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

"^-t 



X 



LOCAL I T Y^-^OF 



R EC Q R D S 



S^N FRANC4SC0 

COUNTY ' 

S AN FRANCISCO 



^ 



CALIFORNIA 



'V^- 



\ 



TITLE 



OF 



R ECORD 



ATM 



I CROP I LMED 



FOR 



T HE GENEALOG I CA Liz:: S C I E T Y 



VOLUME 32 01 



3500 



/ ■ 



SALT LAKE 



C I TY 



UTAH 



C A L I FORM I A 



D AT E 




APRIL 



PH OTOGR AP HER 




CAMERA ■no2683 




19 7 5 



MAX J OHNSON 



RED 



*: •.,. » 



Jt *"*'. *« ^*-f(4f 



0« f ■*" 



EGIN 





^^p«l 



V 



K * 



Tl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I^>arfl .)t II' !li!i r \. 



r- ; or Xj i{,«t I' (V, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^.^VAA^IoAni Deputy Health Offjcer 



Registered JVo, 



3201 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eath 

i 11. S. StaiiDnrO ; 



Ml i ^ 

PLACE OF DEATH: — County of n <X'-v^ J .HXXyYVClXVCO City of C' CLAA; .XxX-^^OL^to 
No. Iblb y>W'^tnrx St.: I Dist.; bet.U cJxt^ andd^ 

f if DEATH OCCURS AW/*V FROM USUAL R E S I D E N C E G . V E FACTS CALLED FOR UNDER ipEC.AL INFORMATION" N 
\. .F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S^R EeI AN D N UMBER ) 

FULL NAMeA/oI^^ (1^ <X, ^ Jurvv 



and OiU^t^Pu 



PERSONAL AND STATISTICAL PARTICULARS 



«K--C^, ft 

IiATK <>I l:iK 11! 



COI,OR 




.\jJj 



MEDICAL CERTIFICATE OF DEATH 



D-\TH OF DKATII 




(Month) 



I Day) 



(Yt-ar) 



Month) 



(Day) 



(Year) 



AC.K 



(dC) ) ;■.!,.. 



Minitfis 



Days 



STNf'.I.K, M.\KKIKl> 
uiixtWKi) OK r>i\(»Krj;[) 

iWiitf-iii '.iicial (lrvii.r|]atioii ) 




niKTffPT.AOK 

! Statr or Cuniitr\i 



1- ATll i;k 



/ ^ocL<rvAj^<L 



^ r HHRHP.V CI:RTIFV, That r attended (leccascnrfn) 

that I hist saw \\SJyj ahve on VX-OV^ H ^^ •-( 

an.l that death oceurred, on the date stated above, at ?> 
U^ M The CAISV: (>!• DhiATir was as follows: 



iuv^tpy-vuti "^5.(0. ;i,tjw."tA^, s 



HiKTuri.ArK 

•>r lAIIIKK 
(Statf or Conntrv^ 



VTAII)1:n- NAM1-. 

OF .Murm:K 



Miurm-i.ArK 

<)I" MOTHKK 

(Statf or Coiintr\ ) 






Oo>v<i 




DrRATION 1 Vrars Mouths Days 
CUNTkllUToRV \Xj-YyjOJU^rY\JU0^ 



Hours 



? 



( SIGNED )J...|\,<)^ X. 
nW \\ Tc)oM (A.hlress) H C aljL) 




Davs 




Hours 
M.D. 




nOCI-P.^TrONT 

ffi'sifffff I'rt San Fmnrfrfn "^ ^',■(^;,s *^ .yr,>i,t/i^ 



^-'^-O^'OUivu.y 



nr^.^J?'^'-J'^!r°'^'^'^''"'ON o"'y f«r Hospitals, Institutions, Transients 
or Recent Residents, and persons dylni} away from home. n«"»Mcnis, 



/)„' 



i!i-,si OI. Mv k\o\vm:i)c.h AM) inaji-i- ' 

"(P J ii 



Former or 
Usual Residence 



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



How long at 

Place of Death? Days 



A.M.CSS. IMlT 



4 



I'.^CF: ^>'', IH-KIAI. OU RKMoVA.. I DA-.^^f H.H,.,. or RKMoVA.rl 




rx 



i)i;rtakkr ^WaJUa>v^ d. \) 



^- K. Kvery item of infnrtnnti 

8 



\.i.i..«« iOS MVurrvtn 











WRITE PLArNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n..:.i.l Ml" ll.'.iltli-F Vo. !^ -s-f^^!^^ n& P Co 



l)(((v Fi/r<l\ 





REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



la 



19 0\ 



RegLsfcrrrl J\^o, 



3202 



oa 



Deputy Heefth Omcer 



No. 



DEPARTMENT OF PUBLIC HE ALTH-City and County of San Francisco 

Ceitfffcate of 5>eatb 

PLACE OF DEATH:-County of 6 CVv^ j A^^,^, city oi^O^:^-,^^ 

r - ot.XH oc.ups .w.v .„„„ USU.L RES,0*ENCEc,vr J^clt*' '^*- ^"^ CTW-O-^^-CL and J CrULtT^V 






'<^>1 c o 



D IN A HOSPITAL OR INSTITl 



FULL NAME 




SKx 



DAT}'; ul- lUKTII 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR \ \ 





(Month) 



oXt , 



______ "MEDICAL CERTIFICATE OF DEATH 

DATK OK DHATII 




r 



(Month) 



!% 



AtiR 



clW^" 



» y,a,s 

>^»n<.m:. markihi) "" 

U'IDOWKI) ,)R nivoKci.-,) 

(U iiti' in sori.il (ifsi^Miatioii) ] 



(Dav) 



.'^tiniths 



(Vcar) j.— 



(Day) 



fiavs 



HIKriIl'I.ACK 
(State i>r Coiiiitrvl 



NAMi; OI" 
KA THlvK 



HIHTHn.ACK 
<>(•• lAIIIKK 
IStatc or Conntrv) 




f 



^i.iviii \, Mi.it I attcided (Icctascd f 

"~~^ I90 to 

that I last saw h .- -nlive on — — — 



(Year) 



roni 



T90 



a^ that death occurre.l, o„ the .late stated above at — 
'h I" ''^V^^'^V^^^'^'^-^'^'"-- follows: 



T90 



-C<^..X^<X.-<«i_4L. 



X.'\Xvjj\} 



nruATiox y.ars 

C0XTRIIU:T0RY 



^/o;///?s 



Days 



IIoii 



rs 




I'.iK rin'f.ACH 

OF MOTJIKK 

(State or Country) 






DI'RATION YearK ir, .a 

( Signed ).Ur\.crr>j2A; J ' ' 



/?r/i' 



^\r IQ 



ivo^v 



J. AjJux >v d.. 
(Address) L(y\.(rvAjK^ 



Hours 
M.D. 



ucx 



Mnlitlut 






.rfere«^^Z,s"^„J"°?.!;??,:'ON ;;;!|; '-;»sp„a,s, >.smMA, i„„s.„,s: 

Former or 

Usual Rcsldencf "®^ 'onu a* 

u,. „^ ^. Ware of Death? 

When was disease contracted, 

If not at place of death ? 



Days 



(III foi niant 








J) 



I'L-ACH OF- IHRIA 



' \<1(lrf»;s 



^'^^ OlJU^A_c^. dl 




790 '( 



Ai, OK rj.:m()\ai I ,,»-,.,. . „ ■ ■ 



'• "• ^^UCA^^^'^-!;Z:^:;;l -^ --^'"M. -PPM.,. ACBTZTTTated BXACTLV 



I 

I 






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

Ji'i.lKl ..f He:; nil I' v.). ;^ t^-f^^-i ju<t |' c , , 



r\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered Xo, 



3203 



l)((h /'V/r^/, \JliJ^^^op^-^^^^ |c^ ii)Q^ 

<>^<^vco lay\ru "^^P^^^J HeaMh OfTIoer 

DEPARTMENT OF PUBLIC HE ALTH-City and County of San Francisco 

Ceitfficate of 2>catb 

( "U. S. StanC»arC> ) 
PLACE OF DEATH: -County ofOo.^. J ;v^'>vcc^c,. Qty of CW> v J axvwcv^^ 

/I ^ li\ D i^ 1^(1 

^LUu St.; ^. Dist.;bet:d)aJkvvt<VUm, and LW. 

*W*Y FROM USUAL or es ipiE-iu/»r- y ^^ ' ^^ <*na ^.-^\-WA^, 



I 

1 






FULL NAME 



J 



sj;x 



I>ATK (»!• lilKIM 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 

V , . 1) I) 

OVAT 




iMoiith) 




'<^(^' (llxu^^;\^.iA.l./V dlO^u/^^^ J^^.^ 







ACK 



it) r^m 

(Day) (Year) 



) t'ti I A 



Mouths 



\ 



MEDICAL CERTIFICATE OF DEATH 

DATK OK I)i: ATI! 

(Day) 




(Month) 



IpO \ 
(Year) 



?^ 



I HI'RHHV CHRTIFV, That I atlcmlcl deceased from 

to -- — :::: 



I90 



^ IN' .1.1' MARK 11: 1). 

U II)(>UJ-:i) (»K DIVOKCKI) 

'Wiittin social (Itsj^rn.ition) 



Davs 



HIKIIMM.ArK 
•Statr or Coiintrvl 



N'AMlv OF- 
lATHKK 



HIR rillM.AtH 
<)I- lATIIHR 
(Stat<' or Ccmntry) 



-9 on 1 




T90 
T90 




that I last saw h alive on 

ami that death occurred, on the date state.l above, at S- ^0 
^ M. ^leCAlSHOF DKATI. was as follows : 



A.^'trvv 



u,. 



13 n ( 



MAfnKN' VAMF 
<>!• MoTUHR 



HiRrm-r.ACR 
<»»•' M<>Tiri:R 

'Stalf or foiiiitrv) 







"UCL,. 



CON TRII'.r TORY , 



Mo>iths 



Davs 



I fours 






'"^"•''■"'"■^'rin '■'■"'■' ''"""'■■' 




(SIGNED ):J^cU>wJ^ \).l!cuvv. _ 



I^ays 



Hours 



C 



oCOri'ATiON 



Mn„//n 



^^ci%i^Li z%iT. ?,!,' °':t ?i t::^:^'"*^ '-•»""»«'. f™*-r 



I 



/)</ 



r« 



rni{ AHovi.^ srxri.'i) pkr^c »v i i i. \ o-n • t- , ... — ' -^ 



(Infn: tll.'int 



''\r1.1rcss 3-1 



Former or 
Usual Residence 

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



How long di 
Place of Death ? 



... Days 



fNDKRTAKKK 



N. B.- 




I'LACKOF m-RIAI, or RKMovai | „VTi- r „ __ 



9^0 






J90M 






'I 






i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!. 



.f'th I \o. ■ ■ It-; 



--.^ ^>c 



^ ]\S<.V Cn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Fi/cf/W 





n 



if^OH 



Jie^i6'tered JVo. 



3204 



cvo dvXA-Ma Deputy Heaith Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtiffcatc of IDcatI) 



"U. S. 5tanC>arC> ) 



PLACE^OF DEATH :-Cou«ty ofC3<»^v J.X<X^cul^ City ofOxiAx. J;La.>vcv^^ 



No. 1513, O.cetl; 



/- ,r„r.TH occu.sT„7r;;o'„' USUAL RFs^DENrr. Dist.; bet. V) CS^U. andOxa'vu 



FULL NAME 




FACTS CALLED roR UNDER 
ilVE ITS NAME INSTEAD OF STREETAND NUMBER. 



J 



SEX 



PERSONAL AND STATISTICAL PARTICULARS 
A i COI.Ok 



; fe^ 1 




DAIK ol IlIKlII 




* 



MEDICAL CERTIFI CATE OF DEATH 
IMTK OF DKATH 



Q\, 



(Month) 



(Month) 



(Day) 



Ar.R 




I 



(Day) 



IQO : 
(Yt-ar) 



Ye a I 



M.'Ulhs 



9k b 



^IXr.I.K. MAURII-!) 
\VII)i)\\ Kl) nk DIVoRrKr) 

lUiittiii -<>ci;tl (ksiKnatiun) 



Da \s 



lUR TMPI.ACK 
• Stall or Cotititrv) 



NAMl-: OP 

fati!i:r 



HIKTHl'l.ACK 
«>I- lATHKK 
(State or Country) 



MAIDHN N.^MK 
<>I" MOTin-lK 



T^TRTTTPr.ArH 

<>i" M()'rni<;R 

(State or Contitrv) 




^f 1 



I incURBYCHRTIPV, That I attemU,! .leceased from 

■^^<^ i'^ -i</>H ,„ (h.,^ ii 

that r last saw IiA/Vva alive on VrLfcA^ J^ ,„„ m 



I90 



ami that «U-ath occtirrcl, <„, the .late stated alun-e, at U 
U >L The C4USH OF DI^ATII was as follows: 






DrRAtrox 

COXTRIBUTORV 

nr RATION 




Mouths ^ Days b Houys 







YearA 



'CL'^V V.VOAXCMl/Cii.. 



OCCri'ATlOX 

^''iiif'f ill Sa>i /'laihisro \ T/Vf/v 



n '''/^ M0H//1S 3 



/'.t 3 Days t, //„„,., 

M.D. 



.rfe::,^^^^;.:!"^?^ ?>IJ?4 ?rt ';;.r"'*' -«"««»^. ^"-sien.s: 



.1Av,///v 9.(0 /;„,^, 



Tin: MiovK sTA-n:n I'KRsowi i>\rtioi'i \w< xu t- i-l,,-,. ... "" 



Former or 
Usual Residence 

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



How loni) at 
Place of Death ? 



Days 



( Into!in;nit 



l^- "• F.very Item of Itiformnti 

R 



r-NDHKTAKKR VXXAJLUt "^ t-KY>CyU.Ci iu 




I)A^i:<.f HiKiAr. or KfclMoVAI, 

^^: 190^ 



on. cytn, „.«, ,.0. Home :Hou,rH7.^\:':iViv::::;i';«r:nT::'^ ^''^'*''"^^- '^'^^ *•«•-'«• in^oTJr„"i:':::^, 



i f 



' ^^fy 




'•! 



if! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMA^•ENT RECORD 

ItM.-iifl of Il.-.'imi I-' .v.). u ?"S^^»~4; IK"?: I' Or) 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 






IfJOH 



RegLstcved JVo, 



8205 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beath 



QS? 



( 'a. s. stal1^a^^ ) 



PLACE OF DEATH: — County of JA^^U^'>Yv-Y%_,t,La.(city of 





A 



Na 



-and 



Xcx.k.;.,-\ M)\^.>\.L St* Dist-bet 



FULL NAME 



SKX 



DATK OF I5IKTM 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 

u ' 






«'ff<H>«-«'B*««««a. 



I.*/* »«*><■*:«««*.«.«««•. 



MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH 




(Month) 



' M(iiitli) 



(Day) 



iJQ... 
(Day) 



190 M 

(Year) 



A < ", H 



Srx<-.I.F MAKRIl-.I), 

\vn)«»\yi-:i) OR i)i\<)Kri:i) 
<\\"i iti- ill sot-iiil (If'iij.'ii.-itioii) 



i.Nj )■<•,/;, t I, A M,nilhs 

? 



% 



(Year) 



/>(n.v 



I IinRHHV CivRTlFV, That I attemledTeceased f^^^^^^ 

— to : 



190 



lUKTHI'I.ArK 

'State or Countrv) 



NAMi: OK 
FATMHR 



niKTIU'UACK 
Ol" l-ATHKK 
(State or Coiintrv) 



MAIDHN NAM}- 
OI- MOTUHR 






that T last saw h rr— alive oti — — — — — — 

and that death occurred, on the date stated above, at 
fT M. The CArsrv OF DPIATH was as follows 



-190 
T90 



■y\jlA^rcotti-/>-jb 







•■••••» "r •»■*-•• •-»•! 



**#»■►»■, »,,,,^^^^^,^^^_ ^ _ 



(SIG 



nTRTITPnACK 
OF MOTHI'K 
(Statf or Coiiiitrv) 




DURATION Yeai\^ 
CONTRIIU'TORY 



Months 



Days 



Hon 



rs 



DIRATION 



QfW- 



NED) b J JifrvJLdL 



n 



^^^'J^'^^'s nays Hours 

^ M.D. 



fQOl (Address) O ^■^M\JQKJ \^<xX - 



?.L^?ifih»J "lif 9RDCATION only for Hospitals, Instltullons, Transients. 



OCCTTATION 

f^fsidrd in Sill/ /■'> a>/, i.yr/) 



or Recent Residents. an(i persons dying away from home. 

Former or 
Usual Residence 



I Mi: AitovK STATKi) I'KK s<)N A i ^VhrnrrTTtTTTITrTrr 



f: To thk 



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



How long at 
Place of Death ? 



Days 






(^Adilic'ss r~ 



IMf 



rXDKRTAKK 




K KKMOVAI. '>ArHof H, urAi. or RKMOVAI, 
■m.<>Xi^\^ I MWt [^ j^Q^ 

,u 



N. B. F.very item of information should b- c 

iitate CAUSE OF DEATH In p|„i„ t^rm 
«on, dylnft away from home should be 



K dL. cJ^CLbL^dL \c 



(Add 



ress 



arefully supplied. AGE should be stated EXACTLY. PHYSICIAN 



S should 
for pep. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






f 



in 



Registered J\^o. 



3206 




Ihife Fi/e(^,\i^J^^J^-^ l^ 10 0\ 

LXA Xxamj Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

i XX. S. StanC»arC> ) 
PLACE OF DEATH: — County ofC/CL^-v 0,\xx/yvCc^co City ofClcXAv /\XL/-v^euL CO 
No. il'i LcLdoi St.; ^ Dist.;bet. M ri-<X«.t>A.; and J CuXvx; 

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

FULL NAME J.K.>Crx^x<x^ cLuOnjL, 



PERSONAL AND STATISTICAL PARTICULARS 



SRX 




\oXk 



COI^OR 



XUyKAjtt 



MEDICAL CERTIFICATE OF DEATH 



D.\TE OF I)K.\ Til 



DATK <i|- lUKIll 



(Month) 



(I).MV) 



(Year) 



(Month) 



(Day) 



(Year) 



AC.R 




HO 



Yrars Tr... ...... ..M.^ntfn 



Dav: 



«^Tvr,T,K MARKTKD. 

w ii)( »\\i;i) OK i)iV()kri:i) 

(Wiiniii •^ooial (!rsiKiiati«»ii) 



lUKTHPI.AOK 

(Stiitf or ("oiiiilr^) 



NAM}-: i>(' 

FA 11 1 i;k 



HiK'rni'i.ArF: 

ni- I ArilFK 

'Stiitf or Covnitry) 



maii)i:n N'AMi-: 

OI- MOTHKK 



lUKIin'I.ACR 
OI- MOTHKR 
(State or Coiintrv) 




I HRRnnV CKRTIFV, That I atten(U<l deceased from 

~~~~~~ —190 to T90 

that T last saw h 'rr- alive on — — — 



190 



and. that death occurred, on the date stated above, at - 
M. The CATSFv Oli DIvATlI was as follows 



{^ 



S 




W/i 









^.rv^O-.U. 



DrR.VTION Years 
CONTkllU'TORY 



J/of///is Days 



Hours 



DURATION 



Years 



^ (51) 



i\/o}ii/is 



Days Hours 



( SIGNED ) Uyumx^. J VD. UJ. Ixio/vvcL M.D. 



OCCII'ATION 

Rrsitirif in S(jii /'i nm isrn 



\ 



(^vr. )5 



190 



( 



Ad(lress) Wv^rVvXA^ Vj^li 



S 



OCjC 



?^^9'flK"^'^0'^'^AT«0N only for Hospitals, Institutlons.translcnts. 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 



'Wuirs 



.^r.iiitfi.t 



Da 



TUl- AHOVK STATFI) PFKSONAI, I' A K TlCr LA KS AKl; TKIH TO THF 
lUvSr OF .MV KNOWIJ.DC,}.: AND i{hmi:f 

(Informant V<r^,^rVAJt^^ U >Mv-UC^ 




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



How long at 

Place of Death? Days 



(.Xddrcss . .." 



rr,ACK OF nrRi.xr. or rhmovai, DATKof h.-h.^i. or rhmovai, 
3A^..^-^X/:in^..U.0L-L?' I Q^UV-. 1^ ^^^ 

(Adclres.s 3j (oH X ' l^ jJ^LIt. 



IN. B.- 



.^taU^c'l7sE'oF 'DTA%'S"ln*L7^ \' '""'^k "' f""'*"".- ^^"^ '^""'** **' ''"^'^ EXACTLY. PHYSICIANS .hould 

•tate CAU!>t: Uh DEATH In plain terms, that It may be properly classified. The "Sneclal in?nr»,.fi»»M »« 

Ron. dylnft away from home should be ftiven in every Instance. . "•'''* »"*«'«' information for per- 



^ li 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l!<.;ii<l .if II(:iltli !■■ N<v i ;, tf^siS":-^ USi. V C n 



Dff/c Filed , 




-Ou IS 




•9 M. ^. 



VJO\ 



,?^*^ 



Registered J\^o, 



3207 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( 11. S. Stan^ar^ ) 

(^ J? 



(^ 



PLACE OF DEATH: — County ofO/CL^vx- J .^XXaxcOi c c City of 0<X/>^ AXXA^C^-^L/a-o 



No. ?) m 




n.o 




\' 



St.; k Dist.; bet. vD A-CU'V 




and 




(ir DEATH OCCURS AW4l\v FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U N D E R A' S PEC I AL I N FO R M ATI O N ■' A 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of'^TREET AND NUMBER. / 



\X/^\JX) 






FULL NAME vixJUUUj 




PERSONAL AND STATISTICAL PARTICULARS 



si:.\ 



DATK ()| I'.IK III 




f 



COI,OR 




\\.' 



Ujl 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DK-- 



Uonthl 



10 

(Dayy 



zlU 

(Yt-ar) 



a<;k 



;.::: ou- 



(Month) 



1^ 

(Day) 



(Year) 



I HnRHBY CKF^TIFV, That I attended deceased from 

to i: 



Hi 



) ■/•,; > .T 



\A 



Months. 



) Davs 



SIN('.1,K MARKIKD 
iWiitriii "iot-ial <lisi<.'-iiat i« >ii ) 



i!iKrni'i,\(M': 

'Stalf or C'>nutry* 



^ 



J rVOwVVOlxi 



\AXy-W^UL 



FATni:K 



— VJAXVvX 




I9O - to 'loo 

that T last saw h ." "alive on \ao 

an<l that death occurred, on the date stated above, at — - 

-jrr— M The CAUSH OF DlvATII was as follows: 




A.xrn 



)-cv>v/:law.''CvjL 



HIKIIiri.Ai'K 

OI* l-ATIIKK (VN 

(State r)r CouJitry) ^Ui 1 

^— - - A>o^>v<:jl 

MAIDHN NAMK 
<)I- MOTHKR 



OJVO 1,01 



DURATION ........ )Vrtr.? 

CONTRIIU'TORV 



Months 



Days 



Hours 



Dl'RATIOX 



Years 



Mo}iths 



J^ays Flours 



lUR'iiiri.ACK 

Ol" MoTllHk 
(State or Countrv) 



» 



3 



A^Cv^-' 



OCCrPATION 

Resided in Sun /'i tiin isro 



^SIGNED )\Jf\Jr^yJiXj . VD. Uj X«Xcxm.cL 

ICV^- l^ IQOM (Address) L(rUrYVJL\^ Ulivo^^ 



M.D. 



Special Information only for Hospitals. Instltutlii^n^. Transients 
or Recent Residents, and persons dying away from liome. ' 



) 'ru I 



Mni)lh<i 



Pil V. 



'Infoiiuaiit 



TIIK AHOVH STATI-.I) I'HRSONAI, 1' A RTIlT I.ARS A R )•; TRTK To Tin-- 
HKST Ol- MY KNOWLHDC.K AND HKMHF 



rx.i.i 



rt-ss 



3H1 



N. B." 




Former or 
L'sual Residence 

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



How long at 

Place of Deatfi? Days 



^I,ACK OF BrRIAI, OR RFMOVAI. 



ii,i\\-f. Kit- m K 1/ 



'^^TFof HiKiAr, or RKMOVAI^ 



^ ioS 



(Address 




ttaVe^J^u" E of DTrxH" •^'T'^^ 1" care?ully supplied. AGE should bo stated EXACTLY. PHYSICIANS •hould 
•tate CAU8E OF DEATH in plain term*, that it may be properly classified. The "Special Information" for o-l 
«ons dylnft away from home should be given in svery instance. mtormatlon for psr- 



'#1 



m 



s 



Jl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



M.Mi.'. .■>: lie. 'til 1- No. 1= fr- ■'»>-^;. HXlI' (.' 



/>r^/r /-VA''/, MlruO^TYviv^Aj IH 2.9(7^ 



Krgintei'ed ^V 



3208 



.CrVAX/^ 




An^ Deputy HeaSth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( XX, S. StanDavD ) 



PLACE OF DEATH: — County of^O/'W' .^vol ^rxcu^ cc City of 0,cc->^' o;\.cu>\.ev^co 



- A h 



a 



NoJl^ ^ X'CXXAIow-V) St.; Dist.;bet.^AxV>VTV<X/Yv and'Vl&AA.yOL/vAl) 

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



FULL NAME 




U<X/TVY\; 



PERSONAL AND STATISTICAL PARTICULARS 




■ i:\ 



» \rc < •! r.iK III 



\< .K 



MEDICAL CERTIFICATE OF DEATH 



nATK OF I) HATH (\ 

VWr 



(Month) 



(Day) 



190'i 

(Year) 



J ra I s 



b 



Months 



IS 



^C| A I HI«:R1-:HV CI-RTIFV, That r attended deceased from 

year) I dX^ 'Xh lyoH to ^^.Tvr ..tl I90H 

tliat I last saw hXh; alive on ArUrvj^ II I90H 

and that death occurred, on the date stated ahove, at ' 



I\l t.s 



^INt.l.j;. MAKUIi:i). 

\VM)(>\\i-:i) <)K i)i\< iKii;i) 

(Wiilr ill sori.il <|csi^rii;i| joii ) 



\.rv\klikx 



niKTTTrT,ACK 

(Statt or Coiintrv) 



SI ^ (1 

5;J^-',tVr ^ ^ (^ ^^ /^ 



N 

I 



BIRTIlPf.Ai'K 
ni ixrm.-.R 

(State or Conntrv) 





U<X/Y\/TV 




vC\A^uUX; 



M. The CAISI- ()!«' DIvATfl was as follows: 



DT'RATTON-.......JVa;^y S Mouths Days Hours 

C()NTUIl'.rT()kV \>sJ\J^^U^6-^':u^^ 




or MoTHKK (y. V M y B 

'wk riii'i.ACJv a" 

<>l' Mo'l'IlI'lK /?\ IL . 

(Stale or Coimtry) I \ 



DTRATION ^ ycars'^\'\ Mouths Days Hours 

M.D. 

A.-" i"^ rqoM (A.ldress) S 1 1 ' ?^ Axi .^ t. 




(SIGNED) AJ fUrVv^ui) OID/OKOMIU, 




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



OCCITATIOX 

Resided in Siin I'l iiiii isri} 



)'/(7is Mdiil/is lo Pdvs 



Till'. \noVI<: STAT »••,!) I'KKSONAI, I'A UT Iff I, \ KS A k H TR IF TO TilF 
IU:ST OlpiiA' KN'oWIJvDCK AND IllvMIlF 



Former or 
Isual Residence 



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



How long at 

Place of Death? Days 




)F BIRIAI. OR R1<:M0VAI, 



rNi)i;KTAKF;R N 1 1 



1 




OATI-; of ]{ri<iAr. or RKMOVAI^ 



(Address /JL^^ \uil<X/lJk^ CJ± 



^' "*~rt«V/cl'ir«;F^Ap^nTri'M"."*'7V' ''' '^«''«f""y «"PPl1e.I. AGE •hould bo stated EXACTLY. PHYSICIANS .hould 
• tatc CAUSE OF DEATH In pln.n term., that it may be properly classified. The "Special Information'* for osr- 
sons dyinft away from home should be l^iven In svory instance. 



Wy-^ 



'^ &« 



« 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H...ii.l..t' Ilcilth I-' No. !', •^-i'T'-'^i; 11^:1' C) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(f/(' /'VAv/,...\I.ya)^/YYvi>^\) 



H 



JfMJ'i 



Registered J\^o, 



8209 




ULA 




<No. 



^v^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of "©eatb 

( *Cl. 5. StanDarc> ) 

PLACE OF DEATH: — County oi^Ojy^ Xo^^n^ouu^o City of XXox> .^.aoac cci cfi 

.uLu^ ''^L^vv^y^t^. OOcKJ^vvixvi St.;— Dlst.; bet. and -----rTrTrrT—-^ 



(IF DCATH oceans AwvAv r^ROM USUAL 
ir DtATM OOCURRtD IN A HOSPITAL 



RESIDENCE GIVE facts called for under "spec 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



IAL INFORMATION" \ 
T AND NUMBER. / 



FULL NAME 




I 



rxorv 




Sl.X 



DAIl". (•! r.lK III 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 






ACK 




(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 1)1 



!: ^ 



(M(5nth) 



ll 

(Day) 



(Year) 



Hi ,v,„, H 



Mo,i//iy 



Pa rs 



SIN. -.I,!* MAkKll'.I) 
\\M»<)\Vi:i) (»K DIXOKiKI) 

'W'litfiii >iMri;iI di ■iiviiatioii) 




OJvH-OlxL 



MiK I'll I'l, \oi-: 

I Mati_ I IT Codtitrv^ 



\ ANtK OF 
I- A TFtl'R 



I IIIvRICHY CKRTIFV, That I attended deceased from 

Ckl 190 '1 to \.iL(r>J:. ...i^ 190 H 

that I last saw hA..»"!L alive on NlL^rx: Id. 190': 

and that death occurred, on the date stated above, at 1.15" 

U.. M. The CAISIC OF DI'.XTH was as follows: 

^-W4JLoL/V-0.^>%^^^ U.<ijtA'\XOU....Crl..3Naj^:XX3^ 



lURTHPT.ArK 

«)! 1 Aini'.K 

1 State Df c'oiiiitry) 


MAll)i;v XAMH 
OI- MoTHlvR 










vj 









Dr RATION Years Mouths Days Hours 

.CONTR I lU'Tl ) R V iAi>\A^a-<<r^-s^ . ^I-r<L^..u^c^^^ 




-u. 



()!■ MOTHHK 
(SlatL- or Country) 



)A^/cLDXt 





M Uv" A. TQoM (Address) L 




t)CClTP.\TION~^ 1 1) 3 



Mouths Days Hours 

M.D. 



DURATION \^'cars 

( SIGNED ) .sJ Vk. .'.(l.b.Xl.\l: 



SPECIAL INFORMATI 

or Recent Residents, and persons dying away from home. 



iress)Lctu. VLo (A:)(y^,|ut<xi. 

ON only for Hiispitals, 



Former or 
Usual Residence 



Institutions, Transients, 
oOb- '^i^t jii Place of Veath?5i. 



/ hi vs 



Till-: AHOVK STATl'I) I'KKSONAI, I'A R T U' f I,A KS .\ R I) TK T K To Till' 
15i:ST Ol' ALY KNOW'IJCDCK AM) HI-n.IlCF 



(ItiformaTit 



N. B. 







^^UrvCt,aJ(J 



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



Days 




T90H 



lURlAI, OR RKMOVAI, I DATi; of Hiriai. or RK.MOVAI, 

INDl'.RTAKlv R \. Aj . \J L,^-yAyWO\; "^ V^ 

(AdUvss ...1 bl . .NfyUxi^u<r>.\i., .3.1 



F.very item o* informntlon shnultl he cnrefully supplied. AGK sho.ihl be stnteii BXACTLY. PHYSICIANS should 
state CAUvSE OF DEATH in plnin terms, thrit It miiy be properly clossWied. The "Special Information" ?op p«p- 
«on« dyinft away from home should be ftlven In every instance. 




m: 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.o.ii.l ..t' Hi. I nil I- No. IK t*"-^; ssr;.^ H& I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' n/r(/ )^\^t/YY\l>vv \i 



290H 



liCgistered J\^o. 



3210 



i^^W.\ Depuiy f-!eaith Officer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccvtificate of IDcatb 

PLACE OF DEATH: — County of CJaTY- A<xax'C14,<'0 City of "^ /CL-'^v -Hxl^yv^ca^/C^O 



'¥k>. 




Lt) . at . \K.d\.kc^ I WiX. 



C^'>'Y\' St,; — — Dist.; bet." 



and 



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



FULL NAME 



..-.C^X^^^:V^•^ 




'Y^AXXy^.AJ 



PERSONAL AND STATISTICAL PARTICULARS 
(^ ft I COI.OR 



^- (00 I 

DA'i'i-: oi- r.iR rn tC 





^- 



!.._ 



ct 



OfMiUin 



as 



/Hon 

(Year) 



A < ■. i-: 



MEDICAL CERTIFICATE OF DEATH 



date; of Dl^ATH 




( Month) 



1 L . 

(Day) 



(Year) 



) V<i t .V 



MonUi.s OS. cil^ 



/)./ V. 



SINC.I.Tv. MAKRIl'D. 

\\n)()Wi-:i) ( >k i>F\"<)kti:i) 

iW'iitciii >i()oiaI ili>-ii.' ii.it ion) 



niRTitin, \»M' 

i Stat( 111 r<iiiiili vl 







1 Hl-:kI':nY CHRTTFY, That T^attenrlcd deceased from 

'.C; 190H to ..^......>.ALEDJr...l.L iQo'i 

tliat I last saw li-i-V alive on VlUrv^: ik 190 '- 

and that death occurred, on the date stated ahove, at ~ 
M. The CArvSl-: Ol*^ DI-iATIf was as follows: 



aAAi<x-»^lvli M^: 



VAJLCL'^^w-A 



UX*UX.«L/'>'\1.AA^ 



lUKTHT'I, ACK 

;)!•' 1 ATin-;K 

(StriU- or Coniitrv) 



MAin]-:N NAM1-: 

IJI' MOTIiEK 



r.ikrHpr^ACR 

()!• MO'niKR 
(State or Country) 



I 



J? (^ 




DrRATION Years 

CONTRIBUTORY 



3/0 fi ihs ^N 0. . Oa )'.' 



ays 



Hours 



.*(»*•* fc#^«#,,**i^,^#^»=«3.V».»-,., »-**»»„«, 



3fo)itlis 




OCCI'PATION 

Kf^idrd ill Sail I'laiU isi^n 



kXiXL. 



)'ifiis " .y/,)i/f/is (y\c-\ /'"' 



V.v 



nURATIOX rears 

( SIGNED )..LLUVc<LnQ'Y 
^CV- lb ic,oH ^ f Addressin,w4 11 tL iL^U 




I^ays Hours 

M.D. 



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



Former or 
Usual Residence 



riii', AHov}-: srA'n:n i'kksonai, par ticci.aks ari-; trih to tid" 
HKsr ()!• MY KN()\vij-:i)c.K AM) in-:i.ii;p 



( In fo; niant 



c 



\XjXv\ \)\aX\ 



\ 



\<1<lress H. I Jt 0% V^AlifUk^ UAuUX/>rVy 



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



fiow long at 

Place of Death? Days 



I'l^CK 01* niKIAI, OK RKMOXAF, 




& 



rXDl-.R TAKKR 



M>A^ 

Lcul<x^Axi.U V 

Ad(iress . W.3...U axXi^-o . at 



DAIUlcif III KiAi, or RKMOVAI, 



t?^-^ '^^- 190H. 




\,^jj.. 



^' **• Every item of informntion •hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be ftiven in every instance. 




% 






U' t 



g 


if- 




i 






' 






1^ 








"■■ 


1 


|;| 


P ' ' 


i 


II 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.oai.l '•( U.alth I- No 1^ ■5'*f^'^» H^'tl' C, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((h' Filrd y 




■v n I'-io^ 



Registefccl J\''o. 



3211 



,Cr\A^A^o 




/\M^ Deputy Heaith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



dcvtificatc of IDcatb 



( "U. S. 5tan^ar^ ) 



^ 



PLACE OF DEATH: — County of C'-CV-ru J.\-CX.> v^cuicv City of C'/<X>-u JA„xx>vec^cc 



No. blH " ".^ 0-vv>-o^'vcL St.; .& Dist.; bet. SkAx^cL and 

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



FULL NAME 




T^J 



X-trp^i 



t 




>j.\ 



PERSONAL AND STATISTICAL PARTICULARS 




\x\Xjl 



lol 



Ctx 



MEDICAL CERTIFICATE OF DEATH 



vK^, 



i).\ri'. t)i- I'.iK Til 



Aci-: 



(Month) 



3-S 



)'rat . 



iDav) 



M.»,fli^ 



/lis 

(Year) 



D.tv. 



si\r, i.i', M\Kkn:i). 
wiix >\vi':i) OK i)i\'oKti:i) 

iWiili'iii sofial ilrsij.'iiati(>u) 



? 



HiK run, An-: 

(Statf or (.'oniitry^ 



NAM»-: OI'* 
F ATI! 1:K 



lUk'nnM.ACK 
<>i* 1 xriiKR 

'Sl.iti or (.'oiintry^ 



MMT^vN NAMK 
nl .M()Tni-:K 



Hlk'rHIM.ACK 

OI' motiii:k 

(Slal< oi I i)iiiilt\) 



Llc^^' 



C^^LV/COU 



n 190 H 

(Day) (Year) 



(Moiitli) 
I mCKI'HV CI'RTII'V, That I atteiuUMl decvased from 

: "190 to . : ■ ■ 



that T last saw h 



alive on 



I(>0 



and that death occurred, on the I'.ate stated alxn-e, at 
.—^ M. The CAT SIC Ol- Dl-ATII was as follows 

^ J /VCX/X>tvUvA CrL a^VLvAlX...,-. 

\.W/c.v<<:Ll 




IJIRATION Yrars ,.. MofitJn 

C( )NT K I lU'TOR V „.„.._„. 



Days 



Hours 



-• M* « *^ »_#*>»«■ vfi ^1 



I^IR ATIOX 



XS^ 



i-^ 






^Ar-CC.4_4->OLKi 



^ '''''' ^ p^ ^fotiths Pays //ours 

( SIGNED )..U^<<rvviL>v i AIj.UJ.'IjlIol',,:^ M.D. 

,V) Uxril TQoH (Ad<lress) LvX-CrV^JUU V 



"V^^^IL-*- 



SPECIAL INFORMATION only for Hospitals, Inslitutli^iV, Transients, 
or Recent Residents, and persons dying .may from liome. 



h'e'^idrif ill Still /'itiinniii 



) 'lil ) c 



U. iif/iy 



l\l 



\'\\V. AHOVK ST All" I) I'KKSON \1, I'AK iliri.ARS AKi; TKri-: To If! I' 
Hl-IST Ol' MV KNOW 1,1; I )(■.!•; AND \\V.\,\V,V 



(I 






f \.!.1rr<* 



Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



^,ACH OI' nrRIAI, OK KHMOVAI, I DATj; „f HruiAl. or RKMOVAl, 
rNl.KRTAKKR JvOlXxM ^^ ot ^XXXtX-TV 



IS. B.- 



-r.very item of informntion Hhouid be cnrefully Huppllcd. A(iK Hhoiild bo ntnted KXACTLY. PHYSICIANS should 
• tnte CAUSE OP DEATH In plnin tcrmH, that It mn> be properly clanfilfied. The "Special information" for n.r. 
«on« dymft away ?rom home Khoiild be ftlven in evory inntance. 



•< %»ymt-tn ' 



ir 




JkT 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H..:.i.l of Mt-allh- »■ Nn i> ^-{.^V^' ^'^^^' ^"' 




m 



i i 




\J 1^1 



'\>\A 









REFER TO BACK OF CERT IFICATE FOR INSTRUCTIONS 



Be<!Lslet'ed ^^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 5)catb 

( X[, S. 5tanc>arC> ) 
PLACE OF DEATH; — County ofQCL^A,' ^Vou^^-C^c^iy^:^ City of C)<a.^y^ oAxXtj^-vCaA^CX) 



No. \2>n u>\jLx/>\' 






St.; I 



Dist.; betAJ OaJk ..............and LcM^uia. 



( IF orATH OCCURS AWAY FROW 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. / 

m 



FULL NAME 



\^JX{X\/r\^JL.S}LoJhJULSb 



XJi 



si;\. 



PERSONAL AND STATISTICAL PARTICULARS 




a^ 




I» All'; ol" lUK Til 



\r.v. 



iMMlltlll 



ot> y.-ais 



(Day) 



M<n,1h> 



(Year) 



J>a\. 



^I\< .I.lv M AKk Ii:i». 

\\in( >\\j;i) OK i)i\nKC};i) 

'Utitfiii soi'ial (ltsi}.<n;ition) 



HI Kill ri, AOl-: 
'Slate <>i i."iMiiitr\-^ 



NAM1-: OI' 

I" ATM i:k 



lUK'iiiri.ArH 

n|- lAIIIKK 

(State (>i I'dMiitry^ 



MA 11)1-: N NAMH 

Ol M()Tin';K 




MEDICAL CERTIFICATE OF DEATH 

i).\'ii": Ol' i)i:\ III 

ife. 



IW,. 



(Month) 



(I)av) 



I go 

(Yfnr> 



I UliKIUJV CI'RTIFV, That I attended (lerea.sed from 



M.\.cy: i.D Tyo'i to xJLilur: Life Tgo't 

that T last saw h JL^u alive on !uLC\nr....„.t.^ 190 '. 

and tliat death occurred, on the dale state<l above, at -5 30 
•il... .M. The CAISIC OF DI'ATll was as follows: 

)Or^^.^-'^:IU 



.^!^*/Y\JU^^ CfV sJb^ 



I 



urK rni'i.At'K 

Ol" "Mnrm^K 
(Slate i>r Country) 



\>^ 




OCCUPATION 



fc CKA.<udR_uivtNJ 



DL RATION • Years Months 4> Days 

CONTRIIU'TORY L\.!Lolcv^.^ 



Hon 



rs 



,\<:^C!C\t;,t,^^ 



Dr RAT ION Years Mouths Days 

( SIGNED )....m.M\. LIvoxJU 

^W n 190H f A.ldress) :^l Vl (V^A.MLii dt 



Hours 
M.D. 



Special Information only tor Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away Irom fiome. 



Former or ^ . "V^ 

Usual Residence 



'^\'\3. 



\JUm//. 



rlt. 



Kf'iiir,! in Wiff /'i ii in 



f-i'n 



I ) ra I < 



Af.>i/f/i^ 



/h, 



I" 111", \linVl'. srATllK I'KKSONAI, r\K IHll.AKS AK1-" TKIK To T H 1 ' 

liUsT ui- MY ivNowi,i;i)(".H .\M) in;i,ii;i' 



( Infill niant 



I 



AX. 



(A.l.lress 1 3. Tl d>V A.X'Y\; 01 



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



How long at 

Place of Death? Days 



ri,ACK Ol' nrRi.AT, ok ki':movai, 

^0 



VU/^i-yKJA^ 



A.\.^^ 



i)Ai"^;or HiKiAi. or ki';movai, 
vTlrLr Xb T90M 

(AC.lress. )^ H 05 (j frU>LU.. ..Ml. 



l^- "• livery item of liiformntton should be ciiretfiilly Hupplietl. AGE shoulil be Htateci EXACTLY. PHYSICIANS should 

HtHtc CAlISn OP DEATH in pliiin term., that it miiy he properly clussified. The "Special Information" for per- 
sons clylnft away from homo Hhoiild be Jitiven in every instance. 



:4 



■JJ 



•» 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

)!,:,,.lnf ii.Mhh I No ,. r.:r^^^::£i,HS:I•C^ REFER TO BAC K O F C E RTI Fl C ATE FOR INSTRUCTIONS 



Dale /vVfv/, XlUv^^ l^ lOO'i 

\,^^^^ LtvL^ Deputy Health Officer 



Re^isfercd J\^o, 



8213 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Xl. S. StanC>arD ) 
PLACE OF DEATH: — County ofO/C^-yv C; AXXa^-a::aa c c City ofOxx^^^V J Axxovx^c^Jl^c c 



'No. 



^0^ 




St.; 



Dist.; bet. 




and druTV 




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



n 



FULL NAME 




aaaX VJuctLi' 



K; 



PERSONAL AND STATISTICAL PARTICULARS 



SI.X 



DA'n; ()!• iuK 1 II 





Coi.oR \ j\ 




I Mniith) 



lb 

(Dav) 



iXl'} 

(Year) 



A ( ; K 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol' DKATH 

1,^, 

(Day) 




I go 1 

(Year) 



ioX 



)'i'ii I . 



M,»tlh.- 



Pa V: 



SINT, I.l' MAKKIl!!). 

Wlix )Ui:i) ( >K DIX'OKCKn 

'W'litt in social (i<>-iKiiatio!i) 



IWk'lll I'l.ACI-: 

'Slatf MI ("oniitrvt 



I A'l hi;k 



nik THiM.ArK 
<>i" ia'iii}:r 
(Stall- or Country) 



maii)i-:n namk 




A-^^AAxX^n^ 






(Month) 
I Hl'Kl'BV CI'RTIFV, That I attended deceased from 

LLlw^^-t. 190 (. to Li^Ugv: I9i igo M 

that T last saw h U . - alive on \rW\^ i% igo 'i 

and that death occurred, on the date stated above, at 5" 
LL M. The C.VrSlv OF DIvATlI was as follows- 

sX<::A.Ajt^ yS^V^r'-v^.^::^'! 




DURATION 



) rars 



A/oui/is .^ ■ Days Hours 

COXTRIIu:T()RvQu:urv^Aj^JU.a^ 






^ 



( 



Fuu'nii'i,A('i-: 
Ol" ^:<)l•H^:k 
(Slat>- or Country) 



oCCTTATlOxfN 




% 



/ cars ...-. 

J Axxjj ..yj. 



Mont /is 



Days 



,1 



DTRATION '' y,'ar^ 

( SIGNED ) .. J .4\JL^ ..|JU.A.a/a/v^M. 



g^ B rc>o'. (Ad.lress) IblXO^Xhti ^t 




Hours 
M.D. 



?^^9*fl^. "^fO'^^'''A'''ION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



.1A^;////« 



l),i 



■\\\V. AHOVIs SrATl-.I) I'Kk^ONAI, I'A kP IC T I. A K S A k }■ Tkl l-" To Tni' 

jiivST oi- MY kn(»\vi,i;i)(;k AND iji;m)-k 

(iTifunnant O-^ ^. VJU^^LijtV 



( \(l<lr«-«.s 



S'^S 



ClL.J 



i 



at 



Former or 
Isual Residence 

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



flow long at 

Place of Death? Days 



(Address ik'^iS 




DATK of III KiAi. or KICMOVAI. 

^^^^^5\^ 9>0 T90H 



ri.ACK OK lUKIAI, OK RKMOVAI, 

rNDi:RTAKKK V ' ^ vAaxhu*. xA V^C) 

'Vxx^JkjLt'. c 



IN. B. 



^ZlVzl^^Vof^Tx^^^ '': '""l"."^ r^^"*^;*- ""^^ ^'^"'^ ^'^ "*"*'^ exactly. physicians should 

Btate V.AIJ5,L Oh OEATH m pl...n terms, that it m«y be properly claiislfiecl. The "Special Information" ?«r «-l 
«on« clyinft away from home should be ftiven in every instance. intormation for per- 



t 



i-i 



f 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



HoMr.l .>{ Hi;.Uh - I' N.. i> ^X^:^- "''^•'^" 




/>a/r /•V7(v/,.'\ricu^VAJUA^ Q H^OH 



Megi.stered .A'*o. 



321 4 



,^1\XAA 






■'^' 



Deputy HeaJth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDeatb 

( XX. S. Stan^arC* ) 
PLACE OF DEATH : 7- County of CJ/CO^ ;v<X ^ v_ tLA^CL-^City of O CL/W J /v<V>a^Ca^<l c c 
ff^,LvXu, ^"^ Lctu^aTLu. Ob^-^i^Wct.aljSt.; Dist«;bet, and ~ ) 






(I r DEATH OCCURS 
I F DEATH OCCU 



S A/*VAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
RHIED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




OlVLu d 




/ALKa„..,„. ,,.....„., 



SKX 



PATH or niR III 



PERSONAL AND STATISTICAL PARTICULARS 

COI. 




oSjl 



'■°"Uj1 



UUL 







(Day) 



./%-S..<^ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF Dl.ATH A , 



AC.K 



\ ^ )'<•(//.> o 



.V< '»////> 



3.H 



/)</ y.s 



W F I )( » W !•: I ) OK I ) I \( ) R I ■ 1-. I ) 
IWritf in mkmmI dt vi<.MKtt ion I 



lIRTHPI.XrK /^ K 

Stiitf or Country* [ \J 



NAMK 01* 
FATUHR 



niRTHPl.ACK 

n\- I Ai"m<:K 

(Statf or Countrv"! 




/C K^^^^JL»^^YvO a'X' 



- XL /Qo H 

(Month) fOay^ (Year) 

I H1';KI':BY CI<:RTIFV, That I attciukMl deceased from 

dJ^^ti 10. 190 H to (rUlV- li Tcpl 

that T last saw h*-^ ^ . . alive on \jL\.,<r\^ I lt> jcp H. 

and that death occurred, on the <late stated above, at ^ I 
\I M. The CAISI-: Ol" DlvATII was as folLnvs: 



.\A»<XjO^>U<iAAX-^.^<^ 



DrRATION }'(U7 rs 

CONTRIIU'TORY 



Mouths - Days 



Hours 



mmi)i;n NAMK rir\ ^ jT 

()i- McyrnKK \0l) ^ \j 

)iX)\Jj^O^^ i. 

\ 



HIK rUlM.ACK 
01 ■ MOTHKK 
(State or Country) 



OCCUPATION 
Re 



DURATION 



(SIG 



NED ) ...i„.......yL.. m <Xh 



Pa ys 



iH 190 H (Add res 



<X\,t 



r.-ss) LCU.4^ L^ fe^^l 
5N only for iMspitaJs, Institutions, Trar 



Hours 
M.D. 



sidfd ill San I'l tiin ist'o ^ )'rtii.< 



^rn„fhs 



fa) 



rm*. AHovF, sTAii-n pkusoxai, i'\R'ricri,AKs akf: I'RrF: to Tni<: 
uFsT oj" ^Lv KNo\vi.i:i)c. f: and iu;mi:f 



[Informant O-OO \J ^-V/CXAX) 



'\M 



rt*»<s 



N. B.- 




'VLo ob^^l^A.ioLi 



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

Former or Q (nq il , ^ ^ '^ , How lonq at 

Usual Residence a u i 0\Jc/aVvvu OX. Place of Death? I'Ai^i.L..; Days 

When was disease contracted, y ^ 

If not at place of death? 



I'I,ACK Ol' niRIAI, OR KKMOVAI, 




i)Ai;;^F:or ijiriai. or rf:movai. 




(Address [\'h"l \f)X^^XlX^,\JrY\. s\± 



-Kvery Item o* informntion should be cnrefully nupplied. AGR should bo stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that It may be properly classilfled. The "Special Information" for per- 
sons dylnft away from home should be i^iven In every instance. 




WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD 

n-irir<l of MriiUli !•■ Vo. 1!; t'^s^TSi: \iSc\' Co 



1 



RETER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l^OH 



'C<,CC 




Registered JS^o, 



32 1 5 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( tl. S. StauDarC* ) 
PLACE OF DEATH: — County ofCvcXA^ JXaywcuvct City ofCjCUV\/ J AXX/rvcuLeo 






No, sso M iVc^.^i 



V..C ■1^ 



St.; i Dist.;bct. \AX 



and 1 iYVC . 



C "^ D«^*TH OCCURS AW*Y FROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION- \ 
V .r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STReIt AN D NUMBER ) 



) 



FULL NAME 




GIVE ITS NAME INSTEAD O 



PERSONAL AND STATISTIQAI. PARTICULARS 




'^^JC. 




± 



^>:^.V^ccyA; 



0— i. 



si:x 



DATi: ol I'.IK III 



I'OT.OR ^ 




MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH 



Moiitli) 



iDav) 



(Year) 




(Month) 



fl)aj') 



I go I 

(Year) 



AC.K 



ae^ 



I JIKKIUJV CHRTIFV, That I attemlecl (leceased from 

190 ' to rrr——rrr—r-~——-. 



that I last saw h 



alive on 



\'rai s . 



Mi'nlhs 



D,t\ 



^FM". 1,1* MAKUIi:i) 

uiix )\yi:i) ( »k i)i\t »K(}:i) 

i Write ill <i)i-i;tl <l<«iij.rn;it i.iii) 




lUkl'Ul'I.AOK 
IStatf i}\- Coiintryl 



NAM1<: <)J 

FATni:K 



>uuk 



^ <» 



<Xjy\j AxXy^vvxiA^/tL o 



aii.l that (U-ath occurred, on the date stated above, at 
^^Y" ^^' '^''^'A^''^'^^'' ^>l' DKATH was as follows: 



T90 
190 



..vhx^^,^VA.U^....„.,.... 




voJt ,<K,>Ui 



!*«»** J(#k*««S^ 



XX/^\^.Ju\ 



HIKTMI'I.AiI': 

Ol- 1-AIMHK 11 

(State or I'ouiifrv) 



MAIDHN XAMK 
01- MOTlIIvK 



nTRTrTpr.ACK 

<»1' MO'IMHK 
(Stat<- or Coiititrv) 







r 




y^^ 



DIRATIOX Yvai's 

CONTRinrTORY 



Man //is 



/)ays 



Hours 



*M*\-*-^'^**i:m< 



crVAnAX- 



-C>\jJux^»axi. 



DIRATIOX >V'^/--v^ .7A;„//,., 

( SIGNED ).U\..Crv^aA/ J-Uj-^XLLxAvdL 

^^^^^^ n iQoH rAddn...-> UvcmjiA:^!). 



M.D. 

-v^.i 



t^^^iilfd ill Sav /'i, 111. ism X '^ )r,iis "^ ,1A-;////c 



/J,/i 



.■^_ 



ini: AHovK sT\ii;i) pkksonai, tar ruri.AKs xri-tkck t<> tiik 

rx.hiress i^q- 2)aJL di 



«r?^^9'?^."^fOR'^'^"'"ION only for Hospitals, Instltutbbk TranslfnK 
or Recent ResUenfs, and persons dying away from home. "^""''«"«. 'ranslents, 

Former or 
Usual Residence 

Wlien was disease contracted, 

If not at place of death ? 



Hew long at 

Place of Death? Oays 



ri.ACH OK niRIAI, OK RKMdVAI I UXTV ..( „, ' ' 

(JJV) f| /^ * < NAJ, I I'AIK(,f HiR.Ai. or RHMOVAI, 



N. B.- 






should 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



f 



; 1 






*M 



fV»ar.l ..f M.-.-iUh -I- Vo !■= -i-^-.'TKr-^ H5tl' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Jtlegii^tered JVo, 



3216 



huh- Filcil. MVcvo/r^xiv^'v i^-l 10 0\ 

\ i 

(X.<s^LU^ cLL\K Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 



{ XX. S. StanDarC ) 



PLACE OF DEATH: — County of 



(D 



No. 5vl ,..JX'>\„.t.Avr\.- 



4 (^ 

'/Oy>>j ,ivoL/wOui.cc City of O/Cu^x^ Jjv<X^v^a.^^oc 
St.; H Dist.;bct. i^ Ur and 



^7 
I 




(IF DCATH OCCURS AWAV FROM USUAL 
rF DCATM OCCURREn IN A HOSPITAL 



RESIDENCE GIVE fac 

OR INSTITUTION GIVE I 



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



FULL NAME 



A 






D^yy:xJUi 




PERSONAL AND STATISTICAL PARTICULARS 



SK\ 



I iVowLt 



COLOR 



Xv{\AAJj 



n\"n-: m- imk rii 




(Month) 



(Day) 



A^.^. 

(Year) 



ACK 



Vfar." 



Months !^ Pan 



< I NT, IT* MAKHIKI) 

U IDnWJ'l) UK IM\nkr):i) 

(Write ill *^«KMriI (l(>.i^'iiatii>ii) 



, fVcuwu-^cL 



( St;it<- or Country) 



NAMl". ol" 
FATHl'K 



RIKTH PLATK 
f)l" I ATHKR 
(State (ir Country) 



MAIDKN NAMl", 
OI- MOTUKR 



nTRTTTrr.ACE 
()»• MorilHK 
(^tatt or Country) 



r A ' 



MEDICAL CERTIFICATE OF DEATH 

DATH ol I)1;aTH 

^Day) 




(Month) 



190 H 

(Year) 



I Iir-RKRY Cl-RTIFV, That T attcn.kMl deceased from 

: " 1 90 ■■j:.-.....q. to . ' 

til at I last saw h ■'■ alive on "— — — - 



190- 
190 



and that death occurred, on the date stated above, at 
rrn-r- ^r. The CATSLLOI- DIvATH was as follcnvs: 

AJ J!r\X^tV\./a^\^ Vl.AAJt:T>av0^rvoJU-^'i 




DIRATIOX Ytars Mouths 
CONTRIBUTORY 



Days 



Hours 




OCCl'PATIOxO , . * 

/yesiifrit in :'iiu /'> din iM'ii o\j )'iui> 



DIRATIOX 
(SIG 



}\\irs 



J/'ou/As 



^ 



NED)Ur\^rnji>\; 0.ifi.U).ljLLx/> 



/^(O's Hours 



v<:L 



f^ IS 



Cl 



U)oM ( 



A.hlress) Ur\Xn'\JAA ID. 



M.D. 



r\-CX 



SPECIAL INFORMATION only for Hospitals, lnstituM)h's, Transients 
or Recent Residents, and persons dying away from liome. ' 



Former or 
Isual Residence 



Mniiflu: 



nuvs 



VUV. AHOVH STA'n:i) I'KKSONAI. I'A K'lIC T I.A K S ARl'. TRIK TO THH 
HKST or MV KN(>\VI,i;i>C.K AND MKMKF 



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



flow long at 

Place of Deati!? Days 



(1 



nfo:inatit C>JL&-V.YC^ L\J J^AAAyVVJU.! - 

ll A) -t^WlAhOu t 



(Address 




OK HrRIAI, OR RKMOVAI, DATICpf H.RIAI. or RKMOVAI. 

VA^)^^^^ I Aruvj- 



9^Cj T90H 



(Address, l.m 






N. B. Rvery Item of Information ahould be cnrefully aupplled. AGB should bo stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it muy be properly classified. The "Special Information" for par- 
sons dyinit away from home should be ftiven in overy instance. 



\M 



I < 




.1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



*t 



Ho:.!'! ..f H. :i!t!- I V. : - '^^j rx-;-i.:- V.ScV C^ , 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(f/r /'VAv/, \JX^^^xoTJM;v [^ .l^JO'i 



Registered J^'^o, 



3217 




\^ 




X'M 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "Gl. S, StanDarC» ) 
PLACE OF DEATH: — County ofC'/a/^x- 0.\.ia^-k^.eui, Cl City of Cjo^^ru>^A,<XAA.cv4. c o 



'No. 



.Lctci^ L^o^viu fc (y<Ll'v\-tculi St. 



Dist.; bet. 



and 



A /if death occAjns away trom USUAL RES I DENCE Gi VE facts called for under "special information" \ 

J V. IF death dlpCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



t 



<Z\\jy\^ LL.L 





si;\ 



DAT I". <tl' lUK in 



PERSONAL AND STATISTICAL PARTICULARS ^ 





.V 



bu 



(Mouth) 



(Diiy) 



.r%X[ 

(Year) 



ACK 



^3 



)'i\ll s 



Movlfis /></ v.v 



STNnT.K. MARK1KI>, 
WIDnWHI) OK I)IVt)Rli:[) 
(Wiitiiu -.iiM-i.'il ilt^ij.'^tKitinti) 






lUK rill'I.Al'K 
(Stiitf or rDUiitrv^ 



NAMJ-: t)l- 

I ATI! i:r 



nTRTTTPT.ACK 

oi" i\rin:R 

'St.ilc or Coimti y) 



MA !!)»•: N' NAMH 
»)I' MOTHKR 



luR rniM,A(,"i-: 

<»!• MO'IIMvK 
(Slate or Country) 



t 1 



U X\/'VYVCX-> 




MEDICAL CERTIFICATE OF DEATH 

DAT!-: oi" DICATH 

^r^ IS 




(Mouth) 



(Day) 



(Year) 



I IIHRHBV CICRTIFV, That I attended deceased from 



^^ A.H 190 M to ftV5\r..i.5 j^ m 

that I last saw liL > v, alive on ..yCV^^TV". I -b jcp . 

and that death occurred, on the <hite stated above, at S.SsS" 
.iJ„ AI. The CAlSlv OF Dl-ATII was as follows: 



' Cx,^"vAX>A.X^'V.<^'1L-<\^^ 



(y\Ji^.^>Jr\rY-^.Arlr>,^^.^<X^ 



occitatujnJ? q 

f\fsiilt'i! in S,ni I'l ,1 11, nrii c^L v ' ''" v 



I )r RAT ION -- Years -Moijihs 

CONTRIIU'TORY 



Days 



Hours 



DURATrON Years 

(SIGNED ) LU. 




Months Days Hours 

M.D. 




^^ 



jaaJUxX 



Months 



Hi) V. 



Til I', AUOVF, SPAT i: I) rKR^ONAI, I' \ K I" U' T I. \ R S A R l". TRri': I'l ) 1)1 IC 
IJlvST <)1- MY KNOWI.I'.IX'.K AM) m.IJl'.l-- 



ilufoiuiaut 



z.Q%. a<xa 



1 



< \d.h.-s VjJLuu ^ ^ . (JV) (saAv*wL<xI' 



or Recent Residents, and persons dying away from home. 

Former or 1 f_ 1 1 - () ** ^ 

Usual Residence UCrUwAxUx. YXjJ ■ ^ 

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



Institutions, Transients, 



How long at 
Place of Death ? 



^ Days 



lU.ACI-: ol- lURIAI, OR RICMOVAI, 

INDl-.RTAKl-R v.'VL^ULujL ^ Hx) KKAX^O^x, 
fAd.lress ^jblk.' ...1.^. jtk M 



DATKof liiHiAi, or KKMOVAl, 



Ul 



TQO 






N. B. Jivcry Item ol infornmtion should hi cnrofuliy Hupplicd. AUR nhould bo Htiited RXACTLY. PHYSICIANS iihould 

Htatc CAUSE OF DEATH in phiin terms, tlint it miiy l»c properly cinssified. The "Special Informution** lor per- 
i«on« <lyinft nwny from home should be ftiven in evory inntance. 



I 



I 



11,' 



ih 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l(():ii.l of II.:. 1th 1" No ir 1^-'?^^^;>4) MX: P ( 



l)(tl(' Ff/cff fML^xy^X/y^'x^ 



Ixhj 



IS 



IfWH 



Eegi^tered J\^o. 



3218 



1 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeath 



( U. S. Stan^arD ) 



\ % 



^ 



PLACE OF DEATH: — County oiOOuTxj JX<X^^x:.w. : City of C.' <Xtv vJAxx^YA^evA^^o 



<N 



o.^\'\ Jb^^VKX^Vd 



St.; ^ Dist.; bet. 




and b 




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



FULL NAME 




si;\ 



DATi: oi I'.iK in 



PERSONAL AND STATISTICAL PARTICULARS 





\x 



kXx 



kt 



(Month) 



\r,v. 



bOx )V(;».v 



SO 

(Day) 



Mntilhs 



./l.H.9. 

(Year) 



IH 



/),i 



SIN<.I.Iv M\KKIi:i). 

\vii)» )\^■I:^) «>k inxtiKi IvD 

iWiiti ill ^ociiil <1( •^i;-'ii;it ion) 




<uu 



niKTriPi.ACK 

'State or '."ouutrv) 



NAMK OP 
lATIIl-.R 



IURTmM,A<'H 

(»f iai"hi:k 

'State or (.'oiintrv^ 



MMI>1:N' NAMlv 

<>} M(jTni;K 



lUR'Iin'F.ACK 
<>!■ MO'IMM-.K 
(Statf or routUrv) 




i 

? 1 



d 



MEDICAL CERTIFICATE OF DEATH 



DATK ol- I 



:::::...ai 



(Montli) 



(Dav) 



(Year) 



I III':KI-:HV CIvRTII'V, That I atteiKkd (leceased from 

■,^...— 190 to • ' ■ 



that T last saw h 



■alive on 



190 



and that death occurred, on the date stated above, at ol 
aJ M. The CAISI': OF Dl'lATlI was as follows: 



X/^ry^..<C^\X^^\.OuoJL. 





)V<r>.* iD .^fonf/is D(7\s 



nt'RATlON )\uirs 
CONTRIIUTOKY 



ISIoiitha 



Da \s 



Hours 



DTK AT ION Years 



Hours 
M.D. 



Mofiths Days 

( Signed )\j:h^^-^\, j . VC. U)..XsLLx/>^-di... 

V IUKJ' l.°l. TQO''. (Ad(lress) V.^^^.(rV^JL^^ UJ(!^ A,c.il 

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



Kfsidfd ill San rianrisro 



Illl', A1U>VK STA'rKI) PHRSON'AI. I'A RTICn.ARS ARl-: TRUE TO THE 
UHST OF MY KNOWUKIXiH AND ni:MKF 

(Iiif..nnaiU M «V\^. OftA\J^^ 

(AM.lrcs« a \\ feo^^Aj^AJ^^ dt 



Former or 
Usual Residence 



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



How long at 

Place of Deatfi? Days 



TQO'i 



PI^ACK OI<_Bt'RIAI. OR RKMOVAI, DATE „! Hikiai. or REM()V\I 
UNDERTAKER \yi\X><,^ U- \D 



(Address .. 




crru. 



dt 



N. B. Every Item o? information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information** for per- 
sons dying away from home should be glvon In svsry Instance. 



n-i 



!'(• 






I mm 

i 

lii 

:l'rl 



till'! 

IP 





i.l 



I- 





iH 


.'<! 




1 


1 


} 


i 






li 


ft 


k 


Ifli 




IHH 




II 


m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ii..anl ..f Health K No i. ^-g^^^H^l' ^ ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i) ^ 




xo 



nwi 



Registered J\i''o. 



3219 



I^v^I^K, Deputy Heaith Offi-^rr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( la. S. StanDarD ) 
PLACE OF DEATH: — County of^O-^rX; .\<v-^C^AC<i City of Oxv^^j Axx/w<tAXLt^o 



'No. 1^C)1 





.St4 ^ Dist.;bct. n[i\<X>:i. 




^try^AJO 



and 




V<xl; 



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



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




_^ <i JUYY\.<XAX 

DATK tU' r.IK in 



\XjA\KAJb 



ACK 



13. 




Motith 



(Day) 



/ t>.3l^ 

(Year) 



) I'a I . 



X 



Muut/is 



(Year) 



I hi \s 



«IV('T,H MARRIHO. 
WIDOW HI) «)K I)l\«)Ki"HI> 

(Wiitriti '^(u'ial "It'iiv'iiatiiMi) 



niRTflPT.ACK 

(Statr or I'ounli y) 



NAMi: Ol 

V A T 11 1: R 




J ^CcLtrv\.^-^xL 




^'V\^^r\A 



nTRTIIlM.ACK 
Ol- I AIMKK 
(StHtf i)r Country) 



mah)i:n namk 

Ol' MOTHKK 



HIK'lMl'I.ACH 
Ol- MoTIIKR 

(Stai-- or ro\int' v) 




Ml^^^rvX) vj X/V\J2.AxtXAxL 




V>jLA-^t 



1 



YV^WOAV 



%.oS^^ 






MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATII A- 

,: ^j\c\C \\ 

(Month) (Day) 

1 nivRHBY CIvRTIFY, That I atteiukMl deceased from 

M^crvr:....^.... ,i^?Ht. to vh^(JV^ \%. igon 

that I last saw h-)L^.. alive on VTUsxt I5 tqq ': 

and that death occurred, on the date stated ahove, at o -oO 
0^ M. The CAlSJv Ol- DlvATII was as follows: 

\J.ot:v\JL-:>^J:/cx.L 



DT'RA'I'ION ^ Years Months Days 
CONTRIIU'TORY UoLAJk-t/^Oo^xx, 



Hours 



/hivs 




XKX^Ayw^KJX: 



OCCfPATION 

Kfsntfif 1)1 Son /'i iiiii ism ^ )'r(its •- yfnutfix T^ . Ihiy^ 



TH1-; AHOVK STA'n-:i) PKKSONAI. 1" A K licr I.AKS AR1-: TRTK To TMK 
HHST Ol MY KNOWI.I'.DC.H AND in-;M}-:K 



\\ nfoiniaiit 






DURATION Years ^ Mo fit /is 

(SIGNED ) cLojuUvxs. US. abAA-\.d 

MWt IH '*U)o\ (Ad.lress) 'ICib Qa^IUkj 01 



I /ours 
M.D. 



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



Former or 
Isual Residence 



How long at 

Place of Death? Days 



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



ri.ACK 01-" lUKIAI, OK RKMOVAI, 

UNDKRTAKKR ^ (HxLft'^v^V J 
(Acl(hi-ss ^H^sS 



DAT}': of Hi KiAl, or RKMOVAI, 




N. B. Every item of informMtlon should be carefully nupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home should be ^iven In 9\9ry Instance. 



w 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i 



f ' 

I 



Registered J\^o, 



3220 



Dale /•V/r^/.Mltv-t'YYviKA) AO HWi 

itrvw^ „LiL^., Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( tl. S. Stan^arC> ) 
PLACE OF DEATH: — County of Ooyv^' J.^vay>x-i,Li ccCity of OxX/vv O.'UX/Yvev^Ci. 



M3i^ f 




No. ^?>C) 'X J (rW-Cr-ov Sl*.....'i D;st.;bet. 

TS C« 
TS N 



^ 




O). 



and b aJv 



(ir DEATH OCCURS AW»V FROM USUAL R E S I D E N C E G I V T FACTS CALLCD FOR UNDtR "SPECIAL INFORMATION • '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





"W /\^Vl lL. 



DATi: <)1 IMKIII 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.OR 




A 




\i.V. 






\ I )>(//> 



lb 



, a 

<Day) 



.^f.'ulhs 



A%13 

(Year) 



Pit v. 



SINT.I.K MAKkll-.I). 

wiix >\\j:i) (»k F)i\oKii:i) 

(Wiitc ill NDcia! <l<-*>i}.'iKitioii) 



lUR rm'i.AOK 

'Stiiti or I'ountry) 




AXX^VA>->ui_ 



S- 



I I 

i! 



s > 



I, 



NAMJ-: <)l 
FAT 1 1 IK 



THRTMPI.ACI' 
(»I I AIIIKK 
(Slatf «ir Couiitrv' 



MAII)I:N NAMi 
(>l MOTIIKK 



lUkTHI'I.ACK 
nj MnTllJ'.K 
(State or (.'oimtryl 




MEDICAL CERTIFICATE OF DEATH 



%5xr 



(Month) 



(Day) (Year) 



I lIl'RIvHV CI'KTII'V, That I attended deceased from 

.yX<j:>j^. ..,1%. 190H to .ttw^t. 3.0 up H 

that T last saw hXH; alive on .....NTLiTSJ^ I'l 190'! 

atnl that <K'ath ocettrrcd, on the <hite state<l above, at A 
Uw M. The CAl'SIv Ol- l)i:.\TII was as follows: 

CJjL/>WLa 



^ 



or RATION - Wars 
CONTRIIU'TORY „. 



i^Io)itln 



Days 



I /ours 



■»*-% •.-^>.»***:«*iL*»^4^rt #*»*#**#♦*»«• • • . 



DURATION 



i. 



Years 



i\fo)iths 



( SIGNED ) 0-Ui Vj. V3_ 

nTUvT- '^^^ l()oM (Address) HCH* % 



Pays 




SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons d>ing away from liome. 



OCCrPATION 

Kesiilrd in SmH Fttt»n'sri> I )'>lll^ 



M,mlln 



n,i 



TUlv MU)VH STAII-.D I'KKSON AI. 1' \ K I |C f I.AKS A K l". TK T K T< • VW)-. 

nivST <>i)JiIv KNowij'ix.K AM) in:i,ii:i-" 



(I 



\,i.ir.-s S?iC)'!l IcrUUrvTvO 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 




DA'PKo! Mi KiAl, oi K1:M()V.\1, 



at 



•: <)l- ItlKI \1. OK Ki;:M()\ Al, 




^\i 



I90H 



IN. B. r.very item of informiition should be cnrefully Kupplied. ACiB shntilil be stated F.XACTLY. PHYSICIANS should 

Htntc CAUSE OF DliATH in pltiin tcrmM, that it miiy be properly classified. The "Special ln?orinfition" for psr- 
sons dyin^ nway from home Khould be Itiven in every instance. 



>M 1 * 



itr. : 



u I 









tr.t i 





I 



w 
^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n.,n.l uf iK.Uh r NO ;. i^fS^u:!kV c„ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/c /w/r^/,Muiv^^^0b-Ov' 



SLO 



/.96>'i 



Begistered J\''o. 



3Q21 



L^op^ty He 



£4 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "a. S. StanDarJ) ) 
PLACE OF DEATH; — County of OCU^^X 0Xa.^rvCv4.CO City ofO/CX.nrv 0A.<X/WA2a^cc 
No. I'i^H vi)A,v.ol\.CL''v^<:XAv. St.; ^ Dist.; bet. U^u::^ -..■..-».^- and ^cL^d.u 

/ ir Dt*TH OCCURS *WAV FROM USUAL R E S I D E N C E C I V E rACTS CALLED rOR UNDER "SPECIAL INrORMATION ' \ 4 

Vy IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTklAO OF STREET AND NUMBER. / 'j 

it } h \ 

FULL NAME vLLAHX-CO. ^KlXa^J.i~lKc^ ....„ .„ 



) 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



_. OJL/TrX<xLl 

DATK <)I- lUKTU 



U}.Lju 



* 






A<". K 



c**-/^ )V,I>.v 



(Day) 



M.'ulhs 



.Uo 

(Year) 



1 

MEDICAL CERTIFICATE OF DEATH 

DATK ()» DKATII 




V*V.3^. 



Pa 1 .V 



SIM, I,K MAKKIl'.n. 

\\ IDOWKI) OR DIVORrKI) 

(W'rittiii social <1» si^Miation) 







nTRTITPr.ACK 

(Statf or Country^ 



NAM I'. OF 

jA'iM i;r 



TURTHIM.Ai'K 
Ol- lAPHKR 
(Statv or Country) 



mai!)i;n' n'amh 

Ol- MOTIIKK 



lUR rilPT.AOK 
Ol MOTUHR 
(Slatf or Coiuitiy) 



OCCUPATION 

Kfsiiird in Siui 1'} Dui^ro .•:.... fVdrx, 



yXK.^ 




_„0 JLh^' 




.<PJ- l*ii igo\ 

(Month) (Day) (Year) 

I III':RICliY C1{RTIFV, That I atteiuletl deceased from 

rxi 1 190H. to \rU>jrr:....ll T90 H 

that I last saw h-itA.- alive on .\rLC\r... .. l*^ 190 "1 

and that <leath occurred, on the ilate state«l above, at "^ 
^^ JU. The CAl SH Olv DlvATll was as follows: 

dJ xjxXi-JLX^^^^. L<r"v-vxxx/'. 




.«»••••■■ ■a«-4*-k^*k»3»«-4'> ■ 



DlRAriON )Vw.9 Months 'X Davs Hours 

.CcJLiLL)L^...iuliJLljL^ 



CC^NTKIIU'TORY 



<XVU 




.yr„nths 



Da 1 . 



'I'll).: Aiiovi: srATi-:!) rKRsoxAi, i'\r iumi.ars ari: TRri". ro vwv. 

I»1%ST OJ.' MV KNo\VI,i:i)C.K AND Ml'.Ml'F 



111 



foniiant JVxXxxX^v>^^O^^ru ^ KJULyy^Jh^-^LKjCt. 



DT'RATION ( Vears t I\ronths Pays I/ours 

(SIGNED) HtrVVW OcJLiLuj-iu M.D. 

MUj- iH 190^1 (Address) iDOXL^JUlcVAOA^Ot. 



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



Former or 
Usual Residence 



How long at 

Place of Death? Days 



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



IM.ACH 01- HI RIAL OR RHMOVAI. I DATK of Hi kiai. or RHMOVAI, 



% 



Y^w<X/-VX/ QjX, 



XXxK/y^^^oX ^^ ^y^jL i MU5\r a.D. T90M 

INDICRTAKKR ()v9 ojU;txJw ^U. aIo 

'^HwJy>\^^ 



(Address 



N. B. Hvery item of informiition should hv; oirefully Hupplied. AGH should be stated 6XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that U may he properly classified. The "Special Information** for per- 
Rons dyln^ nwny from home should be given in e\cry instance. 



1^1 




i 




WRITE PLAINLY WITH UNFADING INK — 



Jioiird utH. :i!th IN.. ,-. t!>-^«-_^:-t H.<vr (■'. 



/ )((/(' Filed , 




ao 



ivo\ 



THIS IS A PERMANENT RECORD 

REFER T Q BACK OF CERTIFICATE FOR INSTRUCTIONS 



Bp^istc/'cd J\'*o, 







^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( 11. S. StanC»arC> ) 






PLACE OF DEATH: — County of cW-aj Vo-^ k^^ ^^ City of U.UxLxyTv d\A, 






No. 



St.; ..- . >:...i Dist.; bet. 



and 



/ IF DtATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V C FACTS CALLED rOR UNDER "sPECIAt INFORMATION ' 'V 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



.N^CLAYViU^^ J^ 











I 



JyULx 



3>0 

(Day) 



(Vear) 



H 



igo 

(Year) 



ACK 



It 



) «■</ 1 



\ Months \ O 



Da \s 



^IV**I,K MAKkn:i). 
\VIl)i)\\ J.;i) (IK DIVoKrKI) 

iWiitcin >^i><-i:il (li<i(.'n;iti<>n ) 



niK lIM'I.At'K 

I Slate or Country^ 



NAMlv <M" 
FA 11 1 JK 



(I 








lUKTmM.A("K 

Of I Aiin:K 

(Stiitt or (.■iiiiiiti v' 



iO^j-rwJJ^ 



dJt 



■ML-' 




MAIDICN XAMH 
(H MOPHHR 



HIK'I'm'I.At'H 
()1 M<iTHKK 
(State or iNmiitry^ 







MEDICAL CERTIFICATE OF DEATH 

DATE Ol' I)1:aTH a 

\lW 15. 

(Month) (Day) 

I ni':Ri:r>V Cl-iKTH'V, That I attetKlea (k-coased from 

. " ; -. : - . 190 -r— r— to T9O 

tliat T last saw \\ rr~ — alive on ■!L..:i-vii;i»-.ji".i..i.; — —— T90 ~ 

and that death ocinirred, on the date stated above, at — 



M. ^'he CAISH OF DICATII was as follows 



.oUAXn-AJ-nf^.<iw'^^^.^. 



DTK AT ION Years 

CONTRIIU'TORY 



Mo)ttln ■■■ Pays 



flours 



I ) r k A T 1 N rears...'...-. Mouths 



Da ys 




Rfsidfif in San /> iiikim'h " )',-,n ^ Mnyith- 



l)ii\ 



\'\\V. M?i)\'K ST xri'.l) I'KKSON Al. 1' \U riiTI. \KS AK l', TKrH 
linST <>1- MV KNOW 1, 1:1 )(•.}•• AM) IW.l.Il'.K 



To Till': 



(I 






(Signed ) 

,'GV'^. V:l. i()o'\ ( 



S-^JJ\J 



Address) OXo-^^ixrW' L<XA' 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recfnt Residents, and persons dying away from l)ome. 



Former or 

Usual Residence n I "^-^ 



"A \ \ A How long at 
OUAxXA^<LAix^.dti Place of Deatli ? » .. 

Wfien was disease contracted, 

If not at place of deatfi? 



Days 



i;^ACK 01* ni'RIAI, OK RHMOVAI, I DATi; of Hiuiai. or RliMoVAI, 



INDllRTAKKK 






N. B.- 



ivery item otf infopm.itlon should he cnrefiilty supplied. AGE should he stoted KXACTLY. PHYSICIANS should 
tnte CAlJSn OP DEATH in plain termx, thnt it m»y he properly classified. The "Special Information** for psr- 
— s dyin^ nway from hnmu nhould he f^Sven in every instance. 



-\. 

s 
son 



i\ -I 






I ,: 
• t 



: t 



I i'ft.;| 



{'i t 



ir| 



> ' I 



» ' » 



< 1 






ifi 



WRITE PLAINLY WITH UNFADING INK 



H-.Mr.l ..nii:iltli- I- No : : -i-i-^-am^: V.^]' C 



if)(n 



— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CER TIFICATE FOR INSTRUCTIONS 



Begi.sfrred JVo, 



I idle /'V/r^/, N^U^M^T^x(^JL^J XO 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



W^ *? ■«<! 



PLACE OF DEATH:— County 



Certificate of 2)eatb 

( "U. S. StanDar^ ) 

ofO/O^^v^ J .^-<XA VCaA/C,0 City of O.-CWv/ ^.-Oy^vCvx^C:^ 



\i 



No. ^j'XO ^^-ic'TV>XA.'a/'WMX.^rAA><X) w\.n^S4»; o Dist; bet. 



w 



il 



and 



1JC'TV>V^WVV~\X/T\A><JU vyv 

/ IF DEATH OCcLrS *W*V FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPtClAL INFORMATION ' \ 
V IF DEATH OrtCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Ml 



FULL NAME 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



CLKAaj dA.XXyTv.Ltu. J -\iJ\A4 



u 



DATK «)I" III K Til 




JvUJl; 



AC.K 



I Month) A 



) III t s 



(Pay) 



M.'ntfi.^ 



/a OH 

(Year) 



I5> 



/>,/!. 



SIN» .l,i:. MAKKIl.I) 
WIDOW i:i) OK DIVOKIKI) 

iW'iitiiii si>i-i:il (|i si^riijitioii) 



Ky'^ 



niKTftn.ACK 

' Slatf t»r Couiiliy^ 








NAMK «)l 
I- A r 1 1 1-. R 



LU 




A^^O^TYX; 



HIUTHri.AcK 

<)i I Arni:K 

Statr or Country) 



MAini'.M N'AMi: 
{»!• MOTHKK 



!UK rm'I.ACH 

oi- M<)rni':K 

(Stall- or (.'oiintiy) 







r 1 1 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- I)i:ath A^ 

Mlcvr ...ii 190 H 

(Month) (Day) (Year) 

I in:Ki;i5V CI«:RTIFV, That I attendoil deceased from 

xl^UV^ .1.1 i9o'i to \lU\J:...ia 190M 

that T last saw h u >-v\ alive on •- ....„.SX4»4EW!r...iie.., 190 "i 

ami that death occurred, on the date stateil above, at 3L 
iX M. The CAUSl': OF DlCATIl was as follows: 

VwJlv\..«r>>,A>C ...^..<Ov.aX^VAwA.a.A. 



Dr RAT I ON Years 

CONTRIIU'TORV 



Moni/is •- . Days 



Hours 



DURATION Years Mouths \ Days Hours 



(SIGNED) )J. 3J. MIUx\l.v-',xJLCX.-ojt 
jfUxT- l^ 100 H rAddn^ssI bOb JVI 



OCCrPATION 

Kfsidfii ill Siiii /'rapu'isfn 






CjV^A.UXi 



)V-,f/A (o M<nilhs 16 /'<n 



Tin" MIOVK STAll,!) PK Use )\ A 1, I' \ U lini.A KS AKl", TKIK To I'lll-; 
linsr Ol- MV KNOW IJ'.IX.K AND Ml". 1, 1 1". !•" 



(1 






M.D. 

IH i()oH (Adilress) ipQb JXtOA^xM q1 

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



Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



ri.ACH OI- HrRIAI. OR RKMOVAI. j DATi: of HruiAl- or RHMOVAI, 

INDKRTAKKR wkxX^ NL.vD M iWvi/'VjtX) 

fAil.lress b'i b UJ O.y^'V^-^X^yt^t-Vv n't; 






>•. K. livery item of Informnllon should be ctirePully Hupplieil. AGE nhould bo stated EXACTLY. PHYSICIANS should 

Htate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information'* for psr- 
sons dyin^ away from home Hhoiild be iltiven in every instance. 



•H 



i 

I 



H ., 





■i 




t !* 







liH 



^ 



ll 



I • I 



i i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



|l..:,r.l ..t M. lit!) I' Vo i< t'-S;^»^r. lift!' Co 



I) 



(fir Filed , M Urv>C^'>0(>JL\/ lO,. 



V)0'\ 



Registered J^^'o, 



3224 




v\^ Deputy Heailh Officer 

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

Certificate of Beatb 

1 11. S. Stan^arD j 

PLACE OF DEATH: — County of^OJWj J X^X/WC/^^^CC City of 0/<Xa^ ^ KAX/\\^\Ji.^o 
'No. OIAAj MIV/> 



tr>A' 



St.; 



Dist.;bet. 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 OP INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME OxArv^o^^x 




.<lX 




JJ. 




V\i 



PERSONAL AND STATISTICAL PARTICULARS 

I C(H.(»R \ . 



DATl". nl- HIK III 



W 



Mciiith) 



MEDICAL CERTIFICATE OF DEATH 
datb: of DKATH 




(Day) 



f%'i 

(Year) 



AC K 



) 'e'H ; > 



Mo>ilhs I 



n<i vs 



SINCIJ* MAKkn:i) 
WIIXtWKI) «>K DIXOK^KI) 
iWrittiii •HiK-ial dt vi>.riiati"n) 



/>Vy>AXl'^JL 



lUKTIiri, AOK 
(SUitf or Coiinti v' 



Cy\X H I VoU^trrv K^oJ 



NAMK Of- 
FATMl.K 



U) 




HIK IHI'I^ArK 
<)|- I ATIIKK 
(Slate <»r Country) 







MAIDHN NAMK r\ /I 

Ol- MOTMl'lK .y 1 M 



.^^ 

(Month) 



....Ua..., 



190 '\ 

(Year) 



I Unr-IKBV CRRTIFY, That T attciulcd deceased from 

\)X.<r\r: 11 190S to \b-i3\r i.b igo M 

tliat I last saw h .«i' v. alive on vUor lie Kp ' I 

and that death (occurred, 011 the date stated above, at 3-30 

CX M. The CAl'SI': Ol- DIvATIl was as follows: 
nI rVxXA/V>wVvX'\AA-A 



-\.^VU. 



DTRATK^N 
C0NTRII51:T0K\ 



)Va;\9 Mont ha 



lURTHIM.AOK 
Ol- MOTMI'.K 
(Stat« or Country) 







nCCri'ATION 

h'fsiifnf ill Siiii I'l aiu isfo 



) 'ra / >■ 



Moiilh- 



( Da I 



\\\V AMOVK STA'D-.I) I'KKSONAI, I'AKTlCrLAKS A K !•: TKIK TO TMK 
lil-;sT 01 MY KNO\Vl,i:i)C.H ANI) lUvMlCK 



(Infcvinatit 



(\,i,itess (y\jt M rixXA><r'\ 




Days Hours 
XciAX tto 

-^ Years ^fonths \ Days Hours 

VjkyCX/i UJ - vJ <XA>\j M.D. 

UV'- IH Tc)o'\ (Address)>J OVt VIKovMrn. CclI 



DURATIOX 
(SIGNED ) 



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



Former or 
Isual Residence 

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



How long at 

Place of Death? Days 



PI.ACK Ol- lUKIAI, OK KHMOVAI, I DATi: of I$ri<iAi. or KHMOVAI, 
(Address v3 {r*\jt \Jf\>CUQ.Xrw LoX 



IN. B. F.very item of inform.ition should be cnre?ully Hupplied. AGB shoiiltl he stated RXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special ln?ormution*' ?or per- 
sons dyin^ away from home should be (Iven In every instance. 






r <■ 



v! 






i 



■^4 






4 



<•, 



:l 



fl^ ^ 



I 



• t 



» IJ 

I llfll- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



li. .,1.1 ..f llr.iMli I' Vc '^ ■*-?""!V^r) (U«t!M'o 



/)((/(' Filed , 





in 




LCv4^.r>.vl>Jl\' 11 10 (r\ 

Deputy Health Officer 



Registered JSTo. 




\> 



\ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

{ XX. S. Stan^ar^ ) 
PLACE OF DEATH: — County of Ocl^^v OAOo^vcaAC. City o{^Ou^\j OAxx/^vcuaco 



^ X '^ 



^T 



J^XuwLv '•^LtJ'V\yT\l.u flb CKt:\\AXa.li St,; Dist.; bet, ..:-r- — — — and 

IF DEATH occu^ *w*v FRoAi 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 ^Uv Q 



si;.\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.tiR 




<x,.^ 




XA^ 



u 



DATK Ol- I'.IKTM 



A«R 



(Month) 



(Day) 



(Vear) 



O .C% J ■/•</» v 



M.»,t/is .*•. Day. 



SIN(,I,I': MAKI<U;i) 
UIDoWKI) <»K l)I\i)!<ii:n 

(Wiitciii >«<Hi.'il (1( <i^'ii:iti<)ii) 



I5IK inri.AOH 

(Statf or OoiMjtrv) 




XAMl. <il' 

jATii i:r 



nTRTITPI.Ai'K 

oi" iArm;K 

'State or Count I \'1 



MAIDHN KA\fK 
<H" MOTIIHK 



IUK1M1'I,ACE 
(H- MOTIII'.R 
(State or Country) 



XAJ^XAX) 

? 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




(Month) 



j.a... 

(Day) 



(Year) 



1 IIF.R1-:HV CI':RTII'V, That I attended deceased from 

— to 




f^ 




that I last saw h 



190 



190 



— alive on •• 1 1 90. 



1 



and that death occurred, on the date state<l above, at 
"T— ^^T. The CAl'Sr: OF DIvATlI was as follows 

\Xx'\AjL<rvA.AXv^ L^/Ca^aJI^ 




? 




^Xs^Qsi 



OCCttpATlON J? n J 

h'r^itlri! in Win /'i tnn i.u'i) ' )'i'<ii 

Till". MloVK Sr \ I1:M I'KKSoNAI, I'AKTIiTI.AKS AKI; TRIH T« > TMK 
HHST OI- MY KNnWI.j; DCH AND BKI.IKf" 



Dl' RAT ION )'r(irs 
CONTRIIUITORV 



Months Days 



.•».*»•*« *-*^jt^^^«iha***0««>«M«#-P**»-r««»> ' 



I /ours 



DC RATION 



}'rars 



i\font/is 



^ ^,(E.\A).-Ua.v^ 



( Signed ) ux^uxvulaj 

nTUvT ...3^.1... too'; (Achlress) WvflTYAJLh^ 



190 



Pays Hours 

■&. M.D. 

\y^JL 




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



r' 



^"^ 




Hi- 



r 



Former or 
Usual Residence 



How lonq at 

Place of Deatli? Days 



M, ml lis 



h.iy 



:inf..rniant \^Js\Ar>nJlJ\A ^ XU^/zJL 



f \(1(lrt'H« 



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



PI.ACH Ol' Bl'RIAU OR RKMOVAI 



UNDHRTAKKR JUlOjLm^VI. OID <X . 



DATK of Hi KiAl, or RHMoVAI, 
V^<5vr ai j^Q.^ 




IS. IS. Every item of infopmation 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** fop per- 
sons dyin^ away from home should be ftiven in ey^ry instance* 



♦ , 



\ 



II* 






,, 



l(iii 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,„.,,„„. .Uh 1 No .-C*^^"'^''^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/r rilr<l, vfUv'^a^^. . . 



^1 100^ 



Registered JSI^o, 



3226 










-^; 



d^^c^ cUa>m Deputy Heai>h Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

(Xcvtificate of Beatb 

( "U. 5. StanDarC^ ) 

,acX<X>^\X/^xii) City of ^''<^C\./CX/»xX"^^^0 



PLACE OF DEATH: — County of 

No, VO-VC^vtu. flV9CKl'r\^l.<X.b St.; 




Dist.; bet. 



and 



'vtu (^ v9 CKl r\^t.Aj^u 

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



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




y\.\x 





AXLiAAt^A;.. 



n\TK <>I- HI k I'll 



\xxJu 



COI.OR 



\jA\jJ^Jb 



* 






.\(.K 



fl»;l Villi > 



a5 

(Dav) 



M.^nlhs 



(VfMr) 



15 



Da v: 



mNT.l.K. MAKKIKI). 

\vn>o\\i-;i) OK DixoKiJ", I) 

(Wiilriii sMi-ial (It >-ij.'n.ili<iii) 



rURTITPI.ACK 

(Statf or roiiiitry^ 



NAMl-: Ol 

}<A'in i:r 




IMRTH!M,A("K 
Ol" lAIHKR 
(Statf i>r Country) 



MAIDKN NAMi: 

oi- moth):k 



niR'nii'i,A("H 

Ol' MOTMKR 
(State or C<nintry) 



OCCfPATIOX 



ocr\) 

'0 








MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Month) 



W... 

(Day) 



(Year) 



1 III';kI':HV CI^RTIFY, That I attenikMl deceased from 
: .. ■' :■: ■ ■... ■ :.. 190 to 190 .-rrr:. 



tliat T last saw h .n—— alive on 190 -^-^ 

and that death occurred, on the date stated above, at 1 o. 



^' M. The C. 



M. The CAUvSK OF DICATII was as follows 
OJLi-\AAXlX/>X^-^'<^"' <X/>^-^ .— 

LLIx^- 




ZJUiM. 



Dl'RATION ".-^.- )V<//.y Months Days Hours 
C(^NTRIHUTORY ,,.«» 







Kf sided ill Siin /'niiiiisni 



)Vn ) . 



A/on/Zis 



/hivs 



TMl- •XHOVl-: srAl'KI) PKRSONAI. I'ARTICVLARS ARK TRTK To TliK 
lil<:sT Ol" MV KNoWhi:i)<*.K AND HKMltK 



(A.i.iress \X \yy\^Ji\JrO\^>^AM o t 



DURATION 
(SIGNED) 



}\'(irs 



Wr 



1 IjOivJU 



ISTovths Days Hours 

M.D. 



IH TOO M (Address) OXX/C/y^XX^-v^-^J^/^N^ 



rLc.LaX 



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



Former or 
Usual Residence 



V:1T^TV\ \^ How long at 

llOb^\l>Uk; CJa: Place of Deatli? O. 



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



? 



Days 



PI.ACJK OK IMRIAI, OR RliMOVAI, 

UNDKRTAKHR AJk/CXAjLu ^\ J 
(Aa<lre«s l^M^--^' 



DA'l^, of IJiKiAi. or RHMOVAl, 
^^ 1 1_L90*^ 





'vL 



N. B. Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

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



ii 



,1 ' 
' , i 



, 1 




I «» 



'II! 



►* 



Hi ^i 

■^ ... 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3227 



J?...Mr'l ..f II.Mlth I N'li. i> ■*i^3»'^) JUS:l' Co 



/)u/r lu/rr/ }<(U\>-VyyxLjOv X[ J'^O'i 



Registered J\i''o. 



Mj^'^ ^ 



Xjom^ Deputy K --.-i Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( *a. S. StanDarD ) 
PLACE OF DEATH: — County of Q/CL'^^ -*-^V.CV->a.cu^ ci City ofO/<X/>-v sJA.x3--ivoccia,o 

1 * 



• No. liSM ' ic^Lk LUv^ 



St.; ^ Dist;bct. 




and 



/ ir DE*TH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N TO H M ATIO N ' • \ 
V IF DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




L 



Ldj\wui, V' 




.-v^/...^wA/^x. 



,OJLhJ:^<sy:xi. 






PERSONAL AND STATISTICAL PARTICULARS 



s,.:x Q^ 

I) \i"i-: I >1 i: IK 111 



L 



uJiJ-L.\ix_. 



• Month) r 



I)MV) 



r.^.^S. 

(Year) 



A<.1-; 



.>D ) Vi/; A 



3 



M..utfi.- 



liu 



J)il v. 



SIVC, 1,K M\KHIKI> 

W Iix >\\ i:i) UK I)I\i ikil-.l) 

iWritt in «Ki:il df^ivMialion) 



niKTnri.AOK 

(State «ir Cuuutiy 



NAMl' oi- 

FATin;K 



MlKTHl'l.At'K 

OI lATHKR 

I State or Cotiutry't 



M\n>i:N NAMK 
ol MOTHKR 



lURTJn'I.AOK 
()!• MOTHKK 
(State or Countrv) 




VL. 



MEDICAL CERTIFICATE OF DEATH 

UATK C)l- DKATH 




(Month) 



AC IpO^i 

(Day) (Year) 



I lUvKIiliV CIvRTIFV, That I attended deceased from 

.i3\r 11 190 H to SXWJ^....XC). 190 M 

that I last saw hX'v ahve on y\^C\r., '^.0 190 I 

and that death occurred, on the date stated above, at 11 l5 
il M. The CAUSI': OF DlvATH was as follows: 

\_<^' \-A_A^V„,A TK .,..,*»,.»„„. 

^:Y?y.'VAvC. . J.ft'N-^WA^ 








Wl/Ou d &-i'w\\>Ow 






K^^^'\ 



orcri'ATioN 



rm- MIOVF. STATl-.I) PKRSONAl, I'ARTICn.ARS ARK TRIK TU THK 
HKST OF MY KNOWMCIX.F: AM) lU'AJV'.f^ 



-^ Cr r\j 



13.5H - i.D.iJL Uj 



(Address ... 



.AJOL. 



nt'RATION rears Montha^^ Days 

. <X/>>w<X'..0..cy:^.OLJL.>r>rvA^.a»^ 



Hours 



DURATION Years .^ront/is .M-.D^ys Hours 

( SIGNED )...UJ. Vl "l. M l\. \.OJ\j><.^\.x M.D. 

Ni\<^r \\L 190' I (Address) I^H- H LIv . C 



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



Former or 
Usual Residence 



Hew lonq at 

Place of Deatli? Days 



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



ri,ACii or m KiAi, i»K J . 

INDKRTAKKR J\0 OJuClXx<A. ^<^ Lx) 

^Hb QQ\AA>iA.'(nru .. .dJt 



(Address 



N. B.- 



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



ja 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



-.1 , 



Ho;,r<l ..! H. ;,Uh I N'.. •- '^'^'I^J-^' I'"'^ '' ^" 



i 






w 



. !^ 



! ! * 



1 V 



1 



i 



I • 



■ ) • 






.1 
: I 






.Is-Uv- 



7ry6> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3228 



Registered JVo. 



-frv^ujocvt Deputy Hcailh Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "Q. 5. StanJ>arD ) 
PLACE OF DEATH: — County of^ a-r^' oXcuOVCUlC' City of^/CC^^ A-XX/wcu^iXUi 



^ 



Qip 




(tr DtATH OCCURS AWAY FROM USUAL 
If Dt*TH OCCUHRtD IN A HOSPITAL 




'^"'ChNL-KAXoLlSt. 



No. \.CXKxM ^' X "»xL' 

ir orATM OCCURS AWAY FROM USUAL R E S I D E N C E G I V C FAC 

OR INSTITUTION GIVE 



Dist.;bet. -•••■ ' and 



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



) 



FULL NAME 





^Jb\KrY>Jj 





/Jj. 






L 



PERSONAL AND STATISTICAL PARTICULARS 

ccoKy J ' 

KiJLJY^^JiJ^-^ UJ.'lvCLib 

D \T1-: « >l" lUK I'll 

X^Kja i^ /."^XiS 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




M.)tith> 




A < ■. 1-: 



1.5 



) I'll I 



"i 



(Day) 



M.»(l/is 



(Year) 



l 



Da \s 



SINCl.H. MARKIKO. 

\\n>()\\i:i) OK i)!V<)Kii*.i) 

iW'iitt ill voiiiil <l«sij.riiiiti<'ii) 



CJA/WO/Cii 



IURTTTPI.\<^K 

i Staff <n Country^ 



NAM1-: iW 
PATUHR 



CATVcLa^ CV'^ \XX 




niKTuri. Ai'H 
«)i iAiin:K 

(Statf or Country) 



MAini'.N' NAMi: 
Ol. MOJIIKR 



^ 



ry 



axIa. 



-Cv wou 




lURTHPT.AOK 
Ol MoTin<:R 
(Statr or t.'o\nitry^ 







(Month) 



XD... 

(Day) 



(Year) 



Q I JII^RHBV ClvRTlFV, That I altcMidcd dectased from 

aJL^xfc AS 190 H to \I'X^3\^ aa 190H 

that I last saw h-*-^-' alive on .\rLO\?r.„.iB. 190 H 

and that deatli occurred, on the <lato stated ahove, at ll 2>C 
\3 M. The CAl'SK OV Dl-ATII was as follows: 

(m CKLa'K^A^^.. oU^v^CLJ^^ 



Dl'RATION )'t'ars I I Months Days Hours 

CONTRIin'TORY 



Dl'RATION ^^^ Years 

(SIGNED). OAJUij LO.. 



'otiths Days 




orcrPATioN 

fCrsitifii in San /'nnhisrn 



)','(iis C Moil f /is 



Tin- ■MU)VK STAri-.l) T'KRSOXAI, I>AR TlCr I,A KS AKl! TRIK TO TIIK 
lilvST Ol" MY KN'OWMJX'.K AM) nHMi:K 



(Informant 



Address Oi^^eJ^CWvu LojL 



1)1 



vCA: ai iqo'v (. 



Achlress) Vj ITUaXo y>^A. Jl<1 



Hours 
M.D. 



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



Former or \ 4 y X. I U How long at 

Usual Residence OU:r^:^-^nX^rvAj V<XA; Place of Deatfi ? 



Days 



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



^I.ACK OF HIKJAI, OR RKMOVAI. | I)A'I>: of BlKlAL or RFIMOVAI, 

Mlcxr X'X. 

1' "" 



INDHRTAKKR VOjv.8.XAj~ ^^ Oys^XyU^^ftJhj 



(Address 



/.\Mi.. 



IS. B. F.very Item of InfonnHtlon should b.- cnrefuliy supplied. AGE should be stated EX4CTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for psr- 
sons flying away from home should be l^iven In ii\9X'y instance. 





( { 



\> 



H 



?■ 



ii i 1 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.,.,.Ut n. dth .No :.^^^v.ns.vc., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



3229 



luth' /V/fv/, llaK/vvXe^j 3.1 I'tO'i Registered JVo. 

itou^c^ijtxM^. Deputy Hcaith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( U. S. 5tanC»arC> ) 
PLACE OF DEATH: — County of Oo^^ A.OLV^cui^'City oi' J (X^ns. AXX/>AyOUi/CX) 



,1 



(^ 



\' 




No. ^^lo ^'j^OJvu. St.; 2L Dist.;bet. Oaxl^<5^;.. ...and M I LOc<i.caA; 

/ ir DtATH OCtUPS AWAV TROM USUAL RESIDENCE Give facts called for UNjbER 'special INFORMATION" \ 
V "" DEATH «CCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAtJ^OF STREET AND NUMBER. / 



FULL NAME mDJ^J\j^ 




<Cc\- 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR\ 




u 



I»\TF <>! HI Kin 



a 



Uj4U^tjb^ 



AC K 



Months 



So >■■„,., i 






(Year) 



yfnut/lS 



■\ 



l\l 1, 



«?tV«".I,T3; MARK [i:i>. 

\\ii»n\\ i;i> OK iM\"i »Krj:i) 



1 l\aA;wJL<L 



lukrmM.ACK 

t stall- or (."ounli y) 



NAM!" <>»• 
I- AT Mi: R 



HTUTIiri,ACK 
()l- lAIMHR 
(Stittr or Country 



M AID V. N N A M ! 
ol- MoPHr.K 



lUK I'HIM.ACK 
«)l MorillvK 
(State or Country) 






vb <^xXJ. 




MEDICAL CERTIFICATE OF DEATH 
DATK OI- Dl'.ATll 

Lc\r....... ....:.. IR. 




(Month) 



(Day) 



igo\ 

(Year) 



I ni':KI':i5V CI;RTIFV, That r atttMi.lc«l ilcccascd from 

.\j\cvr .^ 190.^. . to vKx5\r i.<^ 

that I last saw hA-^vr^. alive on \\\jS<r \'\ 



190 H 
190 M 



aiitl that death occurretl, on the <late stated above, at " 



y 



M. The CAl'SI': ()1« DICATil was as follows 




ii.US 



DC RATION 



Years Mouths Days Hours 



ears 




f**»i*HM».i 



'h 



orCTTATinN 



QLa 



Rrsiiird in Stitt /'nrnrisro' cN )'riiis 




Afoiif/is 



Ihn. 



Till" \IU)VH Sr\li:i> I'KKSONAI, I'A RTICr LA RS A K K TRIH To TIN-: 
HKST Ol' MV KN0\VM:I)C.K AM) MHMHK 



COM 
Inf.nnuint \K • Lh.y^'V'^X) 

(A.mrfs.H 1 S. ckjUXA>€^rvJ^O-tr\Jj^ Oi: 



CO NT R I lU' TORY ckXU? 

flw n 11 

.'^L^^.v?! 

Pays Hours 

(SIGNED) 4^V>A;VKN^ M.D. 

1\ looM fAddressVl^S U -UXA^u U: 



DTTRATION 



Years 



Mouths 



\)\gV".1\ iqo'l (Address) 1^^ U -UXA^u cJ t 
SPECIAL INFORMATION only for Hospitals, InstituAns, 



or Recent Residents, and persons dying away from home. 



Transients, 



Former or 
Usual Residence 



How long at 

Place of Deatli? Days 



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



vL{ 



MWt 3kQL. 



UI.ACK or HTRIAI, OR KKMOVAI, j DATK of HruiAi. or KICMOVAI, 
UNDKRTAKKR (AD oJLAAJuI ^^ \A> 



UI.ACK OF m'RIAU OK 



(Adtlres.s .. 



VuCLLO^AJ 

__tXt _. 



190H 



IM. B. Every Item of Informntlon should be cnrofully itupplled. 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 dying away from home should be given In svery Instance. 



ni 




If 



\ ! 



^1 ;'■ 






if 



4 



t 

\ 

4 

il.ll 



J. 



!'■ 



[.| 




:k^ 




iMa 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l{<.anl. f Ik .ith I v,. .^-?^^,iuti'i.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A 







D/t/c /'V/fv/,. M.Ll.\>--~ vYvGv . X\ 
(LtrvA.^ .4oL\hu Deputy >• 






Registered J\''o. 



3230 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "U. S. Stan^ar^ ) 



PLACE OF DEATH: — County of 




Xol'RA City of 'o.<X,tt'' (LcxAx UiojK. 



No. 



St.; 



Dist.; bet* 



and 



(ir DtATM OCCURS *W*V FROM USUAL RESIDENCE give facts called for under "special INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



.<XA^' 




JLU\J:s. 



PERSONAL AND STATISTICAL PARTICULARS 

si;.\ QC\ <\ I coi.oR 



DA ri'. Ill- lUK III 



L 




'Moiitli^ 



\ ( •. i-; 



(7^ <A ) \'ti t .V 



(niiv) 



Miiutfis 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 

' ''.mr 11. 




4 



igo 

(Year) 



Da vs 



SIVCT.K VAKKIi:!) 
WIlXtUKK »>K I)!Vi »Kr l-:i> 

(Wiitriii sori:il (Ic^i j'ii;it ion ) 



HIKTHrM.ACK 
! St;itr or Con nil y) 



NAM1-: ()!• 
lATin-.R 



Q 





A^ttV^V^OL 



(Cx.\kJ^Caj VyjJUtM 



lUKTHI'LACK 
«)l' I ATHKK 
(St.'iti- or Country) 



MAIDKN NAMK 
<)l' MOTMKK 



lURTiTrr.ArR 

OI- MOTIIHK 
(State or iNmtitryt 




.^VNJij 



? 



(Month) (Day) 

I lIltRI'iHV Cr:RTIFV, That I attended deceased from 

to r • • 



■ - -l^Q-— to ■. • .•••• 190 

that I last saw h alive on 190 

and that death occurred, on the <late stated above, at ■""" 
— M. The CAT SI*: OF 1) I- AT 1 1 was as follows: 




ni'RATION Yeat's Months 

CONTR IIU'TOR Y «..-*..« 



Days Hours 



DTT RATION 




<XAyy^JL 



KXj:)o\Jlaj^ 



OCCrPATIONi 

Rz-siilfil in San /'nitin'sro ck\ )'i'(7is 



.yf.inths 



Days 



\'\\V. AHOVl? STATi:n I'KKSONAI. I'AK llCf I.AKS A K )•; TKIK TO TliH 
HHST OI" MY KNOWM'.nC K AND HKMlvF 



f Informant 






(Addrt'NM 



JULKA 
A/>aJL CjI 



Years ,>^.^.>^ Mouths 

(SIGNED ).\j,.\j. U rv^.cv'cL^J 
MWt 11 iqoH (Address) 



Days Hours 

M.D. 




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



Former or 
Usual Residence 



Hew long at 

Place of Deatfi? Days 



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



ri^XCH OK BIKIAI^OR KICMOVAI. 



I)AT^;of HCRiAi. or KKMOVAI, 
^1. I90H 




INDKRTAKHR JvO cJLoXjuL "^i Co 

(Address *^H.^ \^VV^.^.^^^6r:>a, ...di. 



N. B.- 



-Hvery Item of Information should be CBPe?ully supplied. AGE should hs stated EXACTLY. PHY8ICIAN8 should 
state CAUSE OF DEATH In plain terms, that It m»y be properly classified. The "Special Information'* for psr- 
sons dying away from home should be given In svsry instance. 



. ! 



'■'TJ''*^''!^ 









I 



m 



■-, '■'»■ 



\ -i 



*f 




» •? * 



M 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HoaTi! -f II. ..Ith r N.; : <; •*-f;;^-^) 5U<L I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




RegLstcj'ed J^o, 



3231 



l),(lv /■•//<■ >/.\Cuyv^JUnJj~ii\ 1\ 1-^0 H 

Lv^. 1l^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDarC* ) 



% 



(3^ 



3: 



PLACE OF DEATH: — County of ',a:x\;.J/V<Xy>A-OVAyat City of^<X/>x; J A.<X/v\.XLA^^eo 
No. 15 Vlxv^v^i .„.„.. SU 3l Dist.;bct* 1 rrucL and '^ \A. 



^^ ""-- 

/ \r DB«TH OCCU 

ir DEATH occynncD in a hospital or institution give its NAME i 






BS away from usual residence give facts called for under "special INFORMATION" \ 

INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




J <x.y\A 



'X\Xl 




y^^, 



u 



PERSONAL AND STATISTICAL PARTICULARS 




si;\ 



DATi: «•! HIK III 



COl.OR 




^VL 



k 




Mnhtli) 



A<". K 



1H 



) /•(/ ) 



I 



(Day) 



A/(>»//is 



Axs 

(Year) 



X 



Da V.V 



«tN<'l,K MAKKII.n. 

U IDOU i:i) OK IMVOKCKI) 

• Write in >-<ici;tl dt^iviuitiim' 



Qv 



RTRTnrr.ArT? 

(Statr or I'ouutry^ 



NAM)-: <)l- 

»• a'iiii;r 



RIKTHI'I.ACK 
()|- I ArilKK 
(Statr or Coinitr.v) 



MAIDKN N\MK 
OF MOTHKR 



lUKTMPI.ACR 
OI- MOTIIKR 
(Stall' or Country) 



<X^\.ou:L 



\ 

^)XKXjXAA/^r^cL 

? 



Medical certificate of death 
date ok dkath 



vj'W. 

(Month) 



(Day) 



(Year) 



I IIURKBY CKRTIFV, That I atteiuled deceased from 

■ ....>..««„. IgOf. to-.. • - 190 H 

that T last saw h .^-'^v-rv alive on vUrvJ" It igo M 

and that (leath occurred, on the date stated above, at 13^0^ 
Uv M. The CAl'ialv Ol- Dl-IATII was as follows: 

LLcAXtX \SDA.*rVXXLXV-VAAA^ 






-C )AA>X/cLcy>\j 



nCCt'PATTON 

hVsidfd in Sun /'i a ik isfo ^ () )V(H s 



DURATION }'t^ars Months \ Days Hours 
CONTRIBUTORY . U-iL^^AjLutcv; 



duration 
(Signed) 



) 'ea rs^y^ Jlfon ths 




^Uj'TL 



Days Hours 

nni\>o^. M.D. 



IQOH (Address) HS^- 5A^ d± 



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



Former or 
Usual Residence 



How long at 

Place of Death? Days 



.\/,>nf/is 



n,i 1 v 



Tin" AHOVK ST\THI) PHKSONAI. PAR TIlMI.ARS A K Iv TRIK TO TllH 
BEST OK MVKNOWl.V^rx'.K AM) HKMKF 



(In 



,y:r)<.K AND nKMh;K 



(Address 



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



PLACH OF ni'RIAI, OR Rl%MOVAI, I DATH of HURIAI. or REMOVAI, 
UNDURTAKHR (tO <xXaXx/cL ^V^ C<) 

^Hio S^fYu:.<L,^^^ 



(Address 



N. B.- 



-Bvery Item of Information should be carefully supplied. AGE should be stated EXACTLY. PHY8ICIAN8 should 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information** for per- 
sons dying away from home should be given In avsry Instance. 



J 

I ; 






'I' 



, 



) 



ii 



< ''^' 



'1: 

' i 



II 



\i 



> \ 



n i 



i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



U.,;w.l ..f lKi.:t)i !■ Vo • - '^^S!S^ "'"^ '' ^' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/r AV/rr/,MWsJl^^ ^l I'JOH 



Res^istered J\^o. 



3232 




ju Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of Death 

( "U. S. StanDarD ) 

PLACE OF DEATH: — County ofC)cc^>\; ^ KO^rK^iAM.^k^ Ciiy of Cj/(Xonu Axx/>^^oa^ e.o 
No 3.'^^ H VJ.\,->A-ic St.; ^ Dht.;bct, 0.0(Amx.^.:.\^ and Olx^^vvJLK.' 

/ IF DtATH OCCURS AW»Y FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N '■ A 
i, IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





Oj-w^ \JJsJ^jOOJ\^6^ Vw/QJVX/' 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



Qo\JL 






vcLt. 



n\TK <)i lUK in 









ACH 



) fit t . 



(Day) 



M.,i,lh> 



/ ao -^ 

(Vear) 



la 



Da ^.^ 



STNV.I.Tt. MARRlKt*. 
U!I»o\\I-;i» OK IHVnKil<:i) 

Wiiti ill -.oiial <lr-it'ii!it iiiii> 



niRTrTPT.ArK 

I stiiti 1)1 loiiiitry) 



NAMl, ul 
l-A'IH IK 





niKTnri,A(K 
<M I Arin<:K 

(Staff or Country) 



MAIDl'.N NAMi: 
OF NKJTHKK 



\ ! 

I' 1 i 





MEDICAL CERTIFICATE OF DEATH 



DATE OI- 



^ 



(Moiitli) 



(Day) 



(Year) 



1 IIICRIJJV ClvRTir^V, That T attended deceased from 
CrUV- H... 190' I to QrU5\^r. . SLCi 190 H 

\l\cvr-....QL.Ci iQoM 

e date stated above, at OJC^XT ST 



that I hist saw h-A^"v>v alive on 
and that death occurred, on th 
M. The CAT'SK UF DICATH was as folhnvs 



O^vJULA^rvvX/CJ^ .wU*X 



DURATION Years. 

CONTRIBUTORY 




Months Days IV Hours 

KJoJL(SX.s,My><^ 





BTRTHPLAC'l* 
OF MOTnF:K 

(Stall' or Country^ 



LoJLaJU' 



V>X^<Xt. 



OCCrPATlON 1) 

Rfsidrd iit Sou f'iini,i-,-o I Vrars O M'Oiths \ \ /hir: 



Tin' AMOVH ST^IF'.I) l'KKS(>NAI, I'AKT K'F I,A KS \\<V. VRVK TO TUF: 
IJFST ()!•• MY KNOWI.IUX'.K AND »KI,IKF 



(Address 



a'^^H Vjl^-^JL C 



DITRATION )V«7r.? Mouths Days 

(SIGNED) B. O-. (AD <UUvoCl,>&-v\. 

NfWr a\ iqoH (Address) l^l 0-X XX^.^ C)l 

, InstittMions, 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals 
or Rfcent Residents, and persons dying away from home. 



Transients, 



Former or 
Usual Residence 



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



PI^CK OF BURIAL OR RHMOVAI, 

UNDURTAKKR 

(Address 1 <?(» 



Hew long at 

Place of Death? Days 



DATFlof ncKiAL or RKMOVAl, 
^^ I90H 





've. 

-oiu......CLv'.4. I 



„f ln?ormHtlon should be carefully supplied. AGB .hould be stated EXACTLY. PHYSICIANS should 
E OF DEATH In plain terms, that It may be properly classified. The Special information for psr- 



N. B. Bvery Item 

state CAUSE 

sons dying away from home should be ftlven In ^y/^vy Instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H„ar.1 of li.aiih ! No r. TS-i"^ H.«t 1' c o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■» ■ 'H 



i I 



t t 



! ', 




'v. 



4 '^ 






i % 



{ I 



• •* 



i > ■ 



-\ 



/)((/(' /'V/fv/.VJ[\.cvvoC-n\.i^-e,>v ai 



7,96^ '^ 



Begisfered J\^o. 



3233 



.^rV^^^x^ 




/v^v< Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( *U. S. Stan^arD ) 
PLACE OF DEATH: — County of c)<XVu J.\.ay'vvc^ac. City of d<X/irx> v^iXxxa^^ccl^ic 
N^ 3C'Cl^'>^^<TK<X.Ur^A.':: d/CWVcAlcc'vSt^^^VYAJ Dist.;bct.— and 

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




FULL NAME 



<XA^^H, 



-i- 



PERSONAL AND STATISTICAL PARTICULARS 

I COI^Oit \ ft 

L AjuL 

DAii: Of" liiKrii 



r _^WL 



.K. 



U 



MEDICAL CERTIFICATE OF DEATH 
liATK OV DKATH 

,<^r ^0 



|^^oluh^ 



\«.K 



V\ 



) I'm . 



(Dav) 



.l/.iW///A 



(Vear) 



/hiv: 



'^TNN'.I.K, M\KUn:i) 

iWiittin v,Hi;iI (lt>.ii.Mi:it ioii ) 



I 



♦ • 



lURTiiri, \r»-: 

(St;it« i.r C'juntry^ 



N \M»-; <>i" 
» \ III j:k 



!UK'nii'i,.\rH 

()l I AIIIKK 
iStatf or Cojintr^') 



M.MIHIN NAMJ- 
or MOTMKK 



HIK riirUACK 
oi' MOTIII'.R 
(Siatf or CN>untry> 



«)i\:ri'ATi()N h)p 





(Month) 



(Day) 



/go H 

(Year) 



(^1 



I lII';Kl';nV CI-RTIFV, That I attended (let eased from 



lAr\r i 190 H to ^l.Ui^r ^.0 190 H 

that T hist saw Ua-'wa aUve on ......yTLCTU'. XCi 190 'l 

and that death occurred, on the (hite stated above, at -^ 
J M. The CAISIC OF I)l<;ATn was as follows : 



'S 



Rfsiilrif ill Sou /'i iiih ist'o 



),,n> yfoiiths X,^ /hn.y 



■|II|- XHOVl' srATl'I) I'KRSONAI. I'A R TUM' l.AKS ARl-: TRIK Tt> THH 
!ii;ST OI" MY KNOWl.KDC.K AND HKMIIK 

(Infonnant 0- U O CrLAX^-V.«.\^>V 

(AddroHs CjaaJp^' Cj /CXyvv/-tcxA>ci.>.-/'y vv 



DT'RATION ,^..l..- Vrars Months Days Hours 

CON T R 11 U • 'i' O R Y <^)^a\XLA,iAu >^<<X-L.y Jl\Jk tA^ 

iyjUjLhw>OLto«rv^ \^ A..dLtx4- A\AJ^tLjLJLcl:i 

DURATION Years .^tout/is 3. Pays /fours 

(SIGNED) H<X''\YvjU) lO. \Xj <(X^\A, IV 

\)V^- Xl T()o'l (Address) bOb O^uubliAj Ol 



M.D. 



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



Former or 
Usual Residence 



.IAa/XAX) L<xJl Place of Oeatli? Ifi) Days 



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



ri,ACH OK niRIAU OR RKMOVAI. I I>ATJ<: of IUkiai, or KICMOYAI, 

UJLxJL Col I m<nr XI ,,9oH 

oJlA-tCcL A^L Co 

^lio NLy\Aja^c.«ry:x.. 




uni)i:rtakkr 

(Atldrtss 



.31: 



N. B. Bvery Item o? Information .hould be cnr«?ully supplied. AGB should be stated F.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It mi.*y be properly classified. The "Special Information'* for psr- 
sons dyinft away from homo should be ftiven in svsry instance. 



k^WkMhM^A^MMtfiki 



'1 1 



I 



■■;■) I 



< I 



! 1 



t 1 



; \ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoar.l of Hc.Mltli' »■ N'o i" *-^. *''.'-i-' •'•''^ '" ^'" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



d^{ 




,-^ X\ /.^^^H 

Deputy Health OfHcer 



Be^istered J^o, 



i 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ceittficate of 2)catb 

{ H. 5. StanDarO ) 



PLACE OF DEATH: — County ofO,cx,'>x vJ Axxy>a/^^A/O^City of 0/CL/vu AXc^vx/:m.A/Cl<o 



^ (^ 



No. 



ISl 



(j,<xt,u VAam. 



1^- 



St.; ^ Dist.;bet. 



V0| 



/ ir Dt»TH OCCURS AWAY FROM USUAL R E S I D E NC E G I V t FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N A 

V IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / \^ 



H OCC 

H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 

^ K A 

FULL NAME cUXcL/\AAxcLa 




and OCrLAOX)^ ) 



^^ 




"Y^V^J. 



• •«.•***••'•«•«. »'*««»-^**^.*»t**.- 



PERSONAL AND STATISTICAL PARTICULARS 
SKX OS?) (\ I COI/)R 

Li 



JLTV^CX^LiL 

I) \'IK «»l- III Kill 




M'.V. 



/I'Moiithir 



XS /I Ha 

(Dav) (Ytai) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF m 



!:" JK 



Month) 



(Hay) 



.I90H 

(Year) 



ST 



)'iilHi 



M.»itfi\ 



XL 



Da vs 



<Wr,\,V M.\KUIi:i) 

WIIM lU i:i) OK |)!\< iKD-'I) 

'W'lili ill ■N.icial (l«vi;,Miat iotO 



IltKTliri.At'K 
(State or Country) 




judUruj- 







HIKl'mM.ArH 
<>I- lATIIF.R 
(State or (.'ouiitry) 





Oj^lo 



MAI !)»•:%' NAM I'. A, A 



I IIIvKliBV Cl'iRTIl'^V, That I attended deceased from 

0\<5\r: .1 T90 ^i to QX(^r. Xb. 190 H 

tliat T last saw h X^J alive on VrUCVT: Xb 190 H 

and that death occurred, on the date state<l above, at ' 
CI M. The CAISH OF DIvATlI was as follows: 

^^^KJry\/:LA■\^^JLf^J^.^^\^ 



DTRATION Years Months 5^0 Pays Hours 




(Statr or i'ountry^ 



BTRTTTPT^ACK \ A 

ni- MOTHKK ^ y \ V 



hJXJ-^y-L. 



OCC r PAT ION 



Months 



/),n: 



rilV AHOVK STATKI) PKRS(^NAI. PARTICT I,A RS ARK TRIK T«> TIIH 
lil':sT OI" MY KNO\VM<:i)C.K AND IJKMi:i* 

(Informant VA/VV-A^^^^Xi \AJ:lLuLaxX) 

Hol BJbMJkJbr^ ck 



(Address 



Dl'RATION i years...:...... Af OH ths Days /lours 

(SIGNED ) ..Mil, . V)rijLu^/vvA.xt^ M.D. 

\Jl^5>J'a5 TQo'^ (Address) 0^5 i J AA^Ok ot 



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



Former or 
Usual Residence 



How long at 

Place of Dealli? Days 



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



PI^ACK C3F m'RIAI. OR RKMOV.AI, 

UNDKRTAKKR 

(Address ....^A.. 




....W..i 



DATj^of Hi'KiAi. or REMOVAI, 

vd :: 



N. B. Every Item of Information should be carefully «uppHed. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" Ur psr- 
sons dyin^ away from home should be given in svsry Instance. 



S.I 



! II 



\\ 



^'\ 



4' 



i,- 



'w 



i 



■^1 



, « » 



i 









I » 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

Re^Lstered A'o, ^'^o5 



)!.,;,r'l..f Hi-:. 1th 1 Vo :=; t-'fj^^ar^- i:.S:l' ( 



luilv /••/7,'</Ail^CV^CA:JH.tv...lL ...._ VJO'\ 

^k^^Ajl^^ Deputy Health Omc.er 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. Stan^ar^ ) 



(?^ 



^1' 



PLACE OF DEATH: — County ofOCL'^^ J ,^^a/vwCv(i.C.( City oiO CXrrx' >vO^>x-0(_4. cx) 



St.; X Dist.;bet.OCl 



No. bia u^L-u/cLt 

' OtATH OC 

ijir DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 




and 



/ ll^'otATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CAULtO FOR UNDER SPECIAL INFORMATION" \ 
\ 'lIF DEAT" r>rr.iBPrn in a mospiTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




1 



FULL NAME cLOw^^^^JL^x.o. ^S^xJ 




PERSONAL AND STATISTICAL PARTICULARS 



MX 




^ 



\-CkXx 






--U. 



DA ri: <>i iiiK III 



\< .H 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 

V \i \ 

.C\r S^l 




(Month) 



(Day) 



(Year) 



/|M..nth)| 



31 Q t. \ ' 

I /. I..U..7; 



JV'(/i 



(Dmv) 



Mmiths 



XI 



(V.ai) 



lhi\s 



SIN<,i,l.' M\KkIi:i» 

W IDt »\\ I". D < IK DI\« »Kv i:d 

I Wi it. in '-'K-inI <1< vij.'ii.it imi ) 



mkTIUM.Al'K 
!Stat<.' or Country) 



NAMI', <>1' 
lATMl-.K 



niR'I'UIM.AOK 
()!• lAIIlKK 
(Statf or Country) 



MAIDKN NAMI, 
(U- MOTIllCR 



HIH'rnr!<ACK 
«>l' .M(>'IIII\K 
(State or Country) 




I HlvKIiHV CIvRTH'V, That I atteiidcMl deceased from 

m'UtJ" l.H 190M to QfUt\r 5L.0 K^M 

tliat I last saw li'LAiA alive on • MMJV" 3.0 Kp ^ 

and that tleath occurred, on the date stated alxn'e, at X 

iL M. The CAl'SI': C)l- I)I':AT11 was as follows: 

^ \AXj\.hJr\.<>^^.:. Os-r>Xo.^v\X^o(u.....,.,...,,.^ 






DIRATION Years I Months \ Days Hours 

C()NTRII?UT()RY M lXcO(wZyvA-\AA-vJ^^ 




Cly^i^'VOvO 



OCCTTATIUN 

Rfsiiii'd ill San /'i <niiisi't) 



) 'ill I s 



A/iiiif/t'^ 



fht V.v 



TFIl' -XnoVK STAI1:D PKRSONAI. PAKTICtl.ARS AKl", TKIK Tn IMH 
IJKST Ol* MY KNOWl.HDC.K AND MI:MKF 



(Infotniant 






(Address 



DTRATION Years \ Motiths \ Days 

(SIGNED )...fewi^..Uw....U0aJO^ 

\lU\r. . ai . Tt)oH (Address) "J I S JjLaxA dt 



Hours 
M.D. 



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



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



PI.ACK OF lURIAI, OR RHMOVAI, 



(hit OJLv^ ^>w 

UNDFRTAKKR Nj^^O.^^ (fc 

(AddrLs. 111^1 '^ 



I)ATi:of FU KIAI- or KEMOVAl^ 



ax 



T9O 



«.! 



y\j 




X^J)X 



N. B.— Every Item of Information .houlcl b. carefully «uppned. AGE •hould be stated EXACTLY PHYSICIANS .hould 
•tate CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for psr- 
«ion« dyinft away from home should be ftivcn in every instance. 



I 

I!? S 

1 1 



.J 



4 



1 



I 



' I 

i 

I*' 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,,,.,„, H..:.l. . V. .= -'^j?^:,.u^I O. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JS'^o. 



3236 



Duir /•VA''/,\lWMyYY\3Lov X\ lOO'i 

dUr^c^ lot a^l^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^ 



Certificate of Beatb 

( "CI. S. Stnn^arD ) 

J? Q^ 'A 

PLACE OF DEATH- — County ofOa>^ Ox<Xa \X>-VC<- City of .CUv^ Jxo^CULC^ 
No. ^5 5.1 OlLi,A^^-\X>VK St.; "^ Dist.; bet. V.' OJxKjXb and UXOA-Ci, 

/ ir orATM occiBS *WAV rROM USUAL R E S I D E NC E Gi VE fact 

OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I" 

FULL NAME .cL'.Cr^UX' mCh-UL/K^b^.. 



/ ir orATM OCC.RS AWAY FROM USUAL RESIDENCE GIVE facts called FOR UNDER "SPECIAL I N FO R M ATI O N • •^ 

V IF DEATH ^r^r-MOorn .M . kJOSPlTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / \J 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 



sj Jt'TYVO^LR 

liA'I'l". ol- 1!IK 111 



A < . } ", 





30 



) lUU . 



3i 

(Driv) 



1 Months ^S V 



r\- 



LI .. , 
(Year) 



/hivs 



U IIH»U i;i) Ok IH\oKCKI> 

iWiitiiu MH-ial (1< si;.'ii;it ton) 




\(x>\\.\JL<^. 

IUKTH»'I,AOK Q (7P\ 

i.Stiitfoi (.•(.iintry* -Y \} y 

% I 



\ \MI ni 
1- A I" I I IK 



I go 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK <)1" DlvKTH r\ ^ 

M.Lcar ^L.. 

(Month) (Day) 

I lIlvRIviV CIvRTIIV, That I atten.led «lecoased from 

CLu^q. r. i9o'\ to VTUyxT Xi 190H 

tliat 1 last saw h-^^v alive on VlVoAr ^.&„ T90 H 

and that dratli occurred, on the date stated above, at I 30 
CL M. The CAl'SK OV DlvATII was as follows: 



v-Ss-XAXj.. 



rL/^ 



lUK inri.AiK 

01 I All 11; K 
(Statf i)T I'oniitiy) 



MAIDl'.N NAM1-; , .. 

«>l' m<)Thi;k ' ^ 



'Xhy'Y'>"VXX'0<X^^ 




-vl 







nTRTTTPT.ACK 
01 MoTllHK 
(Statf or I'onntry) 



OCCt TATION 




1) 




AV.v /<//•</ ill Sail /'xttKist'o ^ ' V-ujis * .\f„iiths 



/hi v. 



Tin- MIOVI.- S'lXrivI) I'KRSONAU I'A K ILiT LARS AK l'. l" K I K To IHK 
MHSr <)!•• MN- KNOWI.KIXJK AND in:iJHF 

. Q[d (M.oKX> 



fl 



nfnnnant UtUX^ 0^^ . ()\D (M.OKX>V. 



( Xrlilrcss 



sai 



Dl'kATIOX ]'rars (o Months Days 



Hours 



CONTRIIH'TORV 



.> V 



DURATION 



(SIGNED) 




Ymrs I ^^ouths - Days 



3\A^OULXJJ\y 



Vl'Uvr. 'Al i()o'i (Ad.lress) "^ l^ dx^^Xlxrv 



Hours 
M.D. 



d± 



Special information only for Hospilals, Institutions, 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 



rj.ACH Ol" ni;4<IAI. OR RIIMoVAI. j DApvof lltKiAl, or Ri:Mt)VAI, 

V^U^ a.B. 



QnU UXcxnU) I vu^^a.^ 190H. 

(Aii.it iss 1131 VM^c^-A'wxnAA. ..& 



o? Information .hould be cnrefully supplied. AGE •hould bo stated BXACTLY PHYSICIANS .hould 
E OF DEATH In pi(.in tcrma, that It may be properly cia.slflcd. The Special Information for |>«r- 



N. B. Bvery Item 

state CAUSE 

sons dylnft away ?rom homo should be ^Iven In ^s^ry Instance. 



1-4 



. I 



t 1 



: ti 



•-%j 






• i 



\^ 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3237 



Board, f ll*ahli - »• No. u *•?;•»■;;, ~) }U"^ l' C . . 



Registered Ao. 



tr^j^<^ (ix v^u Deputy Health Officer 



Dale riled ,\S\jS\>-^^ ^OO'i 

i 

DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 

Certificate of H)eatb 

( XX. S. StanDarC* ) 
PLACE OF DEATH: — County ofClcuoAj JXCl/y^c<^ccn City ofO/ay>^ AXL/^rv/Ci^<^c^ 



St*; 



Dist.; bet. 



— - and 



/ ,r Dr. TH OCCURS AWAV rROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ 
( rroEATHOCC^RReD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME 





Is crLdLx^' 



s}:\ 



PERSONAL AND STATISTICAL PARTICULARS 

C01,0R 




CUJl 




AX,^ 



U 



DAli: (»l MIKIll 



A«,K 



<M..nt1i) 



%0 



) fit t . 



(r):»v> 



M.»tlli> 



/111 

(Vf.'ir) 



/>(/!. 



•.^IM.l.K M \KK n'.I> 
'Wiit'iii >«<)i-ial (l(vi}.Mi;iti')ii) 



(Stall «)i Cixintrj) 



N A %! 1 < > I 
FATm:K 



HIKTIiri.ArK 
oi I AlllHk 

(Statf III Country' 





MAIDKN NAMK 
OI- MOTUHR 



IIIKTMIM.ACK 
<)l- MO'I'III-.K 
(State or Contitry) 



OCCITATION' 



Kesi,!rii ni S.ni /■i<iu<i.uu\^ 5C))V.//5 - y/oiifhx 



Till' XHOVK ST^T^:I) PHKSONAI, I'AKTUT I.ARS A Kl- TKIH T« > TUlv 

iJi;sT iH- Mv kn<)wm:i)<",k and ijhmkf 



(IiifoMiiaiit 



\,jy;\AryyJU\j^ 




( \(h\rvHH 



^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I)F:ATH 

.{j\r. 




(Month) 



(Day) 



IpO 

(Year) 



I HI^RI^HV CI'IRTH'V, That I attended deceased from 

. - ' 190 to •• 190.-—— 

that I last saw h alive on ~~~~ — — r— - igo — — 



and that death occurred, on the date stated above, at *- 
M. The CAl'Sr: OP DIvATH was as follows: 



a 



^JvAA^.C-.WCSJL 



DC RAT ION )'i'ars Months 

CONTRIIU'TORY 



Days Hours 



t* <>.«« K4^ «•«»«*«• 1 1 



nrRATiON 

(SIG 



Mouths 



Days Hours 



NED ) L AJj. Uj , .^jkjlXx^ L(A..(rvJA) M.D. 

VlWr W TQoH (Address) LoVcrv^>lAJ:> UX^^^ 
SPECIAL lNFCR!V!ATION only for Hospitals, Institutions, rtm 



or Recent Residents, and persons dying away from home. 



sients, 



Former or 
Usual Residence 

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



Hew lonq at 

Place of Death? Days 




I'l^ACK OF HURIAI. OR RKMoVAI. 

C^. iy. C/. i Go/rrvaicvu 

UNDKKTAKKR OVD . J . \l 'rV<X<X.^.^ \-.0 



DAXHof niRiAl. or REMCn'AI, 

Xl I90H 



(Address .. 



<^ I n \ry\A.xi/^i..corv.....D^^ 



, o. .„for„,«tlo« .hould be ca.cfuMv supplied. AGB .hou.d *>« -i^^^^.f .^fj^^,^', .rrmlJtTon^'Vr"::!.*^ 
8E OF DEATH in pIbIi. term., thut It mny be properly cla»«.tied. The Special information for p«r- 



N. B. Ykvtry item 

state CAU ... 

son* dylnft away from homo should be given in every Instance. 



i 



J ! 





WRITE PLAINLY WITH UNFADING INK 



H..;ir-! "f H.-:>1th I- 






iVr (•>, 



Dale /'V/r^/, \JL<rNJ^'^"'x4M.X 1 



lOOH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3238 



Registered JVo. 



it^coVxH, Deputy N-''«^«-0'^-er» 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Ceitificate of Beatb 

( XX. S. Stan^arD ) 



(^ 



of'JO.A^ vJ^a--kvCA^c.i City ofJcLA^ JA.Cl/>^x^ulX:^ 



No 



i^ 



Ot) M iLcUv^^V^ ub CMi.kJ^Cvl: St.; Dist.;bet. and 

• ^ /.r nr.rJoccuRS AWAY rpoM USUAL R E S I DE NC C Gi VE facts called for under 'special information- ^ 

( Tf OFAVh OCCURRtD IN A HOSpVtAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



\x 



LOKoJL^ 




-A^^^w..LLu 



r 



,.^w<ii^^^***»wif**m*-»*v***^ 



KX 



PERSONAL AND STATISTICAL PARTICULARS 

CUI.OR 




\ 



^ 



OwLl 



LvtxaXc' 



IiATK «»l I'.iK 111 



AGK 



(Month J 



lb ytats 



(Day) 



Miiuthy 



r%5% 

fV,-;ir) 



Dii i.v 



SINt.l.I* M.\KUI!:n 

\vn><»\vi:i) ok l)l\t iRri'l) 
(Wiitf in smMal iUsij.'iiati<>n) 



lUKrillM.ACK 
(State or Cmuitry) 



NAMI' or 
lATlN.K 



TUKTMlM.ArK 

<»! I Arm;K 

(St:il«- or (.■((initry) 



MAinHN NAMK 

«n- M<>Tin:K 




cOu' 




niKTm'LAn-: 

Ol- MOTIIHK 
(Statf or Co\inlrv^ 



occri'A'riox 

Kfu',!r<f ill Sav Frann'sro H \o 'Vvrrv 



Afoiif/i^ 



/hn. 



TMl- XHOVKSTMIDPKKSONAUI'AKTKM.AKS AKi; I-RIK TO TllK 

ni:sT OF MV kno\vm:i)<".k and in-I.IhF 

<,„f.„„ ^IVvA QfVuxKAu %^Oixu, 



( Addrtss 



U%' H 



IpO V 

(Year) 



^MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH (\ 

Vllcv- 11... 

(Month) (Day) 

I HKRICBY CMRTn^'V, That I attcMidtd deceased from 

d^^ .1 190H to QcUKvr. la 190 H 

that I last saw h ^uv^v alive on Vl V^r. .i.hl icp 

ami that death occurred, on the date stated above, at ^ 

..Q M. The CAISI-: Ol' Dl'ATlI was as follows: 

LX/y\jU-^ 



-UA.A><i/r>.r,v. . crt LAjx^Ia^ .CrV. LLcr^Xa.!. 



DTK ATI ON }'rars 
CONTRIIU'TORV 



Jl /(>>// /is 



Days Hours 



Years 



Months Days 



DURATION 

mW-A^ tqoH (Address) Oti M iX- CXAuQ ot' 

SPECIAL INFORMATION only for Hospital 
or Recent Residents, and persons dying away from liome. 



)itals, Instititions, 



Hours 
M.D. 



Transients, 



Usual Residence clO%r...H..^A^. 

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



Hew long at 
Place of Death? 



- ****•**#«*. 



Days 



i'Lacf: of iukiau ok kk.m<>\ ai. 



'LACK Ol- \\\ KIAI, UK K 



DATF; of niRiAl. or kkmovai, 

vV^cyv- %x '--'^ 



190 



l-NDFRTAKKR \-^- ^ r>:^^^^^^ 

iVlrc-ss ...Ibl \rhwA.A^V>C^ 






(Ad<- 



IN. B." 



■"""^^ ~7~ a •. li I APF .hoiiltl he Stated F.X4CTLY. PHYSICIANS should 

-Every item of information .hould he cnrefully supplied ^f^^^l^lll^^^^^^^, ..gpedal Information" for pT- 
state CAUSE OF DEATH in pinin terms, that it may he properly clansitiea. i nc ^v 
sons dyinft away from home should he ftiven in every instance. 






Ill '^':r 



f m I 



ri il' 









I 



I 

I 



I I 



-I »;! . 




Hi,:!r«'. <.t II. I M' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

> V. .lsr?^H.«t.'0. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health Officer 



Bo^lsfej'ed J\^(). 



3239 



hair Fil('<l^C\JS^>^^yrY\jyo\j'k 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)catb 

( H. S. Stan^arD ) 

51 ^ ^ 



Q^ 



PLACE OF DEATH: — County ofOco^^ UJv^ vvc^^co City oiO^^ OXxx^vc^co 



«o 



. Lctu,^ V<y\.Ln<ijn vtU-V\-4ylv feUA.v. St.; 



Dist.; bet. . ■:- ' i and 



t \ i.ciiAi orcinrNCE: GIVE facts called roR under special information- a 

( '^ rF^orAT^H^^CctRrcV.^THo's^PrAt 0^"Ns"T'.?"o^N"a.v77Tl ^.AME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



\XOJ 




PERSONAL AND STATISTICAL PARTICULARS 

COI. 



I)\ IK ul- lUK IM 






(Month) 



Ar.R 



,bH y.a,s 



• Day) 



Months 



(V<ar) 



lhi\s 



WIDOW Kl» <»K I)IV»»K( Kl> 
(Writf ill MX'ial flesijniatii)ti) 



lUK IHIM.AOK 
(Stale «r Comitrj) 



N*AMi' or 

FATiniR 



HIK IMPUAOK 
()!■ I AIMKK 
{Stalt oi Codiitry) 



MAIDKN NAMi: 



lUK rni'i.A('i': 
ol mdthhk 
(State or Cotmtry) 




hLcjV^u^cv 



OCCri'ATlON J) . D 



t 



.y/<»tf/t<! 



/hn: 



,K riOn.ARS AKi; TRIK TO riih 



in;sT Ol- \v^KNo\vij:i)<;.h AM) ni-,i,ii-.J- 



(Infoiniant 




(Address 



-\./<^CUL 




<:.-^\}-<LUr\i. 



MEDICAL CERTIFICATE OF DEATH 

DATIC Ol- DKATH 




(Month) 



A 

(Day) 



(Year) 



I in<:Ul':iJV C1*:RTIFV, That I attended decoased from 

MXc^^ 1.x 190 'i to yCU^r. ...i^ 190 H 

that I last saw h x/rvvxaUve on \J\,-<5\i:.„..lk.. 190 M 

and that death occurred, on the <hite stated above, at ^ 
\J M. The CAl'SIv OF l)l-;ATn \yas as follows 




nt-xAyysJJL 



nrRATION )'i'ars Mouths ^J Days Hours 

eoNTRinrTORY 



1)1' RATION • Years JSFouths Days 

( Signed ).....Uj.. ^: Nw^^tyOlcx/^aj 

\j\^vvr 1^1 iqoH (Address) LlX^YVaJivfe V 



Hours 
M.D. 

yj^J-^ 



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

Former or "o^ l«nfl a* ^ , 

Usual Residence Pla<"e of Dealli? Days 

Wlien was disease contracted. 

If not at place of death ? 



I'l.ACK OI- lUKIAI. OK KKM«)VAI. 



DATHuf HiKiAi. or RKMOVAI, 
VU\r ail I 



90H 



UNDKRTAKKR 

(AildreHS . 








^YV 



■""■""""■"■'■""^ « .. li J Arp ahriMid he Htatecl EXACTLY. PHYSICIANS should 

N. B.— Every Item of information .hould be cnrefu.ly applied ^^^^J;;^^;;'^^^?!'^! The "Special Information" for p.r- 

state CAUSE OF DEATH in plain term., that It may be properly ciassinea. nc v 

sons dylnft away from home should be ftiven In every Instance. 



•I 



It? 












i I 



It' I 



if f ^ 



:r 



iK 






■Jits 



iXtfr rih''l}^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3240 



,..,,.,!,,!■ H..U1. I Vm , . t-^:»|;X-i HM' Co 



1>^IJ\J 






<y\MyY>^<j-JL>v 3vl lOCi 

Deputy Health Cflflcer 



Registered J^o. 



1 



\>u 



DEPARTi\lENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of S)eatb 

( "U. S. StanDarD ) 



N 



PLACE OF DEATH: — County of 

oUv3\MVulaVu h ^VAA. St.; 



Dist.; bet. 



* IJL. %. "J 



- City of 0^ Cn vcr 



and 



^'^^'«-*^^^^ ^H ^ 1 ■ ,'_,,.■, or«;iOPNCE GIVE FACTS CALLED TOR UNDER 'SPECIAL INFORMATION" \ 

( " r/*;".T°H"o±%*".V,~^rHOS^r.t :":""u"o';"'c,.t^.S nam. .NSTC, or ST,»T .-.O «U« = C.. >) 



FULL NAME JxcVaxAl JLO^aJAj, 




PERSONAL AND STATISTICAL PARTICULARS 



sj:\ 



vn\<^' 



\\ 



*.(iI,»»K ^ 



^ 



(\ 



LL.KcLc 



DAI1-: nl- i;iK 111 



(Month) 



AGR 



ck,^ Yrai < 



(Dmv) 



M.>„tfis 



(Year) 



Da vs. 



SIM.I.K. MARK 11. n 
WinoWKD nK I)IVnKri:i> 

iWiilt ill sdtial (l» •.iv'iiiUi"'!* 



? 



lUKTHlM.Av'K 
I State m Country) 



NAMi: 1)1 
FATMI.K 



lUK inri.ACK 
<>»•• lAriii'.K 
(.state or Ctmulry) 



W. 



TV >vJLA.<rv'a 



ft 



MAmKN NAMK 
OI- MOTMKK 



iuK'rmM.Ai'i<; 
()!• M«>Tin:K 

(stall- or Country^ 




oCCrPATION 

Kf^idrd ill Sail Fi (intisrn 



) 'ra 1 a 



.\hnilh<: 



n,i\s 



TMK AHOVK STATH I) I'KRSONAI, I'AKTU'rKAKS AKJ. TRrE TO THK 

iu:sT oi" Mv kn()\vm;i)c.k and nvAAv.v 



(Infoimaiil 



(j(x/yv>,,(pj-oJL NJ XV^tv-x-aX 



1} 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



\S^ I go H 

(Day) (Year) 



ict 

(Montli) _ 

I 11I':R1:HV CI-RTII-^V, That I attt'iKlcd (Icccased from 

— 190 -r—— to • •••• 190 ~~~ 

that 1 hist saw h t::"^ alive on ^^P 

and that death occurred, on the (hite stated above, at 
M The CArSl'lJ4l'' DlvATIl was as follows: 

AyI^V'0^-<^ J X/.\>4LJv] ...-. 



DfR ATTON yeaf\<! 

CONTRIIU TORY 



Months 



Days Hours 



•«-4?»**»M«*«i 



I) r R A r 1 N ..«..™J 'ea rs 
(SIGNED) dJ 



\) 



i^Fonths 



Days 



flours 
M.D. 



19^'-^ ( 



Address) . Ok^ CP/V-cLuJl^VV (To^J 



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 



DAXK of in-KiAi. or RI:M()VAI, 

I90H 



(\<l<lrf! 



PI.ACK OK BURIAI, OR RKM()VAI. 
rNDKRTAKKR ck . \I I A.. 



{Ad<lresH 



QrUvr ai 



^ . •! J Am .hniiid ha atated EXACTLY. PHYSICIANS should 



N R — F.very Item of inTormaiion snouiu oc win«i"..^ — t-i- ^i«t.j ti*.. *'Ark«cl«l 

rtate CAUSE OF DEATH In plain term., thnt It may be properly clarified. The Special 
none dylnft away from homo should be ft'ven In svsry tnstsnc*. 






i > 






1 



I 



M t 



i 




I 
t I 






W 



RITE PLAINLY WITH UNFADING INK 



l!..-i- 



•t'. I 






j fhi/r /■'/7r'/.V(\(rv>JoTvJiaX' ?,l 



/.'>r;l 



THIS IS A PERMANENT RECORD 

REFER TO BAC K OF CERTIFICATE FOR INSTRUCTIONS 



"i 



N 



t^^v..IjLA>^ Depu.y Hearn Officer 

DEPARTMENT OF PUBLIC HEALTfi=Cit> and County of San Francisco 

Ccvtificatc of Bcatb 

J ■ 0571 A ^ 

PLACE OF DEATH : — County of O.'^-v . V<X ^ vca„;icj <.ity ot ' 

^ ^."o^'lTH^OC^URr.V.rrHo's'^T'l^ O^R ^1 S nT JV'o^N^O . V E ITS NAME I^SrEAO Or street A.O .UVBER. ) ^ 



) 



FULL NAIVIE 




CPrVCAXXj J 




--l-X 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.nk 



•V - - 



DA IH <»I- r.lK I'll |\ |\ 



ljJrv«w\jl' 




(I>ay) 



(Year) 



O sJ Vrars A. 



.U 



',,,/,'//> 1 5 />"' 



MEDICAL CERTIFICATE OF DEATH 



1) 



m 



(Month) 



...IB /pr?'! 

(Day) (Yt-ar) 



SINC.l.l?, MAKKll-.I) 

wnvnvHi) OK i)iv«)Kv i.n 

iWiitc in -^fWMal ik'sr^natiou) 



(Slrttf or Country^ 



FATilHR 



oUcw^vCv 




I ni;Rl'r.V CllRTIl'V, That r attended (leccasotl from 

jy.cjb. v5^ 190 H to C^x^sNj- la ^..TcpH 

that Ilast saw h-^^^ alive on ^ ^\^- ^-^ ^^O ^ 

and lliat death occnrred, on the date stated ahove, at b^O 
Q M. The C.vrSI' Ol" Dl'.-Xril was as follows: 






I )r RAT ION J'a'''"^ 



HiK rm'i.AOE 

OK lArHKK 
(State or Cuuiitry) 



MMDICN NAME 
OP MOTHKR 



i!iR ritPLAri-: 

(»!■ Mo'llll-.K 
(Stat<' tii t'oinitryl 








C 



.tXxx/> 



'vxi-. 



occu 



:UPATION(^ 






Months ' T^a\ 



nr.ST Ol- MY KNoWI.l.D'.H AND IH.Ml.l 



Mouths %\ pays 




Hour 



Dr RAT ION 



Hours 



Years "- Months -.^Days 

i SIGNED ) -G . \J . ^n\lAyvm....... M.D. 

A)Wr Xt Tc)oS (A.-.dre-.^: 13^0 5 



/X^ycJkxtrv^ 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



( Iiiloiuant 






r,,„vss ilia dttrOi-CL<X>-v ..)t 



\\X< 



i)\'n: of lUKiM. or ki;m()V.\i, 

Ql^jvr IX T90H 



n.ACK oi" lUKiAU OK ki;m<»\ AI, 



/v-/0-<Xxi.^VvvMXx^ 



— — — ' """" TT HmT A(;r. Hhoulcl be «tntecl I.X4CTLY. PHYSICIANS should 

N. B.— F.very Item of ln*<>.m,.t1on «houhl "j^' --;;'' ^^ ^^f;. ^^ ^^.^.^Hy claHnified. The "SpeciH. Information" for pT- 
*. * r'lii'ir or DFATII in plum terms, tnni ii mn> y.^ i • 
:"...> 'nft-w»i ."L ho„,c -hou.d be »K.n In ever. 1n»..n«. 



i 



t '1 






w 



RITE PLAINLY WITH UNFADING INK 



I',, .-.r.l .:f H.n'tli I X.. !-- t'--:;^^^i)I»."vr I'm 



id I 



I si 



\ , 



. : 




/hi/i' l-ilc'l r 1 LcA>-0'T>\A.U>,..3U, 



a 



7.96>H 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

lie<^Lstered ^^o. 3242 



^ 



^ 



cL^vAA^^ Vx.X'-u 



Deputy Hcc-lth Officer 



DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco 



• I 



\ 



Certificate of Beatb 

[ "U. S. StauDarD ) 

ofaa-TN. J .fVO^^vCvA^O City of^'-C^^ JA.o^wcv.^/.io 

5-LL and bX'L 



(^ 



PLACE OF DEATH : — County 

1M ^ '^ ^ Cri Ci ^■"A^• St.; " Dist.; bet. 

No. W^ J^V.^i..l.^> „ ..OUAL REsTdENCE GIVE TACTS CALLED FOR UNDER "SPECIAL INTORMATION- \ 

( '^ r"orATroCc"u%rEV."rHO^S^Pr.L rR'?NSn?'u^4'; O.VE .TS NAME ..STEAD C STREET AND NUMBER. >/ 



FULL NAME 



J oJL\A.-<:Jf.. • cLcX/>-y:v£. 



'M- 



I f 



u' 



< * 



^i:\ 



DAIK »tl IlIKin 



\r.K 



PERSONAL AND STATISTICAL PARTICULARS^ 

((>l,« >R \ 





VC' 



,u 




Month) 



SlS 



J tUl t s 



\ 



(Day) 



Months 



X 



ll^.^ 

(Year) 



n,iv 



WIDoWl.I) <»k DfVoRrKI) 
iWiiuin Miciiil «1» si/tiati"n) 



(Slate or CoMntry) 



NAMl, i)J" 
I- ATI! VM 



lUKI III'l,AiH 
OF I ATHHK 

'St.itr or t'otintry) 



Ol- MOTIII-.K 



I'.IKIHl'l.ACK 
()| MoTHHK 
(Statf or Coiiiitry) 









'VS./J^ 




Mu,ith^ 



1 1ll 1 



IU;ST OI" MV KNOW l.l.IX.K AND Hl-.Ml-.J 



(Infoi niant 



f \(l<lrr«is 






QT^ • ^ 



MEDICAL CERTIFICATE OF DEATH 

Vj L^5>J~' .-■. 

(Moiitli) 



(Day) 



(Year) 



I lUvKI^nV CIvRTIFV, That I altended deceased from 




,?, 



to NiA^xT^ Aa 190 H 

^^h-crsr .9v ......190M.. 



Dl 190 

that I last saw h^^vv^ alive on 
;ind that death occurred, oti the date stated above, at 
M. The CAfSlv Ol' DICATll was as follows: 

J . AAJUx^./C,^.AXxi-<LA^ CrV Xoi-/v-.ua. 



DTRATION I Yearn ^^ Mouths B^^s Ilourn 



CONTKIIU'TORY 



'•*«*»«:«*««!*« 



DIRATION 



Years Mouths 




Days Hours 

M.D. 



(SIGNED) ,. - ^ ^ ^^ 

\\\t^/%\ TooM (Address) i^ aJ-LlIcl^ \.j> A. A 



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

Former or "«** '«"« »* 

Usual Residence Place of Death? Days 

When was disease contracted, 

If not at place of death? • •;-••• 



I'l \CF ()1- HIKIAI, <)K KHMOVAI, I DATKof Hi kiai. or RKMOVAI, 



(Address 







!N. B.- 



,^-^»fe^ 



.. , TT^ »u„..i,i he Htated EXACTLY. PHYSICIANS should 
-Every item of information .hould be careVully -"P"'-;^- „^,^J;,t7,a,«med. The ••Special lnform«lio«" Ur pT- 
•tate CAUSE OF DEATH in pIhIh termn, that it may be properly cla8«.tica. 
^on. dvinft away from home nhould be ftivcn in every .nntance. 



1^ 






1 






i;. ;,-,! ,,f ll< ;i!tli 1' V" 



Pi! 



I 



,'i 



t I 



t t 



Dal 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

-.r,?>-, lu'^ V Co REFER TO BACK OF CERTIFICATE FOR (N3TRUCTION9 

^"'^""^ " 3243 



iiiv7r^/,\rUv<-eyYYj6<iL>v S.I 



IfJO'i 



Be<!i\stcred J\^o. 



^ 



Lft^v. Ua>^ Deputy Heallhpfr.cer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of Beatb 

( U. S. Stan^arD ) 



No, 



d 



t"(\Q "X St.; ^ Dist.;bct. 1 b yLAvj and 

^ "" ..O..JII Drcinrrsirr nvc facts called for under "special information" A 



nU 



1^ 



i.\ 



, ;!l 



V*. 

\ I 



FULL NAME 



^yw^u. m<xa^Ux^.. m 







PERSONAL AND STATISTICAL PARTICULARS 



■ i;\ 



^ 



>\TK oi lUK 111 



L 



COl 



Uj>i'v\.tx' 




(Month) 



(Day) 



\«;k 









hi, !. 






" tf 









10 



JVrt»^.« 



11 



.!/./>////.- 



ai 



(Year) 



/)<J I A 



NlNC l.K, M.\kKli:i> 

un)t>\vKi> <»K i>!\«»Kri:r) 

i\\'iit<iii s(Hi;i) (1« sivrnritinii) 



VTlfVcavi 



.KaX'CL 



ruKTm'i,AOK Qr\ 

' St:. ti- or Country^ _Y Hjl' 



NAMl" OF 
I- A in IK 



C^ 



«T) 



LdA\KV\.<i J.\X>_^\MX« 



BIRTH IM.AlH _ 

<)i' I APin-.K fO f 

i state or Country) )• \ 







MAinKN NAMK 
OF MOTIIKK 



lUK riM'LAl'K 

<)i M«»Tnj-:k 

fStatc or CotiiUry) 



h'f'iiifil ill Stiu /'mm ism 



lb )v 



t! I S 



.}f,>ii//i< ".... An.v 



TMKA1M)VKSTATKI)!M^RS(>NA^^AKTI^^•^AKSAKI•TK^KT^ THK 
IJl-ST OI- ?.JY KNOWIJ'.DOh AM) HI-.I.IIJ' 



( \(l(lrcss 



50C\ 



Jt 



MEDICAL CERTIFICATE OF DEATH 

DATi-: oj- i)1':ath 




(Mont)i) 



fi.. 

(Day) 



(Year) 



1 IlIiRIUiV ClvRTII'V, That I attendLMl deceased from 

lot aa^ 190M to .....Qru>j- a 190 M 

tliat T last saw h XV alive on VA^SUr. i5" 190 H 

anil that death occurred, on the date stated above, at I 
OL M. The CArSl<: OV DHA'Vll was as follows : 

.<;;l.-voiucLJJSXxx.cLcLjl>>j. 



Months 



Hours 



DTRATKIN 'i'ears Months Days ^ Iloiit 

CONTRIIU'TORV \JXy-yy.JUlJ\j...'S)^..S)sjM::y^^ 



DURATION 



(SIGNED) 



Years 



Months 



Days 



.Qftl... & . l) 'Ouyxj M)UltA, 



Hours 
M.D. 



CVr 1*1 iqo H (Address) I 



s%H QfYioAi^d. ii. 



k 



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

Former or ""^ '»"9 at 

Usual Residence Place of Death? Days 

When was disease contracted, 

If not at place of death? 



I,ACK OI- lURI^I, OK RHMOVAI, 




D.VI'Kof HfRiAL or RKMOVAI, 

xTUrvr xi i9o_H 



rNI>KRTAKKR VrK^^OAXxJkxX/^V V/ jfo (OA^U '^\x 
(AcMrcss .%'h^ I \J rU.XMJ^A..'<rVV. Q.l 




N. B.- 



■""■"■"■■"■""■"''^ I ATP oKr^.iia he Htatetl EXACTLY. PHYSICIANS should 
-Bvery item of InformHtlon .hould be cnrefully -upplled J^^^^^^^^^l^^^^^^^^^ information- fer p.r- 

state CAUSE OF DEATH In plain term., that It may be properly claMinea. f- 

don* dylnft away from home should be ftlvcn in every instance. 



3. 
I 







n 



'■ / 




! 1 



i ■'' 



,1 







J 

.4 



» ? 



I 



, J 



li^li 



I 



I 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered ^'o, ^^^^^ 






'L^^^lw^ Depurv Menl^h OPncer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 



( tl. S. Stan^ar^ ) 



J) (^ J? 0?^ 

PLACE OF DEATH: — County ofC'OyYv J^vay'vA.c\.4C^ City of 3a.v 



j /VCL "WCA^OC 



^No 



. licLnl 



^ 

(3S.. 




and 



(!l). 



( '^ r/rr':Tricc"!ircV.;''rHo"s"prT'it ^^^^i^n.^^o^^'ijr.ii name ..st..o o. stb..t ..o .umbch. ; 



FULL NAME d^xAQ 



. Qx 



(Xu^h;.. 



PERSONAL AND STATISTICAL PARTICULARS 

i»\ 11. «>i 1(1 k 111 



Uj.Av<Jjb 



iMotUh) 



Aon 



bi 



J V</ 1 



(I)i»y) 



M.mlhi- 



A-H.D 

(Year) 



Da v: 



SIM-.M' M\KKIi:i> 

W IIM »\\ I- I) OK I>I\'« »Kri:i) 

I W'l iti in ->.>ci:(! <lt-iv'ii;ili' m > 



lUKTIUM.AOV-: 

'St;iti 111 Ooinitryi 



I AT Hi: R 



mu IMPl.ACK 
ol I A 11 IKK 
(Sliilt <it «."<)untry) ^ 



MAIDl'.N NAMi: 



lUK'rnrr.ACH 

Ol'- MOTUHR 
(Slate or Country) 






rY\AJi-\juw\y\x>j 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DlvATM 



(Month) 



QvO 

(Djiy) 



(Year) 



I 1JI':RICBV CIvRTII'V, That I attended (leceasecl from 

.^vr- 190 5 to ^^^^"^^^ ^-^ ^90 H 

that T last saw hJL^. alive on \IW^. ^^ 190 'I 

and that death occurred, on the date stated above, at 
is. M. The CATSI-: OF DICATII was as folUnvs : 

V,^Vv^<!,CU^V/CLv.Lv^^ OJILa^aJLu^ 








^JLrr\Ki 



OLaXoj 



7 



n 




iJAK.'yy'\jDsyy'\Mr 

OCCUPATION 

P.siJ,,! iv S.nr r,n,„h,'o XI )V<m.v ^.^fn„ths 



/hir: 



TMK Am>VH STATIC) rKKS(>NA,PAKTU-ri.AKSAKHTKrH TO TIM- 
lU-ST Ol' MV KNOWl.l'.IX.h AM) Hl-.Ml-.l 



(Infoiniant 






f Xddrcss 



lb 



V V..' V 



'K 



Mouths 



Days 



DIRATION -^ )Vrtr.v 



Hoitys 



Years 



Mouths Days 



Hours 



nr RAT ION 

(Signed) v).- 0- cL^VA...^tnnu!...,...,.. M.D. 



VJXCV' Ssi iqo^ (Address) ' 3> 1 L '.. CX-vvi 



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

How lonq at 

Place of Death ? Days 



Former or 
Usual Residence 

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



'I,ACK OF KrKIAI. OK RliMOVAI 




CO-^^L 



(^ 



jLo^/ex 



DATK of HtRlAI- or REMOVAI, 

\KxnJ- a^^L 190H 



INDLCRTAKKR 



X9 oJUAxA '^'^'^ Co 

Address ^Hb \l(TLA.-Ci>lAwXrV\j 3 1 



^ 1S..I AfiE Hhould be stated EXACTLY. PHYSICIANS should 

Btion should b. carefully «upplie«l. A(.E «''""'" "j^" ^^^ "Special Information" for per- 
ATH in plain terms, that it may be properly classified. The »pecia 



N. B. Every item of inform 

Atate CAUSE OF DEATH in p ... 

^on. dyinft away from home should be ftiven in every mstance. 



« 



J 



mtftmmmmtmmmm 



^r' 



i 4 



I 



I .i I 
i 



1 ' i» 



I . 



' k 



J* 



Ir 






1 >» 




. » 




» J ■ r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!u:,i.l.,f ll.altti I \<), Is 'fr-i;;ar^^lJS:l' 



Co 



RFFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' /vVr^/ArUru-o^A-jL>-c\^ 



XI 



100\ 



Registered JsTo, 



3345 




A>Vf Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "a. S. StanDarD ) 



PLACE OF DEATH: — County ofO/CL'W /v<X/>xxi^c^cc City of 0/CXA^ Axl^^. 



<:,\Xi.c<Q. 



'No. 'bl 




rv<r>v 



( 



/V-4, St.; '\ Dist.;bet.-- I'd 



tl 



and 



n 




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



) 



FULL NAME 




v<buLAAr H iLcX^LA^. 



^ry;\».. 



> !•; \ 



PERSONAL AND STATISTICAL PARTICULARS 

C01,OR 




ux 



I, 



f 



I) \TK < •» HI Kill 




M.mth I 



Liv<Jji- 



...a /15..1 

(Dmv) fVear) 



\«.H 



m 



) eu » . 



Moulh.s 



10 



/?</ » .V 



siNvn.r. M.\RUII-;i). 
WIDOW I'D OK I)I\'(iK«,h;i) 

iWiitt ill siui.'il (lr>-iuti;iti<iii ) 




|{IRTHPr.\OK 

(Statt i>r <.i>uiiti>> 



WMl'. oi 
FATUIK 






.^VVvMrvu. 



HIRTHIM.Al'K 
OI' I'ATHHK 
iStatf or Couiitrv) 



MAIDKN NAM I 
OF MOTHKK 



IMR THI'LACK 
OI" MOTUKR 
(State or Contilry) 




MEDICAL CERTIFICATE OF DEATH 

DATK OF I)F:.\TH 

:,..... \'\ 




(Mf)nt}i) 



flJay) 



(Year) 



I IlKKKIJV CICRTIFY, That I attcmkd deceased from 



190 



. LAa/^ ic 

that T last saw h-Co^vvj alive on 



to 



190 H 
190 *A 



yfV^ssr.. V^. 

aij^l that death occurred, on the date stated above, at H 3 

)i<:a'i 



ami tnai iieaiii occurred, on iiic dale stated al)Ove, at 
Aj M. The CArSl<: OF IMCATH was as follows: 



nr RATION ^ Veat-s 
C O N T R 1 B U T O R V 



Mouths Days Hours 



duration 
(Signed). 



Years 



Months 



.™VyjtXx) cL<XXAAi 



Days Hours 
M.D. 



Resided in San /'i itmisri} lO }V(/;.* 



.^ foul ha *■ fhns 



' h^- XO iqoH (Address) ^ 0^ IxXA^vKt d± 



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



», Institirtlons, 



Transients, 



thf: ahovf: sta i i:i) phrsonai. i'aktkmi.ars AK1-: TRFK TO tuf: 
in:sr of* my knowijcdcf; and hfi.if.f 






'\ML 



Former or 
Isual Residence 

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



How long at 

Place of Dealli ? Days 






^^I.ACK OF lURIAI, OR RF:M0VAI, 

rNI>F:KTAKF:R ^^.-</<./>\JRJJ\) ^^ cL 
{Address Slbb^ 



DATllf.f HiKiAi. or REMOVAI, 
VUVT X^ igoS 



A-v^vXi 



IN. B. Rvery Item of information should he carefully supplied. AGE should he stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for psp- 
Rons dyin^ away from home should be ^iven in every instance. 



tit 






[' ' f 



t 






.fii^ 



■ 1 



I 



i'M 



i'l 



I ^ 



f. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!,.:it.l -.f H. ..Uli ! N'n 



.. ■<:. 



h.SlI' r 



pfffr rifcd , ^4l.CV'^T>\.l^\' 



:xi 



1 9 OH 



REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3246 



Ee^isfered A^o, 



-? 



dcfrv^v.^ V. Deputy Hccfth Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of Death 

PLACE OF DEATH:— County of CW-vO.-VO^Tv^Vstco City of Oayy\> J Axv-v^c^vlco 







^ LKA>^xt<.iUJ^>"y\A.mt<.>LCSt.; Dist.;bct. ^ ..- and 

/' IF Ot*TH OCCURS Vw*Y rROM USUAL R E S I D E N C C G I V F FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
V IF DEATH OCCy(«R«0 IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



•^ V. 



VV.OL.A..TUO 




'I 



(5'\A^w^w.€rt^. „ 



PERSONAL AND STATISTICAL PARTICULARS 



SK3C 




COI.OR ] j^ 

LL'/K^U; 



D.XTK ni* I'.IK 111 



ItX/YV 
Month) 



\<'.K 



7 'i 

I V' ) til f .V 



(Day) 



M, I II I /is 



(Year) 



n 



iht ) , 



sivr.T.F, MAKK n;i) 

WIDnW I-:i) OK I)I\t)Kri:i) 

(Wiitriii >itKi;il iltsiviiat ioii ) 



BTRTnrr.AOH 

fStatf or Oountrj-^ 



O .CO VO/Lt 



(\A^O 



NAMK OF 

FArmiR 



CX-tX V) l\-{ruJLt<o V. 



IUKTm*I.A(.'K 

Of I \iiii-:r 

iStalc oi lOmiti v) 




MMKI'N NAMK /?\ 

OI- motiii;k ' ^ 



lUK IIU'I.ACR 

til' Morm-^K 

(Slate or I'oiuitry) 




^ 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATll 




(Month) 



( Day) (Year) 



1 m:RI<:nV C1<:RTII'^V, That I attended deccasctl from 

V ^(rvr lb. ...igoH to ...=^NiXis>jr..l.a 190 S 

that r last saw h L^ . v alive on ... ■ .M^^^ 1"! 190 S 

and that death occurred, on the date stated above, at 5 O 
.U M. The CAISI-: OI- DliATII was as follows: 

LiLNJlX-VCLl Jb-e/\>v.oVX„^v<xci.x 



DURATION Years Months ^ Days Hours 
CONTRIBI'TORV ...- 



oi 



cr,.AT,oN(^^^^ , 



_UXA./»"v-^rvvAj 



Kf aided III Siui rtamisi'<> 



)r,ti 



y/oHtfr 



n,iy 



VWV \1U>VK STATI'.I) I'KK^ON \1, rAKI" IC C l.A KS A K K TRIH T< > IHI- 
ni<:ST «)1" \IA1 KN<)\\1,1",I><.H AM) HlU.MiK 



(111 



(A (hires 



LA-Vvrai.'l 



VCr\A..^C 



DTRATIUN Years ^ Months Pays 

(SIGNED) LO . \3 ■ ^^-<r^rJL>a/Yv 

Vfl (^:' ft I (,o 'I ( .\ <1 d ress ) UJC-^^A^^-, 



Hours 
<X/y\j M.D. 



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

Former or How long at 

Usual Residence Place of Death? Days 

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



i-UACH 1)1' m'RiAi. OR ri:mov.\i 



i:ni)i;rtakkr 



DATHof HiKiAi. or RKMOVAI, 

mWj- rx 190H 



N. B.— Kvery item of information .hould be CHrefuMy supplied. AGB should »>« stated BXACTLY. PHYSICIANS .hould 
•tate CAUSE OF DEATH in plain term., that it may be properly classified. The Special Information f«r psr- 
sons dyinft away from home should be ftiven in svory Instance. 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 

3247 



|lo:.!.l ..f n.:,l(h lN-<> i;. S-^^srv-^^luS:!' C) 



r,)()\ 



Registered J\'*o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



,^A.-C'V--^ 



>^ » ;, f 1 



cer 



Certificate of S)eatb 

( tl. 5. StanDarC> ) 



PLACE OF DEATH: — County of OOlxv, JAXx.>vCv.act City of J,Co'>a. sJAXX/>%aiaa^c 



0?) 

0. 



No. 



St.; 



Dist.;bet '" and 



'^^ ' 7^ ^ v. V- ^ ..cil*. QFSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" A 

( '^ rF"D;ATH"o?:u%;rD\"rHO^S^PrA;: o"r"nSt'.?J;!o"'o.VE .TS name instead OF STREET AND NUMBER. ) 



FULL NAME 




OXh^'. 



lrL\^ 



VUl 



r\M. 




SKX 



DAIl". < »1 lUK in 



\<.K 



PERSONAL AND STATISTICAL PARTICULARS 

"" " I coi. 



UuJvAijb 



(Month) /T 



^ 



iVats 



t, 



5 

(Diiv) 



Mntllll! 



1 3 



(Y.-iir) 



/></ 1 



^INt.I.T', M AKKIi:!). 

WIlx >\\ i:i) OK |)I\'<)K(, l'".I> 

(Writf in s<K-i:iI (!(>-i;'ii;iti'H\ ) 




lUKTHlM.At'K 
(.Slate or Couutry) 



I' AT in: K 



IMKTliri.ArK 
Ol lAfUllK 
(Stiitc or Country) 



MAIDKN NAMK ,T) 
(>» MOTHKK 



niK'rmM<At"H 
«»i' M<)'nM:K 

(State or Country) 






cU' 



r 



x^ 



.t 



JLkKJ^ 



XV^vcxyvxAL. 



.Ow\XX.^ 




i) 



iLhyvY^a^v^M^ 



OCCrPATION 

Rcsitlfit III Sini liiiiiiisrn •■' 



^ 



) Vi/; v 



Mniilhs 



Ihivs 



Tin- AHOVK STXTHI) PKKSONAI, I'AKTKT I.ARS AK H TK f K TO TllK 
linsT Ol- MY KNO\VM-:i)<'.K AND HlU.Il'.K 

„„r .„„ \)nrw.o CI . C. *o -dv\^ 



( AfldrcH.s 



MEDICAL CERTIFICATE OF DEATH 

DATH Ol I) i: AT 11 




(Month) (Hay) (Year) 

I HliRIUiV CI'IRTII'V, That [ atten.lcd ilcceascd from 

r.. 11 190'i to Vlf.Vcvr i\ 190 H 



that I last saw h^/> xvalivc on 

and that death occt 

^.'?>^fiM. The CAl'SI-: OF DICATII was as follows: 

■'0 p 



^xv alive on HJ,/ii:^....,*M 190 • 

urred, on the date stated above, at CMkAJ. 



V^'VAwA^JS 



Q ^ ■ 



DT RATION )\'ars Mouths 

CON T R I III 'TO R N' L<X\.d.A..o..:^ 
CL'VA.cL J Cr'V/COi-^VAA.'CU 



Days 



Hours 



kaJ^.\^.\ 



DURATION Years i'ifouths \ Days Hours 

( SIGNED ),..yJ/...MV^ M iV Xo-K^JL'-vv M.D. 

VyWr 1% iqoH (Address) 1%'^- H jjy It 



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

Former or o ocj iA zi-tf- 

Usuai Residence t)^o L^ UAi 

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



Hew long at , ^ 

Place of Death? v. Days 



rj.ACK OK nrRiAf. or rhmovai. 




n.VriCof HiRiAr. or REMOVAI, 

vyuv- .3vi 



Ob JliC/cx<' t{ 

rNDHRTAKKRlD-MijUVV. ., 



I90I. 




.•J^'^u. 



F OF DEATH In plain term., that It may he properly dsMhlctl. The Special Information Tor p«r 



N. B. Every Item 

state CAUSE OF DEATH In p 

sons dyin* away from horns should be ftlven In svsry Instance. 



f: 



■1 



•♦ 



ir^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

3248 



J.,,:,,,! ,,f n.aith I N'- :- ■*--;..'«':r-»"'"''^ ''•''' 



ajvi 



Res! Loitered JVfl. 



l.frv^» "lox-v^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 



(^ 



N 



Cevtificate of ©eatb 

( tl. S. StanDarD ) 

PLACE OF DEATH: — County 

o. 5 b O^CX^'V \ e^VO. -^^^ St.; t Dist.; bet. H^ iL via> ■- and,-^— ) 



of OO.^'V ixiX'YX^U^^C^ ofdoy^^ JA^ayi^..c,4^CX5. 



CiCL^v OCV^ O -^ -^ St.; t Dist.; bet. 10 v^'rv; wuu-ano ..••_ 

>V^L,VA. > V ^ *. V ..V,. - prSIDENCE GIVE FACTS CALLED FOR UNDER 'SPECrAU INrOBMAT.OW ^ 

( '^ rF^or.T°"occu%rcV.;''rHO^s^.r/AL ^nV.lf.'i^.'ioV.... .ts name ..stead of street and .umber ; 



FULL NAME 



Ckctd L. rnX'^^JuS- 




M^^!\... 



PERSONAL AND STATISTICAL PARTICULARS 






DAT!-: nl- BIKIII 




cor.oR ^ 



\ 



LUyVxvAX 



I ^ MEDICAL CERTIFICATE OF DEATH 

DATE OF DEATH /V 

\IW IL 

(Month) (Day) 



MVcvr 

(Month) 



(Day) 



(Year) 



ACK 



^,tJLlQ> 



IV^IA 



M,.>it!is " ''^<" 



S INC. I.E. MAKKIICD. p. 

\VII)(»\Vi:i) OK DtVOKCl'.D J) 

iWiittiii MK-ial (h sij^tiation) "^ 



I 



HiK rm'i.Ai'H 
(State or Country I 



NAME Ol" 
FATHER 



lURTHPl.At'R 
0|- lAlMlEK 
(Statr or Country) 



MAIDEN NAMli 
OF MOTHER 



lUK rniM.ACE 
oi- MOTHER 
(Statf or Country) 

















OCCrPATION 

K('sidrif in Sun I'lanrism 



n 



)V(7;.T *" M.DltllS 



/),n. 



THE AHOVE STATED .'ERSONAl. l'^^ '-{J'/JivX*^^ ^»^''- ''*'' ^' ''' ''"^• 
lJfc;sr OF MVJs.NO\Vl.EDC.E^AM) HEMEt- 



(InfonuaTit 



(I'^q \ryw^^u.-<r>\. at. 



(Year) 



I HFCRIUJV CIvRTIFV, That I attended deceased from 

, '■ 190-^— —to 190——. 

tliat I last saw h nrrrrr. alive on ■■ ~ ^9° ~~~ 

and that death occurred, on the date stated above, at — —— • 
~r~ M. The CAT SI-: OF I) HATH was as follows: 





nrRATION " }'ears Months Days Hours 

CONTRIBUTORY \.I^^l-iC^LcU..^»JL ....LL:v>^^^ 

^^t'x.'cL. Ov>A.-<aX^vxxA-v-xX^vs-txxX J 

DURATION Years Mouths Days Hours 

( SIGNED )..i.;)Na.A^.>^- VJ jd>U^J ^ 

VJTUvMC iqoH ( A.ldre.ss)lU Oo. XXkl dt 



M.D. 



SPECIAL INFORMATION »nly 'or Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from tiome. 

How long at 

Place of Death? Days 



.**»*«•»***•***■•' 



Former or 
Isual Residence 

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



DATE of BfKiAL or REMOVAI^ 

\[\.^ssr. X\ 190.H 



( \(l<lress 



PEACE OF lURIAE OR REMoVAI. 
CNDERTAKER 0^9. J. '$^.kJo^ 



(Address 



s-;r,2n;rr'. r,-rt -j^-'isr-J^ "'S ,r==-.^'=;". 



N. B. Every item of in?orma 

state CAUSE OF DEATH in p ... 

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



; »: 




• ♦ 



lit 






1 li 







M. 



w 



B.«»rclof lUnlHi I ^' 



R,TE PLAINLY W.TH UNFADING .NK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3249 






/)f(/r AV/r^/. \KtIvXT>vlvX\' 11 



/.V/'yH 



Jlrgi.slrrpfl .A^^>. 



Lv.v."L^>.^ Deputy Health Omeer 



DEPAraF:N7oF PUBLIC HEALTll=City and County of San Francisco 



Gcvtiticatc of Bcatb 



PLACE OF DEATH:-County of 3 Cu^ i^V<V.xc^ .^ Cty of dxx^ l^^>^c.... 






Dist.; bet. 



and 



JLI.. V.UV.U "^ ^trUL/^-vtu ']V3^<l.V\>^'va.lSU - - ^!^tVV^!LrD rOR UNDER "SPECAL .NTORVAT-ON ' \ 



) 



FULL NAME 







si:x 



PERSONAL AND STATISTICAL PARTICULARS ^ 




i\^ 



^ 



OATR <>I-' I.IK I I! 




yY\AAX 



(Ml.iilht 



30 



(Year) 



\«-.i-: 



}V(f» 



b 



,1/ 



.,////> ^H At.vj 



MEDICAL CERTIFICATE OF DEATH 



datk or i>i:ath 




(Month) 



I a.. 

(Day) 



(Year) 



I finUl-BV CI'RTIT-V, That T atteiKk-.l (kccasc-d from 

Q^t %\ icpM 






WIDOW l-"I> <>K l>I\'oKil-.I> 

\\t it' ill -orial (lr'-ii,Miati"ii ) 



r.iKrmM.AOK 

(State or C'luntiy^ 



^fAMF OK 

FA I'll i:r 






r.iKiinM.Ai'R 

<)|- lAIUl'.K 

(State or C'Miiiti \ 



MAIDF'.N NAMI-. 



BTRTTTrT.ACK 
Ol- Mo'llIl'.K 
(Stale or C()»intry> 



OCCrPATlON 



I 



(pl to \IA/13A^...ia Tc)oH 

11,at I last saw h A.^^ alive nn ?h.^n^ . la...- 190^ 

an<l that .loath ocrurre.l, <.n the .late statcl a1,.>ve, at 19. '^0 
G^ M. The CATS Iv Ol' ni'-A'nT wns as follows: 




isJ(x^,,cr^^,AXL AjJAjt^ 



v-\Ji:y'\./xX,KJs 



j)^ I> AT i( )N years ^ Mrni/is .»^^Dav<i 

COST R I lilTOR V •■ ••— --^-'- 

Pays 



/lours 



In-RATl()^^.— ^A'''^(>JYp ■ '^^''"^^" 

W- VI TOO''. rA. l.lres.)UU.^^^U. fe^^l 



T fours, 
M.D. 



^ 



Resided in Sc'i r-nnuisi^n \ I K^^" 



M.nilll! 



n<; 



HHST Ol- MY KN<>\VIJ^(.K AM) m-.Ml.H 



(In 



UO(XA.^>v\ 



SPECIAL INFORMATION only for HikpildK Institutions, Transients, 
or Recent Residents, and persons dyin^j away from home. 



Former or ol,^ 

Usual Residence I cK 

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




-V I How lonq at 

CJX Place of Death? A't Days 



(A.Mri-^s 



(^aJaaXoJu 



I'l.ACK Ol' IHKIAI. OK ki:M*'\M. 

r.aa.-.« Hl^ "^CrUUAv 



DATl". of liriu.M. or RlvMoVAI, 

\jUj\;~ XX igoH 



,«- 4 ' ""^ TZ 77L -h„.,,d be stated EXACTLY. PHYSICIANS should 

:in';dy.„» «»ay "L h„,.c should be ftWen i y •"..,««. 



♦S 



ai 



.Jf 



t 4-. 1 






1*4 



i 

I] 

I. 



1 4 j 



SI 



> ) 



* 1 



J',. >:ii( 



,rH.aMh I' V' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTITICATE FOR INSTRUCTIONS 

3250 



^) ii.ti' •'■ 







11 



ai 



Deputy Hea 



f * 



0-\ 



V,)()\ 



Registered J\^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Beatb 



PLACE OF DEATH:-County of O^^v -^.V^mvCv^ City of O-CU^^ J .VXX. >^Cv<.^o 






■^ 



FULL NAME VbCLXA.X/^u U.A. 




-v^ 



si:.\ 



PERSONAL AND STATISTICAL PARTICULARS 

^ LlJJ\Aij6 

i>A'ri: <'i I! I Kin 




i.Mtmllil 



A<.K 



(Hay) 



^/,,l^/J^^ 



(Year) 



W lI)<)\Vl-:i) <»K Divnwi Kl) 

i\Viit( in soiial dt siy.iiJUi'Hi) 



RIRTHIM.ACH 

' St;ilc or Ooiinti v' 






Pa v.v 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DEATH 




(Month) 



(Day) 



(Year) 



I IinRHBY CI':RTIFY, That I attendcMl deceased from 
A looH to nTUvT \R 190 U 




190 



that I last saw h^/Y>^ alive on 



c\r. \a 



190 



\ 



and that death occurred, on the <late stated above, at b 
aL M. The C\' 



X^n-y\xx^y^ 




NAM!-: «U" 
FATin.K 



lURTHPT.ArK 

(»!• I Arm:K 

(Slate or I'oiintrv) 



MATDV.N NAMK 
Ol- MUTMKK 



lUKPHl'I^ACK 
OJ M()Tm:K 
(State or Country* 

.KofPArioNf^ Jj^^ 

Rfsidf<! in Sitti l-Kriiiis,;) AC )V">'' 



.}r,»if/i.<; 



/hirs 



TMKA,.,vnSTATKIU.KRM^NA,rAKTK-r..AKSAK,.TK>-K To TMK 
IIHST OF MY KNOWM-IX.K AND HhMM 

nnnant GLu^jU^-A^ ^^C^^J^^ 

foo^^KXAyd- Oi: 



(Inf 



(Address 



IbS 



..VL M, The CArSIC OF W^-^'^""' ^^'*^ as follows: 

^ v>yj JOvi ^>i/>^>a.^y^jJ('vx>^ou4i ...cry^ 

iJl:^X^.^Au^^-^:>.^-QjO 



rr^r**i>**::t*.t^^^^^f-*^-f*- 



DI'R ATION Vc-ars Jo nfonths ^Days Hours 



CONTRIBUTORY 



Dl'RATION Years Months Pays Hours 

(SIGNED) L\.."o\JuLAy>-jL^^ M.D. 

^j\vC\r 14 TOO S ( Address) 1 1 i I : aA.<VA,k 0± 



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

Hew long at 

Place of Death ? Days 



Former or 
Usual Residence 

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



FI ^CK OF BFRIAI, OR RKMOVAI. 



D.yiFof HriUAl- or RKMOVAI, 

S)[\.^\r /X-^x 190.1. 



(Address bA AAJ <XAJt- 




state 



te CAUSE OF DEATH In plain term., that It may be 
. dylnft away ?rom home should be ftlven in every In 



..,„„, ..PP...-. '^^^^:T'^^/^^::iL .rr:i'or,.rp:'4 



IN. B.— Every Item o? information .hould be ca;;*"-'^ wl'^rbc properly clawlffled. The "Speci 



stance. 



M 






^ 




* il 



It 



1^ 



Ji K 



il 



WRITE PLAINLY WITH UNFA 



J5,,.,.1 . t !!• ''''" I' ^'' 



-^-^ -ar-^- lU'tr >"•> 



i 



] \ 




DING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 

lie ("» isle red •A^j. ^^0\. 




\ -^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 



w 



Q^ 



PLACE OF DEATH: — County ofOo^J-' 



\.a/>vC\AC.C City ofCJ<X".vJAXXy->vev^CC 



.'D 



, (jnrvAAiw/)\. ■ 



- ) 



) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

C<>1.«»K \ 



1 




SKX ^ 



'd.' kcU 



DATI* »>!■ niKTlI 



M'.n 



3v\0 JVrti.* ' 



(Day) 



,1/,. »////> 



<Yt'ar) 



l'( 



/>.! II. 



MEDICAL CERTIFICATE OF DEATH 

DATK OK Dl-.ATH A 

MVo\r 10. 



f(^. 



ipo*i 

TiTfuufnV CF,KTII'V, That I alU'iKlod deceased from 



SIN*'.!, P.. MAKun:i> 

WIDOWKP *>K DIVnKv 1 I) 
( Wtitr in >^<K-i:il .!- sii'iiiit iuti 1 



HIKTHri.ACK 

(St:tt« <>i Country 



n\xx>vVoocL 



(^ 



.€Vy>^' 



<xAo^ 



NAMR OF 

FATin-.K 



lURTinM.At'H 
Ol I APIIKK 

(St:ite- or Oonnti y"" 



[}) 



ny\: 




XxiX/vxj ,-_ 



>i 



\ 1 



'\ 



I 




v_ 






M\!1)1:N XAMl". 



lUKrHlM.AOK 
Ol Mt>Tni\R 

(St.itt.- or Country) 



V^ X^i 190^ to Vlmr:....5.0 190 M. 

that I last saw h JUv alive on SfX<^ ^h^.O. 190 H 

and that death oc rurred, on the date stated above, at 1 ^^ 

U.. M. The CAlSlv Ol' DlCATll was as follows: 

Oi>-<jUA..v/ciA^>Aj 4 ^-^^^^-^-""^ •■•"" 

OLcA^tjL.. .M\jU-^4^^^^^ ■ •-• 



nr RAT ION JVrt;-.9 

CONTRIBUTORY 



nfouths > Days 



Hours 



Rf>.uifi{ in Sail /niiiiisio V, )' 



(•(f ' > 



yrmifti'^ 



- An^ 



NAI.rAKTUM-LAKSAKKTKlH T< > TMl-: 



Tin- AUOVK STATKO ''»^«:^"\r 1 ' , ,,,,, ,,• I 
liHST Ol- MY KNOWM'.IX.l'. AM) Hl.Ml.l 



(Address 




DIRATION ^ YijUrs 

( Signed )..„....A....vl.,.. 



SPECIAL INFORMATION «nly lor Wspitals. Instilutions. Transients, 
or Recent Residents, and persons dying away from home. 

How long at 
-\"v^cu Plare of Death? <<A Days 



Former or 
Usual Residence 

When was disease contracted 
If not at place of death? 



503Mlal<r-> 



.••^M***-*****' 



1>I,ACK 01* lURIAI. OK KHMOVAI. 



DA ri; of IlrRiAi. or RKMOVAI, 
"^.'^ I90H 



.•A.i.ir..c« QlCj.-: 6 X-HrAJ ol 



■^■^'^^^^■^"™ ♦ t d EXACTLY PHYSICIANS should 

N.„._Bv.r, ..en, "»• l"J"_r.»i:r.."L7j;i •;;::;:';?. rrnr»rHe p^rerirc'...."-.:..! 'Xh. "Spec.;. .nfor.n..lon" ..r PT- 



:V rAllSF OF DEATH In plain terms, that it m«> "- .- 

•tote CAUM- Ui- "c« • ■ ^. . . ,, !,_ A-.ven in every instance. 

•on« dylnft away ^rom home should be ftiven in e 







1 



i; 



< ■;! 




^ 1 .^ 




w 

Il,,at.l ..f Hv..;tli 1 V 






R,TE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3252 



TV*-* 



i-j Its. I' <.'•> 







Ke^Lstered J\^o. 



JUk' ^5.1 1'^O^ 

Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of IDcatb 



jp 



Q^ 



PLACE OF DEATH : — County 



o&o.^ Skc^-^^^c City ofdcv>^ i'v<^'>vc.^cx. 




( 



if oj . I, Dist • betM-4->vXl-'tL a.. and U-X 



) 



FULL NAME 






1).\TK nl- lUK IMl 



PERSONAL AND STATISTICAL PARTICULARS 

COl.oR \ ^ 




)L 




l^v^cL. 



V^Vi; 



(■> I f-i 



«MuntU> 



ACK 



Si 



y^ats 



(Day) 



M.,>ilhs 



(Year) 



MEDICAL CERTIFICATE^ OF DEATH 

DATH OI- DKATH A 

Vllrxr W; 

(Month) ("»>;' 

__-----^---— -^-^^^^^^;-p^^^ ,j,^^^^ I atteiukMl deceased from 

to • • ^9° 



I go 

(Year) 



I9O 



^.15 



Davs 



^T^•(•.I.l•■. MAKKIKO. 
WIDoWJ'.n <»K IHVOKiKI) 

' Wiit. iti •~>n-\-A\ (l«sivMi;iti<>nl 



I iVcVV^V.^C/d- 



(Stiiir 01 c"<)unUy 



VAMl-: <>1 

I- ATn j:k 



d.-oo 




Os/i^-vcL 



lUKTllPl.Al'K 
01 I AIMKK 
(StMtr or Coiintry) 



M All) I". N N X M 1 •■ 
nl MorilKK 



yj4v>\. 




-nt 



XO'CL'yv 



that 1 last saw h -i^V alive on LUAXJ..™......i.a..., 190 M 

and that death ..ceurred, on the .late stated above, at 
LL M. The CAI'SI-: OF I)I':ATII was as follows: 



DIRATION y^-ars 
CONTRIBITORV 



Months 



Days Hours 



,c 




/cL 



v.OwOl\xX 



ItlRTHPI.ACK 

01 Njorni'.R 

(State or I'otintry) 





>^ - 



duration 
(Signed) 



Years 



W^jl^ 



I\rouths ■..>..' Pays Hours 



(XJUSj. 



^\V^ n iqo ' (Address) S.lCO'^VXMtix. C3l... 



J? 



M.D. 



( )C01*PA1 






Kfsidfd ill S,ni /xin.isro 



<X/'> 



r»<i' 



aX7— - 



.^r.'iitfn 



/hjy: 



■^'";^;}S?i^'Si'^^^^!;^^'^^-'F^' 



KV. TKIH T«> '''"^'- 






or 



SPECIAL INFORMATION only tor Hospitals, Institutions. Transients, 
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 




,«*irt»«*»»i»*M«»«»*<^*»;^* 



PLACK OF lUKLM. <»K KHMoVAI. 



I)\Ti:o!" IliKiAi. or KKMOVAI, 

vVu^T ai T90H 






.,a.ir.ss "^Sn QfVuva^c-irvx, 31 



,v„„e« Svl*^ (yVur>^A-<MxLv vv. ')t 

J -^— ^^.^i^^^ ^i^— i—— — — ^— ™^^''^™^^'^^^~~ , . J 1 FXACTLY PHYSICIANS should 

:r /Z -way" ."ro^ hi. ^Hou.d he ».v.„ > , .".«-"«. 



)J 



i 



i 



! 1 * 




I 




I' 



WRITE PLAINLY WITH UNFADING INK 



V^nifl ..f I Ira nil t 



V . ■'^-'^•^y^i. ]'.K r I' 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS 



!}(f/r Fi/rf/SC[..€\3-VTrJi>~V\) ^ 



I90\ 



Ee^i^'<tered JS'*o. 



3253 





^ 



Deputy Heattfi Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of Bcatb 

< -Q, 3. 5tanC»arD ) 
PLACX OF DEATH:-Co.n.y J^.J.^Cr^^^ ^V oi CVcv^ ^ VC^-vc^-.o 

i, ir DC»TM occunRto in a hospital or iNSTrru 



) 



FULL NAME 




CrVCrL'lx-u. <jXju<.^^ 



-1 



PERSONAL AND STATISTICAL PARTICULARS 



SK 



, JjL/YVV<X 



I 



C< il.< >K 




y 



)\x. 



Xxj 



!)\TK Ml HIKIII 






4 Month) 



(Day) 



/RtH 

(Year) 



ACK 



} Vm > s 



! 

M.niUlS I. ViVV' 



iQ&y^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I)I;ATI1 A 

Ml^r ;. li 

(Month) <i^'»y^ 



190 ^ 

(Year) 



•^TVf.I.T?. M\KKn;i>. 

W II)(»\Vi:i) <»K IMVOkCKI) 

'Write in mk-iuI dt sivMintioii) 



HJKTmM.AOK 
(Statf or Country) 



•^A'^-R or 

I'ATlir.R 



lUKTHIM.Ai'y-: 

<)i.- j\riii:K 

(St;ttf or Country' 







.t \. a:Lt^<L:i 




FHi':kHHY cVrTIFY, That I atten(k<l deceased from 

Qx<^r a 1 190H to.^ • -" ^90 

that I htstsaw hXrv< alive on MV^TX^ Xl up " 1 

and that death occurred, <mi the .late stated above, at 1 
(X M The C\rSI': OF DlvATll was as foll^)ws 






■^"^^^^■^^ ^ p ^ 



\j. 



DrRATION JV(i/-5 .]/.>;/)>/.?....... V^a v.? Hours 

CONTRlliUTOKY "«"•••• 






()J- MoTin'.K 



niRrnpi.ACK ^^ (J 

o|- MoTHI'.R ^ ii\\ 

(statf or Country) -A ^v I 

OCCri'\TU)N 

,..., CI. \. olxv«^ 



)■(•(;/ ^ 



M.nith:^ I /TV' 



,>V Mtt5 



DIKATIOM >VarJ - Mouths 

( SIGNED ) .. wL^-V \)JXXJ•^J^M^ 
r.V Xl TQoS (Address) At) g^ 



Davs Hour 



"special information only for Hospitals. Inkltutlons, Transients, 
or Recent Residents, and persons dying away from tiome. 



Former or 
Usual Residence 

Wtien was disease contracted, 
If not at piaceof deatit? 



How lonq at 

Place of Death? Days 



I'LACK OI' nrRIAU l)K KHMOVAI. 




DATIvof lUKiAi. or RHMOVAI, 

QrUxr XX 1901 






N. B." 



.^^_^_.^^^ — — 1^— — ^■^— ^^ t t d EXACTLY PHY8ICIAN8 should 

_P.„., ..en, of .„,„.n....on .hould be c«..«u.., .upp...-. )^l::;;'^tJi'J. 'xH. ••«p.ci.. .n.or„..t.o„" .or p.r- 



:r-^,Caw°> .""hi. Should b. t '. <".'"«• 



•I 



•i 



I 



•♦ 






4 



.r i* 



i ': ■■■'I 









I I 

{ 



^H 



♦ 



' 










i ! 



IJ 



f ■* 



I' 



!i1 



il 



WRITE PLAINLY WITH UNFADING INK 

. , . ,,,.,■ II., I, I, IN.. ,.1^g^»" M'>-" — 

huh' /•■/•/<"/. ^iv-j^^^oi^^ 11 ^'^"^ 



THIS IS A PERMANENT RECORD 

REFER TO BAC K OF CERTir.C ^TIT rOR .NaTROCTIONa 



,U^co^"La^' Deputy Health OfT.cer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( TH. S. Stan^arD ) 



0^ 



...^TH r ntv ofOcv.^ J^o^<^<^^> City ofCW-,-J^vc^^v^<^-^ 

PLACE OF DEATH: — County otJtc^x. 

(^ i -. - Disfbet. '^tL and 5 tk ) 

L ,F DEATH OCCORRCD IN A HOSPITAL O P ft (\ (l"!^ ^ ft f\ 

' Ixm. i JxLcAHxLd ^ -•^■•■- ■ ■ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



DA IK nl HIK I M 



CO I, OR 




(\ 







A«.H 



%'i 



)'i-iit > 



ID . 

(Day) 



.M,>„lh 



(Vtfiir) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF ni^ATH 




..^^: 

(Month) 



(Day) 



(Year) 



rnlTinarrCKRTII-V, That I attended deceased from 



H 



/></!> 



SINT.I.K. MAKKIJ-.n. 
WinnWKI) OR IHV()KiM> 

tWiit. in M«ial <l.sivMiMti..ii) 



Hikiin'i.ACK 

(Statr lit r-Minti V' 



wMi-: <>r 
lA rm.K 



l)u^ 



MIKTIiri.Ai K 
()|- I AIUKK 

(Stiit<- <»i Cotiiit' y) 



MAIDKN NAMl. 
ol- MOTllHK 



HiK'rnri.Ai'K 

(Statf or rountvyt 



oocrrATioN 







y Uru: a .....I90' ^ to ^iuiur.....ia„.........,...i90 ^ 

X , * 1. i.»^ ' alive on y\<JV^ t ^ 190 ' ' 

that I last saw h *.m alive on 

and that death occurretl. on the <late stated above, at I C 
y; ^1. The CArSK^)F DHATH was as foll.ms: 



r»AJtVw^>x,X5''VVA.^aj 






CONTKIIU'TORY 



t 



^v^. . . >^. A.^rv.?uC^i.VA.L.v^ 




Months 



DURATiOX Years 

(SIGNED) V>^^> 

C\A ax. ioqM (Address) ^PH 



/?aj}'.? 




Hours 
M.D. 



■J? 
w ■ j.t.. 



Ke.Uhd iu Sav r,.n/wwv. 5 C. )V»>-^_ 



Month': 



Ihivs 



^^^i^S^^ili^^ 



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



Former or 
Usual Residence 

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



Hew long at 
Place of Death ? 



^ 

^)i 

^ 




J 



... Days 



iXAJ 



(liif't.niaiil \J I V. • ^*-' 

,.. (WUbolW ^ 



fo" , -^ .....NlWv^.... 



I)\Ti: of Ml HIAI- or RKMOVAI, 



X[ 



i9o\ 






lli 



IN. B.- 



L— — — — — PYACTLY PHYSICIANS should 



v^ 



Wl 



^....^ iMK THIS IS A PERMANENT RECORD 
RITE PLAINLY WITH UNFADING INK — THIS 15 M rt 

REFER T O.ACKOFCERT.nr ATEFOR.NSTRUCTIONS 

l,,;.T<l '>f Ml riltn I >o I' - ^^.„^ —— — ^— — ' ^~^C^r^ t^ 



I )(//(' /v/f'^/. M\^ro^"oxl>^^' ^^ 



lOO'i 



IjLAv., Deputy Hcaith Officer 



cLo 



DEPARTMENT OF PUBLIC HE AITH-City and County of San Francisco 

Ccvtiffcatc of Bcatb 

PLACE OF DEATH,-C„„.,V ..3^- i,..^^" Cy .,60^ J^.vc^oo 



1 

i 



No. 



.t 




VD-CHi. 



Ia.vXcx.1' 




St.; 

IDI 

1ST 

^■0 



DIst.; bet. 



— and 



) 



V^V •Jl.f •^ ' ~" „ ,^_ ,,»,nrR "SPECIAt INFORMATION" "\ 



^ 



-L ^ 



FULL NAME ^^V^^<X J... ^ 




.cVCV'^v 



,t 



fel 



^1 



1 






PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR 



DATi". «>i r.iK in 




r\A. 



I M.mUIO 



A(.K 






(Day) 



.Moulhs 



/lib . 

(Year) 



/1</ v: 



MEDICAL CERTIFICATE 6f DEATH 



DATK OK DKATIl fN^ 



(Month) 



.1^ 

(Day) 



(Year) 




SIN<-.I.K. MAKun.n 
WinoWKD OK DIVOKi 1.1^ 
(Wrilr in Muinl (U-sivnatioti) 




TTlFRHRV CKRTIFV, That I atteiuled deceased from 

' 0..' 199^.-.-.- to OA^^ja 190^ 

t,at I last saw h V. alive on _ CK^ ^ ^^ l^ ^^ 

,,„.l that death occurre.l. on the date staled above, at ^ 
M. The CArSI<: ^^^^'^pA* ''-V ^^"^ ^"^ follows: 



lUKriUM.AOK 
' Stiitf or (.•(nintry' 



s'XMK or 

»• A III I'.K 



HIK lin'UACK 
OI- JAIMHK 

iStatr or Country) 



maii)i:n nami: 
OI- Morm-.R 




niurmM.ACH 

OI- MOTIIKK 
(stall- or Country) 



7 

_ . , # ■ 

7 

e ^ ' I ' 








roNTuir.i'TORV 



JJays 



^fotiihs % Pays Hours 



DURATION 
(SIGNED) 



TQoS (Address^ 



\.A.,^r>^ 






Addrc-ss) 5?^-^d>uJbUv dt 



M.D. 



)'>t1l s 



A/.nif/r 



IKi\ 



OCCrPATlON 

"^ •.>.rri>PKKSONXUl'AKlUMl.AKSAKK TRrK lO i"K 



(1 



(A<l«lrcHS 






j AAVWO oJ 



, HoH long at q 

t Pidfcof Death? ^ Days 




I 



"crpFCIAL INFORMATION only «or Hospitals. Institutions. Transients, 
or Rcrent Residents, and persons dying away from home. 

Former or C i f\ 

Usual Residence ^ i ^ 

When was disease contracted, 
If not at pla ce of death ? 

rUACKOr lURIAI, OK RHMOVAI. 
INDl'.RTAKl'^R wwww T^ -.- 



'I 



i 



DAI'I'of IJiKiAl. or REMOVAI, 

Qru>j- XI 




190 H 



U 



'^^^-^—^-^^——-■— ■————"'* , pvACTLY PHYSICIANS should 

E OF DEATH In pl..l» «""• : •"" ."„ "t .„.««.. 



N. B. Every Item 

..... CAUSE OF OEA rn .n - — • J-^;":.-- -,„ ...„ .„...nc.. 
•Ofia dyln» BW»» Irom homo «houia nc . 






ti i'^ 



1, 1 ♦ I T 



J 



I' 



^ » 







I 



*Xx 





fl 



i • 




> 






t 


*1 




tI 


' ,, r 


4^ 


J ' 


■■ i&i 


HlHl 


K 




I 


1 



lUv.nl . f !l.:.!th I" N 



WRITE PLA-NLV WITH UNPAD.NG ,NK-TH.S .S A PERMANENT RECORD 

-„.„ .» n»r.K or CERTIFICATE FOR INSTRUCTIONS 

3356 



..^•-;r5.ni.5^i'.; 



VJO'i 
Officer 



Rei^Lstered JS'^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot ©eatb 



i 



PLACE OF DEATH : — County of ^ Cc^^ ^ XOx<:- 



(5;^ 



•^^o: City of d>cu-r^ JaXX/>vCv^^o 



No. l^^^ 



( ,r DC.TM OCCURRtO IN . MOSP.T.L OR INSTITU • 




FULL NAME 



\ < 



crn-x) .ucA.v^x 



± 



L,««l«i|l ♦*•*«»•' 



SKX 



i».\ri-: <n r.iKTii 



PERSONAL AND STATISTICAL PARTICULARS 

' • vuu 




Co^ 




v^-v.? ^ 



otith) 



(Day) 



(Year) 



A*. )•: 



o )'fttn> 



SlN.-.l.K MARKIT-D. 
WIDuWl.I) OK DIVORI in 
(Write ill MK-i:il (1« -uMiatiMii) 



lUKTIUM.AOK 
(Statt or (."ouutryi 



CJx,^^^ 



M,,,tlhs 



I. 



n 



MEDICAL CERTIFICATE OF DE^TH 

DATK OV DKATH 




ID 

(Day) 



I go H 

(Year) 



cv:.„. ........... 

(Month) " 

TTrFRKHY CKRTIFV, That I attended deceased from 

— ::....i90 ~~ 



i^ -— to 

- alive on ~ 



190 



Davs 



NAM I". <>J 
1 ATin-.R 



lUKTinM.ACK 
()»•■ lAPlIKK 

(Statf or Country) 



maii>i:n NAM1-: 



^ 



,W^\y<\j 



cn^f^' 



.<jJ^ 



that I last saw h . 

an,l that death occurred, on the date stated above, at 
M The CAI'SIC OF I)I<:ATII was as follows 

A^>.A.^:>^. 






Dr RATION-.- )V^'-^ 

CONTRIHUTORY •■ 



Months 



/}ays //ours 



U***»"t»»*^>»»**t«***»»«*"***'* • ■ 




ru^or^^xx 



..kjJb 




HiR'nnM.ArK 

(>|. Mi)Tm'".K 
(statt- or rouiitry) 






DURATIO>^ 



y,,ars Mouths Days Hours 

^^ M.D. 




( SIGNED ) i v\JL^cUX^ ^V W^^mJA^^ 

^^^ :H ...c^ (Address) b Ob dxJli^ 01 

■ SPECIAL INFORMATION ;nly^«;|;_H(»spitdls. Institutions. Transients 




-^.XXj 



?>0 y>'ius - Montin 



Da v.v 






Tn 



(In forma tit 



or 



RereS 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 



(Address ... 



I'l.ACK OV BURI.^I. OR RKMOVAI 

%.A Uux^ at. 



DATKof m-RiAl. or REMOVAI, 

\^\j^sr...%'^. TooH 



190 






(Address 



itlon'* for p«r- 



, FYACTLY PHYSICIANS should 

state CAUSE OF uc>% 1 " •" I*. , . . j,. *jven In every Instance, 
sons dying away from home should be ftwen 



m 






I, 



\ 



\ 






WRITE PLAINLY WITH UNFADING INK 



-Im; 






L-^^v(>t\^ 9-i 



i.96>M 



THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 






DEPARTMENT 0^ PUBLIC HEAlJIWity and County of San Francisco 



Cevtificate of 2)catb 

( 11. 5. StauDaiD ) 

A ^ 

PLACE OF DEATH: -County ofOcu^ lva/.x^^e.'. Gty of 






No. 



Dkt'bct. - :.: .and 






) 



FULL NAME 



L UJx^ijfe^-.....^--.---. 



PERSONAL AND STATISTICAL PARTICULARS 
• vW^ . COI.OR ^ 



w ] 
J X/~y'^r^<^^ 

n\Ti'. nj r.iK ru 




^ 



,<xoK 



I Montlit 



AC.K 



\ O Yeats ** 



iP.iy) 



}/.„i!//s 



(Vear) 



liavs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Month) 



f r 
(Day) 



'J 
(Year) 



SIN<n,t*. MAKUll-.n 

wiDowi.n «>K nivoKt 1 I) 

(\Viit«' in soriiil (l< suMiation) 



\:>i<iiiiii' 

I IIKRKBY CIvRTIFV, That I atteiKUa .Icccased from 

0a: '2>a 190V to vW- la icpM 

n Tc^oH 



190 "i to 

that I last saw h ^^' al»vc on 





HIRTtfPI.ACIt 
(Stiitr or ContJtrv" 



N.\M1<: <)1" 
lATJll-.R 



lUKTmM.AiK 

01 I Arm:R 

(Sl;it( 01 *."<)untrv' 



MAini-N NAMK (^ 
OI- MtjTllHK V 



lUKinri.ArK 
oi- mothhk 

(State or Ocmntry' 



Q 












tr\.ib 



that 1 lasL >>aw II '-' ' -- Q ^t\ 

an.l that death occtirre.l. on the .late- stated above, at H.clO 
Q M The CAISU Ol- DKATII was as follows: 

A) ' ' 4/ • 




i.,. 




Days 




Days 



.'YXX/OJ- 



OCCUPATION 



1V<»i 






f r> 



Rtsiifett III .^.(" ^ ' ""' ' ■• . . — : ^.,,,. 



Dt'RATION^ - J): 
CONTKIIU'TORY 

DURATION ^''''^N /v '^^'^"'^''^ 

(SIGNED) i. Ov.XoKt 

O rl.t^;- 1% 190^ (Address) L iu V'^ 
■ SPECIAL INFORMATION only tor Hofebitals. Instil 
or Rercnt Residents, and ^ons dying away rom home. 

ai'^0 JJ>LAj-voAt UJQ^^ long at 

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



Hours 



Hours 
M.D. 



n Days 



(lnfi>;niant 



0-A/ 



IvvX-olX) 



IM \CK or m-RIAI. OR RKMOVAI. 



DATlCof Ml KIAI. or RHMOV'AI^ 



190H 






^^'''''^*""* ^^^ ^ I FVACTLY PHYSICIANS should 

state CAUSE OH DEATH m P»«'" , Instance, 

son. dyi.ift away ?rom home should be ft.ven 



t» 



I 



!i 



.i : 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



BcKtr<: 



II. ..'til 1 N'" 



f..y^5^) ii.'v 



1' <■ 



R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'l^ .1 , Deputy Hecilh OfTicer 

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

Ccvtificate of IDcatb 

PLACE OF DEATH:-County of 3,C^>vKcc>xc^ec G.y of C^ >^ Xxv^c v^c^o 

FULL NAME UJUr'v.c\.v U.'.Vv\,-4. - ■ 



) 



SKX 




PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



' _ • 






i» \ IK «M r.ik III 



A».K 







H 

i- 

(l>fiy> 



uXi 



(Year) 



IR 



)■(•<;»* 



i Cj v.. >////.' 



15 



/'.f 



Nlsr.l.K MARklKP 
'Wiit'-in vnriMi <ii si^Miatioii) 



luk ruiM.AOi- Q (JV^N n 

iSlalc or ConiJlry' -< V^' | V 



NAMl, <>l 

iathi:r 



lUk IHIM.ACK 
Ol I AfUllK 

State or t'ountry't 



MAIDKN NAMl* 

«>i M<>Tm:k 



MIRTIirT^ACK 

()i M()rin:R 

(Statf or Country) 



OOlM rATH>Nr^ 



Ojw^Jv ^'. 




K\J\^ 






,-Oc^wAU) 







Tin.xi.>vKsrATKi.rKk.oNA. ru<n;M^..vk . a k v. v k , ■ .•: r. > r m .■: 

in:sT Ol- MV KNOW 1, 1. 1 )«.»-. AM> HI. I, II. I 



MEDICAL CERTIFICATE OF DEATH 

DATi: (>! 1)1:A 111 



XILOV^. 

{\foiith> 



„ .m.........„../pf7 ' ( 

— " (Year) 



1 III;KI:P.V CIIRTII-V. That I atton<lc«l itercased fn»ni 

\0.t£b ^0 i^M- to M'V<JV^ ia.._.«..... 190 M 

tliat I last saw h v. .>. alive on ..^.... M\CVr-.A^. :... up > 
an<l that death occurred, on the date state<l above, at VI 
LL. M. The CA1'SI«: Ol- DI-.ATIl was a^ follows: 









l)rR\TI()N Vtuirs 1 Months />(tys . ■■//outs 
CONTRIIU'TOKY \JJi^<^^ LLtv^CjaLO. 



//our. 



DrU.ATION .^ }'('<irs Months /^ays 

( SIGNED ),l).^V^KlLc^x. \ M.D. 



SPECIAL Information «nly 'or Hospltdls, insHtutions, Iranslfnts, 
or Recent Residents, and persons dying dw.iy from home. 



Former or 
Usual Residence 

When was disease rontrarted, 
If not at plac e of death ? 



flew tonq at 
Plare of Death ? 



Days 



IM.ACK 0|- in klAI, ok ki;Mo\ AI, 



csLoJla^' 



(J> 



I)ATI%o! HiKiAr. or k I".MO\'.\I, 
MVtJ\r 'AX.,.,..... 



' 




\j 



— — ^ " ,. .. ,. , Z7p „»,o„id bo Ktntecl f;X4CTLY. PHYSICIANS Hhould 

N „ — r.verv Item otf in*orm..t Jon «houhl I.-- ...retully HuppI.e.l. '^<'^: ;,77^' '^^^^^^^ ^he •'SpecJnl In,'orm;.tion" tfor p.r- 

HtHtJ CADSi: OF Di: ATI! in plain term., thnt il m»y be properly .laHS.^.cd. P 

«on. dylnft nwoy from home hHouI.I be feiven in every .nHt«ncc. 




' I 



1 i *' 





, I 


o ■ 1 


ill '1 


J^ 1 


ss 


ll 


fta i 


W ' 


wU 


H 1 






'wH 




iff 




^^^^^^^H 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



): 1 V;i. !«. 



'■^'■TLi-. MM' Oo 



Bc(^i,slei'e(l J\^o. 



3259 



I />(//(• /■■//;■'/. \j\/Cv-t'Y^'v'Luv 3>^ ,, — 1:)0\ 

ifrvvvAljyvvM «>*P"»y ^e»l*-:^ Omcer ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticatc of IDcatb 



^ 



I 






(?D 



PLACE OF DEATH: — County of C',ay>^ J^vO^^c^et City ofO^^.A. Jxx^.v<:..<.xm. 
f + \ C 4 ^ 

No. UXu, "^-V^oaXu ^ 

A / ir Dt»TH OCCURS AWAY F R O I* 
\] V !'• OCATM OCCHJBRtD IN A H( 



^'^- ^\\\x\.(xX 



St.; 



Dist.; bet. 



and 



i «.» ••ciiAl RrcSIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION' \ 

occuR^ AWAv ^"OM U^SUAL R^^f^^^^.^J;^^^^'^^^,,, „s NAME instead of street and number. ; 



FULL NAME 



V.>r./W-.-.S^.OL/ 




^^ Lv^ 




WAS^-^^U, 



> I : \ 



PERSONAL AND STATISTICAL PARTICULARS 



r- 



DA 11-; ol- lllK III 



uJJv^tx 



U 






ACK 



5^ 



)'tti I < 



11 



• Day) 



.\h»l!>l.-: 



A'iB 

fVcar) 



1 



A/1 



SiM-.I.K, MAUKIi:!) 

WIlx >\\l-:i) OK DIVi iRiJ"[> 

tWiitrin s.K-ial dt i^-'iiali'Mi) 



A.. 



lUR i"niM,ArH 

(State or C<nititr>-^ 



NAMI- nj 
I- A I" I I 1 , k 



lUKIIIIM.ArK 
0|- I A II IKK 

iStati- or VNniiitrv^ 




ft 



Aj<^^1\ LL' yvL Av ts \ 



h^\.\Ul/^-XX; 



MAinKN' NAM I. A) 



Ol' MOTiniK 



lUK'niri.AiK 

Ol- MoTlll'.K 

I Stale or C'oiiiitry) 



\J\XXj 




t5'>^ 



OCCUPATION g;3_^^^^^^^^ 



Mouth-: " /^"'i 



M-HKAiun'KSTxTia)rKKs.>NAi.rAKTic-rLAKSAKHTKri- n. TlIK 

in:sT Ol" MY KNO\VI,i:i)t'.H AM) I.JsMI.H 

JJLX) • vj X<xX^ 

\<1(lrrss Lulu, ^^ ^ 



(InfoMiiant 



±i 




MEDICAL CERTIFICATE OF DEATH 
DATK Ol I)1:A Til 




(Month) 



Q.'X igo^\ 



(\ 



(Day) (S't-arl 

I HI;RI{RV CIIRTIIA', That I attfudoil deceased from 

, .iD-ct D.l icp'l to ...^\/U>.^ XX ....I90.H ... 

that I last saw hV>r>A alive oil Vv^TVT X'X \Kfi% 

and that <lealh occurred, (.11 the dale stated above, at 1 H5 
A.'. M. The CAl'SI-: Ol-' DlvATM was as follows: 



\ 



,\/v>-t.hj 



I )r R \TION Yi-ars MoviJn Days Mours 

C< »N TK I Hl'TORV Wr'^Vtry'NA^ C/\-^u1cLHi-:Cxx'^v<L^X^wa 



DIRATIOX 



kV^ 



}\'(jrs 



Mont /is 



Pavs 



Hours 

^ s^^'^^'^ ' ^-^^- ^^ ^^ <r WW"- ^'^■^• 

ax Tco^ rx.ldress) L^i^U .(!tcH^> 



W- 



i.,...yi,. jL.a..>vfc.. 



ess) V<^^^^4 
i|^ only for Inisf 



VV 



I. 



SPECIAL INFORMATION on'y i<»r inispitals, Institutions, Transients, 
or Recent Residents, and persons dyinij avvay from tiome. 

How long at *\ ^ 

Place of Deatli? '=**<^ Days 



Former or '\'^ a t . n 1 a f *4" 
Usual Residence O^0:d .*vi,<i.u J 

Wfien was disease contracted, 

If not at place of deatfi? «..*-. -• 



•**»»♦**■•••*•■' 



IM \CK OF lUKlAI, OK KKMoVM. 1 DATK of HiKiAl. or KKM.)VAI. 

" A ) 1 vyVciv-...9kH 190't 

rsni.-.KTAKKK OcrtcU^ OoJU U^aAq U 

(Address J.Hl'^ Vn\^<.v.trVV ^^"t 



^ ,. , KCA should be stated F.XACTLY. PHYSICIANS «hould 

^, B._Every Item o? information should be CBrefuHy «upp .ed. ^^^ J;;^';"^^,,,.,,. The "Special Information" for p-r- 
— ♦.. CAIISF OF DEATH In plain terms, that it m»> « proper y 



•tate CAUSE OF DE. . . ♦ «^. 

son, dyinft away from home should be ftiven m every mstance. 



M 



r..Mi.! . !' 11. <'th r N' 



111 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,i^^. M.^ .■ O, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■1 



^.» 



-. » 



< 1 



tevooiwM. Deputy Health Officer 

DEPARTMENT OF PUBLIC nEALTfi=City and County of San Francisco 



Ccvtificate of ©catb 



PLACE OF DEATH:-County of6<!C'>^ i-vc^.ve^^cc City ofd<u>^ 3xc^>x^^^^o 



1 



n^ 



No. 



loxci and .^vV.CV 



• i 



I f '1 



it ' 



'S\\ Vf);V<XYV>V<:X>X p.S^'^Nc'e CVE Ri's^^Lu'EO .or U.OER -SPECAL INFORMATION.. ^ 

( " r"o7.T°"oCC^!RrcV.rrHo''s^P^T'Ai: r'^N^'lTU^O^'^VE ITS NAME INSTEAD OF STREET ANO NUMBER. J 

lO .cLloOLT>x; VD CrV^'tLL 



FULL NAME 



A 



^Mi 



si:\- 



DATK «»J HIK Til 



\».i-; 



PERSONAL AND STATISTICAL PARTICULARS^ 

j a •!,< >k \ 

11. 




it 



( M.iMth) 



5-H 



) til I > 



Dav) 



M inlhs 



/^5C . 

(V.-ar) 



/'.n. 



SINT.I.K. M.AKKlKD. 
WIIXiWKI) OK l>IVokri:i) 
i\\iit< in social (Usii.Miiitii)ii) 




LcLcruc>-iL<:^ 



XTTn 



i,9 
ii 



HiK riin, \oi-: 

(State or Country') 



NAMl, <)I' 
FATII 1':K 



(H- lAIIM-.K 

(State ()! (.'niintry) 



MAinHNT NAMK 
<)!• MOTIIKK 



niKTIIlM.ACl-: 
Ol- MoTlllCK 

(Slate or Oonntry) 



OCy 



trUu 



Oc^"v 



cL 




occri'A iionO ■ X, 

f.'r nhu! ni Sau f-nni^i^rn 1 A ) ra t < 



}r.»if/i.< 



/hn. 



THK ^m.^M^ST^TKnPKKS<>NA. WAKTUM^J AKSAKK TKIK To TMK 
UHST Ol- MV KNOWl.r.noh AM) lU'.Ml.l 

it 



%9 



,,1.1re.s TfeO (lb -OU>>.>V\^Ur->X' 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- DlvATH 



fM..ntli) 



Xt 

(Day) 



(Year) 



I iTp:K1':HV CICRTIFV, That I atteiided deceased from 

T90 ~" ' 

— — — — — -r- 190 • ■ 



tliat I last saw li 



190 " to 

— alive on ~ 



and that death occurred, on the date stated above, at 
M. The CAISP: OF DICATII was as follows 



L...dU/VsX.>v %<L J\AxL-rv^v.LO 



DTRATrOX Vrars - Months Days .^^^^HoHrs 

CONTRIHITORV 



.V(>'{//is 



nr RATION ^ V'-'rrs 
(SIGNED ) UyV(n^-«A> . ---W-. 
xlUvr %\ looH (.X.ldnss) Ltr' 



J.MJ. JU.Xi^Xou^^cL 



IC)0- 



/hn'S Hours 

M.D. 



SPECIAL INFORMATION <>nly for Hospitals, InstitutlWiV; Transients, 
or Recent Residents, and persons dying away fro;n home. 

How long at 
, Place of Deatfi? .....«», 



^>«**«sj;4^44 



Former or 
Usual Residence 

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



Oay« 



D.Vn.of HcRlAi. or KIC.MOVAI. 
mJ^. X.O. T90H 



I'l.ACK «)F HIRIAI, OK RKMOVAI, 



(Address 



.1.1. 'in 



"""■■"■""■"^ TT \rx AGE should be stated RXACTLY. PHYSICIANS should 

«tlon .hould be cnrefuUy ^-^^^^ p^operir^IaUified. The "SpecJnl InWmaf.on" for p.r- 
\TH in plain terms, that it may be propeny 



IN. B. Every Item of Inform 



i I 



M 



IN 
p.] 



^ 



WRITE PLAINLY WITH UNFADING INK — 



!.,■!•: ) V 



.f -sr 'Sir, \\K\' Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



. \ 



J i 



> 



Bji 



f i: 



C I'lli'd , ■ 




^■rd^^ Os'X I'-'O'^ 



Jlro^/.sfrrrd JVo. 



33GI 



1 




Deputy Health Officer 



DEPARTMENT (JF PUBLIC HEALTn=City and County of San Francisco 



PLACE OF DEATH: — County 

No. CjI . cLi.oVU.« TC CHtK J-Cv.^' 



Certificate of Beatb 

( H. *!'. StnnC^arC^ ) 

ntv ofCW->-v) O^^O.-^xcv^cv City of C)^xy>^ Axx^^-vC^-c^ 



St.: 



Dist.; bet. 



and 



.Oy\-CQ /V O-NtyrVV.X. .^^ RESId'eNCE give facts CALLtD rOR UNDER -SPECIAL INFORMATION" \ 

( '^ rF"nr.Troccu%rcV.;THo".^PrAc o "^I^'tu^tU oive its name insteao of street ano number. ; 



-V 



ro 



FULL NAME xcc^x ^CL^ 



AxJ 




ouvo. 



'-KX 



i 



H 



'> 



PERSONAL AND STATISTICAL PARTICULARS 



LLvtxaJLj 



i»Aii; <>i I'.iK 111 



ACK 







XZ /ll.l 

,,):«%) (Vear) 



X?^ 



)V,n 



!^ 



Mnfilfn 



-kl 



Da r.v 



SINT.I.K. MAKU 11. H 
WIIJOWKI) OR DIVoKD.l) 



ci 



iuKrm'i.A''K 

(State or Country' 



.\.Ow > V'C^t^c^ \.OJ^ 





niK 1 iiri.AiK 

Ol- I'Allll'K 
(Statt or CDiuiti >•' 



MAIIiI':N NAMK 
OF Mo'niJ'.K 



iuKrmM,Aii<; 
<»i' M«)Tin:K 

(state- or rouiili >■• 



^Jlow^ 



[}\xX>v. 



V.CU 



..L/C.'<1 Aw/^V'CO 



occu 



JPATION P, , A 



A',->!',lr.f in S,i>i /'i,! 11, !'},-.> 



;-,i>s h Months 



I)(X »A 



TIIK AIM)\MsSTAlM-nrKKS()NAI TAKTICri Al 
ni-ST Ol- MV KN<)\VI,i:i)t.h AM) lU-.Ml.H 



<S AKI". TKl K lt> Til)-. 



lNDHKn^KKR\)/all/>All MJfUX\:^mA; VL 



(.\(l(lrf»^s 



i5^H 



cilt^Jk-'tt'^v 0' 



^- ' ' ■ TT T"!i \i\^ «ho .Id be stated EXACTLY. PHYSICIANS nhould 

r,. B.— F.very item of informBtlon should b. cnreVuI.. -PJ^ -^; ^^^^ classified. The ^Special InfornnUion" for pT- 
.-AiieF OF DFATH in plain terms, that it m»> ne pr i 



MEDICAL CERTIFICATE OF DEATH 

DATK «>I'" DKATII 

\ f \ 




(Month) 



.10... 

(Day) 



1 1 
(Year) 



iHi;RI':BV Cr:RTlI^'V, That r attended decea-sed from 

KjO-:— — " 

' - I(p 



190 



t(J 



that t last saw h 



alive on 



and that death ocenrred, on tlie date stated above, at 
— r:>JiI. The CM SI': Ol" IMv.X'i'lI was as follows 







Drk.xrioN )''V7/-.9 Months Days Hours 

CONTRIurTORV 



Dl'R.XTION Yrars Mouths Days Hours 

(SIGNED ).Wunu>v ivJj. U3.AjlLx/>a^ m.d. 

OW ^! rqoS (.Address) UVynl^UlK^A 



SPECIAL INFORMATION only for Hospitals, InstitutWWs, Transifnfs, 
or Recent Residents, and persons dying away from liome. 
r rm.r nr ^A^ivN^^, CUvJL ^- <^- How lonq at 
Us[.al Re^dence eo.v>-^v^^ ^t Place of Death? Days 

When was disease contracted, 

If not at place of death ? ■■- 



PI. ACK OK lURIAI. OR RKMOVAI. 



^\./Q-oaju 



l)ATi;i)f UlKlAl. or RIvMOVAI, 

mXckt a.3> T90H 





:r„r/.t"/»Z "r^-^'Ho:". ^L.. .e ,,..,. .«...««. 



m 



i: 



li 



n...in1 ..r !l. ./•!' 1 N" 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A.!r*rjrX> ISS: J' v'o 



'ill'?. , Dp^t.: 



* 



^^ 




lir^Lstered J\^o. 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




I'^r 



Certificate of IDeatb 

( XX. S. 5tnnC»ar? ) 
PLACE OF DEATH:-Coun,y ofOo^' Jx^v<^c. City oICJaX^ A.CvwC^.C.^ 
' "^ Dist.; bet. Ba. ctijLM and^ 1 ^A.t 



No. i'^vHb O^ciLt 



A->-v.t\J. 



St 






..CHI RrSlDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ^ 
( " rF"o;:T°H"oCc"u%ro\;"rMo's"prAt o"r'?n?^.Tu"o^. O.VE its name instead OF STREET AND NUMBER. J 



FULL NAME 






.Xi- 



si-:\ 



PERSONAL AND STATISTICAL PARTICULARS 



QmJL 




vKCLi 






!f 



1 : 



DAI 1 nl" HIRTII 



A(1F, 



( M.iiilh I 



XI 



) .,l> 



(l)av» 



v. ->////* 



/^Ib 

(Vear) 



/)<; vi 



SIN<".1,K MAKKlHn 

'Wtitfiii ".(Kiai (1( >ii.'nali"iii 




H 



lUK rHIM.AOH 

'State or (."oumrv'* 



NANtl'. ()l 
I- ATIIKK 



nikTHl'I,A<K 
<)l- FATHKR 
(Staff or Contitry) 



M M I > 1-. N N A M K 
<»1 MnTHHK 



lUK riiri.ArK 

^}\^ M(tTHi:K 
'Statf or C'ojiutrv^ 



X^ V>^<X'' V xu 



./ 



/ 




vb'ojkxr^ 



oCCri'ATION 

h'fsiilfil in S,iti I'liUhi^i'o 



Yrm s 



A/.iiif/is 



I hi 



TnKAm>VKSTATHI>t'KRS,>NA. rAKT.rr,.AKSAKHTKrK n> TMK 



nnfoinianl \jJ fy>r\J 






MEDICAL CERTIFICATE OF DEATH 



DA 



TH <)1 DKA TH A 



(Month) 



XV.. 

(Day) 



(Year) 



I ill':RlvHY CICRTIFV, That I attcinkMl ilcccascd from 

- ,.;- ' ' - '...190 .— •■ '"■ to '^90 ~ " 

til at T last saw h -alive on ^^ ' 



and that death occurred, on the date stated above, at 
— M. The CAl'SI*: OI- DICATH was as follows 

(jfc^oA^t 



f 



OrR.VTION ViiJis 

CONTRIIU'TOKV 



Mo til /is 



Days Hours 



DIRATION 



/)ays 



(SIGNED 



s' Vcars ^ MonI/is Days 



Hours 
M.D. 



■A-^C VT 9.1... . TtloH.- ( A.ldress) UV^^^^V^XA V4.Vv.OL 



SPECIAL INFORMATION only *or Hospitals, Institute, Transients, 
or Recent Residents, and persons dyinq away from home. 



Former or 

Usual Residence .......-..-.• 

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



Hew long at 
Place of Death ? 



Days 



I'l.ACK Ol" inKIAI. OK KKMOVAI. 



DATKof m RIAI- or KKMOVAI, 



rNDl.;KTAKKK%. i ^A.JvV ^^U 



190'^ 



IS. B.- 



' ' T"! APF «houl.l bo stated F.XACTLY. PHYSICIANS should 

-Bvcry item of Information .hould he cnrefu..> suppl.ec ^^J;;;^''^,...,,,,,. The -Speci-I Infor.n-tion" for pT- 

* * r'AiisF OF DEATH n plain term*, that it may •»«• i» h ^ 
r„;d"n« -w", frL ho„,c -hould b. »W.n i„ .v., ln,.,nc.. 



1XIET 



I 



HfMi ; • ' ' ' " • 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 










19 0\ 



Registered jXo. 



3263 



i^ ,1 V Deputy Kealih Officer 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S>eatb 

( "a. S. Stan^arC* ) 

PLACE OF DEATH:-County ofGo^v >^X<Xyvc.^e. City of Oxx^v Jaxv...c^c^ 

L^A^„ \s. . . -^ St.; V Dist.;bctJruxnrvk.Lu%a: and :(n.tC^ 

^ V,^wV. .V-VJ „ ,,<;iiai RESIDENCE GIVE r*CTS CALLED FOR UNDER "SPECAL INTORMAT. ON ■ ^ 

( " r/rCATra^C^%;ro\rrHi's^P^T*L " "ns'tJV'oN^O.VE .TS name .NSTEAO O. STREET AND NUMBER. ) J 



No. 



- ) 



FULL NAME CL-nr^^AX 



c^wdALc 



\jy\x 



Hi 






I \ 



II -f 



» 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.oR 



QUcuL 




UATi: ol lUK 111 



ac;k 




Month! 




b^ 



)V«J»A 



sI\(,|,K MAKUIKI) 
WIlMiWHI) OK DIVOK^ HI) 
iWiitfJti MH-Jal (k'xivrnation) 



\c 



fu 



'I>:iv) 



M.'til/is 



(Yrar) 



/>(/ 1 . 



Ol\A.V.! 



Ld. 



HiK rm'i.ACK 
(State or Country^ 



KATIl l.K 



HlkTHri.Al'K 

Ol- I AfUKK 

• Statt- or C«>utitry) 



M\II>K!f NAMK 
or MOTIIKR 



^ 




^•'<LL6 



;lla 



,ct<l'LLV'>\) 




ex. 







mK'nuM.Ai'H 

til MoTllKR 
(Statf or I'ountry^ 



DJLAVvC.U^tOu 



vCX 





^ 




OCCri.ATU>N^^^^^^^J[^^fc 

k',-u,!f'if III San FnrfK ism A-^ >'.'.mx 



.y/n>if/is 



..... /'(/I 



RS ARI-; IK IK TO ini- 



Mli: AHOVK STATI:T) I'KKSONAl. »'.) « '"I-"/', l" K 
»KST ♦)!• MV KNoWlJ-.lX'H ^^^'^ Ml. 1. 11. f 

Informant MIcUUv^^^^ NjCV^C^'U' 



( \(l<lrrss 



[["hX 



MEDICAL CERTIFICATE OF DEATH 

I»\'rK Ol- DKATH 




ai 

(Day) 



(Year) 



^W-^ 



(Month) 

I IllvKlvliV CIIKTIFV. That I attemlcMl deceased from 



XJC 



190 



-^ 



to 



%\ I90H 

tViat I last saw h L. vyx alive on M XJSV^ 3.1 190 H 

an. I that death occurred, on the dati- stated above, at v 
...OL M. The CAl'SK OF DI'ATII was as follows 




DIRATION 



X Veti 



Mouths 



Da vs 



Hours 



c ( ) N T R I m "i' ( ) R \' UkA.^rvcA./C ,>XU-.^:J(^^ \Lv\m 

DURATION Years Atonths Days Hours 

( SIGNED )..^rUoW{A^KbY^YA.' M.D. 

Vi\.(^r X'X IQOH (A.ldr.ss) llC>n O.LAAlt\-^ j1 



SPECIAL INFORMATION only 'or Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinq dway from home. 

SZdence^O^^ U<iH .A*^ nl^7L^l Days 

When was disease contracted. 

If not at place of death ? 



I)\TKof HiRiAi. or RKMOVAI. 

0- 



I'l^ACK Ol" m-RIAI. OK KKMOVAI 



\^' X^>. 190'i 



f A«l(!i<-ss 



— ^ „ , »,h .hoi.1.1 bo •tated EXACTLY. PHYSICIANS should 

N. B.— Bv.ry U.n. of ,„.,.r„.«.lon .h.,u..l be .»..«.."» ...PpMca. A<.t -h ,^^ ^^^ ..s,„^,„ ,„,„,„.„.„.. ,.r p.r- 

.. *- ^AiiKF OF DFATH In phiin term*, that It mH> ne i»rwi # 
.tate CAU8t OF Dt A i P .^_^^ ^^ ^^^^^ l„«t»nce. 



son 



• dying away ?rom home Hhould be A'v 



I I 



i>H 



...1,,,. 



% * 1 



% 13 



f 



•■I 




ii 



u 

I. 



E| 




;& 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.i.r.l .,f ni;.:th »• Vo :v ^'^'^^^^ US^ V C, 



REFER TO BACK OF CERTIJTICATE FOR INSTRUCTIONS 



liemistcrrd J\^o, 



3264 



t^vv^lx'v^ ^^'p'^^y ^^23'^*^ o^''^^'- 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of 2)eatb 



( 'O. S. Staii£>atO ) 



U'CX'^y^ JAxx.>x^a.^co Cltv of 0, 



^ 



PLACE OF DEATH; — County of *- '^^'^^ JAxc>"^-^a^^<^ City of ^^^x^^v J A.<X/>vc\..cl.c^ 

No. 'I'^^ vlh «^Jt^\cv-^ c Ia St,t 1 Dist.itiet.oL^'xUv'trYvt and JUXU\^v< 



0;VLt^v*^^-^.c1\ St.; \ Dist.;bet.^^A.J,V'trYvX and JU-^ 

/ \r DfATH OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR U Im D E R "SPECIAL INFORMATION • \ 
V IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME^^i^^^ 



5^i:\' 



i).\ I1-; I >i' r.iK III 



PERSONAL AND STATISTICAL PARTICULARS 

A I COI.nK 




<XAx 




^V^^ 



U _ 







A(iK 



bl 



} ra t s 



1! 



IH 

(Day) 



M.'uffi^ 



(Vrai) 



Da%.^ 



siNc.i.iv M \Ku n:i> 
wiix )\\ i: I) OK i)i\( >Kvi-: i> 

(Wtitt in s(H iai ilt <i}^tuiti<»n) 



'SiMtc or Country J 



4 



^^ 



I 








4 



yy\l^ U Aaa:>^s-<^ ^ xAj 



MEDICAL CERTIFICATE OF DEATH 
DATR OP r>KATH 



(Month) 



(Day) 



(Year) 



A 



I UF^RrcnV Cr-RTrPV. That T attendcil decoasetl from 



dx^vt I ft.......... 190H 

that I last saw h'*- >»i alivt- 011 



to ^a.\«c^^: .LH. 



190 1 
190 H 



and (hat (Kath occurred, oil the date stated above, at 




.M. The CATSIC OI' Di-.XTII was as follows: 






lUK riiiM,\rK 

01 lArilHK 

' Stalt or iNiviiiti \ * 



MAIDI'.N NAMK 
(I I Morm-.K 



mkTlIlM.ACK 
«»l Morill'.R 
(Slati' or ("(luiitrv) 





DrR.ATIOX 



)'i(jrs Months _ Pays Hours 



ocrrj'Ai'ioNfVvv 



A\ 



Yy/iffif i» %r» fvilMi h^O C>K: IVvfl « 



\rnilfll\ 



/hi v. 



C()NTRiI5l'TORY U cJLa>WLoJ\^ jj 

otoXCLAAJ ajL^^^v^XiXu ... 
I)l'RATI()N }'i'(jrs J/,>f}///s Pays Hours 

(Signed) A Aj Mi\jL-rv<ixA M.D. 

MW.r'X^' 100 S (.\ddress)ll'i't ■tlbA.MU,\.\xH~n 



Special Information only tor Hospitals, institutions, Transients, 
or ReienI 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 



iiii: AHovK sr \"n:i) rHRsoNxi, i'\urnri,\Ks ark trik t<> tin-: 
m;sr ()!• Mv knowi.i-ix.k .\ni) iu-:i,n;K 



ifoiniruit UJ(T>V vTjL/C3UOtr^K 



( A'MrcsN 



Maio 



\JUt'> VXAJ-A./OK' 



V crt 



l'I,.\Cl': ()»• IHKIAI, OK RIiMn\\I, 

I 



HAJlCut Mt Ki.M, or KKM<>\'AI, 






"VO 






IN. B. Kvery Item oV iiifcirmntion should hi; carefully Hupplied. ACIfi Mhould bo utHted EXACTLY. PHYSICIANS nhould 

•tatc CAUSi: Ol- DI:A TH In pliiin terms, thut it mjiy be properly cfaHnlfied. The "Special Informiitlon" for pur- 
sons dylni^ tiway from homo Hhould be (iven In every inHtance. 



I 



\ 



1^ 



,■ .J ' 



I 






I 



4 



i 



1i 



♦ 



I 



r 



H, .:n«l of !!■ .i'!!i ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

V . t^r"-^*^; lu-^l-.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







-VNAvJt^ 



>v %% 



IVO'i 



Registered JS'^o, 



3265 



"LvvvA L-- Derutv Health 0«r,cer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( wl. S. Stan^arD ) 
PLACE OF DEATH: — County ofO<X/>^; 



J.\xx-Yxcv^Ci. City ofO/Oy^^ JAxXyVL.eA^c^ 



No. ^U xxLcLtc^ K) 0-<L'Wvicc-l' 



St.; 



Dist.; bet. 



—and 



iiciiAi orQinriNirr nvr facts called for under SPECIAL infor wation** A 



FULL NAME 




^ 



A\i \0^,^\J^ 




<X\}\.<.C\.QJ\) 



'•••■^ OS?) 



PERSONAL AND STATISTICAL PARTICULARS 

~~~^ I COI.OR 



? 



X/^^-VCL'AJl 
n \ri". < ii r.iK I'H A 




VU 



\jb 



•1( 



.CAT 



.\<.i-: 



O S J '■<' ' * 



(Day) 



Motilfis 



/!> I A 
{ Year) 



/)</ 1 .< 



<I\«. ? r MARHIKD, 
\\II)t)\\l-:i) OK n!\nK(.l'I) 
(Write in stx'ial .It ~.i).Mi;iti')n > 



5). 



lUKTnri.vrK 

(Stiit<- or Country* 



NTAMK OP 

FATHKR 



0|- lATiniK 
(Statf or Country 



MAIDV'.N NAMK 
Ol M()Tm:K 






' X^N 



Z)\n\^ 




(?. 







HlRTTTrr.ACT* 

t>i' Moriii'.R 

(St:itc or Comitry) 



( )CC ri' AT ION (^ il 



Rfsjiln? iif Sav /'i mn /S''>) 




Ml 



EDICAL CERTIFICATE OF DEATH 
DATH O]' DKATH 



(Month) 



(Day) 



(Year) 



I llHRIUiV CIvRTIF'A', That I atten'kMl deceased from 

lD,c:t 15- 190H to --^^^^ ai..„....-:...T9oH 

that I last saw h X" .' alive 011 UVOX. %X tqoH 

and that death occurred, on the date stated above, at ' 
.S£. ^^. Till' CArSr: Ol" DIIATII was as follows: 



^\^<3r> X 



1)1 I'lATION ^ 'X'-^ Months, IH Days Hours 

coNTRinrTORY UjlLvva.<i UJ>^.'^:JLa^ 



cars 

9 



nr RATION ^ 

(Signed) U. <>v. (ibX'U>^'^-^ 

VflcA^ .^l 100 'i (A.ldress) IHO M I'VoJV' 



Months IM Days Hours 

\jyrY\Ji^ M.D. 



Special information on'y for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away froni fiome. 



Former or 
Usual Residence 



Tin- -\MovKST\ri:n pkksonai. pakticclars aki; tkck to thh 

HKST ()!•' MV K \oWl,i:i)C.K AND Hl.l.n.I' 



f InfoiinMnt 



9.% 



( \<l(lrcss 






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



L .J (^' \ Howlonqat 

O^ULXLLtu UoJl Plare of Death? '1 



Days 



I'l.ACH OF lU RIAI, OR RKMOVAI, 



\Sa>^cLUo Col 



n 



DATI^of HiKlAt. or RI:M0VAI, 

. Ml<Jvr Xa 190'i 



INDl'RTAKHK O O^^rJt/YVAAj VjjV^-C^ 



(A 



d.ln-ss 11 OH MYUXL^lA^^TPu dt 



■"■"■"'*'— '^ ■ .. c. .. n ^ Ar;F «h»uld bo ntntecl EXACTLY. PHYSICIANS should 

N. „._F.very Uem o? Jnfor,nHtlon should be crefully -"PP"-^^' „^.^J;H^7,3„,nr^^ The "SpeciHl InformHtlon" for pT- 
state CAUSE OP DEATH In pinin terms, that It may be properly ciassmeu. 



state CAUt - . , 1 .-„^* 

sons dying away ?rom homo should be ftiven In evory Instance. 



69 







«.; 



'Ii 



• I- 



)\ 



i 






> * '.' 



f 



fi ! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



»;,,.•, 1(1 . J II- nlth |-N<- - '**l3,-^i>'*^l' *■ 



Dff/r F//rfi .\\jS\>4/r>\X>Xh^ ^'^^"^ 



Jfes^lstered A^o, 



3266 



, dx- 



L..^ outv 



fOBT 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of S)catb 

( "U. S. StanDar^ ) 

J? m SI Q?) 

of J/ayT\; AXX/^^caa.'Ca City of 0<X/yv k) JvXxyY\.A^<^Q.c> 



No, 



PLACE OF DEATH: — County 



oaJ.\.\X 




..Ot.MiU.' 





Dist.; bet. 



— and 



( '' r/oix°"c^c^%reV.;"rHo"s"p".'.^ rH'?r;sf,?'JvVJ^o.;r.;i name ..st..o or sth..t ..o .umb.^. ; 



FULL NAME JOJlA/ryx.a/Tv 





Y'>X'Ol^W. 



s \: X 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.oR 



^xJL 




DATi: ol I'.IK in 



IXlxV'^U 



(M<it)th) 



I 
(Diiy) 



(Year) 



AC.H 



5)0 



}/•</> 



n 



.1/ 



otit//y J\ V 



A; r.* 



^INT.I.K MARKTl'T) 
WIDOW i: I) OK l)I\«)K*i:i) 

'Wiiii ill vixial (1( <i!.'niitiiiii) 



NNUXJv^-. 



aJL-<L^ 



HIRTMI'I, AOK 
(State or Coiuitry' 



NAMl'. ()l 
FATIllvR 



lUK TUIM.ArK 
()l lAlIIHR 
(State f>r C<nintry' 





lpX\A>^^<X/"tv 



AXX/'iCu 



MAIDHN NAMH 
()|- MOTHKR 




TlTRTHri.ACR 
OF MOTHKR 
(State or Couutryl 



OCCUPATION (^J^ 



/hn: 



THH AIJOVK. STATK I) I'HRSONAl, "'A Hnf/ll'^.*^^ ^ '^ '• ''''''^- ''" '"'"'• 
IIHST Ol MY KNONVKHDCK AND HKIJl'l* 



H^iDUcrw^^UC at 



'^/W 



(Address 



Medical certificate of death 



DATH Ol- DKATH (\ 

MUr 3. 



(.f 



(Moiitli) 



(Day) 



/QO 

(Year) 



I Ill-Kl'iHV C1";RTIFV, Tliat I attendtMl deceased from 

,C\r l.b 190 H to \).V..<s.\r. :^l....„........„i90 H 

that I last saw h'i-'^>'' alive on XTUC^T. !>».fc.............«..i90 \ 

and that death occurred, on the date stated above, at \ ^ C. 
CX M. The CATSIv Ol- Dl'ATH was as follows: 

<jj2yYNwL^vXXA vJjiA^Ct-<r>-v^v-v^ 



or RATION i'ears Months 



Days 



Hours 




rONTR im 'TORY W,>)pJLA-Ow\-^-^nr^ '^^'...... 

1)1' RATION Years ^^^'^ff^'-"^ ^ /^^j'.? 



raVWatrftW-i >«•'«.«« «>'••*«' 



(SIG 



NED) ijAi-^^A^-^ 0. Mil UAywl^ 

Address) OIMVUX' 



'1 



'^ I iqo'l (_ 



i, Insmu 



Hours 
M.D. 



Special information »nly for Hospitals, Insmutlons, Transients, 
or Recent Residents, and persons dying away from liome. 



Former or q o / 

Usual Residence i ^« 

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




~K . How lonq at 

nt 



Place of Death? Days 



JLACK OF lU'R^AI, OR RKMOVAI, DVTlvof IJiKiAi. or RHMOVAI, 

I VjXoJ- 3l2> i90_H 

:ni,krtakkr LLxaA Vvi^c^trtl'v ^ 



(Adc 



•tatc CAUSE OF DEATH In plain term., that It may be properly ua.«inea. 
•on. dying away from home should be ftiven .n .very Instance. 




n 







♦ 



r 



i 



WRITE PLAINLY WITH UNFADING INK — 



Si? 



DEPARTItlENT OF PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFtCATE FOR INSTRUCTIONS 

Me^isteved J\i''o. O-^^OV 



City and County of San Francisco 



(Tcvtificatc ot Beatb 



{ tl. S. 5tan^a^^ ) 



PLACE OF DEATH:-County ofOo^o^- l^VCU^^vACv^Gty of ^ J^V^ ^ A.C^^'^^'^^ 



No. 



\X% - q tL St.; 5 Dist.;bct. ^lllu.CiLO\. 

/ .r or*TH OCCURS *«/*y trom USUAL " ^^ . DE NCE give rAcxs CAtLED ;o« ^^^^ 

C ,r Dt.TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF 



"special informatio 
street and number. 



and ^t CrL^JOJuL 

N) 



FULL NAME 






CK^'\.aJL^ 



e4> * ■« K ••*4r'«* k' 



^'•"GT^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.okX (^ 



v^^oJm. 




I) Aii: •)! r.iK 1 11 



.... /^Sl 



iM.mtli^ 



ACK 



11 



5 >(;>.< 



(n:iv> 



.1 /<>»////> 



(Vcar) 



/^</ r. 



si\<,i.i' M\ki<n*.i) 

w I iH iv\ I-; i> ( »i< i»i\i >K«' )•; n 

iWiiti in >-<)ii;il ilr>«i^.'ii:itiii!i) 




HIKTIIPI, Afl-: 
iSl.itf or Cuiiiitrj") 



N.WIF OF 
FAT 1 1 l.K 



luk'rm'i.ACK 

(»l I AIJIKR 
(Striti- or Country) 



MAIDJ'.N NAMK 
OF Morill'.K 



TlTRTTTPT.ArK 

<)!■ M()rni<:K 

(State or Countrv) 



( HHT I'ATION'I^P 















(j-v.\.^ 






V/'/////' 



/A/r 



•IMF MioVFSTMFI.1-FKS..NVl,I-XKTI|-rLU<SAKKTKI F T. ► TIIF 
MJ'ST OI" MV KN<»\VI,J:1«.F AM) Ml-,J,n.»' 



n nf<ii niMtit 



(A(l(lr<"s»4 






MEDICAL CERTIFICATE OF DEATH 

I).\ TF <»1" ni-ATH r\ 

, Ml 



(Month) 



(Day) 



LI 

(Year) 



I 1II<:KI*:HV CI:RTM'V, Tlmt I attendod deceased from 

^ .Q.L 5Maai\.i9oH t., ^>UNr ^1.5 H5.?.0)\,i9O H 

tliMt T last saw hSi^^^ alive on ...\lUry:....'^l T90 'i 

and that death occurred, 011 the date stated above, at o M 
AJ^ M. The CAl'SI<: Ol*^ I ) I; ATI! was as follows: 



i^ 



.U i. 



IM RATION )'i'ars 
CONTUim'TORY 



Man I /is 



.XXI,. 

o, 
/A?;/^ ■ "^1 J /ours 



Dlk.VTION )\'ars ^/ont/lS /hiys //ours 

(SIGNED) yk'XAVv^j, 5b, ob<xvt 



0.1 tco'l (Addres.) 1^^ Ui^Ot 



M.D. 



Special information «nly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinq dway from fiome. 



Former or 
Usual Residence 

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



HoH long at 
Pla< e of Death ? 



Days 



DATFot MiKi^i. or K 1';M< )\'.\I, 

yClcx- ^-^ ---^' 



PFACF Ol" IHKIAI. <»K K1:M»»V\I 
FNDFKTAKFK U <X^>^CL>^JL/V VTSk^KQ^ 



^a i9o^\ 



fA( 



"""""—"""——■— —""""""""""^ n7,l Ar.B nhoiilcl be ntptetl EXACTLY. PHYSICIANS Hhould 

N. „._Rvery Item o^* information •houl.l h-. cnretully HuppUed ^ f^^^^.^^^,,,,,. ^he "Special lnifor.„«t1on" for pT- 
•tote CAUSE OF DLATH \n pl»ln term., thot It may be proper y 
Hon. dylnft oway from homo should be ftlven In every mHtance. 






I' » 




li 



» I 



I 



f 



H' 



i 



» 






III 




♦ ^ii 



w 



M, .Mh ! 



RITE PLAINLY WITH UNFADING INK 



S.,. -S^^iU) »,<tl' Cm 



/)r//r AV/zv/. \j\^vX-r>vUyy ^!I 



/ry6>H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\^o. 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Bcatb 



PLACE OF DEATH: — County of 



a 



oC<XO"> vJL^^ City of 




>->OU 



CMX^ 



LcJL' 



NT QL?^'^'^ V,r\ a/ « Itv ^ St.; Dist.;bet. 

No. ^^^"^-^ S-CV^ V.^ . ro«« USUAL RESIDENCE GIVE FACTS CALLED roR 

( - ':rot^i'%Tci:::o ::rJ^'!.\'i :« ?.sx,tu..o. .... .ts name .nst 



and 

UNDER "special INFORMATION" "N 
EAO OF STREET AND NUMBER. / 



) 



FULL NAME 



'^ 




^\^K.' 



<^ 




PERSONAL AND STATISTICAL PARTICULARS 

*.('1.''K \ 



OATK OF iiiK ru 




\A, 



XXr 



i\fiinth> 



AC.K 



Oc% JV(7» ' 



(Day) 



Mnvlh^ 



(Vtar) 



/)./ l.s 



SINni,K. MARKIK1>. 
WIlMiWKD «>K IHVoKCKI) 

Wiitf in •>(ni;il (li>.i>.'n;iliuti) 



\3 MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH A 



(Month) 



.11.. 

(Day) 



(Year) 




HIK riU'l, AOK 
(State or Country^ 



\\M1". 01 
lATHlvR 



I'.IK IIM'I..\il'. 

()i- i\rm:!< 

(Slatt «»r Country^ 



MMDHN NAMH 

oi- m()Tih:k 



lURl'niM.AfH 

«n M()Tin':R 

(state .11 t'onntry) 



L<3jLJt^ 



. I 



tr\yvN^v^<X 



1} f\ u 




OXA/ 




tt^ 



\ 






Rf>idri! ni S,ifi Finn, i-ro 



\ 



)'f-<!l T 



Mnllth^ 



IhlV. 



rm 
1 



• \HnVHST\TI'ni'KKS(.\\I PAKTirri A 

n-:sT oi- Mv KNOW 1, 1:1 )<.»'. \M' ni.i.ii.f 
^. \. \AAAJilX 



Ks AKi: PKl K To l'"»-" 



(Infouuant 



I lll':Kl";r>v\:i:RTIFV, That I attended deceased from 

190 to .- «..,.-....U....l<p 

tliat I last saw h alive on •■•-•- ^'P 

and that death oceurrcd, on the date stated above, at 
M. The CArSI<: ()lM)i':ATlI was as follows: 



Hours 




DERATION Years .....^J/outhi 

C ( )N T R I HrT( ) R Y 



Days 



• W • •#• • «# «.«*w*'»k4 f 9 



Vrars 



Mont/is 



Pa vs 



/lours 



M.D. 



w rD w 

(SIGNED) J V). JxAlxrLOA^lL 

VflcV a?. KK^M (Address) UXcX.^-^Jutcu Lo-l 



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

How long at 
.-CX/ Piareof Deatfi? Days 



\^XX-Oyv\^JlXA.< 



Former or 
Usual Residence 

Wlien was disease contracted, 
If not at piareof death? 



I'l.ACH OI^rRIAI, OK Kl'MoWXI 



l)ATi:<>! Ill KIAI. 01 KKMOV'AI, 

M'Urv^ 3.^ T90M 



IM \0H OI-nrRIAI, OK Ki'..M>i 

rM.KRTAKKR ^ <JLUx^ V U 



— - — — — ^-^^iMii— — ^— — ^^— — . , ^ .. 4. I FVArTi Y PHYSICIANS nhould 

N. „._Kvcry Uen. o! ,„»„rn.M.on .h„„l.l b. c.r.fu.ly -up,. U. . AG"-. • ,_^_^__,,,^j .^hc "SpeCa. InW. n" for p.r- 

...., CAUSE OF DKATH In pinin «orm». that H mi.y >« pr P 



:"';."nf fw^r trom hon.c .hou.d b. ft.v.n ln..."«. 



* 



5 




i 



. 



H. . Ml' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3269 



S,fc US: I' Co 



Dale Ay/r^/AUCvMyY^-UMA^ ^^ 

■S 1 



1^)0 "i 

Deputy riearifi Officer 



BcilLstercd J\^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Ccvtificate of IDeatb 

( "U. S. 5tan^ar^ ) 
•-County oiOCL^-'>^^^<^^^^ City oi^y<X^ ^VCC/> v^i^co. 



PLACE OF DEATH: — County 





fto-l Dist.; bet. — 



FULL NAME ^«^^ ^^ 



~ and 



- ) 



TS^CALLED FOR UNDER "SPECIAL INFORMATION" "X 
TS NAME INSTEAD OF STREET AND NUMBER. J 



Sl'.X 



PERSONAL AND STATISTICAL PARTICULARS 




.^. 



^\oii 




A\A^ 



UWV. ol 111 Kill 



r%'^\ 



M-iiithi 



AGE 



bS 



}', ill .< 



(Day) 



M,"i!hs 



(Year) 



Pa Y. 



SINCU.K MAKKIl-.l) 
\Vinn\VKI> «>K l)I\nKti:i) 
(\V!it( ill soriit; ih-ij-Miati'Mi) 



iiiKTnri..\CK 

(&tai«ar Country' 



NAM]' (>1- 

fatiii:r 



niRlIlIM.ACH 
oi- l-ATHKR 
(State or Cotintry) 






D.\TE OK 



MEDICAL CERTIFICATE OF DEATH 

DllATM r\ 

Va^r XI 



(Month) 



(Day) 



igo M 

(Year) 



I 111- R !•: BY C !•: RT I FY, That I attended deceased from 

- T90 

• « ■ 190 — 



190 



to 





.<X/y\(X 



sJvlL<XO'\xL 



MAin>rN NAMK 
nl' MoTIlIvK 



lUK'rmi^ACK 
Ol" MoTllHR 

(Stall- or (.'onnttyl 




orCl TAIION 



,.V^i,!r,f ill S,ni r,a,..is.-o X\ V'" > .< ' ^f'-'tf'^ 



/hn 



Tin- AHOVK STATHl) »'>^-«^'^>'.V; l*.^'*L'•'/^:• 
lJHST Ol- MV KNOWMvIX.h AM> ni'.M»' 



ARS AKl' TRIK TO l"'"' 
F 



(Infoinuint 



Uiat I last saw h -^-^ alive on 

and that death occurred, on the date stated above, at 
. ^j 'I'j,^. CAlSlv Ol- l)i:.ATII was as follows 

,v.r>^^ cri,. y^..<Hi^i, 



..ci.^.OwLcLv.r>^. Cri,.iy5..<HiH 



nr RAT ion' yi'<j>'^ 

CONTRIIUTORY 



)''rars 



A/on //is /^ay 



Hours 



••••«*»«««•*•*••' 



Mouths 



Pars 



DI-R.-XTION , 

(SIGNED )...J...yb.. L^' \iLUx.>V<A,UV(o^\' 

^^"\j\r ^i TooS (■\.ldress)Uvn^XMUlU 
SPECIAL INFORMATION only for Hospitals, InstitutfdiK, 
or Recent Residents, and persons dying away from liome. 

\ \ \\ How long at 



I /ours 
M.D. 



\ JUL 

Transients, 



12.% 



Former or 
Usual Residence 

Wfjen was disease contracted, 
If not at place of deatfi ? 



Place of Deatli? Days 



pd. 



PI \CV OI' nt-RIAI. OR RHMOVAI, 

(Ad.lrc-ss ini VjTWt^iA^^ 



DATKof HiRiAl. or RKMt)VAI, 

MVcv- '^H 190 H 



K-^VJ 



V 



% 



\JUuy^ 



( \<1 dress 






■"^ I I K t ted EXACTLY. PHYSICIANS should 

tlon .hould be carefully supplied. '^^^^ "^^loMWlcd! The 'Special Information" for p«r- 
TH in plain terms, that it may be properly clossnie 



N. B. F.very item of informs 



■I I 



I 

i 

I I 

* 

1 



I ■ * 



^ 



'p. 



^i 



i 



WRITE PLA.NLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



r N 



:.\ i 



REFER TO BACK OF r.FRTIFICATE FOR INSTRUCTIONS 



Dff/c /-V/f'^/, \l\cx^^^^vi>^V Xl 



nfo\ 






■^ ^ Deoutv Health OfHcer 



DEPARTMENr OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



(iD 



PLACE OF DEATH:-County ofV-^>^ OXCv.vCv^C _aty of 

<;f . S> Dist • bet. W (X^vJLl and La^I 

No \^'^l OXCL-lVV^^C^Vv .o.bwrEa.VE rACTS CALUrD rOR under •sPECAU . NroRMAT.ON- ^ 
1>«U. 1 ^ ^ i ^ iiciiai RCSI DENCE GIVE facts c«v-i-r.jj --nEET AND NUMBER. / 



^ 



(\r DEATH OCCURS AWAY F 
IF DEATH OCCURRED I 



(X^ vn. 

MCIIAI REsTd'eNCE GIVE FACTS CALLED FOR UNDER "SP 
^^rHo'^S^pyT*!: OR ?ns't''u';'oN give ITS NAN^ INSTEAD O F ST R 






) 







FULL NAME 



(X\xy\.zJu 




"VV 



i- 



SKX 



PERSONAL AND STATISTICAL PAPTICUL^S 




IIATK OF lUKl n 



K 



\Sja\^^^' 



f Month) 



ACK 



IH 



lVrf»5 



u 



(Day> 



M.,>ith^ 



(Year) 



X5 



/Jiir-i' 



MEDICAL CERTIFICATE OF DEATH 



DATK «>i- ni:\Tn A 

VRcv- 



(M<uitli> 



L...- ..JQO"^ 



"" I III;K1:BV CI:RTI1'V. riiat I attciuUMl aecoasod finui 

M^O to 

tliMt I last saw h - — '>l>ve on -• - ■ - - 



up 
190 



-^IN. I.l' MAKKIKI> 
WIDOW i:i) «>K Divnk* Kl> 
'Wiiti ill »"Ki:il tU'si^-rnati-'ii) 



MIKIHri.ACR 
(State or CmtntryJ 



^-\^J^: •>: 
i ATll !:k 



ItIK rui'i.Ai'K 

oi- JATHKR 
State or r.>ii!itry) 



MAIPKNT N.XMK 
(»I" MoTin:K 



inKTnri.ACK 

oj MoTHl'.R 
(Stall- or Couiilty) 




an. I that .U-ath occurrcl, ot, titc .latv ^tatL-.l ab.,vc. at - 
'. M. Tbc CAISI-: l»l' Ui; ATM was as follows: 



i- 



n 



OAAAX:v.X>-i .-.. ................ 

nrUA'PlON Years ... 3/on//is ^^.-^^ /Mys Hours 

CONTRinrTORV 



DrUATTON 



navs 



Years _ Months 



Hours 



(^ 



( SIGNED ) UV^^^ ^-'^- ^J^- ^^"^^^.(N^ , '^•^" 



la T«)oH 



# 



f\A/fi 



Ke^idfii III S,ni /•")./;/< /w,) '^ )^'.r'> 



Month < 



n,n 



lilvST Ol- MY KN()\Vl.i;i)«.H AND Hl-.l.Il.J- 



(T 



W^ 



.KAAjOL^^^y'^ 



(\(l(lr.<ss ibol 






^^'^^^ 



(8^ 



1- 



<5PECIALlNFORMATION only for Hospitdls. lnstituti(W4, Transients, 
or Rerent Residents, and persons dyin.| .may from home. 



Q5T^ 



Former or ,. r. , +. 

Usual Residence 1 « J I J-^vxx. 

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



WKJU/vxjOtl 



... Days 



ri.ACH OI- HIRIAI, OK KKMOVAI, 



1) ATI". '»}' lliKiAl. or Kl'^MoVAI. 






.,.^^__^.^^,^^ i^,^M^M^—— ^i^"^^^^^^™^ I pvACTLY PHYSICIANS Hhould 

Ktate CAUst. ^tt l»i-« »- , ^.,^_„ inittnnce. 



Vt7t7cAUSE OF Ut A . n m m.»... '-■•■■;:".„ ^^^^y ln8t«ncc. 
«on, dylnft away from home should be ft.ven m oory 



i 



i 




11. H 



♦ 



f I 



I 



i 



!i 



:)■•■■ 



if 




M' 



!■! 



. 1 ) 



»« 



♦ 



'■■i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ ,, „f „c„.,h- . N., .. *-S^fe ..SI' <•■. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3271 




Vv^^ 190 'i 

Deputy Health Officer 



Be^istej'ed J^o. 



Date Fili'iJ , 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "d. S. StanDar& ) 
PLACE OF DEATH: — County of Ocu^ru O.^-ccvA-^vAtc. City of J/CXatu >v^/<X'Y^>^M-<^vC 



an 



c ^.. 






L St.; "^ Dist.; bct.VJJAAX:4\XL'^xa.^A. and 

/ IF DEATH odCURS AWAY FROM USUAL R E S I DE NC E G I VE FACTS CALLED FOR UNDER "SPECK 
V IF DEATHnoCCURRtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET 



(No. '^'^H (Jl^CccO.AO^ St.; '"^ Dist.;bct. 

EATH OCCURS AWAY FROM USUAL R E S I DE NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 

__ ^ ^I^P NUMBER. J 




>\Xl. ) 



FULL NAME 




rr\jx/T\) 




s }•: x 



DATK Ol lUKTll 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 





iMortth) 



a<;k 



S^ 



)lUltS .. 



X 

(I)!iy) 



M,>u!hs 



vlbi 

(Year) 



la 



Davs 



SINT.I.H. MAKI<n:i) 
WIDOWKl) OK DIVoKri",!) 

(Wiiliin social (ltsi>.'iialinii) 



lUKTm'I.AOl? 
(State or Cmintry'* 



NAMl". Ol" 
FATHKK 



RIRTIU'I.AC'K 
0|- I'ATHKK 

(Slate or Country) 



MAIDl'tN NAMK /^ 
OF MOTHKR I I 




MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH A 

VlUjvr^ _ X\ 

(Month) (Day) 



fpo H 

(Year) 



I HHRHBY CERTIFY, That I attended (Icccased from 

'/otj XX 190 H to NjCUvr Xa iQoS 

that I hist saw h ■*..'> ^ ^ alive on Vl V/Cv* Xl icp , 

and that <leath occurred, on the (hite stated above, at 
JVI. The CArSHX>r' DICATII was as follows: 

rW.<r'Vs-'OLAA^ 



_AI. The CA^^SI 




DURATION ^ )\'ars 
CONTRIRUTORY 



Mouths 



Days 



Hours 



\X/wn\x>j 



niKTJIPl.ACH ^ 

<il- MOTHKR y 

(State or Country) -\J 

Rf sided ill S<ni /'i n iniw.) OD )'<(iis X .'\/,>iith< I i. Ihns 



t 



THK AHOVK STATKD rKKSONAl, PART UT I.A KS A K l', TKfK TO THK 
IJKST OI- MY KNOWM-.IX.K AND HKMlvK 



Informant \J I^VCi VAAA/WOj CjOTTVA-AJk. 



Adilress £7v«^ t 





DURATlON^i^ ^^'^nK ^^fi^ftths Days Hours 

J..-i ^ /J</\/x\^J<Ay:^^r\, M.D. 



(Signed) 

vW'Cv^ XI 



TQO 



H 



f 



Ad.'lress) 0. \ U (yVA^U '^1 



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



Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



ro 



IM.ACK OI-- IMRIAI, OK K1';MoVAI. I DATK of mKlAI- or RKMOVAI, 

vc 



INDKRTAKKR >wA.XXA-<V 
(Address ^ 




IN. B. Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special information" for psp- 
sons dying away from home should be ifciven in every instance. 



H 



'!( 






f 



'•a 
'Si 



I 



'♦I 



i/b- >m 



WRITE PLAINLY WITH UNFADING INK 



)',■;■'.'] ,,] 1I( ..nil 1- N" 



-•^•^5^ HJ 



8:1" Cn 



Duli' /'V/r^/,\lrU^M.o^^i^-t^; VX , ^^^H 

t> t,- t-' *-'- ■ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. StanDar^ ) 



PLACE OF DEATH: — County of CJ/Cor^ 




..,.,..City of Q/Ol/^^ m)j;v.«oV^a^ \^<x) 



No. 



— St. 



Dist.; bet. 



— and 






FOR UNDER "SPrCIAL INFORMATION" '\ 
STEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 
»\lH OF 151 Kill 



iMoiitlO 



\<*.K 



bo )V.M.« 



<Oay) 



Mniith.y 



(Year) 



/)./ 1 



sivr.i.i* MARUir.n 

w iix >\v'i-j) <)K I)I^■< »K* j:i) 

' W: ill in soriiil divivMKit i"ii ' 




!UK THIM. \<'K 
<siiitr III <'imiitry) 



NAVU: ol 
FATIll'.K 



lUKTHIM, ACK 
Ol 1 A 1*1 IKK 
(St.'iti- or Cotintry) 



MAIDI.N NAM I", 
OF M<)Tni;K 



KTRTHPT.AOR 

Ol" mo'iim:k 

(st:itc or Country) 



Qu^Q^oJi 




OCCVPAflOR 

h'fsidfii in Soft i^rmmeiiuw BO )>«?' 



Mnlllll^ " /'"I 



TlIK AnoVKSTATKI.l-KK^oNAl.rAKTirrLAKSAKK TKri- To TlIF 

iii:sr or mv knowm-.ix.i-; am> hi-.mi.h 




MEDICAL CERTIFICATE OF DEATH 



[)AT1-: Ol- Dl'A'l'll A 



U 



(Month) 



^0 IQO 

(Day) (Yr.ir) 



I m:Ui:r.V CPJ^TIFV, That r attended deceased fnmi 

I90 to IQO 

I90 



that I last saw h ~ "alive on 

and that death occurred, on the date stated above, at " 
■ ■ >T. The CM SI-: Ol' DI'.ATII was as follows: 



_^_'X o.^:tv<X CSorv/)fAA.*v^X/;^ e>aA/VA>ix7w. atv* 

IsA^v^vO. AiXAX^C^k JUu XU^ctA-^v^ /tLX>-V 

I ) r R A T I ( ) N ) V77 r.? Mon l/is .... Days IIoii rs 

coNTRinrTokV • •• •- 



( SIGNED )\9.t). L 

^\(yxr -^1 



)'<\7rs Moulin Pays 

f 

iqoM f AddrfS>.)\Xct). Lfr\^\iA. vyp 



I /ours 



M.D. 



Special information »"'y '"•^ Hospitals, institutions, Transients, 
or Rccfnt Residents, and persons dvinq away from home. 



[kn?! R?sidrnre 5^ I io ^ oImtT^ 3 1 KeToelth ? 



Usual Residence 

When was disease rontrarted, 
If not at plac e of death ? 



.... Days 



I'l ACK Ol' IIIKIAI, OK Kl'.MoXM, 



DATi:')! Ml KIAI. or KlvMOV.AI, 

'(\\ 1 I ,VU>J^ Ql3 190H 

rx.,....s xx\ Qna^ CLlU^ttH..3i 



IN. B.- 



" .. , .pR -hniilil be stnted F.XACTLY. PHYSICIANS should 

-Kvery Item of Jn?..rm..tlon should b. cnroVul.y h"PP''- ' „;.^„,h " leLwicd. The ''Special information" for pT- 

• t«tc CAIJSI; OF DBATH In plain tcrm«, thnt .t mi.y be properly clo««.»ic 

"in. dylnft nw«y from homo should be ftWen In every InHtance. 



I..' ""P.. 




i 



ff 



:aiM^ri^^tt4^ 



iM 



i 



K 







. t 'f 



ii 



I 

I i 

i 



H,,:.T,1 ..f Hi alt h I" N 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Re^istei'ed J\ro. 3373 



-5-?^air^ 1J& I' Co 



Ihifc AV/^v/,\4UvM^-rY>^^ ^^^"^ 

DEPARimENT OF PUBLIC HEALTH=City and County of San Francisco 



I- .. y. 



Certificate of 2)eatb 

PLACE OF DEATH:-County ofd<XA^ ixr^.^a..c.City ofO^^ Oaxx^-<^^<^^ 



^ 



(No. 




rv^JL 



Dist.; bet. • and 



( 






FULL NAME 




,4.A\-o>.vvr 






■^^•Qlii 



PERSONAL AND STATISTICAL PARTICULARS 
~ I COLOR 



JcA'Y^oCX'Vi. 

DAIK nl" r.IK 111 



.1 




I MEDICAL CERTIFICATE OF DEATH 

DA TK OF DKATH 

■"' ^, - \± 




(Month) 



\C.V. 



x± 



Years 



11 



3.S 

iDav) 



M,»ith> 



/lia 

(Year) 



11 



Pa v.v 



S INC. 1,1". MARun:i). 

WIDOWKl) OK l)lV0R(.i:i) 
iWiittin social (ksiKuatioii) 



UAy^^^wU. 



HIKTIIPI.AOK 

(Statt or Oonnlry^ 



J? ^ (1 



\' 



VAMK OF 

iATm:R 



TUKTIUM.Al'K 
()|- I-AIIIHR 
(Statf or Country) 








(Month) 



(o»r) 



(Year) 




I IIHRKBV CKRTIFV, That I attenckd (Icceaseil from 

: 11 igoH to aVVcV^ \%. 190 H 

tliat I last saw h ^v alive on . ..\jA^B\^...i^ 190 '^ 

aivj that «Uath occurred, on the date stated ahove, at O 
(j M. The CAI'SP: OF '^^AA''^'^ ^^"''' ^^ i'oHows: 



':)fX) 







MAIDKN NAMI-: r\ /O rt U 

lURTTIlM.ACK n /-Y^A 

OF MOT.IKR V (5(11) 

(State or Country) ^ ^1 

occrrATioN 

TMKA»0VKSTAT1U..'KR:;..NA. FARTUM^UARSARKTRlKin THK 
BKST OF MV KNOWI.FDOK AM> HFMHh 

(Tnf.,nnant X ■<XWu \jS ^ ^a>^Jr^^ 

1X0^ aijAMyvx<L Cnrv ot 



(A«l<lrfss 



Ur RAT ION 



Years Mo fit /is ^i /^aj.? Hours 

' (Ja^^^xixAjl^ 



nr RAT ION 



)V(7/.J Months ^l /?<7j5 Hours 

(SIGNED) UJ'.Aj. UkJL^X' ^ 

(!rU^r d rnn-. rAddress)Ofc.lwkx^ Jbi 



M.D. 



Special information »n'y fo"^ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 

fiSVsldence ISkO^ oijLA>iL^vv4^^^ naVTlkU? 5bl 



Usual Residence 

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



^\^^.. Days 



lUACK Ol- nCRl^AI. OR RKMOVAI. 

-A-ATY^ 




DAPIvoC m KiAi. or KlCMOVAI, 






N. B.— Every Item of InformBl.on .hould b. c„re*ully HuppMecl. ^^^^;;;7;3^,X'i!''Thf '^S^^^^ In^o^m^Ifw' W ^r- 
.*i.te CAUSE OF DEATH In plain termn. thnt It mii> ne prop 3 
Tnl^XllZy from home .hould be ^Ken In .v.ry In.t.ncc. 



^Mm^itmi^.:^.^^ ^ -,..^^...^^»^ .... ^■- ... 



^ii^^b 



I I '4 



' f 



f 



H 



» 



M 



't, I 



if 



a*'.? 



Pi 



« 



-/it* 



w 



RITE PLAINLY WITH UNFADING INK — 



,;, ,,.1 . f ll.;>lth l-N.. ;. t.>-_-y;;7-t.!UVlMo 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be^istcrcd J\^o. 0^74 



i ' 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



f%fT; 



.5y^>M 



Ccvtificatc of Beatb 

( 13. S. StanOarP ) 



4 



^ 



PLACE OF 



No. 




( 



DEATH: -County o^^ajTs. J,>ux^Cv^c*,^Gty of Oxx^^ O.VXU>v<.c^<:-v 



^-crw-v 



/CV^W'<>^ 



r\ 



St.; 



?^ Dist.;bet. % .cc,^'^-^v^tr>v . and Sxd. ^^ 'l LL ) 



..on&l RESIDENCE GIVE FACTS CALLED FOR UNDER -SPECIAL INFORMATION • \ 
*^" °''oCCU%*RrD\NTHo''s^PrAL o"r' f N ^ '.?J;i O^N^O I V E ITS NAME INSTEAD OF STREET AND NUMBER. ) 



IF DC 

I F DEATH 



FULL NAME 




LCJL 




>l.i/'l:^_• 



PERSONAL AND STATISTICAL PARTICULARS 



DA IJ". OF lllK 111 



C( 






i\.^lx 



Klontli' 



AC.K 



)"fi;» 



10 



may) 



M.nil/l.y 



1 



(Vtar 



/'(/ lA 



sI\«'.l.K. MAKKIl'.n 
WIDoWKl) OK DlXoKD-.I) 

• Write in mmkiI <1. >-i!.Mi:itioii) 




lUHTlIPI^AOK 

(St:it<- 'ir i.'onntt V 



NAMK Oi- 
l-ATI n-.K 



niKTHPl.ACR 
oi- I APHKR 

(Stat* or (.'oniitry) 



MAIDKNf NAMK 
Ol' MOTHKK 



niKTin'T.ACK 

oi" MoTin-:R 

(state or C'outitrv^ 









(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- I)1;aTH C\ 

V V^^ il 

(Month) {tHs} 

FllHRl'ir'V CJvRTIPV, That I attendcMl dccoascMl from 

yX^rvr H icpH to .. >xU\r .X.i ......190 H 

tliat I last saw hXh,- alive on nTUxT LvS".. 190 H 

and that (loath 00011 rrcl, on the dato stak-d above, at d. 
.y M. The CArSl*; OI- DlvATII was as follows: 

^^JjoLV a».X<x>v MYU/>^vy^-x.cv^v.^ 



J 





VOuLJl< 



OCCrPATlON 

AV>i(f/-tf lit S<rn l'iiiiiii^i''> 






CjVvu^<X^ 



)V,n> I Cj .V..«///.v 7 ^^'^' 



r„H AHOVH STATHl) ''HK^ONA. VAKTirr .,A KS A K K TKIH To THK 
in:sT Ol" MY KNO\VI.i:i)(.K AND Ml-.Ml-.b 

„„r , %j^>V^-^ijtt^ MVLUx-U^v 



(Addrt-ss 



DIR.VTION Years Moulin 

CONTRIIU'TORY 



Days- I Ion PS 



DIRATION 



Years Months ^ J- Days Hours 

( SIGNED yixA^'UUi LtrUw^^<lAv^ J^'^' 

^\j^x\ Tc>oH (Address) n^n ^»Ue»V^t 



Special information ""'y ^^^ Hospitals, institutions, Transients, 
or Recent Residents, and persons dyin.j away from home. 

r„,m«r Ar How long at 

SlResMe.« ■■ Plac .1 Death ? Oa,s 

When was disease contracted, 

If not at place of death ? 



DA'PHof MiKlAi, or KI-IMOV.-M, 

mWt as T9on 



I'l.ACK OI- IJIKIAI, OR RKMo\AI 
rNDKRTAKKR V) <X/aAJ^*-'<k^^^ 



\AA^^dJ^AJtoJki-^ 



V:::l^^^lZ ^rL hon,e should he .Wen In ever. Instance. 



V. \\ 




.\ 






I 



'•» 




I 

I 
I 



'!«* 



J 



W 



RITE PLAINLY WITH UNFADING INK 



H, •\)'. I' N'v 









7.9ryH 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3275 



Be^isferrd Xo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



J? 



( XX. S. StanCiatP ) 



•SI 



(^ 



PLACE OF DEATH:-County of Ocu^x- J;.c.->^.^^^c City orV<xorv J Axx.^xa^^^.0 



( '^ r/;;:x°H^o^:u%iv,r°i"s"pr.t o^'f^?r^^".^o^.'^o^;.;^;l name ..sr..o o. stb..t *.o ...s... ; 



-ti 



FULL NAME UJLtrVqi^ 




\D. 




a 



SEX 



PERSONAL AND STATISTICAL PARTICULARS 

I CO 1,0 R 





DATl-: nl III Kin 



AOE 



\ 



|lMr.lltll) 



x^v 



}'lll> « 



a. 

(Day) 



(Year) 



n 



/)<n 



'ilN*".!.!*. MAKKIl'I). 

w n)<>\vi-:i> OK i)!\nKri' I) 

(Write ill •<(H-ial dc^ij-Miati" m) 



1UKTHPI.ACK /^ . /O i'^ 

(Statf or I'r.nntrv* [ L' Ij ' \ 



cOL<w^ci?X/^^^ 



NAMI' 01 ■ 
FATIll-.R 


hirthpi.acp: 
(>i- i-AinKK 

(Statf or Coiintryl 


MAIDKN NAMK 
ni MOTHKR 


Hiur!iri.A("K 
oi' N;()'nn\K 

(SUitr or Coutitryt 









0^~>-\^' 



&^ 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DICATH 



(Month) 



(Day) 



(Year) 



I HERHUV CIvRTir^V, That I attcndcMl decoased from 

- ' . - 19O to 190 

"190 : 



that T last saw h -r— alive oti 

an.l that .loath occurre<l, on tho <latcvstatc(l above, at - 
" ~-„^ M. The CAI'SI": Ol' I)i:-\J'II was as follows: 

cjvca.-a,'Ca«<:^L^ •■■• 



niRATION Years Months 
CONTRITJUTORY 



Pa vs 



I Jours 



DIRATION ■:, >V<?'-J 



Months 



/Mys- Hours 

(SIGNED) ..L55^.<^nJU^J J.M3. tU. <:MJUx,'>vcL M.D. 



^ '^i^.(^.lo.-LL^ 



)Cn 



oc'crrATioNfT) 4. 



...... ,, . ,. "^Q iv,M<r 5~ ^r,>,l^ll!< VX '^'"■' 

NAi.rAKTiiri.xKS \Ki:TKri-: to thk 



r hi: a \m ) V K SPA r i- n i- k k ^o n a „ , . , i ,. k 

1U:ST OF MV KNOWl.l-.DOh AND MF.I.U.J 
(\<l(ln'^s boo 



^VA^KX^JX 'j1 



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

S Residence %5^^ (]bfrU^'Va..it Place of Death? Days 

When was disease contracted, 

If not at place of death? ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ 



I'LACK OK nrKI.U. OR RKMoVAf. 



'M 



DAT j; of HiKiAr. or KF:MoVAI. 

MWt X%. T90M 






^, B._Bvery Item of Information •houlcl he cnrefuHy -nP;--'- „;!„';^:H!;7laLmei?''Th^:'''^^^^^^^ InWraf.on"^ Jr p^r- 



state 

Kon 



te CAUSE OF DEATH In plain terms, that it may he proper.y 
. dyinft oway from home ahould be ftlven in every .nHtance. 




liilttiMtttJllii^te^^Ei^Mi&^ 



! , ^«l 



II li 



ur.. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„.,., n. .U. . S.. . . r-^n^.C. ^ R.PER TO BACK OF CCRT.P.CAT. FOR .NSTRUCT.ONS 

3276 



lUO'i 
Deputy Heaiwii OlTicer 



Br^isfered Xo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificate of Bcatb 



(W 



PLACE OF DEATH: -County of O^^a^ vl ^a^xC.^c. City of Cl<X>v. 0.^xx^^,<:^tc 



I 



Off) 

FULL NAME V.KaV 




-^J.X 



PERSONAL AND STATISTICAL PARTICULARS 



'"'' L 



1) All", ol- lUk 111 



Coi.oR \ (^ 



V^' 



JLii 



iMonthl 



A<.K 



bS )V.M' 



(Ditv) 



M,>fiths 



(Year^ 



/'<n 



■ Wt itf in ■. H'ial dt vi^-nat i' ■!! ) 



HIHTniM, Al'K 
uSUtc ot Country) 




XcLcrVA>X<X 



(X^^^/tX, aX^CV 



HAT 11 l.R 



lUKTHri.AOK 
<)l lArilHR 

(Stalf or Coniitry* 



MAIDKN NAMK Q 
()1 MOTIIKR ^ 




jn 



TUk'riTPI.ACK 

or MoriiivK 

(Statf or Cotmlry) 






OCCUPATION 

Rfsiitrd ill Sii» /'inihisro I A) ) 'co i 



Mouthy 



Da v. 



TMKAm,VKSTATKI)PKRS,>N..y rAKTirrjAKSARKTKrKT.. THK 
m%ST OF MY KNOWl.l-IX.H AND HhI,n.F 



(li 



(XcvJlvCU ^. U)-t.UixA. 



(Address 



JwCL/d-^ 



MEDICAL CERTIFICATE OF DEATH 

DATE OI- DKATII (^^ 

' \c>Jl 5.t 



.U 



(:M<)iith) 



(Itey) 



IQO 

(Year) 



I HI'Kl'BV ClCKTIl'V, Tliat I atlonded (Icc-casi-d from 

dX^AjC. V\q 190H to . MVCTV^ ^0. 190 H 

that I last saw hX>u alive on .U\.mJ~-...J.*i........ t<)0 ' 1 

.,n.l that <U'ath occurred, on the date stated ahove. at ^Uvl 
ILm. The CAI'SI-: Ol' DIvA TH was as follows: 

<i^.\JOoCvxxA. v^^r^Aj 






•VOv^ 



!^J . 'CxJaIA^vu *^ 



-n" 



DIRATION 5) )Vr?r.? Montin 



nays 



Hours 




DIRATION 
(SIGNED ) 



Years'^ Months Days 



Hon 



rs 







a.»vci. M.D. 

M\c\r Xi TooM r.xddre ss) k)0<o dj^^tU^, )t 



SPECIAL INFORMATION «nly 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'UACK OF HFRIAI, OR RHMOVAI, 







1 



I)ATI-:<)f MfKiAi. or RI;MoVAI, 

M\€\r Vi T90H 



iJiv^jtjL 



^^XAjuy^ 



^AM^ 



N. B.— Every Ue„. ot ln!.,rm„.lon .houl.l be c„.c(uMy .uppMed *«^, •J'':','^'',.%:S:"Th^.''-*8p«l-> InWrJu'on" Vr ^r- 
«tate CAUSE OP DEATH in pliiin terms, that it mny ne proper y 
:o". dyfn* aw.y from home »hould be ftiven 1» .very .n-t.nce. 






% 



iMHMliMfllHil 



■i If 

- \l I 






h 



i 
iff $ 



1: I 



'I 



w 



!■ .-'h 1 



RITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

HEFER TO BACK OF CEHTIFICATE FOR INSTRUCTIONS 

3277 



, t-t'^X? MS: I' Co 



Ihffr Fi/t'J Sl\/ss>Jin^\X>^^ VX 



li)()\ 



Be<^lstcred J\'^o, 



A \ Deputy Health Of^cer 

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco 



No. 



Certificate of Beatb 

( tl. 5?. 5tnnC»arC» ) 

■ \ ^:f 

PLACE OF DEATH: — County of^Jo-'V^ ]xa>vyC^^o. 



J? 



01^ 



City ofC3<V>^ JA/0.->^OMi..co 



^^_ St.; H 

,r o.J»TH^c^cuBS Awv FROM USUAL R E S I D E N C EG • , 

I F 



rl. 



Dist.;bet. OlDCUvWL^v 




and 3 CrVA,<pf:>r\/. 



VE FACTS CALLED FOR UNDER SPECIAL INFORMATION • \ 
( " rFTr-H"0CCU%r.V.rrH0VprrA: OR-TnST-.TUT.ON OIVE its name instead of STREET AND NUMBER. 



FULL NAME 



N 



u 



\^K\Mr\.' 




u 



yx.o^'^^ vu^k^.. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



¥v 



COI.OR 




DAll-. Ol lUK I'M 



Ar.K 



D 

i^llonth) 



JVrl>^^ 



']> /^ic.'^ 

il);iv) (V<-ar) 



.1 /"'////' 



1 



/)<n.v 



MEDICAL CERTIFICATE OF DEATH 

DAi-H oi- i)i;ath r\ 

Vi.Lr^^ ^'^ 



(Month) 



(Day) 



(Year) 



"l HHRHnVClvRTIFV, That I attciKled decease.! from 
;:?! fl i.t an t^ H to \hw<^r. '^2. igo H 



dX^xt ^G 190 "i to 



SlNt.l,}-. MAKUli:i> 
WIIMiW i:i» OK I»IVnKCi:i) 
(Wiitiin social ih-Hiv^'i-'it'""' 



lUK ruri.ArK 

(Statf or Co\!iitrv1 



HATH i;k 





HIK llirT.ACR 
()|- lATlll'.K 
(Stalf 01 CmuiU y) 



MAIDHN NAM I". 
OF MOTHHK 



lURllirKAllv 
o|- MOTHICK 
(Slatr or Country) 



^■OJVv^ 



i \t Nj l\i/\'VCua-w^-oru 



o^klL' 



CLA-v 



cL 



IQO 

that T last saw hA..^^- ahve on ^^^ %X..-^....^..l^ N 

an.l that death occurred, on the date stated a1)ove, at- -^-^ 

kK M. The CAISI- Ol" Dl-Alil was as follows: 

L\^^l-^"vJi^"v-^-''^^ 



nrRA-riON Y^ars 'k-Moi^'ihs /hivs • //onrs 

CONTRIP.UTORV LLc.v^t«. J. <XNLt\. vlkA 






Hours 






OCCVPATIDN 

Rrsiih-if ill Siin /'linn ism 



j,,„. ^1 .u...///.^ ( i />'M> 



•rnKAUOVKSTATKI>PKKSOVMVAKT|CrKAK.AKKTKrH To TH. 



(Iiifonnnnt 



/\XXX.'»NA/^ 



(Address 



XX rc,oH ( Address) lUH 



(SIGNED) V.^'^- i^^^^^ (2^ p f-^- 



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



Former or 

Usual Residence 

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



How lonq at 
Place of Deatfi ? 



Days 



I'l.ACK OK nURIAI. OR RKMOVAI 



DATKo!" IHki.vi, ui RKMOVAI, 

V^Uv 3.3) iQoS 



.ACK OK lU R 



( Address 



— — ^-^^— i 1^— i— — — ^'^^^^^""^'^ , FVACTLY PHYSICIANS should 

F OF DEATH In plain termM. that It may »>« P^ P 



N. B. Every Item 

state CAUSE OF DEATH In P'"" :-.•..; „ ,„ ^^^ry Instance. 
!• dylnft away »rom home should be <l.>en .n e e y 



soni 



HI 



^fc 








A. 



JiW 



w 



RITE PLAINLY WITH UNFADING INK 



B.'U\! 



II. 'Ub 1 



*^";..-^.l'^^. 



Ihf/r /•V/f'^/Al\<^>^^^''^^^' "^^ 



19 OH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 



3278 



.ev^c^Vw^ <XW 



Dep* 



» » 



a? 



It-l^ o*^ ^ /^ f 



DEPARTMENrOF PUBLIC HEALTll=City and County of San Francisco 

Ccvtiticatc of IDeatb 

PLACE OF DEATH : - County of Oo^-rv J .rva.^C-C»-Ct C.ty ot ■ 



FULL NAME 






Ni:\ 



n\Tr <)i" luK rn 



PERSONAL AND STATISTICAL PARTICULARS 

i CUI.OK 





iMDiith) 



\<". K 



) liU 



(IJay) 



Months 



/acH 

r»'ear) 



Pavs 



I 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATII ^ ^ 

\^fAr 3*C^- 



(MontlO 



{o«y) 



(Yearl 



7 IllvKUHV CI-:RTIFV. That I atten.le.l .lecease.l from 

— . .- ■ : : 190 to ..rr-rr-rrr^TTrrrrrrr" 

— alive on -——rrrrrrrrr. 



STNr.T,!*, M \KK U-.H 
WIDoWKl) OK IMVORCKP 
iWiili' ill v(.<-i;il <l.vij.Miati'>ii) 



IHRTIIPt.ACK 

(Slati or <."nuutiy 



NAMR OF 

i'athj:r 









UX^VV>A-^wA) V />^vCLULtW 



niRTuri.M'K 

(»|- lAllll-lK 

t mate or Count rv> 



t 



M MDJ'N' N AAtl*. 
01 MoTHlvK 



BTRTWPI.ACI? 

(»i- \u>Tm-:K 

(State or Country) 






til at I last saw h ■• 

and that (loath occi.rred, on the .late- .tate.l above, at 

M. The CAISI- Ol- DI'ATII was as follows: 

^iJU ^ crv>^ <^ .a..mA.(^.... 



190 
T90 



DTR \TI()N JVar.? 



Mo'il/is i^m Noftrs 

CONTRIBrTORY V-V^^(Ua.x.|^^ 

<^'YXAi>^.'-^^v^^-^'rvUx.'L^'^^^ 

r)ITR.\Tl()N Vairs ^f'^^'th. Pays Hours 

:„ ,.3 (i.o> 



(SIGI 




M.D. 



A 



( (vClI'A'riON 



)'riii 



^r,»/f/l' 



n<i\s 



nrMiirii '" _^ ...111-" 

r„rA,U>VKS.vxTKnrKKSONA, rAKTU^M;AHsARl. 

liKST ()!• MY KNOWIJ-.IM.K ANH lU.UIl.t- 



(Vl-CVr aC ^^^4: /Address) HOfcdxv. 



-tU>V Cl 



SPECIAL INFORMATION «"!> tor Hospitals. Institutions. Transients, 
or Refent Residents' Vnd persons dying away from home. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death 7^ 



flow lonq at 

Place of Death? Days 



(I 



VUlrt-ss I OS VJX.V<L 



.^UL 



n ACF Ol- lUKIAI. OK KKMOVAI. 



DATl-: of niKiAl. or !<KM<>\AI, 

^)\Ar>J^ U.'^K 190H 






Of>Ur^OLx\ tr>>^.JLh^ >s^l\>^ 



1 *" , FVAGTLY PHYSICIANS should 

OF DEATH In pl«!n t.rm., f- »_ ""f, . .r,„„. 



"■ "• «-« CAlTsE OF OEAT" In P— ^'-'^i/^.n .v.ry ln..-nce. 
mrm* dylnft Bw»y from home •noul.i nc k 



Mi 



t 



^ 



w 



m 



)•„ :i: 



■ f ]]. I'th I- N 



:i> it 



p,TE PLAmLY WITH UNFADING ,NK-THIS .S A PERMANENT RECORD 

PFrER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 



%i- V.S^VCn 



Dale Fih'(L M l^^-^-A^^ 

J? ^ 



Luv -X^X i^^^ 



He^i^'^teved JVo. 






» ^-k 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



od 



Certificate of 2)eatb 

( XX, 5. StanDarD ) 

PLACE OF DEATH : - County of O ^^ .\xx.tx.c.^^^^ Oty ot 

^ , ^^ c* ^ Di^f ♦ l5et H:0.yCA\AxCPru and - -- ,^ 

KT M r,^ lYCr^H AV<.' ^^'^ "^ VVr.rnVoR UNDER "SPECIAL INTORMATION- A l\ 




v<i^.. 



) 



FULL NAME 



.i.,*»**»**«iw****' 






PERSONAL AND STATISTICAL P^RJJfyili^ 



LO A-Ctx. 



U.VTK or HI Kill 



ill ii 



I 



\ 

n i 



(Monlh* 



.\r.K 



S3 



) f(/» 



a 



1 

'Dav) 



M ,,iths 



r%"\ 

(Year) 



m 



Aim 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 




(Month) 



.3.1. 

(Day) 



(Year) 



SINf.1,1-:. MAKKIl'.n. 

\vii)n\vj-:i) OK i)!v«»Kri-.n 

(\Viit( in social (b.si^Mialion) 






\:t m 






lUKriiri.ACK 

(State or Coiintry' 



NAM1-. (>»• 
KAIIII-'.K 



r, 







#1 




lURTfin.ArK 
oi- iArin:K 

iStatf or i.'ouiitrv) 



MAIDKN NAMK 



inKTHlM.ACK 
i)V MoTinCK 
(Stale or Country) 






fVmRlUiV CHRTIFV; That latten.le.l aeceased from 

Q\^ \3. 190H to Jl^ --'^'^ 

that I last saw h X^v alive on ^^KcUT:. :>.l....... ..t^^ 

an.l that <lcath occurre.l, -n, the <late stated above, at 1 
I d M. The CArSl- C)F DI-ATIl Nvas as foll.nvs: 

Q) ^...cryyjOry^ vj ^^^JL^^-/^>v.<r-vxA..^ 








DTUATION 

CONTRIIU'TCM^Y 



)'^ars Months 13> Pays Hours 



Years 



M()ut/is 






;.r 



M. ml lis 



Dors 



^Hr^UOVKSTATKI>l»KKS<>NA.^AKT;;;^;,^KS AK.TKl:K TO THK 
liHST OI- MY KNOWI.KIX-.K AND HI.I.H.l 

informant ^ O^V^Vv^ C}XbA^<^' 



DURATION 

(SIGNED). - . 

W XI lOoH fA chlrcss) bCn lU^-^. 



i^xxhJLi) O/CX/^^^^^ 



Pays 

o 



Hours 



M.D. 




:^ 



-^^CIAL INFORMATION only f«r Hospitals, Institutions, Trtinsients, 

or Refent Residents, and persons dying away from home. 

How lonq at 

Former or pi^fc of Death? Days 

Usual Residence 

When was disease contracted, 

If not at place of death ? 



(A«l(lrcs« 



5 



I>I,\CK OK BITRIAI. OK KHMOVAI, 



DATliof HiKiAi. or KllMOVAI, 
X^ TQOH 



UNDHRTAKKK 



d . (ycLiLCWo 



. , FXACTLY. PHYSICIANS should 



N. B. Every Ite 

state CAUSE - - ». , , 

sons dylnA away from home should 



I 



'H 



I 1 



• p 



WRITE PLAINLY WITH UNFADING INK 

,,,,r.! . f II.. .Mb I v.. •■• -^^j^i'^t'^'" « 



7.9 6>i 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered ^'o. S2S0 



DEPARfMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of S)eatb 

( Vi. S, StanCatP ) 

J? (STt i ^ 

fio ^, J V<X->vc*^ct City of CJ-'^'Yv OAxv>^C(^CX 

ocn.4,b>T\' ) 

) 



PLACE OF DEATH : — County of'-^O-^^ 
,, MM V^." St.; 5 Dist.; bet. db C>^^<^^^- and' 

( ,r DEATH OCCURBED IN * HOSP.TAL OB INSTITUTION GIVE IT* ^^ 



ION' 



FULL NAME 



.\/TsjA.-6^ J AXuorv.e^^.^J..•fc^-;U.^a 



SKX 




PERSONAL AND STATISTIICALJPA RTICULARS 

I COI.OR 







'\o.Xjb__ 




\ 



u 



Mutith) 



*.^VC 



H /HCiH 

(Day) (Vtar) 



AriR 



) V<f > .V 



M,'i,ths 



lb 



/>« V4 



MEDICAL CERTIFICATE OF DEATH 
DATK <)!• DKATH A 

....... \ll(5\J- 5lo.. 



(Month) 



(Day) 



lOO I 
(Year) 



SIN(.I,K MAKHII'.I) 

\\ ir)(t\vi;i) OK DixitRii'.n 

iWritf- in scHJal <lf siv:"ali«>n) 



HIKIMJM.AOR 
(State or t'onntrv) 



NAMK OI' 
FATIIKR 






CVWAcXXJ 



xjjij^^^y\j vjx^vo 



\\hJ 



\) 



niRTHPt^AC^R 
<)»•• I-ATIIKR 
(State- or Coiuiiry) 



MAIDKN NAMK 
OF MOTHKR 



HIR rUTLAOK 
Ol-- MOTm:R 
(State or Country) 



1 

OXXAj 





I HF.RRBY CKRTIFY, That I atteiKled ileccased from 
..H 190H to nA^tV: %X>. ....190 H 

that I last saw h -c. . . v aUve on VK^^ !^0...„.. 190 H 

aii.l that death occurred, on the date stated above, at 
- ^I^ Xhe CAl'Sr: OF DICATH was as follows: 

<3~ry\yO^^^'^Ls^^rv^ ^-j; ■. 



DrRATION y^'tJ's 
CONTRllJl'TORY 



Months 1 i' Days 



Hours 



c>>**4»*aft»*' 



Yciiys 



^fonths 



/hjys 



( SIGNED ) G 2). m. 'Jxtlv^tV.^ 

.Address) l^X^O ^^^^^^ Jt 



Hours 
M.D. 



Qa^ 



^6 looH ( 



f^ 



\^XxLJk<5V>vvXXJ~ 



OCCUPATION 

Rrsidfil in S un Fntfni^.'o ^" )><?>" 

(Infoiiuant U>-^ ^-' 



Mouths 



C /'. 



; 1 : 



RS AK1-; IRl H Tt> '••*'" 



' Xddif'iS 




SPECIAL INFORMATION only «or Hospitals, Institutions. Transients, 
or Recent Residents, and persons dying dv»ay from liome. 

_ How lonq at 

Former or piare of Death ? Days 

Usual Residence — 

Wtien was disease contracted. 

If not at place of death ? ' 



L'l.ACK OJ- HrRIAI, OR KKMOVAI 

^0 



ri.ACK Ol- m K iAi< « 

.m.hkt.Jkkr %^ QfW^4^ Co 



DATlCot HiRiAl. or RKMOV.M, 



IK t t d EXACTLY PHYSICIANS ahould 
N. B.— Bvc, l.em oS ,„.„rn„..on .houl.. he CBrofuM, »«PJ."«.«. ^^^^.'J":;...,:-,.'/ Th. ••8,..cl.. Inform..l<.n" for pT- 

<. * %Aii«F OF DEATH In p iiln term*, that it maj nc pr ^ 
•t«te CAUSr OF DEA 1 P ^^ .^^^ ^^ ^^^^^ |„8t«ncc. 



«on 



« dylnft away from home nhould be &i 



I"f i 



fe m 




:1 



m. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HonHoftU-alth .- No , . t.>g"-g?^ ^^-^ 1' Co REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS 



l)i 



Be^lsteved J\^o. 



3281 







Deputy Heafth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDeatb 

( XX. S. Stan^a^^ ) 

J? on Si Qy 

PLACE OF DEATH: — County ofCJa'Yv JA^>^^:^.^i^ City of CJcva^ J;u<v>xc^a^c 
No 'i'^b Vj\a:l<r^->-. o St.; M Dist.;bet. S t-L -and ta 

iNO. • «^V, A V^V^AwV — ,,c.i*l orQinCNCE GIVE FACTS CALLED FOR UNDER SPECIAL INrORMATlOW A 

( '^ .Vo7AT^^CCc"uVRrD\;"rHo"s"rAt o"?:S.^^*;^o':,"c.vVTs NAME ..STEAD O. STREET AND NUMBER. ) 




FULL NAME 



VIjUxVa 




^XJLA 



.V.)\jLck. 



PERSONAL AND STATISTICAL PARTICULARS 




.\jtjL. 



i)\ ri; oi iiiK I II 



AOR 



Moiithi 



V-\ 



) lUJt s 



\b 



(Day) 



M.'nHis 



rlhB 

(Yt-ar) 



ID. 



Pit vs 



SIN(.1,1-: MARkUJ) 
WIIX »\Vi;i) OK IH\< »K* ». I> 
W'littin oinial (Icsivnatioii ' 



lUkTIUM.AOK 
iJstate or Country) 



FA 111 J.K 



lUk IIII'I.At'K 
Ol I AlMl-.K 
(Sli(l«- <ii t'oiititi y) 



maiukn namf. 
oi" motiifir 



lUKTHri.ACF: 
OI MorHF.K 
(State or Ootiiitrv^ 




. i\xxcL<ix 



y\' 






^ 



medical certificate of death 
datf: of i)f:ath 




(Year) 



.cv^ 2iC) 

(Montli) (Day) ^^ 

1 111';RF:HV CKRTIFV, That I attenckMl (kcoased from 

BjJpwt "bC). i9oi to JjX^Jvr 3wD 190 H 

that I last saw h X\^ alive on VTUvT. ^0..... Kp H 

ami that death occurred, 011 the date stated above, at oO 
\1 M. The CAISI-: ()!• DI'iATH was as follows: 

\ijr\X)r<.\Jii\A Vj-CAXvvv^cr>^.xJLv6 ,.., 



Drk.XTION Years b Mouths iHfS 

CONTUinrTORY - 



Hours 





oCCri'ATION 

Rfsiilrit in Snv f'l aniisro 



)'iit I 



M.nillin " /'«'••.' 



THK AHOVI-STXTKI.PFKSoNAI.rAKTUM-KAKSAKl-TKl H To TllH 

hf;st of mv knowi.I'DCH anu ni.i.iF.i* 



(Iiifoi tn.Miit 



i \rlilrfHS 






DURATION JVr/r? Months Days 



SIGI 



Hours 



M.D. 



I'WrOwl looH (Address) ilCH 



• ' Ow>. 



WvU it 



SPECIAL INFORMATION only lor Hospitals, Institutions, Translrnts, 
or Recent Residents, and persons dying away from fiome. 



Former or 

Usual Residence 

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



Hew lonq at 

Place of Death? Days 



190 \ 



I'l \CF Ol- HI- RIAL OR RKMOVAI. D.VTF of HCKIAI. or RKM»)VA1, 



(Ad.lKSH ^C" O A-k- Cjt 



-^ """"""^T „ , Kiv Hhoultl be Bt«tecl EXACTLY. PHYSICIANS nhould 

N. B._P.very Item of ln?or,n..t1on .houl.l Iv. —;•'"> "";;;; '^;; „; '..^^ Ja..Wlcd. The -Sped.. Information" for p.r- 

•tatc CAII8I! or DflATH In ph.ln term., th,.t It mi.> »e ,r.»periy 

:or. dylnA «w«y from home should be ftiven In every .nHtnnce. 



t 1 



1^1 




iii 



i) I 



n 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE TOR INSTRUCTIONS 

S2H2 



ll..;.r.! ..f IK-ii!tti I No. 1^ »^»^) ll&l' Co 



Registered M'o. 



Dale Fileil, Vb-cv^-^^-v^^Luv \X I'JOH 

L..cv.1l.h,| Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 5)eatb 

( U. S. Stan?arC» ) 
PLACE OF DEATH: — County of UCWXv JAJX-yv-C-Ul^Cc City ofOoyVu J.VCX/^VOUI CO 



(?c..t 



m 



No LQ.OvVlCh^.t} St.; Is Dist.;bct. J /a.uA^-^^....™.... and VtO-U^N 

/ IF DEATH OCCUnS AW*V FROM USUAL R E S I D E NC E G I V t FACTS CALLtD FOR U N lAt R "SPECIAL INFORMATION - \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAO^^F STREET AND NUMBEH^, / 




) 



FULL NAME 



I LwAyOu <X- OXjO^t^- 



— i > 



»-****<•» » ■*« — • • 



PERSONAL AND STATISTICAL PARTICULARS 

I COI. 



L 



:" bo J 



VL 



Xju 



(Month) 



Ar.K 



"^ V y,;us 



(Day) 



M.inlliy 



vilO 

(Year) 



Pit \s 



mvni.K. MARKIKI). 

wiDowKi) OR i)iv<)Kr»:i) 

(Wiitrin M)oi:il (Icsij.'^iiatioi)) 




\xX'V\.u6cL 



lUKTnPT.ACK 

(Stati' or Coniitry^ 



NAMK <>»• 
|- A r 1 1 1-: R 



UTRTTTPT.ACK 
OI* lATHHR 
(State or Country) 



MAIDKN N'AMH 
()!• MOTHKR 



AXavLu^/O' 



X/^Xy^-vo:^ 




n 



HIRTHPLACK 

OI- m()Thi:r 

(state or C«Mintry) 




MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATll 

(Day) 




(Month) 



(Year) 



I HI':RI':BV CIIRTII'V. That r atteiideil deceased from 

~ 190 to ' IqO 

that I last saw h ::~~~~ alive on i<p 



and that death occurred, on the date state<l above, at - 
M. The CAJLSK OF I) I* AT 11 was as follows: 

r 0.\J?,.'CVX>VV/COA.A„'CX 



TTT M. 1 he L. 

oU^n>JWLiiL 



DT RATION Years 
(.ONTRIIU'TORY 



Mouths Days 



Hours 



DIRATION 



Years 



Months 



Days 



Hour 



( SIGNED )LClX^'V\iAi. 1\£^ U). XJlxX/Y^kL M.D. 






VPUv W u 






A/.oiffn 



r>(ivs 



rnV AHOV'K STATlvD PHRSONAI, I'ARTIOr I.ARS ARlv TRIK TO THK 
linST OI" MY KNO\Vl.):i>C.H AND HKI.n:K 

(Informant ci JLpJtA-'YYX^..^^ OAXAyW. 



•' \(Mre««»i 



4?.^ ' SH 



.U-\. ll\ 



yn : 



( 



L(3\X0^ 



-M- 



L ti^. 



SPECIAL INFORMATION wly for Hospitals, Jnstllutioite.^Translents, 
or Recent Residents, and persons dying away from liome. 



Former or i ^ an ( r . 4^j. "•*♦ '^"fl *• 

Usual Residence V? cJs A y ChNiX C)t Mace of Oeatli? Days 



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



PI.ACK OF ni'KIAI. OR RKMoVAI, I DA IK of HrKiAi. or KKMOVAI, 



IQO'H 



vJl 



I ni>i:ktaki:r 

^\d<lress 





e-w-cci 



IN. B. Every Item of Information •houltl hi cnrefully Huppliecl. A(JB nhould b« stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In piiiin terms, that it may be properly classified. The "Special Information" fsr psr- 
sons dying away from home Hhnuld be given in svery instance. 



i| Hi 






I 



\'Ai 



ill 



h f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3283 



f-r !:*'*-> 



Bnnnl ..t ll..i!tli f V- i "^ *— •qru^«:-fc HS: 1' Co 



Da/r /'V//v/.\]Xa^^v>-vi^^^' ^^ 



If^OI 



Iic(^(\sterr(l J\^(). 



"^ "i De0«f^v H<?*sf*-H '"»«icer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( 11. 5. Stan^arC» ) 

i (5? A 



w> 



PLACE OF DEATH: — County of <X/>^ AXX-^xcu^^^ City ofO/Cv>\. 0.>v<x.-w^ia^c^o 



I 



No 3ll "tcX^M^y^^ -'A^^ S*.: 1 Dist.;bet. a/^CL^a. „ and lUvV«^ ) 

FULL NAME J ^^v.\J.\v\\.o J aa><X.\^OvJj. 



MM 



SKK 



i»\ri-: oi iiiK iH 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 





\.K^ 



Xji> 



(Month) 



hi%n 



5.H 



}Vrt>.T 



IC) 



(Day) 



M.nitli.^ 



/iHS 

(Year) 



/)</!> 



S1N<,I.H MARKlKn. 

Wlix )\Vl".l) <iK I)IV< >Kii:i) 

iWritiin s.K-i:il (U<i<.'iiat i<>ii* 




CXAA^vt^i^ 



lURTIlTM, \('K 
(State or C'ntutry^ 



NAMl'. (M 
PATin'.R 



IHKTHIT, ACK 

OI' !'Arni:K 

(St tit f or Country) 



MM1>);N NAM1-: 
oi MOTHllK 



HIRTTIPT.ACK 



(^ 







? 



cu' 



ni- M()*nii:R A A 

fst.ilc or Country) \ \ [j 

CTTATTON -V j| A 



A*^ 



h ■ 
siiffif III Sii» /'laiitisfo <^^ ) '.M A 



^f,,>itfn 



l',!\ 



MEDICAL CERTIFICATE OF DEATH 



(Ycar^ 



UATK Ol- DICATM iV 

VjW 1.^ 

(Month) (Day) 

I lUvRIvHV C1:RTI1-V. Tltat I ;itteii<lc(l dcrcased from 

..lb 190H to M\«\r .1^ .„..i9oH 

that I last saw h ^.-^^ • alive on MVOVT L^ 190^ 

and that death occurred, on the (hite slated above, at t»- "iO 
v) M. The CAl'SH Ol' DIvATII was as follows: 

d^.AS^\jOJyj Vj rv'v^XcA./v-w^O'^.AXX; 



DlRAriON )\(irs Months o Days ■^^-.JI outs 




CONTKIIUTORV 



Years 



.]fonl/is ~^>--,d)ays 



Hours 



DURATION* 

(SIGNED) t) . b . 'L^m.^xi^ ....... M.D. 

MUvT')^ r<.n r.\ddr.ss1 5 0^ MKtr>vt<\vv Ll'^^^ 



I()0 



utions, 



-A 



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

Former or "o^ 'o"*! «* 

Usual Residence P'^^f «» D«'«t''? Days 

When was disease contracted. 

If not at place of death ? 



Tin- AHOVK STATKI) PKRSONAl, J'A RTICT I. A KS AKK TRfK TO THK 

iJHsT Ol- Mv kno\vij;i)(;k and nKi.iiJ- 

(Info;mant vLuejth-^ J xXkxXOwAJ 



(.\<l<lrcss .. ..^ 




XX-CJZ. 



I'LACl-: OK lURIAI, OR RKMoVAI. 



I'LACl-; Ol- lu I 

C>1xxXa^< 



nATi;.>f Hi KiAi. or RKMoVAI, 

0\^5\r .Q^3k 



190^ 



/^ 



rNDl'RTAKr.RV/OjjL/^rjLil ^TV\XX>VX/>X4J J^ ^ 
(Ad.lrcss !5X1 Otx>^tJLU>V Ot 



<, .. 1-1 ArF Bhoiilil he Htateil EXACTLY. PHYSICIANS should 

of information should he carefully supplied. AGE should »*« "*"'*,^ ^* ..^; , , ,„jop„,«tJo„" for pT- 
F OF DEATH in plain terniH, that it may be properly classified. The Special Information for p«r 



N. B. Every item 

state CAUSE OF DEATH in p 

sons dyinft away from home should be 6,\ven in every instance. 



i i 



ifi«l 



.! . f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



t !h .illh !•■ N.. 1^ -^'ZltJ-^- "''^'' '^" 



Dad' /'V/^'^/,mIcvvX->^Jlv>-Ov XX ^'^O'^ 



v^A^^. Deputy Hee-H Office 



Ro^Lsfercd J\^o. 



3284 



I 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)eatb 

PLACE OF DEATH: — County ofCW^ xa/>vcvA^.i City of Cl<U>x. ^<x^v<.^ <.c 






N 



Ufv 



^ lio 'V^k.^^a^-v.^ St.; ^\ Dist;bcn 15 Uv and 

O. . .^VC ^-X^CA/^^ -V-A- V ..e.i*. DFQinFNCE GIVE FACTS CALLED roR UNDER 'special INFORMATION- A 



iti.l 



FULL NAME /V^x^^kAXi^c^ Jclaa.^ 



.Ol.\X'Y\,^*w<X'. 



s I : x 



PERSONAL AND STATISTICAL PARTICULARS 




DAl'l". < il' lUK rii 



A(.H 



/]< Month' 



)'iUJI 



(I):iv) 



s5 Moufh'i u% 



/"^tH 

(Year) 



/'<; 



S1N»,1,K MARK IKK 

\\M)()\\i:i) <»K i)i\'<)i<^'i:n 

i\\!itiiii social (Usi}.'niiti')n) 



lUK riU'LACK 
(Stale or Country^ 



NAMK Ol" 
|."A I'll }.K 






nxjy^oA 



^ 








'CA^CU 



HiK riiri.At'K 

OI- 1 AT I IKK 

(State or Country'' 



MAIKl'lN NAMK 
OF MOTHKR 



I'.IKTIiri.ACK 
()| NinTllKR 
(Stati- or Country) 







Ayvvx 



>Suy\/'yyj<Jii' 



L^ 



\' 



OCCri'ATlON 

Rt'sidfiJ in S,7H /'mn-isrn 






THKAnoVKSTATKD.'KKSONALrARTICl-KAKSARKTKlKTO THK 
HKST Ol- MV KNOWIJUX'.K AND MKMKH 



f IiifM:iu;mt 



,,,,,..,. l^b \<Xy^>.AJL\A ^t 



MEDICAL CERTIFICATE OF DEATH 
DATE OK UK.\TII 




(Year) 



.^\r Xi. 

(Montli) (Uixy) 

1 1II:RI;HV CI^RTII'V, That I attended deceased from 

S^ 190H to N/.'Uvr. %.V 190 4 

that I last saw h .v^^TL.alive on xrVCXT ^0. I^..^., 

and that death occurred, on the date stated above, at (- 
OL M. The CAISI-: Ol" Di-ATH was as follows: 




DT'R ATION 'i'cars H Months /Jays ■■,■■■■' I Jours 

CONTRIBUTORY «,.«.....-.. 



nr RAT ION Years 

iNED) .U* LU. 



M())iths 



fhiys 



(SIGI 



\^" %\ TQOH ( 




jjOJxh^J^^. 



Hours 
M.D. 



.\<ldress) 5C^ U OjLX^ VC.\.CV ot. 



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



former or 
Usual Residence 

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



How lonq at 
Place of Deatfj ? 



... Days 



I'LACK OK lURIAI, OR KKMOVAI 



I)Aii:of HiKiAt, or RKMOVAI, 

. .'9w^ I go 'i 




LACK or HI 
INDKRTAKKR^O'VCLIL/^^ 0<^^ 1Xva.X:U)lU 



■"■"""""^ ... **-!= -.K«..i,l ha stflted EX4GTLY. PHYSICIANS should 

atJon .hould be carefully supplied. ^''^^^J'^l^^)?^^^^'^^^^ Information" for p.r- 

4TH in plain terms, that It may be properly classified. ne op 



N. B. Every item of inform 

state CAUSE OF DEATH in p 

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



m 



i 




1 1 



ill 

ii 

t f 
MS 



I 

MS 



m 



A 



). 



H"; 



r !K .'th r V 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■*-'!i 'sr-ii-, lus, 1' I- 



Dafc AVA'^/, \j\ 







_J90H 



Be^lstered Ao. 



3285 



a^ 



^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 



/aD 



PLACE OF DEATH: — County 





oi'CL.'-^yj l^a^vc^cfc City of CJa>^ O.X<X'-»vc^^co 




vksi;a.l Dist.;bet. 



and 



No. OL">xtv<Xl) ^^^'^'^^r'^"^''^--, .jy,^") prsToTNCECVt rAr/sVArJeO .OR UNDER •SPEC.AL .NrORMAT.ON- \ 



^ 



FULL NAME J >^VU 



k 11-^? 



i.\^/y\.K>>J 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



-O.' 



i>Aii-; (»» HI Kin 



A<.K 



bC) 



Montli' 



)>(J/ > 



I Day 



.1 A />////> 



(Vtar) 



Pa v.. 



^INt.I.l* MAKkli:!). 

'Wiilfiii -oriiil lU sij,'natiiiii) i 



HIR I'lUM, \0K 
(Slate or C«>ntitry^ 



NAMl-: ^^]■ 



lUk lIll'I.ArK 
Ol- lAlllKK 

(State <>! I'oimtrv^ 



MAIDJ-.N NAM1-: 
«>1 MoTMKK 



lUK rHI'I<Al"I': 
Ol NIOTIU'.K 

(Slate (it Cuiinti y) 



OCCUPATION 



UJX'CLcrVv-^\' 



»avHXVca> Ox^'Vvva' 



,/> 



1 




A'fsn/nf ill Smi rmmisfo ^ ''"> ^ 



.y/,>,i//i> 



/),;i 



TUK AnoVKSTATKn.'KRSONAM'AkTirr.-AKSAKKTK. K TO TMK 
H1-;ST Dl- MY KN()\Vl.i:i)(".K AM) MlJ.Ml- 



„„,„„„„„ ^jt^urvJiK VGLU^ iLWwwuWl^ 



f \<l(lre«s 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 



'W 



(Year) 



i% 

(M(.mh) (i>»y' 

I 11I<;K1:1'.V CI-.KTII-V, That I attoiidcd (U'ocased from 

■ :" 190 "" 



1 90 



to 



lliMt T last saw h — alive on 
aii.l that (Uath occurred, en the dati- stated above, at - 
M. The CAT Si-: (»1- DilATIl was as follows: 



T(p 



Lnvclr vcvl Ltl v(i'KX«i v-\ 



DTK AT ION V'ars 
CONTkllU'roKV 



Moiilhs 



Pays ....... Hours 



DTK AT ION 



Years 



Months 



flavft 



(SIG 



NED ) LcA^^mX^ l\ij. AP-IsaJLoa 

(0 



vcL 



fours 



M.D. 



'\'S\r \:i looM f Ad.lress) L^XC'V^i^^ W B-^^"^ 







% 



SPECIAL INFORMATION only for Hospitals, InstitutroAs, Transients, 
or Retent Residents, and persons dying away fro;n home. 



Former or 
Usual Residence 

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



b S VOA^a dL^-v-OM, 01 Place of Death ? 



LA/-tVvjL 



Days 



l-I \CK OF- lU KIAU OR RKMoVAI. 



DAllvo! HiKiAl. or RF:M«)VA1, 

vKcvT ^a 190H 



I NDF.RTAKKR 







.x,M,e.sbS9>"^V^ cv_ll^t dt 



AJU 



— — ^— ^— ^ „ , AfiF iihoultl bo stated F.XACTLY. PHYSICIANS should 

N. B._F.very Item of Information .hould be corc.uHy ^-PP"«'^^; p.op^rly cl«.«lflcd. The "Speclol Information" for pT- 

— - rAiiSF OP DEATH in pinin term»«, that It may be propeny c 



• »«te CAUSE OF DEATH in pi 



r- *t 





U •T-A...-M tir.,;.''..-^.. ..■ -I.. . 



^^1^ 



i' 



I* 



I 




i 



RITE PLAINLY WITH UNFADING INK 




THIS IS A PERMANENT RECORD 

PCFER TO P.r. K OF CERTinCA Tt FOR INSTRUCTIONS 

3286 






1 

DEPARTWENTbFPlBLlC HEALTH 



J^rd/sfrrcd v\'^>. 



.trM>^ : 



=City and County of San Francisco 






Ccvtiticatc of Bcatb 

^ •a. 5. •I'tnilC>:uC I 

,L ^XCU.vC.icoCity of^C^^ vlv^vxe^^cx 

PLACE OF DEATH: -County of O.^^' ^ ^^^c^ 

V IF DEATH OCCURRED IN • HOSf- ft 

FULL NAME Oa^CXQ^a 




SKX 



1»A1 I". n» I'.IK in 



\C.K 



•;;^;;^AL ano statistical particulars 



UUixAJLL^ 



^0 

i Month' 



^i)..c. 



H.^ 



> V(/' 






M,.,ilh'' 



r%^i 



50 



('\"fin 



/)./ 1 > 



"""STeDICALCER T I F I C AT E O F_D E ATH_ 

I. ATI-, oi 1)1- \ni A^ 

' ^ (Day) ^VfMf) 



(Moiitli> 



W 



SlNr.l.l- MAKKH.l* 

iWriti in ^-ortMl (U-ivMiati. >n ) 



BiKrniM.ACK 

(State or Country^ 



]l"h-X3^^.^'^-^- 



, iiMU l-.V li:R-ni-V. -n;;,! I :,li;.,.Io<l .Icrcas..,! fro,,, 

vWr I .90^ to W iO .<^.H 

,l,„inastsawl.^=^" alivcm 
,„„Ul,:,..U.,.h..,v,„ro,l,..„,.,..i.u...aU..l..,..ve,at IO:!.b 

a M. •n,cCArsi:<n.'^i.i|\ni was as miiow.: 

T 



Ji_)x<Ljt'>^X'CV Cji ^<x>^v< 



NAMl nl /s 

F AT I n-R \\ 1) 

K 




(1 



^v^^ 




uiRTnri,ArH( . 

(»!•• jArni'.K V I) 

iStalt or rountryi -\j 

\i\ii>»:n n\mv. 



rX/K^4 



iUK'i"nri,Ari-: 

ol' Mol'lM'.K 
(State or Country 



V 



. i',,.c Vonths \X Days Jlom-^ 

^l\x\^KXAAA.:i '■• • 

( SIGNED )b^^^^nH^\,> "•°- 



Special information «»i« •»' » '»^"'"««"^' '™*"'^' 



/><7r 



'<'•'""" '" •"'" TTwYTKrF TO Tin-. 

.n,K.i,ovKSTvn..,^^K;..s.i.^^^^i^^ •• 

in:s'r oi- MV KNOW MIX-'- ■'^•^' 



(II 



Former or Xt\(\ \ 



\, How lonq at 
Ot; piare of Death? 



Usual Residenfe30U ^JJ^xX/wc^..i.^ 

Wl»en was disease contracted, 

If not at place of deatti ? • : 

7., .\CKOl- m-KIAI. OK KKMoVAI, 



\% Days 



DAI'l". ol" HrKiAi. or kl-:M0VAI, 

($jssr ... X3> 190M 



N. B.- 



,v,Mr..ss 30 j X ^^WC.^-^^^ ' -"^ . , „.cTLY PHYSICIANS .hould 

-Bvcry ...n. o. I"'"-"!'- ;';7j,: "^ .-^ ? .h"'. U ma. he proper., <l....».e<l. The 



^m 





WRITE PLAINLY WITH UNFADING INK 

11. .:tl: 1- v.; 







THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Ee^lstered */Vo. 



3287 



r 



\ \ Deputy Heaith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

, "a. 5. 5tan^avc» j 



^Nc 



n i) , 

PLACE OF DEATH: -County of ^Ll^^^^^^^Ui. 



- St.; Dist.; bet. 



City of 




>vcL' 



\Jodj 



and 



A\J.. ■ -KJUu 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

DA TK <»| MIRTH U 




(Mi)iith 



AC.K 



5-M 



) t i/i 



(Day) 



M„uth' 



/Mo .. 

(Year) 



/><! Vi 



<.IN< .1,1',. MAKUn-.D. 

\vid<)\vi:d ok divokckd 

iWiitt ill s.K-ial tk'sitniatioii) 



\ 



BTRTMIM.ACK 
'State or Conntrv 



NAMl-: HI" 
F All! l-.K 



RIRTHPT.ACK 

()|- 1 AlllKR 

t State or Country) 



(^ 




oLiu^ 



OXy 







MEDICAL CERTIFICATE OF DEATH^ 
DATE OF DKATH 




(Month) 



AC. 

(Day) 



(Year) 



I HnRRBY CtTrTIFV, That I attended deceased from 

; 'IQO 

— — — — — — - - : ~ Itp " 



— — — 190 - to 

that I last saw h alive on - 



aiKl that .leath occurred, on the date stated above, at 
- M. Tl;e CAi;SI': OF Di'ATII ua^ as follows 



d x)(\X^^ U'x\^t:^^x VcL^t «^ 





^cr>^Q. 



MAIDI-.V NAMK 
Ol' MOTHER 



lURTHPUACK 
(.^\■ MoTHKK 
(State or Country) 




OCCUPATION Q^^^^^^^^tj,^ 







Dl'RATK^N >Vrr/-s' 
CONTRHUTORV 



Months • Pays ..Hours 



DURATION 



Years 



Mouths 



Pays Hours 



(SIG 



..o),.%.4.5QiJ 






M.D. 



Oi 



J^^ X% iqoH (• 



Address) Q<X,kJUx.--^<:^ V <xl 



K,->~idi'd III Sail I'laiK /■>'•'• 



)',-iiis 



Month. - 



I\1^■ 



A. V\\<\\CV\.\V.>' A 



THK AHOVK STATl-D »'>^»^:V.!^';i;:rn I lEK 
IIHST Ol- MY KNOWM-.Df.hAND lU.l.U.i 

(lufonnant UJa.^^^ ^^ 

^3 



Rl-; TRIH l** 1"^- 



A.l(lrev;s *^ ^ 



<^PECIAL INFORMATION only for Hospitals, Institutions. Transients, 
or Rerent Residents, and persons dying away from home. 

Hew long at 

Former or ^rt al Deatli? Days 

Usual Residence 

When Has disease contracted, 

If not at place of death ? ^^^^^__^ ^ 



I'l.ACH or lURIAI. OR RKMOVAI 

l-NDURTAKHR UJ A/>^ ^^ 
f Address % AC) ' V 



D.\ IK of lUKiAt, or RKMOVAI, 

\\\M\r 'XSi T90H. 



aj 



:X^ cS: 



:r;<.tr» ,Z «"- h"- «-„„.. b. .Wn ^ .v.r, .n...nc.. 



■■■■'■■■'^^■""'""'^^^"^ .. I rvACTI Y PHYSICIANS should 

aneJully Huppl'.ed. AGB «'^""'^»^«!*»*';^He. •Special Information" for pT- 



lassified. The * Sp« 



l.4^-_- 





t 




, 3 



HV 






w 



Hf.;(t<l ■ ■ 1! 



R,TE PLA.NLY W.TH UNFAD.NG INK-TH.S .S A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3288 










'^^ 



I!) OH 



K(>(^Lstcre(l J^^'o. 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDcatb 

PLACE OP DEATH = -Co.n. ^^^^^^^^-^ of^^^^. J.^^c^cO 

V ,r DEATH OCCURRED iN A HOSPITAL OH INS^TU _^ 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 




si:x 



1) A TJ", < il r.IK I'll 



A«.H 



C< 'I.' 'K 



/{wXsL 



M..nlh> 



O I )Vt/'> 



a);iyi 



M,,utli> 



(Vf:ir> 



/)<7 V.V 



MEDICAL CERTIFICATE OF DEATH 



\^^ 



QfW 



9v^ 1 90^ 

MuTiTrBV CiTrTII-V. That I altt-.i-lol ilecfascd fn.ni 



lLk^vv.I I 190^ 



,^^^. I90C> to JJ^ ^^ ^VO ^ 

tl,at I last saw h ^L .. . alive on O^T -.S^^ = - 190 ^ 

a„a that .Kath orcurre.l, o„ th. .lat. .tatc-l al,..vc>, at b.HO. 
^.l M. The CAISI' Ol' I»i:.\lll was as follows 



SIN<,I F MXRKTF.n. 

\vn>(>wi:i) OR i)!V()RCi-i) 

'Wtiuin MH-ial di^i vii.-iti'Hi ) 



.O^cLcrV.^v-C'v 



GUI-' 



niurniM.xoK 

(State or Counttyi 



\ \M 1 < •!• 
J- A Til l.K 



HIKTIiri.ACK 
<)I- I AlllFK 
(State or Country^ 



MMDICN NAMK 
Ol- MOT I IKK 







? 



^ 1 



nrRATms' Vc.rs Mo.ll.s Pays Hours 

c()NTRnu-r(>RV^^-.<^^^o^--<^4-^^^ 

0,/YvcL O'vXAJt Uj oJJL •■•■ 

DURATION ^ Years ^>'i^'s Pay^.^.^.^-^.- Hours 

(Signed) oU.^sj!lXx^ v. <x^,...,«............ 



M.D. 



rA- an 



nTRTTIPI.ACK 

OK MO'IHKK 
(Stati' or C«Mnitty> 




Ci/^X>J 



ore 



rPATION (tS „ ^ 



/'.M 



,„KM,OVKSTVrH,M.HKS„XM;;AKT,;;r.AH..K.TKrK To n,K 
IM-ST Ol- MV KNOWl.l.lli.H AND U^MI' 



(Adilress 



1()0 



,A,,,ir!..s) lts■^u>A dt 



"etPCCIAL INFORMATION "nl> lor HospilA, Inslitulions, ImMs. 
or tocnl Residenis, and persons dyin) d..> Iron home. 



HeM long at 
Place of Dfdth ? 



Days 



Former or 

Usual Residence - ' *" ■— 

When was disease contracted, 

If not at place of deatli? ...«"— ^__ . 

-.:,CVnV HrK.AI.<.KKKM<.VM. l^VfV.'^ '»- .u... o. KKMoVA,. 



N. B.- 



^ irvAGTlY PHYSICIANS should 

„. .W.«.on .Hou.M,e c„.e^r. r^PP;-; ;r:r:;oUw,:i'r^T J: •'S.,.,.; .nW.«..on'. .0. ...- 
*E OF DEATH In pl«ln terms^ ^^"^l^'Tl il.r.nce. 



ttat^CAlTsE OF DEATH In ^;;';; ;-",,;„ j„ every In.tance. 
nonm dyinft oway from home «hoiikl be ftive 



Il ♦ 



! ' 



\\ -i 



II 



ill 



i 



Hn:! 



WRITE PLAINLY WITH UNFA 



^r~»v 



i'„<vi' '■ 




3 



DING INK — THIS IS A PERMANENT RECORD 

REFER TO «»rK of CERTIFICATE FOR INSTRUCTIONS 

3289 



j)(i/r Fi/c'l. j\cv-^v/rnJWA( 3.5, 



/.Vf'V'-l' 



LJ 



JRegldlejed J\''o. 



4 i Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



PLACE OF DEATH: — County o 



Certificate of Seatb 

I -Q. S. StanOatC ) 



-O 






-f n 



Dist.; bet. 



and 



n ( '^^^E-Vrn^ --?^^^r^^^S ^^^ .X^O . STREET AN. N...ER. ) 



) 



FULL NAME 



_.. -il-MX- 



SKX 



I) ATI", ni- 111 K 11! 



PERSONAL AND STATISTICAL PARTICULARS 




)^\\jXi 



(Moiithi 



A'.l". 






(Uay) 



\fn1ltllS 



(Vf;ir1 



I \\i it<- ill sorinl (lt>-UMi.'it i<iii ) 



(Slatf or Country'* 



Pays 

/ 



MEDICAL CERTIFICATE OF DEATH 
DAI'K OF PKAI ^ ^ 



(Month) 



/ 



y 






NfAMH OF 

fatiii:r 



HIR'rHI'T.Ai'H 
OI- 1 AlUl'.K 
(State or Country) 



maii>i:n nam I'. 
(»!■ M(»tim:k 










(Day) _1^'^'*''* 

TlTn'RlTTrv- CHRTIFV, That nitteii.UMl .Icccascd from 

t.^ -h 190H to ^^J^ "^^ ^'P'^ 

^,,t I la.t saw hX^ alive on M\^^ ^0 i<p H 

a„,l that .k-ath ..cc-urrcl, on tho .lato statnl al.ov.. at 1 l^ 
M. Tlu- CAISLC ()!• DIvATlI was as follows: 

U Cvtt^ «L'.,A.^iX: 






CONTKll'.l T 



yfouihs, 



Pars 



IllRTHPt.AOl* 

01 MoTlllsK 
'State or t'ountry) 



OCCTTATION 

h;fu,h',1 III S,i>i Fntvi^r.i 



);<-ii 



^r.'iif^if! 



Pirv 



"'';.A:^v^^i\^i::^^:^--'^^^^^^^^^^^^ 



' SIGNED ) 4 yV- - - -WW- ^ ^ 



/A;// 



;',v 



M.D. 

i 
4- 



■c;pFCIAL INFORMATION on!v for lUJpitdls. Institutions, Transients, 
or Recent Residents, and persons dyini av^-iy fro-n home. 



Former or 

Usual Residence 

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



How loni) at 
PJare of Death? 



Days 



,.,,ACK (H- IMklAI. OK KHMOVAI, 



CTi^xto 



( \(l(1r«'ss 




1)/cx.Ll 



DA TIC of 151 Ki\r. or Kl'.MOVAI, 

VuxT an T90S 






VMn-ss 5^1^^ \j^.]lX'vAv.<X.C 



IN. K. 



wmi^mmmmmmmmmmmmmmAmmmmmmmmmmmmmmmmmmmmmmmmm FXACTLY PHYSICIANS hIiouIiI 

■'•■•''S;'i;-'r;;",::s;::;rr, net ;;;:rri:r"w ■.,-... - -■ 

stote CAUSn 01 iJt.A I n II I AUen In «vory nstance. 

«on. dyinft «wfly from home Hhould be ft.ven 






tfc;. 



iH 




h\ 






I 



li 



I 



/\ 



|l,,:ii.I ,.t' II. .'Uh !■■ N' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






H&P Co 



/)((/(' Fi /('(/, \£li:Ps}-Vy^y\^ 




2f)0H 
Itti Officer 



Jleo'isfcred J\''o, 



3290 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDcatb 

4 QS^ 






No, 



PLACE OF DEATH: — County of^a^v v^Vclaxc^^co City of^ cl^v J.Vcx^cv^<m) 

ll'^ QX^V^c^ lU-t. St.; Dist.;bet;^b^tyt^>^ and V.ava.>^nrvaA^ ) 

1^0 M|U^V\.V.O VVV-V '^.g. ^,^^ p^cTS CALLED rOR lAjDER "SPECIAL INFORMATION • -S 

( '^ rF"o7AT°"oCCU%rEV;NTHO^S^pVTlL o"' f N S "l ^JV'o^N ^O I V E ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




hj:>o\h: Wcyrw-^A; 



PERSONAL AND STATISTICAL PARTICULARS 

j Ct»I,<>K 



^'••■HlS^ ft 



UJ.4v\Xx< 



iLU 



[ Month) 



.\t;K 



bH 



)"<(j; 






M'lil/r 



(War) 



Ai V. 



SINC.I.K MAKkll'.l) 

wiDowKi) OK i)i\t)Kri;n 

(Wiilf ill sociril (U si;.' iKil mm ' 



MEDICAL CERTIFICATE OF DEATH 
DATlv <)1" DllAl'll ^ 

.{TU^ -- *.. ^^ 




(Moiilli) 



(Day) 



(Yfiiil 



X -LcLtr-U^ 



(Still*- o! <'onnti v^ 



vlSrv^/^l 



K.<rcr1(V^-C>Ajj 





I'A I ni:K 





oX} 



liiK 111 ri. \ci-; 

Ol- IwrilKK (\ 

(State or Coutitiy' '^ \ 



% 



MAIDICN NAMl', 
Ol MoTinCK 



HIRTin'I.ArK 
1)1 M(»rillvR 
(Statr or Country^ 






b -cJUL 



,^^Ck.' 



uLur 0\j /Ou'Tw 

oocrpAi'iox 




I 



^j 1!!<:rI':RY CKRTfFN. That T alu-tiik<l dcccascMl frmii 

^yVmr .:.\ up"'. t(» SVussJ^.. .X'^ 190% 

tliMt I last saw h-ihx. . alivf on \jV<5>.r Xl up H 

and that «K-atli occuned, on tlu- ilatr statt-d ahovf, at 
v-l. M. Tlu' CAlSlv Ol" DI'.A'I'll was as fallows: 

L>x cLo^cy^-^^^"^-^^ ' -•■'"■ 

LX^-Zl^kjUUL \j\-Ax^A/"k:v.v<X-LvxjyY>\i -. ■ 



Dl'R ATION y'oirs Moulin /hivs Hours 

C( ) N '1' u I in "ro R V \l /^^ Vj^^o^<xhw>cU„lAi>...„..„........_...«... 



DT RATION^ Years 



}Tonth!s 



Pays 



Hours 



( Signed ) VJvcvCi Hf I. 0,A.4ir:|.\K/rru^a^ ^'^' 

M^fA.T- a:i TQoH f A.I dross) L^'t^H Mllx>xJfl-Jt OJ 



Special information «»!> '*»'^ llospitdls, Inslitutians, Iransients, 
0! Rt'd-nf Residents, dnd persons dvinij .iwhv fro.n hone. 



\r.'>'tii' 



/).M« 



nil- \IU)VFSTATi:i) l-KKSONAI, P \ K I' U' T l.A !<-> A K l', I l< I 1-. To 111); 

iii;sr 01 Mv KN()\vi,i:i>«".i", and niu.n.i' 



if. It ma tit CN . V^«. 




Former or 

Usuiil Residence 

When Has disease rontraded, 
If not at place of deatfi ? — .« 



HoM lonq at 
Plar f of Death ? 



Days 



I'l.ACl-: Ol/vlURlAI, <'K K »•;%!( >VA I. 



. ., ... .. -iv-OirR, 



1 



l)\Tl-;of HfBIAl- or ki:m«)\ AI. 







^5^ 



TQC'^I 



(A.Mi.ss 55^' '^S' 



q. '^ 



sT r\.AAti L.N, "^ 




""""— """""""""^"^ ... II \i'i «'i,.,ilil he HtHletl r.XACTLY. PHYSICIANS nhoulti 

;S. B.— livery itc.n oV 1n^'or.n,.tio„ -houM .>. c,..c»uH> supplied. ^'; •;.;• '^'^^■^..^^ '^t^h, ..«„.,•.... Infor.nHllon" Ifor p-r- 
Htiitc CAllSr. or DIATH ill pl.iin tcrmn. tlmt it m.iy ho properly cluHHincU. 1 nc opcw 
sons Hylnft iiwny from homu nhould he j^iven In every Jnwt«nc«. 



*y| 



if 



iti 



I) , » 




H' 






WRITE PLAINLY WITH UNFADING INK 



trJI" 



H.Mt.l ..(• ll.;i!lh l- No. 1'^ *^j-Si^nSi.\'C.o 



l)((f(' Filed , 




yXrrrO 




15 100^[ 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

3291 



Beglsfered J\^o. 





uc5 6JL'\K{ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Bcatb 



( *a. S. StanDarC* ) 

J? 0^1^ 



A 



;0 



f^. 



PLACE OF DEATH: — County of ^)o^^a; v1/vCU->x.^:>UiC/City of ^"' <V>v ^^ AXV^ru<^v<iAi.c 



y'>aA-\vCrV»-:St,; Dist.; bet. 



and 



T / IF DEATH OCCURS UWAV TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" ^ 
y ( ,F DEATH OcJJ^RCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

I C()1<()R \ A 

DATl". Ol lilK III 

- , Ana 

iMniuh) (Day) 




UAAy^ 



■\JU.- 



4- 




Af.K 



b2 



op^. )V<;/. 



.\f.,)ilfn 



(Year) 



Dii 



SINr.i.lv MAKKIl'.n. 

wiDowi".!) OR DivoRi ;i:n 

(Write ill ^oci;il divivMiatixii) 



lUKrnri.Ai*!-; 

(state or C«Hititry^ 



NAM I', 0|- 
l-'ATIt I'.R 



MIRIIII'l.ACH 

ni' iwrnKR 

(St;itf or founti y) 



MAIin'N' NAM I 

Ol- M()Tin:R 



HlR'rHPI.ACH 
()!• MoTMKR 
(Stale or Country) v 







occ 



:ClTPATION/7> 5 j^5 

f\f.<ii{f(l ill Smi /'iiuiiix-n .At ) '(M ^ 



Moiilfi^ 



/hn 



Tin- AHOVK STM-i:i) I'KRSONAI, I'A R T Hf I.A RS AKK IRIK To THK 
HKST Ol* MY KNO\Vlj;i)<.K AND lU'Ml'.K 



(I 






( \(l(lr<-«« 



\^<r\^<^Q.JL. 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol' DKATH 




(Month) 



(Day) 



(Year) 



] IIlvRIU'.V CIvRTIFV, That I attciuled deceased from 

'^^^AAZV^ul. ...ID 190 H to \rUv^' \.^ icp M 

ClXc\J- IH nx)H 



190H 
Ihat I last saw li A- vv. alive on m .v-^v;- ir\ up 

and that death occurred, on the date stateil above, at I OO 



"■> 



M. The CAI'SP: Ol- DI^ATFl was as follows: 




DIRATIOX )'((irs -5^ Months \ Days 
CONTklHlTORV ' • 



flours 



Years 



Months 



W- 



Days 



DURATION 

(Signed) LL). V) . W>\^L<xa«v. 

Ad.lrrs^;) UJCa^^^VA 



3^0 T()0 \ 



( 



Hours 
M.D. 



SPECIAL Information »nly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dving away from home. 



Former or 
Usual Residence 

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



»»»**»«-«*■•=*-., - 



How long at 
Place of Death ? 



... Days 



IMr.ACH Ol" lURlAI, OR Rl-.MoVAI. J I)\ri;of HiKiAi. or RKMOVAI, 

i-NDi-RTAKHK (^^ /^x.O{0.yyyo ^ A^AJLUi 

(Address S^X V 'C\JuL^>A.yt:^V/(X 't 



State CAUSE OF DEATH In plain term., that It may be properly claMiHed. The Special Inlformaiion lor p«r 
IS dylnft away from homo should be ftiven in every instance. 



Roni 



iiyiiMiihJtfJb^iiMitt^iiiikidi*dii.*£^ 



Hrth^^iHi 



"i ,: 



w 



, 



I 

4(i 



I *f 



la * ? 



•> j|. . 






[•.,ar.l '.f Jn :;"t'l J' ^'" 



WRITE PLAINLY WITH UNFADING INK 



I Ihifr Filrf/!^^h^r^>^^ a.a... ^'^O'i 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

lle^Lsicicd jYo, o2 J2 




A,A^ 




Deputy Heclth Officer 

DEPARTMENT bp PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of IDcatb 



( n. S. 5tanC»arO j 
PLACE OF DEATH: -County of^ <X-.^'i.^XX,^vCvACo City of C^^ J /uCv-^^ 



ao 



No. 



,.cUl 



^ M i?^ Ov: N<1 A C\ ^X St.; — Dist; bet. ' ""— — and ;^-. 

^<^^.J<J^ ^V^V rA.L\. -V RESIDENCE G.VE tacts called rOR UNDER -SPECIAL . N TO R M AT. O N • •^ 

( " r^orATrOCC^SRrEV.rrHO^S^pVT't o^"NS^^^"o'N'c.VE .TS NAME ..STEAO O. STREET A.O .UMBER. J 

\ '\ I ) 111 



) 



•<.{ 



FULL NAMEdt'CL/i^Uu (3. O.U 



x,u^ 



s}:\ 



PERSONAL AND STATISTICAL PARTICULARS 



DAT1-. ul- lUKTII 




}.KCbb 




(Day) 



/in 

(Year) 



\<".K 



as 



)Vu> 



^.ixc.i.i* M\RKn;i> 

U n>n\VHI» OK I)IVnK(i:i) 

iWiiti' ill social (Icsi^'iiatmn i 



i state 1)1 C'otintrvi 



tXI'Ill'.K 




I .0 M.'iiHi.y X I. 



tXK,K.AJLcL 



Pa 1 . 



-H 



MEDICAL CERTIFICATE OF DEATH 

DATl-; «)!• DllAlll 



(Mouth) 



XX. 

(Day) 



(Ytar) 



1 1I1<:KI':!'.V C1:RTII*V, That I altcn«le<l (leceaseil from 

iL\<ltj ^60. igcH to " 



o . ^Xcv^ .'XX. 



that T last saw h -^^^^ ' alive on 
an.l that (U-ath occurre<l, on the -lato v;takMl above, at ' \ 
\\ riu" C M'Sh: oh* Di: A rH was as follows: 

.vaJlsXA--' 



190H 

TcjoH 









,\^0^^1\j 



'I ^Viak 



lUK riii'i,.\rH 

oi- I AlIll'.K 
state or Coimlry'l 



MAllM'.X NAM I". 
<»!• MOllU'.K 



P.TKTHrT^ACI-: 

01- M()'rm';K 

(state or Country) 










1 




r-vJtX'Cl; ^VLo.'tu 




^A-^rv 



^ 



•A^. 



DfRATION 



[7/vr t- 



Jioii 



rs 






Dtn^ATloN 



(SIG 



NED)...\; . U)...\r^ 



Days- 



0ui 



//ours 
M.D. 



QrUvr 9.21 ,00 H (A.M.v-^sl'^t)'^^^^^ lt.-^vJpi 



SPECIAL INFORMATION onlv lor Hospitals, Institutions, Transifnts, 
or Rerent Residents, and persons dying away from tiomf. 



OCCMTATION 



THrxm>vKSTAiM:nwKKsnNAi rvKnr,^..xKSAU..rKrK n> thk 

iIkST Ol- MY KNn\Vl.i:i)<-.K AM) Ul'.I.H'.H 

(|,,f. ,• tiimt \_/>^r\^'^rvwA^ V^#. 






S';::i,HccJ.i?>iM<wlia:uilKVa.h. as. 



Days 



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



IM.ACK «)!• Ml KlAl, <>K KI'.MnVAl, 



irxri: of Hi KfAl, 01 kj:m(>\ai, 

\}\4vr 'X5' 190H 






-^ ,. . AfiF H'lo .1.1 be stated EXACTLY. PHYSICIANS should 

:s. B.—Kvery item oi Inform.tJon «hou.c. h. careVuIIy --^^^ \^f;;,^ .,„H«hlecL The "Special Infor.n«t1on" for p-r- 
. ♦ r \imF OF DFATH in P "»n term«. that it may he propcny 
::':. d^'i^t -"r "oJI h„™.. «.u.u.d be aiven in every 1n».,ncc. 



P" 






rib 






I :, 



m 



n t 



n 



I' I'M 



i\ 



u 






1^ 



w 



RITE PLAINLY WITH UNFADING INK 



j..,.,,.I ..t H. .'.th INo ,. •?''^^>i7l!'S:lM-M 



/)fffi' Fi/cff, 




11 



>.■>_«»••«_*«•*•#«*•*■ 



190'i 



THIS IS A PERMANENT RECORD 

RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Er<^istered ^'o, O^^O 



^_-C»vV-*>^^ .-^jtA>^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2>eatb 

( "U. S. 5taMC>arD ) 



PLACE OF DEATH: — County of 



iA.Aw>LIjO City of 



^*^XM) KXXAj 



St.; 



Dist.; bet. 



and 



No. " ..«,.». orcinVlSICF GIVE FACTS CALLtD TOR UNDER 'SPECIAL INFORMATION ' ' \ 



FULL NAME 



x.KJuLs^r^. 





■H- 



SEX- 



PERSONAL AND STATISTICAL PARTICULARS 




i>,\ri-: ni- liiu 111 



a<;k 






^0 



) '>tl I s 



H 



9kH 

(Day) 



Muttlhi 



(Vtar) 



15 



ihi 1 > 



siNc, I.1-: M.\Run:i) 

aVritt ill soiiril (U sij-niatioii) 



lUK TMl'I.AOK 

(Stiiti 1)1 Ootjtitry) / U 



NAMl-; «>»■ 
FA'ini'.R 




Jstau' or Country^ ( V () | | 5 . f l 



BIRTMIM.ArK 



MAIDKN NAMK 

OF M(>th1':k 



MtDICAL CERTIFICATE OF DEATH 

vl'W 



(Month) 



(Day) 



(Year) 



I 1I1':RI':HV CI^RTIFY, That I attcndtMl deceased from 

, ■- 190 to .7nr....;:...:r:igO--:-:^"- 

that T last saw h ^^rr-. alive on - • \ '9° 

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

M. The CArSI-: OF DIvATII was as follows: 



DT RATION Years J/ofi//is /hiys Hours 
CONTRIHFTORY 



iMouths 



lURTITPT^ACK 
oi' MoTm-'.R 
(Slati- or Coiuitiy') 



VILuat Mo/tjxA- — 



Rt>sideti in >"<•" /■> ii'iiisrn OO 



)Vrtrr«^>„,*.. Months 



l\n 



•nn<An.WKSTATHUPKK.ONA. rAKTK;r..AKSAKl.rKrK To T,.K 
HHST OF MY KNt>\VI.F.I)«.h AND HI-.I.lI.l 



A<l<lrcss 10 



-<yj 



DERATION )t'ars .^ j/ofir/is /hiys 

(SIGNED) U). dlD Vj )XoA.<Xt^r^^ 

\Kc\r :i,C iqoM (Ad.lresv;) UKa^O ^-^-^ 



Ho UPS 

M.D. 



SPECIAL INFORMATION «"'> '""^ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 

utljalVsidence I oQj^tn (daajl^^ 3t Zt TDeath ? 3"^ Days 

When was disease conftacted, 

If not at plareol death? 



IM \CV. OF" lURIAI. OR RKMoVAI. 



I ni)f;rtakkr 




(Au<lrt'»*s 



n^a 



i)Ari:<}f i?t K.Ai. or rf:movai, 
OfWr ^H ■_\9o\ 

O xNx:'^^-/OL/'v-y^Je/vvX^ aii 



,. . AfiE should be stated F.XAGTLY. PHYSICIANS should 

N. B._^;very Item of Informetion should be cnrefu. ly supphed ^^^^^ ^^^/^^^^.^j.^^ The "Special Information" for psr- 
.*„*- r AilSF OF DEATH In plain terms, that it may i>e proper y 



state CAUSE OF DEATH In pi ... 

son. dylnft away from home should be i^lven in every instance. 




'^mMJttmt^Hii^j^^iM^^^iam^^^Ji^^ 



!« 



4 



IH 



ti 



^- 



N 



-i 



i 



WRITE PLAINLY WITH 





UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FO R INSTRUCTIONS 

' ' — "" "" QOQJ. 

DEPARTMENT OF PUBLIC HE AITH-City and County of San Francisco 

Ccvtif icatc of ©eatb 

PLACE OF DEATH:^Co.nty of^-- i Xc^xc^^Cty of^^- ^r^^^ 

^5 on • 1^^ ^ St.; ^ H fs-%^ -co ic-V^nr- -s.^cu ,~.o«».T.P... ) 



) 



No. 



FULL NAME MJWV^ 



-'vaJj 



1 r, 




'\Ji^. 



PERSONAL AND STATISTICAL PARTICULARS 



^'i' 



DATl-. <)|- I'.IK lli 



.oLcU 



( Month) 



(Day) 



AID 

(Year) 



.\<".H 



1H 



MEDICAL CERTIFICATE OF DEATH 
DA TK OK DKATH 




\ 



(Month) 



9.1 

(Day) 



(Year) 



)'>a> s 



M.>u//is ''^"■'■ 



\vil»()\VHD OK niV«»Ki l.I) 
(Write ill s<H-ial (ksii.'ii;iti<>n) 



RIRTHPt.ACK 

(State or Country) 



NAM I'. 01 

I A'rm.R 



nTRTTIPT.ACR 
<)I- lATHl'-.K 

(Statf or Coiiiitrv) 



MAini'N XAMK 
Ol- M()TH1%K 



BlKTHri<ACE 
Ol- MOTIIHK 
(State or Country) 




I HRREBY CKRTIFV. That I atten.lo<l .lerease.l from 

5 .T90M to M\^j\J- XI 190H 

that I last saw h^ aliv. .n ^^^^ ^1 ^90 H 

an.l that death ocotirre.l, en the .h.te stated al.ove, at H \S 
Q ^i The CAISI': ()!• I)i;A'ni was as follows: 





y\XA 



■ 






^Kh) 



T)T-R.\TTOX )'i'ars % Months Days 

CON T R 1 lU'TC ) R V (XtA-t^V^Cr'V-vMXj 



/lours 



Months 



Pars 



(SIGNED) bo. mI.(J. tt<^vl 



Hours 
M.D. 




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



OCCUPATION 



- ^r>»lthf " /''" 



^^^^^:^^^¥^^^ 



(I; 



OLoJ^^^"^^^^ 



r\<Mr(.-ss 



5k^o"i M^'>Nji cJ 



Former or 
Isual Residence 

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



HoH lonq at 
Place of r)eath? 



Days 



I'l.ACK Ol' lU-R^XI. OR RJ:M<>\AI. 

'0 ' . 





DAll". of UiKlAl. or RI:M<)VAI, 






be stated BX4GTLY. PHYSICIANS «hould 



, -.nWrnBUon .hould be CBnefuHy suppMcd ^J^^'J^;'^^^^^^^ Vl,: •'Specia; lnfor„,atlo„- for p.r- 
: OF DEATH in pln'm terms, that it may be prope 



N. B. Every Item o 

state CAUSE OF DEATH In p...... "--_ . |„«t«nce. 

IS dyinft away from home should be ftiven m every 




I: 




soni 




Aft 



■ * 



Is 



\ ' 



'.,,:,. -,1 nf lh;ilth »•■ Nf^ 



WRITE PLAINLY WITH UNrADING INK-THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

8295 



•*-?*.*r^i!v'vi' 0.) 




pfffc Filcfl , 



^vJt/^^xl>-Ov Xh 



190 "i 



Registered JYo. 




Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Bcatb 

( "U. S. StanDarD ) ^^ 



PLACE OF DEATH:-County ofd^^ Jxx^.^o..ccQty of ^^X^ O.^XU^^. 



(Ne. 




OLdAJLno/i 



)b CK lv^<X.l St.; 



Dist.; bet. rrrrrrrr-rrrrrrrrrrrrr.. and 



- ) 



(■ 



r DEATH OCCURS AWAY 
IF DEATH OCCURRED 



riou li<5UAL RESIDENCE GIVE FACTS CALLED FOR UNDER 
,N rHOSP^TAt Tr INSTITUTION GIVE ITS NAME INSTEAD OF 

vj AJLcL ..Ra. JLl^lAJ .............. 



ER "special INFORMATION*- \ 



STREET AND NUMBER. 



FULL NAME 









si:k 



PERSONAL AND STATISTICAL P ARTICULAR S 

Cni.oR 



lYuilt 



k: 



UvUji 



DAI 1-: oi HiK'ni 



^Jjj 



vJ „ 

(Month) 



/ I 



^0'5 



(Day) 



(year) 



A<.R 



I 



Yeat s 



^ 



.yj.»i//i' 



JhlW 



MEDICAL CERTIFICATE OF DEATH 

DATE Ol" I)I:aTH 



(Month) 



......3.'^ /pO H 

(Day) (Year) 

I m-Rl-BV Cl-RTIFV, That I attended deceased from 

()\^- -^ I T.^M to Qx^iv- 



,^- 11 190H to \mr\r 3.3. ic)oS 

m.<s\r aa 190', 



WIDOWKD l»K I)IV()KCi;i) 
iWiiliiti MK-ial (It-tKiiiitioii' 



lUKTmM.Al'K 
I St;itt (»i I'lumti v' 



NAMI-. or 

I' A Til j:k 



HIKTHI'l.ArK 
Ol- lATHKK 
(State or Country) 



maii>i:n namh 

OF MO'l'lll'.K 



lUR Tliri.ACl': 
Ol- MofUHK 
(State ol C-onntrv) 







•tnd that death oeeurred, 011 the date stated above, at < 
Q M, 




i) 



CrV 




\lSlv Ol' 1)I'!A'PII was as follows 



-O^^.' 



DC RATION JV-ar.? I\/o>itlis %. t)ay^ flours 

CONTRinrToRV LL^v.Kw'V'vcrUUrtX^-.... 



DURATION 



OCCUPATION 

Rrsidr,! i» Sa>i I'unuisrn \ ) "" ^ I 



:f<>iit/r<! 



/)<!\ 



■n,KA,.,,VESTATK,...KKS,.N.,PVKTKr.;AKSAK,;TKrK To TMH 
llKST Ol- A'^I KNOWl.l-.IX.K ^^' nRn 

flnfoiniaiit 




(SIGNED) k).\. C)^Ccti^>lX ^. M.D. 



)(y4.k,t 



SPECIAL INFORMATION «"'> «or Hospitals, Institutions. Transients, 
or Recent Residents, and persons dying away frorn home. 

u"s™rRe*ncAaH^!OU>V>^XX, \ Ke'dV'a.h? I D.,s 

When was disease contracted, 

If not at place of deat h? 

I'LACH Ol" m-RIAl, OK KHMoVAI 



)ax/vl/vlajl 



\j^ 



DAI'Eo! HruiAi. or KKMOVAI^ 



INDllK TAKl-.l 



(A«U1resH 









IS. B.- 



^ „ , 77^ should be stated EXACTLY. PHYSICIANS should 

-Bvery Item of information •hould b. cnrefuny HuppUed AGF « ^^^^^.^^^^ ^^^ ..^^,^.^,^, Information" for pT- 

.-•/cause of death In plain terms, that it ma> ne pr ^ 
:"'. d"n. .w^y from ho„.. -hou... b. tU.n In .v.r, .n...nc.. 




1', 



wl 



li 




Hi t! 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Registered J\^o, 



3296 



\j^kaj>\lvu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

4 Q^ A ^ 

PLACE OF DEATH: — County ofClo/^^ Jy\XX/"ruCA.XLCiCity of CJ<x/>\; JA-CVyvcc<ixlc- 



No.^^aXc< '^Lca,v.\ J.a^\Lvyvul 



D 



'V^^i.Vi.. 



Dist.; bet. 



and 



(IF DtATH OCCURS 4wAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




il 





vcrv 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

A I COI.OK 



(Tu'u 




\ 






a.c 



Jjb^ 



DA II-: oi r.iKiii 



a 



A«-.H 




I M..iith> 



3 

(Day) 



/in 

(Year) 




MEDICAL CERTIFICATE OF DEATH 



DATE OV DKATH A 

vrv 



(Month) 



(Day) 



(V.-Ml) 



k1 



)'rti > .> 



M,'}il/i^ 



a 



Day. 



SINCI,!!. MAKKIl-.I) 

\VII)i lUMD <»K I)l\<)Krj;i) 

(\Viit< ill social (Itvi^'iuiiion) 



luurm'i.AOK 

(SUitf or Couiiti v^ 



NAMl' OI" 

FAT 11 i;k 



lUK'IMIM.ACH 
OI- IWTHHK 
(State or Country) 



MAIDKN XAMK 

OI- MornKR 



nTRTTTPT.ACK 

OI" mothi:r 

(state or Country) 




I HKRRRV CT'RTIFV, That I attended deceased fr..iii 
\J(zXj So 190M to \f\JSsr. Xt)...^^,,i9o H 

that I last saw hiL/>>^ alive on ViUSNT XO -up M 

ai^d that death occurred, on the date stated above, at t 
ii M. The CAl'SI': OF DlvATII i^as as follows: 

IaCvCLx, Lx)JL(X.\aJ\.XxX 3J A^A/LiL'VV't^Uvu. 



DTRATION Vrars Mo ft //is ^\ Days Hours 

CONTRIBUTORY .-.. 



Years 



A font /is 



OCCUPATION J? 



DTRATIOX . -, - - 

(SIGNED) UJ. X:) _\^>aX<XA^ 

X*" ::^j iqoH (Address) UJC 



/^avs 




Hours 
M.D. 



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



Rfsidnl ill SiDi f'laih ism 



)V'(f/ V 



M.nith> 



Jhl\ 



T\\V. AHOVK STATICI) I'KR<>()NA I, I'A K 1" I*' 1" !.A Rs ARl", TRll-: To Till-; 
HKST 01* M\'-KNo\Vl.I-;n»".K AND Ml-Ml-K 



(Tn fornjant 



(Afklress 



LUo^r^-ooJr 



V^Aa-^lX 



Former or 

Usual Residence . .....^ .-... 

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



How long at 

Place of Death? Days 



•I,ACK OF HlRIAl, OK Kl.Mo\AI, 



'AAAA^V^wL 



DA'LF )t" lit KiAi. 01 RF:moVA1, 




^...:^ 190H 



INDllRTAKFR Jw 



%, 






(Address %^ TiX* 1 4 A^V\j Ot. 



N. B. Every item of m?ormHtion should be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly claHsitfied. The "Special Information" for per- 
sons dying away from home should be jfciven in every instance. 



n 

il 





¥ 







4 



mm 




«wt ( 



i 

4 



WRITE PLAINLY WITH UNFADING INK 



i.„„,.i ..f n. .Mill, r No '= ■^'%^^^': ns^v c,> 



l)nli> rilr(L iXcyyUxvoi^ ^'^O'i 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

" 3297 



liecii^slered JS'^o. 



.'CTLW^'N 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( *a. S. StanDarD j 
PLACE OF DEATHt-County ofO^^^ J,\^>vCvi« City of 0^^ ^X<X^^^ ^ 

.No^OoAOll-ailV St.: n Dist.;betJJLU4 andO^OX^^^O 

'INO. V^^^V.' V,\^^. V "Vi- V ^ V. ,,-,,«, orcinFNCF GIVE FACTS CALLED roR UNDER SPCCIAL INrORMATION-^ 

FULL NAM E Ox\xJLdj Ml \J !laX<mJLj. ■ 



SKX 



DATK or I'.IK lil 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 





^aJLic' 



LIXA 



tMo!ith)£ 



(Day) 



. -I. A 

(Year) 



At .}<; 



11 

CK/7\ JVrt/A 



MmitJ/.s 



Pa vs 



SlNT.i.K. MAKUIKD. q 



Write in social dt >-is.'nati>in ) 



TUKTHIM.AOK 
ISlalc or Country 



1- AIM i;k 



HIRTHri,A»K 

()i- lArm-.K 

' Statr or Count ry) 











M 
<)1 



\ii)i-:n NAMi". (y\ 

• MoTIU'R ^Vj' 







dU 



lUKTIiri.ACT': 
oi' M<»THHK 
(State or Country) 





OCCrPATIOX 



/),M 



Tin- AHOVK STATHl. PKRSONAL I'AHTICrLARS ARK TRIH TO THH 
in-:sT (>!• MV K>;()\VIj;i)C.H and Uhljl-.b 



(Info- ni.'nit 



(Address 



GNOWIJilX.H AMI' lw.J,ii-.r 

2)0 00 AjO-eAKit^ ot 



MEDICAL CERTIFICATE OF DEATH 

DA TIC <)J- Dl.AI'H 




(Month) 



dw3k .../po 1 

(Day) (Year) 



I UliRIUiV Cl-RTIl'V, That I atteiidcMl deceased from 



(5\^ ^ 190 H to ..r.V.(5\r ^.^ upM 

that T last saw h -A-^-^a alive on ^.iX^St. ^ T90H 

and that death fjcctirred, on the date >^tati-.l above, at 

M. The CAIS^OI" DllATII wa-^ as follows : 

^{yj<AJ<J^ vj AAX^'WC'»-C<^t\^ ,,., 




1)1' RATION I Years ^. Mont /is 
CONTRIHrTORY 



Pays 



Hours 



Dt 



Months 



/^aj's 



(SIGNED) J. J. v.a ^ 



VtV^O-l^^TL' 



Hours 
M.D. 



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



Former or 

lisuaj Residence 

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



How lonq at 

Piare of Death? Days 



I'LACK OP lURIAI, OR ri-;m«ivai 



DAlHo! IM KIAI. or RlvMoVAl, 

Q%<JV- 9vH 190H 



iru MjVv.;i.>i.\.f>v; ai "^ 



(Address 



t,. B._F,very Item of Information .hou.d be cnrefuMy supplied "^J^^^l^^^ll^.^^t^^^^^^^^ X^^^'^.oW^or^^^ 
state CAUSE OF DEATH In plain terms, that .t may be properly Uass.tiea. 
j..._v. .».. ««««, hnme should be feiven in every inHtance. 



sons dyinft away from home should be A 



fi 



II 



l!l 






^^1 



iiij 



ii 



WRITE PLAINLY WITH UNFADING INK 






/)/'//r F/7('(/. 




sy'YTX 




as. -J^^H 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be mistered ^'(h o^-io 



.4-v\aJ:) 



4jtaH4. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( 11. 5. StanDar^ ) 
ofa£X,-^\.'vl\.OL.YvcUL-<:^ City of^J/Cx/vv ^a./w.e^c.c - 



PLACE OF DEATH: — County 

(No.^'^iincV 



A^^:^, M A.<x.e.<, 



St.; 1 Dist.; bet:0 CrtA>iL^ 



and M. I LOA C W- ) 



( " r"o;rH"oCc"u%;rn\rrHo''s^pVT'L o'?N?T'?JV'o"'o.Vr.TS NAME ,.STEAO Or STR.ET AND NUMB... 



e 



FULL NAME 13^^^^^-^^ 



FACTS CALLED TOR UNDER "SPECIAL INFORMATION" A 
STEAD OF STREET AND NUMBER. / 

Qj.::AjCKhJJ\^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 







\ 



.X^' 



"Xjj 



DATl", »»I lilKI'M 



ACK 



bo 



UiWv^i 



M.liith' 



) Vi/> 



(Day) 



Mn,il>l> 



(Year) 



I I 



/><; v.v 



sixi-.i.i:. MARK n'.n. 

\\II)»>\Vi:!» OK IilX-oKD-.l) 

(Wiitfin social il. --i'jiiiit ii>ii' 



w/juk. 



inR'run.AtM-: 

(Stall or Country) 



namj: ()!• 

FATIIHR 




MEDICAL CERTIFICATE OF DEATH 

DATK *>l- Dl'.A'ril 




(MotitlO 



.3.5... 

(Day) 



{Year'i 



I IlHKI'iBV CI'RTIl-V, Tliat I atU-iuUMl (leroaseil from 

^JllcM- % icpH to ^^. a.o.....,_ic)o H 

that I last saw h-x-^u alive on VK-^-^ 1 '^ i^P 

ami that «Uath nrriirrcl, <u. tlu- .laU- stated above, at S.. 
M. M. Tlu- C^' •'^''' *•' 1)1'. A'llI was as follows: 

durtnaA; U/>x.l.vA/-r>'x^«r>rxA^ix ••• 



lUKrin'i.ACK 

Ol.- lAPHKK 
(State or Country) 



MAIDl'.N XAM1-; 

(U" M<)Tin.:R 



RTRTTTPT.ACK 

«)!•• M<)'rm':R 

(Slate or Co\uitry) 



a,0LmiA^OL.a'0 ^i^XVvA^vtai; 




n 



IcL^ 



occrPATioN(Xy J 



M ,uUi< 



fhn 



HHST «)|." MV KNoWMUX.h AND Hl-.I.N.f 



.AKs AKi", rRri-: t»> riij.; 



( \(Ulrcss ^^ IX C 



DIR.VTION Vrars \ Months 1 C) Days I/ours 

CONTRIIU'TORV lLgaaX^ atry<LLbJ:A^>sIL^J>JL 

\KiUxi\/vA.Wi •— •• 

DrRATlON-v, JV(?;-i^ Months - .pp* //ours 

M.D. 



(Signed) DjoJ\joo \D . LUa..^^ 



^v- 



'^ .*.. I no I ( 



IC)0 



\.Mres4 fc'^t) OxxlLKyy At 



SPECIAL INFORMATION only lor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyini dw.iy fron home, 
c -,-, A- How long at 

'SZm,, Pl>,re.lD.a.h? Days 

When was disease contracted, 

If not at place of death? .^^^ .^^^ ^^ 




i)ir»; ->! It; KiAi. oi ki.;m«)V.\i, 

(TNT X^ l9o"i 



I'l.ACK 0|- lURIAI. «>K K1:M«>VAI, 



ni)i.:ktakkr V 



(A.Mrt-Hs b'rS I) o^ULaxo ••^■^ 



■■— — — ^— ^— ^^— — ^— """^^^^ I fXACTl Y PHYSICIANS should 

^. „._Hvery Item of -.nfon.n.tlon «houhl h-. cnrefuHy -PJ^''-^- p^.t^^;;,; Ja««Wieci? Th: "Spcc'la; InformHtion" for pT- 
stote CAUSE OF Dt.ATH in plnin terms, that .t may he proper y 
^^s dyini pway from home should he liiven in every .nntance. 



* 

Si': 




i 



i.'^ 



V' ii 









m 



m 



fill 

i 



r'f 



L^i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Dfffr Filed, Tlc\^JLmxlM.\^ ^?> 



7.96^ H 



Mrgf'*'<h'/'('(l A'^o. 



iy^[)9 



l^AA^ixv^ Deputy Health Oflficer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccitificatc of ©eatb 

( 11. 5. StanDarD ) 
PLACE OF DEATH: — County of^JCVv^' J-^<Vv^c>^'CO City ofC),<X'^^ J .V^CV^v^a^ ei 
No» ^0 b H V.(J^.cc^k<V ->A.<X o^' St.; T Dist.; bet. H '^ ^ ^^^^rn.- and J -A^ 

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



^ ■ Ll^^t 



'0 



FULL NAME 




:JL'iXK^X\J\}.:d.<X. 



,WV-i..uL. 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



0\o 



<X-U 



w.-rvLXi 



1) \ ri'. I >i- I! 1 Rill 



\<.K 



Mi.titht 



15" 

(Diiv) 






) 'id f s 



L( In P 



\\innwi':i) OK i)!v<>Kvi:i) 

lUiilfiii social (lc^i;.':iKitii)n) 



.^UX'>-xeXAt,^ M'aAJl>u^'vt 



luk rn I'l. \f J-; 



MEDICAL CERTIFICATE OF DEATH 



DATK <n- I>1*AT!T f\ 

XLGV: 

(Month) 



...IS.. 
(Day) 



(Year) 



r ni-:Ri:r.V CI:rTI1-V. riiat I atten.lid (hvi-asLMl frotn 

15 o . 



I()0 



.\.l VEV i:d ic/5'i to xlU^iT. )..S: 

that I last saw li '^. > - valive on ^iXAT^. I 5 190 'I 

ami that (k-alli < xu'urrcil, on (lie dati- staU'<l abovi-. at l.'.o" 
y M. Tlu' CAT SIC ()]■ I)i:.\rfl was as follows: 

DCR.VrioN )V<?r.? Mmiths DaysH'l'^//( 



ours 



RIR'rmM.Ai"K 
()}■ I AI'HKR 
(State or Country^ 



MAIDKN NAMi: 
Of MOTIIKR 



mR'rmM.,\(,K 
oi" \j(»'rm;R 

(Stiitt' or Country) 




ll \ 



.W-Oj 




CONTKIIU'TORV 



DURATION 
(SIGNED) 



)'t'iirs 



Motiths Pays 



->ojL/cL 



.^;^ \\. rqoM (.\<Mrcss) '^SX C<icLu oti 



Hours 
M.D. 



SPECIAL Information f»"l'' '''f lldsiHldls, InsflfuMons, rransients, 
or Recent Residents, and persons d>iny <m.iv from home. 



M.'xlh^ 



I'.n 



Till- MlOXl" Sl\ ri'I) I'KR^^ONAI, T \ RT IC T I A RS .\ R l'. TRD: To 1' 1 1 I-: 

jIhst «)I' MyKNnui.i;i)('.H AND im-:mi:i" 



{Itiforni.'iiit 



( \(l(lrcss . 



3. UA/'W^CJl^va; CJA) 



Former or 

UsudI Residence 

When was disease contracted, 

If not at place of death? 



HoH lonq at 
Pld( e of Death ? 



Days 



ri \ci': oi' lURi \i, ok ri;m<)\'.\i, J daii.o! ihki.m. <>i ri:m()Vai. 



x\r^\/' 



T90H 



rNI)KKTAKT?R 




(.Address 



, .S,(s', J .-. ,.V°l tl 



\ 




cv>v 



... L> ■• i'...! Ar:r Hhrmltl he Ntntecl fiXACTLY. PHYSICIANS Nhould 

N. B. F.very item of mformntlon should h. cnreiully suppi.ed. A(.F. shoi Id »>« ^Y''^^. ' ..s,.eci«| Information" for p.r- 

«t»te CAUSE OP nrATH in plain terms, thnt it m:.y he properly cluHS.tied. The Special Information tor p.r 
«on« dyinft away from home should be ftiven in every inHtance. 



91' 




m '■ 



i It, 



i;' 



I' 

in 



I 



WRITE PLAINLY WITH UNFADING INK 



H'>ar'l "f H. ;i!tli I N- 






JJdli' Ih/iuI , A\M^,M^x^\^i>^'^J^^ 12x . .. 



IfJO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3300 



llei^isteicd Xo. 




Deputy Health Offl^^r 



DEPARTMENT OF PUBLIC HEALTH=Cit) and County of San Francisco 

Gcvtificatc of 2)cath 

PLACE OF DEATH: — County ofCcx iv ^ KXLPCOZaj^i^Zaj City ofCJ O^vx- OXo^/wCiAtto 






No. S H V/Kx4l-rA„v.^t 

IF DCATH OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V E FACT 

OR INSTITUTION GIVE I 



St.; 1 





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



FULL NAME 




Dist.; bet. J CrU>CA.Aj and H I L<X<LCnrV/ 

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



Aj ' }-UL\yZX 



s..:x p 



DATl". < >I- !!1K I'll 



.\<.i-: 



PERSONAL AND STATISTICAL PARTICULARS 




> Month > 



1^ 



) il! I « 



I Day) 



.v.. »////> 



%;i5 



( Vtar ' 



\^ 



/>< 



1 1 



SIN'C, Uv MAKkn:i> 
\VII)<»\VJ-:i) «»K I)!\nRrHl) 

iWiitf in -iK-i:»l (U'si<.'nMt i"n ) 



lUKI'inM.AOH 

• St 




/V\.vJxL 






NAMK OF" 
FAT!1 j:K 



lURTiiri. xr]-: 
<ii I Arm-.K 

(State or lOnntrv) 



m\ii)!:n' na^ 
<>j- .M()'rm:R 









MEDICAL CERTIFICATE OF DEATH 

DATi: oi- i)i;\i'n 




(Month) (I>ay) (Year) 

I lIi:Ri:nV CI.KTIFV, That r attc'iiik (I deceased from 

\jXrj- a 190^1 to Oo^r- i.a up s 

tliat T last saw h ^^^ v alive on \K^C\J" l^ i<p H 

aii.l (hat tkatli < uTiirred, <«ii the date stati-d ahove, at 



M The CAISI-; Ol" DI'ATII was as follows 

a- 



i XXK. <:t^^Cr>'> -vOu Cri ^:K^^\.<T-0\jytx.\Ju' 



I )r RATION I y'ears b 1 Moni/is 

CONTRIIU'TORV 



Days 



Hon 



rs 



'r\ 



^^Ic^V-tLco ' 




lUR rniM,ACK 

(State or Cotuiti^) { W 



Jh^^J^>o^aX.LAv (-vua* 0-^ 



i'VUOl* OX/>\av 



) Vc? . 



1/, ./,■///■ 



OCCUPATION 

}\t'>iiU'ii ill Siiii /'■' aiin'sf o 

rm' MiOVF ST\T1I> i'KRsOXAI. 1' A K T U' T LA RS A R !■ TRCH TO THi: 
linST Ol- MV KN<>\VI.i:i)(".K AM) MKLHIK 



(Ii 



VA/V"\jLtO^^^CU ^nJ. 






(x,M,,.s 5Ta QxjA.^^^ ^t 



DIRATIO.V 



MiUitlis 



'nZ\'^xl^v 



Days 



(SIGNED). . J. .:'/vo-o . M 1 1 K^^r^t-xMjju^ 



Ml<^\r.A:). mo'i rAddivss)HCbdAA,ilx^; 



flours 
M.D. 



gpg-QI^L Information only hr Hospilals, institutions. Transients, 
or Recent Residents, and persons d>inq away from tiome. 



Former or 

Usual Residence-- • 

Wfien was disease contr.irted. 
If not at place of death ? 



flow lonq »\ 
Plare of Deatfi? 



Days 



P|,ACK Ol" lURIALoR K1;m<»\A1 



nvri". of HnuAi. or ri-;mo\"al 

..MUo- x% , --^^ 



.A-wfwVJL^'^^-xLOwV.^i^yy -i ^. _ - ^~ 



TOO 



, .. ,. , »rp -lio.il.l ha stnteil fiWCTLY. PHYSICIANS should 

^. B._,,very Iten, o.' inf,.r.„«f.on should b. cnrctully -ppl.ed ;^^^f;;^';'j '^'^^^^^ ..Special lnform«tlon" for pT- 

»tote CAUSt: OF DKATH in plain terms, that it may he properly ciaHsme". . 

sons dyinft away from home nhoiild he ftiven in every instance. 



n^ 



Hi 



i 



w 



RITE PLAINLY WITH UNFADING INK 



,,,1 ,,f 11. '!'; 1 






/)(f/r F//('f/fM„Ur\^L/Yy 




,.£a%0- 



**»***#•♦*»••' 



ie96''( 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

die cli stored ^'o, Of%0 1 




\ 



Dap' 



Health Qmcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

, "U. 'Z\ JTitanDavD ) 

PLACE OF DEATH: -County of ^ C^^^ JA.<X.^OUiC^City ot 

and OX^ 




^ 



fsfo, '^5 '^ '^^i3 x^rcU. v^ c H 




JIDENCEGIVE FACTS CALLE 
/ IF OtATH OCCUBS AWAY F R O ~. w^w^^ ;"o"' ^N ^T I T U T I O N GIVE ITS NAME 1 
\ ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 




r cr.T„ occ.s .».. .»o" USUAU «_.:S.O._NC.^O,.^C »CT. =^.^.;^.o -".."r^^ sx.'cSTi.TrM^'^p""' ) 



FULL NAME 







\x.yu^ 



PERSONAL AND STATISTICAL PARTICULARS 

I ^.OI,* iK "^ 



DAli: nl 111 K 11 1 



I 



( 



'vCX'vxX^ 



rlVi 



Month' 



AC.K 



?>D 



1 'I'tl I . 



(I ):(>•) 



}/,„i,'/i^ 



(V<ar> 



/>.n. 



wnxiwHn OK nivoKCHi) 

i\Viil< in >ru-i;il (U>is.MUiti<>ii) 



(Stat« or t.".innti 



NAM I" OI" 
l-ATIl!.K 



HIK riM'I, ACK 
OI- lATHI-.K 
'Stiitc or Country) 



MAIDHN NAMK 
OF MOTHKR 



MEDICAL CERTIFICATE OF DEATH 

DATK oi- ni;ATH A 




9>3l. 



(M'inth) 



ipo^'l 

(Day) (Ye:«r> 



^mc^vvoA 



1 lii:Kl-;nV CI-KTII-V. Tliat I atUn.U.l .UTt-ased from 

- ■-; . _ '—-—,.190 to ■•■'-"-'■" »90-"— 

that I l;ist saw h alive- (^n — : t-t— -r-^-^rrr up 

;n,a tliat.U-alh "<<-urr(Ml, <,n tlic -latr stalol al.ovc. at- 

.. y^ 'j>j,^. CAiSI-; Ol" Dl'-Xril \va,s as follows: 



C\ 



CLj-uCL^X' 







lUK'nirLACH 

OF MOTHHK 
(State or Contitry) 



OCCUPATION G\ 




(A.X^^'YV 






V,,/////-.- «^.^ A^.''"' 



imST OF MV KNOW M.l'..h ANI) m.l.lKf 
nnfonnant QOOol^lA^ d.KA>VX.^Y^ — 



CLoo ^xiX"><i^<^wX. 



CONTUllU'TORV 



Months 



% 



Days Hours 



DIRATION 
(SIGNED) 







)'tais, 



irs 



Months 



XiJLcu^xxL 



/>(7>.5 .Hours 



M.D. 




^CNvT /^"^ n)0 '\ ( 



( 



^XX^K.^. 



Special information "nlv for Hospitdls. Institutlwis, Transifnts, 
or Recent Residents, and persons dvinj dwa> from fiome. 

How lonq at 

"™fo •/ r» ' Plafpof OeatI)? Days 

Usual Residence • 

Wlien was disease rontrarted, 
H not at place of death? 






nv ri". ■)! i!i KiAf. 01 kf;m()Vai. 

.....^^K(jvr XS 190H 



f \fl(lrrss 



Sic\ t) A,<xh.vUl....d».. 



(Ad<lre'«s 



IN. B.- 



— ^^ 1— w^Mi^— — — ^""^"^ , I \4CTLY PHYSICIANS should 

H.O.C CAUSE OF DEATH in p -in ;""-.;;;„» J'.:^';; Tj.J,,. 
.on. dyinft away from homo should b« *.»«" y 





I'i 



MMihMliv^ll^iMkiHUl 



WRITE PLAINLY WITH UNFADING INK 



li,,:n.l of !I, Ml'h I- No ^•-'^'V.yi^J^>^'^''' "- " 



y 



cUial^Iaatv Deputy Health Officer 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered ^'o. Of^U^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



% 



Ccvtificatc of IDeatb 

( Ta. 5. StanPatCi ) 
PLACE OF DEATH: — County of JCL^^ ^'— <^^^^-^ -^^^^^^^ oi^AAy 

( '^ r.^;;rH"ocro%r.v.;"rHo^s^r.t r^^f^s.^^^^^.'^o.v^Ts name ^..*o o. s..... ..o .omb.«. ; ^ 

.Wv\Xw>vou Oaa.\^xUAj 



and 




xy 



•cU^ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



i) A'll-: » >!■ lUK I'll 



coi.oR 



U}l^-u 



( M.iiitlO 



\ 1 . 1-: 



iH 



I 



) i\ii . 



"D:tv) 



M.itith- 



(Vcar) 



Pin.' 



S!\C, 1,1" M\KKn:i) 

wiix »\vi;i» <»K i>!y< tKri'i) 

I Write in >MHi;iI •!. 'if tial ion ) 



lURTnn.AvM-: 

i state or Crmntiy' 



NAM)' ol' 
I- A'ni);K 



lUKTm'I.ACH 

Ol- i-Arin:R 

ISlatr or Country* 



MAIDHN NAMK 

OF MOTHKK 



r.TRTTTPT.ACK 
Ol- Mo'I"lll-:k 
(Stiitf or (."Mnnirv) 







d^cAXcv-^^^^-''^' 




.<XO\) 



■Ou 



LcV"r>XO<lk 



d 




AVsi,!r<f III Sail I'nimi.^'o 1 ' ^ '''' ' " 



M.,,iHn 



/',/i. 



HKST ol- MV^KNOWMvIMvlv -^N!^ 1.1.1,11. J 
(InfonnMnt Uk<XA t ■ J' 



(Address V ,\-'\->-'^*-''^^i/*- '-' 



MEDICAL CERTIFICATE OF DEATH 

DATl-; Ol- Dl-'.ATH 




(Month) 



(Day) 



(Year) 



I HI': K I'! 15 V CI'RTII-V, Tliat I iitt».Mi.k<l dcccasea from 

.Ojllmv i 190 H to ...^<rvr. ^a. icpH 

that T last saw h i-^ alive on \h^<JV^ ■ '^SL 190'i 

and that .Icatli occurred, on tlic date stated above, at I ^0 
LI M. The CArSIC OF Dl- ATI I was as fol^nNS : 






nr RATIOS )'('ars ISIoulhs Days '- Hours 
CONTR115UTORV :„/y:YCLluiA/Vw^xl....i)1C;X^ 

JSIouths I Pays I lours 

(J,i). 



DT RATION^ )cars 



( SIGNED ) J X<X vvk M .DA.au. 



%. 



la' 



I()0 i 



{ 






M.D. 



SPECIAL INFORMATION <>"'> ^«r Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyini away fron tiome. 



Former or 

Usual Residence .,....•■"-"•-.' 

When was disease fontracted. 
If not at place oldeath ? 



How long at 

Place of Death? Days 



ri.ACKi)!' m'KiAi. OK ki:m<»\ai. 







DAIl-lo!" lU HIAI. or K1-;M<)VAI, 



190 



Lrls 5.5^^?^?^ dLxlU>V.>^t 



' ' .. . 77>p «h„uld be Htntecl RXACTLY. PHYSICIANS should 

of information should be cBreVuHy »"PP'-'^;^- ^^^'^Hy claHsWied. The -Special information" fer pr- 
E OF DEATH in plain terms, that it may be proper y 



N. B. Hvery item 



1 



T 'I iO. 






f 



1^ i 




w 



RITE PLAINLY WITH UNFADING INK 



lJ(,:i!.l -if !1.. :l'it)> 



,^- ^ . t- ,«^«r,^; lU^ 1* '*<1 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




■4' 




"k-^ 



jfjcn 



Be^isfei^ed JS'^o. 



3303 



.' 



\.,..^\. > Deputy Health Officer 

DEPARTMENT OF PUBLIC HE AITH-City and County of San Francisco 

Ccvtificate of S)eatb 

( Ta. S. StanC»arO ) 

PLACE OF DEATH:-County of 6^.^^ ^.^^xc.^ Oty of ^A..^ Jxo^vc^o 



\^ 



No*5il 



^ 



/ ,r DtATH OCCURS AWAY FROM USUAL J^^ S I D E N C E O V ^ ;ACTS CALU^^ ^^^^^^^ ^^ ^^^^^^ ^^^ NUMBER. 
(, ,F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE IT* 



and H'^^CnUla/J ) 

-■) 



FULL NAME 




^A^' 




{nv 



PERSONAL AND STATISTICAL PARTICULARS 



ix^^-v-uxJu ' H-^ 



I>All-, »U- lilK I'll 




Mdiilh^ 



(Day) 



.^7b 

(Year) 



AiiR 



5.^ 



) Vi''A 



.1/-. ;////.' 



/'(/ V5 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




,C\r .., •. '^3^ I9o\ 

(Month) fl>«y> i'^'^"'^^ 

l~lIKRl':r.V C1;RTII-V, That I attcMKkMl .Icccased from 



190 



-to 



that I last saw h • 



alive oil 



1C)0 



SIN(.I,K. MARKU-n. 
\VII>n\Vl--.I) «>K DIVOKn-.I) 
(Writiin 'iocial dr^i^' nation) 



lUK'nnM.xcK 

(State or Cotintryl 



VAMl-^ ni- 
FATm-;K 



niR'iin'i.ACK 

(>|- 1 AIHKK 
(Stati' or Ooimtry) 



01 MoTTlKR 



lUK'riTPT.^CK 
(11- MOTlll'.R 
(Statf or t.'onntry^ 



OCCrPATTONCljNp 1; 




an.l that death occurred, on the date stated above, at IC^O 
(1 M The C M'SI-: OF Dl-ATl! was as follosvs : 



A..<r'yv ex,*- 



I )rR AT ION Years 
CONTRIIU'TORV 



Months Days 



Iloitrs 



Months 



,NED)..H. V 




/hjys 



DIRA TION 

'Al^' X' 100. fAd.lrc'.-O ^Ot. n>> t- L.cv. nt 



/fours 
M.D. 



I()0 



U 

Rf silled i» >"■'" /'i<nn/>r» 



)'<ft I 



- yf.-ntll^ 



'/). 



ri 



n- Mu.VKSTXTKl.l>KKsnNM.l'AKTUTI.ARSAKi:TKrK T< » TIIK 

'hHstoV ^iv kn..wi,ki..;h^I' hki.ikf 

Uja/^^xx o\d^ 



(Inf'>;niaivt 



SPECIAL Information ""'y '"•■ Hospitals, institutions. Transients, 
or Recent Residents, and persons dying dwdv fro'n fiome. 

Hov^ lonq at 

Place of Deatli? Days 



Former or 
Usual Residence 



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



> 



oM 



l'l.\CH OI- lURIAI. OK KKMoVAI. DATl^.i" I'.'IUAI. or Kl-MOVAJ. 

% It) jQ<>^C/\XX,->>AJU>A^L<» sjtJ 



rNDl-.KTAKHR 



Address. 



N. B. 



'■■ T^c „u,»,.i,i he Rtfited fiXACTLY. PHYSICIANS dhould 

-fivery item of InformHtlon «houId b. cnrefully HuppI.e.l. J^Jl^^^/^'*^^^^,,:^ I„fon.n«t1on" ?or pT- 

state CAUSE OF DEATH In ph.m terms, that It m»y be properly claHS.tied. «P 

nnn% dyinft away from home should be ftiven in every instance. 






^ 



; * 



I i 



< N 



ii 



Hf 






Mi 

Hi 



Ml 



WRITE PLAINLY WITH UNFADING INK 



,,,.:,,.!..' lie..', h i^No: ,-;a^^^:?^HS^rco 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ixilr FiJ(><L vflcvN^-A^l^^Ov. IH ^'^^"^ 



Tie^Lslered JVo. 



3304 




LV'^ 




DeDuty Healtfi pfTicer 

DEPARTMENT OF PIBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)eatb 

( U. S. StanDarD ) 

.ccCty ofCJ/ 



1. 



0^ 



PLACE OF DEATH: — County ofO-CL/^v J,X.<X YvCAA-cxUty 

(? ft 

St.: I Dist.; bet.VJ CrVU-^^^ and 




V IF DEATH OCCURRED I 







. DEATH OCCURS AWA. ^^O. USU.. ^ f . O^ NO E^ VE_ -TS CA.^D _^ U^.J ,---—--- ) 



FULL NAME 



%. 



<X/\.\.Oj 



Ujvc^AjLo. 



"" ^ 



PERSONAL AND STATISTICAL PA RTIC ULARS 



DAli: <>!■ I'.IK lli 





jyy-wXJU 



Ai.K 



) '(f/ » .« 



(Day) 



^ M.ntlfis V*..V 



(Yoar) 



Pa 1 .^ 



SIN<-. 1,K. MAKUIl-.n. 
\VII)n\Vl-:i) OK DIVourKI) 
iWiit»in ^'H'iitl (lc-ij.Mi.itii)i\) 



HIK'rmM.ACK 

(State or Coiuiliy) 



NAMl" «)]• 
1 ATHl-.R 



P.IK rmM.AOK 
OJ- J AIMIKK 
(Statf or Countrv) 



maii)i:n namk 

Ol" MOTHl'.K 



nTRTTTPT.ACK 
Ol' MolMlKK 

(StMtf or i'owiitrv^ 



J QD ft 



,<xJLXyo<.'y\M 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DlvATH 




(Year) 



as.. 

(Month) _ (Day) . _ 

"~TinvRl':HV CI'RTIFY, That I attended deceased from 

iQ,^ -^wO 190H to M\.<rv^ ^3^^«^©«st... 

that I last saw hXV alive on VrUv"- :^.^.„, 190H 

and that death occurred, on the <lato stated above, at i ^0 
y M. The CArSK OF DI-ATH was as follows: 

. v^/O^^QiA^U^) t/>-sJwX/VOvvA 






X.xx) 



"Ux^Va^cu iJxV'^vv.c.Lc.j 




(xCTTATION 

Rfsidfd in San /'nun /}>■<' 




)\>!l 



X y. ">'/>< oC- 



/),,M. 



THK vH.>VK<r\T»'I>l'HKSnNAI.PAUTirri.AKSAKl- TRrK To TIIH 



1)1 RATION Viars Jl/ofi//is ^ Days I/ours 
CONTRIIU'TORV • - 



DTRATION 



K (/;■.? 



Afonths 



ft ays 



(SIGNED). ^ AA- XJkxJIjX.' 

^ %Z l.,o' i f A.ldress) ^ ^ b dxCfclcV jt 



Hours 
M.D. 




Special information only tor Hospltdls, institutions. Transients, 
or Recent Residents, dnd persons dyinij awdy from fiome. 



Former or 
Isiial Residence 

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



How lonq at 

Place of Death? Days 



(A<lilress 



SOb 



DAIi: o! Ht KiAi, or RFMOX'.-M, 

QrUvr- XH 190H 



I'l.ACK OI- lUKIAI, OK KI:M<«\\I. 



^'^Cc 



'v< 



N. B.- 



«tate CAUSE OF DEATH in plain term*, that it may be properly clasH.^led. 1 ne 1 m 

»on« dyinft away from home should be j^iven in every inHtance. 






' ul 



I1 1 






If 



i 






R,TE PLAINLY WITH UNFAD.NG INK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRU CTIONS 

8305 



W 










IH 



V, * • ^. ~ 



lOO'-i 



** .Offl-C 



BeiLstcved J\'o> 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiticate Qi IDeatb 

( -U. S. StauDarO ) 
PLACE OF DEATH = -County of^O^ i X<v>x...^ Gty of 0<V.v Jaxu>..<..^ 



,No. 2.bHi Mllv^^ 



. S Dist.; bet. 11 C>^ and IS >^ ) 



M I LV^L'^OC^^ „r = ..;r^.rF r.vr TaCTS CALLED rOR UNDER "SPECIAL INFORMATION- ^ 

/ .. DEATH OCCURS AWAY " O M U S U A L J ^ S ^E NC E G • v. ..CTS C^A^LL^ ^ _^^^^^^ ^^ ^^^^^^ ^^^ ^^^^^^ ^ 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUIiur. O . . /-V 



FULL NAME ^XXXCX 



cLcaX^Ow/TV' W 



-C-Ow/rv' MjX^xcLoj 



PE 



RSONAL AND STATISTICAL PARTICULARS 






DA'fl". «>i uiKrii A 



j COI.oR > ,^ 



r\AAJl) 



15 . 
( Day) 



(Year) 



Ar.K 



}'/•(?» 



O. . Months . . .1 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



(Month) 



(Day) 



(Year) 



Ihivs 



SlNr.l.K. MAKKIKD 
WIDOWKD OK DIVOKCJ-.D 
iWritf in social (ksi<.'nati<>n) 



HIKTin'l.ACK 

(Statf or t,'ounti y I 



NAMK or 
lATin.K 



HIRTHr'l.ACK 

()»• J APin-K 

< State or Country) 



MAIDKN NAMK 




I IIKRICHV Ci-RTII'V, That I attenckMl .leccased from 

0\<iv:.....5 190H to Oxc^^ ^-^ ^90"^ 

that I last saw h XK.^ alive on ^1^ .^9. icp M 

and that death occnrred, on the <late stated above, at 5 H5 
M. The CAl'SIvjUl' DI-ATll was as follows: 




,HyCA.VA-OuS.? 



r-VCVO^ 



I 

(Statf or Conntryi i i 





'>"uOl H •VcrVv^-^^'^'v 




occr I'A'iioN 



.CXXXlD 




! ' ' 



DURATION --- Yeai'S ....... Months "■ Pays Hours 

CONTRinUTORY 



DT RAT ION 
(SIGNED) 



ci. 



Ycius „ Mouths 



Pavs 



. Qb^ 



^ 



•n- 



I/ours 
M.D. 



.xa 



I()0 



(Address) ^'^ ^H - at JA' ^t 



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



AVv/VM/ /// Siiii /'xriicyo 



)'iii I 



^r,„iiii< 



/):n 



■r...- AU<»Vl.-ST\rj-DfKKS<>NAI, J> \ KT 10 T I. A KS A K K T K T K 
'"\^KST i)F MY KNoWi.KD«;K AND HKUKF 



TO T!IH 



I Informant 



\J Y\.\AJi\^<iy 



(Address 



Former or 
Usual Residence 

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



How lonq at 
Place of Deatti ? 



Days 



PI.ACK Ol" lURlAI. OK KKM«»VAI. 






DA'n", of Hi KIAI. or K1':MoVA1, 

V^Wr XH T90H 



(Address 11 



N. B.- 



-Every Item of Informotion .hou <l be CBrofully ^"PP'''^^ properly da-Wied. The "Special fnJormallon" #or pT- 
•tate CAUSE OF DEATH In plain term., that It may be P-'oP^'y 
^on. dying away »rom home should be ftlven In .vry Instance. 



* 



I 



1^ 

14 



.V^^^fiTc'-^,*';-'^^ 



>t- 



1! 



1 

1 -i 



i 



5 



1 



:-* 



II 



W 



R.TE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



n„...l..ni.MUh-KXn.^^-^^?^:^^"^^'^-'^ 



I)(f 



f(> Filed , \Cl^<hJ^ry\l>^Ov X\ 



li)0\ 



lle<^istetcd J\''o. 



8306 





DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

^ -U. S. StanDar^ ) 
PLACE OF DEATHi-County of 3 0.^^; W^S^^-^ City of 




^t^ 



<x 



No* 



St ♦ Dist.; bet. ^^^ . . 

V IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION 



— ) 



FULL NAME 





SKX 



PERSONAL AND STATISTICAL PARTICULARS 

KolU y OuJkcU-^ -^ 

DATi: <'!• i;iRTH H • (1 Oo . 






I Day) 



AOK 



IH 



) V(/ > 



SINCl.H. MAKUIl'.n 
WinnWKl) OK DIVoK*. I'.l) 
(WriU- in •^iH-iiil (U^u'iiiiH'""' 



HIKrilVM.AOK 

(Jstiitf or (.■■)nntry) 



V2 .\h»ilfis •^ O 



1 



(Vrnr) 



/)<! >A 



MEDICAL CERTIFICATE OF DEATH 

DATE ()1-'I)KATH 




fMoiitlO 



(Day) 



lYc«r> 



I ni'RHHV CIvRTIl'V, That I attcn(U'il dcct-asetl from 

— to — r:rrr!7-rrrrr!r:rrr^ 



1 90 



alive on 



FA rill. K 



lUKTliri.AiK 

<)»• lAriii'.K 

'State or Country^ 



MAIDHN NAMK 
ol- MOTHI-'.K 



lUKTlTPT.ACK 
01 MmTUHR 
(State or (.■oJinlryi 




^JirrSJs 



til at I last saw h — 
an.l that death occurred, on the date stated above, at 
rrr:r../M. The CAISI-: Ol' DI-ATII was as follows: 

\JrY^JlAA^'V> vtr>vs.xx.( .-." 



190 ' 
X90 



DURATION Years Mouths Days 
CONTRIIU'TORV • 



Hours 



( lOCUPAT ION hD 






IhiVS 



DURATION ^ Years ^ Afontiri 



( SlGr^ED) 

vjUxr a?. 190 "^ 



flours 

M.D. 




Resiiifi! ill Sail / laHeiseo 



) , It I 



M,.,itlr 



/>,! 



HHSToV MV KNMWI.KIH^H AND HKl.IKh 



I.ARS AKl'. PKIH Ti» I" Ml-: 



(Iiifo'iiiant 



"^i.^ S3,.a^v. 



^, 



■A 



SPECIAL INFORMATION «nl> •«' HospitaK, Inslilulioiis, IrjnslfBls 
or RetenI Residents, iiid persons dvlni| dvids Irom home. 

K*.ce PI«e.lDe-.h; 0.ys 

When was disrasf fonlrartrd, 

If not at place of death ? -—' 



I'l \ci: Ol" HiKiAi. <»K u»;m<»vai 



I)AJl"o;" Ml KiAl. or KliMoXAI, 

9^H T90H 




(.vM,..s^ ^5^ N rv^^^A.<r>v. 



■it 



S51 M>\\^'^v>crr^ ol 



(Adtlifss 



■ ~ ., I- should be *tBte.l RXACTLY. PHYSICIANS .hould 

N. „._Hv.ry Item oV' inJormHtion •houl.l b. cnrefuHy -PP -'•• ^; ;;^ clarified. The 'Specla. Informallon" fer p.r- 

-tnte CAUSE or DEATH In plnin terms, that it m«> he proper , 

^l^l^'^f^VL-v from home Mhould be ftUen In every InHtance. 



«on« dylnft away from 



•I 



,1 



I 



ii 




t 



■ 



ii 



WR.TE PUA.NLV W,TH UNPAD.NO .NK-TH.S .S A P.RMAN..T R.CORD 

-""■ -^ °'^ K "- CERTIFICATE FOR INSTRUCTIONS^ 

3307 







Beo'i.sfrred Xo. 



l.(rwc^ ij^v^ Deputy Health Officer. 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

I "U. S. StanC>arO j 



JJ 



K 1 



PLACE OF DEATH : - County of d OA^ 1-ux.vx^A^ '.C.ty of ^ -O. 



, , ^ ^.1 Dj,. . bet ^ J CrV^^^U and M I ^O^-COa. ) 

... 



FULL NAME 




Oj 



PERSONAL AND STATISTICAL PARTICULARS 



^'•^^Qy?) 



C<)1.*»K \ 



DATl-, OJ' HI Kin 



\(*.K 



Jj.lv^tx 



\JS\r 



} V<» » > 



sIN.M.K. MAKKIKl). 
WIDoWKD OK DINOKi l-.n 
iWiiti in ^ociiil <K siviiatioiil 



L-A^^^Vw. 



a:5 

(Day) 



Mntllh^ 



■f 



/^Cl.H 

(Yt-ai) 



/)a V. 



MEDICAL CERTIFICATE OF DEATH 
DATK Of- 1)1;aTH 

(Day> 



C 



(M(inth) 



(Year) 



niKTin'i.ArK p Opj 

(Stall oi Cmntrv) -^ X/| 





NAMi: Ol 
J- ATM l-.K 



.0000^>">^VO 



^UVNw<>C3AXcu 



~ I in-KHI?V CKRTIFV. TliMt I aUcndcMl .Icfoascl from 

(yU\r ^a upH to C)xm^....^2^ 190 1 

that I last saw h alive on • — ^'^ 

,,n.\ that (Uath occurrcl, nu the .late stated above, at I ^ ^0 
Q M The CMSI-: Ol" DIvATll was as follows: 

■ ■ V^jlJU, (J^, . . ^ , 



c 






DT' RATION Years 

CONTKIIUTOUV 



iMo'iths 



Pays ^ Hour 



lUKTliri, WK 

OI- I APllKH A, \ 

(Statt <>i rotnitiy) \\ . II 

MAIDKN NAMK A (j JJ | . 

lUKTIU'LACK 
OJ- MoTHKK 
(Statr or Cu\mtry> 



i>XxXA^ 



/\_y\^^\^|-'>-~''wi 



Days 



DT' R A T I < ) N > ■'■'J'''-^ Mouths 

(SIGNED) ^CUVC^ M)\. ■:Kv*^"'^N "•°- 



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



\ 



)V„;v - M'oilln 



/)./VA 



OCCUPATION 



(Infoitnaiit \J 



A^OL^.'^^'^*^^^^-^ 



v^\yvv'C-^cr\X/Ou 



Former or 
Usual Residence 

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



How fonq at 
pure of Death 



Days 



PI.ACK <»»• niKIAl, OK KKMoV \I, 



DATl.o! Hi KiAi ui Kl'.MoVAI, 

0\<iN-rr. SLH 1 90*^ 



^,,,,_ nnft ^ ^t 






— ^^^-^1— ^— —— ^^^*^— ^— ^^^""^"^ I rvACTI Y PHYSICIANS Hhould 

state CAUSL OF PtA in in P , tnntance. 

lions dyliiA oway from homo nhoultl be ftiven m 



»' 



!: 



I' 







I' 



I 



H<.;ir<l <<f II. :iilli 1' ^' 



WRITE PLAINLY WITH UNFADING INK 

, A.^-^?rs.ii )',y<.\' Co 



lOO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 



8308 



a^vouiXi-/v-u Deputy Heaitfi Omcz^r ^c r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Ccvtificate of Beatb 

( 11. 5. StanDarD ) 



No. 




^' U -ojL.. VI <x^ 



St.; 



Dist.; bet. 



— and 



(ir DCATH OCCURS AWA^ 
IF DTATH OCCURRED 



X*"''w l^> ^t.; l-'li>l.t '^ ♦ UNDER 'SPECIAL INFORMATION" \ 



FULL NAME 



fVOJv. 




D 




.nj. 



Rj\i 



PERSONAL AND STATISTICAL PARTICULARS 

si:x ~ 





yvc 



.tjb 



DA 11. •>! HI Kill 



Month) 



AHH 



o.lt 



c:A.c^ 



)Vi;' 



(I)ayt 



M,,,itfn 



(Vfur) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH " 



(MoiJtli) 



(Year) 



1 HnKHBV CHKTirV, That I alUn.U-.l dcrcasc-.l from 

to ..". .It^.-^r^ 



190 



lip 



J\n: 



S1N<-.M- MAKKIi:i). 
\VII)<»\Vi:i) OK DlVdKCl-.t) 

( Wiitt- in '^oi-ial di'.i^.'nation ) 



mKTm'i.AOK > 

(Statf or <.".)Mntrv* 



NAMl-: <»1 
I'ATllKK 



lUK inri.Aci-: 
<)i- iaihi:k 

(SUitf or Country) 



maii)i:n namK 

OF MorUF.K 



-{ I) 

c.) A^'wcjAx - - ' 

0. V.0-0'V-OL>\.' 





lURTm'T.ACK 
ol" M>)TnF:R 
(Statf or Conntry) 




tliat T last saw h alive on — — - 

ana that .Icath occurre.l, on the .latr statol above, at 
M. The CAT SI-: Ol" l)i:.\'rH was as follows 







I )r RATION »<'''^ ...Mofiihi 

CONTUIl'.rTORV 






(SIGNED) 



\X^vw>>-^-*^-4.^** 



■■•••i;,^^^T^^f^'^>;;^^^-'f -.!<-- ^^'^''^"^ '"' '""^ 



C)icv- 



V^CrVcrv- 



/fours 

cl,>v<:^ M.D. 



SPECIAL INFORMATION ""y '•" •■" 

or Recent Residents, and persons dying dv»a> from home. 



Former or \\ r\i 

Usual Residence v) /CXA-^j 

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



Cliio 



Transients, 



Days 



(Infonnant 



(Address 






I'l.ACK <)1- lU KIAI. OK KFMoVAI, 



l)ArK<»t III KIM. '>! Kl%MoVAI, 

(yUxr QLH .... 190H 






r-\(Mrfss 



■"^■■■^™'"^^^"''"'""^"'"'""'"^'^"""'^"^^^ I FXAGTLY PHYSICIANS should 

«tlon .houhl he c»re?ully -PP"'^;'; 'l':l'j^;fL''Ji^^^^^^^^^ Infor.nat.on" for p.r- 

ATH in plum tcpm», that it mny •>« pr"i» ^ 



N. B. Kvery item o? inform 



8 t^ 



(I 

f i il 



it 



II 






1 1"! 



' '.i 



h 

'1 1 



RITE PLAINLY WITH UNFADI 




. , f-r-sr^: n^VCn 



NG INK — THIS IS A PERMANENT RECORD 

REFER TO BACK ^.crPPTmCATE FOR INSTRUCTIONS 



llJO'i 



Ee^Lstned jVo, 



3309 



I Dale Fi/rff.HV^j^-rrJM^j Q.H 

1^^^^. "v . v.. . Deputy Heaitn Ofn.ur ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)eatb 

I 11. S. StanDarD ) 

J} '5? A 



PLACE OF DEATH:-County of^^^- i;v<v^c^o Gty of d c^>^ 3^c.r..^^ 



«o«Ofc 



/ ,F DEAT^OCCUBS AW4Y FROM USUAL 
I, IF DEAJrH OCCURRED IN A HOSPITAL 




St 



Dist.; bet. 



- and 



■) 



RESIDENCE GIVE FAC 
OR INSTITUTION GIVE 



-Ts'cALl'eD rOR under 'special INFORMATION" 'S 
',T1 NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



( 



-1^ 



'lco4\.Ow' 





Aj^y 




SIX 



PERSONAL AND STATISTICAL PARJjCULARS^ 

I COl.oR 




C^Li, 



.IjJvcbb 



DAiH «>i iiiKrn 



(Month* 



ACK 



L"2> 



J III I 



W 



(Day) 



y Inn I lis 



11 



rViX 

(Ycar^ 



na\< 



MEDICAL CERTIFICATE OF DEATH 
'DA^rE OK DKATH ^ ,^^ 

/{yvr -^^o... 




(Moiilli^ 



(Day) 



(Year> 



SINMM.K. MAKUll.n 
WinnWKI) «>K DlVoKil-.I) 
(Wiittin stK-ial <lc<ii.":iiiiti->iw 



lUKlHri-AOK 
(State or Country) 



PATH »;k 



HiK rin'i.ACK 

<)l- I-ATMKK 
(State or Ccnintry) 



MAIOKN NAMl-: 
<»!• MOTHKK 



lUKTlU'LACK 
ol- MorilKK 
(Htati- or Country' 



oCCri'ATHIN 

A\-sN/n/ ni S.!>i li.nh ism 



^^'V<xv^.^w^^- 




1 HKHHHV CHRTIFV. That I atu lulcl deccascl front 

l£),^ la 190 H to vKxsv- %n> ..igo-?*.-... 

that I last saw h^^^>v alive o,t M\^- ^^ - "W^" 

ati.l that .loath occurred, on the .laU- stated above, at 
G^M. The CArSl' ()I'*4)i:ATil vva< a< follow! 



vs : *. 




I )r RATION 



Years 



.Vo>iths 



^m 



Hours 



CONTKIBrTORY U-^"^ 

O JL^-x-vXvtx^ 

Dl-RATION -^^^'ff^ Months Pays 



(SIGNED) O. cr|\^w^^^^- -■ ^ 

Q(\<IV^ 1^ tooV fA<ldre..)"at.MXaW JV' 



' v\yV\XV~^^^- ■ • • •• * 



IC)0 



//ours 
M.D. 



,<x/>axL 



y,.„,< 1 tA>;,///v i^l /'■". 






SPECIAL INFORMATION onl> for Hospitdls. Ins^iitions. Iransients. 
or Recent Residents, and persons dying away Irom home. 

KwdenccV. cJXuo CJ; £e':;V-.fc? Il D,,. 

When was disease contracted, 

If not at place of death ? - 



I'l \CK en* HrRIAI. OR KKMOVAI. 

I'D 



DA rj: o!" iiiHiAi. or k1':m()Vai. 



I Address 






IN. B. 



..— — — — ^ — Ai— — ■^■— — '^^"""""'^ t t I FXACTl Y PHYSICIANS nhould 

-Kvery l.em .W lnS,.rn,„.inn .houl.1 b. c„rc!ully '-"^^^ ^"LC"!"-"'''" Th: ••8,.cci.. Inforn,..W W p.r- 

. . <-lll«F OF DEATH in plHin ternni, that it mny t>e proper , 
:r;<.Wn» .w« "-„. h„.e .ho.,... H.. <tW.n y .n-t-nc.. 



! H 

i'l 



^tfbM^khBd 



<! 



\$¥ 






f 



M 



WRI 






-u.c ic ik PERMANENT RECORD 
TF PLAINLY WITH UNFADING INK — THIS IS A PERMAINt 
TE PLAINLY Wl ^^^^^ ^^ ^^^^ ^^ cERTinCATE FOR INSTRUCTIONS 



**!r^. 




lledistercd vVo. 



8810 



i -1^ Deputy Health OflHcer 

DEPARTimOF PUBLIC HEALTH-City and County of San Francisco 






CevtWicatc ot Scatb 

( 'U. S. StanDarD ) 



^ 



e^ 






^ 



PLACE OF DEATH: — County of 



"l^-,vOA^t)L,-rv.''iAX>.tc City of ^-''C>->^ 



No. 150 



M , ^. O Dist • bet. V ^veAi^XJ^ci andUjC-lLj 



FULL NAME 




h.K 



L^V\A^. 



PERSONAL AND STATISTICAL PARTICULARS 



1) \Ti-: < >i itiKi'ii 



COl.OK 




^y\\jJ<J. 



lM<)nth> 




A<".K 



13, 



>•,■.) 



(Day) 



M.'uths 



1 



,%i:\ 

(Year> 



Da vs 



MEDICAL CERTIFICATE OF DEATH 
DATK OF I)i:.\TH 




(Month) 



a^ 

(Day) 



(Year) 



SINC.I.lv MAKk n-.D. 
\VIIM>\VKD OK Dl\nKi I'D 
iWiitr ill sM.-ial <U-sU'iiali'>ii ) 




nTUTHlM.ACK 
(St;>tc or Contitryt 





NAM I'. <>»■ 

i-atiii:k -A 






QaiM \ 190^ to. -m\( 

that I last saw h a/', alive on 

,„a that .U-ath ocotirrcl. on Ih. <latc- .tatc-.l ahovo. at 
a;. The CAISJ': Ol- DivATll was as follows: 



\j v-CNT" %% IgoH 

(}"Uv- X\ 190 "4 



\3.0C-v•^.<X^_X,>vJL 




BTRTIiri.AiK 
Ol- lAlHHK 
(Stalf <ir Coiinlrv' 




,^V^^O^ - 



)■<■<//•-? 






,,o^-<i-^^-<^- 



I fours 



MAIDKX XAMK 
«)l M()Tin':K 





lllKTinM.ACK 
nl MnTJlHK 
(Stale or OoiuUiy) 



OCCUVA'lION 






,<V/CJ. 



(SIGNED) V^^ 0J1^^^._ M.D. 



Wr X^) loo'. (A,hlress)lDC^ 



SPECIAL INFORMATION ««ly t«' ""-P't-I^. I"-'^""'""^' '""-'"''• 



- ^r,>nth' 



/hi 






( L' 11 ^ ^ , How lonq at 

S«°sidfn« ISoVfo-tUNXdiAi 't Place .1 Dealt.? 

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



Days 



QJVP p si\^:sj- 3^H 190 H 

.SDHKTAKKK ^^^^^U^ ^^ ^^ O 

(AcMr.ss 1^ U <X^x; V\X^4X> 0.0 



\j^.w. 



N. B.- 



'^'^*^""' ^^ ^ ' TTTxACTLY PHYSICIANS should 

state CAUSE Oh Ut^ • n »; . |„ ,very instance, 

son. dylnft away from homo should be ft.ve 






Il 
i 



fii 



4 



II 



II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!,,.ii.' . f !l. illli I- Vo. 1- -^^ *■«.:---;: |',8:l'f., 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!)((/(' Filed, \)rt( 




■^^>^Lnr^^^yXhJ . iH / '^ \ 



llegiiitcrcil J\^o, 



;53ii 



OVCV'^ 




'> 



Deputy Health OfTicer 



No. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( 11. S. Stan^ar^ ) 

PLACE OF DEATH; — County ofCloLA-v J ^vCl woui^C) City of <CL/>^ J Axx^a^cv^. co 

His i'9. V) iLv^lL^^trrv St.; ...5^ Dist.;bet. lOJJhu and W !Ui\, 

(ir DEftTH 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 




uJ-vcL 



Crt,/! 



I dJ CrLcO/'OOA 



<i:\" 



PERSONAL AND STATISTICAL PARTICULARS 
/^ , i coi.oR 



fX 



OwLl 




M^Oub 



— I 



MEDICAL CERTIFICATE OF DEATH 



DAIK ()1- HI KIM 



I Month) 



AGK 



5-1 



5 Vr// 



(Day) 



M.oiHi^ 



(Veari 



DATH n|- I)1;a TM f\ 

LW 



190 ' t 

(Year) 



.i^^A 

(Month) (Day) 

I lf}{Ki;P.V CI'lkTIFV, That I attemUMl deceased from 

to :: 



~~~ "" — — — — 190 

til at I l.'iSt saw h alive oti 



I90 
190 



IK: 



SIN'r.I,R. MAKRIHI*. 

\vin<»\VKi) OK i)!\<)KrHj) 

IWiittiii soriiil (Irsi^Miiitioii) 




V'v <.X^&,^ 



niKllUM, Ai'K 

(Stiitf or •"ounti v< 



A 









NAM]-: «>i- 

HATin;K 



lUKTinM.At-H 
Ol- lAIMIIlK 
(Stiitc- or Couiitrv) 



MAII)1-:M NAMI-; 

OF M()Tin<;K 



niuruiM.ACK, 

oi- MOTIIHR 
(state or Countrv) 



C\^CO 
i) 



OCtL^-O.' 







A 




15 



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

— -^ M. The CArSl<; ()!■ I)i:.\TII was as follows 

'1) 



vlcuOo-'Cnr^ \Jj\<n'VvCr^v-cL'^ VJ 



. LLc<xxL?^vCL.aA. 



I)r RATION )'ears 
CONTRIPd'TORV 



I\Io)iths 



.1 



Days ■■.^- Hours 



Aj:x) 




OCCUPATION ^ 






DURATION , Years ^rouths Days Hours 

( SIGNED )L&\,'CrT:U.>v vJ.yS.yj. cLiUxx.YV'tL M.D. 
]rU\r ^1 Tqnt (Addrt-ss) UA^-vaXV^ V^'uvc:.;. 



m*" 



J xxaJc. 



^"^ 



Pf'^idi'd ill Sail Fi oii( isci) i 'Win 



i M.nilh^ 



lhi\ 



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



Former or 

Usual Residence ................. 

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



How long at 

Place of Death ? Days 



TM1-: AIIOVK STATKI) I'KKSONAI, 1- \ K r UT I.A KS A R I-! rKrK To Tm". 
HKST (II- MY K\t)\VI,HI)C. H AND nHI,Ii;K 



Infonnant ^JiXJjL Mil cU C}^w\Xt'txLi 



I'l.ACK OI" lUKIAI. OK KI;M()\AI, J DAfKot IUkiai. or KIvMoVAI, 



INDl-RTAKKK dU 'OXcL.tjuL "^^V^ 



(Address 



SHb ^jlV'Ui.^^OX. -^i.. 



N. B. F.very Item of inJoritifition •hould be cnrefully supplied. AGB should be stated F.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it m»y be properly classified. The "Special Information'* for p«r- 
son« dyin£ nway from home should be J^iven in every instance. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ll 1 



Ji<.:,r<l ; f Ht.iltl! I- V 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



K4 



Ddfr Filvil , MX(^^^^v-r^I)aAJ V\ 100\ 



Begisfered J^^'o, 



3312 



\jy' 



XJ^'U^ 




VHI 



DeDuty Hea5{*^ O^c^ r 



No. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtif icate of E)eatb 

( "CI. S. Stan^arD ) 
PLACE OF DEATH: — County ofO/CX/Vu J AXX/YVC^v^iX^O City of CjxX^'>^ JAXX/vs^^^XiXM) 

(yVrvCLoJj St.; Dist.;bet.— — and ■ ■■•■■■• ■■ ) 



\Xrr^ZA\) 



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

FULL NAME U^^'^a./OlXX.CsX' J o^l^trcu^. 



SKX 




PERSONAL AND STATISTICAL PARTICULARS 
f\ I COI.OR 




iylxOU-' 



DATK Ul- niKTU 




Ar.K 




Month) 



n 



J -.a 



SIXC. I.K. MARKII'tn. 
WIDnWKD OK I)I\'( )K(' K D 

I Wi itr i II soiMiiI tUni j^iijitioii ) 



JUKPHPhAOK 
(Statt* or Country^ 




n 

Day) 



M.mtht 



'VvvX'Ct 



:/l1..b 

(Yt-ar) 



Da vs 



WWV. OI- 
FATHKR 



HIKTHP1<A*.'K 
OI" FATHKK 
'Statf or Countrv 



MAIDKN NAMi; 
OI M()TH1;K 



lUR rmM.AOK 

OI" MoTHKR 
(Stale or Oountrv* 



OCCITATION 




|X<XV > V 



\ 



Ucv.- 



AVClX/vu 



(^ 




MEDICAL CERTIFICATE OF DEATH 



DATK <>}•■ I)1;a TH 



ia< 



(Month) 



%.% 

(Day> 



(Year) 



I inCRHHV CKRTIFV, Tliat I attcnilcd (leceasc<l from 

m\^^ lb 190M to \rUv-...a3» T<)oH 

tliat I last saw li -'- "■ alivt- on \'^'0V" %0 190^ 

ami that death occurred, on the date stated ahove, at "J 
(-1 -^r. The CAlSli OI- DFvATII uas as follows: 
^^-VCV- J. Ji_\>X>V , 



^J 




DrR.xriON )'t'ars 1 .Vou//is 
C N T k I BT T R \' ............. 



Dmfs 



Hours 



rcr<xo 




Months ^ Days 
Cl 

\\\^\T %% T<,oS (.\d.lresv,) HOb 



Dl'RATION Years 

(Signed) J VJV. 



Hours 




dxctiiLv ^t 



M.D. 



Special Information only for Hospitdis, institutions, fransifnts, 

or Recent Residents, and persons dyiny away from home. 



Re^^lded ni Sav Fi iUtrf^ro " )V<;/c *" !/.<////> 



/i,/i 



rm: ahovk sr\'n'i) i»kksonai, rAKTicri.xKs aki: tkik r<> Tin-: 

1U';ST Ol-^ MV KNOW I.ICIX.KANl) HIvI.n.K 
tifoMi.ant >VAXXAV J '<XX/1><\^ 



fl 



(Address I (d 




f^X 



tls. 



Former or 
Usual Residence 

When was disease cont^ted, 
If not at place of deatti ? 



\'X ya oR^^v 3 1 



How lonq at 
Place of Dcalfi? 



Days 



PI,ACK <)1" lUKIAI. OR RKMoXKl, I DAI'JLof Mikiai. or RKMOVAI. 



^ SOS 



(.Adduss 



\jrt(rv-ctou 



^rv-wL' 



':! 



a 



'\.yJL. 



oi Information .hould be cr-cfully Hupplled. AdB «houlcl be stated EXACTLY PHY8ICIAN8 should 
E OF DEATH In plain terms, that It may be properly clo.shleU. The Special Information" for p^r- 



N. B.^— Rvery Item 

state CAUSE ,. __ 

«on« dylnft away from home should be ifciven in every instance. 






I 



)i 1 



f 1 



: 



WRITE PLAINLY WITH UNFADING INK — 



^ ^^zi!y^^ ,,c i> (• 



/>/f//^' Fi/r(f, 




X\ 



100 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

8313 



Be^/\s/ered J\^o. 





Deputy r^eal.h Officer 



t 



cMrV^A^ dvJlAH^ i-»cH«^y "»-'"-" ^"•^~' 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^ 

J A 



Certificate of IDeatb 

( XX. S. Stani>arD ) 
PLACE OF DEATH: — County of^'^^C^^ 0^^^^^^^^ City ofO^v^^ J .Vc^-^^.^^^^ 

NC^O YV\.^W^) ^^^^-^"-^W^y^^H,,.^ "^^ pfsTdENCEg.ve tacts called for under 'SPCCIAL INFORMAT.ON" \ 

( '^ r"orAT°H^OCC^%irD\;"r4oS^.V.'.L o"R't;^T^^^^O^/a.VE .TS NAME ..STEAD OF STREET AND NUMBER. J 



FULL NAME 



TU^">'^-:OwA 




>i;\ 



PERSONAL AND STATISTICAL PARTICULARS 




f\- 



DAll-: «»t HI Kill 



AC. l' 





'V.*^ 



U 






5n 



)■»•<»/ 



15. 

(Day) 



Mn},lll> ^ I 



(Yt-ar) 



/><n,N 



SINC.Ij:. MAKKIi:i). 

\\ii)()\vh:i) «)K iM\'<»K*.'j-;r) 



HiK TurhAoi-: 

(St;itr or Cotiiitrv) 



XAMl-: (>I 

FA Til );k 



niRTiirt.ArK 
oi' iAini-:K 

iSl.itf or Couiitt y^ 



mait)i:n namk 

Ol- MOTIIlvR 



lURTIIlM.ACK 
<)I- MoTUKK 
(Slate or Country » 







OCCUPATION 






Da V 



TMK AHOVKSTATKDPKKSONAI, rAKTI;ri.AKSAKi;TKI-K To TMl- 
in: ST OI" MY KNOWIJ'.IX.K AND Hl-.I.ll-.h 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DI-.ATH (\ ^ || 



(Month) (Day) 



(Year) 



I invRI^nV CF;RTn*V, Tlutt I :ittcn<lc(l (lecease<t from 

— — 190 to ~~~" ~ Tip 

thai I last saw h alive on — - " ^190 

and tliat <Kat]i occurred, on the «latc stated above, at 
-: — M. '11k- CAI si-: OI' DivX'I'lI was as follows: 

VTVULrvx^A'v.Ov-X'oJw 'vA.iv.tjLW ......... 

DT RAT ION ^ o^'^n -^^'"'^^'^ 



DURATION 




(Signed) X^tsX^yxXs 



^Tonths 



hay. 



^ ?,(EU].Ua..^ 



Xl I<>oM ( 



Hours 
M.D. 



Special information on'y ''"^ Hospitals, lnstilutlb'*s, Transients, 
or Recent Residents, and persons dying and) from home. 



Former or ^^^^^^ 



Usual Residence 

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



M^v^(j>\ 



4 , How long at 



Piareof Death? 



Days 



I'l.ACK OF m KI^\U OK KF.MoV.M, j I)\^F;o; Hrui.M. or K1-:M()VAI. 




t^ 



\XAA <\XX^^\^t^ 




(Address ^Hb Qf>Vv<i^Cfr■y^; cSt 



.ilv 



N. B.- 



^ , .. ,. , A (IF. «hoiil.I be Htatecl EXACTLY. PHYSICIANS should 

-F.very Item of information should be cnrc.ully «uppl.cd. ^ f- '^^7;^;.^.,^. The "SpeclBl Information" for pr- 
•tate CAUSr OF DEATH In plain tcrm«, tha .t may be P'--nj'"> 
.<on. dyinft away from home Hhoulcl be ftiven m every instance. 



i \ 



V 

I X 



T 



I :| 



«3 i 



ii 



'.I. 

1: 



l!,.anl I'f lltalth l" Vo 



I)(f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE F OR INSTRUCTIONS 

3314 






A 



/r /-V/f'^/Al\.Cv>X."mJl^v X^ 190": 



Registered ■jYo. 




A^j^ da.^>v^. Deputy (fealth OfHccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 



( XI. S. StanCarD ) 






No. 



PLACE OF DEATH: — County of O^Xa^ ^ Sx^ty^^aa^'o City of O.CC'^^' J/v<uvvca^^ 
/cLkJI/^^ Ob ChUvU^oJI' St.; — ^rr Dist.; bet. --:---——--:——-- and - ..;^. 

, = ...,«v W = nM ll«;iJAL RESIDENCE GIVE FACTS CALLED rOR UNDCn SPECIAL I N FO R M ATI O N" A 

( '^ rF"o;':TH'oCC^%rEr.'"rHo''s^Pa"AL O "N?n?J;'o^'o,V. .TS NAME ..STEAO OF STREET A.O NUMBER. ; 




FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




KXA^V^ 




ylxyCix 



1» \l"l-" (>!• Ill Kill 



AC.F, 



U 



(Month) 



iq 



} V (/ ; A 



1^\ 

(Day) 



.1/.. »////.' 



An 5 

(Year) 






/>(/ r.v 



SINt.l.I-:. MAKKII-.I) 

\\ii)(i\\"i:i) OK nivoRrKi) 

tW'ritfiii uncial dc^ij-'iiat i<m) 



HlKrillM.ACl-", 
i State or (,'ountrv) 




VouVvoLci 



\AMi-: ()i 
FA Tin: K 



^ 







lUK rUPI.ACK 

oi- i-ati!f;k 

i state or Coiiiiti y) 




MAinKN XAMK 

oi" m'>thi:r 



niKTIIl'I.ACK 
OI- MOTHI'IK 
'Slate or Ct>\intry) 




KJJ M.xtr'V'K 

JLi/0 



OCCUPATION 

RfsiilrJ ill Sail Fiiiin ism 



MEDICAL CERTIFICATE OF DEATH 

DATI-: OI" I)1:A III 

11 

(Day) 




(Mouth) 



IQO 

(Year) 



I fn':Ri:F?V CI;RTII""'V. Tlmt r attendcil deceased from 

0\xv\r I 190H to Ql^nr 11 icpH 

that I last ^a\v liXh.- alive on \lX<5\^ 0.0. t^ 

and that diath orriirre<l, oil the date stated above, at 11 oO 



1 I I ' t 

Cj M. The C.\rSl{ UV I) 1: A Til \va>^ as follows: 



- ft-. - ••'■■•• "•— ; 

DIRATION Years ' Months /hivs //ours 

(.'ON '1" 1^ 1 1 u ■ T ( ) R \' C JA^^^X<i.^-4ir;>;v<aX.. . J kCwL^ 



or RATION 
(SIGNED) 

z\r 0:x. T()n^ 




)'i-ars Months 



/hrvs 



flours 
M.D. 



( 



\ d d n ■ < s ) H^aXc'JU AV& ob ^^\^L<X-i(■ 



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



Former or n a "Vi ~^\\ ^"^ '•'"^ ^' 'n ^ 
iicii:ii Ppdrfpnrf lO 1 CiXCL/>AA-t<v>vi CjI PJare of Deatti? ^^ 



','in < O 



}r,<iitii' 



/hn. 



TIM- MtOVESTATKDl'KKSONAI. I'XKTU'l-I.AKS AKi: TKIK To TFI1<; 
linST OI-" MY K NOW 1,1; IX '.H AM) IU-.l,Ihl- 

(Infonnant 



-ess LcjLi (2).^^^aXcL^>VC^ 




When was disease contracted, \W ^ ^ J ^ (f ,4. 
If not at place of death ? \l ' t<V>vv.La. VJ. •, aJ- 



Days 



IM VCK OI- IHRIM. ok KKMOVAI. DAIU^ ot Mikiai. or kKMO\AI. 
rA.l.hess XioCsb \Jl\v.-ClA^<rY^ *jt 



■■■■"■■■ ,, , ^rt-' »^r...lrl he Rtnted liXACTLY. PHYSICIANS should 

N. B.— P;very Item of Information «houlcl be cnrcfuHy Hupplled ^^^^;;;j7;j'^,^^^^^^^^ ..Special Information" for pr- 

•tatc CAUSE OF DEATH in plain terms, that it may be properly ciaHsmca. 
Aons clylnft away from home nhould be ftiven in every Instance. 



I 'H 





I 



.1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.u.inl Mf Health- I-' No. i^ -"'^^r''^' H-*^'' ^''> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begl.sfcred J\^o, 



3315 



Diffe /'V/fv/,y\,c\MyY>^i^ XS l'^0\ 

.^ucv:^ dOAMJ ' f..t-.ty. Health. Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( H. S. Stan^ai^ ) 

ClcL 1 V 0.\xx.->vcv^.c< Citv of Ocxr^\) 0^^ 



PLACE OF DEATH: — County of 



^\<Xy-wcvM.c<. City of U/CX^\; 0^\.a.AX<M^Ct' 



;No. ^5 5 Vj>-<dj. St.; X Dist.;bet. 




^^^xj and 




a^vd^ 



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



FULL NAME 




Q! 



iQJ\K.UL. 



I Q % 



A.<^VAry\i. 



01, OR \ \ 



PERSONAL AND STATISTICAL PARTICULARS 

DAT!-: nl- ntKllI 

- axkt 

1 MoiAh) 

O 0*» ) I'll I > -^ 



15 

(Day) 



(Year) 



M.^titln 



w 



/)(IV^ 



WIIX »\\l-:i) OK DIVoKi'l!!) 
iWritiiu '^(H-ial (Usi^Miatii'ii) 




luk rm'i.ArH 

1 stall- or Country^ 







xAMr: o}' 

\- A l" 1 1 H R 



L 




MEDICAL CERTIFICATE OF DEATH 



nAri<: cu' diiaiii 



fXtjV- a<:l. ipn'i 



(Month) 



n 



(Year) 
I HHRI'iHV CI'IRTIP'V, That I atteiKkMl deceased from 

ID/ttj iH i9gh to ....0'v<j\^ a,"i ..190H 

that I last saw h a-^x aHve on \fX^\r %'^ ujoH 

and that death occurred, on the dale stated al)ove, at *" 
^ M. The CArSl<: OI- DI-ATIl^was as follows 



.'^.^^ULsxjiJL 






MAIDI-.N NAMK 
Ol- MOTHKR 



Ol- MO'I'UlvK 
(Statf or Country) 



\jy^^oJL<X/y\jd^ 



I) r RAT I ON }>ars Months Days 

CONTRIIU'TURV LL' 



yVv.<XA««»«^5Mg^SM^ 



^•»*«j«4t«a«*aiir>r* 



DURATION 
(SIG 



)'riirs 



AfoHt/is 



Days 



NED) U) . MHVicA^ilAA 

[dli instil 



Hours 

Hours 
M.D. 



SPECIAL INFORMATION onlv for Hospltdlii, Institutions, Transients, 
or Recent Residents, and persons dying dwa> from fiome. 



OCCri'ATION (JjV) A A 



M, :11th' 



fhi 



VnV AUOVK STATI'I) PKRSONAI, t'A Kl IC f l.A k S A K I". PRt IC To TIDv 
lilvST OF MY KNOVVI.I.IX.K AND lll-.Ml.F 



(Info: man t 



Vj . ^0. vjW\>-UvU 



S^UKU^^laKXax >0//cJkX(X/^vxi. 



-\aKXax 



Former or 
Usual Residence 

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



tfow lonq at 

Place of Death? Days 




H 01 IM RIAF. ok k»,Mo\ \1, 



i-_jjrkiAr. ok k»,N 



INDKRTAKKR \J^ • UJ - Vl iXoLAJI 



OVri: of lit KiAi. or RICMOYAl, 






fA<l<lrcss 



?>ia 0' T<x.vxJI ;k 



N. B. F.very Item o? !n?orin«tlon should be cnrotfully HuppUeci. AGE should be stnted F.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH mi pln'in terms, that It may be proper'y classified. The "Special Information" ?©r psr- 
sons dyinft away from home should be i^iven In myry Instance. 



I 



\V. 



WRITE PLAINLY WITH UNFADING INK 



H.wml ,:t Ilr,MMh-»- No. i^ ^'^^^nScVC 



!)((!(' Filed , 




%^ 



VJO\ 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be <:> J stored J\'o. ^^^i6 





A>^ Deputy Health OflTicer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of IDeatb 

( tl. S. Stan^ar^ ) 



^ 



PLACE OF DEATH : — County of Oo/vv J ,VXX/^%^v.^iytx: City of O/X-rx- AXca-^cca/C* 



<NoR^l Clj^^t^^.^^U. St.; b Dlst.jbet. 1?) ^vd. and 

i^U* 1 v^ 1-^ -^ V ,,c.ii«i Dr«=ir»riMrF nur FACTS CALLED FOR UNOrR SPECIAL INFORMATION 

( " r/o;:r-occ.%r„',"r„ "s""*t o""~?'tu" ""c,;";! name ....... o. ...... ... .u„=„. 






X' 



) 



FULL NAME 



Sl'.X 



DA ri-: (»i luK'ni 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR \ 




Ux. 



k; 





J,\.><,^\JO 



iM<)iUh> 



ACK 



xs 



)'l-ltl 



17 

(Day) 



.1 /,.;////> 



/%T^ 

(Vt-ar) 



11 



/)<! VJ 



SI NT. I, J- MAKKll'.n 

WIDOW 111) OK DIVoKClvD f) 



iW'ritc in s<>ci:il (ksi;.:!!;!^'!!!] 



c) 



X/>^ 



uiK iiiri.AOK 
(St:iti- <ii Coiititry) 



NAMI'". Ol- 
FA'IH ):r 



lUKTIiri.ACl-". 
Ol' I ATHl'.K 

iStiit< or ("omitt y) 



>fAinKS NAMK 
Ol- MOTHKK 



lUKTHri.Al'H 
Ol- MoTin-'.K 
(Slatf >>\ Country) 







/CX/YV vi .h^XX/>\. Cl^OCLOO 



Qf;^ 



rv<r>"vx/x-A 




,cyvy">vX 



vv cL 



IX-^ 



/et^ 






A*^ 



.'/ifr.f III Sail l'iiiihi>i'i> A^ )Vrf/ 



* 1 



A.»////v !X1 /)«n^ 



rm-* \HovK s'r\ ri:D i'kksonai, i'akiuti.xks aki-: vkvv. lo tin-: 
iJKsT Ol' MY knowi,i;d('.k and i5Ki,n;i 

ilnfonnant \Xry\y^f\J<J^ J}Ayv/>^^ 

rx.Mrcss ^3il dJLcrt^..o-cOj at 




.L«wV.Uj 



TV ex, VA^VUi . ViJ -W VO v-i 



-y 



MEDICAL CERTIFICATE OF DEATH 

DATIC Ol-* D1-:AT1I a 

M L<jvr .^H,. 



I'MontlO 



fDav) 



(Year) 



I 11IUnIU5V CiikTIl'V, Tliat I nttetiiU'il dcrcased from 

JUJLO U ic)o3> to V^rV<3\r:.....t'^ itpS 

CK.^^ 1% 



i9o3> 

tliMt I last saw li ..v.vvvalive on VrUJV^ 1% icjoH 

aii<l that (U-ath occurred, oti the <latr statcil above, at 
M. The CATSI-: Ol' DMA 111 was as follows 



coNTkir.i rouv 



Pars 



I lours 




Dl'RATlON Years X Mouths 



/hi vs. ....■>. /Fours 

(Signed) ...........„..„.,.j^. SiJ /<xa^X^.,..:,,.„.;..=w,..,»., M . D. 

Ml«\r arronM (Arl.lres.) " ^ 0^ "^ Jt<X.\^ 'V> 



Special Information only lor Hospital 

or Recent Residents, dnd persons dyiny dv»H> Iron home. 



itals, Institutions, 



Former or 
Usual Residence 

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



HoH lunq at 
Place ot Death ? 



Transients, 



Days 



I'l.ACH OI- lUKIAl, OK KlvMoVAI, 



rNDi'KTAKKK viUrvvoJixxxyvv \J OvQoAxxj 



DATIvot Hi KIM. *.i kl-:MoVAl, 



N. B.- 



-Bvery Item o? information .houlcl l>e cnrcfully -uppllc.l. A(;K «h«ul.l »'« •'V'''l'''^..«^'^ V*. . ?*''*"!l"'^.'*, "*'^"'** 
Mate CAimE OF DEATH In ph.ln term., that It m,.y be properly cla-ifled. The "Special Information for pr- 
«on» dylnft away from home nhoiild he 4lven in avery Imitance. 



-I M 



<lj 



(( 



l:; i 






Ur ' 



, I 






WRITE PLAINLY WITH UNFADING INK — 



Hnanl «»f Health- I" No. !^ ^'"LI^l.T* '*^l' ^*" 



/^//r /'V/r^/. \j\.cv-t'-r'>AjLvJc\' Q..^ 



VJCi 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

3317 



Re^i:^tei'C(l J\^o, 



.^VKJ<.^ 




'"V 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( H. S. StanOarD ) 

4 OS? -^ ^ 

PLACE OF DEATH: — County of 0<Xav JA.O^vc^4.ct City oiO<Xrr^j OX<Xav<m^cc 



,Q 



^, 



No. n MJa.>\>-»v<X/^-v VJAO^^U. St.; 1 Dist.;bct. dXXJL/>A. 



1 

and ^ 



I 



>V^^C"yv 



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



fU 



FULL NAME >1HJ^\.W'^ax 




A^CO.^^ 




<Xj 






PERSONAL AND STATISTICAL PARTICULARS 

ft I COI.OR 



MEDICAL CERTIFICATE OF DEATH 



DAT1-: t>F ItlKTIl 



bo 



y\ 



(Ntoiith) 



(Day) 



(Year) 



AC.K 



)'rat . 



M,'uf/i> 



Da 1 



SIN(.1,K. MARKIKI). 

winnwKi) OK i)ivoKCi-;n 

(Write in social (Ksiv'iiati<Hi> 



niRTHPI.AOR 
(State or Country"' 




FATHKR 4^ I 



' 



KIKriIlM.ACK 

oi- j-atiii:r 

(State or Co\uitiy> 



MAI1)1;N NAMK 
(»!• MOTHKR 



lURTIiri.ArK 
()J- MOl'HKR 
(State or Coiiiitry) 




CHi. 






i') 




OCCUPATION A 



/iiiyj 



TUl" MIOVK ST\Ti:i) rKRSONAI, rARTUlLARS AK1-: TRl K To IHI-; 
HKST Ol' MY KNoWIJ'.nC.K AND MKMKF 

(Informant UwV/CJLO^ VXXwATV/^'VaJLo 



(AiMrcss 



DATE OK DKATH A 

\JW IH ........... 



(Month) 



(Dtty) 



(Year) 



I lIlvRfCP.V CI'RTIFV, That T attended <leceascMl from 

VTUv^ aa 190H to \fi<i\r. X'L......,..,«^i90 H.. 

that I hist saw h A,\v alive on vVV^V^ %'h 190 ""l 
and that doath occurred, on the date stated aliove, at ^ 
lI M. The CAlSIv i)\' DI-ATIl was as follows: 

vJj.Axr^rv/e^lvAXv-0 



DT RATION )V«^ J/o////is Ifays Hours 

CONTRIBUTORY .\j..A^\X.S^<U^s^. 



I )r RATION Yiai'S Months ?^ Pays 

(SIGNED) ...Uj\<X^,h \|i\,..jW<s^JLtx 

._■? " 



(JV" XH TQO^ (A<hlrcss) ^Ot) cLU)wAK.-yxA^v-& 



Hours 
M.D. 



Special information only (or Hospitdls, Institutions, Transients, 
or Recent Residents, and persons dying dwav from home. 



Former or 
Usual Residence 

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



How lonq at 

Plare of Death? Days 



I'l.At^^K Ol" HIRIAI. OR RKMUVAI. 



DAlHoJ J«t KIAI. or RKM()\AI, 



CK Ol" HIRIAI, < 

'5A-<xXa./cv. 

INDKKTAKKK V/OJLeyvCtx NmUxXa^^VJ ^^ L^ 
(Address ^5^"^. Q Xft^cJkX^'^N- .1 



IM. B. Every Item of Information •houltl be corefully Hupplled. AUB •houlcl be utatecl EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In pinin terms, that It may be properly classified. The "Special Information" far psr- 
sons dyln^ away from home ithould be it'^en i" every Instance. 









'r 



Mil 



"f 



WRITE PLAINLY WITH UNFADING INK — 



Hoanl of lliallh I' No i =^ **^^;^ Hft i' Co 



Dff/c Fi/r(/ ,\f\j^^^i/ry-d>V\j IS l^^OH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Ilro^Lstered A^o. 3318 




\.cvA 




\vM Deputy Health Officer 



1 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Bcatb 

( XX. S. StauDarD ) 
PLACE OF DEATH: — County ofOOA^ .^UXy^vcv^-ccCity ofCJXVYv ^ \<Xyyy^^J!L^^ 
No 5l5 Vv^M^ St.; 10 Dist;bet. MUK; -.-..« and VXVA'Uv^ 

U .F deathWccurs away from usual residence give facts called for under "special information- \ 

( IF DEAiH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

^XKjYxnwX cU/OjWcLvLC: 



) 



FULL NAME 







SHX 



PERSONAL AND STATISTICAL PARTICULARS 

COI,<)R 





XC 



u. 



I>ATK «)l- lUK IH 




Month) 



(Day) 



(Year) 



AC.K 



-&jtJl(B 



) I'll I . 



Months *. Days 



STVf.I.K. MARKIKn. 

wrDowi'iK OK i)iv<>Krj<:i) 



I-Aywo. 



TURTTIPT.ArK 

I State or Country I 



-? 



^ 




NAM!-; (H* 

i-athi:r 








-CL/\r\xL^(rYv_ 



lUKTHn.ACK 
(>|- lAl'UKK 
(State or Country) 




MAIDl-.N NAMK 
()1 MOTIIKK 



lUK THI'I.ACK 
oi" MOTHHR 
(State or Country) 







MEDICAL CERTIFICATE OF DEATH 



DATK t)H DHATII fV^ 



an 

(Day) 



(Year) 



(Month) 
I mCRHBY CHRTIFV, That I attendod deceased from 

/k.'X i9o'l to \S\fS\r a.H T90H 

that T last saw h. alive on '~ - 190 - 

and that death occurred, on the <h»te stated above, at A 
Cl M. The CArSn OF I)I:ATH was as follows: 

oXvXJl Uj &VVV.. duuxw^L ^txl; Jcrs-^jL.k 

Xv<vJLX tx\/>vu .cJlvs^LcL........ 



or RAT ION ^^- )'ears 
CONTRIin'TORY 



Mont /is 



Days 



I lour. 



DrRATIOX 



(SIGNED) 



)'cays 



l/ofiths 



v£)Jl\AAXX/>>\; ai^^rn^ 



Days 



Hours 



OCCUPATION 

Rfsiiifii ill Sun /'id IK I MO 



)'iUt I . 



M.xilhs 



na\. 



rilK \noVRSTATKl) PKRSONAI, rAKTIClI.ARS ARi; TRIK TO TUlC 
IJKST Ol" Mi^NOWI.KIX.K AM) lUCMKF 

nformant J AOUvUK Cd oU /CLA^-VxL^L^TVu 



(I 



(Address .... 



5%s 



.^AX^a, 



dt 



•w 



f^_. 



3.1 loo'l (Addre'^s)V^.^Cr>\l^ 



Lou<Jtrv<5 V 



M.D. 



IKu 



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



^ 



Former or 
Usual Residence 



How long at 

Place of Death? Days 



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



PI.ACH OK 



lAI, OR RKMOVAI, I DA PK of HfRiAl. or RHMOVAI, 

vVujxr at 




.QOOi; IL^XoxK^ I v»v^ '^b 190M 

INDHRTAKKR y&A^^/>>Jkx\^^^^ cXxA^^^t 

ess Abiofe MTtc^^^^s-^rrv ut 



(Ad<lre< 






N. B. Every Item o? Information should be carefully nupplled. AGE should bo stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information'* f«r^ per- 
sons dyln^ away from home should be g^iven In every Instance. 



%; 
S 



I 



^i 



SJ 



\ 










WRITE PLAINLY WITH UNFADING INK 



!;..ar.l ..f !l,:iltli I' N(^ '= t-^'^!S?^ USc V C , 




Dfffr /v7r^/, VrLcxN^^vlvJLh^^ 15" 



cL^VcU^ 



IfJOH 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

tr,i 1 9 



Re^islrrcd Xo. 




^.^ Deputy ^leafth 0«Tfcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 

( tl. S. StanDarD ) 



• 4 ^ i ^ 

OF DEATH: — County of U OL^^v vJ XXXA^Cvx^^ City of O lX/Vu . VcXAvOL<i^<^o 



No. 



PLACE 

Lc. ^k^-^WO^-aA: St.; 

/ IF Dt«TH OCPURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER " SPECIAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 




— Dist.; bet. 



and 



FULL NAME 




^ 



PERSONAL AND STATISTICAL PARTICULARS 

DAI'K <)1" I'.IK I'll \K\ 

J^lr a /Ua 



.1 




,\.C 



kJb 



AGK 



CT^ CN 



)'ran> 



(D.iv 



.}/,■>!///> 



n 



(Year) 



Da 1 



siN«-. i,K. M.\Run:i) 

\\ iDowi-:!) OK i)ivoKri;i) 

iW'rit' in -(Kiitl dt-si^'iiat ioii ) 



Hiurni'LACK 

( Stalt or (."oujitrv^ 



fathi:r 



lURIIIPI.ArK 
Ol lAlUKK 
'Statf or Ci)iiiitryl 




MEDICAL C ERTIF ICATE OF DEATH 

DAPH OK DHA in f\ 

Xi 



Mltv _, 

(Month) 



(Day) (Year) 



I ni-:Ri;HV CICRTIFV, That T attended deceased from 

U^ '61 1 90 H........ to Qftcvr Xii 190 H 

til at I last saw h -C'»\ alive on \h-Cvr O^t 190 H 

and that death occurred, on the date stated above, at L. 
M. The CAl'S^: OF DKATTT \vas as follows 



O vC^^-^C . . . J-j^a.sJL\;. 



nr RATION }>ars Months %\ Days /fonts 

CONTRIBUTOR V 



««4-*«^p*«*f4a«**4i«aa»«*' 



MAIDKN NAME 
01 MOTIIKR 



lURTHri.ACK 
OI- MoTlUvR 
(State or Country) 



occ 






>LKJL/vy\>o^^vv) 

Rfsiiin! in Stut /'i din i.^t'D 



)', fi I V ( Month' 



/)<iv> 



THI-, \HOVK STATIU) I'HRSONAl. rARlUT I.ARS AKI", TRIIC To TUl-; 
Ui:ST OI" MY KN()\VI,i:i)(".K AM) lU'lMHK 



(liifoiniant 



^.a.a 



vLAA^^VVO 



(Address .... 



a.\J. Cc> fo (H^'LU^d) 



I ) r R A T K )N - } 'rai'S -.m. - Months 

^ ( 



Pays 



) rars ...^. , 

(SIGNED) U- sj. Mb;_ . 

mUv- ai rooi (A<idr..ss) .M. U, Ol:}^4v^.Ui 



/lours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyiny d^ny from home. 



Former or ( k \{\ 

Usual Residence M UL VU. ^ Ltf 

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



\r 



How lonq at 
Place of Death ? 



Days 



ri,ACK OI- lURIAI. OK RKMOVAI, I DALj; of niKi.Ar, or KI-IMOVAI, 

(LJa/v^ £l<v^ioJ^ CawaA ^"^-^ ^5 '90H 

rVDKRTAKKR {/U oJlAtX^l. M.L^ 

(Address ^.H.b M Ytui,^4.A.>CrrV • O.t. 



IS. B. Every Item of inf.irmatlon should be cnrefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for psr- 
sons dyin^ away from home should be i^iven in n\9T-^ Instance. 






A 



M 



* w 

•7'^ 



;l 



t 



11 



^^iiMiilittlliiliiu^ 












t 



N 

II 
If 



1 

I 



5 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Ihf/r ri/(>f/,\pL 



<jv^-<IyY>v 



Lov 



a5 If^OH 



Registered JVo. 



3320 




DeD 



V. Ci 



?th Offices- 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiftcatc of Bcatb 

( TH. S. StanDar& ) 

4 OS? J? 

Oa^cl/vv^ca^^ CO City of ^ 



.^ 






PLACE OF DEATH; — County ofU/Oyrv^ OA.ay>^/^o:i.c<o City 
No. l^H^ OcWc^^\a» St.; i Dist.;bct. 5.A^<i> and %K0<.- 

(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 LcL.-k:Y..cv du. VJAJUL/TXA^trOcl 



PERSONAL AND STATISTICAL PARTICULARS 

i COJ.OR 



i).\ri; oi lUKTM 




iXK, 



Xaj 




MEDICAL CERTIFICATE OF DEATH 



DATK ()1* i)i;ath C\ 

yUr 



(Month) 



ACH 



) '/•<; » >■ 



(Day) 



^f.'UlllS 



vni 

(Vear) 



11 



Da r.v 



•^INi.Mv MAKKlIvI), 
WllXiWKI) OK DlVORtHI) 
iWiittiu social (IcsiKnatioii) 




IJIRTHPI.ACR 
'State or CoHntry'* 



NAMl". (^r' 

!• atiii:k 



MIKlinM.ArK 

Ol' !ArMi:K 

< stall- or CcuMitlj') 



maidhn nami-. 
'»!• mothi:r 



lUKTIiri.ACK 
«)!• MorHKR 
(Slatf or Country) 







A,^. 




OVH 



aa... 

(Day) 



(Year) 



I nivRI'BY CKRTIFY, That I attended deceased from 

lb igoH. to hWt .3.2) npH 

that I last saw h ^i-N alive on XTUlxr 7s^ ic)o'\ 

and that death occurred, on the date stated al)ove, at ^«l. 



aim 



M. The CAIS1<: Ol- I) I! A Til was as follows 



DT RAT ION )Vtfr.? 

CONTRIIUTORV 




Mont /is \ /)ays 




Hours 

.^.C 



DURATION 



)'ears^ 



Mouths 



\| rUuvx^txAJlX Jul 






1 



Rfsi'dfd ill S,in I'nuiiisrn ^D. JV'ar.f 1 Moxtli^ I \ Da\$ 



(SIG 

A 



NED) M Jk/uLdo) \jAj.. \ i^^zJi^ 



Days 






I fours 



M.D. 



VJUv'^^'i Tc,oH (Address) 1^*^ J 0-LcUrv>v O t 



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



Former or 
Usual Residence 



How long at 

Place of Oeatli? Days 



rm: miovk staii: d im'Ksonai, rAUTicn.AKs aki-; tkik to thi: 
Hi;sT Ol" Mv KNo\\i,i;i)c. K AM) in;i.ii;F 

u.idifSH toi^ vl o^L<L<rv>v ox 



(ii 



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



J'l.ACH Ol' HIKIAI, OK^ kHMoVAI, | DATJvof IMhiai, orRKMOVAI, 



M T\xX\AA-o-uLa, v-o^JU 



UNDlvRTAKHR 






T90 



IN. K. P.very Item of Information shoult! he cnrefully Hupplied. A(]K nhoulil be Htnteil EXACTLY. PHYSICIANS iihould 

Htate CAUSE OF DEATH in pltiin termw, that it may he properly clanHified. The "Special Information" for p«r- 
nons dyin^ away from homo hIiouUI he fliven in every instance. 



W^ 



% I 

l 






m 



Iv-'T 



f 



I t 



i 



Ki 



1 



r 



U 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



)!. ..ir.l nf Il.alth \- No. !' **^l3^; HS.1' C 



Dfffr /vVr^/, \h^^I\^JL/vnJUt' 



\) xs 



lOO'i 



Megistcred J\^o. 



oo^i 




?auf- 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of IDeatb 



( tl. S. StanOarO ) 



(^ 



'No. 



PLACE OF DEATH: — County ofOoyTV AXL/YU:.c,icc City of-Cj<iL/>v J A.xX/-n.xxA-c^ 
^ "^^ J I- 'If 



AvJj vvc^^v. St.; 



Dist.; bet. -■ ' i- 



and 



(ir DEATH OCCURS aw/y FROM U^SUAL RESIDENCE give facts called for under "special information- "\ 
IF death OCCURREb IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




dlKXcl- 




PERSONAL AND STATISTICAL PARTICULARS 






COLOR 




(yiJ^ 



MEDICAL CERTIFICATE OF DEATH 



D.A TK Ol- DKATH A 

vW 



I) Al'J". < >l- IlIK I'll 






(UayJ 



(Year) 



\c.K 



) 'tit I > 



x 



M.»ilhs 



% 



n,i vs 



siNt.i.i-:. M\Ki<ii:i). 
wrnow i>:i) ok i)i\oKri:n 

(Wiitciii sfM-iiil (l(>iij.'n;it iiiii) 



UIRTHPI,.%C*K 

(Slatf (ir Country'* 



N'.AMK OI' 
F.\TH]:R 



Oj<yy\^oXX 



? 



(Mf)iitli) 



3.0 

(Day) 



(Year) 



I HHRICHY CI'RTirV, That I atton.k'.l deceased from 

ID.^ l.^ I90.H to QX^TJ- . a.O jgo'i 

that I last saw h -»^*^ alive on •.--. ,\rV_^V SIC loo H 

and that death occurred, on the <late stated al)ove, at 
-^•-- M. The CAT Si-: OV Dl'ATIl was as follows: 

xnYxx^xxxA/vrtouo 



HIKTnrT.ACK 

OI" j'\rm-:K 

i'St;it<- or Coiinli v) 



MA!!)1*>J XAMI* 
OI- .MOTni';R 



MTK'IHI'I.ACR 

OI" MoTMKR 

(Statf or Country) Jr 



? 



JO 



DIRATION )'(<irs l Month\ Days 



Hours 



CONTKIIU'TORY 





OCCUP.ATION 



1)1' RAT I OX .|1?<7ri AfoHt/is Days 

(SIGNED) mTi. 3. vn^uxWA^aii 



Hours 
M.D. 



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



Kt'sidfii ill SiDi /'i (l)li ;m-ii 



)'ifii , 



.1Am.'///« 



/),n 



Former or 

Isual Residence 

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



How lonq at 

Place of Deatli? 4'"i Days 



TUH AHOVK srAII'",!) rKRSONAI, I'AK lUri.AKS A K !■: rKD". TO rui-: 

iJicsT OI" .MY KNo\vi,i:i)C.H AM) iu:i,n:i'" 



(Infoiujant 



^jVVvi y6.^A.'>^JK 



(Address .. 



ioSX CJ/CLAA/ 




PI^CK OI" lURIAKOK KKMOVAI. j nvriv of HiRiAL or RKMOV.\I, 




CNDHRTAKKR UAyCL-L'VV.' 



a^ 






190H 



O 



N. B. F.very Item of Jnformntlon fihouYcl be cnrefully supplied. A(IE Hhoulcl be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for p«p- 
snns dyinft away from home should be ti;iven in every instance. 



n 



11 r 






1 



It 



IT iiiii'fiiiiiiitirtfciiliinii-ii 



Iif»^ 



ij I 



I 



III 



H i 



I 



*.♦ 



L-. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



l!.-:.i<l .,f H.:i!t); I- V;). ;; ■^•?- '-r-'^ki I'.iSc I* Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)ff/t' Filed ^ 




^?r 



ioo\ 



^^KJ^AJ^ 'XXAXJ ..4^^'>: * 



Registered JS^o, 



3322 I 



?v 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( XX. S. Stan&ar? ) 



N< 



PLACE OF DEATH: — County of Ocu^ru JAxx^^xc\.Ac<City ofCJ/CX/^r\j J Axx-^yvccXI^m 



VJy>xt 




and 



'Y>.\JlA-C\X'->-^CA.^. Ob MsllOi.vXoLi. Dist.;bct. 

DC*TH OCCURS A^AY FROM USUAL R E S I 6 E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURrtJCD IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME ^Vtr:.V:^.a:^r i h mJox^.. 



PERSONAL AND STATISTICAL PARTICULARS 







MEDICAL CERTIFICATE OF DEATH 



>};\ 



QfKc^L 



COI.OR \ ^ pj 



j DATK OF DKATIl A 

va^iv-. 



I»AT1-: ul- IHRTH 



AC.K 




(Month) 



(Day) 



(Year) 



(Month) 



(Day) 



(Year) 



CS. I J I'll I > 



M..>ilfis 



\\ 



Da » .• 



SINT.I.K MAKKIKI) 
\Vri)(»\\KI> <»K I)!\(»KCi:i) 
'Write in MK-i.il dt ^.i^^iiation) 



mkini'i.AOi? n 

tlitate or Cmuitry ) J/ 






I HI'iRHHV CICRTIKV, That I atten.kMl .Icceased from 



190 



"•)^« • "..Igo 

that I last saw h alive on „■...,...:.„,.. 'x....iA.i igo 

and that death occiirreil, oti the date stated above, at ~— : 



M. The CAISIC pF ^)i:ATn was as follows: 




XAMI-: <)I- 
FA TMI'.K 



JUKTlin.ArH 
<>l- lAlMKR 

(Stiitf or Conntrv) 






Hours 






Days 



CONTRIIU'T(1RY 



...,...4i^»V*.,.r**-*«#»#*t-***Mi«***Ml*»»#«*«**«»«»,.*,» 



maii)j;n xamk /s 



--- M I Uxw dbcryv'vUA,. 

HIKTm'UAl'H r 

OI- MOTIIHR Q U 

(State or Cojintry) Jif ' 

DCCUPATION/O ± 

Rr>idfd ill Sail I't am isiui J^'\ Yrai^ 



DTRATION 



Years 



Mouths 






/?^/ v.? 



( SIGNED ),L^(r>\jJ\/J.^J). IJU. cU^lou^v^ 
VTuiXr "^^ IQO H (Address) \Jti\Jt5'\\JL'^,^ 




I fours 

MD. 




Moiittn 



Pit 



rgo'l (Address) Vgur-tAjciV^ N^4..fA.-CLJL 

Special Information wly for Hospitals, lnstitutLl»5, Transients 
or Recent Residents, and persons dying away from home. 



yH \\aaaaa>-^ 



TFii: AHOVK STATI",!) PKRSdNAI, PARIirr 1-ARS A R l-) TRTK TO TIIH 
IIKST t)|- MY KNO\VIJ-;n«".K AND HHMKF 



(In 






( \(Mress . 



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



- Days 



PLACE OF JRTRIAr, OR RFMoVAI. I D.VrF: of HfRiAi. or RKMOVAI, 



T9on 



UjLA>v<xt<)\u I ^^^^5^^ aic 



N. B. Bvery Item of Information should be carefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may he properly classified. The "Special Information** for per- 
sons dying away from home should be given in svery instance. 



y^ 



i 



- \ 



!! 



• 



V 



i: ! 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Ff7rr/\ 



^-b-lAA^ 




IS 



IfJOH 



Be^i sieved J\'*o, 



OOOO 



1 1 



Deputy Healtli OMcc- 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

PLACE OF DEATH: — County ofU/CXA-v O/vc^^-vcuicc City of C)/<X/>x^ J/vxX'-a^ca^.'C^. 



*No. 



/;di 



VX'CrW^^r^V/i; VCA_L»J.j, St.; '^-. Dist.;bet.U) a^t^O^xcAtrband V.A.Cl^ 

" / it^fkATH OCCURS AW»V FR^M USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECiML INFORMATION'* "N 
\ ^llHoEATH OCCURRED IN «( HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



oXtr.. 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

I COl.ok, 



DAT!-; <)|- lilK III QO) 



VLxllcrAX^- 



'jU 



i>!oiitli^ 




MEDICAL CERTIFICATE OF DEATH 



DATE OF dp; 



CATH (\ 

MfU 



f\r.. 

(Month) 



i\ka 

(Year) 



ACK 



O 1 )>,7;.v .. M 



M<>}tths 



IH 



/l<r r. 



sivf*.T,K. MARK n:iv 
wiix »\\ i-;i) OK i)i\'t>Krj.:i) 

(U'litciii -^oi-ial il<si;.'nat inii 



HIK THIM, \CK 

(State or CDMiitrv) 



NAMK <)I- 

I'ATH i;k 



lUKTHri.ACK 
<)l' I'AIIIl'.k 
(State or I'ouiitry) 



MAIl)i:X XAMI" 
<>I" M«)Tm:K 



lUKTHPT.ACK 
OF MOTllHK 

(State or Co>nitrv) 




(Day) 



(Year) 



»i 



^ If 



I nr^RKnV CI-RTIFV, That I atteiKled deceased from 

— to 



I90 



tliat I last saw h alive on 



190 



and that death (»ccnrred, 011 the date stated above, at 
AI. The CATSlv OF DI^ATII was as follows: 

J-<uJiM,h^/i.u'w.t.(>-aA^ 






I )r RAT ION Years 

CON T R I \\ U T O R Y 



JSiouths 



Davs 



J /ours 



OCCUPATION 



oOOJLrcj^l^v 



DTRATIOX-^ Years .^,Vont/is Days 

vrU\r ^5 Tool (.■\d.iress)ioCib O^^vtUn. e 



Hours 

M.D. 



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



r 



V 



Kfsidfil in Sou Fiamist'iy \ Z> )''iiis 



.yfotf/is ..^. /)(ns 



I'm", \HOVK STA ri: I) rKKSONAJ, rAR'riiTLAKS AKK TKIK TO fllH 
IlKST Ol- MV KNOWI,i:i)C.H ANH HI.Ml-.K 



(Iiifoi maiit 



(A<l(lrcss 






Former or 
Usual Residence 

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



How long at 

Place of Oeatli? Days 



PI.ACK <)I- HI KIAI. ok KKMoVAI, 

OiOyw Vl kaXjLo Co _ 



DATlvof MiKiAl. OT Kl^MOVAI, 



190^ 






(Address , 



N. B. livery item ni informHtion should be caru?ully supplied. A(]F> 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 dytn^ away from home should be driven in ovcry instance. 



I 



h 



I 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






i;n:ir<! .^f 111. Ith 1- V') : - t-> ■^■<^; !)& 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







■\Ay~-.>. 15 2i'6'M 



4' 



Registci-ed ■A''o. 



3324 



cL^vv,^^ kevh.^ Deputy Health Officer 



. -.f 



I !! 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( H. S. StanOarC> ) 
PLACE OF DEATH: — County ofOo^OTV A^o^^xaA^XLCx City ofCjXX/Yv \XX^\VC<^^<;ic 



'O^ St.; S Dist.; bet. 3 .\.<L 



and 



..H.lj 



/■ IF DEATH OCCUBS *WAV FROM USUAL R E S I O E N C C C I V C FACTS CALLED FOR UNDER "SPECIAL 'NFORMATION • \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



^-- ) 



FULL NAME 




AXX'^yXcLlK;. 




kXXJJL 



t 



V 



<|l 



SKX 



DAri; oj I'.IKTII 



PERSONAL AND STATISTICAL PARTICULARS 

i CGI. 





AC.K 



Month) X 



H 

(Day) 



/.^.D..H.. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DK.ATH 

\ n 

l:^... 




(Month) 



(Year) 



J V.M .V 



SINCl.K. MAKRIi:i). 
WinoWlCn OR DIVoKfKI) 

'Wiittin social lU siv^natiDn) 



IMKrul'I.AOK 
iStati' or Conntrv) 



O M.>„ths I \ 





A? r: 



.^A-vcvLi 




u 



0\^ 



I III«:RI-:BY CHRTIFY, That I attended deceased from 

1% I90H to I^^ .X3 190 H 

that I last saw h-i-> * - alive on ,,St^\^St../^'^ j^q ~. 

and that <leath occurred, on the date stated above, at li H5 
U M. The CAISJ-: OF DIvATII was as follows: 
\1SL^JUC\J>JJ .. vY)\jLo^.A>\^.<vd^^ 



.UrtsVrxAXX 



li 



NAMl- 01 ■ 

J A r n 1 : K 



HIRTMri.Ai'K 

<)I- rAPlIKR 

• state or C<juntry) 




K)xxJ\JLxxj 






DC RATION 






..•^••sal^.l^., 



M MDKN NAMK 
«H MOTHKK 



lURTHPUAOK 
Ol" MOTIIHK 
(State or Count rv) 



\ 



occri'ATiorf 

Rfsiitf<f in ^tiH Fi inii i^ro 



■<X^T\.^ OvCr^njLAXi 



\/^cj/ayY\i 




1)1 RATION 



( SIGNED ) 



Years Mont /is i *!' Pavs 




Hon 



rs 



M.D. 



VrVcrv^ ?.5 Tqo'i (A«idress) I'iOb J ouLc-vyv ai. 



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



1 '^ 

J til I s ,_> M-iiilh< \ Pii I N 



Former or 
L'sual Residence 



How long at 
Plare of Deatli ? 



Till-: AHOVH STA'n:i) I'KRSONAl, TART UT I.ARS ARi; TRTH To THK 

HHsr OF Mv kno\vij;i)<;f; and ium.ikf 



(Infoiniatit 



f ^ 3 J? « 



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



Days 



190 M 



I'l.ACK Ol- IHRIAI, OR RKMo\ \I, I DATK of HfRiAi. or RKMOVAI 
INDKRTAKKR V . VsJ - U L<r>V>V<j\; ^^ ^o 



L 



N. B. Kvery item olr inforinHt'ion should b-.- cnrefully nuppl'ied. AGE (thoulii be stutetl EXACTLY. PMY8ICIAN8 should 

state CAUSn OF DEATH in pliiin terms, that it may he properly classified. The "Special Information** for psp. 
sons dytnft away from homo Khoulil be fiiven in every instance. 



H 



I 



II 



?1 

II 



\\ '' 



i tl 



n 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ji..;inl ..f H. ;iUh- }■' Vo. !v '^'^'r^i-'v^ nScV Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



/ )(//(' FiJrd , \| L-CV-it 




/TvOLmJ 



K XS. 2^^H 



Deputy Health Offjcer 



Bcgisfer'ed J\^o. 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( "U. S. Stan^arD ) 



^B 



PLACE OF DEATH: — County of UCXnX' A^XX/^xcv-^cCity 



City of C). 



^ 



0^y\j vj AxxA^v^xi^u^ 0.-0 



■tl 






'No/^^Hi^ OAXiL'>x^^v<:J\; St.; 1 Dist.;bet.VJAX^CJl and y/C^Jrtl 

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



FULL NAME 





SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



ll 



I IcuU 



DAI1-: nl lilKllI 



LLu^i 



.UUxvlx' 



AGK 



Montli)^ 



(Day) 



(Vt'iir) 



I V )V./;a O M.'Hths SJ 



Davs 



SIN(.I,l-: MAKKIi;i) 

WIDOW }.n «»K Di\'< iK>. i;d 

(\Viit( ill stK'ial <U —ij-'iiatinii) 



I'.iK Tiiri.Aoi.: 

(Stati- <ii (.■iMiiitry^ 




?«fAMK OF 

FA Til i;r 



RIRTHIM.ACK 
OI" lArilKR 
(Statf or C<»iinti y) 



MAIDKN* NAMK 
<)J MOTUHR 







t\x/:^\A. 



medicalx:ertificate of death 

DATE OF DlvATH "^ 



w 



.cvr., 

(Month) 



(Day) 



7pO I 
(Year) 



I in{Rl':nV CI-:rTIFV, That I attctuled deceased from 

VTUvr. .^0 190 H to \jXfl>vr. X\ uyo H 

0\(^r a.H 



that I hist saw h t i alive on 



190 



lows : 



and that deatli occurred, on the date stated above, at I 

LL M. The CAl'Slvi)!' DIvATII was as foll« 



^\j:>.Jijyy:\AMi,. 



TUR'riipr.Aci-: 
»)i MoTni;k 

(state or Country) 




DTRATK^X I )\'ars 
CONTRIIU'TORY 



Mont /is 



Da vs 



Hours 



occ 



RVsidfif lit Sail /'i (7iitiM-it O v) ),-,;; Mmiths 



Hours 



DURATION ■. Years ^ Mouths Pays 

(Signed )..\j. Ob. AJLt^w.<x/>v M.D. 

nTW l^H i()oM (Address) ^'^hUaXVOoUx) Llv^-i\ 



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



/><M 



\'\\V \H()VK STATIJ) I'KRSONAI. 1' \ KTU T I.ARS .\ R I". TR IK To PIIH 

HicsT oi- Mv kno\vi.i;dc.f: and m;Mi;i' 



(Infornumt 






(A«Mrcss 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



I'l.ACK OF' IHKI.U. OK RHMOVAI, I DATIN)) Hihiai. or KF:M0VAI., 

CXjvX^ i^ccc^v I \^^^-^^ '^^ T90H 

INDFRTAKKR VA- UJ • \J IXcXAXa^/Vu ^^ 

(AUdres.s. 3»l^ 0' J-OOV^OJU. a.t 



N. B. Every Item of Information should be cnrefully nupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for psr- 
nons dyln^ away front home should be i^iven in ms^r'n instance. 



■'mmmmm^ --^nm^m^ '^ 



1 



Iv*^' 



'U 



1^ 



I 



I ; 






I 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



}l..ar(l i.r Iknlth-I- No. i =; t-^^a^^; lUSil' Co 



1 




trUw^Ci 






as IfJO^ 



Deputy Health Officer 



Registered J\'*o. 



3326 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. Stan^ar^ ) 

J? Q^ 



PLACE OF DEATH; — County of ■ '<X/'v^ Ax>./^^^m.^co City of ^^<X/y\, JX<x/^xc\^^o 






No. lib \)X^^'^r\JLC 



±(?i 



St.; .'^ Dist.;bet.U/<X/C.V(XA^ve>\Xoand LA^-Oai 

(IF Dt«TH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ \ 

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



o^<Ji, 




FULL NAME ^>-Oj Uoj\) ^.wy\) 



i 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 COI.ol 



II \Ti' oi" r.iK lit 





O^UJ" 



<Day) 



An 

(Vear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Month) 



(Day) 



(Year) 



■ i 



m 




AC.K 



3l5 



)'iiU. 



H 



Moulhs 



/>in- 



si\t ,1,1*. M \KU ii;d. 

u n)»)\\i;i( OK DivoRCKi) 

iWiit'iti >->iciaI il( si}.'-n;itioii) 



nTRTf!t»T.ACR 

iStatc or Country) 



x.\Mi<: OP 

l- ATJI I'R 



RTRTTIPT.ArR 
<)I" l-ATIIl-.R 
(State or Country) 



MAII)1':N nam I". 
Ol" MOI'UKR 



IHRTIIIM.ACK 
OI- MO'I'UKR 
(Statf or Country) 




I HIvRI'IJV CIvRTIFV, That 1 attciKkMl .leccascd from 

190 ~~~r. . to ,.......;..„.J,i,... iqo ~ """ 

that I last saw h ••. alive on " .-.;....... ,,.......,„. up 

ami that (Kath «)ccurre(l, 011 the ilate stated ahove, at H 

U M. ,The CAT SI-: ()1'J)I;aT1I was as follows : 




f 






OCCttpATTON 



fCfsidfii III Siiti I'l iitii i^i'i} '^ )'i'fiis. 



M„iilh< k^ /'./!' 



1)1 RATION Years 

CONTRII'.rTORY 



nr RAT ION ,v-v X^'^*'^ 

(Signed) .0 0. L 



• Mont In 



B^m 



I/oin s 



«f »«a*I«*tf««**H 




rV.T 



Mouths 



Davs 



//ours 

M.D. 



VUV Ql.S^ tqoH (Address) b L ~A XxXLlhj At 



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



Former or 
Isual Residence 



How long at 

Plare of Deatlj? Days 



Til I". \!!OVr, STATI- I) I'KRSONAI, l',\ R rU' l' I,A KS ARIC TRT-K To THK 

nHsT OI' Mv KNo\\i,i;i)<'.K .\M) i!i:i.n:i'" 

(Infoitnant UJa/>V/CI Uv)a> 



4 



n 
I' 



r\.Mrc«s %10 C)ov^:ixxx/vvA.^x'L<, ox 



Wlien was disease contracted. 
If not at plare of death? 



190'^ 



PJ.ACK OI" HI RIAI, OR RI:moVAI. I D.XTKof HikiAi, or RHMOWl 



N. B. Rvery Item of information Kh()ul<i be cnrtjfully Hupplied. AGK hHouIcI bo Htated HXACTLY. PHYSICIANS nhould 

state CAUSE OF DEATH in pinin terms, that it may be properly claHRifietl. The "Special Information" for p«r- 
Aons tlylnft away from homo Hhoulcl be ftiven in every instance. 



1 



i? 



^^tUUBSSSSSttr 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

V ^t"^?^;,^; - REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



liro'/sfej'ed ./\V>. 






v<^vc^o v^ HJ Deputy Health Officer 

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticatc of iDcath 

PLACE OF DEATH: — County of Ca/->^ O^V<X.-vxc<^C. City of U .O.A^ J/^<X/>%<i,^.A^C: 

No.otj.\I llcLVul-CJ ob(HLlvCt<xl St.; Dist.:bet. — and 



I LCWU.C5 UU 0-^5. VV^ vex. V M.; uist.: I3et. ana 

/ ir ot«T4 cccuws *w«iv FROM USUAL RESIDENCE Givr tacts callcd ron UNnt« "%Ptc\h\. iNroBMATioN" ■% 

v. If DE^TH OCCURRED IN * HOSP'TAL OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Q^ 



^ 



FULL NAME JiAjL^CLAJvO 




1 



PERSONAL AND STATISTICAL PARTICULARS 

( COl.OK > ^ 



DATE OF BIRTH 



Uj^xcb:.' 



MEDICAL CERTIFICATE OF DEATH 



D \Ti-: <>»• Di: \ 1 II 



Month) 



iDav) (Year) 



Ar.R 






M'tidis 



Pay 



<itNr,i,K. M \KK n:i>. 
\vri>(>\vi:i) Ok nTvnR»i-n 

'Wiittin MK-ia! »U <itf^natioii> 



BrRTHPI.ACR 
(State or Cmuitryi 



NAMi: (>!' 
I AT Hi: K 



TURTHPT.ACK 
()!• lATHKR 
I Stat f or Couwtry) 





XV.LU 




MAinKN NAMfi 
OF M(VrilKR 



lUR'inri.ACK 
oi' Morm-'.K 

iStatf or Countt\ 




Vile- ,. 

( Month) 



(Dnyl 



IQO 

(Yeai 



1 Hi:U!:rA" CI;RTI!'V. Tliat I Mttcn.U-.l dcroascl fnmi 

Ulxrvr lb 190H to Ml.cv- XH i.pH 

that I h\<{ saw hJLhj alive uii \J Vtr\r S^H T90 H 

autl tliat iKatli ncrtirroil. on tin- <la(i' '»tato«t at^ivCi «t I »0 
L^ M. Tlu CAlSIv oi" Di: \TH wav. M< follows: 

0.J8>-v-cv.tj 



'h 



C(»N'rKn'.i"rnKv 



Mouths. ■ /hn"! 



Hoiit 



T-^i.f-:', iii^ri^m\_% 



I )r RATION Years 

^SIGNED ) VJU 4 



occr 



ION %K .[) 

(JVC' fr^-^^^^u.Aj-<X£ 

Kf sided ill Sini f-i atni^ro ^ ^ )'/•«/« 



M.',it/n 



Ihn 



THF AIU)VK STATl'I) PKRSONAI, I'AR'lirri.ARS ARK TRll-: To TMi: 
linST OK MY KNOWI.KIX.K AN!) lUCUlKl" 






rXiMress 



ViUvr V\ T.,oH rx.Mrr-;- 



Miuiths Pays 



X 



f lout \ 

M.D. 



SPECIAL Information ""'> l"r Hospitdls, InHifuflons. rranMfnt^. 
or Recent Residents, and persons dying awav fron home. 



Former or n /<l^ , i ^^ H«w loii<| ^f 

Usual Residence I ' ^ '^^\J^Jjy\K^J^jOf\> Oli pi^ff of Death ? 



.... Days 



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



ri.AeK oi- J»i K i.\i. < "K 



ri.ACK OI'^nrRIAI. OR ki:M<>\ \I. J !)\lj;..: p.; riaj. or kl'.MoVAI. 

i. O^LAJhA' "^ Co 



IN. B. Every Item of Information .houltl be cnrefully supplied. AGE nhoulcl be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. The Special Information far par- 
sons dying away from home should be given In every Instance. 







If 



'>/• t»'*TrWT*'^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






■1 



I 



if 



Il.ai.l ..f U< M'th r Vm \r. ■^•^^^^^ HvS: 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hf 



(e Filvil^SKj^^Mf^-^^ 



XA, 0>S 100'\ 



Begistei^ed J\'*o, 



3328 



.^VCA^ 




\H^ 



'*■< 



■*"»«TT 



No 



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

Ccvtificate of Beatb 

( "a. S. StanDar^ ) 

J? QjT^ J (57^ 

PLACE OF DEATH: — County of JKXo ^xX/wC^^-acx City ofO<X/'>^^ J Axx^xcULec 



(ir DCATH OCCURS AWAV mOM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" N 
IF DCATH OCCURH^O IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



•St.; 10 Dist.;bct. '^rk(X\.6^ and X^K^^ 




Iru. \!.n^cAA.o^nAX^ 



^'•^-' % 



PERSONAL AND STATISTICAL PARTICULARS 



v-^ 





\ i 



XJL 



1).\ iK OF KIK III 



<M.>iithl 



/%kU 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 

an., 

(Day) 




(Mojith) 



(Year) 



I UI<:UI':BV CI:RTIFV, That I atttMi<lc<l (leccasc<l from 



Ai'.K 



..... Ou )■-.//> 



M..}ilhs 



Da lA 



SIMU.K. MARKIi:!). 
WriXiWKI) OR niVdRCKD 

' Wi itf ill suciiil lU •«ij.Muitit)ii) 




\OJ\K.^^Jj&- 



lUKTHPT^ACR 

fStatf or Coinitrv^ 



FATHlvR 



niRTHPl.ACH 
OK I APHHR 
(Statf or Country) 



MAIDKN NAME 

<)I' MOTHKR 



lURTHrLACK 
0|" MOTIIKR 

(State or Country) 





JjX\J\-KjJ^ 



^n\r\\.^ 



0^\XXj:y^ 



I9O to ; V Igo^ 

that T last saw li ^.^A. alive m» CX.\M, S-OCVX^o ^Cuat. 190 

and that death occurred, on the date stated above, at <<oO 
CL JJ. The CAlSlv Ol- I)JK,\TII was as follows: 




">'\_^' » \-,<X)u 



: ^, J AxXs.tK>CL\^Lft,.<i.A^ . 



I ) r R A ri N } 'cars Months Days 



Hours 



CONTRIIU'TORV 



• »v**«««***^%#«*«tiw»»99««^,;awi> 



V. 



a. 




V<X/>v 




YV 



<L 



OCCKPATION 



DTRATIUN Years Mont/is Days //ours 

(Signed) \. (ro. U ^v^-rwv\jtr*.u . m.d. 

VlUxJ^ ar, r«,o '\ ( Ad.lress) -'^ 1 C ^JoAX^^tL vb.iULi 



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



f\'f'^!i!rii in Smi I'l ant I'sro 



)'fii I 



.\r.>nffis 



r>,i r.v 



TH1-: AlunK STATKl) I'KRSONAI, PAR T ICK I.ARS A K 1 •: TRKK TO TIIH 
BK.ST OK MY KNo\VI,1<:DC.E AND HlUJIvK 



nnfotniant 




fAddrcss 







4^ 
cYl 



Former or 

Usual Residence .... 

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



How long at 

Place of Death? Days 



190H 



PLACK OI* nVRIAI. OK RKMoVAF. DATKof Hirial or RKMOVAI^ 

rNDKRTAKKR U - VJ . vj K^^rVWWJfAj ^'^ VO 
(Ad.Yress ./lAol MnA./VXl/aA.xrrv. O-t. 



N. B. Every Item o? Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for psr- 
sons dyinft away from home should be £iven in every instance. 







Ht i i 



ii 

Hit 






WRITE PLAINLY WITH UNFADING INK 



I^.;il<l i-f IIi:illll I- Vo. 



, . '<:■ 



.fT-^^ 






THIS rS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)((fi' Filed , 








r^\A^ IJ 100\ 



Registered JVo. 



8329 



i 



c^^^v^vA .^-vn- Deputy Het^ith Officer 



-"^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( "U. S. StanDarD j 



^No. 



4 ^ \ ^ 

PLACE OF DEATH: — County of UxXw Axx,^^A^c\.<iC(City ofUxX/^ru OA.O./YX<^ui^<^o 

t0V^ ...„ St.: 5 Dist.;bct. U X.4V and IaAJv 




tV^ 



(ir jDCATH OCCURS *W*Y FROM USUAL 
\^ DEATH OCCURRCO IN A HOSPITAL 



RESIDENCE GIVE FACTS CALLED FOR UNDER "SPE 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



CIAL INFORMATION" \ 
ET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 
SKX A A I COI.OR 






UyrA^\.Aj 



DATK Ol- UIKTII 



\<*.R 




3c 

(Day) 



bl y>'iu: 



^ M.nlks V\ 



.1%^^ 

(Vear) 



Da I'.v 



n 



MEDICAL CERTIFICATE OF DEATH 

•_ 

DATE OF DEATH A 

MW... ...an 

(Month) (Day) 



i9o\ 

(Year) 



I HI':RI':nV CI<:RTI1'V, That r attended deceased from 

\^^\r \a iQoH to Oxcvr.. 



siNci.i:. MAKKn-:n 

Winnwi:!) OK \^\\^ iKC}-:d 
(Write ill M>cial <U'»i}.rnati()n) 



lUKIIIl'UAOE 
(Statt or Cmintryi 



\ 




\j X^ cL Cr wMJv- 




X \Mi-; I )i 

lATIIl'.K 



HI KTH PLATE 
Ol- l-ATHER 
IStatc or Country) 



MAinKN NAME 
OF MOTHER 




t 










[90 A 



[gon to V( MSV....A!! 190 H 

that I last saw h u v v. alive on V/VCV^ \%, j 

and that death oceiirred, nn the date stated ahove, at 1 
U. M. The CAISI-: OF DIvATH was as follows: 




V'V^.*lA^^ 



in- RAT ION Years 

COXTRTRUTORY 




Months Days 
^>V\A.£U 



Hours 



'•'»*tt*lBti9m 



DURATION 



L 




niRTMri,A("E 
Ol- MOTHER 
(Statf or Couiiti v) 



OCCrPATION (V 1 - ^5VP 



}\'ars MoJiths 

1 

0-tKLoJji. 
nTW ^5" TooH (Address) ^%'\ fc<X\XA^<nv jt 



^'ars 

(SIGNED). 3. UJ. J 



Pays Hours 

M.D. 



TqO 



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



Former or 
Usual Residence 



How lonq at 
Piare of Deatli ? 



Days 



M.nith^ 



Dav 



THE AHOVE STATED I'EKSONAI, PAR f Hf I.ARS ARE TREE TO THI-: 
nivST OF MV KNOWIJCDC.E AND lU'.MEF 



(Iiifoiinant 



( A<l(lrcs.s 






IS 



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



PEACE OE lURIAE OK REMOVAE I DATE of MfKlAl, or REMOVAI, 

INDERTAKER M iWWoJrVtX > \. vJ (W CX\^^Oj ^ 's^ 
(Ad.htss A3>2)^ \lh/v--a,<LvytrYu ^vi: 



N. B. Every item of InformBtlon should be carefully nupplied. AGB should be s<«ted RXACTLY. 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 9\9ry instance. 



If 

", 'I 

'i 



H, 



i i 



I 









li 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I,,,,!.!, f ll.alih 1 No ;. r-t'r^^ iK-vl'C- , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i)((h> /•v/^v/,\jW^o-rvl)4X) as ^^'^H 

1 \ Deputy Health OfHcer 



Registered J\^o. 






No 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( XX, S. Stan^ar^^ ) 
PLACE OF DEATH: — County ofCj<X/~v^ J X>(X'> x/Ca^^l<^;>^ City of O /0^yy\^ vJ^vay>Ax:.<^AXL.<:) 
,a . vJ . \|) ,CLU oir-'r- H llxu:va^ LL:! \.a.\|st.; Dist.; bet. — and — ' " 



/ IF At*T^ OCCURS AWAY VJbM USUAL RESIDENCE give facts called for under "special INFORMATION" \ 
V \f DEATM occurred Oh (> HOSPITAL OR (/JSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



a 



JLK/y:)jOjuX- 





<XA.^y 



\JUl.. 



PERSONAL AND STATISTICAL PARTICULARS 
si;.\ f^ ft i ^^^^•**'* \ V f) 

IiATK OF lUKllI 

- - Ass 

•Montli* (I):ty> 



MEDICAL CERTIFICATE OF DEATH 

DATK ()!•■ I)1;aTH 




(Vear) 



ACK 



S5 



) I'il I s 



Mn„l/lS 



Pay 



>^IN<.I.K MAKKIKI). 
\\II)<>Ui:i> OK IUXOKCI'*.!) 
'Wiilf itj Mxial dt.-<i>.^nalion) 



lUU rm'I.ACR 
'State or Country^ 



NAM1-. nl 
I ATI IK R 



RrRTHPI.ArK 
OJ- lATIIHK 

'State or (."oiiiitrv 



maii)i:n namk 

OI" MoTIIHR 



inK'in!M,ACB 

OK MOTHKR 
(State or Country) 



OCCUPATION ({5\P 







(Month) 



^.D. ipoH 

(Day) (Year) 



I liliUI'iBV CIvRTIFV, That I atteiKkd decoascd from 

.— — ■ — ~ I90 to ..- IcjO * 

that I last saw li ■' alive 011 ^ Up 

and that death occurred, on the date stated abf)ve, at 

.-rr-r- M. The CAl'SIC ()!• Di: ATI! was as follows: 

\T)\JXrr\/YyJU>j ^^.^>yy>J8,/rrs^\J^r^Jt. „ 



1)1 RATION }'i'ars 
CONTRITIT'TORV 



Mo}iths •... Days Hours 



>**-»«a««»4-«««'#*«*t.i>« ••••>•■. 



DURATION _ Vi'ins 



Kt'yided ill Stiii /'i iiiii/u<> AC )V(n\ 



Afnllf/lS 



Am 



Tin*. AHOVK STXI)-.!) I'KKSONAI. I'A Kill' l" I.A KS AK1<: TRTH TO TMH 
in<:sT OI- MY KNO\VIj;i)C.H AND HHMHK 



(A^l.lross 1^0- q iX Ot 



y\i 



. Mo)itlis Days 

( SIGNED ) J-, sfj. Uj- (kjUOcXyvv^ \J^\JS\ 
\jrU\r :>s'5> 190'i (Address) V^^.^^JA/i 



XXhi 





Hours 
M.D. 



,<• < 



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



Former or *> u 1 4 J -^4- 
Usual Residence ^\r^. KM < 11. 

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



How long at 

Place of Death? Days 



190 



PI,ACK OF Bl'RIAI, OK KKMOVAI. I DATK of Hi kiai. or KICMOVAI, 
rNDHKTAKi:K >^^^. M K \i rUyW<K\->A>u ^;V ^ <>"' 

51 vYVU/Q.^A.^ey'-yx. 3t: 



(Address 10 1> 



IN. B. Every Item of Information .hould be carefully Hupplled. AGB lihould be .toted 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 ftlven in 9\9ry instance. 



1 ft 







I',. ,.i!.! ..f Ih altli F N". 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

S33i 



«j^ "?*>-, 



f, IK^I' ('■, 



Dull' /7/r^/, 'vb^cv^X^ %5 1'^O'i 

^^^A, ,^, Deputy Health Officer 



Bo^isfcved J\^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Bcatb 

( Ta. S. Staii&ar£> ) 

vj . 




PLACE OF DEATH: — County ofC)<X>^^ ^./a.^^^^^^ City of ' J XX/>^ J AX>^>\x:.v^<u> 
/No ?>H^ UvcvVcL - St.; ^ Dist,;bet. l.H ."LL and 15 JUb. 

/ ,r DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE TACTS CALLED rOR UNDER "SPECIAL INFORMATION••^ 
( ,r DEATH OCCURRED ,N A HOSPITAL OR .NST.TUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

FULL NAME JLJ/CX/TnaJUI; \J .>±^.J^.^JL/>i^J.,^^^^^^^^^ 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 




^ 



ecu 

DATT" <>J* HI K I" II 





\ 



i-v 



ct^- 



\«'. !•: 






) I It > .* 



4 



->I\<,I,1', MAkKIl-.I). 
\\II)«»\\i:i) (»K DIVORt'Kl) 

Wtitiiii <.H-i:il (Ic^i^MKitioti) 




n 

(Day) 



M,»ilhs \ 



\XVAyCL 



(Year) 



n,n 



niRTTtPT.ACK 

' ^^tali' or Cotiutry 



N \\\V ()1 

1- A III i:k 



lURTHlM.AOK 
oi- I API IKK 
(State or Country* 



MAII)1-:n NAMl-; 
<H' MOTHKR 







lUR'lHPI.ACR 
Ol' MOTIIKR 
(Stall' or Country) 




CAKXy^'V 



OCCUPATION 

ResuhJ ,» Sou Fnin.i.u'o^'X ]VrM. ^ ^f^'ifhs " Pav^ 



Tin- AHOVH STATKI) VKKSONAI. I'A KT KM" I. \ K S A K 1 -, TRIK TO TH1-: 
lil<:ST Ol' MY KNO\Vl.i:i)C.K AND lU-.Ml.I- 



(Infonuant 



(Address 



L/kA^\.ot\' ax 



y\j 



MS 



MEDICAL CERTIFICATE OF DEATH 



DA ri-: OI- i)i;ath 



mX^".. 



(Month) 



.AH 
(Day) 



/go i 

(Y«-arl 



I III';Ui:i{V C1:RTIFV, That I attcMnUMl deceased frntii 

Qlcnj" \ 190^ to \ix(rs^ an up H 

^\'^SX:....%'± TOO M 



tliat T last saw h X. i^ alive on 



anil that death orrurred, 011 the date stated above, at H-2> 
tf JSI. The CArSl<:^()I- DI'ATII ua^ as follows: 




W\^S^ 



osjc d. 






1)1' RAT ION 1 )'cais 
CONTRinrTORV 



Months lyays 



J lours 



DURATION }'i'ars Muulhs Pays 

( Signed )..U. ULLccrtAj L<rvv-«-v.cx-lu. 

MV^^ an TooH (Address) \o^- ^..Ik dt 



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 long at 

Place of Death? Days 



DAI K of HiRiAi. or RKMOVAI, 



-or, ...a I 



ri.ACK OI" m KIAI, OK RKMoVAU 

^.ao.'.,s^ At 



190 1 



(Addrrss 



"^ TTi I- I ATI should be stated RXACTLY. PHYSICIANS should 

N. B._F.very Item of Information should be carefully «"PP'-'- ""''"'J^lZ^^^^^^^ "Special Information- for p.r- 

«tote CAUSE OF DEATH in plain terms, that it may be properly classitiea. i ne o, 

•on« dyinft away from home should be ftiven in every instance. 



a^ 



\"5f ■ ' 



i 
i 

II 



WRITE PLAINLY WITH UNFADING INK — 



i;.„,-,l ..f" II. I It h !■■ No :-. '^"t.^^JU^' ^^^^' '''" 



ij 



f 



. 



I )<(((' Filed , 




%% VJO\ 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JVo, 




^' 






Deputy Hesfth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "a. S. Stan^arD ) 

\ OS? 4 ^ 

PLACE OF DEATH County ofC'^X^vv 0;va/VU^vCL/c^c City of OOy^v Axx/>-v<:yu:i co 

No 5" vJ.vL^Cc/Uj Urv^vt ^ St.; 1 Dist.; bet. ,a./yv4.- 0^-> vA. and M I Ur^^lcrAi 

/ ,r DtilTH OCCUPS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER -SPECIAL INFORMATION- \ A K 

C ,F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 7 U \J 



^l CLA I ) 



FULL NAME 




KJ^.\^'<. 



/y 





• ■-*-««»*"i»SM-*#' 



si:\ 



i^ 



PERSONAL AND STATISTICAL PARTICULARS 

COF<(>K 



ViXccL 




OATE Ul- niKTII 



Ai.i-; 



i Month) 



I 



j)y\jJ<Xj. 



15 ..../. "iC^i... 

(Day) (Year) 



Q 

Yrats I 



M.'vUi- 



\ 



Pavs 



SINni.R. MAKKIi:!). 
WIDoWKD OK DINOKrKl) 



HIKTHPI^ACR 

(State or Country^ 



NAMK (>I 

i-athi:k 



lUKTHPT.ArK 

oi- I'xrnHK 

'St. iff or Con tit ry) 






)X.' 




CrvA^A^A 



.UvU 




.'^O. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 1)1 



'::: (k 



(Month) 



X,3). I go H 

(Diiy> (Year) 



I 1IKR1{BY CliRTIFV, That T attended (lecease«l from 

.Q\/3vr XO 190H to \Vt(n/- ^.2>. iqoM 

that I last saw h-t.'v>^- alive on ViV^SV" %% up '{ 
and that death occurred, on the <late stated above, at ^ ..uO 
LL M. The CAISI-: ()F DI'IATII was as follows: 






AXi 



DTRATK^N 



)V<;;-.v 



Hours 



Mouths o Days 
C N 'J' R I H r T ( ) R V >J A<C-\>:<>w^LCa '^-Ola.a^-qAvAj /CUd^.LcL 



MA!I)KN NAM1-: 
OF MOTIIFK 



in KTH FLACK 
OF MOTHHR 
(State or Countryl 



da3\Ji/>^"Y^ \J/ojolLoj, 




pcx::^. 



OCCUFATIOH 



TUF Mun'KSTATFDFHRSONAl. FARTICFLAKS ARFTRIH To TMK 
HHST OF MY KNOWKFDC.K AND HFFIl.b 



(Informant 






DURATION 



J V<?;. 



"% 



iMofii/is o /^ays /Fours 



(Signed) oU . vjAX/\rv/v\^ 

M^Uvr a?) TQOH (Ad.lress) U i b Vj (^\.AJ-d(JL' O.j 



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 



FI \CK OF nrRFM, i)R KHMoVAI. j DATF o! Hi kiai. or RI:M0VAI, 

%X,(1^ .^.J ^^.^^. '90s 

fNIlKRTAKKR H. O. 0(KO,0-«.V 

(A.l.lrM. 30 S V)X«-V-»Xo.'Ul lL\M. 



State CAUSE OF DEATH in pinin term*, that It may be properly ciassiTica. i nc c5h»= 
none dylnft away ?rom home Hhoultl be ftiven in «vory instance. 



II 



r 



g: 






I 



I 

I; 
1 
I 

i 



* 



4 



! i 



WRITE PLAINLY WITH UNFADING INK 



Bosti-l of HrM'tli »■' N'o. 1=; ^■"v:~'^''''^'' *•' 



I)(f/r n/cf/, 




IS 290H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered .A^o. 




^-^.^ Deputy HtF^afth Ofncer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 






No. 



( tl. S. Stan^arD ) 
PLACE OF DEATH: — County ofOay>-u J^<x-.-vc«^ct City of '^'CV-r-v 



V'OA-ac^c) 



St.; i Dist.;bet. 3w rrvdj and 3AxL ) 



/ T nr*TM OCCURS *W»Y TROM USUAL RESIDENCE GIVE FACTS CALLED FOB UNDER SPECIAL INFORMATION ■ ^ 
( ,r DEATH OCCURRED IN ^HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




'^ua\,i 



PERSONAL AND STATISTICAL PARTICULARS 



JX/^rrvo^ 

DATF. nl itlK 111 



t 



COI.OR 



\ 



LL>Jv<^ljb -.^ 



(Month) 



ACK 



OlW bO ),c,*.« 



(Day) 



M., Ill /is 



A^H 

(Year) 



P^/ r.v 



SINC.!,i:, MAKKlI-:i> 

\\"n)<)\\i:i> <>K i>iV()Kvi:i) 

iWtitciti soci.'il (It^iiMiatii)ii I 




,JL.^<rv«J- 



TlTRTIirT^ACK 

(Stiitr (ir Country) 



NAMH OK 

I- AT in: K 



mKTm'i.ACK 

<)l- 1 AIMKK 
(Statr or Country) 



maii)i:n namk 
oi- muthkk 



luk iiirr.ACK 

(H' MOTIIKK 

'State or Countiy) 



? 

? 



MEDICAL CERTIFICATE OF DEATH 

DAT?: OK I)1<:aTH 

M 

(Day) 




(Month) 



190 H 

(Year) 



I ni':RI':r>V CI':RTIFV, That r attetuUMl deceased from 

— — — — T90 to I90 

that I last saw h alive on ~" 190 



and that death oceiirred, <iii the date stated above, at 
"~. M. The CAISIM)]-' DICATII was as follows: 

L<rY»Jlv/trvs.^xX:^ J />.^olx:^IaaAX Crt Q JfLA-AjW 

\I\A<\A^i\.w.yx.a oil Lrlv^v.A.'t .„.„ 

\Ju.A.^oj (Jvn-^Ja; jch^'AXjl€^j\,kj^ '^^ 

DI'R.XTION )'ears Months Days Hours 



CONTRIBrTORY 



^^KxXyo^ 



'\y' 



&. 



OCCrPATION" 

f\fsi(tfd III Sun /'iiiiiiist-n 



) V,7 / 



M.nilli^ 



na\. 



TUl .\HOVK ST \TKI> I'KKSONAl, I'A KTICT I.AKS ARK TRKK T< > TMK 
Hi;sT OK MV KNOWIJ'.IX'.K AND lU.IJJ.f- 



nnfoiinant 



%. d GcJ 



'\JJyj 



X.l.lrcss 3^.^ CU^O^..^XjU UJ' 



Dl'R.XTlON Years .}ro}il/is Days 

(Signed ) \j^'\<n^Ji\i J ^. UJ. A^JLo^-^-v.-cL 

VlUv- ^-l TooM (.Address) WurvUJUi U^^v 



Hours 
M.D. 



SPECIAL INFORMATION »nly for Hospitals, InstitutiMsV Transients, 
or Recent Residents, and persons dying away from liome. 

Former or ^e. ^^ \ f*®*^ '""fl ^^ 

Usual Residence ^1 ^ wv) <<XWL/Ct<r>vU t piare of Death? Days 

Wlien was disease contracted, 

If not at place of deatfi ? 



"I.ACK OK lUKFAI. OR RKMoVAI. I DATKof ItrKLM, or RKMOVAI. 

'^ '' ........ ViUkt as I90I 




l-NDKHTAKKR H. . Ci . U Lcrru>X^rX> ^S^^ 



■"■■■"■'"■■"■^ ., .. •• I APF aVioiilfl he Htated BXACTLY. PHYSICIANS Mhould 

mnnm dylnft nway from home should be <>ivcn 5n every Instance. 



\ 



IP 









I 



i {, 



B<xir<l oi HtiUli ■ S 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 










V 



.vSiS 190\ 

•jtv Hei • OfT'cer 



Rci^istcrcd J^''o. 



3334 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of ©eath 

( "a. 5. Stan^arD ) 
PLACE OF DEATH: — County of^WTv 0AAU>\XAy9uCX> City oiOiO~jy\j 0^^^<v>^-<M-a.-cx) 



(' 



QR^ 



No.O^^l\-0 o CrVLAt)- - - St.; "^ Dish; bet. u^r 

/ ir DC*TM OCCURS AWAY TROM USUAL R E S I D E N CE G I V E FAC 
V If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



jVH,' 



tt VU 



and 



r DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED ^OR UNDER 'SPECIAL I N ro R M ATIO N " \ 
r DEATH OCCURS AW«T F H o w w^ ^^ NAME INSTEAD OF STREET AND NUWBER. / 



) 



FULL NAME 





SEX 



\^\rv. oj- I! IK in 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 




Qf>\o.u 



\<".K 



I 5 )>(/;.« 



,0. 

(Day) 



M.mlhs 



;VA.VJL - 



(Year) 



aq 



/><f 1 .V 



sIN<-,l.i:, MAKKIKl). 
\VII)<)\\ HI) OR I)IV<»Kri:i) 

'Wiitr ill •*<H'i:iI (h'^iv nation) 



nrRTitPT.ACK 

(State- ur Country) 



NAMK <>J' 

KA'iH i;r 



( 



niRTnn.ACK 

oi' lAI'IlKK 
(Stale or Country) 




M\I1)1:N NAMK 
«>!• MOTHHK 



lUKTIMM.ACl': 
()»•• MorHKR 

(Statr or Country) 



(J XVYWOwAVLt 

? i 



OCeiTPATION 



dL.oJG-< 



Rfsiiifd ill Sit II /'i iini 'u,> 




)'i ,1 1 



y/.u/f/i' 



n<i \s 



TM^•.Am)VKSTAT^••l)I•KKS..NA^l^^KTIC^I.VKSAK^. TRIH TO THK 
ni':ST OI- MV KNOWI.l-DCK AM) Hl-.Ml.h 



(iufonnaiit 



X,,,,.. HOST ■ 'xsij^ dt 




M^ 



'•'t^ 



Ovi 



.«•«•■ •.•••*$*4 •*•••«•)' 



lEDICAL CERTIFICATE OF DEATH 
DATK OF I)1;aTH 




(Mouth) 



1?> 



I go H 

(Year) 



I miKinJV C1:RTII'V, That I attcndtMl deceased from 

-:. IQO 



190 



to 



that I hist saw h - 



alive oil I90 



and that death occurred, on the (hite stated above, at 
rr"M. The CArSIC OF Dl^XTII was as follows: 



,.U:C:*.v. 



U-CCVCa^cLx 



DT RATION }'t'ars 
CONTKIHITOKV 



Months I^ays 



I /ours 



DURATION ^ Vt'ors Mont/is Da 

(Signed) L^tVtyxXA; ^ ML). LU c*julcl> 



/hiys 



Hours 
M.D. 



^\i 




m 'V5" TooH (Address) Urv>CPyx.S.rvA UJ^ic^ 

SPECIAL INFORIVIATION only (or Hospitals, Instituti6tis, Trdnsients, 
or Recent Residents, and persons dying away from home. 

Former or .^iJ ZU Hon lono at 



Usual Residence 

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



1 i \x new lonq ai 
H051 ' 3l5 Ln CJT Plare of Death? Days 



T90H 



I'l \CK ol" lURIAI, OK KKMOVAI, I DATl^ot Uikiai. or KKMOVAI. 

VM\v<L^>u<r>v at 



(AiUlrt-ss ^3^0'-\ 



"■"■""'■"■'^ » .. 11 1 APR .hmild be stated EXACTLY. PHYSICIANS ahould 

N. „._F.very Item of information .hould be carafully -"PP"-;^- ^^^,ll^tt^^^X \L -Special Information" for p.r- 

state CAUSE OF DEATH In plain term., that It may be properly clB»«mca. me p 

nons dylnft away from home should be feiven in every instance. 



K 



1 



•f» 



— ffl-T"'"'*'-- 



3 . 



1^ 



'; -1 



m 




III 



WRITE PLAINLY WITH UNFADING INK — 



}«„v.] oi n.nitii- r No i^ ^^-cE^''^^'*--" 



i)(ff(' /vVfv/, \)rL(j\v^>-\x.i>-cv a^ 



l^OH 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFtCATE FOR INSTRUCTIONS 



Registered Xo, 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of "©eatb 

( "U. S. StanOar^ ) 
PLACE OF DEATH: — County ofOcL'>^ Jxcx^vc^^C.City of Oxv^ OA^VyvCa^^O 



m 




M„ IHT JX.{\.a.^r»-v-<Xi St.; ^ Dist.;bet. "l^^^ and 

INO. ' ' ' ~J.A^I \^V^S^ I r >--v.^ ,,-,,,, orCinrNCE Cl»t f«CTS CALLED fOn UNOin "SPtCl»L lNFORM«TION••^ 

( '^ rr"o;rH^occ.%reV."rHo"s^r.t o^"Ns^^^"4N"o.vr.TJ name ......o or ST«..T ..o .UMB.B. ; 



iyVdL 



) 



FULL NAME (lbj^^^a.^v 




XA^^JJu-... 



si-:.\ 



PERSONAL AND STATISTICAL PARTICULARS 

! COI.OR 





JVL^l^t' 



b 



DATl", <)I- lUK I'll 




I M.iiith^ 



.\<.K 



u 



) Vil > s 



1 



(Day) 



M.IHlllS 



(Year) 



30 



IhlV. 



SIVC.l.lv MARR!i:n. 
(Wtilr ill s(H-ial (Itsi'/iiati'in) 




HIKTUri, AOH 
(Stale or Coiiiiti\ t 



NAMK OF 
FATin.K 



lUKTHrLACK 

oi- I Arm'.R 

(Stale or Country) 



MAIDl'.N NAM I". 
OI* MO'PHKK 



'VocWv^std 




nTRTITPL.\CK 
OF MOl'UKR 
(State or Co»iiitry> 



OCCT'PATIOX 



Rf.Kuinl ill Son /'xiiu/sro Xo )''^'^ 



M, 'II tin 



n,i\s 



TMl^^m)VKSTATKI.PKRS.>N^I rART,rrLAKSARHTRrK n. THK 
ni;ST OI" MY KNOWI.I'.IX.K AM) Ml.Ml.H 



(Iiif.)Titiaiit 



0>JLrwjOj 



JOsj 



(A.Mress IHl jJkO^^XXX. c3 t 



MEDICAL CERTIFICATE OF DEATH 
UATK Ol' DKATll "^ 



A)Vo 



(Month) 



(Day) 



790 n 

(Year) 



I UHRICIiV Ci:RTir'V, That T attended deceased fro 

1 to . Ov^rvr 3.3.. 



ni 



1 90 



190 n 



190 



that I last saw hA.^nv alive on • .MX^OXT ^i 

and that death occurred, on the date stated above, at A 
GL M The CArSH OI- DK-VTH was as follows: 

\vJr\/v-Cr>'^A.^ Vi rU.vtr^<x/v€Lv-Loi 

{XaXjlK.^^ .O.SiXjU\^^ 



.<i^<LKJ^ 






Di; RAT ION '^ )'cars 
CONTRiniTORY 



Mouths Days ■■-•" Hours 



DT RATION 



)'iars 



Afoulhs 



(SIGNED) tox\JWAtj 'v). ^xfVimdi 



Days I/ours 



tt; 



\jn<5\r %\ TQOM (Address) t!)0(o 6xJ1j^\j ^t 



M.D. 



SPECIAL INFORMATION o"') *»r 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? 



Hew tonq at 
Place of Death ? 



... Days 



I'l.ACK 01 IJIRIAI, OR KKMOVAI. 



I)\rK.>; 111 KiAi. or RIvMOV.AI, 

3Ho T90H 








N. B." 



""""^'^ ^ „ , Ztf .K»,.i,i ha KtRted BXAGTLY. PHYSICIANS iihould 

-F.vcry Item of inWrnBlion .hould be cnrefully -uppncU. J^^^^^^^/^^.^Vfl^^^^ ,„form«llon- for pr- 

•tate CAUSE OF DEATH In pIbIh term*, that It may be properly UaMinea. 
sons dying away from home nhoi.ld be 4iven in every Instance. 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



r.Kird ..f II.:. 'th - r V' 



■^.^-S^fcli&ITo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




l)(f 



f (' Fiii'd . \rWvM/'vv\^\;^ 



rA.'x^xJh-k.K^ as 



VJO\ 



liei^isieved J\'*o. 



3338 



Sl 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



v«.vA kxA>v, Deputy lieaiih Officer 



Ccitificate of S)eatb 



( XX. S. StanC^arD ) 
PLACE OF DEATH: — County ofacc-vx Xar.x<^UvC ( City of CJ ,<Xa^ Jaxv^vc^^ 



(^ 



QAj 



No, H5. 



i 



(IF OE*TH 0( 
IF DtATH 




(XCX 



St/ 1 Dist.; beti4^ ^^CLOAAh.OvM. and V) <XC 

** EClAti INFORMATION" '\ 



,-,-.. oe auuAV FBOM USUAL RESIDENCE GIVE FACTS CAtLED FOR UNDER SP 

"CCURRCD .nThOSpVta!: Tr institution give its NP^ME instead of street >,ND NUMBER 




FULL NAME 



-AJL>\Jj 



^^•■•^' Q^ 



PERSONAL AND STATISTICAL PARTICULARS 





\ 



yVVA. 



^ijt 



DATl", ni HIK I'll 




'vJu 



1> 



AGE 



m 



I 



)V,.'; 



1 



a 

(Day) 



\/..>///i- 



r'lt'^ 

(Year) 



VI 



Pa vs 



sivci.i-: M.\RRn:i) 

\VII)n\Vi;i) OK I)I\< »Ki l-.I) 
(Write iti >(>oi;il doij." n;il '"" ' 



HIK IHIM.ACR 

f Statr 1)1 <.'miiitrv> 



1 f 



NAMT" OI" 
I'ATIIKK 



(^ 




DJ' I' API IKK 
(Slate or CoiitJtry) 



OAJL/cL ^JV^'d.Vv.avv.iua^ 




M 
()I 



XIDKN NAM1-: A 

• MOTHKK ^ \\'\ 

cLw^LOL ^ 1 I IXAXXJ 



lUK rni'i.Ac']': 

oi' MOTHKK 
(Slate or Country) 



^ 



OCCri'ATION 

THKAm)VKST^•IM^nIM^<S.)NA^.•AK^^^^AK^AKKTK^K TO THK 
HF.ST ol_MV KNOW 1,1, IX'.K ^M> HhMJ.H 






(A<l«lreMI.... 




CJL 




MEDICAL CERTIFICATE OF DEATH 



(Year) 



DATE t)i- di:a'ih /V^ 

MUv IH 

(Month) (I):iy) 

I 1I1;R1:BV C1:RTIFV, That I attemled dccoascd from 

Q^^5V- \% TcpH to \fl^...'^'h icpH 

that I last s.tw h Ji^ ■ alive on Sl\^\r .'^'i 190 . 

and that death occurred, on the <late state«l above, at y> oO 
Uv M. The CAISIC OF DIvATIl was as follows: 

^Cr\MXA/ .......i 



rrsJiJwW> wcrw.*- o^ 



DTRATK^K }'((irs Mouths < Days Hours 



CONTKIIU'TORV 






ni'R \TION Ytuu-S . Mouths i Pavs ^ ■-Hours 

(SIGNED) ^ JAJL/V-V^^w^-. ■■-. M,D. 

'jUvr XH TooM (A.ldress) Id^ IjCTLo-^U) dj 



Special information on'y 'or Hospildls, Inslitutlons, fransienls, 
or Recent Residents, and persons dying anay from home. 

Former or J^ '"!V^u, 

Usual Residence •.• Pl<»<"f »* D^^^''- Oays 

When was disease contracted, 

If not at place of death ? 



I'l.ACH OF HlRIAl. OK RIlMoVAI. J DA H'. o! IUriaI- or kKM()VAI, 



LNDHKTAKKKOoJUx^tx ^j^ 

(Ad.lres.. I5 3.H O-Lo-^tictft-rV Oi 



N. B.- 



"' .. , ..>p „u,,..i,i Kp Ktntetl F.XACTLY. PHYSICIANS should 

-Kvery itcn o.' informHtlon «houl.l h. cnnefuMy «upp1.e.. ^^'^^ "^^/^..Yflei? Th^ '^ Infor-natlon" Ur p.r- 

Htntc C4lJSr. OF DEATH in pli.in terms, that it mto be properly Uassmeu. 

«on« clymft away ?rom home should be fclven in every inHtonce. 



I if 



I ( 



if^ 



B^ 



Iff 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'.,atil ..f H.:iMli-|- No. := *t;3/-'- l'-S;l'<-'" 



Ba^istered j\'*o. 



Dale AV/fv/, AjWk-^vJImA' 3.5 190^ 

l^vv^"L^,M Deputy HeElth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U, S. StanC»ar^ ) 



^ 



PLACE OF DEATH; — County of n Lc 



A>'Cvd^cu City of U;vcx^-;:i 




(.No- 



St.; 



Dist.; bet. 



and 



— ) 



• ■ c> 1 1 A I De-eir»rMrF r\\ir facts CALLED FOR UNDER "SPECIAL INFORMATION" ^ 

( '^ r::..'':iTcZ::.': ::r.^^'^"^'i :^v.^':^.^.o^l:r^^l name .nsteao o. street and number, j 



FULL NAME 




V\^ Cj <X,CC''TY>wCn. :,u. 



SRX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK \ 

,CuU ^ 

DAI'l". «H" lUk 111 




l< 



jJwU; 



>ti>mli) 



A<.K 



bo jvw,.v 



(Day) 



Mnnl/is 



(Ytar) 



Pa y. 



STN<".I,lv M\KKIi:n. 
\VII)t»\\l".n <)K I)IVnKrj:i> 

IWiitcin M>c-ia! dtsiiMuit i-iii ) 



lUKTIII'l.AOK 
(Statf <>T Coiiiitiy 



NAMl" oi 



RIRTIIl'l.AOK 
OI- lAIMHK 
iStatf or Coimti y) 






MAIDKN NAMK 



lUKl'IU'KAOH 
()|- MciTMl-.K 
fStalf "It r<)unlry) 




nrrt*rATinN 

Rrsidfit ill Siiii /■> iini i.-i'<> 



Vrai s 



.\/,.>if/i' 



/>,IV. 



•nil- XHOVKSTXri-,!) J'KKSONAI.l'AKIUri.AKS AKi: TKIH To TIIH 
IJHST OI vAJV KNOWl.HDf.K AND I!i:i<n> 



( 1 11 fur tna lit 




Q. 



X\/»-cvA 



( \<l(lrfss 



MEDICAL CERTIFICATE OF DEATH 

DATl-: OI' IHvATM 



as. 

(Day) 



(Year) 



\J Uv- 

(Month) 
I llI':Rl':r.V CI:RTII*V, That r ntteiKled deceased from 

:'■ : ' .. '. 190 



■190 



to 



that T last saw h r. alive on 190 

and that death occurred, on tlie <late stated above, at 
"" — M. The CAISIvJ.)!'^ I)I«:ATII was as follows: 

L^^nUXVA-xXX' vJ^.^X^CrVoi 



I) I' RAT I ON )'t'ars 

CONTRIIU'TORV 



.)/<)/! //is 



J)a \s 



Hours 



DURATION 
(SIGNED) 



Months 



Days Hours 



\ 



C\r -x 



\ I.,o'! ( 



. J \tr>Aju M.D. 

\ddress) '^K<XA^ OwLUu Wl 

1; 



Special information only 'w Hospitdls, InstituHons, Iranslents, 
or Recent Residents, and persons dying away from home. 

How lonq at 
, Place of Deafli ?......... Days 



Former or 
Usual Residence 

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



l'I..\i:K OI- Ml KIAI. OK KI<;MoVA1, I DAIljo! MrKlAl. or K1-:MoV.M. 

.,., mUat ';cs I90M 




INDHRTAKKR 0^4vJL^><l.C'V; oU.ULA,^.^ 

(Ad.lt.-ss ^51 \.n\A^-<i.vXr>v B.,t. 



N. B.- 



"■■■■""■■■■'■■■'^■■*''^"^^^ ,. , .^c „K„,.i,i he atnted FiXACTLY. PHYSICIANS should 

-Kvcry Item oi info.mnt^on «houhl b. cnrefully «uppl.ccl ^^^J;;;7;^',X7*'The •'Special lnfor,naUon- fer pT- 
suite CAUSE OF DEATH in pinin term., thnt .t mH> be properly clossltleu. 
sons dylnft away from home should be illvcn in every inntance. 






I 1 



) l| 



»^5 



'»' 









"^TrJl 



l!.,;ii.! .,1 !l. lUh I 



VVRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

N , . . . t-.^^X- JU'v I* C, R CFE R TO BAC K O F C E R TIFICATE FOR INSTRUCTIONS 



/>>r//r /•V/r^/AjVc\^oWUA; Q.S ^'^^"t 






i i 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 



PLACE OF DEATH; — County of 

I V .1 w rn^.. IICIIAI 



( ^1. 5. StanDarD ) 

k):0<J>C\j OX<Xy>\.cv^.ci. City of 0/CX/>^ .\,<X/vA.coi.<:i.^ 



St.; 



Dist.; bet. 



and 



1 V ^J w r«^.. iiciiAi Rr<;incNCE give facts called for under "special information" \ 

I ( '^ rF"o;:TH"ofcR';,ro\N'^rHO^S^rAL o"r'?n?~n"o.VE .TS name .NSTEAO OF STREET AND NUMBER. ) 



"0 



FULL NAME 



'\XX/VL<.^N O/C^Ko^Vy. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



nicL 



LLiJ ^cLio 



i)\ii-: »ti uiK 111 



A<.K 




( Mdiithi 




11 

Day) 



rVl 






) V<; / 



b 



M.uth^ 



1 



(Vfar) 



y:><i 1 .V 



STXf.I,!*. MAKKIi:i> 

WIIx >\\ i:i) OK 1)!\< »KvI-.I) 

W'lit'iii social dcsi^.Miat i<iii) 



lUKTHl'I.ACH 
(Statr <>i Cniiiili V 




'X ^'vcy' 



Aa 



I" A I' 11 1,R 



IUKiMM'I,A("l-: 

oi 1 Arni':K 

(State or Country'' 



MAIDl'.N NAMT: 
<)1- MoTIll'.K 



HIK'nilM.ACl-: 
OI- Mo'lMllK 
fSiatr or ("()nnfr>^ 




<x; 









n 



<L 



^ 



■T>\XX/T\/>V 



nc 



XrPATION/^ A 

Kfsidrd ill Sail /'iitini-^i'o 



]■, ,11 ' i Mnlltll^ 



PilX. 



Till- M»(>VhSTATi:ni'KKS<)NAI.I'AKTMTI.\KSAKi:TI<rK H • Tm- 
llHsr (M- MV KNoWlJ'.IX'H AM> IM.l.Il.l' 



(I 



..fonnant., .aIx^ Vj.iuxXo 



f \.l(lri'ss 




MEDICAL CERTIFICATE OF DEATH 
DATH OI' I)1-;a TH A 

Ml 



(MoiUh) 



(Day) 



790' I 
(Year) 



I HI";UI{HV CIvRTII'^V, riiat r .ilteiidcil deceased from 

Qaco \ 190'i to \VVa-vV 9.2, iQo'i 

tliat I l.isl saw h <\-^»^ alive on VjUNT ^2> 190I 

and tliat death occurred, on the dale stated above, at ^ 
y M. The CArSl-: ()!• DI'ATn was as follows: 

wrVv(rYA-vxi .\l l\uL/&^cv''vcLvXi^ .... 

V_JkA./(rvx.v^'t. Xu^-\Ak,<r'^LA:xJ>^tk^\ju^ 



DlRAllON 



Ihjys Hours 



)'('ars A/on i /is 



SIGNED) J. mV. db-CVN-t' 

.(PC -XH i(>oS 



Ihjys 



Hours 
M.D. 



f Addrev^s) Ldxy -t. ' (Hj Q-<l|v<utaX 
Rpitals, institutions, Transients, 



SPECIAL INFORMATION only lor H 

or Recent Residents, and persons dying away from fiome. 

Former or ? "r'^IV**., 

Isual Residence P'^^f »' Ofa^h? 

When was disease contracted, 

If not at place of deatli? 



Days 



I'l.ACK OI- lUKIA/. OU KI':M<»\AI. I)ATJ:o!" Hihiai. or Kl-MoVAI. 
I N I ) v. K T A K 1'. R \rrUr>X>oJk<'wQ^ U Jb CL>V<X» ^^ Lo 



{Ad«lre«H 



l?SHl MD\w4y^A.^rYv Ot 



I ] ,, , .,,c, „u,.,.i.| he Rtiited fiXACTLY. PHYSICIANS nhoiild 

^, B._i;very Item of informHtion hHouI.I b. .nretully -'nP"- ' ^^^'f^^^ ^u Uw^^ The "Spcci«I Informntion" for p.r- 

Htate CAUSt OF DKATH in plum UrniH, that .t may be properly cl..H«.tie. 
lions dylnft oway from home shoi.UI be feivrn in every mHtancc. 



< 



LOCAL I T Y OF 



RECORDS 



SAN FRANCISCO 
COUNTY 

S AN FRANCISCO 
CALIFORNIA 



TITLE 



OF 



V 



RECORD 



DEATH CERTIFICATES 



I CROF I LMED 



FOR 



THE GENEALOG IGAL SOCI ETY 



SALT LAKE 



C I TY 



UTAH 



CA L I FORM I A 



D ATE 




APRIL 



1975 



PH OTOGR AP HER 



MAX JOHNSON 



CAMERA 1n02683| red 



VOLUME 32 01 



3500 



/ 



■»;•».«• -ie^(fiam^ti^ 



LOCALITY OF 



RECORD S 



SAN FRANCISCO 



COUNTY 



■-: ^■v; 



S AN FRANCISCO 
CALIFORNIA 



TITLE 



OF 



RECORD 



DEATH CERTIFICAT ES 



I C R F I L M E D 



FOR 



THE GENEALOGICAL 



SALT LAKE 



SOC I E TY 



CITY 



UTAH 



C A L I FORN I A 



DATE 




APRIL 



1975 



%«f 



--P44 OTOGRAP HER 



MAX — d OH N SON 




CAMERA BNO 26831 RED 




UME 32 01 



3500 






.1 



,r 







i 




WRITE PLAINLY WITH UNFADING INK 



!)(( 



f(> rilr(l}\i\j^^Mjr'<\)^^ ^^ lOO'i 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Beiistered J\'o, 3338 




,^^ Deputy Health Officer 

DEPARTMENirbF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "U. S. StanOarO ) 



OS? 



\ 



PLACE OF DEATH: — County of OcL^ Oaxu^^vA^ City of O ^:x/t^ .>vcx/-va^^<:.-l^ 

-:and ■ ) 







(yA/rwX.OwV 



Dist«; bet» 



^VAX \.^\rV.A/Y\/U>L V^^^J^r ,' ,,^, QrctinrNCF GIVE FACTS CALLED FOR UNOEB "special INPORWATION" 'V 

I ( '^ rF"o;:x°H'^oi^%rcr .^'^rno^s^rT^At o^"^s^?o"x^o';^ --eao of street a.o .umber. ; 



FULL NAME 



'\XXAy^ 



rVCX\/' 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR 



n\ 



DATl-: el- IlIKlll 




)XO 



Ix 




(Mdiitht 



3.1 

(Day) 



/I'll 

(Year) 



A<'.H 



PC) \rn>. 



X 



MnHl/lS Jw /'"'-^ 



STN'f.I.K MARKTKT>. 

wii)i»\\i:i) OK nivoK^Hi) 

iWritriii s(K-i:il (l(>.ij.'nMti<)n) 



mKTHPI.ACK 

(Statf t.r CoMiitrs') 



i-A rur.R 



lUKTHri.ACK 
<)1- I ATI IKK 

(St.'itr or CDUiitry'i 



MAIDKN NAMi: 
Ol- M OTHER 



lUKTHPT^ACK 
(H-- MOTHKK 
(Stale or Country) 




MEDICAL CERTIFICATE OF DEATH 

DATK OJ- DKATH 

Xh. 

(Day) 




(Month) 



(Year) 



1 HI<:R1':BV CIvRTIPV, That [ attendtMl deceased from 



.LU.MX 



\ 190'i to 

that I last saw h ^V/»^ alive on 



.3l.3i 



190 



M. 







AX^Tvyrv 



oc 



crPATioN/?^ n 



Rfsidrtl ill Siiri /'iiiiiii.u'o 



J- 



);,ii 



y/niltlK 



n,n.- 



THl- AHOVK STATi:i) J'KKSONAI. I'AKTKT I. XKS A K l- TKlK To TIIK 
iJHsr OI- MV KNOW M-.IX'K AM) HI'MIJ" 



(I 



„f.,nnant K^JL^i vJ.LoJLo 




...3^ft .....190'i 

and that death occurred, on the date stated above, at " 
(j. M. The CWrSIv OF DlvATII was as follows: 



l^^^Jfvv'C^yx-'V./^:' Xy>A.'cL^&-^XX.\^cL4jlA.<d 



or RAT ION 



}'('arx Monlhs 



/)(7ys 



"M , ""y^ 



Hours 



(.ONTRIIU'TORV \JrVv-<r>v^^ LAXhJk-^yr^JL^-^ sLa./v*^^?^ 



Days 



DTRATION .^- .yJV'^W CMd'"'^'''''^"^ 

SIGNED) i. ViV. db'C^ ^ 

A.ldress) LcUy ''^ ^0 ^ 0^4\Atal 



Hours 
M.D. 



.CX- as T(,oH ( 



ife 



SPECIAL INFORMATION only for Hb^pitals, Institutions, Transients, 
or Recent Residents, and persons dying away from fjomc. 



Former or ^ 

IJsuai Residence 

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



How long at 
Place of Death ? 



Days 



D.xri; .)!' niKiAi. or khmovai. 



IM.ACK t>l" rn'RIAI. OK KI:M0VAI, 

INDHRTAKKR VM "UTo.^^J'VOw^^ U ob CL>V<X; /^^ VX 



T90M 



I'O 



, B _Hvery Item o.' i„for.n„tlon .hould he cnrct'ully Huppllecl. A(IR should *»« «»«*«•• ^^XACTLY P"V8'C«AN8 -hould 
H^atc C.MJSE OF DEATH In plum tcrmH, that it may be properly cIo««i¥led. The •'Special information ?or pT- 
«on« dyinft away from home Hhould be feiven in every instance. 



I 



II 



Iv^ 



i\ 



4' 



.1 .» 



vM 



WRITE PLAINLY WITH UNFADING .NK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ll,,.,r.l 'f II' •>"!' '■ ^'" 



"».t*-ar:ti, iu«v I' f 



I) 



(ifr ri/rfJ ,\(\j^vhX/^>rY\X^ 15 



d^As\j^^^^^ 




.-rficer 



Registered J^^o, 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)catb 

, tl. £. StaiiDat? ) 



^ 



PLACE OF DEATH: — County of 



^,cuw a;vcv>vev^ct City of Oxxm. ^Ax^^^^^ 



No 



m> 




"jlTYvjlvtA^ UIO (yU^vjl<xi St.; ^^^**^^Hn.O« under' ••SPC^iA'r.Nr^AT.ON 

4 . -^ i 



)- 



) 



FULL NAME 




\Xrc<X} 



nATK oi- niK 1 M 



PERSONAL AND STATISTICAL PA RTICULA RS^ 

1 (."(iI.oK 





Ka^ 



\jb 



MoiitlO 



Af.K 






(I):iv) 



Mntitha 



(Vcar) 



MlV.v 



MEDICAL CERTIFICATE OF DEATH 

"^•" ""^ "•^^:':" (iw 2LH 



(Month) 



(Day) 



(Year) 



^THrvRUBV CI-RTIFV, Tliat I attcn.UMl .lereased from 

i9;ci . ' ' looH to Qf^^^^ ^ ^oo H 



WIDoWlCn OK DIVOKCKl) 
iWritt in soiiitl dtsi^MKition) 



lUK rnri,.\cK 

'State or ConiUry' 




\oJ\XULd^ 



C:tV'>xvxx' 



NAMl". ni- 
I ATHl'.R 



lUkTlirLACK 
Ol- l-A ruivR 

(Statf or Country) 




MAinKN NAM1-. 
OF MOTHKR 




OT 



txJu 



^\ 




HIKTHIM.ACH 
Ol- MiVrHKK 
(Slatf or Conntry) 



that I last saw h ^A'v alive on MXcv-.... X2». 

and that .loath occurre.l, on the .late state.! above. 
Ol M. The CAISI- OF DIvATlI was as foll.ms 

0>a.<:L-^-<ixx/v-<:LaJmw^ ....,...- 

.tyvvJ(J-C'Av.\-^-rvr>:vt 



190 

at ...X, 



^ 



DT^RATION 
CONTRIIU'TORY 



Hours 



Cvv/dL<rt::.<<x.^wd^-'sJ^ • 

Mouths ^ Pays Hours 

O^ \| iLocA^c'^-^rvA. M.D. 



Years 



nURATIOX 

(SIGNED ).V^J^J^ ^ \|rLocA^v.^^A. 
Qf\c\:- XH Tc,oH "(A. Mress) Hl/ ^ ^^O^ 




OCCUPA 



00 ^-^^^>/a-.e-A,A.^^>i^ 



Rfsidfd in Siiu f'iaii<isi-<y 



^ X\ y,uu 



•- ^rn„f/lS ", ■Al' V: 



XHOVKSTATKnrKKSONA. ^AKT.^^^AK^AKKTK^K n. THK 
x,r;ST or MY KNOWI.l-.IX.H AM) in-.I.Tl.f- 

infonnant WjuM^ O -JU<X. . 



TUlv A 
UK 



,,,Mr.ss J0\^ Lliui dt 



SPECIAL IN FORM AT ION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from tioine. 

Former or )rt^--, .^^ol' 

Usual Residence uv/CU^Wtx- 

When was disease contract™, 
!f not at place of death ? 



( ^ y How lonq at 
K<L^ LoA I»lare of Death? I nrvvcf |Uys 



1M,ACK OF lURIAI. OR RF:MoVAI, 

fc/OLu^c^o<x.>v.t:U voJu 



i)Ari:of niKiAL or ri:m.)vai, 
QrUv ^b 190'i 



INDKRTAKKR 




A«Muss O05 



VnV^-^rvA/CMj, 



iLv^i. 



N. B. Every Item 



».rF k I I he Btatetl EXACTLY. PHYSICIANS should 

, of information .hould be carefully supplied. J^^^ ^^^i^^^jyj^j. The -Special Information" for pT- 
«F OF DEATH In plain terms, that It may be properly classnieu. 



•tate CAUSE OF DEATH In plain term* tnat .t m», ";--'- 
^on. dylnft away from home should be fciven .n every mstance. 



■* 



it 



Ivx^ 







I 



a 



WRITE PLAI 



l!...-ir.! of 11. :i!tli 1 



<^-,, , , •*.?'*»r54) ]\8i. I' Co 



I) 



(t!(> /-V/r^/, \jrLo>J-<L/>^»^-^^ 3lS 



NLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



li)0\ 



Registered A'^o, 



cW^-^-v^ 




DEPARTMENT OF PUBLIC HE ALTH=City and County of San Francisco 

Cevtificate of H)eatb 

( "a. S. StanDar^ ) 
PLACE OF DEATH = -County of^CL^ ivcx^c^c. Gty of J^- .}x^^^^ 



No 



.dJbUO 



X'^^^^ 



rV«.<i' 




O 



Ch^Vx 






St.; 



/ If DEA^T^ OCCUBS »W«Y FROM L 
V I*- oldATH OCCURRCO IN A HO 



AY FRod. USUAL RESIDENCE G.VE facts 



SPITAL OR INSTITUTION GIVE 



Dist * bet* ■ and 

-Ts'cALLED FOR UNDER "SPECIAL INFORMATION • ^ 
ITS NAME INSTEAD or STREET AND NUMBER. / 



FULL NAME 




VAX 




DATE nl lUK in 



PERSONAL AND STAT tSTICAL PARTI CUL ARS 



oJUi 



COT.OR 




iMoiith) 



AGR 



}>«».* 



(D:iv1 



M.>nt>is 



(Vt-ar) 



Dii\ 



M 



EDICAL CERTIFICATE OF DEATH 



DATE OK l)K 



■"" Q\^ ^H 

/l^.t,^»th> (Day) 



(Month) 



ipoH 

(Year) 



SINC.l.K. MAKKIl'.n 

wiDowKn OR nivoKrF.p 

iWritf in MK-ial (U-»ii>.'nati<>n) 




\<x\XoLcL — 



lUKTIll'KAiM-: 
{Statf or Country^ 



NAMH «»F 
lATHl'.K 



HlKTIllM.ACR 

oi' 1 •Arni':K 

iStat«- or Country^ 



MAllU'.N NAMH 
t)l MoTHlsR 



Axx-'^^v 



I 




VAaJtXj 



iuR'niri,Ai'H 
oi M»)'rnKK 

(State or OonntryV 



OCC\ TATION (Vn 



Tin*, \ 

HK 







I HHK1-:BV C1:rTIFV, That I attcmkMl deceased from 

.0^t...' 190H to Wa^ X^ too H 

that I last saw h X^•. alive on MIxJV" 12, 190 '"l 

and that death occnrred, on the date stated alKn-e. at U- ... 

..(X M. The CAUSr: OF DIvATH was as follows: 

C>Ax:*s^cr^i-.<xA-^cL>Xv^. 

C/v^^L<rUw<^^' 



^'Yy.-^.^. 



DrRATION }Va^ A/,w//;s ^ Mm /lours 

C()NTRIin'T()RY^A^^ 

Vj\Jt\XA^A-^V>AXX,'LvtL. 

DVR\TlOS Vt'^fS Months ^ Days 

(SIGNED) W ^ ^ 

()W- 2>vH igoM (Ad dress) 111?^ U/O^' 



^OOV^^TvA. 



Hours 
M.D. 



■ " ' ?^ I) OLAa' M\x\,^^ vl V K. 




Ihns 



,»OVKSTATK,M.KRS„NA, ^^^KT,^^.AKSAKKTK.•K T. . TH... 
•:ST or MV KNOWl.I'.IX.H AND Mhl.lhl' 

Infonnant V^JUWiv O . cW<X. 



,„,uoss wi-i uuLa Bt 



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

r .r„r % i^ I Howlonqat 

S Residence (fo<Xuj>.^>v<t. 'vaxA Place of Death? i.^>W ^s 

Wfien was disease conlractrt, 

If not at place of death ? 



ri.ACK OF lU'RIAI, OR KKMoVAI 



l)Ari:o!' Hi KiAi. or RKMOVAI, 






190 



(Ad 



T ir\ ItF should be stated EXACTLY. PHYSICIANS should 

ion should be carefully supplied. ^^^ "^""''^^^^^^ The "Special Information" for per- 

'H in plHin terms, that it may be properly classified. 



N. B. F.very Item of informal 

* *%Ail«F OF DEATH in plain terms, tnai n "•*., "- ,,.-.- 
"r;d"n?.w°r V-^ h««c Should be »!«.„ , y Ins.nnc 



f 



4" 






j--i»",yW 



WRITE PLAINLY WITH UNFADING I 

,„-|.No ..^?l?»'"--^'-^- 




NK-THIS IS A PERMANENT RECORD 

PE«R TO -.OK or CERTir.CATr rOR INSTRUCTIONS 

Re^Merecl ^''o. 'i'^*" 




,-.. ^-i^rt * - p. 



DEPARTMENtI)F public HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX, 3. Stan^arD ) 



PLACE OF DEATH: — County of 



ai 



OL^^^OL^ 



^oj .......City of 



)JJU>-^ C<J- 






PERSO 



si:x 



1>AT1-: (>»• IHK 111 




FULL NAME 

NAL AND STATISTICAL PARTICULARS _ 



C(>I,">K 



o^^ 





(Month) 



(Day) 



jVil 

(Year) 



MEDI 



CAL CERTIFICATE OF DEATH 



DATE OF DKATH 




..-••*•■** *rM**' 



(Day) 



I HHRKHV C 



IpoH 
„ (Year) 

(Month) _ — 

MarriFV, That I attendea deceased from 

loO -~— 
190 -^ 

190 




\C,K 



ba 



)'itn s 



\ 



M 



„.,„s l.^ -^'^ 



v." 



SINM'.I.K. MARKIKP. 
WIDOWKDOR niVOKCKl 
(Write in S(x:ial (Usivr"»t'^>"' 






BIRTH PI.ACK 
(State or Country! 




thatllastsawh.^— aliveon 

,„a that death occurre.l, .u the date stated above, at 

— M. The CAUSE OV DHATH ^vas as follows 

CU^^\^^^ 



vca \]Xrrsj^^ 



"^""'.(JULbU 



BIRTHPLACE ^ A 

OP FATHER ( \ Vl 

(State or Country) 




XAI 



DrRATlON )>''^''^ 

CONTRlBrTORY 



Months 



Days 



Hours 




MAIDEN NAME 
OF MOTHER 







Oj 



Months 



Hours 
M.D. 




- FORMATION "nly (or Hospitals, loslituHons, Transients. I 



orlefelS^csfdhnls^ndrerVonVdiing away from homr. 



Pa vs 



I^E^B AND BEUIEF 



? 




.yi.KS./vJk 



Former or 

UsMal Residence 

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

PI ACE ORnrKIAI, t)K RKMMVAI, 

UNDERTAKER 

(Address I ° OH 



How lonq at /. 
Place of Death? ^l 



Days 




DATKof lURiAi- or REMOVAI, 

Qrux^ ^^ 190H 



^.t 



Ion'* for p«r- 



_____^ ^ . pvACTLY. PHYSICIANS •hould 

- 7T. ...H AGB •hould b« stated EXACTLY. •: „ g„^ „.^. 

,tl«. .hould be crefuHy •^^J^^*^^ J^^^^ cl...ifled. The -Specal Informatlc 
Wm In pl»l" term*, th«t It m^y »• p^|^ 



-P 






n 



rfMI 



r 



A 

.t 



i l| 



WRITE PLAINLY WITH UNFADrNG INK — THIS IS A PERMANENT RECORD 

l..,ar.lnf H.ain,- » No , . l^g^ nS.V C., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)f//r /'V/rv/, VlTL^voL^rrJii 



,v^A; as 



IfJO'i 



Registered JVo, 



8340 



.CrVAA^ 






r' 



I- 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of H)eatb 



( "a. S. StanDarO ) 




No. 



PLACE OF DEATH: — County of LLlo^-wXcLoj City of U/oJk. 




d 



Loji' 



St.; - 



Dist.; bet. 



and 



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



FULL NAME 




iy>xN.u. . vU a^<^x-<r(Yv QXcr^um-'v^ 



1 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



DATi: ol- HlKril 




COI.OR 



<X.^ 



kj)f\jjjb 



Hi 



UDJv 

(Month) 



AC. K 



b X )v.,.A 



(Day) 



M.nitflS 



(Year) 



n 



Da vs 



SI\«,i,K >!AKKn:i>. 

\\ II)o\\i:i> nk !>I\()KrKI) 

lUiittiii '^ofial (1< viviijiliiin) 



lUK'rMPl.ACK 
(Stalf ut Comitry 



NAMK OI- 
PATHHR 



HIKTIiri.ACH 
Ol- lAllIKR 
(Stiite or Couiitrv'i 



MAI1)»:\ NAMi: 

OF MuTm:K 



RTRTTirr.ACK 
Ol- .M(HI1i-;k 
(stall or Country) 



oCCT'PATlON n 




dxA^cwJl 



cL 




lO 






MEDICAL CERTIFICATE OF DEATH 



DATK OF I) HATH 




(Month) 



A'6.........,„...79o'i 

(Day) (Year) 



I Hr:RrCnV CT':RTIFY, That I attencUMl (leccased from 

"190 to 190 "" 

that I last saw h alive on — 190 ~ — 

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

rrr-. M. The CAUSIv OF DMATH was as follows: 



LL W {rVOULyA . 



uvty^ 



/t3 



^OLVCTL-C^XOL' 










DIRATION Yt'ars 
CONTRIBUTORY 



Mouths 



Days 



/lours 



DURATION 

(Signed) 

A. 




CV :IH iqoH c 



IW/r.? Mouths Days 

(000. 



Hours 



ivr.D. 

Address) UoJkXoyvxxL VoJu. 



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



Re. 



sidfii in Stiv Fi iini i.u'ii iC )'iuns *" ^/l>llf/l.< 



/Javs 



Former or 
Usual Residence 

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



V*>«H»*»rit|i«.,. - 



How long at 

Place of Death? ^1 Days 



TJ11-: AUOVH STA ri-;i) I'KKSONAI. I'A K flCC I.AKS A K I-; TKll-: To THH 

HKsT Ol- Mv KNo\vi,i-:i)c.K AND hi:iji-:f 



(Infoimnnt \j . vJj . cU CrivvX 



X.Klrms \| l\\AAAJ^^XxJ[J vD <CN-^V\Jk 



ri,.\CK oi-iiUKiAi. OR ri-:movai. 






I nduktakkr Urvcuulxo (AO \ J; 



nAri-:of Hikiai, or RKMOV.AI, 



(Address .1*^ 0*^ \jYuJi'^<,tr>V (jL 



IN. B. F.very item of information shoulti be ctirefully Huppiied. AGE shoiiid be stnted EXACTLY. PHYSICIANS nhould 

iitate CAUSE OF DEATH in pinin terms, thnt it mjiy be properly classified. The "Special Information** for per- 
sons dyin^ away from homo should be f^iven in mvcry instance. 



11 

fl 



il 



f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



)i..riT<l <•(" Mi.ilili I- N(i. 1- '-'Xl'??^-'^ "^ '' ^" 



Ihile Fil,'<I^SV^^j~JLrrrX<hj aS" WO'i 



Regintei-ed J\''o. 



3341 




AA/) 




• , Wr%. •* T -* r /•- J™ 



DEPARTMENT iOF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. Stan^arD ) 
PLACE OF DEATH: — County ofO/CtOA. OX^Cv^x^culcc City of ^Cla^ J Vcx.^^c.v,^;lx:.q 

No. a,t<x>A.v.cx^v'^ '- JA.JLd,.:.Vv r.J: St.; '^. Dist.; bet. 

^ t(»\DEATH OCCURS AW*V FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECI 



and 



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



STREE 



(?5? 



:IAL INFORMATION'- \ 
T AND NUMBER. / 



FULL NAME 



y I \. 0"^"^ UCL :, ^J.co-Y>-^^rrULAy\rL.-' 




S5:\ 



PERSONAL AND STATISTICAL PARTICULARS 



A 





\ 



\\J^ 



,U 



I) ATI". Ill HIK III 



\<.K 



Month) 



51 



) I It t . 



<I>:iV> 



M.iHlhs 



(Year) 



Da vs 



MEDICAL CERTIFICATE OF DEATH 
DATK (1F DIvATH 



(Month) 



XS ^ I^O^[ 

(Day) (Year) 



si\(,i,i-: M\kui!:i) 
wiix t\\i;i) ()K i)i\» ti<ri;i) 

(Wiit'in sorial di -.u'liatioii) 



niKTni'i.AiM-: 

(Statf oT •."omit I \* 




NAMJ-: Ol- 

PATH i;k 



lURTlll'LArK 
0|- lAIMKR 

• Statr (»r C()\iiitry) 



MAIDKN NAMK 
Ol" MOTHKK 



T?iuTm'r,At'i-: 
()»•■ M()Tin«:K 

(Statf or I'ountt v) 



OCCUPATION 

Resided in Snu /'i ij in i^t-ii 



UXXXOLxi. 






I HI<:R1:BV CHRTIFV, That r attended deceased from 

~~~~ 190 - — to 

that I hist saw h ■— alive on -r-r-r-rrrrrTTrrrrrrrrrrr. 



190 
190 



and that «leath occurred, on the (hite stated above, at 
M. The CAI'SI': OF DICATFI was as follows 




.-i^inrynv... 




^*1 



^AJU' 




'\u' 



cL 



DIRATIOX )'ears 

CONTRIBUTORY .™ 



Mouths Days Hours 



>*«**(!*"*■--.-. 




( 



7 



DURATION _ }'tars ■. Months Pays 

iNED) W 



( SIGNED ) Wcr\^nvtv, J. Vij. U3. 'JUx<V>v€L 



OJ^ T90'; (Address) L<yUnv?A.o 



Hours 
M.D. 



Special Information «nly for lloNpildls, lnsliluiwlrs, Transients, 
or Rerent Residents, and persons dying away from home. 



y,ui, 



M.iiilhy 



l\t\. 



Former or ,o^'>M 'J -^L How lonq at 

Usual Residence \^^^ U XJU/k v-v-i-<^'u cJt pjare of Dea 



Oeatli ? 



Days 



rm-: ahovk s'iv\'n:i) i-kksonai, i* \k iirn.AKs ak i-; tkik to tm )•; 

Hi:ST Ol- MY KN()\Vl,i;i)C.K AND MI-.MI'.K 



(I 



iifotniaiit \| rVOJVU C)xA.yvvv/\'>xXAyvMjLLi?. 



\ 



(\,l,l,rss 1^03. OAJU^W.0- 



i. 



■\yU\\} c3" 



When was disease rontrar ted, 
If not at plare of deatti ? 




I'l^C^K OK lUK^M. OK KI:m»»VAI, j DAPKof HiKiAr. or RKMOVAI, 

^^\r. 'k^. ,gon 



(AcUlress ' ^ X^ - S Xl\ It 



N. B, Kvepy Item ol? iiiformHtion «houl<i be carefully Hupplied. AfJB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain termK, that it may be properly classified. The "Special Information** for psr- 
sons dyinft away from home should be £iven in every instance. 



I 



( I 



% I 



1 



1 



-J%. 



••. 'i * >•- 



1 



i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



l!<,:ii<I Ml" II. tit I; i' Vo. K '»-?^i^^. 158:!' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale /'V/^v/.mt^^^-rnJ^ 100^ 

dur^A.^ cLl/v>u Deputy Health OfTicer 



Registei'ed J\'*o, 



8.342 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( Ta. S. Stall^atS) 
PLACE OF DEATH: — County ofO,CL-Y^ O^O^YVcvwSj^ct City of O/Cu^rx' J Axx.^>Aya\^. c<o 

ti 




No, ^Oa VTUx-vX^VCrO^cl- \k.f\>Xj St*; k Dist.; bet. W KJc^ and llX-k Ll-A^AA ) 

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



FULL NAME^-2-'>^-vtx 



.nt'V VA^'^A.' 



V> 



cnx' 



^ 



QO\. 



,AwX/YX' 



PERSONAL AND STATISTICAL PARTICULARS 
'^JIX Art I COI.OK 



it 






> A ri': Ml I ; IK in 



M..iith) 



\ < ■- K 



Ho JV.;;.s 



(Dav) 



Mojit/is 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH 



iWr. 



J hi I -s 



SINC.l.K. MAKUnCI). 

U IIX »\\"i:i> Ok I)!VoK«.Kl) 

lU'ritciii soi-iiil (ltsi).'ii:it ii III ) 



niKTnpr.ACK 

'Statt or L'outitrv) 



NAM1-: OI 

FA'rm' K 



r«TR'i"nPi.A('K 

OI' I XIIIKK 

(State oT tNiimtrv^ 



X 



'A/WO/U. 



XK/y>'^<X/^'\,^\ 



CTru 




an fpo'x 

(Month) (Day) (Year) 

1 lllvRrCRY CKRTIFY, That T attejidcd (lcccasecr7n^i 

I90 to 



190 

that I last saw h. rr — ^alive on ■ ' .j.^ loo 

and that death occurred, on tlie date stated above, at "~~* 
^M. The CAlSlv OF 1)I<:ATH was as folU)ws : 




v'-yy^^.. 



<X 



\aX^X' 



I 



v) 



X>V>^VO.AAA.. 



maii)):n ^^^^^K 
OF MoTHHK 



JUK rn iM.Ai K 

OI" Mo'PHKK 
(Stale or Countrv) 



? 



} 



Dr RAT ION Years 
CONTRIIUTORV 



Mont /is Days Hours 



)X>WVV<X/>A„<.,( 



D r R A T I O X ^ ) '^(Jfs Afont/is .Days .^..^llours 

(Signed) ur\(mjav; OVb UO. djJla/>x<L m.d. 

\IICV- 3.S Too'\ (A(hlress) L^^..cmJL^.o 




o^„ 



SPECIAL INFORMATION »nly for Hospitals, InstifutlWii^ Transients, 
or Recent Residents, and persons dying away from fiome. 



OCCrPATION ^^\^ \ 

Kfsidfd i)i Stiff I'laitiisro c**.0 )V<;;.r ^.. Mniiths ..': Duvs 



Till', AHOVl". STATl". I) I' KK SON A I, I'A K I" U' T I,A K S ARi; TKIK Ic ) Til)-; 

HHsr OI' MY KNo\vi,i;i)c.K AND in:i.n;K 



Former or 

Usual Residence * 

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



••.»i»*«-ii-.**»i 



How long at 

Place of Oeatfi? Oavs 



*f>4»*«V*4ft*««>~«V«»«>^ 



(Iiifonuant 



^Address . 






P^.ACK OI' lUKIAI, OK KlIMOVAl, 



I)AI>: of HrKiAf, or KKM(JYAI^ 

VrUxr a>b, 190 H 



(Address IQwO^ \nXcXl^«u4..^-r\^... aJb. 



N. B. F.very Item of information should be cnrefully supplied. AGE should he stuted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information*' for per- 
sons dyin^ away from home shouiti be given in every instance. 



I f 



f 



I 



1 > 
; t 

t1 



I 44 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ll,>ar.l (if !I,:i!tli I- X... ; ". '^'<.-^:^'i'' i'-f^^ i"" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



iJff/r Filed, \jrt 



^\>^Sjy-rO 



\sV\) 



as 



100\ 



Registered J{o, 






tuc^^ dolvu Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Xl. S. StauDarD ) 

PLACE OF DEATH: — County of Jxx .X' Axc YveoCiXK. City ofO/Oy^x; 0XxX/>-v.qa_A.CO 

No. OjZAA'raXAV Ob (H./KA.tx3Ju St.; D;st.;bet. and —————rr=r.. ) 



0. 



(ir DCATH OCCURS A W AiY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' "X 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





SH.X 



PERSONAL AND STATISTICAL PARTICULARS 

! cf)i 



DATl-: <)I- lilKlH 



HL 






WO 

'Month) 



:t 



M'.V. 



1^ 



) V w t . 



(l)av) 



M.nitlis 



i%X\ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



J UV 

(Month) 



.15, 

(Day) 



(Year) 



IH 



Da \> 



-^l^<.IJ■: MAKun:i). 

\VII)tt\\i:i) <»K IHVoKiKI) 

iWiitfin •social (]r^iJ.•■natil)I1) 



RIRTHIM, M'K 

' Stati- or <,'o>intrv' 



XAMK <)I 
l-ATHl.K 







Jcr\)v 







nTRTTTPI.ACK 
Ol I Allll-'.R 
•Stall' or CN)untry) 



MAIDllN NAMK 
()!• .MOTUKK 



HlRrHPI.ACK 

Ol- M()'rm:R 

'stale ur Country) 





I IIHRI;HV Cl-RTIFY, That I atteiulcd deceased from 

ASL^\sSi^\^^AjUK,^^Jx'tx.f:v.l(p to AlTLOJ"- 'X^. I90 H 

tliat I last saw h -<-A>\ alive on VTLcV OvS". ..........jjpi.^... 

and that death occurred, on the date stated above, at ISO 
CL M. The CAI'S1<: ()!• DI'.XTII was as follows: 

vij->L^ryX/cJx>0 V]ryAXoL/v>v^rvA.CU. 



I 



X^yVYVOLAXlL- 




Drk.XTION Years Months 'S Days //ours 

CONTRIHITORY o(oJi/y^,n^UrdjUY^^/^^ 



DURATION ?)0 Vciirs 
(SIGI 



Months Days Hours 

NED )...jri^, .0. 0(9 0-''|Jk.v..-y-vj:j M.D. 

V jU?^ X5 , xqo H f A (hi ress) "<!) JUvW'xXXa^ (JC' 



M> 



i^t 



•V\rr\\/Xj-r\.K, 



oCCrPATlOH 



esitteif ill Sau /'i mii /m'h O l.- )'''ir> s 



AV.v/. 



Mioilhs 



Ihn. 



Special Information only for Hospitals, institutions, Jranslents, 
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? Days 



■*»•»"•• *■*#**■**•*-• ►*#<»!• 



IIU-; AHOVK STMl'l) J'KKSONAI, I'AK TICn.ARS ARK I'RIK To TM K 
IJHST Of- MY KNOW 1,1; DC. K AM) in^MKF 



(In foiniaiit ^ 



XN^A^v\,x:x/>^ 



ih ^^^f^^QjL 



(\Mrv 



»<s 



1*1, ACH OF RIRIAI, OR RHMoVAI, 

lni)i:rtaki;r flVD . 



F)A ri; of m KiAi. or rkmovai, 
Sh^^ ^.'L 190H 




L. 



'Address '^ IT. ^yr\A.XL^lAw'(rY\.^,.g..t 



IN. B.- 



-Bvery item of infoririHtion should he carefully Hupplied. AGB Hhould be stated BXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" f«r p«p- 
sons dyin^ away from home should be ^iven in every instance. 



I i 




;l 






i 

m 



»! 1 



ftl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J?.,;ii.l ..f IU-:i:tli 1" No ;•; t-^'^sr^-i; UScV ( 



Registered J\^o, 



fjf 



Dale /'V/^'/, Ql^Ajv-VryvWu X5. lOO'i 

^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( XX. S, StanOarC* ) 

PLACE OF DEATH: — County ofU/ar^Tu OA<<X^Aycc<i c t City of O/CXyw A^X/yvoa.axi.o 
i'No. Ibbl V£).U^<L-'(v St.; 1 Dist.;bet. JAxX/>%J[^\/yV'. .. and UCAAXXIX/. ) 

(IF DTATM OCCURS AW*Y FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N \ 

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



f 



I i 



1^ 



FULL NAME 




^a.^w^ A! Wcu.\^ [XjiA^i^^lhrihM.. 



^1 



PERSONAL AND STATISTICAL PARTICULARS 
X (JC\ ft ! COl.OR \ 



UJJ^"VVAJ6. 



1) A ri-: <ti liiKiu 



I Month) 



10. 

(Uay) 



/I'll 

(Year) 



\('.K 



ii 



] iiiff 



IL 



M.'vtfis 



X 



Pa 1 .V 



sixr, 1,1-: %t\Kuii:i). 

Wllx >\Vi;i) <»K IMN't »KCi:i) 
Write in sorial tli — i^'iKitiun) 



( )\0L'U\^OL/dL 



1 

(S 



st.it. ..I ''M.intiv> ^4 t^j^jtjrv- \ )^ JLcrtr-vv\JrvJLX./cL 



. ^ 

MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATII A 

\jW IH.. 

(Month) (I)av) 



(Year) 



NAM!-: or 
FA I" 1 1 1".K 



RrRTIIPT,A(*K 

oi" iaiiii;r 

(Stiitf III C"i)iinti v^ 



MAIDKN NAMl" 



BIRTIIPfMCR 

(»»•■ MorilKK 
(Statr or «.'onllt^^ 



OCCUPATION 



I R M OAA^ 




\kaa. 



CtlvAju 



a 






X^rVM3oOu 



I HIvRlUiY ClvRTlFV, Tliat I attended dccca.sed from 

lb. 190M to M'UnJr XH iQO ^ 

that I last saw \\-V\: alive on .VrUJ\r: %Sh n^ ' | 

and that death oeeiirred, on the date stated above, at ol-Ho 
li. M. The CATS]': Ol- DI-ATII was as follows: 

UJvJiyYWAXl \^<n^v./V^i.x.L^^-fc::^r^A...... '' 

DCRATKJN Years 3^ Mouths Days Hours 

CONTR I lU'TOR Y U</^CA.xLL/^xtxx..L....U^Jl«^ 



M.D. 






^ 












DIRATION Years Months' ' ib Days J/ours 

( SIGNED )....Uj<i"vaj dJ. UL<x;wk 

3-H TQo'i.^ (Address) bH'i OXAjtijlAj ofe 




Special INi-ORMATION Miily lui lluspildb, liiililuiiuns, Transients, 
or Recent Residents, and persons dying away from home. 






t1 

Sim 1 1 III), I -III ; D 



);-,ii 



Moiith- 



thn. 



Former or 
Usual Residence 



How long at 

Place of Death? Days 



rHK XIJOVK STA T1-',I) PHRSONAI. I'AKTKT I.A KS AKIC TKrH To V\\ V. 
UEST Oi- .MV K.VOW l.l'.DC.H AND III;I,11:F 

nformant dJ/0U>vOUj M l\ . lJjX4AayYVlMJU>.. 
(A'1.1r.-<s \{d%\ ^$iX\AMj 0% 



(I 



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



I'I.ACP: OK BURIAI, OR KKMOVAI, I DATi: o! Mckiai, or RHMt)VAI, 
I'NDKRTAKKK ML- O AXXA/J ^\k V-C 






\<l.lr.ss ^^S'i^ ^''i>5"T 3>U..t/LL\i dJL 



N. B. F.very item of informatton •houlcl b^ carefully Hupplietl. AGB dhould be ntatetl HXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly clasnified. The ''Special information'* for p«r- 
Rons dyin^ away from home nhould he lliven in every inHtance. 



f 



'i jj 



§ ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



D^f/r FiJrd, MWml^/>J>^ lOO'i 

Deputy Health Officer 



Registered J^o. 



8,-345 




DEPARTMENT OF PUBLIC HEALTn=City and County of San Francisco 



Ccvtiftcate of 2)catb 






( '0. S. StatiDarD ) 






^ 



PLACE OF DEATH: — County of J/Cta^' >uX/^v^CA-<a<^^U) City of Cj/CX/^ru >Vcx/vvyovxi. ex 



4 



No. Ibl^ OxaJLLuv St.; 1)" Dist.; bet. ^/cJLcX/^j-^Ou and ckxx^vv-vvaj ) 

(IF DtATH OCCURS *W*V rROM USUAL RESIDENCE GIVE facts called rOR UNDER "special INrORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




u 



DA'll-: (>l IIIK TM 



(Month) A 

\^ 



.ijJvcMj 




cinw...... 



MEDICAL CERTIFICATE OF DEATH 



W A'iS 

(Day) (Year) 



ACK 



?S 



) ra t . 



M.>uth< 



H 



Day, 



sinc.m:. MAKKn:i). 

\VII)()\\l-:i) OK DIVdRTHI) 
iW'ritt in social (U-^iKnat i<«n) 



lUKI'Ul'I.AOK 
(Stiit<- or (.■onntrv^ 



NA>fI* OI- 
I ATHHK 



HiK inri.ACK 

()»•• lAIHllK 

(Stiitf or r<)vintt V 




^ 



Cvr.. 

(Month) 



'^O I go^ 

(Day) (Year) 



I in:i<l<:i5V CM;rT1I-V, That I attenfU-d <lecca.sed from 



LLa^aOX S u^H 



■^ 



to V urvT: %%. i^ H 

Ajl^rir a.Qw looH 



that I last saw h ..*»..■ alive oti .,...> m \^\r (js.«^ iqq 

and that dtatli occurred, on the «late stated above, at M 
LL M. The CArSl<: ()!• DIvATII was as follows: 

^Vm^vAtKexxVcL*^^^ _. 

O /Ql-CLca. oUjL.Q^..ey\:'vX.VO^^^ 



MAlDlv.N NAM)-. r\ 

OF mothi-;r \\f\ 11 1 

-_. -..^ M IV/CXXXX-CXAXAj 

inKTHI'I.AOK A 

OI" MornFR fv> vJ A 

(State or Country) L, 11 

-_ \w/^rLXD/\XX':vvcL 
:ci'rATioN {\i • ft , A 

Kryidrd in Sav /'i nin isro OO )V(M \ 



Dl' RATION Years Mouths Days Hours 

:ONTR IHI'TORY UJLt..cdk-.^^ .<X<vv^ 




A^\^j(L O/WV'Cr'V'^-A^v 



^ 



DURATION 
( SIGNED ) 

\jWr XH.. 



Years 

,|.(f. li 



Months 



Days 



I /ours 



T90 



( 



-<^^>^^VJL M.D. 

Addre>>s) ^jOvI: \JlU>vt<Xv4 Ot 



^ 



SPECIAL INFORMATION only for Hospitals, Institution?, Transients, 
or Recent Residents, and persons dying away froni home. 



occ 



1 A. >////- 



A/ 1 



Tm-: AHOVK STAT)",!) rKKSONAI, 1' \ KT KM' I,A K S A K I-; PKIl-; To Till': 
IJKST OK MY KNOWIJ'.DC.K AM) H1:MJ:F 



(InfoTinant 




a. iL'.a 



^->crvA< 



A.idrcss Hl2)*l* '^S X^'Vx^ Oi 



Former or 

Usual Residence .-«, 

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



How long at 
Place of Death ? 



Days 



PL-ACK OK BURIAL OK REMOVAL I DATi: ot Hikiai. or KKMOVAI, 

9sbAj>b VirlAA^^A^^rnj uL 



(Address 



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 he properly classified. The "Special Information** for psr- 
sons dyin^ away from home should be l^iven in every Instance. 



I 



■|a 



v-- 



1 



4n 



'3 1! 



' I 



'. -I 



lii 
1 1 



t 




fc. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






/)((/(' h'iJcd , 





U'^'\^o 




\) 



"1 



as loo'i 



Deputy K-ieaith 0<Ticer 



Rpgi.stered J\''o. 



3346 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



PLACE OF DEATH: — County of 



dj^r<i) LL^POVJLU Ci 






ty of 





'y'\xxxXx.^ Ox\ 



No. 



St.; 



Dist.; bet. 



and 



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

Crt) J.Aa.... 



FULL NAME 




':'0^y\,.. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



w 



I 



<X'<-il 



DATK ol UIK 111 




t Month) 



(Day) 



OL^^ 



zib^ 

(Vear) 




\C.V. 



ss 



) 'rti I s 



M.nit/is "" Ditv 



siN(.i,K. MARKn:n 

WIDOWKD OK DfV'oRrKl) 
I, Writr in sociiil drsij/jialioii) 



lUKrmM.Ai'H 

(Stiitc f)r Conntrv 



? 




^V^\^<X> 



N'AMl-; OK 

FA'i hi:r 



lURTIIlM.ArK 

oi-- i"Arni;R 

iSt.itc or Country^ 



MAinKN NAMK 
OF MOIHKK 



lUKTHIM.ACK 
Ol" MOTHKR 
(St.'itf or Country) 




-^ 



MEDICAL CERTIFICATE OF DEATH 



I HICRI'BV CI-RTir-V, That T atten(UMl deceased from 

— to 



"~~~ — ' 190 to 190 

that I last saw h ...~~" alive 011 ^ 190 

and that death occiirre<l, on the date stated above, at 



~ M. The CAl'Sr-: OI*^ DI-ATH was as follows: 



or RATION Years Months Days Hours 
CONTRimiTORY 



OCCri'ATION 

Kf sided ill Siin /'i ail. i-r,i 



)'iars 



DTaRATIOX 

(SIGNED )...lij,. LI 

VlU^r \% 100 H. (Address)Xo^ 





M.D. 

Lu Lai. 



Special Information »nly for Hospitals, In^ltutlons, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 



How long at 
.,. Place of Deatfi? Days 



IV,?; 



Mnllth^ 



Da 



Tin-: AHOVE STATl-.I) I'KRSONAI, I'A KTIC T I. A KS A K I*. TRTK To THK 

UKST OF MY kno\vij;i)c.f: and ni:i,N;F 



(Informant . VsJ\jL^rrN-^OV-CxX vJjL'W>xaX 



^ \<l(lrt"<s 



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



ri^ACK OF niRIAI, OR RHMOVAI. j DA Ti^ of Hcriai. or RF:M0VAI, 



^I'l..- 




rNDi:RTAKF:R 






^^aucL-. 



N. B. Every Item oi information should be carefully Hupplied. AGK should be stated EXACTLY. PHYSICIANS should 

state CAUSE OP DEATH in plain terms, that it may he properly classified. The "Special Information" for per- 
sons dyin^ away from home nhould be ftiven in every instance. 



I ^ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Mar.l .f He ,1th 1 No . = t-^-g^ lK«t 1' C; REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)(Ur riJr(l}^^hj^\yJ^^ X^ I'^O'i 



Registered Ko. 







u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of IDeatb 

( "U. S. StanDarC* ) 

J? (^ J? 

Ox 



^ 



of^'^CU^rv^ ^/UXAAXi.uic.t City of OyCX/rv /vx:>^^^<i\-^:l^u^ 



-? 



No.1 1 H la dJxU">''r»xiji St.; X Dist.;bet.d/X'C\,0„-vv^i->'JUand UUX.^.i. 

- TORUNDER"SPCCtALINFORMATION"\ \ 

NSTEAO OF STREET AND NUMBER. ) J 



/ IF DtAT^ OCCURS AWAV FROM USUAL R E S I D E N C E G I VE FACTS C*_LL_ED F 



IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



FULL NAME sJO/x^o^o ^ 



PERSONAL AND STATISTICAL PARTICULARS 



DA IK «)1- lUK 111 



COI.OK 



kOLKoi/'fvJUJl 



u 



M'.V. 



X\ 



tMoiith) 



Yrat 



( Dav) 



Mntilh\ 



(Year) 



Pa y: 



SINC.l.K M.\KHn:i) 
'.W'titc ill MK-ial ilt^ii^Miiiti'iii) 



lUK riiri. \oH 

(Statf or (.■ounti yt 




olWul-cL 



Ow/VV'CX^A.' 



FATIUCR 



F'.IKTHI'l.ArK 

()i- I Arm:K 

istatr or I'Diiiitry) 



OF .mothi;k 



oi- MOTIIKR 
(Stat*.- or Country) 



r 



1 




CU:3Cy.\^CV>Q/^-^^^^^-sA ■ 



MEDICAL CERTIFICATE OF DEATH 



D.\ TH t)F DK.XTH 




(Month) 



(Day) 



(Year) 



I III<:RI:HV CIvRTIFV, That T attendtMl deceased from 

ftliJV- Q.?> 190H to CK^P-^ . XH 190 H 

lliat I last saw h-»<!-'A. alive on \i\<OJ-: .3».H.... 190* 

and that death occurred, on the date stated ahove, at ^ 
M :\r. The CAl'SIv OF DICATII was as follows: 

J XAJl>«-Oy./CAAX^^-^^-<<x; ^J A.AJ0^^v/A..^<rvvoJLA-4i 



Dl'R.VTION I )V<7r.y H Months Days /Jours 




0-Q^a. 



Hours 



CONTRIIU'TORY 

..CuL\^ ,.... ,.».... 

DURATION ^ )'rars ^fouihs Days 

(Signed) Cb . M R/xL<x/^vxixx.k>u M.D. 

nJUV" XH tqo"\ (Address) 5^0 5 jJj-U^Jn^t ut 



occ 



f\ f.u'ihil III Sitii /'i dill i-i-ii V-< )V(M\ 



rF.\TION (Vo 



yr,»itiiy 



n< 



T[\V AHOVK STAII".!) I'KKSONAl, FAR lUri.AKS A K l-; TKrF TO TIIK 
IJHST OI" MY KNo\V1,1:1)(^.F: AM) lUCl.IHF 



(Iiifo! inaiit 



( \<Mrfss 






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



Former or 
Usual Residence 

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



How long at 

Place of Deatfi? Days 



fi,acf: of ihriai, or rfmovai. | DATFiof m KiAi. or rf:mov,ai. 



indf: 



Qa.(JV- aiu 

RTAKKR (X- LO. \Jn^^XL^^r^ ^^'^ 

(.Address 3)1.'^ U J /OL^v.AJuLi O.t 



N, B. Rvery item o* informntion •hould be cnretfully Hupplied. ACIE should bo stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnln terms, that it may be properly classified. The "Special information*' for psr- 
sons dyinft away from homo Hhoiild be f^iven in every instance. 



I • 




-V. 



*^Smmmmmam 



» 



*i ! 






1 



■i 




! i 



■^' i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,„„,,,, iialth ! v> - t-^^4 lU^tl'Cn ^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

" 3348 



Beglstered Xo. 



Ihtfc Filed. \)rL<3V^-i/Y\'vl^\; ,Q^k^ 100'\ 

<xcv^^o^ •LiA.M< 'Deputy Hcaiih OfTloer 

DEPARTMENT W PUBLIC HEALTH=City and County of San Francisco 



■'No. 



Certificate of 5)eatb 

PLACE OF DEATH; — County ofOou^^' JX<X'rs..CAA<:' City of 0/CX/>\; J A<x/>^<ivA^cc 

3.^1 1 (jC^V^^aL' St.; 1 Dist.; bet. KJLX/^^O vdlA. and 

/ IF DF*TH icCUBS AWAY FHOM 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. / 



r ^11 4 

Jv<14'\.. and AAAMJUj. 



FULL NAME JXVL4.a \^>>^-tx-»v 




.cLcr 




PERSONAL AND STATISTICAL PARTICULARS 

I C"<»I.()K \ fk 






\\x^ 



u 



DAT!-; OF lUKlH 



''CX.'^-v 



(Day) 



/UH 

(Year) 



.AC.fi 



'ID 



) (•(I^.' 



10 



Months 



Davs 



WIDnWI-: I) OK IMVoKi}-:!) 
i.Wtilfiii s.Hial <l«Hij.Mi;ili«.n) 



(Stafr or i,"MUiitrv^ 




)x^6^<!KKr 



N.wn: OI-- 

I-ATIU'R 



m 






lUK TIll'l, ATI-: 
Ol' l"A rilKK 

(Stiitc <>t Ciiuntrv) 






<X\a..CC'C 



MAinKN NAM I', r?\ . 

i)V .MOTin-.K III 

__ LcLAwL<X\A/Y>^OL; ViJJ-^iAXX' 

^___..uL ^ 

OCCUPATION (T\ t A 




MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH 



(Month^ 



(Day) 



IQo'i 

(Year) 



I 1II':R1:P>V CI-:RT1I'V, That r atteiidtMl (leceasea from 
^^^i.AiA., 3 190S.. .to Qft^TU- 3lH I90H 



1 



that 1 last saw hXV alive on V WCV^ An Kp 'i 

an<l that (k-ath occurred, 011 the date stated above, at i- 10 

,' '' 

.U.... M. The CAI'SP: of 1U:ATH was as follows: 

^. .( f ^ y A 

....%D.l<<xbJL. 




^..crvv Cx.tfT... 



DTR-XTION X }'i'ars iMoutfn .- 

CON TRII'.r TORY J XO:-s-«A,^<^....Lv. 



Mouths ...... ./J><7i'.s- Hours 

>0.^:C^.<l^QyA<l^cx» 



HlR'niF»I.ACK 
o|" MOI'III'.K 
(Slatf or (.'ouiitrv) 



M,;i>h^ 



Ih, 



III)' MiovK ST \ri:i) I'l'KsoNAi, I'AK'ruri. \ks aki; iki }■: 10 111 !•; 
iJKsr Ol" MY KNo\vi,i;i)('. H AM) iii:i,n;i- 

JJLVjUOu-Ou dLO^^AjJltvA/ 



(luf'iMiiaiit 



( \il(lr.s^ 



ni*^ 



Cri-c 




)t 



Dl'RATION lV^//-.r Months Pays Hours 

(Signed) dv. iJAJj<xcv<a^i:x.u^vu M.D. 

\llcV' '3i.^ ic,o'( f.\ddress)^OS U aXCty ^ jt 

s, Institutions, 



SPECIAL INFORMATION "nly lor Hospital 
or keient Residents, dnd persons dyinii dWHv fro;n home. 



former or 

Isual Residence ............ 

When was disease confrarted, 
If not at plareof (iealh? 



How long at 
Plare of Death ? 



Transients, 



Days 



IJ.ACl'". Ol- UrkFAI, OK KlvMoVAl, 



ri.ALl'. I M- HI K \\ 

ObcrUx Ul 



DAI'Kol" Ui HIAI. or K1-:MoV.\1, 

yV<5-^ '^'^ ---'- 



5\r '!'[ 



T90 I 



INI) 



iirtss 15 XS. 3ix>-^:Jw.^I^'vu oJL 



N. B. l.very item otf iii*..rmrttion should bs cnrultully .suppHtftl. ArJE should bo stated liXACTLY. PHYSICIANS should 

Htotc CALISK 01- DliATH in pliiin terms, thjit it mjiy be properly claHHified. The "Special Informiition" for p«p- 
«on« dyin^ away from home Hhould be J^iven in every inHtnnce. 



I » 



*s 



i 



It' 





;^T 



/)(f/(' Filrf/Mi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3349 



15<>ar<l ..r" M.altli - I" No i^ '^'^S^:!?'^"--^' "ftl* C 



C\>X">^V 



WJ\J 



Xio 



lOOH 



Ee^l^teved Xo. 



dUn.M^lji\hu. Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Ccvtificate of 2)eatb 

( tl. S. Stan^arD ) 
Cj/CL^^ J . Vol/-^ V ac4 c L City of 'O^^ J A><X ^^<^v^ec. 



..3^.\ .aaj 



No. ^nr VlitrvA- -.- - St.; 5 Dist,;bet. 

/ ir/tEATH OCCURS AW.V FROM USUAL RESIDENCE GIVE FACTS CALLED rOR UNDER S PEC I AL . N FO R M ATI O N \ 
\ (jF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



and oil lYvcL ) 






FULL NAME 




^\jj 



PERSONAL AND STATISTICAL PARTICULARS 

COI/)R \ A 

DAii: oi luuin 

Qx'kl... ^H 

M(.ifth) (Day) 



SKX qj> 

0. 



(Year) 



ACH 



.^ 



)'i lit s 



Mouths 



Pa 1 . 



slXi.I.}-: MAKRlj;!). 

\\ii)o\vi:i) OR i)ivoK(i;n 

'Writ' ill ^■>ri;il (lc^it.Mi;iI i' m ) 



HIKTITri.AOK 

(Statv or (."oMiiti v^ 



NAMK (>1- 
I'ATin-R 



niRTUPI.ACK 
OI lAllll'.K 
(St.itc (jr Country) 



I XX' 



nrvLoj 





A 



\/ 




o^\ 



Lv^-^uIxao.' 



MAIDl-'.N NAMK 

oj Mo'rm<;K 



!U1< IIII'I.ACIS 
ol' MOTHKK 
(Stiitf or Country) 




\XX) 





MEDICAL CERTIFICATE OF DEATH 



DATK OK ni-:ATH A 

ilUr^ 



as. 

(Day) 



(Year) 



(Month) 
J HlvRI'JiN' CliRTH'V, That I ;itteti(U-(l (Icccascd from 

^J\{^^J.!© 190H to ft\^3xr ik.S:: k^ h 

that I last saw h -i-^^- alive on xPUTw^ /a^.r!..., 190 't 

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

- M. The CAI'SI': OI' 1)1:ATII was as follows: 

U-cUL^rv'^-^<>-^-^^^X^.>lLA^ J<^J\)^\^^\^^K,^r<ir\.^\ 



DT RATION ^ ]'t'ars I Months Days I Jours 

CONTRIIU'TORY 



JUMxiju^ij 



OCCITATION 

h'fsiiifuf ill Sail Fnnni.uo 



)'('(// 



\n',iths 



l\i\. 



TIM', XnoVK STATI-n I'KRSONAl. I' A K I" IT K I.A KS A R !•; TK K K TO rui-: 

iii:sT OI" MY kno\vi,i;dc.k and i{i;mi:k 



(InfoMnruit 



C\<l<ln-ss 



^Hl 




DTRATIOX 

(Signed) 



I()0 




)'('(irs 



Mofiths 

AaXVAj CnXX-Q Cu>tj 

1 1 % 

Address) 9.3 5 k) ^W/<Xv\d. t 



Days Hours 

M.D. 



(.^ 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyiiiy awdy fioiii lioiiie. 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



ri.ACH ol" MIR^XI. OR KKMOVAF, 



UjAvvJlA^ 



-UJ-TV' 



DATliof Htriai. or RKMOYAI^ 

\j\(r\r X'o T90H 

l^\U)KRTAKKR X n.^rV\XxXvOL/VV vj (Jb OX/Ou ^^ 

(Ad.lifss ^^'^^ \J lLA-.^,Xi^V-^r>-W.....d.t 



N. B. F.very item of information should be cnrefully Huppliod. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it miiy be properly classified. Tlie * Special Information" for psr- 
sons dyinft away from home should be ftiven in every instance. 






» 



1 if 



i Hi 






WRITE PLAINLY WITH UNFADING INK — 



IVwi 



r.l ,.! II. ,-.!t1l- !•• Nn. i^, f-SlS^^ »&*' ^'' 



A 



/ )((/(' /vA^^/, ^Nn(^My>^vl-\V Aic 



/ry^;s 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

8350 



Bro^i''<f^rrfl A^o. 



tfrv^c^lt^H, Deputy Health Officer 



^> 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( XX. 5. StanDarC> ) 
PLACE OF DEATH: — County ofCiO/^-vsJ/L-CLAVCA^CL City of JCU^v J;vxX-->^toa.cc 




tiv 



• No. iOl'i OtcrW^xvcL . St.; H Dist.;bct. 1dX/v and 

- ^ / .r or.TH OCCURS AWAY TROM USUAL RESIDENCE G.vr PACTS CACLED ^O" 7^" J:IVt^\,^o'^U^bIh 

C ,r DEATH OCCURRED IN A HOSPITAL OR .NSTITUTION GIVE ITS NAME INSTEAD or STREET AND NUMBER 



FULL NAME 



)X^KX"yxr>AAJ 



)X^.' 




PERSONAL AND STATISTICAL PARTICULARS 
SK.\ A ""~~^ ) COI,OR ^ A 

.<xu : ^^ vXJ^ 

i».\ ri. < u lUK 111 

/ HO. 




i-XA.' 



Ijb 



ti 






ACK 



iitn s 



(Day) 



M.itiUis 



(Ytar) 



/)</l.v 



\viiM>\\i-:i) <»K DivoKn-j) 

!Wiit<iti •^<n-i;il lit •^ij.Miiiti' >n) 



lUKTHPI.ACH 
(Stall' or Coiiiiti y 




Q^UvvOyUL 



c^^ 



NAMl. <H 

»"ATn i:r 



LCC' 



niRTnri.Ai'H 
oi- i\rm:K 

(Statf or Ooiinf ry) 



h 



MVc 



)Jb\j 




\x»^jYyJo 



1 



OOV 



1- MOTIIKR \J I \ • 



OI- .MOTHHK 
(Statr or Country^ 





AJ 



OCCrPATION 

Rfsidnl ill Siiti I'litin ism 



... O Months I J /'(/!> 



Kwi*af. 



I'm- \1?()VK srATl'.I) I'KKSONAl, PA R TIC r I.A K S A K l! PRTK T« > VWV. 
IlKST OF MY KN<)\VM;I)(1K AND Hl'.Ml'.l-" 

(V '^ 



( liifo; niant 



(Address. lOoO 




ChwAj-<XXXL c.ji 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)F;ATH 



..M\'t5^^. 



(Month) 



..IH.. 

(Day) 



790 H 

(Year) 



I in':RI{HV C1;RTI1'\', Tlmt I attemUMl dcciased from 

..\hj^^:.....X'± 190 H to NXUv- XH 190 M 

that T last saw h-u-v>\ alive on VfVtjv- XH 190 ^'^ 

and that death occurred, (MI the date stated ahove, at D-^C 

M M. The CAUSlv Ol- Dli.XTII was as follows: 
LrVv^^^n-OCAv/rvv^ JU^^r»v kA^^ XJ^^Aa (S\. 

J{)--^0LA./>VQ, A-'ft'V^V • ■ 

I)rR.\TI()N Years Months \ l^ay^ I^Ioi 



Hours 



Years 



Mouths 3v Days Hours 

O Crl^0-^JiXcM4 M.D. 



nrR.\TK)N 

( Signed ).\ a ctv-cka^cm^ 

.^~ XS \K)o\ (Address) lOM'H'bJ 



Special INFORIVIATION «nly for Hospitals, Institutions, Transients, 
Of Recent Residents, and persons dying awdy trom home. 



Former or 

Usual Residence 

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



How lonq at 

Place of Death? Days 



I'LACK OF" lURFM. OR RFMoV.M. 



^i-sJLv^^zw 



OXTF: of HiKiAi, or REMOV.\I« 

\A'<rw"- 2lL 190H 



I- .V I ) 1: R T A K F. R 'oSjLt^TkXJL VTVUXAA/VX^V) ^^ L( 

f Ad<lri-ss 1 5 V\ Okjy^LMXAn^ -tj.l 



^. B.— Kvery item of information should be carefully supplied. AGK should be stated BXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special fnfc.».mat,on for pT- 
sons dyinft away from home should be feiven in every instance. 




<* 



II 



4», 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hoar.l ..I HcMltli I- No i - -^'l":*^— -■ Hv«t I' Co 



l)(l 



l(> J'y/r(fSK^Ss>-^i^^\^^ ^»o J'^O'i 



Be^lsfe?'ed J\^o. 



3351 



cLc-v^^^ 



t 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certiticate of S)eatb 

( "U. S. StanDarf) ) 
PLACE OF DEATH: — County ofjoyy^ J;va/>v^;;.uMLC City of^ O-^r^. J AxxyTv<:.v^^o 



-? (^ 






t, 




No G'bS Ciixv-t/^^«i.trrv- St.; 1 Dist.;bet. h JJ\r and 

FULL NAME U^uxxA.. WX.c<xA^' 



T i I V 








PERSONAL AND STATISTICAL PARTICULARS 



DAIi: Ol IIIKTU 



Month) 



(Day) 



(Year) 



A<,K 



bo 



) Vi; > s 



.1/..;////* 



/)<n 



SINC I,K MAKKIi:!). 
\VlI)<)\Vi:i> OK IHNoKCKI) 

'Writt in ><n<M;il (l<si^Mi;»t ion ) 



niRTITPT.ACR 

'Statf or Coniilry) 



NAMi: ol 

I A'ln i;k 



PTRTITPI.ACK 

Ol" j-A rm-:K 

i stall- or I'onntt \) 



MAIDl'.N NAMK 
Ol- MUTIIKK 



niurnri.ACi; 
Ol- MoTm-:K 

(Stair or C'ountry) 



OCCUPATIUN 




Krsidfil ill Sini /'i nii< i^''<i 



Vr,! I 



Mn>,lh< 



Ihiv. 



ISAEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 




(Month) 



A3. 

(Day) 



1/ 



igo 

(Year) 



J HHRICnV C1;RTIFV, That I attondod deceased from 

Qfl^xr ^ 190 H to \h'<TVr ^2) 190 H 

tliat I last saw li.i-^>^ alive on \r^<3V 9sS up H 

and that death occurred, on the date stated above, at v) 
Vj M. The CAl'SIv OF DIvATH was as follows: 

s-<Ka^<^^ . U /cu(yv-s..AJL'?^'xt, 

JL,{0^'\Xi, 



.<rL...y.v,. 



DT RAT ION ^ Years A/oni/is Days Hours 

CONTRIBUTORY LL5:L\..\^Lt. M\xA^J[.x.^^ 



DURATION 
(SIGNED ) 



Years ^ Mouths ^^ Days 

t- 0/:>VVYT\JLAyX, 

Address) "l Si Jb <^^-^^<V^xi. jt 




Hours 
M.D. 



( 



Special information onlv 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? 



Hew long at 

Place of Death? Days 



Tin: AHOVK STA IKI) I'KKSONAL »'AKTICri,AKS A K K TRTH TO TUH 
IIHST 01 • MV KNO\VI,l-:n(.H AND lU-.Ml-.l' 



(InfoMuant 



(Address 






ri,ACK OF HlKIAr, OK KI-IMOVAI. I)ATl-:<>} Miriai. or RKMCJVAI, 



indi-:ktaki-;k 

(Ad<ln-ss' 1*10 T 



NkKu^Ok (rO^x^xtvvv 



.^.t... 



.... c II.. «..»»i:...l AGE should be stated EXACTLY. PHYSICIANS should 

" "•-r^r/jr.^E orDT:;H'',:''rn ^:;^::' h':^ rrX't :-Z:^, c....,..-. th. -spec,.. .„,o.™....™" ,.,. p... 

son. dylnft away ?rom home should be ftiven In^very Instance. 




II ''I I 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



no:,i.l of Ui-.M; r No, i^ -th-- ~-^> !5S:1' Cj 






IVO'i 



Registered jVo. 



Qorro 



'VMU, 

^1 



Deputy Health Officer 



DEPARTMENTS PUBLIC HEALTIl=City and County of San Francisco 

Certificate of Beatb 

( 11. 5. i5tan^ar^ ) 
PLACE OF DEATH: — County ofCa^v O.Vc^->vc^cc City of 0<X^ J-VCl>vc^cc 



(NoJ 




( " r.'"»,°"c"^r.",'.T„o"s'r.t o%"«s"?'u"o'^~"v'"i NAME ,.ST„. or S,«.T .»0 .U« = .R. 



) 



— ) 



FULL NAMEUvc 




^ 



,ttU L<XXM3-aQ,rv 



t 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




i\oJa 



lo,! 



-k-Cti^ 



i> ait: < ti- I'.! Kin 






<Day) 



(Year) 



A<. K 



. JVtiJ.v 



M„nlh.^ 



.1 



/?a v.v 



W M X > W 1-: 1 ) ok I ) 1 \'< ) K I ■ 1-". I ) 

iWiitt ill -iooial (U'sis.Mi:iti'>Ti) 



\ 



niK'rnjM.M'K 

(Stiitf i)t i,"<)Uiiti y> 



Si (^ I 



NAMI-. t»I 
I- A'lUKR 






RiRTin'i.Ai"]-: 
()(• 1 aphkk 

iSt.'itc or C'otintiy) 



MAIDl'.N NAMl' 
t)l- MOTHKK 



nTRTHPT.ACK 

OI" MOTHHK 

(St:it«- or Cotiiiti \-1 



? 





X' 



.Lvlvotjj 



LoXAXt 



occri'ATiox 

Rf stiff,! Ill Sitii riiiihiu-o ....... ..Yt-ii I < 






trVovu^u 



M.r.itir 



I\i\ 



Till- M?<>VFST\|-J-I) WKK^oNAI, I'A KTUT I.A KS A K i: TR TK TO Till-; 
HKST Ol-' MV KNo\VM;|)<; K AND Ml-.I.tl-.l' 



(Infnnnruit 



L/(f*V/CrYAj8Jvo 



DO 



f Xddre 



MEDICAL CERTIFICATE OF DEATH 

DATK «)I'" DKATH 

(Day) 



,{i\r. 

(Month) 



(Year) 



I II1':R1:BV CIvRTII-V, That I atteiKlcMl tlercased from 

.,— r— 190 to T90 

that I last saw h ~ alive on • ' ^^P 

and that death occurred, on the <late stated above, at 
:VI . The CA r S 1 •; 1 •' dm a r 1 1 was as fol 1« )ws : 




DURATION Years 

CONTRIIU'TORY 



Mouths 



Days 



Hours 



DIRVTIOX ^'<''?''^' /v-v ^^oHt/js ^ Days Hours 



(SIGI 



1 UO. dJlXcuvxcL M.D. 

Special INFORWATION «"ly for Hospitals, InstitWWns. Transients, 
or Recent Residents, and persons dyinfj away from home. 




90 "i 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



tqqH 



IM \CK 01 lUKIAI, OK RKMOVAI, I DA TK of Ht rial or KHMoVAI, 

(Ad.hcss 5iow- i^ ^. at 



... . I, 11 H. nrefullv suDoIied. AGB should be stated F.XACTLY. PHYSICIANS should 

■on. dylnft away Sron, home »hould b. ftiven in ev.r, In-t.nce. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lioar.l of li. alth I' No. 1^ ^^^^^ Uf^V Co 



i r 



Iflll 

am 

^ 11 



I)(f/(^ Filed , 




..k^ 



VAw^ 




.V- 



n- 



y^^ X\o. 10 o\ 

Deputy Health Officer 



Registered J^o, 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( tl. S. StanOarJ) ) 



PLACE OF DEATH: -County of0,cv>^ J.Vc^^-vav^ciGty ofU.C^^ a,V<xy^^^^.cc 



-? 



< No. >H t) Si l)x^>-vA.Cv.cU. V* . .St._; I Dist.; bet. 



<:x>^J\jJJb. and lIXCLVq 

FULL NAME •' iV.<xh.^.i JAxu-^vVjcXi................. 



PERSONAL AND STATISTICAL PARTICULARS 




si 



r 



DATK «>1- P.IKTII 



I 



COIA)R 




r\A.^ 



ix. 



oxK:t 

iMolith) 



as 

(Day) 



7^0.^ 

(Year) 



AC.K 



J V«l # A 



Q^ Mon/Ziy . -"■ 'H'-^ 



SINC.I.K. MARKTKI) 

WMXtWl-:!) OK ni\'<>KOKI> 

(Writf ill <orial •If'iv'iiatioii) ~^ 



niKTMlM.AOJ-: 
(State or Country' 



}■• A l" 1 1 I". K 



HIRTIMM.ACK 
»)1- lATHKK 
(Stiilf or Country) 



MAIDKN NAM)-: 
OF MOTHKK 



lilRTIIM.ACK 
Ol- MOTHKK 
(Slalf or Country^ 



OCCrPATIOK 

AV.v /(//'</ /// Siin /■'Knnisi-it 









Tin- MJOVF STATJ-.n I'KRSONAl, I'A K lUl- I,ARS AKi: TKlH To THH 
liKST OF MY KNOWIJvIX-.K AND lUIJl-K 

(InfonnatU Aj . US. OAXX/yUL>V) 

(A.Ulrcss )H0^ jJjlArLXL<Xxixr^-C> at 



MEDICAL CERTIFICATE OF DEATH 

DATK OH DKATH A 

.Vll^NT. 



(Month) 



.as 

(Day) 



(Year) 



I HI<:R1':BY CI^RTII'^Y, That r atten(le«l deceased from 

vr. XO 190H to 0'l<3\r ^H 190 H 

that I last saw h ^A- aUve on U^U?^ -.5^.1...... 190 i 

and that death occurred, on the date stated above, at ^ "^0 
U M. The CAl'SIi: OF I>I«:AT1I was as follows: 

CLc.A..jt:L y\JLA:^JL^d^4 



DrR.\TION 
CONTRIIU'TORY 



}'ears Months ^ acK^^"^ Hours 




DURATION Yiats \ Mouths Pays Hours 

(Signed), i- \X- Cj-A.yv>^:\.<iu«rk-u M.D. 

,^r ...^.b .. iqo'i (Address) biX- XO jjo-- at 




Special Information on'y 'or Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from iiome. 



Former or 
Isual Residence 

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



How long at 

Place of Death? Days 



PI.ACK OF lU'RIAI. OR RKMOVAI, I nATH of BlRlAl. or RKMOVAI, 




190 



qS 1 Vn\AXL<i.v.>tr>^ ...0.1. 



fAd<lr«-ss 



flons dylnft away ?rom home should be ftiven in every instance. 



i 



[ : 



4ri 



I 



i! 
jl 

II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF C ERTIFICATE FOR INSTRUCTIONS 



Jj. ,:,,,'. of Health - I- No. i^ f-y^^^tR;^ UScl' C 



/>.^/^Wv/fv/, MW-^i-^^A^Ov ^L I'^O' 

J) 



Registered J^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "U. S. 5tanDarC> ) 
PLACE OF DEATH: — County ofCW^lV^^vcc^^^ City of O.O^ O/vc^yvCc^c^ 
TM S^9 Is> Crvu-a^V d St,; 'H Dist.;bct. S .tk and b^ 

No. i^ I UU U^^^.rnj'^VV.V ,,«,.AI nrSIDENCE GIVE FACTS CALLED rOR UNDER "SPECIAL INFORMATION- \ 

( '^ rF"orAT°H"o^c"u%r.V.NTHo"s^PyT'it o"r"n S " T^^O^N^G I V^ ^1 NAME INSTEAD OF STREET AND NUMBER. ) 



) 



FULL NAME 




rfWjLjs 



SlvX 



DAT]-: or r.iK III 



PERSONAL AND STATISTICAL PARTICULARS 

COI.<)R\ f) 



1 





(Dav) 



i%r.^ 

(Year) 



ACK 



2)0 Yeius 1 M<;,ih< A 1 



Pa 1 .V 



SINC, l.lv MARKIKD 
WIDoWi: I> (>K I)I\< iKii:!) 
i\\iit<iii MH-iiil (U^iv'iiali'iii) 



HIKTmM.ACl-: 
(State or Cuiuitryi 



NAM)-: (>1- 

I' A 1' n i: R 



^ _ I ]\<XKKU^ 



lUK rnrLACH 

(>»■ lArHKR 
(State or Country) 



MAIDKN NAMK 
OK MOTIIKR 



niRTITPT.ACK 
Ol- MOTHHR 
(State or Oo\intry) 



OCCrPATION 




v-<^0'A.' V-COCL<X' 



.Ow:~>:\-d — ^ 




Rrsiiif(f ill Sail r-nunlyt'o CSO )'>iiis 



.\/,>iif/i'^ ' i /'"< 



THl- AHOVK Sr\TI-:i) I'KKSONAl. TA RT UT LA RS ARI! TRIK TO TIIF. 

linsr oi" Mv KN(>Nvij:i)c.K and iu-.mij- 



(III 



(AcMress ^^S db ^W<X^V<:1. ^^t 




MEDICAL CERTIFICATE OF DEATH 

DATK 0\< DKATH 

.c\r 3.k.. 




(Month) 



(Day) 



(Year) 



ThHRIU?V CIvRTIFV, That I attended deceased from 

O-C^t. 1 190H to ...l)fW:.....9Kb. 190 H 

that I last saw h .^^> v alive on yLcv:....9^.<^ 190". 

and that death occurred, on the date stated above, at l^-^O 

UwM. The CAl'SH OF DIvATII was as follows: 

yJjfvVCrr^vC. . \TYvx.vo-'C^cx.^-<:^^ "-. 

LLt^^I\-^-«^. ..Oij-^:N-^5^<l'Us. ^..«.... ••■ — • 

,, ) nVviXxxJC 0\jU3^A^vA^vLojLA.,<r>:u.,«-..« 

DT RATION • }'ears Months Days Hours 



CONTRIIU'TORY 




;%JL:>.:vv.'uCX.-. 



Dl'RATION Years ^ Mouths Days Hours 

(Signed) .a Uj . ^ o-c^cUxJu^ M.D. 

AVLCV^. XL ic)o'', (Address) "WX ObaA,V,^Cnv OJ 



Special information onlv 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'l.ACK OK BURIAI, OR RKMoVAI. 



VwA.«»-^A/ 



DATK of HlKlAl. or RKMOVAI, 

UVc^^ al iQoH, 



INUKKTAKKR M H CXXixL«yVA/ M K ViD 



(AcMre-ss U1 



1 (^ 



'^i^v^mj C 




sons dyin4 away from home should be ftiven in every Instance. 



\i i 



il 







( V 



1 1 



f: 



!i M 



WRITE PLAINLY WITH UNFADING INK 



H.,.n! nf H. :<lth- T No. i :; ^'^^'^ H^t' Co 

7>/'//r Fi/('f/,\[\js\}-Vyy^{sV^j X\o IfJO'i 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J^o. *^355 




\^>^kM o^^^M 



*i,-. r\^an 



iY 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

f tl. S. StanDar^ ) 



PLACE OF DEATH: — County o{\LL^-rr^^<^'^ . .. City of 




CXAy^A;<>JvcLci 



f i 



No. 



St.; 



Dist.; bet. 



and 



,, «.,,•• RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \ 

( '^ rF"D;"TH^OCc"u%reV."rHO^S^PrT"AL O^R^NS'^JV^O^N^CVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




PERSONAL AND STATISTICAL PAR TICULAR S 

: /ISI 




DAIi; Ol lilK 111 



I M.)tith^ 



(Day) 



(Voar) 



\«,K 



5" 2) 



Vea^s 



M.>f,//is /^<'.i- 



SIN<-. 1J<:, MAKUli:i) 
WlDDWKl) OK niVOKi KI> 
iWritf in social rUsiv'iiatioii) 



niRTMPl.ACK 

tStatf or Coniitry^ 



NAM)-: OF 
lATHllR 



HlKTHPI.Ai'K 
(U- 1-ATHKK 

(StaU- or Country) 



MAIDHN NAMK 
Ol- MOTTIKR 



HIRTIIPLArK 
Ol- MOTMHR 
(Statf or Country I 




OCCUPATION 

Kc-iilrii III S,in I'laiiiisro 



)'l'll I A" 



Months /><n> 



TIIF ^m)VKSTATl•I)l•KRS<)^•Al. rARTIcri.AKSARi: TRIK To THK 
liKST Ol- MV KNo\Vl,i;i)C.K AND HhlJl'.H 

(Informant J\D ■ ^- UX^ JU . .. 



(Address 




MEDICAL CERTIFICATE OF DEATH 




(Year) 



DATE OF I) K AT II 

(Month) (Day) 

I HJvR1-:BV CI':RTIFV, That I attended deceased from 

190 to ■• 190 

that I last saw h •""" alive on • • ■ ■ • • 190 ~~~ 

an.l that death occurred, on the date stated above, at ~~ 

■3^:" M. The CAUSK OF DIvATII was as follows: 

LLcAA^tx ^\Js^>rs,^Jf\.^^k>Js 

tJoCjL^'n./%.'>:N.<X/.....^ 

L/C^.^Sw<Lv.'Ok.<^ aAY^tr*^^^^!-^ •""" 

DI'RATION Years Months Days Hours 



CONTRIHUTORV 



DURATION 



(SIGNED) 



QO 



Hours 



Years Mouths Pays 

J .Uj..A^A,<r\An^A.a ^ M.D. 

ICVr 9w6 TQOH (Address) . -. CUv^»-O^^w<:^.0 ^*' 

Special iNrORn/lATION only for Ho^ltals, ln<ititiitlons, 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 lonq at 

Place of Death? Days 



..^li. 



i'i,acp: oF^iriyAT. or rkmovai. 




f 




DATKof m RIAL or RKMOVAI. 

^^TUtlt M 190 M 









(Address 



N. B. Bvery Item of information should be- cnrefully Hupplied. 

•tate CAUSE OF DEATH in plnin terms, that it may be 
sons dyinft away from home nhould be ftiven in every ins 



AGE should be stated EXACTLY. PHYSICIANS should 
properly classified. The "Special Information'* for per- 
tance. 



I 



i \ I 



P. < 



WRITE PLAINLY WITH UNFADING INK 



11,,:, nl ..f ll.alll-. 1- No. 1^ ^•^.3K>^-"-'^''^'" 






lOO'i 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Ee(Sistered Xo, 




h^hP"^ 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)eatb 



4 



(10 



PLACE OF DEATH: — County 



of CO-AX J\xi.^^ov^co City of C.\<Xo-«.. .x.<X/-vwoi,<i^ o 



rNo.cSij lXlL/^A^.t^ 



kd. 



W»Y FROM USUAL RESIDEIMOt._GlV_E_FAi.^a „ « », e .^.o-rrAP. nr STREET AND NUMBER. J 



Oo' 



St.; 



Dist.; bet. 



— - and 



(IF DE*mH OCCURS *W»Y FROiM U3W«U nt~...^»..-~ 
.F dIJaTH OCCURRED .N A HOSPITAL OR INSTITUTION G.VE 



FULL NAME 




ITS NAME INSTEAD OF STREE1 




Ajy\<x.^\jO^\. 



DAIl", t)» I'.IK lU 



PERSONAL AND STATISTICAL PARTICULARS 
_. ^ COI,OR 




(Month) A 



I Day) 




\jyr\jduu 



/ITH. 

(Year) 



A(,K 



,V .Sf. . )'■(»' > 



M.iul/i.' 



5 



Da 1 A 



SIVC.I.lv MAKKIKH. 
\VIlM)\Vi:i) OK DIVftKiKI) 
(Writf in >i<>ria! d.siv-'natioii) 




MEDICAL CERTIFICATE OF DEATH 

DATK Ol" DlvATll 




(Month) 



IS 

(Day) 



c; 



I go 

(Year) 



WOLcL 



MiK ruiM,A»M-: 

Slatt or Cotmtiy) 



FATin.R 



IUKTHIM,ArH 
Ol- lAIHKR 

(Statf or Conntry) 



maii)i:n namk 

nl- MOTHKR 



niRTTirT.ACK 
ol- MOTIIHR 
(Statf or Conntry^ 






i^JL/\AJc CNA-'YV'OJxxL 




occrrATioN p 

h'fsiilfd ill Sail I'liUichfi* 






) V-(/ ; \ 



J©., MoiitlK 



riii\.- 



Tlll- XHOVK ST\Ti:i) I'KKSONAI, I'A K I" U" T I. A RS AKi: TRrH To TMK 
JlHST ()!• MV KNOWIJ-.DCH AND UKI.I1> 

(Informant . MVVv:. ^<X) a.V-r>.<X^ti. 



(Address 



iHl 



(^ 



^w/^-'tx.'cL^.AXx. 






J HKRICBV CIvRTIFV, That T attendtMl deceased from 

...QQAxx^H. ^^ ^^^ ^« ... AKfiv: :3.5. up ^ 

that I last saw h '• alive on \lX^\r ^S .......190 , 

and that death occurred, on the date stated above, at 1-3.0 
Q. . M. The CAUSH OF DICATll was as follmvs : 

J,AAJ.>Ht^MC>LJLa?V y\^*|V:Lv^tv^ rjj. 



....^.wcL^nULi 



t 



DIRATION ^ Years Mouths Days Hours 

CONTRIIU'TORY ..L.L^.XV-X/:v:>.^wv-aj.....<X^cw-.<i^». 

^w/ft''^'^y^-^^.^^■ 



\j^j<^^ry\^ 



nr RATION )'rars ■ Mouths Days Hours 



(SIGNED) 




(A.ldress) \\^\ O.CL-^v W-.<L<1 LI ■'>■■ 



SPECIAL Information «nly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 

J P , 1^' 5 How lonq at 

0\j/V'-r\; LCW vOA-' Plare of Deatti? A..I Days 



Former or 
Usual Residence 

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



IM.ACE OK HIRIAI, OK RKMoVAI, 
INnKRTAKKR C>/CV^C<^ rXX>vA_ 



I)A'li:of MiKiAi- or REMOVAI, 

ViUv^ . xr^ T90H 



fAd.lre-ss Ip X^ US.V{HX<LcU<XA,t...Bt. 



'C 



1 



, ,n.>..«tion .houUI He cn.e.u,.. supplied. AOB «hou.ci »»' -«-:;^f .^^7^^,^;, .r^J^Ton' Vr'^:!-! 
OF DEATH in plain term., that it may be properly clai.«.fied. The Special Intormation for p«r 



N. B. Every item o^ 

state CAUSE _ . . ^ 

lions dylnft away from home should he feiven m every instance. 



■it 



I 

I .1 



I 



f' 



i, 



■■I ' 



im 



\ . 



. i 



5 









* 

1 


ii 


J 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



V.xAVi] <>i in :i!t)t I' No !> ^'^-'^-^^.j) 15^1' Co 



Beglstered J\^(). 



335? 



Dale I'ilvd, VrUv-t->>JLuL»v Xb 10(n 

(-Lc^^-o> Wm, Deputy Health OfTlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( 'U. S. Stnn&ar^ ) 
PLACE OF DEATH: — County ofC CX->^ J.'v^D^-^x.tvA.coCity ofC)xXo-u AxX/>^c;.a.c^ 



<-No. H H H 



i 



LCUV-'Cr^^'w^O,. 



St,; "^ Dist.; bet. 



5:t^ 



and 



fcti 



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



FULL NAME 




.rLC^4*V'^,.<CDi':\i......„. 



'■«^ 4 •*t4** ••+-*••■•*••*■•«■■•» •*»»•••■•••«•••*••• 



PERSONAL AND STATISTICAL PARTICULARS 



•^,\J 



DAri-: ()i- i!ii< rn 



a 



j COI.OR ^ 

I UO.kJU ___. 



a(;k 



Moiithyf 



(Day) 



Vents 



,^A»////.^ 



/Sex 

(Year) 



ID Davi 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



ArXiCTUr.............. 



(Month) 



15.. 

(Day) 



(Year) 



^INC.l.K, MAkUIKl*. 
WIDOUHI) (»K DIVoKij; I) 
iWrittiii social <Uvi;.'iiatioti) 



lUKTHlM.ArK 

(Sliiti' or •.■i)imti\'i 



N'AMK OF 

lATin.R 




I HfCRiniY CKRTH'V, That I attended deceased from 

.uUvr 1.1 iQoH to .....Qx.{ 



190 

that I last saw h i-')^ v ahve on 



to \1\.^>J^.....^^.. 190 H 

y\'(n^...„a.5:..... 190 'v 



and that death occurred, on the date stated above, at XX „.^... 

U: M. The CAl'Sfv OF DFCATFI was as follows: 

yj.A,<5r>.iw^^.v_L 



.v.-a. 



O^^A/ VCX'-W^C'ClCO 



^\DJU 



lUKTHPT.ACH 




roK^fc .V 



i» I K 1 III i,.-\v r, A 

OI- l-ATHKK 1/ 

( Stilt t or Country) "1 

r 



MAIDKN' XAMl 
()»• MorilKR 



HtkTlTlM.ACH 
Ol" MOTMKR 
(Statf or Cojititry) 



\i I \aX^\j(ak.kJO\Aj<x/ dU. 






DIRATIOX Vears Mouths % Days Hours 

..•U.A.<<L.€s*wcLCA^ 



CONTRIIU'TORV 




DU R AT ION •■ } 'cars X Months 



YV 



OCCUPATION 




yv\^oj 



^ 



,-a> f -"^ Mn„Hi< ' /),/). 



(SIG 



N E D ) 1 . a criHy<X<x.w 



Days 



Hours 
M.D. 



/A, 1.1, \ f^w';'^ - (, t',^, rif; 



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



Former or 
Usual Residence 

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



HoH lonq at 

Place of Death? Days 



Till-: AIIOVK STATKr) PKRSONAl, rAKI'ICn^A KS AKI-. TRIK To THH 
BKST OI- MY K.VOW MIIX.K AND IMIMHF 



(I 



iifomiant vW. 



(Address ' l' i ', 



ya.cJI' 



*vA^<rv"s^' 




aXxr-^wxX' olj. 



DAlHot MtRiAL or RKMOVAI, 
^K^^ -^^a.. igo^l. 



I'l.ACK OF lU'RIAI, OK KKMoVAl, 

^. (h Q'W.VA^i-^a 

rNI)KRTAKF:R \N V Kjj^'YX'y^/ V'T.S, ■> 

(Ad(hess3.QLH ATri LU[Xv<Lt,Ov^t» 



IN. B. Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information** for psp- 
sons dying away from home should be i^iven in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



'I 



i 



Jill 



■n 




'i 




*• 
f' 








! 




1 


. i 


?R » 





l?f 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



r\ 



l)((h> r//('f/ S]\j^yUL^^JiKr'Xh l^Wi 



J^es^Lsfered JVo. 



*^ O r^ c 



Cr\XAA 



ti Healtri OfHccr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

CPevtif icate of 2)catb 

( *Ul. S. StanDarD j 
PLACE OF DEATH: — County ofO.CL^v^' vJ.^vO-0 vcaA^^C<: City ofO<X/^Ay .\xVy>^CA.^Cc 

(No.. bl'^*\ ^ 'O. c.cU-r^ St,; 1 Dist.;bct. jbLa,\,/>aAX and -^^'x J»vcr>\i. 

(ir OtATHi^CCURS *W*Y FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPOCIAL INFORMATION" '\ 
IF DCaVH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRCIET AND NUMBER. / 



) 



FULL NAME 




XAAz-^.X-CL. 



SKX I 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




DATl-: <)I- HIK III 



M'.K 




(Day) 



c\Ar 



Am 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 




(Mouth) 



(Day) 



(Year) 



J t 



Ha 



i'ftns 



'i 



L 



1/">////« VU Days 



STXCTJ*. MARRTKP 

wiDowHi) OK i)i\'<)Kri-:n 

(Write ill s«x-ial <Usi)/ii;itioii) 



HIKTMPI, AOK 

(Statf (»r Couiiti v) 



NAMK OF 
FATMHR 



BIRTH PI. AC K 
Ol-* l-ATIIKK 
(State or CoiiiUrv) 



MAIDHN NAMK 
Ol" MOTHKK 



lUK'nil'LACK 
Ol' MoTHHR 
(State or Countrv) 




\<XKKjUL<L 




I HKRHRY CKRTIFV, That I attended .leceased from 

— . to 



190 to .:. .....:.... .190 

that I last saw h •-— alive on L.jjjr f i;^^;'!..>.....„„.j.jj^?.ug igo 

and that death occurre<l, on the date stated above, at —rrr-. 
M. The CAI'SP: OF DIvATII was as follows: 






\J J.A^\y>:>. amj:>.\-<xNa4 . . . .' 



^ 



Lx.. 






DFRATION rears A/ofi//is ./)ays 

CONTRIIJUTORY 



//ours 



» •***<fc*<(« ^**;#-AJ(|fy«|,t«*«-ItS »»#*»«»»^**f ****, 



DrRATION. 



}'rars • Jloft/As 





Pays 



( Signed ) ..lAX.cLl^L,v-c/n.....a....v<x<-yxo^^ 

VlW'^ Ife too'' (Address) toOb 3^V,ttjL^v 



//ours 
M.D. 

1 



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



nccrPATioN(V\A ? *- 

Rfsidr<f in Siiii /'i ant i.wo OL) )'riiis , •* .'\fi>iifti!< 



/hn 



THK AIIOVE STATHI) I'KKSONAl. PAR P KTI.AKS AKIC TKIH To THl-; 
BKST OI" MY KNO\VIj;i)C.KANI> HICMKF 



(I 






(Address 



10b 



M <XXxlv^ 3 



Former or 
Usual Residence 

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



flew long at 

Place of Death? Days 



t 



PI.ACK OF lURIAI, OR RKMoVAI, I DATK of HrKiAl. or REMOYAI, 

-i^£u:vx.-^LxLu, Ll__. I ^^"^-^V- 'Xl T90H 

fNDlCRTAKKR CSAaXTvAXI. ^ CrVH OxX'VUX 

(Address ID^.U iXC^\.<l a.t....!' 






N. B. Every item of information nhould be Ciirefuliy Hupplied. AGE should be stated EXACTLY. PHY8ICIAN8 should 

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



-1 



IH 



fl 

k 



1' 



I f 



>! I 





? 




! 


r^' 





WRITE PLAINLY WITH UNFADING INK 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Filed ^ 






"v^V^lvjoV %\: 



lOO'-K 



Meg isfe I'C (J JS'^o. 



3359 



-p 



,£n^v. ci-Xz-vM.; Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 

Certificate of 2)eatb 

PLACE OF DEATH: — County ofClcu^rL- J /vOw^^x^o^Xi.c^ City of CJ/CX^rv 0,\xx.-r^.x^\^^i 

No. ^ LLLM^ St4 oL. Dist.;bet. Clt^ck.iry\ and VJ Cr^\.v4LLl] 

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



FULL NAME "iU-tv^ 



v.) 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



DAI"}-: nl- lUK 111 





>:\-.., 



MEDICAL CERTIFICATE OF DEATH 



DATK OK 1)K 



Month) 



AC. H 



ST 



) '/•</ ) 



11 



H 

(Day) 



M.niths 






1".' \lVr., 



(Month) 






(Year) 



H 



/)rt ♦•* 



SINCl.K MARUIKI). 

Wllx i\\ )■ I) (»k I)I\oHrKI) 

•Wiiti in social (lt"-i<rnat ion ) 



J Kojwo-cL 



lUKTHI'I, MM-: 
(Stiitf or C<nuitry) 



NAMi: (II' 
!■ A Til i; K 



r.rK'niiM.ACK 
Oh iArm-;K 

(State «>r Country) 



MAI])i:\ NAMH 
Ol" MoTMlvK 



RTRTHfLACK 

oj- m«)Thi:k 

( Statf or Contitrv) 



OCCUPATION 



1) 



\ 



I irFCRICnV CI:rTII'V. riiat T attendtMl deceased from 

UUV^ I'J. loo'l t„ 0\<I>J- iSt 

VrWr IS 



i9o'l to yv<i\r I'i 190 H 

that I last saw hXK: alive on VlVcsv^ I 2> 190 *1 

and tliat death occurred, on the date stated above, at ^^0 
U M. The CAlSIv or ^DMATH was as follows: 






rn 




DrRATIOxN,*, Years • Months -... Days 

CONTR IBUTORY Ovvirr^A^ . .&,w^^^ 



Hours 




^L„- 



ci,^c^% 







Roided ill San Fi aiirhtn lo )■/•(//>- 



k 



DI'RATIOn'^^P^ )Vv7;.y Mouths Pays Hours 

(SIGNED) VlUrVs^ a. \n\xx\.t^<>x. M.D. 

\rU\r Ho T()oH (Ad.ins.) 3b^ a.A^tU\; Ui 



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



.lA"////*- 



]hi\. 



Tin: AMovi-: si" \'n:i) i-kksi inai, r \k ihti, \rs aki-; tki)-: r» » in }•; 

KHST OI" MY KN(»\VI.1%D<",K AM) I'.I:IJ1:K 



inioMM.int O-^^crV-cy^ vv \J /Xcc^^x^jl'OOl 



A.>AX> 



{ V^drrss 



I 



LaXa^ Ci- 



Former or 
Usual Residence 

Wlien was disease contracted. 

If not at place of deatti? ........... 



How lonq at 

Place of Deatli? Days 



1U,ACH Ol' lUKIAl, OK kl-;M<)\AI 



;* 



__Lll''iWJIax> cMX^wU-XSnl- 



\ 







rNI)KRTAKi:K 



e.O' 




AdLss Ibl QlK^- 



^c.<r>A.^rcxy-v '^\ K^ 



•^-^.A>.xrw ■; j t 



IN. B. 



-Hvory item of informntion shouUI bs ciirel'ully supplicMl. ACJR should be Htnteil EXACTLY. PHYSICIANS Hhould 
«tHtc CAlJSn or DF.ATH in pltiin terms, that it maiy be properly ciaHsi^fled. The "Special Information" for p«r- 
Ron9 dyin^ away from home should be (^iven in a\firy instance. 






I 
>l 



4» 



^ » 



•i^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Btutl.l i.f III :iUh 1" N'< 



Y.-f'w^^v. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Boi^lstered J\'*o. 



3360 



Xt'v-iL ,D.e.,pMty, Health Of^cer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






No, 



Certificate of 2)eatb 

( tl. S. StanDarD ) 
PLACE OF DEATH: — County ofOct^r^' A^Oy^xcui^c^ . City of 0<X/ru A-O/yvcv-am::^ 






Dist.; bet. 



and 



(If DEATH OCCUB5*AWAV F R O 1^ USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' 'X 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

Lv\j ...._..... 



) 



FULL NAME 




KjSJ^ 




PERSONAL AND STATISTICAL PARTICULARS 
Si;\ A ft I COI.OR 



(X<xL 




MEDICAL CERTIFICATE OF DEATH 

DATH OF I)I:ATII 



DATi: oi i;ik III 



\r. H 





5vk> 



MMUth) ^ (Day) 



/lb5 

(Vc-:ir) 



W 



)'t'i!l . 



b M->nths 3^b 



Diir: 



i 



"^iNf.i.i:. 


M A R U 1 1 


.1). 




\\ iix >\vi-: 


I) OK l>!V<)KiKI> 


' W'litc in 


social <1( s 


iL'^ii; 


itioTl) 


MIR'riTPT, 


ACR 






1 State (.r L 


'ouiitiy> 


• 




\ WW <)1 


' •'■■ ■ 






1- Ai'ii i;r 








niRTHrr, 


\CV. 






()!• lATIIKR 






fStatf or (,~ 


oiiiitrv) 






MAIDKN* 


namj: 






OI- MoTIllCR 








Xcv- 'XX 

(Day) 



(Mnutli) 



TQO M 

(Year) 



I IIHRUIJV CliRTll'V, Tliat I attended dcceasetl from 

y./c-fc %:i iQoH to ^^K^cxr- XX. 



190^ 



0\<jv^.. 



190 1 

that I last saw liA.^r»-\ alive on Vr\,<rv.^...^^.,„.,.„.... j<p 'I 

and that death occurred, on the date stated ahove, at U 2>S 
AJ. M. The CAISK OI- DIv.XTFI \vas as follows: 

oUo-<caA>-Ll ^Jr 



to O^OOXL^yU.- 




VC) 



DCK.XTIOX '^^"-^ Mouths /\ Days Hours 
:ONT R I lU ' TO R V J -M.i^n^<fr^^ ^.^\ijL^..., ...,..„. 



C 



BrRTHPI.ACR 

OF M()T!IF:R 
(State or Country^ 



XV^ 




S./N 



M5^ 



^" 



OCCUPATIONJ) ft 

"os./oJ6--tAJi>o 



nT'R.\TTON }juirs I JfoJi //is ........ Days 

( SIGNED ) J \jV., m ojJc „...„.....:. 



Hours 
M.D. 



Special information on!> tor fiipitais, 

or Recent Residents, and persons dying away from home. 



X 



institutions, Transients, 



Kf^idfii ill Sail /'i it ih i^r.i 



);-ins L M.-i'tli- 



iKn, 



\'\\V, AHOVK SI" ATI-: I) I'KRSONAI, I'A RT ICF I.A R S A R l". IRri-; 1( ) I'll )•; 
liHSr Ol" MY KNo\VI,i:i)C.K AM) MliUHCF 



(I 



h 



nf,);inaiil \J . \J . (Jl^. V.A^CO^j6 ' 

U.l.lriss V^cLu ^"^ V 

n 



'MJrL^.t-<xX' 



Former or V| ) ^J W How ionq 9\ ^ . 

I'sual Residence dL/i»v\N^\; (iU(K\.4A Place of Death ? At Days 

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



I'l.ACK oi- r.rRiAi, OR rf:movai. 



DAT i: of HiHiAi. or KKMo\AI, 
\j U>J'.....a>.k? 190H 



<X<:X-rx./>A_ 



f.\(l(ll CSS 






N. B. Kvery item of Informntion »hoiilii be cnre?ully supplied. .AGH should be stBted RXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information'* for pmr- 
«on» dyin^ away from home should be ^iven in every instance. 



' fl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;,i;M.1..f fl.alth- !•■ No. It; ■5"?^^'T!W'vl' (.%, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^\ I 



II 



! 



♦ 



/)((/(' F//rf/, \h.{^^X/YvxLx^; lb 290^ 



Registered J\^o. 



336 j 




■^ 



<js Jvic V M, Deputy He a It h Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



I I 



1 1 



i I 



Certificate of 2)eatb 

( VL. 5. Stan^ar^ ) 



PLACE OF DEATH: — County of ^ .<X">Aj JAXX?mJU^C(City of *^'/0-^^ A>CX.>^<iui.CL 



No 



A% 




Dist«; bet> ••»..■- and 



(IF DtATH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLCD FOR UNDER "SPECIAL I N FOR M ATIO N '■ "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

si:\ ('A . (% i COi.oK 




'\ 



D.xri-: oi- i;iK IM 




^A'xxXju 




Month) 



10 
(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

.,.,., :iiQ. 




(Month) 



(Day) 



(Ytrar) 



I m^Rl'HV ClvRTIFV, That I attended dctoased from 

U^t) L<e TooH 



\(.K 



3.^ 



)'iun 



Mnnlfi 



'^INT-IJ:. MAKklKn. 

\\ii)( i\vi-:i) OK nn'oKiij) 

I Write ill stHJal <lt sij.'fii.ili'ni ) 



lUk rill'I.AOK 
(Sfatf or Coutitry^ 



NAMJ-. OI- 
KAIIIICR 



niKTlII'l.ArK 
0|- ! AIIIKK 

(State or Coiuitrv) 



MA1I)J;N NAMJ-, 
or MOTMKK 



HIKini'LACK 
OI" MOTHHK 
(Slati' or Coiiiitrv) 



i 




11 



<1 



/)./ IS 



(lljl 



cl/vv y^w<x/vvcc4 CO 



190 -^ to .^iL^cxr: ^.fc. upH 

tliat T last saw h J^/V>v alive on XTLcfX^ !^5 Kp ' ': 

and that death occurred, on the «late state<1 above, at n 
CL^I. The CArSJv ai* DKATH was as follows: 









DURATION Years t) Jf/onihs Days Hours 

CONTRIIU'TORV ..........S.^CIw:^wrsX 



DT RATION ^^^ Years 



(SIGNED) 



j-^ -^ I^fonths Days Hours 

J pU- \j / V<X<'^xX^' M.D. 

(Address) 5 OS. a.AA.tAjL^^ J.t 



OCCUPATION /^ C ^ 




SPECIAL INFORMATION »n!y for Hospitals, Instltytlons, Transients, 
or Recent Residents, and persons dyinq away from home. 



Former or 
Usual Residence 



^-y 



it 



III How lonq at 

/VCV>v CX VVx^ Place of Death ? 



Months 



w 



r\r 



Tin: ABOVK STATKI) I'KKSOXAI, 1" A KlU' f I.A KS AKK TKIH T( ) THK 

JJHST OI" Mv K.N()Wij';ij(iK AM) hi>;i.ii:f 

(Informant \J . H. ■ vj\sJULC<.| ....... 



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



QTTN 



c1 



Days 



C;.t. 



PI.ACK OI- niRIAI. OH KKMOVAI. I DATK of Mikiai, or RKMOVAI, 

INDHKTAKI'IK vj O^AX/VaXJI )J I VX\A.A^/Waj "^'^.V.C 

(Addri-ss J 5 IH cjA.O-cJk;tfr>^ 01 



n« 



N. B. F.very item of Informntion should be cnre?ully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plHin terms, that It may be properly classified. The "Special Information** for psr* 
sons dyin^ away from home Hhould be f^iven in svery instance. 



) 'I 



fi 



! 
r • 



I ■( 






i r a 



I 



f ! 



ft 



m 



\i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board «.f Ikahli l" Xo. 15 t^-s^n:^ H&l' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



: 9Ksasssm<fm 



i i 



ImJv 

Ceputy rle 



»• f 






Registered J\^o. 



3362 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of H)eatb 

( "CI. S. Standard ) 



^ 



PLACE OF DEATH: — County of (J<Xa^^ ^ Axuivculcc City ofO/CL/vu /ux^^eA^^-c o 



No» cLcU'^^Jl' 




I V 1 



St.; 



Dist.; bet. 



and 



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



- ) 



FULL NAME 




(y\HJ 



?Ct)^,U 




cL 



cU 



si;x 




PERSONAL AND STATISTICAL PARTICULARS 
A I COLOR N ^ f^ 



icLsi 



-L'Vl\A,tjb 



ivx'ii: or lUK 111 



\\oJ\i 

1 Month) 



(Day) 



r%Vi 

(Year) 



M\r 



MEDICAL CERTIFICATE OF DEATH 

DATlv Ol- i)i:atii 

\ \r\ 

as 




(Year) 



•41 



AC.R 



io 



) '(•(? / . 



1 



^ 



Mntilhs .1 Da 1 



>INT.T,K. MAKKIi:!). 

'Wiitrin vrniMl (lr»ij.'natiiiii) 



Ux^^<aAx 



lUkini'i, AIM-: 

' Statf or C'onntiA'^ 



NAM1^ OI- 
J'ATin:K 



nTRTITPT.ArK 
<)l' lATHl-'.K 

'Slatf or Cf)initrv) 



MAim-:x N'AMM 

oi" M()Thi-;r 



niKTHI'LACK 
ni' MOTH I-: R 
(.Stale or Country) 







JVULCVAA^X 



(Month) (Day) 

I IIHRIU5V CIvRTIFV, That I attendcMl deceased from 

.ffxr oLSl 190 M to mfl\r: 3lu \(^p\ 

tliat T last saw h ^'^rs. alive on VrLirvr 9*H 190 H 

and that death occurred, 011 the date state«l above, at I 
CL M. The CAUSIC ()!• DI'.ATII was as follows: 

'^t^A.^ULt C^' LLlx-WjJ^-c/cLX-cl-c-nc'M* 




\)VR\r\OS ....... )'rars JA;;///;.? 3 /)ays / loins 

C O N T R I P.r T R Y S^ M^ivOH^Loi^c. . i JmJU.w>r>A^: x,u<x. , . 










XJu^~\^'^r^^^'\ VQ. 



v^\XA^CX -^a^cL^ 



i 



DrRA'noX Vrars Mouths 3, Days 

( SIGNED )...\il.:. 0.....'vjjLt\^frrv' 
VjUv-. as T90H (.Address) (H 00. LUvcCrvA, ()t 



Hours 
M.D. 



occ 



:ci:PATiON (7N 



Rf^idi'd ill Mil/ /'i Ill/I /'i'') X\. )''■(! I ^ 



lAn////, 



/),?: 



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



Former or 



^ 



Usual Residence I l^io AiU 'UrtxcLccvcu^ "1 1 piarp of Death ? 



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



iJ 



Days 



(Itifoi maul 



rnV. AHOVK STATKI) PKKSONAI, PAK'ncn.A KS AKi: TKCK To TH1-: 

iu;sT 01* Mv KN()wi,HDOK AND i?i:mi;k 

.a 



I'l.ACK OV m-RIAI, OR RHMOVAI, 



DAIKof Ml Ki.Ai, or RICMOVAI, 

(Achlrrss ini \JllA./Ci^^V<rvo ^t " 



• I 
1 


1 ^^^1 


If ; 


r^^l 


1*-, i 


H 


P 


H 


ft 


^1 








I^^^^H 


u 


1 



N. B. Rvery item o? InformntJoti should be cnrefully Hupplied. AGB sMnuld be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly cIsKsified. The "Special Information** for pap- 
sons dyinit away from home should be <iiven in every instance. 



I *^ 



i i ^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



pff/r /vAv/,\Ilcv>-C 



rwA>t\; 



'^ 



IfJOH 



JRrgf.s'fr/'cd A^o. 



33G3 



I I . 



dsw'CrVCAJi cLi/ 



n 



DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 



No. 



Certificate of IDeatb 

PLACE OF DEATH: — County oi'^CuTv JX/Ol-yvux^oo City of C -c^^v^ JyV<X'^vc.\.ac^ 

1 \ I X/^L^ Wcn-Jj.. . . St.; 1 Dist.; betAj <XCv^U.o and H^ok^trvx 

(IF OEaVh occurs away from usual FJESIDENCE give facts called for UND^)» "special INFORMATIjttN" "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD ^ STREET AND N U M B E Bl / 



FULL '1>JAME :>^axkr.. 




..U>v 



.PERSONAL AND STATISTICAL PARTICULARS 



l).\rE OK lilUTII 




(Month) 




I 



AT\.>J \JA\JJ^, ....,.; ,......._ 






MEDICAL CERTIFICATE OF DEATH 



.^W.. 



(Month) 



(Hay) 



(Year) 



(Day) 



.\(.H 



CN-D )'r(iiy 



v.. »////- 



Da V. 



SIN(.I,i:, MAKUllvD. 
\V!I)()\VI-:i) OK I)IV(>Ktl-:[) 
'Write ill social tU sitMiatioii) 



!UK'rill'f,.^CK 

i St; tf or <.'otintr\'^ 




\cU\,K^JLd^ 



x/>r^^o^ 



VAMl' OI' 
1- A THICK 



RIRTHI'I.AlH 

OI" l"ATin:R 

I State or Country) 



MAII)]-:n NAME 
Ol' MOTHKR 



9 



I III:RI:BV CI-F^TIFV, That I aUcii.lc.l (leccased from 

— to 



"~^ — — I (JO — 

that I htst saw h aUvo on 



~lt)0 

190 



ami that dcatli occiirrcil, 011 the date stated above, at 



r 



^3i£), 



:3" M. The CAl'Sh: OI' DI'.ATfl was as follows: 

S^JuULr^^■^..^r\\^xxJ\>u^..sJ,^,^*^^ 



DT RAT ION }'c',rrs ISIonths Days Hours 

CONTRIIU'TORV 




K.^ V^CU 



Pays 



? 



IMK lIlPI.AClv 
of MoTIIHR 

(state or Conntrv) 



(^ 




'W/\\jOo 



occrrATiox 



r 



DrRATION^ i'cars drouths 

(SIGNED )...0.. 0. ^XX.^'VaAXu, 

VrUV- 1% T90"'. (.Xihlress) CsOib 0.uJX^J^^ ~J+ 



Hon is 
M.D. 




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



'\'\\V. AIIOVK STATKn I'KRSONAI. I'ART IC C LARS ARl". PRrK T» > rill-; 

in-:sT Ol" MY KNo\\ij;i)c.K AM) in:i,rKF 



(In 



fovmruit CSXX.VAJ" x^t> 



(Address lO I 




x^r>v 



i 



-t di 



Former or 
Usual Residence 

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



flow long at 

Place of Deatfi? Days 



IM.ACK 01 niRIAI. OR RKMOVAI, 



' jr)\ojtju> vio_ 



rXDlCRTAKKR M ' ^-<X^L/YV sJ 



(.Address 



I>A'n:o! UiKiAt. or KKMOV.AI, 

... 0\^rvr xn. T90H 

1 ■ ■" 



.a?)xG^<xcNl^.. cSt 



N. B. F.very Item of lnf(»rmntion should Wi ctireV'ully supplied. ACJB should be stated F.XACTLY. PHYSICIANS should 

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



Il^ 






h 



. i 



It; 



!■ H 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H...ir.! i.f H..,ilt»i 1- No. ; - ^:.3'^-^^ i^Sc !' < 



Dff/c /'y/r^/,\lX<!\MyY>A,VvJt\] lb 



!«««^r#«.*««'< 



IfJO'i 



Registered J\'*o, 



3/364 





n^u Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of Bcatb 

{ X\. S. StanOarO ) 

PLACE OF DEATH: — County ol 0--\-\} XCO^tvj.rCc City of CJ-Cu^v OVct>^c<.^c^ 
^ I) %' 



No. ^^'AX^ 




CHL/WvXa_L 



St.; 



Dist.; bet. ^ and 



(IF DtATM OCCURS *WAY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

.UxLLuxry'iv. cLtX"-o_t_a.\,cl, 



-) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 
SKX l\^ h I COI.OR 




LUJfvCU; 



1) All': Of- I'.IK 111 



C 

(Month) 



t 



\r.V, 






(Dav) 



M.>utlis 



.r%SJ^ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF Dl'ATH 

^ov 1$^ 




(MontlO 



(Day) 



igo \ 

(Year) 



0, 



a.': 



Da 1 . 



siN(.i,i:, MAKi<n;i). 

WIDoWKI) OK I)noK(KI) 

'U'ritriii vioi'ial (Irvivtijitiim) 



lUK'Pin'K AiM-: 

'Statf or Coiuitr.v^ 




NA\n<: oi 

l-ATIIKR 



RIRTTfPI.ACK 
OI- lAPHKK 
(Statf or Conntrv) 



\^ 



[ 




«? 



MATDKN XAMK 
Ol MoTHliK 



lURlin'UACK 
OI-" MOTHKK 
(Stall- or t'omitrvl 



OCCIPATION 



CiJL/^^^OAjl 



? 



I HHRICIiV ClvRTIh^V, That I attciKlcd deceased from 

-cl^ M 190 H to yLcar .-3,5. 190 t 

that I last saw h '- > • > alive on VrL<5.V!:...,'^^„ i^o 

and that death occurred, on the date stated al)ove, at v 
\X ^I. The CAUSE OF DJvATII was as follows: ^ 

...vJ/Cv.XlAA.A,^:.xx^ 




'^ 



DC RATION c< Years 
O 

DTRATIOX ( )'^Ciirs 



M out /is 



N T R I H r '1* o R Y UA^-a^t^^w1^tAA>^„ 






AfoHths •■ 



(SIGNED) \Jb. A. UJodUivvo 

\l\r\r at rqo'l (Address) IS I SxvtllAi Ot 



/)ays Hours 

^t.XfMUv«l 

Days Hours 

M.D. 



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



Kfyidfd ill Sail f'l tJiii i.wii 



) Vi7 ; 



M.'iith' 



/),n: 



TM1-: AHOVK STATKI) I»KRS()NAI< TA K I" U' I' I,AKS A K 1-: TRiK TO THH 

HHsT Ol- MY kno\vm:d(.k AM) in:i,n-:i" 

uformatit vAx\j2JLAyVs.XX> cL<xXmX<VXX^V<X/ ......^.„. 



(I 



Vddri'ss I i?->'^ 



\±ix 



A 



t. 



t ■ It 



Former or 
Usual Residence 



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



IJ^UoXuiV't.dt Place of Death? X[.. 



Days 



n.ACK OF JirRIAI, OK KKM(»\AI. I DATH of HtKiAl. or RKMOVAI 
INDHRTAKKR J^-OL^ C3 . v) (HXJt. 



1 90*1 



<Xcvj 



( A <1 < 1 J e ss C) O \I 'UrVvXO/CJ^^AJi >t</ W v.* I , 



/ery item oV* information should he carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should 
ate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'' for psr- 



N. B. Ev< 

state 

sons dyinft nway from home should be given in every instance. 



>4 



i 
I; '1 



k 



tfi 



iii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



15..;il,l of Hcilll', 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



[)((!(' Filed ^ 



J^y\.*^K,^ 




^b lOO'i 



Deputy Health Officer 



lle<iistercd JVo. 



'?65 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of IDeatb 



PLACE OF DEATH; — County 



of CJcoox; J •x<xi\.ckAc.fCity ofCJ/^v^^ J;v.cc> 



No. 11^ .^ va.c 



rU^b^rw' 



-< 



St 



.; X Dist.; bet. Ax^CX' 




and 




x^C,<^<i_c>o 



(1^ DEATH OCCURS AWAY FROW USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
JJIF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME cLiUL^^ Ai) (^taxi. 



u^y\^cp>^u ) 






% 



PERSONAL AND STATISTICAL PARTICULARS 



Sl'K 




DA ri". < ti luk in 



C(»1,(>R A 



V 



I Miiiithl 



VU^CLcVAT 

/i^'X 

(I)av) (Vcar) 



MEDICAL CERTIFICATE OF DEATH 



DA TI'; oi' di:atii a 

QfW 



(Year) 



AC.K 



y\ 



) fUl t 



Moufli^ 



Pa \ 



U ID<»\\ I:D ok DIXoKOl I) 
<\\iitriii sociiil (ltsi<.'nali>)ti) 



luu riii'i, AC)-: 

I state <il I'DllIltl v' 



NAM} <)1 
I- A 'II I IK 



RJKT!n'l,A»K 
'M I AlllllK 

' Sl:ili III (.'((illltrv^ 



MAIDt'X NAMj; 

ni- MuTIlliK 



HIRTUFM.ACK 

OI- M(>'nn<;k 

( Slati' 111 C'ouiitt v^ 



oi-Cll'A TION S) Ij 




lia... 

(M(.mh) (Day) 

I ni'RlCBV CI:RTII'V, That I atttMidcMl deceased from 

to :. 



rrrrrr---—-—--r-r---------- \ ip 

that T last saw h ■.."■ ' ■ alive on 



I90 



^ : 



%- 



? 

r 



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



•:^ 



CI 



M. The CAISI-: ()[• I)i;.\TII was as follows 



W^rrooc 



C^'>x.UL^.^Lvt.v,<Uw ^jl^-^w^hw^jtv^ 



cUUt' llVz-VX' 



1)1 RATION )\-ars 
CONTRflM'TORV 



Months 



Days 



Hours 



t*»*^3{l.-*.*j«S,iii,. 




^1 
(1,0 





DIRATION 



^ 



)'cars 



Months 



Pavs 



Hours 



vllO\r %So u 



\A^'>V0L' 



.Hy\XM 



Kf-idi-d III Silll / '1 (I III l^ii) l-A )V(MV 



^J,.,l!ll^ 



lKl\ 



)0 



f 



Address) (o b c3aaHx>V) Cj.l 



( Signed )...J^U:L^A.vxA .sV La.-wvutM- M.D. 



■i^ 






SPECIAL Information only for Hospitdls, institutions, frdnsicnts, 
or Recent Residents, and persons dyini) away from fiome. 

Former or How long at 

llsuat Residence Piarc of Deatfi? ... Days 

When was disease ronfrarted, 
If not at place of deatfi? 



rin", AMovK sr \ri:i) pkusovai, i-xKiicrLAUs .\ki', rKCK ii • rii i-; 
in-;sT oi" .Mv K\(»wi,i:i)C.H .xnd iii;mkf 



I iil'i! m;it)t 



'a; 



Xd.li.ss V> I iC\^CAXX.^>xXA'A..Lo C 



dt 



i;i,ACK OI" muiAi, ok ki;.M<)V.\i 






DATi;..! Miinxi. (.1 kl.:M()\-Ai, 

IrXijv^ xi 190'; 






IN. B. Hvery Item of iiiformiition Hhould ho csiputrully Hupplied. ACH Khotiltl he Htnted EXACTLY. PHY8ICIA!>8 «hould 

Mliitc C.ADSI! or Dl'A TH in pliiiii terms, thjit it m»y he properly clHHHh'ied. The "Hpecial liiformutiun" ?or p«r- 
Hons dyin^ iiwiiy from homu Nhould he ^iven in overy inHtance. 



r-=»= 



ft 



14 


:; 


1 






* 


•r 


ii 

li 






1 




{ill 


li 


,L 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.X:l' (* 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Jfrs^isfe/'ed Ko, 



8366 



cUv^x^iiUxh^ Deputy Health Cfficer 

DEPARTMENT OF PUBLIC HE ALTll-City and County of San Francisco 

Certificate of E)eath 

J? ^ \ ^ 

PLACE OF DEATH: — County ofO<X>\) o.V<X'^x<XA/<iO City of OxX/>"u J /Vcc-vvCva-c* 

\ \ \ '^ 

\l St.; 1 Dist.; bet.VX ■CUL 'r-LC'\vaXc V and 



No. lie 



HI 



F DEAtH OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPEdlAL I N FO R M AT r O N ' ' '\ \ 

TS NAME INSTEAD OF STRERJT AND NUMBER. J J 



(IF DEAtH OCC U I 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



) 



FULL NAME 



(W 




\]£^'Xm OwOrW 



(\ 



Ni; \ 



PERSONAL AND STATISTICAL PARTICULARS 

i COI.nK 



■ l\oJ-.c 



I) A 1 j; • U i'.IRTlI 




\J^J 



iMunth) 



A<". K 



bx 



!>,.'». 



SIXC. |,|.- MARK n", I). 
WIDdW I'll ( )K DIVORri:!) 
iWiiltiii sfjcia) (ksiLni:iti"ii> 



I! I R rill' I, \<M', 

' St.iti or I'l.iiiitrvl 



Ow- 



iDny) 



M..ii!li> 






(Vcur) 



/^</). 



/^ 




^>XCU 



NAM)'. «)1' 
I- A I" 1 1 l.R 



lURIll IM.ACK 

<>l iAiin-;R 

i stiitt ot (."outitrv 



? 



MEDICAL CERTIFICATE OF DEATH 

DAi'ic ()!■ i)i;aiii 




..StH 190 H 

(I^y) (Year) 



(Motitli) 
I H1:RI-:HV Ci:kTll"V, That r attciuUMl deceased from 

~~~~ — — Ttp to 190 

tliat I last saw h -v— — alive 011 . — ■ - ■■ 74^ 



ami that <U>ath occurred, on the date stated above, at 

vas ai 



0^ 



M, The CArSi' Ol- DI-.XTIi was as follows: 



c 



.CW^Oj 



MAIDKN NAM1-: 
OK MOTIII'.R 



I'.IRTin'I.ACK 
()l- MOTHHK 
(State or Coutitry) 



? 



OCC 



UP AT ION JP f) 




WOu 



I )( RATION )Vu;-.v 
CONTRII'.CTOF'IV 



Months ■-. Paxs 



J lours 



P 

Si 



3?f) 



f^ 






^ 



•J 



Mouths 



Days 



Hon 



m RATION Years 

(SIGNED ).... J - 0. v>CX/ywua^ M.D. 

\,l\<5V" .^5 T,,o' (Address) (oOb CJ^U^fcl ii ^j H, 



SPECIAL INFORMATION only for Hospitals, Insfifufions, Transients, 
or Recent Residents, and persons dyin;| away from home. 



■tr\JUv 



J 1 



h'r-^idfiJ III SiHI /'iinni'-o <)\ )'i<i>^ 



.1 A .///// V 



/',M 



Till' AHovi-: si'A'n:i) rKRs,()x m, par ri'Ti, ars ari. iRii-: TO I'll }•; 
UKST Ol- -Mv KNowij'ix.K AND ni;i,ii;i- 



'Info; inaiit 






fA<1flrcss 13)X ..'-Cue 




C ^t 



Former or 
IKual Residence 



How lonq at 
Place of Deatli ? 



Days 



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



ri.ACK Ol- IM RI.XUOR ri-;mo\.\i. 






• N I ) 1 ; R T A K 1 -; R ^ ' rUxv.'VNi J Ci-<rr< ^^ \^ 



n.\TI-; of 151 lOAi. or Ri':M()VAI, 

M\^(rsj' 3Lb 



T90H 



r 

r 



m 



IN. B. livery item «»lf iiiV'ormntion Mhoiihl h.> cnrefully siippli^jl. AGB Hhr>ul(l be Htnteci liX4GTLY. PHYSICIANS should 

Htntc CAlJSr or Di; A TH in plniii ttrins, that it miiy »>e properly ci»H«!fied. The "Spcvial hiV'ormntion'* for pmr- 
nons (Ij-lnil nwny ?rnm hditic Khoiild he t^iven in every inMtiince. 



I 5 

I 

.1 1 
ii 



tl 



iti 



i ' ~ 'i 



1: 



' I 



II 



i ij 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



W««ir(l of !I, ilili IN- t-*'W.^»jlJ&I'Co 







1 



tVVN^ 




REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 



.^ U i 1 IL- 



^->^(sUv Ab., I^Wi ^ 

Pe|)Uty Health Officer 



Jic^isfefed Xo. 



^^TIC? 



No. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of 2)eatb 

(11. 5. J?tnn^arD ) 

J? ■ (5j^ "^ ^ 

PLACE OF DEATH: — County ofO/OyVu Xvcx, >vov/^CLCity of OxX/rv AXX-^a.xi^vA CC' 

2LC) nUk. St.; ?^ Dist.;bet. Sa^cL and H i^K' ) 




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



FULL NAME 




AyrwoL'X! I LoX<Lrryj 



'PERSONAL AND STATISTICAL PARTICULARS 

coi,()K\ r\ 

DATH (»!■■ I! IK I'll A 

MW ^5 ,HOH 

!M-.nlh^ (Day) 



"~^ 



\<.H 



) V'd / 



M'mlh.y 



(Vt-ar) 



Da V. 



\VII)<)\\I<:i) <»K I)I\'<)Krj<:i) 

iWiiti'in s«H-i:i] iKsij.'!iati' >n) 



niK'rmM,\('K 

iSt;itf or (Joiiiitiy) 




MEDICAL CERTIFICATE OF DEATH 

DATl-; Ol- Dl'ATM f 

j\r %5: 




(Month) 



(Day) 



(Year) 



I HHRlUiV Cl'RTII'V, Tliat J attciukMl deceased from 



\rU\r 3^^. 190 "t to \X\ASSJt Ts5 190 i 

tliat T lw»t saw h ••j'--*^^ alive on -~'~~'^' 190 

and tliat death oceiirreil, 011 tlie date staled al)(»ve, at 

M. The CAlSlv ()!• DI-ATFI was as follows: 




<Li^^Ji rLc lvN.Xft.XUAAX .^: 



CJ O^^ru J XXX/Y\Xl\^ CX> 



NAM1-: Ol' 

i-aihi:k 



niRTTIPT.ACK 

Ol' 1 Arm:K 

I St.'itr or Country^ 




cu 




\a.t 



NfAinilN N\M1' 

Ol" .Morm;K 



BTRTHP!,.%CK 

Ol" Morm-tR 

(Slattj or Country 



OCCUPATION 



^^<rrX' 



C)\xcKXu, 



. tT> "^^ Ow' Cj f^c-JL^r^^s)^ -Y v; 



I)IR.\TI()N )'f(7JS 
CONTRir.rTORV 



Mo)tt}is 



Days J/oiif s 







DIRATIOX 
(SIGNED) 



)'tars 



MoNt/is 





Pays Hours 



)jLVVN.cLt 



J lev- Ov^ 100'! (.\<Mr.>>) ^.^^. vWl^(t»-v d.t 



i 



M.D. 



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



Former or 
Usual Residence 



How long at 

Plare of Death? Days 



l\f'M'ih-i! 'II Sa>! /'iin/i!^ 



)'(■(! I 



M.,>ilh< 



lhj\^ 



THK AROVK STATKD I'KRSONAI, I'A K TKM" I. AKS AKl". TKIK To Til 1-: 
HI'tST Ol" MY KNoWl.i;i)(".H AND MIIMICF 



'Informant 






^r\\) 



( Nddrrss 



5kO 



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



I'l.ACK Ol- lU'KIAI, OK KI'IMOVAI. 




I NDl-lRTAKHK (JVD 

(Achlrcsv^ 



DAI^Kof HiKiAi, or RKMOVAI, 

XJUpj- QLIo 






190^ 



IM 



al\ 



vA.^^c->v; d*t 



^ 



IN. B. F.vcry item of informntJon should he cirefiilly supplied. MW. nhould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DFiATH in plain terms, that it may be properly claNKified. The "Special Information*' for pur- 
.^'>ns dyin^ away from home should be j^iven in every instancet 



m 



■? ■ I 






( 




f 



I ■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ft-jfn,, 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




/)ff/<' I'^ih'd , M tfiVM^vJLuA' V^ 



y\Xy 



100^ 



Reglsfei'ed JVo. 



'3368 



o•v»cv^ ,-L^v-v., Pep*-'*" »-'<??'«:*i Offi.c.e.r 



1 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( *a. 5. StnnDar^ ) 
PLACE OF DEATH: — County of LcroKv^- City of ^iJ-C^l^<-K. AX\.t/iyCnxa; 



No. 



St.; 



Dist.; bet. 



and 



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



FULL NAME 




XXPCM 



koJL 



<^{rY\; 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 




c'OI.OK ^ 



\cvLl 



LLJvvAji 



DAI !•: Ol r.lRTH 



Af.H 



M.Milh) 



O w y lilts 

SIN. ; l.i:. MAKKIlvH 

\\ n)n\\}-:i» t)K i)i\-oK(i;i) 

«, Write in social cksi^nialioii) 



I Stiitc or <,'")iinti y^ 



'Day 



Mnllths 



(Yfur) 



MEDICAL CERTIFICATE OF DEATH 

DATl", tH' DKATH 




fMoiitli) 



..iO..... igo'^\ 

(Day) (Year) 



Da 1 ^ 



NAM I". f)I 
FAT 11 )!!< 



I'.n<llHM,At."H 
<)»• I'ATHHK 

(State or foiintrv) 



MAIDHN NAMK 
oi^ MOTIIICK 



lUKTHlM.ACK 
or M(»Tm<:R 
(State or Country') 




I Hi'iklUJV CMkTII'V, Tliat I attended deceased from 

— I90 to I90 

that T last saw h •^- alive on ■ - ''^^'- ■-" ^190 

and that deatli ociiirred, on the date ^taletl ahovi-, at .. ?.j. ' .a!..4iw^-. 



^ 



M. The CAl SI-; ()V DI-ATII was as follows 



J XCVci^A.A_C 



4 ^-i 



V\->aJ, 



I) r RATION Years 



coNTRinrTokv 



Months 



Pays Hours 



DTK AT ION Years 



dLoJtKAJ-*v' 



OCCUPATION 



G 




Mo)iths ■■ .' Days 



\a.w 



I lours 



( Signed ) \J . LC M U dJCnxcuUt UrVcrvAXh.- M.D. 

(TV^ V^^ r<io'l (Addn-ss) Uj,\.^(viX. \X> 



Vv-O^trvvo. 



Special Information «niy for Hospiidis, insmutions, Transients, 

or Recent Residents, and persons dying away from fjome. 



Yroi 



Mnnth- 



Da 



\'\\\-. AHOVF: SPAIi: D ft'- K son a I, I'AR lIiMM, \KS AK l". I'Kri-: To TH I' 

iJi-;sT Ol- MV kno\\ij;d(.h and hhi,ii;h 



fill fotniMtit 



L<rurv 



^JL>\A UXi^^^rJc 



(AfUlre>;s 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



IM.ACi: 01 lUKIAI, OK K1;M0VAJ, I DAIllot IMkiai. or KKMOVAI, 

^lu Oic^^ I ^' '^■^ T904' 

rXDl'KTAKKK ^^^^Kyy\JKSUK) ^<C OOV,^C^v-Jt 



fA(l<h«'Ss 



N. B. Bvery item of informHtion should he cnrefuliy Hupplied. X^W. Hhould he ntateil hXACTLY. PHY8ICIAIN8 should 

stntc CAUSE OF DEATH in plain terms, thnt it miiy l»e properly classified. The "Special Information" for par- 
sons dyin^ away from home should he fti^'cn in every instance. 



^-'/^M^'^-Jumm'^slAtm^. 



I 



i 

\ 

r- 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



u.,.,.-,l • I r '• 1 IV, 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc h^i/cd , ViXcv-C'Yw u 



Bp^istered J\^o. 



33G9 



,(JV'>-t'Ywl'-Ov 2Lb 100^ 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Cevtificate of IDeatb 

(11. S. StanC»arD ) 



PLACE OF DEATH: — County ofCcL'^x OXa>vac^t^. City of Clo/^O) JwVa/>A.c<^<ic:c 
No. S3k\:) vI(rUk St.; X Dist.; bet.M l\ UJJLc^tx\^ and 1lJL1^\ 

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

FULL NAME ^ * L<:vLui' cL> M / ULCL^c^Xi.......... 




PERSONAL AND STATISTICAL PARTICULARS 

j Cf)I,<>k 



DATl-; <>1 lUK TH 

ajL.|\l^ 

iMo'iith) 




A\.<XjiL 



lb 
(Dav) 



(Vear) 



AGE 



It 



}',,;».* 



M.'Utfis 



Pa 1 . 



^iM.i.r: MARK ii:i), 
uii)«»\\i:i» Ok i)i\()Rri-:i> 

(Wiittiii social (Itsiv.natiuii) 



Wc' 



\.^^AJ-XA- 



HiK riii'i, \*'i-: 

'State i>r I'oimti v^ 



N'AMl' (>! 

f.\tiii;r 



lUK'iii I'l, \ri<: 

Of" lAlllltk 
(Slate or I'ouiitiy^ 



-..wK/^r^ (jIdolK/vmlu 



MEDICAL CERTIFICATE OF DEATH 

DATK <)I' r)i;ATH \\ 

MWj" [% ipo'i 

^ Month) (Day) (VV-arl 

I m-RI'HV CI-:RTIFV, That I alten.ltMl (IcHvaseil frDiii 

\jVXi\r \^ upH to VPl^Cat \% npH 

tliat T last saw h-wV alive on ..,..\f\<^r:. H -[cp^^ 

and that lUath ocriirrcd, nn the date stated above, at O- O 
LL M. The CAISI*: ()!• DIvATH was as follows: 




MAIUHN NAME 
or MoTlII-k 




Dr RATION Years Months Days /lours 



CONTRIIU'TOR' 



£) 



-w?3uC<x>a^iL 



ai at) 



-iJwrOuV.. 



-jL/O-%1 



in: RAT ION 






)'('(rrs 



Months 



Pav. 



(Signed ).A.V . J-UA-Iavcx Jx/»v^-v^Ji 



HiKTni'UArK 

III" MOTIIHR 
(Stall- or CoiitJtrv) 






Sr'ULow'- 






VlLcv- 1^ TQoH (Address) ...io 13L VJcrLk dt 



I lours 
M.D. 



Special information only for llospitdls, InsMtuflons, Transicnls. 
or Recent Residents, and persons d>in;) dv\.iy from home. 



f\f'.--!(fl',! Ill Situ Fl il III I'si'd 



1 



'lUJ I s \ 



Mnllll,^ 



I\l\ 



Til v. \n()\i-; SI" \i"i;i) iMrUsoN \i, pxkiim.Aks ari; rRii-: ro iin-; 
nivST ()!•■ Mv KN<)\\i,i;i)c.i<; and i{i:i,ii;f 



Hn fo: niaiit 



A.l.lrrss ^^b VJ CHLk Ot 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



iM.ACi-; ni' lukiAi, OR ri:mo\ai< 



DA'll'.o;" m wiAi, or RlvMoVAl, 

vVuv- Xl T90H 






N. B. r.very item of informntion shoultl he ciircV'ully Hiipplieti. AOR nhojild be stnted EXACTLY. PHYSICIANS should 

stntc CAUSE OP DHATH in pliiin terinw, tliat it miiy be pr<)perly cluHsified. The "Special Information*' ?or p»r- 
ftons dyin^ away from home Hhoiiid be (liven in every instance. 



I 



II 



•ii'li 



f 



w 



14 

I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



r.'..ir(! of llirillh I No. !> «■-'_; ir-.^j iii\. 1' (o 



Ddfc /'V/^''/. \Jl^>s-C'^A\/' 




h-xAj 



at 



Ileo^7\slered jYo. 



8370 



rjOH 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of Bcatb 

PLACE OF DEATH: — County ofOa^^ J VXVyvCv^co City of Cj-CX'>vi ^ A^o^-y\,ZA^Ci^ 



No. Ii5 Obcu.ix« 



St.; a 



Dist.; bet. v.)xvcy>v<x> 



v<^>^ and (X<XQA,v>xo. 



/ IF DEATlJ OCCURS AWAV fVOM USUAL RESIDENCE GIVE FACTS CALLED TOR UNDER "SPECIAL INFORMATION" Vi 
V, IF DCyTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /U 



I V. 



FULL NAME Ld^^-o^vcL 



PERSONAL AND STATISTICAL PARTICULARS 
Si;X ^ . i COl.OR \ « 

so A'io 



(kcli 



^<JL^\i'v 




-4- 



■cunrv... 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



LluJl 



,MlM 



iMlmth) 



D.MVt 



ACE 



ill 



Vi_ 

WIDOWED OK DI\'oKr J-D 

iWiit< ill soiial (h sis.' ii;it ion) 



) Vif > . 



Mniilhs A 5 



(Year) 



/)</ r.v 



c/>-ViCy\Jl 



TnKTn»M,Aoi<: f) 

I St;it< or Coiiiitry' -X 

rATn,^K" e Py. 

„_. LcLac^^^o^VcL M iX<yVct^c»^>^ 

lURTIIPI.ArE (\ 

oi' i"Ariii-:K ^ 

iStatf or l"<)iintry) C\ _ 

I T 




(Month) 



xs. 

(Day) 



(Vf.ir) 



J lIl'KIiHV CI-:RT1I'V, That I attended deceased from 

Llot Si looH to \)rU\r.....^.S... 



190 H 



Si 190H to ■■ 

that I last saw h -L'nrx alive on v vuMr...»;o up 

and that death occnrred, on the date stated above, at 
\J M. The CArSl' OF IHiAIlI was as follows: 



Cv^fr-lMX^v AJr 




DlkATION }'(iu;s Months H Daxs 



I lours 



DI'R.XTIOX 



Years \ ^foiiths 



MMD!:\ NA MI- 
DI' Morm<;k 



litRTHPl.ACK 

ol' MoTHIvK 
(Statf or t'ountry^ 



^^hxk. 



<x/>v 



d 



OCCUPATION J • J ^ 

k'l.iili'd in Sill! /'i,!ihi>ii> a\\ )'r(M> 



(SIG 



NED ) ..Uj...U3. XitCO^ti 



Pavs 



Hours 



^5 Tc)oM (Address) 5 C)C)U 'Ci/^ 



M.D. 



Special information only for Hospitals, Institutions, Irdnsicnts, 
or Recent Residents, and persons dyinj awny froii home. 



M.hIJi- 



Ihl.. 



\'\U-. AUOVE ST\'ri-;D I'KKSOXAI, rAKTItT LAKS AKIC TKIJ-: To r 11 1<: 
JU;ST ()!• MY KNOWLEDtlE AND WVAAV.V 

u.Mivss bS'O ^ c^ijm at 



f Iiifoimrint 



<Xa^UL^ 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



ri.Aci: Ol' lURiAi, (»K ki:mo\au 



DATi: ot HiHiAi. or KlvMoVAI, 



0^1 



190H 



L ndi:ktaki:u VJ iVcpv'XXlAvcuvv^ U oId clA.xX' VC vc 

^^(l(lr(•^^ ^"iMl \) l\/\.XL>4.^^>\, Ot 



N. B. F.very item otf informntion 8houlcl be cnrefully Kiipplieii. AfiE shoiihl be statetl F.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnln terms, that it may be pr«>perly classiried. The "Special Information" ?or p«p- 
flons dyin^ away from homo should be (^iven in every instance. 






''ll 



r 



jU 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



li.Kii.l ..f IKiiUli- !■ N'c. !■; t-f?rrj.X-;IU<vl' C. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



'J 



i ( 



I 



Dale Filed, j un^v^^A'vlMjv %Sc 

i \ 



VJO'X 



Be^lstered JVo. 






171 



DEPARTMENT OF PUBLIC HEALTH 



City and County of San Francisco 



■I 



Ccvtificatc of Beatb 

( "CI. 5. StniiDai^ ) 
PLACE OF DEATH: — County of Ccb^rxj O.Vcu^xcu^cc City of "^^ CL>^ Jy\x:^.>xeu^CC 
No. li)Ol VlC^LI^N St.; Si Dist.;bet. ulcU^u and J.U^\.'rv 

f \r DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDeA "SPECIAL INFORMATION" \ 
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O^ STREET AND NUMBER. / 



FULL NAME 



/CLuo'^CX'VcL 




C-Cr'UL- 



SKX 



i>\'ri: Ml HI Kill 



PERSONAL AND STATISTICAL PARTICULARS 




^ 



\Xj)(\kjJL 






(Day) 



./acM. 



AGF. 



)V(fi.> ^ Mioilh^ 



b 



(Vear) 



/).M> 



^iM.i.i:. MAUknii). 
\\"ii)(»\\i-:i) OK i)i\< >Kt ):i) 

Wlitriii ^oci.-il (lt>.i;'ll;it loll) 



11 



niRTHPLArK 

iSlMtf or Comili yl 



FATMI-R 



nTRTTirT.ACK 

<)!• I AI'm-.K 

' Stall' or rountrv^ 






MEDICAL CERTIFICATE OF DEATH 

DATl-; ol- DKATH 

.cv" '^5 




(Vtar) 



fMoiith) (Day) 

1 HIvRlCUV CI:RTII'V, That T atteiukMl (Icccascd from 

\jUrvr 1.5:. 190H to Mlmr..9..5 k^m 



190 V to 

tliat T last saw hvrv^;>. alive on 



Kp 



and that death occurred, on the date state<l ahnve, at !0. -rsC 
..UM. The CAl'SIv Ol- I)i;.\Tll was as follows: 

vJ/0-XiA/v<i \.^\J^ 



^ jLl^jCLwA 




I 



I 





D I RATION Ytaxs I\/onl/is "XX Days Hours 



CONTRinrTORY 




'.(>:>Jli-iu^"v x^^^.x^.ua. 



3foNl/is X /)(irs ' X Hours 



MAIDMN XAMl". 
n|- .MoTllKk 



lUR'rm'T.ACK 

<)I' MnTMI':R 
(Slate or Country) 



A ^ n 



OCCUPATION 






/"O 




Dl'RATlON^^ Years 

(SIGNED ).vJAXcL L). LtVCLcLcUi-VX^H M.D. 



(V.,- 



*> £; 




sfc 



±1^ 



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



}\f>iilfi{ ni S,!if /'/I///. /- 



);,!>. 



Mr.xth^ 



1h-.\. 



Tin-, AHOVK STA'n:i) I-KKSONAI, I'.\K'lirri,AKS AKl' TKI K To TUl-: 
DKST OI- .MV KNo\Vl,i;i)C.K AND WVAM'A' 



(Info; iiiaiit 



'XMrc'^s 






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" IMRI.M, OK RllMoVAI, 






fiLu- La-^-^-^ 



DATI-.of MfKiAi, or K1-:MoVAI, 



^^cl<lrcss M. U/OU-ru xHliL^LO L\.v.kv 



I90H 



N. B.- 



-Bvery item of information ahoulcl be cnrofully Hupplietl. AGE nhoiild be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, thnt it mjiy be properly claHHified. The "Special Information" for per- 
sons dyinft nway from home should be jiiven in every instance. 



» 1 



t 



II 



<i 'i 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTSFICATC FOR INSTRUCTIONS 



Eegii^tered J\^o. 






\j^u^\x\^^^. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of H)catb 

( "U. S. StanC»arD ) 

J? Qf^ \ ^ 

PLACE OF DEATH: — County ofC)<Ct^»^ vj .\xv>vc\A^ci City o{Oouy\j OA.<x>v.<^ut<:x 
'No.' jti. WAXM'Vi Ob ^<L'Wv^t<xl St.; 




Dist.; bet. 



-and 



(ir DtATM OCCURS *W*Vl 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 \m^ 



PERSONAL AND STATISTICAL PARTICULARS 





SHX 



DAT!-: oi- r.iRrn 



COI.OR \ 



sXjMjJjl, 



MEDiCA 
DATK OK UKATH 




Month) 



\<.K 



J 'fit t 



(I):iy) 



.V'..«M.v 



/ ubl 

(Year) 



Da vs 




\vii)t>\\i-;i) (Ik i)i\()Kri;i) 

i\\iit«iii sociiil (Irsij/iKitioii) 



lUKTHri.AlM': 
(State or Country' 



\.\M1-: OI 
FA in i;r 



RIRTHPI.ACK 
OI- lAPin^R 
(Statf or Coiintrv) 



MAn)]-:N NAMH 
Ol' MOTHKR 



lURPm'UACK 
OK MOTHKR 
(Statf or ('o\intr\ 






(Month) 



(Day) 



(Year) 



^ I Hf':in<:BY certify, That I attended deceased from 



1901 



X3 190 1 to y.Vtrvr: an 

that I last saw h '^'»x alive on \l v<IVr ....^H, 190 

and that death occurred, on the date stated above, at v 
\^ M. The CAISP: OF DI-ATH was as follows: 




Y 



\X.?vrv.<^wVr«r^X.L^'i 




vui. 




OrRATIOX rears Mouths I I^ays 

CONTKIIU'TORY ........,_.„.„ 



Hours 



OCCUPATION (? 

fyfsiilf,! IIP S,ni /i,ui,isf» W Vfors . 



DURATION ^'''•''"/L Mouths Pays 

(SIGNED) UJ.V OIj *QWM-^V^-^-''>>-^ 

Mlc^r %Sc 190M ^ (Addresses XI mo; Jut it 



Hours 
M.D. 



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



Mn„tll> 



l),n. 



THi: AHOVH STAT>:i) I'KRSONM, I'AR rUTK ARS ARI", TRIK TO Tlllv 
HKST OI' MY KNO\\I,I-:i)«". K AND lUlMl.K 



(Infonnant 



2),^^\%"aa^|.. 



f \<l<ln 



51 VJJLVvo^ It 



Former or 1 1 ^n i fn ^\ ^•^ '""9 ••* 

Usual Residence 'O c^\J4AA^ ^.'A place of Death? 1 

When was disease contracted, 

If not at place of death ? 



Days 



■ •*t«HM.y*»>»*««a»i«ft»^*a*«.*> 



^,ACH or lURIAl, OR RKMOVAI. I DATHof ItrinAi. or RKMOVAI. 

' Criu.U '-'•^A I uUv- 



ai 



-^^^-^-ii. 



T90 



IS. B. Every Item oir* informHtion shouUI he cnrefully Hupplied. AGE should be ntated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it may he properly classitMed. The "Special Information** for psr- 
sons dyin^ away from home should he i&iven in 9\«ry instance. 



c_-ir' 



63> 




r 



fS 






MaWWMMita 



11 i 



I ! 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hnnr.l f H. .!tl) IN.' ; ^•^'p^^ H&l' C. REFER TQ BACK OF CERTIFiCATE FOR !NSTRUCTiON3 






:i 



Deputy Health Officer 



Registered A^o. 



8373 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDeatb 

( X\, S, Stan^arD ) 



PLAGE OF DEATH: — County of ^ CV^v Xvcx>vCUi,C< City of O/CX^^ J.^^<X>x/Ov^c.o 



4 M' * (I I 

\ / IF DEATH OCCUH6 AVWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION ' ' \ 
U V, IF DEATH OCCWRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Dist.; bet. 



■and 



^) 



FULL NAME 



'll^. 



LV/LutXr^-^^ 




\^ 



J^'U^^Z.hj. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oK ^ 




<Xy^ 



DVVV. <t|" IlIKTll 



Mi>i!th> 



jJxu^ --^ - 

cJjX /tS,.l 

(Day) (Year) 



M.K 



qlU 



l^ iVats 



M,»ilfis 



Pa 1 .V 



STN'C.T.K. MARKlKn. 

\\II)( >Ui:i) OK DnnRrjM) 

'Uiilciii 'iotial (1< »^i>.'^atil):l) 



nTKTFTPI,\rK 

(Slittf or Coiiiitiy) 



NAMl-. OI' '\ 
I- A I' n K k I 




MEDICAL CERTIFICATE OF DEATH 

DATE OF DI.ATII 

I \r\ 

.f^ ai 




/go \ 
(Year) 



0- 



(Month) (Day) 

I m:Ki:iJV ClikTlFV, That I attcii.led deceased from 

>\.OLM U looH to \rWC\r:.....Xl. Uyo'\ 

that T last saw hii/v»r\. alive on .......... \0*^Wr...,3».L.. 190 H 

aiul that <leath (Occurred, oti the date stated ahove, at C!)-5>0 
V.^ M. The CAISI-: C)l- DliATIl was as follows: 

LJrW^rv^vii Vil.\jdbA,<xJ!L O o-LIj^^^v^^^vcol. 



lUkTHI'I.ACy^ 

01 ■ i-Arm<:i< 

'Statf or (.'ouiitiN-^ 



MAIDI'.N NAMH 
01 MOI'IIKR 






Dlk.X'riON )'cars b Months x^ Days Hours 

CONTkllU'TORY - 



DTR.XTION 



Years 



Mouths 



Pays 



MiurmM.xci-: 
01 M()rm-;k 

(State uf CuuiUiy) 



occupation 






(>AxLcu 



>^*^X7^_„. 



w, 



A'f^/iffi/ in San I'liiihii- 



^>^ 



(Signed) Id. \d. Lcr^^Oo^ 

MI'CV- 1:a. t()oS r-Xddn-ss) LUOrvA/^lrv 



/fours 
M.D. 



(^VA.-AJi. 



Special Information »nly for Hospitals, institutions, Irdnsicnts, 
or Recent Residents, and persons dying away froni liome. 



)-, ,n 



yj.nithy 



Ihl 



Tin-, \iu)VK ST\ rj:i) i'Kksonai, i- akik'i-i.aks Aki: tkij-; im im)-; 

ItKST ()!• MYJsNOW l,l-;i)<". K AND mil.IHF 



(Info! mnnt 



^ \'Mrcs'; 






,<y»v.v^_jL 



Former or 
Usual Residence 

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



Hovv long at 
Place of Death ? 



Days 



I'l.AC K ol- mklAI, OR RFMoV Al, 



l>Ali:of HfRiAl, or K1':Mo\A|, 

VVUV- 2,10 ,9oH 



r\.l.lr<ss nC)1 O /CVX/VCC^-rV.<^>v>Lo Ot' I 



IN. |}. Hvery item o? in?(>rni>itinn should Hl- ctireftill.v Hupplteil. WiV. Khdulil ho Htiited EXACTLY. PHYSICIANS nhouid 

state CAUSE OP DEATH In pliiin tcrmw, thnt It mjiy he properly clasKili'ied. The "8peclnl InformHtlon" ?or p«r- 
non« dyln^ away from home Khould he tltiven in every inHtnnce. 



yi 



I. 



V 









tijt 






I ►, 



It I 



IVwt 



!!■ :i!th 1' N 



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

^^^'^t.l^S^l'C,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

8374 



Ijff/t' /'V/^^/. AJYov-CyixJULv lie I'^O'^ 

Icrv^vA^ 1jl.v^ Deputy Health Officer 



2leili\sfcred JS^o. 



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



Certificate of IDeatb 

( XX. 5. StanDar^ ) 
PLACE OF DEATH: — County ofC 0_^x! wXix>^CA..t.cc City of U.CX-»%; 0X<x.-»vc^<uCO 

(7) ii ,1 ^ 




Kx> 



No. 1^ D I Vj CLCU^^C lU^ St.; 1 Dist.; bet. .OX'^X.^M and U^X^v.<t AJL\. ) 

/ IF DEAT^ OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER " SPECIAL INFORMATION ' \ 
V, IF DEARTH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME a Vculx 



OR INSTITUTION GIVE ITS NAME I 



V\.>syyx.rv\j 



U|:» 



-4- 



PERSONAL AND STATISTICAL PARTICULARS 



DA ri': ()i- ii!K 111 




COI.OR 






I ^T,>Iltll^ 



M'.V. 



Ho ),\us 



(Day) 



M., 11 tits 



(Year I 



Pa vs 



STXr. l.lv MARUn: 1) 

\\ii><»\\ i.i) OR i)i\<>Rr»:i) 
(Write in six-ial (ksiiMJatiou) 



i 



UIR rill'I, AOl", 
(Stiitf <ii <"'iunti >^ 



NAM I CM 
FATHKR 



lUR Tn ri.ACK 

0|- 1 ATHllR 

( Stat* or I'oinilrv^ 



5. 

, 1 V \^\J\^\^^\.'^^JLk} 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DKATII f>, 

_ \jlc\r IM.. 

(MoiitlO (Day) 



IQO 1 
(Ye:u) 



I HI':RI':H\' CIIRTII'V, That I attentUMl deceased from 

— to 



190 to : 190 

that T last saw h ..r— — alive on I^ "" 

and that death ••ei-urred, on the date state<l above, at -— — r-r- 
M. The CAI'SI- Ol- Dl-ATll was as follows: 

cjJk^uJuL ,„ 








MAIDltN N'AMH 

Ol" m<)Thi;r 



niR Tnri.ACR 

o|' MOTHKU 

(State or Cmnitry) 






^^Xi. 






1)1 RATION Years Months ..Days 

CONT R I nrT( ) R V ...... 



Hours 



DTRATIOX _..}?<? ;-5 
(SIG 

^'\CV Xf=^ T<,o'i ( 



Moulh^ 



NED ) WurvvUvs) vil.LO. \sdj(x/s\A.. 

Address) U 



I lours 
M.D. 



% 



( )0 ; ( .\ ( M re s s ) >-<^V (rwJLV^ \^> .i^ ^ k. r.-. 

Special Information nnly for Hospitals, lnstitufi^s\ Transients, 
or Recent Residents, and persons dying imay from fiome. 



OCCUPATION 

h'f^i.ifi! ill S.Di /-'i ,!iii i'f''' 



/\: 



riii" vnovi' sr \ri:n I'KRsoN \i, i'\R ririi. ARs \ri: iri )•; 10 iiii-; 

UHSr OF MV KNOW 1.1: IX. K AND 15 J! I, IF;!- 
(IiifM-mant. .Qs..^.,„sJL-. V^O-^'WW.'^A^ . . 

fA<U1ress \X IX 0~^<jL\KjL\Ai oi: 



Former or -^ o * ( V 
Usual Residence '^oO I Vj <X 

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




How long at 
Place of Death ? 



Days 



IM.ACF: Ol' lURIAI. OR ri:m(»\\i. 



ri,.\eK Ol- m Ki \i, ( 

r\I)F:RTAKKR V<XvuL-CT*VVVA..^i IA> 



i)Aii^;()f in KiAi. or ri;m(>v.\i, 
,<5\r.. "XX T90H 




[S. B. livery Item ni iii)fi>rmiitlon shmild h.- v;iirct'ully Hupplied. AJiB shoiilil be stiiteii EXACTLY. PHYSICIANS «hould 

Httite CAlJSr or DfiATH in plain terms, tliMt it miiy be properly clasfiit'ieil. The "Specinl InlforitiHtion" for p«r- 
fions Hyin^ iivviiy from homo Khoiihl be li^iven in every inKtnnce. 



i^ 



'li 



; 1 



^ M 



I ^ ^! i 



l\ J: I 



i : 


i 


i 


1 



w 



RITE PLAINLY WITH UINFADING INK — THIS IS A PERMANENT RECORD 



i',i ■',•,']' 'I 1 1 ■ . i . 1 1 ^ 1 . > ' ). 



^.*-''C!*v. 



REFEir? TO SACK OF CERTJPiCATg TOR } NSTRUCTtO.NS 



Rpgisteied jYo. 



3375 



Ifrvv^liAi^ ^~-- •" - '• '■^^''"' ■' Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of IDeatb 

( II. S. 5tan^ar^ ) 

ofCJ/a"r^^tv<x>vCv^ix:c City of ClcX/Vv^ ^\xx/>vec^ Co 



D 



N 







O. Lctu, <L<^VA^^\.t 







y"yAA VV^V^V •: St.; .— - . Dist.; bet. 

SIDI 

INST 



adi 



/ ir DEATH occiiWs AWAV FROM USUAL RESIDENCE give facts called for under "special INrORMATION" ^ 

(, ir death OdtuRREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



J. 




TVCUi 



SEX 



n\Ti-: (>! i!!k in 



PERSONAL AND STATISTICAL PARTICULARS 

I CO 





LL Jvvjtil 



( 



-L 



(Month) 



(Day) 



(Yea it 



1- 



MEDICAL CERTIFICATE OF DEATH 



DA'l'K ()1- DKATH 




(Month) 



(Day) 



(Year) 



AT.K 



IS 

SINT.T.K. MARK li;i> 

WIDOW i-: I) OK i)ivoKii:n 

iV\'iitein soiMiil (Usij.'iialii)n) 



)'/•(/; . 



\\ 



3 



Months O Diiy- 




\\\\<\'\\\'\,\CV, 

(St.'itf or I'oiMitry^ 



NAMI" OJ 
PATHHR 



lUR IHri,ACR 

oi" I ATm;K 

(Statf or Conntrv'' 



MAIDKN XAMK 

oi- m()Thi:r 



MIR riiruACK 

Ol' MorilKR 
(State or Country) 



r 






mcuvu. C^^-. 



^rvcj\ 




o^'^-A.xi^. 



I HlvRIvBV Cl'IRTIl-'V, That I atteiKled deceased fri)iii 

O^l^V S 190 H to \Vuj\r 3y.'2».„„........i90 M 

tliat I last saw h -v^vt^' alive on \fXfid|illi.,„.„.XS...„.. igo H 

an<l that <leath occtirred, on the date stated above, at » *^0 
CL M. The CAISP: Ol- l)i:ATn was as follows: 

\w^-W<rvw-c VJ^Ar^^->wC^ixvAX4> -. .« 



I )r RATION Years ^Months \H Daya Jloiirs 
CONTR inrTOR V .....,..„.......^w„ „ 



IH'RATIOX )\'ars ■ ■ MoNi/is Days /lonrs 

(SIGNED) LO- W. LctvaXol/^.V M.D. 

VrLcrV'^H 100''^ (Address) LLt^*^V^K>CrA^^.';.. 



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



AV\ /(//•'(.' i!t Situ Fitiir'.'^f'o 1 V )r,ii<: 



.!/.);//'//> 



/)ii\ 



\\U- \UOVl'' ST \T}-I) I'KRSONAl, I'A R f HM' I. A R S A R !•; TRIK To Till-: 
IJ1-;ST OI' -AJN- KN«)Wl,i:i)r,K AND Iil-:MKK 

nfonnr.nt AOw^yX/K \X . O ^J^-S-y^^: 



(\ 



( \(lilress 



dl- 



■^ 



"v-\ v^ V "c <y\^^^A^ L 



Former or 

Usual Residence 

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



How long at 

Place of Death? Days 



DAIJ.ot HiKiAi, or RKMOVAI, 



HIRIAI. OR RI:Mo\AI 



TQOH 



N. B. F.vepy item of Wiformiition should be cnrefully Hupplied. AdK should bo Htiited HXACTLY. PHYSICIANS nhould 

state CAUSK OF DLA TH in pinin tcpinH, that it may be properly classilfied. The "Special Inlrormation" for per- 
sons dyinll away from home Hhoiild be feiven in every inHtance. 



yi 



|ii hi! 



it 



i fl 



! 



■I 

ti 




I 






1 ill I , t . ! ' \ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






iia!iCM«VHic*B 



I 



7,9(94 



jResiisfe/ed jVo. 



3376 



"Lfrv^^ "Uv-u Deputy Health QMcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 



( XX. S. StanC>avC> j 



PLACE OF DEATH: — County 



ofCJOo-Yv J;va.^xc^a^c.^ City ofC]/CX>^' J.VCu^x.c\A.c.o 



No. 






Dist»; bet. 



and 



iV ir DtATH OCCURS AWAY FROM USUAL R E B I D E N C E G I V E FACTS CALLED FOR UNDCB SPECIAL INFORMATION • ' \ 
I IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 






FULL NAME 




>-ir(X. 







SKX 



PERSONAL AND STATISTICAL PARTICULARS 



HL 



DAli; ol 151 KTH 



iLlk^'U; 



MEDICAL CERTIFICATE OF DEATH 



DATE OV DKATII 



^ 



(Month) 



AC'.K 



<A<=N > V(/ / 



X 

(Day) 



.1 A />////> 



(Vciir) 



^3 



Ai 1 . 



sIN-(.!,l-: MAkKIlCI). 

\\ ii)( >\\}': I) OK i)!V()Rri:n 

iWritrin M)c-ial <U si).'!);!! imi 



1>IK1'HI'I,M*K 

'Stati- or ruiintrv^ 



lATHHK 



HIK rn l'l,\<K 
«)I' lArHK.K 
IStatc «ir c'oiiiiti y) 



MAIt>KN VAMK 

oi- m()Thi;k 



lukTiir'i.Ai'i': 

OI' MoTHlCK 
(state or I'oiuitiy) 




(Month) 



(&ftyi 



(Year) 



I90H 



I in':RF:HV ClvRTri-V. That T attondcd (U'coased from 

Q.\^^ 1 190H to .^UV- X^: 190 H 

that I last saw h '^^^^ alive 011 VrVffV^ 3>H 

and that death occurred, 011 the date stated above, at ^ 
CL ^T. The CAl'SI-: Ol' DI^ATH was as follows: 

,A^ WIa-^-v^^- u X^vhL\^ „ 



lA^Wi 



IX'KATION ^'"'^'/L J/o>///is ^"^ Pays Hours 

►XTRIIU'TORV ()\:^Jl<>>VrO'NA^>^^C^-^L....<^ 




?-w^W 



L^'-\%^i CJ4_A.KX^ 






]XVv>v^X^ 



occri- \'ri()N(70 



^ 



'f.'iiii-d ill Sail /'intni^f'rj i C )''M 



!/..„///« 



/>,n 



IIM' \HoVl' sr XTJ'.n I'KKSON \I. PA K IH" T I, A Ks AKl. ruil-. It) TUl-; 
Ui;sr (>!■ MV KNoWl.l'.IXW'Lt^NI) IW'.UIlvF 



(III foi iiiaiit 



V^tocrtr vjLv<\tu 



(Address I ^ I 



Oc! 



■^xXa 



^Xcv 



"WOU 



( Signed ) cLfrwv^ M.<xcfrl>-^ 

'\{JVr a 5 TooM (Address) U^*^ 0XO.^.c^ C).' 



Hours 
M.D. 



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



Former or ^ ^ 
Usual Residence * ^^ 



?\, 4 iHowlonqat 

N^U/VYV^Aviv>vaOtpidfe of Oeatli? 



Days 



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



ri..u:H oi- lUKiAi, OK r|';mo\ai. 



DAlKo! MiRiAl. or KlvMOVAI, 

S(\^SSJT.....X\ 190H 



(Ad.iuss \\^1 \n\vA..^^A..<r>\. u.l I 



7,j. R. livery item of inJormHtion should be cnrefully Hupplied. AdT. Hhoiiltl he fttnted HXACTLY. PHYSICIANS should 

state GAlJSn OF Di:A TH in pljiin terms, thnt it miiy he properly cluHHifietl. The "Speclnl Informiition" for p«r- 
iinn« flying awuy from home Hhoiild be given in every instance. 






ii| .1 









« 



»i . 



' 11 



1'^ 



»! 



■I 
'J 






i 



I 




r 



B^ 




fii i 

llf 



i^li 



WRITE PLAINLY WITH UNFADING INK 

DEPARTMENT OF PUBLIC HEALTH= 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCT(ONS 

'577 



V 



Be^Lstered JS'^o, 



City and County of San Francisco 



Certificate of IDeatb 

( tl. S. StanDarD ) 



PLACE OF DEATH; — County of 



^ asp ^ (op 

CcLO^OXCc^xc^^CA City ofOcuTv 0Xcx-*vev4.^o 



N 



cVxls 




F DEATH OCC U B^ 




St.; 



Dist.; bet. 



and 



/ ,r DEATH OCCUB% AWAY TROW USUAL RESIDENCE GIVE FACTS CA. LED TOH UNDER "SPCCIAL I N ► o H M ATi O N ' 'J 
( ,F DEATH OCc|rRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



W^UL' 



x\A\) U cry-^j^LMa 



PERSONAL AND STATISTICAL PARTICULARS 
SEX (\ K . \ COI,«»R 



\] 



) 



\\aAx 

DAil-; Ol- lUKTll 



hjfXKAJl^ 



Ll 



MoiUh^ 
It 






(Day) 



(Year) 



Af'.R 



MEDICAL CERTIFICATE OF DEATH 



DATK nv DKATH A 

\l\<rv- 



('Mi)iitlO 



..j(3\.^.. 

(Day) 



(Year) 



5 a 



)V<;;. 



.yhniHiS 



% 



n.n. 



"^IN<.!,K MAKkll".!). 

WIDOW i-:i> OK i)i\'< »r*1':d 

.iWiitciu social df^ii-riiutioii) 



lilK run, AOK 
(Stall- or (.'ountrv) 



NAMl-: OF 
FATHKR 



lUR rin'i.ACH 

OI' l-AlHlrR 
(Slate or foiiiiti vl 



MAinKN NAMK 

()«•■ M<)'rin:K 



lUK'ruiM.Ati-: 

OF MOT 1 IKK 

(Stiitr or roMiitry) 









t 



v^ 






Jl^V>A V CX/A -\A,' 



7 



\ 



I nivKniJV CI'RTII'V, That I atteiKlcd (leccased from 

O.^t v^ 190H to \ruTsj- '^.a 190. H 

tliat I last saw h Lmr-^. alive on V'V^^ ^^ 190 H 

and that death occurred, 011 the date stated above, at H.'.!li> 
LL ^^ The CATSl*: Ol' DI'A III was as follows: 



('>"nJLva-'>vv(^ >.x,\.<a». 



I) ( ' R A r K ) N ) 'ears Mouths Pays Hours 

CONTRIBUTORY M lXiwA.aSwr^3i-<C,,JbijR^ 



1)1 RATION 



( SIGNED )^^.....A^ 



YtdtS 




Mo}iths 



<X\X5 



Pays 



X\J^^ Xh u 



)0'\ 



( 



Address) vCLu ^^^ V-C ^^ 



Hours 
M.D. 



^ 



; Ox^w ao-vol/aa^ 

occri'ATioN J? A n 



J\rsf(h-(! ill Sail /'i d in /'M'n 



)-r,7t\ 



)7oi/f/,.- 



/>,. 



TIM" \MOVl*. STATi:!) I'KK^OXAI, I' \ Klh' T I, A K S AK1-; rKn-; To rilH 
I!i;sT Ol" MV KNoWI.i;i)t".K AM) in-.i.ii;!' 



(Ill fci; maiit 






< Xddrcss 




...^ %.., • ' 



vu 



J ^f^v>jJ^<xX 



Special Information "hIv for HH'spifdls, institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or . ,, 

Usual Residence I * 



^ VltoXrrwva ut Place of Death ? 



5>H Days 



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



I'l.Aci-: ()i- lUKiAi, OR ri;mo\ai. 



DA IJ-: o; lii KIAI. or RlvMOVAI, 



INHICRTAKKR 

(Address 



XA4 vJ O^U. 




N. B. F.very item olf informntion should ha carefully Hupplied. AGF. should be stated fiXACTLY. PHYSICIANS should 

stiitc CAliSr. OF DEATH in plHin terms, thnt it mjiy he properly clussified. The "Special Information** ?or per- 
son* dyin^ away from home should be ftiven in every instance. 



i?.. 









I ' 



I 






pf 



i 1 



li 



•I 



l< 



t 



*il 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H";ir<! lit iu;i;iM i- >"■ ;- ' i.,,.'Si^^ 



I)(f/e /v7rv/,\jlij\^.o-o^lNL\; llo ^•^>^'5>H 

A_ ,1 Deputy Health Officer 



RCPER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 



Res^isfercfl A'^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of ©eatb 

PLACE OF DEATH: — County of ^" a."r^ v/UX^'VCi.^C City of V-ia.^wiX<x/>A.ccaoO 



No. V^L 





\ 



'^^ Wu.'YLtu. (!b(>Nl-K^^^-'-St.; —— :....Dist; bet. ^—t- -— ' and 

/ ir DEATH OCCURS A^AY -^ROW uiUAL R E S I DE N C E Gl VE FACTS CALLED FOR UNDEB "SPECIAL INFORMATION • \ 
C IF DEATH OCCURRkD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME ..^.^^OuOJi^.S^ljUv^^: 



\A 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



DATK <)1- lilKTU J? 

_ ...OJLipJt 




AXKjix 



Ar,K 



JJq )V</>> csL 



(Day) 



.!/-./////> 1 



H 



(Year) 



r>av: 



siNt.l.K. MAKUn-.I). 
WIDOWMI) OK I)I\«»K('Kf) 
tWiit' in M>cial dt si^imtioti) 



HIR I'lll'l, ATK 
(Statt or <.'<)untrv' 



^jVcLVuu^cL 



N'AMI-: OI" 
FATHKK 



lURTUPI.ArK 
()(•• I-AIUKK 
(State or Country' 



MAIDHN NAMK 
OI- MOTHKR 







MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH l\^ 



(Month) 



IH 

(Day) 



(Year) 



I HKRl'iBV CP:RTII'V, That I attcmled dccoased from 

...\il.c\r. a 190 M to \lX.G\r. 'X'± 190 ^ 

tliat I last saw li ^V alive on .xK'irw'^ IM 190.%. 

and that death occurred, on the <late stated above, at XAO 

M. The CATSK OF DIvATH was as follows: 



-\-^. 




Xil' 



DTRATIOX }'t'ars Mouths 



Pays 



C ( ) N T R I IJUTOR Y ....\A^Ca.aJU- ..C^.'%^^@n^^ 



Hours 



HIK'IHPI.ACH 

OF mothf;r 

(State or Conntry) 



A, 



OCCrPATlON Ci\p 






Rfsidrif in Sim f'rainrsrn '' )V<7; ^ 



U I, 



M.nith'' 



/III 1 < 



THI-: AJ'.OVE STATF'.l) I>KKSONAI, I'A KTIC l" I.A KS AK1-. fKlH To 

im:st oi" mv k^nowijvIx.f: AM) i5i:mf;f 

(Infotniant . QJL^ \ . \J XyOjCo ....... ™ -. ■ ...- 

.0 . ,^ ^? i + ^ 



1' I \ JC 



f Address 



ilfuN^Ct '''' 





DURATION )az/-J^ Mouths 

(SIGNED) J....yi. k)ccd: .^. 

\rU\'- ?v5 190M (Address) VxU^ ^ Lr 



r> 



Hours 
M.D. 



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



Former or '^ ^ r M * j "^i V \\ ''•^ '""^ ^* 
Usual Residence-lo^ JiruMAvOCv^J^Wupiare of Death? 



Usual Residence 

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



Days 



PI,ACF OF I^IKIAU OK KKMoVAI. 



Pl.ACF OF m K 



DATF.o; Ml KIAI, or KFIMOVAI, 



^1 



-b 



I90I 



rNDKRTAKHR U /OjLX'V>Xt N lUxA^A^'>^Jj ^"C \,.C 
(Address i 5 3^^ O X<ft'^KjL<rW...c3jt 



N. B. Bvery Item of informntion should be cnrefully nupplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for per- 
sons dyin^ away from home should he ^iven in ^s^ry instance. 









u 

II i 



H 






(I 




, 



i; 



■« 



i , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



11,, a 1(1 -f Health |- Vo '-■ "?-lr?::?^») H'S^J' * 



I)(f 



Ic rih^il }^\^\>^-ry\L^iAj 



{ \ 



Dcpr tv Health Of^cer 



Registered JVo. 






DEPARTMENT OF PUBLIC HE ALTH=City and County of San Francisco 



Ccttificate of S)catb 



^ 



PLACE OF DEATH: — County ofCla.-,v JXa.->vcv.<L<:xi City of U/CC-vx. J , Vo/vvcaacx) 
'^No.VlO.vk U^vJlAxuc-v^yc-u Jb(S^kv.\..a' St.; — Dist.;bet. ., "~" »"<* 



FULL NAME 



L 



'>'>::\/^.:^xCL. . 




CLL\-si.Ci.A-Q, 



'■i 

— I. 



• «^4«4J •«■«•«••«''••-' 



PERSONAL AND STATISTICAL PARTICULARS 



si:\; 






COI.OR 



i^ 



UJxa^Ol' 



DATK «»»■■ HI Kill 



Ar.K 



COw 



MEDICAL CERTIFICATE OF DEATH 

.as: 

(Day) 




i-i 



(MoiitlO 



IQO 

(Year) 



\1 



(Month) 



V CN )V(//> 



% 



5 

(Day) 



M.niHi^ 



(Vf.-ir) 



ao 



Davs 



^.iNc. i,K M\Kkii:n 

U IDoWl".!) OK I)!\'« >K*KI> 
(W'lilciii Muial (1( si^'iiatioii) 



CX^JV^^J^CV 



lUK rni'i, \i'»-: 

(Stall or •■oiiiiti N^ 



NAMI-: Ol 
J'ATinCK 



HIR'niPI.ACK 

Ol" iArm:K 

iStatf or Country) 



m\ii>i<;n namk 

Ol- MOTIIHR 



lURTFiri.ACK 

()»• Morm':R 

(Stat»' or Ooiintrv) 




llXCAcT 

3r 



crv\j 




r\ 



X >\-LCK-C 



kx 




^y^ I II I'! R I* HV C I-; RT I !• V, That J attended deceased froni 

JX^ 9^.1 i90i to XjXxiV 3.5: ..;.._.i9oH 

that I last saw h-«LX. alive on VjUrvr 9.^ 190 '1. 

and that death oceurred, on the date stalf*! above, at 
..- M. The CATS I-: Oh' I ) I!. \ I'll was as follows: 

U^-v^UXv^rvOu y. JLtX^\<\<A 



Dr RATION }'('ars Mouths Days Hours 

C N T R 1 lUJ T U R Y UrvA-^rYX^C M ).l^^ C,.0-V<i,wtv...i. 



Oft- 



^uirCta /A^^ cv^ X cL 



00c r PAT ION 

R'rsi<ir<f in San /■'i,nhi''r(> .^0 V'ttx ~ Mmilh^ 



l),i\ 



vwv AUovK ST \ ri;n i'Kksonm, i-ar ririi,\RS aki: iKri-; to Till'. 
iii;sT Ol- Mv KNowi,i;i)c.i<: and iu:i,ii:k 

% n '^ 

.f.umant U\Dx^w<M) VK 



(Ii 



(AiMioss 



J AJ^\X^\J OX 



a^^'io 



/hiys 



DURATION. years "^ Months 

(Signed) 1p/>^^ Lu. J\JLt-»vtx| 

Mlcv n*.. TQoM (Address) 1 f^^ I CJ AA±.ljl.V At 



Hours 
M.D. 



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



Former or 
Usual Residence 



J5 4 U oJSj^^' at Place of Oealfi ? 

When was disease contracted. 

If not at place of death ? ......„.«.„.„... 



Days 



190I 



IM.ACK Ol" HIRIAU OR RHMoXAl, I DATIlo! Hikiai. or RHMOVAI, 

l-NDl-RTAKKR QO oJu^XjiA^ '^Lc 

(Address *^ *^ b MlbULCL v,<r'rw, dl 



rs. B. 



-F.very Item of Informiition •houfil be cjircltully Huppllecl. AdB should be stnted EXACTLY. PHYSICIANS should 
• tote CAUSn 01- DILATH in plain terms, thnt It miiy be properly classit'ied. The "Special Information" f«r p«r- 
iKr»t\% dying uwny from home (thould be t;tiven in every Instance. 



Ml 



r" 









i^ 



i-; . i 



III 



I 



f 



fm 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H,,:ii.l nf lha!th !•• No ic !S-.^Sg^5-^r, HS: IM <> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Ile^lsteved J\^o, 



< < 



dv(rv^c^ iji..vi|. C*.p.^ff Hea«tfl^Of¥lr^r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( 'CI. S. 5tanC>arC> ) 
PLACE OF DEATH: — County ofCho^^ru JX.O^>x^cux.Ci City ofC)<X.'>v vJ,vcu^'voc<^c, 
'No.Ol S.kcrtttXd. lllixu, SC; a Dist.;beti.L'0.^.kLvvqtc- and V„W.. 

/ ir &c<^TH bccuRS AW*Y fronI USUAL RESIDENCE give facts called for under ' SPff '*•- information- \ 

( U OEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRE^ AND NUMBER. ) ^ 

% iV V'^- 



<i 



) 



FULL NAME 



.Cr:B-\:.. 




Lrv 



V' 



lll^ Oxo.. 



•^KX 



PERSONAL AND STATISTICAL PARTICULARS 

. j coi.ok p 



via 



au 



I) \ ri; < >» MIRTH 

> 



M\% 



(Mouth) 




SO 



' y,'a, 



(o 



(Day) 



Mouths 



evv.:: 



/%HH 

(Year) 



10 



Davs 



si\»,i,K M.\Kun;i) 

\\ IIxiW KI» OR DIVnKri'M^ 

iW'iitriii soeiiil (h^iv'iiiit i'>ii ) 



(Statf or C'ouutr y) 



NAMi-: or 

FATIIHR 



niR rm'UAOK 

0|- l-ATUHR 

(Stale or Coiuitry) 



MAIDKN NAMH 
OK MOTHKR 



P.IRTH PLACE 
Ol' MOTHKR 
(State or Country) 






MEDICAL CERTIFICATE OF DEATH 



DATK (>»■ 1)1- AIM 



W- 



(Moiilb) 



...AS. 

(Dav) 



IQO 



M 



(Year) 



I III:R1':HV CI:RTI1"V, Tliat I attendca deceased from 

190 " to :. 190 

that I last saw h.r~~ alive on 190—"- 

and that death occurred, on the date stated a!)Ove, at — 

^"M. The CATSR t)F DI'ATII was as follows: 
vIX^^Ctcr-v^wvXvA ..<Lv^rv\-:v. 

.(i>y:>.xtl.AXv.:\:v.l 




.■&:\ 



\^.it:v.... 



s! cr>iv 



'A^-VVI 






3 




Dr RAT ION Years Mouths 

CONTRIIU'TORY 



Pa ys 



//ours 



• ••*M«**°«a*i 



Dl'RATION/v^ Viars Mouths 

(SIG 



NED ) vJ.AX<LuVA./Jk. "^.. V 



^.^Icv^ 



^\. 



TqO 



(Address) ^ Id C.VcA^.t.LjlN) .H 



/'>ayS.- //ours 

M.D. 




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



occ 



upATioN n 

Rfsidfd ill S(jn /'mm i>i(> XC. )r,iiy 



yf,.>iths 



/hiv. 



THK ABOVE STATED PERSONAL PARIUT LARS A K I*. TRLE TO THE 
BEST OF MY KNOW LI;D<".E AND IU:LIEF 



(Iiifoiinant 



(.\<l<lress 



OU- Qk^^vo. 



Former or 
Usual Residence 



How long at 

Place of Death? Days 



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



1U,ACE OF BIRLAL OR RF:M0VAL j DATE of BfKtAi. or KF:M0VAI, 



1<X/Y^ 



INDERTAKER \l •"^-<X^'^X; CHJ-K V^ >- 



(Address 



Mta 



IS. B. Every item ai in^>pmBtioti should be carefully Hupplied. AilF, should be stated EXACTLY. PHYSICIANS should 

state CADSn OF DEATH in plain terms, that it may be properly classWied. The "Special Information" f©r psr- 
sons dyin^ away from home should be g^iven in svery instance. 






I 



i 



M 



.1 ..f ]U .ilih ! N 



WRITE PLAINLY WITH UNFAOING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■* rr- i,. i;,S^l' Cn 




'CV-lA^A^lh^V 1\: 



I!)0 



j l>(ifr Filrd , 

1.^1..-, D.ou,v Hea.H 0«c.. 



lla^Lsteved Xo. 



.3381 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( 11. i?. GtnnDarD j 



Q^ 



PLACE OF DEATH: — County of UCL-rv J.»UX^k^..a^^co City of U/CU^-v J A-CV^vov-clco 



NoiJl^^vlNX^LAj La'vvCXoX^x.cu. Ob,^^ .\A.'fet:v'. Dist.;bet. 



and 



) 



/ ir DEATH OCCURS AWAY FRc/m U S U A L R E S I D E N C E G I V r 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 OvOA^ MlW 




3: 



■X)OsM. 




Tsj.. 



SKX 



persona^l and statistical particulars 

, C'Ol.OK A 



^\Ax 



\ 1 1 



DA !•»•: Ul' lliK'l'II 



A<'.K 



iM'iiillOA 



H\ 



J V<; J 



?^ 



10> 

(Driv) 



M.nilh' 



/ik^ 

(V(ar) 



H 



A; r. 



SINi'. I,F NTAHRll".!) 

\\"II)» )\\F-:i) «)K I)I\(>Krj"I) 

iWtitfin «)i-i;il (ksi>.'iiat i"ii I 



i!iK rn J' I, xi'i-; 

(St.itf 1 ii i'<)miti\-1 



i 



L 



medical certificate of death 



kl\ovr 



(Month) 



(Day) 



(Year) 



I HRRKRV CI":RTrFV, That T nttcndtMl dcccnsed from 

— — — — — - — 190 to " ~~ I<)0 

tl'at T last saw h : alive <iti —""r-r lyo 

aii<l that ilt-alh (xu-iirrcd, on the <lato stated a1)f)vc, at 

-: - M. Tlu- CArSF'! Ol-' I)I:ATII wa^ as follows 






NAM!-; O!- 

i"atiii;k 



HIR'lIllM.ArK 

oi- iArm;R 

(Stall- or Coiiiitrv) 



MAIDl-.N NAME 
OK MorilKR 



IUkTin'I.A("K 
Ol" MiiTHI'.R 
(State or Country) 



rO. 



■^^' 






O^/^vUL^jtX'-yvJL^ /Ow^N-'cL ^jn^\jLCUi^^'CL«A.vx 

DIR A'IMON }'rars Mouths . Davs •• Hours 

CONTRIUUTORV ^^ JWLcru>^ 




C'Trw^wCccLjc. 



I )r RATION Years Months Pays Hours 

NED ) LffV<mahJ Ui U). dJLLcLa-uc^. M.D. 



()C 



c,-..ATiox(;y^^^ <xW<x>vdL.U^. 



fsf'uird III S(j}i f'ia)ii!St-ii 



I 



)7'(7;.f 



.yr,n,th< 



/hi\ 



(SIG 



f A.l.ln-s'.) 




kli::la. 



Special Information only for Hospitals, InstitutiiW^i Transients, 
or Recent Residents, dnd persons dying av>A\ froni liome. 

Former or • 1 1> 5 5 "fx Hon long at 

Usual Residence ^ LKjJiX.ZA\j OX Place of Death? Days 

When was disease contracted, 

If not at place of deatli? ■... ,.......,...„„.„.„. 



IHl- MiOVI-; STxri".!) I'KRSONAI, 1' A R I" I' " I I. A R S A R l", TRIK l O 111 Jv 
HHST OF MY KNO\VI,l-;i)('.H AND Hl'.I.lKK 



(A.l.lress ^H Lo^^\5 CjX 



PI.ACK Ol- HIRIAI, OR Ri:.Mo\AI, 



\JXw<^. 



DAIllot in KiAi. or RICMOVAI, 



.aio. 



TQO 



A) fQ 



(A (1(1 rets 






IN. B. F.very item of int'ormntion Hhouici b>- carefully supplied. AGK shmild be Htated liXACTLY. PHYSICIANS should 

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



^1, 



III 
•f 1 1 



.if 

! 






I I 



i 



I 



f 

■i. i 

£ I 

S 1 



'i|j 



M 



I 



I'll 



v\ 



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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




lJ(f/(' /'V/^^/,..„JLl<^;^^-^^(MA; Xk ,..._... i ^ 6> H 

.V\.^ DepL:fv Health Oftlcer 



Jie^Lsfe/'cd jYo. 



S3H2 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of S)catb 

( 11. 5. 5tanC>arC> ) 



PLACE OF DEATH: — County ofC'a 



^^ '^ A\> J ,\,<X/>x.cu^.cv City of '^3 CL ^-vj J ,Vc 



\_CV.rv^CA-<L 0<3 



N 



o. VlLll ^"^ Wv. <--><! 




OA.' 



Kctxict 



St.; 



Dist.; bet. 



and 



/ if or.TH occuni away trow USUAL RES I DENCE give facts called tor under 'specal .nformation- \ 

C rrDEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

I 



FULL NAME 




j^YX' 




\j 



T 



f>Lc. 



PERSONAL AND STATISTICAL PARTICULARS 

I) All-: t •! IWKlll 

'M..nth> (nay) 



\(.F. 



TO 



M.»tl/i- 



(Yetir) 



/Kns 



SINC.F.i:. MAKRIl'I) 

\\ ii»t >\\i;i> OK i)!\(>Ki i:i) 

'W'litiin s()i-i;il (li -lii' iKit ii i!i ) 



iUK'rniM,Ai'K 

iSlati or t'oimti y^ 



NAMl <>| 
FATHKR 



1UK rii IM. \C\-. 

ni 1 \rm:K 

tState or t'ouiiti v' 



MAIDI'.N N'AMl". 
tH- Ml)Tm:R 



I'.iK riii'i, \ri-: 

<>l" MoTlllsK 
(State or Cnniiti \ 



OCCUPATION 



'O 



C 



O.A^'^'vcy 



L'>X,Q/V, CX.> x^C^ 



MEDICAL CERTIFICATE OF DEATH 

DA Tl-: t)l" 1)1:AT1I 




.<^\r 

(Month) 



rpn'i 

(Year) 



'Day) 
1 IN'.RlvHV Cl';kTil"\', That I attciuU'd .IccL-ascd from 

______ — _________ j^^ ^^j 190 

that I last saw h ~ alive (^11 -''"■—•— "1 90-^^ 



and that ckath (KHnirrcMl, on tlu- date statf<l al)Ove, at' 



M. The CAT Si-; Ol' I) 1: A Til was as follows: 

JvN-^r^xv^.. M '\A.yo-<:.<x.\,.o-\^tA^ 

iK I 






.^^^ 






)( RATION Vi-ai.^ 



CONTklHrTORV 



Months 



Days 



J Jon IS 



1)1 RATION' )'i\us 



Dm 



Afouths 

i Signed ) Wvoyxxa^ J.^ij.UJ- <LiJUxm^ 
xiUixr ^5^ TooS r\dd rrssi Wv^rw 



FFonr'i 
M.D. 



I()0 I 



iUU. 



SPECIAL INFORMATION only for Hospifais, Institutrons, Translfnts, 
or Recent Resident';, and persons dyinq .mny from tiome. 



Former or 
llsiidl Residence 



plbvOk' 



.'WCr-v,»-rv 



flow long at 

....... fldce of Dfdth? IJxh. 



Days 



AV.v/V/a/ /'/ >^'('" I'nrin i^i" 



) ,-^n > 



M.,„th- 



/',,M 



Tin- Mtovi': ST \Ti D im-:ks()nai, p\Kri("fi.ARs AKi': i-KD-: r(t riif' 
iu;sr (tl' MN' K N«)\\ i,i;d<'. !•: \nd ma.n;!'' 



(Ill foiiiiaiit 



Cc 



VcWw-L^X^^s 




f \<1(trr=s 



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



PI^ACH «>!• JU KIAU OK KI-lMnVAI, 

UoJjL ^ 









D\l»^o! HrMiAi. or Kl.MoVAI, 



. _ . _ . _Cl. 



<X,CV<X<'VW 



IS. B. Hvery item oV iiiformiition Hhould h^- cjirci'iilly Hupplle*!. Adh Hh<nilil be Htiiteil V.\ iCTLY. I»ll YSICIAINS HhQiild ' 

Htiitc CAllSi: or DI:ATM in phiin tcrmH. thtit it im»y be |»r(»perly cluHHit'ieil. The "Spcwiii! Intformiition" for p«p- 
«f>n« <lyin^ nwiiy from home «hoiil«l be J^iven in every InHtnnce. 



!i 



\i 



i 



.t V 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I ,^ ,,,,,,, , ^., - ...t-^.,,,uv.i ... REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



t 



CV-OAV 



Uv'9.1 V'^Oi 



3383 




frvkjwj cMLAKt Deputy Hsa!th Omcer 



^ 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( 'U. S. St^n^ar^ j 
PLACE OF DEATH : — County of JxXA^ ,>U3lAvo-i.CC City of ^ ' a vu J .►v,a./>T-OcA.c.O 
No 1 1 .W>xrvt(r>^. St.; '•' Dist.; bet. J Crli-Cr.>^. and yb,a>uVUi.fr>^' ) 

INO. 1 1 V ,,, „,.,Y-,^,,.. .„., ^„o„ USUAL RESIDENCE OlVt FACTS CALUtn FOR UNOEP SPtCi.L INroHMATlON" ■) 

( "„rV" OCcInPtD .~ ° HOSP.T.L OR ,NST,TUT,ON S.VE ITS NAME INSTEAD OF STRtET AHD NUMBER. 7 



FULL NAME 




si:\- 



PERSONAL AND STATISTICAL PARTICULARS 



\'\ 



DAll-; «H lUKTM \K\ 



LLJvlIx' 



AGK 



(Month) 



5 b iv„... °i 



W 

iDav) 



M.ni'Jn 



(Ytar) 



IH 



/)<? v.« 



SINC.I.K. MARUIKI). 
WIDOWl..!) OK niXOKi i:i) 
'Write in sorial <k-^ij.Mialion) 



IlIK IMU'l.AOK 
iStatc or Contitry^ 




'V<x^.^.uuL 




^ 



xA\fi.: <>r 

1 ATJllvK 



IiIKlIll'I,AOE 

<)i- I Arm:K 

(Stat<- or Country 



MAIDEN NAMK 



lU KM* HI' LACK 
(>!• MolUHK 
(StatL- or Country^ 



Q-\JL v<x^vcL 



MEDICAL CERTIFICATE OF DEATH 



DATI': Ol- Dl-.ATH A 

^f\^. 



.iDa., 



Xk 

(Month) (Day) 

I in;RI'P>V C1':RTI1'\'. rimt I atUiuUd dcccastMl from 



J 90 \ 
(Year) 



It 190 H to "sJ.urwr :j..iD k^o 

that I last saw h «^ • ' • alive on nTVCv*".. .5y.5. igoH 

anil that tkath occurred, on the .Lite stated above, at i-^ 
M. The CAISI-; ()!• DI'-VTII was as follows: 

^\..L/ftr.A..V;:^..(>i....4u.a>Hi^^ 

DIR.VTK^N Years Miinths I^ays 

CONT R IIU'TOR V 'lACA^^U. 




1 1 our a 



.OlA. 



nrRATION Yrara f Af.uitfis ...Days 

(SIGNED) > Mi\ J (T-rOA? 



C>AJtl 



u^f^Aj 



<X^^jk. 



occ 



Lx\^xCL<x3(lA^'t' 



vs 



THl- AHOVl-- ST\Ti:i) I'KRSON \1, I'A KT IC I " I. A KS AKl', T K C K T< > Till-; 
HKST OF MY KN0\VIJ;D<'.K AND Ml'.Ml-.h 



1 \ ^^CL.\^^C^A^n^* 0' 



I \(Mrfss 






^.^r 



1^ ^ 



wi ' - . 

rxddress) lllH J (rt4u<r^rrv Cji 



Hours 
M.D. 



Special information nnly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyin?] away from liome. 



Former or 

Usual Residence 

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



How long at 
Place of Deati! ? 



Days 



I'l.ACH Ol' lURIAI, OK KKMOVAI. 
I NDl.KTAKKR 



DATllof Hi KIAI. or RKMOVAI, 



^'QTi 






i 



j^. B Rvery Item of infofmntion shoultl Iv-- cnrcJully supplied. ACIK should be stated I.XACTLY. PHYSICIANS should 

state CAIISK OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- 
son* dyinft owny from home should be feiven in every instance. 



¥ 






I I 



1 i 



i » 










; 



1 f I!, .'Ith ! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

V, t-'^'^'^^ H& I' c. . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

— g^g^ 



Dff/r /7/r^/, \j\c\'^T>vv 



sW X^ 



190 H 



Re^Lstercd jYo. 



M^icA ^AHu. Deputy Heaith Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of 2)eatb 

( 11. S. StnnC»arC» j 



PLACE OF DEATH: — County of OcL^' J^^V<:^^^^^^<^ City ofaxXAv J,\.avxC^c^ 

0C\ t\ (\ /,^ A 



I^lo* 2) 1 H V^^-CVCL vrvCL 



St4 ^ 



^ OP 

Dist.;bet. JxJLv' 



and 



XXIiU. 



w ^»^„ IKSIIAI RFSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ 
( " rr"„;".T°„'cCCU%'.r„\rr„o"s*PrT*.^ O^f-S'T^" ~ --r ,TS name ,NST..0 or STR..T .NO .UM.„, ^ 



FULL NAME 



L 



yr^yy-\^oj 



-tU^A 



.VLLU". 



PERSONAL AND STATISTICAL PARTICULARS 



OXY>%oJU. 



Ill 



^VL 



U 



:i \ 11-: ( tl HI R Til 



A<".R 



MotitlO 



lA 



) 'i it I 



(Day) 



M.nilhs 



(Year) 



/:»rti.s- 



SIXC.1,1*,, MAKUIKI). 
\\'lI)()\Vi:i) OK I)I\oKri:i) 
iWrittin ■^oi-ial dt >^ij.»^iialit)n) 



KiK Turi.Ari-: 

Slat'- (tr I'oiinli V* 




\cw\,AjLcL 





NAM I* f»I" 

f.\thi:k 



RIRTliri.ACR 
Ol- lATHF.R 
(State or Country) 



MAIDlvN NAM I". 
<tl' M()TH1:R 



LUix^ 



1 



CL>AJ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DHATH A 

M\rv- 



(Month) 



.%k> 

(Day) 



(Year) 



I HRRFCBY CKRTII'V, That I attended deceased from 

aV \S 190! to Ja\C\r . M iQoH 

that I hist saw h-*^; alive on M^flVT 9»5 up 

and that death occurred, on the date stated aliove. at H 
CL M. The CAT SI-: Ol' DI-ATH was as follows: 

^^■^^ •--ate 

DTR ATK^N Y^rs Mofijhs i^ Days ' Hours 

CONT R I I?UT( > R V w>\J^.O"A.^^-<C AiD A^^^^ 



lURTlttM.ACK 

• )!■ M<)rnF:R 

(Stair or Country) 



\^- 



-^ 



,^' 



nrcn 



'AT ION 9W I , 

(]\0 (Vvw^e.-uj'M^ 



/\f>;drif in Sii>i /'i iUiri'iri 



'"( ) -.fi > 



Xfoiiths 



/hivs 



Till- \MOVF ST\Ti:i> l-KKSONAI, I'A K I' IC C I. A K s A K 1 : IKt l' To TIIK 
1?J<:ST OF MY KNOWI.l'.LM^H AND iu:i,ll-.l' 

ifoMnant IL) /i . aJaJLU^ ._ 



(I 







(A.l.liess 5lH vl'/cto.V-UX; of 



^1 



Dl'RATIOX X Vj-ars Jfof/f/fM 



cf, 



(Signed ) J. >) ..0,U..a^.TL,^a^.ir:% 



J^fm 



^n. 



tlV^ Xk) Tf)oS fAd<lress) ^3>^ UXCt^UJl..Clt 



Hours 
M.D. 



Special information on'y for Hospitals, lnstil*utions, Frdnsicnts, 
or Recent Residents, and persons dying anay from home. 



Former or 
Usual Residence 

Wtten was disease contracted, 
If not at place of deatfi? 



HoH long at 
Place of Deatfi ? 



Days 



ri,ACK OF RIRIAL OK KF:moVAI, | DA 1" I- of IUkiai. or KKMOVAI, 
INDKRTAKKR \J CTwa^ W oXi- LO\xLqLo 

r\(l.h,^s ClH%5 vJlVuiav^r^v "O.t 



iS. B. 



Rvery item otf information should be cnret'ully supplied. AGE Bhould be stilted EXACTLY. PHYSICIANS should 

state CAUSK OF DEATH in plain terms, that it may be properly classitfied. The * Special Information" ?or p«r- 



-Rvery 
state 
Rons dyinft away from home should be feiven in every instance. 



* 

i 



M 



I 



) I 



in 

■1! ; 



,! 



WRITE PLAINLY WITH UNFADING INK 



!!. '.II 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIF ICATE FOR j^N STRUCT(ON3 

3385 



lle^lstercd J^'^o, 



ihifi' nird, ^j\cv^»xlv^v n I'^o'i 

\ 1 Deou^*/ Heaf^*^ Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Ccvtiticatc of Bcatb 



J? 



(?fT^ 



PLACE OF DEATH: — County of C^CC-^' O.'UX VlCc4C'. City of a.,>v JxclavC^^CO 



(No. 



St.; 1 Dist.;bet. :)jACCivcX>x<XAv and \^tX^> 






FULL NAME 



cnD.. 



PERSONAL AND STATISTICAL PARTICULARS 

I COI, 



I) ATI-: oi- itiK in 




Loltk 



\ < ". J'; 



i'tb 



)>,/;. 



IS 

(Day) 



H M.niHiS - i- 



(Year) 



Pa vs 



slN<', 1,1", MAKKI):i), 

\\H)<)\v}-;i) OK nivoRri'.i) 

Wiitriii social (U'sk' nation' 



r.IRTHlM.AOK 
' Stall- or Contiti y) 



NAM!-: Ol" 
FATHKR 



lURTHlM.AiK 

()!• i\\'rni:K 

(Statf <ir Conntrv> 



MAini'.N' XAM1-; 
til' MoTHl'tK 



HIRTHPLACK 

(Stalf or Country) 



OCCUPATION 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DlCATIl '^ 



(Month) 



%S ...fgoH 

(Day) (Year) 



I HI':RUBV ClvRTlI'^V, That I attctiilcd (loctased from 

Qct 'X'h. 190H to 0\C^ ^.S i9on 

that I last saw hX*U alive on \i\<^....%^., np'^: 

and that dt-ath occurre.l, on the date stated above, at I 3 
A.I. /M. The CAlSlv Ol" DI'.ATH was as follows: 

.LL^>rvx(XcLfe*\;. .\1^ CoX ,„..^„. 



M,nifli> 



n,T\ 



Tin- ATIOVK STMin I-KKSONAI, PA KTIC C LA KS A K H TKIK To Till- 
HKST Ol" MV KNOW I.i:i>C.K AND MKIJhH 



r\(Mrfss 



5IH 



DIRATION ]'('ars > Months % Days 

C O N 'I' R 11 U ' T ( ) R Y A/yvvJfV^ ^Wi^^i . . VrU. -aJX^v. . 



Hours 



Years Mouths 

MIcX"" It. IQO f. Address) 4 be L- 



DTRATION 
(SIGNED) 



Days 







//ours 
M.D. 




Special information only for Hospitals, Inslitulions, Transients, 
or Recent Residents, dnd persons dying anay from fiome. 



Former or 
Usual Residence 

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



How long at 
Place of Deatti ? 



Days 



PJ.ACK OF lUKIAI, OR RF.Mo\ AI, 






DATi: of HiRiAi. or KFIMOVAI, 







Q\f Q ^^ [ID P (^ 

W Jl 510' sXk cSt 



190 



'Address 



N. B. 



Kvery Item of informotion should be c,,re?ully suppHed. AGB should be Htnted KXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pluin terms, that it mjiy be properly classified. The * Special Information for psr- 



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



HIT 



^ 



I- i 



! (■ 



M 



II 



•it 



It I 



In 



T'.ii:ir. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3386 



r , J , ., ', 1; }• Vm ; .. *-« -ar-jiii: (;.<v P (* 



n 



L 



Rei^istercd jYo. 



i^u.lfv Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Ccvtificate of S^catb 

I XX. 5. Stan^arC^ j 



r^o< 



PLACE OF DEATH: — County of OaX^^x. ^.CL/>x<^UiX^ City of '->a.> 

V itiAll Mi^hi (IOf^vJt(xl St.:- Dist.;bet. — — and 

V VVVU ^VV^OVLTLAXt ^^'*^!y^^^ REsTdENCEGIVE tacts called tor under 'sPtC.AL.NroRMAT.ON ^ 

(J ( " rr^rE:Triltc^%rer.rrHi's^PyT^.L O "ns'?u"0N O.VE .TS name .NSTEAD O. street and NUMBER. >> 



^, 



FULL NAME Oxc^m ID ^xV 



d, 



JLajlv 



:i 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 



(^ 



UAT1-: t>I" HlRTll 



COl.oR \ ft 






AtiR 



HH 



)><?#,t 



S 



(Day) 



M.nlh^ 



(Year) 



'X<\ 



Da ss 



\Vnu)\VKI) OR I>lVt»Ri HI) 
(Writf in social doiK":'''""' 



HiK rii ri, xri-: 

( Statf <ir (."DUiitrv^ 



^^'" OlLob 



Mil QC\.\JUL<^. 






HI KIM ri,.\ri<: 
()i- iAiin:R 

(Slalf or Coviiitry) 



MAIDKN NAMR 
()!■ NU)T!IKR 



lUR'niPLACl-: 
oi' MolUKR 
(SlaU- or Country'' 



CL 



)X)V»VCV>vci 



a^vLLocu 




/rv 




iJXV^vux^A-u 

:crrATioN (Xy J i 



Kr^i,fril ill S,i>r t'litmi^m 'l ^ ''■'^' 



\n>iilh^ 



/Kn> 



(Infoiinant 



•„KAm.VKSTX.Kl>rHKSnNA. rAKTjrrKXRSAKKTK,K TO THH 
MHST Ol- MV KN(>\VI,i:i)t.h AM) Hl.I.IJ.I- 



MEDICAL CERTIFICATE OF DEATH 



DATE OF I)K.- 



ATH A 

M lovr J^h /po'i 



(Month) 



( Day) 



(Year) 



T 111;RI:15V CliRTn-V, That I attLMulcl deceased fruiii 

Qruvr a I upH to Ovmr ab ........upH 

tliat I lastsaw h-tn) alive on ■ vROV- ib k/d M 

and that death occnrred, on the date stated above, at 3 2. 
(X M. The CAI'SI*: ()!■ DI'ATII was as follows: 

Uv\Jv^r>w^ U^.V^xV^t^ ^-KAJUk^idi .UJ^M\ 






I)r RATION )'i'(jrs b Months Days Hours 

CONTRIIU'TORY - 



„- Years ^ Months 

1 (Jl '-' 



DrRATION 

(Signed) .vJ ^\ oucl^X 




Hours 
M.D. 



Q'V.ffvr 



QLb Tqo^ 



(Ad.lress) LcicL^^U ^^A^l^'^--'' 



SPECIAL INFORMATION only for H 
or Recent Residents, and oersons dvintj rfwdy from home. 



H^spitdis, 



Usual Residence 

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



How long at 
Place ol Death ? 



Institutions, Transients, 

s 



Days 



I'l.AClC Ol- lilKIAL OK RKMo\ AI, 



I)A'n;of MtKiAi. or RKMOVAI, 

\f^(s\r ai5> 190H 



ri.ACiC Ol" lil'KiAi, OK Kn.Mo 

INDHRTAKKR W<V,le.>^ix MlUXAX^TUJ ^ \^ 
fAd.hfss |5aH 5i*cK..t«>v C^.i 




^ B — rverv Item «.^ •.^.^>l«t•.„^ hHouIcI he cnrefully HuppHed. AGF. should t-Ht"tccl EXACTLY PHYSICIANS «hoMld 
I'tatc CrUSn OF DHATH in plain term,, that It may be properly claHnificd. The Spec.al information for pT- 
«on« tlylnft away from home should be 6«ven In every Instance. 



.1 



Sj- till 



"*■■*• 



HMMMiniliMH 



It ! 



m 






i 






;» 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

338? 



,.,.,,,1 ..f H, M-th 1- No. ;^ ^^^i^hS^V Co 



Jhf/r /vAv/.\A^^ML/Yvxf^^ Al ^'^^' 



Ee^istei'od J\^o. 



i,..odcv-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( 'd. S. Stan^arD } 
PLACE OF DEATH:-County of 0^>a. Jxc^^cc^co City of ^ -3.a,^YJj^<^..v..v^o 

( ^ r.^re^xToC^^U^-r .N^rHo's^PyTll: o^":s^'.?J;fo^N"o.VE ITS NAME .NST.AO OF STREET AND NUMBER. ) 



FULL NAME 




K-'lv, U \ ri<x^<^<i' vxxL<ij. 



PE 



RSONAL AND STATISTICAL PARTICULARS 



si:x 




,(XU 

I) \i"i-: oi- luk rn 



X 



COI,OR\ (\ 



iM.Hith) 



AGK 



aa 



) v.; ' 



«»- 


.. /Sib 


'I):iV> 


(Year) 


M.inlhs 


/)(J.V.V 



\vn>t)\\i:i» OK IHVnKvl". 1) 
(Write in ^(u-iul desiljnati' -n) 



lUKTIIPl.AOl-: 

(Stiitf or Ooiintiy^ 



NAMK Op 
FATHHR 



niK riiri.ACK 
^^\• i-.\rin':K 

(State or fomitrv') 



maii)i:n namk 
OI- M()Tni;R 



CVnJlLcvyvcI 



? 



niuTiTrLACi? 
<)i' M()'nn':K 

(stale or C'otuitry) 




OCCUPATION^ - 5 . 

Kfshifif ill Still /'nun/yrf) ^ ) , rn > 



.■sr.oith^ 



/>,!)> 



BKST OI- MV KNoWlJ'.nt.h AND Ml-.Ml.f 

;1) 



KTICTI.AKS AKi: 'I'Ktl". T< » I""'" 



(Iiifovin.'Uit 



L^^LcrvcurLo 



rX) 




(A.ldre'is 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKA in 



(MonllO 



(Day) (Vear) 



I IIICKICHV CI';RTII'V, That I attcMidcd (Icccascd from 

IQO "~~ 

•r.:;: ••■" ' T9O "~^- 



IC9O 



to 




that I last saw h ' — " alive on 

aii.l that (loath occurred, on the "late stated above, at ■ 
M. The CAl'Sr: (.)I<\1)1;A'('H was as follows: 

DIRATIOX )'cars A/oiiifis /)ays 

CONTRIBUTORY „««.««,.... 



//o/irs 



DTRATIOX ^-^ }'c'(irs 

(SIGNED) Jv\Xt/>.Vt^.. iJxJL4 

A fA p il 



Months Days 



//ours 
M.D. 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Davs 



IM.ACK Ol- lUKIAL OK K1:M<»\AI. 



DAIllof UiKiAi. or K1:MoVAI, 

^S 190*^ 



INDKRTAKl-K N-OJvXAAT ^ p.- 

(A<l(lresH ^H iJouWJ MXiA/V LW?^ 





. ~\, ^ ,, ... ACF ««io.ilil he Atateil RXACTLY. PHYSICIANS should 

«on« clyinft iiwoy ?rom homo Hhould he ftiven in every mHtnnce. 






I 

t 



I 



"ii 



i^ 



i-««W»b'fc»i:^ 



i 



|): I 



I i 



! 



if 



^■' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



nn..t,l .! 11- ,Mh iS, : r-X7^r^i^ynScVC<, 



'.a^' 



•^'"►r 



Dfffr Fi/rd, M\iJ\U...T>AjLvl\; X%. 100\ 

L^^^vo^v-H Dcp-ty rleailh Officer 



REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

3388 



Res^Lstererl jYo. 



DEPARTMEiNT OF PUBLIC HEALTH=City and County of San Francisco 



Ccitificatc of S)eatb 



a, 



PLACE OF DEATH: — County of 



OlK o. 



City of 



^■^x.% 



n ^ 




No. 



St.; 



Dist.; bet. 



and 



^ IICIIAI BF«5IDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 

' '^r.rj^viii::.': "r^o^^^'i o""^"tu"o';'o,v. ,ts n.me ,n.t»o o, .t,..t .™d numb.,,. ; 



FULL NAME 




\ 



LO. 



,cuwvx:yrai. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 




COLOR 



oJ 



DA'ii-: <)i I'.iK rn 



.'" A5% 



M<.iuh) 



AC. I". 



Hb )Vrt#: 



fDMv) 



Motilfis 



(Year) 



Da vs 



SIN'C.I.K. MAKKtKn 

\\n)()\vi:i> < IK ni\<>Kii:n 

(W'littin sot'ial dt >-i!-' ii.-it inti) 



TUKTmM.ArK 
I Stall; or Conulryl 



?€AMK OP 

lATlIKR 



T\IKrniM,ACK 
Ol- I AIMKK 
(State or Country) 



MAIDKN NAMK 
Ol- MOTHER 



lURTHPT.ACK 

Ol- M()Thp:k 

(Statv or Count ryV 




OCCUPATION 



Rfsiiifd in Still I'l mil isio 



r,-,;/ 



M,<„lh- 



I)ii\ 



Tin- -\H()VK ST\TJ-I> I'KK-ONAM'AKTUTI.AKS AKK TKrK To THK 

liKHT OF MY K^•o^\ IJ'.IX'K and lUvI.IhF 



(I 



nfoMuant \»Sj 



f \<Mtf^s 







'U 



% 



/CV'C^.XXy^-v^J^^>A.t Ci 



c dt 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH A 



(Yesir) 



Up 

(Month) (Day) 

1 HI'iRIUiV C1:RT1FV, That I atttMided (leceastHl from 

- to ■ IQO — ~ 



"I90 



that T last saw h •: -rilive on 

Mii.l that <leath occurred, on the date stated above, at 
M. The CAlSlv Ol* DlvATII was as follows 



Tip 



At- 



ii 



,V<X/^:X^Cl:\w\-K,-KX.wC:-^. ^.Ahj>i1S.^^^ 



I) r RATION Years Months 

CONTR rnrTORY •— 



Days 



I )r RAT ION-.. 



)\ars Monllis 



Pays 



(SIG 



NED ) LO^.'Sv. vJjXMLa^Mr- 



Hours 

Hours 
M.D. 



n •■ '. I 



rqo 



;.„„..) ^0^%.ue.j 



Special information »n'y '<>'■ Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



I'I^\CK OF* lUKIAI. OK KHM'iNAI, 



l>ATF"of Mt KiAi- or RF:MoVAI, 

Qnusxr.Qs.1 



1901 






-^ 



AddrcKs %V0 O '<VCS..<X<^>aJL'>v1c>....J1 . 



r^- 



rs B —Every Item of information should be cnret'ully suppIle.J. AGB Hhould be Btatecl EXACTLY P"VSICIAN8 si 
state CAUSE OF DEATH In plain term«. that It may be properly classified. The Special Informatior ?or 
8on« dylnft away from home should be ftlven In every instance. 



PHYSICIANS should 
per- 



ii 



% 






H 



#1 



%i 



II 

ill 

It II 

III 



W 



RITE PLAINLY WITH UNFADING INK 






/)((/(' rih'^L 'flc»-t^^vi(^<> ,ai.._.. 



100"^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\o. 



Lv^ij^ , D^p'^^y «^°'^'*^ o'^'^^' 
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Death 

( 13. S. Stan&ar? j 
PLACE OF DEATH;-County of cW>^ -I'v^V >^cc4 cc City ofd<X^->v J.X<v>v^^.CO 

! \ 



Dist; bet. 



and 






^^ 



FULL NAME 



CrVVYv 



l^ 



AJl,UHLha 



PERSONAL AND STATISTICAL PARTICULARS 



ir 



SKX 



(:h\c.i 



Ct>l,«>R 




i^lxCu. 



I) \ ri; I >f iiiK in 




vt 



l):tv^ 



AGR 



O I J ''' ' ■ ^ 



Mutit/is 



S 



(Year) 



Pu \s 



<\sr.\.\\ M.\KI<n:i). 
WIDoWKI) <)K DiVoKVKI) 
iWrittin '-ncial (IfsiKiiatioii) 



^OV' 



iSt.'itf or Comitry) 



NAMK OF 
FATin:R 




(^ 



C>xcyvcx"ivcL 



Lkavuu vt 



hXv<y-<^ 



RIK'rUlM.ArK 

()|- lATUKR (X) 

(State' or Country) L 



M\n)i;N NAMK 

uF motuhr 



lURTHPI.ACK 
tH" Morui'.R 

(Slate or i.N)iuitry"> 



1^(1 M, !} 1 



iK'crrATioN Of) A 



Rfsiiirtf III SiUi FraHii'in'o 



as 



) VV7 ' 



yf.'i'ih^ 



/h!V' 



TMK Xm)VKSTATKI.l'KKS.»NAl.rXKTU;i;i.ARSAKKTRl K To THH 
HKST OF MY KNOWI.I.IX.K AM) lihUlKt- 



(I 



nformant L'.U jt Ct<X^^ 



(A.l.lr.'ss 







H. Co Ob (Sll V \.t. at 



MEDICAL CERTIFICATE OF DEATH 

DA ri-: oi- i)i:a rii ,^ 

vjW 



(Montlil 



%k 

(Day) 



(Year) 



I 11I';K1;BV CI-:RTIFV. That r attended deooascd from 

kh^IN- %1 190- . to \Wr....a.b 190 H. 

that T last saw h^^- alive on JX^^.X^ up H 
an<l that .leath oceurred, on the date stated above, at D-^-^i).- 
...iJ M. The CATS!'! O.l'" Dl^ATH Nvas as follows: 
\J J(vLi\A,4A^ y JJLU1^X^"> VoXUi 



DT RATION )'t'ars 

CONTRIlU'T(^RY 



J /(If// As 



Days 



Hours 



DC RATION 



Days 



I /ours 



( SIGNED ) J VlV (?b.<Ou\tj.. .,,....„_.. M.D. 

SPECIAL INFORMATION only for l^spitdls, Institutions, Transifnts, 
or Recent Residents, and persons dying dwdy from home. 

Former or 1 \4 ^^^ '""^ *' 

Usual Residence 11 U .^iA.<nmf-Sj2i Place of Deatli ? 



Days 



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



i'i,\cH OI' iiiRiAi, OK ki:mo\\i. 



l)ATi:of m Ki.vi, or KKMOVAI, 



\iX^r^...%%. I 



(Acl,lr.ss b I X ' b ! M I) <X->AJ MLu.^ LI 



90 



uv... 



^ ... (! .. 1-1 \rr Hhcuild be stiiteil FiXACTLY. PHYSICIANS Ahoultl 

ftons dylnft away from home should be ftiven In every InHtance. 



ti 



,!i 



1^, 



1 



m 



i 



w 



RITE PLAINLY WITH UNFADING INK 



. , f ! I . 



#!•»?«>*, 



,;th r V,, . f-::*;,^-'*^ ''<■■'» 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nah> Filed. \l[l^vs.^/:wJ^ ^^^'^ 

i^wc^du^ Deputy Heal^f^ Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of E)eatb 



PLACE OF 



No. 



IF DE 

I r 



( \1. S. StanPavCi i 

DEATH:-County ofCj<:^^ .1,V<X>vc.Ui.C,: City of ') O.^ J^<X^c^<.o 
^ St.; .^ Dist.;bet. iU OVvvO^Vd.. and JO-LiCr 



^S^.::t: ::t^:^^ r^^|^^ J/^^I^^^ ^-" ;^;^?ri;?r:^;;f 



YV 



FULL NAME 




tc^a 



c 



nrM- 



SI 



PERSONAL AND STATISTI^CAL PARTICULARS 

COI, 



^" \\X 






I) A 11". t M r. IK I'll 



^>\ 



M.)nth) 



^D 



SIN<-,l.lv MAKKll-.n 

\vii)n\vj:i) OK in\iiKi):i) 

I W'l ilt ill v.xinl (Ifvi-jitatioii 



lUKTIIPLACK 

(Sl;it<- or Country) 



J V(7 ) 






n 

(Day) 



M,i)itlis 



f%X\ 

(Year) 



Ifr 



Da \s 



FATHl-.R 



HlKTliri.AfK 
Of I A'lin'.K 

(Sliti or c'oinitiv) 



MAI1)1:N' NAMI-, 

(M" M()'i"hi:k 




HIRTflPT.ACK 

oi- MornHR 

(Sl;it.- or C'o\iiitry) 



\i^ 






Rfyidrd in Sati Fniiiciyro S . ' '"•" 



U .11 III ^ 



n,n. 



TnKAKOVKSTXTKDWKK-^oNAI.PAKTI.M-LVKSAKKTKrHTO THH 
HlvST OI- MY KNo\Vl,J-;i)<'.H AND Hl.I.n'.l' 



Ollfo: nillllt 



liil 



(a . ^- vfyvcvtUxjtM^s •..-."■ 



w 



4H- 



MEDICAL CERTIFICATE OF DEATH 

DATl'. ol- DI.ATII 



\l lev- 

(MuiitlO 



XI.... 

fDay) 



/<?f> ^i 



(Year) 



Ol 



1 llURl'ilJV C1;RTI1-V, Tliat I attcnilcd 'Icrt-astd frotii 
fu- 3iId I90S t 



that T last saw h X">'>\ alive on 



. .rrr-rr-rr. 



190 



%b 



aiKl that (Ualli occurred, on the .late stated above, at 
M. The CArSI*; Ol" DivATH was as follows: 




II 



a 



Di; RAT ION )'r(ir.s 

CONTRIP.rTORY 



Mouths 



/)aYS 



Hour 



Hours 



DURATION YciDS Months Pays 

\0\. b. MKa,q^i^4 ^ M.D. 

(A.hire.o t\i^M)laA-k-.t ^. 



(SIGNED ) 



lr)0 



SPECIAL INFORMATION '»n'y for Hnspitdls, Institutions, Iransifnts, 
or Recent Residents, rtnd persons dyimj .may froii liome. 



Former or 

Usual Residence .,.,,.....„. 

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



Mow long at 
Plare ol Death ? 



Days 



K 



I'l.ACK Ol'" lUKIAL OK KHMOVAI 

■NDHRTAKKK Njl 0>w<X4L4 ^^ VC 
,. Xt^ -K^ ^ 



I)\ri:o! HiKiAi- (ir Kl^MOVAI, 

I9OM 






.Iress is?)- ^3S1 d-^L.ttjL\i .dt 



N. B.- 



"■"■"— —■——"'^ , .. ■• I \cr Hhoiiltl be stHtetl r.XACTLY. PHYSICIANS hHouIcI 

.Bvery Item cW information •houl.I he cnrct'ully -PP'- • , '^.^[^^^^/^Lwird The "Special InformHtion- for pT- 

state C\USE OF DKATH In pliiln terms, thnt it m^y be properly Uaiismeu. 

non« dylnft away ?rom home Hhouhl be ftlven In every instance. 



I • 



i 



'VI 



I I 



ii 



If ^11 



^ i 



! ■»■*■ 



f^»^lf^ 



i I 



i m 



id 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. ,. .^*':T^.,,...uc RfFER TO BACK OF CERTIFIC ATE FOR INSTRUCTIONS 



Be^istered J\^o, 



3391 



\ ^ - ... ^ or 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)eatb 

( tl. S. 5tan^arD ) 
PLACE OF DEATH: — County of ^'a^V JXC^^vC^^i Gty of ^-^-c^vv J AXVaa^cvvICO 
LCtu ^LcrW^vtAA k)iyVi\,UuxX St.; -— Dist.; bet> :::rr and — ^. 

,. \^^wVVt V,VV^I^VVy ,,eil*l or«;iDFNCE GIVE FACTS CALLED rOR UNOen "special INroRMAT. ON \ 

( - r"orATH^oc:u%rEr i^-rHo's'r.^ :.'?^?.^'J;^^.'^c.ve .ts name .^^sxeao o.^sx.eex a.o .U.S... ; 



No 



FULL NAME UCUv^^^nXl 



„ C . I 



cnv 



'^L^-. 



DATI* <H" I'.IK 111 



PERSONAL AND STATISTICAL PARTICULARS 
^ I COI.OR 

oJLx 



Lv^4v^Xi• 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATll A 



i). 



(Month) 



T /iHl 



AC. K 



5 5 



) V(/ > 



w 



(Day) 



Mnulh.y 



I'l 



(Year) 



/),/), 



sINt.l.K, MARKIl'.I). 

w 1 1 )i ) w !•: I ) OK n I \'t > K r v. \ > 

iWiitfin sociiil i!rsiv.-ti;it ii iii) 



niKTin'i.ACK 

'State or Count ry^ 




>c/cLcrv\>^cL 



F- ATlIl-R 



^ 



U) 







RTRTlTrT.ACK 
<)1' 1 All I)-; K 
(Statt 111 (.'onntry^ 



NtAIDl'.N N\Mi- 
<)1- Mollll'.K 



lUUTHIM.AC H 
Ol- MOIIIKK 
(Stall- or Cotmtry) 



\ 







(Month) 



lie... 



igo \ 

(Yean 



I in':Ki:r.V C1:RTII'V, That r attemled (leceascd from 

. ^)^^.v>xJt ^*^ 190H to LKcv^.. ..^.kj IqoM 

that I last saw h ■'- ' « * alive oil \/X5V^ ^'e I90 

ati«l that (loath occurred, oti the date stated above, at A 
V ^i_ xiu- CAI'SI*: OF DlvATH was as follows: 



■'Si**? A * * f^ "^ 



1)1 RATION )V<// 

CON TRimTOKV 



Months. 



/'>avs //ours 




OCCUPATION 






Rf^iilfi^ ni S'l/)/ /'/ (///r /•'•(» 



Yr.u 



M.'xfh' 



/'.? 



TMKAn..VKSTATKI)rKKS,>NAl.rAKTIcri.AKsAKK IKt K TO TUl- 
HHST Ol- MV KNOWIJ.IX.K AND lU.MI'.f 



infonnant L) . ^J . J^- Cl<X,^^j. 



( \(l(l!rs« 




"^Vc Lt utHv^kv:t<v.c 



nr RATION ^^y^ VcQTS ^ 

(Signed ) J . 




M(i>ith: 






/ ^/ j'.v ... //o Ii rs 

M.D. 

ft) 



TqO '^, 



(.\ddre<;s) UIm!"^'^ Cc 'jV-(V<L^. 



SPECIAL Information «nly for Hirspitdls, institutions, Irdnsients, 
or Recent Residents, dnd persons dyinj dwdv from tiome. 



Former or .^^f^ j ik4- How long at ^^ 

Usudl Residence ^^^ vC^CU4. OX Pidce of Death ?' ^^ ^ 

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



(J 



Od)s 



j'l.ACi-: c»i- lUKiAi. (>K ki;m<»\ai 



I) \ 11: of HiKiAi. or KICMOVAI, 

.0.\fi\r. %'! 



T90 



C^t^Vxrv-cv>v ^^ Co 



,^ 



^ r r, ,,. ..rot'ullv supplieil. AlIH should be sti.tcd liXACTLY. PHYSICIAIN8 should 

N. »•— f^-ver> item „nnWm«Hon .^ »-^^^^^ ^^^^-^ ^^ ^^^^ ,^, ^^^^^^^^^,^ .,„««ir.cd. The •SjH.cial Information" *or pT- 

rnrd^ln^o^wa; TnomLmc Uou.d He .Ucn In e.co Instance. 






I 



I, 



I 



■1 ! 
« 1 



il 



t n 

r n 



I 



ui 






WRITE PLAINLY WITH UNFADING INK 



}!ii;ir'l (>r n«-:'"t '> I N- 1 



, ,. -i^x^r^^ M^v y 



nah' Filed , SS,^\:^X/Yr\h-^> "Xi 



lOO'A 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3392 



Ee^Lsfercil Xo. 



1mhmw(^'W>^ Deputy Hoal.h Officer 

DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 

Ccrtiticatc of IDcatb 

J( (3? A ^ 

PLACE OF DEATH: — County of C\<X^' vK<x ,vC^<^C.City of )<V>^ v];v<X>xcc^^,0 
No W'Xh'^CU^^^vJ^A^wxO U-aM. St.; .5. Dist.;b€t. rliJiv and \^XL 

INO. \- ^X W -VVyTV «..^WX.^ T '-V^ ,,c,,., ore, nrNCE GIVE FACTS CAtLCD FOR UNDER 'SPtCfAL INFORMATION' ^ 

( '^ rF"orAT°H"ocru%reV.;"rHo"s"pyTlt 0^"N?fl'J;^o';"aiVriTS NAME INSTEAO OF STREET ANO NUMBER. ) 







FULL NAME 



LoJLl\.t^^u^^Jl oU ^Lou^:xi. 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



vW 



1) A'ri'. oi- I'.IK I II 



I Month) 



-^ » 



.1 



MEDICAL CERTIFICATE OF DEATH 

DATK (»1" ni:A TH 




(Month'* 



%ki I go* 

(Day) (Year) 



\<". i-: 



ii^S }V./;> 



IDiiv) 



M.oilhs 



rV\\ 

(Year) 



/'■M 



HINC.I.K. MAKUIKH 
WIlXtWHI) OK I)I\(>Kv i:i> 

'Wiitt ill soii;il (K--ii.' nation) 




niKTrirrAOK 

(Statf or Country^ 



NAMK OF 



niKTHPI.AOK 

()!■ I Ai"in:K 

(State 1)1 I'onntry 






dUJlXo^vCV^ 



»)} MoTHHK 



r.lR'I'in'LACK 

oj- MoTm':K 

tSlatf or Connlry) 







I IIi:Ri;r.V CI;RTII<"V, Tlmt r aUendcd deceased from 

i[?ct 1 i90*i tf) 'yVflV^ ^i» .-...,...190 H 

that T last saw h ri>V alive on ^xWv ^3 ...,...,.190 H 

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

.....'"... ..M. The CArSi-: OI' I) I! AT 1 1 was as follows: 



. >.]! Vt>V oJl mX<<:VV:V^.cv^ial.i^tr>cx . 



.QA^SJ^O^y 



I) r RAT ION J'<y'^ \ A/ont/is^^^ Days Hours 



OCCUPATION ^^^^ 

h'lM'ilfd III S,ni /'iiiinr^'-" \ )'•<">' 



.}/.>,if/i^ 



/»,n 



T.n: .\M0VHSTATKl>»'KKS0NAl.lV\KThri,\KSAKi:TKrK T' • THK 



liKsr OF Mv kno\vi,f;i)<".k and HFun:i" 



^^A/'TN. 



,fo:,nant \lXca.'cJLMXVv "^.JlC^A 




y'cars I Months l^ays 



Ur RATION 
(SIGNED ) 

Vrlnr '^/" i(,o H fAddressi \^V\ 



Hours 

M.D. 

-4f 



. fV. 



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



Former or 
Usual Resldenre 

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



How long at 
Place of Death ? 



Days 



I'l.ACIi OF lUKlAI. OK KFlMoXAI. 

{ 



DAI'llof lU KIAI. ur K1;M0\A1, 



INDKHTAKKR ^i/C30CUk-WC Vt'WCLil^Ct^CXv UjiA^. 



T9O 



(Ad.lrcHS lllY^Xv 



l«ijL.Cr^V 



;U 



N. B.- 



<! . w ♦;«« «hm.I.I h^- cnret'ully Hunplied. A(iB nhoiild be stnte.l KXACTLY. PHYSICIANS nhould 

««.7cr"8E OF dTa'tH in pMn trZtZ^ Tly ... propeMx c..»...ied. The -Spccl-. .„f„.„.,.lo„" fo. p.r- 
nons dyinfe away from home should be ftiven in every instance. 



7 
I 



t 






■[• 



I^!l 



i 



i 



!lf 




IV,., -.1 . f \\' :!:t!i I 



WRITE PLAINLY WITH UNFADING INK — THIS S A PE RM AN ENT RECORD 

»E'E= "C 9*C* C«" CEgTiF GATE FOR INSTRUCTIONS 

B.'^i^tered Xo. 3393 



♦^•"•"•V^^ 



HcV:!' r.i 



icv.^l..>^V Deputy HcaSlh Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beath 

( "a. 5. £itnnC^arC» ) 
PLACE OF DEATH : — County o^i)'LOUla.-vva.c City of oCV'V^a.OJv 



(!_i 



No. 



-St.; 



and 



Dist.; bet. 

..^..«. oc-cine-fsir F nwr FACTS CALLED FOR UNDER SPECIAL INFORMATION" A 
/ ,r DEATH OCCURS AWAY FROV USUAL " ^ ^ I D E N C E G J V E FACTS J^»^^ ° ,f,sTEAO OF STREET AND NUMBER. ) 

\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUT'ON GIVE ITS NAMt INSTEAD ^ 



FULL NAME 




0^ 



Ld\) oU,Uw'VCt>:XCL 



t 



si;x 




PERSONAL AND STATISTICAL PARTICULARS 
^ K I COI,OR 



1 



I) ATI". <)I- 1!!K)H 



.OJxaJ^. 



(Month) 



AC.H 



I til » .■< 



STXr.T.K MARKir.D 
WIDtiWKD OK I)iV« >Kv}:i) 

iWritiiti social <!( oiiMiat imi ) 



FUKTHIM.AOH 
(Statf or Conntiyt 



NAMH OP 

}• ATIIIK 



TUK'nilM.AOH 

<)! i'Ariii:R 

(Staff or (."otiiitry) 



MAIDI'.N NAMi: 
Ol- MOTlIliK 



niR'inruAii-: 

OI' MoTllKK 
(State or Country 



OCCUPATION 




MEDICAL CERTIFICATE OF DEATH 



DATK Ol- I>1:aTH 9 

axlvt 



(Monfh) 






.ign 

CYcar 



1 in':Ri:HV CI-RTIFV. PIimI I attended deceased from 

\ ;.: ,:.\ I QO ~ — ~ 



Ic^O 



to 






tliMt I la^t saw h ~ alive on •—— - 

atid that death occurred, on the date stated above, at 
T— - M. The CAl'SI-: Ol' DlvATM was a^ follows 

^X.e-V4JnxJLd- ....-» ^•— 



■190 






iv,// 



Months 



/>.,•) 



TMK ^H<.VKSTATKI>.'KKS,>NA1 rAKTirrKAKSARKTKrK To TlIK 
In-:ST Ol' MV KNoWlJJX.h AND m. 1,11-. 1- 

(infonnant VlKoUVt^. ^ • ll i)x^%rtrl 



i \<Mi-e<«« 




cx.-\y^'. 



DT RATION Years 
CONTR IBrTOR Y 



Months 



Days 



Hours 



DURATION 



Years 



Months 



( SIG 



ned)1a,..V9 X.MVc 



Days 






T90 I 



( A.ldres^) 




Hours 
M.D. 



U^^^ 



Special information "ily *"'■ Hospitals, Inslltulions, Iransients, 
or Retfnt Residents, and persons dyiiKj awdv from home. 



Former or 
Usual Residencf 

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



How long at 
Place of Death ? 



Days 



PI.ACK Ol" HI KIAI. OK Ki;Mti\ Al. 



SciKL^v^/XcL^. 



I)AXi;o: Hi KiAi, or KKMOVAU 



^^atx" 11 



190 



INDHkTAKKR 

(AiMress 






. . t- en o..^..i:..i ACK Mhotiltl be 8tnte<l F.XACTLY. PHYSICIAIN8 uhould 

"• "— r.7crs"'or"DT;;H".:';;:" ".^""'.c t^^x .";.':..';; "ii.meu. tk. "s,...,.. .„fo....i„„" u. ^r. 

Bon. dyinft owny from home Hhoiild be ftiven in every inHtance. 



mi 



1 



.!' 






31 



ill 



•iiin 




T ' 


m 


M 


1 




II 


'Ri '^ 


1 


f» 


1 


'"'"l 


Hi 



JJ- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

llp^istcred A'o, 33 JS 



]■..,■, 1^1 ..f HcnUh - I- Vo. '.^ '-^X.^^ '^^^J' ^*" 



^v^ttvv^ Deputy Hcaith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot IDeatb 

( 11. 5. 5tanC>ar<> ) 



f ^ I 



PLACE OF DEATH: — County 



oM)a.JjLol^vcx^c... City of Oxx^-v-uxKa 



(J, i 



No. 



St.; 



Dist; bet. 



and 



- ) 



.V ror.« IJ<5UAL RESIDENCE GIVE FACTS CALLED TOR UNDER SPECIAL INFORMATION ■ \ 
r DEATH OCCURS AWAV FROM USUAL "5 = ' ^_'^.;;.X.. „T. ^ . v. c- .jS NAME INSTEAD OF STREET AND NUMBER. / 



( '^ °/dEAt''h''oCcJrRED IN A HOSPITAL OR INSTITUTION GIVE . 



FULL NAME 



'4 



WKJO^"^ 



Xt^wCL^^^cL. 



s I •: K 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.oK ^ ft 

DATi-: (>!• itiK rn 



WL 



(M.)ntli> 



\ * '. )•: 



>Vti»> 



STXC.T.K MARKIKD 

w inowi-;}) OK nixoKr}"!) 

iWiitcin v«)ri:il (U siiMiat ion) 



HIK'rHlM.Ai'H 

( state or Country) 



NAMK OF 
FA'I'III'K 



(>I I-Allll-IK 
IStiitr or v'ouiitrv') 



MAIDl-'.N NAMl-: 
()!• MOTllHR 



lURTK PLACE 
Ol' MOTHl'.R 
(Stiitt or Coiuitry* 



OCCT'P 




MEDICAL CERTIFICATE OF DEATH 

DATI-: oi" i)i:ath 



(Monlh) 






I go 

(Year) 



I II1';UI';BV CI-:RT1FV, Tlmt I attemlotl dcocased from 

to — — 1 90 — 



190 

" alivi- on 



that I last saw h ~ "' alivi- on - ^9° 

aii.l that death occurre<l, on the date stated above, at 
..rrr-. M The CAlSr: Ol" DIvATlI was as follows: 

^X^0-UJ-VVX<1. ; • 



DTK AT ION Years 
CONTRrRT'TORY 



Months 



Da \s 



Hours 



crl>dbUiH) 



fsf^i.lrJ //' Siiii /'; i/"i 



)'rn I 



yr.,„tfis 



f\r f 



•niK VHOVK STAT.-I>PKKSONAI,rAKTl;;rLAKSARK TKIK To TlIK 
UKST Ol' MV KNo\VI,i;i)C.K ANI) Mhl.Il'.H 

nnfonnant MXcLVOX I' li D X.\rtX 






A.«^^ 



1)1' RATION _ i'tars 



SIG 



^^^^,^, ISlonihs Pays 

NED ) .iA,-\9 1 .Smu.^ 



Hours 



KncUL 



M.D. 



V*^ \\X 



-M- 



T9O 



( 



Address) V| Ka^TVvLxX^ ' >'^ 



Special information only 'o^ Hospitals, institutions, IranMents, 
or Recent Residents, and persons dying <twdy from home. 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



I.ACIC o»" 2UKIAI, OK Ki;.Mo\ AI 



fcUd. 



V-i\; M / LCUlx*) 



DAXiio! lit HI. M 01 ki-;mo\"al 



V)\c\'- ^l 



T90 



IM)1:k i'AKKR 

(Ad(lrcs«* 






— — ■""""""■""""'"'^^ .' u I I h. nr.,fullv suddHmK AGF. «hotild be stnteil fiXACTLY. PHYSICIANS should 

■on. .Ijlnt owny from ho.nc .houl.l b« ftiv.n in .v.r» instance. 



.» 



I 









I f 



I! 

in i i 



ii «' 



ir ( 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

J!'.:ir.l iif H(:,ll!i I-' No. n i'*-'S^^^;]\S<.VC(< 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(f/r Filed 




.OV>^Y^ 



-Olma- 



x% 



VJO''\ 



J) 



l^vwic^A^u Deiv^^v Hr^nf^h O^cer 



Registered J\^o, 



33941 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticate of 2)eatb 

( ■m. S. Stan&atO ) 
PLACE OF DEATH: — County of 0<X^nj -J.Vcu-vvc.uii.ci. City of ' '<V>v OAxoAytt^ ac 

No. iH^Vvi.! LL^VNt St.; 10 Dist.;bet. C{n%CU) ,,. andlJxUtvt 



■1. 



FULL NAME 



I) 



.O..JLI 



■ULLo^a..C:'waj., 




AA.\^KhJL. 



PERSONAL AND STATISTICAL PARTICULARS 



DAT1-: Ol JIIKTH 



\xxXl 



COI.OR 



U)i 



.A^jL 



\,'^\Jj> 



' Month) 



AC.K 



.M.H . )•,-,?;> 



(I):iv) 



,.lA'>////.v 



r%HS 

(Vear) 



.. /)<n.v 



MEDICAL CERTIFICATE OF DEATH 



VKmr. 



(Month) 



.Ik. 
(Day) 



/QO 1 

(Year) 



r! 



SIXC. I,K, M.\KUn:i), 
\VII)<)\VI<:i) OK DIVORrKF) 
(Writf in scu-ial fl(,<i>.':nalii)n) 




A/cLcrv^-MxL 



iiiRrm-i, Ai'K 

fSlatc or I'oiintrv) 



NAMK Ol* 

fath}:k 






} 



I HHRHBV CJvRTlFV, That I attciKlcl .Icreased fn.ni 

■^^nj^'- ^a 190M to O'Uvr ...3>..iQ. i,p M 

that I last saw hJUW. aHvc on M^TV^ 3.5 ^^^ 

and that death occnrred, on the date stated above, at I cSO 
A^ M. The CAL'Sl-: 01' DivATIi was as follows: 



n 



MIRTH PI.ACR 
OF l-ATJIHR 
'State or Country) 



.MMm';.N NAMK 

01 M()'rin-:R 



F!IRTmM,.\l'K 

Ol- .Morni:R 

(state or t'ountrv) 



OCCri'ATIOX 



I 



DLRATION^ }>ars ^>/^Mi ..... /yays 

coNTRrnrToRv 



//Of^ 



rs 






) • 
> I 

r 



vX\a^V<X->%^ 



? 



(1 



Dl'RATION ^ Years 



ISrouths 



(SIGNED) i.. *sA). ^']v<XVv^,A 



Days 



>Jt\A> 



\XUyXAJL^ 



"^ 



L^V" 



•''- rcjo'i (.Address) -Jo Cl 



v3.aljy> 



-viivcv 



Hours 
M.D. 



?^^9'fiK"^r^^'^'^TION only for Hospitals, Institutions, Transients 
or Recent Residents, and persons dyinq away from home. 'rinsients, 



Rfsiibul III Siiir /■'; i/;/' ,'-/•() 



) 'rir I • 



lA,^////> 



/>,rr. 



Tin-: \HovK sT.\ri-;i) pkrsoxai, r\K iuii, aks .\Rr; irii-- to thj- 

HHST ()!•• My KNOWM'DCK AND lUnjFF 



(Infoiniruit 



/ 1 |-v 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



f.Xrldrcss 



UJLa^-v-r\wi.dLcv vcv'i 



I90M 



I'LACHOF nrRIAI. OR RKMOVAI. DATK,.f H.k.al or RKMoVAi" 

i-ndi:ktak):r (lb . j . VJTUxo.^^ Lc 

(Address SH ^)V\.^^^€r>^ ^1 



IN. B.- 



-F.very item of information shoul.l hv cnrcfully supplied. AGK nhoiild bo stnted KXACTLY PHV»iriAM« u . . 
state CAUSE OP DEATH in plain terms, thnt it may be properly clansified The "S-.l lli 1 ^ , , . » "^**"'** 

«on. dylnft away from home should be ftiven in every inslance. ''"'*"'*''^**- ^^^ *»'»'^'«' '"^ormHtion" for p.r- 



ia:*t_.ii,-=iifciL.J*iS.-ie_jij.- i 1 



J.: 
1 



i ^'i: 



tif 



til 



■jliS 



U'Kir-] ..f 11, a!tli - »•■ No. ! -, T"?'^^- lUS^j 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Re^Lslcj'ed JVo. 



3395 



Dale /vV^v/, M\aM.r^vLt\- %X lOO'i 

d^^r\x^-^\\A>A^ Deputy r!cai:h Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( la. S. StanCarCi ) 
PLACE OF DEATH: — County ofC'Ct^v O^CX^XCVA.CC City of ^^'O/T^^ >J/V-<X>vc\,4ic.c 
No. iHn lltcvK St.; L Dist.;bct..., „.M.JLL and lb ±K 

r 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 J 

FULL NAME s^.Ax<m^^(X^ ,\xx/>vcu^. 




^;r:x 



DAllC n\- lURTH 




PERSONAL AND STATISTICAL PARTICULARS 

Lie CO n rStH 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK ()1- I)1;aTH 



flw 



A(.K 



M.mth) r 



)'iit> s 



^ 



190 H 



Mrmlhs . Tktvs 



uii)<)\\i:i) OK i)i\( »Kri:i) 

iWriti ill v(ui;il di si).Miiiti<)ii) 



^ 



lUKTjri'I.Ai'K 
'St:it< or Country) 



NAMl-; OF 
I- A rUHR 



O.vTvaLi 

H ft 



^ J .oJC>v^-c-k ^J ccu^l 



311. 

(Mojith) (Day) (Year) 

I Ilf'RI'HV ClvRTlI-V, That I attiMiVkMl dccvasetl from 

^1 ^^^^^^ '^ti 190 s to vH'^rsr ..a.! i^Q «^ 

tliat I last saw h u. . = alive on \h-d5M^.Jkri igo H 

and that death occurred, oti the date state<l ahove. at 'X 
^ .^\- The CAl'SI-; ()!« DI-ATII was as follows: 



^.■IctktW.. 



lUk'rm'i.At'K 

Ol- 1 ATHHK 
(State or Of)i!ntrv 



Kk) 






maii)i:n xamk /^ 



niRTTTPLACK 

<)!'■ MoTm-:R 

'State or Count) v) 



DURATION Years ^... Mouths \ Days 



/lours 



DIRATIOX .^ Vtars 



Months i /)<ivs 



(Signed ) 




//on 



/ s 



^hcv yn u,n^ f^ddres.) ntio" - XhIL it 



M.D. 



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



OCCUPATION 



Rrsiiifii ill Sttii f'l a !•• iM'ii 



)'>'ll! . 



Afi'iif/tf 



/)<!) 



Former or 
Usual Residence 

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



flow lonq at 
Place of Death ? 



Days 



rn }•: amo\'k srA'n:i) im-k^on ai. r \k iicr i, \k> aki; i'k ri-; to ih )•: 

UKsr Ol' MV KNOW 1,1; DC. H AND liJM.IIlK 



InfoMiiaiit vJ CxXx^vO'k ^ CL^wwt 



(\(l<lr.ss 



HOI atoJv dt 



n.ACl' Ol- HCRIAI. OK ki;\J(i\ AI, J DATl-ol- H. kiai. or RKMOVAI, 

ini)i:ktaki;r ^ cHLcLi/vw C.atjL LJL>xd.a Lc 

(Address 0^11 3> \1 iVv-A.^i-V-C^V oi 






M. K. fivery Item «>»' inlr'ormiitlnn fihoulcl be ciiret'ufly Htipplied. AdK Hhotild be stated KXACTLY. PHYSICIANS should 

Htnte CAlJSt: OF DliA TH in pliiin termiK, that it mjiy be properly claMsilTied. The "Special Information" ?op p«p. 
«on« dyin^ away from home Hhould be ftiven in every instance. 









i 



* 



I*. 

v 



I 



i !" 



i>( 



j 



k 



\ >l 



i ij 



II; 
1 f' 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n'.:H'l .if HcMi'.li I- V.v 



nSiV Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begistercd J\^o. 



3396 




Dale Filr<l,\Tl^oJLr^-X^\^ '^ lOO'i 

A.VVA dct\-L| Deputy F?c;;;th Officer 

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

Certificate of 2)eatb 

PLACE OF DEATH: — County of 0£t>X' .^Ow^vcv^^t City of C'aov J.^Lawc^<t^o 



No, llb^ 







iL Civ. 



St.; 



D 



Dist.; bet« 




and 



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



FULL NAME 



s}:x 



Q^ 



PERSONAL AND STATISTICAL PARTICULARS 

j COI/>R ^ I 




\ < 



X. 




L 



.UL.. 



DAil-: ()(•• lUUI'H 



AC. H 




MEDICAL CERTIFICATE OF DEATH 

DATK OJ* niAIII ; " 



llo 

(Dav) 



/.IH.5 

(Year) 



SIXC.I.K MAKKHav 






wiix >\\}-:i) OK ni\'<)is 


ii:i> 


iW'iifciii social (ltsi}.Mii 


ilicii) 


HIKTHl'LACK 




(State or Country) 




?fAMK ()!• 


(S 


FATUI'.R 


\ 




lURTHlM.ACK 


\ 


(^ 


Ol' I'AIIIKK 




(Statf or Coun(rv) 







bl Vtats "5, -, Mntiths ,M„ 



Pa vs 



l^v ., as 



(Month) 



(Year) 



I rnvRHHY CHkTIl'V, That F attendcMl (U-ccased from 

to r. 




r 




190 to ••■■■ ^■'^- 190 

that I hist saw h ~ alive on ..:..-.;..;.:;.,. igo 

and that dt-ath occurred, on the <latc stated above, at 
n- M. The CAISIC C)l- DI-ATFI was as foIl,,ws: 






(t-\J!i^^r>r\^yy^ 



t 




^. 



Lb 



;W^c{r' 



MAIDKN XAMl-: 
OI' MOTIIKK 



lUK TFIPr.ACK 
<>l- MOTHHK 
(Stall' or Coiuitrvl 




1)1' RAT KIN )'ears A/oui/is 

CONTRIBUTORY 



Days 



I/oit 



rs 



«.»:«■* •«-« » f k-iimt 4 *• 



Hours 
M.D. 



I) U R A T I O N J \\u'S MoNt/is Pays 

( SIGNED ) Lyv(r^^X\» L\h \}^.\suijOj>\A, 

'\l\(r\r b Tf)o S (A(Mress) L(rV(rvv^\^'^ Lgy.. /^... 

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



OCCUPATION 

R/'sideii in Sntr /'i am isrn I I )'»•<;»■>■ 



M.-nths 



Da 



Tin-: AT»)VK STATIU) I'KRSoNAI, T A K I' IC r I.A K S A R 1". TRIK TO TUl-: 

BKST oi- MY kno\vi,i:i)<;k and iii;iji:k 



Former or 
Usual Residence 

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



Now long at 
Place of Deatli ? 



Days 



(Informant 



(\(Mr<'ss 



1 tlv CI 



Ib^ 



XlMw 



I'l.ACK OI- lURIAI, OR RHMo\ AI. I DAJllof Mi kiai. or RHMOVAI. 

r N I) 1: R r A K H R v<X^^<w\r 



(A(Mre-ss 






N. B. F.very Item of Informiition should be cnrefully supplied. AGE nhould be stated HWCTLY. PHYSICIANS should 

state CAUSn OF DEATH in plain terms, that it may he properly classified. The "Special information** for iMir- 
snns dyin^ away from home should be (^tven in every instance. 



! ! 



I 



*'*'>..-'••**•*»» 



li!i 



iiij 



1 1 



I 



I 



{i 



! 'M* 



I 



I ^1 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



};-n.N.f n. ;i:t}i l \'.> ,-. t-^^^^H8cV Cn 



l)(f(r /'V/r^/.ll(lcvU.^xiv^ '^^X 



dv^LCu^ 



1. 



''\>^,. 



lith OfTlcer 



Beglstered JYo. 



3397 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



•^ 



Cettificate of 2)eatb 

( ■«. S. Stan5ar& ) 



2t "VI' ~\ *m 

PLACE OF DEATH: — County of*^ Cu>^ d;v<V->vc\.^c<^ City of^J^'^'vv 0-n.o..-y%cv4.cc 

vJi^ ,1 



St.; H 



(IF DCATH OCCURS 
IF DtATH OCCU 



Dist;bet. 5 t>k- 



and 



fc JL 



i-m 



'J». 



s AWAY FROM USUAL RESI DENCE GIVE fac 



RRED IN A HOSPITAL OR INSTITUTION GIVE I 



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



FULL NAME 




^ 



hJXXJL... 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

cor.oR 



\^ 




VI 



LKvti- 



\ 



DATl-: nl- IlIRTH 



AC. I-; 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATFI 



t ' 



I 



<=>* 



(Month) 



U 

(Day) 



190 n 
(Year) 



(Month) 



5^ b JV,/;> 



vj 



'"^rxc.I.K. MARKTKn 

UIIX lUHl) OK I)l\'i >Kii:[) 

iW'titcin <<)ii;il (l<'-.ii.'n;it ion) 



u. 



%5 

(Day) 



M.'nUis 



,7.iHj: 

(Year) 



A/ 1 -X 




v.<x\,\.<^wcL„ 



lUk'rul'I.AOK 
istiitf in- (.'..llllti v^ 



JSTAMH OF 

1 ■■ A I- n 1; R 



d /t^CruCo^'-t^cL 



190 
I90M 



I UliRI'RV CKRTIFV, That T atten.le.l deccasetl from 

y^^^ar. ab igoM to .... Qlujvr- Xb 100 H 

tliat T last saw h-^/^w. alive on v)"M5Vr JXVD 
and that tUath occurred, on the date stated al)ove, at 
U M. The CArSi: ()1< DliATIl was as follows : 



% 






fc 






JL.OL': 



niK'niri.ArK 

0|- I-AIMII'IR 
(State or Country) 



M.\II)1:n NAMI-; 
Ol- MOTHKK 



lUR'l'Ul'I.ACH 
OF MOTHFR. 
(State or Country) 





? 



OCCUPATION 






l/C(PIa 



DrR.ATION }'rafs -Months 

C () N 'i' R I IJ U T ( ) R V ......„.^..«„..„.^„.. 



nrR.ATrON Vi-ars Mont /is 

(Signed )_„,S^)rvcui .[a...O cujX 

vrv^iv ak: ic,o'- 



Days 



I /ours 



Pi 



/^<7 J'.9 



CLl^V^*^ 



(.Address) "its \1 0-L<l(nAv H 



Hours 
M.D. 



Rfsidrti ill Sail Fiain/sYo OV )Vw/ ^ 



SPECIAL Information only for Hospildls, InstituMons, Transients, 
or Recent Residents, and persons dying jway from home. 



Former or 
Usual Residence 



How long at 

Place of Death ? Days 



U.o,//l< 



/>(n. 



THl': AHOVK STAri:i) I'KKsoNAI, PA R f IC T I. A RS A K !■: PRl K To TH)\ 

HFsr oi' .MY K.xo\vij:i)('. K .\Ni) nFMi;»' 

nfotmant vOjL^V;?A,A^/^^JC 0A^< 



(I 



fV.l.lrt-^s 





^--y^ ' 



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



I'l JlCK OI' IH'RIAI, OR RI:MoVA1, I l)\rKof MiKiAi. or KKMOVM 




■h 



INDKKTAKKR 






IN. B. F.very item olt informntion should he carefully Hupplied. AGB Hhoiild he stated KXACTLY. PHYSICIANS should 

state C.4USE OF DEATH in plain terms, that it may he properly vlassified. The "Special Information'* for pwr- 
Rons dyin^ away from home should he ^iven in every instance. 



I 



' I 



H 



k 



.41 
Iff- 



il-i 




y 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'..:tr.l ..f II,' !ltti »■• No. 



■=r;-St:. liSil' C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



A 



nJOH 



Xtrvv^5 ixa-v Deputy r!c.a:th Officer 



Registered J\^o. 



3398 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

PLACE OF DEATH: — County of Cj cc^^ oXO^>vc^4,^c City of '^'/Cua'v ^^VccA^euLco 
No. XO^^xJl ('U)e-<i-^,-v^\0..l St.; ■- Dist.;bet. and — r-r- 



n 



(\r DtATH OQCURS AW*V FROM USUAL 
IF OEATH OCCURRED IN A HOSPITAL 



RESIDENCE GIVE fac 

OR INSTITUTION GIVE 



:ts called for under "special INFORWATION' \ 
ITS NAME instead of street and nuvber. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



HKX 



(Uc ^ 



cvU 



COI.OR \ 

^.lOJxctx 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



I).\ PK oi' r.IK 111 



^. 



1 Month) 



(Day) 



./1^..0 

(Year) 



A t . 1-: 



\\ 



}>0tS 



% 



Mituihs 



IS 



Da r: 



(Mouth) 






a.. 



IQO 

(Year) 



STNT.I.K. ^fARK^^I> 

iWriUiii social (!i»-ij.'iiatioii) 






iuHTHPi,A(M-: 

(^Stalf or Coiiiilry) 



FAT II ):k 



lUk'lIiri. ACK 

OI- i-aiiii<:k 

'State or (.'oiinti v'' 



MAIDI'.N WMK 
0»- Mo'lUHK 




CJ .\jy\,{ 

? 



I IlKRHnV CKRTrrV, That T attended dcrcasod from 

..-.iy.ct XO i9oH to ...... uVffV- ....'Xa. icp ^ 

that I last saw h v-vry\ alive on \i L0>J*....^n up ' 

antl that death oceurred, on the date stated ahove, at O 
.LL M. The CAI'SIC ()1- FlPIATrT was as follows: 

LoxX.lrVa,!'. Ccri 



,\,A^^\^<9nc\^. 



. .-XUi^^s-fOijtw^-^^-.-uaL. .'A»-.:y:v ^X^JlX^^« . 







ni'R ATrON \^^s X ■ AfoHihs i."*. Days 



Hour 



itiKinpr,ArK 

OI" MoTlIKR 

(Stat* or (."outilry) 




cIc\>XCOj 



OCCri'ATION J 



C()NTRll!rT( 

duration 
(Signed)..... 









.^foHt/lS 



?C 



navs 






Hours 
M.D. 



Ul^P.r- '^1 i()oS (Address) illH X^X'V^v^oloLl'vo ,)t. 



I\f>idfd ill Sail /'i ii III isfo 



) V(M . 



M.'iiths 



I hi v. 



SPECIAL INFORMATION «"!> I(»r Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 

Former or | . n i l' ,1 i^ How long at ^ 

Usual Residence wCM!rdwL<X A xC«v. V^ a » Place of Death? ot Days 

When was disease contracted, "^14. ^ 

If not at place of death ? *.' t- ,\X' b in C H 



Till", AHOVK STATi:!) I'KkSONAI, V \R lUMI \KS AKi; TKrK To rilK 

in;s'r oi" my know i,i;i)r.K and iu:i,ii:i" 



(Infoiinaiit 






ri.ACH OI" BIRIAI, OK K!.Mo\.\I, 



i)\ri:o:' Hi HI. A I. or ri;mo\ai. 






190 H 



N. B. F.very item of infornuitlon should be ctirufully Hupplietl. AGK Hhoultl be Htntetl EXACTLY. PHYSICIANS should 

stnte CAUSE OF DEATH In pinin terrtiM, thnt it may be properly ciuKHifiecl. The '*8pcclat lnform»tliin" ?or p«r- 
Rons dyin£ away from home Hhould be (^iven in o^cry inntance. 



<:l„jr 



«5^ 



ft 

?- 



r»i 




I I 



ff# 



I -I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IV.ard of Il-alth - )•' No. i =; t-^'W^^ H& 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc /v7rv/A(l.(r\M^-rvlKOv.' X% 



190H 



lle^istcrcd J\!*o. 



3399 



i 1 



^j^^. Deputy FJccith OfTlcer 

V 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(^ 



Certificate of IDeatb 

( 11. S. StanOarO ) 

PLACE OF DEATH: — County of OCLA-^ J^VCL/^-vSUUiecCity of /Cv^ v 3 A. cx-v a^cv^ c^c 
No. b^O (lll\a.u.^A. St.; ^ Dist.;bet.wA,CC}V<X'-kA.a.lv.and cLCVOAv^-X'^ 

/ .r DCATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLtD FOR UNDER "SPECIAL INFORMATION ' • \ [\^ 
V irioEATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



LIxOLcL 



sj:\ 




PERSONAL AND STATISTICAL PARTICULARS 
r\ 1 COI.oR 



XoXx 




.IvvaJul- .^.^ 



DATK «)!• lilK III 





%\^ 



c^^a- y\i),a^.^.vc 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH A 

_...„ M\c\r X\ 



,(3vr 

I Month > 



A«'.H 



I lit » .» 



(Day) 



Mnulhy 



./.^O.M...... 

(Year) 



Pil V 



si\(.i.i:, MAKRn;i). 

W IDnwivD OK l)I\'<)R(i:i) 

'Wiiliin K(K-i:tI (l(si).'ii;it ii iti) 



'^■^rV' 



HiK run, AC1-: 

(St.itr or •'(iiiiiti y) 



XAMi; oi 
F ATI! IK 




0i> 



(Montli) 



(Dav) 



(Yf.-ir) 



I III':ki;HV C1';UTII'V, That r atU-iKKMl deceased from 

Qx^ :..;: 



X9Q 



to 



til at T last saw h .r'ST-r-', alive oa .s^stsrswrt 



190 

T()0 



ami that death orciirred, mi the date staletl ahove, at 






M. The CAlSlv Oh' DIIATII was as follows: 



d-tJLi y^ CrV>x> Ufx\,vi.\.. <:LC-ivx-4,N«4..d....\h r.~ :.'• 



lUKTflPT.ACK 
OF" 1 AIIIKR 

(State or (.■()mitr\') 



MAinT'N NAMK 
ol- MoTHl'.K 



MIKTm'I.ACK 

OI" M()Tm:R 

(Slatf or (.■oiinliy^ 



OCCri'ATION 







..;a.ti.H JiA%M...S...'^ <3Ct alnm^t kdl 

DC RAT ION }Var.\- Months Pays J louts 



CONTRIHrrORV 



ry\^ 



DTRATIOX ^ Years Monf/is /Javs Hours 




/\'r-i(lr(f in Siiii f'l iiii, I'^ro 



) >(7 ; 



M.oithy 



n,n 



(Signed) AJXCrVo^ ^>- ^-vb JL^^^k/vto^. , M.D. 



p.A J( 

(Address) ! C) i^ H l\t^i^uO\ jl 



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



riii'. AisovK sr \'n:i) i-kksonai, i>ak iuilaks aki-; pkih m rin-; 

H1%ST OI" MV KNOWLJ.DI". K AND ni;Mi:K 



f Illl'o;iii:mt 






fA.l.li.-ss 



W'X'h 



Former or 
Usual Residence 

Wfien was disease contracted, 
if not at place of deatti? 



How long at 
Place of Oeati! ? 



Days 



I'l.ACK 01 lU RIAL OK K}:Nro\AI, I DA Ti; r)t IUkiai, or KKMoVAI, 






190 



'\ 



rNi)i':RTAKi-:K J^foL-^tX^'v oU-oiA,K^ 



N. K.- 



-F.very item of informjition hHouIiI be cnrcV'ully Huppliecl. A(iB shoiiltl be stnteci BXACTLY. PHYSICIANS should 
• tatc CAlJSn OF DEATH in pliiin termH, thnt it may be pr<»peply clusnifietl. The "Special Information" ?or p«r- 
«on« flying nwny from homu nhniild be Jiiven in every inHtance. 



1^ 1^ 
w 



I - 

f 



1 



l\ 



J 



f 



Il 



If 






I 



I 






^i I 



It 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Heard ',{ HtaUii- I- No. i> '*'-?;-.^i^»5 i^^^' ^-'^ 



!)<(/(' Filed , 







^iyJLK'Xl 100^ 

P^^^.ti-v/ t ■- .^ Officer 



Be mistered J\^o, 



3400 I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( U. S. StanDarD ) 

J? QD ^^ 



Q^ 



PLACE OF DEATH: — County oi^O^'^^ 4-MX^1w£a^cc City of d.<X/:ry J^Vo^>^cwi.C(. 



' No.0 % Xlc IvU UO CH^KvlouL 



St,; 



Dist.; bet. 



and 



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



FULL NAME 




.Yy\JU. 



iLlL 



^'^ 



^D.toljUwa. 



rf 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 



"^l 



Ol' 



COI.OR 




^vv 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 



DEATH A 

..:...,... \Jl 



DATK <)!•• ItlKTII 



1) 



(M(.mh) 



IH /laa 

<Day) (Year) 



AC.H 



} Vt/ > s 



II 



Miitil/i.\ O Diiv.', 



SINCI.T-:. MAKklKD. 
WIDdWKI) OK DIVoKiKI) 

•W'ritt'iti ■ic>ciril disiiJiiation) 



lUR'nn'i.ACK 

( Statf or Coutitrv* 



NAMl". ()!• 
I' ATIIIIK 



lUR TTIPI.ACE 
<)»• IWrUHR 

I S(at<- or Country) 



MATnrv NAME 
<)I" MOTHER 



IUR'niPI,ACE 
OI- MOTHER 
(Statf or Coiiiitrv) 



VO^TWU 



(Month) 



(Day) 



(Year) 



I Mi:Rl<:nV CI:RTIFV, That I attended deceased from 

— . to ...nrrrrrrr--— --r-r-r 



19P 



IQO 



that T last saw h : alive on :..:..."-....-. itp 

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



■\^■ 



M. The CAISI-: OF DlvATII was as follows 












1)1" RATION 
CO 



}'n7rs 



,^ 




NTRIUrTORV VjiiA^ ,k.viNX 



Mouths Days /Joins 
?SL\..<rY>j..A/:rv...(rrvA-rnJL.. wkt 



DIRATION 



Vrars 



Motiths 



Davs 



I lours 



( Signed )...Ur.'\<r>xlKi J. Vfc. U^)XLlaA\.d^ M.D. 



c VjUkLo^m 



Miu^-o 



occupationQp^^^^^ 



Vl\^r 



0^1 



T()0 



C\d<lress) 






Vfr^vlXA L 4 






SPECIAL Information only for Hospitals, InstitutloVJ^, Transients, 
or Recent Residents, and persons dving away from fiome. 



Kf'.^iJr'if in Sdll /'l i! Ill /\'i') 



) \<1 1 



\ I nil 111 ^ 



fhn 



THE AHOVE STA'n-.T) PKRSONAI, PAR riCf 1,A R S A R I-; TRIE To THE 
MEST OI- MY KXOWI.l'DCE AND HEUlIvK 



(Infoiinant 




•^ 






O O-tr'UUvw., 



x.Mrr^v v)x<wl^y^'^%JlAJnJLLl \jyJ... 



Former or 
Usual Residence 

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



•L HP "o»* Ion? -t 

. v),UJAyVwi^nXU. ..yX'.. plare of Death? 



Days 



PEACE OF nrRIAI, OR REMo\AI, I I)ATi:of HrKiAl, or REMoVAI. 

INDl-RTAKER UVD . J . aA.^J(\.^.' ""^ Lc 

(Ad.lress 1 i 'i^ ^n\A>i/XA^>V *jt 



!N. B. Every Item of in?ormntion 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 psr- 
son« dyinft away from home should be (^iven in every instance. 



> I 










\ 



! I 



il 



iif £ 



( I 






It 




11 'Ml 



(I 



I 



i 



WRITE PLAINLY WITH UNFADING INK 

Boar.l ..f II.-.iHh I Vo. i «. ■^•^^^^-^ USiV Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hf/r /'V/rr/,^<iv..c^mi>XV 1% If^OH 



RegLstci'ed JVo. 



3401 



CVi 



^ 



trx^o .Uvvu Deputy l-Iaaith Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of S)eatb 

( 11. 5. StanDarC> ) 

PLACE OF DEATH: — County of OO^^rv.' OA.CU^ve^.xi/Ci: City of Ocl^ia; JAXV>-vC\_<i,Cc 

\ } (? 

No. \%\\ \ayCi\.si-^>v St.; A Dist; bet. cUx vKv./v\... and ^<i^' 

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

FULL NAME J.^.^:r:nx<x>^ . X'. Hctr>\M. 




IF Dl 




SKX 



F)\ri-. ni- i!iK rn 



PERSONAL AND STATISTICAL PARTICULARS 

COI, 




m 



2) 



uoJ 



^jXi^ 




^^..llth) 



AC. K 



4^ 



\'tiii . 



II 



n. 

(Dav) 



M.>ti!hs 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol' I)l-;ATn 

.<ro" X\ 




igo'i 

(Year) 



(M(nilh) fl)ay) 

I Hl'RlU'.V CIvRTH'V, That I attenckMl <lcccase(l from 



IH 



/VV.S 



SIXC.!,!:, MAKKli:!). 

\vn)Mwi.:i) ()i< i)i\< iKTHi) 

(Writ'' in <(>oiri1 <U'-i).''"atii)ti ) 




\<xwouL 



^ 






nTRTFIPT.ACK 

f Statf 1)1" Country) 



XAMI'! OF 

1" ATii i:k 



niRTHIM.ACK 

oi i-Ariii:K 

(Slalf or Coiiutrv) 



MArnj-N; vamp; 

(»i .mothhk 



lURTIIPLACK 
<)I- MoTHHR 
(State or Country) 



OCCUPATION 

AVMiff'd ill Siiii I'l ,iiiii>f-<i I 1 5^-,7/>- 




190'i 



to 



[v: 2Lip.. 



icK) H 
that I last saw hews alive on .......\O^I^^....3^v Kp'i 

and that death occiirrcil, on tlie dati- stated al)ove, at 1 ■^. 
M. The CAl Slv Ol' DI'.V'PII was as follows: 

LxX^.^Oc^OL.trvvA.'OL' Crt- LL>AiJt^-^^<5^^...JJyJCLU• tl 

U..Lr>:\\XX.«.<i\i 





DL RATION ^Ia Years Mouths Days 

CONTRIIU'TORV ....,....„.._^ 



Hours 



/)avs 



I )r RATION }'t'(rrs Months 

.NED ) Mr- 0l:)-£/>WM,^<wivd 



(SIGI 



QJ 



\\U\rX% HpH (Address) ^HO acctU\. Jt 



Hours 
M.D. 



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



Former or 
Usual Residence 



Qi<y^ it 



How lonq at „ 

Place of Death? < \ 



Days 



M.-uth^ 



n,!\. 



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



THK AHOYK STATl-.I) I'KRSONAI, I'AKTUr I.AKS A K l- TKrK To Til)' 
UKST Ol' MY KNO\VIj:i)C.K AND in:Ml,F 



(IiifoMuaJit 







PI.ACK Ol- lUKIAI. OK KI.MOVAF, I DATi; of IMKiAr. or KFMOYM 




(Address H^^ "VJo-LcLt^rv uoJLi. LL 



1901 



AJSri. 



^. B._P.very item of information should be cnrefuHy «upplied. AfiG •hould be stated EXACTLY PHYSICIANS .hould 
•tate CAUSE OF DEATH in pinin terms, that it may be properly classified. The Special Informatton" for per- 
son. dyinft away from home should be ftiven in every instance. 



«^ 



f% 



i m 



? 1: 



I- 



tv 



• » 



♦'I 

'11 



• I 



1 i 



! r 

1 






n, 



i 





m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IV ,:,!,' . f M. :.'th I- Vo 



n -^^^^^ V.^V (•' 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da/r n/cd , MLrjotmOlMA) 



n lOO'i 



Begislered J\^(). 



8402 I 






Deputy Keaith Ofncer 



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



Certificate of IDeatb 



0^ 



PLACE OF DEATH: — County of Q/Ct^^; X<Xo-ccui.o_ City ofCJ/CXo^ J .\xx^vcaa/C^ 



kl4e. 0.'V)- W^LtlvAvA (j^Cnv..A 



St.; 



Dist.; bet. 



and 



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



FULL NAME UJ.X/U\JlWx^:^-vo. 




I) \'l i: n\ lilKTlI 



PERSONAL AND STATISTICAL PARTICULARS 

COl,r>R 







MEDICAL CERTIFICATE OF DEATH 



DATE OF 1)1 



A<". !•: 



is 



)'t(tt s 



H 



(Day) 



Months \).. 



/la.; 

(Yeur) 



'.S. 



!"■ Qi 



c\r.. 

(Month) 



(Day) 



(Year) 



/hn 



'^INT.l.i:. MARKIl'IV 

Wlix >\\J".I> OK 1)!\< iRii;i> 

iWiittiii >-<.ri;tl cl< si<.rii;iti'iii) 




XcLtyVV- 



lURTIU'I, \<'i-: 
' stall or C'lunliy) 



NAMl'. OF 

FATm:R 



luuriMM.Ari', 

(State Ml I'oiiiiti v' 



maii)i:n namh 

<>J MorHFK 



RTRTHPT.ACI? 

<)l MoTin-.R 
(Slate or C'cmntry) 






J 



p u 



i 



^d 



T IIi;ki:nV CHRTIFY, That I altciulfd <1ecease(1 from 

Ji<Uw3-ww i up'-. to yX:CVr. %Xt. I90 - 

that I last saw li-^^.'.. -alive on VV^^ X,k 190 '1 

and that (Kath <Kciirre»i, on the ilati- '-tatt-ij ahovc, at * 
M. The CAlSIv ()!• I)I':.\'I^H was as follows: 

Lil^(^"i^J(jL"u-i. ..,...„«..„,.... 

TM'RATTOX Vears Months , •-. i^fef^ .4, Hours 

CONTRir.UTORY LWLi.N.W0 . a^cLL^u&^l^ 



? 



K 



OCCT'I'ATrONrrU 

Kf^iilfii III Sail /ninrff^O 






t 



Vfars i'lA tut /is / hi vs 

TCK»H ( 



1)1' RATION 

(Signed) Lv nrw^ \\b -o^a^i^^w^xx Ok.\..L,^ , \. 

VM\r...3v'l TooH r Address) C^ '>»-SL.tyxA4 U^M^^j 



//ours 
M.D. 



H4 



y^ars 



M.'iitli^ 



/),; 



TIM': Auovi-: ST \ii:i) i-kksonai, r\Ki h( i.\k> aki: vkvv. to tiik 

llIvST OI- MV KNOWI.I.IX'.I'; AM) Hi: 1, 1 1". I-' 

(Info;, MM Ml MrVV0U>V>X.Ow Vl /XilVy^^' 



\,Mn-^s SOl CXtrVV 



Special Information only for Hiwpitals, institutions, Iransients, 
or Recent Residents, and per^ons dyinij riwdy from tiome. 

Former or ,a'lA i I '\l Hoh lonq at 

Usual Residence 1 ^ I A s) /'VU.Lavyj OX pjare of Death? » '^l\ Dsys 

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



I'l.AlK 01 Ml KfAI, OK KI:Mo\ AI, I DATKn! Uikiai. or KKMoVM 



'\ 



17 



I NDl.KI'AKFK 

(Adili CSS 






igo'i 



N. B— livery ltc„, .i •.„.'orm,.f.on hHouI.I he carefully «uppliecl. AGK f "!;•;«;;''!;" ^ , ^"^^'^'^n* •»»0"'<' 

stote CAUSf: OP DIATH In phiin ttrmn. that it m»y he properly cla.iilfled. The Special Inforaiation" for per- 
son* clylnit away from homo nhouM he liiven in every InHtance. 






if 



If! 



I, 



Ik 



^1 !i 



i. 






'HI 






II 



WRITE PLAINLY WITH UNFADING INK — 



■ 1 115.1 ... i - . ■ . »*. ^ii - ■*- ' 



THIS IS A PERMANENT RECORD 

REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffr /v/fv/, \j1(jv*-^vvvImL\. Xl 



1*^ #* *% » t ■f' • J 



/,96>'^ 



:jniccr 



Bei^i.sferod J\^o. 



3403 I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 



PLACE OF DEATH: — County ofC)ct'-»v 



( tl. S. i?tanC>arD ) 

l^.c^^xcc^cx City of a.<X^ ivo^cv^et) 



(^ 



No. ^JXt'>XO^\' 




D^4-kA.ta.l? 



St.; —■ Dist.;bet. 



and 



■j:f I ■" \ 



( 



..CMAI RFC;iDENCE GIVE FACTS CALLED FOR UNDER •'sPCCtAL I N FO R M AT ION" "^ 
,r DEATH 0---„7-;,"rHo''s^Pa'iL Tr^N S T^^u" ^N O . V E .TS NAME .NSTEAD OF STREET AND NUMBER. ) 



IF DEATH 



FULL NAME 





-X/XK^L^iu. 



I 



PERSONAL AND STATISTICAL PARTICULARS 






COI.OK 



.LiKctjL 



DA ri". t)i- r.iK 111 



(Month' 



\ ( . 1-; 



5^ >'v;a 1 



It 



M.oilln 



■7I.T.X 

(Year) 



n 



/)(n 



^IN<.I.I" MVRKII-'.n 



u iixiu i-:i) OK i)!\«)Kri:i) 



HIKrmM.AOlC 
(St;it« or Country) 



NAM]' 01 
FATHl.K 







lURlH J'l.ACK 
<>!• lAPIlHR 
(Statf or Ccnuitry) 



MAinitN NAM1-; 
OF MOTHl'.K 



V<X >VCL CLCL 




-vex 




d^^J^' 




RTRTIIPT.AOK 

oi" MOTIllvK 

I Sl;itc or cN>\intry) 



!L<x^ 



'"v^cL. 



occi 



'PATlON(Jf\p 



! liH 



Rfsiiifii in Soti /nni.i.u'i) -^^ ^ >" ■ ' 




Mnulln 



n.iv^ 



THK^m.VKS•.^V.M^n.M.K«.ON^. PAKTU-t-l.AKSAKKTKrKTu THK 
HKSTOl" MV KNOWl.l-.IX.l-. AM>J«''''''* 



'V>. 

.foMu.n. M^Vvo Uj^v '3x\^^ 

(X.Mr... I^a^ JA.C<xt II 



\M,. 



MEDICAL CERTIFICATE OF DEATH 



I) 



ATI-: «>!• i)i:\rii A 

vll 



(Month) 



a.i 



IfyKf 

(Day) (Year) 



I lIi:Ri:nV CI-RTIFV, That r atteiKkMl (Icccasod from 

.ix^^xt iS 190 M to .... W- ...M np 1 

tliMt T last saw hJi^ alive on VA-O^^.- .1^^ -..• np • 

an.l that death ocourre.l. on the date staled ahove. at i 
UL M. The CAISI': Ol" DIl.XTIl was as follows: 

CLl^^Xav<LcCi.tus ■ 

' ...QJ^^M^J:xl^^^ VK^. f^ 



r 



DlR.xriON }'tajs 
CONTRIIU'TORV 



Mouths -' /></;'.? 



Hours 



iMotitfis 



/)avs 



DTRATION ....'-. ^ .-- - 

( SIGNED ) WIvrt Ih. .MXQj%idJS^ 

(h.f\" %". rrfn'^ (Addnsv) I Q D ?> U all. \ vCa-0> HI 



//out s 
M.D. 



SPECIAL Information on'y *or Hospltdls, institutions, Transients, 
or Recent Residents, and persons dying dwdy from tiome. 

former or ..,J, L \^ ""^ '»'"' «' 

Usual Residence 1 C S U a..U>-^OL<v '.)t 

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



\. now lunij til 
/>vOV<L .)* Place of Death ? ID Days 



DAII. ot" Hi KtAi. or kI';\U)\'AI, 



ri.ACl-: Ol' IMKIAI, OK KKMoV.M, 

(Ad.irt-ss 5)H .i <>j^yuJjL M 



TQO 



IN. B.- 



' — — . f..iiv «unnncd AGB should be Htatecl EXACTLY. PHYSICIANS should 

-F.very Item of in?orm«tlon hHouIcI be cHrcVully ^u»>P'"=;'- ^^1^- .lag^hled. The •'Special information" for pT- 

«tate CAUSE OP DEATH in pinin terms., that it mny be properly clasH.neu. 

(,nn« dyinft away from home should be feiven in every mstance. 



' \\ 









i 



r' i 



% 



!^1 



if 



I 4 



"I 



m^ 




WRITE PLAINLY WITH UNFADING INK-THIS rS A PERMANENT RECORD 

^^-v .„,.,. REFER T O BACK OP CERTIFICATE FOR INSTRUCTIONS 

3404 



-Imik; 



I90'i 



llc^i.slcrrd Xo. 



i^x.u^'iU'VKf Deputy Hcailh Officer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of E>eatb 

, U. S. StanC>arD ) 



PLACE OF 



DEATH: — County of ~'n^vu O-fUX-^x-cvAcx City of 






No. ^5 4'i:l 
(' 



■ H.tl St. S Dj^;;^^et.„^„^.^irr.o-jl.i'T^ 



FULL NAME 



^..LctKxLd. X^^-^li^^' 



'ERSONAL AND STATISTICAL PARTICULARS 




•HX 



DAii; tti niu Til 



AGK 



(XX 









iMoiUh) 



1 

'Diiy 



US ,v.,. n .v„w.< 1 1 



(Year) 



Da r.v 



«*INt;i.K, MARKIKn 

WinoWKD OK DIVoKiKl) 
iWiitr ill social lU sii.'tiati<>ii) 




HIKTlirUAi')': 
iStati- or Oountry 



•1 



( 



i' 



.<XWOL^ 



X>'VA^\cx,\,n 



i- ATii i;r 



niRTHPTvAOK 
OI- 1 ATIIF.K 
UState or Country) 



MAIDKN NAME 
OF MiVrUHR 



X 



X 




'\^ 



TUR'rnri,ACK 

OI' MOTIIHR 

(State or Country) ^^ 



OCCri'ATIOX 



<?, 






)fo,ltll^ 



!hn 






„„„,„.„„ Qiw %^U^-^-^t^ 

(Address €^0 T l-^ * ^^ ^_____^_^-— — — — — — 

^_^—i— ««———— ————"^'— "—"■^ _ , ... -tateil EX4CTLY. PHYSICIANS should 

state CAUJ^L Ui "'^''» ' ' .„„i,i k*. «Mven In every inRtonce. 

sons dyinft away Prom home should be fe.ven m e e y 

I 1 1 m i m mmmmmiiltUmtltiimmmmmmmmmtmma 



MEDICAL CERTIFICATE OF DEATH 

•H A 






(Mouth) 



Ik... 

(Day) 



(Year) 



I lII'RlUiV CI':rT1I'V. riiat r attciKkMl clcccased from 

W>V 190;^ to .... 0XC\.- a.b. igoH 

thMt T last saw h <■ • ' alive- o,t Ox^T %S igO-l 

an.l that .Icatli nccurrcl, on the .lato statc.l al.ovt-. at • .' 

- M. Tlie CATSIi m" Dl'lATII ^^■•«s as follows: 



Vj J\X^:i VA-^V^ 






»v«'>v<^ 



tw6. 



Ur RAT ION J''*?'-^" 

CONTRIIUTORV 



O 



Months Days 



Hours 



\^ iysJju^'y:'^\.<^^:Sr^Mj. ......;« 



Hours 



DTRATION I >V'i/5 ^\ Months -. ■ Am 

( SIGNED ) b.....L, yl^U^'^.-^ ■••■••;•■ "^-D- 

CllcAT a- ,90^. (A.i.irc.ss) 1^0^ oi^<^i^i-^>v ^^ 



SPECIAL INFORMATION only for Hospitals, Institutions. Iransients. 
or Recfnt Residents, and persons dying away from fiomc. 



Fornifr or 
Usual Residencf 

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



How lonq at 
PUce of Death ? 



... Days 



DA'll'.of F'.iKiAI. or RKMoVAI. 

Ol-cv-.a.^ T90M 



V\ \CK OF lUKIAI. OK KKMoVAl, 

INDHRTAKKR ^l- ^ O^t^^W ^ 0_^ 

(Address U '^l VrXu3.^V^>V 3 t 



n 



% 

i 

11 

1 

Hi 

I* 

V 

I i 



. I 



;i» 



til 



h^ 



i * 



11 ill " 



II 



11 



WRITE PLAINLY »1TM UNF.OING INK-TMlS IS A PERMANENT RECORD 



I , ,- H, .Ml, 1- N., ; ^'t^?*?^- 1'^'*''^ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)/ff 



r AV/^v/,M^l(^>--€>^vi[viLrv Xl 



IfJO'i 



lie o'i stored J\''o, 



3405 



1m..., liAVM Deputy HeaUh Officer 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

I ■a. S. StanCarO ) 



jp (^ 



PLACE OF DEATH:-County of rW^'^vC^-c-^c - Gty of a^^~3A.a,>vc^-o 



N 



t.; 9. Dist.; bet. JVt-a^v^ 



C-Cu.r.i.; .ROM USUAL «^S70.N« C,VE;.CTS C.LLE. ,^0^R^ U^N__0 E R ^^^-^-JJ -° -.'r." - ) 



O.TDl,klOcV<v!xLV.q'. • . „„^OENCEO,VE .ACTS C.LL.P 

( ■' :roi"..i"T..To\'rr.^s%'^^^': ^^%i...^>o.^^^^ .ts name , 

FULL NAME '^^^ ^^-^^ 



fl. 



I 



y^ and .L^-CvV^xr>x.' 

STRt^: 



i 



) 



/VLQ, 




I 



^ 



SKX 



PERSONAL AND STATISTICAL PARJICULARS 

I CUI.DK A 



QXccL 



^<r 



DATK nl lUK in 









AC.K 



3^ 



) V(// 



( Day) 



M.nitll.^ 



10 



(Yt-ar) 



A/1. 



WinnWKl) *>K niVoKiM> 
Writtiii MK-inl (UsiRnatioti) 



MEDICAL CERTIFICATE OF DEATH 



DATE «)1 DHATH A 

\jl^ 



(Month) 



(Day) 



(Year) 



I HHRKBVCIIKTIFV, Tliat I ittoiukMl deceased from 

" to ..rrr-rr-r-r... :. 



190 



ic)0 
up 



tliat T last saw h ..:^--^alive on 

and that .leath occurred, «>„ tlu- daU- •stated ahnve, at % 1.5 

(J M. The CArSfvJ^r I)K ATII Nvas a^ follows: 



HIKTIiri, \<*K 

I State or t'lniiUi V 



NAMF or* 

J A rm.K 



RiK rnri.ArH 

Ot" lArHKK 
iStalf or Coiuitry) 






AjLfi- O 



X>V 



'^l- 



c 



^1* 



MAinHN NAMR 
OI" MOTHKR 



HiirrHri.ACK 

OF MorilKK 
(Statt or iNmntry) 



^ 



^ M 

SJfS^'^i^O^ — — — 

OCCUPATION ^y^jj^^o^^^ 



/),M 



^™^ilS^^^Si^^ '■" '"^^ 



ll 



ii: 



(In 



,,„„„„, ^c^^ 'i ^^^ d^>v^. 



,,s,M,.<s TOb Ucccvluc -H 



i 









Ur RAT ION }Var^- 
CONTRinrTORV 



Months 



Pays Hours 



DI'RATIOaN 



Yi'iU's 



, MoNihs 



Pays 



(SIGNED ) .sJ./.V^VS^'W1^wr,u....x. .^-^j -^-j 

OlcNr ^5 n>oH (Address) bCt dxctUh^ 



.Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals. Institutions, Trdnsienls. 
or Recent Residents, dnd persons dving anay from fiome. 



Former or 

llsudi Residence ....,..»..-".••. 

Wlien was disease rontrartflt 
If not at place of death ? 



How lonq at 
Place of Death ? 



Days 



DATI,^.)! Ml in.Ai, 01 RICMONAI, 
'-U^C i 190* 



ll, ol 

i) 



I'l \CE OF HlKFAl. «>K KI'MoV Al, 

(A.Mrc.s n5cAi.a.cv,if^c 3t 






^3^< 



,/*-- 



K' 






1 < 



& 



ri : 



1 



' \ 



..^^^■^■■^M IB— ^i"^"-"""'""'"" J f-XACTLY PHYSICIANS should 

SE OF DEATH In pl»m terms, that .t m»> |>« P^ » 



!S. B. livery item 



■liHi 



mw ' 



tr^ 



/ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

r^X'^'^-^-Uf^y- ^^^^^ ^^ ^^^^ ^^ CERTI FICATE FOR INSTRUCTIONS 



Co 



■lmA« 



4'' 



Ea^isfcred jVo. 



3406 



>„/,■ /••///"/, \K<nMy>^UMA' n '■^'^'■^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeath 

( tl. 5. 5tfm^al■^ I 
PLACE OF DEATH:-County of^a.v J,Xa>vc^<.ec^ Gty of '^'ru^ ^^ .VCU>vcu.cc 



No. IICH O 



A\ f 4 <;f . \ Dist » bet. \<xck<l ^-^ .. and O^Cclv: 



rVS. ) 



FULL NAME 



1 



Ub-^. UAA.-'n'N.: 



I- 



]!■. 






# H 



<KX 



PERSONAL AND STATISTICAL PARTICULARS 




COI.oK 



DAIl-, ol- HI Kin 



AGK 



9f8 )Vrtf.v >5 






Month- 



/1^5 

(Year) 



1-. ^ 



/>in. 



SINC,I,1" ^T.VKUI^■,I> 

\vii)( »u i:i> <»K i)i\t >Kr i;i) 

( Wi itr in -.'.(i;!) (1» >-ij.M>;itii'ii) 



•in 



i i 



"I 



l! 



ill 1 


H 


II 


i 


1 1 


, ^1 


H U 


Hl^fii 



mKTin'K\OK 

(St.'itf or Country) 



MAMF. Ol' 

FA'rni:K 



HIK'niPUACK 
()»•• lAlllKK 
(St:it«- or I'onnti v) 



MAnn;N NAMK 

<)I- Mo'I'Ml-'K 



nTRTTTrT.ACI? 

()!• M(>riii:K 

(Stat.- or foniitry^ 



,^^/>^aAJi 



CI 



MEDICAL CERTIFICATE OF DEATH 



DAll-; ol- Dl.ATIl > 

\iW 

(Month) 



.Ala.. 

(Day) 



%j 



(Year) 



rni*:KI':BV CI:RT1PV, Tliat I aUen.UMl .lecvascd from 

to ..: --' 190-—" 



190 

~- alive oil 



190 



that T last saw li 

nn.l that (U-ath ..criirre.l, on Ww .latr <\aW^\ above, at rrr^ 
.3 M. The CArSI'! ni' DI'.XTII was as follows: 



-^ 



? 

r 

r 



C, 



1)1 R.xriON Years 

coNTRinr-rokV 



Months 



Pays 



//oiii < 






(SIGNED) 



Pavs 





VN^'>V0L' 



om^PATION 

Resittf({ III San 



d^^oJo 






M.n/tin 



/>,n 



TMK AIU>VKSTATKI) I'KRSr.NAI rXKTHM-LA 
IJHST OF MY KNi)\VI,i:i)<.h AND Hl.Mll 



KS AKi: TKII-. TO IIN-; 



(In foi nianl 







IIoHt s 

M.D. 



^\r^^- '^^t xnoH^^^fArVUns s) ^0^ aXct tX?V>Jt 



"St)/^ 



SPECIAL INFORMATION only for Hospitals, Insfitufions. fransients, 
or Recent Residents, and persons dyinij anay from fiome. 

Hov* lonq at 
^,,>, . ,;...^ Plar e of Deatli ? Days 



f^ormer or 
Usual Residence 



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



*»•*.««'•»«***»' 



LI.ACK «>l HIKIAI, OK \<V.'SV>\ W. 



i» A I'L', o; H' 1' i.M "' K );mi i\ \ 1, 
'i^* 1 90 *t 




NI.KRTAKKK dcA-X^ VCL ^^ C-C^K 3 



CWAvC^. 



■^ 



^i^ A«| Mho.l.l be Ht..te.I r.XACTLY. PHV8ICIAM8 should 

.ve.. f ln^>rmut1on «houhl l>. o.rc^uH> r;",;;; ''^l ', „;•;;, J,..HMh'lcd. The -Special l.n'or.«Htion" ?or pT- 

. . r All^r or DIATH \n plnin tcrniM, thiit it m»> i)^ proper y 
"'. .b?nl ..wn> frL ho..,e .h„.,l.l ..e »W.„ in .v.r. -.n.-nc 



N. K. hvcry item o 

It 



fi 



\ 



I» 



I 



li 



i fill 






^m 



lit 




1 l4 i .1 



.r\]: ( 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

HEFER TO B OCK OF CERTIFICATE FOR INSTRUCTIONS 

3407 






/)((/(' /'V/r^/, M\<^^^O^0(>X>v 9.% 



Jt\^KAJ> 






¥i^^\m Officer 



Bp<^isfci'cd J\''o, 



1-- , , . 

DEPARTMENT OF PUBLIC KEALTH=City and County of San Francisco 



Gcvtiticatc of Beath 

( la. 5. 5tanC»arC> ) 



^ 



(Vs 



PLACE OF DEATH: — County of CL^ ^''^<^^ .vA.^. w. i^ity or 

St.; b Dist.;bet. LtnvcLt-Y^. and J<XVun 



/?N 



No. 1^^ ^iI},^^<Xa,V*^^ VV'^>A. „r^^V^.r'^r.V^ t^CTrc'j^LED'rOR UNDER '-SPECIAL INTORMAT. ON- ^ 



FULL NAME 






SKX 



PERSONAL AND STATISTICAL^ARTICU LARS 
, I COI,OR\ 



X. 



,OJU 

n\ll'. (»!■ lUKTU 



ACK 



Uu 



*/ 



fvctx- 



'0 



f 

JoiithI \ 



)'t-ll > s 



H 






.l/..;////.v 



/.a<M.i 

(Vear) 



/!</ 1 -« 



siNci.i:, M\KKn:i) 
wiDt )\\i-:i) OK i>i\ ' »Kt i;i) 

i\\tit( ill '.<ui:il ii<<i>.'"i«ti<>"* 



lUKTHPLACK 

! Stutf i)V Country^ 



NAMK en* 

FA'rHi-:K 



BIRTH IM.ACK 
(>»•• 1 ATIIHK 

(State or Country) 



MAIDKN NAMK 
1)1- MOTHKR 



lURrni'T.AOK 
oi' MOTHHR 
(State or Country'^ 



OCCri'ATKlN 






\\ 




Ow^-x-^^s.. 



I '' " 



/)<M. 



HKST OF MV KNOWLKDC.H AM) Hhl.H. 
(inf.n.nant J . ivtO^ ^^^-^^ d^-UlAJL' 



.\KS AR1-. TRCK TO Till- 






fAddn-ss 






la 



MEDICAL CERTIFICATE OF DEATH 

DATK OI" DlvATH 



(MolUlO 



Xh 

(Day) 



I go I 

(Year) 



I inrRKBV Ci:RTn'V, That I atteii.U.l cleccased from 

Jk^...! 190^ to Oxcxr a.k 190H 

that! last saw hv.^>^ alive mt 0%^ ^^ 190-^ 

ana that .loath occurrcl, on the .late stated above, at X'h%\ 

Va M. The CArSI- Ol' DI-ATII was as 



follows 






WvC^^tOLV vn\t>vv>^^^N^- 



Dl RATION Years \ Monihs Pax^ 
CONTRiBl-TORV LL^JJ^cLf^V^^-a. 



Hours 



.k. * •-«t«3^^««-^ *:«<!*'.■ 



DTRATION Years 



^^onths 



Pavs 



Hours 



SIGNED ) Nl'CnV^v vl' 



(S 

(A 



<xa^xX?v W.D. 



H%^ 



I M ATI ON only for Hospitdls, Institutions, Irdnsients, 



SPECIAL INFORI , . 

or Retent Residents, and persons dying awny from fiome. 

How lonq at 

Usual Residence 

When was disease contraftfd. 

If not at place of death ? .._^....^^^..^^ 



Oavs 



1>I,ACH OI- lURlAI. OK K1;Mo\ \I 



I)\n-;,)t" IJi KiAi. or RIvMOVAI. 

0V(3\r %X 1 90S 



. JLtakkr*^^^- koXl li^^ C. 



_^-i ^--■M«i»»-— «^— ^"^■■^"■"■■^"^^^"^"'^^"^^^""'"^"^^^^^^^^ I I K t t I FXACTLY PHYSICIANS should 
/-AiitsF: np DFATH in plain terms, tnai u •"»•* . *^ _ • 



•tate CAUSE OF DEATH in pi- instance, 

son. dying away from home should he fe.ven m every 



U 
•»«' 






m 



M\ 



•III 



w 



RITE PLAINLY WITH UNFADING INK 



nnrir<! • II. ''! i '^' 



Dfffr n/rf/. 







^ ^^^H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

' TT 3408 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 

( 11. 5. t?tanDar^ ) 



(srs 



PLACE OF DEATH : — County of C CV^x^ .1 -vcox .c4 -i Qty »* ^^ ^ ^ 



^ ^ 



No. V CV.v.i'-^"'-^ 



St.; 1 Dist.;bet.V ,CX\.^Ol. 



\ 



I' and ^tA.'-^ 



) 



FULL NAME \trK'>'X' Ox^XVtca.^'>^-.' ^H 




!^'T^Jl/vXu, 



SKX 



1) \ I 1. t 'I i;iK I II 



AGE 



PERSONAL AND STATISTICAL PARTICULARS 




Ct)IA>*t 




Ht 



) til I s 



(Day) 



Muulhs 



(Year) 



S'h 



Da vs 



siNt.i.i- MAKi<n:n. 
wiiM i\\i:i) «»K i»iv«)Rri:i) 

iWiitr ill •social (Ifsiiriiat i< >ii ) 



HlKrHlM.Ai'K 

(Stntt. <n (.'ouiiti y) 



A 






NAMK or 
FA'lUl'.K 



BIRTH PKAOH 
OF lATMKR 

(State or Country) 




'V>\; 



|\ O.UT\J-Vtt^ 



11 



^^A^)l^N xamf. r\ /'^ !^ 

ni- M()TH1.,K I i, I 1^ , U 



nTRTTIPT.ACK 

«>i- Mo'i*ni:K 

(State or Coiiiitry) 



OCCT'PATTON {O .i 




TMKA,..>VKSTATK,.PKK.ONXl r.KTU;.;..AKSAK..TK,KTn TMH 



(Ii 



^^vc\y»-^ 



fA(l(lr<'s>< 



S^S - H 



.ti i- 



x- 



t 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- DICATH ; \ - 

Vll 



vi tov-, 

(Month) 



(Day) 



U 

IQO « 

(Year) 



I in-Kl-BV CHRTII'^V, Tliat I atteii<lcMl dctvastMl from 

- to ..:— — r—. T90 — 



190 



"190 



that T last saw h .rr~ alive on 
aii.l that death occurred, on the date stated above, xxi.-r'rTrr^ 
"7~~: M. The CAlSIv Ol- DI.ATIl \vas as follows 
Q^X>v.^OOu^^<i-Ct^ Axrvtk 




vsr^:v.-ar»a.. 



1)1 UATION Years Mouths f^avs Hours 
t'ONTKllU'TORV -' ••" 



Years 



Mouthi 



Pa vs 



nr RATION 

(SIGNED) _. j^ 

Xft^^ 'J^ I lc;o 1 (Address) ^'^ ■ 



UfUP.^ 




Hours 
M.D. 



->t^ 



SPECIAL INFORMATION only tor Hospitals. Institafions, Iransients. 
or Recent Resident, and persons dving avvay from home. 



Isual Residence 

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



Plaieof Death? 



>.. Days 



n.ACH Ol- iHKiAi. t)K ki:m«»\ \I 




i>Ari'. ol HiKiAi, I'l ki;m<>vai, 






190 



^-^— ^^ w— — ^^™^— I— — ^^^^'"*" I I K t t I FXACTl Y PMYHICIAINS should 



ll 






»»' 



i 11 



p-nnl nf H. :'.!t!i I' N'--' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3409 



V; -r-X; U.S.!' C 




Xl 



njo'i 



^m 



i ' 






Hi 



l^..^io.v.. Deputy Hea5^^iCfnc-r 



Be<!istcr('(l JS'^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( H. 5. £^tan^ar^ ) 






PLACE OF DEATH:-County of 3^^'i^c...o.<.. . City of d^^^^c^^^^-^ 



u; m1\._. 



ii: 



I U, Orv.v>-o..>v 






FULL NAME >M.U|pur^^ ^ 



ii 






M{> 



I ^ l^« 'I 



fci-i 



If f i 



(ifi 



'jfcf 



>i:\" 



PERSONAL AND STATISTICAL PARTICULARS 

i COI, 



WcXx 



III 



t VA,^ 



^tx- 



i).\ Ti-: « I)' liiK III 



AGR 



iM.mlli' Q 



5- 

(Pav) 



i^ JV./».^ ^^ '/""'^'^ -^^ 



/V;5 

(Year) 



nu\. 



siNci.i-:. MAKun:i). 

WIDOWl-". 1> <»K I)!\'OKvi:i) 
(Writfiii ^ori;il <1< -ii.Miati'iii) 



lUKTHl'I, \c'K 

(Stati oi fMuiit 



NAMK ni 
!• ATHl-.K 



-, 1 



'^V' 



niKTIII'I.AlK 
<)l<- l-APHKK 

(State or i'<i\iiitrv 



MAIDKN NAMK ^ 
OI Morifl'.K 



(lk\jLMX>x<i. 



^ 



RTRTTTPI.ACK 

OI' MoTin';K 

(State or C"o\iiitrv'l 









) V<;; 



M.,ntti 



Do 



OCCT'PATION 

T„K.m.VHSTXT.,.rHK...NA, ^^KT,^.M^KSAK,: TKL'E T- TMK 
HHST ()!• MV KNOWI.HIX.H AM) ni-.IJJ.l 

.fonnant VjYlOXU t:' • CtUu 



:h 



(Xddrcss 



\oV\ 




MEDICAL CERTIFICATE OF DEATH 



DAl-l- ol' Dl'A TH A 

m^- 



(Month) 



(Day) 



lYtai) 



I liHRHI5\'CI-RTIl-V, T1i;it I alten-U-.l <Uioa^cMl frmn 

_.„. 190 to .rr—::. T..\ip.rrr—. 

tliMt I last saw h - "' alive- .ni — — — ^ I90 

aiKl that death occurred, nn the datf -stated above, at 
.__„„ ^I ',1,^. CAISI-: OI' i'i:.\'in \va< as follows: 

O^y-s/^ %^',x^.cL ^{Htv^^-aA^ 

Dlk ATION >V.ir.? JA^;////.? />(/)> Ilonr^ 

Cf)NTR I lU'POk V • 



DTKATION 



Ycar^i Months ^...- Days ....... Hours 

( SIGNED ) Wvfr^AJlXi J y&lW.XiixXm^ M.D. 

SPECIAL INFORMATION onlv »,.r Hospitals. lnsfitJnotis, [rdnsients. 
or Recent Residents, and persons d>ing awdy Irom home. 

^ %OL^UU St 

When Has disease rontrarfed, 

If not at place of de ath ? 

I'l \CH OI- lU KIAI. OK K1;M"\ W. 



Former or 

Isual Residence ^ 



Hew lonq at 
Place of Death ? 



Days 



DAi'i'o! i'.i luAi. 01 ki:mo\ai. 






r a-i 



T90H 



Address ^ ^ '^ ^^cU>X "^^CvU d X^-^ | 



«— ^ 11 K t t I PX4CTIY PHYSICIANS should 

i information •houlcl be c«re?ully Kupplicd ^^^I^^^X^^.^.j^d" %hc "Spec'lHl InformHtion" for p.r- 
OF DtATH in plain terms, that it may be properly wibb 



N. B. Kvery item o* 



> 



V 



\u 



m 



w 



RITE PLAINLY WITH UNFADING INK 






i 



- ' 



100 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Br<^isfcred A'o, 3410 



\ \ DeQUtv Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtiticatc of iDcatb 

I ■U. S. StaiiCiitCi I 



% 



PLACE OF DEATH:— County of^ Cl,^^ JA-a.-^a^cic Uty ot 







N 



tvli 
n 



y ,F DCATH OCCURRED IN A HOSPITAL OR .NST. TUT. ON GIVE! ^ '0.1 f"i^ 



UH. 



.f i 



It 



rf 



!*» 



FULL NAME 



y\^^ 




^o.^x^.'^. 




CO'^^'VXU 



■^ J*. K 



DATK ni lUK 111 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR 




,1 

u 




/VVw'Ci' 



^Icvr 



A. 



AGR 



} 'tUt > . 



(Day) 



.1 /-.;////> 



,/..5.C).'-i 

(Year) 



/hn 



SIN«'.I.l-:. MAKKIl.n 

\vii)o\vi:i) OR DivoK* i:n 

I Write ill sm-ial tlesi^nalion) 



Mt . 



mi 




':i-'vi 



m' 



iStatf or C'liunlrv'' 



NAM It <>I* 
1" ATiniK 



RIRTHIM.AOK 
<>»• lArHlvK 
(Stall- or Ci)viiitry^ 



MAinKN NAMK 
ni MoTHKK 



J? iW ft 



Ucu^ 



-trV>-'v\.<\. 



RIRTIIPI^ACK U 

<)l- MolllllR /^ ^ 

(State or Covmtry) 



.1 ^ ..M 



J^^'V^VLO 



,L\.cuJt,- 



OCCUPATION 

AVuJfJ III Si'" /■l<lll.!<f'* 



JV.n 



M.ntli' 



/hn 



T II 1- A lU ) V M ST A T J : 1 ) 1 • K K SO N A I i; \ K T ] J ' ' ^ ' ■ ^ 
BKST OF MY KNOWI.lUX.h AND lU.l.u,r 

0' 'i)^y^Jd 



KS ARK TK( K TO THh 



(I 



.v,>.„...s S'lST' itlU ■:)! 



^ MEDICAL CERTIFICATE OF DEATH 

DA'l'H ol- i)i:atu 



(Month) 



lb.. 
(Day) 



/(?n 

(Year) 



I HHKi'BV CKRTirV, That I attcn.lcl .Iccoase.l fmni 

to --r-r --- 190-;^^^" 

^^ -— ,-rr- — ■— ■ - ■ ^^- 1 90— 



I9O 



tliat T last saw h .: :ilive on - —^ 

an.l that death occurrcl, on the date >tate.l above, at " 
-"'-".. :M. The CAlSIv Ol- DK.XTH wa^ a^ follows: 



CONTRIIU'TORV 



Mo>tths fhirs 



11 out 



Viars Mouths Pays 

\h. Uj-i^'tLcL-'Yvd., 



DTK. AT ION 

( SIGNED ) Vtj\<rvJL\' _ . ^ 
^CV^ X\ TooH r .Ad dress) l.(fv<?^V^A 



Hours 
M.D. 







SPECIAL INFORMATION only for Hospitals, Institutions^ Trjnsients. 
or Recent Residents, and persons d>inij dway from lioine. 

HoH long at 

f"^'"""^. ,, Place of Deatli ? Days 

Usual Residence ■ .--•-••• 

Wfien was disease confracW, 

If not at place of deatti ? —■-"-" "' 



ri.ACH 

^?5 



V\«V' a.l^ 1 90S 



'%crUL W>^<t^ . 



H 



...^^^___^,^,^ — ^1— —^^■^"^^—'^^^^^^^'^ ft! FXACTLY PHYSICIANS tthould 

state CAUoti ur ui^« • •■ » a:v*« tn avarv inHtance. 



son 



• dylnft away ?rom home hHouIcI be A 






v'l? 



•»1 



'^JmP^ 



II 



T>.,;,i,1 of 1!. :ih I ^ 



«! i, 



ii 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3411 



..«-*•«., 



oIUS:!' Co 



\ 




Ep^isfrved J\''o. 



DEPARTMENT OF PmiC HEALTH-City and County of San Francisco 



Certificate of IDeatb 



-P 



<^ 



PLACE OF DEATH: — County of 



'-VoAv i Vcv^v'Cv(i-C-« City of '^'o^^ J.v<v%vt^»^<M> 



'0 ^^ t) <m9 



St.; 



1 ' : 



W^ ^-Ct^ , AlL<J-VCAvtM. ^AL^^^iWaX^^ ^t*» ^'teV'i^LrD'roR UNDER ''SPECIAL .N^ORMAT.ON••^ 



Dist.; bet. 

CTS 
ITS 



and 







FULL NAME 



8 OA^cuL \jlr\>uvtA, 



crY%^. 



PERSONAL AND STATISTjCALJPARTICULARS 
% I COT.<1R N A 



liATK i)F ItlK'ni 



!»i 



m i 



fM#rl 



II 






ACR 



S5 



) V<? » * 



II 



(Day) 



M.nith^ 



/;Il:l 

(Year) 



.\' 



.^**- 4. 



/1</ 1 . 



SINC.I.K. MAKKIKI) 
\VII)(>\Vi:i) OK DlVnUri: I) 
iWritfiii s(K'i;il (k'si^natiDii) 



i . ^ 



ll ,ucL 



^rvu" 



MIR rin'i. MM-; 

I St;itf or »."i>nnti v' 



NAMK OT* 
FA TlIl'.K 



lUK'nUM.AtK 

()i- iArin;K 

iStalf DT c'oiuitry) 







MEDICAL CERTIFICATE OF DEATH 
DATK OJ" I)I;aTH I 

"^ ^ .(TV) 




(Month) 



llo. 

(Day) 



H 



igo 

(Year) 



I HERKBV CliRTIFV, That latteiKled dcccasecl from 

,H to ULCV^ ^io T(p S 



A 



.J CV*:....3>.1 190 

that T last saw h-^- ahve on U\^ ^^ I90A 

an.l that .Icath ..rourrcl, on the .laic- ^tatol above, at • H./ 
Cf. M. The CArSi'.Ol* Di; ATH was as follows: 

vJ>v^Wr 



l^^^' 



c^.:S 



or RAT ION >'^'«''-y 
CONTRinrTOKV 



Months IMys 



I fours 






m\ii)1':n namk 



n ,-..,-,. ♦- 



HI R Til IT, AC Iv 
(Statf or Cotuitty'l 



i 




,CL.-rwi^- 



occ 



M..>:ih- 



lhi\ 



:cri'ATioN (?5\p ^ ^^ 

C\3 c^v<L,LcO-tyV^ 

A'..,„^-; /» V,7,; rrauci^eo ^^ )><■' 

—^ ,. ■ « u 1- r w r !•■ '1"< ' 1111 
K A,U>VH STATF.) '■HKSONAl RAKTUMM.AR. AKl. . ^ 

nivST OF MY KNOWI.l-.lX-.K A>>> l?" •''"-' 



phf: 




(Informant A-' 



^JjUrVcv^ OXoJ^- 






.'^^ 



(Address 



1)1- RATION ^'-'^'-^ 7A../M. -W />^n'^ //'^"'-^ 

^QirNFD) ^- OV. M-CuJj... M.D. 

(SIGNED^ ^- ^'^ ,^ ^ ,/^ (V. 

^Kc-V- '^ t. T OO--. (A.Mress) Utu. ^ i-^ % (S^W^W^ 



s 

or Recent 



FECIAL INFORMATION only for Hrispitdls, Instilulions, Transients, 
■cent Residents, and persons dying away from home. 

\ \ ^ Hou long at ^ 
.^b ViyM. dt Plarc of Dcatti? .^5 Days 



Former or 
Usual Residence 

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



,.,.ACKOF lUKIAL OR KKM-VVI. | '•^'•';^..! M- .OAI. ... KFNK.VAI. 



-) 




1 • . I : I ! r i< 1 A I . 



^^ 



T90 






NI.FKTAKFR CxxicL^O^^U VV<i^ Cc 



(Additss 



1.0 5 U^vv-^^CV. 



IN. B. Kvery item o^ 

«tate CAUSE 

«on« dylnft nwoy from 



—4 ^ ' ' ~, Zv «^'>"««« »>« "•"»'^'' EXACTLY. PHYSICIANS should 

, i„^...„„f.on Hhou.d be cnrefully sup,> .e.«. A^' ;^,^ „„«,jf5ed. The "Spccla. Infornia.lon" for pT- 

OF DEATH in p.»in J«^;-^;;;; /.rer . Instance 
^„v from home Hhould be <l.^en m ever> 



*t5 



■m 






1*1 




1 1. 



u i 



I! i '■ 



t « 





i ^i: 


i 




' i ; 


I 

i 






■ * 


. 


II 





i ■%: 




w 



RITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



I V ,• , 



r-'i-"'v'>^ HSc !• 



{'<. 




r^^<E:^^?*s***♦» 



iy(?H 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Bi'<^isfered jVn. 34x2 



1nv..^<»1L/v^^ Deputy HaamiCmcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of IDeatb 

, ^1. 5. StaiiDavD ) 
PLACE OF DEATH:-County of dxx.. ^X<X v.cv.c.. Gty of C\<V^ J.Va.-^..c^cc 
, q , /^ . ? ^s St • 1 Dist.; bet. IL>^C.V, and >J 4^<' 

No. 11 ^ ^ la^-iA. C\ ^.c.nVNrrCi.VE FACTS CALLED FOR UNDER "SPECAL INFORMATION' ^ 




FULL NAME 



\h, 



AAAaJu 




C4\.€L' 



PERSONAL AND STATISTICAL PARTICULARS 

^4 



tVAEDICAL CERTIFICATE OF DEATH 






L"A*-^< 



itA ri: oi mHTu 



U 






' Moiith I 



\<".K 



)',■<!> 



s 



(Day) 



.\r,>„th} 



(Year) 



/)a ! .s 



->IN«".1.K. MAKKIKI). 

U II)()\Vl-:i) OK niVoKrKl) 

iWiitt ill >()cial dt^ivT'iatioii* 



Qj\yw.OAJi 



I'.iK riiri, AOiv 

(State or •/ouiitry'i 



I- A ini.K 



liiR rn JM, Ai^K 
oi' jArin-'.K 

Statf or Countiy 



^tAll)^^N NAMl- 
«»1- MOTHHK 



niu'nuM,A('i% 

oi Mit'l'IIHR 
(St;it. «>r Country) 



(1, 



ith^J^r^^^' 











DATK OF DKATH A 



(MontlO 



Xi... 

(Day) 



(Year) 



J IIlUUvBV CI-RTIl-V, That r attcn.KMl .Icccasetl fnm, 

^CX- XD... 190 'I to MrUJVr XX 

Aj"Uv- 3L.b, 



ic)oH 



tliatllastsawhX^ alive on AJ A^ ^^ ^^P 

a„.l that .U-ath ..ccurrea, on the .late stated above, at 1. 50 
\.\ >L The CVrSIC OF I) 1: AT II was as follows: 

'rs D (0 



DIRATION 
CONTRIIirTORV 



Years Mo>///is 3 /?<M'.v 

U jL^Xvw'ft.A.\^ 



Hours 



DIRATION' 



Years 






MoiiHn 



l\r\. 



(K\T1'AT10N 

h;,'<idf,l ni S,i> i i'xnh isri} 

TnKAmn-KSTATKn.-KKS..NAI rNK.Mrri.AK^AKl-TKrKTo ...K 

ni-:sT OI- MY KNO\Vl,i:i)«.h AM) MI I-n.l 



' I tifonnant 



,„,,,„.,. Rib JW- 



rVCX 



//(f)//; V 

m ^.- n?, .„.'.• rA,Mr..<0 1565 O.C(^oRUrrv 01. 



^ronthsX^ /hiys 

IICV- Xt Too'l fA.Mn-O i5 6 5 



" SPECIAL INFORMATION "nl> lor HospitdK Institutions. Trdnsients. 
or Recent Residents, dnd persons d>in:) .m.iy horn home. 



Former or 

Isiial Residence 

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



Hew lonq at 
Pld« e of Oedth ? 



Od>s 



— — ,, ,. i-M, ,\ \ I I Dvri .1; III KIM. or ki:mo\ \i. 

1M,ACK 01 HIKIAI, OK K l-.MU\ A I, I i»A ' '^ 



l-x,- 



.ft-'^sL- 



%S\ i9oH 



(Ad,Irc.», 15 9.1 Bltrt.kt6>v ^ 



_^^^__.^M ^^— ^— — ■■'■— I t I r\'4CTLY PHYSICIANS nhoulcl 

,.«tc CAUSE OF DF.ATH .n >•'"■""'"'•' ,„ ,„„,, ,„»,„„«. 



,.«.e CAUSE OF "F-^T"^';. 'X:". b:* >- 1 ln,.,nc.. 

>>on« djinft oway Si-om Hon... »houi.i 



I 



l| 



M 



I! I 



I ; 



|i ■ I 



III i 



\i 



■jte 



)!,,i\r.! of 11. -'ih 1 V, 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



f- :r-.^>luS^PC() 




If) OH 



Bp^lstered .Mo, 



3413 






Ualii J''ili''l . 

lfrvvv«Xt.vKM Deputy Healt^iOmcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDeatb 



N 



PLACE OF DEATH: — County of 



ll 




St.; 



-oAxd^cx 



Dist.; bet. 



City of 




•»A^. 



cLcv. \^0J 



and 



Vj <XVY-, .r;Kirr r.ur r.CTS^CAULeD roR UNDER -SPECIAL INFORMATION ■• \ 

FULL NAME W^^c^ dc^'^vcivL.^-^- 



|»H 



-^1 



PERSONAL AND STATISTICAL PARTICULARS 

COT.OR 



I' \ 1 I-, Ml r.iK I n 



^ 



Lllia 



M-iiithi 



\<".K 



J Vif ' 



ID 

lDnv» 



Muiilhs 



/, i.w...' 

(Year) 



/^</r.v 



>^iN't,i,}.: M\kKn:i> 

u mow i:i) OK ni\'< »Kri:i) 

' \\t ilr i 11 ^ui-inl (l(-ii.''ti;itii»ii) 



HiK riiri, \rr: 

I Stiitf or I'niint I v1 






CJjt'tvO/Ci 



^n 



liMi 



IJN 'f^k\ 



N \MK (IF 
I ATUl-.K 



ItlRlHl'l.Al'R 

oi' !• \ rm-:K 

'Statr or Cimiifiy) 



OI" MoTHlvK 



lUKrHJ'I.Adv 
OI Morill-'.K 
(St;iti- or <."omjtrv) 




MEDICAL CERTIFICATE OF DEATH 

DATK, <>i- I)i:a'ih 



\Wr^ 



fMoiillil 



(Day) 



(Year) 



I lIKkl-liV CKRTIl-V, Tliat r attciiilcMl dcrc-ascl from 

to — -•- TTii^^:::::::.. 



1 90 
-""uiivc oil 



tliat I last s;i\v h 

.,,,,1 iliat .U-ath orcurrc.l, oti tlu- .lati' statcl above, at 



190 



M. 



Tlio CArSP; ()!• I».I':A Til was as follows: 

O^CcJU vibA.tr-kVt:iuJj^ 










ri\<x^v.v<x ^^^^ 



IV 



\Kj^-^ 



OCCrPATlON 



) V(// 



M.,i,th> 



n,i 1 . 



:^H0VKSTA.•.■I..•KKS0NA, rU<Tirt|.,AKSAK. 
IHST OK MY KNnWI.l-.lx.K AM> in.ljl.i 



.. iKri-; TO riiJ': 



I" in 
1 



fTnroiiiiritit 



_ 3 X^^-rc'doL'X 



( \(l(1rc'<s 



lHll)^culW ^-^*- 



I)t RATIOS >>''''^ 

CONTKIl'.r'roRV 



nr RAT ION 

SIGNED ) 



Months 



Days 



Hour 




Pays 



Hours 
M.D. 



( =»i<ji>iiiu» / r 1 J^ ^ 



•SPECIAL INFORMATION only for Hospitals. Institutions. Irdnsicnts. 
or Rercnt Residents, and persons dying dnay Irom home. 

HoH long at 

f»'''"f';"^., Plare of Death ? •■• Days 

Usual Residence 

Wtien Has disease contracted, 

If not at place of death ? — '•' ' '""" 



,.,,AC1-. nl- MlKIAl. oK KI-MoN Al 



DAII. of Hi KlAt. or KKMOYAI, 

Ov(r\r %% 1901 

7> 



II 



,, 



— J— ^^— — ■— — f VACTIY PHY8ICIA1N8 nhould 

"~7; „tion should he cnrefu.Ty MuppHea. ACJH "'''"/^^XV tJ: •S.^lal lnVor.«Htlon" for pT- 

IN. ,1.— hvcry Item "^ '"^''TrVh in , nin tcrmn. th»t It mny •- properly J«H«.t.cti. 



sons dyinft owny 



from homo Hhoulcl he ft 



tr 



I 



!l 



1 

II 

:1f 



I- 



'f«r WRITE PLAINLY WITH UNFADING INK 



Dale /V/f'//,, I^^ '^^ 



;.9i^>>4 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3414 



Bpgisterpd JS'^o, 




Deputy Hcaltti C^cer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 







PLACE OF DEATH: — County ofL a^^ ^ X<X>xCUi.c^ r^L l^Sil ^ 

Dist.;bet,N[lft Ull^tu^: and O.L^lt 



A 



\ 



No. t' i CC'W ,,c.iai RFSIDENCE GIVE FACTS CALLED 

/ ,r DEATH OCCURS AWAY FROM USUAL ^^^IXfvT^-UOfi GIVE ITS NAME 
( IF DEATH OCCURRED IN A HOSPITAL OR I N ST ITUTIO N G I V E 



O^: 



FOR UNDER "special INFORMATION" A 
INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



JO 



-hjt) 



LJ-O.'xX 



d 



PERSONAL AND STATISTICAL PARTICULARS 



III 



^l.\' 



'W 



CO...., . 



oc 



LU-fvLix 



i> A n: « ii I'.iK 111 



\f. ic 



(^ 



Jxlr 



Moiitli) 



}V</».'i 



^ 



(Day) 



.1/,. >////.< O 



(Year) 



Da ys 



WIlx »\\ i:i) (»K I)I\()Ki."i: I) U 

iWiitcin ^<ifi;il (It-i^'niit i- >it ) *n^ 

ri 



UKTHri.AOH (TD 

St.itc or Country ' —A \U\ 



N \MI-, <>! 

!■ A III i;r 



lURTHIM.ACK 
<)|- lATUHK 

(Stiitt- or Country") 




MEDICAL CERTIFICATE OF DEATH 

\fl^- ^t r 



(Day) 



IVcar) 



(Montli) _ __ ^„ 

I nivKl-HV^CKRTM'V, Tli:it I atteiido.l dcrcnscd from 

iO^ct I3L 190H to Ch-^S\r. ..aU icp H 

vKffNT:. ,S..b. , t^X 



190H 

that T last saw h *- •■- alive on 
a,M that .Icatli occiurc<l, on the- .late stated al.ove, at 
Q M. The CAl'SI;: OI" Dl'.ATII was as foIl.)w^: 

3::).cM^0v^ 'L^^:Ix^aX^ 



DIRATION Years 1 .^/onf/is ^' /><n'.? 
CONTK 1 IHTORV • 



I lout 



MAIDKN NAMH/-V-^ ft 

(»!■ MOTIIKK VOi -\ "A y 4 



BTRTTIPLACK 
OI-* M(»Tin':R 
fStcitr or Country) 



m 



OCCrPATTON 

Kf sided ill San I'lan. />-'' 






M..iilli> 



I\\\: 



KAnOVKSTATKn.•KKSOSA.^AKT|C^J.^KSAKKrK^K m THK 

<9. OCU^v-v^ ' "" 



(Infoi niMUt 







DURATION ^'^''^ f) •'''""^^''■' 



Pa »'.<■ 



I/oitrs 
M.D. 



(SIGNED) lO Us. X-^A^-Ctl 

SPECIAL INFORMATION «nly hr Hospitals, Institutions, [ransients, 
or Recent Residents, and persons dying away Irom home. 

Hov» long at 

\^'^V^A.r, .-^ ■"• Place of Death? Days 

Usual Residence ..„,......-«• 

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



L*....*««**il^»#*»»"*: 



DAIllof HfKlAi. or KI;M0YA1, 



I'l \CK Ol- JU.K1AI. OK KJ;M*'V\I. 



(Ad.lrt-ss '^^bl M I V 



\^^^c^cnA. 



'•i!« 



..^____^_^^— — — —— —— " t t I FXACTLY PHYSICIANS should 

state CAUSE OF DEA in P ^^^^ .^ ^^^^^ ;„Ht«nce. 



sons dyinft nwny from home should be (I 






^'111 



ill I 



ssm 



n 



Dale FUi'<f . 

i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 
^ _ 

l()0^ FiPgisfered jYo, t^-rA.^ 



1 N. 



V- -sri^H^cf' Cu 




^^ 



\ 









DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



PLACE OF DEATH: — 



Certificate of S)eath 

County ofC'O.ATjO.'vOw.-vvcxa.c.' City of 






7^ 



n 



Dist,; betX i^^ 



-h 






1 



^^" TACTS CALLED .OR ^ N O E ^^-'SPJC.AL. A FORMAT IJ> N - ) 



xu 



FULL NAME 




■-\XXj KjlTi'XXyjX.^^ 



PERSONAL AND STATIST^CA LJPARTICU^LARS 



DATE oi- r.iK in 



LLv4vvJsX 



I 




Af.K 



!''' 



«% 






Ml 






i-fr^ 


1 ^i i 


1 1 




1 ■ 


; 


I 




^ 





(IN 



^1 



Ho 5.,M> 5^ 



(Pav) 



\;,,fii/is 



r % b H 

(Vear) 



H 



A/t> 



"^INT. l.K, MAKUn-".l> 
\\ II)(>\VV:i) OK DIVOKI Kl) 
Write in s<K-ia] (U «>i>niali<>ti) 




CXWOL, 



d. 



I'.iK ni t'l. \oi-: 

^t:iti- or <■• innlr\- 



XAMT-: Of 

I- ATH i;k 



lURTHPUACK 

0|- lAPIIl'tK 

' Statf or Country^ 



MA!1)1;N NAME 
wl- MUTIIl'.K 




h 



.tuO^'ZJb 0-<Ai''»^^'^^H 



e 



t 



<XCX OX>V"rrV<X/^x.c 




— *1 



l'^ 



•] 



MEDICAL CERTIFICATE OF DEATH 

DATi-; <>i' ni:Ai'" 



(Month* 



X.l /9o'\ 

(ttoy) (Year) 



'~" I I11-;RI-:I5V CllRTfl'V. That I atten.lc.l rlcccasd frn„, 

CtlcTv- n 190 "^ to ^^^ ^^ i^p 'I 

that T last saw hX>x:. alive o,t ^^^UvT X^l up 'i 

a„.l that .U-ath occurre.l, on tlic -late ^tatcl ahove. at U 5D 
'^^' M. The CAlSlv OV DHATII wasas follows: 







J/V<-*\^.V<Uw*VC8U-„... 



fS 'i 






Hours 



Dl-RATION S Year. Mo^ ^ Am 



SIGNED) 



„-A«A».?C."%-^-, 



IIOU)' 

M.D. 



lUR'i'mM, \rK 

oi- MoTlIK.K 
(Sliitf or Conntry) 




,-U^^-^ 



OCCri'ATION Qju» 







n 



1/ .'/// 



/),M 



liKST OF MY KNOWl.l.lX'H AM) nhlJl' 



(Inroiinant 






^. 



a* 



roo 



( v,i.,.-...o4^Q.M1Uv^UmU.... 



^SPECIAL INFORMATION on!v lor Hospildls, Instituliin.. Frdnsienls. 
or Recent Residents, dnd persons dvinq .iw-iy froni home. 



Former or 
Usudl Residence 

When Hds disedse contrdcfed, 
If not at place of death ? 



HoH long at 
flate of Death 



... Ddvs 



IM.ACK 0|- HIKIAI. OK Ri:Mo\ \1. 
, VDI'RTAKKK U oJU/vCti. 



l)\lj;or lUKI.M o! Rl'.MON'AI, 

Qruv- 3ka 



[^O "v 



(Address 






vC 



N. B.- 



PHYSICIANS should 
p«r- 



_^.^^^ ^^^M^^— ^^'"^^'^^'^^^ I pYACTLY PHYSICIAINS si 

state CAUM: 0» OtA 1 n •" k ^Jven in every Instnncc. 

son, dyinft owny from home should be ft.ven 



'I. 



.mmm^' 



r^^'r- 



i! 

] t 
\ 



Vs 



IVutrt! of Il*?ult 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERT IFICATE FOR INSTRUCTIONS 

3416 I 



h I V 






100 



jRo^isterrd Js'^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




Gcvtificatc of 2)catb 

I XI. S. StanfatC > 



J? Q^ 

1 C\ >A I v1 



(^ 



PLACE OF DEATH:-County of m.J^Xa^vc^c. City of dcv^^^^A.cc.ve.^.o 



N 



'■ ^ ^"(>^\.^-l; Dist.;bet. 



o. U.'^xIvclI U^\jUv.q.i^x<tM 



0^ 



md 



'■jjXux.-^yx. . 1 O rtx<-cLi.H.. 



FULL NAME 



~^ 1 : \ 



■%i 



» , 
i i 



ail 



ii!i 



PERSONAL AND STATISTICAL PARTICULARS 



fXcli 



1) ATI-; « •! I'.IR 1 11 



Mdiith) 



AC.R 



CUj-t) bCMv,//> 



n>av) 



M.ifillis 



(Vt-ar) 



/J<7 1. 



W IIX >\\'J-,I) < »K I)!\t>Kr»;i) 
iWiiU ill ^iociiil (Usiv^iiatioii) 



[y\o ^- - vxd 



lURTinM, \<"K 

iStatf ui Conntty ' 



NAMJ- o! 
F'ATIIIR 



lUK'nilM, \l"K 
<»!• lAini.R 
(Statf or Coniitiy) 



MAIDI'.N XAMi: ^\ 
OF MOTIIKR / {) 



BTRTHPr.ACH 

OI- MoTHKR 
(Stair or Coiintryl 



orCTTATION CN 



? ■' 

? 



MEDICAL CERTIFICATE OF DEATH 



DATK <)l' DlvATII 




U 



(Mouth) 



(Day) (Vtar 



IIirUKBY CI'RTIFV, Tliat T MltiMi.1o<1 (Icronsorl frmn 

T- : - .". :■"- ■ 1 cp- ♦■n^-"^- 

— — 190 



190 



to 



that I iMst saw h 



alive oil 



and that (Uatli occiirrc-.l, on the .late state.l al...ve, at 
— - :\T. The C'Al/Slv Ol" DlvATII wa^^ as follows: 

(X<:^CAydUt/>vL'0^t 



DIR ATION )'rars 
CONTKll'.l roKV 



MoniJn 



Days 



I loityi 




fitMti 







/If.. 



}r.>i>///' 



/hn 



BHST Ol' MV KNOW I.l.IX'h ^NU 151. J.n-' 



Iiifoiniaiit ...\}-MA'%-^ 









JK& 



\i)\\^^<L^' 



I \(iin ('*-s ••• *- 



l>r RATION 



}'{•(!> S 



JfoN/ZlS 



Ihtvs 



( SIGNED ) Ccr\r>^Uv J Uj.u) ijLUXvMl 



/fours 
M.D. 



(0 ((>j)j) 



\j\a- %^ Too*^ ^ 

SPECIAL INFORMATION only for Hospildis. In^titulMrt^. Transients, 
or Recent Residents, and persons d>in(j .iwdv from fiome. 

Wfien was disease contracted, 

If not at place of deatli ? —.■ - 



Former or 
Usual Residence 



HoM lonq at 
Place of Deatti ? 



Days 



iM.ACi-; <)!■ inRiAi, OK ki:m<'\ai. 



DAIlvo! Ml KIAI, or R1:M«>VAI< 

Oxcv- Ql^ I got 



(hu iD.l 



_^— -■.■•--IB— i^^«i— ^^^■^■"'^■■■■'■^^''^"'''''""'^""^"^'""^"^^"*""''^^^^^^^ I I K t t I IXACTLY PMYSICIANH Nhoultl 

:"*;.bin» »Z «ro". h„..c -I h. ftlven in .ver, in»..n«. 



i| 



M 



* 



r^»«-«f; 



t^P^HPr 



I ! 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!■ !■ 



■■■. if_-- 1-'- 



lit 



\l% 






lilO'i 



Be^istcved Xo. 



3417 



i.frv.co doL-wi Deputy Heall'h OfHccr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of IDcatb 

, 11. 5. StanOarD ) 

1 ^ ^ ^ 

PLACE OF DEATH: — County of^O.^^- k^A^oj^xzlh.. ^ixy or ^ ^ ^ 



No. I'iO^ vtx^cclia. LL\> 



St.: 



1 ' J V 

DisUhctX^CvV^<Xy^d^ and 



XX<XN^\wU..' WW -^ „ro.r.V^irFr,^y^ FACTS CALLED TOR UNDER "SPECAL .NTORMATION' 





aL-^C-YW;.,..) 



FULL NAME 'tsa^V-^ ^ 




1 * 



?'»♦ 



II 






^fll 




PERSONAL AND STATISTICAL PARTICULARS 

iiAi j: tti itiKTii ^r\ 

Uzt 

t Month* 



. ! COl.nR \ rt 



(Dayi 



/"ILL. .. 

(Year) 



At'.K 



M 



)■<•■/ 



M. oil lis 



IC 



Pit r.> 



WIDOWKD OK DIVOKOKI) 

Write in soriiil (k-is-'nation) 



i 



lUK rnri, Aoi*. 

(Stiitt or Country^ 



NAMK OJ- 
I- AT 111". R 




((5? ft 

J I 



HIK IHPI.ACH . 

oi- lATHi-.K I; 

(State OI Coniitrv) J\[ 

^ UXV'^^xO.'>^ 

MAITll'N NAMK P J) 

(n- Morin-:K \ ' \ 



^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:ATH (N 

Macxr -^t 



(Year) 



(Month) ">-'^'' 

rnRRJUlV ClvKTII'V, Tli;il I altcM.lc-il (Icrcascil from 

(kcv- ^^ 190^ to ^<r^.^fe I«)5*i. 

that I last saw hX^. alive- on \^X^^...%^ ^^^^^r 

and that .loath orciirrcl. on tho .late statc-.l ahovc. at I^M.... 
M. The CAT SI- Ol' DKATII vVi'^^J^^ follows: 






Months ^ Days 



C O N T R 1 lU "r ( ) R V V-JrX^ C rCi/>%'Xi.. 



Hours 



fiPjHfc. 



HIRTFirLACK 

of MOTIIKK 

( Stale or Co\intry) 




cnvctV\.l\ 



jl/v^-Nvcv^-xu 



()(.CVl'AriON 



liuST OF piv KNO\Vl,l'.n«-l'- AM) Hl.I.ILi | 

,„., „ %JLKm^<X/w>^ -Slvtct^^^H 



/\>^ 



DURATION 
(SIGNED) 



Vt-ars Months \ Days Hours 



\i\rc-, an^^H_j 



A.i.irr-s)Hi^ CnA\.tla>vd.\J. 



SPECIAL INFORMATION only for Hospitals, Institutions. Iransifnls. 
or Retent Residents, and persons dyin(| awa) from tiome. 



Former or 

Usual Residence -• 

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



How long at 
Place of Deatlj ? 



Days 



I'l.ACK Ol" Hl'KIAI, •)K KI«;>t«»VAI, 



DAI'Ko! liiKiAi or KlCMO\AI, 

v.Krg^„.a.i 190' 







Hi 



.._^^— ^— ^M ^— ■^^^^^■— ^'^^™^^™*'"'"*"^^^^ » t I FWCTLY PHYSICIANS should 

:r„';..yrn» .-, ."o-n h„,„c »....„... h. »!>.„ <„ ,„., in-.nc.. 



t 
I < 



• ili^ 



f 



II 



ii! !•* 



il 



i^9 



ml 






l;i 



.Mil 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,„, , .fn.aub IN.-.:- ^■f^oli^vl^r„ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3417 



/) 



(tie /•V/^^/.^Kt^>-<lT^v!^Jl^; 5v% 



lOO'i 



Rcf^Lslcfed J\^(). 



1 

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco 



j^r^)^^ Ajt'VM Deputy Hcai.'h Officer 



^ 



NoJ'iO^ '^ixvc^Lla) 



.\ 



V - >' 



(Tevtificate of IDcatb 

( /U. S. StanDarD j 

(^ A 

City of '^^ 
St.; '^. Dist.; bet. L{y^^\Ll..O..>'v..C^- and Vc(|.t\.CL (m.' ) 



PLACE OF DEATH: — County of 0,CL-t^' OAyCXAX-CLQ.Cc. City of C'cx^^ 0-^^a,A^^v<i.eo. 



/ IF DEATH OCCURS AW»Y FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION 
( .F DEATH OcC^RRrD .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE^. 



FULL NAME fco-V 




[ 




n 



I 






m;\ 



oo 



PERSONAL AND STATISTICAL PARTICULARS 



y 



l>.\ri-; nl- HI K I'll 



L 



lli.lvctL 



MEDICAL CERTIFICATE OF DEATH 



DA TK OK I>T-; 



Wr 



(Month) 



\<;k 



M 



5 III I v 



I 



10 

(I)av) 



.}/n>,//tS 



..I.±i)..(j 

(Voar) 



10 



/^</ VJi 



SINC.I.K M\Kkli:i> 

\\in<)\v}:i) OK iti\t>Kr»:i> 

(Write in sm-ia! dc si).Mi:iti«)ii) 



HiKTin-hAoi': 

(St:iti or •.■onntry'i 



\ \MT Of- 
lATIN.K 



lUK'niiM.Ar]-: 

Of I'ArMKK 
'Statf or Country) 



MAini:N NAMK 
ol< MormiR 



lUKTinM.ACK 
ol- MO'I'iniR 
(State or Co\iiitrv) 




O 



a,v>vaui 

J (^ ft 

(JXVY>\XXa-vu 



(Mouth) 



(Day) 



/go 

(Year) 



r irrCRKRV CTvRTri''V, Tlmt T attctuled deceased from 

Ql^CVT ^3. iQoH to ^X^^ :^.k^ icpM 

..0X(ru'-....3...to.. 



\r. ^.0. 190H to yv^cvr c*-.v^ up 

tliat I last saw h --L' alive on -• v vov.r... 4*.jy.. 190 

au«l that death occurred, on the date stated above, at .i.X.^.v.... 
LI.. M. The CAISK ()!• DI-ATFT Nvas as follows: 



Nvas 






Dr RAT ION 



J? 



x\%Ul .i^crvAXX'Lv't 



XV>-VV<X/>XA.i 




i 



J7w.? 3fofrihs j^ /hiys Hours 

CONTRIHrTORV Ox.^'C-J('U-<>-V'Svl6:>-'- 



DURATION Years Months \ Pays Hours 

I 



(SIGNED ) 







M.D. 



^ rirt^ %r\ TooH r A.Mress) H 1^ u^vA.vt(,a>v<i LI • 



Special information only for HospUals, Institulions, frdnsienls, 
or Recent Residents, dnd persons dying awdy from fiome. 



occri'ATiox 

Kf^idrJ in Sou I'laii, i^rn \ )'ra>< \ Mouthf; lU />.n. 



Former or 
Usual Residence 

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



HoH lonq at 
Place of Oeatli ? 



Days 



rm' AIJ0VI-" sT\ri:i) i'Kksonai, i-ak ini i.aks aki; ikik 10 Tin- 
linsT 01 iiv kno\vm:i)<".k and im;i,ii^f 



(Infoimanf 



f AdilrcHS 







*.>-w 



I'l.ACH OI' lUKIAI. <»K Kl-:Mt)\ AI, 



DAPKof I«i RIAL or KKMo\AI, 

Ovc\- xl 190'-: 






A' "^^^Ct 



(A.Micss 



N. B. 



— I.vcry item ot' information .houhl h. cnrefully supplied. Afif. Hh.,uld be «tHtecl KXJ^CTLY. PHYSICIANS .hould 
Btnte CAUSE OP DliATH in plain terms, that it may be properly clBHsliried. The Special Information for p«r- 



Ron« (lylnft away from homo Hhould be J^iven in every instance. 



»f 



t 

I 

if 

I 'I 



:r 



I» 






I 



i 



I 



• 



;■■ * 



)■ .,!.! ,,f U'.allli » 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR (NSTRUCTION3 

3418 



■*'•■ "Srr :<; UScV C 



Be^Lstet'cd JVo, 



lUih' riJcd, ^\\^:^^\X>Vv 1^ ^'^O'i 

\^^K.^^ l^vu Deputy He-fm..O.0.w .r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( v.. 5. StanCiar? ) 

5 ^ ^ 



1 



(^ 



1 -Oo-W' J 



PLACE OF DEATH: — County of O.^ v^A-<XA^Ca,-cl City of '^ CU^ -> \.<X.^<i^z.x 
ivrn k\^ ^K.>-.Ju St.; 5. Dist.;bct.Btcrckt^^^ an(! i^-<A^^ 



:d 



FULL NAME VI 



I fUxrv 



-1 



L 



. J .CXixL^' ^ -..- «.-.--.•. «• 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



OAT1-: <>l HI K I- 11 



I 



XlIvvJu 



tMojith) 



(Day) 



^^TC 

(Vcar) 



A <".}•; 



^ \ J V <» I > 



V'fi/^is 



Jktvs 



siNt.i.i-:. M\KKn:i) 
wrix »\\ i:!) OK niv<)K(i:i) 

(\Viit( ill social di •^i}.'"ati<»ii) 




.VvX/cL 



lUk'niiM.xoH 

(Statf or Coiintrvl 



NAM)' «»I 
I' AIM IK 



(Vtcu- 6 Cr-vc^ 



!^ 



.^. UJXX^. • 



nTRTHPT.ACR 

OI- 1 ATIIKK 
'State or c"oiiiitry> 




MEDICAL CERTIFICATE OF DEATH 



DATE OF I)i:ATli 



(W. 



(Month) 



(Dftr) 



(Year^ 



I HI':RIvI'>V CIvRTII'N', That T altfiidcfl «1eccasc<l from 

OtLcvT VX 190 *H to .. Ovcvr.aS „..iqoH 

that I hist saw \\ Mx>. alive on \j\M\r "^S. 190 1 

and that death occurred, on the date stated ahove, at \ 
\}. M. The CAl'Sh: Ol* DIvATII was as follows: 



wiK;viiv/.> Years '—Mouths "— • 



,\A-^v \Ow^rruU 



maidkn XAMR 
OI- mothi;r 



hirthpi.acp: 
Ol- MornKR 

(state or Country) 



? 

■ 

? 




',<X' 




Dl 
CONTklHlTORV 



Hours 



IM;RATI()^^ -..^ Years 



IloUt s 



occri'ATioN CTvP I ^ 

or «• 



M.,>,tln 



rhn 



■VnV XHOVESTATI-Dl-KR^ONAI. PA KT HM" I.A RS A K l". TK f K T< • rill- 
lii:ST O'Tvi^' KNo\VIj;i)<".K AM) I! 1 J. I hi- 

fotmant J LI JCUlV^T^' 



(In 



(A.l.lrrvs lO?.? V)-*^>VX O t. 



Jt 



.I/0U///S Pars 

(Signed) J... \J f ^vXXAAA.^ifXJt/ ^ ^•^^ 

^.C- n TooM f.xd.lr.^^) HOC 0'gK^.w^l^ ^t 



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



Former or 
L'snal Residence 

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



How lonq at 
,,.„:;.:.„... Place of Death ? 



Days 



I \CF Ol- HIRIAI, «»K Kl-:Mt»\Al, J DATIvof llnnAl. or RHMOVAI, 



' A.'"' 



9^^^ 



T90H 



INDl-.KTAKKK ^J "w ^' 



/VO.X4 



x< C<: 



Ad,in-ss S5'b' '^51 d-^vt:U-^• '^t 



IN. B." 



, .. ,. , Arf-- «tiotilrl he Htnteci F.XACTLY. PHYSICIANS should 

-Bvery Item of Information should be cnret'ully Huppl.ecl. ^^'^^^^'^ ''* ^•;,.^i"*'^hV-Specla! Information" for pT- 
state CAUSE OF DEATH in plHin terms. tli«t it may he properly Uai.fi.tied. I He special 

Ron« dylnft away from home «Iiould be &\ven in every instance. 




4 |- 



lUmrd >>{ Ihaltii- I" No 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. r..!r'^>-.!K'v! r.- REFER TO BACK OF CERTIFICATE FOR (NSTRUCTtONS 

3419 




i 



Bo^isfercd J\^o. 



\k-^.^a:M§T''^" ^*-r^i-^ ^mf^.f^r 



DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 



Certificate ot E>eatb 

PLACE OF DEATH:-County of CJ^>^ -' Vcv.xcv^cc . City ofCa.v o;va.>vcv,^co 



((!J 



ilWii 



3 



J*. 

i 



I J 



St.; — Dist.;bet. 



and 



No. VCWCCUC Obiy^Kv\a.V' „,„., ^--f'VNCEo.vr t^rTrc^rrco r<,R u»ot- "spec, .npopm.t.on ■ ■) 



FULL NAME >^^^'<^''>^■^^R^^^ ^a\j>.U.ajjt\^. 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

COLORE 



I iXcuLi 




]I.U 






MEDICAL CERTIFICATE OF DEATH 

I) \ I'K Ol- Dl'.A'l'H 

(Day) 



H A Tl" ni I ; I kill 



\ 



/jiM..!ith) 



AGK 



J lit ) .\ 



5 



13 

<I)ay) 



.\/,,ii//n i 



fl'^.S. 

(Year) 



H 



n,n. 



sivr.T.r MARKIT'n. 

wiix >\vi:i) OK i)i\nK('j:n 

'Wtitrin social il<sii.Miat ion) 







' I V<X\.XOLcl 



lUKTHlM.ACH 
i.Statr or Country) 




NAM1-: OJ" 

!'Arni:K 






lUKTIlIM.ArK 
Ol- I'Arill-'.K 
(State or Countryl 



MAII>j:N' XAMl- 
ol MOTlllCR 



MIR'I'mM.AlK 
Ol' Mo'rill'.K 
(Statt ur Country) 







A-V'>A,CX- J A.U^^aJJUiM^'^' 



OCCUrATtON 



oJk.<»-0>A' 



JX '>Ay"v^'vCX\^' 



I 



(Month) 



790 S 
(Year) 



I HKRIU'.V C[':RTIFV, That I attftided (lcccase<l from 

AitV^t us 190H to Sh-(r\^...Q.X„^-... iqc '. 

tliat I last saw h \.>v. alive oti V\4r\r.,a.1 ic,o 

and that <k-ath occurred, on the daU- statcMl above, at v 
y ^1, The CAl'Slv Ol' Dl'ATll was as follows: 

OJl/^A.^Lt .-.<=<J;r!UV>:xje^:^A.l^ 




^>:VV^-wa.. Ai^rr. .^.-O.-.^^. CK, W».' 



DC RAT ION r<v?;\ 

CONTRll'.rTORV 



;ua 



Months /hn\- 



Hours 



IHRATION 



^ 



}?<//.v 



Mouths 



Pays 



(Signed) SjTi^^^yyJ^ . vlivv<t-'fv.^^i m 



|\f\r !ll T<)0^ 



r 



Hours 

yivvC-ltltu. M.D. 

J] I .-. 

\<ldress) ^000 i^fr-^Wfr>v2l__ 



Resided ill Sau l'ta>ui^>-'i ':'-'. ^ '''-' 



}/,>if/i< 



IKn. 



T,n:AlM.VKSTATKI.l'KKS.»NAI,rARTU;ri,AKSAKKTKrKTO TMK 
lUvST Ol' MV KNO\VI,i;i)<".K ANI) Hl-.l.Il.l- 

(infonnant ^ ^tlvC<i L J Jx-VaX^X^ -.:. 



SPECIAL INFORMATION "nl> lor HospUdls, Institutions, Transients, 
or Rerent Residents, and persons dyinij awdy from home. 

Usual ReTidencei 1 OT laVJ ^LCvLU 31 Place of Death lX^^^^ -. Days 

Wfien was disease fontracfed, 

If not at place of death ? 



I'l.ACK Ol' mKlAI. OK KKMo\.M. 



DATlCof Hi KiAl. 01 K i;Mo\'AI, 

.ykv-,3,^ 190^1 



.V,,,,'..,. aw Q^' aii^t. V \ 



J ,1 



N. B.- 



"■"""""""■"■"""^ ^\ ACF h'iouIJ be sti.te«l RXACTLY. PHYSICIANS should 

-F.very Item of Informntion «houhl he cnrcfully hupp'-'' .;^. ',;; ".^^^ifieU. The "SpecSal Information" for p«r- 
•tate CAUSE OF DEATH In plain termn. thnt .t mny he properly cl»«s.i 
son. dyinft nwoy from home should be ftiven in every mstance. 



w 



II i 



I «•• 



1 . ■ 



I 



H 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BAC K OF CERTIFICATE FOR INSTRUCTIONS 



;■ 11. ;i1th— F N"f»- !«■. "^'.Ir^i?"^' ''•^'' ^ 



l^wv^ljtA>H Deputy ^loc.i.'h OfHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of*^^"*^ 



Certificate of ©eatb 

J? ^ 






^ 






TVT \^\\ r Hf^r^K t Y^ A St/ Dist.; bet. L ClUJLa^ and J X^Lt > V 

No. I H C^ > - .^CrC yW^CnX ^^^ otsTdENCE CVE tacts called .or under -TsPECAL INroRMAT.ON' ^ 

( " r/^rATH^occ^RreV-rrHO^s^PyT^L or"ns'tu"o'n cive ITS NAME instead o. street and nu.ber ; 




Dist.;bet. L (X.LLL\/t 



t 



) 



FULL NAME lUvcL-U-Lcr Uxv 




si:\- 



PERSONAL AND STATISTICAL PARTICULARS 

j C«»1,<>R 



h 



\\oJ 




A\x, 



Xi' 



I) \ ii; Ml Hi Kill 



(Month* 



\r.v. 



Sa 



) */•(/ I s 



(Day) 



M. filths 



(Year) 



Pa J . 



srxf.i.i' MAKwii:i> 
\vn)M\vi<:i» OK DiN'oKv i;i) 

(Write ill social «UsiKi'ation) 



lUKTIiri.AOK 
(StHlf or Country) 



j\t.c<r ^^ 






/tfv.^ 



NAMK OF 
FATHHK 



HlRTHPl.AiV: 
Ol" lAlIIKR 

(Slate or Count ry) 



MAn>]':N XAMI-; 

OF .M<)TIIi:u 



.C'^KX/^ruYN-^ V XK 




MEDICAL CERTIFICATE OF DEATH 

DA PK «)1- 1)1. All! 

,c\r Xi 




. IQO ' 

(Month) 'r)''V^ ^^''•'♦'■^ 

1 lli:i<l':r.V CIlRTri'V. That r aUcii(lc<l .Ifooased from 

Oct X^ icpH tn . 0\W Xsi t^% 

that T last saw h-..^" alive on vK^rvT 3^'^^ - ^^^ 

and that death occurred, on the date ^tatc-.l above, at 3^ 
UL M. Tlie CAISJ'; OF DljA'IM wa^ as follows: 




■YXJ2,A-A^'>vv<rt vA^-a- 



Di; RAT I ON J''"'^ 
CONTRir.rToUV 



.]/o>i//is 



Pays //ours 



A 



t 



Cy ■^vvCv-^ 



i: 




t 



Ah-O. 



f^ 



„ V^Or^-dU. 

TURTlirT.ACK A 

<)i- m»)Tiii:r ^' r\ 

(Statf or «.'oviiitiy) y\ 

_.^^.^-— ^^wtX-Uj, -- 

OCCfPATlON/^ II ft 

h'f>iifr,{ tn Sail I'innciseo J*^ '''" 



Mnuth- 



n,i 



rnV. xnnVHSTATK.,,'KKS.>NM rXKTUM^LAKSAKKTKrK Tn TMK 
iU-.Sl* ()I- MY KNOWI.I-.IX-I-' •'^^" in.I,IJ-.f 



f hi foini.iiit 



^i 



.jU:>\<yL 






(A.i.hrss fOOH vJA.ex^>vA.\rvoW at 



DTRATIOX )V<//-.? Months Hays 



(SIGNED) 



I ()0 ' i 






/fours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions.' Transients, 
or Recent Residents, and persons dyinq awav Irom home. 



Former or 
Usual Residence 

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



How Innq at 
* Pla« e of Death ? 



... Days 



n ACK OF HiKiAi. OK RKMnvAi. I i)Ai;r:of iukmx., or ki:m..vai. 

^ ' ,vrL< 




j^sAaj. Wvc-^; 



.<jvr M. 190H 






rs. B." 



"-= ' -""""""""T ui InF should be Htnte.l EXACTLY. PHYSICIANS should 

-r.very Item of InformntJon Hhould Iv. cnreVuMy -PP '- ' J^J^^^^ .,aH«Wled. The "Special Information- for p.r- 

Mtntc CAUSF OF DEATH in pliiin terms, that it may »e properly 

:on. dyfn?nway from home should be feivcn in every instance. 





^ 



V- 






ii 



u 



f 



!nB 



■srf 






It 



U' '^\ 



Mil 



WRITE PLAINLY WITH UNFADING INK 



m! ..f }' 



- 1 I V 






u 



ah' n/i'd, MW^-r>xWv al ^^^"^ 



THIS IS A PERMANENT REC*"'^^ 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




'1^ Q 11 ice r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



No. ^ ^ b 




% 



<XLKV»\^ 



Gcvtificatc of Bcatb 

da.>v0^cv>vcuLco City of O^->v0;vcL^xcc4.co 



lb 



St* ^ Dist.; bet. v 

•^ * ..-r, T^o iiiunrp "special INFORMATION ' 1 

( ,. O..TH cccu.s .w., rpo- USU.. "f^°f,:'«<,-\',;r,;s NAME .^rc^r" st%c., .-,» -.."«- >> 

V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



FULL NAME 



YvLcTU UJ /OL/ VW<:LinjL\i 



SKX 



PERSONAL AND STATISTICAL^RTICU LARS 
A , COI.OR > f) 



^ 






^ 



{jixdu^ 



AGR 



( Month )rt 



I2> 

(Day) 



5.H yra,s 3 V--..///.V ^S 



ASi. 

(Year) 



Da v. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATM A 



(Month) 



(I^y) 



(Year) 



^INf.I.K. MAKKlI.n 

wiDowKi) OK i)iv«»K,ri:i) 

'Writfin >i<KMal (Ic^ij-J^nation) 




Xoc'W^^Xd 



HIKTHri.AOK 
State or Cotuitt v) 



XAMK or 

I- ATIII.R 



lUKTHPI.ACR 

Statf or Coiuunr) 



M\II)1;N XAMl', 
Oi*' MOTllKR 



niK'nn'i.AOH 

()»•■ MOTH I'". K 
(Statf or Country) 



J4A/YYV<X>'^ 



\A/>\X^"^v \Xj 



1 







I HHKKirv CHRTIFV, That I atto.i.kMl deceased from 

. .Chwrw- an 190M to MlCVT ^t up H 

that I hist .aw hx.-^ ^ alive n,t \a^ ^5, icpH 

a„.l that death occurre.l, ..., the date stated above, at \ 0^0 
U^ :\I. The CArSh:^C)l- l)i:.\'l"ll ^v'-^ "< follows: 



"xl-X-^^oiViXv \J.(CL^XA..Ul 



DLRATION J''^^ 

C()NTRTBrT(Un' w:' 



Months H /A/i.c 



l/oins 




^Jonths 



fhus 



\ 



iXVvwCv 



occrrATioN [\i 



n 



M.'.iHi^ 



Am 



in:sT oi' M^vNo\vi,i:i)<-.h and ni.un.»- 



(III fo! niant 



(\.l.li 



DIRATIOM ,^ )Vi/r5^ -. 

(SIGNED) AJVcc^^ vH V ^^ 



Hours 

M.D. 



-A" 



t 



SPECIAL INFORMATION only for HospitdK, Institutions. Transients, 
or Recent Residents, and persons dvin*! .mdy from fiome. 



Former or 
Usual Residence 

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



Hew long at 
Place of Deatii 



Days 



I'l.ACK <>»•• III RIAL OR RJ:M<'\M 



i).\r):i>: mi kiai. or ri-:m()\'ai, 
\}V<5\- %'\ 



T90H 



I Xilillfss I I ■.- _ _ - ■— — 

^— ^— 1^— — ^— — "— ""^ , . t » I FX4CTLY PHYSICIANS should 

state CAUSE Oh Ht--^ • " " » ^iven in ©very mHtance. 

nnn^ dylnft away ?rom home Hhouid be <l..en 



'> t 



^' 






^%i 



fc 



ii im 



I- * 



U 



i i 

i t 



5 i 



1 1 



I 





li| 



w 



RITE PLAINLY WITH UNFADING INK 



• !1 il !i IV' 






/>.^/r /•V//'^/,M\{^^'^^v^>t>v ^1 



y,9^;H 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Bc<^lsfercd Xo. ^422 I 



dw^A^CCA <LiAK4 



t^ rS. «fS» 



1«-M 



N: 



■stt* r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificate of IDcatb 



PLACEOFDEATH = -CountyofCW^.>i^aAvcc^ccGty_^ofU.a^JA<v^>^ 



N 



/ .r DC.TH OCCURS AWV TPOM USUAL " ^ f ' ^f, J^JV^^^^' "^ , V E -tI NAME .NSTEAO OF STREET AND NUMBER. ) 

\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



VClA CO ......... .. 

Wa ) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 






? 



1) \ ri'. (U- luu 1 11 




UJJkcU 



AGE 






Yeats 



( Dm y) 



MoUlll!' 



.iH.L'i 

(Vear) 



xn 



na rs 



WIDOW i:i) OK I)I\'< >Kci:i) 
(Write ill social (l<''-i).Miat ioii) 



niRrnpi,.\OK 

'Stritt- or Country) 



M.MVtK OF 

f.\th};k 



inK'rHiM,.\cK 

0|- lAIMKK 
(Statf or Country) 



MAII)I:N NAMl". 
(>!•• MOTHKK 




„ a,c^A.ctAji - 



MEDICAL CERTIFICATE OF DEATH 



pVnroH'l>KATH A 

\i \J^ . JLl TQO 

(Month) <0«y> (^'^•■■"■^ 

" rilKRirHV CI'RTII-'V. That T attt'iKU-.l .leooased from 

jOct al 190H to QxCVr- Xl upH 

that T last saw hi.^' alive on VTUvr ab 190H 

ami that death occurrcMl, o„ the .lafe staled ahovo, at 1 
\X M. The CATSF-: Ol" l>i:.\;rN was as follows: 



.-^.r^-v 



DIR.VTION 



J 'cars 



Mouths H Pays 

hL^....s>^yy^ ——■ 

'^ Months '-■"■ /^<U'S 



//onrs 



■;>.;-.(.L 



lUKTHPI^ACK 
()I- MoTlIKK 
(State or (.Nmntry) 







d <X^XV»JJiVO-'>vCv.5.C0 



)',<■!> 



H }/,;iffKA{ /'■" 



OCCFPATIOK 

h't'siifrd in Situ l'iini>is,.< 

,„K.„..VKST^T.,.1.KKS„v.,r^Kr|^,;^^K>A.KTK,K T., T,n. 

HKST ol- MV KNoWl.i:i)<-K^^" lU.I.H.i 



DT RATION • Vt-ars 

(SIGNED) W-1. - '- ^ 
VKCV- :^t TOO*: f.X.ld ress) ^C5 ^'AlA.i dt 



J. Uj^"Lik\-vv 



IloUffs 

M.D. 



SPECIAL INFORMATION onlv for Hospitals, llisfitufions, Transirnts, 

or Recent Residents, anti persons dyng away from tiome. 



Former or 
Usual Residence 

Wfien was disease contracted, 
If no! at place of death ? 



How lonq at 
Place of Deatli ? 



Days 



(Infoiiuant 






., xcrol- lU KIAl. OK KKMoVAI. U\VV.'^^ 1«-k.a., -r Kl-MoVAl. 

11 1^. vKcv- 



Lt 



V{M,^ 



an 



i90'-l 






(\<Ulress I -^ W V\. *•' *^ ^ 

_^_^__,,^— — — — — i— — ■ ■— — — t te I rX4CTl Y. PHYSICIANS should 

state CAlJSf Ul ut.«ii »._..,. . ^.^^„ •, „.--. instance. 



state CAlJf^i ^M -- Hhoiil.l be ftiven in e%»ry instance, 

sons d> Jnft iiwny from home Hnoiim "v k 




I 



«. 



n 



■i ( 



II 

.1 



If I 



I i 



i i 



M 1 






; % 



}lf? 



r 



i| 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.^.t-^>. l-^l . REFER TO BACK OF C ERTIFICATE FOR INSTRUCTIONS 
Ikianl of Health l N" '-^^.3 ^ '' i ___ 



v| 



7-96>H 



Rf'O'istered Xo, 



Dale /'V7r</,VWML/'Y>^I(M\) P.'l 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



-t/vn^ 



Certificate of 2)eatb 

J? ' Q^ A ^ 

PLACE OF DEATH:-Coun,y of "JCL.., ix^.vCc^cc City of ^ O^ A^^^^^-^ 

FULL NAME ^\AX LLa-^^-vx 



) 



^ 



s 1 : \' 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 




1) ATI". < »i r.iK rn 



\(.H 



L 




/■flNIoiith* 





JUUk.k 



^ V ) ''U I ■- * 



(Day) 



M,>uths 



/l. .L.< 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATH OI" ni'.ATIl '^ 




ac 



Da I .V 



'^TN'f.T.K MARKTKP 

\\II)t i\\KI> <»!< I)!V»)KrKl> 

' \\'\ it! ill -..u-i.-il (l<vij.rii:iti«iii) 



3 a.' 



>^^ 




niKi'uri.Ai'K 

( Siatf or C'niiilry) 



»?.%MK OF 

FATlll.K 






Kj^y 



lUKTIIPl, ACH 

<)i I aimj;k 

(State or Country) 



MAIDl-'.N' NAMl". 
Ol- MoTMKK 



Ol- MoTIIKR 
(State or C'omitryl 



OCCll'ATION 




n 



f* .., 2.b ,....,.^JQO ' 

(Month) _^ (Day) (Y*^ar> 

I in-Rl-nV CIIRTIFV, That T atteiuUMl .U>(vaso(I from 

— — — - ,.,..,.. ' ;?:: i90 ~ — to „...,.--...• ".- 190 

that I last saw h •• alive oti - 1<jO — 

and that death occurred, on the <late stated ahove, at 
~"~~ M. The CAISI': OF Dl-ATH was as follows: 



DIR.ATIOK Vf'ars 

CONTKIUrTOKV 



Months 



JJaps 



J /ours 



Mouths 



(SlGNED).....,l..,J..J^5j.^-^,^ 



Paxs 



Flours 



M.D. 



. 1 v.i W- 



Ton 



'« r 







v<X^. 




f-t^^OLN? 



Rrsiiin' III S,nr /'i ,i »'i''-'' ^- ^ "' " 



.lA-;///n 



An 



•nMCAnnVHSTArK,..'KKS.,NAKrU.TJ..M.XKSAKKTKtH T. • THK 



(Infoiinaiit 



dUA.XJ>V<V. ^^'O'-K 3 



/CX/>xO 



f\.Mr.-«s 10 b 



vTcL^cxXvc d: 



Special information ""'y '""^ Hospitals. Insfifutions. Ifdnsimfs, 
or Recent Residents, dnd persons dying dwd> from home. 



Former or 
Usual Residence 

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



HoH lonq at 
Place of Death ? 



Days 



J'l \CF ol-- lUKiAI, <»K KI:M»i\ \l 



^ 



(Addres'* TC\L ^ V CL-C<C, 



DA LI'."!' it' KiAi. or KKM(i\AI. 

iL<j\r 3vE 190H 









k 



,. . 771 Hho-ild be stated IvXACTLY. PHYSICIANS should 
'". .lylnft «««y trom horn. »h.>..l.l be ftiv.n in .v.r> Ii..t«n«. 



^ 






1 c^ 



i 



'4> 



il i| 






iii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



^* 



II 



H..;ir<l <,f Hi-aJth— F No. ; > "^-^^ ^-^^^ 158:1' T 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I' 



»*li *t 



' !i if 



«l Is 



r 



V 



n 



'H 



' -H 



iPHil f 




34S4 



Itrv^o XjiAH^ Deputy Heai-h OfTicer 

DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco 



N'j.^^'x 



Ccvtificatc of ©catb 

f *a. 5. StanC»ai*C> ) 

PLACE OF DEATH: — County of ^ V/a>^' 0.\<x.>V/OU1Ca City of 'CV>^' J;v<X.>vc^<i ol 



cc>\. 



ivl^w^aHu, St.; 



Dist*; bet. 



and 



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



FULL NAME M..l:;(J:^.:W:->:xq (JJLv^nrv!. 




PERSONAL AND STATISTICAL PARTICULARS 



HEX 



.^, 



I> ATH < »!•■ liiK 111 



COI.OK 



M^UlLLctuj-^ 






AGK 



H3. 



} til > . 



II 

(Day) 



.!/">////. 



/ i.l:^ 

(Year) 



IS 



/>.i\. 



iW'iitciti <tH-ial (It si;,Mi.»t ii>ii) 



I 



RTKTITPI.ArK 

I Stall' or I'ouiitry) 



MAMR or 
I- AT 111. K 



MiK riiri, \('H 

(H I Arill'.K 
(Statf oi I'caiiitrv^ 



i r 



M\II»1:N' VAM1-, 
<>l MOTIIHK 



lUKTIITM.ACK 

oi' MornKK 

(Statf or Cuuulry) 




MEDICAL CERTIFICATE OF DEATH 
DATK (»1' DKATH 

Ik 

I m<:Ri:r.V Ci;KTn-\', Tlmt I attemknl dcccasccl from 

to 



(Month) 



(Year) 



til at T last saw h 



up 



alive on 



"T90 



and that di-atli occurred, on tlu- date stated above, at H oO. 

...wk M. Tlie CArSl<: ()l"^i)i:ATIl was as follows: 



J .A.x.tviLS.Xix.\,L6-Ck^' 



DL RATION Years 
C(>NTF^II5rT()KV 



A/on //is • « /)ays 



Hours 



1)1 RATION ^_ Years Mi>u(/is Days 

(Signed) J. <J vcc^a^^^^m 



Hours 
M.D. 



\ 



c\- '^-X 



I()0 



■fjL^> £) % . e (j p 

(Address) ioCb ^xXXJ^JLh^ ol 



OCCITPATION 



Haj^^^VA.J'^.'^'^V^VW 



h'ryid'',l ill Sdii I'l iiii, i-i'ii ^S '>■'"'■ 



lA"////' 



/■'(f 1 



Special Information onlv for Hospitals, InslituHons, Transients, 
or Reffnt Residents, and persons dyin!) away from liome. 



How lonq at 



Former or <^o(^ il ..-.. .-^..^ -. , 

Usual Resldenc? Ab vJV^o-OX) vJL.Ua^^ pjare of Death? L. Days 

When was disease rontracted, ^ 

If not at place of death? 



nil- MJOVl-: STATI'D I'KKSONAl, |V\ K'l" H' T l.A K S ARl", TRUE T<» III I". 
lil'.ST Ol' MV KNoWlJ-.IX.Iv AM> lU-.Ml'.l"" 



[ Info; niaiit 



'A» 






ri^NCH <»l HIKIAI, ok K1:M()\ \1, I DATKot Hikiai. or KHMoYAI, 



190"^ 






IN. B." 



-fivery Item of inV'ormiition should b.- cnrofuliy Kupplle.l. Adfi h!ioiiIiI be «tnte«l I'.XACTLY. PHYSICIANS should 
stuttf CAIISI; OF DKATH in pliiln tcrmH. that it miiy be pr<M>erly claHnifird The "Special Intormatlon" for per- 
son* clylnUt «way from homo Hhoiiltl be ftiven in every instuncc. 



k ii 



il 



»i 



fH 



n. i '; 




'-% 






M 



T:', 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

);,,,.! of ll.:,lf!i » So !« C-r^r":>l'-«tP(:', REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



, 






IfJOH 



Beglstet'ed J\^o. 



3425 







vvvA (kjLA>u Deputy Health OfTlcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

[ XX, 5. StanOarC> j 



Q^ 



PLACE OF DEATH: — County ofCl/(X'>V JAOaaX^^c^ City of C^CL/^x- J.Va. -vx<:.^^^.^C^ 



No.LcvlLU\---/./^AUrv\A,- --^ ^ (tlr^^LW^a-l: Dist.;bet.- "and 

IF OC*TH OCCUBS *WAV FROM USUAL R E S I D E N C E G. V E FACTS CALLED FOR UNDER ■SPECIAI INFORMATION" ^ 

.SPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



l/ if death occubs away from U 

N IF death occurred in a HO! 

FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



COl^OR 







MEDICAL CERTIFICATE OF DEATH 



DATIC Ol" I)1;aTH a 

\j\^xr 



i»\i I', til r.iK III 



(Moiith)ft 



(n.'iv) 



A-Xl 

fV«-ar) 



.\<.H 



. a.b 



> 'lUI I s 



•h 



M..,ilh^ . » 



'D 



Da IS 



^FN«', IJv MXKKIKD. 

WIIK )\\1-,I> (»K I)l\'< »K*):t) 

iWiittiii '•<n'i;il drsi j.'i);it ion ) 




p.iKTnri.xcH 
'st.'itc or Cuiiuiry) 



TffAMK OF 

FATHKR 



HIK'niIM,ACK 
Ol lATIIHR 

'St.ilt or (.'ouiitryl 



maii>i<:n NAMH 

Ol" MOTHKK 



\<xnj\^UL<X. 



L cut C'W-^v>x.co, 



iO 



f^" 



■\)^ 



: -sLyi iQo\ 

(Month) (fi»fl (Year) 

I IIKRIUiV ClvKTll'V, That I atteiulcd <letH'ase«l from 

il/..db aa 190H to 0x<j\r....,3»i 190 H 

that I last saw h .^.^ alive on .^.»A^^ ^^ Tcp 

and that death occurred, on the date stated above, at 10 lO 
L\ M. The CAlSlv Ol" DI-ATU was as follows: 



^months ^ Pax 



Hours 



(.oNTRinrTokv 



niRTTTrr.ACK 

OI" MOTIIKR 
(Statf or Cotiiitry) 



tAA^cLwOw>^iXt - 



ocrrPATioN 

h'fsiifrd in Sou /'iiuiiisfO 



DT'RATrON JVrrr? ."ifoufhs Pdv; 

(SIGNED). J. .UJ-., U 0-VA.rv>^kxt 

-'^..%% Tool. (Address) ^0^l'<X>v^rU4..> Ll 



M.D. 



SPECIAL Information only (or llospildls, InstUullons, Iranslfnts, 
or Recent Residents, and persons dying dvvay from l>ome. 

\) „ 

5.1 



)V'(/A-5. 



.1 A. /////> 



/).n 



THl- VMOVK ST\Ti:i> I'KKSONAI, I'A K T IC I" I, A R S A R K TR TK TO rilK 

iii-;sr Ol- Mv KNowij;i)<".H and iu;i,n:K 



UiifoTinaiit 









UCJK-UX^AXL VO.A' Plart of Death? 

Wfien was disease r ontrar ted, [( ] I ; , 1 j 

If not at place of deatli ? \J^\\.\.0. > '^. ^,. al 



Former or 
Isual Residence 



Days 



liLACJC 01 lURIAI, OH Ki;.Mo\ AI, 






i>atj:o! Ml kiai, or ri:movai. 



190^ 



INDlvRTAKKR 



RHb 0)1 



ua.^.c.<rvv 



ci.t 



N. B. 



-Every Item o»' Information should be cnrefutly Huppliecl. A(IF. Hhoultl be stoted BXACTLY. PHYSICIANS should 
state CAUSE OF DEATH \x\ plain term*, that it may be properly classified. The "Special Information" for psp- 
sons dyinft away from home Hhould be it'ven in every instance. 



ft-L 




H 



'r\ 



l\ 



I 



li 






> 



' . 



i f 



I ..'th 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CE RTIFICATE FOR INSTRUCTIONS 

tU26 



1, !■ V 






L 






Jteo^/.sfrred A^u. 



dwO-VW^ <X,t'\M^ 



.D€DUtv Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "U. S. Stan^ar^ ) 






OS? 



No. 



PLACE OF DEATH: — County of^O.-,^ J Vorv^ct^;^ <: City of d(X>x' iva-irv^^Atc 

ni^Qwtt^Wv^dJ,. St. 



Dist.; bet. 



and 



/ ,r DTATH OCCURS *W*V FROM USUAL R E S I D E N C E G . V E FACTS CALLED FOR UNDER SPECIAL .NFORMAT-ON- \ 
( ,F DEATH OCCURRED .N A HOSPITAL OR INST.TUT.ON GIVE ,TS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




^^ 



VI 



\/y\,KX \}.iA^' 




PERSONAL AND STATISTICAL PARTICULARS 



^'■■^ QO 



Ctn.t'K ^1 



Jtrv^OLLsi 

DATK OF lUK IH 



UjJvctjL' 



Muiith) 



AOK 



3t 



}'i\n 



i|);iv) 



l/-.;////* 






Pin 



SIxnUR, MARklKIV 
WnxnvKI) OR DIVOKCKI) 

(Uiilciii soi-ial (U'^iKiiatioii) 



i;[R riii'i, \CK 
(Statf or I'liiintrv'* 



»• A IJl l.K 



IStatc or Country) 



M MDICN NAMH 
ol' M<)Tm:K 




0. OxoLuX' 



I 



MEDICAL CERTIFICATE OF DEATH 
DATK »>!■ PKATH (S. 

VjW n lOoH 

(Month) J^^l (Vtar) 

[ IIP:RI:I5V CI^RTIF'V, That T atteitflod <leceasecl from 

AlLCV- Il> 190 H to M^^^J:::...,aJi.«.«.....iI9oH 

that I last saw h Xh.' alive on \V\-<rv- 3.1 I90H 

and that ik-ath occurred, 011 the datr stated above, at ' l^ 

J M. The CAl'SIv i)\- l)i:.\ Til wn«! as follows: 



,\Aaax> 



,\Ai. 



h 





£ 



f\/Xj 






nr R.XTroX Vturrs 
CONTkllJlTOKV 



Months 



Davs 



J/oin s 



DC RAT ION Viuirs 



Mouths 



Days 



niK THIM.AOl-: 

til .M()rm-;K 

(State or Country) 




\koJ 



.CCL 



OCCUPATION ^ 






M.nith' 



fhty 



•V«r MU.VKSTXTi:i.l'KWs..NAl.|-\KTIcr!.AK>AK>. i" K I 1 '. To IIIK 

iii:sToiMv KN.)\vi.i:i)<'.i-; AM> '"'-"••»' 

,,„,,,„,,„ )b. Ob. 'Li.Al^hj 



(Signed) LcLcu v>v Uj-ul^v^^x^ 

vVUjV" 3Lt) looH f.X.Mresv) l^?> LLL^ jl- 



M.D. 



Special information ""I* '"f Hstspifdls, institutions, Irdnsients, 
or Rpfent Rrsidpnts, and persons dyinq HWiiy Iron fiomr. 



lsu.ll Rpsidrnre^ Oo M Ux 



TOi MUxUrvvvC3w 



HoH lonq at ^ 

Place of Death ? T 



Davs 



Wfien was dis»'dsp rontrarted. 
If not at pla( p of deatli ? 



i>\ri;.)! lUKi.Ai. or kj:m(>vai. 



I'l \('l' III \\\ KlAI, <>K ki-;m(>v.\i 

indi-.ktakkkVmV A-ci.>djL>v \jR ViD 






^\(l.lrl■s^ 



N. K. 



.,-vcrv Item oV inVormt.tion Hhouhl h. cnrc.-ull> huppIKmI. A.U; Hhoultl he Htntecl F.XACTLY »;HYSICIANS should 
HtHt/cAllSr OF DI:ATH !n plnln tcrmn. tlu.t it may be pr.>per!y claHshle.l. The "Spcc.nl lrnornu.t.c>n for pT- 



iinn» clyinft nwuy from home should be ftiven In every InHtnnce. 



-3 



O-'^ 

^^, 



c — s> ; 



('• 






il » 



i 



M 



fcf 



!i I 









Il 



!l:| 



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

„,„ r,t , . . H .|,-KNo, ,.-*a'y:-WIM'C.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/Mf0 Filed,. 




vIhUv.A^ _.i^^^ 



llei'isleved Xo, 



^ L 



<k^w^^ JaA>cv Deputy i^oaUh Cfficer 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of IDeatb 

( 11, S. StnnDavD ) 

J? ^ 



PLACE OF DEATH: — County 



i?0 



of C)a->A.' JxcX' vvevXLcc City of -^' cu^x- J ,Vtx. ^ vc,<-xl^^-c 



^ 



A 



rNo. JCrlcL^^v n,<xtl V) (xvk 



St,; 

SID 

I NS 

I 



and 



^ IV , v»w w, . w^ ^ . V -.., Dist.; bet. 



^ 



^ 



FULL NAME 



(j,va/->vt \x) oJt^ n\i 'dcq a<'>\ 



'^I'.X 



PERSONAL AND STATISTICAL PARTICULARS 

I cui.cR ^ iA 




n 



I) \ I r: 1 II HI Kill 



.LUwtii 



\h 



M.liith) 



(Day) 



rWd 

(Yt-ar) 



MEDICAL CERTIFICATE OF DEATH 

i).\TK ()!• i>i;a rn 



l\<^r. 



(Month) 



.11 

(Day) 



(Year) 



I lli'lRf'lIJV CI'KTII-'V, Tliai I .itlriuKMl deceased from 

— to xtp-"-— 



I90 



A»". }•: 



oL y,,ns i 



MiDiih.^ '^ 



n 



na\ 



siNc.1,1'. \! AK 1^ n:i) 

!Wiit< in -^o.-ial ili-iv nali' >n ' ! \, 



A, 



lUK rm'i.Aci'. 

(State DT (.'Diintiy) 



NAMl' 01 
I- A 111 IK 



lUKTIII'I.ACK 
OI" lAl"in-:K 
(Slate or I'onntry) 



MAIDKN NAMK / 
()I- M()Tin:K 



lUK rUlM.AC'K 

nv Mo'riii'.K 

(State or roiuitry) 







tliat I last saw h.:~™ alive on 



190 



and tliat dealli orcitrreil, 011 the date- stated above, at "^ 
"~ M. TIk' CAl'Slv Ol' I)l';.\'ril was as follows: 



aJax^va./^vx^^'^ Lkj.&-w:>>..c<- Cry 
.OuC*-^vx:^wcLx.., 



>>V.;CL:V«a.\... 



DIR.XTION Years Mouths Pays ^ Hours 

CONTk 1 lU'TORY • 




OO'^.C^- 



lL 'Cvt 



4.tlV 



jJltcc 



(irrtTATTON f^n 



R^sidfii ill StTii /■'ii!iit/<ii> 



CrV-^ 



) Vi/; 



DrR.ATlO.N -^- )'rdrs 

i 

( Signed ) LcrVovtv 



Mouths 



Days 



1 (E.U.Llcw^vdL- 



I lours 
M.D. 



m 



I()0 



Mn.th- 



THKXH..VKSTXiM^.MM^KS.,XA. PAKTirrLNK^AKKTKtKT.. TMK 
lU-ST ()!• MV K\<t\\ l,i;i)'-l. AM) r.I.Ml.l- 

a.,r„.,' ^^^\^. ^^XU^ 



<..) a.-'^^'-M^ 



(Addri's^) V fr\(n^iL\-^ L .V. V '..-U'.. 

Special information onlv for HDspitals, InslifufwiH, [ransients. 
or Rctenf Residents, dnd persons dyinij dWHy Iro.n home. 

Former or CV / * V \ , 'A 4 ""^ '""'' '^' 

I'sudI Residence ^VDt U /CLUt> VOvO- ■ ^ PLire ol Death? 

When was disease fontracfed, 
If not at place ol death? 



... Oavs 



i»A'n; of Hi Ki.\i. 01 ki;m<i\ai. 
MlCV" M 190^ 



PI.ACH Ol" nrKIAU OK ki;.M(tV.\l, 

I ni)1-;rtakkr VJ3A^w^r^kx\^ ^^ -iwcv^-wl 

(AtMreHs.. "^icAD^O Vl) Vv^ 5l V <r^ V v-.A 



should b. cnrefuHy HupplJecl. AGR Hhouhl be Htate.l F.XACTLY. PHYSICIANS should 
in plain terms, thnt it m»y be properly claHHifleJ. The "Specinl Information for p«r- 



l\ \\ F.very item of inVorni'ition 

state CAUSn OF DtATH 

«on« dyinft oway from home should be Jiiven in every instance. 



M 



' f 



t . 



i< 



Wl 



I 



I f) 



I 



* 



ti 



I 



i',.,.it(i ot" n. :i:th i V 



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

REFER TO BA CK OP CERTIPICATE FOR INSTRUCTIONS 



'-' ^ Xi,HS:H Co 



t' l-'ilcd , sj Lt»>-*-' I"" 



H^, ^c^ 100^ Ilegislered Xo. 

l<^v^lit\n< Deputy HeaSthOfficer 

DEPARTiyiENT OF PUBLIC HEALTH=-City and County of San Francisco 



Certificate of Beatb 



i (^ ^ ^ 



No, 



PLACE OF DEATH: — County 



of O/CXy^rx- J-V<v^vcvA<: ' City of *^ <Xo^ J/v<X'->x^a^'C<j. 



St.; 



Dist.:bet. -— --r------r-— and 



i.ciiHi orc;inFNCE Givr facts called roR under "special information- 'X 
( " °"or.r^cc"Sp-ro',"r»o"s^."" o^f-Is^Tu'r'o^'^vc ,.s NAME ,»STC.0 or st.cct ... NUMB.,. ; 





FULL NAME V' . U Ch<:v^^Jl 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

COl. 




\<^i 



"""bl 



jl 



voCb 



i> A ri-: < u' i!iK rii 



Ml 



Month) 



,\<.K 



CL^'V p**^ )></( 



(Day) 



.\/.'>/{/i^ 



(Year) 



/)(/ r> 



wiix >\\ i:i) < >K I)!^■< iK(i: i> 

• Wi iti- in Hoi-ial (l<-i<.Mi:il i' >ii ) 






lUK THIM, MM'! 

(Stale or (."ounti V* 




dj^^'xcyU 



^ 



MEDICAL CERTIFICATE OF DEATH 

i).\ri-: (»F i)i:ath A 

mI^sv 



(Year) 



Jib... 
(Montli) (Day) ^^ 

I lII'iRI'lBV Ci:KTn'^V, That I atUMKlcd <U'<x'a.seil from 

NJl-cxr ^2> 190 H to ^ xKcu^ "^^ 190H 

tliat I last saw IiA/xj.. alive 011 STUV^.^b.. I90H 

iii'.d that death occurred, 011 t lu- date stated above, at -. -i* 
V M. The CAl SIvXH' Dl'-.X'rH was as follows 



t^A-tJlA-A^ ..^Ju\>-^\> 



OL^\,M 



NAM)-: OI' 

I A 11 1 i;r 



(^ 



niK I'll iM,.\eK 

OI" I AlHlvK 

(State nl (.■(lunti v"! 



J X^VXxWI V^.^^CL ^-Qpr^X 




■xo,^ 



MAIDKN NAMl-: /"> 

i>F Mo'rni'.K / 1 1 



UJi^>jt^ ^^^^v 



? 



1)1 RATION )'e'ars 

CONTRIinToRV 



JMontln 



Days •' J/ou>-.'\ 



DIRATION 



)\:ars 



T) 



(SIGNED 



, I). 0^ c^ 



Months 



7V^VAJ»rY\jt 



Days 



//ours 
M.D. 



\^v wvAX' 



niRTiTPL.'vrK 

OI- Moriii-:K 

(state or eoutitry) 



\ 



vLcUax 



nrrtT.\TioN 



);■.■! 



}/,.,,/// ^ 



Dm 



Tin-;AHC.VKSTATKn.-KKSoNAl PXRTierLAKSAKKTKri- TO T.IK 
HHST Ol' MV KNoWI.I.Dtih AM) in-.l.nj- 



f Infoi iiiaiit 



i(?. to %^uia 






( VfMrf^** 



■yVZ^r^ :'X np - (Address) ^ V> V^ '^•■■-■'^^ { 



Special information "nly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyin-) away from home. 



Former or 
Usual Residence 

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



(V ( i! HoH lonq at 

\| UaT, vJyU^yB ..;;,„.,, Place of De« 



. . Days 



DXrKof lUKi.M. or K1-'.M()\AI, 



I-l \(.l-: OI- lUKIAU ok K}-;Mt»\A!, 



.l..,?CAlISi; OP 0|:ATII in pinin l.r,,,.. Ih„t it m«v he proporl, .h.,.i.-k-.l. The Spccnl ln.orn.,.l...n for pT- 



sonj <l>!nft »»uy from homo ahoiihl he ftiven in every in«tnnce. 



I 



w 




) 



«^ 



If ' 



m 



iii *« 



f 



I •■■' 



I <i 

.11 



,1 , ! I!' I'th »-' No 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



^.iri^.'S;^, jj&i' (• 



i 

DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 



.{^l^X'\vuM.^' aa ^ '^ ^^ "^ 

^VVUsilA^U ^^P^^^ ^•^^?*'^ ^^^^'' 



PLACE OF DEATH: — County ofCW^x J 



No. 



^ 







(tcvtificate of 2)eatb 

( "U. t5. J?tanc>arc> ) 
Mn ^M J KCU>\ CC<1C0 City oiOp^^ JAXIAvCc^ C 



® 



vll'(v^^''^'^"^%' 'C^-'vX'tV 



St.; ^ Dist.;bet. 



a-cc>v'ci^iL/V ^^^ ^'^ 



C-V.WCV^LC^V oc-=?nrNrrr,vr t^CTrCATttD tor' U N DEB -S PrG. AL INFORMATION- ^ 

( '^ .VorATrocr^Rrr.N-rHo's'rA^ rR'?^?f,?u'4^'^o.;-;i name .nst.ao o. str... ano number. ; 



) 



FULL NAME 



,0"t/>A.U. JX^Xxiu 



PERSONAL AND STATISTICAL PARTICULARS 



I 



-- 0(7) 

I M<iiitht 



uu.^kcU 



AC K 



i i )V.r;> M 



15 

may) 



Mioiths 



(Voati 



15 



/>.M. 



\\ii)n\\|.;i) < >K i)i\'»)K'.'i:i) 




HIK'rniM.AOK 
(state ur Coiniti \ * 



VAMI <)l* 

I- ATin:R 



SI 9^ 

LL Ul't .nu^ vdLi\) \^ toucll 



MEDICAL CERTIFICATE OF DEATH 



DAfb: 01-" I' 



Qw 



(Moiitir 



iUay) 



iYear) 



I IIHKKHV CIlRTIl'V, Tliat r iittonrkMl deceased from 

Oflc\r %S.. TooH to MVcv- JX'^ 



' A^^s 190 

that T last saw hJt^- alive 011 



^^Icv^ %%... 



lip 



.md that death nreurred, on tlie .hite stated above, at b 
M. The CArSjv Ol" DI'.X'IH was as follows: 




CO^V.0 



vj^cX'> > v^r> V (xLvAi 



lUR riii'LAfi-: 

(Stat< (II c'otuiti yl 



M\1I)1%N NAM1\ 
Ut MOT HICK 



nrRTnrT.AOT* 

01 MO THICK 

(Stall- or l"inmti\-^ 




(>rrTTATION<^l y 

.n^:^,«n■KST^■,■K..,•KK:.oN^■ rjKTirri.AKSAKKTK.K To r„K 
HHSTOI-MV KNOW I<i;i)t.h.XM) »«»••''''•' 






4 



DT RATION )\uit'S o Mouths 

KV M\r*\^t 



/hlVS 



Hours 



coNTkir.r'roN 



DT RATION }Vt//'.9 



Mouths 



Pays 



(SIGNED) J U). AjUrC.lvL .....^ ...^. 

vj ^. f\* A,, T()0 ( Addrtss) ',.'t>.. V -3 I ■A.>.a..rv..<. > 



Hours 
M.D. 



SPECIAL INFORMATION ""•> '"^ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying .may trom fiome. 



Former or 

Usual Residence — — 

Wfien was disease contrafte<» 
If not at place of deatti? 



How lonq at 
Place of Death ? 



Days 



IM.ACH Ol" lU'RIM. <»K KllMoVAI 



ri,AC:r, or lu r^ 1 



I)\Tl". <>; HrtOAl. 01 KKM<»\M, 



\\^<r Jh^. 



T90H 



rNDlCRTAKKK 






» i^w a ■' 



"" - ^1 .. ,. , ...p „h„,,i,i ho Htnteil liX4CTLY. PHY8ICIAMS nhould 

"on. clylnft away from home Hhouhl be feiven Wi every inntance. 



r 









urt 



III 




^mr WRITE PLAINLY WITH UNFADING INK 



»'"_r"v.. 



Ikiat.l .-I II. .ilth 1- Vo^ 1^ *TH1-^-*" "''^'' ' 



/ 



>r//r /'VAv/, \lfW)^^-^l^ ^^^"^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,^^AA^ 




D0pusy Ha ait *^ Officer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



> :.M 



n 



i 



Certificate of IDeath 



(^ 



PLACE OF DEATH:-County of C^^A^ -' V^v>^^^^^ City of dxX.>vviKx>..>vccACc 



N l\ V^A CV.VXI ' 



:lll^ 



TVT ^^^ \^ lw^ ^ rrv ^H IN St.: b D st.; bet. 1^-M and 

No. ^ -^ <^ N I LV^^A C^V.\..-Vi orcTnrNCE GIVE facts called for under "specal information' \ 

( ,F DEATH OCCURS AWAY FROV USUAL « ^ ^ I D E N C E G ' V E FACTS ^ .nsTEAO OF STREET AND NUMBER. ) 

\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS IMMIVlt 




at 



m 



mk 



V * IB 



h i. 



FULL NAME 




.-OL/^-V/VwCU.. 



t 



-r. \ 



PERSONAL AND STATISTICAL PARTICULARS 
""" ' COI 

DATi: <)L i, IK 111 




Qnicxu 



li).I^AiJl 



iM..iit1ii 



J 



A< .!•; 



) V</ 1 s 



b 



<Day) 



M.'utlis 



(Year) 



iq 



/)>? I N 



\\ I i»i >\\ i-:i) <>'< in\'<»Kri:i) 

iWlilrill v(U-ial il.'sijMKlt i"ll) 



!UK rm'I.Ac'H 
I State <>i Country) 



N \\T !■ <)1- 
I AT II IK 



lUK'nilM.ACK 

<)I lAlHl'.K 

' Si.iti of r<>\intry) 



MAII)i;x NAMH 
OF AIOTHEK 



Ol- MOTHKR 

(State or Country) 




MEDICAL CERTIFICATE OF DEATH 



DATK OI- I)1:ATH ("\ 

Vl'\c\r 3>1 

r\iM,.tii) (Day) 



(V.-ai 



iU|':RI':I?V CI-RTII-V, That r attended (U'ccasod from 

O'^-^rU- ab 190 H to \XUPcr' %\o up H 

(hat T last saw h A. • , . alive on yi\^'\r '^^-^ up . 

anil that death occurred, on the date stated above, at ^ 
Uw M. The CAUSK Oh" DI'ATII was as follows: 



6 



nr RATION )'V7/-.v Mouths 5 Pavs Hours 

Cf^NTRinrToKV chiy>iSXj~\^^\kjs.'^r»^ 






tfVTLA^OU- 



oCCT'PATrON \j 



M 



'o,'ih< ^H /'<"•>• 



THK AHOVK STATKP ''HKS.,NA, PAKTUM^.-A'^^ AKK TKIK TO TMK 
lUCST OF MV KNoWUl-.IX.h A NO lU.MM 



(Infui uKUit 




asa VI rivcuu5vv\x ox 



C Xddross 



DURATION 
(SIG 



Years 



Mouths 



/hJVS 



NED)^A.^^tl>uJl 



Hours 
M.D. 



-i- 



SPECIAL Information •>»'> ''"f Hospitals, institutions, Transients, 
or Recent Residents, and persons dyinii dHdv troin home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



ri \CK Ol' lUKlAI, tiK Ki;M<»\\i. 




O-Lu, ^h-<S^^^ 



daC'""; r.i KiAi. or ki;movai, 
.^^ 190H 




i"Ni)i;i 



L<r>v/vx/t' 



N. B.- 



""■'"— —"—""'"""'"'""''^^^^^^^ ... II ACF Khoiilil be Ktiiteil l.XACTLY. PHYSICIANS Hhould 

-F.very item of !n*orm..tion should b. carefully suppl.ed. '^^•^•;^"'' ';^^;.^: ."''^^He •Special Information" for p.r- 

stpte CAUSE or DEATH in pinin terms, that it may be properly J»HH.».cd. he .>pe. a 

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



{ : 



111 






la 




U 



liii^ I 



\ ! 1-1 






|8u« 



!!• /!'; 1 "^ 



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

, t-^^-^iHScP.-o REFER TO BACK OF CERTIFICATE FOR JNSTRUCTiONS 



KJOH 



Jf.po'is/^erejl jYo, 



l.trvAA^lxAH>|, Deputy. HcaitflOfncjer 

DEPARTMENT OF PUBLIC HEALTH=Cit} and County of San Francisco 

Certificate of IDeatb 



PLACE OF DEATH: -County ofClcx^ .K<x^c^<Lcc City of Ocu^^- Jxc^vvec^ao 
M..dt) "X^.*^ivtA (R.' ^Akv,t a j St.; Dist.; bet. — ^nd --— — ) 

INO.^"^ OeV^^^TVCO JVV^,^V . '■ pFSIDENCEG.VE TACTS CALLED .OR UNDER "SPEC. AL .NTORVAT, ON- \ 

( '^ ^."o;:rH"cc^%t•o^^^Ho's^R'.-L ?R'fNS°n?u'4^N O.VE .TS NAME .NSTEA. O. STREET ANO NU.BER. ) 

0'^ 



FULL NAME 




'\.<x>JjJ) OlD<x^vcr 



U.. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 




L 



oJUi 






MEDICAL CERTIFICATE OF DEATH 



DA I i: ol HlKTIl 



.\<.K 



(M<)iitli> 



12> 



) ■/•</ ' 



(Day) 



M.'utlr 



(Year) 



Da I . 



NlNt, I,H M\KKn:i) 
WFlXiWKI) «>K DIXoRv' j:I> 
'Write ill social <ltsis.M)atioii) 



niRTIlI'LAOH 

fStatt or Cotintry) 



VAMK OI' 
FA TH j;R 



lUKIII IM.AVK 

(>!• l"Alin\K 

I Statr or Country) 



1 



(Year 



DATE OF DKATH A 

\JLcv- 2lT 

(Motith) 'i>'iy) 

I IIi:i<J:i{V CIvRTII'V, That I attciukd decoasotl from 

kmvT Xt I90H to .^^^ on 190 H 

that T last saw h A..-r.- alive on MV^VT .-'^'l T90 •^i 

and that (katli occurred, <»n the date stated above, at \ <>0 

d M. The CAT SI': Ol- DI'ATII was as follows: 
OX^XaJCaX^jl 



3.xxX<x 



MAIDKN NAME 
<>jH MOTIIKR 



lURTUPLACK 
«»1" MoTUHR 
(Statf or Country) 



? 



DIRATION 



. , , ,^ } \uu^ Months DttfS 



Hours 



ihji.\Uv\Al 



KK.t> 



DERATION 



)'i'(jrs 



Months • 



>/Mpr 



<>xjJl 



<X/0^vds_ 






(SIGNED) V. UJ- ^'5X^ (-M 

QlfXmr X\ IQ04 fAd.lre<s) dt.'lcAgA -^^ 



I/out s 
M.D. 

! i 



OCCrPATION 

AVwV/^'/ //' Sail />,>>/< />>;> O ' > ' <" ' 



THKAUOVKSTAT.U.PKK.ONA. rAKT.rr.-VK.ARHTKrH TO T.MK 
llHST Ol- MV KNOWLHDC.K AND lU.I-Il.f 



(I 



nfonnant Vi^ UUXX^ 



SPECIAL Information only tor HnspitdK, institutions, Transients, 
or Recent Residents, dnd persons dying away from home. 

Former or ^., f . 1 -^^ "r '"? V* .. , 1 

L'sual Resident eO Ob U\<XM OX Place of Death ? M 

When was disease (onfrarted, ^ 
If not at plare of death ? 




-•dvs 



I'l \CK <)!• lURIAI, '>K KJ-;Mt»\ AI. 

i 



Q\o±, 



,\_<r>'s-ct- 

INDHRTAKK 



DAI'l-: of lit KiAi, or RlvMoVAI, 

Ox. 






kYC ot, 



, . .... ,„^ef..llv HUDDlied. A(;K Hhoiild he Htiite.l r.XACTLY. PHY8ICIAN8 •hould 

^. «.-p-ve.y ..e- --^n;— -7, ;'';,':^ ".':;:::;c r. r:'; ..e .......n, ..».»;.•..... thc "hoc.,.! i„» -..,.„•• .«, ^r. 

'". dytn* away from home »hould be ftiv.n in every in-t»nce. 



I 



i, 



mc4 



»f 



™i 



141 il 



lii 



1 1 



! I 



I; I 



m 



I m'^ 



I I 






_^R.. 



i;^ 



WRITE PLAINLY WITH UNFADIIMG INK 

Ho.-ud of Htriltli }■■ No. 1 1; '5.?J^;[S^j uScV Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



<s^^^^^ <^a/v\'^ Deputy rioulLh Officer 



JRegisfer'od ^\7>. 



3432 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX. S. StaiiJatf ) 






V0,> 



PLACE OF DEATH: — County orJ o.^^^'^i^^^cov^..^* City of Occ^l 



(?P 






c^ 





FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

^'-^' QSp I I COLOR 

X/>-YX<xjij, s^A / // 



DATl-: Ol- IIIKTU 





Ojuxnzvxi „.. 



MEDICAL CERTIFICATE OF DEATH 



(Month) 



(Day) 



/%3 



O 

(Year) 



DATK OF I)J:aTJI A 

\iWr 



(Month) 



(Day) 



(Yt-rir) 



A OK 



(o5 

^INO.I,K. MAKKIi:i) 

u'n)()vyi%i) OK i)!\'oK(Hr) 

'Write ill social il(>ii.'iiat ion) 



MiK ini'LAt'i-; 

estate or c'(iiiiitr\'') 



NAMK or 

FA rin;k 



lUK run, ACK 
Ol" iwriiiiK 

'Stat* or Country 



MAlI)}-:x NAMH 
Ol" Mo'niKK 



}•'•, 



^!'»ii'is *: n,i\s 



U)0 \ 




&\xXxXj 






I HRRF.BY CrCRTrPV. That T attcn.K.l clcHvased fro 

^<^ ^^ .......„....190H... to aKat ^% 

that r last saw h ^..' . alive on ^lUXT 'XX 

MU.l that .li-ath occiirre.l, on tlu- .late stated above, at id. 
^4 M. The C4USIV OF DIvATll wa. as follows: 



MIK'I"inM,A("K 
<>l- MdTlIlvK 
(State or ConntT\ ) 




(.ONTRIHrTORY 



/hiy 



Hours 



DT-RATrONY Years 

(SIGNEDJ.UJ, J. ^AAJUii^iri 



.^ ft) ft/ /is /^(fVS 



Hours 

M.D. 



«rf ^ ^ 9 ' ^ *-. "^ f ^ '^ "^ '^■^ ' O FM only for Hospif dis, InstituMons. Frdnsie nf s 
or RpcenI Rrsidcnfs, dnd persons dvin? dWdy from fiome. 'fdnsienrs. 



occri'ATrox ^ 

h'f^iiird ir Sail /'i ,n/, /',-,i' oi.Cj )'r,n 



1/,,;////. 



/;- 



Till". VHnVK STATI'I) PKKSONAi, |.AKTICII.\K^ \KI TKI )• To TMK 
UK ST OF MY K.\o\VI,i;i)C.K AND lU". I, I »: F 



(In (<)• mant 



former or 
I'sudI Residence 

Wfien was disease contrarfed, 
If not a( pidfp of deaffi ? 



HoH long af 
PIdf e of Oeatfi ? 



Days 




INDKKTAKK 



rii^iAi, OK k,.;m,,xai, 1,ATK.., m. k,.,. o, kfmovai. 



iH \ku> Vm' XlXy >v<r»xvi. '"^^ cU^v 



'A<Mi. s. 



»^51 



^'^^ ^v <r> V 



N. K. 






i; " 



I 



.( 



!fii 



M 



lf<<i 






V 

ll 

Wi > 

f 



UH 



li 



': I 



li f 




> I 




;--jV 



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



Dff/r /^y/rr/ }<(\^^\)<Jirrt\l^ 



^H 



.^rVCUS 




n^ Depu 



7.9^; H 



h Officer 



REFER TO BACK OF CERTinCATE FOR IN STRUCTIONS 



3433 






DEPARTJIENTOF PUBLIC HEALTH-Cify and County of San Francisco 

Gcititfcate of Scatb 

( 'a. S. StaiitiarO ) 
PLACE OF DEATH:-County of CW>x .j.Vcu.vc^^Ct City of ^CC^ i.Va^vc^^^ 
<No..^a^M]U.vlc^tA>^>vu Llxvl St; I Dist.,bet.l'cv[Lvt> and l\^ivrvvl 

/^ IF DtATH OCCURS AWAY TROM l)<5liai R r C ■ n c- lu /> c- ^ . »•>''-«.• -w x^ ■«.,^ y w aUU -V -VV.wV\r>VV 

FULL NAME U^-l/^^-wO... iJ JliU^xdLcxll 



— ___ PERSONAL AND STATISTICAL PARTICULARS 
^f--^' \^ [j j COLOR ^ 



MEDICAL CERTIFICATE OF DEATH 



i>.\r}-: «)i liiKTji 






.N; 



(Month) 



AOK 



Si 



)>, 



T 



(Day) 



M.niths 






DATE OK DICATH A 

Ml 



(Month) 



.ai. 



(Year) 



r\ 



I IIICKKHY CRRTIFV, That T ntteti<|^4ee«>ase«I from 



1^. 



/),M 



^FNC, I,K. MAKKIKl). 

wiixtwHi) OK ni\okrHr> 

(Wiittiii sin'in) (U-i!.'iialioii) 



' Stilt (.■ or I'ouiitrv) 



ro 




NA\fK OF 
FATJlllK 



I 



lURTHIM.ACK 

oi- iArm-:K 

(Statf or (.■oiintryl 



MAIDKN NAMK ,o, 
OI- MOTFIHR '^ 



HTR'riiri,ACI': 
OI' MOTHKK 
(State or Coiuitrv) 



UXirVca UJ/CudjL 




iVocWaxcL 



that I last saw h -J^\ aHvc on Ovmj- X\ n^\ 

an.1 that death occurre.l, on the <late stated al.ovc, at °['hC} 
<\ M. The CAlSlv OF DI-ATIF was as follows: 
UwC^cdjl VVL^^VnI.*^ 



t L' YVA^XX.1 



V ! 

I n "^ f 



VTV^u,V\hCX.'>:\-UOL! 




1)1 RATroN JW., ,lA>;////.v 5 Z?^,,, 

CONTRinrroRV t^^^v^vAJl U.^.UvL,t Oc>vdL 

I)rRATI()!<^ Vcars 

^SIGNED) ...U. t). mcVQiL^t 



//ours 






/)«)'. 



IIoios 

M.D. 



:aa 



1 



OOCUPATIOX 

rm-. \i{()VH sT\ri:i) i-hrsonai, par ri(-ri. ars ari-; trif to rm- 

lU-.ST OI- MVKN()\\1<1:D(;H AND I5HMl-:i-- 



nr^p^J^' M^. "^5'^"'^?"'"'0'^ ""'^ ^**' ""^P'f''''*' 'n^tif Unions. Transients 
or Recent Residents, and persons dyin.^ anay fro;n home. 



M 



(IiifoonMtit 



4 



Former or 
I'sual Residence 

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



ftow lonq at 

Place of Death? Days 



P^ACH OF IHRIAI. (,R RKMOVA,. j DXTFof IMk,.,. orK,CM(,VAU 

Lu^\L^^ ivOjccv-»x I vU\r X'\ T90H 

t • N D 1-: R T A K ,-: R IcuiXcca ^ vL.tU VCo^^vci alcvU .• 

(A<Mre.. bV^. UclILljO it 5 



''■ ""Ilre'c'rU^E'oF dTa'tS" n"'^^^^ ^' '""^""'t'' :*"'"'"^'- ^^"^^ **'""'^* *'*' ^^^^^'^ HXACTLY. PHYSICIANS •hould 
state c A II Jit Uh DKATH in plnm terms, that it may he properly daiisiflcd. The •'Soecial lnform«Ho„" »«» 
«on. dylni away from homa should he feiven In every Instance. Information for p.r- 






t 




I 



i 



i. 



i 



If 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






a^ 



290H 



4) 



Ileo'/s/c/'rd A^o. 



m-i *f* flL £ 



3434 I 



i 



% a IL ' ^ 



% C^^' 



DEPARTINENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Seatb 

( "a. S. Stnn^ar^ ) 
PLACE OF DEATH: — County of^ 'O^-v A,xx/YVC^.^^cCity of Cj <V>^ vJ.>v<v>xcc<lcc 



No. So 5 \!JrOL<X-v;~vCX' SU ^^ Dist.;bet. v/jc^a^V and 

r ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G . V E FACTs'cALLED TOR UNDER •SPECAL I N FO R M AT . mT" ■ \ 
V .r DEATH OCCURRED IN A HOSP.TAL OR ,NST.TUT>ON GIVE ITS NAME INSTEAD OF ST R E eI A N O N U M b E R ) 



FULL NAIVIE 




i 



\J^L^^rrxJL 



JVtr UrcuU. ^.A-j 






PERSONAL AND STATISTICAL PARTICULARS 

OX^vcvU , ILi^KuU 

Jjx^ IH /l.Hb. 

uMunih) (Day) (Year) 

AGK 

S^ ):a>s . . 



MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH ~"~ "'^ 



dx 



(Mojith) 



3v7 

(Day) 



(Year) 



ID 



.^■'>l///S 



X% 



Davs 



^ixt.i.i:. \T\Kkii-;i). 

(Wiilfiii >ii)(.i;il <U siv iiation) 



lu 



(Stall' or c"i>\nit 1 >•* 



NAMJ-: Of- 

I" ATM j;k 



niRTH IM.ACK 

(»!•• i"Ariii-:R 

(State or Couiiti \- 






I llHRliliY Cl'RTII'V, That I attende.l deceased from 

^5^^ '^^ Up'i tn igo 

that r last saw h*Xi alive oil \/\/CV^ Qib ,,p«^ 

aii.l that death occurred, oil the dad- stated al)uve at "^ "^ 
U._M. The CAISH ()!• DlvATll wa«; as follows: 



VXU>^ci\.>«L/C Jj 



-&'^QLX^v^UUXjCX.,Liwft:->lj. 





C ( ) \ T R in r T () R V .LL^jLi:^ 



kx^rv-vx-Clu. 



m.mi)i-;n XAM1-; ,7\ 

OF MOTHHK v 



liTRTurLAn-; 

(>!• MnTIIHK 
(State or Oouiitrvi 







^\tWi TooH... (.Address) "l. 1^0'' j 



/^<J vs 



IIou 



rs 



(Signed) \j J. \i»Lj.u^ci=L.iXAj m.d. 



CXK\JL. 



Jt 



()ccri'.\ rioN 



Special information only for tlospltdls, Inslitutions, Trdnsienls 
or Recent Residents, dnd persons dyiny awwy fro.ii fiome. 



lA./////. 



fhiv 



Till-; Aiun-K sTA'n:i) j'Krsoxai, partutlaks ari; i'kii' to i-in-" 
iu:sr oi" MY KNo\vi,i;i)C.K AM) i;i-:i,n-;F 



fill fi>i iiKint 



3v. JWc^j-clcolI^v 



Former or 
Isudl Residence 

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



Hovv lonq at 
Place of Death ? 



Days 



(\.1<lress 6 0b 



I'LACH Ol- m RIAI, OR KHMOVAI, j DATK,,! !J, kiai. ,„ K1:MovAI. 

%^LLlJv^<^ I ^^'^^ 2>0 T90H 

rA,Mr,..s 9 51 Vn\A^^V-e>X sSt 



N. B.- 



-Kvery item of information should b.- carefully supplied. AHIi «houId bo stated EXACTLY. PHYSICIANS nhould 
«tnte CAUSE OF DEATH in plnin terms, that it may be properly cloHsifled. The "Special Information" for D«r. 
«on» dyinft away from homo should be ftiven in every instance. 



f 



M 



i 




r 

I 



l||| 



If 



i'\ 



i 



lir 



I;) 



m 



7 t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J5'i;n(! 1,1" III ;il!li I No i , '^-^'^^T^-, JU<v I' (."( 



.^^-<yY>V- 



Lov' 



M IfJOH 



cV<yvvc6 S.XVM Deputy MecMh Officer 



lie^istcred jYo, 



3435 



DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco 



Certificate of Seatb 



:A 



( tl. S. StanDarO ) 



^ 



^^ 



PLACE OF DEATH: — County of U/CX>vO,/v<X^vCv^cc City of c)/Ce/>v o.VCV/vcc v^t::^ 



No 



(IF DE4TH OCCURS 
IF OEATH OCCU 



St.; 



Dist.; bet. 



and 



4th occurs ftWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAMEC'LAii 



.\. 




o^u. oK^ia\i 



si:.\ 



PERSONAL AND STATISTICAL PARTICULARS 



Jx»\.<X-* 



DATK ()1- r. Ik I'M 



\(.K 



^^ 



U) Ltx 



vO 



iVt- 



[Month) 



h 

(Day) 



./llO 

(Year) 



t 




\ a>\» 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATIt A 

QVr 



(Month) 



(Buy) 



(Year) 



I Hl'ikl-HV CIvKTIl-V, That I altcn.lcd d^ea^ from 
0JL\\L L i<^o H to OxfiV- 5La,_...... uyo 1 



SH 



} >(/ ' , 



^ 



.1/ 



./»////> c\ ip 



/^./lA 



SIM, I.J-. M\KUIi:i) 

wiDtiwi: I) OK i>i\( ii-:<"i:t) 

iWtitr in social iksi;.^tialiiin) 



HiK rnpi,.\rK 

(State or Conntrv^ 



N'.XMK OI" 
lATlIKR 



I'.IR'nil'I.AfK 
n|- J-ATHKK 
(Statr or Coiintrj-) 




'Cxitvvcll M l\iLt kcL'-y^ 



\ 



90 



that I last saw h-^^ alive on .Oa-C\^ .^.t?..... i 

and that (loath occurred, on the date ^taltd above, at *\ 
V\ M. The CAISI-; ()!• I)i;.\T[l was as follows: 

a:V:W.P^ 



DIR.VTION Years 

CON T R I HI 'T( ) R \' U ivLf 



Mofitha . .. Days 



IIou 



IS 



»vcr>^a.iui. 



MATDKN NAMK 
OK MOTHKK 



IUKrHIM..\CE 
()l- MOTHKR 
(Statf or Coiintrv 







Pax 



1)1- RAT ION 'X Years 

( SIGNED )....yA.LJrVuJV U. \\\^ l).t^vt^ 



^r,>nt;is ■ 



'S 



M\a' X^ i„oH 



IIi)iirs 
M.D. 



r(>oH.. (Address) 3t Ml la*vip .lllWllxAal 
L Information onl> for Hospitals, lintilutions, Iransicnts, 



SPECIAI 

or Recent Residents, and persons dying away frorn home. 



OCCri'ATlON 

PfsitJrif i>f Sdii Ft a )tifw<) 



)'rfi I 



yfn„fh^ 



l>,IV 



Former or '\ x 

Usual ResidencfOl) . N I Ca\UC 

When was disease ronfrarted, ^ 

If not at place of death ? 



VCW^^ % jaflowlonqat 
. N I Ca\UC Jl y^|a Place of Death? 



Days 



Tin-: AMovK SI" \'n:i) pkkson ai, r.\k rnri, \ks .\ri-; tkik T(t rn v 
iu-;sT OI-" Mv kn(>\\m;i)('. K a.\i> !!i;i,n;K 



(I 



tifonnant ^ J^^^XjJ\i O-^^w-^xXi 



Kj<M\] 



\.Mn-;s at>. MlVOA^yO vt) (Hi.^, vvl^vt 



I'I,ACK OK HlKIAl. OK KI-MoVAI, I DATKof HfRiAr. or RKMoVAI. 



u. 



(NDl'.KTAKKK 






igon 



N. B. Rvery item of inforniHtion •hoiihi be cnrefully supplietl. AGR should be stilted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it mjiy be properly classified. The "Special Information'* for per- 
sons dyln^ away from home should be ftiven in every instance. 



ill«lh» 



i 






10 ; < 



m 



i i» 



WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD 



lUal.! ..f 11. ,,;th - \: \, 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registeved Xo, 



3136 



^cer 



lh(h> Filed ,%^J^^^^^rJMy>^ M lOO'X 

l^vcv4.1xxM.^ Deputy Health git 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "U. S. StauDarD ) 

\ ^ 4> 'TO 

PLACE OF DEATH: — County of<. )/tX^A^ ACIavcvicl City of ^JcLvu OX ovCvA'CO 



No. 



llH' ?N.vci 



St.: 3^ 



Dist.;bct. Ml 



\ 



VO,AA.<nx. and 'JV.>Vu-CL\.ii^ ) 




/ 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. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

^j:\ r\ T\ I coi,«»R 

■cvU 



\\\, ' 



Uil 



duLi 




riX::>\X^. 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol' DIvAlll 



1> ViV. ()!■ HIKTII 



\<".K 



dxkt 

(Maiilh) 



(Day) (Vear) 



T 
i 



<^, 



.>C\r.. 

(Month) 



(Day) 



(Vt-ar) 



kl 



) V'<// s 



M.niths 



%\. 



Du 



\viiM)\\ i!i) OK i)i\()Kt'i:r) A 

(WiiU' in social dcsi^'iiation) ' ■ 



III!-; riij'i. \»'i>: 

(stall- oT ("niinti v1 



l-ATHl-K 



niKTHi'i, \ri<: 

()»•■ t'ATIIIvK 

(Statt- or (.■oimti v"! 



MAinHN NAMK 
Oi" MOTIIKK 



lUKTinM.ACH 
()!• M()Tm:K 
(State or Coiinlr> • 



It 







yC^A 



I in<:Ri:HV CI';rTI1-V, That r atU'n.k-.l (Icceascd fruni 

lt^/..'i^^^Jl^^.'Y^^.^Ig«r to Ql.<3\j- .3^0.-.. 190.H.. 

that I last saw h .-La-ja alive on xTVlSVr XI itpH 

and that death occurred, on tlu- date stated above, at <?toryx'(yt 
-HAvfxj-M. The CAU8U Ub* J) J! AT II was as follows: 



r 



kV^.\ 



'JXK,0/\\) 




^ 



AV>\jU 



fi^JoLrvvx cx.^Kj 

I ) r K A r I( ) X ..,. Years 3l^ths « n€i»$ iJonr 

Cf)NTR I lU'TOR V S <^^tl^ A^^ 










A.XtJLAJ 



1)1 RAT ION ^ ycays(\i^ Months 

(Signed) &)X/>Vvm. v) 'VM^tr>V), 



Ihiys 



'V 



i(>o 'i 



(Address) HXCiVO-CR r^t 



Hours 
M.D. 



i/C 



0-tJLoL''> 



vcL, 



OCCUP 



AT ION (^ 1 . 

Rfyiiirtf III Siiir /'/ iiin iu-ii 



) 'ill I 



\r.'nlJn 



A/1 • 



Special information onl> tor Hospitals, Insfitutions, rrdnsienls, 
or Recent Residents, and persons dying away from home. 



Former or 
Isual Residence 



Tui: \i{()Vi<: sT\'n:i) i'Kusoxm, i'\k rifii. aks aki; TKri-; To rm-; 

lUCST Ol" MY KN<)Wlj;i)(".H AND HI". 1, 1 1", K 



(Iiifo-niMiit 



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



'vTAilHl/.ti^ tj Howlonqat 

M I \SXX \jSXkXx^\JXx Place of Death? ."^ D 



Days 



I'l.ACK Ol" nrKIAI. OK RKMOVAI, 1 OVtU-of ISikiai or KKMoXAI, 

^ . (^ q ,0 



-\.»-\. 



N. B. fivery Item oV information Hhoulil ht- cnrefully Kupplied. A(]K hHouIcI be stated EXACTLY. PilY8ICIAIN8 should 

iitnte CAlJSn OF Dt;ATH in pltiin terms, tluit it miiy be properly claftnilficd. The "Hpecinl Inlr'ormntlon" for per- 
sons dyln£ away from home should be ftivj'n in «very instance. 



I! I 



hi > 



n 




I i 



« » 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



}'..Kii.i ..r II. lit)', r V', . ^•^'''w^"'-,- it5;;i' (•-, 



liogLsfercd J\^o. 



XM-v^l-iAM.< O^outv Heafth O^eer 

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



Certificate of IDeatb 



■a. S. StanJac? ) 



X (^ 



A (^ 



PLACE OF DEATH: — County ofCJayTuOyVCL/w.oui.<U; City of ^Jco^v Vcvyvcuico 



^«e. 




I fc . M rLoALio Ik o-lk\la,li 



St,; ■ - Dist.; bet. 



and 



(IF DEA-rtl OCCURS A\4/AY FROM USUAL R E S I D E N C E G I V E FACTS CALLTD FOR UNDER "SPECIAL INFORMATION ' • \ 
IF oepTH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



^.) 



FULL NAME 



CLCL.' 




\XU.. 



si;.\ 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.oK 




\a.« 



.L'/rv^.tx; 



MEDICAL CERTIFICATE OF DEATH 

DATH ()!•' DKAIH 



DA 11. ul nikrn 



AGK 



Mwiith) 



5L 



) .■,, 



il);iv 



.U '>/.'// s 



(■»'t:ar! 




(Month) 



(Day) 



/po'i 

(Year) 



/>,iy 



SINC.KK. MAKKII'.I). 

wiDowKD OR nt\-<)Kri:i) 

(Write in sofial (ltsij.rnat inn) 



lUK'nilM, \f}-: 
tStatr III I 'ninti \ ' 



1 m«:ki;HV CI^RTIFV, riiat r attcn.k.l dtocased from 

K<5V- a. up 'I to aIX^^T^^ 0.% 190H 

(liat I las( saw li -Vvn alive on \j\<SsJZ 7<^. K/jH 

and that dt-adi occiirrc'd, on the date stated aliove, al v 



N'AMl-. ol' 
FATIIl.K 



lUKIH n, Al }•: 
Ol" lATlIl'.R 
(Stale or Coiinlry) 



MAIT)KN NAMi; 
or MOTIIHR 




^C 




M _J\I. The CAl'Sli Ol" l)i:.\Tn was as follows 



s) A4^r\J(v<rV<i- 4. 






I)IK.\'ri().\ )'('(! rs 



Mo)iths 



/hlVs 



//ours 



-i'TL'TVO^ 




A^ 



iajU^^kX 




>\ 



,y\)Lajr\-^Ub 



t'oN'i'iu r.r I'oRN' 



DLRATHJN 



)'iars 



Mi>uUis 



/)av. 



luRTni'i.Ai'i-: 

Ol- .Mo'l'Hl'.R 
(Statf or Coiintrv) 




<\/yvca. 



f Signed) Uw\iJtwA; J. Mil dc-^vt^ 



HjO 



( 



.Address) Bt.Mn 



UXhxio 






//ours 

M.D. 



occ 



ri'ATIONJ? f\ 

OsXxX- 



Rrf?il/-,f III Sill/ /'i (lilt i^fi' I 1 )'/-i7is 



}f.<,il/n 



/),,M 



Tin: AHovi-: siwri:!) rKRsoNAi, i- \k i kii.ars .\Ri-; irif. To rii )-; 
Mi;sT oi" Mv KN«>\v 1, 1:1 )<■.}•; .\Ni» iu;mi;i-" 



Special Information only lor llospitdls, lifslifutions, Transients, 
or RerenI Residents, dnd persons dying dway from fiome. 

Former or . , , f ^ ( 1 ""** '""'' '^' -v . 

L'sual Residence ^O 1 * 1 1 >Uh».....VV\M^ Plare ol Deaffi? * V 



Days 



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



(In fill ni.'int 



U<l(1re.s.M X2>T " II XJr\) L\/vM. 



ri.Aci': 01 lURiM, OK i<i:mo\ai. 






DAI^-.o!" Ut i<;ai. or RJ-lMoVAI, 

^C- T90 I 




N I ) 1-. R T A K 1-: R \l ll CtCLdlX'YV NK VJ6nXa\iH ''^ ^>Uji. > V 



(.\<l<lrtss 



nil Qry\vvi.^c<s^v '^1i 



N. B. livery item of Infopmiition fthoultl b.- cnrefuiry supplictl. Adfi Bhoiihl be Htiiteil HXACTLY. PHYSICIANS lihould 

state CAUSE OF DEATH in pliiin terms, that It may be properly cli.HHi1tied. The "Special Information" ior p«r- 
Rons dyinft away from home should be ilii\en in every inHtance. 



i 



m 



M 



( 



!! II 



I.! 



t 



i i 



I 




ill ^, 



% 



write: plainly with unfading ink — THIS IS A PERMANENT RECORD 

I ■• ' • " " ' ^■^''- /•. I15LIC., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 






Registered JS'^o. 



34.38 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eath 

( 'U. S. StanJ>art> i 



PLACE OF DEATH: — County ofClcu^^ OXCw-»x>cx^c^ City ofU<X/>x< 0-A.o^-»vcv^co 



No, 



'.t .MlW 




Vu>^ UOO-<1'|\ 



kctoLV 



St.; 



Dist.; bet. 



and 



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



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS *^ 




ajl^ hL^.\J\jl^ 



si:\ 




\clU 



CoI.oK 




UxLUl. 



DA ij: (•! i;iu rii 



Ai.H 



Moiilli) 



SO 



)'iin . 



iDav) 



M,»itfis 



/ibh 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



i)\'i*i-: (ti" i)i:ATn 



i\. 



(Month) 



(Dayy 



/go \ 

(Year) 



A 



I mCRI'HV Cl-F^TIFV, That I attciKU-.l .Ictvased from 



(K< 



Par: 



siNc.i.K, MARK n:n. 

WIDOWKI) OK I)IV()kt-i:i) 
'Write ill social (k sij-'Malioii) 



lUR rUl'LAOK 

• State or ("otintrv^ 



VAMi: ()l* 

I- A I" in: K 



niKTIIlM, \*'H 

oi" lA rm:K 



^ f 



. \)XCV XS. IgoH to \l. vvv *3k.4 up 

that I last saw h i.3>:^ alive on y^MSXT.-.........^..,.,.-. ..,..190 M 

ami that (U-ath occurred, on the date stated above, at 
' M. The CArSl-; ()!• Dl'ATII was as follows: 



Aaa^ 



C-'iX/vdL \X^ 



V^D 



iSlatf or Country 



M \1I)1;N NAM1-; 
OF MOTMKK 



mKTnri.Ac'ic 

(state or C'oiintrv) 




DIRA rioN )'i'ais Mouths Days 

coNTR I i!r'r( )K V A^'>x«cLcrxL<x^^cLcLv^ 

- vA^L<i>crT(x/<^\.A-^'';'v"vv..-.. 



Ilou) < 



diratiox 
(Signed ). 



)V( 



% 



OCOri'ATlON'/^ j) 

Rrsfifn^ ill Sill' /'i itiici^rit 






^\0x-: 



.C9.-....sJ O-^pJi 



MiUitfis 



/\iys 



xt 



T<)0 



<■/ 



f 



Address) dt M ila.\c 



10 



//ours 

M.D. 



'R. ^A,', 



[\ 



Special Information oniv for Hospitals, instuufions, [rdnsients, 

or Rctent Residents, dnd persons d>in!] dHdv Iroai home. 



Former or 1 n U ) ? M 1 1 ^"^ ''''"' ''' 

I'sudI Resident? I C) KJOJA 0\C\'-i IWv. Pidre of Dedtl>? 



Days 



Vr,,i 



1 A './///. 



/),/> 



rm: miovk srAri:i) i krsonau i-ak iicilars aki; tkik vo tiih 

lii:s'l" Ol- MV KNoWl.l'.Df.K AND IU-;IJ1;K 



niifoimaiit 



Address OXO-C- IvLOV Vw<X,'0 



When was disease rontracted, 
If not at place of deatfi ? 



T90 






I'l.AT)-: Of lUKIAI. OR Ki;.M(»\AI, j DATIv o! \\\ kiai. or KllMoVAI, 

% A^ Gvc ^^. L ^^ ^^^ 

INDl'RTAKl-R (/\0 . O O^oiNA.- H VO 



IN. B. H%ery item of informntlon should b; cnrefully supplied. AGR should be stated r.X4CTLY. PHYSICIANS should 

state CAUSE OF DfZATH in plain terms, that it ma> be properly classified. The "Special Informntion" for pmr- 
srtns dyin^ away from home should he ^iven in every instance. 



'h 



im 



mi 



i I, I 



m t- 



I 



|i^ 



a 






I 



^•1^; 






h 



i I" 



jii? 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



}?..,! 1-1 ,,f Ili;iM!i I- 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






X^vA,v4^X«,AM^ Deputy r.'caMh OfFlcer 



Ih'i^isfn'ed JVo, 



*3439 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



to 



PLACE OF DEATH: — County of icx.'ry J.^N.^V'Vvcv^te.o City of*^ C^^^ ^-V<x>vCM.^ao 



No 






St.: 

IDI 

1ST 



Dist.; bet. 



and 



1 / IF DtATH OCCUFIjS AWAV 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 OCdUnRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



^ 




■'•^OD 



PERSONAL AND STATISTICAL PARTICULARS 



"{ 1 

DATl-: of lilK lil 



MEDICAL CERTIFICATE OF DEATH 



lU,-kd; 



I Ml. nth I 



\ < '. K 



ob )v,n.« 



II 



n 

(Day) 



.1 A '///// f 



Ahl 

(Vvnr) 



Pa vs 



(Month) 



.1%.. 
(tkiy) 



(Vear 



SINr.i,!-:, M \RN Ii:i) 

wiix >\\i-:i) (>K i)t\'<>K* i:i) 

iWiitcin •^ofi.'il (lt->i'.Miat ioii ) 



(state or i-'ountry 




\<x>vvu-xL 



CV>^cCk. 



NAMIC or? 
FATHl'.R 



lUK rill'I.ACK 
0|- I AIHKK 

'State or Ootintry) 



maii>i;n xamk 

Of- MOTHl'lK 



nTRTTTPT.Arr 

oi- moiiii-:k 

(stale or Country) 




^ I Hi:Ri;r.V CICRTrrV. That r attcn.UMl deceasod from 
L'.^i:;^. il 190 . to y\^ar '.^% K^H 

that T last saw h X\) aUvc 011 V/X^TV^ 2% fgoH. 

aiul that (k-ath ocrnrrcd, 011 llu- <latf stat».il ahuvf, at - -^ ^' 
...US, M. Thf CAISI-: Oi" 1)1'^ Til was as follows: 



t. 



-\,nf*V"v.ciul.A^A<y?»:v . 



r)('R.VTl()N Years Mouths Days Hours 



CONTKIDITORV 



A tru. cv "Swtx-wtv.v. . . ou.JC.<XX: 






DT RATION' Years ■ Mouths 

(SIGNED) J. .y^n 



Days 




Hours 
M.D. 



^CX4^XOU'^"vx 



1 



OCCTTATION (JV) ft 



^r. 



X\ TooH ( 



A.Mt.-) Citjf k County Hospital 



Special information «nly 'or Hospitals, Institutions, frdnsients, 

or Recent Residents, and persons dying away Irom home. 

Former or '^ ^ ^ 1 J ' 4 Hon tonq at 

.-'^ciC J, ■ 



Isual Residence- 



!a.vVK .^l 



Plarf ol Death ? aI . . Days 



.1A./////>- 



Ih. 



Tin-: Mjovi-: sr.\ ri'.i) pkksonai, i'\i< i hi 1, \ks .xki: rkijc To rin-; 

IJKST OI" MY KNoWlJvlx'.K AND lUllJl-.F 



nnfoiTiiant 



C,(? %. CIcc^Om 



X.l.lress . LCtu.^ Lo Jb ^^l VV-LO-L 



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



i'i,.\c"i': ()i- Fu Ki.\i. OK ki:mo\ \i, I 1) \ n; gi; HiKiAi. 01 ki:mo\ai. 






T90 



CA..e> 



IS. B. Rvery item oV* inform»t!on should be cnrefully Kiippl'ecl. AGF. should be KtHteil EXACTLY. PHYSICIAINS Hhould 

state CAUSE OF DEATH \n pinin terms, that it may be properly classified. The "Special Information" for p«r- 
Kons dySnil away from home should be i;t<ven in c\ery instance. 



^i 



I 



f '11 



ill 



I • 



i' 



ili 



wi' 11 



i; i 



ud 







4.« 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H'.;mi1 '.f n<-:.it!i 1- Nfi 






r=r- A>liS:I' C-. 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jieo'/.sfr/'f'd jYo. 



8440 I 



Da/r /v/r^/,\h.{^KOrvvW aS L90H 

aL^VLAu^l^a^M D^P^^^ »- ri Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

[ U. S. StanC>arC» ) 
PLACE OF DEATH: — County ofO^t^x' \.cu-rvC'Ji,CCi City of ^'O./^x^^ J Ax>.-n^A.A c,^ 
No. io'-^ LaX^l^tV'>>A,^.' St.; X Dist.;bet.<xjlaAh^^vu.v;-t\l.ivand u\i:'M.cl.. 



/" IF DEAt^l OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED F 
V IF DEATH OCCURBED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



f^OR UNDER "special INFORMATION" \ \ 
NSTEAD OF STREET AND NUMBER. J V 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



-.i;\ 



(Koj 



COLOR \ 



X 



{jJawXj 



^ ■! 



MEDICAL CERTIFICATE OF DEATH 



DAT!-: t »1' r.lK III 



(Month* 



A<; H 



53. 



J •,■.// 



I 



«4. v 
(Dny) 



M.'iilfis 



(Year) 



DATE oi PKAIH A 

vW 



^ { 



/QoH 



Da li 



^I\<". !>* MARK 11% I) 
WIDOW }'. 1» <»K I)!\(>Kri;i) 

iWiittin 'Social di^i^Miatioii ) 



liiKTuri.AiM-: 

I, state or C'nnitry) 



!• AIM i:k 







(Month) (Day) (Vt-ar) 

I lliCkl'HV ClvRTII'V. That I alUii.K<l dcicased from 

\\\^'- %^ 190 s to ''rt45v^. /^a __..i(pH 

^<ssj-..%rx 



190 s to vK 

tliat I last saw hi-"- alive on ^ / v<ru~^...«h, i up 

an«l that <k'atli occurred, on the date stated above, at *" 
" M. The CAISIC OF Di-ATH was a^ follows: 



A\X 0>J^ 



\,-vx^ 






ai 




r.IRTIH'l.ACK 
()!■ I AriN'IK 
(State or Co\inf ry) 



MAIDICN NAMK 
ol' MoTHKK 



i''V\^L>dw'^ 



L 






CONTRIIUTORV }t)Xc3Lvt J 0„.vJla,.vNJI.. 



DIRATIOS ■. y^cars 



uuwa. 



U- 



"X/W^^ 



RTRTHPT.ACK 
or MoTIU'lK 

(Statf or I'oniitty) 



OCCTTATION /?) ! i _ 




/?<7t'.? ^ //oNfS 



A 



^a<5Vr 9^% 



I()0^ ( 



A d « I r e s s ) ' 1 ' ' J CrlcLi^v v!lxxt J. U., 



( Signed ) ^ \\)i\j^^^/^\,^^^ M.D. 



\fN*. 



Special information only tor Hospitals, Institutions, frdnsients, 
or Recent Residents, and persons dyin;) .may from liome. 



Krsidt'il III Siiii /'i ,111, two of' ..Vfat'S 



M.'iilh^ 



/hn 



Tin' Anoxi'". sTATi:!) I'KKsov Ai, r \K iiiii \Ks \Ki: iKri-: r<> rin-: 

IJKST «>I" MV KN(tWl.i;i)<".K AM) iu:i,ll.l- 



(Illf 






( \.hlri«;s 



former or 
Usual Residence 

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



How long at 
Place of DeatI) ? 



... Days 



I'LACK nl' JUKIAI, OR KKMoXWI. I DA Tl-; o! Hiki.xi, oi kl MoVAI. 

indi-ktaki-rMiX 0OxLcU;>v\lR\Jj^JXLA,tu "^^ jKx.-- • 



'A.idrf^s WW 



[S. B. Hvcry item of Informration should be cnrefully Hupplieci. AGE fihould be stated F.XACTLY. PHYSICI.4IN8 should 

state CAUSE OF DRATH 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* 



ili 



it 



M 



I 



W 



RITE PLAINLY WITH UNFADING INK 



! V(i 






\ I- <■<) 




i.96'H 



DEPARTMENT OF PUBLIC HEALTH- 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

— — ■ Of J I 



City and County of San Francisco 



Ccitificate of Beatb 

I 11. 5. tBtanDavD ) 






No. ^C> \ 



PLACE OF DEATH:— County of Ocv .v ,1^v^>-ve^^ 



((P A (^ 



nil 



c L City of ^/a/>^ O.-v^x. v\.cv^ci> 

I 



VI L 



and 



{ ,F DtATH OCCURRCD IN A HOSPITAL OR INST ^ ^ ^ 



llA 



FULL NAME "^A.O-cto\ 





PERSONAL AND STATISTICAL PARTICULARS 



si:x 



\\d^ 



Col. 



l."K \ 



UCkctiC- 



i).\ 11-; t>! r.iK rii 



\«M-: 



. Mi.nlh) 



cK v 5 'ii > ' 



iD.-ivl 



\! >nths 



(Year) 



/)(/l^ 



^fN'c.t.i:. M\ukii:i> 

\V!1>«»\VHI) OK I)!\i»K^;KI> 
i\\i iti ill MK-ial (U^ii.Mi;ili'>n) 



iiiK riiruAv'K 

(State or Country' 



!■ AI'll J.R 



lUKTHPT.ACK 
oi- lAllIKK 
(State or Coniitrv> 



^fA!!)l,^' N'AMK 
(•»• MOllll'.R 



lUK rillM.ACK 
<t|' MOIIIMR 
(Stall or k,<>untry) 










'1 
( 



MEDICAL CERTiyiCATE OF DEATH 



DATK OF DKATII 



f()0 ' 
lYtar) 



^]\(5^^ ^^ 

(Month) (Day) 

Vm<:ki:i'.V CI-.KTI1-V. Tb.t I atumUMl .Uhvm^c.I from 

■ ^ ' - igo^^ig^ 



190 
rrlivo on 



to 



t],at IlastsMwh - mivo on ..-rv t^ 

^^,,^1 ^,,^^t .Kath uocurre.1, on the- .late- statr.l above, at ^ ..- 

_„- ^j^ -^.,,^. CAisi'-, ()!• i)i;.\ rn^;v''^ =»^ loii.^.v;: 



(Xoc^^^^'T^'^ ^^ 



Dl RATION y^<J'-^ 
CONTKIl'.! TOKV 



Months 



Days 



I /oars 



Mouths 




I, ,Vin>- ' •'^■"''^' 



Das 






s aki;tk' '•■ 1" '■"•■• 



( I llfoMUMIlt 






,Sio..o,U.-'?(^.l^>^. M.D. 

.SPECIAL INFORMATION «™l« '»' ""^("l-'^ '"^''''«"^' "''"^'""" 



or 



Rennt Mrnts" and persons d>h., hh.v Iron. home. 



former or 

Usurfl Residence - • •• 

When was disease rontrarfed, 
It not dt plare ot death ? 



HoH lonq at 
Plat e ol Death ? 



Ddys 



l-LACKOl' HI RIAI^OR KKMoVAL 



DXri'o! IttidM 'II KJ",M«»NAI, 



'\}v«v: ^H 



iqo 



C) 



c 



i). 






v,,,,n-< » DVO V. , II II r PHYSICIANS Hhould 

~: : ,,h.c,.rcn.llvHU,>pned. ACJ^ H^-'"' 'l"^VTh:- * Special In.-or.nHtion" fer pT- 

N. «._r.vcr.v l.om oV ^^^^^^^^^^^ u-n thai It .na> he pnopcn.y CaKsmecl. I 



1 1 

* « il 



■i^ 



I. 



r 
I 



1 



t ■' * 



\ i 






% 



*'i 




^;: ik % 



- ^f 



WRITE PLAINLY WITH UNFADING INK 





X4 /'^^^^^'^ 

prT^ .if. *...»■•..■. 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIO NS 

2 



Hcgisfei'ed J\^o. 



844P 



Dnir i'iliil. \i lC\N-t'>-T 

-V' -; 

DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 

Gcvtificate of Bcatb 

( H. 5. 5tanDavC> ) 

J? ^ -^ ^ 

: — County o{O.C^/y\^' <^>^^'y^<^-<^^^-^ City of CjA^m. Ox<x/rve^^ C..O 



PLACE OF DEATH 




Cr^\X<i^ and AAX\.\-.th-A ) 



No. SlS' 11 ttv - St.: 10 Dist.;bet. 

/ ,r Dr*TH OCCURS AWAY FROM USUAL RESIDENCE GIVE F* 
\ ir DtATH OCCURRED IN A HOSPITAL OR 1 N ST ITU HO N C I V E 

1 iVcx^voxxVxi .d\X^l'V^LljL 



.^..., r^rcinrMrr nur FACTS CALLED FOR UNDER "SPECIAL INFORMATION" 'X 
AY FROM USUAL RESIDENCE CIVE facts C^A^LLE^ INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



L 



\.M>.. 



VO/CXVX.^ 



^i:\ 



^ 



PERSONAL AND STATISTICAL PARTICULARS 



DATE Ol- IJIKTII Q'?\ 




^4xcUj 



I Month t 



AGR 



lb 



) lUII 



R 



(Day) 



M.}ifliy 



/Hi 

(Vi-ar) 



MEDICAL CERTIFICATE OF DEATH 

nATiv (M' I)i;aiii 




VI 



(Day) 



(Ycar^ 



X 



fhJ\. 



s\'sv,\M, M\KKn:i>. 
\vrD<»\vi:i) <»K n!\oRri;i) 

lUiitiin ^orial (l(si;.Miati'>Ti) 



.\;X<iLc^v.^u::^- 



lUK IHI'I.AOK 
(Htatt' or Cotintry) 



NAMl" (II* 

iATni;K 



llIK iHl'LATK 
Ol' l-AIMIl-.R 
(Htatt (.1 Coiiiitrvl 



MAIDKN NAME 
<)!• MOTIIHR 



MIKIIII'I.ACK 
(»!• M()'r!I!';K 

(Stale or CinMitiy* 



X -\>x. 



X^./T>^-<Xy^ 



"^-M 



OCCUPATION (J\p ft 






i- 



h't-^i,lf'ii lit Siiit I'l (III' I"'" 



IM 



)'rtn f 



M..,i'li< 



/),,M 



Tin: AIU.VI-. ST\Ti:i) I'KKSONM. >' ) '< 'I:/; i. X'"^ 
ni:sT ()!• MV KN<»\\ IJ'IX'K AND lU.MJ.I' 



Ks AKi', TKi 1-: TO rill': 



(Infoiinaiit 






^ \.l.lr. v^ 



(Mi.iitli^ 

1 HI';R!":BV C1;KTI1'V. TIimI I attcn-k-.l .leix-asod Irmu 

.Ort<5\r ^0 190M to \huj\r aa 190I 

lliat I last ^a\v hJ^^ alive on vUvr :Vl Kp'^. 

and tliat .hath orcurrc.l, on the date stated ahovc-. at "l ^0 
LX M. Tlic CAlSlv Ol" Dl'iA'ill wa>^ as follows: 



VsJL>ULArVojl UJ/\^WtXvv^ 



V 






T)T-RATrON 
CONTRIIJUTnRV 



Year^ Months ^ Vays. 

QlA^do^ 



■Hours 



I )r RAT ION JV(?;,s- Mouths fhivs Hours 

MW^ ''^ TooM ( Ad.lress) St^ UaltT\^.<.<X 3l 



SPECIAL INFORMATION <»n!v tor Hospitals, Institutions, Transients, 
or Recent Residents, and persons d)i!i(| away fro-n fiome. 

t!™l WTidenct • ;•■ P'*' »< ""'"^ »'>^ 

Wtten was disease contracted, 

if not at place of deatli? 



ri \ri- Ol' lUUIAI, OK KI'MOVAI. DATl-.o!" Urinxi. cr RllMOVAI, 



,■ ,1 WW KhHittl be stilted nXACTLY. PMYSIOIAINM . 



N. W. Hvery Item of hif<»rm 

Mtnte CAlISn OT Dl. 

«on, dyfnri HW«y from home hIk.uI.I be feiven 5n avery mstnnce. 



PHYSICIANS Hhould 
r p»»r- 



It 






M 



!i 






I, 



I 






I 



I) 









ft 



;-, I 



.1- 



WRITE PLAINLY WITH UNFADING INK 



II. ..ltV»-F So :^ -t'J^' H.*^r '•" 



JfJOH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Bj'i^istered ^'o. 3443 



i(v^vv^ Xx^^ Deputy Hoclth OfTicer 

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



N 



Certificate of IDeatb 

( n. S. 5tanc>nrD ) 
PLACE OF DEATH:-County ofCct^- CXccovCv^cc City of ^ O.^^ 






es-^oi) 



)b ^^ vSiA- 'w — Dist.; bet. 



and 



H occu.s ;^w.. ..CM USUAL ^tS.^^^CJ.o...^^^c^c.u^o ^-^ -o.. ^-^^^i,'--:-',-' ) 






FULL NAME \>J^^ Olt^so^^c 



PERSONAL AND STATISTI^CAL ^RTICU LARS 

COLOR ^ j\ 



DATK OF niK I II 



L 



OwUvJOi 



sMontHJ 



AiiK 



ib 



5V,;» 



(Dny) 



M,:H(hS 



r'\S% 

(Year) 



% 



Daxs 



siNr.I.H. MAKl<n:i> 
W IDfiWKD OK i)iv<»Kri:n 
W lit' ill social lU si>.'ti:itinii) 



BfK riii-i. \*'i- 
fSlatf or lOtinlry) 



NAM}' 0|- 

i-A rin.K 



lUR'nilM.Ai'K 

oi- 1 \rm:K 

IStattj tjr Couiitryl 



MATDKN NAMl. 
ol" MOTHKK 



lUR'nil'I.At'K 
OI" MoTHKR 
(Statf or Co\iiitry^ 



[TIclwu^cL 



ort ri'ATION 





Kf^iife-J in SiJii /'tain i'"'o 



HHST ()!• MV KN»)\Vl.i:i)<-.K AND ni.I.HJ 



KS AK1-: I-KIH i"" '•'"»'• 



(III foi niatU 






(Address 



^\l 



MEDICAL CERTIFICATE OF DEATH 



DATK (»l" I)1;ATII 



VlL 



(Month) 



in.... 

(Day) 



IQO 

(Year 



I IIICRl'BVCI'RTIl'V, That I attciKled deceased from 



190 



190- 
190 



tliat I last saw h :^- alive on .— r^^-trTr-r- 

and tliat death occurred, on the dale stated above, at 

-_— ^j_ The CAlSIv OF I)l';.VrH was as follows: 

.^L.ClLcuJv.^.'^^'. CU.^^^-cUl'^1 



.rxJ^ 



DT RAT ION years 
CONTRinrTORV 



Months Pays 



Hours 



nr RAT I ON 



]\ars Mouths .Days 



(SIG 



'1^ il\ il 



Hours 
M.D. 



Qlc^...3wt. i<,o'- fA.ldrcs.) Ccrv<rvviK:> UtKcX 




WiH, 



SPECIAL INFORMATION only for Hospitals, InstitulWiH. Transients, 
or Recent Residents, and persons dying away fro-n home. 

7^ 



^;i?f pL.„re 1511 Vi^V^J-iil KeTo^th? 



Usual Residence 

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



Days 



PLACK Ol- HIKIAI, OK KHM<'\A1, 




D.XTKoJ MiKiAi- or KKMOVAI^ 



^ 



nr .St. 



rNDKKTAKHK V^WvO ^ ^ ^-ttc 

(Addris S.D.S M>Vcr>A.lcvvy.LU-. 



190 



Ov:VW. 



N. B. Every item of inform 



.•r,r;,-Ji ;:~::s rr t A'i -■.■r.:r-i-.«ei .rrsrw'i:;'- 



:r .a".".",' .™"™ '«-" <- .'■ ' ' — - 



!;i r 



I 



^ t 



u 



( ' 



i :.i 



'1 



I ! 



' t 



1 J 



V' 




, ' '■ ! 1 ' > ' ■• i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

8444 



1^.C•^^^M^^lM• 



■Mim 






J!)0'i 



Me^i'sfercd jYo. 



^ tv^o "l^v^ Deputy Hci :■ ■•• OfTicer 



DEPARTMENT OF PUBLIC HEALTH -City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of Beatb 

^ U. 5. StanOarC^ ) 
LLL<X'^^^JtcL<X' City of 



X^si. 




^jj\Jf-^Oaj^ 




and 



4,' 



No. 5.S \^ JXCV--^- or«^nrNrVr.Tvr FACTS^CAfLEO FOr'TnDER "special INrORMATION- \ 

(- r/r.rH^^OCCO%r.V;;rHO^S^Pr.L o^'?^S^^^"T^O^'^C.;-Tl name INSTEAO of street and NU.SER. J 

FULL NAME wU^ ■ - — ^^^-- ^ 



V( 



,€u: 



.:^.::».'!^... WVVvv , J AX/>^q, CTU^.. 



-i4- 



->i:.v 




PERSONAL AND STATISTICAL PARTICULARS 

I C'»I,<)K 



ii\ri>: OF HiK 111 ( 



X^lxU'-A' 




< Month* 



M'V. 



Olp >V'rt>.v 



11 



(Day) 



M.'ul/i^ 



/Ikl 

(Year) 






Ai vs 



■-iN<".T,K. MAKUIl'.l). 

winowi:!) «>K i)ivoKi]:r^ 

iWiitciii s.>i-i:il (Usij.n)atitiii) 



9 



\ III 
t ^1 



■MJ 



!. 



ntRTflPKAv IC 
'Stittf or Country) 



NAMl". (>l- 
l-ATHl'K 



(? 



nTRTHPT^ACK 
ni I AlllKK 
(Stale ar Country) 



• )1" MO'i'HF.K 



HIK rui'KACR 

OF MormcK 

(Stale or Country) 



1 




vruivcu^x^ 



.KCll'AT10N(p^^^^^^^ 



Resiiifil I" S,ni /'i ,111. i^ro 



;^ )',(!!< 



yr,, lit lis 



n,i\ 



,U,OVKSTATK..rHKSO«,P;KT|.;.;.;XKSAKHTK,K H. THK 
lU-ST Ol- MV KNoWI.J-.DCh AM) nhMl.l 

^C^idX'^v v^<vU dvX.... 



I 



(Infoi niatil 



,v,,,,.s ^f^5C 



MEDICAL CERTIFICATE OF DEATH 
UATK OF DEATH 



(Month) 



%x... 

(Day) 



lYfHf) 



I lIi:Ui;!'.V (.I-.KTH'Y, That I aUen.K-.l .lorcase.l fnuii 

■ to — - ■ 1 90 

■ :m__ ' .:.:: " Mp ~ 



Tip 



that I last saw h .:r— alive on • ■ 

an.l that (katli occurrcl, on the daU- staid al.ovc, at 
r: M. The CAISI-: Ol' DIvATII \va> as follows 

O .cOLmX^vaX-^^v-^. 




nr R AT ION ?V<?''? Monihs :•• 

C ( >N T R I lUTOR Y •" 



Days 



I )i; RATION ^ )V<7;'5 
(SIGNED) U.. VO 





JSTonths Days 



Hours 

/lours 
M.D. 



UiI'^ie:.!^ / ^^ ■ ^^-^ ~"^' ? /O 'i 

r- n T90H (A.iaress) ^:^xJkjX^M Vv^' 
>ECIAL INFORM AT ION only for Hospildls, Instf^ulions, Ti 



or Recent Residents, and persons dyiny away from liome 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Transients, 



Days 



DAI'}", of BrKiAl, or RF'.MoVAl, 



'^^ 



I'l \cf: <)|- HiKiAi. OK hi-:mo\m- 



^0. 



190 



s 



.-V.6 'V 



^— ^^— ——■———'— —^ ^^^1 rXAGTLY PHYSICIANS should 

"n'.'.bfn'i" °- Hon,, should b. aW.n i.. ev.r, In.t.nc 



I- ., 



H 



t .» 



:i 



mMw 



■iiwirff-^ 



fi 



if 



I 



W 



RITE PLAINLY WITH UNFADING INK 



i;. ...'.'■ f !(■ "tl. ' ^' 






Ihffc riJrfl , \}\(JVOc^Ywl^-t\^ ^"^ 



mo'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

KcilLsfcred ^'o, 3445 



(K^A.'^<-'* >^'^ ^i 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificate of IDcatb 

^ "U. 5. StanDarC* ) 
PLACE OF DEATH : - County of ^ K.U.^'^ • City of J AX^--^ 






No. 



- St.; 



Dist.; bet. 



and 



■ iciiAl O F ^ I DE NCE GIVE FACT 



TS^CALLED FOR UNDER "SPECAL INFORMATION ■ \ 

t1 name instead of street and number. J 



FULL NAME 



.Ol- 




A\j. 



A 



PERSONAL AND STATISTICAL PARTICULARS 

COI.nk 



I 



DATE OF i'.IK TU 




/Ki,.iilhi 



(Day) 



/ W'l .... 

(Year) 



A«-.K 




11 



J .(/ » > 



Mi'nths 



Da vs 



mvr,i,Tr MARkiKn. 

WIlx )VVHI> OK lUVnKvHn 
(Write in social <U •>i>.'iiati>>ii) 



HIk I'UVKACK 
I Statf or (.i.uiilry) 



NAM} or 
!• A Til i;k 



lUKTIUM.AOH 

Ol- 1 AIin-.K 

( Stall- or Ciojtitry) 



MAI 1)1-: N NAMl 
ol" MOTHKK 



Ol" M()'rin:R 

(Statf or C.'onntry') 



(1( 



.c,....vnoK (0|^J^ 




MEDICAL CERTIFICATE OF DEATH 
'^S^^V DKATH rV ^ 

' (Month) <I*'»y> 

nTnlufSvCl-RTIl-V, That I attenae.l aeocascd from 

-—to - —■..-. -- 190 



(Year) 



.I9O 



190 



til at I last saw h .rr-rr. .alive on — ' 

nn.l that <U-ath occurred, (m. the date state.l above, at " 
—— M The CATSIv Ol' Dl'-ATll was as follows: 

Vj Y^xXi^iw-^^^O"^^-^^- • 



T)rR.\TION y^-ars nfovths 

C ( ) N T R 1 B U T R Y ' 



Days 



Hours 



Rt-si<i,-<f ni S<i>i ri<i"< '"'" 



)V,n 



)r,',if!i^ 



ha V. 



HHST Ol- MY KNOWM-IM.h .^M' lU-Un.i 



3)55 - M iL ot 



Months 



Pays 



DURATION —-JV^-^ , 

(sioN.o)k(? to^L^ ^ ^- 



Hours 

M.D. 



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

How long at 
Former or piar e of Deatli ? Days 

Usual Residence 

Wfien was disease contracted, 

If not at place of deatli ? ^ 



l^.ACK OF lUKIAI, OR Kl'.MoVAI 



UAlU", of IlfRiAi. or RHMOV.\I, 

JVUv- a^ 190^. 

"0 



,A„,L» n.ioT Miw^v,c.>v at 



(\(Mrcss. ^^ — ^■^^— — — — 

^^_^^_^^— — ^^M^— — ^— — '"^— ' t t I BXACTLY PHYSICIANS should 

state CAUSE OF Ut A in m v every instance. 
A.A^A. „«.nv ?pom home should be feiven in every 



sons dyinft away ?rom 



< I 



• I 



.1 

: r 

n 




§u 



i 

v'; 



^ 



I ■ . \ 



! ' 



■u 



u 



WRITE PLAINLY WITH UNPAD.NG .NK-THIS .S A PERMANENT RECORD 



H":i"l 



li, •!'■, ! V' 



A.'r^x^Li) wScV (''> 



REFER TO BACK Or CERTIFICATE FOR INSTRUCTIONS 



/)af(' Fi/r'i, \Jl(^^^^v'L^^^J ^^ 



L96>H 



llc(^lsterc(l ^'*o. 



8446 



1 



n 



DEPmMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

! *a. S. t5tnn^ar^ ; 
PLACE OF DEATH: — County of UO.->vv..v , ^ (\ I 



r 



^,N 



.UfiJiA 






) 



FULL NAME V.I tn vci 




-tA-V ■■■•- •■■■ 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.IIK 



^ . 

i,.\TK <»i- r.iK in A 




.-OVV-. 



(Year) 



\«m 



IS 



)V.i^.< 



% 



M,,)i:ii> 



w 



fkiv 



MEDICAL CERTIFICATE OF DEATH 



llATK OK ni-ATH r\ 

m 



(Month) 



1%. 

(Day) 



igo . 

(Year) 



rmnU<BY CKRTIFV, That I atteu<lc.l .Iccvased from 

- v ::T 90.-rr--r, tO -.rr-rrrrrrrrrr-rrrrrrtrrr: 

• alive on .>;............ 



siNT.i.K M XRklKP « 

\VII>t»\VKI) OK l)!VnKi"hIl U 

(Write i« HCKMal d.-vivnatioii) 



HiKrnri.AOK 
. statt t>r Country 



NAMK <>K 

FA 'I' 1 1 ),K 



tbat I last saw li 

n„.l that ac-ath occurred, o,. the .late stated above, at 

.^ ^j 'PI,,. CLAJSI- Ol' i)i:A'ni Nvas as follows 



ngo 

190 



HIRTHri.Al'K 

<)i- I aih1':r 

(Statt or Cuuiitry) 



MAIDI.N N\M> 



HIR r!nM,Al'K 
()!• MO'IMIl'.R 
(Stair or Country) 




ei^ 



txx)vcLv3U-4 




I 



(' 




DC RAT ION ^'-"^^''^ 

CONTKIHI'TORY .- 



Months 



Days 



Hours 



h I 




,du »« t*^***"-*"^^ #**#1t***^*-**f ■* •*'*-■**- 



l)rRATI()N^-.>V^^''^ 
(SIGNED) 




Months 





Days 



\h^^.•^ ^'^^ 



TC)0 



( 



A.i.i....^->bOb d.tLtL.S)nt 



■c;pECIAL INFORMATION only f" ""P"-!^- I"*'"""""^' '""^""''' 
or Rcrent Residents, dnd persons dying d*ay iron, home. 



/)<M 



OCCri'ATION 



fyf^KItU III '"" ■ .^ ,v Till.' 



(Infonnnnt 



{A<1(lress 



\X) (PrvA. jaX 



Former or 
Usual Rcsidcncf 

When was diseasf fontracJcd, 
If not at pla ce of deatti ? 

"pi \(K 01 HIRIAW «>u ri;m(»v\i. 

• ) 



Hew long at 
Piare of Death ? 



... Days 



DATI-'o*^ MiKiAi. or RI",M()VA1, 



voAov 






l-N„KRTAKHR W ^-^ ^"^^O ) 'L 



■■'■^ ^ , rvACTLY PHYSICIANS should 

.tate CAUSr OF DEATH in P'"'" |*^ ^,^„ ,„ ,,,^y 1„Ht«nce. 

•on. dylnft oway from home should be ft. 



Ill 



11 ;:' ■ 



>;■(? 

ry } 






I 



I 



11 



1^ 



II 






y 



w 

Board.. t II-mMIi ! v 



mTE PLA.NLY WITH UNFAD.NC .NK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIONS _ 

3447 



...f^^;.^ U<v 



r ^^' 



J}afi' /•V/fv/AlUvM.'^^'vlNX: 



^^'\.l>X.\j ^"^ 



n)OH 



Be^i^tered jVo, 



{ i , Dcouty ::oi-;:h Officer 



DEpTrL^ENT W PUBLIC HEALTH=City and County of San Francisco 



Gcvtificate of IDcatb 

PLACE OF DEATH:-e««wi^^<---- c-^^^^^ 






No. 



Su; 



-- Dist.; bet. 



and 



-) 



/ ir DEATH OCCURS AW 
V^ IF DEATH OCCURR 



- "- ^^t :^^:^f^^^-- -^ '^-- :^:ii-:r=- ) 



FULL NAME 




PE 



RSONAL AND STATISTICAL PARTICULARS 



si:\ 



iY^ 



uxJLx 

KATK Ol- HI R 111 



« Month) 



ACR 



. i't'iltS 



>i\<,i.i-: M AH un"n 

W Il)<>\Vl-:U i>\< IHVoKi KI) 
W tit. in AOClal <Jesiv:"»ti<)n) 



lUK rniM.AOH 

' stilt. .>t r.mnti A'^ 



\AMJ' <>!■ 
I A 11 1 l-.K 



lUKl'lirKACK 

OI I Allll'.K 

I. Stilt* or c'nuiitiy^ 



M \!I)1:n NAMl 
Ol MOTHI'.K 



lUR rnri.ACH 

«H- MO'llll'.K 
(State or Co\uitry> 




MEDICAL CERTIFICATE OF DEATH 
PATH Ol- DKATW ^ A 




(Day) (Vear) 



(Moiitli) 
TTTH^'m^'cKRTn'V, That r atten-lcl .leccasea from 

„ ■. , : I9O -- -"" 



190 



to 



that I last saw h " alive on ■«•-.- 

,„a that .l.atlMKH-urre.l, on the .late statc-a above, at - 

^j yi,^. CATSP: of Dl'.ATIl was as follows: 



T90 






iC/>^,/i^<:^<^'^'^'^^^ 



DIRATK^M ■ JV^'"^ 

CONTKIHITORV 



Months 



Pays 



Hours 



DURATION 



Yt-ars 



DCCUPATION -\ » 



h\u,f>-:f ill >■"" /'I'l""'"'" 



Mmitlr 



n<t\. 




(ii 






(SIG 



jr,>,/f/is Pays 



Hours 
M.D. 



iA^YVt l3woo'i (Address) 



^^^^lAL INFORMATION «nly for Hospitals, Institutions. Transients, 

or^efenl Residents, and persons dying away from home. 

How long at 

former or pi^^p of oeath? Days 

Usual Residence 

Wlien was disease contracted, 

If not at place of death ? 



I'l.ACK OI- lURIAl, OR RKNK'VAl. 



DA'Pl'o! lUKiAi. or RKMOVAI^ 

Olci\r. XH 190^ 



INDKRTAKKR ^- ^^ ' V ^T 7^ 



(Address. 



(Address \^ ' 1 || I PHYSICIANS should 

•tote CAUSE OH pEATH in P !» n J .^ ^^^^^ Instance. 



son. dyin* «w»y ^-" »»«•"« "'^'^"'^ **' ^ 



1 


1 


ri 


fi 


' 1 


■ I 



''I 



( 



i, ^ 



II ti^ 



I 



\k, '^ 



ft 



li: 



«».; 



4 



■1 i 






1^ 



WRITE PLAINLY WITH UNFADING INK 



f II. :.Uh I 






/,7(^;h 



THIS IS A PERMANENT RECORD 

REFER TO BAC K OF CERTinC ATE FOR INSTRUCTIONS 

Be(> isle red jVo, o44o 



DEPARTilENT OF PUBLIC HEALTH-City and C«unfy of San Francisco 



ecl'-h C-^cer 



Ccitificatc of S)catb 






PLACE OF 



DEATH:-&««W^vt^aAc.--c^-^-- W^cxa^ 



Dist.; bet- 



No. 



St.; UlSt.;Det. _„ ^,^„^„ .special information- \ 

~" =rcTnFNCEGIVE TACTS CALLED TOR ^^0" otREET AND NUMBER. / 

ijL'Lt'\' LuJlvvu ■ 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

COI*OR' 



DATK Ol I'.IK 111 



MoiUh'i 



\<'.F. 



)■/■<:>.« 



->i\<.M-: M,\Kun:i> 

W n)o\Vi;i) OK DIVnKrKl) 



I Stntr .n (.'oimtry) 



N \Mi: Ol- 
lA rn i;r 



UIR IHri.ACK 

()i- i-Ariii-.R 

(Stat<- or C'>\intry'> 



MAIDl-.N' NAMK 
l)l- MOTMKR 



lURTHl'LAfK 
OJ- MoTMHR 
(SUiU- or Coiuitry^ 




MEDICAL CERTIFICATE OF DEATH 

nilT^ii^rCKRTlFV. Thai I attci-lea .leccased from 

TOO 

190 "• 



to 



alive on 



««wiia..L...!.i.I90- 
at 



tliat I last saw h^^ 

,,,1 that death occurred, on the .late stated above, 

M Thv CAL'S1< or nRATH was as follows 

Cl'k^^BjiA.a- ■■— •••■• 



DIRATION JV^rr.? 
CONTRlia'TORV — 



3foftf^^ 



Pays 



Hours 



(S 
ct 1 



Hours 



RATION >v„« ^ro'^"^ '"^- 



TC)0 



i^C.AL INFORMATION .»!, for H.spi.als. Instlt.li.rs, Iransienh. 
.rleren^isMenls, dnd persons dying away Iron. Hon... 

How lonq at 

Former or piare of Death ? "ays 

Usual Residence 



occr..A'.-.oN .^^JjLO^ 

K,,„M h, s.,„ r..,„.i..:, _^ ^ ^ ,^.^^ ,^.|,|., 

.,.,„. An„vK STATU,. yy^;:f^'^ri^^n:y^ ■ 

,,::::'cz:e:a«^ 

. (\<l(lress JU^U VA.- c^- 



When was disease contracted, 

If not at pl ace of death ? 

PI^ACHOK lURIALOR RKMOVAI 



INDKRTAKKR ^ ' ^ * * ^ i"^ Vv) l) 

(AcUUess ^...i ^-^^ 



DA'I'lf, ot H' KiAi- or RKMOVAU 

AiVCNJ- XS i9oi 



^^^^^__^_^^ ^^^— ^^^^ ,. . AGE should be «ta 



if^vArTlY PHYSICIANS should 




'^ 




»; > ' 



I 



* 



i. 



'M 



< . 






h • 

I 
I 

f 

I 



^ 



' -i « 



s\ 



^...^ iMK —THIS IS A PERMANENT RECORD "^ 
BITE PLAINLY WITH UNFADING INK — THIS is m i- 

RITEPLAINL ,-- .».,.,...TE rOR INSTRUCTIONS 

--^^•'"'•- ■ Z n 3449 

A' H 



JlociiHteved ^yo. 



o^x 



DEPARTNENT OF PIBLIC HEALTH-City and County of San Francisco 



PLACE OF DEATH -. — Co«nty ©f 



Certificate of 2)catb 

(l..vo.>v Gtr otXcv<^>-<=^' VJ. - 



Dist«; bet. 



and 



No. 



R 1. 
If 



/ ,r DtATH OCCURS '^^'"'^ ';^W^^^,^^^ o R^ frl ST^.^u^T .o''n"'o I 

^ ir DEATH OCCURRED IN * HOSPITAL ^ 



DlSt.; bet. •special mroRMATioN • ^ 

FACTS CALLED rOR UNDER ^P^^J^^q NUMBER. ) 

,VE ITS NAWE INSTEAD OF STREET 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



^cuL 



VO.Lu ._ 



UATI-; l»l lllK 111 



^MootH) 



Af.R 




SIN. .I.K MAKUli:i>. 

\vin<)\vi:i) «»K i)ivoK^»-.i> 

iWiitfin MM-ial (kbJKtuitioi 





!■ 


iiaH 


1 




■i 




■ 




.ij 





'Sl;iti i.r I'onntry) 



l-Alin-.R 



TURTHPT.ArK 

()i- 1 \rm-.K 

(Stiitc or I'outitry) 



MAIIH.N NAMK 
«)!• MOTHKK 



inKTHIM.Al"!-: 
()!• MOTin-.K 
(Slatf or Country'* 



oeCl TATION 




MC 



DICAL CERTIFICATE OF DEATH 



(Year) 



v!:^\ 



— to 



that I last saw h r- alive on 

•urre.l, on the .late stated above, at 



190 
T90 



and that death occ 



M. Tha-CU-SJ.; OI- I.i:aTII w.s as follo«s 




coNTRinrTHRY -"•■ 



,«*,*»'••■••'•■***■•"•• 



Hours 






) V-rt ' •^ 



yi„»l1n 



l.\]fULulKi;u>rvt. M.D. 

(.ddr.ss)(:nw.vJ-^ ^^ 



(SIGI 



T„KAm>VESTAT,U>PKK:^>NAKWAKTUM;.,A^ 



(hifovtnant M ' V<XWV ^ ^^ 

' a.i© 



r\(l(lro' 



— .. ,>.FORIVIATION only lor Hospitals, loslil.llons, Iransients, 

How long at 

Former or piare of Death? Days 

Usual Residence 

When was disease contracted, 

If not at place of death? ___ , „..„,,,.,, 

- — -,..,.,vvi l)\Ti:<)f nrKiAi. or RhMo\AI, 






(AtWress 



W vX c^ JJxXATuxs in I i>nn •houid 

- i ■ r, . -nrefully nuppHed. AGE should »>« «^«**:J^7.?8;eciBl Information" for p.r- 

„f ,„form«tion .hou d «'-;"-\;'^^, ^, ^^„y be properly classified. The «P 
E OF DEATH in P «'", VT!; ' „ n every instance. 



N. B. Bvery item ^^caxh in oiain terms, *.■.•- . ^.„^- 

•tate CAUSE OF fEATH m pla. .^^^ .^ ^^^^^ instance. 

sons dyinft away from home should 



I. 



I I 



i I --Ri: 





1 i 



} 

'■fl 



' * iii 



li- 



if 



i 



^Kl .* 



I 



I 






■ ■ J.' ■ 



in- 

ill 



i 



WRITE 



PLAINLY WITH UNFADING INK 



»i .'til r ^ 



Nr--i'X:l'.M 




i 



'\>\ 



.\. ^'-■', 






THIS IS A PERMANENT RECORD 

PEFER TO n .r.K OP CERT^FICAT rrOR INSTRUCTIONS 



DEPARTMENT OF PUBLIC HEALTH=City and Coanty of San Francisco 



Ccvtificatc ot iDcatb 

PLACE OF DEATH: — errmtT-^ -^^ 



and 









-) 



No. 



- St.; 



IE 
OIVE I" 



,.^...-^- „„ USUAL RESIDENCE Giv 

/ ,. Or.TM occurs .WY ^"°** -^3%7T,t OR INST.TUT.ON < 

( ,r Dt*TH OCCUR«tD .N . MOSPlT.t ^ 



FULL NAME 



DlSt; bet. , -sPrCAL .ntormation • \ 

,.CTS CAtLtO rO« UNDER SP^ ^^^ NUMBER. / 

,^ ,TS NAME INSTEAD OF STRE^ 



v^C^BJOv 



PERSONAL AND STATISTICAL PARTICULARS 



DATK OF r.IKTl! 



iMuulht 



\<.K 



)Vi?*."': 



(I)ayt 



M,inlh\ 




Pit W 



w ii)«t\vi:i) «>K i)iv<mcKn 

Write in social dtMjitn.Ttuini 



iStiilf <ir Country^ 



I \ 111 KR 



MEDICAL CERTlFIC^T_E_OF DEATH 



i.a.. 

(nay) 



(Year) 



KKKMV cKrTIFV, TlKU r .tl.naca .leceasc, fnm. 



HI- 



to 



[90 



tint I last saw h r— alive on 

^1 nn flu- daU' statc'l alxn-c, at 
;,„.lthMtacatlioconrrc<l, on tin 

— M. ThcCArSKOF I)1^AT1I was as follow. . 

;\,^di^t?^^^ ■""""'■" 



01 !Arm".K 

(Stale or Country) 



MAIKI-.N NAME 
(H- MOTMKK 



nik'IHl'I.ACK 
01 MoTHF.K 

(St:itf or Codtiti v) 




Dr RATION y^'<^''' 
CONTKIHT'TORY 



^fonths 



Pays Hours 



DURATION 



Years Mofiths 



Pars 



flours 



OCCUPATION 



Kf.idrd ill S.iii /'linn /><■•> 



\h'>ith< 



(S 





/^^ " -L — -. ... .„, Hncni»;.u Institutions. Trdnsieiits, 



S''-5C-A}-J,NrORMAT,0.^-^,,,^,„,, 



IM only lor Hospitals. Institutions, 



or Recent 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



TT"^, OF mUlAl, OK KHMOVAI, | I 



U-WCV*- 



)A'rJ:ot Ht KiAi. or KHMOVAU 

^\mr %^ T90H 



AV,nlr.f I II S.ni Hcii" >'- ^ . . ... ^ , ■ j.- Tc . Till- 

T^KAm)VKSTAT.^I>I;»^K:y;^Al^l^^ J,,^,K,. 

}U',ST <»1- MV KN««\M. ».!».. 1^\>" -^ ft 

.„ Qn.o.j^ C iX'-l^^ 

d A^ ^ ^'^^"^ TT^CTLY. PHYSICIANS should 



XW ^^a:^ U^-d 

7\ i ^O^C 



(AcMre«5H 



( \(lilrf*<s 



N. B.— F.very item of ••^^'^-^i'^H^irpl':^" ter-'' ^'^"^ '' """' !" ^ZT/ 
.tote CAUSE OF DEATH In p.«^^^^^ ^^ ^.^^^ .„ ,,,,, .„„t«ncc. 

ftnns dylnft away from home 



, I 



i 



« . 



if 11 




h 






if 




tis t 



li- 



*i 



<!• 



1 1 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3451 



II. .'^ I N-. :• ^-z!:^-^ V.!kV<'o 



Dff/r /7/rj. Micv^^^vii^^.V' la... 



I!) OH 



Ee^istered J\'*o. 



•V ^^ "; Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtificatc of ©eatb 



PLACE OF DEATH: — Gounty of 



CX-^KkX' 



'1> 



Gtr ^ ^ '^^"^'^If^ ' 



St.; 



Dist; bet. 



and 



-.) 



V if DEATH OCCURRtD IN * HOSPITAL OR INST.tu 

U)a^^ O, U)^vcLiVi 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



I>\TT- of" TIIKTH 



A<.H 



M.mlh) 



J tUl > > 



( Day) 



M.»ilJi 



niRTurT,\<K 

Ol- lAIUHK 

< State or Omiutry) 



MAIDirN NAME 
Ol MOTIIKR 



niR'riirT.ACK 
Ol- Mo'nn:K 

(Statr or Country) 




MEDICAL CERTIFICATE OF DEATH ^ 
DA rE OF DEATH 



^iVVUl ^ 



(Month) 



(Day) 



(Year) 



r II i:K1':BV CERTIFY, That I atteiidcMl deceased from 



190 



-190 



STVf.I.r; MARKtED. 
WIDtiWl-D «>K DIVORlKD 

\\iit< in s.H-ial (Usis.'iiation) 




niRTnt'KAOE 

iStatr o! Country) 

SAWK or 

FATHER 


i 



that 1 last saw h .-T— " alive on " 

,„.l that <lealh occurred, on the <late stated above, af^ 
M. Xlie CALSH Ol- DlvATlI was as follows: 

-L(rLiA.a.' "— •• 



DrRATION y^ars Montin 
CONTRIBUTORV - - 



Days 



Hours 



OCC 



:Cl'PAT10N A § i 



Rfsitifd in San /'nnnr's,;) 



\r.>>if/is 



n.t 1. 



HEST OK MV KN*)\V1J:1)«.E AM) I5J-''"-^ . 



(Infonnant 



(\<l<lrcss 



t 



nr RATION ^ ^'^'^^^" ^^''"^^^ 



Hours 

M.D. 



f. 



SPECIAI 



^K,.^,«L INFORMATION »»M«r H«PiWs, lnslilull«"s, Ir.nsifMs, 

or ^reS fosidtnts, M persons dyinq awy from iiomf. 

How lonq at 

Former or place of Death ? Days 

Usual Residence ' 

When was disease contracted, 

If not at place of death ? 



I'l.ACE Ol- HIRIAI. OK KKMoVAI, 



DA'Pl* of Hi KiAi. or RI:M()VAI, 

(K«v" as T90H 



rNDl.RTAKER 



Address -a^-i- ^^^■ 



state CAUSE OF DEATH In P n.n «^/''"«:;'^f „ ,^^,y inHt«ncc. 
«on. clyinft oway from home shonhl be fe.>cn 



- , pvACTLY PHYSICIANS should 



/ 



I 



1 ! 






% 



11 



Jl 



w 



RITE PLAINLY WITH UNFADING INK 



Hoar.! ..f !!• : Mb, T ^'^ 



T-r, H.«v r 



/>///r /-V/fv/, m\(JV^'>^''^'^^^ ^"^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE TOR INSTRUCTIONS 






Deputy K 



IfJOH 
h Officer 



Jlrciisfcrcd ^'o• 



i._ 

DEPARTMENT OF PUBLIC HEALTH-Cit) and County of San Francisco 



PLACE OF DEATH 



Ccrtiticatc of Bcatb 



'^ 



No. 



St.; 



Dist.; bet. 



ACTS CMLLCr r 

AME I 



imiiai RESIDENCE GIVE facts c» 

/ ,r DfTH OCCURS A^AY rPOM ^ S ^ * ^ ^^f^^^.^^^T.oN GIVE ITS N 
(^ ,r DEATH OCCURRtD IN A HOSPITAL OR INS 

FULL NAME lU^-vXce =^--^^- 



— rt i 1^* 

roR UNDER "SPECIAL INTORMATION ' \ 
NSTEAO or STREET AND NUMBER. / 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR N f\ 




I>\ IE OF lUKTH 



»MotUh> 



M.V. 



J r'il ' 



(Day) 



.\fnlllh> 



/ 



(^car) 



Pax 



siNCl.i:. MAKKIl'.H 

WIlx t\VKI> OK l)n'< >K^'1"I> 

(Writf til smMal (k'si>.'uatioii) 



lURTin'l.XOV: 

( Strit( 1'! •"■ miiti >■ ' 



MEDICAL CERTIFICATE OF DEATH 



(Ik^ 



an /^H. 

(Day) (Year) 



A.L/\J 

TTlT-RKHV CKKTIl^V, That I atten<Ua -leroascd frrnn^ 

-■: ■■" T90 ~~ 



that I last saw 



h 



•190 "■ to 
— alive oil "~ 



T90 



„,1 that .Uath occvirrea, on tlu- .late stalL-l above, at ^..^ 

^ M. The CAl-^jA C)l- DlvATll wa> as follows: 



SAMi: <»i- 
I'A TH IK 



HIK'IH I'l.AiK 

(»i- I Arm':K 

(Slate or Ctmnti v 



MAIDKN NAMK 
OK MOTIIKR 



1!IK TinM.ArH 

i>i- M«»iin:K 

(State or Count r\ 



(K-CITATION -5 [ 

dcrtcL 




^ 







DT RAT ION >>'?''^ 
(.ONTRilirTORV 



Months 



Days Hours 



R/-sii1fi! I>i S(i» f'unrn'sro 



fyV.^Ntflf III .XI" f«">'-- — ■ -,.,11.- 

HKST OI- MV KNOWI.I-.IH.IV ANDjn.I.H' 



(\ 



„„.„ '^Ifw^ C tl- ^^^^ 



,SiaNEO)(ii.i^Vlc4KA/^ M.D. 

nXlxtr 'X^ Tr)0 






'1 ( 



k. M {jLLxy-b^KmX .^ ^ 



SPECIAL INFORMATION «nl, lor Hospilnls. Instiluhons, Iran.,e.ls, 
or^eren^^'side«ts,7iid per«ns iyin «dy Iron, home. 



Former or 
Usual Residence 

When was disease contrarted, 
If not at p la( e of death ^ 

Vl^ACKOl- lU KIAI.nK Kl^MoVAI, 



How lonq at 
....... Plai e ot Death ? 



Days 



DAJHof 1UR1.\I. or KKMOVAI. 



s.^ ^A)-4>t ii.3.a 



N. B." 



fV.Mress .U-U VA. ^ - rrvArTI Y PHYSICIANS should 



'.' I 






I i 



\- 



\ 



i v! 



/ ' 




t J 



M 



^ 4 



if 



!; 






f ' 



i 




H 



WR-TE PLA.NLV WITH UNPAD.NG ,N.-TH,S .S A PERMANENT RECO.D 

'^"' p,..R TO .« CK OP CPTinCATtrOR INSTR UCTIONS 

r.,,:ir.l <.f He; 



ri 










o4o^-.* 



\ \ Deniity Hee1*H Officer 

department' OF PIBLIC HEALTH=City and County of San Francisco 



No. 



Certificate of Beatb 

PLACE OF DEATH:-— Gmn t y o ^ v^^^ 

■r^. 1 ± ■ ■ and 

g^. Dist.;bet. 








Q^ 



( „ O...H OCCU.S .W.V "°- „"/U«t «„"^^f„~„^^,°. .,VC ,TS NAME .NST..,, C. S,»..T 

V. ir oc*TH occuRRrD in • hospital '^ A {\ 



FULL NAME 



- \ 1 y 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLORE 



n\. 



,<XA_<. 




ikctL 



i.\ ri: (OF iJiK I II 



\«-.K 



/ 



1 M.Mitb' 



> 'I'li t 



il)ay1 



M.;/f/f 



r / 



/ 



/)<tv 



^^JEDICAL CERTIFICATE OF DEATH 



I)\ 



1 H oi- ni-A'iii ^\ 






10 

'Pay'* 



(Year) 



>-«iNr.i,K. MARK n:i>. 

W II>o\vl-,l) OK l>!VnRil-.n 

U ) itt ill v.K i;il lU-xi^'natioti' 



HIK rillM, ATI". 
(State or Cotuitiy 



NAM1-: i>I 

J- AT in: K 



-" TlPn^HnV ciirnrV. That I attcuU-.l .leceasea frn„, 

tn r: --iQO-r--' 

__ — — 190 to 

ll,;,t 1 last x,w 1. - - "live "" ""\^ 

„„nlK,..U...I,occurrc,l,..n..K..l...s.aU.,lahov.,.t 

- M. 



UIK ruj'i.Ai'H 
OF lATHKK 
istati- or Coiititry) 



MAtnKN NAMH 
OI" Morm.K 



lUKlllPI.ACR 
1)1 MoTHl'.R 
(Slat< or Coniilry> 





M. T.u. CMS,.: WMH.:ArM«ps follows 

i . J A^'-tHX.«w*wL<HQ,4Ji 



JS^J^ 



1)1- RAT I ON ^''''^'-^ 
CONTRir.l TOKV 



Months 



Days 



/lours 



DlRATloN 



)V</;'.s' 



dcrLAxJm^ 



Yr,ii 



M,,nlli> 



OCCUPATION 

K\-'.i,{,;l i» San fu'i' /'"" ^ 

TlIKAU(nM< STATKOlM^KSONAi rAKTirri J.KbAK . 

in-sT oi- Mv^KNowi-i'.nUJ;- ^^'' "''' a 



l>.n 



KlK TO THK 






I lours 
M.D. 



( A<l<lii'^*^^ 



-^^ . .^.^oiuiaTiON onlv lor Hospitdls, Institutions, Transients, 



Former or 
Usual Residence 



How long at 
Place of Death ? 



... Days 



ii 



MHST Ol- M\;.^KN«)\VI-i;i>UI;; AM) •"••«"■ ^ Q. 



<X^vrv^ 



When was disease contracted, 

If not at place of death ? : 

T.I.AC:H «)1- lUKIAl, <.K RKMOVAU 



I)\lI-:o!" HiKiAi. or RKMOVAI, 



•Nl.HRTAKKR ^'^'^' j" Q^ [^ ^ 



(AcMrcss 



^.'J?. ^ 



iBtion shouUI 



IS. B.— F.very Item ai '■'^-''-rl^" ^.X t^rms, that it m»y be proper.y 
Btate CAUSE OF DEATH m P'«'" '^J^^i.en '.n every instance. 
«on, clyinft away ?rom home should 



" , PY4GTLY. PHYvSlCIAtSS should 



i. 



" < 



I • i 






• r 



!^^* 







w 



RITE PLAINLY WITH UNFADING INK 




h,ifr rili'<l , M'W^^^"^'^^"^^ ^^ 



M 



OfTieer 



THIS IS A PERMANENT RECORD 

REFER TO BAC_K OF ^co..c.rAT. FOR INSTRUCTIONS 



.'3454 



y 



■ 



M 



•1i 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate cf IDcatb 

PLACE OF DEATH :-Cnunty n f V^^^^<^-^^^ 



No. 



„^_ •cprciAL INTORMATION' ^ 



DIst.; bet. 

ACT 

■ IT 

1^ 



5 

and 



■— > 



FULL NAME 



SKX 



PERSONAL AND STATlSTICAL^RTiCU LARS 




<x' 



VolcU 



UATK <ii- niK ni 



^A 



iMi.nlht 



ACK 



)■(•■;' 



(Day) 



1 A ■'///'■ 



(/ear) 



MEDICAL CER^iJ'CATE OF DEATH _ __ 

Datk^h !>i-Ain A 

MU\r 

(Month) 
"^ , IIKRlMi7cnR-f7rv; That I attc.M.U..l .Iccascl t^m 

^90 



JLO.. 

(Day) 



(Year) 



/ 



Ai ' ."' 



/ 



ifflft 



STNC'.I.K MAKUn-.D. 

\vnH>\vi:D OK invoKAhD 

'Writt in sufial tU-iv'ii;t«i""' 



'St.'itf or Country' 



NAMK Ol- 

I A Tin: K 



/ 



/ 




'Ijll^ 



I'.IKTHrT,A(M* 
<)! 1 Allll-.K 
(State or Country) 



MMDl'.N N\MK 
Ol- MOIIIJ'.K 



iUK llllM.Arj': 
Ol- MOTin-.K 
(Statf or c"ountr\ 







1 90 " to 

that Ilast saw h ..-- alive on 

1 ,„i til.- clali- ■itiitoil abi'Vf, ilt 

— M. Th.. CMSi; Oiyjl-VIII WM-^ as follows: 



T(p 



^"50 






.!/()'////? 



/)ays 



//ours 



nrRATioN 

( SIGNED ) 



y'rars 



Jfof/Z/is 



,Dav.<: 



klA/VV^ 



\ ' 



TQO'A 



(A<lilrt,"^s) 






Hours 

M.D. 



occr 



CrLdLoL;^, 



R frilled i» ■^"" 



I'l ,!)>' I ■"> 



}'r,it'- 



T^K^,.)VKSTATK.)^KKr;<>NAl.l;;«-;^;,l;^" "'^ 

lU'ST Ol- MV KNOW I.l-.IX.h AM) 1^'. 



.1/,. ,////« -Am. 

1-Kri': TO ■'■'"'■ 



h— . ^ca;, ATION onlv for Hospitdls, Institutions, rrdnsienls, 

How lonq at 

Former or ..,. pjare of Deatli? "ays 

Usual Rcsidcncf • ••• ; v 

Wfien was disease contrarH 



(I 



lU-.ST Ol- >.n K.x.u. .-■.-'■' •_ . 

.„ .Wv^c.a'i)-^ 




C>/vu^ 



^^yu^^ 



I ndkrta'^'""'* 






\<l(lri"^s 



IN. B. r.very item off hiform 

state CAUSE OF DE 

(,on« dylnft away from home 



<^' du^^ ^„^ TfvIcTIY. physicians should 

ATH In plain term«, *j- ';;;4. ..n„t»nce. M 

« home should be fc.vcn m every , J 



|t 



}'] 



1 it 



. I 

I 



I , 



i 



rtii 



t: 



• 4 ♦I 






'a, • .r^w^- 



1'^ 



Lii 



t. 










I 



Hi 




i' J 



W 



RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H ,'tt! 1 N- 



fw.f^-i^ji HM' <■') 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1U()\ 



]teo^i\s/ered ^Yo. 



3155 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



I 



Certificate ot Beatb 

( XX. 'I". *3tanDav^ j 



PLACE OF DEATH; — County o^ 



r 



City o f Va^^xv (JK) 



"11 






No. 



— St.; 



Dist.;bet. 



and 



_„ ^^r> iiKirtra ""SPECIAL INFORMATION" ^ 



/ ir DEATH OCCUBS AWAY WFIom 
\ IF DCATM OCCURRrD IN A H 



OSPITAL OR IN 



STITUTION GIVE ITS NAME M 



FULL NAME ifcx^aM^ 



CVI «^xXj 



SKX 



PFRSONAL AND STATISTICAL PARTICULARS 

DATK OF HIK I 11 

/ / 

,,-.v) / (Vear 

t M out h ) . I ).t > ) / 



/ 



\<-.H 



) V-(i I > 



V- ■>////> 



SIVni.H. MAkkll.I). 
WIHoWKIl OK I>lVn'U"KI» 

•W lite in »iiH-ial 'Ir^ivnatiou) 



nTKTHPT.XCK 

( siati III louiitry^ 



NAMK OF 

FAT INK 



iMKi'nri. ACK 
ni 1 Arill'.R 
I stale or Country) 



M MDl^N NAMK 



IMRTlirt.ACK 
<»l MoTHl'.K 
(Mate or Comiti yi 



OCCUPATION 




Par 



h',-sidf'<f ill Sntf riaiuhfn ^.Yeo' 



\l..„th< 



n.i 



THK \U()VKSTATKl)l'KKs.)NM.l'\KTU-ri.AKSAKKT 
lU-ST ()!• MV KNi>\Vl,i;i)C.K AND ni'.Ml.l 



Kl K TO yn^' 



(It 



,f„nnan, VHlCVCX^ \) XK ■ ^JjU^ 



MEDICAL CERTIFICATE OF DEATH 
DA I K ul DEATH 



3A 

(Day) 



(Year 



/Jix^ 

(Month) 
I IN'Rl'IiV Cl.RTIFV, That [ atU-M.U.l .IcrcascMl from 

to .'■■ '^90 " 

— 1 90 "■ 



190 



that I last saw h n— - alive on 
„,1 that (Uath iH-c-urre.l. .m, the .lato statc-.l above, at ^«^ 
M. Tlu- CAISI' ()!■ DliAfll wa- a^ follows: 
\^J^ l^- O-W-y^^ . OAX^evcU' 



I 



y 



^v^v-Vl 



DERATION '''^'^^ 
CoNTKir.l TORY 



Mouths 



I lours 



DIRATION 



)'i\u-s 



Mouths 



Pars 



(SIGNED) M>\....sJ«rY^^ -j^ 



Hours 
M.D. 



VI- 



or 



Rrrcnl Resrtols. dnd p.rs,»s d,in, .«h» Ir,™ h.me. 

Ho\\ lonq dt 
former or p|j,p „f Oe,,th? Days 

Usual Residence 

When was disease contracted, 

If not at place ot deatli? - "' '•-•:: 



,ACK 1)1' in-KiAKnu ki;m«>vai, 

cLcu 



I)AI"i:<if lU KIAI i>i KlCMOVAIv 



rsni-.KTAKKR ak' ^'iV (^ 

(Acl.lnss D. a. ^'<^-'- 



(x.i.in-ss vrv, I I YACTLY PHYSICIANS should 

..a.c CA.SE OF DEATH -„ P -•",—•;,•;;;;',,./, In-.--.- | 



8ons tlylnft oway from home .jhoiiltl be ft 



t ^ 



i. 



.;f| 

m 



1, * 
• <• I 

I 

I 



!'■)■ 








« L . , i 



<!« 



It 



» iM 



II 



i 



III 



iii >^ 



I 



ri-i 



h I 



(i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

RtFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



1 • 1 1 



I V 






/)///^' AV/f'^/. ' Tt^^ ^"•v'Lm.v v\ 






100 \ 



Re^istrred J\^o, 



8156 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

i 11. i5. StauC'arc) ) 

(\^ (^ ^ 

_r Ci t y o f VI iV<X'>'v.vX<x 

PLACE OF DEATH :--€mmtr^?l 



(?j.. 



fNo. 



— St.: 



Dist.; bet. 



and 



^^** * ^„„ M^inrn "<?PECIAL INFORMATION" \ 



FULL NAME 



I.AA/W.CJI 



jv. LO /cx^Ltx^^). 




!':x 



DATE «>F lURTTl 



M\V. 



PERSONAL AND STATISTICAL PARTICULARS 

C01...K ^ ^ 




(Minith) 



J Vif ' 



U>ay) 



M '>i'h- 



' f 

/ 



K'tar) 



na\ 



wiiM >\\ j:i> < »K i)i\<»Ki):i) 

(Writt ill K.u-JMl cl.^i).'n.iti'tni 



/ 



MEDICAL CERTIFICATE OF DEATH 

"•^'•'^ '"""";';" Ol,_ x%. 



XV. a. 

(M.mth) Q 



(Day) 



(Yfiir) 



I 111 



IRnBY CKRTH^V. That I attended (Iccoased fmn, 



190 ■ ■ to 
— alive on — 



/ 



/ 



lUKTIIIM.Al'H 
' suitc or i.>)uiilry) 



NAMW OP 

FAT 11 IK 



Hik'niri.Ari-: 

01 lATlllCR 
iSt.itc or Coutitry) 



MAIDKN NAMK 



nTRTTTPT^ACK 
t>l. MoIUl'.R 
(st:ite or Country^ 



/ 



/ 



r/ 



/ 




tliat T last saw \\ ■■ 

,„„l,l,nt,U..tlw.c.M,rre,l, !„■ .h.lc staU-,1 al.nvo, .t 

^- M. TlK- CAISlv Ul- I'I;ATII «.s ,.s foU.m. 

^^ ' ^ .CrVcL.. J^-</Vvi.\. ■ ^ 



190 



J AVp-^^< 



nr RAT ION J>^''^ 

CONTKlIil loKV ■• 



iMoulhs 



Days J Jours 



Years, 



Mnuth:^ 




I 



sJ^-yy^JJX 



/)tjys ..„....>...I lours 
M.D. 



fV..,....^QfKa^v.lcv-3 5 



oiHTl'A TinN 



c) ft-LcLvS 






M.-.i/f/r 



n.n 



,..uai/i)-v.. 



DIRATION 
(SIGNED) 

:^^:^^;^^ institutions, Transients, 

or^ercn^ Menis' Vnd persons dyim a.ay Iron, home. 

How lonq at 
Former or . Plare of Death? 

Usual Residence 

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



Days 






I NDI-.RTAI^^'*'^ 



(Aihlifss 



S 'y c 



O..X. 



U-llrr^s A>^ V^V c^ - " TTi VAGTLY. PHYSICIANS should 

-^ : nhcnnC-uHysuppneC. ACF. should I^^J^^^"'^:;, ^^.^s^'.Lia. lnfo.MnHtu>n" for p-r- 

N. K.—Hvery Item of InV'.rnu.tion «hou Wl »-;';";;/, ,, „„y he properly cIa«H.^lcd. J 

- 1. :«A ..^«v from homo shouhl he ftiven ■ 



Ron« dyinft uw»y from 




' » 



^ 








4 



1 ** 



f V. • ' I I 



WRITE PLAINLY WITH 






I)(ffr Fi/t'f/ ,\l^>^^r>r\JjJi)v'^0 



UNFADING INK-- THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

345? 



lfU)\ 



Urcfisicred J\^o. 



\^\j^K.^^ VfAMi Deputy Health Officer 



5 ^w^ 



DEPARTMENT OF PUBLIC l1EALTH=City and County of San Francisco 



Certificate ot Beatb 



PLACE OF DEATH: — Gmiit y o f vVj^-a ^ 



No. 



St.; 



•and " 



fT"K 



■ ICIIAI RESIDENCE GIVE FACTS L< 
/ ,r DC*TH OCCURS *WY rPOM ^ S U * L ^^f^^^^^^^.oN GIVE ITS N 
V ,r DEATH OCCURRED IN * HOSf'^TAt OR IN^ 



DlSt»; bet. ,,,^^0 ■ .^pfcial information' \ 



FULL NAME 






J4F.X 



PERSONAL^AND STATISTICAL PARTICULARS 



^-\\o\x 




\ 



Mj^ 



I»ATH <>l- ItlK III 



AiJR 



M..ntht 



} V<j» .- 



tUny> 



Mnulh^ 



/ 



/ (Year) 



/ 



/ 



f 

/ 



Da « v 



% 




SIN«'.1,1'. MAKKH'.n 

un>«)\vKi» OK i)i\< >K^ »•■.'> 

tWritf ill social .li vij.Mi;it ii-n) 



niK rnri,\»'»-: 

(Stall- or i"n<tnti v'> 



XAMt: OT' 

FA 111 J. K 



MEDICAL CERTIFICATE OF DEATH 

T>\TK OK UHATH ^ 

JilollllO 



11 

(Day) 



(Year) 



1 I 



n-RTOn' CHRTTFY, That I atlcn.K-a .leccasc<l from 



I <>o 



— to 




HI Kill I'l.ACH 
ol- 1 Alin-.R 

iSliitf or (."ouiitry) 



MAIDEN NAM I 
OF MOTIIKR 



niurnPLACK 

Ol- Mo'niHR 
(Statf or Country^ 





that I last saw li -^— ^'I'v^' <>" 

^_^^^ ^^^^^^ ^^^.^,,, ^„,,,,,.,. on the .late stated above, at::- 

AT The CXrSI- ni- Dl-ATIl was as follows: 

'■.j\jx^ ■ •■' 



^190 
^90 




DIRATION >''-'?''^ 
CONTKIIUTORV 



Monfhs 



/)avs 



//ours 






DIRATION _ 

,NED)\K^■X:^•^ 



(SIGI 



T()(T 



( 



OCCUPATION -X , 

Rfsi.h'.f ill S,i» naiui':i'o 

rin, \Hovr. srA'n-:i) '•kus.>n.u i-ak nrri-A 

HKhT 01- MV KNoWlJ'.lX-h AM) in.I.lt.i 



K> AKi; IK 



n.n 



(iMfoniiaiit 



c.a.5).^ 



,. \I\jluA«u>.:nJ...... -^ M . D. 



„1«^ MenK,V«d persons m ■»-> "»^" "»""■ 

How lonq at 

Former or piare of Death ? Days 

Usual Residence 

When was disease rontracted, 

If not af place of death ? 



I)ATl-:of H'Ki.M. or RKMOVAl. 




as 



,.,,,U-H or Ml RIAL OK KHM-VAl. 
INDKRTAKKK O' J^l^ f' \ 



190 



1 



\d.lnss JLHjl VV c*- '^^^^^^^ ,^,^|LL PHYSICIANS should 

,.au. CAUSE OF DCATH In P"" " """'i^^ ,„ .v.r, ln»t-n«. J 



.on. .lylnft 8w»y «ron. home "hould be & 



^^|P f 

SI 



1» I 



; > 1 



I' I 



4 1 ' s 



^i 



! 



* I 



I * 



* s> 



I I 



' .tl 



! . 



1 k 



^ 



ri .t 



s? 



'"Ppwl 



lii 



111 



w 



R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 






! K 



REFER TO BACK or CERTinCATE FOR INSTRUCTIONS 



lie Sulfite red jYo. 



3458 



\ i« Deputy Health Officer 

DEPARTiMENT OF PUBLIC HEALTH^City and County of San Francisco 



Ccvtiticate ot Bcatb 



PLACE OF DEATH: — 




No. 



XXTVi 



( k 



} ^ 



-Dist.;bet. 



and 



) 



. — St.;- Dist.;bet. ^„ ,.^^,„ -special information a 

( ,r OtATH OCCURRtD IN A HOSPITAL OR INS 



FULL NAME 



tl>^LVV'k' ^^iJ.^-tru.n^.. 



»i!:x 




PERSONAL AND STATISTICAL PARTICULARS 



UATK OF HI K Til 



A«',K 



tMuiith^ 



)'nit 



(Dayi 



M,„ith^ 



tYeaf ' 



Pa 1 



Wir>0\VKI> »»K niVnKv 1-1) 
<WrUf in «MK'iiil «U'M*rmition) 



BIRTH PI.ACK 
(State or Country^ 



(Year) 



SAMF or- 
f.\thi;r 



HiK rni'i.AtH 

• M- FATIIIK 

> '^lale or Ciiiuilry) 



t»i MOTHKR 



iUK !"nri,ArK 

Ml MoTllKR 
(Siatr or Country^ 



OCCUPATION 




MEDICAL CERTIFICATE OF DEATH 

^'^■^^'^'^^^'"^■'^IW 3 

" "l IMM^KHV ClvRTfrvT That lattcnaoa.U-ccasea from 
__— ■— 190 to ..-r--rrrr-=rrrrrr...i90 - 

that 1 last saw h ..-— ahvc on ^^^ 

,,„atbat death occurrea, on tlu- .late .tatoa above, at 

M The CVrSI-: Ol- I>i:a ni ^vas as follows: 

*/'Dn r _ 

vtrlX/^-^O. 




DIRATIOX >V«^'^ 



Months 



Pays 



Hon 



rs 






/\f^iiiri! in .^ii'i I /«".'■■■ ____— — — — ~^^^^ . ■,•11 i> 

TMKAM<>VKSTATKI.nKK^oNA1 rAKTUMMAK^AKl. 
UJ-ST <)!• MV KN(.\Vl.i;i)f.K AM) lUvl^l.f 



I )r RATION 
( SIG 



Mouths 






A7V.N- 



II OH IS 

M.D. 



( 






orlereS M™I ' -"- P"«"^ *'"" -""> """ '""'• 



Former or 
Usual Residence 

When was disease contract, 
If not at pla( e of death? 



How lonq at 
Place of Death? 



Days 



HAll-of nnoAl. or Kl-MoVAl. 
a^ T90H 




Info.maut ^ I V-CCV/CTV) V- ^"^^ ^^ 






(AlltiK'*^ 



^ VA ^ ■^-V^. VAJ^) — TTvACTLY. PHYSICIANS should 

± .-. r™:-s "S;-t B;;--" ™ ■-'•' '■ — - ■" "'• 

OF DEATH in plul" «^.'''"«' V'"* ^^^^^ i„Ht»nce. i 



N. B. Kvery item of . . , ,„««,- i..„. 

„„te CAUSE OF DEATH in P'^'''" ''7-;,;„ ,„ ,v.ry ln»t«n«. 
«an, .lylnft owa, from home .houKI be fti*" 






fi 



I < 




■fi 




• I 



hi 










il 






!!..» ' 



I I 





>i t 



W 



RITE PLAINLY WITH UNFADING INK 



-. !;\ !■ ^" 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,Q\ 



Iktte Filed , \1 unM/yrOMAj M 



1 i) 4 



h^ro'/.sfrred Ao. 



0'l<3vi 




Depyty Health Officer 



DEPARTiENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc of Bcatb 



^TT ^ * I oVru^v C^-^V ex. ^>v^L^C' City ot 
PLACE OF DEATH: — County of ^ tv>v ..v. ^ ^ 



0| 



No. 



Dist.; bet. lO ,CUl] WyV]i;b> .and Licv^ 



{ .r DC.TH OCCURRED IN • HOSP.T*t OR i N 5 ^^ 

\Jx elc\'- -x '^.\.cJ! vWl-u. 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



SKX (^ 






COLOR 



I>ATH OF HI Kill 




A\J^ 



Ai'.F. 



i\f until) 



SH 5V./M 






M,>n.'>n 



iS't'ar) 



x\ 



An-v 



MEDICAL CERTIFICATE OF DEATH 



M 



(Day) 



(Year) 



WIDOWKl* UK HIVoK*KI> 
(Writrin j*c»ci.'U (Usivri»ati«»ti) 



.1) «^dL^ 



fr\^o- 



nik run, \oK 

(Stalfor Country' 



NAMI-: ot 
FATHl.R 



luk iin'i, \rH 
oi iAiin:K 

IStatf ui Country) 



MATDKN NAMi: 
OP MOTHKK 



BIR rmM.ACK 
OF MOTHFR 

(State or Cniuili y> 



-i, 






s 



; Vjlcv- 

(Month) 
rHFRKnVCHRTlFV. Tl.a latlonilcaiKceasedfrom 

Cu ... *,, \rtc\r: 23. 190 • 

... Ux<rvr a^*^ Too'i 

ti,alIlastsawhXK Hl.veon ^ ^ 

..„.,tl,at.Uath.>ccurre.l,nnthcilaU..tatcaal.nvc.at ^ 

Q M. Tlu. CMS!- or Di^NTIl wasasfoUnws: 

CTiVxxkxc^^^^-^ c)j^-vv.u • 



DIRATK^N JVrtr^ 
CONTRII'-rToRV 



_V,,;,///.v 3.3 /hivs Hours 






\ X)\.rrs^C^^^^^\ 



>CCl!PATION 



^^ _U Xh^'% "wOc V-V.U . 



N f- 



IllF AH.>VKSTATKl>l'KKsnN\l.l'\Ki;u;ri.AKSAKH 1K( K 1" 



nr RATION 



)Vjri 



Months 



/hrvs 



(SIGNED) Lo.'V-i^' 



i.iHijX 



Hours 
M.D. 



3,01 ot^ (^vv*- oaA_^ 



or 



W:L- r ^o^y.ATlfM ^^t"r Hospitdls Institutions. Trdnsienfs. 

How lonq at 

former or .,.. Plaff ot Dcitt)? 

tsual Residence 

When was disease rontrarted. 
If not at plar e of deatfi ? 



Oavs 



*r.r*«*^-t^**=** 



ll 



IIF.ST OF MV KNOW I.F-.IX-.F. AND MFLO-^ 






INI.I-.KTAKKR C^VO. v>. .. 



(Addif'^'* 



(XMr.ss ni^ VJCr^^,. - TpyIcTLY. physicians should 

— — — — ■ ne.1 AdB H?^'^^''^' »»« '**"'*'iJ ''Sncclal Information" *or pT- 

•1- --- "r ."L^r: :r..:r;-; > — i 



«on. clylnft oway ?rom home Hhould be ft 



i 
I 



j 



i 

' 1 
I 1 < 



K 




' I ' 



Ji 



! 



I 



, :., »l 






I* 



tl 



I 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




() 



ijvML'v>^JLMl>\j i.C: IPO'i 

*^.*nf't"f M.'^-alt*^ 0^^r'^,r 



Bp^istered J^'^o. 



3460 I 



I)(if<' Filed , 

i 1 
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of ©catb 

( 'a. S. StaiiDarO i 



PLACE OF DEATH : — Cuunl r »t X^vO^ eit7-of VL) oX<X^^ tX6 




(J^ 



No. 



St.; 



Dist.; bet. 



and 



(ir DEATH OCCURS AWAV FROM USUAL 
IF DEATH OCCURRED IN A HOSPITAL 



USUAL RESIDENCE GIVE facts called for under "SPECtAL INFORMATION \ 

TS NAME INSTEAD OF STREET AND NUMBER. / 



OR INSTITUTION GIVE H 



FULL NAME 





^(XX) 








PERSONAL AND STATISTICAL PARTICULARS 



si;x 



^\ai 



coi.,K N ,| 



IvcALi 



DAIM Ol" 15IKT1I 



/ 



(Mmilli) 



<Day) 



-/ / • 

5'car) 



AC.K 



5 */•«/ / .V 



.!/..»/ ///.«.. . 



SlNC.I.K. MAKkll-.l). 

\\n)(>\vi:i) OK n!\(»KrKi) 

(Wiitfin sociid (k><iv,'»ati<)ii) 



lUK IIIIM.AOK 
(Stall- DV < "oinitiy'l 




/ 



Pavs 



NAM!' Of" 
lATHl-K 



RIRTlllM.AiH 

or iwrnKK 

'State ur (."ountry^ 



MA1I)1:N XAMl 
0|- MOTIIKK 



niRTIirLACK 
OI- MoTHKR 
(State i)r Country 



OCCUPATION 




Rfsiilfif ill '^'1" Fiiiiiiisn^ 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DF.A III ^ 




otith) 



1 

(Oar) 



(Yeari 



I iri':kl-:BV CIvRTIFV, That T Mttt'n.U<l «lcooase«! from 

. ' ■-— — — — - 190 to igo ■-:"-• 

that I hist saw h r™ alive on ■ ■- - ■ ^^P 



and that dc-ath ocriirrcd, cii the <lalf stated above, at 
lie CAT SI-: OI' I 



M. ThcCArSI-: 01* DIvATII wa-^ as follows 






DTRATION Years 

CONTkliUToRV 



J 'CiU'S 



Mouths 



Hours 



Mii}iths 



Pays 



Hours 



nr RATION^ 
SIGNED )\J\ ^.^ \JWl^LlK.'>\X . M.D. 

t Too'1 ( A.l.lnss) \J ll<Xn^.JLa.M -5 



QX^ ^^ too' 



Special information onb tor Hospildls, institutions, Iransients, 
or Recent Residents, dnd persons dying .may from fiome. 



r.-.f/ 



v.. /////> 



l),iy. 



Tin- \HOVKST\'n-,l) I'KKSONAI, I' A KT IC f I,A KS A K l- TKt J-. To IHK 
lilisr K^\• MV KNO\Vl,j;i)«'. !•; and lU'.MlJ' 



(Iiif<)!iiiat»t 




a 12 



CUAJ-v>Ci 



Former or "^ ''?V'.k, 

L'sual Residence • f'-Jre "I Oe«<th? 

Wlien was disease contracted, 

If not at place of death ? -. • •• •■ 



Days 



ri.ACK OF lUUIAI, OK KICMOVAI, 



DA !!;..>! I'.' lOAl i.r KIIMOVAI, 

(K^J^^ ^S 190^ 



'I.ACK Ol- lit Kl \1, '""^.'^ 

(Ad.hfss a. O VwCV.'C 



U ... .... I- I KCP »hniil(i be Htnteil r.XACTLY. PHYSICIANS should, 

P,. B.— Every Item oV informBtlon shou d be cnre.ully nuppl.c J^^;^;;^^,'^'^^'^;.,;^ '^Vh, ^Special Information" for p«d| 
state CAUSE OF DEATH \n phiin ttrmH, that it may be properly cla»«meu. i ne o, •« ^ 

«on« dylnft away from home Hhouhl he feiven in every instance. 



I 

» 

1;. 



I 



Mil 



■I' 

i ' 









.j5 






r 






I! 



^^m 



^ 



1^ 







el 



WRITE PLAINLY WITH UNFADING INK — THIS fS A PERMANENT RECORD 

„,,„,, .,f „.,,,!, . N-.> t..f^^>i),K^ro. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lipglstered Xo. 



mm 






.^fyv^.'^:, <Xi 



c ijLAHA Deputy l^scUh Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

of Ca'^ J >v<X''vxcui<L0City ofC]<x/^^' J \xvovcA^eo 



Ne. 



PLACE OF DEATH; — County 
^d^i VLtrULAvt.u Vtl'Y>AAk^'- St.; Dist.;b€t. " ; and " 

A 'WU vr^ I V. v-x.^, ,.-,,-, oB-einrNrr riwr TACTS CALLED FOR UNDER SPECIAL INFORMATION' \ 

ft ( '^ rrDrAT°^occuVRrD\rrHo"s^rAt o^'?^s^^"JvU"o.v7Ts name .nsteao o. street and number. ; 



FULL NAME 



Jxtl^j. .'I!). 



\jJ\JiiX^ 



sj;\ 



PERSONAL AND STATISTICAL PARTICULARS 

I).\ Tl'. < )!■ I'.IK IM " 




Ar.K 



rilau 



%H 



J '('(/> 



t 



15 

(Day) 



Monlh- 



(Vc'jir) 



u 



Ai v.v 



SINT.l.K. MAKKIl'I). 

\vn)n\vi:i> ()i< ni\«>Kii:i> 

;\VrJt(.- in scicial iksiKn.'ili""' 



niKlIU'LACH 
(State or <,'nuntr\ ' 



NAMIC OI* 
I'ATIIllR 



RIRTHri.ACH 

()i iArin-:K 

(State or Coiititrv^ 



MATT>KN' NAMK 
UJ" MOTm;K 



lUR ruri.ACK 
oj- M»>i"in-:K 

(stale or C'oiiiitry^ 







IxbA^ Vi'iXcV 



lu 



m 



? 



« 



Vxxw^e. 



OCCUPATION (^^i, 

A'f n/fif III S,ii/ I'KD'.i-rn 1 O ^ " 



MEDICAL CERTIFICATE OF DEATH 



PATH <^1' nK\T!I 



(Month) 



(Day) 



(Year) 



I nr^FU-nV C1:RTIFV. riiat I atttn.K.l .leccased from 

\d<>....\ 190'i to Ovw 3^Vj..„ 190 "< 

tliat T last saw h^> > ^ alive on U\4\r . .^lo 190 H 

and that (Uatli (.ccurrcMl, on the date- stated above, at li-HO 
[j^ ]V[. The CArSI- Ol" DI'.A'I'll was as follows: 

, OX ■i'N-AwXA.t 



h 



I)'- RATION )V<?/.s- 1 .^foni/is ^% Pays 
C N T R I BL' T R V -— 



//oin<s 



Mofitha 



Pays 



I )r RATION )'''^a 

NED) IJJ.J^. 

A d d ress ) LLvWXja./' V(H^^*4X 



(SIG 

Ih fV^ %\.^ TOO*' { 




M.D. 



SPECIAL INFORMATION "nly lor llospitdls, Institutions, Trdnsients, 
or Recent Residents, and persons dyinj dway from home. 



\ I A' 



Months 



/',M 



THK A.U.VK STXTK.) '"'<KSONA, PAKT.rtJI.AKS AKK TKrH To THK 
in;sT OI.MV KN'OWM.IX.K AM) '»'••''".' 



(1 



nfonnant iVCV^^A LL /CL 




Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Davs 



I'J.ACH Ol' HIKIAL OK KJ:Mo\\I, 



i»\ii'.o! inioAi 01 ki;M<)\Ai, 

%js<r so 190H 



^1^ JV-'CL^cv a.>v> 






————"""■"""— """"""'"""^ ^^ AHF H'lould be Htntea I.X4CTLY. PHYSICIANS should 

N. B.— Bvery item of information hHouI.I b. cnretully -PP''->- p^^,,*:;;" .aerified. The "Special Info. ..»tion" for p.r^ 
«t«te CAUSE OF DEATH in pinin terms, that .t mn> I>«^ P;"'*f "^'^ A 

«on. dyinrl away from home should be l^lvcn in every .nstance. J 




I- 



»l 



H.,;il-.l of 111 .lllll i N' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Blistered J^'^o, 






Dnlr Fi/r>/,'\\i:y , , .-JjA'v. *0 ^-^OH 

Lvcc.L^ Deputy HecJth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificatc of S)eatb 

( "U. 5. Stan^a^^ ) 
PLACE OF DEATH; — County of ^^Oorw 



doUTU aX.\JoJL Cily of ^' ^^O/Oc 



a.. J (? i 



No. 



St.; 



Dist.; bet. 



— and 



-) 



(ir DCATH OC 
IF DEATH 



DCATH OCCURS AWAV F 
OCCU RR t D I 



>.r^■.«. occinrNrF riwc facts called for under "special information- '\ 

nThO^S^P^TAL 0^'fNS^'Tu';'0N"0.;ETTl NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




'YY\jU UVD. 




\.C L^^V 



si;.\ 



PERSONAL AND STATISTICAL PARTICULARS 

Cnl.oR \ |\ 



DATl". 1)1- HIK 111 



Month) 



AC. H 



1 Vrt / ." 



SIVC.I.F MARKTTvn. 
\\ll)()\\i:i> <>K I)(V()KCi:i) 

• Writiiii Muial dt si<.'ii;if ioii ) 



niRpmM.ACH 

(Slate or I'onutry 



NAM)': <>I" 
h A Til 1",K 



lUKTlII'LACK 

()i- i-Arm-.K 

(State or Coutitrv) 



MAI 1)1 ".N XAMK 
()!• MOTHER 



lUk IFIPT.ACT^ 
Ol' MOTHKR 
(Stall or Countr 




^ 



nCCrPATION 



o crC< 



Pcsrtff(f ill S<iv I'lmii is'-o 



)'iai < 



M,n>tll- 



n,'.^ 



HHST Ol' MV KNOWi.J-IX'H ^^" ''•'••'•' '-^^ 







( \(1<lrcss 




MEDICAL CERTIFICATE OF DEATH 



DATK Ol- Dl'.ATH 




^Moiitli) 



i 



%\... ^igo 

(Day) (Year) 



I HKRKHV CI-RTII'V, That T attiMi.led doceastMl from 

to 190 ~~~ 



I 90 



that I last saw h .rr" aUve 011 

and that death occurred, on the <latc stated above, at 

„„™_ ^l_ Yhe CArSIC ()!• DI'.ATI! was as follows: 

_..._LK.C^^wL*v£U 



or RATI ON yt'tir-'^ 
CONTRMirTORV .- 



Months 



Days 



I/otns 



)'i\jrs 



Months 



Pays 



^SIGNED) '^•^-^- ^^^^ -^ . 

3jLipjb ?.1ic,oH fA ddre>^^)N[>Va/TX.clay (^ 



Hours 
M.D. 



SPECIAL INFORMATION «n!y fnr Hospifdis. Instifufions, Irdnsirnfs, 
or Recent Residents, and persons d)inq .may (ro:n home, 
r „, How lonq at 

When was disease contracted, 

If not at place of death ? 




DA'rr o'. lUKiAi, or K1'!M<)\AI, 



I'l.ACK Ol' lURIAI. OK K1:M<)\AI 

3. J Co„c 



CNI 



(Ad'li f*^"- 



XA 



1^ Ilk t t I FXACTLY PHYSICIANS iihould 

^. B.— F.very 1.e„ oV ,„«,.r,.,..ion .h„„l.l be cnr^fuHy ^uppM.... ^^^l^^^.^J.^, Th: "Spcci.. l„for„...ion- for p.r- 
. *^ rAimF OF DEATH n plain terms, that it mi«> nc 1 » 
::"*.<."?. La, "on, ho.e ,ho...d be *iv.„ in .v.., i.,.«n«. 





I 



^ 




i 
i 

n 



¥ 



c! 



! I 



'i 



I 

li- 
lt 



Ifl 



\ 



\H 



m w $ 



r 



>1 -ii 



:t I If 

In ;; 1;' 






:ii 



!■!: !!• 




i ill 



^1 



^IM, 



WRITE PLAINLY WITH UNFADING INK 



B.,nr.l . t IK iMh I' Vo ; -, ■^^^x.-^US^V ( 



/>^//r F//r</ ,\i\^></y>\XsVv?>^ 



IfJOH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

3463 



Bn^lstered J\^o. 



fttr Mf*?^!t^ o^nsr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Gcvtificate of IDeatb 

( tl. S. Gtan^ar^ ) 
PLACE OF DEATH: -County of O^t'vc^ ."w^o^lt City of d^C>v.v^^to 




No 



. So?^ 



. 1) 



Su 



Dist,; bet 



"and 



..O..AI nF«;iDENCE GIVE FACTS*CALLED for under "special INFORMATION" '\ 

,AV FROM USUAL RESIDENCE GIVE FAc^^ NAME instead of street and number, / 



(IF DEATH occurs AWAV FROM U a U » 1. nt^.w^.- ' ...^ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



FULL NAME 





.t\ 



iXXXMJL. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

"^^^ COI.OR ^ ft 







cUyK.\-'^> 



(MciitlO 



AC.R 



^4» Vtai. 



(Dttyl 



M.'iilhs 



^oL' - 



./■ w.f^»> 

(Year) 



/)</ 1 y 



(Write ill >i<)cial <U sij.>ii;iti'<ii) 



IMKTmM.AOl-: 
'Stiilc or CoutUry' 



NAMK OF 

»athi:k 



HiK riiri<Ac'K 

ol- lATHKK 

I Stat f or Country) 



maii)i:n namk 

OI» MOTHl'.K 



lURTTTPLACK 

Ol" Morin'-K 

(St;ilL' or Cotiiitry"* 



occrrATioN 

R,'M,h-J in S.in l'i(in>i»',i 



A.CrV<^^<^- 




,., 5 V<M 



\!,.iilh' 



l\iy 






Cliifonuant 



{Address 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- I>1:aTH }■ 




(Month) 



3,.fc 

(Day) 



/go 

lYtar) 



I IIiVrIUJV CT'RTII'V, Th.it T Mttoii.U-.l <UToase«l frnni 

...Jl ...\ip 



190 to 

■ alive on — " 



that I last saw h t- 

and that (K-ath ncrurred, on the date stati-il above, at 

M. The CAISI-; Ol" DI'.A'ril was as follows: 

"b-uw-.-^-^-vO-t \ky^^s^iy^6^ 



I) r RAT ION J*''"-? 

CONTRII'.rToRY 



Mouths 



Days 



//i>nr< 



nr RATIO N.- 



}\iirs 



Moiil/is I^ays /fours 

( SIGNED )U)i. ^vJrvr^J^^ ^-ft^^-ff^^ "Vt-D. 

SPECIAL INFORMATION only for Hospitals. Institutions, frdnsients. 
or Recent Residents, and persons dvinij away from liome. 

HoH long at 

Usual Residence - 

Wlien was disease contracted, 

It not at place of deatfi ? 



•I.ACK OF BrRIALOK KICM"^^ 



l(\n;,,; U; KiAi. "I KFM<>\AI, 



190 



^ ^^ ?!:1 u" « «h„ul.l be fiiven In every inntance. 



r.NDKRTAKFK ^^ % v^vrvyrv- ^ 

(Addn-ss <3/(X^V<X.-.va. .xXc. V. 



N. B. Bvery item 

state CAUS .. 1 1 k^ a 

sons dyinft awuy from home shoul«l be 6 



tHte.l i;X4CTLY. PHYSICIANS should 
The "Special Information" for p«r- 



■ 



Ui\ 



\ 



I * 






j 

I 












WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






If)OH 



Beiilsiered J\^o- 



Da/r rili'(l,'^i' ■ rvvWa SO 

DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 



Certificate of Bcatb 

( ■«. S. StallP:u^ I 
PLACE OF DEATH: -County ofO-CV^' vUcv^^^^^ City of^^V^' ■^.^<^>>^^^^ 



-p 



QO 



1- 



' ht,i' 



Dist.; bet. 



- and 



(iyo.UL^V\VOjb l.>^%XVX>X>VCU, ^'^^^^^■^^■»W_,„~ tie's ..:;. .o» u.r,t» -sPcc,.. ,~ro.».T,o. ) 



(?sn 



FULL NAME 






• i:x 



PERSONAL AND STATISTICAL PARTICULARS 

COl.DR 




<xU 




liATl". nl r.lK 1 II 



l^!onth) 



w.v. 



CU>t -^ C »<:»> 



(IJay) 



M, 'II His 



(Year) 



/).; 1 



sINC. I.K MAKKIKI). 

u ii)»)\vi-;i) <»K invnKri:i> 

'Write ill MK-i;il <l(-ii' ii;iti)H ) 



HIRTHri.AOK 
I St;it(.' or Coiuilry) 



NAM I? OF 
1 ATHKR 



HiR riii'i.Aii-: 
oi' lAriii'u 

'Sl:ilc or ronnti y) 



M \iiu:n namk 

nl- MOTHKK 



nTRTiiri.ACH 

<>» MOTIIKR 
(St;ite or Country) 



OCCT'PATTON 

Rfsiiifil in Siiii f'l iin, />'•.' 



)',.n 



\f,i,itln 



/),!\ 



,.\K iUri \KS AKlv TKIJ. !•• ' '"■ 
lU'ST (»|- MV KN"\\ I.l.lx.h AM) HM.n.i 



»\1'. srAri'I> l'HK-><>VAl 






MEDICAL CERTIFICATE OF DEATH 

DA TK OH 1)1-:a'1 H 




^fc rpn* 

(Mouth) 'J_ J£''=^L._. '^''■'■"■^ 

fTnuVlUrs'T'T^RTII'V, Tliat I attcnrlerl (lecea^a from 

- to — ■ ~ ^<>o 



190 



alive oil 



T</) 



tliat I last saw h : 

an.l thai .U-atli nrcurrcMl. m, tin- <lalr statcil ahuvc, at «-^ 

M Tlu- C.\l Slv Ol' I)i:.\ril was a< fotlnws t 



1 



DIR A'PION >Vrt;-5 
CONTKIIU'TOKV 



Mouths 



Day^ 



Horn 



Months P'JVS 

r '-^^ 

(SIGNED) V.VUn^>v 

illa^M TOO*' fA.l.ln-) U\-(r> AjLK^ 






Hours 
M.D. 



SPECIAL INFORMATION onh tor Hospitdls. Institutfons. Irdnsienh. 

or Recent Residents, dnd persons dyiiiy cn^ay trom tiome. 

How lonq dt 
Former or place of Dedtli ? • 0«ys 

Usiidl Residence 

Wfipn wds disease contrdctcd. 

If not at place of deatli? — "-""^ " -' "•"""" — 



I'l.ACK Ol- lUKIAI. OK K1:M<>V\1. 



\ 1 



i)\ii,o! Ill KiAi. or ki;mo\ai. 



'rwJLixo ''< yt <xcvo, . 



(Ail<lr(>*'* 






N. B. 



r \(l(lreH« ■■;:. """■ ' _ . ,. 

— — ■' iVACTlY PHYSICIANS Hhould 

tote CAUSI. "» iJt-/*i" • » .... Au-n in every tiHtnnce. i 

on. dyinft oway from home shouM be ft.>en e^ery j 



-J 
Bon 



il 



I! 



I 



G 



i «• 



H 



i 

I* 






* 11 



^fj-l 



t 

if 



lii 






w 



RITE PLAINLY WITH UNFADING INK 



,,,.,,,, ,.n,..,Mh 1- N<,. ^.^^^y^^l^ScVCn 



irH)^ 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE TOR INSTRUCTIONS 



i^vvv^1aAM( Deputy iiealthOiTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Gcvtiticate of IDcatb 

( XX. 5. StaiiCiatJ i 

J? (^ 

PLACE OF DEATH:-County of6^V^v1.Va.>^-e.^c Gty ofC cvov O.vco^^c* 



.1 ^ 



No. 



UM 



{\.A St» a. Dist.;betX<V>^^ HlLCJ.,il. and V 

VJ O^V V' ^^* *-^ i^iow.t uMnrR •special information 

, .. oeA.H OCCURS AWA. .RO. USUAL ^""^^,^,,-J;^,--;r.;i nVmE ^t.^o"" s?:eiT A.O NU.e.R. 

t ,F DfATH OCCURRED IN A HOSPITAL OR rNSTlTUT. ON GIVE 

~0 (^ 



) 



) 



FULL NAME 



JVcxX 



OL V. Cr->x.^^..05^• . 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



DAll-: ol 1;1K 111 (57*, 



JXAX 



iM..nIlO 



\<;k 



45 



5 ■'•</' 



^ 



wKc' 



(Day) 



A/,»ii/is 



Li 



(Vt-ar) 



/><» 1.N 



Nivt. 1.1".. M\KKn:i> 

W IDoWKI) OK DIVOK^l-.n 
Write in *;ocia1 (ltsi}.n,;iti<)Ti) 




\a.>v^ULd. 



MEDICAL CERTIFICATE OF DEATH 



DATE UF DKATH A 

M\.c%r ^^ 

,vf,w.tiO (Day) 



^M<>Ilth^ 



(Year) 



' \ IIKRHHV CKRTIFV. Tliat T alton.lr.l .lcrra<.c.1 frnni 

to :: : .- -IqO — 

— -— 1 ip 



Up 



that I last saw h .-n-— lilive on 



aiK 



1 that .U-ath <KCurre(l, oi, the .hitc statc-.l above, at " 
— :M. The CAlSh: OF DI-ATU was as follows: 




IMK ril JM.AOK 



NAMK OF 
FATHl'.K 



RIRTlllM.AlK 

(u- i-Arni-:K 

iStatr or CDinitry) 



^1- 



JLUJ- 











MAIDKN NAME 
or MOTHKR 



lUKTIiri.ACTv 
OF MOTHI'.R 
(Sliite or Count ry'l 







_^lt 



LO^ 








OCCUPATION y 

^" A-^v/,/.-,/ /// V,;" /■>.<». i^rn 43 >>■.>> 



M,,iitJi< 



Ihn 



Tin^Am>VKSTATF...'KKSONAKrXKi;U^-^;;AKSAKl 



. rurH TO Till"; 



(Til fr)nn:iiit 






*a,'.Yi% 



DURATION )V<7« •'/'""Y ""•■' """" 

coNTrMiuT,,RV iiu-i^*i*^4^*^*" ''^ 
vwi^ali.':^.- tlxA xxW*. ■SAMAl 

M^a;- 3>c. Tc)o 

■ SPECIAL INFORMATION ;.nlvJorlfhspita^^^ Institutions. Irdnsients 






or 



Rcrent Residents, and persons dyimi .may Itom tiome. 



Former or 

Usual Residence ••— 

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



lloM lonq at 
PIh( e of Death ? 



... Da\s 



J'l..\CKOl- lUKlAI. OR KhMoXAI. | "^jJ^V'" 



^CrUvG 



U^c I 



K.^r<^^ 



190I 






^^'^'"''^ n . iiYAGTlY PHYSICIANS Bhould 
"■"! »;„n «houhl be cnrefuUy supplieC. AGF. «h.uld »;^«;;'^'-'^,;l. «,,,;..«, ,„,-oP,„„tion" for p.r- 

t:\\?Xr^Z ^ro^ ho.«c sHou.a he .Iven In eve.y .nslnn.e. 



%♦ 



I 



I 






1-] 

I i 




^ 



f" 

5 
/> 



Mr 



ill: 



S J- 










"liMM 



kk 



WRITE PLAINLY WITH UNFADING INK 







lOOH 



^\,KAj^ 'VIAH4. 



TrMMAJ So 

Deputy Health Officer 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 



Dull' Filed , 

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



Gertificatc of IDcatb 



PLACE OF DEATH: — County of O-O.-^^ >~ ACX^v-CLACtoty oi v. 
(^ c^ [^ % , , 'i . ) 

,4\rYYV0u^ cL/ CL,L::y^- 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

! coi. 



DATE OF lURTH 



I.OR \ I 



Atoiith' 



ACiR 



Lo% 



) V*i7 » > 



Diiv^ 



M.')i!lis 



(Veur) 



Pa 



SINC.I.K. MAKUir.lV 
WinnWKU OK DiVnKri.I) 
(\Viit<in xorial .k-«i>fnati"ti i 



liiK Tiii'i. x^'r: 

(State or CoMiitt v'> 



? 



MEDICAL CERTIFICATE OF DEATH 

DAT)-. i»i- DlsATH A 



(Month) 



ai. 

(Day) 



I! 

/ on 

(Year) 



WMJ' o1 
FATIIl-.K 



niK iiiiM.ArK 
ni- lAlIIKK 
(.state or Country) 



MAIDICN NAME 
OK MOTHKR 



HIR TlU'I.ACl-: 
<)l- MoTin-lK 
(State or Co\n>trv» 




/)./! 



oocrrATioN (^ 

.^ , ,, \ !• I.- r k r }•■ '!"< » I II r. 



"' ThHKIUW CK RTIFV, Th-it r at(cn-U-.l .UTcascl fmm 

0\cv- ib 190H to .m<J\r %.^ 190H 

,,,,nn.tsawh-.'v alivoon ^OXT ^b 190^ 

,n.l that dcatll ocourrcl. .-,. ihc -lat. ^tatc-.l al.ov., at b- 5 
ll M. The CArSI<: Ol' DI.ATII NVi^s as follows: 



1)1 RATION 
C()NTRII5rT()RV^-^J^^^?> - 



-?! :\ (1) 




,'>V'V>V< 



u 







(SIG 



Hour 
M.D. 



Kj\f - 






ION f"''' '"'^ ^'^f 



"i^^.AL INFORMATION «nlv n.r Hospitals. Inslitutions, Irdn.ients. 
or Rerent Residents, and persons d>ini d^ay Irom home. 



ceOrrJbA/>"^-^-«^'^^ ^ ' 



Wtien was disease rontractH, 
II not at place of death ? • 



'■J' "i^-K^^^fe"- """■'""" 



It\r*v«>! !:■ wiM "f l<l-"M"^'-^l« 

'£)x^ a 190H 



, ni.i:ktakkr ^^A,v<_*-^ (V. 4 ! 

„■£. 305 M^a^to^^;^ ^ -' 



,0LC4-» 



<^'''"'*''' nr i iiYACTlY PHYSICIANS « 

^, „._r.very Item of •'^*' >7;Vrn:':; 1 un ^ thnt It mny •>. P-.P-y clanH.t.cd. The . 
«on. (lylnft nw..y from home Hhoi.l.l he Ji'^e 



f» 



t; 



. 1 



,i « 



* 



I i t 



* f 



n 



' 




WRITE PLAINLY WITH UNFADING INK 



.1 .f !Ii :.Mh I V 






:^cvo li.^-i Deputy Health Officer 



THIS IS A PERMANENT RECORD 

REFER TO BACK Of CERTIFICATE FOR INSTRUCTIONS 

Keo-istcred X'>. '>4G7 



DEPARTHIENT OF PUBLIC HEALTK-City and County of San Francisco 



Certificate of Bcatb 



tl. 5. StauCtarD ) 



\ 



0^ 



No. \ 



PLACE OF DEATH,-C«™,v o.^<^'5'— " C«, .1 ?»^lx^-p.. 

Q. H Dkfbet c^wdLviNvvvc^vL and l-U^ '•^^■^'■'- ) 

^^^■^^K- ^f*» ^ l^lbU, l^^l. „„ .,„r,rR "sfl'tCIAL INTORMATIOW N 




FULL NAME 




/(rk/>\' li^Lllrn. 



PERSONAL AND STATISTICAL PARTICULARS 

I C'ol.iiK ' 




SKX 

\ Y Aa 

/CLU 

1) All- ol' 11 1 Kin 



UCalU 






A<.K 



J III I 



(Day! 



1 /,»/'//' 



(Vcai 



n,i \.s 



SlN(.l.lv MAKUn-i' 



SlN(.l.lv MAKUllI' ^ 

\vii)i»\vi:i) OK i>iv.»K* hi) y ^ 

<\\rit< in M«i;i! .Ic-ivriiati<'i»' -*A U 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 1)T 



'"" %.- 



(Month^ 



(Day) 



(Year) 



1 iin^rHV Cl-RTIFV. That nitten.lc.l .leceased fmn, 

Wet i^ 190H to AK^ 190 s 

,,,U last .aw hX.>S alive o„ ^^^-^^ -90 H 

a„.l that death occurre.l, on the .lat. statc.l alH.vc. at 

- M The CAISI' Ol- DivATll was a. follows: 

YP * ■ ■? - y 



fAA.tvAw''VrUn^^'>»..^ 3vCrv>-aXi 



lUK IHl'LAri-: 
*Slat«' or t'oiuitry^ 



NAMK OF 

FATin- K 



RTRTTiri,ArK 

(>»•• lA-nii.R 

iSt;>t< ot lOinitry' 



J? (5p \ 




MAini'.N NAMF 
«)t MOTHF'.K 



ink IMl'I.Ai'K 
ol' MoriU'K 
(Slate «jr Cuuiitr\ i 










,OJT^ 



.<L 



} t'a;'5 



Moiilhs 



Pays 



CONTRIin-TORV ^lX<X/^^^t^fi3X 

(SIGNED) VvYV J aJ^U^ ^ 

VVupj-.aa iqo:- fx.Mr—i ini — 111 — 



I /ours 



f fours 
M.D. 



■i^CIAL INFORMATION onlv for .h,srit.ls. Institutions, Transients, 
orleren^^esidents and persons dyin, dvv..y Iron home. 



nOCUrATION 

hVsiifrJ ill '<<"' /■"""''■ 



iu:s'r oi- Mv KN<)\M.i'.i><'ii^^" ' • 



(Ii 



"" ■ ^M -5 , 



i' \. 1(1 1 !•*<»< 




Former or 
I'sual Residence 

Wfien was disease ronlractrd, 

If not at plareof death? 

ruACKoF iu;kiai, «>R kkmuvai. 



HoH tonq at 
Plafc of Dfdth .' 



... Odvs 



11, \v.ji •_'• r\ 



i)\ri; u! iM Ki.Ai. ..I ki-;m<>\ \i, 
0,\>5\r...'^,0..... T90' 



ini 



(A(l(lr«-H«( 



\lfyvv^^v(r>\ ^..H. 






'- I II I PHYSICIANS Hhould 

rH In plH-m tcrm«, tHa -t -»> ^ »,^ '^^ 



N R r.ycry item of informiit 

• „„.e CAUSE OF DEATH In P ■»' ".J'^;" -.;;„■ j » in-.nnc 

.an. <Iyln» a«oy «■-"" '«>""' «''""''' "' » 



r 



:i 



[• 



■I I 



I ^ 



\ 



4i " 
4t 



i ' 



I' t' 



w 



RITE PLAINLY WITH UNFADING INK 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/hf/r AV/r^/. Mlro-i^^vtx^ ^a,,-.. .......J'^OH 



Bei^lslered ^V'^>. 



'M(i8 



.^VL^.^ 




A.H4 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtiticatc of IDcatb 

^. ^x. * TH r n.v ofC^^Av 3 KOA vc.^cc City of C.W^v Ox<x.wau;.c,c 
PLACE OF DEATH: — County otv ti--^^ ^ ^ 

(^ IF DEATH OCCURRED IN A HOSPITAL OR INS -.^ 



FULL NAME 



lf\a\.Q a\JiA) oL'Xw^^<^'0^/^^ 



? 



f).\Ti-: <>i r.iK ! II 



ULllv^i-i* 



PERSONAL AND STATISTICAL PARTICULARS 

/Kiuiith)jj 



n 






AV.V. 



19. 



)'iil' 



S 



I /■ 



Mouths 



t 



/>,; 1 



^AEDICAL CERTIFICATE OF DEATH 



DATE OF 



..K.n- Q^ 






(Day) 



lYcar) 



siNr.i.-R, MARun-.i» 

\V!1)0\VK!> OK DlVOKt M> 

i Wiitt it! v,Hi:il (Usij.'iiatn>ii» 



U). 



RTRTnri.AcM-: 

(Stati or CotnUiv^ 






t<^^ 



NAMR OF X / ^ I 



1 HKRHBVClUrriFv/Tha. Iatton,U.l.U.va.c.lfn.,n 
IWr ^ i9oH to Al\0V^M u^S 

,„a llua a.alh oocurrca. on the .Into staU-,1 aWc. at 
Q M. The CAISK 01^ DIATII wa. a. follows: 



\iJ^oLt'>'>">-^' 






)Vjr.v 



/?'^V\ 



I Four 






I'.IK riHM.Al'K 

o|. 1 A rm-.R 

iSt;ttc .'1 rntmt lyi 



O^CCrt^^^'^^^-^-' 



M \!i»i:n NAMK T) 

1)1 MoTilHK ! 



BIRTHPLACR 

<)|- MoTllKK 

(Statf or t'oimtry) 











(X^^ 



cL 



o^Cri'ATION 



Rfsidei 






nruATioN 



/7) iC\^ 



Montfis 



Days 



t SIG 



NED)iI '<! O'Cb.VUbru 



Hems 
M.D. 



V,Mr>.^1 1^5 LJUO CH 



„,^e" M™t^ ^"« persons im -.h. Uo:" !.»">'. 



Former or 

Usual Residence ...»•■."—-• 

When v\ds disease ronfrarted, 
If not at place ol death? 



Hov* lonq at 
pure ol Death ? ■■ 



Od>s 



,.,,,CKy.^ mKIAI.UK KKMoVAU 



I) \ ri-: o! Hi HI Ai 01 ki;mo\ \i. 

QrUv- ao iQo'^ 









(\cl.lv.-« ''''^ Vt^.vo-i.'^ ,_ — , piiVSIOIAlNS .hould 

...,U. CMIsr or pi.ATH .n P .. " ,„ ,_.^„,, UMoncc. 



:r.;;^r:;"^ -"-""=■--'-" '■-'°^'"""'"''^'- 



1 

j 



, I 



f 



H' 



I ( 



( I 




1 



1 m 



H 



:*• 












II 



Ji 



^ 



W 



RITE PLAINLY WITH UNFADING INK 



H 



- *.^*^'^i, Hf^l-l- 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CFRTIFICATE FOR INSTRUCTIONS 



■■«^ 



y1 



,/r /■■//,'./, M\n.><-'V>^tjiA' SO,. l''^^"^ 

DEPARTMENTOF PUBLIC HEALTH 



lie<:isfci'ed jVo, 



3469 



,,^e^\^ „, 



=City and County of San Francisco 



ft 



Ccvtificatc of Bcath 



n 



^. . -rw r ntv of 3.CV.V ''^"' VO. v.cv.. c. . City of 3 C^^ ^ ,VOl,>v^v^C.<> 
PLACE OF DEATH: — County ot -"^'^ ^ . (J^ . -^ 

-^ ^.. ^ DisfbetJJOxUW and^.aU>^C^ 

t'-rAVj UOnHA^i St,: V> ^^^^'^ *^^;„p UNDER SPrCAL iNFORMAT.ON- \ 

V IF DEATH OCCURRED IN A HOSPITAL OR 



FULL NAME W^>^^- Ux^v^-"^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



Wl 



LivX< 



n.\TK nf i;iR I'll 








AC.F. 



iMiifjlh' 



O V ) ' ill > 






iDavi 



M.»illi< 



C 



I Vear) 



i \. 



Pa v.v 



mNf.i.p. M\KKn:i> 

UinoWKl) tm DlVOKVKfl 

' Utitc ill <oi-i;il <l.siv'"ati<)tii 




ii 



jukTnri.xr'K 

I siatf (iv i."<iunlry) 



NAMK «r ft 

FATIII-.K V\ 

-^- 4' 

niRTinM.ArH l\ 

oi- i.\rHi-.K \j 

'Stall- or Coiuilrv' 



MAIDI'.N NAMH 
Ul" MoTUHR 







.^LMPnAJl 








MEDICAL CERTIFICATE OF DEATH 
DATH <H- I.i:ATH P\ 

VI If vr 

(Month) '^'-''-^ 

1 lli;Ki;nV CI-RTIFV. That I atU-,t.U-I -Icroase.l fro^ 

that I last saw h v- aliv. 0,1 ^ 
,^Uhat.Uath..co.r.e.l..nnt..lal.stat.1al.ove.nt lU^l^ 

0' M The CAISI. (.1^ 1>1V\'»-H ^va. as foll-ms: 



igo 

(Yt-ar) 



igo 
190 ^ 






:! 









1 t- 




pr RAT ION J'^'^'-^ 
CONTRllU TORV 



Mitnths 



Puvs 



Hour 



BIRTHPT.ACT? 
Ol' MOTMHK 
I Slate or Contili > 






' ''^ L^tUn 



\) 



X IfLcx.^''^'^'^ 



AV 






I l'\K III I 1, \K- ^-■' 
ANH lU-IJl-.f- 



( SIGNED ).il) J -^^^^---^^^^^^^ -0 



Hours 
M.D. 






.(jv-.m___f^ 



-^ . Tl^oMATlON ""'V for Hospitals. Institutions, Transients, 



Former or 

tsurfl Residence 

Wtien Has disease contracted, 

II not at place of deatti ? 



HoH lonq at 
plare oi Death ? 



Days 



'JbC \ 



I 



( A.ldross I l «A V 



7l.ACH<)l- IUKI.\^I. OK KKMUVAl, 



,,\XK.,! I!. wiAi. or KKMoVAl, 

2). 




4 



111 



T90H 



sXt^N^ ^^^ 



I 



(A.Mross nan ^-^-^ ^^^n ^ ^ ^ TTTxACTLY. PHYSICUISS «hould 

. ._ .-■^-rsStBs--"' ~ ■■-"•■ ■••• ■■ '"■ -'■ 

:r;:fr.t' .S'i". :=,ir.; - —•• — 




r !!• . '"■ 



W 



RITE PLAINLY WITH UNFA 



iS.!' I'm 



m 



DING INK — THIS IS A PERMANENT RECORD 

nerER to bock of CERTincATC for instructions _ 

_ — ■ — ^— — — — ♦? I'^/i 



/;/^/r /••/•/,"/. ^jrUvM.V>vU-AA' 2)0. -/•'^'''''^ 

i^vc^A^v Deputy HcaJth OflTlcer r • 

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

Ccrtiticatc of Bcatb 

; Xl. S. St.in5.KC ) 

J? QTl -r^ *^ 

f^rc^i\<XAVCV^c.o City ofO^^^^^^^-^^^'^^ 
PLACE OF DEATH: — County of <X^O,-VW>vw 



N 



St. 



Dist.; bet. 



and 



-) 



r\ O K ni'^lV^ 'f'S ^ '1 "Jl^i '^ ,. r-«o (iiMnFR "special INFORMATiON" \ 

FULL NAME Wv^V'-^^^ 

^ M ^ ■ ^r-OTICI<~ATr OF Dt 




PERSONAL AND STATISTICAL PARTICULARS 

I COI.<)K 



'^xA. 



.^.'kctt 



t)\Tt* <)l- lUK I 11 



A ••.I", 




! 

I Day! 



ft 



(Vear) 



5 I )V<TI.< "^ 






I 



Pll Vi 



(Year) 



mN'(*.!,T* M.\KUn.l> 

W il)0\\ j:1) ok DIVnRClt) 

:\\! it- ill -<)<i:(l il<--iv'iKiti'>ij) 



lURTTirt.ACK 

(State or C'liintryi 




I |\<XJ^JvU^d, 



<x\><x^*--'^- 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATH (V 

mW ^\ r 

(Month) <»«^__.-^ 

- 1 IIFKFHV CK RTII V. That I atte,t-U-.! aereased fron, 

i)^% an ..oH to ^^^ '^;;- 

,,atnastsa...- alive ott C^^^ ^ '^■*^- 

^^,^, , ,,,acath occurred, o„ the-. late staU-l above, at I 

a^ M. The CAISH OF mCATH was ^follows: 



NAMl" t)l- 
FATin-K 



OS? 



l\a V OX'^^'Jxt^'^^o^^'^'^ 



lUR rHI'T.Al'K 

()]■ I'Aini-.K 

istatf or Coiiiitry) 



MAIDI.N NAMH 
(II- MOTllliK 



"D 



C 




DIRATION H )Vrt/', 



H-RATION 1 J^''''^ I 

ONTRIIUTORN UU^*^^ ^ 




(<XA.NOJV^O. 



HIKTHPT.AOK 
oi' MOTHlvK 
(Statr or Country') 




jlLc^ 




<x< 



Dv 




oc 



^ iOwAKXA.V/0^ 



C()NTR^5^T()R^ ---- " 

( SIGNED ),meVW. Jb.lV>^^ ,^ 

Mlcvr aa ..- < A.M"-^^ ^^- - ■ ■ 



l/out ■•■ 

I lout's 
M.D. 



Ke'^uh-d I II .^o" - '" "■ '■'■■ . —— T. .^.,jj.. 

HFST Ol' MY KNt)X\lJ.l>*'^' •^^" 



(Informant 



(Address 



It 



Former oi 1 UH Cj M jUYtJ, C 

Usual Residence l'^^^ dJu^^J^-^ 



How lonq at 
Place of Death ? 



Days 



,,ATi:o! It. KiAi. ot KKMi'V.M. 






(Aildress 



3.\>1 \ V\XUt ^ , PHYSICIANS Hhould 

" . AGE should be «t*'*'^i. ' ..« !. l«l information" «or p«r- 

^ ^ /-Aii«F OF DEATn m pit"" "^ ^. ^ :« ^verv instonce. 

state CAUSt ui^ i^ , j,^ ^.^^n m every 

8on« dyinft awoy yrom nome 



i 

I i 



;i 






« 



) i 







w 



R.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF r.FRTIFICATE FOR INSTRUCTIONS 



-^..'r***?- H.v. 



m 1 



Be(^/^f''rpfl Xo. 



8471 



l<rv..oWv Deputy Health Off.cer ^ 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtiticatc of Bcatb 

i 11. 5. 5tan^arC» ) 
PLACE OF DEATH :- County ofC)£UO^JX<v>vc..- 



City of 'C^-^' 0-va/>^-^^^^^ 



Dist.; bet. 



and 



ii 



(!^..S4#.v:™ ^A- .■.■•r.".™..r--:^^^" ==•" •— ■■"=^" ' 






FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



^^\ 



ecu. 




Jl^Kj 



DATl". Of I'.IK rn 




( 




I M.nitli) 



AGR 



) fui » 



(Day) 



M,,tiHis 



(Veil) 



P,iv^ 



\> -|« ■ ^1 



W II)«»\VKI) <»K DIVoKfKI) 
iWiitt in <<K-ial (U^ifiiatio" ' 



lUKTin-I.ArK 
(State Ml Co(U)try) 



■ ^iilmCAL CERTIFICATE OF DEATH ^ 

DATE OH DHATH (\ a*. • 

I 11HKI-:15V CKRTIFV. Thai I aUcMide.l .Ic-.v:.m-.1 fron, 



190 



to 



that I last saw h .:: ^live on 



- I()0 









NAMF. or 

I- A 1*11 i:r 



lUKiiiri.An-: 
()i- lAiin-.K 

f Stat<- or rount! V^ 



MAlDl'.N NAMK 



1URT!TPT;AC1? 
()1- MOTHICK 

'State I't I'osnitry) 





. ^i)fyv vA COAX.^ <x.^^ 



nr RAT I ON JV</rA- 
CONTRllil'TORV 



Months Pays ■ ^Jonrs 



nrRATioN 



Vrars 



//ours 
M.D. 



A/ofil/is Pays 

, SIGNED ) UV«-i»v'^.^.lai^ vvA 



OCCtTATION 






Former or 
Usual Residence 

When was disease ronfrarted, 
If not a t place ot death ? 

7j.M-Knf lUKlAI. OK Ki:M"VXl. 



Hov* lonq at 
plai e of Deatli ? 



Days 



DAli: ..! HrKiAJ. or Kl'.MoVM. 



OXL 




1^ ft i- '" ''■ ' 4 



pp 



f X.l.hes. nr- "^' . » te.l f XACTLY. PHYSICIANS «houl.i 

- , a,;F. Hhouhl be state.l »-^*^' intonnat'ion" for p«r- 



M|-" 



i « 



» 



I 1 



I ■ 1 i 





?. 



I' i 



i » 



m ^«{ 




I i 



HI 




I ii 



I) 



Ml.' 

< . It 



'\ 



WRITE PLAINLY WITH UNFADING INK 



l!,.;.r(l of Heiilth J- No i^ ^'I'Sr^'' '^^^' ^"" 



I}(t/f' /'V/r^/,M\^^M.'YvjUA; 30 1'^OH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Re^Lsfered J\^o, 




cLxv. 



'^ 



D C P t: 






DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of S)eatb 

( H. 5. StanDarD ) 



/Cw^-x^ vl 



^vcC'^cv^iCity of ^cv^^ .JX<X^»^cvo.c.o 



No, 15^ 



e 



t 



cv>i. IX 



o 



St.; M Dist.;bct. IS t.^^' ^^"d ^C) 

/ ,. or.xH OCCURS *w:rr;'oM ■uSUa'lp,3 c,^^^^ c^.^.^eo ;-^-o^« st%%%"*U'o '."u"::"-"' ) 

C .F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 




. ) 



ITS 



NAME INSTEAD OF STREEl 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 






DA'ri-: <»I- lUKTH 






loldi. 



(Mi)iUh) 



A CI' 



51 



)'riti 



(Day) 



Mnlll/lS 



(Vear) 



Days 



SIN'C.I.K, MAKKH",!). 
WIDOWMI) OK DIVOUrKI) 

(Write ill -social lU siuiiat i<i!i ) 



BTRTITri.ArK 

(State <ir Country^ 



.LLccL^^^>^<^ 



NAMR OK 

1 AIJIKH 



TUK'nn'T,A(^F. 

oi- i-APin'.K 

(State or Country'' 



^taii)i:n namk 
oi- mothhk 



I!IR inrLACK 
{)]■ M<)lMn:K 

(State or Country^ 




hYUuvu MVvcJvfU. 






7 



OCCt'PATION 



M.iith^ 



Iht\ 



„„„„.„„ ^;.-±A^ 9 ^^^^^.^^^ 



MEDICAL CERTIFICATE OF DEATH 



IHTK OF I)i:.\Tll A 



>^ 



(Month) 



(Day) 



(Yearl 



I nf':RI':BV CnRTirV. riiat I attcmUMl tieceasefl from 

Vi\.<jy- i..._.._., ,9oH t.) M\4V-.....Q.a 190 H 

tliat I last saw \x^^ alive on VrUNT :^°^ Kp '\ 

Mii.l that .Iratti occurred, <iii the <latc stated alM.vc. at 
M. The CAl'SI-: Ol' !>i;ATII vva^ as follow-;: 



^ 



^X>>>^wk.<xtx^ Cri Q^Kcx.^J^.. 



(.x)NTRiHrT()RV Q:b.A,.r>^:ti.ivix.klAvatm\-ft:i:%A^ 



DURATION 



Years -r-'-^^ouths^^ Days 

{ SIGNED ) BaA^x^ ^' ^'^^ 

?>C) loot ^ 






f fours 
M.D. 



SPECIAL IN FORM AT ION onlv for Hcspitdls, Institutions. Irdnsients. 
or Recent Residents, dnd persons dylnij awdv from t)ome. 



Former or 
Isual Residence 

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



Hah long at 
Place of Death ? 



.. Oavs 



.■LACK OF niKUI. OK RKMMVAl. I DAT^of l.rui.... or KKMoVAI. 



■b 



I 



i) 



JLC I 






190 



,M 



.^-^-^-^— — — ■^— — *— ""—"^"'"'^''''^ t t I fiXACTl Y PHYSICIANS should 

"on.'clylni away ?rom home should he ftlven in every inHtance. ^ 



i I 

I 

4 1 



I 



4 



Ill 



hi 



H t 






WRITE PLAINLY WITH UNFADING INK 



/,9/9M 



DEPARTMENTlOF PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be Mistered jYo. ^>2V'^ 



City and County of San Francisco 



PLACE OF DEATH: — County ofv'a.vu 



Certificate of Beatb 

J? Qi?) \ ^^^r 

CW^ JAXL/>vOU^ct City of 0/(X^ aAX5.^>^cc4co 



(S? 



No. 



fcUl 



Vid.^ flb Ch4|\AXxx.l St.; 



Dist.; bet. 



and 



( '^ r/*o^:^occ^%;ro\rrHo^s"'.'ic r"^?T^^J;^o^.'^c,;r.;i name .^t..o o. s..... ..o .umb.. ; 



) 



FULL NAME 




i. 




UoLC.'my.:>v<L<rY\/ 



I) ATI-: nl- HIK III 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 




]k&.. 



A(.K 



l". 



Month) 



) til I 



10 



(Day) 



M,,iit/i> 



v.13.5 

(Year) 



a.D 



iO(/ lA 



^.IN'i'.M' MAKKIl'.n. 

U IDnWl'.K UK I>lV<)Rv-HI) 

iWtitf in soiiiil (lc-i>.Miatioii) 






niKTJiri.ACK 

I state or (.cniiiliy) 



NAM I". <>!• 

FA Tin: R 



151 Kill ri.AOK 

oi- i\iin:K 

(Stat»- or I'ounti v) 



MAII>j:N NAMl". 






\t^V>^' 




ici 



XvAwC i VV'^V^i.eYV 



e D 

So 



nTRTITPT.ACK 
(»!• MuTHHK 
(Stat*- or (.(mntrv' 



ooon-ATioN (T^tc^^x^ 




AV.s/<i'/v/ /" '^■"" /'xnnisrn >. 



i* ,' 



T'lM > 



}h»ith' 



/)„■. 



^^^>y,ni-^'S^^^:^-^'^"C!"--^^'''^^^ 



(Infonnatit 






MEDICAL CERTIFICATE OF DEATH 

DATK OI- I)1:a1II _ _ 

JS^ ^"^ 




(Month) 



(Day) 



'i 

rgo 

(Vcarl 



I lIIvKl-nV CtYrTIFV, That r atton.lcd fleceasefl fmni 

Q\M ^5 ic^oH to Wr a^l i<P^^ 

n,,t , last saw hum ..alive oti ^b.^ ^^ 190". 

a,„l that .katli orcurrcl, on the .late stated ahove, at I 
OL M. The CAlSr- Ol" DIlA Til was as follows: 



I )r RAT ION 



Ye^s Months ^ ^^'^^'K ^^'""'' 

..\i jyuLtU ^.,^..^.-.' — = ^ —'- " 



DIKATION 



.........Ytius .JiroN/Zis 

(SIGNED ) vAxtrVU nDOw' Jai^i 



Pays 




M.D. 



<^" '^" 



I<)0 



(Afhlress) ' '^ *______, 



SPECIAL INFORMATION f) 1"^ "o^P'*'''^ 
or Recent ReM.'.enis, and persons dvlnj awdv trom home. 



^ 



ijtdls, Instiflitions, 



Former or 1 1 t c: 

Usual Residence \^\^ 

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



\j'(Hlt 3 



i 



lloM lonq at 
PIdf e of Death ? 



Iranslents, 



Days 



,M ACH oi- m KiAi, OK ii:m<)V\i 

,.,„„.„ No 5 (j^^vai"^*- 



DXI'liof HfKiAi. or KHMOVAI. 



X 



190 A 



(Addn 



— ^^— ^^^^ ^ii^^— ^— ^— — "'"^^""^'"^ , fTVACTI Y PHYSICIANS nhould 

o. ,n.o..«t,on .H0U.CI He c„.e^.. «.PP-a ;,^f:;--l^i:i:"THf .•Spc.U; ln.>..,.,o„.. .0. p..- 
E OF DEATH in plain term.. th» .t "i»> *»; ^ ' ^ i 



N. B. F.very ite 

state CAUSE UH ut a . " .n m-— • *-■-;_ .„ ^,^ instance, 
son. dyinft away from home should he A'ven m 



I 



) ' 




•.It-: I 



1 

■!■! 



« 
' 4 



i 




(*^* 



I 






I 



. 



iki ^ 





tl 



ti !il 



!•.,>:,!, 1 of II. M'th I' No 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.- ^ .. , . REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 




Br<Jistere(l J\^o. 



*?i^4 



\ 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccitificatc of S)catb 

( -a. S. StanDav^ ) 
PLACE OF DEATH:-County of ^^ a^ Jx^.x^.-C- C,, of CV.^ -Ivon vcv. .. 

No.V c^ccLc t ^<Lkd, clI 



'...__ -«= i.iunro "«5PrClftL INFORMA 



r-o^.TH-ocruRrEVlN-rnO^S^rAt :R"^?.%^^4^'^0.;r.;i name .NSTEAO of .TREET and NUMBER. ) 

iC 1\ \ . . u 



-) 



FULL NAME ^^' 



\ ■ \ \ 



sj:\' 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



llwu 



XJv'X 



DAli: «il lUKTll 



AC.R 



/I Month i A 



Hi JV<M.v 



m\<-.l,K, MAkKlK.l) 
WIDOWI.I) nK nivolu I'.I) 

iWi it! in -.Hi;il <1< -i).'ii:itioii) 



lUK rinM.Ai'i<: 

(Statr or dnuiti >' 




(I)av') 






.CXAA.'^^ct 



(Year) 



A;i 



MEDICAL CERTIFICATE OF DEATH ^ 

DA TK <»!■ Dl'.A I'H ( \ ^ 

MfW- f'^^ /9^^', 

I lIl'KT'i^V Cl'irrilV, That r attended flecease.1 from 

Ch,^- .ab 190M to 0^^^'^ ^"^ »<>o'"' 

tl,at r last saw hA.., . alive on Ox«v^ ^ t^ 

,,„1 that .leatli oocurrcMl, ..n the .late state.l above, at \X I 

a 



M. The C.\ 



s : 



I SI-: ()!■ I) I". A Til was as follow! 



NX Ml-: (H" 

FATin:R 



lUK'lin'l.AVH 

()i- iAi"m:K 

(SUite or Country) 



MAID'RN NAMK 
ol- MnTHl'.K 



HIurnPt.AClv 
(H- MOTMICK 
(Statf or Coiintry) 



? 

? 



Ov 



occ 



:cr PAT ION Qpp^^,^^^^ ^ .1 ^c^JLA-. v.a. >x 



l\i\ 



f\f^nifii I" ■■•'■ ■ ^^ _^ . •flit- 

"-|,„VKSTV,-K„,.H.<-N-.--,|;,M;-'"'"""^ '"' ""■• 
lil-ST Ol- MV KNO\VUi:i)«.K AM) I5»''"' 



^W. 



5%3. 




odl '-31 






DURATION )Vjrr. ^ •'^"''^^'\,:; ""- ^^"''' 



I' . \Tnnth'i \^ Pars Ilour^ 

(SIGNED) %.U. fcx^b^^.-^^-^^ ^ 

<^Vrx- gq r.oM (A.Mress^aC^t)^ dtfcU- 



M.D. 



s'pECIAL INFORMATION onlv for llospiWs, Insl.tufions. Irdnsients. 
or Rerenl Residents, and persons d)in,i .m..v troni home. 

L.j -\ . Hov* lonq at 

,.„.,„_ .-- fi^UvJ-dlpi*-' »"'*•■ 

When was disease contrarN, 

If not at place of death? 



Days 



I'lACK OF m KiAi. OK k»;m<»\m. 



DXi'ii,"! I'.iKivi. ot ui-;m<>\'ai, 
<iJ-vC i 190 



'I^^CK Ol" HI K'^'' '"^ ' 



^ ^ ''^' '''' ,1 Y PHYSICIANS should 

Htate CAUSE OF DEATH .n P^«'" ^ ,„ ^,,,y '.nHtance. 

«on« dyin4 away from home shouiu oe k 







i 

-4 



.4 



It* 






« 



w 



RITE PLAINLY WITH UNFADING INK 



T^..:,i,! ■• !!■ 



Vf 



, f-.t"'^.'^ H,«t I' Co 



0. 



/)(U4i^ Fi/f''^,^\M}^yrUsHhj ^0 



lUO'i 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

3 4 -^^P^ 



II ■ " 



l<.v;c^it.v4. Deputy HeaSthOm^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDcatb 

PLACE OF DEATH:-County of5a^. 0,^^..c..c. Gty of c)^>v .ix<v>.cv.e. 

FULL NAME >tnv^ .^^ivn. 



and 



ALLED rOR UNDER "SPECIAU INFORMATION" \ 
AME INSTEAD OF STREET AND NUMBER. / 



ft ' 



^i:x 



I,\ n: OF UIRTM 



"personal and statistical particulars 



iM*)iith^ 



\c.K 



cttt H^ 'v<"> 






M^mJhs 



/lis 

(Year) 



A< I -v 



11 



l\ 4 



I 



SIN'tU.K. MAKKIl.l) 
\Vin«»\VKI> OK DlVoKi l-.I 
Wiittiii MK-ial <!. sivnation) 



l;lk rillM.Ari-: 
stiitf i»r Coiititry' 




CW^vC»-^ 



NAM!" Ol 



juK riii'i.AOK 

OI- lAlUl-.K 
(Stair or Country > 



MAIDI'.N NAME 
OI MoTIlKR 



HIRTIiri.ACK 
OI- MoTllKR 
(Siatf tir Country' 



_y' 






OCCrPATION 







MEDICAL CERTIFICATE Ov DEATH 
DATE OF nKAlH .\ 

(Day) 



(MontlO 



IQO 

(Year) 



rili-RKBV CKRTIF\\ Tlu.t I atton.U.l .1erc:med from 

In — -r— r-r 



U)0 



that T last saw h .-:— - alive i.u 



190 

Up 



au.l that .Uath orcn.rre.l, o„ the .lato .tatoa alu.ve, at *— "^ 
M. Tlu- CAISI' OF DIlATII^was as follows: 



Dl R \'ri<)N Vcar^ 

coNTRir.rroRV 



Month} 



Days 



HoHt N 





Pays 



M'// 



;.v 



M.D. 



Q^xcv^^ 









/),;i 



UKSTol- MN KNOW i<i,i" ■'• ^_;^^ 



( Iiifoininnt 






sP 



„,,i„- 1H lev. 



ajfc o: 



( SIGNED )U\.eT\i>v J 

" SPECIAL INFORMATION onlv tor Hosp.Uls, l«.Ututfons. IrnnMents. 
or Rcren^ Mfnts. and perM.ns dvin;, d.ay Iroin home. 



liiU.- 



Ho>\ lonq .if 



Former or llvJVVVH^Mnv ... Pla.e ol Dedth? 

IsudI Residence WW rv^iv.y.v«.'w*'. 



,yi . Days 



When Has disease rontrartd, 
It not at place of dealt) ? 



PI \<'V 01 lU KlAI, UK KliM*'VAI. "V^"' 



nyiij', "! Ill i;i,\i. 01 ki:mo\ \i. 






190H 






^^'I'l'"^^ ^ " ,11 I pHYSlCIAMS Hhould 



ri 



I 




'<♦ ii 



i 



i 






■?'i 



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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



f 11 






1 

if 








UJO% 



Bc^istercd jVo, 






\ ir Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate ot 2)eatb 

( 11. S. iTitnnDarC* ) 
PLACE OF DEATH = -Countv ofacvv \l ..c...c..c,Cty ofCWvv .Ka.>^X..cc, 



Q:^ 



FULL NAME lU^^W/Cy^c L->^t<X'vci.^ 



-M- 




S 1-. \ 




PERSONAL AND STATISTICAL PARTICULARS 



\oJlx 



\^}\&M 



j)A rj". nl- lUK 1 li 



M..nth» 





.\(.H 






(Day 



M.mHis 



r%'hS 

(Year) 



Pa ys 



SlNr.I.K. MAKUn.I) 
WflXtWHI) OK DIVnKi }.l 
(Wiilf in suoial (Itsij-'iiatioii) 



lUK riiri.ACf? 

(Stulf <>i (.•.xintryi 




NAMl" <»1 
FATin-:K 



lUkTIIPl.AiH 
<)I- I-ATIIKK 
State or Coiuitry) 



MATDKN NAM J, 
ol .M()Tm;K 



luurni'i.AiM*. 
<>c m(ithj<:k 

(Siatf or Covintry 




MEDICAL CERTIFICATE OF DEATH 

DATH t)l- DKATII ( \ 




(Month) 



(Day) 



M 



(Ycarl 



" 1 II KkTbV CHRTIFV, That Tatten-Wa clcrcnsed from 

CK^ as 190H to AK^. aa. k^h 

t,,tna.t.awh^^^ alive on VH^. « ,90^ 

,„„1 that .Uatl, occurre.l, on the .lat. ^tatcl ahovo, at -.:■■.-■■ 
- M. Tho CATSI- (>!• Di'ATIl xva-^ as follows: 



Dl RATION ^ ^Xl^P 



Monlhs 



(.•ONTRIIU'TORV 




pavs fJoHt 



')Aj^-ysj^\^^^-^ 



f % 



u 



iXm^ic^^slM^. 



DlRATloN 
(SIG 



)'tiu-s Mouths 



•o/ydu. 



M.D. 



Lcvnlo^^^^^'"^*^- 



/J,.M 



OCCUPATION 

r^f.,\l,;J :>l San /•"» rr/" ■'■"■" 



_^ « 1. 1 ■ ]• w I ■ )•■ '!'< > 111 *'• 



(InfoMiiain 






.A^i 



SIGNED ) GT-- -^-'>^y^'- "I 



" RPECIAL INFORMATION ."!« lor H«sp,Hls. I.s.iti.li»ns. Ir^sie.ls 



/ 1) -\ , Hov* long at 

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



.. Davs 



,.I,A0KOl in KIAI, OK Kli.MoVAI, 



l).\T14o! lU lOAi. nr KKMOVAI. 



Si) 



X^ H 






190 



U.l.lriss ^^^ ^ 1*^ \ "— ' . . ■ .1_IL L. PHYSICIANS should 

— ■ : rrrrTwully suppr.ed. A(;F. Hhouia »>« «*«^^^ •; ..J, ;,„, Information- ?or pT- 

Htnte CAUSE OF DLATH .n ph. m .^^ ^^^^^ i„Ht«nce. 

«on. clyJnil aw«y from home shonM be ft ^^^^^^ 



\ 



•I 



1 
I 

t 



\ 



11 







! 



f ' 



>■ :. 't 
if 









1 




8 'H 



it'ti 






It 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,,,.!,, !i, MM !V -'"rX li.^lMo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/> 



ff/r /'V/f^^/, \l\f\M.Y>v(MA^ 



SO 



2,9/9 H 



FiPiiistered J\^o. 



3177 




Deputy Mealtfi Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of 2)catb 



^ 



PLACE OF DEATH County of .iiCU-*^ OAXUYVCXCLCi, City of C3(0.m.. VaA-v-Cv-A^co 



No. 5\% V<^*-^ 



St.: H Dist.;bet. 



b i 



and 



Tt 



rt 



) 



ir DCATM occuns aw*v from USUAL RE S I DE NCE Gi ve facts callpd for under 'special information- \ 

... . ,.. ^r, .».^.r,-r,.-r.oiM r.iur ITC NAME INSTEAD OF STREET AND NUMBER. / 



DEATH OCCURS AWAV FROM USUAL R E S I D E N C t G I V E FACTS. CALLtu ► i^ r. u n. l. c r, =..-.. v. > 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE1 



FULL NAME*^l-u 



IvuLoj .c'w aUwau - 







/.^fvoAyL 



Li 



PERSONAL AND STATISTICAL PARTICULARS 



six 



on 



COl.oR 



Vj 



JLvt-volU 



c 



ijL-UL^v.v 



i>.\ri-: <)i iMkiii 



\c,v. 



to 



a". 

(Day) 



(Year) 



) itii 



.\/. I )////.< 



al 



A/ » ; 



siNr.i.i:. M.\ki< n:i». 
\\ii)<)\vi:i» OK i)iv« tmKi> 

iWiitL-in scK-ial (k-i>.'.iiati'Hi ) 



I'.IK rill'I, AOK 

(Stat<- or (.■'iiuiti y"! 



NAMi: Ol' 

!• A riii.K 



inKTiirLACK 
()i- i-A-nn':R 

(Stat( or rouiitiy^ 






\JXM.- 




MEDICAL CERTIFICATE OF DEATH 



DATK <tF I)T:ai II 




(Mouth) 



.2,1 /pol 

<t»ay> (Year) 



I Hf':RI{I'A' CIIRTII-V, That T attcn-ltMl <locease(l froti! 

Q\.a\r Sv.a iQoS to .Qx^rvT. 



( i 



1 






—J i 



^.0 190^1 t<} M\'^\^.:^l, -190 H 

tliat I last saw liX^v alive on VTUVT Xl t^S 

aii<l that death (MTurrcd, on the date- statiil ahovc, at 1 
y :m. The CArSIv OI' DIv.XI'II was as follows: 

LvCA,\jtt yjvVfr^'XyC^iv^J 



A„V6. 



MAIT>KN NAMK 
()!• .MOTMIvK 



lURCm'I.ACR 
tH- MoTHKR 
' StaU' or Coiintr\ 






X'tn^i ^ 




<xC<rwCu 






(X%oury 



CONTR I I5r'l"( )R\' ^'C^/^^C ^^^^X-ti-CuLv/vx-aX. 

Vj )^ojLa'VA.Ac.\A.A.lA.<r>x. ...••. --^ 



I ) r R A T I O N . > 'Citt'S ^ Mouth:; Pays, 

(Signed) \D. \I I Uxt^.cvA.<xJl.\,' 

Vhcv at. too" r.x.Mr.^;^) >^05 Xuvj^eYvt ■'H: 



Hours 
M.D. 



SPECIAL INFORMATION »n!y for Hi>spitdls, Institutions, Fransients, 
or Recent Residents, and persons d>ini| dwdv Ironi fiome. 



OCCUPATION 



)V.M 



\r.nitli 



Xi 



/),n 



■IMH- An<>VKSTATKI.I-KK^..N.Xl.i;AKTirr.,ARSAKl-TKrK To THK 



(lnfo:inaiit 






Former or 
Isiial Residence 

When was disease contracted, 
If not at place of deatfi? -.. 



How long at 
Pldf e of Deatti ? 



Days 



I'l^ACl-: Ol lU'RIAI. OR Kh.>Io\ \l 



I)\ll- o; l!i Hi.xi. or RI:Mo\AI, 

VV^v^ So i9oh 



l, \V^ I', » 'I " 

,-i,..,.,KKK il U). QXaau.^ Va^< 



'IN 



1 



:,. „._r.very Item ni Information shou cl be carefully -^'^ ^^ ^ pX;Hy laHHificd. The "Special Information" for p.J 
state CAUSII OP DEATH in plain terms, tha -t ma> ^ P;"'^f '^'^ / 

son, dyinft away from home should be feiven m every instance. ■ 










I'M 



^ if 





I w 



! 



til 



/ 



w 

,1 , 1- 11, ■»?■ • V 



RITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF C ERTIFICATE FOR INSTRUCTIONS 

3478 



■t-v ^ -^-u-. liS.1' C, 



■■■•••^"^""* 




^\>XJy^^^ 



bJLK) 



M 



Si-- *^ > 






DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Ccvtificatc of ©catb 

^ n. 5. StauDiUD ) 



PLACE OF DEATH:-County of da.x. J Va .. cv^c. Gty ofClcv^TV Jx<v.. 



^VC^^CO 



\\> 



NoA Ml 



^?^J 



v.t IX. 



St.; 



Dist.;bet. ""■ 



r~ and 



. 



IlA)VXi/i Ot) 0-^A^ V. *< IX.^ ' bt.; ' i71SU; DCU ^^„ „^„p„ ■spfciAL INFORMATION ■ \ 

V IF DEATH OCCURRED IN A HOSPITAL OR INST.TU ^ 



— ) 



FULL NAME 




.C^'V.Ul. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



n\> 



1 C<il."K. 



UNTF ••» r.tK in 






(Month » 



\«;k 






5 Vi; I 



(Day) 



Months 



(Vral) 



P(f r.$ 



-IM.l.l-. MAKKIl-.I). 

W llxiWKP t»K DIVnKi J-J) 

^ Writ, ill s-K-iiil (Itsiv-Miiitionl 



HIKlHI'l.AOK 
(Stati or Countiyi 



? 



C>t.<XCu 






nTRTHri.ACK 
()!■ lAlllI'.K 
(State t»t Countryi 



OK MOlHl.K 



iMK rnrnAcK 

()|.- MoTin-.R 
(Stale or Country' 



( 




MEDICAL CERTIFICATE OF DEATH 

,M.,„.h) _. ««_?l_J}[!L'l 

" I lll-KlUiV CI.KTII-V. Tl,:,l lMlUM.K.l.k-.v:«-.l fr.mi 
CtVar al .90'> t,. (>W A^ ../=H 

U,.. , last saw h .vvv. alive o„ ^^^^ ^^ >'^'' 

„„.Ul,at ,U-aU, .« .•uru-.l, ,.„ ll,c ,laU. .tat, a al...v., af 

Q M. The CAISh; (11- lll.ATH «a- as follows: 
(^.IvVCryw/t M'^Vi.jfecix.xcL'-.tco - 



DERATION )'V^''-^ •'^""^^'■^" 




ni'"ST <)!• MV KN<>\\ »<i«i''*'^' 
f) "ft 






(SIGNED 



n,n:1 ■ /li'liiK 

M.D. 






„,^ere»^ M«ls,':nd;;;r«,n;7>in;17.V, lr»^ l..^.^ 

/^ -\. HoH lonq at 

Former or a^. UN h^tDw<JUA^<Ui,ut Pl.i<e ol Dtdlh 
Usual Rfsidfnrr^'*' viU/\A..VMW>-^ --| 

When was disease rontraffed, 
If not at place ol death ? 



Days 



(Info: niaiit 



,,,„., H^^^l Cb\>cvcUvM:x^y'Si 



i.Mj^oi 11. K.Ai, o, ki:m«»v\i, 
JLc V T90M 



„.^. 



ni)i;ktak)'.k V' <A,v^ ^>^ g ^ .^ 



PHV\SICIANS Hhoulcl 



(A.Mic-s '<^v v>^ (1 ^ iFYACTlY. PHYSICIANS HhouU 

.^^^:;-^rJ==E™^ — 



i 



.|fc j 



ii 



' .! 



i 



I" 



It 




w 



RITE PLAINLY WITH UNFADING INK 



•.,:iT.l f !!• I'.th i ^'^ 



- t^y^-^U UKVC 



io(n 



^ 

DEPARTMENT OF PIBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INS TRUCTIONS 



8!?9 



=City and County of San Francisco 



% 



Certificate of S^eatb 



PLACE OF DEATH:-Co.n.v of a^-i>V<V.vc..C. CUy of B^J/vC-^co 

. N il . y W I 1 \) •,,. -n:.. .U^f — : ' and -rrr-—-^- 



'No. 






A J /T W m" fw-\^ AA K^ O. ' St.; ' " Dist.; bet. _^ ;^^^__ ...ppcAt information • \ 

FULL NAME^' JlL ao^ O VJxhiu.^ v* 



) 



->KX 



PERSONAL AND STATISTICAL PARTICULARS 



n\ 



ecu 



UOJxt^L 



n\ii-: «>j niKrii 



iMontlO 



\<'.K 



H?- 



):;ti 



tDity) 



M,,uth^ 



(Year) 



/><! 1 -v 



MEDICAL CERTIFICATE QF DEATH 
DATK OV I>K ATll f^ 

\1W • ^^ 



(Month) 



(I>ayJ 



.IQO 



(Year) 



SIN.. I, J-. M AKKn.I> 

winnwKi) OK nnoK* i-.t) 

,\\ lif in MH-ial .U-.iv'.iii«ti..n) 



UIK rUlM.Ai'K 
I Stale or C<ninti V' 



NAMK OF 

I ATHKR 



(8? 







" , HKUlUiV CKRTirv;Tlmnattc,i^le.inerca^^^^ from 
CKcxr^^o ,<^H to W- 5.1 

tliat I last saw h ^ >-> ^ alive <mi 



i()o H 

and that aeath occum-a. on tin. .l.a. <tat..l al...v.. at n- I ^ 
"V' M. Tlu- CAlSi: nlDI.ATM was as follows: 



v)^nJLCr( 




17 



lUk'ruPT.xrK 

OI- 1 AfllKK 
(State or Country! 



•dLcrVi Vl) MXV/K^wOr-x^. 



f\<X^>^^ 



lJ^AJLl^^X>w-l 



v^^ V^' A ^XvA 



Month's 







MAIDI'.N NAMK ,1^^ 
Ol' MOTHHK V 



lUKTinM.ACK 
Ol- MOTHKK 
(Slate or Country I 



.U\/0. 




Qjsj^rrusy^ 



iVoLA'VOl 



... <• .. /■. ,T II. I v,'/) } rn> ' 



AV.v/</a/ /'/ S-.,>/ /-/>7 ;/./>'■" 






nrRATioN 

(SIGNED) 




)'t'ijrs 



Mofiths U Am 






M.D. 



Special inVormat.^"'* '"'^^p''^'^' '-'''""»«• '""'* 



Its, ana pcnuns ujn-i "■•"; 

Usual Residence VJU.'VV^ ^ ^^ ^ ^ ^ 

When was disease rontracted, M ji ^LuJl^^ AiXi/^ 
If not at place of death ? ___^iZZZL 



Days 



(Iiifonnatit 



-0 



d^^Mh-rOA) 



C 

f A.Mress ^^ 



PXHm; It. KiAi. or Kl-MOVAI. 

OfUV- '2>D 190H 



7,^CKOFmKIAI..'H,KHM-VA.. 



/ 



/ 



^ ^ ..H -«refuMy Hupplled. AGE nhouUl "« «»«'*^^f .s,;,..^, ,nfor.naf.on" Sor p.r- 






n 



« 



i 





I! 



I 



HI 



} r 



.! ,.f 11. I'th IN 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CgRTirlCATE FOR INSTRUCTIONS 



.:^^'^^ \mkvc 



L....iM.u Deputy Heailh ORlcer ^ 

DEPARTMENT OE PUBLIC HEALTll=City and County of San Erancisco 



Ccvtificatc of Beatb 



PLACE OF DEATH: — County of 




^^^^ 



.i.<LOw City of 



,^ 



NoXtla» 



Dist.; bet. 



and 






FULL NAME 




CVVYV c* 



i:x 



;, XI i; . u lUK 1!1 



AC.K 



PF.RSONAL AND STATISTICAL PARTICULARS 




Aj. 



I1I.U 



I Month* 



iDL )V,/.- 



(Dny) 



M„t,l/r 



( Vciir) 



MEDICAL CERTIFICATE OF DEATH 



DATK «'t- 1>i:aTH a 



^l 



(Motith^ 



At...- 



/QO 



H 



lYear) 



Pa vs 



sivr.i.K M AKhn.I> 

WIIM>\VHI> «)H I)!\OKi Kl 

.\Viit. in <.xMal atsijrnatioti) 



^ 



X'^^OAJI 



, HKKKI^V u:RTirV:Thal laUcn.UMiacccasea from 

— : ' ". - up ~" 

— T90"~~ 



I90 



— t( 1 



that I last saw h " -alive nu ^ 

,„athat death occurrc.l, .... tin- .lat. ^tatcl above, at 

M. The CAISI' or DI-.XTII Nvas a. foll-nv.: 



nTRTmM.AOK 

iSl.itf or <,''nintr5'' 



'I I \ 



NAMH «»1 
FATH l-.K 







/ 



.y^' 



01 I ATIIKK 
(State or Country) 



/ 



MAIDl-.N N\MK 
OF MOTUKK 



C^' 



C:^' 



/ 



ni- RAT ION y^^'^''-^ 

CONTKllUTOKV 



Mouths 



Pays 



Hour 



ni'RATION 



)\ars_ 



Mouths 



nTRTHPLACR 

Of- M()Tin:R 

(Statf <ir Conntivl 



OCC^rJkTION 




s-Al.lVXKTirri,.\K-AKl-. IKl 1. 1 






/W.5 Hours 

mo. 



T^rnPMATlON onU tor Hospitals, Institutions, frdnsifnts. 

HowtoiMjaf 
former or .. piare ol Dedtli? 

Usual Residence •-• ' ' 

When Has disease contracted, ......... 

If not at place of death ? 



Days 



D.vncut 111 KiAi. ni ki;m«>vai. 



s 



M 






<.v,„„..s. q C% 0^2ll!I2i-i ■ T^^^US. PHVS.C.A.S -hou-d 



TQO 



TTX^HOF mKyi,'>K KKM'.VM 
UNI)l':KlAKhK v/vvw. -^ \ ' "t 



:r.^-rZ"^rH^^::r.Jv;-.i.;. .-'"""• 



i f : t 



' <, 



I 



Jii 



WRITE PLA.NtV WITH UWrAD.NG .NK-TH.S IS A PERMANENT RECORD 

HEFER TO BACK OF CERTI HCATE FOR I NSTRUCTI0N3 



,! , ,r H- '•'' 1' ^^ 






Jlc'Hstrr^-^l J^'^o. 



3481 



.V 



l,nlr /•VAv/.VTlCV^tmJUu.a.O J'^0". 

L.^Uk. Deputy Hen- Officer ^ 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtiticatc of IDcatb 

, XX, 5. Stan^atD ) 



^TT .- 4 ^^''W'^A; Vao\CA-4:C0 City of ^- CL 
PLACE OF DEATH: — County otv cl-ia. o 

^" '^1 ' " t ^' ^ ^<. U . ^ ' • St Dist.; bet. — 

y .-^ DEATH occurs *W*VtROMU ^ ^^ ^^^^, 



>v 



)L<X/TLCUi'CO 



and 



) 



^ ,r Dt«TH OCCUBRIO IN A HOSP'T.l 



FULL NAME 






SKX 



T^^T^I^ITaND STAT.sTicAL PARTICULARS 




UuJvJw 



I.ATK <)! I'.iK 1"H 



M.iiilh' 



\r.H 



C!? D 5V<M' 



1 1 )a V ) 



M.'uifr 



h 



fVciitl 



/!(; 1 > 



iwEDlCAL CERTIFICATE OF^EATH 

I, ATI- <>l. Dl-.ATH p^ 

( D:iy> 



v,C^''' 



t(i 



Up 



ii*N 



\V1I>0\VKI) c.K I>!\<'H 11 
(Writ, in social <U-sJK»ati.n>) 



lURTHrt.ACK 

,st:tti <ii Country' 



N \Nn OF 
FATHHR 



I!IKTIHM,\' K 
ol J AlinK 
(Slate ttf CowntryJ 



MAlIti:N NAMH 
t>F MOTIIHR 






ntRTffPLACt? 

()|. MO'l'in-.R 
(State or Country) 




that I last saw h --^ '>»ivc ot. 

1 .> Hi,, .litr stMU-<l al>'i\«.', at 

— M Tlu-CAISIC (.F 1.1-.\TII was as follows 

O^W^v^XAycL.*- 



1 90 



j\ly^ 



CONTRir.rTOKV 



.l/o>////-^ 



Pars 



ff(yurs 



.V/UO.AyA VCL 



Cb^v<x<i^^ 



! SIGN E D ) Cc-Unxtv*^ ^ W ii^ 



flotn s 

M.D. 




\f,nlth< 



*:./'<'.' 












Nrmer or .0 
Usual Residence '^ 



■^ now IMIIlJ ni 




pVl.v*^- I'.'KlAL or KF.M..VAI. 



h. I il 



fA(i-rifH>^ ow^ A_,^__^ 



,,,,,. ^^ 10 3>^ 3*^ ^-^ ^^ ' — ' rrVACTlY PHYSICIANS •»'«" "A 

'^^^::r:;::=z7:^^ -- '"J 




!. 



I' 



ir 




.,TE PLAINLY W.TH UNrAD.NG ,NK-TH.S .S A PERMANENT RECORD 

REFER TO BACK OFCERTT.CATtrO R.NSTRUCT.ONS 



Wl 



iirrl of Health 1 V 






Piegistci'cd jYo^ 



^^^u^K^^ KSl 



Deputy Healtei u^^c^^r 



DEPARTNENT OF PIBLIC nEALTH=Citj and County of San Francisco 



Certificate of Scatb 



\ ^ 



k: City of C' <X^rx' .^XC/rwCAw<^CC 



No. 



^ao 



. R Dist.; bet. 



(■ 



^, , /- » „f C A./>^' J VOUl^CA^ct City ot ^"^^ ' >• ^ 
3F DEATH: — County ot^cvr^ | 

^ ^. R Disfbet. !t)tk and „V»XL 




PERSO 



NAL AND STATISTICAL PARTICULARS 



i:x 



iUclI 



COl.OR 




JActjl 



"^ ■' 



^ '\ f* 



DAii". «»i r.ikin 



ACK 




iM..!ith) 



) V(/ ' 



tl)ay) 



M.tHlIn 



/HCH 

(Vear^ 



MEDICAL CERTIFICATE OF DEATH 



[Month) 



(Day) 



(Year) 



'^' I Ul.KI'llV CI-RTlKY7l^.at lattcn.lol.U-ccascl fr„.n 

(K.v-.L'^a .^H t., W^^. ..-oH 

...vK^rsc. ..3^'V 190 ^ 



th 



at I last saw h.^.> alive on 



'l<2t,.W*\) Anv 



WIlu.Ul.l) (•!< IMVOR. M 
iWritf In social •U'HijrtiJ't'""' 



r >■■ 



tSlati- 01 ("oiniti V' 



. 



VAMK 01* 
JATin-.R 






8*: 1 



rit 



4 ' 



i 



Il ■ 



lUK TlU'I.ArK 
Ol- lAlin-K 
(Slatf or r..iintry 



maii>i:n namk 
OF M«)Tin:K 



lUR rnri,Ai*i". 

(»!• MO'lllKK 
(Statt' or Country! 







„„,H„at ,UmU, occrrcl, o„ ,1K. .late stat.,1 .t...ve, at 
-L JSl. Tlu- CAtSi-; <.!■■ OI-;-Mll was as foll.avs 



3..k.t, 



CivViA-v 



/I- J / 1 , . . • 



CONTRllU'TORV 



.1/ 



.„/M5 /;ar^ 'fa /A^/^r 










Q ^'x. aiu 




ft 



\n|\r 5.0 ,, ^ (.-xa.ir.ss) i_:;i: — ^ ^ — __- 

_ _ r"rri,u. ATiON onlv for Hospitals. Insfitulions. Transients. 

SPECIAL NFORMAT(DN 



or 



Recent Residents, and persons dyiny 



M:'llHl^ 



/hn 



OCCUPATION y 



Former or 
Usual Residence 

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



HoM lonq at 
Place of Death ? 



.. Days 



:inf<)iiii:»nt 



(Adili'fss 



S.%^ 



X h 



r-x-a: ' 



I)ATl-:«)! lUHlAI. or K1;M<>VA1< 



rNl)i:RlAKT-,K V-w V 



i 





„,!„„ .hould be c,.r..-u..y -upplied 



;S. B._P.very '«"• r'or DEATH^n P "in .;.m,. .h». U "« !>« 



. . 1 H\*CrLY. PHYSICIANS »hould 

^•''^ f-tU'wwiTh: ••«,->- ln.-o.n,„f.o„- for Pj^ 
properly ciassmcu. ^^m 



stance. 



1^ 



i 



'.I 

i 

•'I 



I 



i 



L ti 






ii»j 






* 



Si 



*iii^ 



IfflB 



t 



,1 



WRITE PLAINLY WITH UNFADING INK 



!) 



. ^^*^'*:.. i;5^lM-M 



■*» J5?f i»«». , 



departnent'of public health 



,cAw/^ .K-oVvy 



THIS IS A PERMANENT RECORD 

p.FER TO BACK OF CERTIFICATE FO R INSTRUCTIONS 

Ilea isle red Xo. -VJo.i 



City and County of San Francisco 



Ccvtificatc of IDcatb 

( 'U. G. StnnDarD ) 



PLACE OF DEATH: — County of 



Qjt dx^-' City of- 



„iu^.>^J-- ,.„,_ ..S-j,^^ 






FULL NAME 



i \ A 




77;;^;:;r7ND STATISTICAL PARTICOLARS 






\X,>wi 



M«iiUh 



ACK 



ait H5 



(Day) 



M, oil lis 



/i5 °^ 

(Year) 



WIDnWKl) «>K I>!\ ••".»•■" 

Writ, in '^.H-ial dLMRnati-.n) 



lUKrm'J.ArK 

(State or Country! 



FATin'.R 



nTRTTiri.ACH 
OI- 1 A 11 IKK 
(State <»r Cixnitry' 



MAini'.X NAMK 
ol- MoTHKK 



HIKTHPLACH 
ol- MOTHHR 
(State or Covjtitry) 




MEDICAL CERTIFICATE^J^DEATH 

DATH Ol- Dl-.ATll /\ 

\^^^ (IHiy) S'ear) 

that T last saw h :— alive oti — -— r-r^ ''^' 

.,..Uhat.lcathocct.rrea,..ntlu..lat.stat..la,..v..at 

^, Tlu- CAISI- (M^ Dl^ATU was a. follows: 

^XA^^f^^---^-^ Q(y^.^^^-x^ - 



m RATION >^"^-^ 

CONTRll'' ToKV 



( SIGNED ) UA.(P^X'Vv. w wv .^^ 



//(tins 
M.D. 




A'.w-,/.-./ /" ■'^"" ^-"^"^^'^:- 



^ ^iu^ - 



Former or 
Usual Residence 



Hov^ lonq nt 
Pldie ol Dedfh 



,,XT,.-,..! lUKlAI. ot KKMOVAU 



(Infonii:»'rt 



C^Vtn^Jt^^■ W^ll*-^ 



( \(l(lr("*« 



(Ad.lress 1 i D l. ^ ^ 






-:,- ; — — , , YACTLY. PHYSICIANS Hhould 

of in?nrm«f.on «h.>uM b. ^^ c J^ .^ „,„^ ^^ properly dasH.^.e ^^ 

n OP DKATH In p am ]--"'-'' .„ ^,,,y instance. ^H 



^- «-r:f J^n O. OHATH . ;;;:-.;—:.-•.. v.r. instance. 
«»•<• <l>in4 o*"* *'^"'" 



* i 



t 




WRITE PLAINLY WITH UNFADING INK 



<.t^^^vUS,\-r. 



Dnfr /v/rv/,.MWNVrYvW cC 



lf)0' 



THIS IS A PERMANENT RECORD 

p.PER TO BACK OP CERT.P.CATE FOR INSTRUCT IONS^ 

""^ ' M484 

J!('o isle red A"o. «^tc^-t 



.9 



OEPARTNENT OF PIBLIC HEALTlKity and County of San Francisco 

Certificate of S>eatb 

{"^rk/v-x^ Ja.<XvxXUlcc City of^''^^^^ nn \ 

PLACE OF DEATH.-C„.»„..--. (\>,.nH.f., .^, /It.. 



*-^^* >',.-^^rllTW OCCURS 



«■♦♦ '^^^* "oomftl I 



T^. ^ L+Mii I ;v.V/V^vi/vA^ V and ^ ' A.^ 

OR INSTITUTION GIVE ITS NAiyi^ 



St.: Dist.; bet. ^ I >> ^^„ •oprciAL information- \ 

( ,F DEATH OCCURRED IN A HOSPITAL 



(^ 



FULL NAME J O/w^vU 




,-IV OlfiYOl- 



" "" ZZTricTirai PARTICULARS 

PERSONAL AND STATISTICAL PAM 



DA'i'J'. <>J" i;n< in 




foi.t >k\ 



01^ 



VAw. 



MEDICAL CERTIFICATE OF DEATH 
DATEOK Dl-.VIH ^ ^^ 



(Month) 



(I>ay) 



(Ycai' 



<niiy) 



/6.t( 

(Year) 



AC.K 




JXH 



JVii' > 



q 



I 



ti 



ii 



mN-C.l,K. M.\KKI1".1> 

(Writ.- in -uial .l.MVM.atu.n) 



iukthpt^ack 

(Stitti- tti Country ' 



N\M1-. <>1- 

!• ATin:K 






IJU 




lUKTmM.ACK 

(II- I athi:k 

(Statf or Coimtry' 



Mn}llhS • 



.rvOld. 






Da vs 



, „,;K,,MV el<KTnv:l-h.. Ia.U.„,U.^.tcccn,«d fro,., 

,„at,,at,K..U,,.co,rrc,,,o„Uu..lM....U..,M,ov>.,.l -.1... 
U M. Tl,.- CMS..: Ol- m.,ATIl ,«a-. .^ foil.™-. 



«M^W 



-CtO 




Dr RATION >''''''^ 
CONTRIIU'TORV 



Months 



Pays 



tir^ 



MAini-.N NAMH 
01. MUTHF.K 



UIKTHPf.ACE 

(State t>i Country 



ticCUPATlON Q[Nf Is \3 



Yciirs 



/'iin 



(Informant 



a^tjv-'v u... ai^ 






HoH lonq at ,. , ^ ^ ^ • 



l,A!;Hof HI «'^> '"^ KKMOVAl. 



( Address ..^-^^ ^ ^_— ^— — — 



N. B.- 



l\A/Lt'^'-^ ^^ ' — TTTrTv PHYSICIANS should 



sons dyinft away 






f» 



i 
* 

i 

+: 



w 



I 







i 



WRITE PLAINLY WITH UNFADING INK 







"Lft^^A>^" ■ T^-nu»v M^^l^h OWc^- 



THIS IS A PERMANENT RECORD 

REFER TO PAC K OP CERTIFICA TE rOR INSTRUCTIONS 

3485 



liccilstercd J^'^o. 



DEPARTHENT OF PIBLIC HEALTH-City and County of San Francisco 






Cevtificate of Bcatb 

tl. 5. 5tau^ar^ ) 



PLACE OF DEATH: — County of -^<X^ ^ 

FULL NAME t..Q,«-^ J(OTV^ 




si:x 



7r;;^;:ir;^^^^^A^=^'^*^ particulars 

j cm, OK >| 




^wi 



UjJvJjl 



i)\'n-: <ii' I'.iKin 



,t 






'N 

.r^ 





(Day) 



(Y<^ar) 



AC.K 



5.1 



) 'itl I s 



M.ni!h'< 



I 



lht\: 



mNT.i.K. ^^•^»^'^" '*^...,.n 

iUTif in s.H-ial (Us,... nan. .n) 



(Stale or C'xjntiyi \ • I U J 



MEDICAL CERTIFICATE OF^ATH _ 

U,bf[f I :j"^.^ ^-"- 

Q.S .^H to. OW ^i .*.H 

U M. T,K.CArSKO,M.K^Vn..asa.foM,.«.: 

OUt, VV. VXO^L.-Uo s\ ^Ost^v^-u^ 




DIRATION 
CONTKir.rTOKV 






Hoiit s 



iW IMHI'.K 
(Slatr or Country' 



\ 



lOL<X''»^-<^ 






«)1- Mo'niHK ! ' * 



Years 



MiniUtS 



,1^:1'^ 



lUR rillM.ACK 
Ol- MoTIIl'.K 
(State or Country t 






> , XxC^M^ 



M.D. 

f 



DlKAllON 
(SIGNED ^ 



J^ , , (^ 11 HoH lonq at ^ 

Plai f ot Dfath ? ^ 



)■/•<; 'f 






(It 






Formfr or \ J 
tsudi Residencf^-^^ 




Oj 




Da>s 



,,\llW MrK.Al, o, Kl.M-VM. 



'ui 



X<Z.-. \. 






T90H 






I NI 



(A(l«lri-<H 






I'llVSICIAlNS .hould 



I.I \OAh IV-r> (T-<>>J-^M. - Tv-l-lV I'llVSIClAINS .houl. 



I 



I 




I 



i 



^ .«■< THIS IS A PERMANENT RECORD 
...o.xF PLAINLY WITH UNFADING INK — THIS IS A f 
WRITE PLAINLY w ^^^^^ ^^ ^^^^ ^^ .„T,ncATi FOR insti 

1^^-*'''*^^ lit' 1 > ( 

1 V/. • !• th'?* aT""!-*; l>^i.i * 



p,r„ TO ....KnrCERT^rlCATr FOR INSTRUCTIONS 

8^86 



^ A i,)nu Jirgus/rred jVo. 

I, a/,' /••//../, M\CV^^^'V.„^..0 1'^^^ ■ 

Lvcv^Wm Deputy Hsrr.h Officer ^f C^n FriHirKfO 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of ©eatb 

, -u. 5. 5tanC»arO ) (?P\ 

P^ CL -^^ va -> v/^A^CX City of ^-cc >^ ^ ^^ 
PLACE OF DEATH:-County oK <X^^^^ ^ ^ 



Dist.; bet. 



— and 



^/V I 4-^1 Sf — Dist.;bet. „pb 'sPtcAL information • \ 

( ,F DTATH OCCURRED IN A HOSP „ . 

g Id. b' 




MEDICAL CERTIFlCATE_OFJDEATH 

"^•'•■^ •"':"::" w i 





(Day) 






^ Month) 



ack 



HCi 



}V(/i.« 



IS 

(Day) 



\},^tilh$ 



(Year) 



Da 1 .' 



^IWOIIIH' , __ . — — . — — 



Q^ a I "^ 

tliMt I last saw U .i-^^^alivc o.l 






(Writ.in MKial .i.-uMiatmn) 



niKTuri.Arv: 

I stall- or C-nititry) 



NAMH <>l- 
FATHKR 



UlRTlUM.ArK 
OF lATllKK 
(State or Coniitry' 



MAIDHN NAMV: 
<)»•• MOTHKK 



lURTTirrAcK 

()»■ MoTin-.K 
(Statf or Ocmiitryi 







tlKdllastsawU *">""-"■• , , . ,, b I 

,,^H,,at,U.atl.occ„r..l,o..Uu.,la....aU.,lal,,..,a 

(} ^, The CAVSI- <..•• OXATll was as follows. 



Pars 



JJout s 

JCM 



(SIGNED ) Uv.^-^t ^^«'^^n) ^ . V 



-'»', \wcJUCJ. r;va.. 30 0. 

Usual Residence ^^J'^^^^^-''-^'^ 



]'rf! I 



I i/„»/Ax ..^«-_^ 



7Tr=^-^y;,^:^^»^"^^^^ 




(Itifovinatit 



rx,Mr..ss U:a.cuL«A 



fO 



INDI^RI'^'^''*'^ 



^ \ JAvA^>v>aA^' "^^c 






lUa,CxJLv€L VCL.4 ^ ^^^^^ ' " VASTLY PHYSICIANS should 

,,,,,,ss ^-^-^ , — -— ^^„^,a He «t«^^:;^^f .^8'^p^ec1a» Information- fr P— 

«on. dytnft fl>vay from no _ 



!• I 





«..,^ ,MK THIS rS A PERMANENT RECORD 
WR.TE PUA,NUV W.TH UNrAO.NO ...-T^ ^^ .on ,.^,,, 1^ 

, ,. 84 87 

\ A.^M Deputy Hcr.r.h Officer 

DEPARTMENT OF PIBLIC HEALTH=City and County of San Francsco 



Certificate ot Beatb 

( XX. S. StauDavD } 



Q^ 

1 ' 



No. 



PLACE OF DEATH: 



■ County of9-^'^'^<^—r^''^ °*^^'^"r" 



3 S Ic- X>w\. 

( 



^( 




Dist.;bet.U^-^^^ 



.UiAXAv. 






,F DEATH OCCURRED IN A M03 , 



^■" ) 5 






FULL NAME 

color) , {] 



A 



^^axa<x\x. 



i Uj^c^- 






I M.mtli* 



\(".F. 



%t l'"'^" 



(Day) 



M.niHn 



,UH 

(Year) 



Al V5 



(Yiar) 



SI NT. I K MAKHIKTV 
(Write in sooi:.! <U-.^'i.at...n) 



lUKTHl'KAOK 

(State or Country' 



N*AMK Ot- 
FATin.R 



V 



RIRTlirLACK /) 

OI- JAI-HKK I 

iStatt-' or Co\intrvi 






lUKTIlPT.ACK 
()!• Morill'.R 
(Statr or Vountryl 









MEDICAL CERTIFICATE OF DEATH 

„.„.K OF .>H-V" A, r^^ 

,„o.uh) ^ '^"L- 

r,n.:U,.:l.V C..:KT..-V, TlK^t. atte^^Oc^a^sed^fmn. 

,1,„t I last saw U — alive on " 
„.at,.t,U.at,.,ccur.e,,,..ntlu..V.U.s,a,,-,la,,,.v...a 

.._^. „. ,,u. CA.-S,.: OF llKATHwa. a. follows. 

(JOtM:A^dU/-trv.CcOL ■- 

rr RAT ION >''''-^ 



0" v^^'^'VA/tirx^ 



Hours 






(I 






CONTRIIUTORV 









nrRATioN 



i'turs 




(SIG 

A 



(0 



m 



Months^ 0ays 



\slMmJ 



VI. D. 



VlXc\r 31 I'l"'' 



(A,l,lr,^Xl£Ili^^iML^ 






occri'ATioN 



M,,iitli:^ 



Pa V. 






Hev« lonq at 
Pldff of Death ? 



Days 




(I 



ni-:sT OI" M^ K.x'x 

nfoTinatit ^ ' ^'■^ I 

Address . O v \ o^w/ '" - 



1 




190 



pHYvSlClANS should 



::n::^:^'»".---^:-::':;;:^ rrr.rt .^".•:- —•"-'• ^^" '"■^ i 

E OP DEATH in »'" " 'T«: .„ i„ .v.r, in-l-""- __ M 



- "-r;:;^ cp^-o^- -:-:: srriivv::n .>..> -."""■ 






1 



•♦ 



: iiRk 









i .> 



m 



Is. tl 



-^ ! 



w 



RITE PLAINLY WITH UNFADING INK 



nur.iM of Hciiitv. »• 



y,, ,. ^.■f^^> ]',SiV *■'<> 



l)(((r Fih'(h 



DECl^--^^4 



THIS IS A PERMANENT RECORD 

REFER TO Biir K OF CERTIFICATE FOR INSTRUCTIONS 

8488 



lie^ititcTcd J\'^o. 



LOUIS LtVV, 

Deputy Health Offlcar; 



DEPARTMENT OF PUBLlcfEAlTH-City'and County of San Francisco 

Certificate of 2)eatb 

PLACE OF DEATH:-Co.nt. oAo.. 1^0.^-- Cy of 0,0^ ^^<^--- 



) 



Ri 



FULL NAMeU^X^I^!! 



-U- 






-;-u 



i 



Sl.K 



DAli; »)l lURllI 



PERSONAL AND STATISTICAL PAR2ICUhABS 




\ 



Af.K 



\l\cv- 






»flKf 



(Day) 
M,->i!hs ... 



/.^D.H 

(Year) 



An.v 



SINC.I.K, MAKRIKI). 

(Write in social (U siv:"i<tH.ii) -A 



MEDICAL CEF^TIFICATE OF DEATH 
DATE OK DKATH 




.{[NT. 
(Month) 



(Day) 



(Year) 



HIKTHri.ACft 

iSt.itr or (■■miilryi 



rAlHl-.R 



lURTliri.AOK 
OI- KAIMKR 

(State or l'o(Uitry) 






Tui'RlUJV CIvRTIFV, That I attcnacl dcccasecl from 

. (k.c\- n 190 ^ to .. ^^^W.- ...sia 190 H 

tbat T last saw h^uv^^ alive on M^^JV^. .9.^ 190 

and tbat death occurre.l, on the date stated above, at 15. 3>0 
(X M. The CAlSIv OI' Dl^ATlI wis as follows: 

dJUil^c^^^ 9i i^ys-^t^. 





:t 




MAIDKN NAMK 
<)1- MOTMKR 



HIR'nUT.ACK 
()|- MOTIIHK 
(Stale or Country) 






(^ 



^jLXcJ^<yy\^ Ux^^ixxxxx; 




DrRAriON-I Years Mouth. Pay. H Hours 

CONTUM'.rTOKY O.^VO^^t^^ 



(SIGNED) LcuA^^J-U '^<^-'^*^^^^ "•"• 



Address) Q(\ndAA-..(^i^-^-> 



SPECIAL INFORMATION only for Hospitals, mstltutions. Transients, 
or Rerent Residents, and persons dyinq away from liome. 



^^^^iii^i;^^ '""^ 



(Informant 



( Address 



m 4 • - • 



Former or 

Usual Residence 

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



How lonq at 
Plare of Deatfj ? 



Days 



I'l \CK OI- lURIAI. OR RHM"VA1, 

J! ■ 



rj 







^._J^i«— — — — ^^ ■" , pvACTLY PHY8ICIAN8 should 

,on .hou.d be cnre^un. nuppIUd ^^^^^^^'^^V.ri! TH^ '^^ ,„fon„,atlo„" for pr^ 

rH Jn plain term., that U may be properly a ^ 



M R Bvery item olt informat 

• • state CAUSE OF DEATH in P;""' r-;"-:;^„",„ ,,,^3. Instance 
sons dylnft away from home should be ftiven 



f* 



i 



w 



R!TE PLAINLY WITH UNFADING INK 



n.,;»l.! ..f 11. allh I' N" ' 



t^.t-.-. 



^I'.fclM-') 



I /^//r Filrd , 



DEC! ^^^4 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

Kc^Lstcred jYo. ^^489 



LOUIS LEVY, 

DEPARTMENT OF PUBLfrETLTll^^ and County of San Francisco 



i» 



PLACE OF DEATH: — County 



Certificate of "Seatb 

^ 11. 5. StanOarD ) 



Q^ 




1^^ jxc^.^vco^. City ofO^L/^^ Jacv^vc^^cc 

i) 4 1 



) 



FULL NAME 




.HjltaJL 



"v: 



..-cncu.. 



SI 



PERSONAL AND STATISTICAL PARTICULABS 



i)\ri". «>!• liiKin 





iMuntlO J] 




AC.K 



55 



) Vi) ( 



Muuths 



(Year) 



Pars 



MEDICAL CERTIFICATE OF DEATH 

DATE Ol" I>HATH 




(Month) 



3>D 

(Day) 



IQO 



(Year) 



SIN(.IJ-.. MARKIKI) 
WinoWKI) OK I)I\«>K^ Kl 
iWriti' ill social <K-i^Miali..n) 



IMKTinM.Ai'W 

' SlMtf or rotmtry) 




NAM J" OI 

JA riiiK 




\ouVvOLcL 



o^^^<X 



' 1 HFRl^nV CHRtYfV, That [ attcn.Wa aeccased from 

QnVox. S.t i9o'^ to ^ ^<ivr SO ...„,9oH 

,,,,nas/sawh-^ alive on (VCVT 3ft T.pH 
„M that acath occurre.l, on the .lato slatc.l above, at 
. M. The CAISI': OV Dl'ATH was as follows: 
(JUAJ-vJc-v^^vO^ ,.,....»..- 



'_' 1 _. Sfiu^^x^^^^urrs. UUvK^^^^^ 



niRTllIM.ACR A ^ 

(Stilt* or Cotmtry) > _ , 

(KCUPATION q^^ _ ^ ft ..... . 



)'(^r;-.? I Mouths 






Hours 



v.\..aj. ..v:.wSr* 



J\fonl/is 



Pays 



MATPKV NAM I 
OF MOTHHK 



niRTHPI.ACK 
oj: MOTIIKR 
(Stiitc or Country) 





<rix 



M,,HtU: 



PilV 



^=^^;^¥i^^ '■" """^ 



or RAT ION H >''<"'-^ 

(SIGNED) H "^WU^vA^^^— ^ 



Hours 
M.D. 



I()0 



SPECIAL INFORMATION f- '»' ""^P''-'^^ '"^'"''»°"^' "•'"-'"'^• 
or Refel^ MdfDis, M persons dyi»« a«d> from home. 



Formfr or 
Usual Residence 

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



HoH lonq at 
Place of Deatli ? 



Days 



IJl-ST t)l' MN K>"" • 






A.Mr.ss \'\^^ Ob(>^^^<>^^ ^^ 



ruACK or lUKiAi. OK ki:m..vai. 



i)\i'K'>! lUKiAi. or ki;movai. 

.^Jt«. ^ T90H 






IN. B.- 



'" , FYACTLY PHYSICIANS should 

-„„„..„ ...... .. ..^.-;;^ ^--t peHr:t.::^<:r"T.:: -pec..; ."—-■• - --- 

,r DKATH In p.mn tern,., th" .<""•> . .^,„„. i 



":riHi -^ -• =- ■^••-" '" -- '"••"""• 




a^-* 




w 



RITE PLAINLY WITH UNFADING INK 



,,.a„l..f Health )V.. , . --^^^v-^^ BM' On 

I Dale I'llt'd , 



DEC! ^'^^^4 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE F OR INSTRUCTIONS 



.3490 



I ^ 



V 



U0UI8 LEVY, 

DEPARTMENT OF PUBLCTm^ and County of San Francisco 

Cevtif icate of 2)catb 

((i (V'^'''i VCU>^c v^cc City of O^^x, Xxx.'wav<vc.u, 
PLACE OF DEATH: — County ofO.a^ - va.>vcv^ y 






r ) 



FULL NAME 



.o.Ai^ Cii^a\^cL.<xA-^- 



''>.:>.:v.^w.*w ^>"^»^'<^- 



PERSONAL AND STATISTICAL PARTICULARS 






KATi". <>i i;iK in 



AC.1-: 




COl/>R\ 



XUu-^--^ 






1 <A > '" ' •'•■ 



ID 



1 

iUay) 



Mofif//- 



/. U. i .'S, 

(Vein) 



MEDICAL CERTIFICATE OF DEATH ^ 

DATE OK DKATII A 

M UV- -^v 

(Month) <»»y^ 



(Yt-ar) 



a a 



na\^ 



SINC.I.K. MAKKIKI). 
\VII>(>\VK1) OK niNOKi KI) 

,\Viit<- iti <'H-ial .U-iviiation) 



lUK'riTPT.ACK 
(Statf or C-miitryl 



dx-vvClV.' 






ThFRFBV CKKTIFV, TltaH 'iUeti.k-.l .leceasea frt>m 

^\^.%^ i90-i to. AIVCNT ^^ I90.H.. 

,,.U last saw h..- alive on ^^^ ^a. .............,^^^^^ 

,,,l that aeath ncotrre.1. on Ihc.lat. stat..l above, at 

(? M. The CAISK OF DKATIl was as foll.ms: 

<^xlCU/^X^r»'x.v..Q^ — "-'■ 



NAMt". til" 
I A rill. K 






lUK'nU'l.AOK 
<>|- lATHI-K 
(State or t.'oiuilrv' 



MAI1>>',N NAMl- 
OF MOTIIKK 



!UK'nnM,AC-K 

oi- M()Tin-:K 

(State or Cotnttry' 



ji-VO^ V'^ X 






^^cx.->-^cX- 



OCCrPATION 



Resided IV S.n, rn:».i^rn_ 



)V<?' 



M.oith^ 



Pnv 






CONTRIIU'TORV d^^^^-^.oAc.^^^ ••-.-" 

Qj^J^-,%./cLv<l4±4.-o •;•'• ■— ■ 

' ' 1 ,' Mntiths /^<n'.? Hours 

DURATION I >"''-^^ •'^''"^^'' 

( SIGNED )..W^-^ I ■ 



M.D. 



^gyr S^t 190' 



SPECIAL INFORMATION ™ly i" ««l-i'*l^. '"^'i'""""^' '""^""•*' 
or RefeS Menh'Vnd persons dyin, .»ay lr«™. I.«n.t. 



Former or •, , 1\,^ 
Usual Residence '- ^ ^^ 

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



,k^ 




How lonq ^^ 1 „ 

Place of Deatti? o Days 



t\ 



^ 



/^' 



f 



j^ 



? 



J 



(I 



>\rii.o! ItriUAi, or K1'.M»>\AI, 



,.j.XCKOr lURIAI, OK KKMOVAI, 




i 



M 






(X.l.Uoss ^^VDlO. ^^^^^ PHYSICIANS should 



f' 



*'^:i 



w 



RITE PLAINLY WITH UNFADING INK 



r. 



..,;,, .1 ''f llcaltli 1- ^■• 



••>.^*^c"^i>n5ti'^- 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CE RTIFICATE FOR INSTRUCTIONS 



l)((h' Filed , 



DEC 1^^^4 



ne^isfcrcd jVo, 



841)1 



LOUIS LEVY, 

Deputy Health Officer, 



DEPARTMENT OF PlBLlcTEALTiT-City and County of San Francisco 



Ceitificatc of S»cntb 

^ 11. S. Stan^avD ) 






I 



PLACE OF DE 



.^^H:--^..^^^'--*-'^^ ^^"^^Y 



I 



No* 



St.; 



Dist.; bet. 



and 



) 



• •cilAI RESIDENCE GIVE FAC 

( - -o;:Trocc.%r;;N"rHo^s^rAt o^^Tnst.ut.on g.. ■ 



FULL NAME 



.<X.^..'^-rtO"»-^ 



St., Del. "cprriAL INFORMATION" "\ 

:ts called for unde^ s^r"! ^nd number. ) 

ITS NAME INSTEAD OF STR-ET ANU 

\j .>J^.vU.^Llk^-. 



PERSONAL AND STATISTICAL PARTICULARS^ 

I c<)I,t)R 



DATl*. nl- lUH I'H 



l)0.kU 



11 



Muiith) 



(Day) 



./ / 

/(Vearl 



> ' I 



ACH 



/ 



MEDICAL CERTIFICATE OF DEATH 
DATE OI" 1»i:aTH 



(Moi^li) 



\ 

(Day) 



(Year* 



I llUKlUiV CI 



.:rTIFV, Tliat r atteii<K«l .IcreascHl from 

„ - 1 (p 



I9O 



to 



)'^ .;>> 



M »illis / 
/ 



Da \s 



sIV.,l.l-. MARK n- I) 
UIIX.WKI) «»K I)IV.)Kt J-.n 

, Wiitr ill <o.i:i) (Irsikriiatiotl) 



HiRTnri,\*'K 

.Slatf or Coiuitryi 



that Tlast saw li-:r- alive on 

,„a that .Icalh occurrea, on the .lato .lat..l alHivc. at 

M XhK CAISI-: Ol- 1)1. ATM was as follows: 

sJi^.'^AJJxM. 



TA rni-.R 



lURTHri.ACK 

<^i- iArni:R 

(State or Country) 






fw / 



DT RATION >''''^''^ 

CONTRIIU'TORY 



nrRATioNy^ ^'^''^V 



Months 



Pars 



f fonts 



Months 




Pays .....-..//<'//'•"■ 
M.D. 



MAIDl'.N NAMK 
Ul- MOTUHR 



IURTHPLACH 
Oj; MOTHl'.R 
(Stale or Coiuitry' 



OCCrPATION 




( SIGNED ).vi., to I.mUw^^ ^ ^ 



,c.t 1 



TC)0 



( 



SPECIAL INFORMATI 

or Recent Residents, and persons dyinq 



ON only tor Hospitals, Institutions, Transients. 



^<LkJJ\> 



)'rai < 



M.^,itli> 



irri-ARS AK1-; i 



ri 



(I 



.„, %^f^ C a Sx^A 



KIK 10 rHi'. 



Recent Residents, and persons dyinq aw.y from home. 

How long at 

Former or pi^rp of Deatti? 

Dsnal Residence „.......,...•.—■-•• 

Wfjen was disease contracted, 
If not at place of deatfi ^ 



Davs 



i)ATl-: '.;■ HiKiAi. '^\ RI-.MOVAI, 

%B iQoH 



fA'l(lrf<s 



PI.ACKO.- m-RIALOR RKM-VAI, 

-^"^■^ ^1A -M^ u J. a 

^ n\ fAd.hess .3 a ■ V--<^ '^ 

a. X- ^^^- : . FXACTLY. PMV8.C.ANS hHouIC 

.^,. that U mny be pr..perly daHS.t. 



"■•■-=5asHEB'ri;i: ..-.-•■ 



«on« clyinft away 



1 1 



' 1 

1' i 






if 



m. 



ri!^ 









tl 



I 



JuT 



w 



RITE PLAINLY WITH UNFADING INK 




(>.,,.ii.l "f Hi:iUh ■'•■ ^■' 



J)(ff(' I'lh'd , 






DEC 1 l^'^O^ 



THIS IS A PERMANENT RECORD 

REFER TO PA CK OF CERT.F.CA T. FOR INSTRUCTIONS 



LOUiS LEVY, 

Deputy Health Officer. 



Deputy Health UTTioer. C^ort/^Icz-n 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of U»catb 

^ . *CLCXy>\; O.V<X^XC<^eo City ot ^.c\y>v v 
PLACE OF DEATH: — County of^^X^ 

'MO.V..V NJ Jl„ OCCURS AWAY rf,OM I 



Dist.; bet. 



FULL NAME OxtUw W^vU^^Jv^. 



>iKX 



"personal AND STATISTICAL PARTICULARS 



^lul 



lilkd-^ 



I, All-: (U iiiKrii 






.t, 



ACE 



kl 



)V«ii.« 



11 

(Day) 



Mnnlhs 



\'\ 



Ml 

(Year) 



Daxs 



MEDICAL CERTIFICATE OF DEATH 



DATK <)l- UKATll fS 



(Month) 



.St. 

(Day) 



(Year) 






"T HKKHHV CKRTIFV. That^-Mol acceasea front 



mNC.l 1* M AKKIKTV 




j^6sJ:r^j^MJJs 



iStiitf or <."outitry> 



NAM1-. •>' 
lATHl-.K 






\rU!vr 2».0.. 190 1 

that I last saw h.u»v ahvc on ^ ^ ^ 

,,a Utat aeath occnrrcl, on the .late stated above, at^ .^- 

..' M. The CAISK OF DKATII was as follows: 

(J^AA^^^-iUN^v.'o- ' "" 



Mofii/is 



Pays 



Hours 




HIKTHPLAOK 
nV JATHKK 

(State or Covuitrv) 



MAIDKN NAMH 
Ol' MOTHKK J( 



IvIvcCOv^ 




.1 



(SIGNED) lcLc.hC^<^ ^^(r^(^'" 



M.D. 



lUKTlTPT^ArK 
01. MoTIlHR 
(State or Country 1 



^^^cv lc\^vx:f^<^ 



(K- CITATION 




\j^C I T.>oH (A.MnssI 



s, Insintu 






] Vi7/ '■ 



,u."////>- '^ /'"'^ 



.»,,»nvrJ0'i55S?SS^^ 



Cm- 



,-v^wV^XX. 



d 



;v^K>w<xuJ^' 






^^^^^^-^^^^-TT^VoRMATlON only «or Hospitals, Insmulions. iransienh. 

H) {\ Hovv lonq al p. 

Former or U , ^^ . mYLaT Pl«»f f «' '^"*'' ' ' "^ ■ "^^"^ 

Usual Residcnc^JU/^^ Hvjuvj 

When was disease contracted, 
If not al place ol death? 



Tl.^KOl- H.-K.U.OK KHMOVM 



DAX^.of lU lUAi, or KHMOVAl. 

X)x^ i ^90 "^ 



I NDKRTAKKR 



,.,,,,,.„. >:xq (^ ^»-cu:u.^^ 



N. B.- 



rcss . 5^ 1 1 \^}^^fO^ '<:^-^'^^'^^ ^^ _ ! — rFVACTLY PHYSICIANS should 

:AU8E of death in P'»'" "•"':.„ ,„ .v.ry in»t»n«. 



«on» dylnft away ?rom nome 



f 






!i 



w 



RITE PLAINLY WITH UNFADING INK 



«-"^'*'-. 



K,,.n.l..fn. >Mh ,S„ ..^^:^^^^^^S.VCn 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hi 



/)((/(' Filed , 



DECl-^'^^4 



Eeiisteved JS'^o, 



8493 



L0UI8 LEVY. 



I 






DEPARTMENT OF pyBLl£liMH!gyand County of San Francisco 

Ccvtificatc of 2>catb 

( n. S. StanC»arD ) 
PLACE OF DEATH,-C.«.,V .-9-- ivc^.-.^C^ .■?— J'-<>--<-" 



iwi 






No, :XciHH\ixmX. 



. I 



f jaJUla^ 



x<j\,.i. and "3XxAyi U^ ) 



^^•» ^' l-'lSlM "'^'^* ' u,MDi:R "SPECIAL INFORMATION- '\ 

V r,;;.;-"cu.s .».. rpo« usu.l residence c. »cts c,.,.^.o -n^--j j„„ .„„ „„„,„^ ; 

(, IF DEATH OCCURRED IN A HOSPITAL 



["Oil ■' lO 



»♦ « 



FULL NAME 



a 



I 




.CL^n^O.A 








UuJvaJLl 



— PERSONAL AND STATISTICAL PARTICULARS 

^^ n 1 col, OR ^ 

M..Mtll)A 



il):iv) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 1)1- ATR (T\ 



(Month) 



(Day) 



igo • 

(Yt-ar^ 




A«iK 



I y<a>' V 



yh'}i(h^ 



Da\ 



^ i 



,„,\VK1) OK DIVoRi 1 I V Q 

lit.- in s<Kial (k-hijiiii't>""' \ If 

I' i I . ^ ^ 

1 ? f 



niRTITPLACT^ 

( Statf '>r Counti yl 



NAMl. OF 
1 AlllH* 



iuKi*m'i,Ar"K 

OI- I AlllKK 
IStatt' or C'ounti v) 



MAIDI'.N NAMF 
nl' MOTHFK 



IMK rmM.ACR 
or M()TnF:K 

(Statf or Co\nitryl 



orcri'A'noN 




i HHRHHV CKRTIFV. That Irittenacl .leoeasea from 

.^a. ...igoH. to^.....M\^~ ^^ '^^^ 

that I last saw h -^-H. alive on ^Wr ^0 T90 

ana that ckatli occurre.l, on the .late state«T above, at 
Cl. >L The CArSIv Ol- I)1;ATH was as follows: 




DIRATION 
CONTRIIUTORV 



Years Months ^ Pays 



Hours 








IJKST Ol- MN KNoWU.l'or. -^ 4^ 



„r RATION ..)iw« ■'^""^« ^^^ /"'-" 

( SIGNED ) U3 Aib. ^'^^> A 7f 



Hours 
M.D. 



)jLC I 190"^ 



"special information «I. l.r Hospitals, In.li.uti.ns Transients. 
.,t«S Mrnts'Vnd persons d>ini away fro. home. 



Former or 
Usual Residence 

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



Hovt lonq at 
Plare of Death ? 



.. Days 







— * ■ ■ i_IL I PHYSICIANS i»hout.l 

- o„ .H..U. .. ^""-^--t ;:;r;rr::iv.:r';?:: -..^^ «— - -- 

SE OF DKATH In pl.nn -■""•'••»■• ""t in..-nc.. 



'■ "■ SSrZ r ;-:: ^nZJ-^r^i/cnin ... ln..-nc.. 



li 
f i 




* J^ 



if 



•ill! 






■ i 



i''^ ; 



WRITE PLAINLY WITH UNFADING INK 



H 



I 



o-.vd ..f Health - V N. 



"fr-V^^^j iUS: I' Oo 



M. -„— *• 



I )((!(' Fil('(L 



DEG1J'^>^4 



THIS IS A PERMANENT RECORD 

REFER TO - ^rPT.P.CATE FOR INSTRUCTIONS 

3194 



Rci^l^tered J\'*o, 



L0UI8 LEVY, 

Deputy Health Officer. 



Deputy rteaiin sjuiu^r^* ^ ^ P * 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 

( 11. S. StanOarO ) 



No. 



PLACE OF DEATH; — €nTjntr-»*VjW 
________^ St.; 




[hmXDCs.^:..- City of V) OJ^'^O. 






and 



.0. o.vc ^^^, X ^or s?;^^riJ?^::;e^^' ) 



- ) 



lAME M 






FULL NAME 



rrrsj. 



WW 

DAii: t)i' r.iKiH 



PERSONAL AND STATISTIC A L^ARTICULARS 





Ol'>nth> 



A<-,R 



Years 



^' 



;i)avi 



Months 



vctt 



(Wvm) 



7 



MEDICAL CERTIFICATE OF DEATH 



.sjyxX 

Vtotitll) 



L. IQO 

Day) IVear) 



I in':Ri':HV 



CHRTn-V, That I atteiiacd deceased from 

190 —— 
190 ~~~ 



190 



to 



.i.iuii'iliii' iwi 



\\ ii)n\vi.:i) «»K i)i\«»Hi i-n 

(Wiit. in MK-ial (ksiv'.niili"H' 



niRTHlM.AOK 

(Stiit«- or (.'onnlrv' 



N \M J OF 

I A iiiHR 



luKTnrT.Ari^ 

()|- !■ A 11 IKK 
(Stati- or Coinitrv) 



MAIDKN KAMI* 
<)J- MOTin:K 



lUK IHIM.AOH 
ol- MOlMllsK 
(State or Co\tiitryl 




Da » ji 



that I last saw !i rr— alive oil 

and that <leath occttrred, <.n the date stated above, at 

. ^I 'Phe CAISIC ()!• I)I:ATII was a< follows 

CJ^<rLftA.:ix. 



DTK AT ION >''''^''-"*' 
CONTRIIU'TORY 



Months 



nays 



//ot/rs 






•prRATION 
SIG 



)'(-(lJS 



Motiifis 



IhJYS 



Ilouy^ 






Vju -A. *• 



IMl'. 



'XX/vM.'C^ 



"i^i^AL INFORMATION »"ly '«' ""^Pi'-^ '-''•""»"^- '""^""'^• 
„,1er«U«*rnls,7nd persons d>in, aw., Ir.m h«n<r. 

H«w loncj at 
Former or pidce of Death ? Days 

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



^ ...1 1 1 \i"i.' .i'^ HiKiAi, or Rl'MoVAI, 

7, XCKOl- mUlAI.oK KHM..XA1, " ^ "/^ ' ^. ^ 



1 Q 1 ^D 

„,,,„.s, -V^Vt VA < *>■ oU^-— -- ^__ T^.CTLV. PHYSICIANS .hould 

finn« dying ow»y 



i 



I i 



i. 



^11 



1 ! 



H 



i 






# 



Dale Fili'd y 



WRITE PLAINLY WITH UNFADING INK 



DEOl^^^ 






THIS IS A PERMANENT RECORD 

REFER TO BACK OF ^^^.r.rATE FOR INSTRUCTIONS 



Be^lsfercd ^'o. 



3495 



LOUIS LEVY, Officer 

DEPARTMENT OF PllBLCTEALTH-City and County of San Francisco 

Ccvtificatc ot S>catb 

, -U. S. Stan^a^:C» ) ^ ^-j^ 

PLACE OF DEATH,-6««r-( .'c^^<x„va^v €«r^M ^ -^ 






No. 



— St 



■ ■ it.; l-'i:»lM •^" UNDER "SPECIAL INFORMATION" ^ 



^rr-r — and 



) 



FULL NAME 



SHX 



'personal AND STATISTICAL PARTICULARS 

j COl.uR 




LlLLO.,-. •..•: 



» 1 



ilvl 



.vi^K^Xi 




i»\TK <>i" in Kin 



iMunth) 



AC.K 



}>•«!»> 



(Diiv) 



M.<tilli' 



/Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 






...Li 

(Day) 



IQO . 

(Year) 



\U^ 






mNM'.t.K. MAKUll.n. 

,\Vrilr in -'H-i;.l .l.^u'iiation) 



lUHTHPT.ACK 



NAM I" <>l' 
I- ATin.R 



niKTHri.Ai'K 
lSt:it( or l.'«iuiitrvt 



MAIDl-.N NAMK 
()»• MOTllKK 



HIRIHIM.ACI? 
OI- MOTIlKK 
(State or C<>»nitiy' 



oocr...vnoN-JJ^-^ 




190 
190 



TilH RUnV CI-^TIFV; 'Htat I attemlcl <lecease<l from 

■ ■.190 to 

tliat T last saw h ■--— alive on "^ 

a„a that death occttrrecl, ot. the date statcil above, at 
M. The CAl'Sl': OF i>i:AT!l was as follows 



JsJL.C'v-'^^^^^ 



DT RAP ION ^'^'"-^ 
CONTRir.rTORV 



Moutln - Anv Hour^ 



,^'- 






//ours 
M.D. 



SPECIAL INFORMATION * l.r ». li.sM..i.-, ..a«..«.s 
.r1e«lu Wdents'Vnd pe.»n. d,i., iwa. from h.mr 



VfV?; 



M.<ii//i.' 



• Aha 



HHST «)1' M^ »^>''»^^'''" /J) A (i\ 

OfKoLXCV V) . LI 

(Infovmant M ' ^^VA^U ^ 




Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



.. Days 



DATKo! m Kl.Al. or Kl-MOVAI. 

yv^^ ^^ '90*^ 



I'l.ACKOl- HIKIALOK Kl.MnVAI, 



(AiMk"*' 



Ua ^L ^- '^^^^- ^TrXACTLY. PHYSICIANS should 

-4 : Mh nrefully Huppr.ed. A(;R nhould *>« «^"^'^:;^^H?**sVec1a. Information" for p.r- 

of InformBtlon «hou d ';^;"-*;J^^, ^, ^':., He properly cl«««W.cd. 
r OF DEATH in P «•" «^''"^»: ^Vf „ ^^^.^ instance. 



'^^ "'SSJ^r ii^^^^" Sa-^i^V^-i" .^"^ ...."«• 



fi i 






i 



WRITE PLA.NLV WITH UNFADING .NK-TH.S .S A PERMANENT RECORD 



Hoard f)! n» ;i!tn i >o- '^ — .« . i^^— t- 



REFER TO BACK OF CERTIFICATE TOR INSTRUCTIONS 



III!! 



I 



/)((/(' Filed , 



m^ii^^oA 



Registered Xo. 



••jtoe 






L 0U»8 LEVY, 

Deputy Health Officer p c C * n. 

DEPARTMENT OF PIBLIC BEALTIl-City and County of San Francisco 



t)i 



I 



■ !('«;< 



PLACE OF DEATH: — County of '^OJ<r\.K.Kj 



Certificate ot IDeatb 

, -a. S. StanDarD ) 



'No. 



-Dist.; bet. 



and 



) 






AW»v FROM USUAL RES 



I JNST 

FULL NAME i^O/^^^ 








mKX 



n.\rv: oi umrn 



"personal AND STATISTICAL PARTICULARS 

Ct)l,oR 




ACK 



,!4._ 



mVf'T.T:. MAKU1H1>. 



HIKTHPT.ArK 

I Stall- <•>■ Country) 




MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATIl ^^ 

K/y\JL '^ 






tonth) 



(Day) 



(Year) 



T ilFKU15V cWRTirvr-ntat I attenaecl cleccased front 

tltat T last saw h-.r— alive on ^^ 

a„a that death occurre.l. ot, the <late stated above, at 
- M., The CM'SIC OF Dl'.ATH was as follows: 

Ll-wc-^-^--^-"- 



\AM1-. 01 
lAllll.K 



niKTIllM.At^K 
Ol- lAlMl'.K 
(State or Coiuitry) 



MAIDI-N NAMK 
Ol- MOTHKK 



Ol- MOTHl'.R 
{State or I'ountry 



oCCUrATlON 



CONTRir.rTORV 



Months 



/)avs 



Hours 



nrRATION 



Years 



Mo fit lis 



Pays 



Hours 

Xl Fo 1 Qnx^4r<.A/vU. M.D. 

( SIGNED ) nK- '^^ =*^ ^ ^pjf jj r 



I()0 



-X 



N only for Hospitals, Institutions, Transients, 

Days 



"AHOVKSTA-n^>^K;.>NA.rAKT.CM.^ 



^KSAK1■ TKCK T« > niK 



(Infoiiuaiit 




orleren^isidents, Vnd persons dyinq away fro. home. 

How long at 
Former or pi^f c of Dcalli ? 

Usual Residence 

Wften was disease contracted, 

If not at plac e ot deatti ? urvinvM 

— ■ u.MoVM DMT. o! HnnAi. or KhM<>\AI 







\<J^- '^^ 




'LACK Ol- i>v n. i.T* -■■ 



190 



H 



\X\. VO^^^^^ ^ TT^ACTLY. PHYSICIANS •hould 



,. «.-Bver. 1^^^— ;:- :';:y::;l ^: -«: that U .«. He pnope 
«tate CAUSE Oh ^^^^ ^^^^ ^^^^,j ^^ ^ 



«on« clylnft away 



ii 



il 



«} 



I 



\m$i 






\r 



I 






WRITE PLAINLY WITH UNFADING INK 




/)(i/c Fi/nl, 



DEC 11 'J 04: 



THIS IS A PERMANENT RECORD 

REFER TO RACK OF CERTiriC^ rr FOR IN3TRUCTI0Na 

Z TT ^^497 



LOUIS LEVY. ^^ 

DEPARTNENT OF PUBLIclTLTB-city and County of San Francisco 



Gevtittcate ot ©eatb 

( Vi, S. StanDarD ) 
PLACE OF DEATH:-County of6^^ i-vc^— - C.ty ofCO^v 



-? 05;^ 



,No^t> ^'^Ic^vu^ lbM.WdJ. 



-niQfbet. - : "^"^ 



\][\rv,a VxL'>^>^c 



FULL NAME 



si:x 



;„SON.L AND STATISTICAL PARTICULARS 

^^ ! ^ 

^nl^ . \1 7.^1.0. . 



U^.k\tiL 



DATJ". <>l- I'lKlH 



ACK 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DHATH , ,^ , 




(Month) 



(Day) 



(Year) 



O V ) Vii' * 



M,nith'^ . 



i'S. 



siNC.I T?. MAKKn:i>. ^^ 

aVrit. in ^.H-iM ,U-UM.aUun) 




I Hi/kUHV CHKTlFNVThat lattenaeaacccasea fron, 

^^.'..a t^H. to Omr ^a 190^ 

t.atIlastsawh.^N alive on ■ ^>^-^ ^^ ^^ ^' 

^^ , ,„, that death occurrea. on the <late state.l above, at 
'" a M The CAISK OF DKATH was as follows: 



llIKTflPT.ACK Q 

tStatt or Country' -\ I 




.'>'%^ 



vV-» 



,.«*»....— —-"■•^-"'•'■' 



I-ATIIKR 




CX/YVO^^'V-— 



HlRTHri.ACK 
()!• I AlUKK 
(Stiitr or Ooniitrv' 



MAIDl-.N NAMH 

oi- mi)Thi:h 




DIRATION 5'^''^'-^ 
CONTKIIUTORV 



i\/0HtflS 



/)ays 



//ours 



Mouths 



Pavs 



I fours 
M.D. 



UK ruri.ACR / 

)|- MoTllHR , vj C\ ^ 

St:il<- or Country' M V J 

(Informant yTjruvv/ wv^ 

(A.Mrcss (O'X^ 



(SIGNED) yl*^^ fcx^.--^., . 

.,1erJ^'sid™i'," d persons d>in.| »wd, !..». h.™^ 



(\ w HoH lonq at 

D^^ H l\(!\vX<VH 3t pure of Death ? 

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



Former or , 
Usual Residence ^ 



1 



Days 







(A.Mrcss bXa ^^^-<^^^^ •-.; 



r\ "!a4 (A<l<lri-ss yj<^ * ' ^ ^^^^^.^l— — 

to'X^ N ruTAXyrv^^-^^^ ,,,^ 11 

. -^ ',y«uppned. AGB should ^^ «7*^:J,f .^8Vec•.-l Information" for pT- 

of information .hould ^e cnrefully « PP ^^ ^^^^^^,^ da.s.f.ed. 
E OF DEATH in pa." Jej-m., thp i„«tance. 



^- »— r;:t7cr«rSE of OEATHjin P-- —;;;;-.;„«.•/. In^tance. 
son. dylnft away from home «houia 



i 



I 



r ! 



: I 



IK 



itf 



\' 




w 



RITE PLAINLY WITH UNFADING INK 




.,,,1,1 of IIi.:tUh' !' N' 



!)((/(' FiJcff , 



^.v:-j?>.,„^v^,.om 



DtC IL'JOA 



— THIS IS A PERMANENT RECORD 

REFER TO p ..-..c.r.Tr FOR INSTRUCTIONS 

JlcoUslei'od J\o. 



L0UI8 LEVY, 

Deputy Health Officer, 



DEPARTNENT OF PIBLIC HEALTH-City and County of San Francisco 



'■^ 




,OUV 



Ccvtiticate of Bcatb 

( tl. S. StanC»ai:C> ) 

PLACE OF DEATH = -eo.«W^^^-%^^^^^^ : ^^ 

Dist.; bet 



. ■ St.; -UlSt*; Oet. „ .,,„r,FR •special information- "^ 



— ) 



FULL NAME 



I ^7^i^;:;n;^^^T.ST.CAL particular^ 





— 



sex 



DATi'. «>r I'.iK in 




.1 



iMuiith) 



ACK 



JVrt»; 



«;TV(*.T T. MAKKll-.n 



iStat«- or Cuuiiti V 



l.-ATllKR 



lUK'nirKACK 
Ol- J ArilKK 
(State or Country) 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII 



Month) 




(Pay> 



tYcar) 



— ; - \(p 



I9O 



io 



that T last saw h-- alive on 

,„a that death occurrea.nn the .lat. stated above, at ■ 

M The CAVSI-: OF DI'ATII was as follows: 

00 ;] 

.L^-.o^ * 




nr RAT ION >'^'<^''-^ 

CONTRIBUTORY 



jro;///is- /^ays 



Hours 



rO 



.v/ 



/ 



DURATION 



)V(/;'5 



Months 



Davs 



MAIDKN NAMK 
<)|- MOTHHK 



UlR rniM.ACl! 

Ol- MOTHER 
(Slatf or Country) 



OCCXTATION 



'~-^".!-true " 



flours 
.D. 



pio 

SPECIAL INFOBMATIO 

or Recent 




Resided ill S.n> r>,:">>.u-» 



)',-iri 



KlK TO TIIK 



Days 






^\(l<lrcss 






^^ '^■' '* -"^^'^- • ■ TT^TLY. PHYSICIANS .houW 



IM onlv for Hospitals, Institutions, Transients 

SeXts'^nOerVon'sTyinq away from home. 

How long at 
Former or pjar c of Deatli ? 

Usual Residence 

Wtien was disease contracted, 

If not at place of death ? — — 

"n.ACKOF lU-RIAUOK KKM-VAI, 



DATi;..'- lUKiAi. or KHMOVAI. 



8tl 

sons dylnA owoy 



^'. 



1 i 






i ■' 




ii) 





w 



»u.c= le A PERMANENT RECORD 1PB 
BlTF PLAINLY WITH UNFADING INK — THIS IS A PERMANE 
R,TE PLAINLY W .■.....-..T. POR .nstruct.on 



Hoard <.f n»:iltli i >"■ -^ ^... >-«- ^, 



p(ff(' Fih'd , 



mOlV'fOA 



Re i^i sieved J\'*o. 



8499 



L01H8 i-^V^^ -« 

Deputy Health Officer, 



DEPARTNENT OF PUBLOEALTH-City and County of San Francisco 



Ccvtificatc of Bcatb 



•XX. 5. StanDaro ) 



PLACE OF DEATH: — Cuui^ t y o f 




la^Vc.' 




,^^Cu Cily o f-V)WX^ 




>/cJl) VJ A.: 



1 



— St.; 



Dist.; bet* 



and 



.St»; DCU "oprCIAL INFORMATION' "^ 

:TS called rOR under j;^^;*i^o NUMBER. ) 

ITS NAME INSTEAD OF STREET ANU 



(^ ,F DEATH OCCURReO IN A HOSPITAL 

k Lu-V^U.^^' 



FULL NAME 




SKX 



"personal AND STATISTICAL PARTICULARS 




DATl", «»1 HIKIH 



l^tMntlO 



(Day) 



AC.K 






lUKTnri.MM-. 

lSt:it<- or CoJintty' 



VAMH <»l' 
FA'nil'.R 



lUKinrLAfK 

OI- J ATUKK 
(State or Country) 



MAIDKN NAMJ' 
(>»• MOTHKK 



lilKTTTPT.ACi; 
,)i; MoTllKR 
(State or CoiMitrvl 




— MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DlvV'l'lI 




k : 

(Dayl 



(Year) 



I Hi 



(Month) 

UUaiV CKRTIFV. Thariattemloa.leccased from 

— -: "- ■ ■■ 190 



19O 



to 



alive on 



that I last saw h 
,,, ,,,t acath occttrre.1, on the .lato statea above, at 
--- ^. ;^he CAUSH C)F DHATII was as folU.ws 

ilix,<rLuvcu. • • •■' 



190 



CONTRIIU'TORY 



...iMontlis 



Pays 



Hours 



nrRATlON 



Years 



Mouths P<ivs 






Hours 
M.D. 



IV-iM.f 



Mi>nfli< 



(I„foin>ant M ' V.CCV'U >^ 




_ ^,X^vt yi^ ''>° , ,„,, ,„ H.s|,IU K, lnstlt«ti.ns. Iransirnts, 

How lohq at 
Former or piare of Death? "^p 

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

TlACKOF mRIAl.«»K KHMOVAU 
fAd.lrt'SS 



UATKof lUKiAi. or KKMoVAI. 




• FVACTLY. PHYSICIANS iihould 
-^ . . K .e?uny «uppr.cd. AGE should »>« «^«**:J.,f .^Sped-l Information" for p.r- 

,tlon .hould be CHrefully «upp ^^ ^^^p^^y clB»8.«icd- The P- 



^ R_F.very-.temof •.n?ormaOon»no"."'-^^ that It may be proper 
^- "-rt/cA.S. OF DEATH .„ P «';,--•;,,„ ,„ .very instance. 



«on« dy'inft away 



from homo should 



|l 

I- 



\\ 



^. ' 



If 



'')• 



5 ' ' 



1 



III 





WRITE PLAINLY WITH UNFADING I 



/>^//r tiled , 



DEC iV.vrM 

LOUIS LEVY. 

Deputy Health Offioer( 



NK — THIS IS A PERMANENT REC6RD 

. »rp TO BACK OF CERTIFI CATE FOR .NSTRUCT.ON3 






POpuvy no«ii.n v^ii*v»^p*^ (• r^ F* * 

DEPARTItlENT OF PUBLIC tlEALTH-City and County of San Francisco 

Ccvtificatc of S>eatb 

( xa. S. Stan&atO ) 

r'^^ ^n ol /T^ c ui<- ' City of C)c^/>^ J X<XAvc^c.o 
PLACE OF DEATH:-County of OxXA^ J^^^^^^^" ' ^'^^ 



, y ,-, 10 Disfbet. '^.a(•>^A. and X'AA.CL ) 

(^ ,F DEATH OCCURRED IN A HOSPITAL u p. a (jX 



^ 



FULL NAME 



jxxjy^^ dJ rwc\HX/v\;.. 



7^^;;^^;:7rZ^;^^VrAT.STicAL particulars 



JJlA-YVCXA.^ 

i>\ ri: <>i lUKTii C\\ 

tM.iiith) 



eoi.oR 




MEDICAL CERTIFICATE OF DEATH 



I). 



\ « . »•: 



H% >>«»' ^ 



(Day) 



M,»i!ln 



v.l5,L 

(Year) 






Days 



m\< I T^ MAKUii'.n. 



murnri.A^'K 

(State: oi v'oiiiitiy' 



FATHl'.K 



lUKTlirLA* K 

Ol- 1 Aiin-.K 
(State or Country' 



maii)i:n NAMi: 

,,1. MdTHKK 



lURTHPtACR 
Ol MOTHKH 

(Stat<- or Covtntry) 






(Month) _ ^"**^' 

"l lli^^iMiV CKRTIFV, TlianTttcn.lo<iaecease<l from 

OUu. i .90'i to Waa .90 H 

,., nastlw h -'. alive on..- ^^^^-^a.- I9O ^ 

,„., utat acath occttrre.l, ott the .late state! a1>ove, at 
M. The CAISI' ()!• DI^-XTII was as follows: 





'vU 



iji 







DIR-XTION 
CONTKIHI": 






Hours 



nrRATlON 



i 



Years H ^V..//M.v 5.^ /?./».. ffonr, 

(SIGNED) VL^ ^^Xv ""-a!" 

-i^i^^^TT^^T^^^ii^^^N only for Hospitals, Ins.ilu.ions, frans.ents. 
or^efela^esidents, and persons dyinn nwny from home. 

.. Days 



.■,.„;.,;,., v.... /..■"■'■■'■ *'■' '" :- 



occrr.xTioN 

A 



(Infonnatit 






Former or 
Usual Residence 

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



Hov^ lonq it 
Place ol Death 





^x.^ ^ 190H 






Cr~>'^- 



!N. K." 



(xa.ln- ^^^<^ v^^^.ww.^^. ^^ , . TfVACTLY physicians .hould 

.;„VcU,sn OP D.ATH in P ---:;,„ ..„ ever, -.n.t.nce. 
Aon« clyinft away from nome 



>• •» 



»•• * •■ 



■^"X^v^.s^r-v- 




LOCALITY OF 



R EC R D S 




SAN FF^AMCISCO 



^^' ' ' ' ' I i"" n^i'nii^.Bj't-nij.i 



OUNTY 



^^^V^W^^N^^w^^^^^^J^^^^'V'*' 



S AN FRANCISCO 
CAtlFORNIA 



T I TLE 



OF 



RECORD 



ATH 



JX 








904 



M ICROFI LME D F R- H VOLUME 32 01 

THE GENEALOGICAL SOCIETY 
OF SALT LAKE CITY UTAH 
C A L I FORM I A ^ 

DATE^APRIL 1 1975 

PH OTOGR AP HER : MAX JOHNSON 
CAMERA MNO 268 3B RED 12 

' . * . ' ■■.■'■■• 

^r ■. -.f ,.,'•■ " , ■ ' . ■ ' '' *' "■'"'■■■■~'"^^'-"*'*-"'^*'-~ * ■ T^ 

• '^; ' ''. ' / ' . ' ', ' *'■.'*■■ ' ' 1"/ - ^ ^1 

> - ■;. '.. - -.^ - - • - - . ■■ ■ ^ -'. - ' - ■ . ■ . " ^ . 



3500 



5* 




ROLL