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

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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H,,;,r.l .,f H.alth-l- No i^ i^'g^^n&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffr Filrfl, 



1 



190 "i 



dL(M^.A^ dUtA^vi Deputy Health Officer 



Registei*ed J\^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( la. S. StanDarD ) 
PLACE OF DEATH: — County of Oo-vu J /ucv>vc^A/^City 



^No. 



"lis \\J<A)e^ 
( 



St.; 



1 



of 3 






^ 



Dist«;bct.O/VXVYL^H.AAyv\j and 

F DEATH OCCURS AWAV FROM USUAL R E S i D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATIO 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 






FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

I COl.oR 



DATl", <»!• HI k Til 



L 




\ 



C 



'iji 



r%A 



i 




"O^KAj. 



^ MEDICAL CERTIFICATE OF DEATH 
DATK Ol' I)I-;aTU 

(Month) 




(Day) 



(Year) 



Month) 



A OR 



%h 



) I'it I 



(Day) 



Mnufhs 



(Year) 



Da 1 



SINCI.K. MARKIKI). 
\VII)<»\VKI» OK ni\'nR( Kr) 
iWiitcin sorial lU-siv^iation) 



lUKTHPI.ACK 
(State or Country) 






I in-RIvRV CivRTIFV, That I attendcMl deceased from 

I9O to IQO 

that I last saw h -r—— aHve on 190 ' 

atid that death occurred, on the date stated above, at ... • .f t ...'. 



M. The CAl'SK OI* DICATII was as follows 



NAM!-: Of- 



U) Jlti^) ^\o^i 






niRTHIM.Ac'K 
Ol' I-ATHKK 
(State or C<»untry) 



MAIDHN NAMK 
«)l" MOTMKK 



UIRTniM.AOH 
n|- MoTlIKR 

(State or Country) 



OCCl'l'ATION 



m 




UXv^'\Jl 



..3v^,yJL:x:va. i-<%X)*rA'fr'AAnvllcC4^\4 



!*.\A 



Di; RAT ION Years 

CONTRIIU'TORY 



Mouths 



Days 



Hour, 



1)1' RAT ION Years 



Mouths 



(SIGNED ). .J... yi.UJ- JjlXoLmJU . WUTV 



k\^>JL3.t. i()o't (Aihlress) 



LfrV(rv\Ji\>^ V 



Days Hours 

\JiA. M.D. 

<i.*^ 




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



0-A^A^AJl>vv7^VL 



Kfsidrd ill Sdii /'i ini< i.''i-ii ^ \J)'ii!is ^ yfi'iiUi- /hn> 



THK AllOVH STATl'.I) I'KRSONAl, I'ARTICr r,ARS ARI-; TRIK TO TH1«: 
IJKST Ol-' MY KNOWI.ICDC.K AND lUUJlvK 

(Informant M )V\^ Lv . M fo &-VW\XA/ 

f ^.i.iress (fe (RaX . ...all Mlvci^vAowA, 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



ri.ACK OF niRIAI, OR RKMOVAI, 



DATJ^of IVKiAr. or RliMOVAU 
I I90H 



(Ad.lress iHl^ ^[^^1^^.,^.^^.. .^ 



IN. B. F.very Item o? Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may be properly classWied. The "Special Information" for per- 
sons dyin^ away from home should be ftiven in every instance. 



rMLT RFCORD 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



HoMnl of IUmUIi" f- N'o i^ "^^.^5?^' "^"^I* ^<^ 



Date Filed,. 




290H 



Registered J\^o, 



4£ 

\ 



A^e-cvu) XtLoM.! Peputy Health Officer 

DEPARTMENT OF PURIC HEALTH=City and County of San Francisco 

Cevttftcate of H)eatb 

( XX. S, StanDarD ) 
PLACE OF DEATH: — County of Ocv^v ^cwt.cv^^;u)Citv of C3/a/>v 



'CVTv A^CVvuCv^'Cr^City of ^ 'CX/>v X<V/yv<.v/Q^c^ 



(No. 



I 3 I "iiryAX^.' St.; 3. Dist.;bct* LXcLo and UJ^UU 

/ ir DCAT^ OCCURS AWAY FROM USUAL R E S I DE NC E G I VE FACTS CALLED FOR U N D E iT "SPECIAL INFORMATION" '\ 
V IF DE»TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD oij STREET AND NUMBER. / 




L^ > 



FULL NAME 



(^ 




i\^rv:YVC3uA 



\jAjL: 



SKX 



JPERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



DATK OF lURTH 






(Montlil 



13 
IDny) 



/.l5.^ 

(Vear) 



AOK 



lie 



J V'<7 ) 



Months 



\x 



Days 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 

30 

(Day) 
I HI<:RI':BY C1<:RTIFV. That I attt?i7k.l deceased from 
30 190 S to IvuyvjL 3.0 igo't 




Month) 



(Year) 




I90H 



SINC.I.K. MARKIi;!). 
WIDOWKI) OR niVoKtKD 
(Write in social <h-><iv:natioi)) 



^ 



\| f VcLVvvJL<L' 

THK .^^»(^'E>STATl-:i) I'F'iSONAl. I'ARTIiT I.ARS ARK TRIF TO TUF 



inKTMPl.AOH 
(Statf or Coiiiitt v) 



NAMF OF 
FATHKR 



HIRTHrUArK 
Ol- I ATMKR 
(State or Country) 



MAIDHN XAMK 
Ol- MOTFIKR 



thatyi last saw h xa-v\ alive on >VWN«t. 3.0 

and that death occurred, on the date stated above, at I 6^^jO 
^' M. The CAl'SH OF DHATIT -vas as follows: 

'V. ilb.^^-Va^frVA^I.VtX.CLJL 



DURATION 



) ears 



Months 



Days Hours 




CONTRIIUTTORY Uk^^.^r^v^^ d^.^JL,^^ 

DURATION Years 



^-.i 



T»TRTJIPr,ACK 
OJ- MOTHKR 
(State or Country) 



(Signed) 



uwuu-t» Isb 



Mouths Days Hours 



,Mv-t\^ 3CiQo'^ (A<ldress) 



""'^:t r-^- 



D^^9'ft'-J'^^Of"^A"''ION »"'5' »or Hospitals, Instilutlons, Transicnls, 
or Rfcfnt Residents, and persons dying away froni home. 



Former or 
Usual Residence 

When i»as disease contracted. 
If not at place of death? 



How long at 
Place of Death ? 



Days 



\ 



fArldrc.s.s 



Si 



\^tr>vt^ otj 



IM.ACE OF m-RIAI, OR RKMOVAI. DATK of IUkiai. or RKMOVXI 
INDKRTAKHR Vf\ ^^ 



(Add 



less 



^ 1 C^V.\^t«Ai 



"' ^'~Ttlx^CXV^to^ZrXT7'^^^^^ 1" '""''"J'*' f"''^""^- ^^^ •^""'** »»*» «*«*-• EXACTLY. PHYSICIANS should 
!!^1% • . c T" '" **!"'" **^'''"*' '**"' '* »"«> »''^ properly clarified. The "Special information" for o.r- 

8on, dyinft away from home should be ftiven in every Instance. maiion for per- 






.MAi^E-M-r RECORD 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Hoard of Health- I-" No. I's ■^^^Sft^ IJ&I' Co 



Date Filed,. 



^/LA^Lu 



190^ 



Be^istered JVo. 



XArvuui \jL^^.. Deputy Health Officer 



Vi 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( in. S. Stan^ar^ ) 



PLACE OF DEATH: — County of O O^^rv JK^^cv^^^cv^icCity of O-ouvu Ja <xwcva'^-0 



1^ 



^No. 



Id 1 5 ih o.^ 



SU I Dist.; bct.XiUXAJ^L-vx.ccri3^fcfv and 



(IF DEATH OCdURS AWAY TROM USUAL R E S I DC NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH <^CCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 




a^ 



FULL NAME 



J..x:V\JlL.^:^.^^. Lu. 



^A^X^.O. 



PERSONAL AND STATISTICAL PARTICULARS 



DATK OF HIRTH Q^ 



COI,OR 



kildc 



ij. 



(Month) 



n r.'^A.^. 

<Day) (Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKA'l 




'\JU 

(Month) 



AC K 



.-I JV'(j>,'. 



MnulfiS 



13 



Da \. 



SINC.I.K. MARKIKI). 
WIDOWF:!) or DIVOKl'Kn 

(Write in social (Ifsi^'iiiitioii) 



niRTHPKACE 
(State or Cotuitry) 



VAMK Ol" 
FATIIICR 



BIRTH PI,ACK 
OF FATHER 
(Statf or Country) 






3.0... 

(Day) 



(Year) 
I JIHRHBV C1-:RTIFV, That I attended deccaj^dTrom 

W^WO l.a .. 190 S to ..Nk.A^^^JL'. 2>.0 iQO H 

( (\// 

that 1 last saw h XV alive on >Cc^^^^X .A D. igp ^ 

and that death occurred, on the date stated above, at <^-V~Jtv\t' 
1 O^Im.^ The CAUSH OV DIvATH was as follows: 

.3^-^^LWXX/...y^r>::uL4.A^^.^'V4r>^^^^ 

^^xa, LLcaaIx <w^Aa^i.va^^ l-'v-(ryvu 

•<^CL<Uv>-va ;4X\/c^<iv>^'\»^\.\,\X?' 

DURATION -^ Years - Months i^ Days- Hours 



^ 





MAIDFtN NAME 
OF MOTHER 






KIRTHPI.ACE 
OF MOTHER 
(State or Country) 



.^Aa. VJ (XV0L'\>VA^^rU0 



CONTRIRUTOR\^ 

s) A.^L/y^J^.^-vC^ .C^x^tMrvv 

DURATION - Years. .'^..Mouths \t Days 

( SIGNED ) Lo^>^J!^«xi J O-'ui 



Hours 






OCCUPATION 

Rfyiiint in Sun I'nuirisro ^ )'/(/;> ^ Mnvih^ \ 1^ /),7i» 



THE ABOVE STATED PERSONAL I'ARTUr I, X RS AR F: TRFl' To THF 
IHCST ()F- MY KN^nVI.F;i)(.E AND IU:I.I):f 



O^^X^V M.D. 

VvL^ 1 iQo'^ (Address) 5^0^ ^lurvvtoX^ l.l\^. 

itals, Institutions.'^rj 



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



Former or 
Usual Residence 

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



ffow long at 
Place of Death ? 



insients. 



Days 



(Informant 






(A<Mrcss 






2 



''^'^SiJ^n^^'*."^ '*^"^^' "•* "»'^">^-^'' I I>ATE<.f MiK.Ai- or REMOVAL 




(Address 



LoAXcvr V 

a^ 1' a.. 




.O^v^^...ll.:^A 



"■ ^'~llllV^^^^^toX^X^^^ \' '"""'"J"' r"'"'"'^- ^""^ '^""'^ ''^ "*"**^ BXACTLY. PHYSICIANS .houlcl 

state CAUSE OF DEATH in plain term., that It may be properly classified. Tl»e "Special Information" for osr- 
sonsdyinft away from home should be ilven In every instance. ■niormation Tor per- 



MT AECORD 



'St lil 



? 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoanl of Hc.lth 1 No. i«i i»^^^H&r Co RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date Filed, 



I 



.^O-Aaa^ 



190^ Registered JV^o. . 

Deputy Health OffS^'^r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( "CI. S. StanOarD ) 



PLACE OF DEATH: — County of 

..c-K,/D.y'^^r^j^iM'u^\J\) \uxlj 




tXW\^; City of 





■^'VVAA: 



' LoX' 



Dist«; bet. and 



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



) 



FULL NAME 




X^: 




■^ULaa 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

) COI.OR N 



QU^L 



<\)A\a1j^. 



DATE OF JURTH 



(Month) 



3 

(Day) 



rlX'h. 

(Year) 



AGK 



1\ 



) V(i I . 



X M, 



>H//>S 



0.5 



Da rs 



SIxr.I.K, MARKIKD. 
WIDOWKD OR DIVORCKD 
(Write in scx'ial (ksijjiiation) 



HIRTHPl.ACK 

(State or Coinitry) 



NAMH <>J' 
FATHKR 



lURTHPKACK 
0|- 1 ATUKR 
(Stalf or Country) 



MAIDKN NAME 
OK MOTHER 



lURTIIPI.ACE 
Ol" MOTHER 
(State or Country) 



OCCUPATION 



%\4 



r 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




(Day) 



(Year) 



I HHRHBY CHRTIFY, That I attended deceased from 

190 to 190 

that T last saw h alive on 190 

and that death occurred, on the date stated above, at 
M., The CAVSH Op; DIvATlI was as follows: 

.V:^vx. 




■ rsi. The CAlSfv OF. DIvATlI was as f 



DLRATION I'ears Months Days 

CONTRIBUTORY 



Hours 



DURATION JLear. 

( Signed )..UL).. J 

1 190 H (Address). 



Afonths 




Davs Hours 



\'^Xa^..!L.V-\ 




SPECNKL lNFOR^ATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from Ijome. 



Former or 
Usual Residence 



UUJL MJ\<X<U\<V Plare'roeltli ? X\ Days 



Rrsidrd in Sun ritiiiiisro "^ )>(.';< ^ Mnnllf — l)r.\> 



THE AnoVE STATIU) PHRSONAl. PARTICC l.ARS ARE TREE TO THE 

iJF:sr OF iMY kno\vm;dc,e and HEI.IEF 



(Informant 



( \<l(lress 






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



PI,ACE OF BIRIAI. OR REM<»VAr. I DATE of Hiki^l or RFMoV\I 



o 



I) 
indertakf:r 



1904 



(Address 




OL^Vvu 






lm: 



IN. B. 



-Rvery Item of Information should he cnrefully Rupplied. AGK should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
sons dyinft away from home should be ftiven in 9\9ry instance. 



MT RECORD 



M 



i« 



r 



• 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hoard of Health— F No. i^ "C^^^^Jll&P Co 




lOO"^ 



Registered J^o. 



Date Filed, H4.\JLu, 1 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



5 



Deputy Hepfth Officer 



Cevtiftcate of H)catb 

( Ta. S. StanDarD ) 

J? on J? 



(^ 



^o. 



PLACE OF DEATH: — County of C) o^o^ ClAXV-y%/Cv<i,cCity ofC'C^^-rsj J .V<X^w<:.vq.cl^ 

St; ....*^ Dist.; !»*• ^.OJsJl ^m..djL. and 

FACTS CALLED FOR UNDER "SPECIAL INrORMATION" "N 
E ITS NAME INSTEAD OF STREET AND NUMBER. / 

;LL.^....^I^^.^-ct>rw. .. J 



it V^i^L % 

/ / IF DEATH OCCURS AWAY ^ROM USUAL R E S I D E N C E G I VE FACTS 
y V IF' DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



J&-^. 




FULL NAME 




OJ^J 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



(TluL 



COI.OR 



\X}MjXx 



MEDICAL CERTIFICATE OF DEATH 



DATK OF IJIRTH 



ACIR 



I Month) 



(Day) 



(Vear) 



1 b )ra,s 



Months 



*~^ Days 



SIN<;i.K. MARKIHI). 
WinoWKI) OR DIVOKIKD 
iWritfiu siK'ial <U sij^nation) 



HIRTHPI.ACK 

(State f>r Comitrv^ 



NAMF OF 
FATHKR 



HIRTHPI.ACK 
OF FATHKR 

(State or Country) 



MAIDKN NAMK 
OF MOTHKR 



lUKTIIPI.ACK 
OI< MOTMKR 
(State or Country) 



OCCUPATION 

Rfsidfd in Siiti Fi mil iu-ii 



LUX<J^^ 









I. 



(Year) 




DATE OF DKATH 

onth)(j (Day) 

I HKRliHV CivRTlFV, That I attended deceased from 

>^^ XC> 190S to %ul^..\ 190H 

that I last saw h-A^^wc alive on H^\.^V>xX ^..0. iqq '| 

and that death occurred, on the date stated above, at 0\ 

CL M. The CAISH OF Dl-iATII was as follows: 

OU CW 

. . .U.^\r.tfriJwl/.aU c . . . .L\ JLoA^ax.^^ ' 
DURATION 5" )' * 



.V-i5. 



ears 



Months "Days ^ I /ours 



CONTRIIU'TORY 



DURATION Years Mouths Days Hours 

(SIGNED) ^ L). ot\rtyJUrt^ M.D. 

d>WAjttxNj at 



SPECIAL INFORI 



(Address) 5 3> "i 



'MAT! ON only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



I Mnnlh^ 



Ihi^ 



TMI*. AHOVH ST\TF.I) I'KKSONAI. PAK TUM I.ARS A R 1% TRFK TO TIIF 
HKST Ol- MY KNo\M.i;nc,K AM) IIHIJHF 



( ^'!(lrcss 



U AXcVt^jL (AjO-^^V- 



N UUaT M^^-Vtx UU^ Place of Death? \J Days 



former or 
Usual Residence 

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



VbtOV 






PLACK OF KIRIAL OR RKMoVAI, I DATK of IUkiai. or RKMOVAI. 



UNDKRTAKKR 

(Address 




N. B.- 



-Fvepy Item o? informntion should be CBPe?ully 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 p«p. 
sons dying away from home should be given in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Boanl of Health- K No. 15 ■^^liag^B&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i 



II :?! 



Date Filed, 




lOO'i 



Registered J^o. 



6 



cL/0"-\AA^ 




P^PM^y Health Officer 



Mi 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of H)eatb 

( "Cl. S. StanDarO ) 



(No. 



PLACE OF DEATH: — County ofOcVru vJ.^^o.^yv^cA^c^ City of 0<:vwj vJ A,a^^x^^.^^c^o 

15 ^M dlOMAKXhJj St.; Dist; bet* i^^a^JlA>. .rL a«d SI I A^T St. ) 

(IF DEATH OCCURS *WAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPKtIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRCET AND NUMBER. / 



FULL NAME 



tou' 



^.A^^X .y../V.CM 



PERSONAL AND STATISTICAL PARTICULARS 



SKX Q^ 
DATK OF UIRTH 



TVUxJ(jL> 



coi.o 



\XjJrvdju 



AOK 



0)\cw 

(MontH) 



(Day) 



(Year) 



)'i'at . 



MoHtfis 



Davs 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKAT 




1 



(Day) 



(Year) 



SINC.I.H, MARKIKD. 
WIDOWKI) OR niVORCFin 
(Wrilfin sfxial tk-si^nation) 



MIRTH PL AC K 
(Statf or Country) 



d^C^n^j^AJ^ 



NAMK OI" 
FATHHR 



hirtmpkacf: 

'>I' I'ATHKR 
(State or Country) 



MAIDKN VAMr, 

01 • motiif:r 



lUK'ririM.ACK 

OF Mrj'rHKR 
(State or Country) 



OCCUPATION 

Rfsiiird in Stnt Fi iitu isrit 



at J * (^ ^ 



I HEREBY CERTIFY, That I attended deceased from 

f^^yyjh VS. 190 "H to X^KhA^ 1 igoH 

tha^ I last saw h XK,' alive on yVvLw \ k^ ^ 

and that death occurred, on the <late stated above, at U 

CI" M. The CAUSE OF DEATH was as follows: 



^SrV.."v-y.>.. 






oxau 



Dl'RATIOX -Years ^ Months \XDays '^ Hon 
CONTRIIU'TORY . ..UAJL>Tv.aX:C.v^Jl....fi 

n.. A-VV^r>vOvoi 



A.\kA 



^■^oo^ 




U-t^A> 



) ra I A 






Davs 



/fours 



DURATION ^Ycars ^Months 

( SIGNED ) 'a1.-<-0 %^. ...|^^ M.D. 

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



thf: abovf: statfd pkksonai, pak iutlars arf; trif to tiif 
iih;st OF MY kno\vm;dc.k AM) in;Mi<;F 



(Informant 



(A (Mr CSS 






Former or - ^ , « 

Usual Residence 35 vVcv^^ 

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



(Is * "^4- ^^^ 'o"? «* I / 
VVCV^^ O A; Place of Death? lb. 



? 



Diys 



Pr,ACK OF JU'RIAU OR RHMOVAI, | DATl-! 



y RIAL Of rf:movai, 

I 190V 



UNDlikTAKFIR 

(AcMrt'ss 



B 5 1 00aAJuu...,c>% St 



^' "*~r.«V*^clT«FUp*nTriM" ■*'7'.** ^" ^"'•«*""y HuPPHed. AGE •hould be stated EXACTLY. PHYSICIANS ..hould 
Btate CAUSE OF DEATH m plain term., that It may be properly classified. The •'Special Information" for p«r- 
«on« dyinft away from home nhould be itiven In every instance. 



«.«a^riav RECORD 

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



noanl of Htalth- I- No. ^^ t'^^^^ahSiV Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafe Filed, ^ajJLu \ 1^0^ Registered JSTo. 

l^trVLA^ Ijl^^ Officer 

DEPARTMENT OF PUBLK HEALTH=City and County of San Francisco 



r^ 



PLACE OF DEATH : — County 



Certificate of 2)eatb 

( xa. S. Stan&arD ) 
of Q) Olaxj vJX<x^.v.c\A<;.{City of O 



«? 



(CV^y-Nj J ^ O-'^x^iVvA. 



(No. 



351 , 3.0...il 



A* St: ID Dist 



>ist:bct. LILmw\C^" 



''VM^i^./C^vrv and 



C) CL/^luORx-l ^ 



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



b- 



FULL NAME 




«, 




.^CVA.' 



.AjUL'^ 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



J-tWvOAJL 



COI.OR 



\X)kdx 



DATK OF IlIKTH 



(9*fc 



I Month) 



(Day) 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DF:ATH 




1 

(Day) 



(Year) 



ac;r 



as 



)■/•<;; . 



I 



Motifhs 



Pa 1 . 



SIN(;i,F.. MARKIKD. 

wino\vF:i) OR nivoRTF:!) 

(W'litrin social (Usij/^natioii) 



HIKTHIM.AOK 
(Statf or Cotuitrx') 



n'amf: of 

FATMKK 






I IIIvRHBY CKRTir'Y, That I aJtendcMl deceased from 



" ■" .>kvlL i 



190 S 

and that death occurred, on the date stated above, at T:.... 



[90 \ to 
that T last saw hJ^A.* alive on 



^Sl. The CAl'Slv OF J)1<:ATII was as follows 



'VO 



niRTMFM.ACE 
Ol- FATHKR 
(Stale or Country) 



MXIDKN NAMK 
Ol' MOTHKR 



HTRTIIPLArF. 
OF MoTnF:k 
(Slate or Country) 



-J '"rvCTYWOL^ J CrtjtM. 

7 



Vears Mont /is Vc> Days Hours 
:ONTRIBUT()RV .^■...<^^\<^-)^'^^ 



DURATION 
C 



OCCrPATlON 

Pru'.fnf in S,in It ,ni, /•■m %}\ )'riiif (i Afniif/is 3 



DURATION Vtars Mouths 

(Signed) vj-.A?, 'J 



cxk'^ 



Pavs 



/fonts 



SP 



'^\M^\ Too*^ (Ad<lress) 



'OA^Tvw-rw' M.D. 



PECrAL Information only for Hospitals, Inslilutlons, TransicDts, 
or Recent Residents, and persons dying away from home. 



t 



/).M. 



Tin-: \m)VK st\T)"i» i'krsonai, PARTrcri.ARs arf; trif to tuf 
in;sT oi- ,Mv knowi.i'.dcf: and hhukf 



(Infotinant 



(Address .. 



35 T* 3»ot!v ^t 



Former or 
Usual Residence 

Wfien was disease contraited. 
If not at place of death? 



How long at 
Place of Death ? 



Days 



''''^^''/5>iT "'a'^^-^^'I'** RKMOVAI. I DATl;^of HrK.Ai. or RKMoVAI, 

^ I90H 



A\ »' K'-^l'^K KKMOVAI. I DATKof »i kia 



indf:rtakkr IVW-^vJCcx^ ^-^-^vu^.^i^^jtcvKJ^A^ 

*£ b b \)^^ 



(Address 



IN. B.- 



-Kvery item o? information ahould be carefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that It may be properly classified. The '•Special Information" for pep- 
sons dyinft away from home should be ftlven in every instance. 



AUCORD^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board of Health— K Xo. 15 "^^^^^ H&I* Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



<::':; '; » ■; 



i! 



Iff 



Date Filed, ^<uXcl 1 

J( d L 



190^ Registered JSTo. 

Deputy Health Oflflcer 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 

( xa. S. StanOarD ) 



(^ 



PLACE OF DEATH: — County of C)<v>^j J/vo^-^xc,v^xl<* City of ^^Cn^ J/v(X>v^\^^d 



(No. 



ai 



vJjA^^Lcc^o^-^r^' St.; .^ Dist.; bet. UJ (xLXjlSj. 



and 



% 



(\r 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. / 



r4:\/VWCV,c1W. ) 



FULL NAME 




,CL\x^^."»'xn/;'Lr\A^. 



t. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^JL 



COI,OR 



DATK OF lURTH 



? 



] ] 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATJ 



^■.\j:^-\JU 

(Month) 



(Day) 



(Year) 



I Mouth) 



(Day) 



(Year) 



AOR 



cuu-tnvX' 



It. 



) I'd I > 



Months 



Dii 1 .s 



.tl !«' 



SINC. I,K. MARKIKD. 
WIDOWKD OR DIVORlKO 
(Write ill social desi^ualion) 



niRTFfPI,ACK 

(State or Coiintrj') 



NAMF, <)!•■ 
FATIIKR 



BIRTHPLACE 
OF lATHKR 
(State «)r Country) 



AX 



<x>L.S^A^^wa,Lcn:y 



MAIDEN NAME 
OI- MOTHER 






T 



I HRRRBY CKRTIFY, That I attendetl deceased from 

-^ to 



190 ■ to .rTrrrrTTrTT^Trr:::::::::^:...... igo 

that I last saw h -^ alive on '■ 190 



and that death occurred, on the date stated above, at 
■^ M. The CALSI*: Olf .DHATII was #is follows 




. \Jfv 



V.^JrwAAA^ 



rVQv^t. 



SJnrs,^'^, 



\^^-<k.A^\ 



DURATION Years 
CONTRIHl'TORY 



41 



wJi,*\4 



3 /on //is 



Days 



Hours 



^t^CJ-Vy.n V' 



niRTH PLACE 
OF MOTHER 
(State or Country) 



OCCUPATION 



o'^^UlIxx^^.A^ 






DURATION years Months Days Hours 

iH<A,^nvt>v J ..y;...lD...ljLLx.>^A. M.D. 



(Signed) 



iqo 



(Address) 



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



.lA';////« 



/)./). 



Tin-: ABOVE STATF.I) PKRSONAI. PARTlCn.ARS ARE TRIE TO THF* 
BEST OF MY KNOWI.EIX'.f: AND BELIEF 



(Informant 




^ Address 




Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



J'Ji^\CE OF BURIAL OR REMOVAL I DATE of Bt rial ux REMOVAL 



UNDERTAKER 



^^ CvtaLvA^k;. 



(Add less 



.i.^..l)<X>v Q\^^..ill 



^JstL.. 






N. B. Every Item of Informntlon should be cnrefully nupplled. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for par- 
sons dyinft away from home should be ftiven in %\^ry instance. 



aJS-Ml 



['fTy^Vl- 



In 



It 



^i'. 



It 



■ ( 

! 






I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H...nl of Health K NO .s -^Sg^»&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date Filed, 



iLj^ 4 igO'i Registered JSTo, 9 

Ltrwu) Ixoh.^ Deputy hfeafth omccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( la. S. StanOate ) 



-P 



<^ 



(No. 



PLACE OF DEATH: — County of C) .O^w ^ Ko^/w^iiKi/t^CHy of O xXav A..O-^w-t:,v«,/C^ 

St.; 15 Dist.; bet. C) ii^vvvvq, U 



f ir DEATH OdluBS AWAY rPOM USUAL RESIDENCE give facts called FO^ under Q'SPECIAL INFORjaATION" A 
^ IF DEATH^CCURRED in a hospital oh institution give its name instead of y^TREET AND NUMBER. / 



.^i 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



""" *? 



JtT>^ 



oJsJj 



COI,OR 



UJ.rujtx- 



DATK OF HIRTII r|\ Q 



/..lli. 



(Month) 



AC.K 



3.x. 



) V'(/ t s 



(Day) 



Minilhs 



(Year) 



X's 



Da )v 



SINT.l.K. MARRTKD. 
WIPOWKI) OR niVORCKO 

(Write in sot-ial (l<-si).'Jiati<)ii) 



niRTHPI.AOK 

(State or Country) 



XAMK OF 
FATHKR 




HIRTMTM.AOK 
Ol- lATHKR 
(State or Country) 



MAIDFtN NAMK 
OF .\tOTFIF;R 






L^(nA.v^t( 



MEDICAL CERTIFICATE OF DEATH 




..3j.O... 

(Day) 



(Year) 




I IIRRRBY CKRTIFY, That I attended deceased from 

. i.^rfcigo H to .|lwA/rsJL. 'hOi T90H 

that I last saw hXH; alive on VV^VAxX/ 14 190 "^ 

and that death occurred, on the date stated above, at r? . A 
M ^I. The CATSlv OF 1)I<:ATII was as follows: 



<\^ 



Days " Hours 



DIRATION I Years '^Months * . _ 
CONTRIHUTORY W-^.d.<^VNA.1>j rip .. A^c^^ 



^'^Kaj6u:i^ MuuxXrvv 
. . _ C>AxX/Ol^-vcL 

OCCUPATION %^^,^^,^^^^ 

h'rsi<if<f in San f'iniuisti> ■J«i)'i(iis v Mmitlis JLo /^"ia 



KIR TIIPT.ACK 
OF MOTHHR 
(State or Country) 



Tin; AHOVK STATKI) PKRSOXAI. P ARTUT I.ARS ARK TRIF: TO TUF: 

iJF;sr OF' MY kno\vm:i)ok and nFi.iivi' 



(Inf<)rniant 



f \(U1ress 



4 as XuM ^t 



N. B.- 






DURATION •- Years '^ Mouths "^Days ^ Hours 

(SIGNED) Lii JvJC! 




M.D. 




\ IQO^ (.Address) 



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



Former or 
Isual Residence 



How long at 
Place of Deatli ? 



Days 



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



PI,.\CH OF HIRIAI. OR RF:\H)VAI, 




INDHRTAKKR 






DATICof IMkiai, or RF:M0VAL 




u a.. 



190H 



< ^^ (X^\\Kjy\X>\j n^\/fe-^ 

(Address I X D *^....yOXLAJL>UrVV.3..t» 



-Every item of information should be carefully Huppliecl. AGE Rhould be Htateti EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information** for per- 
sons dyinft away from home should be ftiven in every instance. 



fw 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HoMKl of Ilcalth-FN'o. \y t'^^^rit^. Mk.]' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.f '» 



i 



^ 



Jh,fr File,!, W^ ^ ^^^"^ Registered Ko. 

XiiwvLj Deputy Health Officer 



t 



>Oa.aa.a 



DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco 



Certificate of H)eatb 

( ia. S. StanOarD ) 
: — County of C) 



PLACE OF DEATH: — County of O^v^v J a,^^^v<:^^c o City of O 






(No. HH C)J[vcrtiA.^Ll St.; ^^ Dist.;bet. 1 5 Ov and lb 

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



t^ 'qJ^ ) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



CP 



0-C^vvv/OuLiL 



COI.OR 



U)Jvct 



DA'I'H Ol" HIKTU 




AC.K 



<M<inth) 



} ca > s 



\ 



(Day) 



Mouths 



(Year) 



Dii \s 



SINr.I.K. MARKIKD. 



\vii>(>\vi':i) OR DiVoRrKn Q a 

(Writr in social (It-situation) "A II 

crrvr 



HIR rUPI.ACK 

(Statf or Conntry> 



NAMK OF 
KATHKR 



(lb crrvrLo^Lvc' jI) . J 



BIRTUPT^ACK 
OF I ATHKR 
(State or Country) 



^C^'^ 



MAIOKN XAMF 
OF MOTHHR 



niRTHPLACR 
OF MOTHKR 
(State or Country) 






OCCUPATION ^j;,^.^^i 

A'fsi(fr(f in Siiu I'l iiin isrn 7^ )'iois 



M.oith-^ 



Da \s 



THK AROVE STATKI) PKR^ONAI. PARTICn.ARS ARK TRUE TO THR 
BKST Ol- MY KNOWUKIX.K AM) HKIJICF 



(In forma 






(Address 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DEATH 




(Month) 



.3>.0... 

(Day) 



(Year) 



I HEREBY CERTIFY, That I attentkMl deceased from 

Vv'^Jl ^3 190 H to ^^^>>JL X.1 190 S 

tliat I last saw h iLhj alive on ^^-^^^vftr %'^ 190 H 

and that death occurred, on the date stated above, at ^ 
^ M. The CAUSE OF DICATII was as follows: 

J A^JU^-^-.CA^LQr^^ .. \I ^Vi'>^.^^^./ryCtva 



DURATION 



Years Months d\\ Days Hours 




DURATION Years Months Days Hours 

( SIGNED ) %Xi. ^..-^A.^^ M.D. 

'iDiooM CAdilressV IbO N IVtTKv^y^vVv SA^.^L, 





> FECIAL INFORMATION only for Hospitdls, 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? 



PI.ACE OF niRIAI, OR RKMOVAI. | DATE of ntRiAi, or REMOVAL 

g I90S 




UNDERTAKER 

(Address 



%1 ^ 




1 1 'hi. (Vyvv^.4,v^> ^ t 



N. B. Every Item of information should be carefully nupplied. AGB Rhould be stated EXACTLY. PHYSICIANS should 

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



ACCOBS. 



.1 







il' I 



.^r^ 



»« 

i: 



k^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



BoMHl of H«i.lth-I' No. 1^ -i^^^mSiV Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dafe FiJed, 






I 190^ Registered J^o, 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( TO. S. StaneatO ) 



J? ?!> 



PLACE OF DEATH: — County of O-Cu^v' J A^txwCA^ccCity of Oo^^>(\j J Ao, wCa^co 



fNo. 



^H 



tl 



\Ji^>XJCVM 



St; I C) Dist; bet. 3 OJUb and 



AJk. 



ifJu^.^'TNxJv^tXAJj 



/ IF DtATH OCCUHS AVyVTv FROM USUAL RESIDENCE GIVE r*CTS CALLED rOR UNDER "SPECIAL INFORMATION" N 
V. IF DEATH OCCURRtlD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





^^Jxjyy^XX/y^j'yy^. . 



SK.x 



PERSONAL AND STATISTICAL PARTICULARS 

COI^OR, 



JJUy^xoJjL 



■U)Jv.u. 



n.\TI-: ol- ItlKTM 



(Month) 



(Day) 



rial. 

(Year) 



A<-.K 



I \ )Vins 



Monllis 



Da vs 



SINT.T.R. MARKlKn. 
WIDOWKI) OR DIVORCKI) 
(Write ill sorial (U-siv:tiation) 



niRTIUM.AOK 
(State or CoutUry) 



NAMK Ol" 
HATin-.R 



lURTMPI.ACK 
Ol- lATUHR 
(State «)r Country) 



MAIDKN NAMK 
Ol- MOTIIKR 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




30..... 

(Day) 



190 H 

(Year) 



I \\\'A<VM\ CIvRTIFY, That I attended deceased from 

l\^:>\^ %S \^^ to ....M^LA^.^V?JL 2>..0 Igo-H 

that I last .saw h-&^^ alive on VW>>««r .iO lop ^ 

and that death occtirreil, on the date stated above, at OJj^^f^^^ 
1 Cl.M. The CAT'S Iv Ol-' DUATII was as follows: 



\X^^Jih-\oX 0^ 



DURATION 



)'ears "^ Alonths ^ /)ays T Hours 

CONTRIBUTORY \X>'OUU^,.^^.'^./^^ 



DURATION Years Mouths Days Hours 

(SIGI 



1URTHPI,ACK 

01* MoTMHR 
(State or Country) 




OCCUPATION <W 

V Q p. 

Rrsiifcif III Stin /■ i nm isiU) O \J)''tiis 



Ar,>,i//is 



/hj^ 



THK AHOVK STATKI) PHRSONAI, I'ARTICri.ARS ARK TRl'K TO TMH 
BKST Ol' MY RNOW^KDC.H AND nKMi:F 



(Itiformaiit 






(Addres.H 



SH 



I 



k. 1.3.0. 



NED ) .ly... .X AX^^jL^h/Vvv^vOv M.D. 

^0 iQO^ (.Address) H (p O-U^tfa^X cj.^ 



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



Former or 
Usual Residence 



How lonq at 

Place of Oeatli? Days 



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



IM.ACK OK niRIAI. OR RKMOVAI, 



DATKof HrKiAL or RKMOVAI, 



JV). vj. C)vcUVv%.U 

1131 OOwxL^^v.. it 



INDliRTAKKR 

(.Xddress 




IS. B. Every Item of tnfopmatlon should bs carefully supplied. AG6 should be stated EXACTLY. PHYSICIANS should 

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



i'ilil 



Si 



•SI 



( 



<1 






>r!' 



' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIV.ANENT RECORD 

,.„„nl„f,U.I.„-.-So.,.^-g^>»^.-Co REFER TO BACK OF CERT.P.CATt FOR INSTRUCTIOMa 

Dale Fi1e,l, LJL I I'-^O'i Registered J^To. Jjl 

Deputy Health Offlcor 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cettificate of H)eatb 



( in. S. StanDar& ) 

of O <cx^w 



PLACE OF DEATH: — County of O KX^kv J A.<X.>vCA.<^cCity ofO<X^>v; J Axv>viia^ t.o 



(No* 



I la 







tLiL 



St 



4 a Dist,; bet. A^KAjJfi. and ^ q^U^' 




/ ,r DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED ^OR "N"p "«;";*i '^ "^J^JJ'^^ "^ " ) 
V IF DEATH OCtURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SHX (T^ 



OX/Vnu<xJuL 



COLOR 



UjJvvtx 



DATK <)I- lURTll 



Mfloxoru 



(Month) 



as- 

(Day) 



(Year) 



AC.K 



J 'ra t s 



M.inlhs 



Pa 1 . 



SINCI.K. MARK I K.I). 
WIDOWKP OK DIVORCKI) 
(Writf in sm-ial desiKmili'*") 



niKTm'i.ACK 

(Slate or Country) 



NAMH OF 
FATMKR 



niKTMPI.At'K 
Ol- lATHKR 
(State or Country) 






MAIDHN NAMK 

<)|- M«vrnKR 



lURTHPLACK 
OF MoTlIKK 
(Slate or Country) 






ilCCTTATION 



(K( 



Rf}ii(ifif in Snti / nun isro 






) til I s 



/>,n 



(Infoiniant 



TllF MU)VF STAII'.I) PKKSONAI, I'A KT KM" I.A KS A R IC TRIK TO rill-: 

BKST OF MY KNo\vu:nc,F: AND HF:i.n:F 

1 \ X (k'^fU "dt 



(.\(Ulress 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




y\JL 

Month) 



3.C 

(Day) 



I90H 

(Year) 



I HRRKBY ClvRTIFY, That I attended tleccased from 

^^^ %lo 190 S to ..H^vw-wftr %'\ 190 H 

that I last saw h X^v^ alive on Ha^v^vvA- . ^*^ T90 S 

and that death occurred, on the date stated above, at V- I 
(P M. The CArSFv OI' Dl^ATII was as follows: 



r.VO.VV. 



Dr RAT ION •- )'ears '^ Afonihs X Ci Days ^ Hours 
CONTRIIU'TORY 



a. 



DURATION 

(SIGNED) v)-MA.<:V^ 



Years Mouths Days Hours 



M.D. 



'\\ H)on (Address) ( I 0> vHvft.^L<^y>\ 0"t 

S'^ECI^L Information only for Ho-ipitals, Institutions, Transients, 
or Rrcrnt Residrnts, and persons dyiny away frorn home. « 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



IM.ACK OI" lUKIAI, OK KFMOVAI. | DATF, of 1H kiai, or KF:M0VAI, 

I 190S 



(mx oi.'v^ 



INDKRTAKFK 

(AiMteHH . 






C^CV-CV.TN^A 



;>vto at 



IN. B. F.very Item of InformHtlon shoulfl he cHre?uliy nuppli ;fl. AGE should ho stated EXACTLY. PHY8ICIAN8 should 

state CAUSE OF DEATH In plnln term*, thnt It miiy he properly classified. The "Special Information" for per- 
sons dyin4 away from home should he ftiven in ms^ry instance. 



Si I 



M 




WRITE PLAINLY WITH UNFADING INK — 



Board of Ilealth-F Vo. is «^^^li&l' Co 



Date Filed, 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONt 



190'\ 



Begistered J^'^o, 



,^v,cvc» 



\ju^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( "Cl. S. StanOarO ) 



(No. 



PLACE OF DEATH: — County of 






S ^ 



aiio 



crvYx. 



St.; 5 Dist.;bet. 



itL 



and 



qt 



I 



ru 



/ ,r oc.TH OCCURS *w*Y FROM USUAL RESIDENCE GIVE FACTS 9.*'-i/p^';°"„7°" :;;";*iJJ"^^^^^ 

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



FULL NAME 



Q 



PERSONAL AND STATISTICAL PARTICULARS 



"•^^ 



d L^vaxAX 



COI.OR. » 



DATK OF lUKTH 



Month) 



ACK 



an 



) V'c » .< 



(Day) 



M.nillis 



(Year) 



Da vs 



SINT.l.K. MARKIKTV 
WIDOWKI) nK DIVoKiKl) 
(Writi- ill smial (lesiv:»«'itioii) 



niKTmM.A('K 

(Stalf or Country) 



NAMK <>1 
FATHKR 



HIRTMIM.ACK 
OF lATHKR 
(Stall c)r Country') 






CV-^v 



ck. 



v^ oJL 



MAIDKN XAMK 

Ol MoTin:R 



BTRTTTPI.ACK 
OF MOTnF:R 
(Slatf or Country^ 



fo 






^vr 



oCCrPATION 



%^ 






Rfsidfif ill Sail Ftaun'sro I <A. )'iiiiy 




.yf.>iilhs 



I hi 1 > 



Tin-; Mu)\ K sTAi i:i) ckrsonai. i-ak i utlvks aki: tri k to Till-: 

lUvST OF MV KN<JL\\T.KnC.K AN!) Hltl.MIF 



(Informant 



(AtlilresK 






3?)S 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




onth) 



3d. 

(Day) 



(Year) 



I HEREBY CIvRTIFV, That I attended deceased from 

k\/YviL.....aa..i9o'^ to ..|^v^>^.....3..Q 190S 

that I last saw h-t^; alive on >^">->wiL 3D T90 \ 

and that death occurred, on the date stated above, at O 3 
U M. The CAl'SH OF DKATII was as follows: 

{XjcjuXjl J.awJ[mJI y\^|\JvA-i,tv^ 



DURATION ^ Years ^ Mouths '^ Days ^ Hours 

.LL.C,V>Xi?r.....\Ar^.'.CMUO.>.A.V.<\ 



CONTRIIUrrORV 



DURATION Years 

(SIGNED) 



Mouths 



Pavs 



Hours 




(Address) 13»0 b J( 



-L4.^^>v. o'l 



M.D. 



^FECIAL Information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 



former or 
Usual Residence 

Wfien Has disease contracted, 
If not at place of deatli ? 



How long at 

Place of Death? Days 



IM \CF: OI- hlRIAI. OR RKMO'v AI, DATK of HiKiAl. or RKMOVAI, 



(Ad<lrcss 



N. B." 



of I„f„r™..ion .houl.1 b. cn.eSuM, -uppM..I. AGE .hould be ,.»Ud EXACTLY PHYSICIANS .hould 
E OF DEATH in plain term., that It may be properly cla..lfled. The Special Information for per- 



-Every item 
state CAUS 
son* dying away from home should he ftiven in every Instance. 



•iII.y!! 
ir 111' 



M 
11 



ijii' 






7 



no.'i 



WRITE PLAINLY WITH UNFADING INK 

r.l of HcMlth-K No. I-; -^f?^^ H&P Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafc Filed, 




Eegistered JVo. 



»• — ^ 



-^ .m,- •» j^i~ f^ ^**f .^ ^ ^* 



DEPARTMENT^PuIlIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( •a. S. StanDarD ) 
PLACE OF DEATH:-County of C^^Wv^^-^va^v^^cCity of 3o^. Uo^x^oc 



No. ^\H 




(IF DCATH OCCUBlp AWAY F 
IF DEATH OcdijRRED I 



r A^^^t -?^?^?if^^;^^;i ^- ^^" ;;;^^ri^o -;:eir •• ) ( 




FULL NAME 




si-:x 



DATK OI- lURTH 



COI.OR 



PERSONAL AND STATISTICAL PARTICULARS 



lol^t. 



M<)iilh> 



(Day) 



(Year) 



AC.K 



,3s 



) 'ra I s 



Months 



Da vs 



SINC.l.K. MARKIl'n. 
\VIl>(UVi:i) OR DIVORiHl) 
(Write ill social <k-.sijj:nation) 



Ql 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



Lu.v^JL 3wB /poH 

(Month) (Day) (Year) 



Til R RUBY CKRTIFY, That I attended deceased from 

190 -^- to 190.— r-.. 

that I last saw h - — -alive on '9° 

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



\CUV\.^^CL 



HIRTHPI.ACK 

(St:itc or Country'' 



NAMl-: OI" 
lATmCR 



niRTHPI.ACK 
0|- I- ATI IKK 

(Statf or Country) 



MAinKN NAMK 
<)1- MOTIIHR 






vfr-v.''-^ 




cLo 



cnx^Vcv 



U dJUXK 



lURTHl'I.ACK 
OI- MOTHKR 
(Slate or Country) 



I 



CA JlncLu.'vsjl vKtuj- vLi>-^Jk 



.)CCUPATION (^ >vwx^->^-«.V 

PrsNfnf III Sail /'nnniwo — )V<n.« "^ .lA.;////\|*4_Arr> 



THK MlOVK STVTlsD I'KRSONAl, PARTlcri.ARS ARK TRIK TO THH 
IJKST OF MY KNO\VI,i:i)C.K AND HIIMKF 



(Informant 



(Address 






— M. The CAl'Slv Ol^ DI^ATII was as follows: 

\jy\xr\.lv)^^ M cruiu<nruwnruDL 



W-^wA..^ 



wcLt 



DURATION }'ears 

CONTRIIJUTORV 



Months 



Days Hours 



duration 
(Signed) 



)\\irs 



^Tn}lths 




f 




» 



Days Hours 

\<Lr. M.D. 



yArO^^o iQo 

SPECIAL INF 



(^ 



^ (Address) VfrVcn\X\^ 




Vr^-::^.-!!,.. 



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

Former or (Vi « w D, ""^ '""' ** I U . 

Isual Residence ^J iLuJ" M-i trV^K _ Place of Deatfi? '3... Days 



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



? 



^ 



PI.ACK Ol- niRlAU OR RKMOVAI, 
INDKRTAKKK Vl\ J <X^MXt/VU 



>'^V 



DATlvof IMKIAI, or K1:M0\AI, 
^ I90H 




(Ad«lre«*s 



1 in I QfYluLA^vrn jM 



Jc/\> 



p, B Bvery Item of in?ormnf.on should be cnrefully Hupplled. AGE should be stated EXACTLY. PHYSICIANS should 

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



^..^ mm.m>r*f\ar\ 



;'l 



* 



lluanl of Hc:.lth-KNo. l^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



JaE?i)n&PCo 



I)(f/r Filed, VaXu, 1 



y 



loo'i 

Deputy Health Officer 



Begixtercd JVo. 



.i.Q 



DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



Certificate of S)eatb 



( Vi. S. Stan6atO ) 



PLACE OF DEATH:-County of Ho^v i/vO^v^c^^Chy of C^<V>v aA^^.Cu^Oc 



'No. 



aSb lj>LU-cU 



St.; X ^ctoist.; bet. w a,\.' 




and UXClH^M 



\J U"^'^^^^^ MOUAL RFsTDENCE'civE r*CTs"cAljED FOR UNDER "SPECIAL I N TO R M ATIO N " \ 

( '^ r."o;ATH'^occ^%;ro^"^Ho"s^pyT"l: ?r"ns'?o"oVo.ve ,ts name ..ste*o o. street ano number. ; 



FULL NAME 






<jb 



SK.\ 



DATi-: or HiK rn 



PERSONAL AND STATISTICAL PART ICUL ARS 

I COI. 




.OR \ 



'dl 




Kjih 



\ 






(Year) 



AOK 



?1 



) ■»•»; » > 



A/.)fiffis 



JDavs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Day) 



(Year) 



Y~]7[7R]7rv CI-:RTIFV, That I atten<kMl (U-ccascd from 

^-— r 190 to 190 

tliat I last saw h ■••—^ alive on — ^9^ 



SINC.I.K. MARK IKD 
WIDOWKD OK DiyoKiKD 
(Write ill >M>eial (U-'<i^':naliiin) 



HIKTHIM.AOK 
(State or Country) 




N'AMK OF 
FATHKK 



niKTHPI.Al'H 

0|- l-ATHKK 

I State or rounlry) 



MAIDKN NAMK 
OF MOTIIKR 






[LyyJkjy 




.^ 



and that death occurred, on the date stated al)Ove, at 

I was as fol 

— Months Days Hours 



^X The CAl'SIv OF I^Ji-Vl''' ^^"^ ^^ follows 



.v^r^kiVOw" 



l)rR.\TI()N Years 

CONTRIBUTORY •— ^ 



I)rR.\TION — Years — Months -^ Days —Hours 
(SIGNED) ^.(B.ljO.lJU^^vd. LvVtrW^ M.D. 



HIKTHPUACK 
Ol MOTHKR 
(State or Country) 



OCCUPATION 







Kfyidfd ill Sdii I'l niKisri) 



)'iiji 



-^ }r.<lllll: 



Pit 



THF XHOVRSTATHD PKK^ONAI, PA KTICF I.AKS A K F. TK F H To TUF. 
lUCST OK MY JiN<l\Vl.i:D(*.K AND in:i.Jl,l; 



(Inforniant 




rxddress 






kL>\X> g^ligoS (Address) 



LfrVcrvvJtN^A UJLlLuiLi. 



oPECIAL INFORMATION only for Hospitals, InstituliW^ Transients, 
or^Rccent 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 



PI.ACK OF lUKFM. OK KKMoVAI, 



UNPHRTAKKR 

(Address 



DATF; of IJiKiAl. or RHMOY.Al, 
^ I90H 



lb oJuliul V U 

.q.H.b.*^lvc^^'t^v...d 



"""^ \^ I I h t ted EXACTLY. PHYSICIANS should 

N. B. Every Item oif Information .hould be cnrefully supplied. ^^^ * "" ' .t V yhc "Special InfformatJon" for per- 

.tate CAUSE OF DEATH In pInJn terms, that it may be properly dass.t.ed. 
son. dylnft away from home should be ftlven in .vopy instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IVjard of Health— K No. n 



H&P Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



loo'i 



Dafc Filed, Y""""^^ ^ 

dvcrvw^ Xjl-^^ Deputy Health Offlccr 



Registered JVo, 



*! r» 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( H. 5. StanOarD ) 



i 0? 



PLACE OF DEATH 



. County ofC3cu>\'J/viX-vxcv4,C^ City of COa^ JXxa^^ow^c-o 



% 



ti 



(No 3.M1b ^dbc^VvKXn.C^. SU ^ DisUhcU ^^ %tv and SI 1 -^^ 

^^°* / T or.TH OCCURS *wAy TROM USUAL RESIDENCE give tacts called ^o" "no J;!,^;*^^'^^^;:;;',^''' ) 

t IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. y 



t 



FULL NAME 



lLJtvl^ w... (iw^ 






SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



DA TH <>l" lUK 111 






Ia.) AwXju 



\c.v. 



(Month) 



,. *- )■/•</;> 



0.% 

(Day) 



Mi»iths 



(Year) 



3 



Pa v: 



STNC.l.K. MARKIKD. 
WIDOWKI) <)K DIVORCHI) 
(Writf in social iN-iijfnation) 



HIR rUPKAOK 
(StaU- or Conntry) 



NAMK OF 
FATHKR 



BIRTHPLACE 
()l- lATHKR 
(Stalf or Cotinli y) 



MAIDKN NAMK 
Ol- MOTHKR 







MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH^ 




(Year) 



1 HliRKBY ClvRTIFV, That I attended deceased from 

.^^JC. %B. 190 H to .^VW^^fN^ 3.C> 190 ^ 

th^t I last saw h .<WV\alive on W/>^JL 30 190 M 
and that d-ath occurred, on the date stated al)Ove, at ^5^ 
...G; M. The CAUSH OF DliATH was as follows: 
."aJ CV^^Xvo L^yvijL^t^Jt-A^ 



DURATION Years 

CONTRIHUTORY 



Months Days 



Hours 



La^V-<X' 



Lev 



-W(A.V 



PTKTIIPLACR 

<M<" mothf:r 

(state or Country) 



r 



nOClPATION 

Rfsititil III San /-'i ii ii< iM'o 






)'i'ii I . 



Tin-: AHOVK STATi:!) I-KKSONAI. par lIiTI.AKS AKl-, PRl !•: T* > IHIC 

hf:st of my kn()\vi.f:i)c.k AM) iu:m):i' 



(Informant 



(AtMiess 



5. S T b dbjM^KJLVcb Q.t: 




DURATION )'i'ars Afont/is Days Hours 

(SIGNED) VKov \J^ ^\uJJU^J M.D. 

1 T90S (Address) ( C) S H \) (xImv^:^ CJt 



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

Former or Sr'Tn'*.., n 

Usual Residence P'^^e «' Dfatli? Days 

When was disease contracted, 

If not at place of death ? 



PI.iiCF: OF' BTRIAI. OR RHMOVAI, 




DA'Pli of lifRiAi- or RKMOVAI, 
51 I90H 



INDHRTAKKR v) A^^^ p^ U^^^V^UNtol^ 



^ 



t' A APF oVionlil he Rtnted EXACTLY. PHYSICIANS should 

IN. B. Every item of Information should be cnrefully supplied. AGE should ^'.^ "'"^''jj.^ .. J* ^ .^, ,„Cor,„atlon" for pT- 

state CAUSE OF DEATH In plain terms, that it may be properly class.ticd. The Spcw.al Information »or p,r 
son* dying away from home should be given in every Instance. 



III! 



■ t 



<ii 







li 




s) 



:! 



. -1 



Jloa 



rdof nt«lth-FNo. n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCrCR TO BACK OF CCRTIPICATC FOR INSTRUCTIONS 



HM'C) 



Date Filed, 



1^ 



7^0^ Registered JVo, 

Deputy Health Oflflcer 

DEPARTMENT OF PiJBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "CI. S. Stan^arD ) 



PLACE OF DEATH: -County ofcW^ d^ux-v^^^ City of 0^^^ J/vcwwcv^c.. 



(No, 



mty 

71 b VDVCLXvi ItvM. SK; b Dist,;bct. Ujukx'i^^ and 

I i U \3J \^l'^ V^ V V rfsTdxnCE give facts called for under "special information- \ 

IF DEATH OCCOR^IaWAV FROM USUAL R j- S ' ?E NC t^GI V^E JACT^ ^. * „ p l^.sTr*D OF STREET AND NUMBER. J 



( " r,"o;':r°H"o^c"5t;"cV,'«"rHOSPa.^ ""„.,V^"c»<r,vr ,;; NAME ,.,T«o or .r.ct 



(y>w 



^ ^A.A.'* ) 



FULL NAME 




n^-x^^KAx} 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR , 



mJi. 



u> 



DATK OJ- lURTH 



AC.H 



CllxK-d 



at /SHH., 

(Day) (Year) 



(pO 



] 'i\i I 



.UoMtJii 



Pa vs 



MEDICAL CERTIFICATE OF DEATH 



DATK OV DKATll 



(Month) 



3.^ 

(Day) 



(Year) 



I IIICUIUiY C1':RTIFY, That I attended deccasea from 

190 "~~ 

190 ■~~~ 



that I hist saw h 



190 
- alive on 



to 



sivr.i.K, MAKHn:i> 

WinnWKD OK DIVOKCKI) 
(WrJttiii social (UsivrnalJnn) 



tStiilr or Couiilry) 



JATHllR 



niRTJU'LACK 
01 lATHKR 
(Sliitf or Country) 



MAIDKN NAMK 
oj. M()Tni':R 



niK'ruri.AOK 

«)l" MOTHKR 
(State or Country^ 



OCCl'PATION 



S) 



f ! A. 



and that defth occurred, on the date stated above, at 
— — M. The CAl'SH OF DICATIT was as follows 




nr RATION Years 

CONTKIIU'TORV 



Mouths 



Days 



Hours 



Pars 



Rcsiifrif ill Stin /'i ii>i< :■"••> 1 v ) rai s 



Moiilh^ 



Pay. 



TMH AUOVK STATJ-n PKRSONAl, I' A K lUT 1. \KS \Ki; IKri-: T» > IHK 

HKST OK MY KN<»\vi,i;i)r,i<: AND in-.i.n-.i-" 



:infonnant LAAX^Lo ^''^- 3 /»-wt.)(v 

1 lb (B 



(Adclrt-ss 



>v<x,aul> Uc-'v^. 



DTRATION Years Mouths J 'ays Hours 

{ S\GiiZD ) \js\^tnyJ^ ^- VdAI) '3s^a^^>^ M.D. 

.^>JL SO. iqo H (Address) L^r^^Vi^^ U rU-^<;^ 




FECIAL INFORMATION only for Hospitals, Instilutions, Transients, 
or 'Recent Residents, and persons dying away from liome. 

Usual Residence Place of Death ? 

Wfien was disease contracted, 

If not at place of deatli ? 



.. Days 



ri,ACH OF lURIAI. OR Rl-MoVAI 



DATl". of HCRIAI. or RKMOVAI, 

^wIm. ^ 1 90S 



vnJkrtakhr hA^^^^ ^^ ^t£ \WU C, 

....S.M.'l.S. m1\n^^' — -^^ 



(Address . 



^ufr'y^. 



"^ 1^ ^ APF «hmild be Stated BXACTLY. PHYSICIANS should 

N. B. Every Item of Information should be cnrefully BuppI.ed. ^^'^^ « |„««5«led The •'Special Information" for p«r- 

state CAUSE OF DEATH in plain terms, that it mny be properly wlass.tied. ne » 

Rons dylnft away from home Hhould be ftiven in every instance. 






•; hi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nnar.l of He»lth-F No. ., -fr-r^.-i^ MS: !' C. 



i' 



Dale Filed , 



190H 



i Li. Deputy Heaitn Officer 



Registered J\^o, 



18 



n 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



H 



PLACE OF DEATH: — County of 



Certificate of H)eatb 

( "U. 5. StanC>arD ) 

ity of X^wOvOuT^^-fr^-^ La.v 



(X/Lol^"v>aJU^w<v City 



St.; 



Dist.; bet. 



and 



(PI©, CY\JLO^\' ^X-VX'-^'V^rVX.C-^w^ M^nr. besTdenCE give 7^7ys c^v-l-Vo ^on under "special information- \ 
( " ^^"o;ATrocc^^rEo^"rHO^s^pVT'il: nnVnl^s^^.'ion.. ITS NANIE INSTEAO or street ano number. ) 

VJ OaaJL 8o>vlLL 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

COl.nK 



...ttllS 



r 










SKX 




(hi 


c<xu 




n.\Ti: 


Ol- 


lUKlll 




7 

Month) 


A (.I-: 





1 



« ] 



ta 



) 'fVJ » .V 



(Dav) 



M,»illi^ 



{\vi\r) 



Pit r.v 



MEDICAL CERTIFICATE OF DEATH 

DATK (>!• DHATIl 



(Month) 



1% 

(Day) 



(Year) 



I in<:Ki;i5V CI.KTIFV, That I attcndcMl deceased from 

-" •': icp *" 

- ; 190 - - 



•I()0 



to .-:—. 



that I last saw h alive on ■^— 



SI\<,l,I*, MAKKIi:!) 
\\ll>»)\\J':i) oK I)1V(»R>.KI) 
iWiitcin viH-ial .Itsij^natioii) 




HIKTIU'UAOK 

(State or Country' 



NAM I" Ol" 
JATHl'.R 



niRTmM.ACK 

Ol- iwrnHK 

(State or Coimtry) 



M \II)1-:N NAMK 
<)»•• MOTMKR 



lUKTnri.AC'K 
Ol- MOTHKR 
(State or Country) 






Aj^i. 



IX^ VCUL C-XAtcL^ A>wt<^ 



dU 
cL<) 



aii.l that death occurred, on the date stated above, at 

..rrrrr-M. The CAl'Sl-: OF DlvATII was as follows: 

(JLAJLlJ^^.<xl - J^^^ 



1)1' RATION )'t'ars 
CONTRIIU'TORY 



Mouths 



Days 



Hants 



Years Months 



/)avs 



DURATION 

(SIGNED) lU.d. J^Y^ 



//ours 
M.D. 




'VOl'iOiooH (Addi 



OCCUPATION \X^v<V^tJLvJtcUv>^lL 

Ri'yi.fcf III Sail /'iiUhi^rn )'rfrt< 



\fnlltliy 



/hn. 



rnV \HOVKSTATl-.I> I'KKSONAI, V \ K lUT l.AKS AKl- TKlH TO THH 
lil%ST t)l- MV KNOW 1. 1:1 )(■.!•: AND in.I.Il-.l' 

(informant Orrvlo ^NjL^ -^ VCX'Tvl ^^JK ^ ^^<t 



(Address 



FECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or'Recent Residents, and persons dying away from tiome. 

How long at 

Place of Death? Days 



Former or 
Usual Residence 



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



I'lACK Ol- lURlAI, OR RKMOVAI. DATK of HiRtAl. or REMOVAl, 

,„„.... (J* i>UO-A 



~ -^^^tW^!^ 



^v 



"""■"■"""■"""■"""■^ Tw VA AGE should be stated EXACTLY. PHYSICIANS should 

IN. B. Every Item of inform«tion should be carefully supplied. ^^^J classified. The "Special Informntlon" for p.r- 

-t«*. CAIISF OF DEATH in pl«in terms, that .t may be properly Uassmeu 



state CAUSE OF DEATH in pi 

sons dyinft away from home should be ftivcn ui every instance. 




I 



i 11 ' 



\i 



IP ■- 
I'll 11 



n 



(Kinl of llf.ilth 



Dafe Filed , 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

_.. NO .. -^^H^.Co RCFER TO BACK OF CERT.F.CATE FOR .NSTRUCT.ONS 

Registered J^o, 



I 



IDO^ 

v-vi Deputy Health OfTlr*»r 



Jkr,.%J... 



DEPARTMENT OF PUBLit HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "CI. S. StanOarD ) 



(^ 



PLACE OF DEATH: — County of ^^Oj-^ 



vi A.^-yA/:A^ cxCity of ?> Clt^ ~^ A.OyTx.o^^ C.C 



11.^ and aa^cl ) 



No. 3^ 5 t M. 1\D ^L^KUV'dj ^^^^'^^^^^.^^ Hixs^^Jio ;o« u.oc« "spec*. ..ro«.*..o.- ) 



( 



FULL NAME 



Q.KOsJUb 



''■"m 



DATi; OF lUKTH 



M,V. 



PERSONAL AND STATISTICAL ^51'CU>^5^_. „ 



JX/^mcXxXX' 



COLOR 



(Moifih) 




y\) 



) 'lUt » « 



10 

(Day) 



M. nit lis 



(Vear) 




EPICAL CERTIFICATE OF DEATH 



DATE OF DKAT 




(Month) 



3 

(Day) 



I go \ 

(Year) 



I in<:Rl*:HY C1:RTII'V, That I attcMultMl deceased from 

J^JTSJU l.l. IQOH to....W>^ '^■^- ^90 H 



ao 



Days 



SINC.l.l'.. MAKKIKI). 
wnxiWHD «»K DIVnKfKI) 

iWiitf ill s.K-ial ilf><ivrti:iti<)n) 



lUKTIU'I.ACK 
(Statf or Co\iutry'> 



NAMK Ol- 
FA rill'.R 



niKTHPI.ACK 
()!• lAPUHR 
(Slatr or Country) 



MAn)i:N namf: 

OF MOTin:R 



iiiKpmM.ACF: 

OF MOTnF:R 
(State or Country) 



r ! 






that I last saw h X>V' aUve on 
and that death occurred, on the 




.10 190 H 

above, at ^ 



(Lm. The CAl'SIv OF Dl-ATll was as follows: 



) J CJuM^' 






OCCUPATION 

Rr<-{dr<i ill Sun f'l mn isri> 










DT RATION •- )'t'ars - Months J -< Days 
CONTRIIU'TORY itdJoX) cUxcL 




DURATION -.nv7r5 ''^^^'"^^'' .(jV'''''' ^^^^"''' 



(Signed) uXC) 



'J, 










/)<n 



THF MIOVK STXTF.I) PKR^ONAl. l-AKTIcr I.A KS A K F". TKlK TO TMK 
IlKST OF MY KNOWI.KIX.F: AND Hl-.MFJ- 



(A.Mrrss 



1\ ^ \ 



U\ c)t) 



Special information only for Hospitals, Institutions, Transients 

or Recent Residents, ano persons dylnq away from home. 

c „, How long at 

'^"^'"""'^ Ware of Death' 

Usual Residence "*'^ "' """ * 

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



Days 



im.acf: oi" iuriai. or kf:movai. 



\CF" OF lU KlAi. i»K iM 



DATKof .in-RiAl. or RKMOVAI, 

aJLh. .1 190H 



lNnF:RTAKF:R 

(Address 






H Hie. ^v<i^^^ 



,. . 77f -hould be stated EXACTLY. PHYSICIANS Bhould 
Btlon .hould be cnrefully j.uppl.ed J^«^^ "^X^,,.,^. The ^Special Information" ?or p.r- 
ATH In plain terms, that It may be property 



N. B. Every Item of Inform 

•tate CAUSE OF DEATH _ :„.»«„ce 

«on. dylnft away from home should be ftWen In every Instance. 



. 



Mil, , t 



Inrrl 










WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

, „ .,_,.„ ,..;S S^,....Oo . .».» TO 8ACK OP C.BT.r.CATt POH ,N,T.UCT.ON, 

/,,,.F/^.,^ ijLl 100^ Registered J^o. 20 

LrvL iL^v- Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



1 



Certificate of Death 

{ Ta. S. Stan&atO ) 

<7r> 



<(V 



OjWi 'J \/CV"W'CV^-CO 



PLACE OF DEATH: -County of ^ ^^ + V^^^c^-^City of J A.^ 

•No "I \% C^^v>>^>v^oc.i st^^ Hi?.•^^^.o^li^^-^ia,.^;«rJl.,l■r 

FULL NAME ''^'^' w^^^vm^^a^ 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.DR 



^^wL 



DATK «)I r.lKTII 



a<;k 




<l,lUr_ 



Motilh) 



(Day) 



r ILL.. 

(Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



..s^Y^JU ^-0 

(Month) (»ay> 



T90H 

(Year) 



il 



) V«7 > A 



Mmiths 



W 



Day: 



SINC.l.K. MAKUIKI) 
WinoWKD OR niVi>KrHI) 
(Write in social tk-sivMiation) 



niKTm'UAOK 

(Statf or Cntuitry) 



FATHKR 




HlRTHPl.AOK 
or lATHKR 
(State or Country) 



MAIDKN NAMK 
Ol- MOTMKR 






I HEREBY Cl'RTIFV, That I atten.lcl deceased from 

■y^ .1 190 H to ^WV-O. a..fe 190.4 

190 H 

51 





tha^ I last saw h ...^--malive on A^-Va^^^^ ^^ 



lURTHlM.ACK 
OF MOTHKR 
(State or Country) 




an.l that <leath occurred, on the date stated above, at 
(J M. The CAUSE OE DEATH was as follows: 

Lw^>^Jv'«■-<iA/> -^ ....dU^v.'v'. V 



VVRATlik^ y^^ ^foni^s Days Hours 
CONTRIBUTORY UrA^^^AAX^ 



/hiVS 



Hours 



AW/././ /. sL r,a,ui.o 'W Vr.,. ^ Mnnfl,s k\ />.n. 



THK AROVK STATKD PKRSONAl, l'AK^;|^;^;!v,\»*^ ''''''- ''''''''*' '''' '*'"' 
KKST OK MY KNt)Wl.KDC.K ANP Bhljl-.l' 



DURATION Years ,irou//is 

( SIGNED ) tLxO C U) a^cU^n^VUv M.D. 




Special information only for Hospitals, Institutions, Translfnls, 
or Recent Residents, and persons dying away from home. 
_ ^, How long at 

Usual Residence 

When was disease contracted. 

If not at place of death ? 



^ I 



a»o 



(Informant LU -'^^^VVOu ^^ 



AA.^W 



(A<lclress 




PI \CK OK BIRIAI. OR RHMOVAI, 

^0 " 




D.vriCof niKiAi- or rk;moyai« 

.':\ :_i90l_ 



rNDHRTAKKR 

(Address 



U) 




i<k. 



^iq ''CLIh....!^. 



.. , APF should be stated EXACTLY. PHYSICIANS should 

N. B.— Every Item of information should be carefully «"PP'-^- J^^^J classified. The -Special Information- for p.r- 
.tate CAUSE OF DEATH in plain terms, that it niay »>« prop y 
son, dylnft «w«y from home should be ftlven .n every Instance. 



Ifl 



y\ • 






WRITE PLAINLY WITH UNFADING INK-THiS IS A PERMANENT RECORD 




I'jo'i 



BEFER TO B *CK OF CERTIFICATE FOR I NSTRUCTIONS ^ 

21 



Registered JSTo, 



Dale Filc'l, V™!' ^ 

Xe-vA-vo Xji^v^H Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(Xettificate of Death 

( "d. S. StanDar^ ) 






(^ 



PLACE OF DEATH:-County of A o^ >^^.^^^ of ^^X^^^^A.:.— -. 

^ ( - ^^lcc^^ro^trHo^,^pVT^ 0%^-^^rT^c;;'- -i ?.;^m7 -;te7o o. street and n^.^er. ) 



FULL NAME 



ornxx^ 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



si:\ 



^oL 



COI.oR 



^\^}Ji 



DATK oi r.iK rii 



^! M 



7 

(Month) 



7 



A(.K 



S4 



) V*(T ; > 



(Day) 



Motitfn 



(Year) 



DA'lE OF DEATH 




MonthT) 



I 

(Day) 



(Year^ 




Pars 



SIN«.I,K, MAKKIKD. 
WIDOWKD OR DIV()Kii:i> 

(Write in Mxial (l<>iv'iiali'iii) 



lUKTUl'LAi'K 
(State or Co»intr5'^ 



NAMK Ol 
F 



\| |\0L^.A.->^-^^-<A- 






.A^CU 



AMK Ol- /^ 

ATHKR f i; 

^L). 






niKTMIM.AOK I ^^ 

Ol- I \rnKR [7) 

(State or Country) I 1/ 



V(X>v 



t 



maii)i:n name 

Ol' MOTHKR 



II 



lURTHPT.ACK 
oj- MoTHKR 
(Statf or Conntry) 



Qa,cttcu ^"^ 




FHKRIil'V C1;kTI1-V, Tliat I atten.U-.l (Iccoascl from 

\% .90H t" Vnt'^ "^'^ 

that 1 last saw h^w^ alive oti f^^^ I^^ 

a„.l that death occurred, on the date stated above, at 1-^ «> 
(P, M The CAl'SIi OF l)lv.\TIl was as folUnvs : 

% M K^Wt^ 4 yVv^tft. M<^>.<^. 

nrRATION f^ Years ^ Months ^ Days - Hours 

nrRATION..!.^. )V.rr5 '^■Mouths X Days ^ Hours 

(SIGNED) ^)\- 




M.D. 



a looM (Address) 1X0 T d-^ 



\,ttt»v a.i 






Rfsufrif in S(in I'unuisro 



a^v.n> 



;;/// 



1 



/)<n. 



rm-: ap 






HFS'Itl)!* MY KNO\V1J:dC.K AND HhMl.t^ 



(I 



.. PEciW" I N FORMATION only for Hospitals, Institutions. Transients, 
or RereS Residents, and persons dying away from home. 

^ 4 i Mow long at u n 

^"T?^ . iTOX JA^^^ot Place of Deatli? -^ Days 

Usual Residence 1 * ^ -^ n 

When was disease contracted, -f^j^,^^^ \kUx.^^ 4v\vfr\ UAk. 
If not at place of death? ^-^ ^-^^ fl ' -^ 

■ .. o,.x,,,\ VI niTi.nf HiKiAi- or RKMOVAI 

l'I,ACK OF lURIAU OR RHMOX AI. 

OlOLAJL/"VVV' 

.3..ICV '^"TaNVLli ..-^.t 



iress 



<5»V 



DAj"K<if HtKlAi- or RKMOVAI, 

3. 190H 




INDHRTAKKR 

(AcUlress 



Mi.«^i-— ■-■■■"" t t cl EXA<5*rLY PHYSICIANS should 

. .houlcl be cnreful.y suppUed ^^^^^;,;;7;3',,^*,,:i: %he ^Special InWmation" for p^r- 
in plain terms, that it may be properly 



N. B. Kvery item oV' information 

state CAUSE OF DEATH in p...... ^^ ■ -- - - i„8tance. 

son. dyinft away from home nhould be ftiven in every 



» I' 



ll 



% 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Xa.{. cl. 



i^Ol 



.., , M / ^, ^c/L/i Eegisterecl Xo, 

Date Filed, J i" 

Vtr^w^ IviAh^Y Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



«i> 



Certificate oi 2)eatb 

( "a. S. StauDarD ) 

^f. ^ Disfbct. '5-XwvK.V>v and M (^U^ 



^ . ^« ^ . f -^ OL-tv 1 Vcv^vcv4^^ City of '^^<^^ ^ KC^^^L^^^ 
PLACE OF DEATH: — County of ' <^^^ ^^ ^ '^ ^^ 






FULL NAME 



vLcdt^vck !S.cv>^kL 



PERSONAL AND STATISTICAL PARTICULARS 



DATH OF HIRTH (^ A 

^(r 



COI.Oli 



iMonlli* 



.\<".K 



31 



) V'rt > .« 



3. 

(Day) 



■^l Moul/is 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



u 




I 

(Day) 



igoH 

(Year) 



xs 



Davs 



siN».l,K. MARKIKD. 
\VH)i>\VKl> OR DIVoKrFD 



lUKTHPI.ACK 

'Statf or C'miitry^ 









NAMF <>J 
FATHER 



niR rniM.AOE 

<H- I AIHl'.R 
iStaU- or C<»uiitry) 



MAIItKN NAME 
OI MOTHER 



IMR rniM.ACR 
()l- MOTHER 
'St;itr or Oo\iiitry) 






I IIICRICBY CHRTIFV, That nLttended deceased from 

^yyJL '^ 190S to ■^■'^ ^ ^90 H 

thatllastsawh-^-^^liveon ^f^-^^ ^ '^ "^ 

a,i<l that death occurred, on the date statc/l above, at 
M The C\rSI<: OF DlCATH was as folloNVS 

i^ . ft f) ^ w '' ■ 









DURATION - Years - Months \Days ^ Hours 

LrVrL 



CONTRIBUTORY 
DURATION 

(Signed) 



Years 



ai-^ 



Mouths Pays Hours 

lvUryv<\^<i^ M.D. 



■ SPEdlAL INFORMATION only lor Hospitals, Institutions, Tr«.slents, 




«)CCri'ATION -^ I) 

Rffidrd t>i Sini Fiattfiscn • i ^ > ' ■" ' \ 

THE xnnVE S, ^TE.) rKKSONAL lS#^;|;;';iv;^'<^ ^'^'^ ■'*'^"'- '" '"'' 
BEST or MY KNOWEEDCE ^^^ "^•''"''^ 

(A<Ulres.. HI "Lct^atm- ^^ 



(InformatU 



SPECIAL INPUniviMi \\ji^ "•• ■. 

or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 

Place ot Deatli? Ns 



l-EACE OJ- lURI.M. OK REMOVAL 



I)\TEof HruiAi. or REMoVAE 



^ (n\'V>v-tBvi , 



N. B. 



-A— ^^ — — ■^■— ■ . FVACTLY PHYSICIANS should 

.tate CAUSE^ DEATH In P'-" J-'"': ^l" „ .very rn«rance. 
•on, dylnft aJCiy from home should be ft.ven m «very 



di 



i 



;l| 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^^.^^^ ,rrrp TO BACK OF CERTIFICATE FO R INSTRUCTIONS 

Registered J\^o. 
I)((fr FiJedy 



1.1! 



a. i'-^o^ 

^^^^^^ 'Ll'V-v|, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



23 



,^^^-^v^'* 



Ccvtificate of Bcatb 

( XX, S. StanOarD ) 
PLACE OF DEATH = -County of C^^-' i.va>vc^coGty of O^O^^A.^^- 



•J J 




No. 



aiH 



. 



c*. R ni'«:f»l5ch <V<X>CVVA»^vU>J and 



CavC/tvOAv 



^ 



cv>>) 



H /^ v. ' ll„\^d > W tJ\*t • ' - . ^ ,,»A.rB "«SPECIAL INFORMATION" "^ 



FULL NAME 




SHX 



PERSONAL AND STATISTICAL PARTICULAR 

i COI.oR 



4 



katk of 111 Kin 






LL'.VVAjtx 



(:ll..nth» 



AC.H 



4*^ ..„.. ^ 



IS 

( Day) 



ytnulhs 



rl^S 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 




(Month) 



(Day) 



(Year) 



1-^ 



Aj v. 



-^iSi.l.l-., MAKKIF.D. 

W IDnWF.D OK DIVOKiF.n 

Wntfin •^<H-i:il «l«--ij.'tiation) 



niRTffPI.ACR 

Stiiti- or C-mtitrv 



namf: oi- 
FATin:R 



lUK'nUM.ACH 
ol lAlUKR 
iSttitf* or Country) 



maii)f:n namf: 

Ol MoTIIF.K 



HIKTHPT.ACK 

OF mothkk 

(State or Country) 






1 ni-klUiV Im<:rTIFY, That I attended deceased from 

a^vvvllio 1901. to 4^v^>^ 2.0 TcpH 

that I last saw h .^-> alive on |^>-<" 3 ^ up S 

and that death occnrre.l, on the date stated above, at I ^ ^ 
.*■ M. The CAlSr: OF DICATH was as folUnvs : 









nr RATION I i JV^r.v 
CUNTRinrTORY 



Months Days 

-VaTV-^-. 



Hours 



7 I I ! iqoH (Address) Hb 




'^^.li^i 



iik^t 



OCCTTATION (VVA , X- 

RrshUd in Siiti I ion, isnt 1 "^ > "" ' ^^ | — 

TIIHAM<>VKS-1VXTKI)I'KKS<»NA1 rVKTjCriAKSAKKTRrKT.. IMF 

UF:ST (JF MV KNOWl.F.DOh. AMI lU.I.N » 



(Infoini.'int 






"ciprciAL INFORMATION only for Hospitals, institutions, Transients, 
or Rerenl Wsidents. and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 

Place of Death? M^ 



FI.ACF: 01 lU KIAI. OK KHMOVAI. 




(Adare.. 3^i.H\ ^Kv^V^^ « 



(Address ^<Jk • » VVYWWCV .^i,— —————"■■"■— """"^ .^,« . ,j 

Jl^ mm , FXACTLY PHYSICIANS should 

..„.. CAUSE OF DEATH In P-"'" «"•"•• l''"'' ,7/, .n.«n«. 



|1 : 



State CAUSE OF Dt A I n m pm-n ^' ■""';"".„ _,^y Instance, 
son. dyJna away from home should be ft.ven .n every 



V 1 



n 



ll,,anl..f H.aHli- »■ 



No. I ^ "^^^^r^- M& l*Co 



WR.TE PLAINLY WITH UNFAD.NG INK-TH.S IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

" ' — 24 

, r-7 7 V^L. ^ I'^O^ Registered J^o, 

I)(ffr I fled y T^^^ ^ 

^js,^.^r\-xAj) rM^v-vi. Penuty Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. 5. StauDarO ) 



P,ACE OF DEATH:-C.»,V o,ci.v,v'?^-^«--0,v .. ??^i---- 



No. 



\%%'\ - l^ 



-Cvv' 



St.; ^^ UlSl*f Oet.^ -sf^EC AL 1NF0RI«AT10~- ^ 

:R^?:?.^^^4rc^;ETs "am" ^t- " s?r1ex ano nu.ser. 



) 



VTf ;c.TH OC;uRS;wA. FROM USUAL RESIDENCE O.VE FACTS C^-^^-:,--J 3?r^% ,,. .u.BER. ) 

V IF DEATH OCCURRED IN A HOSPITAL 



FULL NAME 



,,U^H).CU,v..U.,v 



sex 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR \ 



^oL 



llVfvvtL 



1 1 \ IK or niKTu 



tM(iiith> 



u 

(Day) 



/ 



IHI, 



\<,K 



.T5 



)■/(// > 



^ 



.\/.iii//i< 



Xt 



(Ycsir) 



Pay. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

(Day> 



,\ Month),'! 



(Ycar> 



\VII)o\Vl-:i> OK DlVOKiKl) 

iWtit'in "iorial fl<sH'"ati«>ii) 



%^> 



niRTfiPT.ArK 
iStatt. oi t. ouiitryi 



i\Tin-.R 



Sj^\>c6juy^J 



U^vk 



AV^-vvrvv 



^. a \xOLVV<rvv 



niK rnri.AOK 

()|- 1 ATHKR 
ist'ltr or Countrj') 



MXllM^N NAMK 
«H- MOTJIKR 



.1 



1 m^RKBY CHRTIFV, That la^tenaea.lcccasea from 

h^^ ^^^ '\rfy} ^^' 

that! last saw h.■V^>^.■ilive on ^WU^ I ^^ ** 
ana that death occurred, on the .lato stated above, at ^ 
..tM. The CAISH Ol'' Dl'-VH' vn.is as follows: 



x^aL. <^-^ 




/;a.v^ 1^0 UPS 



/)<7V.? 



,^-V' 



lURTHPT.ACK 
(>»• MoTHKR 
(Statf or «.'r)mUry) 






/l.M 



OCCUPATION •-•►•' 

Rfsidrd in Snu I nJtxisr.i \1 V ) ,ti>- . 

TUK AHOVK STATK.) PKK.ONAl. l^AHTirrKARS ARK TRlK TO THH 
HKST OK MY KNOWM^UCK AND Hl-.lJI-.l^ 



(Infoimaiit 



-W^ 



X) Ot^vwC^^rvc' 



DURATION 'I JV^'-^ -'^'^"^^'^ 

CONTRim-TURY d>vtjlA<^ 

DIRATION X Years JN^'/^-^ 

(SIGNED) l.i^..<U ^^^-^ 

V.L .X u>o4 --— .Irvc^^vt^cl 

" ipEC AL INFORMATION only lor Hospitals, Institutions. Transients, 
or Refelu Ments. and persons dying away fro:!, home. 

.. Days 



Hours 
M.D. 



a 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 






(Address 



.il5>l^A - i^^<v 



4t 



1-1 ACK or lURIAK «'K KKMoVAl 

UNDKRTAKKR 

(Address 



DATl*. of lURlAl, or RKMOVAI. 

3^. ig?! 

91 H..W .^Vv^t^^^ov. a1 



^^"^''-^^^^ T " 1 FXAGTLY PHYSICIANS should 

..„.c CAUSE OF P..ATH in P-«J".|"-- ♦'';;„''.rr^ .n.^-.nc. 



•tote CAUSE OF DtAin m pi».n «■■■■- -- i„»t»nce. 

•on. ,lyln» away from home should he ft.v.n m .v,r. 



■% .. 



Hoar.l . f H.:iUh 1-No. i^ 

I)(ffr FiJrdf 

i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

■*.t^S^ H&l'io REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\i' n 



t-w 



I 



Kju 



'i 



cs. 



WO'i 



BeSisteved Xo. 



24 



ww^ www. — v-vj. Deputy Health Oflficer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiffcate of 2)eatb 

( *a. 5. StanC>arD ) 



PLACE OF DEATH : — County of C O-^^v J ^o.avxm^<m3 City of Hca^ J ^,<wv-c,v4,/t^ 






No. 



lax^ - R Ov 



ti 



St.; v^ Dist.;bct)j''U.^^^'^^-^^W and ^^'uO.Aj 



f \r ot*TH occuns •w»y rnoM USUAL RES I DE NCE gi ve facts called for under "sfJEC^L information- \ 

t ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



j^irrtov H. 



'a/>\Aj^ 



L4.C \>. 



SEX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



^\ctU 



DATK t)!- lUkTU 



Motith^ 



III' 

II 
(Day! 



VctjL 



(Vear) 



AtlK 



i'.'^ 



J • •< # 



S 



M.iuihs 






//<f 1 



( WrUe te iKici«l de»txOatton) 



lUK THPI.AOK 






SAMf. nf 
FATHKR 



HIRTHPLACH 
OF FATHKR 

• State or Cotjiitry^ 



MAIDKN NAMK 
OF MOTHKR 



BTRTfflM.ArH 
"f VoTHKk 

or Coentrj- 






OCCIPATION .. 



'V ./^ ' 



!f 1 .11 - f,' 



I , ;> 






1/ ,.'A 



THK \H<»\ K -iT \ TFt) 5•^••k-^MN- JlK |'\K r r« » I. \K-. AK>. IK t }-. lo IIH, 
liK^T OF MV 



informant 



KNOW lj:i>f,F; AM) Hi:i.fKP 



XVlf"** 



J\%\^ ' \^ 



L 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I) i:\Tn 

(Day) 



^IfMonthl'T 



(Year) 



I ni;Ri:i{V CI:KT1I"V, That I a|ten<le(l rU-ccascfl from 

Wvu. I up'i to /^-V ^ "- ^'f" "< 

tliMt I last saw h :^^'^^;tlivc• on V^^^"^ l ^'/^ ^ 

an«l that dtath occurred, oti the date stated above, at ^ 
'J M. The CAT SI-: OI' I) I-: ATI! wm^ as follows: 



1)1 RATION 'x Vear^ Months Pays 

CONTRIHrTORV WvLt.V\-^ ' cA-^' 



Months 



DTRATION '•^ i ^"rr% 



f)av^ 



Signed 



f>%J- 



Hours 

M.D. 



' 






S r>d'lr. 



VCCrtt r <t<^-a 



Special information ■»"!. t<ir linspitdls. institutions. friBsients. 
or Rrrrnf Rrsiifnts, dod persons drinj d>»^y frou home. 



formff or 
tsu.»l RfsMrnff 

Whin **«*> (JiviJSf fonfr.}f*td, 
If nol at pla<r of dfatlt ? 



Now loni] <4f 
Ware •! D<at* ? 



Bays 



PI,\f »•, '»f f'.' P i \I. "H V V.V- '' ^f. 



]frVt U Xv\Mjt 



irNl>KKTAKKK 

'Aflclre** 



r>AT} 



^M 



r 



or REMOVAI, 









PHYHICIANS nhould 



•tate CAU«E OF DhATH In pI»Jn term.. .h«t It mny Ue proprrly clH—fied. The 8pcwl«l Inform 
aon* dyinft away from home should he A'lven in av^ry Inntance. 



.' 



V. i 




f 



> t 



lii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

1 ni ilth-KNo i^^^^'^^IKSilTo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

K 



0) 



190H 



Megisterecl JVo, 



Date Filed, 

<jwtrvA.v^ .4sXa>^. Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



24 



Certificate of 2)eatb 

•Q. S. Stan^arO ) 



No. 



PLACE OF DEATH: — County of C' Cc-vv v7^<x>vcvi^oCity of ncuy^ :} K<X^y^^^^Ay^L^ 
WX^ ^ IS -tlv St.; ^^ Dist.; bet.NOU^^^^^x.^ and JX/)/.CX4 

FOR UNDER "sPECfAt INFORMATION" N 
INSTEAD OF STREET AND NUMBER. / 



( \r DEATH OCCURS AWAY FROM USUAL R E S I D E N C_E Gl VE FACTS ^^^^^f^ ^^ 



EATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME I 

FULL NAME 



n[u:Vxa\) . J /iJ..i.a.'>.xAx.:L4., 

-y — 



icsa.v. 



m:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.iiR 



^\oh 



i.ATK ov i;n<Tn 



iMnllth*^ 



id; 

U 

(Day) 



VctjL 



(Year) 



Ar,K 



-5-5 



) < ■;, 



S 



M.>»it/is 



Xt 



Dij vs 



•^iN*.!,!-: M\KKn:n. 

\VJI»nU HI> OK li!V< iRt | I> 
I Write in MK'ial flcHij^tiulion ) 



HlKTmM.M'K 
' StiUf or Country^ 



^ 



vh^wtcL 



(S ^v^JtcLt'Wj 



I- ATUl-.R 



TURTHI'l, ATK 
•)!• I-ATHKR 
(State or Comitry) 



maiih:n namk 
nl- mothkr 



U^vk 



AVCrV^ryv 



^ a\^uJLA-&Av 



nTRTTIPT.ArV, 

<>»■ M()rm:R 

(Statf or Country^ 



4 A 



>V.^'V^rW 



nCdPATlON •. •► — 

^V^/ifrd III S,ni /'i ijihisf,' y) V ]V,ri' *" M.^nth^ 



lht\. 



TM1-. MlOVK ST\'n:i) I'KKSONAI, I'AK rifri. \KS AKl". I" K l" 1-: TO ini-; 

HHsT oi- Mv KNOW i.i.ix.K AM) in:i.n;i'* 



nTifdintaiit 



-VA^ 



^ 



(X-AVV-^ 



(\<U1 



rcHs 



./ni'-"\ - R 



i 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



%1. 

(Month) 



\ -Z 



1 

(Day) 



(Year) 



I HI':R1:1'.V C1:KT1I"V, That I a^ttended deceased from 

.WvyX I 190 S to . |Y^-•^ ^'^ ^ 

tliat T last saw h -N^^vdivc on ^ WLu. . 1 190 H 

and that death occnrred, on the date stated above, at A. 
(P M. The CATSIC t)l' I)I-:ATn was as follows: 

LL^xl>-^^. . .^..^>^^^^'^^•<^^^^^ -<^^^ 

.Jw/>vv"^-v^Xr<A^s^a.tJil. ...':C^<x..\A.A^. 




DIR ATION % Years Months -^ Days 

CONTRIRl'TORV U>uQAa^ 

...^}\A..t^cvl.....f:^.<1^x^vAi.L^ 

DURATION X Vfars Months 

(SIGNED) i.. T). <UJ^ 

^di^ ^ Tqo4 (A ddress) '^A.1X^ ^>t V^.Un 



Hours 



Days 



/fours 
M.D. 



^pc(^|;^L INFORMATION «"') ^^^ Hospitals, Institutions, frdnsicnts, 
or Recent Residents, and persons dyiny away froii home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



IM \Clv OI- HI RIAL (»K K1:M*>\AI. 



DATHof lURlAl- or Ri;MnVAI. 

% 190I 



rNDl-.RTAKKR ^/V U.V*-^^ Jj, 

.,.u,res. ^.HJ.^ Vrrlv^J^^m. ni 



N. B.— F.very item o* f1|form«t1on should be cnreV'ully supplied. AGE 'j'^'"/'' ^^,.^'"'^^he^.^^^^^^^ In^rrm^a'tTon- fo^r p.r- 
state CAUSE OF DEATH in pl»ln terms, that it may »>e properly dass.Hed. I he op 
«on« dylnft away from home Hhould be ftiven in every instance. 



•I- 

I' 



i-; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Una 1.1 ..f H.MHh -I- So i^ 'O'^gg^ lUS: P (V 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IC'i 






,^il<' 



I 




pii/r Filed , 

DEPARTMENT OF 



X 



100 1 



Registered J\''o. 



25 




De|ju'.i' Heafth Officer 



UBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( "a. S. Stan^arD ) 



"^ 



PLACE OF DEATH: — County of ("^ <X^v '^.'vc.Avc.A.^ui^City of <"' <X,"w v) ^{Vrc<^A^^ ci^o 



rfO. 



, CJIu^^C^ %6^K^1wcJl. St.; Dist.;bet. 

"f / ir OtATH occults AW*Y TROM USUAL RESIDENCE Gl 
'J V. "■ Dt*TH OCCURRtO IN A HOSPITAL OR INSTITUTION 



and 



Vt FACTS CALLED FOR UNDER SPECIAL INFORMATIO 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



") 



FULL NAME 



i 



CL ^-^.WsJL 



'-CW-^A^^^ 




r 



-i.\ 



PERSONAL AND STATISTICAL PARTICULARS 



QXcL 



|t\ IK OF lUKTM 



7 

t Month) 



1 



A<-.K 



cd>t 5J) 



y^ats 



1 



{ Day) 



M.tntln 



\ 



(Year) 

An.s 



\vii)i»\vi:i) OR nivoRi'Ko 

I Write in M>cial fli«<iKnatii)n) 



lUK TMPI.ACK 

St.itr or ('oniitrv' 



» ATMl.R 



d"AxLcXAvrL 



niRTHPUACK 

<)|- lATMKR 

I Stat f or romilry I 



MAIDKN NAMK 
<>1 MOTHKR 



HIRTHPI.ArK 
'>! MoTHKR 
(State or Countrv) 






} 






cL 



/L(X ^ 



nccrPATioN ^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATIl 



Month) jT 



1 

(Day) 



(Year) 



I HIU^IvBY CIvRTIFY, That I .attended deceased from 



\ 



.XI I90H to ...)|^wAAlt...l IcpH 

that I last saw h ^;"):itValive on j^VvLLv I 190 'I 
and that death occnrred, on the date stated above, at 
-^ M. The CAI'SP: Ol' DIvATH was as follows: 



1 



DTRATION '. )V(/r.s- 
CONTRIIU'TORV 



Mouths 



Days 



//our. 



I )r RAT ION )\'(7rs jrof///is Pays 



(Signed) 



//ours 
M.D. 



Ktlu \ uA (Addres>.) ^-^^ ''^ U 'Id M |^ 

'A ' . _.A.. ,^ni.. Sftr Mncfkifilc Inctitiifinnc Trail* 



Special information only tor Hospitals, Institutions, Transients, 
or Recent Residents, and persons dving a^a) Ironi home. 



/)<M 



TMl. \ HOY K ST ATI; D PHR^ONAI. P A R P lOf LARS ARl-: TR IK TO TMl-: 
HKST Ol- MY KN0WI.I;DC. K AND HJCMKI" 

(Informant UjA>\;An\. "cLcL^vV-Ct-V -mV ob • 
(Xdflress Vvtu "^^^ ^ (I C^-Mv 



Former or . 

Usual Residence I 

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



^ (1 \ ^ -^A^ How lonq at 

b X,* l^caX^'V^.^ O^ Place of Death? 



Days 





PI.ACKJ^)!- HIKIAI.OK KKM<»VAI, 

,Ad,i,e« l(,lJirVv«A,vm. 



I!A'l"l';o!" HfRiAi, or Rl^MoVAI, 
(g ■ ^ I90H 



'V Cc 



! .. 1 *rp -Noi.lrl he Btatecl EXACTLY. PHYSICIANS nhould 

E OF DEATH In pinin terms, that it mny be properly clossiHeU. 1 nc opct u 



N. B. Every Item 

state CAUSn Uh UtA Itl in p 

«on« dylnft away from home Hhould be jfciven In every instance. 



iii 





VK 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,..r,1.,ni alth J No i^-S^^S^ H&I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lf)OH 



Registered J^o, 



r'LfrA.A.v^ Ltv^^ '^h Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



26 



Certificate of S)eatb 



( "U. S. Stan^arD ) 



PLACE OF DEATH: — County 



unty of "'OL^v lA.tV^wtA^JytU)City oi^^O^'y^^ J AxJ^vo^i^^ 



0^ 



No, 



InO i^^^vlMXVd.. St.; I Dist.; bet. J 'tXvXtr^ and >t. l^NJtl' 

/ IF DtATH OCCUHS AWAY TBOM USUAL RESIDENCE GIVE FACTS CALLED FOR U(<1dER ' SPECIAL I N FO R M ATI d*( " ^ 
( ,r DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME .NSTEaJ) OF STREET AND N U W B E rIJ ) 



FULL NAME 



Llv-tlv 



\^vV 




m;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COl/JR, 



QlwL 



loivcU 



i)\'n-: <n- lURTii 



A(*.H 






a a 



Yea*i 



10 



10 

(Day) 



Mnil/i^ 



(Vt-nr) 



C7%^^ 



Da vs 



>-IN<.l,K MVKHn'.I) 
Un)o\Vi;i) (»K DIXnRrKI) 
(Writr ill Mjcial (h'sismatinn) 



O^^xqUj 



UK rm'i.ArK, n ne^ 

Stiiti or ('Dtiiiti V' -A hM 



<^ 1 



<Xrs.' J/vOlo-v<1^.^oc 



Cat 



NX Ml- •»! » A ^ /-^ 



HIKTIIIM.ACK 

<»»•■ f-ATin:R 

'Stati- or Country) 



MAIDKN NAMK 
<H' MoTUKK 



lURTin'I.ACK 
<U M()Tin«:R 



Vhn^o.^vc^ 



cyv\M^v 



ClMii^a^rJv! 



\xan^XAHA<' 



"■•■"■■•■ (nwi^^Uc^ii 



<>cc 






nil*. AH(»VK ST\ ri.l) PKR^ONAl, P A K lirr I.A KS AKl". PRlH r<> TIIlv 

m-.sT <n- MY KNowijax-H ^>"" Hi;iji:»- 

(1^ (? 



'Iiifi.tmant ^/r 



VOl^ 



(i^ 



^ V'Mrrss 



mi 



TlUt 4. 



a 



MEDICAL CERTIFICATE OF DEATH 

DATI-; nl- DKATH 




M(»n(h 



1 
(Day) 



I go i 

(Year) 



HiAAvt 'X'S 1904 

tliMt I last saw h -A^^WValive on 



I IlKKlUiV CI-.RTII'V, That I attended dercascd from 

■ to .^Vr:^.V^ 3.^ 190 'i 

and that ileath occurred, on the date stated above, at i 

LL M. The CAlSlv OF Dl^ATII was as follows: 



Dr RAT ION Years 

CONTRIIU'TORY 



Months 



Days 



/louts 



DTRATION Years .Vof/f/is f^ays 



Hours 



(SIGNED) 



M.D. 




v ^ 1 ..o4 l-Nddre..) ^fvWv^ l)cJ:txH.^-^ « 



:* 



^FECIAL INFORMATION only for Hospitals, institutions, Transients, 
or "Recent Residents, and persons dying away froin tiome. 
c ,m«r nr ^ow lonq at 

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



I'l \C1C OV m'RIAI, OK RlsMOX Al 




rNDURTAKKR ^ ^^^^ > . t) 

(Address l;'3i.b UJ O^M^A^.^S->X. dl: 



-9s^ 



n plnin terms, that !t may be properly cIomWIccI. The »pec a 



N. B.— — Rvery Item of information 

state CAUSE OF DEATH In p 

son. dyinft away from home should be ftiven in every instance. 



M il 



•r-4 



WRITE PLAINLY WITH UNFADING INK 



HunnlofHcMl.h y-' So :. 1^^r^^:y.r.V Co 




X 



7f)0H 



/)((/(' tailed y 

DEPARTMENT OF PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

27 



Registered JVo, 



'HX 



City and County of San Francisco 



Certificate of 2)eatb 

( 13. S. StanOatP i 



PLACE OF DEATH: — County of r) cu^' J/vaov^.4TCity of "^.a-w i.va.>vcv^t,c 







/ 



M I a a a a.>V' Xt^X CI V^ -St.; I D Dist.; bet. ^ '^ A^K- and '^A t ^ ^ 

r^O. \ .^ << ^'CV.TV T^^7-7~^^ ,, -UAL RESIDENCE GIVE FACTS CALLED FOR UNDEB "SPECI^ INFORMATION ■ \ 

( '^ rF"o;iTrOCcJCV.;''rHO^S^Pa"L o"r fNsfl^JV'o^N O.VE ITS NAME INSTEAD OF STREET^NO NUMBER. ) 



FULL NAME 




VtOLvixJc-.. 



,.Qli ii ,0. 



vci-wrT^.' 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 






COI..)R 



JU 




!> \ IK nl- MIRTH 



\C.K 



Vl i\av<vr 



I V.uithi 



m 



) 



» (/ 1 



5 

(Day) 



MnHlll! 



(War) 



"X H /><" 



MEDICAL CERTIFICATE OF DEATH 

^s^^yJL. %.^\ 

(Month) ''>:'>■) 



IQO J 
(Year) 



Nl\r,l,K MARK 11*1). 
W IDnWKP LiK I)!\< >Ki j:I) 
Wriff iti social <le^iKtialu>ti> 



inKTmM..\OK 

^tatf or Country! 



N" \MI <)l 
1 A 111 ).R 



i 



lURTIiri.AiK 

It! » \iui:r 

' st;tti or <.'oiintry) 



III MOTIIKR 



lUR riCIM.ACK 
•»l MoTllKR 
(Stall- or Co\intry 



OCCri'ATION 






I in':Rl'BV Ci:RTirV, That I atUMKlcd (lecoased from 

.|vv lAX 1 190 '•( to ^^.'^^ .l-'l 

that I last saw h XV alive oti W»^ V^ 
and that death occurred, 011 the date stated above, at / C ■ <i 
.(J M. The CATSI-: Ol' DliATll was as follows 



I90H 

190 H 






(? " 



rvtrv.vt^ll.-vvtv^ 



CL. , Ccv kcuLo^UA 



Dlk \TI()N ■ Years 
CONTRIIU'TORV 



Months I ^'' Piiy^ ■ Ilours 
^\^1XJL...sX::y.\£LJur)r:^\^ti^ 

DI-RXTION ^ Years t .V.;;/M.? ^ Pay^ ^hmrs 

,S.O..O) [(B.aiUUk.ll^ M.D. 

■ SPECIAL INFORMATION «"!> I" ""^Pi'-I'*. Inslilnlioi's. Transitnls, 
ot Rftfnt Rcsidcnh, and pfcsons i)\n away lt»^ Home. 



1- 



f\'rsi(fri! Ill Salt /i iiHi tu-i> *« ) '' 



7 / » 



^f.uilh' 



/hn 



TUV. AnoVK ST\Tl".I> PKR<.ONAl, TAR TUri.ARS ARl". IRIK I' > 
IIHST Ol' MY KN(>\VI,i;i)r.K AM) HlvIJl'.K 

ixa ncx>x- V^-^'^ U\M. 



r 1 1 !•: 



^\<Mrcs^ 



Formfr or 
Isua! Residence 

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



How lonq at 
Place ol Death ? 



Days 



,.,,ACEt)F m-RIAI, OK K'-^'"^ ^' 

^ -icu Cat 



DATK'.f TUHI.VI. "I" RIvMnVAl. 






V-w. 



■■"i"^— ■— ■^^■^^— n^— i^— ^■^^— ^^■'^^^^^'^■^■^^■^^^'"^"'"'^ I pxACTLY. PHYSICIANS should 

N. B. Rvery Item o? Information -houlcl l« cnrefully HuppHecl. '^'''"' "I""!','' ^.^.,^j" %he "Special information" for p«r- 

«tot/cAU8E OF DEATH in pinin term,, that It m«y be properly cl»HH.tled. 
sons dylnft nway from home nhould be ftWen in every Instance. 



it III 



t- 



; 



■ 11 ^ ' 



Heard. .f H.nUli 



ill 



OS.' 



loo'i 



Registered J\^o, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,. ^,, , , tj^fS^fc; n.-^ V Co REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 

, '"^^ .. .. , 28 

l)(fli' Filed , 

dc(rvcA^ oOtoru^ Deputy Health Officer 

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

Certificate of 2)eatb 

( -a. S. Stan^arD ) 




4 ^ ^ '^ 

PLACE OF DEATH:-County of ^ cv^v JA,(^vCv^c.Gty of O^w. 1 Axwt.u^i^ 



KT ^1' ^o^a^ St.; R DIst.;betXcui^vTv<V and 

No. ^-^ ' '^ '.^'H^-^ USUAL RESIDENCE GIVE r*CTS called roR uiAder 'SPECAL .NrORMAT.ON" \ 

( " ^"o;:Trocc^^;ro^"^Ho'^s^RyT'L r'TNSx.TJV.ON o.ve .ts name .nstea:1 or street ano number. ; 



'^ 1 M 



''D^wCxi^A^v-a > 



FULL NAME 



.i. )W W'^:^^:><^---^--<^^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.nR, 



t 



DATK <•! niKTM 



It- 



\x) AxOjl 






ID 

(Day) 



(Vear) 



\<".K 



i1 >•-./»' 



^ M.tNthii 



IM 



A/ 1 . 



MEDICAL CERTIFICATE OF DEATH^ 
DATE OF DKATM 




slNi.l.K MAKKIl'l) 

u ii)«i\\ j:i> ok i)!v«tKri:i) 

Writ*- in ^'Hial <le«iv:tjatiun) 



HIRTinM.AOK 

stMt«- or Country' 






im 



i'l 



»1 




N \M1, ()t 
I ATMLR 



(IIKTIUM.XOK 
<>| I APHKK 
'Stiitf or loiMiti y 



• »l MOTIIKR 



r.iR'rmM.ACH 

t»l- MoTllKR 
'State »)r Country) 




r\^-v-vfr^v^v- 



<^ A^Lcv^vcL 






A-v^frvcnv 



I lU'RICHV C1:RTII'V, Tliat I atten.kMl deceased from 

V^^VC O.a tc/dH to ^VL-WV4L .an i(/)H 

that i last saw h XV- alive on ^^>^ ^'^ 1<P H 

and that <leath occurrcl, on the date stated above, at 
Ub M The CArSH OF I)IC.\TFI was as follows: 

"a 



./yK)LU^>^ \xrvx v<x.. 




I )r RAT ION >Vrf;.s .1A>;////-? -^ /^rtV.? 
CONTRini'TORV >^'^ 



II outs 



I lour 



M.D. 



nrRATION years Mouths Pays 

( SIGNED ) Jv<X^ C . JJ CL^UvOn^vtK- 

SPEciML INFORMATION only for Hospitals, Institutions, Irdnsients. 
or Recent Residents, and persons dying anay Iron liome. 




CCNA^CL 



\!n„th' 



n,t\. 



OCCrPATlON <»-•►•- 

Rf>iiirii I ft Sdtt f'tnmiu-it .1 > ''' 

Till- AUOVK STATHl) I'KK^OWI. I'AK lU' T I.A KS AKJ-. TKlK T< » Tl'l'. 
in;sT Ol- MY KNOWMCIX.H AM> m.MJ.i- 



(Iiiformaiit N rVVA>5 <7VWV 



JLvlxvkvcLc 



U.l.l 



ross 



.^lO. ^^aq>c "5"^ 



Former or 
Usual Residence 

When was disease contrarted, 
If not at place ol deatli ? 



How lonq at 
Place of Deatfi ? 



Days 



,.,,ArK Ol m KIAl, OR RKMOVAI, 



DAIi; of IJiKIAi. or RHMoVAl. 



TQOH 



rNIH-.K'lAKl.K 

(AtMreS!*.... 






N.B.— Every item o? Information •hould b. c..rc?ully HuppHed. ^^^^^^f;;;';^,'^^^^^^^^^ %he •'SpcJia! lnform..f..>n" for p.r- 
•tatc CAUSE OF DIIATH In p1..5n tcrm«. thnt It m»y »^ ';*'^;'"^ 
nnn% dylnft away from home hIuh.I.I be ftiven m every Instance. 



• I 



h 



ii 



tii 



l:i 



•|i 



, li 



", J 



i 




HiiaT 



., of iicaith-r No. .. ^^^Sr^ns^vcn 



lOOH 



Registered JSi'^o, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

„ _.. S9 

Dale Filed , 

Xm-vl^ cLt-i-v^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




Certificate of Beatb 

( "a. S. Gtan^ar^ ) 



PLACE OF DEATH: — County of 




<\^ 



City of 



CcJUAt^O^X' L<XV.' 



r 



No. 



St 



Dist.; bctr 



■ and 



- ro«« IIQUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" 'V 
( " rF"D;ATrOCCU%;r;iN''rHO^S^pVT'AL o"r TnSt'iT^^t'o'n O.VE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




^CA^A^/^A^O-^^-A^^ 



m;x 



(JUa-L 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR r^ 

l\ iM<»nth> 






AC.K 



n . 



«»flr* 



(Day) 



.MfOilhs 



(Year) 



IL 



) Da 



».\ 



MEDICAL CERTIFICATE OF DEATH 



DATK <)I- DKATH 




(Day) 



190 A 

(Year) 



1 lll'iKl'BV Cl'RTIFV, That I attcMKltMl deocascMl from 

: "" 190 " 

— — — 190 



190. ~— "~to 

til at I last saw h • ^a live on — 



--INt.l.K, MAKK IK I) 

U IIHIWHI) OK DIVKKiKI) 

■Write in MK-inl iksijf nation) 



I'.IK IHIM.AOK 
state or ('ountry^ 



N'AMK OF 
1 AT 111: R 



HlRTHIM.ArH 
or l-AIHl-.R 

'State or (."oiuitry) 



\t\II)i:N NAM1-; 
«»1 MOTHKR 



lUKTMl'I.ArK 
o|- MOTHKR 
'State or Couiitt \ 






ati«l tliat (U-ath occurred, on the date stated above, at 
.rrrrr ^J. The CATSF^ OI- DICATII was as follows: 




I 



v.^. 



v^vvAvrcA.^^ 



(^ 



# () 






<>cci;i-vTioN ^^^^ cKnnU-vt*XX 



',-si,f,;i in SiUi / 1,111. I',-.' \'A )'■>"- I ^f'O't'i'' 



rhir. 



TMK AnoVKSTATl-.l) l-KK-^ONAl, rARTUT LARS A RK TK T H TO Tllh 

m;sT oi' Mv KNo\vi,i;i)<".H and m:Mi'.i- 



(Informant 



f \<MresH 






DIRATION )'t'<irs 
CONTRinrTORV 



Months 



Days 



I louts 



nr RATION 



Years 



Months /^<n'.? 

(SIGNED) k>\^ 0<XVVV4.1^ 

J.L m Too'i (Addre>;>.) ColLlttrva 
lit |N=''^°'^'^"'''^'^ ""'■ *"^ Hospitals, InsH 



Hours 



M.D. 



rj 



SPECIAL INFORMATIO 

or Retenl Residents, and persons dying away from liome. 

/TJ , How long at ( 

4 H ^ W^ rvMV CVCv^<Lv!LJ»lafe of Oeatli ? 

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



Former or 
Isual Residence 



^ only for Hospitals, InsHtulions, Transients, 

.. Days 



? 



ri,ACH Ol- lURIAI, OR Kl-:Mt>VM 



DATKof IMRIAI. or R1:M0YAI, 

\lwvu Ij L99H_ 




<..a,„c„ L5J-.H d.Uc4<-., r^* 



■"^ I I h t t tl FXACTLY. PHYSICIANS should 

information bHouIcI be cnrcfully Hupplied. ^^^ *;;"" ^,.f,^j" ^The •'Special Information" for p.r- 
IF DEATH in plain terms, that it may he properly claM.tie 



N. B.—— KverylKem of 

state CAUSE OF DEATH in p , i„„t«nce 

«ons dylnft away ?rom home Hhoulcl be Jiiven m .very instance. 



Y 



% 



:l: 



8 



I -I 



\ 



, I ■'■ 



■ I, ■'» 




f 1 



'• * .a^f ^ . ' '■ !j!!! t L! 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 






I 






S^^-vv^v* 



V 



100'\ 



REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

lie^lstci'cd J^'^o. 



30 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 



Ccvtificate of IDcatb 

( •Q. S. StanC»arC> ) 



PLACE OF DEATH = -County of ^^^I^^V.V^^-.Gty „f ^^^'^^-c^- 



No. 



S-'?'^ Lev, 

IF DEATH OCCIF 



St.; ^ Dist;bet. I 



% ti 



and 1^ 

V IF DEATH OCCURRfD IN A HOSPITAL OR INSTlTUiiu™ ilS A ^ l\ 



tlv Ou 



) 



FULL NAME 



.O.AA.A.a 



,l\/\vcu- . dwX' 




SK\ 



personal and statistical particulars 

vTX^>volUw 



COI.oR 



U). 



kttx 



MEDICAL CERTIFICATE OF DEATH 
DATE OF UKATH 



DAIi: «»l- J'.IK I M 



\(.H 



a^ 






(Dayl 



(Year) 



siNc.i.K MARK n:n. 

WinoWKD OR DlVoRrKI) 

iWiitfin ^'K-ial th-sij^iiatioii) 



S 



M.nilhs 



v\ 





(MoiUlO 



I 
(Day) 



IQO H 
(Year) 



Davi 



^Vv^rUOAX 



niRTnpi.ACK 

I state or Cotiiitry^ 



I \ini".R 



((^ '^ 



?s 




X'V'V'wc*-^"^-' 



MIRTMri.\<*K 

t>i I Arni:R 

iStatf or Country) 



MMDl-.N NAMl*. 
()!•■ MOTHI'.K 



BIRTinM.Al'K 
oi' M(»TnHK 

(Slate or «,'(>\it\try) 



h 



llDA^Ur^J^tiv 



I HKRKRY CKRTIFV, That I atUMuleil .leocascd from 

.v-^vV X^ 190 M to l^n^ ^ ^^ "^ 

t,.it I last saw hXV alive ott '' YH ' T a , 

n„.l that .Uath occt.rrc.l. on the date stated ahove. at .^ -"^ i' 
J ^f The CArSl- OF DICAT'.I was as follows: 

(%Xxr<i C<rLuiA.>> •■ 



DTR.XTION )Vrt;-.? 
CONTRII5UTORV 



Mouths I'>ays Hours 



(irCfl ATTON 

Rrshtrtf iti Stift /'i iiih /yrn 



XvA"v^CV>v^{^ 



JV<r;'5 



.}rotiths 



Pavs 



./ .»///! /'..,.. Hours 

DURATION J^''?''^ ../<^'////-^ 

, o.uNED ) T^^<^t^^ -.0^. ^^-^^ 

Viu 1 .no-i (A.l.lress) 1^^W>V 
SPECIAL INFORMATION only lor Hosp.l-ls, Institutions, Transients, 
or Rerent Residents, and persons dying anay froii home. 




M.D. 



)'rii> 



I 1 A, ;////> 7^ 1 /''■' 



lin:Am)VKSTATKPl'KRsnNAUrXRTK;ri;VKSARKTRrHT<) THH 
HHST OH MY KN<)\VI.i:i)C.K AND IU-.l,n.l' 



HHST OH MY KN<)\VI.i:i)C.K AM> lo-.i.ii." 

„„r,„ , ^XV'-r^O-A^ %XvUvtk 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



n \CK OV niRlAL OR RKMOVAI. 




nxri'.o: miuAi. or RHMi>v.\i, 

,X % TQOji 



l^Vvtu -^ 



I NDKRTAKKR 

(.Address 






( \ddress 



IN. B.- 



— ,^^^ L»Li— ^ . EXACTLY PHYSICIANS should 

Htfltc CAUSE OF DEATH In pIhIh terms, tha .t r„»> .^e P^ ^ 
«on. dying aw»y from home nhould he ifc.ven m ever> instance 



I 



1 . 



vinw^ ,'»->■ 






m 







l0 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

*rS>-^H*I.Oo REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

j,,n' FiM, V-K ^ '^^^ Begistered J^o. 31 

^tr^.v.v.> <x\^ nei^'i^vHeafth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Death 

( XX. S. StanOacS ) 



1^ 



PLACE OF DEATH: — County of 



J? ^ 






^ 



^OcivOt^CCGty of ^5a>v J/VC5^>v<^v^C^ 



Plo. 



.e 



I S ..V 



Dist.; bet. 



and 



-VVXvjtOwl 2J ^'^1^-^'^^'^^ ""'.'■ „^^^^;NC^ GIVE t^cVs^T^^^^^ UNDER "S PEC . AL . N FOR M AT.O N ' ^ 

„ OEA.H OCCURS aJaV -° "-^.^.^.V.'l.t J," f^ ^.^^'u"^^^^ NAME .NSTEAO OP STREET AND NUMBER. J 



( 



IF DEATH OCCURRED II 



FULL NAME 



:\9.(rru 




AJO.. 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR 



DA IK *H- lUK III 






/ (Nfoiitht 



15 /..US-- 

(Day.) (Vear) 



ACK 



3^ 



JV<;» A 



siNCI.K. MARUIKP 
WIDOWKI) OR niVoRrKI) 
iWritciii MK-ial (U'-i>rn:ili<iii) 



lUKTMPI.AOK 
'Statf or Counlry^ 



SAMK Ol- 

I- atiii:r 





inRTHlM.Av'K 

<)» iArin:K 

(Slate or C<Hnitry) 



MAIIU'.N NAMH 
ni- MOTllHR 



luu ruruACK 

(»F MOTHKR 

(Slate or Coiintry) 



^ .M.,tilhs \.\ 

Oft (] 

n 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DP:aTH 




Davs 



Lrvrv 



I HKREBY CKRTIFV, That I attended deceased from 

. W Xl 190S to .. W ^9oH 

that"l last saw h-^^^alive on • f^ ^ '"^ 

and that death occurred, on the date stated above, at 
Cb M. The CAISIC OF I)1-:AT11 was as follows: 



DFRATION ^ Years 
CONTRIBUTORY 



.C Months ^- I)ays 




I)i:ration 



Years 



Jfonf/is 



Davs 



Hours 
M.D. 



(SIGNED) .U)... "^.M rtU. 

sUciiL INFORMATION^ tor Hospitals. Institutions, Transients 



CiJh 



00 



11 

CrPATION 1^,^;^ 



nlltll' 



n,n 



VnV. AHOVK STATK n .'KKSONAI. TA KT IC r I. ARS ARK TRVK TO THK 
UHST (U- MY KNOWI.KPr.H AND lUJ.ll-.^ 



(Iiif()t«n;int 



\Ay\^ 



(Address . 






or 



ReTeni Residents, and persons dying away from home. 

J '?p How lonq at 

Former or r) A -n.. J ;v<X a VC>^.4 c tpiar c of Death ? 

Usual Residence ■^'^'^ ^^ ^ ^^^ 

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



.. Days 



f 



ri,ACK OK nVRlM. OK RHM««VAI, 



DATi: nf HfKiAl. or RKMOVAI, 



V[l\atcc C 



0_- 



Vvvu 3 T90H 



r 



INDHRTAKKR 

(Address 



A/TUV 



A^VW 



,..iB EUm ''^^^ 



■— — ^■^^■^■■■^■■^^■■■■■■""""""'"""^ * I FVACTI Y PHYSICIANS should 

„.,on .hou.c. h. cniefu.ly suppHec.. ^«^^ ^^"^/^U'^T:" Th: '"^^^^ .„for„,ar.o„" for p-r- 

4TH In pInJn term*, that it m»y be properly class.tic 



IN. B. Kvery Item of inform 

state CAUSE OF DO.- . . Instance. 

•on. dyinft away from home Hhould be .iWen m every Instance. 



••riiKi*"»a >av 1 " 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



,,,,,.l..fH.:-,Mh-KVo ,.^^jg^lUS:PCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

32 



Registered J\^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of Death 

( ■a. S. iataiiCatS ) 



PLACE OF DEATH:-County of ^ ^^ .U<x>vc^c.Gty of ^^v J A.rt.vc.vvc- 



A 



No. 






) 



FULL NAME 







SKX 



PERSONAL AND STATISTICAL PARTICULARS 



QtxcL. 



C 



'Vv^aX^^ 



DATi-: <>i- lUK in 



i Mouth > 



( 1 ).M y) 



/^SS 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DICATH 




(Month) 



.3..^ 

(Day) 



(Year) 



I UKRRBY CHRTIFV, That I attctKled deceased from 

to 190— "■ 

— - " " IC)0 




A(*K 



'^b 



)'/'.f I 



M.mth- 



Da v. 



that I last saw h - 



190""" 
— alive on 



SI\<.I,K. MAKun-.D 
WinoNVKD OK niv«'K^Hi> 
(Wtitfiu scKinl (lt--iv'iii»ti<>u) 



lUKTin'I.AvM*. 
iStatf or Country'' 



lATHl-.K 






a„.l that death occurred, <.n the date stated above, at 
^___^I_ The CAISI': m- DlvATlI was as follows: 



lURTTTPT.ArK 

01 1 Ariii'.u 

(St;it<- or Country) 



MMDKN NAMK 
Ml- MOTIIKK 



lUKTMlM.ACK 
01 MoTin'.U 
(Statv or Co\intryl 



;o 



Ukx/' 



.;S..^J^..r^.•vv'^-^^^^^ VOL . .-^.'^^ 



nr RAT ION 

CONTRIIil'TORV 



Years 



..,L.4-v..<^^-^<^->~ 

Months Days 



Hour 



DIRATION 



Years 



M'onihs 



Pays 



//('//; V 



WOw 



JoUpw< 




'VUL 



(X> 



( SIGNED )..l'^.^a).l^lc^v^Uu.vt^ M.D. 
LvyvJL '-^0 IQ0'1 (A.hlress) 




V^VVOs. 



OCCl 



fffsiitr.f ill S.ni / Kim ism A,i. ) "" > 



yrmitii- 



n,n. 



rm-. MM.VlisTNTKl.l'KKSONAl, CAKTICl 1. V KS A K K. TK T K T« • THK 

in:sr o.J? mv knowmcdck and iu:mi.i- 

(Infonnnut ot CTV^ V^^^^VO^ 



(Address ... 



.1 I'l d.'O.C>v<X>^^JtAV 



^rpECIAL INFORMATION onlv lor Hospildls. InsUlutions/Lnslenls, 
or RereJt Residents, and persons dyiny awdv from hone. 



OJk, 



Former or 
Usual Residence 

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



Hnw Innq at 
|»l,i( e ol Death ? 



Days 



I'l AtK OH m KIAI. OK KJ-MoVAl. 

(AddK'^'^ 1 .-^ A ^ 



1»\ ri';ol UiKlAr, or Kl-.MOVAI, 



it 



— — — i«— — ^ t I I XACTlY PHYSICIANS s 

N. „._P.veo. item of i„fo.n..tlon should be cnrafuUy suppned ^»;»^;^";;^',Xl" ^Vh: ••Special lnfo..««f.on" ?or 
state CAUSE OF DEATH In plain terms, that It m,.> ''^J ^ 
sons dyinft away from home should be ft.ven m every instance 




mv> 








WRITE PLAINLY WITH UNFAD.NG .NK-TH.S .S A PERMANENT RECORD 

^_^ =r.r«rB -TO BACK OF CERTIFICATE FOR INST 

Hoard of u.-.Hh-l- No- ''. -^..^.^y^ 



I)((/e Filed, 



^v,v,Lu A. 



1V0\ 



REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

Re mistered JVo. 



«1S 



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



CcrtiHcatc of ©eatb 

( tl. 3. StanDarO ) 






PLACE OF DEATH: — County ot u^rv 



- ) 



FULL NAME 




AA^^^'O.^i^'V^ 



SKX 



i)\ri: t)i lURTu 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK , 



" rViEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 




(Day) 



(Year) 



a^t HVV'^^Ul' 



MonOit 



(Day) 



\<.K 




4>S )v.M> 



Mouths 



(Year) 



/)(/V.V 



SlNC.l.lv MAKKIKD 

\Vn)t»\Vi:i) OK DIVoKlKI) rt 

(Write ill s<x'i;U (lr«*i>r":»l'<>"' -^ 



lUKTinM.AOK 

I Mali- or Covintry ' 



NX Ml- OI- 
!-ATin-".R 



lUKTUri.ACK 
OI- l-ATHKK 
(StalL- or c'oiintry) 



M MDl'tN NAMK 
(.1- MoTHl-.K 



lUR'nnM.Aci-: 

oi- MOTHKK 
(State or Country) 









rT7?MUCM^~CM^J<^ 'H'^'t I attcMuled aecoasea from 

.; ——..190 to ^^ 

that 1 last saw h •- »live on '^ '"^ 

,„a that .loath occurred, on the date stated above, at 
-M. The CAISP: 01* I)1-:ATII was as follows 



Jrvrnfv. 



DIRATION y^'ars 
CoNTRll'.rTORV 



Mouths Am Hours 



Pays 



I.IRATION years ^Tonlhs 

( SIGNED ).C*^«^^' ■* . 

-JpEC.AL INFORMATION .^H.spi.-M-ti...i.nU™s,e„.s, 
or teeM Menls," d persons dyi»g a»»> I™" I-"™'- 



//ours 
M.D. 



kr^idr.f il l S.ui rxiinisro I b )V<?>^ 

TMK ABOVE STATED PKRSONAl. i:)'^^;!),^!^;^'^'^ ''''^ '''''' "' ' 
HEST OF MV KNOWI.EDOE AND HEMIJ 



Months 



/),n^ 



TMH 



Former or 1 Sj J^Lt(X ^'-^< 

Usudl Residence I 'V.-VVW. 



(Informant 



(JU <Ctq n.n \. 






Ho\« lonq at 
, vj^v-atX Place of Death? 

When was disease contracted, j ^ XctvC\tu, T"^ 

If not at place of death ? 



,., XCEOI- HIRIAI. OK KEMnVAl. 



Days 






,uv^' 



,,Ml.:n! hIuiai. or REMOVAL 



l%c.ac..vVt 



..DER-.KER J-^>- -JJ-^^^^^^^ 
(Address ^ l ^^ _^__^^ 




IN. B. 



(AddresH "n \ -^^ V ^ • ^ ^ ~ FXACTLY PHYSICIANS should 



i I 



Ni'^.^'--r:«>ff»^^»'^' 



i 






f 



H 






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

, ,,.,,..«r,-^...,..v, HEFtR TO BACK OP r rPT.nCATt TOR .NaTRUCTIONS 

j /I J (I 

/Lti-vcv/' ,Lia^u Deputy Health Officer „ ^ n r ' 

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

Certificate oi Beatb 

( H. 5. Stan^ar? ) 
<^a.>v^-^c^>vc.^^^ City of 9^^ J^vc^^c^x^ 



rftn 



PLACE OF DEATH: — County ofUCLW 



Ltii"^"^ wv^' 



1c 






FULL NAME 



Ox'vI'v.vaAx 




^nx^ 



PERSONAL AND STATISTICAL PARTICULARS 



DATK <>l- lUKllI 



U).ivU 






I Day) 



(Yeur^ 



MEDICAL CERTIFICATE OF DEATH 
DATK OH I)P:aTU 





(Mdtltlj 



1 .. 

(Day) 



(Year 



'A 



\(.K 



ai 



) 't\i I 



\ 



M.itilhs 



n 



Dn \s 



nn?RF.BY CKRTirV, That I attemk-d aeceasca from 

^TNX 'X\ 190 H to .^.f^ » ^90 -^ 

T90 ' 

i ' - 
D. JO 





S1N(.|.K. MARKTKD. 
\VIl)«)\Vi:i> » »K DIVOKtKH 
(Wrilf in s(km:ii il<si^'n.ili'>n) 




lUUTHIM.M'K 
i<tritf <ir Connlry^ 



I A Tin: R 



lUKTHlM.ACK 
01 lATJlKK 

'St:itc or Cotinlry) 



M VIDKN NAMK 
«tl MOTHKR 






V^Ow 



en 



^<X>V- 



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

an.l that death occurred, on the date stated above, at 

Ll,M. 'Hk' CArSI-: 01' Dl-.-Vni was as follows: 



. . .y . . >cJi>«-^«-^*-'"^-^- 



\.^- 



Dl'RATION ^'-^''-^ 
CONTRIIU'TOKV 



Mouihs Days 



I lours 



a 






lUkTMlM.ACK 
Ml- MoTIIKK 
(State i>r Tottntry) 



OCCVI'ATIO 






lor lilospitdls, Institutions, Iransients, 




or 



/)(M 



TMK XM.>VKSTArKnPKRS..NAI.rAKTU;ri.AKSAKK TKIK To THK 

ni:sT oi- MY KNo\vi,i.i)»".K AM) ni-.Ln-.i- 



iiPFc lAL INFORMATION only 

Re^n^Vsidents' and persons d>inq a.ay [ron home. 

Former or a aa (y*>^.*^Xv O't pjarf ol Death? 

Usual Residence < ^-^- --^^^^ 

When was disease contracted, 
If not a t place of death ? 

Vl.ACK «)1- m-RIAI. «> KKMOVAI, 



^ Days 



] 






«... b^. Cn\ 1<^U 01\ ^£^ I ^^J2 ^0, vo ^.V^i'^A" 

(^ . a r^ u^ W I h V (Ad.lross 0»^ ^ 

'-'-^S ^^-^ ^^^^^"^ . „*CT.V. P..VS.CUN« »H„„.7 



•on. dying oway from home should be fti 



1^ 



ih 



!i 



W':. \ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed , \.JL\j^ X 

t 



( 



l90'^ 



Me^Lsferecl Jfo. 



35 



ChWVW^ 



AsJUv 



^i Deputy Health Officer * ^^ t^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX, S. StanDar^ ) 



r?r> 






<?Ji> 



^>. 



PLACE OF DEATH:-County of Aa.v''V/v<x.v^c.Gty of rV^^v OA.<v>v^v^ .. 

( " ^/rc:Trocc^^;ro^^rHo^s^pVT':;t r^Nsn^J'^'^c.v. .ts name .^st^o o. stb^ct ..o ...s... j 



Dist.;bet. 



and 



FULL NAME 



Q)\ 



<XCL C5L' 




Ni:\ 




PERSONAL AND STATISTICAL PAR TICUL ARS 

.Month) •I>ny^ ^^^^""^ 



M 



EDICAL CERTIFICATE OF DEATH 



ttVVvCUA^OL-a 



\«.K 



UV OV> )V«Mv 



....i 

(Day) 



(War) 



C^ 



SJN(.1.1-., MARKIK!> 

W n)«»\Vi;i) «»K T)!VnKrKI> 

Wiittiii vtH-ial iU->»iv''ia»i'>ii) 



Miitifhs 



An 



'4 
■« 



Stiitf or Country) \ l\ . 







NAMK OF 

I AT in: K 



HIK IHlM.VrK 
<»1 I AT 111'. K 
'Stall- or c"o\intry^ 



n jwv 



->vOw' 



MMDl.V NAMK 
ol- MoTllKR 



lURTHlM.ArK 
<>1- MOTHKR 
'St;itr or c'o\intrv) 



OCCrPATlON 



-%. 




DATE OF DKATH^ ^ 

\x\Xjji. 

I (Moji^i) 

~T7FhRI:1'.V C1:RTIFV, That I attemkMl .U'ccased from 

W'>Vt X'?». I90H to . W TcpS 

that T last saw h ^^ alive on f^^^ ^ 'Oo"- 

a„.l lliat .loath .)ccnrre.l, on the date stated above, at %X<> 
M. The CAISI- Ol- DlvATII was as follows: 

t^^d^t^^^ 5^^0vc|.^^U..:^J^^^^l^... 



DrRATION..-^ >V.;^, - ^fontl^s^ ^ Days . _^ Hours 

,rai....ai\..i^..^.v 



CONTRIBUTORY S <A.w^-C^ 



\.^i 



(Signed) 



J/ont/is P(iy< 



Hours 
M.D. 



DURATION >Var^ -. 

C..i)Jli.i- .. 

cIal INFOR 



i i MATIO 



IM onh for Hospitals, Institutions, Transients, 



AV.wV/rr/ /»» \(7»/ /'i iiiK isro ,•'. !*'<?' 



lAu^/Z/v t /'.M, 



Till-. \H()VKST\TF.l) PKKSONM, l' AK I I*' T 1. \ KS ARK TRTK T« > TIN- 
KKST Ol' MY KNOWI.ICIX'.K AND lU'.l.ll'.l- 



(IiifotmatJt 



M l\v. V CV>AXV 



or1eren^^es7de"nfc' ' j rerVonV diing away Ironi home. 

vl> ^a,>x<vU Ubf l?fe Toeath ? C) Dav 



Former or ^ f\{ 'i 

Usual Residence <?k U D «> 

When >»as disease contracted. 
If not at place of death ? 



ri.ACK 01-- HIRIAK i'K Ki;MoVAI 



DATi; •';" HiUIAI. or KKMOVAI, 
X T90"\ 



rNI)i:KTAKKR 

(Address 



C.li.VUX^NtN 



. FX4CTLY PHYSICIANS should 

N. B.— Every item of Infor.m.f.on .houh. b. crcfuHy supplied. ^^«^;;",7;3t,^k'i?'%h: "Special ln»'or„.af.o„" for pT- 
state CAUSE OF DEATH in plain term., that .t may I'^j;"^;'^'" 
son. dying away from home should be given In every instance. 



I 



> 



I ' i 



I ♦ 



; 



! il 



i! 



II < 



IJ 



Si 



i ■,.:il 
ii'j 

IS 



ii 'il 



)!ii;if<l 'if H' :i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„ ,.^,, „■*,?*:>; MS. I. Co REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 



X 



lorn 



lies^Lstered A^o. 



36 



pff/r Fih'd y Nk^JLu 

fA^fr-vvv'^ cLi^\>u Deputv M#*ar*-h off'-^f^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificate of IDcatb 

( n. S. StanDarD ) 



4 



J? ^ :4; '^ 



No. 



PLACE OF DEATH: — County of ^ Cc^aj 

t.; ^ Dist.;bet. .>7 (rV4.r> ; 



and 




IP f) I 

v5 35 J A.V^L| ' >^- RESIDENCE GIVE TiicTS*c1^tLED FOR UNDER SPECIAL INFORMATION • \ 

( •' rF^O^^TrOCC^J^rcV.^'^rHO^S^rT'it O^R^Nsf.^^O^N^O.VE -TS NAME .NSTE.O OF STREET ANO NUMBER. J 



(OJK-^\A^^n^- ) 



FULL NAME 



Q^Wvu flT^vt^lxJll. 



SEX 



n\'i J. oi- lUKiii 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



OjItaxolUI 



lOlvU 






\r,K 



JV**^^* 



I 

(Diiyt 



!/.<»//// « 



(V<ai 



MEDICAL CERTIFICATE OF DEATH 

DATP: of DKATIt 

I 



(Day) 



(Year) 



/»,n 



\VIIM>\VKI» <»K DIVOUrKP 

Wjit'iii viM-inl (IrsivMiatioii) 



<^ ^^\.aL^ 



I'.ik rm'i.AOK 
istatf or Country^ 



N \ Ml ■ n I' 

lAi II i:r 



lUkTHlM. \CK 

(ti- i-.\rni:K 

• state or Country') 



M.MOKN NAMK 
<il MOTMKR 



lilk TIMM.ACK 
n\: MOTIU-.K 
(State (If Coijtitrv) 






nrrrpATioN 



(>v. 






iVwLM 

(MotithJ 

I lli:ki;i>.V C1:kTIFY. That I a1:ten.le<l (leceascd fn.ni 

[VvUl. \ i9o'\ to jv|^^^ ^ '"^ '' 

that 1 last Lv h .v^ alive o.i |^^"^^- » '^^ '^ 

a„,l that <Uatl, ..cct.rre.l, m, the .h,U- stated ahove, at I i-^ 
U M The CAl'SH Ol' DlvATII was as follows: 

■ rJiJi. ,.^^..vx^ 



DIRATION ^.. Vrars ' MontlH ^ 

CONTkllU'TORY 



Days 



J lours 



^ Ltb 



in- RATION ^>V^''-^ n''^^''"\'" 



Pays 



//ours 




(SIGNED) 



M.D. 



^SIaL information onMor Hospitdls, Institutions, Ifdnsients. 



Rfsiiinf in S<iv /'i iini lu-n 



^ );-,j,, •- MiHiths. 



/'.M 



Till- AHOVKSTXri-l) PKR^ON \i. I'A K T U" ( I. \ K s A K 1 : TRTK T« ) Till'. 

HKST OF MY KN<)\vM:i)<".h AND m:i.n:i- 



(Inrmnrint 






or'Rcrelu^es7de'"nts' Vnd persons dyin^i awny Irom Home. 

How lonq at 
Former or p, p „{ oeatti ? 

Usual Residence 

When was disease rontrafted, 
If not at plare of death ? 



Days 



,M \CV OI- HIRIAI. OK Kl-MOVAI, 




rNDKRTAKKR 

(Addri-ss. 



DATIC ol HiuiAi, 'II K1:MoVAI, 

1 Vi>VvM-wr>v '' 



.: 3 ^ s i^^cHtk^ ■■->. ^^:^^ ri^ 

[l , EXACTLY PHYSICIANS should 

N. R._P.very Item of l„?or,«„tlon .houlcl b. cnnefuM. HupplK-cL ^^^^^^;^^^^^^^^ '^h^ ^Specla; ln9or.«utio„" for pT- 

state CAUSE OF DEATH 5n pl«in term*, that .t may .'^'^ »';"»*; •^"' 
son. dylnft away from home should be ftlvcn in every mstance. 



I 



II 



ilti 



il 






} ) 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hm;ip! -f lli.iltl'- »•" ^"'^ '^ '^■t:!rXi.l\S^V 



Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IV 




tc 



L 



7.9(9 S 



Begisterecl J\'*o, 



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



37 



Certificate of 2)eatb 



PLACE OF DEATH: — County of 



r) /t-N^ 



D^x.<r>i V ct' 



:ity of l^-^-yvL M f UX'lu.^v; L<xt 



No.- 



St.;' 



Dlst.;bet. 



and 



"1 



( ir Dt*TM OCCUBS AWAY TPOM 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 



\[^^^k MiVm. 



C..^u£r.v.v:. 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR 



^HcvU 



UlLt 



ItAIi: •»!• IUKTII 



Q <Motith> 



15 
(Day) 



(Vcar) 



\<-.H 






L'VA^^ •^A^ -d,'>->-^'^\v.*-vA,*^V' 



Mouths 



Do YS 



W inoWKlJ nK IHVoKCKn 

\\iitt ill •.(K-iul (l»*«ii>?n.iti<>n) 



M i\awoLcL 



BlRT»n'I,AOK 
(State or Comiti v^ 



N\M1- (H 
1" ATIIHR 



V^V< 



lUKTni'i.ArK 

<>1- lATHKR 
'^tale or Country) 



^! \!5)):n NAM1-: 
"I MoTHHR 



I'-iK'nnM.ArK 

<>»• Mt.TMI-.k 
fstate or roiii!trv> 



Dcrt'PATION 










MEDICAL CERTIFICATE OF DEATH 



DATK Ol- I)1:aTM, 



k 



(J 



(Month) 



aa 

(Day) 



(Year) 



I llIvRI\P.V CllRTII'V, That I attended dccoased from 

190 to IQO 

that I last saw h ■• alive on I90 

and that death occurred, on the date stated above, at - —. 

:SI. The CAl'Si: Ol" DIvXTII was as follows: 



LC t^c^^^cC»-'vv Ct 



.'^.Uv\^K.u>A.q ^^v. ri\^^<k., 



A 3 



'<X/>'vCv 



DCRATION )'tars 
CONTRIIU'TORV 



Months Days 



I lours 



DrRATIOX Years Mouths Days Hour 

NED) '^Jj V\) -JL'i^n V iX civ wq LncYu' . M . D . 



(SIG 

HVS.Va'^OTQoS ( Address) O^^ 



"^ - d<v (ivMta- Cn 






1 'lit I 



yfniiih^ •• . f^m-: 



I HI. AIIOVI-: STATKI) I'K K noN M. p \ K r IC T I,A K !> A K 1 . rKlH Tt » I'H!-: 
lUvST OF MY KNOWI.IDCK AND nKl.Il.l" 



'iTlf. 



'inrnit 



i t > V 



(Ad.l 






Special information nnlv for HospINs, institutions, Transients, 
or Recent Residents, dnd persons dying andv from home. 



Former or 

Usual Residence 

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



HoH long at 

Place of Death? Days 



i'l^ACH <»1- lUKIAI, (iK KKM"\ AI 



I)\I"1' •>! IltRiAl. or K1-:M«>\AI, 



190M 



rNni'.KTAKKK 

'Adilic^^ 






N. B.- 



-Kvery item oi? in?orm«tlon «houhl h. carefully supplied. A(iR -'^'^^l^'^J..;'^^^^^ ^lZr^TJ^l^^''*i^r^^^^^^^ 

state CAUSE OF DEATH Jn pli.Jn terms, that It may he properly claBSitied. I He o»>«.w a 
•on« dyinft away from home Hhould he HUen In every Instance. 



ft. 1 



» I 

11 



ih 



,r -f 



•>• rf 



:l 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)(ffc Fi/r(L 




nJOH 



Registered Ao. 



;38 



•f^. 



r^T 



■f%ff>ft. 



er 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDcatb 

PLACE OF DEATH: — County of .LvLCL-Vt- 0\iO.\ City of U A-^<^"^^'C»- 






No. 



St.: 



Dist.; bet.- 



and 



/ ir ot*TM OCCURS Avw*Y 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 



dUrlLu. -N-!^Xa/^^^ 



PERSONAL AND STATISTICAL PARTICULARS 






\y\VK of IlIKTH 



COI,t>K 



bJuL^ 



/ 6bl 



(Mr.nth) 



XC.V. 



^% 



] V</ » 



wrnowKn OR niv«»K(Kf> 

'Write in sfirial (l»"*iviintiiti) 



HIKTIU'I.ACK 
< Stair or Country^ 




(D«y) 


(Vear) 


Months ... TT.. 


Aj.v.v 


kKUlA^ ...- 





N.XMK oi 
FATHKK 



IMK rH|-I, ACR 
'>l I MHJ'.R 
'Stat I- »»r Country^ 




>A^^^V.^J^-W - 



<>1 MoTIIKR 



BIRTHPT.ACR 

<>l- MMTIIKK 
ISIalt «ji (uiuitrvt 



'• y \ \' \ iiuN 




f^ffuffd in Siiti /'i ii III /'■fit 






MEDICAL CERTIFICATE OF DEATH 



D.ATH OF I)T-:.\TH 




(Day) 



'i 



/go 

(Year) 



I III'Rl-nV Cl'.RTII-V, Tli.it I MtleiKled deceased froni 

" — llyO ■— " to ' Kp 

;ilivf Oil ~ • 



that 1 last saw h 



ItjO 



:ni<l tliiit death occurred, on the d;»tL- ^tatrd ahove, at 
M. The CAT SI-: Ol" DiCATII wa>^ as follows: 

4ltUU' t^Li 



1)1 RATION Vtdrs 
CONTRIHI'TORV 



Months 



Days 



Hour a 



DTRATION 



)'ears 



Mouths 



Pays 



Hours 



f....i).JBL^M<-tt M.D. 



^f^^"^ - 07 u (^ p 

VvXu l.Tao.H.. (AddrL<v) \ \^XoJ >JL VOJ 



.\^\ iqoH.. ( 



.^f<»if/> < 



lhi\ 



IHI'. AHOVK M" \ I 1-,I) I'KKsoN \1, I'A K I' im,.\ K^ .\ K l-. IK! )■. 1< • III » 
BKSr OK MY KN'nwi.l'DCK AM) HIII.IKF 



(Inf. 



i'liirnU 



A.XJL 



'Address 



(1^ 



»^\.^6VT>- 



\j Oxn.^1 -x 



Special information onU for Hospitalsjnstilulions, Transimts, 
or Recent Residents, and persons dvinij dway from home. 
rnrm«r nr HoH long at 

[::;:*«« «-«'»"'" »'»^ 

Wfien was disease rontrafted, 

If not at pla*e of deatli ? 



I'l, 

,0 



^^F .U HI KIAl. OK KKVK.VAl. I LMKof H.hiai. or KKM..VAI. 

r , i O^^l^X 0^...3^.... T90. 



t t \ r\4GTl Y PHYSIGIAINS Khould 

IN. B. Kvery Item otf in^'orm..tion should b.- crofully Huppli^d. A^Jfi «li..uld •»•:"*' The ••Snccia'l Information" for p«r- 

• tatc CAUSE or DLATH In pinin terms, thnt it m»y »>f pr.)perly classitleU. me c.| 



"on* dylnft uway from home nhoiild he ftiven in every inHtancc. 



I 



I 



f - I i 



»< 



h 



t 



!> I'm' 



(:.• 



*P 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,.,„.,> . ' 



If, iitii I' ^'f) 1 = 






: nf<.\' r.) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/!((/(' riled , NluXu 5 



i^(9S 



liegislcrcd Xo. 



39 



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



Ccvtificatc of Beatb 

1 "U, 5. StanDarD ) 



4 



PLACE OF DEATH: — County of '^ A^^:V.UJv..0.a^tAA<«*City of Oclav 






vCrC>l "• '.. 



No. OM JaaAJ. 

(ir DC*TH occurs I 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



St.* ^ Dist.;betil<^^t 



and 



1) JLA;-uuxcL2.^Ji ) 



• w.Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ 
AWAY FROM US,UAL «tl, , JS N A M E I N ST E A D O F STR E ET A N O N U M B E R . J 



FULL NAME 



LcL.^:>:\-M»^"n-«L V' ' 



'XAjJ^Ji^-^ 




kk.. 



HKX 



I>\TK (IF lUkTH 



COLOR 



PERSONAL AND STATISTICAU PARTICULARS 




I 






3o /,B,a 

(Day) (Vearl 



ACR 



10 



I^Vtfrj 



10 



Mamths 



na%s 



Hfsni,K. MARK ten. 
\vri)«)\vKi) OR nivoRrKi) 

(Write ill .social de.siKiiulioii) 



BIRTH PLACH 
< State or CowntryV 



NAMK nv 
FATHER 




k.'UjLu^ 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




I 



(D«y> 



ipo \ 

(Year) 



I HFRHP.V Cl'RTIFY, That I attended deceased from 

|vvtu^ 190 ^ to .^1^vL^.....i iqpH • 

that T last saw h ^v^vvvaUve on Hvs-Ujl. 1 190 H 

^ U C) 
an(i that <kath occurred, 011 the- date stated above, at v?- T v 

..(P... M. The CAl'SIv OV DI-ATIl was as follows: 

t/v^^^^^^^^-^^---^*^^ 



^^.1 



\^\Axy^^- 



nTRTTTn.ACK 
n|. I ATHHR 

(StHtCOT COMtttir) 



NfA!l»KN N\M1-: 
<>l- MuTIlKK 



nTRTHPf.ACR 

n|- MdTHKR 
(Slate Mf (■(>\iiiti\ 



II 






rm \iio\ |-. sr \ n i> i-kkson \i, w\k ruri.ARs xki: ikii-: to Tin-: 

IlKST OI- MV KNOW I.KIX.K AND HIU.IICK 



nilfti;iu;nit 



(.% i dress 






IDIW 



^Km.. 



I)rRATK)N ■ )Vrt;-.? 
CONTRMU'TOKV 



OU^.Ur^^'^f.. 



Months 



Days ^^-Hours 



Dl-RATION i Years Months .^ Pays --Hours 

^.Jul,^ .uvJv. vdi M . D. 

fA.l.lrcss) 14\^\)0->v^Ki4^ll- 



(SIGNED) 



T()0 * 



SPECIAL INFORMATION onlv tor Hospitdls, Institutions, Transients, 
or Recent Residents, and persons dying av^ay from liome. 

_ How lonq at 

Former or pjace of Deatli ? Days 

Usual Residence 

When Has disease contracted. 

If not at place of deatli ? ' ""^" ^"' "' 



n.ACH OF HIRIAU OR KF:M0\ Al 

6 




DAfHo! HiKiAi- <jr KF:M(»\AI, 

190 I 



UNDKRTAKKR 



f \iMifss 






I rXACTLY. PHYSICIANS should 

N. B. r.very Item of ln?nrm«t5on should be cnrey'ully supplied. AGK **''""'*' *^,."*" %,,; ••Special InformHtion" for p«P- 

«t«te CAUSE OF DLATH In pli.in terms, that it may be properly classi^uU. 
sons dyinft away from home should rte feivcn in every instance. 



i 





» 5 




11 



*> 




linlllit 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^'f^r^r^wKVio REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,,f II. Mini- »■ V'> i*- ^'K'^. 



J)nf<' Filed , 




tu 3, lOO'i lieglstered ^'o. 40 

/I 

-Lev-., Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( XX, S. StanDarD j 



PLACE OF DEATH: — County oP' Ct^v T \a'>vCA^ m City of C'a^ ^T.'vaTLCUlcc 






/ ir orATH occurs avm»v r» 




V' St.; — — Dist.;t5Ct. 

RESIDENCE GIVE FACTS CALLED FO 



and 



(ir OEATH OCCU*S AVMAV fnOM USVAU HtaiUtrn-E. Qivt rw^ia .--luii^ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



FOR UII©tl» "•PECIAL INFORMATION- N 
NSTEAD OF STREET AND NUMBER. / 



FULL NAME^ 



uLiU^ L}j^y\/r\^trZjt.\^^- 



%9.X 



PERSONAL AND STATISTICAL PARTICULARS 



lATR OF BIRTH 






Vo.Ltt. 



v^^-^^-^*M:v^. / 

■ Monlh* (Iter) (Vear) 



\<'.V. 



oJA 3,5? 



)■»■(/» 



Affmtki 



Day: 



W IIMJWKI) OR DIVOKCKO 
< Write in mciiU desiKnaiioti) 



r.lK lHIM,\OK 
Slide nr I'uuntry) 



FATHKR 



HIRTHPl.ArH 
<>I" lATHHR 
'State or Countr^ 



MAIDKN NAMl 
OF MOTHKK 




l> 



■v>i:L 



niRTlll'LACK 
'H- MnrilKR 
(Statf or lOuntrvl 



'""■'■ "■'"''^Ivv^t ^ 




WWCc 



f\fiifrff in San Franrhm 



t^ 



);-,i> 



* V-..////t 



Pars 



Tin-: \H0VK ST ATKI) I'KRSnNAl. P \ R 111" f I, \ KS AKl". I'RI K To IHI-; 
HKST Ol'- MY KNOW I.I.IX.K AM) iu:i.n:i" 



Unf. .-TiiMtit 



i\i\A 



KNOWI.I.IX.K A 

'1 04 Tyia,<L.ir>v3t 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH. 



(Month) 



(Day) (Year) 



1 IlKRlUiV C1':RTIFV, That I attended (IcccastHl from 

■' ■ 190 to 190 — 

- 190 



that I last saw h -r— alive on 
and that <leath occnrred, on the date stated al)Ove, at 
M T he C \ r S I*: ( ) 1- I > \-J^ 'r 1 1 ^^■•^^ «^ ^^^ 1* >^^^ • 



O.-'S'^SrS^^^^i.d-J^ ---■ 



I )r RATION Years 

CONTRIIU'TORV 



Months 



Days Noiirs 



Days 



nr RAT ION Vi^rrs J^'"'^^'% 

Vv>v4.30 TQOH r Address) LnaiVaA-^ U|f.C^. 



(Signed) 



I louts 
M.D. 



T 



fepECIAL INFORMATION only lor Hospitals. Institutions, Transients, 
or Recent Residents, and persons dying av^ay froxi f»on)e. 



Ml?.. 



Former or 
Lisual Residence 

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




^s 



I 



]')..\CK Ol lU KIAl, OK KKMOVAI, 
rNDKKTAKKK U olcwU- 



DATKoiJ. niRiAL or RKMoVAl, 



VC 



(Address 



15 W Ht^t^ktevu ',' 



N. IS. 



-Hvery Item o? informntJon should be ciirefully Hupplie.l. AHK «'^""'*'^°. 
•tnte CAUSK Of- DP; AT 
Ron» dying awny from home should be given in every instance. 



stHte.l EXACTLY. PHYSICIANS should 



ion should bL- cnr«»'ully supplied. A«.r. sn.n nu .^ •'Sneclol informntion" ?or p«r- 

•H in pinin terms, that it mny be properly class.tieU. 



If 



I ! 



^1 

1» 



1* 



iU 



II 



11 



*il 



i 'i 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i'„,.,i.i .>f n 



r.i)l»l- l-No !«. "fr^l^^M&J'Oo 



!)((!(' Filed , 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,Vvlu 3 ^^^^ Registered ^'o, 41 

cLtrv^\^^ dUL/v^wi Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( tl. S. Staii&at£> ) 

(TO 



A 



^ 



JP inn -^ en 

PLACE OF DEATH: — County of '^- 0L/>^ Xh^<X>vcv^C.lCity of ^-O^/^v Lv<x--vvc.ui^'S^ 

-O-A-vxvLu G'b 0-A.K\^La.lSt.; '"* — Dist.;bct. • •• and 

/ IF DEATH OCCUnS,>WAY FROM USUAL R E S I D E < C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N 
V, IF DEATH OCCUHJRED IN A HOSPITAL OR INST .UTION GIVE ITS NAME INSTEAD OF STREET AND NUM3ER. / 



(Pfc. LCtu^vi C 



FULL NAME 




Xa^w^ .^,C 



''llX 



? 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



^J 



n.\ IK OF lUKlH 



{• 'Month)/ 




\l 



\x\. 



u. 



ac /I'll... 

(Day) (Year) 



\r.K 



Xl 



M.mlh- 



"^IM.I,!-:, MAKUIKI). 
UIDOWKI) OR DlVoKCKn 
UVritf ill s(K-i;i1 iUHij,»ii;(tiuii) 



lURTHPT.ACK 
i Stittf or Oonnlrv 



WMK Ol- 
!• X'lHKR 



1 




IC 



Pars 



CV\^v>-\Jt^>^/tiJL '"'XMrlv^vv. 




1u>.v 



MEDICAL CERTIFICATE OF DEATH 

DATK OF Dl'.ATll^^ 

.\jyyJL S..(ii. 



(Month) 



(Day) 



(Year) 



I HI':RrCr.Y CIvRTII-V, That I atteiKk-d (leceaseil from 



OX^ 



<X^.Xb.. 



X¥ iQoH 



to ...Ua,: 



yyJL, 33.Ci. 



190 



that I last saw h f^'tA^ alive on k^-VA-^. 3ii 190 '1 

atiil that death occurred, on the date stateil above, at 60O 
U M. The CAl'SIC OF DIvATlI was as follows: 

rVAw^-'V^ y-wLwv{r\.\.o^L.uo 



nTRTHl'l.AiK 

oi- I A 11 if: R 

(State or Country) 



mmi)i:n' namf; 
01 .motiif;r 



hirtiipi.acf: 
oi- MoTin:R 

'Slate or Countrv) 



Ivci 



CL\^cL 






\/^c^clc\) 



f) 



d 



Hi 



DTK ATION ) 'cars Months Days Hours 

CONTRIIU'TORV 



Years 3font/is 



DIRATION 

(SIGNED) ^ ^ ^ 
%Au 1 iqo4 . (Address) utM^i U..%»^.ki. 



/hiv^ /fours 

M.D. 



^^^j^Lcw^^^-db^ 



oOCrPATlON 

Rfsidrd ill Sail I'l atuisra o )'i'<ji.<i 



Ar.'iif'/s 



/),n. 



rm-: aijon'f stati-i) pkrsonai. far tuti, ars arf; trif, to tiii- 

HHST OI- MV KNO\VUKD<*.K AND HF:MF:F 



Address LCLu ^^ ^ )bc»-:^kl 



'h 




SPECIAL INFORMATION only for H 
or Recent ResWents, and persons dying away froni home 



(Kpitals, 



institutions, Transients, 



Usual Residence O 5 1 ^1 HA^ 

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



trwv 



How long at n h 

Place of Death? O...J. Days 



VI \CK OF nrRIAI. OR RKMOVAI, I DATJ: of m kiai. or RKMOVAI, 



rXcMiess 



L^H'^ '^-^ <vtt. 



!N. B._Rvery Item oV informntJon «hou1.l I,. cnrofuMy supplied. AdB should be stntcd EXACTLY ^"Y^'^*'^?;*'. f ^"'*' 
«tate CAIJSL OF DnATII In pl..ln terms, that it m»y be properly classified. The Special Inlormat.on for p.r- 
sons dyin^ away from home should be ftlven In every Instance. 



f M I 




1 



1,: 

fj 



'li 



'I 

li 



IN 



'H, 



■i 



I 



If 



m 




.'• 



11^; 



H'^^^ 



luL 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li.MvlMf ilr.Uh I No i^ *?^^)HS:PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed y 




100 H, 



Registered J\'*o. 



42 



<^^wv^ x^^L Deputy Hearth OfHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( Xl. S. Stan^ar^ ) 

PLACE OF DEATH: — County of ^ tX>v' v'/Va ^\c\ALC City of Olvl' 1 N^^X^x/t^uiac 



'Tlo, 





.t^> 




(HL. 



V^. 



La,L 



St.; 



Dist«;bet4 and 



/ IF DEATH OCCURS Awi*Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



_ PERSONAL AND STATISTICAL PARTICULARS 





■^y^j.. Jj\j,Os.:y\AJU\\^. 



<!f)\c.u 



DATK OF HIRTH 



ll).LtL 



i\,^'^yJL '^l / '£ iXi... 

I Month) (Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OI- DKATH 



1, 



(MontflT) 



A(iR 



^H 



IVrt»jr 



Mi»ii/is 



\t 



Da vs 



^INC.I.K. MAKklKI) 
WIDOWKI) OR niVORrKI) 
(Write in social clesi}fnati(Mi) 



4 



T'.IRTMF'LACK 
(State or Countrv) 



XAM1>: OF 
FATHKR 



inUTHlM.ACE 

<M I-ATHKR 'I 

'State or Country) 



il] 






Ok 



(Day) (Year) 

I 1N{RI;HV C1;RTIFV, That I attended deceas^Trmu 

:y>^.X^. 190*^ to .XW.VtIUa^.I 190 S 

that T last saw h'Ar'^-\vaHve on 4v\<<L'Li, i jqo S 

and that death occurred, on the date stated above, at 3 
...>.L M. The CArSiC OF I)F:ATII Nvas as follows: 
wf \/V^-VWV^. . /^^\\,lr1J■r^L.CL^.r0L\..L^«^ 




n 




r\ 



<XA\^i>v 



L 



MAn)F:N XAMK 
01- MOTIIKR 



.If- 



RTRTIIPI.ACK 
<>l" MnTHF:R 
(State ur Countrv) 



aL 



-Vcv't 

? 



kjLK.^^ 




ut^A^vV\- 



DURATION U^;^Afi^R^WtW\^/?Vr^ 

contriiu'Torv Uv!utrv-u^^\ 




Days 



Hours 



X^X'>VL<XA-'k 



or RATION 

(Signed) 



T()0 



^i^ayh^^-^f^tlis nays 

Lv. Aj. L'V'v./V.L4^^r>v 

'; (Address) Ot \,K.^UjU /S.ft^fV 



Hours 
M.D. 



orcrpATioN r»> y 

ffrsidfd il, V- . J-,,ji,.i\,-,> !Sh ) 



'X/y\'>r\\.OJ\,' 



I'd I 



U, :>,///< 



/hn. 



UhSl OF M\ KNO\VM:D(.f: and HKUnCF 



Special Information only for Hospitals, Insmutlors, Transients 
or Recent Residents, and persons dying away fro-n home. ' 



Former or *> ft ^ ( Vl f 

Isual Residence ivX^I UaU^yivO, 



HoM lonq at 
Place of Death ? 






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



Days 



fiiif. 



'M)irint 






(fv '<X^vv<i..C<rv^' 



Vj LaX/o>vtx 



ri.ACK OF lit RIAL OR RKNfoVAI. I DATF! of Hi hiai. or RFMoV\I 



(Address 



hvery item o1? information should be carefully Hupplled. AGE should be stated EXACTLY. PHYSfCIAINS should 
state CAIJSF OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
son* dyinft away from home should be ftiven in every instance. 




I 




I 



V 






I' 



! 



» ' ■'* 



li 









nn 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

arc! of llenlth-P No. i^ t-f^^^ H&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



T)ff/r FiJed, ^ 



<X-<rwU3 SJU: 




100\ 



Registered JVo. 



43 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Wo 



Certificate of 2)eatb 

( "U. S. Stan^arD ) 

SI n -? . 

PLACE OF DEATH: — County of ^^<X^^ vj AX^^\^:^4aCity ofO^X^nu O.VCL >xca^c<c 

(IF DEATH OCCURS 
IF DEATH OCCUI 






St.; Dist.; bet. 



and 



IS AWAVH FROM USUAL R E S I D E NC E G I VE facts CAtLED FOR UNDER "SPECIAL INFORMATION" \ 
IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




CtN- 




U^ 



,,.. 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



"'"__ "WJ^ 



jMjJJl^ 



MEDICAL CERTIFICATE OF DEATH 
DATK Ol' I) HAT 11/ 



DATK or lURTM 



(Month) 



(Day) 



(Year) 



\t'. K 



b JV,7;.. 



M->n//is 



Pa t . 



VilNC.I.K. MARKIKI). 
W IDONVKI) <>R niVOKCKD 
Wiitoiii s()ri;il (ksivrtialioii) 



HIKTUVLACR 
(State or Countrv^ 




NAMK (1F 
»"ATin:R 



lURTHPl.ACK 
<)l" I-ATHKR 
'Stale «)r Country') 



^w j^^Wtru^nAj- 



\ 

.)^u^W 

f (Moiyfi) 



X... 



i) (Day) (Year) 

I HI':R1':BV CI':rTIFV, That r attended deceased from 

.W-rUL X^ 190S to |v\Xu, a iqoH 

that I last saw h «*-^v>>.alivc on ^lAArVUL %. ^'PI 

and that death occurred, on the date stated above, at \i) ■^ 
ff M. The CAl'SIv ()I« DI-ATII was as follows: 

'^w^«^CX^.y.O'^jLA-A^A-VA,^;:\:XA^a^ 



DIRATION ^ Yeats ^ Months S' Days " Hours 

coNTRiuuTORY Lm::,>.aJLl . ^o\.:^^^ I 



u 



MAinKN NAMK 
*)I- MOTHKR 



)nRrnpi.ACK 

Ol- MOTHKR 
(State or Country) 



•« 



occT.P.vnoN (Xt^-Uv^ ^X, 



f\rs/ifrif III S,ni I'l ,i ih :sii> X • )'riiis 



.y/,',if/is 



Pax. 



DURATION •" Years ^ Months 3 Days 



(Signed) 



" Hours 
M.D. 



(^ 



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



Former or 
Usual Residence 



30lDl)alx. 



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



How long at 
AVCV.CL Place of Death ? 3 Days 



Tin: AllOVK STATi:i) I'KRSONAI. I'A RT ICT l.ARS ARi; TRUE TO TU H 
HHST OK MY KNOWM.DC.H AM) MIIMICF 



(Infonnnnt 



'-^'T^' 






(X.l.l 



ress . O 



^ 



l)\'IM;<)f Hi KiAi. or RIvMoVAI, 

S' T90H 



ri.ACK OI- HIRIAI, OR RKMcWAI, 



INDHRTAKKR 

(Atlchess 




/O 



•^^ •*• E-.ery Item of infnrmntion should hi cnrefully Huppfied. 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 H^iven in ^\^ry instance. 



m%^ 



' t 



I " 



i \ 



) M' 



) 



{ 



' 




fl 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Borinl of Health~F No. is -^'tS^ »^»' ^o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Eegistered JSfo. 



Duli' Filed, WU, A l'^)0'\ 

d X^ () 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "a. S. Stan^ar^ ) 

i ^ \ ^ 

PLACE OF DEATH: — County of '^'/CLax' A^o^-tl coa.^o City of ^'<W\.) vt\xX'>-L/e^4 c <. 



44 



'No. Uf-U. 




.1 



\L^O.A) 



St.; Dist.; bet. 



and 



(IF DCAT 
IF DE 



H OCCURS AWAV 
EATH OCCURRED 



FROM USUAL RESIDENCE GIVE FACTS called for under "special INFORMATION" \ 
IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



^))Wl' 



fVOU 




"\^A^CU^V 



VtK'KV. OF' lUJtTM 



PERSONAL AND STATISTICAL PARTICULARS 

COI,()R 





15 

(Day) 



(Year) 



Af.K 



O y lilts e>V 



Months 



IS 



/></r.s 



SINN'.I.K. M,\KUli;i). 
\\II)t»\\I-:n OK IMVoRrKI) 
fWriti' ill s<Hi;il (lfsi>.'iiati<)ii) 



HIRTm'I..\CK 
(State or Conntrv) 



NX Ml-: oi.- 

lATHKR 






c 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 






X 

(Day) 



T90% 

(Year) 



<^ 



I,HBRI':BY CI«:RTIFV, That r attended deceased from 




IS? 190 A to \>r\XAj^ 3i. 

that I last saw h -^^^v alive on >kv.U.v X 



190 4 

190 S 
and that death occurred, on the date stated above, at 3. 3 Ci 
ll. M. The CAl'SH Ol'^ DIvATII was as follows: 



^ 



HIRTHPT.ACR 
or KATHHK 
'St.itc or Co\iiitry) 



MAIDKN NAMK 
OK MoTm;R 



niR'nn'i.ACK 
<»»•• MoTm':K 

• Siatf or Coiuitrv) 



V/V'^PV^ VOl/^aj 






DIR.VTION " Years " Mouths H Days - Hours 
CONTRIIU'TORY X.Kr>r^^CUU\^^^X^^ 

(fc-UXA-t; "ijL4j.^..>r>x 

DrR.ATION '^ Years X Mouths \^nays Hours 

(SIGNED) ..wXc3L^^v^J^JL Ct>v ^^.wa^vJVI.D. 

WL^ 1 iQo'l (Addrrss) U^vOUiNX^ 'rO.^!^\<X 



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



.W<X_ 



OCCUPATION 

Krsidrii ill Sail I'l aiu i>ri) ,-J )\\u 



q 



Mnlllh^ 



Dax. 



rnj-: Aiun'K st\ti:i) i'hrson m, PARricn.ARs akh trik to thk 

HHST Ol- MY KNO\Vl,l-;i)(',H AND lU'.IJllK 
(Itifonn.Tiit •CvJL^ A^ CVXA^" 




f \.l.Ii 



iHl^ 




A 



former or a u n <3 ( K k . .. J ""^ '""« ^* (n></v '^. 

Usual Residence «*! 1^ VU ^'fr<>-cl.^A^<Xu pijff of Oeath? />j^.V!. toys 

When was disease contracted, T j 



If not at place of death ? 



-NJL-v-i^ 



^ ^^vd.cvi 



i;X,ACK OI- lURIAI, OR R1:M0VAI, I DATK of ncHiAl. or REMOVAL 

^ ' ' V^M ^ 190S 




kxJUA' 



<^*.<CVW\-' 



UNDHRTAKKR 

(.\(l(lrcss 



YV^^A-O ^ 

Qi. o^vxw.Hl Co 



N. B. Every Item of Information should he 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- 
Rons dyin^ away from home should be ftiven in 9\^Ty instance* 




m 



I 



+1: 






t 



f 



H 



W 



i 



!( 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, „ „,, , v<, ..-^'■S-^.IKS.l.Co REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 

45 



D/ffr Filed, "iW 

i 




% 



VJOH 



Registered J^o. 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( H. S. StanOar^ ) 
C'OL'^nj o,N.<x >xcc^ a<: City of C3<X^V' O^vaTvcui/CL 



PLACE OF DEATH : — County of 



I 



Mo 3)^?^ -^ II tlv St.;^ Dist.; bet. V <X.ii/>x^v^ and A.Uu.hA.cH-^ ) 

^^^* c^ "-- i.eiiAi DceinrNrr nvr facts called for under "special information" ^ 

( '^ rF"DrAT°H"o^c"u%rcVirrHo"s"prAt o"r": ^n^JV^O^N^O./ETTl NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



Lii^kx>v' \I ILcLu. 



PERSONAL AND STATISTICAL PARTICULARS 



DATK t)l- HIRTH 



L 



COI.OR 



vX^^VvCLl 



AGK 




Month) 



,.q 

(Day) 



tlVx.. 

(Year) 



(i)0 



J 't'O » v 



D 



M .1,1 1 In 



3*.X ■^"• 



\s 



SIN(".1,K. MAKKIKIV 
WIDOWHI) t)R DIVORCK!) 
(Write in social desijftiation) 



Statt or Country^ / H .^1 



NAM1-: iW 
FATHKR 



HIRTHPI.ACK 
Ol- l-ATHKR 
'State or Coti 



WVt^TVV 



MAIDKN NAMK 
Ol- MOTHKR 



;try) \ n 

LtLv l^] 



1 



\hjiK,^-^QL,K^ 



niRTHPr.ACR 
OF MOTHKR 
'Stale or Country) 



k 



OCCT'PATION 



.O-^Xtu vJXh^\vuX'>vu 



sidnl in Siui /-Ktrnist'o \i ]rais 



.}/,>ii//i? 



/hi v. 



■nil'. AHovK srA'n:i) pkr^onai, tar tutkars ari*. trik lo rni-; 

HKST OF MY KN<>\VIj:i)C.K AM) lUUJKF 



flnfiiniant 



(Adilress 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




Month) 



th)T 



H 



(Day) 



(Year) 



I HKRICBY CliRTIFV, That I attemled deceased from 

^XcuuL lk> 190 H to 4"-^^ 190H 

that I last saw li ^"^ alive on T" ™:l^ ' ^'^ "^ 

and that death occurre<l, on the date stated above, at Ij -oO 

Q. M. The CArSIC Ol- 1)1:AT11 was as follows: 

voLh^xJcyuoJL UUv^ivLc-vu- (>c/ca^vs-juL wvt I 

.(?...^M..., .&i^. ..|v\l.vi. .1 At IhLaH.'/^^^v^^^ UjLcdjLiL 

fc,.. aoiXt<i.'ttryv^. ih^AxX. 
\Ti(')N ** }'t'ars '•^Mofiihs Days 1 b Hours 

^/yXXA^ij^^\jL^. 



CONTkllU TORY 



Hours 



DTRATION - Years ^ Months *" Days 

r Signed) J J jL4 vL<LA,<iJt^ \..'^ M.D. 

,4 (Address) \X\ ^"^^cttx^- J 



M^ 



f 



iqo 



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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



ri,ACK OF niRIAI. OR RKMOVAI. j DATlCof lii KtA(. or RKMOVKI. 

I90H 

a 

if 






M. B.- 



-F. 

8 



ivery lUn. „« -.nW.nB.lon .h„uld be cnrcSuMy ».,pplie.l. AGK »h„uld I.. „....d F.X*CTLY PHYSICIANS ,ho„ld 
tote CAUSE OF DEATH in plain term., that it m..y be properly cl...i«ie<l. The 8,».c,nl l..,„r„. n for per- 



son* dylnft away from home should be ftiven in every instance. 



Wit 







[,: 







a- 



m 




V 


' ♦ 


iPPW 


rf 


fp. 


t 


1 


M 




! 




\\ 




i 




'H 




'■ ♦ 


* 


s 


t 


( 


% 


■;- 


i :., 


t.Ji 




' I 



1 1 



:L 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







lOO'i 



nal.mul, --• - '•"- Registered J^o. 46 

i 

d^trvv^U) '^^-^^-^^^ Deputy He.Tlfh Off?--*r * /^ r* • 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiticate of IDeatb 

( H. S. StanDarD ) 



No. 



PLACE OF DEATH:-County ofC^O^ ^KO^^^x^^^^ City of ^^'O^r^ v] A^.v^<. 
I l^ %&U\vlnl' St.;— Dist.;bct. ■ and "^ 

!. \^^ UVW v-l V.VV, ..v .,^,,^, orcsmrNCEGivE facts callcd for under "special information- 

( " r/o;':TH"c".*r;,"r»o,^p"'.t "f»"?u" "".'"S name ,»st..o or .....r .»» »u„s.,. 



CO 



^\ 



FULL NAME 





n 



9ii 



trtr'.uc 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 

COI,()R >^ 



%.. 



DAIK OI-" niKTH 



„S 



(Month) 



1 / "s."!;'.. 

(Duy) (Year) 



A CI- 



U 



} ra I A 



M.>},ths 



X\ 



Pn\. 



WIDoWl.n OK niVOKOKI) 
(Writr in sofial dtsiKnatioii) 



O >L^ 



auOVjL 



MEDICAL CERTIFICATE OF DEATH 
DATE OV DKATH 



m.uLu. 

/] (Montwf (I^ay^ 

rTlT:Kl';HV CIvRTIFV, That I attended dcceastMl fruiii 



(Ycrir) 



190 



to 



that I hist saw h-.-r:^ alive on 

and that death occurred, on the date stated al.ove, at 
M. y\\<^ CAISI-: OI- DIvATII was as fo lows 



190 

190 



niRTTTPT.ACK 

(Statr or Country) 



NAMi; OI" 
lATHKR 



niKTnPt.AOK 
OI" lATMKK 
(State or Country) 



MAII)1-:n NAMK 
ol- MOTHHK 









\JL 




lURTMPI.ACK 

OI- MoTHKR 
(SiaU- or Country) 



_ Cy .cv^Aj J . VOL'Av'C.^A-^c^ 

OCCrPATION -\ 4 , X 

h'r.-iifeJ ill Siui I-,,!!!, nro ! ■ )>'?'> . M.'>ith> t 



/)<M 



THK AHOVK STATJ- 1) PHRSONAl. PAKTICII.ARS A K l*. TRrK T«> Tl ' H 

m:sT OI- MY KNOW 1,1: IX .K AND in:i.n:F 



Otn 



(ll 






N,i.„..s iMk; (^ <X^v<:.k.iL'^ ''^t 



4 



COvd; (A;T U.-^.tv-UsJ 

DC RATION }V<i/'J Mouths Pays f fours 

CONTR I m'TOR V .9..fciLV)uC<k lv\i. jJu^lAA.t.^. ..^^ 



DURATION Ytars Mouths 

;iGNED ) ..L^V^^raA) a3^ lU. AjlLow-^v 



(S 



f')ays Hours 

cL M.D. 

ydu .1 TQo'i (Address) Lcr\tn\X\^ Uij'.':^.. 

Special information «nly for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from liome. 



Former or »^ ^ 

Isual Residence i v 

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



,.b..,d.a.>vc.fvi. 



1 

^ 



VLt 



IM^ACK OF liTRIAU OK K1;MovAI, 



'i..\en yiv ru rvi-n. >' 



^1^ n Art 



4 



HoH tonq at 
Place of Death ? 



..5:.M;' 



Itoys 



UNDFRTAKKR 

(Adtlri'ss 




1)A'1'L;i>! niKiAi, or RICMoVAI. 

. I^^-Ul-^ T904 



cdltul ^^vc' C 



N. B._Bvery Item of ln?orm«tlon nhouhl be cnrefully Kupplled. A^^' «;°!;'''^;;;"f j^*"''ti!I'''^8^^^^^ In'Jo^Jl'tTon- Vr^'p.r- 
stDte CAUSE OF DEATH In plain terms, that It may be properly Ja8«.tled. ope 

sons dylnft owoy from home Hhould be ftWen in every instance. 



■0 



'?JF 



7' 

m 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,,f ll.allh 1" V«i 1' 



-*.t!r»r5LjD nfav 



c<, 



RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

47 



Registered JS^'o. 



,uU,'l-Vr<J, XJ^ Z 1^0^ 

dLt^^^ c^o^Mj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificate of 2)eatb 

( tl. S. Stan^arC» ) 



^ 



PLACE OF DEATH: — County 



of ^CU>^'O.VCV^v<M,^cCCIty of ^* ^>^ ^^ Vcv>vC.^C^ 



( '^ r/rrlT°H^o^:u%roVN"rHi's"pVT*.t o"r'?:?t^^^t^o^n'^ci;e7tS name instcao o. street and nu.ber. 



) 



FULL NAME 




CUV' 




at 



tx \ 




^'■'" n 



PERSONAL AND STATISTICAL PARTICULARS 

COT.OR \ 



VJ 



DATH «)i' lUK rn 



J JirY\^JoJil^ 




aJjL- 



\c.K 




/,l.1.L... 

(Year) 



%%. 



)■<•<;» > 



o!^ Mimffis I. 



Davs 



'^IN'.I.K. MARKIi:!). 

w inowKi) OR i)iv»>Kri>;i) 

I Write in social <Usij):"ati<iii) 



lUKTHPl.AOK 
(State or Country^ 






<X^\.UL 



^cL^- 



LAxavcv>vc^> 



1 ATin;R 



HIRTHIM.ACK 
ni- I ATMKR 
'St;itf or v"(ninti y) 



MAIHKN NAMK 
<») MOTHKR 



X^Oj^aJZ. 




MEDICAL CERTIFICATE OF DEATH 
DATE OF I) HATH ^ ' 

vJiu I ^90^ ■ 

(Moulin (Way) (Vear) 

rrrHREBV CKRTfFV, That I attendtMl deceased from 



T90 



to 



tliat I last saw h alive on 

and thai death occurred, on the date stated above, at" 
M. The CAl'SIC C)l'' DlvATII was as follows 



190 



.C).fr^W\r.V«.^>w<:^JL. 



Dr RAT I ON Vrars 7A;;////\ 

CONTKIIU'TORV 



Davs 



Hours 



niKTMIM.ACK 
<»1- MoTHKR 
(State or Country^ 



e if 



\jy\ 



OCCIPATION 

Kf sided in Situ Fi 1I ih isri> 







<^vxx/'\rv 



O-VvAJUA.A-M^^-fe, 



ruj-, AUovK sT\ri:i) wk.rson au i'akiuti.ars ari-; irtk r») rni-. 

IIKST Ol- MY KN«)WI.i:i:>(".K AND nHMi:K 



n n f. It ma tit \JJ .^AAt' 



vo^-v-w 



(Address 



H 1 IJOlct.v^^, '^-^ 



nrRATIoX Vrars Afotiihs Days 



(SIGNED) 

X iQoS (Address) 



I lours 
M.D. 




\\ \\ 



gppQ|/\|_ Information ftnl> for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from tiome. 



Former or 
Usual Residence 

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



HS UJ .Kvt^xJlM ^ ^' Pla^f of Death ? 3» 5" 



(toys 



ILACK OH BIRIAU OR KliMOVAI, 



iiiu I l^lOSAiU)llCtvw,fAt 



DA'CH of. Hi RIAL or RKM«^VAI. 

tvu^ X 190*^ 



INDKRTAKKR 

'Adiln'sv 




CWcVA-s-jiA' 



n^i>-c 



I acq Q^\v^4.vtAv ^M. 



IN. B. F.very Item of h,?ormnt1on should be cnrefully suppI.eH. A(,b «^^' ''' J^^,.^*" The "Soecial InformHtion" ?or p.r- 

state CAlISt OF DEATH in plain term*, that it may he properly claHH.V.cd. The Spc.al 
«ons dying away from home Hhould be given in every instance. 



t 



!! 



1 





i 




"^ 



% . 



)l» 



i 
I 



i 



WRITE PLAINLY WITH UNFADING INK — 



,,,,,, ,1 .,f Ik:.U1i I- No ". ■^'Z^-^S^'^ScVCo 




VJO\ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Ee^is'tered JVo. ^v^ 



l)((fr Filed , 

d<w.(rvvvo ' dUL'^Mo^ Deputy ■Health- , 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



ficer 



Cevtificate of 2)eatb 

( "a. S. StanDarO ) 



A ^ 






No. 



■^ 



PLACE OF DEATH: — County of 

\ % ox V vxh St4 H Dist.; beJi^^^^VtV^ and^^ ^a^^^v.^ ' ■- ) 



FULL NAME 




.cr>x.OL.L 



PERSONAL AND STATISTICAL PARTICULARS 



sicx 



(?0 



I 



\X/y^^\xs^ 

DATK OF I5IRIH 






COI.OR 



\ 



UiUv^jU 



(Month) 



i 
(Day) 



./.ao..H 

(Year) 



AC.K 



^Vo^.* 



( 



MnHt/lS 



1 



/^rt v.v 



SINCI.K. MARRTKD, 
W 



MEDICAL CERTIFICATE OF DEATH 



DATE OI' DKATH 




1 

-% 

(Day) 



IQO 

(Year) 



VIDnXVKI) OK DIVORi'Kn (\ A 

Wiitf in siK-ial <ksiKnati<in) "A U 



niKTiiri.ACK 

.Mate or Covintiy^ 



\\M1', OI 
J-ATllllR 



lUaiu...vW'2)o.aU 



(^ . 

A^ L crV\'VC<x- 

.Vi.-'M.'iTHHR'"" n M^^^^On 



T'.lRTHn.ArH 
OI" lArilKR 
(State or Country) 



MAIDKN NAMK 




r.IKTHPI.AC^: 
ol- MoTlIHR 
(Stati- or Country) 



.LoJla^v 



CyV'^ v/- ^. 



I IllCKlUiV CIvRTIFV, That I at^tendcd deceased from 

.w%^.....a.s....i90.H to jv 1^*^ ^- '90S 

that I last saw h-^i^ alive on H.VA.Lu, X 190 1 

and that death occurred, on the date stated above, at ^ ^^ 
ijt„ M. The CArSH OI- DIvATII was as follows: 

y.,^:1r^JLvw'"^<^^.<C^^^-vC^^^ 



DURATION 
CONTRIBUTORY 



Years Months Days 

.m'Vr.Cr^v.C-r^X.tJL.*^. 



Hours 



DURATION 



)'i'ars Mouths 



Days Hours 

(Signed) v. Virl- J-v^^-'VvW^avcx.'-vv^v' M.D. 

JprciAL INFORMATION only for Hospitals, Institutions, Transients, 



or 



Recent Residents, and persons dying away from fjome. 



OCCrPATlON 






Resided in Sou /'iiiiiiisfo 



]-e,ns 4 .U,.»//;- \ /'<" 



Tin: AHOVK STATl-.l) I'KRsONM. CA K T UM' I.ARS ARK TRlK TO TtlK 
BKST OF MV KNO\VI,Ki»«".F: AND IU'.I.1F:F 

(informant Ll) TW^ • \- M^fV ^' r^^^cdJ^ 



^\(l<lrcss 



Former or 
Usual Residence 

When Has dise-ise contracted. 
If not at place of death? 



How long at 
Place of Death? 



Days 



ri.A^K OF lURIAI. OR KKMoVAI 
rNDF:RTAKF:R 




(Adtlress 






of information nhoulcl be c.refully supplied. -^^'^ "^""'''Jj^.j^j^'^Th^^'^SpTc^^^^ Information" fo^r pT- 
F OF DEATH in plain terms, that it may »>e properly dassiHcd. He op 



N. B,— — Rvery item 

state CAUSE OF DEATH in p 

sons dyinft away from home should be ftiven In every instance 



i'iii 



n 



J? 



m. 



I I 





WRITE PLAINLY WITH UNFADING INK — 



llnai.l ''f H 



^._,,,j,,„,.So, ..T^^^Hftl'Co 



/)((/r Filed y 




100^ 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

49 



Registered J\^o. 



DEPARTMENT OFfUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of 2)eatb 

( "a. S. StanDarD ) 
PLACE OF DEATH: — County " "^ -^. T ^ n ...^. ^^cruv nf O 

'7^ 



No. 



unty ofCJO/^rv J A^a^vCUtMCity of "<5^^ J-'v^X-Tv-C.vi, ct 
S.'VO Mcr\cd.O_ St.; -5^ Dist.!bet. 3.J and 



«« lieilAI RESIDENCE GIVE FACTS'CALLED FOR UNDER "special INFORMATION" \ 
( " °,"o»TH"oCCU%'-"V,"rH"s^P?T*' O^T^Sn^u" « C.e ,TS NAME ,.ST..O O. ST-..T .HD ~U« = t,. >» 

FU LL NAME nOTU J^xJj lO JlLa-^.. ^ IT Jlu>.^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



DAl'l-: nl- lURTH 







,1,1 

(Dtiy) 



r%hl 

(Year) 



A ( . K 



>Va».v 



1 



Moiilhi . 



l^ 



Pa v.v 



^IN«'.1<K. MARHIKD. 

U IDOWK.D OK I)I\'«)RCKI> 

iWriteiti social fk-sivrnati<in) 



lUKTHIM.AOH 
^Sliitt or Cowntry) 







MEDICAL CERTIFICATE OF DEATH 
DATE OI' DKATll 



() (Montli^ 



1 

(Day) 



(Year) 



NAMlr OF 
FATHKR 



a 



X 



<XV>vv.O 



V ^X l^m.. 



r.lKTMl'I,ACK 
Ol- 1-ATHKR 
(State or Country) 



<X/^vcL 



maii)i;n namh 



lUKTHPI.ACK 
«M- MOTIIKR 
(Statf or Country) 






''WW 



I HI'RI-'BV CI<:RTIFY, That I attetulcd deceased from 

tliat I last saw h ..:^v»dive on .."^vU^ Ov 190 . 

and that death occurred, on the date stated ahove, at 4-30 
(P. M. The CAl'SK OI' DICATII was as follows: 

,.V<^>:\.^^^^►:^«v•'^v^>^^■ 




DL RATION •" )'cars ^ Months " Days ^ Hours 

y Ji^^v^*v^^vcA-^-.*^^ 

Years Afont/is ^ Days I/ours 

V \jL' ^1.V^'^^.:^x V' M.D. 

Address) 0? 



duration 
(Signed) 

v^lLy a ic)oH 



(Address)^-)^^C^ a^^.t''\C W^^^^- ^^ '-^ 



Special information only for hospitals, institutions, Translfnts, 
or Recent Residents, and persons dying away from home. 



/',M 



OCCUPATION 

Rrsidfil in San /'i uni iMo ^^^^^^^^^^^^^_^^^^^^ 

rm: AllOVKSTATKI) PKKSoNAI, I'AKI-UMI.ARS ARHTKri' T< > TUJ- 
hV.ST OI- MY KNn\VI,»".IK'.K AND iu:i.n.l' 



1 )V,M> ^ M.'iilh^ 



KT 



(lufuMuant 




iA crr\' -ij^^ 



( \(l<h'ess 



WO 

30 *Xo 



'^Jo 



"\.\^cL 



^ 



^ 



former or 
Isual Residence 

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



How lonq at 
Plare of Death ? 



Days 



IM.ACKOl" lUKIAl, OR K1;M'»VAI, 



U1 






Ki v^.^-<A; 



DATJ^t'f Hi KiAi, ot kllMnVAI, 

190*1 



'^-VA,Lu. •! 






(.Address 



I Hi Q0l.v<lAwrrs.....t;5.' 



« <, >v 



^ r\l It 1 ACF Hhoulcl be stntetl EXACTLY. PHYSICIANS should 

N. B. livery Item o? in?orm«tlon should he cnre?ully supplied. ^^'^^ '^^Y'' " ,.^ ^he ''Special InformHtion" for p.r- 

state CAUSE OF DEATH In plain terms, that it may be properly classified. he », 

son. dyinft away from home should be ftiven in every instance. 



Hi 




' \] 



»,^' 

yn 



}i..:i 



;,1 ,.f !Ir:l)tll 1 



I 

t 



n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

..„,.*r^„U^HC„ BEFtR TO BACK O F CERTIFICATe FOR INSTRUCTIONS 

Reiiisterecl •A'o. OU 



atcFih;!, UL 3. ^^^H 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( xa. S. StanDar^ ) 



J ^ 



PLACE OF DEATH: — County of 






(No 



ti 





11 u.. 



lL 



FULL NAME y, jl^^vux^U ILl J 




SKX 



^ 



VJ 



PERSONAL AND STATISTICAL PARTICULARS 

COI^OR 



jc 





DATl-: OI- lUKTU 



M iVcuvt^vv 



(Month) 



ACK 



m 



) Vvj > > 



(Day) 



Mntifhs 



,%Kl 

(Year) 



3LC 



Da I .V 



^INT.I.R. MARKTF.n. 

wiDowHi) OK niv<iKri:i) 

iWritcJti social <ksiv:iiiiti<ni) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DEATH 



(' (Month) 



ac 

(Day) 



7poH 

(Year) 



niKTnrKAOK 

(Slate or Conntry) 



NAMl-: «>F,^ 
I ATHKK , ^ 



•ATHKK .^ t 



niRTHlM,A« K 
OI" lAlllKK 
(Statf or Conntry) 



M\ini:\ NAMi 

Ol- MDTIIKK 




C^.V<LL<Xn^u:L 




HIKI'Ul'I.Ai'K 
<M- MOT I IKK 
(State or I'onntry) 



OCCrPATlON 



I UXVu 

Rfsiiifif in Sail /'i attcist-o IS )'>,}< s 



Months 



/),n: 



IHl \n()VHSTATl-n PKRSONAM'ARTIcri.ARS AKi: TRIK TO TIIH 
Hi:sT Ol- MY KNOWl.HDCK AND Hl^Llh^ 



(Informant 



IC V%l1 



1 HRRI":HV ClvRTlFV, That I attended deceased from 

.W^v^^. 1 190H to W^^^ ^^ ^90 H 

tliatl last saw hXK; alive on |wv-»<>JL IH 190 '< 

and that death occurred, on the date stated above, at 1 
.(x....M. The CATSK OF DIvATlI was as follows: 

'JJiJ/\.riX^\:£,...\^K^\^\x.^riL\^^. 




DURATION Vears ^ Mouths Days 



CONTRIIU'TORY A. 



dt ration 
(Signed) 



Years 



Mo)ilhs 



Days 



htrvv^v (A-.cx-cx/tx. i 



QfU, 






Hours 

v.^ 

Hours 
M.D. 



FECIAL INFORMATION only for Hospitals, institutions, Transients, 
or^Rcccnt Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



.. Days 



^ \(1(lre«s 



IH^ 




LVVO-Yv.' 



.,a. 



\^4. 



ri,ACE Ol' lURIAI, OR KHMOVAI 

dktw, Cvft-^^ 



DATJCof III KIAI- or KKMoVAI, 

,vvJUf A 190H 



; 1 

INDKRTAKKR 

(Address 



■'k 



W. U' L^^VVCtrV V Lt 



Ibl 



OYv 



V^A^\.^<n\ 



-i 



N. B.— F.very Item of 1n?ormik1on should be cnrefully supplied. ^*^^ ^^^/^'^^'j^j^'^'Th^^^ lnform..tlon" fo"r p.r- 

«tatc CAUSE OF DEATH in plnin terms, that it may be properly dassitica. 
sons dyinft away from home Hhoiild be ftiven in every instance. 



•in 



llij 



I 




,,„„,,, ,,f n..,.,nh~ F No. IS ■i^^^mvc>> 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Dale Filed, 

-? 



190'i 



3 

cL^rvAA^ djLri-u Deputy Health Oflflrjer , 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of "©eatb 

( TH. S. StanDarD ) 



Jl 



im 



nCt'VX' JX^-YVCA^A- 



No. 



PLACE OF DEATH:— County of<"^CU>v J.>UX^^Z^.A^aty of 
l^l^\lnL-wo. o St.;^ Dist.;bet. )i)W^R-i^ 

( " °r'r»TH"occu%*R"V,"rHos^p"*l: o" ^ st'tu"" " .. .xs NAME ,nsT„o or S-^.CCT ..O «U«=C.. J 



and 



■^ if 



FULL NAME 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



^fflJj. 



UJJvLiji 



I»AT1-: OI- HIRTH 



i) 



(Month) 



31 

(Day) 



./I.IM 

(Year) 



A»".K 



..i.M... )■'•'"> 



M.ml/is 



X 



Pa \s 



SlNC.l.K MARRITtn, 
WIDOWKI) OR I)IV()K< Kl) 

iWritfiii social (ksU'nation) 



lUKTITPT.ACK 

(Slate or Country) 



NAMK <)1- 
PATMKR 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



h 

(Montri) 




(Day) 



IQO '. 
(Year) 



I in<:UIvHV Ci:RTn^V, That I attciKled (leoeascd from 

.^v>^j^ X^. IQO H to ...WW i 190 H. 



^v^ajC X^. 190 H to •■•WtH- ^ 

that 1 last saw h r.V-i^x alive 011 Hvv-"LLf.. I 
ami that death occurred, on the date state<l above, at 
..U. M. The CAI'SP: OI' DICATH was as follows: 



190 \ 



niRTMIM.ACK 

OI" i-ArnF:R 

(Stale or Coimtry) 



MAIDKN XAMF: 
OF MOTHKR 



lURTHPUACE 
OI' MOTllKR 
(Slate or Country) 



OCCUPATION 



^•^ Oxcl^ 







Rrsiitfit ill Sau /•"; (///< /W'' 



L I. "'■ 



'VQa.^'V.J^'^ 



-^ 



5 V(7; 



Mniilh< 



f\n 



TMF \HOVE STATFI) PFRSC^NAI. PARTICn.ARS ARK TRFH To TMK 
HF.ST OF MY KNOWMCDOF: AND lUU.lF.F 



.!L>v£L^C-CL\^cL.v-.Lv^ 



L Days 



Hours 



Dr R AT I ON * Years - Mouths 

eONTRIHUTORY aX.jf\lvc .(^^^tt^voI 

DURATION '•^. Years I Mouths \^ Pays '^ Hours 

'\ddress) H b D nII tnvl-avt L lv 

, Institutions, 



(Signed) 

a TQOS { 



M.D. 




^FECIAL INFORMATION onl> for Hospitals 
or Recent Residents, and persons d)iny awdy from liome. 



Transients, 



Former or 
Usual Residence 

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



flow long at 
Place of Death? 



Days 



(Informant 






(Address 



i^a 



A„eA.CL 




ri \cH oj- iHRiAi. OR rf;m<)V\i, 



ISDERTAKER 

(Address 



DAli: o! IUki.m. or RF:MoVAI, 

^^-tH \ 1 90S 
^ H ^ 'M>V^^4A..c.(m ...it 



H„„.H H. ...... ...pne-. -^•-;l- -•- -?-k:, .rrrn^vr.:'."- 



IN. B. Every Item of InJormntion s 

state CAUSE OF DEATH in plain terms, that It may be properly 
«ons dylnft away from home nhouUI be ftiven In every instance. 



I V 



ll' 



I 



I 



I li 



hf 



I 



HI 



H 




I ( 



\m 



'i 





nyHfli 



►IK- 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„,.,H„-.No...^^...-Co B.PER TO BACK OF CERT.P.CATE FOR ■NSTRUCT.ON. 

Italc Filed, \JU, H 100^ Registered ^^o. 52 



^trUUVO 



AjL' 



^ 



.A>u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "CI. S. StanDarD ) 
PLACE OF DEATH: — County of J ^VV1X^^^^^ City of 



.>aA/Ol 



No. 



St.; Dist.;bct. and ;^ 

„ ^„„„ IICIIAI RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
( " rF"DrATH"oCCU%;rD\N''rHo''s^PrAt o"r"nSt'i?u'V'o'n OIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



..w.^LLc 




O^^VAA.. i! •)■ OlA.^-< 



n-- 



PERSONAL AND STATISTICAL PARTICULARS 

— COI.OR 



•™ (IftlaL 



luJLu 



DATK OF HIRTH 



A(".K 



(Month) (J 



,3* ^ )Vrti.v A 



(Day) 



/ill 

(Vear) 



M.nilhs 



Pa r.v 



SINC.I.K. MARKIKM. 
WIDOW HI) OK DIVoRfKO 
(Writf in »;<K-ial (Wsiv:iiiiti<)n) 



TUkTMPT.ACK 
Slutf or Coiintry) 



NAMK OJ- 
FATIIKR 



RIRTMPI.ACK 
oi lATHKR 
(Statf or Country) 



MAIDKN NAM1% 
OF MOTHKR 



HIRTIIPI.ACK 

<»F MOTHER 

f State or Country) 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 




X 

(Day) 



I90H 
(Year) 



I HI^.RICBV CICRTIFV, That T attended deceased from 

— to 



190 



that I last saw li ■":—" alive on 

and that death occurred, on the date stated above, at 
.TTrr- M. The CATSK OF ])1':ATII was as follows: 

tXc/5-^^-^t^^'-•^!^A^^fcoJL ...^^^ 



190 

190 



^ 



■X-^ 



c) AJu^y^^JC'^rJ^ 



OCCri'ATION 

Rffidrtt in StJti /'t niiiisri} 



)''(i I . 



" M.^iitli> ^'"■ 



TIIK ABOVE STATED PERSONAL PARTICTLARS ARE TRIE TO THE 

in%sT oi" MY knowij:d<*.e and in:i,n-.F 



(Informant 



f Adilre'ss 






TWO 



DIRATK^N Years 

CONTRIBUTORY 



Months 



Days Hours 



nu R \TION Years Months Days Hours 

t) . J >:M•^A.^-A-.^rvv.....LfeV•rv^JlV M.D. 

A,1dress) (Lul ^i^^Cal. 



(Signed) 



(•A 



^PEcJaL information only for Hospitals, Instituflons, Transients, 
or Recent Residents, and persons dying away from Ijomc. 



Former or 
Usual Residence 

Wl»en was disease contracted, 
If not at place of death? 



How lonq at 
Place of Death? 



Days 



PLACE Oi^IURIAI. OK Kl-MOVAI. DATE of lU KiAi. or REMOVAL 

T90S 




1 bl u)1a^i,'^i<^.*>a.. 



N. B. Every Item o* information .hould be carefully «uppl.ed. AGE •^°"'^ ^* "'"* ^^^ -Special Information" for p-r- 

Btate CAUSE OF DEATH In plain term*, that it may be properly classitied. The »peci«. 
«on« dyinft away from homo nhould be ftiven in .very instance. 






m] 



( 



I 



, ( 



t'! 

■pi 



H . 



i.^ 





I i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nlof llrMllh |-N". l^Tf'*ii 



n&pco 



nw^ 



Registered J\'*o. 



Dale Filed, '^k^'^-W H 

X^yv^uva Xt^vMjL Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



53 



Certificate of Death 

( Ta. S. StanDarO ) 



PLACE OF DEATH: — County o 

No. 15.0V LLLtXAKX^-VAyO- 

(ir DCATH OCCURS AWAY FROM 
IF DtATH OCCURRED IN A H 






St.: t Dist.;bet. 



as 



tl 



^nd d<. sj 



.rfv 



USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "S 
OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



dL-trvvA^ U).L<Xoa,c4^^JtA!^ 



PERSONAL AND STATISTICAL PARTICULARS 



si-;x 



DATK OF lUKTU 



3J. 



COI/)R 



U)Jv^ 



( Month) 



II 
(Day) 



(Year) 



AC.K 



.bl. 



) 'ea / i 



Months 



3.1 



Da vs 



SIN'r;i.K, MARKTKn. 
\\II)()\V1\I) OR DIVOKC'KD 
(Wiitf in social di-siKHation) 



lURTHPT.ACK 

(Statf or Country) 



NAMK OF 
FAT11HR 



RIRTHn.AOF, 

Ol- lATIlKR 

f Statr or Country) 






v'Xl\>4A) ^O^.uxA^/Ukjixii 



V^X^^^WOwXXO. 



MAIDKN NAMK 
<)!• .MOTHKR 



Vl iLoN^o^ 




(^ 



su 



J (O^wIa 



niKTnpi..\CK 

oi MOTHHK 
'Statt* or I'ountry) 



occrr.vTiON 



c^i- 






C 3 ^^.V^A A \^o^) 

K'rsidrd In S,ni /'i itii, /•■r'n I J ),(ii.< 



1A"////> 



n,r 1, 



TMK AnoVKST\Tl-,I) I'KRSONAM'AKTUT I, A RS ARi: TRIK TO THH 
HKST OF MY KN0\VI,F;I)C.K AND nFtl.IKF 



'Informant 






( \<l<lrrss 



MEDICAL CERTIFICATE OF DEATH 

DATK OF" DKATH (\ -^ 



^r Month )(] 



.% 

(Day) 




(Year) 
I III':R1:HV JI^RTIFV, That I atteiKkMl (leccased from 




igoH 
that I last saw h <W*^ alive on yVAAA.^ :^ 190 4 
aii.l that death occurred, on the date stated above, at t- ■^0 
(j M. The CAUSE OF DIvATII was as follows: 

L/u^>:^A,I^,,^r^r^ 



•^'A-A.^CL.. 



DURATION "" )'ears 
CONTRIHUTORY 



Month 



s " Days Hours 



Hours 



DURATION Years Months Pays 

^axAJr La ')iA/A-v>vt M.D. 

Ic^-' Incfifiidnnc Trsnc^ailic 



(Signed) 

:^ i<)oS (Address) 



FECIAL INFORMATION only for HospltalsVlnsfitutlons, Transir 
or'Recent Residents, and persons dying away from home. 



Former or 
Isual Residence 

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



How long af 

Place of Death? Days 



n acf: of iuriai. or ri-.movai. 




,5-V^ 



DA'l'F^of lU KiAi, or RF:M0V.\I, 

5r 1904 




UNDKRTAKKR 

(.Address... 






N. B.-Bver. Iten, of Information «houU. be c„refu,Uv supplied. AGF. should be stated EXACTLY .^^^"^^^J^^J^^^^^. V^pr'r' 
stnte CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information tor pT 
sons dylnft away from home should be ftlven In every instance. 






I ■ 



. in 



m 



I 



f 



s\ 



\ . 



"/ 



I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ „, „.,„„ ,.• so . ^-tl^..^ ■■<-■» REFER TO BAC^ OP CERTTICATE FOR INSTRUCTIONS 

54 



ii".it 



100"^ 



Ue^istered J^o, 



I )((!(' Filed, V^^/h '^ 

X^H^vuN doi/vM.u Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( Ta. S. StanOarO ) 
inty of UJLoL/^v>"UU^xx> City of 



\jK^yy\J<\j\j^^ 



^No. 



St.; Dist.;bct. and 

• •eiiAi or einPNCr r IWF FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
( '^ rF"DrAT°H"o^CU%r;."rH "s^PrT^t o%":St'iTu"o^n"oi;eTt1 name instead of STREET AND NUMBER. ) 



FULL NAME 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR, 






DATK ni* lURTII 



LUv'vJ- 

I Month) 



lOiwbL 



(Day) 



(Year) 



KV,V. 



Oo )Vi/>> ov 



Mouths 



10 



Pa vs 



SINCLK. MARKIi:n. 

W IDOW HI) OR DIVORlHI) 



.(XK'^JJl/j^ - 



MEDICAL CERTIFICATE OF DEATH 
DATE OI" DHATH 

X 




(Day) 



(Year) 



I n|.;RI<:BY ClvRTlFY, That I attended deceased from 

190 to 190 '-■ ' 

tliat I last saw h ^^r— alive on '9° 



P.IK rupi.ACK 
(Slatf or Codiitry^ 



NAMH OF 
IATm:R 



RTRTnn.ArK 

OI* l-ArHKK 
(State or Country) 



MATDKX XAMK 
oi- MOTIIKR 



lURTHPT.ACK 
OF MOTHKK 
ISlalf \n Country) 



.c-o^uLcvvoL 



a 





A- 



VvMP^v 



."vv 



( 



OCCUPATION 

Re.iifi'd ill Sill! I'tdihi^rn 






)'i(t I . 



.y ;,'>///,' 



— /?,/i. 



Tin-. AHOVKSTATl-.I) l•KR'^0^•A^ »' A RllCr l.A RS AR !•; fRTH TO TMH 
HKST OK MY KNO\VM;d<".H AND lUllJlCl" 



(Informant 



■^ ^' ^i^^t^tp^^t 



■A.Mre.s UL^'AX.VWv>V4X W.' 






and that death occurred, on the date stated above, at - 
M The CArSl*: Ol' DIvATH was as follows: 



DTK AT ION )'t'ars 
CONTRIIU'TORY 



Mofitfis 



Days 



Hours 



duration 
(Signed) 



Years 



Mont /is 



Days 



W) T ^^.vyAvOrsj 

H VV?» T.)oH (.Address) tt>\U\^vV^t ^Cyl 
'T • __.. _ ^1 ^^m.m nnli' {/\r MAcnU^lr I ncf if III Iaiic Trsncta 



/Jours 
M.D. 



SPECIAL Information only *<>•■ Hospitals, institutions, Transients, 
or Recent Residents, dnd persons dying awdy Irom home. 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



I'l^ACK 01-- lURIAI. OR K1:MoVAI 



DATi; of^HiKiAi. or RKMOV.\I, 

.^v%fVM. 'S' T904 




tNDKRTAKHR 

(.■Xddrcss 



%' y oa^k'v'^'^^vc 



II 



3.nCy>v 



VAA^i^rv\ 



IN. B.- 



E OF DEATH In plain tern... thnt It n.n> be properl, clo.»med. The Spici.l In.ormntion lor p 



-Every Item 

state CAUS 

son* dyinft awBy from home shoiiltl be ftiven in •very instance. 



it 



IM 



.1: 






I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^_, ., „,,,„-. NO. .. .^.u^.Co RCPER TO BACK OP CERT. F.CATE FOR INSTRUCTIONS 




190H 



Registered J\^o. 



Date Filed y 

Xjr\j^^ osX^\j-\y Deputy Health Officer 

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

Cevtificate of Beatb 

( Tfl. S. StanDarD ) 

A ^ J? C^ 

PLACE OF DEATH: — County of (^] CC-^ ^ AXV^v^^^^City of CJo.^ JA.aA^xevA.^M) 



55 



'No. 



'xiXA^A^^ 




CHi-Wvva.i 



St4 — :"■" Dist; bet. - ' and 



-^ 



/ ,F nr*TH OCCURS *»i*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER •"SPECIAL INFORMATION" \ 
( Tf DEATH OCcJrrIo IN A HOSrVtAL OR INSTITUTION GIVE ITS NAME INSTEAD OP STREET AND NUMBER. J 

FULL NAME .LJvuav AjLwL/\\jri^ ^.LvvJLL 



/WXl- 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



DATl-: <)l- lilRTH 






(Motitli) 



0.% 

(Day) 



/ M.a 

(Year) 



.\(*.R 



J 'i-a I .< 



M 



Moufhs 



5 



Da vs 



SINCI.K. MARRIKI). 

\vn)(>wi<;i) OR DivoRn.i) 

iWritfiti social (lisid^ nation) 



niKTnri,.-\CK 

iStatf or Coutitry^ 



^]TI<wvv^cC 



a 



f\,^^^o^ 



NAMH OF 
FATin:R 



WrWw dsA/OL^ 



BTRTHPT.ACE 
OF FATIIKR 
iStnlf or Country) 




^^O^ 



MAinKN NAMK 
OF MOTHKR 



HIRTHPT.ACK 
OF MOTHKK 
(Stati- or Country) 



^\^. if 



^jul 



hL<!Uj-V\xX' 



IVCWOW 



OCCUPATION 

AVsidt'd nt S(i)i /'i ,iih iri' 



) 'nt I 



U.. ;////> 



/>.n 



THF. \HOVH SrATF:i> T'KR^ONAl. FAR IKTI.ARS A R 1-. TRl K To TMH 

iu-:sT OF MY kno\vi,f;i)<*,k AM) in:i.n;i- 



(Infojnuint 



(Address 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 





(Mont 



(Day) 



(Year) 



I HRRIvBY CI^RTIFV, That I attciidcfl deceased from 

h-VV X^\ 190 H to . jkN^vy X 190 S 

(l/ ii /i 

that 1 last saw h .^^>Aalive on NLvsA^.. <^ 190 H 

V (] Q 

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

Cll M. The CAI'SP: OF DlvATII was as follows: 

U^VA-L■'0-A.^'vL{rv-W1:^.■(^^;v.s.c::^.v. 



1)1' RATION 



Days 



w. .X.. ..w., Vt'irrs b Months 

CONTR I HUTOR Y \JJ^S,r\.^^^^^rr\...'o.^'>iy\^^^ 



Hours 



DURATION ^ Years "" J/o>///is ^ Days 
(SIGNED) V ^A. "tIJLC 

^ ic)0^ (.Xddress) 9 Cl Vl ^^^< 



I /ours 
M.D. 





PECIAL Information only for Hospitals, institutions. Transients, 
orUecent Residents, and persons d\ing dv^ay from home. 



Former or 
Usual Residence 

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



-^ V \) ^ - ^ How long at t , 

CjL^^RUnv err Place of Deatli? 1 



> Wfr.^ Days 



FLACK OF HFRIAI. OR RF:MoV.\I. 
FNnKRTAKKR 



I)ATF:of niKiAi. or RKMOVAI. 

H. 190H 




(Address "Li!).' 'n..tVtA^>vv4^>.v^ .1 



£ 





^\ 






-f 



^ .. It I *npf oV,r..ii<i Ka stHteil EXACTLY. PHYSICIANS should 

ai in?orm«tlon .hould be cnrefully supplied. AC.F. should »l« «*"'*^ ^'"".r^ ' "^^^^^ Information" for p-r- 
E OF DEATH in phiin terms, that it mny be properly class.Hcd. The Special intormation tor p«r 



IN. B.— ^Bvery item 

state CAUSE 

son* dyinft away from home should be Jliven in every instance. 



i 



M 



1 1 



I If 



u 




I 



^ 



I',<i;i!'l "f ' 



])((fr Filed, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

56 



lealth-K No .^ l^^-Wi^^ H& P Co 




H 



100^ 



Registered J^o, 



.^vy^-A^/LVO cijLA>'U 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ceitificate of Beatb 

( "CI. S. StanDarD ) 
. . v^,wv^..w.^ SU 3) Dist.;bct. '^^^^ and H pk 

• ■<>iiAi DC-einrNr r r lur FACTS CALLED FOR UNDER "SPECIAL INFORMATION" | 
( '^ .V*DrAT°H"o^CU%rD\"rHo"s^PrTAt o"r ?NSX^^U^4^n"c.;e7t1 name instead O. STREET AND NUMBER. ) 



PLACE OF DEATH : — County 

No. SH^ xi VCV^V^xOj 



FULL NAME 



E UkuLcl (^ J 




t 



PERSONAL AND STATISTICAL PARTICULARS 



jL^na cuUL 

DATF. or III KIM 



COI/)R 



lUJvctc 




(Day) (V«'ar) 



AC.K 



) (1/ ; ^ 



M,>ntlis 



Pa V. 



SINC.l.K. MAKKIHI). 

WIUOUKI) OR DIVORil-:!) - 

'Write in social <lt>.i>.rii:>ti<)ii) I' 



L 



UIKTin'I.AOK 
(Statf or Comilry^ 



NAMK OK 
FAIHKK 



lUKTITPI.ArK 
«M" I AIMIKK 
istatf or I'ountry) 



MAIDKN NAMK 
Ol- MOTHKR 



lURTHPLACR 
Ol" MOTHKR 
(State or Country) 






.1 



^ 






QUvJv 



o^-s^^^^^.jsjy\,iy^ 



\JX^ojyy^ 



J? (^ 



OCCUPATION 



Rrsidrif In Sa» /'i aiK /sro 



)'i(!l ^ 



\/,.,>f//y 



n,i\. 



TFIl". AIIOVK STA'ri:i) I'KR^ONAI, PARTUTI.ARS ARK TRfK TO Till-: 
HKST 01«* MY KNO\VI,i:i)C.K AND invMi:F 

'4 



(I 



^\<l(lrt>ss . 







VOw^v-v"<-0- 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol- DKATH 




(Month) 




3 

(Day) 



190'i 

(Year) 




I. HKKKHY CIvRTIFY, That I aUeiuUMl dccoased from 

3 190 S to ..^\(^^sL^ .^. IgoS 

that I last saw h - ali%-c on ^' AAA-V yj^TV/W 190 

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

M The CAUSn Ol' HIvATlI was as follows: 

(l.>U^5rL^r>A..aX<i^ ■,V<xl*-*r>J 



vj v^-LcUi 



DIRATION Years 



.1 -C'»^> 



Mouths 



CONTR IHUTORY oXlLs. JJj. ^\^^ 



Days Hours 



duration 
(Signed) 

3 190M 




^ 



) 'ca rs Mo nths Days 

Address) ail- Ttfv it 



Hours 
M.D. 



( 



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

Former or N«^ '•>"<! af 

Usual Residence Place of Death? Days 

Wlien was disease contracted, 

if not at place of deatfj ? 



DA 11:0! Ill KiAl, or KlvMOVAI, 

^ 190 s 




PI.ACK Ol- lURIAI. OR KKMOVAI. 

ITNDICRTAKKR VtTLvtX<A. V^\V<:L^A.t<0(<JL^ 



(Address.. 



N. B.— F.ve.y item of liWon.naf.on .hou.c. be c«rc.'u.,y suppi.e... AGE should »>-i«*'^^f .i^^^^^^.^^', ,rrj,Tot» Vr'^:!." 
state CAUSE OF DEATH In plain term., that it may be properly classified. The Special Information »or p.r 
sons dyinft away from home should be ftiven in every Instance. 









I 



"II 



'i 

■tvv 



i 



m 



P 



% 



WRITE PLAINLY WITH UNFADING INK — 



„,„.l of H.-alth- I' No. ..-»-gEg^n&l'Co 



Dfffp Filed , 





H 



100^ 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered •A^o. 



\^ cUyVKU Deputy Heallh Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DE ATH : — County 



Certificate of S)eatb 

( xa. S^tan^arD ) 
of 5<xmt(V IXoA^ City of 3 <X.>^ %r^ 



VOuL' 



Wo/ 



St.;—-— Dist.;bct. 



and 



( " r,"JcU=i^e"„%;ro\'."r-o".^r.t o%^f^?/,?>:^<^";r,;i ?.*«c r.c-rs? s;%%^Ti.';;°::=';r ■ ) 



FULL NAME 




sj:x 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 






LvJ^aAX 



DATK Of' HIRTH 



7 



? 

(Day) 



, Il3£> 

(Year) 



ACH 



IS 



) V(i ; 5 



MoHlllS 



Dii vs 



SIVC.I,K. MARKlKn. 
WIDoWKI) OK DIVORfKO 

(WriU ill Mxiiil ih-vij.Miatiou) 




lUKTMl'LACK 
(State or Co\intry^ 



NAMK OF 

iatiii:r 



nTRTlTPT.ArK 
<)l FATIIKR 
(State or Country) 



MAIDKN NAMK 
nl MOTHKR 



lURTHPUACK 
(»»•■ MOTHKK 
(Slatr <)r Country) 



yy^mA, 

r ^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATH 



(Month) 



3.C.. 

(Day) 



(Year) 



I HIvUlUlV Cl'RTIFV, Tliitt I attended «leooasc(l from 

— . to 



that I last saw h 



190 — 
- alive on 



190 



and that death occurred, on the <late stated above, at - 
M. The CAUSI*: OF DI'iATIl was as follows: 

^Vvrvx^^'C .^J'^-4^X^A.<^^^^<XAA^ 



B 



DURATION Years 

CONTRIIU'TORY 



Mouths 



Days 



Hours 



Years Mouths 



Days 






'U<^^^\^^-' 



/wd^- 



OCCIPATION 



Oil 



Ki'-'idr,'. Ill Siiti / 1 ii ih i.^i'i 



I I'll I 



Mmith^ 



PilV 



Tin: \1U>VKSTAT1*.D PKRSONAI. TA KIICK I, A KS ARK TRIK To TIIK 
HKST Ol" MY KNOW I,j;D<".K AND nKI.IlCK 



(Itifoimant 






iXcvkjL\lu 



\(l(lro>;s 



\bH 



.'OwVCXJ 



^^^w^ 



DURATION 

(SIGNED) 

\ iqoV (Address) O/avo >»^^ Vat 



V^^M 






Hours 
M.D. 



,L) y. 



SPECrAL Information only for Hospit^, InstituHons, Transients, 



or Recent Residents, and persons dying away from home 



former or 
Isual Residence 

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



HoH lonq at 

Place of Death? Days 



DVlKot HiKiAl- or KKMOVAI, 
M T90H 



I'l.ACK OK m-RIAI. OK KKMoXAI. 

l-NDKRTAKKR Co^NJLW- ^ '^^W-^K 



1^ 



(Address. 



!s-r:^:^rr:^ -^t :^ti:^'^^^^ ::^=^^t 



N. B. Kvery Item of Informnt 

state CAUSE OF DEAT 

«on» dylnft away from home Hhoiild be ftiven in •very inBtancc. 



n 



ii( 







IT r « 



( !' 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,„ ,„ ,..„,. ..»S1^.,,..,.C„ R.rER TO BACK OP CERT.PICATt TOR .NSTRUCT.ONS 

I „., , 1) u 7«^M Registered JVo. 58 




• ' *' • J ; * 



MA. ScOuty Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( •©. S. Stan^ar^ ) 



^ ^ 



PLACE OF 



DEATH:-County oAo.3k^^^^<^ City of Q^^^^Ko.^^^^ 



(ir DEATH OCCU--- . ^» .^«ti 

IF DEATH OCCURRED IN A HOSPITAL OR INSTI 



St.; ^ Dist.;bct. JA.<Xy^ 



^AXU^JLL^ and 0(^vva4\ ) 



. OEA^H OCC-URS AWAV FROM USUAL ^^ S . D E N C E^O ■ V^. - ™ sTVEE^riNJ^rU^^*E'R°~" ) 

cixcuxc \l i\ ....o..^a..^A-^^> 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



A) ft 



SKX 



DATE OF niRTH 




il 



COI.OR 




\ 






AC, P. 



4?. 



J 'I'a t s 



IS- 

(Day) 



Mouths 



(Year) 



li 



..Davs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 




O 

(Day) 



(Year) 



i' 



SINCI.K. MARKIK1> 

wnxnvED OK nivoRCKO 

iWritf in social (ksi>.niatioii) 



HIKTHPI.ACE 

(State- or Country), 



^u\a.v>vOL'i^ 



N'AMK OK 
FATJIl'.R 



niRTHPI.ACE 
OI" FATHER 
(Slate or Country) 



MAIDEN NAME 
oi" MOTHER 




VUX 



\)JL^^^ 



"V 



(Tl- 



^ 



X^^ujs v).\.(x^vk 



I HRREBY CHRTIFY, That I atteinle<l <lccease«l from 

.v-^vA„ iS: 190 H to V^ ^ 190 "S 

that I last saw hJ-^vv alive on (^^""^^ ^^ * 

an.l that death occurred, on the date stated above, at 3. -3 
OL M. The CAl'SIC OV DIvATlI was as follows: 






^ 



DT RAT I ON )'t'iJys 

CONTRIIU'TORV .......".< 



nAX^^*w/>'>v*'yvs;?Vr. 



Months I '] Days \\ Hours 



l\ 



lURTHTT.ACE 
OF MOTHER 
(State or Country) 






^ 



OCCIP 






Rfsiiifd i)i Siin /'I'ltn ism 



] 'ra I s " yfoufhs 



\ 



/hn: 



THE AHOVE STATED J'KRSONAl. I'A RTICC I.ARS ARF; TRIE To THE 
HEST OF MY KNO\VI,f;DC.E AND BELIEF 



^Informant 



(Address . 






Mouths 



Days 



Hours 



DURATION Years 

( SIGNED ) Ui.JJLo^^ C . \) G-&AJi.a.>xxr^ M.D. 

OAxtttV 0+ 



■a TQoH (A<l.lress) 1S\ 



SPETCIAL INFORMATION only for Hospltdls, Institutions, Transients 
or Recent Residents, and persons dying away from liome. 

When was disease contracted, ^ ^u^<XA^<XA_^___ 



Davs 



If not at place of death ? 

PI ACE OF m'RIAU <>R REMOVAI 



INDERTAKER 

(Addrp«<s 



DXTlvof HiKlAt. or REMt>VAI, 

5^ 1 90S 



%cJUU<*-VL\ 



SH^ 



,NwA^-a,A-'Or>\ 



of Information should be cnrefully supplied. AGE •''""''* !^'"j"'*^h^'^*^^^^^ Informstlon" 

IF OF DEATH In plain terms, thnt it m«y he properly classified. The »| 



N. B.— Every item 

state CAUSE OF DEATH in pi 

sons dying away from home should be given in .very instance. 



PHYSICIANS Hhould 
for psr- 



if ■ II 




#«i 



WRITE PLAINLY WITH UNFADING INK 




i:>A 



i 



Date Filed, 



.100^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered JVo, 




v^w ^^^ ^olwjL Deputy Health OfTirj-r t* ^ r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Vi. S. StanOarC» ) 



PLACE OF DEATH ; — Cumi t y 



■^ Lit d 



JLOC 



City of 



rNo, 



St; 



Dist.; bet. .: ..:.z:rzzzz7..^n6 _ 



( 



ir DEATH OCCURS *w*y 

IF DEATH OCCURRED I 






FULL NAME 



PERSONAL AND STATISTICA L PARTICULARS 

I COI.OR 



DATK of niRTH 



\A)Jk\AX 




Month) 



AGR 



O^ Vfatf \ 



3. 

(Day) 



yt.oiths 



(Year) 



Diivs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




fc 

(Day) 



190 1 

(Year) 



I HRRHBY CERTIFY, That I attendcddcccased from 

to ..; " 190 " 

190 •""""" 



190 



siN(u,K. markif:t>. 
winowF:!) OK DivnRCi:n 

(Write ill social (U-iv'nation) 



URTHPI.ACK ^ Q 



that I last saw h rrrrr alive on 
an.l that death occurred, on the date stated above, at 
M. The CAUSI*: <)!• DliATIl was as follows 

1 -uJb^V't'VwVfr-r^^ 



y ^.O^y-vv^rvv 



^ 



,V4 



NA>fK OT 
FATHHR 



niRTHPI.ACK 
OF FATHFTR 
estate or Country) 



MAIDKN NAMK 

oi- mothf:r 



lURTHPUAOK 
in- MoTHKR 
(Slate or Country) 



OCCUPATION 



^, 



Pfsitffif ill Siifi /'itiiuisro 




Dl-RATION Years 

CONTRIBUTORY 



Months 



Days 



Hours 



M.D. 



DURATION Years ^ Mofiths Days Hours 

( SIGNED )..U^'C^W^ '* • ^ ^ IjJuvwtL. 

luX IQOH f Address) Uv^r>AXV. 

9ECIAL INFORMATION only for Hospitals, Institutions, Transients, 



KU 




\^JL 



Yrars Mouths 



Pa rs 



TllK AHOVK STATF.I) PKRSONAI. PARTlcn.AKS ARK TRlK TO THK 

nF:sT OF M^L-KN(>w'^H^oK and nF:i.ii-.»' 



(Informant 






(Address 



BivAj^. (j (r\t ulcj^v^ 



or RfCCTtUe's'idf'iils'Vni ptrsiiiV'dyiiis m>i from hoiiw. 

Whfn was disfasf contracted, 
If not at place of deatli ? 



Days 



PI.ACK OF BIRIAI, (^R RKMOVAU | DATK of M. k.a.. or RKMoVAI, 

Y^aXaut b 1 90S 






(Address 



.. ^ APF should be Mated EXACTLY. PHYSICIANS •hould 

N. B.— F.very Item oi InWmatlon .hould be cnrefully supplied. ^^^ '^7" ,|„^d. The ••S,>eclal Information'- for pT- 

•tate CAUSE OF DEATH In plain term., that It may be Pj-^l^'y ^l^n^lilca 

«on« dyinft away from home should be ftlven In every Instance. 




IP 



i 



i( 






1 



! I 



WRITE PLAINLY WITH UNFADING INK 






I)((/e Filed y 



190^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICA TE FOR INSTRUCTIONS 

Registered J^o. ^v 



'I ;l 



n 







VU5 



ov.^ws/s^ <^^^v;-vA Deputy Health Officer (• r r • /v 

DEPARTMENT OF PIBLIC HE ALTH=City and County of San Francisco 

Certificate of Death 

( tl. S. StanDarD ) 



PLACE OF DEATH: — County 



of^. 



.OUTVJ 



ix-CL^vcv^t^ Cityof O^v^O^v^^^^^^A.*^ 






and 



^A 



FU LL NAM E .lxLj.v.xi b,...l<x^^va^ 



SKX ^ 



PERSONAL AND STATISTICAL^RTICUUAR^S 

COI,OR 



1 



DA TH 0\- lURTH 



AGE 

SINC.I.K. MARKIKI). 



L 



\X)-A\aXjL 



Oct 

(Month) 



>Vtfr* 



I 



(D.MV) 



Mimlhs- 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF'' DKATH 




I 

(Day) 



(Year) 



€.. 



Davs 



riII':RHBY cirRTIFV, That I atteiuled deceased from 

Wvv. .1 190 H to ,^ 1^^^^ ^ '90H 



->^sX- a^- 



iWritt in social (lt•^i^^nati(>n) "^ U 



that I hist saw h ...t^ alive on ^"^ 
and that death occurred, on the date stated ahove, at 
^^^j The CAUSH OF DlvATlI was as follows 



190H 



v,-* 



niRTMPI.ACE 

(State or Country) 



NAMK Ol" 
I ATin:R 



BIRTHPLACE 
Ol- l-ATHKR 
iStat«.- or Country) 



\JxtjL>u >. ^^^<X 




Aj'-Vw'W 



MAIDEN NAME 
OF MOTHER 






Dr RAT ION Years Months 
CONTRinUTORY 



Days 



Hours 



Mouths 



lURTHPLACE 
n|- MOTHER 
(State or Country) 



OCCUPATION 



Resided in Stifi Fioniiseo 



:X TonS^ (Address) bO^ 



(SIGNED) 




n )v<M5 6 yr.wiiis 6 



/>.n. 



TMK ABOVE STATED PERSONAL ^ ^^V^}'^c/i^'' ■^^'- '^'^''''' '" '"" '' 
BEST OF MY KNO\VLED<'.E AND BKLIEF 



(Informant 






(Adflress 



^ticlAL INFORMATION only (or Hospitals, institutions. Transirnls, 
or RcrdS Residents, and persons dying away from home. 

How lonq at 

formff^f Plare of Death? Days 

Usual Residence • 

When was disease contracted, 

If not at place of death ? 



PIACEQE niRIALoR KEMOVAl 



E OE ni RIAi. 
UNDERTAKER to^^^^^ 

0.^ A) OLAv 



DATV, of IM KiAi, or REMOVAL 
H I90S 



(Address 




CU>^.. 




AGE should be state 



tl EXACTLY. PHYSICIANS should 



N. B.— Every Item oi lnforn,«tlon should be carefuMy supp. ed ^^^^^^^^/^^....j. The "Special lnfor„,af.o„" for p.r- 
state CAUSE OF DEATH In plain terms, that It m»> ^^^^^ 
son. dylnft aw.y from home should be ftWen .n every instance. 



i 



i 



iJ 




lil 



f 



r . I 



■A 



r' 



I 



\¥ 






WR-re PLA.NLV WITH UNFAO.NG ,NK-TH.S .S A PERMANENT RECORD 

^" „F« TO «CK or CERTT.CAT r TOH INSTRUCTIONS 

-■ ..-INul^^^t^^'"^''^-" — 



/>r(/*' Filed,. 



.190^ 



Megintered JVo. 



Gl 



1 



.^ft-VA^ Llxvu Deputy Health Officer -r r • « 

DEPARTMENT OraBLlC HE ALTH=City and County of San Francisco 



dertificate of Beatb 

( la. S. StanDarD ) 






P.ACE OF DEATH,-C»«„ J C..Xo......^n ., ?^ <X^ W,.=^=. 






Dist.;bet. :::.;:.::::: ,„.f"t 



) 



/ IF DEATH occurs! AWAV FROIW WOW«w ..- 
( Tf DEATH OCCURRED .N A HOSP.TAL OR 

FULL NAME 




.UrU-.(X .2^.C.CL/.YS-^. 



PERSONAL AND STATISTICAL PARTICULARS 






C01,0R 



UjJfx^^ijL 



1)\TK <)I" niRTH 



(Month) 



X /H.^ 

(Day) (Vear) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 




• **^\ • ■ ■ 

(Day) 



fpO 

(Year) 



\<',H 



IS 



)''ii > > 



M,»illis 



Days 



siNC.l.K. MAKK1KI>. 
WinoWKI) OK l>IV()ki KI> 
iWritf in stKMal drsiK^'iation) 



UIKTHPI.ACK 
(State or Country) 



I 



JATHKR 



HlkTHPLACK 
OJ- JATIIKR 
(Stalt or Country) 



MAIDKN NAMK 
OF MOTUKR 






FhKKHBY CI<:RTIFY7That I attenacil deceased from 

.^WvAJL^:^ 190 H to ...|ijAL^--i 190H 

U.L last saw hX^. alive on |^ ^ 190 S 

a„.l that death occtirred. on the date stated above, at C^ 
I M The C\USE OF Dl-ATII was as follows: 




'r\ /y\,.Z^^y-^^]r^^\JL^^^ c^ ■ 



CONTK , BUTORV (JUU^VV^N^t.^^. 



JfoN//is Pav'i 



AaU) 



luKrniM.ACF; 
oi' mothf:r 

(state or Country) 



_c>l^a.v^i 



J 




Hours 
M.D. 



DURATION >V<?^« 

^AaIllX looN (Address) b ^ ^"^^ ^^ 



Special information «"iy •«' ««»"*• '"^"'""•«' '"«""''• 

or R^tS ResWrnls," d ptrsons dying a*ay from Hon.*. 




Ihirs 



OCCUPATION — 

a 

Rrsidn f ill Siiu I'laxrhrn '^ )>ui,s <J M'Oit i> 

THK AHOVR STATFl) PFUSONAl. »');<';! 7, l^O^*^^ "'^'^ '**''■'' '*' '*'"' 

UFST OF MY kno\vm:i)c,f: and nhi.n-.i 



(liifoiiuant 



(X^wLrvxA^ '3vcvc^v>-^.-<i 



I' 



(A«MrcsH 



UJJrut 



Former or . /. 

Usual Residence 1 <A 

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



I How lonq at » a « 
yjr^s.'U^ Place of Death? it Days 

7 



ri.ACE Ol; m-RIAI. <»« RHM<-VA^ 



OF m KIAI, »>K r. 



DATF^ol Hi KiAi- or RF^MOVAI, 

H 190H 




INDKRTAKKR 

(Address 



___^,.^.._.«— — — — — — """""^^ . , FXACTLY. PHYSICIANS should 

N. B.-nve.v Ue. o. ln.>..«..on .Hou.a He .„.e..l.> supplied ^^C^^^^.J^/^^,- :i!%He ''Special in.o.n,«..o„" .0. P-.- 
•tate CAUSE OF DEATH In pla.n J^-;-"'*;;" „'*,,'",;^ |„,t«nc«. 
•on. dylnft away from home should be ftlven In e.ery 



i 



1^1 
11: 




^1,4 



i 



i' 



1 . .«' 


Mi 


1' ' 





-Li.e- le A prRMANENT RECORD 
«,-rc PLAINLY WITH UNFADING INK — THIS IS A PERWAlNt 
_ WRITE PLAINLY WITH „-- .......t. roR .nstruct.on. 

,,,,,,,.1 ,,(• ■■•.HV-t N". '•> -w.^. 




/,9^H 



Megistered J^o, 



J)((lc Fifed, 

X.^^c^ Xt^^ Deputy HealttiOfncer Ct-otiricrA 

DEPARTMENT OF PBBLIC HEAITH-City and County of San Francisco 

Certificate of Beatb 

( tl. S. 5tan^ar^ ) 
9.0^^ T.>va^vcv4c^ City ot ^ <^'>^ ^ -'^-^ 



PLACE OF DEATH: — County of 



St.; 3. Dist.! bet.5 M^^ ..,„c,.. .»-.m.t.o.- A 



1 LI u /\ V V ^ St.; ^ DlSt»;bCt. ^jl.MnrR "special information- \ 



FULL NAME 



Q]Uw (L:tL 



,vDv<X>^- 




-^l-A 



PERSONAL AND STATISTICAL PARTICULARS 

coi.oi 



i)\ ri-: «)i" luRTH 



'\ivLcU .-- 




lUay) 



/^tsM 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE <)!■ DKATH ^ (^ 




(Day) 



(Year) 



Ai.K 



) ■/'(/ » A 



M,niths M VV' 



VVi /Jn^-i 



SIN., 1.1- MARKTKn. f^ . 

(WriU- ill social (Ksi^nation) \ U 



lURTMri.AOK 
(State or Country^ 



NAMl". Ol" 
FATHl-.R 



RIRTHPLACK 
Ol lAPHKR 
(Slate or Country) 



i 



nTS^iSY'cF;RTnA\ That latteiuUMiaeceased from 

that T last saw h JL>V alive on J^^ "^ ^ A 

,„a that aeath occurred, o,i the date stated above, at 
(?. M. The CAlSIv OF Dl'ATII was as follows: 

- Mofiths - Pays ^ Ilour-^ 



nr RAT ION >'^''^'-^ 

CONTRIHIITORV 



MAIDKN NAMK 
Ol' MOTHKR 



^\}1^^^^^ 



Iv 



ItlRTHPT.ACR 
OF M(VrnKR 
(Slatf or Couiitryl 



\jxh 






Hours 



M.D. 

Institutions, Transients, 



OCCUPATION 



)'rn I 



/hn. 



THKXnoVKSTATKnwKR^«1N^I rVRTK^riARSARK TRVH T.> M 
BKST Ol- MV KNt)\VM:i)<-.H AND Hl-.Ull.J 

(Iiifonuatit 



..tot^ Residents, and persons d,in5 a.ay Um home 



Former or 
Usual Residence 



HoH lonq at 

Place of Oeatli? Days 





DATKof lUKtAi. or RKMOVAl, 



I 



ri.ACK OF m RIAL OR RKM«>VAI. 



rSDHRTAKKR 



V 






N. B. 



^^^^-'^'^ ' ^^-^ WV^VA^ I , FXACTLY PHYSICIANS should 

..otc CAUSE OP DEATH In >>'-'" "7!.;;J;"„"'.r.ry .n.U™«. 
..n. dyln* awa, «rom home .ho.,ld be ft.>en m . 



Jli 



1 I . 





« 1 *- 





,5. 




WRI 



*«.K.r» INK— THIS IS A PERMANENT RECORD ^^ 
Tr PLAINLY WITH UNFADING INK — THIS I5> m 
TE PLAINLY W ^^^^^ ^^ „ ..k or cert.f.cate poR .nstruct.ons 

63 



H&PCo 







, u V M ^»^^ Registered Xo. 

lh,l<' Filed, V^^ 

DEPARTMENT OF PIBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH 



Certiticate of Beatb 

( Ta. S. StanDarO ) 
; -County of S.VV^^V^Ax City of 



Dist.; bet. 



« 

and 



Levi 



'No. 



, „,^ USUAL RESIDENCE GIVE r*CTS CM.LCD ^O" ^^''^J 3^%%eT AND NUMBER. >/ 

/ ,r DEATH OCCURS *«'*\"°'r ^s^pVt..: OR INSTITUTION GIVE ITS NAME INSTEAD O 
^^ IF DEATH OCCURRED IN A HOSPITAL O ^ 

s^dsJX)^- 



FULL NAME 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



^ 



VU-^v^tc 



n.\TK OF IHRTH 



AC.K 




(Day) 



AfcH 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
^\TE OF DEATH 




as 

(Day) 



(Year) 



So JV.n. I ^'-*'<'" ^^ 



Da VA 



ThEREIW CKRTIFY, That I attendcl aeceased from 

;. T90 



T-rr. 190 



to 



siM.J.r.. MARRIKP 

W innWKI) OR niVORCKD 

Writrin social lU-sivnation) 



lURTHIM.ACK 
(State or Country • 



XAMK OF 
FATHKR 



4! 



NTlVot^JvAJl^cL 



that I last saw h-:— alive on 
,„a that death occurred, on the <late stated above, at^ 
M. The CArSiv C)F DlvATH was ^^ f^"^^' 



190 



-«':J:iXvtLu=^..^4 ^-^^ 






DURATION >>«'-^ 

CONTRIBUTORY 



Months 



Days 



J lours 



niRTHPl.ACK 
(II- lATHKR 
(Slat I- or Country) 



MAini'.N NAMK 
<)!• MOTHKR 



HIRTHPI.ACK 
OF MOTHKR 
(State or Country^ 



Afonths 



DURATION Years 

(Signed) v. <•<• ^^-^^ 



Days 



Hours 
M.D. 



X 



iqo \ 



Address) ■ ^\ 



-CWU^. 



Cc^L 



t< 



OCCrPATION 



Jo &-^->»-<Xa-^u-^-^ 



Rfsidrd ill Sati /■'njnn'srn 



«* ]■(•(// < 



Months 



Pa V, 



,PEC;.«u INFORMATION only for Hospitals, Inslllutlons, Transients, 

RefelS Ments, Vnd persons dyN away from home. 

How lonq at 
Former or pjare of Death? wys 



or 



IMK AHOVE STATKI) P««^«>NA1 rARTjCrj.ARS ARK TRrK TO THE 
BEST OE MY KNO\Vl,ED<-.E AM) Hhl.U.I 



(Informant 



(\(MrcsH 



5^ 1 yOcC "Ltxx Urw^t 



Usual Residence 

When was disease contracted, 

If not at pl ace of death ? 

■,.,.ACE OE m-RIALOR KEMOVAT 

0\^ "A 



NDERTAKER U^' ' ^ ^ (\r\ 



DATE of HtKiAi. or REMOVAL 

A' 



(Ad<lress 



5 *^ vYYVAA<^-<v=<tnr\..a.t. 



■" ^ . FVACTLY. PHYSICIANS should 



u 



w 



|i! 



*l 



tl 



WRITE PLAINLY WITH UNFADING INK 



H(i:il<l "' M1.1HM 



THIS IS A PERMANENT RECORD 

REFER TO PACK or CEBTTICATr TOR INSTRUCTIONS 




Date Fileil, 




lOOH 



Registered J^''o. 



DEPARTMENT O^'PUMALT H-City'and County of San Francisco 




Certificate ot S)eatb 

( •a. S. StanDat& ) 



PLACE OF DEATH: — County of 



Q^j^y^Ji^'K^LsL City of ff^>vx^ ^^ 



Dist.; bet. 



— - ) 



'No. 



( 



— ^ St.; Uist.; DCi* -^ ^ _;, .:gp^j.,^L information- ^ 





FULL NAME 




<.KX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR 



1)\T1-. Ol- HIRTIl QrS j] 



lO.LtL^ 



MEDICAL CERTIFICATE OF DEATH 
D.\TK OF DKATH^ 



VMoiith) 



n 

(Day) 



r \ fc C, 

(Year) 



(Month) 



•IB. 

(Day) 



(Year) 



HTliRln^- c'iTrTIFY, TllHt I altc-.,.UMl .lecoascl from 

■ :....i90 



AC.K 



M.H 



^INtl.K. MARKIKD. 
WIDoWKI) OR DIVOkiKI) 
IWritf in social (kHijf nation) 



niKTIUM.AOK 
I Slate- <»r Country^ 






Tl/I '<> 

that I last saw h—— "live on 



,,„, that .U-ath occurred, o„ the .late stalc.l above, at 
.-.-^.. ThcCAlSHO.- 1„.:ATI.«^s as follows: 



NAMK or 
FATin-.R 



Lv^vO( 



XV^^^ol/a^m 



DURATION JV'?''^ 

CONTRIHUTORY 



Motit/ts 



Days 



Hours 



^W^AX^V- 



I 



lURTnPT.ACK 
Ol l-AllIKR 
(State or Country) 



MAIDKN NAMK 
Ol- MOTHKR 



lURTHPT^ACK 
OF MOTHKR 
State or Country) 



M 



(« 



Dl'RATION 



Viars 



Motitlts 



Days 



Hours 



(SIGNED) 



(^_ ^ , ^JX^CJUJ-TTL U^^ 







it 



.Kei-p.\TioN (f^JJtc^JU^ 



^ i()oH ( 



A,l,lress)_J^tV>^£Ul 



or 



KfsiiUd in Stifi /'I'ln, isro -^■ 



)Vais - .V...////^ 



n,i v> 



K XHOVK STATKU VHRSOVAl VAHT.Crj.ARS ARK TRlK To TMH 
HKST OK MY KNOW I.KIX.H AND HKMKl* 



(Informant 



Le^u'*ent.,Vnd pffsons dyin, a«y fr.n, homf. 

HoH lonq at 

Former or pjarf of Dfath? wys 

Usual Residence 

W'len was disease contracted, 

I, not at pl ace ot death ? 

P.^ACKOK lURIAI, OR RKM.»VA1. 



J 'AlAvv^oXrvv\ 



rNi)i:RTAKKR 



( \<l(lrcss 



(Address 



Cn\t4.4^BVS Si 



lian 



AGB Bhovild be sta 



N. B.— Bvery Mem o9 Information .houlcl be carcffully --^fj\^ ,^, c.a..i«cd 

.tate CAUSE OF DEATH In pla.n --•;;J;» ;*,,": ry Instance. 
«on. dyinft away ffrom home should be ft.ven m • e y 



. f^vACTLY. PHYSICIANS should 
:"Th. ^sZci- .n«or.„...on- ..r PT- 



I' 




••'il 



i'< 



ii 



(, ' 



>■*; 



«: '*« 



I 



r;< 



m 



tl 



1 * 

\ \ 



t: 



IU> 



m 




WRITE 



^.K./^ .MK — THIS IS A PERMANENT RECORD 
— ^ W.TH UNPAOmO -NK TH.S ^^ ^^^^ ^^ . .,, ,3..„c.o.3 

65 



190'\ 



REFER TO BACI 

Registered Ao. 



DEPm WmBEM^ra^and County of San Francisco 

Certificate oi Beatb 

( Ta. S. Stan&atO ) 
OF DE ATH : -County of ^^>^^^ ^ 

FULL NAME 



No. 



PLACE 




.'c.'^^jt'V. 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



vYtvL 



U)^kdx 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



DATH Ol- lURTH 



/]( Month) 



ACK 



30. 



) V4J » A 



5" 



(Day) 



Mouths 



rW\ 

(Year) 



(Monrti) 



5. 

(Day) 



190 1 
(Year) 



\\ 



n,i 1 . 



TlTWi^n- Ci;RTI1-Y, Tlu,t I atten.Ua .lecea^ed from 



— to 



alive on 




SINr.l.l-. MARKIKD. 

wiDowKU OK ni\<>Kv.i.n 

(Write in social (UsiKnation) 



nnrnn'UAOK 

iSt:ttc or Country) 



NAMK OF 
FATHKR 



mRTuri.ACK 

nV J ATUKR 
(State or Country) 



MMUKN NAM1-: 
(H- MOTHKR 



AIL 



^-^ Ak 



that I last saw h 

„,„Uhat ,K-:,U, occnrrcl, on t.,e .late staU.,1 ahove, at 

-^ M. The CArSl..Ul.-n..:ATll«as as follows: 



<?:S..^.\.^) 






'^. 



DURATION 
CONTRIIU'TORV 



Vears Months 



Days 



Hours 



«i 



lUKTHFt.ACF. 
OF M(»rHKR 
(Stale or Country) 



DURATION >'''^''^ 

1, 



.lA,«//;,v nays. Hoik's 



TQO 



(Ad 



PFdiAL INFORMATION only «»;^";^P"*'^ 
or RereS Residents, Vnd persons dying a.ay Vm home. 



.«M ftnlv for Hospitals. Institutions, franslents. 



tl 



Former or a ^ NjXuAt'UL ^l^VK- Plafc ol 
Ilea! HfOdence (^i) ^ * LUA.w^* 



;r^' 



OCCVPATION '"J^^^^^tt^ 



Rfsidfti in Sati /'lannsrn 



\H V'-" 



Tin 

RKST OF MV 

(Infoiniant 



ARSARi: TKl K TO TMK 



•. AUOVF STATKl) ''^-^^'^^V; i:^'* Jiir/iVF 
ilHST OF MY KNOWI.KIM.F A^" HlIJl-l" 

% QYui^xL- CUm- 



Usual Residence "X^ \1 i ItjjV 

When was disease contracted. 

If not at place of dcatt< ? 

Tm.ACKOF m-RIAI. <'K KKM..VAK 



How long at ^ 

Death? 



Days 



OATH of Hi KlAi. or RKMOVAI, 

'|vJL....H.... T90S 



(AddreM 






(AiMrrs** 



1131 CfVVAA4A«^r>'v «^- 






N. B. F.very Item 

state CAUSE „. -- . • i k^ aj 

«r>n. dyinft away «rom home should be ft. 



* M FVAGTLY. PHYSICIANS should 



I" 



^^. 



Ik 



11 



I 






'^^yjyx^^ Xlvvvv. Deputy Health Officer 



Registered jVo. 



> .X ) < 



DEPOTNT 0WBKlLfH=Cit7and County of San Francisc, 



Certificate of Beatb 

( H. S. Stan^arO ) 



-« '^ 






(No. 



PLACE OF DEATH,-C»..»oirta,~J^a^ "ft ^Xk ^l 



(IF DC*TH OCCURS «w-. ' 
,F DEATH OCCORHtO II 

FULL NAME 




.(.L.irWvt £). 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



HAT1', «)H HiR rn 



AC.K 






iDivvii. 



iMonth) 



(Day) 



^J^.O.H.. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




a 

(Day) 



(Year) 



} 'tUl > 



n 



Mouths 



.Davs 



SINCI.K. MARKIKP. 
WIDOWKI) OR nivoRi KO 
iWriU- in social (U-'«i>.'iiittion) 



lUkTHPT^ACH 
(St;iU' or Country' 



SAMK OF 

FA rm-.R 



niRTnruACK 

oi- lAfUKR 
(Stall or Country) 



4 



L 



r.TERFl^'c.rRTYFY, That I attcu.le,. .leocased fro,,, 

..Wvt as-^oH t"JnH ^ "^. 

Jnastsawh^aUveon.^^^ "^H 

,.,„, that ,lea.h occurre.l, on the ,latc statcl above, at 
jj ^1. jhc C/Vl-SR Oi; 1)1-;AT1I was as follows: 

.•p^,y>^.VVVr:>.'V\ 




MAinF.N NAMK. 
Ol- MOTHHR 



lURTH PLACE 
Ol- MoTHKR 
(Stale or Country) 



Si 4 



DURATION >'''<^''^ 

CONTRIIUTTC^RY 



Months 



Pays 



I /ours 





DURATION >'^;«f'^ 

(SIGNED) 



or 



OCCITPATION 




Residfd ill Sun Fi ttinism 



)'r<n s 



Mniltin 



I\l 1 .V 




TMHAmWESTATHnPHRSONA, rARTICri.ARSARKTRrKTO TMK 
BEST OF MY KNOWI.KIX.K AM> HFMl.l 



(Informant 



(Address 







^^A.^ Mr>A 



IMPORMATION only tor Hospitals, Institutions, Transifnts. 

How lonq at 

Former or pjarc of Death ? wys 

Usual Residence 

When was disease contracted, 

...,..CKO.;^nv«.M.oV,..M.n.,. ^^ ^. ^ ^^, 




iA/^^^-^ 



UNDERTAKER 



(Adilrrss 






N. B. Every item o? ln?orma 



. fTVACTLY. PHYSICIANS Bhould 
tated EXACTLY. •-" 



.,„„ .houia b= o«..«u,„ -upplU-. „^«f„-r;U..'l°.:i The "Special .n?o-..n...o™ 



for p«r- 



I Item Ol infuriiii.%."- *hnt It miiy *>e properly 

•tote CAUSE OF DEATH In »»•«'" J^.T^:;,*;" J every Instance. 
«on. dy-.nft away from home should be ft-ven 



ff n ' 



I if 



i 




11' 



h I 



t 



\> 



I -.'r 



\r 



• M 



^ 



m 



.,,.K./. .MK— THIS IS A PERMANENT RECORD 
„„,TE .U.,NLV W,TH UNP.Om. .NK TH,S , ^ _^^^__j__. 



li&PCo 



190^ 



Registered JSTo. 



•? ."Ioam^i DeDuty Health of'ficc'' 

DEPAOT^NT^mV HEAJJl^^ and County of San Francsco 

Certiiicate of ©eatb 

( tl. S. Stan&atO ) l\ /o fl 



67 



PLACE OF DEATH:— County of 



St. 



Dist.; bet. 



and 



No. 



.^..^ro "«sPf:CIAL INFORMATION" "N 
. TACTS CAttCO .'0_R_ON^DER ^«;^^^;*i„„ „,,mbER. ) 



FULL NAME ^*v^ 



PEPSO 



NAL AND STATISTICAL PARTICULARS 



Sl-.X 






L l"""U)JLt. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



DATK OH HIRTII Q(f\ 



y^^ 



iMotith) 



AGK 



) 'lil I A 



(Day) 



Mouths 



(Year) 




a 

(Day) 



(Year) 



I HEREBY 



Tt^ Cl^RTIFY, That I attende.! clecease.1 from 



190 



to 



Pa 



vs 



an 



SIN«-.l.r.. MARKTEr*. 
\V1I)«>\VKI) OR DIVORl KD 
(Write in social (U«ii>rtiation) 



lUKTHVI.AOK 
(Stiitc or Connlrj") 



N\MK OJ 
FATHKR 






that I last saw h alive on 

a that death occurred, on the date stated above, at 
M The CAl'SE OF DICATII was as follows 



igo 
190 



^\ 



/-V^VV^^ 



r 



t: 



v». 



DURATION J>«''^ 

CONTRIHI'TORV 



Months 



Days 



Hours 






lURI'lirKACK 
Ol' lATHKR 
(Slate or Cotiiilry) 



H 



M.MI)1\N NAME 
OJ- MOTHER 



niRTTTPLACE 
or MOTHER 
(Slate or Country) 



Mouths 



M.D. 



,,,^^ y.ars M^mns Days Hours 

DURATION^ ^>^^ 



^"fflVK.-S"!"'-"' 



OCCrPATION 

Residfii ill Sau rnuuisfn 



\\ 



- U,. »///>• - ^'"' 



or Recent 



TM1-: AltOVE STATED J'K 
DHST OH MY KNOW 



KRSONAM-ARTICILARS ARE TRIE TO THE 
•i.EDC.E AND HEMEH 



(I 



„<,. , 0^ 'V^w^«^^ -^-^^— ^ 



Former or 
Isual Residence 

When was disease contracted 
If not at place of death ? 

TarEOHmKrAl.;>K REMOVAL 

UNDERTAKER <^>-^ V?4 

(Address ■' ' 



ON only lor Hospitals, Institutions, Transients, 

Days 



How long at 
Place of Death? 



DXTEof HiKiAl. or REMOVAL 

^vJlu H T90S 







(Address 

N. B.-F.V.., U.™ o. ,„„..»...." .HouU. He -;.«,;';.^. --^''t Proper., ..a........ TH. ' 8P- 

..... CAUSE OF DEATH ,„ P'-'" Vrliv'.n In .v,r, .n,..nc.. 



I FVACTLY. PHYSICIANS iihould 
-.!;.^"THf 'Cecla. .nW.»t,o„" for P-r- 



«on. dylnft away ?rom home Hhould be ft. 



' ! Vv 



!v 



11 



V. >■' 



r 






. I 



h ' It 






1.1 



!| 



r 1 



'Hi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Jin ,r ! nf Hti.Ul>-K No. 15 -^^^ H&l' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jhf/r Filed, >\aXh..H 



190^ 



Registered JSfo, 



68 




Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Ta. S. Stan^arD ) 



PLACE OF DEATH: — County of "'Ow/^v J^a^vcu^ccCity of '^^'<^^vv J^O-^^ev^ ao 



^ 



(Ti^. \L .NaJL^ 



XoA (/UC^^iA^a 



St«; Dist.; bet. 



anj 



/ IF DtATH OCCUBS AJWAV 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 



k) 



.c« 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



DATK OV niKTU 




■<x.u. 



COI.OR 



^KT' 




(Month) 



.1 /^HD 

(Day) 



(Year) 



AC.K 



(pS 



)'riii 



Motilhs 



\ 



Da \s 



SIXC.I.K. MARRIKI), 

\\ inoWKI) OR I)IV(iRCKI) 

'Uiitf iti social (lesijrnalioii) 



niK rin'i.ACK 

(Statt or Contitry^ 



NAMK Ol- 
KATin:R 



BIRTHPLACE 
Ol- lATHKR 

'State or Country) 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



.J, 



(Mont 



'•il'. 



3 

(Day) 



(Year) 



I HICREBV CERTIFY, That I attended deceased from 

Wv%x. XI 190H to %-J^.X 190 H 

tliat I last saw h^V^w>aliveon W-vva X KpH 

and that death occurred, on the date stated above, at 5^ 

CI' M. The CAUSE OP DICATII was as follows: 

C/>aAX\,^Xn^ /^^.U^ 'V'>\irVvC.<xi/uin.\ 





DURATION 



)'ears Mouths ^X V^iys I lours 
CONTRIBUTORY W.-y^Ar^rA,<:v\.'^.....C..L 



MAIDEN NAME 
OF .MOTHER 



HI RTH PLACE 
01 MOTHER 
(Statf or Countrv) 



n 



OCCUPATION 



DURATION Vcors 

(Signed) 



M out lis 



Hours 
M.D. 



A^^3X 

Special information only for Hospitals, Institutions, Transients, 



Da \s 



Tin-: AHOVE STATED PKRSONAL PARTICTLARS ARE TRIE TO THE 
11E8T Ol-' MY KNOWI.KDOE AND HEMEK 



(Infonnant 



(Address 



^ 1 ooL^A/cvvwii/vcto n\ 



or Recent Residents, and persons dying away from liome 

LCtL 

Wlien was disease contracted, ^ 

If not at place of death ? 




Former or 
Usual Residence 



How long at 
Place of Death ? 



I! 



Days 



3 ACE OK ni'RIAL OR REMOVAL I DATE<jf Hi KIAI. or REMOVAL 

undertake:-. UjA^n (J^A. 

^ 1 .0 C)<<?w<LV/CL/-»>JL>.vU .a.<t 



'J- 



(.Address 



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

state CAUSE OF DEATH in plain terms, that It may be properly classified. The Special information for psr- 
sons dyin^ away from home should be ftiven in every instance. 



■■^11 



\ 

h\ 



II 



f' 



I 



i 



i '■ 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RKFER TO BACK OF CERTIFICATE FOR IN8TRUCTI0Na 

G9 

I )((/(> Filed, 



H,,;inlof Menlth-KNo-'S 



H&l'Co 



r 190^ Registered JSfo, 

DEPARTMENT 0F>UBL1C HEAlTH=City and County of San Francisco 







Certificate of ©eatb 

( •Q. S. Stan^ar^ ) 



No* C 



Si ^ in 

PLACE OF DEATH:-County of ^O^ C>X<X^xc^^City of 0^>v JXCV>x^a^ tt^. 



St.; — Dist.; bet. 



V.,^. 7WW>4^«www, ;,^„ ,,_,,., BESIDENCE GIVE FACTS CALLED rOR UNDER "special INFORMATIO 

( " r,"o»T°»"occ".;"V,"rHo.^PrT*c o"?-:»n?u" « a... .ts name ,»st..o or sT«eT .«o »u«.c.. 



!" ) 



FULL NAME 



a 



,/vu^.vajl.. 



t) vLLlx^.: 



SKX 



w 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR' 



n.XTH (IF IMRTH (Tq^ 






U),SLt£ 



l^^()nth) 



II 

(Day) 



r%1 5 . 

(Year) 



AC.K 



a^'i 



) tO I 



Minilhs \cy 



Ihivs 



SINT.I.K. MAKKIKI). 
\VII)()\Vi:i) OR DIVORCKl) 

iWiittin MK'ial (Usi}.rnati<)u) 



lUKTHlM.ACR 
(State (ir Country) 



FA'rni:R 



niRTMPI.ACK 

0|- l-AIHKR 

( State nr Country) 



V 



OCCU PAT ION ^ 

Ob o^v4uuaj-uU- 

Kfsidfd ill Still r'miiiisri} * )'rai s 

Tin-: MU)VK STATi:i) PKRSONAl, I'ARTirr I.ARS ARK TRlK TO TllK 
IJKST OF MY KN0\VM%I)<;K AND HKun:F 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



month) 



1 



(Day) 



(Year) 



" FinCRICBY Cl'iRTIFV, That I attended deceased from 

I9 to 190 ~~~ 

tliat I last saw h rr^ alive on '9° """^ 

and that death occurred, on the date stated above, at 
— M. The CAl'SI-: C)l-' DllATll was as follows 



d 



I) r RATION Years 

CONTRinrTORY 



Months 



Days 



Hours 



maidf:n namk 

01 MOTHKR 



IlIRTHl'LACE 
«>1- MOTHER 
(Slate or Country) 



<=\ 



^f,»lf/ls 



Pil vs 



(Infonnant 



(Address 






DURATION years 



(Signed) Wvrvvt^' 

5 IQOH f 



Months 

\ 



nays 



Hours 



TAE\A)-lJUvy^A M.D. 



PEc'Ial information only for Hospitals, InstiluliknS, Transients, 



or Recent Residents, and persons dying awdy from liome 



Former or 
Usual Residence 



r\, ( 1 How long at 

Vi UtA.^ iX" -^Ware of Deatfi? 



7 



Days 



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



? 



I'I,ACE OF" lURFAI, OR KKM«»VAI 



rNDERTAKF:R 

(Address 




DAIl". ')t j^n wiAi. or RlvMOVAl, 
R ___IQO"i 

0|. 




10 






.H„„U. H. ......un, .UPP.I.... ACB .-u... h. ..eu. P.XACTLV. J-S'C'A:-.V;-'': 

In plain term., that It may be properly cla»s.Hed. The »pec a 



N. B.^— Bvery Item off inforinollon 

state CAUSE OF DEATH In p 

«on. dylnft away from home should be ftWen In every instance. 




ill 



I 



I 




WRITE PLAINLY WITH UNFADING INK 



190'i 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\^o. , 7U 



I: 



■M 



/)(//(' Filed , 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( TX. S. Stan^atP ) 



PLACE OF DEATH:-County of oi^^x. ^ )V€V>v^C-City of OCV^ Avo^x^a^c^ 



^ 



Pt5.^ 





(IF DtATH 0( 
IF DEATH 



St.; 



Dist.: bet* 



and 



CCUR« AWAY r 
OCCURRED I 



^ ..eii«l DrCinFNCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ 

':Tho^''^.\. Jr^ns'it^^V^o^'VivYTs name instead of street and number. ; 



FULL NAME 




hJX 




PERSONAL AND STATISTICAL PARTICULARS 



I 



hH 



/i 



^I'.X 



I)\ ri". Ol" lUKTU 



.\<.h; 



5) 



"■" lU.Lt. 



iMoiitl'J 



3.^ 

(Day] 



,%'\\> 

(Year) 




<^ I ) 'ti ' ■'■ 



Moul/is 



1 



Da v.s 



SIVCI.K. MARKTl*n 

W IIxiWlvI) OK I)IV()RCl<:i) 

i*Aiitt'iii social (UsiK'iialion) 



isiateor Country^ \]\\ 



!r 



WMK Ol- 
1 ATHKR 



n 






MEDICAL CERTIFICATE OF DEATH 




X 

(Day) 



(Year) 



i\<X 






.Ltt 



RIRTTTPI.ACK 
OF I ATMKR 
(Slatf or Country) 



IV 



i 



I 




MAIDKN NAMH 
Ol' MOTHKR 







'(Xovil 



^iNttt 



niRTHPLACR 

Ol- mothi-:r 

'SiaU- or Country) 



OCCl'PATION 







Ki'sidrd in SiDi I'l ath i>.'i> 



— T,-,n- *- yf">ilh 



. It 



I'lii 1 > 



f 



TMK AHOVK STATl-.D PKRSONAI. rAKT IC T I.AKS ARK TRrH TO TUlv 

HKST OI-- MY kno\vm-;d<u^: and mi-:m1":f 

(Informant LvVOL^ UJ QjMXC KXtL 



I HF.RHRV C1:RTIFV, That T atteiuled (Icceased from 

^kvwvvx lb 190 H to ...^vJUv. a 190 H 

that I last saw h .^^^^milivc on ^|aaJIu^ X 190 H 

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

(X.:SI. The CAl'SIC Ol' DICATII was as follows: 

J..\.,ajL^WA'.A.'VC5L.O^/.>.:>^ 



DURATION * Years ^ Months X"^ Days -Hours 
CPNTR IIU'TOR V <^AA^tX.^-w^t^-<^.v^..|^^ 



IHRATION ^ Viiirs * Mont/is I Id I^ays - ffours 
( SIGNED )10'a.llaoC <^ )JU^^^ M.D. 



y-JL?> iCoM (A.ldress) IS 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying a;va> from tiome. 
r,m.r«r /n rt > ^ ■''^^^^ low lonq at , ^^ 
KlR^idence(Bxka\)v.t<^ ^c^ Place of Death ? 1 :7. Days 

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



I'LACKOF m-RFAI, OK RKMoVAI, | »^^'».:of IMRiA.. or RKMOVAI, 

I90M 







(Address ., . 9^ .:SHi 0^VVUL4^^^ 




.vC 



N. B.. 



""""""^ u I I h t tetl F.XACTLY. PHYSICIANS should 

-Every Item oi Information should be cnre?ully supplied. AGE s "".**" The "Speclol Information" for p«r- 

state CAUSE OF DEATH in plain term., that it may he properly classified. The », 

son. dyinft away from home should be ftiven in every instance. 



i- m 






W 



u 



\ ^ p 



iii 



^1 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,., „-,.s-„.,..^H^HCo n.P.R TO BAC. or CERT.F.CATe FOR .NSTRUCT.ON, 

,„fr Filed, |vdu 5" I'JO^ Registered JVo. 71 

TvC»-w<^ XlAMJ- Deputy Health OflH'^er 

DEPARTMENT W PUBLIC HEALTH=City and County of San Francisco 




Certificate of H)eatb 

( xa, S. StanDaiD ) 



of ^' 'C^ ^ V ^ ' • 



i 



PLACE OF DEATH: — County of ' 0.-»v TA^^vCv<lCc.Gty of 



'No, utu "^^ L 



.t 




and 






FULL NAME 




vuLv (^ <* 



A.^.VA.n.VL. 



PERSONAL AND STATISTICAL PARTICULAJRS 



DAIK Ol- lURTIl 



CGI. 



Out k 



(Month) 



>v^-v^n.^^. I 

(Day) 



(Year) 



A(iK 



O..^ years 



M,i)iths .^^ /^"'-^ 



sin(;i,t:, marhikI). 

WlDoWMI) OK DIVOROKI) 
(Write in scxMal litsi^'naliori) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



onth) f) 



-H 

(Day) 



(Year) 




inRlMll'I.ACK 
(State or Country^ 



,r^ 



NAMK OJ- 
FATHKR 









I HEREBY CIvRTIFV, That I attended deceased from 

X .'h^. 190 H % 4o"^^ ^ '^ *^ 

tliat 1 last saw h -^^-^"^^live on J^'^^'^^ *^ ^'^^ 

and that death occurred, on the date stated above, at I 
LLm. The CAUSE OF DICATII was as follows: 



U5 



RIRTHT'LACK 
Ol- I AIUKR 
(State or Ci)»intry'> 



MAIDJIN NAM I". 
OF MOTIIKR 



«t 



M 



RIRTHPI.ACK 
OF MOTHHR 
(Stale or Countrv^ 



u 



f 



Rfsitifti hi San Fnx)iiisro ' ^ )'rai s 



Months 



/hi t . 



Tin-: AUOVH STATl'.I) I'KRSONAI. I'A R Iicr I.A RS ARl". TRri-: TO THK 

hkst Ol- Mv kn()\vij:i)('.k and iu'.mkf 



(Informant LU rWU VlR- 3s.XXA.A>A..<rV 




DURATION y'tars 

CONTRIBUTORY 



Months H Days ' Hours 



Years 



DURATION 
(SIGNED) 



Months 



Days 



Address) C "^X^ C ^ M- K 



Hours 
M.D. 



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

/I) I [\ How lonq at 



[i^rWVnre I b HU O^V^ 



Usual Residence 

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



Place of Death ? 



4. 



Days 



u 



n \CH Ol' m-RIAI, OR RKM..VAI. I. ^TK ..f n. k,a,, or REMOVAL 
,M,KRTAKHK ^alvl«M^<^ ^\^^^^ ^' 



^ . . •_ » * ,1 PVACTI Y PHYSICIANS should 

Ion .houlcl b. c«refu1ly supplied. AGF. f ""'^^^^^ ^^^'^The ''^^^^^ Information" for pT- 
H in plain terms, that it m,iy he properly classified. T he «pe 



N. B.— livery item of informHt 

state CAUSE OF DEATH 

son. dylnft away from home should be ftiven in overy instance. 




, ' t 




i 





; i 






■P'""**"^*'. 



■k- f 



IVinrc 



loflKMltlv KNo. l^T^^^ 



H&FCo 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

^., J V..., w .,..^ Ra^isterecl JVo. T'V 




,Vv^vv^ 



^a^' 




100'\ 



M Deputy Hearth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




I 



Certificate of 2)eatb 

( ■Q. S. Staii6at6 ) 

Si ^ ^ 



^ 



PLACE OF DEATH: -County oi^Ojy^ Ka^CV4^ City of ^Oav 0,rv^>vC.V4CC 

Sl'^a ()i^A St/ I Dist.;bet. ^M"^ and r^Ovk 

No. bO<^ i'.VL't^ ....... oTOi/cMrr r.lUF FACTS*CALLED FOR l/l 



/ IF OtAT^OCCURS AWAY FROM USUAL 
V, IF DEA,H-H OCCURRED IN A HOSPITAL 



\p<r^ ) 



RESIDENCE GIVE 

OR INSTITUTION GIVE I 



FULL NAME 



TS CALLED FOR uTndER "SPECIAL INFORMATION" \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



LtVvvuL^l/ 



PERSONAL AND STATISTICAL PARTICULARS 



•SKX 



^\A. 



COI.OR 



UJJkvix 



1>\ IK nj- llIKTH 



Ar.K 



I Month) 



(Day) 



(Year) 



»' ! 



. I -J 1V<?».v 



M.nilhs ^^ays 



SINCl.K. M\RKlKn. 



WIDnWHP «»K DIVgKCKI) U A 

(Write in '^(x'ial dfsijf nation) ^A I) 



■4- 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DP:ATH 



Month) T 



(Day) 



(Year) 



HIiRHBY Ci:RTrFV, That I attendtMl .lccoase<l from 

.-v^X '^ 0190 H to |vlL^ a 190 H 

thatl'lastsavvh<^^>>Hliveon j^vaXvJ^ 3 190 S 

and that death (occurred, on the date stated above, at T • 5^ 
U:. M. The CAl SJv Ol" l)I*:ATn was as follows: 



nikTMlM.ACH 
(Statf or Country* 




FATHKR 



RlkTUn.ACE 
OI I-ATHKR 
(Stntf or Countrj") 






MAIDKN NAMK 
01 MOTIIKR 



niKTHPI.ACK 

ol- MnTnKK 

(St;'.l( or Country) 



occrp^TTON 





Prsidfif in Sntt Fniii'isrti ^ G )V'7>> 



<X"rv 



xL 



1/,.;////' 



/'./ 




CLcxATtx 1L<^V-1XA^ 



nr RATION ^JVarj -^ Mouths ^ Paya I ^ //ours 




L .iLCX^v^"?^ , t-.*'>v\A.^v-AJ'VvXu^>^<:» 'C'D«\^\A..<C-. 



CONTRIIJUTORV 



I )r RATION >V'7r.? 



Mi)>iths 



/)avs 



//our 






Special information onU for Hospitals. Institutions, Transifnts, 
or Recent Residents, and persons dyint) anay from fjomr. 



Former or 
I'sual Residence 

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



How long at 
Place of Death ? 



Days 



TT^iiOF m-KIAI, «.K KKM..VAI, LATKol HrK.A.. or kl-MCVAI. 

iq\) flu^^ CKiUU.. M\>* 






N. B. 



i^^"^^^**"^^^"'^"^"'"^^^^^ u If! K t ted EXACTLY PHYSICIANS nhould 

Htion .hould be carefully suppHed. AGE *^«7J* ^^ " " ^^ "Special InforniBtion" for p.r- 
ATH in pl«in term., that it may be properly classified. he »pe 



-hvery item of inform 
Rtate CAUSE OF DEATH in p . 
«ant dyinft away from home should be fe'ven in every instance 




If 



Jit 



WRITE PLAINLY WITH UNFADING INK 




H„Mnl of Hcalth-FNo. 15 



Ddlc Filed y 



B& I' Co 



.^-V^-A^ 




WOH. 



THIS IS A PERMANENT RECORD 

WCFgR TO BACK OP CgRTIFiCATC FOR INSTRUCTIONS 

73 



Registered J^o. 



V 




Deputy Health Of^cf^r 

DEPARTMENT 0F1»UBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate ot Death 

( Ta. S. StanDarD ) 

i J .>LUrLuyv\ wU. City of ^' 



.VL^WO. City of C3 irru'lrVcu 



loi 



No. - 



St.; — — -" Dist.; bet. 



and 



(IF DEATH 
IF DCi 



if death occurs away f 
:ath occurred i 



FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 

N A hospVta!: ?r institution give its name instead of street and number. J 



FULL NAME 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

CO I, OR 



i))\cJL 



WjaxxXjl 



f 


^ 


1 


:'P 


\' 


i 



DATK <)I- HIRTH 



AC.K 



(Month) 



■it 



J 111 » A 



(Day) 



MoHlhs 



A^'i 

(Year) 



Pa vs 



Slxr.T.R. MARRIKD. 
WIDnWKl) OK niVOK'.Kn 

(Write ill siK-ial (U'sij^iuitiou) 



niRTHPT.ACK 
'Slatf or Country) 






MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATI^ „ 



/I (Moivffh) 



,1 

(Day) 



I go \ 
(Year) 



\AM1-: Of 
FA'lin-.R 






Vj.OUlaJL X'X/Wv^X.aXa^wL 



HlKTHl'I.AC'H 
or J \1MKR 
(Stair or Country) 



m\ii)i:n namk 

Ml- MOTUHR 



HIKTHPI.ACK 

<>» MorUKR 

• Stale or Country) 






OCCII'ATION 

Rfsidfii in San /'i <i n, isro •- ^luji 



y/.iiiih' 



/hiv 



TID: AHOVK STATKI) I'KKSoNAI, I'A K lUT I.AKS ARK TRrK TO TMl- 
l»KST OI- MY KNOWI.IWX.K AND lU'.I.Il.F 

(Informant ij A-^C^-VV dL) JL-^-VV^OLXXv^^sA 



I HI<:R1':HV CIIRTIFV, That I attended deceased from 

190 to 190 

that T last saw h alive on 19° 

and that death occurred, on the date stated above, at 
^I. The CAl'SIv Ol' I)1:ATII was as follows: 

0^i:/::..^Juuy\tol^ 

.r4^\>CX.ivi' 



r 



DURATION y^^ars 
CONTRIHITORY 



I\font/is 



Days 



Hours 



DT RATION 



Years 



Mouths 



Pays 



/fours 



(SIGNED) 



^ JbA^'^^-'^'^^'^'^ ^^^^''^-^^^^ M.D. 



-? 



a (.\.l.(n-ss) ^)^r>\■^\-0 



.Col 



Fecial information only for Hospitals, Institutions, Transients, 
or "Recent Residents, and persons dying away Irom home. 

When was disease contracted, 

If not at place of death ? 



l)AIJ%o!' Hi KlAf. or Kl-iMOVAI, 



PI.ACK OF lURIAI. OK K1:MoV\I 

INDHRTAKFR ^AkKT LcV^d^V^)^^ '"^ ^ 

(Address bH3.b<xi.U^i>...M.. 



190 



■»«■*»«*«••• 



^^^"^■■^^"'■^■■'"^■'^■^^^^^ , , , . J j-j EXACTLY PHYSICIANS Hhould 

n?ormatJon .hould be coreVully supplied. A(iE "'""'^ J^' " " -,j^ ••Special Information" for pT- 
.F DEATH In pinin terms, that It m»y be properly cla.Hlf.ed. 1 he »pec 



N. B.— F.very Item o? I 
State CAUSE OF 
Rons dylnft away from home Khould be ftiven in .very inHtance. 




! M 



I 1 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,„,„ . .„ „„-,-So.,.^?^n<.,.Co R.PER TO BACK OF CERT.P.CATE TOR .NSTRUCTIONS 

I,. Filed, UU S 1^0^ 



H ki\ 



I 



J)((. 



Registered J\^o. 



74 



Xjj-^j^Ajs Xxahjl D.ep.u.ty..He.aith...omcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( la. S. Stan^arD ) 



No. 



PLACE OF DEATH: — County of 

r) tatjL (lb cHiJ^vto-o 

(IF DEATH OCCURS AWAV FROM USUAL 
IF DEATH OCCURRED IN A HOSPITAL 




City of 




O^ <\jyj v<X/\ 



St/, — Dist.;bct. 



and 



RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATIO N " \ 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




.£L<^^v\X.> 




A.^w^:C<r^ 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 



COI^OR 



UlfxvU 



DATl-: OF HIKTU 



ACF, 



(Month) 



<I)ay) 



(Year) 



_l.cL.... Yi'iji s 



M.>uf/is f' /^i-s 



S|\C.!,K. MARKIKD, 
\\Il)»t\Vi:i) OR DIVORCKI) 
1 Write in social desijf nation) 



HIKTmM.AClv 
(Slatt or Country 






N'AMH Ol- 
FATHHR 



HIKTJin.ACK 
Ol- lATHKR 
(State or Country) 



JX^>v<rLru^ ^ 



\^\Jl<Z^<r 



u 



-Ui 



MAIOKN NAMK 
OF M()THF;R 



niRTHPLACK 

OF mothf:r 

(Siatf or Country) 







OCCri'ATlON p 



r: 




vjt\ 



CIA. >v 

fCf sided ill Sail /'i iim i\r,> AQ )<t7i.^ 



Afon/fis 



/hn. 



Tm: AUOVK STA'IFI) I'KRSONM, FA K I" UF LARS A R F, TRIF: TO TUK 

bf:st OF MY knowi.f:i)<.k AM) iu:mf:f 



(liif'.rnianl N iVvO LA. VWU\X 
fAddres.s 3<» C/ 







<rvv 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DK.^TH (^ f^ 



(Mont 




3 

(Day) 



(Year) 



I HEREBY CIvRTIFY, That I attended deceased from 

to igo":^ 

iQO-^Tirrrr 



:i90 



that I last saw h — ^^ alive on 

and that death occurred, on the date stated above, at 
...-r-rr- M. The CAISE C)E DliATII was as follows 

\Jf^.ULUf<X^ii. Mn^\rwU-c<<rt.^.?i 



DFRATION years 

CONTRIBUTORY 



Mouths 



Days 



I /ours 



nU RAT ION 
(SIG 



Years 



Mouths Days Hours 

NED ) v) ^- OXv>cX M.D. 

H TooH (.Address) vKa^yVa. ^^^ 



^PECfAL INFORMATION only for Hospitals, Institutions, Transients, 
or* Recent Residents, and persons dying away jrom fiome. 



c).A/w.ivfi-cy\' J X 



Former or 1 r-^ . ,^ \ 
Usual Residence >5 ' /^v^^'^rx^ 

Wlien was disease contracted, ' 

If not at place of death ? 



How long at u 1/ ^ 

Place of l)eatli?TlSL<V>.k«|%s 



n 



,ACK OF JHRIAI, OR RKMOVAI, 



DATF^ot" ItfKiAi, or RF^MOV.AI, 



UNDKRTAKKR 

(.\d dress 



Tiol 



N. B. Bvery Item of informntion •hould be c 

state CAUSE OF DEATH In plain term 

Ron. dyinft away from home should be ftJven In every inBtance. 



^^ A AHE should be stated EXACTLY. PHYSICIANS should 
"^rthlt U :t - p:^oTeH'T.a-i^lcd. The •'Special Information" W per- 




n 






i'j 



.il{ 



i\ 



t 






h 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„„„l,.M„„m.-l-No..^^'Sgg»l"^'"--'' REFER TO BACK OF CERTIFICATt FOR .NSTHUCTI0N8 

/,,,/,. FiM, LJh -^ ^••'^'* Registered ^^o. 75 






I! 



. . t ...><-« 



i-^^fcfcor 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticatc of Bcatb 

( "d. S. StanDarD ) 

PLACE OF DEATH: — County of d ^X/>v- Wa^ v r < . - <Gty of H^Yv ^lA.a^.vCv^at 



(No UVL-tclhJL^Ax/i 0\P^^ kvtal St.; Dist.;bct. ;; and 

<iNO. ^' ^^ , X VtATH OCCUHS AwU FROM USUAL R E S I D E N C E Gl VE FACTS CALLED TOR UNDER 'SPECAL . N FOR M AT.O N • \ 
( ' "iEATH OCCURRED in"* HOSpVtAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



a 



■^^\jJ\) 



I 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



^\aL. 



UjJLJU 



DATi; n|- IIIKTM 



I'MotiUil 



1 

(Day) 



(Year) 



A(*.K 



I 'I'a » . 



...Moulfi! 



XL 



Da I i 



*^1\<.I.K, MARKIKI). 
\V1I)(»\\KI> «)R niv<)Ki'i:i) 
(Writi- in s<K'ial «lesi^ni>tioii) 



^ 




if 



f } 






niKTHPl.AOK 
(Stat« or Country'* 



FATJIHR 



BIKTinM.ACK 
OF 1 AinKR 
(St.iH' or Cr)uiJtry) 



MAIDKN NAMK 
OF MoTlIKR 









'<5^V/>wa. 




HIRTTIPT.ACE 
<>»■ MoTHKR 
(St;\tr or Oountry^ 



(jn (1 






T»n: AHOVK STAri'.n PHRSONAI, I'AR'lUri.AKS AKi: IRIK To TMH 
BKST OF MY KNO\VM:i>»U% AND HKMKF 



(Add 



rcss 



5100 



ijlvi^^ 






Yi>^^jJvro AJ- '^sJL- 



^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



/(iMonth) a 



H 

(Day) 



fpoH 

(Year) 



HEREBY CivRTIFY, Tliat^I attendod dcccasetl from 



iVLtU i 190 ' i to .....^|vNXvi .4 ^ 190 H 

that I last saw h-xmv alive 011 ^j:^*-^ ^ Xt.-iri 190 V 
and that death occurred, <>n the date stated above, at A 16" 
^... M. The CAl SIv OF I)I<:AT11 was as follows: 

vA'W'lx^^ Lfr.LvWj 



nrRATTON - JV^rry 'A/on //is {Days 
CONTRIlU-rORY LL^nJk.^^&^.uny.w. 



Hours 



nURATION 

(Signed) 

i^^^W H TQO 



Years 



Mouths 



Days 



ii. 



Hours 

'%..J. lvo^l^t^JLL M.D. 

H ( Ad«lress) Uv^^^^^:4 ^' ?> s\|J. 



Special information ""'y '"^ Hospllals, institutions, Iranslfnts, 
or Recent Residents, and persons dying away froni home. 



Former or 



.1 



How lonq at 



Usual Resldencer;Av|a>vt^ IxitU'vpiare of Death? .^. Days 

When-was disease ronfrcted. ^^^^V^^t^ oJvAUv 

If not at place of death? '- ^^ 



v\ \cf: of nrRiAi, or rf:movai 




(Ad 






nATF:of Hi KlAi, or REMOVAI, 
I I 90 *i 



h^ 



rXI.KRlAKKK ^v^>'^^X9 , - y 



0)\' 1:1v>v->v''v 



c 



^ Th AfiF iihould bo stated EXACTLY. PHYSICIANS should 

oV inform«tlon .hoi.ld be carefully supplied. ^GE shoulci De ..g^cial Information" for p.r- 

C OF DEATH In plain terms, that It may be properly classified. ne ope 



N* B.— -Every Item 

state C A US ^ 

sons dylnft away from home should be ftiven In svery instance. 



i| 



{ 






f 



lii 



'I 



I 



i 



■■\i 



])((/(' Filed, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. vo , . *4?J^^ U& I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



100^ 



Registered J\'*o. 



76 



(S^fr^^AX^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Ta. S. StanC>arD ) 



4 ^ 



PLACE OF DEATH 



J _ County of ^' tt-v^ 1 .VCXAvCv^yao City of ^ ' <X/Vu 3 VCUvx/Cv^ c>o 



(No. 



A 

iHbHjxvWoL (L\>-^ St.; '1 Dist,;bctX^ait^^MX. "and '^WtX.M.n.0 ) 

/ ,r DCATH OCCURS *W*Y FROM USUAL RESIDENCE G.VE TACTS CALLED ^OR ^"R ™ ci^iN O 'n U M B t r" " " ) 
^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



. M ]A^Xn.<IU\JLt) \jy^yJLhXM 



3 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



oJji 



(Month) 



U)-Lu._ 



n 

( Day) 



r i H.J) ... 

(Year) 



AC.K 



.0 ...i. . }>«l».v 



Mitnlhs 



ii 



/>(Z r. 



SI\<'.1.K MARRTKD. 
WIlxtWHl) OR niVORCHI) 
(Writtiii social (k*si>»natioii) 



niKTMIM.AOK 
(State or Country) 



NAM1-: OF 

fatiii:r 



RIRIIUM.ACK 
<»l- I AIIIKR 
(Statr f)r Cotnitry) 



MAII)1:n' NAM}.- 
OF MOTUHR 



niRTMPI.ACR 
OF MOTHKR 
(Stait- or Country) 




OCCUPATION 



% 



QaxvouyuL 



xX^^^i. 



ft-A-A^AA^^VM-Lc 






Rfsidfd iv Son 1'nini isro '5^ X' ''<" ' 



.\r,>iitii<^ 



/),IV. 



THH AHOVK STA li:i) PKRSONAl. l' \ RIICT I.ARS AR1-: TRll-: TO 
HKST OF MY KNOW I.HIX'.K AND HKLIKF 

(Inf<.nuant JX^TV^^X C^ >\X>\jLcr>\. 



tiif: 



f AiMress 



r'\>M^ 



MEDICAL CERTIFICATE OF DEATH 
datk of DKATH ^ r 



1 H 

|Montli)|] 



(Day) 



(Year) 



I HKREHY CICRTII'V, That I attended deceased from 

x^ H 190 S to , V^Jl^ 5^ 190 H 




that^I last saw h ..4>U alive on 




190 H 



and that death occurred, on the date stated above, at 1 
ijL M. The CAl'SIv C)I'^ DHATII was as follows: 



■■^ 



nr RAT ION •" Years *" Mouths ^ Days \ t //ours 
CONTRIRl'TORV 



//ours 



DTRATION )'i'ars Jfof///is Pays 

(SIGNED) ^ 'yV-v\^t\Mj M.D. 

,S r Address) |gr^HMK.o\i^^t ii 



lf)0 



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

How long at 

Place of Deatli? Days 



Former or 
Usual Residence 



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



DATHof Ht KIAJ. or KFMOVAI, 

I90H 



\ I i\ 01 I 



VV i 



PI,ACK(M- BIRFAI, OR RKMOVAI 



^K 



(Address. 



Itrr^ 



H In plnln term., that It may be properly cla««lflcd. The Special Informs 



'"• B* Rvery item of Informatt 

state CAUSE OF DEATH in p 

Rons dylnft away from home nhould be ftiven In •vory instance. 



1 



t 



■ 



I 






* , ;)■. 



It 

■?f. 



< s 






I!, 



i] 



Boi.ninf llcMlth-KNo. 1^ 



!)((/(' Filed, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFEW TO BACK OF CEWTiriCATE FOR INSTRUCTIONS 

77 



H&I* Co 



lOO'i 



Registered ■N'o. 



S 

XlA^tr Deputy Health Officer 

DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 



cMhWVil 



Certificate of Death 



( xa. S. Stan^ar^ ) 



Jl ^ 



PLACE OF DEATH: — County o{<^CL^ ^<V>vCaA^^ City of ^'Ct^V vlA^O/WCUl^^ 



(>k). 



mt C\\ \vUL)tyJi\h a^l.lu.:vv\. St.; —:-.■. Dist.;bet> ;, and ...^.._-^ 

/ .r n^TM OcduRS *W*V TRoi USUAL R E S I DE NC E Gl VE facts CALLCO rOR UNDER SPECIAL INFORMATION \ 
( IFrfeEATH OCCURRED IN JtoSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




.Cb.O^CU 




PERSONAL AND STATISTICAL PARTICULARS 






DATK OF lURTH 



A(". K 



COLOR 



iLlkJjL 



n (Mouth) 



(Dav) 



r 40O 

(Year) 



^.. )V.;;a O 



M.nilh.^ 



xs 



PilVS 



SlNCl,]-. MARKIKD. ,, 

winowKD OR nivoRiKi) U 

iWvitt ill siicial tksi^Mialioii) "A 

. 

RIRTHPI.ACK 
'Stale or Country) 




NAMK OF 

fathi:r 



RIRTHPT.ACE 
OF I ATHKR 
(Statf or Countrs') 



MAn>KN NAMK 
OF MOTUHR 






C 






¥, 



mRTHPLACR 

OF m()Thf:r 

(StaU- or Country) 



OCCUPATION 






',.'1 



THK AHOVE STATl<:i) PKRSONAI. PARTUTKARS ARK TRV 
nF.ST OF MY KNO\VI,KDOK AND 1U;IJF:F 

(Informant C ' A.A^IX'^^ 



K TO THH 



'A.ldrcs.. 



CVVU 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DEATH 



ll 



(Moj 
I HERIUiV CIIRTII'V, That I attended dcroastHl from 



VTyiCUA. I 

that I last saw h X>v alive on 



Montfi) 

r 
190H 



(Day) 



190 \ 
(Year) 




190 S 

190 ^ 



an<l that death occurred, on the date stated above, at » U 
CL M. The CArSI*: OF DI'IATII was as follows: 

J -A^vU.i^,^!twi<t^r>v MlV^^ 



DURATION Years Months \ Days /fours 

CONTR IIU'TOR V M\iC^6-^^^ .•<><>U-^A..CA v'^^ 

DIRATION ^ Vi-ars *" Months I /:>ays " Hours 



(SIGNED ) 



SX^ ^XV^ 1L<X"^vqyVv>l\,-» V 



M.D. 



K 



\\^ 



•\ T ,)o H ( Address) Ik -^X L^V^<i \l tlk. lk>-^- 



FECIAL INFORMATION only for Hospitals, Institutions, Translfnts, 
orXcent Residents, and persons dying away from home. 



P1,ACE OF" IMKIAI. OR RKMo\AI. 






ou>\ 



DA! 1; of IJi KIAI. or REMOVAL 

S: 1 90H 



\ 1 I. Ill III 1< 






Tj^ 



N. B. Every Item o? information should be carefully supplied. AGE "^""/j* '^° *j*'*'.Jj,^'^.^g^^^ information" fo"r per- 

•tate CAUSE OF DEATH in plain terms, that it may be properly classified. I he opec a 
son* dylnft away from home should be ftiven in every instance. 




\ I 



t 






»i 



I 

ll 



i 



'* .! 



i-\ . 



hI 



li! 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CCRTIFICATC FOR INSTRUCTIONS 

Daio Filed, H^Ih -^ ^'^^ ' 



,,,Mr.1 of HcMlth »■• No \^ -ft^^^iM&l^ 




llegistered J^o. 
\jy\jsju^ lsJL\s\jl^ Deputy Health OfHccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( Vi. S. StanDarO ) 
PLACE OF DEATH: -County of ^3^^ «1x^^>vcv^Gty of .i,a^ axrv.rwt^c.0 



'No. 



*; ' 



■L:' 



/ ir DEATH OCCURi AWAY FROM USUAL 
V IF DEATH OCCURRED IN A HOSPITAL 



St.; I Dist.;bct/ 

RESIDENCE GIVE FACTS CALLED FOR UNDI 
OR INSTITUTION GIVE ITS NAME INSTEAD 




and Ua/VL4.t^»:^-.t. ) 

lAL INFORMATION- '\ 
T AND NUMBER. / 



FULL NAME 




\ 



vAx>v 




(\ 



OL 




n 



CVvu 



SKX 



DATK OF niKTU 



ACH 



PERSONAL AND STATISTICAL^ PARTICULARS^ 

COI.OR 




loi 



M.OJ^ 



16. Yfars ' » 



(Day) 



M.niths 



(Year) 



Xi 



Da v.v 



iH'i^ 



III 1 1 



SIN«.I,K. MARKIKI). 
WIDOWKD i)K DIVOKTHI) 
iWiittin social iksi^rnatioti) 



HIR TUPI.ACH 

(State «)r Coutitry) 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

" " ^lu 4 

(Day) 




Mont/fcl 



190 1 
(Year) 



I HI'KIUJV CI<:RTIFV, That I attcmUMl <lc(va.se<l from 

that I last saw h ^ »\alivc on ^^XK^y ^ 190 H 

anil that death occurred, on the date stated above, at r^ 
Lb M The CAlSlv OF Dl^ATll was as follows: 

"3w.(r'\)-i:^.V ^Jn.AXvA^>vv<i>'v<v/3w. .. . 



VAMK Ol" 
FATHl'.K 



luurnj'i.ACF: 

0|- I-ATHKK 

I Slate or Country) 



MAIDKN NAMK rt. . 
()|- MOTIIKR l^ ^ 

lURTIiri.ACH 
OH MoTUHR 
(Stale or Country) 



'Kaa; 




-IL 



5 



T 



(^.VJuL'Ct^w^.. 



OCCUPATION 






Months 



/>,i\ 



L i 


'''flll 


ML 



rm- \novF st\ti:i) phrsonai, par rici i.ars ari; irif. to rm- 

HKST Ol' MY KN()\Vl,i:n<'.F: AND HKI.nCF 

(Informant JV CCtjL (TO oXiva "D^V 

All l)'oJ.Uvt *^t 



(A<Ulres.H 



DURATION *" }'t'ars " .^/ou(/is 3% /Mj-^ ^ Hours 
CONT R I lU'TOR Y CI\ArrirrWV^ J^^ 

DURATION Years Months Pays 

(Signed ) J • vX' L^rY-vwoAjL.ci 



Hours 
M.D. 



S- i^oH (Address) J^ipS (fe a\V\^^ tW B.^ 



FECIAL INFORMATION only '""^ Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from tiome. 



Former or » 
Isual Residence ^ 

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



(BiLv.^ ^! 



1 



How long at ^ 

Place of Death ? si^WM... D«ys 



PI \CJi ()|- lURlAI. OR RHMOYAI, I DATlv of mKiAI. or RKMOVAI, 
INDICRTAKKR U CUX'»lx MVI^ 



(A<l(lre«?s 



15X4 ott>-(il<.t-fr>v cit 



N. B.— Kvery Item «« infor.n«tion .houl.l be cnrefully Hupplled. AGE should bc-tatcd EXACTLY ^"YSICIANS .hould 
Ttotc CAUSE OF DEATH in plain terms, that it may he properly claimed. The "Special Information for p,r- 
Kons dying away from home should be fciven in eve.'y Instance. 



I I 



II • 



j :^ \ 



i' 






II i 



•ii' 




I 



II 



t 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

, , ,.„.,. ..^ ^.....c. .,P.B TO ».CK or ceRTir.c.TC .or ..stbuct.ons 

/.,/. ^',7.,^ %JU. ^ I^^O^ Registered ^^o. 

:L(yvLil/wu DeputyHea-- Officer 

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

Certificate of S)eatb 

( 'CI. S. StauC)arO ) 

rA A^v ^1 -^<v^^<^L^ ^ City of ^'^'<^^^ ^J K^^x^^Ji^^ 



PLACE OF DEATH: — County of 



rNts 




L.f 



, (!\;;,^kAA<\li.. 



St; 



Dist.; bet. - ^^^ 



'r vS^^".i^"r.."A5;; .■.■r:j-:A;.r-,.v%: •-■&■.• ==r 



'special INFORMATION" '\ 
STREET AND NUMBER. / 



FULL NAME 



SKX 



^ol^ 



C01/)R 



DATK <)I HlRTll 



PERSONAL AND STATISTICAL PARTICULARS 



'>VtrVw>:T.V...../. 

(Day) 




\X'>\.'K 



(Month) 



(Year) 



A(;K 



CLtt Sa y..us 



Mntilhs /'".»•* 



SIN<-.1,K. MARK 11:1) 
\VII)(»\VKI) OK niVORiKI) 
iWiitf'in sorial (U'<i>;n:tti'Hi) 



lUK rul'I.AOK 
(Stall- or Couiiti y) 



NAMl-: Ol" 
lATMl.R 




> vK'^ v^A^^nx' 



u 



•1 



niRinri.ArH 

<>I' l-AIUKk 
(Siatf or Country) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



[Month) 



1- 



(Day) 



(Year) 



rHRRHIiV "^^'vKTIFV, That I atteiukMl deceased from 

190 to 190 

that I last saw h • • • u Hve on ■ ^^ ' 

and that death occurred, on the date stated above, at — "-rT... . 
-— M The CAUSIv OF DICATIl was as follows: 






L>u. 



nrRATION Years 

CONTRIBUTORY 




Months 



Days Hours 



Days 



MAIDEN NAME 
OK MOTHER 




aiRTIIPI.ACE 
OF MOTHER 
(Stale or Country) 



'^h^ 



Rfsidfd in S,!n /'i unii^ri} 



)'/U7 I s 



Monthf 



n,i \s 




Tin- AnOVE STATED PKRSONAK PAKTUT I.A KS ARE TRIE To THH 
IJEST OE MY KNOWl.l-.nCE AND ni%MEI- 



....... Sx^l^ \^^ ^ 



DURATION. Years ^ ^^""^^'\ 

( SIGNED ) Ln^rnJAJ Ai^ UJ dXX^O/vv^ 
Hv^Ll\.'^ iqoH (Address) .L-fr^-fr^ygA.^ 




Hours 
M.D. 



PECIaL information only for Hospitals, Institutions, Transients, 
or^cent Residents, and persons dying away from fiome. 



Former or ^ 1 \ O 4 5\ P ""^ '®''*' ** 

Usual Residence Uj<XA.Kv>A.'OuVrvvcJV! Place of Deatfi? 



Days 



Wtien was disease contracted, 
If not at place of deati) ? 



ri,ACE Ol-' mRIAI, OR REMOVAL 
INDERTAKER 



DATE of lltKiAi- or REMOVAI, 

\KaJc<x S ■•• 190S 



-I 



(Address 



L\ a U A^^ vv^ 



„ .. ... .^c „H„,,iH he stated EXACTLY. PHYSICIANS «hould 

N. B._Every Item of inWmatJon .hould be cnrcfully HuppI.ed ^f^^l'^l^^f.l^^^X^^ information" for pT- 

•tBte CAUSE OF DEATH In plain term*, tliat it may be properly ciassiiiea. i 

sons dyinft »way from home should be ftiven in every instance. 






h ! 



I ■ w 





ii 



IH 



< , 




liial 



,1 of 1 1. -M It hi- No. 1 



WB.TE PLAINLY WITH UNFADING .NK-THIS .S A PERMANENT RECORD 

REFER TO ..^C K OF CERTIFICATE FOR IN STRUCTIONS ^ 

80 



T^^^ nikv Co 



l!)0^ 



Kegititered J\,''n. 



die FiJ('<J, ^wW -'5' 

DEPARTMENTOfIpIIBUC HEALTH=Cit/and County of San Francisco 



Certificate of 2)eatb 

( ■a. S. StanOate ) 



PLACE OF DEATH:-Countv of ^ ^- ~^ MV^vc^cCUy of ^^V>v .IA^.vc..^ 

^ \ IF DEATH OCC<i>ReD IN A HOSPITAL 



and 



) 



S^?^?J=4rc^,;r;4 ^«v^^° .x»o"sr 3;%"c;-i~r.°::r.'r - ) 



FULL NAME 




)J 



XjuOj^' 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



QlicuU 



li J 



I>\ 11-: ol" UIKTll 



\«-.K 



(Mouth) 



tl 



)'»(M 



SINt.l.K, MARKIKl). 
WIDOW I'D OK l)I\'OKtKI> 
iWiitc ill MK-ial <k«-i«tjalion) 



lUK lliri.ACH 
(Stall- or Country^ 



I A rilKR 




aUvcU 

% A'^x 

(Day) ^X.^'iL 

[ M.ntffis <r*^ rtays 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 




I 

(Day) 



IQo\ 

(Year) 




a,^i. 






HIKTHJ'I.ArK 
<)!• I ATIIKR 
'State or Couiitrv> 




1r\ 



I.. 




_ M W v^ vU tj v)k 

OCCrPATlON l^v^ii^wtiLx 



MAIDl-.N NAM I 
ol" MoTMKK 



lURTHIM.ACK 
• >»• MOTMKR 
(Slate or Country* 




I HRREBY CI':RTIFY, Tliat I atteiKk-d deccase.l from 

£). JIC IX 190 ^ to .. V.v>^..?.0 190 H 

that I last saw h V^alivc on ^^^a.--^ ?. 190 4 

and that <lcath occurred, on the date staled above, at 
(p ^i. The CAlSIv OV DlCATII was as follows: 



Dr RATION ^ Years 

CONTRIHl'TORY 



b Months 1 4 Days 



Hours 



DURATION 



Years 



Mouths fhiys 



Hours 
(SIGNED) U)^. UmXa^ MD. 



M^VvUi i 



u,oH (Address) 




R,-^i<irif III Sitii i 



1 iiii, iM'tf ,*i \ 5 '-«' 



Months 



l\iy. 



I.AKS AKl'. TKI }•; TO THH 



Tin- AnoVKSTATI-.I) I'KKSONAl, »' )»< '"ir,^' .l; ,V 

HHST t)i- MY knowi.i:d<;h and m-.i.ii-.v- 



SPECIAL INFORMATION onlv for Hiipitals. Institutions, Transients, 
or Rcicnt Residents, and persons dying away froni home. 

Now lonq at , 

Plare of Death ? b <» vVt)ays 



? 



Former or 
Usual Residence 

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



I'l.ACKOF lUKIAI. OR KHMOVAI. DATKof miUAi. or RKMOVAI. 



A. 



INDHRTAKKR 

(Adilrt-ss 



% 



C\ 



OwCytv^w 



\Jl 



^biX' IH tfv ii 




N. B. Every Item of lnform«t1on should be c.irefully supplied. 

•tate CAUSE OF DEATH in pinin terms, that it may he 

•on. dyinft away from home should be ftiven in every Instance. 



AGB should be stated EXACTLY. PHY8ICIAIS8 should 
properly classified. The •'Special information for per- 



l^i 



)ii\ 



It,,ai.l..f HfMltli -»■ No ' 



^-^^^J^n&i'Co 



■'I 



i:M 



WRITE PLAINLY WITH UNFADING INK-THiS IS A PERMANENT RECORD 

R,FER TO BACK OF CEBTIFICATE TOR IN STRUCTIONS 

I l\ II ^ iQoH Begistei-ed JVo. OX 

Dale Fifr'l, VU^ S" ^-^^ i 

-^ M (J 
DEPARTMENT OF PUBLIC HE AlTH=City and County of San Francisco 

Certificate of S>catb 

PLACE OF DEATH:-Co.nty o^Wv '^a^^-^ CUy of<^<X^i^vA,— - 



fm 



No. UJ ^AJ I ' ^U^^^^^Jr: ..„_ „„„ USUAL RESIDEI 



Dist.; bct.- 



— and 



-^ 



( •' ^™S^^"HiiA^^^^^<^"« ■" — -- ^'--^-—- ) 



FULL NAME 



.s\iti\u,MfW, 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

-_ I COI.OR 



IjATH OI- llIKl'll 



oJuL 






OLu 



vVl'VvcLc 



\ 

(Uayi 



(Year) 



Ai.K 



At> 




.^mj 




v^„cv% 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH , ^ ,, 

(Day) 



0(Mo 



•"I'r 



(Year) 



) 'i(t I > 



Months 



WIDOW KI» OR DiyoRCKn 



.awuuL 



nTRRRBY CKRTIFY, That I attended deceased from 

^XoJvzL. 190 H to . -^HH -^ '"^"^ 

that I last saw h .r^ alive on ^^ ^ ^^O H 

7 p„,„ and that death occurred, on the date stated above, at 

'— ^'' , j^ ,j ^i,p CAUSH OF DIvATll was as follows 



ii: 



HIKTmM.ACK 
(Stiit«- or C'xuitiy' 



%\, 



.Oc^tnv. 



>> 1 ^ 






niKTnri.ArK 

01 lAPHKK 
(Slate or Country") 



MAIDl^N VAMK 
ol- \U)TnKR 



M- 



lURTHri.ACE 
OK MOTHER 
(Statf or CoJintry^ 



ri^x^vn^K' MllOAAxUMfyv 






UrRATK^N '^ )W//.9 - Months ^^> Days X'X Hours 
CONTRinrTORV LL>AjL^Lf\XA^Oc 

DURATION -Years -Mouths'^ Days -Hours 
( SIGNED ) Oj . VO MU(i\U Vv 

X .^ ^ rAddrcss)UlS ^Vvtyti v^.)x.<^.q.. 

ii?s7 



M.D. 




a PEdlAL INFORMATION only lor Hospitals, Institutions, Transle 
or Recent Residents, and persons dying away from home 



OCCUPATION 

Rrsidnf in San I'laihi^ro 1 }>ats 



yr»ifii 



if/i^ 



/)-MA 




THE Am>VE STATED VERSONAirARTlorLAKS ARE TRrHT.. THE 
llEST t)E MV KN0\VM:D(.E AM) JU.UIl-.l- 



(Informatil 



(^ 



' \(Mrfss 



^ 



1>01j tlXCcN. 



a 



it 



•^P 1 , How lonq at ^j 



Former or 



i. 



Days 



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





.o^.<Ji 



^-<^Jd\ 



I'l.ACE Ol" m RIAL OR ri:movai. 



^^(\\.^' 



DATE of HfKlAl. or REMOVAL 




%\i>\p^ Cy\\vfl^wir» di 



(Address 



mmmmi^^ammmmi^m^a^^^^^^^^^'^^^^^^'^'^^^^^*^^^^^^^^^^ ... f t I EXACTLY. PHYSICIANS llhould 

N. B.— Bv.ry Item o« Informntion .hould be cnr.fully -"P-''';'- ^^J^^y "lawWl'd! The 'Sp.cl.i Information" for p.r- 
■tate CAUSE OF DEATH In plain term., that It mi.j be properly 
-on. rtyln* away from home .hould be »Iv.n In .v.ry Instance. 







3 






pi 



If 



I ill 



I 



! 




i 




di 



^■■ 



WRITE PLAINLY WITH UNrAD.NG .NK-THIS .S A PERMANENT RECORD 

WRITE PLAIN ^^ „CK OF CEHTTICATC FOB ■r.3TRUCT.ONS 

„ ,, .,r -■■■v.. ..^^g^ ■*■•'•" -^ — ■ 

1 ^ j(jQ<^ MeifMered JVo. 



82 



.U\A,A.vi 5!, 



Diitc Filed, Np^^vi. 

iLtruvVA XtAM.1 Deputy Health Officer 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate ot 2»eatb 

( Ta. S. StanC>arC» ) 



^ . n-ur r *. of ' •' <X > V .>va.>vCc^t<.Gty of 0'<X >v J /v<X.^c^ C^ 
PLACE OF DEATH: — County ol cv ^^^ -j c 






No. 



^b r^^nAVv^v St.; a. . HctV%^ " 'o™- ■■s-cc,.L ,H.o%«^^^^ 



FULL NAME U>v>vOL 



a 



k-uiJL 



df^ 



,\.yCX. ^IXcJ'^^i.''^'-^-' 



PERSONAL AND STATISTICAL PARTICULARS 



SK\ 






COl.OR 



lX'4vv^ 



DA TH OF lURTIl 



tMotith) 



H 

(Day) 



AW 

(Year) 



AC.H 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




( Month ] 



(Day) 



(Year) 



^5 



) 'ni I > 



H 



.l/„»///l.v . .1 ^*" 



SINC.I.K,, MARKIKD 

WIDOWKI) OK DIVoKiKD \ 

(Writf in s«H-ial <U >-i>rn;»n<)n) 1 I ) ' \ 

\X) \.v^- 



■WV^ 



lURTlUM.ACK 
(Statf or Country) 



NAMK OK 
FATm:R 






L^cLvo 



lURTllPUAlK 
or lAlUKR 
(St(it«- or Country) 



(^ 






rr[7nU?RV CKRTIFV, That I atten.lea tleccascMl front 

.^ 190 - ^''aIT^ '^ ^ 

that 1 last saw h -^^ alive on Y^(f '^ 

a.nl that death occttrrctl, on the .late staged abcn-e, at ^ 

CI M. The CAl'SB Ol' Dl'ATII was as follows 



Uvv 



rv^^v 



■^ 



xixK-M ^^VVWCL. 



11 



1 



DIRATION ^ >V^^ -.1/0;/^^ "./;aj.y 



coNTRinrTORV Ulw^trwA/tL 




Hours 

'xJU:\^.ir^.\\..CL, 



MAini:N N'AMl 
tJF .MOTHER 



HTRT1I PLACE 
()»•• MOTHER 
(Statf or Cotuitryl 



nrRATION ^ ^ >V<'''-5 



Days 



Afoiiths 

(SIGNED) a UJ OUOXAXA 

^ TOoH f Address) 5 OaU<X.ix^ 



I fours 
M.D. 



=>PECJ^L INFORMATION only for Hospitals, Institutions. Transients, 
or Recent Residents, and persons dying away from liome. 



A*/ 



•yidrd in S.tu /'i •}>!< isro A Vi ^rui" 



yroiifhs 



n.i 1 > 



THUAHOVESTVrK.n>KRSnNAirARTICrjARS ARE TRIE To THE 
BEST Ol- MY KNo\VK1-.l)«.K AND HKMl.f 



(Informant 




f^^^A^'CT^v 



'\(Mrc<=s 






Former or 
Usual Residence 

When wa*-. disease contracted. 
If not at place of death ? 



How lonq at 

Place of f)eath? Days 



ri.XCEOE m-RlALOR KEMOVAI, | DATE of ^HrniA., or REMOVAL 



UNDER lAKEK 

(Ad»lrt 



JAI, OK NI',.M"x ^., 1 Aft 



N. B. 



■i— ^"■^— ■"^■■^■■"■^■"^^^^^^^^^"^^^^^"^"^^^"^"^'^^^ I I K t t I FXACTLY PHYSICIANS should 

Every Item of in?orm«t1on should be cnrefuHy «"PP";^; J'.^^J^yZLJixld. ^The -Special informsHon" for p.r- 
-♦-♦^ CAIISF OF DEATH \n plnin tepm«, that it m»> nc pr ^ 
:". dytt aw°^ rrcn. hon,, .held b. »W.n t„ .v,r, ln,..nc.. 



»$ 



'F 



I 



'^1 



I' I 
I 



ft 



WRIT. PLAINLY WITH UNrAD.NG .NK-TH.S .S A PERMANENT RECORD ^ 
WRITE PLAIN ^^^^^ ^^ ».K or CERTTiCATr for ,N3TR»CT.0NS 

77"; TTT won Registered A'-o. 

Dale I'lh'il, YuJLuT^ 

Xm^^^v^ cLLvM^t Deputy Health Officer . 

DEPARTMENT OF PIBLIC HEALTH=City and County of San Francisco 






PLACE OF DEATH:— County 



Cevtiticate of 2)eatb 

( tl. S. Stan^art* ) 
of ^.O^S^C^^-OJ^Criy of 4<X^.,i;UVvv.:^ 



No. 



( 



P 

I 1 

Ir. 

i 



DF DEATH:— County ot ' 'WTV...V. ' L ^ 

,F DEATH OCCURRED IN A HOSPITAL ^ A "l 

-.... K.AMr t6L^ "^uXW 



FULL NAME 







PERSONAL AND STATISTICAL PARTICULARS 

t Void. 



!)\ri". «>!• lUK'rn 



ACK 



T*^ 



Ml. nth) 



) 'I'H > > 



(Day) 



M.iutlis 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 
UATK OK DKATH 




L 



Month) /[ 



A.. 

(Day) 



(Year) 



Da 1 A 



'^INt.I.r MAKKll'.n 
\Vint)\VKI> «»K I)IV(»RrKI> , 
(Writf in social chsij-Miation) ^^ 



lUK rUlM.AOK 
(Sl.itf or Conntry) 



NAM]', Ol- 
FATIIKR 




lURTHPI.ACK 
()|- l-ATHKR 
istalf or Co\intry) 



MAIDI^N NAM1-. 
Ol- MOTFIKR 



nTRTTTPT.ACK 
Ol- MoTllHR 
(State or Country) 









t 



T17fIUCB\^C1<:RTIFV, That I attcn.lecl deceased from 

|w^vt IS IC/3H tn . 1^^ '90 "i 

that I last saw hX^v alive on |^^^ '90^ 

and that death occurred, ou the .late stated above, at -^ 

M. The CAISIC Ol' Dl'ATIl was as follows: 



DURATION 
CONTRIIU'TORV 



-^'cars * .Vont/is • ^ Pays 

jt->:v.vLt.....O./.a.>vCy:'SK^^>^. 



Hours 



i" 




VVV'\\. 



DURATION >V^^r.v 



(SIG 



ku 



„Ec)iw(^.^'^«H^ j"«-°- 

x.l.lu.s) 11X1 d^-A^Writ: 



H 



or 



=*Pe6'|AL information only for Hospitals, Institutions. Transients, 
Recent Residents, and persons dying away from home. 



OCOT'PATION 



Hi 

'•I! 



Rrsidetf ni Sutf Irati.isro \ v ) > >' 1 ■ . 



7MKA„OVKSTATK,M.KK..,NA,rAKTHM;j.AKSARKTKrH To TMH 
imST OK MV KN<)\Vlj:i)(".h AM) HhMl.l 

a^HMo^t ire 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



DAlK'if HURIAI. or RKMOVAI, 

NivJlvi S" 190H 



(Infovniant 



(Address . 



PI. ACK OK HIRIAI, OR RKMoVAl, 

INDKRTAKKR ^''^ "^ r^/v » H H 4^ 



*(^: 



(Address 



— » t I EXACTLY PHYSICIAtNS should 

^. B.-Hve.y Iten, oi ,nfon.«t.on .houU. be cane^uHy «uppnc.. ^«;';;;;7;,t^«,,:,: ^^He "Speda; .„fo..«at»on" for pT- 
-*„♦.. CAUSE OF DEATH in plfl-n terms, that it m»y « ^ ' 



state CAUSE OF 

sons dylnft away from home s 



hoiild be ftJven \n every instance. 











r 







l( 



( 



ii'! 



1 



1 1 



I 



-uie iG A PERMANENT RECORD '^m 

'lilrZZTjT. "^0, n,,.u,.a ^'o. 84 

.LwIIm^ Deput, Health Officer { c,„ F,,„nV« 

DEPARTMENTOfIuBLIC BEALTH-City and County of San Francisco 

Certificate of Beatb 

( -a. S. StanOarD ) 



PLACE OF DEATH: — County of OA.^ ^^ 
^_ V ^;r. . ^ L . t . ^ f;t. Dist;bet. 



— ^ and 



I ir DEATH OCCURRED IN A HOSPn*"- 

FULL NAME 



c> f>:v.T-<XAj. 




:-W-V 



PERSONAL AND STATISTICAL PARTICULARS 



DA'IK <>!•• ItlRTH 



COl.OR 



MEDICAL CERTIFICATE^ OF DEATH 
DATE OK DKATH 




/L^V 



M<.ntb> 



(Day) 



(Year) 




3, 

(Day) 



(Year) 



A«-.K 



R ,,,„, * 



M.niths 



Pti I .V 



( 



I „nRr;^C.:RTIFY, That I atten.U-.l .lecease.i from 




yh 



SINC.l.K. MARUIKI>. P A 

\vn)»>\vKi) OK DivoKcv.o n y 

(Write ill -oiial (k-Mjfnation) (^ A^^A»Xy>«-^ 

ni - 



thai I last saw h X^J alive on 

a„a that ,U.atl, occurrcl, on the ilat. statcl above, at 
CI M The CAISIC Ol-' DliAl'll xvas as folUms 



I90H 

190 H 



^v^.. 



lUKTIUM.AOH 
(State or Coiinlry) 



FATIll-.R 



RIRTMJM.ACK 
nv lATllKR 
'State or Country) 



.^ 



MAinKN NAMH 
»)H MOTIIKR 






or RATION 
CONTRIBUTORY 



) v^!. c^vt/v J^>^«^-vvrr«J'-^- ^^^"''-^ 






X^>rv. 




iC^CV-'V^^. 



"^ 



'(;^^^y^v:^i,,<frVV v2A\^ 



DURATION >V^''^ ^^^^"'^^" 



(SIGNED) 



Pays Hours 

M.D. 



BTRTIirT<ACK 
or MOTIIKR 
(State or Country) 






4 TooH (A<l.lrcss) 



ip X./dAu. u it 



i^ 



OCCUPATION 

Resided in SiUt /'iniir/fro 



I r,,M' b ^^"''^^^' ^ 



/><M 



THl", AUOVK 
HKST OK 



(Infonnant 



/sT XTKI> PKRSONAL fAKTICK t.AKS ARK TKKK To T.lK 



N only for Hospitals, Institutions, Transients, 

ig av 

/5 J( 1 How lonq ai (j ^ 

V J^»^ nX Plarf of Death? 1 Days 



-*PFC1AL INFORMATIO 

or ^efelu Residents, and persons d^ing away from home 

JJ 1 How lonq at 
Former or ^^^ ^J^^^Ji Ot 

Usual Residence O ^ '^ 

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



PI.ACKOK lURIAl, OK KKM..VAI, 



DATKof HiRIAI- or REMOVAL 

5" 190H 



(Address O » » ^^ 



^ ^^ ^^""^ , pvACTLY PHYSICIANS should 

T^ tlnn .hould be crefully Hupplicd. AGR should »>« « Y'**^^ '; -Special InformHtlon" «or p.r- 

N. B.— Hvery Item o, ..j^formBUon^.^^^^^^^^^ ^^^^ .^ ^^^ ^^ ,,,„„,„> das^.tled. The 8p 

:r d>Caw^y 'o^ho-ne Should He .Wen '. r. Instance. 



t 

1 1 

I! 

f ! 
1 

I 



*^ll 



11 



! 1 






r 



ill 



H 



«■) 



1,'*^' I 



i\' I 



. 1 



i 



'■I ' 



r# 



WRITE 

1 f Jii-iUh !•■ >>*^ '"^ 



- ,,^ ,MK —THIS IS A PERMANENT RECORD 

85 




IJ&V Co 



REFER TO BAC 

j(jQ^ liegistevecl ^'o 

l)((h> Filrd, Yi)"^ ^ 

DEPm» P« «EAlMy and « of San Francisco 

Ccrtiticate ot Beatb 

( -a. S. 5tan^ar^ ) 



PLACE OF DEATH:— County 



of C' tX'AV' J '^-'<^ 




^^^* / IF DtATH OCCUR* *W*V 

V ir DEATH OCCURRED 



>N" N 



i (ll:>>-alu.'lDSt; """* ^*S**»^**",„buNDEr"sPEC.AL INFORMATION- 

•V A f] (lip 

FULL NAME ID J-i^'^>^ ^^ 






PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 






lOiv.U 



MEDI 



CAL CERTIFICATE OF DEATH 



iM.mth) 



(Day) 



/lit.. 

(Year) 



H 

(Day) 



(Year) 



AC'.K 



3.^ )V</».v » 



Mimlhs 



Da vs 



SIN<-.I,K. MARKIKIV 
WIDOWIU) OR DUoKv l-.D 
Wiitf in social .Usjpnation) 



lURTMPI.AOK 

(State or Co\iiitry' 



NXMK nv 
lATHK.R 



JURTlllM.ACH 
OI- lATlir.R 

(Stalf or Country) 



MAIDKN NAMK 
OF MOTllKR 






DATE OK DKATH Q 

/|MontliV 

rnirEiTTHRTIFV; That ■ attc.,„U<l .kccased from 

. IQO 

190 to ^ 

that I last saw h alive on '^o 

a„.l that death occurrea, on the aat. staU-a above, at 

M The CArSH OV DlvATIl was f^,^^''''- 

■■■;;;jlcw^. i^-^^^^^-^^ 4.%^^ 



DURATION y^'^''^ 

CONTRIHUTORY 



3/on//is 



Days 



Hours 






lUKTinM.M'V: 

»ti- \w)'rm:R 

(Statf 111 i<(\iiitry) 




Dl'RATION 



Years Months 






'?t?l 



(SIGNED) \.<^^^^'^ 



r 





Days 



.duS ,„oH -'■— ^^^^^IJ^ 



Hours 
M.D. 



HKST Ol- MY KNOWl.KIX.b AM) HI.I.U.I- 



SPECIAL INFORMATION only for Hospitals. Institutron, Transients. 

orle^S^esldents. and persons dying away from home. 

('^ n-L Mow long at . 

former or 1. h U \I\ Hl a i uX Plare of Death? i Days 



When was disease contracted, 
If not at plare of death ' 




??0 ISCH 



iiii" 



; lnfo)in!«nt 



(Address .. 



y^^^v^*" 



l>.\Tl-"'>f miuAi. or KKMOVAI. 
\j I90S 



,,,.,CK Ol- Bl RIAL OK KHM"VAI 

(Adtlrt-ss 



l5XH c^UcLtrvv 




tatec. BXACTLY. _ PHY8iC.AN8 .Hou.d 



.; « .hould be cnrefully suppHecI. AGE f ""Z** 1;^.,^^** ^he ^Special Information" for p.r- 
N. B.— Every Item "* '"J"-"?!^^" f^.n X.rZ, that U may he properly cla««.flccl. 
state CAUSE OF DEATH In plain «'/''"• instance, 

son. dyinA away from home «houhl be ft.ven 



.';, 1 5 ' 



H 








i'l 



mm 



t, 












w.^' 



I-,,:, 1(1 .-f Ui-iiltll" !■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„ „^.53»n^rc,. REFER TO BAC^ OF CERT IFICATg FOR INSTRUCTIONS 

86 



na/eF/M, V JL S ^^^H 



RegistcTed Xo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2>catb 

{ Ta. S. StanDarD ) 



•! 



PLACE OF DE ATH : — County of CJ^X^v Oa,<x YvC/UM^oCity 



Q^ 






^ 






Wo. 



t • o Dist* bet. \ni^^^A.tr^ and ib^-VV-aH^ ) 



( 



IF Ol 



4 y 

n ' V. r\) ,, C.I.I DF«;iDFNCE GIVE FACTs'cALLED FOR UNDER "SPECIAL INFORMATION- "\ 

" "TATH"oCCU%rEV."rHO^S^PrAL o"r"n S ' ?u';'o*;"a . V E '. T S NAME INSTEAD OF STREET AND NUMBER. ; 

-nxK) JV\.^^^kiva.L^A^Jk 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SHX 



Q)\A 



COI.OR ^ 



I 

L 



Ol.L 



llATl-; «)!• HIKTU 




^^ 1% /..a^.H- 

Month* (Day) (Vear) 



A(iK 



) I'll t s 



. A/oHfAs . 



IS ^'^.'* 



si\(.i,i:, MARRii:i>. 

WIDoWKI) OR niVORCKI) 
(Wittr in siK-ial (U-si^rnatiuii) 



HIRTIUM.AOK 

(Stiitf or Country^ 



O^L^vJui 




NAMK or 

FA i!n:R 



RIRTM PLACE 
Of lATHKR 

'Stall- or Country) 



MAIDHN NAMK 
• )l- MOTHKR 



niR'ruj'i.ArK 
Ol- MornivR 

(state or Country) 




CL 






Q^ 



I 







j\jl^<kAj^ 



OCCrPATION 

Rfsiifi'd ni Siiii I'l <iih niit 



OxVtw<x^w\ 



"")V'(n s 



'T7i>iilli> I O Ptivs 



rnK AiiovK sTAri',1) pkrsonai. i'ariuii.ars ari-: rRi h to tiik 

IJHST OF MY KNO\VM-:i)OK AM) HKI.IltK 



(Infor jufint 



( A«l<lrcss 



±dLy 



c\tlv at 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



i 



(MonVl 



X 

(Day) 



i9o'\ 

(Year) 



^IHHRlvBV CI':RTrFV, That I attctidcMl deceased from 

190 •"~"'~ to •" 190 

that I last saw h rr-^ralive on ^9° 

and that death occuried, tin the date stated above, at — 

T— M. The CAl'Sr: OF Dl-IATH was as follows: 

sJ.^4Xa.^"wvv<5 



DTRATH^N Yrars 

CONTRIHl'TORV 



Mofif/is 



Days 



Hours 



Mouth a Days 

( SIGNED ) ...L<rV<nvi2A' 

S iqoH (Ad.lress) L^-frVOAA 



nrRATION Years 



Hours 
M.D. 




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



Former or 

Usual Residence 

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



How ionq at 
Place of Deatli ? 



Days 



IM.AX'K Ol- III RIAL OR REMOVAL 



rNDF:RTAKER ^V 



1 90 4 



(^Addrrss 



DA if: of m-RlAl. or REMOVAL 

CI." 




t(rT> 



N. B.— P;very .ten, oi lnfor.««tlon should be cnretuHy Huppllecl. AGE should be stated EXACTLY ^"YSICIANS should 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The Special inWmat.on for psr- 
sons dyin^ away from home should be ftiven in every instance. 




' ■ 



:! 






5 1 



i 







I: 



Jl^ 



WRITE PLAINLY WITH UNFADING INK 



. r II ,.i»1, |- Vo n -fr-^^S^^HM* Co 



ifJOH 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS ^ 

Ke^isterecl JS'^o, o7 



ih(h> riled, m^lu 5^ 

DEPARTMENTOfI^UBLIC HEALTH=City and County of San Francisco 




PLACE OF DE ATH : — County 

O. 4 0\ ll ^^M^^^^,,_ ^3^^, RESIDENCE c.v. r*CTS c*LLCO,^ 

2jjl.' d 



Certificate of Beatb 

( XX» S. StanOarD ) 

VCVcJ\.^. '^IV. and UlxX^lvL'WOA.t >) 

rOR UNDER "SPtCIAL INFORMATION" '\ f| 

NSTEAO OF STREET AND NUMBER. / 



St.; '^ Dist.; bet. 




FULL NAME 



A^V^W.. 



PERSONAL AND STATISTICAL PARTICULARS 



DATK OF HIRTH 



L 



C( 



)I,OR 



vJ-: 



V^ ^ '"^^"^ 



ith) (J <i>«y^ 



AC.K 



*" ) V<; ; 



Mnnlha 



(Year) 



Pavs 



SINT.I.K. MARKIKD. 

\V I now HI) OR DIVORCKI) 

iWritf in social (k-sivtiatioii) 



4., 



lURTHPI.ACK 

(Htate or i'oinitry^ 



NAMK Ol' 
FA rHKR 



niRTUri.ACK 
OI" lATMKR 

I State or (."oiuitry) 



MAinKN NAMK 
Ol- MOTFIKR 



lURTMl'LArF': 
Ol MOTMKR 
(State or Country^ 









.V-^'V<^» 



] 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



|( Month 




3 

(Day) 



I go *1 
(Year) 




I HRRKBY CI':RTIFY, That I attended deceased from 

: 190 "■ 



190 



to 



that I last saw h - 



Tfllive on 



rrr- T9O 



ami that death occurred, on the date stated above, at ■ 
AT. The CAlSlv OK DKATll was as follows 

(J^A^^^VcJa^ i>)/>^JLv^s^^ 



nr RAT ION years 
CONTRIIU'TORY 



Months Days 



Hours 



nURATION 



Years 



( SIGNED ) J^SJxUaaCU '^. Lol/ 

|vJL^.H TQoH (Ad.lress ) Ic b cSaa/ 

SPEdlAL INFORMATION 



Mouths Pavs Hours 

VwulA.* M.D. 

'tb^L ! ut . 



only for Hospitals, Institutions, Transients, 
or^Re'cent'Rcs^ents, Vnij persons dying away from home. 



W^CV- 



OCCUPATION QrU^^ 

AVw'./a/ iu S<in /'i iJir.fSfit 



•^ )'r(ii 



•- ,lA//////> 



^ /'"' 



THF, AHOVK STATl-D PHRSONAl. )-A K Tir F I.A KS A K F". TRFH TO TMH 

hf:st OF' Mv knowm:i)('.k ano nF:MF:F 



(Infonnant 



.V^0^^S-X3 



r\<1*lrcs« 



IDb 



VV^X^^cl^vcJM 



Former or 
Usual Residence 

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



How lonq at /^ 

Place of Death? '^ Days 



*«••••••*•♦****•**••••' 



PFACK OF IHRFM. OR KKMoVAI 




DATK of ncRiAi- or rf:movai, 

b 



T 90*^1 



indf:rtakkr 

fA(l<lr«'ss 



'1 C-t^H .6. 



/tX-Yv^V^.. 



... !• I ArF »lir>.il(l he Rtateti EXACTLY. PHYSICIANS «hould 

ai lnform«tlon .houltl be cnrefully KuppI.etl. AGE should ^ «*"**^^ ..^ ' . information" for p«r- 
F OF DEATH In plain term*, that it may be properly clarified. The Special Information tor p« 



N. B.—— Every item 

state CAUSE OF DEATH m p 

i« dyinft away from home should be ftiven in •very instance. 






.2^ 




-Ui^ 



11 



' 



-4 



■! 



8on< 



w 



u 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^t'^.ns.vcn Prr ER TO BACK OF CERTiriCATE FOR INSTRUCTIONS 



Dn/r hllcdy ^I/wLca S 






\ 



lie^Lstei^ed J^o, 




I 
I 



;■'. > 



ft 



I' » , 4 k 




1)1 



i 



V)0^ 
Deputy Health Officer 

DEPARTMENT OFVuBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( •Q. S. StanOatC ) 
TLt.CE OF DEATH:-County ofOxX.>X. :)A<XW^^-.Gty of ^W^ .1AxV>x^^o 
:X^'h O it'V'-C'^vo. t->- ' St.; -^ 

c^ v./ w -^ -H- ,»^„ iiciiAi RrsiDENCE Give facts called fo 



88 



No. 



5 Axi 



and 



Dist.; bet. . 

CALLED FOR UNDER •"SPtCIAL INFORMATION \ 
ISTEAD OF STREET AND NUMBER. / 



ii 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^^\J^ 



COI.OK >^ 



IjjJvdx 



DAI 1-; Ol- niRTH 









CUwd 

i>roiith) 



.\( . V. 



(dS 



) tit » . 



a 



(Day) 



Mnnfh^ 



(Year) 



XL 



Pit 1 . 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DK.XTH {\ r. 



(Monti 



.5:.... 

(Day) 



ipoH 

(Year) 



I HRRKRY CIvRTIFV, Tliat I attended (leceasetl from 

l..!y iqo H to .. WJU. '-^ 190 H 



t 



P^Lh 



SINT.I.K. MARKM'.I) 
\\n>M\VKn OK DIVoKi KD 
Wiite ill Mx-iiil (Usiviialioii) 



luK rnpi.AOK 

(Slatr or Cotnitiy) 



^\ 



<XWOL<3^ 



'm^* 



^ 



»5 




rir ^ 1 

.tc ur country) "V H ft ^ V . 



NAMK OI- 
FATHKR 



niRTniM.AOH 

nv i'Aiin:R 

(St 



MAIDKN NAMK 
OF .MOTnF:R 



iuktiu'lacf: 
of mothkr 

(State or Country 






rm-: m«ovk statkd pkksonai. vak iirri.AKs aki; tkii-: to tiih 

HFIST Ol" MY KNoWIJ.IX.F: AND HlCl.Il'.F 



(Iiifdiniant 






that I last saw h .<^-^f»alivc on 

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

(X M. The CAlSlv OF DICATII was as follows 

L<Vvt:<'V>v-«rvv"vt>>. .^L^^ 



190 S 
I 



DrR.XTION • Yeai^i \ b Mout/ts ^ Days Hours 



nrRATION ^ )V'7r5 % Mouths ^Days ' Hours 

(Signed) ^>>U.W!^' <ic^v.\^s^ '!b^\.ucv^/.C M.D. 

TQoH (Address) S'^A I 0.^wA.tL^L>v O'i 



.a 



ECIAL INFORI 



FECIAL INFORMATION only for Hospitdls, Institutions, Transients, 
ortecent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



IM AOF: Ol- lUKlAI. OK KHMOVAI. 



I 



I)ATt:of lUKiAL or KKM()V.\I« 
b I90H 






rNI.HRTAKKK JU Cw<MV>V "U. 



(Address. 



Jb.ni ' \'\ 



state CAUSE OF DEATH In pinin term,, that it mi.y be properly classified. The Special intorma 
sons dyinft away from home should be ftiven in every Instance. 







1: 




■A. 



;i! 



'II 



il 



f 



*■ ' 









I 



I' 






•:»'l 



i 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

-i-n. REFER TO BACK OF rgR TIFlCATE FOR INSTRUCTIONS 

Ihdc Filod, MA^Lu ^T 



H.,anl-f H'-'"^' I-NOT 



i&\ 



t 



100^ RegLslered J\^o. 

rLvvvv^ 1jL\>m Deputy Health Officer 

DEPARTMENT OF PUBLIC HE AlTH=City and County of San Francisco 

Certificate of Death 

( "CI. S. StanDarD ) _ 

PLACE OF DEATH:-County of ^^X^i^^^X.^^- CUy of c) ^ >v ^^a>vc^t.c 



NaU'Cw 



(ir DE 



*TH C< 
DEAT» 



FULL NAME 



lI> 




QfH. 



ccc ri.\^^>^^-^r:^^^ 



Xtt^w 



SKX 



PERSONAL AND STATISTICAL PART ICULARS 

COI.OR 



^\A 



UjJwtA.. 



DA II-; Of- lURTn 



,vvvUt .. 

(Motith) 



X?^ /S:?.-.U.... 

(Day) (Vear) 



AGK 



bS )v.,,> " 



M.niths 



\X 



Pays 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DEATH 

LU-^^*' 5... 



UMonth) 



(Day) 



igo i 

(Year) 



SIVr.I,R. MARKIKD 
\VFi><>\VKl) OR DIVomKD 

iWiitein stK-ial tksi^Mialioii) 



It 



BlRTinM.ACK 
(State (ir Country^ 






NAM]-: Of 



^jru\A- 



i\Ojy\} 




<xc 




^vL 



.^-i^Av 



\ 



I'-. 




BIRTH n.AOK 
OF l-ATHKR 
'State or Country) 



maii>i:n namk 

Ol- MOTHKR 



HIRTHPt.ACK 
Ol- MoTHKR 
(State or Coiintryl 






I Hr:RHBY CKRTIFV, That I atten.U-.l .Iccoasetl from 

^lvc->A^ XI 190 H to ...VJ^ ST. 190 H 

that I last saw h<.VA>^ alive on |<\.^-^^ ^ ^9©^ 

and that death occurrea, on the date stated above, at cO^t 3-.^C 
U M The CAl'SH C)F OK AT IT was as follows 



.LL'>"v<yL/^^'^<^. ..vLr^LcLtr'u.'W^.. 



DI'R ATION Years Mouths Days Hours 
CONTRIBUTORY LL^JuL.^-<^^^...3.^.'LL^^ftr^ ^-« '•' 



d /c^cLvcu^-vcL- 



OCCUPATION 



1: 



Rf 



sidrd ill Sii >i I iiiiuisrn ^ 



)'tiii < 



}f,nif/l.<! 



It a \: 






Tin MOVKSTXTl-.T) J'KRSONAl. I'ARTH T KA RS A R !• TRll- TO TH1-; 
liliST OH MY KNOWI.I'.DCK AND Hhl.Il.f- 

(Ad.lres. llO X^t<VV^l '"'"^ 



DURATION Years J/oNi/is Days Hours 

(SIGNED) vxU/v-cuv^L i 'bl^^<-*^ M.D. 

kvLl^': iQoM (Address) t-T^^^'lvvl-teL "^ ^ 

'[ J •..^^n.. A-ri<^i\j nnlv for Hosoitals. Institution' 



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



Former or 
Usual Residence 

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



.<)\.vim% 



. How long at f^ 
oU' Place of Death? >J Days 



T'l '^CK OF in-RIAI. OR KKMOVAI. 



T'I,ACK OF I' 



DATKof WlRlAi. or RKMOVAl, 



INDK 



'^rt>?p- 




t 



N. B.- 



""""^ " ^ VA A<;F should be BtBte.l EXACTLY. PHYSICIANS should 

-Every item o* information .hould be cnretully suppl.ed. ^ur, 8 ^j j ^^^ "Special Information" for pr- 

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

son. dylnft away from home should be ftiven in every mstance. 



• i 



m 



,% 




'WW i 



li 




I;' 






1 



I 









\ 



I i 



\u 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hr.aid 



.nicMlth-FNo. >.i^?^i-'»&»'^"l 







190\ 



Ee^istered Xo. 



90 



S,^,t,.^^'uu>\su^y Deputy Health Officer 

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

Ccvtificate of Beatb 

( "CI. S. StanDarD ) 

of C)/Ou^ .tA^L/wCUl/Cfty of n.OAV :\Ko^x^^^^^ 



PLACE OF DEATH: — County 



No. 



cnu^t 



(IF DEATf^l I 
IF DEikTH OCCURReD 




i^UVu>nSt.; 



Dist.; bet. 



and 



. o....,.cc Y:^^ o%=?:?^,?J=4ro,;r,;i ?.Vm7 r..";o-^; ■^:^\:^'^::^r ) 



FULL NAME 



[ft\ 



tXUAACX. 



SKX 



DATK OF mK'in 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 








AHK 



)V<7». 



I 



H 

(Day) 



M.nifhf^ 



(Year) 



^t 



/>« v.v 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




I 



(Day) 



(Y 



lear) 



siNC.i.K. markikh. 

\VII)(»\VKr) »)K I)!Vt)kV"Hn 
|\\ ritf in sorial (U>.itf nation) 



HIRTHPI.ACE 
iSlatf or Country) 



N'AMl-. OI 
I AT Hi: R 



lURTHl'I.ACK 

<)!• iArm-:R 

(State or Country) 



MAIDKN NAMK 
OK MOTHKR 






IXmA' 



AVCK^^'V>^' — 



lURTHri.ACK 
<)l" MOTHKR 
(Statf or Cotintry) 



1 1 



u 



«• 



I HKRRBy'cIvRTIFY, That I attctided deceased from 

DKoI^ H 190 H to .^H • ^ ^90 'i 

that T last sLv h ..^^^tliYe on VJaA/>^ ^ 190 H 

an<l that death occurred, on the date stated above, at .^■^- 

^ ^I^ The CAUSlv OF DICATII was as follows: 

A.^JUl^CvL .OOVaV/rvA,>-^^cv^ 






nr RATION •" )Vrt;.y 
CONTRIBUTORY 



^ Months \ Days 1 Hours 

.0..<.>.A...t:V':?kA^.\AL^n.> 



)'cars 



OCCUPATION 

^'f"'f-',f ill S,ni /'inii.nrn "^ ) ''i" 



yhiiiths 



x\ 



/h!V: 






TMKAm)VKSTATKI)PKRSONAI, IVXKTICl-I.AKSARi; TKIH To THK 
HKST <)1- MY KN<>Wl.):i)f.H AND Uhl.n-.H 

(Infonnant OA.vtt^ ^ irVaVvV 



Months I Days 3^0 Hours 



PECrAL INFORMATION only tor Hospitals, Institutions, Transients, 
Recent Residents, and persons dying away from fiome. 

Former or \' A ^^^^A \ a ^'K^l. 1.+ Ke'TDeath? Days 



or 



Usual Residence 

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



U^^l%^^d. 



I'l.AC^: (U- m RIAL OR RVV' "M 



nxriCo!" Hi KIAI. ot RHMOVAI, 



\X\A. ^ I90S 



ini)i:rtakkr 

f AcMrt-ss 






?>bia- l^ 



be «toted EXACTLY. PHYSICIANS should 



, .. !• I \r:F Khould be stated ^.XAVill.T. t-ii i c»iw.r..^w „..^ 

N. B._Rvcry Item o? informBtion should be c.retully «v.ppl.ed '^^'»^ classified. The "Special Information" for p.r- 
stote CAUSE OP DEATH in plain term., that .t may be P''"l»«'''y ^'»"'' 
• son, dyinft away from home should be ftiven in every instance. 






t '' *!. 



I.; 



^ 



I I 









!(fe 






..v_;1 



Mi 



,.f 11. allli '•' 



I 



!)((/(' Fih'd , 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,,, ,. ,C=^.,.,;c^, ..r» TO BAC. OP crRTiP.c»Te roR .n,tpuct.o.» 

Regisievecl Xo. 




tJLj.^ ^^^^ 

"Ixv-M Dept-'y Health Officer 



91 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Til. 5. StanOarD ) 



4 ^ 



PLACE OF DEATH:-County of da>X. 1 ^a^v.^C<. City of ^ 'CVw 



V 



aAa^CA.^l^^ 




LaVtV^. A-^kdal. ^.^^rri^.Hi^'c^ho rOR UNDER ••sPE;.AL.Nr^AT.ON-) 

( - r.4E:T°H"oCc"u%iro\"rHO^S^PrAt ?R^?^?^i?u"4^N^C^;eTtI ^NAM. INSTEAO O. STREET AND NUMBER. ) 



'-) 



FULL NAME 



\l^OJL 




uwv- 



PERSONAL AND STATISTICAL PARTICULARS 



^i;\ 



Q^A 



coi 



■"\\).Lh 



I) All-: OF lUKTU 



a 



Monti) 



A OR 



CS s' ) 'ij I > 



11 



t 

(Day) 



MntllhS. 



All 

(Vear) 



Da vs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DF:ATH 




..y 

(Day) 



(Year) 



HINr.I.K. MARKIKD. 

W IDOWF:!) <»!< niVoRfKI) 

iWiittiii smial (ksi^ruatioti) 



niRTHPI.ACK 
(State or Coiintry) 



NAMK OF 

jathf:r 



d^^vcytx 






CC'>XL- 



HIRTH PLACE 
OF FATHKR 
(Stalf or Country) 



MA1Iif;N NAMK 

oi- motiif:r 







PhVrKBY CURTIFY, That I attendcil deceased from 

that /last saw h -^ >^ ^Hve on . mXt^ .d^..|^^^ 190 : 

ana that death occurred, on the date stated above, at ' 

^ ;^j The CAl'SrC OF DliATIT was as follows: 

'^vwl>t^<^A.^i'^txA,...^^^ 



DURATION 



Years 1 A/on//is ^ Days 



Hours 



CONTIUBrTORY --■■ ■ 

(LuX^^^.V^:v<X^Lv( ll-VvLIL. 

DURATION Years Mouths Days 



.VA-'V., 



Hours 



lUR'rniM.ACF: 

<»1- MOTUHR 
'Statf or Oountrv^ 



O^J^l 



<XW'( 



OCCUPATION P jj j 



M, mills 



Par. 



THK AnOVK STATFI) PK.RSONAI, I'A K P U" F l.A RS A R F. TKl F: TO THH 
nF:ST OF MY KNOWI.I-.IH'.F: AM) lU-.l.IF.H 



(Informant 



(AdilreHS 






<Xrs^^ 



(SIGNED) 



ll\.ttv^-V ^- ^^ vW^fc^M.D. 



^IGlNtU; >*.>vwrw- - -■ (?1\/ ^ 

kauH. lOoH r Address) 'li ^^ ^^M^ ^^^\-^ 
Special information only for Hospitals, In^itutlons, Transients, 



or Recent Residents, and persons dying awi«y from liome 
Fonner or , 5 5 :^. , ^ ti ^t """ '""' " 



tsual Residence 

Wiicn Has disease contracted, 
If not at place of death ? 



Place of Death? 

t 



30 



Day? 



FI.ACKOF HFRFM. OR RKMoVAI. 



CK OF' lU RIAL l»K Ki 

Hi 



^ 



rNI)F:RTAKF: 



DATF: of JH KiAi. or RF.MOVAI, 

^vJlu I T90M 



(Acltlress 



— ■"■""^ ,. , AfiE should be stated EXACTLY. PHYSICIANS should 

of information .honld be .nrefully HuppI.ed. '^"^^ "^7' „.^,,^d. yhe "Special Information" for p.r- 
F OF DEATH In plain terms, that it may be properly ciassitiea. 



N. B.-^Every item 

•tate CAUSE OF DEATH . :„«t„„ce 

son. dylnft away from hom« should be ftiven .n every .nstance. 








^\ 







WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,»-Ji. ,..,., """ TOBACKOF CERTIFICATE FOR INSTRUCTIONS 






Dafr mod. YV^H ^^ 






1 ' 



ii^OH 



Registered J^o, 



no 



or 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( XI. S. StanOarO ) 

Jl ^ i ^ 

! — County of n 'Oov ^t A^-v^UMlOGty of n^,>v) .J.V<x-»x^^.c.o 



PLACE OF DEATH 



L'f 



«T r\t^ M y^ > ? k k"A 4"' .M k ^ kn h St.: — -"" Dist.; bet. ^"^ ■.•.•■ 

/No. VJ.\) \^-^C]V'^^^ .. V^. >.|\. ..^.^■'^, ^^.Y^*' -J.., ^^ „CTS CALLED FOR UNDER -'SPECIAL INFORMATION- \ 

(]( '^ rF^rATroCC-lRreV-L-rHo's^rAt rR^f^^^^^T^O^'V.vV^l NAME INSTEAD OF STREET AND NUMBER. J 



w- V> 



FULL NAME 



^rl:V>.V. 



(^Itl 




:A.\A.t^V 



i:x 



PERSONAL AND STATISTICAL PART ICULARS 



Qua 



DATK OF HIRTH 




7 

(Month) 



U)J 

(Day) 



(Year) 



A(iK 



IH r. 



? 



7 



(C<»r5 



Mouths „-..» rtf^}'^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKAl 




S 

(Day) 



(Year) 



I HRRFBY Cr'RTIFY, That I attciKkd (!cccasc«l from 




SINM.I.K. MARK IK!) 
\VII)t>\VK.I) OR DIVORvKO 



U'II)t>\VK.I) OR DIVOKCKl) \ 

WiiftiTi >;(K-ial tlfsi^natiou) ] I \ 



. If 



niR TMPI.ACK 
(Slate or Countryt 



NAMK oi- 
FA rillvR 



e 1) 






? 






lURTHPUACK 
<U- FATHKR 
dilate or Countryt 



MAIDKN NAMK 
OF MOTHKR 



lURTHPLACK 

nj- MOTHKR 

• State or Country) 



7 

7 



? 



that I last saw h ^>>>Hlivc on 

and that (loath occnrred, on the date stated above, at 
(y.yi. The CAI'SIC OI' Dl^ATII was as follows 

Ql'VvtvoLl CKjLavu>^AXc^t^ 



-crw. 



DT'RATION ^ Years \ Months '<S Days Hours 
CONTRIBUTORY Llhjur^v^-^ .ii^A^6:>.^ C.K^ 



Mo>i//is 



/)avs 



DURATION years 

(Signed) UU'Vw ^y^ou.A.^>v<Ytx\AJ^-v^. 

ddress) ^1 |t^cklv % 



\^XsMh iQoH (A( 



Hours 
M.D. 




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



I'M 

lit 



OCCVPATION QX^^ 

TIIK MIOVK ST\TKI) PKR ^ONAl, I'A RT UT I.ARS ART. TRFK To TIIK 
HKST OF- MY KN0\VI,F:I)C.K AND HKMKF 



(Infovniniit 



vrv\ 






(J 

f AfMrcss 



Former or , /» ^ 

Usual Residence ' ->" 

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



dda 



\'-v<X 



-1^^ How long at - 

o' Place of Death? dajAl... Bsys 



pi.ACJ^OF- niRIAI, OR RKMoVAI. 



i)ATF:<)f juKiAL or rf:movai, 
t> T90H 

U nun (YV 




INDKKTAKKR 

/AiMre'^s 



nbn MYtv<L«.-urv\ 



E OF DEATH in plain terms, that it mny be properly ciassnicu. 



N. B.—— Every Item 

state CAU8_ . - . ^ 

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




t 









til 



, 



i' 



t 



,''! » 



WR.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,u,u.riM, Llv, .^ I'-^O^ JtegLstered A^o. 93 

i^^.lLu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanOarO ) 



J^ ^ 



PLACE OF DEATH:-County oiSa^ ka>xCV^t.Gty of^^^X^vv J|UXa^v4.C,. 



No. 



Ha) . 0CMJt'^uLU/>x-a U.^-aA^ '■ ■"•>' 



( - r."o;AT°H"o^ciro\;^"-Ho"s^PrAt o"r^?:St^^^tU'^0.;eTs ^NAME .STEAO O. STREET AND NUMBER. ; 



) 



FULL NAME 



LcLo^tH) \l riir->\.lats^>^'<'' 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 



i'Hli' 



QTlJL 



w.Kvtji 



DATH Ol" lUKTU 



AC.K 






I 



,T, r..Hfc.H.. 

(Day) (Vear) 



) ■/•<; » v 



1 



M.mth 



. ..,3 



/la » .V 



MEDICAL CERTIFICATE OF DEATH 
DATH OF DKATH 





(Mont 



.a 

(Day) 



(Year) 



1" 



mNc.i.K. MARKii:n 

W IDoWKD OK I>!VnKi»-:D 
Wiitfiii siK-ial (k'sij/.nati»)n) 



HIK riUM.AOK 
(Stall- fir Country^ 






l-ATHHR 



ll/>vK/ 



\v<^v^^^>v 




BTRTHPl.AOK 
OJ- lATMKR 

istMtr or (.Nnintry) 



MAini'.N NAM1-; 
OF MOTMKK 



lURTlllM.ACK 

or MornKR 

(Stall- or C«)>inlry) 



»• 



*\ 



I HI-RI'IiV CiVrTIFV, That I atteiKled (Icccase.l from 

Vv>^-^ ' ^190 '^ to .WLv....X 190 4 

that I lastsawh -'uv>valivcon ^AA/VUL. v?> u 190 ^ 

aiKl that .U-ath occurred, on the date stated above, at H-3 
(JL M. The CAISI-: Ol' DI'iATH was as follows: 

Uk/<HLtA.^o- o/^v.|iX'>\-t\x/v^ 

'JAL^^^^ 

in-RATION - Years X Mouths Pays Hours 
CONTRIIU'TORV -^ - 

ni'RATION ^ Years I Months 1^ Pays * I fours 

( SIGNED ) ^V^ QllOA^I^X^H 

IajJL" '^ *^ rv.ldrt.ss'l IS'^O ^^XX' 



SPECIAL INF 



H (Address) 



M.D. 



«« 



Of^CUPATION 

hVsidrtf ni Snv /'i ,!iit iu;> 



-1V.MV 1 V„„//;v Pt D A71.V 



THK AHOVKSTM-|-:i) VKKSONAl. 1' \ K TUT l.A K S A K K TKlK TO THH 
HKST OF MY KN0\VI.F:D('.K AND IM.I.H.I- 



(Informant 



(A.ldrcss 






v^.r,.. ..JFORMATION only for Hospitals, Institutions, Transients, 
or^ercnt^csWeiJts' 'and persons dying away from home. 



Former or 
Usual Residence 

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



Itow lonq at 
Place of Deatli ? 



. Days 



L«*»«t»a«* 



PI ^CH OI- m RIAL OK KKMOV.M. 

J 



ini)i:rtakhr 



, I, OK KI',.M« '\ . 



nATF^of lUKiAi- or rf:moyai, 

5^ 1 90 M 



^\(1<1t«-ss 






i>n 



.1 



OF DEATH in plnln terms, that it may be properly dassitiea. ne p 



N. B. Kvery item otf 

state CAUSE -u'. ^--- - . , , „».„^- 

«on. dyinA away from home should be ftiven in .very Instance. 



1-& 






i« 




Hi':) 



i» 



*' JIl'T 



t: 



i'l^ i 









^1 






[F ! 




/)///r Filed , 



WRiTE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^ 



H&rco 



5^ V)()'\ 

Deputy Health Offlr^cr 



Be^istcved J\''o, 



DEPARTMENT 0?PUBLIC HEALTH=City and County of San Francisco 



94 



Cevtificatc of Bcatb 

( "U. S. StanDarC» ) 



PLACE OF DEATH: — County 



<^ J) (^ 

of (^ O. > V .VOu>vc v^^ City of ^J <Vav J ,>v<x^c^^c^ 



N 



5SPITAL OR IN! 

0^ 



Dist,; bet. 



and 



— ) 



W Jt^l " V VT""**^* V *• * v-w w -^ --T *..,-.„ r<>ia iiMnrR "SPECIAL INFORMATION"^ 



FULL NAME 



\J ( U.vL^^OL.K 



^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



OUa,L 



UJJvctjL 



DATK (>l- HIKTll 



^lU' 



iMonlh) 



(I):iy^ 



I... 

(Year) 



AC.K 



CC 



u 



^lST.. 



JVar-v 



.!/,.»////> 



Pars 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

3,. 



/I (MontlJ 



(Day) 



(Year) 



I HKREBY CKRTIFV, That I attendc.l deceased from 



.a.jL.|.vt 10 190-^ to^ J^^^ 



^. ^ 19^*1 

that I last saw h ^>v alive on ^^^^- ^ '^o 4 



rred, on the date stated above, at 3 i O 



SINni.R. MARKIKD, 
WIPOWKD OK DlVORrKO 
I Writf in socia 



< DlVORrKO % 

1 ik-siKiuitixii^ . 11 



/yv^^^rvv^^VN^ 



HIKTMri.Al'H 
(State nr C<»untry^ 



NAMK Ol" 
FATHKR 



_IA 



mRTHPLACK 
OI- FArnl'R 
'State or C<)\nitry) 



and that death occn 

J M The CArSl*: OV DICATII was as follows 




-4^^cLi. 



-.^, ^ -^ 

JURATION rr- years *" J/ou/Zis ^ 

:()NTRIIU'T()RY LL>x.H/ 




'>v....a'>v<:C' "to IQL-^Kj -Vv.V-. 

Days '"Hours 



MAIDEN NAME 
OI- MOTHER 



M 




HIKTHIM.ACE 
OF MOTHER 
(State <jr Country) 



OCCUPATION (^^^^^.cXw 



(« 



h'fMdrd ni Stin /'i ttiii i>ri> 



) V(M f 



U 



Month- 



n,i rs 



THE MUHE STATi:n PKKSONAL rAKTU" T I.A KS ARE TRIE TO THE 
BEST Ol- MV KNoWKEUCE AM) lU-.l.Il.F 

(Inf-.Tmant VJ . VJj A^<!VA-VX 



(Adrlrc* 



,Vofi//is ^ Days ^ //ours 
v^r ^ N-/»>-\v^^>^ M.D. 



nr RATION "^ years 

(SIGNED) i.:..Uw' O 

VVWl^ H TQO 

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



Ltwi^ 



Former or 
Usual Residence 

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



'•I, W-^"^-^-^"^^ 



How lonq at , ^ o-v^ v^^ 
Place of Oeatli ? v w 



wy^ 



I'LVCE OI-- lUKIAU OR REMOVAL 




DAT/: of HiKiAl. or REMoVAI, 
-dL^l t> 1 90S 



CK^itCC 



r 



A-^O 



vv'lcyAA CL^M^ 



' ^ 'J , .. ,. . T^F should be stated EXACTLY. PHYSICIANS should 

N. B. Every Item of information .hould be ci.retully supplied. y^^^'J classified. The "Special InformaLon" for p.r- 

state CAUSE OP DEATH in plain terms, that .t may be properly class.tiea. ^ 

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



» 



m 



1 






"(J 




"!l 



\\ 



1' 
ill. 



)i' 



: f I 



t 



r 



I 



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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

,, . _ > Eeai.s/cred JVo. 95 

lld/c I'ilcil , 



n, .1.!. I' N" i^ t-gg.^. iiM' '■" 






100^ 



X^vvv. 'W^u Deputy Health Officer ^ 

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

Certificate of H)eatb 

( la. S. i5taiiBatC> ) 

:i,Ou>^TX<X>v<^VAao City of O-C^A^OVavv^^v^cit 




PLACE OF DEATH: — County of 



) 



— MEDICAL CERTIFICATE OF DEATH 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR , .^jj 



fYruJL 





DATl-: <>l- I'-IKTU 




(Vear) 



A OK 



) V<i / > 



A/,»i//is 



Da f. 



DATH OF DKATH 



.aXu 



(Month) 



(Day) 



(Year) 



I HI^;RF.RV Cl'RTir'V, That I attemk'.l deceased from 
AaX\4 '^ ..190-H, to 



1 



alive on 



sINOl.K. MAKKli:!). 

winnwi'i) OK i)ivoKri:n 

'Wiitcin social (ksiv:natiuti) 






ffit 



BtRTHPl-ACK 

(Statt- or Cotintry) 



NAMK OF 
FATMl'.R 



r1 









RTRTMl'LACH 
O!" I ATMHR 
(Stall' or CDUiitry) 




MAIOl'N NAMK 



HIRTHPLACK 
<)l- MOTHKR 
(Stalf or Country) 







that I last saw li ^^ 

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

____ ^j 'j'li^. CAI'SP: ()»• Dl-A'PH was as follows 



up' 
190 



a>^^ 




(B. 



or RAT ION y<'<irs J\/i»f//is 

CONTUIHl'TORV 



Days 



Hours 




CUVM. <^^^ 



OCCUPATION 

Ri-'-idrd ill Still /'nnhisi-it 



Lvawv'TTs^- 



•• )'iiT 



— }r,,'itii< "^ -"'"• 



TMl^AHOVKSTATKDVKRSONAl. rAKTIO(;i.AKSAKlC TKIH To TllH 
HKST Ol- MV KNO\Vlj:i)i".H AND lU-.I.H-.l' 



Dl-RATION years Months Days Hours 

( SIGNED ) J..Jvv^>V.Lrvvr MTlclUn. M.D. 

.^ T<,o M ( ^.l.ln■.s^^^n^Xa^^-^ "^^ 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home, 
c , „r How long at 
KVsidence • -^ ^-' »' »"'*' »''' 

When was disease contracted, 

If not at place of deatit ? 



(Inforniatit 



fA'ltlrcss 



inW 



i'jn 



w/vv<v 



DAIliot Mi KiAi. or K1:M0VAI. 

r 190S 



I'l \CK Ol" lUKlAI, OK KKMoVAI, 

11 T*'! VD\va,^t-^ff>% "at 



r.NUl.K'IAKlvK 

(AiMvfSS 



!S, 



"•'""""■"^■"""■""'""'""'"■"■"'"""''""''^T 77 \nF should be 8t»tetl HXACTLY. PHYSICIANS should 

B.— F.very Item of !n?orm„tion nhould b. cnrefully -'PP '- ' ^^J^^^^^^ dasshied. The "Special InformHtion" for p.r- 

8tntc CAUSE OF DEATH in plnin terms, thnt .t m»> ^*^ P;"*^;'^'^ 

sons dylnft oway from home should be fe.ven ..1 every instance. 




m 



: I ( 



!i ( 



k4 



'^-Ifts-- 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



, ,■ ,, .,,,1, I- No 1-, ■fr-'^^w^- 11^:1' Co 

I, ,1 111 111 111 in II I ^" '^ u. ,.,,^ ^ ^^^ 



1^ 



i'VaJIu !^ 



i:' 



Si 



'■' 



VVA-^^ 



Xi^- 



^p>f^t?ir\j M<st?l*'N f^Pfli^-^ 



lie^Lstcrrd J^o. 



06 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiftcate of Bcatb 

( la. S. StanOatP ) 



PLACE OF DEATH: -County of'^ Ol^ .1^^>vC^C* City of -^^tXAv /VaAX^V<LC^ 



I, 



tia 



\n 



W 



1 1 






M Hnk - llCk. Uv^ St.: ^ Dlst.;bet.Ui ^frWi- and U) 

No. 1 I U *• I \ (^ k U V.V ,.^,,^, orcsTnFNCF GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \ 



) 



FULL NAME 



CUU fft ^t^K^v 



i 





lI^^Huu 



8KX 



i»\ ri: o!- luKi'M 



PERSONAL AND STATISTICAL PARTICULARS 




I 



1X.U 



I 




.1 



\x>k±. 



tMl!liitli> 



\ 



s 



V.J 

(Drty) 



(Vrar^ 



.\<'.l.: 



) V(/ » . 



M.oifh; 



MEDICAL CERTIFICATE OF DEATH 
DATK Ol' DKATH 



Montlf] 



(Day) 



(Yenr) 



-pH 



/Jij li 



^IN'C.l.lv ^!AKU^^I>. 

w n)t)\vi:i) i)K Divomi'i) 

(Writfiii social <lfsi>fiiiiti<in) 



m 



!|'-iM 




I stilt t or Comitiy^ 



XAMJ-: Ol 
I-ATIU'.R 



lUKTMl'LACH 
«»l" lATMKR 
(Stiiii- or Cu\iiiti y) 



MAII)1<:N nam I", 

Ol- M(>Tin:K 






I in':KI':HV CI';KTIFV, That r atUMidcd dcocasea from 

Y^^'^ H 190H to Y^"^ 

that I last saw h alive on ^9° 

and that death ocrnrrcd, on tht- datr elated above, at 
M. The CAT SI-; OIL I ) I-; AT II was as folK>ws: 

y..L\JUv...Mj.fi"*vAv 

ai'-Wvt l.'l.^. <^>vtr>vHw> 



lUKTJTPr.ACK 

oi- Morm'.R 

(Statf or Country* 




CXA,ll4 



a hxla'>x<L 



Rrsiiini in Sun I'l iiii> isro 



)■»■(// 



^- Months 



/hn: 



ru j; AHovi-: sr \ii:n i-kksonai. tar rui i, \ks aki-: i'ki)': lo riii-: 

mCST Ol- MY KNO\VI,l-:i>»'. H AM) III-; IJ l-".l-" 



(InfoniKiiit 






or RATION •^ )V<7/-.v ^ Motilhs ^ Days * J/oius 

CONTRIHl'TORV 



DURATION ^Vcars -^ jron/Zts - Pnys - //ours 

(Signed) y^TYV\\^ ^^^o^ixv^^^ M.D. 

Pr looH (Address) J S" ^-^ 'IImVa-A t 5>x cjt 



SPECIAL Information only for Hospitals, Instilutlons, 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 



lAi, OR ri-:movai. 



DAI'l'lot MiKixi. <»r RKMOVAI, 



190H 



I NDURTAKKR ll^wtl cL W^ VCLc\l rL.V-U.\.^ 



(Address 



state CAUSE OF DEATH in „l..!n term,, thnt it m«y he properly cloHHifled. The Special Information for p.r- 
nons dyinft awny from homo Hhoultl he liiven in every instance. 



• I 






I 

I 
) 

I 
if 



i!i 



1 



1 




u 



^ 



i 

w. 

I 



■ I 



h ' 



'.rt 



f! 




WRITE PLAINLY WITH UNFADING INK 



,,,,,,,1 of ll. nHH- t-^-" " ^'!!^^'^ I'S: 1' Co 

/)r//^' AV/^v/, V^Jtu 5^ 

J) hi 



/^(^H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 

^Reglstei'cd J\^o. ^^< 



Dep 



i.l,t 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of IDcatb 

( XX. S. StanDarD ) 

4 ^ 



(3i> 



No. 



PLACE OF DEATH:-County of^^a^^ W^.C^^^ Gty of^^^'o^ ^ Xa^^ 

( '^ r."or.T°H^S^c"u%reV.;THo^s^r.t :«^?^s°.^^"o^.'^cf.vr.;i name ..sr.^o or STBecT ..o .umb.«. ^ 



FULL NAME 




./yva4X./Yv. 



si.:x 



PERSONAL AND STATISTICAL PARTICULARS 

i c'oi.oR 



DA'nC Ol- IllKTH 0> A 



tO^vvtx- 



iMontli) 



IH /^^M 

(Day) <Vear> 



At'.R 



)'i\i> * 



s 



Miitillis 



hi 



/)(/ r.v 



wiDowKi) OR i)iv»n<ci:n 

I Wvitf ill scKial iU^ij.Miiiti<m) 



n c^vo/cXt 



(Day) 



(Vtar) 



lURTHn.AOK 
i^tjiU- or Country^ 



\A^tl•• Ol' 
FA riii.R 



lUR'nilM.ACK 

op i-atiii:r 

'StaU; oi Country) 



MAIDKN NAMK 
*ti MoTHHR 



r.iKi"in'LACi<: 

Ol' MOTIIKR 
iSt.Ttr or Country) 










.CtVAA.'^^ 



MEDICAL CERTIFICATE OF DEATH 
DATK Ol" DKATH a ^ 

f\ (Mont.fi) 
I niCRl'HV CI-IKTII'V, That I attotidcd deceased from 

^vsjc 15^ 190 S to |vvi^ .3^ 190 H 

that 1 hist saw h .<VA^ilive on ^)'WUA^c^^>%t'^^ 190 H 
and that death occurred, 011 the <late stated above, at %. 
...(P M. The CAl'Slv Ol' Dl'iATII was as follows: 

.^/./■Y^^,<X/>>-v\•^-'fi>"'» 




DT' RAT ION •" )'cars H Moutin - Pays - I lours 

CONTRIBUTORY L^N^W^\<<vt\.«:\i. 



DURATION ^ Years ^ Mouths ^ Pays Hours 

(SIGNED)... Ll-.Li.l) (MJ^^^^^^ l^-^. 

\A^.2s I90S (Address) UM^f^^- tJL0'< 
SPEdiAL INFORMATION only for Hospitals, Institutions, Transients, 



K\) 



,K^<ix^' 



OC en- AT ION 

R^siiifii ill Sail /'niih nm 



);;ns 4 .1A./;//rv ^ '^ /'"v.^ 



Tin: AUOVKSTATKP PKR^ONAJ, I'A K P IC T I.A KS A R l- TRll- TO Nil-: 

iiKsT Ol- MY kno\vm:i)C.k am> iu:i,n-.i' 



(Inrotnirmt 



X6 CLa^vv LL/vm: 



(Address 



or Recent Residents, and persons dyinq away from fiome. 



former or 

Usual Residence 

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



How lonq at 
Place of Deatfi ? 



Days 



II.ACK 01* nrRIAI, OR RKMoVAl, 



i)\ii"of m Ki,\i. <n ri<:mo\ai. 



INDKRTAKKR 

r\{l<ln'ss 



\ \ 'sn. ClD\v'<^4^^>A ci'A 



N. B. 



state C\USE or DHATH In „l«in ter. ,s, that It may be properly Uoss-fled. The Special 
«on« dylnft away ?rom home should be ftiven in every instance. 



|!| 




r 



i t 



I 



i^ 




H 



1 



I 
» 

II 




k 






} 



:.i\ 



'11 



Hnar.l.-f M.Mlt1i--|- No_l^ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CgRTIFICATC FOR INSTRUCTIONS 



Rl|.| 



^tl 



I 

ii 

V 







n„,rii.<J, M..1., s 100^ 

Xt^wv* Uv^M. Deputy Health Officer 



Registered Xo. 



98 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( Ta. S. StatiDarD ) 



4 ^ 



PLACE OF DEATH : — County of 



(^^QywAAXXAVt-UM^o City of nXX-^ -1 A.<XAMM,4yC^ 



T^o. 






) 



/■O 



FULL NAME 



V.XA^T:A_.U 



DATK OK lURTll 



PERSONAL AND STATISTICAL PA RTICUL ARS 



k! JU^-y\,oJjL 



OjI^kXjl. 






5. 

(Day) 



(Year) 



A« . K 



t)v5") -,•,,,> ...X..- !/.»»////> X\ ^'" 



\s 



SlNCl.H, MAKKIKI) 

winnwKi) OK nivoKCKl) 
•Wiitf ill social <ksii':n:iti<>n) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Day) 



f9"H 

(Year) 



!i 




lURTMVl.AOK 
(Slate or Country) 



NAMK <»K 
FATin.R 



niRTHIM.ArE 
Ol- FATHKR 
(Slatf or Ci)iintry) 



MAIDKN NAME 
<)»• MOTHER 






niKTIIl'l.AOE 
OF MOTHER 
(State or Country) 



^ 



I HERI'BV CI'RTIFV, That I attended (leccasetl from 

3jLh a ,90 S to ...Wiv^ H KpH 

that I last saw h XSj alive on f^*^ "^ ^'^ "^ 

and that death occurred, on the date stated above, at b • 6 
(J ]VI. The CAUSE OF DlvATII was as follows: 

3j \,^.lN-^AA,a Wfr>^-VCT^ 



nr RAT ION 

CONTRIIU'TORY 



*^ Years "^ Months 

^..^ 



Days 



Hours 



DURATION years 

( SIGNED ) L\A,^^^VLVA; 

i\.cLm B"" iqo'i (Address) 



c^/vlLcvwcL 



OCCUPATION — - •" 

THl-. \HOVE STATi: 1) I'KRSONAI, PA KT U' T 1-A KS AKI. IKlH TO THE 
niCST ()!• MY KNO\Vl,i:i)<".E AND HIMJI-.K 



(Infonuant 






(A(l<lress 



i- 



Aroiillis Days /lours 



t 



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



Former or 
Usual Residence 



J\ I How long at -. 

^ 5 S (^1 CtONi-^v^MJ^v piare of Death ? 5 <>>vo^.^s 



When was disease contracted, c- 5- u "PsX a 
If not at place of death? ^^ -^ ~ "^ 



\'^/%x>^^tr>x 



I'l.ACE OF niRIAI. OR REMOVAL 



% 




I)ATF;of Hi KiAi. or REMOYAU 
I I90H 




UNDERTAKER 

(Address. 



il'^^'A^VW^xt it 



be iitated EXACTLY. PHYSICIANS should 

for p«p- 



state CAUSE OF DEATH in plain terms, that it may he properly clawitie 
son. dying away from home should be given in every instance. 





1 

I 



|l 



It 



I 







WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^-^ RE FER TO BACK OF CERTIFICATE FOR IN3TRUCTION9 

99 



Be^istcvcd JVo. 



naloFiM, f^^ '•'^'* 

"L^vJl U^M^ Deputy Health Ofificer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( -Q. S. Stan^arD ) 

^ ^ :ity of V lcuJli>^'>^^ ^^^ 



PLACE OF DEATH: — County of O^Vvcx^^vo. City 



No. 



c^ . Dist • bct« ^^^ 



FULL NAME 



liixLl 



PERSONAL AND STATISTICAL PARTICULARS 



si;\ 



^>\^ 



COI,OR 



Uj-^vwij: 



DATl". nl' lllKTll 




lonlh) 



< Day) 



/Ib.a 

(Year) 



AC.R 



SS" ) V„; V t .!/..»///> ^- -^'^'^ 



WinoWKI) »)K DlVOKi'Kn 
(Writtin social tlcsiKnatioii) 



I 



O-c^xoU. 




AUX^>\ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



L 



(Montli 



^ 

(Day) 



(Year) 



I90 

— alive on 



to 



I HICUl'HV CI':RTIFV, That I atten(le<l deceased from 

-- " KjO "~ " 

' " TQCr- 



ill! 






r 



niRTIUM.AOK 

(St;itf <ir Co\intry) 



FAIHKR 



niKTHPUACH 
<)»" I'ATllKR 
tSlatf or Covintrv) 






r 



MAIDKN NAMK 
or MOTHKR 



Cri'ATlON -A ^ J , 4. 



V'^WAX 



lURTTIPLACK 
"I- MnTHKR 
(State or Country) 



.'C\^^"V_ 



d.- 



ill at T last saw h :^ 
and that death occurred, on the date stated above, at 
T^j The CAT SI-: OF 1)I{AT1I was as follows 

O^^C/VC^>vt^ SJ A^-VA^-^vw^vg, 



DT RATION Years 

CONTRIBUTORY 



Months 



Days 



Hours 



DURATION Years Mouths 



Days 



(SIGNED ) 



Hours 
M.D. 



yi, r,...H ,..„..... ^^^14^-^ 

' (1 _ . -_i. l«, UArnit-ilr InctifiifiAnc Trsiici 



Special information oi'y ''•'^ Hospitals, Institunons, Transients, 
or Recent Residents, and persons dying anay froni liome. 



HoM lonq at 



Rrsi,if,i in S,n, r.ann^rn'h^ )V,;/> (q .V>.,////> ^ /'■' 



rm: amovk stati-.d pfrsonai, i>\kiui i.aks aki-; tkih to thk 

1U:ST 01 MY KNOWl.HDC.K AND Ill'.IJl.l' 



(Infotmant 



(Address 



tLvJ.JX a. iDw 

9»\ (iS Id ti-v\>-avrL B 



SV"den« X 1 ^ n'lt.frvvvav^k, ?ia:rTo;U? S 0.ys 

When Has disease contrarted, 

II not at place of deatli ? 



PI.ACK OF HFRIAI. OR RFMoVAI. 



jSWui. bw^^ 




I)A'II;^ol MiKiAI. OJ RKM«)VA1, 

wtuL 5u 1 90S 



INDHRTAKKR 

(Adflress 



. y TJ .tvttcUX^VvUv Co 



^L^ ► 5 tl "it „ 



E OF DKATH in plain terms, that it may be propepi> ciassmcu. 



IN. B.^— Rvepy Item 

state CAUSE _ .... 

son. dylnft oway ?rom home should be feiven \n every instance. 



'lit I 





■ill 



M 



r k, 






m 



\r^ 



I 'I 



U 1 



> ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



„. ,:.,.! ..f 11. Mlth-K No. i.l^^ac^H&PCo 



I)(f/r Filed , 



Registered JVo. 



100 



.T 190 '\ 

"Xjj^^y^ Deputy Health Offl'"'"" 

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of Beatb 

( Ta. S. StanDarD ) 

^ \ 

J /va'YvCAjlC^ City of ^' 






No 



PLACE OF DEATH: — County ofO^^v tXa'VvCUlC^ City 
i 1 ti Nl I j^r\K \Vtu ^^ ^^l-k^ bv.! St.; Dist.; bet. . 

,. Ct\li ^ VCrVV.>A,V4^ .V |\_;^.. „r„.A;K.<.r ...wr p.^TS called rOR UNDER "SPECIAL I N ro R M AT.ON " \ 

NO NUMBER. / 



and 



( " r,"o».°H"o^i%*,"r,rj'"Ho".=rt o%^f^^%"J=4ro^,vYTs 'ur^i :. 



STEAD OF STREET Al 



FULL NAME 






■i 



■n 



O^.rsxJU^ ' i .U.\<c,L. 



SKX 



PERSONAL AND STATISTICALJPARTICULARS 

COI.OR 




<:u' 



L 



DATH ol- lUKTH 



AGK 

SIXt.l.K. MARKIKI). 



(Month) 



) V(/ » A 



i J, 



lOJ 



(Day) 



(Year) 



M.'udis f>*tys 



winowKi) OK nivoRiKi) /\ 

(Write in sfx-ial dt-sivf nation) I y\a 



HIRTMPI.ACH 

I State or Country) 



NAMK Ol' 
FATllHR 



lUkTHI'UAOK 
o|- I ATHKR 
(State or Covuitry) 



MAIDKN NAMK 
Ol MOTHKR 



KsXjm} 




cv'>^v)(rv<v 




VUC 



lURTHPT.ACH 

i>i- NKvrnHR 

(State or Country) 






"VVil 



OCCUPATION 

A' 



>sidr,i i,> Sat, l-,,j>i.,,,;> ^^'^M^vV.v ^m,n1tP 



Mm. 



Tin: AnoVESTATl",!) PKKSONAI. rAKTUt L \ KS A K J', TKlH T« ) THK 
HKST OK MY KNOWI.KDC.K AND Hin.IlvK 



(Infornmnt 



( \(l<lreH!i 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH, 



Montft) 



(Day) 



(Year) 



I HEREBY CERTIFY, That I attendcMl deceased from 

^tA/^V\X....'?).0 i9o4 to .|l^L^..X i9oH 

that I hist saw h ^^ > > alive on ^AaJUa, 5» H)oH 

and that death occurred, on the date stated above, at ^-oO 
CI- M. The CAl'Sh: C)E Dl^ATII was as follows: 



\]j^^ci 



»"U^-^»A.XXJfVA^ 



,/&-<LAw^ 



nr RAT ION -^ Years 
CONTRIBUTORY 



Motitha 



Days 



Hours 




Years Mouths Days 



Hours 
M.D. 



Xd .lress) LL V U .%>^- jd 
ION only for II 



SPEC^Kl Information omy lor Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from home. 

How long at ^^ 

Place of Death? J^ Days 



(|).,C 



Former or 
Usual Residence 

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



PI ^CK OK IHRIAJ. OR RKM<»VAI.J DATK of HrRiAi. or REMOVAI, 

(Vy'Wtv^cv^l SxWnX^^.* ^ ^ ^ 






INDERTAKKR 

(AtMrefls 



^'b 1 % 



^ -,. •• I *rK .koiild he Rtateil EXACTLY. PHYSICIANS should 



N. B.— ^Kvery item o9 iiiSorm 

state CAUSE OF DEATH In p 

«on« dylnft away from home should be ftJven In every instance. 




! TT? 



i|;i 



'ill 



1 1 



I 

'I 






ii 



'> . t 






h ; 



h 



^ 'i'i 






)i,,ni.' '.f Hc:ilt»^- » 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

s.„,,*^,.<..Co REFER TO BACK OF CERTIFICATE FOR INgTRUCTIONS 




I'JO^ 



Dale Fih'tl , 'ivvLu. S 

X^Kt-w<5 Xtvvu Deputy Health Officer 



Registered JVo. 



lOJ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( ta. S. StanOat? ) 



-? 



PLACE OF DEATH: -County of <^ C^^v'l'VO.vtC^^City of *"W >v 1 ,^XX,^a.CA..i/C^ 



■1; 



(]( " °,'rrl|"ccc"u%rcV,"rHos1."*.' o"."~""u" » o.,e .ts NAME ,NS,e.o or st.c.t .«o hu«b». J 



FULL NAME 




a,-UA,\^v.y. 



PERSONAL AND STATISTICAL PARTICULARS 






L 



COI.OK 



lUlvt. -, 



DATK «H" HIRTH 



A(iR 



(MinithlT 



(Day) 



(Year) 



) Vlf > .V 



I 



Matllhs ^..- ... /^aVA 



'^INC.I.K. MARKIKIV rN 

W IDOWKI) OR niVoRCKl) JO 

(Write ill social <lcsi>rnati<>n) *^ 



lURTMl'LACK 
(State or Country) 



NAMK OF 
FATHKR 



n^ 






i/wiU).^ 



lURTHPI.ACK 
Ol" FATHKR 
(State or Cojuilry) 



MAIDKN NAMK 

OF MOTHKR 



niRTTIPLACK 
0|- MoTHFlR 
(Stale or Country) 



h 



KL^y\/\. 



OCCrPATION 

Rfsidfii in Snii /'nnxi^rif 






)vV;7 ^^^^-^7yfo>,f7,r :.:..... Pay 



THK AHOVKSTXTF'.I) i'KRSONAI. 1' A KriCF I.AKS AKlv TKF K To TUIC 

ijf:st of* my knowi.kdc.k AM) ni:Mi:K 



#■ 



(Informant 



(Address 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH A J 

M.\^.L 

I^Month) 



-^ 



...H 

(Day) 



i9o\ 

(Year) 



I HHRIUiV CI:RTIFY, That I attended deceased from 

|.u..>.^ .^. 190 '.{ to ...WU^-.S 190 'i 

that I last saw h -rChJ alive on |^AX^^ H 190 H 

and that death occurred, on the date stated above, at L 
.....CL M. The CAl'Sl-: OF DHATII was as follows: 

.VllV<x\/nLitt.'..»'XA.^^ 



DT^RATION Years Months Days Hours 

JtLLlciv...v.vv. .A^.A^^CViviHvtf^l 

DURATION Years ^Touths Pays Hours 

ilj^.^. VvJiH M.D. 

.^\ TooH (Ad.lress) i^ ^^ (y^vM^V^.S! 



(Signed) 




g-p£Q,^L INFORMATION only for HospiUls, 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.ACE OK IHRIAI, OR RKMOVAI, 



Cu^wt^ 



UNDEKTAKKR 

(Address 



l)ATF:of m-RlAl- or REMOVAl, 

^vJlu 5^ 190 H 



.. .. 1- I APF ehniild he Stated EXACTLY. PHYSICIANS should 

N. B. Every Item of Information should hs cnrefully suppi.ed. AGE «^"7'' ^* ^^''^.^ ..g^^^^ Information" for p.r- 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special InVormat.on o p 

sons dylnft away from home shotild be ftiven in every instance. 





I 



I 



il! 



( i 




II 



, 




li 






1 










I 





// 




l! ♦^ 



1^ •>' j 



llii'^ 



1il 






I 



■ i 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^^4-v. M^Pco REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Xf^^vvA^ 1oi/LM^i_ Deputy Health Officer 



Registered J^'^o, 



102 



I A^AAvW> ' AJiyVM^i li^C|/vt*.j ric;ciivii v/iiiv^«^r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County of <* (X-Vu 



Ccvtificate of Bcatb 

( Ta. S. StanC>arD ) 



(?> 



1^ yvvL 



lL/> d a^wat t\^v^^^^^ St; Hi'A^^ho .o« U.O.. ••spec... ...f±.o. 



FULL NAME 



te^l 




XOLtV/YNJl 




) 



hMJ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.ol 



i)\ri-; oi" lUKTii 



I 




)AjLi 



otolith) 



It 

(Day) 



(Vear) 



.\<.K 



)•'■./'> 



Mouths 



M 



Da vs 



SINC.I.K. MARKIKl). 
WinoWKI) OR I)IV<»Kt'HI> 

I Write in siu-ial (U-siKtiation) 



O) v\vcvul 



HIRTH PLACE 

(State or Country^ 



nl' MOTIIKR A/> 

\\]\ 



NAM}-: (>I- 

i-athi:r 



niRTHPI.ACR 
OI- J-ATMKR 
istiiti or Country) 



J? % I! 

J Axt A VOL 



\XA.' 



MAIDllN NAMK 



HIR IMl'I.ArK 
'>l- M<»THKR 
iStatf or I'onntrv) 



orcfPA riox 



Ko^^^^^UL 




\SL 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Mon 



5. 

(Day) 



(Yoar) 



I HRRKBY CKRTIFV, That I atteiuled deceased from 
IJe iQO H to ..Ww. ^^ 190 H 



190 



that I last saw h-^^^ alive on ^^d^.. 3 190' i 

and that death occurre.l, on the <late stated above, at ^ H ^3 
-M. The CAlSlv OF DI^ATII was as follinvs : 

.OV-cJUL 



nr RAT ION 



Years 



Mouths 



Da ys 



Hours 



CONTRIliUTORV J^.hJL^^-^oXs^>^. (d A^tL.f J>Vv^. 



1)1' RATION 



Years 



Mouths 



Ihivs 



(SIGNED) v)X^ %• l^'^'^f^ 



f fours 

M.D. 




H,oH fAddress)XS^&M T^r^V^^^^ ^t.. 



AVv/,/^7 ,„ s-,.v /■•;,7;/,/v.. "^ )V'"^ ^ U,>;////> 1 Q />■■''> 



Till AltOVl- ST\Tj:I) PKRSONAI. PARTICn.AKS AKl' TRlH TO TIIK 
P.i;sT ()1- MY KNOWM-.DC.K AND H1:1JP:F 

(Informant \ JaX\XX 'l^ OlaJuAJU M VVO 



( Address 



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



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



? j% 



Days 



I'l \CK OF lURIAI. OR KlOtoVAI 




V<L^ 



DAri:-'! MiKiAi. or RFCMOVAI, 



T90 



INDHRTAKKK 






E OF DEATH in plain terms, thnt it nin> he properly clBBSitiea. me «^i» 



N. B. F.very ite 

mate CAUSE OF _ ^ 

«on« dyinft away from homo should be ftiven in every instance. 




^I'l 



'il 



! ! 



1 










» 



t 



^i 



Hoanl .'i ll.nUh 




i I'. 



li 



K :fj. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,,., ,,-,^^r^?^n^,.Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

103 



lOOH 



I)(i/c F/7i-d, .^UaXu S' 

dMt-^-^-A^ XxoMA Deputy Health Officer 



Re^isteTed J^o. 



^'•• 



■ i 



'i 

li .I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "Q, S. Stan^ar^ ) 

^^ a Y\j ^ J KO^^\Z\^1li^ City of ^ 0^/>V , 

/ IF DEATH OCCURS AW.V TROM USUAL R E sTd E N C E G . V E FACTS 'cALLED FOR UNDER "sJeC.AL I N FO R M ATljjs N " \ 
( ,F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ST»IIeET AND NUMBE«. J 



PLACE OF DEATH: — County ofO a>V J V<X^VCUi.t.<^City of ^^ Oy>V /UX/>x^C^UMM) 
No, iHia TaJLUvlVvJL St.; 1 Dist.; bct]i).a4.fU.^vCj7Uvx and 



) 



FULL NAME 




MahivcL JJ iryrt a.aijul 




PERSONAL AND STATISTICAL PARTICULARS 



SHX 



(hiJi 



COI.OR 



llU-vax 



DATi-: oi- lUK rn 



Q\ 



iM(jiith) 



(Day) 



(Year) 



ACR 



) lUt I 



1 



M,itil/is 



Pa \s 



SINT.I.H. MARK I HI). 

\\ii)()\vj:i) or i)iV()K4"i:i) 

'Wtiltin social iksijiMialiun) 



(Stall- or Country) 



NAM}- oi- 

fatiii;k 



lURTHI'I.ACK 
OI- l-AIIIKK 

(Statf or Cotuitry'* 



MAIDKN NAMK 



c\ 



1 



"V^ 



(^ ( 




1 



OF MoTin 



.^"^ J) 



-p 



>JUn wv-t .x^ V q cv a \A' 



(Slate or Country) "^ ^Ol' 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




(Month 



3>. 

(Day) 



(Year) 



I HF.RKBV C1':RTIFV, Tlisit I attended dcccasetl from 

W VUL 0. "^ 190 H to . N^Vsi^ igo S 

that I last saw h .rV\vtilivc on Jpr\AAA.. O 190 1 

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



r M. The CAUS!^: OF I)F:aTII was as follows: 



DURATION "^ Years " Months / Days '^ Hours 
CONTRIBUTORY VjD..-\.^A/CHAaXa^ 



DURATION '^ Years I Jfotit/is •" Days "Hours 

(SIGNED) \J ■ \J AT TWyVW-W M.D. 

H 190 H (Address) S M ^l) ^tVW 0\tV^ Qav^ 



H 



OF MoTMHR 



"i 



n fOjyyj J A^C5L/>V'^:AA^t- 



OCCl'PATlON 



^'''^/(ffif III S',ni I'l iiiii isi'ii •" )'<-/7)N / 



yfoiiffn 



/'<n. 



riii; AMovj; stati-'d imsksonai, i'\k rnri.AKs aki-: tkik to thf: 
in-;sr oi-- my know ij-dch and ni;iji-:F 



'l'ir<'?n»ant 



a a (Lcf 



(A.l.l 



ress 






3; 



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



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



I'l.ACK OF* lURIAI, OR RKMOVAI. I DATI-*, of niRiAl. or RF:M0VAI^ 




Iwjw^^'^^'. 



INDHRTAKKR MTU^Xv^ ^ 

1^ \) OL^v OAxajl" JX, 




I90H 



(Address 






N. B. livery Item of informntlon •hould ba carefully nupplted. AGE should be stated EXACTLY. PHYSICIANS should 

«tote CAUSE OF DEATH In pinin terms, that it may be properly classified. The "Special Information" for par- 
dons dyin^ away from home should be given in avery instance* 








' 



1, 







I 



:l. 






11 



I 



A 




H..MI 



,1 , f I!, ilth - » 



WS{ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

v., „ -i^r^^nScVCo REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

104 



/),,/. FiM, WLvL .T ^^^H Registered J^o. 

l«-lv/^ Iw-U^ Deputy Health OfHcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( tl. S. StanOarD ) 
PLACE OF DEATH:— County of H-tX^v J .VtX^^vOv^xoCity of O^Av -J^VO/vvOAA-CyO 
■No IS'^a Ot "LcrW* ll--, St.; ^ Dist.;bet. XOV-CL and ."^ 'vA 

( ■' :v"o;i.°„"occ"„%-,r„','»"rHo".^v,it o^^f^s^^"J;To';-o^v774 ^nV«7 rrcTo-s? s?;c%=;-i»o «::=';'r ■ ) 

Jj /i> 

FULL NAME O AA^^i^O- >^' 





-vvo^ 



PERSONAL AND STATISTICAL PARTICULARS 



liti 



h ' 



» 



si:\ 






CO I. OR 



\).\\'V. t)I- lUKTII 



llUvvU 






A».l{ 



( O J V</ / \ 



(Day) 



Mouths 



(Vt-ar) 



Par 



WIDoWKI) OK DIVOKCKI) 



■^ n M I \\ iM ) ( » K I ) 1 \ n K t I*. 1 1 \ 

Writf ill social (l(.sij.'iiati()n) 1 i \ 

Ov\^cv Vex >"^^^ 



HlkTHPUACH 

(State or CinMitrv) 



NAM I' <)1- 
FATHKR 



HIRTHIM.ACK 
<)»• l-AIMKR 
'Statf or Country) 



MAIDKN NAMH 
Ol- MOTIIKR 



Q 0_f 






TtlKTHin.ACK 
"t" MoTMKR 
(Statf or Country) 



Ca.-* " 



XtrVv-vxJl 



t.. 



Nw^LOhL 



v^vxav<x>vdw 



OCCUPATION 

f^fsittfit in Sail /'i iiih iM-ii . j )''<?■> ^' ^fnuths 



MEDICAL CERTIFICATE OF DEATH 

DATK OI" DKATH 




H 

(Day) 



(Year) 



LHRRnnV CI\RTIFV, That T attended decoasefl from 
>tVW ^ 190 X to ^ H4rVl^ H K^H 

that I last saw h .rt'V alive on tWLv^ 3 up ^ 

and that death »)ccurrcd, on the date stated above, at I 5^ 
(X M. The CAUSE OI' Dl-ATII was as follows: 

WOlA^ cvv^c ixJ uv<^A<^vVv<n \ 



nr RAT ION 



) 't'ijrs 



Months 



/hivs 



Hours 



C O N '1' R I li U r O R V U oXv^^^vvtv^/ jb XrOXt^ 



DIRATION Years Mouths 

(Signed) \> v v ^cwva^iCi-*^.. 

_^VvXLi ?> TQoM (Ad.ln-ss) To 



Davs 



Hours 
M.D. 



^Pe6iAL Information only (or Hospitals, Institutions, Translfnts, 



or Recent Residents, and persons dying away from home. 



i\j 



rin: aiiovk sTA'n-:i) rKKsoNAi, r\u tkti.aks aki: TRtK t<> rm-: 
iiKsr OK MY KNo\vi.):i)C.H AM) ina.iiu" 



[Informant 



(Address 






vI-cvnJt'I ni: 



Former or 
Usual Residence 

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



How lonq at 

Place of Death? Days 



ri.ACK OI- niKIAU OR KICMOVAI, j l>ATi:(>! HiKiAl. or KlIMOVAI, 

6\D. J..,...d'VvlvV' N<C Q 



rXDKRTAKKR 

(Addresj* 



i.i^n O^yvv^^^^x..^.! 



^- B- Every item of information should be cnrefully Huppliecl. AGE shoiiltl be stated EXACTLY. PHYSICIANS should 

state CAUSE OP DEATH in pinin terms, that it may be properly classified. The "Special information" for psr- 
snns dyin^ away from home should be &iven in every instance. 






y., . 




! I 



1 



il"l' 



m 




b 



i'»i 



r ' 



' t 



Jl<),ii<! •■' "' •'" 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

„- ,. s,. ,. »*^S*. H^-C, RCFER TO BACI. OP CERT.F.CATE FOR ,NSTRUCTION» 

Registered JVo. xOo 



/,./. AVW. LJL !? i^^O^ 

"L^vvvl ivtv^ti. Dep,u.ty...H.e.a.!.tb....Ofinccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of H)eatb 

( tl. S. StanDarD ) 



^ 



PLACE OF DEATH: — County of '"' tnf^.-*^^-^<>^ City of V.a 



c, 




c 




(No. 



St.; 



Dist; bet. i^^d 



w ,»«« ll«illAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL I N FOR M ATIO N " 'V 
( '^ rF"D;:TH'ScCU%;rD\;''rHo"s^PrT"AL O^'Tn^^u" "n G.VE .TS name .NSTEAD of STREET AND NUMBER. ) 



FULL NAME 




tXA<A> 



PERSONAL AND STATISTICAL PARTICULARS 



SI-.X 



V 1 JOyy^oJjL 



CDI.OK 



i)\;i'. oi- MIRTH 



lO.lwU 



l9.^t 



(Month) 



(Day) 



(Year) 



AC.K 



I O )V./»f vJ 



Moiilhs 



xs 



I hi » A 



MEDICAL CERTIFICATE OF DEATH 
DATE OP DKATH 




3 

(Day) 



(Year) 



I IIHRKBY CIvRTIP'V, That I attciKlcd jleccased from 

— to 



190 



190 



that I last saw h a live on ■ """ ...■■.. .nu.uu... . Lu i. i ...i . .i.. .. ■ ■ .. . 190 -^- 

aiid that deatl'. occurred, on the <late stated above, at 



\\ii)<>\vi:i) OK i>i\<)Kii':n 

(Writt ill st)oi»l (Ifsijf nation) 




lUKTinM.ACK 
(Stal<- or Coiintrv) 



FATllKR 



lURTHIM.ACK 
Ol- I-ATMHR 

(State or Coiintrv) 



A.1^^^\>^<X 



V 1 X^z-wv^'^v^^ 



\a/>\a. C'.cKvvvWAt 



vJXV^WMX' 



maii)i;n namk 
oi- M()Tni:R 



niRTllPLACK 
•H' MoTHKR 
(St.itc ,,r Counlrv) 






J] 



XVyvx-Ow-vv 



'"'''■'''■'■'"^ 0\^^ 



> 



Rrfidfd in San /'i ntnisr,) ^0 )'r,ris .y/iniffis /hivs 



Tin: AnovK sTATi;n pkr^^onai, i-ar iim. ars ark trtI': to riii" 

lU'.sr ()!■ MY KN<)\Vl.l<:i)C.K AND IM'.l.Il.K 



(I 



af(„mant [XrvyyjJL^^X O ^C^ V^xX^^ tXA>^ 



( XddresH 



1 \S '-Cvvirw ^^ 






- M. The CATSIv UV DI'ATII was as ^'o'Jyws : 



Dr RATION }'t'ars 

CONTRIBUTORY 



Months 



Days Hours 



DURATION 



Years 



Mouths 



Pavs 



f .Gl. (^ 



flours 
M.D. 



(SIGNED) 0,\J\. HL^OA/YnXM 

VA.iu:^ TooH (Address) L^OY^<iit^.i>. Uxl 

^PECi'aL Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from liome. 



Former or >*[ \t^ 

Usual Residence i ' ^ 

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



Vwrw nT 



How long at • (. 

Place of Death? La Days 



IM^.'XCE Ol" niRIAI, OR RHMOVAI, 



DATlCof lUKlAl. or RKMOVAI, 

b 190S 



l-NI.HRTAKHR % • J'- mVIO^Ow^^ U) 

^ I 1 Cy>V\,<L^ rVA J t 



f Addrt-ss 



N. B.- 



-F.very item oV hiformntSon should be cnrefully supplied. AfiB should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The * Special information for per- 
sons dyin^ away from home should be ||t<ven in svery instance. 






iN 



li 



I 



i 

11 



M' 



it 



^i 



< '- >i 



h\ 



WRITE PLAINLY WITH UNFADING INK 



„„^„,, „n,. ,.„i,-^KNo. ..l^t^^H&l'Co 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J^o. 




cy^r.^.f 



J)a/r Filed, f^^ ^ ^^^"^ 

DEPARTMENT OF luBLIC HEALTH=City and County of San Francisco 



Ccrtiffcate of H)catb 

( 13. S. StanOatO ) 



PLACE OF DEATH:-Coonty of O'^.^v vi;v<v>vcv«CcCity of* J^>v J>vCV>x^:a^i^ 



ti 






riM ?Nl\ij&->tl<,v^>vdL' (U»^. St.; ^5^ Dist.;bct. I 3. Ov and IH^il^ ) 

^NO. ^^ ^ UUOnr.V^VV-\.V.^VV WV . or«SIDFNCE GIVE r*CTS CALLED FOR UNDER "SPECIAL INFORMATION- A 

FULL NAME M/^t^u^ 1 J cm^^,^ 



sj:\ 



PERSONAL AND STATISTICAL PARTICULARS 



COI.OR 



lDiv.t. 



I)\ri', nl- lURTH 



lontli) 



I 

(Day) 



(Year) 



ACK 



bo JV.M5 fe. 



MoHlhs 



Da V.V 



M . L ■ ■'t 




SIN(,UK. MARHIi:!). 
WrDoVVKl) OK niVoRi'KI) 
(Writf ill scH-ial (U"iiy:nati»m) 



lUR'ruPI.AOK 
(State or Country^ 



NAMi: Ol- 
FATHKR 



niKl!lIM<AC'K 
<)I 1 AIHKR 
'State or Country^ 



MAIDKX NAMK 
OI- MOTHKR 



OnwcuLt 



BIRTHPLACK 
Ol- MoTJlKR 
(State or Countrv) 



OCCrPATTON 



"4i 



ci vcvc^'^^'^-^ 



1 



Rfsidfd in San /'lairr/sro O I )'fa>s 



.yfonths 



Pa If 



Tin-: ABOVE STATl-I) PKR^ONAI. P ART lOf I.ARS ARK TRIH To THH 
HKST OF MY KNO\VI,KI)('.K AND HKMKF 



(Informant 




(Address 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 




t:- 



H 

(Day) 



IpO \ 

(Year) 



I Hr:REBY CICRTIFY, That I attended deceased from 
AjiXf^ 190 S t(^ \A^ *^ ^9oH. 



that I last saw h ...Uv-voalive on JjA^lAA-t^ H 190H 

and that death occurred, on the date stated above, at X^S. 
(1 M The CAUSE OF DIvXTII was as follows: 

Q.Ar<r>r\v<x^c<4cw 



Lo^ 



'Cv/w<^'>^ax^ 



o|tL.. 



DTRATION % Years '^Months *" Days '^ours 
CONTRIBUTORY M-OrrV^^H/t^JL Uy\JL :vx.<*r*' Wi 



DURATION I Years Months Days 

Ytl'^vol^ lU.'UJ/ax^. 



(SIGNED) VTL'V^^JL^ 

H iQoH (Address) b Ob 



Hours 
M.D. 




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

How long at 

Place of Death? Days 



Former or 
Usual Residence 

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



ri^ACE^l; m RIAI., OR RKMOVAI, 

L>uv^^ 




HATH of IU'RIAI. or REM()VAI« 

lo 190S 



v\\\ ot IH'R 

1^ 



UNDERTAKER \>^ ^^ ^A\\jUy^t>\\\A^ b^ 



(Address .. 



(0 51 ^V)Xv. 



'^^cfim 



ix. 



N. B.—F.very item o? ln?orm«tion •houlcl be cnre?ully HuppIJed. AGE •hould be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The ' Special Information for psr- 
sons dyin^ aw9y from home should be ftiven In every instance. 



I 




I! 



,J 



I 

t 



r 



1 



,:,r<! . f n.:<Ul 



V KNo. i^-fe^^^H&I'Co 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

j,,r File,!, %A^ ? ^^^^ Registered A^o. 107 

DEPARTMENT OFPUBLIC HE ALTH=City and County of San Francisco 

Certificate of Death 

{ 13. S. 5tan5at& ) 

J) (^ A ^ 
ofG£V'vv-J>v!X'^vt^M.Gty of d-CWu -JA^Vn^t-l^ 



• '" 



rpft>. 



PLACE OF DEATH: — County 



St.; 



Dist.; bet. 



— ~ and 



) 



^CV/V'\XQ .C-^A> ''^^^"^'^X.... R^sTDENCECVETACTrc^ruCOrOR UNOER'SPEC.AL.NrORMAT.ON.\ 
( '« rr"o;toC-%rcV.;'*:"-Ho"s^rAt :^^:.°sfn.%^oTo^^:rr% name .NSTEAO O. STREET AND NUMBER. ; 



FULL NAME 




OL- 




ry.\. 



PERSONAL AND STATISTICAL PARTICULARS 



SEX 



OIIcAl 



COI.OR 



lllvvcbL 



DATK OF BIRTH 



AOK 






Vfat-s 



[ 

(Day) 



(Year) 



I Mtmms 3 ^«' 



SlNi.KK. MARKIKI). 



win* wKD OK nivoRiKi) a 

'Write in st>cial (lf«i)d:iinli<)n) "\ U 

^'^-vxcvlx 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




...3 

(Day) 



ipoH 

(Year) 



I HIiRRBY CKRTIFY, That I attended deceased from 





v'OL 3» 190 H to y 

that t last saw h .<^^^^Mlive on J'^'^^^^ ^ 



BIRTH PUACE 

(State or Conntrv^ 



AX-VA^nx 



NAMH OV 
PATH 1 IK 






*% 


.- — . — 


BIRTH TM. ACE 

or I ATin:R 

(Slate <)T Country 1 


« 




_^ 


l« 




MAIDEN NAME 
OF MOTHER 


•« 




niKTHPl.ACE 
OF- MOTHER 
(Slate or Country) 








•• 


- 



OCCUPATION 



Rrsidnl in Sav /'i arrisrn 



)Vtjt < 



I V, '/////> % />' 



ri'A 



THi: AHOVE STATED PERSONAL PAKTICrLAKS ARK TKIK To THK 
HEST OH MY KNOWUHIX.E AND I5EI.IEF 

(In forma 






(Address 



XS D (i 



L 190H 

X I90H- 

and that death occurred, on the date stated above, at 1 
Cl M. The CATS R OF DIvATII was as follows: 

rvo 



DURATION 
CONTRIBUTORY 



)ears 



Afonths^ Days iX^ours 

^^.i^^.'^^XL^^.^c^ 




DURATION }'ears Mouths I b Days 

( SIGNED ) ..\|()^ 

a iqoH (Address) X^ ^ J^ AXl^><>X<>Vi . .B'^ 



Hours 
M.D. 



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



Former or 
L'sudl Residence 

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



How long at 

f»lareof Oeatli? Days 



PLACE OK mKIAJ. OK RKMoVAI 



DATi;<.f HrKlAi- or REMOYAI, 

I90M 



UNDERTAKER ^ (H.<U^ yUOji IX-^uUl L^ 



(Address 



N. B.— Ever, item of InWmatlon .hould he careful.y supplied. AGB .Souid »>««i«ted EXACTLY »'"^8'CU:t ^r'^:;'*' 
•tate CAUSE OF DEATH In plain term., that It may be properly cla^sUicd. The 8pec.al Information for pr- 
son* dylnft away from home should be given in every instance. 




V, 



'i'^ 



i| 



^\ 



. I 



I 






I 



:| 



' 







WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H&rco 



100 H 



])(ilc Filed, l^-^-W ^ 

L,ww luMi Deputy Health Officer 



Registered JVo. 



108 



DEPARTMENT W PUBLIC HEALTH-City and County of San Francisco 



No. 



(Xcrtificate of Beatb 

PLACE OF DEATH:-County of Oa/>V J ^OAl^^^^^Gty of ^ ^ 

(On ' 



'^ ^ u - M t i St . H Disf bet. J O-AJUrv^v and JL/OAM^m. 

laH 1 ^^^ „^^^^^ Resi^NCEcivE Tacts c^LCO roR under 'special .NroRMAT.ON- ^ 

( '^ r."o;"AT°H^O^c"u%r;.rrHo"s^PrT"A ^R^f^^^^^T^O^N'^l/ETTl NAME INSTEAD O. STREET AND NUMBER. J 



OjW) Aa/VUCAA^<).. 



FULL NAME 




U) [XjJah^ 



PERSONAL AND STATISTICAL PARTICULARS 



sKX 







WW 



\i' I 



QVL 



CO I, OR 



lllL 



I»Ai J-: (»l UIKTU 



(MdHth) 



ACK 



45 



) Vfl » A 



(Day) 



M.mtfis 



/IS'l 

(Year) 



Davs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DP:ATH 

( Month V 




3 

(Day) 



(Year) 




REBY CKRTIFY, That I attended deceased from 

I looH to WJIm ^ 190 H 



SlXC.l.K. MARKIKD. 
WinoWKI) OR DIVORCKD 
(Write in MK'ial <U-si(fnali<)n) 




X. 



HIRTHPI.ACH 
(State or Country^ 



NWIK or 
FATIIKR 



RIRTHn.ACE 
or hATHKR 
(State or Conntry) 



MAIDKN NAMK 
OF MOTMKR 






1- 



(« 



K\ 



HIKTITPI.ACK 
01 MOTMKR 
(State or Country) 



OCCri'ATlON 



A^<Xa> 



Kryldrd in Sun /'i niii iwd 



) 'r'tr I « 



.\r.>„iii' 



lhl\S 



\l\ 



.U. 



THK AHOVK STA'n:i> 1'KRSONAI. I'AR'IUM I.ARS AKl", IRIl-: To TMH 
ni:ST OI- MY KNO\VI.i;i)<".K AM) in:MHK 



(Iiifornmnt 






( \fMres<< 



that f last saw h..V»x alive on ^^Jl^^ U Jlittl . 190 'i 
and that death occurred, on the date stated ahove, at b 
Q..M. The CAUSE OF DHATII was as follows: 



nr RAT I ON 

CONTRIBUTORY 



)o AA-feorVu.vV^^^vN^^ 



Years Months Days 

LAw'VvIXJL'Vvva./CU. 



Hours 



Months 



Days 



DURATION Years 

wVvvl) i U)-JLL5:>A. 



(Signed) 

S T90 S 



Hours 
M.D. 




(Address) 



Tb'H 



^FECIAL INFORMATION only for Hospitals, institutions. Transients, 
or^ccnt Residents, and persons dying away from Ijome. 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



I'l.ACK OF IJIRIAI. OR RHMOVAI. I DAT K of Mt kiAl. or RKMOVAI. 



INDICRTAKI 



(AthlreMH .ll{i.l....O <M:A.<X/V^%4^ 



V 1 r ^^ 

J o,AJ\^^jywx.^>M^ Ox. 



N. B.- 



-Bvcry Item of Info.n^atlon should b= carefully •uppl.ed. AGB should »>« «»«*«:; ^^'^.^^^^^.^l .^llItTon^'Vr*':: 're- 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The 8p«c.«l Information for psr- 
sons dylnft away from homo should be given In •\^ry Instance. 






,V. 



ill 



11 



I 



ir 



»l 



1^ r 
il 



I 



:(i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR IN STRUCTIONS 

Dale Filed , 



nlof ll.;.ltli-KNo. I«i 



H&I*Co 



•»«f t«it««*«*T*4*e**'** 



lOO'K 



1^ J LvKU Deputy Health Officer ^ 

DEPARTMENT W PUBLIC HEALTH=City and County of San Francisco 



. I 



' ■< 



PLACE OF DEATH: — County of J A^L-aKX. 



Certificate of Beatb 

( •a. S. Stan^arC> ) 
^ >^ Gty of I) VvoJU. Lxi. 



fNa 



. Ox. Dist * bet* *^^ 

.jj wrux/>"v^Ji^:^^^ 



) 



FULL NAME 




PERSONAL AND STATISTICAL PARTIC ULARS 

COI.OR^ 



^^" (^ ft 

DA! I. til HIRTH 



U).Lju 



Month) 



AC.K 



Is 



} 't'a » A 



(Day) 

MnulftS 



(Year) 



11 



/)rtij 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




y...^ 

(Day) 



igoH 

(Year) 



I HKRKBY CERTIFY, That I attetuled deceased from 

to 190 -:-:-^- 

l(p TTTTrr-. 



190 



SIN(.I.K. MAKRIKI) 
WIDoWKI) <»K DIVoKlKI) 
(Write in social «ksivrnation) 



HIKTMl'I.AOK 

St.ttf or I'ountrv) 



lo 



FAT in: R 



RlkTHIM.ACK 
0|- lATllKR 
(State or Country) 






vO'Vvrv:^' MLIUL' 



IL 



%• 



MAIDKN NAMK 
ni MoTHKR 



HIKTHPt.AOK 
«'»■ MOTHKR 
(State or Country) 



II 



It 



that I last saw h alive on 

and that death occnrred, on the date stated above, at - 
-- M. The C^\l'SH OP DEATH was as follows: 

C^v^r'vcwL 




DURATION Years 

CONTRIBUTORY 



.l/ofi//is Days 



Hours 



DURATION 
(SIGNED) 



Years 



HwLl5- iqoH (Address) 

Special information on 



Mofiths Days 

\j.,^^ \T^\/y\AX^sy>*. 



Hours 
M.D. 



oCCtl'ATlON 



%, 



Kr^idfd ill Siiu f'l (im hi'ii 



+ 



) 111 1 s 



Months 



Purs 



1111: MIOVK STATKI) I'KRSONAI. I'ARTIcrLARS ARK TKl K TO THK 

HKST OF MY kno\vm:i)<;k and hkiji:k 



'Informant 






(Address 



Special information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying a\vay from liome. 

Usual Residence .-...-.. Plate of Death ? Days 

Wlien was disease contracted, 

If not at place of death ? 



PI.ACK OF lURIAI. OR RKMoVAI. 



l)\ri;of Hi KIAI. or REMOVAL 

yu-lu. b ■■■■ T90H 



:ndkrtakkr \J . JvD y J Vu^v^vo^ AC U) 



I 
\M I 



E OF DEATH In plain tern... that It may he properly classified. The Special Inlormatlon lOP per 



N. B.^— Rvery item 

state CAUSE OF DEATH in p 

8on« dying away from home should be given in every instance. 








M 



fl^l 



|.^; 



^-, 






I'. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, „, „.,» .-KS-o...>g^H^-'0.. REFER TO B^CK OP CERTT.CATE TOR INSTRUCTIONS 

110 



!)((/(' FiJedf >U^ 

i 



I 



1 



100\ 



Rp^istered JVo. 



Jct\Mj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County oK^OjTJ 



Certificate of Beatb 

( "a. s. stan^at^ ) . -^ 

ofCjOL/ru JXxx/^^>x\a/;m) City of Uo/w A.<xavca^^c 



No. 



H3lb - R 



d 



St; 



Dist.; bet 



a 



uMtL. and oU-UXAVL^cr^-wd. . ) 



..cMiAi orcinrNrr nwc facts called for underA"special information" \ 
( '^ ,VD;AT°H"oc:u%reV.NTHo"s^rT'it o"r'?^^^'JV^o';'Vi;e7tI S^AME .nstead ofUtreet and number. ; 



FULL NAME 






\\ 




PERSONAL AND STATISTICAL PARTICULARS 



si:x 



DATH i)\- HIKTU 



COI.OR 



lOicfct 



(Mhtitli) 



I 



30 

(Day) 



(Year) 



A(".K 



Oi .)>,;».< "^^ Monl/m V nay,s 






i 



siNt.i.i*. maki<m:i) 

W 1 1 )< )\\ }•: I ) OK 1 ) I Vi » K r K I> 
(\Vrit« ill muial (lisijfnatioii) 



IUkTmM,\OK 
istati- or Country) 



NAM1-; <>1" 
FATUHR 



lURTHIM.ACK 
<)1" I-ATIIKR 
(Statf or Coiintry) 



MAIDHN NAMK 
ol MOTMKR 



RTRTTIPr.ArR 
<)|- MOTHKR 
(Slate or Coil lit rv) 




VvvNJX 



'CVavA.^C^V 






h,A 



O^y^jkt, 



OCCTTATION 



Rf 



,/,M n, S.,n /■>„>,. >sro 0^\ )'<" ^ X .\fn„ths k^ lhtv> 



IM1-: AIU)VE STA ri-.I> I'KK^ONAL 1* \ KIHT I.A KS AKl", rKll-: T< > THH 
HKST OK MY K:4j>\V1,1;:I)<-.H AND HKMKK 





(InfoMuant 



KX1>\V1,1;:D 

1 




f \(Mrcss 



SiHo - l'^ 



ti ^t 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 



(Monti 




t. 

Day) 



(Year) 



I HICRIU5V CMRTII'V, That I attended decfased from 

• ^[ - . 190 ~ to '90 """"' 

that I last saw h alive on 190 — 

and that death occurred, on the dale staled above, at ' 



"M. The CAl'SIC OI-' DlvATII was as follows: 



\}A^JL 



AO^V^ 




1)1' RAT ION )'cars 

CONTRIIU'TORV 



Mouths 



Days 



Hours 



DTRATION Years 



Mouths 



Days 



Hours 
M.D. 



(SIGNED) WUrrVl^ i iC, U3 JjJLcvvxH. 

\A,^ b TQoS ( A.ldress) I crV^xiM ^^-l^- 

SPECIAL INFORMATION only for Hospitals, InstitutionVTranslfnh, 

^^ ' ^" ^T _ . . a » _- - ,-. Cams llABMA 



or Recent Residents, and persons dying dway from home. 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



i.r,A<;iC,pi- ij^rRiAi, OR rhm«>v\i 




I NDKRTAKHR 

(A 



nXlHof ^URIAL or RKMOVAI, 

r 



190't 



.v^ 



.Mr.ss" 30>$ Cl^g^V^^.U^. 



M^.. 



..I Krr= <.Kr^,.l<l he HtRted EXACTLY. PHYSICIANS nhoiild 
N. B.— Every Item .W Informntlon should be carefully «uppl.ed. AGE f " ''* ^^ ^'"^'^^^ ..^^^^^^ Information" for p.r- 
state CAUSE OF DEATH In plnln terms, that it may be properly classified. The J>peclal into 
sons dyinft away from home should be feiven in every Instance. 



••' ) 



J 



1 .1 



I! 



W 



I ) 



li 



k 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„nnnl nf il<atth-» No .. TJ-^g^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



)« 



Registered J\^o. 



Ill 



luitc Vih-il, \^>y^ l» -'^^'^ 

\j^\.Kj^ cLsLvu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( Xa. S. StanDarD ) 

PLACE OF DEATH: — County of Oo^v A/CX/lv^\.vLCcCity of O tW.' vl VC/we^^ a<c 
'No Snli^VVC^^. nh St.; 1 Dist.; bet. oL/Xvyx^\^ and V UUX.'Vyv.u, 

ir OrATH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOB UnAeR "SPECIAL INFORMATION" ^ 1 



I Dist.;bct. oL/AaXx-T^aI) and yL<X:\A^A 

(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C t G I VE FACTS CALLED FOR UnAeR 'SPECl 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



Ni:\ 




•f 



\ '^ 






1^ 



;1- 




I 



^l^L 



COI.OR 



lLll.1. 



I>\II-; •)!•■ lUKTlI 



(m 



(Month) 



Ar.K 






1 




srxr.i.i.: 


MAKklKI) 




WIDOW!- 


1) OK 


1)IV( 


iRil 


•:i) 


1 Writf in 


social 


«k-sij.'niili< 


>n) 



) 'I'll t s 



V.' 



1 

(Pay) 



M.nilhs . 



(Year) 



ai 



Ai t .V 



L 




UIRTMIM.AOK 
'Staff or Country) 



NAMi: oi- 
FATHKR 



niRTMIM.ACK 
Ol- FATIIKR 
'Stritf or Country) 



MAIDKN NAMK 
Ol- MOTUKK 



nTRTIIPI.ACK 
<>l' WOTIIKR 
'Statf or Country) 






a 



ji^oJc-iXx^ c>.uJt<x 



r 



"t'OXA.i 



oocrpATiox 

h'r^i'iii'ii in Situ /'i iiiii isi'it 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(Day) 



(Year) 



I HRRRBY CKRTIFY, That I atteiided deceased from 

haaXvl 5: 190^ to ...y\aXaa^ 3. 190 1 

that I last saw h ..<V^>Xhvc on ^^OJL\.^ 5" 190 H 

and that death occurred, on the date stated above, at 1 13 
JT M. The CAUSIC OI" DICATII was as follows: 

^^A-f\jbkjt> 



,\J^CL Tv.OL'V^^V'Oy^-') 



DTRATION * Years "^ Monihs " Davs f -a Hours 
CONTRIBUTORY ^ - 



nrRATION Years Mouths Days Hours 

\). ^Xk^Ax M.D. 

(Address) IbOH ot^Jt^tm, Q% 



(Signed) 

:WCU. Cj 190 4 



^FECIAL INFORMATION only for Hospitals, Institutions, Transients, 

or'Rfcent Residents, and persons dying away from home. 



),-,/;> ) Months 



Xi 



/hi vs 



I II). AIlOVl-: STATi:i) J'KRSONAI, I'ART ICT I, A RS ARlv TKIK T<> IM Jv 
MKST OJ- MY tNo\VI.i:i)C.K AM) HHM1:F 

^ D ^^ } 



(Iiifniinjini 



<x 







(Xdclrcss 



Hn 



lu 



"wcw u 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



1M,ACK OI' IMRIAI, OR RKMOVAI, 




I)AIJ\of UlRlAL or RHMOVAI, 






(Address . 



N. B. 



ntlon .hould be cancfuMy Hupplled. AGE should ^r.rT'i:''''^^'^^] . ^^^^Jn'!;^. V."::!.^. 
^TH in pinin term., that it may be properly cl«««i?led. The Special Information for p.r- 



-Rvery item of inft>rm 
state CAUSE OF DEATH in p 
Hon* dyin4 oway from home should be j^iven in every instance 






fii , 



I f 






I 



*!?i|;i 



I 



:l! 

■ i 






•i 



r 



It 






\'i 



It,,;ii.l of Hi'nlth"»' 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. so . . *?"^!^ H^'t '' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

±12 




Registered J\^o, 



|;gll 



b lOO'A 

LL Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( tl. S. StanOarD ) 



PLACE OF DEATH: — County of 



^ 



£^^v vT'Va'^vcv^ CLtCity of ^ -"^CVAV ^ 



\(X^y\CKA.^t 



(ir Dt*TH 0( 
ir DCATH 



St 



Dist.: bet. and 



CCL)nS *WAV F 
OCCUBRCO I 



r.no USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
N A HOSPITAL Tr IN ST I TUT ION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



i]±.^s\WL 



'.X. 



4i. 



^»:\ 



PERSONAL AND STATISTICAL PAR TICUL ARS 

I COl.oR 



ii 

1 



OlUit 



LuAxvLw 



IiAli; n| IIIRTII 



AC.K 




k)5r,w»> U 



(Day) 



M,nilhs 



(Year) 



X\ 



Daxs 



sI\(.l,K. MAKKIKU. 



WIDnWKI) OK 1)IV<)KCKI> \ 
Wiitt ill MK-ii»1 tksivnation) 1 \\ i 



lUKTHPI.AOK 

I Stiitf or Country^ 



KATMKR 



lURTHIM.ACK 
»)K l-ATHKK 
(Stalf v,\ Country) 



Vjl^v-a' ^/^^X<.a 




OfYvj 



(?.cd 



i 



w<v»>> ^' 



Jxdldx^- 




trviX' 



J. 



,^ VVv CV 



MAIDKN NAMK 
')!• MOTHKR 



HTRTITPT.ACK 
•>l- MOTHKR 
(Stale or Country) 



tL^t.lUtl(S,Lcl 



vt 




OCCUPATION '<^ 



or 



a^ n /otv<x 



Krsidfd III Sdu /'i lint isri) 



) 'ill I . 



.\fnnOis I H /^"' 



Tin: AHOVK ST\T1- I) PKRSONAI. PA K l" ICT I, \KS A K l". I'Kl K TO Till-: 
1»KST OI- MY KNOWMCIX.K AND HI^MKK 



flnfornjant 






r\<l<lrcss 



\DM\.<rvu KoX 



fr 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



[ Montb)(T 



i? 

(Day) 



(Year) 



I HHRP^BY C1':RTIFY, That I attended (U'ceased from 

,v vut XH 190 S to 1^^^^ ^ ^'^ "^ 

tliatllastsawh^'^^aliveon ^JwU^ 5^ 190H 
an<l that death occurred, on the date state(i above, at IV 
d) M. The CAUSH OF DICATIl was as follows: 

L<\A,/CA^>"s--:tr>> VCX^ Q./Ctr» vcv^sJv 



nr RATION X Years "^ Months 

CONT R I PUTOR Y }l.CS'>^XJ^^^.\^^.'^^^^r\.^^ 



Days 



Hours 



DTRATION Years 

,,.G..Q\ 111 



' Mont /is r> Days 



(SIGNED) 



xL^s 



7) 



flours 
IVI.D. 



TQO 



( 



Ad.lress) 1l'1:^hV1<XCv|vcU.V>-.. 



FECIAL INFORMATION only for Hospitals, Institutions, Translfnts, 
or 'Recent Residents, and persons dying anay from home. 

^ HoH lonq at 

S- Place of Death? 



Former or 



I 



u;ua^ResidenceW>^Jl>vt^^-T^A^'- Wace'Jikath ? ll-.. Day? 

Whe*v^as disease contracted, (U ^ n . ,t * v>-Tv^rlL Ca^ 

If not at place of death? VDA^.^vVw^Trnv^ V^ 



PI.ACP: OF RIRIAU OR RKMOVAI, 



i)\Ti: oC HiKiAL or rf:movau 



INDKRl AKF:R 

(A(l<lress 






t T90H 



E OF DEATH In pinin terms, that it m»y be properly tiassmea. 1 



N. B. Every item 

state CAUSE _. 

«on« dying away from home shoulti be given in .xery instance. 



Ell II 




ill 



I 






'i 






(4 1 



Mm - 



1^ 



I I 



I : 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

_,.•:,, .^ ^^^rnvco REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

VOLu b 



113 



jUQi^ Jiegister'ed J^o. 

dLvLvuj Ia'VH Deputy Health.Offlcer 

DEPARTMENT OF VUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( ra. S. Stanear& ) 
PLACE OF DEATH -.-County oi^(X'^ -t rva^.cUCO City ofdo^ J.^-Oaa^V^^ 
M n'^S (?\n..OL>>t, St.; 5 Dist.;bet. S^i^ and 9A^>>Vtk.. 



FULL NAME 




V^lLi^laJvoA-^i, 



PERSONAL AND STATISTICAL PARTICULARS 



^i:x 



I) \\'\-'. «)!• lUKTM 



COI.OR 




\r< 



rVV^^K- 



iMotitM) 



m:v. 



)'i(n > 



5 

(Day) 



Months 



r \bX 

(Year) 



.lhi\. 



^I\r. l.i:. MARKIKH 
UIDnWI-in OK DIVokrKI) 
(Write in s<K'ial (Usij^tiation) 



lUK TMIM.AOK 

' "-tatf or (.'lunUry^ 



J AT 111. R 



HIKTHPUACK 
ni I-ATIIKR 
(St.'iu- or fouulry) 



MAIDKN NAMK 
«>!• MOTHKR 



V I /Pi /-V-N I v) 



L 



rgo \ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH (\ A 

:IaXci. 5 

,tonth) \\ jl>^^ 

I HIvKlUJV C1;RTIFY, That I attciKUd (Icccased from 

•to 190—— 

■rrrrr- I (p 



190 



-pTfnwiwmwtwiTrmwwT 



UtRTlIlM.ArK 
or MOTIIKK 
(Slatf or Country) 







) 'ra I .< 



A/,»/f/i' 



IhXV: 



OCCrPATlON 

Rfsiiird in Siiii /'i u n( ist'it ^ 

Tin-: AHovK STA ri:i) i'krsonai. i'\k iuii.ars aki; tkih to Tin-: 

IJKST Ol- MY KNOWM'.DC.K AND MKMKK 



(Tti forma lit 



KNOWM-.DC.K AND ",l:"''">,^ 



(Address . 



^ 



that I last saw h ^rrr^^alive on — 

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

— M. The CAUSP: OF DlvATII was as follows 



DV RAT ION )'cars 

CONTRinrTORY 



Mouths 



Days Hours 



DrRATION years 

(Signed ) ..o.,.r\,^rv>.v<x^ 



Mouths 



Davs 



Hours 



.^.Uy5 TQoH (.^.Idrrss) ^"^H 



<J. j3^n^'VvvOLAv M.D. 

1) alil^.vC^a. D.l 



FECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or^Reccnt Residents, and persons dying away from home. 

c ., „, How long at 

aV*.cr PlacclDcalhJ Days 

When was disease contracted, 

If not at place of deatfi ? 



DATi:of m KlAi. or KKMt)V.\Iv 

wvv^ b 190'i 



j.I.ACHOI' niRI.M, OR RKMOVAI. 

irNDHKTAKKR ^-^ ^ ^^^4^ ' ^^ 4' 

ii?ii vnxv^^^^^N. dl....., 






(Adtlrcss 



N. B. Rvery item o? in?ormBtlon •hould be carefully «uppnecl. AGE «''""''* J^* *j***%,^ •'Special ln?orm«lion" ?or p.r- 

state CAUSE OF DEATH In plain term,, that it may be properly class.Vied. »P 

Bon. dylna away from home should be ftiven in every instance. 



•frr'' 






p^ 



« 

it 



\ 






\\ 



\ 



'li; 



t 



m 



^1 



r ' ' t 



^j 



ill 



I, I . 



','1 , 




f ]| i 



i 



Ji.,,i!il "f H':il 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



til iVn i^-^ggj^H&l'Oo 



/)((/(' Filp<L 




190\ 



Registered JVo. 



114 



X^v^cA Xn/v^Y Deputy Health Officer 

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

Certificate of 2)eatb 

( "a. S. StanDarO ) 
FLACE OF DEATH:-Cou„ty of ^.CX^ .K<V.X^Gty ofC).a..v -1 XO^ev^C 



V. ir DEATH OCCUBRCO I* A HOSPITAL OR '" 



FULL NAME .C)AaL^.x)x.vc 




TAX 



SKX 



DATK t>F HI K I'll 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 



JXAVUxXt 



LU^vvw^ 



^ 



AOR 



(Month) '] 



) lit I 



1 



(Day) 



Months 



r 'V OH. 

(Year) 



3L5 



Prt VA 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DHATH /\ ft -, 




[Month) 



(Day) 



(Year) 




7R1:HV ClvRTIFV, That I atteti.le<l deceased from 

M •S'. 190 \ to ,. WIh S:. 190 S 




Hi- 



TC/3 



S 



SINC.l.K. MARKll'.I). 

\\ Il)t>\\ KD OR niVORCKD 

iWiittin soiial <Usijf"alion) 



lUR TMPI.AOK 
(Slate or Country) 



NAMV: <)|- 
FATHKR 



HIRTHIM.ACH 
Ol- l-ATin:R 
(Stalf «ir Country) 



MAIDKN NAMK 
OF MOTMKR 



nikTMiM.ArH 

<>»• MOTllKR 
(Stntr or Country) 



1 



^ II- 






that I last saw h t^^ alive on ^ ^^ 

a„d that death occurred, on the .late stated above, at I 0* 3yO 
(X M. The CAl'SH OF DI'iATll was as follows 

LxrTNy\rwCa.A^i 



<^r>v3 




I )r RATION " Vrars 
CONTRIHUTORY 



Monifis 



Days I Ilour^ 



/hns 



nCCri»ATION •■ 

Rfsiihd ill Sun !'i iiiii isr n 

THl- Amn-K STATKT) PHRSONAI, VA RT U T I.ARS ARK TRrH TO THH 
HHST OF MY KNOWI.HDC.K AND ina.lF.l' 



(Inf<irn>ant 




(Address 






Dt'RXTION Years Months Pays /lours 

(S.O.EO)l0vaL.-.'^.%0j..^..- M.D 

W du S looH ( Address) 1 ^ OH "ka xN^-^VvrrVttv P ^ 

ipECtAL INFORMATION only for Hospitals, Institutions, Transif nts, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



n ACE OF m-RIALOR RKMOVAI. 





I ndf:rtakkr 

(Adtlii-ss 







N. B.- 



' rr 77'F should be stated EXACTLY. PHYSICIANS «hould 

-Every Item off ln?orm«tlon .hould be carefully m.ppl.ed. ^Ob 8 j^j^j. The ^Special Information" for p.r- 

atate CAUSE OF DEATH In plain term., that It may '"^ P^^PJ*^ ^ 

aon. dying away from home should be given In every instance. 





I 



I I 



I ' 




I 

I?* 



\ 



%i 



):'• t 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIPICATg FOR INSTRUCTIONS 

„ - . -. Rc^iateved M'O' l.XD 

Dale Filed f. 



HoiU'l "T Hciiltlr I- 



So i.1>??S^'H/tlT 



, i.96^H Jiegisterea JMo. 

T^^^. dsji/v-u^ Deputy Health Officer 

DEPARTMENTOFTUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( Tl. S. Stan^arD ) 



PLACE OF DEATH-.-County of ^^^ ka->x-^.X Gty of^a^dAXX^e. 



I 



Dist.; bet. C^ mXX) 



,!). 



FULL NAME .'va.'YUU.V^v 



)X>lAj^ 



>i;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



QOlaL. 



iD.lvvU 



I)\TF. <)l* HI K I'll 



.1, 



\' 



10 ct 



(Month) 



(Uay) 



(Vear) 



A(.K 



(i-l 



) Vi; > 



^ 



Mouths 



rx 



Pit \s 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH , , ,, 



OMoiith) ( 




(Day) 



(Year) 



ThRRKBY CHRTIFY, That I atteiKlcl deceased from 

OkcxA; b 190:^' to Wki-.a 190 H 



% 



SIM.l.K. MARI<n:i). 

wii)<)\vi:i) OR DivMKrij) 

i\Viit« in 'iorial lU >ii/nation) 



lUKTin'l.AOK 
Statf or Country) 



NAMK OI- 

I ATIIKR 







niRTuri.Ai'K 

oi- JAIIIKR 
(Statf f)r Country) 



MAIDKN NAMly 
OF MOTHKR 



niRTHIM.ACK 
O!" MOTHKR 
(Sliitf or Count 




irk/>v % 



(y^iu\' 



(XVAVi 




^ 



tl,atIlastsawh:^>Valiveon. |v^>>^ ^^ ^OO H 

a„.l that death occurred, on the date stated above, at 
•^ M. The CAISIC Ol' DJCATll was as follows: 




.'U>-:*a*f«. 



.!ti.. 



DrRATHlN I Yrars ^ nfonihsX^ Pays 
CONTRIIUTTORY 



^)\a\ilvcL ot^O^vwxrt^c)- ^)X\\L 



avvm 



/).n. 



Former or 
tsual Residence 

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



How long at 
Place of Death ? 



% 



ri..\cK oi- HiKiAi. <iK ki:movai. 



OCCUPATION Qf>VW J^^^ ^ 

THK Am)VK STATKT) 1'HRSONAT. rARTIcri VRS ARi: TRTH TO TMH 

"— ^ tt 1 EXACTLY PHYSICIANS should 
N.B.— Every Iten, of Information .hould b. cnrefully «uppliecl. ^^f^^^J^.'^.^j^.^.V %h: "Specia; InformBtion" for pT- 
state CAUSE OF DEATH In pl«5n term., tha It n,»y ^e P^J^ 
•on. dylnft away from home should be ftWen m every instance. 



DURATION .rears .^A^W//. Pays 

(SIGNED) i).^. (S. Bcn>wv^ 

^ TooH (Addr>>ss-| L)&b OxvtUv 



pfAaL information only for Hospitals, Institutions. Transients, 



or Recent Residents, and persons dying away from home. 




Days 



DATKof IHKIAI. or RKMOVAI, 

* yvlvjL.l ■ 1 90I 



I NDKKTAKKU 

(Address 



J51 ^Sivtu-u At 



L 



n 



t -t: 





li 



II 



I! 



i: 



I 



1 



II 



» : J.i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„.,, ,1 ,,f Health 'F No. u -S-^g^^HftP Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I - 



i 



If. 



D/i/r Filed , 

t 



^vu^ 




_ lOO'i 

Deputy Health Officer 



Registei'ed ^^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. Stan&ar^ ) 






No. 



PLAO: OF DEATH: — County of ^^0./>\; J\a>\CL4<:t City of ^/CV^^"'^^^^^^-^ 
1 I ^^ "^ V LJ >x St.; I Dist.; bet. V) (KanJUu and Vl rWu>v 



( 



\F DEATH OCCOHS AWAY FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 

ITS NAME INSTEAD OF STRtET AND NUMBER. / 



IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE H 



FULL NAME 





D./U-.iAX.'Vx.* 



t 



s}:\ 



COI.OR 



lui 



vctc 



PERSONAL AND STATISTICAL PARTICULARS 

^ I 

DAT!-: «)»•■ ISIRTM ^ 

llcvq, r / 'It 3... 

iMoiit^lT (Day) (Year) 

AGK 

J. y Mtfnfks A^\ An.v 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



rears 



^IN<". I,K. MARKIKD. 

W IIXtWKD OK I>IVOKrKr> 

'Wiittin s(K-ial <U-sij^tiation) 



4 



J 






m\ 



'M 



^L'4 



niKTHPI.ACK 
State or Country) 



NAM1-: or 

I ATUKR 



lURTMPI.ACK 
Of l-ATMHR 
!Statf or Coiititjy 



MAIDKN NAMK 
OF MOTHKR 



HTRTIIPI.ACK 
<>»•• MOTHKR 
(Slate or Country) 



J C^ (1 




(Month) 



H 

(Day) 



(Year) 



HHRrCBY CIvRTIFV, That I attended deceased from 

r.VU.VVJL.Xl...l90.H to )iiuJL<^..H 190 H 

that 1 last saw h Xhj aHve on ^\aXw C?v 190 H 

and that dt-ath occurred, on the date stated above, at H 
V M. The CAUSIC OF DIvATIl was as follows: 

\jS A,t^A.OiA^ A) A:>JLVV'^t^«-'\ Vvo. CVVvvUXv t^tOljL/tL 

4>r^jXc^ctjL .."Vy.ouLt^ 

1)1' RAT ION •" )'t'ars * Months t Days - Hours 
CONTRIIU'TORY lA^.-....!^..:tXA.\\rA....t..^.\-LL^^v.V.S^ 



OCCVPATION 

Rrsidr.i in Son r>a>i,i\,;i • )>,;;> I C ^''tf/is .}J\ /^<m> 



DURATION 
(SIGNED) 



}'iUl>S 



Months 



Days 



^l^.'r TQoS (Address) ^ ^ (^ ^^ ^^ 



/fours 
M.D. 



Special information only for Hospitals, Institutions, TransieRts, 
or Recent Residents, and persons dyiny av^ay from home. 

Former or ^ /m '^^L \i ""^ '"?V* u, M 

Usual Residence 1^ ^ JM^tn v. > Place of Death? 1 



.l\JhU.{.vOays 



THl-. AHOVK ST\TFI) PFRSONAI. PARTIdl.ARS ARl-. TRCK To TMH 

hf:st t)i- MY kno\vi.i;i)<*.f: and ijkmicf 



^ Xfhlress 



-I 



l'\ JAXX^. o.' 



t 



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



PI.ACK OI- IHRIAI. t)R KKMi»VAI, I DATlvof UrKiAl- or RKMoYAI. 




t^W^^^-- 




..b.. 



rSDKRTAKKR 

(Address 






190H 



ME.. 




\HL 



N. B.—Bvery Item of Information .hould be carefully supplied. AGE nhould be stated F^XACTLY PHY8ICIAN8 should 
state CAUSE OF DEATH In plain term., that it may be properly clarified. The Special Information for per- 
sons dyin^ away from home should be fiven in every instance. 





V. 



I! 



M 






P 



i 







w^' 



>'• 



It'j 



•\ 



M. 
U1 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i^tJffi^, H&l' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



„,,,,.! -f II.Mlth-K No. !^ T?'t:2R?5» 




IfJO'i 



Registerecl J\^o. 



XjLi 



^ 



l)((le Filed , 

3cM.vv^ cUlA^M Deputy Health Officer 

DEPARTMENT OFrUBLIC HEALTH=City and County of San Francisco 



No. 



PLACE OF DEATH: — County 

/ \r OtATH OCCURS hW*V FROM USUAL 



Certificate of Death 

( H. S. StanDarO ) 

of C a'^X' ^CV>VCC4 C{i City of C' O^V \.a^>Vll\A/C-C» 



St.; 



Dist.; bet. 



and 



( 



RESIDENCE GIVE FA 

IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIV 



FULL NAME 



■ACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
E ITS NAME INSTEAD OF STREET AND NUMBER. / 



JLhAr...Axv. J..O...U 



PERSONAL AND STATISTICAL PARTICULARS 



sj;x 



^oh 



COI.OR 



i)\ri: «>!• lURTH 



\<;k 



'Ol 



(Month) 



13 /.U-k..... 

(Day) (Yfiir) 



tl yra,s ......1. 



Miiiilhs .. 



13 



Davs 



^IN'.l.K. MARK IK I). 
WIDOWKI) OR DIVORCKO 
'\\iittiii social <lcsiKUatit»n) 



HIRTHIM.ACK 
'Slatf or Coiintrv) 



I A'l IIHR 



I'.IRTMI'l.AcK 
<>l I'ATIIKR 
"^t;itc- or Country) 



MAIDKN NA^NtK 
Ol- MOTIIKR 



lURTHn.ACK 
<)|- M(»THKR 
(Statf or Country t 



OCCI'PATION < 



^ 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DHATH 




(Month 



h 

(Day) 



190 1 
(Year) 



I UKRKBY CIvRTIFV, That I attended deceased from 

\i.^\JLu.,. .H 190H to ..^Wa-.!Ul..."1 I90-4 

that I last saw h •<^^'>^^alive on jK^ ^ 190'^ 

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

U. M- The CAl'Slv OF Dl<:ATn was as follows: 

IaA^^TW/V:^ M\x,\.\i:NA<A^U.^ 



tl: 



DTRATION Years'^ Afonlhs Days 



/Fours 



CONTRIBUTORY 







^ 



O 



iy. 



DURATION Years Months Pays Hours 

(SIGNED) U) t^-MCH^^ M.D. 

ivdul lc,oH (Address) R 0.1 OfHaH^Ltt. Vll 



XVTl<X 



f^rsidfif in Snti f'l a nrisro J. )*/'(M\ 



.y/n„f/i.^ 



na\: 



THH AnoVK STATKn PHRSONAI, I'ARTlcn.ARS A R 1'. TR T H T< ) TM1-: 
1U;ST OF MY KNOWIJ'.IX.F: AM) BHIJllF 



(Infotniant 



U)^.v<x% 



C 



(Address t I O KX^^V<V\AAJ?^\1^ ^ 



^ 



i 



PECi'lAL INFORMATION only for Hospitals, InsHtufions, Transients, 
or^Rccent Residents, and persons dyiny anay froiu home. 



Former or 
Usual Residence 



-^jvL^. tcJl "•*'""'" '- 



n 



nuw luim m (j 

Plare of Deatli? 1 Days 

WlipKS»as disease contracted, ' "^ ► i s iwi , ' I n L 

If not at place of deatti? v).^;VA^^^V WOA.. 

PI \CF OI- niRIAl, OR RHMOVAI. I DATF of Hi^kiai. or RKMOVAI. 
l-NDHRTAKKR VJ J^^T^O^ OVV .. 



(Address 



N. B._Ever. ,te„, „. l„for„,«t,o„ .houU. he cnrefuHy -upp.led. AGB should ^« 7-:^^^ .^fj^^^^; .rr.u'o'^'lr *;:!." 
•tate CAUSE OF DEATH In plnJn term,, that It m«y he properly class.^ecl. The Special Iniormslion for p«r 
«on« dyJnft away ffrom homo Nhmild be ftiven in evory Instance. 



:f 



I! 



lit 



I 



) 



'^\ 



\ 



I ill 



\ 

t 



il'' 






n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,„„,.i ,1, ,ltl, I No ,.1^CS^»«"^''''> „___^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(//(' Fih'fl f 




lf)0^ 



Bc^isfcj'ed JSi^o. 



118 



^1 



Deputy Heafth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "a. S. Stan^arD ) 

SI m i (3j . 

PLACE OF DEATH: — County of H aX^x) J X(V>vtui^^ City of O /0^/>V \/VvvCv(Mr<i 



^Ng 



.3t 




a>v\yi (lb CHI 



\'VAwl<xl' 



St 



Dist.; bet. and 



) 



/ ir Ot*-^^ OCCURS *vIaV rROM USUAL RES IDENCE GIVt facts called for UNDtR "SPtCIAL INFORMATION- \ 
( IFobiTHOCcjRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



^ 



ItvmkLvu. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR \ 



Oric^L 



JJM^kXjl 



I 




y\A^^\> 



MEDICAL CERTIFICATE OF DEATH 

datp: oi" i)i:ATn 



i>\'ii-: «)i itiK rii 



AC.K 



V(TU\Xciv» 



iMoiitli) 



(Day) 



(Year) 



SH 



) lit I s 



Mniilliy 



I i An 



^IN'.I.K. MARKIKI), 
\VllM>\yi:i> OK DIVORTKI) 

|\\iit(. in MK'ial dcsiv^nation) 



r.iKTm'i.Aoi.: 

(Stiitf or Country' 



NAMK Ol 
IATin:R 



*i) 



O.f. 



iVA^^ 



HIRTMPT.ACE 
Of lATHKR 
iStati- or Country) 



Ol" MOTIIKR 



HIRTHPLACK 
<>»• MOTIIKR 
(Statf or (.'ountryl 






d 



IVAV^C^V 



AV^'^-^'"^^ 



raioiiih) rt 



(Day) 



(Year) 



I HI'iKlvHY CIvRTII<^V, Tliat I a UeiuU'd deceased from 



that I last saw h-CV>\alive oti 



^ 



Iqo4 



Of S^ OLA 

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

CL- M. The CAl'SI-: ()!• DICATIl was as follows: 

iX^CA^wtt. /iJ AJLoLtrtXe-<r>x ^ flb^OAl 



M 



•» 



OCCI'PATION '^ 



It 
Ri'sidrd III Situ /'i aiii isri> ,' •' )<■(/(> 



^J\JL/W^s,y^^V\, 



^r,uif//s 



n,i\ 



DURATION )'cats Months Days Hours 

C(^NTR I lU'TOR Y ab.A^^vV-ft^Vai-N.cAr.x:\\XA-VfVv v^^^^ 

US A.,rvv<iXvwXxJL IX^vv^-vvO. 

1)1' RATION Years Monf/is '0 /hiys Hours 

(SIGNED) Lbct? vvvh- M ^ ih!^ vlA^^tAa M.D. 

^v ltyS^ ,ooM (Add re ss) dt QOXqW 7W^f^> 

'CIAL INFORMATION only for Hospitals, Inslinjtions, Transients, 



iPECI 



or Recent Residents, and persons dying away from liome. 



Days 



■IMlv AHOVK STATKD PKRSONAK 1' XRTICIKAKS ARK TRlK T' ) III! 

HivST Ol- MY KNOW i,i:dc.k AND in:i,n:K 

(Informant \JOoL\A; V> ytH V>V<t.Cr"iV' 



z 



Wfien was disease ronfrarted, 
If not at plareof deatli? 



ri.ACK Ol- lURI\L.t)R R1-:M<>V\I. I DATl'lof Hi kiai. or RI:M0VAI, 



twl^i* ckacvn-x 



rNDKRTAKKR CHT M a{l<U VU W (B \ita\t^' ^^^ D 
(Ad.lrt-ss U 1 I M^Vw4.CrkV.. U.t... 



N. B.-lBvery Iten, oi information .houhl be cn.oUUy Huppllecl. AGB should »>« «\«^«;1^»^''^.^^CT'7; , ^"^^J.^Lt^,!:^!:!.** 
•tate CAUSE OP DEATH In plain terms, that it may be properly classified. The Special Information for p.r- 
Ronn dyinft away from home should be ftlven in every Instance. 



I .'. 



IM 



!l 



I ; 



I 



11 



I 



Mil 



't I 



"'I '■ 



ill 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.,,„,,,„„-..■ NO. ..tC^^H&l- CO BtFER TO BACK OF CER TIFICATE FOR INSTRUCTIONS 




190^ ' RcgisteTed J\fo. 

\jy\jj^ IxoKUL Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( H. S. Stan^arO ) 



PLACE OF DEATH: — County ofOo\^ J ^a/\v^ULC^ City o{^-'0^^y\) 



No. 



ti 



lib Vl^^a'>■V'^va. v\^ St.; M Dist.;bct. io U\^ __ and 

~-... iieiiAi or Qinr nce: civE facts called for under special informat 
" rr"o»T«"ccc"u%*-ro',"r-os^Pa*l: o%"~"?u" «"a,v "ri NAME ,«te.o or st.«t .~o nu-b. 



1 il. 



( 



ION' 
R. 



) 



FULL NAME 



lx\t\ 



K. 




a. 




.'A.rv-U. 



i^.. 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 



DATK (»F HIKTU 



COI,OR 



lu,Ltc 






(Day) 



(Year) 



AC.R 



)'(•</>.> 



Mouths 



.l_l /?<n. 



'^IN<".l,K. MARKIKI). 

W ri)U\VKI) OR DIVOKCHI) 

'Wiitfiti schihI ilfvi^natioji) 



HIKTU IM.ACK 
iStatf or Country) 



NAMK or 
FATin.K 



RIRTHPI.ACK 
OK FATHKK 
(Stall- »)r C<)\iiJtrv) 



MAinKN NAMK 






t 






*^a>vtl 



M I loJk{nvlu. 



^Ji 



ol- MOTHKR -^ 1 






VtVvvsJ^ 




inRrniM.ACK 

oi- MOTIIKR 
(State (ir Countrv) 



OCCUPATION 



^' 0\i 



.ci.\JLLoL' 



1 



Rfsidrii 111 Sim f'l iini ism 



Vmrs 






.k\\ 



MEDICAL CERTIFICATE OF DEATH 




(Day) 



(Year) 




tended deceased from 

H T90 H 

H^ 190 S 



I HRRKBY CHRTIFY, Tha 

>kvv^ 190 M to 

that I last saw h »^*>-' alive on ^V\-A»cjl 
and that death occurred, on the date stated above, at 
M. The CArSH OF I) i: AT II was as follows: 

,C^.rv:vo^.'!^^A.A.Lvtr-i \. 



DURATION years Months Days Hours 







Months 



Days 



Hours 
M.D. 



DURATION A Years 

(SIGNED) ."yjAaUviA^ 

iv du S TQoN (Address) ^V U frVN^^ii . D ^ 

■dlAL INFORMATION only for Hospitals, Institutions, Transients. 



PE 



or Reeent Residents, and persons dying away from fiome. 



M.,>ifhf 



/)<M> 



Tin-: ABOVE STATK.n PFRSONAI. PARTICri.ARS ARK TRl K To TlIK 
HKST OF MY KNO\Vl.i:i)(*,K AND H K I.I HK 



(Informant 



(A<l<lrcss .. 






Tib 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Davs 



IM ACH UI" lURIAL ok RHMOVAI, 




DATliof IV KiAi. or RKMOVAI. 

b T90H 




l-NI)KRTAKKR^ J , klUTtUA^ oD ^U. VKA. 



(Address 



N. B._B.eny ,te. o. information .hou.d be c»refu... supplied. AGE should ^?^^^;'-'^^!^^J^^,;^, .n^oVnfa^To^n^' Vr'^Tr". 
state CAUSE OF DEATH In plain term*, that it may be properly classified. The Special Information o ps 
sons dying away from home should be given in avery instance. 



\ 




J 




■ « 



:'1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






$ 



t t 




190^ 



/)(f/r Filed , 

d^crvcv^ cLtana Deputy Health Officer 



RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

120 



Registered J\^o, 



DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco 



No. 



ft I 



*i{ 



Certificate of Beatb 

( "CI. S. StanDarD ) 

SI ^ i ^ 

PLACE OF DEATH: — County ofOaAV J ^^X-WCU^^* City of ^^^ a;uvvvt^-^C^, 

VtO%atv^4' St.; ^"^ Dist.jbet.WxUtt'v and -^-tUnvVv.: 

X ••cMiKi DC-einrNrr r-iwr FACTS CALLED FOR UNDER ' SPECIAL INFORMATION"' \ 

( '^ rF"DrAX°Hnc:u%rD\;THo"s^rAt O^R^N^T^^^T^NVlvr.;! "aME .NSTEAD of STREET AND NUMBER. ) 



FULL NAME 




trWi^^c^^x 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,()R ^ 






llllut. 



n.\Tl-: OI- lURTH 






(Day) 



(Year) 



\«.K 



..,.2»0 ) •<•«/»> 1 I 

SINC.I.K. MARKIKl). rt 

\Vn)«)\VKn OK DIVOKCKI) \) 

(Write in social (Usiniialion) ^-K 



Months 



Da V, 



lURTHPUArH 
(State or Country) 







I ATIIHR 



HIRTHI'I.ACK 

oi- fathi:r 

(Statf or Country) 



i 

v 




trVvu.(j>x 





/OlA'V 



.ci.PAi.oN ;4,v.Jtx>v CrltlvO. ^(V'L. ^^ >>--^v^ 

TH)-, \HOVK, STATI*.!) I'KKSONAI, PAR llCf l.A RS A K 1-, IRt I". K ' 11", 
ItKST Ol- MY KN<)\VJJ:I)(".K AM) 15KI.IHK 



MAIDKN NAME 
•»!• MOTHKR 



r.TK.rnpi.AC}-: 

<>»•■ MOTHKR 
(Slate or Country) 



OCCl 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATFi 




(Day) 



(Yt-ar) 



I HEREBY CI^RTII'V, Thai I a^U'tuU-.l dcceasea from 

iX^Vvvi^a lyo'i to Wt^*^ 190 S 

thatllastsawli-^'.'ilivcoM ^^^^ ^ ^'^^ 

and that death occurred, on the (htte stated above, at b vS Ci 
...U. M. The CAl'SI*: OF DICATIl was as follows: 



DT RATION 



(Infomianl 



^^VLo. 



(Afldrt'ss 



lb ou^sM^ i .JLh-s 



I, 



'/CU^ut^ 



^1 



)'('ars ' j\/o////is'i Days " Honrs 

CONTRIIU'TORY L^'^VCA>.La^^ J^^ 

DT RATION ^ Vrars " Mont ha -^ Days '^ Hours 

(Signed) "^ .. \.J <v^amLvc<^ M.D. 

ia.u '. ,.pH (Address) lll^l)^>^^^^^^ 
Special information «nly '"'' Hospltdls, institutions, Iranslfnls, 



or Rftcnl Htsidrnts, and persons dying away froni home. 



Former or 
llsudi Rfsidenff 

When Has disease contracted, 
If not at place ol death? 



How lonq at 
Place of Death ? 



Days 



V\ \C1- Ol- lURIALoR KKMOVAI. I DATKof lURlAI. or KKMOVAl, 




,>VV^-^' 



y nui vCt\^ 



1, 



T90H 



/>xoX' "^v^Lo 



(Adilrt'ss 



ibi (Yyi\A.'«,A,^> "^^ 






• f i ArP .KnnlH ha ntntetl BXACTLY. PHYSICIANS dhouid 
N. B.— Bvery Item of Information .houM h. crcfuHy -pnlled ^^^J;;^;^;;',,^^^^^^^ .^Special Informallon" for pT- 

state CAUSE OF DEATH In pliiJn term., that It miiy be properly wiasBitiea. 
«nn« dylnft away from home Hhould be ftlven In overy Instance. 




I- ! 




H 



\\\ 



I I 



, ! 




I' 



* 



il 




i 








f ' 





«l 




fll 



>. 




^w 



I. 



( 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

121 



„,„,,i ,.f n.-:.lth-K No, ,. t>>gggS4-.nS:fCo 



Jhffr File<h ^iWUwA b 




H-W^ 



<u 



fV-U 



loo'i 

Deputy Health Oflflcer 



Registered */Vo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



PLACE OF DEATH: — County 

11 10 «L'x>v-v^OL<:Lilvc 



Certificate of 2)eatb 

of C' OL.>v G A.a'^vCAA OO City of CJ XX^v 0X/X->v-tv4. "- c 



Q^ 



<^ 



St.: I Dist.;bet. Ulllu. and OaVuK ) 



f ir DfATH OCCURS *w*y trom usual residence give facts 

V IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 



St.; bet. V^^l^u, 

TS CALLED FOR UNDtffc "SPECIAL INFORMATION' \ 
TS NAME INSTEAD 6k STREET AND NUMBER. J 




PERSONAL AND STATISTICAL PARTICULARS 



SKX (5> 



vJ JlA"WoJ!jL 



COI.OR 




^ixv 



t^. 



DATK ()!• HIRTII 



Q^u 



>v 



iMonth) 



(Day) 



(Year) 



.AC.K 



b5 



) ■/•(/ » . 



Mnnths 



J...1. 



/>rtiv 



StNC.l.R. MARKIi:i) 
\VI1><»\VKI> OR niVOKiKI) 
iWrittin M>cial <K •^i^nation) 



niRTMPI.ACK 
(Slate or Comiiry) 




NAM)-: <)!•' 
lATHK.R 



lURTHPLACK 
OI- I'ATHKR 
tStatt or Country) 



MAIDHN XAMK 
OK MOTHl-.R 









n 



X^-VATW 



lURTIll'I.ArK 
oj- MOTIIKR 
(State or Country) 



«< 



OCCUPATION •- ^ •- 



1 A. /////- 



/>>M 



THK AnoVK ST ATI". I) I'KRSoNAI. I' A RTlcM^ I, A KS ARI", T K T l". To Till-: 

iiKsT oi- MY KNo\vi.i:i)c.K AND i?i:mi:f 



{Informant 



,Ow/>\J 



JUx^^"V4XLdx>uC) ot 



r\f1(lrcss 





MEDICAL CERTIFICATE OF DEATH 



DATE OF I)K 



CATH A I 

N^AjJLu 

/Month)/! 



■■*. 

(Day) 



(Year) 



r HRRRRY CHRTIFY, That I aUeinled deceased from 

Clf>V^ IS 190 H to ^ W^ "^ ^90 H 

that I last saw h JiSj alive on V^^H^ ^ '^^ '^ 

and that death occurre*!, on the date- stated above, at o 
.1 M. The CArSI<: OF I)l':ATn was as follows: 



± 




JU\- 



...a.-L<v:^JU....\A).X'OL.k.-v w^L^'i. 



nr RAT ION ^ Vcars I Hi Months /hus ' Hours 
CONTRIIR'TORY ' 



^fouths 



I\iys 



Hours 



DURATION Ur(^'"'^ ^ 

(SIGNED) JIvLO VrwC.y\X\^'i M.D. 



1\aJL(j Io i()oH 



M V i()0^ 
cPaL INFORI 



^PEC»'AL INFORMATIO 

or Recent Residents, and persons dying anay Irom Home 



( A<ldress) 0\0^^ 'y\)^M^,^M..'y^. 
1 ATI ON "nly 'or Hospital^, Institutions, transients, 



Former or 
Usual Residence 

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



How jonq at 

Place of Death? Days 



PLACK OP lURIAL OR KP:M0V\I, 

% <JlA."Lt<k^<. Co 





rNDKRTAKPlR 

{.•\»l'lres< 



HHb 



IN. B.- 



. ,7^, .p.B -hoiiltl be stated EXACTLY. PHYSICIANS should 

-Kvery Item o? Informntion •hould be c«reVuIly supplied. '}^J: '^^^/^'^^.^j^j. yhe "Special Information" for per- 
state CAUSE OF DEATH in plain terms, that it may be properly dassitiea. 
sons dylnft away from home should be given in every instance. 




I! 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„,,„, , , „..H h^KNo...^^:i^-H^PCo REFER TO BACK O F CERTIFICATE FOR INSTRUCTIONS 



Ddfc Filed f 

4 




1 



VJO'\ 



Registered J\^o. 



3^^^v^LA^ "Ijl/v-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtiffcate of Death 

( 'U. S. StanCat? ) 

J? W -"^ "^ 

PLACE OF DEATH: — County ofO^J^ov JAXVtvc^^^ City of Okxav XxXoM^UlyC-C 






Na JaJL/ 




illvvJ- 



and 



vCTu 0\:)O-;UVvJ^<>wV St.; — — Dist.;bct. ;; ■ ano 

vw I V ^. >r V --^ ,,eii»l BF«5inrNCE GIVE FACTS CALLED FOR UNDTR SPECIAL INFORMATION • ^ 

( '^ .VrE^T^H'^OcJjir.V.^rHo's^VT*.^ 0^"n ^^^"o^N ^C IvY Ts NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




■U^: 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



COU^R 



Vuld^. 



DAI'l-: »)!•• lUKTII 



.\<.K 



iMontli) 



(Day) 



(Year) 



I I )><M.v 



•^ .y/uuf/is * /^rt vs 



^I\<".1,K, MARUIl-:!). 
WFDoWKD UK DIVORCKO 
'Write in stx^ial <lesiv:"ati<)ii) 




H H 



niKTHl'I.AOK 

Stiiti' or Coutitry^ 



NAMi; Ol- 
FATHKR 



lURTnn.ACK 
<)|- l-ArilKR 
(Statf or Country) 



MAIDKN NAMK 
<>»• MOTIIKR 






lATy^ 



x^rv-vnv 



M 



lURTiirr.At^K 

Ol' MoTUHR 
(StMte or Country) 






)V(7;a " yfiinths 



Par 



OCCrPATlON 

A'rsi(ff(f ill SijH /'i oiii ism ^^^^^^^__^_^^__^^ 

TH}-. AHOVK STA'n;i) I'KRSONAI, I'AR licr LARS AKl- TKlH T<> »"•»»'* 
BKST OF MY KNONVUHIX.K AND MKMKF 






(Address 



Cd. 



\ 




.(y\x/yx. 



MEDICAL CERTIFICATE OF DEATH 



CATH . . 

>aaXu. 



n- 



igo . 

(Year) 



DATE OF DK. 

/I (MontiiA <"«y^ _ 

vKlvBY CIvRTIFV, That I aUcii(lc«l (lercased from 

.._ X 190 H to JW H 190 H 

dt I las? saw h ...-^^^ilivc on V^^'^ "^ ^^o H 



190 "\ to, 

th^t I lasl saw h .'^►^^ilivc on 

and that (k'ath occurred, on the I'latc sta'tcd above, at 
ex. M. The CArSJ<: ()I< DICATII was as follows 

Q^ A/^'>vt^lA^ vy/vvJU..v<^>^<?^^-wcc 



nr RAT ION ^ ^''''''-^n ' -Vc^/zMi 
CONTRIHUTORY (£) Xa-c^IuXu 



\ Days ■:K /fours 



nr RAT ION 

(SIGNED) 

b IC)0S 



•^ }'((us ^ ^^ouths ^ Pays * Hours 

M.D. 




( 



wPECIAL INFORMAT 

or Recent Residents, and persons dying away from home 



Address) b^^ ^XxlLu O^ 
XTION only for Hospitals, Instiluffins, Transients, 



e\U^iAA\X\/vtU. Wt 



Former or 
Usual Residence' 

When was disease l/onfracted, 
If not at place of death? 



How long at 
Place of Death ? 



^ 

.^., 



Days 



pi.ACEiiF; nrRiAF, or rhmovai. 



OAl'tof m-KiAr. or RKNK'NAl, 

...a... T90S 



50 5 C\Uc^vt<vu. IvIa.^ 



l-NDHRTAKKR ' HvJU^yiJ O U 



^€L^X> 



(Address 



xt 



F OF DEATH :n plain term*, that it may l»c properly <.ia8»iiieu. 



N. B. Kvery item 

state CAUSE OF DEATH :n p 

«on« dylnft away from home should be ftlven in every instance. 



V 





I 



• t 



H 



fl* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



It,,, tl ,.f ll.:.lt1i--l- No 1=. -^^S^^ nf^iV Co 




/)((/(> Filed , 




190\ 



REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 



Re^i^tci'cd J\^o, 



100 



dU^VW/i cLlA>M 



Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Cettificate of 2)catb 

( "U. S. StanDar^ ) 



PLACE OF DEATH: — County ofOa^v .T\a^v^v<l^c City of na'>v J;va->vt^«-^t. 







No. rct^^^vUJ- 



Kcv-L^^-^-^ C.)a/>\al 



^>\altA-u.L^A\ St.; 



Dist.; bet. 



"^ and 



) 



J. I 



b 



»., 



I 'I 



vvj 1 w w-w >^ M >... » >-.. .-,^ . . . — ,,«. DC-cirkriurrriur F*CTS CALLED FOB UNDER "SPECIAL IN FORM AT ION" ^ 

( '^ ^ro\\.v%ir.::^o\T.'*.o^'!.\'i o^"Ns^^^"o^N"o.;E74 nVme .nstead or stree^ and number, j 



FULL NAME 





PERSONAL AND STATISTICAL PARTICULARS 
SK\ <.AA ft I COI.OR 






loivou 



DATl-: or HIKTM 



a(;r 



'i) 






1 I) )V,„.v 



(Day) 



.1/,.»////' 



(Year) 



13 



A/ 1 A 



si\<-.i.K. MAKun:i) 

U !I)<)\Vi:i) OK DIVoKii:!) 

•Wiitriii sorial (ltsi),rnati<»n) 



IMKTUVM.AOK 
(State or Country^ 




U X\/"v^ VOL > wv- 



»'atmi;r 



HIKTUPUACK 
OI" l-ATHKK 
(Statf or Country) 



vjA^^dl Vb 






vAv<:i/ivo^v<b 



MAIDKN NAMK 

•M- MOTIIKR 



lUKTlTlM.ACl-: 
<>»•■ MOTJllvR 
(Statf or Cottntry> 



luJ(^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII 




(Moiitli 



(Day) 



190 1 

(Year) 



I nivUi:HY CMRTIFV, Tliat I altemkHl deceased from 

mixci as 190H to aW^ -^ '^"^ 

that I last slw h.^^!. alive oti ^ (^ '^ ''^ "^ 

and that death occurred, 011 the (hite stated above, at 1 ^ oO 
OL. M. The CAT SIC Ol- DICATH was as folhnvs: 



oi- cvVvJ' 



DT RATION Years 

CONTRIHUTORY 



Months 



Pars 



HoHt s 



Hours 



'^vcrv^rvv 



_ ll/rJk/" 

OCCrPATlON (j^XeS^iL^L 

KV<iiir<f in Situ I'j niii i'^i'n "^ ? ^iM > 



>X^^-W-v>. 



\/,,„ffi^ 



... lhi\ 



Tm-: AHOVK STATi:n PKUSOWI, I'AK rKMI.AKS AK1-: TKIK TO THK 

mcsT OF MY knowmcdof: AM) iu:mf:f 



Inf.nmant M l\\^ X\, \ % \U. Ui><.A.A,l 



(A.M 



rt'ss 



Sl'Xl'l^tlx, Ot 



Dl'RATION Years Motilhs Pays 

(SIGNED) C>d.0U^O UX > v^jL^..^ >vi M.D 

lu S lon'l (Ad.lress) OtcvV^' 1k^^^ ^Ji^C 

^ _ £^IAL INFORMATION on'y '"^ Hospildls, Inslitull^ns, Transients, 
orTccent Residents, and persons dying Hway front home. 

WheH^vas disease contracted, o'A/^l .iQ n^ "^^ 

If not at place of death ? a^ ^^ ' * 




Days 



I'I^ACF: oi* IUKIAI. ok KliMoVAI, 



DATFlof HiKiAl. or KKMOVAI, 



,-ni>f:ktakfr fc i Oa^V "^^ Co . 



(AtMrt'ss 




N. H._F.ve.. .ten, of ,.Wo.„,«tlon .hou... h. c...c.'uM. Hupplied. A«n ';'^-'^.;^;:i-^':;,f:^.^^^^^^^^^^ .nwL^JlTon^'l:':: In- 
state CAUSE OF DEATH In plHin term*, thnt it may be properly cla«i».»lccl. The «>peciai 
8on« dylnft away from home should be ftlven In every Instance. 




I 

I 

III' 




Hi 



I 



fi 



»■ 




i 






I! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.,.ni of n.:.Uh- F Vo 1. *^^^. H&l'Co REFER TO BACK OF CERTIFICATE POR INSTRUCTIONS 






II 



r 



'^} 



J!'- I \ 



\M 



Hi 



Registered J\'*o, 



124 



lUilr Iuh'>f,.\AA^ b J!^0^ 

3LfrVL^ lxA.Mji Deputy Health Offlo^r 

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



Certificate of H)eatb 

( "U. S. StanDarO ) 

0?^ 



Na 



PLACE OF DEATH: — County of 



.Ow/>"V :J.<>VCLA\CA^^-City of ^'/O^ryj '^K^CL V 



St.; 1 Dist.;bct.\Jo-VWt) 



and 




CUL^CX) 



> ,r Dt*TH occuns *w*y from USUAL RESIDENCE give facts called ^or "ND„ "^;";*; '^^^^^fJI'J"*" ) 

t IF OtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




dL^..\j...^.a.l 



PERSONAL AND STATISTICAL PARTICULARS 






DATK tH IMRTH 



U)J-vJL^ 



tlkvJl 



I Month) 



(Day) 



ACR 



H 



I V(; > A 



.1 A »>////.< 



(Year) 



Aji.< 



STNC.I.K. MARKlK.n. 

winowKi) OR r>ivoRri:i) 

'Wiitfin siK-ial lUsi^rnation) 



HIRTHPLACK 
(State or Country) 



NAMK OI- 
FATUHR 



R1RTHPI,ACK 
OP' FATHKR 
(St:it<' or Country) 



MAinHN NAMK 
OF MOTHKR 



niRTHPi.ACK 
OF MOTHKR 
(State or Country) 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




L 



onth) jj 



(Day) 



(Year) 



HERHBV CI<:RTIFV, That I attended deceased from 

.UL 3 190 S to NjA.nJL^. B: 190H 

that f last saw h .rV\^ aUve on ((^''''^^ ^ ^9° '^ 

and that death occnrred, on the date stated above, at t 
OLm. The CAl'SH OF DEATH was as follows: 



\.«? 






^OLLUvAw^va VM/v-olVo/ 



clVm 




OCCUPATION - ^ -- 

Rr<idrif III Sijii /■! iin, isr,i v' )riji< 



Dr RATION '^ Years ^ 
CONTRIBUTORY 



Mouths ' C: Days 



Hours 



DURATION Years Mouths Days Hours 

( SIGNED ) Ll).....A. "^ \^X..'>V-.\W^^v.. M.D. 

UUy^ TQoM (Address) ^^X ^X^^^-XK M 



^Special information only for Hospitals, Institutions, Translrnts. 
or Recent Residents, and persons dying anay from liome. 



M,>iith> 



Da \ 



\'\\V. AHOVK STA PFO PKRS<1VAI, PARTICIKARS ARi: TRFK TO THF 
HliST OF MY KNi)\VIJ:I)C.f: AND nF:MHF 



(Informant 






Former or 
Usual Residence 

WIten was disease contracted. 
If not at place of deatli? 



How lonq at 
Place of Deatli ? 



Days 



ri.ACK OF lURIAI. OK KKMOVAI, I DATi: ot HruiAL or Rl^MoVAI, 



rNDKRTAKKR 

(Address 



N. B._Bve.. ,te„, „. lnW.,at1o„ .houid be cnrcfu... supplied. AGB should ^T^^;'^^:^^^!^^'^^^^, xZrZV.o^^:^^^^ 
•tate CAUSE OF DEATH In plnin terms, that It may be properly class.tled. The Special Intormat.on tor p*r 



son* dylnft away from home should be ftiven in svery instance. 



• } 



f ^ 





V. 



It 



'MK 



\ 



II 



i81 



% 



lU 




Boa 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nlof H..lih- iNo .. iS-t^?.^lutl'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTI0N3 

125 



/)(itr Filed , 



b 



190'\ 



Registered JVo. 



L^^llAvu. Deputy Health pfflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH: — County oi'^Oj^V \.^>\<tA.4,^ City of^O 



/OAV v) ^<X/>V^A^ C Ci 



i 




Dist.;bet.M]la<!.t^- 



Na UIX^X. .^(nvO. Lt\Nv St; " Dist.jbet. M I La<!.t\Vl.a and 




^.\\.bxC\.u ) 



FULL NAME 



U-t^L^ryoiyruu 



PERSONAL AND STATISTICAL PARTICULARS 



^Hx (T^ 






DATK <>I" r.lKTU 



COI,<)R \ V A 



(K 



Ar.K 



iMoiith) 



) V</ / .» 



Ik 

(Day) 



/..a.o.o 



'2 

>wJ.... 

(Year) 



1 



M.iulJis 



in 



/^<i r.v 



^I\<".I,K, MARKIKO. 
\\II)()\\i;i) OK DIVoKvKn 
'NVritiin soi'ial <k->^iKiiatii)ii) 



CJ,vo 



lUKTni'I.AOK 
'Statf or Coiintrv) 



NAMK n|- 
FATin:R 











:^rLa/>A3 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH A A 

Viu, s 



d 



Month)! 



(Day) 



(Year) 



;R1';I^V Ci'lRTlFV, That I atttMi(U-(l deceased from 

to ...AVV. 





that I^'last saw h ••■r*'^ alive on IC*'^^"^'^ 

and that death occurred, on the date state<l above, at 1 • »^5 

CLm. The CAl'SH OF DI^ATII was as folhnvs: 

L^vAlx-h^.c CcXaXvo 



I) L" R AT ION "^ ) 'ears 
(.'ONTRIIU'TORY 



Months "' Pays 



Hours 



lURTTIPT.ArE 
')!• lATMKR 
(State or Coiintrv) 



MAIDKN NAMH 
nl- Mt)TnKR 



niRTHPLACK 
<)|- MOTIIKR 
(State or Couiitrv) 



\0.dL 



OXAjt'VA^^-dLx LC'.CLtCiL'Kv 



Ox.- 



^AAjX^<Xn VCU- 



DU RATION 
(SIGNED ) 



Years Months Days Hours 



viu.5 igoS (Address) IPOH L tO-M d ^ 

PEC1AL INFORMATION only for Hospitals 



Onstitullons, 



or Recent Residents, and persons dying away from liome. 
Former or ""^ '«"«' «* 



OCCUPATION 

AV.\/(/^,/ /■// .S",;;/ I't tJUi is)'i1 



]'t<n . 



n I ^ ^ . 



TIIK AHOVK STAT»:i) PKRSONAK PARTICl'I-ARS ARK TRTK TO THH 

HKST OK MY iv^)\vij;i)C.K AND nj:Mi:F 



('iifoitnant 



(AcM 



rfss 



11^ 






\ML 



Usual Residence 

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



Place of Death ? 



Transients, 



Days 



>I \CK OJ- lURIAU OR RKMoVAI. D ATK <>! Hi kiai. or KKMOVAI. 






1 90S 



KNDKRTAKKR 

(Athlress 






N. B._Bvery ,te„. of information .hou.d h. cn^oiuUy -uppHc... AGB should »>« «*«^'^J^^.^^^J^^,^;, ,rrjf,Ln^. Vr'::!-" 
•tate CAUSE OF DEATH in plnin term*, that it may be properly cia.s.fied. The Special InVormation for p.r 
«on« dying away from home should be ftiven in every instance. 



11 



I! 



ir 



M 




i 



vt 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hon.lof Health-KNo. i^-ft'C^^H&rCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,!• 



"*•!' 




200 'i 



Itegistered ^'"o. 



126 



X<j-VAA^ <Ltavu Deputy Health OfTlcsr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "a. S. StanDatD ) 

PLACE OF DEATH: — County of O/CX^PU J AaitCL^^tCity of C)/CXAVvJ,va^xac4C( 
'Nt).Ll.tu ^- L^^AAvtu 4"Nlkdal St.: — — Dist.: bet. and ■■■•■■) 



.U ^ L^^AA^u %Nlkdal St.; — Dist.; bet. and 

K f ir DEATH OCCuA's *W»V fIiOM usual residence give rACTS CALLED rOR UNDER "SPECIAL INFORMA" 
y V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBI 

(Mi? , 



TION" \ 
ER. J 



FULL NAME 




CUvVu 



I 



m^' 



\.4.. 



SI,\ 



PERSONAL AND STATISTICAL PARTICULARS^ 



COI.OR 




DATK <)|- HIRTH 






I Month' 



(Day) 



(Year) 



ACK 



Ovi i< 



) ro I . 



.y/.>,if/is 



Day: 



^IN<".l,K, MARKIi:i). 
WIDOWKD OK I)IVORt'KI> 
'Wiitcin snoirtl (I<>vi}/rtiaii<)n) 



HiKTin'i.Aoi-: 

(Slate or Oiniiitrx ) 



Ca^l 



^VVUVTVL 



NAM!-: ()l- 
FATHKR 



mRTHPI.ArK 
<>! I ATIIKR 
(State or Countrv) 



MAIDHN NAMF 
<)l- MOTIIHK 



BtRTlTPUACK 
OK MOTUKR 
(State or Countrv) 



M 



i( 



U 



M 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATH 

(Moiit^) 



(Day) 



/9oM 

(Year) 



I HRRKBY CKRTIFY, That I atteiided ilcccased from 

YVA/WC ip 190 H to ... Np'vW. ..^ 190 H 

that I last saw h ^^V>filive on YVWVU^ "^ 190 

and that death occurred, on the date stated above, at I 1 ^ 
L\.-M. The CAUSK OI' DICATII wa« a*^ J°"j?v '^ * 

■-VAja(Q...QSr^>>r^...^.V.N^:*^.V 

DrRATION Vt^ars Mouths Days 




..-VYU. 



Hours 



CONTRIBUTORY 



OCCTTATTON 

Rfsidni III Sijn I'l ti iii isro 



M 



Years 



^Fouths 



Pars 



DTRATION 

(SIGNED) h . ^\ %A;vI 

.LvS 100 H f Address) utnV U %^\ 



^wvvv 



Hours 
M.D. 

x.t 



_PECIAL INFORMATIO 

or Recrnt Residents, and persons dying awd> from liomf. 



Institutions, Transients, 



) 'i(X > t 



yr.niths 



Pit V. 



Tin-: AHOVE STATK.I) I'KKSONXl, 1' \ Kill T I.A KS AKl-; IKl K Tn THI-: 
HKST Ol- MY KNOWUKIX.K AM) HKI.IKK 



(I 



, fib U3o.44VvA\xajtfNv O^ 



(Arid 



Former or 
Usual Residence 

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



S'oaUJa^lv^x ^ 



\ 



How lonq at 
Place of Death 



? ^ii Days 



l-I ACK OF lU RIM. OK KHMOVAI, J DA TF of HiKiAL or RKMOVAl, 



1 



(A<l,lr<.«s bit" W <C4j;w>vCyts.sv "1 



.f.t. CAUSE OF DEATH In pf.ln term., that It m,y he properly clarified. The Special Inform.t.on tor per- 
«'>n» dyln4 away from h6me should be ftiven in «very instance. 





' I f 



! I 









If 



!i 



I 




y\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,1,,;...! ,,f !l.:iHlr"l- So. i <; J^V^^^ USlV Co 






il ' 






Registei-ed J\i''o. 






l{(-vw^ ijl/v^. Deputy Health Officer 

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "U. S. StanDarO ) 



PLACE OF DEATH: — County of 



City of 



n% .A^tKvvA^^ \l I b 



No, 



St.; Dist.;bct. 



-arnd —-' 



:i I 




..<M.«i Dreinc-IMrP riWC FACTS CALLCD rOR UNDER "special INFORMATION ■ \ 
( '^ rF"orAT°H"o^?u%;ro\;''rHo"s^rT*.t rR^f^^V^U^T^^N'^O^/ETTl NAME IN^TEAO OF STREET ANO NUMBER. ; 



FULL NAME 



.Mx\\LAj\.i^ 



O/TU. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI. 



^liJL 








DATl-; »)1- IMRTH 



AGE 



Ltuwi 



(Motith)/) 



as 

(Day) 



rlXL.. 

(Year) 



O 5 y>ars 1 



Mouths 



1 



Davs 



•^INf.I.K, M \RKIKI>. 
\VII)«)\VHI) OR niVoRCHI) 
tVVritf ill MM-ial 'IfiiKnatioiO 



lUKTMPUACK 
StMtc or Cotintrv) 



N'AMl" <>l' 
FATIII.R 



niRTMPI.ACK 
<>!• I-ATHKR 
(Sliitf or Country) 



MAIDKN NAMK 
«>F MOTHHR 



HIRTHIM.ACK 
<>»■ M«)THKR 
(State or Country) 



^11 



rlXrrUU' 



Hi 



(5-vlLo\cL 



LOjysi 



f Ur\/a' V . v^rVL'^^^l 



OCCrPATlON 

f\r\iiir<1 III Soti /'i iiiii !sr<> 



OfPi 



%.. 






. Vn-^^^-^^- u-vC 



I 



1 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



[Month] 



-I 

(Day) 



/po 1 

(Year) 



I in^REBY CI{RTIFY, That I atlondcl <kH cased from 

1 90 



'1 90 



•to 



that I last saw h ":^ alive on 

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

I was 



190 



AT The CVrSI*: ()!• DliATlI was as follows: 



y: 



/TVJLcw^^ ^ (n x.v<x.. 



T)r RATION Years Mouths 

CONTRIBUTORY 



Days 



Hours 



Mouths 



Davs 



Hours 



) V-(7 » 



.\r,»lfh<: 



Ihix. 



Tin: AHOVH STATi:i> PKR^ONAI. »'\K PKILAKS ARl", IRlH T«> '"HJ-; 
HKST Ol- MY KNOAVMUX'.K AND J»i:i,n:F 



(Informant 






^ 



Dl'RATION Vt-ars 

.l[).jtL>0 n.CvU^. M.D. 

Address) OT A,^VVV> m11^ 



(SIGNED ) 



kvi\.v^ TQoS (-A 



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

El Re"[idencfl'^^C)^V>Xv^Q\<X^ KedVlth? .5^. Days 

Wfien Has disease contracted. 

If not at place of deatli ? _^ 



PLACE 



OF IHKIM. OK KKMOVAI. DATE of HtKlAI- or KEMOVAI, 



IN DICK TAKER 






!*<• B. Every Item of Information shou 

state CAUSE OF DEATH in pi 

«on« d>ln4 away from home should he ftiven in every instance. 



T7, iTh \C.r Mhould be iitatecl RXACTLY. PHYSICIANS should 




V 



f ) 



I 



♦ 



i\ 



il 






J. 



('. ,t 



11 




w. 



• fir' 



ii^Mi 



I) 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,„„. „ sv, ,. *r^:^lMl.M-o REFER TO BACK OF CERTir.CATE FOR INSTRUCTIONS 

128 



a/r Flh'il, AltJUi b 



190^ 



liegLstered JVo, 



A Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 






PLACE OF DEATH:-County of Scu^^ i>ua^cuaCc City of O CV>^ J V<X>%c.va.C^ 



,1- 



1%. 



Dist.; bet 



and 



.du "^ I^^^^XIU 1^ ^K\'^^ L^t,;— -CTrc'^:;0 .OR UNOER •SPECAL . N .OrVaT.O N - ) 

\ ( '^ rr"orAT°H^^O^c"u%ro\;THotVT*A^ o^'?^^^"u"T^o';"c.v7yS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




v^ 
%^.. 



PERSONAL AND STATISTICAL PARTICULARS 



X'^^ VoJuL 

DATK nl- HIKTII ^-. 

sX^wVO 

(Miiiithn' 



CO I, OR 



UlJvvU _- 



(Day) 



/ 1 L- A 

(Vfnr> 



A(;K 



I ^ )V.n.v ' .!/.<«/// .^ ^. 



Daxs 



•-IN*'.!,!':. MARKIKD. 

\vinu\vi:i) OK nivoROKi) 

'Wiitt in s(K'ii«l <U->iv.iiatit)ii) 




C\A^\XCL 



lUKTMri.AOK 
(Slatr or Cniiiitry) 



\AM1-: Of 
FA IHKR 



mKTMIM.ACK 
OI- l-ArilKR 
ISlatf or Country) 



MAIDKN NAMK 
OH MOTHKK 



lURrillM.ACK 
<)»•■ MOTHKR 
(State or Coiintry) 



L<vv 






J? 



MEDICAL CERTIFICATE OF DEATH 



nATR OF DHATH 



(MonthO] 



H 

(Day) 



TOO U 

(Year) 






I HftRnnV C1-:UTIFV, That I alteiult*! (Icfoascd from 

^^ ^^^ '''■^'Hi ''^), 

that I hist saw h X^ alive oil J^^)^ ^ ''^ ^ _ 

and that <lcath oociirrcl, <»n the date stated above, at U I '^ 
[k M The CArSP: Ol' I)I:ATII was as follows 

' ■ ^ 






^.CSr.....^7S-A-V'^--w»V 



DTR ATION ••' Years • Mouths 



Pays 



1 



Hours 



CONTRIIil'TORY 



DURATION Years 

(SIGNED ) .. LUrVW 



Hours 
M.D. 



" M.,nlh^ 



OCCl PAT ION ^?[\f 

Till-. AHOVK STA'ri'.n PKRSONAl. I' A K I' HT 1. A RS ARl". TRri". l' » 1" 

iiusT OF MY KN'o\vi,i;i)(VH AND in.i.n;!' 



(ArMress VVCo, ^^ V^ 




OVO-^ 



|xd d 



Mouths Pays 

'^vduH t.oM (^.Mn.ssaltu/-^U %^^M^ 



^PECTAL information only for Ifaspilals, Inslitulions, Trdnslenls. 
or Recent Residents, and persons dying dway from home. 



Former or i i » v^ 

Usual Residence ' ' ^ - 

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



. w I i. -Ka. Moh lonq at ^ ^ 

.WllMlvt OA Place of Deatli? Oi Biys 



VI \CF: of IURIAI, or KMMoVAI. I DATF.of 11, KIAI. or KHMOVAI. 



fndf:rtakf;r 

(A 



., . .^p «K„,.l.l he Rtate«l BXACTLY. PHYSICIANS ithould 

IN. B. livery Item of ln?ormHtlon .hould be CHre?ully Huppliccl. A(.b «''""';• "^" ^ ••gneclal Information" for p^r- 

•tatc CAUSE OF DEATH In plnin term,, that It m»y he properly cla-s.tleU. I He o, 
Hon. dylnft away from home should be ^'ven in .very instance. 



Jtl 



1 



i(l 



I; 



!'> 



I, 



li, 



ir 



iiii 



ffi 



H.uu.l -f ll.:tlt1i- I" N'l I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

120 



■V'^r^yaih^f^ WSi. V Co 



De 



Ith Off! 



Reilsieved JVo. 



DEPARTMENT ^\ PUBLIC HEALTH=City and County of San Francisco 



ccr 



No. 



PLACE OF DEATH: — County of 



Certificate of 2)eatb 



a I rj-Lh^-^xCV'^vcCV St.; i Dist.;bet. fltUV^Y\^a.mi and 

^t U-Va/>^^cV > VCXV. RESIDENCE GIVE r*CTS called roR UNDER ■special INTORMATION' •^ 

( '^ r.^DrAT^H^OCruNreV.rrHO^S^PrT'At l^^.l.ll'^^.^^On.. .TS name ..stead O. street AND .UMBER. ) 



FULL NAME 






I a ^ L 



^..fs^L4 



PERSONAL AND STATISTICAL PARTICULARS 

alt U)Jv.tt 




1)\TK Ol- HIKTII 



4)' I 



W> 



Vlijiith) 



It 

(Day) 



(Year) 



AC.K 



O ) I'll > > -J 



M,>tiths 



l,L 



Davs 



W IDilWKI) OK niVOKrKI) 
tWritfin social <Ksiv:Jiali">ii) 



HIR TMIM.ACK 
'Stati- <»r Couutrvl 



\AMi: (tf. 

»atiij:r 



MIRTMJ'l.Ai'K 
OF- |-ATni:R 

(Statf or Cduiitrv 



MAIUKN NAMK 
OF MOTHKR 






llVll 



VXX > >A. 



.tK.fi^^uA^ 



I 



i? 



Wv^^*^ 






iu 



H 

(Day) 



f9oH 

(Yt-ar) 



MEDICAL CERTIFICATE OF DEATH 

DATR OF DKATII A 

\vu 

|flMonth)| 
I HERnnV CI'RTIFV. That I aUeii.UMl dcrt-ascd from 

^VL'>>X %% 190H to |vvU|. ...H 190 4 

that I last saw h ^>valive on V^W "^ ''^"^ 

and thai <Uath occurred, on the date stated above, at >• ^ 
v[ M. The C\VrSl': i)V I)I':ATII was as follows: 



CONTRIHUTORY 



Jfof///is 



Pavs 



(SIGNED) 



Hours 
D. 



lURTMl'LACV 
OJ- MOIMKR 
(Stat. . Connlrvl 



OCCUPATION rVs 

V ^v<r>^JL 



JL/l/^^^'CV'^vo 



Rf-iih'if in SdH I'l (1 Hi t^i'i> 



-V^->^ 'y?^,>,M^ n,n 



ini*. \HOVK STATI-I> PKKSnNAl. 1' A k IK' T I. \ KS A K l", IKlK To IHI-: 
HKST 01* MY KNOWIJ.DC.K AND Hl-.I.U:!" 



f Infntinatit 



U).clLc^... di^ 



(hO^ 



(Add 



rrss 






-I 



'Special information only lor Hospitdls, institutions, Transients, 



or 



Recent Residents, dnd persons d>ing dHdv fro.-n home. 



Former or 
Usual Residence 

When Has disease contracted, 
If not at place ot death? 



How lonq at 
Place of Death ? 



Oavs 



,., XCF 01. HI KIAI, .»K RKMOVAI, "^''-f """•^' "' XHMOVAI. 



t-NnHRTAKKR J .Ivft^ft^cL^'V ^ ;^ vfw 

SSI V^^.v^'5,l-^y^ "t 



(Address 



N. B. F.vepy item of Information should b^ cnrefully KuppUcd. AdB "''""'^^* ^*"**1. ^ •SDeclal Information" for p.r- 

•tate CAUSE OF DEATH In pl»m term., that it m„> he properly .lB««.iled. The »pcc . 



•»on« dylnft away from home should be ftiven in .very instance 




fi, 



' \ 



: 



•1* 




i 



M 



V 

I 



i: '1 



If I 



)1 



it. 








lU'Aul . f II. :iltli »•■ N') "> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i!ari.-5*)l{S:l' Co 



/ )/(/(' Filed , \^<X^L b 



100^ 



Registered J\^o. 



130 



(V^VA-A^ 



Qfiicer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






0?i 



No. 



Certificate of Beatb 

( XX, S. StanDarD ) 
PLACE OF DEATH:-County ofO^X^ Jx<X^l^UirCity of ^'CV>^ JACV^vCv^t^ 
^bT 0'*^,a\VLil ' St.; :X Dist.;bet.m^A,«T^. and VljLv 

0\D I V g^VVVVV^VV „.,-,,., pcsiDENCE GIVE FACTS CALLED roR UNDER "SPEC. *L INrORMATION- \ ^ 

( " .VirATM^O^rURrcV.^rHO^S^pV.'L Tr T^ ^T^. T^"" O.VE .TS NA^IE ..STEAD OF STREET AND NUMBER. ) ^ 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SK\ 



DA ri-: oi- niKTii 




<V 



L 



COI.OR 



UJ^yxaX^ 



(Motltll) 



AC.H 



J 'I'iJ » .V 



1 

(Day) 



Mnuf/is 



(Vt-ar) 



Xl 



Pa vs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I)K.\TH 

h 




I go ; 

(Yeail 



iMoiith)!] (I>«y^ 

Y\\ M R MV^Tc K RTI FY, Tliat^ I attetidcd deceased from 

K/D i 



tA^V^^U '1 looH 



to. 



that I last saw h .Vvvv-alive oti 



.li.J. 



1 



wrnowKi) <^K nivoRTKn 

'Wiitfiii social lU siv:nati<iti) 



lURTHlM.ACK 
(Stall- or Cotnitrv) 



VAMI-: OF 
FATHKR 



lURTHIM.ArK 
o|- lAIIIKR 
istatf or CoiMitry) 



MMDKN NAMK 
<>l MOTHKR 



^1^ 




'4 f a 



lURrniM.ArK 

«>l- MoTllHK 
(St;itr or Cotnitrvl 



i'j a : 



aiul that death occurred, on the .late stated above, at I 
(P M. The CAUSI' Ol- I)i:.\Tn was as follows: 

[>w4<v.a» 




DUR.\TI(>N - Years '-Months %% Pays - I/outs 
CONTRim TORY QjsjL^^-^oX^>.A,hJLlL^S^^^ 



.Lrwcu-' 




nrk.ATioN y^'^^'i 



(SIGNED) 



s 



Mouths 



Days 



Hours 
M.D. 



OCCri'ATlON 



(K, 



Kfsiiifii ill Situ /'i mil ly'ii 



)'r<r' s 



Mnnfhs 



Ihiv. 



Tin-. AUOVK STATl'I) J'KRSONAI, PA RI IC T I.AKS A R I', TRlK TO Tl 1 H 
Hi;ST OI-' MY KNOwi.KDCK AND HKMllK 



'Iiifotniniit 



(A<U1 



rcss 






S TQoM (Ad.lress) 3>Xlo - AJUX>v/-wva.l d <. 
• iiue-rkDiuiA-rinN onlv for Hospitals, Institutions, Transients, 



^FECIAL INFORMATION only for Hospitals, Institutions, 
or^ccnt Residents, and persons dying away from tiomc. 



former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



n.ACK a»' niRiAi. OR ri%movai. 



l(AA>-tt 



I)A;J1: of^BiRiAr, or RKMoVAI, 



INDl'.RTAKHR 

^\cl(ll«.'SS 






TT 7\\ AGE should bo stated EXACTLY. PHYSICIANS should 

N. B. Every Item of Information should be cnretully supplied. Aur. s ^ "Special InforniHtlon" for p«r- 

st«te CAUSE OF DEATH In plain terms, that It may be properly classified. The »p 
son. dylnft away from home should be given in every Instance. 



I 



I t 



i 

1 


i 


1 




t 








i1 




\ 




V 


\]\ 


1 



'1 



I I' 



rl 



n 



:i 



4 




n 

1 1 

• 

m 

1 i 


1 
1 


V 



#j 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



To 



{ 




L 



3 



ioo'\ 



REFER TO BACK OF CERT IFICATE FOR INSTRUCTIONS 



liegLstci'cd Xo, 



iGi 



\j,^^^.^^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificate of Bcatb 



I 



( H. 5. StanDarD ) 



i 0J 



PLACE OF DEATH:-County of^^a>^. ^1 Va^v^vvc. City of CW>v J^-a v.cU-^. 




( 



^ r."o;:T°H^oicu%ro .^Tho^ o%^?:?.^"J;^o^'^c.;e7Ti name .nsteao o. st.eet and nombc. ; 




FULL NAME 



Iw^La^u^^ 




PERSONAL AND STATISTICAL PARTICULARS 

SK\ Aa . (\ I t:ni.<>K 




oJ 




vvtt 



UXll'. ()!• lilKTII 



\<,K 



LL|vw(j 



(Mi)nth^ 



CS O ) V(j ' A "^ 



19. 

(Day) 



Mn,i//n 



(Year) 



3.3, 



/)« YS 



SINC.l.E. MARK IK!) 

\vin<)\vi:i) OR nivoKi I'D 

'Wiileiii siicial (lisi}.'iiati<)ii) 



inKTm'I.AOH 
(Statf i>r Country) 



NAMK OJ- 
FATin-.R 



HIRTHIM.ACK 
n|- lATHKR 
•State or Cmititry) 



MMDKN NAMH 



^\ 



CWVUL<L 










*1 



lUk'nn'i.ACK 

«>1- MnTUl-.R 
(Slate or Country^ 






t 



Tin-, AIIOVK ST\T1-I) t'KRSONAl, 1' A K 1' K" f I, \ kS AH)'. VRVV. r«» THH 
m:ST Ol- MV KNOWl.l'DC.K AND lU-I.Il'.H 

niifoiniatit 



(Ad.lrcss 5 b1 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

.5:.... 

a)ay) 



.L\ 



(Month 



(Year) 



I in: U I*; BY CI-RTIFY, riiat I atteiKUMl deocasol from 

t<i "" 



190 io- 190 

tliat I last saw h rr— alive on '90 



jui.l that (U-ath ()ccurre<l, on the ilato stated ahove, at 
- M TIr' C\rSI-' ()!• DlCATIl was as follows 



nr RATION )'ri7rs Months Pays 

CONTRIIU'TORY 



l louts 



DURATION ^''''''■^(X> ^ ''^^''*'{^'\ 

iNED) Uv<r^XlV.imU' liLta>X<^ 
5 ^.^r.'i rA.l.lnss) LfrV(r>v(-Va 



Ihivs 



(SIGI 



I 'm' 



Hours 
M.D. 



t^. 



oPEChALlNFORMATION only for Hospitals, Instituto, Iransifnts, 
or Rrcfnt Residents, and persons dying away front liome. 

-> [^^ [IH'4 HoHlonqat , 

3 bl vJ ^ a\NXU' v1 b Piarc of Death ? ' 



Former or 

Usual Residence ^ 

When was disease rontrarted, 
If not at place of death ^ 



Days 



,.,.ACK.)1 in RIAI,()R RKMOVAl, I I . STH o! H.k.ai. or RKM..VAI 





n 



4 






190 ". 






"*""^ T- . , I L tnted FXACTLY. PHY8ICIAIN8 should 

IN. B. Kvery item of informntJon should h^ c.relf.ilty supplied. '^^''^ *! "" * .j," . The •'Speclol InformBtion" for p.r- 

state CAUSr OF DEATH In pinin term., thnt it m»y be properly class.tlcd. 
«on« dyinft away from home should he ftiven In every instance. 




f 



W 



•11 






f 



n 




In I 



li 



• .{ 



•Ili 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.f I!(;iUli-FN(). 1^ '^'^^y}:^^^^^''^''^ 



W0'\ 



Begislcrrd JVo. 



1,00 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



^f^^ 



Certificate of ©catb 

( xa. S. StanOn^^ ) 



PLACE OF DEATH: — County of 



LLloLa^vt<i-<v ^eitr^ vb rvfrtr 






A4^; 



No. 



St.; 



Dist.; bet.- *^nd 



( 



'^ ^;— ^^:!«^v.rj:^;^^t -f-^j^^^c;;:-;^^;^ ?;^M^ .^^" s^;^^ri^o'^:::^r" ) 



FULL NAME 




X/' 



"VWtU 



'i:x 



PERSONAL AND STATISTICAL PARTICULARS 

C()I/)R 



i)\ 1 1". o!- itiK rn 



a 



UoJxdi 






% rl^'X... 

(Day) (Year) 



A •■.»•: 



loH. IV./»5 I. I V.m//« 



. Ik 



/?ti >i 



^IN<.I,K. MAKUIl'I) 

W II)t>\\ KI) OR l)lV<)R(j;i) 

(Writf in social desijf tiation) 



^l 



0^\.\.<Ji 



<^w 



IMKTMl'I.AOH 
(stiitf or Counlrv) 



NAMl". i»l 
FATHKR 



h 



^K{i>v 



HIRTHn.AfH 
oi- I ATHKR 
'Stall- or Counlry) 



MAIDKN NAMH 
<»l- MoTUHR 



niRTITn.ACK 
<>l" MoiMlKR 
(Statf or Country) 



OCCT 



Jt\/A AX OL'^X C 




Residfii in Sa>i /'idih ism ^ ) '^''^ ' ''" 

TIIK AHOVI.: STATKI) rKKSONAl. J' A KT UT I.AK S A K I', TRri-. i<> THH 
HHST OH MY KNOWl.HDC.H AND HHMHK 



}fnntfis 



fht y. 



(Infotinnnt 



Lv d>»t^ \A.V-*"V-^VvM 



a 



f A'ldrcss . 



%[% 



.V>\X 



o -3 La 



t 




:<r>.i./:>.v 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ^ y 



..a 

(Day) 



/go i 

(Year) 



(Mont) 
rillUUUiV Cl'RTIFV, That I atleiKkMl <kvfasc(l from 

to -.■ 190 

~ : Up 



I9O 



that I last saw hr-— alive oil 

and that .loath occurred, on the .late stated ahove, at - 
.7ZZ7. M The CAl'SI' Ol- DI^ATIl was as follows: 

(Ju<^^i..A^^J- cr|. %^a^l 



DIRATION )Vrf;.y 

CONTRinrTORV 



Moni/is Days 



I/our^ 



Days 



DURATION Years Months 

W LvH Too'-l (Addn-ss^ C.a>vliL<V>v^VO 

'' n _ _ . 1 I.. U U..\„ InrlitlltinnC 



(SIGNED) 



Hours 
M.D. 



U 



Special information only lor Hospitdls, institutions. Transients, 
or Recent Residents, and persons dying away from liome. 

How long at 

Place of Dealli? ^»)'> 



Former or 
Usual Residence 



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



n XCK OF KIRIAI. OK KKMoVAI. DATKof M. k.a.. or RKMoVAI. 



^ . 1 I u t ted EXACTLY. PHYSICIANS nhould 

N. B. F.very Item of in?orm»tion .houlcl be cirefully Buppliecl. '^^^^ " °" ' .IV ^j,^ ••Special inV'orniBtion" ?or p«P- 

state CAUSE OF DEATH in plain term., that It may be properly cl«««.t.ecl. 

•on. dylnft away from home shouid be ft'.ven in every instance. 



If 




Ti 






W 



i \ 



U\ 



^ 



h' 



■t. I 



il #ii« 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H.,.„ 1 .,f llealth-KNo. l. »g^g;») lUS: I' Co 

Hfr Filed, wLi b ^^^1 



I) 



Be^istered J\'*o. 



100 



dL^LVU^ (U'v^^u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 



PLACE OF DEATH: — County of 



St.; 



Dist.; bet. 



:rr— and 



.ic^iiAi or e I nr NCE Give facts called for under s 



SPECIAL INFORMATION" 'N 
REET AND NUMBER. / 



FULL NAME 




k^s..^yxJiJ\y 



PERSONAL AND STATISTICAL PARTICULARS 



m:.\ 



QOXcJL 



COI.OR 



ll). 



rvUjL 



DAli; »>l' IlIRTH 



\<'.K 






ti 



(Day) 



(Year) 



b.. 1 . IV<M« 



M,,tiths JhiVi 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I)1:aTH /\ fj 



/rM<)ntli)/r 



a 

(Dav) 



IQO 



(Year) 



^IN<.1,1". MAKKIKI) 
WIDOW i; I) «)K DlVt »Kr j:I) 
'Uiitfin Mnial (U'sijfiiatioti) 



HIK TUn.AOK 
(Stittt or I'otintry) 




NAMl- (»l 
FATMllR 



IMKTHIM.Al'K 
Ol" l-ATHKR 
IStatc- or Co\n)try) 



MAIDKN NAMi: 
01- MoTHKR 



7 







X^VWVCLV 






Hik rni»T,ACK 

<»l' MOTIIHR 
(Statf or rountry) 



OCCT'PATION (ijX'^,^j^ Or>\jLA^tJx C ^vt 

Kcsidni in S,iv i;,>n.is.;, ^1 Vrai^ 'X. Months ~ Ihiv 



I HI'kl'HV Cl-kTIFV, That I alU-n.U-.l.leocastMl from 

Va.>^l .3). 190 'i to .....|va^ .3 i(,o H 

tl,a( I last saw h.:^^^ alive on |^^^ ^ ''^ ' 

and that death occurrcil, oti the .late state.l above, at 1 
Q.. M. The CAl'SIC Ol" D I! A Til wa-; as foll< 



Qvt^Jx 




VVJl/VW^Oo'' 



lows 



.Uva.i;>^vr^^_^^ -.Dens 



CONTRIIiUTORV 




I louts 



T 



Dr RAT ION Years 

VCyV^AA-voi 

DT^RATION ^ Yiars t) JA;;////.v - Pays ' /A'//' > 



(Signed ) 



^<X^?n^ 



M.D. 



i^ 



(.\<l(lri-^s) 



JjAaavA>v }l:»A^vv^.v' 



Special information only (o. Hospitals. Inslitiifions. Transipnis. 
or Recent Residents, and persons dying aMdv trom home. 



rill', MIOVK ST\ri-I) IM'KSONAI, I'A K f U' C I. A K S AKl- IKri-: lo TIIK 
IIICST OF MY KNOWMUX.H AND lUJ.IlCF 



niifoiiuant 






former or 
Usual Residence 

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



pM l^CiVonXU COiX Place of Death? 



li 



Oa\s 



I'LACK Ol- nt KFAI, «»R KFMOVAI, 



l»\Ti;of UrKiAi. 01 Ki;M(t\AI, 

TOO* 



,T,.: 






I'NDFtRl AKFR 

(AdilrfHS 



IN. B. 



livery Item of ln?orm«t!on nhoulcl be c.irolrully HiippMc*!. Adb "^''"'j* 1"° "j"**^,^J ••Special InforinHHon" for p«r- 
•tau CAUSE or DEATH In plain term., that It may be properly .la.shlccl. «l 

-on. dylnft away from home hIiouIcI be ftlven In every InHtance. 





li 



I •'! 



it .* 



IN* 



1^ * ' 



• t 



} 



WRITE PLAINLY WITH UNFADING INK 



Ho;u,! . f H.alth-F No. i. t-^^aS.-^ 1U«^ »' t'<> 



lOO'i 



Dali' Filed, WLi T 

Inv^cv^^Ix^u Deputy Health £ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR IN8TRUCTION9 

134 



Registered Xo. 



<-^^^v^vo JoiAvu L»epuTy HegJth O'^^^r 

DEPARTMENT OFPUBLIC HEALTH^City and County of San Francisco 



PLACE OF DEATH:— County of U^\,O.OiA. 



Certificate of 2)eatb 

( Ta. S. StanC»arC» ) 

•City of C'av^'vl^-^^^v vat 



No. 



Q^ , Dist * bet* ' — — ~ and 



- ) 



FULL NAME Cl LcLa 



5.„..L<i^.cv.>v' ILL 



^'V<^/v^^• 



SIX 



PERSONAL AND STATISTICAL PARTICULARS 
^ I COI,OR \ p. 

I»\IK nl lURTH Qr-s 



iMotith) 



11 

(Day) 



/tit., 

(Year) 



Ar.K 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



(Mo4h) 



.5. 

(Day) 



(YeaH 



I HKRI'HV CKRTIFY. That I attcnfUMl deceased from 

"Tgo 



190 
"" alive on 



to 



IT M 



1/,,.////* 



/1<l Vi 



SIVr.I.K. MARK IK I>. 
WIDOWKI) OR DIVoKrKI) 
W till ill MKJal ikHJ^tiatiDti) 



HIRTMPl.ACK 
Stall or Country) 



VAMF. OF 
J ATHFR 






niRTHPI.ACK 
<H I ATHKR 
(Stale or Country) 



Ol- MOTHER 



lURTHIM.ACK 
OF MOTHHR 
(SiaU' or Coiintrv) 



»« 



(I 

) 'til I 



}fnirf/l- 



n<}\ 



OCCrPATlON 

fy'fsiilnl III Siifi J'i(tiitni') ^^^^^^__^^^_^^^ 

THK AHOVKST\T)I))'KRsoNAM'ARTUri.ARSARi:TRrF. To THH 

HKST oi- Mv kno\vli:i)<",f: and iu-:i.n.J* 

(Infoiniant O'^vtu NXA>VtaHX*- -^\jl\y»vvt 
'^.l.^r^■H^ 



that I hist saw h -• 
and that death occurred, on the .h.tc stated above, at 
.rrrrrr..U, The CAl'Sn OF D I- AT II was as follows 
Vfrn>-\!'<>AA^.>.V^.'--N;-\'*^-^ 



190 



IH' RAT ION Years 
CONTRIIU'TORV 



Mouths 



Davs 



Hours 



DURATION Years Mouths 

( SIGNED ) i).,..Uj<^-^vi^.Nvj.a>vl .. 

kvlcv ^^ i()0 ' t (Add rcss) -" 



Davs 



Hours 
M.D. 



i- 



ifSI only for Hospitals Institutions, Transients. 



SPECIA' INFORMATIOI 

or Recent Rcslo .its, and persons dying anay from t>ome. 

r „, HoH long at 

Swdme Place .tD...h; - 0->. 

When was disease rontrafted, 

If not at place of deatli ? ■>..--»^.-«.- 



i)\ii;<)! iiiKiAi, or rf:movai, 
1 190H 



H 



PI \zv. OF m RiAi- OK ki;m<»v\! 

F.nKRTAKKR ^ X^^ ^ ^^ ^^'^^^ J^ 



"■""■"""■"""^ r^ ItF Hhould be st«te.l EXACTLY. PHYSICIANS •hould 

N. B. F.very item of in?ormntion .houlcl be carefully suppl.ecl. JJ »' ^ « c,a»sWied. The "Special Information" for p.r- 

•tate CAUSE OF DEATH in pinin terms, that .t may >* P^^PJ*^ *' 
J. ._^ e i,««,e should be ftiven in every instance. 



«on« dyinft away from home should be ft 



11 



k 



1 




f 



i£ 



,1 i 
I 



il 



(I 

! • 







H 
I 

!■ 

f 



I' 




♦ t 



1 



I^= 



H„:,,,! .,f lliallh- F No. \^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Rt FER TO BACK OF CERTIFICATE FOH INSTRUCTIONS 

135 



llSiV Co 



pff/r Filed, 

i 




190'\ 



Eeiisteved J\^o, 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificate of Beatb 



( XX. S. Stan&at& ) 
SI ^ 



J? ^ 



PLACE OF DEATH:-County ofCW.v()Ka'>^x^^ Gty of O^V^ OAXX^C^LA^C 



No. 



l'^ tl 



St. 



R Dist.;bct. 

E FACTS CALLED FOR UNDER 




and 



,.CV4AA^ 



'special informatio 



( ■' r."„;i,°.=i^c"u%'.r;,;'r„o",^pr.t :.^f^^^"J=rjv,v774 '«.». ,-s.„o o, =...., .-» ~u-=.. 



>N" \ 



FULL NAME 




yx^.. 



lOJ. 




PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



J JL/vv^.cx'Ul 

DATl-: OK HIRTH 



UJ.l\Atx 



(Month) 



(Day) 



(Year) 



AC.K 






.y,>n//ts ■'^".'•■s 



«^IVnT,K. MARKIKI), 
WIDOWKI) OK DIVOKCKI) 
(Write in social «lesip:nation) 




Mi^' 



^vvr 



niKTHlM.ACH /'Q 

'St.-itf or Country^ | 



^ . /CL vc\Ktu . C 



NAMK OF 
I'ATMHK 



lURTHTM.ACF 
<»|- lAPUHR 
(State or Country) 



MAIDKN NAMK 
OF MOTIIKR 



HIRTHPI.ACR 
OF MOTHHR 
(State or Countrv) 






J w 



,(j^>j 



•r\.t 



L<X'>\<C- 



^ttXv 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




Month)] 



b 

(Day) 



/90 i 

(Year) 



I IIHRHnV C1\RTIFV, That I attended deceasetl from 

.Wv^ an 190 H to r^v^-*^ ^90 

that T last saw h Xv. alive on ^^^vL^-t 190 i 

and that death occurred, on the date stated ahove, at 
(ll...]VI. The CAl'Slv Ol* DI'^KTII was as follows: 

.(£)..^-ca^^i^.. .pL)'^ 



I 0^; 




O^rlv. . . . y^ . .Ow^C^ViV.vOA-.'fi . 



nr RATION ■- Years ^ Months .'-l Days 

CONTRIBUTORY ll:^.<XX^::v^v.c....Lcr.>.:>.v.^. 



/louts 



YiiU'S Mouths 



Paxs 



Hours 



OCCITPATION 



Rfsidfif i„ Sat, l-iiinrisro .'\M )>«7»5 ■^•. ■'^f"""'' 



n,n. 



r nn \ m > v e st \ r v i > p k k so n a i , v \ u r ic r i , \ k s a r K T r r k ro v 1 1 K 

HKST OK MY Kis'OWUKDC.K AND lUCI.IllH 
(Informant \Jj rS>,\> (-\A,\''r> V<i ' 



(Adrlrrss 



HOIR- 1^ tlv '^ 



DURATION ^ 

( SIGNED ) LL Y^UtL.d. 1^^^ M.D. 

|J^^ TCP". (Address) b b V ilcX^Av. ^^ t. 



SPECUL information only for Hospitals, institutions, Transifnts, 
or Recent Residents, and persons dying away from liome. 

t ,, „, How long at 

ESlR«Men« "««'»"'*' "''^ 

When was disease ronfracted, 

If not at place of deatli ? 



PI.ACKOK niRIAUoR RKMoVAI. DATK ot Hru.A.. o, RKMoVAI, 



•c, 



n X 



(AcMrcHS 



N. B. Kvery Item o? Information •houfcl be careVuHy supplied. A(.B « .... th^ "Special Information" for p«r- 

state CAUSE OF DEATH in plain term., that it may be properly cla««.*ied. 
«on, dyintt away from home should be ftiven in .vory mHtance. 



I 



I ■ 



f 

I I 



\ 






!| 



II 



'.< Ii 



I 

lU 

;1 T 



I t 



•™2n«ir- 



»"'*->* 



^^ii|g«»>^^^4i 



■\. iil 




i I 



If 

[\ 
b 



J 






POIl! 



!li;ilt)\- I 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



No I ^ '^4^^i3|ff'jV^< lilt 



I' Ci) 



190 '\ 
Deputy Health OfTlcer 



lie^lstct'cd J\'*o. 



136 



DEPARTMENT OlF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StanDarD ) ^ 

PLACE OF DEATH = -Coun.v of WIaCV. vC^^CGty ofao^^V >.a.vvc.^cc 



(Jfll 



Ne, 




Ulu'^^ Ltn.C'YJtn t^i CHi,.kAlo, (■ St.; — ^ Dist.; bet 

VAyV-M ^ V^V ^^ T V^^>^V *- "- _,^,«r-iu/«Cr.iwr rACTS CALL 



— W^tCTVXU ^^'^ ,"-,,., prSIDENCE GIVE FACTS CALLED rc 



-1 



FOR UNDER ' SPE( 
STEAD OF STREI 



FULL NAME 



m\/r\). 



SKX 



PERSONAL AND STATISTICAL PA RTICU LARS 

COI.OR 



m^L 



DATl-: l)F lURTH 



X'^vL 

[Month) 



lie... 

(Day) 



\.A^ti^ 



,.lia 

(Year) 



A(iK 



^.^^^,^..1H 

^I\«.l.E. MARKli:!) 



) 'la I .< 



10. 



.11 



CIAL INFORV.ATION" "N 
ET AND NUMBER. / 

\-^VV^4- __ 

^ MEDICAL CERTIFICATE OF 



DEATH 



DATE OF DKATH 



Montl/j 



U^ 



.....H 

(Day) 



(Year) 



M,.u//is l.W -'^".'■^ 



wiDowKi) OR nivoRCKi) n A 

(Writf in MK'ial (lisii.Miation) -\ ' il 



niRTHPI.AOK 

(State or Coiuilrv) 



'\jLv;rVUtrvk 



NAMF or 

KATni;R 



RlRTnPI,ACE 

oi- iwrnKR 

(Statf or Country) 



^0 Hf} 



MAIDKN NAMK 
OI' MOTHKR 



I L^ v'iL.,_ 



HlRTllIM.ACK 
<>»• MoTHKR 
(State or Country) 



occu 



C^AJ^'L.<X'>vcL 

JPATION ^ J 

h'rMtlrd ill Sn>i /■'miiii>i'ii O )''i".t^ 



Months 



/hn 



TMK AH()VKST\Tl-.I^ PKR^i^NAl. l-ARTIC I I.ARS ARK TRlK T» • HIH 
BKST Ol- \1V KNOW I.IJX.K AND Jti:i,n> 

(Informant u) 0> V m7\ ^^C^ V vHU^r-L- 



TllI<Rl'HY CI«:RTIFV, That I atUMulea (Icccased from 

Cl\-i'l.<^t to , l^-H .^' 

that I last saw h<vrv> alive on ^^^^^ ^ 190 ' 

and that death occurred, on the date stated above, at • U^^ 
i; M. The CAL'SIv OP Dl.ATll was as follows: 

5 ^CvisriA.'lw^^ 



\)j\.Ck>:Sr'L^<^: 



DTRATION 
(SIGNED) 



■^.b too'; (Address) VtU^ 



t,t u ' ' U ^%^^|^^^A■ 



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

SlR^idence m.^U^^ AA JlTceWath? ?^ Days 

Wlien was disease contracted, 

If not at place of death ? . . ■ 



ri.ACK ni- lURIAK OR RHMoVAI, 




DA I't of MrKiAl. oi R1:Mo\AI, 

190S 



Kd^.l 



N. „._B.„, ,.e„. „, <ni„,».-.o„ .h„u... he c,..^ul., .uppn.d J^^^^^^l^^l^.^^lT'^ 
■ Ute CAUSE OF DEATH In ploin term., that it mn> be prope 



(Ad(irc«ts v> V > 



.ould be stated EXACTLY. P"^^'f,'^^** "^'nlll.*' 
clBSsiflecl. The "Special Information for p«r- 



state CAUSE OF ^^r^ . . ^^ :««t«nce. 

•on. dying away from home should be fe.ven m .very instance. 





f 1 I 






;* 



I 



h 



|i 



« 



1 



t^. 






. t 



4s,?? 



■>V T. 



l'-' 



f\, 



W: . I 



V i 



M. 






,jy 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ..V .^-rSn»i.HS.l.C.. REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

137 






o-vwa 



cLia> 



I 



VJO\ 
Deputy Health Choicer 



lle^Lstcred J\''o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( "a. S. StanDar^ ) 



SI 



^ 



PLACE OF DEATH: — County 



of (J/OL^v J ,^a'>\^^AA.;:^,Qty ofCJ.cv^v JAxV">x^^v4.a,o 



(^ 



m 



^ 
j'( 



cs? 



ivT ^';^ v) ' V ^ H St.; 1 Dist.; bet. 'CX.uA,<^' and 

No. Vj ^ V.n.. ,,«.„*. PrS.DENCE GIVE TACTS CALLED rofl UrAcfl -SPEC. AL INFORMAT.C 

( '' rr"orAT°H^o^cu%rEV.;"rHO^s^."*At 0^^,; sn^JV^o^.'c , vc .TS NAME ..steaVo. stbeet ano numbeb 



J ^vuwk. 



FULL NAME 







JL 




^O;.. 



.c 



PERSONAL AND STATISTICAL PARTICULARS 



KKX 



DATK «>I MIRTH 



1. 



COLOR 



UJJ'voIjl 



<m 



ijuth) T 






(Year) 



\<.K 



.^3. 



) V<7 » .» 



II 



Mnulhs a', X.. /^WVi 



SIN(.I,K MARKll'.n 
WinoWKI) OK DIVORfHI) 
Wtitciii MH-iitl (U'siK'niliuii) 



Ql\ 



OJV\^'^JL&r^_ 



niKTIUM,\OK 



Stat., or Country) U iff li ) 



Kt<yr>v 



NAM1-: <)!•• 
lATMKR 



niRTHlM.ACK 
<>!• lAlllHR 
'StMif or Country) 



mmhi.:n namh 
<•!• M()Tin:R 



inu rin'UACH 

'»» M 'TIIKK 
(State or Country* 



U\ 





5 



vU\ 







dv 




^ 



OCCrPATlON 



». 



■ 



X^rto Vt^^tt; 



Rfniiifd ,,i Son I'lan.isro - )V"»^ t. ^f<»ilfi^ 



/),i\. 



Tin: \H()VK STXTI'I) I'KRSONAI, 1' \ K I" H" T I.A R S A K l. T R '' K TO THK 
Hi:ST Ol- MY KN<)\VI.i:i)<'.K AND MKMT^»' 



MEDICAL CERTIFICATE OF DEATH 
DATE Ol" DKATH 



^V^^^n 

/jMonth) / 



...5. 

(Day) 



fpcy 

(Year) 



/jMonth) J ____„ 

TlllvRirBY CI'RTIFV, That I attciidea deccascl from 

to 



190 



that T last saw h alive on ■ •"-- 

and that death occurred, on the date stated above, at 
M. The CAUSE Ol' DlvATH was as follows: 



190 

190 



3..k.^ytJL.<cv.oo^. M- 



A\^i 



,C'"yYV:V^v.i:^w«- 



/>"S 



Dr RAT ION yt'ars 

CONTRIBUTORY 



Mo?i//is 



Davs 



■r^.^o•:>^.v.^ 



Hours 



DURATION >V'?/-5 



Mi)ulhs 



/hiVS 



Hours 



;^(E.U)Ua^v.<^ 



(SIGNED) U\.ir>AjA^ 



M.D. 



Special information only for Hospifdis, InstitulMs, Iranslenh. 
or Recent Residents, and persons dying away from liome. 



[,!:!rp"iH.„r.C^^^>vtaU/>v<V Ca,V PlareToelth? 



Usual Residence 

Wfien was disease contracted. 
If not at place of deatli ? 



Days 



'Iiifiiiniatit 



(A.ldr 



CSS 






vto 




n.ACKOF BIRIAUOR RKMOVA,. I>ATK of H, w... or RKMoVAI, 

^ ' .vlu 1 ^ 



a OU^vtcU Cl'>XOJ "CckX 



V' 



1 



190 






(AtMrcss 



.i informnf.on should be cnnefully Hupplled. ^«^^;;;7;^'„^5;:;,^''Th?'^8,I^^^^^^ ,nWr«\To^n- Vr^'^r'I 
£ OF DIZATH In plain terms, thnt it m»y be properly claMi^ietl. 



N. B.—— livery item otf 

state CAUSE ^. . , ..„^* 

«an. dylnft away from home hHouI.! he feiven m every instance. 



S^StR* 



m^' 





\ 






\% 



1 




■1 


H 


, 


\ 


■ 


\ 


\ 




, ■ 


\\ 


t 


1 


1 

i 





ll:!.| 



i 






i 



11' 



il I 



m: 



M 



SM 



■■ I 



I 






it 



[) , 



y I« 



^Itj 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^ 

Tfpdi.^fpvpd J\^0, loo 

J)(il(' Filed y 



nonnl Mf nrri)lh-F No i^^ 



aK3i)H&l'C.) 




L.^ 



^ 



Dep 



' Officer 



^ J ^^ . 



DEPARTMENT OF PUBLIC HEALTH-City and Connty of San Francisco 



I 

I 

4 



Certificate of Beatb 

( XX. S. StanOarD ) 



i 



0ll 



PLACE OF DEATH:-Countv of ^ ^^ >v^;ta.>v^.... Gty oS^^ ^X<X.^^C, 



N 



^1 

o. ^u 







i 



.<X\yYVA 



FULL NAME 



Ll>JLKAAA)....i.... i^^/r^JJ\JUx) 



^i:.\ 



DATK UJ- BIKTU 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 







{llikd. 



Month) 



(Pay) 



(Year) 



ACK 



1 (O )V.„.v X 



Mouths 



.1. 



Pars 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DP:ATH 




(Moulh) 



.5: 

(Day) 



/90 \ 
(Year) 



I HKRKBY CHRTIFV. That I attc.iaed acroascl from 

l..a...^>l |-^H.9oH t<. 6..0ll...|.vJ^.H icp 

hat I last saw h -^>A>.ilivc on >^^^ *^ '^o 1 






,n.l that death occurred, on the .h»te state<l al.ove, at 



S!N<U.E, MARKIKI). 
WIDuWKI) i)R DIVOKiKO 
'Write in social dtsij^natinn) 




HIKTHPI.ACK 

(State or Country'! 



NAMH OJ- 
lATllKR 



HIR ruPI.ACE 
Of l-ATHKR 
'Stale or Country) 



MAIDKN NAMK 
OI- MOTHER 



<k^ 



■OArvv 



CC\Aa.>Ol/vv<X 



tcL 



V 1 J A/^r^lr VuxL^^_ 






rf 




\JL<X 



'yi) 



niR'rupuAci-: 

Ol- MOTHER 
(State or Conntry) 



i 



'ft-A.^C^ UXa X/tV 



OCCUPATION (? 



V_^VX^^M/>vAX^ 



Rrsidfif ill Sun Fmnrisro 



30 )'iti' 



yf,nith< 



/hi 1 A 



THK AHOVE STATED I'KKSONAK PA K IK' f I. A KS AKlC TKlK TO Tllh 
BEST OH MY >S^''»^^'*«*-''^'^/^ HEMKH 

(Infornjant 




(Adilress 









d M The CATS!': Oi" DI'ATH was as follows 

/^^ ^^ J^o/trs 




'^ 



nr RAT ION )V'<7;.? 

CONTRIHl'TORV 



Months 



DURATION 
(SIGNED) 



Years 



Mouths 



Days 



//outs 
M.D. 

At 



K^^^^^^' ^^ ({' Y [^ n 

VL l. TooH (Address) ^ O^AfiH 

^PcilAL INFORMATION only... !-spilals, ins^tullons. Transients, 
or Recent Residents, and persons dying anay from home. 

How lonq at 
Former or piar e of Oeatli ? 

Usual Residence 

When was disease contracted, 

If not at place of death ? 



Days 



PI \CK OI- m-RIAL OK REMOVAL 
INDERTAKER U OwU^^vU V 



(A(Miess 



DATi: of IMKIAI. or KEMOVAI, 

kWtM 1 T90H 




AGK should be st 



ateil EXACTLY. PHYSICIANS should 



N. B.— Every Item of information .hould b. CHrefuHy h"PP'-'«- „^,; J;Hy''"lass!fled. The -Special In?orm«tion" for p.r- 
•tate CAUSE OF DEATH In plain term., that .t m..y ^^ J.J"^;'*"' 
J. .._^ c K«.«« «hould be ftiven in every instance. 



son* dyinft away from home should be & 



: I I 



t 

■I 



MJ 

\ 



k 




•v.. 



u 



n-. 



1—. --^.. 



w 



N"I 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFiCATE FOR INSTRUCTIONS 

J?i^(Si\'fprprl A^o. loo 



noav'l -f ll<:ilth- 



l-No ^^1^^^n!kl'C< 



d-trvvvo 




XiA>' 



190'] 



V 



V 



Dep 



•■« I ■>■ f/^ 1^^ #^ ,•-, ■f% ^ 



DEPARTMENT Of PUBLIC HE ALTH=City and County of San Francisco 

Certificate of H)eatb 

PLACE OF DEATH:-County of 6 ^ W i;uV>y:^^Gty of CJ^^v OXapXV^CC 



fNo. lU U^«-t'>VA...'-'.C'\~.' 



1 



/.<wM'"»-<r>AX) 



FULL NAME 



St.: I Dist.; bet. cC/Xvyvr^xlj and 




v\u 



7 .TIc^TH OcTu.s .w.v rnoM USUAL RESIDENCE o.vr r*cTS c_*^.t^.o -j,^U^N^bcP ^J.^^^;- JJ-^^^r^^^'^^"" ) 
V ir DEATH OCCURRCD IN A HOSPITAL 




.A/"y> 




0(M.. 



<]:\ 



DATK t)F niRTn 



PERSONAL AND STATISTICAL PARTICULARS 




a 



0\ 



COI.OR \ 



Month* 



\(.K 



1 io )V.,,.. T 



(Day) 



M.iHlhs .. 



(Vear) 



a 



/J«» »;v 



MEDICAL CERTIFICATE OF DEATH 
I).\TE OF DH.ATH 



i 



r\.A.U 
(Monlli) 



5 

(Day) 



(Year) 



SINT.l.K. MAKKIKD. 
WIlxnVKD OK I)!V«»Ki'KD 
'Write in s<kM;i1 (k-siKiiation) 




HIRTHPI.ACK 
(State or CotMitry^ 



<x^ 



OJVK^^ 



ucv^^'CX/wOw 



<L 



N\MT«: OK 
FATHKR 



HIRTHP1,ACE 
Ol- l-ATHKR 
iStittr or Conntry) 



MAIDKN NAME 
Ol- MOTIIKR 



HIRTHPI.ACK 
Of- MOTHHR 
(State »)r Country) 



11) ^ 




OCCUP.ATION 
A' 



t^ 



VA^Ow -^-- 









.y/onf/f! 



Ihivs 



I'ill-: AHOVK STATKl) PKRSONAl. PAR rUlI.AKS A K Iv fRlK T<> ' ' " • 
HKST Ol- MY KNO\Vl.i:i)UK AND MKMHF 



(Iiifotniant 




W W> j) 



tlv 



(Address 



411 



^ 



AAJL^VA^XAj"-^-^ H 



A 



li 



"f III-RI'BY CI'RTIFV, That I atten.lea »lcrcase.l from 

. 1 a. Q^>i p^Hi9oH t<. ^.i^ni ..|.sLj.H ... up 

that I last saw h -V>^>ftlivc on J^^'^ ^^ '"^ ^ 

ami that death occurred, on tlic date stated above, at <b 
j . M The CAUSIv OF DIvATII was as follows: 

(^S.^Ib'VoJL fo.r<rf>>v^rvJlva>aJi- '■ ■ 

Cl/^«^^vi1>^U 



nrR.XTION years 
CONTRIIUTORV 



Monihs Days 



I Ion PS 




)'(\irs 



I)r RATION 

(Signed) .— n a j, 

k) iqoH (.\d<lress) 1 H ^ 



Hours 



a 



}fonths /yays 



FECIAL INFORMATION only for Hospitals, Insrttutlons, Transients, 

of^Rfcfnt Residents, and persons dying away from home. 

How long at 

Plareof Death? Days 



former or 
Usual Residence 



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



W.CKOFBI-RIALORRHMOVA.. I PATH of H. k,.,. ... RKMOVAl, 
INDERTAKKR V /CCOLAVAwiL ^H^^ ^ L , 



(Ad»liess 



15 ^H 



■I"— — —1^— .i^^^— —— ^-■^— ■^^^■'"'■"■^■"■"■"" ... » t cl EXACTLY. PHYSICIANS •hould 

N. B. F.very item oi inform«tion .hould be careV'ully HuppUed. ^'"^^ "^7,3„j',*d" %he "Special lnform«t!on" for p.r- 

«t«te CAII8F OF DEATH In pinm term., that It mny be properly claMltie 



state CAUSE OF DEATH m pi- 

-on. dying away from home should be feiven .n every instance. 





1 j 

-■I 

ii 






^ 'I 



•!^l 



mi. 



'Mil 



1 



r 



IIT ■ » 



!i.M 



^ir 



i-i 



m 



't 



II 



WRITE PLAINLY WITH UNFADING INK 

,,,,,,,1 ,,f iir.ith !•■ No. >^ 1^'gS;?»l»^^^^co 



/>^//r Filed , \L\^K^ 



Im 1 



ie9(9'l 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

139 



Mes^isfered J\^o. 



i 



^tL\^ 



i 



\^i 



D^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of ©catb 

( X\. S. 5tanDar^ ) 
PLACE OF DEATH: — County ofC'O.^ 



Ill ;:i ^ 

;v<XAAXA.<i/C'0 City of -Oyro .)UU>xCV<La() 






FULL NAME 



i 



)l 




•-i;\ 



PERSONAL AND STATISTJCAL PARTICULARS 

COI.oR 

vvtit 



QfXcuL 



i).\ 1 1". t)i- itiKTn 






(Day) 



./.'^..Q.H 

(Year) 



\<'. K 



^IN<".I,H, MAKUH".!) 



J 'ilJ I s 



M.iuths 



I hi \s 



WIDnwici) OR I>IV(»Kii:i) l) 

iWritfiii siK'ial (Usi^iiatioti) »^ 



L 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Month) 



t :;: 



.t.„ 

(Day) 



(Year) 



I HHKi;i5V CI;RTII-V, That I hUoh.UmI deocased from 

u..b 190 H to ...i^-' 



1 



.-\Ar.\X..\j 



190 

that^I last saw h " alive on ^- '9° 

and that dc-ath ..ccurrcd, on the date stated above, at 
^ M. The CAT SI*: OF D I*; AT II was as follows: 



lUKTmM.AOK 
'St:itf or Covmtry^ 



NAMl'. U|- 
lATin;R 



J^ 




lURTHPI.ACK 

01 l-ATFIKR 

I Stall' or Country) 



MA 11)1:%' NAMK 
<>l< MOTIIHR 



TITRTHPI.ACK 
01 MoTllKR 



9 OC^V .>V<V>VCA^^ C.0 

% ^ A 



Slate or Country) -Y ^OP 








tKCri'ATlON 



f\Vsi(lri1 ill Siui /'i mil is.'ii 



) 'lUt I 



}r,>iitii- 



/).M> 



rm: xuovk stxti-d pkrsonai. far lun. m<s ari; trik t«> inh 

IJKST ()!• MY KN()\VM".D<*.H AND ni-.I.ll.l- 

\J0 j^voLcLvvc^^ 



(InfoTniant 



*• KN 



Jiyy\K 



(Addrrss 



1 
^3H 



V\ 




1x4-1^ 



,<X>^^rv4-Kvvt 



4 



- 



.4a?x< 



DrRA'I'ION )'<'</;j, 

CONTKIIUTTOUV 



VD..(5-.X.Ok-xj 

Months 



Days 



Hours 



Years 



Mouths i^ays 



Hours 
M.D. 



DURATION 

(SIGNED) lI lAu CLltv>Wv 

Address) lOOS^nWo-tO^ ^^ 



'^V^^Lu^ b i()0 ( 



SPECIAL INFORMATION only lor Hospitals. Institutions, Transients, 
or Recent Residents, and persons dying a^»dy from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



PI.ACK 01 HIRIAI. OR K1:M<»VM, 



H 



:t 



I'NDKRTAKKR 



^. !vL<K<.<^V y^ ^^ ^H.<t. 



KxriCof iM KiAt- or ri;mo\ai, 

1) .., 



T90 i 






u Ilk t tcti EXACTLY. PHYSICIANS Hhould 

!N. B. F.vcry Item of Information •houhl be cnrefuMy m.ppUcd. ^^*'' " ""asiil'fled.' The "Special lnform«tlon" for p«r- 

.tate CAUSE OF DEATH in plain term,, that it mny he properly 
«on. dylnft away from home should be given .n .very instance. 



I' 






il 



n 




I \ I 



' 



1: 



' 



ivu^ 



^f^: 



lii iiiitt 






^ 



I ' 



r 



\u 



U 'f 



h * 1,1 



,,f Jl. .'Ith- I- No I' 



f-y^aft-wi nf^y <-'') 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^ 

^,1.1, yiu n ^-'^^H ""-•'-' ^'^ ^^^ 



llei^istercd -A'o. 



_ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH:-County of6,CV>^ ^^UV^VCV^ Gty of C) O^ ^ VOjVV^ .. 



No. 



loll O.vlU- 



^d^J. 



' " ••eiiAi orCIOrNCEGIVE FACTS CALLED 

( - rF"o7AT°H^o^c"u%r;.;"rHo^s"prT^At Tr^t^^'^.tJv.on o.ve .ts name . 



FULL NAME 



St/ ^ Dist.;bet. h^O^lL^.. and 



g -lIX. 



FOR UNDEffl'SPECIAL INFORMATION" A 
INSTEAD OF^STHEET AND NUMBER / 




■^HX 



PERSONAL AND STATISTICAL PARTICULA RS 



COI.OR \ 



cU-'^^y^- 



DATK OF WIRTIl 






as /iH.a ... 

(Day) (Y«^a''^ 






AGE 



bl 



) 'rn I s 



[ Mmf/is IaJ '^".'•s 



SfNC.I.K. MARKIKH. 

winowKD OK nivoRiKn 

iWritf ill social tli»i}.'nali>'ii) 



^\ 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 



/l(M<)iith)(l 



..b 

(Day) 



/go 

(Year) 



ThRREBY CKRTIFV, Tli:»t I attcMuUMl .Icccased from 



,at I last saw h A.'v\xalive on . H\A!Xu..b 



1 90 



niKTMPI.AOK 
'Stale or Country'* 



f\) 







\M^V<X/>v 



''''': ii^iic^xu 



.y<u 



HIRTHPl.AOH 
OI- FATHKR 
(Slate or C(Miiitry) 



e 



MAIDKN NAMH 
<)1" MOTHKR 



R\-n<ir<f III Snii rninri^>'<> ^ J^(7»5 ■ 



lUKTHPLArK 
•>l- MOTHHR 
(Slate or Country') 



that I lasi saw 11 --' " »o..»- -.. ,/| r 

and that death occurred, on the .late stated above, at 
.0. M. The CAISK OF DlvATlI was a^s follows: 



» 1 
1 



M) -i A^V^^u^Jt-v^^-^Ct^ 






DI'RATION t Yi'ars 
CONTRIlU'TcmV 



Hlofiihs * Days ^-Hours 



DURATION rears Months Pays ' Hours 

( SIGNED ) ..U) OlIL^ C ^iv^tU.v .. M.D. 



■V^ 



■^ looH 



/)</ V.v 



KJ: TKIl". 1"<» '"'""• 



r 1 n-: a lu > v k st a t 1-: i > i • k k so n a i , 1 • a u r i r i • i , a r s \ 
HKsr oi" MY kno\vi,i:d»".k and hkmkh 

<.nf„™,„n, CUJUa CI ^M^ ^^ 

!,JJLv.NX ^^ 



(Addrtss 



b3.1 



0^ 



Special information onl> for Hospitals, Institutions. Transients, 

or Recent Residents and persons dying awav Irom tiome. 

HoM ionq at 
Plareol Death? Days 



Former or 
Usual Residence 



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



I'l ACK OI- lURIAI. OR RKMoVAI, 



DATI^o! HiKlAl. 01 KKMo\"Al, 
^vUa ^ ■■ T90H 




(Adilress 






PHYSICIANS Rhould 



"■ ' .■ . ACF should he «tate.l KXACTLY. PHYSI^IA^^ snou., 

IS. B.— Every Item o* 5„form«tion should be cnrefully «"PP'"=«'- ^^;^^^l^^ classified. The -Special Informstlon" for p.r 

state CAUSE OF DEATH In plain term., that it may .^^ [»-»;'•' ^ 

... .._^ _.. s i,««^ should be Aiven in every instance. 



son* dyinft away from home should be ^ 




\ . \ 






**» 



^•^, 






t 



WRITE PLAINLY WITH UNFADING INK 




CV^O-VCA^ 




i.90 4 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

141 



Ee^Lstered J\^o. 



Deputy Hea!th Off?^'*r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( la. S. StanDarD ) 



n 



No. 



PLACE OF DEATH: — County 



^ ^ ^on 



St.; 



Dist.; bet. 



' and 



/ ,r OCATH OCCURS AWAY "OM USUAL « ^ S I D E N C E o v^ ;*CTS c^^t^^ ^^^^^^^ ^^ ^^^^^^^ ^^^ ^^„3„. ; 

V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTlun u 



FULL NAME 



IX' 



.NJjLLuix 



(^ 



K 




LS^'yxr^M.. 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



vJlA^xoJx 

DAT!-: OI- lUKTH 




iMontlO 



(Day) 



(Year) 



ACR 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



.1 

(Day) 



(Year) 



31 



Vfars 



j^im/ks 



Da \s 



SINC.I.K. MARKIKF). 
WinoWED OK DlVoKiKI) 
' Write ill siKial (Itsipnalioii) 



niRTHlM,AOK 
(Slate or Country^ 



NAM1-: <)»•■ 
FATHl'.R 



niRTHlM.ACK 

Ol J-ATUKR 

I Stale or Country) 



O Au\ vcvLc 



V\-CU 



.AwWV^V. 



w^^H 

f (Montl^) _^ 

TliRRrvBY ClvRTlFY, That I atteti.kMl .leceased from 

.aN^L.I.a 190 i to .|vlL^..b 190 H 

that T last saw h •A'v alive on |^^^ ^ ''^ "" 

and that death occurred, on the .late stated above, at c 
Qj.M. The CAISP: C)F DlvATII wis as follows: 

£olxcv^x^-.^^..4.^-j^^«^*^ 0L^^^->^ 



PI 'RAT ION - yi'iJ'S 
CONTRir.lTORV 



L Monihs ^ Days 



Hours 



_ /C-trvL^ 



lURrnl'LAl"H 
«»J- MOTHKK 
(State or Country) 



^CL'V 



x/L. 



/),7 1. 



(KCIPATION 

TIIK \U()VKST\T1-.I) I'KRSON-M. J>A K rU" T l.A RS A R 1-, P R T K TO THh 
ni:sT Ol- MY KNOWIJUX.K AND nKUIKf- 



(Address /I A b 





T\ 



^W.K.(X.\J 



DURATION 
(SIGNED) 



)'r(7rs 



Mouths Days 



\^„/^\'\/^<r\i 



I lours 
M.D. 



JJ^ 



190 



( 



lldre^s) iDafdcv^uiJ^^ 



""^P EC lAL IN FORM AT ION only for Hospifdis, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 

KlR^^dence oMa^A...)^ St^e'Ti;^^^ 30 Days 

When was disease contracted, 

If not at plar e of deatfi ? 



I'l \CK OI- m RIM. OR RKMOVAI 



INDERTAKER 

^Address 



DATl'. of HiHiM. or RI:M<>\AI. 



<i F.XACTLY. PHYSICIANS should 



!S. B. Every Item of Information •houlcl b. cHrefuliy HuppI.ed. ^^'^ clB««Jfled. The "SpeclBl InformBtion" for 

state CAUSE OF DEATH In plain term*, that .t may \^ ^J^^] 
•on, dyinft away from home Hhould be ft'.ven m every m^tance. 




\ 






•i 



^ll 






V 



\>v. 






\\ 



A^ 



,i 



^w^. 



.Hr.'i^tfi'V. 



*• '<.<•. LV 



ll\ 



■,\ ' 



I ••■ 



(•!, ' 



•A 

it 



\\ 



's,k 



i 

'mil 



,,;,,,! Mf llcnlfh- »•■ No. 1 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

*S3r»>, „..,. ,... RtrER TO BACK OF CERTIFICATE F OB INSTRUCTIONS 

142 



t'-?^»'«?i) Mftl' C<t 




iy^s 



Beifislcrcd J^''o. 






cer 



/>^/^' Filed y 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of Beatb 

( U, 3. StanDarD ) 
PLACE OF DEATH:-Coun.y of iou^-i^^U^m^^C^y ,^ OJ^lyyJX^^'^^ 
No. nm i^-ta^,A, ^„.^„,^Sj.,^^l^,^^Djs.;^bet.ffAX^^^^^^^^ ) 

( " r,"or.T°»"o^c"u%*.r;/.''r-o".^p"*.t o%'?-;"?'4';"'o',;r,;i name ,.sx»o ., .r.... .«. ~u»=„. ; 



FULL NAME 



iV\_' 




PERSONAL AND STATISTICAL PAR TICULAR S 



SKX 



Ollcli 



COI.OR 




DATE OF DKATH 



EDICAL CERTIFICATE OF DEATH 



.^tt 



DATE OF niRTH 



L 



(Monthfl 






b 

(Day) 



v.a.a..H-.. 

(Year) 



AGR 



Ww« 



•^ Mottths . T /Jul. 



"-INCI.K. MARUIKD 
WinoWKD OR DIVoRfKD I) 

Write ill s«x-ial (1< sivriiatioii) -n[ 



lURTMPLACK 
I State or Countiyt 



NAMK or 

FATin;R 




HIRTHPI.ACK 
<)!• FATHKK 
(Stall f)r Country) 



MAIDKN NAME 
OF MOTHER 



TUkTHIM.Al'E 
oi- MoTHF'.R 
(State or Country) 



OCCri'ATlON 

hVsidrit ill Sdii I'l a III m'i> 



1 

\1 U 11 



lonth) ^ 



...b.... 

(Day) 



(Year) 



I HKRKRY CI'RTrFV, That I atteii.KMl (Uocastnl from 

to ."" 190 — 

, - — 190 ^ 



Tgo 



^ 



tAj./VX/ AjMaj^>^^ 



that I last saw h :::— alive on ■• 

and that death occurred, on the date stated above, at • 
^j The CAISI': OF DlvATll was as follows 



l)rR.\TION Years 
CONTRIIU'TORY 



Mouths Days 



/fonts 



DURATION ^''Y^ ^ Motiths Pays 

( SIGNED ) ti) . U. Vl[y\iL\Am. 

Addrcs.) ISOSdU^ktov^-^ 



/fours 
M.D. 




)'riii ' 



j^^^^ff* ^^3 - 



lhi\ 



tmj: auovf. st\t»-i> pkrson.m. i'\k ricri,\Ks akf: trfh m im- 

in:sT 01 MY KNOWI.HOi.E AND m;MhF 



(Informant 



Si 



x.uiress aisi 'L(j>'wiha\.4...a.t... 




i4...a......wH- ( 



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

HoH long at 

["^•".V., . Place of Death? Days 

Usual Residence 

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



•"»" 



n \CK OF lURIAI. OR RHMOVAT. 



DA rj", of Bi RIAU or KF:Mo\\I, 

190 \ 



^wL\A,n 



UNDERTAKER V itV.V^'^V'w.- 2 ^ A v , 



^\(i(ii I ''^ 



N. B.—Hvery Item of inWmntion should be cnretuHy supphed. A*;J; « '^ 
state CAUSE OF DEATH in pl«1n term., that .t m«y »>« P;"''^'"^ 
•on. dying away from home should he ftiven m every Instance. 



.uld be stated HXACTLY. PHYSICIANS should 
classified. The "Special information" *or p»r- 



t- 



M' 



'.i 

i 



\ J 



: it 
I I 



'41 



I 











WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 
A ft ..... M i:>.. ,^ :..!.>. .n /I X^n l-4o 

I)(it(> Filed, M/L\JLu 1 






100^ 



Jic^i.slcrcd jVo. 



ic^^vv^ XcA>M Deputy Health omcer 



¥■ 



A 



DEPARTMENT OFfUBLlC HEALTH=City and County of San Francisco 

Cevtificatc of IDeatb 

PLACE OF DEATH = - County of O^^Jx^Xm^xxi^ City ofO^'rv O^^x^^a^ 



v ' 



N 



o. liV"\ lUDuAi 



SU \ Dist;bet. ^>oJ 



and .U\JLi/>\' 



( -^^i;fec!«-v -::i^^t?^^^s^^^^^-^^^^^ 



FULL NAME 





O^aa^d^ K)M^h^^^opu^ 



PERSONAL AND STATISTICAL PA RTICULARS 



lA-VUX, 

DATK OF HIRTH 



COLOR 



liiLtk 



0^ 



(Dny) 



(Year) 



At.K 



(p^ IVfl.. V 



Mtmths 



Vi: 



Dii 1 . 



^IM'.l.K. MAKKIKI), 



«l 



WinoWKI) OR DIVOROKD A 

iWiiuin «MMal (ksi>.rtiati<>ti) \ Yv^ I 



4r 



4- 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



hfonth) 




(Day) 



(Year) 




niRTHPI.AOK 
iStatfor Country^ 



ti 



N'AMK OF 

iATin:R 



niRTH PLACE 
<1I" lATHKR 
(Stiitc- or Country) 



MAIDEN NAME 

<M MOTHER 



lUKlHVI.ACE 
<>1 MOTHER 
(Slate or Country) 




sXfruMx 



TITrrT^BY CMRTIFV, That I attoii.UMl dercased fn.m 
%\ U/^S in |^^?f ^ ''^"^ 

that I last^saw h JL'v alivo on ^ ^ 1^'^ 

an.l that death occurred, on the .late stated above, at 130 
...Gb. M. The CAl'SIC OF Dl^ATH was as follows: 




-VX) 



TM'RATIOK -^ >Vrt/-.? b Months -Pays ^...Hoiirs 

CONTRIIU'TORV 






_ c 



^vJLaA 



\^ 



OCCUPATION 






/),n 



Till- \]1.>VEST^T1-I) I'KKSONAl. \'A RT IC T I.A K ^ AKl. PR 11. 1" I""' 
1?HST Ol- MY KN()\VIj:i>«*.E AND HEI.li:!' 






'Tnformant 



Qw 



^ 



1 



(Afltlress 



\%l'\ 




aU,v-tJ% 



I ' mi 



^ 



d.1 



^1 



nrRATIOX yr<rrs .V.»///is /hjys 

Addr..s)l^^^ Ul.cKvc^-_! 



( SIGNED) 



hh^ 



//ours 
M.D. 



IQOH 



( 



^ SPECIAL INFORMATION "nl> lor Hospitals. InMitutions. Transients, 
or Rerenl Rfsidcnts, and persons d\inq av^av tro-n home. 



Former or 
Usual Residence 

When >»as disease tontrarted, 
If not at place of death ? 



Hflx lonq at 
Plare ol Death .* 



Days 



l.j,\rh: Ol- lURIAL OK KEMO\ \I 
rNHERTAKER VO^VtVLT 



i» \TK of iMKiAi ..1 ri:m« tV \i. 



— — ~— •■•—i^— ■^— — ■— — ^-■^•■'^■^^^^^^■^■'^^"^ ,, . t t I FX4CTLY. PHYSICIANS rthoulcl 

IN. B. F.very Item of lnform«tion should h. c.ru^'ully supplied. ^^;|^ ?/;;'" ^^^"..^j" ^he "Specinl lnform..tl on" for p.r- 

«tatc CAlISr OF DFATH In pinin terms, that .t m»y he properly 
».r»n, dyinft away from home should be H'lvcn in every instance. 









I 



;♦ 







fi^ 






I - 



\\ ' 



;» 



> 



V 



Mi 






1 



Jktm 




WRITE PLAINLY WITH UNFADING INK 



j.„,:,>.! ..f llc.mi-l- No i^ t"J^fll^nSi.]'Cn 



1^^-c^iwHA. Deputy Health 

DEPARTMENT OFTUBLIC HEALTH 



— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

144 



liegistei^ed J^o. 

=City and County of San Francisco 



^No. 



Certificate of Beatb 

( "a. S. Stan^arD j 
PLACE OF DEATH:— County ofCVoAV Aa/-YvCcA C t City ofCJ<V>v 0;v<X. yvcui.cc 

l"^S"^L.d.^M St.; f Dist.;bet.i)jtArv<tCuix>U> and €>Xfr(LtAA^^^^^^^^ 

/ „ DI.TH occAs .w.. r-o« USUAL RESIDENCE =,.1 r.CTS CM.LIO 'o- "X"" ,"";'i„'"'°„";;E'.°" ) 
t ir Ot.TH oefcuRRED IN « HOSPIT.l OB INSTITUTION OlVt ITS NAME INSTI.O Or STRtCT «N0 DUMBEK. / 

FULL NAME a.:^kkA.,0- Q^aXA) 



PERSONAL AND STATISTICAL PARTICULARS 
(JO, „ I COLOR 



s !•; x 

DATK <)I- lURTJl 



L 




LL'»J(v> 



(Month) 



(Day) 



(Year) 



\<;k 



^ iC> y,-ii,, ...Tr. \t»uihs...T. Days^ 

"^l\(.l,K, MAKKIKP, 

WIDOWKI) OR DIVORrKI) \ 

(Wiittin sorial (It si^nation) I I \ i I 

I. 



MIRTHTM.ACK 
(State or I'ountry^ 



» ATIIl'.R 




\.V0 KJhJX 



aA.v a 




lURTHPl.ACH 

ni- I'ATMKR 

• Statf or Comitrv) 



MAIDI-.N NAMK 
<>)■ MOTMKR 



JMRTHI'i.AOK 
»>»• MOTllKR 
(State or Coumrvl 



Ll/>vk/ 



^'V^A.O'Vy 



*« 



OCCUPATION 



'(Xj\ . 



hV^idfif in S(in /•"tanrt'ifn 



MEDICAL CERTIFICATE OF DEATH 
DATE OH DKATM 



Motith)n 



(Day) (Year) 



I Iir^RKRV CI^RTIFY, That I atten<kMl <lecease<l from 

JXy\}. 10 190 S to ...|\.\.lu. k; 190 4 

tliat I last saw h -XSj alive on .^^^tv.!, b up '; 

and that (Uath occurred, on the date stated above, at « 
(X M. The CAl'SI*: OF DlvATlI was as follows: 

\JL.^sk. 



DURATION 3. Years ^ .iron f /is ^ Davs ' Hours 
CONTRIIJUTORV LlvtilA.A^ Ox.U>v.tHi^o 






Hours 



DURATION 10 Years Mouths Days 

( SIGNED ) \J. \J .\l...rl<a.VVV>V' M.D. 

xLb TooH r Address) H 1 \) a>v W^> .iL^^.. 



PEcHaL information only for Hospildls, Institutions, Irdnsipnts, 
or^Recent Residents, and persons dying away from liome. 



"S 'I'iJ I . 



yr,»iths 



IhlVS 



THJ-, AHOVK STATi:i) I'KRSONAI, PA R rirf I.ARS ARl". IRIK TO THK 

HKsT ()i- MY kn()\vi.i:d»;k and in:Mp:K 



(IllfoTIIUUlt 



( \<Mrt'ss 






qs^ 



■\ 



Former or 

Usual Residcncf 

Wfien was disease rontrar ted. 
If not at plare of deatli ? 



How long at 
Plare of Death ? 



Days 



PI,ACK OI' HIRI \I. i)K R1;M»>VAI. 



DATllof m KiAl. or RKMOVAI, 



I-VA." 



TQO i 



nd,.:rtaki:r UJ4rWvvMX lUx <^ Cc 



r;:;^^: ;:::r. -:^:t. .r:rr.r^.:r'^r-e.v. J=r.r-'/- 



^« B.— — Rvery Item of InffoririBtion 

state CAUSE OF DEATH In p 

son* dyint away ffpom home should be ftiven in «very Instance. 



• I 



t A 



w 



\ 






«' I i I 

' 1 



.1 '' 

■I 




mi^iMt 



I 





\ *\ 



1 



^iV 



■■ill 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,,,,,,,,,,.,111. . No ic^-SS^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dft/r Filed y 

{ 




a 



Re^isfci'ed JVo. 



145 



\ny^>u Deputy Health Qflflcar 

DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "U. S. StanDar? ) 



PLACE OF DEATH: — County of 



^\ 



XVC'>X' 



City of a^>v 



6 a^>v (K^l^cul Co. I 






^No. 



St.; ——" Dist.;bct. 



and 



/ ir DEATH OCCURS AW*V FROM USUAL R E S I D E NCC Gl VE FACTS CALLED FOR UNDER "SPCCIAL INFORMATION \ 
( IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



.l/YCL 



^CV'>"vA..rO: 




PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 

DAT!-: »>l- lURTII 

cxv H /. 11 V 






lllk.U 



0)1 



MEDICAL CERTIFICATE OF DEATH 

DATK Ct\- DKATH 

...b.. 




I go \ 

(Year) 



(Mutith) 



(Day) 



(Year) 



AC.K 



O^ Vrai 



H 



Moulhs 



Pa 1 . 



MN<".l,K, MARKIKI). 

wn)n\vi:n or i)!v«)Kii:n 

•Writfiii .MK'ial (li"«iv'iialit)n) 



Q1I 



o/vvvxdjL 



HIKTUIM.AOK 
(Slatf or Cotintrv^ 



\ \M|- <)|- 
IATin:R 



lUR IMIM.AOK 
f>J" FArHKR 
(St:itr nr Country) 






^tAll)KN NAMK 
<U- MOTHKR 



IHKTHPI.ACK 
'>K MOTHKR 
(Staff or Country) 



•I 



M 



OCCUPATION 



(JVDCKLv^ 



Krsufrif III Siiii /iitniiM'i) 



I IIi:RlUiV (.M'RTII'V, That I attcmliMl deceased from 

— to 



190 



til at I last saw h alive 011— 



^90 
190 



and that death occurred, on the date stated above, at 
•rrr— M. The CAl'SIC OF DICATII wa^ as follow? 
vj A.,'(Ky>JL>^AA^^V^.. U<X\Xvivva^v^ 







nr RATION )'ftjrs 
CONTRir.rTORV 



Mouths Days 



Hours 



DURATION 



Years 



Mouths 



Days 







(Signed) \J \JJi.W«rv\-L 



/fours 
M.D. 



Mu- 



Jf 



W 



qo 



4 (A.ldress) d/0.>v. ^ <^ ^" '^ ^ 



SPECIAL Information only for Hospitals. Institutions. Transirnls, 
or Rcrenl Residents, and persons dving andy from fjome. 



) V.7 ; 



y/oiif/n 



/),M 



TMi: \HOVH ST\I1-I) PKR<.ONAI, I'A R IIC C I. \ RS A R I: IRIK li ) TIN-: 
HKST OH MY KNOW M.IX.H AND lUvlJi:!- 



fiiifoMuaut !rw 



vu -\X^Ax.rv'^<x.v A\x\/v>v\X' 



(\.1.1uss 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Diys 



PI.ACP: OI- lURlAI. OR KKMoXAI, 



KOI JU 



I) A'ri: <>: juhi \i. or ri-;mo\ai, 

T90H 



INDICRTAKKR 



(Address 30 S OlX^^^t^V,^ 



*. .. ^ .. 1. I AHF .Hniilfl he Ktiiteci liXACTLY. PHYSICIANS should 

N. B. Rvery Item of Informntlon .houltl be cnrefully supplied. AGE should ^ ^y'^'^^/^^r^^ , ,„w'o-^ation" for iwr- 

•tate CAUSE OF DEATH In plain term«. that it mn> be properly classified. The Special Intormat.on for pmr 

•on* dylnft away from home should be ftiven in every Instance. 



'I 
til 



« 



I « 



if 



u 



Ir 



i I 






h t 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



T,.,Mnl..f H.Mlth-FN'o. ,5'«-?'»?.i-.H&I'Co 




d^^-vCAw^ dOA^vi ^^^ 



if \^-ti <r- 



190 ^ 



Bc(^^f\sfri'e(l A^o. 



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



Certificate of "©eatb 



( "a. S. StanDarD ) 



PLACE OF DEATH: — County 

( 



ofCJO/^V .KOuyx^^J^^ City of O/Oav K<X'if\^^^^^ 



h OwiX^a^VvCu, ub>-M^vtstiV "'""' Dist; bet. 'and ^. 

.O VyrLVVVlVrvwL^ ..ouaJ residence g.ve tacts called tor under "special information- \ 

' r."D;iTH^OCcXRr;.N'<E:o^s'rT"Al^ o"r"nSt'.?J;'o'/cIVE its name instead or STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




x^^CPrv).. 




L 



Uliuti 



DATl-: OF' niRTll 



<Motith) 



<I)ny) 



(Year) 



AC.K 



O J V(7 I . 



Miiiil/is 



Pil \s 



WinoWlU) i»K I)!Vt iKlKI) 
fWriU- ill stKMal (k-sijfjiation) 



IMKTHPl.ACH 
'State- or Country^ 




NAM I'. Ol' 
J A Tin; R 



lURTHlM.ArK 

Ol' l-ATHKR 

I Stat f or Country) 



MAIDKX NAMH 
Ol' M()rilI.:R 



iMK I'lnn.ACR 
or MoTin:R 

'Siatf or Ooiintrv') 






OOCt'PATION 
Re 



fsidfd in San /■'iniu/s/'n \ ^ )V(M a 



''I 



*■ .\/.;if/i' 



/),i\ 



TIM-: \UOVK SI'XTII) I'KK^ONAI, I'A KT FTf 1. A KS ARl- TRTH T< ) THH 
IJKST Ol- MV KNOWl.I.lx'.H AND m.I.Ii: I' 



'Infotinant 




vnUvCtt^ 



Xddvrss 



Hllll* 5 



\A.^r\\, 



ti^ 



t 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH 



(Vi-ar) 



iITkrI^BV d-;RTII-'V, That I attoii. led deceased from 

— — — — -1()0 

— — -■ 190 



til at I last saw h 



— nlive on 



to 



and that death occurred, on the date stated above, at 
— — M. The CAISIv Ol' DI'ATII was as follows: 

/)ays " 



DTRATION 



} 'tars 



Mouths 



CONTRIRUTORY 



Dl'RATIOX 



Years 



.}fonths 



/hivs 



( SIGNED ) UfrVCTVUA; 



HVV.I1.L. 5^ T()oH 






PEC 



( 






Hours 

Hours 
M.D. 



v<:.t 



Special information only for Hospitals, Insfiriifions, Transients, 
or Recent Residents, dnd persons dvinq away Irom home. 



Usual Residence i » a>i^ ^^ 

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



PI.ACKOl-' lURIAI. OK Kl-.MnVM. l.ATI'. ..1 HrKiAi. •>. KKMoVM. 



1 



smCRTAKHR ^l ivlL (KU V^ '^^^^ « 

1 S 1 MyVvA,4.MrrL at 



T90H 



fA«l«lr«-ss 



N. B.- 



— "—""^ I- 1 A(^F. Hh.nild be stntecl F.XACTLY. PHYSICIANS Hhould 

n of •mforniHtlon .houicl be cnrcVully suppI.eH. ^^^' "7"'^' " ,j^j ^hc "Speclnl Inform..tion" for pT- 
8E OF DEATH \n plain terms, that it may be properly cla««.tieU. He , 



-Kvery Item 

state CAUJ^.- w. -- - , • . - 

son. dylnft away from home should be ftiven In every instance. 



t! 



« „ 



i 



< 1 



• ♦ 



\\ 



u 



•*. » -*, 



ii 



\u 



m 









1^ I 









i»^« 

" 




(;. :'H 



,,f I led nil- »•' N" ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



-t^^^^. HSc I' C< 




1 



n 



njo^ 



JL^vuv^ loi/v-VL Deputy Health Officer 



lic^isfcrcd M*o, 



147 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccrtiticate of Beatb 

PLACE OF DEATH:-Co«nty of Oa>v.i^.v^v^^ City ofCJ^^v ^r^a^CV4CC 



ro 



JI|o. uXli ^ Viy^'-»\tM 



I Jl^) ^^|\A l<xi 



Dist; bet. -. ^'^^ 






FULL NAME 







.tM:.\/vx' 



PERSONAL AND STATISTICAL PARTICULARS 



SK\ 



(HioL ''■ "lli.kd^ 



i)\ I1-: «)i" niK I'M 



Vl.itithl 



(Day) 



(Year) 



AC.K 



3^ 



) V<f » y 



1 1 M„uUi.>. V>. 



Pay: 



SINC.I.K. MARK IK I). 
WIDOWKI) OR I)IV«tRrKl) 
(Write in s<x:ial (k'sijfnalion) 



lURTinM.AOK 
(State or Country) 



NAMl". ()1* 
FATUKR 



niRTHri.AOK 
<)l" l-ATHKR 
(Statf or Country) 



MAIDKN NAMK 
OI- MOTllKR 



HiR rnri.ACK 

<>»•■ MoTIIKR 
(State or Country) 



.K.'yxcx 



L 



MEDICAL CERTIFICATE OF DEATH 
DATK on DKATH ^ k 



(Montm 



5- 

(Day) 



(Ytrar) 








1<:HV Cl'IRTII'V, Tliat I attended dcccase»l from 

% 190H to |v^Lj,..5: 190 H 

that'l last saw h^iw^v. alive on f^^ ^'^^ 

and that <leatli occurred, on the date state<l above, at ^^^ 
(? M Tlu- CVrSIC OF ni':ATII was as follows: 

n 

vj rrUU^A,''V>A^«nv\..<i-. 



I )r RATION 
CONTRinrTORV 



^. 

)'t'ars 



Months 



Pays 



Hours 



Yj^ys 



.}fotilhs 



Pars 



.a 




.\.tLot'>v'cL 



r 



ore I" PAT ION 
Rr 






rVA^ 



THH AHOVKSTATKD PKRSOXAI, I'A RTICC lARS ARl*. TRCH TO TIIH 
HKST OK MY K.NOWI.i:nC.K AND lU'l.H-l- 

(Iiifi)iniant 



(A(l«lress 






^ 



i i K . % OA-t 



Hours 
M.D. 



DIRATION 

(SIGNED) • ,0, a> i» W ■ -. , 




t 



\ 



''SPEfclAL INFORMATION only for rt*spitdls, Insmutions, Transients, 
or Rfccnt Residents, and persons dying away from home. 

Hov^ lonq at ^ 

.^- Plareof Death? O. Days 



Former or 
Usual Residence 

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






PIXCKOF HIRIALORRKMOVAI, DATKo, HrH.A.. or RKMOVAI. 



INDKRTAKKR 

(Aihlrt'ss 



^> O- act I u 



11.61 0.<xt.voLw-wx.' 






"■^ I I K t t il EXACTLY. PHYSICIANS should 

N. B.— F.very item of ln*«rmntmn .hould be cnrefujly suppUcd. JJ;^f; "^^j^^^i'i^j! ^'xhc -Special Information" for p.r- 
--JcAllSF OF DFATH in pl«in term*, that it may be properly cl»H«ni 



•tate CAUSE OF DEATH in pi :„„.,„ce 

son. dyinft away from home should be ftlven .n every .nMance. 



I 

T 



P 



|: 



I ' 







^^ 



ii 



\i 









1 




^ i GiiJ 

H i IHiR 1 




Hi 



m 7' 



i 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

„afr FiM, WU. T ^^^^ RegMered Xo. 148 

lf.vv^ li^H- Deputy Health OfHccr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(Xcttificate of Beatb 

( TU. S. StanDarD ) 



SI Q^ 



PLACE OF DEATH: — County 



of ^^^ .\.-0U^ vOL^-^.i.. City of ^^^^ ^ K<X^^K^ ^€ 




%h- yj:. uumK^J-^J 



St.; 



Dist.; bet.- 



— and 



) 



( ■' -■^B'£^}:v^^:^ :^^^^^—^"i^i^^ -^-" -;^^;'i^" =r •■ ) 



FULL NAME 



IjLO-V' 



,Li: dflir^k^d 



SKX 



DA li: <)1- HIRTII 



AC.K 



PERSONAL AND STATISTICAL^ PARTICULARS 

COI.OR 




Ix 



llUwU 



(Month) 



9... 

(Day) 



rlhX- 

(Year) 



HX JV.n,v \ .V,-.//.s_AX:_^_Au. 



SINC.I.K. MARKIKD 
WIDOW'KI) OR DlVORcKI) 
iWiitfin social (h-sijirtiation) 



HIRTMJ'l.AOK 
'Statf or (.'ovMitry) 



^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH (\ ,j 



JMonth) 



t 



H 



(Day) 



igo 

(Year) 



TlU'RlUiV CICRTII'V, That I attcMi.kMl dcocascl from 

V^:vxJi..Xl 190 U *- .A\Alu....b.. 

that 1 last saw h ..'• • • ulive on >vvU^^ '^ ^^/^ 



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



^;uL-- 




NAMr or 
» atiii:r 



niRTHlM.ACR 
01 I'ATHKR 
(Slatf or Country) 



MAIDKN NAMK 
nl- MOTHHR 




niRTnpi.ACT': 

OK MOTHKK 
(Stale or Countryl 



? 






? 



-M. The CAI'SIC OF DI^ATII was as follows 



....0.'>v^:*!wCW^vv^^>.^<^^<-•^^ 

DURATION ^ Years - Mouths 1 1 /A/j-s ~ Hours 



CONTRIIUTORY 



S' M*mths ^. 



A» 1. 



I 



OOCri'ATION n Li 

TlIK AHOVKSTXTl-Dl'KRSONAl.rARlUl l.ARSARi: TRCH To TMH 
HKST Ol- MY KNo\Vlj;i)(.K AND IJHMl-.H 

(Infonnant OwtvOL ^^Vtr>\l,t\l.k 



(Address .. 



10 Ob 



DURATION 
(SIGNED) 



)'iars 



Mouth: 



Zii 



/hiys 



Hour. 






I()0 



K.ldr.ss^ ^'^^ ^.C.tiu.'X 



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



Former or n h%. 
Usual Residence I ^^ 

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




-r , How lonq at 
( ^ ' Place of Deaf I)? 



th, O ' Place of Deaff)? ^ Days 

M ^^->i" '.^ i cUi-t>^-t . , 



I'l ACK Ol- lURIAI, OR RKMOVAI. 



DATi: of HiKiAi. ..I R1;MoVAI. 



wIa^ 1... 



^qo 



,n....:rtakkk ll^vJX<i. ItvvcUvUk 



(Address 



'Ibt.'^U 



V . 



V^AA^A-tr 



■^■"■^■"■""■^^^^■■■■■■^^'""■'■■"''^■^■^""'""''"^^^""""""^"^^"""""""''"'^^ iH K t t I FXACTLY. PHYSICIANS should 

N. B._Rvery Item o* information .houi.i be cnrefujly supplied. J^;^J; 'l^^.^^.'s^d? ^Th^ -Special Information" for p«r- 
stote CAUSE OF DEATH in plain tcrm«, that .t may ^e prope 
«on, dyinft away from home should be ftiven .n every instance. 



1* 





I i 




• '1 



' " '." 



\ 



, \ 









! ♦ 




■ l I 



lf« 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

EciiLstcred J\'*o, 14 J 



,,„„,, I ,,f II.Mlfh- !•• Nn .^ I^'^^JHSj^MV, 



151 



ii 



nalrFilcl, IjJL n I'^O^ 

Ifrvcv. Lanu„ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of Beatb 

( -a. S. StanDarD ) 
PLACE OF DEATH:-County of6<L^d.Vx^C^0 Gty ofCJo^^v J..va^^^^ao 



) 



(ir Dt»TH OCiuRte AWAY FROM 
IF OCA 



„ OCtURtS AWAY FROWI USUAL RES 
ATH OCCURRED IN A HOSPITAL OR II 



4- 



ii 



^i. 



FULL NAME Uun^«Xl) 





T 







PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



DATK <)I- IIIRTH 







I 



IxaXl. 




I Month) 



^\ /...'^.&H. 

(Day) (Yi-ar) 



M.H 



)>rt» J 



1 



Mnvth.^ 



Pa \s 



MEDICAL CERTIFICATE OF DEATH 
DATE OF I)i:.\TH ,, „ 

(Day) 




190^ 

(Y.-at) 



I HFRIUJV cHkTIFV, Tliat I mUcikUmI .U-ocascMl from 



.„ a y 



that I last saw hriW^ alive on b V^^lr 



190 



190 H 



SINCI.K MARKIi:!) 
WinoWKD nk I>I\(>Kri:D 
I Write ill social <l«sit'itation) 



<3 jL^qAJZ. 



« 



IMKTMfM.AOK 
'St;it«' or Country^ 



NAM}; ()J- 
lATHl'.k 



niKTHPI.ACK 

<>!•■ I-AIMIKR 

I State or Country) 



MAIDHN NAMK 
01 MOTUKR 



r.ik'iMii'i.ArK 

in- MOTIIKR 
(State or Conntry) 







OCCn'ATlON 

Residfd in Sitti I'l a m i^ro 









u r" 

aii.l that <U'ath occurred, on the date -stated above, at O 
..Oj M. The CAISI': OF DHATII was as follows: 

Cn\iL/>A.v^a^^ LtS^^ ' • 





) Vvr ; A 



i Mnnlh^ \ />"' 



Ii 



iili 



lin: An.>VKSTATi:i)I'KRSONAM-AKTirri.\KSAKi: TKIK T' > '"'IK 
HHST Ol- MV KNOWI.Jax'.l''. AND H1-,M1'.H 



(liifoiniant 



(A<hlrcHJ< . 



La UIa, Ol) 



10 3C) C(xi-a\^ ^^' 



DrRATION ' )W;-. ^ Months "X Jhus -/fours 
CONTRIIU'TORV ^S^KoJK^XAy>r.\^.. 

DrRATION - Years H JA';/M.;^- Am ' /fours 



(SIGNED) 



i.W 



A.I T()0 

.4- — 



,\<1«ltvss) lb I 



,tl 



M.D. 



"special information only for Hospildls. InsfiluYions. Transients, 
or Recent Residents, and persons dying away from fjome. 



Former or 

Usual Residence 

Wlien was disease contracted, 
If not at pla ce of deatti ? 

ri \CE or m-RiAi, OK kkmovai. 



How lonq at 
Place of Deatli ? 



Days 



undhktakkr w^ 



vav 




a^ 



DAI'l-", <'•■ IUkiai. 1)1 Ki:Nt<>\Al, 



T90S 



(A(Mi ' ^"^ 



IS OH ^^WXv^^^^OV 



J 



N. B. 



—^^^^ ^B^B^L^— ^^■— ^■^■— ^^— """"^ . pvACTLY PHYSICIANS should 

F.very Item o? InJormnf.on hHouIcI b. cnrcfully -pplled. J;^'^'^^^;f^J^C2 'th; -Speclai Int'ormalion" for p.r- 
state CAUSE OF DEATH In pIhIh term, tha .t m»y - ^^'^^'''^ 
Ron, dylnft away from home should be ft.ven -n every mHt-nce. 




! 



f^ 



i 



« 



IVM 



V 




I'lt: I 







ii 



i. 

y, 

I 



H 



H.>at 



,1 ,,f n.-.-ni> '»• N" "« **ii:«»^n^'t''^ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BeFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

150 

Dii/r Filed, %^M "^ 

J Ml 



c-V^-VVV-O t^Jl/\M^ 



Deputy Health Officer 



Registered ^''o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)catb 

( n. S. StanDarD ) . ^ 



PLACE OF DEATHt-County of CV^X'^V v];^<V^vcv^ City 



No. 



3H^ 




=au 



*>« 



\ 



(?, 



and \).AX>>w't,- 



( 



ir DEATH OCCURS AWAY 
IF DEATH OCCURRED I 



^*-» ^ ^^^^*' ^ .OR UNDER -SPECAL INFORMATION- ^ 

NSTEAO OF STREET AND NUMBER. / 



) 



rROM USUAL RESIDENCE GIVE FACTS CA^j-" ^ 
N° HOSPITAL OR INSTITUTION GIVE ITS NAME IT 



FULL NAME 






.>\.>^>juy\i. 



SK\ 



PERSONAL AND STATISTICAL PARTIC ULARS 

COI.OR 



DATK t)l- BIRTH 





iX 



vtjL. 



(Month) 



..% 

(Day) 



(Year) 



AGK 



X\o yra,s 3 y'->"'s '1 '^^ 'l 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ,, „ . 

....io.. ... 

(Day) 



L 



..\-Aw<C4. 

/ (MotithJ __ 



/go 

(Year) 



>-lN(.l,K. MARKIKU 
W IDOWKI) OK I)IV(tKi'i:n 
Writi- in social drsiv.Miation) 



i 



lUk riU'LAOH 
(State or Conntryl 



iArM}:R 



HI RTH PLACE 
Ol" lATHEK 
State or Country) 



MAIDHN NAMK 
OF MOTHER 



mKTin»LACE 
nl- MOTHER 
(State or Country) 






,o^v(:y 








TllEREBV CKRTIFVr'rhat I attcn.le<l .Ici cased from 

190H to^..|^^v^.. ^ ^9oH 

that I last saw h-^^alive on |vJl^ ^ ^^ ^ 

and that .leath occurred, on the date stated above, at IXH.v 
ij M. The CAl'Sn OPDICATII was as follows: 







DrR.VTION Years "-^^"''^^^ ^^''^'^ ^^^'''" 

CONTR iP.rroRV ^>.^J^^■^■'^r^^---^-'^ 
% JC>QXt 'i <v.0U-N^ 

DURATION >V./r. ^ JA'W/n ^^ /^^v.v //.^^rv 

Li rooH Address) l^^ -'^-^-^^^ ^^ '' ^ 



\\.\ljLt^'^ IQO''^ ( 




i, 



occ 



^^^^<^^ *(B) (^U^ ^iUv () f 

Rrsufr,f in S,ni liaiutsrn U )'-wi.t 



Month- 



Pa \s 



THK AHOVE STATE O I'EKSONAI. »' ^ «^.I^;\ !;}:'< ^^ •^'''- ''''''■' '" '"'''' 
HEST UK MY KNOWT.I'-.IX.E AM> Hl-.LIl-.f 



(Infiinnatit 



f \fMre*«s 



— , 



^PEd^lAL INFORMATION only tor Hosplldls, Inslitutlons. Translfflls. 
or Recent Residents, and persons dying av»ay from liome. 



Former or 
Usual Residence 

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



HoH long at 
Place of Deatlt ? 



. Days 



I'LACE 01- niRIAL OR REMOVAL 



(j.iO^^X^ 




DATl', of lUHiAi. *>r KIIMOVAL 



N. B. 



...^^______^^ ^^^^Mi— i^M^'i^^— ^^^ I pvACTLY PHYSICIANS nhouid 

-Even. Iten, „.' ln..n„,..tio„ should he cre^uMy KuppUed ^^;'; ;,^/;;;'.::*^,:r 'tU. ^^S^c^.^ Info.n^aUon" .or p-r- 
atate CAUSE OF DEATH In pln5n tern,,, tha '» 7;> ,^,^,J,„ 
aon, dylnft away from home nhould he ft.ven In every 



t f 



i i 



1 I 



a 
I! 



i; 



J ■ 



it„ 



)♦ 



1^ 




II 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

.f-^^u^vcn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



']' 




"? ""f .'^^ , Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)eatb 

( XX, S. StanDarD ) 



^ 



PLACE OF DEATH:-County ofCW^x^'i'/UXnACV^.'. Gty ofCW>^ ^ -VO^vCv^C, 



'No. 



,ct 



U U L&\^'>vtu OV) M, - .^.^ ^sTdENCE o,v. ..cts c.l.co .o. UNO.. 
( " °/';r„"Ju%;ro',"r„os^Pa*^""^snTUT,oN =,ve ,T» NAME ,«ST»o or 



k *. I a. I St.* — — Dist.; bet. ^^^ 



ER "special INrORMATION" '\ 
STREET AND NUMBER. / 



IF DEATH OCl^URBEl 



FULL NAME 




ustOuyM.. 



SKX 



DATK «)1- IHRTII 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




CcLO 






loi^u 



(Month) 



...l.H flh'i 

(Day) (Year) 



AC.R 



O (o 



) Vvr » A 



M„ttllis 



JL.X. ■/><'.'-^ 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DlvXTH 




...lo 190 i 

(Day) (Year) 




SINC.I.K. MARKIKI). 
WinoWKD OR DIVORiKI) 



* 



Wiitfiii siK-ial (UsiKtiation) | . 



lURTMPUACK 
(State or Cotjntry) 



N'AMK OF 
FATIIl'.R 




HIRTHIM.ArK 
Ol- FATIIKR 
(Statf or Country) 



MMDKN NAMK 
(II" MOTHKR 



lUKTHri.ArK 
t»l' MOTllKR 
(Stale or Country) 



OCCrPATlON 



rLcJCr 






I HF.RIUiV Cl-RTIFY, That I atteiKkMl deceased from 

•OL...X.i. 190H to.-4fi^t^^' '^ ' 

that I last saw \x^^-^ alive on ^ \ ^' ^^^ 

and that death occnrred, .)n the date stated above, at 'S^ 
Q,) ^I^ The CAUSH Ol' DiCATII was as follows: 

L^5-C<V<AA^0^ vc^-*^ 



.^.^^'Tuxflfv 



DIRATION Vi-ars 1 Monlhs 
CONTRim'TORY 



Pays 



Hours 



nr RAT ION 
(SIGNED) 



Ycays 



Mouths 



Pays 



/fours 
M.D. 



CX^'V 



<L_. 






y/onf/is 



/hn 



THK. \UOVKSTATl-.I) PKK^oNAl, »' ^^^ '^if/.Iv^'^'^ "^ '^ 
UKST Ol- MY KNOUI.I-.IX.K ANH HKKH-.l- 



1; IK IF. TO tmf: 



(Informant 



(Plat 






f A(Mress 




t 



I()0 ' 






)[>4 only for Itospitdls, 



SPECIAL INFORMATIO 

or Recent Residents, and persons dying dway from fiome 



Institutions, fransients, 



Isual Residence H C) li U O. 

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




~\ . How lonq at 
t Ot piare of Death? U Days 



ri.ACK OF lURIAI. OR KFM<»VAI 



n\ri; '>! m kiai. or rf:mov.\i. 



■NDKRTAKFR V ^^^-^--^^^ n n 



(AdtlrcHS 



N. B. F.very Item of information 



shoiilil be cnrefuMy suppHetl 



^ I rvArxi Y PHYSICIANS nhoulii 
AGE should bo statetl EXACTLY. khto.w ^ 

-i.vcry iiciii "• - »!,„» :t mnv be proper 

«tate CAUSE OF DEATH in P'"'" ^J""': ^1 n Ucrt Wisrance. 
sons dyinft away ?rom home should be given m •very 



be properly class 



)0 stateti ij.'v'^w • "u. 

Ifled. The "Special InforniHtlon for p«r- 



i 



).■■ 






1' 



i .: 




i i« 



if '• 






'!, 



W 



I 



u 



i ■ !■ 



i.,i,i.i .,f iiiiiiui- ''N" I- »Ti:a 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\'*o, J 0<w 



-Wi^wJH&I'Co 



Dale Filed, Y-"^ "^ ^''^^ ^ 

t^ ItLu D«P"ty Health Pmccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "d. S. StauDarC* ) 
PLACE OF DEATH: -County ofO^^ A^V.vtU, U City ofO<^v VOavt^^c* 



(^ 






St.; T Dist.; bet. OXiWOAi 




(?, 



and VJ,U,V<,<. 



) 



..^...1 Dc-einrNrr nvE r*CTS CALLED roR UNDER "special information 

( '^ r."orAX°H"oCc"u%ro\;"rHo"»".V.*At 0^'?,;s^^^"4°N^0.v77xl name INS.EAD or STREET AND NUMBER 



) 



FULL NAME 







/LLtrw' 



PERSONAL AND STATISTICAL PARTICULARS 



sKx q^ 






COI.OR > 



'LO,tv^U_. 



I).\ 11-. OI" HIRTH 



(Month) 



15. 
<Day) 



./■■ t>- -^ -^ 

(Year) 



KV.ft. 



)■»■<»>. 



M.nillis 1 1 /'«>•* 



SI\<.i,K, MARKIKI) 
WinoWKH OK DIVORrKI) 
'Writf iti s<xMal lUvivMiatimi) 



)j^/y^ 



niKT!IPLACK 
I Stilt* or Country^ 



NAMK OI' 
FAT I IKK 



niRTHTM.ACK 
OI- FATHKR 
(State or Country) 



MAIDKN NAMK 

oi' MOTHKR 







<V>"V 



U>^J-H b %o' 



niRTHPLACK ^ ^.^^fl 

OK MOTHER Q (^TTN^ 

(State or Country) -^ 



occvPATiox OVcn^Ji- 

Rr.rr'dnf in Sii)r I'lami'i'o 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH , , 



(Montli)(j 



(Day) 



190 N 

(Year) 



I HERICHV CI;RTIFV, That I attciidcd «leccaso<l ftotii 

^;»^....a.l 190 'I ^'^ ¥ [j^ '^ 190 H 

i„HL I last saw h -L^' alive on r"^^ '^ '^ ^ 

aii.l that (loath occtirreil, on the .late state.l above, at \...X.S3...... 

Qj M. The CAlSIv OF DIv.^TII was as follows 





vl.VV.ILN. •« O. 



nrR.XTION r^^Viais 

CONTRIIU'TORY 



^ Mofitfis w Days ^ Hours 



DURATION _ Ynrrs 



Mouths 



/hU'S 



(SIGNED) 



LI) \J ll) crirTLcucuw<C 



■+1 ^ ■ .... .„u„,„:.,^ insfiWllons, 



Hours 
M.D. 



) I'll I f 



L .\ro,tfhf -Cs /'"'A 



THK AHOVKSTATl-I) l-KRSONAK PAKTIcT I.AKS AK H TRTH TO TIIH 
Hi;ST OI- MY KNOWI.IUX.K AND Hhl.H.F 



fitif., 



nnruit 






Special information only for Hospital 
or Recent Residents, and persons dying anay from liome. 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of deatf! ? 



How lonq at 
Place of Death ? 



Transients, 



. Oavs 



,., ^CH OF BIRIAI. OK RKMOVAI. I DATK of H, h.a,, or RKMoVAI, 

, NI.KRTAKKR UcCVOL UUvV^'YU ^ UC 

,,,,,,.. M A ^3 (^tcU>v -^ <VU ltN>^. 



"— """"""""■^T T^ AHF should be stated EXACTLY. PHYSICIANS should 

IN. B.— Every Item of InformBtion should be cnr«tully supplied. J''»^ « ,|assWled. The ^Special InforniHtion" for p.r- 
state CAUSE OF DEATH In plain terms that .t m»y ^^^^^P^''''' 
son. dyinft away from home should be given m .very Instance. 



II 



I 



I I t 






h I 



'» 



H' 



i 



I i' 



i« 



: r 



'. I 



A 



') <l 




h' 



% 



'•■..I. 



9. 



♦ I 



«ft! 



I 



,,,,.,,.1 .,r iiraiih-J- N-i i^ "H:' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

153 




/>„fr hied, "i^^^^i T ''^^'■■' 

jL^frA^^cv^ Ia/xn^l Dep-. ']/.,H.e.a,I.th..,Ofncer 



Registered J\i''n. 




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



Cevtiflcate ot 2)eatb 

( Ta. S. StanDatS ) 



Op -f ^ 

PLACE OF DEATH: -County of O <X>v J ,'V<V>vcv4cCity of 0,a'>V 0.\xc> 



VCC^.C'^ 



N^ 



.^oAAi^xX iJ AA^u.n.x^.J^-^.M ^^j-;^^ ^,^^ ::rTrc";;r:;o;oB UNDER -specal iNroRMAT.oN.. ^ 
( '^ ^."D;AT°H^occ^%;ro^"rHo^s^prT?co^'?NST^^^^^^^^^ .ts name .nstead o^ street and NUMBER. ; 



AO.Kl\ St 



Dist; bet. ^^^_ 



FULL NAME 



U) 



cri^ 




•oJ 



L^L. 



u. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR , 

' vLau 

I) \I1-; ol" lURTH vj 



(n\«.t. 



v>a^ 



(Month) 



Ar.R 



Aw Jv<M.v 



(Day) 



Mouths 



(Year) 



A/». 



^IN'.l.K. MARK IKI>. 
WIDmWKI) «)K niVOKiKI) 
(Write in social dcsijrnation) 



lUKTinM.AOK 
(Slate or Country^ 



NAMK ()! 
FATHHR 



HIKTMri.AC'H 
oi" I ATHKR 
•State or Conntry) 



MAIDHN NAMK 
OI" MOTIIKR 



lUK IHl'LACK 
OI- MOTIIKR 
(State or Country) 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH A A 

%dM ■ if- ^ 

J Month) K <0«y^ 



I inrRi:HV CICRTIFY, That I attcmkMl deceased from 

190 to 190 

that I last saw h ^r- — alive on '^O ~ 



and that death occurred, oti the date stated above, at 
rrr— M. The CAl'SIC OF I)I':ATH was as follows: 



1 



\Xj <X^\j o^ 




^w^A.a^ _ 




^ 






-UUL' 




L^>-o-k 



:1\^*- 



OCCVI'ATION 

Rrsidf(f in Stui Fmiiiism 



!V,M 



Month- 



/Ml 



TnKAKOVKSTATKI)»>HKSoNAI.rAKTU;r:.AK<AKT. TRCK To TIlK 
BKST OK MV KNONVI.KIX'.K AND HhI,IKh 

(Infonnant LU -V^^-CL VV \J 

R— — ^»ii^i«^i«^™i— ^-^ii— — ^-^■■■^■■■■"^^^■"^■■^■^""''''""" . . ^j^jI liXACTLY. PHYSICIANS nhould 

N. B. F.very item o* lnt'.>rm..tion .hould be carefully f"PP"'=;|' „^^J:Hy7la«»rflcd? The "Special Information" for pT- 

«tate CAUSE OF DI:ATH In plain term., that ,t may ^^ P;"^**-'" 
-on. dyln^ away from home nhould be ft.ven ... .very instance. 



or RATION 



Months 



) 'cars 
CONTR IIU'TORY Ua.VuLr^ vU.v^ 



Ihi\ 



Hours 



DURATION 



Years 



Mouths 



(SIGNED) JiA-UixK-A^H '^.■.\J>J 



Days 



^lu '1 T.o-^ ^vMn-ss) bOb c).t.tU^ ^^^^ 

FECIAL INFORMATION only for Hospitals, Institutions. Transifnts, 




<^> 



'SPECIAL iiNrv^niviw I iv^'-" ■■ - 

or Recent Residents, and persons dying anay from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



190't 



riACKOK niRIAI, OR KKMOVAI. I UATKof HrK.A.. or RKNK.VAI. 
INDKRTAKKR U.^ <-^^^ / ^3 V- 



(AtMre««« 




I> : 



i'" 



if 






> 



.1,." 



ws* 



IV 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ho.'inl of HcfHtn i' - ^"- '^ ^ "...^^ 



Registered JVo. 



154 



Dale Filed, ^K^'^ ^^^"^ 

W^ ll^ D«P"*V "«^«*»^ 0*"^*=' 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of ©eatb 

( Ta. S. StanDarD ) 



PLACE OF DEATH: — County 






(I5^ 



,OL^dAAyT\^^U^t City ofO<X/>\J O.^O/AVCvA/a^ 



4' 



'WcCLr 



i 



\\<l d/OL/^^fr^-^^^^^^^t.; — — Dist.; bet. 



^NO. OVU'l^'VL^I N.v^^, ^.^- . ^^^ ,,o.,AL RESIDENCE GIVE FACTS CALLED FOR UN 



and 



OER "special INFORMATION" \ 
D OF STREET AND NUMBER. / 



FULL NAME 



.^...cr\;u^ .^iD.^^^^^^ 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 



x»\<xLl 



1. 



COLOR 




DATl'. OF HIRTH 



(n\ 



(NTonthVT 



(Day) 



r'\M 

(Year) 



ACK 



) ViJ ; .* 



I 



M,)i///i.< 



Pa ys 



w ii)«>\vi<:i) OK i)ivoRii\n 

Wiilt ill M>ii;il (Itsij-MiJilioii) 



niUTITPT.ACK 
(Stiitr or Cojjntry) 



NAMK Ol* 
FATHKR 



BIRTH PI. ACK 

Ol iwrnHR 
(State or Country) 



trWcvcx 

II .11. ijJU,Uv 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATII 



(Mont 




h 

(Day) 



(Year) 



I m^KI'HV CMRTIFV, Tliat T atleii.lea deceased from 

Vv^vt up H to %aXm-I£> ^*/> "i 



/ j 

that' I last saw h -i>vj alive on 



aiKl that .leath occnrrc.l, on the .lato stated above, at ^ 

...CL M. The CAISK Ol- DlCATIl was as follows 



MAIDKN NAMK 
Ol- MOTIIHR 



lURTIIPUACK 
or MOTHKR 
(State or Country) 



ttL. 



k\A.t) 



k<X'^vv 



IJy VL \VV^VVq. vtv.-l . 'C^O^^V^vX VtL IXWvx^ 



v.. , WW . w»< A r\ — • 






Hants 



DURATION ^ Years " Moufhs \\ Pays " Hours 

(SIGNED) .Xc^lXO^ ^. %-WvcC M.D. 



OCCUPATION 




tr\/\\vO>» 



Residfd in S<Jn /'unh is,<> 



)\ i! I - 



\f.<»lll' 



fhn 



TMHAn(.vr.STATKl.i'KRS,,NAI. PARTICri XRSAKFTRrHT.) TilK 
IlKST Ol- MY KNO\Vlj;i)C.H AND MF.Ml-.l' 



(Informant 



f \(Mrc^s 






^SPECIAL INF 



V<X'\V<5U>V 



it 



..J FORMATION "nly (or Hospitals, Insfitulions, Transifnts, 
or^creS^es'idenls'.'and persons dying away from home. 



J , 1 f^ B How lonq at , 

nXL^vt ^oJ<J Plarcof Death? I ^^^''V.- 

usual KCMUCIItC v^ >-V/ r >-»-■ 'w /->. t 

Whfh*jas disease fonfracted, H j JL ( ^*J^ 

If not at place of death? O-UL-vv^ Vw<:CVV 



Former or 
Usual Residence 



•;. Days 



I'l.ACK Ol" lUKIAI. OK K1:MoVA1. 



rSDKRTAKKR 

(Address 



DATl". of lUHlAl. or KF.MoVAl, 



\kJLu ^ 190H 



IN. B. 



' ~ ~ Tge „,,„.^u, he Htated F.XACTLY. PHYSICIANS kHouIcI 

livery Uen, o^' InVormBtion nhoulcl be cnrefuMy f^PP '-•• ^^^^^^ .,a«Hit'led. The "Special Information" ?or p-r- 
«t«te CAUSE OF DEATH In plain term*, tho .t n.»y »>- P^^^J 
«->«. dyinft awoy from home should be ft.ven m ever> InHtnnce. 



*! M 



\ 






\ ! 



f 



i I 



'xm 



i 



i^ 



i 



S:, 



WRITE PLAINLY WITH UNFADING INK 






T)(ffe Filed, 



% 



100^ 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J^o, lOO 




Deputy Health Officer 

DEPARTMENT ot PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( XX. S. StanDarD ) 




PLACE OF DEATH:-County of 3 CtTvl^a^vC^t^ City oi6oj^^^-^^^ 



t^ 




^^w^ 



IF DtATH 
IF DEAT 




Ml^' 



\\jX. 



<XX: St/, 



.Dist.;bct. and 



-rh^^^ ?^?:?^?;^c;^^;^^xi ?;^ir^ .^^" ;?;^^ri^:'^:::c;;^ 



..) 



FULL NAME 




&:LA>^.*i 



SKX 



PERSONAL AND STATISJICAL PARTICULARS 

COI.OR 



Q)\cJL 




\\\Xx.. 



DATK OF lilKTII 



(Month) 



(Day) 



(Year) 



AC.K 



\0 )Vrti 



. Motii/is 



Dti ys 



SlNC.l.K. MARKIKl). 
WinoWKI) OR DIVOKCKI) 
(Write in S(MMal desifrnation) 



HlRTflPI.ACl*. 
(State «)r Country) 



NAM I'. <>»• 
KATJIKK 



lUR'IIIIM.ACK 

OI" I ATIIKR 

I State or Conntry) 



MAIDKN NAMH 
OI" MOTIIKR 



HIRTIIPI.ACE 
OI- MOT.MKR 
'State or Country) 



orri-pATiON 






MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH ^ . 



(MontliQ 



1 

(Day) 



(Vt-ar) 



rinrRlTBv"ci'RTIFy, That ntttcn<lc«l .Icceased f roni ^^ 

.^uioL.b 190H '^'to' ' ..|v.vLj..::^i T90I 

that T last saw h .^V^^alivc on V^H- ^ icpH^ 



a.i.l that .leath occurre.l, on the dato statcl above, at 11 '^^ 
JX M. The CATSI-: OI' DI-ATII was as follows: 



(Y\\ 



\<CVA^ 



Hours 



DURATION " Vsars ^ Months - Days ' 
CONTRIBUTCM^' XpAJj-Jl^N/t^^ 



DURATION ^ )'rars 

.NED) J (R.jbavt 



Jfon//is 



IhlY 



/lours 
M.D. 



(SIGNED) .J VX.UV^vv . • 

N^wLly 1 T()oS (A(hlress ) \^^\ ^ J 

SPEdlAL INFORMATION only for ithspitals, Institutions, Transients. 



f^r 



shfr.i n, S„„ /■nnnisr,, Xh )-'<" ' ■'^^"""" 



/),jy 



THH XMOVKSTATKDrKKSONAI.PAKTU-ri.AKSARKTRrH To THK 
IlKST OI- MY K>vONVI.KI><'.K AND Hhl.ll.I^ 



'Informant 



(Address 






or Recent Residents, and persons dying away from fiome 

When was disease rontrarted, ^ 

If not at place of deatti ? 



How long at , ,^ -^''^^ 
VtOL Place of Deatli? n ^'> 



PI ACK OF lURIAI. OK KKMoVAl 



l-NI.KRTAKKR Mfl' J ^<:^cU 



DATl-.of MIKIAI, oi K1:M<>\AI. 



h 



I 



(Aildress 



,U^ b 1901 



■^ ♦ t I FXACTLY. PHYSICIANS nhoulti 

N. B.— F.very Item o^' informntion •hould be cnrefully h^PP''^;'- p^,^*;Hy7la8«?^'ieci? 'xhe -Spcclai Information" ior p.r- 

state CAUSE OF DEATH In plain terms that It may ^^ ^^ '^ 

«on, dylna «woy from home should be ftiven m every instance. 



Ji 



' 



i 



.1 < 
1 



'J 



i ^/j 



Ipm^ 





h 




I 



WRITE PLAINLY WITH UNFADING INK 



P.oM r<l "I Hen II II " •^"- '^ •"- -f 



hide Filed, 




100 H 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

156 



Be^isfered JVo. 



,^aaaJs 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( "a. S. StanC»ar^ ) 



^ 



No, 



PLACE OF DEATH;-County of c)<^^ J-VC^-C^^^^City of O^.v JXa^vCC^^c 

T^^'^.TU^o'; o.vc .t1 name .nst.aI or st«e.t ano number. ; 



/ \r DEATH OCCURS AWAY FROM USUAL RES 
V IF DEATH OCCURRED IN A HOSPITAL OR I 



) 



FULL NAME 





r^^TvOi v^vo.'^jL 



UwIcLa 



PERSONAL AND STATISTICAL PARTICULARS 



si;x 



% 



DATK or- r.!R 111 



A<.i<: 






COI.OR 



Uj4'X<-'bL 



/JMoiith) 



lb 

(Day) 



(Vfur) 



3),H )Vw;> b .V-W//V 'Xi 



/)<n 



SIN(-.l,!f. MARRTKn, 
WIDOW I'D OK niVOKCH!) 

iWiitr in MKi:il <k'si>j:nation) 



niKTIMM.ACK 
• Stiitf or Country) 



NAMJ". Ol" 
IATin",R 



niKTIlIM, ACK 
OI- I AIUKR 
(State or Cotintry) 



MAini'.N NAMl-: 
Ol- MOTin:K 



lUR riiri.AOK 

OI- MOTIIHU 

(St;itf or l'(Mintry) 



orcrPATiON 



VlYla'vVAjiA 

V<Xa%<XO^C^ 

^ [1] 



MEDICAL CERTIFICATE OF DEATH 
DATK Ol" DICATH 

(Day) 




Month)/) 



tVcar) 



I III'KF'I'.V Ci;i<TIFV. That I attc'n.Uil <1croasca from 



that I last saw h -5-'v alive on 

and that death ..ccurrcl, on the date stated ah^ve. at 



]^l 



i(>oH 



-r 



°i 



<Xy\/y\jJ^ 



M. The CATSIC C)l« DICATII was as follows: 



VA^^^-^^aXa^va^ 



CONTKIIU'TORV '!)'^^^.<U^^ ^^ ^oi^vA^ 



■^vtrv 






n 



Dl'RATION I Years -.} font hs ^ Pays -/fours 




A.i, 1 i.KiH ^ fA.l.lr.^-) mC' 



l^Cvv'U ^t 




'<Xuy\J- 



R<>sidrif ill San /'iiiiiriM'n 



)',-ij I 



.}/,,, I f/i' 



/',/). 



Tin: \novi-. srxri-:n i-kksonai. r\Kru;ri,\Ks auk tkii- 

HHST Ol" MV KNoWl.I.IX.K AND llhljl'.f 



TO TIM*. 



I Illfi)!ni:lllt 



f Addrrss 






tePEdAL INFORMATION only for Hospitdls, Institutions, Iransients. 
or Rfcent Residents, and persons dyini .md> (roni home. 



Former or 
Usual Residence 

When was disease rontrafted. 
If not at place ol death ? 



How long at 
Plare of Oedth ? 



. Days 



190H 



W..UHOF lU RIAL OK KKMoVAI. I I.ATI". of Hru ■ v.. o, RliMoVAI. 



(Adtlrt-ts 



"iaa ^ iyi^Um.... J^.9^..... 



■■i— I— i«»«w«^ii^»i^"i™«^"^"^"^^"^^"^^""""'^^"^'"^^""^^"^^^^^^ I rxACTl Y PHYSICIANS should 

IS. ».— F.very Item of Information •houlcl b. crefully f;'P»>;'-^- J^i^^^lrllZL^^iCJ. 'Th^ -Spcc'lal Information" for p^r- 
•tatc CAUSE OF DEATH !n plain term,, tha .t m»> ^^ ^^^ - 
«->«• clyinft away from home hHouIcI be Jk-ven m exer> Inntance. 



I. 

i 



J, 



, V 



I • 



* / 



I'f 



i 






1)1 



nl! 






m^' 



ti ! >. 1^ 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,,,,,1 .,f M..MUh-F No, 1. ■-t;^^^^ Uf<.V Co 



r.Miii 



'il 



/)(ffr Filed, 

i 




Registered JS'^o. 



157 



1, 100 "{ 

..^tcv. <^^>M Depun/ M-'^rh Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "U. S. StanDarC> ) 



\.<X'>vCAw^C(, 




% \ ^ 

PLACE OF DEATH:-County of 3 Oav J^VO^^^^C City oiOo.'^^^ 

<N0. llH ilvvkLM, ..„.S^^.cl.VEHi^^C^J;of Ml; •SPECIAL .N.^T.t 

( - r."o;rH"oCC^Rr;.;"rHO^S^pVT^At ^R^T^^T^^^T^O^N-^cflvYTs NAME INSTEAD O. STREET AND NUMBER. ) 






FULL NAME 



MlWy 



PERSONAL AND STATISTICAL PARTICULARS 

sKx qrs - " I COLOR 



JXo-^V>(xLt 



DATH Of- I'.IKTH 



lu.k^_ 



iMoiitlil 



I 

(Da>t 



(Year) 



ACK 



1 '^'ij I 



M,,»lhs 



1 



/>fn. 



MEDICAL CERTIFICATE OF DEAT H 
DATE OF DKATH 




Month) 




1 

(Day) 



(Year) 



Sixr.l.p,, MARklKl). 
WIDOWKD OK l>IVORt'KI> 
iWiittin sorial (ksiKiiatioti) 



L 



tUKTJlPI.Ari' 
"State or Country^ 




.-! 



NAM1-. Ol 
I'ATIIl.R 



lUUrillM.AOK 
Ol' I ATIIKR 
(Stale or Country) 



MMDKN NAMH 
OI- MOTHl-.R 



nTR'lHTM.ACH 
OF MOTllKR 
'State or Country) 






\\) 



AX/^vta^^^a 



K 



I IirRFRV CI-RTM-V. Thai T atten.led dcccasol from 

^^H^ ^^^^ "J'lHn "s 

tba^IlastsawhXX; alive on Y^^ '^"^ 

and that .loath occurred, on the <1atc stated above, at A 
(?.. M. The CATSb: Ol- DICATH was as follows: 

■ Months ic. Days ^^ Hours 



DIRATION " Years 
CONTRIIU'TORV 



Years 



Mi>uths 



Pays 



Hours 
M.D. 



cLcxa^ 



L. 



orCTTATTOX 



"•0\^ 



Rrshifd ill Snii /'ntih /■''''> 



)'ri! I 



M,.,ith- ( /''?' 






THKMU>VKSTATKl)rKK^.)NAI.''\KTK;ri,ARSARKTRrHT.) THH 
HKST Ol-- MY KNO\Vl,i:in".K AND Hl.MI'.H 



'Infoiniant 



Vnlo/v L.(rvv>v; 



(Address 



V^\ 



^IvIvLm M 



I 



(SIGNED) t) t). MlrJva.^^ 

=iPECliL INFORMATION only for Hospitals. Institutions, Transients, 
or Recent Residents, and persons d>inq away Iron tiome. 



Former or 

Usual Residence 

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



HoM long at 
Plare of Death ? 



Days 






n.ACK (M- lURIAI. OK KKMoVAI 

INDKRTAKKR ^ 

^^ddrcss 4 5 H 








HiAi. M ki:movai, 

U % TQOH 



' ' ^ * n Trv H'loulcl be Htnte.l EXACTLY. PHYSICIANS nhould 

N. B.— Hvery Item oV InformBtion should be cnreVuHy -Pj* -;^- ^ ' ;;,y .,„HHh'lecl. The -Special InV'ormalion" for pT- 
.tnte CAUSE OF DfZATH In plnln terms. th„ .t mn> ^^ '^^^^ 
«on. clylnft owny Worn home should be ftlven .n ever, .nHt«nce. 




i i 



i 



t < 



1 il 



Ir 



1 



^r'* 



•«'l ' 






ii 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

158 



, f II 1.1. »•• No ic ■*'5-;a»i-S;."i;H&PCo 



I)f(/r Filed, 




cv'^-v^w/M5 (XV\>-\- 



\ 



100^ 



HcSistered ^'"o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of 2)eatb 

^\o.^ c QUdl UclLj W 



^No/ 



— and '^ 



o^ , "D'xsX * bet. — :■ ano 

( - ^;;:;^^^;;r^ "°:^^t --?J^?\^-;^-i^-- .^^°ste7d°^; -^^i-no r^Jer ■ ) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^wL 



COI,OR 




DATl*. or- lUKTU 



% 



(Month) 



(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




(Year) 



1 lIHRKIiVCl-RTlFV, That T atten.lcMl (leceasefl from 

to : "-190 

— — T90 



■190 




ACK 



jji )>./ 



f^S 



n 



Mouths 



l^ 



Pa vs 



^INC.l.K. MARKIKU. 

w ino\vi:i) OR nivoRCKn 

(Write ill social (U'sijj:"iiti<>n) 



i 



A.AV 



r.TRTUri.Ai'K 
(Stall- or CoiMitry^ 



NAM1-: Ol" 
HAIIIKR 



niRTuri.ACK 

<)!• I-ATUKR 
(State or Country^ 



J? ^ 




O^/VV^ vJ .VCV'^XC'Va'C-O 



/wcL 



maii)i-:n namk 
of motiikr 



niRTIlPt.ACE 
Ol- MOTHKR 
(Stall- or Country* 




that 1 last saw h 3— alive on 

at,<l that .Uath occurred, on the date- stated above, at - 

..7rnr-M. The CAl'SI-: Ol- DICATH was as follows: 

(J^. vv^.tr>.vOAA.r T 



DT RAT ION >''<'''-^ 
CONTRIIU'TORV 



Months 



Days 



Hon PS 



^4/^^rvc>{tvTw _- 



UulOI^. 



OCCrPATION 

Residril ill S,in /'i,iit.nr,> 



]'>iti .< 



.l/,,y////- 



/>,!\ 



TMKAB()VESTATKl.l'KKSONM.l"XKTI:;ri;ARSARl-TRrKT.» Tm- 
BEST OF MY KNO\VM-:i)<*.K AND Hl-.I.H.i" 



(Iiifotnumt 



4 



Special inf< 



,«.. ..J FORMATION "nly for Hospitals, Institutions, Transients, 
or^crdS^ResidJUts' 'and persons dvinq awdy trom home. 



Former or 
Usual Residence 

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



HoH long at 
Plare ol Death ? 



. Days 



iSl M,vvtU^ -it 




I NDl-.RTAKKR 

(Adilresx 



■ —^^^^mmam^^^^^^^^^^'^^''^^^ ^ » i frvArTI V PHYSICIANS Hhould 

N. B.— Every Item of lnform«tlon •houlcl b. cnrcfuliy -nP'-'' p^l'.ferly classified. The "Special lnfor.«Hlion" for p.r- 
state CAUSE OF DEATH in plain termM, tha if may •'^ P^^^ 
«on, dylnft away from home Hhould be feiven in every instance. 



i I 



. \ 



1 S 



w 



'v 




I 'I 



WR.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

159 

l)((fo Filed, ^IvvXu^ 



r .1 1,1, —I." Vn H J'9".'iSfr««mD lt& I* Co 



IQO^ Registered JSTo. 

l^vJ ItL D«P"*y Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( la. 5. StanDarC> ) 



on 

PLACE OF DEATH: -County of 0<X^ J^^a>xcvA.ec City 



4 



^ 






^ 



ity of C;<^^^ J.\.CV'\vCvClC{) 



(1^, 



.u)<x3LAx^ 



St.; 



Dist.; bet. ^^^ 



) 



XCJ^ CjCt'VV^CLVA.AX.^^V at.; li'VlTLtDroR UNDER ■•social NrORM.TlOK" "V 

^ ,F DEATH OCCURRED IN A HOSPITAL OR INSTlTUi 



FULL NAME 



ei 



OaAX 




.iAvUL 



f 




^VA^u^^^UV^VO. ^•^.^J 



PERSONAL AND STATISTICAL^ARTICU LARS 



sKx (TT^ 



vi 




COI.OR 



IJivCtX--. 




I)ATK OF I'.IRTH 

(Month) 



a?> /.i^..i 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH /\ (^ . 

1 




(Month) 




(Day) 



(Year) 






A(iK 



lo )>.M> o 



M.niUii^ 



w 



Pavs 



SINCI.K. MARUIKD. 
WIDOWKD OK DIVORCKIJ 
iWriltin social dtstKnation) 



^. 










HIRTMn.AOK n 

(St;itt or Country) *V MJ I ' '-' 1 I 

^VXlLJU^av^ 

OCCrPAT.ON p^^^^^^t 1^ 



N AMR or 
FATUKR 



lURTHPI.AOK 
<)|- l-ATTIKR 
(Statf or Country) 



MAIDKN NAME 
Ol- MOTHER 



I'.IR rillM.ACE 
<tl MnTlIHR 
(Stale or Country) 




rin<^IUnVv7:URTn'V, That I attends .leceased from 

^syJL 3.0 190 H to 1^^^ *^ '"^ "^ 

tha^ I last saw h ..^ alive on yOL| b 190H 

an.l that death occurred. ..,1 the .late stated above, at b • 
{J_^,\, The CAISI': OF DKATH was as follows: 

Dl RATION - Years - Montl.s b /).,.. \^ Hours 
CONTRIIU'TORV tlA^.^^^^'-A^^ 

(SIGNED) "lc^\v<W^^^^ *^°- 







- /),/ 



THK AMOVE STATED I'KRSONAI, »' ^ X^' jj^.lvX'^^ '"'• '■"''' '"' ' ""'" 
in;ST Ol- MY JpiN'>^^''^"'^?ii^' ^^" llEI.Uvl* 

(Infnnnnnt > L\) ■ ^ 0^aX^^ n 

Ml I \ 



."C^Y'>X\/CL 



"ipECIAL INFORMATION only for Hospitals, Institutions, Iranslents. 
or Rerent Residents, and persons dying away from home. 

Eru7ReVeU)0^tUva^ C<:Lt ?iaVofVelth? H Days 

When was disease contracted, \ 1) j^^J^^^cU 1 cLtVu^. ^aA: 

If not at place of deat h? ^^ ^ j_ 1 , 

. . lit. ..A. ,.t kJ'MoVAl. 

ly ACE OE niRIAI. OR REMo\Al. 

(Vl "M 

rSDl-RTAKER ^' ^- '-J 

(Addres'i 






J 

r 



i9o*i 









I 



IN. B." 



_^^^__^_^^^m J^^— i^i^"^"^^— '— '™'*""'''^*'^ , f-vACTLY PHYSICIANS should 

..a.e CAUSE OF DEATH In plain «"'"•;«••» „''•""' TJxJc. 



state CAUSE Oh ut a i n m """■,■::,„ i_ .v,ry instance, 
.on. djlnft awa, Srom liomo «Iioul<l be ftlven in o,«.-y '" 



^ 



f 
I 



H 



\\ 



I ! 



. ^ 



M 



1. ' 






I t 



%^- 



\' 



WR.Te PLAINLY W.TH UNrAD.NG .NK-TH.S .S A PERMANENT RECORD 

REFER T Q BACK OP CERTi nr.ATE FOR .N3TRUCTION9 



i)ah-riU'<i, %J^\ ^'^^"^ 



Registered JVo. 



160 



Deputy Health Officer 




DEPARTMENT^ PllBLlC HE AlJH=City and County of San Francisco 

Cevtificate of IDeatb 

{ tl. S. StanC>arC» ) 
PLACE OF DEATH: — County of a^V .V(X>VwV^ w^uty or 



V IF DEATH OCCURRtD IN A HOSPITAL OR INS 



Ql\.. 



) 



FULL NAME 



vi!SJc^:^A./CavcL 



i3ok 



CL^yXV 



SHX 



PERSONAL AND STAT I S-MC A L PARTICULARS 

I COI,OR 



QovJL 



LU-VV^JL 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol* DKATil 



DATi: t)!' HIRTIl 



cyyjX' ^ 



(Montli' 



AOK 



) 'ru t > 



(l)!iy) 



Mout/ts 



(Vear) 



Ihiv.- 






:,.hjj- 



1 

(l)ay) 



(Yf:\r) 






SlNC.l.K. MAKRIl'.n. 
WIDOWHl) OK DIVOKIM) 
(Write in -iocial (Icsijf'iation) 



HIKTHri.ACK 

'State <ir Comitrv^ 



NAM1-: <»»■ 
KATHl-.K 




axvv^^^<^ 



r UKRHHN' Cl-RTIFV, That I atten-U-.l ikroascl ln>n. 

. cn^ov' is^ 190H to Yf^^ '^'"^ 

n,,t I last saw h ..t>>^livo on |^ ^ ^j>^;j ^ 

ana that death ocrurrcl. on the .hito stalo.l above, at \0.^. 
CI M. T\e CAISI- OF Dl-ATH was as follrnvs: 




niKTlUM.AiK 

m- 1 AriTKR 

(State ui Country) 



MAIDHN NAMK 



«• 






MoNi/is - Days /fours 



'"1 
DTRATION 



Yiars 



Q^ 



Afoutha 



Pavs 



Hours 
M.D. 



HIRTMPI.ACK 
oi' MinHHK 
'Stilt-' or Country"! 



(SIGNED) A!V\^ J-^^"^'^ C 

sWclAL INFORMATION ««!> 'j' ""^P"*- l"*'"""""^' "'"'""'^• 
0, Berent Wdrms, and pftsM- m^ -»'» I"' """"• 



iiii 







nCCrPATION 



/),ry 



r,n:vuovKSTvrK..rHKsnxv. rNKnrr,,AK>^vKHTKrK t. . r.n- 

1U:ST Ol- MY KNOWIJ.IX'H '^>'" l^'" ''" ' 



Former or 



S . '} 1^' HoH lonq at '^ 

„ .. Hn ^Ia L\A.vv VCL^ Pidf c ol Dfdfh ? 
Usual Residence ^^^^^^^^^^^V 



nd>s 



When \»a<i disease ronfrarted. 
If not at place of death ? 



(! 



' I n fi)' nnnt 




N'VCV'^^^i-^ 



X.l.lress d OU^J:^ ^^^ V 



l-UATH Ol- HIRIAK oU K1:M"VA!, 

n CMC 



i,\ri: ,,: in, hiai. <^r kkmovai. 




INDKRTAKKR 

( \(Mi' sx 



i . I90S 



V . rxAGTLY PHYSICIANS should 

%. .iiocT r»u ni-ATH in ulnin tenn*. thai ii mitj i 

state CAUSE Oh DLA I n *» pm JnstHnce. 

«on, dyJnft away from home nhould be fencn in o.or> 



II 



i 1 



i 



) 



* 




. ;] 



ti 



ii 



I 



"i 



U 



II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„, ,, <.f „. .uh-F NO „ «.^ REFER TO BACK OF CERTIFIC ATE FOR INSTRUCTIONS 

161 



W^ 



l^JO^ Registered JSTo. 

Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Dule Filed, 



PLACE OF DEATH: — County 



Certificate of Beatb 

( "Cl. 5. StanDarO ) 

ofO<XA\t/tX) U'L<X.^<X- City of ^JoJU) LULuj 



.<X\. 



No. 



St.; 



and 



Dist.; bet. 

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

FU LL NAME Lo^u^rLmJ. J. JJ..Qj>J:fSJkj. 



PERSONAL AND STATISTICAL PARTICULARS 



DATK or IIIKTU A 

/1( Month) 



COl.OR 



loivju 






AC.K 



7S 



)Vif ;.v 



(Day) 



Months 



(Vt-ar) 



Da 1 . 



SINCl.K, MARKIKI). 
WIDOWHI) OR DIVORfKI) 

'Writfiii S(X'ial dcsivrnation) 




BIRTH PI. ACK 
(Statf or Country^ 



FATHllR 



BIRTH PI.AOK 
(>»•• lATHKR 
(Slate or Country) 



MAIDKN NAMK 
OF MOTHKR 



lURTHI'KACK 
OF MOTHKR 
(Slate or Country) 



OCCIPATION 

f\i\^i(lfff in Stiti /'i (I II, /U-.) 







^Crryjfc JYK/y^^<rv\r 




K'y\X 



[^) 



MEDICAL CERTIFICATE OF DEATH 




1 

(Day) 



/go \ 
(Year) 



I HlilRHBV CuRTIFV, That T attcndofl deceased from 

190 — — to 190 •"— 

that I last saw h r^— alive on igo •^^:-— 

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

.-rrrz:...^!. The CAl'SIv OF DIvATII was as foll<»ws: 



Cl.|a,<r|x<Lt.>.u 



DTRATION years 
CONTRIIU'TOKY 



Mouths 



Ihiys 



Hours 



DURATION 



I\U'S 



Years Mouths 

( SIGNED )..0-.W.U<X>voUja.L^ 

1 igoH (Address) McJu LLLtc L<vl 




I 

) rai s 



Mniitfr 



/t.ivs 



THj; AHOVK STA'n:i) I'KR^ONAI, I'A RIICF I.A RS ARl'. TRIF: To THF: 

nicsT OF Mv knowijix'.f: and iu:mi:f 



niCST OF MV KNOWIJI) 
Informant O , V^ o^/ 




yy-yj 



Hours 
M.D. 



^_ ^^IaL Information on'y 'or Hospitals, institutions, Transients, 
orlfc'ccnt '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 






n, ACK OF lURIAI. OR RFIMOVAI, 

,ess as^^Cfti. 



I)A'IF;of Hi KIAI. or RF:M0VAI. 



id /o 



190H 



(Addr 



\.^^j<.<r\K 



M, 



.tate CAUSE OF DEATH in plain term., thot it mny h. properly cla...tl«l. Th. Spcc.l Intormatlon tor p.r 
■on* dylnA away from home nhoulil be »iv«n in .very instance. 



i 



M 



1 



1 1 



*l 



Hi ■ 

if 



' I 




i^ 



im 



1^ 




^ 



i,^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, f„,.„,l,-|.s-n K»*SatS.«&I-Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)a/(' Fifed, 



% 



loo'i 



Registered J^o. ^^f^ 

'XjfM^ liA>u DeTJutv Hes!*h ^*n--r 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH 

No. V,' S H CV^k.a. tnr'v 



Ccvtificate of S)eatb 

( TX. S. Stan^ar^ ) 
: — County ofC)ct^v 



vVOvCULCt City of< ' Ct^A) O.'va^vcvAct 



s 



ir DEATH OCCURS AWAV FROM USUAL P E S I D E NC E Gl VE FACTS CALLED 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



St.; X Dist.;bet. CclaX and 

FOR UNDER "SPECIAL INFORMATION" A 
INSTEAD OF STREET AND NUMBER. / 



.\AV\'v\"yiAjj 



^ 9 q\ ^ /Of 

FULL NAME J.'V.Ol.^'JI^ s^' X^.^^...fr^J AJ..<X,N-.'^.a. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



1)\ I 1-: ol- IIIRTII 



\r,V. 






IX "VVvLc 



n 



Mcinth) 



} ra I 



(Day) 



Months 



w 



r I S H 

(Year) 



Pavs 



SINC.l.K. MARKIKI). 



\Vin<»\VKI> Ok DIVoKCKn f) 

(Write ill sjK'ial <ksi}.'iialioii) ^ 

a 



niRIHPI.ACR 
(Statf i)r Coiinti v^ 



NAM J" (>I- 
lAllll.R 



HIR IMPI.ACK 
oi- IArHI':R 

istatf nr 0(>iintrv'> 









MAIDHN XAMK 
01 MOTHKR 







MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 




(Month) 




1 

(Day) 



(Year) 



I liniRICnV CI'IRTIFV. That I attended <U>t>oamMl from 

190 t(i "190 

■ — alive on •■ 19° 



that I last saw h 

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



M. The CATSH OF DIlATIl^ was as follows: 

.d.t:Sr;\r^<C'V CL... 



ft-v;i,<iCr>.w vx>o 



I)r RATION y'e'ars 
CONTRIIUTORY 



A/on //is 



/\us 



I/oit 



rs 



DURATION 



Vears 



A/on t /is 



/\ivs 



I /ours 



y \ 



AVtAxn^' 



HIRPHl'UACK 
<>l- M(»THKR 
(State or Countrv) 






OU^V^: 



Aj\ 



)"/•(/; 



* !/,-/////> 



n,i\ 



oCCrPATlON 

Kf^idrii in Smr I'l oiii isi'o ^ 

'\'\\V. AHOVK ST ^T I'D I'VRSONAl, rAKTKMLARS A K I-: TKrK I" > TUl-: 
HKST Ol- MY KN<»\VM:DC.K AND ni:i.Il".K 



(Iti forma tit 



( \(1(1r»'ss 






( signed) 

1 



UrVcrvyJA/ J Uj Uj.XuL(v>vcL M.D. 



-LC*.. 



,0 \l\ \ 

_^ 4* 

PECtAL INFORMATION only lor Hospitdls, Institulioils Iransifnts. 



|\au_^__l9oH__ (A.ldres.) Ux^^^^^fiA^ 

«. ^CTAL INFORI , ^ 

or Recent Residents, and persons dying away froni home. 

Former or (V S . P ii ""^ '""*' ** 

Usual Residence M >-VAjU UXV Place ol Death ? 

When was disease contracted, 

If not at place of death ? 






Oavs 



I'l XCK OJ- lUKIAI. OK KHMOXAI. I DATl-. ..! I!i w 1 A i. oi Kj;M«t\AI. 

■ cyivk. Col I Y^ '^ ''°^ 

s 5 a...^JfX^^^^<J^^ 3-t 



rN!)i:KTAK1":R 

(Atltlrc«« 



N. B. 



State CAUSE OF DEATH In pluin terms, that it may he properly claMiiica. 



non% dylnft away *rom home nhoiilcl be A'ven in every Instance. 



i 



k' 



• \ 



\ ', 



i 



1* 



I 



i; 




U: 




I 



(I 



BO! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„„,„f „<,mh-l'N-o ,.* g^.l.^FCn REFER TO BACK OF CER TIFICATE FOR INSTRUCTIONS 

163 



190H 



Resiisterecl JVo. 



Date File(l,..y^fl.O^ % 

DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



fflcer 



Certificate of Beatb 

( xa. S. Stan^arD ) 
PLACE OF DEATH:— County of JCV>V IVCUVXCViCC City of Ha^v J^va^^Ov^C^ 



'^No. 



IS 11 W St.: 9 Dist.:bet. IS iL and \\ 



FULL NAME 



LI 




PERSONAL AND STATISTICAL PARTICULARS 

--^^ Q^ (1 i ^""•"'' 1 , ^ ft 



°J 



L 



DATK OF HIRTH (JTS 




?Jr 



(Month) 



(Day) 



, l,H .0.., 

(VL'ar) 



AC.K 



b V )>,/;> .v.. Mo 



iths 



H 



Da vs 



SlNC.l.K. MARKIKH. 

wnxnvKi) OR i)iv<)KO!:i) 

iWiitciu s(K'ial ilcsi^rnalion) 



lURTM PLACE 

'State or Country) 



^ 







NA>!K OI- 
FATHKR 



(B^ 



Jyyvcrrv 



\jOJS 




trv^voL-^xi 



niRTH PLACE 
OI' »-\THKR 
'^t.itf or Cotnitry; 



MAIDEN NAME 
OF MOTHER 






lURTH PLACE 
OF MOTHER 
(Slatf or Country* 



AA-/WW^Vv^V 



_ v[X^VX'^\JL4A-^C 



W 



OCCIPATION 

Rfsiiffif ill Siiii !'i aiii isro 



)V,7; 



}f.>,i//n 



/),n> 



THE AHOVE STATI' I) I'KRSONAI, P \ K T IC F l.A K S A K I", rRFl-: To THE 
nEST OF MY KNO\Vl.i;i)«-.E AND HHIJl.F 



(Informant 



\JiK' 



< ^<Mre««s 






\juUA:<A.:<X.y^. 




D.avtA^^.\.Q>v 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



/ ( Month y] 



(Day) 



(Year) 






I HKRKBV C1:RTIFV. That I attendctl decease*! from 

V^Ui... A.. 190 H to .yv:vXu...'"l up H 

that^ last saw h i^ alive on P-^'^'H' '^ 190 S 

'J y I T ij '* 

and that death occurred, on the date stated abovi'. at I A "t ^ . 



\T 



M. The CAl'SEXU' DliATII was as follows: 






DT RAT ION 



)'rars 



.IFoNths % Days I/outs 



CONTIUUrTORV 'c}-ltr\-LX/va.L trUXi.Vw* 
DTRATIOX *" Years " J^oNf/is^ ^ /hiys 



( Signed ) a>va.>x^ ^A <' s^a. 



Hours 
M.D. 



vJla.^ TqoM (Addrc-ss) \\^ d^ClUv "^^ 

PECTAL INFORMATION onlv lor Hospitals, Institutions, Translfnts, 



or Recent Residents, and persons dving away Irom fiome. 



Former or 
Usual Residence 

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



How long at 
Place of Death 



Days 



PLACE OF HFRLXL OK KFlMuVAL 



DA rj" "f HrmAi. or REMOVAL 



'k 




NDEKTAKER \) oX^tx^ 'V L 






I90H 



(Address 



(r>\vA.4v<r^\ C^^ 



state CAUSE OF DEATH In pinin terms, that it miiy »»e properly clBBSineu. » 

son* dyinft away from home should be ^iven !ii every Instance. 




f 



' I " 



; f 



I 



.( 



i 



\ 



W 



% 



t. 



) <\ 




I 



iij 



!' 




t."' i f. 



f'; 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

164 



Hoard"' ili'i'iiii ■ ■^ "- '^ ^■^■nik-» -_^^^^^^^^ 



Ic Filed, \^\ ^^^"t 



Registered JSi^o. 



,v^V^-A^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 



( Ta. S. StanDarC> ) 
PLACE OF DEATH: — County ofCJ/Ct^ lA.a^vC^^acCity ofO^t^v ^aivCc^Ct 



No, t<c 



'0 




(IF Ot* 
IF D 




Cs^' 



KwCX* 



St.; 



Dist.; bet. 



and 



*TH occurs/Taway from>USUAL R E S I D E NC E g. ve facts "'-l^%^';°'Vr7r,°or ST%7Ei*iNrNUMB^ 

EATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



N) 



FULL NAME 




n^uCH 




.^ 



^tvt^ 



c 



PERSONAL AND STATISTICAL PARTICULARS 

si:x A ^ A i c<)i,t)R 




iD.k.b 



OATlv or- HIKTU 



ACR 



C^ CTV J I'll I > O 



I 

(Day) 



Moulin 



/111. 

(Year) 



Da v.v 



SINC.I.K. MARKIKI). 
WinoWKI) OR DIVOKCKI) 
(WiiUiii social (Usij^iiittioii) 



lUKTHPI.ACK 
(Slatf or Country^ 



NAMK ni* 
FATUHR 



HIK I'M PLACE 
0|- I ATHKR 
tSlalf or Country) 



MAIDKN NAMK 
OI- MOTIIKR 



lUK ruiM.ACK 
<)1- MOTMHR 
(State or Country) 




. jAi^iL/Q.ov<xLi^ 



A 



r^\xL<x-^^-^ 



yfnnlh- 



n,i\s 



OCCUPATION ^ i 

Rfsiitrd in Stiti rnrinisra >.. )'U7f< 

THK AHOVK ST^rKD PKKSONAI, 1V\K lICC I.AKS AKI-. I" K C H TO TH}'. 
IIKST OF MY J<N()\VIj:i)C.K InI) inUJlvF 

(lu forma nl UXWOA ^ 'V'^VO- > 



{ m 



i\.' 



(Address i b C) 



^ o.\x<xtU 



MEDICAL CERTIFICATE OF DEATH 



DATR OF DKATU 




Mouth) 




3 

(Day) 



(Year) 



rTlKRI'^RV CI{RTIFV, That T nttcndcd deceased from 

...' 190 to TrrrrT~rrTrTrrrTT~~'~ 190 

that 1 last saw h -rr— alive on ^^P 

and that death occurred, on the tlatc statctl above, at 

r.T;;:: .M. The CAI'SB of DIvATII was as follows 




^-v-vA.Vvvvv'cx 3,,.v. |r*un^- 






J \.CkXt!CvVNjr '^ ..ri^t^. 



DIRATION Viars 



•t 



or RAT ION )'rars Monl/is Ihiy 

CON T R I P.UTO R V Llvv>V.. .(TV^?^... Jbr.^^ 

..LhuaLy»^.\.V 



Days /I curs 



diration 
(Signed) 




}'rars Mouths I^ays 



Hours 
M.D. 



iun icoH (A.ldrcs.) \j^K\\V\A UJU. 



FECIAL INFORMATION only f^^ Hospitals, Insfltufions, Transients, 
or^Retent Residents, and persons dying away from home. 

Us™lV'iden« 100? J A-lLat dv . tlllLm 'ii.>A.C..... fcys 

When was disease contracted. 

If not at place of deatfi ? . 



(Ad<lress 



I)Alj:of ^iiKiAi- or RKMOVAI, 

*i ^ 190H 



i'i..\£;k 01 inKjAi. OK ki:mov\i 

HLlO^I. 



^VA.^\-«>A' 



state CAUSE OF DEATH In plain terms, that it may he properly UaBH.tied. The Special into 
unns dylnft away from home Hhould be jt'vcn in every instance. 



H 



lii 



Ml 



4 







I! 



Illi' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Bunnlnf li.ilth 1 No ^ r if^^t^. ]\fk vc n REFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS 



Da/r Filed, 




Ov^ft-UA/i ^^vt 



100'\ 

Deputy Health Officer 



Begi'Strred J\^o, 



165 



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



Certificate of 2)eatb 

( "a. S. Stan^arO ) 
PLACE OF DEATH: — County of '" CI W'O Aa>vC^4.C() City of C',Ct">v J /VO'-VA-CUi. C 



A 



No. II' (LlcLtok QaA\.AXaA.cL\. 



■v\.\.. 



St. 



Dist.; betr 



and 



( IF DEATH OCCURS AW*Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPrCIAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




V>\A JlOL^iWO. 



-U. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COT/)R 



^\J^ 




4^' 



JjL 



DATl-; or niKTH 



\C,V. 



iMoutA) 



5- 

(Day) 



(Year) 



<^. \ ) 'l'(t > s 



Mouths 



Pa v: 



SIN'C.I.K. MARRIKI). 

W IDOWKI) OK niVOKi"i:[) 

'\\iil«iti social (ksi).'iiatioii) 



niKTHPI.ACK 

'State or Cotintry^ 



NA>!1-: OI' 

katui:r 



niRTllPI.ACK 

nj' r-APHKR 

"State <jr Coiuitry) 



MAIDKN NAMK 
<)l- MOTMKR 






luJ 



( 



I 



MEDICAL CERTIFICATE OF DEATH 



DATK ov i)i-:ath a 



(Year) 



(jiMont!i|T (Day) 

I IIF.RIUJV Ci;kTII'V, That I attt'iKud <kHvasc(l fr«)iii 

QUo^Hk^^^ 190M to V^ '^ >«K5H 

tliat I last saw li v^»^»^ alive oti //^^W ^ '*>° ♦ 

and that death cxicurred, on the date -stated above, at I 

0^. M. The CAV'SFv Ol"' DI-ATII was as follows: 
.abx>vvV^A.|v<vouL. ..cCvnX -Li -v-vvxA^-kvQ <?Jx^^L.i^A' 







y\J^ 



^VtrU'^'^V 



or RAT ION 
CONTRir.rTORV 



)'('(jrs 



Mouths >>. Pays 



I lout \ 



/CLAoua^JL->A.^^-Vr^V^...LLlx-i.\JL \vCLv CvLvJ 



I) f RATION 



(Signed) 



Years 



LA/VuL^t ^ft 



Afonihs /hirs 



niRTniM.ACK 

<)l' MOTHER 
(State or Ooutitrv) 



OCCrPATlON p 

Rrsiiln? in Sttu f'l (iin isfii 



lK^i^/^JO^^ 



\\/>^^JiX>><} 



1- 



)'/•(! I 



-■ Mnllth- 



nnvs 




4 



a ic,oH f.\ddn-^s) Sbb d^va^ 



//out s 
M.D. 



.^ t1'+ 



_ FECIAL Information only for Hosplldls, institutions, Iranslfnts, 
or decent Rcsidqifs, and persons dyinij dwd;^ from fiome. 



I'ni: AHOVK STA ri'i) i'Kksonai, par putlaks aki-: tri k to thi-: 

m;ST Ol-* MY KNt)\VM:i)C.H AND lUUJi:!" 



'Iiirotmntit 



%.QQ^u 



\"L^n%, 



\(l.l^^^^ U.'iXo 





A,A. 



-Ua dt 



Former or ; . , n , d J , "«** '""«'«* 

Usual Residence vAJ <yX<KLiJ.i, oo.^v^U^^... Piare of Death? 

Wljpn Has disease rontrarted, 
If not at pla( e of deatti ? 



Days 



l'I,Ati;ol HIRIAI. OR ki:Mo\AI. 



DAri;.»r m kiai, «»i ki;mo\ai. 



INDHRTAKKR 




Address 'X%% OU' CLLlulL.^. 



,\Ju^r\^ 



N. B.- 



-F.very Item of InformntJon should h. cnrcfully Huppliecl. AGR nhoulcl be «t«ted HXACTLY. PHYSICIANS «houid 
state CAUSE OF DEATH in plain terms, thnt it m..y be properly classified. The Special Intormation for pT- 
sons dyinft away from home shouUI be ftiven in every instance. 



t 



t ? 



If 



I 



Mi 



I 

1 



ii il 





It 



\i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Horn.l of H. ..Itli- 1 No i- ^^^^U'.ScV Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Filed, 



A..tKtVy^ dJL^ 




% 



IfJO^ 



JiegLs/ered A^o. 



166 



Deputy Health Ofincer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)catb 

( "a. S. Stan&arD ) 
PLACE OF DEATH;~County ofClaw^' A.Ct^'vCA.^CCGty ofCJ 






ini>. UyvdAai vw 



>JAXVt/>x^<.L ^V'M 




vwt 



m 



Dist.; bet. 



and 



/ IF DEATH OCCURa(\*WAV rR&W USUAl) R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 
V, IF DEATH OCCdJiRED IN (j HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



C\/yujiL.i4^ 



.Ot>c.4v.>->^a/>\^ 



PERSONAL AND STATISTICAL PARTICULARS 



^'•"' ^ 



n.\i i: or iiiktm 



CO I, OR 



LvJxcAJL 



MEDICAL CERTIFICATE OF DEATH 

DATi-: oi- i)i;.\Tii A ft 



VV. 



(Moiitii) nT 



n 

(Hay) 



(Year) 



A(.H 



I C> )'•'"> 1 



Mnulfn 



ICl 



Ihns 



"^iNi'.i.i-:, M\Kun-:i), 
wiix >\\i<:i) OK ni\'oKri:i) 

i\\'iit( in sooial (lcsJ>fnatioii) 



Ql 



lUUTHPI.AiM-: 

' *^t.ifc or Com lit I v^ 



NAMl. Ol 

fathi:r 



tUKTMIM.ACK 
Ol' l-ATHKK 
'Statf or Country) 



MAII)i:\ NAMK 
Ol" MOTHKR 









XV>wo^^\v( 




Month) f| 



1 

(Day) 



ion'-' 

(Vi!n) 



r iri':R i:i'.V CI-IRTII'V, That I :itUMt<UMl <lerease(l frnm 

~" up to ■ lip 

til at I last saw h " alive on rep 



an<l that (it-ath ncciirred, on tlu- <lati' stated ahovo, at 



'M. The CAT SIC Ol- I) I! A Til was as follows: 
ci.-:WV.V;tV.V<i^ 



t-^V-Q^Kt 






\ 



,^"LCrV\rw) 



niRTiiPT.Aci.: 

Ol' MOTIIKR 
(Stale or Country) 



I, 



J 



(H'CTTATION 

f\Vsidr,i in Smi I'lainisro X U )V'M.< Mmit/i- 

I'lll': AUOVI<: ST ATI", I) I'KKSONAl, r\K lUTI. \KS AKl'; TRIJ'; To TIN'; 
HHST Ol- MY KNOW l,l-;iJC,K AND itl': 1. 1 i:i'" 



or RATION Vrars 
CONTKIIU'TORV 



Months 



Davs 



I lours 



Pays 



DIRATION Ycius Months 

Address) l^rVrwiv^ vi-tv<i<^ 



(Signed) LavrvUA- 

N^VVLC^^ l()nH (Address) v 

SPECIAL INFORMATION onlv 



Hours 
M.D. 



H 



/)./!. 



(Infonn.'iiit 



\5 (nLU/Yv vj/att Li 



_ Iv lor Hospitdls, Inslituhons, Irdnsltnls, 

or Recent Residents, and persons d)inq dnay from home. 

Former or , « ^ <> \» 8 J , "M 4 ""^ '""'< •*' c- ^ 

UsudI Residence ICO b JK<lt'W X)^ix Pjd.e of Death ? «^ 0>U.! Jays 

Whelt^dS disease contracted, ...n 4!»^yj, 'VA^'|.(i,,a 

If not at place of death ? 10 Cl \]a-tcU>v ^<Xl- 



l'I,ACK Ol" lU KlAr, OK KlvMoVAI. 



INI)1;K 1 AKKR 



\. Micks 1 bo 5> 



A.l.ln 



i)\i"i-;'>!' rti KiAi. oi kj-;movai. 



IN. B.—Rvery Item otf informntlon «houM be cnreV'uIly supplied. AGE should be «tnted EXACTLY PHYSICIANS should 
state CAUSE OF DflATH in pinin terms, that it mj.y be properly clansU'led. The Special In»ormalt.,n for per- 
sons dyin^ away from home should be feiven in every instance. 




i 




I 




I 

* f; 

t 



h '^ 



T 




' »' ■( 




n 



!«!- m 



I ,Hj 



^flii:f 






If 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hou.l >f Hcilth KNo i^is-f^^HSclCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ddlc Filed, 




I 



100^ 



Registered J\^o. 



167 



^No. 



XiH-^v<3 c<Jixn\ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "U. S. StanDarD ) 
PLACE OF DEATH: — County of Oaiv OMXvtCA^C^ City of 0<^^v Vancv4Ct. 
'X%\^ ^)dJuJ\Y. St.i 1 Dist.:bct. AJ'Vtt^^^'^V and OA. 




'J\J 



,t 



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



FULL NAME 






L^.j|Vi\^t >.^Ul. . cL.CX.>x,0 



PERSONAL AND STATISTICAL PARTICULARS 



DATl-: OV IHRTH 



0)1 



(Month) 



5.1 

(Day) 



/.H,C)-H 

(Year) 



AC.K 



J ra I 



Months 



n 



Da\s 



SINC.I.K. MARKIKI). 

\viiH)\vKn OR nivoKij:!) 

'Writfin s<K-ial ih sijfiiiitioii) 



niK TMPUACK 
'State or Country) 



V\MK OF 
I ATHHR 



niRTH PLACE 
o|- lATIIKR 
'State or Country) 



•0 . ^\Jk CNAxla^cL 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



(Mouth) 



i 
(Day) 



(Ye.-r) 



MAIDEN NAME 

<•!• MOTHER 



HIKTIII'LACE 
<>l MOTHER 
(Slate or Co\intrv) 



oOCrPATlON 



tl.J^tW)!' 



,ff 




'/JA>\JUj 



/\f'Mi/ft/ III V(?» /'l dill /M'i> 



\.vrv\ 



)-,-,MC 




d 



a^ 



/>\xL 



I HRRI'inV CI':RTIFV, That [ attended deceased from 

|wU^ ,9oH to ^|l.vi^ 1 IcpH 

that I last saw h XV alive on ywXlA 1 Kp S 
and that death oceurred, on the date stated above, at 
M. The CAISH OF I)I:ATII was as follows: 

I) r R A T I () N ^- ) 'tU7rs 3 Afon/fis " 



/)(7vs " Hours 



CONTRIIUTORV 



Pay: 



I/otn s 



DURATION Yrars Mouths 

y.Vr»\jl LI 'iD'CvaVvL^ M.D. 



(Signed^ 



T<>0' 



{ 



_ FECIAL Information ""'y '"•■ Hospitals, institutions, franslrnls, 
or decent Residents, and persons d)ing away from home. 



MKiith^ 



I>i)\ 



I" III', A HOVE STAT1-*I> PKRSONAI, }V\ RT irC I.A KS A K I". TKIK To PMK 
H1':ST OK MV^ii^oWMCnC.E AND MllI.IlCF 

(In for ma nt J A.XXVS^C^V^ <XXC"VV0UL 



(\ih\ 



rcss 



Xlx^ (D«v.kt>v n 



4 



Former or 
Isual Residence 

When was disease rontrarfed. 
If not at plare of death ? 



HoM long at 
PIdf e of Death ? 



Days 



PI.ACEJ^H; lURIAI. OK Ki:Nn>\AI, 



NDERTAKKR M R <i CK^jiX 

\ 1 \ CVXvi.4.v^^ 



It \Ji; o! Jli KiAl, lit REMo\AI, 
t T90H 




(AtUlres«. 






tN^i' 



H 



IS. B. 



Rvery item of in?ormRtlon .hould he cnrelfully supplied. A<JF. hHouUI be «tHtecl liXACTLY. PHYSICIANS . 

state CAUSE OF DEATH in pliiin terms, that it may he properly clasulfied. The Special Intormntlon io 



PHYSICIANS should 
r per- 



sons dyinft away from home should be ^^iven in every instance. 




•> 



't» 




i \ 



! ! 



I' I 

J 



Hi I 



U 



f/r I 



»i 



m 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



M„i,rrl of Ih:.llh- K No. IS ^^-t^^^H&P Co 



Bcgistered J\^o, 



168 



Dale Filed, XAaj, I 100'\ 

cWvovo dOAyu Deputy HealthOfncer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 

No. 5iC)U vCX.Lvir^\/"v^^w.A. 



Certificate of S)eatb 

( xa. S. StanC»arD ) 






O^yv vTACVavcv^'O-o City of ^ ' 0^\j ^jX<Xaxcv^ e.c 
St.: D Dist.: bet. ^M^^CrrvJ and 



., - Dist.; bet. 

ENCEgive facts calle 

A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAJs OF STREE 




(IF DEATH OcltioRS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR U/**DER 'SPECIAL INFORMATION ' N 
IF DEATH pCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTeJu) OF STREET AND NUMBER. / 



FULL NAME 



LlAAivk MD..CL.>vcA.^r^ M )IvcJ\.culX' 



PERSONAL AND STATISTICAL PARTICULARS 



SlvX 



'^.d. 



„,... ^^ 



DATH or- IWRTH 



yCL/ 



V 



Av 15 /.lai... 

/itoiitli) (Day) (Year) 



A(1K 



\J 



11 



I '/•<; I . 



5- 



MntilfiS 



%% 



MEDICAL CERTIFICATE OF DEATH 



DATE OV DKATII 






^7 

(Day) 



/go \ 

(Ycnr) 



Da vs 



SINC.I.K. MARK1KI>. 

\vin(»\vi-:i> OK nivokCKn a 

iW'iitt ill social (lisijftialion) "nf \) 



niKTFIPI,ACK 
'Statf or Cnuiitrv'> 



NAMlv ()!• 
l"ATm;R 



niRTUPI,ACK 
Of lATHKK 
(Stale or Country) 



MMni-:N NAMK 
<)|- MOTHKR 







UX/^ 




J 



^^\OJJ 



I IIHRI'iHV Cl-KTIf'^V, That I Mttcn.lcMl (k'nascl from 

Q"lVav^ IH 190H to ^^'^ "K^'i 

that I last saw h-V>>A alive on HvOaa^ 1 up S 

ami that death occurred, oti the date stated above, at 1 ' ^ 
U M. The CAI'SI-: Ol- DI-ATII was as follows: 

.LL-cv^tx LLN^txc^JiLcvvyU('v:-x.i^-»-k^.<xt\^.-vvi 

Lx<^.x.b-V^ o ^YWAxo^iC .\I RJlAxv'VvcyAXvo 

1)1' RATION ^ Years ^ Mouths I /Vi v 9vS I louts 



CONTRir.rTORV 






MTU/\vavOI ^U.^^ 



r.TRTMPI.ACK 
<»1' MOTHKR 
(State or Couiilrv> 



OCCITPATION 

Rrsiifrd in Snu Ft iiiii i^i'o 






na\ 



Hours 
M.D. 



DURATION Years ^ foul /is 

(Signed) "^Xo VJ ^xa^Llyvvua 

WLl u)oS (Address) H^H-'^^cic 

Special information ""'> '•"■ Hospitals, institutions, Trdnsifnts, 
or Recent Residents, dnd persons dving dnnv Irom home. 




/),n.v 



rm-: \movk sTAri:n pkksonai. par ikmi.ars aki-: rkn-: to iiih 

HKST Ol" MV KNo\Vl,i;i)C, K AND lUlMllK 



Cliifotinaiit 



VjiXv^^^vxAjL Vn\vcJLoaX 



(0 




>xvcc 



3f 



Former or 
Usual Residence 

When Has disease ronfrarted, 
If not at place of death ? 



lloH long at 
Place of Death 



Ddys 



PI.ACK OI- lUKIAI^oK K1;M<'\\I. 



ItAp: oI m ui.\i. 01 Kl",Mo\AI, 

IQOS 



-^r 



HRTAKKR ■ C^*JjL>>J '^lOJivAijL, 



I \ D 



N. B.- 



-F.very Item of Informntlon .houUI be creVully supplied. AGR should be «t«ted F.XACTLY. PHYSICIANS should 
state CAUSE OF DEATH In pliiin terms, thnt it miiy be properly ciassilfied. The "Special Intormiition for per- 
son* dylnft away from home should be jt'ivcn in 9\ory Instance. 



, '■' 




^ * 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lioanlof Mf.'.lth"KNo i.; "tf^^g^ lUt I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




100^ 



Meglstcred JVo. 



169 



lutte Filed, WXu ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( tl. S. Stnn&arl> ) 



\ % 






^ 



No. 



PLACE OF DEATH: — County ofn/aA^O/UX.>\CUlC^ City oiOOjW ,rL<XAAX\.4. C<) 

ti 



Q^ 



DOA. 



cLi 



s 



III 




(IF otATH occuns 
IF DEATH OCCU 



Dist.; bet. 



bt' 



S AWAY FROM USUAL R C S I D E NC E CI VE FACTS CALLED FOR UNDER SPECIAL INFORMATIO 
RREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



N) 



FULL NAME 




MJLvrti/rLi 







PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^ 



0-^y>yuxJsX 



COI.OR 




' vutii 



DA 1 }•; or luK rn 



AHK 



Moiitl^ 



1 

(iJay) 



( Vcar) 



) 'ea > .V 



Months 



Pays 



SIXC.I.K, MARKIKI). 
\VlI)()\yKI) OR I)IVOR('KI) 
• Write ill social (k-si^rtiatifm) 



f 



niRTfUT.ACK 
(Statf or Country) 



NAMK OI- 

iatiii;r 



nTRTllPI.ACK 
OI- I ATHHR 
(Statf or Coniitrv) 



MAIDKN NAMK 
oi MOTIIKR 



in RT HI' LACK 
OI- MOTIIKR 
(Stale or Countrv) 






MEDICAL CERTIFICATE OF DEATH 

DATK OF nKA'I'l! 

1 

(Day) 




(MontH) 



/go ^ 

(Ye«r) 





l/yVCLTLt 



I m':Rl':nV CI-RTII-V, That I atUMKk.l dorcastMl from 

jKaJUa* "1 I90S to -r- «- 190 

that I last saw h alive on "^ " I90 - 
ami that death occurre<l, 011 tlu' date stated above, at "" 
r... M. The CArSI') (>!• DIvATM was as follows: 

in' RAT ION )'t'ars .Won ^ As Days / loins 

CONTRIIU'TORV .»... 



OCCUPATION •► 

A'fsiifr(f in S,in /'i nm isro 



uxloPti V->Ax a 



DURATION 
(SIG 



) I'd IS 



Months 



Pa j'.v 



NED).lU- 0. OXOULavItJUa. 



Hours 
M.D. 



ivd^l ic,oS (Address) a^^'Vlbtk^" 



FECIAL iNFORiVIATION onl> lor Hospitdls, Inslitutlons, Translfnts. 
or Recent Residents, ar^ "ersons dyinq anay fro:n home. 



) V(M 



.1A.*////> 



Da \s 



TMl", AHOVK STA'n:i) PKRSONAI, PARTICCLARS ARK TRIK TO TIIM 
HHST Ol- MV KXO\Vl,Hl)(.K AM) IJKMKF 



(Iiifonnant L<XA^rUA/V>XX \I I I Cl TV 



Ct»jL 



i \rl,l 



ress 




lb ^,lV,,a\clucit 



:! 



Former or 
Isual Residence 

When Has disease contrarfed. 
II not at place of death ? 



HoH long at 
Place of Death ? 



ftiys 



igoA 



IM.ACK 01- lURIAI, OR K1:M<»\AI< I DVlliof IUkiAI. <>r RFMOVAI. 
ITNDHRTAKKR U/^-V^-tX^ ll>XcLtvi<XV\X''U 



( A.1.11-SS 



IN. B. Every Item of ln?apmHtiofi •houid be cnrefully «uppl5e<l. ACIK should be stiileil liXACTI.Y. PHYSICIANS should 

state CAUSE OF DEATH In pinin terms, that it mjiy be properly clwKHh'letl. The "Hj»cci»l InformHtion" for per- 
sons dytnft away from home should be |!iiven in every instance. 




4 




li 



1: 



¥ 



^t * 



\\ 







I ;i t 



' 'I 



ii-r 




MH^ f 



h}4 , 



♦ ■ 







i ; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H..an! nf Htitlth-F No. 15 1^^^^^l\&.\' Co 



I)(ffr Filed y 



10 OH 

Deputy Health Officer 



Registered J\'*o, 



170 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



,4 



( "a. S. Stan^ar^ ) 



PLACE OF DEATH: — County ofC/CL"y^ ^-VOw-^vt^c^C^City ofCJCL^X) v)AOw^>vco,c 



CO 



(T) 



N®. 




Vuv 



v^vLu 




v^ 



hwk. 



aist.; 



Dist.; bet. and 



(ir DEATH OCCURS/fWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N ' ' "X 
IF DEATH OCCUH^EO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



^yj..^AA.att \I W\Xr>- 



\j 



PERSONAL AND STATISTICAL PARTICULARS 
SKX ppV A I COI.OR 



OX^^voJijl; 



I).\TK or* lUKTII 



XvVvcl 



7 

(Month) 



^ 



Ar.F. 



bS »„,.. '. 



nay) 



Months 



7 



(Vt-ar) 



A; 1 



SlXr.I.E. M.\RHIKI). 
WIDOUKI) OR DIVORi-KD 
|^^'Iitt•i^J social dcsij^nat ion) 



HlkTHJ'I.AOK 
(Statf or Country) 



VAMl-: Ol' 

I ATni:R 



niKTHPI.ACH 
<>l" FAIUKR 
(Statr or Conntrv) 







MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH A a 

VL b 

jKMontlrT (Day) 



(Year) 



MAinEN NAMl? 
OF MOTIIHR 



lUKTMl'LACIC 
OI- MOTHKR 
(State or Country) 



OCCUPATION 



% 







r- 



I HKRICHV C1:KTII<V, That I atteiKlcil .lcocase«l from 

CL|v\a1 n 190H to WW^ T90S 

that I last saw h X\j alive on M'^V^A.^ L njo H 

and that doath occurred, oti the date stated ahove, at 106 
lL M. The CATSI': ()!• DliATII was as follows: 

1)1" RATION )'t't7rs X Motitha IH nay.<i Hours 



CONTRIIU'TORV 




:>.\-i.^...r.<teV.> V iv.> vvfr.uit.>ft». 



^ 

^ 



^ 






^■4,..AJ"VA-C 



yr.o'ff,^ 



/)<! 



DTRATION 
(SIGNED ) 

^VLU-^ b i(,o"i 



) t'llfj J A ' ;/ //is Da \s 



Hours 
M.D. 






SiPECl'i\L INFORMATION onl> *or Hospitdls. Instilutions, TransifBts, 
or Recent Residents, and persons dying anay from home. 



Former or 
Dsual Residence 



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



5.1 Jb a\tU\^ "^ ^ [luf 'otVath ? % c 



Days 



rni<: ahovk st \ri:i) i'Kksonai, i'ari'uti.aks aki: rKiK to tiik 

HKST OI-- MV KNtiWlJ-.lX.H AM) Hi: Mi:!- 



(Infornmnt 



(\<l.lrcss 







IM.ACKOl' HIRIAI. OK KKMOVAI, I iJATllo! Hikiai -i KI;Mo\A1. 

^ « ' ' kUio . 



r\ 



Cv^-^iA' 



rsDi 



vrv^vu „ _ 

(AcWre.« U^^ VmV^4Ai^^ "?5t 






i9o'< 



3rw 



N. B. F.very item of {nforniHtion should be cnrefully Aupplied. AGE nhould he stated KXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par- 
sons dyin^ away from home should be j^iven in every instance. 



\ 



\ ■ 



n-' 



!» 



•Jl 



i 



1» 



I, 



mi I 




if 



I 






f 



I 



« 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,,i,r.l of Ileiilth— FNo. i^ **?.: ^U^ri^ H& I" Co 



])((l(» Filed y 



S 100^ 

Deputy Health Oflflcer 



Registered J^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticate of 2)eatb 



i 



( "Q. S. StanOarD ) 



A ^ 



(M®. 



PLACE OF DEATH: — County ofC'OL^^ ^AXX^-^vtM^X^CoClty ofO<X>^ vJAa^wCUtCt 

(IF DEATH OCCURS 
IF DEATH OCCUI 



utu'^C^ 






Dist.; bet. 



— and 



IS/iwAV FROM OSUAL RESIDENCE GIVE facts called for under "special INFORMATION" \ 
lED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



vyj..>L^,d.caJj . \i. W\i^\j. 



-U 



COI.OR 



PERSONAL AND STATISTICAL PARTICULARS 

DATK or- HIRTH 





7 

(Month) 



^ 



(Hay) 



./ l^^-S.- 
CYear) 



ACK 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 

'Moiitm (Day) 




(Year) 



bS Yra.s 



? 



MnHlfn Diivs 



«>TN'r.I,K. MARHTKD, 
\\I!)()\yKD OR DIVORCHD 
(Writf in social (Usijftiation) 



MIRTUl'LACK 
(Statf or Contitrv) 



VAMK OI- 
JATMHR 



HIRTMPl.ACK 
oi- IWrHKR 
(Statf or Country) 




tvorvcuX 



MAIDHN NAM1-: 
<)1- MOTHKR 



lUR'rilPI.ACK 
<>|- MOTDKR 
(Sl.'ttf fir Coiintrv) 



OCCT^PATION 



'% 




I Hr^RKBY Cl<:RTn-V, That I MUoiidcd <lcroase<l from 

Cll\AA.l 11 190H to |vAJUl.b I90H 

til at I last saw h XV alive on H^VaJu^ l;> j>p H 

and that death occurred, on the date state<l above, at i' 06 
CL M. The CAl'Slv OF Dl-iATlI was as follows: 

g -VO^cXaaAX &4- i.X'-wwv^N.' Ovi -Ak^w^^jC^u J.3 

...r\/vajL^l<v,jrviL...X^ 

„., (IUAA'i\-'«-'QA<3uLvx, V 'T%X\-v'w.\,.fl-iLwa» 

DT'RATION ^ }'('ars % .^fonihs !^ Days //outs 

CONTRIIU'TORV .1 .l\<C^/lfT^:>.\J(L^...r:M^.>A..^^ 



DURATION -... Vt'iirs 

(SIGNED ) 



qrs Mouths /hjys 

(Ad.lress) Vj'^vCVj fe&^|\^.Uxl 



//ours 
M.D. 



SPECi'Al Information »nly lor Hosplldls, institutions, Iransicnts, 
or Recent Residents, and persons dyinq away from home. 



Former or . 

Isual Residence I 



5.1 0ba\tiU\<l n "^ Place of Veafh? % 



c 



sitfcif til Siiti /'nnii/'iro .l5 )V<n s A/i'iif/i." 



Ihn. 



THl". AHOVK Sr\li:D I'KR-;<)NAI, 1" A l< T H" T I, A R ^ ARl", l"Rl !•: To Till-: 

ni:sT ()!• Mv KNo\vi.j:D<".h; AND m:i.n:i- 



(Infornirint 






JL^ 



C Address 




]b CK^A,ulai 



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






Days 



'^c\ 



190S 






ri.XCK ni" lU RIAL «»R RKMOVAI. i DA IK of M( kiai. or RKMoVAI. 

(1 I K i? n ( V> 



fAddn-ss 



iD-^n V>r\v4AA.fi^. It 



IS. B. Rvery Item o? information shoulil he cnrefully HupplJeil. AGB shoulil be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that it may he properly classified. The "Special Information'' for per- 
sons dyin^ away from home should be J^ivcn in every instance. 






r 



> \ 

1 



I 



\ 
I 



^1 



i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lUiid . f Htalth-FNo ^^-^^^^liSiVCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.290^ 



Date Filed, VJLiS 

J J J (] 

cLvu-v^ cLov-u Deputy Health Offlcer 



Registered J\^o. 



171 




h> 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(Tevtificate of IDcatb 

( in. S. Stan&arD ) 



PLACE OF DEATH: — County of 



LLLcuT^VuLo; City of LUL<Vvv\X^cLow 






( No. vLL<X/V'>^Jt<VOj CJ <O^AAA^\,: 



v<M^^>^. St.; :. ' Dist.; bet. - 



and 



(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPEC 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



FULL NAME 



;IAL INFORMATION" "\ 
T AND NU MBER. J 



-) 




PERSONAL AND STATISTICAL PARTICULARS 

^!;X (TTN ^ I COI.OR 



!>.\T1-: or HIKIM 






) 




VC 



.t^_ 



'MoiitlO 



Day) 



A\'.. 

(Vcur) 



AC.K 



lc5 



) 'I'a > .^ 



H 



.}/<>ft//ts J%^ /htvs 



STNr.I.K. MARKIKI). 
WiixnyKi) OK DivoRCKO 
(Wtittiu siK'ial desiKiuition) 




niKTMPI.ACR 

(State or Coimtrv) 



XAM1-: ol- 
FATHKR 



BIRTHPLACE 
OI- I'ATHKR 
(State or Country) 



MAIDKN NAMK 
OF MOIHKK 



XAH^\} 






MEDICAL CERTIFICATE OF DEATH 
DA TK OK DKATH 

X 



HA.\.Lu 

flMonth) n 






(Day) 



(Year) 



1 in':RI':HV CICRTIFV, Thaf I attended deceased frotu 

— to 



190 



tliat I last saw li-rr—r-. alive on 



^QO" 

Tcp 



and that death occurred, on the date stated above, at 
.TrTTTr.M. The CAUSR OI' DI-ATH was as follows 

X)..A,<.<X'*U^tj^a. 




lUkTHl'I.ACK 

01 mothf:k 

(State or Countrv) 



ocCrPATION 



I UxVQ-CXNjtt 



DURATION }'ears 

CONTRIBUTORY 



Montha 



Day 



Hours 



xsJL'L^^yo^y^l 



DURATION Years 

a a 



i) Tout /is 



(Signed ) 

/^ I()On 




/^ays 



Hour 



(.\d<ln-«^s) 



M.D. 



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



Rf'''iiir<1 lit S'dn /■') ii II' fi'i) 



)'r<i I 



1A./////.V 



/hi\ 



Tlir. AUOVF. ST A IJ:I» I'KKSdN \I, I'AK ITCriARS ARK TKCK To THH 
in;ST OJ' MY KNo\\M.D<".K AND lUajl'.F 






tX^'v^^-'ftW 



( \<l<lrcss 



Former or 
Usual Residence 

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



How lonq at 
Plare of Death ? 



. Days 



I'l.ACK Ol" HIRIAI. OR RKMO\'AI, | DANCof UiKlAi, or R1:MoVAI, 



INDKRTAKHR VXV\XA.Ar ^^ W>AXlVv4.K- 



(Address 



aa l)'Cw>^ ^\i.L 



N. B. Kvery Item o? Information should be cnreV'ully HuppIJecl. A(JK «hov.hl be stated BXACTLY. PHYSICIANS should 

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



I 



! 

- 

(I 
\ 



\i\ 



li 






* 






, 



Iff 



'\ I 



l>; 



$ 




f 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' lu'led , 




IDO'i 



RegLslei'cd J\''o. 






Deputy Health OfTicer 



^No 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( XX, S. StauDarD ) 

PLACE OF DEATH: — County ofClCL^\; vJXa>vCVA.C*: City of vJ <CL/>V A.C^>xc V.4.C0 

, ?^ I /x ^ I a LIaj St.; 5 Dist.;bet. crViyrrru. 




and UU'CtVVU.ryv ) 



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



FULL NAME 



Mllcv^vd. M cAlt dvJ.4 



PERSONAL AND STATISTICAL PARTICULARS 



DATi-; or i!iu rn 



COl.OR 



bJJvvU 






1 /,a..o..H.. 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII 



/ (MuntJi^ 



(Day) 



'J 

/on . 

(Year 



AC.K 



) >«/ » > 



M, mills )Q..A\\A Davi 



>TN'r.T,K, ATARKIKD. 
WIDOWHD OK nivokri-.D 
iWiif'in sorial (Ifsij^iialioii) 



MIRTH ri.AOH 
(Stalf or Country) 



NAMK OK 
lATHKR 



niRTMPI.ACl'. 
o|- IWrilKK 
(Stjitc or Country) 



MAini-:N NAMl-: 
Ol MOTHKR 



niKTMI'LACK 
Ol" MOTHKR 

(State or Co\intry) 



OCCUPATION 



(j Cuy\) .VOL vuL'C^c-C) 

I ... 1 



■t^vt^j.. 




I'iklUiV Cl'lKTll'V, That I attcii.Ud .liMvasod from 
1 iqoH to .^ ^l^vJU^ 1 Kp*^ 



IgO'X to 

tliat I last saw h'^^AJ alive on ^'^^"^V ">° "^ 

and that death occurred, on the <latc stated above, at A 

(F M. The CAISIC Ol" Di-ATII was as follows: 

\^ AJuyyKrQ^Xj^r^KJL y^-cvLiv 



DTRATION " Years " Mouths Days i- Hours 

.^. .a-^vL -rrl..>.A.r«rtVA.>r. 



CONTRini'TORY 





CLCU 

J? (^ 



Dl'RATION 



S TqoH 



Years 



Mouths 



f^avs 



^1 H 

( SIGNED ) J ,i\.<m'V<Xft > > HtX jv.^, Ni 



(Address) I 1 S c5 -mXUv d t 



/fours 
M.D. 



S'PECIAL Information only for Hospitdls, institutions, Transirnts, 
or Recent Residents, and persons dying away fro;n fiome. 



Rrsiiffif ill Sail I'l iiin isiut 



) '<•(! I s 



.y/iniths 



/>,n. 



TIM'. AHovK sr \ri*n i'krsonai. ivAKTuri. aks \\<]-: TKii': ro rm-: 

HKST Ol- MY KNOW 1,1 JXUi. AND Ml'MlvK 



{Inforniant 



v,.„,-. ilC)'lx-|5. tk -^t 



Former or 
Usual Residence 

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



HoH long at 
Place of Deatli ? 



Days 



I'l.ACK OI" lU'RIAI, OK RKMOVAl, 



DAT 



f JK KIAI, or RKMOVAI, 

"^ 190 S 




UNDUKTAKKR 



%, i Q.-L.Jw.'^ ■^ 



C 



11 



a>\ 



VA.A'V^^y^ 



it 



N. B._r.very Uem of information nhouLI h. crefully «upplied. AGF. nhould »»« «V"*i/^^''.;\?''K''; , ^''^'T'!;^. If :;!.** 
state CAUSE OF DKATH in ph.in term., thot it mny be properly claHHifled. The Special Information for p.r- 
«on« dyln^ away from liome shouhl be feiven in every instance. 



.: I 






I'i) 



i; 






t ♦ ■ 



■ 

" 

r 

; 

1 



I 






u 



I 



^1 



'.i 



1 



i 



h 



# 




L 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.,n.l. f lUr.ltli -I No i - -^^^Sf^ USi V c. , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' nied, W^ ^ 




rjo\ 



Registered J\^o. 



173 



d^-trvv*^ Axamjl Cej>uty Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( n. 5. Stan^arD ) 
PLACE OF DEATH: — County ofOa^v Xa^vcui CC City ofCa^V 



.\a/rc>ciu5.c c 



'IHo. 




fl 



trr\. 



loK^V^ta. 



St.; Dist.; bet." 



and 



\r DtATH OCCUR$ 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 



.OLLlCLO/CLLci 




PERSONAL AND STATISTICAL PARTICULARS 

si:.x {7r\ \ I coi.oR \ 



^0 P 




v^ 



t^ 



DA it: nr lUKIMI 



ACK 



(Motith) 



(Day) 



(Vtar) 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DICATH 

.VcltU ^ 



Month) (J 



{I)ay> (Year) 



O I Yntts 



Moul/is 



Pa 1 . 



SI\(.I,I-: MAKKIKT). 
\VII)<)\Vl.:i> OK I)IV«>Rij:i) 
(Wiittin ^<K■ia) (ksivnation) 



lUKTmM.AOH 
(Statf or CotMitrv^ 



UJ AwCL^V^r 



X\A\va'>v.i, 



NAMK OI- 

iatiii:r 



IlIK THIM.AOK 
ni I-AIUKK 
•State or Country) 



? 




V"^'%V 



^ 



V 



uXX^wvaAvi 



I Hi:KI<:nV CI-RTII-V, Thai I attcii.U^l ilcHvascd from 

Cl|wvl 13 ,9oH to .^^^- ^ '^^o'i 

til at T last saw h X\) alive on HaaAajl. b up 



s. 



and that (loath occurred, on the dati stated above, at -. i '^ 
LI M. The CAl'Sr: OF Dl-ATfl was as follows: 

xidv> 



T 



1 ? ■) 1 

DTF-IATION Years Mouths ■ f^ays Hours 
CONTRIHUTORV 0'r>vUlA<^vtv<xX \K.^%JiA^\^ 



MAiniCM NAMK 
<»!•• MOTIIKR 



lURTIIPLACK 
<>l- MoTHKR 
(State or Countrvl 



lUvli 



\ 



IV^VAHV 






OCCI'I'ATION 

/\f>i(!fif lit Still /'i ii III i''i> 



\ 



HXv.-,,,. 



Moiith'^ 



/),M 



Dl'RATION )\\irs Mouths Days Hours 

K\ A. J^^VC^. M.D. 



(SIGNED ) 



V^L^ 1 icoH ( Ad.lress) 5 H b ^ v-vtic A M 



fePEClAL Information only for Hospitals, Institutions, Transifnts, 
or Recent Residents, nnd persons dying rfHdv fron home. 



Former or 
Usual Residence 



c30 vJ-CoJk 3t Place of Death ? ?S 



Days 



TMi: AHOVK STATKH I'KKSONAI, rAKTIi'f I.AKS A K 1 •". TKrK To TlIK 
liKST OI- MV KNONVM-.IX'K AND mil.Il.K 



niifunnant 



XililrcKS 






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



PI<,ACK <)l HV1^'^'«<*'< RKMo\ AI, I DAIJ-of MtKiAt. ..i KI:Mo\\1 

WU\X4A ^avvt\\. Ut-vw^^t^i^l J^ (( 



90H 



(A«Mre««s 



^51 cyyiuL^cin^.^'^ 



of lnform«lion .houl.l he cnrefully HuppUed. AGJi «houl.l bo «tntetl EXACTLY. PHYSICIANS should 
E OF DEATH in pinin terms, that it mny be properly cloH»ilfled. The * Special intorm«tion tor p.r- 



N. B.— 7— Kvery Item 
state CAUS 
«on« dyinft away from home should be ftiven in every ioHtnnce 



\ i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



•*«. 



H,.;,i.l of Hc-.ilth !•■ No !- ^'Z?^::^>- J«&I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/}((/(' Filed , 





D 



100\ 



Registered J\^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)catb 

( "U. S. StanC»arD ) 



(^ 



PLACE OF DEATH: — County of C' CtUl^-co 



City of U^ULtjLt) L-<x' 



No. 



-St.r 



Dist.; bet. 



and 



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



FULL NAME 



iim'Yu Lf\x<iXihi d/iv-acLi 



t 



PERSONAL AND STATISTICAL PARTICULARS 



"" QllccL 



DAPK or* HIKTU 



CGI.OR 



LAjJtvctjL 



AC.K 



%\ 



'Mnllllj^ 



A,...,.v.b 

(Day) (Vear) 



) 'ra t >• 



Mont /is Davs 



STXr.I.K, MARRTKI), 

wiixnvKi) Ok i)ivoKri:i) 

(Wiitfiii sfK'ial dcsiKnalioii) 



%\ 



a^.xu.'cL 



lUK rFlPI.AOK 
(State or Comitt v) 



NAMK Ol- 
FATHKR 



/^ 






MEDICAL CERTIFICATE OF DEATH 
DATK OK DP:aTH^ , 

r.\A,Lu T 

(Montli) (Day) 

1 mCRr-:RV CI':RTIFV, That I atUMi.k.l .Ucoased from 



(Year) 



190 



to 



that I last saw h ■• alive on 



I()0 

190 



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



i 



M. The CAISIC Ol" DlvATH was as follows: 



....ar.:>.>vJ 






vo-vcn-^^ 



HIRTMPl.AOK 
Ol- lATHKR 
(State or Country) 



MAinKN NAMK 
t)i- MOTHKR 



lURTHIM.ACK 
Ol- MOTHKR 

(State or Couiitrv) 



W 



-ii_ 



ni'R ATrc^N Years 

CONTUIIU TORY 



Months 



I\u 



•\ 



Hours 



DIRATION 
(SIGNED ) 



Years Afont/is 

(I) (P ^ 



/\ivs 



Hours 
M.D. 



i:\JL un iQo'i (Address) U <>w-LLi.vi \ VCtL. 



ti 



OCCT 



•r.T,ON- Q^^^ }, 



Resided in S^in f') a iii isr<t 



Special information '»nly '"f HospUdls, histitulions, Iransienls, 
or Recent Residents, dnd persons dying riHd> (rom tiome. 



) V<7 > 



.\f,ntths 



Pit v. 



Tin-; \HOVH ST \ri-:0 I'KRSONAl, rXKrUTI.AKS AKi: rKlK To Til)-; 
BKS T OK MY KNo\Vl.l-:i)C.K AM) HKIJKF 






Former or 
Usual Residence 

When Has disease contracted. 
If not at place of deafli? 



How lonq at 
Place of Death ? 



Davs 



f \'Mrr<>< 



I \CK Ol" lU RIAI, Ok kKMoVAI, I DATK of lit KiAt. ui KKMOXAl. 
INDKRTAKKR VCULv|'«V>Vv<V W\^d.^ VC 



f A.ldres^ 






,7^ 



HO 5 .r^^ ^-^ ^ > 



N. B. Every Stem of Information should he carefully supplied. A(JR should be Htnted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Intormation ' for per- 
sons dyin^ away from home should be fi^iven in every Instance. 




. i 






i t • 



■ ( 

I 



i 



♦ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1I,,:,"I ..f ll< :iltll I' Nn 1 =^ t 



♦*»''"*^. 



i-. US:!' ("(I 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



\i' li' 




I' ^' 







% nwH 

Deputy Health Officer 



Regislei'ed *A^o. 



175 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( U. S. StanOar? ) 
PLACE OF DEATH: — County of CJ/a'WO >VCt>vi:o C( City of "^ ' <Xa v A^^<X/>vc\A^^ 



'No. 



• 



I 



1 H ?5 - S iL. St.; 5 Dtst.; bet. h O^V^KVK^ and U ^^inp^. 

(IF DEATH OCCURS *WAY F R O W USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ "N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

LcLl.u-oX'cL HlS^Uv>kj d./y.\/cu.v 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



QoiJlc 



COI.OR 



ll),lcb.. 



KATIC or- lURTII 



rVtVUL 



3 

(Day) 



(Vtar) 



AC.H 



6 b )V./;.v 1 



Months .v: 



3> 



Pa vs 



SI\(.I,K. MARKIl',!), 
WIDnWKI) OR DIVoKCKI) 
(Write ill s<H'ial fksiv^nalioti) 



lURTMPI.AOK 

(Stiifi- or Cmintrv) 




-t>\cvLi 



I 



M 



L^l i 



m 



m^^ 



NAM1-: ^^V 
I'ATllllR 



MIRTH IM.AOK 

oi- I Aini.;i< 

(Statf or «."()\intrv) 



mah)i:n namk 
of mothkk 



lURTHIM.ACK 
OI- MOTIIKR 
(State or Country) 






MEDICAL CERTIFICATE OF DEATH 

DATK OI" I)i:ATn A ft 



A^Vit 



MontWl 



(I)av) 



(Year^ 



I mCRI'HV ClvkTlI'V, That I atU-iiiU'd ileccasc<l from 

igo - to "■■ Kp 

tliat I last saw h n alive on 190 



and that (K-ath (Kciirrcd, on tlu- dat*.- stated above, at " 
.— M. ^The CAl'Slv ()!• DI-A Ti! was as follows 



..i). 



I,X^.^JL^, 



Jl.^Q..: 






.'^kA.CUi. £>.\ CO... 



^VUC^vJVV.' 



• » 



OCCUPATION 



h'r^hh-i! Ill Siifi /'iiiihnro ■ ),■,ll^ ^f,nlt/l^ 



-\) 



,V^-^ 



DrR.ATION Years 
CONTRIHrroRV 



Mont /is 



1 



PilYS 



Hours 



I )r RATION Years 

/X) 



Mouths 



/hi YS 



Hours 



(Signed ) LeVcrvuLKj ^1 \0 ID Xttcv^vcL M.D. 

iclu 1 t.,oH fA.ldros.) UV(nviAJ> ^ |r -'• 

iPEcVaL Information «nly for Hosplldls, Instilufions, Transients. 



or Recent Residents, nnd persons dyinq hv»iI\ Iron fiome. 



/'./ 



Tiu", AiiovK s'l" \rj:i) I'KRsoNAi, iv\ R I" n' c i,A R s A u i". I'Rri': TO riij-; 
lucsT OI- Mv KN(>\vij;i)c.H AND iu-:hii-:i" 



(Iiifoiin.'int 



VI ilcx^u W (6cc«u^ctt 



■\ 



o^ 



\<l.lrrss 9s Hi " ^ 



tli 



I 



Former or 
Usual Residence 

When Has disease contracted. 
If not at place ol death ? 



HoH lonq at 
Plare of Death 



Dd)s 



ri.ACK Ol" lU RIAL OR kHMoX \I, 



NUHRTAKKR t\j ■ <^ O W V 



I) \ ri: o! imhi.ai. oi ki:m<»\\i. 
AA^Lu % T90H 






ci 






f.^dilrcss 



11 



3.1 0)\^^<lvc>x •< 



N. B. Rvery Item «« int'ormntlon should be carefully supplied. AGF. Hhoul.l be RtHte.l HXACTLY. PHYSICIANS should 

state CAUSE OF DFATH in plain tcpins, that it may be properly classified. The "SpeclHl Information" for per- 
sons dyinft away from home should be ftiven in ^\«ry instance. 




'i. 



li a 

I 
I 




) 1 



r 



\|^ 



iti 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,!,,,, .1 -f H.aUh »•■ Vo. It; -fr-q-^.^i^lU^rro 



Dafc Fi/rdj 




luo'i 



lieg/.s/ered A^o. 



176 



vMj^ Deputy Health omcf^r 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of H)eatb 

( "U. S. Stan^ar^ ) 



i ^ 



PLACE OF DEATH: — County of * ^^iv ^ K<x^\^^Ji.Qc City of ^O^w KW^\Z^^<^ c 



No. 



"lia 0^.lU'T\njU .St.; I Dist.;bct. *J'^A.ttt\,' and V'^VVA^K^ 

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



FULL NAME 



,LLc\,-Out-<Lt.>M ^V:^^AX 



M- 



PERSONAL AND STATISTICAL PARTICULARS 



\>\TK or niKTu 



,Ol UjyVvctjL 



M.mthl 



<Day) 



(Year) 



MW. 



.kX. ):a,s 



Months T: . Pays 



-•INt.M:. MARRTKIV 

W II><>\yHI) OR I)IVORti:i) 

iWiitt in s<H'i:tl (Irsi^nation) 




CUvVvJl/cL 



lURTHlM.AOK 
' Statt' or Countrv^ 



NAMK Ol- 
I ATMKR 



A 




niRTHPI.AlH 
Ol- lATHKK 
(State or Country) 



MAini:N NAMK 
oj MOTUHR 



niR linM.ACE 
OJ- MOTHHR 
(Statr or Coiintrv^ 






.'^nv 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII ^ 

.lu 1 

(Day) 



Month) J 



(Yi-arl 



I UI';Ri:nV lI:RTII<^V, That I atu-n.lr.l .kivasctl from 

Olvav H 190 3. to W^4: ^ itp H 

that I last saw h rt\) alive on ^kOlu Ic i,p ""^ 

ami that death occurred, on the date stated above, at 
"" M. The CAISI'! Ol- l)i;.\ Til was as follows: 



Xa^wLolA; 



oOOt'PATlON ^ 




<X^x 



cL 



Rfsidft! in S<iu /'i ,inii}>'i> iS)V-(M\ 



nr RATION 5L )'r<7rs H Months ^ Days ' Hours 
CONTKinrTORY SrLtrwjL 



> / 



OrRATlON Years 

(SIGNED) 

1 V^Lti T()oH (A.l<Yrrs^) R DJvLLclav 



cm 



.^fotiths 



Day 



Hours 
M.D. 



(lLlIclav y^.Ldi 



S^ECIIAL Information *»nl\ tor Hospitdls, institutions, Irdnsients, 
or Recent Residents, and perse <; dying dv»a\ trooi home. 



Months 



/hJ 



'«M 



Former or 
Isual Residence 

When >»as disease confrarted. 
If not at place ol death ? 



HoH lonq at 
Place of Death 



Davs 



Tin", AUOVK SrATl-D I'KRSONM, PA R I" UT I,A RS ARl". rRlK It » Til »•: 
HHST Ol- MY KNO\VI.i;i)C,H AM) HKF.IKK 



'M 



'In 



f..;in;nit J A'O^^VX^R ^ ^^»■XJt■ 



(A.1.1 



rcss 



^la^^-vU 



1 



-i 



I'l.ACH Ol' niRIAI. OK KliMoVAl, 



1 



DATi; of Ij! KiAi, or RKMoVAI, 



vviu ^ 



T90H 



rNDKK fAKKR 



(Aililn'-'- 







N. B.— F.very item of Information »ho«I<l be .nreVully supplied. AGK should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plnln terms, thnt it may be properly vlnssWIed. The * Special Intormattan Vor p«r- 
«on« dyin^ away from home should be jiiven In every instance. 



t f 



* t 



II 




!ii 



I 51 



f I 






^W"* 



I I 



i!^ 



[ 



ih 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hm.h! . f Hcilth »• Nn i^'6'^ia^^l\{icl'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ii fr 



Dfffr Filed y 



dL^^W) 





100^ 



Registered JSfo, 



177 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Bcatb 

( XI. S. S:an&arO ) 

J? ^^ -? 



<^ 



No. 



PLACE OF DEATH: — County of n.O-ru J^VOLWCA^ot) City of C)/a--yv OA/CV-vvCA^/ayC^ 
l.n OAXt-'^' St.; 1 Dist.; bet. '^-CUuKv'^X and vl ^Lk 

(ir orATH OCCURS *WAY rnoM 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. y 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

I C01,OR 



XA'^A^O-Lt 



w-IvCLl. 




.4aX siXi/ 




MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



DATK OF MIRTH 



W^viL XX /.S.fcH. 

Month) (Ony) (Year) 



\<-.f: 



)'llll 



Movlhs 



IH 



/)./ I .V 



^IN'.I.K, MARKTKI) 

W II)(»\\l-:i) OK DIXORiKI) P 



\\'iittiii social (Ifsijjnatioji) 



I 



lUKTMPKAOK 
State or Country^ 



NAMl', ()| 
FATMI-.R 



lURTMPl.ACK 

<>l" I AlllKR 

I Staff or Country) 



MAIDKN XAMK 
Ol MOTHFR 



C Ct^X' AX5c >v Cv^ CO 



[Month) (| 



i ■ 
(Day) 



(Yrar) 



I HKRF':RV CivRTrFV, That I attciiUMl flect-ased frotii 

J^^H-^ 190 H to V^^ '^ '^/^I 

that I last srw h •'A>u alive on H WtCL b i<yo H 
ami that death oocurred, on the datf stale<l above, at 
^ M. The CATSI-: Ol- DI-ATII was as follows: 







(J 



.\j^L(x>vcL 



a 



AV^VU. (h'L^.V 



HIU PHPKACK 
•»l- MOTIIKR 

'SiMtc or ConiUrv) 



1 






DT'RATrON )V^/'5 

CONTRIIU'TORY 



.1A» ////'? 



Pay a 



//ours 



DURATK^N Vrars ^fouths /\ivs 

( SIGNED ) WUn-yvJJ^ lL K) \^i\X^' 

U.iu..l TQoS (Address) ^bR g^lxK. Bl 



/lours 
M.D. 



^ 



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



R^suirtf in Sati /■'> (iiu t^ri> 



)'i\ii <t 



Months 



/hn 



Till-: AUOVF. S-PAII-I) I'KKSOX \I, P\R riCfl. AKS A K l-! TKIl-: TO TMl", 

BHST OF MY KNo\vij<:i)c.K AND ni:ui:F 



'^ItifoTinant 



\X vs^^-vOt J ^W^jJ^ 



(\(M 



ress 



'XI 



-A 






Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



PI.ACF Ol- IM KIAI, OU K1:Mo\\|. I DATI-.of HfKiAl. nr RI:MoV\I, 



>V- 



imm;rtaki;r \}y'>\X^<i<Lr^J dJ '\J^\.K> . 



^ 

/5^ 






J 



i.\tl<lrcss 



N. B. F.very item otf inform.itlon «houI«l b.- cnrcV.illy Hunplic-.I. AGR Hho..l.l be stnted KXACTLY. PHYSICIAr^S should 

state CAUSE OF DHATH In pln'in terms, thnt it miiy be properly claHHiried. The "Spocinl Informntion" for pur- 
«on» dy!n^ away from home should be ftiven in every instnnce. \ 



ft < 



I" 



< i 



\ 




1 1'- 



i 






y 



Ui 




m 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



,-,,.,, 'I ..f ll.:Jlh- I' No. I', t"^^^*5^MUtl'C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)(t 



h> rih'd, \ 




Jf)0^ 



llpgi,st('t'e(l J\'*n. 



178 



&j^\kKA) KiAM^. Denutv Mr^glf 



N /r>i^ -» 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttiffcatc of IDcatb 



( 11. S. 5tan^ar^ ) 



SI ^ A a^ 

PLACE OF DEATH: — County of^J<X>^'^J ^^^^t^^^0 City of Cla^nj Va^\ciAllo 



(V^, 



,. IV^a\lrovCvvU\ai>\cu Ob'^Uxaal St.;- 

r DtATH OCCURS AWA^FROM iJsUAL RESIDEN 



(IF DtATH OC 
IF DEATH 



Dist.; bet. 



and 



oocurredJin a hospital or 



FULL NAME 



ilDENCECIVC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "N 
NSTITUTION Give ITS NAME INSTEAD OF STREET AND NUMBER. / 




IS 



^.. 



, %JL- 



1 \\. vir^/>v 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 

coi.ok 



QllcA 



DATF. or- IMKril 



(Month) 



a 



MEDICAL CERTIFICATE OF DEATH 



DATH OP DKATH 



\V'>\X4X 



(Day) 



ACK 



30 >■'•"' ^ 3» 



MnUfflS ... 



(Vcar) 



Pars 



'^iv". r.K MAK un:n 

WIDUWKI) OK DIVOKiKI) 
i Write in stjcial desijf nation) 



(Month) 






(Day) 



/Q(y \ 

(Y<-:ir^ 



I ' 



I ITRRnRV CI'RTIFV. That I attciKhMl deceased from 

....I...................... 190 to • I90 ■- 

tliat I last saw h" •■" "■■ alive on — '■ ■■■- - up 



^:) 



lUUTHPI.AOK 

i,Sl:iti- or Cojintrv^ 



NVMi; Oi- 
l-All I i;r 



JUKTUI'I.ArK 
<»!■ I-AIUKR 
(State or Oonntrv^ 



MAIDICN NAMK 
'>!• MOTHKK 



niRTniM.ArH 

<»i Morni:K 

(state or Conntrv) 




ait<l llial (leatll oceiirrcd, on the «hite stated ahove, at 
M. The CAl'SI-: ()!• DIIAI'II was as foll.nvs 






\*-C*..>v. 
DC RAT ION y'rtir.^ 

CONTRIIU'TORV 



Mouths 



Da vs 



Hours 



^lA^C'A-.^rYV 



f \ 



H 



nccr 



t-pATION J^ I 



f\'/\\iiff'>f ni S(j}i / iiiiii 



DC RATION )V(//-.v 



Months 



(SIGNED^ LcrV(J>U»Nj 



TdbU) Uv 



/hiys 



/ fours 
M.D. 



.FECIAL Information only tor Hospitdls, institutions, Transients, 



v. ''•..t„ 



> III / wM 



I Vrins 1 }r,»)t/is '.L fhn 



Till AHovi-: ST \ri:i) i>kkso\ai, p ak iuti.aks ari: iki k to tii 1: 

HHST Ol- MY KNo\VI.i;i)UH AND MI-.LIi;!" 
(Infoinjant 




(Address 



„10L Vjatav^ ^^ 



or Rerenf Re^dents, dnd persons dying dH^y Iron home 

Former or ^^^^ fe*7"ft J. How long at 

Usual Residencf ''^^ Lo.U||5-&\>xv«, 0t piare of Death ? 

When was disease rontracted, 
If not at plare of death ? 






'^ 






Days 



I'LACH »)!• HI KIAI. (»K KKM<»\ AI. 






It W'V. of iiiKiAi. oi ki;mo\ Ai, 

■Ml ' 



190 I 



O. r \^(s 






■^ 



!N. B. Kvery Item »f informntlon should \^i carBt'iilly suppHed. AGF. should be stnted F.XACTLY. PHYSICIANS should 

iitote CAUSE OF DFATH in plnin terms, thnt it mjiy he properly classified. The "Speciiil inlr'ormatiun" for p«r- 
«ons dyin^ away from home should be j^iven in every instance. 



I 



♦ 



|i' 



'li 



III 



(»' 



).' 



in 



1% 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I 



LI 



■it 



I 





.1 



„nl -f Hciltli- I- N'<v -v •*-^':^^i;> nScV Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Filed , 



100^ 



\^L^v^ A.t\>vj Deputy Health Offlcer 

OF 



Registered J\^o. 



179 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "U. S. 5tan^ar^ ) 
PLACE OF DEATH: — County of*^ OLYw J^VCLavcc^loo City ofd'<<X/>vOA/OyAvCui Co 



No. 



bS 1 3.U 



Ys-t^v^-r^' 



+ 



( 



St.; H Dist.; bet. 1 Wv 



and 



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



) 



FULL NAME 



cLlcam^o LL^Vcn^ \.4,tox) 




sax 



PERSONAL AND STATISTICAL PARTICULARS 

COI.(»R 




OL 



DATl-: «)I- BIRTH 



It 



lo,iv.u_ 



(Day) 



I:.'; 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



D.\TK OV PKAIH 



i 



[Month 



i 



1 

(Day) 



(Year) 



AGK 



)'ritt s 



v.. ;////> 



x\ 



Pa IS 



uiDowKi) OR niV()K(i:n 

(Write ill sixMal iltsU'iiation) 



)MRTHPI..\CK 



NAM I- Ol- 
FATin:R 






r Vmx4i.-^v 





I Hf':Rl-:i5V CI^RTII'V, That I Mtten<UMl deceased fn-in 

W^ "t 190S .to 1^^"^ ">oH 

tlial I last saw h XN^ alive on VvOLul % i<p S 

and that deatli occurred, on the dat<.- stated above, at O-C 
U. M. The CAl'SK Ol" I»i:.\Tll was a< follous: 

'3W\MX\; \J A^Xw^^vfr^'wa. 



mRTHPT,.\rH 

OF FATHKR 
(Statf or Country) 



^I \n»KN N.AMK 
<'l MOTIIKR 



inkrmM.ACK 

"I Mo'l HlvR 
(Slate or Countrv) 






l)rR.\TION "^ }'t\irs " Mouths 3 Pays '" Hours 

coNTKiin'TokN' U.^v.^K-<vw^-v\ryv. 



LrivJi. 



"y\) 



UXa^<X 



t>CCUPATION rU 

f\f>!iirtl IK Snu r I nil, isi'.i )--.r;> 







DIRATION "" )'cars '^J/of///is •^ Pays *' Hours 
(SIGNED) Y 3 CrVvtHJujujL 

^uici C\ T«)nS f \.Mnss) lOH'jQ.- bth, at 



M.D. 



I 



PEClAL Information ••"''^ l*>r Hospitals, institutions, Transients, 
or Rcient Residents, and persons dying dHH> trmi fiome. 



/',,M ■ 



in: AHOVK STA ri:i) I'KKSONAJ, I'AK lUri.ARs AR.K I'KI )•: 1' • IHl- 

nj:sT o}- MY KNt)\vij:i)(-.H AM) hi:mi:i-" 



• liifottnniit 



(jb -OAAa-^ L\J(>Vtrvvv«-^5V^ 



' \'Mrf».s 



b^ 



^U^ 



\K^>xA,.^r«v "^ 



^ 



Former or 
L'sudI Residence 

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



HoH lopq at 
Place of Death ? 



Days 



1'i,\cf:(>j liiKiAi. <>k kimi'\ \i 



^ 



Cj CLLii_'>'>Aj 



> \ rij n; \\\ \<\\s •■: \^ i:m< i\ \ I. 

10 IQOS 



INDICKTAKKR 

(A<Mr<«< 






N. ».- 



-Hvery Item of itifonnntion should be ciirelfully Hupplied. AOF. should be stnted r.X4CTLY. PHYSICIANS kHouUI 
state C4USE OF DP :ATH in plnin term-*, thnt it mjiy be p-operly clnHHilt'led. The *'Specinl ln1roriii.iti..n" for per- 
sons djln^ away from home should be fti^en \t\ every instance. 



1! 






* * 



Kit 






l1 



til 



I 



I 



(f' '•! 






I! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Re gist ere (I J\^(). 



180 



Date /•V7f'<'/,JsUAlA^ S 1!)0^ 

jUm^vu^ locAMi Deputy Health Officer 

DEPARTMENT tfp PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "U. S. 5tanDari> ) 



PLACE OF DEATH:— ^ 



CU ( 






city of CJ AjUVAAxxnj C'^va 



^jum O /Ouwl <X) VJ I (\ c a 



No/ 



St 



Dist.; bet. 



and 



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



FULL NAME 



\Xyyy:>JU\r' ^'<XhXX±!^ 



PERSONAL AND STATISTICAL PARTICULARS 



sj:\ 



^xAv 



C(>I,<)R 



I).\TK or-- lUKTU 



7 

Muntli) 



lOJvJtt 
? 



(Day) 



/ 1 b a, 

(Voiir) 



Af.H 



O O )V(7; .> 



? 



? 



MEDICAL CERTIFICATE OF DEATH 



I) ATK OF DKATH 



Month) (J 



T 
I 

(Day) 



(War 



Mouths :.. Pavs 




'^TVCl.!' MAKKIi:!). 

w n)« >\yi;i) (tu i>ivok(,i-:i) 

(Writf in social 'K-sip^nation) 



lUKTMPI.ACK 
'State or Count! V I 






x.\Mi-: oi- 
iATin:R 



wVnJvvV' 



I HBRERV CI:RTIFV, Tlmt T nttctiiled (tc(VMst<l from 

i.....i..,i.ji.',i. 190 to H)0 

that I last saw h alive on — I90 ' 

and that doalh occurred, 011 the date ^tati-d above, at 
.rnr— . M. The CAISK ()!• DI-ATII was as follows: 




(X.K. 



^^^X, 



I 1 



nr RATION Yeats 

CONTKIHl'TORY 



Mofiths 



I 

Pays 



I foil IS 



tru.^'^v 



''.IKTJIIM.ACK 
<)I" l-Al-IIHR 
'Statr or c'ountry) 



MAIDHN NAMK 
<>I" MoTIIKK 



I'.IRTITPT.ArK 
"1 MoTHKR 
ist.itc or Conntrvl 



DURATION ;. ViUirs 



Hour's 
M.D. 



«< 



<H'0ri'ATlON 



vjVOLAjCh.^O'tVfC J .'V-CC't^+^^^-vvO-.^v 



Rrsiifri'. Ill S',;ii I 1,111, 



)Vii I 



.y/,>iif/is 



Hfivf 



(SIGNED) Lo^'Crv^UZA' J ^^ UJ XuIcL'^vaxL 

iciALlN FORMATION onl, tor Hospitals, Institunftnv. Iran^ifnts, 



,^<,\ 



PE( 

or Retent Residents, and persons dviny dHiiv trom liome. 



Tin-: AHovi-: sr xriD i-kkson ai. i' \k ii* n. \ks aki'. rKii-: t<> riiK 
BKST OK MY KN()\vi,i:i)C.H AND iu:i.ii:i" 



' InforTnant 



\.Mr,s< VnJUArlOxAX.i\>v JtotrUL. 



Former or 
Usual Residence 

Wtien v*as disease ronlrarted, 
II not at place of deatfi ? 



HoH long at 
Place of Deatfi ? 



Oa>s 



1 



I'l.ACli Ol' lUKIAI. tiK KI;M<i\\I, J DAn;..; r.nux: 01 l<l,,M(i\ \i. 



r.\i)i:K r.\Ki:K 



A(l(li( 




N. B. 



8 



ivery item ai informution shoul.l I,-- ...rc>\i1l.v supplied. .4<;F. s'lould be stnte.l HXACTLY. PlIYvSICIANS should 
tate CAUSE OP DI:ATH in pinin terms, thnt it mjiy be properly classiried. The "SpcciHl Informiition" »or pur- 



Ron« dyin^ awa>' from home should be jiivcn in every instance. 




^ ( 



!i! 




• 1 








I' 



¥ 



ii 







♦ ' 



'^ J. * 



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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Dff/c Filed , 



X^ 




S 



in(A 



lU'gisfci'cd J\''(), 



181 






tru^a kx^Mj Deputy Health Officer 

DEPARTMENT tfp PUBLIC HEALTH=City and County of San Francisco 

Ccvtificatc of IDcatb 

( XX, 5. 5tanc>arC> ) 
PLACE OF DEATH: — County of 0/Cu^rv 0X<:V'>V'CA>i/CO City of Uctru ACt>vC^4^c o 
(I^OtMlXaW^ IbcHlkvlal St.;—— Dist.;bet.— — 

IF dcHth occurs' away frow usual residence give facts callfd for undei 



and 



(IF DtttTH occurs' AWAY FROW USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ N 
IF BEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




\^^ 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



11 LoXjb 




1 



\x 



h_ 



HATH ()!• r.IK IH 



I MEDICAL CERTIFICATE OF DEATH 

DATi: ni' I) HATH 

\ "^ 



iMoiitli) 



- /Us., 

(Day) (Year) 



\r,h\ 



oM % 



)'t'ats -.. 



.Months 



Ihivs 



W I DOW HI) OR DIVnK(l<:i) 

'Wiitcin ^(M'i.'il il(<ii.'iiatii>n) 



XVt 



niRTHlM.AOK 
fSt.iti- or Coiiiitrv'' 



N'AMK <)I- 
lATIll'K 




(7 vUl<X/^\x:L 



(j(Moutir] 



(Day) 



(Yf.Ml 



I Hl'l'i I'lr.N' (."1;RTI1'\', That I MtteiKlcd (iLnasid from 

\'^^v I ic»o3> tt) vvULu, S i(,oH 

that I last saw h 'V^vwalivc on )f^'^\A^ \ upS 



and tliat death occAirrcd, nii the date -stated above, at I 
QwM. The CAISIC Ol- Dl-ATII was as follows: 

LLtiA.4\XAA^vOL 



niRTMPI.AeK 
'>!•■ iwruicR 
'Statr nr Country) 



^T\n)HN xwiH 

Ol- MoTllHk 








1)1 RATION }'tiirs 

CONTUIIU'TOKV 



Mofi/hs Days 




//ours 



HIKTHIM.ACK 

Ol" MoTHHK 
iSi;Hr or Country) 




y\^' 



a. 



OCCUPATION ^ » -^ 

/\'f'M'(ffif ill SilH /'l ilHI i.'-i'O \ V J ''i' ' 



M.'iilh' 



/),/i 



DIRATION 
(SIGNED ) 



Mouths 



Yeats 



/\l\'S 



I lours 
M.D. 



IGNED) LL^Jt•tv^Jt^J J \| /\ OA.>\tu M.D. 

PEfclAL Information only for Hosplldls, InsHfutions, Irnnsients, 



TIIH MIOVH S,rA|-]:i> I'KK^ONAI, 1' \ KTICf I.A RS AKl' rKTH To THH 

iu-:sr Ol- Mv KNowi.i.Dc.i-: and iii-:i,n"i" 



(1 



iifinuant SA . • M /V "^J -V^vvtu \l A. ^ 



v^\Xu 



X,M,..s 5 1 Ml WVct^ Jl^tK^-l''^'^^ ■ 



or Rercnl Residents, and persons dvinq dnay from home. 

Former or "i4-(Y\A v 'W. I 4 ""** '""" ^* ' ■ /^ .k . 

Usual ResidenctCiX) ^ I / lOL\^J0 \ 5-^KX PJare of Oeatfi ? i 0^.... ««ys 

Wfien \»as disease rontrafted, ^ 
If not at plare of death ? 



PI.ACK Ol" m RFAU OK ki:M(»VAl, 

^ ova 



I»A li: <)! Hi UlAl, ot K i:M( i\ ai. 

W^ W IQOH 



INDHRTAKHK 

fAil.ln 



^^^VC; 



^m 



IN. B.— Kvcrv item of mV'orm.tlon should b. cnrcVully Hupplk,!. AdH should he stated HXACTLY. PHYSIC! \>S should 
state CAUSE OF DEATH in plain terms, that it may he properly clossiVMed. The "Special InU»rmHti..n ' ior per- 
sons dyinft owoy from home shouhl be ftiven in every instance. 



J 



'^^f^iS^' 



i'' I 



li « 



^iii 



' H 



M'- 




1 f \ 




I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






7,9(9 4 



Mcoi.slcrrd jYo. 



1813 



1 



fr-A.^UJ 



ye:: 






I ,« - S * 4_ 



llcer 



DEPARTMENT OT PUBLIC HEALTn=City and County of San Francisco 

Certificate of IDeatb 

( XX. S. GtnnC>nrc> ) 
PLACE OF DEATH: — County of 0<X'>vJ;^^V>vC>utCo City of U <V>v J AxXavOUl c o 




.X'v^'Crv^ 



■ORRNDER "special INFORMATION" "\ 

nstUibIo of street and number. J 



No. 9-lo'iS M lV<Xw4.<nv St.; 1 Dist.;bet. 

/ IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS N A M E ll 

AXLAO/LiAyC^ WC)-VVv-<X 



and^v)UXa.C^4\j 



I 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



(^TuL 



cr>i/>R 



llUvd. 



DATE OF III Kill 



U^^ 



(Month) 



(Dny) 



/SHI 

(Vear) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH a a 

.J.VVUi 

/M(intli>/J 



(D.iv) 



(Yf.-ir) 



ACE 



.?ftS t^M Moniks 



nar-s 



<y\i'.\.v.. M\Run:n. 

\\ H)<>\\ i:i> OK DixoRiKD 

(Write in ftoeial desij^nation) 



niKTIIPI.AOK 
< Slate or Cuuiitry) 



NAMl' n|- 
FATMlvR 



mRTIIlM.ACH 
<>1 I'ATIIKR 
'SiMtf or Coiintrvl 





J HRRl'i'.N' CIvRTlI'V, Thiit I altLii(lL<l .Iccr.i'^tMl fmin 

3 looS to Wlu. i UpS 

that I last saw li -V>vv alive- on "ivv-AwO^ {^ T<>o ^ 

ami that ilcath oriurrcMl, <iii ihv dalt- stalc-d above, at I • 
(P ^M. T!u> CA^^iIv ()1<^ DI-A'ni was as follows: 




MAIDKN NAMK 
<>1" M()Tm:R 



RTRT!TlT,Ai"E 

<>i' M<>'rm-:R 

'St.Uc or Coiiiitrvt 



OCCBPATTOX 



w 



oL cmt) 



.C>AyoJLu 

( 




TirRATrON •" Ytuirs '^■■•Mouths b /hiys * //ours 
CONTKIIU TORY .....LuCtxNwS^ 3 tl.ijiA.>ft^ ' s 



or RATION Yea IS Months. /\iys //ours 

( Signed ) \j. J. O a oowivou^.<mJL M.D. 

R i.,oH fA.l.ln-ss) 30SN)l(Pr,l-., , ll v ■ 




PECiAL Information only lor llospitdls, lnslifullo^^, Irdnsienfs, 
or Rrccnt Residents, dnd persons d\in'j dway Ironi home. 



.'LAAXX^V/W>.^3COVl 



Tin-: \iiovi-: sr \ ri:i) im-k^-on m. i- akihtl \k-. \ki-: rkti-: t»» in i: 
HHsr OK Mv KNowi.i.ix', !•: and iu;mI':f 



Iiii'i nrmt 



-^. 



\.l(li.-< 






former or 
Ijsudi Residence 

When Hds disease rontrdfted, 
If no( df pidce of dedffj ? 



How long dt 
PIdre of Oedtfi .' 



Days 



IiAji; .>C M' KlAr, or KKMOVAI, 



I'l.A.ci: <>i iMKiM. OR kj.:m<i\ai, 
m.i:rtaki;r Ua)ULrdjLVn\aA>y.^ 



I90H 



N. B.- 



-Kverv -.torn ni 1nf>rm,.tlon Hhm.ld U: .nrc»\.lly HuppUcd. M.U Hh....hl be slHtc.l EXKCTLY. PHYSICIANS nhouKI 
«tntc CAIISI: OI= DliATH in plnin terms, thnt it mi.y be properly cluHHifieU. The ' Special Intormiition for per- 
son* dyinil uwny from home should be JXiven in every Instnnce. 




'fl 



■ j 



\\ 



it 



k 



4 



ll H 



ttf'.V 






I;; 
I! 






IJ' 



If HP 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I!r,:.n1 ..f llrnltli I' No. 1^ ■^■t'^rsr^US^yCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






li)(A 



liegistci'ed J\^o. 



183 



^VA^V/^ 



\>U 



sjm 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 

{ la. S. Stant>arD ) 
PLACE OF DEATH: — County of O-Co^ VCLVVOA^CtiCity ofCl<X/W JActovc^ACo 



0?) 




No. %\ Vflat(r^> 

(IF DEATH 
ir DE« 



St.; 3 Dist.; bet. ( AA) 



id 1 



<XVCr^^V<X bt.; o L>ist.; bet. i alu an 

OCCURS AWAY FROM USUAL R E S I D E N C E C. I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 








PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



I 



cx/Vqtx\xt LcK,LLU..t. 



MEDICAL CERTIFICATE OF DEATH 



n\Tl-: OF' l!IK Til 



u 



^ 



^^Wv 



u._. 



\<-.i': 



/ Month) 



nJjG )V<ma '^ 




.3.. 

(Dny) 



./ % t) t? 

(Vrar> 



Motit/ts 



,H. 



nay^s 



^INCI.K. MARKTKD. 

\vn)tt\v)-:i) <»u DivoKrF.n 

tWrittiii MKJiil drsijfiiatioii) 



nTRTTiri.AOH 
' St.itf or ComUrv) 



\\Ml-. oi- 
L A rill-.R 



^Tvq/ 



^ 



(V»Vi^ ^thNt 



lUKTHIM.AOH 

<»|- ! ATHKR 

I st:itc or Contitry) 



M A I n 1 ■: \ N A M !•: 

ol- MOTMHK 



lUK'nilM.AOK 
»>»• MO THICK 
(Slate tir CouTitrvt 






[)ATK OK DKATH A f] 

/[Month)/' 
I HI-:RiniV CURTII'V, That I attcMKkMl .U'CcasLMl from 



1 

I)ay» 



/go 1 

(Year) 



" icp' to 

tliat I last saw h"::: alive oti — ■ 



T()0" 

190 



an«l that death occurred, oti the dale ^^tate*! above, at — 
M. The C.MSf': Ol' UIvATll was as follows: 



■ ^ M. 11 

KJ-^^jJi^' 



lLlLLc 



AX.L<xy^ 



^ 






li 




occrp 



.vrioN v^ J , 



I ) r l< A r K ) N' ) 'rars Mouths 

CONTUinrTORV 



Ihjy 



Hoitt s 



OrRATTON 
(SIG 



Years, 



AfitHlhs 



Pavs 



Hours 



NED) L^rVcr^AJA^ J^JbAOA^ioLv^dL M.D. 
VJL.< % i.)oH ( .xddres^) LerVrvveXA U -I k.gx 



SPECI^^AL Information '^nly tor Hospitals, Instifuffrfns Irdnsients, 
or Rpcent Residents, dnd persons dyin:| dnay fro;n home. 



vX'v 



Rfsidfii III S<iu /■'iiiiiirsi-,1 O D )'^ars .. 



}r,>iilh!(. 



Pavs 



III 1" \U()\i-, sr \ii-i) i'i<*Ks.oN \i, r \K lu r I. XK'- aki; rkri-: ro rn i-; 
Hi.sT ui- MY KNowMviH'. !•; AND ni-;i.n:i' 



'Infunnant 




T 



U) 



,4,-trw 



r\-i.in.. iH5ib oId^VvkO-VcL 



U- 



Former or 
Usual Residence 

When Has disease ronfrarfed, 
II not at place of death? 



How long at 
Plare of Death ? 



Davs 



iM,.\tM{ (H- r,r Kj.\ I, ou ri;mo\ai, J n \ ri: (jf hi-riai, or kkmovai, 

ID 190S 







I ni)i:ktaki:k ^v 

■ \:MrfSS 



, Item ni inV'ormHtmn «houhl h. cnrefully supplied. AdP. should be «tnte.l F.X^CTI.Y. PHYSICIANS should 
GAUSL OF DEATH in pinin terms, thiit it miiy he properly clossilfied. The "Specinl Inlormiili on ' tor p«r- 



N. li.— — Rvery 
state 
sons dylnU; awny from home should be jiiven in every inslnnce. 



If^ 



; 1 



•1 



I ) 



i I 



I.. 



L' "^ H 



> 



i . 




r ; 






m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l'„,:n 1 of H.alth — »•■ No. i^ ^*^:^'^'> H&P Co 




liegistered J\^o. 



184 



Dale Filrd, "MjJLu S 10(A 

dv^vvui libxMji Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



PLACE OF DEATH 



: — County ofC'/CX'^^ JA.CL>vC^4a<c. City ofCJ/(X'>v Va >vC.C4 C C 



^« VlfU). VLv^x. (fb^A^Lvtai St.: Dist;bet. "and 

(ir Aeath occurs aw*v from USUAL RES I DENCE give facts called for under "special information" \ 
Vt death occurred in a hospital or institution give its name instead of street and number. J 



FULL NAME 




Clla^ 



dji \Jvcri:^.4 



-LL.^J.. 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 



L 



COI.OR 



Uj JkJCi 



DAT!-: or i;iK in 



(Mouth) 



(Day) 



/ t b 'A .. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



AC.K 



4b 



) */•(/ 1 



M.mlfis 



n,n 



■^ivf.T.r:. MA Run: I). 



winouKD OK i)ivoKri-:i) (\^ 

iWritf in soiial iUsi>irnatiuii) Vj V^ 



niKTiiPi.ArK 

* State or Cojintry) 



N'AMl-: oi- 
l^ATHKR 



MIRTH PI, ACK 
OI- I ATHKR 
IStale <ir Oninitry) 



MAini'N NAMl-- 
OI MOTm:K 







(Day 



(Vtar^ 



1 IIKRKBV CKRTII'V, That I attended (Unvase«1 from 

>tvra. 3L5^ 190M to^ V^ ^ ''^""^ 

that I last saw h X^J alive on (C"^^^ ^ ^'P^ 
and that death ocriirred, on the date staled above, at 
" M. The CAUSl") OI" DI-ATIF was a>^ follows: 

\f-i^,AA^ryvCtv^ X<^^t^-uv^vAvQ 






•ytrVK 



DTR ATION ^ )'rars '^ .Votiths 'Pays 

CONTRim'TORV 



Hours 



Years 



Mont/t'i 



/hiv 



nTRTMPl..\CK 
<>l- MoTHlvK 
iStati or t'ouJitiv^ 



OCCrrATTON 



'""%, 



chuT^ 



trvo 



'1 



LOl^^- 



Rrsidnf in Sdii / i nin /.yrn oL )''(?/> 



DTRATIOX ~ 

(Signed ) v . c^Jt\>'^-4^.<^v^J 




TOO'H (Address) I'ilb 



I lou) s. 
M.D. 



SPtCIAL Information <»nH l»r llospitdh, InstituMons, Transient, 
or Rfccnt Residents, and persons dyinq .may fron home. 



Former or 
I'sual Residence 



I. C'A^ttt\' (J A piarp of Dealh? 



m 



Days 



- Months 



lhr\ 



I" III-: A HO VI-: ST \ 11 !» I'l-RSONAl, V XKilcrLAKS AK1-: IKD-; \'<'> Till: 

ni-:sT oi- Mv KNo\vM-:i)c.K AM) iu:mhk 



Oufo-tiiMIlt 



(Add 



rc«s 



(1 U) -IcXluv 



When was disease ronfrarted, 
If no! at plare of deafti ? 



lUvt. 



>A^fr-vvrw» 



I'l.ACH 01 lUKIM, OK K1:MoV\1. 



C^. U. U- J ■ LM^>vvcCt (r\ 



> 



i)A'ri:o!" niKi.vi m ki:m«)vai. 



I 



ITXH '■<)j4.xvv4.ad-<,'L.6 li 






^ 



^ 



iA.Mk--- 






H 



N. n. livery item of Jnformntion «houhl \rc cnrufully supplied. AGB Hhould he sti.ted HXACTLY. PHYSICIANS Khoulcl 

state CAUSE OF DEATH In pinin terms, thiit it miiy he properly cl»8i»ilficd. The "Spcciul liilforuuition" for p«r- 
Ron* dyinft away from home shoultl he ftivcn in every instnnce. 




I 
■I 





t 





Ili; 



»iii:^^^ 



tv. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,,,,, ,,,,]ih I No ict^^l^^WJ^rCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



{ 




/.9/9H 

Deputy Health Officer 



lleglslri'cd J\'"(), 



185 



DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco 



Certificate of S>eatb 

( "a. S. Stan^ar^ ) 



PLACE OF DEATH: — County ofO/CUVu J ^w-OtTVOL^CoCity of OCU^^ l^UX/VUlAAXlCi 



Pk) 





i.vvVLA.A^\) St.; 



Dist.; bet. 



-and 



IRS AWAY FROM USUAL R C S I D E N C C G I V C FACTS CALLED FOR UNDER 
itATH OCCURRfD IN Avi<OSPITAL OR INSTITUTION GIVE ITS NAME I 



=-OR UNDER "special INFORMATION" \ 
NSTEAD OF STREET AND NUMBER. / 



■ 

4 



FULL NAME 



-V^JLlIou 



YCX,aMji 



PERSONAL AND STATISTICAL PARTICULARS 



OX-rroxXl 



COI.OR 



liJJLt.. 



!• \ I1-; HI- HiKTn 



cnioM 



Muntii) 



(Day) (Year) 



\<'. !•; 



) I'd I 



H 



M,>iilhs 1 Davi; 



HINm.K, MARRIl-.F). 
WIIK)\yKl) OK IMXOKCKI) 
(Wiittin s(K-ial (U".i}.' nation) 



niRTMPLAOK 

(State or Countrv) 



,^.^' 



(I< 







l''ll<ll||-I,ArK 

<>i- i-ArMi.:K 

(Stat«- or Co\iiitrv) 



M Mni:\ N AMI-: 

<•»• M()riii-;R 



HIRIHIM.AI'K 
*»l MttTHKK 
(State or Countrv^ 



\Xyy\Mj 




MEDICAL CERTIFICATE OF DEATH 

DATK oi" I)1;aTH 

^. 

(Day) 




(Year) 



I Ill'iRI'HV C'l-IRTII'V, That I atlcii<kMl deceased from 

(X|wJl ll,yo4 t.. I^aIul 1 kkdS 

that r last saw \\ -Vk' .dive on /"^V ^ ^<^ "H 

and that death occurred, on the date stated above, at 
XL M. The CAl'SH ()!• DIvATII was as follows: 

\P ^Vcn\^OK^ Or 



^\jy^<nro 



3SL 



l)V\<\'\H)S -)\ars " Month:^ S Days " //o/ns 
CONTKinrTORY OYVUX/^rc^LwiOL 



M 



OCCUPATION •- ^ 

h'f'^ufrif in Sd)/ /'i ,i ni /sin 



JL 



I)rR.\TI<«)X ^ )'r,/rs ^ .Vonlhs ^ Pays " Hours 

(SIGNED) ULLf N/L ^<Xwcv1vAa^vv. M.D. 



HuJLu 1 iQo H (Address) \J\.VK "^U. U U\. ULvtc^ 

Special In 



FORMATION only for Hospildls, Inslilullons, Iransienls, 
or Recent Residents, .ind persons dyin!j awdv from home. 



)V,,; 



1 



M.„ilh^ 



I 



/'</ 



m: \Movi-: stai'i:!) j'krsonai, partkm'i.aks ari-: iRrH to tiih 
HHST OI- MY KN()\vij:n<;H AND m:i,n';K 



(iiif, 



nnatit 



dA-^^tt^ mK.- 






N. B.. 



A,i.i,v.. ^UTt at. H>sije^\Jk.o IU.u1a 



Former or 
Usual Residence 

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



HoH long at 
Place of Death 



Days 



^^^ 



PI.ACK or lURlAI, OR RKMOVAI, I Kxriof ItiuiAi, or R1:M(»VAI, 



-F.very Item olf informiition should he cnrelfully Htipplietl. .^fiK should he Htnted EXACTLY. PHYSICIANS should 
state CAUSE OP DKATH in pinin terms, that it mjjy ho properly cliiHKified. The "Special lnform«ti«m" for per- 
son* dyini^ nwny from home should he (^iven in every instance. 



*■■ .- 



ill 



i 



m 
I i 



i 

1 



) i 






I 





. \^ 



• /' 



|*»i 



\n\ 



Pi 1 



Mi 



I 



w i I 




3PP WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hn;n.l of Hialtli I" N'>. i" '^'l-;';*'^^: IJftl' Co 




^ 



R 



7,9 r;^ 



i{H-cu cUvu Deputy Health Officer 



Bo^isfd'od J\^o, 



186 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



i 



TX. S. Stan^ar^ 



PLACE OF DEATH: — County of C'<v*v J Vct\x<^ul.Co City ofO.CtYu J 'UXavCa^cc 



No.3Hio Lcolc; 



( 



IF D 




A.X3U 




OCCURS AWAY FROM USUAL RES 
ITH OCCURRED IN A HOSPITAL OR I 



FULL NAME 



St.; Dist.; bet. 

;IDENCEGIVE facts CALLED FOR UNDER "SPECIAL I N FO R M ATI O N •' ^ 
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



I t 

and (X'&':CAA,4l 



PERSONAL AND STATISTICAL PARTICULARS 

si;\ » I coi.oR \ 




Qr.A 



vixdjL 



DATK OP BIRTH 



\{VK 






(Day) 



./.3o..a,. 

(Ytar) 



4^ 



MEDICAL CERTIFICATE OF DEATH 



D.^TK <)l' DllATM 



^ 




(I)av) 



(Year) 



)'i'mts 



y/<wifis 



ai 



/),n,> 



SIM.I.K. MARHM<:i) 

W IDnWHl) OK I)IV<»Kv Kt) 

i\\'ritein WK-inl disi^'iialimi) 



HI KTH PLACE 
(Stnteor C<wntry) 



NAMK OF 




1 '^ 



Month 

IN'RIvHV Cl':RTn'V, Tliat T ..tUMKU'd (IctvastMl from 

5 tgoH t() |vvLu. 1 1(^4 

that r last saw li ^.^wv alive on yAA^A-m. ^ T(>o 4 

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

U;.M. The CAISI': ()I< l)Iv.\TII was as follows: 
Vio^^^-AJL 0>aXca.a^- 



<V<J 










BIRTHPLACE 
OK FATHKR 
(State or Country) 



MAiniCN NAMK 
OF MOTHKR 




DIR-XTIOX Years 
CONTRIin'TORY 



Mouths Days 



Hours 



lUKTMpr.An-; 

<'!• MoTHKR 
(Stale or Countrv) 



'^^V^VVXcL VU^-tx^ru 



OCCUPATION 



^ O KxXj^^'x/^ 



or RAT ION Years Aroni/is Days Hours 

( Signed ) fc . & , xn m.d. 

^VCCU C\ lc,oH fA.l.lre^s) bDl l)/a^\.\j\jL^<lL. l>l':uK4L. 



Special information "nly for Hospitals. Institutions, Irdnslcnts, 
or Recent Residents, and persons dying av^ay from hon^e. 



I\f uiiii III Sen /'r ,! I/, . '''/•'> 



)'ii1 1 



yfi>llt?IS iT\ \ /'(M > 



THi: AISOVH STAri'.l) ?'KKSO\A!, I' \ K lIC C I. \ KS ARK TRlffi T<J TflH 
Hl'.sT oi.- Mv KNnwi.I-.DCF AND lUCl.ll'.F 



''liifMTin 



'Xd.ircss 3S\C) N-XcLcvvvA-v^x^. Cj"t 



Former or 
Isiial Residence 

Wfien was disease rontrarfed, 
If not at plare of death ? 



How long at 
Plate of Deatfi ? 



Days 



PLACK OI* lURIAL OR K1;Mi»\AI, 



.^-^.^ 



DATlCof III Ki.M, or KKMnXAI, 

l^ i9oH 



II. \ 1 I', oi n! 

1^ 






\M>v 



(.\d(hcss 



N'. K.- 



-Kvery Item ot' informrition fthould hi cnrcfully supplied. A(IF. should be Rtnted F.XACTLY. PMVSICIAINS nhoiild 
stnte CAlISf: OF DEATH in pinin terms, that it may he properly cloHsified. The "Spcwinl liiformntion" for p*»r- 
Rons dyin^ nwny from home should be Aiven In every InHtance. 



i i 



i\ 






fs^; 



' I 



» 




> ! 



(I. 



} h 



} 



\\a 



(!!» 



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

II. ,1.1 .flhiith \ s<^ i-> -^'^rp^^ws^v Ci, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



iJd/c Filed y 



i 




ChV>L^o 'JoLo^u Dep 



g * 



lOO'i 
3lthQffIcer 



Registered jYo. 



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



Cevtificate of Bcatb 

( U. S. StanC^arO ) 



<^ 



A 



PLACE OF DEATH: — County ofU/CL^A,) OXOl/^vC.L4.tCCity of*0/CUl\) o , V CX-y v c t^<:.<: 



.-^-x^ 



/Li\\V<LV\M\.St.% 



Dist.; bet. 



and 



n / ir DTATH OCCURSjIaWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \ 
y \ IF DEATH OCCU'l|lRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



.LcL^:^i<u.:^.V:<i ^u 



Crov>- 




'^KX 



n\TK nr niRTH 



PERSONAL AND STATISTICAL PARTICULARS 

'J-ct 



I ^tolltll) 



,...H 

(Day) 



/.ll.H 

(Vear) 



Af.R 







^0 )V,7».v O 



M.tHlhs 



Da vs 



>iiN«".i,K. MARkij;n. 

WiDnWKI) OK I)IV<)Ri,Hn Q 

(Write in social dcsiKtiation) -Y ij 



RIR THrT,ACK 

(State r)r Cotnitryi 



NAMK OF 

iA'nii;R 



.1 



I 










MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH A 

(Day) 



/ (Month 




(Year) 



i) 



I irKF-il^BY CERTIFY, That T attended deceased from 



-J^-C 10 190 3 to "ivv^A^ 5 190 S 
that 1 last saw h <Vw-\.alive on yV-'AJLvy 5 190 H 
and that death occurred, on the date stated ahnve, at Cd I O 
.... Ll.M. The CAl'Sfv ()1< I)i:.\Tll was as follows: 
OJU^VA-AjLvtu 



nTRTHI'l.ACF 
<M" ixriiHR 
iSt;itf or Cuntitrv) 



\) \.XX\^W^v/a 







MM DEN' N'AMF 
<'l MOTHER 



HIRTIIPI.ACK 

OI-" mothi:r 

(Slate or Comitrv 






nrRATKlX -r. Years t ^rofl(hs XS^ /hiys 
CONTKlIU'TOkV 



Hours 



^ K.^^J^'^^ix^ 




OCCITPATION f^ 

C oJjL,0/vwouvo 

f^^sidftf ill S,,„ /'iitttiisfo ^^ ]'rni 



^ cjcvLo^v^'^jLcL. 




JA;;////.? /)ays 



flours 



DURATION Years 

(SIGNED) La). U L^r^viCcov M.D. 

b Ic,oS (Address) LClu UU VAlA/W^JrV^v.^^ 



iN "nly for Iws 



Special Information only for Hhspitdis. institutions, irdnsifnts, 

or Recent Re!>idents, and persons dving dnay fro^i home. 



Former or 
Usual Residence 



01 



How ionq at 
\'%\^r\.^rVV4^ Place of Death ? 



Days 



•" M<»itii> " /hn> 



IJESr OI^^IV KNOWI.EDC.E AM) nEl.IEP 






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



-WV-VthVV^L 



I'l.ACK Ol- lURIAI, OK KEM<»\AI, j DATHof IJikiai. oi K1;M<)VAI, 

INI ) 1 : K i- A K }■: R C\) CL.cttx y\) ^^ 3\XXXu 



N. B. 



-Every item olf int'ormHtSon shouhl l>j ciirev'ully suppliejl. \C,Yl k^ojiIiI he stntetl EX4CTI.Y. PHY,SICIANS Nhniild 
state CAUSE OF DMATH in plain terms, that it miiy he properly classified. The "Special Information" for per- 
sons dyin£ nwny from homo should be i&i^en in every instance. 






fJ 



! 



t 






't 



ill 



m<, 



■i**^^ 





m ^ 



* '--i' 3 





u 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hm.ii-,! -i' Hl ..Ith -»•• No. 1=; ^^.:^^'^' lift J' t'o 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc FiJrd , 

1 




<J-WU5 



i^< 






EegisfcTcd J\^o. 



188 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of S)eatb 

( tl. S. StanC>arD ) 



PLACE OF DEATH: — County of- 



City of 



o-^t 



^r>-\i 




'X 



<xaa> 



No. 



St.; 



Dist.; bet." 



"and 



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



FULL NAME 




.Oj Ll. 




O.LiA^L'.. 



PERSONAL AND STATISTICAL PARTICULARS 



COI.OR 




XKJiL 



\y\'vv. OF- niKTH 



ACR 



vlll. 



<Motith> 



(Day) 



(Year) 



^1 



years 



Months Davs 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



[Montli) 



'Hay) (Yt-ar) 



^TNr,I,K. MARKIKI>, 
WIDoWKI) OK DIVORCKI) 
I Write in 8oci«I <Ic.itj;ufittoti) 



niRTFIPf.AOH 
Siiitc or Coiintiy) 



\ \Mi-: oi- 

1 ATlll-.R 




I'.IR'nilM, \CK 
<»1 lAIIIKR 
(State or Country^ 



MMDl-'.N N.\MK 
'•1 M<'TI!J-.R 



HIKTliri \0K 
<»l" M<»Tni:R 
(State or roiiiitrv) 






I IIRRHRV CliRTfFV, That I attended deceased from 

— — — icp to .:'.!iv;.-'j igo 

tliat I last saw h ■alive on . ■..:.Mr..mKu.»vfe.Mg»...... up 

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

:\r. The CAUSfi Ul' DICATII was as follows: 






^ 





DTK ATION Vcuirs .VonUis Days J/onts 

CONTRIIUTOKV 



ni'RATION Years Mont/is Days //ours 

^SIGNED) -:— — M.D. 



OCCUPATION 






Tqn 



f Ar1dre<;si 



Special information onl> for Hospitals, Institutions, [ransients, 
or Recent Residents, dnd persons dying away froni fiome. 



Former or 
Usual Residence 



How long at 
PIdf e of Death ? 



. Days 



Rrfiilnf hi Stiff /'itiiiii>rn I "" )'rais ,.?*• ^fn/tfhs •" P^avx 



When was disease contrarfed, 
If not at place ol death? 



rni \H()\i.: si- \ iin !'kks( »\ai. tak ru ri..\Rs aki-. rkri-: ii • rii i-: 
iti.M" OI- Mv jiN()\\j,i;i)(;K and hi:mHK 



'I'lfii'iiKint 




^\.l<1r(ss 



aoi \ 



'-'>V 



,0-4 



ri.Aci-; Ol" lUKi.M. OR iu:m<)\ai. 



I) A ri; o! Hi lUAi. ..I K i;mo\ai, 
YOm It^ T90^ 



ni)i:rtaki:r \i^-\.\.-y\,Kx\j \l cLl^^-sJ^T 



(Ad 



dns- 'lbl£)b vm\ 



VA.A ^^A\. 



\i 



[N. B. Fivery item of liiformiitioii Hlvuiid he cnrefully Hupplietl. .\(]r. Hhoultl be Htiite«l nXACTLV. PHYSICIANS should 

state C.XUSI; OF DF:ATH in plnin terms, thiit it miiy he properly cluNsified. The "Specinl ItiforniHtion" tor pmr- 
sons dyin^ away from homu Nhould he lOtlven in «very inHtunce. 



^^ 



I'n 



■\ 



• ( 



T 1 



I 1! 










t-r^ 



I f^^l 



El 



IP 



rt 



h. 



Vi^aJii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



It,,;:nl of lUalth !•• Xo. !^ 'P'^^i;.^'* H^: I' Co 



J)(tfe Filed , 



.thVC\^ 




lOO'i 



Registered J\^o. 



189 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of 2)catb 

{ 11. S. StanDarD ) 



^ 



PLACE OF DEATH: — County of C' ,0.-^^ .^.0^>xc\AC.{) City ofCJcuvuJ 



<Xrw) J AxXA vCA-^oo 



Na 



f^ 



5 "IR VI I lu^vrYX St,; 3 Dist.; bet. ! ^X" and "X ^>VcL 

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



FULL NAME 



VC)4^\J^VOj 




PERSONAL AND STATISTICAL PARTICULARS 

__ "OX-W-VCX^lx; UJ 

IlATR OP BIRTH 



Jv^kXjl 



MEDICAL CERTIFICATE OF DEATH 



DATK or DKATlI 








AOR 




19.3.. 



MlMith* 



i'Mrs 



(Day) 



/is I 

(Year) 



.^toHtks T. Pays 



SlNt.I.K. MARKIia). 
WiDoWlil) OK 1>IV«>KCHI) » 
(Wrllelii nocial tk-si^uation) 



Hik rni"i,AOK 

(Statf «)r Con lit rv) 



NAM).; OF 

i"aimi;r 







M(Mitii|r 



k- - 

(Day) 



(Year) 



I in^RlCBV CI'RTIFV. That I attended deceased from 

io up 

that I last saw h-^::~ — ahve on " ~ k^o 



tr^lgo 



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



— M. The CAISIC ()!• DIvATII was as follows: 



-\.^C<x.aaL 



»UK rniM.ACK 
<>l- FATIIKR 
(State or irountry) 



■ r 



1)1 RATION Vrars Mouths Days I louts 

CONTRIIU'TORY 



MAIDKN NAMK 
ni- MoTMHK 



nTUTlTlM.AfK 
OI- Morin-IR 
(Stale or Country) 



K\ 



<X*CUPATION 



DURATION Years Mouths Pays 

(SIGNED) UA-^P^UA) J Ai3.U)-"liJ^ 

^ i()oH (Address) U-VinvtV) 



Hours 
M.D. 




FECIAL Information only for Hospltdls, institutions. Transients, 
or Recent Residents, and persons dying rtHdv from liome. 



P^^titfif {ft Sail Fiavrhrn 



) >(7 IS 



}fnnfh<: 



Ihiv 



iin: AHovH sTATi'.n rKKsoxM, rxRiMrn. \rs \ki: tri i*. To thk 

HKST OH MY KNoWI.l.DC.i; AM) 1U:IJI:K 



' \'V\m-<s 



Former or 
UsudI Residence 

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



How lonq at 
Place of Death ? 



Days 



I'I,ACK OI- lURIAI, OK K1;M(»\AJ. 






I)\ri-;<)!" Hi KIM. or ki:mo\ \l. 



T90 \ 



(Add 



ress 






N. B.- 



-r.vcry item of inforniHtion should lu- cupofully supplied. AdR Hhoiild be Htiited liXACTLY. PHYSICIAiNS nhould 
«tutc CAIJSI or DIIATH in pljiin terms, that it mny be prt.peply classified. The "Special Informjition" for per- 
sons dyini^ nwny from home Khoiild be Ji'iven in every instance. 



i| 



I 
I I 



i i 



;•■■ 



11 



Cf 



i , 



i ■ 




f I <i 



^•**t'^* 



.»' 



.>'■/•,. 






I > 



n 



^*.! 



^'^ 



^i:^ 



;■■/ 



r 



■II. 



Il'l 



'* (1 



II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I llraltli IN.. 1= *|^ai>^>luS:l'C<, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/>(f 



l(> Filed . \>J^'\ 

1 ^ 



^^:y\\jsj^ 



VJ(A 

Deputy Health Officer 



JicgLslercd J\^o. 



190 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDeatb 

( "U. S. Stan^arJ) ) 
PLACE OF DEATH: — County of CW:u?. JA/Oc<:\.\.aLA<e^ City o{ODjy>aAjUXr^s^^,<: <i 



No. 




ti 



b5...\l f U4.4.\-CY\i St.; 3 Dist.; bet. 3 /VOj and H A^v- 

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



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



:i.^i}uL, 



COI,OR 




4 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



n.\TK iW lURTI! 



(Mbnth) 



AC.K 



., I, V ) f'lti s 






Mouths 



(Year) 



H 



Davs 



SIvr.T.R. MARRTKn. 
WIDoWHI) OR I)IV<)KiKl> 
iVVrittin social (U si;.Mi:iti()ii) 



i 



RTRTHPtAOK 

'St.'ite or Coiiutrv^ 






I (Montlvf 



'1 

(Day) 



/go \ 

(Yfar> 



I HEREBY Ol'KTn^V, Tli.it I Mttciided deceased from 

.-■ ■-■^■■..^ .. iq^ ' ■• to ■.......,-... 



tliat T last saw h:rr-??r- alive oti '?? 



190 
190 



and that death occurred, on the date stated above, at 
:rr— M. The CAISI-: {)V HftA'1^11 was as follows 

U 'C\^V\)^OUv^J ioJUxVV ^j-^VSJ^XX-a..^. 

.'yx^:Y^X^<3Li....yf<^v:!u<^ 



NAM I-: n|- 
FATin-R 



^ 



RTRTIIPI.APR A 

<>I" I'ATJIKR * V 

ist;itt or C"oniitry> H A 



<>i" MoriiKR 




lUKTHPLACK 
oi" MOTHKR 
(Statt- or Country) 



.C> ajJl<x >x<L 



Dl RATTOK Vtars 

coNTRinrroRV 



AFonfhs 



Day 



//outs 




nrRATrOX Vrars .iroHtfis /)<Tvs 




OCCUPATION -P 

f\'''siiiri1 in Snti I'l (DIi ism <J^ )'>nis \ Mi>ii/h^ <^ />a\^ 



(Signed) 

% 



<L 



^'^{ 



T()0 



( 



A(Mress) L(rVr> 



//ours 

M.D. 



\XKfi 



.f ^ t.C 



Special information only for llospitdls, InstilirtCr 
or Recent Residents, anC persons dying awdy from home. 



THl-: AHOVK ST \'n:n I'KR^OX \I. !• \K lirri. AK-. AK)". TRIK Ti ) I" ! 1 l-; 

ni:sT oi- Mv KN(»\vi,i:i)( .K and iJKi.n':F 



(liif.innatU 



Y\/W) 



XiMress . 



y 

SI - ..H..,L^a; 0' 






Former or 
Usual Residence 

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



HoH lon() at 
Place of Death .' 



Iransients, 



Days 



I NDl 



iCK Ol" lUKlAI, «iK UI:M»»\AI. I DATi;..! Itii'iM 



ki:m(»\ Ai, 

TQOS 



N. B.- 



-r.very Item oV' inV'onmition Ahoulil h.- cnrofully supplie«l. \(\V. H^iould ho Ktiitetl I.XACTLY. PHYSICIANS Khouiti 
state CAlISIi OI' Dl: ATII in pliiin terms, tlint it may he properly claMtiit'ied. The "Special Int'ormation" for p«r- 
Ron* (lyinil nwny from home Nhniihl he i^iven in every inHtnnce. 



II 



, ! 




, 



f 



i» ^ 






fl pi 



I 



MM 



< i 



i'^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.,l,f Hraith I No Is ^-?SD^ "''^''<^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






xluS 




i;joH 

Deputy Health Oflflcer 



Registered A''o. 



190 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. £tanC»arD ) 
PLACE OF DEATH: — County of Ua^:>\i..JiUX^3i4M':t.£i City of 0/Cl/Vu Jaxv^avCaaC C 



No.1b5 



1u 



(ir DEATH OCCURS 
IF DEATH OCCU 



St4 ^ Dist.;bet. 3/VcL 



ii 



S AWAY FROM USUAL RESIDENCE give facts called for under "special INFOFfMATION" \ 
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



and \XM> ) 



FULL NAME 




SEX 



DATK (ir TURTH 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR 





(Mbuth) 



I 



...Si /..L.s.S... 

(Wy) (Year) 



AGR 



1 1> »>-?•« 



MiJtttlts. 



Da vs 



\\ ii)(»\y>:n «>k divoroki) 

t Write in social (ItsiLMiation) 



^ 



^CA^ 



HIRTIfPtACF, 

I State or Country^ 



NAMK OK 

I- ATin:K 



HIRTHPT.ArK 

<>i' I- \ riiKR 

(State ot Coiiiitrv^ 







MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH A f 

.„«.«... \/\.K.\.Ll i /(?oH 

/ (MojitW'^ (Day) (Year> 

I HEREBY Cl'RTIFV, That F attended deceased from 



«»«^'*$-*»>*>«#a«. 



I9O 



to 



that I last saw h "::"" — alive on 



I90 
190 



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



rr..M. The CAISIC ()!• DI-ATII was as follows 

.jd«&^^^Jl^aX....y^v.OL^txA,dL,^ 



OI- MOTMKK 



.W 



(XAX'CX, 




RTRTHPT.ACE 

OF MoTlll-.R 
(Slate <jr Cuuulry) 



Lx>UA. vJ 



nrRATTON Yrars 

CONTKIIU'TOkV 



Mouiha ..Days 



Hours: 



DrRATlOX... ^ Ynits 



Mouths 



Pars 




oLcuu--tr\jLh.' 



OCCUPATrON 

Ki-sidfd III Stiti /'iiinrtfea A-O... fV^Kf \ Afymfiu ..Mk. A»w 



(Signed) \.^yvcn^Nj^ \J>. 10 Ax,W 

k^Lu ^ looS r Address) L&Vn\XH^ ^^If^- 



Hours 
M.D. 



*.l^ 



Special information only tor Hospitdls. Insfitatfons. Irdnsients. 
or Recent Residents, and persons dying dHdy fro.ii home. 



'rin-' AHox}.; si" xrin i'Kk^ox \i, i-ak iirr i. \k<. aki; 

MHST OI- Mv KN()\VM:I)('.K AND IlKlJI'.l' 



rxri-; to thh 



'Iiifonnaiit 



1,1-. IM . v. 



.IX'^'^J 



\(Mrc<« 



3a - H ti, dt 



Former or 
L'sual Residence 

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



HoH lonq at 
Place of Deatfi ? 



Days 



I'l.ACH OI" nrkiAi, OK ki;mo\ai. I dati;.,! hiwiai, ..r ki:mo\ai. 



.... .... I90H 



INI 






Addres* 



.A^^a,c<: 



'^^ B. livery Item of Iiif()riniition should l>j cjireltuliy supplied. AGH should be stiiteil EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may he properly clasHil'ied. The "Special Int'ormation" Vor per- 
sons dyln^ awny from home should be j^iven In uvery instance. 



I 



k 



i 



. ! ) 



' . 



1^ 









'»i«i9»m 



■It 






.i' 



i f 

i' * 






<ii' 







'■ ) 



'■'I 



i 



i 



^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.kikI of He .iltl 



1 -l' No. l^ f*^^2]^J HftP Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)af(' Filed , 



i 




100^ 



Registered J\i''o. 



191 



^-U-^U) 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of S)eatb 

( tl. S. Stan^arD ) 
PLACE OF DEATH: — County of C'/OL'W -J.>va.%vt.i^<i'C^ City of 0-Vd \J/va-vvyt^^ly<M) 






St.; 



Dist.; bet. ~ and 



(IF OtATH OCCURS AWAY FROM USUAL R E S I O C N C E G I V C FACTS CALLED 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 




\ 



•J Kcl >v 



\u^: 



vu \jyy\/^-^: 



\jSX) 



si-:x 



PERSONAL AND STATISTICAL PARTICULARS 

COI<OR 



QluL 




m^Ojl 



DA IH OF IJIRTH 



(Month) 



(Day) 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF I)1;ATH 




(Day) 



(Year) 



I I[I':RHBY CICRTIFY, That I atteii.led (k-ccased from 



\<*.K 



5-0 



)'t\ll s 



Motilhs 



Pa v.v 



^IV<W,K, MAKUIKD. 
W IDoXyKD OK DIVoRri-:i> 
\V lite in social (Usit'iiation) 




'\cO\K\JL<L. 



HIK rni'KACR 
(state or '."oiititrv) 



NAM]-: OJ- 

FA'nii;K 







that I last saw h*^»^>^ alive on 



190 H 



1 90 



H 



1901 to >VwtLi,.9 

and that death occurred, on the date stated al)Ove, at i 

CL M. The CAISI-: ()1< DUATH was as follows: 



HIKiniM.ACK 
<»l- I-Arni'-.K 
IStatf or Conntrv) 



MATTJHN NAMH 
<>|- MOTHKR 



? ^ 



LLu^-cX^.^ 

DURATION }'i'ars 

CONTRIIU'TORY 



MoutJn 



Days 



niKrin'T.ACH 

oi- MOTHKR 
(State or Coinitrv) 



oocrPATiON^,^ Cn^^^^^^^^^ 






DURATION Years 

(SIGNED ) 



M^iUjt/is 



Davs 



La). ()b. cujIji^ 




S rqoH (A.ldress) (oOb 3-uXL^Aj Ok 



Hours 

Hours 
M.D. 



FECIAL Information only for Hospitals, Insfilutlons, Transients, 
or Recent Residents, and persons dyinq away from home. 



f\rsiifrif ill Snu /'i ,1 )/• i>,'ii " ]'\ii\ 



•- yh'iifh'^ \ />,n.< 



Former or 
Usual Residence 



Till-: \iinvi<: ST ATI-: I) i'kks(^nai. r\Ki'u'ri,AKS ari-; tkii-: to thh 

HKST Ol-' MV KNo\VlJ-:i)C. !■: AND J5i:Ln-;i<' 
(Inforinatit 



(x.l.l 






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






Days 



I'l.ACK ni<- HTKIAI, OK KI:MoVAI. 



I90H 



DA 11 ; o! Hi KIM. or K1:Mo\'AI, 



(Ad.heKS 



N. B. 



-F.very item of inV'ormrttlon ahotihl be cnrcfully Huppllecl. A(iB should be stntetl I.XACTLY. PHYSICIAINS should 
state CAUSE OP DLATH in plain terms, that it may be properly claMnified. The "Special In^'ormiition" for per- 
son* dyinji away from home should be (^iven in every instance. 





( 



f i 



»•: 1 



« > 



I I 

t I 



I 



^ 



111 



' 1 





^ /i 



yxrM. 



m^ 



V' 



►I' 

1 1 J 



;i 



Ul 



fi 



i • « 

.' I 
I 



Vi 



1 1 



■!*■ |. 



'■^it^ l , 



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



n:,r,l .,f lliallh-l- No. I =; ^?j:*!:.-?i3 V-Sil' Co 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health Ofn-er 



Registered J\^o, 



192 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc of Beatb 



PLACE OF DEATH: — County of C'OL">vO ^a.^VCUL^c^City ofO/CLA\^ OAxX/vvttA^C 



ft 



No. VC 



.Cvl 



-Cr^Aw^v 



XaU^ 




r^ 



CHL 



K*^t<XvSt,; 



Dist.; bet." 



and 



n Z' IF DEATH OCCURS AMAV FROM S U A L R E S I D E N C E G I VE 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.JUu.XL/v>'\ V\n^\JlLL 



'--HX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ 



^^L 



\))i\JOjL 



nATK OF lilR I'll 



& 



Mont'lit 



X 



\> 

(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

(Day) 





(Monrfi) 



(Year) 



A<.K 



ba y.a.s \ 



Mouths 



Da vs 



siNt.i.F. MAKkn:n. 

WIDoWKD OR ni\"ORrKn 
'Wiitf in social desiKnalioii) 




niRTUPLACH 

'State or Country) 



NAMK OI- 
lATIU.R 



RiRTnri, \rK 

«>|- lAIMKR 

I State or Country) 




MAIDT-N X\MK 
OF MoliiFR 



niRTHPI.ACK 

OF MOTIIF.R 

i State or Countrv) 






LcLuj-tx^<^w Cv>-iMJX 



.1 HKRRBV CHRTIFV, That T attended deceased from 

NIa^'^vJL -x 190 h to p^W '^ 190 H 

tliat I last saw h -V\>^alive on WuLchu '^ 190 H 

and that death occurred, on the date "Stated ahove, at » oC 
...S^ M. The CArSI<: OF DliATH was as follows: 

V r^-^^CvOAAv ^ Vl'lV VV^^V Va 



Dr RAT I OX Years 
CONTRIIU'TORV 



Months 



/)avs 



Hon 



> s 




OCCUPATION 



'^U 



I Vcvmxx-'yv 



d. 



f\rsiilrii in Sim /'i iini i^ri> *m )><?;> 



DURATION J'cars 

{ Signed ) 



J/i>f///lS 



vJ 3\. tk)CL\t 



/hirs 



Hours 



VVl 



f)0 



N 



r Addn-^^) 



.. aV I %^\A 



M.D. 



Special information only for 

or Recent Residents, and persons dvin;j c»w<j> troni home 



mspitdls, 



former or 
IsudI Residence 



It. - s 



a-V I How lonq at 
0\ piare of Oeatfi ? 



Institutions, Transients, 
3 V. Days 



Months 



/hn< 



When was disease fontrarted, 
If not at plare of death ? 



Tin- mm)vf: sr \ r).-,n i'i,R^,)\Ai. 1- \R iirri. \RS ARI-. iri i: !(» 111 )•; 

UKST OF MY KNOW I.lix-.K AND HKMKK 



(Ii 



iformanl LaJ ^WV) . V/ '^ ^CV-Cv4^ 



f\<]i\ 



re.. Lvl^.'^C % 






I'l.ACF. Ol- m RIAL OR RF,M<i\AI, J DA TJ-.-f I'.i kiai. .m RF;M(»\AI. 

d-U-W^-v^bculiL^ i ')lvOUi. 16 190H 






(Address 



N. B.- 



-l.very item otf int'ormjition fthoulti h.- carefully Hupplied. AtlK should be Httiteil EXACTLY. PHYSICIAINS should 
stnte CAUSE OP DEATH In plain terms, that it may be pr<.perly classified. The "Special Information" for p«r- 
w^ns dyinft away from home should be ^iven in every instance. 









I tl 




M w 



n 



m^ 



J!. 'Ml' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

fll.ilth VSoi-.-^'^^^-.m^VCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






100^ 



Registered J\^o, 



^^Luja 



Pep 



om 



^*er 



DEPARTMENT flfp PUBLIC HEALTH=City and County of San Francisco 



Certificate ot 5)eatb 

( "U. 5. StanDar? ) 

,4„.,.^ .i 



w 



3' 



PLACE OF DEATH: — County of ^ . CX"W J.VOL>\^^wA'CcCity ofC'/a>v 0,>UX/>v^C^4 ac 
I^. ^ ^ 0. J CM.O>va^A.j^-vvQ. 1-WliIiv.'V>\. St.; Dist; bet. — — and 

(ir DEATH OCCURS AW*]V FROM l/i\sUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURREQ IN A HO<^PITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



.OlUAvUt'v:^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




<xXx 




JvlAJI 



i»\ii-: or- HiRTu 



.1 



lilw^l I / ^D4 

(MoiiAi) (Dav) (Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OP DKATII 



otith) K 



(Day) 



(VfMl) 



\<;f. 



) 'rn t s 



.Mouths \ Pavs 




>IV<.l,F, MVRRIKI) 
WIDuWKl) <»K DIVnKCi:!) 
Writf JTi •«x;tnl designation) 


JUKTFIPr. 
St.-itf or C 


ACK 

ounliy) 




NAMl. (H 
1 ATHKR 


- 








,^'\^^r^Kj^\} 



UVMVMY C1:RTIFV, That I attciKkMl .liHvascd from 

VVUt i up^ to^. WluL .1 190 H 

that [ last saw h v-v>\alivc oil ^WvLoi 1 k/dH 

and that dcatli occurred, on the date stated above, at I 
IV- M. The CATSFC ()1< DICATII was as follows: 



lURTHIM.ArK 
<>»• I AIIIKR 
<Slat«- or Tonntrv) 



maidkn namk 
<>!• m<)tmt:k 



BiRTitrr.ACK 
OH m<»imi;k 
(Suite or Counlrv) 



nrRATION ^ )V<;/\ ^ Moutln 3 />«7r.s * Hours 
CONTKNU TORY M l\.^L'>A^vtA„v"tvCrVL 



DURATION Yiiirs MonJhs 



*i 



»i 






(SIGNED ) 

|V.A^U^^^ T()0*i 



fAddrc-sv;) 0.5^0 J.'JX^\ 



Hours 
M.D. 



Special information only for Hospltjls, institutions, rransients, 
or Rc(cnt Residents, and persons dying away from home. 



lin: AiJovH sTA ri:t) i-kksonai, par iiiti.ars ari; trik to thh 

HKST OF MY KNOW l.i;i)(*.K AM) 1U:IJ1:K 



'Illf,i'iil;uit 






\<l<lrcs. A 5" C^ 



Former or 
Isual Residence 

Wfien was disease rontrarfed, 
If not at place of deatli ? 



flow lonq at 
Place of Deaffi ? 



Days 



I'l.AOH 01 lUKIM.dR KHM<)\AI, I DATj;.);" ItiHiAi. ot RllMoXAI, 



C'a_c-v-\^^vc 



rXDlCRTAKHR 



^■^itlL^vct ' 



IC)0H 






(Address... /?> io ^1 ^ ' ^^vt^ ' 



'^^ ^' Kvery \Um o? inf.>rm»it ion should b.- cnrcfully .supplied. /\(;ii shriuld he stilted fiX4CTLY. PHV«SICI/\!SS nhnuld 

stiitc CAUSt OF DTATH in phiin terms, thnt it nmy he pr(.peply cluHHified. The "Special Infopiniition" for per- 
sons dyin^ away from home Hhould be i^iven in every instance. 






IP 



:l 




II 




I I . 



u .. 






ii 



f.f 



•l i 






i' I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i Il( .ilHr-l* N') 1-^ -^v-ar! -i liN.!' Cx 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale l'if('<l,\vJ^u. n 



V)0\ 



]ie<^Lslci'('(l JS'^o, 



194 



C-tcv^ 



i 



Ue 



Officer 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of IDcatb 



-C 



( n. G. StauDavO ) 



PLACE OF DEATH: — County ofOoLVU .VCtWCA^^CO City ol'OiOjy\> JA-0,^*xCv4,-t« 



0? 



No. H 3> \ .CU,\> y oJu St.; 1 Dist.; bet. 1 



(IF DTATH OCCURS A\M*V FROM USUAL RESIDENCEGIV 
IF DLATH OCCURRtD IN A HOSPITAL OR INSTITUTION < 



^ U\ 



ind oI(d XJ(\ 



tl, 



t FACTS CALLED FOR UNDER SPECIAL INFORMATIO 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



N.) 



FULL NAME 



|v JLu X\ cri<JL 



'WJJ\) 



PERSONAL AND STATISTICAL PARTICULARS 



''■^" <!5i) 



COI.OR 






I'Aii: or- jtiK Tii 



Moiiih) (Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 
1).\TK OF DlvATH 



\ < '. V. 



1 I )V<M.V 



.Unn/As *".. , />a\.s 



\\ lUOWKI) OK IHVOKfia) 

iWiitfin «Hial dt >H'n,itiMii) ' 



ItlKTUI'I.At'K 
'St;itt or CiMintry) 



I 



NAMK OI- 
fATiniR H 



w^^luJu G 'txJyviuX d aXIrn^A-^uw. 



'Montii) (Dny) (Year) 

1 HI'Rl'MN' Cl-RTIi'V, That I Mltc-iKlc-l dioiascd fn.m 

|VV>V^:5.^ ,cpH tn Ixvl^S KKdS 

tliat I last saw li -^^N^ alive on ^"^^^^^ ^ 190 M 
and that death occurred, on the- date stated above, at S 
C^.M. The CAI'SIC ()!• l)i:.\rn was as follows: 



0-^tlvJL>-^A^o. oi \)t<L CLa-^ 



HIKTITPI.ACH 

<»i I Ariri:K 

fStatt or l.'o\iiitrv^ 



M MDMN N \Ml- 
<»1 MOTMHK 



HIKTHIM.ACK 
"» MOTIIKK 

'State or Country'* 



X\.^wva>v 



•>^'cri"A'ri(iN ,\y 






t 



1)1 K A I" ION 10 )>nrs •- Months - /></i.s- - //<>//;.? 
CONTRIlirToKV C/AV^C3u-rcvfcj> 



F)r RATION (0 )\'iirs .Souths /\iys /lours 

"Jv-O^Uv^X VjD. OUaaaA. m.d. 



*^>'U&-\-ArT>j 



X^^^WA.^. 



n 



(Signed ) 



r 



Address) IDb 3^v'tLt\. "ot 



S^PECIAL Information «'n!> tor Hospitnls, hstitutions, frdnslenfs, 
or Rt'tenf Residents, dnd persons dying in»dy from fiome. 



A'fM(/ri/ III Sill/ /'i iiiii 



% 



) , 



M.'lltfl- - /'</! 



formfr or 
Dsucil Residence 

Wlien Mds disease rontrdrfed. 
If not at pjare of deafli? 



HoH lonq at 
PIdre of Dedlti ? 



Days 



III I", AI{<)\I.: sr \ 111) I'KRSON \l, r VK Ih I 1. \Ks \K1. IKl V. ft) III l- 

iii-:sT «»i MY kn()\\m:i)<". J-; and ni:i.ii;i" 



(rnfortiiant 



ai|vuic -^c^u 



y^JLKj 



V'ldicss 



m^W^MUu^h 



i'i.Aci-:<)i iMKiAi, OK ki;mo\ \I 



DA II", .1; itiK! \i 01 ri;m< )\ \I, 

'I^aLul li 190H 



N. B.- 



-Kvepy item ott hilf()rm itioti should h.' ciircl'ully siujplied. A^IR shoultl be Ktiiteil riX4CTLY. PHYSICIANS Khotiid 
(ttfite CAUSE OF Dl:A TH in pinin terms, that it m:iy he properly classilfied. The "Special InformHtion" for p»r- 
Rons (lyin[^ awny from homo should be j^iven in every inslnnce. 



1! 



'. " 






11 



i 

1 



♦ I .i 



I', a 



l!?!l 









{ 



I ' 



Iff 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Pff 



d<.^^^^t> Aji\> 1 Deputy Health Officer 



Registered JVo, 



195 



DEPARTMENT 0^ PUBLIC HEALTH^City and County of San Francisco 



Certificate of IDeatb 

( tl. S. Stan^av<i ) 

^ ^ J? 



^ 



PLACE OF DEATH: — County of C a^v O-^^a-^vCulC^iCity of C'/tX^v A.CX'^VC^^ C^o 



No. 



1HH 



,L <X^kv 



avqA^\j 



St.: SL. Dist.;bct. jVeaVAv^,^ 



and 



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



cl/-t^Wc^VNX' ) 



(^ 



LlVt^LdLo^- UUO^C^AA^ 



FULL NAME ^ivt.\.a)(rt ^^^y^\^j^^K\^^-^o^ 






AAk^\. 



^o- 



PERSONAL AND STATISTICAL PARTICULARS 

HATK <U-' lUUTH * ft 

T'^M' 

(M.>|)th) j 



5 

( Day) 



(Vear) 



3 



.^ 



WJJJ. 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol- DKATH 






5- 

(I)av) 



(Year) 



I iri':kl{nV C1:RTIFV, rimt I altciuUMl tleccased from 

4\.v.Lu 5 . T90N to - 



) V</ / A 



Movths 



Pit I .V 



WIIMiWKI) OR DIVOKCKI) 
•NVritf in Mvial <it^i;.Mialit)ti) 



L 



lUKTMPI.ACR 
'Stati' or Coutitrvl 



\ WW ^^\: 
lATIlKK 



niKTHPI,ACK 
<»> fATIIKR 
">t,itf or Country) 



^'AIDKN NAMK 
oi- MOTHHR 




I'-TRTIIPKACH 
Ol- MOTIIHR 
(Slate or Conntrv) 



c1 . 

c? 



til at f last saw h 



alive oil 



190 
190 



and that death occurred, on the date stated above, at 
-.- M. The CAl'Sl': Ol- DMATII was as foll.nvs 
OXcLL Obo-V^'V CXlMJ-vvt'. '\ 'T>vo:> 



DrRATlON )'rars 
CONTRIIU r(>K\' 



MofU/iS 



Days 



I lout s 



)'tars 



Mittiths 



/)a\s 



OCCI'PATION 



w>vou 



DIRATIDN 

( SIGNED ) \i)\\^. \\) C^vLu 

^V^wUu. 5 T,,nH (Aildiess) R I vlo^^i O*^ 



Hours 

M.D. 



^ 



FECIAL INFORMATION only for Hospitals, In^itutions, Transients, 
or Recrnt Residents, and persons d\inq anay from liome. 



/\/':i(fr(f III Still /'i a III f'^io 



]■-■,;/ 



Moiifh- 



/),M. 



Tin; xnovK sTATi:i) pkrsoxai, par ri*ri.ARs ari'. TKrK I'o rm-: 
iu-:sT Ol- .Mv KNo\vi,i:i)c.K AM) hi-:i,ii:k 



(IiifoTinant 



% 






former or 
Usual Residence 

Wfien was disease contracted. 
If not at place of deatli ? 



HoH lonq at 
PIdf e of Deatfi ? 



. Days 





PI.Al^K Ol- m RIAI, OR K1;MoVAI, I I)ATi:.i;" Ml Ki.xi, ..I RKMOVAU 



^-v^v 



^ 



liJ^ 



(>\0 



\0 



T90S 



rNi)i:RTAKi;R 

(Ad 






!N. B.- 



-Hvery Item oV in?ormntion HhouUI be cnreltully supplietl. AGF. sSfuilil be Htiited liXACTLY. PHYSICIANS Nhoulil 
state CAUSE OF DHATH in pbiln terms, thnt it mny be properly cluHKifled. The "SpeciBl InlformBtion" Ifor p^r- 
Ron* dyinjt away from home should be ftiven in every intttnnce. 



,1 



I 

i 



\ 



|i 



\ 



\ < 



il 



I ' 



iii 



I 




::i. .. 



|'< 'i 






ill 



: i 



li 

III' 



hi 



III 




W-. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.uiH of II.'MHh- - I' Vo 1^ "^'ir^^ 



i. Hf;:!' O.) 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i 




Registered J^o. 



196 



^ 100 "i 

Xl/vKu Deputy Heatth Off] 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



^CH^C>L/i 



cer 



Certificate of STeath 



PLACE OF DEATH: — County oiOOuy\) 0XOL^xcc<LCoCity of ^' CL^V Ja.<V>vcv^co 
No. Sl'l i'o.<.^. St.; !0 Dist.;bet. C^a-^X^IuLY and \l\^^ 

(ir DEATH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "sPEcAl INFORMATION" "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREETAND NUMBER. J 



FULL NAME 



'Ji.- 





■\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



■"'. OlxJx 



lOJwb. 



DAI'l-; OF HIK Til 



a<;k 



/" Month )|j 



Is 

(Day! 



,iS.O 

(Ye;ir) 




jv^ 



U^...sJ.\JL^^^\A.- 



Qs-U 



MEDICAL CERTIFICATE OF DEATH 
DATK oi' DKATH 




I 



lontli) 



1 



,..a.... 

(Day) 



ign 

(Year) 



IH 



) 'ra I s 



MntitllS 



PilV: 



"^IN'f. l.K. MAkUll-.l), 
\VII)<)\yKI) OR DIVOKCKI) 
(Wrilf in .siK'ial dtsij^ nation) 



HIUTHPI.ACK 
• Stiitf or Conntrv^ 



NAMi: (IK 

fathi:r 



lURTHr'I.AOK 
<>l I'ATIIHR 
(Statr or Couiitrj-) 



\ 



r HKRI-BV CI'RTIFV, That I atteii(KMl deceased fr.)ni 

'^VUl i 190 H to . \v.sJlu,....a T(>o'. 







til at I last saw li -A/^^alive on >V'sJLu ^ 

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



CC M. The CAI'SIC ()1< DI-ATH was as follows 
■oU..'VA>^AvtdfV^\.\.aL^.. 






kVTV 

.0 



' JVt^wucL. 



i> 



\ 



DC RATION ir::.. Years ' .l/ou/Z/s '1 /)ays 1 //ours 

CONTRIia'TORV LLcA.A,iw^ J -w!>wLa.\^ 




MAIOKN NAMK 
"I- MOTHKR 



ItlKTHIM.ACl-: 
"I- MoTHKR 
(State or Conntr\ > 



OCCII'ATION 



f\'f'^/Jrif ill San /'; ,7;;. /v,) IM !V,;/> •" ^fr>vfh< o I hi \ 



\VLuJU\Js 



DURATION Vnns " Mouths 1 Pays 



(SiGI 



I lout s 

M.D. 



II11-: A»()\K STATi:i) rKKSONAI, I'A Kill- T I. A KS AKl" rKlK lO Til )•: 

MKST <)i- MY KN(»\\i.i:i)<.H AM) iu;i,n;i-' 



U ^ iQoS (Address) U) (n^-Ql^ \c X^, tk O ^. 

FECIAL Information only for Hospitals, InsfKullons, Transienls, 
or RctTnl Residents, and persons dyinq away from fiome. 




Former or 
Usual Residenre 

Wfien was disease confrarted, 
If not at plare of deatli ? 



How long at 
Plare of Death ? 



Days 



'Inforiiiriiit 



(A.M 



rfis 






I'l.ACK Ol" MIRIAI. OK RKMoVM, 



e V. K}v m 
NDHRTAKKR ^ I I LCTWO^VVCV W V ^U^CVOL- Nl Lo 



i)\ri^:of uiKiAi. or K i;mm\.\i, 
■\ 1 90 H 




N. B. livery Item of informtition «houlil bj cnrefiilly supplitMl. AdTi hHouIiI be Ntntetl f;\ACTLY. PHYSICIANS NhouUi 

state CAUSE OF DliATH in pliiin terms, thiit it nijiy he properly cluHHilTied. The "SpecinI liit'oriiiHt ion" for per- 
son* (lyinil nway from home Khoiild be gtiven in every inHtnnce. 




' I 



If 



\ 



n 



I 




\ ' 






'<fr 



l\' 



m ii ■ 



i 



u 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,1.1 II, ( 11)1 1 No [< *-f,^S^.nlii <■•.-,, REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



frtcv<» ^LJvvu Deputy Health Officer 



i 



lie gi, si ere (I J\'*o, 



197 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( 11. S. StauDnr^ ) 



PLACE OF DEATH: — County of C /a^v vJ /^a/WC^.^C<) City of U -a/T^ 0.\XXAv^\^c^o 






^^^ (tVu^lvCioA; St.; Dist.;bct-— and 

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



FULL NAME 



clA/eJvAJlKi 



-.VCL^ 



m;\ 



I'ATi; or HIRTH 



PERSONAL AND STATISTICAL PARTICULARS 

I CO I, OR 




IX^^^k 



UjAVAjtt 



t 






MEDICAL CERTIFICATE OF DEATH 

DATK ol' ni'.ATH 



lMnllth> 



(Day) 



fVear) 



\c.i-: 



..Ho 



Month) f1 



t:\A. 



(IXiv) 



)Vf/; .V 



IA0////.V .T!.. Pavs 



-^IN'i'.Mv M \Rl<Ii:i). 

wiDou i-;i) Ok i)i\-nRrKi> 
I U riff in Muial dfsijfnation) 



iuRTm'i,.\rK 
st.itc or Country) 



NAMl' or 
I'ATin-.K 



IMRTHPI.ACK 

<>l' lATIIKR 

I Staff or Country) 



\ 1 f " 1 



/\A>.Crvunrv 



mmi>i:n n'amf 
«>i- MoTin-:R 



niRTHPT.ACK 

Ol" MorilHR 
(Staff or Country) 






(Year) 
I HHRI-nV CI<:RTn-V, riiat I .itlcii.U.l deceased from 

u 190H to p'-^v '^ 190 "i 

tliat I lasrsaw h Wvv.alivc oil nIv\Ju^ "^ 190S 
ami that doalli occurred, 011 the (lato stated above, at 
^M. The CAlvSIv Ol- Dl-ATH was as follows: 




\J w\,^^:L\>A-- trvV-CUVM V Xv^gOtV^ v..V<V>-i V ; 



f 



,'AVtrV^Al'^^^ 



„ C) ic^Lo. 



OCCTTATION 

Rffiiird in Siiti /'i mi, ism "" )',ni 



>V(^ 

^7 



DURATION * Vrars Months Pays 

(."ONTRIIU'TORV OrAA^CO \-,v.Luir\.v 



RATION V Years Months nays 

\.ldress) bi3 UcLtliLvD ?^ 



Hours 



DU 

(Signed) 



Hours 
M.D. 



PECl'kL INFORMATION only for Hospitdls, Institutions, Iransirnis, 



( 



X 



Months 



lh,\ 



111 !•: \Ho\}.: siwri'i) chk-^on \i. iak riiMi, \rs aki: rRiiv ro im- 

Fllvsr 01. MY KNOWM-.DC K AM) HHMHK 



or Recent Residents, and persons dying cmay frofn home 

Former or .0, u \V\l \i- How lonq at 

Usual Residence 1 Ibi M fU^^^c^cryv OX Place of Death? 

Whe1i<yvas disease contracted, \{\\ A 4 

If not at place of death ? H bH N I lv^^c<n\ O K 



Days 



Iiifdtniant 



P 






o ,|w(i^\A.L y^.Li<^ 



»'i,.\CK Ol- HI Ri,\i. OR ri.;mo\\i, j i»vri*,ni" itiKi.^i. ..t ri;movai< 







i.1 



190 i 



INDl'.RTAKllR 

(Addifss 



^4b OfX 



V«3 -Lvc-^v 



N. B.- 



-Kvepy Item o(t in'formiition shnuld hj ciirufully supi>lie<l. A(1R should be stilted F.XACTLY. PlIYSICIAINS should 
state CAUSE Of* DHATH in plnin terms, that it nisiy be properly classified. The "Special Int'ormation" for p«r- 
Rons dyinfl away from home should be 4iven in every instance. 



\ \ 






I : 



' Si^ 



I i 



fi . 



" I 



!i 



I 



I '1' 



i 



■I 



I 



! 



« 

t 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,nh.,lth 1 Vo i> ^••tT?r^''I5ftI'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I )((/(' Filed y 






.^vcv^ 



Xx-^^u t)eputy Heafth Officer 



jRe^istet'cd J\^o, 



198 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 



( 11. S. GtanC»arO ) 



PLACE OF DEATH: — County ofC'tX^v 0A.<x^vCA^4.^i* City ofOouw 1A4Wv^:,a_^c^ 



No. 



3H^t -[lU^. 



tl^ 



(IF OrATH OCCURS AWAV FROM USUAL RESIDENCE Gl 
IF DEATH OCCURRCD IN A HOSPITAL OR INSTITUTION 



FULL NAME 



St.; 5 Dist.; bet. M I Vaa^^hx , and U oJL 

FOR UNDtR "special INFORMATION" "X 
NSTEAD OF STREET AND NUMBER. / 



\vc\>.a.. ) 



IVE FACTS CALLED 
GIVE ITS NAM E I 




XA\J 




<UU' 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



vj.iL^'xaJuL 



COI.OR 



U)lvU 



i).\Ti<: or- niKTii 



? 

(Month) 



7 

(Day: 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



r X'hX 

(Year) 



A(JR 



O t y.;t>y 



Months 



? 



Pit 1 . 



SINT.I.K. MARRIKI). 

iWiitt in sorial (Itsij^iiiitii)ii) 



HIKTHI'I.AOK 
(StiJti- <»r Co\intrv^ 







1 

(Day) 



igo 

(Yenr> 



JIIIvKI'HV CI'RTII'V, That I aUcnilcd dei easel from 
tX^v I 190H to Ma-v.L\jl 1 190 M 

last saw h '^'^^ alive on J^^J^ 1 190 M 

and that death occurred, 011 the date stated a1)ove, at ID O.Q 
.' M. The CAI'SI-: ()!• DiC.XTII was as follows: 

U OlI VJ-vJlcVV oL)Ar^;.^UX-«U. Oi K^>..CaA,rt 



lATMllR 



HIRIillM.ArK 
ni I-AIHKR 
'Si.iti- or (.'oiiiitry') 



MAn)}:N NAMI-: 

*>I MoTHKR 



niR'rniM.ACH 

<>l MOTHKR 
(Sititf or Co<intry> 




\,^\: 



,Q^y4)xv....il 



Dr RATION ^ )'t'ars " Monl/is ^ Days^ Hours 
CONTRIIU'TORY .LL<I/tl,cV.L.iL<3 






^V 



occri'ATioN ^^ 1) 




V 



-cL 



DIRATION I )\'ius ^ .U(>>///is ^ /hns ^ //ours 

(Signed) wivw v3 cvXu.v>u^ 

t> inoH r.Xddress) v^c>viv« U. 



M.D. 



'. «► 



PEci^lAL Information only for Hospltdls, Instltu^dns, Transifnts, 
or Recent Residents, and persons dying away Iron home. 



) 'rtt I 



M.<i,th> 



/),M 



TMi': xnovi-: si'ATi'n i'Krson \i, i>ak'i'kti.aks aki: TRri-: to rm-; 

IU;ST Ol'- MV KNo\\lj;i)C.H AND lU'MICF 
(Infoinuuit W\J "1- <A..\-yC-4XA- 



^\(1.1ti> 



SH%to - \\ 



tl k 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



.. Davs 




I'l.ACKOI- lUKIAI. OK K1;Mo\AI, 
(Address 



rNDi:K iaki:r 



DAIi;.)! Hi Ki,\l. or KKMOXAI, 

V^tu '\ 1901 



N. B. — F.very Item oV Informiitioti Hhnulcl be tnrefully Hupplied. AGf. Hhoulil be «toteil RXACTLY. PHYSICIAIN8 should 
stntc CAUSE OF DHATH in pliiln terms, thnt it mny be properly cluMMifieJ. The "Speciul Information" for pen- 
nons dyinjl away from home .should be given in «very inHtnnce. 



T 



\ 



t 



J . 



•i( 



s . 




f, 



'1 



> 1 



m 



'*ii 



r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n ,i.i-,f il.Miii. I No 1^ T^-t-^^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Dafc Filed, W^U ^ ^'^0^ 



Registered J^o, 



199 



Deputy 



fth OHI-^r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of H)catb 

( Xl. S. StauDarD ) 



PLACE OF DEATH: — County of O nvr^wa 



:Uy uf Lo^ vy^lv U <X'Caturro La.l.' 



'Na 



St.; 



Dist.; bet. 



and 



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



FULL NAME 



\X/y\r^Oj LLtLuLo MlLt. 




COI,()R 



PERSONAL AND STATISTICAL PARTICULARS 

I>.\T1-: i)V lilRTH 



lilLu 



(X\^K>X 



(Moiitli) 



(n.'iy) 



(Near) 



MEDICAL CERTIFICATE OF DEATH 

nATR or ni:.\TFi 




b 



roo'i 

(Day) (Year) 



I HRRI'iHV CI'RTM-V, That I attciiiUMl dccc-ased from 
~ " ~ — up to 



ACH 



CK\ I 'tui t s 



Uotif/is 



XX 



Daws 



SiV<'.l.K. MAKHIl'I). 

\vn)()\yi:i> OK nvoRCKi) 

(Writfin soi-ial (IcsiviialiDii) 



I 



HIKTIIl'I.ArK 
(Stati- or Country) 


NAMK Of 
FATinCR 


<)l lAI'UlCK 
(Statf or Ooiintry) 


MAIDl-N NAMl-: 
«>I" MOTIIKK 



J? <T^ ^ 



til at I last saw h 



"alive on 



icp 
I90 



and that death occurred, on the <lato staled alxne, at 
^ M. The CAl'SIv OI- Dl-ATII was as follows 



I )r RAT ION ]\uirs 
CONTRinrTORY 



Mouths 



'1 



Days 



Hours 



Jfoui/is 



Days 



HI Ml' HP LACK 
'»»•■ MOTUHR 
(Statf or Couiitrv) 



occri'A'noN 



Ov< 



R^'fiiifii ill Sail /'i (Jin isiui 




Dl'RATION Years 

{ SIGNED ) J. iD.lO'ou^\, (XtU^vvQ Inm 



Hours 



\.J^^n 



TqO 



N f 



cva^j M.D. 

\ddress) 0/Cl'>\io. VJbtH^CX V^ t 



RECTAL INFORMATION only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dying away from tiome. 



) ViM A 



M >„ffis 



/hi 



Tin; MIOVK STAT}-.!) I'KUSOX M, 1' \K IKTI. \KS ARl' TKIF To Till' 
UKST OF MV KNOW I,i:i)C.K .\M> m:MKK 



Former or a ^ ^ 

Usual Residence o C> ^J ^^xX 

Wtien was disease contracted, 
If not at place of deatfi? 



[f T\4 How long at 

^J^^xX Ul' Place of Deatfi? 



Days 



^\> 



\'i,ii. 



IM.ACH Ol- lUKIAI. OK R l-M. .V.\ I, I DATl-.of HruiAi. or RKMOVAI, 



9 51 QrVW^AA^mx ^t 



T90N 



(Atldrcss 



N. B.- 



-fivcry Item otf informntlon should b.- ciirolr'ully Hupplied. ACIR should be 8tnted F.X4CTLY. PHYSICIANS should 
state CAUSE OF DhATH in plain terms, that It m:,y be properly cluHHiTI^J. The •'Special Information" for per- 
sons dyinft away from home Hhould be j^iven in every instance. 



t 



i 



I 
I 



* i 



I: 



It » I 

to 'J 

m 



I ': 



W1I 







"i«R 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J!.,;il<l of Mi;iltl!--I- No. !<- '"':.' ^':.-' ''''^'' <-'•* 



Dale Filed , 



I 




lOOH 



Registered JVo. 



200 



i; « 



uej 



k^' it I Os^ C? i 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



{ II. S. StanDarO j 



No. 



PLACE OF DEATH; 



P 0J \ ^ 

County of CcU^^ J.\-OL.l\CULC0City ofC)/CL">\; Ja.CC'VUIl^CC 



St. 



Dist*; bet. 



4. 



t 



and 3v'>\'Ca^ 



(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 




X^L/^rvvcx/^Aj. 




PERSONAL AND STATISTICAL PARTICULARS 



si;\ 



^\oh 



COI.OR 



lU.l.u 



nxri-; or- iuktii 



\-rJ^ 



iMoiiDi) 



(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATM A [\ 

/fMontli) Q (Day) 

I UI-RI'HV CI-I^TII'V, Tliat I atlcMikMl deceased from 



(Year) 



I90 



to 



190- 



ac;k 



.0 ),ats yti'tiths 



Pa vs 



SINCI.K. MAKKn:i». 

WIDOW KD OR nnokrKf) 

(Writf ill >i(>ciai tksi}.^iialicii) 



^^L 



niKTHI'I.ACK 

(St.itf or Ooniitry'l 



-i, 



'A^^VVA' 



XAMK OT* 
FATiniR 



RIRTIIPl.ACK 

OJ- l-ATHKR 

I Slate or Comitrv) 



MAIDKN NAMI-: 
oi- MOTIIKR 



OXV^"N^CX-v' 



iL^^lk' 



1 



lliat I last saw h 



alive on 



Tgo 



and that death occurred, on the <late stated above, at 



^r. The CAl'SH OF I)i:ATn was as foll.>ws 






niR rupi,Aci>: 
oi- mothi-;r 

(Slatr or Conntrv) 



occ 



• « 
M 



I) r RAT ION Years 

CONTRir.rTORY 



..W-A^Wt^VcL^...... 

J/0////IS 



(K^-O-trvwAx-q. 



/)i7 1' V 



//ours 



DURATION )'rt7rs 



Mo}iths 



Pays 



Kfsidrd ifi Sitft f'rait, i^ii< o V--,}! 



(SIGNED) UV(n^Ul\)JAl3.Ll) ljLiou%v<L 

"^ U)oM (A.ldre'iv) LVtfrA v^Va kJ \ i V ^,C 



I lours 
M.D. 




'SPE<ilAL INFORMATION «n!y for Hospitals, Institirtllns. Translfnts, 
or Recent Residents, and persons dying anay fron home. 



}rnntfi'- 



/', 



T ''].-. AUOVK STATFI) I'H K SON M, !• \ R r irr I, A Ks \ K I" TKIK To \\\\\ 
i?KST OF MY KNoWI,i;i)t-.K \M) lililJllJ- 



^Informant \J . V LO Cujtt 



' X.Mn'^s 



Has 



v) crLdx^-v; oXx \X\ • . 



Former or 
Usual Residence 

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



HoH lonq at 
Place of Death ? 



Days 



n^Aci: 01 in KiAi, OK kkmovm. 



l,.A V I'. ' »r IS I K 1 .\ 1, 



I)\ri:of HiKiAi. or RKMOVAI, 

HvN^Lu ^ 190H 



rM)KRTAKi;R 



Has '^oicU^^<:LUClv 



IN. B. 



-hvery Item of inform»tlon should hi cnrefuify Rupplieci. A(tE Rhmild he Htntecl F.XACTLY. PHYSICIANS should 
state CAUSE OF DHATH In plain terms, that it may be properly classilflcd. The "Special Information'* for per- 
son* dyin^ away from home should be ftiven in every instance. 



It 




! i 



" 



:l I 



( ' 



H 



.:l 'I 



I 



T. 



ii' '1^- 1^ I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



r.„:n<] .if llc!ilHi'-r No. iK "^H^f^;-^. IS& P Co 



Registered JSTo, 



201 



Dale Filed, VJLu ^ -?^^H 

X^hwv^ JsJi^KMi Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanC>arC) ) 



,4 



® 



' 



No* 



PLACE OF DEATH: — County of L'CU>\;0 7vcu^x/eAACcCity 
(LoL-v'Vil' (lbcHMXvl:<xl St.; 



J (3T 
:itv ofC'/cuvu 



(3p 



Dist.; bet. and 



(IF DtATH odcURS *WAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR > ^ A 

DATK or' HI K Til A 

VfVxr % rlkX.. 

(Motith) (l)My) (Year) 




-VVyCU 




:U^./W-A«-CL \\) 



'SL'yy\.<XAJj 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



loiitli) 



t 

(Day) 



(Year) 



AC. K 



.W..1 y\ 



ears 



1 



Miiiitfis Dav: 



SINC. I,K, MAKUn:i). 
WIDOUKI) OK niVOKD-:!) 
(W'ritriti soci.-il <lt.-si>.' nation) 



lUKTUPI.ACK 
(Siatf or Co\intrv) 







WMK or 
kathi:r 



"IKTHPl.ACK 

<^I' l-ATHKR 

• State or Comitry) 




tcJvci 




HHRHBV ClvRTIFV, Tliat I attended (lercaseil from 
^yJL. ^X 190H to VJLc 1. 



to >VVLA^ li igoH 

that f last saw h X>v» alive on Ha^wLu. 1, 190 H 

and that <U'.'ttli occurred, on the date stated above, at b 
tL M. The CAl'SrC OF J)i: ATI! was as follows: 

JvwUJ:v<^Ar^ J.'Jt1,^r«^'V. 




MAIDKN NAME 
<)I" MOTHKR 



HTRTHI'I.ACK 
<»l' MOTIIHR 
(Stall' or CojiiUrv) 



ClxVwvcx^vciL, 




Dr RATION }\'ars ^Months \ L Days Hours 
CONTRIIU'TORV 



DURATION 
(SIGNED ) 







occrpATioN 7r\P \ K 

Rf^-uifif ill S>ni /'i iDhisro I i )'i'ii i s 



M.nith^ 



/',/' 



,t 



iWLCi L T()n 'I 



^ 



}'t'(7rs Months Days 

(Addresv^) l5'(^3>C'/ac\-<XA>viL.>\to Ot 



-^. 



Hours 
M.D. 



^Pe6iAL Information only for Hospitals, InsfituHons, Transients, 
or Recent Residents, and persons dying away froni liome. 

Former or , 

Usual Residence > 

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



^ U /O^vcU.v^rtxtit'v piar e of Death ? I L 



Days 



I'm-; AHOVK ST ATI*, I) PKRSONAL )'A K lUr 1,AKS \K V. PR IK T« ) Til K 
HKST OK \n- KNO\VI,i:i)(,K AM) lUlMKF 



IiiforniatU 



\.Mi 







I 



90H 



'•I.^CK Ol- lURIAI. OR Kl-MnVAI, I I)\n;,,! Miui.xi. nr RKMOVAI, 

1131 OryVv-M^-<r^v ^t 



rNI)p:RTAKi;R 



I Atl.lo ss 



IN. B.- 



-F.very item of informntSon shoiiltl hi cnreV'ully Kupplied. AGE shoul.I be Htnteil HXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In xtWxn terms, that it may be properly classified. The "Special Information" for per- 
sons dyin^ away from home should be ^ivcn in every instance. 



I '' 






it 



I 






:i * 



f^ 



I' 



fit . 



i. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ho.n.1 of III iilHi r No. In :t*r«2~V. IKSc 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




IfJO'i 

Deputy Hearth Officer 



Begistered J\'*o. 



202 



f. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( "U. S. Stan^ar? ) 






No. 



PLACE 



J ^ IT 

OF DEATH; — County ofOo^^Tu ).Vcv\vCv^toCity of C' £t vu X^a/^xt^^^o 




n 



a: 




CrLvKX^w<:L and vJ CtLm-^-vv; 



(■ 



0Lv,^.^L4v^Vn\JL' St.; 6 Dist.;bct. 

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



" ) 



FULL NAME 



'.JUr\.'aA 




X/.>V. 



PERSONAL AND STATISTICAL PARTICULARS 



SIC.X 



\)\['v. or lUKTii 



v)UcJL^ 



COI,OR 



loJLic 



MEDICAL CERTIFICATE OF DEATH 



I).\TK OF DK.VTII 



\C.\f. 




MontlO 



30 

(Day) 



(Vear) 






\\ IV,;/.v O 



.1A 



onths..^. 



Pa vs 



SINC.I.Iv MARKIKl). 

\vn)o\yi;n or nrvoRrKi) 

'Writfin sikmuI (U'sij-rnalion) 



lURTm'I.ACK 

(State or Cnniilrv^ 



N.XMl-: OI- 
FATHl-.R 






^Moiilh 



5} 



(Day) 



(Year) 



Y 



I ni'RI'lHV ClvRTll'V, Tliat I attendtMl dcct-ascMl from 
N->VjL I I90H to_ 'prA^^ \ T90 S 



that I last saw li •<)^^ vxalive uii HvaXul ^ T90 S 
and that death occurred, on the (htto staled above, at 1 
LIm. The CATSl-: ()!• DIvATH was as follows: 

yYt\wt>va.L UAjUYv.vv<ivLtxlvt->A 





niRTHn.ACK 
ni- l-ATHKR 

(Stale or Country) 



MAIHKN NAMK 

OF MormiR 



HiRrmM.Aci-; 
oj- Morm-'.R 

(State or Countrv) 







DURATION 3 Yt-ars "^ Mouths ^ Days ^ Hours 



*r>:-v. 



OCCITATION r^ p j] 



I 



'^AJ 




DURATION 3 Years ' Mouths ' Days ' Hours 

(Signed) . w>v>^ Xolcv-o^-*^ m.d. 

^ iqoH (.x.idrcss) I5 3.^V.; \ry\'^^^^r>\ ot 




FECIAL Information «nly for Hospitals, Instiluiions, Transients, 
or Recent Residents, and persons d>inq away froii home. 



Rr\i(frit ill Situ /'i niiiism 



cell -VVVO J-V^t^ 



TH1-: AHOVH SI'A ri-.l) I'KRSONAl. 1' A R I'lT F I,A R S .\ R l". TRFK To THH 

BHST oi- MY kno\vm:i)c.k AND ni:i.iF:F 



(I 



nfoTinant ^>JJ ' V^ VcL^CLt.'v X_ 



C^-'V W > X 



( \.l.lrr>.s 



\-^ (?ccl 



'■>-^kjL^. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'l.ACK 01-" HFRIAI. (»K lOiMoWM, 



D.K'n: ■'!" jM uiAi. 01 ri:mo\ai. 



fndkrtakfr'^mV 3 a<iUU>A. N^*^ ^i^ \il^\+H '^vC '^I s . , 
(A.l.lit^s nil M /AA,^;,<Lv-CrvA 



^JyrtA*^^ 



'^' **• r-^very Item olf informiitlnn hHouIcI b.- cnrefully Hupplied. ACIK shniilcl be Htntetl BXACTLY. PHYSICIAIN8 Rhould 

state CAUSE OF DHATH In pinin teririH. thnt it mjiy be properly classified. The "Special Information'* fop per- 
sons dyin^ away from home hHouM be given in o\9ry instance. 



i 



I 



■|i 






i I 



'f 






: 






IHi 



I,: 

I? 



> « 



It 



i . ", ij 



,* 






li 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i;..;,,.| ..f II, Mllll-l- Ni>. 1=. »'?!S^- "'*"' "■■" 



REFER TO BACK OF CERTfFICATE FOR INSTRUCTIONS 



dcfc-ux^ ^O^wu Deputy Heaffh Officer 



Re^infered Xo. 



203 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( in. S. StanDarD ) 
PLACE OF DEATH: — County ofCJa^v ^' ^^^^vCcA.tt<) City ofOa/vu X<Wv.ca.4.>cO 



N?. C 




.k\xj^ _ ^ 

/ IF DEATH OCCUBSIAWAV 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 




\ 



(SAHuval'. 



St 



Dist.; bet* and 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



CL^vwX^i^. oJixxtsJs 




si:\ 



DA'i'i-: OF itiK rn 



vY^oi. 



COLOR 



U)JvCU 






I 



ACH 



) ra I s 





(Day) 




(Ve-ar) 


'»>- 


Motil/is 


3 


Days 




^iNc.i.iv M.\Ki<n:i). 

w ii)f>\vi-:i) OK nivoKTHn 

(W'ritfin soiial iU-».i<.'tiati<)n) 



^"W 



niKTMlM.ACR 
(State or Cotmiry)) 



NAMK Ol 
J'ATIIl'.K 



(( 







MEDICAL CERTIFICATE OF DEATH 



DATK OI<- DHATH 



[Month)/!* 



1. 

Day) 



(Year) 



I HBRBIJV CI'RTII'V, That I attendetl (Iccoased from 

Lt-rvX- ao 190 H to . VaXcl.^.H 190 H 



alive on NU-A^Lul. 1 



tliat I last saw h 'V.vw alive on "^^^-vU-y '1 ic^oH 

an<l that death occurred, on the date 'Stated above, at " oO 
M. The CAl'Sfv OI-^ Dl-iATIl was as follows: 



BTRTIIPI.ACK M 
oi- lAlUKK U 



.\J 



.Stateor country) A J (X^ () MO f 



MATHKN VAMK 
Ol' MOTMHR 



^ HIKTHPI.ACK 
' Ol" MOTHKK 
Slatf or Coiiiitrv^ 



C^/CLou V^ JVvAvccuvcL 



DURATION 
CONTRIIU'TORV 



)'i'ars 



Mont/is i k Days 



Hours 



'^ 



OCCUPATION -^^^^^^ (& 



IcU^ lAxc^vlKtt L 



^\ 



C»-v 



^Vsi(fr(f ill Siiii /'i(!>i, 



t 



% 



)'r,r 



/XiU^ 



.yr»ith< -- /)'.■' 



DT RATION )'rars Mont /is /\iys 

(SIGNED) \nl. VIj AlUit\; 

Xul i.,oH (A.ldres.) 5Hb Xn^^VK M 



/fours 

M.D. 



,vu 



I 



_iPECrAL Information only for Hospitals, Institutions, Transients, 
or Rfcent Residents, and persons dying a\\ay from home. 



THl. \KOVH STATia) I'KKsONAI, »'A K I" HT I,A K S A KH TR I" H To TUl-: 
IIKST Ol- MY KN<)\Vl,i:i)C,K AM) lU-.l.Ii:!-* 



'Infonnant 




r\.Mt. 






'V>^\. 



Former or ^ , .-, VA J J . M K '^"** '""1 ^* ^ P 

Usual Residence o II 0(rUU/YV y)0\l Plare of Death? oM\Q. 

Whrtuy^as disease fontrarted, -M.ij. ^\ "f- (1 

If not at Dlare of death ? ^ 1 1 KAJi^w /a>U V^ ^--^ 



Days 



I'l.ACH Ol- nrKIAI.OR RHNtoVAI, I DATICof lltHiAi- or RHMOVAI, 



I »-. or in H 

_.^^ \^ 

•ni)1-:rtaki-:r \A.CLV<X W^CKA^^vv ^^ v 



s n'^aq xj ol<U->v "X) ^U Cl>,^^ 



N. B. Rvery Item oif information Hhoiiltl be ciirefully supplied. AHB bHoviIiI be stated F.XACTLY. PHY8ICIAIN8 nbould 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par- 
sons dyin^ away from home Nhotiltl be (^iven in every instance. 




W 



' 1 ] 



li 



!* 



I 






w 



\ 



V 



! 



liMl, 



I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n.l .,f lIralth-1' No. i-^ '^'l'~-^'H&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Drf/r FiJe<l , 




Re^isicrcd J\^o. 



204 



q 7,9C4 

IvvwA It'vvu •^'^r-ty Health Omner 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticate of 2)eatb 

( tl. S. StauDavD ) 

J,CVW J A.0L/>VCAA.OCi City of 0<€L'>V J.\^>VC^Aeo 



^Nw 



PLACE OF DEATH; — County ofl 

\] I U) at) • W^slW^ Vi Ul4^v iu,/-mj . St.; 

/ I F P "ATH OCCU 



Dist.; bet. and" 



/ IF ptATH OcfcuRS AWa'y 'fro! USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL 1 N FO R M ATIO N •• \ 
V iYdEATH OCCURRED IN aJhOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

J, 



FULL NAME 




JAX^OL 




^.\XX/TU 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 



o Jb'V\^oJuL 



COI,OR 



LLVwIjl 



DA ri-; OF lilRTH 



<?^^ 



I Month) 



(Day) 



(Year) 



AC.K 



) I'd I . 



S.IN'<n,K. MARKIKI). 

\\ii)()\vi-:i) OR i)[\'oMri-:r) 

'N\rittin social dtsiv^iiatioii) 



niRTHPl.ACK 
(Statf or Country) 



NAMl" Oi- 
l-ATM 1;R 




7^ M,»,llis A) 



Pa vs 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

KMonthyi (Day) 



I9o\ 

(Year) 



I III"R1{BV CIvRTIFV, Tliat I attcMnkil deixased from 

^^ -^ ^Xhi ""3 

that I last saw h ^^A/ alive on 1 CHv \JVVUJL T90I 

and that death occurred, on the dale stated above, at 
.^.M._ TheCAl'SI-: 01' DICATH was as follows: 



1 



(^mXcv-v- 



^'Cu'VA'W'^A 



M. 



RIRTHPT.ACE 
Ol" lATIIEU 

• State or Country) 



MAIDEN XAME 
Ol- MOTHER 



HI R Til PI. ACE 
Ol- MOTHER 

(Stalf or Countrv) 



*i 



M 



DERATION "^ Years 3L Mouths ^ Days " Hours 
CONTRim'TORV CT'/Vc-tX.OfA-AiA.^tnrv 



OCCUPATION 



h'^^idfii III SdV /'l il III /'''(> 



) '>•(! I '■ 



}f,>llths 



n,i\ 



Tin-: amovp: statid pkrsonm, rxRricri.ARs ari-; trie to riii-: 
in-:sr oi-' MY i-vNo\vi,i;i)i".E and hkijef 



'Infonnant 



r^drlress 



Vmt oi. vk)-?Lt^v^ ll^uXut 



>\v 



Ur RATION -^ Years ^ ^font/lS % /hivs ^ Hours 

(Signed) UXi^x<l nDI^ ^uxvvaAvL^x M.D. 

1 Tc,oH (A.ldress) \J\.IK V< \ltll. (l\Nti 




FECIAL Information onlv for Hospitals, Institutions, Transifnts, 
or Recent Residents, and persons dying away from fioine. 



Former or 
Usual Residence 

Wfien \\as disease confrarted, 
If not at plare of death ? 



HoH lonq at 
Plate of Death ? 



Days 



I'l.ACE OI-" lURIAI. OK R1-;MoVAI, 



DAIE..!' Ill Ki.Ai. or R1-:MoVAI, 

ICi 190H 



r N D 1-: R T A K 1-: r u v <X cvO- vv ^^ ^A-'^-^^'M^ 

(Ad.lit ss ^b1 ^ ^ l^ KJ^^ u.^ 




IS. B. Rvepy item of Information shoulil be cnrefully supplied. ACIR should he stilted liXACTLY. PHYSICIANS should 

state CAUSE OF DF.ATH in pliiin terms, thnt it miiy he properly clnssified. The "Special InformHtion" for pur- 
son* dyin^ away from home should be dt'ven in every instance. 



I 



f 









\h 









t I. 

i \ 






Pi 



E <' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Honr.l of !Iea1th-F No. i> 1^*S§S^ H&l' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I ' 



Registered J\^o, 



205 



i)„h' Fih'ii, vjLu q I'-^O'i 

DEPARTMENT cfr PUBLIC HEALTH=City and County of San Francisco 



Ccitificate of Death 

{ "d. S. 5tanC»arC> ) 






PLACE OF DEATH: — County of Oo^^ JVcx/^evXLi^oCity of HxX^ J.Va/>v/CA^^o 
( ^fe. wtu, ^ Ww^-y^dL ' ^ 't '^^\ ;ft i> ,A^\X4.LSt-? — . Dist.: bet . ■ ' ~~ and 

h f \r DEATH OCCUI 
\J V, IF DEATH OC< 



R/k AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N " \ 
cURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



^ 



FULL NAME 




Ka' 



Osjj^\\K'y\A. 



PERSONAL AND STATISTICAL PARTICULARS 



DAll-: OF niRTH .^ 

( Month >/] 



COI.OR 



bJlctt 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DICATH 






^1 

(Day) 



r\X\ 

(Year) 



ACK 



15^ y..us 10 



M.nilhs 



Da VA 



Srvr.T.K. MARKIKI), 
WHXiWHI) OR DIVOkCHI) 
(Write ill social (lcsi"iiation) 



HIKTin'I.ACK 
(State or Conntrv) 



NAMK OI- 
FATMl'.R 






vX Vuk^ > VtrvO^ \j 



RTRTHPI.ACK 
<ll" I-AIMFR 

(Statf or i.'t)initrv) 



5- 

(Day) 



(Year) 



I in-iKI'iHN' CI-kTII'V, That I attcn<lctl ilcccased from 

Nkv>x> IH 190 M to . Ai-vX\A. S i()o M 

that I last saw h XV alive on HvOLx^ H T90 H 

and that (Uath occnrred, on the date stated above, at \ O o 
CL M. The CAl'SI^ ^)V DI-ATH was as follows: 



DIRATION •► Years S^ Months '^\ Days ' //ours 
CONTRIIK'TORY —.... 



1)1" RATION 



//(>i/rs 



MAIDKN NAMK 
Ol- MOTHKR 



hirtiii'laof: 
oi" MoTm-:R 

(State or Coiiiitrv* 



M 



M 



OCCUPATION 



% 



It 

31 r.,, 



A'r^/ifrii III Sdti /'i II ii( i^i'ii Cf 



\l..,iili' 



Dii\- 



'\\\V. AHOVK srA'Pi:!) I'KRSONAI, I' \ K !' U" T I, A R S \ K l'! T K T l-! To TUl-: 

iJF:sr OF MY knowij:i)*. 1-; and iu:i,ii:i" 



fit 



.Aw^tC 



N. B.. 






Years Mont lis /hiys 

(Signed) tU \j . L^^^OLtx^ru M.D. 




or hIs 



lAL Information nnU tor Haspltdls, institutions, IrAnslents, 
or Recent Residents, and persons dyinq ciH.iy tro:n liome. 



Former or 
Usual Residence 



LULyvv.^^ 



Hovv lonq at 
\At^-\^^X, Pidf e ol Death ? 



Days 



When was disease contracted, 
If not at plat e of death ? 



I'LACE OF niRIAI. OR KFMo\ \l, 



k 



XJ^^t\^ 



n 



\)JUL 



l»\li:o! MtKiAf, or RKMOVAI, 



rNI)i;RIAKl-.R 

(Ada rev V 






■ voc 



U. i^ -•■Z1I90H 



TA'-' ^JL^ 



-Bvery Item o* InfopitiHtJon iihould be cnrufully supplied. AGE Hhould he stnted RXACTLY. PHYSICIANS should 
stBte CAUSE OF DKATH In plnin terms, that it mjiy he properly claHsit'ied. The "Special Information" for p«r- 
nons dyini^ away from hnmu should he f^iven in every Instance. 



\ 



\ ' 



^ 




Ki 




n 



i > 



w 



It ' I 



'■ n 



WRITE PLAINLY WITH UNFADING INK 



>;oar,l .,f Health-K No. 15 *'^:^«?,^ "S^^ Co 



— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 




m 



, 



ffilj 




190H 



Registered J^''o. 



1^ *t 



riiilr Filed , 

DEPARTMENT 01^ PUBLIC IIEALTH-=City and County of San Francisco 

Certificate of 2)eatb 

{ Ta. S. StanC»arD ) 
PLACE OF DEATH: — County ofC /0U>^ Z >\SX^y\JlKAJ^ City of U^>v J AXV^o/OUiet) 

iVob lU^A^rvv St.; ^ Dist.;bet. V^C^O^V^VCL and "cWo^vavCL ) 

/ .r Dr*TH OCCURS AW*y from USUAL RESIDENCE G.VE tacts CAULto ;oR ^'N^R „%"^;*;; '^"°"*;*!'°''' ) fl 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBCR. J 

LL^^x<x/>v<Lo^ M IL. .d/c.^ljLa> 



^No. 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^ 



i).\ ri-: or" iuktm 






coi.ok 



UJiv^bi 



oxAr 



AC.H 



"iH 



M<intlJ> 



J ■»•(/ ; > 



(Day) 



(Vcar) 



MEDICAL CERTIFICATE OF DEATH 



DATK t)l" DlvATH 




a 

(Day) 



I9o\ 
(Year) 



MmiHis 



Pa vs 



STXni.F. MARKTKn. 
\VII)<)\\i:i) OK DIVOKI'KD ■* 
(Write in social iUsij.'nation) 1 



nTRTHPT^ACK 

(Slate or t'ounlrv) 



NAMH OF 

fathi:k 



RTRTHPl.ArK 
oi- lATUHR 
(State or Country) 



MAIDKN NAMH 
OF MOTHKR 



niRTlIPLACK 

oi- mothi<:r 

(State or Country) 



(], 



LaJ .VcL<rvv>-^cL 











^^^s-'^^\n^ 



I IiI';Ri:BV C1:RTIFV, That I atteiKk'd deceased from 

Ii^mJL l.At 190H to ^|a«JLu...'1 190 M 

that T last saw h XK) alive 011 HvsJUa. 1 190 S 

and that death occurred, on the <late stated above, at '^ 
(j, M. The CArSIC OF I)I<:AT1I was as follows: 



i4i 









!.A,<Xa«>.V 



DT RATION •" )'rars I Months -^ Days ' Hours 

CONTRIHUTORY 



DTRATION 
(SIGNED) 



Yeats 



Months 



Pays 



Hours 
M.D. 



u 



I « 



/),/! 



OCCrPATION .^ •► •► 

Krsidni in Sun /;,/»;, /.w-» O ) > ./' - Mmilh:- 

tiif: arovk staiki) pkr^^onai, pARiicii.AKs AKi". iKri: 10 rm-: 

IU:ST Ol' MV KNOWl.i;i)C.K AND HIll.UvF 



(Informant CLLa>1XA^cU^J ^JV/CrW> 



'j\OXCtXVV c>wC3UXiX/vyj 

Hv^lul T()oM (Address) Ib^b Ob CrV<^^V<l O t 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



. Days 



PI.ACF: OI" in RIAL OR RKMoVAI, I DA I'H of Hi lUAi. or RFMOVAI, 




V\^ 



I90H 



rNl)F:RTAKi:R 






(IvDaJuijtdL '^\L U 




IN. B. F.very Item of InJormntion should be cnrefully Huppllecl. AGB should he ntnted RXACTLY. PHYSICIANS nhould 

state CAUSE OF DEATH In pinin terms, that it may be properly classified. The "Special ln?opmntion" for per- 
sons dyinft away from home should be ftiven in every Instance. 



.1 



l« 



l\ 



\ i 



ill 



M' 



pi* 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

207 









lUOH 

Deputy Health Officer 



Rc^istej'cd J\^o, 



•» . 




■: ,!■• 






K'k 



B I" 



i: ISi. 






m P 



[It J 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( tl. S. StanC>avC> ) 



PLACE OF DEATH: — County ofOtX^ 0;v<X^\CUC: City of 



No. 



lo^l oXlaXtpu 



St.; ^ Dist; bet. 



i.c^iiAi Dce I Pir wr r r lup tacts called rOR/UNDER "SPECIAL INFORMATION" \ 
/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE "^ACTS CALLtO ""(r STREET AND NUMBER. ) 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. • 




and vJI^YuXxUJ 



) 



FULL NAME 




XhJ^. 



PERSONAL AND STATISTICAL PARTICULARS 



SlvX 



OTOoJU 



C01/)R 



iDJLtt 



\y\TV. or lURTII 



Ar.K 




(Monlhl 



loH .■,.,„.. 1 



(Dav) 



Mnulhs 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE Ol' DllAlli 



iMonlh) 




(Day) 



vpoH 

(Year) 



a^ 



/)(M. 



STXr.I.K. MARKTKn. 
\VII)<>\Vi:i) OK niVnKCKD 

iWiiteiii social (U"»i<-':nat ion) 



niRTHPT.ACK 

'Slatf or Country^ 



NAMH OF 
I-ATHKR 






d/oiA^ 



niUTTin.ACK 
Ol lArilHR 
(State <^r Cotmtrv) 



\j I UX^NXIOlMA) 
\1 I UXaan^L _ 



XxVO\^ 



MAinitN NAMK 

or M()T!n;k 



IMRTHPI.ACE 

oi MoTm:R 

(state or Country) 




tov. 



Ki-sidr,! ni S,ni /■utiui.-rn ?^ )''-.m < -^ yr<i,lh^ 



na\ 



THK AllOVK STATi:i) l'KRS(^NAI, rAKTUT T.AKS ARK TRIK To TH1-: 
IlKST Of MY KNt)\Vl.i:nC.K AM) in-.I.Ii:!' 



(Informant 



' \(l<lriss 






I ni:Ri:HV CI:RTI1<V, That I attciKUMl <lcocasc(l from 

Q^\ouulD 190 Q» to. HAAJui. Jl u/D S 

that I last saw h .<^^ahvc on T'*^-^^ * 190 T 

and that death occurred, on the «late statetl above, at 1 r I 
„ij. M. The CAUSI*: iJV DHATII was as follows: 



i-\j 



DIRATION *^ Yrars 
CONTRIIUTORY 



Months 



Days 



Hours 



)'i'ijrs 



Mo?iths 



DIRATION 
( SIGNED ) 

R l«,o'{ (.\.l<lre<s) lo 10 



Days 







Hours 
M.D. 



^ 



_ FECIAL INFORMATION only for Hospitals, Institutions, Trdnsients, 
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 uf Death ? 



Days 



T90 



1M,\CH Ol- lUKIAI, (»K KKMoVAl. I DXTlvof m Ki.Al. or KKMoVAI, 
UNDKRTAKHR O^ oXaXju6^^\^\^ 



f.\(MrfSs 



N. B. F.very Item of inf irmHtion •houlcl be CHre?ully supplJecl. AGE should bo «tntecl F.XACTLY. PHYSICIANS nhould 

state CAUSE OF DEATH in pltiln terms, thnt It miiy be properly classified. The "Special Informatian" for per- 
sons dyin^ awny from home should be ftiven in every instance. 






t 



^1 



.1 



ilM 



M! 



■I 



'\\ 



\m 



Ji;;: 



' ♦ 



,i) 



In ' 



i^H" 



im^ 



'i 



i: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

308 



,.,,,,,,1 ,,f ll,;,llll-l- N'o. .^ i-lTSS'"''^'' ^" 



Registered JVo. 



Dale FiU'il, Wc. S ^^^S 

l^ucv^ ioyv^ Deputy Health Officer 

DEPARTMENT # PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of H)eatb 

( •a. S. StanDarD ) 



\ ^ 



PLACE OF DEATH: — County ofCJ/CWu JAa^xCUCo City of O/OAo; vj;uX/\^e^^t.<) 



No i3lVlaiVt.av^,u ..ViLa\ir St.; \ Dist.;bct. U^/VUL^<rru and UA.0^'>^.- 

^ ir otATH occuJfe AW.v TROM USUAL RESIDENCE o.VE tacts CAL.eo ;oj, 70ER j;^%^;*iJJ'^°;;;*j;°'^- ) 
V IF DtATH OcdiRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 



\IllxXA.^O...U 



XK.Ui^. 



si-:.\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



I) \\v. or- lURTu Qr\ 



K 




vc 



b. 



'h^ 



I Month) 



(Dav) 



f -1 0...H, ., 

(Year) 



AC.H 



)V(M > 



>J Mntiths I...Q An. 



<I\<". 1,1:. MARKIV:I), 
\\II>()\Vl-:i) OK l>!Vi>Rri:i) 
• Writtiii sfK'ial (k-ii^ualion) 



^ 



^C^V^ 



niUTHPI.AOH 
'Slalf or Cimiitrv) 



NAMK OI- 
FATHKR 



mR'riiiM.Ac'K 

OI- lACHKR 
(St.'Uf or Country) 







LcLl) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



VIonth 




^ 190 H 

(Day) (Year) 



I HEREBY CI<:RTIFY, That I attended deceased from 

HAAXlJLb 190 "H to JwLu.S 190 S 

tliat T last saw h •-'>•' alive on >V^U^S T90 4 

and that death occurred, on the date stated above, at 
...Qu M. The CAi;Sl{ OF DIvATII was as follows: 

(Xa^A.tA O' 



'^VCW-\ 



V 



MAII)1:n NAM1-; 
OI- MOTHKR 



lURTHPLACK 
0|- MOTIIKR 
'Statt- or (.'ountrv) 



OCCTTATION — 




"WV<XC<X 



t< 



o t<xi^ 



Rmiiird ii> San /'i aniisiii " ^'rais O .^fi'nffi'' 1 U /'(n> 



IHi: AMO\K SPAri-.l) I'KRSONAl, 1' \ K I' lOf I, ARn A K l-. T R T H PO TMH 

iii:sT OI- MY KNowi.Knc.K AM) iu:mi:h 

J? 



Infonnant v 



^^■ 






DT' RAT ION }>ars *■■ Mopitfis ^ Days o Hours 
CONTRIBUTOR V ...S-^^>^^0>.\r^>r^!i^'ir>:^ 



DURATION Years Mouths 1 Days 

(SIGNED) 0- VA. CitoLW) 

^ T()oH fAd<lress) (j>5 1 U -a^Uljlvt^ Ot 



Hours 
M.D. 




^ 



_'PECrAL INFORMATION only 'or Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



HoH long at 

Place of Death? Days 



ri.ACKOl' lURIAI, OR KKMoVAl, 



INDICRTAKKR V 'CXAX-VnX^ V I V\ 



DAI'}; of IUkiai, or KKMOVAI, 




OXa^^vaa. 



(Address l.-^.^sH O.JLCr^JtLtfr>v Djt:. 



S^l. 



N. B. F.vepy Item of m9.>rmHtion should \m ciireVully supplied. AGE should be stnted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pluin terms, that it may be properly classified. The ''Special Information" for p«r- 
Aons dyin^ away from home should be i^iven in every instance. 



J ' ' 
t ! 



fi! ! 



I«! 



,. . \ 



' \ 



m 



\ 



I 



I 



Mi 




N'll 






WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



noar.l ..f Hralth-F No. ,, TS^^agK.S. l^S:!' ( o 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,Vi-VL^ 



|JL R ^^^H 

Ijbv-u Deputy Health Officer 



Registered J\^o. 



209 



/>r//r Filed, 

DEPARTMENT OI^PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)catb 

( tl. S. StanDarO ) 



J? * ^ ;i ^ 

PLACE OF DEATH:-County oiO^X^y^ jA^^^^CGty of O^^v ;va/>^x:AA OC 



^No. 




crvwX' -VCrV} Wvi- ^\Ci^t4. 



St 



Dist.; bet and 



(IF DEaHih occurs /4WAV FROM L 
IF MhTH OCCURRED IN AHO 



USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER '"SPECIAL I N FO R MATIO N " A 
aSPyTAL ?R INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 
SK.\ nr\ A I COI,OR 



IX/TUb. KJ-.-^JV^O^'^^- 



<3f I 

Xa'>^/Ol\X' 



DATI". or lUKTH 




(Month) 



.\<;k. 



I I ),\11S 



(I)ay^ 



Mntiths 



(Year) 



Ihi \s 



SINC. I.K. M.\KUn:i), 
\\II)<)\Vi:i) ()K DIXOKCKO 
(Wiitf in s(H'ial <k-sijfnation) 



JJ K,<Xy^yuoJL<^ 



niR'rm'UAOH 

(state- or Coiintrj'^ 



N.VMK OI- 
F.\Tin:R 



lURTHn.ACK 
OI' l-ATHHR 
(State or Couiitrv"! 



MAini'.N NAMI-: 
OI- MOTHKK 



HIK'niPKAClC 
OI'" MoTHlrR 
(Statr or I'omitrv) 



OCCT'PATION 








Q^jUL/Oc/"^^vxL 



h'rside,! in Satt Ii,ui.isro Js\ ''''"^ *" Months 



na\: 



r 1 1 1-: A HO V K ST \ r i-: i > r k u >-^o n a i , r a k r u- r i , a u s .\ k i: r u i ' K ri > r n k 
nKST OH MY KNo\vui-:i)r.i-; and iu-:mi-:k 



(I 






fXddrc.'^s . ' 






MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 





% 

(Day) 



(Year) 



IF':RlUiV CllRTIFV, That I attended deceased from 

190H to^ ^^InaL^.-.H 190 H 

190 H 



I 



thai I last saw h XNj alive on yA.lL H 
and that death occurred, on the <1ate stated above, at i^ 
(}. M. The CAUSK OF DHATIl was as follows: 



'Sw-<nMx\^. sJ ^ 



ry:\JLc^K<vv:^-^.'V.:vA.<aj. 



1)1' RATION ^ Years ^ Months ^ Days ^ Hours 
CONTRIIU'TORY 3.rt^>X\JU-tu 



Months 



niRATION 

(Signed) 

1) iqoH (Address) 11 3^ 



C"^(niJLLxK. 




Pays Hours 

M.D. 



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



Former or \ \ if%.,uhl fl "«^ •«"« «» ^,T' 

Usual Residence ^JOJKX^ ^^\KM U\\^piare of Death? iO..>Hv»..?... 

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



Days 



PI.ACK QK RIRTAU OR RKMOVAI, 





rNI)KRTAKl":R 

r\d<lrfss . 



"^Ln (V\v..,^, -X^ 



Kjir-^irKJSrW. 



^1 



IN. B. F.very Item of information •houltl \m cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plnin terms, that it may he properly classified. The "Special Information" for per- 
sons dyinft away from home should be ^iven In «very instance. 



!; 






\ •! 



i 



1 

i ' 

I 



III 



I, ,. 

-J 



" 

4 



I 



'.f 



i 



WRITE PLAINLY WITH UNFADING INK 



,„:m.! ,,f Her.lth-»-- No .^ 1^^^;^<ynlkV Co 



/)((/(' Filed y 




190"] 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

2 



Registered J^o, 



^10 



Deputy H^^?*-*- Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StanC»arJ> ) 



PLACE OF DEATH: — County 



of <0w^^ 



(s;^ 



a-^^ .VCt'vvcvAX^Oty of ^l/O^^^ vJ.^vCt'^^CA^C.o 






Wts VVU 



i 




'Lj m CHlku^al St; — Dist; bet. ; and 



( '^ rr"o;:T°H'lci%-V.;.''rHO^s^PrT'!;t rp'frlsn^JV'o'^o.ve .ts name ..stcao o. strc.t a.o number. ; 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



si:x 



<5I> 



COI, 



JX'WXOL^AJL LvUvvtx 



DATl-: or lUKTU 



AC.H 






b 

(Day) 



r =1,D H., 

(Year) 



) V'(f » .< 



.i/,„//A> S -/K\^ 



^/Vv^ 



iOWl: 



SlNf.l.l-:. MARUll'I). 

\\ IDnWKD OK DlXt »K*. l! l> 

t AVritf ill social (IcsiKHsition) 



lUKTHn.AOK 
State or v"oinUrv 



NAM1-: »)l 
FATIIKR 



lURTnri.ACH 

<1I' FATMKR 
iStatf or Country) 



MAIDKN NAMK 
OI- MOTHKR 



lURTHI'LACK 
<>!• MorilHR 
(State or Oovuitrv) 




OCCrpATION ^ ^ -^ 

Kfsiifrd in Sou fr iiinism -^ )r,}i.< " Mmilhs T.^... 



. 11,1 y 



riU*. A HOVE ST\'ri"I) PKRSONM. I'AK I'UMI. \ K > A K T, f K 1 !•: T' > 
HKST OK MY KNOWMIDCK AND lUU.IHK 



r 1 1 }•: 



(111 forma lit 



U) VHI X<XVArUrVi 



f Afldrcss 




XlU IbM-Uvlal 






MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATll 




hlontlO 



(Day) 



f9o\ 

(Year) 




IRREBY CI':RTII'V, That I alUMukMl <leccasc«l from 

b. « 190H UK \y^^ 190 H 

5^ -^ v«^ 



111 at I la St 'saw li-Uv alive oil 



l^"" 'f\ 

and that (loath occurred, on the «late stated above, at I I I Cj 
G.- M. The CATSIC OK D I! AT 1 1 was as follows: 



DT RATION ' )'rars 
CONTRIIUTORV <-!*> 



' Mouths ^ Days 6 Hours 

CYy\J'>r\^:y.^^>X^>,^J\JL...^J^ 



Dl' RATION 
(SIGNED) 



^ Years •- Jfon(/is 



► Days "^ Hours 
M.D. 



qo 



3 Ak- %<v\t 

(Address) UXu'^U. Jo 




C^ 



^PEC'lAL INFORMATION only for Hyspitals, Institutions, Transients, 
or Recent Residents, and persons dying away from liome. 



Former or 
Usual Residence 

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



How long at 
Place of Deatli ? 



Days 



PLACH OK nVRIAL OR RKMoVAl. 



DXn.o! HiHiAi, or RKMOVAI, 

'jioia- \^tk mt 



^\(Mrc»?«« 



!N. B. 



— F.very Item cW Information .houlcl h. cnrcfully supplied. AGF. «hould be stated EXACTLY PHYSICIANS nhould 
state CAUSE OF DEATH !n plain terms, that it miiy be properly classhlod. The Special Information kor p«r- 



-Fvery it 
state C. 
«on» dylnft away from home should be ftiven in ev^ry Instance. 






: 



I h 




mm 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



liblii 1 



/hf/r Iu/r(/,.%sA^ S 



REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\^o, 



211 



10 ()\ 

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



Certificate of 2)eatb 



( ■a. S. StanOatD ) 



A % 



PLACE OF DEATH: — County of '-^ CV^ 

I>o. , -1 OA^>vcLLi^\^oa U^^4.civc\. ^ \ \. St.; 



I XOL'-kVCA^..c.(. City of CJ^O/^-u AXX->v/aA.;x- c 



Dist.; bet.-: and 



/T Ac. .A. oreinrisirr nvE FACTS CALLED roR UNDER -SPECIAL INFOHMATIO 

( '^ .VD;A.°H"oCC^%*ir ."rni^yT'it o^'?:s^^'"T^O^"al;E7Tl name .NSTEAD of STREET AND NUMBER. 



N.) 



FULL NAME 







^OL^^'^ULvu ULcvHXaI).. 



PERSONAL AND STATISTICAL PARTICULARS 



si;.\ 




ICL 



L 



cni.oR 




VAJL 



i)\T»: or iiikTn 



\(.H 






(Day) 



) ■/•(? » 



MnUl/li. 



(Year) 



3^^ />(/.v.v 



UlUnWlI) (»K DIVoKri-'.n 
(Wtitr in <s<MMal (U-sivrnation) 



lUKTHri^AOK 
(Slatf or Country^ 



NAMK <)!• 
FATHICR 



HlKTni'I.ACH 
Ol" lAPIlKK 
(Statf or Countrv) 



ll^vl 



.OVO/ 



L 



I'^vtrcu^v 



mah)i:n namk 
oi- nh)thkr 



niRTHlM.ACK 

<»i- Mt>Tin':R 

'Sl.'ilc or (."oiinlrv^ 



w 



tl 



M 



«« 




oCCri'ATTON - •^ " 

Rfsiiinf ht Sit'i /'nun ism *" )tuif. 



1 yrnnths ^ S 



/J.Jl.- 



rni-, AHovi: srx ii-d i-kkson m. r\K iiici.aks .\kv. TRn: ro rm-: 
iu;sr ()!•• MY KN<>\vij;i)<'. 1-; and in-',i,n:J" 



'Infoiiuaiit 



Cr^\ ^. Cnvcvv^L JUL 



f A.l.lrcss OsO C) 



aAX^VA vtr Vt ox 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DHATH 




(Day) 



(Year) 



I mvRlUJV CI';RTIFV, That r attended (k'ccascd from 

Hw^VJt IX 190*1 to W 5". igoH 

that I last saw h ^V>Yvalive on ^^-^ ^ '*§ '^ 

atitl that death occurred, on the date stated above, at C> 
CI. M The CATSH OI-'' DIvATII was as follows: 



VOLVdlAxC^ C>A\.xO^^-^^iXA.<-»'V/tU^ 



nr R A r I( ) N ^ > ><''-? " Mouths "" Pays \ JJ/oiirs 

vl T\/Oj!L^A.A.AX^^XMr»A 



CONTRIIU'TORV 



DT'RATION ^ )'rars I Months "" /hiys "^ Hours 

(SIGNED) Qf)\-<^ CWUx'V^LcJj. M.D. 

^ b iqoN (A .Mress) as i^Wv^tOt 




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



former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



I'UACK OF nrRIAI. OK KHMoV AI, 
I NDICRTAKKR 




(AiMi.ss 






N. B.— F.very Item of i,i?ormHt1«n •houlcl b. o.refully supplied. AGB should be «tnted EXACTLY PHY8ICIAIN8 should 
state CAUSE OF DEATH Jn pli.tn terms, that it may be properly classified. The Special information for per- 
sons dyinil away from home should be (^iven in every instance. 




w 



X 




H' 




Mj 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Tv.fini .'f n 



(MUh-KNo. ,^ t-f^^?"^'"'^''^"" 



r, 



P 



Ul 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Resist ered JVo. ^1^ 



Ut Jl^K. D«p"ty '^^^'^'^ o'""'' 
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



No. 



Ccvtificate of 2)eatb 

( XX. S. Stan&ar& ) 
PLACE OF DEATH: -County ofO,C^^%. J^vO^vC^i^Gty ofOOAv jA^>vev^ 
lo-^l Qf\nla'V>-^<V St.; H Dist.;bct. llfv and ^ t!^ 

too 1 \J UJwV<ri>^\.V ,,.,,.. besTdENCE GIVE ..CTSCAtLED roR UNDIP "5PCCI.L .Nr0HM.T10N"-\ 



c t 



! 



H' I 



I 



4^ 



FULL NAME 




OJ 



PERSONAL AND STATISTICAL PARTICULARS 

7 1 

(Day) 



vj 



DATl-: or lURTH 






(Monlli) 



. I H S .. 

(Vf:»r) 



ACK 



5^ b }>,;» 



1 



Moiilfis 



7 



/^(D.^ 



\\II>t>\Vi:i) OK I)!\oKrKl> 
(Writf in stK-itil (U«*ivi!;ili<>n) 



r.iK rupi.Ai^K 

' Stiitf or Country^ 



FATHKR 






IUKTHI'1,\CK 

oi- iArni-:R 

I stall- or Coutilry"* 



MAini'.N NAM1-: 
OK MoTin-:K 



1 



^AX/LoL'\x^ 



\\ 







><XK\\, 



RIRTHPUACR 
o|- MOTHKR 
(StMtf or Country) 



i 



OCCrPATlON 



jciAxJLa 



M.iiith^ 



/'',!\ . 



TllH MIOVH STMin rKK>-;o\Al. rXKIKM I \Kv AKl', TRVH To IIH-, 
ni:ST Ol- MV KNOWM'.IX.K AND in.IJl'.l-' 



f 



nnforniaiit 







Ua.^ 




"VV. 



MEDICAL CERTIFICATE OF DEATH 

DATK OI" DKATH 




I 



H 

(M<^nth)f' 



I 

(Day) 



/go i 

(Year) 



IIlvRl'HV CI'RTIFV, That I atteii(U«l <U>coasc<l from 
Id iqoH to . VvIm,^ 190"^ 




that I^ast saw h -r^^^ alive oil Y*"^ " ^ ^'^ "^ 

mikI thai (Uath occurred, <ui the date stated ahove, at V l«^ 
Q. M. The CATSIC OV DlvATII was as follows: 

(?o^A4/v\/Jv^>)A>^^ Oxd^JvvJ:^ 

LJKV^.:<^5k':^-c^ 



DIRATION 1 )'rars * A/o>iths ^ Days * Hours 




Years 



Mofiths 



DIRATK^N 

(SIGNED) \ \mI J^T^JtJV 



Days 



Hours 




\ U)o4 ( 



M.D. 

Adilress) II (H i C^iv^AV, "3 A 



^PEcFaL Information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons d>inq anay Iron liome. 

Former or , ^ ^ (V i ;f^ "®^ '**"*' ^* ., £ ^-^ .^ 

Usual Residence ^^^ Mlat<rNv%'C3c C't place of Deatli? JCi.O:>:vtK.. Wis 

Wlien was disease contracted. 

If not at place of death ? 



ri.ACH 1)1- lURIAI. OK KKM«>VAI. 



T90H 



DXTi: oi \\\ KiAi, or RKMOVAI. 

tV^^^V^'" 

ini,i:rtakhr H O. ^ fr-^JL^ 

y SOS M>i(nv"UM IUk. 



r\<Mii-ss 



in 



N. B. 



«.« 



iverv Item oV In.'ormntion nhouU. b. cnretfully supplied. AGF. «Sou1d be stated EXACTLY PHYSICIANS should 
tate CAUSt OP DEATH in plain terms, that it may be properly classified. The Special Information for per- 
son* dyinU away from home Hhcuilil be ftiven in every instance. 



-Fi 

8 




! J 



!- 



. ! 




i , 



w 



\ 



)■ T 




WRITE PLAINLY WITH UNFADING INK-THIS \S A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Of r> 

Dale Fil('<l, VXmS 



„„Mnl ..f Ih :.lth-F No. i> "*>^^W^^;) HS:l' Co 




lijQ^ Jicgistcrea j\(), 

<^(.vv^ ksL^^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiticatc of 2)eatb 

( H. S. StanC>nrD } 



^ 



0/CXy>\)OA<X'>v<^oi.cc^ City of Oo.^ 0.>vO.^cvxl co 



No. 



PLACE OF DEATH: — County of 

'\\h VA■^^^'^^^i^c.<cxl' St.; '^- Dist.; bet. ^ ^^WtvaX 

^CiO V^^AV'^^^tVC.V-CL^' resTdenCEg.ve tacts called tor urJoER 'specal in format.on- \ 

( '^ .Vo;ATH"o^:u%rE;\N"A':OS^pVT'iL rR"r:ST'.?u"o^/o.VE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



and 




V■^\M 



FULL NAME 







PERSONAL AND STATISTICAL PARTICULARS 

COl.oR 





DAIi: Ol- HIK I'll .-jv y 

.M..iith» (Day) 



lol^u 



/Us 

(Vear) 



AGE 



ab 



) 'ro > s 



Mnvths 



-14 



Da ti 



siNci.i--:. M.\Run-:i), 

WIDOWKI) OK niVOKCi:!) 
'Wiitfin social (lesij.'rnatioti) 



lURTinM.AOK 

St.Mtf or Country^ 



4 



^ 8 n 



NAMi' or 
FATin:R 



mRTHPl.AOK 
O!- lATMKR 



VjJLtjL\; J ;vc 






oi I A I MKR /-^ 

'Statf or Conntrv' ( \) 



yWUW.'S NAMK 



] 



vcLaakx>v^ 




a 



>V<L 



'-"-:^, ±,xi 



CVrwj 



IMKl-HPLACK 
•M NJiVruHR 
(State or Country^ 






occri'ATioN n\ , 



\f.'i<irif in Sati /'i iDh im'i) <A U ) -iM > 



^ri>if/r 



/>,i\ 



'I1I1-: \iu)VK srATi-.n i-krsonai. i-xk iicti-ars ari; rKii-. t»> iin-: 
HHST oi- MY KNovM-:i)r.K AND jn:i,n:i- 

'Iiif-Minant 



\l rVxWVVA^ A^O^V/^^it\) 



fA.1(ln->.s 



uJlIv^h 1.0.1; 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ^ j\ 



[Motith) (I 



(Day) 



(Year) 



r HKRICHV CI-RTII'^V, That I attendtMl tlcrtascd from 

: ■ -190 — -to *90 

til at I last saw h — alive on " ^9° 

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

rrrrr^.M. The CAl'SIC OV DI'^ATll was as follows: 




A.C (X'CA.^..U.fr^^-^<J'>^ 



Dr RATION )V<7/-.? 

CONTRIIU'TORV 



M out /is 



Days 



Hours 



DrRATION Years 



( SIGNED) L^«^^^'''^^^^•^^^^ 

\djj^ "I TQoS (Address) U^()^Vt^^ 01 |v..^X 

Special information only for Hospitals, Inslitutfons, Trail! 



Days 



Hours 
M.D. 



or Recent Residents, and persons dying nnay from lionie. 



Former or 
Dsual Residence 

Wlien Has disease tonti acted, 
If not at place of death? 



How long at 
Place of Death? 



Transients, 



. Days 



rU\CH Ol- lURIAI. OR RKMOVAl 





INDICRTAKKR 



DATi: ut" lu Ki.M. or rf;m<)vai, 

Vu . P . Q u 



N. B.— F.verv Item of Information ,hou»cl .,.- cnrcVuMy Huppliecl. AGR Hhoulc! be stated EXACTLY PHYSICIANS should 
state' CAUSE OF DEATH in plnin terms, that U may be properly classified. The "Special information for pT- 
sons dylnft away from home should be feiven in every instance. 




M 



' I 



\\ 




^ 



\n 



I 



p 



,;l 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I?..;inl nf H(;.-iU»r -»•■ No. i= '^'l^.'^'-JT^ H5;: P Co 



J! ^ 




10 OH 



liegistered jy*o. 



214 



cLm^vv/:) dsjc\>M Deputy Health OfTlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 

( •Q. S. StanDarJ> ) 
PLACE OF DEATH: — County ofC '<X>^'J-VCX/1vCAAA:,0 City ofCJ/OUYu J/UX/^wti^-t^-CC 






^No. 



-t> 



.^v\. > V 



M-Wv. 




St 



Dist«; bet* 



.^ wvvvTV'^ vvy-^rvvvvwA,' M.j Uist.; bet. and 

/I / IF DEATH OCCiyhs AWAV FRcJm USUAL RESIDENCE Give FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ 

V V "■ DEATH od^URRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



xtL^:...LUXLoL. 



0>^\^s^^. 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 

J COI.OR A . 

' UU. 



^\aL 



'y\\j<j 



.U 



DA I}-; or luRTu 



IMonlli) 



la 

(Day) 



(Year) 



A(iK. 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- DKATII 

k 

(Day) 




(Year) 



) V(7 1 S 







Mouths 



n 



/)u 



■^IVf'.I.K. MARKlllD 
WinoWKD OK DIVoKiHD 
'Uritfiii social <l\si;.';iJati<m) 



niKTlUM.AOK 

(State or Cnniitiv) 



' I Uxvv\x<JL 



NAMl-: OI- 
lATin-R 



lUKTMPI.ACK 

<>(• i-ATin>:R 

(Stall' or Cotmtrv) 



MA!l)i:\ NAMH 
<>l" MOTHKK 



r.IRTHPl.AOK 
•>l" MOTHKR 
(State or Couiitt v) 



(I 



a. 



V^OuVCL 



I IIJvRIUiV Cl-RTII-V, That I atten.led deceased from 

*^1^aJL ..2.:i. .190 ^ to W^. lo 190S 

that r last saw h vto<^\ alive on NU^aJLvjU lo y^p «^ 

and that death occurred, on the date stated above, at 1 25 



T> 



1} 



ei- 



M. The CAl'SI-: OF Dl-ATII was as follows: 



AA^fr-vWC 





trS^ 




JLLiUv) lUxLdLcLc^ 



CL 




V'lLJL 



? 



DIRATION Vrars 
CONTRIHUTC^RY 



MoJiths 



Da vs 



Hours 



Os^(xXHf*\JiK) 



OCCrPATlON 

f\rsiifi'if III Sdu I'l ii III isi'ii 



LXu^^UAax^l 



)\\irs 



Davs 



DIRATION 

(Signed) i.vA. ikifXht 

"^ TQoH (A ddress) Ut^^^^Lt (lb M.\ 

riON only for iVospitals, Institutions, Ti 



,^ront/is 



FECIAL INFORMAT -..., 

or Recent Residents, and persons dying avvay from home 



//ours 

M.D. 

^^^ 

Transients, 



) ■-■,; , 



O 1/,.'/ 



///- 



Ihn. 



Former or 
Usual Residence 



%\\o 



i 



"'nvJVW^^J^''"'"" ''^^'^^'^^AI. I'AKTrcMI.ARS AKl- TRIK To TMIC 

HUM OI- Mv Kvowi,i;n«'.i-: and hkmi:k 



(Iiifotmant 



A'ldfc.s Lctu ^ vo It' o-^ivcio-i 



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



<XvL^tr»\JL Place of Death? IH 



Days 



T90H 



n^CK OF m-RIAI. OR KKMnVAl. DATlCo! HrinA,. or RHMOVAI, 
I • N D 1; R T A K 1-: R 0\juULu /^vL (JvD CUXiX-TU 

(AcM,..ss.3.b.li' iq 't|^. ^t" 



"' '"'"IlrJc'l^SEof dTath^^ ""' cnrefully Hupplled. A(iR «houtd be Htnte.l EXACTLY. PHYSICIAN 

«on- I ^ . c '^T" '" »*'"'" *'''•"«• *'^«t 't '""> '^'^ properly classified. The "Special Information" 

sons dyinft away from home should be ftiven in every instance. ^'Pe^iai inTormation 



S should 
for per- 



^f 



if' 



-K^- 



■—*■?• 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

j^.M..l of ncMlili - 1 No i: "5^r!^r^i »&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/c Filrd , 




^ 



lOO'i 



lie^istered JYo. 



215 



-f De:^ ty Heafth Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of Beatb 

( "CI. S. Stan^arD ) 
PLACE OF DEATH: — County of U 0^^\j A^O/AvCA-^/C^City ofOcuvu J.>uCL^vaA^<M) 



^Ai. 




St. 



Dist.; bet. 



and 



(IF DEATH OCCURS Uw*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 




>vA..^\^^>a... \( 1 1 . \Jsj. rUijUjtTv 



PERSONAL AND STATISTICAL PARTICULARS 



s 1-: \ 



iD,ct 



COI.OR 



IdIju 



DATl-: OI' HIRIH 



iMonth) 



(Day) 



(Vear) 



AC.K 



,ol3 )V<i;.v ^ 



Months 



IX 



Day. 



WIDOW HI) OR DIVORrKI) 
'Writfin social dcsi^^iiat ion) 



oM. 



BTR rnPI.AOK 
' Statt or Coimti VI 



N\M1' oi 
I- A ini-.R 



lURTMPI.ArK 
OI- I APHKK 
iStatf or Country) 






LolI 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




1 

(Day) 



190^ 

(Year) 



I HF^RHRY CICRTII-V, That T attended (kcoasea from 

Wwt .^a 190S to JWlci *! iQo4 

that I last saw h Xhj alive on J^"^^ '^ i<P *^ 

and that death occnrred, on the date stated above, at b' OO 

(t 

U M. The CAlSIv ()!• I) '-AT 11 was as follows: 

"rixvuLVoX ^\At-^->-v-vtA^ . Urvv:K^-^^v^v^ 

...arlAJ^^^.-:oJ.^-.^A .. ..-^^ 



^ 



M \II)1:n NAM1-: 
<>l' MOTIIKR 



lURTHPI.ACR 

•>! MOTHKR 

I Stat( or Cr>niitrv) 






nCCT^PATION \ I ^ 4>. 



\X\^y\Oj\' 



n 



ni^RATION * Years - Mouths \ Davs ^-i^ours 
CONTR I ni'TOR V U JL^J-^t:Ct^ 



>\-t(. 




DURATION ^ Years ^ Afotiihs ^ Pays '^ /fours 

(Signed) LU. \j. Ck^.uun^ M.D. 

i TQo'i (A.l.lress) Ot. XuJkx^ JvD (Va.||Ajb 




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



Former or ''^ <5^ a^ W, J "I-*- ^^^ 'o^fl ^t 

Usual Residence cioOb (JOtHAhOA^ CJA pidre of Death? ^: 



-1 



Rrsiifrd in Siitt I'l ii ih isi'ii ^" )'ritis *" .\finiths 



Pays 



nv. AnovK ^1- \ri:n pkr^onai, PAKiicri.AKs ari-; rRiH ro rui': 



hp:st oi- my knj()wi.!:d(".k and lUa.IKF 



(Informant 



(Ad.lrc 



X%t\\ 



Hv-OAcL 



^t 



Days 



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




* t 



* ! 






PI.ACK OI- IHRIAI, OR RHMOVAI. I DAH: of ItiuiAi or RHMOVAI 

__OTit iDlcv^ I Y^ a .9oH 

r N I) H K T A K 1-: R ft) . O A^^vVv "^^^ L<) 



N. B. Kvery Item of inforniHtion should hi cnrefully supplied. AGE should he stnted KXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plnin terms, that It may he properly clussiified. The "Special information" for per- 
son* dyin^ away from home should be iQiiven in every instance. 






'»' 



"I I 



iii 



i 



■ \ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



B<.ai.l..f H..:.llli 1' N<> 1^ TS-',^-.-~ill.tI"l'.. 



BEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dufr Filed, V^H ^ ^'^'^'^ 



Be^istcrecl JV«9. 



216 



.K\JS 



Dept?ty W*»'?»ft-h Oflfl'"**'' 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of IDeatb 

( Ta. S. Stan^arD ) 



PLACE OF DEATH 



. — County of a >\? OXCL >vC. L4.<:.<) City of ^ ' CL>^ ^ VO^ VCV4A!^ 



No. 




/ ir DC*TM OC|tuRS AWAY FROM USUAL RESIDENCE GIVt FACTS CALLED ^OR UNDER "SPjtciAL INFORMATION" \ 

V. IF DEATH Occurred in a hospital or institution give its NAME instead of street and number. / 




FULL NAME 





iM 



! 



;} 



PERSONAL AND STATISTICAL PARTICULARS 
SliX X> ^ I COI.oR 



OXa^^UX^v^ 



i».\'n-: OF MiKTii 



Af.H 



}U 



\L.uJ(JLcr^.cr 



ecu 

Month) ,'T 



) 'ra I s 



I 



as 

(Day) 


T S.OH 

(Vcnr) 


M.iiit/is 


1 H An.s 



sI\(,I,K. MARUIKT). 
\VII>(>\vi:i) OR DIVOKrKO 
!\\'iit(in ^oi-ial di'si (.'nation) 



UIR IIUM.ACK 
'Statf or Country) 



-{ ^ i) 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 



._(' 



Month) 




1 

(Day) 



T9o\ 
(Year) 



I lIlvRlvBV CI:RTIFV, Tliat I attended (kvcased from 
— — '190 to IQO ■""— 

that I last saw h •^:^- — ^-^live on •■■ '"' "■"" 190 

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

— M. The CAl'Sr: ()!• DlvATH was as follows: 

\jsjia.k!Lsl snjLAx.KA^tv'i 



NAM}-: Ol- 

i-ATni;R 



RIRTHrT.ACK 
OI' lATHKR 
IStatf or Country) 



MAITIKX VAMK 
Ol' MoTlIlvR 



h 



f! ■ 
i 



lUR rniM.ACK 
t>i' M(t'nii-:R 

<Siat«' or Conntrv) 



(^ 




VVAVCL 



1)1' RATION Years 

CONTRIIU'TORV 



Mouths 



Days 



DURATION Years Months Pays Hours 
(SIGNED )...iAX^ij.Vvci< ^JAwOlaa^u^ M.D. 
'^ 190M (Address) ioOb UA.ottjlA.Qrt; 




ih 



Hours 




Special information only for Hospitals, institutions, Transients, 
or Recent Residents, and persons dyln^ away froni home. 



OCCUPATION 

/\''^i,ir<1 III Siiii Fi (I ii< isrd 



)V,M 



yr.uith^ i 1 n.i\ 



M 



'nn<: ahovk stati'd pkrson.m, pARruni.ARS ark trtk to thh 

ni:ST 01* MY KNO\\I,i:i)C.H AND HlU.Il'.K 



^Informant 



^\'l.ll(--s 



SI 




Ow^Nt\^ 



L (?iao.. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



PI.ACK OK niKIAI. OK RKMOVAI. I I)AT>: of ISikiai. or RHMoVAI, 

^\cvtu C* I VK "> .90S 



Q^rixi 







o^ 



^\(^l^.■^v 



4 



N. B. F.vepy Item of informntion fthoiilil be cnrefully niippllecl. AGB nhoulcl be stntetl F.XACTLY. PHYSICI^INR fthould 

state CAUSE OF DEATH In pl«in terms, tbnt It miiy be properly classified. The "Special Information" for per- 
sons dylnft away from home Hhoiild be ftiven In every instance. 



i 



\M 



ft^ii 



:1 



i 



I 



i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M.,:.n1 ..f HeMlth- I' No. !■> -y^'f^^^, hSi.V Cn 



REFER TO BACK OF CERTIFFCATE FOR INSTRUCTIONS 



Dafr Filed, \Au R lOCi 

o^^i\.K^J!s Ajla^u Depjytv Hesifl-h Ofim^.^r 



Registered JV*o. 



216 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( *a. S. StanDari) ) 



PLACE OF DEATH: — County ofO (X^^J0.Va.>veLJtOD City of "^ -Ct^v JVouavc^jfC^ 



No. 



is*i 



L (^l 



/a \>^\X'^ ^ ' ' V a <u. 



(ir DEATH OCCURS AW 
rr DEATH PCCURRE 



St.; 3, Dist; bet.UJya 



AY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SI 
ED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STI 




\1 




and 

;IAL INFORMATION" "\ 
T AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

1 COI^OR 





' 






DATl". OF lUKTH 




Vu^JUL^rvu- 



MEDICAL CERTIFICATE OF DEATH 



(Month) 



15 

(Day) 






\c.v. 



) I'a > .V 



Mouths ... 



IH 



DATE OF DICATH A 



fj Month) 




I 

(Day) 



(Year) 



Dav: 



SINCI.K. MAKRIKT) 
WIDOWKD OR DIVOKOKI) 
(Writfin stK'ial (k-sitjfiiiitioii) 



HIK rnPI.AOK 

* State (ir (."(iniittv^ 



NAM)': Ol- 

I'ATiii;r 






\ 



\ 



LL' (Tvv 



lURTHPl.ACF. 

Ol" I-ATIIKR 

I Stat f or Country) 



MAIDKN NAMK 

OI- MOTHKR 



1 



. ©. ^ 



I in<:Ri:nV CI-RTIFV, That I atteiKk'.l dcroased from 

' —190 to 190 — 

that I last saw li — hHvc on -^-^ — 1 > kxd — 

and that death occurred, 011 the date stated above, at 

— M. The CATSK OF DKATII was as follows: 

vXo^/JiX \^.^CLAXr\.A^^\^ ._ 

^J>.Xju^Xjl \r\JLA>^KA^tA,,0 



? 




^^ 



i it 



<ny^M 






I )r RAT ION Years 

CONTRIIU'TORV 



Months 



Days 



Hours 



DURATION 



® 



)\ars 



M())iths 



(Signed) iAJLcLtVvdk "^. Lola 



IMK I'FIIM.ACK 

'M- Morm-iR 
(Statf or Cojjnlrvt 



XJL 




OCCri'ATlON 

K^sidrii in .S'liti /'i (I III iu'n 



VVAVCL 

* )V-nv I .1/../////. IM n,,\^ 




/hiys 



'^ i()oM (Ad.lress) ioOb 



aA.^.tU.\. 3 ^ 



Hours 
M.D. 



■ 



Special information only for Hospitals, Institutions, Trdnsients, 
or Recent Residents, and persons dvini awa> fron home. 



Tin-; VUOVK STATJ-.D rKK^ONAl, I-AKIirri AKS Akl- rRIH TO TUF 
nhST t)F MY KXOWl.lCDCK AND I{1:M1;F 



'Infn-niant 



A." 



r\<Klrcss 






IN. B.. 



<^CiL 



Former or 
IsudI Residencr 

When was disease rontrarted. 
If not at plareof deatti? 



How lonq at 
Plare of Death ? 



Days 



ri.AOH OI- m KIAI. OK RHMOVAI, DATJ. of lit kiai. or RKMOVAl, 







I I 



I I 






I'NDICRTAKHR 

(Addrt'ss 




-F.very item of Informntlon fihoulil !>.' cnrefully supplied. AGB should he stnted F.XACTLY. PHY8ICI4NS should 
stntc CAUSE OF DEATH in plain terms, thnt It mj.y be properly classlltled. The ••Speciiil Information" for per- 
sons dyinft away from home should be ftlven in every instance. 



I ' 






ii 



; ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Roar(l..ni...lth 1 No. , . 1«^^^< H& P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 





1% 




Da 



Registered J\^o. 



217 



Ic Filed, l^LvUi ID I'JO^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( "a. S. StanC>arD ) 



PLACE OF DEATH: — County of C3 CT 




City of 



b 



CNo. 



^0*1 




V\A^. 



SXa Dist.;bet. 



^ 



and 



Lcxb 



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



■) 



FULL NAME 




.% 



/CL/^X^AXXrM3.AjLA.'>.-^^ 



PERSONAL AND STATISTICAL PARTICULARS 



si;x 



I).\TK OI BIRTH 



Af.R 



^ 

I Month) 



U L y.uns O 



COI.OR 



LLvivctx 



(Diiv) 



M. •Ill /if 



r % \% 

(Year) 



/)</ 1- 



NI\<.1J<:. M.XRUIHI). 

\\ii)(»\\i:i) OK i)i\'»)KC}:n 

' \Nritf ill social iksi<':iiatioii) 



iMK rm'i,.\0K 

(Statf or C'otititi y^ 



X.\MT<: <)I 

I A'nii.R 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



.>tfV^l^. 

/3M(>ntli)4 



1 

(Day) 



(Year) 



I HIvKHIJV CIvRTIFV, Tliat I ;ittcii(lo<l deceased from 

' '"'.itp to 190 

that I last saw h "^ alive on ~ ' '" • 190 —■ — 



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



M. The CATSlv OF DI-ATII was as follows: 

J (C^^AA>ut» wr:v>Ax^-.<JwX^ 



r 



v(rA\\.<xo 



1 



niRTHPT^ACE 
OI- I'ATMKR 
(State or Con lit rv) 



MAIDKN XAMIC 
<M MOTHKR 




niRTHPLACR 
OI" MOTHKR 
(State or Countrv) 



% 



OCCUPATION 

Rrsidrd in Siiir /^i ii in i.'-ro 






DL' RAT ION }'fars 

CONTRIHT'TORV 



Months 



Days 



Hours 



DURATION 



)'rars 



MoHt/i.^ 



/Mrs 



)V,M, 



.yr.'ufh^ 



/hn 



( Signed ) \j . Ip . Lvv^a^VUL 

^ i<)0^ (Address) U'lXLlLLVD vat 



Hours 
M.D. 




f 



'FECIAL INFORMATION only for Hospllalf, Institutions, Transients, 
or Recent Residents, and persons dying away fron home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



rni': xnovi-: siwri:!) rHusoxAu par iirn.ARs arp: tr^p: to tii p: 



Hi:sT oi- Mv kno\vi,p;i)(*.p: ani) ni-:Lip:K 

TOO 



(Infonnant 






^ \.l,]l-r<s 




DA rp; of Ht Hi.Al, or rpmovai, 

10 ,90s 



PI,Ai:p;^()P TMRIAL OR RHMoX \I. 



1 v. 01 IJl Kl 



rNi)p:RiAKi:R 



N. B. F.very Item oV informntion should be cnrefully supplied. AGE should be Btiited EXACTLY. PHYSICIANS should 

state CAUSE OF DliATH in pliiin terms, that it may be properly classified. The "Special InformBtion" for p«r- 
nons dyin^ away from home should be [fliiven in every instance. 



i 



I 



C '•' 



h 



( > 






•i ft 



A 



f I 



lit.. 




¥ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I! 



or.i.lof Ikilth FNo. i^ "rtT^^-^^Mftl'C 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Fi/ed , 







loo'i 



Bcgisfcrcd J\^o. 



218 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 



( "a. S. Stan^arD ) 



No. 



A ^ A ^ 

PLACE OF DEATH: — County ot^CL^ro jvol/wouI/C^ City oi^^^CLnro 0Xa>\auLe<3 



Dist.; bet. and 



/ ir/JDEATH bcCURS AWAY FfloM USUAL R E S I DE N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V, IjlF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



.^kaJu<X) 




^s^\: 




1 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



JX/^^^ux.Lt- 



DATK or- lUK III 



LU-'Vvctx 



* 






(Day) 



/U3 

(Vc-ar) 



AC.K 



\\n)(>\\i-:i) OK nivoRi'i-:!) 

'Wiitt ill MK-ial (lisijf iiatii)ii) 



^ JV.f/.v Mintlis 1 I 



Do vs 



C) 



lUK ruri.AOK 

'Statf or Country^ 



v) cr^jULoo^x^ c/'V' 



MEDICAL CERTIFICATE OF DEATH 



DATR OK DKATH 







(Day) 



(Year) 



I ni':Ri:nV CIvRTII-V, Tlmt r attciKU-d dctvasdl from 

WwUa \ U)0^ t.) . V^W^ I^P "H 

flu C\ ^0 

til at I last saw h XSj alive on Hv'-W S tc)0 S 
and that death occnrrcd, (Ui the date stated above, at "- 
r. :m. The CATSIC ()1< ni'ATlI was as follows: 

sjAXaAx^.^^..^^'^ vT^ca^V-a a x,<r vvaJL/i 



-V^-V 



NAM1-: OI- 
!• A'nil-.R 



lUK rillM.ACE 
OI- FATHKR 
iStatf or (.'ountrv) 



maii)i-:n namh 
oi' motiihk 



niKTinM.ArK 

OI MorHKR 
(Stall- or Comitrv 



aUovt ,TL^yv 



-O-VA^ 



II 



•I 




Lh^fr-LAJAX 



OCCl'PATION -- 

fy/'^Kfrif lit Salt I'l ii tit'isf'ii 



11. 



t 



or RATION ^ Years 5 Months ^ Days 



Hours 



CONTRIIU'TORY 



r^!y^^Q^^ 



!L>0 



DURATION ^ >Vr?;-.? 'X Mouths -" A/j'.v ^ Hours 



(SIGNED ) 

^ T(,0^\ 





.CV'Vv'Lv.^v M.D. 



FECIAL Information nnly for HospHhIs, institutions, Transients, 
or Recent Residents, and persons dying a\Vfiy froni home. 



yr.'iith- 



n,n 



Till*. AHOVK ST All- I) 1>K K SON A I. I' \ R Tier I, A KS A K l-. TKIH To TUl-: 

ni;sr oi- my kno\vij;i)»". h and Hi:i.n:K 



(In forma nt 



a.^t^ Crvv 



'CCV 



w^li 



1 



.<A^W\. 



Former or 
Usual Residence 

When Has disease rontrarted. 
If not at plare of death ? 



HoH lonq at 

Plare of Death? Days 



IM,ACK Ol' HIRIAI, OR RllMoXAI, I I>ATi:..f HrKiAl. -.r RI-;MoVAI. 



im)i:rtakkr \IiV OA^a-v^^tv vD/V^^ 



I90M 





M. B. H%ery Item of informntinn shnuici be cnrefuily Kiipplicd. AGE «hould be stated EXACTLY. PHYSICIANS should 

slate CAUSE OF DEATH In pliiin terms, that it mny be properly classified. The "Spewiul Information" for per- 
son* dyln^ away from homu should be fl^iven in every instance. 




m 






I <\ 
) 



'I 



r 



iiii 



I 



\ - 
' 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.,,!.l of lliMllli -I- No. 1^ "^••V..^i^ K-'tl' ^''> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 





n<(h> Filed, iuXu 10 10()'\ 

i^L^ 1^<' Deputy Health Officer 



lleglslefecl J\^o. 



^J9 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of IDeatb 

( U. S. StanDarC» j 



PLACE OF DEATH: — County of 0/OL^\) J \aAVC^wAU:City of v'a/>Aj J /vCV vvCAA/C<) 



,1 / ir DtATH OCCURsTi 
\J V, IF OtATH OCCli^ 



St, 



Dist.; bet. and 



AWAY FRoJ USUAL PESIDENCE give facts called for under "special informatio 

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



N.) 



FULL NAME 




^WOJL 



U O^ClLui: 



^.-^AJ 



PERSONAL AND STATISTICAL PARTICULARS 



si-:x 



0>WL i' lUlvU 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

1 



DATl-; or lUKTH 



\r,v. 




(I)a\) 



(Year) 



VIDnXVKI) OK nivoKrKO Q 

Writr in siu'iiil dtsivrnation) "^ 

cV 



Da 1 A 



SINi-.i,).-;, M.VRKIKD. 



lURTHPI.ACK 
(Statt ur Country* 



N \M1-: ()|- 
lATlIKR 





flMoutli 



I Day) 



(Year) 



I Hr':R!<;H\; CllKTIFV, riiat I attc!i<UMl <1ecease<l from 

9OI to O. Lia ^.V>^<^.1 Iqo H 



1 M \\K ;< li\ »^ 1', K 1 



) 1 

that I last saw h .i^"^-*^ alive on 



V"S 



1 up H 
and that death occurred, on the date statetl above, at o S 
.(F M. Jhe^CAlSH ()!• DlvATII was as follows: 






lUK'ruri.ACH 

Of lATUHR 

I State or Country) 



MAinilN NAMK 
Ol- MOTIIKR 



HIRTHPLACK 
oi- MOTHKK 
(Statf or Conntrv) 




^ (?) 



OCCl'P 






nrRATIOX Ytars Mouths Days Hours 
CONTRIBUTORV 



DT RATION Years 

(Signed ) 



Mo}iths 



ii. 0\. %.0L\t 



/J.n- 



.t\,t 



^ 



TqoS 



f 



Ad.lress) Utu HU K^^^llt 
IXTION only for iWspitdls. insfiluflons. Transients. 



Hours 
M.D. 



FECIAL Information "nly for iWspitdls, Insfiluflons, Transients, 
or Recent Residents, and persons dying anay from home. 



Rfsiifrif in Siiv /'i iim /'■ro 



)V<7> s 



y foil thy 



l)a\f 



rin: AHovK sTAii' 1) i'kksonai, I'ARiirri-AKs aki; rRii-: lo riii-: 

HHSToi- MV K\()\Vl.i:i)«.H AND HKMKF 



(Infnnnant 



3J JLVC^^ VVVVVWVNJ 



Former or « r^ 

Usual Residence ^ v 




.&rM>1XA:<^ 



HoH long at ^^ 

Plareof Death? >5 mO 



Diys 



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



I'l.ACF, Ol- lUKIAI. OR ki;Mo\AI, I DAIi:.)! Utkiai. or RlCMoWM. 



-A^ 
,* 



ni)i;rtakf.k M R O/CdxLi^yv V|lV\b\XCL\t<4 H UVUi' 

I n I Cyyu4.^ce>x di 



(AiM!-"<s 



N. B. r.%ery item of iiif.>rm«tion should hv.- cnre»ull> Hiippliecl, A(IK should be stated EXACTLY. PHYSICIANS Hhould 

stute CAUSE OF DEATH in plniti terms, that it may be properly classilfied. The "Special Information" for per- 
sons dyin^ nwoy from home Hhoultl be ^iven in every instance. 





I . 



I 



! ' 



I 



\n 



f 

IP' ^11 




hm 







If 



H 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Uorin! of Hi-nltli— K No l^ "^'Ui?-/' '^^^J' ^^" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Filed , 



100^ 



licgistered J\^o. 



220 



X{>-u.v4 luu>u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

(Tevtificate of Bcatb 

( "a. S. StaiiDarO ) 

PLACE OF DEATH; — County oiO'<X/y\} Xo^^xCUXCCCity ofO-CUTvO AaAVCA^<i C(. 
^No. 3 H 5 M I lv>^LA.V<^A.ck.lxJL St.; 5 Dist.; bet. 1^ tk and 1^ Xk 

/ IF Dt*TH OCCURS IvilX FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 COI.OR 



met 



llli.-L 



DAT!-; or- lURTII 



(JMoiUhV 



""1 



(Driy) 



/.S.D.M.... 

(Year) 



A(".K 



i 




V ) V</ > 



y/.DiUn 



Da rs 



SINCI.K. MARklKD. 
\\'II>o\Vi:n OR DIVoRrKI) 
'Wiittin s<K'ial (k"«ij.^iiatioii) 



lUKTHPI.AOK 
(Stiiti- or Country^ 



NAM1-: (>1 
FATIIKR 



lURTm'I.ACK 
<>»• J-AfUHK 
(State or Country) 



MAIDKN NAMK 
OV MOTIIHR 



BlRTMri.ACK 
<>l" MOTMKR 
(State- or Cojuitrvl 



nCCTTATlOX (V 

Rfsfdrtf ill Siin /'i tiin ism 









-fr^r\JL 







M\a. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 







(I)av) 



(Year) 



I IIRRF^RV CI':RTIFY, That [ atUn.kd .Icicasctl fioiu 
^ 190M to .|vJ^...^ 100 S 




v^ 



t halt last saw h-N.^Vw alive on ^'L^wA^^ ^ 190 H 

and that death occurred, on the date stated a1)ove, at *" 
.:" M. The CArSl':j)l- DI-IATII was as follows: 

0:'V.»rf.. 



rUe CAISI'- U 

d-tJi ^ 



DrRATION ^ Years ^ Months 
C O N T R I lU ' TO R V oL/.'M-iAx&r.t^^V. 



RIIU'TORV cU..'U,2uLl>r: 



Days \ Ih 



ours 



DURATION ^ Years ^ Afont/is - fhivs - Hours 



( Signed ) 



UL av-r^\ 



VA>^-Vv4-'^2r>v 




4 



CrVy^A^^cv 



C\ TooH (A.MrrsO bia- %0 



-ti .^t 



M.D. 



PECrAL Information only for Hospitals, Institutians, Transients, 
or Rfcent Residents, and persons dying away from home. 



) ''-(M * 



yfoiiihs 



Ihi y.< 



Tui: AI50VK sr \ri-:i) pkksonai, r\K rifn. ars aki-; tri 1; to iiih 

HKST OK MY KNOWM'.DC.K AM) m-;Ml-:F 



(Informant 



AiMrcss 






A^^A.^^ V VJro^ '^ A 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



PUACI\ 01-- niRlAI, OR RI-;.Mo\AI, J I )A11-; ..;' HtKiAi, or R1-;Mo\AI, 

Xccw>^ I l^'-^^^ ^9oH 



ni)i:rtakhr Crux\^Lu h \ 0. 






-•^■v 



(Ad.lirss l^.ft.'X 



\i Vv' 



"-x.^r-^-^rrs qX 



ion should he careVully supplieii. AGK should he «tnte(l liXACTLY. PHYSICIANS should 
rH In pluin terms, thnt it inny he properly classified. The "Special Information" for psr- 

1_ t III ^ • • • A 



i^' B.— ^Rvery item of informut 

state CAUSE OF DEAT ^ , - . . 

sons dyin^ away from home should he feiven in every instance. 



M 



* 



^ 



' ' 



M 



I 



1( 



H 



n 



w^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hnanl .rM...lth I No , . If^^g^irjv, B.^t P O, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






I '{ 






Registered J^o. 



/«w^w 



lutlc FiJc<l, V,,_iu 1C> lOOH 

t^u^ itoM. Deputy Heafth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( tl. S. StanC>arC> ) 
PLACE OF DEATH: — County oi^ Ojy\) <^ '\0^y\^Z^U^^^^{iY ofCW^vyj ^^cx-y^v^^Lvxi. c^t 






No. 



s 1 1 Liau 

/ IF DEATH OCCU 



xJU\j 



St.; 16 Dist.;bet. 



and V<X^iv<i ) 



RS AWAY 
IF DEATH OCCURRED I 



FROM USUAL RESIDENCE GIVE facts called for under "special information ■ N 
N A hospital or institution give its name instead of street and number. / 



FULL NAME 




^ 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



-^A'xoJul 
DAT)-: or lUR rn 



LV-^tvv-Ol 




I Ml. mil 




U)ay) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



datp: of dkath 



MMontlvf 



■^ 

(Day) 



(Year! 



Ar.K, 






Months 



Dti 1 > 



^INC.I.K. MARKIHI) 

W IDoWi:!) OR DIVOKll-:!) 

(Wiilt in "^(K-ial (It'^ij.'Uiition) 



^)W 



\A.'OL<L. 



UIKTIIHLACI? 
(Stittf or Country^ 



NAMK OF 

iatiii:r 



RTRTHPT.ArK 
OI- l-AIMKR 
'State or Countryt 



MATIti:\ NAM}". 
Ol" MOT I IKK 



HrRTMIM.ACH 
Ol MoTMIrR 
(Statf or «.<)uiitrv> 



1 



^>^>x 



^Iv 






I nivRlvHV CI'.RTIFV, That I attended cleocased from 
BTW Hvw\a>u 'S 190M to 



1 I 1 1 V K I 



IQO"" 

tliat T last^avv h A^" alive on ywU^.. I 190 'i 
and that death occurred, on the date stated above, at 1 
iJ.. M. The CAl'SIC OF DIvATll was w*-lo;k»wt*: <^ 



.A-^Li-CL^^k^... 




I 



t 



vA\i 



occi 



ION ^ I 

h'r^i,ir,f III Sdu /'i n ii, i-r,> ^0)',.w- *" M.'iifh^ "^ 



/>,M 



Tin: AHOVK STATl'I) PKRsoNAI, 1' \Rlirr I.A RS AK l". TR IH T« ) TFIIC 

ni:sT 01-' MY KNowij-.Dc.H AM) ni-;i.ii:F 



(Iiifu-mant 



3n LLl-l-«^^• ^^ 



\'Ml. vv 



JjvJ 



VwVv.VviA.. 



DT RAT ION )'t'ars ' Mouths Days % Hours 

CONTR ITU'TOR V CV^ /^^l^oXJuA* ^oX-ftv-r^. 

)'iiirs Miiuths 1 Pays Hours 

\i \Xi LLc>v.Lf, , . M.D. 

f Address) X\ ^"^K ^^...^^ ^ 



DIRATION 
(SIGNED ) 

XU^. R i,,oS 



_>PECIAL Information "nly for Hospitals, Institutions, Transients, 
or Recent Residents, and persons d>ing away froni home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



. Oavs 



ri.ACK Ol" lURiAi. OR ki;mo\ AI, 



%0'icu V 



.'^-va-^b 



i)\ri;u: hikiai. m rkmoyai. 



T90S 






N. B. Hvepy Item of 5nform«tlon should be cnrefully suppHed. AGR Hhould be stnted EXACTLY. PHYSICIANS nhould 

state CAUSE OF DEATH In pinin terms, that it may be properly claHHified. The "Special Informiitlon" for par- 
son* dyinft bway from home should be ftiven in every Instance. 




ii 



I \'m 




VI 



I 



r 



§ 






v! 



'^iw^ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,. ,nl ..f Hcalth-F Vo. .. '*'!35^ IkS.}' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Fi/ed, 



Lu, 



lOO'i 



Registered JVo. 



222 



dUyvcvo IxAKi -Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "CI. S. StanOarD ) 
PLACE OF DEATH: — County ofClcL^^vJA.<X/>v/:icA^o City of O/O/w OAo^vCv^ c 



It 



O, 



% 



No. I H crVMrv>v 



a 



/vMJ St.: 4 Dist.;bct. 1 



ti 



and ^ 




( ,r DE*TH OCCURS AW*Y FROM USUAL RESIDENCE G.Vt facts CALLtO ^OR UN^D^R J"^'*; '^ ^°;;; *^'„° " " ) 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



.A^.JLU^kX^' 



\X'^W.ylDLA<.L.Lil.' 



SEX 



PERSONAL AND STATISTICAL PARTICIJLARS 

I COI,()R 



^oL 



bO.lvA. 



DATK or-' lUKTM 




.\<".K 



Month) A 



3>0 

(Day) 



(Year) 



) ■/•(/ » s 



Mouths 



ii 



Da I .V 



SIxr.T.K. MARKTKT) 
WIDOWKI) (»K DIVoRiKI) 
• Writtin social (k-sij^iijitiotj) 



ntkTMPI.AOK 
(Sliitf or Coiititrv) 



NAMK <)»• 
I A Tin: R 







|/(X^cUj 



niK'nnM.ACK 

Ol I APHKR 
(Stittt* or Country) 



MAII)1.:n xamk 
HI- MOTIIKR 



HI K TUP LACK 
Ol" MOTIIKR 
(State or Cotintrv') 



^^ SI \ 




r 



,1 



CU' 



OCCUPATION 

ffrsidrtf in Sati I'l mn i'-rn 






»////> 



M 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



Monthyj 



1.0 

(Day) 



(Year) 



I UICRIHiV CI.KTIl'V, That I attetiilcMl (leroascd from 

^ 190 H to >a1h..i.& 190H. 



A I y '• 



that 1 last saw h .V*^ alive on ^V^wUa " I C 190 1 

and that <loath orourrcd, on the date stated above, at 

- M. The CArSI<: or 1)I':ATH was as folhnvs: 

g/OL<lvv.o L:>vtJL^-.A-l<v,a 



DURATION ' Years ' Months ' Days 3 Hours 

CONTRIHUTC^RY 



DT'RATrON 

(Signed) 



Years 



^ro)li/ls 



Pavs 



Hours 



QO\OL>U^ V)\. ivv^J^tta. M.D. 

VvL^li 190 H (A.Mress)!^05 cl.iLaaa.N vcvni\Uv nt 



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



Ihxvs 



Tin-: \novK sT\'n:i) i'Kksonai, pxKiuri.Aks akj: iki i-: to rin-: 
HEST OF MY kno\vij:i)c.k AND iu:i.ii:i' 

(Infonnant (J OwLL CX. "> \ 



f Vddrt-ss 



H 



i.n:i' 
(jbcL^LOUL 



,'vM, 



Former or 
Usual Residence 

When was disease contracted. 
If not at piareof death? 



How Jonq at 
Place of Death ? 



Days 



pi \CF Ol" mKIAI. OK KI-:M0VAI. I DXTI^df m HiAi. or RHMOVAI. 
l-NDERTAKEK U O^Ll^nIx M]^aY'>'^^ ^^ '^ ^ 



IN. B._Bvery Item oi J„for.„..tto„ .houM b. cnrefully HuppHed. AGE ahould »>« ^^^^'^ F,XACTLY PHYSICIANS should 
state CAUSE OF DIIATH In pl»m term«. that it may be properly classified. The Special Information for p.r- 
sons dylnft nway from homy nhoufd be ftiven In every Instance. 









\ 



\\ 



■ I 



I 



; ' 






I I 



1 ! 



f. 





ri 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„...„ .,f H. .Hh . NO .. -r^S^H^PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



iH 



])((/(' Filed, 



Registered J^o. 



223 



11 100^ 

Deputy Health Officer 

DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bcatb 

( "a. S. StanC»arD ) 
PLACE OF DEATH: — County of Occ-rv OVO-^X^Ult^Gty of n^'^XMl VO^/vxCL^ C 
No 'XOa i^ijtlv St.; >i Dist.;bet. lbfrt^a^.4 and •Ul*'*^^- 

^^"* - f ,,eii*i DE-einriur r ri\/r rACTS CALLED rOR UNDER SPECIAL INFORMATION" 1 

( '^ .7;;:Tr0CCU%rD\;"rH0"s^Pr.L o"r ?nSx'.?u" "^O./eTs "aME instead O. STREET AND NUMBER. ) 



FULL NAME 




UtsJXLL Vi^rLikOL'YX^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 




a J 



DAT}-: or lURi'n 



7 



llOJ 
1 



(Day) 



(Ye!»r) 



ACH 



ot> )V,f/> 



? 



1 



M.tnths. 



Pa \ .V 



SIVCI.K. MAKKIKl). 
WinoWKI) OK DIVOKCKf) 
(Writf in social (ksivtiatioti) 



HIK rUl'l.ACK 

(State or Country^ 



NAMK Ol 
KATHKR 



RTRTTTPT.ACE 
Ol" lArilKK 
(State or Country) 




MAIDKN NAMK 
OF MOTHKR 



RlR'rillM.ACE 
OF MOTllKR 

(Slate or Country^ 






■■\\^/&^ 



OCCrPATlON -? 



THK AHOVR S'P XTJ'.l) PKRSONAK I'AKricr I.AKS ARK TRIH To TIIK 

in-:sv OF- Mv knowM'Ix.f: and i»f:i.m;f 



(Infojmant 






rv.Mress \ \ ^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



L 



(ikonth) 



t 



(Day) 



IQO \ 
(Year) 



TQO 



1 IIKRI*:HV CI'RTIFV, That I attended (leccascd from 

19C1 • 

^90■ — ~" 



to 



that I last sa*^ h 



alive on 



and that death occnrred, on the date stated above, at 
..rrr-.M. The CArSlv.OP ni':ATn was as follows: 

Lv^.^^.kJ;^-:^^r^-<i db- A^v^Hin . 

QL.Cv,^AJl .$). JUX,/CX,ti.^.v ol %rUx^t. 



DURATION Years 

CONTRIBUTORY 



Months Days 



Hours 



3fovths 



/hlYS 



Hours 
M.D. 



DURATION ^ Years 

( SIGNED ) L(^rvvi\; J ^. Uj. Xluv >v^ 

-lu\D U)oH (Address) UV^V^\.^^U|--"-g 

'cAaL Information only for Hospitals, institutions, Transients, 




PE 



or Recent Residents, and persons dying away from tiome. 



Former or 
Isual Residence 

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



flow long at 
Place of Deatli ? 



Days 



PLACE OF nURIAI. OK KHMoVAI 



INDFiRTAKER ^tXO 



DATF:of lU KiAi. or KKMONAI, 



'|;:x 



\ 



\\ 



190*1 



" ^ ^\^Cn\Mv"< — ."v,^ 



(Address .. 



l.l.S.lJy^lUL<LVC>xMt 



of 1nfon.„«f.o„ .hou.c. he careful.. ^uppMeC. AGB should »>« 7*^:^^^ .^^^^^T,^;, .r^nln^' Vn';:!-' 
E OF DEATH In plain term., that it may he properly classified. The Special InVormat.on for p.r 



N. B.^— Bvery ite 

state CAUSE OF DEATH in p 

sons dyinft nway from home should he ftiven in every instance. 



w 



lit 









1 



f ^ 



I 



\ \ 'I 




* 






5^1 



In? 



i h 



ir," *i 




|S 




r» 




M' 1.1 1(1 I if II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,Uh . No ..^^"S^.l^^ICo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/c Filed y 




II 



100^ 



Be^Lstcred J^o. 



004 



dL^wca Xsu\j<i Deputy Health OfHrer 



DEPARTMENT ()F PUBLIC nEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( "a. S. StanDarC* ) 



PLACE OF DEATH: — County of LUa^lvul^ City of 6 a yv d^VlAxy 




a! 



riHo. 




dL^ 




A^^JLcL<X) cUvivV^xa.\'.( St.; — — Dist.;bet. — — ^^ and " " 

1\. ••c<iijti Are 1 nr Mr r r iwr f*CTS CALLED FOR UNDCR SPECIAL INFORMATION" \ 

( '^ rF"o;AT°H"oCCU%dVN''rHo"s^PrAL ^R^ f ^ S f . T^JV^" ^O I vV 74 NA^ME INSTEAO OF STREET ANO NUMBER. ) 



FULL NAME 



:i;rK'>A;.M)Ax.v./ 



SF.X 



PERSONAL AND STATISTICAL PARTICULARS 

COI,<)R 




DAIK or lUKTM 




V 



OJL 



(ni 



iMuiith) 



b 

(Day) 



(Year) 



\c.K 



bl 



) ■»•(/ » v 



H 



Mouths 



Da vs 



•^IN« .1,1:. MARK1HI) 

\vii)<i\vj:i) ok nivoROKi) 



\ino\vj;i)OK nivoKrh.u \ 

U'ritf ill s(Ki;il ilcsivnialioii) | I \ ' • 



lURTMlM.Ai'K 
'State or Country) 



NAMK Ol" 
lATin-.K 






TURTTiri.ACK 
Ol- I-ATUHR 
'State or Country) 



MAIDKN N'AMl-: 
01 MOTHKK 



HIRTHIM^ACK 
Ol" MOTIIKR 
(State or Country) 







oCCrPATlON •. -. •• 

rin- \HOVKST\Tl-I> I'KRSONAI.l'AKTIcri^ARS AKKTRIK T<> THH 
1U:ST ()I- MY KNoWKl-.nC.K AND MI-.IJKF 

'Informant J JaJLAw^L^Ou Vi^ ^JLV/pL 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII 



|Month)(J 



(Day) 



(Year) 



I HIvRIvIiV CICRTII'V, That T attcndod deciased from 

..— — ■ — 190 ——■■ to I90 "~ 

that I last saw h n:^— alive on 19° 

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

M. The CATSIv OF 1)1':ATM was as follows: 

,/CL 0Xtr'V^\^0^<l<:iv 




DIR.XTION Years 
CONTIMIU'TORY 



Months 



/)iU^ 



\s 



Hours 



Months 



Pavs 



DURATION Years 

(SIGNED) lO CI Li<XV.k 

,Lt IC loo'i (A.hlress) LLlo^AavJMia ^H 



V.CJ 



L^ I C TQO'i (.Xddres 

CIAL INFORMATION 



/fours 

M.D. 

,CC ^y'"*\HV'»v 



FECIAL INFORMATIOIN on'y ^^^ Hospitals, Institutions, Transients, 
or'Recent Residents, and persons dying ana) from liome. 



Former or 
Isual Residence 

When was disease contracted. 
If not at piare of deatli ? 



How lonq at 
Place of Death ? 



Days 



.a 



I'l.XCK Ol" HIKIAI, OK K1-:MoVAI. 

l-NDHRTAKKR LOAJW ^ C\WUa^ 



DATl'.o! IJruiAl. <>i Rl'.MOVAI, 
uXu l^ 190'^ 



(Address 



v-t 



.hould b' cnre?ully supplied. AGE Hhould be stated F.XACTLY. PHYSICIANS should 
,: p,H^ ';;:;: that U Z., be proeny classified. The •'Special Informat.on" ?or p.r- 



N. B. Every Item of Information 

state CAUSE OF DEATH 

sons dylnft away from home should be ftiven In every instance. 






1 \ 



« 



[I 






i 



i ■ 



/ 



LOCAL I T Y 



RECORDS 



SAN FRANC I SCi) 



COUNTY 



FRA 
CALIFORN 



-I 



TITLE 



I 



A^TH 



^■\ ■ 



['■ 



' \ 



OF 



RECORD 



:ai^ 



UCA 



M I CROP I LMED 



FOR 



THE GENEALOGICAL 



SOC I E TY 



SALT LAKE 



CITY 



UTAH 



CALIFORNIA 



D AT E 





APRIL 



PHOTOGRAPHER 



MAX 



1975 

JOHNSON 



« I 




CAMERA ■no2683H red 




VOLUME 



338 



904 



■Ml' 



,|»^ 



*;. 



i, 



ff 



LOCAL I TY OF 



RECORDS 



SAN FRANCISCO 
COUNTY 



SAN FRANCISCO 
CALIFORNIA 



T I TLE 



RECORD 



DEATH CERTIFICATES 



W 



•SJ^Ifl.^'Wv 



M I CROP I LMED 



FOR 



TH E GENEALOGICAL 



SALT LAKE 
CALIFORNIA 



SOC I E TY 



CITY 



U T A H 



Date 




APRIL 



PH OTOGRAPHER 



1975 

MAX JOHNSON 



C AJA 1 R A 




N02683 



RED 



VOLUME 



338 



904 




' I 



I ' 



CONTINUED 




\ 



'I 



" 4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoard ..f Mcalth- » No i^ -^^f^^^^liSiV Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Drffc Jailer?, %J^ \\ l^JO'i 

J) m ^ 

(LcKx^ Xjj\)^ Deputy Heafth Omcer 



Registered JSTo. 



224^ 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of 2)eatb 



( "U. S. StanC>arC> ) 



PLACE OF DEATH: — County of 




<vm 



aX<L 



/CU. 



riSo. LuLo^ 




City of C'/CL^w dtrVt^AX'Vo 



a I 



AX-^vxaN.*./ St.; 



and 



(IF DEATH OCCUnS AWAjV FROM USUAL i E S I D E NC E G I WC FACTS CALLED FOR UNDER "SPECIAL I N FC fl M ATIO N ' N 
IF DEATH OCCURREi'lN A HOSPITAL QR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Dist.; bet. 



FULL NAME 



nKf'y^j.M) KX's.f 



X 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



(IXA 




.^^vc 



1. 



DATK or- HIRTH 



01 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(Month) 



A(.H 



(d1 



)'rarS! 



H 



(Day) 



Miniths. 



(Year) 



Davs 



SINC.1,K. MARKIKD. 
WIDOWKD OR DIVORlKD 
(Write ill social ilt-siv^nation) 



111 



vcLcrvwiL'dL 



HIKTMPI.An-: 
• Statf or Country I 



^ 



NAMK OF 
FATHFR 



BIRTHPLACE 
0|- FATHER 

(Statf or Country) 



MAIDEN NAME 
<)I MOTHER 






pionth)rt| 



(Day) 



(Year) 



I HRRKRY CKRTIFV, Tliat T attcnflcjlflercastMl from 

I9O to I90 

that I last saw h — alive on 190 



and that death occur rctl, on the date stated above, at 
M. The CAI'SP: OF 1)I-:.\TII was as follows 

,0UV/CV/\A,0'>>A.'CL '..) A.«r-rvv(X C„ K 



t 



or RATION Vtars 

CONTRIIU'TORV 



Mouths 



Days 



Hours 



DIRATION 



)'cars 



Afouths 



Pavs 



^\^^y\Kry\) 



lURTHIM.ACE 
Ol' MOTHER 
(State or Country) 



J) 



XKrsrv>u<X-\\ 



1- 



OCCT'PATTON » «. * 

Kfsidni ill Sun /'i tiiii >sr> ^ y^ )V(M > *" .yfonf/is 



(SIGNED)... 10. LI) ULoLvk 

IC Too'i f Ad(ir«-ss) iJw'LoL/VvvJuLcL 



flours 

M.D. 



V\.M^ I C TQo'i (Addri-ss) UvLg 

PE(iilAL Information on'y for Hospitals, institutions, Transients, 



or Retent Residents, and persons dving anay from home. 



- />f/r 



THE AIIOVE ST\Ti;i) I'KkSONAI, 1' A K IIiT I,ARS ARE TRl E TO THE 
nEST()l-MV KNOWl.EDC.E AND HEIJEK 

(Informant J JaJ-AX^LOu mD 



^^ 



r\<i<i 



,,..« Cctu^^VLLo |lD(ML|wta.l 



Former or 
Usual Residence 

When was disease contracted. 
If not at plareof death? 



How lonq at 
Place of Death ? 



Days 




v^XA.^ 



I'LACE ()]•■ BURIAL OR RlCMoXAI. j l)Ari;i.; Mikiai. <.i RI-.MoVAl, 

rNDi:RTAKER v-OAJLv^j' ^<C v^v<yL*-A4v 

(Address la A) <X^VvM^jdr^..M.^^-^ 



N. B. F.very item of inpormntlon should be cnre?ully nupplied. AGE nhould be stated EXACTLY. PHYSICIAIN8 nhould 

state CAUSE OF DEATH in plain term*, that it may be properly clasniified. The "Special Information" fop per- 
sons dytn( away from home should be g^iven in every instance. 






i- 



'\^ 



\\. 



I, 



v\ 



W 



•!' 



I ii 



Bonnl of Health— K No. i«; -^^^^nSiV Co 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTR UCTIONS 

Registered J\^o. 



lOO'i 

u Deputy Health Officer 



l)((fe F/7ed, \\jj^ [\ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Beatb 

( "Q, S. StanC>arD ) 



PLACE OF DEATH: — County of 



(j.'OU^ru JA^^X^wCAwA/I^o City of Ool^w J-\.<X^-v>c^^il e.c 



(No. 



-P 



r\tl^ 



i H :^ mD rV-MX :cl.*.A.-3u^t St.; 1 Dist; bet. <ixa/vX''VVUJTr\llAand ^"^l^^^^ 

(IF DEATH OCCURS Aw'nV FROM USUAL R E S I DC NC E Gl 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 




PERSONAL AND STATISTICAL PARTICULARS 



SEX (J-^ 



J Jl/WxoJjj 



DAIK OF IHRTII 



COI,OR 



k) 



\\<. 



Xjb 



.vvwA^Lu ^ <■ 



<XhKL} 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



\^L>x.'h^^w^^ 



I Month) 



(Day) (Year) 



ACK 



O oL )></».* 



.!/.»»////,. 



Da rs 



M^i 



t ■ i 



r^' 



li 



n '.; 







RIvni.R. MARRIED. 
WIDOWED OR DIVORCED 

(NN'ritt'in s(K-ial (k'si;.^iiati<iii) 



BIRTMPL.ACE 

(State or Cotintry^ 



L<XA^^txd<x_ 



I 




u 

^MonthV 



(Day) 



fpoH 

(Year) 



I HRREBY C1':RTIFV, That I attcMKlod deccaseil from 

Vvlcx.3 190 N to ...Wl^ I iQO^ 

that T last saw h -^CAj alive 011 ^vL\.]^ % 190 S 

and that death occurred, on ti:e <late state<l above, at 10 30 
\J M. The CArSI-: OF DI^ATII was as follows: 



n'amf: o! 

F.ATHER 



niRTHn.ACE 

oi- iathf:r 

(State or Conntrv) 



M.MDEN XAME 

OF motiif:k 



lURTHPUACE 

OF mothf:r 

(Slate or Count r ) 



OCCUPATION 



%, 



h'^'iifrii in Siiir !> an, is,~<i / )\,i\ 



rvvw O tLtttcrru 



DURATION ff>UL Yeays ' Months ^ Davs ' Hours 

.LcUvcLvOw/*:. U.<^ri^v-vvv<x.\i 



CONTRIIU'TORV 



<JL 



M.,„fi,- 



/>. 



or RATION " Years ^ Months ^ Hays - Hours 
( SIGNED )U)JULvOL'>voO ^ vJ>^-n^vVA.^^ M.D. 

li 190H (.Address) 1 1 H XjUtYO/vsjcAj-fc^vtlk, S* 




PECIAL Information only tor HosplUK, institutions, TransifRts, 
or Recent Residents, and persons dying away from home. 



Former or 

Usual Residence ., 

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



HoH lonq at 
Place of Death ? 



Days 



THE ABOVE STATED I'KKSONAl, FARTlcM' I,A RS ARE TRIE To THE 
JJF:ST OF MY KN0WIJ:D<.E AM) HFI.lFtF 



(Tnft.innant 



U'Mir 






I 



FI.ACE OF niRIAI. OR RKMOVAI. | DATE of BlRlAl. or REMnVAI, 



ft' 



-f 



Uv 



^05 vOXo-vvtavt Cl-.^^, 



190H 



INDFIRI AKER 

f.\(l<1r«s« 



N. B. Every Item of information should be carefully Hupplied. AGB should be stated KXACTLY. PHY8ICIAN8 should 

state CAU8E OF DEATH in plain terms, that it may be properly classified. The "Special Information** for per- 
sons dyin^ away from home Hhould be ftiven in every instance. 



m 



>i 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boar.l of Htalth-l- No. 15 "^^^^^ »&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




190'{ 



Registered J\^o, 






Date Filed, 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



6 



De 



'ealth Officer 



Certificate of Beatb 

( "a. S. StanOarD ) 



<3?> 



(IHo. 



PLACE OF DEATH: — County ofUO-OO) v, \XlAVCAACt City of^-^X^i^ OVCWxCA^^it 





St 



(ir DtATH OCCURS AwWv 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. J 



Dist.; be t and 

NDEI 
.D 01 



FULL NAME 




vj 



hjj^\xj\i 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



Q'yvL 



CO I, OR 



UJyvv\Xx 



MEDICAL CERTIFICATE OF DEATH 



IJATE OF DKATH 



DATK OF- lURTM 






'VO-A.A.r^nJ 

(Day) 



rl2% 



(Year) 



AOK 



aJLt 



2.b 



) ■/•(/ / .V 



Months 



Pa 1 .< 



SINni.K. MARKIRD. 

wiixiwKi) OR nivoKrKi) 

iWritriti sociii] ik'sijj:n:iti<>ii) 



niRTlTPI,ACK 

(State or Country^ 



NAMR OF 
FATHKR 



RIRTHPI.ACR 
O!" lATHKR 
(State or Country) 



MAIDKN XAMK 
OF MOTHKR 



birthplacf: 
of mothkr 

'State or Country) 







S\) 




tontJi) 




10 

(Day) 



(Year) 



I IIRREBY CHRTIF^Y, That I attetuled deceased from 

-VVOj H 190H to ....Nk,\.LjL ID iQoS 

thiit I last saw h -W^v. alive on ^aaJuj 10 190 4 

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

0: M. The CAl'SB OF DIvATII was as follows: 

Dl' RATION ■ )V<7;^ ' Afofii/is I I Days Hours 

C O \y R I B I' T O R V VJUAA VA.VAXV ^ JLrr>r^Ai\f^y 



JVOUVVC/O.. 




JUy\y 



VA-'CL 



OCCITATION \X)juduU^yy^, OI 

Rrsiiird in Sati /'inmisin )',■,•> 

Till-; AMOVK STA IJ-.I) I'FKSONAI, I'A K T ICF LARS AKI- IRn: K » 

ni;sT oi" MY kni)\vm:im-.f and ulilm'.f 



nr RAT ION 



)'i'ars 



^Touths 



Havs 



Hours 



(Signed) 01I)^A3/Lcv"vvla-njl m.d. 

iqo (Address) Co a v) 0<V-^N ' lalu Lc 



\x_ 



LI 



\r.,,f/ii- 



? 



! Ii!\. 



rnK 



(Infoiniunt 



( \<1(lH'SS 









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

Former or So Oo^ ixxw<^^^ How long at ^ 

Usual Residence o-ol.'vc^ 'sy>\xxCco ^o Ware of Death ? ...ft Days 

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



PLACE CiF IirRIAL OR RKMoVAL | DA Ti: o! Ht kiai. f.r RFMOVAI, 






la. 



190^ 



rXDl'RTAKKK VD -A^v^^A^kx^U ^<<- du^J^rv^ 



(.\<MresR 



N. B.- 



-Kvery item of Information .hould be cnrefully supplied. AGB should be «t»ted EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plnin term*, thnt it mny be properly ciaHKifted. The * Special Information for per- 
son* dyinft away from home should be ftiven in every instance. 






I" 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H..anl of Health F No. .^ 1^5^^ B&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J^^'o. 



227 







Dale Filed, \kX\a II 100'\ 

\jtyvK^ <L4amj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

(Tevtificate of H)eatb 

( "U. S. Stan^ar^ ) 

PLACE OF DEATH: — County of O/OL^v v)K<X^veAw4CX City of V'a^v ^J^^a/>^>eA4.1::c 
^r^'^X^u^V^<X^ru fccHlKctx^^i^ St.; Dist.;bct. and 



(IF DfATH OCCU 
IF DCATH OC 



iwAV FROM USUAL RESIDENCE give facts called for under "special information •■ \ 

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



RS 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

COLOR ^ 



DATK or niKTn n 

'MoiUh) 



AJ JfvA.tt 



(Day) 



(Year) 



.\<". K 



!^ 1 J 'ni I .V 



M.mths 



1 \ l\ns 



SINT.I.K. M.XRKIKI). 
\Vinn\VKI> OR DIVOKcKO 

(Writtin MK-ial lit'iiK'iati'iii) 




HIK THPI.ACR 
(State or CoMJitrv 



NAMK oi 
FATin.R 






RTRTHPl.ACK 
OI' l-ATMKR 
(Statf or Country) 



MAIPKN XAMK 
Ol MOTIIKK 




>VajL 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

(Day) 



/ Month)/] 



(Year) 



I HFRHBV C'HRTIFV, That I attctKlcMl dci easetl from 

— — 190 to ■■ 190 

that I last saw h ^^r— alive on Hp 



and that death occurred, on the date stated above, at 
ttt:- M. The CATSF. OF DI^ATII was as follows 



Lah-<\HrVA^ Uw^udL SJ. 



DF RATION }'cars 

CONTRIBUTORY 



Months Days 



Hon 



rs 



VuyyJrow^ 



vu^v 



it 



HI RTH PLACE 

OF MOTHER 
(State or Country' 



Days 



DURATION VcafS Months 

(Signed) LoVo^^^A; J \0.UJ. AxiayvvcC 



Hours 
M.D. 



- W ID 190H (Address) Lj^^,fln^^.,• \iL'(|i 

^CIAL INFORMATION only for Hospitals, Insfitiltions, Translrnls, 



L^ 



OCCUPATION *■ •" 

Rfidfd ill ^'<rn /'i iiii. I'^r, 



)',ui I •• *' yfxiifh^ 



Ihi 



THF MIOVF STXTI-D PERSONAL F\KlI«*ri.AKS AKF: TKIK lO Till: 

iiF:sT Ol- mv.knowlfix'F: and hi;likf 



I liif'iTinant 



trv.'* >'»»!. >.•"''• ■••-•■ ■--• 

-4 



SP . ^ 

or Recent Residents, and persons dying dwdy trom home. 

Former or , ^ ^ (\V\ ^ ;, ,^ ':5-k "»* 'o"9 «» 

Usual Residence I 3)5 ^J f Ux.A.<r>V(3X Ware ol Death? 

When was disease rontrarted, 
II not at plare ol death ? 



Days 



I'LACE OI" lU RIAL OK RKMnV.M. 



VXtA^w>odVv' 



:^ 



n A ri". of i!t K!vf. or kf:m<ival 

190H 



] . i>: HI K! A 



INDERTAK 



vER Jt) • ' r^ K.J<\.\} "^^^ U) 



(Ad<lrfss 



state CAUSE OF DEATH In plnln term., that It muy he properly classified. The Special information for p«r 
sons dylnft away from homo should he ftiven in svery Instance. 




**H 



fi 



{■ 



m 







! ! 






r 1 



t f 



-f.-. > 






Registered JVo, 



<ir^S 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l,.,:,r.l of H.a lll.-^l-N.i is ^tg^ll&l'C, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

T)afe Filed, \Au\[ I'JO'i 

(Lfrvcus ^avu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTn=City and County of San Francisco 



Certificate of H)eatb 



A 



on , i ^ 

PLACE OF DEATH: County of*^<XAV JAxVt^.x^L^'ao City of V'<X vu Otvcvyvc.^^'CC. 



ecu I 



St,; 



Dist.; bet. 



and 



(ir DEATH OCCURS A 
ir DEATH IpCCURF 



»w*vIfrom usual residence give fac 

IRED IN A HOSPITAL OR INSTITUTION GIVE I 



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



FULL NAME 




( 




\V^JJy^X IJfOxjLrLLL 



i 



PERSONAL AND STATISTICAL PARTICULARS^ 

vJ JC^yyoJhj LAJyVvUJi 

I).\TK or lURTIl 



Vl >^H- > 



>^H- >v«-A^vr>AJ 



(Month) (Day) 



(Year) 



AGR 



bl 



LA./»J'-i^ 



) 'ra t . 



M,>}il/is Dav)' 



SINt'.l.K, MAKHIKI). 

\\n)()\vi;i) OR DivttKi i:i) 

Writfin social (ksiKiiatioii) 



HIKTJH'I.AOH 
(Stale or Cotiutry) 



NAM!-: OI- 

I A III i:k 







.w^^ 



niRTHPT.ACK 
or JATIN'.R 
• State or (."oiiiitry 



MAIDKN NAMK 
OI- MOTMHR 



IlIKTin'I.ACK 
OI MOI'MKR 
(State or Country) 



OAjJL' 



r 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



MontlO/f 




(Dav) 



(Year) 



I HF.RIvBV CI':RTIPV, That T attentU-.l <li'<ras«.(l ftnm 

VnVouo, io upH to ^v.W I a npM 

that I last saw h X^b alive on V^L/ I & t«>o H 

and that (k-atli occurred, on the date s(ate<l above, at vS 5 5 
...0 . M. The CArSI*: OI- Dl'ATII \va^ a-^ follows: 



l)r RATION Years 
CONTRIIR'TORV 



Moulha 



Day 



Hour 



(X/^X/cC 






OCCUPATION ^ 



Rr sided in Vr;,/ rmiiri-eo 15" )>-/;> M,„itli, 



Dl'RATION 

(Signed) 

1\ Ic,oS 



Years Mouths 



Pays 



//ours 
M.D. 




SPECIAL INFORMATIO 

or Recent Residents, and persons d>ing awdy from home. 



rxddrc.o l<iu^'^ ^ AD^^vt 

1 ATI ON only for '^ospitdls, institutions, Transients, 



IhlV. 



THH AHOVK STAPIP I'KKsoNAl, r\KTHri, \RS AR1-: \'\<\ V. To TIIK 

iIkst OI' MY K\<)\vi,j".i)«.H AND in-:i.n'.i-" 



A^CLv-A^-VfrV 



(\fMress 



^ 



Former or q /> *c "^ 
Usual Residence^ 3.3 

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



% 



How ionq at i ^ 

/OK^-C-^Cr^v I'lace of Oeatli ? k? J. 



Oavs 



ri,\CK OI' nrkiAi, t)K Kj:M<t\M 
- ■ 




C 



>v^o -^ 



INDliRTAKHR 

(AtMress 



DATKof lliKlAi. OI RKM<»\AI, 



8tatc CAUSE OF DLATH m plnln term*, that U mny be properly cl»«Mtlcd. The hpc.ini Intormnt.on for p« 
8on« dyinft awoy from home should be ftiven in every instance. 




iv 



■ 



f. 



tl 



ii 



Ml 



'■lit 



I I. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„„,,r.l of lie. .HI, V No .^ ^^^^Uf^VCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



4 



Date Filed y 



/VU 



lOO'i 



lu 1 1 
dL{ru.v^ \^j\su Deputy Health Officer 



Registered J^o. 



009 



DEPARTMENT 6f PUBLIC HEALTH^City and County of San Francisco 



Certificate of Beatb 

( tl. S. 5tanC»arD ) 



PLACE OF DEATH: — County of OCvlWU) 



ity of U^OLLLu^t 



.>a> 



^No. 



-St 



Dist; bet- and 



( ,r DE*TH OCCURS *w*v TROM USUAL RESIDENCE GIVE facts ""-i," ;»''";''»" str%"I*ano'numSer°''" ) 

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



FULL NAME 



VliX.OAfcwA^ 




SHX 



PERSONAL AND STATISTICAL PARTICULARS 

CO I. 




CL. 



kjb 



"" Ullvd. 



n.X'IK OF" HIK I'M 



(Munlh) 



(Day) 



., iH3. 

(Year) 



ACK 



b I V.-cm: 



.^/,>ft//lf 



Dan 



SINT.I.K. M.\RKIKI>. 



WFDOWKl) <»K DIVoKrKI) A 

(Write ill -^oc-i.-il (lt«;i^'ii.itioii) I V ^^ 

01 



lUK TJnM..\CK 
(State or Country) 



F.ATHKR 



RTRTHIM.AOK 
0|- JArUHR 
(State nr Country) 



MATPKN NAM1-: 
(H MOTHKR 



niRTHlM.ACK 
<>!• MOTHKR 
(Statt or Coujitry) 



LLwk 



CO 



M 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




onth) 



.1 

(Dav) 



/go 1 

(Year) 



I inU^ICHV CivRTIFV, That T atteinlcMl deccasfd from 

TQO ""■ 



190 



to 



that I hist saw h alive on 



Kp 



atul that death occurred, »>ii the <late stated above, at 
— — M. The CAl'SIC OV DlCATIl was as folU.ws: 



DC RAT ION }'t'ars 

CONTRIIUJTORY 



Mouths 



Days 



Hours 



DURATION 
(SIGNED) 



)\uirs 



Mouths 



Days 



V V) Llx/Vc<rvcL 



Hours 
M.D. 



OCCUPATION 



(?i 



^'C'CXX/w. 



Rfsiilrii in '<i!ti I'l.iinisr,) V<-,M > 



Month' 



n<iv: 



THF M?()VFSTXTI-n I'FRSONAI. I'AKTIcn.ARS ARKTRIF T< > TMH 

nHsr oi- MY KNowi.i.n'.K and in:Mi.f'" 



(Informant 






VvL.q TQON (Ad.lress) U<xiU^t^ ^ 

SPECIAL INFORMATION only for Hospitals,' Instil 



a'v 



FORMATION only for Hospitals, Institutions, Translfnts, 
or Recent iResMents. and persons dying anay from home. 



Former or 
Usual Residence 

Wfjen was disease ronfracted. 
If not at plare of deatfi ? 



How long at 
Piare of Death 



Days 



I'l \CF OF niRIAI, OK KliMnVAI, I DATi:..! Mikiai. 01 Rl'MoVAI. 



rsDKRTAKKR Calc|;^V>vva^ lUvdJivt<K,kwv4a L^ 



I9QH 



(Adilress 



Sc^s Q^^-^ 



U^t. 



'■"""■■■■■'"""■^ » .. I ATF .^r...lH he Rtnteil KXACTLY. PHYSICIANS nhould 

N. B.— Every Item of Information •hould be cnrefully -uppi.ed ^^^^^^J^/^'^^^,.,^^^ Information- for p.r- 

state CAUSE OF DEATH In plain term., thnt it mny be properly claMineu. » 



son. dyinft oway from home should be ftiven in every mntance. 




;^l 






li 



!' 



. I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I!<,:.r.! f H.:.lth-F Nr) i c, -^^^^^ v.Sl V C n REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



■ i 



li 



190H 



Registered J\''o. 



2m 



I)((te Filed , 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanDarD ) 






(3n 



PLACE OF DEATH: — County ofO^'Vv \J ACU^vCA^ACCGty of *^Clav AO./>\/CA,vc-0 



No. 




SSI LLLoJLv<X/-m.^ St.; 5 Dist.; bet. 3. 1 A) and 3. :^ . ' >.V:d. 

/ ir Dt*TH OCCURS AWAY FROM USUAL R E S I D E NCE Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 





O^r^A 



.m:. 




SKX 



DATi-: or r.iRiii 



Af.K 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



U)J^u 



(Month) 



(Day) 



(Year) 



O ^ J V,/ ; V I 



M out fix 



1% 



Pit 1 .s 



SIN'C.I.K. MARKIKP. 

w!i)(»\vi:i) OK i)iv< >Rij<:n 

(Write in '>oiial <1t*^iy nat inn) 



U 



lUKTinM.ACK 
(State or Country) 



NAMK OI- 

fathi:r 



niRTHPT.ACK 
Of I AIHKR 
(Statf (^r Country) 



MAIDKN NAME 
Ol" MOTHER 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




...ifit.- jgo^i 

(Day) (Year) 



HI KTH PLACE 
OF MOTHER 
(State or Country) 



OCCrpATION 



^ 




I HI':Rl':iiV Cl'iRTIFV, That I attcMiMcMl dfivased from 

ivXu. X 190 H to ..V^M- *^ i*)0 "^ 

that I last saw h.A^»T- alive on HvN^U,! 1 £> ujfi *i 

and that death occurred, on the <late stated above, at O .o.^j.. 
M. M. The CAUSIi OF DICATII was as follows: 



Dr RATION ^ Years " Months Xi/hjys Hours 



CONTRIHUTORY 



■\Xj\KOJi, 




1)1' RATION 

(Signed) 

11 i<,oH 



^fonths 




Years Afonti 



Days 



Hours 



v/w M.D. 

^I^PEcI/aL Information «n'y '<>f Hospitals, institutions. Transients, 
or Recent Residents, and persons dying away froii tiome. 



(Addresv^) 



Kesidcil ill San /'i itii,isro 1 •?> )/■<?'> 



Month' 



Da 



Former or 
Usual Residence 

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



How lonq at 
Place of Oeatti 



Days 



THE ABOVE SPATF-.n I'FRSONAI, 1' \ K lUMI.A KS AKH TRIE TO THF 
IlF:sr OF" MY KNOW I.liDCE AND IU;M1:F 



(Informant 









1'I,ACF:oF" m rial ok RFMo\ AI, I DATI:.)! IU kiai. .i KF,M(»VAI. 

rsDi'RTAKER LU'U-tiv'W LUicl^^-v^nv o-<-^>v4A<xl[i .Ikvwct 



(Acl( 



N. B.- 



-Evcry item of 1nform«tlon .hould be cnrefuliy HuppUed. AGE Hhould be H.„tcd r.XACTLY PHYSICIANS «ho„Id 
Ttate cIuSE OF DEATH in pl«in term,, that it m»> be properly cla.Hiflcd. The "Special Information for p.r. 
snn« dyinft away from home Hhould be ftiven in every instance. 




i ■ i: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I{,,an1..f Hialtlv 1 No i". '^?!^^ I5&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f 



le Filed , ^a^JLi 



^ 



-f 3 



II 



190'\ 



Registefed JVo. 



231 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "U. S. StanDarD ) 

of 0/€u7V) A^/yv(MA€City of Oo^yv 0>UX/VV1^C<l'^C 



PLACE OF DEATH: — County 



i^. at XtJvu li 



i5(Ht4vv\a 



h 



St. 



Dist; bet. and 



r IF DEATH occurs' AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



J\SK'ZJb 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 






' IlUvcu 



DATH or HIRIMI 



^ 






(Day) 



./.il'^ 

(Year) 



AC.K 



%(^ ,•,.„,, 10 



Moullix 



Da 1 .s 



SIN<.1,K. MAKKIKI). 
WIDOWKD OR I)IVOK('KI) 

'Write ill "^orial <l<>i(.riiati(iii) 




A.cLo-VvmUV 



HIK rUPT.ACH 
(State or Country 



NAMH Ol" 

FA Tin: R 




U 



HiR'riTrf.ACK 

Ol' lAIHKR 
(State or Country) 



MAIDKN NAMK 
OF MOTHER 









MEDICAL CERTIFICATE OF DEATH 



DATE OH DKATH 



(j!|lonth) 




(Day) 



(Year) 



I in<:RI':HV CI'RTII'V, That I attciKleil deceasiMl from 

Vdu,^ 190H to V^ *^ '^y^"^ 

that I last saw h . -^ alive on V^^-W ^ ^ ^'P ^ 

ami that death occurred, on the date stated above, at 1 ^ ^^ 



a' 



M. The CATSIv ()!• DIvATH was as follow^: 



A/1 



DURATION Years AfoHths 

CON T R I W U TOR V O^AA">aA^ ^ MJl>| ^J\^ vt- 



Hour 



V<5 



<rryj 



X/\\, 



aJLvC 



3 Vv^-vvU. 



Dl'RATION Years 



Afonths 



(SIGNED ) 



k). G. CLL 



/A;j'.v 



CTvv 



niR THPLACK 

ol" m()Tiif:r 

(State or Country* 



4 






Krsidfd ill Still /'i iiin /u-,! 



),.n 



\r,>iitfr 



l>ii\ 



LlIC ,<,oH (Address) q1 l^ckt/^'V^V^ 



/fours 
M.D. 



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

Former or aMA^i/^KH a a. ,1 f ""** '''" V' . , « 

Usual Residence oOlO 0V)aW\A.<rvvOTpiafe of Death? ft. Days 

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



THJ- AnoVF STATF:!) I'KRSONAI, r\RTIcri,ARS ark rRlK TO TMI-: 

nF:sT OF- MsiKNow m.ix'F: ani> hi:mff 



(Iiifotinant 






190 H 



PI.ACK Ol" lU RIAL OR RF;M0\ \I. I DATI.of Mikial or RFiMoVAI, 



(Addres". 



- ^--:^;i^^^v^^:^ t:-':z ---;:; -T:::::^-r^:^^ .=:;-^';rr 



lions clylnft iiway from home Hhould be ftiven in every Instance 



T 



i- 



f 



i - 



If 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board <>{ Hc.ilth — F Xo. i=; ^*.-;3p^; HSlV Co 



Dale Filed, 

^ -.0 







REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



100^ 

Deputy Health Officer 



Jie^isfej'ed JSTo. 



232 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX. S. Stan^ar^ ) 



i ^ -f ((51) 

PLACE OF DEATH: — County of O/O^-hj J \^Xavca^4 Cc City of 0/CV>vvJA,claxcc4 e{ 



(No. 



51 




C'YVA\<X. 



St.; i Dist.;bet. lo t|i 



md 1 




r IF DEATH OCCURS AWAY FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V .F DEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR EET AN D NUMBER ) 



1> 



FULL NAME 



.Ll/V^vAa \X^' \U{)-Lu.. 



si:\ 



^ 



PERSONAL AND STATISTICAL PARTICULARS 



DAIK «>r- ItlKlII 



.1 



COI,OR 



Ullv.u 



MEDICAL CERTIFICATE OF DEATH 



DATE OF 1)P:ATH 






10 

(Day) 



v.li.'^ 

(Year) 



a<;f: 



I I )>-a,s 3 



Moutlil 



Kv, 



10 

(Day) 



Months 



...0 



Da I i 



■^IX<.I.K. MAKKIKD. 

\\nH)\\i-:i) OR i)iv<)R('Kn 

iWritt' ill «HMa] (ksi^uation) 



lUK THI'I. AOK 
(State (ir Country) 



XANfF: OI 

fathf:r 



KUUL 



niRTH PLACE 
OJ- FATIIKR 

(Stalf or Ct>utitry) 



r 1 1 




^— __.^_ (Year) 

HRRRRV CI'RTIFV. Tluij^ I attcn.UMl <leivasca froin 

1 Jt ' ' ^^-^ ^ 

ami that deatli ocnirrcd, en tlie dal^- <U\Wy\ above, at f ?»0 

nF M The CArSiC ()]• DICATII was as follows: 



» *. .. .X ..1. . V I . IX 1 I I 1 , 1 Hill 1 aiieiKKM 
that I last saw h ..-CX» alive on yvCtu I 






X'v^'vcrWk'CCQ-e^ ccwAj^cC X 



MJ-irA. U. 



nr 



(X^vo 



MA THEN NAMF 
OF M()THF:r 



lURTHPr.AlK 
oi- MOTHFR 
(State or Country) 




nr RATION ^ )'rars: Mouths H Days b Hours 

U^tx^A^ ..D./lcXi^^OHLA^/) 



CONTRIIU'TORV 



Hours 



i . Lit a.t 






ixu,a. 



OCCUPATION 







DlRATrON * );v7/-.v S Mouths - /),/,, 

{ Signed )V|)lajLvVcUL(j5 0>U^^iv.>v m.d. 

»i looM f A.]<lre^s) laXO CjA^^ttuv ot" 




u 



Rf>:ifi'ii in S,!ii /'t <i i/i ;\,i> i C ]',■,! i\ 



Special information only for Hospitals. Instifulions. Transipnts. 
or Rpffnt Residents, and persons dying away fro;n home. 



M,»ill, 



lKi\ 



TFIF; AHOVK ST\Ti:n PKRSOXAI, I'KRTICII.XRS XRF* TRIF" TO IMF 

iJF:sr OF MY KNtm i,i:i)(,f: axd iu:i iff 



(luforniant 



f \.1.1rf<« 



51 1 \nlv'>\^x<x o!+ 



Former or 
Usual Residenrr 

When Has disease rontrarfed. 
If not at plare of death ? 



HoM long at 
Place of Death 



Days 



ri.Acj 



lAI, (»R kFMo\ AI. I DAIK..;" ItiKiM. ..i ki:Mt»\AI. 

^ I90H 



rXDKRTAKKR Iv^VAjtCCV IXAA^dLX^JLo^ K i V<> 



!N. B." 



-Every item of Information should be cnrefully supplied. A(JB BSould be stated KXACTLY. PHYSICIArSS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Inlormation' for D«r- 
sons dymft away from home should be feiven in every instance. 




I 



1^ 




IV 




m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no.Mnl..nu.ltb-F.Vo. ,.-»-gSjb>HS:PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J)ff/r Filed, 



loo'i 

Deputy Health Officer 



Registered J\^o, 



233 



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



Certificate of Death 



( U. S. StaiiBarO ) 



PLACE OF DEATH: — County of O/OaV JyUX/VVC^LMLX City of O/O/YV ^ 



^\.<VvvCA4a<) 



(f^M'y\ 



XkoX l/»U\X\.t>ui.q, ()l9M,kttaSt.: 



Dist.; bet. 



and 



(ir orATH OCCUrtk away F^OM USUAL RESIDENCE give facts called for under "special INrORMATION- 'X 
IF DEATH OCcl|JRRED I N^ A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 





x.uJ\j. \J.AJjs:>Abj. 



SF.X 



PERSONAL AND STATISTICAL PARTICULARS 



^xAs, 



vfeXoc^- 4 



DATl-: OF IMKTH 



a(;k 



(Month) 



(I)av) 



rll\ . 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH a . 

\vlu I 

(Wonth) /T 



(Day) 



(Year) 



^O )V'i;;.v 



yiinilhs Days 



SINC I.K. MARKIKI) 



MIDOWKI) OK Dl'voKCKI) 

(Writf in S(K'ial <ltsij.'iiali<)ii) —\ 



lUKTHPI.ACK 
(State or Countrv 



N'AMI-. (>I- 
FATIIKR 



niKTHPl,ACK 
0|- I ATHKR 
(State or Country) 







I in-iRIUJV ClvRTirV, That I atUMidcd decvascl from 

— — — — 190 to 

that I last saw h ~ ahvc oti \ 



up 



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



X'>A./\v. 



-r-M. The CAl'SK OF I)I{ATH was as follows: 

.vl).,OH-v>^w>ii....cr| 



'>vCnW)->v 



MAIDKN NAME 
Ol' MOTHER 



M 



M 



DURATION i'cars 
CONTRIIUTORY 



Moutln Days 



Hours 



lUKTIlFUACE 
Ol" MOTHER 
(State or Country) 



OCCUPATION 



^. 



-CVXX^vv^t 



DURATION Years Months Days 

( SIGNED ) Lcr\tmX\> J ^i3\il^ dutl<vvv<L 

ULu- ^ iQoH (Address) ^VU^vtV^ UU 



^ 



i 



Hours 
M.D. 



FECIAL INFORMATION only for Hospitals, Insfltunotts, Translfnts, 
or Recent Residents, and persons dying away froni home. 



■^ 



Rrsided nt S(>n /-'i ti n, isrii *" )'riiis •- M^nth^ 



na\ 



THE AHOVF STATED rKKSONAI, I'A KTICl I.A KS A k l-! IKIE To THE 
HEST Ol- MY KXOWI.i;i)C.E AM) IHCI.I]:!* 



Former or 

Usual Residence <VLO 



When was disease rontracfed, 
If not at plai e of death ? 



X•^,^Jl<iiXV-^tU. 



How long at 
Place of Death ? 



I 



Days 



(Informant 



\ 



d.lOC^ 



\j^^yJO\) 







(Adflrcss 



5.5 '^X<x>vudt 



P]LACE OI" mKIAI, OK KEMOVAI, | DATE of Ht kiai, 01 K1:moVAI, 

U ....... 190H 



rNDl-RTAKEK ^'''1' ^ J <V<i<^aAV V W ^S vi ol\1m H "TJAJU^V 



(.Address 






IN. B. F.very item of in?ormntinn should be cnretPully 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 psr- 
sons dyin^ away from home should be ^iven in «very instance. 



I 



« i 



I i 

h 



\ 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lio.r.lnf Mrrlih- »No i ^ ^^^^^ "'^ '' <^''^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dff/r Filed, 

{ 




U 100^ 

Deputy Health omcer 



Registered Jsl^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( H. S. StanDarD ) 



PLACE OF DEATH: — County ofC/CL/^\^ VartCUI/^o City ofC^Yo ^ KO^^x^^m^ 



Wo. 



(ir DtATH 0< 
IF DEATH 



St.; 3v Dist 



ist.: bet. cLoXtU^A) 



and 



ccuns AWAV FROM USUAL RESIDENCE Give facts called for UNorR "special informatio 

OCCURRCO in a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



uL Ibolll 
"1 



m^ 



FULL NAME 




.^MD;^. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ (N 



^ol 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



DATi: OI- niKTH 



Ar.K 



\ 



/>1<>iith) 



() 



n 

(Day) 



( Vcar) 



(M«)nth 




(Day) 



1/ 

Tgo \ 

(Year) 



I HRRKBY CKRTIFV, That I attendc.l deceased from 

O^t x^ 



dk I ) ■'•'/ » A 



v. 



Dili lis <A D 



Da r.v 



SINfU.R, MARRIKD. 
WIDONVKD OK niVoKCKr) 
tWritf in WK-ial (ksijruatioii) 



niRTMlM.AOK 
(State or CoiMitrvl 







NAMK OI' 
FATFIKR 



RIRTHPI.ACE 
0|- J-ArHKR 
tStatf «)r Country) 



MAn)i':N XAMI-: 

<)1' MOTIIKR 



lURTIIPI.ACK 
0|- MOTHKR 
(State or Country) 






V 



\(p% to ..^J^WvU^ 10 190H 

that I last saw h -^.'vrv alive on HmJUjl I 190 H 

and that death occurred, on the date stated above, at oO 
U. M. The CArSB OI' DliATII was as follows: 



^G-< 

DURATION 0. Years Months 



Pays 



u>-t<:Lt> 



A>0-{rw 



C O N T R I HUTO R Y LL:>x;..^:vxa^v^o. A^sjri6r*uHA.-wv.a 

.. Cv\X VvMrrtrrLo 



I /ours 

..^VlW 



Dl'RATK^N Viars Months 



Days 



V 



\) 



OCCUPATION -P [| 

Rfsiiffif in Sijn /'iiniiism .), )'riii s H M>>nfh> 



/',n> 



(Signed) 

10 iqoH 



Hours 
M.D. 




( 



Address) \%V\ NOloAJk.Lt m. 



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



former or 
Usual Residence 



How lonq at 
Place of Death ? 



Days 



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



THK ABOVE STATl'^D PKKSONAI. PARTUM'I.ARS ARK TRIH TO THH 
IlKST OF MY KNO\VM:n(-.l-: AND MFI.Ii:!" 



(Informant 



.tv^ 






PI.ACE OF Bl'RIAI. OR RKMoVAI. j DATlv of Hikiai. or RKMOVAl, 

.t I r^ '3^ 190H 




k>>J^^ 



r 



NDICRTAKKR YCL >>vUi (fU CtCt a ^v 



N. B. Every item of Information should be carefully ituppliefl. 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 ftiven in every instance. 




% 

I* 



f 






t\ 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hnanl of H. altli — K No. is '*XS[!;i** H^^I' Co 



Ihf/r Filed, "isjJUi ^ 

i H 




190H 



Registered JYo, 



335 



^-VA^V) <\.iA>Vl 



I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ceitiffcate of Beatb 

( H. S. Stan&arD ) 

J? ^ 4 op 

PLACE OF DEATH: — County ofC'/CU>\;O.VOL>vc^<i.ct. City of OcLav ' A.<X vl/Ca.^ e C) 



(H^. 



,. Htu 'v^. LtK,v-^vtu ib (k1 vvl a i 



-^ Ltr^v^AXu U \J (K i vv I a l- St.; Dist.; bet.— and — 

(\r DEATH occuiTs *w*v FRoL USUAL RESIDENCE give facts called fob under "special information-' '\ 
ir DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




UCL^:af>v,a..C: v/A-Ixa^.o.. 



PERSONAL AND STATISTICAL PARTICULARS 



"" (J)uL 



COI.OR 



DATK or l; IK II I 



li^^L' 




-^ "V"V^ rl'> VO- W->V' 
(Month) (Day: 



AOK 



k . . Veati 



Mmitfis 



>^va/v\X4^. 



/IS.H 

(Year) 



Days 



MEDICAL CERTIFICATE OF DEATH 



SINC.I.K. M.XKKIKI). 
WIDOWIU) OK niVOKi'Kl) 
(Write ill sjx'ial de.-^i^.'natinii) 



inKTMlM.ACK 
'Stat*' (ir Couiitrv) 



^ 



OuWvt<C 



NAMK or 
FATMKR 



HIRTHPLACH 
Ol' lATIIKK 
(State or Countrv) 



MAIDHN NAMK 
<»l MOTHKR 



niK IMPI.Ari-: 
<>l" MoTm<:R 
(Statf or Country) 



OCCrPATlON 





a 

(Day) 



(Year) 



I HHRKBV CICRTIFV, That I attendeil deceased from 
VA.-ryJL 5)0 190 H to 
that I last saw h ^^A>a. alive on 



rVl 



atul that death occurred, on the date stated above, at 1 » u 



S M. 



The CAUSK OF I) HATH was as follows 



.c^ 



Dr RAT ION }'tars 
CONTRim'TORY 



A/oPiths 



Days 



Hours 



\ 



CL-YVCX^YV; 



DURATION 
(SIGNED) 



Years 



Mouths 



Days 



i 



IqO 






(Address) 



Special information only for lospitals, institutions, Transients, 
or Recent ResiiJents, and persons dying av^ay from liome. 



A' 



y.u'iirii ill Sail f'i,iii,i\,-<> 10 )''ais '' MmiHis "^ /)t!\s 



Former or u '^ i ( r n i) i) ^-^ ""^ '*""' ^^ 

Usuai Residence i AV? J O-V^.'-OJu '^M pjare of Death 



Days 



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



rin-: abovp: staiid ckksonai, i-aktuti^aks akk tkik to thk 
iiKsT oi- Mv KNo\vij:nc.K AM) Hi:i.n:K 



(Infonnaiit 



^W, 



vrvi XoLA^^Aj-t^v 



A.Klrcss Lxtu,'^U }b(M,^v\to.V 



I'l.ACK OI" niRIAI. OK Kl%MoVAI, I DATK of IJikiai. or KKMoVAI, 
INDi: RTAKKR Uj • Uj VJfVAAtvA^ \i Lo 

,„.„ ,3.l'\ OT<wvtlL.^,t 



(Addi 



N. B. Every Item of Infopmation should be carefully nupplled. 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 dyinil away from homo should be g^iven in every instance. 




c^ 



T 



. '1 



1 



* 



t' 



f. 



f- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Il,,rir(l of Hc:illll-I* No. I^ <-^?^|«i IK^T Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ddlc Filed y 



II lOO'i 

Deputy Health Officer 



Registered J\'*o. 



836 



I 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( U. S. Stan^ar^ ) 






PLACE OF DEATH: — County of do/Yw JVO-YiC^ACti City ofO/CLru fVOyvx-CciyCC 



J 



No. 




Ox^uX' 




i; Dist.;bet. and 

IF DtATH OCCURS AW*V FROM USU4L R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' 
F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 
SKX A - (s I COI.OR 




loiv.-u 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



DATK or-' KIRIH 



\C,V. 



i>!<.iith» A 



(Day) (Vear) 







)'iiti > 



10 



yf.'titfis 



X'h 



Pit I . 



n 



']:• 



1 1 >t 



>' 9 



SIM.I.K. MARUIKO. 
WlDnWKD OK DIVOKCi: I) 

•U't"it<-in s(Ki:il (l<"-i).'nati<>n) 



niKTHPI.AOK 

(State or Coviiitrv) 



r1 







/ktontli)jJ^ 



-.11 190 \ 

(Day) (Year) 



I HFilREBY ClvRTIFV, That I attended deceased from 

^ 190 H to . >iL.JL4, ...U Tc)oS 




lATHHR 



niRTmM,A('K 
OI" I AlllKR 
(Statf f)r Country) 



MAini'.N' N'AMl-: 
OI' MOTHKR 



HiR rm-uAri-; 
OK MornKR 

(state or Cnuiiltv'l 






Lc^vLm 







„1^ 



UA'Vvtt, 



y 



OCCrPATlON 



Rfsiiinf in Sat/ I'l mi, !.->;> I )V<mv I U .'^fmilhs ^^ /^iM.v 



that I last saw li't^-'^^^ alive on N|/ULJL4,ii U T(p"l 

and that death occurred, on the date stated above, at A 
lI. M. The CAl'SI-: OI- DICATH was as follows: 

.(X^l^JL\AJi„t<^tfr>Y\x(L 1^^ vkv^JLu, <^ 

DURATION •" )'t'ais ^ Months %^ Days - Hours 

CONTRIIU'TORV 

IXcl-vIjc CvJc^U.tvv'^ O^-UL^vcCxCvtv..- 

DURATION ^ Years " Mouths \ Pays * Hours 

(SIGNED) cLfr^.^.^^ MX^Uy^^ M.D. 

.vtu il iQoS (Address) 1 1 'i^ J-ii.aVu 3:^ 



^ 



InstitulMn 



PECIAL Information only for Hnspitals, Inslitulwns, Transients, 
or Recent Residents, and persons dying away from tiome. 



Former or 

Usual Residence^ "j 



dyVvote^v^il ^ Pla?e"ofVeatli? 3, 



Till-: AMOVH STAIi:i) I'KRSoN \I, I' \R IHTIAKS A R l-) TKrH TO TIIH 
HICST OI" MV KNO\\I,i;i)C. H AND lU'.1. 1 1: t<' 



(It)f(irmant 



No\\I,i;i)C. H A>" 

\,Mr.s^ *5li C3yVU^C^A^J(JL ot 



Wfien was disease contracted. 

If not at place of death ? ^■^ 



aJk^tcvr^lUL 



Days 



PI,ACR OF lU'RIAL OR RKMOVAI. I DVlHof m kiai. or RFMOVAI. 

Q^ IDlc.vsd I Y\ la ,5oS 



INDKRTAKFR 

'A(Mri-ss 



N. B. Kvepy Item of information should b^ carefully supplied. AGE should be Htated EXACTLY. PHYSICIANS should 

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



t 


1 '• 


• 

• 


^ 


j 


1 




\ 




- 1 

■ t 

'■ i 







,1 




p 



r 



"I 



II 



I 



l 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoar.lcf JlLalth-FNo i^ "S^^Jii) lUSiP Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




L 11 lOO'i 



Registered J^o. 






17 



l)((fe Filed, 

cVchvcv^ <kiUvKu Deputy Health Offlc^^r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( H. S. StanC>arD ) 
PLACE OF DEATH: — County ofC'/CUYu ^K/X^^jZajuz^ City ofCJOwAv JKolavx^^l^co 
^No. 3.0^ M^UvKt^ St.; 2. Dist;bct. \1X0.>VV|^ andvJO/aWX^ 

(ir OCATH OCCURS « 
IF OCATH OCCURI 



AWAY FROM USUAL R E S I D E N C E G I V C FACTS 
[RED IN A HOSPITAL OR INSTITUTION GIVE 



FULL NAME 



» ■ 



:ts called for under 'Aspecial information" \ 
ITS NAME instead of street and number. / 

dLti 




PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



DATK or IWRIH 



I\<XUj 



COI.OR 




\t 



tt 



< Mont hi 



(Day) 



(Year) 



\ I . K 



V O . y^ars 



Movl/is. 



Davs 



SIxr.l.K. MAKUIKI), 
\VIl)0\VI-;i) OK DIVOK*. HI) 
(Write in s(K'i<'il desivrnatioii) 



niKTHIM.AOK 
'Statf or C'nintiy 



r 



^Av 



(y)u 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




.ID.., 

(Day) 



(Year) 



I IIRRI^BV Cl':RTfFV, That I attended deceased from 

— . to 



Tgo 



that I last saw h alive on 



iqo 
'190 



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



rr- M. The CATSF, OI* DHATII was as follows: 



/^^Ct 



\AM1-: (H- 
FATHllR 



lUKTMPI.ArK 
OK KAiriHR 
(Stntf or Country) 



NfAIDHN NAMK 
»H- MOTHKR 



TITRTTTPT.ACK 
oi' MOTHKR 
(State or Coniitrv) 







C)/OlL^<.c 



i. 



UL 



VwH^^vcfVA.rw 



DURATION Years 

CONTRIBUTORY 



Months 



Davs 



//outs 



K\ 



«« 



nu R AT ION Years ^/ontfis /Mys 



( Signed ) L^tV^taJ^ 



VCu l^ 100 H (Address) L*V<pv\XVA \J\\'. c 
A lit' 



//ours 

M.D. 



f 



OCCl'PATION ^ „ f 

X-CV'^A'V^ViLAj 



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



Kf^idnf ill Sail /'i ain ist'o 



)'i(ii 



M,<iilh^ 



Par 



Former or 
Isual Residence 

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



How lonq at 
Place of Death ? 



Days 



rin<: \i»ovk stati:i) i'Kr^^onai- iwk ncri.AKs aki: run-: to tmk 

HKST OF MV KNOWI.HIX.K AM) HKI.IKF 



(Itiforniaiit 



(Address 



^lO^At ii 



TLACH OI" niRIAI, OR RHMOVAI, | DA'Ji; of Jli kim or K1:Mo\AI. 

\X T90H 



(Jlorw La^v^.^ 







I ni)i:rtaki:r 

(Address 



M b Jo-cLt<x<-v 






N. B. Every item of informntion should be cnrefully nupplled. AGE should be stnted EXACTLY. PHYSICIANS should 

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



Tlf?' 



f 



(i 



\ 



WRITE PLAINLY WITH UNFADING INK — 



}U)iriI nf Hi-.iltli -!•' No. i:; If'-^S^^n&P Co 



Dale Filed , 




U 190^ 

Deputy Heafth 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTR UCTIONS 

Registered JSTo, 



238 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of Beatb 

( XX, S. StaiiOarD ) 



PLACE OF DEATH: — County of 6 (Prur^^x^ Qty of 





^No. 



St. 



Dist; bet. 



- and 



— "T — - •fc* *»y ^^^ V* ^ TlCl 

'" ."/nll."*'*'"''^ *'*'*'' "°** USUAL RESIDENCE GIVE FACTS CALLED rOR UNDER "SPECIAL INrORMATIOM.. \ 
IF DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E eI AN D N U M « R ) 

FULL NAMEA^V<^ 



^Lloi OJuxAJk "^i. 



PERSONAL AND STATISTICAL PARTICULARS 
si:x /A^ ft I cOI,OR 







UL.. .d.ma.v,LL.. 



MEDICAL CERTIFICATE OF DEATH 




10 

(Day) 



fpo 1 
(Year) 



srxc.i.K. MARun:i). 
wn)()\vi«:i) OK i)i\'()Rii-:[) 

(Writf iji social iksiirnation) 



HIRTHPr,ACK 
(State or Country) 




N'AMK Ol' 
FATUHR 



JUKTMPI.ACK 
or lATIIKR 

(Statf ar Country) 



MAIDKN NAMK 
OF MOTFIHR 



<^ 



lURTHPI.ACK 
<)|' M()Tm':R 
(Stalf or Cojintrv' 






I HKRHRY CivRTlFV, That I atten.le.l deccasetl from 

~ to ■ : | (p- 

-190 



that I last saw h'rr- — alive on- -■ : — 

and that (Icath occurred, on the date stated above, at 
-r::rr:.:M. The CAISH OI-^ DIvATII was as follows: 

U^^X'A^V'afc»vAJL...y^^ 



nr RATION }\'ars 
CONTRIHUTORY 



Moriths 



Days 



Hours 




Days 



\ 



DTRATION Years Mo,it/is 

(Signed) L'. 0\<x>^t 

VOt/.tP TQ o'j (Addrc-ss) ll^v^'ulaL Caf, 
Special In 



Hours 
M.D. 



OCCUPATION 



/CXtu \CX >\,^^ cc 



h'f iiiril in S,ni I'l ,nii im'h •- !>,/;> 



^ Mnulhs 



Hay. 



'"" v. >"J.^^''*'^'''^ '''■•" ''f^*«^*»NAl. PARTICII.ARS AR1-; TRIH T( ) IMF 

ni-.sr OF- Mv KNOW i,i:i)(.K and iu:mf:f 

(Informant vJA.<X'>VH ^V C) ^> WaJLIv 



n . „ ., FORMATION only for Hospitals, Institutions, Transients, 

or Recent Residents, and persons dying dHdy from liome. 

Former or 
Usual Residence 

When was disease contracted, 

If not at place of death ? 



HoH long at 
Place of Death ? 



..... Days 



rNI)i:RTAKF:R 






(l^ ^ 



I 90S 



N. B.- 



-Rvery Item of Information should b.- cnrofully supplied. AGE should be stated EXACTLY PHYSiCIANR i. i . 
ro^/d^f?^ OF DEATH In pl„ln terms, that It may be properly cl-sslflcd. The "SpLlIi Info" matlln^' for ^ir 
son. dylnft away from home nhould be ftiven in ovory instance. iniormaiion lor pep. 



f ■ 



'1 ■ 



• y 






m 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boanl of Hc-mIHi-F No. i^ ^^^^^.fi&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Drrfe Filed, 

i 




idO'\ 

Deputy Heajth O^ 



Registered J^o. 



239 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



^No. 



Certificate of S)eatb 

( H. S. StanOarO ) 

PLACE OF DEATH: — County ofUtX-YuO \/Xy\CKA1t> City of 0/a W A.OLAa/tA.A cc 

(^ I 
^'-^ ^"i-' St.; 3^ Disti bet. M ' UXV-CPTV and XXctl{i*i. 



.15^ 



; 3^ Dist.;bet. AffUx 



/■ ir DEATH OCCURS *W*V FROM USUAL RESIDENCE GIVE TACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




vvv 




SKX 



D.ATK OF HIRTH 



PERSONAL AND STATISTICAL PARTICULARS 

fxtr 



(Month) 



2.3 

( Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

I).\TE OF I)F;.\TH 

(Day) 




oiith)4 



(Year) 



AC.K 



OS * . I V<; » J 



.V. -»////> 



I '6 



Da 1 A 



SINT.I.K. MAKklKD 
\VII)(i\yKD OK DIVOKCKD 
(Write iti social lif-ivrtiatioii ) 



niK rnpi.ACH 

(state or Countrv'* 






v<V 



NAMK OF 
FATHKR 



KIRTHPI.AOK 
Ol- lATIIKK 

IStat«- or Ci)iintrv) 



MMDKN NAMK 
OI .MOTIIKK 



lUK rnPKAiF: 

<>l MOIIIHR 
(State or Cotiiitry^ 




I HliRI'UV CICRTIFV, Tliat I atteiiikMl deceased froni 

i\JL. ...'5>a 190 S to IvJIyIp- 190 S 

that I last saw h ...VVy> alive on Nj^^^^Xajl-^^^^^^ j^q i 

and that death occurred, on the date stated above, at ^ 
....^U..M. The CArSH OP DKATII was as follows: 

iyLcvv<?.. ..^ /cNt^iXaa^ 



-:SA.. 



Uvll 



VCL/\>V 




'I 




DURATION - Years 



Mouths 



Davs 



// 



on PS 



CONTRIIU'TORV 



DIRATIO.N 



)'('(irs 



^fouths 



Days 



( SIGNED )...Ll- 0. LOcht^d 



Hours 
M.D. 



_U_J__jQO 

:CIAL INF 



_ PECIAL INFORIVIATION only for Hospitals, InsNtiaions, franslfnts, 
or Rfcpnt Residents, and persons dying away from home. 



OCCUPATION 



'Icuj^iJU' 



V\v>CrLU>V' 



Rf^iilfif ill Still f'l itlli iuii )''>li\ ^ A/'ii/f/iy \,, Ihj V 



Former or | I * (j 

Usual Residence vXUw^Ul^xJU. 

Wlien was disease rontrar ted, 
If not at place of death ? 



CL 



Now lonq at 
Place of Death ? 



Days 



TIIF: AMOVE STATI I) PKKSON \|, I'AK riiMI.XKS XKllTRFF To THK 

in:sr OF" Mv k\o\vi.i;i)(.f; and in;i,ii:F 



<Af1<lre««« 



PI.ACK or HFRIAI. OR RF:M«)VAI, I DXTHof Ht kiai. ..r RKMOVAI. 

INDICRTAKKK VV<XV<X V^^C4W<V>v. ^^< vc 

i\.Mr<ss HQk^ vJO-Vcix^Vx; Ocvtjt U.AHI 



N. K. V.vcry Item of tnformntion should hi.- ctirefully mipplieil. XVtf, nhould he stated EXACTLY. PHY8ICIAIN8 should 

state CAlJSn OF DEATH in plain terms, that it m}i> he properly classified. The "Special Information'* for par- 
sons dyinit away from home should he ftiven in 9\ory instance. 




\i 



t 



I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noinlof Htalth-FNo. i^ f^^^. UScV Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/e Filed, 




lOO'i 



Registered JVo. 



2 



40 



De 



Officer 



DEPARTMENT OF PUBLIC HEALTI!=City and County of San Francisco 



Certificate of 5)eatb 



{ XX. S. StanDar^ j 



ffioX 



PLACE OF DEATH: — County of a^^ J A^^x/C^^ix^O City of C3/(Vw AXX^weui. ec 



Dist.:bet. 



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



FULL NAME 




:aw<.>^yx4j. 



SK\ 



<^ 



PERSONAL AND STATISTICAL PARTICULARS 

1 coi. 



H'tKjjt 



'<'j 






'" lolju 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



DATK OF IMRTM 



I Vllonth) 




(Day) 



(Year) 



AC.K 



Wars 



1.1 



... .Months I ..Day; 



SIN(.I,i:, MAKUIFI). 
WIDoUKI) Ok I)I\'oRri:D 
(Writ'- in sf)cial (lesivrnatiMii) 



HIKTinM.ACP: 

(Stati- or Country I 



! ; 
V: 



NAMK OF 
FATHKR 



niKTUlM.AfK 
OF lATHHK 

• State iir Country) 



MAIDKN NAMK 
nl MoTHFK 



niK thim.acf: 
oi" MornF:k 

(Slate or Country) 




iwXx^i 



lonth)/! 



(Day) 



(Year) 



I HIt;Ri;nV CI:rTIFV, That I atten.UMl deccascl fnmi 

.^.JL/S^ XH 190A to J|vJLu..a iQot 

that I last saw h /■ alive on V^^OUjl. I 190^ 
and that death occurred, on the date stated above, at ^ 
U M. The CArSK OF DICATH was as follows: 
LJvucrvA.^'C. \|\jiLWvvv^tv^, 






tVVX^YSj 



DIRATION 3 Years - A/ on //is - Days * J /ours 
CONTRIHrTORY 



OCCri'ATION 



(Ad 






Days 



Hours 



^Vfr-VAJ^V 



V/CV 



DIRATION Years Afotiths 

(Signed) d. M T^^^>,\Mjuy\x.... , M.D. 

n lf,oS CA.ldress) I bib LalcloA/WV^-i '^' 



Special Information only for Hospitals. Inslhutlons, Iranslpnls, 
or Recent Residents, dnd persons dying dway from home. 






Afu,if/,> 



fhix 



THF. \H0VK STATKD I'FKsONAl. I'ARTIC F I.A KS A K J-: TKt F TO TUl, 

HKST OF MY kno\vm:i;(,h AM) mf;ijf;f 

f Informant J VV<rWMXXi W aJULa-^UVvA^ 4vC\. ^F ^ 



Former or ^ e r 'A u 

I'sudI Residence (^ 5 I o - <k\ 

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



a-K. How K^nq af 
or piaff of Death? k C Days 



^\(l<lress 



M 



v-i XvJL(xkjdi 



i 



I'l.ACK 01 HI KIAI, OK kICMoVAI. j DATICuf Mikmi. or RFiNfoVAI. 



AChC OI- HI 



V^L^-4.^ 



() ,a 



u \X 



1901 



'Ad.lrcss 






N, B.- 



-Bvcpy item of informntion ahoulcl be ciipefufly Huppliecl. AGB nhould be ntateil RXACTLY. PHYSICIANS nhould 
atate CAUSE OF DEATH in plnin terms, that it may he properly classified. The "Special Information'* for per- 
sons dying away from home should be given in svsry instance. 



If* 



M 






1 s 

\ 
I 









I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTI0N3 



Hoard of Health— K No. i«, "^^^^^^^^ ^^ 



Dale FiJeil, %Aj^ \\ lOO'i 



O'-^SA^L.KJs ^ 



u r 



liegisterecl J\i^o. 



^w' 



41 



i'- 



CA^ ^tOM^ 



D< 



(T^. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccrtiftcate of S)eatb 

( X\. S. StanOarO ) 

PLACE OF DEATH: — County ofU/CL/>^ A,<XAxC^4C€iCity ofO^O/w A.a/>vc^4/ao 
avVA^v^l OL^^^Li h (M_kv I at St.; 




Dist.; bct« *~~~~" and" 

(IF DEATH OCCURS AWAY T^OM' USUAL R E S I D E N C E Gi VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" 'N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME A 




X.<HL'1\A'. \L 



/^jyw.O^i^ 




K).. 



SK\ 



DATH OF llIkTII 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 




7 

(Month) 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



/.li.a... 

(Day) (Year) 



ACiK 



7 



. . rears 



Mouths 



? 



Davs 



SINCI.K, MAKRIKD 
WIDOWKD OK DIVokrKI) 
(Write in sotMal dcsivrnation) 






ink rniM.AOK 

(Statf or Conntr\ I 



NAMK <)I- 
FATHKR 



HIkTHIM.AC'K 
Ol- f-ATHKk 
(State or I'onntry) 



? 






■\ 



f 



[Monthfl 



i 

(Day) 



190 I 

(Year) 



I IIRRRBY CHRTIFV, That I attcncU-.l (U-ctascd from 

..^\^.UjL ..b I90H to^.^^wU^l K^ i 



npH 



that I last saw h .ci-^^ alive on yVwA^Lci, t> 
an«l that <U'ath occurre<l, on the date stated a!)Ove, at ^ ^ 
:^- M. The CAISH ()!• DI-ATII was as follows: 



t 



-=) 



J 



i1 



tXAV<V'>A.' 



Mj/'tX'WVOLA <X ¥LO 



MAIDKN NAMK 
ol MOTHKR 



niRTHI'LACK 
ni MuTHHK 
(Statt- or Country* 




>(X>Xv 



Wcrv^-''»-' 



nrRATION • }Vtf/-.v b Mouths Pays ' Hours 
CONTRIIU TORY oLlA^tijx/a^w. 






XV '>V) 



DT RATION Years Months Days 

(Signed) G. \j)\ai^^Mi/a>Lc 

.<JIm, % T90S (Address) 50 5 aU^^cjvtrvvt d't 



Ilours^ 
M.D. 



i 



h 



FECIAL Information onl> for Hospitals, InsJituflons. Translfnts, 
or Recent Residents, and persons dying awdy from home. 



(>CCl'PATIO.> Pyy-fs-li 

1 

/yf^lilf'if III '^ilil /■ I il III l^rn '^ )fUII 



y/iiiitfi' 



i)ii\ 



TU1-; xMovK STA ri:i) I'KksoNAi, I \k ruri.\k>^ \ki: tkii-: m thk 

MICST OF MY KNo\VI,i:i)<.K AND UI:MKF 



Former or 
Usual Residence 



\x 



LaXvo 



HoH long at 
Place of Death ? 



3 Days 



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



7 



(In forma 



nt A. JVa 



K^K^^\y<:\jU^<XJ 



(Address 






1901 



l'I,ACK OF m KfAI. Ok kFMo\AI. I DAIIlot Hii/iai, ..i KllMoVAI, 

J oi^ik^w.^ I Y^ ix 



(Address. 



N. B. Bvery item of int'ormatJon should be cnrolr'ully Huppllecl. AGB should be stated CXACTLY. PHYSICIANS should 

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






r • 



I 

I 



I 






4-' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho:.r.l of HtflUh-l No !«; '«^^^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Registered J\^o, 



\\ lOO'i 

vMu Deputy Health Offl-^^r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "U. S. Stan&arD ) 
PLACE OF DEATH: — County of O/aru Jaxvyl/C<.A/^^ City of O^-ru A.<X/>vc.cA/Cc 
No. 11 clcxcvVtliV)Xa<L-'.. St.; i Dist.;bet. J-^'-'ViX and l^ 

(ir DCATH OCCURS AWAV 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. / 



242 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



. 



D.\TK «)F IJIRTH 



L 



COl.Ok 



UJjLdji 



aA.<MX 



KlA) L<XAr)^lJj-i 




MEDICAL CERTIFICATE OF DEATH 



D.ATE OF DEATH 



^. 



• Month) 



H 

(Day) 



(Year) 



Af.K 



Ht )V<MA I 



A/ovf/is V r>ttvs 



^i\(.i,K MAWkir.i) 

WIDnWKD OR I)IV«>K('KI) 
iUiitfin s(K'i:il <lr<^iv:!iation) 




avv^ixL 



niRTHPI.ACK /-^ 

(State or Coiintrv* 1^ 



■IX 




(Day) 



(Year) 




I URRI<:RV Cl'RTIFV, Tliat I atteiidcMl deceased from 

^ 1 190 a to ....|^^^L .1 i) 190 H 

that I last saw h ■rL\> alive on vvvXv.y, 1 1 190 'i 
and that death occurred, on the date stated a!)ove, at 3 10 
tL M. The CATSK OF DICATH was as follows: 

LL\.0L1avn.a.^C!C 



NAME (>I- 
FATHER 



niRTFlPEACK 

OF- FATHER 

• State or Country) 



MAn)EN NAME 
01 MOTHER 



Nxt 




DERATION " }'ears 'Mouths '^ Days ' Hours 

CONTRIBUTORY LK>UrY\A</a \)\i^.^oJ[lL^i-J.i^ 0^'\\A. 

V'-KAjv-lhC-OL^xAAXvo 




HIRTHl'I.Al'E 
OF MOTHER 
(State or Coulltr^ > 



oOCrPATION 'MP J 

Krsiiifii 1)1 '<(rv /'i mi. nf.> ^^ )r,i i ' " Months ' Days 




'\,yI/>v0^u>v 



DURATION \ Years 

(Signed ).Ll)rrryj v Mflvx/urvvvu 

iiA^iM I'i 100': r.\ddn-^s) IO& flba\n.i.^<rvv o.t 



Mouths ' Days 

i 



Hours 
M.D. 



a 



190 



FECIAL INFORMATION only for Hospitals, institutions, Transifnts, 
or Recent Residents, and persons dying a^ay fro.n liome. 



THF: AMOVE STATED rKKSONAl, I'A Klirr I. \ KS AR i: TR F E To THE 

nF:sr of my know i,i:i)<.e and ijei.iicf 



(Di 



3,1 XotMAxi Vl Xa.< 



Former or 
Usual Resic.RCf 

Wtien was disease contracted. 
If not at place of deatli? 



How long at 
Place of Death ? 



Days 



I'I.ACF;<n" KFRIAI. OR REMOVAL | DATE of Mi kiai, oi R1;MoVAI, 




'A.ldrt".^ 



(Address.^ 1 bT. mYIvAXa^-V\ ot 



INDERTAKER "i ^ '^ V^rvVVV^j'V ^ Lo 



N. B. Every Item of information should be cnrofully supplied. AGB should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information" for psp- 
sons dyin^ away from home should be ^'^cn in every instance. 



T- 



a 



h 



M '' 



u 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



MoitKl /.r II. .iltli I- \o i^ "*'?^'S|^ lUS:!' i*o 



Dff/c Fi/e</ , 




\X i'-JO^ RegLHtered ^''o. 243 

<i^uvvo oU-v^u Deputy Health Ofncer 

DEPARTMENT OF PBBLIC HEALTIl=City and County of San Francisco 



Certificate of H)eatb 

( xa. S. StanDarC» ) 

PLACE OF DEATH: — County of 'tJ/(X/>v OA.<V>AXA^CCCity of OxXAXj OXOL/YvCC^ Co 



(No 



. \\ 



A^jHUv^LtA' 




O '^ 




St; 3^ Dist.;bet. ULccu, and KXCX^YiVi^^^ 

(ir |DE*TH OCCUnS AWAY FROM USUAL RESIDENCE give facts called for UNDeA "special INFORMATION" 'S 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 6m STREET AND NUMBER. / 



FULL NAME 



SHX 



DATI-: ()| HI KIM 



PERSONAL AND STATISTICAL PARTICULARS 

i C<»I,<)K 




\u^> 







i\ 



(Month) 




trv^r 



(Year) 



A(.i<; 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1;a TH 




(Day) 



I9o\ 

(Year) 



V. .1. Ynxts \ M.wths I.H 



Pavs 



^IN'<".I.i:. MAKKIi:i), 
WIDOUKI) OK DIVoKi'KI) 
(Writf in sot-inl (k-sivrnatioii) 




OJ\J^^^JL<k, 



lUKTHl'KAi'H 

(Stiitf or C'i>mitry) 



NAMi; np 

fatmi;r 



MlkTHJ'I.AlK 
<)?•• I-ATMMK 
(Stalf or Country) 



MAIDKN NAM1-: 
<>!• MOTHKR 



niKTIlIM.ACK 
<)l" MoTHHK 
(Statf or Conntrv) 



C: 








I m-:RI-:HV CI^RTIFV, Thnt r attended dcct-ased from 

"X^ 190H to H^w^^b IH Kp*^ 

that I last saw IiLvya. alive on ^Vw>-i' I H T90 H 

and that death occurre<l, on the date state<l above, at i 3L I S 
^■^l. The CAlSIv OI- DI'ATII was as follows: 



2^- 





DTRATION Years Mouths 



CONTRIIU TORY 



l^ays Hours 

.UvsC*v 



\. 




DIRATIOX ^ Years '^\ Mouths 15 Days Hours 

(Signed) . m.d. 

Tgo fA<ldress) 



occrrATioN f^^T^L 



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






Former or 
Usual Residence 



iQUw I + 'Pk How long at 

I c» \J ^ft-ojUL'tX, lac. piare of Oeatli ? 



Days 



MoiiUn 



I\i 



Tin". AHOVK STAIi:i) I'KK^ONAI, TA K'lICl LAKS AK !•: TKIK TO TH H 
Mi:sT Ol" MY KN0\VM;I)<;K and lUCIJKl- 



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



(1 



nfoMnant vU -OLLvCC^VWj LU AX 



'i.rvv 



(Address . 



naio 



111 



% 



CV4. VXv \\.ClL(5Vu 



i 



ri.ACK (^\■ JUKIAI. OK KHMo\AI 






rNDHRTAKKK 

(Addrrss 



I90H 



I)ATi:of Hi RIAL or K1<:moVAI, 

LcL la. 



N. B. F.very Item of inforniHtion should bs carefully supplied. AGE Hhould 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 ftiven in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

B^mrd of HtMlth - F No i. iS^gg^ HM- Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



7)(ifr Filed, Ht 



i 



d 




\X 



190^ 



Registered JSTo. 



344 




a 



Deputy Hearth Omcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( TH. S. Staiieat& ) 



^ 



0p 






rNo. 



PLACE OF DEATH: — County of CI/Oax^ OAAyrvOucicoClty of C'/CL/Vu OA,<X/>-n^.-UL-C 



-VC/Y\.tjJ. 




0(K,kcta.l 



Dist.; bet. 



/ \r DEATH OCCU«»[aWAV FROMUSUAL residence give facts called fob under "special INFORMATION" N 
V IF DEATH OCCU\^RtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




^UDU'XNrL/.TV.X;., 



sk: 



LUJk^tx 



H 't 



PERSONAL AND STATISTICAL PARTICULARS 

DATK <)I- lURTH s « 

LUAAjk^WC-X^V^-VU / .J.l.S. 

I Month) (Day) (Year) 

a<;k 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



1, 



ronth) 1 






1.0..... 

(Day) 



9o\ 

(Year) 



jgo 



.3.S 



J 'ra I .? 



Mimlhs Da\'S 



'»i; 



SINC.l.K. MARKIKI) 
WIDOWKD OR DlVokrKr) 
(NVritf ill s<K"ial iltsijfiiation) 



( I Wvv^ouJL. 



HIRTHPI.ArK 

(Statf or Oo\intryH 



NAMK OI- 

FA Tin: R 



niR IHIM.ACK 
<)»•• FATHKR 

'State or Coimtrv) 



MAIDKN NAMK 
«)!' MOTHKK 



HiR'rnrLACK 

<»I MOTHKR 
(Statr or Country) 



OOCrPATION ^ 



lol 



I HHRICr.V CFRTIFV, That I attended tleceasetl from 
190 to IQO— 

that I last saw h -rrrr- ahve on ■■——-r—:r7:r:T-rrrrr- iqq 

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



—„.- M. The CAUvSH OF DI-ATII was as follows: 



H, 



.C}-A^VxAx^:< 



VCXA^Ul^; 



'VCCVX/^V 



DC RATION Years 
CONTRIIU'TORY 



1.. . . /C!x-U>:;».iu^.>x*CUV 
Mouths Days 



Hours 









DIRATIOX 
(SIG 



Years 



Mouths 



NED)..Ur\^rvMA; J Mi.U.-."3u.Lx 



Pays 



Mi 



(^ 



CIAL INF 



(Address) Uft\^vC.^4 



life 



Hours 
M.D. 



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



Kfsidfd III Siiir /'i lint isro ' )'mis 



.1 A ./////» 



/)/; I . 



TMK AHOVK STA ri:i> I'KRSONAl. PARTICCKARS A R F TRCF: To TUF: 

hf:st of my kno\vi,f:dc,k and rfi.ikf 



Former or 
Usual Residence 

When was disease contracted, 
If ..ot at place of death? 



How lonq at 
Place of Death ? 



Days 



[Inforiiiant \jLJji/y\> uO 



JL\^^/^^JLA.AJ^ 



(A<UIress i 3> I CJ /A \^ V\. LCu, CJA 



I'l^ACK OF niRIAI. OR RHMoVAI. I DATK of HrkiAi. or RKMOVAI, 



I'NDHRTAKKR M (l ^J <X.d.<Vi rx m i v vx \.Jt..\.WVu 



(Address 



N. B. Every Item o^ Information should be cnrefully KupplSed. AGE Bhould be stated EXACTLY. PHY8ICIAN8 nhould 

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



7 



fp 






■a 



?■ 



k 



» '• 



1 

I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of Hen 1th- F No. is "t^^^ H&I* Co 



Dff/c Filed , 




RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



\X 100^ 



Registered JVo, 



245 



c^M-A^vo Ax/\>^ ^*^.P/-'.^'y.,.'^.ea|.lf, Of/Ice r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( Ta. S. StaiiOatO ) 

A '^ i ^ 

PLACE OF DEATH: — County of Octav OTvCLvt^c^A/C^ City of ^'^>v Axl >vc.A.^a^o 



'No. 



O^X'X J-^Vv\.k St.; X .Dist.;bct. (Ibvy^ and XiLaA)-iAVLA^vi)t 

/ ir DEATH OCCURS «WAV FROM USUAL R E S I D E NC E G I VC FACTS CALLED FOR uAdER "SPECIAL INFORMATION ' \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ 



<^JL^y^<xXju 



JdXxjJtx, 



DA T1-: <>!• HIKTH 



ACK 



ID^ 



(Month) 



O O J f'<j#> \.. 



<Day) 



Months . 



/lit. 

(Year) 



Dars 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




on 






11 

(Day) 



I go 
(Year) 



SFNr.I.K. MARKIi:i) 
WfDOWKI) OK DIV<)KrKI) 
'Write in MH.ial (Usivrnatioii) 



HIKTH PI. At'K 
iStatt' or Country^ 



NAMK or 
FA THHR 



-? 



^ 

^ 



CLWOuA. 






I HRRKBV CrvRTIFV, That I attetided deceased from 

^kA^'YO. I.X 190 H to IvlLa. .1.1 iQO H 

that I last saw h ...-C^.>al^ve on HA^aJUjl 11 iqq ^ 

and that death occurred, on the date stated aJ)ove. at CVV-9-Vrt 
H-IT M. The CAt'SK OF DIvATII was as follows: 




^l^W>.. 



RIRTHPI.ACK 
OF FATHKK 
(Statf or Covintry^ 



MAIDFN NAMK 
OI- MOTHHK 



niRTHPLACK 
OI MoTHKR 
(Slate or Conntrv^ 




v/>v 



DURATION Years 
CONTRIBUTORY 



Mouths 3 Ihiys 




DURATION Years Months 

% 



^ Ko/o^vi 



Days 



LA-A^VW 



(Signed) (;u)-t^vVA^ 

1^ IQOS (Address) I C13 




' eiLri 



Hours 

Hours 
M.D. 



'Special information only for Hospitals, Insmuflons, Transifnts, 
or Rrcent Residents, dnd persons dying dHdy from home. 



<wvdw. 



OCCT'PATION ♦. * - 



Tin: AiujvK sTA'ii:i) i'kksonai. i-ak ru i i. \ks aki; ikik to tmk 

IlKST OF MY KN«»\\ I.KIX.K AND BFI.IICF 



f Tiifonnrmt 



(A<l(hess 






Former or 
llsudi Residence 

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



How lORI) »l 

Place of Death ? 



Days 



I'l.ACK OF HIKIAI. OK KHM«»\AI. | DA'i>; of Mikial or KKMOVAI, 

'3 IQo't 



%.i^Cv.v^ I M^ 

INDFRTAKFR VJ &Ajto>J ^^ vU^kctl 

(AcMres,s S X'b.'V O'IcUL'W ■xV<vtA-...OU, 



N. B. Every item oi Information should be CBrcfuliy supplied. AGE should be stated EXACTLY. PHY8ICIAN8 nhfybld 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- 
sons dyinft away from home should be given in c^/ery instance. 




* 





t V 



I 



■i! i 

¥: ? 1 



•s i 



N 






\f: 



ii 



i 



1^' 



■II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.oatd of llialth- !•■ N'o. n, 1^*^^k~^ Jj&p Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begistered J\''o. 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



100^ 

v.^ Deputy Health Officer 



Certificate of 2)eatb 

( •Q. S. Stan^arO ) 



PLACE OF DEATH: — County of 



*^ 




r\ 



City of \i itn^ruLi 



/:kjUk<X: 



(No." 



St.; 



Dist.; bet. 



and 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N • \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




PERSONAL AND STAT<STICAL PARTICULARS 




\(xLh 



llllct 



DATK <>l- IMK in 



' Month) 



(liay 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DEATH 




(Month) 



1,1 

(Day) 



I go ^ 
(Year) 



ACK 



..0./!*V Yiuus 



Mimlhs T.. Davs 



SINCI,].:. MARKIi:!), 
WIDmWKI) ok ni\()Kl. HI) 
• Writ* ill sfK-ial dt-sivrnatioii) 




0J\)>^^JU6^ 



I nJ-:KI':RV CICRTIFV, That I attended deceased from 

— to 



190 



I90 



that I last saw h^^^^ — - alive on ■ — \^ ' Kp 

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



M The CAUSB Ol- DMATH was as follows: 



-aVA^VVsi^A^.. 



IMKTHI'I.ACK 

(Statf iir Coutitrv) 



NAMK. ()!• 
FATlll-.R 



niKTIII'I.AlK 
Of I AI'MHK 
iStatf or Country) 



MAIDEN NAME 
(>|- MOTHER 



lUR'niPLACE 
<>»• MOTHER 
(Stati' or Country) 



/T) 






\l N I IaJJuiA) 




DURATION Years 
CONTRIIU'TORV 



Mouths 



Days 



Hours 




^y^Uj 




DURATION Years Months Pays Hours 

(SIGNED ) (fc. O Jj)\(Hr\^^ M.D. 

— — - igo — (Address) ^flinwJL/ U^la 1 K a. 



Special information only for Hospitals, Instilufjons, Iranslcnls, 
or Recent Residents, ari^ persons dying away from home. 



OCCUPATION O^Vi^vtivC^^vt 



Kcsiiird in Siin /'i o iii iyro 



)'rn) . 



.yr.i,///,^ 



A71 



THIv AMOVE STAri:i) PKRSON \1, I'A K I" IiT LA RS ARl'. TRIH TO THE 
HEST Ol" MY K^WM-.DC. E AND ME I, I EI" 

J. LU. LcLt^crvo 



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Days 



(Itifoiniant 



fAfldress 



3s lb ^©-a.^<lIv Ot 



ri^ACE OF Ml RIAUOK KEMo\AI. [ I)ATi:of MtKiAi, or REMOVAI, 



190H 



INDICRTAKER 

(Ad<l)rss 






N. B. F.vcpy Item of nifnrmntion ithould be ciirefully Hupplied. AGK should bo stated EXACTLY. PHYSICIANS should 

state CAUSE OF DF. ATH in pinin terms, thiit it mny be properly classified. The "Special Information" fop pep- 
sons dyin^ away fpom home should be f^iven in every instance. 



!•* 






•j/fm^. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)t..;ii.l ..f ll.-riUli- F No. n **^^i;,?»^. HScV Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale i 



A^^H^v^ JU/v-u Deputy Health Officer 



Registered J\''o. 



247 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( ■Q. S. StanOatO ) 

r. 



s; 



PLACE OF DEATH: — County ofO/tXo^\» 0/v<t/vvcc4.CC) City of C'/CL/>\) Jxctwcv^Cii 
. ^-<tu^^ Uu. >xtu h ChNl k da I St.; Dist.; bet.— a nd — 

/I / ir DEATH OCCUH5 *W»V FRoWl USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION 
\J V IF DEATH OCdiJRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBfR. 



FULL NAME 



? 



>...) 



AXX. 




V 



viau^csl) 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



•il-uL 



COI,OR 



X'^KCtx 



DATl-: nl III K Til 



(M..iit)i) 



(Day) 



(Vcar) 



AC.K 



1 



J v./ 



Mouths Davs 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 

a 

(Day) 




(Year) 




m 



SINt. I.F MAKUn:D. 

\vii)(i\v}.:i) Ok DF\nKrKD 
iWritt ill sorial iUsij>:natii)n) 



UIKTm'I.AOF 

'Stuff (ir Country 



t 






namj: of 

FATllIiK 



niKTHI'I.ACK 
OF I-AIIIFK 
(Statf ur Coiinr rj') 



MAn)F:N NAMK 
oi MOTIIKR 



nik'niiM.AiK 

<»!• MoTIIKR 
(Stati- i>r Ci>utitrv) 



? P 



I,^Hl':^U<:nY CI{RTIFV, Thai r atteiKkMl ,U'Coasc.l from 

^ ^9oH to V,SL a TcpH 

that I last saw h r^^-^x alive on yUJLu. H 190 H 

ami that death occurred, on the date state<l above, at I I 5 5 
^ ■ M. The CArSp; ()!• I)l«:ATn was as follows: 

sX.c.vJtji \J OAX ^v-c^l; wp> v^t6-vvy.Q:\^ivlvi..v.U^.. 



1)1 RATION )\>a>s 
CONTRIIU'TORY 



Mouths 



Days 



J /ours 



>VOl/>vqX 



^"} 



Mouths 



Days 



DURATION 

(SIGNED) J VA- ()b0L>vt 

H ic)oS (A(ld rrss) UIm M.Lc) AD0->i| 

>N only for iTospitals, Institutions, Tn 




Hour's 
M.D. 



FECIAL INFORMATIO 

or Recent Residents, and persons dying away from fiome. 



OCCUPATION 



^.k 



O-t "v-vvoc KjL'v 



KjL^ 



Former or 
Usual Residence 



bl^ ut{Kj^.tr^x, Ot Place Toeath ? 



Transients, 



Days 



Rrsfiffif in San /'i an, isi-ii *" )'i'iiis *" ^/"l/f/ls *" / hi \ ^ I 



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



TMH AHOVF: ST ATFn I'KRSONAI, T A K I" U" C I,A K S AKl': TRFF To TIIH 
in':sT 01 MY lp^NOWI.i:D»".K AND I'.llI^IllF 

M 



(Informant 



i:lii;f 








190^ 



ri.ACK Ol- IHKIAI, OR KKMOVAI. I DATi: of IJikiai. or RICMOVAL 
rXDKRTAKKR \ O- J O-i^^JLO^^^' 

30 5 Chv^r^lc^v, U'. 



fAddresK 



N. B. Every Item of informntion should bs oirefiilly supplied. AGE should bo stnted EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In pinin terms, thnt it mny be properly clossified. The "Special Informntlon" for per- 
sons dyin4 away from homu should be iltiven in every instance. 




ft 



fl. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Ho.'ii.l of Mtrtlth' K No. n 'fr'*^^^. lUt I' Cf» 



111 



I)(ffi' Ft Jed, \ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Registered Ko. 



247 



W 100 H, 

AjiyxMH Deputy Health Officer 

DEPARTMENT OF PUBLIC liEALTH-City and County of San Francisco 

dcrtificate of Death 

( Xa. S. StanDarD ) 
PLACE OF DEATH: — County ofO/CLAV 0;va/>xac4.Cf> City of C'/OL/Tu Ja^Wv^^v^Cci 



' Wo. LCLu ^^ Wu./Y 



WUwtal 



' St, 



Dist.; bet« a nd 



/ f ir DEATH OCCUyfe AWAY FRoL USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 

\J V IF DEATH OCdpRRED IN A HOSPITAL OR I N SJI^TUTIO N GIVE ITS NAME INSTEAD OF STREET AND NUMBER. ) 



^ 



FULL NAME J A^f^Jk.AAau'Cl). 









s 1 ; \ 



PERSONAL AND STATISTICAL PARTICULARS 

COl^OR \ 



(hwL 



I) A ri-: <>!• HIKTH 




I Month I 



u 



(Day) 



}Jjb 



% 



rl'hl 



(Vear) 



\<*.K 



11 








I> 




SINT.I.K, 


M A K U 1 1- 




\VfI)«»\VK 


I) OK DIVOKC 


KI) 


(Write ill 


social (Us 


il,Miati 


on) 


luk rnpi. 


AOK 






(St:itf or I 


niuitry^ 






NAMK ni 








FATJIJIK 








niRTHI'I. 


M'K 






()!■ 1- AT! IKK 






(Stall- or Country^ 







}>.; 



Moulhs 



Da v.v 



MEDICAL CERTIFICATE OF DEATH 
DATK OK DKATH 

^u ^ 

(/^onth) X (Day) 



T9o\ 

(Year) 



MAIDKN NAMK 
ol .NH)THKK 



lUK'i'inM.ArK 

Ol- MOTIIHK 
(State or Coiintrv) 




iyn':J<I-;HV CI-RTIFV, That r attended deceased from 

)l/t" ^^° *^ ^*A o^W ^ ^^^ '^ 

that I last saw h<VyK alive on yuJUjl H igo H 

and that <leath occurred, on the date stated above, at I I 6 6 
• U. M. The CAl'SI-: Ol- DlvATII was as follows: 




!v<l5., 



DERATION Years 
CONTRinrTORY 



Months 



Days 



Hours 



DURATION 
(SIGNED) 



Years 



Monf/is 



/Fours 
M.D. 



} 



OCCrPATlON J! 



yuJLu 11 iQoM (Address) UUi H. Co A} (Hlkt 

SPECHAL Information only for iVospitals, institutions, Transients, 






.!/,./////> 



/>, 



or Recent Residents, and persons dying away from liome. 

\d\\ Ot&okAtrvv. ot Place of Death ? ^ 



Former or 
Usual Residence 



Days 



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



TH1-: \HOVK STA'ri'.n PKRSONAI, PAUIICri.AKS AKl' IKIK I'o TMl-; 

HKST Ol' Mv kno\vi,i:d(".k and in:yKK 

(Inrormaiit X^VVOX 



sD in:LiKK 



Xildrcss VA^V\ 



PI.ACK Ol- niRIAU OK KKMO\ AJ. I DAT); of Ht'RlAI. or KKMOVAI, 



Q-LcL wV»-A^ 






IQOH 



rM)i;KTAKi-:K 



(Address 



Cl/N t 



30 5 0>Ur-^l 



n 



!N. B. r.\cry Item of infornuition should b? carelrully nupplied. AGB should be ntnted EXACTLY. PHYSICIANS should 

stnte CAUSE OF DEATH in pliiin terms, thnt It may be properly cInssWIed. The "Special Information" ?©r p«r- 
sons dyin^ away fpom home should be il^iven in every iuHtance. 









: rlf fl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Bonnlof Ilenllh-FXo . s *^£^^ US: P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jieglstered JV*o, 



•cL^vvvo -Li/v-u Deputy Health Ofr?crr 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eath 

( "a. S. StanOarD ) 



J? ^ J? «J 

PLACE OF DEATH: — County of O/Olav J A.^ax.c.<-Ac< City of Ocu^v A^X-W'C\.<ico 



2481 



No. MHH dbacV 




it 



St.; t 



Dist.; bet. UJxI)AU>v and Gxll 



(IF DFATH 'OCCURS AWAY FROM USUAL R E S I DE N C C G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEA-rVt OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



>vUr\jL ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



srx 



4 

4 



(3f I 

D.\TK or- lUKTU /Tn 



COI,OR 



iDlvh 




LvulI^. 



MEDICAL CERTIFICATE OF DEATH 



(Month) 



(Dav) 



/.n.x.. 

(Vear) 



AOK 



.w I )v<jiv b 



Miitilhn 



3.3 



Davs 



SINT.l.K. markit:!). 
WinoWKI) (»K DIVOKIKI) 
(Write in social clcsijirnation) 



'V'>X 



( 



HIKTHPI.AOK 

(Stati- or Cotintrv) 



J- AT Hi: R 







(D 

(Day) 



/po H 

(Year) 



I HHRRRY CI':RTIFV, That I atteiuled deceased from 

h\X ^0 1903 to ^h^LjL 16 U)0 H 

ist saw h "thj alive on /i'^'^^ ^ '90 *t 

atid that death occurred, on the date staled above, at I oO 
\|. M. The CATSr: ()!• DIv.ATII was as follows: 
Myiu}uJL D'oXv-saXoAj «t' voXolax (Jt.fcLi Jb.x.a-vt 



i 



»•! 






niRTMIM.ACK 

Of lATlIKK 

I State or Country) 



MAIDKN NAMK 



niRTlIPLACH 
o| MOTHHR 
(State or Country) 



Dl'R.XTION ( }'fars io Mouths' Days Hours 

C ( )NT R I in 'TOR Y \k.^JQ^^r^.A^Ax .(!.D.vv..d\.irl \\^\,<Xx. 



\Mj.] 



DIRATION -r Years (d ^rouths ^ Days ^ Hours 

(SIGNED) L). G Vl/U'lrVCA.vu M.D. 

.LU^l'I 190S rAddn-ss) S^* U<X>vv)llc4^ U\M.. 



i 



Special Information only for Hospitals, InstituHons. Iranslfnts, 
or Recent Residents, and persons dving anay from home. 



AV 



■^idrii i>i S,nt f't oiti is,-n ^1 r<-(7»> t M.oith^ Jt ,^ Ho \ ^ 



THl-: \KOVK STAIi:i) I'KKSONAI. PAR llCf I,A K S AKH TRIH TO TMH 
BEST Ol" .MY KN<>\VI,i:i)f.K AM) HIIMHF 



(Infornmnt 






Former or 
Usual Residence 

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



HoH long at 
Plare of Death .' 



Days 



PI,ACK OF ntRIAI. OR RKMo\AI. | DATK.if UtKiAl. or RllMOVAI, 



Jy<Aj 



f A<l<lres»< 



Apg-Lj La 

rNDKRTAKHR )t ' 



I90H 



(Address 




IN. B.- 



-Every Item of information should be carefully Kupplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special information" for p«r- 
aons dying away from home should be gi%en in svery instance. 



T 



m" 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hoanl of HL-.'iltli I" No. l<, t"r^^r^^ IU«vI' Oo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J)fff(* Filed , 




Deput 



lOO'i 



Registered JSCo, 



249 



» r 






^^, 



lier 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( Ta. S. StanDarD ) 

PLACE OF DEATH: — County of <X/r\j AXX/VtOLAOi City ofC)(a>>V' o AX]La^v^a.4.C c 



fNo. ^JAl^"yvCyV\' 



St.; 



Dist.; bet* 



and 



(IF DEATH OCCURS kwAY 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 




\\X 0.\JLC 



L>u.|. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

j COI,OR > 



QUccL 



SjA^sjJJl 



DATH <)!■ HIKIll 



(Month) 



(Day) 



/lis. 

(Vear) 



AC.H 



So 



) '/•(/ ; A 



M.ni/hs 



Davs 



w iiM)u Ki) OR nivuKi}-:!) 



Wrifriii •iocijil (lisiv:iiali<»ii) ] i\ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

\l 

(Day 
I HERRBY CKRTIFV, That I attoiKled deceased from 
5^ I90S to^.. )|^U^ icp ^'l 





that I last saw h A/YVvalive on 



KS 



II 



BTRTfflM.ArK 
(Statf or Couiili y^ 



FATIIHR 



lUKTMIM.ArK 
<)l- iwrnKR 
(State or Country) 



MAIDI-.N X.\MK 
<)l< M()I"in:i< 



niKTiiri.AOK 

OF MOTHFR 
(State or c"o»iiitry) 



^ 



AJO^-y^JUL 




and that death occurred, on the date stated above, at d^ 
ir M. The CATSH Ol- DFvATII was as follows: 

. .Q.ri/^rvA.L^^t.v^ 

(3 



V 



VJ <VvA^ /VOL > V/Q.C 

? 



Dr RAT TON Years Months - Days 

C O N T R 1 1 a' T ( ) R V O/^.-v our* x. vLv 



Iloiit s 



r'.>.'V:OU:>.x..vA^v.crjx 



DURATION Vrars 

(Signed ) 



Months Pays 



vVvvU i()oS (Ad.lress) io 2 3 U <xl 



I /ours 

M.D. 

k 



OCCT'PATION 
Re 



1 1 ^ 

stiff if in Sill' /'lumisro I )^(f/v- A/niff/i.'! ' /></i.v 



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

Former or Vl 

Usual Residence J.'U.>\ 



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



7 5 %. 1 4 I How long at ^ 

J.\X>\ ZA\} (IOM.^A.X<J.X piare of Death ? I ^jts.t... #tys 



Till". \HOVl-: ST ATI*. I) PKKSONAI, I'A KI"U" r I.A KS AKl! 1' K T F TO THH 
HKST Ol- M\,KNo\VM;D(iK AND MliMHF 



(IiifoMiiritit 



\JU^^zX\; (/b o-^lxvfccjJL 



( Add re 



FI.ACK Ol" IHRIAU OK RFMoVAI, | DATllot HtKiAi. or KFMoVAI. 



Ul- m Kl.\ I, ( »K K J-..M( M 



190 s 



rNDi:KTAKF:R 






fAddrt-HS^ 3>0S \H^AA:ioA.r .UaK 



N. B. hvery item ni inform.itlon should b.' Liiret'ully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

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



! 



^ 



Wi 



V 



m 



WRITE PLAINLY WITH UNFADING INK 



Ho.ii.l .-f Ili.'ilth- I' No. i^ -^^^^^ifc lUt I' Co 




— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Filed, WLu 1^ 100^ 



Regisieved J\'*o. 



250 



■ » J • -J. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 





Certificate of Beatb 

ofC'/CU>v vJ.rva/WCVsLCX City of^'<^^^ ,AUX/VU1V4 1 c 




iV^ (i ^^ n.>vur 



JUrWoLAwlw^t CJ-Ow/YvCtoJvUA/rfit;; — Dist.; bet. a nd 

/ IfIdEATH occurs away from usual residence give facts called for under "special INFORMATION" N 
V IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




L 



^AJL^V 




/cCl 



-CK; 



SKx Q^ 



PERSONAL AND STATISTICAL PARTICULARS 

coi.ok 



DAll". OI" MIKTII 



oJui' 



LoJv^. 



I Motuhl 



5- , 

(Diiy) 



, "il b 

(Vear) 



AC.K 



11 



10 



M,»illis 



Da vs 



SINC.I.l-:. MAKKIHI). 
WIDOWKI) OK l)lV()Kii:i) 

(Writi-iii s<K*i:il (1< ■^itrnatinn) 



lUKTHlM.AOK 
(State or Contitryt 



NAMK ^^V 
FATUliR 



(^ 




\, 



cccL 



JUXOJ^ 




niRTHPT.ACK 
<)l' I AIHKK 
(Statf or Country) 






iU. 



r>\j- 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII 

' XkL^l I..1. 



Month)/ 



(Day) 



IQo\ 
(Year) 



Q I HERIiBY CRRTIFV, That I attciuled ileciased from 

cSx^t. ID 190 a to^-lvvIL ...I ..D 190 H 



190 '1 

that I hist saw h '^^ alive on V^<>^ '^ 190 

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

U M. The CAUSH C)I< DIvATII was as follows: 

0> 



vj -VA^f>rt^./CA^:MH^,vO... U -il\Xi^tt-\ <V,i. 



DURATION ^ Years ^ J/of///is Days 

CONTRIBUTORY ....u:L\xsr^ wy,>^.:5J.A,A^... 



Hours 



MATDKN NAMK 
()!•■ MOTIIHR 



niRTHPUACK 
OH MOTHKR 
(State or Country) 



cbwri 



y\Jr\jJT^. 



M 



OCCl'PATIO 



% crv^^^ vAj-^Xe. 



I ) r R A T I O N ^ ) 'ra rs Mon ths Days 



Hours 



(SIGNED ) 






V^Im U I()o'< (Address) bOb d-^>-^t i^-\, 1 



M.D. 



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



Former or 
Usual Residence 



30bLol4c^'>v^<^..C^^ prare'ofVath? '0 '"^^^ays 



Ri->iJrd in Sdv /'i ait, ism ^[^)'riii< '^ Mi>iith^ 



/hi\.s 



TMK \m)VK STA'ri-:i) I'KRSOXAI, I-\KrFCri.ARS AKl*. TKrK To TMK 
IIHST Ol" MY KNOWI.KDC.H AND MlUJlCF 



(Infornjant 



(A'ldrcss 






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






^i 



How long at 



PI„\CK OF IHRIAT, OR RKMoVAI. | DATF: of HrKiAl. or RF:M0VA1, 






r N I ) K R r A K K R W -iAAJLvvu L v<X>Cv vX ^ f^ V X WUA. ad dU v\Jl ctl\o 

<A<Mi ess n XM dJ X\^^ ^ adjLV* 3A 



IS. B. F.vcpy Item of informHtion should be carefully supplied. AGE should bo stated KXACTLY. PHYSICIANS should 

state CAUSE OF DKA TH in plain terms, that It may he properly classified. The "Special Information" for per- 
sons dyinfl away from home should be ^i^cn in every instance. 



-f 



1 



■'■ 



ft 






u 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of Hcnlth K No . ^ *.??^^ H&F Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((fe Filed , 



<L^KAA^ 



la ioo'\ 

Deputy Health Officer 



Registered J\^o, 



851 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( xa. S. StanDar^ ) 



Ji 



(^ 



f^No. M 



PLACE OF DEATH: — County of OiaAV O.MXiva\ACcCity of'^'C^Vu .^va >^cv*. c o 



'<X.cU 



/VM. 



r^ 



L Dist.; bet. C' /CC/^v yjAAA/y\^ and Iv a.\.-L ) 



Ic 



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



FULL NAME 





A^ 



:<XL 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



(W 



x^^v^v^/oJut 



"'" kjj^u 



DAIK UI-- niK'ni 







HO^ 



ACK 



) 'ra I 



M.mtlis 



\^ 



(Vear) 



/></!. 



SIM.l.K. MAKklKI). 
\VM)<i\Vi:i) OK I)IV(>Kri:i) 

iWiitiiii siK-ial <k"-iv:ii;iti(jn) 



Ova 



HIKrnlM.AOK 
(Statf or Countryl 



NAMK Ol" 
I ATIIIIR 



rURTHPI.ACK 
OK lATHKK 
(Statf or Country^ 











Levi 




"V.A.<nx: 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



Lev 

(Monthlf 




. i.Ci. 

(Day) 



(Year) 



I HICRIiBV CICRTIFV, That I attended deceased from 

190 to ' I90 

that I hist saw h rr— alive on ~ i<p 



and that death occurred, on the «late stated above, at 



M. The CAl'SB OF DIvATII was as follows: 



'\.,xrvA^ 






s^trtx 



MAinKN NAM1-: 
Ol- MOTIIKK 



^)lc. 




inKTIUM.ACK 
oi- MOTHRR 
(State or Country^ 









DURATION Years 

CONTRIBUTOR V 



Months 



Pays 



Hours 



Oe^TL 



dL 



OCCUPATION 

h'r^idr.i ill Siitt /'kiik /lo \ )V<m> (^ '\foiifh- \\ /'<n 



DURATION Years .^foutlis Hay.^ 



(Signed) 



vcL. 



I /ours 

M.D. 



KjO 



(Address) C(rV<r>vi.V^ 



L(r\<rvve.V^ u \ \ ', «:„.. 



FECIAL Information only for Hospitals, Institutions, Transirnts, 
or Recent Residents, and persons dying anay from fiome. 



IMl" JlHOVK STA ri:T) I'KKSONAl, I'AK IHT I,A KS AK K TR f H in IFIK 
liHST t)l- MV KNOW 1. 1; DC. H AM) Jn.l.n^F 



(Add res'* 



h(? 



CVvv^ 



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



.. Days 



ri,ACH OI" HrRIAU«)R RKMoVAI, | I)ATi:of Hcriai, or RKMoVAI. 






N I ) 1: R T A K V. R O ^^LcVt'^V O oXX ll/wcl ; 



■h 



IS. B. Rvery Item of InformHt'ion ahouftl b^; ciirefully Hupplied. AGB «hould be stntetl EXACTLY. PHYSICIANS «hould 

•tate CAUSE OF DEATH In plnin terms, that 5t mjiy be properly claHslfled. The ''Special Information" for par- 
Rons dyin^ away from home should be ^iven in every Instance. 



I 



Y "♦ 



T 



lii 



4f 



[)(i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Iloanl of IIc-:ilth- I- No. i^ - '--i^!:^ H& P Co 



l)((te Filed, 




VJO'K 



Begistered JYo, 



<vO'^ I 



Deputy Health Offlc-r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of 2)eatb 

( *a. S. StanDarD ) 
PLACE OF DEATH: — County ofO/CL-Yv AXtAXXM^^c^cCity ofO/CUVv 0;vo. -vvcvi. Co 



\ 



(No, 




M^^'^^^^^ 



OU^Mr^w^ ^ ^ &-M^^^<^^^ St.; Dist«; bet. 

3IDENCEGIVE FAC 

) IF DEATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE I 



"~ and 



/ V DEATH OCCURS AWAY FROM USUAL R E S I D E NC 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 

COI,OR 



Vi iVcJui^ 



DATK OF HI kin 




fVC 




XXM.. 




hh). 



WEDICAL CERTIFICATE OF DEATH 



u 




II . 

(Day) 



(Veur) 



A<*.K 



Tt-flk... }'(•«;> 



.^hinl/is , Da \s 



SINCI.K. MAKKIKI), 



\vil)n\Vi:i) OR DIVORrHI) P A 

(Wiitfiii MK-iitl (Ic'^ij.' nation) ~\ || 



nTRTJtPLAl'K 

(State or Country) 



NAMK OF 
FATHMK 







HIRTHIM.ACR 
OF I AIIIFR 
(Slate or Country) 



maii)f:n namf: 

OI MOTHKR 



ihrthplack 
oi- mothkk 

(State or Country) 



Cj ^oM1JLol/>xA 




occ 



U PAT ION (^ I 4 -„ ^ 

AV'.W(/<"f/ III Siiii / idiiii'i'ii < )'i<ii 



L)F:Arii 

i.boCi.cy)\ 



/po'i 

(Year) 



DATE OF DKATH 

'' vlu 11 

(Month) f\ A (Day) 
I UI-:RI';HV CI-KTII'V, That I attended deceased from 
^ IqoH to Nkwlu. .1.1 IQO H 

J [} ft n' 

that I last saw h ^>>v alive on ^^^^*^^ ^^ I90 N 
and that death occurred, on the date stated above, at o o 
CI M. The CAISIC ()!• DI-ATli was as follows: 

.'A^.^rv-txsj Vj ^ 



I rv?wL^s<^:^.\,.(r^ A-ucc 



I )r RAT ION *" )'t'ars ^ Mouths \ Days " Hours 
(." ( ) N '1' R I H r T () R \' LL^UL^Vrv %-V<N» A^JJr-YTv. . .Si &- V <w.a:>:v;. 

Months Days /fonts 

>v<V vi>^vC.)kXjLu M.D. 

V^Uj^ ig iQoH (Adilress) Vj ^CV^OC ADo-^^vt? 



DT RAT ION Vi-ars 

(Signed ) L/v>v^ 



Special information only for HospltdlS, institutions, Transients, 
or Rftrnf Residents, and persons dying away from liome. 



1, 



U. ///A. 



/',/ 



Tin-: AHOVK, STATHT) PKRS<»NAU PA RTHT I.A RS AKF: TRl'R TO TIIK 

hf:st OI- Mv kno\vij:i)c. f: and ni:Mi:i' 



(Informant LU (^VVAj . CJ 



<OL^WNwV\-^' 



I 



(A'Mrf>^s 



IW 



\ 



(yvo-cv\ 



a ^t 



former or ,tc<5^'/K^ j \\ How long at 

Usual Residence i C> ^ (lO(Kvva\A^n pia« of Death? ^ ^^ „■ Days 

When was disease contracted, ^ ^^^-<vU. U % 
If not at place of death ? 



»-4 



eath / .^ Day 






.a )^..j.v. 



PI.ACK OF lURIAI. OR RHMoVAl. j DATFof Hriu.At. or RF:M0VAI, 

mfc O-Lv^ I }^^tt i» .90' 



0^ 



u 



N. B.- 



-Every Item olt inffopmntlon Hhoiild h.- cnrefully supplied. AGE should be Htatetl EXACTLY. PHYSICIANS Hhould 
stnte CAIISF. OP DHATH in plnin termft. that it may be properly cfaHsifled. The "Special Information" for per- 
sons dyin^ away from home Hhf»iil«l be fti\en In every Instance. 



i'il 



i.. I 



! %■ 



^^i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

"""" 853 



Hoar.l of HcMlth-K No. i^ ^^^*2^ "f^l' ^>> 



I)(ffe Filer/, 



I a 



Be^lsteved J\^o, 



loa ■ 

Deputy Health Officer 

DEPARTMENT # PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( tl. S. StanOarD ) 

PLACE OF DEATH: — County oi^O^r^ J/V(X>vC^C<>City of O/OavO AXX>vttV4.e.o 



(No. 




St.; ^ Dist.;bct. 

SIDENCEGIVE FA 

DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



lb 



tl 



and 



itL 



/ IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" ^ 
( "^ ,VtT.",?r^^r..»»*V.^ . ^««o.T.. OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



Q^ 



FULL NAME 




1 

M 




^M. 



1 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OK 



d^vL 



lOJ 



VUJL 



DATK OF MIRTH 



lvv>\JL a^ „ A^X-. 

C^wiith) (Day) (Year) 



AOK 



JL Years 



Mouths 



Vh 



navs 



SINC.l.K. MAKKIHI). 
\VII>()\Vi:i) OR DlVoKrHl) 
(Write ill soci^il (ksi<.rnation) 



niRTHPI.ACK 
(Statf or Country) 




NAMF, or 
FATHKR 



niRTHPI.ACK 
or FATHKR 
(Statf or Country) 



MAIDKN NAMK 
OF MOTIIKR 




UlRTin'I.ACl", 
Ol- M()TnF:R 
(Stall- or Country) 







O^cv^ 



OCCUPATION 



'ffi'ird III Siiii I'l tith i^i''> ••*< 



AV,'/. 



V.„i 



}/.;if/l< I i /^/i 



III}- AHOVK STXTFl) I'KRSONAI, I'A K 1" U" F I,A RS A R f; rRFK I '> 

nF;sT oi- Mv knowmux'.f: and nF:MF:F 



I" 1 1 )•; 



MEDICAL CERTIFICATE OF DEATH 




II 

(Day) 



(Year) 



I in^RF.RV CKRTII'^V, Tliat I attended (leccase<l frotii 

.QVUXCA n 190 H to |vvLa. 1 1 uyo H 

that I last saw h-A.^vx alive on H^^'U^ VO 190 H 

and that death occurred, on the date stated above, at li'sJ v 

LL M. The CAl'SI': Ol' DlvATII was as follows: 

U^JuU-sA^'Ot^ .U^/.^^ 



DT RAT ION ^ )'t'(jrs I Mouths " Days " Hours 
CONTRinrTORV a^<r>vcK.\-vA^Lvo 



Hours 



nr Nation ^ Years "X Mouths 3 Pays 

(Signed ).. J Jvfrv>v<x^ u yawto M.D. 

_wivA II H,nM (Address) lOa.'>^VvtUvd 



rfc 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residentb, dnd persons dying away from fiome. 



Former or 
Usual Residence 

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



HoH lonq at 
Place of Death? 



Days 



(Tiifotniant 



G . ^yujx^ 



(Address 



111 



LUUrvcrvv Iwc 



I'l.ACKOF lU RF\I. OR RHM<»VAI, 



o-u^- V/W^^ 



DA IF. it HiKiAi. or RF:moVAI, 

Vclu 13^ 






I90H 



INDFRTAKKR J /CL wl ^Va-^, ^O 'W^ 

(Address W^^ vX^-J^aciTV V...djt. 



!S. B. F.very item ot' information shoiihl be cnrefully supplied. AGE should be stnted BXACTLY. PHYSICIANS should 

state CAUSE OP DF.ATH in plain terms, that it may be properly classified. The "Special Information" for psr- 
sons dyin^ away from home should be (^iven in every instance. 



\ 



^*1<fe^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



}!o;ir<l of Iltalth — K No. is '^^ 



i\ 



/ 



I 



H& V Co 



RCPER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 




.P..e.p..y" 






Registered JYo, 



254 



i r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( xa. S. StanOarD ) 

PLACE OF DEATH: — County of O/CLOA; J /UV>vCA^/C^City of O/OUVu 07vx3la^v/c^^^.c 

)XWrL^-\^c<>. St.; S Dist.; bet. liJxlKltiAj and J ■VU/>tv^.U. 

/ ir DtATH OCCURS AW*V FROM USUAL R E S I DE N C E Gl VE FACTS CALLCD FOR UNDER "SPECIAL INFORMATION" \ 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Wo. 



FULL NAME 



I 




(JA^CULi \l f V pU .Cnr\/>x.' 




SKX (^ 



PERSONAL AND STATISTICAL PARTICULARS 

OX/VWoJjL 



COLOR 



Xrrsx 

DA'll-: OF lUKTH 



iDJLt. 




MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



ACK 



<^>? Yeats V. 



(Year) 



Months * /></r.s 




iMoiitli 



11 

(Day) 



(Year) 



SIN<;i.E. MARKIKD, 
WinoWKI) OR DIVOKCKD 
(Write in s<xmm1 dcsiKiiatioii) 




lUKTMPUACK 
(Statf or Couiilry) 



XAMK OF 
FATHFR 







KIRTHPI.ACK 
OF FATHER 

(State or Coiintrv) 



MAIDEN NAME 
Ol- MOTHER 



MIRTm'I.ACE 
OF MOTHER 
(Stale or CcMMitrv) 






I ^KREBV CIvRTIFV, That I attended deceased from 

"^ 1901 to I^aXul. .1.1 IQO H 

that I la.st saw h tVv alive on vl^lu, I igo 4 

and that death occurred, on the date stated above, at ^ 
^ ^i- The CAUSE OF DliATII was as follows: 



Jl 



r 



1 



\ ^ • P '0 



DURATION -y.ars - Mouths 7 Days ^ Hours 

CONTRIiU TORY Ul 



[•:VULN.^.U^^....LjLt3u.vvU; 



\A,MX,.. 



DURATION - Years ^Mouths " Days 

'^ ^ ^ » 

(Signed) J J Jxi-vtvJiHj-tnv 



OCCrPATION 




>^ IQOH f.Ad.lress) 3.|Via-VvUL.U C.Vt 



Hours 
M.D. 



D^^9'fi'-J'^fO"'^'^"'"'ON only for HospiJals, Institutions, Transients, 
or Rccrnt Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How lonq A 

Place of Death? Days 



THJ-: AMOVE STATIU) PKRSONAI. PAKTUrUARS ARE TRl'K TO THF 
IJEST OF MY KNOWl.EIX.E AM) HEI.n:F 



(Iiifoniiant 



(Address 



i n 



''''\^/"' "'''*'^''"'' '^'••^"'^■^'' DATEof M.K.Ai, or REMOVAI. 



NDERTAKER U /COuL/VlAJL ^'fUxN^vVVV 



1 90S 



^Address 



5XH ^U^Lktc... jt. 



IN. B.- 



'^1^7 ^CL^K^^t '^IZTT^lT'^^^'f^ *" carefully Huppllcd. AGF. should be stated EXACTLY. PHYSICIANS .hould 
•tate CAUSE OF D^ATH .n plH.n term., that it moy be properly classified. The "Special Information" for Dsr- 
sons dylnii away from home nhnuld be Itiven in every Instance. 



A^V? 





» , 


A 


* 




., - 


'..'A-^-m ::. 




- 




f ' 


• 


Hh 


>' 


< 


A 


t: '■ 


xi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



4 



; t 



lUiard of Hfiiltli — I' No. i^ '^^^^^^B&.V Co 



RCFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



7)af(' Filed, 




190^ 



Registered JSTo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certiffcate of SDeatb 

{ 'a. S. StanOarC> ) 

(Tin 



PLACE OF DEATH: — County of OcLooj O.^^Olavc:>U5X^ City of ClcL^rvjvJA<X/>x>CAA/ao 



No. 6fc. /duw^l^u Jb^4vA:i<xl 



St. 



Dist.: bet. 



~~ and 



f IF DEATH OCCURS *wkv TROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "S FECIAL I N FO R MATIO N -N 
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 > 




y\Jb 




UL: 








DATK «)I- lUKTU 



?) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



I Month) 



..H. 

(Day) 



/111 

(Year) 



\C,V. 



S^*^ Yeats I M.oilfis Jl 



[Month 



I 



1 



II 

(Day) 



190 H 

(Year) 



Davs 



SINC.i.K. MARklKD. 
WIDOWKI) OR DIVORCHI) 
UVritf in social il\si}.Mi;iti()ii) 



BIRTIU'I.ACR 

(State or Country) 



NAMH Ol 
FATHKR 



HIRTMPI.ACK 
iW FATHKR 

(Statf or Countrv) 



MAIDKN NAMK 
«)|- MOTIIKR 



lURTHIM.ACK 
<H< MOTHHR 
(State or Country) 




.1 HRRHRV ClvRTlFV. That I atten.lccl deceased from 

iP^ '^ '9oH to ..|vJL U 190H 

that! last saw h ..r<A^ alive on Ua^^JLu 1 1 I90 H 

and that death occurred, on the date stated above, at ll Ol5 



^V M. The CArSK OF DIvATlI was as follows 




^JtvoXv^jw. 



OCCUPATION 

h^fsiiirii in Situ /'i il III i.^iit 



O )'i III ' 



dVraTION ^ Years ^ Mouths ^ Days ^ Hours 
C()NTR IIUTTOR Y t>il<Xh^'>>N^xJb. .(^^ 

DrRATlON........ )V^;., P. JA„,,/,, j^^^y^ jj^^^^^,^ 

\A ''3-v»vy^4jucj>v M.D. 

(Addrrs.) ipg ' a tk T^if 




nr^irS9^ft'-,"^f°^'^^''''0'^ ""'^ '"' Hospitals, Institutions. Translpnts. 
or Recent Residents, and persons dyiny dHd) Irom home. 



)A./////- 



I'll 



THF AHOVKSTXTFI) I'KRSONAI, lA K III! I.A RS AR F TRIF To Till- 
DKST OI- MV KNO\VM;i>C.K AM) IIIM.IKF 

(lufonnant mKm) OYI V (]1(^>N±;5 



Former or *n t, ^ flfVi 1 , Now lonq at 

Usual Residence Xb'XW] wV<Ulv^^vj\jv^ piare ol Death ? H Days 



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



I'l.A^F OF lU RIAL OK RHMi»VAI. I DATl-o: HrKiA.. o, RFIMoVAI. 



r.NDKRTAKI 






190H 



'.Address 



N. B.- 



"rtoVe^c'll'sE^of d7;^ThV''T'^ ^ -rofully nuppiied. ACiK .hould bo Rtated tiXACTLY. PHYSICIANS .hould 
•tote CAUSE OF DLATH in pl„,n term., that it m„y be properly classified. The "Special InlormHtion" f.r dt- 
i»on« dying away from home nhould be ftiven in every instance. iniormBiion T«r psr- 







r 



?- 



a* 



-^^ 



»iBr» 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



){orn<l I 



if Hf.iUh — FNo. 15 3^^^^?I{&PCo 



REFER TO BACK OP CERTIPICATE FOR INSTRUCTIONS 



J)(tlc Filed , 




190'\ 



Registered J^''o. 



856 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 

( ta. S. StaiiOatO ) 
PLACE OF DEATH: — County ofO/O/vu J >^OL/VsX>LA^t^ City of CJciAv A^aA^vec^Ai^ 
rNo. ti /uO^vklv^ .St»; . H Dist.;bct*. Al^/CL^k and UXX^C 

(IF DtATH OCCURS AWAY FROM USUAL R E S I DE NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ || 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / ^ 



FULL NAME 




•^Kk 



PERSONAL AND STATISTICAL PARTICULARS 
SKX (K\ rt I COI,OR 



Jtz-vTuxLt 



DATK OI- lUKTII 



(MoiAh) ( 



UjJkJjl 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 



\ 



. 1 1 

<Day) 



./...g..C)..H.... 

(Year) 



ACK 




onth) X 



(Day) 



(Year) 



Ytwts •- Mutilhi 



Pavs 



SIvr.i.K. >fARKIKI). 
WIDnW'i:!) OR DIVORCKD 

(Writf in MK'ial iltsivrnalioii) 



O-X^y^UlAjl 



IHRrffPT,ACK 

fStatf or Coutilry) 



WMK <»K 
FATin:R 



A ^ ^ 



BIRTH FM.A*.K 
OK KATHKR 

• State or Coiiiitrv) 



MAIDHN NAME 
OF MOTHHR 




d^ VJ OA.. 



I 



I Hr?RKRY CHRTrrV, That I atten.led deceased from 

}^^^' ^9oS to 

that I last saw h .::— alive on — — 

and that death occurred, on the «latc stated above, at 



190 
190 



M. The CAl'Sr^: OF I)I{ATII was as follows: 

oXJUl (>DCrXAAj 

jS...rv>^'CH3 






DT^R ATION. ...... Vears^ A/ont/is 

CONTKIIUTToRY „ 



Days 



I /ours 



duration 
(Signed) 



}'eat's 



niRrnri.ACK 
OF mothf:r 

(State ur t'oiintiy* 



c 






OCCl'PATIOH *- -^ 

Kf^idfii III Siiii / iiin,/^,.i 






Mouths Days 

UlX iQoM (Address) v^b^. duXtx^;cil 

Special Infori 




Hours 
M.D. 



„ , „ ,, - J MAT! ON only for Hospitals, Institutions. Transients, 

or Rfcenf Residents, and persons dying away from hop*-. 



)v„ 



lA'/////- 



/',/ 



Tin-: amovf: stmfi* i'hksoxai, i-ak int i.ars ark trfk to thk 

IJKST <JF MV KNOW I, Fix. K AM) HFIJ1:f 



(Fiifoimatit 



r\.i.ii.v 



5b^ axvtliA. ni 



Former or 
Isual Residence 

When was disease rontracted, 
If not at plareof death? 



How long at 
Plare of Death ? 



Days 



ri.ACK OF HI RIAL oK kI-;M..VAI. I I>ATF ol Mi kiai. or RFMOVM 
FNDKRTAKFR M I liC'Civ^iaA dU-Uvt) U'VVVaVi\«.ctci ot CclL 



r\(Mi< ss 



[N. B. 



Hvery item of Information should bs carefully nupplietl. AdK bHouIcI be stated EXACTLY. PHYSICIANS «hould 
state CAUSE OF DF.ATH in plain terms, that it may be properly classified. The "Special InformHtlon" for per- 
sons dyinft away from home should be ftiven in •\9ry instance. 






V ■} 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD 



Hoai.l ..f Ik.iltli - J' No. 1^. a^-Fw^i? J1& p Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



D(f/r Filed, 




190"^ 



Bogisfej'cd JVo, 



356 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StatiOatP ) 



PLACE OF DEATH: — County of'-'O.^v JA.<x>vCtAALo City of 0<X/\aj 'VOn^vcoO/Co 



(^No. I^i J/uX'>vk.U>v St.; R. Dist.;bet. V-^oJk 



(IF DEATH OCCUnS *W*V FROM USUAL RESIDENCE Gl 
IF DEATH OCCURncO IN A HOSPITAL OR INSTITUTION 



FULL NAME 



and 



IVE FACTS CALLED FOR UNDtR "SPECIAL INFORMATION" N \ 



GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 




(TV J ,L{Hyd^ ^v. 




PERSONAL AN D STATI STICAL PARTICULARS 

j COI.OR 



-^- im j) 

DATE OF BIRTH 



lOlcU 




(Modkh) 



II 

(Day) 



/...a.D.H... 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DEATH 

l\ 11 

(Day) 



1 

roiith) 



1 



L 



l9o\ 

(Year) 



AGE 



Yfati 



Mouths 



Day. 



STVC.T.K. MARRIED 
WIDONVKD OR DIVORl'KD 
(Writf in «KMal <lt-si>.rnatio!i) 



HI RTH PLACE 
(State or Countrv) 



NAME OF 

fathi:r 



RIRTHPl.ACE 
Ol F.VTHER 
(State or Countrj-) 



maii)i:n name 

Ol- .MOTHER 






I HKRHHV CI'RTIFV, That I atteiide.l .Icocased from 

f^ ^' 190S to 190 — 

tliat I last saw h .^r— alive on — 



190 



ami that death occurred, on the date state<l above, at - 
~ ^^'J^''^n^''^'^''' ^*'' ^^'-^-^'i'H was as follows: 

^......l3.wLtA&C)^v/\Aj 

„^..«.« jS...o > V 0^ 



A-o-vt/ix 




lUKTmM.ACR 
nl-- MOTHER 
(State or Countl^J 



OCCrPATION — - 

Rfyitirii in Siiu /■'> ntti i.'.rii 



L\ 1 ■ 



DrR.\TlON Yeats 
CONTRIHUTORY 



Months 



Days 



I J ours 



DL'RATION .yiars 



^ - - - Months Days 

(Signed) VK C<x<icvratlaoU\j 

^tMl^ Tqo"i (.Address) ?L'"'. ^cvtti^^ol 

eCial in 



/fours 
M.D. 



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



Vfttnt •* .\r,nifh' 



/). 



THI-; AMOVE STATED I'KKSOXAI, I' A K IIC r I.A R S XKl- IKIJ- T« t TIIF 
HF:ST OF MV KN<)UI.i:d«.E AND BEI.IEF 



Former or 
Usual Residence 

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



How long at 
Place of Oeatfi ? 



Days 



(Infonnaiit 



(A.Mrc 






I'l.ACE m- HI RIAL (.k REMUVAI, j DATE .,f Ht k,ai. or REMOVAI. 

LlvLA.Ar ol C«.L I VW '3. igoi 

MlWU<:aA dlJ-Uvt) IWx/vxj'n^^^f j^ Cat 



I » , .-» V. I-, 



(Aihlrenn 



ai^vUtiA e.iLu^ 



'\ 



\..: 



I 



IN. B— ^ver> item onnform,.^^^^^ be carefully supplied. Mill should be atHte.l KXACTLY. PHY8ICIAN8 .hould 

state CAlJhE 0» HI ATH in plain terms, that it may be properly clasRified. The •Special Information" for d«p- 
Rons dyinft away from home nhould be ftiven in «v«ry instance. 






•***. 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Board of lltalth- F Xo i^ ^"^-^S^ U&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



T)ato Filed , 



\x 



190^ 



Registered JsFo, 



857 



cU^„v^ IxoMj Deputy Health Omccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( "CI. S. StanDarD ) 



PLACE OF DEATH: — County ofO/aAvJ.tuX^KVCA^^yCUi City of CJ/CU>vOAxX/>vca.^!u/co 



Wo. 




X 



lEATH OCC 
DEATH O 



URS/iAWAV FROM USUAL 
CCUARCO IN A HOSPITAL 



L RESIDENCE GIVE fac 
OR INSTITUTION GIVE I 



JJo-l/t' 



St.; \^ Dist.;bet.daAv WJl SX/vMi and <^ Q-I^M^ 

TS CALLED FOR UNDER "SPECIAL INFORMATION" "N 

TS NAME instead\of street and number. / 



) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



DATH OF lUKTM (\7\ f\ 

JX-ir 

(Month) 



COI.OR 



lllijU 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



-1 

(Day) 



(Year) 



a<.h; 



) V*</ » > 



Motilhi: ^. 



Davs 



SINC.I.f:. MARRIKD 
WIDOW f:i) ok DIVoRCKI) 
(Write in social dt'siKnatiuii) 




avvA^^L 



hirthpi.acf: 

(Statf or Country) 



namf: Ol- 

FATHKR 



HIKrinM.ACK 

OF fathf:k 

(State or Country) 





(Day) 



(Year) 



^ HKREBY ClvRTIFV, That I attended deceasecl from 

Vlll^CXLjL i 190 H to ^l^l^ 190 H 

that I last saw h ...-Vv alive on ^ivA^Lu /I 190 H 

and that death occnrred, on the date stated ahove, at S XS^ 
^ M. The CAUSr: OF DICATIT was as follows: 




maiih:n namf: 

01 MoTHFK 



RIRTHPI.ACH 

OI" MoTnF:K 
(State or Country* 



OCCT'PATION 



%, 



«f (I ^ 

- r^ 



DURATION Years Mont/is Davs Hours 



CONTRIBUTORY 



DURATION Years Months Days 

(SIGNED) U ^ VJ U>^>^^\, 

-vtu.ll loo'i fAd.lrrss) SlDMOn^Ml fli 



Kfsiiifi! ill Sail //(/;/. /.wo ■_' )'iuti. 



.1 A »/////> 



/>„ 



TH)-: AIIOVI-: SIX II I» I'KK-^oNAI, l' AK !!• lI.AKs A K J-; T K f F lo DIF 
HKST OF MV KNOW I,i;i)(,K AND IIFIMFF 



(Infnniinnl 



^\JLh. 



n\)<Jixu^t 



f Arl(!re«»H 




:CIAL IN 



Hours 
M.D. 



FECIAL INFORMATION only for Hospitals, Institutions, IranSknts, 
or Rpcent Residents, and persons dying dHdy from home. 



Former or 
Usual Residence 

When Has disease (ontrarted, 
If not at place of death ? 



HoH lonq at 
Place of Death ? 



0«ys 



IM.AC_F:oI- IUKIAI. ok KFMoVAI. I DSlFo! IM Ki.Ai. .)r KHMOVAJ, 

13.. igaH- 




rNDl.KTAKKR /I ^ ^ V^'>V/VV^'\) ^<i VO 



IN. B. hvery item of informHtion should be cnreltully Kupplied. AGB should be stated EXACTLY. PHY8ICIAM8 should 

state CAU8E OF DLATH in plain terms, that it mn'i: be properly classijficd. The "Special information*' for p«r- 
nons dyin^ away from home should be ^iven in svery instance. 



I 



Ik ^ 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho.rl of n.Mlth-i Xo .5 TS-g^^iH&HCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I a 100^ 

^ Deputy Health OfTicer 



Registered Jsl'o, 



258 



Date Filed J 

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



Certificate of Beatb 

( "CI. S. StaiiDarO ) 



-? % 



PLACE OF DEATH: — County ofG<Xnru JXcl/>v€ULA^o City of'^'<X/>v \]A_<L/'t\-c*^'Co 



(No. 



133 



,0^cv\.L 



la 



\M. 



St 



1 




Dist; bet.'^/U.C^hXXA^XX/yX) and 




(IF DEATH OCCURS *WAV FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER SPECIAL INFORMATIO 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



FULL NAME 



'" ) 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I cor.oR 




boia. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



DATE OF IHRTH 



ACE 



t-^Vvi^ 

iMontliQ 



1.1 /SOH 

(Day) (Year) 



(y^.'AAj 



JVrtJ.v 



Mimihs r. Davs 



S INC, I.E. MARRIED. 

wiDowKi) OK niV()Rri;i) 

(Write in social (ksijrtiatioii) 



HI K TUP I, ACE 

(Statf or Country) 



-C^x^yUl 



NAME OF 
FATHER 



niRTH PLACE 
Ol- 1 AIHKR 
(Statf or Country) 








th) 



II 

(Day) 



190 4 

(Year) 




-AxLiX/vv 



<k 



m,\ii)i:n namh ^ (s\ 

OF MOTHER ( L[ 1^ 1 

\DXAxLcycti O'V'^v/v^iUJ/OL^YV 



I M^RREBY CI-:RTIFY, That I attended deceased from 

U 190H to.^W^n 190 4 

that I last saw h .^VWali^K? on N^a.v'U^ lA igo H 

and that death occnrred, on the date stated above, at "^ 

". M. The CATSIv 01< DICATII was as follows: 

..........Q tJLl NC) ^X'.y^j U'^0-^t>^<rr^i<:CU<X\t^c.VAjb^fr-^ 

<D X<)X/VOiA/OXv^rYv (nL J Aa/>\a^ <CXm^. vL<XC.tMvta. 

Davs Hours 



nrRATK^N 



) 'ears 



Months 



CONTRIIU'TORY 

o-xxtLsywxixA ol. Jtv^.LL. 



DI'RATION 

( Signed ) 

w ic,oH 



" Years ' i^fofit/is 



Davs 



lUR THPLACR 
o|- MoTHFR 
(State or Country) 



OCCrPATION •- 



K^sidfii in Son /'i tJ>ii iM'o 



)'iun s ...^.......Mntif/is^. /*a\s 



Till-' \UOVE ST\'n;i) I'KKSON \1. PAR ritTI,\RS ARE TRCK To THH 
HEST OF MY KNOWl.i:i)C.E AND lU'.I.IIIF 



(Infill iiiaiit 




( \«1<lre»!i 






\M. 




f Ad<lress) 45*^ \X \D\^<X'Y± C 



vDuv<x'r± at 



Hours 
M.D. 



FECIAL 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 



PI.ACE OF IHRIAI, OR R1;Mo\\I. 



sa 



1 



L>V<>^4^A. 



DVDio!' Mi HiAi, or Ri:.MOVAI, 



\\^^\ 






T90S 



I ■ N I) 1-; R T A K 1: R v /CCC^iU^c Uy>\ <AjAA.<3unJA^ 

(Addres.s . . 1 ll M YVui/a^«^V .t 



!N. K. Every item o)r' iiiV'ormRtion should be cnrufully Hupplied. AGH should he stated EXACTLY. PHYSiC:AIN8 should 

state CAUSE OF DEATH in plnin terms, that it may he properly classified. The "Special Information" for psr- 
Rons dyin^ oway from home should he felven in every instance. 






4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HoMr.l of 11. Mlth I" v.) i"^. ■^^•5^!%^H!kl' Cn 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dff/r /^y/^r/, ijj^ la ifjoH 

O-vcA^ 'XjL^sj^ Deputy Health Of^n-^r 



rVH 



Regisfard J\^o. 



359 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



''No. 



(Tettificate of 2)eatb 

{ "CI. S. StanDarO ) 
PLACE OF DEATH: — County of O.CV"if\) /V a-ivCA.AM City of C'<V>vO A^CVvA./CA.ttyCc 

St.; I Dist.;bet. OA^xll and ^J-«.'V«cltiX 



105 llV 

(IF DEATH 
IF DEA 



QCCU 



Rs AWAY FROM USUAL R E S I D E N C E G I V E facts called for under "special INFORMATIO 

A-^H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



FULL NAME 



" ) 




PERSONAL AND STATISTICAL PARTICULARS 

si-:>: Qr\ ^ j coi.or 






DATl-: <>!■ lilKTII 



(Moiilh) K 



U-Uvv-u 



X 

(Day) 



(Vcar) 



MEDICAL CERTIFICATE OF DEATH 



D.\TE OF ni: ATI! 




(Day) 



190 { 
(Year) 



Af.K 



bo )V,;;v 



1 



Months 0. /lavs 



^Wi.i.v.. MARim-:i), 

WIDOWKI) OK DIVOKtHD 
(Write in s<K-ial <k'si>.'nati<)n) 




HIK rmM.AOK 
(Stiitf or Coinitrv) 



N.\MK OP 
FATH J.R 



lURTHIM.ACK 
<)I- FArHKR 

tSt:itt* or Coujitry) 



MAIDKN NAMK 
OF M()TI1F:R 






I HHRI-HV CI-RTIFV, That I atten.U-d .leccased from 

W>vit ^0 igol to ..|vJL. 1.0 iQoH 

tliati last saw h Xhj alive on T^^-^ ^ I90 H 

and that death occurred, on the date stated above, at 5^0 
..,..,rf.:...M. The CArSI^: OV Dl^ATII was as follows: 

L\.^uvvv^h*2^v^...cnr iJvi i<^- 



t) 




MJRTHPLArF: 
Ol- MoTUKK 
(State or Country) 



1 

3 Vv cL<\aX) _ . 

r 



DIR.ATION ^ rears 3 .^/o>///is ^ Dav^ 
CONTRIRUTORV 



Hours 



.'^^<U^.vvVjl^i.. 



OCCUPATION 



DURATION ^ Vcars ^ Motit/is % /)ays ' 

(Signed) JAxctk (X \Kvvoxji 

A. 1 dress) UXlla<\ka>v xQAclq 



Vlvvtv 



FECIAL INFORI 



f 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospl(ar<, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



laK, Ins 



(Infotniant 



xwv. \n()\i': ST A 11: 1) i'Kksonai, par inr i.aks aki; iki i-: to rn i<; 

UK ST 01 MY. KNOW I.l.IX.K AND I'.l-.I.I i:!- 



Former or 
Usual Residence 

Wl»en was disease rontracted, 
If not at place of deatli ? 



flow long at 
Place of Oeatfi ? 



Days 



ri.ACF 01 in RIAI, OR RF:M<»VAI. I nMFof HiKiAi. or RF:M0V.\I. 



f Aildrcss 



rNI)F:RTAKHR 

(.■\<l<1ress 









N. K. Rvery Item oV' informntlon should h;; cnrefully Kupplietl. AGE Hhould be ntntetl RXACTLY. PHYSICIANS Hhould 

state CAUSE OF DEATH in plum terms, thnt it mny he properly claRsified. The "Special Information" ifop per- 
sons dyin^ away from home Hhniild be (^iven in tsvery inntance. 






m 



*^.,^ 



11 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



HoMr.l uf n. .-ilth- I- Xn, i ■;, '*'?>'^^ HM' Co 



RCFCR TO BACK OF CEBTIFfCATE FOR INSTRUCTIONS 



Registered J\''o. 



I)<,tr Filed, Wlu la 100'\ 

cLc-Aj^^ui dLxoMj, ^^P^x^y ^^thO^-^-^" 

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



fia.f\ I 



60 



Certificate of Death 

( *a. S. StanDarO ) 



PLACE OF DEATH: — County of 



City of \J A^oUtVoOj 



oLr^ 



^No,- 



(\w otATH occuns 
IF DEATH OCCU 



St.; 



Dist.;bct. 



-and 



S AWAY FROM USUAL R E S I O E N C E Gl VE FACT 
RREO IN A HOSPITAL OR INSTITUTION GIVE 



:ts called for under "special information" N 
ITS NAME instead of street and number. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

SKX Qr\ ft j COI.OR 




:s\Aj 



OX^VtOLAJl' 



DATK oi r.IRTH 



UjJ^^JLe 




.4Xm ' / i.3.l.. 

I Month) ^ (Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



Q 



H 

(Day) 



I90H 

(Year) 



AOR 



....1,.^!^... Vruis 



,.,, Motif/is ..>3 Davs 



SINCI.t:. MAKKIKI). 
WIDOW 1:1 ) OK DIVOKCKD 
(Writf in siK-ial fh'^ij.'iiatioii) 



Uj 



K/tXMWT" 



IMKTHIM.ACR 

(Statf or ''(itintrv) 



XAMK <)F 
I'ATH1:R 



HIK THPKACK 
Of hATUHR 

(State or Countrv) 



MAIDKN NAMK 
OI- MOTHKR 



lUK'nirKAl'K 
OI- MOTUHR 
(State or Country^ 



P 







X'CrvTvo^^ 



(j (Moiifli) 

I IlfvRl'lJV CI'RTII-V, That I atteii.lc.l decoased from 

19*^ to ~...i90 

tliat 1 last saw li ~ — — alive 011 — — - — - iqo ~- — 



and that death occurred, c)n the date stated above, at 



M. The CArSK OK UI-ATII was as follows: 



JLi:xj\J 



-O^vLw^JL 



DrRATI(3N Years 

CONTRIIU'TORY 



Mouths 



Days 



Hours 



OCCVPATION Q^^^ () 






Rryitfnf in Situ Fiavrisr') 1 )V(7/f 



^/>'>if/i.> 



/\!y. 



DTRATION }'i'ars .Vof///is Days 

(SIGNED) iil \M\ MnviU; 

Xi^^, 5 Tc,oS { A<ldress) U V et.^\\.0.. VD L' 



Hours 
M.D. 



\\j^^ 



:CIAL INFOR 



FECIAL INFORMATION only for Hospitals, inslitutions, Transients, 
or Recent Residents, and persons dying away from liome. 



■\'\\V. AHOVK STATI-;n PKKSONAl, I'A KlhT I.AKS A K I-; TRIK To TMH 

iJKsT OI-" Mv KNowi.i-.DC.H AM) in-:i.n-:F 



(Iiifi);ni:iilt 



(AfMress 









Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



I'l.ACH Ol- lU RIAUOR RHMo\AI. DATKu^ Hikiai. or RKMOVAI. 



AvuLAA- XavAryv I H^^W i.^. 



190M 



INDICRTAKKR ULaVH ^cC MD Chll'tk. 

(AdtlreHP ^0 IDs * b\H U <X >v v\t^^. ^LvC 



N. B. Kvery item of informntion should be cnrefully supplied. A(JB sho-.ild be stated KXACTLY. PHYSICIANS nhould 

stntc CAUSE OF DEATH in plnin terms, that it mjiy be properly classified. The "Speclnl Informtition" for per- 
sons dyin^ nway from home should be (^iven in every instance. 






V 




♦r,<> 



4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nn,,t.l..r iliMlth I- Vo I'.-i^^^hSiVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffc Filed, 




190^ 



Registered •A^o. 



86 1 



li 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH 



Certificate of H)eatb 

( Ta. S. StanOarD ) 
inty ' ^ " 



(^o. 



X^O^y^<t/v\j K)^>\ 




: — County of CJ/CW\j AXX/Tl^CAA^t^i. City of ^^CU>v <^ K/X/yyj^^sj^j:^ 



.Kv,t<Xv 



St4 



Dist.: bet. and 



(ir DCATH OCCURS AWAY iJROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




tXL 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



vJ -£/Y>v<xLi' 



COI.(^R 



lllLt^ 



DA IK Ol- lURTIl 



vlK 



<XNj. 



I Month) 



(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 




(ffllonth) 




(Day) 



(Year) 



KV.V, 



.. ' '^ Years V 



X\ 



'MoHiki ^...\ Davs 



SINC.I.K. MAKKIi:i). 
WinnWKI) OR DIVOKCKD 

(VVritt-in social dtsi^.tiatiou) 



lUKTUrM.ACH 
(State or Cotintry) 



1, 




U XV»x<X/>x\.K 



XAMK or 
i-athi;r 



lURIHIM.ACE 
ni- I ATHKR 
(Statf or Country) 



MAIDKN NAMH 
<)I' MOTHKR 



JVolcc 



I 



VVYOw'"V\/ 



'^i 




I^HHRnnV CHRTII-V, That I attended defeased from 

t looH to ^^yJLi.. l.X 190 H 



190 



that I last saw a ■>SJ\) alive on 




I 



1- 



X 



190 "'i 



and that death occurred, on the date stated above, at V 'A 
tt-M. The CAl'Sfv OF I) I v AT 11 was as follows: 

Uaju^^-^cJI LL|v^.^:JLe^u 



1 



KOw^CWi 



DIRATION Years Mouths Days Hours 



CONTRIRUTORY 



-^-«-AA^ 



X V^WlOLA 



Ltl 



W\) 




't 



^n^JL 



lUKTIIlM.ACK 
Oh MOTHKR 
(State or Country) 



OCCrFATlON 



Orv. 



(.J X^LOWCC^vc 



f^^sidi>if ht San riiiiu isro oD 1V<t;.« 



i- 



Mouths 



DTRATION Years 



Days 



Hours 



(Signed) 




(Ad<lress) -8Aa^W(3l A\i (/Ij^^UAt 



M.D. 






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



Former or 



.lAo/ZA/v 



Pa 1 > 



THK AROVP: STATHI) I'KRSONAK PARTICri.ARS ARI-: TRCK To THK 

HHST Ol- Mv kno\vi.i:dc.k and nHIJl*.K 



(Informant 



^ 



XV^vn.OL'Vnj 



(AD(5-^^vA-.'t'CL.i.. 



(Address 



ilsiiaTResidence S 3 I C) \U. 

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



A Jli How long at 
'A^tX/wL Ok piac f of Death ? 



t 



Days 



PI^ACE OK HI RIAI, OR RHMOVAI, I DATE of niRiAl. or REMOVAL 

rXDERTAKER vA W A T VA^\X VA v \LA. C 
(Address 3l^ U'TcVNVitii .<^.t 



N. B. Every item of inlrormHtion should be cnrefuli.v supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pinin terms, that It may be properly classified. The "Speciul Information'* for p«r« 
sons dy!n( away from home should be ftiven in every instance. 



'^mi 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n.KU'l uf Iliiilth -I- Xo. !<; <*^ 



hKiVCa 



RCPCR TO BACK OP CERTIFICATC FOR INSTRUCTfONS 







190^ 



Registered JSTo, 



262 



r-i 



l> 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "a. S. StanCJarD ) 



PLACE OF DEATH: — County ofO/a/Vu OJUX/iVCLiCt Gty of 0,<Vvu J.Va %T.Ct^c c 



CNo. 



^la U 



/CuLLti.t 



St. 



Dist*; bet. 



W 



ccA^rvA^. 



and J CS.^ 



(IF DCATH OCCuAs AWAY mOM USUAL RESIDENCE Give FACTS CALLCD FOH UNDER "SPECIAL INFORMATION" N / 
IF DEATH OCOURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / I 



FULL NAME 






e ';„ 



) 



PERSONAL AND STATISTICAL PARTICULARS 



sKx q^ 



v) A'yy^^^KXjj 



COI.OR 




yvvA^. 



,u 



DATK Ol- HIRTH 



fl\^. 



(Month) 



11 /..^..O.X. 

(Day) (Vear) 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



LI 



(Month) 



1 



l..i. 

(Day) 



(Year) 



AOK 



.a\ Years I Miuiths T Days 



SIN<;i,K. MAKKIKI). 
WIDOWKI) OR DIVOKCKO 
(Write in s<H-i;il (ksi^rJiiition) 



Ajy\X>i 



I 



niRTHPI.AOK 
(Stiitf or Coiuitrj) 




VAMH or 
FATHKR 



niRTHPl.AtK 
Ol" I-ATHKR 
(Stall- or Country) 



MAIDKN NAMK 
Ol- MOTHKR 



I LaAwcJL VTLCrdL 






IJIHRHBY CIvRTIFY, ThaJt I attcii.lea deceased from 

'i f- .HfV.s-lu...L.l 



190 H 



-^"U-V 1 190 ! to HfV.S^LU 

that I last saw h ri/v alive on HA-AlCul^ i v 190 i 

and that death occurred, on the (late stated above, at ^ 
^ M^The CAUvSH OF DFATII was as follows: 

Q., 



JX^J^'yii^c>t%*^^x^<\> 



VvOA-OL 



T J 



IK' RAT I ON ^ }'tars ^ A/o»//is t 
CONTRIIU'TORV 



Days 



^Hours 



' 



V<XV>v, 




<^ 



OAxCltv^-vco vi 0\.VL_ 



lURTHIM.ACK 
01 MOTHKR 
(State or Country) 



nr RATION -Years ^Mouths - Days ? Hours 

(Signed) J \l /ux\ivvvL<\ ivi.d. 



xXkk IX KpM 



(Address)qCI (f&-A.cviU. "^t 



«•«•**• V^*4«r*. 




u 



OCCVFATION 



^<Ui-^ 



f!es t'lfrtf III Si III Fi am isrt » 



) 'ro I 



yhnilh- 



Da v: 



T MICA no V K Sr A Ti: I) P K R SON A I . I' A R T I C T I . A R S A R K T R T K TO T 1 1 K 
HKST OK MY KNOWl.KIX'.K AND nKI.IKF 



(In forma 



' OK MY KNO\Vl,KD('.K AN 

nt.. yb^JLcL 



(Address 







\'t K 



M 



^FECIAL Information only for Hospltdls, institutions, Transients, 
or Recent Residents, dnd persons dying away from home. 



Former or q ,% n 1/ 

Usual Residence ^ i-L U O^LCci b 

When was disease contracted, ^ 

If not at place of death? 



How lonq at 

Place of Death? .^ I Days 



1M,ACK Ol HIRIAI, OR RKMoVAI, I DATK of Hi hiai. or RKMOVAI. 



INDICRTAK 



\5 X\ dlt,^.k;tt.v '^X 



(Address 



N. B. Every item of information should be carefully Hupplled. AGE iihould be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for per- 
sons dyin^ away from home Hhould be given in %\9ry instance* 






:M»h 



•if-- 



t„»^-^. 



l'Wk7>,«.*V '^_ 



\-^^ 

-!":• 



^mff^v^ts^^r^m 



ft If 



If. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HMMr.l of Mr.iitli I No i^ *^^J;^)H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffr Filed, 





190 "{ 



Registered J^o, 



2 



63 



Deputy Hearth Officer 



DEPARTMENT Of PUBLIC HEALTH=Clty and County of San Francisco 



Certificate of Death 

( la. S. StanDarC> ) 



^ 



PLACE OF DEATH: — County of U/CLvu AXX/>\^A.^^{i City 



St.; v-T Dist.;bct 3.0 



;ity of O/CL/TvO 



^ 



(IF DCATH bcCURS AWAY FROM USUAL 
IF DCATH OCCURRCO IN A HOSPITAL 




y^^<XAx<^L4.'<^o 



and '^^ 14a^ 



RESIDENCE Give FACTS CALLED FOR UNDER "SPECIAL INFORMATION' 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 



jy\r.y\AJL 






SK\ 



PERSONAL AND STATISTICAL PARTICULARS 



.Ix' 



COI.OR 



llOl^U 



MEDICAL CERTIFICATE OF DEATH 



DATE OV DKATH 



DATK OF BIRTH 




(jifonth) 






./.a.D.X... 

(Year) 



AOK 



) 'ra ; . 



A/iinffts 



X 



Davs 



sinci.t:. makkiki), 

WIDOWKI* OK I)F\M)RCM:r) 
(Writf in scx-ial dtsiptiation) 



lUKTm'I.ACK 
(Statf or Country) 



NAMH OP 
FATHKR 



Ox^r^cJui 



niKTHrLACK 
or FATHKR 
(Statf or Country) 







(Day) 



(Year) 




190 H 



r^nPRKRV CI'RTrrV, That I attended (lecoasea from 

that I last saw h X>u alive on Y^^W ^^ 190 H 

.ind that death occurred, on the date stated above, at -^ 

d M. The CAUSH OF I)I<;ATIT was as follows: 






U jIV vwcX/> 



maii>f:n namf: 
of mothkr 



btrthflacf: 
oi' mothf:k 

(State or Country) 



OCCIPATION 




nr RAT TON ^ Years 
CONTRIBUTORY 



Mont /is 



Ov. 



13JU-:? 



Days 



Hours 



cJkL_ 






Wf-iiied ill Sail /'i tiih i^ro .:K )>nis ^ A/mif/is c*.. /'</). v 



DURATION ^Viuirs ^ Mout/is 1 Days - Hours 

(Signed) t UJ. X-K,^-v-wa^ m.d. 

\X 190 M (Address) 4^*1 ' 'h\<k Ok 




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



THK ABOVE STAIl-.I) PHRSONAl. I'AK IICF LARS AKi; TRIK To THK 

bf;st of mv knowijcix.f: and bi:mf:f 



(Informant 



(Address 



.11 ^ IbAXKvvtt dt 



Former or 
Usual Residence 

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



How long at 

Place of Death ? Days 



i'i.acf: of bikiai. ok kkmovaf. 

(^ . J) 



T903 



DATlvof Bt KiAl, or RF:moVAI, 

rsniCRTAKKR 0^vi\x^v\< J^cxta. IL'^'\ ci^'ciAO 



(AiMress 



N. B. Kvery item of informRtion should be cnrefully Ruppiied. ACJK should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for p«p« 
sons dyin^ away from home should be &iven in every instance. 



.i.-- ■ 






.«fes- 




* 



b 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



HoMi.l of Ilcaltli- K No. !•; iS^^f^^^ U&.V Co 



Dafe Filed f 




\'h 190^ 

Deputy Heafth Oflflcer 



Registered JSTo, 



264 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( xa. S. StaiiDarD ) 



PLACE OF DEATH: — County of 






(Mk. 



Clu,V Wvv^rci 







C»-<tK\X<X.^ St.; 



Dist.; bet. 



and 



n /if death occurs away FR(^M usual residence give facts called for under "special INFORMATION" "X 

\j V IF DEATH odcURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




i 



V <S^^:i:\^JU.. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



OfUcJL 



COI.OR 



Vw^VW 



DATK Ol" HIRTH 



(Month) 



oJL"t 

(Day) 



/IH.H 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



AC.K 



Jtf.O... 



. Yeats TTT.. Moulhs .TT. 



Daxi 



SINCI.K. MARKIF.D. 
WIDOW KD OR DIVORCKD 

(Wiittin MK'ial "Icsi^nation) 



niRTMPI.ACK 
(State or Coujitry) 



NAMK OI- 
FATHKR 






-C-v^^r-wj 



-A^c^X) _ 




10.. 

(Day) 



l9o\ 

(Year) 



I HERHBY CICRTIFY, That I attetided deceased from 

■""""""""" 190 to '. '^"190 ~ 

that I last saw h - — alive 011 ' . 190 ' 



r 



«► 
w. 



and that death occurred, on the date stated above, at 
rrTT— M . The CATSI': OF DIvATIl was as follows 




.\J..*-CA.r'?S(VV.<<rv"\.AXJ\.A4....V/VV^ 

LLbufrivvvMiL WnaJ^v^-Ouv^ .dLvvvR..>vi...,«^ 



-VV^-VAJ^A^ 



RIRTHri.ACK 
(>»•• » ATMKR 
(Statf or Couiitrv) 



MAIDKN XAM1-: 
Ol" MOTIIKR 



HIR rUPl.ACK 
Ol" MorHKR 
(State or Country^ 



OCCUPATION 



«« 



*• 



DURATION Years 
CONTRIBUTORY 



Mouths 



duration 
(Signed) 



Years 



Mi)nths 




lOoH (Address)^Ob c),cv.n-t>T_ 3*^ 



SPECIAL INFORMATION onjv for Hospitals, Instifufions, Transients, 
or Recent Residents, and persons dying A^tA) from fiome. 




-VA.'-wJk^l 



Rfsidfii III Still /'i iiiii iyrii )Viti<' .V"/////^ 



/>,iy 



TUlv AIJOVIC ST A I" I'D PKRSONAl, PA Rl'ir f I, A R S .\Ri: rRll-: To Till-; 
HKST OF MY KNOWI.l.DC.K AND Hi: I. lit F 



hf:st of mv knowm.dc.k and m:i.n:i 

(Informant J AJL<\JJ\^'^JA. V 



'CC'V-w-v 



\.l.lrrsH 



loOk" C 



9xxXUv i-^ 



Former or 
Usual Residence 

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



How long at 
Plare of Death ? 



PI.ACK OI" lURFAI, OR R):Mo\ AI. 









FNDICRTAKKR 

(Address 




N. B. Kvery item ol' in?nrmntion should he cnreV'ully supplied. AGK Hhould be Htnted KXACTLY. PHYSICIANS iihould 

Htate CAllSI: OF DFiATH in plnin terms, that it may be properly classified. The "Special Information" for par- 
son* dyin^ away from home shoulti be given in every instance. 



JfBF^5*^ 



^^l^q 



■■eMi 



If! 

If 



111 



ii;l 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H,.:ii.! ..f II( ;il(h -I* No i=; ^-Ij^^' HS: I' Co 



l)((tr Filed, 



Registered J^o. 



265 



i?> 10 o\ 

\jjsj^ Deputy Health Officer 

DEPARTMENT # PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( tl. S. StanDarO ) 



PLACE OF DEATH; — County of 



City of 




^No/ 



(ir DEATH OCCURS 
IF OCATH OCCU 



St.; 



Dist.; bet* 



and 



s AWAY FROM USUAL R E S I D E N C C G I vc fa 
RRCD IN A HOSPITAL OR INSTITUTION GIVE 



FULL NAME 




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



X/U>^VXCL/^A/> V 



PERSONAL AND STATISTICAL PARTICULARS 



SRX 



^kJL 



C( 



>I.()K \ , A DATE OF DP:ATH A^ 

LoJxJU vfl 



MEDICAL CERTIFICATE OF DEATH 



DATK or* IlIRTM 



nXaX-It^'A 



(Month) 



(Day) 



(Year) 



AC.H 



t'at 



Z^/ou//is r>ari 




SINCM* MARKlHn. 

\vn>()\\i:i) (»K nnoKiKi) 



Wiitcin siKMal tk-sijf nation) \ \ 

. LL>^>k. 



\Vfrv*.r>\, 



(Statf or Country) 



FATHHR 



«« 



niK IMJM, \<H 
Ol" I-ATIIHR 
'State or Country) 



MAIDI'N NAMK 
nl- MiVrHFK 



nTRTTIPT.ACR 
Ol- M(»rHi:R 
(Slate or Country) 



5Ut_ 



-4l_ 



(Month) 



a3 ipo3 

(Day) (Year) 



I lir^RPinV CI'RTIFV, Tlint T atteiKkMl deceased from 

"190 to ■ ~" I(jO "* 

tliat I last saw h :- — alive on ——— — up ■ 



and that (Uatli occiirre<l, on the <late stated ahove, at • 
~ M. The CALSl-: OF DICATII was as follows 



. <Kr^y:\j . 'XX C- VA- -o->xi 



DURATION )\'ars Months 

CONTklJiUTOKY 



Da \s 



Hours 



D'.'RATION 



Years 



Afi)}it/is 



I^ays 



Hours 



OCCTTATIOX 



9 crv<Ls.JL^> 



-IX. 



( Signed ) UV.to. XAMjUAj-VHLvrr^ m.D 

vjllaui^ ic)oM (Ad.irrss) \i /la/vx4.1l<x ^i ' V 



a 



Special Information onlv lor Hospltdls, institutions, Transients, 
or Recent Residents, and persons dying d^ay from tiome. 



Rr.\iiifii 111 S1IH f'l aiiiisro 



) V'i7 ; 



Month, 



n,r 



Former or 
Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



Tin". AHovK sr \ii:i) ('Kkson \i, iv\k lu ti.xrs aki-: rRCK to Tin- 
HKST 01 MY kno\vm:d«;k and iu:iji;f 

(Infonnant VlPUXiLtj'V V \A) oU -^OTtX 



\.J4t^ss 



CV V-VsS 



ri.ACK Ol' nrkiAi, OK ri;m<»vai. 

1 



i,.\v.n 1 ir 

QlcCt. 



A^^^VCCJ 



I)\l*i:i)f Hi KiAi. or ri:mo\ai, 

IX 1904 



INDKRTAKKR 

(Adduss 






IN. B. ^;ve^y item of informntion should b.- wnretully supplied. AGB should be stnted F.XACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, thnt it mriy be properly classified. The "Special Inlformation" for par- 
sons dying away from home shoultl be i^iven in every instance. 



Ml 



i.JMBF^ 



iies^4^ 



^^. 



iwiM\i 



j:.- 



'WfelMf-% 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n ail of II. i. nil )■ Si, i^**^^^-jhkvco refer to back of certificate for instructions 



Registered J\^o. 



266 



I)<((r Filed, \y^ \^ ^^<^ H 

il^rw^ Ijuvvu deputy Health Officer 

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



Certificate of H)eatb 

( *a. S. StanCarD ) 



PLACE OF DEATH: — County of O^Xa-u VXVwc^^jyCc City ofC> 



^ 



CNo. 



.13 




'V ^L. St.; 'i Dist.; bet. sS tlv ^^ Ir U\ and \fe^vi=^vl; 



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



) 



FULL NAME 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

CK\ A I COI.OK, 



'■li 



DATl-: ol- in k Til 



L 



UUxJi 




[^ 



^KX- 




kaxXv 



MEDICAL CERTIFICATE OF DEATH 






S... 

(Day) 



/a.oH. 

(Year; 



M.V. 



) \'ii t . 



I A/tmfks ^. Dayi 



SINi.l.i:. MARKIKT) 
WIDOW HI) OK niVoKOKI) 
iWiitfiii '■ooial rlfsiv:nati<)ti) 



niK ini'i.AOK 

( State' or I'ontitrN') 



NAM1-: OI" 
FATMIIR 



HIKTMPI.ACK 
1)1" lATHKK 

(State or Country) 



MAIDKN NAMK 
OI- MOTHKK 



MlKTlIPT.ArK 
OI" MOTHHK 
(Slatf or Country) 




*^'<X/>v v) A/C^>v c^^>t^-o 
<XV\x>i. v<x,vcLv >\jlUo 



DATK OF DKATII 



(NfAnth 




13. igoH 

(Day) (Year) 



I HKKiniV CICRTIFV, That T attended (Icceasod from 

J^^^ ^^ i'p4 to . - - 190 - 

tliat I last saw h Jih> alive on M'VaJLa.jl I X 190 "^ 

and that death occurred, on the <late stated above, at \b 

0- M. The CATSH OI- l)l«:ATn was as follows: 

(?,. ^ 



DIRATK^X years A/onths Days 

CONTRIIU'TOKY 



Hours 




^<X 






Days 



Hours 
M.D. 



OCCUPATION 

fy^fj-idfif in Suit I'l init i'm'i} •■ )V(M>- •" M,>iith> •■ l'>a\. 



DURATION Years... Months 

(SIGNED) ^.iJj "^c^^cLau 

yJUl'^ iqoS (Ad.lress) ^C^^^U^^Cyg^d J^r. 

SpEb'lAL INFORMATION only for Hospitals, Nistitiitlons, Translfnts, 
or Recent Residents, and persons dving away from home. 



Former or 
Usual Residence 



How long at 
Place of Death? 



Days 



rm-: ahovh sr xti-.d i-hksonai, tar ricri.ARs arh trik to \\\v. 

HHST OI" MV KNoWlJvIX.H AND IU:M1:I' 



(Infoiniant 



(Address 






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



I'l.ACKOI- HIRIAI, OR KI:MoVAI, I D\Ti:of HtRiAi. or RKMoVAI. 

INDHRTAKKR H'O^^-VNJJ) M / V T) V>V-),,v >^VC 
(Addrei %W £cCciu Ot 



1 



IN. B. F.very item n? iiiformiition should be carefully nupplieii. AGB nhould be stated EXACTLY. PHY8ICIAINS should 

state CAUSE OF DKATH in plain terms, that it may be properly classified. The "Special InV'ormatlon" ?or per- 
sons dyin^ away from homo should be l^iven in every instance. 






\l\ 



w 



7f^-rf»t: 



,JS& 



¥ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hojii.l -if llialth I' N'o !«; ■^'^^^■x!^^ It^|' C, 



Dale Filed , 




13» 



vjo'i 



licgislercii J\'*o. 



;267 



u Deputy Health Ofiflncr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



( "a. S. Stan^ar^ ) 



^ ^ 



Si 



(^ 



•No. an c 



PLACE OF DEATH: — County of 0'Q-/>v >JAxXaaxa.^mu. City of C'/CX.ru 0AXU>vOULCC 

1 





a 



Va mXiu St.; X Dist.;bet. --. 

URS AWAY FROM USUAL R E S I D E N C E G I V c facts called for UN 
CCURRCD IN aJhOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAC 





and w 'Ct^yK.v\vaU^)L 



SPECIAL INFORMATION" N 
TREET AND NUMBER. / 




FULL NAME 




^y\^ 



X>\; 



r!: 



PERSONAL AND STATISTICAL PARTICULARS 

si;.\ A/* A I coi.o 

U . II i) 




\aJji; 



DA'll-; ni HI K Til 



lllvvJl 2. rl\~\ 

(mJiiUi) (Sttir) 



(Veat) 



a<;k 



"^ ^ )/</>> .O Vr;«///.V IS 



Da \s 



SINT.I.K. MAKUn:i). 
WIDOW i:i) OK niV(»RrKl) 
(Wiitrin social dcsiKtialiuu) 



\^>X 




lUk THI'I.ACK 
(State or Count ry) 



NAM1-: oi- 
FATin:R 




HIRTHPLACK 
Ol' I-ATIIKK 

(State f)r Countrv^ 



MAinKNT XAMK 
Ol- MOTHKR 



lURIHPI.ACK 
Ol" MOTHl'.R 
(Statf or Coiiiiti \ ) 






MEDICAL CERTIFICATE OF DEATH 
DATP: ok DKATII 

I I 

(Day) 




(Year) 



I IIKRIvHV CICRTIFV, That I attcMuled deceased from 

to ":.: 



that I last saw h 



I90 

~~ alive on 



and that death occnrreil, on the date stated above, at 
The CAI'SIC ()l« Hl-iATlI was as follows 



M. The 



>"L<^VSw<XX:U Aa^Is-L^w^la.vL<)-^ 



vo 



(3? 



i 






ni* RATION Years 

CONTRIIU'TORY 



Months 



Pavs 






DT RATION Yrars Mouths Pays Hour a 

( Signed )..O.AX<Lt\xcK \) Ca 



.^\/wXm 



vl^-tA 




OCCUPATION 



yi 



\ 



\% 



tQol 



( 



Ad.lrrss) l^Ob d^JX,t»\_0' 



SPEJCIAL Information only for Hospitals. Insfilutlons, Transients, 
or Recfnt Residents, and persons dying away from home. 



THK AHOVF. STATi:D I'HRSONAl. I'ARTICl'I.ARS ARIC TRIK To Till-: 

ni:sT Ol- MY knowi,i;dc.k and ni:iji:F 



(Infoiniatit 



f \.l.lirss 



lob 



Macc|-v.c q 






Former or 

Usual Residence 

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



flow long at 
Place of Death ? 




M.D. 



ri.ACK Ol- IHRIAI, OR Ki:M(»\AI, I DATIvo! IJikiai. 01 ki:Mo\\l 



I) U 



I NDKRTAKKR 

(Ad 



/CC W 



.Irc-ss aC)''b (?^t^vivC -M 



• 1 90S 



3- 



N. B. fivery item ni inV'armation should be carefully supplieii. AGF. Hhnulil be stntetl EXACTLY. PHYSICIANS ftbouid 

«tnte CAUSE OF DFATH in plain terms, that it may be properly cloHAifled. The "Special Information" for per- 
sons dyinft away from home should be ftiven in every instance. 






•HpiM 






( r^>r 





Ir 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I'.o:ir<l of Hialtli - 1- 



N'o I V T?-f^^>) H&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



11 



(ifc Filed, WL li 100^ 



Registered JSTo, 



2m 



M Deputy Health OfTicer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "d. S. StanOarO ) 



PLACE OF DEATH; — County of*O<VY0>JA<X'-YvC<.A/Ci City of O-OyVu AXX'V\/C^<lco 



rNo. 



Xax ^ L^vv^tu. J\3 Ch^U, vtcvl St.; Dist.;bct and 

(l /■ IF DEATH OCCUR«\aW*Y FROIW USUAL R E S I D E NC E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
\i V IF^ DEATH OCCUJtRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



^X>\jy\XkJ^ 



>cL sJ Lcr^yrV/Oul 



PERSONAL AND STATISTICAL PARTICULARS 



si<:x 




V<xXJj 



COI.OR 




rVC 



tc 



DATic or HiKrn 




(Mi)iith) 



(Day) 



(Year) 




I 



AC.K 



.O.i )'/V7;.v O. 



Mottihs 



as- 



Davs 



SINC.I.K. MARKn:i) 
WIDMWKl) »)K DIVOKvKI) 
(Write ill social tlesi^rnation) 



niRTHPI.AOH 

(State or Country^ 



NAMR OK 
FATin:K 



HIKTIiri.Al'K 
Of J-ATMKK 
'State or Coiiiitry) 




MEDICAL CERTIFICATE OF DEATH 



(Day) 



(Year) 



I HJU^lvP-V CI'RTIFV, Tliat I attcii(U«(l deceased from 

"X^ 190H to |vvluL. va 

that"! last saw h.A/»^ alive on V^^-M- ^^L 




up H 
190 H 



and that death dccurred, on the (hite stated ahove, at 2L 5^^ 



aP. 



M. The C.VTSIC OF DIvATII was as follows 



MAIDKN NAM! 
()I- M()T!11:R 






BTRTITPT.ACK 

ui M()'iin-;K 

(state or Coutitiy) 



OCCri'ATlON 



^1, 




DrRATIOX Years 

CONTRII'.rTORV 



Months 



Days 



I /ours 



Dl'RATION 

iNED) UJrrvviAiyV dLcxvoJL 



(SiGI 



Years Af,)nt/is 

\1 T(,oM ( 



/)ays 



Hours 
M.D. 



Vvlu \3> T(>oM (Address) VaIa^ ^^ V^ } V) & ^xt 

fePEcJlAL Information only for »ll>spitdls, institutions. Transients, 



-_ O VAXavvdi 






FORMAT! 

or Recent Residents, and persons dying away from t>ome. 



* 



Mnnths 



/).M, 



TI1I<: AIJOVK STAri:i) I'KRsONM. par rUTLARS AKi; IKIK TO THK 

BHST OP Mv kn'o\vi,p:i)<;p: and np.MiCK 



(III forniatit 



(V.l.lress Liu ^^ V<) fc ChQ, k.vt.<xi 



Usual Residence 3,b I * I 4Aj 31 

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



How long at , , -. 
Place of Death ? 1 b b 



Days 



PI.ACH Ol' m RIAI, OK KF.NIOVAI, I DAn-.of MiKfAt, or RllMOVAI. 



I90H 



rNDP:RTAKKR 

(Address 



VAJ. JJ(jLW>VM 

i..-^3tl 



,^ 



/CCVCV K.<xX, 



N. B. Hvery item oV' inforinHtion should h.- cnrct'iilly supplied. AGK should he stuted liXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pltiiii terms, that it miiy he properly classified. The "Special IntformHtion" for per- 
sons dyin^ away from home should be feiven in every instance. 



■I| 



t r 






h 



Kl 



t 









^f^^W 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board of Health— K N'o. i=, "S^iW^^H&P Co 



'Kl 



il 




If 



t1 



i 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ffc Filed f 




li WO'i 

Deputy Health OfTscer 



Registered JSTo, 



269 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Certificate of Beatb 

( XX. S. StaiiOatO ) 



PLACE OF DEATH: — County 



'No. 





(\r DEATH OCCURS 
IF DEATH OCCU 



\ ^ 1 

ofO<Xrnj OAXlU'V^CXwA/COGty of 






Dist.;bct« 



and 



USUAL RES 
OSPITAL OR I 



ilDCNCCGIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




y\JUi 



f 



Kjy\j^^u^^r\'^ 



"" (^uj^ 



DATl-: «)I- HIKIII 



COI,OR 



cxJU. /Up b 




/Ol/vw* 



MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH A \ 

WU_ I 

(I^onth) 



(! 



ipoH 

(Day) (Year) 



(Month) 



(Dmv) 



AT.K 



celt ^l^ 



)'cais .*.... Mnul/is 



(Year) 



/)<; I .V 



SIN(.I,K. MARUIKI). 
WIDOWKI) OK DIVOKiKI) 

(Write in stK'ial disitrtiatinn) 



niKTHPT.AOK 

(Staff or t^'oiintrv^ 



NAMK OI" 
FATHKR 



dvL^vvxyUj 



C) ^c^UL<X/»^ 



IL^^K 



I HRRHBY CRRTIFY, That I attcfulcd deceased from 

-— — — 190 to 



that I hist saw h 



alive on 



-T90 
190 



ati<l that death occurred, on the date stated above, at 



M. The CAUSK OK DICATII was as follows: 



AX<\wJL^-c<i 



/>V/CrA-A.rVV» 



nTRTIIPT.ACK 
OI- l-ATHHK 
(State or Country) 



MAIDKN NAMK 
OF MOTIIHR 



HIRTHPLACK 
Ol' MOTHKR 
(State or Country) 



nrRATION Years 
CONTRIRUTORY 



Mouths 



Days 



Hours 



• « 



OCCUPATION 2R P . I 






^f•>nths T.... n.ivs 



DTRATION ^^ Years Mouths Pays Hours 

( Signed ) L^rUrvuth^ viS, U) dUX^vvvcL m.d. 

__JJ^^^-U4 I CJ rqo^ (Address) Lc\^>^X^,A vJ. 

Spi 



-l-CJl 



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



Former or 
Usual Residence 



X^^' aa-vcC^i tl7Ly.^ 1 



Days 



TH1-: AHOVl<: STATKI) PKKSONAI, P \ RIUT I, A KS AKI' IKt }•: To THK 
HHST OI" MV KNOWM'.DC. !•: AM) IU:1.I1:K 



(Inrorniant 



( V.hlress 



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



PLACK OF lURIAI, OK KKMoVAI, I DAn-of Hikiai. or RKMOVAI, 



INDKRTAKKR C/Vj 



(Address 







T90S 



3 bl Ql ^ IS tl Oi 



N« B. Kvery item olt informntion should be ciirefully supplied. AGfi should be stated EXACTLY. PHYSICIANS should 

state CAUSn OF DEATH In plain terms, that it may be properly classified. The "Special Information** for psr- 
sons dyin^ away from home should be feiven in svery instance. 



-**i^ 



•?5 



r 



i^: i 



^^m1« 



i 






.^ ' 



'U 



'M 



i!i^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Bo.tr.l..f Fl...ith -I No i^i^'t^t^US^VCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\/*o. 



870 



l),(t,' Filed, VJU, I % 190 S 

<M^wu oU/uu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certiftcate of 2)eatb 

( X\. S. StaiiDarD ) 
PLACE OF DEATH: — County ofO/tX^Aj OAXX>^ru^\AC^City of O/CUvu AXV/w/d^^ iMi 



(Hq. 



(IF DEATH OCCURS 
IF DEATH OCCU 




St.; 



Dist.; bet* 



and 



S AVkTAV FROM USUAL R E S I D E NC E G I V E FAC 
RRED IN A HOSPITAL OR INSTITUTION GIVE I 



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



FULL NAME 




X' xXaa^ocJtuj 



PERSONAL AND STATISTICAL PARTICULARS 



"'" %.A. 



DATK <)l" lUK rn 



COI 



UJJ[v\AJL 
oXt r\ 



(Muiitli) 



KC.V. 



5% 



. ) fa t s 



(Oav 



M, nit ha 



Hb. 

(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE <)1* DKATH 



(M^nth) ^ 



11 

(Day) 



(Year) 



Da vs 



SIN(.I,I.:, MAKRIHD. 

W II)()\\ 1,1) OR l>I\»)KvKI) 

'Write in ^^ocial (ksip'iiatioii) 



Vl iWvv 



vX<V 



HIRTT?PT.Ar'K 

(State or Country) 



NAMK OF 
FATHKR 



niRTniM.At'K 
Ol' I" A I'll KR 
(State or Country) 






MAinilN NAMK 
Ol- MOTMHR 



niRTHPT.ACR 

Ol- MOTIIKR 
State or CouTitry) 






I HHRRBY CKRTIFY, That T attemlcd dcceasetl from 

T-vW "^ 190H to V-^JL^ i:x 190H 

that T last saw h -Vvvv ahve on Nj^a^Aa,^ \ 'X 190 S 

and that ileath occurre<l, on the <latf stated above, at t» S. S. 
Ll.M. The CAi;SI<: ()1< DlvATII was as follows: 



DURATION ^ Years X Mouths "* IJays Hours 
CONTRIIU'TORV 




occrPATiON (\^Xo.,U^ ^ 



duration 
(Signed ) 



)'r(irs 



Mo>itlis 

IvOLl^ \X i()oH ( Address) 'Mx\A\\>a'w 



Pays 



I lours 
M.D. 



ECIAL INFORI 



fe(V^|\vt 



A 



yr.nit/i." 



Ihn 



Tur: \Hovi-: stati'd i-krsonai, partici'lars art. iRiH To Tine 

nivSr OF MY K\o\\lj;i)(". H and BKMICF 



(Iiifovmant 







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

Former or U .0 (Rk . J 7^4 "«^ '»"*' ^^ -5 

Usual Residence It C)HDM^Ct^Ctu^.u J X Place of Oeatli ? o 

Wlien was disease contracted, Xr 

CUM^ 3L fVvA.0-^ <Va<) 

KiAi, or ri;m<)yai. 



Days 



If not at place of death ? 



I'l.ACJ^ Ol- nrRIAI, OR RH.M()\AI, \ U.VV 




I N I ) 1: R T A K l-; R O CX ^ ^\X W JL' -C V-<L^^^ ''M^ C^ 
(Address bX^Vij\^<Xtivv>CUu O" 



2l_l 



N. B. F.very item of information should hi cjirefully supplied. AGR Hhnuld be Rtnted KXACTLY. PHY8ICIAINS Hhould 

state CAUSE OF DEATH in pinin terms, that it miiy be property classified. The "Special Information" for per- 
sons dyin^ away from home should be given in every instance. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

WtFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 

271 



Hoiir.l i.r IKnllh— !•■ No. 15 ■«»:g;^»U IlSlI' Cii 



Registered JVo. 



,/e Filed, Viu I i 100 H 

rUrVu^ 4sJiA>u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — C o unty of 



Certificate of Beatb 

( "a. S. StanOarD ) 

City of OJOM^ VJ -Ov 



(No. 



St.; Dist.; bet. and 

/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER 'SPECIAL I N FOR M ATIO N - 'V 
^, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




O.A^jy^YyJu 



.<3jA.AjU,,rinj. 



PERSONAL AND STATISTICAL PARTICULARS 



DAT!-: OF lUR in 



(Month) 



ACH 



lx/>x.lk 



} I'll > s 



(Day) 



Mouths 



(Year) 



Da vs 



SINf.ij.:, MARRlKn. 
WIDOWKI) OR DIVORCKD 
(Writtin social (k-siKiiation) 




V^A,AJ-v^J 



lURTTTPLACK 

(Statf or Country) 



NAMK Ol 
FATHKR 



«« 



TURTHPI.ArK 
0(' I ATHKR 
(State or Country) 



MAinKN NAMK 
OF MOTHER 



BIRTH PLACK 

OF MOTMF.R 

(Statf <ir Country) 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKAT 



:'■ T) 



(Montli) 



.a.(p... 

(Day) 



(Year) 



I HEREBY CERTIFY, That I attended deceased from 

— to 



I90 



^190 



that I last saw h alive on ■ 190' 

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

— ■ M. The CAUSlv OF DEATH was as follows: 




DURATION Years Mouths Days Hours 
CONTRIIU'TORV 



DURATION 



Years 



OCCrPATION 



Kl 



cL*^U\) 



Rfsidrd ill Sini I'l <iiit ism 



«« 



«« 



)V(M 



.y/out/is 



/)<M. 



THF" AHOVF: STATl",!) I'KKSONAU I'A R T U' l" 1, A RS A R F; TRIH T( ► TUF] 
HKST OF" MY KNO\VI,f:DC.K AND IM%M1>" 



(Infonnant 




>o \X dlJX'V-trV 



U444:< 



^ss .Wu.c3.dL) 



CLOMJ^ 



( SIGNED ).yi.bdL>. \]fU.A..cMjsOvA' 

l^ TqoH (Address) \I IXo/rs^lUL U <^ 




.Ifont/is Pays Hours 

\JL M.D. 



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



Former or 
Usual Residence 



How long at 

Place of Deatli? Days 



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



pi.acf; of niRiAi, or ki:movai. 






fndi:rtak}:r 

(Address 



k,...£,CL 



DATi: of III KiAi. or RKMOVAI, 



190H 



N. B. rivery item of i n form iit Ion should be carefully Hupplieci. A(jB should be stated F.XACTLY. PHYSICIANS should 

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



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no«,.U,nU:,m,-,-So,.*l^^>i^V,o RKFER TO BACK OF CERTIF.CATC FOR INSTRUCTIONS 



**i' 



1 



i 



D((fe Filed y 





(! 



15 



WO'i 



Registered JVo. 



272 



^u Deputy Health Officer 

DEPARTMENT $F PUBLIC HEALTII=City and County of San Francisco 



Certificate of Beatb 

( Til. S. Standard ) 



-? 



PLACE OF DEATH: — County of CjiCL^w 'VCXywCVM^o City of O/O^ruO-'UX/^vc-ui.C* 



^f!J«. 



4 




St.;"^ — Dist.;bct/ 



and 



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



FULL NAME 



D 




PERSONAL AND STATISTICAL PARTICULARS 

COl.OK 

DAT}-: «)!• HIKTH 

11 AS.x. 






Ujljbt 




(Day) 



\<*.K 



O JL )■(•(/; 5 



Mnul/n 



fVear) 



Da vs 



SINr.i.i:. MAKKIKI). 
WllxtWICn OK DIVoRi'KI) 

iWrittin '-ocial lU-sij^nalioii) 




niKTHPI.ACR 

(State or Coutitrj-^ 



NAMK OF 
I- ATJIHR 






iL^vIv' 



ruK^ryv 



niRTHPT.ACH 
(H- I ATMKK 
(Slate or Country) 



MAIDKN NAMK 
(H- MOTMHR 



MIRTHI'LACK 
<>!•■ MoTIlKR 
(State or Country) 



»* 



M 



\\ 



MEDICAL CERTIFICATE OF DEATH 



DATB OF DKATH 




Month) 



11 

(Day) 



(Year) 



I HEREBY CERTIFY, That I attended deceased from 

W-.^ at 190 s to ...WL^. .1.1 190 H 

that I last saw h .X>v alive on M^U^ 190 H 

and that death occurred, on the date stated above, at \ I " 5^ 
V -M. The CAUSE OF DEATH was as follows: 

0-i/\\Xv<-CAA-\.A,<X 4^^<s\X.■^■^^^\y■\r^r^^ M-cJIaj-wC 

IJjU^Nt^tAr^.^ 



DTK ATI ON ^ Years I Mouths ^ Days " Hours 
CONTR IHUTOR Y O A^LtXA^A-tvixX \ (\J^'^^ 




OCCri'ATIO 



Resided in Satt I'lamisri) - )'r,iiy 



^f,>,^f/ts\^ Days 



Tin* \M(tvi'. SI' ATI-: n i'Hksonai, par iriTi.ARs AKi. IK I 1; Td rm-: 

IJi:sT 01 MV KNoWI.HDC.K AND lU'I.n.l- 



fltifoMuant 



a Aj o \^\) 



\cMrr.^ OAA^c/^JkjU^ VxxX' 



DURATION I Vicars " Mouths ' Days 
(SIGNED) t). t. 0^JUUUA. 

ic)oH (Address) IS I c)^vClx^v 3t 



"^ Hours 
M.D. 




IX 



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



Former or 
Usual Residence 



vJuyVOi vKjJaT Place of Vj 



Place of Death? IH Days 



Wfien was disease contracted, 4-9^1 vi) 

If not at place of deatli ? Ty>X (Vvv^-ryXiv AKAtXi 4s4,,aMv 

\Ly. ^^\■ HIRIAI, OR l< 

R 5 1 C^V>o..a..c^^ 'ix. 



V\.\^'. 0|- HIRLM, OR K1:moVA1. ( DA;^!-. of in KlAi, or KKMOVAI, 

'3j IQO'i 



INDMRTAKKR 

(Addi «vs 



IN. B. Kvery item of in?ormHt1on ithould b; ciircfully ftupplied. AGfi Hhould be Htated EXACTLY. PHY8ICIAINH should 

state CAUSE OF DI:ATH in pliiin terms, that it may be properly classified. The "Special Information" for psr- 
sons djin^ away from home Hhould be l^iven in every instance. 



s 



*^i 



tfi' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hnanl of iic.Uh FNo i. 1*-^^^ Hct P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafe Filed, 




lOO'i 



Registered J\^o, 



273 



Deputy Health Officer 



DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 

( TH. S. StanDarD ) 
I — County of ^' 



PLACE OF DEATH 

(No. 1 0^ 




:nty of U/OL/^Aj J KO^yx^u^Jvzh City of ^3 O/Tu ,>uCL/W'Ca.>^C^ 

St.; b Dist.; bet. M U5\tn) IW^ and \^r\^>XLoj\vL. 

TIT 



(IF DE*TH OCCUBS AWAY FROM USUAL R E S I D E NC E Gl VE FACTS CALLED r(.l\ UNDER "SPECIAL INFORMATION • \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




.OaLu J , <i JJva\/xr\\AM 



t 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR > 



Qf)vL 



^vtfci 



DATK or niKTM 




MEDICAL CERTIFICATE OF DEATH 



(Year) 



I NDoiUh) 



X^ 7.a.0.H 

(Day) (Year) 



ACK 



) t'li I 



. Motil/is 



a5> 



Pavs 



SINT.l.H. MARKIRT). 
\VII)n\\i:i) OK DIVoKOKf) 

(Wiittin >;iMi;il fksivriiation) 




/'VVOAO.. 



BIRTH PI, ACK 

(Stiitf or Country) 



NAMK OF 
FATHKR 



niRTHPI.ACK 
<)l' J APHKR 
(Statf or Country) 



maii)i:n namp: 
<»p M()Tni;K 



HIKTHPI.ACK 

OP motiip:k 

(Stale or Country) 






DATE OK DP:ATH A ft 

(Wonth) /j (Day) 

HF.RICRY CIvRTIFY, That I attended deceased from 

VAJL.Xi 190H to ....|ju^ 190 H 

that I last saw h -VAVvahve on >^^aXul 5 igo H 
and that death occurred, on the date stated above, at *" 
^ M . The CAl'SK OF I)I':ATH was as follows: 



-<X'V <XA/"N ^ \A.A^ 



Dl'RATION ^ Yfars - Months Q,3> Days ^ Hours 
CONTRini'TORY MAj;i"V^^t>jbuw'vX iife,.^^ 



.(\ysjy^ 




(rn^^rvwLuj 




0iN 



rx'CrPATlON ^ * ' 

Resided in Snu J'l niit i.<-en •" )'eiiis 



^/'intfis ^O /^I'l. 



DURATION ' Years ' Mouths X'h Days ' Hours 

/w M.D. 



( SIGNED ) . UjLlxJui CT^^ 
\X ic,oS 



(Address) VK. ^°'\L I I LL LL^n^ 



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

How long at 

Place of Death ? Days 



Tin: AHOVK STA'n:i) PKRSONAI, I-AK TUTLARS ARP: TRIH To TIIK 

np:sr oi Mv KNo\vi.i;i)<".p and mi:ijp:p 



(II 






I'N.Mrr^s 



Former or 
Usual Residence 

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



>9oH 



PI.ACP: OI- lURlAI, OR R1:Mo\AI< j DATKof HiKlAL or RP:M0VAI, 

^&HxL l^s.^-^^ I r^^ *^ 

ini)i-:rtakp:r ^VJ OUY^-^vv ^^ AXaXu 



r\.M 



IfSS 



!S. B. Hvery Item of ]n?orm>ition should be cnrefully Kupplied. AGB should be Htated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it mio be properly classified. The "Special Information** for par- 
sons dyin^ away from home should be ftlven in ^s^ry instance* 




I 

ii 



., i« 



'i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoar.lof iicMltli-KN'o . .; ^^•^^^ H& P Co REFER TO BACI^ OF CERTIFICATE FOR INSTRUCTIONS 



"WiSWr 



Drffc Fi/ed, 



cv^vtVi 




190 H 

Deputy Health OfTicer 



Registered J\^o, 



374 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( "d. S. StanDarD ) 



(^ 



PLACE OF DEATH: — County ofO/CV>X"l -*UVy\xX<1'M City of O/O^Yu OAXxyvvcvA.'OO 



^ 



^ku 



W^WVcJL C^rnJl^^Ctt^C^ ''bc^UvvlsiJl' -— Dist;bet> and — 

(IF DEATH OCCURS(Uw*Y FR<Am U S U A l' R E S I D E NC E GI VE FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N " 'V 
IF DEATH OCCUBRED IN aJhOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 



i) 



.(ru.L acxA^VAJl .0. A^-tn^, 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



""^ '^X^A^ 




\. 



DATK OF THRTII 



Month) 



.. cUt ^SbH 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

a 

(Day) 




(Year) 



A<*.K 



oik HD 



3 1'u t s 



.Miitil/is ". Davs 



SIxr.I.K. MARRTKD. 
WIDOWKD OK DIVOKrKn 
(Writi- in »<<KMal dtsij.Miatif)n) 



' LvvJJvv 



V&-A.ArvNJ 



RTRTnPT.AOK 

(State or Coiintry) 



NAMK ()I 
FATIIKR 



RIRTHPI.ACK 
<>(•• I APHKR 
(State or Country^ 



I HBRRBY CKRTIFY, That I attended deceased from 

- - 190 to 190 

tliat I last saw h • alive on ^ — — 190 



and that death occurred, on the <late stated above, at 
M. The CAUSI': OF DIvATII was as follows 




«« 



MAIOl-.N XAMK 
Ol- MOTHKR 



niRTMlM.ACl-: 
oi- MOTHKR 
(Slate or Country) 



nr RATION Years 
CONTRIBUTORY 



Months 



Days 



Hours 



DURATION 



Years 



Mont /is 



Days 



OCCt'PATION 

Rrsidrd ni San I'ramiseo 



( SIGNED )..UV0^U^ iy>W^ 
YtV.lu. 10 iQoH (Address) \wVurK>JLV^ I: fM^Ci 



Hours 
M.D. 



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



Former or 
Isuat Residence 



Yaclc4,i>vA<M^v^,wiLX Place of Death ? 



I 



Days 



)'<•<?;> ' Mniif/i' 



/>,n 



rm MiovK ST^'^1^I) phrsonai, p \k i hi i. ars ari-: trcp: t<> tup: 

BKST OP MY KNoWlJ'.IX'.p; AM) UV.IJV.U 



(InfoTniant 



L^'V<r»"OL^v 



\'M!<»;s 



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



PI.VCP: OJ- lURIAI, OR RP.MoXAI 



I NDliRTAKKR 

(Address 



DATH of i.iKiAi. or RKMOVAI. 

>w.i)-ait.' r^ '"^ '90S 



iihx- I'^JbLJi 




N. B. Every Item of in?ormntion should be cnrefully supplied. AGE nhould be stated EXACTLY. PHYSICIANS dhould 

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information** for pmr- 
Rons dyinft away from home should be tiii%en in every instance. 



-I. 






''i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l?onnl of llLalth' J No i^ t^^^BSiVCo RgFER TO BACK OP CCRTIFtCATg FOR INSTRUCTIONS 



Regii^tered J\fo, 



275 



Dale Filed, A^jJUi 1^ I'^O'i 

•:Wu_A^ dOjv-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( "a. S. StanOarD ) 
PLACE OF DEATH: — County of Cj/CUTu J;va^vCAA/a) City of O/aAv J A.XX/\vcaA/Co 



(No* 



(TVOXm; 



oIjl 



/OLA. 



St,; 



Dist.: bet. and 



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



) 



FULL NAME 



DjjJrJfWb-^LxAj AA A^. 



PERSONAL AND STATISTICAL PARTICULARS 

SF.X {\^ ft I COI.OR 





vUx 



DATH «)I HIK in 



(Month) 



(Day) 



./.llrH 

(Veav) 



AGF. 



oJUt 



HO 



) 'I'tt » . 



M.niltis * Pars 



SINC.I.K, MAKKIKD. 
WIDoWHD OK DIVOKlKr) 
(Writf ill s(H'ial <i«.si^Miiitii)ii) 




lUK rm'i.ACK 

(StHtf or Country) 



NAMl' OJ- 
FATHER 



«« 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DF:ATH 




(Day) 



(Year) 



I IIKRHBY CI':rTIFV, That I attended deceased from 

190 to 190 

that I hist saw h ^^^ alive 011 ~ 190 



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



--- M. The CAT SI? OF 1)F:ATH was as follows 






G -*w*.A,/SlA../cL^ . 






BiRTnri.ACF: 

0|- l-ATMHR 
(St.'itf or Country) 



MAIDKN NAMF: 
OF MOTHKK 



lURTHrLACK 

<n- M<)'rHF:R 

(State or Country) 



M 



DURATION Years 

CONTRIBUTORY 



Months 



Days 



Hours 



DURATION 

( SIGNED ) \J^\J^\}y\^ 

A(Mres^) UtV 



OCCrPATION 

fyf^iilfif ill ^'ilii /'i itili i^i'ii 



) 'r<! I > 



}/,n,f/ly 



n,i\. 



Tin* \hovf: sTAii:n pfksc^nai, par ricri.vRs aki-: rRCK t«» rni'; 
liFsr OF MY knowi.i-.dcf: AM) iii:mi;i- 



(lufoiinant 



C<rV'rv\Jt\» 



f \(Mrcss 




)'i'ars Mouths Days 



10 



I<)0 



(. 



(rvvfiA^ 



19. 



Hours 
M.D. 



I FECIAL Information only for Hospitals, Instlfunolis, Transirnls, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



ri.ACl-: OI- lUKIAUoK KKMOVAI. I DATF: of Ht RiAi, or RKMOVAI, 



dXA^^^XVL V) /oJuL 



'^ 



I ni)f:rtakkr 

(Ail<lifss 



(Ibac . 

i^rL' iqti., M ^ 



N. B. Every item of information shoulfl be cnrefully supplied. AGR should be stated EXACTLY. PHYSICIANS should 

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



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no.i.lorn.alil. i No ,. -?-^fS;^;iu«vI'ro REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




la 



WO^ 



l)((fo Filed, -vKAy^ju 

^..^vtv^ ^Wm.^ Deputy Health CfTlcer 



Re^isteved J^o. 



276 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of Beatb 

( "d. S. StanC>arC» ) 

of 0/CWuO -V>a^TVCAAC<^ City of Ci/Oyru /L<Xnvci4 CO 



PLACE OF DEATH: — County 

(No. 5)5^.1 0/VvlxcL 



St; S Dist;bct J^IM^^W 




y 



XtX St; O Dist.;bct. ^y^^Mjryv and yV'/OVtVCL^rw ) 

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





FULL NAME 




<XhX/yy 



AXX/YV^-X' 



PERSONAL AND STATISTICAL PARTICULARS 



SK.\ 



^TUU 



COI,OR 



Uj.Lt^ 



MEDICAL CERTIFICATE OF DEATH 



DATR OK DKATM 



DATl-: or- MIK I'll 



(Month) 



AO.K 



X% y,uns 8 



<Day) 



M.mths 



I V\K 

(Year) 



a^ 



Day: 



SINC KK. MAKKIKIV 

\Vn»«)\VKl) OR DIVOKiHl) 

(Write in social (lr»iij.r"atioii) "K 

CJ 



cJ^ 



w^n/VJl; 



niKTin'KAOK 

(Statf or Country) 



NAM1-: or 
i-ATin;K 



TURTnri.ArK 
oi- l-ArHKK 
(Statf or Country^ 



^ 



VCLivlrCV'>VV/a. 




(Day) 



(Year) 



I HRRr-nV CI-RTIFV, That T attiMidcd deceased from 

..-r———. — i(p to ' T90 ~~~~ 

tliat I last saw h ^^^^ alive on "~" ——— up 



and tliat dcatli occurred, on the date stated alx^ve, at 



"~y M. The CAI'SI-: ()!<' DI-ATH w.ls as foll<nvs 



follinvs : 

r t 



^o-vw 



O'tcrVni' (fb axL>vc<v-yv-v\j 



MAIPKN NAMK 
«)l MOTHKR 



lukrm'T.ACM 

OI- MO'I'MKR 
(Statf or Country) 




i 






] 



^ 



OCCUPATION Ci \ (C 

Rfsiifrif ill Sa» /-'i niii i^ro J^\ )',iii< 



Di; RAT ION Vt-ars 
CONTRIIUTORV 



Mont /is 



DiU 



'V 



Hours 



DTRATION ^''''''"/w Months Pays Hours 

(Signed) Lvtry\jl\' J AoLU AjlLx^anxC m.d. 

KaJL^ n Tc)oS (.\<ldress) Ld\xnv«A:« W>i,V'-/C„i 



^ 



PFCIAL Information only tor Hospitals, instifuHons, Transirnts, 
or Recent Residents, and persons dying away from home. 



\r.i„ih- 



/hn 



Till-" MU)VK STA ri-:i) I'KKSONAI, I' \ R I' U" T I. A K S A K 1', TKlK Tv> THK 

UKST oi- MY KNowi.i-;i)(.H AM) Mi:i,n;i- 



VVVOL'VWV 



(Informant (]b O. Vvu (lv3 ^OaXa^ 



(Address 



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



Days 



ri^ACH Ol- lUKIAI^OR k}-;mo\ai. 



i. 



l)AJl-;o;( lU HIM. or kl.MoV.M, 

13 I90S 



rNDKRTAKKk U V VSD VlYLtt/] 

(Addr.-ss b'ib UJ <>^^Vvv->V'Ctt'0-YU J"^ 




IN. B. F.very Item otf int'ormjition should b- cnrefully supplied. AHR should be stnted KXACTLY. PHYSICIANS should 

state CAUSn OF DHATH in plnhi terms, that it may be properly classified. The "Special Information'* for par- 
sons dyin^ away from home should be i^iven in every instance. 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no:.r.l..f IIcMlth- I- No iK-^^^uSiVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Registered J^o, 



277 



Dale Filed, Ldo li lOO'K 

\ji:\ju^ isA>u Deputy Hea'th Omo<-r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




Certificate of H)eatb 

( "CI. S. StanOarO ) 



A ^ 



PLACE OF DEATH: — County of 0/0L/^^u^J7UX/>^XlUlAU) City of O/Ouvu OAxX/yvCaa^C^ 



r^lo. 




AX/VuX<XXXC' 



wni 



(IF DEATH OCCURS AWAY FROM USUAL 
IF DEATH OCCURRED IN A HOSPITAL 



St.; ——. Dist.; bet. 



"and 



RESIDENCE GIVE FACTS 
OR INSTITUTION GIVE I 



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



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

DATK <)I- llIRTn Qr\ 



I 




cti 



Txir 



(Month) 



a3i 

(Day) 



i%\\ 

(Vear) 



AOK 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




I a. 

(Day) 



(Year) 



bo )v,7».v ^J M.-ulhs 1^ Davi 



SIN<;i,K. MAKUIKl). 
WIDOWKI) OK niVOKCKD 
(Writf ill 'Social ilf-.sij.riiatioii) 




niRTHPI.ACK 

(State or Coiintrv^ 



NAMK OI 




tf 



m 



;vnn.:K A J (D j) , ^^ 

niRTnpi.ACF:/| f] 

OI- I-ATHFK^ n '-' 

(Slatf or Couiitrj-) •Xl 

occrPAT.ON OX^^^vc^^t f 



I Hr:RI':RV CI':RTIFV, That I attencUMl deceased from 

Vi^\xw 190 M to WLjl la 190 'H 

that I last saw h 'iw/^-w alive on ^J-wUa i^L T90 H 

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



M. The CAT'S K OF I)I':ATII was as follows 



.CA./w>/cryvvoL 



3. A.^y-v^^^,.«rnw-dL i X 



ho 



.'\<VV>UV 



DURATION 



) 'ears 



Months 



/)(7VS 



MAinKN namf: 

01 MOTHFtR 



niKTHri.ACK 
OF MOTHKR 
(State or Country^ 



CONTRinrTORY LLo-A. vJj^N.,uvcix^ ,,. 



Hours 




Years 



Months 



Pavs 



DURATION _ 

..Eo) %^vUaCMU 

Address) bObO'VvUX^; Ol 



(SIGI 



Hours 
M.D. 



' -^ ( -^ 



^PECHAL INFORMATION only for Hospitals, InsUtutlons, Transients, 
or Recent Residents, and persons dying away from home. 



1 ij • 

hVsnfi'if III ^>iii / I ii III /W11 >^i '\ ) ri7 1 < Miiiitlis 



/hi lA 



THJ-: AIIOVF, STA'IFI) »'HKS()NAI. TAKTHMLARS ARK TRFK TO TJIK 

ni:sr oi- mv kno\\i,i:i)c.k and iu:i.ii:f 

(Informant 



a^.^ 



(Afhlress C> S "^ VCX^A^ 



^it 



Former or « ^ 

Usual Residence ^ o 

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



v^XXavKj 



Days 



I'I.ACF: OF lURIAI. (^R RKMOVAI, I DATK of IltRMi, or RKMOVAl. 



rNDF:RTAKKR 

(Address 



N. B. Bvepy Item o? information •hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for psr- 
son« dylnft away from home should be Itiven in every instance. 



i 



HI 



I: 



J 





i 



. ii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Hoiird of Hc-allh— F Vo. i =, t'^S^^.WS^.V Co 



Eegistered J\^o, 



Dale Filed, VJLu I 3 i^^S 

DEPARTMENT d PUBLIC HEALTH=City and County of San Francisco 



378 I 



Certificate of H)eatb 

( *a. S. StanDarD ) 

4^(3]^ J? 



^ 



PLACE OF DEATH: — County of O-CLa^ AXu-ruOLXL ccCity of ^'/CL^vo; Jx^VwCv^/Co 



(No. 12)H 



ViW^Jl ILvHl^ 



St.; S Dist.;bet. 




and 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED 
V IF- DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



FULL NAME 



FOR UNDER "special INFORMATION" "\ 
NSTEAD OF STREET AND NUMBER. / 




) 




PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^ 






DATK OF lUK rn 



VcJub 



COI.OR 



LuJrvCLil 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



AC.K 



/Month) 



] Vrt » 5 



(Day) 



Mouthi 



(Year) 



XH 



Day: 



SIN(,I,K. MAKKTRD. 
WIDoWKI) OK DIVORCKO 

(W'riti- in social (Usij.'natioti) 



C)->Ln^vCAJb 



HiK rm'UACK 

(Statf or Coiuiti v) 



NAME OF 

FATHKR 



RIRTnri,A(*K 

ni- I A iin':K 

(Stalf or Ooiititry) 



J (3^ ^ 





(Day) 



(Year) 



I HRRRBY CI-:RTIFV, That I attended (kccascd from 
|V\L^ ?> 190M to Wiu I2i. 



to -pVMa ixi 190H 

that I last saw h--4A; alive oil ^vLc^, b np\ 



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

"M. The CArSl*: OF DlvATH was as folliuvs 

\U\<X>V0U1/^ 



<^^VArW<J. 



DERATION ^ Years "^ Mouths 'X^ Days 
CONTRIliUTORV 



Hours 



MAini:N XAM1-: 

Ol- MOTHER 



(^^O-U) 



/OlmA. 



RIRTIIPLACE 

()»• MOTHER 
(Statf or CotiiUry) 






OCCUPATION 



Afo>it/is d\\Davs 



DURATION ^ )cars " Mouths ^\ Pays Hours 

f SIGNED) nI A) (/OA^-I'LCu, M.D. 



13) Tc)oM (Address) 3^1^ H 



tlci 



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



Rrsidfd in San /'i aiu isfn 



) r,n 



lA-/////- 



M 



/ ht\ 



■\'\\v. \Hovi>: SI" \ii: I) I'KRsoN \i, 1- vKinTi, ARs ARi; iR! I-; To Tni<; 

1U-:ST OI- MY KNt>\VI,i:i)('.E AM) 151-; 1, 1 1", F 



(Iiifonnatit 




l'\(l(llC-S 






Former or 
Usual Residence 

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



How long at 
Place of Death 



■ Days 



I'l.ACE Ol- UFRIAI. OR REMo\ AI. I DATFlo!" JJikiai. or REMoVAI, 
r.NDERTAKIlR V-^X^^XA-aT ^^ V^'^MVVaA^ . 



(Adilress < 



IN. B. Bver.v 5tem of information ohouUI b- cnrefully supplied. AGE Hhoulii be stated EXACTLY. PHYSICIAINS should 

stntc CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information'* for per- 
sons dyin^ awny from home should be (^iven in every instance. 






'"■■-ff^- 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFCR TO BACK OP CERTIFICATC FOR INSTRUCTIONS 



Hoiir.l of HiiiKJi- !'■ No. K -fr-^iaifeSfc i»& 1* Co 



J)((fc Filed , 




190^ 



Registered JSTo. 



279 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtiffcate of Death 

( H. S. StanDarO ) 



PLACE OF DEATH: — County of O/CV^a; o^Va^vCAA^^D City of Cj/CL/\\; vj A^<x-^vC^<i.C{i 



(^ 



(No. 1 ^ V J ,<x c^l -^^^ 



St.; I x^*.t., 

IF DEATH oldcunS AWAY FROM USUAL R E S I DE NC E G I VE FACTS 



Dist.: bet. ^KJtOaXjsY^ 



and 




(nv 



i 



(IF DEATH oldcunS AWAY FROM USUAL R E S I DE NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" ^ 
IF OEATH'OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 
SHX (K\ ^ I COI,OR f\) 



JXVWoJuO 

DATl-: <)I- MIKTIl 






./^y^>f^JLA^„ 



iMontlO K 



ICl 

(Day) 



.7..H..0.t. 

(Year) 



A<'.K 



J )V<i>.«: ds, Moul/is .sJ.. 



Dan 



STNT.T.K MARRTKD. 
\VIl)<)\Vi:i) (»K DIVOKTHI) 
(Write in social <Usij?iiati<)ii) 



lUKTUPKACK 

'Statf or Country) 



NAM1-: Ol 
I ATIIKR 



lURTMPI.Al'K 
t)I- 1 ATIIKR 
(State or Country) 



MAini'.N NAMK 
Ol' MOTHKR 



^_ dx^xoAjL 




MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 




(Day) 



(Year) 




I HEREBY C1':RTIFV, That I attended deceased from 

190 to 190 — — 

that I hist saw h alive on — — ■ 190 

and that death occurred, on the (hitc stated above, at ———.... 



-- M. The CAl'SIv Ol- DI^ATIl was as follows: 




oUJj uJ' 



RTRTHPT.ACK 

Ol- M<»TnHR 
(Statf or Country) 




f\JUU 



X/Ou 



Dr RATION Years 
CONTRIIJUTORY 



^fouths 



Days 



Hours 



DURATK^N 
(SIG 



Years 



Mouths 



Davs 



OCCTTATION 

Rfsidfif ill Stfn /'i (7Hi iM-i) \ )'i<ris *" Mmiths 



/hi ) , 



THl" AMOVK STATKl) I'KK^nXAI. PA KTllT I.AKS Akl-: TRIK T» > THH 
HKST OF MY KN<)\VIj;i)<.K AND miMHK 



(Iiifotmant 



(A.ldross 



wUwT VirUrtrvu 




NED )....oA<iU3U.VMjq. "o. Lcto^ 

'3 T()0*i (Address) loOb O-ii^ttxA. ot 






Hours 
M.D. 



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



Former or 
Usual Residence 



How long at 

Place of Death ? Days 



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



PI.ACK OK lURIAU OR RKMOVAl. 
I NDKRTAKKR » ' V^-A^VVJ J 



DATl'df niKiAi, or RKMOVAl, 



(Address 1.3>.3. V'CV^.JLc 0^. 



CUol 



N. B. Rvery item olf informntlon should be cnrefully supplied. AGK Hfioiild be Btated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plnin terms, that it may be properly ciassit'ied. The "Special Information'* for p«r- 
sons dyind away from home should be ^Iven in every instance. 






i' I 



1 '^^i^m_ 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoard of lit:. 1th- 1 No. k -^^^^ Hl^V Co WgFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Registered J^o, 



280 



Date Filed, )kuXu 1^ i^^l 

^Ltrcw^ SJUXHA Deputy Health Officer 

DEPARTMENT # PUBLIC HEALTH=City and County of San Francisco 



Ccttiffcate of 5)eatb 



( Ta. S. StanOarD ) 



PLACE OF DEATH: — County 



of O/CUru vJ AXVrtCiAC^ City of O-CX^Vu vJ AyCt^vc^^^CuO 



St.; 5 Dist.;bct 



AiAAA4^L/trYL 



and vj^ 



U/w 



(IF DEATH OCCURS AWAY FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\ 
IF DEATH OCCURRED IN A HOSPITAL UR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



cva ) 



FULL NAME 




/cCtuji 




PERSONAL AND STATISTICAL PARTICULARS 



sj-;.\ 






DA'I'l-: OF lUKIH 






(Month) (Day) 



rl-^A 

(Year) 



at.p: 



3^ 

SINC,1,K. MARKIKI). 



\UJ 



)'<at s 



Months 



Pa 1 .V 



WIDOWK!) OK DIVoKi'Hl) A 

iWrittin social (Usit.'natioii) \ V v^ I 

M I UXAAAJUL 



lUK IIIPF.AOK 
(Statf or CoiMitryl 



NAMK OJ- 
I ATlll-.R 



RTRTnPI.ACH 
OI- I-AIMKR 
(Statf <»r Cojintry'* 



a 







MAIDKN VAMK 
OI MOTIIIIK 



niR'IMPl.ACR 
OI" MOTHICR 
(State or Cotmtry) 



-J 



>^ '\Jlatn^' 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

II 



(Year) 



Cl^a.1x(^CU^\) 



occu 



; PAT ION OM A 

Kf.siiifil ill Still I'l tiih iM'o \ki )'/■<//> 



otith) (J (Day) 

H!;RKBY CI'RTIFY, That I attended decca.sed from 

5:. igo'i to ..|vU^...L\ 190 H 

that I last saw \\ rVv alive on vC^\aa, 1 1 lop H 

and that death occurred, on the <latc stated above, at CVV-8-M^ 
^SQ^M. The CAISI<: OV \)\\\'\\\ was as follows: 

(to <Mlj^C,^VLAJ-VAXcucrv>^ cn^' V 5" 

....Wv\XcCtHy<JX t>^^ djUX.t^. /i^-^^ ii oUA..<XCt\-v<H)-v.<! 

Dr RATION ^ Years " Mouths b Days ' Hours 

coNTRiHrroRV v^V.(r^><J!^^U^.^..s^ 

DURATION Years • Mouths Days Hours 

(SIGNED) M K u' . LLui,<lL.-.v M.D. 

-^LU \X 190H (Ad.lress) 2>'ilb - R Uk Ot 



Afouths 




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



.!/,»///// « 



Ihiv 



THl" \noVF: STATF:D PKRSONAI. PARTIcrLARS ARK TRTE TO THF: 
IJKST OI" MV KN0\VM;I)C.F: and nFI.IHF 



(Iiifotinatit 



C \'1(lrcxs 






Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



PI.A^CE OF BIRFAI, OR REMOVAL 



i)ATi;of nt KiAi. or rf:moval 






T90H 



TN-DERTAKER fc. J. 3x^^[\A; "^^"^^^ V_ 



f Addrt'ss 



\\'^-\ Oryu.v<i^(-,v c\f 



IS. B.-— Every Item of Information shoulti be cnrefuliy supplied. AGR Hhoiiltl be stated EXACTLY. PHYSICIANS nhould 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for par- 
sons dyin^ away from home should be ftiven in every instance. 



1- 





t 



■ 7 



« 



f 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n..at.l of M.Mitli FNo I.; i<^^^i{&I>Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J\^o, 



281 



Date Filed, UaXu li I'^OH 

Ltrwu) dJOv-u. Deputy Health Omc^r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccttificate of Bcatb 

( "CI. S. StanDar^ ) 
PLACE OF DEATH: — County oi^Ouy\)^KO^^\^V^^JZ^ City of O/CL'^j AXX/wcv^ CO 



^No. 



H^'la^xcUvo.1 



4- 



St.; 2) Dist.; bet. I At and 1 '^^^ 



(ir DEATH OCCURS AW*V mOM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



yjusSsuu 




SKX 



OATK <)i- r.iKTn 



PERSONAL AND STATISTICAL PARTICULARS 

I cor,oR 




iD.L-u 



AC.K 



I 






Years 




(Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




(Day) 



(Year) 



l^IIRRHBY CHRTIFY, That T atten<lc(l deceased from 
^aJL-^jO 190H to ^IvvW IX 190 S 



T90 n 



ytouths. 



Pars 



SINC.I.K MAKKn^I) 
WIDoWhl) OR DIVoRrKI) 
(Write in <(k ial (U'»ii)/Jialii)ii) 




HIKTHl'KAOK \) (K\ A 

(Stal< 01 CounUvi -X ^Ul' ^ 



NAM1-: (>!•• 
FATHER 



RIKTIIPUACE 
Ol" KAPHEK 

• Stall- or Country) 



MAIDEN NAMK 
OI-- MOTHEK 





tliat I "last saw h A-^Vk alive on pAJLoi I2l' 
and that death occurred, on the date stated above, at I v 5 
ii M. The CATSI? OF DI^ATIl was as follows: 




-tvA.^v"Vyv 



. oU X/VvA-CVA--«rvv. 



DURATION - Years ' Afonf/is ^"^ Days ^ Hours 
CONTRIBUTORY iu..X<<vCLwW^rv:v 



mRTiiri.ACi-: 

ni MOTHER 
(State or Countty^ 




OCCUPATION 

Rrsi'drii in Siiii I'l tiiii i<'rii 



I 



Wtu-Ow 



DURATION Years .Vouths Days Hours 

(Signed) ^. U/ClLu Mjjt/>v^v,Lt(j m.d. 

^^ T()oM (Ad.Iress) 1 0^ Uavx- v)\jl<L4 UaMI 




PECIAL Information only for Hospitals, Insfitufions, Translrnts, 
or Recent Residents, and persons dying dHay from home. 



JV'iM 



M< 



nit /is ^ 



/),,' V. 



THl-: A HOVE ST AT EI) rERSONAI. PAR IKT I.ARS ARE TRIM To Till-; 
BEST OF MY KN'OWI.iax'.K AND MEMl'.F 



(Informant 



Former or 
Usual Residence 

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



How long at 
Place of Oeatti ? 



Days 



ri.ACE Ol- in RIAI, OR REMo\AI. I DATi: ol' in kiai. or REMOVAL 

'■ ' 'Ha- 






T90 



rSDERTAKER 

(Address 



IN. B. P.very item of information should be ciirefully Hupplied. AGB nhnuld be stated EXACTLY. PHYSICIANS nhould 

ntate CAUSE OF DEATH in plain terms, that it may be properly classified. The "8|>ecial Information'* for p>«r- 
sons dying away from home should be given in every instance. 



1< ) 



^1 




'ft 








^•4^ 



till 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noanl of iK.lih-i No i -^ i*^^c^li&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)a/e Filed, 




.100 "i 



Registered J\^o. 



882 



Xxamjl Deputy Health Offir-r 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( xa. S. StanDarD ) 



0^ 



PLACE OF DEATH: — County ofOo.^r\jO AX)./vu^UiX.()Gty of O <X^^ vJ A<V>VCAA/C^ 



^No. 




D^<Uv 



(IF DEATH OCCURS A 
IF DEATH OCCURF 



WAY 



/vX-^UL) 



St.: ' Dist,; bet. 



and 



FROM USUAL RESIDENCE Give FACTS CALLED FO 



RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I 



^OR UNDER "special INFORMATION" \ 
NSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 



SHX 



DATK or- lUKTll 



PERSONAL AND STATISTICAL PARTICULARS 

COI/>R 






iMAnth) 



(Day) 



(Year) 



AGE 



I <^ ) V<7 » > 



Mnulfis 



\x 



Da IV 



SIXC.I.K. MAKRiKn. 
WinoWKI) OK IinnKCKD 
(Wiittiti s<M.'iiil ilisiv;iiatitin) 



RIK TMPI.ACK 

(Statr ur Conntty) 



NX MI' oi" 

fatiii:k 



BTKIUI'KAfK 
()!• ! ATHHR 
(Statr or Country) 



I 



<))u 



\>LU-d*. 





MAIDKN NAMH 
Ol" M(JTHKK 



inRrni'i,A("H 

()1 MorilHK 
(Stati- or Coutilry) 



OCCUPATION ^a* 



pi 





MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 




Month) A 



(Day) 



790 "i 

(Year) 




IHtRIvHV ClvRTIFV, That I attetided deceased from 

5 190 H to^ vb-^-^'-M- ^X 190 "^ 

190 s 



tfiat I last saw h .■V'%^\ alive on yV-xJlvA. \'\ 




3' 



Rryidrd in SiUi /i iju, isrit 




)'r<r) 



" M.nilln \0 lhl\y 



Tin-: \HovK ST \ii:i) i'kksonai. rAKinri, aks aki-. prie to the 
UEST oi- Mv kno\\m:d<".e and iii:iji;f 



'Infounant 






(1 'I ; 

and that death occurred, on the date stated above, at CX-\KL 
H (X M. The CAUSI<: OF DI'ATH was as follows: 
V^XXVc-vw.xrv>voy cHp> OA,«r\>%xj|^^ 

DC RATION 31 Years ^Months ^ Days ' Hours 
CONTRinUTORY SJv^^Jk -IrfrA^^ 

DURATION - Years - Months \ Pays - Hours 

(SIGNED) iS^ '\^^\JOjXV\^ M.D. 

,JLu la i(>o'-( (Ad.lress) '^ 1 3 0>uXtjA) O^ 



ECl 



FECIAL INFORMATION «nl> for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from home. 



Former or I Vv ( How long at 

Usual Residence M UUArn^VCV^^ \JX\j piare of Death ? k) 

WheWas disease contracted, fu [ U 

If norat place of death ? v Ut\AJnn<\xX/vu VaV 



Days 



ri.ACE OF niRIAU OR Rf:moVAU j date of HiKiAl, or REMOVAI, 



VJ^»H T90H 

INDERTAKER OVD M UUXlA^^^^VV ^<^ Co 



IN. B. fivery Item olt infnpm»tion should hj cnrefiilly Huppliecl. AGK Hhould be Rtnted RXACTLY. PHYSICIANS nhoulcl 

ntnte CAIISL OI" DI:ATH In pliiin terms, thnt it miiy be properly clasHifiecl. The "Special Inltormation" ?or p«r- 
nonc clyin^ iiway from home Hhoiild he (i^iven in every inntance* 



MM 





Mi: ' *^- ■^•-^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

UnMilof M.aiil, \-Sn.i^-»^^^r.lilkyCn RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 










Depu' 



190 "{ 

ilth O 



Registered J^o, 



283 



prr 



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



Certificate of 2)eatb 



( Til. S. Stan&arD ) 



PLACE OF DEATH: — County 



of ay>v KOjy\/l t4<l.o City of C' O^^yX) J Ko^r\ 



rNo.33vl 




a, 



.5h; I Dist.; bct.^^^CuiA 



( 



>\v«Au VVAM. .5h; I Dist.; bct.vUAJ^cuXuJ^au and 

ir DtATM («>ccuBS *w*ltrROM USUAL RESIDENCE GIVE facts callcd roR under "specAl information 

\r DEA-fil OCCURRCOgiN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE^IaND NUMBER. 



\<tAJiJ^<^ 



.D 




) 



FULL NAME 




Wyv^ 



CCWOl. 



lOJ 



'Ixx^to 



PERSONAL AND STATISTICAL PARTICULARS 

sj:\ n^ , I COLOR 



<^cJL 



\x)Lju 



DATl-: or MIRTH 



(Month) 



(Day) 



r^^^'^ 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OI' DKATII 

ID 



AT.H 



ci\ O ) ''■(/ 1 s 



A/oti//is.. Davs 



sinci.h:. MAKKIKI) 

\V II)<>\Vi:i) (»K DIXnkfKr) 

(WiitfiiJ M)rial ilcsivriiatioti) 



lUKTHPI.AOI': 

(State or Coutitiyl 



NAM}-; <)!• 
I ATHKR 



C).v>^cv^^ 



li I 




(Day) (Year) 



I IIHRHnY Cl<:RTrF'Y, That T attended deceased from 

' I90 to 190 

that I last saw h alive on — — 190 



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



M. The CAl'SIv OF Dl-ATII was as follows: 






i 



HIKTHri.AOK 
()|- 1 AlUKK 
(Statr or Country) 



MAIDKN NAMK 
()|- MOTIIKK 



niRTll"LACK 
OH MOTHKR 
(Statf or Country) 



_ — M 



u 



nr RATION Vrars Mouths Days 
CONTRIHUTORY 



Hout s 



DURATION Years Motiihs 



Days 



Hours 

(SIGNED) Wu^^vlt^J O.vfc.UJ XuUv^^ M.D. 
^0 i()oH (Address) vfrV^rvvjeA^a liJ^i^vtU 




«>OCr PAT ION 



oLolL- 



tr>JLK» 



Resided iit Sav l'iatui<i'o ' Yrtxis ^ .^fmiths " Pays 



THl" MJOVK STATi;i) PKRSONAI, PA K lUr I,A KS AK Iv TRIK T< ) TMH 
IlKST OF MY KNOW^KDC.K AM) MKI.IHF 



(Infotniatit 



c 



^VO^AJ«-\' 



(AdttresMi 



FECIAL INFORMATION only for Hospitals, InsfitufloK Transients, 
or Recent Residents, and persons dying av^ay from home. 

Former or How long at 

Usual Residence Place of Deatti ? Days 

When was disease contracted, 

If not at place of death ? 



I'l^ACK OF lURIAI, Ok KFMoVAI, I OATliof Ht hiai. or RKMOVAI, 



i 

rNi)i;Ri"AKi:R vvj 



Vvw^wcL 



<5C<Vt3^W '^Xulo 



I90H 



V 



(Addres. 3b hx - l^tlv iA 



!N. B. Hvery item oi inlformHtion should be ctirefully Hupplied. ACB should be ntated EXACTLY. PHYSICIANS dhould 

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information** (op par- 
sons dyin^ away from home should be fttven in every instance. 



li 



' iiM 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



llo.n.l of lliiillli- !•• N'o 1-^ 1!^;^^HiS:r Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



' Fih>1, AvJL 13 1'-^O'i 

Ifrvcoi iju^JM. Deputy Health Of?!-— - 



Registered J\i'o. 



284 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( XX. S. StanDarD ) 



PLACE OF DEATH: — County of 



City of 



(fi^^<u.\ \S 



0jl 

J V 



ii^ 

/\|F DCATH OCCURS AWAY rROM USUA 
Vj If DtATH OCCURRED IN A HOSPITA 



<5lav 0;\^CL'Wc.>ui.'Cc 



St. 



Dist.; bet. 



"and 



L RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATIO 
L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



" ) 



t 



FULL NAME 




XXA/CJLi 



PERSONAL AND STATISTICAL PARTICULARS 



si-:\ 



(yivcit, 



COI.oR 



LAjJtv^jLi. 



DATK of HIKTU 



(Month) 



(Day) 



(Ye.'ir) 



A ( ■. H 



5H 



) 'lUi » .<r 



^ /.>,!/ /is 



Da vs 



^lN(.I,i:. MARKIK.n. 

uiDDWKi) OR nivoRCKn 

(Writf in socini riesiRnatioii) 



lURTnn.AOK 
(Slate or Country) 



NAMK ()»•■ 
FATIIKR 



HIRTMPI.ACK 
<>l lAPHKR 
(Statr or Country) 



MAIUKN NAMK 
OF MOTMKR 



TURTnri.ACK 
oi- MOTMKR 
(State or Country) 



c1 I 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DKATH 



(Month) I 



I 



(Day) 



TQO i 
(Year) 



I IIRRERV CICRTIFV, That I attended deccaseil from 

■ ■' I9O : to 190 ~ — "■ 

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

and that death occiirre»l, on the date stated a!)ove, at — 

rr— M. The CATSlv OF I)I<:ATU was as follows: 







«i 



«« 



•» 



nr RAT ION Years 

CONTRIIUTORV 



YXJ 

Mouths Days 



Hours 



OCCVPATION- ^^ JJ^^,^ 



Kfsidfii ill Sail / i <iii, i^ro 



) rn I ,v 



yr.nith^ 



nij\ 



THl" AHOVK STA rj:i) PKKSONAh I'AR lU 11. VR^ AKi; IRIH To IHK 

nKST OF MY K.Nowi,F;n(;K and mkmf:f 



(Tiif. >'niMnf 



L^cvctvulV 



.19. 



^HJL 



(Address 



DTRATION Years 

(Signed) 

13> iqoM 



MoNt/is 



Days 



Hours 



LcrVCPAJL'v vo UL) duJL/tXrrudL M.D. 




(^ 



(Addrt 



s<) L 



frVfr>v«A^ 



ID. 



-VCJl 



PECfAL INFORMATION only lor Hospitals, Institutions, Transifwts, 
or Rfccnt Residents, and persons dying away from home. 



Former or 
Usual Residence 



Li^w-nr* 



v^>-w»-vw 



How lonq at 

Place of Death? Days 



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



PI.A^F: OF nrRI^M. <tR KKMoVAI, | DAi;^: of Ml KIAI. or RKMOVAI. 

iH 190H 



ri.ALh OJ- Ml KI.\I, OK KhMOX 



r N D 1: R r A K K R Lv"V^CLX<]L vX^vx^JLxXX'O^KXh-A 



(Address 



IN. B. F.very item of information should b.- cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

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







r 



• — 4i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, r,l,.ni..ll1i -l-N-o ,.*g^?Sfc!IS:PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registej'erl J^fo. 



Date Filed, Vlu 13, -'^'^^ 

"Lrw^ ix^;^ Deputy HeaJthOfnc-r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( m. S. StanC^arD ) 
PLACE OF DEATH: — County ofCW^rv 0.>UX/wc.o^c^ City of O^o^ V<V/yvCa,^ c^ 



(No. V) /CLCMkrV/^:' 





^<L>|vCLcJlj 



St. 



Dist.; bet. 



and 



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



FULL NAME 



.XA>-i\^>XX) VjA^L/OXl^W 




PERSONAL AND STATISTICAL PARTICULARS 



SHX 



QOlJL 



COM>R 



lOJvJU 



MEDICAL CERTIFICATE OF DEATH 



DATK or" lUKTH 



\Xkj^o^ 

I Month) (J 



.3 

(Day) 



(Year) 



AOK 



ai 



)'r(irs 



W 



.^foti/Z/s 



. Da li 



SIN<;i,K, MARKIHI). 
WIDOWlCn OR niVoKCHI) 
( Wiitc ill social (ksif-Miation) 



6j^x<Jjb 



(State or Country) \Y\\ | () 9 X- 1) 

^ (? If 



NAMK OJ" 
lATIIKR 



BIRTH PI. ACH 
O!" lATHKR 
iStale or Country) 



MAIDKN XAMK 
OF MOTUHR 



RlRTinM.ACl-: 
Ol MOTJIICR 
(fttalf or Country) 



OCCUPATION J? (] 




DATE OF DEATH A a 

^./LxJLu J 



X 

(Day) 



fpoH 

(Year) 






I Hr<:RI-;BV C1:RTIFV, That I attended deceased from 

3 190*1 to Ji^^JLuL iX iqoS 

that I last saw h -Ao^ alive on NK^JLu, b 190 H 

and that tleath occurred, on the date stated above, at " 

^ M. The CAl'SK OF DIvATII was as follows: 



Dr RATION ^ }'rars ^ Months ^ Ihiys * Hours 
CONTRIIU'TORV 



1 



Rfsitifi! ill Siui /'i aihisra — ]'r(7i< — Mi^iiili^ 



/hns 



TMl-' \HOVK STATl'D I'KRSONAI. 1' A Klicr LARS AR1-: TRTH TO THH 
HKST Ol- MV KNOWI,i;i)C.K AND ni%Mi:K 



(Informant 



3w C/ -Owt^^tvX^-A 



( \flclrrss 



b:X^\JjMHxdLcvK3LA^ ot 



DURATION y'njrs Months Pays Hours 

(Signed) V-XXhJLc u^a^vvajTrtXo 

X TqoH (Address) bOI Uj ola^vwu gt; 



M.D. 




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



Former or M^, | f P [| Hon lonq at 

Usual Residence ^^V^^^'UwwAvil Mi ^^^Vpiare of Deatli? 



Days 



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



DA p: of JtiKiAl, or ki:MoV\I, 

»H 190H 



PI.ACHOK niRIAI. (tK KI.MoXAI. 

Oto^L?w<Xvs^ 

rXDl-RTAKER O /O^C^l\XV^ oU-^C'C.Lv^ ^^<^ L<> 
(Address (pX^ Uj'V-O'tX tA^VvMXu 9 ^ 



IS. B. Rvery Item of Inlformjition should be cnrefully Huppliod. AGE should be stated HXACTLY. PHYSICIANS should 

state CAUSE OF Df: ATH in plain terms, that it may be properly classified. The "Special Information" for pur- 
sons dyin^ away from hoaie should be i^iven in every instance. 



i- '' 



I In 



. I 



J)((fc Filed, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

286 



Hoard ..f Uraltli- K No. !^ TS-fT^^Ji! H& P Co 



cL^H^^^^ 




l^ 190'\ 



Registered JVo, 



vv(. Dep.u.t«/..Hc.3it.h...Of^c»r 

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 

Certificate of Beatb 

( "a. S. StanDarD ) 



PLACE OF DEATH: — Cuuiily uf 




^f^DT 



St.; 



CU> uf 



Dist.; bet. ^nd 



VV<V 



/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E NC 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 




•Olu^.v 




XK 



li ^ C\A<\.v-v 



PERSONAL AND STATISTICAL PARTICULARS 



SF.X 



^c^L 



cor.oR 



lOJwU 



DATH or HIKTU 



Lt>AJ-^ 



MEDICAL CERTIFICATE OF DEATH 



■f 



DATE OF DP:ATH 



(Month) (Day) 



(Voar) 



AC H 



IXaOJ^ 



) 'ra I A 



A/ouf/is Pars 



SIN(,I.K. MARKTKD. 
\VII)<)\Vi:i) OR I)IV»>Kri:i) 

( 



,VII)«)\vi:i) OK I)I\ »>Krj-.i) \ . 

Write in s(Ki:»l dt sijfiialion) j n 



^Vtr^-v^VNj 



lUKTUlM.ACK 
(State or Country* 



VAMl" ni 

KATii j:k 



BIRTH ri.ACK 
<)|- lATHKR 
(State or Country) 



MAII)):N NAMK 
OF MOTUKR 



niRTHPLACF; 
OF MOTHFR 
(State or Country) 



*« 



«. 



«t 




onth) 



(Day) 



iqn'X 

(Year) 



I HEREBY CERTIFY, That I attended dcHvascd from 

"■■■■-■ : 190 to ...— — — — — — — — — i()o —"' 

that I last saw h "r— - alive on — ■■'-?■ ' i<p — 



and that death occurred, on the <late stated ahove, at 
..— - M. The CAl'Slv OF DI'ATII was as follows 

lLvx.k.-v 



A_^^S^r>AJ 



nr RATION ytay% 
CONTRIIiUTORV 



Mouths 



Days 



Hours 



OCCFPAT 



■■°^ Ofjl^v U ^ ^ 



R^siilrd in San /■'> ,iiii/\ri) 



) rd I 



M<nitl>> 



/>,!}> 



Tin-' \M()Vi-: ST \ ri:i> i'Frsonai, r \k iuti. \ks aki-: trff to rn i-: 

liF:ST 01 MV KNo\\l,i;i)C, F AND in-.Ml".!" 



(In foiniant 



-. L gj.^ 



<X/\^-\^ 



DURATION }'ri7rs Mont /is 

(Signed) <i.. w LwxXawO 

t)o4 f Address) v\. ■ O 



Special ini 




FORMATION only lor Hospitals, Inslilutloffs, Transirnts, 
or Recent Residents, and persons dying anay from home. 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



I'l.ACF <.H lURIAI, OK K1:Mo\\I. 



Ah. « >) 111 K 1 \ I, OK K 1. .M< 



I> AXi: of^ F?t Ki Ai. or r}:mov.\i, 

13» 190S 



rxDiiR iaki:r 

(AfMtrw.^ 






IS. B. Kvery Item olf information hHouIcI b.' cHrelr'ully supplied. AdF. h!ioiiI(I lie Rtntetl EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in pliiin terms, thiit it mny be properly classified. The "Special Information" for per- 
sons dyin^ away from home should he given in every instance. 



f: 




I 



.. I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,„.„ „f >,.„.„-,■ NO ,. ^5?-.-. .*.-•.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

287 



Registered J^o. 



Dale hlle,l,\jXu \% lOfH 

DEPARTMENTiIf public HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanDarD ) 



PLACE OF DEATH: — County of OcVYV ;uVYX^t^/l/C^Gty of ^J/a^ Jx^>A.^,v<t^ 

St.. H Dist.;bet. (Jbo^A^-^S-rvv and^DAH-tX^vvt/ ) 



1 -f 

(A U '1 M /x \ \~ 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



D.Vl'V. nr lUKl'M 



(M(iiit)i) 



(Day) 



(Year) 



AC.K 



) 't-ii t s 



W n)»)\V):i) OK I)!\t»KiKI> 
(Write in sm-lal (k-sij.M«:itiuii) 



lUKrnpi.AOK 

' Statf nr Count rv ' 



i 



5 



K^-yx 



Muiillis 



H 



Day:, 



? 




N'A\fr: Of 

FATin.R 



HIKTHPI.ACK 

oj- lArnKK 

< Statf or Ooiuitty) 




1 



p I 1 

lURlHIM.ACK u A U 

1)1- MoTHKK V y 

(state nr Country) '\J. 

ij XWwcX/"vvu 

OCCrPATION 



/',7\ 



rin- \novK sTATj-n pkk-^onai, rAKricri.AKs aki: rKii-; m riu-: 
liicsr oi- Mv KN(>\\u,i:i)<".K and mI' 



(lufniinruU 



( \.l.ln-«^ 











V^CX/UJVV- 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATII 




(Monti 




(Day) 



(Year) 




nCRIUJV CI'*RTIFY, That I attemled <k>ccase<l from 

\\ 190H to W 190 H 

that I last'saw h Wrv alive on o'^^H" ^ '^ '^ *^ 

and that death occurred, on the «late stated above, at I 

C :si. The CAl'SI-; UP DlvATH was as follows: 

^TfVoLV<XA^VSrv^v^ XXa^^vJI ti) ^ 



DTK AT ION )'r(irs "" Mouths ' Days ' /lours 
CONTRIBUTORY 



Years 



^^onths 



Days 



Hours 



DURATION 

(SIGNED) L^^VsX UJxMLiv'cJMj M.p. 

\% lOoH (Address) HIO ^ a^VA^Xn^ Ol 



PECIAL INFORMATION only for Hospitals, Inslitullons, Transienls, 
or^Rerent Residents, and persons dying away from home. 



Former or 
Isual Residence 

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



How long at 

Place of Death? Days 



IM.VCI-: Ol- m-RlAI, OK KICMctVAI, 



DA.ri: o!„ I5t KIAI. or RKMOVAI, 

tH 190H 






(Adili f^s 






... J 1. 1-1 ATF Bhnuhi he Htnteii EXACTLY. PHYSICIANS should 

N. B. Hvrny Item of In?orm.ition should he cnretully HuppI.ed. AGF. should ^'.^ «;"*^^^ .^J* . , information^ for p.r- 

• tate CAUSE OF DEATH In plain terms, that it may he properly classified. The Special Information for p«r 
son« dylnft away ^roxn home should he given in every instance. 



\^\\ 



II, 



y\v 




I 



^ 






M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^r''Sy^.n!^VCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

ic Filed, H^vXu. 13 



1 



7,9^<^ Registered J^o, 

LhvJi"Lv^u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "d. S. Stan^ar^ ) 

ofO/aiV AXVA vtAACC City ofOKX^V vJ /^.<X'TV^^^^^O 



PLACE OF DEATH: — County 



1^ vJLu^VfrU^'>vtu ('t)CHi.kvtaX' St.; Dist.;bct. and 

I^» VCVL^ /^ V\rVA^Y\/VA^ V _ I ^^^^^^^ „,«,n;Nr,P r.iwr r*CTS called for under •special information- \ 

:t and number. / 





1- I 

Xo<J^ St.; 



) 






FULL NAME 



'*UL/>v<U; 




|ft{| 



ii 



Ml ' 



PERSONAL AND STATISTICAL PARTICULARS 



^'••^ Q^ 



Dvri". or- MiK 1 n 






COLOR 



lO.LcU 



I Month* 



\<.I- 



ao 



> Vvr » A 



n 



5- 

(l):iv) 



Moulhs 



(Vi-ar) 



3 



Pit 1 . 



SIM.iJv MAKKn-:i> 

WIIM )\\ l.l> <»K I)l\'« tR*}'.!) 

iWtitt in - "1 .' <k-»iiK"i«t'<>'*^ 



(St:it< c.r Cnuntry) 



A 



v WW. ni- 
1 \ THKH 



lUKi'nri.AVH 

(>!•■ lAl'Ul'lK 
(Stat*.- or Countiyi 



MAlDltN NAMi: 
oi- MOTHKR 



lUR rUPUACK 
Ol MorilKK 
(State or Cotmtry* 



1/1 IK. 





OCCUPATION 



^ 



'triWyj 






^Vsil^rlf ill Sini /'i ii in i'''" <A ' '' 



•|M 5 



.y/nii//r 



/).n.v 



Tin- AMOVK STATl. I) PKRSONAI, »' )»<^;'^;i,!:\'^'^ '^ '^ '^ '"''^■'- '" '■'"' 

ni:sT oi- Mv KN(>\vi,i;i)<".K and uhi.nj- 



(Infotiniml 



(\ 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DK.XTH 




VI 

(Day) 



I90H 

(Year) 



I 1I1;KI{HV CICRTII'V, Tliat I attciKled deceased from 

N^^ X^ Ic/dH ^V V^^^ ^'^"^ 

that I last saw h -^O^j alive on V^^ ^^ ^')^ ^ 

and that death occurred, 011 the date stated above, at I 

Qr. M. The CArSI*: OI' Dll.VTII was as follows: 

^JlAvAa^ Vj JLA^A-rvvAJlA-^ 

(P(H3Jt 0-lvJL»vQuU' 



-C>A 



DIR.XTION 
CONTRllH'TORV 



}'c'ars Months 



Pays 



I /ours 



Years 



Months 



Days 



nrRATION 

( SIGNED ) d.AA .% <Xvt 

»N only for Hospitals, Institutions, Trai 




Hours 
M.D. 



SPECIAL INFORMATIOI 

or Recent Residents, and persons dyinq away from home. 

^ J?. How long at ,^ 

Z\^ ^<X\^Aj^ Ol^ Place of Death? '^ 



Former or 
Usual Residence 

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



Transients, 



Days 



PI.ACK OI" lURIAI. OR RKMOV AI. 




DATllol" Hi KiAi- or KI:M0V.\L 

NLwLvv. 12) T90H 



ini)i:rtakkr 








stote CAUSE OF DEATH Sn plinn terms, thnt it mjiy be properly classiiiea. j 



sons dylnft nwoy from home should be (ii%en in every Instance 



I5,.:ir.! of Hii.lth I* No l> 1^*;' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



n&pco 



Date Filed, 



Bcgistered JSf'o, 



\^ lOO'^ 

\r. Deputy Health Officer 

DEPARTMENT oIf PUBLIC HEALTH^City and County of San Francisco 



289 



Ccvtificate of H)eatb 

( "a. S. Standard ) 

* ci 



0^ 



PLACE OF DEATH: -County of <3<U>^. 3 AXVvvtU^cCity of O'CU^O, ^ A^^x^VA4tX) 
No 111 ic^kt St.; 1 Dist.;bet. "hf^ and H tk U^-t^ ) 

INO. CS ^ • 'W^ ^^ „„ ,,o,,.| OFtSIDENCE GIVE FACTS CALLED FOR UNDER "special INFORMATION" A 

( '^ :ro\\.l'%Tci::.'o\Tr.o^''.\'i :iVul^n5.';o::^..^^^l name .nstead of street and number. ; 



FULL NAME 



.SJXS^.. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



(^UcJU 



COI.OR 




W 



iu 



DATH «>! IJIKTII 



Month) 



( Day) 



(Year) 



AC.H 



(X 



It 



b K )>,/,. 



Motitlii 



Davs 



WIDOW KM OK l»IV(»K(K.l) 
iWritf in s«Kial <lt-ji>rnatio>i) 



lUKTIUM.XOK 

(Stat* or Country 



NAMK or 
1 AT in. R 



lURTHIM.ArK 
ol- lATHKK 
Stair or Country^ 



^ 1 

dAxi 



WW) 



MAIDKN N'AMl-; 
Ol- MorUHR 



HIKTMl'UAOK 
()|- MOTHER 
(State or Country^ 






:rcr> AJL 



OCCUPATION 

Rfsitfnl ill Still Franriyi'o 



)'r,ii <■ 



.\ /nil/ /is 



/),I\: 



Tin- AHOVK ST\TKI) PKKSONAI. I'A K lIC T I. A KS AKi: TRIH TO TUK 
HKST Ol" MX KNOW I.l.lx.K AND Hhl.Il-.H 



(\ 



ijr,r> I yjf -^y^ rx.i^'.. a ■ 

nfonnant vfe K^uL<xd. O^K^XAri '.^^ 



H 



( \(Mross 



^^l 



Xcvk-si' 3 



t 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 




(Day) 



(Year) 



I HF{RRBY CICRTIFV, That I attetKU'd deceased from 

H 190 H to N|\Ai^ 1.x 190 H 

that I last saw h A^^vvc alive on |r'^"(^ * ^ ^^ ^ 

and that death occurred, on the date stated above, at X ^ 
M. The ^'ArSrjCU' DI^ATII was as folh^ws : 

Lo*\.xXa.O^L lU-i^>>V^V\.K>CMX<. 







I)r RATION *" }'ears " Months 3 Days Hours 
CONTRIIU'TORY L«-NJL.<J-XoJ^ Oi^^ 



Years 



DURATION 
(SIGNED) 

la iqoH (Address) 



Months 



Pays 



OJbJp^kJt^vx; V"UUXAx4 




ab^-HOv CUmi *J^ 



Hours 
M.D. 

V 



FECIAL INFORMATION only for HospiUls, Institutions, Iransients, 
or'Rccent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



Now long at 

Place of Death? Days 



ri.4CE Ol* lURIAI. OK KEMOVAI. 



DA TE of Jit KIAI. or REMOVAI, 

IH _I9oH 

rNDKRTAKER ^OlNJLW^ ^^ Cv^<jXvA^ 



(,\d<lress 



■""""■"■■""^■■^■■"^"" „ .. ,. , .r>p „u„,.i,i Ke atnted EXACTLY. PHYSICIANS should 

N. B.— F.very Item of inform«tion .houlcl be CBrefuIly «uppl.ec ^^^^^l^^^^l^^^^^^^^^^ Information" fer pT- 

state CAUSE OF DEATH in plain term., that it may be properly tiassmea. i ne o, 

Ron« dyinft away ?rom home should be given in svory instance. 



. o 
i; 1., » 



hi! 



i) 



1; 



;.H 



( i 



i 
i 






'li 



'if 



it 



' \ 






i ' 



i^l( 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.,.,„, .,fn.:.M, , NO ,.--S^M.<t.M.-., RgFEH TO BACK OF CERTIFICATI FOR ir.3TRUCTI0N8 

290 




13 



19 OH. 



Dale hlli'd , 

Xft^^vu) itA>u, Deputy Health OfTicor 



Ue^istcved J\fo._, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( H. S. StanDarD ) 
PLACE OF DEATH:-County of CW'^v J^Vo^xCv^C* City of U-C^^ X^%^4^ 






(5D 



No. 



CTVL'^vv 



oJlvA 



X^A^^^-y^y St.; 



Dist: bet. and 



r I ..^••«i BC-eiorMrr riwr FACTS CALLED FOR UNDER SPECIAL INFORMATION | 

( '^ .VirAT^H^O^CufRr^.N-^j^o's^PyT^At Tr' f^ ^T^^^T^On' ^O^vV ^tI 5, A M E INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 




CL/Y^J. 




PERSONAL AND STATIST ICAL PARTIC ULARS 

L ' '""111 lite 



^ 



s I-: \ 

DAT)-: <»i III Kin 



Q^Wv 



(Month) 



a I /^oH 

(Day) (Year) 



AC.K 



J 'f-fj » .« 



Mnnth^ 



Ji 



/^«1: 



^INCI.K MAKUIHU 
WIDoWKH nK IHVoKiKl) 
WiiUiti H.R-ial iltsiy^natioii) 



niKTin'i.Ai'K 

(Slate <ir Country' 



NAMl-: <H 

!• A r 1 1 1 ; R 



HIRTHPI.ACK 

ni- rAiiiKK 

(Stair or I'ouiitry) 



maii)i:n namk 

nl MoTUHK 






'Wtrv^'^v^ 



«« 



t« 



lUKTHI'LACK 
OJ" MOTHKK 

(Stale or Coiuitry^ 



OCCUPATION 



/),M 



TMl- XHOVKST^II I.»'KKS.>NAM'AK-nrri.\KSAKKTRrH To TIIK 
lil'ST <)l- MV KNOW 1. 1: IX". K AM) \U:\A\:\r 

„„„„:„„„. Qfni QUc.^Ac.a 

.vMns. as OA.lL>Ax^rViL ot 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 




(Day) 



(Year) 



I HHREBY CIvRTIFV, That I attendcMl <leccase(l from 




I 



190 



to 




190 H 

VJLlIc^ 190 H 

and that death occurred, on the date stated al)Ove, at I I 
(j ^I. The CAl'SIC OF DKATII was as follows 



that I last saw h ^^ alive on ^^-vW, <^ 



^ 



xaJlk^^/ocJl^-vc^ ffV 3wx^ 






^. 



Dr RAT ION ^ JV<7;'-? 1 ^f out lis ^ /^«>'.? ^ Hours 
CONTRIBUTORY 



nr RATION 

(SIG 

10 T90M 



Yt'ars 



Mouths 



Pav 



f fours 
M.D. 




NED ) m)\- o ATy\xx;>^vc^^ 

(Address) ^$00 J JUUvMyNJl ^i 



FECIAL INFORMATION only ^^^ Hospitals, Institutions, Transients, 
or'Pecent 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'l^ACK Ol- niHIAI. OK KHMoVAI. 



UNDERTAKER 

(AcUlrr 



I)\ri-:o! Ml KiAi. ni KEMOVAI, 

|vcL 1.H 



190H 






... It J APF ahoiilcl he stated EXACTLY. PHYSICIANS Hhould 

of mformation .houlcl b^ cnrefully HuppUcd. AGB «hould *».* «\"**^^ ..^ ' , , ,_fo^„atio„- for p«r- 
E OF DEATH in plHin term*, thnt It m,.y be properly ctaBs.f.ed. The Special Information for p«r 



IN, B. Every Item 

state CAUSE OF DEATH In p 

Kons dyinft away from home «hould be ftJven in every instance. 



'■|1 



' i ' 



-: 'I 



I 



m 



i 



# 



m 




i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,u..rA of He.l.h I No ,^ -^^^P M&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)f(/r Filed , 

i 




1^ 



lOO'i 



Registered JVo. 



291 



Of^. 



\jUK>u Deputy 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of 2)catb 



^ m 



PLACE OF DEATH: — County 



Qsp ^ m 

of Qa.'yyj VOl^vcULOc City of CJ <Wyj , V.€^vlc\A. C^ 



St»; ^-— Dist.; bet. 



^nd 



/ ir DEATH OCCURS *w»v trom USUAL RESIDENCE GIVE facts called for under "special information-- "J 

( "death OC^^RRtD IN / HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 








PERSONAL AND STATISTICAL PARTICULARS 



"■" ^uL 



COLOR 



IAjl 



I) ATI". «»l HIK 111 



ACK 



lOct 



(Month) 



(Day) 



m ,v„.. I 



M.nilfis 



.chk. iS% 



(Year) 



Ihi vs 



■^IN^.l.K MAKUli:i>. 

\\ IDdVVKI) l>K DlVnKiKn 

(Write III nodal *te«lirnation) 



8x>vaU 



lUkTm'i.At'K 

St;it«- or (.">nintrv' 






-p (^ *' 



N\M1" <)I" 
I- ATHl.K 



j.\X<ixv^cl^ 



niKTMIM.VCK 
OI- I AIMKK 
(St;il» or ioiiiitry) 



MAIDKN NAMK 
Ol- MOT I IKK 



niKTIIl'KArH 
<il- MoTllHk 
(Statr or Country) 




.vJUl- 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




(Month) 



li /poH 

(Day) (Year) 




that I last saw h .<Wrv alive on 



I IIICRl'BV CIvRTIFV, That I attended deceased from 

s 190 s to A>vL^ 13. 190 s 

ami that death occurred, on the date stated above, at ^ I H5 
(p. M. The CAISI-: OF DUATII was as follows: 

'^..^^^^JU>\^ W&-w.>.^cL 

nrRATION *f^ )'cars ^ Mofiths 4 Days T Hours 

CONTKllU'TORV 












OCCt'PAT.ON^^ J^^^ (]J 



TIM' AHOVK ST\Ti:i) PKKsONM. r \ K lUT I.A KS A K i: TKIK To Till-; 
liKST Ol MvLkNoWI.I'IX.I: AM) m-.M!.!- 



(Informant 



'•\«l.lr. -s 



400 



G.JL\Nt\; ILu-t 




•^ Years "^ i^fotiths I /^r/v.v * io< Hours 
%. \. lOx/>^WtjL. M.D. 

S (Address) 151 O^tvilti^V Ot 



wPECIALiN FORMATION only for Hospitals, Institutions, Trdnsients, 
or'Rccenf Residents, and persons dying away from fiome. 



i:-i. 



z' 



i| 4 . 



5 



1^ Jl v»-i\, iX\Mj I H 5 piarf of Deatfi ? 4 



Former or 
Usual Residen 

Wfien Has disease rontracted, 
If not at plareof deatfi? 



D«ys 



IM.ACH Ol- lUklAI, OK KHMo 



\CV. Ol- IJl K 1.^ I. 




^ IHIH 



UNDl'.KTAKKK 



(AiMi'"''- 



DATllof III KiAt. or KKMOVAI, 



N. B.- 



Btute CAUSE OF DEATH 5n plain term*, thnt it m»> he properly claM.fled. The Specnl Inlormat.on for p.r 
Hon* dylnft Bway from home nhould he ftiven in •very Instance. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Hour.) of Mialtti l" N'o i . ^''^S^^ lUt P C, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




^ 4 



100'\ 



Registered ■A'o. 



292 



DeD»'* 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 



( H. S. StanDarD ) 



PLACE OF DEATH: — County of 




i 



'No. 



KoXh 




DCK4 



K^<^^'(j 



ctVvOu 



City of 




StT 



Dist.; bctr 



OXX; 



and 




/ ir DEATH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION • \ 
I, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



O^\r\jjo Oa^tvl^' 




si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR 



\t^X 



\)jAxOJb_ 



DATI-: Ol HI KIM 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



(Month 



(M(intli) 



(Day) 



(Year) 



ACE 



15 



Vrats 



k 



yr,<„tfi< 



n,i' 



siNT.i.K MARK n:i> 

WIDoWKI) OK IMXoKiKl) 
iWiitriii MK-ial ik-sivii.ttioii) 



a^^' 



lUkTHIM.AOE 

'Statf «»r Country^ 



NVMl or 

}■ A I n i; R 



HIKTm'I.AfK 
Ol- I ^TIIHK 

(St.'ttr or I'oiMitry) 



MAIIH.N NAMi: 
OF MoTIIKK 



HIK'nnM.Ai'H 
Ol- MOTHHK 

(Stat*.- ut Country^ 




OCCIPATION 



ON [i (3f 




II. 

[Day) 



(Year) 



I HRRKBY CICRTIFY, That T attended deceased from 

190 to T90 '~~~- 

that I last saw h :::— alive 011 - I90 



and tliat death occurred, on the date stated above, at 
:rrrr-.. M^ The CAUSI<: OF DI^ATIT was as follows: 




nr RATION Years Mouths 

CONTRIHUTORY 



Davs 



Hours 



Months 



O ■ fe- LiTYWu 



/^a vs 



r, „ 



- M.nifh^ - An 



THI MIOVF ST\-n:i) IM-:Ux()\Al, r\K 1 U ri.AKs AKI-: TKIK TO WW. 
lii;ST 01 MV KNOW 1,1. Di.K AND HICIJKI" 



(Informant 



f \<l<lr<-«s 






SOb 



dfration )v<"'^. 

(Signed) 

*-' ^\ddress) \l\akxx' \J>X 



Hours 
M.D. 




T90 



\ { 



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



Former or 



persons oyiny away 



Usual Residence ^o-wJ«Ji.<x^x<<^V(v>a^trvv pi^fe of Death? 



Days 



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



I'l.ACKjJI; mKIAI, OK KHMOVAI 




INDKRTAKKR 

(AcMres.s 



D\'li:<;f Ml HiAi, or KEMoVAI. 

hXu 13 IQOS 



^, B._Hvcry iten, .W ln.or,n,..lon .houl.l he carefully supplied. AGB should »'««t«t«i EXACTLY PHYSICIANS should 
Htate CAlJSi: Ol DIATH In pl..in term*, that it may be properly clanslfied. The 'Special Information for pT- 
«on» dy Inft away from home Hhould be <iiven in every instance. 



; il 

i It ■ 

,'■• 

1. 



II 



J ■ 



I I 



iijirl 

s 

\ 



1 



k 






if 



I 







:(' 'n.^ 





I s 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

P,,„, ,,f H.ait h ,.vo. ,.i»rg^.iu'^l-Cu RgFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

293 



Registered ■A''o. 



Dulrluh;!, ^uJLu IS I'-WA 

\v^K^ Xsukma Deputy Heclth OfTlcer 

DEPARTMENT CfF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 



Wo. 



( H. S. StanDarC» ) 
PLACE OF DEATH: — County ofCla.>\) \X»y>vMw4XU) Gty of C'-CL'V^ 



A-CX/^vcvAyC^O 



Lvcttt^voLtv^ OlS^nvu.St/, Dist.;bct. and 

/ ir Dt*TH OCCURS *W*y FROM USUAL RESIDENCE GIVE facts CALtrO FOR UNDER 'SPECIAL INFORMATION • \ 
( IF DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




^YVj 



(a,Lv)-U>ry 



\yCuw. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



DATI-: o! niKTII 



a<;k 






S /ROS 

(Day) (Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




q 



(Day) (Year) 



iVar* 



Mouths \ 



-VW. 



SI\'<.I,K. MARKIKD 
\VID<»Ui:i) OK DiynkrKD 
lU'iitfiii siK-ial ()»-.i^naliuii) 



HIKTIIIM. M'K 
(Statf or (."oiuitry^ 



N \MK oi" 
I- A 1 M i: K 



lUK rUPKATK 
()»• I AIHlvK 

I St:it< or i'onntry^ 



MAIIU'.N NAMi; 
Ol- MOTHKK 



lUR rniM.AOK 
()|- MOTIIF.R 
(Siatf or Co»ititry^ 



OCCUPATION — •- 

f\'riif/-,f III S,rn /'laiiii'tif 










'\^^-^r\^<xy\) 



«i 



U xjy^ ou Cj ,v\mX. 



X^L Ou Cj , v\M,>L/»v<X- w 



cvcrV/WwCCL 




I HRRRBY ClvRTIFY, That I attciKU'd decoastMl from 

"' "'\Ji:^.' '"s 

alive on VJLLu 'i 190*^ 



1 1 1 1^ K 

rh 



that I last saw h •*>'^^ 



anil that lUath occurred, on the date stated above, at 
"^ M. The CATS !•: Ol' I)l<:ATn was as follows: 

OccLtAvb d>x<x/>->'\jtA^.JJ'\><vJu.. 



DTK AT ION ^ Years * Mouths ~ Pays I Hours 
CONTRIHUTORV ^^ 

Years ^ Mouths ' Hays I Hours 




131 RATION 



fA.ldress) 1 S' C3xO 



(Signed) !0. '0 OO <x\A,v>MrYA. M.D. 

:1AL IN 



^ I90^i 

FECIAL INFORMATION on'v for Hospitals, Institutions, Transients, 



or Recent Residents, and persons dying dvvay from fiome. 



) 'rn 1 



yr.nitln 



l),i\ 



TUT XHOVK STXTKI) I'KKsoNM, IV\ K licr LARS ARK TRIK T< » THl- 
liHST ni- MV KN«»WI.i:nf.H AND IW.IJHI' 



3i^s - an tL A 



f \<l<1rr«>< 



Former or 
Usual Residence 

Wf«en was disease contracted, 
If not at place of deatli? 



How long at 

Place of Deatli? Days 



IM^XCK OI- lURIAI, OR RKMoVM, J DATi: of IMkiai. or KHMOVAI, 

•IH I90M 



bJx^ 



INDKRTAKKR VV* 



(Address 







N „ —Hvery item of Information .houl.l be cnrofully Hupplled. ACIF. should be stated EXACTLY PM^S'f'^N 8 should 
state CAirSE OF DEATH In ph.in terms, that It may be properly classified. The "Special Information for pT- 
son« dylnft away from home Hhould be ftiven In every Instance. 



! II ' ' 

ill 



''ll 1 



'1 
If 



it 



V\ 



^ 



'H 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 




H,,.n.! ..f M-altli »• No. •. '. '*-^:.»::^^ HS: T C 



(I 



I 




B 



100'\ 



B EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

294 



ll('gi!it«red JVo. 



Dale Filed , 

i^^ui liL-xvu Deputy Meslth OfHc-r 

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

Certificate of H)eatb 

( "U. S. Stanc>arC» ) 
UkctMJU 



PLACE OF DEATH: — Cuuutf of 





frA V vo^6 



FULL NAME 



crvv>c4A.cu. 



:>.\A). 



PERSONAL AND STATISTICAL PARTICULARS 

DA 11-: nf lUK in % ft 



MEDICAL CERTIFICATE OF DEATH 



MW' 



(Mimth) 



(Day) 



a<;k 



lUvk 



) V(f »,* 






(Year) 



Da I .V 



SINi.IJv MAKHIi:n 
\\I1)(»\VHI) OR |>I\t»Kri;i) 



AI1)(»\VHI) OR |>I\t»Kri,I) \ . 

\\!it«-iii '««K-ia1 lUsi^natioti) \ Ij 



wcrvo->A^ 



HI kill CI.ACR 
Statf or Cotiiiti v^ 



N \MF o| 
I A 111 l.R 



lURTMiM, \ri-: 

Of lAllll-.K 

i*^t.if<- or Country) 



M \1I)KN N AMI. 
<)1 MOTHKR 



lUKIHI'KACK 
<>|- MnTUKK 
(Statt or Coimtry' 



•« 



(Month) 



(Day) 



I(^0 \ 

(Year) 



I HF^RIUiV CI'IRTIFY, That I atteiickMl deceased from 

190 to T90 

tl'at I last saw li alive on IQO 

and that death occurred, on the date stated above, at 
M. The CAISI': Ol-' DIvATII was as follows: 



a 



N-\-'0-wlvfr->-V<S \J'"WiA.^^»V,«r»..VfiC 



.3s»0rV^>^'^. 



V<y t\X .c?s.V;v^^a 



nr RATION Years 

CONTRIIUTORV 



Mouths 



Pays 



Hours 



I )l' RATION Years AfcJiiths 

(Signed) Vj v^ o/>xo'i^<iu 

V/VlaV IH i„oM (Ad.lre^v,) U-d La 3. Ji 



/^ays Hours 

M.D. 



OCCUPATION 



abM 



h'rudrd in ^iiii r'ltiii. :^i<> )'.:;> 






Tin- MlOVK ST\ r)-l> I'HK^ONAI, l'\K 1 I'TI.VKs AKi: TKIl-: !•» TMI-; 
lii:ST Ol" MV KNOW 1,1. IX. H ANI> Mi:i,Ii:i' 



( Info; ni;int 



viowv^ c a>i)^u Ida 



( \ 



ai.i^ 



'CV'^.^v^ 



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



Former or 
Usual Residence 

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



HoH long at 
Pla< e of Death ? 



Days 



l'I,\CKol- m KIAI. OK KiiMoVAI, J DA^li;.)'^ Hikial oI KKMoXAI, 

^^^i I WW '3. '90S 



(Wt 



I NDKKTAKKR 

(All.lK s. 






-#il^^. 



IN. B.- 



_F.ver>. 1,em ol' •uWo..n«t1on •hould b. .nrefully supplied. ACU. Khould »>« «»"''^;J/-^^^CT'7; , ';"''''\T„';:!1:'::'^ 
sVoteCAUSi: or Dl: ATH In plain term., that it may be properly .ia^nificd. The Special Informntion for p.r- 



8 

nnn 



• dyinft away from home should be ftiven in every instance. 






\i 



f . 



If ■■ 



i t 

! 1 



t 
( 

I 



.1 



i-i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lUK.r.l of II. -a nil - I" Vo is "^-^l^^H^I' Co 



I)((tc Filed , 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



7.9(9 4 



Registered J^o, 



295 



<LiA>u Deputy Heal.h Offl'^'^r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( 'la. S. StanC>ar^ ) 

J? W A 



Wi 



PLACE OF DEATH; — County of O/CL^r^ J 'vOyvv/OLA-'C^oCity of ^J^tX^vv >vCuvvc^4.co 
No, ^"^vtvo^i C^^AXVt^A'\\CM_ ()\) 6^vvt<x. St.; — Dist.; bet. and 



/ IF Dt*TH occurX*w*y fj o m uSuAl RESIDENCE give facts called for under "'special information- \ 

C IF death OCcjl^RtD IN^A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

i\i 



FULL NAME 




:taK)ui\). u-LVC.<cro^<i«i 



PERSONAL AND STATISTICAL PARTICULARS 



si;x 



^■\Jb. 



COI.OR 



DA IK <^\ lURTH 



U /li ^ 



(Month) 



(Diiv) 



(Year) 



AC.K 



CUlt 6o )V</'.v 



M,»tlfi.s ".. /^<f.v^ 



SINr.l.i:, MARKIKD 
WIlxiWi:!) nK niVoKvKI) 
iWritciti siH-ial iltsi^iiatioti) 



lUKTHri.AOK 

iStatf or Country) 






NAM}-: ()l- 
FATIM-.R 



lUKTlirUACK 
<)|- lAPHKR 
(Stiitc or Contitry) 



MAIDKN NAMK 
ol MOTHKR 



LL>vv-La 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

I 




(Day) 



(Year) 



I HEREBY CHRTIFY, That I attended dccoased from 

190 — — ■ to 190 

that I last saw h alive on — ——-—. — \cp 



and that death occurred, on the date stated above, at 
.— M. The CAUSK OF ^Il^A'I''' ^^«s a^ follows 



t 



DT'R ATION Ycais Mouths Days 
CONTRIHUTORY 



Hours 



HiR'rnri.ACK 

(»l MoTHHR 
(Slate or Country) 



)CCrPATION -? 



\y 



\ \ 



H 



.r-tr*vX^J 

Rfsiiffif III S(7ti /■'iiJUii'^rn 



J 'ra I ^ 



.\r, tilths 



Da V. 



Tin- \HOVK STXril) PKR^oNAI, rARTIClLARS ARlv TRIH TO THH 
lii;ST 01' MV KNOWIJ'DC.K AND m:MHF 



(Informant 



Lvv<nvji>u 



Address 



DURATION Years .drouths Days Hours 

(Signed) L<A^rv%.x^u i AJj. UJ-ljllo/vvcC M.D. 

10 iQoH (Address) Urur>^ 




i^JLKA 




\<Jl^. 



_iPECiAL INFORMATION only for Hospitals, Instilutlons, Transients, 
or Recent Residents, and persons dying away from fiome. 



Former or , /> ^ r- ir O.i X\- ""^ '""« ^* 
Usual Rtsldence 1 A s) UMCtvlCX C X piare of Dea 



Usual Residence 

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



Death? 



Days 



ru.vcH «n' lUKiAi, or ri:mi>\ ai. 



t 



VWVA 



n 



i),j^ ' 



190 



rS'DlCRTAKKR 

(Addrt-ss 



DATlCof HiRiAi- or RHMOVAI, 

WL IH looH 

si.Sa-\^ ttvM. 






N. B.— Bvery item o^ information should be cnreV'ully supplied. AGB should »>«.«*«'« 'J J^''^.^^^'^ 7' , ^^^'.Tot^,!;^!:'^ 
state CAUSE OF DEATH in plain terms, that It may be properly classified. The Special Information for psr- 
sons dyinft away from home should be ftiven in every instance. 



I 1 
I, 



I i' 



!; \ 







WRITE PLAINLY WITH UNFADING INK 



n,,;,,.! ..f Hiiiitii I N" I- "?'T.:?rL'r^»^*'^'" 






i 



VJO^ 



— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

296 



Registered J\'*o, 



^t^J^AJS 






De-~' *• 



11^ -, I A I, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificatc of Beatb 

PLACE OF DEATH: — County ofOa-rvOXO/^vC^^^O City of O/CVVJ OA^Wv^^A^ 



^IHo. ^ 




.^^Ikx^ ubcK, ^.., , -- 

/ Tr De*TH OCCURS *W*v trom usual RESIDENCE give facts called for under "special information • \ 

( "death OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



\ 



VUJX 



St.; 



Dist.; bet. 



) 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
DAT!-; OF-- lUKTll \ 

cdA, / I H t 

(Month) 



lOJvvU 




(Day) 



(Year) 



AOR 



(xtt 5 



I 



)'itn 



M,.,itli- *...-. Days 



^IM.l.K. MARUIHI). 

\V Il)»t\Vi:i> «)K I)IV()RCKI> 

iWjittiii M)oial (l»-«i>^nati<iii) 




lUK rHIM.AOH 
fStati- or rounlry) 



NAM1-: «>l" 
I ATHKR 



RIR rm'I.ACH 
(>!• I AIMKR 

(Statr or Cotintry) 



^ 






L 



e 



\ 



MAim-.N NAM1-: 
(II- MoTllKR 



niRTHPLACK 

oi" MoTin:K 

(state or Country) 






li 



OCCI'PATION 






I IIRRRRV CICRTIFV, That T attended deccasetl from 

Vvvwt lip 190 H to^. ^^^ 190 "i 

that I last saw h XV alive oti jK-vicj, 10 190 'i 
and that death i)ceurred, on the date stateil above, at ^ 
\A.M. The CAl'SIv OI' I)i:ATn was as follows: 



or RAT ION 
CONTRIIU 



) 'cars 
TORY C>V^r<rk 



Mouths 



Da vs 



DURATION Years 

(SIGNED) LU V LrLA^Lv^TTV 




Pars 



Hours 

Hours 
M.D. 



-V LLta iqoH (Address) dtlxjLu> fco^ 
FECIAL INFORMATION only for Hospitals, Institutions, Transients, 



or Recent Residents, and persons dying away froai liome. 



\r.'„tln 



Ih: 



VnV \H()VK ST\T1-.I) I'KRSf^NAMWRTKTI.ARS ARKTRIH TO THH 
lii:ST 01' MV KNoWM-.nCK AND IIHMI^H 



(lufoTiuant 



J.vvo-<5 llW^ki<r^'cL 



(AiMrc 



\[\jl/vMX/cLow Lctu v<xl 



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



n.ACK OI" lU RIAL OR RKMoVAI, I DATKof IUkiai. or RHMOVAI, 
rNI.KRTAKKR v)>^CA^A^Jk.tV ^^ Aa^C^*^! 



(Address 






N B —Hvery Uom oi information should be care^'ully supplied. AGB should He «t"ted EX ACTLY ^"YSICIANS should 
Itate CAirSE OF DEATH In pinin term., that it may be properly classified. The Special IntormHl.on for per- 
sons dyinft nwoy from home should be ftiven in every instance. 



( 1; 



! 



I '■( 



\ '' 



I i»l 



I 



\ ' 



iV 





>l 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n,..nluni.aitl. iNo ,.*C^>"''^»'^'" WCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!)((!(' Filed , 




1?, 






D"" 



190\ 



Begisfered J\^o. 



297 



DEPARTMENT OI^PUBLIC HEALTH=City and County of San Francisco 



IHo 



PLACE OF DEATH: — County of 

,. ll) Owl cite K<?£L>xd 



Certificate of H)eatb 

( "a. S. StanDarD ) 

O^a'Ty.^ OtCLwcvac^ City of O/a^ru J Ko^^^'Z\AytA> 



*/a >\v.tav^c<wA<w 



su- 



Dist.; bet. 



and 



/ ir OCATM OCCUBS *WAV fROM USUAL RESIDENCE give facts called rOR under "special INFORMATION" \ 
t If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME 



LUV^JX^J- 




VCt/TV 



/CL^ 



PERSONAL AND STATISTICAL PARTICULARS 



DATi-; <»i ink r II 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DHATH A J 

H'^-A-^H ^-^ ^9o\ 



(Day) 



(Year) 



<X\) M 7^ ex. 

(Mniith) (Hay) (Vt-ar) 



a<;k 



la 



) V(/i 



?, 



Mnlllhs 



PllXS 



SIM,!,!-: M\KKli:i> 

wnx >u i-.i) nK divoR(i:d 

(Write ill s«KMnl ik-><i^iiati<>ii) 



IllKTmM.AOK 
I St.itf or Country^ 



\ \MI O! 
I ATin.R 



niRTUIM, \rK 

oi- I AIIIKK 

I Sl;il«' or Country) 



MAim:N NAMH 
(»l- MOTIIKK 



lUK lIirLAOl": 
Oh MOTHKK 
(StJitc or Country) 



i)CCl'rAT10N 




CrV'>v\^Ou 







I HRRIUJV CIvRTIFV, That I atten(U-<l (lecease«l from 

V^JLu, 1) 190 H to rti^W ^^ ^90^ 

that I last saw h .^V>^ alive oti W^Vu 1 J. 190 '"^ 
aiul that (loath occurred, oti the date stated above, at o <) 
(P M. The CAl'SK OF DliATII was as follows: 

CJ/ctvc^fr^'v'^-'Cu trv XftxA^cjjiL c^-v-jLc^vv>%A, 

Dr RATION Years ^^"^/oHtTs^'^^^^Days Hours 

CONTRIIU'TORY <3xlCt^^C-A.^v:Y\-\XL -^^ 

U.-i>JA.OuU-^v 

DURATION " Years " Mont/is X Pays ' Hours 

%.(jj. XaWI WtxJ; 

Address) ^^0 CJAaXIxA) C' .Aj 



(Signed) 

X iqoH 



M.D. 



(A 



Ki-siihd ill S,i>i /'i.iiniyrn •^ )>n> 



M.olths O /''MA 



Tin- \HOVK STXri-D PKKSONAI. I" \ KT UT I.A K S AK1-: TKVV. T» ) 

iii;sT (H- Mv kn()Wij;d<.k and i{i;i.n:i' 



Tin-: 



(111 fill inant 



( \(1<lre-ss 






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



Days 



,r (^^ 5 r 5 How long at 5. 

sidencedJXVlvOuvru V^". Place of Deatli ? o 



Former or 
Usual Residence 

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



I'LACK c)i" niKiAi, OK ki;m<>vai, 

rNDKRTAKKR 

(Aildrt-ss 



nvniot m KiAi or rhmovai, 
yjJLu V'i 190H 

3.S 1 oxJ^LtK. Bt 



N B — F.vcrv item of in^>r.n..f.on Hhouhl be carefully Hupplicd. AGB «hould »>« «t«tcd KXACTl Y ^"YS'CIANS should 
Ttatc CAUSf: OF DEATH in pinin terms, that it may be pruperly cla««ified. The Special Intormat.on for p^r- 
sons dyinjl away from home Hhould be ftiven in ^y^r^ Instance. 



:1i 









^> .,. 




< < 




n 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H..;,r.1oni...Hh-l Vo i'.^:^:lM^VCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Q 



Dff/c Filt'd y 



Registered JVo, 



298 



"Xxa^u. Deputy Health OfTicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 



( H. S. StanOar? ) 



PLACE OF DEATH:— County of 0.\(V-w KXU>vci>l to City of "-J 'Q-'Vu V<V>vcx4X^ 



I 



No. 0^ -^CLVVN^L 

(ir DtATH OCCUBS «W*V FROM IjK&UAL 
IF OtATM OCCURRtD IN A HO|^FIT»L 



L VlLcX'tLX Git l-4.t St.; ". Dist.;bct. ^\) ^O^hXLAJsyM and 

M UA&UAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION* 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 





\\X) 



FULL NAME 




Lu /(XL4.CVA,. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 COlA)K 



(TiicL 



UjJxitiL 



uATi-; «ti luK rn 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DHATH 

II 




(Month) 



(Day) 



190^ 
(Year) 



iM.mth* 



IS- 

(Dav) 



(Year) 



A<.K 



bl y,a,s I 



Months 



II 



Ihi\ 



U II)it\Vi;i> nK niXoRiKI) 
iWrittiii «»<MM.il il< si^tiatioii) 



niKTMIM.AOK 
• Statf or C'Miiitry' 



N\MI<; 01 
I ATIIKR 






nikTiiiM, \('V. 

01 I AIIIKK 
iStatr i»r Coiiiitiy) 



MAIHKN NAMl. 
01 MOTHKK 



lUKrm'I.Al'K 
tU Mol'lMlK 
(Slat*- or t'ontitry) 




J JiL CC A-v>w,Ajtx^ 






I IIHRIvBV CI'RTII'V, That I attended deroasod from 
1901 to V^Jlu. U. 



that I last saw h .V>>^alive on 



|vd<u.U 100 S 

|^>civi. \l icpl 

and that death occurred, on the elate stated above, at J 

Cy M. The CAl'SH OF DICATII was as follows: 

VU\aJkV*-<la^'!> ^|r 6^^f\K^^^ 



nr RAT ION -^ Years %Mo/i//is i Days 

LLvC,cHiA-^&-Lw^r::>r^ 



Hours 



CONTRIIU'TORY 



XX^ 



OCCrPATION 



/hn: 



IMl- XHOVK ST\ ri-I> I'KR^ONAI, I'AKTU I l,AKS A K l- TKIH TO Till- 
lii:ST t)l' MY KN(>NVI,i;i)i".K AND HinjKF 



(InfoMimnt 






O 9 

( \«Mre«»N 



cy^^A^ 



ni' RAT ION 
(SIGNED) 



A. 



X\.J. 'I^ ^.Ow J^xtt 



Pays 



//ours 



M.D. 



( 



Address) VJ^^ujL'CUVU \jj L<i'q^ 

, Transients, 



SPECIAL INFORMATION onl> for Hospitdls, Institutions 
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 



ri.ACK 01- lUKIAU OK Ki:>fOVAI. 

\ J LoXurv"c<^'L 



INDICRTAKKR 

(Address 



DATKof Ht-KtAi, or RKMOVAI, 

HI?) ^3chl<U>v x^cxb. Cl'\^<. 



dtate CAUSE OF DEATH tn pinin terms, that it m«y he properly clBMiiied. The »pcwlal intormBUon o p 
sons dylna away from home nhould be given in every Instance. 



. '1 




if 



^ ( 



H' 



i I 



t^Sfc "^frf 



t ii .;■ 




' II 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 










1"^ 



lOOH 

Deputy Mca'th OfTiccr 



Registered JYo. 



299 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 

Certificate of H)eatb 

( H. S. Stan^ar^ ) 
PLACE OF DEATH : — County of C' O^-vv AXX>\.CCA.C^ City of -CU^v J A-OywCv^^^-o 



I 



(\r OE«TM OCCURS 
IF DEATH OCCU 



St.; I Dist 



-i 

ist.: bet. J vL^ 



and 




i'xX^ 



S AWAY F 
RRCO I 



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



y^J^\\ ) 



r\ 



FULL NAME 




OJUA- \JLa^^.X0U \lv D-.:^XC.\.^.^u 



PERSONAL AND STATISTICAL PARTICULARS 



DA11-: ol HI KIM 



oXi- 



coi.t>R \ 



JJJivuJi 






(Day) 



(Year) 



AGX 



«^I^<.I.^• MARKIKI). 



) 'fa I } 



M.mdn \ \ Pttys 



\V!I)(»\\ i:i> nK DlVOWrKt) f) |\ 

' \\ !it< in Mxrial tlesiKiiation) -T II 

CJ^^oaWU) 



mKTHPf.ACH 

(Statf or Countiv' 



I' \thi:r 



HIKTHPI, \lK 
Ol- I AlllKK 
istatf or Country) 



MATni:N NAMK 
nl- MOT 1 IKK 






Ck.k,'^ 




<X'>v<n"vi', 






MEDICAL CERTIFICATE OF DEATH 
DATK OF DEATH 

\X 

(Day) 




l9o\ 

(Year) 



lUK ruPT,At*K 
<»|- MoTHKR 
(Stato or Country) 



A 



)(\^K^\juJUs^_ 



OCCt'PATtON 

Rfsiiif({ III Siitt FramftMW 






\'\\V AHOVK SIX III) rKK-^(»NAI. IV\ K IICT I.AkS A K 1- TRIH T« ) TUH 

ni:sr oi- mv kni»\\ i.i:i><-h wd lu-.i.ii.i- 



(I 



nfonnant ^' lUVO 




\rI<llfSS 



I HKRKRV CI:RTIFV, Tliat I attemUMl ilecoased from 

VV,VU II 190 H to ..VaJLu Uyo\ 

that'l last saw h --^^ alive on VV-aJ^ H up ^ 

ami that death occurretl, on tlie date stated above, at "^ 

- M. The CAl'SIC OF DIvATH was as follows: 

Uj A.'fi^'V^^b^A^ A^rvtJv 

.{^Utry^AJL^yJir^.....MPi:S{<^ 

'< •> 7 

DT RATION Yf^ars ■ Months Days Hours 

CONTRIIU'TORY 9'lJ,^<Nr:...'C^4X .(^^rJi^^.C^ -koA. 

ccAX/frtJviU\' Wt\^jA^^CN.a/-»-v vvHrvo <VtXAA-t ^cxxajL.-a^vj ,..., 

nr RAT ION Years Mouths Pays Hours 

(Signed) J.iv^A'Mj w cLtLcL/\xxL M.D. 

Htvl<J ig Tcp'- (Address) aSb QuJAjl^ OJ 

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



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



I'l.ACHOI- m KIAI, OR RKMOVAl. | DA'^i; of Hi KIAl. or K1:MUVAI. 






(Ad(lri'«*s 



IN. B 



•Vote CAUSE or DEATH In plain tern... th„t il m..> be proper., cla...Hed. The Spev.ol .nVor.nnt.on 



-Kvepy itei 

state CAI ... 

Rons dyinft away from home hHouIcI be ftiven in every instance. 



PHYSICIANS should 
per- 



: I 



ill 



H • 






\ 



\ . 



k \ 



il 




I ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Jl.,;.v.l of !ri':i!th I- V" I'- 1^'?»]~i-]i.«vl' C(, 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dftfc Filed y 



i 



^\XJ^ 




Deputy Her^f^h OfH 



Eegisfered A^o, 



300 



'— 4^' •• 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Bcatb 

( tl. S. Stan^ar^ ) 



No. 



PLACE OF DEATH: — County of CVa^v •IxA.^vcuicc City of O/CU^O; J A.<V>vou^cc 
5 4b m (KVKXV'C^. ' St.; 3) Dist.; bet. ^ ^- and l.r>vcL. 

r .r DtATH OCCURS *WAY FROM USUAL RESIDENCE give facts called for under "special information- \ 
( ,F death occJrrcd .n a hospital or institution give its NAME instead or street and number. J 



FULL NAME 



' * 1^*4 ■.>-%*-•«-•* •**»»*' 




a^^ 




^l.i<L4^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



'^\ioL 



UJ>vvux 



1) \ii-: <)!•■ I'.iK rii 



(Month* 



- flV] 

i!)av) (Year) 



A«".K 



b I y.-ats 



MimHis 



Pavs 



^INC. I.K. M \KK H'l) 

W IDOWHI) OK I)!V< »Kt j:1> 

(Write in social drJiirnation) 



niKTm'i.At'K 

i state or rountry^ 



N'AMT? or 
FATllKR 



lUKTHPl.ArH 
0|- lAlMlKK 
istatf or (.'oiiiitry) 



MAIDHN NAMH 
()|- MOTIIKR 



HIR iniM,ArK 

<)!• M()rin:R 

(State tir Country! 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATFI 





(Year) 



llonth) K (Day) 

I lII';Rl';nV CIIRTIFY, That I atteiKkMl ileccased from 

to : 



til at T last saw li 



1 90 

— ^ alive on 



•190 
190 



and that death occurred, on the date stated above, at 
T^.. The CArSl*: ()!' DICATII was as follows 



1 



Vn^Wtr^CVA, 



nrR ATION Years Months 

CONTRIBUTORY 



Days Hour a 



DURATION 



Yearn 



^fonths 



Days 




/Fours 
M.D. 

A.ldress) C^rVtT^xXA^ U-VUc^. 



( SIGNED ) urVcrvx^v J. vfc.LU. XtLx-'^v^ 

13. TOO S' (Address) MyV(n-XA^^ Uv 



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



OCCUPATION •" «^ "^ 



M.uith^ 



/hrys 



Till- Miovi- sT\-n:n pkksonai. rxKTuri.AK^ aki-; tkii-. to riu-: 

linsT 01- MY KNOWI.KIX.IC AND <n-.MlJ- 



(Infntnuuit 



ViMii'ss 



4 1 1 \!\vm.i. (5t 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



IM \CK Ol- lUKIM. OR RI>:MoVAI, I DA'li; ot IUkiai, or RlvMoVAI, 

c^ HA) QfyVvs^v^cnv O.J 



INDl'RTAKHR 

(Address 






... ^ .. •• I ATF ahnulil he stoted FiXAGTLY. PHYSICIANS nhould 

N. B.— Kvery item o^' Information should he cnre.ully «uppl.ed. ^^J^^^';''"/'* 'l^^j^^"'^ ^Special information" for p.r- 

•tate CAUSE OF DLATH in plain terms, that it may be properly classified. I he opeviai iniorm 

IS dyinft away from home Hhould he ^^iven in every instance. 



Koni 



'I 






. i 



H 



1 



ii 



'i': 






I 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I,,,n.1 ..r Il.aUh »■ Vo \ k -fi^V'-^^^ \\S^ V C n 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



cruwo Jo^^^^ Deputy Health OPlccr 



Ifes^isfrrrd J\^o, 



301 



1 



DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



-p % 



?^ 



Ccvtificate of IDcatb 

PLACE OF DEATH: — County ofC'/a-|vO \CL/>v^L<LC{ City ofO-CL^v 0/VO.AveiACO 
. Ltu"^'^ LcTLVwtu h ly^ \\\^cd St.; 



Dist.; bet. — -r-rrr—— and 



) 



/ ir Dr«TM OCCURS jTwAY FROM USUAL RESIDENCE GIVE facts called tor under "special information- \ 

( "death OCCu4^tD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME .NSTCAO OF STREET AND NUMBER. J 



FULL NAME 



/t!L:>A\JL^ 



trvvA-v. 



<\. 



-L 



RRX 



I)\ iR OF HIRTM 



PERSONAL AND STATISTICAL PARTICULARS 

CGI. 




cCLv ' vX''-v 



vvLi? 



? 



? 



;. , / l3 t ... 

(Dav) (V<-ar) 



AGK 



(d V? )'';ifi 



1 



1 



.%h>ut/is 



...Jhns 



<I\<.i.i.- MAKUIKI) 



WIDi »\V)- I» OK IHVORrKI) U f\ 

< Write ill Mx-inl de»iirtiation) "A If 

'^^ if * 

(L 



lUK rniM. A«*K 
<stMt«- <it touiitry) 



N.VMI. ol 
F.XTIIKR 



clvav 






HIKTHPl.ACR 
()!• lAIMKR 
iSl;ilf ut Country) 



MAIDl-.N NAM I. 
»)1 MOTlll'.R 



niK riiri.ACK 

Ol- MorilKK 
(Statf or Coutitrv^ 



3 call 



Utrv^wvv 



1- 



1 



^y\.^uL 



MEDICAL CERTIFICATE OF DEATH 

DATl-: Ol" DlvXTH 

w t.. 

otolith) fC (Day) 
I HF.RICliV C1;RTII*V, That I attemUMl deceased from 
X'\ 190H to ...W^ '^ i9oi 



(Year) 




that I last saw h A^»^ alive on Nk\^cjL ^ 190 H 
and that death occurred, on the date stated above, at I 
0^ M. The CAT SI*: OF DlvATIl was as follows: 



nr RAT I ON )'('ars 



CONTRIIU'TORY 



Mouths 



Da vs 



Hours 



r!Uy:^y.^^r>J>r^C^fSL. . 



KfKJifr^f ill Sav /'rnvn'yrn ^4 )'•<'' 



*" }/..iif/i' 



Pa \. 



Till- \H0VK ^T\lin l>KK>^oVAl. I'XKIUri.AKS AKI-.TKIK To T 1 1 H 

liFsT o»- MY kno\vi,i:p<.k am> mi;mi-.i- 



(Infoi tnant 



k 



-UrVa^ 



(?lat. 



VM„..s Cdu V (!« lb 



o-Mv-to. 



1, 



DTRATrON Viars 

(SIGNED) 



Mofiths 



IsJCVLAyvol LA^Ay-^UL/Vu 

)\ars Moi 

N only for lilispitdls, Institutions, Transients, 



Hours 
M.D. 



ECIAL IN 



( A<ldress' 



SPECIAL INFORMATIOI 

or Recent Residents, and persons dying away from tiome. 

^ ^P How long at ^^ . 
11 OXiV(X>\vaj Place of Death ? ^ ....Days 



Former or 
Usual Residence 

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



IM.ACK Ol' lU KIAI. OK Kl'MoWM, 



igoH 



INDl.KTAKKK 

(Ad 



DATKof ncKiAi. (^r RKMOVAI 






^ , ,, ... AHF tthniihi he stnteil EXACTLY. PHYSICIANS Hhould 

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



M 



-> 



I 



W . 



1 ■ 



ii; 



( 



H 



« I 



#i:! 



|. 



) 



5 f 



I < 



^vjkT 






if 




i 

[ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M.,:n.l..f Mcalth-l-No. ..'^•t??4•Hc-tl•Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/){//(' Filed , 



i 




\H 



lUO'i 



JiegLsfered JVo. 



30^ 



^^ 



^wA^-s iUc^j-s^ Deputy Health OflHcer 



DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco 



Certificate of 2)eatb 

( "U. S. StanOarO ) 
PLACE OF DEATH: — County oiO /Cuy\> kS A.O^^y\XAA^^ City of ^ ' a/>v J X^V>vc^ 
No \2.'b'x\j-OJU.^x^^o^ St.; 10 Dist.;bct. 3.5;vJw and ^H 

/ ,r OC.TH OCCUBS »W»V FPOM USUAL RESIDENCE give tacts called for under • SPECIAL INFORMATION" \ 
( "death OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



-t'lAi 



FULL NAME 




rv^ \] ./CUX6 vCULiL 



PERSONAL AND STATISTICAL PARTICULARS 
DATK or BIRTH 

1 . L 







Ul) AlU 



(Month) 



<I>:iy> 



(Year) 



ACR 



5t^ )V„/> .. Mmfhs nays 



S!Nni.R. MARKIl^D, 

wiixtWKi) Ok nivoRrKn 

vWiilciti iMHljU (Usi^iiatixn) 



HIKTWFt^ACR 
(State or Country^ 



NAMK OF 

I- \thi:r 



HlKTnn.ACK 

(tl I AIHKK 

I Statr or rountrv^ 



\fX!t»HV NAMK 
(H- MnTMl'.R 



lURTHPLACR 

(•I- Morm.K 

(^t;itr or Country) 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH A 



(/Month) 



13 

(Day) 



(Yt-ar) 



ITRREnV CICRTIFY, That I attended deceased from 

\\sXul,X i«»^- to ...H^wLu \X iqo H 

tliat I last saw li -L^-^ -alive on VWUiL. 13. 190 H 

and that death occurred, on the <latc stated above, at 11 
CI. M. The CAUSH OF DICATII was as follows 




VJt|v\WLA.vo 







DURATION ^ Vca. 



cars 

4 



Mofit/is 



Days 



I /ours 



'>W^ wft'UJav- 

OCCUPATION Cj|^^^^^^1L<V^ tl£A^^.v<>.>v. 

Rfsitfed in Sati /'nnt,iu;> \^ ),-,j'^ 



\h<iitfi^ 



Pa \ 



Ti.KAH<.VFSlXTi;i.rFKsONAl.PXKTj|;ri,AKSAKKTRrHTO THK 
1»F:ST «)1- MV KN< »\\1J:1 '<•»■■. AND Ml-.IJl-.H^ 



niilortnant 



^ 



CONTR IIU'Ti )RV . .J.fir^OJU^a.xA^CX 



DUR ATroN r^'^V'^ Months ■ Days 

(SIGNED) ^\ M Ltv\,^waw 

tui^lH TcoM f.\ddr..<. ) \^^ ^\Ak^t 



Hours 
M.D. 



wPECIAL Information «n!y for Hospitals, institutions, Transients, 
or Recent Residents, and persons d\inq away from home. 



Former or 
Usual Residence 

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



How long at 
Plare of Death ? 



Days 



I'l.ACK Ol- lUKIAI.oK K1•:M<•^AI, 




DAI'K.j: lirKi.M. or ki;m(>\ai. 



==y' 




15 



1 90S 



INDl-RTAKKR 

{A<l«lress 



q H b 



^, -^^ 



.VAr-'^vcnv 



■"■"■■"" ^ .. ~ \ .pF «ho,.l,l he Stated EXACTLY. PHYSICIANS Khoulcl 

N. B.— livery Item of Informntion nhouhl be carefully HuppI.ecl "f^l'^ll^f^^^^^^^^ ..Special Information" for p.r- 

statc CAUSE: OF DEATH in plain terms, that it may be properly claBsitiea. me , 
son* dyina nway from home should be itivcn in every instance. 






I 



\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 




ItMMnl ..f H..iHli"-!- N" i> *^;,»v-4>IU«tl'Cu 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 





> > 



I )<((<* Filed , 



\ 




IH 



W()\ 



Registered J\^o, 



303 



(^A^VV^ 



\)Cv-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH; — County of O.Oj^\j 0.\.1Xav^^4CC City of^'Ow^^ JA.OavC^O.C.^ 

lib V^VU St.; X Dist.;bct. \X<Xx.L and ^^a^am-UA^c^ 

/ J Dt*TH OCCUBS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U N D ^k "SPECIAL INFORMATION • \ 
( ^ "death OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 3} STREET AND NUMBER. J 



FULL NAME 



No. 




SEX 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR" 






U 



lOivCU 



OATr or lUK III 



dUvJl 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Day) 



IV car) 



\«.i-: 



So 



J t'a I s 



3 



.M.iH/Zis 



lb 



An. 



SIM. I, I?. MARKIKr*. 

\\ ll»<>\\ i:i) <>K 1)1V(>RCKI> 

(Writ* in «*ocial de»ij|IMlti'>ii) 



J VcUrUj- 



HIKTHIM, AOK 

iStatf <ir Country) 



NAMR OP 

rATin:K 



^ i 



1/ 



iOLNXX'WCX JJiVvwck. 



1 



'VtU 



(")(^'VL\Xr 



inKTMIM. Ai K 
<)l- lAIIIHR 
'Stuti- or Coiintrj-) 



MAIDKN NAMi; 
<»I MOTIIHR 




-^1 



'y\>vt. L'/Ct^^^vv^ 




(Day) 



(Year) 



I lII'lRIvHV CIvRTII'V, That I attended deceased from 

Hiv>\jL \H 190 S to NLwLA,.l.3k KpS 

that I last saw h-Uv alive on HvaXo. 13 I90S 
and that death occurred, on the date stated above, at I I ^5^ 
CL.M. The CArSr: of DI-ATII was as follows: 
CLivcr|viL^ .UlvuXaxJl 



DT RATION T-. }'tuirs .'" A/off^/i.'! I VA/j.v Nonrs 

CONTR IIU'TOR V .Q.^-rVwv 




lUK IlllM.ACK 
(Statr "I roiintrv^ 



I 



.yJA'>^vcv\v 



OCCl'TATION 

h'r^iiir,! Ill ^\tii /'i, 1 11. ism 



O \ )'rii>s 



t 



Mfimtks Pay 



Tl!)- MU.VK ST\TJl.I>KI<S.>NAi.r\KlM-ri;XK^AK>'. '"'^l '•■ '" ""• 
in;sT 01- MV KN()\VI,i:i)C.K and lUl.IhH 



(\\\ fonn:int 






( \»1»lrrs.s 






OOw/Wj 



nr RAT ION )'r(jrs 

(Signed) 

IH TooH (. 



J/i>f///lS 



/hrvs- 



M.D. 



LI )t v)<CUxU^) 

\ddress) t)Ob ^.vJCttn, Ot 



SPEtilAL Information only tor Hospitals, institutions, Transients, 
or Rccf' Residents, and persons dying awdv from tiome. 



Former or 

Usual Residence 

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



HoH long at 
Place of Death ? 



Days 



I'l.ACK <)!•• lUKIAI. <;K RKMOVAI 



lCK Ol" lUKIAI. <)R RKM« 



rNDl-:RTAKHR 



D.\ TK of IHki.ai. ni ki:m<)\'AI, 

^vJIm 15^ 190H 

S H b CV>VvA.^^ov J.i 



N. H. 



... ■• I %f'F ahmilfl he KtHtecl RXACTLY. PHYSICIANS hHouIiI 

Hon. dyiiift away from home Hhould be fciven in every instnnce. 



I I 



til 






I 1 



! 



\ 



\ 






-«5>i-^--^" 



> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lU 



,.,,,1 of I!. ■..nil- »■ N'o !«; ■^'-r^r^li-J' i^f^^' <■"•» 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)((/(' Filed , 




IH 



100^ 



Registered Xo, 



304 



'Icr'^cva ix/v-M Deputy Health Officer 



DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



Certificate of H)eatb 

( U. S. StanDarD ) 



PLACE OF DEATH:— County of 



^^^A. 



^OtAyrU) City of 






Ne. 



w 



I 



■ V 



aA\oUrcv/>vo C^atx u\9CHLk\.ta)'st.; 



Dist.; bet* 



and 



-) 



/ ,r DC.TH OCCURS *WAy from usual residence give tacts CALuto ^OB UN :f "^;*;^^'^^°;;;*^'„°'*" ) 

^^ ., ^,-,^ «^^..oorr, ... . unsPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 

FULL NAME U-LA" 





SKX 



PERSONAL AND STATISTICAL PARTICULARS 



^\A 



COI.OR 



iDi 



VA.t^ 



DATBOr BIRTH 



M 



(Month) 



may) 



AOR 



.JW£^ >V*<T» V 



Mtmths 



A. 
(Yi'iir) 



Ai V. 



RTNm,H. MARMlKn. 

WIDOUKI) OR nivuKfKn 

Writ' 111 MK-ial Uf'>iKnali<>ii) 



HIKTHFf.APW 
(Stair or Country^ 



NAMH Ol- 

I AT»n:R 




a^/OL 



A"VCrVV.^\/ 



nTRTT?rT,\rK 

Ol lAlin-.K 
(Statf 1)1 Country') 



X 



UlX. 




r\. 




MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH A j| 



Month) /T 



13. 

I Day) 



(Year) 



I IirCRRRY Cr-RTII'V, That I attended deceased from 

TQO ~~~~ 



igo 



to. 



#«i^JfW*«f4*#*^*t«»*4*a«<^*<i 



that I last saw h alive on ■— - 

and that death occurred, on the tluLc stated above, 



I90 



>r. The CArSF^: of DHATIT was as follows: 



L^tvuLLiv-iJu^ 



or RATION Yrais J\/otit/is 

CO NT R I I'.rT( ) R V 



/)avs 



Hours 



M MDI-.N NAMK 
Ol- MolllK.R 



lUK rwm.ACK 

Ol- MoTMKK 
(Stati- or Couiitiyl 



I A 



M 



IH rri'ATlON 



D 



A--c^. 



A^ 



h^fshhd in Sii>i / 1 iincis/'it ... 



)r,,i 



}f,.iif/l^ 



/',n 



■nir NHoVKSTXTKI..'KK«...NAI. rAKTUM-l.ARSARKTRrK To TIIK 
Mi:ST op MV KNOW I.IIX'B A>JJJ ^KMl.l- 



(Info'inant 



f A(l<he**s 



,0<J\./C^ 



or RATION 

(Signed ) 



)'(<n'S Mouths 



Pars 



i^lu. i: 



U. \'h l()0^i 

e!cIAL INFORI 



Addnss) LUkvoJk) \oX 



Hours 
M.D. 



FECIAL INFORMATION only for Hospitals, Institutions, Transients, 
orfpffnt Residents, and persons dying away from fiomt. 



former or p 
Usual Residence^ 



Wlien Has disease confrarfed, 
If not at place of deatli ? 



A^ ?\ P Howlonqat ^ 

/OuvOX UOa\XX UXX Place of Death? Jwaj^-A.. Days 



i)\ri-; of m Ki.Ai- or ki-;movai. 



l'I,.\CK 01 in RIAL OK RHMOVAI, 

l-NDHRTAKKR ^^^^^ .^ '*^^M ^ n, 



C.^ddresH 



11 AflF Khould be utntecl EXACTLY. PHYSICIANS should 



IN. K. Kvery item o» inVorm 

state CAIJSI: OF DEA . . 

son. dylnft owoy from home should he ftivm in every Instance 








V^ 







» • 



I- 



U 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



JioiiT.l nf Hcilth I 



So I . ♦y.farS^) ]iSi V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health Officer 



Registered J\^o, 



Dufr Filed, \\^X^ \H 

DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



^ 



"U. 5. StanOarD ) 



4 ^ 

a^ 



No. ^O^u, 



PLACE OF DEATH: — County of ^^0-^V J VCLtvCUICo City of ^J/CtAv 0XCl^vCC4C^ 
lu^^ L^VV>vtu h ^\Os.<sX St.; Dist.;bct. — — and 



^' 



J ( ,r Dt.TH occuRs4w.v TR o M U S U A L R E S I D E N C E G . V t facts c*'-^/^ ;°" "''°" :^%%";%'^^^ 

(J \ ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTCAO OF STREET AND NUMBER. • 



FULL NAME 




Ty\M.....y^ 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 COLOR \ 



(n\c.L 



.ruXju 



DATB or r.iR III 



,131 



(Montht 



AC.R 



t)^.... I>f». 



<0«y) 



yjimths 



(Year) 



An. 



STNM-.T.R. MARKTKn. 

\vn>< >\vi:i) » IK i»iv«»RCED 

(Write iu JMJcial dtv^itrtiatiott) 



1 



UJ vcL^^aMA; 



HIKTfllM.ACK 

(Statf or «.ouutry) 



NAMR OF 

FATIIKR 



lURTHIM. ATH 

(»I I AIHKR 

( Stilt «• or Country) 



MAIPHN NAMl". 
OF MQTUliK. 



niRTTTPLACK 

oi" M<>rin':R 

(Stat*- or Couutrv) 














^KxXjX^y\A^ --^ — 



WEDICAL CERTIFICATE OF DEATH 
DATK OF I)F:aTII 

II 

(Day) 




(Year) 



I90S 



I HFRFRV CIvRTIFV, That f attemleil (k-rt-ascd from 

Vin!.! ^ ■■ 



til at I last saw h .-WWv.alive on \ 

and tliat death occurred, on tlie date stated above, at 

...vJl m. The CAISFC OF DI-ATH was as follows: 



'iL^: 







Ur RATION Vears 

CONTRini'TORV 



Mouths 



Dai 



•s 



Hours 



> « »H g^*» » *i** «#*»«*»-y****' 



or RATION 
(SIGNED) 



Years 




CSWi 



oOCrPATlON 



^^ 



sulr,1 i„ Sov r,^fuis,n \% Yrof* *^ M^h% Z... Ar 



THKXHOVKSTXTKI.l'KKsONAl. rVKTI;;ri,VKSAKi;TKrK TO TllH 
1U:ST Ol- .MV K NOW 1.1: IX '.K -^NI) lU-.IJl.l- 



f Infotniant 




( AfUlrcss 






Mouths Pays 

\\ T.oH (Addrcs.)Cd.>U %^\^X. 

SPEfclAL INFORMATION only for li)spitdls, 
or Rrccnt Residents, and persons dylnq dnay from home. 



Hours 
M.D. 



institutions. Transients, 



former or ( 

Usual Residence 

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



How long at ^ 

Place of Oeatfi? X Days 



n\Ti:of HiKiAr. or ri:movai. 



I'UACK OI- lURIAI, OR RHMOVAF, 

INDKRTAKHR V/V^ViU VW ^SxJy^^^ U 






T90H 



'A.l.lrcss 



j 3k 1 H t<<.<^ it 



') , .. 1^, .('F Khoultl be «tnted F.XACTLY. PHYSICIANS Rhould 

N. B.— r.very item oV WO'ormHtion .houlcl b. c,,reVull.v -PP'- • ^^^^.f^.'^^^.^^^^^^^^^ The -Special lnt'or.n..tionV for p.r- 
atote CAUSt OF DKATH In pinin terms, thnt .t m»y be properly class.t.cu. 
«on. clylnft as^ny Ifrom home nhould be iiiven In every .n«t»nce. 



\ , 




"jMA 



H'iij 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



n,,;,,,i.,r n...iti. 1 V" ■. ly-'^'^^.uf^vr, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






VvlulH ^'^^^'H liegLsicrcd jYo, 306 

Lcr^vv^ ioL/vH^i Deputy Health Omcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiticatc of 2)eatb 



"U. S. 5tan^ar^ j 



PLACE OF DEATH: — County 



4 ^ \ ^ 

ofC a^vO,^.CL^xec^C<) City of CxX'>v OXaAv^uicc 





'^ 



C^^ 



Kd 



<x 



St.; 



Dist.; bet. 



and 



rCATH OCCuJs *W*V TROW USUAL R E S I D E N C E Gl VE FACTS CALLED TOR UNDER SPECIAL INFORMATION ' \ 
F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




AxUU^^O::v>j.. 



^HX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI^It 



QiHcvL 




DAli; «»F ntRTH 



\('.K 



I Month » 



(Day) 



/IHB 

(Year) 



'3 1 }>«»■* ^ Mtmths lJ%, 



Dayy 



WIDOWKD nK mVORCHD 
I Write in Micial tlwiigitatwu) 




iStatt or C'»»iiitry^ 



NAM! OF 
FATMKR 



lUKTHIM.ACK 
«»I lAlHllK 
ist.itc or Country) 



MAII)1:N NAMK 
oi MOTIII-.K 



MTRTTiri.ACR 
<»l" Mori IKK 
(Statf or (.■oinitrv^ 







MEDICAL CERTIFICATE OF DEATH 
DATH OK DKATH 



(Month 




IC 

(Day) 



(Year) 



I HI{RI-:BV Cl'IRTIKV, That I attended (Iccoastul from 

.|^^^>aX./X'~'v 190H %-|v > '^ ''^"^ 

that I last saw U ..l«»**-alivc on VV^Xci IL up 

and that «leath occurred, on the date stated above, at I » 

Cl. M. The CArSI*: OI' DICATH was as follows: 



Days 



II 






1%. A'l 



TnKAHOVKSTMKI.l-KKsnNAl. rXKTirri.AK^AKKTRl K T. » TMK 
HKST 01* MY KN<)\\M<i:i)*".K ANI^ lU-.Mlvi* 



( Iiif iTtnant 



%.a.% 



JU^ 



Address ^J 



<XaMrV^ 



in 



^A 



IvCtal' 



D L' R AT ION ^i ) Var5 ..*--..• A/o'i//iS 
CON'TRTBUTORV ...'y..'0-id.A^vt.va.. 

DIRATFON i }'vars " Months 

fAddr.^.o Macavt h) 



Hours 



Pays 



(Signed) 



V^w 



V-lO i{)0 



Hours 
M.D. 



Special information «"•> '«r Hospihls, institutions. Transients, 
or Recent Residents, and persons dying HHdv from fiome. 



Former or 
IsudI Residence 



QOu. 



VAvi^O-^^ 



.t. 



HoM lonq at 
Place of Death ? 



1% 



Days 



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






N. B.- 



fl 



— ■""■"■""■"""""""'"^ i 1. I \rr= <.h»..l<l ho Rtnted CXACTLY. PHYSICIANS should 

-;ver> Ucn otf inf.n.n.tlon should h. cnrc^'u.ly «uppl.ed ^^f^^^^/;^^:,.^^^^ ..Special In.'on.nHlion" for p^r- 

^t«tc CAUSi: OF Di:,\TH in plnin terms, that .t may be properly Uaasmea. 
ion« dyina owoy from home should be feivcn in every Instance. 



; ^ 



W 



H 

I! 



I 



¥ 



''<■', 



(JT ::'^ 



! 







f 






t It 

St 






f 






11...M.1 of Hi-rilth I V'> 1- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

■*.f*4^-; JUM' ( M REFER TO BACK OF CERTIFICATE FOR ;NSTRUCTI0N3 



Dfffr Filed, %u^^ IH 



U)0^ 



Be^isfcred J\^o, 



307 



\ 



i 



dLtrvvv^ U.\M^ Deputy Hcafth Omcer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

: — County ofdc^^v J .V<X'WCUl/CX) City of 0-CC'>V J \./ay\v^tv4'-5^0 



PLACE OF DEATH 



No l^X '\c^tk St.;^ Dist.;bet. % C^V^KaVcl and 1 ^-U^^^' 

iNO. C7S %/ av v-w ,„^„ ,,c,|A| DF«:inrNCE Givr FACTS CALLED FOR UNDER "special INFORMATION ■ \ 

( '^ rF^D7AT°H^'oc:u%rEV,NTHO^S^yT"Al: o'r^N s'nT^^T^O^N^O . V E ^1 NAME INSTEAD OF STREET AND NUMBER. ) 



FULL NAME 



Lctcv-OLvd aX^\'<xa.<\ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS^ 



Ci)vtt 




DATE or HI K Til 



iMDiith) h 



<Dfty) 



(Year) 



Acm 



tp 3 Vfats 



Months 



Davs 



U IDOWKD OK IHVORCRn 

iWjittiii 'iorial (Usiyjiati'<u) 



lUK riii'i, \t'i: 

tStatf f»r « «>imlrjf) 






w<^t 



<L 



N \MV Ol 

I AIM i:k 



lUK rilPKACR 
<W l-ATHKK 
(Statf «ir Country^ 



MA1I>i:N NAMl- 
<M" MoTIll'.K 



lUK'nil'I.ACK 
OI' MolllF.K 
iStatf or 0«)»intry> 



e 












..CCrPATlON (^^^,_;^ 



yr,'i)f/i^ ' 



/>(n 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

/|M<)iith) n 



II 

(Day) 



(Year) 



I HEREBY CERTII'V, That I attcndtMl (Icceascd from 

— to ■. ....,.- I <P ~ 

alive on — — ' ^'P 



190 



that I last saw h * — 
ami that death occurred, on the date stated above, at 
— M. The CAUtfi OP 1>^IvA;^'1I was as follows 




DTRATK^X Years 

CONTRIUrrORV 



Mofiths 



/)avs 



Hours 



I )r RAT ION Years 



I^a vs 



(Signed) L^rV<n'vW 



Hours 
M.D. 



PE 



|»o\ TOO -I (A.iure<>.) LyUrVvJ^M^ Vn„--^ 

61 AL INFORMATION only for Hospitals, Institutions,' Iranslents, 



xLtl^X TcoH fA,]dre<>.) LfrVXrVvM^ ^^VU>a 



or Recent Residents, and persons dying away fron fiome. 



,n; VHnVKS,VXTia)PKRSON^I rAKTUMM,XRSARKTRrK TO THH 
HFST ol- MY KNoWl^fc'miH AND BKIJI-.l 

0\< - -^ 



(Infi>!ni;mt 






Former or 
Usual Residence 

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



flow long at 
Place of Death ? 



Days 



I'l.ACK Ol' HIKIAI. OR KI<;M<'\ AI, 

.0 cHLu, Uuiy^A^ 




D 



rNDi:RTAKl'.R 







Hi Ki.M, or RKMoVAI, 

15 190^ 






Ibl (\>\v^4.A.{nx "^^^ 



'' , .. ,, . Anr Hhoulcl be stnte.l EXACTLY. PHYSICUINS hHouUI 

IS. „._Hver.v Ite.n oV information should be CBrctuMy f"PP ^ ' ^^ /p':;^ ^ asshMcd. Tbe "Special InformHt.on" for pT- 
state CMlSi: OP DF.ATH in pl«m terms, that .t m».v be properly 
^on, dTinft away from home should be ftiven in evory .nntance. 



( : \ 



K • 




f 



mt 



^ 



h 



.,,,] ,,f II. :.'.t:i -I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,rf^^- ,,. ,. c REFER TO BACK OF CER TIFICATE FOR INSTRUCTIONS 

308 



i r -p 



vL 



/-9/9H 



Registered JS^o. 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Certificate of S)eatb 



PLACE OF DEATH: — County of 



Lo^A.txCu L<y^OJ City of ^^-^^' 



Lv-CrtLyVUCtl) v<X 



I 



No- 



— St.; 



-Dist.; bet. 



and 



( 



..O...I oreinPNCE give facts called fob under "special information" \ 



FULL NAME 



vYlu 



VC\.CXVjUj ■iwf^v.^UU^, 



SKX 



PERSONAL AND STATISTICAL PARTICU LARS 



I.ATK OF HI kill 



L 



UJ^vvCtA 




Vli.nth) 



I 



\« .1- 



^ y. 



Van 



I Day) 



^mau. 



(Year) 



IW 



Davs 



stNc'.i.f?. M.\RKn:i> 
\vinn\vi:n nk i)!\i»Rii:n 

U lit' ill -<H-i;il cl< ••iiMiation) 



lUK rnri.Avi', 

'St.'itf or Onniitrv 



NAMK 0|- 

TATIUK 



lUk TIU'LAiK 
<>|- I A IMl'.K 
(Statf «>T Country) 



C.c^vcvu. 



Mxini'N v\Mi: 
<»i m<>i"hi:r 



lUK iiirLACK 

ul- MOIUHR 






LA 



I 



0^^\A^ 



om TATION 



5 V<7 ' . 



- \r.'i,iii' 



Pity. 



r I n 



:XHnVKSTVTK..rKK..>NU.rXRTU;ri,AKSARKTRrK To TH,- 
IKST ni- MV KNOW I.llX'l'. ^^'1' Hl-.i,n-.i- 



(!itfi>- m.iiit 



L 



x,ia,e-ss C^VCrUlxtt Co. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




11 

(Day) 



190'i 

(Year) 



I IIKRRBY CI:RTIFY, That I attended deceased from 

190 to ^90 

that I last saw h alive on I'P 

and that death occurred, on the <late stated ahove, at 
:SI. The CATSP: of DI'lATH was as follows: 



I )r RAT ION"-." >V\7/-.? 

CONTRIIU'TORY 



Mouths 



Pays 



Hours 



DURATION Years Mouths Days Hours 

(SIGNED) H. OAIVJULU.^ M.D. 

ydi-yiX TQoS (Addrc-^s) LMv<J^Atl- LclI 

Special information only for Hospitals, Institutions, Transients 



or 



Recent Residents, and persons dving away fron home. 



former or 

Usual Residence 

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



How long at 
Place of Death ? 



Days 



V\ VCK Ol" lURIAl, OH KHMOVAl, 
INDl-RTAKKR V^ ^ U^^W\; 

i 1L-I (YV\ 

(Addross 



DAl'i: 0;" HiKiAi. t)r RHM«>\'AI. 

^lJ^ W T90S 



Ibl 



V-^^uVfl 



::jj 



IN. B.- 



"~~"""""""""-"""'— "^ v^A AGB Hhould be stnted EXACTLY. PHYSICIANS should 

-F.verv Item of InformntJon should he cnrufully Huppl.cd. A(,B «^"''« '>«, 



sta 
«r»n 



:..> .- . . ... ., „..^ he oroperly classh'led. The "Special Information" for p»r- 

te CAUSE OF DEATH in pliiln term*, that it mu> he propcny 
s dyinft ow«y from home should be feiven in .very Instance. 



Id 



I I I 

< \ \ 



\ I 



> .1 




» I 



i«P-i^ 






I 



M 



1^ 



WRITE PLAINLY WITH UNFADING INK — 



Ji..l!^ 



,f 1!, ;Uh »■' V" i: t'-f;._ja^^>1.iS;I' Co 




IH 



IDO'i 



Dale I'iU'il , 

DEPARTMENT OF PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

neiistered ^'o, 309 



City and County of San Francisco 



Certificate of IDeatb 



( tl. S. StanDar^ ) 



PLACE OF DEATH: — County of 



VVctWcx^ 



City of 



Vr Loi^Ou Lo^l 



iNo. 



QjLaAx l\C5^^1vAwloL.L 



St.; 



Dist.; bet.— 



and 



|# ot*TM OCCURS *w»v r 

ST OtATH OCCUnHC D I 



rooM USUAL RESIDENCE GIVE r*CTS CALLED »^OR UNDER "SPECIAL INFORMATION" ^ 
N A HOSPITAL Tr "nST-^UTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. ) 



FULL NAME 



d: 



OlL\a, 




LlA:^ 



1 




SSM 



PERSONAL AND STATISTICAL PARTICULARS 

C01«0R 



5n\A 



\Mj^ 



IJATK OP BIRTH 



iMantH) 



ACR 



kx 



Veatf 



ID 

(Day) 



M4mihs 



CVear) 



Pavs 



WinoWKI) OK DIVORVKH 

»\Vtit» ill xKial tk'siieimtion) 



^. 



»IRTHPI,Ae« ^ 



SAMK OP 
PATHKR 









UTRTHPT.Ari? 

(>!•• FATHKR 
'State or Ctnintryl 



M\n>ItN NAME 
OF MoTHKR 



BIRTH I'UACR 
oj- M<»THI'R 
istat*- or CoHiUry^ 






oc< 



^^Aa^^/vx.'LmA 



h>gfl^ I'l *^'"' / """ 



*- Villi 



V.^riftt: 



/ Un. 



(lufoTtunnt 



TMF XHOVKSTATKnrKKSoNAl.rXKTirrrAKSAKHTRUETi* TMK 

ni:sT «u Mv knowi*f;u<".k and in-ijn- 

.^Ivu -vcy^v/cvv 



MEDICAL CERTIFICATE OF DEATH 
DATE «)H DKATII 



Month) (" 



(Day) 



(Year) 



iFhRRHBY CI:RTIFV, That I attended (leoease<l from 

up to ^90 

that I last saw h " alive on ~ ^9° 



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



- M. The CAUSP: Ol- DlvATlI was as follows: 



DURATION rears 

CONTRIIU'TORV • 



nr RAT ION 
(SIGNED) 



Man tin 



Days 



Hours 



Yt'ars 



Mi))iths 



Pays 



^,^_ ^ __ L^-VwYV 

V^L^l^ TQoM (Address) VfUxl^XX^ Mxi 

!) ' . I. f„, U„.»:t .Ir Inclifiitlnnc 



Hours 
M.D. 



Special information only '^"^ Hospitals, Institutions, Transients, 
or Rcctrnl Residents, and persons dving away Iron home. 






Days 



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



vJ\/\-W^ 



\«l(1rf»i»« 



ri.ACl-:^>i;' HIKIAI. OK kKM«»\AJ. 

^' crlu, lV(yt 

rN'DHKTAKKK 



A^ 



I) xri: oi 111 HiAi. or ki:mo\'ai. 



^Address 



1 U 1 QfVlV^,4.L^V 31 



■"~"~"''~— ■"■— "■""""""■"'""'"""^ i- .1 AGF. Hhoul.l be stated EXACTLY. PHYSICIANS should 

N. B._r.vcry item of inl'ormHtJon hHouM b. -«''«»"'«> T;^^' "^t properly clasBir.ed. The "Special Information" ?or p-r- 

•tate CAUSE: 0\ DF.ATH in pl«m terms tha .t m»> »- ';"^^- ^ 

•on. dyinn away from home should be Ji.ven m avery inHtoncc. 



1 



1-1 



'! il: J 



II 



6 ' 



S 






, 1. .-'■-' 






i 




) ■ 



i 



li,,;,,.l ..f Hi.ilth 1- N" I 



l)((lv Fih'fi y 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. iit!^S^,\s^V^^^. REFER TO BACK OF CERT IFICATE FOR INSTRUCTIONS 

310 





1c(rvAwV/\ lui\Mj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( "a. S. Stan^arD ) 



PLACE OF DEATH: — County ofCW^^vl 'V<V>vcvA.co City of "' ^CJ.^ J AXV>^-<i^.4yC^ 



cWo. 



A 



t) 



-> 




kct 



a\) 



St.: -'*— Dist.;bet. 



and 



y ' ,,eii»i DrcinriNjrF rivr tacts called for UNDER "special intormation" a 

( '' r"onro":u%;rD\rrHo",^rT*.L o^"^s'nTJ;^o^"o'^.;r.;i name ..stead or street a.o .umber. ; 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PAR TICUL ARS 



DAVi^ OF BIRTH 





\ 



J 



1 
(Day) 



(Vear) 



Ml« 



S!?«ir,f.R. MARKlKf*. 
\VllM»\Vi:i) OK IMVoRrKO 
'\Vnl» ill -"Hial >lf»ii/iialion) 



Mmlks 



II 



Days 




(mate w OMittry> 



I \ rm K 



HiK I n i'i,\f*K 

(II lArilKK 
(State or Country^ 



MAIDl'N NXMH 
«»I MuTin.K 






UuwacU Mfl 



cnvjo 




Avrv^>\^v^n\) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

a 

(Day) 




ipoH 

(Year) 



I HRRr^BY CI'^RTIFV, That I attendc*! deceased from 

CI\vvJL H 190S t., |\^^ 190H 

that I last saw h .vwv alive on ^UvXu. I 190 S 

and that death occurred, on the date stated above, at T 
...Ol. M. The CAl'SR OF ])i:ATir was as follows: 

.i:jxYUL>vojL Ll^ 



iXYjjL>voX Li^va^^o.v>Q.<X'-. 



l[\,^o-->Lv<^...rL 
L trt-'Cx^^-duJLA^ 



CONTRIIUTORV 





'W<rwv^ 



1)1' RATION yciif'S 





Hours 



Mouths 



Pays 



HIRTIIPf^ACK 
<>l- M«V. ilKR 

(Statf i»r v'oiuitry) 







M oifh 



I >,i 1 



TMKAHOVKSTXTI lM'KK>...NM.l>XUIu;!;KAKSARHTRrfiTO TMH 
BEST <H MV KNn\Vl.i;D<".K AND m'.uiJbr 



nnf>>;iii:mt 




1 



CC^ V cC VA, <2,'C^ 



f Add reus 



ixa 




lo-i->- 



1 



n 



a 



,\Kj.. 



(SIGNED) 



llvtJvuA^ vl m. a1. 'V-y^iu 



//ours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Irt^litutions, Transients, 
or Recent Residents, and persons dvinq anay from liome. 



Former or 
Usual Residence 

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



1 3. 2) mWvvIoCu Cl\vv pue Toiath ? '^'1. 



.. Days 



n ^CF Ol- m KIAI. OK KI.MOVAI. l.\l>;'.f niKiAi. ..r KlCMoVAI. 

L^^ I WlH.i.i..,.. .,.,0^ 




1!ndi:rtakkr 

(Ad<lrfss 



y . <3 - b^&JCOuuo 



MiVcr^'CLa u 



.:^*^.' 



»tntc C\IISI OV Di: tTH in pInJn terms, thot it mi.y be properly classitieci. 
nr,n% dyin^ awny from homo should be ftiven in every instnnce. 



I 



:| 



I 
» I i 

I 



I- 
I 

,1 



' 



1 ■ 



\ 




m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ ,, f,. Mb ! v.- t.r5^^n.^,ro REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Re^istei'ed J\^o, 



I)i(h' Filed , 



wL 



IH 



,cv-v 



^ 



Deput" Mealth Officer 



311 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( 'd. S. Stan^ar^ ) 



No. 



PLACE OF DEATH: — County of a^>^ ^ .\.aAvCC4C<City of -^/Ct^^ J-^O^vOCA CC 

and B^AltlxK) 



(IF Ol 



St.: X Dist.; bet. ! Ch^ 



I . . CM ■ « I Eire I P>F Mr r r ivir F»CT^ CALLtD FOR UNDER SPECIAL INFORMATION" \ 

' "dT°"»c",*»r„',"r„os^p"*t o"f:"?u" ^'o,;";? name ,™st»o o. =t«.t .-.o »u«=tR. ; 



FULL NAME 



il 




h 



li^atu te tLwui, 



sEX 



PERSONAL AND STATISTICAL PARTICULARS 

I COT.OR \ , n 




DATE OF Kt«TM 






"JJr 



n 

(Day) 



vill 

(Year) 



Kcn 



ab 



. Vemts 



Al^mtto 



^. 



Da VA 



-INT.l.K MVHKIKI* 
WIDOW i:i) OR IMVOKCKH 
iWritt- in sfK-ial de«tgn«t»««) 



BIRTH IM.ACK ^ 
(State or C«wintrr ' 



NAMK Oh" 
! ATHKR 




u 



rC^VC^ 



lUKTHPl.ACK 
ol' l-ATIIKK 

'Strit*' or r<»tnifry) 



M MDKN VAMF 
Ol MOTIII.K 



niK rm'i.ACK 

o|. MoTJIKK 
(StHte ur CoinUrj*) 




L<X'i.'Uxdv'C^^ctXA 



t 



a ^ 



q A^^ V a Co V 



_y J2u\^^wa/vv^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



JMonth 




11 

(Day) 



(Year) 



I HI':RI:BV certify, That I attended (Icccasetl from 



y^yJx>*Jo 190Y to^...|vL^^x. l.H up S 

that I last saw h ..-i.^v^alive on H\^A-^-w^wiL. L^ 190 'j 

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

CI. M. The CATSIC OF Dl'ATII was as follows: 



V) al\^vJ.c^ ..S)..s,.^ulcv^;l^ {r|..%:^;^*>A 

t^iD irrnv IV/rr? Months Days 



or RATION Years 

CONTRIIU'TORV -. 



Hours 



I )r RATION 



Vt-ars Mont /is 



Pars 



(SIGNED) 'A-. CvM)\jI^V<U.I 

^vdu IH u,oH (Addre>.oalH^Mb^frtLl>v^i 

Special information only for Hospitals, Institutions, 



Hours 
M.D. 



or Recent Residents, and persons dying anay Iron iiome. 



fCf>i,ir<1 in Silir /'tin, /W.> 



)■,■„•' 



1 /■»//'//■ 



/'■n 



Tin XH..VH STAT|-I.I'KK^ONAl.rAKTI;;ri,A«^ARi:TRrK To 

m:sT 01 Mv knowm:i)c.h and im.i.ii-.j- 



Tin-; 



Onformant 



.<3.3Lcr^Tvtcryv Vat 



\<l«lrt's>« .. 



Former or 
Usual Residence 

Wh«-n was disease contracted, 
If not at place of death ? 



How long at 
Place of Deatli ? 



Transients, 



. Days 



I'l.ACK Ol- lURIAI, t)R liKMoNAI, 



D\ri-;<)f I?' KiAi. wi ri-:mo\ai, 
>VAXi^ l5 T90S 






(Address 






N. li. 



'— "— — "■^■■""""■■"'""""'"""^ 1^^ APF «hould be stated EXACTLY. PHYSICIANS should 

-r.very item of Information •hould b. cnrcfuHy -PP'-H. ^^^^^^^^^/^'^^Mei? The -Special Information" for pT- 

state C41ISE OF DEATH in plain terms, that it may be properly classitie 

sons dyinii a«ny from home should be feiven in every instance. 



f 



1 { 



•I 



I 

I 



' i 



/A' 



I 






• i, 



I 



\ 



I 

i 



'. r 





WRITE PLAINLY WITH UNFADING INK 



BoftrdufJI.^.Hh- l-vo ,.'»>ra]^lU'v>'CM 




THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS 

312 






Dale Filr'l, \K^^ IH ">^'\ 

l^^vvc^ Ix^^M Dep«m- Hea'tb 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Certificate of Beatb 

( 11. S. StanDarD ) 



<^ 



PLACE OF DEATH: -County of'O^^v -trvOAV^U - City of 'J-Cb^ X^VA^^v^U^t 



^ 



No. ^\Ay^y\Ci, '^ i0^^y\oX^u^^'^y\. 



I 



Dist.; bet." 



V ..oiiAl DrQinFNCE GIVE FACTS CALLED FOR UNDER "SPtCIAL INFORMATION- "V 

( " iVrJ.".".r.nZ" "11^.%."'" c%'?:"?u'VU"v77t1 name ,«stc.o o. st„.t .no numbe-. ; 

■ a.d: 



) 



FULL NAME 



ytXAAVt'^ 




SRX 



I>ATK or lUK III 



PERSONAL AND STATISTICAL PARTICULARS 



(Mi.mh) 



(Day) 



,.Jil 

(Year) 



\<".l« 



1\ 



)></» > 






Days 



WIDOW K I > ()K DlVoKTHD 

Wiili ill siH-ial iltsiK'ntti'iii) 



HiK riiri, \0». 
(State or Country) 



\AMK OP 

I A Til JR 



HIk IMl'I.Av'K 
of I-AIIIKK 
tStatf or ConntrjO 



c 






•Ix. 



>W\J 



vcrv-v^vv 



M 



M mdi:n NAM1-: 
ol MOTHKK 



HIK IIIPUAOK 
Ol- MoTHHK 

(Slalf or Voinitrv I 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



(Moiitli 




(Day) 



(Year) 



I HERHBY C1':RTIFV, That I atteiuletl deceased from 

|u.A^«. XO 190 M t.) ^I^J^.1.3 190 H 

that I last saw h Am^alive on j'^''^^ '^ ^9© H 

;nid that death occurred, on the (hite stated above, at 5 • 
...CI M. The CAlSIv OF DFATII was as follows: 



CLU^^^ji.^.^ "H" 



K.O>J^rvr:%. 



DURATION •" Vcars "• 3/o;///is ^ Days ^ Hours 
CONTRIBUTORY a.jJrA.^JiJU.y^:^fu^ 



1* 



%t 



Re<tidrif in Sun I i tin, is,. > 4^ ^ ' "' 



\f,»ifh 



/Ki\ 



, XHoVK>.MKn.-KKS.>NA,.rVKTirrKAKSAKK TKIK To TDK 

iiUsT Ol- MV kno\\i,i;d«^k and lU-.IJl-.l- 



rill 



' Infoiin.-mt 



DURATION " y'rms I JA)f///is * An'v 

(SIGNED) 10 0.. TO<XV\nU1 

11^ i(,oH (Addre ss) 111 \)JUXV<^ 

s Insiiii 
or^Recent'ResWents' Vnd persons dying dnay from home. 



"^ Hours 
M.D. 



\ddress) 1 X i \) JUX V<.i at 
FECIAL Information only for Hospitals, Jnsiiiutions, Transients, 




I, 



Former or i /^ c- j .^ . *- 

Usual Residence I ^ ^ VfrCCC^ 

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



J n HoH long at , _ 

A sAaM, Place of Death? » i Days 



I).\ Ji; ol'. Hi KIAI. or KKMO\'.\I, 



IM,ACK Ol' niKlAI, OK RKMO\ Al, 

t NDHKTAKKR ^CrVt^ V ll) A^ 



^>rS-.... 



"""■~~"~~~""^ ..J *rF -Kr^nlfi he «tHted EXACTLY. PHYSICIANS should 

^. „._,.ver.v Hen. oV ln....n..U.on hHouM .>. cr.^u... «upp .ed ^^^^^.^^^ ;',,^:,:^^^^^^ .nVonn^ation" for pT- 

• t»tc CAllSi: or DKATH in pl«in terms, that .t mti> be properly 

ion. dylnft mvoy from home should be Aiven 5n every instance. 



' 'I 



6S) 



r 




ri 









^^^- 



mm 



f:^^ 



™ 




II 



WRITE PLAINLY WITH UNFADING INK 



I'.,,,t.l ..f ll.iilth I N' 



^-Taft^lU*^!' I'. 



Ddii' AV/fv/, IwlcL IH 



THIS IS A PERMANENT RECORD 

REPE R TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

B.e<^isterc(l ^'o, 31.3 



DepMty Hea'th 

DEPARTMENT OF PUBLIC IIEALTH=Cit)' and County of San Francisco 



i 



^\^us 



r* <» ?• 



Certificate of Beath 

( "U. S. StanMr^ ) 



^ 



PLACE OF DEATH: — County of ' ''O^vv ^Ju 



City of 




-VCXXVO; 




No. 



St.; — -^ Dist.;betr 



~and 



, = ^.- IICII&I Rrc;inFNCE GIVE FACTS CALLED TOR UNDER "SPECIAL INFORMATION" \ 
( " ,Vd»Th"cC ".*."'■.', "rHO^S^p"*' O^f^s'J'JV'o'i'^VC ,TS NAME ,«ST»0 OP STRC.T .«,. NU-B.B. ^ 



FULL NAME 




XJLX^ \_/CX/»v. . \J A.' 



JLouJvA.' 



sKX 



PERSONAL AND STATI STICAL PARTICULARS 



^cL 



lUJUu 



l»ATK OP BIRTH 




A(3« 



So 



Yfttts 



II 



(Day) 



Mimlks 



iVear) 



IS 



/)«J V.v 



W I1M>\VKI) <^R T1TV(1R(*Kn 

i Will, ill -MHial lU•-i^'nati<>lI) 



4 



0-^'>V 



IURTHFI,ACR 
'State or Country^ 



lATHKR 



llL 




7> (1 '1 



nTRTHPT.ACK 

<»!• I ATHKR 

I State or Country) 



AIL 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




(I)av) 



(Year) 



I HEKIUiV CKRTIFY, That I attended deceased from 

.^... I9O to ' iqo 

that I last saw h alive on "- 190 

anil that (katli occurred, on the date stated above, at 

AI. The CArSR OF nivATlI was as follows: 

(j^^^vL^-yv<r>\<X.^uj^....J..rV^-^l^ 



nr R .\TION " Years Moutha 

C ONT R IIRTTOR Y 



Days 



Hours 






lURTHPLACK 
<)l" MOTUI'K 
(Stall- i>r Country' 




^^^A:r\JL^^ — 



occrp.%TlOK fy^ 



?rv-uL 



^ n 



Rfsided in Siiti I'l ,1111 i.^m .*- 



W 5V,M 



^r,„,fh^ 



n,)\ 



ini-: Mtovi-, SI-MI i> ''"^^'^^'^^V- ''\'* ' '/, 'k 



'ARTICn.^RS AKi: TKIH T« > THH 



(Tntorrtiaiit 



(Address 






a»-. 



DTRATION Years Jfotiths Days flours 

(SIGNED) VKU) U VOOAV^yvrw ... M.D. 

k^l u \ X TQOH (.Address) %(^iiv<LbA. U-^ 

31 A L Information onl> for Hospitdls, institutions, Transients 



PEC1 



or Recent Residents, and persons dying dway Irom home. 

, obcr\Xs^t>v VOJj- Plare o( Death? S.yl'jA^... Days 



Former or 
Usual Residence 

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



IM ACF Ol- Ml KIAI. OK KHMnVAI, 1).\ ri! o! MiK lAi. <.r KKMoVAI. 

JlHO'^^^vLyi.< 



I'NDhRTAKKR 

(.Address 



, .. , .rp -Kr...l.l he stnteil EXACTLY. PHYSICIANS should 

^. B.-..V.O 1.C V „..-,.r.n...ion .h,.uU. h.- .„.«fun, .„np ... • ^".t^'J";;,''. ^.i:i?":;He "S.^cia. .„for.n..i,.„" ,0. p..- 

iitatc CAIJSL OF DEATH In plum terms, that it m.i> t»e proper.y 
"on, dyini nway from home mHouIcI be feiven In uvery mstance. 



• ^ 



.1 '^ 



\ ^V 






l.ti 



■t 



* i^ 






I- 



ft 



ftk«.«x 



Jlitt 



H.;i)th 1 N 



I )((((' Filed , 

{ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFICATE FOR INSTRUCTIONS 

314 






lA^ 




IH 



V.)(J\ 



llegi.slcred J^''o. 



Xju^Ku Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

1 U. 5. StanDarD j 



Si 



^ 






PLACE OF DEATH: — County of ^^<XAV -Kct^vCUiCC City of (^'Oav -3 ^L^vw^^ c^ 



I^xC 



aLma\u.fl Ibc^^U^t 






\r oi3*T 



^AV FROM 

H OCCURRED IN « HOSPITftL OR INSTITUTION GIVE I 



Dlst«; bet 



and 



' y ••»■•>■ Drcinrfurr riur F»CTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 

,r ot.^ OCCURS A>i,Ay from USUAL RESIDENCEg.ve facts c^a^lleo ^^^^^^^ ^^ ^^^^^^ ^^^ number. >/ 



FULL NAME 




QoiArtrtix. 



<LLi .U.OAarrCr:! 



i-x 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR \ 



^ 



DATR or «!R rn \ 



\XjJr^^ 



wL>^^k 



i»<>iithl 



\(^n 



IS 



I'farx 






MoHlll!^ 



,%1'\ 

(Year) 



Da \'s 



*^!Vr.T.1* MARKflRn. 

\vnH»\vi;i» OK i)iv<»RCKn 
^Wril* ill jwcial dcsiir nation) 



r 




r.iKTiU'i. Xi'K 
stilt* or Cotjiilry ' 



NAMR OF 
lATHKR 



I'.IKTHPI, ATK 
ol" lAlUKR 
•Stale or Country^ 



mmih:n name 

t)I MoTUr.K 



mRTTfPT.ArK 
(State («r Cto«ntry> 



(KCfPATION 



4 



MEDICAL CERTIFICATE OF DEATH 



DATR or DKATH 




II- 

(Day) 



(Year) 



I nF:RI':RV CI-IRTIFY, That T attended deceased from 

M'Wtvi 1 TQoH to ..^.^'^Xu...l.l IqO'i 

that'l last saw h ..<Vm>alive on J^^^^^ '^ ^90^ 
and that death occnrred, on the <late stated above, at 10 3 
(X.M. The CAUSE OF DICATII was as follows: 

'aLrVH>J^;..U..(>^J?*<M^ 



DIRATION "^ Years ..'^Mo>i(fi<; \ ^ Days- '^ Hours 

CONTRIIU'TORV 



.^\rtrLlX 



<XtM 



V 



r 




V^arf '^ Months f^. 



Ha 1 



ni':sT OI' MY KN"<)\VLi:i)<.K ASP Bbl*lfe»' 



\K> AKi: TKii-: r«> thh 



'InfoMMMllt 









DT RAT ION 
(SIGNED) 



I /ours 
M.D. 




)'tars Mouths Pays 

y^ u>o'. (Addres.) Jt ^Qj^^^ ^^ 
^ ""■ .._u-„u,,.^ Institirtlons, 



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

SVsidencf vLlo^r^xUiou UxJu Plare rOeatfi ? 

When was disease contracted, 

If not at place of deatli ? _^ 



Transients, 
^ Days 



ri,AC 




rNDKRTAKKR 

'Address 



UlRIAI. OK KHM<'VAI. ( DA'^I-: <)f^ H' K lAi. or KHMo\AI, 

V 14 190H 

3. O 0<LlL<XAV 



^UO^'^\. 



S05 



vTyVtrvvt/cyvA 



a 



'V-C 



,. , Arr shoulil be «tnted EXACTLY. PHYSICIANS «houlcl 

N. „._»;. ery Item of Information «houI.I h. cre.ull. «upp -e . ^^ ;,,f;7;;^^^^^^^ ^he "Spednl Info.nu.f.on" for pT- 

«tnte CAlISr or DKATH \n plum terms, that it msi> Hl propei .y 

'on. dyinft away from home Hhould be feivcn in every m«t»nce. 



•I 



ii 



I , 






•» 



r:-' 



Mi 



' ^» 



^^ns^f^m^ 






^akj^ 



'r^ 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 



h I V,, * 



".\ ! 



\ Ml 



Deputy Health Officer 



Be^islcrcd J\^o, 



315 



DEPARTMENT 0^ Pl'BLIC HEALTH=City and County of San Francisco 



Certificate ot IDeatb 

i ^ 



(3J 



(No. 



PLACE OF DEATH: — County of "a>^ Va ^vCv«-CO City of^^XX^ ,jV<XavcvACC 



Su A t«st.;!5et.V^u\.>Cr\i 



and U ^-VJU 



"^"^ ^•^^i^-i.^r rr*^^^^^ .^^^^ s^;^^rij:-::;cr ) 



C 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



OATK or MIITH 



ACR 



Ox/vvx<xXu 



IOJUj 









at • 



iWW 



1 



.%/«m4k* 



(Ve{»r) 



5 



/Xtfi* 



trinoWKH OR DlVrtRCKIJ 




niRTHPl.ACK 
State or CounllT* 



) ATin.R 



lUR TIIPI.XOK 
<>l" I ATHKR 






lUH inri. \CH 
• ti M..rnKR 

<Siat«- or 0(M>ntry> 




y KxJLiLAAJtA.vUj L^i^JlAX 



t 



MEDICAL CERTIFICATE OF DEATH 



0ATK OF DBATH 




(Day) 



(Year) 



ThERMHV Cl{RTirV, That T atteivled -U<*a^r.1 from 

«— .— r— — : XgO - ■•■■■ to .rrrr— rrrrrrrrrrrr:rr-:r-- up — 

that I last saw h rrrrr.alive oil ■■- ■ " '90 ' 



and that death occurred, Ott t^e date stated al)«n'e, at - 
r— !!e M. Th« CAUSK OF DEATH was as foll.nvs: 

....P^^^,4A^5iA^^ 



■\ 



Ul R A 1" H )N • years ■■ Mo>iihs 

CONTK nU*T< >U V "« 



Days 



f fours 



[ SIGNED ) .....J.J"i,lU XlI<X/\v<:^ ^C^^- 



Houy\ 



Months P(rvs 

crwthj M.D. 



OCC I' PATIOS 



A*^ 






^rvs4. 



/),71 



TMK x.u,vKSTXTKi..-KK.oNvi ^^KTI^^l,^KS XKi: iKrK n. Tin- 
m-;sr«»i- mv know i.i.ix.i-. and in-.i.ii-.i* 



'InforinnBt... 



CL.J^\^^J 



,-\^X^^^^-vx-U\j 



f\(1r!reK« 



3k^o 



M rU^vvcycrv 



V\XHX|. 



w 



^kXh \'h TQo'i (A.Mn.O U vCr^V-tV'l- lv.^^ 



i 



FECIAL INFORMATION »"'> '"• Hospitals, Inslifuflons, Transipnts, 
(U Rnrnl Rrsldpnfs. and prrsons d>inq anav Um homr. 



formrr nt 
Usual Rrsidrnrf 

Whrn was disrasf ronlrac tfd. 
If not at plarp of drath ? 



Hn\> Innq at 
Plarp of f)patli ? 



nays 



IM.ACKOK IURIAI. "U KKM<»VM, 

f 






nxrivcf niKiAi, <>r kkm«»\ai, 

JLu 1 5 IQOS 

f/D 



N, 



TTT^ ,. , A(;i shoul.l be «t«teil r.XACTLY. PMYSICIAMS should 

B._r.very item ot' infor.n.tion .H.m.I.I he .nt-cU. I.v -"M. - • JJ/ ^^^ „^,,j,,^. ^he "Spe.M.. l,Ho.,„Hf.-.n- W p.r- 
stutc CMIS» or Dl ATM in plHin tcrmn. tlii.t it mn> n propcr.y 
«on, clyinft ttwny t>om home should be Uiven in .very Irmtnnce. 



I 



I 






'^WfT 



-WT'i 







f II. ,,Mh I V 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. ^J^TiTti luKl . ., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

316 



llegistereil J\i''o. 



dL<H.vv6 .Uv^ Deputy Health OffTcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 



PLACE OF DEATH: — County olO iOj-^^ i K<X'^\^^Cl City of CVoAV J^UVYvC^^CO 



i 



^ 



No, OXNA-wa vy 



CHll 




Su 



Dist.; bet. 



and 



Vvavu us. CHlt^'cV>(XAJ M^^^-JSS!-^ i>»ist.; Dei. ; *tiiu ;^ 

f t» nr.TM occurs A»l»V TROM USUAL RESIDENCE GtVE r*CTS CALLED roR UNDCB SPECIAL INFORMATION- \ 
i •' Tr orATH OCCU%V;o',;.''rHO.P.TAL OR INSTITUTION GIVE ITS NAME .NSTCAO O. STREET AND NUMBER. J 



FULL NAME 



nmx 



PERSONAL AND STATISTICAL PARTICULARS 



(n\ ' 



COi»oft y 



'KaX^ 




\J 




ur\jj 



MEDICAL CERTIFICATE OF DEATH 
DATE or DKATH 



DATS OF IlIRTH 



t 

(Month) 



"^A. 



A, 

(Day) 



CV*ar> 



AC.H 



%5 j^tf'i* ^ 



Mttnfkf 



II 



Dam 



S|N*<;!,H. MARKn%D. 
WflMlWKD OK DlVrtRCKD 
• Wrilf in «iocial de»lrnalion) 



WIITHPr*AC« 

(SUile or C«)««try> 



lATHliK 



HIRTWPT.ArR 
ni- rATIlKR 

(State <.r t'ouiitry) 



MAIPTtN NAMK 
«>1 MoTIIKK 



HIRTMI'f.ACR 
nl Mo'PHKR 
(Siat«- or Country) 



It 



,'^V'C^VAr^^J 



•t 



^^AV^^^--^^"^ 



OCCUPATION 



"Cm^ 



at<xl 



Month) I 



(Day) 



(Year) 



I HKRI'iHV CI'IKTIFV, That I alteii.UMl deceased frcjiu 

.H^A/^r\4i....X. 190 H ^"'/\ jV^ ^^^ 

that I last saw h .i/.>.>V«live on VoLu, I ?> 190 '{ 

and that death occurred, on the date stated above, at o I 0. 
...If. TTie CAT'SH OF DKATH was as follows: 




X 




DT'RATTON. 
CONTRIIUTORV C)X^ 



Vats Months 

A. 



Days 



Hours 




nr RAT ION Years 

(Signed) v 



( 



Mouths Pays 



Address) 



Hours 
M.D. 



SPtlCIAL INFORMATION «"'> for Hospitals, Inslilulions, Transients, 
or Recent ResiiJents, and persons d>ing away Iron home. 






1 



)'r,t 



I M.<nth< M f^nvs 



TmAH<>VKSTXTK1»PKRSnNA..rAKTU;ri,VKSARKTRUBT.> TIIK 

ni:sT oi- Mv KNOW 1,1. ix.1% AN" in-.i.ii-.t' 



(In forma nt 







Former or 
Usual Residence 



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



i 



"< / 



,0-tHrtL Ictci ^oSj Place of Death? o b Days 



fl XCl- «)I- lU KIAI. OK KKM«>\ AI. I )A Tl , o! 1!. H i.M. o, K1:M»»VA1. 



rNI)KRTAKKR 



> 



. .. ,. , .pp «hoiiItl be stntcil r.XACTLY. PHYvSICIANS should 

»._,:,,,,. Item oV 1n.'or.„,.tion should h. cnrcfull.v -PP'- ' '^^'^^^^^^'tLj^^^^^^^^ 'Spccinl Information" ?or p.r- 

• tiitc CM'Si: or DI:ATH in pliiln terms, that it miiy be properly cinssmeu. 
«on. dyini nwny from home should be ftiven in every inHtiince. 



I ,; 



i' 1 



,'f 



t 



I rl 




' ii=" 



>HP6tZ?J?' 



.♦^ '■ ' 



i 



»!% 





♦ 



!'.■ 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.,,,f ,.. .HI, I vo :.^'?55^>»-'^'''" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

317 



lUih' Filed , 




oLc^^wC^^ 



L 



\V\j 



15 lOO'i 

Deputy Health Officer 



llegi^tered J^'^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( "U. 5. StanDarD j 



4 (^ 



PLACE OF DEATH: — County 



4 % i ^^ 

of 'O/CU^X) ,\<XAA>Cv^/tCs City of O/a.'Vu OAX^^vvt^LA/ao 



1^ <X<X>\Jb ovO^ 



St.; 



Dist«; bet. 



"and 



/ ,r or*TH odcuBS *w*v mom USUAL RES I DENCE give facts called ron UNDER special information \ 

( ,rOtATHOc"RRtD IN A hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



,V(\jyy^. ^...C:if.voJL<L. 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



mn% 



Q)ulL 



COI,OR 



Ui 




OATE nr lURTff 



S) 



A6R 



^5 



tMotiih) 



Vt'ats 



rlS'K . 

{^y) (Year) 



MttMths 



x\ 



Da v.v 



WIlxiUi:!) OK IHViiKCKD 
(Write Itt mKxml ae«l«ttAl»on) 



( stair <jr CMvuitry) 



\ \MI Ml- 

1 \!mi:r 



mRcuvvouL 



niKTMIM.ACK 
(H 1 AIIIKR 
(Statf i>r I'ontitry) 



M.MDKN NAMK 
ol- MOTHKK 



nTKTiiri.Ari-: 

nl NUnHKK 
(Statt* or Country) 



XY<3L 



C) <C.^VA.XV>vcL 




DATK OF DKATH 




(Day) 



(Year) 



I IIHRrUiV CI':RTIFV, Tliat T attcinled fleccased from 

H\a1u,. 11 190 H to Wiu, I.S.. 190 H 

that I last saw h .4./>^k\»alive on AA>Ji.^xv^ |vvlcy 1 H 190 S 
and that death occnrred, on the «lato stated above, at M 
iX M. The CAUSH OF DIvATII was as follows: 



t*^ *»•#••»•»#•*** *••*•*••* 



DT RATION ^ Years ^ Months 3) Days ^ Hours 

CONTRIIU'TORV LvJLoL^^Q^d^ AJ^^^-^^ 

V^ri\XN./C^^ vlTvv ,..,.......,.„. .......„„,.«.„„.. 

DURATION Years Months Days Hours 

..1)1. i>. UbL<^.cLtaxj M.D. 



(Signed) 



\ 



OCCl'PATION 






1»HST OJ' MV KNOW 1. J. IX. H AND lUJ.Il-J' 



(Iiifoi tnimt 



(Add 






ri<s 



IvS^ TQo't (Aildress) 




^\Vs> 



Ui 



% 



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

SrResidencf Sib U>vwil^^^lwi.-di Place TDeath ? ' { Days 

Wlien was disease contracted, 

If not at place of deatti ? 



n ACH Ol" HIRIAU OK KKMO\ AU 



Olu dL 




(Adiliiss 






-f, 



■"■"""""— """——^ 1^ I ATF «hnuld be stated EXACTLY. PHYSICIANS should 

[N. B.— F.very item of InJormHtion should b. cMrcfuliy «UPP'"^««- J^^^J^ cl««8i«ed. The "Special Information" for PT- 
«tflte CAUSE OF DflATH in pli.in terms, that .t may be properly cl8«8.i c 



-F.very itei 

«onrdyfnft'oway f^om home 'nhould be ^'ven in every instance. 



I 

li 

,1; 



Si 



»% 



i! 

* 1 

■ 






< + 



* 







mMNKKW. 



!V«f» 



'"-"WfY^^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.«,.! ..fn..l.h-FNo ,.i^^-i-lu«^lM„ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 





I 
j 

'j 



II - 

i) ^ 



.( 



i I 







IS 



l',)0\ 



Rai'islcrcil J^''o. 



318 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( XX. S. Staii£>arC> ) 
. — County of ^a>V'lAaAV'CA^CO City of O'CWv 0/vO_/vv<lv<l,CC 



PLACE OF DEATH 

(3? 



(No. .5X1 ^lAO-VvkUNV St.; % Dist.; bet. -J ^vlUnv and 



..ciimi D rc I nr Mr F r iwr r»CTS CALLED FOR UNOCR SPECIAL INFORMATION \ 

( •' rF"orAT*'H"occ"u%rEv;N"rHo^."r.^ ^^v.i^.'i^.^.oTir.v.i name insteao of street ano number. ; 



FULL NAME 



SRX 



PERSONAL AND STATISTICAL PARTICULARS 

C«U>R 



MEDICAL CERTIFICATE OF DEATH 



(kA 



klL-u 



I>\ 1 »; Ul lllKTH 



Q1l 



iMuuth) 



3. 

(Llay) 



(Vcar) 



\nK 



5^ 



J>it#i 



Mofilhs 



U 



At I .^ 



\vn><>\\ i'i> OR i»iv«tKOKr) 

Write in miciMl il«-»»iie««l»**«> 



HIRTUri.ACK 

iSlatf or iuuutiy^ 



1 NTlll-.R 



niK riiiM. \rK 
ol I xniKK 



M \iih:n NAMl-; -^ 
.•I MOTHl'K ( 

inRTTTrT..\f'K 
(H- MOTIIKK 
(Stfttf or Country^ 




>V"WCU 



I 



OCCUPATION (^^^t£^x^^ 






<^>v^u. 




Uhtm OP D«ATll 



[JMoiith) 



1?, 

(Day) 



(Year) 




I ITRRKRV CIvRTIFV, That T attended deceased from 

%% 190.^ to I^W ' "^ '*^ ^ 

tliMt I last saw h ..A-^malive on f-"^^ ' ' 190 M 
and that death occurred, on the date statcl al)ove, at ^30 
Li, M. The CAISIC Ol'' DI'.XTIl was as follows: 

—""• ■ J 



nr RAT ION Yi-ars Mouths Days Hours 

CONTR 1 HI 'TOR V vlA-AX-v-o^<niA.-cvA^v vtlS4 



-4U5UC«X<Oi. 




f^f.i,M hi ^an Frttnrffm \ y^«rs^.-^:^f-'»f''^ 



TI!HAm»VKSTATr:..rKKSONAl rAK1M.M_K\K^AKKTKrKTO 
ni-sT OF MY KNOWl.KIX.h AND Hl.I.Ihh 



/),n. 
THK 



(Iiifortnant 



(Aclflress 



^ if i 



Dl'RATION 
(SIGNED) 



)'t'(irs Months 



IMvs 



t# 



/Jours 
M.D. 



I S r»>oH (Address) b&gj AC VV.KX^->A; O t 



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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



PI \CV: Ol- niRIAI. OK KKMOVAI 



I)\ri"o! MrKi.Ai- or KKMOV.Xl, 

iu,.. 



rWW.l 



INDHRTAKKK 






1 90S 



bl 



^ 



xAV<-<^^\ 



IN. B. 



"■"""— ""■"■"""■"■"""""'""''^ VA AGE «houUl be stateil EXACTLY. PHYvSICIANS should 

-Hvery Item o.' l.,for.n..tinn .hould b. cnre.uMy «upp l.e . ^^f;;^^";';'^^,^,,,. t^Hc "Special Information" for pT- 

«t«tc CMISF Of- DI:ATH in phnn terms, thnt it mii> be propeny v 

^on. clylnft away ^rom home should be fe.ven in •very .nst«ncc. 



h 



I , 









» » 



ft. 



» 



^^^ff^ 




i M 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



}»< 



M.r.l ..f lli-aUh I- S" i «^ ■*'?!5S?'*' "''^** *^'" 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






llcgLstci'cd J^o, 



319 



Ddlf l-'ilt'<l, V^W 15 

DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Cevtiticatc of Death 

( TX, S. StanOarD ) 

SI m ^ ^ 

PLACE OF DEATH: — County ofC\a^v OXCL^xcuiccCity of CV<X>v 0^cc/>v^v^xi^ 
No oiS Ucldov Jalo llv-^^ St.; '3. Dist.;bct. ()V)xj.cLi. and X<X>uk^v 

/ ,r DC*TH occurs .w*Y r»,OM USUAL RESIDENCE give facts called ^or ^nJ>" ;,*^%"^;\' '^'^''^^J';'''' ) 

V ir DtATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAdloF STREET AND NUMBER. J 



FULL NAME 



'Cytw^'Tv^. 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OK 

DATK Ol ItlK 111 



^'^ OOlcL 



Ullvcl. 



(I'Wr 



>M..nthi 



11 

(Day) 



(Yt-ar) 



AGR 



1^ ...„, 1 



Motithf 



n 



Al 15 



HiNfif.p MARK n:i» 

\VII>n\\ Kl» «»K I>I\«»Kt'KI) 

iWritfiii siK-iiil ilcsiK'natioii) 



dx 



>v 



niK THlM,\OK 
(Stiitf «ir C'tunti > 



\\Ntl- «>l 

1 \thi:r 



.^.v^■Ji^Vv^o^ 



1 






II 




(X'W.<L 



AvK^X^UJ->A; 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATII 




I HF^KiniV CIvRTIFV, That I attemled deceased from 
u. IH 190H to. : ' ' ' 190 



Crvv H-vctu VH 



that I last saw h a.^>v alive on )i^^'^H ' "^ '9° H 
and that death occurred, on the date stated above, at "X- '-^ 
^ M. The CAl'SK OF DlvATII was as follows: 

\J/ir\Jtvv^>^^'&->N V a. LLt'^<>'k.^^:S, 



DURATION ^ Yfais ^ Months ^ Days ' Hours 



^xJLA.A^Vd«KV;:>:^<\....J..V.L^>AX.A.\-.!» 



lUR IMIM.ACK 

Ol- I ATMHR 

• State <»r Country) 



MAIUKN NAM1-: 
01 MOT I IKK 



lURTlUM.AOK 
«>|- MOTIIKK 
(Statt or Country) 



l4 



M 






y't'ors 



J font /is 



Pays Hours 



DTRATION 

(SIGNED) VJ. J y^^v^JLLlu^ . lyi.D. 

KUah I5r ic,oH (Address) ^1^ U J ^K^tli) Clt 



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



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



Ml- MJOVKSTMKnPKRSONAI.rVKTU-ri.VK.AKKTKlK T- > THF 
HHST (»!• MY KNitWl.l.DOl-; AND HhUIl-.H 



(Itjfoiniaiit 



On^v^Vt 






(AldroJ^s 



IM.ACK OK lURIAI, OR KKMOVAI 

INDKRTAKKR xLU^V ^"U ll'Wia "t 



DATK of HiKiAi- or RKMOVAI, 

VV.L m . 



TgoS 



r-Sd.lrcss ^Hl*^ ^V^slcAv^t. 



,. . Toe should be stated EXACTLY. PHYSICIANS should 
p,. B._Every Item of ,nform„f.on .hould he carefully sup,, led ^^f^;^^;;.^,,,^^. ^he ^Special Information" for p.r- 
state CAUSE OF DEATH in pinin terms, that it may he properiy 
son. dyinft away from home should be given in every instance. 



'I 



■ n 



1 1 
1.1 



r-:' 




<*^ 



f 1. 



rf 



H 



It. (' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.fM..ih . V. > ^'j??^ I'AIMV. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JVo, 



320 



4) Ml 

jLfrUvvo Ixo^-u. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( TX, S. StanDarD ). 
PLACE OF DEATH: — County of 0/Olo^^ A^Om/Lx^A^U) , City of ^^/Om; J/uvw^a^^c 
N«.vavk t/^vlA.QjL'N'vcu.. Ib'tKifVcial St.; Dist.;bct.- and -— --— 

^^"^ nr.THTcu"s7u,*y r«OMluSUAL RESIDENCE o.v. r*CTS "^^ -« ,7,'>" 3;%%%^;%^'^^^^^^^^ 

t ir DCAtJ OCCU««tD IN A MOSP.T*L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME ob <X/vv>voJk^ Mil', UCL> 




!• \ I 1' or- !!IRI H 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



L 



bJJLt 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

1 H 




(Day) 



(Year) 




iMuiith) 



\C.K 



6 i >Vv' ^ 1 



(Day) 



M.mlh.s 



/SHI 

(Yt-ar) 



1 



Da \s 



*i INT, 1.1' \f\Kun:i) 

WIlMtWIlI* ok 1>!\« >Ki)"I) 

(Write In «oct«l denier 



ijniati<m) 1 • . 



lUK TIUM.Ai'K 

I St:tt' <ii Cpiintry^ 



NAN! J n| 
FA I Ml. K 



lUK rnri. vtH 
oi- !atmi;k 

'St.'itr or I'oniitry) 



M MltJ.N N AMK 
<H MOTHF.K 



^>iLcnv' 




^ V VVvj 



^\J\ 



.Ol/vuX 




niKTm'i.ACF: 

<)»• MOTUHR 
(Slatf or Cntiiitry^ 



. t i 



I 11I-:F<i:HV CIvRTIFV, That I attentled deceased from 
— — 190 to 190—^- 



that I last saw h 



alive on 



190 



and that death occnrred, on the date stated above, at - 
— — M. The CATSH OF DICATII was as follows: 
J AxxctAAAJL Qj CtAJ. Crt 3.)kA,\XA.L, Js^X^L.^^ 

.&A/^>v6'^A-'Vv4xa^ 

nr RATION Years Months Pays I/ours 



CONTRIIU'TORV 



DIRATION 
(SIG 



Months 



Pays 



Mnlltio 



lhl\. 



•rm- MUnKSTA.FI.rKK^nNAI.rNKTU'rj.AKSAKKTKrK TO THH 
lUCST i>l- MV KNOW 1,1. IX'.K AND Ml.Ml-.l" 



[Infonnant M KcL^ VV "^^OJvwtu 



WUy \^ TQoH (Address) Uv^mXA^Uu>' 
SPECIAL INFORMATION only for Hospitals, Institutions, 



Hours 
M.D. 



or Rffcnt Residents, and persons dying away from tiome 



Former or 
Usual Residence 

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



How long at 
Place of Oeatli ? 



Transients, 



Days 



I'l VT}'* OI" lUKIAI. OK KI'IMOWXI 



\) 



chLu VU 



0-QA; 



DATK of niKiAi. or RKMOVAI, 

|vJAx...l..b. 190M 



„,,, abu Uo^ dt '"'■'- " — --^ 

' ^ .. ^ .^F „^„,.l.l he statetl EXACTLY. PHYSICIANS should 

IN. B.— P.vcr.v Uen, o« „.J„rm«.lon .houl.l ... cnrcJu.ly -PP •=-; *';^,,1,' „,i„ed. The ••-Special lnfor„.a.lon" for p.r- 
.to.c CAlISli OF DEATH In pl«in t.rm. th» .t m..> "proper 
.on. .lyin* o«-.y from home «hnul.l be ft.v.n .n .very .nstanc 



\" 






■1 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„.,.!.. ni.,.:th isn ^r^^^^ns^vcn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



:i 



i.. 



/)/(/(' Filed , 



4' -V (3 

d-t^VA-A^ L^t^v^ Deputy Health Officer 



Re^intered J^''o. 



321 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

PLACE OF DEATH: — County of 



\ '(HI 

n<X>>j O.'va-lVCU.ccCity of 'CUYu AXSyvvCAACX,- 




%' 



i ,^u.^xaU>v SU H Dist.; bet. ^UU^\. and '^CLWu^U^^) 

1 ,»^^ iieiiAi or cinrNCE GIVE facts called for under special information i 

( " rr"„;:x-"i'!.'.ro',;"rHos^p"*t o":"tu" ""./.ts name ,«..... or st-..t ... .....n. ) 



FULL NAME 



.Qh.A CLOl-C^^ 




HK\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



DATF. <»r- HIRTH 



Ar.R 







( Month » 



3 



/ ^\ OX... 

(Vear) 



IVrt^s 



1 



1/-. !////> 



II 



/^U I i 



Wtitriii MK'ial «l»»i^naHtmi 



IIIKTIIIM,\ M 

<St«tf nr '■.Hint I V 



\ VMI" « »l" 
I- A TH J.K 



niK IHI'I. \v*K 
nl- lATMKK 
•StHtr or rmmlry ' 



maii»i:n n\mi; 

Ol- MOTHl.K 



IHK TIIIM.AC K 
«»l- MnTHKR 
(Staff or I'omitry) 



C^xaAO; 



■ a 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

a. 

(Day) 




iMonth) 



IQO H 

(Year) 



I HI'RIiBY CICRTIFY, That I attciKlcd .Icccasecl from 

r^^^H *^ 190^ ^"a-W ^*^^ 

that I last saw h . .A^^ilive on |vA^iA^ iS. 190 'i 

and that death occurred, on the date stated above, at " '^ 
.0 M. The CArSI- OI- DIvATII was as follows: 

^%UjCtoJtvdL [j<j^ -syyyj ^J^J^ 






nr RATION ^ Years X Months r. /)avs ' //oins 

CONTKinrTORV 







V\^4Aa.CL 



OCCrPATION 



);-,n 



\t,n)th' 



fhn: 



TMK XHoVKSTXTKl>PFRS<>NAI rXKTirri VKSARl- TK.H To TMH 

in:sT 01- Mv KN<>\vij;i)<".K and hi-.mij 



(Inforin.mt 



IK 



o^y 




OJ\J 



a,,.... laRia lovat^^j dt 



DURATION Years 

(SIGNED) 

JT T()oH 







Pays 



Hours 



Mouths 
(Address) H IH -> M<LO>VV; '. ) L 



M.D. 



FECIAL INFORMATION only lor Hospitals, Instilutlons, Irdnslents, 
orTtecent Residents, dnd persons dying away from home. 



Former or 
Usual Residence 

When was disease rontrar fed, 
If not at place of deatli ? 



HoH lonq at 
Place of Death ? 



Days 



v\ vcF or- m-KiAi. or ri:mo\ \i. dxti;..) m mvi. u, rkmovai. 



rNDFRTAKKR ^ ivC^O<L<rV ^ -OLVK^ 



(AtMrcHs 



-.„».. r-Aiitei- OF OFATH in pliiin terms, that it m»> ne propeny 



mate CAUSE OF DEATH in pi 

«on. clyinft away from home nhould be ftiven in every instance. 



! 



I 



i 



t 
i 



,' 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M.,:.r.lofHe«1th I N. :."^C€?^»«^''^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

322 



4 



lu,i,' l'il,'<l, VvW '^ ^^^"^ Resist eredJ\ro. 

.<frvvA^ ^'^-^l- ^^^'-'^y Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

t "a. S. StanDarC) } 



PLACE OF DEATH: — County of 



City of 




<X/^ 



wJLol 



No, 



St.; 



Dist.; bet. 



— and 



) 



USUAL RESIDENCE Give FACTS CALLED rOR UNOtR SPECIAL INFORMATION" \ 
W9Wf«u rit^ _ ^^^ ^^p NUMBER. / 



/ ^f DEATH OCCURS AWAY FROM USUAL R t S 1 U t. r. v. B. »-. v .: r-^ ■ , ;--"-—■-■-: " 

V .r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVt ITS NAME INSTEAD OF STR 



FULL NAME 




/CX.^^ 




PERSONAL AND STATISTICAL PARTICULARS 



-'i' 



1»\TF OF HIK III 






lU Iv.U 



1=^ 

(I)av) 



(Year) 



ACK 



11 



at 



) III » 



M.ntlhs 



l\ns 



U llMiWKI) nK IMViiRTKn 
\Vnt( ill v.H ial il« siv^tiation' 



niK ruiM.ACK 

' St.)t« 'ir iMiiiitiy • 



NAMK <il 
FATMKR 



Q) 



A 



<^' CL\^ 

OX. 







lUK IHIM.XrK 
(M I AIHKK 
(Statr or C«)»Miti v' 



MAIDHN NAMK 
ol- MOTHKK 



lUK rnrKAtK 

Ol- MoTHKR 
(Slate or Cotuitry^ 






0-1 Oj 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH ^ 



(Month) 



% 

(Day) 



(Year) 



I in':RI':HV CI:RTIFV, That I attended deceased from 

190 to 190 

that I last saw h alive on 190 

and that death occurred, on the date stated above, at 
:SI. The CAl'SF^ Ol' DI^ATIl was as follows: 



yj^yAX'^vtt. 



■^ 



Dl RATION Years 
CONTRIIU'TORY 



Months 



Days 



Hours 



V0VO">V 



occrPATioN (JVf , \ . 






t« 



) V(M 



Months •" /''" 



THK Amn-K ST MFD l'*^" ^^^^ '>-V; l'.),'^ ,',!•,SFF 
HHST<)^ MV KNo\VIJ:IM.K and HI.Ml.^ 



KS AKI-: IRIH TO IMH 



(Itifotniant 






Hours 



DURATION - Years Monihs Days 

(SIGNED). 11.^. X.M\iU.vrU^^ ^ M.D 

QfHcUi lO TooS (Ad.lr.ss) ^VO^-^V^^*^ -* '^ 

rAL INFORMATION only for Hospitals, Institutions, Transients 



or Recent Re'sWe'nts', Vnd 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 



IM \CK OF lURIAI, OR RKMOVAF. DATF of Mt R.ai. or RKMOVAI, 

fAcl.lrrss (?).X\.KJtU<^ Lcvi 



■— — — ^ " V\ AdF Hhould be stated EXACTLY. PHYSICIANS should 

N. B.— Bvcry Item of Information should be cnretull:^ ""^^^"t propeHy classified. The ^Special Information" for p.r- 
^AimF OP DFATH in plain terms, that it mn> t>e propc 3, 



'r:^x:iz °.o^"h1.. :l„m .. *iv.„ > in...n«. 



t 



n 



H,.ni.l ..f III .iHh- I- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

So .t^.^Sj^ni.'tlco REFER TO BACK OF CERTtFICATE FOR INSTRUCTIONS 

323 




H Officer 



licgisteved J^o, 



/}(f/i' til I'd , 

DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( U. S. StanC>arC» ) 



PLACE OF DEATH: — County of 




m 



va\\--VM. a; Cxiy of ^' OXcuJ' VV/^Xi. 



o.LaX wt 



No. 



St.; 



Dist.; bet. 



and 



..<-...■ oeoinPNCC GIWE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\ 
H OCCURS A**V FROM USUAL " ^ b ! D E N C E_G I V E FACTS ^^^^^ .nsTEAD OF STREET AND NUMBER. J 



( " "rE'iTM~OCcJRRtD IN A HOSPITAL OR INSTITUTION GIVE 

FULL NAME ccIkaX) 



\Xj crtrd. . J\lli 



UJ. 



1 t1 



. I 



sKX 



I) \ ri: «)i lUK 111 



PERSONAL AND STATISTICAL PARTICULARS 




cc 



I Mouth) 



q -All 

(l>ay) <Vear) 



K<\ K 



IS 



)..i> 



W I!K»\\i;i> OK DfVoRvKD 

Wiitr in s<K-i!il i)t sivniilioii) 



BIRTm'l.ACH 
tStatf f>r Country^ 



NAMK OF 
!•• ATHl.R 



^ 

A 



Mout/r 






/)«/ V.N 




V\T. 



lUKTMIM.VvK 
«)1 I \rilKK 
(Statt or Country) 



MAIDKN NAMK 



I 

.^ I ) ^ 



Wl 



a 



'>^^\CiO 



\X v),Ltt^vt\> 



BTRTHPI.ACK 

OH MoTin-.K 

(Sl;(l« or i'cMiiitiy) 



\|) 0-^tcr>V' M I ^ 



O^A-^ 




DCCll'A TION 
A' 



..11 )V.;/« U .V-M////V 
?fsttir,1 III S,ni / 1,111. !>'•<> ^ S > "" 



/hi 1 > 



(In 






xUv 



( Afldrcss 





MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



fonth) 4 



AX 

(Day) 



ipo H 

(Year) 



I HRRHBV C1:RTIFV, That I attended deceased from 

to ; ...I90-^^ 

190 — — 



I90 



that I last saw h .r— - alive on 
and that death occurred, on the date stated al)ove, at - 
— M. The CAl'SIv OF Dl'iATII was as follows: 



.UU.ivlv^.vt^^. 



1 



nrRATION y^ars 
CDNTRIIirTORY 



3fo}if/is 



Davs Hours 



nr RATION Years Months 



(SIGNED) 







t\) 



Days 



^ 



[fours 
M.D. 



SPECIAL INFOR 



M ( Address)V? fr^^^i^^^^^ J.A a^ 



J MAT! ON only for Hospitals, Institutions, Transients, 
or'RecentlRcs'idents'Vnd persons dyiny anay from home. 



IsuTResldencf ^3- 1 "^ \tr>AX^ 

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



J How long at 

.0%. Place of Death? 



Days 



I'l \CK OF lUKIALOR KH.MoVAl 



w 



INDKRi'AKKR 



DATHof lU KiAt- or KKMOVAI, 






(Address '' I *1 Ci 1 U 







v.Lo *"- A 



" T^x ATF should be stated EXACTLY. PHYSICIANS should 

be cHrefully supplied. AGE «»^""'*' "« ^^ _. -Soeclal Information" for p.r- 



N. „._Bvery Item o.' Information .hould ^^;^^;^^ T^'^.^Z p;o'p';rly classified. The "Special 
.. . r-Aii«r OP DFATH in plain terms, inai n •••"J 
""i^'rf.'i l?r from h„m. .ho.,..l he »iven in .v.ry in.t.nc 



«on« dylnft away from 



? • .. 



I 



■t 



< ' 



I. 



mmmmmmmm 



WRITE PLAINLY WITH UNFADING INK — 



|!..;ir<1 of lliiilth- I- N' 



"m^Z^ ]\Si V Cn 




(^vc<<.<5 




lUO'i 



THIS IS A PERMANENT RECORD 

R EFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



>• r. 



I)((h' Filed , 

i 

DEPARTMENT Of* PUBLIC HEALTH=City and County of San Francisco 



O^Vi 



Certificate of Beatb 

( XX. S. StanDarD ) 
No. ibai i'.avovl' St. 1 Dist.bet^-lU'vtl andilvLt^Vv^i) 

FULL NAME 'vJ)avWh..a. /lix^frCLi*. JV>va^^>.\.t'v 



PLACE OF DEATH: — County of CV >V 



CALLED FOR UNDER SPECIAL INFORMATION • '\ 
ISTEAO OF STREET AND NUMBER. / 



•^KX 



PERSONAL AND STATISTICAL PARTICULARS 

1 C01.0K 






DATK «>l lUK I il 



L 



lOJvvU 



Qu 



CtvL 



a<;k 



dA ).</»> *^ 



(Day) 



Motilfn 



(Year) 



1 



na\> 



MEDICAL CERTIFICATE OF DEATH 
DATH OK DKATH 






I go 

(Year) 



WVU, 1 5 . 

(Aonth) \ ^ay^_ 

iTlKRHHV CIvRTIFV, That I attenacd deceased from 

1.5. 190 H 

15 



.v-Lu 1 3 



\vnn>\vi'.i> «»K i>;n < »ki i- 1) 

(Wtitr ill •■•Hial i!« HitfiiHtioii) 



lUK riHM.Av'K 

' Nt;it< Mt (.■ilintl > 



NAM I- <H 
FATm:K 



niKTMIM.XCK 

01 I \rnKR 

<St:tt«- <>i i."(»iintry) 



MAIUKN NAMK 
ol MOTMKK 



U) 



cL 



CCC^vv^ 



I 



oxv> 



wcc^vv 




3- 



m 



-Vex > 



x\,cra^ 



\.'CX 



V^VAwT^\^ 



lUKTmM.Al'K 
<U' MoTHKK 
(Stati- <ir Ctumtry) 



OCCri'ATION 



y/,»iths 



lUns 



T.IKAI.OV,.STVrK,U. KRSONA.. rAKTU-.r l.AK- -^X ''^ TH,-: r. > TM... 



l-.KST;;rMv^KNoW.:i:...-.KAN.. l-l^.na- 



(liifotlitaiit 



< V.Mrr';'* 



bll 



190 M to..> 

that I last saw h ..tt^.' alive on J^^"^^ 
and that <leath occurred, on the date stated above, at 
\X M. The CAISIC OF DlvATII was as follows: 

SJ.^VAXcrwv.^Xv.o 



190 



1.0 5 



DIR.^TION " Years -^Mouths A Pays 
CONTRIIU'TORV U CT^^'^^^^^ 



Hours 



-VN.^. 



nrRATION - .>V.^;-. ^..Jlouths a Am ' Hours 

U ILCXA; cvt.^>vr>^j M.D. 



(SIGNED) 

15 



IC)0 



,04; 



S (Address) 






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

How long at 

fTfoLnr, Place of Death? Days 

Usual Residence 

When was disease contracted, 

If not at place of death ? .__ . 



)r RKMOVAI. 



p, •? V^L n 190H 

351 ^<3.vvAX4^.....dA 



INDKRTAKK.K 



(Addn"*- 



N. B.— Bvery Ue™ of „.for,n„.lon .h„u,.l *>_'^-'_''-»_\ ^^f^r^ „;o7erirc.a..Vfl.U. The -'Special 



clTsE OF DEATH 1„ pinin tern,., th.. U m»> be proper 
.^I'l"!?! ,°^™ hi* -hould be tiven in ever, in.t.nce. 



,... .OB -..a b. ..au. BXAc^^^^^^^^^ .rrjfr.vrpr'r'! 



State 

Mon* dylnft awav from horn 



• \l 



•i 



A '.'i 



h-i 



1;, 

ili 

■■A 



h ml 






H^ 



:'r4 



r 1 i 



# 




WRITE PLAINLY WITH UNFADING INK — 



„..,...i..f n.iiith » \" ,.-*-.»>.-*> n^ I' ^■" 



IfJO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OP CgRTIFICATg FOR INSTRUCTIONS 

325 



( ' 



Re^Lstercd JSTo, 



DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



Ccvtificate of 2)eatb 

( tl. S. 5tanC»arD ) 



PLACE OF DEATH.— County of^a^. 1 V£Lavc^W> City of OCt^v OA^v.:^^^^^ 






TM IMl. ri-Ucldr>v St.; a Dist.;betIOaAc^t^Yx and KLC^A^r.- 

NO. IVlb .V^^rVV^r^V „ ..^uA. residence G.VE F*CTS called for under "SpicAL .N^ORM*T.iiN••^ 

( •' rF^;7..rocc"R;r;.H"rHo"s^""L o%"^st',t "^^^o.ve .ts name ..ste-d of street and .u.BEg ; 



FULL NAME 



.t\.AX' 



PERSONAL AND STATISTICAL PARTICULARS 



I \ 



<hlo. 



DATK or- HIK in 




COI.OR A 



X 




< iNiiiiith ) 



\< I-; 



O \ ) >./ » ' 



3 

(I)!ty) 



Mouths 



( Vfar> 



ID 



/)(: \s 



siN<.i.!- M \kutt-:t> 

W IIH ►\VKI> «iK I»;VoKi i: I) 
(Write 111 !»ocii»l (k-^iKnalJ'in) 



HIK rniM.viM-: 

I stMti <ir Country* 



-V^^ 




FA rill. K 



lUK rnri, ACK 
oi I xrnKK 
(St.itr or L"«.nulry) 



mmi>i:n namk 
(»i MoTin:K 



lUK rinM.ACK 
<>i Moriii'.K 

^Slat«' or C'lmnti v> 



OCCri'ATION 



\ -i 



MEDICAL CERTIFICATE OF DEATH 



DATK OK DKATH 



lojith) 




I '■♦ 
(Day) 



igo : 

(Year) 



I ni<:RI':HV CI-RTIFV. That r attetuled deceased from 

to 190 — 

--—--r-rrr-rrrrr-rr--rr-r'rrr-—- I9O ..— 



190 



XN^AAX; 



t^ 



>V< 



"^w^V^t-l 



t! 



'^JUU 



W^^XJX^ 



.>-^^JL^' 



h'rtdr.l in '<<nt I 1 '!'>> >''''' 



I S r,,M> b M.>„ths 'XC/>./v, 



ni:ST Ol- MV KNOWI.l.Dt.K ANP HI. Ml. I 



(Itiforiuiiiil 



'\<1.1i.- 






n b b VJ /<x^vV ^'<: 



that I hist saw h .^rr-r- alive on 

and that death occurred, on the date statcl above, at 
.rrr-.-M. The CAI'SI*: C)P Dl-ATII was as follows 




Df RAT ION Years 

CONTRIIM'TORV 



Months 



Davs 



Hours 



DURATION 



w 



Years 



Months 



Davs 



( SIGNED ) .iv-wdU^^^V^ U. W 



^vvW 1^ looH ^ •^'^■^--'^^^ ^ ^ ^ ^xJXlk^ 



I /ours 

M.D. 

^1 



S'PEClkL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dyinq anay from home. 

, „, HoH lonq at 

Former or piare of Of ath ? Days 

Usual Residence 

When was disease contracted. 

If not at place of death ? - 



I'l.ACK OI' lURIAI, OR KKMOVAI 



'<V'VU 



INDlCRTAKKK CXA, 



X<l.lr.-ss 10.b ^(? 



DA'Pi: >>f HruiAr. or KI-.MoVAI, 

W lb iQOi 



n/cx/\ 



<<x.c>Xv^^ c 






U^ 



A EXACTLY. PHYSICIANS should 



"n';..^ aw°r *rL hen, -houM be t'-v.,. l » in.t.nc 



WRITE PLAINLY WITH UNFADING INI^ — 



II,.., 1. 1 . f II, 'ii'i ' ^ ' •' '^ 



my^> Il,\ V Co 



Vctu I S 



m 



1 



lOO'i 



/)(ffr /v7r^/. 

DEPARTNENT ol= PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CCRTIFICATC FOR INSTRUCTIONS 

826 



Keglstcred J\^o, 



w\^ 



City and County of San Francisco 



^A 




Certificate of Beatb 



■a. S. StanJ>ar? ) 



Na 



la'S'x 



H^ 



(I 



•i.rv>v 



St.; ^ Dist.;bet. t> tn) 



-? 



PLACE OF DEATH:-Coun,y or^V.V .Iva.vcv^cGty of ^^^.C^vv >!xa..v^cc 



and \ 



± 



) 



■i 



I. 

i 



( ■' -•o»,°"cc:.%r;,"r-o"/r.t i^vB^J^^^"^^ .-» "" '^^^^^'^^'"' > 



FULL NAME 




e -p 



V. 



an.u Xd .V 



3 



cv^^ 



1 



c, V 



PERSONAL AND STATISTICAL PARTICULARS 

■1^^ iT!7\ 11 \ \ 






^ 



LUvcU 



•) \ 1 I ' •! ! UK ill 






'!):iv) 



iVcar) 



\< . I 



^^ )V.M 11 ^/""'' •^•^ 



Da\. 



MEDICAL CERTIFICATE OF DEATH 



I).\TH OH ni:ATH 




Month) 




IH 

(Day) 



(Year) 



».|N«.|,K MAKKll.n 

\\ II>o\VFI> <»K J»!V«»Ki Kll 



W n>o\VFI> <»K JHVoKi Kll h 

I Wiitt in -H»;«! h ..JKnHtion) n y 



„ I 



HlRTHlM.Xv'l 



\\MK nj- 
I- VTHl R 



luk riii'i, \^ K 

(»(■ t AIMKR 



M MltlN NAM)-. 
(»F MoTHKK 



lUKTHri.Xi 1. 
iSlatf or i."ouTitry' 



(H\TI'\ 1 1>»N 



1 

\ i ! 



' ) .ccivvc^ 



C>Vt'LOw'>v<v 



I HhRIUiV Cl-RTIFV, That I attended deceased from 

a^xvU o.\ ,9oH to }r^^ ^^ ^^ ^ 

tliat I last saw h ^V alive on ^vU^ l^ igoH 

;nid that death (^curre.l, on the date stated above, at I 
OL M. The CAVSK j;^!' DIvATIl was as follows: 



DIRATION 1 Years - ^fo>,nr. ^ ^^-^'^ * ^^''''''-^ 
CONTRIIU-TORY U) rUlr JUA^ 




Rfsidf,1 III Sav Imnxs,.^ c<\i . 



HKST OF MY KNoWl.hlX.K AND HI.lJl.^- 



( Inf' >; maiit 






VO.'W 






.1 O^VA-t^-vv " 



Q^ 



niRATION 
(SIGNED) 



Ytars Months Pays 

3J • . VjUxaamj.. 



Hours 
M.D. 



iu i Hr^H (Address) lltO^^a^vl^^- ^^ 
<^«*>ECl'kL INFORMATION only for Hospitals, Institutions, Transients, 
or ReTent Residents, and persons dying away from liome. 



How long at 
Place of Death ? 



former or 
Usual Residence 

When was disease contracted. 
If not at plac e of death ? 

I'l.ACK OF lURIAI, OR RKMOVAI. 
FNDl-.KTAKKR >^^ 



Days 



DATKof IlTKlAl. or REMOVAL 

|vJLu lb T90H 



(Address 



1C>5^ 



C\>\v 



v,a.*-^r>^ 



^ '"** rTpXACTLY. PHYSICIANS «hould 



I » i> 




1 



!',■:, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,.l ..f n.;iUll - >■' No '^^^7 



i!: IIS; I' Co 



Registered J\!'o. 



\l>nle File,!, Vlu 15 ^^^^ 

l^io ii^u Deoutv Mp..*h o-i-.'.r 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 



^ 



PLACE OF DEATH:-County of a .^ W-vc^CC Gty of C^aA.,dAX^t.^A^ 



1 










) 



FULL NAME O^cu^vK 



I 



sj \ 



PERSONAL AND STATISTICAL PARTICULARS 



LL'-AvCtA- 



!) \!| or IMK 11! 



\ < - J". 



5 a ,v,.. 






11 

(Day! 



y/.,nffi' 



(Yrar) 



15 



/)(/i 



\vin<»u i:i> uK i»!\ < •»•'« j:i> 

Writ*' ill •Mtcial cle*i»fnHli<ii) 






mKTH»M.A»'K 

i Stat<- OT '"■ iMIlt I v 



I A I 111. K 



inRTHIM. \rH 

ni' I AIHKK 

' St:itr "t Ciiimtt v 



MAIHI'.N NVMJ. 



lUK rMIM..\rK 
(M- MnTlll'K 
(StHtf or C'owiitt \ 






MEDICAL CERTIFICATE OF DEATH 

IH, 




(Day) 



(Year) 



I m':RI<:RV CI-RTirV, That I attended deceased from 

\.y^x as 190H *'V- 1^^--^-'' '^' 

tlia't I last saw h ..W.>valive on ^^H^ ^ '^ '^ 

a.„l that .Uath occurred, on the dato state.l above, at \ I Ci 
l\ M. The CAI'SIv Ol' I ) I*: AT 11 was as follows: 



tl 



X^^^^s-^ 




CUL^H' 



(^.V^V<X 



,^v>vC 



avCa. 




»n'CfP.\TION 



(?- 






<Xy^ 



-cL 






^'.7 ; < 



*■ \f.,titli- 



I hi \ 



^^TT^^ 






DIRATION "^ )V(7r-? 
CONTRIBUTORY 



Months IH /^rti'.? ' //(^wr.? 



)V(/r^ 



Mouths 



f,a.%<.a 



DURATION 

(SIGNED) - - - p ^ 

15- ronS fAd<lres^-> UXu 

onlv for Hosp 



Pays 



I /ours 
M.D. 



SPEdlAL INFORMATIO 

or Rfrent Residents, and persons dying a^ay from liomc. 



Former or 
Usual Residence 

Wlien Has disease rontracten, 

If not at place of death ? 



i^\uJiAX Bt PllteofVeatli? \^ 



Days 



,., vcK OV lURIAI. OK KKMOVAI 



I)\Ti:<)f H' KiAi. or KKMOVAI, 



^^'''''''"' ^^^ ' » I FXACTLY PHYSICIANS iihould 

. ........ -..-jU;S-::s -r:. £:-;~^:" ~ --- — ■ •" -- 

BtHte CAUbC OF Utw^ 1 ,j 1^ ^i^en in -very instance. 

none dylnft «w«y from home Hhouia ne k - 



\ 



1 1 




I 



1 




i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^«.,,..fM..M„ . N., ;-,iS.ggt,.H.^.T.. WtPER TO BACK OP CERTIFICATC FOR INSTRUCTIONS 




I)((fi' Filet I, \jsXka \^ 



190^ 



Xtr\^cv^ loLwu Deputy Health OfTlnsr 



Registerecl J^o, 



3^8 



if PI 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtiftcate of 2)eatb 

( XX. S. StanCatCi ) 
PLACE OF DEATH : - County of a >v J XO^^vCV^ c c City of Oa^ ^ AXX^uc^co 



tl 



and ^ 



ti. 



fj llUCN Vu^Vcia>vt St.; S Dist.;bet. b U\; and I ^V 

No, DV^^ VU. WAX>V^ u<>UAL RESIDENCE GIVE FACTS CALLED TOR UNDER 'SPECAL . N FOR M AT.O N ' ' \ 

( " ^.1rc:Trocc^^;ro^'.''rHo^s^.y/AL o^^Lif.'^^.'ioVi.. .ts name .^stead or street a^o .umber. ; 



FULL NAME 



'l.\ 



PERSONAL AND STATISTICAL PARTICULARS 



ft^aL 



.L' \\<Ll 



I> \ IJ: < >I III KIM 



I J 



rU\ 



'M'.tith' 



Day 



\' .!•■ 



bS )'•- 



Mntith:^ 



(Vc-ar) 



Day. 



v|Ni I J- M \KK IKP 
WIIM.W |.I> OK I»IV<»R*Kr> 

Wilt' in '■iHi.!', !» •iik'Hittion) 



lUK rmM.AOv: 




n 



' St:if »• <>t •"■•uiM r\ 



NAMl ol 
KATHl'.R 



HIKTfUM.At'H 
(»|- I XIHKK 



\! \ 11 ) I : N N A M » . 
iM MOTIIHK 



HiK rnri.ArK 

nl- MoTIIKK 
(St:itr «»r Ccuuili ^ 






/vc-crv ^'^x' 



r>VwUX^VL/cL 






Ihi 1 A 



OCCUPATION 

<„„„„ OKv^. V^ta CJX' U^^ 



/ ^.Mrt's^ % io \iU \-HO./>vt 



;k 



MEDICAL CERTIFICATE OF DEATH 
DATH OF DKATH 

I H. 




(Year) 



I ITI'RKRV CKRTIFY, That I attended deceased from 

.. Wlu q 190H to . W^ '"^ '^"^ 

that I last saw h ^w^ alive on f^^^ ' "^ ^^ "^ 

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



_A.{n\. 



DIRATION Years Vo.fAs Days^ Hours 



\jL-vvVvv 

Years Mouths 



DlKATiON 
(SIGNED) 

KWU I5r ic,oH (Address) 15^^!^ 



Days 



Hours 



NLtJ'Vv'>v <v 



.OuQL0^^y\) M.D. 



=»PECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from fjoroe. 



Former or 
Usual Residence 

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



How loni] at 

Place of Death? Days 



ri,AC£pF m-KIAU OK KKMOVAI 



DA IK of HiKlAL or KKMOVAI, 

Ntwiu lb 1 90H 

.NUKKTAKKK %^ ■ ^xJv^Vlc , 

VfrVv-Qt/ft^rrv CIA. 



fAcl«lii-ss 



H^l 



'_^_^^___^^^ ,A—i — — ^— — —— — ^'^'''"'''*"™'^ . pxACTLY PHYSICIANS should 



State CAUSE OF Dl:« ... - »-■";•-..._„ ;„ «ver> inHtsnce. 
son. dying away from home Hhoulci be fe.ven .n e • > 



f f 




•» 



! I 



J 






♦ <^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



B,wr.l of llt-alth- !• Vn -^ ■^V^Tl.-^' '"^ '" * 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered^ J^'^o, 



329 



J) o () 

X^vcv^ V'vvv,. Deputy !«-^ -h o'^-'-r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 2)eatb 



( "U. S. Stan^arD ) 



PLACE OF DEATH: — County 



No. WX 



a- 






t 



St.; ^ Dist.;bet. l^^^l LUU and ?) 7V<1 U> 



./v-i. ) 



(ir ot«TN occuns »w»y from USUAL 
IF OCATH OCCURBtO IN A HOSPITAL 



RESIDENCE GIVE 
OR INSTITUTION GIV 



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



FULL NAME 



LL:\-V 



'6j\x. 



■UJ 



r^- 




Xi 



PERSONAL AND STATISTICAL PARTICULARS 



Ii \ 1 r < »I lUK IH 



\< K 






lU.Lt 




'Mi.mh> 



1L-. 



/111 

(Vcar) 



71 



)> lit ' 



1 



M.oith^ 



V. 



fhns 



*^IN«.1.K MAKKIi;i> 

U IIX t\\ I- l> MK DIVoKiFI) 

'\\tit> in *«>« jm) >lf oik'iialii'ii) 




., I 



lUK ril»'I,A*'K 
fst;(t« xj <.".«utitry' 



s \Mi-: Ml 

FATIIl.K 



lUkTnri.ArK 

ol- lAinKR 
(St;il«- or rmintry) 



MAIDKN NAMI-: 
<»| M<)rili:R 



HIkTmM,A(*K 
III MDTIIKK 
(Statf or Country^ 



{XXtlvo.^ ) xiLVA^-k^- 



CrVtv^aM- 



MEDicAL CERTIFICATE OF DEATH 

DATE OF DlvATH 

13. 

(Day 
I III':rT\HV CMvRTirV, Thai I attenfled deceased from 



^V 



i 



1 



IC> 



190S 



to 



Wiu 



.1.3.. 



190 H 
190H 



that I last saw h A/V»\ alive on ^-^^^ ^ 
aii.l that .Uath occurred, on the- dato 'Stated ahove, at l ^ "^^ 
^ M. The CAl'SI-: OF I) I- A Til was as follows: 

LL\VCVVA^VOW...U.X^Lfr'Vs^*i 





OOCl'PATION 

IS r,;;< •*• Months "^ /'<" 



UKST «)!• MV KN«»\VI.1.D<.K AND Uhl.H.I 



(Infotniaiit 






nrRATION >>«'--? .Vouths nay's Hours 



^fVrriHL\-rj. 



Mouths 



DURATION J'i'V^ 

(SIGNED) - 



,(J,ili)a..L.I< 



/?r?j'.9 Hours 

M.D. 

AWJi/Vvfc" .^.. 



.U in ic)0"\ (Atlciress; <«> V 

^SPEfclAL INFORMATION only tor Hospitdls, Institutions, Transients, 
or Recent Residents, and persons dyinq away from home. 



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



. Cci^p-'sX^A' ^^-C!L. 



I'l ACK OK BIRIAI.^OR RKMOVAL 

.W-^AJ 

l-NDHRTAKKR V^ vU^X^ 

(Addri'^s 



DAT1-! o!" IJi KiAi. or KlvMOVAI, 
Wiu IS IQOS 

V>\^ CLLL.ii^...ii 



^— ^^^^■■'■^■^^^^■^"^^^'"^^^^^'"*"^^'^^^"^^^ * I FXACTLY PHYSICIANS should 

„ „,• ln«„r,n,.. -oul.! be c,.r.«uMy .uppn..i. J'^^^;;'^!^^^." "t^.^^ "Sp"'-' Intormo.ion" »«r pT- 

SC OF DIIATH In plnin tcr.„. tha .t mn, ^'^'"^ 



N, B. Kvery Item 

state CAlISt ui ui -* • " - *'•"• :."-:_„ ,„ ^very instance, 
pon, dyinft ^way from home Hhould be ^.ven .n e^e^y 



I 



.ti 






I 



4 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,«,.!..( H.ithr v.. ,.^-r?S?^>l.5.!'^ REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 




rVK^ 



I 



I)(ffr Filed , 



IS 



U)0^ 



Be^istered J^o. 



330 



Dc 



DEPARTmENT OF PUBLIC HEALTIi=City and County of San Francisco 



Ccvtificate of Bcatb 

I "a. S. 5tan^a^^ ) 



PLACE OF DEATH: — County of "'<X'>v. ax<V>vc^4-co City of 0<v>v O^a >vcc4/cc 



^ 



No. ^'3^1 'O.Upv.fv^-'. ^ 

/ tr dMt 



^ f 



St; IC) Dist; bet cL^rV-CKa- and J^VaUnvfO 

,-^i^ llCiiiAl RFSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" A 

^iio:::^v^::^o::v^ot:i^ :^^.ii^.':^^"-^o.\... .ts name .nsteao of street ano number. ; 



FULL NAME 



^ 



^y\) w-'^v-i 0/C 








PERSONAL AND STATISTICAL PARTICULARS 



"i' 



DATi; •>!■ ItIK III 



u 



LO.l.-u 



\t..iit!i|i 



15 il^\ 

I Day) (Vcar) 



.%r.F. 



Ha 



) III* 



w 



Month' 



as 



A/1 



HiVOf.l?. MAKKIl.n 
\Vn»«i\VKI> OR I>IV«»R<Kl) 

\Vii1( Til v.K-iMi (IfvivMiationI 



^ 



W^iLcL-. 



HiK rin'i,\*'»". 

I statt or t.'"»uitry^ 



NAM I". «>l 
I- AT 111. K 



HIR IIII'I, \*K 
<)l- I ATHKK 
'Stale or Cotuiti n 



M MDKN NAMK 
(II MOTHKK 



HIK rmM.Ati-: 

nl M«»Tm;K 
(Slatr or t."oniitry^ 



OCCl'PATION 

A 







fl 



(TVV^ 



C>.VlLcu>vc)^ 






M,>nths ' /''" 



T.n.xn,>VKSTXTKnrKK.nNA.rAKTKrj.XK.AKKTKrK T.i TMK 
HKST ()!• MV KNOW I I.IM.K AM) HhMl.f- 



(Iiifotmant 






MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH ^ ft 

/uJLu 15 190^ 

(Month)/] J^"^^"^ ^'^'*'''*''^ 

ThI'K l':i'.V CI'IRTIFV, That I attciuled deceased from 

V^W *' i^pH ^''(\ It^ ^^ ''^'* 

that I last saw h X^ alive on ^ t ''^ "^ 

and that death occurred, on the date stated above, at I * 
.: . M. The CATSl^: C)F I)I<.\TII was as follows: 






1 



DTR.XTION - Years ' Mouths ^ /^tfj'.? 
C ( )N T R 1 1U'T( ) R V 



Hours 



DIR.XTION ^ Viars ^ Mouths 3> Pays ^ Hours 
QfYUxs . . CI . 2).0LAvaxi M.D. 



(SIGNED) 






Vdul5 rooS rLress) '^(^^<^'^^ 



.c\ !■:) rqo 
"dlAL INF 



FECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or^Recenl 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 oi Death ? 



Days 



IM.ACK OF HIRIAI, OK KFMOVAI. 



DA Tj: of HiKiAi- or K1;M0\AI, 

v\.w lb TQOM 



1 






:-S.. 



fAdtlrcss 



^^^^_^_^^_^^^ — ^M^^^M™^^^^—^^™^^^^^*^^"*^^*"^^ IK t t ! EXACTLY PHYSICIANS nhould 

state CAUhP: OF pLAlli m p instBnce. 



■F. 
sta 



• dylnft away ^ror- home Hhould be fti^en eve > 



> 




WRITE PLAINLY WITH UNFADING INK — 



Bonr.lof H.;.H». » N' '' 



■at^'o li.'v P <■'> 




/Xlfr l-'ilfil, ^ivlu 15 

1,.... n 



1 



■) 



lOfA 



THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

331 



Registered JS'^o, 



<r\wCv4 v^vvu. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

of '"i-a-rv. X<X'V\/i oi c ■. City of 'O/CUw ,fUXAvO^Cx 
iM '^l^'^U. . . St.: 1 Dist.;bet. Ot^ckta>^, anda3-M^r>vt ) 

FULL NAME .— ^.^ 6^ 



PLACE OF DEATH: — County 

i 

(\r DtATM ( 
XT Dt*T 



"''oCcJnVtO IN i MOSPIT*U or institution give II 




1,\ 



PERSONAL AND STATISTICAL PARTICULARS 
j» i COI.uK 



0^ 



LL'^lvctx 



. \ II • »r lUKi 11 



Motilbi 



\«'.K 



O ^ )Vfi»< 



1^ 



V. '»////' 



/ISC'. 

(Year) 



<5 



ATI 



--IN'.l.i: MAKKIKIV 

u iiM>\vi:i> OR n!voKi'ji> 

,Viit< ill •"•ciill «le»i|C"«''"l' 



HIKriU'I.WK 



NVMI ni 
i XTMKK 



liikrm'i.MK 
Ml » \rnKK 

' stii' ■ii roniitry 



M VinKN NAM! 
.»! MOTin-.K 



lUK rm'i.Ari: 

ni- M<»lin".K 
(Statr "t lOiJUtry^ 



OCCUPATION ^ 



\J I VccVvwUv. 



ck.(r>vao 



.^^tK 






1 







'\VVw<X 



Lcc) 




3 O^A^AJL*.-vrv 




I I Vnj 



I s 



}f„>,f/i.^ ii /'" 



■'■"ii,>^';"y^^!'>^'K^:.«'^;^^"'K^^»''^"-"^'' 



(Informant 



i»Ki.n:i' 



\ 



.Oj 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 




IH.. 

(Day) 



( i 



(Year) 



J IIRRRBY CKRTIFY, That I attended deceased from 

1jJ)-V^<X\M. ...l.^.igoH to ...IH.1:vJh. 190 S 



that I last saw h -^V alive on 
an.l that .Uath .)ccurrcd, on the date stated ahove. at ^ 
^f M. The CAl'SI-: Ol' DIvATII was as follows: 



/)avs 






Hours 

rVA. 



^fouths 



Paxs 



Hours 
M.D. 



I )r RATION >V«'''-? 

(SIGNED) LoA^Lo J /CC-^-nJCriytU 

. L. IH .nnS fAd<lress) ^ 01 U)/xX\^ cH 

FECIAL INFORMATION only for Hospitals, Institutions, Transients 




or Recent Residents, and persons dying away from home 

HoH lonq at 

f^r'".""'',. Place of Death? 

Usual Residence 

When was disease contracted. 

If not at place of death ? 



Days 



I'l.ACK Ol- lUKIAI. OR kl-MnVAI 



DAIl-!")!" Ml KiAi. <it KHMOVAI, 

Qlvl.L n 190"^ 



J^l'i ^KXX^^ 



1 5 an 3t»':.M<m,..0l 



Address 



^— ^— — ^— ^ * * 1 FVACTLY PHYSICIANS should 

«t«tc CAlJbC or j>f-y"_^^^ ' . , . ^^ ..,^„ 5„ every instnnce. 



.0 



«on. dyinft nw»y from home nhould be i. 




I 

f 




Hoar.! .-f !!■ .lUi I "-' ■ ' •• ^"-l^S? 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.. is:r-S:Xi.nKViu REFER to back of certificate for instructions 




liegLsiered J\''o. 



332 



Xfr\.ccA ^t^'-M^ Deputy Health OfTlccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

1 H. S. StanC>arD ) 



PLACE OF DEATH: — County of 




\ 



Ct^w^' 



City of 




U 




I 



No. 



St.; 



Dist.; bet. 



~" and 



( •' --^v^::^-v\^^^ :^^±^^^^-^^^^ -:^-vi .^:ii-i:--^r- ) 



FULL NAME 




cv^^aaviX) 



. V 



1 ,' 



i, 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 



1 1 WW »»l MIK in 




^ 



M..Mthi 



a>ay) 



rlSX 

(Yi-ar) 



\<.».: 






Miiulhs 



Pa V 



»^l^» .1 |- MARK n:i» 
xviiM lu » 1* <»K i»ivoK».*i*:r) 
Write in ^««i:i: .l'»ii?niiii«>n> 



r 




^ 



mKTmM,x«'r 

(Slatr or t'-nMiti V 



NXMI- Ol 
lATlUK 



fURTHI'UAt'K 

'Stalt- <»r iiniiUt y) 



maii>»:n namk 

nl- MOTIIKK 



lUK ini'i.ArK 

Ml MmTHKK 
(Slatf or Country^ 



OCCl'I'ATION 



^11 



dx^vcX^ 



rVV.0 



O AnJLxX' 



3)... j5 



tu 




;^tv<vw 



SV^„fr,f I" "<">' /'><>"''"'•' 



" )V.n 



" M.nitllS 



Ihn: 



\KS AK1-: TKIH TO TMl- 



nKSTol- MV KNoWI.l.IH.h AM) '»^'-"' 



(Iiifotmiinl 



' \(1(llC>i«< 



% 



i\.LOL.' 






MEDICAL CERTIFICATE OF DEATH 

HATK Ol' i)i:ath 



(j^oiith) /f 



IH 

(Hay) 



(Year) 



I HRRKBY CIvRTIFV, That I attended deceased from 

I QO — 

— — — Tgo 



190 



to 



that I last saw h 



alive on 



and that <Uath occurred, on the date stated ahove, at - 
— ^ M. The CAISIC OF DICATII was as follows: 



DIRATION years 
CONTRIIU'TORV 



Mo fit ha 



Day a 



Hour a 



diration 
(Signed) 



Hours 




L 



Years Mouths Days 

\ O.^^uCrtlvxi.c'J-trrA-. M.D. 



p EdiAL INFORMATION only for Hospitals. Institutions, ilranslcnts, 

or^Rccent Residents, and persons dying away from home. 

_ How lonq at 

Former or pjar e of Deatli ? Days 

Usual Residence 

Wfien was disease contracted. 

If not at place of deatli ? 



V\ XCK OK BIRIAI. OR KKMOVAI 



INDKRTAKKR 



DATi: of IJi KiAi, or RKMOVAU 

\kA.Lu ^^ 190^ 



,,,„,... ^^^>va4c.^tc^. 






"* ^ ... „.„t^rf EXACTLY. PHYSICIANS should 
., He c„r.<u.,, -uppHe.. ^^f' ■;:'':....«.:-!' Thf-^Speci.. ,nVo..„..on" for pT- 



be properly 
stance. 




?i. 



J 

i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



!lfnif«1 of lltalth »•■ N" 



''t!Sr^ 



nfkv c, 




RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

333 



Megititi'iod J\''o. 



t^v.vt Uv^, DeP"^y Health omc..^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( H. S. Stan^ar^ ) 



PLACE OF DEATH: — County 



: — County of ^n\aV^.>v City of O/C^.^v VccO>\Xu>v. ^al 



-X 



rs 



No. ■VOXv ^\^sLtl\ 



St.; 



Dist.; bet. " 



■"^and 



v^V ,\^VW. „„„ ...SIlAl RESIDENCE GIVE FACTS CALLtO FOR UNDER 'SPtCIAL INFORMATION••^ 



-) 



FULL NAME 






1 



«4 



Ni \ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 



^)\<xL 



loJ^cU 



It \ n i »i I'.iK iH 



Ai.K 



'M.)n»h» 



A V ) V-.( » .< 



(Day) 



Mouths 



(Year) 



/),7 1> 



SIN. .1.J-. MXKklKI) 



\VII»o\VI I) »>W I>rv«»KiKl> p A 

i\\nt> ill >-»i;i'i .1. «.ii?iiati<'tO — T II 



V 

( 



\m 



HiKTmM.xov: 

iStatf or C'>initi n 



N \ M »• « » I 
J ATHIR 



jnu rm'LA<"K 

<»l I ATHKK 

'stiitt or i.'o\jntry^ 



NtAini.N NAMi: 
nl MOTIIKK 



JMK rUl'I.Al'K 

til M«>Tni:K 

(Statf or Country^ 






occri'A rioN 



\% 



M 



t( 



)'iti I 



.y/,»ifhs 



Day 



1»HST «>!• MV KNOWI.HDC.h AND HI.MIJ 
(,„fon«nnt ^vL NJL^V^C^l .|AjL»w>^^t 



( \<lilr<-x»i 



MEDICAL CERTIFICATE OF DEATH 
DATK t>l' DHATH 

15 



|Monlh)(|' 



(Day) 



(Ytar^ 



I HRRHRV C1':RTII'V. That I nttemUM deoeasca from 

;; - " I 90 ' to ...:....— -T:^"-^" — " IC)0 

tliat I last saw h :^ alive on ^^^ 



and that death occurred, i>t» the tlale stated above, at 
M. The CAl SIC OF DICATH was as follows 



nr RATION Ytiirs 
C'ONTRIIU'TORV 



Mofii/is 



Pays 



/louts 



Dr RATION 



]'i'ars 



Months 



/hivs 



Hours 



(SIGNED) V^ VCV^LM 



.<^Ui 1 '^ u 



)0 



(Address) 



M.D. 



oPECIAL INFORMATION only for Hospitdls. Institufions, Translfnts, 
or Recent Residents, and persons dying anay fro:n liome. 



P How lonq at 
Usual Residence KJ ^X^J.-syJO^'^oX Place of Death ? 



Former or 




.. Days 



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



PI ACK ()}• HI RIAI, OR RKMOVAI. 



I)\Tl"o! in KIAI. or KI':M(>VAI, 



I90H 



(A<l(lr<><?« 



,. t\ 



,--^« iCoi 



O'Cl'tu ' 



H 



^■^^^^"■^^^"■"■""""^"^^^"^^'"^""^^""'^^^ IK t t d EXACTLY PHYSICIANS nhould 

of i„for„,«tion .houhl be cnrufuMy «uppned ^^"^^^ %he -Speclo'l .„form«tlo„" for pT- 
E OF DEATH in pL.in term». tha it m»> ^e P^«^ 



N. B. Every Itc 

•tate CAUSE OF DEATH in p... .• ";"".; , Instance 

»on« dylnft away from home should be ft.>cn .n •>ery 



1^ 




il 



V 



^m^mtmmmtik 



ITT f 



lif 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,, .,,„■.„,..,-. NO ■■^*:g^:..^PCo REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

l,atrFih:l, *ivdu 15 10(A RegistereclJVo. 334 

l^vcvft "Lvvv. O^'^'"" ^""'■•*^ P-^'-- 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( 'a. S. StanJ>acC> ) 
PLACE OF DEATH:-County of "^ CU^^O Aa>^^ WGty of CVoA^a/vOm-ec^^ 



.1 



1 n 



St.; I Dist.; bet At>VUn\) and DaJU/TL' 

ilVE FACTS CALLED FOR UNDE 
N GIVE ITS NAME INSTEAD 



TVT '•>li lVl>a^>»^u St.; Dist.; bet. L^ >VUn\) an. 

No. ^ ^ ^ JU^AX^^VU RESIDENCE GIVE FACTS CALLED TOR UNDER ■SPECAL . N FO R M AT.O N - \ 

( " ^/relT:"oCC^*ro^rrHO^S^PyT'AL :« f^Sr^^^'o^N^GIVE .TS name instead OFSTREET AND NUMBER. ) 



) 



FULL NAME 



U Ct'VKX./-v^'^^<^ J /Ol>v.<X/^aXaw/\xO- 



PERSONAL AND STATISTICAL PARTICULARS 



K \ 11. of ItlK IH 



LL'.Wo-^ 



\' .1 



HL 



M. nth» 



),-,// 



I I J.I V ) 



y/..„f/n 



/US 

(Viar) 



An.v 



s I N • . ! . 1* M \ K U 1 1: 1 » 



W IIH lU in «>K I>I\'< >KiKI) \ 

(Write in •wKial ilf^itfnati'ni) \ \\ \ 



MikTnri, vt'v. 



N\M1 <>l 
1 \ III IK 



MiK inri.vrH 

Ml lATHKK 
iStat«- <>t i'outitry) 



m\ii>i;n n\mj, 

(»1 .MoTHKK 



HIK'IHPI.ArH 

«)i M<»rni;K 

(Stall- or Cotintrj-^ 













t<X 



I 



occrrAT.ON %^^jj^^\^^r„ 



1 



AV >,•-/'■■/ "' *^""" 



Month- 



Pays 



^^i^Ii^;^^^:^ 



(Inforinanl 



O-cvLx^-oT 



f \(l.lrr-«« 



'5, 1 ^ jVux V 



MEDICAL CERTIFICATE OF DEATH 

DATH <)I- DKATH 

13 



month) ( 



(Day) 



(Year) 



I IIFRnHV CI'RTIFV, That I attended (Icceased from 



190 H 



to .'^aa<Ll+. l.Ck. T90 'v 

that I last saw h «•-' ^ alive on \wlu .' I X 190 H 

aiKl that death occurred, on the date stated al.ove, at 1 
(J; M. The CAl'SI*: OF DlvATII was as follows: 

.C>A"Vw-:0^."V^i-^»-A_^*^X 



DIRATION -Years I Moni/is i^ Au? 



I /ours 



4 



CONXRinUTORY 

CA^.trN^vOw'Ovvj 

DCRATION I )\ars \ Months -Pays -/fours 

L^U...in TOO-', rAddress)(0 V> U^t(|vAlu.L 



(SIGNED) 



'fePEdlAL INFORMATION only for Hospitals 
or Recent Residents, and persons dyini] away from home. 



Transients, 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



IM.ACK OF HIRIAI, OK KKMOVAI, 



D.XTlvof Hi.' "I- *>r KKMOVAI, 



b. «tat..l EXACTLY. PHYSICIANS .houl.l 



State CAUSL Oh Pt a in m p n«t«nce. 
,lvin«» nway ?rom home hHouIcI be Ji.xen m .vory 






li 



\i 



♦»< 



'i 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,„, - ,v,. ,,.^^ .■.■■0. P.r» TO BAC. OP CeRT,r,CATerOR INSTRUCTIONS 

335 

DkIc Filcil, \,kXu I? 



I 'JO 4 



Registered JVo. 



■'i I I'll, V^U, 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2>eatb 



* ~(^ i ^ 

PLACE OF DEATH: — County of vJOwTu OA.<X^vc^<i^ A-ity 01 



.1 



n,. i I c,. ^' Disfbet 15 tL and lb Ik 

FULL NAME \}1±^ U^^y-^'^^^ 



) 



PERSONAL AND STATISTICAL PARTICULARS 

.^^_ - ^■< '1.' >*i ^ 



.'V 



i»\ 1 1 «>i niK iH 



\ < . »•: 



5? f 



II !- .tx, 



(sC 



)V,J 



^ 



30 

il)a\ : 



\l.>nl>is 



rP' 



W 



CI 



MEDICAL CERTIFICA TE OF D EATH 

datp: of dkath 



x^' 



(^onth) 

i 




IH rpo'i 

(Day) (Yt;ar) 




I'RKHV cT:VriFV, That I attende.l deccascn: from 

\X 190H to^ WW^H 190 H 



oil 




190 



u 



y ! 



u 



;1 



mv. .1 1 M \KK Il'.l» 

W 1I»< tW »- I> «»K DIVoK* Kl) 

'Wilt' 111 -<K i:iJ il< •.iviiali-'ii' 



(State or Cotintrv 







' » 



NAMl-: OF 
FAT1IFR 



MIKTMIM.ACH 

(H- r\ rm-.K 

(Statr or Coxintrv) 



MVini'.N NAMF 
(H NHjTHFK 



lUK rniM.Ai 1. 

<»!• MOTHFK 

(State or Co)inti v> 



occrrATioN 




^'^^^\.^^<^^ 



that 1 last saw h --^^ -ilivc y g , ^. 

att.l that .U-ath occurred, on the .late stated above, at b • .6\) 

lows : 

;fr^ttu ^.^^o^.K^t^^A'hMOrhl 



' L_ M. The CAl'SIC OF DlvATII was a^^jfj'j'^*^^'^ 



'^ 



DIRATION 
CONTRIHUTC^RV 






t/lS 



Pays 



Hours 



Hours 



nrUATION Years ^ ^rouths Pays 

(SIGNED) W^^i v^CUV>j^ M.D. 

IH r.A (Address) ^g^Uvc^V^-^A .^ 



(H \juL(x/>v 



Kesuifd n, Sitfi r><nuis.;> 



<X} 



,.,„,. I v,»////- >> ^ 







(Ill foTinant 



I I.I' ■ 

a. 



+5 

3 1 ?5 Lav^v^v^Jk' '"'t^ 



^Ve3iAL information only for Hospitals, Institutions, Transients, 
or Refent Residents, and persons dying anay froi, home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



1M ^CF OF HFRIAf, OR RKMoVAI, 



IVLACF Ol- ,^ , 



rNUHRTAKKR 

(Adilress 



DATHof lURlAi. or RKMOVAI, 

S HAd Qr\\^.A,A-^<nx . al 



IS. B. 



(A.l.lu**s , I L PHYSICIANS Rhould 

' " \ H 1.1 be cnrefully supplied. AGE »hot.1d '^.^,.«7'^^j,^ ..gpecla'l Information" for pT- 

■Hvery Uem of »"*"--'l'"" •*:,7'^' ^^rm'that It m«y be properly cla«s.t.cd. The Spec 
,tatc CAU8E OF DEATH in ^'"J, J^j;'' ^.^ ,„ .very instance, 
son* dylnft away from home should be ft. 



; 

1 



;i ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,.,,., „ , v„ ..^^i^US^V^ RtreR TO BACK or CeRTinCATE FOR INSTRUCTIONS 



IlJO'i 



Ee^istered JVo. 



336 



DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco 



Certificate of Beatb 

( Xl. S. StanDarD ) 



J? % 



PLACE OF DEATH:-County of C)a/>^d AXXm^vACC City of '^J^v Ja^x^vC^c^ 



No. \^^^ ^.0XXX:>^\S^ 



1, 



^^ St.; ^ Dist.;bct. ^ J/'-^-^2:^>r^ ^""^ 

(tr 0ri4TM occurs *W*V FROM USUAL 
|Fk6c*TM OCCURRtO IN A HOSPITAL 



dUcrur' 



\IAj ) 



RCSIDENCC GIVE r*CTS c 
OR INSTITUTION GIVE ITS 



FULL NAME 



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



1 



ii 






II 



11 



I 



nv ■0.ol\xv</^'V' 



tl 






1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

CO!. OK 



DATK OF I»IRTM 



\ > . J". 






ll\!v<i. 



i M..nrhi 



u 



./ » 



S 






M„vth' 



(Year) 



l\i\s 



MEDICAL CERTIFICATE OF DEATH 

DATK ol- Dl-.ATM f\ (^ ^ 

(Day) 




7poS 

(Year) 



WinoWKU OK niVoKv >-.l> 
iWritrin •social •lr«.i>rnati<>n) 



lUK rm-i. \*i 

(State or '".nmtiv 






I III'RI'HV CHRTIFV, That I attcn<lo<l deceased from 

that I last saw h .rV»N alive on ^jf^-^^J- ^ ^ ^'^ ^ 

an.l that death occurred, on the date stated a1).>ve. at ^"^ <^ 
\X;^I_ The CAl'SIC OF DIv.ATIl was as follows: 



. I 



NVMI- <»» 
I- A IH J.K 



lUKTHri.VCK 
<»|- I AIIIKK 

(State <)T C'Hiiitrv^ 



MAIIU'.N NAMK. 
(U- MoTIllvK 



HIR'IHIM.AOK 
Ol- MOTIIKK 
(State nr Countryi 



>vcr^*^">'^ 






( « 



[ V TT" 



i 






.i/,'/////< ' 



. Po 1 . 



■%.^^ry^^|■^■^^^^^^-K■.^fr;.^.^l;^--'•'■^'■^ '■" '-^ 



(Iiif<>:in:itit 






ClAO-^^Vu 



(A<Mre^< 



\\^^- IS 



l^lv-^^^J^'VU,^ 



vOLaXa^ 



e 



5^ ' 



m-RVriON -Years - Months I Days b Z/^;.,;. 

.L'..'\-r.i.V'<x.v.vA.^iwA->^ 



CONTRIIU'TORV 



DI'RATION 
(SIGNED) 



Years 

a (\ 



J/^(>U//lS 



Davs 



Hours 

_ rX.idress) 1^ i V) gUAv^va ■' t. : 

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




IS" TqoH 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



n \Cy Ol- lURIAU OR RKMOVAl. 



INDHRTAKKR V "V y v o 



DATK of HrRiAi. or RKM(»V.\I, 

^vJIm. \t 190H 



i^'^ Qo\ 



\j^^<^^y\ 




■^ ''" ^ "" , , pYACTLY PHYSICIANS »hould 

.tnte CAUbE Ob uci^ • " •'_ _ _ . ^, . .^.,_v Instance. 



Tt'^t^CAUSE OF DEA I n .n p-h... —";:-;. ,^^^y instance. 
«on. Hylnft away from home nhould be ft.ven 



■','n 



<i 



WRITE PLAINLY WITH UNFADING INK 

ru.ar<1 of Hti.lth - I No i< "^-tS^' *»^ '' ^^ 



Ddfi' Filed , 




190^ 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

337 



Re(!istcre(l J\^o. 



DEPARimENT OFPUBLIC HEALTH=City and County of San Francisco 



Ccvtificatc of Death 

i in. S. StanOarO ) 



PLACE OF DEATH:— CountT of 







a^<L^Lt^«>.^ €ity-^ 







No. 



— St.; 



Dist.; bet. 



~and 



-) 



Hi 



/ ,r or.TH occurs .WY r«o«« USUAL RESIDENCE O.VEr*CT 
\ .r OE*TH OCCURRtO IN » HOSPITAL OR .NST.TUTION GIVE IT 

FULL NAME dJo^v-^ 



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





hj 



gL ^^±' aa^^vccl^'^vlcv^ w.U jg 



^j-: 



PERSONAL AND STATISTICAL PARTICULARS 

i COl.oK 






\ 



xLl' 



I»\TK KM niKTII 






(Year) 



ACK 






yJ^r^K.^--, 



Months 



Pit \ . 



(Write In mximi <lr«i>riia 



■■"■" lUvl 



^-u>^'^^.*^v 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH ,-^ ft 







IH. 

(Day) 



(Year) 



I HI'Rl-P.Y Cl':RTrrV, That I attendea deceased from 

to 190 -— 

— 190 ""—^ 



1 90 



that 1 last saw h"::-^ alive on 

atid that .Icath occurred, on the date statcl above, at 

-rr- M. The CAUSIC OV I)i:ATn was as follows 

UJ..o-u^:vcU 



l! 



lUKTmM.Ai'K 

^t.ilf- or r.>iinlry' 



N\MJ" <•! 
FA I III K 



HIKTHIM.ACK 

Ol' I Arni-K 



m\iih:n namk 

{)] MOTHKR 



HIKTIU'I^AOK 

(Sliitr or Country' 



•I 



«• 



„>-ei-.'AT.oN ^ n ,^^, 






u 



) 'nr t ' 



yr.yuthy 



Davs 



l.XKri.TI.AKSAKr.TRlK T< > THH 
,U^^';''y.'^MYKNnW.:KI».;KAN., UKMHK 



Tin- \HOVKST\rKn»-Kk^nNAl 



f Infoiiuiiiit 



\ * »p 1u ' 






0#a>-v>^ 



Dl' RAT ION >''''"-^ 
CONTRIIU'TORY 



Months 



Days 



Hours 



Dl'RATION 



Days 



7) 



)V(7/.y Months 




Hours 
M.D. 



=,PECIAL INFORMATION only for Hospitals, institutions, Transients. 

or Recent Residents, and persons dying away from liome. 

How long at 
former or piar e of Deatli ? Days 

Usual Residence 

Wlien \vas disease contracted, 

If not 3t place of death ? 



I'UACK OK Bl-RIAI, OR RKMOVAI 
ITsOliRTAKKK 1 ■ i n 



DAjlCof HiKlAi- or KHMOVAl, 
\^ I90H 



IS. B. K*ery Item of 1 

state CAUSE OF 



I — ^^^ ^ , FVACTLY PHYSICIANS should 



,0°. dylni ow«y from hon,. -houl.l he ft 



I 



♦ r 



i- 






' i 



liii 



m 






!l 






*••( 



RECORD 



rZ FOR INSTRUCTIONS 



Yo, 



333 






an Francisco 



(0 ^ 

Act'^vXvTs.' vat 



RMATION" 'X 
UMBER. y 



[ OF DEATH 



15 /pr>1 

(Day) (Yrat^ 

I nttciuK'<l deceased fmni 



I()0 

190 



stated above, at ■ 
I was as follows : 



i 



hs Days 



Hours 



hs 



Pays 



Hours 



M.D. 

>r Hospitals, Inslltulions, Transients, 
i«mc. 

How long at 

Place of Death? Days 



iTKol' IMKiAr. or KJ:M<»VAI, 

^u^Lui 1 5^ 190H 

^<xUd Col 



IY8ICIAN8 nhould 
rmation" for p«r- 



I'.,;,l.l ..f MfftUh I V 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. -5^^^; luS^PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Ddtr Filed , 



l5 I'JO'i Registered J^o. 

.^.^vcvfl "i^vvu Oe^"-- "-^'"^"^ 0?«C3r 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

I H. 5. StanOarD ) 
PLACE OF DEATH:-County of "^'CU^^^-^a^^^^^City of CVo/^XKlxOm^cAX^^ 

, , St.; 1 Dist.; bet. ll^^XV^TTU and "yAJLLov 

Jr „ ..oilAI RrSIDENCE GIVt FACTS CALLED TOR UNDER "SPECIAL INFORMATION • \ 



No. ' -^ ^^ 




^>\.u 



) 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



>^J \ 



had: «•» HI urn 



L 



COl.OR ^ 



10 




^M.. 



\' .» 



It 



Mi.iith> 



).;n 



(Day) 



M,,i,lfn 



(Vtar) 



A/ IS 



sIN«.!,l-* M\KKI1".I> 



I Writ' ill s.Kinl «lr"«i»rnHli""' \ \\ \ 



HlKTIiri.MM-: 
'StHli- <»r (.'otilltl N 



. I 



dl 



0L^«^ 



N \M1 (M 

I \ link 



lUK rni'i.ACH 

ol I ATHKK 

' Slat«- ot i."<)inilry) 



maii)i:n nami% 
Ol mothhk 



HiK rni'i.ArK 

Ol MofUliK 
(Stall- or Country* 



-I 




^ac.n>vo 



J <XVvX'^A.~b^^>^C 



cixtcc^ 







ktA 






<)C CITATION 



t 



- ^fonths 



Pit V.v 



KA,.n-KSTATK.>.KK.oSA.rAKD....AKSAKKTKlK m TIIK 
liKST Ol- MV KN<.\VI,i:iM.h .\M> HhlJM 



(Informant 



X.liltr^x 



MEDICAL CERTIFICATE OF DEATH 



DATE or I)K.\TH 




13 190'i 

(Day) (Year) 



I IIFRFHV Cl'RTIFV, That I attendetl deceased from 



1 90 H 



to ^*-^ 

L 



..<K- 



\X 



tliat I last saw h .=■.' - alive on 'V^-^^'^H 
and that death occnrred, on the date stated above, at 
ff M The CAUSlv OF DEATH was as follows: 

4. 



190 \ 

190 H 

X 



..C^r:>.^tX^c"v^ 



ft^ 



DURATION -years I .Von//is i^ Au? 



Hours 



Nw,^!;:.A-'.^'S-<^::>^rwxXJ. 



4 



CONTRIBrTORY 

CiwtrvA'VOw^^vvj 

DURATION I Years \ Months -Pays -/fours 

(SIGNED) ^. VD. Vh <X<^vxx^iA-v|vAj M.D. 

V jLu....a . 100" f Address) b M >W>vWi C1-.--.1 

'Special InF^o'^'^tion onlv for Hospitals, InstitMs, 



=,,-.^w.r,^ ..JFORMATION only for Hospitals 
or Recent Residents, and persons dying away from home, 
c -, -r How long at 

uSwd^nc, Placed Death; 

When was disease contracted, 

If not at pla^e of death ? 



Transients, 



Days 



n.ACK OI- lURIAI, OK KKMOVAI 

.XDKKTAKKR l)'JLvCU QOfVcUU^^VC Xlc 

15^*^ O'iWtctcvv at 




(Ad(lr<--^s 



[N. B. K%'ery Item of Inform 

DE- 
iions clyJnft oway from home hHouIcI 



7 C viis ' OF DEATH In plHin terms, th«t It m»y be proper 



■""■""^^^^ .... » * IPVACTIY. PHYSICIANS should 



„1„„ ,houl<I b.- coreVully «u -^-^ „„,„erly .la..l«led. Th. "S,,.. 



• 'I 



i 



)» 



l! 



• ^ 




WRITE PLAINLY WITH UNFADING INK 



1 «i ' 



O •> 



•■?^ r. 



THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

335 



Ke^Lsterecl JVo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccvtiftcate of 2)eatb 

( "U. S. StanDarD j 
PLACE OF DEATH: -County of CVa^ J.Va'^vC^^C' City of 







St.; ^^ Dist.;bct 




*-»!»*» II '^ Ti , -^ i IJiSt * DCT» ' •' '^-^ ■ -■ alio - 

FULL NAME ULUav J Kri^^e^' 



1 



|,\ I J- »>r lUK I'M 



PERSONAL AND STATISTICAL PARTICULARS 






ll' 



'JvaXi- 






\« K 



bo 



) ra * .< 



1 



30 

(Day) 



M.'nlfi^ 



(Year) 



IH 



Pil V. 



*iINC".I.K, MAKKli:i> 
\VII>«»\VK1» «»R I)!V.»Krj I) 



HIKTmM.VvM". 

(St.i'- ■! totintryi 



NAMI-: «>I" 
HATllKR 




MEDICAL CERTIFICATE OF DEATH 
DAT?: OF DKATH 






AX 

(Day) 



/9o 4 

(Year) 



I IIKKI-HV CI-.RTIl'V, That I attcn.le<l deceased iroiii 

L IX ioo4 to WU-iH 190 M 



190' 



that I last saw h ■■■<^ 



-t^ 



c 






HiKinri. \*"i". 

(Statt or (."ountry) 



MMDltN NAMT- 
(H MoTIM-.K 



lUK rilJM.Av 1", 

(»!• M(vnn:K 

(Stiitf or I'otmti y> 




a.i.l that .leath occurred, on the date stated above, at b • i ^^ 
iL M. TheC\rSK()FI)HATll wasas^lows 



,ttu oUxo^XAXL'- 



DIRATION 
CONTRII^rTORV 



) V.;^^"^'^^^^^ " /^-^'^ ^'"^ 




Yrars Months Pays 



Hours 
M.D. 



( 



A<l.lress) ^I^Uv^v^ 



OCCI TATION •- 

(Infotmaiit 



(AcMrcxs 






3l?i 



nrRATioN 
(Signed) 

^^dlAL INFORMATION only tor Hospitals, Institutions. Transients, 

or Rcrenl Residents, and persons dying anay from home. 

How lonq at 
Former or pia^p ^f Death? Days 

Usual Residence 

When was disease rontracted, 

If not at place of death ? 



,..CK ,..- ..rK.A.-OK KKM„V.,, I .-ATK..: »- «MK ... K.MOVA^ 

n^ . V ^ r V .Ho^v 1.S 190H 



rNDHKTAKKK 



(Adilri'^s 



^H\o 



— ^ !• ,i AGE should be state 

,. „._Bve., He. »« •"«"r-'s".:"pTl ';:;:::'Hr. »:-.:;%■. p^-p-^ '•-••"'■'• 



d EXACTLY. PHYSICIANS should 
The "Special Information" ?or p«r- 



1? 



J 



if 
i 

! 



t* 



'I 
2 



V 






'!( 



WRITE PLAINLY WITH UNFADING INK — 



B.«rrt of Hcfllilt-F ■!« i«^ "*-t'S^^ »* »' ^" 





)5 



liJO'i 



THIS IS A PERMANENT RECORD 

WCF ER TO BACK OF CERTIPICATE: FOR INSTRUCTIONS 

336 



Registered J\^o, 



Oc 



Did I Filet I, 

i H 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( ia. S. StanSatO ) 
PLACE OF DEATH:-County of a^^d;UV>vcv^C. City of '^3^v OAXV>vc^^^ 



) 



i7r\p 



FULL NAME 



XA\)\u. 



I) 



n\J ©OL^UXiA-V 



n 



■ l.\ 



PERSONAL AND STATISTICAL PARTICULARS 

I C01,«»R 



^\oL 



ll'J.A. 



li V rr «»i inK in 



A<.K 



19^ 



' M..nth> 



^1 



)'.uit* 



<l)ayl 



.l/..i///»< 



(Year) 



/)./»> 



MEDICAL CERTIFICATE OF^DEATH 

DATE OK PKATII , , „ ^ 

I.? 
(Day) 




(Year) 



'>IN<.I.K MAKKIKI) 
WIDMWKI) OK I)!VnKri-:i) 
'Write in «m>c«:«' .)» -ivMit«ti<>n> 



(Stat' or i.nmtix 



I- A I H IK 



lo. 



<X^-va^>-^<v 



I 



'X^w^^^'OL''»^*-l 



lUvk' 



>v(r^<^>^ 



HIKTMI'I. \*K 
<»l- rXI'HKK 
iStat* <'T «."<iiintry^ 



MAIIiKN NAMK 
Ol- MOTHKK 



lUKTHri.AOK 
or MOTHKK 
(Slatt or Country^ 



I 






1 



W^^VTtV 



I in-rRI^HV^MCRTIFV, That I attended <leceasecl from 

V^L IH 190 H to ..^|vJLj^ 15: 190 H 

that I last saw h rWYN alive on \-^)^ ^ "^ ^'^ "^ 

an.l that death occurred, on the date state.l ahove, at ^^i 
CVm. The CAl'SIv OF Dl-ATll was as follows: 



y^vOuXu 



i,lKvn<)N ^ Years ^ Mouths I Pays b Hours 



^rouths Pays Hours 

\ OTU^^^oIuA) m.d. 

IS rnoH (Address) g^l I) gUA^^^ '^ 



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



occ V PAT ION (J^jjHt^rvJLCL Cn \X>V'cJk.'CX^<^ 



\r<nitln 



/hnf 



i ! 



■'n.?^r-y^^!v-^y;.^--^^-'-;^-^ •'■^'^ '■" '"^^ 



(ItifoTinant 



OltlsJtdL \) cm. *^f^ OJ^Y^vx. 



(\<l<1rrv>; 



\%[3\o' 15 tLoi 



Former or 
Usual Residence 

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



How long at 
Place of Death ? 



Days 



n \cv or niRiAi, or rkmovai. 

,-N„KRrAKKK G % j J 



DATHof Ht RIAL or RKMOVAI, 

"^vJlu \t 190H 



li 



N. B.- 



^'''^*"'^ " ^ ^ I PYACTLY PHYSICIANS should 

«tate CAUSE OF DEA I n m p .^ ^^^^^ instance, 

sons Hyinft away from home Khoum oe b 



I 



•r 





WRITE PLAINLY WITH UNFADING INK — 



)U m rd of H en It h I V • i' '^1,':*!:^-^ I*'*^ ' ' ^ ' 



, t 



/)(ff(' Filed, \kJlq 15 

J) -fl 



lOWi 



THIS IS A PERMANENT RECORD 

R EF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

337 



Registered J\^o. 






t . 



DEPARTMENT OFPUBLIC HEALTH=-City and County of San Francisco 



Ccvtificatc of Death 

( ti. 5. StanDarO ) 



/'D 



PLACE OF DEATHr-^^Cttxxtr ofCa^^^K'^'L^^^ 




%XX<X/>VOwX) 'J 



N 



o. 



St.; 



Dist.; bet. 



"and 



( 



- --v^::^1:v\^^^^ -^^?i^^^^;^^;j -- .^^^^ -:^^ri:or:e;r- ) 



FULL NAME 




0^\hv 




(^|vt:' aa^^vci.l^^vlcv^ Wj Vi. J 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 




DATK of niH in 



ACK 






AVtrV^.r-rv 



M'.iith' 



(Day) 



VjL^vk 



.-\^^-w.,>-^- 



) Vif > 



Motilhs 



(Yfar) 



Pa V. 



\vn>«>\Via» »»K IMVoKri I) 
(Write in social 



drsivnatixiit | l| 



W^^\-''TV 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



(Mo'iith) 



IH.. 

(Day) 



190% 

(Year) 



I m-Ul'P.V CI'RTIFV, That T attended deceased from 

190 -~~ 



190 



to 



tliat I last saw h-:—- alive on 

and that death occurred, on the .late stated above, at 

rrrrr M. The CAI'SI-: OF I)1':ATII was as follows 

Uj..<h^<>^'«^ 



rt 



lUKTUIM.AiM* 

i St:it»- I'T ridltltt y) 



lA III KK 



•I 



HIKTHIM.ACK 
()|- I A rii»:K 
(State <ir CuvMiti V 



1 



MAIDliN NAMH 
or MOTHKK 



lUR riu'KAOi: 

<»}•■ MnTm:K 
(State or Country) 



u 



)'rtii 



\r.>iith.- 



nav. 



n.ACK OF Bl'RIAI, OK KKMOVAI, 
iNDliRTAKKR ^ ' jP H 



DAjlCof HrKiAl- or KHMOVAl, 
\^ I90H 



OCCUPATION ^ ^,<UL^. V -^ ^ 
(Informant M I ^^^y v v wv 

._ k ^i ^— . 

■■"■""'■■■'■"'"■"""""'"'"^'^ * iFVACTIY PHYSICIANS should 

•^!i^.^^?l^^ from hie should bo ^Wen in .vry instance. 



DTK AT ION >V(7;\? 
CONTRIIU'TORY 



Months Days 



Hours 



}'t\irs 



DIRATION 

NED )yV AD ^ . MIluA^^^ 

Address) VfK-XA^^ta () ^ 



(SIG 



Months Days 

/sjsr^JL. 



Flours 
M.D. 




iqo'-', ( 



PECIAL INFORMATION only for Hospitals, InstituMons. Iranslfnls. 
or Recent Residents, and persons dying away from home. 

HoH lonq at 
Former or piare of Death ? Days 

Usual Residence 

When was disease contracted, 

If not at place of death ? 



«on 



• dyinft away *rom 



i 



1 



m\ 



ii 



* I 



.1 




WRITE PLAINLY WITH UNFADING INK — 







IS- 



i90H 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIPICATE FOR INSTRUCTIONS 

338 



Registered Xo, 



l)(tf(' Fih'd , 

DEPARTMENT 0^ PUBLIC HEALTH=City and County of San Francisco 



.*.'\M.4. 



<^ 



Ccvtiftcate of 2)eatb 

( XX. S. StanOatC ; 
PLACE OF DEATH: -County ofCla^v d ^Ctwcv^A^ City of O^VAv JX<x.>v^v^ ^ c 

,r or»TH OCCURS *w*v rnoM USUAL "ESipENCt gjve f«ci^* namE instead of street and number. / 



\jj\j and^i3^<^cU^V!Lk ) 



/ ir orATM OCCUHS AWAY TROM U»U«U n t o . i^ .^ •- w - - . . ^ ■ -- 
V ir DC«TM OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE I 



FULL NAME 



^ 



SEX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR 



(inici 



lilLu 



i>\ it: « »» I'lK 111 



^M-.tithM 



(Day) 



(Year) 



\< .1, 



bo 



) fO I 



siNi.i.i': M\Kun:i) 

WIDOW JT> Mk l.IV(tKrKI) 
W ritf in •"•rial .h •iitriiatioti) 



IllKTHPI.ArK 

( St;tt« or ("oiiiitrv^ 



I 1 



Oi 



Mouth' 



b 



An.* 



.\.X^ 




tUkT ^i)x^C>VA.CC-vC 



N.XMK or 

FA rni:R 



lUKTm'I.AlK 
()|- lArilKK 
(Still*- <»r v."«>untry) 



(5i^ 



kVO'>'^viv^C^\ 



i 



d^cttL 



MXIDKN NAM I". 
Ol MOTIIKR 



lURTHri.MK 
tU- MoTUHR 
(State «)r Country' 



OCCrPATlON 



^. 



\ 



jvA 



:nn:AH.>VKSTVTK.n.KRS.>NX. rAKTirMAKSARHTKlKTo THK 
lil-sT Ol- MV KNOWI.I-IX.K ANI> Hl.Mhf 



(Informant 



aid v^,A.v^lv at 



f \<Mrr>.'< 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



L/V\,V\ 



IH 

(Day) 



T9o\ 

(Year) 



that I last saw h ..Vrv\ alive on 



t\,vu, 

^""^''Li 

I HKKHnV CI:RTIFY, That I attended deceased from 

190H to |vA.lu ...iH 190 H 

v\ alive on V-"^^ ^^ ^'^ "^ 

do "1 \C 

and that death occurred, on the date stated above, at » ^»- 

\X M. The CAl'SIv UF DI'ATII was as follows: 

i^J|s,^,>orvv.w:^ LllVvjL^cr^ccx.'dA..t:v^ 

Ur RATION \^ Years- Monihs Days Hours 
CONTRIIU-TORV Ow4^<rv>^t&>^^^.Ut^>^^^ 
Ccr>v^'L{vc.tv^ V^'i^i^'Ut U>V<^A.lc.fi>X.. 

( SIGNED ).^<rvtr.v Ov 0^clL.^_ 

VivMH loos r.v.id..ss^^ao^lo<-^'^^ 

■ U**«^l.«. iKic-rkDMATiON only for Hospitals, Institutions, 



M.D. 



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



Former or 
Isual Residence 

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



How long at 
Place of Death ? 



. Days 



,., XCKOF HIRIALOR RKMOVAI. I D.ATK of^IUR.Al. or RKMi.VAl. 



^^^,^^,,^^^^^^^^^-^i— ^^^— ^■'^^^^■■^^^^■'^^^■"'"''^"'" . . EXACTLY PHYSICIANS should 

^ „._F.v.ry ...m of inf.rm-.Ion .houl.l te c»r.full, -"PP'''-; *';f„lj°;i...rfl.%. Th. "Spccl.; lnforn...I»n" »or p.r- 
» . r All«F OF DEATH in p win terms, that it may be propcny 
:".<""»»»« °rL ho„.e -hould be f.v.„ In .v.r, ln,.«nc.. 






V 




.<v^ 



* • 



1 



.i 



LOCAL I TY OF 



RECORD S 



SAN FRANCISCO 



COtJNTY 



SAN FRANCISCO 
CALIFORNIA 



X 



TLE 



.<^ "! 



RECORD 



h 



> 



MICROFILMED 



FOR 



TH E GENEALOG ICAL SO CI ETY 



SALT LAKE 



C fTY 



UTAH 



C A LI FO R N I A 



DATE 




APRI 



1 97 5 



PH OTOGRAP HER 



MAX JOHNSON 



CAMERA 



#.'»•-. ,*i.ntii 




R E D 1 



VOLUME 



338 



904 



V ^ , 



' ; 



% 1