on 






Itp 
lip 



aiul that (Kath ocHMirreil, on the ilatr stateil ahov*.-. at cA 
^ M. The CAUSl': Ol" DI'.A Til was as follows: 



or RAT ION 
LlONTRIP.rTORN 



Years 



Mouths [<^ Pavs 





I lour 



•V' ^l. .>xc/ ;■.'...'..<. .V- P\j!r^y\i 



\^ 



^x 



.v-^;-^ 



1 kTII'A III 



'■LoLWvii^ 



h'f idr I in S,i)i I'l <! If' /<'•<' 



):-cn 



Mn„th^ I ?> /'.M 



VWV MIOVK STATl-.I) I'KKSONAI, I'ARTirr I. AKS A RK TKrH To TIM-: 

Hi-:sT ni- Mv kn()\vm:i)<".h and iu-:i,ii:i-" 



(I 



„f„:„w,„. 0(j Lo %iy4' 



X 



\ulaA. 







A.Mn... IH Aa. "^ M riu^Mm, m.A 



%'^\^\ ■ ' D 

nr RATION Years Mouths ^ /\iys I/ours 

( SIGNED )Q) \L-. vJ/a-^'-^ , M.D. 

M^-tA" '\ ic)oH (..\.Mress)\JO-Vx.AU ^hJAn 

Special information «nly for Hospitals, Institiifions, Transients, 
or Recent Residents, and persons dyinq away from fiome. 

\(\\ A 4 How lonq at 

M I LL/Y', . ^'- ) « pjareol Death? i -'- 



Former or *\ \ri 
Isual Residence ^^'O 

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



Days 



PI.ACK OK^rRIAI, OR R1-:MoVAI, 

rNDi-RTAKHRLcLLOUrVyvvOj LIavcC-Oi vc 



DAji;()! Ill KiAi. (,r RKMOVAI, 

MUat I 190H 



N. K. 



hvcry Item o*' inforniHtion jihouhl Iv.- cnrefully Hiipplied. AGK should be stateil RXACTLY. PHYSICIANS should 

stiitc CAUSr OF DEATH in pinin terms, thnt it mjiy be properly classified. The "Special Information" for per- 



son* dyinft nwny from homu should be j^iven in every instance. 



1 



I 




A *■&•• «jr ■*•■ 



••••• ttAit-nr^iKi/^ iKItiT 



WKIIC ^'l_MII>IL.T VVlin Wl^murii^iSJi ii^f* 



-rule ic ft DTRMANrNT RECORD 



■ t • • ^i' • 



H..;ir(l ..f Hc:i!th-'l' V" :' * ' .-j'-*' J''^'' ' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((li' riJ('(l ,\[\^S\>JL'y^^>-V\^ \ 



iD(n 



Iie(^i.str/'ed J[^o. 



i^tj'^cy 



1 



<^^^A.\.':j >:kx/v-^.; 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

I 11. 5. Stnn^ar^ ) 



(^ 



PLACE OF DEATH: — County ofC)/a->A; .X<X^vc^^c,L City of O^rv^' .^.a.'^'VCv^LCL 




51. 



bl^ 



No HO^la Mlcd_C .' St.; Dist.;bet. O .Uv and 

/ ,r DCATH OCCURS *WAV FROM USUAL RESIDENCE GIVE FACTS CALLED roR UNDER S P EC I AL I N FO R M ATI O N • A 
( ,F DEATH OCCURRED IN A HOSPITAL OR .NST4TUT.ON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



<:\j 



FULL NAME 



^1^ 



v« 



,h^<X/'>A^t\ 




CXAvixs 



>i.\ 



PERSONAL AND STATISTICAL PARTICULARS 

ci )!,( »K ^ ^ 




1 1 \ I 1 < 'i I'.iK rn 






L 



I ' 



I Kk\ 



\ ' . 1 : 



oH 



a 



as 



I Year; 



/■',; 1 



xINtl,!' MAKklJ'.n 

W I I)( >U I I> OK I>1N« "Kv i:i) 

iWiiU in ^ocinl «U-ir"iit'""' 



lUK riii'i. \iM-: 

(Statf or •-■' iiinti \ 



I- ATM 1: I< 



niR riiri. ACH 
o»" iArm;K 

I Slate or L"()\i!itrv) 



MA!1>j:N NA Mi- 
ni- MoTin-.R 



iui-;rn I'l.ACK 

of MOT 111'". K 

( SlaU- or Oouiili % ' 



I 



(jAy^^oAob 



? ^ 



JU 



orori'A TloN 




k'f'hli-if III San /'i iiih i'-'-'i ^\ ''■'•" 



\r.:ii!ln 



/',.M. 



TMl* VHOVH STA'n-;i) I'KKSoNAI< !» A K f UT I,A K S A K l-. PKri-: fo 
1U:ST OI' MV KNO\\I.i:i)<". K AM) Hl'.I.n",!" 



rmc 



( 1 







MEDICAL CERTIFICATE OF DEATH 

1. \ 11-. < il Dl-ATIl A^ 



b. 



1 90 

(I)av' (Year) 



(Montli) 
1 III'.Rl'iHV Cl'iRTIl'V, Tliat I aUcnikMl (lecoasc<l from 

— — — — H)0 to - — Tqo 

tliat I last saw linr—— alive on 19° 

an<l that death ocrurrc(I, oti the date stated above, at -— 

^ M. The CAl'SI'! ()}• l)i:A'ni was as follows: 

I) r R A '[■ K ) N } 'cars J/o>///is /hiys //o/trs 

CONTRiniToRV 



DIRA'PION )'c'ars ..^ Af out/is /hiys Hours 



(SIG 



NED ) LcrV^nJl^J vJ- vfo. LL. ixW V 
\ll(r^r ^( Tc,oH (Address) Lfr^un 



vc. M.D. 



Special Information only for Hospitals, Instiluti^^, Transients, 
or Recent Residents, and persons dylnj away fro;n home. 



Former or 
Usual Residence 

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



HoH long at 
Place of Death? 



. Davs 



DAI'lCof MruiAi. or Kl.MOVAI, 



ri.ACK oi- lUKiAi. OR ri;movai. 



IS B Kvery Item of 1„Wm»t1on should b. cnrcfully supplied. AGR should be stated F.XACTLY. PHYSICIANS should 

•tnte CAUSE OF DEATH In pinin terms, thnt it mjiy be properly clnssifled. The * Special Information" for pt»r- 
is dyinft nwny from home should be feiven In every instance. 



m 



som 



f 



r^ I n I 



K.. w ».#i-ri-i iiivirAniMn INK — THI?; IS A PERMANENT RECORD 



W M I I U. f L.i^l l'«U« WWIIll >^ »■% t r~*m» > ' ^ 



^•'J!!'*' 



j'„,.-,i.! ..f Il.:il(h I- No. ;• thv;'S-r.j^;lU'vJ'r., 



/)ff/(' Fi/cd ,\\ ^<y\^^ri'^i^\> % 



locn 



REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 



(X^^v^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticate ot IDeatb 

( 11. 5. GtanCarC> ) 

PLACE OF DEATH: — County ofO ayY\; J>UX/>vc.LVac City of /CW^ J Axvw<iA.xuu) 



N 



o. 



^M 'kx,\.^. 



St.; ^ Dist.;kt. <X> vCl\J./i^ and 

-. ....^ . -.«...> /. . ■ • c- r. r/->o iiKinrD "c: err I Al 'I N ro R MA' 



V 



i ,,011*1 orciinrMrF riuF rACTS called for under "special in tormation" a 

( '^ ^roZ.ii::?,::.^ :r.iosi'!.^[ o^"Ns.^^"4"^o.vr.;l name .nst.ao o. street .ao number. ; 



FULL NAME 




i\ 




s^^X c coix^i-i. 



si 



PERSONAL AND STATISTICAL PARTICULARS 

t.1 >!,( iK 






V' 



L 




X 



Xjb 



'\ \:\\< \ W 



M. mil 



cu 



.U?) 



! \'i ai ' 



\< . !■; 



^1 



^l\(,l,l' MAKl^Il I' 

w iiM i\\i;i) ( >K i)i\ I )Kii; I) 

Wiit'- in social il« -.i!.'iiati<>;i) 



lUK III I'l, \*"1' 

' St.iti' <»r '''Hiiiti \ ' 






/' 



1/ I > 




cLtlu^'Ua 




NAMi: »•!• 

1 A 111 j:k 



I'.IR 111 I'l.Afl'", 

I ii I \ nil- K 

iSta!( "1 l"««tinti\> 



MA lid', N NAM} 
()l- MO'l'll i: R 



IMU 111 IM.Ai')-; 

ni- \ji»rin:R 

mtal' "I roiuili N* 



I >y\\ r \I1(>N 

kfsidrd III San /'i hik fo O \.'.< ) .« / ^ 






}f,'iilh' 



l\n. 



TIN \M,.V1' m-\Tll.l'KKs;..NA!. r\KTI(MI,AKSAKi:TKl K To TIIH 
IJKSTol' MV KNi >\\I,i:n<-l': AND Hl'.MI.I" 



(I 



OOoJvou \l WOcX/Y\J 



^ 



(A.Wress V\ ^^-^AA^Vu ^ ' t' 



MEDICAL CERTIFICATE OF DEATH 



I) \\\: ol- i>i;.\ 



^ 



(Day) 



/ go A 

(Yt-ar^ 



(Moiith* 
I IIl';m-:r.\' CI'.U'rn-\', Thai I atLcmUil <k»\ascMl from 

^x ^-.l .; up'-' t.) ^i\cv b upM 

that I last saw h •.. alive on ^ ^^ '^ T90 "^ 

ami that «Uath .)Ociirre«l, on tlu- «latr staU-d abovr. at 10.60 
(J M. The CAISI', Ol' l)!:.\ Til was as follows: 



Drk.ATION 



Yrars 



Mouf/is Days I /ours 

(Signed) \j . t). <x/\ ^. 



Pax. 



Iloiii •< 



M.D. 



\jU\r "I icoH (.\<Mtvs.) ^o5"viA.K;voti^^vO.'!.do 



Special information nnly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyin!) .iw.iy fro:n home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



l'I,ACI>: Ol" lU'KIAI, OK KI-.MOXAI, 



ni)i;ktakkk \j 



DATKol lUKiAi, or KI';M<>\'AI, 

XJCUar H. 190'i 



(Address /n A Vl r'Vv^-^iA^xrv^-^l. 



>, H —Hverv Item of infor.n«f.on should b. carefully supplied. AGB nho.ld be «tated RXACTLY PHYSICIANS should 
state CAIJSE OF DEATH \n plain term,, that It may be properly classified. The -Spec.al Information for per- 
son* dyinft away from homo should be feiven m every instance. 



I 



I 



i* 






N 




I 






Hoiinl of II. alth - I" N 



n. ,. -^-t-^- U5tl'( 



/,9i^>^ 



■TLJic lo A PPRMANrNT RECORD 

lit! ^^ • ■^^ • • • -^ . - ^- iw 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

J?r('n'.slrred A'^o. ?3926 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of Beath 

J? ' (?V) ^ ^ 

PLACE OF DEATH: — County ofO Clox. J>\-<xovol4/g<:) City of ^xo^ J .^\.<wvcv(mi^ 



No. ?^H fe-e^vi 
( 



eX-^Y\^ St.; ^ D;st.;bet. .O/CL/YV^^UvO,^ and Ml 

I ■•e^iiHi o r c I nr Mr r r i\jr FACTS CALLED FOR UNDER " S P E C I A L ^I N FO R M AT I O N ' ' \ 



V^-< 



) 



FULL NAME V^CV 




.CVA'CCXivq. 



■"^(^ 



PERSONAL AND STATISTICAL PARTICULARS 



■^ 



J Ju^^ ^mJ 




.(Xjb 



II •. 1 i-. Ml i;ii< 1 !l 



Oil. 



yOXL 

Motithi A 



I ll;i\- 



A^i 



(■»<:ii ) 



\< . !• 



■>iN» .I.I' M \K k n: l> 

w 1 iM »\\ i: i> MK i>i\ » tKii;!) 

iWiitiin social <1« sij-Miatioti) 



lUKTIin. Ml' '"* 



NAMi: <>! 
»• Vl'li l.U 



I'.ikrii I'l, \ri<: 
Ml- I A rm-:K 



M\!!>I'.N NAMI- 
()I .MO'l'Hl'.K 



r.iK iin'i.ACi-; 
di-' m(»thi-:r 

(Stall' or i'lHiiiti v' 




CrUO^nrX) 



OCCXTPATION A 






M.->illi< 



l\l\ 



Tin- \Hovi- sr\rji) pkksonai, par ihti. \ks aki: rRri-: T(. tiij-. 

JJK^T Ol" M.V KNOWI.l'IX'H AND lU.Ml.i' 



(I- 






MEDICAL CERTIFICATE OF DEATH 

j)\TH oi i>i;ath (V,. 

Vfuar b /^^>H 

(Montli) 'l):iy^ (Year) 

I lll{Ri:i)V Cl.U'rn'V. Tlmt I aUcii.lcMl (k-crasr.l fn.iii 
.• , ' ,L ic)0-' to ^vitcv b TOO H 

lliat I last saw h •'.' alive- on ^ '^^ '^ T90 i 

;iii.l that (Uath oniirrt-.l. (ui tin- .late stated above, at I - A 
ij M 'I'lu' CWl SI". Ol" I)!'. AT 11 was as follows: 



)x/Y\<uLsX. 



^ 



or I^ AT [ON ^x'<^'-? Mo/ii/is Days Hours 



crv\; 




CmvLix^tXaa>OLlj \) a.\<viu<'Oi.'.. 



1)1' RATION Vt-ars Months /'>ays 



t 
flours 



ined)Aj. t>. J 



(Signed) V). ^. ^ <x>x.-vxa^<^ ^ ^^ M.D. 

^\jU\r 1 T(,oH f.\<Mrrs.)^OS'Vl<XVv(SLi b.'.. 



1^. o 



Special information only for Hospitals, Institutions. Transients, 
or Recent Residents, and persons d\in!j awa> from tiome. 



Former or 
Usual Residence 

Wlien was disease fontrarted. 
If not at place of death ? 



ftow lonq at 
Place of Deatli ? 



.. Days 



ri,.\CK Ol- r.iRiAi. OR ri;mov.\i. 



i)\ri-;<>!' lit KiAi. or ki;mo\ai< 



Ov 



Ob (ru^ ^p^ 

t Nnv.RTAkKK \J Oo'OUSr^ lIA'vdiL^JtxxJsXh^ 



I90H 



^ B _T.verv Uom o." in9orm«tlon «houU. b. cnrcV'.My st.ppHc.l. ACfi sho.Id be stated nXACTLY PHYSICIANS should 
«tatc CADSI: OF DIIATH In ph.in terms, tbnt it may he properly clHSsifJecl. The "Specal Information- for pT- 
«on« riyinfe away from home should he ftlven in every instance. 











» . a*, te «m • A S ^^ • ik I 1^ 



WRITE PLAINLY Wl I M U IN r MUI iMVa ii^r\ 



■t-Li I cr 
I I I I ^^ 



c: A orDMANPNT RECORD 



.)?M:,r.l -t H.:i!th 1- \'<i. !«i *-*'^-^>l- HS: 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Boi^islvred ^Vo. 



Xt^vcv/idutw Deputy Hcci:h OfTiccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 



PLACE OF DEATH:-County ofOcc^ J .Kxvwc^c^ City of axv>^ jAXXy>x.<i^.>^ 



•J 



111 

(IF DEATH OCCURS 
IF DEATH OCCU 



NoXl) n \|llav^'-A^ oiscH^w 





St.; 



Dist.; bet. 



and 



--) 



IF DEATH OCCURS AWAY F 
RRE D I 



FRoi USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECAL INFORMATION ' ' \ 
N A HOSpVtau or institution aiVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



:i 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



1» \ 1 



vHlck 




vc 



Ax 



K lli 



.^1^ 



\!..-itli 



(I)av) 



\i i; 



aio 



n,i 



\\\\n »\Vl-;i> OK I>;\< >!<*'L 1> 
iWiilf in *i>ci:tl .li -i).'iiat i"n ) 



lllK 111 !•!. \>" 1 

I Stilt'- 'il t"MUMtI V 



NAMi ttl 
1 \ 111 IK 



isik 111 I'l. \>}-: 

Ol' 1 XilU", K 

>| .it . . .; r. 'U lit I \' 



M\I1)|:N NAM!': 
Ol- Mo'l'lli: K 



CA.\jULa\xcii 






niK riMM.Aci", 
Ol- moiim-:k 

( <t:itr iM Ci illlltt \ 

(M (■fl'AI'IoN J? 




- .1 /.'////. 



/'.:\ 



■nil' xHoVI.-STxril.rKR^oNAl. l>\KTUM-I.\KSAKi: TKti-: ro Till': 
lU'.ST Ol' MN' K No\\I.KI)t-.l': AM) IM.l.Il.l' 



(Il 






MEDICAL CERTIFICATE OF DEATH 



I) \ I" 1. < '1 I 



■" W- 



b 

iDav) 






(Motithl 
1 III;KI;!'.\ CI:RTII'V, That I atUM<k'<l <l<r<.-:isc(l fri»ni 

. ^ ' ■ ( K^r/i to xPl-^S^^ t Tf)0 M 

Ih.il 1 last saw h ... .' alive oil U"UtiA-^ ^- 190'. 

.1 that .K.itli occurred, on tlic <late staled above, at b 



,m 



> M The C \1 SI'" oy l»i;.\'Pli was as follows 



-\^^' 



C(»N Tkli'.rToRV 



M out In 



/hns 



//ours 



DT RATION )'i'(irs Months /^(jys //ours 

f SIGNED )vAJ.. 0. OLv^rW.k.;LD V M.D. 

\AtV 1. Tc,o': CA.l.lrrss) \l iVohA-P.i. h(S^\\xlo.X 



Special INFORIVIATION ""'^ '*» MuspitHK, institutions, Transients, 
or Retenl Residents, dnd persons dyini) .mdv from liome. 



Former or 
Isudl Residence 

Wtien Mas disease ronfriirted. 
It not at place of deatfi ? 



How loni at 
Pla( e of Deatfi ? 



Days 



[•LACl-: OI" lURIAUok KI:MoVAI, 

"^ I ) 



V.>L-^A^ 



DA'DN)!' Ill KI.AI. or K1-:M0\A1, 

^Iruv- "^ T90H 



I 



Ni)i;Ki\-\Kr:i<NTC OuLcUaxj Mir\i3\if. caj^ '<<<. vi/vJi^i 

(Address 1 H I vl riUi>>iA.-(OM O-ti 



^. K.- 



... .• u.iii.. ..-^fnllv «uonIie<I. A(;R should be stnted RXACTLY. PHYSICIANS «houlil 

Ron« clyJnft imny from home hHouUI be ftiven in every instnnce. 




I 



I 




^ 



.r^i-t-r- esi niMl V \AIITM IINFADIN 



VW n I i ^ r »-r-» I • ^ 



G ,MK — THIS IS A PERMANENT RECORD 



l!,,-,,Mnr ll,:illll -»•■ N'>. i^ *— --f:^i-His:l'^:' 




Du/r hllcfl . VlLn-^A^'vl^V I 



IDO'i 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



..(rvcA^ .11 



Dcp'Jty r- 



•^ 






DEPARTMENT OF PUBLIC HEALTB=City and County of San Francisco 



PLACE OF DEATH : — County of ^ -K^i^^-'- 



Certificate of 2)eatb 

( 11. S. Stan^arD j 



City of 



^„^L.^>-vO 



Led- 



No. 



St.; 



Dist.; bet. 



and 



( 



IF Dr*TH OCCURS AWAY FROM 
IF DEATH OCCURRED IN A HO 



FULL NAME 



IJCiUAL RESIDENCE GIVE PACTS CAL IE D FOR UNDER •'SPECAL INFORMATION ' ^ 
.SpVtAL Tr frlsT.TUTION GIVE ITS NAME .NSTEAO OF STREET AND NUMBER. J 



1),\ 1 I. 1 i| l; IK I'll 



PERSONAL AND STATISTICAL PARTICULARS 



\ On 



a 






I );!>•' 



HO 



\Vm« »\\ 1'". I» <>K l»i\ < •K\")-I> 



i;iK riiri, \>'i-: 

St;itf iir I •iimtrv* 




<XK^\J<JC<k. 



\ \M I- I >!■■ 
I- A 11 1 l.R 



mK rm-i, ATI-: 

ol- 1 Alin-.R 



M MDl-.N NAM1-: 
t»l MuTHHK 



i;iK rnri.ACic 

ol- MOTHKR 

(Stat( or C'Duntvyi 





(\ !1 



OJVc.'i. 



u^.\.<^v^o 



lo 



MEDICAL CERTIFICATE OF DEATH 

i) \ r 1 , 1 »i I ' r \ r 11 




I lll.Kl.r.N I i:U'ril'V, That I altendctl deceased froiu 



(Year) 



It/J til 

;iliv<.' on ~ 



tli.'tl 1 last s.aw h 
and tliat dc-atli ..ccurred, <'ii the date stated aliove, at 
M. Tlie CAT SI-: OF i^lvATII was as follows 



'iqo 
■ 1 90 



1)1 RATION )'rc7 rs 

CONTUIIUTOKV 



Months 



/^(lys 



DT RATION 



)'rars 



(SIGNED) L. 1 ' ' 



Moiilhs Pays 









Hon IS 

Hours 
M.D. 



^JlcAr 1 T<)o'i (Ad.itess) ^ KL^^^^ '^g..*; 



Special information "nly for llospilals, institutions, Transients, 
or Recent Residents, and persons dying anay Iron liome. 



in.'crr \ri()N 



'1C )^- 



1.', '-','//- 



/),.M 



in-:sr Ol" MV KN< >\\ l,l.l'« •!•• \^" I'l '•''■ 



RTHM I \Ks \Ki-. i-Rii". ro Till'; 



(In 



f,„„,.u Mv^ m)V SUv^v^ 



( NiMr.'ss 






Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Days 



rUACK Ol" lURIAl, OR K1:Mo\"AI. 



KC\(^ 



VDCriLL Lh^<5-^ 



DATi: of nnu.M. «>r RI^.MOX.M, 

Q\C^" T9o'l 



I - N I ) 1- K T A K 1-. R LojX.J-^<^ ^^ Tl/V-UXL V. ^Uk' 

(Address V\ \).CK^^ M\ilH^^.,.Cl'V..-,v 



M. B.- 



I, I 1 K- „,.«f..Ilv suni>r..cl. AGE should be stated BXAGTLY. PHYSICIANS should 
:r/c*U.;r or OHa'Vh" n'";'.:^ :;■•::. H?. rrj::; ;'.; p....,..., ..,«,Wie<.. T..e -specie, .nfo^n-Uon- .0. p... 
son. dyinft away from home should be feiven In every instance. 




1 1 Wt4 



% 

^ 




■^i 



W 

ll.,:.IM .1 II' 'til 1' ^' 



RITE PLAINLY WITH UNFADING INK 



♦-'»'**'*' 



. ll.S; r Cn 




J)(tl(' FiJvil, \J Icv^-Vrv 



Wv % 



i!)0'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A.i/vt(. "^ 



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



Ccvtificate of IDcatb 

PLACE OF DEATH: -County of^^Cv^v j/^^t^vc^cc Gty of ^^^Axx^^x^^ 



(^ 



No 



/ ,F DC»TH OCCMPS AWAY F 
\\ IF DEATH 0<icURRED IN 



and 



^ '^- *-- ^"rno'^s^P t'!.!: c^'frls'ru^o'N o.vtTs NAME .nsteao or sTREtT and numb.b. ^ 



FULL NAME '^^^ 




\ 



PERSONAL AND STATISTICAL PARTICULARS 

t( )I,mK 





] . \\kkh 



\^^ 



At .1. 



Kill 



Al..ntli' 






A?>o 



10 



\ }/.;<.'//- b 



\(;ii ' 



/'./r 



>~IN<', l.K, MAKl<U:i» 

WID* >\\i:i> »•!>• I>IVok> ID 



Ill ' 



HIKTHIM.AOI-: 

, <t:i''- "t '"' ''> 11' '^ 



NAM! i>l 
1 \ 111 IK 



lUK 111 I'l. \*'»-'. 
(U- 1 \ 111 J-.K 
iStati- i>T C'lUiiti V 



M MDl.N NAMi: 
(»1 Mollli; K 



r.iK'ini'hAOK 

.>|- Mo'niHK 
(Statf <>v Connti vl 











MEDICAL CERTIFICATE OF DEATH 

nATK<..in:ATn (V.. 

f Month) 'J>='V^ '^'^''""^ 

I lII'iRin'.V C1;RTII-^V. That I altciukMl dcrcascMl fmni 
VJ.W- n i9o'l t.. '..PL^^r n 190 'i 

that T last saw h '^ > '^ alive on v)\^- S 19O '^ 

and that (Uath orourred, on tlu- .hit.- stated ahovf. at 
;\[ Tlu' CAISI<; Ol' 1)I:A Til was as follows: 





'' ^OlAJvULX . 



H Rxx^.^uxc/lrcv^^L^X'^ 



o.crrATioN 



I )r RATION )'CcJrs .1A>|;////^ H /)ays Hours 



DT RATION 



Years Months Pavs 



( SIGNED )iLV>k.^i LloJu\\ 

iqo'l (Addrc-ss) ^5 i OA.>XLx,\ M. 



Hours 
M.D. 



Q 



W: 



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



M, ■II tits 



/\iv. 



TnKAHnVHSTX.MU.PKK^.)NAl rU<n.rLAKSAKKTKrK H - T H K 
lil-.ST Ol- MV KNt)WM;i)«.H AN!) Mhl.n> 



U)JUL< 



N'Uln-ss ()^ 1 Oo 








Former or 
L'sual Residence 

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



How lonq at 
Place of Death ? 



... Days 



DA/n-:!)!' I'.iKi.Ai. or KICMOVAI. 

nTUaT S tqoS 



ri«ACK (ULIU'RIAI. OK ki:m<)vai. 



— ■■ ■ T' 



" ^' . TTx ...,«wN.i,v «uDnliecl. AGB shoultl be stated EXACTLY. PHYSICIANS «hould 

«ons*'dy1nft awny from homo Hhould be feiven In every instance. 



'I 1 






IWI 



WRITE PLATMUT Wiin w«^» 



A rMivii^ INK 



#-!**••» 



i^/Zr ri/i'^i,\iX^ 



Date I''//i'(f , MXXro-^-Y^^^'^"^ ^ 



lOO'i 



— THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIF ICATE FOR INSTRUCTIONS 

Re^Lstcred ^'o. ^^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Cevtificate of Beatb 

( 'U. 5. StanDarD ) 



^l^KCE. OF DEATH:-County of ^O.. J-X<x..c^c. Gty of 3^1x^vc..e. 



No. 



IVVHJJ^ 



^ 



. ' CLX^V-V „c3;NCE O.VE r*CTS CABLED rOB UNDtR -SPrC.At .NrOBM*T.ON- ) 



) 



FULL NAME 




Cull. .S^O LV.Lu_' 



>1\ "^-N 

1 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK > 



,o^Lv 



U, !.,!. 



i>\i i: (»i i"'iK 111 



\' i; 



c(JV' 



) ,,;* 



i l):i\> 



.1/"////' 






nu\s 



MEDICAL CERTIFICATE OF DEATH 

DATlv Ol- DKAlll 

V U I 







SINC.I.l*. MAKWIl'.n 
WIDOW I.I) OK I)I\»>K^ » I) 
(Write ill socKil <li s)iMi;tti"i>> 



iMK'rmM.ArK 

(State «>r (."(luntrv 






(Month) . 'I^">'^ 

I IM'RIIHV Cl-.RTM-V. Tliiit I MttciKk-.l .Urcascl from 

that I last saw h -^ ^ alive .mi ^ ^^ ' 

an.l that .U-ath occurred, on the- .lak- stated ahovo, at I ^^O 
M. The CArSlC OF I)1':ATII was as follows: 



va>^LcicX-. 



NAM J Ol 
!• A THICK 



niRrmi.AOp: 

OI- l-AIIIJCK 
(St.itr or I'ovmtrv 



m\ii»i:n nam I. 

(»I- MOT I IKK 



lUKlIiri^AlK 
ill- Mi>llli:K 
(State or i"oui»try) 



OCCl I'A TION 

h'fuh,^ III S.lll I-KIIK '•'■" 




n\) 




OUC^AX 



cVa \A-a.^ 




^ 



nr RATION y't-ars 

CONTRIIUTORV 



MoiiUis 



Pays 



Hours 




1)1 RAT I ON Years .Von //is 

(SIGNED) Wlv>-v 0<xt' 

,t \. T U)o'\ ( 



Pays 



Hour 



) V(f / 



\/,, II I In 



lhi\ 



liHsr c.l- MYJiS-o\Vl.i;i)'.l-. ASI> lll^LIM 



'^ 



(Iiifi >i Jiirnit 



y\jcsyy^\ \ '-^^ ^^ •> ^ U . ^ 



<^ 



{ Xddrcss 



14HH 



.VvJl 



M.D. 

Address) (^01 \l<X.'t<^U\ >v-V^^- 't' 

SPECIAL INFORMATION only for Hospitals, Insfttullons, Iransirnls, 
or Recent Residents, and persons dying away from liome. 



Former or tuu. Q^^ ^ . ^ J y A t """ '""^ *' 
Usual ResidenceV^XU >^ ^ a\.\l,L<- ^' 

Wlien was disease contracted, 



Place of OeatlJ ? 



... Days 



If not at place of deatfj ? 



I)ATl':of IHKiAL or KHMOVAI, 






I90H 



,. ■ AGR should be stated EXACTLY. PHYSICIANS should 
,. „._Hvery Iten, o.' ,„»o.«.Ht.on should '- --^"'^^ ^^^^^^'^c prop;rly Tl—Wled. The "Spec... Information" for p-r- 
state CAUSE OF DEATH In P "•"--•' V? J lr"t .n.r.nce. 



:r d^in. aw.; ;;o^ ho.; ;hou.d he .U-n , > 1n.t.nc.. 



It I 






! ' 



( ► 




^.- ^» Mifiii \/ \AflTH IIMC-AQmOi INK 






t\'^C ^-^ V 



I.- 



JlJf)^- 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

" pool 



DEPARTMENT OF Pl'BLIC HEALTH=City and County of San Francisco 



Ccvtiticate of Bcatb 






e^ 



PLACE OF DEATHr-County of "^<^>^ J-^^<^^^^ City of r>.^v J .Va,.^ - -, . 



J\' 



^^. 6% . '-Uokx-^ .' 



St.; 



Dist.; bet. 



and 



— ") 



LV/TVX^ .V ■ ,.c,,^, Br«;iDENCE GIVE FACTS CALLED FOR UNDER •special INFORMATION- \ 

( '^ rF"o;AT°^OCCU%ro\N"rHo"s"rAL 0%'fNST^^" "^C.VE .TS NAME -NSTEAO OF STREET AND NUMBER. ; 



FULL NAME aU.^*-^:^ 




PERSONAL AND STATISTICAL PARTICULARS 



-lA 



111. 



*■« >l.i (K^ 



l> All; «>: ; II 



10^ ^ 



\x^iJJb 



,iab 



l>.^\ 



\l .\ 



1% . 



( Vi-ar) 



/ ' . 



slN< .1.1" M \K K n.l' 

\\ 1 1)1 1\\ i:!» « »K ni\< ii-ti'in 



MEDICAL CERTIFICATE OF DEATH 

I II 1:R i;r.N' CI;I<TI1-\', 'I'hat I atU-ii«U«l <k'ix:isr.l from 

tliat 1 la-t saw h - alivi' OM ^' ^^^ 

ami that .katli occurred, on the .laic >talL-(l above, at I 
^ ^I. The CM SIv OI' DI'-ATil was as follows: 



[(;o1 



,d 




rnKTMri, \c}' 

Si iti ( .r I ■' >nnt I ^ 



lATlilK > 



Q' 






■n 



luuiiiri. \vi: 

ol- lAIlll.K 

I stale ol Ctniiiti %• ' 



[\tur 



^.^^(^ ' 




M \ ii>i;n nam 1 

ol- MoTin-.K 



iuKrnri,AC)': 

1(1 MnTHl-'.K 

(Slate iir Count I \- 



oxiyuCL/^vcL' 







^ ;i. 



\>^ 






.^h'liiii^ -. /^''>> 



TnKA.U>VKSTXT..;n.M^KSONA. rUOM.M^l.ARSAKHTKrH TO TMK 



(Inf. 



(X.Mrcss %^^ ^^JxJiLL OX 



nr RATION y<arj^ A/onths Pdys Hours 



DTRATION 
(SIGNED ) 



)'cijrs 



\i\Q 






/hlVS 



lion IS 
M.D. 



^ 



wt\" 



^ T(p 



Atldrt-ss) O.tj. .>wLA.,k,^.A jV.O^slj. 



Special Information '>nly J«'' Hospitals, institutions, Transients, 
or Recent Residents, and persons dying .may fro.n home. 



aST - u:t 



Former or -« - a -K 

Usual Residence 

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



HoH long at 
Place of Deatfi 






Days 



ri.ACK (>!• lUKIAl, OR RHMoN'AI- 

1 



ri.ACK Ol- m 



I).\TK»>f UnuAi, or KKMOXAl. 

M^Uar. M 190' 



(Address S H lo \/ K A>Q>aX. CH A. 'It 



ii 



... !• I AHF shniilfl he Htnted EXACTLY. PHYSICIANS should 



N. K. Kvery Item 

«or/dyhiT«way from home nhould ho li'.ven In every instance. 



Oliiil 



4 






1^:, 



y^ 





Jkk 



WRITE PLMIIMUT Wiin viii 



cnrMivir^ IIMK 



f-i •* • • « '«* 



THI 



S IS A PERMANENT RECORD 



1 f II .,iti, I- No ic ■*'^^!^^ HM' C*') 



!)((/(> /v7fv/,.\jXcv-0-v^WJiA'/^. 



100^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be (Mustered J\'o, 293/4 



,^\.CU^ dw-^V'.; 



Deputy J-{ea5th Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



Cevtiticate of 2)catb 

PLACE OF DEATH: -County of -)<:- J ^<X/^ vcui c Uty oi 

> J i cx ^ nicf ♦ lv»f b KA\) and ^ -^^^^ ^ 

1 C q J^ VWO. oC«.n*LcE^C.VE r^CTS C^u'tO rOR under •sPEC-.L .NrORMAT.ON- \ 

FULL NAME ^cOJ^v^^v.- VkAxXh.^ ■ 



PERSONAL AND STATISTICAL PARTICULARS 



,,.X -Y-N 



DATl". «>!• r.lK III 



COLOR 



\ ■ 



(MMlltlll 



\t.i-: 



)V,/< 



( Dav 



Monlh 



(Year) 



/)</! 



MEDICAL CERTIFICATE OF DEATH 

i)ATK t»i- i)i:ath 



(Month) 



(Day) 



(Year) 



I in<RI<:nV CIvRTII-V, That I atten.k-a deceased from 

Ql\avv_ ...IS 190'cs to yl^....-b. 



that I last saw h 



190^ to 

alive on 



190S 
190 I 



sINC.1,1* M\KKn;i) 
\V1I)<»\\ i:i> OK DIVoKil-.l) 



UIK rmM.AOH 

(State nr Ooniitrv'' 



N \Mi: nl 

ixrm.K 



HiRTnri,\rH 
()!• i.mhi:k 

(Statf 01 Country) 



MMDJ-'.N NAM1-. /'7> 
01 MOTllKR ' 



lURTlirUACK 
(tl' MOTHI-'.K 
(Statf or ('ountryi 







\. V\A,( 



and that death occurred, on the date stated above, at 
M. The CAlSIv OF DlvATll was as follows 



DrRATION ^ Vi^ars n/ofUhs Pays Hours 
r«r^viM>mi"r()RV \0\^<xXAAA^L^.^AxX^Vv. 












I )!' R AT l( )N --- > ''"'^'"^ .V<»i//is 

( SIGNED )...Uj./"VYV.sJ • vJj^.vL-oJL 



\flca.r % 100 '-1 (Address-) 1^10 J cHUc-^>-v CJt 



/)ays Hours 

M.D. 



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



SVsldence I ^^ ^ U^^lwU^xt cH Pl?re TDeath? 



Months 



Ihtv 



.rnr,mn-Ks.rA.r,a.PKK:.-NA,rAKr,crKAKsA,<KrK,K n, vnv. 

HKST Ol- MY KNOWIJ.IX.I'. AM> »J.^>»'-'' 



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







. Days 



•RIAU OR RKMOVAI, 



DATKof niHiAi^ or RKMOVAI, 

OlcAT LO. 



l-NDHRTAKKRMa 0/O.<UU^W^ ^AXa\^ 
(Address Ul.l \UU-<^<LA^->^ .' k. 



T9oH 



":;*?.. ~~ .™ •— •-" - ' •■••' '■•"-• 



Ns 



;X 



a 



^...,. 



!;i..i!.l ■.!" II' iMh i V 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

t..^""-^*^; nS.\'K-n REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS 

2933 



'l<^vcV'^ Xiv«^ Deputy Hen!th OfHcer 



Re si i. sic ml jVo. 



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

Certificate of Beatb 

J? (^ J? (^ 

PLACE OF DEATH: — County ofCWov K<Xo vCA^CcCity ofJccvu J A.<X'T^v'Cx<i. c ( 



» I 



No* 



and O'L'A^-:' 



^OA^aVv , - St.; '. Dist.;bet. A.O.V.IAJ.. . V 

/ IF dcatM'occurs away from usual residence give facts called for under special information- \ 

( IF OEAtH OCcJR«tD 'N * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



^lA 



l>.\ I 1 < M IliK III 



PERSONAL AND STATISTICAL PARTICULARS 

1 . , • 




I 



l''>^Vt^.-V»' -^ . 



'11. 



\ ' I 



b 



M..iillP 



) 



I);i\) 



rlV. 



1/ 



'^l M . 1,1 . M \K l< l):i», 
WIDnWI I) «>K niX'i >Kk"l' I> 
I \Vi itf in ^M.-i.il (Ksi^'iKiti'Mi i 



I St:it'' or t"'>iiiitr\ 



'A 



1 .^ » 








NWll i>l 
I .\lli IK 



HiK rm'K.xci'; 

Ol I XIIM-.K 

(St.il< "I C'>\iiiti \ 



M \ im:\ \ \M i: 

<>I .MoTIli: K 



HlKlinM,.\(l', 

• ii" M<»'i-m:i^ 

' stall Mf rMiuili \ ' 



I .9P': 



MEDICAL CERTIFICATE OF DEATH 

D.Xl'l-; Ol' Dl'-.-XIII A-^ 

(Month) iDjiyl (Vt-ar) 

I IIi:Ri:r.V I'IIRTII'V, Thai [ al'uiuk<I (IcTcascd fn)iii 

ic)0 to — — — — — up 

tliat 1 la^^t saw h alive on Up ' 

ami that dt-ath occurreil, on the ilalc statctl ahnvi-, at 
M. Tlu- CArSI-: ()!• DlvATII was as follows: 



c'oNTuir.rTokV 



Mouths 



Ihixs 



J /ok IS 



.^ 



X 






f\r'i<{f'J II' Si'ii f'l (111, i-r,i 



) Vrt; 



/'„'! 



lin- \HOVl- ^l- \ ll'-.h I'KK^oN.M, I'AU ri< 11. AK^ AKl', IKr)'. To Till'. 

iu:>T ()!•■ Mv KN'owi.i'.ix'.H AM) Hi:i.n:»' 



( 1 n f'li niritit 



sX^-s 



^ 



U) GIJ- 



<^ t 



' \iMri >is O <T* i^ 



- \\Xl\\^ cJl UoLl\la/Y\ACa' 



DrR.XTIOX 



) V(/;*,? 



Moulin 



U\: '. i(,o^ (.\<i(iu-ss) L(rV' 



Days 



Hours 
M.D. 



(i-vUL\A 



I 



c^..- 



SPECIAL Information only for Hospltdls, InslituWdtis, Transients, 
or Recent Residents, and persons dyinj away fron t)ome. 



Former or 
Usual Residence 

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



HoM lonq at 
Place of Deatfi ? 



Days 



i,.\CK ni-' nrKiAi, i)K Ki'.Mi »\'.vu I h.xn.oi i!i Ki.\i. oi k1';m»)\ai, 




I .\ 1.1', HI' 






T90H 



IS. B. p.very Item of informHtion nhoiiUI be ci.rofully Kuppliecl. Adfi Hhmild ho Hti.te.l KXAGTLY. PHYSICIANS should 

stntc CAUSE OY DfiATH in pinin tcrniH. that it mny he properly clasiiiined. The "Special InforinHtion" for per- 
sons dyind awny from home Nhoiild be given in every InHtance. 






•ill 

' I \\ 
1 



fi 



H 




nr-irt! of Urnnh- »•* V" ! -^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l^Jr-,5:^, H& .' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

"" 2934 



h Officer 



Bci^lsfcrcd J\^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

J? -TlT^ \ '^0 

PLACE OF DEATH = -County ofO^^ J r^c^ >.c.^c. City of ^^C^>v .1 AX^>^va -M- 
•j:^ n1\ MtV^i K'Ian 'lh>v i-.^Lo ' St.: Dist.; bet. — — - and 

Ne. \ IVsi^C V. ><A^ JLa. V -^-^^_ RESIDENCEG.VE tacts called rOR UNDER "SPECAL .NTORMAT.ON ^ 

^ ( " nrATrOCC^%rD\rrHo"s^Pa':;L o'?n?x^^"o'. O.VE its name ..ST^O O. street A.D ^U.BER. ) 



FULL NAME 



-1 \ 



PERSONAL AND STATISTICAL PARTICULARS 




^.c^u^ ) 



^ I 



HIclL 



LliJxci> 



n \ 1 1-, 111 i;ii< III 



.\t.i-; 



si\« ,i,i- M \\< K u:i) 

w ii><»\\ i;i> <»K i)iv«»vM i:t) 

\\i itr ill Koii:il <1» >-i'/ii;iti('n) 



rV' 



I);iv 






A 



' Sl;iti >>t Cminti \ 



1 \'i"ii i;k 



HiK rui'i, \*'l'. 
(>|- 1 xriii'.K 



MM1>1;N NAMl 
ol Morill'.K 



iiiK'nii'i,.\ri-: 

«))• MnTHl'.K 

(Stilts' Ml- Oounti v' 






OUX'v^.^i.t^A 







; \ 



K. 







? 



1 urri'A rioN 






1 



o ' 
Rfsiifft in Sii» /'i nil, I ■ 



\ -, r, I 



M.- 11 His 



I >,! \ 



HrA.U,VKSTXT.l.I'KKS,,NM.rVKTU;i;LXKSAKKTKrK n. TllK 
lUCST (>I- MV KNi)\VI,i;i)«'.l': AM) i.i-.i.n-.h 



( InfMMii.uit 



MEDICAL CERTIFICATE 6F DEATH 

iiAri; <>i I'l'ATii r\^ 



a 



't 



I. 



(Vtar) 



I 11 i;U i:r>\' tl'R'ril'N'. 'rimt I MtU-iKkd decease. l from 






1()0 



,M 



tv ci. ;.-j 190 

that I last saw li ■ alive oti ^-1 V^^J" ^ Kp 

;i!i(l tliat ikatli (H-oiirred, on thr .latv slat*.. I above, at \l oQ 
M. Tiic CAISI'! Ol'' l)i:.\'ril was a^ follows: 



^>,!8 




DTRATION 



Vi'ars J/of///is ^^ /hiy.s Hours 

)NTKII?r'l'()RV Ox^/v^X/wc-oA. L ^ 




.>v>XXA.A..<; > V 



DIRATION 



Ycays Moulhs \ Hays 

( SIGNED ) Uj.^^Y) - Vjj 

Q^ 



n' 



if)o', ( 



O^A.A/»VXV<X^V^' 



^VJ 



1^ 

r lT9Soi 



Hours 
M.D. 



SPECIAL INFORMATION only for ITaspi 
or Recent Residents, and persons dyinq dway Iron home. 



Transients, 



%ll M lloAJkLl' \t Plare of Death ? 1 1 .Days 

was disease contracted, iH x 
II not at place of deatli ? \J^\: lb i H C M 



Former or 
Usual Residence 

When was 



LU,AC1<: (>»•• lUKIAI. OK ki;m(»vai. 



a 



■^•o 



DA'n-.of liiKiAl, or K1:M(>\'AI, 



LCi 



190 



•>3chIcU' 



^\(Mress 



•J- 



V 



i ■' 



IS. \\. 



5on Hhoulcl h. cnrcUWy supplied. AdR should be stated EXACTLY. PHYSICIANS Hhould 
H In pinin terms, that it may he properly cloH«ified. The * Special InVormat.on for p.r- 



-livery item of in^ormat 
Btnto CAUSl: OF DEATH in p 
«on« dyinft away from home should be ftJven in every instance. 



I T 





|i^4lL 



WRITE PLAINLY WITH UNFADING INK — 



*-*jr'>> 



}!..;i:' 



,,• If, .,1,1. I- Nri !- *•-■ -br- ^i.*: lUKil' Co 




CTVN-OTYvIkOv; ^^ 



JfJO'i 



DEPARTMENT OF PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



City and County of San Francisco 



PLACE OF 



Gevtificatc of IDcatb 

DEATH: — County of O XX^ V a^UX'^AXxACO City of CJ <X/>^ AXX/YV^C<iXU) 



fi^. 0XV>^xOl^^' (IOCh^ivXcl 



St.r 



Dist.; bet. 



and- 



-^ 



,,<:,,.. orSIDENCE Give TACTS CALLtO TOR UNOEB ■SPECIAL INFORMATION" "V 
( - To\\.To"cTu:::: ::°''>'0^-'^^ o"fN"Tu"oN"vC its NA«E INSTE.O or STREET .NO NUMBER. ) 



FULL NAME ^ Ccva.^ oUxcX 



Aa 



- 1 



PERSONAL AND STATISTICAL PARTICULARS 




I ux-'Li 



|) \ 1 1. . •! r,!K 111 



Mliiith' 




vB 



\<-. I-: 



SO 



1^ 

!l):tv) 



M.),ih 






! \' t ■ ; 1 1 



%^ 



->i\<.i.j:, MAkuii-.n 

WIDttW i'.I» OR n!yn: 1 !' 
\\\ itr in '.'(liMl (1< >-iv'ii.ai' 'm ■ 



(Vf.'il) 



MEDICAL CERTIFICATE OF DEATH 

1 Ill'KI'liV fl'.K'rii'V. Thiit I attendc-.l (U-ccascMl troiii 

tliat I last saw li ' alivr on VlVrO- "1 icp 1 

■iiid that <Katli orc-nrrc-.l. on tlu' <lati- stated abnvf, at |-0-> 
^\^ M. Tlu' CAISI-: l.>l" Dl'^ATII was as follows: 



^ 



A.^-- 



lUKTHl'I. W\\ 
Sl;it< i>i •■'iiiiili \ ' 



NAM) <>1 
!• Alll i: K 



niKTHIM. ACK 

(>i- iAi'ni-:R 



MAIKI'.N NVMl 
()1 MO'IMII'.K 



I'.iKrni'i.ArK 

()|- MoTIIIsK 

(Stilt'' ' ii t^miUi A 



oCiTl'ATION 

Rfu'ih-i! ill S,i)i I'! mil />'•" 



X,n^^Cs} 




)',et I 



M.uifli^ 



/>.!\. 



TnKA,.>VKSTATKnr.K.oXA, PXKT,rr,VKSAK,:TK.K TO THK 
HKST OI- ^k^^ KN<>\\M.I)«.l'. AM)l?l-.I<il.l 



(IiifoTiMriiit *^ 



X\/yrw/:>^/y\j 



% 




^ 




,^vcL ..J -^AjsJtij 



Months 



Pays 



)'i\irs :fi)nths Pays 



J louts 



' O^.fO^^'^' 



Hours 
M.D. 



^iltAr 1 r()o'i (Address) 'g-^^;V>'VvXX^\J jlo^.^ta.l 



SPECIAL Information only for Hospltah, institutions, Transients, 
or Recent Residents, and persons dyinq a^ny from fiome. 



former or 
Usual Residence 

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



flow long at 
Place of Deatli ? 



.. Days 



( \<Mnss 



l'L\CK OI" lUKlAI, tm KI':MoVAI. I DAIi; ot III KIAI, or Ul^MOVAI, 

ini,i.:rtakkr'^ AJLiIjI^^ ^^T^o'^ 



■m 



„ . , , u .„,,«f..i|v KunnUcMl. AGE «hovild be «tnte.l BXACTLY. PHYSICIANS Hhould 

N. »-^^Y^ J;- ;^' '^^T;;;:;,:^;^^^^^ •;:;::: r^ r:::::; t p^opcH. cla^sWIecl. The "Specla, ,n.o..aHo„.' .o^ p-r. 
8on.\ly1nft away from home «houl.l be 6.Ucn 5n every inHtance. 



*■ i^ 



i!' 




% 




>">i 



• 



t' 




iiiUl 







.jM^ 



!1 ■/;') ! ^ 



WRITE PLAmLY WITH UNFADING .NK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2936 



» W^^H, 



!!,vr <'■' 



I )((((' Filed , \i\.^'^V\^\X>X>j ^ 

SI 



inoH 



Bec!i,stered A'o, 



X^v.^^ cUx-v/ Deputy Health OfTlcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

, "U. ill. Stnn^ar^ ; 






PLACE OF DEATH: — County of 



'City of JVct/A'xXi, CCA) 



Cdu^lXc, 



No.— 



St. 



-Dist.:bct. 



and 



FOR UNDER "special INTORMATION' \ 

( - ---v^:::o ::v\.^^^^ ^^^^f^^^'i:r^ -- ■ °-^- - street and n..ber. ; 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



Qii 



L 



I)\ I 1 ' i !■.!!< Ill 



\| . 1' 






\' 



) - 



l>;i\i 



MEDICAL CERTIFICATE OF DEATH 

DATK ol- Dl'.A'ni ,. X 

I'ct 31 

(Month) 'I>">'^ 



/QO ^ 

(Year) 



^iNt, i.i".. MAKun-.n 

WIIX >\Vl'. n t 'K I>'\i )K» 1 I> 
(Writf ill -• -iv'iialinii) 



Oj^^^oAA 



I'.iK I'uri, \(-*i*. 

' Statr iir •'iiinili \' 



NAMl- >>i 

iAriii:R 



I'.iK riiri.An-: 
ni- 1 Arm: K 

(Statf ..r v'lmiiti v 



M \ 11 UN N \M1-. 
(U Miti'IIi; K 



r.iK'niPLAri-: 

(Stat. ' > 'Uiitry^ 







^Uv.1*" 






I in:Ui;P.V CI;RTII-V. That I attenik-.l deceased from 

^190 to 190 

tliat 1 last ^a\v h -r. T\livc oti ^9^ 

and that <Uath occurred, on the dati- stated above, at 
M. The CArSl<: OI" Dl'lATlI was as follows: 



DIRATION )''(7;-.s- 

CONTRIIUTORV 



Mouths 



Days 



Hours. 



? 



occ 






AVa/,^,)' iti S,r>.' fiain nr, 



),-fi' 



1 A. ;,•/// A- 



/).n 



THK M.>VK STXTKO ''KK-.NA. rAKT.CrUAKS ARK TKlK To THH 
HKSTOJ- MV KNOWUKIX.H AM) Hhl.Ihb 



(IiirDiinaiit 



DTRATION 
( SIGNED) 



)'i'i7rs 



Mouths 



IC-QIioCglv 



Pays 



Hours 
M.D. 



Qriai^ H I c!o S ( A d.lress)'3W\A.<La,0 Utu M P C 

,, Instilution^ 



SPECIAL INFORMATION only for Hospitdls 
or Recent Residents, and persons dying away from fiome. 



Former or 
Usual Residence 

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



How long at 
Place of Deatli ? 



Transients, 



.. Days 



ri,.\CK 01' lURIAI. (IK KKMOVAF, 

l^f^ of 




DATKo!" BriMAi. ur RHMOVAI, 



T90 \ 



q 



fr^fwuV\j 



( 



do- 



(Aiihcss "1^1 V|)\vV^A..<n\. 



\x^ 



, ^ , .pp «u„,,l.l he «tnted EXACTLY. PHYSICIANS should 

„,• information should be carefully Hupphcd ^^^^ "^^/^^^^^^^^^^ Information" ^or pT- 

E OF DEATH In phiin terms, thnt it may He properly classmca. 



N. B. Every ite 

"■•;d>C-w^y «"'o™ "hon;; '.h»ul.l b. ftiven i y in«.-nc.. 



I| 



4 



Hoar.! -f M.mUV !■ V" '^ 



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

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2937 



*-s^^-%r, lt\:l' <*!> 



190 



lle^i.stercd •N'o. 



itv..oi.w. Deputy Heaith Officer 

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

Ccitificatc of S)eatb 

( Vl, S. StauDarD ) 
PLKCE OF DEATH:-County of dcv.v ixc..vc..c.Gty ofOo^ .1 ;.^....... 



No. 



Sn^ 



I ^'' -^ i 1 <;♦. ^ Dist-bct. X^OA^cL. and 






FULL NAME 




\' 



\J).k.LLUx. 



PERSONAL AND STATISTICAL PARTICULARS 



->r\ 



COI.oR 



ItATl". »>l UIK III 



d 



iMotith* 



\< .l". 



)r,/ 



10 

. l).lV> 



i 



I Year) 



/'./I, 



MEDICAL CERTIFICATE OF DEATH 

DATK <>I' I)i:ATn "^ , 



J U V 

(Month) 



' [ 



A 

(Day) 



(Year) 



rN 



I HICRl'UV Cl-KTIFV. That I atten.k-a deceased from 



.Ilex." L 



to QX.tar. 



..L 



190 V to ^!..v.v/.w IC)0 H 

that I last saw h-'^ alive on m\C:V: '^ iQO.a 

and that death occurred, on the <lalo stated ahcn'e. at 



^INM.l.l-., MAKKIl'.n 
\VII)<»\V1-.I) nK l)IV«>Kri,I) 
I \\i itr ill -."H-ial <li viv'iiatbMi) 



BIK THPI.AOK 

(Statf or Oonnti V 



NAMK 01 
FATHl-.K 







^1 - 



P 



LcL^o-CL^vdw 



bQ 



I ' 



( \ 




HiR ruri.ACK 
oi- lArnKK 

(Stall or Conntrv' 



MA11)1:N NAMK 
<)1- MOTHKK 



lUR rmM.AOK 
ol- MOTHHK 
(Slate or Country* 



til 



:\I. The CArSI': Ol- DI^ATH was as follows: 

.. V..^^^wA.A-<^). 




Dr RAT ION 
CONTRIBUTORY 



)'i'ars 



Mo>i(/is 



Days 



Hours. 



/.oJsL^J....ri.-^^.<i^.v.o..\..a 



J 



,A^>:),^CrV^V^. 




^U^' 



.du vLlv c^ 



,0^' 



\^\^\^ \ 




(KC I' PAT ION 

h\-.ided ill Sun I'l^i"' />''• 



\ 



tV^-vcct' 



)V,//v I }h>iith< AO /><n> 



T„K A..,.VK ST vrr,. '•KH-NAl- ^J«;;];,',l;r^ ^^^ ,KrK TO THK 

lii-sT Ol- ^L^• KN«)\vi,i;i)<.H and ni.M».» 



Years 

.0 



Hours 



DURATION _ ^\i^f'^ Months X Hays 

,C\^ L ic,oH (Address) qAcI Jgi^C -VVv J:^ 



(SIGNED) 




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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



(liifoiniatit 



Sir 






I,ACK Ol- niRIAL OR KKMOVAI, 




I)\TKof III KiAl. or REMOVAL 
.ClLOA^ 



T9O \ 






AJCrLdULAA; 



IN. B.- 



' """"""""TT! Z7a age should be stated KXACTLY. PHYSICIANS should 

-■^•"^^ J^SE r DEA-TH-ln-r'n "r^-'r. U^t't .^peH, c....m.d. TH. ••«..ec,.. .n,o....,on" ... P.- 
:r„';d"n"» rZ ."L n... «h„u.U H. »iv.n , m-nc 



4 



f! 



I 



I ^< 



rt 



n 






t! 



ii 

1, 



! r 



^ 



Wl 



R.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,.-^ REFER T O BACK OF CERTIFICATE FOR IN STRUCTIONS 







.Ux* 



7^6/M 



Deptstv Her^.!th Offiner 



liedlstered J\'o, 



•^ 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate ot Beatb 

( tl. S. Stan^ac& ) 
PLACE OF DEATH: — County of '^^^-^V^x^vcv. Uty ot 



'•Wo. 



jYlt, Cit Wcklu LU.vvl.«A.^' St.; —-— Dist.;bet. - -— ^^^^^, ,„.f"„i,o~ 



) 



) 



FULL NAME 



_^ 



ri 



V v^ 



I ri ^ > ; 



.CC<X\AA>V.UV0 



PERSONAL AND STATISTICAL PARTICULARS 

DAT!-: 01- lllK 111 '^ '^ 




a 






\<.K 



) V</ > 



% 



(Day) 



Mouth.- 



'XX 



(Year) 



Pars 



MEDICAL CERTIFICATE OF DEATH 

1).\TK Ol- DlvKTIl 



(Month) 



(Day) 



(Year) 



""l HI;KI;BV C1:RTIFV, That I attciulcd deocased from 



1 90 i 



SINCl.K. MAKKli:n 
\VIIM>\VKI> OK DIVoK^ l-.I> 
(Wiiteiii sorial iU'<iv:natt<)n) 




HIKTmM.A*'!-: 
(Statf or ComitiN 



NAM I". 01 

FA'nn:K 



BTRTHIM.ACK 
(^1- lArHKK 

(State OT Coinitryt 



MAIDl.N NAMl. 
01 MOTMKK 



IMKIinM.AlK 
(»l M<»Tm:K 
(State or Ootintryi 



OCCri'ATlON 



J? ^ 3 



to \i A^v: w up 

that I last saw h .^-v alive on ^^^ ^^ ^ ^90 

aiKl that (U-ath occurred, on the <latc statetl above, at " 
1 Ol M. The C.MSIC OllDlvATII was as folUnvs: 




DC R. AT ION >>'«'•« 

CONTRIIU'TORY 



Months 



Days 



Hours 




.^<UL M iV \ll^^AV>«^U- 




DIR.XTION 
(SIGNED) 



yi'iits 



Months /^ays Hours 

utv M.D. 



\/ on ins 



ftW-,^ ,..o (A,i,ir.-ss)noC)^- antl^l 



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



/)(M 



T„HAm,VKSTATKnPHKS.>NA, .AKTUMM.AUSAKKTKrK To THK 
liKST OF MV KNO\VI.i:i)Oh AM) IM.Ml.^ 



(1 






Former or 
Usuat Residence 

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



How lony at 
Place of Oeatli ? 



Days 



nATl% <jf HiHiAi- or RKMOV.\I, 
^ 1901 






l'I,.\^H Ol" lUKI.XL OR RKMOVAI, 
r.VDKRTAKKR nHY "^-^^ry^^^^'"^^ 



■■■ , . ' ,. . Igb should be .toted EXACTLY. PHYSICIANS should 

:".%,?"» aw"r «r- He™. .hou.U b. »W.n < y .n.t.nc 



» lit 



I 



1 1 \^ '-^^ 



w 



RITE PLAINLY WITH UNFADING INK 






I 



/),f/(> ri/rf/,\rJr^My^'yxM\> ^ 



o^^vJl> 



VJO\ 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.^vc^^Xi/^v^< DeDUty Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticate of IDcatb 

J? (to A ^ 

nd vJ CjVa-M^ L 



No. 



PLACE OF DEATH: — County of 



r^c\ ' St.; 1 Dist.; bet. J .l.^<iA.it - and 

^^' '^ . ^reinrMrrnwr FACTS CALLED rOR UNDER "SPrCIAL INFORMATIO. 



FULL NAME 




r^ 



V , \ ' ' 




CX/\y\yO^ 




.'vex. 'i \. 



Ni: \ 



■^ 



PERSONAL AND STATISTICAL PARTICULARS 



■> 



1 



Vl iW'^^ 



a 



I) \ ri' ( i! !; i K rii 






\K\\ 



\' 



^IN»,1,1': M \Kls II". I » 

\\ii)« >\\ j"i) i>K ii:\t>K* J-.i) 

I Wi ill in siifiii! 



MEDICAL CERTIFICATE OF DEATH 

DAl'l". <)!■ Dl.A'lll 




,cr\r 

(Montli) 






/(?0 { 



I lli:Ki:r.V Ci'.U'ril'V, Tliat I atlemkMl dcixa^^cil iv<nu 

\ . . iQO^ to ^^tc^^ ^ iqo'i 

that I la^t saw h ^^>^ alive on \i\^\^ ^ u^ 

an. I that -Kalli .uHMirre.l, <>n the .laU- statr.l above, at CUj-t 10 



M. The CAT SI- Ol' DIvATH was as follows: 




A 



n 



\ t 



I st:itr <ir (.■mint I \ 



N \M 1 ( •! 
!■ All! l-.K 



lUKTIllM.Ai'H 
<»»• 1 xnii-.K 

iSlali 1)1 r.,nnti \ 



M \ Ihl .\ N \ M 1. 
ol Mtijlll.K 



iMKi'mMAti-; 

(St;it' ■ I ( ' ..mt I \ 



(^ 



■4 










V 



^m^^- 



WTJ-r- ^* 



UJ. 









Months 



Dlk A'rioN 

CON TU U'.irokV 

DTK AT ION )V(//-.v .)fni////s 

(SIGNED) ot. V OA.hXtr'v.-O 

^llta-- 'I i<,oH (ihlnss)lSiom 



/)avs 



I/oin "< 



/hlVS 



//(>li/ s 



*YAXatryAAl.\i 



M.D. 



SPECIAL INFORMATION only '"r Hospitals, Instiiiitions, Traft^ients, 
or Rpcjnt Ri'sidents, and persons dyini) away from homf. 



/VCUv-x/e^L 



I »i * ri' \i ION 



)Vrf' 



M.oillf 



/', 



lll-ST i)l- MY KNOWIJ.IM^K AM» l!I,Ml-V 



( 1 11 f. I' nil 



Qf)vvo wcJx 



N.XJL/YV 



' X.liln '^s 



^^5 




Former or 
Usual Residenre 

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



How ionq at 
Place of Death? 



. Days 



I'l ACH Ol' nrUIAI. OR KHMOVAI, 



(ftu OjLv-ub 



DATl'.df BiHiAi, «.i I<i;MoVAU 



I NDKRTAKKK 

'A( 



6 . ^ o-cLuxa^ 
30 5 '|yuj'>^xci'na 



T90 



'[ 



N 



PHYSICIANS Hhould 
r pur- 



— ' U , ., ... x(:r Hhoilcl he Htiitecl nXACTLY. PHYSICIANS. 

. „._r.very Uem of lnfor.n»tJon should b. ....en.Hy kupH c • ^'^ 1,; c a.siflcd. The -Spcda. lnVor,„..f.on" *« 
Htfite CMJSIi or DEATH m plum Urmn, that St m»> >e propeny 
s dylnft flway ?rom homo nhould he fciven In «very JnHtnncc. 



M 



n 



noni 



1 ! 



« \ 



WRITE PLAINLY WITH UNFADING INK 



!•. ...I.! ..f II' ;.:ih I "^" 



-; iu>vr r. 



li)0'\ 



DEPARTMENT OF PIBLIC HEALTH 



-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTiONS 

Begisto'cd JVo, f<3J4:U 

City and County of San Francisco 



Ccvtificatc of Bcatb 

i 11. 5. 5tanC>atO j 






Qf^ 



an 
PLACE OF DEATH:-County of ^C^-^^' vc^^c^c^City ofOo^ J-' 

IpI "OV' and 



I 



( „ OC.TH OCC.PH = .r, . HOSP.T.L OH ,„ST,TUT.ON O , V E ^^ 

FULL NAME VJ-dx^ W<^^^<^^^ U.'-... 



i?ilU-. 



) 



->1.\ 



PERSONAL AND STATISTICAL PARTICULARS 



c<ii,<»k \ !) 



nu ' 



I) Aii: • u i.iK 1 n 



Moiilli • 



\' .1- 




ri 



)•- 



\>.<\ 



I/..////' 



MEDICAL CERTIFICATE OF DEATH 

DATi", oi- i)i;.\rn 



(Month) 



i 
I I);iv 



/QO 

(YfJir) 



1 Ili;Ui;i{V Ci;UTll-V, Tliat I atk-n-U-.l <UTc-asf(l from 



^^ivt 



}M 



1 90 



S to 



cLclXx 



>>i\«.M".. MAKun:i» 

u iint\vi:i) OK i»i\< >K* i-.n 

I Wiit. ill MK-ijil (lcsij.^ii;iti<>ii) 




A^xL-CtVaMAj 



liiK rii \'\. \''i-: 

( Sl;it,< > <^ I '■ >u 11! ! \ 



\ \MI- « »l- 
I- AT in- K 



HIR in l'I.\t 1", 
01 lAllll-.K 

I <i-,l' >'i C< Mini 1 vi 



MMKl.N NAMl 

1.1 Mi»rm:K 



-^ 



.tcm. MlU 




t 




>^\J^ 




LOL' ■> v.<"^ 



? 



T()on 

that I last saw h '- ■ ■ • alive on VI ^^ \ . T90 '■ 

aii.l lliat .k-atli occurrcl, 011 the date <taU-<l alx.vo, at 
"" M. The CAlSIv Ol- DliATII wa^ as follows: 



^r' 



DlRA-riON • y^'<u^ Moutin Pays Hours 



1)1 RATION 

(Signed) 



I lour 



I()0 \ ( 



Vrars H Mouths Pays 

A.l.irc'ss) l^SH J CrV^cr>v\. '..)T. 



im<iin'r,Ai"K 

Ol- MoTHKK 

(Slatt or Coiiiiti A > 



'^ 







Mniilln 



I hi \ 



•n.KX.U,VKSTVTK.MM<U...NAI .AK..;M^UAHSAKKTKrK T< • THK 
Ml>Tt)l- MV KN0\VM:1>«'H AM) MhlJJ.l 






SPECIAL INFORMATION ""'y '<"■ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinq away fro;n tiomc. 



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



.. Days 



I'l.ACH Ol' UrKIAI, OK kr.MoVAI. 




J\Jb<^ 






(A.l.lnss ^^ l)>CL/>X.\Kxl^ CI 



DApvof Hi IM\I. or KHMOV'AI, 



SBS3 






: ..'■' 



Mitrimr ^^33 



w 



w 



t 




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

REFER TO BACK OF CERTI FICATE FOR 1 N3TRUCTI0N3 




I!U)'i 



llo^istcred ^''o^ 



2941 






1 ijL/vHj Deputy Health Cfflcer 

DEPArTwePoF PIBLIC HEALTH-City and County of San Francisco 

Certificate of Bcatb 



( "U. 5. i^tan^avD 



\ ^ -J ^ 

r- . f ?l cxyy^ \.<Xjy\.^t^ <iC City of -O/'W X.<X/> 
PLACE OF DEATH: — County of -Ci/^ 

No. V^ >vt 



\,CVA..CLO 



\rxi, V ^>V,^VO' ■ .C ^«^\;V^-la,lD;st.;bet. ■ „^„^7:;„„., ,,,t^L,o.' \ 

V ir DEATH OCCURRE6 IN * HOSfpi»i- ^ -^ ^ ll 



) 



FULL NAME 



V.' 



(% r>^ A.Ou6 V, (n-vUj..^ 



. ! \ 



PERSONAL AND STATISTICAL PARTICULARS 



^ 



ll 



I) \ 1 1. ( ii iUK rii 



A I .1. 



M .Mlh' 



(V..-:ir* 



v-> I: r 



/',.■! > 



-.IN, .; V MAKUUnv 
'\Ntitf ill «M>(.-ial tit sivMi.'iti«>ii' 



,•^ 




MEDICAL CERTIFICATE OF DEATH 

DATK (>1 I>1;AT11 (A ^ 

i!;uio 'nav> --^-^ 

I ili:Ki:r.V C1:RTIFV, That I atU-M.lc.l .U-ora^c.l fnmi 

190 to .rrrr— - "P 

thai I last saw h -alive .mi ^^^^ 

;,n,l that .K-ath occuncMl, nn the- .late ^talol al...vo, at 
M. The CAlSI'l^OF Dl-A'Pll was a^ folL.ws: 



lUK riM'i.A'M-: 

(Stuti "t I'l'tiuti 



NAM I'. (>»■ 

!• \rii i:r 



uiK rm-i.A.K 
()»• iArm:K 

( ^t:iti i>l ."ntint t v! 



MAim'.N NAMJ-. 
01 MOl'Ill'.K 



HIUIIM'I. \(V. 

(»f M. >ri n:u 

(Sliitf or Coimli y) 






? 



Lowi 



^v(^^v.^ CJ 



\\ 



1)1 KA I" ION Via IS 

CoNTKlI'.rTORV 



.;^e)F 1)1 -AT 



Months 



Pays 



J lout 




/Oy^A.c). 



(SIGNED ) LcVrnJlKj 0. ^^- <^^^^v\xl M.D. 

vYi^^ "l u,oH (A.l.lrcss)Ltr^^Pr^aAA lyRuC-A. 




<X'>^Oj 



"'■'■'■'"'""' £<XVW/v.tsn, 



Rf^iilr,! i» S,r» I'l mt, />'••. 



1^1 r,,7; 



\/.,,i//n 



/',M - 



" SPECIAL INFORMATION only lor Hospitals, InstitMs. Transients, 
or Recent Residents, and persons dyinq away from home. 

When was disease contracted, 

If not at place of death? ^_^_ 

IM ACH Ol- lUKIAI, OR Kl-MoXAl, 



•LA.. 1', » M' i»i i^"- 



.^^^-^ 



Dxi'Uof HiKiAi 01 ri:m.>\ai, 
Vti-vr It T90H 



"^ 



INI 






i (j M\A/clx.frl/XA 

^-^^M M — ^■^■^■— — — ''^^'*' I EXACTLY PHYSICIANS nhould 

:rnV'..Wn» o-y trL h„.„« .h„u... ... .Wen > ."»«-"=.. 



(A.M,.ss in I VlTlvAav<m. dt 




f 1 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hor.r.l of HcMlth-KNn. iv "S-f^^^) H&P Co 



Dff/r /^y/rf/,..\(\jrv^ d ^'^OH 

1 



Registci'cd J\^o. 



.{^-VVVCi 




^^ Deputy Health Officer 

DEPARTMENT 6F PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)eatb 

PLACE OF DEATH: — County of Qo^-^rv J AxXAVcun-Cf City of O/CX-ru AjX^v^cod/Cc 

.; 1 Dist.;bet.s^C^-0..\,':-v.:0.. and J CrV^^cy.X; ) 



No. S'i4 'lU o ^. 



St 



(IF oeatU occurs away from usual 
IF DE«TH OCCURRED IN A HOSPITAL 



RESIDENCE GIVE FAC 
OR INSTITUTION GIVE 



;ts called for under "special information" '\ \ 

ITS NAME instead of street and number. / ij 



/O 



FULL NAME 



u 



,^^^,/r\^uu 




\l\AJ: 



4- 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ 



l»\l'l-: «>!■ HI Kill 






'Month) 



A«.H 



r,-,/». 



(Day) 



M.>filh- 



fVt-ar) 



/)<? 



SINC.I.K. MARUIl'.I) 
WIDOWKD <»K I)I\< >Kri:i) 
I Wi itf in smial (Itsiv' nat mu ) 



HIKTHl'l, \i'l<: 
(Statf or r<mnti v^ 




.Ud-Cr\^0-CCL 



NAM1-: OI 

1 athi;k 



inKinri.ACH 

(>»•• lAIIIHR 

f Stall or C'onnt rv 



maii)i;n' NAM)-; 



lUKTIIPKACH 
Ol- MOTUHR 
(State »)r Country) 



OCOl'I'A'riON 

/\r^!<{/'(! in Sini I'l tun ism 






( 



MEDICAL CERTIFICATE OF DEATH 



(Monlli) 



1 

(Day) 



(Year) 



I 1I1':RI':HV CI:RTIFV, That I atteiidod dcccasecl from 

ilLt-v-- 5. igo'i t.. ■ /\mr...n 190H . 

tliat I last saw h ■?.''-' alive oti ' Mn," ^ Kp "^i 

and that death oecurred, on the date stated above, at ^x O .0 
CK^M., The CVTSfv Ol- Dl^ATII was as follows: 

Sj..(y\^u..'^^.yy'>Ar^\^^^ 




DIRATION 



) 'ears 



.<X/^- <'^- 



■\XXj^/y^JL 





^ ^ 



)'/■</ ; 



'^'CL 



v.'//'//' 



/),n 



TMK AHOVK STA'I'l-.n PKRSONAI, 1' A RT HT I. AKS ARlC TRrK Tn Till-: 

ni'.sT «)!•■ Mv kn()\vi.i:dc.h and iu;i.ii;i- 

'0 



_,„ a 






Mouths \ Pays Hours 



)r RAT ION rrX^^^^*} 



(SIGNED) 



Mouths Days 



Hours 




qn 



VPv ^.\XJ.^L<X> IV 

(Address) 1 lo 8 ^LA.HJL^J 31) 



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 long at 
Place of Death ? 



Days 



ri,ACK OF IURIAI^OR RKMoVAI. I DA'n:*.!' HfKiAl, or RKMOVAI, 



(Atidr.ss Dvbbb MlU.^ 



V-V- CXAAy^ \X 



190 I 



A.A^{r>"u. 



IN. B. F.very item of Information nhould be cnrefully nuppliecl. AGB «houl<l be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH \n pliiin terms, that it may be properly classified. The "Special Information'' for per- 
sons dyinft away from homo should be ftlven in every instance. 



! 



''^' 



l! t 



i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

•;*Jrv^, .,t.,.,... REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2943 



! ! : n!th )■ V') !<. 



ri-^-j H.^1' Co 



Ilesjis/c/'cd A^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of E)eatb 

( Xl. S. StanC>arc> ) 
PLACE OF DEATH: — County of^^O^^^ Jx^o.-»veuL^City of JCu^^ J ;vxx.o vca^ co 







(I r Ot *TH OCC U 
If DEATH OC 



Dist.; bet. and 

rtk Aw*y FROM USUAL RESIDENCE GIVE facts called for under 'special information ^ 

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



FULL NAME ' aXK^c.4^. =L/ i<x 





PERSONAL AND STATISTICAL PARTICULARS 


^l.\ 




I) \ 1 ; 


>\ l.,U 1 M 




/ 



^H^ 



Month* 



Dav 



\< .1- 



kl 



/'. 



->I\i .1.1* MAK \< 11 n 
W IIii tWl-:!) «>K I);\ < tKi 1,1) 
Wtiti- ill sorial <i('-i'..Miati'>ii i 



r,iK iiii'i. \t'i-: 

(Slate of (' i'llM I \ 



\.\M1 <>1 

I \ 111 i: R 



lUK riiri,\ri-: 
oi- I \rm-:K 

~-.i it 1 or fount 1 \'' 



MMDl-.N NAMl 

m- m()Tiii:k 





mk iiiri.xci". 
ni Mit'nilvK 

( stall or Coiiiiti v^ 



( u C\ r A Tit )N" 



Rfsidrd ill '>." f'l iiiii ;^),> O^ )rrii^ 




M.'}i!li< 



/'. 



•nil- \HoVl- slXTlI. rKKSONAM-AK-ncriAKS ARi: T U T K T<) Till- 
III'nT <>1' MY KNi »U l,»: IX'H AM' Hl'.I.Il.l' 



' 1 11 fo- niMtit 



',IV KN< »\\ l.l'D'.K AM) 

4 — \ 




MEDICAL CERTIFICATE OF DEATH 



DATK (»1' Dl'.A 



mXcxt 

(MoiUlO 



5 

(Dav* 



(Vrar) 



I lil-UIT.V CI'.RTIl'N', J'hat I atU-ii. U-d (k-CLiisod from 
W^r- 5 u>oM ti. \rUV 6 H)oH 

thai I last saw li-Cor^ alive on VlVfrV 5 190 H 

and that dcatli ocriirred, 011 tlic <latL' statt-d above, at 1 iC 



M TIk- C VUSI*: ()!• DI'.ATIi was as follows: 



1)1 RAT ION )'t'<irs t Mon/hs Pays 

CoN'l'KHir'iORV 



Hours 



^ r'T^ ^^0 
(Signed ) 0, 




M 0)11 lis, 



/^<7V.V 



Cllcv- ■ 



\ddivss) Utu V Co obcyvk-: 



\ i(,o'l (\ddivss)C Uu ^^U) (/OCy<ij\d 



M.D. 



SPECIAL INFORMATION only for Wospitals, Institutions, Transients, 
or Recent Residents, and persons dyinj .ivv.iy fron fiome. 



elX'lvaX M'ULIN; (/b&U4£piare ol Deatli? b.Wv^... Days 



Former or 
Usual Residence 

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



IJ.AOi: (H lUKlAI, OR Ki;Mt)VAI, 



-CWvyvw, U cvJUj 

r N I ) 1 ■: K T A K V. R ^ J^XULUjl V j\0 XXCV<X/V\ 



i)A'rH(.f niKi.Ai. OI ri;m()vai, 



^ ,5 — iverv Ue.„ oV informntion should L c.rcfully Huppl'.e.l. AdB h^io.IcI he st«te^ f.XACTI Y PHY8IC1A1NS Khould 
ninte CAUSE OF DEATH In pl„in terms, that it mny be properly claKHh'Iccl. The "Spccinl h,^.rm„t.on tor per- 
sons clyinft awoy from home HhouUI be jiiven \r\ every instnnce. 



M 



^t* 



I 

t 



|uiiii-^ 



w 



RITE PLAINLY WITH UNFADING INK 



1,1 , J II. :^'l') \' V , 






Ihf/r /'V/r./,M\<rVNJLi 



-o^. 



n)0'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATe FOR INSTRUCTIONS 

Jieo/,s/rrcd ^\ o. 





DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

of n Cx_OX. J AX^o-yvCvAcCity of Oo^x< 3;ux>vc, .,c> - < 

^ J 
u u n ^ ( . St.: ' Dist.; bet. ^ CX.v,5,^tr\' 



PLACE OF DEATH: — County 



No. 



and >t '' 




. 1 . \ 



PERSONAL AND STATISTICAL PARTICULARS 



n 



VI II all 



[X} I 



\)\\ \ 1.1 '.IK 111 






\ ' . ! ' 



la 



1 

1);(V 



M.'ulh- 



"y 



\ < .11 



IKi\ 



SIM , 1.1" M \KK li:i> 

wiiMiw 1 i> <»K DiyoR'i-'.n 

' Wi iti in *.»iMl lU-viiMi.-ilvn) 



X' <^v^^VCLJL<A. 



MEDICAL CERTIFICATE OF DEATH 



DATI-; nP ni.Alll I , 



Vjltv 



Month' 



I. 

( I»;iv1 






I II 1:R i:i'.V CI'RTIl'V. That I aUriuU'<l .Urease. 1 from 

— ■ ■ T (p 

— — HjO 



I9O 



to ■- 



that I last '^a\v li 



-alive otr 



lUK riM'i. \cv. 

(St;it< I'l "''inntiN' 



ti V 



\- \ M 1 < M 
I \ I II IK 







aii.l that .leath ..ceurrtMl, on tlie .late slate. 1 ahove. at 
M. The CArSI- Ol' DIvA'l'H was as foll.)\\s: 



DlKATinN )'<'ijrs 

coNTRir.r'rouv 



Mouths 



na\ 



'.S" 



Iloitrs 



liiurin'i.X'i". 
nl' J\llll", i< 

I st;il( <>i t'ltUIit 1 \ 



M \II>r,N N \M1 
.11 M.'I'IMK 



lUK rnri.Aci-: 
or MoTni-.K 

(Stat'- "1 I. >iiinti \ 




.JL 




A 



DTK AT ION . )<'<//\v 
( SIG 



Mini t /IS t 



/hiVS 



//old \ 

M.D. 



J/o/i/Zis 

|U 

NED ) LCV^py-^Ov' 

(A.l.lnss) V,ft\.(n\i.^O 

SPECIAL INFORIVIATION only '"^ Hospitdls, InsfitiiHdns, Trdnsients, 
or Rpicnt Rcs'nlnils, .inrt persons dyin | .iwdy from home. 



H 



t. V- I 



l,.v V 






.\/.,ii///' 



l-m: XIl<>VlsSTAII-l.l'KKs..NM rXKM.MM \K 
lll'.sT np MV KM iW 1.1 1>''1', \M' IH.l.Il l 



Ks \Ki: IK II- 1" I'"- 



( In fii; niant 



Qnvx« ^c<,.vo. l»^^■•-■ 



' \.l.li.ss 



lormer or 
ls11.1l Residenre 

Whfn was disrasp conlrarfed, 
II nol .il pl.i( f ot dcith ? 



How lonq at 
Pld( e ol De.ith ? 



Ddys 



I'J.AVH Ol- I!lKI\I-OK UI:m<>\\I 



i» \ri'. m! m him, m ki-;m<)\ai. 



TOOH 






■- ■ ""^ TT 1- 1 \«:r M^K.uia ho Htntd i.XAC tly. physicians Hh.,uid 

^. „.— fivery Item o^' •.n^„r.nntion -h<.u1.l b. — »;"> j^;",;;; '^i ^ ^,, ;rly cluHshMcl. The "S,>cc5«1 Ir.^ornu.tion" ?or p.r- 
Htiitc CMISI 01 niATII in pinm tcrniH. that it m»> ye proper y 
«on. clylnft .mny tfrom home shoultl be ^iven in every ..iHtancc. 




II 



t , 



■'I t 



h 



II i 



I 



.'! 




I 



(m4L 



.«! 






II,.;,!.: I H- 



WRITE PLAINLY WITH UNFA 



«. r V 



-^'^^riti.u^^r^ 



/;^//r Fifc'l, \rin>X^\X^-^ ^ 



DING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 

"■ 2945 



7,9/9 H 



Be^istcrcd jVo. 







DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Ccvtiticatc ol 2)catb 



PLACE OF DEATH:-County of^a . v'I>.0, ^v^cGty of 6 C .v'^kcx.,^. ...c. 



(^ 



No. 



St.; 



Dist.; bet. 



LV^ii, »\J 



FULL NAME ' 



1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



^ 



> \ I r Ml niK III 



A 



^\^v- 



\! •nil' 



I KiV) 



\' . 1. 



)■...' 



1/ 



4 - ;ll 



/'< 



MEDICAL CERTIFICATE OF DEATH 

DXl'I', Ml I>1 \ Til ^ 



fMontiO 



(Day) 



(Year^ 



that I la^t saw h 



• Ri:i;V CI.RTII-V, Tliat I attrn.k-.l (k'coased from 

■ ■: — — — — 1 1)0 

• T 90 



I9O 

— alive on 



to 



W II). >WK1> OK I)I\«»K> I"!' 

' \\\ \\r in social <U sii.Miali"ii! 



\ 



<-n 



;,„.l ,h;,t .Iratli ocourrc.l, on the .late stato.l above, af 
M. 'riie CATS!' Ol- 1)1';ATII was as follows 



C)> 



'Vv>i/X;<:l3^/\A-v^o^0L.-C 



%' 



oJhX' t' > • 



-t:il' or ' ■ ';;i!l : \ 



NAMl- 01 
lAllIl.R 



I'.iR riu'i, \cv. 
oi- 1 Ai'in-.K 

'St it> or Count! V 



M\n>i:N NAMl-. 
1)1' MOl'IIl-.K 



I'.iR rin'LAi'i". 

01 MoTIll-.R 
I Slate III* Cotmti ^ 



oCCfl'ATloN 






/ 



y^ 



CONTIMIU TORY 



Mo>itfis 



Pavs 



//ours- 



DTK AT ION 



)'c\7rs 



J A' ;////.' 



/h7VS 



)'.<■! I 



.1/.'/////' 



/).M 



r„K^l■.,v,;sT^TK.o ■.K...^^..^KTKr,.^K> akh tk, k r.. . ,n, 

lilCST OV MV KNOWI.I.IX.K AND Hhl.H.V 



( SIGNED) Lcr'V<rvxX^ 



//ours 
M.D. 



SPECIAL INFORMATION only Inr Hospitals, InstifuHons, Transients, 



or 



Recent Residents, and persons dying away from liome. 



Former or 
Isual Residence 

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



How long at 
Place of Oeatli ? 



.. Davs 



;iiifo;in:int 



LVvrv^JLV^^ ^- 



\^<U^ 



^\.Mi< 




PI^ACK Ol- lU'RIAL OR K1:moV\1, 



DAp; o!" MiKlAi, or KI';\U)VA1, 
^ I90H 






^ ■ ■ """^ ~^ w >F s'louhi be stnteil CXAGTLY. PHYSICIANS should 

•'"'/..^.t^l.^v t.o„. home shouUl b. tlvcn in every inst.nc. 



sons tl> inft nway ?rom 



M: 



•■i>^ 



;i3 



i'r 



♦ 




R,TE PLAINLY WITH UNrAD.NG .NK-TH,S .S A PERMANENT RECORD 

REFER TO BAC K OF CERTIFIC Axr FOR INSTRUCTIONS 

2946 




n>oH 



Deputy Hcaith Officer 



lie ^ isle red A'o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of IDeatb 

( X\, 5. '3tanC»ar^ ) r> f\ (\ 

City of 3 <X^A. LWlcOL^t- 




/O 



'\c 



<X\A r\ 



.0.1 



No. 



St.; 



Dist.; bet. 



. ■ ^t.; Lv'lSX.t ^^^* UNDER "SPECIAL INTORMATION ' \ 

y ,r DEATH OCCURRCD IN A HOSPITAL OR INST /^N A 



FULL NAME 



I \ 



O.Vot^'^VcC^ 



V' 



PERSONAL AND STATISTICAL PARTICULARS 

■ 1 



I PlOuU 



1, \ ■] ' il "IKlll 



\i .)•; 



\!. ml; 



i 



l);.v 



Will' ill H.Kiiil '!• oiynatioii) 



lUK run. \'*i-; 



\ \M1' <)1 

1 \ rm-.R 



lURllll'I, ATI-: 

ni- i-Arm:R 

I Stati nr (.'oiiMlvv 





< Ci. c<. 



MEDICAL CERTIFICATE OF DEATH 

I lIi:Ri;r.V CI-RTM-V. That I attcn.UMl .U-ocmslmI from 

190 tc, . - r — TQO 

thai I last -^axv h :. - alive on ' - ~~ ^^o " — 

a„.l that .U-alh occurre.l, on the .late ^tatol al,ovo, at 
M. The CAl'SI^J)!- Dl'-ATH \va>. a^ follows: 



X/>W^V JAAJ^C^^vj^^ 



' 1 V 




MAIltl.N NAM I 

()! MO rm-.R 



r.iK riiri, \ri-. 
oi- Mo'nil'.R 
iSt;itf "t k'i)iinti> 






nr RAT I ON ^''''^'^" 

CONTRIIU TORY 

DIRATION 



.!/(»;////.? 



/hiys 



Hours 



)r RATION )V(/;-.s- J f on //is 

SIGNED) )b. "^A^XV^^ 



/^<7V.s- 



^ 



'Ux 'I 



T()0 



( 



V,hlr.ss)%\'^dL^tUxi^t 



Hours 
M.D. 





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



h\-. ■'.(,■'! Ill S,;>' /'"!"' ' 



),,•'! 



^r.'ii'tif 



Ih 






rin- 



( 



Former or 
Usual Residence 

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



How long at 
Place of Deatli 



Days 



ri.ACH Ol- 1U-RIAL OR KKMOVAI. 



DATi; of niKiAl, (11 KlvMOVAI, 










N. B.- 



_^^.— i^— ^— ^■^^— """^^ , . t t d EXACTLY PHYSICIANS should 



':0\ 



I 



I ! 






w 



RITE PLAINLY WITH UNFADING I 



Nr^ — THIS IS A PERMANENT RECORD 



•^•'"'^ 



!u«cr '■ 



REFER TO 



l)iilc /-V/i''/. M\(ru^orra)X\ 

J? 



o 



r.)()^ 



BACK OF CERTIFICATE FOR INSTRUCTIONS 

2Q47 



Deoutv Health Of^^^er 



DEPARTMENT OF PUBLIC HEALTIWity and County of San Francisco 

Ccvtificatc of 2)catb 

^„ ^ , fOV -vo ,-. -v^ct City ofOcu-.v J;vcv>^^va-.' 

PLACE OF DEATH: — County of V. A. vo, J^ <\ (^ I ^ 

I o. Dkfbet ctC'YvWv-C^ and vJAJ.■^U^A,vJ ) 



-V 



FULL NAME 



,0. . 



J ,o^\.\x1a' 



-!\ 



PERSONAL AND STATISTICAL PARTICULARS 



W' 



n 



^ 



I , \ I 1 . •! l;iK III 



V » > 



/ t 



M.tith 



\' 1 



51 ,„,, 



\>A\ 



i; I ■/, 



W. Ill) 



/>,.■ 



7. 



(Year" 



MEDICAL CERTIFICATE OF DEATH 

DATl-. •'!• i)i;\TII A 

I HI'.Ri;r.V C1;RTI1-V, TIk.I I atUn.lol acrcascl fn.m 

t,, -^ Tqo 

— jcp 



T9O 
— ;ilivc oil 



m\<-,I,l- \\ VKKIl'P 
\VIIH>\\ 1-. l» OK l>:^ "' ' !' 
' Wiitr in "-'K-iiil '!» ~ 



I'.iK niri. \*" 1 



.0 .»^ cL^ 



\ I 



\ AM I'. < •! 

1 \ iin'.K 



I'.iK I'll ri, \* 1-; 
«n J \riii:K 



M \' m; N NAM )'. 

(.1 \i( I'l'in-". K 



itiKiinM-ArH 

nl- MoTHKK 
(Stiitt 111 (.''MintiA I 



-\ 



Ki 



\ \ 



e f 



that T la^t saw h 
;,„.l that .Uath (.rcurrcMl, on the .latr -^tatol ahnvc. at 
""" M. Tlu- CAl'Sl- Oi- DI-ATll was a^ folL-ws: 



/hivs 



\J 




( uiM'l' 



'0 



/Cf nf>;f ill Siiii / I 'III' ''''' 






- M'»itli^ " /'"■' 



(SIGNED) UVCr^UK; J. Vj^- lU- cU.tA.^ v^^^^^^ M.D. 



r i 



SPECIAL INFORMATION only lor Hospitals, lnsfitutk>k Transients, 
or Recent Residents, and persons dyinq awny Irom home. 



Former or iSt ic 

llsual Residence 1^1^ 

When v^as disease contracted, 
If not at place of death? 




. ^' How lonq at 
.A^^-vb ClL Place of Death? 



Days 



lil'sTOl- MV KN..\VI.KI)(.K AM) m.l.II.l 



{Iiif.p:ni;ml 



Q V ) (MAJUO-A^v 




trrrJ^AA^ 



i\.^ 



t^'^L.^ ^0 5 '-ITUrW.yr^- 



I)\!'Uf)f HiKiAi. m ki;Mo\AI, 
lb 



TQO I 



^ASV 



■■■ — i*^— i^"^^*" t t I PiXACTLY PHYSICIANS nhould 

•tate CAUSE OF DtA in m , instnnce. 

ffon« dyinft away ?rom home sh.M.lil be ftiven in c o y 



ilHHN 



' 1 




aAi 




R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE F OR I N3TRUCTION3 

2948 



I'.S;!' *■• 



Bei^istcred J\^o. 



\ l.e^-< Deputy Health Officer 

DEPAmENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate oi Bcath 

PLACE OF DEATH — County of a ^x V ^ n 



No. 



(' 



TV H \! ^ I 

,r OtATH OCCURRED IN A HOSPITAL OR INSTITU .^ 

FULL NAME 



V» \, ^^ I I 



PERSONAL AND STATISTICAL PARTICULARS 

i.\ 1 1 «>i r.iK 111 1 \-N 



\( .1-: 



vlNt.l.l' MAKKll I» 

W |1)(>\VJ-.I) <»!< ''" ' ''•'" ' 'I 

> \\l il< ill ^'>( i;il .ilV'!i ' 



!).ivi 



M.. II III 



\ ' 11 



MEDICAL CERTIFICATE OF DEATH 

DATi-: «»i" i'i:\Tii j\^ 



^!..llUO 



il>:iv) (Yc'itr) 



I iii.-.Rl'.r.V CI-.KTIl'^V. riKiL 1 atU-na.Ml .Uvcasod fnmi 



0- v 



I()0 



Ti. 






lUKTM I'l. \'l 

1 St. it' ■ ' unt I \ 



!•• All! 1 U 



lUKiiiri. \^ !•: 

Ol- lAIHl'.U 

(Stritr Ml Ciiimti y i 



M \11M;N \ a Mi- 
di' MO III IK 



lURi niM.ArK 

ol- MoTlll-.K 

(SUiti or rDviiitvyi 







A 






I I 



? 



y 



? 



,,,,.,t I la<t^awh . ■ alivvot. '^^ ' ^ ^'|^ 

,„.lthat.Kathocrurroa. .m t In- .laU- .tatc<l al.nvv, at 
' M. TlH- C\\rSI': Ol' Dl'Alll yva-^ as^oll-ms : 



DTRATK^N 3. )'r(n\^ 



Months 



I\iys 



lion Is 



coN'n^ir.r TORY 



..U. v..^^..'..' 



^,> < 




'^^V' 



? 



r-- 

I)l-K.\'ri()N ^ -^ r<'<?r.v 



Months 



Pars 




crW) 



r(>n 






Ifonrs 
M.D. 



(HI 



"•^■'■'••^■Ma' 






1 /,.»'///• 



/',n 



UK XHoVKSTVTKI.rKK^nNAl rAKTKri.Al 
i;i.>T<.l- .\LA- KN<»\V1.1.1)<.I-. .\M> >X>-''"/', 

tlLx^ Qf^^ 



l.AK^ AKl. IK IK !•> l'"' 



(SIGNED ) 

^\gv -I 

SPECIAL INFORMATION only for Ibspitdls, Instifulions, Irdnsients. 
or Rfcenl Residents, and persons dying dwoy from home. 



Former or 
Usual Residence 

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



Ifow lonq at 
Phire ol Death ? 



.. Days 



?xll 



■'Kf 



I 




I'i.ACK ni- HIKIALOK K1:M"VA1 



I)\ri*, of ItiKiAi. or K I'.MOV.M, 

C)ltnj: M 



T90 



,„„„_ lib JxAJ^Ol , ■■ — -77 

I -^— ^-^^- — — — ^^— ^^^* , rvACTI Y PHYSICIANS Hhoulu 

Btntc CAUhU IM I'*-'* ■ " • A'.ven in every inHtnnce. 

«on. clylnft ..w«y ?rom homo hHouM be ft.ven every 



!| 






rii; 



I-' 






I 



» y 




♦ 



1 



PBU. 



WRITE PLAINLY WITH UNFADING INK 



THIS IS A PERMANENT RECORD 

PEPER TO »ACK or CERTinCATr .OR INSTRUCTIONS 



Jlcdustered JV''o. 



2949 



-^ ^ Drnutv Health Offerer 






DEPAMENT OF PUBLIC HEALTlWity and County of San Francisco 



Ccvtificatc of Bcatb 



"U. 5. Stan^arD i 



PLACE OF DEATH :-Co.ntv ofQ^.v J ;v<^^^c^Gty ofO 
No. It) ^5 cL 



(W 



•T 



and V<^'^^ 



I 



V ir DEATH OCCUBHED IN A H O S P I T • L ■ 



) 



FULL NAME 



I 



h« mYui,^ 



- 



PERSONAL AND STATISTICAL PARTICULARS 

I \ ri. ' il ;-lK 1 II 



si:\ 



!lWl. 




,CVu 

M nth' A 



/'t^^^ 






\< .1-: 



r\ 



).,: 



. n.'v 



}/.'<,/'/' 



\ . ; 1 1 



/),M. 



\\ n><»\Vl-.l» OK l>!\<>Kv 1 I) 
■W til.- in soi-iiU iUsi^Mi:iti"ii' 



lUK rmM,\'"l' 




Oj^y^oLi 



MEDICAL CERTIFICATE OF DEATH 

(Months '»^"^'^ 

, iiKRUnV CKRTII^V, That I aUcn.k.l acccascd fnnu 

__ 190 to :^ "" 

that I last saw h alive on 

„M that lUathoocurrcl, on the .late stated above, at 

M. The CAISI' Ol- Dl'-ATH was as follows 



C: 



■xz 



JqO 



r 
9 






VV .A 



NAM! t»l 
J- AT II IK 



I'.iK iiiri.Avi-: 

Ol' 1 \ rill'K 

(Stall ' 1 ^"' ''111'' '^ 



MA1I>1:N NAMl'. 

»ir MoTin'.K 



iUK I'lll'LArj-: 
Ol- MolTll'.K 
(Stat< <>i v'oumUa' 





\ 







1)1 RATION J'''''-^ 

CoNTKir.l T<»1<V 








Mouths 



\ 






^ 



r/ 



Days 



Hour 






X^ '\ \ o. 





/'O 









^VY\XX'' 



Mouths I^ays 

^ ^^^ AJUUaaxJ^ "Xi LcY-v ^ VA i.i 

QW 'I .<.o't fA.l.lrvsOlDOb d^ctU H 



DTK AT I ON ,^ >■'■"' 
(SIGNED) 



Hours 
M.D. 



^S{ 



QPECIAL INFORMATION »nly for llospifals. Institutions. Transients, 
or Rerent Residents, and persons dying .iway Ironi home. 



Ki-'-idfJ III S.iii /'lit in '■ 



)■,«;> *" .1A//////> 



/>,/! 



,„-.ST..|. MS KN""'-'"''^ 6 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 






rV/C 



0^^^ .•^^^-- (^ 



DATl'ot Hi 10 \i. or K l". MO\'.\l< 

v|\>CV '1 T90M 






;l 






1] , I'VAGTLY PHY8ICIANH hHouIcI 






■I'l 



i 



I 



; I 






RITE PLAINLY WITH UNFADING INK 



: n. .i!th r \\». r 



•j4 -ar^:: \'.t^\'( ■ 






rjo'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE F OR ■ NSTRUCTION3_ 

Be^istered ^'o, 2950 






DEPARTMEN? OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of IDeatb 

J? ^ ^ ^ 

PLACE OF DEATH: — County ot^^<- ^v. 



Wo 



,:m 



^. 



Dist.; bet. 



- and 



( ifIJeATH OCCURRED IN A HOSPITAL OR . 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




.\Xi^ru 




C( il.t >K 




I ) \ ! 1 ' 1 ! i . 1 K I 1 1 







\< .)■■. 



sIN..I,r- MXKUIl.l' 

iW- ;-,■ M- v.Kiiil (l.-i'-Miatioii) 



5. 



■Dav 



1/ .»////■ 



.cvU 



/RBH 



MEDICAL CERTIFICATE OF DEATH 



0(W 



X5 



'»'i :il I 



/',.•. ^ 



i<)o "i 

1 90 ' i 



i;iK in ri.xri', 

i Sl;itr or '■<iMi\ti \ 



NAMT '" 
1 \lll IK 






OJ «P « 






I'.iK iiiri, \*"i". 
(It- 1 \riii-.K 

(St:it< I '1 '' ■'!"' ' "* 



MAIIM'.N NAMl 

oi- moiiii:k 



I'.IK'lIllM.ACK 
(•I MoTHl'^R 

t St;iti' i>r C'mintrv* 



orcl TAl'K'N 




Id /(?o \ 

(Month)' "^=»-' '''^•^"" 

I ni-Kl-.r.V CI;RTIFV. riu.t I attcMol .U-cvasca from 

that I last saw h A. n. al.vc on ^J '-^ 

,„,l tliat .loath occurrc.l. nn the .laU- statc-.l ahovo. at 
M. The- CArSl<: ()!■ Dl'A'Hl was as follows: 

prUATloN )V.r. I .l/..M.v^O Am /A^'^-" 

CoNTKlinTOKV 



nrRA'PioN 



(SIGNED) YV.^ ^ 



I()0 



Vrars Mouths /^<n'.? Ilouys 

M.D. 




"special information only for Hospitals, Institutions, Transients, 
or Rcrent Residents, and persons dying away Irom home. 



Residfif i" >■"" I'll"" i"'" 



y,'fii < 



^^^i^^^w^r^^ '"' ""■ 






Former or 
Usual Residence 

Wlien was disease eontraited. 
If not at plare of death? 



How lonq at 
Plare of Death ? 



Days 



,.,,ACK <)«■ lU-KIAL OK KKMoVAl. 



DAll", "it Hi KlAF, or k 1'',>!()\'AI, 



T90 



y>\> 






IS. B.- 



^ *^'''* ' [I ^ (1 ,1 II 11 Y PHYSICIANS should 

state CAUbE OF PL^ « " '" »' A-.ven in every mstnnce. 

«on. dyinft away ?rom home nhoultl be ft.ven m e e y 



li 




w 



RITE PLAINLY WITH UNFADING INK 



,, ,M r V,, .. t-.^^^^;i5^tJ'^" 



ii)(n 



DEPARTMENT OF PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

HEFER TO BACK OP CERTIFICATE FO R INSTRUCTIONS 

Be 'U .sir red Xo. 2951. 



City and County of San Francisco 



' 



Ccvtificatc of IDcatb 

,^^ ^x^^C^>^^^ C.ty of C3 ^^-^ ^ ^.^vc^CO 
PLACE OF DEATH -.-County ofea,^\' o/vo^^oa- 



No. 



^ 



MY-i^^~\t VJ^vk.^O..-vv^x 



Dist,; bet. 



\% k^^mj^ ^-^r^\, „„^o-^.t:^= "- --" -" -" 



and 



ER 
OF ST 



SPECIAL INFORMATION- \ 
STREET AND NUMBER. / 



FULL NAME 



W^\' 



\\^' 



ckOJ^ 



-U- 



PERSONAL AND STATISTICAL PARTICULARS 



J 





.kdx 



i 1 '. i 1 



\' . 1 



I ,] \A'< I 11 



M.,ttth'A 



I»:iv 



TOH 



(Vciir) 



■, . :il 



1 



, 3. 



s|\t .1 1' M \K1< Il'l) 



WIIM.A 1 1. OK I)!V«)K« l-.I> 



c].K.^^oA■<. 



MEDICAL CERTIFICATE OF DEATH 

tliat I last «w l.'^1^ M.vv on ^ ' 

„„,,l,Mt.K-..l..«vnm.,l, ..utlu.,la.>.....t>..lMl,.,v.,at M 

CI M. TluCArS|.:(.F :m;ATM «:,s as foll.ms: 



^. 






III 



{ 






1 \ 1 11 IK 



luuriii'i, \<v. 

Ml r\ri!i'K 



M \nti:N NAMl, 

(ti- Moriii: K 



(5? 



^>x J Xou^vcaacc 



1)1 K AT I ON ^''''^''^ 

CoNTKir.I TOKV 



J A 



'„'//// A- ^ />'/v.v //oms 




I hi VS 



I'.iKiin'i.M »•: 

nl- MdTmCK 

(StTit' "I r(iuntr\i 



//ou/s 
(SIGNED) V ^..K^civ.Y ^^ 'J'-^- 

' c^PECIAL INFORMATION onl> l.r llospildK. Inslitull.ns TranMenIs, 
or tocnt Mr.ls, d„d pnsoas dyini ,»-y l.»n, h«r. 



Former or 
Usual Residence 

When was diseasf contracted, 
If not at pla( e ot deatli ? 



How lonq at 
Place ol Death ? 



.. Davs 



in.>r Ol' MV KN«>\\ ij.iX'H ^^" 



(lllfrlMlKint 



i / 



11. ' 






i)\j'i', ot urKi.M. "I ki;mo\ai, 

r\r ^ T QO H 



,.,,A,K or I'.rKlAI. OR KKMoVM. 
INDl-.KlAKl-K OVA-^yVAAi j^ I 



N. B. 1 



'^"^''"•'^'' H'^- LJyU 7^ p- \ r.vAGTlY PHYSICIANS «hould 

;„rcAim.: or d.:a tm m .'■•'"--•;''': n.vTy in-.-"- 



.on. <l>int '-»"> »■•"•" '"""" "'• " 



ll 



4i 





i 



WRITE PLAINLY WITH UNFADING INK 



I!o,(!.l ^t U :i:ill I ^' 






I />r//r /v7r</, VrUx^^'VrXOJLrv' ^ 



/.7<^y4 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lio^ish^rrd JS'^o. 




WV.^ 'Xv\M. 



i 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH: — County 



of'^W-Yv J ,vcxvvCAXi.c^ City ofOo^^rv JX<X/w/ec^cx, 



^ 



\ 



M ^1^1 LHcLu St.; Q. Dist.; bet J /CX^cJUr^ and ^^^tml/^ 

INO. CN I V >- ^ V. X.X,V,^. ..c:i.*l DCQinrNCF riVF FACTS CALLED FOR UfAjER "SPECIAL INFOHMATIC/I*- \ 

( ' r"o;r«"occ"u%r;,'~"r.o"s^p"it :.'?:"t%" ^'y,;.",;! name ,.sx..|o' -"- — — "V ^ 



FULL NAME 



>1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

r< u.t iK 




y\AX 




P 



u 




.^w^ 



JcANVOo 



X - (v\X^ 



i> 



, K I II 



.Ib^ 



3)b 



,,1" M AKk III» 
a , i/< iWI-. !i ( >K ! > ^ ' ' ; > 

iW'i itc in --H-ia: '" 




Itll' III I'l. \»' 1" 



N\M1 <>1 
lATII I.K 



lilRTii I'l, \ri-: 

Of" lAIHl-.K 








r^^ 



M \!I>j;V \ AMI-. 
(»l Mni'Ill-: 



^ . "i^oj 

I'.ikiinM.Ai*!-: n 

<>!• MoTIll'.K \J r\ 



y(j^V\>OL/TVO^<^ cL'' JLA/^nrL(rvu<x 



lSl:ift III roinili \ ' 




) \ ,; I 



\f.,:th^ " /''■■ 



TMl- \H0V1- STATI'I) I'KKSONAl, I'A KT O" T !. A K S A K l! rRri- T« > nil' 
lti:ST<»l' MV KNoWl.i: IX'I'" AM> Hl'.I.ll-.l' 



M 11 I'l- iiiaiit 



'^.M!.s^ (Sl" 



MEDICAL CERTIFICATE OF DEATH 

DA Tl-: < •! IM, \ 111 



\K^ 



H 



(Month) " "> ' (Yfiu) 

I Ill'iUl'illV CI'.RTII'N'. TliMt 1 :illL'ncU(l <k*t ;i^i<l from 

thai I List ^a\v h ." alivL-on XTUpJ^l up *i 

Mini that (Uath occu rrt'il, (ui the- <lati- --tatLMl ahovr, at -J 
UL M The- CAT SI-: (M- I)1':.\'1*II \va>^ as follows 



^-VAA.vUJ^^-CLX M X^^*JL^rY\-CL^^^ 






I/i)nrs 






r' 









DIRATION ^ Years 



Miuitin 



nays. 



(SIGNED ) 



i^^.nlU.. 



in 



r^ ^'\ i<>oS r\MMr.-<s) (iCIUa^vaj 



.mIua 



Uigurs 



M.D. 



SPECIAL Information '>"'> '"r H)spifdls, institutions, Irdnsients, 
or Rctent Rfsidents, and persons dyimj .mris Iron home. 



Former or 
IsudI Residence 

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

I'l.Aci-: oi' lUKiAi, OK ki;m(»\ai, 



How lonq at 
Piai e of Death ? 



Days 



DAI'l", -i! Ill KiAi. or Ki;M(tVAI. 



IN 






N. B.- 



^ o .. I- I APF «ho lid he stated RXACTLY. PHYSICIANS should 

-r.very item of Jnf.rni»tlon should b. carc?ully suppi.ed "f^;^;:^;^^'^^^^^^^ Information" for p.r- 

stnte CAUSE OP DLATH in pliiin terms, that it mjiy he properly Uassitieu. i nc , 
sons dyinft away from home should be ftiven in every instance. 



1 



^J^ 



' i ! 












WRITE PLAINLY WITH UNFADING INK 



i.,„,l ..f IlcUh-l- N«). i> *-?. ?f.:,' 



?-i: r.N:!' '• 



/^/</r- Fi/rf/ }iV^>-^^^^i>^\.' S 



/ry^H 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

11 ('di,s tried .An, 




xoXcAM| Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



ecvtiticatc of IDcatb 

( U. S^'. t5tnnC>arC» } 



^ 



J? (371 J( -^'i' 

Ocv>- I^cx-Yxcoc City of 0,cv>'v^ ,^v<x.Axev^ - ' 



No. 



PLACE OF DEATH: — County of CV 

M^ ^ ^ *. ^ i St.; Dist.;bet. 

-^ A^^V-l ^^' .^v - ..^,,», orQinrNCE GIVE FACTS CALLED rOR UNDER ■special INFORMATION \ 

,r DfATH OCCURS AWA.Y FROM USUAL "f ^ ? E. ^ C ^„<;' ^^^^ J^^^^ ^ ^ INSTEAD OF STREET AND NUMBER. ) 



and 



(IF or ATM OCCURS 
ir pfATH OCCU 



RRED IN A HOSPITAL OR INSTITUTION GIVE 1 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS^ 







^TiaL 



r< 'I.I iK 



^- 



I 



I».\I 1. <•! lUK in 



\' . I'. 



I 






\\ 



si\(,i,i" M \ K 1.. ii: I> 

\VII>i »\\ 1-,I> <>K I>i\< »!•'.>!•; I > 



I'.IU III IM. \»"1" 
I st;it' • ■ • 'Mil I V 



iLojv^ 



\.\Mi: •>! 
I \ri! IK 



lUK inri. Ail-: 
(>i- I AT in: K 

I St:it< >ii T' .ntiti \ 



MAini'.N NAM) 
()J MOTIIl-.K 



lUK rillM.At K 
<)|- MO'l'lIl'lK 
(stritr wr I'ountrv 





In r I 





DL'Crr.XTinN (J } 



O^-YVL 






MEDICAL CERTIFICATE OF DEATH 



VI Uv- 

i Month) 



I 



IQO 



I lll'KI.r.V r i: K'l'I I'N'. 'riial I .ilU-ii-k-.l <lftc;iSL-«l from 

'^\cc \ looM to ' n ■ I^P' 



1 1/) \ 



^■■. 



tliMl 1 last saw h ^ ■ ilivr on ' ' l«P '^ 

;ii!,l that .U-ath occurrcl. on tlu- <laU- statf«l above, at 
M Tlu- C \1 "si ()1 1)I:A'1'II \va^ as folL-ws: 



; oi 1)1-. A 1 II WM 



\)\K Vl'K'^S 



]'i'ais .U(>////is 



CONTRIIH TORY Ox^^^nr^A^ ^1 IW^:^^ 



/)ins 



I lours 



,!lL'.. 



DIRATION 



(SIG 



NED) VV 



> cars 



Months 



Pav 



tP^ 1 T()oH 



•<?r5 Months navs Hours 

Oiv<^^Ni-C IV M.D. 

\.Mtvss)'ot.lA.Jkxo ob^A^■ 



.1 



Special information "fly inr Hospitals, Institutions, Frdnsicnts, 
or Rcirnt Residents, dnd persons dvinij .m<i) Ironi home. 



Ursidi'd ill Son /'i ii n. i^rn ' '''' 



•\J.,nt!r 



!>.: 




THK M»<.VKSTATKI..-KKsnNAI.PAKTI;;ri,\.<SAKKTKrK To TIM^ 
in;sT ol MS' KNoWl.l'.IX.K AM) Ml. 1,11. 1- 



(I 



X.Mross S^l 0XO^>v1j ^V 



former or « \ U> 

Usual Residence '^'^ I M I Lv i ^- 

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



HoH lonq at 
Pld( e ot Death ? 



.. Days 



I'l XCK Ol' lU K1\I, OK Kl,Mo\Al. 



DATi: u!' Ill Ki.M. 01 KICMONAI. 

Ol<a- It 



190 I 



rNI.HHTAKKK ^ CuU W^ ""^^ L 



,X.M,.ss "^H^ Q^AA>a.<i.v.o>A.. 



.. , TTr- B'tntiltl be statetl fiXACTLY. PHYSICIANS should 
N. B._r.very Item of informHtlon «houhl be cBrcVully «uPPl-''- JZ^X^^^^^^x^^, The '•Special Information" ?or pT- 
state CAUSE OF DEATH in plain terms, that .t may he prope- 'y -laHS.t.ea. 
«on« dvinft away from home shouhl be feiven in every instance. 



ii 




WRITE PLAINLY WITH UNFADING INK — 



>?..:. 1. 1 ..f Hi-llth I- V^ 



1 *«? 'W-.^i. lUSiP «*.. 



/A 



/>////' nir'l , ^\in(r\sJL'^v(aA.' ^1 



//y^;H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\^^>^ D-. r:u:.> -'-alth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "CI. S. StauDni^ ) 
PLACE OF DEATH: -County ofO.^^v J.rva^^^^a^ City ofOxXox. J Va,'Yvcu^e^ 



a^, 



No. t C' I VA. L aV O C* ' St.; 1 b Dist.; bet. oL 

i\A/a V . . _ _ 

IN A HOSPITAL OH INSTITUTION GIVE 



,LcL^>Cl. 



and (jLcn.'V>7Va/YV) 



„„„ MQIiai Rr<?IDENCE GIVE FACTS CALLED FOR UNdAr S P E C I A L I N FO R M AT I O N ) 

( " r/n^ATH^OCCURrED ■"• "'^ — - o'?n?t.TUt'oN GIVE ITS NAME INSTEAD ^F ST_REET AND N U ^« B E R ) \) \j 



FULL NAME 





t 



■KJj 



1 ^% 



PERSONAL AND STATISTICAL PARTICULARS 



• I lUKIll 



\' . i: 



Moiitlii 



\ 



' l);i%' 



I 



l>a\ 



si\( . i.iv M \i^ i< n: I). 

U IlH lU l-:i» UK I>1\< tKi l"l» 

Wiilciii v,i(i:i' .1. -if iKitiiiii ' 



r.ii-n'iM'i vi"i-' 

!St:i! 



\ \M 1 nl 

1- \ 111 i;k 



lUk 111 ri,.\ri'; 
(>!•• I xriiKK 

I St;il ■ ■• ('. i'l "t 1 \ 



MMIH.N NAM1-: 

<)i" M()Tin;K 



I'.IK 111 !M. ATK 
oi' MOTIII'.K 

('Stiitf >>v Cmiitt \ 







.^v 



t 




; x,^^^y\h 








^VYvOl JCrCrcL 






1111 \H(,Vl-^T\ll-|)l-KKs,>NAI.l>AKTirri.AK-AKi:TI<ri-: TO THK 

ni;sr ni- ms kn»»\vi.i:i)<".h and lU'.i.n.i- 



( I II fir niaiit 



ULvv-OLV<:vcCt.- ca 



X.l.ln-ss %?)(d 



MEDICAL CERTIFICATE OF DEATH 

DATi; Ul Dl-Al'll r\ 

VrWxr ^ K^o"^ 

(Month) '1>:'V» iV.-ni* 

I II I;K i:i'.N' Ci;iv'l"l 1"N', 'I'lial I aUciuKtl <kH-vasc.l (roiii 

^x.l|\t 'v 190H to . QrUrvr "^^ n,o^ 

that 1 la^t ^aw li ^.'. alive on J Ur\r ^ l()o'; 

ami that death orturrcd, <mi \\\r ^.\\v stated ahovr, at M 
L\. M. Tlu' CAl SI-; Ol" 1)1'.. \ Til \va>> as follows: 

I ir RATION )'i\ir.'< Monlhs Hay^s ^ Hours 

C( )NT1^ 1 ill 'TORY OI'AJ\.fr"yAAXl C_yU^ 

DIRATION )V(//s- ^ Mouths f^iys Hours 

(SIGNED) LUxVK^ VO .UJv>AJva/Viv M.D. 

^.^- ^\ ic,oM (A.l.lrvss) li:X\ eiyX\hA^rt^c^<: M. 



SPECIAL INFORMATION only lor Hospifdis, Institutions, Transients, 
or Kerent Residents, dnd persons dviiuj dw<iy from home. 



Former or 
I'sudl Residence 

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



How lonq at 
Pld( e of Death ? 



Days 



i)\ri; m! Ill HiAi. iir ki:m<»\ai, 

QTUx^ II 190 "H 



I'l.ACi: ol" r.rKi.^i. OK ki-;mo\ \i, 

tNM)HRTAKKKMJ.Ajt'-rOkj2A; ^ dAA,/V\t 



^. B.- 



TX-i::::^:. 7^ :z^:^::^-^^^^ ^=^^tt 



-F.very item of in^ormiition 

ntnte CAUSE; or DEATH i . • . , 

i« clyinft nwny from home Hhoul.l be ftiven in every instnnce. 



Ii 



wont 



. 1 



WRITE PLAINLY WITH UNFADING INK — 



i;.,ar.l <.f II. ^i"'' '' "^'^ 



,,-<:•■• -x:- -. li.V i' 1' 



THIS IS A PERMAWn^T^RECOHU 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




/;^//r /v7r^/. ItCVvX^rrvl^Kj H 



ino'i 



Jiro'isfrred AV>. 



2955 







"-U Lj 



DEPARTMENT OE PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX. S. 5tnn^av^ ) 



PLACE OF DEATH: — County 
.p4o. Ulu "^^ UwTvt^v .i^' (^'' ^,' „„St.: Dist.; bet ,.^^^^^^^ ,..,„„.„„.. n 

( " r"o»,°„^o^c"4r;,;"r„o"s^r.t r„'?:?f,:'J=4°:".^,vV74 name ,.sr». =. st^.^t .~o .u»b.-, ; 



and 



FULL NAME 



V, 



y 



'^K,- 



^L'O^ 




--ix 



n \ 1 i; < >i- r.iK I'll 



\< .1 



PERSONAL AND STATISTICAL PARTICULARS 

I < M,( iK \ '^•, 



I 



Ol 



U 



L 



L 







nth' 






SM 



C ^/. >,:'!■ 



\ : :\} 



/■' ! 



siN( . I.1-. M \K K' M'.I) 

WilM >\\ I-: 1) » lU I»l\«>K» 1- l> 

iW'iitt ill s.K-i;il ilc~i}.Mi;ili')n) 



I St;iti "! ' ' Hint I '. 




[\o 



vwti-: <)i 

I- A Til IK 



Qoi^ 



6 



^ 



vv 



.eV. J\... 



HiK rni'i, \rj-: 
OF iathi:k 

' Sti'i- "ir fount! \-' 



M\iI>I.N N\M1 

«•)• M<>rm;K 



i;iK III ri.Arj-, 

<H- MolIU'.K 

(Sliiti- <ir Cdiinli \ 



d^v^'-.a, . 




occri'A rioN 



UJ <x,\XJJ\j 



AV->/,/.-,/ Ill S.ni I- 1 ail, /w,. 1 )Vvr/ - 



.1.'..;////* 



I',n 




Till- AHOVKSTATKni'KRSONXM-AKnrri.XK^AKl- TKIHT.. THK 
in:ST Ol- MV KNOW I, I ".I »'■''•■. ^'^^ lU.Ml.l- 



(In 






\.i,i,,^s \^aX<^ ^ 



r 



/Oc^<UvAX€ut' 



MEDICAL CERTIFICATE OF DEATH 

DATl-; ol- 1)1-: A Til 




fMontli) 



\ 

(I);iv) 



(Yt-ar) 



I lll'Klvr.V C1;RTII'V, That I atteiuU-d deceased from 

«, r t 11 1901 to . vrVcv^.l 



190 I to ^i\^^\r.s, ic)0 1 

that I last saw h ^ • alive 011 V' ^<5^" ^ ^'P 

iiiid that death occurred, on the date stated a1)ove, at I • i 5" 



a 



M. The CAl si; Ol" 1M:A Til was as follows: 



I UK AT ION 
CoNTRir.rTOKV 



)'rars 



.!/,>. '////s 



Days 



Hours 



/-v^Xx/A-'^iXCLwCv-A.. . .^. XUi'vi^.'-.v.dl.u.. 



1) r R .\ T I o N ^^ > ■' v/ r s- Mou th 

% a H f 



Pays 



(SIGI 
vKoV L 



0^ ,olV 

\(f)'\ fAddres 



M.D. 



V lor Hwii 



.1 



SPECIAL INFORMATION 

or Recent Residents, and persons dying <iwdy from tiome. 

SUnce SbkTOOL'vVutiCK-.h? •& Oa,. 

When was disease contrdrted, 

If not at place of death ? 



i-i ACi-: o) luKiAi. OR ki-;movai. 






crlu L^^^^•^A 



DAri-;-)! IltiMAi. or U1-;Mo\'AI, 

MXtrV^ II 1 00 'I 






,,,„... ^q\)<x^v 0\L.o Civ ' 




^J ~r^, .,>f7 „K„..|.| he «tHte«l liXACTLY. PHYSICIANS should 

^. „._r.vcry Item of Information .houlcl b.- cnrcy-ully Huppl.ec. ^^^^'l^^^^^^^ ^he •'Spcciul InformHtion" for p.r- 

•tatc CAUSn OF DEATH In pinm tcrmH. thnt U m»> .0 prop«^rIy claH«.nc 
«nn, clyinft nwny from homo should be ftivcn In every InHtnncc. 




I J 



i I 



I ' 



i 'H 



11 



\ i 



^liL^. 



WRITE PLAINLY WITH UNFADING INK 



li. .1 



I \ 



,.. O'^x 



Ihf/r AV/r^/A]\^^T>OUt\^ H 



IfJO'i 



THIS IS A PERMANENT Rfc.Q;yKU 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Ficrii sirred jYo, -s^ JOO 







l^v^. locv.. Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 






No. ^'.^^ ^^^'' 



PLACE OF DEATH:-Coun,y of Ac^-^'^'-VC^-vc^-Gty of C^ CU^^' 'J^^O.-e.v^.. 
\\:xr; Sua. Dist.: bet. 4 I Ua^^j I . . and*^ Ks^v- v. . 

FULL NAME la\, • - ■ - cLl<xVva. 



) 



1 I » i! 



PERSONAL AND STATISTICAL PARTICULARS 



IK 111 



/ l 



i-r 



sINt'.I.l" M \KU Ii:i> 

WIDt »\\ 1,1> < »lv I)l\t)Kv >• I) 

iWtitrin -.oi-i.il il(si<.'ti;iti"ii) 



Hiu run. \i"i' 

(Stat< "t • ' 'I !'t • ^ 




./.ccLc 



Nwn- Ml 



il 






aik I II 1!. \' 1-; 

(t|- I \ I'll 1". K 

^1 it . ci! l"i i\l !lt 1 \ 



M \ I I>1N NAMi; 

('1 M(>i'in-:K 



ink ini'i.ArH 
«»|. N;(>riii':K 

iSlatr .ir r<>\iiit I \ 



< IV 1. ri'A TION 



,vv<xcLa' 



r 



,\o V 



(\\ 







MEDICAL CERTIFICATE OF DEATH 

DA ri' ' '! 1>1.A Til 



M lev- 



l);i\l 



(VrMrl 



1 II i:!v l'! I'.N' e'l'KTIl'N'. That I Mttcii.kMl .Uncased l"r«'iu 
that I last saw h i.'^ ah\i- on J v. . . 



Ii)0 ; 
1 < K ^ 
an,! that dralh .Triirrc.l, .-n the ^^U■ -latt-.l ahnw. at > i 



M. Tlu- CM Sh: (>i IMXril \va-> a^ follows 



CoNTKIlil roKV V ■ "^ 



DIRATION 



(? 



)V(7;'v 



(SIGNED 



Mont lis. 

-0 



/>(/! 



Hours 



Pax 



Ql. 



) Lu^<lWvaa-v> vO-vd 



.J^^ i^ 



//<>in s 
M.D. 






iV '1 Too't ( 



.X.hlrr^s) -^ Ti M/W^^nvU 



SPECIAL INFORMATION »"'> '"^ Hosplldls, Institutions, Trdnsients, 
or Rercnt Residents, and persons dying awjy Irom tiome. 



■II Si! II /■ I «.' It> I *'■'' 



^ ),en 



\foiiths 



fhivs 



,11,.: ^noVKSTAT)^I..•KK^nNAH•AKTU;^l.ARSAKl^TK^K TO TMH 
lU.sr <H' MV KNOW lj;in".K AN!) M1.MI.»' 



1 1 n t°< 11 inaiit 



vJlVvQ-^ 'ljL<XV\xfcoj 



*" Xddress 



R^X 




iK^Jsy\) Ot 



* 



Former or 
Usual Residence 

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



HoH long at 
Place of Death? 



Ddvs 



I'l \C1<" «)I- m-RI.VJ, OK KKMOVAI. I DATK "f H. ui.u, ui RHMoVAI. 

i,,i SOS WXit^vIy^ UaM. 



(Ad< 



(J ... II I AfiR Hhoul«I bo «tiite.l nXACTLY. PHYSICIANS iihould 

N. B._r.very Item of Information .hould be c«r«fu.ly H"n|» -^- .,,operly cl»..lflccl. The -Spccl.l Information" for p-r- 
«t«te CAUSE OF DEATH In pinin term,, th.. It m».> ^* *;"»** •^'>' 
«on. dylnft nway from home «hould be ftlven .n .very in.t.nce. 



It 



o 



3> 







^ 

y 



^ ' 



I 




JC 



WRITE PLAINLY WITH UNFADING INK 



, r I. .nil l--\i) 1^ '*~^W-"S-*)r"'tl' I"" 



1 



190'{ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be mistered J^'^o, 



295? 



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



^ 



Ccttificate of 2)catb 

( la. S. StanPar? I 

PLACE OF DEATH : — County of ) ^^ v \.a.^ vx;. ^Ac C.ty ot - ^ 

n ' o ^-^ Disfbet l^.tl and '' 






FULL NAME 



M.:x -^O 



PERSONAL AND STATISTICAL PARTICULARS 

^ roi.tiK 



ii\ ri; *'i i.iK in ,^ 



L 



4 



lC - 

Month) 



\t. J-; 



•^^ 



*^ 






M.^tith- 



\ t;u 



/'-/I 



^ 




MEDICAL CERTIFICATE OF DEATH 

DATK « '1 IH-.AIII , 



(Year) 



siN< ,1,1" M \KK n:i> 

\VM»M\\)-:i> nK IHVOKiKI) 

\\ I it»- ill -.<«i;il lit -iv'Diili'in) 




(Month) 'l>''*y^ 

I m;Ki:HV CI-RTIFV, That I attciKkMl (leivascl from 
^^ ^ to . OCU\^ L U)oM 

tlK.t I last saw h ^^v alive on ^<^^ ^ ^90^^ 

an.l that .leath ocourre.l, oti the .late stated above, at 
M. The CAISI'; OI" Dl'.ATII was as follows: 



jO- 



cri.v^lvv>i^w'.. 



xxv 



(St;itf or (.'ouiitry ' 



NAMl', «)I- 

J* A 11 1 i:k 



lUK riU'I.At'H 

()i- i-ArnKK 

'StMtc or v'ounti v^ 



MAIPKN NAM1-: 
ni- MoTllHK 



illU IIU'UACI', 
(U- M(>Tm:K 
(stair or routitryt 



yxu. - 



w 



JX-. ■ ■ ■ 



i^^^V 



I )r RAT ION '- >C«''-y 
CONTKir.lTORY^^ 




.'Cr^.U^...C.'tr...:;^.U..' • 



Hours 

CV>vcL 



I )r RATION 
(SIGNED) 



I(>0 



Address) H':^t \.) X^UvU 

isjnstitutjpns, 



M.D. 



( 




A'l' 






M,,nth' 



/>,: 



TIIKM,OVKSTMK,.PKK.OSA,rAKT,.;ri,AKSAKKTK.K To TIIK 
HHST ni- MY KNoWI.l-.Ix.h AM) liKl.ll.i 



(In fo: mant 



txlAAA- 



(Address 



TXO 




A.V^.C4V '^ 



SPECIAL INFORMATION only for Hospital 
or Recent Residents, and persons dying away from Ijomc. 

r , „, HoH lonq at 

^^^^"^^ Plarr of Deatli'' 

Isual Residence "*'' "' """ ' 

Wtien was disease contracted, 

If not at place of death ? 

I'l.ACH OI- lUKIAI.oK RHMDVAI, 



Transients, 



Days 



DATK of m KiAi. or RI';M«)V.M, 



(AiMress . 



^^-^^^i^^^^^i^— — — ^"— ™ . » I f YAt'TI Y PHYSICIANS should 

N. B.— r.very ...n, o« ,„!,.rn,».lon .hou... be ...r.i^><y -"PP -^- *«,•;• ^,„.i„.j. Th. "Spec... I„f..r.„...u„" for p.r- 
.t.te CAUSE OF DEATH In pl...n term. «h« '«'"■'> '^'_ 



-r.very Itei 






5I 



1 :'l 



■^wwr: 



i 



i » 



*if 



M 



^1 




WRITE PLAINLY WITH UNFADING ,NK-THIS IS A PERMANENT RECORD 

^^^ ...... .. REFER TO BACK OF CERTI FICATE FOP INSTRUCTIONS 



l-. .,,! .r II' Vth 



. h »■ X 



. t.. 



WSiV c 



r.f(n 



JU'^i'Stered Xo. 



2958 



Dale l-'lli'il . \f\cr\>JL/Y>v(uA, ^ 

v^cco xJL Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc ot iDcatb 






PLACE OF DEATH: — County of ^-'O^n,^ -'^<^^^<^^^ '-'ty °» , 

AK^q%^.voVrL St.; ^ Dist.;bet. I t tf^__^ and Jl I'V 



No. \ b ^'^ lb 6^o 



) 



( ■ -r.-^:::^: ::-^^^ :-±^^-^^^^^^^^ •---" s^-~F''' ^ 



FULL NAME 






{x\ 




IxLi 




PERSONAL AND STATISTICAL PARTICULARS 

/^ . I ' * I i . ' • K 




.0,! ' 



vcU) 



Uk^^' 



1 

ii,i\ 



,^T0 



bH. 



1 



MEDICAL CERTIFICATE OF DEATH 

1)\ Tl'. nl I'l, \ in , ^^^ 

I IlI'KI.r.V ll.kTll'V. That I atloiuU'.l .IcrcM-r.l fn.iu 




M.'tUh> 



(Yfiu) 



Cl^\a. 






li)0 \ 
Tip . 



slNi.l.l* M \KUni> 
IWritf ill -H'ial ,1. si).'nati<>ii) 



)UK IIU'I, \0K 

--• • • >• M•'tt^ 



cV^vq/L^ 



1 A 111 1 k 



r. I kill I'l, \i'!-: ( 
oi I A rill- k 

( Slal»- 1)1 i.'' iinilrV) 



^^ \ 1 lU.N N AMI. 

''I Mtiiin: k 



lUk TIUM.Al'K 

(>! M(»rii»':K 

(Stale t)T (."onnti v* 




\'yy^^i,uJOv 



Ixx^v^^Aji 6 c k^vudU^ 



that 1 la-t saw h i. -.> ahvc<in \l U"^- 

^,„., that .Icath or.an-rcl. < -n the .latr ^tatr.l al.nvc, at ' ^. "-vC 



)V</;.v it Months 



/\n 



Dl RATION >''''-^ '' ../<"/y/.> _ ' "'• 

CONTRIlU-rnKV ^.JUWU iLU^^^-^ 



I /O It IS 



DIRA ri(»N 



(SIGNED ) W '^V 



Months ^b /^(Hv //('/^r> 




A^VT^vt'v'^- 






M.D. 




VJxxoKxrv 



,,n ^M,,vK.rvrK.n■K,<.o^^, rxKT,rr,AK>AKK n<rH To thi: 

lU.M- nl- MV KN.nvl,i;ili-.i; AMI nM.ii'-i 



.„,,„.... ^C)'i°l (Jb(y^AK>jAA 



SPECIAL INFORMATION <»n!y tor Hospitdls. Instiliifions TrdnMfnts. 
or Recent Residt-nts, diiii persons dving dwd> from home. 



Former or 
UsudI Residence 

When was disease (ontrdcted, 
If not at place of deatli ? 



How lonq at 
I'ldie (»t Dfdtf) .' 



. Odvs 



•l.ACK Ol' m-KIAI, ok ki:Mi'\ \l. 



HATI'.d! 15' in.\i. t'T kl".M<>\ \1, 



TOO I 



,i„.:KTAK,.:KnfvaJA^\V 'Jv^. 






N. B. 



-^— ^— ^^■^— ^■'— ^''— ^— * .. ^ I rrvArTI Y PHYSICIANS Hhouid 

•Kvery U.m ..« In( ...Inn .h..,.ld b. cn.ofull, ">'P» '- • J^ •^;^ „„.,i,-Ud. Th« ".SlccI... In.or .Ion" for ,..r- 

. . ciiisf- OF DIATII in l>l"ln term'., Ihnt it miij "><• l"-"!' » 
:r. .Mnt oZ .rL h„n.o Khou.d b. »ivcn in cv.r, .n»..ncc. 



\\ 



{ 



■\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



It.iMvl '.f II.m'i'i !• V.i 



■^- I'.fk i' <• 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






» > 



i \ 



Jlegisfcred ^'o. 2959 

Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

1 "Q. S. 5tanC>avc> ) 
PLACE OF DEATH: — County of 0/a->v J.A^0u>v<X4C{City of^ 'CV/vyj ^ KO- 



^. 







'^>. 



Nn. LClu ^^^L^LCAvla i)\.'lH>VLla^St.; Dist.;bet. and 

A / IF DEATH OCCURS AwAV FPOM UpUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\ 
(J V IF DEATH OCC'JHBtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 






FULL NAME 




-t^^'YvdjA' ^^ 




Ul.' 



I \ 



PERSONAL AND STATISTICAL PARTICULARS 



vMXcoL 



u 



i> \ ri: I 'I i;iK III 



\i.j-; 



bt 






) '<il I •■ 



).(V' 



1 /..;////> 



l>,n> 



1 



si\(.I.|- MAUkli: 1), 

\\ iiM »\\ i;i) OK DivuRiKn 

'Wiitcin viMi;il i|i >i;Mi:it ii Ml' 



i:iK' III I'l, \t")-: 
^^t:lt I 1 It < '• 111 111 I \ 



\ \\1 1 Ml 

i'A I II IK 



I'.IK III I'J. Xt'}*: 

<>i' I \iiii:k 

'St:il> . .1 ( , n nt ! 



I 



'^A 



h 



•;>_ ► y ..^A 




MEDICAL CERTIFICATE OF DEATH 

DATl-; <)!• I)i;\Tll C 



Vll<n,r 



(Vt-ar) 



iMoiitli' (Day) 

I lll-;ki;i5V C1;KTI1'\-, That j atU-n.Kcl ,kHx.a>^r.l from 

>>- ^- A. "• UiO'i to \| L^'^-' 



til at I last saw Ii 



1 90 i to 

alivf oil 



ii<o \ 

1()0 



and that diath oci'iirrctl, on thr il.ilr statnl almvr, at 100^ 
vl^^M. Tlu- CArSI- ()!• l>i;.\TII was as foil,, us: 







VOJXXLV/^ 



"v-^r^^ V 0L-' C % 



\ 




'I 



V. 



1 ,'1 * 



1)1 RAT ION )','cns 

CoNTkilU'TORV 



Moil //is 



/)l7] 



'S 



I Ion IS 



M\!l)i:\ VAMl 



m \ ^ 



DTK A'riOX 



( Signed ) 



l^*/;--? . Months 



/htys 




liik 1 11 1'l, At i" 
oi" MoTMl'K 

( S';i|c I n fount I \ I 



< •' 'TTA rioN 






A^ry/ifrif tit Sinr /'t iiih I'u ■/ 



m..i . 



Ii^O I 



(A.Mrcss) LtUvi ^^ VC C\. ^ V 



//o/n \ 

M.D. 



SPECIAL iNFORMATJi 

or Rncnt Residents, and persons dying .mdy from home. 



ION only lor fjispitdls, 



( ! 



InsNtufions, Transients, 



former or 
Usual Residenc 



e v\w^v\vv^<L'rv^ 



. HoH long at 

-V\A.<L^iV^Vv^^ PIdre of Ocitfi ? 65 ,. Oavs 



1/,./////. 



/',.' 



Ill 1. \Ho\l'. SI \ 11, l» I'1<;kS()\AI, I' \U Ibll, \Ks \K I. IK I !■; To 111 1' 
Ill'.sT nl MV KNi)Ul,i;i)('.).; AM) 111: 1. 1 1! I' 



( llll"..; lu.illt 



A'Ms 




\ Co ' 



Wfien was disease confrarfed, 
If not at pla(Cof deatti? 




Cy^K^i 



ex, I 



I'l.Aci-; oi' iM KiAi. OK ki:m(i\ai, I i)\rK..t itiKiAi. ..I k}:mo\ai, 

I M.l.KTAKKK J\XJlLu>( ^ Jb<X.<\ C\ , 

(A.i.lnss 311 V- h\ LL ' ' 



^' K. J. very Item oV iri1?(.i'iiint ion hIi'iiiIiI be ciironilly supplietl. Mil, mSouIcI »)o stntcil EXACTLY. PlIYSICIAINS Nhoiild 

Htiitc CAlISi: or ni'.A TH in pliiin terms, thnt It miiy l»e fir.ipcrly cliiNNiV'ieil. The "Special Inlr'ormntion*' (f<ir per- 
sons flying uwiiy (from h<»mc Nli«>iii«l he liiven in oory inHtnnce. 



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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H..;,r.l..! II .itl. IN (■■'f^y--^:y.S^vr. R E PER TO BAC K OF CE RTIFICATE FOR I N STR UCTION S 



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lle^lstercd Xo, 



2960 






DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of Bentb 



( 'U. 5. Stnn^ar^ ) 



PLACE OF DEATH: 

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No. H i C) Ll\, XCC'l^ 



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County of '3/CX . ' \-CX, > vcv-i^^ c;.. Qty of CJ/'CX.^^ 0/vo. > 
St.; 1 C Dist.; bet. OAXC \ \X V and ^ ^ 



/ ir Dt*Ai OCCURS *WAV rnov USUAL R E S I DE NCE gi ve facts called roR under "special i n formation • \ 

V IF 0^kTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET kJ*D NUMBER. J 



FULL NAME 



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PERSONAL AND STATISTICAL PARTICULARS 




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(Stiitr or I'oiiiiti yi 



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Till-, AHOVIC ST\ Ti: I) l'KK>^ON M. 1' \ RIHT I.A R-^ A K l'. TK' I" l' ' 1" 1 1 1 

n]-;sT «)i' Mv K\()\v!,i-:i)c.i-; and !u:i.ii:i-" 






MEDICAL CERTIFICATE OF DEATH 

i» xTi'. ni- DiiA rn j ^ -. 

(Month* (I):iv' 

I III'Ri-r.V C1;RT1I-V, That I attcn.K.l (lc'( ca»c(l tr.-m 

190'^ tn uVWLa„i :i.i. rc/o 

•(I ? I, _ 

that I la^t saw h '•• ■ alive on cVl^X up 

and that di-ath occurretl, on the tlat«.' statt.-*! al)i)ve, at 
M. The CAISI- ()!• niXTH was as follows; 



<X/\\^tAJ A^'W/JAA-lr h 



I- V 



in i;\il()N )'i<i/s Mouths fhivs Hours 

CON rKllll'TORV ^' ''^>Jc-..